Presentation of sick sinus syndrome and ECG findings
Impaired SA node automaticity (degeneration/fibrosis of SA node)
- fatigue, lightheadedness, syncope, presyncope, palpitations
- ECG: alternating bradycardia and tachyarrhythmias (tachycardia-bradycardia syndrome); sinus pauses/arrest, SA exit block
Side effects of ACE inhibitors
Cough, drug-induced angioedema
Lab work up of new hypertension
Renal: Electrolytes, Cr, UA (hematuria/proteinuria), Ur albumin/Cr ratio
Endocrine: fasting glucose, a1c, lipid profile, TSH
Cardiac: ECG (LVH or previous MI), echo (optional)
Which bacteria cause endocartitis after dental manipulation or respiratory tract incision/biopsy?
Viridians streptococci (sanguinis, mutans, mitis, milleri)
Tx of torsades de pointe in hemodynamically unstable vs. stable patients
Unstable- defibrillation
Stable- IV Magnesium sulfate
Presentation of Pericarditis
substernal, pleuritic chest pain- better when leaning forward
- inflammatory, infectious, or malignant etiology
- Widespresad ST elevations and PR depressions on ECG
Presentation of endocarditis
**staph aureus= acute, viridans= subacute
- valve dysfunction or vegetations on echo
When do murmurs get louder/softer?
Right sided murmurs louder with inspiratoin
- RINSpiration
Left sided murmurs louder with expiration
- LEXPiration
Increased preload- more flow over murmur (squatting, leg raise)= LOUDER murmurs
Except: HOCM/MVP
*more blood flow over septum pushes hypertrophied septum back into normal positioning and decreases murmur sound
Decreased preload (less blood across heart)- valsalva= SOFTER murmurs
Except: HOCM/MVP
**less blood= septum not back in position= louder murmur
Increased afterload (more back-pressure on heart)= louder regurgitant murmurs, softer HOCM/MVP
Decreased afterload= louder HOCM/MVP
Aortic Stenosis
Crescendo decrescendo systolic murmur, radiates to carotids
- Old patient - syncope, angina, dyspnea
- calcified valve
- bicuspid aortic valve
- pulsus parvus et tardus (late, weak pulse)
Mitral regurgitation
Tricuspid regurgitation
Holostystolic murmur
- rheumatic fever
- radiates to axilla
Tricuspid- holosystolic, IVDA
Mitral stenosis
Opening snap
- hx rheumatic fever
- diastolic
VSD
holosystolic HARSH murmur
- down syndrome, cru di chat, edward syndrome, patau syndrome, TORCH infections
Aortic regurgitation
high pitched, blowing early diastolic decrescendo murmur
- acute= infective endocarditis
- Chronic= bicuspid aortic valve
- Valvular AR best heard along left sternal border
- AR due to aortic root dilation can be heard on left and right sternal borders
Miral stenosis
Opening snap with delayed diastolic rumbling murmur
- SLE, RA, rheumatic fever
- mimckers= left atrial myxoma, bacterial endocarditis
PDA
- continuous machine like murmur (both systole/diastole)
- congenital rubella, premature infants (FAS, fetal hydantoin syndrome- phenytoin use)
Keep open with prostaglandins
Close with indomethacin
Constrictuve pericarditis presents with:
- kussmaul sign- increase in JVP with inspiration
- can also be seen in tamponade
Pulsus paradoxus
Fall in systolic BP >10 with inspiration
- Cardiac tamponade or constrictive pericarditis
Treatment of:
SVT (narrow complex)
Ventricular tachcardia (wide complex)
SVT: adenosine
VT: amiodarone
Who should recieve antibiotic prophy for infective endocarditis?
Just people with prosthetic heart valves or previous IE
Atrial septal defect
Left to right shunting
- Wide and fixed splitting of S2
- mid-systolic or ejection murmur over LUSB
- mid-diastolic rumble
First line tx for patients with septic shock who do not respond to fluid repletion
Norepinephrine
First line tx for patients with cardiogenic shock
Dobutamine
Treatment in acute myocardial ischemia
What treatment decreases the chest pain in acute MI?
Morphine, oxygen, nitrates (venous dilatation), aspirin, beta blockers, LMWH, possibly statins
Venous dilation (via nitrates)- decreases LV preload and therefore reduces stress on ventricle- decreased myocardial oxygen demand
Tx of hyperkalemic emergency (usually >6.5)
IV calcium gluconate or and/or insulin+dextrose
- can result in heart block
