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At what point in the disease do we replace a regurgitant aortic valve?
After LV changes (but before symptoms... same w/regurgant valves)
In what infectious cardiac disease do you see Aschoff bodies?
Acute rheumatic fever (NOT in chronic RH)
What tends to cause endocarditis in IV drug users?
Staph aureus (bad b/c it's more virulent and causes more damage)
What tends to cause subacute endocarditis?
Viridans streptococci (esp. following dental procedures or oral mucosal injuries)
What do Osler's nodes, janeway lesions, and splinter hemorrhages indicate?
Infective endocarditis (rarely seen)
Which heart murmur is likely to vary with inspiration?
Tricuspid valve (expect right sided valves with inspiration changes)
In an infarct, which layers of the heart may be spared?
Innermost (receive O2 from the blood inside the heart itself)
What may be indicated if an EKG has ST elevations?
Myocardial infarction (reciprocal ST depressions usually present in other leads; could also be caused by pericarditis, aneurysm, or early repolarization)
What does an S4 heart sound indicate?
Stiff ventrical (a-shut door... atria is forcing blood into a noncompliant ventrical)
At what blood pressure does first qualify as having HTN?
140/90 (normal is below 120/80, in between these numbers is "pre-hypertension," so not actually a disease)
If a patient presents with HTN, flank bruits, and a fast young onset of HTN, what would we suspect?
Secondary hypertension (renal hypertension; check kidney function and maybe order CT)
What do inverted T-waves indicate?
Ischemia (WITHOUT infarction; we saw this in the hypertensive emergency case; only pathological in V2-V6)
Which HTN drugs also have renal protective effects (and are therefore indicated in diabetes)?
ACE inhibitors, ARBs
If we wanted to use a beta blocker in a bradycardic patient, which would be implicated?
Pindolol (has intrinsic sympathomimetic activity, so it doesn't slow the heart as much)
Immediate treatment (operative) is indicated in what aortic dissection?
Type A (often treat type B with medications, unless rupture or poor perfusion indicates surgery)
What change occurs in dilated cardiomyopathy?
Decreased myocardial contractility (systolic dysfunction!)
What heart disease do we worry about with people who have alcoholism?
Dilated cardiomyopathy (alcoholism is the leading causein the US; ethanol and metabolites are toxic, interfering with ATP generation and calcium interactions)
Which cardiomyopathy results in diastolic dysfunction?
Hypertrophic cardiomyopathy (LV is small and noncompliant, making diastolic filling inadequate)
What do cannon a-waves at JVP indicate?
AV block (RA contracting against a closed TV b/c of atrio-ventricular disassociation)
What could cause a machine like systolic-diastolic murmur?
Patent ductus arteriosus (PDA) (this is b/c aortic pressure is always higher than pulmonic, so the murmur continues in all phases)
When prescribing verapamil (calcium channel blocker), what class of drugs must we worry about?
Beta blockers (both cause bradycardia and can cause HF)
What are the toxicities of amiodarone?
Thryroid disorders, pulmonary fibrosis, liver damage, blue skin
What could be changed on an EKG of someone who previously had an infarction?
Q wave (downward deflection)
How do we rate control atrial fibrillation?
Beta blockers, calcium channel blockers (verapamil and diltiazam, NEVER AT THE SAME TIME)
What causes "paradoxical splitting" upon ascultation?
aortic stenosis (also left bundle branch block; anything that delays LV emptying)
What causes a holosystolic "blowing" murmur that radiates toward the axilla?
mitral regurgitation (also tricuspid regurgitation; MR often cuased by ischemia, prolapse, or LV dilation)
What causes a crescendo-decrescendo systolic ejection murmur after an "ejection click?"
aortic stenosis (pulsus parvus et tardus... pulses feel week but heart is loud; often comorbid w/syncope)
What causes a mid systolic click followed by a late systolic crescendo murmur?
mitral prolapse (most common lesion; usually benign; enhanced by squatting)
What causes a "blowing" diastolic murmur?
aortic regurgitation (often presents w/head bobbing or bounding pulses)
What causes a diastolic murmur that follows an opening snap?
mitral stenosis (rheumatic fever; enhanced by expiration)
What does a sawtooth appearance of atrial depolarizations indicate?
atrial flutter (treat w/class IA, IC, III antiarrhythmics)
What does progressive lenghtening of PR interval until "dropped" beat indicate?
Wenckebach (2nd degree mobitz type 1; usually asymptomatic)
What does dropped beats not preceeded by change in PR interval length indicate?
Mobitz type II (often 2:1 block)
What does total atrial/ventricular dissociation (p waves not linked to QRS) indicate?
3rd degree block (treat w/pacemaker)
What can an untreated VSD/ASD/PDA become?
Eisenmengers syndrome (arterial O2 desaturation; murmur disappears; late cyanosis w/clubbing and polycythemia)
What does early cyanosis indicate?
right to left shunt (tetralogy of fallot, transposition of great vessels, truncus arteriosus, tricuspid atresia, TAPVR)
What does late cyanosis indicate?
VSD, ASD, PDA (progressive PHTN; right to left shunt develops; eisenmengers)
What are the four characteristics of the tetralogy of fallot?
Pulmonary stenosis, RVH, overriding aorta, VSD (patient squates to improve symptoms; fix w/surger)
Angina that only occurs with exertion is:
stable angina (indicates atherosclerosis; retrosternal chest pain; expect ST depression)
Angina that occurs at rest is called:
unstable angin (thrombosis likely present butno necrosis; ST depression)
Elevated ASO titer indicates:
rheumatic heart disease (indicates infection w/group A strep b/c of ab's to anti streptolysin O)
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