Internal Medicine
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| What is the general definition of pulmonary hypertension? | Presence of abnormally high pulmonary vascular pressure
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| What are the diagnostic criteria of Pulmonary hypertension? | 1) Mean Pulmonary Arterial Pressure of greater than 25 mmHg at rest
2) Normal pulmonary arterial wedge pressure of 15 mmHg or less
3) Pulmonary vascular resistance of greater than 3 Wood units
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| What are the causes of PAH (Pulmonary Arterial Hypertension)? | 1) Idiopathic
2) Hereditary
3) Drug/toxin induced
4) Association with:
a) Connective tissue disease
b) HIV
c) Portal HT
d) Congenital heart disease
e) Schistosomiasis
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| What are the causes of Pulmonary hypertension due to left heart disease? | 1) Left ventricular systolic dysfunction
2) Left ventricular diastolic dysfunction
3) Valvular disease
4) Left heart outflow/inflow obstruction and congenital cardiomyopathies
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| What are the causes of Pulmonary hypertension due to lung diseases? | 1) COPD
2) ILD
3) Mixed restrictive and obstructive pattern
4) Sleep-disordered breathing
5) Alveolar hyperventilation disorders
6) High altitudes
7) Developmental lung diseases
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| What are the causes of Pulmonary hypertension with multifactorial mechanisms? | 1) Hematological disorders
2) Metabolic disorders
3) Systemic disorders
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| What are the main groups of Pulmonary hypertension? | Group 1 – Pulmonary arterial hypertension (PAH)
Group 2 – PH due to left heart disease
Group 3 – PH due to chronic lung disease and/or hypoxemia
Group 4 – Chronic thromboembolic pulmonary hypertension (CTEPH)
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| What is the pathogenesis of Group 1 Pulmonary hypertension? | 1) Pulmonary edema, alveolar hemorrhage, lymphatic dilatation, lymph node enlargement, and inflammatory infiltrates
2) Impaired production of NO and prostacyclin and increased thromboxane A2 and endothelin 1
3) Increased PVR and Right heart failure
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| What is the pathogenesis of persistent pulmonary hypertension in newborns? | 1) Changes in vaso-reactivity and wall structure
2) Decreases in pulmonary vascular density with reduced alveolarisation.
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| What is the pathogenesis of Group 4 Pulmonary hypertension? | Thrombi tightly attached to the medial layer in the elastic PA, replace the normal intima--> occlusion of the lumen or stenosis, webs and bands --> Collateral vessels from the systemic circulation can grow to re-perfuse areas distal to obstructions
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| What are the symptoms of Pulmonary hypertension? | 1) Dyspnea (95%)
2) Weakness/Fatigue
3) Substernal chest pain on exertion, radiating to the left shoulder or axilla, and relieved by rest
4) Syncope
5) Peripheral edema and ascites
6) Hemoptysis
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| What are the physical signs of Pulmonary hypertension? | 1) Cold extremities
2) Diminished peripheal pulse
3) Low BP
4) Prominent jugular venous a wave
5) Rt ventricular lift
6) Cyanosis
7) Split second heart sound with loud P2
8) Systolic ejection click
9) Graham Steel and tricuspid regurg murmur
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| What is class 1 of Pulmonary Hypertension? | Pulmonary hypertension without limitation of physical activity or without symptoms at physical activity
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| What is class 2 of Pulmonary Hypertension? | Pulmonary Hypertension causing slight limitation of physical activity, no symptoms at rest, and symptoms at movement.
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| What is class 3 of Pulmonary Hypertension? | Pulmonary HT causing marked limitation of movement. Comfortable at rest
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| What is class 4 of Pulmonary Hypertension? | Pulmonary HT causing inability to carry out physical activity without symptoms. Signs of HF. Dyspnea and fatigue at rest.
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| What CXR findings can be found in Pulmonary Hypertension? | 1) Decreased peripheral lung vascularity
2) Hilar pulmonary artery prominence
3) Right ventricular enlargement
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| What are the ECG findings in Pulmonary Hypertension? | Right atrial enlargement-->right ventricular hypertrophy and strain --> Right axis deviation
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| What equation is used to determine the likelihood of pulmonary HT? | Right ventricular systolic pressure = [(TR jet)2 × 4] + estimated central venous pressure
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| How is the presence and severity of Pulmonary hypertension determined? | Right heart catheterization
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| What is the supportive treatment of Pulmonary hypertension? | Supervised aerobic and respiratory training
Avoiding activities that cause symptoms
Avoiding high altitudes
Avoid pregnancy and OCPs
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| What is the pharmacological supportive treatment of Pulmonary hypertension? | 1) Anticoagulants: Warfarin and Factor 10a Inhibitors
2) Oxygen therapy
3) Diuretics
4) Calcium channel antagonists
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| What is the targeted treatment of Pulmonary hypertension? | 1) Prostacyclin analogs (Epoprostenol and Iloprost)
2) Phosphodiesterse 5a inhibitors (Sildenafil and Tadalafil)
3) Endothelin receptor antagonists (Bosentan and Ambrisentan)
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| What is the surgical treatment of Pulmonary hypertension? | 1) Balloon-atrial septostomy creating a left-to-right intacardiac shunt
2) Pulmonary Thromboendarterectomy
3) Lung transplantation
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| What is the definition of pneumonia? | An inflammatory process resulting from infection of the lung parenchyma by pathogenic microorganisms and usually associated with radiological evidence on CXR
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| What are the types of pneumonia? | CAP
HAP
VAP
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| What is the pathogenesis of pneumonia? | 1) Aspiration of oropharyngeal or nasopharyngeal secretions
2) This interaction is enhanced by cigarette smoke, infection with respiratory viruses, and particulate air pollutants.
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| What mechanisms do the airways possess to prevent adherence and colonization of bacteria? | 1) Epithelial cells synthesize and secrete peptides (defensins and cathelicidins)
2) Pulmonary surfactant proteins A and C can inhibit bacterial binding to host cells and also promote phagocytosis
3) The presence of complement and immunoglobulins(IgA)
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| What are the risk factors for pneumonia? | Age , smoking , alcohol and comorbidity (resp. and non resp), Geographic factors, seasonal timing, travel history, and occupational exposure
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| What are the clinical manifestations of pneumonia? | 1) Fever
2) Cough
3) Sputum production
4) Dyspnea
5) Pleuritic pain
6) Hemoptysis
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| What are the physical findings in pneumonia? | 1) Consolidation
2) Increased fremitus on affected side
3) Dullness
4) Bronchial breath sounds
5) Bronchophony
6) Crackles
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| What investigations are required to diagnose pneumonia? | 1) CXR
2) CT
3) Labs: CBC, serum glucose, electrolytes, pulse oximetry or ABG ,CRP, PCT
4) Microbiological: sputum culture (40%), blood culture(20%).
5) Invasive: pleural tap, Bronchoscopy
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| What are the main serology markers which could be found in pneumonia? | 1) S. pneumonia urinary antigen
2) Legionella urinary antigen
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| What is the sensitivity and specificity of the S. pneumonia urinary antigen? | Sensitivity is 50% to 80%
Specificity is 90%
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| What is the sensitivity and specificity of the Legionella urinary antigen? | Sensitivity is 60% to 80%
Specificity is greater than 95%
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| What tests are used to asses the severity of pneumonia? | 1) CURB-65
2) PSI
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| What is CURB-65? | Confusion
Urea>7mMol/L
RR>30 breaths/min
SBP <90 or DBP <60
Age greater than 65
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| How is the severity of pneumonia indicated on CURB-65? | 0-1 is non-severe
2 is intermediate
3-5 is severe
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| How is pneumonia treated? | 1) Empirical therapy
2) Narrow spectum antibiotic
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| If an ECG shows a HR of 35 BPM and regular sinus rhythm, what does this indicate? | Sinus Bradycardia
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| What is the definition of sinus bradycardia? | Sinus rhythm with a resting heart rate of less than 60 BPM
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| How is sinus bradycardia diagnosed? | Commonly, an incidental finding in young adults
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| What is the most common physiological cause of sinus bradycardia? | Being an athlete
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| What are the pathological causes of sinus bradycardia? | Inferior wall MI, Toxin exposure, electrolyte disorders, infection, sleep apnea, drugs,hypoglycemia, hypothyroidism, and increased intracranial pressure
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| Which drugs can cause sinus bradycardia? | Digoxin, Beta blockers, CCBs, methyldopa, class I antiarrhythmic agents and amiodarone
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| What are some possible clinical manifestations of sinus bradycardia? | Syncope, dizziness, light headedness, chest pain, and SOB
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| What are some pertinent findings in the history of a patient with sinus bradycardia? | MI, CHF, drug history, toxic exposure, and other previous injury
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| What are the physical findings in sinus bradycardia? | Slow HR with auscultation or palpation of peripheral pulses
May reveal decreased consciousness, cyanosis, peripheral edema, and pulmonary vascular congestion
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| Which toxins can cause sinus bradycardia? | Lithium, paclitaxel, toluene, dimethyl sulfoxide (DMSO), topical ophthalmic acetylcholine, fentanyl, alfentanil, sufentanil, reserpine, and clonidine
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| What are the intrinsic causes of sinus node dysfunction? | Idiopathic degenerative diseases, ischemia, infiltration, inflammation, MSS disorders, SLE, scleroderma, and after ASD repair
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| What lab tests may be important in patients with bradyarrhythmias? | Electrolytes,Glucose, Calcium,Magnesium, Thyroid function tests,and Toxicologic screen
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| How can the diagnosis of bradyarrythmia be confirmed? | 12-lead ECG
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| What is the treatment of symptomatic bradyarrythmia? | Treat underlying cause
Permanent pacemaker
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| What is the pathology of Sick Sinus Syndrome? | Dysfunction in the ability of the sinus node to generate or transmit an action potential to the atria
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| What disorders are associated with Sick Sinus Syndrome? | Cerebral hypoperfusion, sinus bradycardia, sinus arrest, sinoatrial block, carotid hypersensitivity, or alternating episodes of bradycardia and tachycardia
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| What type of patients get Sick Sinus Syndrome? | Elderly patients with concomitant cardiovascular disease
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| What is the usual treatment for Sick Sinus Syndrome? | Permanent Pacemaker
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| What is the typical ECG finding in Type 2 SA block? | Progressive prolongation of the PR interval
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| What are the causes of inflammatory heart disease? | Viral,idiopathic, giant cell, and Eosinophilic myocarditis
Sarcoidosis
Lyme, HIV, and Chaga's disease
Peripartum
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| What are the causes of extramyocardial cardiomyopathy? | HT, CAD, valvular heart disease, and congenital cardiac anomalies
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| What are the inherited causes of secondary cardiomyopathy? | NM disorders, x-linked, mitochondrial, familial dilated cardiomyopathy, and storage diseases
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| What are the types of cardiomyopathy? | Dilated, restrictive, and hypertrophic
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| What are the symptoms of dilated cardiomyopathy? | Left-sided CHF, fatigue, weakness, and emboli
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| What are the physical findings of dilated cardiomyopathy? | Moderate to severe cardiomegaly
S3 and S4
Mitral valve regurgitation
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| What are the chest X-ray findings in dilated cardiomyopathy? | Moderate to marked left ventricular enlargement
Pulmonary HT
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| What are the ECG findings in dilated cardiomyopathy? | Sinus tachycardia
Arrythmia
ST segment and T wave abnormalities
IV conduction defects
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| What are the echo findings in dilated cardiomyopathy? | Left ventricular dilation and dysfunction
Abnormal diastolic mitral valve
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| What are the symptoms of restrictive cardiomyopathy? | Dyspnea and fatigue
Right sided CHF
Signs of storage diseases
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| What are the physical findings in restrictive cardiomyopathy? | Mild to moderate cardiomegaly
S3 or S4
AV valve regurgitation
Kussmaul's respiration
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| What are the chest X-ray findings in restrictive cardiomyopathy? | Mild cardiac enlargement
Pulmonary HT
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| What are the ECG findings in restrictive cardiomyopathy? | Low voltage
Atrioventricular conduction defects
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| What are the echo findings in restrictive cardiomyopathy? | Increased left ventricular wall thickness and mass
Small or normal sized left ventricular cavity
Normal systolic function
Pericardial effusion
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| What are the symptoms of hypertrophic cardiomyopathy? | Dynspnea, angina pectoris, fatigue, syncope, and palpitations
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| What are the classical physical findings in hypertrophic cardiomyopathy? | Apical systolic thrill and heave
Brisk carotid upstroke
Common S4
Systolic murmur that increases with Valsalva maneuver
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| What are the chest X-ray findings in hypertrophic cardiomyopathy? | Mild cardiac enlargement
Left atrial enlargement
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| What are the ECG findings in hypertrophic cardiomyopathy? | LV hypertrophy
ST segment and T wave abnormalities
Abnormal Q waves
Atrial and ventricular arrythmias
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| What are the echo findings in hypertrophic cardiomyopathy? | Asymmetrical septal hypertrophy
Narrow left ventricular outflow tract
Systolic anterior motion of the mitral valve
Small or normal sized left ventricle
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| Causes of DCM: | Idiopathic
Post-partum
Post-chemotherapy (doxorubicin)
Acquired immodeficiency syndrome
Infiltrative diseases (hemochromatosis)
Metabolic (DM,Thyrotoxicosis)
Tachycardia-induced
Alcohol-induced
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| How is DCM caused by hemochromatosis reversed? | By weekly phlebotomy
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| What is the irreversible infiltrative disease which causes DCM? | Amyloidosis
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| What are the prognostic factors of DCM? | NYHA, groups 2-4
LBBB
Hyponatremia
Elevated NE and ANP
Nonsustained VT
Syncope
LVEDP >18-20
CI <2.5 l/min/m2
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| What is the treatment of DCM? | Therapeutic modalities are geared towards treatment of HF / arrhythmias -->Beta adrenergic blockers, Anticoagulants (Afib, CVA, cardiac thrombus),Antiarrhythmics, and Dual chamber / bi-ventricular pacing
Heart surgery / transplantation
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| What are the characteristics of the athletic heart? | Septum<1.5cm
EDD>4.5cm
LA<4cm
Always concentric and regresses after 3 months of stopping
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| What are the subtypes of HCM? | Subaortic
Midventricular
Apical
Diffuse
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| What is the inheritance of HCM? | Familial HCM is inherited in autosomal dominant fashion (at least 50%) and sporadic
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| How does HCM manifest clinically? | Asymptomatic
Angina
Syncope
Dysnpea
Sudden death
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| What is the pathogenesis of HCM? | Dilated atria
Normal-sized ventricles
Variable decrease in systolic dysfunction
Progressively worsening diastolic dysfunction
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| Procedure of choice for diagnosis of RCM? | Echocardiography
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| What is the most common cause of RCM and how is it diagnosed? | Amyloidosis
Granular sparkling texture noted in 47%
Increased thickness of papillary muscles, interatrial septum, valve leaflets, and left-ventricular wall thickness
Valvular regurgitation
Thrombi in the atrial appendages
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