Internal Medicine CV

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What does "irregularly irregular" mean on an ECG?: Irregular RR intervals
Irregularly irregular rhythm without p-waves prior to each QRS: Atrial fibrillation
Etiologies of A-Fib (10): PIRATES:
Pulmonary (COPD, PE), Pheochromocytoma, Pericarditis;
Ischemic heart dz & HTN;
Rheumatic heart dz
Anemia;
Thyrotoxicosis;
Ethanol & cocaine;
Sepsis
Signs/symptoms of A-Fib (5): A FL PT:
Asymptomatic patient;
Fatigue (most common);
Light headedness, syncope;
Palpitations, skipped beats;
Tachypnea, dyspnea
Complication of A-Fib: diffuse Embolization
(often to brain, leading to TIA or stroke)
One of two possible Drugs given to A-Fib to control rate in an emergent situation: IV Calcium channel blocker:
Diltiazem
(or)
IV Beta-blocker:
Metoprolol
Drugs given to A-Fib to control rate in a non-emergent situation (2): oral Beta-blocker:
Atenolol
(and)
oral Calcium channel blockers:
Verapamil or Diltiazem
If cardioversion from A-Fib to sinus rhythm does not occur, what should patient be treated with?: Long-term anticoagulants

DOC:
Warfarin (1st)
Aspirin (2nd)
Dx: when the heart is unable to pump sufficient amounts of blood to meet the O2 requirement of the body causing blood to backup: Congestive Heart Failure
(CHF)
What are the systolic dysfunctions of CHF? (EF, Preload, LVEDP, contractility): Ejection Fraction < 40%
leading to Inc preload & LVEDP,
which leads to Dec contractility and Inc cardiac hypertrophy
What causes CHF exacerbation in previously stable patients? (10): FAILURE:
Forgot medication;
Arrhythmia, Anemia;
Ischemia, Infection;
Lifestyle (Inc sodium);
Upregulation (Inc cardiac output--pregnancy or hyperthyroidism);
Renal failure w/ fluid overload;
Emboli (pulmonary); Endocarditis
What are the diastolic dysfunctions of CHF? (compliance, contraction, recoil, LVEDP, CO, EF): Decreased compliance w/ normal contractile function
(ventricle either cant relax or fill properly)

leading to Inc stiffness, Dec recoil & coencentric hypertrophy.
LVEDP is Inc,
CO is nml,
EF is nml to high
Which type of CHF dysfunction--systolic or diastolic has a normal ejection fraction and is more common in women?: dyastolic
What related heart conditions are seen in the systolic dysfunction of CHF that deals w/ decreased contractility? (4): Ischemia(most common);
Dilated Cardiomyopathy;
Hypertensive burnout;
Valvular dz
What related conditions are seen in the systolic dysfunction of CHF that deals w/ Inc afterload? (3): Hypertension;
Aortic stenosis;
Aortic regurg
What related conditions are seen in the diastolic dysfunction of CHF that deals w/ abnormal active relaxation? (2): Ischemia;
Hypertrophic cardiomyopathy
(from disorders causing LVH)
What related conditions are seen in the diastolic dysfunction of CHF that deals w/ abnormal passive filling? (2): Restrictive cardiomyopathy;
Concentric hypertrophy from HTN
What are the early signs of Left-sided CHF? (2): Dyspnea on exertion;
Dec exercise tolerance
What are the late sx of Left-sided CHF? (8): PORNS DD Tits:
Paroxysmal Nocturnal Dyspnea;
Orthopnea;
Rales & crackles;
Nocturia;
S-3 gallop;
Diaphoresis;
Displaced PMI (laterally);
Tachycardia
What are the early signs of Right-sided CHF? (6): A Juicy CHERry:
Anorexia
JVD*
Cyanosis
Hepatomegaly
Edema in periphery
RUQ pain
What are the late sx of Right-sided CHF? (2): abnormal Hepatojugular reflex;
Ascites
What force causes the pulmonary congestion in diastolic dysfunction?: Increased hydrostatic pressure
what (3) ways can CHF be diagnosed by a CXR?: Enlargement of cardiac silhouette;
Pulmonary vascular congestion;
Kerley-B lines
(3) lab methods of diagnosing CHF: CXR;
Echocardiogram (function of ventricles);
Basic Natriuretic Peptide (BNP elevation)
AHA staging guidelines for CHF (stages A-D): A: at risk but w/o structural heart disorder

B: no sx, w/ structural disorder

C: prior or current sx & structure disorder

D: end-stage dz
NY Heart Assoc Functional Classes of Heart Failure (I-IV) [measures pt activity]: I: No limitation

II: slight limitation

III: Sx w/ minimal effort, ok at rest

IV: Sx at rest
SOB while lying flat: Orthopnea
What drug classes are good versus CHF? Which ones are only helpful if patient has a diastolic dysfunction?: Systolic or Diastolic dysfunction:
ACEIs/ARBs
Beta-blockers
diuretics

Diastolic dysfunction only:
Calcium channel blockers
Nitroglycerin
What diuretics are used for mild CHF and (2 for) significant CHF?: Mild:
Thiazides

Significant CHF:
Loop diuretics
Spirolactone
What is the difference in the signs/sx of people w/ right CHF and cirrhosis? (2): Same sx, except right CHF patients have trouble lying flat & have JVD
what are the (5) Tx for Acute Pulmonary Edema & Paroxysmal Nocturnal Dyspnea?: NOMAD:
Nitroglycerin
Oxygen
Morphine
Aspirin
Diuretic
What is the rule for prescribing beta-blockers for CHF?: never give during active CHF--add beta-blockers once the patient is diuresed to dry weight and on stable doses of other medications
Describe (2) types of Malignant HTN (+ BP limits): Hypertensive URGENCY:
systolic >200 or diastolic >110
WITHOUT evidence of end-organ damage

Hypertensive EMERGENCY:
Severe HTN w/ evidence of end-organ damage
(encephalopathy, renal failure, CHF, etc)
what is important to remember about treating a hypertensive emergency? (2): 1) Immediate therapy is needed
2) IV drip w/ Nitroprusside or Nitroglyerin, but do not lower BP by more then 1/4 at first, or patient can have a stroke
DOC for HTN w/o any comorbid dz: Thiazide
DOC for HTN w/ CHF (3): ACEI / ARBs
B-blocker,
K-sparing diuretic
DOC for HTN w/ MI (2): B-blocker & ACEI
DOC for HTN w/ osteoporosis: Thiazide
(dec. calcium excretion)
DOC for HTN w/ BPH: Terazosin
(Alpha-blocker)
DOC for HTN w/ pregnancy: alpha-methyldopa
(3) contraindications for Beta-blockers: COPD
Diabetes
HyperK
(3) contraindications for ACEI: Pregnancy
Renal artery stenosis
Renal Failure (creatinine >1.5)
contraindication of all diuretics: Gout
(2) hypersteroidism syndromes that cause HTN w/ hyperK: Cushing's

Conn's
endocrine system abnormality that can lead to HTN due to episiodic autonomic bursts of epinepherine: Pheochomocytoma
congenital cause of HTN that leads to HTN in arms and low BP in legs: Coartation of the Aorta
renal artery stenosis that causes HTN in: 1) older men 2) younger women: 1) atherosclerosis

2) fibromuscular dysplasia
valvular problem that causes HTN w/ a wide PP due to Inc SV: Aortic Regurg
congenital problem that causes HTN w/ a wide PP due to Inc SV: Patent Ductus Arteriosus
(3) drug classes that cause HTN What metal poisoning?: Oral contraceptives
Corticosteroids
Amphetamines

Lead poisoning
(5) deadly causes of chest pain: TAPUM:
Tension pneumothorax
Aortic Dissection
PE
Unstable Angina
MI
how is the maximum HR determined?: 220-patient's age = Max HR
(6) Major risk factors for CAD which is most prevetable? which is the greatest risk?: Diabetes (greatest)
Smoking (most preventable)
HTN
Hypercholesterolemia
Family Hx
Age
Chest pain that has an established character, timing and duration; pain is transient, reproducable and predictable. What is cause? What is Tx? (2): Stable Angina

Reduced coronary blood flow through fixed athrosclerotic plaque in vessel of heart

rest & nitroglyerin
exertional substernal (precordial) chest pressure and pain radiating to left arm, jaw or back. N/V, diaphoresis, dyspnea, HTN and tachycardia can accompany it. Name the types: Angina:

Stable
Unstable
Variant (Prinzmetal's)
Angina type that is also considered an Acute Coronary Syndrome (ACS). What (3) factors must it have for diagnosis?: Unstable Angina

1) New-onset
2) angina that changes or accelerates in pattern, location or severity
3) Occurs at REST
Similar characteristics of stable angina, but due to vasospasm instead of atherosclerosis. (2) Tx?: Variant (Prinzmetal's) Angina

Nitrates & Calcium Channel blockers
what (2) groups of patients may not show the classic signs pain seen in stable angina? Why?: Elderly & diabetics

(b/c: neuropathies)
What does the EKG look like for the (3) angina types?: Stable & Unstable:
- ST Depression
- T-wave Inversion

Variant:
- ST elevation
62-yo smoker w/ 3 episodes of severe heavy chest pain in the morning. Each lasted 3 - 5 minutes, but he has no pain now. He has never had this before. What is it?: Unstable Angina
62-yo man w/ frequent episodes of chest pain on and off for 8 months. He says the pain wakes him from sleep at night. What is it?: Variant (Prinzmetal's) Angina
what is the alternative to an exercise Stress Test if the patient cannot get on a treadmill?: IV Dobutamine is given to stimulate myocardial function
What is the criteria for a "positive" Stress Test? (5): either:
- ST elevation
- ST depression >1 mm in multiple leads
- Dec BP
- failure to go more than 2 minutes
- failure to complete for reason other then cardiac symptoms (i.e. arthritis)
what does Myocardial Perfusion Imaging detect? (3): - Myocardial perfusion
- Ventricular volume
- Ejection Fraction
An ultrasound of the heart revealing abnormal wall motion due to ischemia or infarction. It also assesses left ventricular function and EF: Echocardiography
(5) uses for a cardiac catherization: 1) MI / Unstable angina: stent or angiography
2) Valvular disease: valvuloplasty
3) Arrhythmias: mapping bypass tracts
4) Myocardial dz Bx: glycogen storage dz or cardiomyopathies
5) Congenital heart dz identification: angiography & closure of defects
(4) serum markers for MI: Myoglobin
Troponin T/I
CK
Lactate Dehydrogenase
How is the right heart accessed in a cardiac catherization? (2) Left heart? (2): Right:
Femoral or Internal Jugular

Left:
Femoral or Radial artery (from right heart)
what is the wave morphology changes sequence in a MI ECG? (6): 1. peaked T-waves
2. T-wave inversion
3. ST elevation
4. Q-waves
5. ST normalization
6. T-waves return upright
which cardiac enzyme is the most sensitive and specific for acute MI?: Troponin-I/T
which cardiac enzyme remains increased (peaked) the longest?: LDH
what does ST depression mean?: ST goes in the opposite direction of the QRS
what does a Q-wave on an EKG in the presence of an infarction indicate?: Transmural infarction
(extends through full thickness of the myocardial wall)
Time of onset for the (4) serum markers for MI: Myoglobin (1-4 hrs)
Troponin-I/T (3-12)
CK-MB (3-12)
LDH (6-12)
which cardiac enzyme has the shortest duration? Longest?: Myoglobin (1 day)

Troponin-I/T (7-10 days)
ST elevation in II, III & aVF: Inferior wall MI
ST depression in II, III & aVF: Cor Pulmonale
ST elevation in V1, V2, V3: Anterior/septal MI
ST elevation in V4, V5, V6: Lateral wall MI
ST depression in V1, V2: Posterior wall MI
difference b/t unstable angina & non-ST elevation MI? (2): non-ST elevation MI has:
1. more severe lack of Oxygen (more severe myocardial damage)
2. Enzyme leakage (Unstable angina has none)
Tx for Unstable angina & MI (6): MONA has HEP B:

Morphine
Oxygen
Nitrates
Aspirin
HEParin
Beta-blockers
primary Tx (2) for the acute MI w/in 6 hours of infarct (name 4 drugs): Throbolytics:
- tPA + Heparin (DOC)
- Urokinase
- strptokinase
- Alteplase
At what level should LDL be in person w/ MI history? What is given to lower it?: less then 100

statins
When are throbolytics indicated in MI? (3): - patients < 80 yo
- within 6-12 hrs of chest pain
- evidence of infarct on ECG
Contra-indications of Throbolytics (9): Having Some Breaks A Blood Clot In Small Pieces:
- Hx of intracranial bleed
- stroke < 1 year
- BP > 180/110
- active internal bleed
- bleeding disorder
- CPR
- Intracranial tumor
- suspected aortic dissection
- Peptic ulcer
drug class that is used to break up clots: throbolytics
drug that prevents future clots from forming: heparin
Tx of choice for MI if there is a high risk of ST elevation (cardiogenic shock) or it has been 3 hours since initial symptoms presented?: PTCA
(Percutaneous Transluminal Coronary Angioplasty)
which throbolytic is highly immunogenic and cannot be used in the same patient twice in a 6 month period?: streptokinase
what should be given 48 hours post infarct if tPA was used?: heparin
drug class that is excellent for late & long-term therapy for acute MI to decrease afterload and prevent remodeling?: ACEi
how many seconds & boxes is a normal PR interval?: 0.2 ms

5 small boxes
define: Q-wave When is it pathologic?: when initial part of ventricular depolarization is downward

Pathologic: greater then 1 small box
normal time & boxes for QRS interval?: < 0.12 ms

3 small boxes
normal sinus rate: 60 - 100 bpm
define: Junctional rhythm: rhythm originating in the AV node & causing narrow QRS w/o P-waves
no p-waves; all complexes are wide; no changes in height (amplitude) w/ each complex; > 100bpm: Ventricular tachycardia
wide QRS complexes that vary in amplitude (2 names): Ventricular Fibrillation

Torsades de Pointes
normal sinus rhythm w/ PR interval > 0.2 ms (> 5 small boxes): First-degree AV block
PR interval elongates from beat to beat until it becomes so long that a beat drops: Second-degree AV block, type 1
(Wenckebach)
PR interval is fixed but every so often there is a P-wave w/o a QRS: Second-degree AV block, type 2
(Mobitz)
no relationship b/t P-waves and QRS complexes: Third-degree AV block
QRS > 0.12 (> 3 small boxes) RSR' in V1 & V2; deep S-wave in lateral leads (I, aVL, V5 & V6): RBBB
QRS > 0.12 (> 3 small boxes); RSR' in V5 & V6; diffuse ST elevation: LBBB
Different shapes to 3 or more P-waves; normal rhythm (what is it called if it is tachycardic?): Wandering pacemaker

MFAT:
Multifocal Atrial Tachycardia
short PR interval; slurring delta wave connecting P-wave to QRS complex: Wolff-Parkinson-White syndrome
diffuse ST elevation that slopes in a concave manner back to baseline + diffuse PR segment depression in all leads except PR elevation in aVR: Pericarditis
Tx of wandering pacemaker & MFAT? (1 drug / 1 "other"): Verapamil (Ca channel block)
&
Tx underlying condition
what Tx breaks SVT (superventricular tachy) in > 90%?: Adenosine

(failure to break r/o SVT)
Tx of asymptomatic V-tach (2): Amiodarone

Lidocaine
58-yo man discharged from hospital after MI 2 weeks ago presents w/ fever, chest pain & malaise. EKG shows diffuse ST-T wave changes. What is Dx? What is Tx?: Dressler's syndrome

NSAIDs
Medication orders w/ dischsrge of an ACS (post-MI) patient? (5): easy AS ABC:

- Aspirin (indefinitely)
- Statin to lower LDL < 100
- ACE-inh (if EF <40%)
- Beta-blocker (indefinitely)
- Clopidogrel for 1 - 12 mo depending on stent placement
Dx: fever, pericarditis & possible pericardial or pleural effusions post cardiac surgery: Dressler's syndrome
how do you distinguish Paroxysmal Noctournal Dyspnea from asthma?: no improvement w/ bronchodilators
SVT w/ AV block & yellow skin: Digoxin toxicity
Etiology of Dilated Cardiomyopathy (6): TIMED:
- Toxic (EtOH, heavy metals)
- Infectious / Ischemic
- Metabolic / Mechanical (arrthymia, valve dz)
- Endocrine
- Drugs
what is the Reversible & Irreversible(2) toxic causes of Dilated Cardiomyopathy?: Reversible:
prolonged EtOH use

Irreversible:
Cocaine;
heavy metal toxicity
what is the Reversible & Irreversible(2) endocrine causes of Dilated Cardiomyopathy?: Reversible:
Thyroid disease (hypo or hyper)

Irreversible:
Acromegaly;
Pheochromocytoma
Reversible metabolic causes of Dilated Cardiomyopathy? (4): HypoC;
HypoP;
Thiamine deficiency (wet beri-beri);
Selenium deficiency
Infections that cause Dilated Cardiomyopathy (3): HIV;
Coxsackie virus;
Chagas disease
Drugs that cause Dilated Cardiomyopathy (2): Doxorubicin (Adriamycin);
AZT
Signs/Sx of Dilated Cardiomyopathy: RAMS:
R & L Heart failure;
A-fib;
Mitral regurg;
S-3 Gallop
Diastolic or Systolic Dz Cardiomyopathy: 1. Dilated 2. Restrictive 3. Hypertrophic: Systolic:
Dilated

Diastolic:
Restrictive &
Hypertrophic
Diagnostic results of Dilated cardiomyopathy - auscultation - EKG (3) - CXR (2) - Echo (2): Auscultation: S-3;
EKG: Vent Hypertrophy, BBB &/or A-fib;
CXR: Inc heart size; pulm congestion
Echo: low EF, large ventricles
Tx Dilated Cardiomyopathy (3): - stop any toxic agents
- anticoagulation w/ coumadin (even w/o evidence of thrombus)
- heart transplant
Right or left ventricular enlargement w/ loss of contractile function causing CHF, arrythymia, or throbus formation.: Dilated Cardiomyopathy
Scarring & infiltration of the myocardium causing decreased right or left ventricular filling: Restrictive Cardiomyopathy
Etiology of Restrictive Cardiomyopathy (7): ACHES:
Amyloidosis;
Carcinoid heart dz / Congenital;
Hemochromatosis;
Endomyocardial fibrosis
Sarcoidosis / Scleroderma
Dx: Pulmonary HTN (right CHF); S-4 gallop; Low QRS voltage on EKG; Exercise intolerance; Diastolic dz: Restrictive Cardiomyopathy
(5) tests used to assist in the Dx of Restrictive Cardiomyopathy: Aucsultation;
EKG;
CXR;
Echo;
Endomyocardial Bx*
Increase in the size of the interventricular septum causing narrowing of the LV outflow tract leading to anterior mitral valve outflow obstruction: Hypertrophic Cardiomyopathy
another name for Hypertrophic Cardiomyopathy: IHSS
Idiopathic Hypertrophic Subaortic Stenosis
(3) causes of paradoxical splitting of S-2: Hypertrophic cardiomyopathy (IHSS);
Aortic stenosis;
LBBB
murmur that decrease with squatting (and increases when returning to standing position): Hypertrophic CM
(IHSS)
etiology of Hypertrophic Cardiomyopathy: 50% idiopathic
50% familial (autosomal dominant, w/ variable penetrance)
Dx: Angina (at rest or exercise); Syncope; Arrhythmias; CHF: Hypertrophic Cardiomyopathy
sudden death from Hypertrophic CM is usually due to what?: Arrhythmias
25-yo man becomes severly dyspneic & collapses while running laps, His father died suddenly at an early age.: Hypertrophic CM (IHSS)
Diagnostic results to Dx Hypertrophic CM - Auscultation (2) - EKG (4) - Echo (2): Auscultation - Systolic ejection murmur;
Paradoxical splitting of S2;
EKG - LVH, PVCs, A-fib, ST & Q abnormalities;
Echo - septal hypertrophy, LVH w/ small LV
Tx for Hypertrophic CM (3): - No exercise
- Beta-blocker
- implantable cardiac defibrillator
Most common infectious cause of Myocarditis: Coxsackie B
(4) systemic diseases that causes Myocarditis: KISS:
- Kawasaki's
- Inflammatory conditions
- SLE
- Sarcoidosis
(4) Parasites that cause Myocarditis: Trypanosoma Cruzi (Chagas);
Toxoplasmosis;
Trichinella;
Echinococcus
(5) Bacterial causes of Myocarditis: Group A beta-hemolytic Strep (rheumatic fever);
Corynebacterium;
Meningococcus;
Lyme (B. burgdorferi);
Trichinella
(8) viral causes of myocarditis: Coxsackie A or B;
Echovirus; EBV:
HIV; HBV
CMV;
Influenza;
Adenovirus
(3) drugs that cause pericarditis: Hydralazine;
Isoniazid;
Procainamide
Etiology of Pericarditis (6): Bacterial, viral or fungal infections;
Serositis from:
RA;
SLE;
Scleroderma;
Uremia;
post-MI (Dressler's syndrome)
Tx for pericarditis if: - infection - pain/inflammation - Dressler's - Recurrent cases: - Tx infection w/ Abx;
- NSAIDs to relieve pain & reduce inflammation;
- Steroids for Dressler's;
- Pericardectomy only w/ recurrent cases
Transient fall in BP > 10 mmHg during inspiration: Pulsus Paradoxus
Physiologic result of rapid accumulation of fluid in the pericardial sac; impairs cardiac filling & reduces cardiac output: Pericardial Tamponade
Etiology of Pericardial Tamponade (3): - Pericarditis
- Trauma
- Aortic dissection or ventricular rupture into pericardium
Beck's triad of the pericardial tamponade (4) other signs/Sx: Beck's triad:
- Hypotension
- Muffled heart sounds
- JVD

Other Sx:
Dyspnea;
Tachycardia;
Pulsus Paradoxus*
narrow Pulse Pressure
Tx for Pericardial Tamponade for: 1. unstable 2. stable 3. both: Unstable: Immediate Pericardiocentesis;

Stable: Pericardial window

Both: Infuse fluids to expand volume
Failure of venous pressure to fall during inspiration: Kussmaul's sign
If pericardiocentesis has clots, what is likely source of blood?: Right Ventricle
Patient has chest pain w/ inspiration that radiates to the left trapezial ridge; Pain is relieved by sitting up and leaning forward; does not respond to nitroglycerine: Pericarditis
additional signs/Sx for Constrictive pericarditis (versus pericarditis) (4): - JVD
- Kussmaul's sign
- peripheral edema
- LV failure
Heart valve dz almost always due to Rheumatic Fever: mitral stenosis
Murmur type: Dyspnea on Exertion; Cough, rales; signs of RV failure; RV precordial thrust; Hoarse voice (from enlarged LA on recurrent laryngeal nerve): Mitral Stenosis
Diagnostic results for Mitral Stenosis - Auscultation - CXR - EKG: Auscultation: mid-diastolic opening snap;

CXR: large Left atrium & Kerely B lines

EKG: LA enlargement; RV hypertrophy; A-fib
Tx for mitral stenosis w/ each grade (I-IV) What should always be avoided w/ mitral stenosis tx?: Grade:
I: Diuretics; B-Blockers; Anticoagulants; Digitalis
II: Drugs from I + Balloon valvuloplasty (if drugs dont work)
III/IV: Balloon Valvuloplasty

Avoid: Inotropic Agents!
Acute etiology of Mitral Regurgitation (2): MI w/ papillary muscle rupture;
Endocarditis
Chronic etiology of Mitral Regurgitation (3): Rheumatic fever;
Mitral Prolapse;
LV dilation
Diagnostic tests for Mitral Regurgitation - Auscultation - EKG - Echo: Auscultation: Loud, holosystolic apical murmur radiating to axilla

EKG: large LA

Echo: valve problem
Tx for Mitral Regurgitation (6): ACEinh;
Diuretics;
Vasodilators;
Digitalis;
Endocarditis prophylaxis;
Surgery if severe
Most common valvular disorder: Mitral prolapse
Asymptomatic murmur w/ genetic predisopositon, seen most commonly in women: Mitral Prolapse
What murmur is seen in Marfan's syndrome?: Mitral prolapse
Tx for mitral prolapse?: not necessary to tx unless symptomatic
Mean survival rate for patients w/ Aortic Stenosis and: 1. Angina 2. Syncope 3. Heart failure: 1. 5 years
2. 2 - 3 years
3. 1 - 2 years
Etiology of Aortic Stenosis (2): - Calcific dz w/ age
- Bicuspid valve (around age 40)
Conditions w/ a wide Pulse Pressure (6): WAH-HAH-ide pulse pressure:
Wet beri-beri
Aortic Regurgitation;
Hyperthyroidism;
Hypertension;
Anemia;
Hypertrophic Subaortic Stenosis (IHSS)
WHat (2) valve disorders result in severe decompensation to CHF due to the absence of hemodynamic compensation. How is it treated?: Mitral Regurg
Aortic Regurg

Tx: Emergent surgery
Classic triad of Sx for Aortic Stenosis (4) other signs: SAD:
- Syncope;
- Angina;
- Dyspna on Exertion

Others:
- Forceful apex beat
- narrow Pulse Pressure
- Paradoxical S2 split
- heard in carotids
Diagnostic test results for Aortic Stenosis - Auscultation - EKG - Echo - CXR: Auscultation: Loud systolic crescendo-decrescendo murmur;

EKG: LV strain

CXR: calcifications on valve

Echo: diseased valve
What is the EKG LV strain pattern seen in aortic stenosis?: ST depression & T-wave inversion in I, aVL, V5 & V6
Tx for aortic stenosis (2): - avoid Afterload reducers (ACEinh & beta-blockers)
- Valve replacement
(3) main etiologies for Aortic Regurgitation: Aortic root dilatation;
Valvular dz;
Proximal Aortic root dissection
(3) causes of Aortic root dilatation thereby causing Aortic Regurg: Marfan's;
Idiopathic (but inc w/ HTN);
Collagen vascular dz
(2) causes of Valvular dz thereby causing Aortic Regurg: Rheumatic heart dz;
Endocarditis
(6) causes of proximal Aortic root dissection thereby causing Aortic Regurg: "C 3 SHET":
Cystic medial necrosis (Marfans);
3rd trimester pregnancy;
Syphilis;
HTN;
Ehlers-Danlos;
Turner's syndrome
Names of the 7 unique signs of Aortic regurg: 1. Water-Hammer pulse
2. Traube's sign
3. Corrigan's pulse
4. Quincke's sign
5. de Musset's sign
6. Muller's sign
7. Duroziez's sign
Aortic regurg sign: wide pulse pressure presenting w/forceful arterial pulse upswing w/ rapid falloff: Water-Hammer pulse
Aortic regurg sign: pistol-shot bruit over femoral pulse: Traube's sign
Aortic regurg sign: unusually large carotid pulsations: Corrigan's pulse
Aortic regurg sign: pulsatile blanching & reddening of fingernails upon light pressure: Quincke's sign
Aortic regurg sign: head bobbing caused by carotid pulsation: de Musset's sign
Aortic regurg sign: pulsatile bobbing of the uvula: Muller's sign
Aortic regurg sign: to-&-fro murmur over femoral artery (heard best w/ mild pressure applied to artery): Duroziez's sign
Murmur presentation: dyspnea, orthopnea, paroxysmal noctournal dyspnea, angina, LV failure, wide pulse pressure: Aortic regurg
Murmur presentation: starts asymptomatic, then dyspnea, angina, syncope, heart failure: Aortic stenosis
Murmur presentation: mostly asymptomatic, atypical chest pain, SOB, fatigue: Mitral Prolapse
Murmur presentation: dyspnea, fatigue, weakness, cough, A-fib, systemic emboli: Mitral Regurg
Murmur presentation: DOE, rales, cough, hemoptysis, systemic emboli, RV precordial thrust, RV failure, Hoarse voice: Mitral stenosis
How do you diagnose LVH from a ECG? (2): 1. S-wave in V1 + R-wave in V5 or V6 > 7 large boxes (35 small)

2. R-wave in V5 or V6 > 25 small boxes OR R-wave in lead aVL > 11 small boxes
Diagnostic tests for Aortic Regurg - Auscultation (3) - EKG: Auscultation:
1. Holosystolic, blowing decrescendo diastolic murmur
2. Apical diastolic rumble (mitral stenosis w/o snap)
3. Midsystolic flow murmur at base
EKG: LVH
Echo: regurgitant valve
Tx for Aortic regurg (3): Tx LV heart failure;
Endocarditis prophylaxis;
Valve replacement
Etiology of Tricuspid stenosis (3): Rheumatic heart dz;
Congenital;
Carcinoid
Murmur presentation: peripheral edema, JVD, hepatomegaly, ascites, jaundice (2): Tricuspid stenosis

or

Tricuspid Regurg
Diagnostic results for Tricuspid stenosis: - auscultation - echo Tx?: Dx:
Auscultation: diastolic, rumbling low-pitched heard w/ inspiration
Echo: diseased valve

Tx: surgical repair
Dx: Patient w/ DVT has a stroke. He has a fixed S2 split: Atrial-septal defect
(w/ right-to-left emboli)
Etiology of Tricuspid Regurg (4): Increased pulmonary artery Pressure (from L-CHF or Mitral stenosis/regurg);
R-CHF;
Right papillary muscle rupture w/ MI;
Tricuspid valve lesions (rheumatic heart or bacterial endocarditis)
(3) causes of a holosystolic murmur: Mitral Regurg;
Tricuspid regurg;
Ventricular Septal Defect
Number 1 cause of death in CHF patients: Arrhythmia
Diagnostic results for Tricuspid Regurg - Auscultation - EKG - Echo: Auscultation: Holosystolic murmur increasing w/ inspiration
EKG: RV enlargement; A-fib
Echo: diseased valve
Tx for Tricuspid Regurg (3): Tx heart failure;
Diuresis;
Surgical repair of valve
What is done first if a patient has hyperK and peaked T-waves? Why?: give Calcium

to stabilize cardiac membrane
Causes of prolonged QT (8): QT WIDTH:

QT: Prolonged QT syndrome
W: WPW
I: Infarction
D: Drugs
T: Torsades de pointes
H: HypoK, HypoC, Hypomagnesium
Causes short QT: HyperC
Causes of Torsades de Pointes (7): POINTES:
Phenothiazines
Other meds (TCAs)
Intracranial bleed
No known cause (idiopathic)
Type 1 Anti-arrhthymics
Electrolyte abnormalities
Syndrome of prolonged QT
Murmur: Diastolic apical rumble & opening snap: Mitral stenosis
Murmur: Late systolic murmur w/ midsystolic click What is confirming test?: Mitral Prolapse

Valsalva - click starts earlier, murmur prolonged
Murmur: High-pitched apical blowing holosystolic murmur where does it radiate?: Mitral Regurg

radiates to axilla
Murmur: Diastolic rumble louder w/ inspiration: Tricuspid stenosis
Name sign: Peripheral pulses that are weak & late compared to heart sounds What murmur?: Pulsus Parvus et Tardus

Aortic Stenosis
Murmur: midsystolic crescendo-decrescendo murmur Where does it radiate? (2) What is also heard?: Aortic stenosis

radiates to:
Carotids & Apex

- S4 also heard
Name sign: Double-peaked arterial pulse what murmur?: Pulsus Bisferiens

Aortic regurg
Murmur: Blowing early diastolic, apical diastolic rumble, midsystolic flow murmurs: Aortic Regurg
Murmur: Systolic murmur at apex & left sternal boarder not transmitted to carotids How is it heard better?: IHSS

heard better w/ standing after squat
When do you hear the "flow murmur" (murmur heard w/ any high flow state)? What is differential dx? (5): Midsystolic:
Aortic Regurg
A-S defect (fixed split S2)
Anemia
Adolescence
Pregnancy
What can be given to a patient to temporarily slow a rapid supraventricular rhythm in order for you to be able to identify it?: Adenosine
What drugs should not be given to someone w/ Wolff-Parkinson-White syndrome? (4) What is the DOC?: ABCD:
Adenosine
Beta-blockers
Calcium channel blockers
Digoxin

DOC:
Procainamide
Causes of Mobitz I (3) Causes of Mobitz II (2): Mobitz I:
Inferior wall MI
Digitalis toxicity
Inc Vagal tone

Mobitz II:
Inferior or septal wall MI
Conduction system disease
Tx for Mobitz I & II: Both:
Atropine & temporary pacing

(Mobitz II should have pacemaker)
Causes of third-degree heart block (3): Digitalis toxicity
Inferior wall MI
Conduction system disease
Causes of Bradycardia (6): if R-R is longer then "One INCH"
Overmedication;
Inferior MI / Inc intracranial Pressure;
Normal variant (athletes);
Carotid sinus hypersensitivity;
Hypoparathyroidism
Tx for bradycardia (3): Atropine
pacing
pressors for hypotension
a 24-yo woman w/ preclampsia Tx w/ IV drip of magnesium complains of difficulty breathing & has diminished reflexes. Next step?: Stop magnesium & give IV calcium
equation for Mean Arterial Pressure: MAP = (2dBP + sBP)/3
heart medication that can cause cyanide toxicity: Nitroprusside
Tx for Hypertensive emergency due to pheochromocytoma: Phentolamine
(2) possible Tx for a preclampsia-related hypertensive emergency: Hydralazine
or
Magnesium
difference b/t Type A & Type B Aortic Dissections: Type A:
involves the ascending aorta & can extend into the descending aorta

Type B:
descending aorta only
Debakey Classification of Aortic Dissection Types I-III Which is most common?: I: Ascending plus part of distal aorta (most common)

II: Ascending only

III: Descending only
What is infected on the aorta when the aortic dissection is due to syphilis?: Vasa Vasorum
Etiology of Aortic Dissection (7): PATC3H:
Pregnancy (3rd trimester);
Aortic Coarctation (Turners or idiopathic);
Trauma;
Congenital heart dz / CT dz (Marfans & E-D syndromes) / Cocaine;
HTN
Dx: Severe tearing chest pain that radiates to the back, HTN, possible unequal pulses distally, possible aortic regurg murmur: Aortic Dissection
(3) tests to confirm Dx of aortic dissection: CXR - wide mediastinum
CT w/ contrast
Angiogram (gold standard)
Drug Tx for Aortic dissection to stabilize BP What is the next step for Type A vs. Type B?: Rx: Beta-blocker + nitroprusside to keep BP < 120

Type A: Immediate surgery
Type B: medical stabilization
When a patient has VHD or previous endocarditis, what (3) procedure types must they obtain endocarditis prophylaxis medications?: Dental procedures
Urologic procedures
GI procedures
Dx: acute onset of fever, chills & rigors; new cardiac murmur, possible associated meningitis or pneumonia: Acute Bacterial Endocarditis
(ABE)
Infection of healthy heart valves by high-virulence organisms MCC? Px if not treated?: ABE

S. Aureus

Px: fatal if not Tx w/i 6 weeks
Dx: seeding of previously damaged heart valves by rheumatic fever, mitral prolapse, etc by low-virulence organisms MCC? What valve is affected the most?: Subacute Bacterial Endocarditis

Strep Viridans

Mitral valve
What valve is most commonly affected w/ IV drug users? What bug?: Tricuspid

S. Aureus
what endocarditis bug is associated w/ colonic neoplasms?: Strep Bovis

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Deck Info

Number of cards 246