1
Q
1st degree AV block - ecg change
A
consistent, prolonged PR interval >0.2 d/t AV node delay
2
Q
1st degree av - pres
A
most asx unless other conditions
3
Q
1st degree AV - management
A
d/c medications that contribute to AV node blockade: adenosine, BB, CCB, digoxin
-observe
4
Q
2nd degree AV - ecg
A
type 1: wenkebach - progressive prolongation of PR leading to dropped QRS d/t AV node dz
type 2: mobitz - same PR w/ randomly dropped QRE d/t his-purkinje fiber dz
5
Q
2nd degree AVB - prese
A
most asx ,some can have syncope / dizziness / CP / palpiations w/ assoc conditions
6
Q
2nd degree AVB - management
A
type 1 - same as 1st degree
type 2 - REQUIRES PACEMAKER - OFTEN PROGRESSES TO COMPLETE HEART BLOCK!
7
Q
3rd degree AVB - ecg
A
AV dissociation - no correlation b/n P and QRS w/ ventricular rate b/n 25-40
8
Q
3rd degree AVB - pres
A
dizzy, syncope, confusion, dyspnea, chest pain, SCD
9
Q
3rd degree AVB - workup
A
- CBC and CMP - r/o infection, metabolic disturbance
- CXR
- echo
- ecg
10
Q
3rd degree management
A
REQUIRES PACEMAKER!
-discontinue AV blockers - may need IVF, vasopressors for OD CCB and BB
11
Q
mitral regurgitation- pathophys
A
acute: a/w endocarditis or rupture leading to rapid LA filling w/o time to compensate –> pulmonary edema, reduced CO w/ hypotension and shock
chronic: gradual dilation of LA and LV with LV dysfunction leading to pulmonary hypertension
12
Q
Mitral regurgitation - causes
A
acute: endocarditis, papillary muscle / chordae tendinae rupture
chronic: MVP, cardiomyopathy, rheumatic fever, marfans
13
Q
Mitral regurg - pres
A
acute: abrupt onset CHF and shock - dyspnea, thready pulses, orthopnea, peripheral vasoconstriction
chronic: dyspnea on exertion, PND, orthopnea, fatigue, palpitations / AFib
14
Q
Mitral regurg - murmur
A
holosytolic at apex, radiating to axilla
15
Q
mitral regurg - PE
A
displaced PMI, holosystolic murmur, JVD, edema,ascites, s3
16
Q
mitral regurg - dx
A
echo - definitive
cxr: dilated Left heart / cardiomegaly, pulmonary congestion
17
Q
mitral regurg - tx
A
acute: emergent! ABCs, intraortic balloon pump, MV repair
chronic: afterload reduction w/ vasodilators and diuretics
-w/ asx: mild - monitor clinically q 1 yr
mod - clinically and echo q 1 yr
severe: clinical and echo q 6-12 mo
18
Q
mitral stenosis - causes
A
1 RHEUMATIC HEART DISEASE! - causes fibrosis and scarring and thus narrowing of valve d/t cross reactivity to strep antigen
19
Q
mitral stenosis - sx
A
- worse w/ anything that increase blood flow across mitral valve i.e. exercise, tachycardia
- often asx until <2.5 cm - sx d/t pulmonary congestions - dyspnea on exertion, orthopnea, PND, fatigue, palpitations
- adv dz: pulm HTN, RHF sx, hemoptysis and hoarseness (irritated recurrent laryngeal nerve), dysphagia
20
Q
mitral stenosis - pathology
A
- increase LA pressure, dilation and pulmonary HTN
- can cause afib!
21
Q
mitral stenosis murmur
A
diastolic decrescendo low rumbling at apex, increasing w/ inspiration
22
Q
mitral stenosis PE
A
- loud S1 (hallmark!!) w/ diastolic murmur, RHF sx
- mitral facies
23
Q
mitral stenosis dx
A
ecg: atrial enlargement, RAD d/t RVH, a fib
echo: dx - mild d/t LA enlargement
24
Q
mitral stenosis tx
A
meds: tx afib - CANNOT USE X INHIBITORS MUST USE WARFARIN!
diuretics for pulmonary congestion, BB or CCB for tachycardia
-abx w/ h/o rheumatic: PCN IM> PO take continuously
-if sx: balloon valvotomy and mitral vave surgery when severe
25
most common arrythmia w/ digoxin
paroxysmal atrial tach w/ 2:1 block
26
multifocal atrial tachycardia is a/w...
CHRONIC LUNG DZ...COPD!`
27
MAT traits
rate >100, 3 different p waves w/ variable PR and RR intervals
28
difference b/n MAT and wondering pacemaker...
MAT rate >100, wondering pacemaker 60-100
29
MAT dx
1. ecg
| 2. vagal manuever / adenosine doesnt cause av block (because coming from different foci)
30
MAT treatment
w/ LV function preserved: BB, CCB, digoxin, amiodarone, flecanide, propafenone
w/ LV dysf: digoxin, diltiazem, amiodarone
31
paroxysmal SVT - patho
2 mech:
1. most common: AV nodal reentry - 2 pathways w/in AV node
2. orthodromic / accessory pathway - "concealed bypass tract"
32
paroxysmal SVT ecg
>100 w/o P waves for reentry, may see w/ accessorry pathway
| NARROW QRS COMPLEX!
33
paroxysmal SVT causes
1. ischemic heart dz
2. nodal reentry, accessory pathway
3. digoxin
4. caffeine, ETOH
5. a flutter w/ rvr
34
paroxysmal svt acute tx
1. vagal manuevers
2. adenosine (se: headache, flushing, nausea, sob, chest pain)
3. verpamil, esmolol, digoxin
4. cardioversin if refractory / unstable
35
paroxsymal svt prophylaxis
1. digoxin most common
2. verapamil, BB
* ablation w/ recurrent symptomatic episodes
36
PAC - causes
adrenergic excess, alcohol, drugs, tobacco, electrolyte disturbance, ischemia
37
PAC - ecg
change in p wave morphology, narrow QRS, pause
38
PAC - tx
- most asx, w/ sx can give BB
| * benign in normal heart, may be precursor to ischemia in w/ structural abnl
39
PVC - causes
hypoxia, electrolyte abnl, stimulants / caffeine, meds, structural dz
40
PVC - ecg
early beat w/ no p wave, wide QRS,
couplet: 2 successive
bigeminy: every other
trigeminy: every third
41
PVC - workup
w/ frequent / recurrent, espeically with structural heart disease need workup b/c at inc risk sudden death - order electrophysiologic study
42
PVC - TX
```
if sx (palpiations, dizzy) - BB
w/ recurrent + structural dz may need ICD
```
43
young patient w/ pleuritic chest pain, worse w/ lying down and improved when sitting, leaning forward. was sick 1 week ago....suggests
ACUTE PERICARDITIS
44
hallmark signs pericarditis
1. pericardial friction rub (best heard seated, leaning forward at lower LSB)
2. pleuritic, positional chest pain (improved seated, leaning forward)
3. diffuse ST elevation and PR depression
4. pericardial effusion
45
acute pericarditis causes
1. idiopathic (often postviral) - majority of cases
2. viral - esp COXSCAHIEIRUS
3. acute mi - w/in 24 hr
46
acute pericarditis ecg changes
4 stages:
1. diffuse ST elevation and PR depression
2. normalization of ST and PR
3. diffuse T wave inversion
4. normalization of T waves
47
acute pericarditis workup
1. ECG
2. echo w/ signs of effusion - get TEE
3. labs: cbc (leukocytosis), elevated ESR, CRP
4. CXR - r/o pulmonary process
48
acute pericarditis tx
uncomplicated:
1. NSAIDS: ibuprofen 600 mg tid or indomethacin 50 mg tid - taper q 1-2 weeks
2. ASA - preferred w/ recent MI 750-1000 mg tid, then to bid then qd
3. colchicine - adjunt to nsaids
4. corticosteroids - for CT dz / refractory to nsaids
* most resolve 1-3 weeks
49
indications for surgery w/ acute pericarditis
pericardiocentesis if:
1. cardiac tamponade
2. purulent / tuberculous / neoplastic effusions
- do pericardial biopsy w/ recurrent effusions
50
constrictive pericarditis - background
rigid, fibrotic pericardial sac that impairs LATE diastolic filling (in tamponade all of filling is impaired)
51
constrictive pericarditis causes
-most idiopathic or viral
52
constrictive pericarditis pres
2 main:
1. fluid overload - JVD, ascites, hepatomegaly, edema
2. decreased cardiac output - fatigue, dyspnea on exertion, palpitations, dec exercise tolerance
53
constrictive pericarditis - PE
* **JVD w/ Kussmaul sign (no decreased in JVD w/ inspiration)
- pericardial knock: a/w rapid decline in ventricular filling
- edema
54
constrictive pericarditis - workup
1. ECG - nonspecific, may have afib
2. echo - increased thickness w/ decreased late diastolic filling
* *3. CT / MRI - best to show increased thickness and calcification
4. cath - shows equal diastolic pressures and rapid y descent in ventricular pressure (sq root sign) when filling stops
55
constrictive pericarditis tx
1. aimed at underlying cause
2. diuretics w/ overload
* admit w/ fever, large effusion, tamponade, refractory
- watch for coagulopathies, immunocompromised
56
contraindication w/ pericarditis
DON'T GIVE HEPARIN AND DON'T DO EXERCISE STRESS TEST!!! RISK OF HEMORRHAGE!
57
new heart murmur and fever suggests...
INFECTIVE ENDOCARDITIS!
58
infective endocarditis pathogens
acute: staph aureus
subacute: strep viridans (alpha-hemolytic)
native value: most d/t strep viridans, then staph and enterococci
prosthetic valve: early (win 60 days) staph epidermidis > aureus, then late (>60 d) strep
IV drug users: staph aureus affecting TRICUSPID VALVE
59
presentation - infective endocarditis
fever, malaise, fatigue weight loss, CVA / TIA sx
splinter hemorrhages, roth spots
janeway lesions: nontender hemorrhagic lesions on palms / soles
oslers nodes: TENDER raised red lesions on hands / feet
sx of CVA (increased embolic risk!!!)
60
diagnosis infective endocarditis
dukes criteria! 2 major or 1 major w/ 3 minor or 5 minor
major: visual vegetation / abscess on valve or displacement of prostehtic valve, new murmur / valve regurg, positive blood cultures x 2 for causative org
minor: PE findings, fever, vascular changes, predisposing heart conditions, positive culture
* *want TEE for echo
61
infective endocarditis tx
start antibiotics AFTER 3 blood cultures, do empiric tx first x 4-6 weeks
native valve: unasyn / augmentin + gentamycin
PCN allergy: vanco + gentamycin + cipro
prosthetic (<12 mo since surgery): vanco + gentamycin + rifampin
-prophylactic antibiotics for oral, gi/gu surgeries
62
most common valve affected
MITRAL VALVE!! MVP is predisposing!
63
prognosis
almost all fatal if untreated!
| complications: heart failure and CVA d/t emboli
64
patient w/ acute onset searing chest pain radiating to back w/ long-standing h/o HTN...
AORTIC DISSECTION!
65
types of aortic dissection
Type A: proximal to subclavian - involves ascending aorta
| Type B: distal to subclavian - involves descening aorta
66
aortic dissection causes
#1 HTN (70%)
in non-hypertensive, think CT dz - Ehlers
danlos and marfan
trauma, 3rd tri prego
aortic coarctation, bicuspid aortic valve
67
aortic dissection pres
- acute onset stabbing / tearing / searing chest pain, radiates to abdomen, back, scapula
- prox most a/w chest pain
- distal most a/w back / interscapular pain
- most hypertensive
- diaphoretic
- asymm pulses/ bp in UE
- neuro changes, LE weakness / paralysis
68
aortic dissection diagnosis
best CT! chest and abdomen!
TEE good for unstable, but rarely done
CXR - wide mediastinum (>8mm)
angiography shows extent of dissection
69
aortic dissection tx
MUST IMMEDIATELY LOWER BLOOD PRESSURE - ALWAYS GIVE IV BB 1ST! to decrease wall tension
-esmolol - good for bradycardia and asthmatic b/c short-acting (book / test answer)
-labetolol 20 mg over 2 min, then 40-80 mg over 10 prn or 2 mg/min infusion
-propranolol
-most often won't get BP down enough...give IV nitroprusside (book answer - dont give b/c get cyanide poisoning!! cyanide is byproduct) ...GIVE NICARDIPINE!
**goal BP: SBP 100-120
*avoid hydralazine! increases wall stress
Type A - surgical emergency!
Type B - medical management, do surgery w/ refractory symptoms or signs of malperfusion i.e. gut, kidney
70
aortic dissection - maintenance
need BB for blood pressure control and annual CT to monitor false lumen - if equal / greater than 6 need surgery
71
70 y/o w/ acute onset back pain x 1 hr. hx smoking, CAD, HTN. on exam, hr 116 and pulse 80/76 w/ pulsatile mass...what happened and test?
rupture AAA!!!! do CT!
72
whats a AAA?
dilation in aorta twice its normal size or larger.
| RF: smoking, HTN, family hx, increased age (>55 men and > 70 women)
73
AAA pres
most asx
74
testing for AAA...
screen >65 men w/ hx smoking w/ abdominal u/s!
| u/s cannot detect rupture!! do CT!! (see retroperitoneal blood!)
75
indications for repair...
1. size 5 cm or larger
2. symptomatic
3. rapidly enlarging
- do open or endovascular repair
76
t wave inversion and wide q waves on ecg suggests...
ACUTE MI!!
| -w/o q waves = ischemia
77
anti-htnsive meds to avoid in pt w/ hx nephrolithiasis...
loops! increase urinary calcium excretion! not good w/ ho calcium oxalate kidney stones
78
28 y/o AA male w/ dyspnea, mild substernal chest pain. S4 gallop w/ murmur best hear at LLSB, decreases w/ squatting and asymmetric LVH - septum twice as thick...dx and treatment...
HYPERTROPHIC CARDIOMYOPATHY!
1st line for symptomatic is adrenergic blockers = BETA BLOCKERS b/c decrease diastolic dysf and hr (dec o2 demand): metoprolol w/ target HR 50-60, propranol, atenolol
-septal myotomy = gold std w/ refractory to meds, dual vent pacing is less effective; minimal aerobics and AVOID DIGITALIS!
NITRATES CONTRAINDICATED!!!
79
week old baby boy w/ VSD w/ dyspnea, tachycardia and poor weight gain...tx...
1st line: digoxin, diuretics and afterload reduction to reduce pulmonary congestion!
2nd line: w/ failed medical tx or large VSD do surgical closure
-observe only if asx
80
fundoscopic findings and causes...
1. cotton wool spots
2. drusen
3. microaneurysm
4. macular star
5. deep retinal hemorrhages
1. cotton wool - HTN (nerve fiber infarcts)
2. drusen - ARMD
3. microaneurysm - diabetic retinopathy
4. macular star - malignant HTN
5. diabetes
81
what type of shock worsens w/ IVF administration?
CARDIOGENIC!!! pump failure leads to loss of 15-20% of CO - treat first w/ VASOPRESSORS OR INOTROPIC AGENTS!!! fluids worsen condition
82
whats treatment for neonate w/ machine gun murmur?
INDOMETHACIN! baby has patent ductus arteriosus - NSAIDS close PDA!
83
trousseau's syndrome
migratory thrombophlebitis and involvement of superficial veins at unusual sites and is assoc w/ malignancy - esp adenocarcinoma
-tx w/ HEPARIN until malignancy gone. warfarin is INEFFECTIVE!
84
benefit of spironolactone in pt w/ mi
blocks aldosterone-mediated ventricular remodeling!
85
silent MI common in...?
elderly diabetic!
| common pres: dyspnea and weakness!! changes in mental status, arrythmias, hypotension
86
ischemic pain at rest and worse at night w/ transient ST elevation...
PRINZMETAL ANGINA!!!
87
key diagnostic hallmark of prinzmetal angina???
coronary vasospasm on coronary angiography!
88
prinzmetal angina tx?
-nitrates, CCB
89
CHF framingham diagnosis requirements...
1 major and 2 minor sx
90
CHF framingham major criteria
1. acute pulmonary edema
2. S3
3. neck vein distension
4. JVD
5. PND
6. pos hepatojugular reflux
7. rales
8. cardiomegaly
91
CHF framingham minor criteria
1. extremity edema
2. night cough
3. D on E
4. hepatomegaly
5. pleural effusion
6. decreased vital capacity by 1/3
7. HR 120 or more
8. 4.5 kg weight loss or more over 5 days of treatment
92
postpartum cardiomyopathy...
- must be in 3trd trimester or w/in 6 mo of delivery
- 1/2 recover (mortality of 10-20%)
- same treatment as CHF, no ACE-I
* *avoid future pregnancies!
93
J point (osborn wave) seen w/ ?
hypothermia!
94
dyspnea on exertion, palpitations, hemoptysis w/ low pitched diastolic rumble at apex....
mitral stenosis! most d/t rheumatic dz!
| -increased s1 and opening snap common
95
holosystolic murmur at mid LSB?
VSD!
96
marfan w/ wide pp, high pitched blowing diastolic murmur w/ water hammer pulse...
AR!
| -no treatment needed unless sig MR or arrythmia!
97
holosystolic murmur at LSB that increases w/ inspiration...
TR!
98
pulsus paradoxus?
drop in systolic BP >10 in inspiration! a/w cardiac tamponade!!!
99
patient w/ bp 250/150, lethargic, headache w/ visual disturbance and mental status changes w/ hx asthma...tx?
malignant htn!
- nitroprusside infusion (nitroglycerin alt)
- no BB in asthmatic!
100
signs of cor pulmonale on ECG..
RAE: tall P in II, III, AvF
RVH: tall R in v1-3, deep S in v6 w/ st changes
101
tx for SVT
1. vagal
2. adenosine 6 then 12
3. verapamil 2.5 then 5
* cardiovert if unstable
102
teen w/ fever, arthritis, nodule on extensor tender and pink rash w/ central clearing and increased ESR...dx?
rheumatic!
| -test for antistreptolysin o titer!
103
high risk conditions that need abx prophylaxis...
1. marfan
2. coarctation
3. pda
4. prosthetic valves
104
paradoxical split s2
- normal: widened of s2 d/t increased blood flow to heart in inspiration
- paradoxical: narrowing of split d/t delay of left ventricular conduction
* LBBB, MI, AS, HTN
pulmonary
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