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Introduction Largest Section of
PANCE/RE 16% of Test 48 Questions There are not any heart
sounds!!
Review: Hypotension Hypertension Cardiomyopathy Heart Failure CAD
Congenital Disorders Valvular Disease Conduction Disorders Vascular Disease Infectious Disease
Hypotension Causes in adequate oxygen to body tissue Types of Shock
Hypovolemic- hemorrhage, loss of plasma, third spacing, anything to decrease volume
Cardiogenic Shock-MI, arrhythmias, heart failure, valve defects, HTN, myocarditis, cardiac contusion
Obstructive Shock-Tension pneumo, pericardial tamponade, PE
Poor blood flow Regulation- Sepsis, anaphylaxis, neurogenic shock
Sepsis is most common 40-80%!
Hypotension Presentation-
Abnormal Vital Signs Hypotension, tachycardia, AMS, metabolic acidosis,
orthostatic changes Treatment
Life Support Trendelenburg position O2, Fluids Monitor urine output (0.5mL/kg/hr) Continuous cardiac monitoring Pressors to increase GFR, help with HR and cardiac
contractions
Orthostatic or Postural Hypotension Causes:
Reduced Cardiac Output, arrhythmias, volume loss, medications, metabolic disorders
Consider this with syncope work up Presentation:
Greater than 20 mmHg drop in systolic blood pressure between supine and sitting or standing
With rise in pulse by >15 bpm
Hypertension Primary (Essential)
95% of patients Causes: Genetics, Increased salt intake, Obesity, ETOH,
Tobacco, Lack of exercise Definition: BP > 140/90 on three occasions Most common symptom: vague, non specific HA
Secondary (5%) Causes: Sleep Apnea, estrogen use, pheochromocytoma,
RAS, Cushing’s, thyroid disease, etc
Hypertension Hypertensive Urgency- BP that must be reduced
within an hour, are they symptomatic? BP > 220/125 HTN Emergency- must be reduced with 1 hour to
prevent End Organ Damage or death Diastolic >130 Presentation: encephalopathy, nephropathy,
intracranial hemorrhage, aortic dissection, preeclampsia/eclampsia, unstable angina, MI
Hypertension Hypertensive Urgency
BP that must be reduced within an hour Are they symptomatic? BP > 220/125
HTN Emergency Must be reduced with 1 hour to prevent End Organ
Damage or death Diastolic >130 Presentation: encephalopathy, nephropathy, intracranial
hemorrhage, aortic dissection, preeclampsia/eclampsia, unstable angina, MI
Hypertension Work up:
Labs: Check for end organ damage (CBC, CMP, Cardiac Enzymes, UA, Lipid Profile)
EKG-LVH? Treatment:
DASH! Deitary Approach to Stop HTN:
low fat, low sodium, low cholesterol, increase fruits/veggies, weight loss…..HEALTHY LIFESTYLE!
Initial Medications ACE inhibitors, Diuretics,
Beta-Blockers
HTN Emergency Treatment Preferred is sodium nitroprusside
NTG if MI Aortic Dissection- nitroprusside and labetalol Other IV Meds: nicardipine, enalpril, hydralazine,
lasix PO Meds: Clonidine, captopril, nifedipine
Heart Failure CHF- dyspnea, water and sodium retention Adversely affects cardiac output and left atrial pressure Left Sided Failure
Excertional dyspnea, cough, fatigue, orthopnea, rales, gallops
Right sided Failure Distended neck veins, hepatomegaly, pitting edema,
(often caused by left sided HF) Hallmark of CHF is nocturnal paroxysmal dyspnea
Heart Failure Testing:
Check for: anemia, renal insufficiency, hyperkalemia, hyponatremia, elevated LFTs, elevated BNP
CXR- cardiomegaly, edema, effusion EKG- Low voltage Treatment:
Correct any reversible causes Low sodium diet, exercise Diuretics to reduce volume-thiazide or loop with ACE Calcium Channel Blockers (amlodipine) if angina is present
Defibrillators are becoming more common
Heart Failure Low Voltage EKG CXR- cardiomegaly ,
edema, effusion
Coronary Artery Disease Decreased oxygen to cardiac muscle Most common cause atherosclerotic narrowing Risk Factors-
male, age, low estrogen state, smoking, family history, obesity, inactivity, cocaine use
Metabolic Syndrome- abdominal obesity, triglycerides >150, HDL <40 men, <50 women, glucose >110, and HTN
Presentation: Squeezing or pressure sensation Stable occurs with excretion and relieved by rest, unstable occurs at rest Prinzmetal’s-vasospasm at rest, usually early morning, will have
normal cath Levine’s Sign- clenched fist held over chest with clenched teeth when
describing pain
Coronary Artery Disease Testing:
ST segment elevation or down sloping (25% of EKG will be normal during attack)
ST segment depression during stress test
Consider Stress images: Nuclear Stress test, Echo, Cardiac CT/MRI
Cath- can diagnosis and treat at same time
Coronary Artery Disease Treatment:
Lifestyle changes Underlying conditions: HTN, DM, cholesterol NTG to help with Pain Beta Blockers- first line of therapy Calcium Channel Blockers- reduce cardiac muscle
demand
Coronary Artery Disease http://www.cdc.gov/heartdisease/coronary_ad.htm
Acute Coronary Syndrome EKG- ST elevation, Q waves Elevated Cardiac Enzymes: Troponin, CPK-MB 20% die from VF before reaching hospital 1/3 of acute MI’s have silent pain or minor pain, think of
atypical presentation (women, age, DM) Presentation:
CP, usually lasting >30 minutes Diaphoresis, weakness, syncope, cough, dyspnea, orthopnea,
n/v Dressler’s Syndrome- (Post MI) pericarditis, fever,
leukocytosis, pericardial or pleural effusion, occurs 1-2 weeks after MI
ACS EKG Findings ST elevations (or
depressions), T wave inversion, NEW LBBB?
Inferior-Leads II, III, aVF
Posterior- Leads V1, V2
ACS EKG Findings Anteroseptal- Leads V1, V2 Anterior- Leads V1, V2, V3 Anterolateral- Leads V4, V5, V6
ACS Treatment IV fluids, O2, ASA, NTG, morphine, Serial
Enzymes/EKG, consider anticoagulation and Beta Blockers
If ST elevation is present- need to have intervention within 3 hours of onset of pain….SEND TO CATH LAB!!
Non Stemi- Use TIMI score or risk stratification
TIMI Score
Congenital Disorders Either Cyanotic or Noncyanotic Cyanotic-Right to left shunt Tetralogy of Fallot-
1) Subaortic septal defect 2) Right Ventricular outflow Obstruction 3) Overriding Aorta 4) RVH
Crescendo-decrescendo holosystolic murmur, cyanosis Pulmonary Atresia
Closed pulmonary valve Atrial septal opening and patent ductus arteriosus Tricuspid regurg sudden onset of severe cyanosis
Tetralogy of Fallot
1) Subaortic septal defect
2) Right Ventricular outflow Obstruction Pulm Stenosis
3) Overriding Aorta 4) RVH
Noncyanotic Disorders Atrial Septal Defect
Opening between right and left atria, most common
Systolic ejection murmur, early to mid systolic rumble
Ventricular Septal Defect most common of all congenital
cardiac abnormalities Systolic murmur at LLSB
Patent Ductus Arteriosus Continuous (Machinery) murmur
Coarctation of Aorta narrowing of proximal thoracic
aorta Systolic LUSB murmur, may be
continuous
Figure 3 sign on CXR prestenotic dilatation of the aortic
arch and left subclavian artery
Valvular Disorders Most common presentation is fatigue, exercise intolerance EKG is not useful, consider CXR and Echo Aortic and Mitral Valves
Aortic Stenosis- Location 2nd RICS, will radiate to neck and LSB, loud with thrill
Aortic Regurgitation- Location 2-4th LICS, radiates to apex, high pitch blowing
Mitral Stenosis- Location Apex, no radiation, Low Pitch at midsystolic
Mitral Regurgitation- Location Apex, radiates to axilla, soft to loud occurring pansystolic
Valvular Disorders Tricuspid and Pulmonic Valves
Right sided pressure overload causes right sided cardiomegaly and right sided failure
Patients have exercise intolerance, easily fatigue JVD, hepatomegaly, peripheral edema
Tricuspid Regurg- Location LLSB, holosystolic, radiates to rt sternum, JVD
Pulmonic Stenosis- Location 2-3 LICS, midstolic crescendo – decrescendo, possible thrill, occurs systolic
Supraventricular Arrhythmias Sinus Bradycardia <60 Sinus Tachycardia >100 Atrial Fibrillation is most
common chronic arrhythmia
Presentation: Palpitations, angina,
fatigue, weakness, asymptomatic
Atrial Fibrillation Irregular Rate and Rhythm Loss of P waves Rate Controlled <100, uncontrolled >100
Treatments Paroxysmal Supraventricular Tachycardia (PSVT)
Initial: Valsalva maneuver, coughing, unilateral carotid massage
Synchronized cardio version DO Not Cardiovert if you suspect Digitalis Toxicity IV Adenosine can terminate rhythm Prevention: Beta Blocker, digoxin and/or verapamil
A-Fib Rate Control Cardio version Amiodarone for chronic a-flutter Ablation can terminate pathway Consider anticoagulants, increased risk for thrombus
Antiarrhythmic Drugs 1a Sodium Channel Blockers
Slows conduction and prolongs repolarization phase (Guanidine, procainamide, disopyramide, moricizine) SVT, VT, V Fib
1b Shorten Repolarization (Lidocaine, phenytoin) V tach, V Fib
1c Depress phase 0 repolarization Slows conduction (Flecainide) Life threatening V tach, SVT
II Beta Blockers, Slow AV conduction Supraventricular tachycardia
Antiarrhythmic Drugs III Prolong Action Potential
(Amiodarone) IV Slow calcium channel blockers
(Verapamil, diltiazem) Supraventricular tachycardia
V slows conduction time through AV node Interrupts reentry pathways Adenosine or Digoxin, SVT
EKGs V Fib
No measurable rate, but tachycardia No P waves No QRS complex
EKGs Sinus Tachycardia
>100 P waves Regular Rhythm
Ventricular Arrhythmias V Tach
3 or more consecutive ventricular premature beats
Frequent complication of MI Torsades de points
V tach with QRS complex twisting around baseline
French Term “twisting of points”
V Fib No effective pumping,
without immediate treatment death
Torsades De Pointes V tach with QRS complex twisting around baseline French Term “twisting of points”
Ventricular Arrhythmias Presentation:
Asymptomatic, syncope, dizziness, palpations Treatment:
Ventricular premature beats use Beta Blockers if symptomatic
V tach cardioversion Meds: lidocaine, procainamide, amiodarone,
magnesium may help Consider implantable defibrillators
Sick Sinus Syndrome Sinus node dysfunctions Mostly in infants and elderly Most patients are asymptomatic Can have syncope, dizziness, confusion, heart
failure, palpitations, angina
Sick Sinus Syndrome Causes:
Meds: (digitalis, calcium channel blockers, antiarrhythmic)
Other: metastatic disease, surgical injury, rare but CAD can cause
Reversible if caused by digitalis, quinidine, Beta Blockers, aerosols
Treatment: If symptomatic usually require pacing
AV Block Presentation:
Weakness, fatigue, light-headed, syncope Treatment: only effective long term treatment is cardiac pacing Types: First Degree
Prolonged PR Interval Second Degree
Mobitz type I (Wenckebach) PR interval gets longer then a dropped QRS complex
Mobitz type II PR interval is the same but will then have dropped QRS
Third Degree (complete heart block More P waves than QRS and no relationship between them
AV Block Which One?
AV Block Which One?
AV Block Which One?
AV Block Which One?
Cardiomyopathies 3 types
Dilated Hypertrophic Restrictive
Dilated Cardiomyopathy Most Common (95%) Reduced strength of ventricular contraction Results in Dilated Left Ventricle Presentation is similar to patient in heart failure Causes:
Genetics (around 25%) Idiopathic ETOH abuse Postpartum Chemotherapy, MUGA Endocrinopathies Myocarditis
Dilated Cardiomyopathy Testing:
ECG- maybe nonspecific CXR-cardiomegaly and
pulmonary congestion Echo is great test, also
nuclear stress, cath- will show left ventricular dilation and dysfunction with poor cardiac output
Treatment: Avoid ETOH Supportive treatment of
CHF
Hypertrophic Obstructive Cardiomyopathy Accounts for about 4% of cardiomyopathies Symptoms:
Dyspnea, angina, syncope, asymptomatic PE:
May have a sustained PMI Loud S4 gallop Systolic murmur Bisferiens carotid pulse
Hypertrophy of myocardium, mostly in septum Will have small LV, diastolic dysfunction Almost exclusively Genetic
Hypertrophic Obstructive Cardiomyopathy Presentation:
Think: Young athlete with syncope Sudden Cardiac Death in patients <30
Testing: CXR- usually unremarkable EKG- nonspecific ST changes, septal Q waves, LVH Imaging (Echo, nuclear stress test, MRI, Cath) – LVH, asymmetric
septal hypertrophy, small LV, diastolic dysfunction Treatment:
Intial start on Beta Blocker or calcium channel blockers Ablation of hypertrophic septum may be required **Dual Chamber Pacing, Defibrillator** May require mitral valve replacement
Restrictive Cardiomyopathy Around 1% of cardiomyopathies Fibrosis of ventricular wall Presentation:
Decreased exercise tolerance Right-sided congestive failure Pulmonary HTN is also common
Causes: collagen-defect Most common cause is Amyloidosis, Radiation, diabetes,
Restrictive Cardiomyopathy LV is usually small and firm with reduced function Testing:
CXR- may show mild to moderate enlarge cardiac silhouette
EKG-may show low voltage Echo is the Key to diagnosis Can consider biopsy to
r/o pericarditis
Treatment: Steroids and diuretics
Pericarditis Usually result of infection Can be autoimmune, neoplasm, radiation, chemo toxicity TB is major cause outside of US Presentation:
Pleuritic pain, relieved sitting upright and leaning forward Can have a friction rub
Testing: CBC CXR, Echo to show extent of effucion EKG- Electrical Alternans, may show low voltage Consider PE?
Pericarditis MI? ST segment will be regional, in Percarditis it is global
Pericarditis Treament:
Pericardiocentesis If only inflammatory- steroids and NSAIDS Infectious- ABX Constrictive requires diuresis
Pericardial Effusion Causes:
Pericarditis, uremia, cardiac trauma Pressure on the heart
Presentation: Cough, dyspnea, can have pain or be painfree
Cardiac Tamponade occurs when fluid reduces ability to fill and thus reduces output
Presentation: Tachycardia, tachypnea, narrow pulse pressure, pulsus
paradoxus
Pericardial Effusion
Endocarditis Most common
pathogens: Strep viridans, Staph aureus,and enterococci IV drug users- Staph
aureus, usually involves tricuspid valve
Prosthetic values-Staph, gram negative, or fungus
Usually occurs in first 2 months of surgery
Endocarditis Presentation:
Fever, nonspecific complaints,
90% have a stable murmur Subungal petechiae Splinter Hemorrhages Olser Nodes- painful
rasied lesions on fingers, toes, feet
Janeway Lesions-painless red lesions on palms and soles
Roth Spots- exudative lesions on retina
Endocarditis Testing:
3 sets of blood cultures taken 1 hour apart
Echo is great to identify the valves
Duke Criteria: Must have 2 major, One major and one minor, or Three minor
Major: 2 positive blood cultures Evidence on echo Development of new murmur
Minor: Predisposing Factors Fever >100. Vascular Phenomena (Olser
nodes, Roth Spots, glomerulonephritis)
Positive blood culture not meeting major critera
Treatment: Consider ABX before dental
work Valve replacement may be
needed Anticoagulation if valve
replacement is done IV ABX
Peripheral Arterial Disease Type 1- limited to aorta, common iliac artery Type 2- aorta, common iliac and external iliac Type 3-multilevel extends to femoral, popliteal, tibial
arteries Presentation:
Lower leg pain with exercise Doppler study is helpful Ankle Brachial Index – less than 0.8 significant disease
Peripheral Arterial Disease Treatment:
Reduce risk factors Stop smoking Lipids Clopidogrel, Warfarin Lower extremity revascularization
Deep Vein Thrombosis Virchow’s Triad
Vascular injury Hypercoagulability Venous stasis
Presentation: Single LE swelling, pain,
erythema, Positive Homan’s Sign Doppler study confirms
Treament: Lovenox, Coumadin,
Xeralto Education for PE
Giant Cell Arteritis Systemic inflammatory condition of medium and large vessels >50 More common in patients with polymyalgia rheumatica Involves temporal artery Can cause blindness if not treated Presentation:
Scalp tenderness, HA, visual changes Temporal Artery can be tender or normal
Testing: Elevated Sed Rate and CRP Temporal Biopsy
Treatment: High Dose Prednisone for 1-2 months followed by Taper
Aortic Aneurysms Weakness in vessel that causes dilation Causes:
Atherosclerosis is most common causes Also: congenital, syphilis, giant cell arteritis, vasculitis,
trauma 90% are abdominal Dissection leads to death in 90% of patients Presentation:
Usually asymptomatic Pulsating abd mass
Aortic Aneurysms Dissecting:
Tearing pain that radiates into back Hypotension Tachycardia Unequal pulses Pain out of proportion
Testing: CT or MRI are better than US
Treatment: Surgical Repair 5 year survival rate after repair is 60%
Summary Huge % of Test Need to devote a lot of time on Cardiology Review Know MI EKG locations EKG/CXR will help confirm your answer, not make it
for you Worst Case Scenario’s
ACS, AAA
learnekgs.com frca.co.uk education.science-thi.org med.umich.edu http://www.cdc.gov/heartdisease/coronary_ad.htm