Cardiology
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| Constant, sharp CP worse lying down, better sitting up and leaning forward | Pericarditis
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| Electrical alternans, narrow pulse pressure, pulsus paradoxus = | Pericardial effusion/tamponade
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| JVD, hypotension, muffled heart sounds are sxs of: | Pericardial effusion/tamponade (Beck triad)
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| Pericarditis post open heart surgery | Dressler’s syndrome; tx w/ ASA or colchicine
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| Lateral displaced PMI, Canon “a” waves, Quincke pulse, Corrigan pulse, Austin flint murmur, deMusset sx, water hammer pulse | Aortic Regurgitation/ Insufficiency
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| Peds w/ leg pain after physical activity, abnormal heart sounds, unequal UE & LE pulses, rib notching | Coarctation of aorta
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| Young female (<30yo), palpitations, long arms & fingers, pectus excavatum, ectopic lentis, flexible joints = | Marfan Syndrome: MVP, aortic regurgitation, aortic dissection, aortic root dilatation, ectopic lentis
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| CHD shunts | R to L: cyanotic; L to R: acyanotic (ASD, VSD, PDA)
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| Eisenmenger triad: | Systemic to pulmonary connection, pulmonary vascular dz, hypoxemia
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| Jones criteria are used to diagnose: | rheumatic heart disease (2 major OR 1 major and 2 minor criteria to dx)
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| Types of myocardial dz | Cardiomyopathy; myocarditis
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| 3 types of myocarditis | infectious; toxic; autoimmune/idiopathic
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| 3 types of pericardial dz | Pericarditis; Pericardial effusion / tamponade; Pericardial constriction
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| Quincke pulse = | subungual capillary pulsation (Aortic regurg)
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| Corrigan pulse = | rapid rise and fall (Aortic regurg)
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| Austin Flint murmur = | low pitch mid-diastolic murmur at apex (Aortic regurg)
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| Pericarditis Exam: | Beck triad, fever, friction rub sitting/leaning forward (pain less); pulsus paradoxus
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| Beck triad = | low arterial blood pressure, distended neck veins, and distant, muffled heart sounds.
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| Roth spots = | Small, white, exudative, edematous spots on retina surrounded by hemorrhage
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| Osler nodes = | tender, violaceous subcutaneous nodules on finger/toes fat pads (= immune complex deposition); often SBE
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| Janeway lesions = | painless red macular, blanching lesions on palms & soles (2/2 infected microemboli)
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| Acute bacterial endocarditis: common bugs = | STAPH AUREUS, Strep, H flu, Pneumococcus, N gono, Enterococcus
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| Duke criteria = | 2+ pos BC (drawn 12h apart) or 3 of 4 separate BC; TTE/TEE evidence; RF heart condition or IVDU; T >38C (100.4); vascular sxs; immune sxs; microbiological evidence (not meeting major criteria)
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| Initial Abx tx for infectious endocarditis | PCN & ceftriaxone (vs old tx: nafcillin & gentamicin)
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| Most common cause of LV OT obstruction | Aortic stenosis (pathogenesis assoc with genetics (NOTCH1) and atherosclerosis)
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| Aortic stenosis 2 types | Subvalvular (d/t: thin membrane (most common), thick fibromx ridge, diffuse tunnel-like obstruction, HCM); Supravalvular (hourglass deformity (60-75%) or more diffuse narrowing along ascending aorta)
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| Aortic stenosis Etiology | US: lipid accumulation, inflammation, CALCIFICATION ; Elsewhere: rheumatic valve dz (fusion of the commissures between the leaflets, with a small central orifice)
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| Aortic stenosis Sx/Sx: triad w/exertion: | HF, syncope, angina; Other: DOE (diastolic ventric dysfn); A-fib, V-arrhythmia, IE, Pulsus parvus et tardus
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| Aortic stenosis: echo | valve opening <3cm2; antegrade velocity across valve >2.6m/sec; progressive concentric hypertrophy
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| Aortic stenosis Tx | prevention of dz progression (statin, ?ACEI, HTN tx, IE Ppx); valve replacement (esp concurrently w/CABG); Survival = 2-3 yrs w/o valve replacement; balloon valvuloplasty
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| Mitral stenosis Pathophysiology | symmetric oval orifice & doming of the leaflets in diastole (2/2 fusion of leaflet tips); leaflet thickening / calcification 2/2 chronic turbulent flow thru deformed valve -> leaflet fusion & thickening -> obstructed LA-to-LV blood flow
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| Mitral stenosis Sx/Sx | A-fib (in 80%); pulmo HTN; dyspnea, hemoptysis, orthopnea, PND, CP, VTE, IE, right HF, hoarse; Graham Steell murmur
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| Mitral stenosis EKG | P-mitrale: broad notched P wave
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| Mitral stenosis Tx | exercise; loop diuretic if pulmo art congestion; digoxin, beta; VTE ppx, IE ppx
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| Mitral Regurgitation Pathophysiology | increases preload but reduces afterload
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| Mitral regurgitation Sx/Sx | Asx for yrs; poss left HF; exercise intolerance, dyspnea
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| Mitral regurgitation Tx | serial monitoring; tx A-fib or LA enlargement (poss vasodilators); surg if LV EF<60% or echo LV end sys diameter >4cm
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| Bacterial endocarditis pathophysiology | SA, Viridans strep & Strep bovis; Enterococci; HACEK group; Rheumatic; bicuspid valve
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| Bacterial endocarditis general Sx/Sx | Fever; regurgitant murmurs/sx of HF; small and large emboli in fundi, conjunctivae, skin, digits: petechiae, splinter hemorrhages (nonblanching, linear reddish-brown lesions found under the nail bed)
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| Bacterial endocarditis Sx/Sx (SA) | SA: more rapidly progressive & destructive infxn (acute febrile illness, early embolization, valvular regurg, myocardial abscess).
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| Bacterial endocarditis Dx studies | 3 sets blood cx; CXR, EKG; TTE & TEE: evidence of vegetation; high ESR/CRP, normo/normo anemia
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| Bacterial endocarditis Tx | Vanc 1 gm q12h IV + ceftriaxone 2gm q24h (vs staph/strep/enterococci); or Unasyn plus aminoglycoside
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| Acute rheumatic fever pathophysiology | Post-GABHS infxn; strep strains with M protein (shares epitope w/myosin, thus may cause anti-myosin Ab rxn -> fibroblasts/macrophages); perivascular granulomatous rxn w/vasculitis
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| rheumatic fever sequelae include: | arthritis, carditis (pericarditis, cardiomeg, CHF), chorea, subcutaneous nodules, erythema marginatum; abd pain, facial tics, epistaxis
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| rheumatic fever DDx | RA, osteomyelitis, IE, chronic meningococcemia, SLE, Lyme, SCD
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| Jones criteria: major criteria = | Carditis (pericarditis, cardiomegaly, CHF), erythema marginatum, sydenham chorea (late finding; face, tongue, UE), polyarthritis, subcutaneous nodules
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| rheumatic fever: non-Jones | high ASO & anti-DNAse B to dx recent infxn
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| rheumatic fever Tx | bedrest, salicylates, PCN, csteroids for joint sxs
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| Aortic regurgitation Sx/Sx | Asx for decades; wide pulse pressure; S3; water hammer pulse, Corrigan pulse (pulse collapse in carotid);
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| Aortic regurgitation Signs: | deMusset' (head bob), Duroziez (bruit when femoral art is partially compressed), Quincke (capillary pulsations in fingertips); apical impulse laterally displaced
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| Aortic regurgitation Tx | serial monitoring; ACEI, CCB; surgery/valve replacement if EF <55%
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| Acute Pericarditis symptoms: | sharp stabbing precordial or retrosternal CP; may radiate to back (L trapezial ridge), neck, shoulder, arm; worse with inspiration
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| Pericarditis pain is most severe when: | pt is supine; relieved when pt leans forward while sitting
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| Acute Pericarditis exam: | most common/important: pericardial friction rub (best heard at LLSB or apex when pt sitting forward)
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| Acute Pericarditis: viral causes: | COXSACKIE B, echo, Flu A/B, adeno, MMRV, EBV, HSV1, Enterovirus, parainfluenza 2, RSV, HIV
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| Acute Pericarditis: bacterial causes: | STREP PNEUMO; Staph / Strep, GNR: Proteus, E coli, Pseudo, Klebs, Sal/Shigella, N meningitidis, H flu. Less common: Legionella, Nocardia, tickborne, Myco, TB
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| Best test for pericarditis / pericardial effusion = | TTE / TEE
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| Acute pericarditis tx: | Firstline: NSAIDs (indomethacin / Aspirin) UNLESS 2/2 bacterial (then ABX is firstline); secondline: steroids
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| Myocarditis: relation to viral syndromes | >50% of pts have antecedent viral syndrome; cardiac-specific sxs appear in subacute virus-clearing phase (2 wks after acute viremia).
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| Myocarditis: sx/sx | Fever in 20% of patients; 35% have CP (pleuritic, sharp, stabbing precordial). DOE, palps, tachypnea, tachycardia out of proportion to fever
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| Severe myocarditis: sx/sx | Sxs of LV failure: JVD, bibasilar crackles, ascites, peripheral edema
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| Most common infectious cause of myocarditis; | Viral acute
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| More than half of myocarditis cases due to: | Coxsackie-adenovirus: CA receptor protein is target of coxsackievirus B (Enterovirus) and adnovirus serotypes 2 & 5
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| Most common drug hypersensitivity reactions causing acute myocarditis: | PCN, ampicillin, HCTZ, methyldopa, sulfonamides.
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| Medications causing acute myocarditis include: | lithium, cocaine, numerous catecholamines, APAP, zidovudine (AZT), doxorubicin
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| Autoimmune causes of acute myocarditis: | SLE, RA, Kawasaki, sarcoid, giant cell arteritis
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| Acute myocarditis tx: | Diuresis (furosemide); ACEI
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| Mitral stenosis: most common cause = | rheumatic heart disease (sxs follow latency period of 20-40 years after initial rheumatic fever episode)
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| Rheumatic heart disease: causes damage to which valves? | 1. mitral valve; 2. aortic valve; 3. tricuspid
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| Rheumatic heart disease: peak incidence: | 5-15 y.o.
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| Jones criteria: minor criteria = | Fever >101, polyarthralgia, long PR interval, high ESR / CRP, high WBC, +ASO titer, A-fib
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| Angina pectoris: how common in severe aortic stenosis? | 30-40% [old: 50-70%]
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| Aortic regurgitation exam: | Wide pulse pressure (inc SBP & dec DBP); Korotkoff sounds to zero; Traube sign (pistol shot sounds over femoral artery)
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| Mitral regurgitation dx studies | TTE, ECG (L atrial enlargement, AF), CXR (LA / LV enlargement & inc pulmo markings)
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| Stages of mitral regurgitation: | compensated, transitional, decompensated (EF decreases)
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| Mitral regurgitation etiology | MVP (most common: 45%); rheumatic fever; IE; trauma / chordae tendinae rupture; mitral annulus calcification, CHD/Marfan, DCM
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| MVP can lead to: | flail MV regurg
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| Bulging / billowing MV leaflets into LA during systole, +/- mitral regurgitation = | MVP
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| MVP etiology | Primary: genetic (AD); Marfan; connective tissue dz (Ehlers-Danlos); Graves dz. Secondary: to CAD, rheumatic HD, or CM
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| MVP exam | Hypotension/orthostasis, dizziness, palpitations; anxiety/panic. Seen w/scoliosis, pectus excavatum, military spine
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| Narrowing of pulmonic valve -> RVOT obstruction and right sided HF = | pulmonic stenosis
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| Pulmonic stenosis etiology: | Usually congenital & dz of the young; rheumatic HD, carcinoid; severe dz presents as HF in neonates; also Rubella embryopathy
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| Pulmonic stenosis exam: | RV heave at epigastrium; thrill w/loud murmur (IV/VI); pulmonic ejection sound; wide split S2 w/soft delayed P2; S4; JVD; ascites/HJR in Rt HF
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| Pulmonic regurgitation etiology: | pHTN from left VHD or pulmo dz; congenital; Fallot tet surgery complication; IE
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| Pulmonic regurgitation sx/sx: | usually asx. Possible exercise tolerance
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| Tricuspid stenosis etiology: | Rheumatic fever (most common), often with mitral & aortic lesions; RA myxoma; carcinoid; endomyocardial fibroelastosis; IE (bacterial)
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| Endomyocardial fibroelastosis is associated with what valvular disorder? | Tricuspid stenosis
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| Tricuspid stenosis mgmt: | Na restriction, diuretics, valvotomy, CT surg if severe progressive disease
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| Tricuspid regurgitation pathophysiology: | Dilatation of annulus 2/2 functional RV dilation; TVP; chronic RV volume overload -> right CHF
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| Pulsation or fluttering sensation in neck can be due to: | Tricuspid stenosis or regurgitation
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| Tricuspid regurgitation exam: | abd bloating/pain; right HF; parasternal lift; RV S3; AF rhythm; JVD/pulsatile; palpable pulsating liver; HJR/ascites; edema
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| SBE bugs = | Strep viridans and S bovis (most common), Enterococcus, SA, HACEK
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| IE NOT related to IVDU most often involves which valve: | mitral / aorta
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| IE bugs (in IVDU): | Staph aureus (SBE bug); Staph epi, Candida, Aspergillus, Strep viridans, Enterococcus
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| Early vs late prosthetic valve endocarditis = | before vs after 60 days post-implantation
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| IE risk factors: | Prosthetic valves & other devices; congenital anomalies; prior IE; rheumatic heart dz; valvular dz; HCM; dental/surg; IVDU
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| Fever in IE | ABE: 102-105; SBE: 99-100
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| IE exam: | Triad (fever, murmur, pos blood cx), conjunctival hemorrhage, petechiae, splinter hemorrhage, Janeway, Roth, Osler, friction rub, JVD, rales, gallups, cold extremity & focal neuro sxs if septic emboli
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| Duke criteria: vascular sxs = | major arterial emboli, septic pulmo infarcts, mycotic aneurysm, ICH, conjunctival hemorrhage, Janeway
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| Duke criteria: immunologic sxs = | Glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor
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| IE lab studies | BC, high WBC, ESR / CRP, micro hematuria, anemia (SBE), positive RF (SBE), immune complexes (dec C3 & C4)
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| IE on CXR: | infiltrates, pleural effusion
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| IE mgmt | Abx x4-6 weeks: Pen G for S viridans, others guided by C&S; valve surg if severe; PPx
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| Dental procedure prophylaxis for IE is indicated for patients with: | prosthetic cardiac valves, prior IE, transplant pt who develops VHD; CHD
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| Pre-procedure prophylaxis: which Abx in which procedures? | For dental, oral, respiratory tract, infected soft tissue, & esophageal procedures: 2gm amoxicillin 1 hr prior and 1gm 2hrs after (Alt: ampicillin, clinda, CTX)
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| Most common acquired valve stenosis = | aortic stenosis
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| In patient with hemodynamic sensitivity & syncope with nitrates, consider: | aortic stenosis
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| Aortic regurgitation etiology: | 80% idiopathic; HTN; rheumatic fever; IE; SLE; RA / ankylosing spondylosis; Marfan. ?SSRIs?
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| Most common valvular lesion: | 1) aortic stenosis; 2) mitral regurgitation
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| Type of CAD/ACS most often associated with mitral regurgitation: | inferior MI
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| MVP mgmt | Beta blocker (eg, atenolol); consider dental prophylaxis
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| Tricuspid regurgitation etiology: | pulmonary HTN (2/2 COPD); rheumatic fever; CHD; myxoma; carcinoid; SBE (esp in IVDU); Phen-fen; Ebstein is most common congenital form
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| Most accurate dx test for mitral stenosis = | left heart catheterization
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| Test of choice for mitral stenosis = | TEE
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| Most diagnostic finding for pericarditis | ST elevation in all leads
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| In infective endocarditis, IVDU most commonly affects which valve? | Tricuspid
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| Patients with this condition may have higher incidence of NTG-induced syncope | Aortic stenosis
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| Most common cause of valve replacement in US | chronic rheumatic heart disease (usually mitral valve)
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| Non-IVDU SBE/ABE bug | Strep viridans
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| If endocarditis in prosthetic valve: | May add rifampin (to vanc/gent/cefepime or carbapenem); usually added after BCx have cleared
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Created by:
Abarnard
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