How do you make diagnosis of prinzmetal's angina?
cardiac catheterization: shows no atherosclerosis, but ergonovine can precipitate spasm
Treatment for prinzmetal's angina?
calcium channel blockers and nitrates
Name 5 precipitating factors for acute coronary syndrome:
1) physical exertion; 2) emotional/ mental stress; 3) anxiety; 4) cold exposure; 5) post large meal
Typical duration of angina sxs:
more than 15 seconds, less than 15 minutes
Three findings on physical exam in pt with angina:
1) diaphoresis; 2) tachycardia; 3) transient S4
How can u differentiate pericarditis from angina from the history?
pericarditis pain is sharper, worse with lying down, relieved with sitting up
Name 5 sxs of PE:
1) tachypnea; 2) dyspnea; 3) cough; 4) pleuritic chest pain; 5) hemoptysis
3 ways to confirm diagnosis of aortic dissection:
1) CT, 2) TEE, 3) aortography
3 ways to confirm diagnosis of esophageal reflux or spasm mimicking angina:
1) upper GI series; 2) endoscopy; 3) esophageal manometry
How do you confirm diagnosis of pneumothorax?
Definition of stable angina:
occurs during exertion; same amt of exercise reproduces pain; relieved by rest
Definition of unstable angina:
new onset CP; worsening pattern in frequency, duration or inte
Work up for angina:
1) ECG; 2) stress test; 3) cardiac catheterization
Name 3 indications for exercise stress test:
1) to confirm diagnosis of angina; 2) to determine severity of dz; 3) post MI evaluation
Contraindications to stress testing:
1) unstable angina; 2) aortic stenosis; 3) IHSS; 4) severe COPD; 5) acute CHF; 6) acute ischemia on ECG; 7) aortic dissection; 8) severe uncontrolled HTN
Name 3 indications for cardiac catheterization in pt with angina:
1) sxs poorly controlled with rx; 2) + stress test --> determine need for revascularization; 3) determine presence of main criteria for bypass sx
What are the 2 main criteria for bypass?
1) three vessel disease; 2) left main dz
JNC7 guidelines for controlling BP in pts with and without DM
without DM = <140/90; with DM = <130/80
JNC7 guidelines for controlling total cholesterol and LDL in pt with very high cardiac risk profile
T.chol <190; LDL <70
JNC7 guidelines for LDL in pts with CAD or equivalent
Effect of nitrates in low doses
increase venous dilatation --> decrease preload
Effect of nitrates in moderate doses
increase venous and arterial dilatation --> decrease both preload and afterload
Effect of nitrates in high doses
increase coronary artery dilatation --> increase O2 supply
3 Effects of beta blockers that make them useful in treating angina
decrease 1) HR, 2) BP; 3) contractility --> decrease O2 demand of heart
Contraindication of BBs
severe asthma (BBs cause bronchoconstriction)
Name 6 treatment options for angina
1) nitrates; 2) BBs; 3) lipid lowering agents (i.e. statins); 4) antiplatelet agents (aspirin +/- plavix); 5) CCBs (only for prinzmetal's); 6) revascularization
In a pt with one or no risk factors, at what LDL level do u institute dietary modification? medication?
LDL >130; LDL >160
In a pt with more than one risk factor, at what LDL level do u institute dietary modification? medication?
LDL >160; LDL >190
Which pts s/p acute MI will continue to receive statin therapy?
those with LDL >70
Name 4 equivalents of CAD
1) DM; 2) PVD; 3) carotid dz; 4) aortic dz
Who has very high cardiac risk?
1) ACS; 2) CAD + DM or smoker
3 questions to ask to determine whether chest pain is typical, atypical or nonanginal:
1) is the pain retrosternal? 2) is the pain brought on by stress? 3) is the pain relieved with rest or NTG?
5 general causes of non-atherosclerotic MI
1) vasculitis; 2) congenital anomaly of coronaries; 3) coronary spas (i.e. cocaine); 4) coronary artery embolus (i.e. atrial thrombus); 5) hypercoagulable states
Which cardiac region is most susceptible to ischemia?
left ventricular subendocardium
Duration of chest pain in acute MI:
usu longer than 20 minutes
Name 4 factors that would make ECG interpretation of MI difficult:
1) LBBB; 2) previous MI; 3) pacemaker; 4) digoxin use
For how long do troponins remain elevated after acute MI?
Which vessel supplies the inferior wall of the left ventricle?
PDA of the RCA
Which vessel supplies the lateral wall of the left ventricle?
left circumflex a
Sign of posterior infarction on initial 12-lead ECG
in leads V1-V2: 1) tall, broad R waves; 2) ST depression; 3) tall peaked T wave
Posterior MIs generally occur in association with what other MI?
lateral or inferior
Indications for thrombolytic therapy for acute MI
within 12 hrs of onset of chest pain plus one of following ECG findings: 1) >1mm ST elevation in 2 contiguous leads; 2) new LBBB
Name 2 complications of thrombolysis:
1) bleeding; 2) reperfusion arrhythmias
Contraindications to thrombolytic therapy:
1) dissecting AA; 2) uncontrolled HTN (>180/110); 3) active PUD; 4) recent head trauma; 5) recent invasive procedure or sx; 6) previous CVA; 7) traumatic CPR; 8) proliferative diabetic retinopathy; 9) active internal bleeding; 10) intracranial malignancies; 11) recent IV puncture at noncompressible site
Contraindications to BB in acute MI
1) bradycardia; 2) AV block; 3) hypotension; 4) COPD
What BB do you give in acute MI?
metoprolol IV q5min
Maximum benefit of ACEI have been shown in what 3 clinical situations?
1) CHF; 2) LV dysfunction (EF <40%); 3) anterior wall MI
Indications for temporary transvenous pacing in acute MI:
1) 2nd degree heart block, type II or greater; 2) sinus bradycardia despite atropine; 3) junctional or idioventricular rhythm w/ slow ventricular rate and hypoperfusion; 4) LBBB in acute MI; 5) bifascicular block with 1st degree AV block; 6) new bifascicular block
RV infarct associated with what other MI
Treatment for right ventricular infarction
Indications for IABP
1) recurrent or persistent MI; 2) severe left or biventricular failure +/- shock
Indications for ACEI post-MI
pts with low EF or LV dysfunction
Most common cause of CHF
MI or ischemia
Precipitating causes of CHF
1) increased salt intake; 2) inappropriate reduction in drug regimen; 3) excess exertion or stress; 4) arrhythmias; 5) systemic infection; 6) cardiac depressants; 7) fluid overload; 8) renal failure; 9) MI
3 tests used to make diagnosis of CHF
1) CXR; 2) echo; 3) MUGA scan or radionuclide ventriculography
3 main therapeutic objectives in management of CHF:
1) reduce cardiac workload; 2) improve cardiac performance; 3) control excess salt and water
Mechanism of action of digoxin
inhibition of Na/K ATPase --> --> increase intracellular Ca --> inotropic effect
3 indications for digoxin
1) CHF; 2) afib; 3) paroxysmal atrial tachycardias
Effect of hyperkalemia on digoxin
decrease dig activity
Effect of hypokalemia on digoxin
Drugs to avoid in treatment of CHF secondary to diastolic dysfunction:
1) digoxin; 2) vasodilators
Rx tx for diastolic dysfunction:
negative inotropic agents: 1) BBs; 2) verapamil; 3) cardizem
Interstitial edema with elevated PCWP
Interstitial edema with normal to low PCWP
Cardiac causes of pulmonary edema
1) arrhythmias; 2) MI; 3) severe systemic HTN; 4) PE; 5) valvular heart dz
Noncardiac causes of pulmonary edema
1) ARDS; 2) uremia; 3) aspiration; 4) head trauma; 5) allergic reaction to rx; 6) alveolar capillary leak
CXR findings in pulmonary edema
1) prominent pulmonary vessels; 2) enlarged cardiac silhouette; 3) Kerley B lines; 4) effusion
Signs and sxs of pulmonary edema
1) tachypnea; 2) cough with pink frothy sputum; 3) cyanosis; 4) nocturnal dyspnea; 5) rales, rhonchi and wheezing
Name 4 CXR findings in pulmonary edema
1) prominent pulmonary vessels; 2) cardiomegaly; 3) kerley b lines; 4) pleural effusion
Work up for pulmonary edema
1) CXR; 2) ABG; 3) ECG
Treatment for pulmonary edema
1) morphine; 2) lasix (to reduce preload); 3) dobutamine; 4) sit pt upright; 5) O2 with PEEP; 6) NTG to reduce preload; 7) digoxin if afib; 8) IV ACEI
Pathophys in mitral stenosis
MS --> impedes LV filling --> increased LA pressure --> pulmonary congestion --> secondary pulmonary vasoconstriction --> RV failure
What is the murmur of mitral stenosis?
mid to late low pitched diastolic murmur preceded by opening snap
What 3 tests help make diagnosis of mitral stenosis?
1) ECG; 2) CXR; 3) echo
Name 3 findings of ECG consistent with mitral stenosis:
1) LA enlargement; 2) RV hypertrophy; 3) +/- afib
What findings on CXR suggest left atrial enlargement?
1) double-density right heart border; 2) posterior displacement of esophagus; 3) elevated left mainstem bronchus
Goals of medical treatment of mitral stenosis
decrease preload: 1) diuretics; 2) sodium restriction
2 most common causes of mitral regurgitation
1) rheumatic fever; 2) dilation of left ventricle
4 causes of acute mitral regurgitation
1) ruptured chordae tendineae; 2) papillary muscle rupture; 3) endocarditis; 4) trauma
Murmur of mitral regurgitation
holosystolic murmur heard best at apex and radiating to axilla
What is the effect of chronic mitral regurgitation on preload?
increases preload (MR --> decreased CO --> RAAS --> fluid retention
What is the effect of chronic mitral regurgitation on afterload?
decreased afterload as a portion of stroke volume is ejected retrograde into LA
Name 4 diagnostic tests to confirm presence of MR
1) ECG; 2) CXR; 3) Echo; 4) Cath
2 findings on ECG consistent with MR
1) LV hypertrophy; 2) LA enlargement
Name 3 entities that mimic mitral regurgitation on physical exam
1) VSD; 2) HCM; 3) AS
What are the 2 goals of treatment for mitral regurgitation?
relieve sxs by 1) increasing forward output; 2) reducing pulmonary venous hypertension
4 classes of drugs used to treat MR
1) digitalis; 2) diuretics; 3) arteriolar vasodilators; 4) anticoagulants
Indication for surgical repair of MR
severe MR with significantly limiting sxs despite optimal medical management
Ventricular septal rupture is associated with which infarct?
Papillary muscle rupture with acute MR is associated with which infarct?
inferoposterior infarcts (posterior papillary muscle involvement)
Blood supply of the posterior papillary muscle
septal perforators of the PDA
Blood supply of the inferior wall of the left ventricle
PDA (85% from RCA; 15% from LCA)
Blood supply of the posterior wall of the left ventricle
marginal branch of the left circumflex a
Palpable precordial thrill associated with rupture of papillary muscle or ventricular septum?
4 diagnostic tests to confirm diagnosis of papillary muscle rupture
1) 2-d echo; 2) doppler flow study; 3) PA cath; 4) LV angiography
Murmur of mitral valve prolapse
mid to late systolic click and a late systolic murmur heard best at the apex
Effect of maneuvers on murmur of mitral valve prolapse
improves with squatting (increased venous return); worsens with valsalva (decreased venous return)
Most common cause of AS
calcification and degeneration of a congenitally normal valve
3 most common causes of AS
1) degenerative (aging); 2) calcification and degeneration of a congenital bicuspid valve; 3) rheumatic heart dz
What heart sound is associated with AS
S4 (forceful atrial contraction augments filling of thick, noncompliant ventricle)
2 causes of increased O2 demand in AS
1) LV hypertrophy; 2) high intramyocardial wall tension
3 mechanisms which contribute to angina in AS
1) LV hypertrophy; 2) high intramyocardial wall tension; 3) decreased diastolic coronary blood flow
Classic triad of AS
1) angina; 2) syncope; 3) dyspnea secondary to CHF
Pulsus parvus et tardus is a classic findng in which disease?
Pulsus parvus et tardus
upon palpation, the pulse is weak/ small (parvus) and late (tardus) in relation to contraction of the heart
Findings of AS on ECG
3 diagnostic tests which can be used to support diagnosis of AS
1) ECG; 2) CXR; 3) echo
3 possible findings on CXR in pt with AS
1) cardiomegaly; 2) calcified aorta; 3) pulmonary congestion
What is the normal aortic valve orifice?
2.5 to 3.5 cm
At what diameter is aortic stenosis considered to be critical or severe?
4 DDx whose murmurs mimic AS
1) aortic valve sclerosis of the elderly; 2) HCM; 3) MR; 4) PS
Maneuvers which increase preload
1) squatting; 2) leg raising; 3) inspiration
Maneuvers which decrease preload:
1) valsalva; 2) standing
Maneuvers which increase afterload:
1) hand grip; 2) phenylephrine
Maneuvers which decrease afterload:
1) amyl nitrate
Effect of hand grip on VSD
increase SVR; increase murmur
Effect of hand grip on MR
increase SVR; increase murmur
Effect of valsalva on HCM
decrease preload; increase murmur
Effect of valsalva on AS
decrease preload; decrease murmur
Effect of squatting on HCM
increase preload; decrease murmur
Effect of squatting on AS
increase preload; increase murmur
Effect of inspiration on TR
increase preload; increase murmur
Effect of valsalva on MVP
decrease preload; OS later and closer to S2
Effect of hand grip on AS
increase SVR; decrease murmur
Effect of handgrip on HCM
increase SVR; decrease murmur
2 common causes of aortic regurgitation:
1) rheumatic fever; 2) infective endocarditis
What is the most common cause of aortic regurgitation?
rheumatic heart dz
6 conditions that may affect the ascending aorta and cause AR
1) syphillis; 2) ankylosing spondylitis; 3) marfan's syndrome; 4) systemic htn; 5) aortic dissection; 6) aortic trauma
Pathophys of chronic AR
AR --> volume overload of LV (increased LVEDV) --> LV dilatation --> dilated cardiomyopathy and volume overload
Cause of increased pulse pressure in AR
AR --> initial decrease in stroke volume --> compensatory decrease in SVR to maintain CO --> drop in diastolic BP; compensatory LV dilation --> increase in SV --> increased systolic BP
2 factors which affect pulse pressure
1) stroke volume (proportional) ; 2) compliance of aorta (inversely proportional)
What is the most common presenting sxs in AR?
Murmur of AR
diastolic decrescendo murmur OR systolic flow murmur (secondary to greatly increased stroke volume)
systolic and or diastolic thrill or murmur heard over the femoral arteries; related to high pulse pressure
Duroziez sign is present in what valvular disease?
Austin Flint murmur
a mid-diastolic, low pitched rumbling murmur best heard at the cardiac apex; seen in AR
Pathophys of austin flint murmur
the result of mitral valve leaflet displacement along with turbulent mixing of antegrade mitral flow and retrograde aortic flow
Austin flint murmur is associated with which valvular disease?
Murmur of PDA
continuous (throughout cardiac cycle)
Effect of amyl nitrate on austin flint murmur
Treatment for AR
treat like CHF secondary to systolic dysfxn: 1) preload reduction (salt restriction and diuretics); 2) digitalis; 3) afterload reduction (ACEI)
Effect of Hypertrophic cardiomyopathy on stroke volume and ejection fraction
stroke volume: normal to increased; ejection fraction: increased
Effect of dilated (congestive) cardiomyopathy on ejection fraction
What is the most common cause of heart transplants?
2 most common causes of dilated cardiomyopathy
1) idiopathic (familial 20-30%); 2) alcoholic
Beriberi disease results in which type of cardiomyopathy?
What does Beriberi mean?
"i can't i can't" in Singalese
Beriberi is secondary to what vitamin deficiency?
thiamine (vitamin B1)
Clinical manifestations of dilated cardiomyopathy:
same as those for left and right ventricular failure
4 DDx for dilated cardiomyopathy
1) acute myocarditis; 2) valvular heart disease; 3) CAD; 4) hypertensive heart dz
Treatment for dilated cardiomyopathy
same as for systolic dysfxn CHF: 1) decrease preload (salt restriction, diuretics); 2) digoxin; 3) decreased afterload (ACEI, hydralazine); 4) ventricular remodeling (BB) PLUS 5) anticoagulants (high freq of pulm and systemic embolism)
5 diagnostic tests used to diagnose dilated CM
1) ECG; 2) CXR; 3) echo; 4) cath; 5) stress test
What is the heritance pattern of HCM?
Hallmark of HCM
unexplained myocardial hypertrophy with thickening of the interventricular septum
Typical EF in pts with HCM
Why does a reduction in preload increase obstruction in HCM?
decreased venous return --> decreased size of the heart --> mitral valve brought closer to the septum
Name 3 mechanisms that increase obstruction in HCM:
1) increase in contractility; 2) reduction in preload; 3) reduction in afterload
3 factors that decrease obstruction in HCM:
1) decrease in contractility; 2) increased preload; 3) increase in afterload
Rx Tx for HCM
negative inotropes: 1) BB; 2) CCB (verapamil, diltiazem); 3) disopyramide (sxs benefit for severely limited pts)
3 surgical procedures for HCM
1) septal myomectomy; 2) aortotomy; 3) etoh ablation
What is the preferred treatment in nonobstructive HCM?
goal is to improve LV relaxation; tx with CCBs
What is the preferred tx in latent obstructive HCM?
goal is to prevent provocation of obstruction; tx with BBs
What is the preferred tx in resting obstructive HCM?
goal is relief of obstruction to LV outflow; tx with disopyramide
How to auscultate for pericardial friction rub?
with diaphragm, as pt sits forward at forced-end expiration
ECG findings in acute pericarditis:
diffuse ST segment elevation, absence of reciprocal changes, upright T waves
Serosanguinous pericardial effusion is classic sign in what 2 diseases?
1) TB; 2) neoplasm
A transudative pericardial effusion can be seen in what 3 cases?
1) CHF; 2) hypoproteinemia; 3) overhydration
What is the best diagnostic test for pericardial effusion?
CXR finding in pericardial effusion
water bottle configuration of the cardial silhouette
Treatment for pericardial effusion:
1) fluid aspiration; 2) manage etiology
decrease in systolic BP of more than 10mmHg with normal inspiration; palpated as weakened pulse with inspiration along with more heart contractions to pulse beats
Treatment for cardiac tamponade:
1) pericardiocentesis; 2) subxiphoid surgical drainage
How to differentiate btw constrictive pericarditis and restrictive CM on cardiac catheterization:
in constrictive pericarditis, end-diastolic pressures are equal in all 4 chambers, while in RCM, LVEDP > RVEDP
Procedure of choice for constrictive pericarditis:
Rx tx for constrictive pericarditis:
conservative: salt restriction and diuretics
Sx tx for constrictive pericarditis
Rx tx for symptomatic sinus bradycardia
What initiates torsades de pointes?
ventricular premature beat in the setting of abnormal ventricular repolarization characterized by prolonged QT
Sxs of torsades de pointes:
recurrent dizziness or syncope
What 2 electrolyte disturbances are associated with torsades de pointes?
1) hypokalemia; 2) hypomagnesemia
Treatment for torsades de pointes:
1) magnesium sulfate; 2) isoproterenol infusion; 3) cardiac pacing; 4) cardioversion if hemodynamically unstable
What is pulsus paradoxus a signal of?
failing cardiac output during inspiration
2 Medical treatment options for stable, monomorphic v.tach
1) amiodarone; 2) lidocaine
What is the most commonly missed cause of syncope in the elderly? How do you make diagnosis?
subclavian steal; diagnosis by 1) measuring both L and R sided BP (difference of more than 25 mmHg = supports diagnosis); 2) confirmed by doppler US of neck vessels
What is the second most commonly missed cause of syncope in the elderly?
carotid hypersensitivity; make daignosis by carotid massage --> bradycardia
Name 3 common but often missed causes of syncope in the elderly:
1) subclavian steal; 2) carotid hypersensitivity; 3) L main or severe 3 vessel disease
Name 2 sxs of PVD of the internal iliac system:
1) decreased libido; 2) pain mimicking DJD of the hip