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What Rx is C/I in b/l renal arterial stenosis (RAS)?
ACEi: will prevent sufficient perfusion of kidneys and reduce GFR
What is the MCC of 2dry HTN?
- RAS: esp in younger Pts
- Best way to Dx RAS: Duplex doppler U/S of kidneys
Good for detecting?
Bad for detecting?
- Good: ischemia, rhthym disfunctions, hypertrophy
- Bad: etiology of HTN
Indications fo CABG are UnLimiTeD:
- U: Unable to perform PCI (diffuse Dz)
- L: Left main coronary artery Dz
- T: Triple-Vessel dz
- D: Depressed ventricular fxn
- 1st d: Heart Failure
- 2-4 d: Arrhythmia, pericarditis
- 5-10 d: LV wall rupture (acute pericard tamponade, PEA), papillary mm rupture (sev MR)
- wks to mo: Ventricular aneurysm (CHF, arrhythmia, persistent ST-elevation, MR, thrombus formation)
HTN Em (911!)
- key: bp >179/119 and End-organ damage
- Goal: decr Diast to 100-105 w/in 2-6hrs
- Goal: decr B/P by 25% over 24-48hrs
- Monitor 'lytes: esp Na
- Drugs: Nitroprusside (MC), Nicardipine, Clevidipine, Labetalol (makes transition to PO easier), Fenoldopam
- Prego: use Hydralazine
- pheochromocytoma: Phentolamine
When: bp >179/119, but NO end-organ damage
NYHA Classification - Satges of Heart Failure
- Class 1: (mild) no limitations on physical activity or Sx of HF, even with mild exertion
- Class 2: (mild) Slight lim of phys activ, but Sx w strenuous exercise
- Class 3: (mod) marked limitations of phys activ, Sx w mild exertion (e.g. walking short distances)
- Class 4: (Sev) SOB, palpitations or angina, even at rest
- P/W: CHF
- Murmur: PanSys that obscures both S1 and S2 & Rad to Axilla
Murmur? / Radiographic sign?
- MCC: Rheumatic Fever
- Murmur: Prominent S1 with an opening snap, and diastolic murmur, heard best at apex
- CXR:"Double Density", LA enlargement, straightening of left heart border.
- Accentuated sound w?: Squatting or Leg lift (incr venous return
- P/W: S/Sx of CHF
- Unique Signs:de Musset sign (head bobbing); Quincke Pulse (visualization of pulse in nailbed); Wide pulse pressure; Water-hammer pulse (wide & bounding); Hill Sign (b/p legs is >40 arm b/p).
- Murmur: D, decrescendo; L low sternal
- Triad of: Angina (MC presentation), Syncope, CHF
- Murmur: Sys, cresc-decr peaking in mid-sys; best @ 2nd R intercostal space & rad to carotids
- MC: ASx
- P/W: CHF Sx
- Murmur: Sys Cresc-decr ejection murmur, Best @ L upper sternal border
- Key: Incr w inspiration & Rad diffusely
Squatting & Leg Raising
Increases murmur intensity from what valvular abnormalities?
Decreases murmur intensity for?
- Increases: MS, MR, AoS, AoR
- Mech: incr Venous return to heart --> incr murmur
- Decreases: MVP and HOCM murmurs
Pt has Hx of HTN and DM-2 treated with meds. ECG shows tall peaked T-waves.
What med is causing this?
Replace current med with?
- Tall peaked T-waves: =Hyperkalemia...depol and incr resting potential l/t peaked T-waves and wide QRS
- Furosemide: Tx of HTN, and K-sparring
- Replace with: Calcium gluconate (stabilizes myocardium for long enough to decr K-level)
- Feat: Acute febrile vasculitis synd of early childhood.
- Clinical Dx:
- Fever: >5d
- & 4/5: Periph Extr involvement (red palms/soles, desqm of finger tips); polymorphous rash, usu generalized; Oropharyngeal erythema, fissuring, crusting of lips, strawberry tongue; B/l non-exudative painless conjunctival infection; Acute non-purl cervical lymphadenopathy (usu u/l)
Anterior Wall MI
- ECG: ST-elev in pre-cordial leads, w reciprocal ST Depr in inferior leads.
- D/t: occlusion of Left Ant Descending coronary artery
Acute Inf MI
ECG: ST-elec inf leads (II, III, and aVF) w/ recipr ST depression ant leads I and aVL
- P/w: fever, CP exacb by leaning fwd and relieved by lean back.
- ECG: diffuse ST-elev
Leads involved in
AV nodal block
Right Coronary Artery
Branches and What they supply
- Post Desc: inf wall of LV & Post 1/3 of interventricular septum
- Marginal: RA and RV
- SA and AV nodal
- Common Presentation: sinus bradycardia, AV block, RV myocardial infarction, and/or inferoposterior myocardial infarction (of the LV)
Left Coronary Artery
Circumflex br: LA & lat wall LV & post wall LV
Framingham Criteria for CHF
- Dx req: simultaneous presence of @ least 2 Major; or 1 Maj + 2 Minor
- Major: Paroxysmal nocturnal dyspnea; Jugular vein distention; Rales; cardiomegaly on CXR; Acute PE; S3 gallop; Incr central venous pressure (>16 cm H2O at RA); Hepatojugular reflux; Weight loss >4.5 kg in 5 d d/t Tx
- Minor: b/l ankle edema; nocturnal cough; dyspnea on ordinary exertion; hepatomegaly; pleural effusion; 1/3 decr in vital capacity; tachy (HR>120bpm)
- Thiazide Diuretic: used in CHF
- MOA: blocks Na and Cl reabs in DCT of kidney
- Use: solo, or synergistic w/ loop diuretics (furosemide)
- Loops: block Na/K/Cl reabs on loop of Henle
Tx: same as STEMI ==> Cardiac Catheterization
S/E: of card cath. Embolization of released cholesterol in subQ tissues
- Indications: acute MI and unstable angina refract to medical intervention
- Fxn: meas blood flow / pressures in heart chambers and vessels
- S/E: Livedo reticularis - skin becomes mottled and discolored d/t ischemia
Beta-bl O/D Tx
- Physiologic: AoV closes before PulmV (incr with Inhl)
- Pathologic: (Wide / Fixed / Paradoxical)
- Wide: Pulm Stenosis or RBBB (path: d/t amnt time for RV to eject blood --> delay pulmV closing)
- Fixed: A/w Atrial Septal Defect (same amnt of blood shunted through ea beat)
- Paradoxical: AoS, or LBBB (PulmV closes before AoV)
- Chronic exposure to:
- Pressure overload state: AoS or Chr-HTN (*MCC of LVH = HTN)
- Volume overload state: AoR or MR, and Dilated Cardiomyopathy (DCM)
2 causes of Pressure overload state
Aortic Stenosis and Chronic Hypertension
ECG of LVH
Sokolov-Lyon Criteria: Depth of S-wave in V1 + tallest R-wave height in V5-6 must be >35mm
Tx of HTN in LVH
ARBs: (e.g. Losartan) shown to decr heart mass of LV
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