Kaplan Cardiology

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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?

CXR

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

LDL <100

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?

1-2 wks

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

inferior wall

Treatment for right ventricular infarction

IV fluids

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

dig toxicity

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

cardiac cause

Interstitial edema with normal to low PCWP

noncardiac cause

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?

anterior wall

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?

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?

AS

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

LV hypertrophy

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?

<0.8cm

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?

dyspnea

Murmur of AR

diastolic decrescendo murmur OR systolic flow murmur (secondary to greatly increased stroke volume)

Duroziez sign

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?

aortic regurgitation

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?

AR

Murmur of PDA

continuous (throughout cardiac cycle)

Effect of amyl nitrate on austin flint murmur

decreases 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

decreased

What is the most common cause of heart transplants?

dilated cardiomyopathy

2 most common causes of dilated cardiomyopathy

1) idiopathic (familial 20-30%); 2) alcoholic

Beriberi disease results in which type of cardiomyopathy?

dilated CM

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

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