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USMLE2 Medicine 08

Cardiology 2

QuestionAnswer
S3 (sounds, reason for sound, where to listen best) SLOSH(S1) ing(S2) in(S3), large volume filling ventricle, use bell at apex
S4 (sounds, reason for sound, where to listen best) a(S4) STIFF(S1) wall(S2), atrial contraction against a stiff/hypertrophied ventricle, use bell at apex.
heart failure inability of ventricle to efficiently pump blood throughout circulation
systolic dysfunction means what? reduced ejection fraction. loss of contractile strength --> ventricular dilation --> decrease in ventricular emptying --> reduced EF
diastolic dysfunction means what? impaired ventricular filling (nl EF).
examples of systolic heart failure ischemic cardiomyopathy, dilated cardiomyopathy
examples of diastolic heart failure infiltrative cardiomyopathies (amyloidosis)
congestive HF SOB, fatigue, inc LV diastolic P --> inc pulmonary venous P --> transudate from pulm capillaries into interstitium --> circulatory congestion (pulmonary edema, peripheral edema, elevated JVP)
Sx's of heart failure SOB, Orthopnea, Parosyxmal nocturnal dyspnea, Fatigue/weakness
Sx's and PE of heart failure SF POW, RJ HEAP, has heart failure. Sx - SOB, Fatigue, Parosyxmal nocturnal dyspnea, Orthopnea (SOB when lying flat, requires pillows), Weakness; PE – Rales, JVD elevated, Hepatomegaly, Edema, Ascites, PMI displaced → enlarged heart (systolic HF).
Class I heart failure no limitation of activities, no sx's with ordinary activities
Class II heart failure slight, mild limitation of activity; comfortable at rest and with mild exertion
Class III heart failure market limitation of activity; comfortable ONLY at rest
Class IV heart failure confined to bed/chair; any physical activity brings on discomfort, sx's at rest
What can you determine on cardiac echo? EF, valvular heart disease, dilation, thickening, systolic vs diastolic dysfunction
BNP brain natriuretic peptide. secreted by cardiac myocytes when stretched. 97% sensitivity in HF pts
Non-pharmacologic tx for HF decreased salt in diet
Benefits of ACEi for HF pts Improve survival, reduce ventricular hypertrophy and sx’s. (vasodilation → dec preload and afterload → dec RA and Pulm P)
which is the best ACEi for HF? they are all equal
Meds for HF - no renal disease Heart Failure: Shit - FML. 1. Spironolactone (if HF class 3-4), 2. Furosemide, 3. Metop or carvedilol (dec mortality), 4. Lisinopril
Meds for HF - have renal disease Heart Failure with renal probs even worse! F*** HIM! 1. Furosemide, 2. Hydralazine, 3. Isosorbide, 4. Metop or carvedilol
What must you monitor when pt on Spironolactone? K levels
Hyperkalemia increases or decreases digitalis activity? K and digitalis compete for the same binding site, so hyperK decreases digitalis activity, while hyPOK increases toxicity.
Effect of digitalis on heart increases force and velocity of myocardial contraction, promotes increased EF (more complete emptying)
What do you use dig for? (3) CHF, afib, paroxysmal tachycardia
Conditions that predispose to dig toxicity REACT By Dig. 1. Renal insufficiency, 2. Electrolytes (hypoK, hypoMg, hyperCa), 3. Age (elderly), 4. COPD (hypoxia), 5. hypoThyroid, 6. Block (SA and AV heart block), 7. Drugs (Increases dig toxicity: QRST Quinidine veRapamil Spirono Thiazides (furosem)
How do you reverse Dig toxicity? 1. stop drug, 2. give K, 3. Lidocaine and phenytoin, 4. if acute OD use Digibind
How to treat acute severe HF? What must you monitor? Dopamine and amrinone (PDEi) --> both increase inotropy. Monitor BP and have pt on telemetry.
If meds fail to manage HF, then what? biventricular pacing, defibrillator, heart transplant
cough productive of pink frothy sputum Pulmonary Edema
Kerley B lines pulmonary edema --> suggest CHF
How to tx pulmonary edema? FUNMODA! 1. Furosemide, 2. Upright, 3. NTG, 4. O2, 5. Dig (if afib), 6. ACEi
Rheumatic fever causes what valve pathology? mitral stenosis
double density R heart border mitral stenosis
Rheumatic fever - what valve pathology most common in men, what most common in women? men - mitral insufficiency, women - mitral stenosis
How to tx mitral stenosis? 1. diuretics and salt restriction for the pulmonary edema, 2. if pt had afib, then Digitalis and anticoagulants
when to surgically tx mitral stenosis when sx's despite medical management AND functional HF class III
click murmur syndrome mitral insufficiency
barlow syndrome symptomatic mitral valve prolapse
barlow syndrome symptomatic mitral valve prolapse
holosystolic apical murmur radiating to axilla mitral insuff
how to tx mitral insufficiency relieve sx's by increasing forward CO and reducing pulm HTN: digitalis, diuretics, ACEi, anticogulants (warfarin). WADD
mid to late systolic click, late systolic murmur at apex MVP
Murmur that improves with squatting and worsens with Valsalva team's MVP feels better when squatting in front of goal and worse when he strains to poop in front of the goal (Valsalva).
Tx for MVP only when sx's: endocarditis prophy, Bblocker for CP, antiarrhythmics for arrhythmias
pulsus tardus et parvus Aortic stenosis
harsh SEM that radiates to carotids Aortic stenosis
When to surgically manage aortic stenosis? valva area reduced to below 0.8cm area or when pt becomes sx-matic
what is surgical tx for aortic stenosis? valve replacement. if too ill for surgery --> balloon valvuloplasty
brisk bifid carotid upstrokes HOCM
SEM that does not radiate to carotids HOCM
large septal Q waves on EKG V1-3, pseudo infarct pattern, LVH HOCM
SEM that is louder with Valsalva and softer with squatting (2 conditions) HOCM and MVP
SEM that gets softer with leg raise HOCM
duroziez sign heart trill or murmur heard over the femoral arteries --> aortic insufficiency
deep Q waves in L precordial leads LVH --> can be aortic stenosis
is endocarditis prophylaxis recommended in aortic insufficiency? in MVP? no in AI, in MVP only in severe cases
stroke volume increases - what kind of cardiomyopathy? hypertrophic
EF increases - what kind of cardiomyopathy? hypertrophic
is HOCM genetic? if so, what inheritance pattern? what chromosome? yes, autosomal dominant, chromosome 14
what is hallmark of HOCM? unexplained myocardial hypertrophy with thickening of the interventricular septum
what is most common cause for heart transplants? dilated/congestive cardiomyopathy
In HOCM, do these things make the murmur better or worse: increased contractility, increased preload, increased afterload increased contractility - worse. increased preload - better. increased afterload (squatting, handgrip) - better.
murmur that improves with handgripping HOCM
what drugs should you NOT give to HOCM pts? increase in contractility (digitalis, isoproterenol)
are B blockers recommended for HOCM pts? yes because slows HR and increases preload
large jugular A wave, S4, adn bifid carotid pulse HOCM
Tx for HOCM B-blockers, CCB, surgery
square root sign on cardiac cath (2) restrictive cardiomyopathy, constrictive pericarditis
M-shaped atrial waveform on cardiac cath restrictive cardiomyopathy
tx for restrictive cardiomyopathy no tx; consider heart transplantation
what is the heart condition that is best heard with pt sitting leaning forward at forced end expiration pericarditis
diffuse ST segment elevation on EKG acute pericarditis
serosanguinous pericardial fluid (2) classic of TB or neoplastic diseases
water bottle config on CXR pericarditis
electrical alternans on EKG pericardial effusion
pulsus paradoxus and equal P in LA and RA cardiac tamponade
Tx for cardiac tamponade pericardiocentesis or subxiphoid surgical drainage
Kussmaul sign JVD that increases with inspiration - abnormal RH filling
pericardial knock constrictive pericarditis
on cardiac cath: markes Y descent in RA P tracing constrictive pericarditis
on cardiac cath: equalization of end-diastolic P in all 4 heart chambers and pulm artery constrictive pericarditis
diagnostic procedure of choice for constrictive pericarditis CT (not echo)
Tx of constrictive pericarditis Na restriction and diuretics, pericardiectomy
valsalva causes what? sinus bradycardia and decreased venous return
Tx of sinus brady Atropine, then pacemaker if refractory
Difference in response to atropine in Mobitz type I and II Mobitz Type I (Wenckebach) - PR interval shortens and AV conduction increased. Type II - no effect from atropine
Most common cause of 3rd degree AV block complete AV dissociation, Lenegre disease - simple fibrous degenerative changes in conduction system that is a result of aging
Adams Stokes attacks asystole/heart block/vfib --> dec blood to brain --> sudden syncope +/- sz's
DOC to tx superventricular tachycardias IV verapamil or adenosine
carotid massage to tx what? AV node massage --> inc vagal tone --> break AV node re-entry tachycardia
who is most likely to get multifocal atrial tachycardia chronic lung disease or elderly
Tx for aflutter if hemodynamically unstable, cardiversion. Then digitalis, CCB (verapamil/diltiazem), and Bblockers. BCD
Drugs to phamacologically convert afib amiodarone, flecainide, ibutilide
Drugs to maintain sinus rhythm in pts with afib amiodarone, flecainide
what is one of the first steps in tx afib? what drugs? rate control <100bpm. BCD again. Bblocker (metop/atenolol), CCB (ver/diltia), Dig (if systolic HF)
contraindications to the use of warfarin TCP, surgery or trauma, EtOH
Drug to tx WPW if pt is hemodynamically stable procainamide
What drugs to avoid in pt with WPW anything that will block or slow the AV node, which will shift conduction to accessory pathway: dig, betablockers, CCB
what is definitive tx for WPW? ablation
intermittent cannon waves in JVP simultaneous contraction of atria and ventricles in Vtach
Wide complex tachycardias with regular rhythms (3) VW's: VT, SVT (with aberration), WPW
Narrow complex tachycardias with regular rhythm (3) SAP: Sinus Tach, PSVT, Aflutter
Narrow complex tachycardias with irregular rhythm (2) MA: Afib, MAT
What is the progression of meds to give to a stable pt in v-tach? What to do if pt is unstable? O2, IV, Amiodarone, Lidocaine, Procainamide. Cardiovert if unstable.
what electrolytes prolong QT? hypo K and hypo Mg
Anti-arrhythmic drugs that can prolong QT quinidine, procainamide, or disopyramide. Also, TCA's and Li
If tosades caused by an anti-arrhythmic drug, switch to lidocaine or phenytoin, neither of which prolongs ventricular repol
Three drugs used in ACLS VFib algorithm epi, amiodarone, lidocaine
Three drugs used in ACLS PEA algorithm Epi, vasopressin, atropine if epi and vasopressin don't work
antiarrhythmic drug that causes blue gray "smurf" skin Amiodarone
antiarrhythmic drug that causes corneal deposits Amiodarone if taken for 6 months
anacrotic pulse pulsus tardus et parvus, aortic insufficiency
water hammer pulse aortic insuff, AV fistula, and PDA
pulsus paradoxus COPD, asthma, pericardial constriction
pulsus alternans pericardial effusion, severe LV failure
majority of thrombi in afib arises from where? L atrial appendage
widened pulse pressure and thyroid issues hyperthyroidism
drug to get rid of torsades give MgSO4
Tx of Vtach amiodarone or lidocaine
best test to dx arrhythmogenic RV dysplasia MRI will show infiltration, wall thinning, and abnl contraction pattern
most likely finding on echo of pt with long h/o EtOH abuse dilated cardiomyopathy
most common etiology of narrow complex tachycardia referred for EP studies in adults AVNRT
most common etiology of narrow complex tachycardia referred for EP studies in children AVRT
what heart problems in Lyme disease? conduction problems and myocarditis
OSA causes.... hypoxia and hypercapnea --> pulm HTN, widened A-a gradient
most common cardiovascular complication of rheumatoid arthritis pericarditis
T or F: for tx of stable angina, PTCA and medical management have same effectiveness for death and infarction outcome TRUE
what tx is contraindicated in aortic dissection? intra-aortic balloon pump, which will inflate in diastole
pre-operative management of aortic dissection inotropic agents and vasodilators until surg can be done
most common cause of unexpected death in Asian Americans Brugada syndrome
RBBB, STE in V1-V2 Brudgada
how to elicit Brugada EKG characteristics? flecainide or procainamide
how to tx Brugada AICD
what do people with Brugada die of? polymorphic vtach
Jervell and Lange-Nielsen syndrome long QT syndrome, autosomal recessive, associated with hearing loss
Romano-Ward syndrome long QT syndrome, autosomal dominant, most common form of inherited long QT syndrome
definitive tx for Romano Ward Syndrome surgical ganglionectomy
Lown-Ganong-Levine syndrome (LGL) type of AVRT, pts w accessory pathway that connects the atria directly to the bundle of His
short PR, nl QRS, no delta wave Lown-Ganong-Levine syndrome (LGL)
Class I anti-arrhythmics Na channel blockers.
Class Ia anti-arrhythmics, mechanism and examples fastNa channel blockers (AP leangthened, leans rt). Quinidine, Procainamide
Class Ib anti-arrhythmics, mechanism and examples Na channel blockers – shortens AP (shorter plateau). Lidocaine, Phenytoin
Class Ic anti-arrythmics, mechanism and examples Na channel blockers – leans R, also shorter plateau, AP overall same. Flecainide and Propafenone
Class II anti-arrhythmics, mechanism and examples Bblockers. Metop, Atenolol
Class III anti-arrhythmics, mechanism and examples K-blockers→prolong repolarization. Amiodarone, ibutilide
Class IV anti-arrhythmics, mechanism, and examples CCB – decrease AV nodal conduction. Verapamil and diltiazem
Tx of tosades after MgSO4 Bblocker
what classes of drugs to avoid in torsades Ic, and III because all prolong the QT (flecainide, amiodarone and ibutilide)
Quincke pulse alternate blanching and flushing of the nail bed due to pulsation of subpapillary arteriolar and venous plexuses; seen in aortic insufficiency and other conditions and occasionally in normal persons.
Osborne wave on EKG camel-hump sign, late delta wave, hathook jxn, hypothermic wave, prominent J wave. people suffering from HYPOTHERMIA with a temperature of less than 32 C, hypercalcemia, brain injury, vasospastic angina, or ventricular fibrillation
peripartum cardiomyopathy dilated cardiomyopathy
what meds to use in flash pulm edema? what meds are contraindicated Nitroprusside, labetalol/esmolol, No nifedipine because unpredictable rapid drop in BP --> strokes. Also and clonidine.
two cardiovascular conditions associated with hoarseness mitral stenosis, aortic aneurysm
trepopnea positional dyspnea in latera decub position; can be caused by atrial myxoma, intracardiac thrombus
bisferiens pulse two peaks per cardiac cycle - HOCM, aortic insuff, PDA, fever, exercise
tx for papillary muscle rupture afterload reduction: first with nitroprusside, then with intra-aortic balloon pump
tx for RV infarction (inferior MI) give IV fluids and do what you can to increase preload, including stopping all vasodilators and starting vasopressor or inotropic support, intra-aortic balloon pump would be helpful
EKG ST depression in V1-V3 posterior STEMI - should go to cath lab!
calculate MAP [(SBP+2DBP)/3]
EKG findings in acute PE due to (S1Q3T3) due to RV strain
what is intra-aortic balloon pump used for? augment therapy after CT surg, bridge to transplant, pain control in unstable angina, tx refractory arrhythmias
vsd murmur, asd murmur vsd systolic murmur, asd no murmur
in pts with mod/severe mitral regurg, what is most likely cardiac rhythm disturbance? afib
in pts with mild mitral regurg, what is most likely cardiac rhythm disturbance? premature atrial contractions
Created by: christinapham