Cardiology (CHO)

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Heat stroke:
clinical features ancient and exercise
Exercise:
High humidity, obesity, low fitness state, medication (anticholinergic)
clinical presentation: tachycardia, tachypnea, low respiratory, mental status change, >40C, ataxia
Complication: DIC, respiratory failure, and cardiac failure
Mangement: immersion cold water
Elderly: evaporate water
MI location based on coronary vessel involvement
Anterior
Posterior
Inferior
Lateral
Right ventricular infartation
Anterior: LAD ECG: V1-V3
Posterior: CX and RAD ECG: V1-V3, ST depresion of AVL and II
Inferior: RCA and LCX ECG: AVF and II, III st elevation
Lateral: LCX ECG: AVL, I elevation, v5-v6 elevation and ST depression of II, III, AVF
Right ventricular infartation: RAD ECG: RV1 and RV4
Causes of bradycardia:
Young athletic patient, obstructive sleep apnea, intracranial pressure, myocardial infarction, hypothyroidism, medication and sick sinus syndrome.
LCX oclussion:
ST segment elevation in I, AVL, and V5-V6
RCX oclussion:
ST elevation in AVF, II, and III. Reciproc depression depression of V1-V3.
AV nodal ischemia and hypotension with bradycardia, it could also present with Mobitz II
CHF with preserved EF:
causes and treatment:
Causes:
-Cardiac hypertrophic: congenital hypertrophy, hypertension with secondary concentric hypertension, restrictive disorder
-Valvular: mitral regurgitation/stenosis, aortic regurgitation/stenosis
-Pericardium: constrictive pericarditis, pericardial tamponade
-others: anemia, AV fistula and thyrotoxicosis
Medications:
-control hypertension, control heart rate
-control AF
-control with diuretics in overdose situation
Viral myocarditis:
Causes:
Presentation:
DX:
Management:
Causes: viral infection caused by HIV, influenza, herpesvirus 6, Coxsackie, parvovirus b 19
Presentation: prodrome viral infection myalgias, malaise, and fever. Chest pain and CHF (dyspnea, orthopnea, and edema) and some cases cardiac death
DX: ECG: nonspecific st elevation, Echo cardiac 4 dilations, MRI late enhancement of pericardium, biopsy with RNA and DNA
Management: control (diuretics, ACEI and Beta blockers), mechanical cardiac devices and transplant in some cases it's getting worst
Cardiac sounds:
Aortic area
Tricuspid area
Left sternal border area
Mitral area
Pulmonary area
Aortic area
Tricuspid area:
-diastolic: tricuspid stenosis and ASD
-systolic: tricuspid regurgitation and VSD
Left sternal border area:
-diastolic: early diastolic murmur aortic regurgitation
-systolic murmur: cardiac hypertrophy
Mitral area:
-systolic murmur: mitral regurgitation
-diastolic murmur: mitral stenosis
-mitral valve prolapse click
Pulmonary area:
-systolic murmur: pulmonary stenosis and ASD and flow murmur
Aortic area:
-systolic murmur aortic stenosis
Primary Raynaud's phenomenon:
Secondary Raynaud's phenomenon:
Etiology:
Presentation:
Management:
Primary Raynaud's phenomenon:
phenomenon:
Etiology:phenomenon:
Presentation: Usually women age <30
No tissue injury
Negative ANA and ESR

Management: Avoid aggravating factors
CCB for persistent symptoms

Secondary Raynaud's phenomenon:

Etiology: Connective tissue diseases
Occlusive vascular conditions
Sympathomimetic drugs
Vibrating tools
Hyperviscosity syndromes
Nicotine


Presentation: Usually men age >40
Symptoms of underlying disease
Tissue injury or digital ulcers
Abnormal nail fold capillary examination

Management: Evaluation and treat underlying disorder
CCB for persistent symptoms
Aspirin if risk of digital ulceration
Drugs QT prolong:
Antibiotics: macrolide and fluroquinolone
Antiemetics: ondasetron and gavasetron
Antiarrhymics: flecainamide, procainamide, quinidine, sotalol and amiodarone
Antipsychotics: SSRI, TCA, opiods (methadone and oxycodone)
Metabolics: hypomagnasemia, hypokalemia, hypocalcemia
Pediatric myocarditis
A man with burning sensation that not relieves with antacids, a sensation that increases with exercises and relieves by rest.
Dx
First! Think cardiac disease. This man has an atypical pain and should be studied with stress test if there is no contraindication
Indication for cornoary angiography:
-typical pain or -abnormal stress test
Acute pericarditis:
Causes:
Symptoms:
Treatment:
causes: Viral infection, autoimmune (SLE), uremic (>60) and postmyocardial infarction (early and late)
Symtpms: fever plus chest pain, sharp pain that increase supine position, rub friction, ECG: st elevation and PR increase with Echocardiogram with efussion
Treatment: NSAIDS, Colcichine
Causes of T wave inversion:
-myocardial contusion, myocarditis, pericarditis, digoxin, myocardial inversion
Causes of single S2:
-Pulmonary stenosis
-left ventricle hypoplasia
Tet spell
Hypercyanosis in children after feeding or crying (life threatening)
Factors associated with poor outcome after witnessed out of hospital sudden cardiac arrest:
-Time initiation of CPR or defibrillation
-Pulseless Electrical activity, Asystolia
-Absence of vital signs
-Advanced age
-Prior history of cardiac disease
-Prolonged CPR >5 minutes
->2 Chronic illness diseases
-Pneumonia or acute renal failure after CPR
-Persistent coma after CPR
-need for intubation or vasopressors
-Sepsis, cerebrovascular accident, or class III or IV heart failure
What is the next step if patient with cardiac arrest fail to be rescued with CPR or defibrillator?
Epinephrine
What is the most common cause of cardiac arrest?
Myocardial infartation
Pericarditis ECG
ECG: PR segment depression and ST segment elevation in multiple limbs
LCX obstruction:
ST elevation in AVL, I, V5-V6
ST depression in AVF, II, III
RCA obstruction:
ST elevation in AVF, II, III
ST depression in AVL, I
Mobitz, bradycardia due to AV ischemia
...
...
Giant cell vasculitis:
Symptoms:
Complications:
Labs:
Fatigue, weight loss, myalgia, fever, headache, malaise, bruits in a femoral artery, brachial artery, axillary artery, sudden jaw claudication, vertigo, hearing loss, Acute ischemic optic nerve, aortic aneurysm, aortic thickness, PMR
Complications: sudden vision loss (amourosis fugax), AION
Labs: high ESR, high CPR, chronic anemia,
Treatment of Giant cell vasculitis:
-PMR 10mg of steroid
-Giant cell vasculitis: 40-60mg of steroid
-AOIN: 1000mg for 3 days and then decrease to middle or low dose
Treatment for penicillin sensitive Infective Endocarditis:
-IV aqueous penicillin G (4-6 hours or 24 hours continous infusion)
-IV ceftriaxone for 4 weeks
Hereditary telangiectasia (Osler-Weber-Rendu) AD
Symptoms:
Symptoms: diffuse telangiectasias, recurrent epistaxis, widespread AV malformations (mucous, membranes, skin, GI, liver, brain, lung). AV shunt from right to left causes chronic hypoxemia and reactive polycythemia
How is the NPV of D-dimer in low Wells criteria?
High, negative D-dimer rule out DVT
Mediastinum mass:
Anterior:
T4
Terrible lymphoma. thymoma, teratoma, thyroid enlargement
Mediastinum mass
Middle:
tracheal mass, bronchogenic cyst, pericardial cyst, aortic aneurysm arch, lymph node enlargement
Mediastinum mass
Posterior:
Esophageal leiomyoma, enteric cyst, meningocele, diaphragmatic hernia. aortic aneurysm, esophageal leiomayoma
Endocarditis complications:
Cardiology:
valvulopathy, perivalvular abscess, mycotic dilation, conductive disorder
Endocarditis complications:
Neurology:
Cerebral embolism, cerebral abscess, meningitis, encephalitis
Endocarditis complications:
MSK
Vertebral osteomyelitis, septic arthritis, msk abscess
Endocarditis complications:
Renal
renal infaction, glomerulonephritis, drug induced acute interstitial nephritis from therapy
Progressive multifocal leukoencephalopathy:
risk factors:
symptos:
risk factors: transplant recipients, immunocompromised
Symptoms: altered mentation, multifocal neurologic deficits (visual symptoms, hemiparesis/monoparesis, ataxia)
Early neurosyphilis:
meningitis
Late neurosyphilis:
dementia, tabes dorsalis (sensory ataxia, fancinating pains, reduced DTR, Argyll Robertson pupils)
Cardiac emboli:
complications:
-Skin manifestations: livedo reticularis (reticulated, mottled, discolored skin), blue toe syndrome
-Kidney manifestations: Acute kidney injury
-Gastrointestinal manifestation: pancreatitis, mesenteric ischemia
Patient with chest pain, dyspnea, smoking history, and family history of premature CAD
dx
management:
suspect of myocardial infarction
management: ECG, and cardiac enzymes
Contraindication of Glycoprotein inhibitor IIB IIIA
major bleeding, recent surgery, ischemic stroke, and HTN
Hypertrophic cardiomyopathy:
ECG:
Left ventricular hypertrophy: Tall R wave in aVL+ Deep S wave in V3 (Cornell criteria)
Repolarization changes in anterolateral leads (I, aVL, V4, V5, V6)
HCM:
Symptoms:
Signs:
Symptoms: Exertional dyspnea, chest pain, fatigue, palpitations, presyncope, or syncope
Signs: crescendo-decrescendo systolic murmur heard at the apex and lower left sternal border
HCM: patophysiology:
genetic autosomic dominant, 2 mutations in cardiac myosin binding protein C and beta myosin heavy chain gene
Mitral valve prolapse:
Presentation:
Signs:
Treatment:
Presentation: atypical chest pain, palpitations, panic attack
Signs: systolic click
Treatment: Beta blockers
Cardiac emboli after cardiac catheterization:
symptoms:
time:
treatment:
symptoms: abdominal pain (pancreatitis), blue toe (emboli), skin livedo reticularis, renal insufficiency
Within 30 days after catheterization
Treatment: statin
DVT wells criteria:
-active cancer: 1
-bedridden more than 3 days, or surgery within 4 weeks
-swollen more than 3 cm in a calf below the tibia 10 cm: 1
-pain along collateral veins
-collateral veins
-pitting edema: 1
-paresis, paralysis, immobilization:1
-previous history of DVT:1
-no clinical feature of DVT:-2
Source of artery with upper 2/3 calf pain
superficial femoral artery
1/3 lower calf pain
popliteal artery disease
Foot pain, source of PDA
tibial or peroneal artery disease
Thigh pain, PDA sources
aortiliac or common femoral disease
Flail mitral leaflet:
causes:
symptoms:
causes: mitral valve prolapse, endocarditis, myxomatous degeneration, rupture of papillary muscles (MI)
symptoms: severe pulmonary edema, hypotension with hyperdynamic precordium
Indication of medication HTN:
Patient >60 pressure >150/90mmHg
Patient <60 or DM or Chronic Renal Failure pressure >140/90 mmHg
Medication indicated for HTN
Black patient: thiazide or CCB or combination
Other patients: thiazide, ARB, ACEI, CCB
Patienti with renal failure: ARB, ACEI
Patients with DM and sing of nephropathy:
Indication of treatment:
HTN >130-90 mmHg
Endocarditis criteria:
Duke major and minor
Endocarditis criteria: 2 major or 1 major plus 3 minor
Major criteria: 3 Blood culture positive for (S. viridans, S. aureus, Enterococcus), Echocardiogram positive for vegetations
Minor criteria: predisposing valvular disorder, embolic phenomena, immunologic (glomerulonephritis), blood culture that not meet the above criteria, IVDU, high fever
Endocarditis symptoms:
Fever, new murmur, petechiae, subungual splinter hemorrhages, Janeway lesion, Osler syndrome, splenomegaly, neurologic emboli, Roth's spot eyes
Infective endocarditis:
1st study to ask
3 different Blood culture before asking any imaging test
Carcinoid syndrome:
Clinical manifestation:
Dx:
Treatment:
Clinical manifestation:
skin: flushing, telangiectasias, cyanosis
gastrointestinal: diarrhea, cramping
cardiac: valvular lesions (right> left) left lower sternal border murmur during diastolic that increase with inspiration
pulmonary: bronchospasm
miscellaneous: niacin deficiency (dermatitis, diarrhea, and dementia)
Dx: elevated 24 hours urinary excretion of 5 HIAA
CT/MRI of abdomen and pelvis to localize tumor
Octeoscan to detect metastases
Echocardiogram: if cardiac symptoms are presents
Treatment: octeotide for symptomatic patients and prior to surgery/anesthesia
surgery for liver metastases
Renal artery stenosis:
Criteria:
Criteria: Hypertension even with more than 3 drugs, hypertension (180/110 mmHg), recurrent rapid pulmonary flash, malignant HTN
Renal artery stenosis:
Supportive evidence:
Physical examination:
-Asymmetric renal size (>1.5cm)
-Abdominal bruits
Laboratory:
-Unexplained rise in serum creatinine (>30 %) after starting ACE or ARBs
Imaging results
-Unexplained atrophic kidney
Renavascular hypertension associated disease:
Peripheral artery disease
Limb threatened oclussion suspected symptoms:
treatment:
Thrombolytic and heparin
Symptoms: sensory loss, rest pain, and muscle weakness
Endocarditis complications:
Cerebral: embolic septic, stroke, brain abscess, encephalitis, or meningoencephalitis
Cardiac: myocardial infarction, conductive disorder, CHF, perivalvular abscess, valvular insufficiency
Renal: glomerulonephritis, renal failure, interstitial nephritis due to medication, renal infarction
Muscular: septic arthritis, muscular abscess, vertebral osteomyelitis
Syncopes
AAA
risk factors:
-Cigarette
->60 years old
-white race
-atherosclerosis
-family history
Indications for operative or endovascular repair AAA:
->5.5 cm
-rapid rate of aneurysm expansion (>0.5 cm in 6 months or >1 cm per year)
-presence of symptoms: back, abdominal, or flank pain, limb ischemia
Complicated symptoms of peripheral arterial disease:
-Symptom during rest
-Increase weakness
-Decrease healing process
Coarctation of aorta:
place of murmur:
Inter scapular systolic or continous murmur
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