TOPIC/Concept Explanation Presentation CARDIOLOGY KAPLAN Qs
183qs
Sick Sinus Syndrome = Chronic state of SA node dysfunction or a sluggish or absent SA node pacemaker
Tx: Venticular Pacemaker implanted Sx:
1. SOB 2. Palpitations 3. Angina
Alternating Bradycardia & Supraventricular Tachycardia… commonly with underlying Atrial Fibrilations or Atrial Flutter Goal: Terminate the Bradycardia-Tachycardia
68yoM checkup after his Acute MI a year ago. Said feeling fine until 6wks ago started having Palpitations, and feel fatigued and SOB. Holter monitor revealed Bradycardia with brief episodes of Atrial Flutter. BP 110/75, 50bpm, Resp 15. Management for this pt? = Ventricular Pacemaker
Stage 1 HTN: 140/90 to 160/100
Need HTN diagnosis after confirmed elevated BP 3 separate occasions. AGE is big RF
1st: if Stage 1 w/o Comorbidities (CHF, DM, CKD)
*Exercise, Diet, + Thiazide (Not Diet, Exercise only…or extra meds)
IF Thiazide Max but not reaching BP goal… use 2nd agent:
ACE-I or BB can be added
63yoF. BP 147/93…she returns 2 wks later her BP is 148/95, another 2 weeks: 152/98. Which is most appropriate intervention?'
HMG-CoA Reductase inhibitors (Statins) - DOC to Reduce LDL
Atorvastatin
Statins most POTENT & well tolerated by pts than other lipid lowering meds.
Risk: Myositis.
Routine LFT ordered (bc SE: Liver Inflammation)
40yoM. Cholesterol panel: Elevated LDL & Low HDL. Diet & excerised done..6mo later HDL normal, but LDL Elevated still. Next Step?
Variant Angina (Prinzmetal) - Coronary vasospasm… angina-like sx.
= Classic: Awakens pt from Sleep
Associated w/Vasospatic condition clues: Raynauds worsens by Cocain, Sumatriptan.
MC: RCA…Inferior heart
Transient ST-segment DEPRESSION in INFERIOR leads
Angina-like sx at rest…due to coronary vasospasm.
Pts w/Prinzmetal: Younger, likely Women.
(Exercise-Hyperventilation induces sx…via Alkalosis…vasoconstriction)
30yo Asian F chest pain. Last 2 years has had intermittent nocturnal chest pain lasts up to 10mins. Pain is substernal & heavy pressure radiates to throat. Has Raynaud phenomenon. Social hx occasional use cocaine. EKG unremarkable. Given this pt's likely Diagnosis, which likely finding on Holter monitor during chest pain?
Pericarditis: EGK:
*Diffuse ST-segment Elevation,
*PR-segment Depression
Acute Coronary Sd: Unstable plaque is partially or
intermittently obstructs blood flow:
Transient ST-Depression 3 separate diagnoses: Unstable Angina, NSTEMI, STEMI
ASPIRIN = ↓Mortality If pt presents with ACS: *New onset chest pain *Worsening pattern *Pain at rest
Next step always: ASPIRIN (to ↓platelet thrombus progression) Oxy, Morphine, Nitrates:
All ACS should be treated with 100% Oxy, Morphine, Nitrates…but none of these has PROVEN to ↓Mortality
72yoF chest pain. 2hrs ago was watching tv when she felt a dull pain that radiated to the jaw. Chest tightness and SOB. She had similar pain before, mostly with exertion. PE: clutching her chest in pain & sweating profusely. CVS exam: Distant heart sounds. No STelevation or Left Bundle branch block. Which steps in Management will give greatest reduction in MORTALITY?
Diastolic Dysfunction: *↓HR via BB or CCB…to ↑time for Ventricles to fill during Diastole
*ensure BP is controlled *prevent further myocardial hypertrophy with ACE-I or ARBs
*Prevent remodeling and regress hypertrophy with Spironolactone/Aldosterone antagonist
*Avoid BB in COPD or Asthma pt
Verapamil
Hypertrophy dt long HTN…get Diastole dysfunction: Concentric hypertrophy →
1. SOB on exertion (EDV↓…preload backs up into lung congested - exertional SOB).... so relax heart during DIASTOLE to improve fill pressures:
1st DOC: BB.... but Pt has COPD (so can't do BB)
2nd line: CCB- Verapamil/Diltiazem = Negative Inotrope...relaxes the LV during diastole
1) Prevents heart relax in diastole - can't fill
2) Time in diastole is shortened during Tachycardia
60yoF h/o HTN, COPD…has SOB. Says has 6mo h/o progressive worsening SOB while climbing stairs. Barrel-shaped chest, prolonged wheezes. Transthoracic echo shows Diastolic LV Dysfunction. Which is Next Best step?
BB: blocks B2-receptors in lungs… lead to bronchoconstriction & ↓lung function
Dobutamine
-only use if pt has Acute Pulmonary Edema, and doesn't respond to IV Loop, Nitrates, Morphine (goal: ↓Preload)
Dobutamine is Positive Inotrope….doesnt relax the LV. *Decreases Afterload….get severe Hypotension
Hypertrophic Cardiomyopathy: *Syncope in Young pts. *Valsalva: ↑Murmur (Any maneuver that decreases LV size →
↑Murmur = obstructive part ↑ as LV cavity shrinks)
BB: Metoprolol
BB help SLOW Ventricle Rate…. To ↑Ventricle Fill time
21yoF professional dancer… several episodes of near loss of consciousness. No famHx. BP 142/88. PE: brisk carotid upstroke with a double impusle palpable. Loud S4 & harsh systolic murmur -left sternal border. Murmur accentuated during VALSALVA. ECG: LV Hypertrophy. Which drugs most appropriate for this pt?
ACE-I: -pril → ↓Afterload → drop in Pressure gradient across aortic valve….exacerbates/worsens the outlet obstruction (in HCM) Digoxin: ↑Contractility…worsens outflow obstruction of HCM Loop decreases preload: leads to worsening the outlet obstrction
CABG: indications 1) Stenosis of Left main, 3vessels, 2vessels in DM 2)PCI: percutaneous
coronary intervention…used in pts with symptoms
3) Internal Mammary artery is donor best vessel for coronary artery bypass graft
Coronary artery bypass using INTERNAL MAMMARY Artery CABG > angioplasty.
*3 or more stenotic vessels or disease of the Left Main coronary artery
Internal Mammary artery > saphenous vein bc saphenous get occluded after 5yrs.
Internal mammary = good for 10yrs Angioplasty & Stents better for ISOLATED vessels rather than multi-vessel CAD
55yoM has progressive, unstable angina that doesn't respond to meds. H/o DM2 & hypercholesterolemia for past 20yrs. Two of his brothers had MI @50yo. Cardiac
catheterization shows 70% occlusion of two coronary arteries, includes Anterior descending EF is 55%. Next best step in management?
Mitral Valve Replacement in Pregnancy
*Pregnant w/symptomatic Mitral Stenosis…failed meds → next: Balloon Valvoplasty is most effective
*Mitral valve replacement is risk to Mom & Fetus
Percutaneous BALLOON vavuloplasty
*pt has Life-threatening Pulmonary Edema in setting of Mitral Stenosis. (Fluid Overload)
(Save the mom is main concern) Mitral Steonsis+Pregnant: do Percutaneous Balloon Valvuloplasty (Not: urgent C-section)
25yoF 24wks gestation…has worsening dyspnea & orthopnea over past 10days. Treat w/Furosemide but no improvement. h/o rheumatic heart disease & mitral stenosis. PE: JVD, Bilateral Crackles. Best next step management?
Pregnant Woman….DO NOT use ACE-I bc can have Renal Defects to Fetus
Digoxin Toxicity:
*N/D/Fatigue, Somnolence *Visual alterations
(confusing green with yellow halos)
*Arrhythmias…
(SCOOPED ST-segments or reverse Check sign)
Toxicity: get AV node blocked, ↑Automaticity of Ventricles…includes junctional myocardium 1st: Atropine
2nd: Check Digoxin Levels (to see if immune Fab needed)
Digoxin Levels
Not: "Digoxin immune Fab"
Initial Step in treating Symptomatic Bradycardia: improve the
hemodynamics
Renal Failure can worsen digoxin toxicity…↓digoxin clearance *Quinidine, Amiodarone, Spironolactone, Verapamil → ↑Digoxin toxicity bc inhibits Renal secretion of Digoxin
Atropine ist 1st to tx: Symptomatic Bradycardia with signs of
Hypoperfusion
68yoF Nausea, dizziness, SOB, somnolence, fatigue. Began sx 4 days ago. PE: BP 98/46, she appears uncomfortable. Vision confuses green for yellow. Lung prolonged expiratory phase, mild crackles at bases. 1+ pitting edema. CXR: large cardiac silhouette, flattened diaphragms. Atropine given...new BP 115/85. Next Step?
CAD
Diastolic LV Dysfunction: dt HTN…Concentric
Hypertrophy… heart can't relax during diastole Sx: Dyspnea on exertion Rx: ACE-I
Goal: HR 55-60bpm (if push HR down, heart spends more time in Diastole…more time in Diastolic Filling)
[Can use CCB: Verpamil or Diltiazem...but don't want HR <55]
Lisinopril
(↓HR...reducing AFTERLOAD w/ACE-I or ARBs)...-pril improves exercise tolerance, but no mortality in pts with Concentric HTN
LV can't fill properly bc:
1) Concentric Hypertrophy…prevents heart from Relaxing during Diastole 2) Time spent in Diastole is
SHORTENED during Tachycardia EDV is reduced & EDP↑ bc LV STIFF & non-compliant → Pulmonary Congestion…bc excess PRELOAD backs up into Lungs → Exertional Dyspnea
Rx: Negative Inotropic to relax the heart during Diastole
58yoM h/o HTN comes in bc of SOB. Has Progressive worsening dyspnea while climbing stairs. No CP and SOB at rest. On Aspirin & metoprolol. PE: Regular HR & Rhythm with absence of murmurs or rubs, has S4. BP 150/80. PE: Rales @bases. LE edema. Echo shows ↑LV filling pressures w/Normal EF. Next Best Step?
→ Diastolic LV Dysfunction Rx goal: ↓HR
*BB *CCB
Decrease HR → ↑Amount of Time for Ventricles to Fill
Other Meds used to Treat Heart Failure:
*ACE-I or ARBs (prevents remodeling and act to regress hypertrophy) *Aldosterone Antagonists (prevents & regresses hypertrophy and fibrosis)
Metoprolol
BB = ↓MORTALITY in Acute Coronary Sd pt - unstable angina etc.) & POST-MI pt.
BB: ↓BP, ↓HR-to lessen strain on heart, ↑Perfusion to heart tissue. BB: ↓Arrhythmias
56yoM CP & SOB with exertion. Exercise stress test reveals coronary artery disease…BP readings given. 146/96, 150/90, 140/96. Drug appropriate?
ACE-I 2nd line BP med.
ACE-I: 1st line BP in DM…bc slows progression of Diabetic
Nephropathy. Also Improves SURVIVAL in pts w. CHF: bc ↓AFTERLOAD
ACE-I: Post-MI pt with LV damage, beneficial effect on SURVIVAL secondary to Remodeling effect on Ventricle AORTIC STENOSIS Angina symptoms bc ↑demand by hypertrophied LV… (Subendocardium ischemia) Bicuspid Valve 1. <70yo 2. Crescendo-decrescendo systolic murmur, Right 2nd intercostal space radiates to carotids. LV hypertrophy MC: Congenital Bicuspid Aortic Valve Less likely sequelae of Rheumatic Valvular Disease
Rheumatic Valve disease in pt from Developing country.
28yoF Chest pain with exertion. Started 4mo ago w/dyspnea, lightheaded and felt faint while exercising. BP 154/92. PE: Delayed carotid upstrokes that are diminished in amplitude. Forceful apical impusle & soft S2. Harsh crescendo-decrescendo systolic murmur best heard at right 2nd ICSpace radiates to carotids. ECG shoes LVH. Likely cause of pt's condition?
PAC: Premature Atrial Contractions
do: 72 hour holter monitor
[Echo doesn't help diagnose PACs]
Order a 72 hour holter monitor Holter Monitor records all of pt's Heart beats…
PACs are extra impulses that can originate from anywhere in Right or Left Atria. ..makes pt feel like hearts skipping a beat
59yoM CC Palpitations. Says feels like his heart "skips a beat sometimes". EKG shows normal sinus rhythm. What's Next Step in diagnosing this pt?
Don't give THROMBOLYTIC therapy if patient has >10 mins of CPR (Prolonged CPR) why: After 10mins of CPR, likelihood of trauma to Anterior Chest Wall is high (Fractures)..= risk Bleeding…
CARDIAC TAMPONADE Post MI complications: 1. Hypotension 2. Tachycardia
3. Clear lungs auscultation 4. Pulsus Paradoxus Cx signs: Same as RV infarct…. But difference is Pulsus Paradoxus (↓SBP >10mmHg with Normal Inspiration)
Next Best Step: Pericardiocentesis
Pericardiocentesis followed by pericardial window
Cardiac Tamponade:
*↓BP, TachyC, Pulsus Paradoxus, Clear breath sounds
= Real Emergency
Need immediate Decompression by Pericardiocentesis followed by Pericardial Window
Cardiac Tamponade… Lt & Rt ventricles get SQUASHED by blood/fluid collection in Pericardial Sac → ↓Capcity of Both Lt & Rt Ventricles.
Inspiration → Contracts Diphragm → Returns Blood to Rt Ventricle. So the Already squished Lt ventricle gets more Squashed by Enlarging Rt Ventricle...so can't keep Contraction during Systole → DROP SBP during Systole
Vs: Rt Ventricle Infarct...there's NO Pulse Paradoxus. bc heart is Not being Squashed, and any increase in Volume in Rt Ventricle is
accommodated by Pericardial Sac.
48yoM chest pain. Suddenly felt dull, crushing chest pain that radiated to jaw and left arm. PE: Sweating. Muffled heart sounds that are regular rate and rhythm. EKG: STEMI… had PCI. BP drops to 105/55, Pulse 120/min. Jugulovenous Distension. BP rechecked BP between 110/55 and 95/55 Management?
MI - Inferior Wall:
= Impairs LV filling….get ↓COFluids
Swanz-Ganze shows Elevated Rt-sided Pressure and Low filling pressure.
RV Infarct: get ↓Cardiac Output…bc Insufficient Lt heart filling
pressures….
RV infarct causes Back up of Venous Blood and Decreased Forward Flow….get ↓LV filling (Low Wedge Pressure)
Tx: IV FLuids
..Then Cardiac Catherization (Balloon Angioplasty)
62yoF…has Acute inferior MI. She's oliguric and has BP 80/55. Swan-Ganz catheter is placed… shows diminished Pulmonary Capillary Wedge of 4mmHg. Normal Pulmonary Artery Pressure of 22/4mmHg. Increased mean Rigth arterial pressure of 11mmH. Which is Next best Step?
AORTIC STENOSIS *Progress to Angina, Syncope, HF
Sx: CP, Dizziness or syncope, HF
Decrease intensity of murmur Hand Grip: compresses forearm muscles on ATERIOLES → Afterload↑. When Afterload increases, heart can't pump out enough blood…leads to Reduction in SV and ↑ESV. Causes ↑LV Volume
64yoF comes to ED intermittent chest discomfort. Substernal pressure occasionally radiates to Left arm and last approx 10mins. ..PE: Delayed carotid Upstroke and systolic ejection murmur 2nd intercostal space right border. Pt does HAND-Grip maneuver. Effect likely seen? CONCENTRIC HYPERTROPHY Chronic HTN → Concentric Hypertrophy → Diastolic Dysfunction Hypertension
DOC: for Diastolic HF (hypertropy) BB
BB: ↓BP & ↓HR to allow improved Ventricular Filling
64yoF obese h/o Alcoholism. SOB. Progressive worsening dyspnea while climbing stairs. No CP. BMI 40. Echo shows diastolic LV dysfunction. Likely cause of her symptoms?
Hypertensive Emergency: *Chest discomfort *Papilledema *BP 220/115 best agents: *Labetalol *Nitroprusside Intravenous Labetalol Labetalol is combined: Beta-Adrenergic & Alpha-Beta-Adrenergic blocker.
Rapid onset (5mins) - useful for Hypertensive Emergencies
Labetalol is safe in pts with Coronary disease
Avoid Labetalol in Asthma, COPD, HF, Bradycardia, Greater than 1st degree heart block.
60yoM Chest pain. Long hx of CAD & HTN and status post coronary bypass procedure 6yrs ago. Pt has chronic stable angina that's precipitated by activity and relieved by rest. Meds: aspirin, captopril, metoprolol. 3wks ago was prescribed sildenafil. BP: 220/120, Papilledema on ocular exam. EKG nonspecific changes. Which is best treatment indicated at this time?
Cholesterol: CAD
Cold leg & Acute Ischemia Atrial fibrillation → Peripheral arterial Embolization & Cold Leg = Surgerical Emergency.
Emergently transfer to operating room for EMBOLECTOMY.
*Important in management of cold leg & acute ischemia of lower limb = Embolectomy
Irreversible damage to tissues occurs after 4-6hrs, so need
revascularization 1) Embolectomy
2) then Anticoagulation - Heparin (but make sure pt NOT allergic to Heparin)
55yoF long standing h/o Arterial Fibrillation 2/2 Mitral Regurage…comes to ED with painful right foot. Past few hours, her foot has become more painful and now is nearly insensate. Pains is Burning. Right foot is gray and cool to touch, has poor capillary refill. Dorsalis pedis & posterior tibial pulses are absent on the right. PT is 14s. (INR 1.4). What's next step?
Left Heart Failure (paroxysmal nocturnal dyspnea, orthopnea, occasional dyspnea)…has Mitral Regurge.
= Pansystolic Murmur best heard at apex, radiates to axilla.
Valve REPAIR AS: Replace MS: Angioplasty MR: Repair
EF: <60%...candidate for Valve Replacement
MR can decompensate into Fulminant HF very fast. EF cut-off is <55%
Surgery is Best when EF is 55-65%
66yoM h/o bacterial endocarditis comes bc SOB. Past 2 montsh been waking up in middle of night gasping for breath. Using 4 pillows to fall asleep and occasionally dispneic on climbing stairs. PE: absence of JVD and pedal edema. Pansystolic murmur heard best at apex & radiates to Axilla is audible. EKG: EF 55%. Which of following is next best step?
Initiate Drug Therapy for Control of his Hyperlipidemia
This Pt's Risk Factors: Family Hx
Age Tobacco HDL >60 = -1RF
= has 2 total RF = Moderate risk for Coronary Disease.
48yo previously healthy man. Fasting total serum cholesterol 299mg/dL. BP 135/85. Labs 2weeks ago. Total Cholesterol: 299mg
HDL: 65mg/dL LDL: 170mg/dL Best Next Step?
BPH+HTN HYPOTENSION & Bradycardia = a Vagal response (Give Atropine: Anticholinergic) Administer ATROPINE IV
RCA → SA node… Inferior Wall… Sinus BradyCardia
50yoM has acute MI. 8hrs after this event, BP 70/50mmHg. Pulse 45/min. EKG reveals sinus rhythm. Which is most
appropriate intervention?
Terazosin
Co-Treatment 2 things at same time: Terazosin is Alpha 1-receptor Antagonist useful for treatment of HTN & BPH
58yoM Difficulty voiding. Delay when he "attempts to go", often wets underwear. BP 160/92. Which
antihypertensive for this pt?
Right Ventricle Infarct - Postinfarct complication *STEMI in inferior leads (II, III, avF)
*Hypotension *CTA
don't give meds that decrease preload (nitrates, diuretics)
DOC: FLUIDS to increase PRELOAD (More in, more out)
Fluids Hypotension Tachycardia CTA
Absent pulsus paradoxus. ST-elevation in Leads II, III, avF [=RCA…supplies Right Ventricle]
72yoF abdominal pain. Waking up in morning with a dull, epigastric pain, nauseous and sweaty. CVS PE: Muffled heart sounds. EKG: ST-elevation in leads II, III, avF. She undergoes coronary angiography and percutaneous coronary intervention. 24hhrs later BP falls to 105/67 with no
variation on inspiration. P: 128, Chest CTA. Next best step in management?
Fasting Serum Lipid Studies Cardiac Tamponade:
Signs are exact same as RV infarct….one Clinical sign that is Different: Pulsus Paradoxus
(↓SBP >10mmHg with Normal Inspiration) Tx: Pericardiocentesis & Pericardial window (moa: L&R ventricles squashed by collection of blood in pericardial sac)...can't fill
RV infarct:
NO Pulsus Paradoxus
Atropine used in cases of bradycardia (muscarinic-R)
Tachycardic in this RCA-MI pt already has overproductive SNS. Atropine blocks M-receptors= ↓Parasym. Tone…. Give atropine to this pt can cause more tachycardia (↑Increased sym. Tone) → induce another MI
Emergency Bypass = for pt in Severe CHF post-MI
[r/o CHF: lungs CTA)
Pt who is decompensating rapidly (CHF), with right & left HF but no murmur to explain the HF….(=Valve rupture is common Post-MI) = do Emergency Bypass
Cardiac Risk factor: *Family h/o Heart disease *Age
*Fasting Lipid *DM
*CHD RF: smoking, HTN USPSTF: recommends start dyslipidemia screen Men: @20-35yo Women: @20-45yo
55yoM…comes for check up. Everything looks normal, but has Family history: mother with stroke, brother with MI at 50yo, Father died MI 58. BP 142/78. Which is most
appropriate screening test for this pt?
If evidence of
*TIA: Transient Ischemic Attack
*Stroke sx *Bruit heard
Order: Carotid Artery Duplex studies
MI. (+digoxin use) Digoxin: for Afib controls ventricular rate. But it interrupts EKG interpretation when pt has Acute Coronary Sd....causes NONSPECIFIC EKG Chnages
*EKG can't be read as having ST-seg elevation bc effects of Digoxin obscure these changes
Echocardiogram
Pt whom diagnosis of MI is difficult due to Nonspecific or Nondiagnostic EKG change, next step: Confirm diagnosis with:
*Cardiac Enzymes or ECHO (see wall motion abnormalities indicative of Ischemia)
(Next step is NOT EKG). If can't read EKG, do echo.
56yoF h/o Atrial fibrillation, complains of CP. Currently on Digoxin. 1 hour ago she's felt sudden, dull pain in chest and left arm. P 132, BP 105/70. Sweats. PE: Muffled heart sounds. Initial EKG elevated J-Point, non specific ST changes. Next Step?
Coronary Artery Bypass Graft & PCI: Percutaneous Coronary Intervention: *Only when MI diagnosis confirmed before mapping out coronary arteries with angiography
1-2Vessel Dz: Tx: PCI-Balloon & Stent
3-Vessel Dz or Lt Main CAD: Coronary bypass Graft
Echo:
*Diagnose Acute Ischemia: LBBB, LVH, Pacemaker, Non-specific ST-T segment changes on resting EKG, Young females
Unstable Angina dt LEFT MAIN CAD → NSTEMI: Occlude Lt Main coronary artery.
= Immediate Coronary Artery Bypass Grafting [Case: Unstable Angina due to LEFT MAIN CAD]
[Lecture]
Coronary Artery bypass Grafting CABG:
*Left Main Coronary Stenosis >50% *Lt main equivalent: 70% stenosis of PROXIMAL LAD, Lt Cx
*3 vessel Disease
*Symptomatic Acute Coronary Sd with ongoing Ischemia…not responsive to Maximal Nonsurgical Therapy
68yoM. Compalins of dull, central chest pain and tightness. Pt feels SOB. PE: Sweating profusely. Distant heart sounds, regular rate and rhythm. EKG: No ST-elevation. Cath lab, Coronary Angiogram shows 60% occlusion Left Main coronary artery. Next best Step?
Cocaine-induced cardiac ischemia.
Rx: IV Diazepam
Acromegaly pt case -1) Order IGF-1 Renal Artery Stenosis →
HTN this case.
Essential HTN is MCCO HTN (91%)
Renal Artery Stenosis: HTN in this case: Clues: 1) sensitive to ACE-I 2) ↑Creatinine 3) her CHF
[moa: Renal Artery Stenosis depends on Vasoconstriction of Efferent arteriole to maintain GFR. But ACE-I abolish vasomotor tone in the Efferent Arteriole → results in Worsening renal function]...renal improves by removing ACE-I
68yoF. Difficult to control HTN. She has 3year h/o HTN and documented intolerance of ACE-Inhibitors-see by rapid decline in her renal function. She has had 2 episodes of Acute Pulmonary Edema in past. 2 weeks ago her Cr: 1.3mg and UA: Microscopic
hematuria. BP: 180/100. PE: Prominent Apical impulse. Which most likely cause of this pt's HTN?
Coarctation of Aorta= Pulses Equal & Symmetrical
*Pt die YOUNG if defect not corrected in Childhood AAA: Abdominal Aortic
Aneurysm Abdominal U/S: ultrasound
*Cost Effective screening.
*Definitive test when AAA suspected (Sensitivity & Specificity almost 100%)
(CT scan of abdomen w/IV contrast… is 2x expensive as U/S. Exposes pt to unnecessary radiation) - CT
abdomen usually preop so surgeon can develop plan
74yoM abdominal pain. Mid-umbilical region dull, aching, constant pain. Pain persisted over past few days with increasing intensity, and not relieved by changes in
positioning or eating. Pulsatile mass in abdomen. Diagnostic test at this time?
MRI: detects abscesses or spinal cord compression
DM+HTN…Proteinuria
Rx Start Lisinopril
BP must be well controlled to prevent Nephropathy progression ACE-I prevents diabetic nephropathy
66yoF recent DM2. Her BP 3 months ago was 140/95, exercise and eat a low-salt diet. Gain 4.4lb. BP 144/95. Next best step?
Acute Coronary syndrome:
STEMI Aspirin, Heparin, Alteplase combo
STEMI: need urgent revascularization w/n 90mins need procedure: Angioplasty & Stent
>90mins delay: give Thrombolytics (Alteplase) - 25% mortality
reduction
LMWH > unfractionated heparin
74yoM Stable angina & diaphoresis. BP 145/93. PE: JVD+, basilar crackle, peripheral pulses faint. CXR: Pulmonary edema. EKG: inferior ST-segment elevations. Closes hostpital with angioplasty is 2hours away. Which drugs most appropriate? Subacute Bacterial Endocarditis: - MR TEE: Transesophageal enchocardiogram
to see if has Valve Vegetation…to estimate degree of Mitral Valve destruction
TEE > TTE if other is not possible. TTE=less sensitive/doesn't help tell amount of damage to valve
40yoM 2week h/o fever, anorexia, weight loss, fatigue. PE: appears ill, T: 102, few petechiae in both eyes. CVS: III/VI pan systolic murmur max at apex and radiates to axilla, and pericardial rub. Blood drawn and culture. Which is diagnostic test most likely to confirm diagnosis?
Intracardiac lesion - dt large Lt Atrial MYXOMA
Obstruction Sx.
Emboli: to CNS, Lower limbs etc.
Intracardiac Lesion
*Mid-diastolic rumble best heard at apex = Mitral Stenosis or Large Atrial MYXOMA (= MC cardiac tumor = obstructs Mitral Valve) *Neuro: arm weakness…bc Tumor Emboli…Low fever = a tumor
58yoF. Episode of Left upper arm weakness resolved after 6 hrs. Low fever last month. Mid-diastolic rumbling murmur on fifth intercostal space at midclavicular line. Sent for Echo. What's likely to reveal?
Acute Pulmonary Edema dt CHF
Rx:
1) IV Loop-furosemide, Nitrates, Morphine
Intravenous loop diuretic, nitrates, morphine
= Reduces PRELOAD (associated with Acute Pulmonary Edema)
(Loop - venodilation then diuresis… moves fluid from lungs to
circulation, then expelled to urine → ↓VR)
Nitroglycerine: venodilates, dilates epicardial coronaries...tx: ischemia Morphine: ↓Anxiety, ↓Sympathetic outflow, Venodilates &
↓Preload...help relieve pulmonary edema
MUGA scan:
(multigated acquisition) inject 99mTc - attaches to RBC …outlines cardiac chambers - LV by imaging the isotope in central circulation during systole & diastole.
Determines EF in pts with sx of Chronic Heart Failure
(Invasive…not for acute setting, or acute pulmonary edema)
Aortic Coarctation *usually asymptomatic *Lesion found on PE. IF Symptomatic:
*Headaches, Nosebleeds, sx: ↓Lower limb perfusion
Aortic Stenosis:
Coarctation of Aorta associated with several cardiac lesions:
*VSD
*Bicuspid Aortic Valve *Lt Ventricular Hypoplasia
Bicuspid Aortic Valves are associated with higher rate of aortic stenosis & insufficiency
30yoM. BP 160/70. PE: Brachial pulses more prominent than femoral, popliteal, dorsalis pedis pulses. CT scan of chest w/contrast shows coarctatino of aorta just above ligmentum arteriosum. Which conditions likely associated with pt's condition?
BLOCK 7
PTCA: Percutaneous Transluminal Coronary Angioplasty with stent insertion: 2 vessel disease Important Exception is DM pt…Tx: Coronary Bypass even if 2 vessel disease present (DM with Non-ST segment elevations + 2vessel
disease….↓Mortality 2-5yrs) PTCA unless:
*Lt Main stenosed (urgent bc if thrombosed....then all 3 major coronary a. blocked)or
*3vessel disease
*significant Lt equivalent disease (>70% stenosis of Proximal LAD, Proximal LCx)
= do Coronary Artery Bypass Grafting
68yoF CP. Dull CP everytime she walks her grandchildren to school. Now she stops and rest for 5 mintues so pain could subside. Denies CP at rest. LDL 140, statin added. Coronary angiography shows patchy disease in distal part of LAD & distal part of Circumflex. Next best step? Femoral Pseudoaneurysm: complication of cardiac catheterization Femoral pseudoaneurysm *Pulsatile mass *Femoral Bruit
*Loss distal pulses/cool mottled lower limb
Confirm: Ultrasound of groin
68yoF underwent cardiac catheterization via right femoral artery earlier in the morning. She's no complaining of a cool right foot. PE:
Pulsatile mass over her right groin with loss of her distal pulses, auscultation bruit over point which right femoral artery entered. Diagnosis?
Cholesterol Emboli
Syndrome: complication to recognize in
post-catheterization patient
Cholesterol emboli presents with Skin findings:
*Distal extremities of Livedo Reticularis, Ischemic Ulcerations, Cyanosis, Gangrene, Subcutaneous nodules
Med SE:
Started new med (ACE-I), gets Cough… now switch to Losartan (ARBs)
Stop Fosinopril and replace with Losartan
ACE-I get dry cough dt ↑Kinin levels
48yoF persistent dry cough….currenty taking fosinopril….
Clear the patient for hip surgery Aortic Valve Replacement
indications in Aortic Stenosis pt:
1) Severe AS+Sx 2) Severe AS in pts
undergoing CABG or Valve repair
3) Severe AS with LV EF <50% Balloon valvulotomy is reserved for adults who are poor surgical candidates bc procedure has high rate of Re-stenosis
68yoF. No major illnesses. Systolic ejection murmur heard. Normal S1 and physiologically split S2. TTE: aortic valve diameter 1.4cm with moderate aortic stenosis, with EF 55%. Appropriate treatment for this patient?
Quit smoking → ↓Morbidity & Mortality
Aortic Dissection: = an emergency
1) Hemodynamic stable? 2) No: Give Labetalol 3) Yes:
*TEE: (pt is intubated) acute CP or when cx unstable *MRI: chronic
CP+hemodynamically stable *Spiral CT w contrast: initial screen in pts with suspected aortic dissection
Labetalol
Aortic Dissection:
*Vitals: hemodynamic state? *HTN → Aortic Dissection/Aortic Rupture.
1st) Control BP: Labetalol (a & b blocker) → ↓Pulse (<60/min ideal), vasodilation
*Keep SBP 100-120
(Not: Nitroprusside, TEE, TTE)
62yoF CP/N/SOB/sudden dysphagia. Pain radiates to left jaw and back; not increased or relieved by changing body position. Diagnosed 7yr ago with HTN treated with HCTZ. BP: 160/92, P115, R26. PE: Apical Impulse with regular rhythm, and asymmetric pulses on upper extremities. Breath sounds diminished on left. EKG: LV hypertrophy but no ST-segment alterations. CXR: hazy aortic knob+mediastinum wide. Next best step?
Asthma or COPD:
avoid Propranolol or Non-selective BB
B1 selective: Metoprolol is ok
Propranolol
NS BB can cause: Bronchospasm (blocks b-receptors in bronchial tree) b+ → bronchodilation
b- → bronchoconstricts
38yoM new onset Wheezing. h/o HTN, been on propranolol, enalapril, HCTZ. BP 134/88. PE: soft expiratory wheezes. Med most likely contributes to pt's wheezing?
Congestive Heart Failure Acute Pulmonary Edema
Rx:
1) IV furosemide, nitrates 2) if no response to these meds, give: Dobutamine to ↓Afterload and ↑Cardiac Output (Pos. Inotrope) Dobutamine SE:
Hypotension (↓Afterload) Rx: Dopamine (↑Afterload)
Dopamine
If pt doesn't respond to: IV
furosemide, nitrates, morphine (all reduced PRELOAD)…give:
Dobutamine (pos. Inotrope & Decreases AFTERLOAD → ↑Cardiac Output)
Risk: HYPOTENSION ↓BP bc afterload reduction
If Hypotension → give DOPAMINE (pressor effect:
↑AFTERLOAD...reverses severe Hypotension effect of Dobutamine)
56yoF h/o DM2, panic, stable angina. Has SOB. Suddenly difficulty breathing. No CP.BP 152/94. Lung: Rales, JVD present. Treated with IV furosemide, glyceryl trinitrate, and morphine, but do not relieve her symptoms. IV dobutamine begun and 10mins later BP 75/60. Next best step?
Pulmonary Regurgitation dt: idiopathic, traumatic, or iatrogenic…could've occur from Surgical Repair of Tetralogy of Fallot.
Pulmonary Regurgitation
*can be long-term complication of ToF surgical repair.
*diastole murmur in 2nd Lt intercostal space
*Long-standing pulmonary regurge → RV failure…presents with Tricuspid Regurgitation and an S3 gallop
36yoM h/o cardiac surgery in childhood. PE: Systolic thrill at left sternal border, soft diastole murmur at heart base that increases with inspiration and decreases with Valsalva maneuver. Extra sound heard after diastole and wide split second heart sound. Diagnosis?
Post-MI complication of CHF: (All listed: Cardiac
tamponade, Free wall rupture, Papillary m. rupture, RV infarct)
*pt doesn't present with tamponade findings: Clear lungs, Pulse paradox (↓SBP >10 w/inspiration)
*Free wall rupture:
hemodynamic collapse...as result of Tamponade (2 answers same/vaguely same = both wrong answer) *RV infarct...lungs clear w/no Rales
82yoM CP. 8hrs earlier he began experiencing dull, "crushing" CP that radiated to his Lt arm. Dyspnea. N/S a lot. Finally decided something must be done...called 911. BP 168/82. PE: moribund,
facemask. 12hrs after admit, BP 103/62 drop. JVD. Auscultation: Scattered Rales & Wheezes. Diagnosis?
Stable Angina- angiography Max therapy: *ASA *Statin (Goal LDL <100, 70mg optimal) *Metoprolol HR: <60 If HR>60, ↑Dose metoprolol before Angiogram is done.
Perform Coronary Angiography Stable Angina sx or on Maximal med therapy for Stable angina…should do coronary angiography to determine if next step should be ANGIOPLASTY w or w/o STENTING or CABG
Angioplasty improves SYMPTOMS (not mortality)
Angioplasty indications: *Stable Angina
*Survives Cardiac Arrest or Vtachy, Vfib
*CHF
Essential Hypertension CCB
Essential HTN, eventually can't control BP purely with Diet & Exercise
CCB for SBP
CCB for Raynaud phenomenon, and prophylaxis to migraines
58yoF. HTN. Wt loss & diet restriction for 6mo….Has Migraines, Raynaud, BP 155/85. Drugs most appropriate for this pt? Hypertension WITHOUT other comorbidities: Thiazide (inexpensive) Raynaud sd: CCB DM: ACE-I, Thiazide, BB, CCB COPD/Asthma: Avoid BB
Post-MI: BB, ACE-I, Spironolactone CKD: ACE-I, ARB
DM+HTN Goal BP: 140/90
Add LISINOPRIL to his regimen ACE-I reduces Progression of Microalbuminuria & kidney disease in DM.
Give: ACE-I (-pril) to DM pt. - DOC bc Renoprotective
Also give ACE-I with normal BP & microalbuminuria in DM
58yoM, exercises 3x a week. h/o DM2, HTN. Currently on hydrochlorothiazide and metformin. BP 147/85 P 75/min. Next Step?
Hypertensive Emergency: *↑SBP & DBP + end organ damage
= Must Immediate IV Sodium NITROPRUSSIDE (↓BP by 25%), or IV Nitroglycerin, IV: Labetalol, Hydralazine, Esmolol, Enalapril… to reduce risk for cerebral, cardiac and renal infarcts
Give pt IV medication to reduce BP *↑BP & ↑ICP and Renal failure → Triage pt as Hypertensive Emergency
70yoM, blurry vision, blood-tinged urine. Hx of HTN & currently on BB, ACE-I, CCB. Forgot to refill his meds… BP 200/110, Flame hemorrhages, papilledema. Abdominal bruit. UA: 3+ RBC, RBC casts. Next best step? Hypertensive URGENCY: ↑BP alone, without symptoms or end-organ damage =Oral Hypertensives Tamponade *Pulsus Paradoxus *Hypotension *Electrical Alternans in pts w/Breast CA, Pericardial Effusion, RV Collapse
Pericardiocentesis w/Pericardial window
72yoF h/o HTN, DM, Breast CA…worsening SOB. PE: 90/60, SBP drops 60 on deep
inspiration. JVD+. CXR: Cardiomegly. ST elevations in leads II and III. Echo: Pericardial Effusion w Rt atrial collapse, RV collapse. Next step?
Pulmonary Edema: dt HF 100% oxygen
for HF → acute Pulmonary Edema 1) 100% oxygen 1st! (immediate relieves hypoxia)
2) then: IV Loop, Nitrates, Morphine (takes time)
3) Dobutamine if others don't work. (AFTERLOAD↓)
4) Hydralazine (↓AFTERLOAD) but SE: SLE like
If Hypotension after Dobutamine; Rx: Dopamine
56yo DM SOB. For past 6 hrs has dypsnea at rest, and cough sputum. BP 156/94. JVD+ & Pedal edmea. Sputum is bloodstained. Auscultation: Fine crepitations throughout chest. Next best Step?
Mitral Regurge mumur ↑: with Hand-grip
Maneuvers:
Amyl Nitrate: ↓Afterload Valsalva: ↓VR/↓AFTERLOAD
will ↓Murmur
Cardiogenic Shock
ASD: Atrial Septal Defect
Inotropic Drugs
Myocardial Ischemia → Cardiogenic shock.
Rx: Inotropes
↑Myocardial Contractility → improves Cardiac Output
Dobutamine, Milrinone (NOT EPI or NE)
62yo M, ICU, had acute MI whil undergoing coronary
angioplasty…XR: Pulmonary congestion…pulmonary edema. Wedge pressure 29, High pulmonary and systemic peripheral resistence. Appropriate treatment at this time? Hypertension: BMI: 30 (N: 18.5-24.9) ↓Weight → ↓BP by 5-20mmHg. Lifestyle modification: Smoking, Weight loss, ↓Alcohol, ↓Na diet, Aerobic exercise
Weight Reduction
PreHTN: SPB 120-139 or DBP 80-89…. 1st try Weight Loss
52yoM. PMI: elevated SBP. BP 154/92. BMI 30. Wants lifestyle modifications.
Recommendations to lower BP?
Atrial Septal Defect
*Relatively young female h/o fixed split of S2, Pulmonary Ejection murmur, RBBB…. = ASD
Inspiratory Split of S2 occurs dt ↑inflow into RV and delays closure of Pulmonic Valve.
ASD:
*Large LtoR shunts and
*Normal Pulmonary Artery Pressure Wide,
*Fixed Split S2 = pathognomonic
42yoF SOB 4months. S1 normal, but there's fix split S2. Midsystolic ejection murmur over left sternal border. CXR: Prominent pulmonary artery, increased pulmonary
congestion, cardiomegaly. EKG: RBBB. Likely diagnosis?
Emergent HTN+coexisting signs of IHD
=IV Nitroglycerin (DOC) (↓BP to prevent ischemic infarct of brain, heart, kidneys)
IV Nitroglycerin
Normally Emergent HTN: IV Nitroprusside (IF no comorbid sx) Here Pt has Comorbid Signs of Ischemic heart disease (CP) IV Nitroglycerin
62yoF CP, Pain began during morning walk. Dull Pressure over breastbone radiated to left arm. Not relieved by rest. BP 190/100. Agent to lower BP?
Transesophageal Echocardiogram
Aortic Stenosis: 60yoM CP w exertion. BP:
160/94. PE: regular S1, S2, S4 heard. Systolic crescendo-decrescendo murmur at Rt 2nd ICS radiates to Carotid Arteries. EKG: LV Hypertrophy. Which is most appropriate to confirm likely diagnosis?
Pulmonary Artery Capillary Wedge Pressure: measures LV End diastolic filling pressures and cardiac output. Thallium stress test: checks
"Hypoperfused areas" during exercise Pericardial TAMPONADE - complication of Transmural MI. = Emergency *Hypotension ↓BP *Equilibration of pressures in all chambers of heart
*Narrow Pulse Pressure *Low volt on EKG
arrange for Pericardiocentesis = to relieve pressure on heart (free wall rupture MC around day 7 post MI)
70yoM EKG acute MI. Vitals are normal… 6 days after
hospitalization, pt becomes confused, drowsy, complains of mild dyspnea. BP is now 65/50, P: 120, R25. Pulse ox 80%RA. EKG: Sinus tachy, Pulmonary artery cath placed: RAP: 18 (N: 2-10), RVP 30/18 (N: 15-30/0-5) PCWP: 17 (N: 5-11)
Next step?
Mitral Stenosis:
MS decreases LV filling and elevates Lt atrial pressures → Pulmonary Congestion. Sx:
*Lt HF - SOB, Dyspnea on exertion
*Hemoptysis occurs as result of Rupture of Small
Pulmonary Blood vessel *later: Pulm. HTN bc RV works against ↑P s/s chronic pulm congestion Increased S1 intensity Mitral Stenosis *Diastolic murmur *↑S1 intensity *Opening Snap
Late findings of MS after Pulm. HTN ensuded: ↑P2 heart sound
Sx: DOE, SOB, occasional Hemoptysis
56yoF h/o rheumatic fever. Slowly progressive DOE and orthopnea 6mo. Pulse 93 and irrgular, Mid-diastolic murmur near apex. Loud opening snap heard after S2. Rhythm
irregular. Likely to be found on PE?
Constrictive Pericarditis: can cause sx: CHF *JVD ↑w/Inspiration *S3 *Pericardial calcifications on CXR
*PA catheter by all 4 chambers have equal Diastolic Pressures RA pressure 20, RV pressure 32/20, PA pressure 34/20, PCWP 21 Constrictive Pericarditis: Sx: SOB dt developing HF. *Tachycardia *Hypotensive *Tachypneic
*Weak Pulse, Low C.O.
*JVD w/↑Inspiration (Kussmaul sign) (Neg. Pressure to venous inflow)…. peripheral edema, but clear LUNG
*Early diastolic sound (pericardial knock)
62yoM progressive SOB, fatigue, hypotension for 7months. JVD increases during inspiration and a weak pulse.
STEMI Ischemic Stroke
*Thrombolytics to revascularize the coronary arteries: tPA (tissue plasminogen activator) Contraindications:
1) h/o Cerebral hemorrhage at any time
2) Structural cerebral vascular lesion 3) Malignant intracranial tumor 4) Ischemic Stroke w/n 3months 5) suspected aortic dissection 6) Active bleeding or bleeding diathesis (not menses)
7) Closed-head trauma or facial trauma in 3 months
70yoM Substernal CP. Crushing 8/10 intesnity without
radiation. …. EKG: ST-elevation Leads V1-Ve with LV
hypertrophy. Aspirin 325 given. Which is absolute
contraindication to initiating thrombolytic in this pt?
Constrictive Pericarditis Pericardial Knock
Constrictive Pericarditis from Chronic Scarring → Loss elasticity of pericardial sac
Pericardial Knock (sound just before S3) results from Sudden Cessation of Ventricular Filling… as Ventricle is prevented from expanding further by Rigid Pericardium
42yoF 3mo h/o DOE. No CP. h/o of rheumatoid arthritis, no famHx of CAD. Lateral CXR shows Calcification of Heart Border. Diagnosis of
Constrictive Pericarditis made. PE: Likely to be seen?
Pheochromocytoma… *Catecholamines… *Paroxysmal or Persistent Hypertension *Tachycardia *Sweating
*Feeling of Impending Doom = sx bc high Catecholamines
Plasma Fractionated Free
Metanephrines 50yoM having transient Rapid heartbeat followed by Sweating, Flushing, sense of Impending doom. BP 195/140, P: 160 during the episode. Goes to ER, but all that is gone by time he's seen. Which is most sensitive test for diagnosing the condition?
Chronic Atrial Fibrillation Decrease the Warfarin Dose Why:
*Amiodarone drug interaction risk w/Digoxin and Warfarin
48yoF treated with Atenolol and Warfarin for last 4 months for Atrial Fibrillation in clinic bc Claudication for last 6wks. PE: bilateral 1+ ankle edema & diminished pulses. ABI: 0.8. Stopped Atenolol bc no structure abnormalities. She's started on Amiodarone. Next Step?
SVT: Supraventricular Tachycardia
ORDER:
1st) Carotid Massage
2) Valsalva (if can't do carotid massage/carotid bruit-stenosis)
3) Adenosine > Verpamil = DOC (if got both choice, pick adenosine)
Forcefully exhaling against closed mouth and nose
SVT: EKG TachyC >100
*Pwaves preceds normal QRS Tx:
1st: VAGAL maneuvers: Carotid massage - usually
But this Pt has Soft Blowing murmurs on neck auscultation = bilateral Carotid stenosis = so CAN'T Do carotid massage
Next best: Valsalva
66yoF palpitations, SOB, lightheadedness. h/o HBP takes water pill. BP: 105/65, P 152, R: 16. PE: distress, ausculation of neck - bilateral bruit, CVS: distant heart sounds, no rubs or gallops. EKG shows…. NEXT BEST STEP?
Synchronized cardioversion: for Hemodynamic unstable patients (Unconsciousness or shock w/severe HF) = need immediate termination of Tachyarrhythmia
RV infarct
(Dopamine is useful if IV fluids alone don't help BP… but risk: Cardiac
ischemia/pressor)
(Metoprolol: can't be used forBradycardia or
Hypotension) - No BB for low BP
Nitroglycerin: avoid in RV infarcts…bc it's a PRELOAD Reducer…↓RV filling & ↓CO
IV Fluids (to maintain BP)
EKG: ST-elevations (II, III, avF) = RV Infarct
ST elevation in V4 = is RV infarct specific (now preload
dependent….need to keep PRELOAD HIGH)
56yo h/o HTN &
Hyperlipidemia. Crushing CP, Diaphoresis, nausea for past 3 hrs. BP 82/60, Pulse 103/min. PE: JVD, no murmurs, clear lungs. EKG shown. Appropriate for this pt?