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Cardiovascular
Internal Med
205
Science
Graduate
09/26/2015

Additional Science Flashcards

 


 

Cards

Term
1st line treatment in static bradycardia
Definition
atropine
Term
What is the cause of most bradycardia rhythms
Definition
excess vagal stimulation - hence anticholinergic atropine is 1st line
Term
sinus arrhythmia
Definition

same as NSR except thythm is irregular (increases with inspiration)

normal varient (esp w/ slower heart rates)

Term
combinations of sinus arrest w/ alternations of paroxysms of atrial tacky and bradyarhythmias
Definition
sick sinus syndrome (brady-tachy syndrome)
Term
what is sick sinus syndrome (brady-tachy) caused by?
Definition
SA node disease,  corrective cardiac sx
Term
What is the treatment for sick-sinus syndrome (brady-tachy syndrome)
Definition

+- PPM if symptomatic (dual chamber pacing usually preferred over ventricular pacing)

byrady alternating w/ ventricular tachy - permanent pacemaker (PPM) w/ automatic implantable cardioverter defibrillator (AICD)

Term
interruption of normal impulse from SA node to AV node via AV node
Definition
AV block
Term
which interval is most helpful in determining AV conduction blocks
Definition
PR interval (PRI)
Term
first degree AV block
Definition

constant, prolonged PRI (>0.20 sec)

every P wave followed by QRS 

Mgmt: none, observation (may progress)

Term
2nd degree AV block (Mobitz 1, Wenckebach)
Definition

progressive PRI lengthening - dropped QRS

Mgmt: atropine, epinephrine +- pacemaker if symptomatic

observation if no sx

Term
Second degree AV block : Mobitz II
Definition

block commonly in bundle of HIS

Constant/prolonged PRI - dropped QRS

Mgmt: permanent pacemaker 

(progression to 3rd degree AV block common)

Term
Third degree AV block
Definition

AV dissociation: P waves not related to QRS

All P's NOT followed by QRS: decreased CO

Mgmt: Permanent pacemaker definitive

temporary pacing if symptomatic 

Term
Atrial flutter
Definition

flutter, "saw tooth" waves (no P's) @ 250-350 bpm

rate usually REGULAR

 

Term
Atrial flutter treatment
Definition

vagal, CCB, BB, DCC (direct cardiac compression) if unstable

radiogrequency ablation definitive tx 

Term
Atrial fibrillation
Definition

no P waves, fibrillatory waves @ 350-600 bpm

IRREGULARLY IRREGULAR rhythm

 

Term
Treatment for atrial fibrillation
Definition

rate control preferred over rhythm control

rate - vagal, CCB, or BB

Rhythm - DC cardioversion. DCC may also be done after 3-4 weeeks of anticoagulation or TEE showing no atrial thrombi. +- Digoxin

Term
MC chronic arrhythmia
Definition
A. fib
Term
Prevention of stroke
Definition

warfarin or ASA as prophylaxis against thromboembolism based on CHADS2 score

atrial quivering (in A fib) causes clots in atria that can embolize to brain/lung

Term
Atrial dysrhythmias
Definition

atrial flutter

atrial fibrillation

wandering atrial pacemaker (WAP)

multifocal atrial tachycardia (MAT)

paroysmal supraventricular tachycardia (PSVT)

wolff-Parkinson-white

Term
HR < 100 bpm & >= 3 P wave morphologies
Definition
Wandering atrial pacemaker (WAP)
Term
HR > 100 bpm & >= 3 P wave morphologies
Definition

multifocal atrial tachycardia (MAT)

MAT associated with severe COPD

Term
sudden & termination (MC preceded by a premature atrial contraction)
rhythm originates above the ventricle
Definition
paroxysmal supraventricular tachycardia (PSVT)
Term
2 types of paroxysmal supra ventricular tachycardia (PSVT)
Definition

AV nodal reentry tachycardia (AVNRT) - 2 pathways both WITHIN AV node (slow & fast) MC type

AV reciprocating tachycardia (AVRT) - 1 pathway within the AV node & a second accessory pathway OUTSIDE the AV node (WPW & LGL)

Term
impulse goes forward (antegrade) down normal AV node pathway & returns retrograde to atria via accessory pathway in circles, perpetuating the rhythm

ECG: narrow complex tachycardia
Definition
Orthodromic AVNRT (95%)
Term
Treatment for orthodromic AVNRT
Definition
vagal maneuvers --> adenosine --> BB or CCB --> direct current cardioversion (DCC) esp if unstable
Term
HR > 100 bpm, narrow QRS
impulse goes forward (integrate) through accessory pathway and returns to atria retrograde via normal pathway
mimics VT
Definition
Antidromic AVNRT
Term
Treatment of antidromic AVNRT
Definition
procainamide or amiodarone
Term
definitive tx for PSVT
Definition
radiofrequency catheter ablation - destroys pathway in both AVRT, AVNRT
Term
accessory pathway (kent bundle) "pre-excites ventricle"
slurred, wide QRS
Type of AV reciprocating (AVRT)
patients prone to tachyarrhythmias
Definition
Wolff-Parkinson-white
Term
Delta wave - slurred QRS upstroke, wide QRS > 0.12 sec & short PRI
Definition
wolf-parkinson-white
Term
Treatment of wolf-parkinson-white
Definition

vagal maneuvers

antiarrhythmis (ex procainamide, amiodarone)

radiofrequency abalation definitive treatment 

Term
AV node becomes the dominant pacemaker of the heart
Definition
AV junctional dysrhythmias
Term
MC rhythm seen with digitalis toxicity
Definition
AV junctional dysrhythmias
Term
ECG: regular rhythm. P waves inverted if present or not seen. Usually narrow QRS (+- wide)
Definition
AV junctional dysrhythmias
Term
types of AV junctional dysrhythmias
Definition

junctional rhythm- HR 40-60 bpm (intrinsic rate of AV)

accelerated junctional - HR 60-100

junctional tachycardia- HR >100 

Term
ventricular dysrhythmias
Definition

premature ventricular complexes 

ventricular tachycardia

ventricular fibrillation

pulesless electrical activity

asystole rhythm (ventricular standstill)

Term
____ dysrhythmias are frequently unstable and unpredictable (potentially lethal because stroke volume and coronary flow are compromised)
Definition
ventricular
Term
Associated with wide, bizarre QRS complexes
Definition
ventricular dysrhythmias
Term
PVC's
Definition

premature beat originating from ventricle - wide, bizarre QRS occurring earlier than expected.

usually the T wave is in the opposite direction of the R. 

Assoc w/ compensatory pause = overall rhythm unchanged b/c it is prevented from reaching the atria by AV node 

Term
PVC treatment
Definition

usually none needed

remember though that most ventricular arrhythmias start as a PVC

Term
>=3 consecutive PVC's at a rate of > 100 bp
Definition
ventricular tachycardia
Term
Ventricular tachycardia
Definition

evaluate hemodynamically stable v unstable

 evaluate sustained v non-sustained

sustained = duration of >= 30 sec

Term
ventricular tachycardia : prolonged QT interval often causes.....
Definition
Torsades de Pointes
Term
torsades de pointes is MC d/t
Definition

hypomagnesemia, hypokalemia

V tach "twists" around baseline

Term
Treatment of V. tach
Definition

stable sustained- anti-arrhythmisc (amiodarone, lidocaine, procainamide)

unstable w/ pulse - synchronized (direct current) cardioversion (DCC)

VT (no pulse) - defibrillation/CPR 

torsades de pointes - IV magnesium

Term
management of ventricular fibrillation
Definition
unsynchronized cardioversion (defibrillation) + CPR
Term
organized rhythm seen on monitor but patient has no palpable pulse
(electric activity is not coupled with mechanical contraction)
Definition
pulseless electrical activity
Term
treatment for pulseless electrical activity
Definition
CPR, epi, checks for shockable rhythm every 2 min
Term
Treatment for asystole rhythm (venticular standstill)
Definition

same as PEA 

CPR, epi, checks for shockable rhythm every 2 min

Term
general direction of impulse through the heart
Definition
axis
Term
vector moves towards...
Definition

hypertrophy

away from infarction

Term
Right atrial enlargement
Definition

cor pulmonale

pulmonary dz; left side heart failure

Tall P wave > 2.5 mm in lead II

biphasic P wave w INITIAL component larger in V1

Term
Left atrial enlargement
Definition

cor mitrale

Broad "m" shaped P wave > 0.11 s lead II

biphasic P wave w/ TERMINAL component larger in V1

Term
right ventricular hypertrophy
Definition
R>S in V1 OR (R>7mm in height in V1) + RAD
Term
left ventricular hypertrophy
Definition

Sokolow -lyon : S in V1 + R in V5 = 35mm (men), 30 (W)

Cornell: R in aVL + S in V3 > 24 mm(M); > 20 mm (W)

Other: height of R in aVL > 11 boxes (men); 9 boxes (W)

Term
Left BBB
Definition

1. wide QRS > 0.12 sec

2. broad, slurred R in V5,6

3. deep S in V1

4. ST elevations V1-V3

Term
Right BBB
Definition

1. wide QRS > 0.12 sec

2. RsR' in V1,2

3. Wide S wave in V6

Term
left anterior hemiblock
Definition

LAD (> -30 degrees no other reason for LAD)

initial R in inf. leads

Q in I

S in III

Term
ST depression usually indicates..
Definition

ischemia

(horizontal and downslope always pathological)

Term
ST segment elevation etiologies
Definition

acute MI

normal early repolarization abnormalities

LBB

LVH

coronary vasospasm/prinzmetal's angina

pericarditis

Brugada's syndrome

Term
ST segment elevation : convex down most likely
Definition
ischemic. AMI
Term
ST segment elevation: concave up usually (not always!)
Definition
benign or reflects other causes (other tham AMI)
Term
Early depolarization abnormalities
Definition

normal variant. seen esp. in thin, healthy AA males

ST elevation > 2 mm CONCAVE diffuse leads w large T waves (esp precordial)

Tall QRS voltage

fishhook (slurring/notching at J point)

Term
Acute pericarditis on EKG
Definition

ST elevation CONCAVE precordial leads

PR depression seen in the same leads w/ ST elevations

NO reciprocal changes

T wave inversion only present AFTER STE (acute MI may have T wave inversions simultaneously with ST elevations in same leads)

Term
Brugada syndrome
Definition

RBBB pattern (often incomplete)

ST elevation V1-V3 (often downsloping)

T wave inversions V1& V2

+- S wave in lateral leads

Term
Brugada syndrome is MC in
Definition
Asian males
Term
What are the local vasodilators in the heart?
Definition

nitric oxide

oxygen

adenosine

Term
most useful noninvasive test in evaluating patients w/ suspected coronary artery disease
Definition
stress test
Term
types of stress testing
Definition

exercise stress testing (ECG) - treadmill or radionuclide myocardial perfusion imaging (MPI)

pharmacologic stress testing 

stress echocardiography

Term
Exercise stress testing : treadmill test
Definition

Bruce protocol: + if ST depression, exercise-induced HTN or hTN, arrhythmias, sx's, heart rate abnormalities

Ind: initial test in most patients w/ normal resting ECG, low cost

Disadvan: does not localize region of ischemia

CI: unable to exercise, baseline ECG abnormalities

 

Term
exercise stress test: radionuclide myocardial perfusion imaging (MPI)
Definition

either single photon emission computed tomography (SPECT using technetium or thallium) or positive emission tomography (PET)

Benifits of MPI - localization of region of ischemia

Term
Pharmacologic stress testing
Definition

done in patients unable to exercise

vasodilators w/ MPI: adenosine or dipyridamole

MOA: coronary vasodilators of normal arteries

Ind: preferred in pts w baseline ECG abnormalities. 

CI: bronchospastic dz (ex severe asthma, COPD), 2nd/3rd degree heart block or sick sinus (adenosine affects SA & AV node)

Caution: avoid vasoconstrictors 24h before test (ex theophylline or caffeine)

Term
stress echocardiography
Definition

localizes regions of ischemia

dobutamine: sympathomimetic that stimulate B1-mediated, increase HR, increases myocardial O2 demand & provokes ischemia)

Ind: used in pts w CI to vasodilator use or in patients w/ recent vasoconstrictor use

CI: sustained ventricular arrhythmias, significant LV outflow obstruction (severe AS), mod-severe HTN, SBP > 180, aortic dissection, if patient on BB

Term
acute inflammation of the pericardium
Definition

acute pericarditis 

(may cause pericardial effusion) 

Term
P's of acute pericarditis
Definition

persistent 

pleuritic

postural pain

pericardial friction rub

Term
MCC of acute pericarditis
Definition

viral - esp the enteroviruses: coxsackie & echovirus

 

Term
Dresslers syndrome
Definition
pericarditis 2-5 s/p MI
Term
Acute pericarditis : Clinical manifestations
Definition

chest pain: pleuritic (sharp & worse w/ inspiration), persistent, postural (worse w/ lyind down and RELIEVED BY SITTING/LEANING FORWARD) +- radiate to trapezius, back, neck, shoulder, arm, epigastric area & can be associated w/ dyspnea & odynophagia, fever usually

pericardial friction rub: best heard @ end expiration w/ pt upright & leaning forward. 3 components. Pericardial friction rub notoriously variable (can be transient)

Term
Diagnostic studies for acute pericarditis
Definition

ECG 

echocardiogram

Term
ECG: diffuse, ST elevations in precordial leads (concave up in V1-V6) & associated PR depressions in those leads (aVr --> atrial injury assoc w/ PR elevation & ST depression) --> TWI --> resolution.
30% +- have + cardiac enzymes b/c of concurrent myocarditis
Definition
Acute pericarditis
Term
Echocardiogram : used to assess for complications of...
Definition

acute pericarditis (effusion or tamponade)

isloated pericarditis --> normal ech

Term
Treatment for acute pericarditis
Definition

1. anti-inflammatory drugs - ASA or NSAIDS x 7-14 days. Colchicine 2nd line management 

2. +- corticosteroids if sx > 48h & refractory to 1st line meds. Dresslers: ASA or colchicine

Term
increased fluid in the pericardial space
Definition
pericardial effusion
Term
Etiologies of pericardial effusion
Definition
pericarditis, malignancy infection, radiation tx, dialysis/uremia, collagen vascular disease
Term
pericardial effusion PE finding
Definition
distant heart sounds (b/c fluid interfers w/ sound conduction)
Term
Diagnostic studies for pericardial effusion
Definition

1. ECG - low voltage QRS complexes suggest large effusion or tamponade, electric alternans: cyclic beat to beat shift in QRS amplitude (heart swinging in fluid)

2. echo - increased pericardial fluid. also good to assess for tamponade 

3. CXR : cardiomegaly

Term
Treatment of pericardial effusion
Definition

1. observation if small and no evidence of tamponade

2. +- pericardiocentesis if tamponade, large effusion, Pericaridal window drainage if recurrent.

Term
acute autoimmune inflammatory multi-systemic illness affecting children 5-15 yo
Definition
rheumatic fever
Term
MC 2-3 weeks after symptomatic or asymptomatic strep pharyngitis. Type II HSN
Definition
rheumatic fever
Term
Complications of rheumatic fever
Definition

rheumatic disease (valvular)

 mitral (MC)

Term
JONES criteria for rheumatic fever : Major
Definition

1. Active carditis

2. Migratory Polyarthritis

3. Subcutaneous nodules

4. Erythema marginatum

5. Sydenham's chorea

Term
JONES criteria for rheumatic fever: minor
Definition

fever (101-104)

arthralgias

increased acute phase reactants (increased ESR, CRP)

EKG: prolonged PR interval

Term
"saint vitus dance" : sudden involuntary, jerky, non-rhythmic, purposeless movements
Definition

sydenham's chorea - rheumatic fever

treat with haloperidol

Term
Treatment of rheumatic fever
Definition

1. PCN G is DOC (erythromcyin if PCN-allergic) 

2. anti-inflammatory: aspirin (2-6 wk taper); steroids in severe cases & carditis

Term
Causes of hypercholesterolemia
Definition

hypothyroidism

pregnancy

kidney failure

Term
causes of hypertriglyceridemia
Definition

DM

ETOH

obesity

steroids

estrogen

Term
Clinical manifestations of hyperlipidemia
Definition

1. most patients asymptomatic

2. may develop xanthomas (esp in eyelids, achilles)

3. hyypertriglycerides may cause pancreatitis

Term
Goals of total cholesterol =
Definition
< 200
Term
Goal of HDL
Definition
> 45
Term
Goal of triglycerides
Definition
< 150
Term
When do you start screening for hyperlipidemia
Definition

in patients 35 or older without risk factors

earlier if risk factors

Term
what drugs are indicated for isolated increased LDL
Definition

statins 

Bile acid sequestrants

Term
what drugs are indicated for isolated increased triglycerides
Definition

fibrates (gemfibrozil, fenofibrate)

niacin

Term
what drugs are indicated to increase HDL
Definition

Niacin (nicotinic acid)

fibrates (gemfibrozil, fenofibrate)

Term
what drugs are indicated for hyperlipidemia in type II DM
Definition

fibrates (gemfibrozil, fenofibrate)

statins

niacin may cause hyperglycemia so use caution in DM pts

Term
Which lipid lower drug has been shown to decrease CV complications
Definition
niacin
Term
MOA: increases HDL (delays HDL clearance), reduces plasma fibrinogen levels
Decreases hepatic production of LDL & its precursor VLDL
Definition
niacin
Term
MOA: inhibits rate limiting step in hepatic cholesterol synthesis (HMGcoA reductase inhibitor)
Definition
statins
Term
What can be given to patients with niacin to decrease flushing
Definition
ASA or ibuprofen
Term
SE of niacin
Definition

hyperuricemia

hyperglycemia

flushing, HA, warm sensation & pruritis - prostaglandin mediated

Term
When is Niacin contraindicated?
Definition

hepatotoxicity

hyperglycemia

PUD

 

Term
Side effects of statins
Definition

myositis/myalgias/rhabdomyolysis (esp when used w/ fibrates & niacin)

hepatitis (increased LFTs)

 

Term
when are statins best given?
Definition
at bedtime when cholesterol synthesis is maximal
Term
MOA: inhibit peripheral lipolysis & reduces hepatic TG production (by decreasing hepatic extraction of fatty acids)
Definition
fibrates (gemfibrozil, fenofibrate)
Term
SE of fibrates (gemfibrozil, fenofibrate)
Definition

increased LFTs

myositis & myalgias esp w/ concomitant statin use (d/t CYP3A4 related reduction in statin metabolism)

increased bile lithogenicity (gallstones)

Term
What are omega 3 fatty acids
Definition

used for hypertriglyceridemia 

salmon, flaxseed, canola oil, soybean oil, nuts

Term
MOA: binds bile acids in intestine blocking enterohepatic reabsorption of bile acids
The liver has to make new bile acids, so it increases its LDL receptors thereby removing LDL from the blood
Definition
bile acid sequestrants (cholestyramine, colestipol, colesevelam)
Term
________ are most useful in combining with a statin or niacin to aggressively lower LDL cholesterol levels
Definition
bile acid sequestrants (cholestyramine, colestipol, colesevelam)
Term
what are the only lipid lower drugs safe in pregnancy?
Definition

cholestyramine

colestipol

colesevelam

(the bile acid sequestrants)

Term
______ are used for pruritus associated w/ biliary obstruction
Definition
bile acid sequestrants (cholestyramine, colestipol, colesevelam)
Term
SE of bile acid sequestrants
Definition

GI side effcts : N/V, bloating, increased LFT's

increases TG (good for pts with increased LDL and normal TG) osteoporosis w/ long term use

may impair absorption of digoxin, warfarin, fat soluble vitamins (so give those meds 1 hour before or 4 hrs after BAS)

Term
MOA : inhibits intestinal cholesterol absorption (lowers LDL)
Definition

Ezetimibe (Zetia)

may be used w/ statins 

Term
SE of Ezetimibe (Zetia)
Definition
increased LFT's especially with statin use
Term
infection of endothelium/valves 2ry to colonization during transient/persistent bacteremia
Definition
infective endocarditis
Term
which valve is most commonly involved with infective endocarditis?
Definition

mitral

exception is IVDA (tricuspid valve MC)

Term
Types of endocarditis
Definition

1. acute bacterial endocarditis (ABE) : infection of NORMAL valves (staph mc, esp MRSA)

2. subacute bacterial endocarditis (SBE) : ABNL valves (S. viridans)

3. endocarditis C IVDA (MRSA)

4. Prosthetic valve endocarditis (PVE): early w/n 60 days (staph epidermis)

Term
MC in men 50y h/o GI/GU procedures (infective endocarditis)
Definition
enterococci
Term
HACEK organisms
Definition

haemophilus

actinobacillus

cardiobacterium

eikenella

klingella

assoc w/ large vegetations. often cx negative. Gram -

Term
Clinical manifestations of infective endocarditis
Definition

1. fever (80-90% including FUO), anorexia, wt loss, fatigue. EKG conduction abnormalities

2. peripheral manifestations

- janeway lesions -painless erythematous macules on palms/soles

roth spots - retinal hemorrhage w/ pale center, petechiae (conjunctiva, palate)

Oslers nodes: tender nodules on pads of digits

Term
Diagnostic studies for infective endocarditis
Definition

1. blood cultures. 3 sets @ least 1h apart

2. EKG : prone to arrhythmias

3. Echo: obtain TTE first the TEE if necessary

4. labs: CBC: leukocytosis, anemia, increased ESR/RF

Term
Modified Duke criteria : Infective endocarditis
Definition

Major

  • sustained bacteremia : 2 + blood cx
  •  endocardial inv. (+ on echo), new valvular regurgitation (AR, MR)

Minor

  • predisposing condition (abnl valves, IVDA, catheters),
  • fever (> 38 C, 100.4 F)
  • vascular & embolic phenomena: janeway lesions, septic arterial or pulmonary emboli, ICH
  • immunologic phenomena: osler nodes, roth spots, + RF, acute glomerulonephritis
  •  + blood cx not meeting major criteria
  • + echo not meeting major criteria (ie. worsening murmur) 
2 major OR 1 maj + 3 minor OR 5 minor (80% accuracy)
Term
Treatment of native valve acute bacterial endocarditis
Definition

nafcillin + gentamicin x 4-6 weeks 

OR

Vancomycin (MRSA/PCN allergic) + Gentamicin

Term
treatment of native valve subacute bacterial endocarditis
Definition

pencillin/ampicillin + gentamicin

vancomycin is IVDA

Term
treatment for infective endocarditis with prosthetic valve
Definition
vancomycin + gentamicin + rifampin (for staph a)
Term
treatment for infective endocarditis for fungal
Definition

amphotericin B

capsofungin if severe + valve sx/replacement (tx 6-8 wks)

Term
With Acute bacterial endocarditis (ABE) do you give the abx before or after culture?
Definition

AFTER 

 

but with SBE if pt is not stable - BEFORE

Term
Endocarditis prophylaxis : Cardiac conditions
Definition
  1. prosthetic (artificial) heart valves
  2. heart repairs using prosthetic material (not including stents)
  3. prior h/o endocarditis
  4. congenital heart disease

 Amoxicillin 2g 30-60m before (Clinda 600mg PCN allergy)

Term
endocarditis prophylaxis for procedures
Definition
  1. Dental: involveing manipulation of gums, roots of the teeth, oral mucosa perforation
  2. respiratory: sx on respiratory mucosa, rigid bronchoscopy
  3. procedures involving infected skin/musculoskeletal tissues (including abscess I&D)

Amoxicillin 2g 30-60m before (Clinda 600mg PCN allergy)

Term
Is endocarditis prophylaxis routinely recommended for most types of valvular heart dz (including MVP)?
Definition
NO!
Term
inability of heart to pump sufficient blood to meet the metabolic needs of the body at normal filling pressures
Definition
heart failure
Term
MCC of heart failure
Definition
coronary artery disease (CAD)
Term
Forms of heart failure
Definition

left v right sided

systolic vs diastolic 

high versus low output

Term
MCC of l-sided heart failure is....
Definition
CAD & HTN
Term
MCC of right sided heart failure is...
Definition

L-sided heart failure - 90%

(pulmonary dz 2nd most common)

Term
systolic heart failure
Definition

decreased EF assoc w/ S3 gallop (S3= filling of dilated ventricle)

systolic MC form of CHF

Term
diastolic heart failure
Definition

normal/increased ejection fraction assoc w/ S4 gallop

(S4 = atrial contration w/ stiff ventricle)

HTN, RCMP

Term
high output heart failure
Definition

anemia

thyrotoxicosis

beriberi

Paget's dz of bone

Term
low output heart failure
Definition

HTN

CAD

Term
initial insult leads to increased after load, increased preload, decreased contractility
injured heart tries to make short term compensations that over the long term, promote CV deterioration
Definition
heart failure
Term
Pathophysiology of heart failure
Definition
  1. Sympathetic nervous system activation
  2. myocyte hypertrophy/remodeling
  3. RAAS activation: fluid overload, ventricular remodeling/hypertrophy
  4. All three --> CHF (pulmonary &/or systemic edema)
Term
increased pulmonary venous pressure from fluid backing up into the lungs
Definition
left sided heart failure
Term
Clinical manifestations of left sided heart failure
Definition
  1. Dyspnea MC symptom.  Initally exertional --> orthopnea (dyspnea when pt is supine --> increased venous return & cardiac work) & paroxysmal nocturnal dyspnea (same reasons) --> dyspnea @ rest
  2. Pulmonary congestion/edmea: rales (fluid in alveoli), rhonchi, chronic nonproductive cough (commoly miss) esp w/ pink frothy sputum (surfactant), wheezing "cardiac asthma" d/t airway edema, pleural effusion. Nocturia
Term
MCC of transudative pleural effusion
Definition
CHF (left sided)
Term
PE of left sided heart failure
Definition
  • HTN
  • rapid/shalllow breathing (tachypnea)
  • cheyne stoke's breathing (deeper faster breathing w/ gradual decrease & periods of apnea)
  • cyanosis
  • S3 (systolic)
  • S4 (diastolic)
  • increased adrenergic activation: dusky, pale skin; diaphoresis, sinus tachy, cool extremities (d/t poor perfusion & periohal arterial vasoconstriction), fatigue, AMS
Term
increased systemic venous pressure --> signs of systemic fluid retention
Definition
right sided heart failure
Term
Clinical manifestations of right sided heart failure
Definition
  • peripheral edema: ex. pitting edema in legs
  • JVD: increased JVP
  • GI/hepatic congestion: anorexia, N/V d/t edema of GI tract, hepatosplenomegaly, RUQ tenderness, hepatojugular reflex (increased JVP w/ liver palpation); cyanosis
Term
Most useful test to dx HF
Definition

echocardiogram

  • measures ventricular function & EF
Term
most important determinant in prognosis of heart failure
Definition

EF

  • normal EF = 55-60 (EF < 35 increases mortality) 
  • EF <35% = cardio defibrillatory placement to reduce mortality 
Term
What would systolic heart failure show on echo?
Definition

decreased EF

thin ventricular walls

dilated LV chamber

+S3

Term
what would diastolic heart failure show on echo?
Definition

normal/increased EF

thick ventircular walls

small LV chamber

+ S4

Term
What would CXR show in someone with heart failure?
Definition

cephalization of flow

kerley B lines

butterfly pattern

 cardiomegaly infiltrates

pleaural effusions

pulmonary edema

Term
may identify CHF as the cause for dyspnea in ER
Definition
increased B-type natriuric peptide (BNP)
Term
What does increased B-type natriuretic peptides (BNP) mean
Definition

indicates severity & prognosis of HF

ventricles release BNP during vol. overload in attempt to reverse the process (causing decreased RAAS activation, decreased TBFV, increased NA excretion)

BNP > 100 means CHF is likely 

Term
Tests used to diagnose HF
Definition

echo

CXR

Increased BNP

Term
Unless contraindicated ALL heart failure patients should be on...
Definition
ACEI and diuretic
Term
1st line treatment of HF
Definition

ACEI - prils

vasodilators (decreased afterload, and preload)

Term
which drug is safe in pregnancy for HF?
Definition

hydralazine

vasodilator (decreased afterload)

Term
most effect tx for symptoms for ps with mild-moderate CHF
Definition

diuretics 

decreased preload 

HCTZ, metolazone for mild-moderate

loops -severe

Term
what drugs are used SHORT TERM in severe acute CHF
Definition

sympathomimetics (positive inotropes)

 

digoxin -only one used long term

Term
Which HF meds decrease mortality
Definition

ACEI

ARB's

BB

Nitrates + hydralazine

spironolactone

Term
Which HF drugs are typically NOT used in systolic HF
Definition

CCB

(exceptions: angina w/ HF or normal EF)

Term
HF outpatient regimen
Definition
ACEI + diuretic +- add BB, hyralazine + nitrates, digoxin
Term
implantable cardioverter defibrillator in pts w/ EF <
Definition

35% 

(b/c they poorly tolerate arrhythmias)

Term
acute decompensated HF w/ worsening of baseline sx characterized by pulmonary congestion (worsening of dyspnea, rales, pink frothy sputum eat), sympathetic activation or CXR findings of congestion
Definition
congestive heart failure
Term
CXR finding sin congestive heart failure
Definition

norm pulm capillary wedge pressure (PCWP) 6-12 mmHg

  • cephalization of flow: increased vascular flow to apices as result of increased pulm. venous pressure. Seen when PCWP 12-18 mmHg
  • Kerly B lines: short linear markings @ lung periphery of lower lung fields when PCWP 18-25 mmHg.
Term
Management of acute pulmonary edema/CHF
Definition

LMNOP

L: lasix

M: morphine (reduce preload/heart strain)

N: nitrates (venodilators, reduce preload/heart strain)

O: oxygen

P: position (upright to decreased venous return)

Term
MOA: synthetic BNP (decreases RAAS activation, increases NA excretion, decreases TBFV). IV only. only used in ER or inpatient settings for severe cases
Definition

Nesiritide

CHF

Term
Diastolic heart failure management
Definition
  1. BB, ACEI, & CCB : HR & BP control & relief of ischemia. 
  2. Diuretics for volume overload
  3. CCB helpful for diastolic (unlike systolic where is is generally not helpful or even harmful).  
  4. Exceptions for CCB & sys: angina w/ HF or normal EF
Term
inflammation of the heart muscle.
Definition

myocarditis

  • compared to adults, the majority of children w/ myocarditis present w/ acute or florid HF (often mild in adults)
Term
myocarditis is mostly commonly d/t
Definition

viral infection (or post viral immune cardiac damage) - enteroviruses (esp. coxsackie B) & echovirus

  • 17% of pts w/ SIDS have evidence of myocarditis peaks in infancy (btwn 6-12 mos) and adolescence (16y) overall it is a rare dz in children
Term
Etiology's of myocarditis
Definition
  • viral: enteroviruses (esp. coxsackie B) MCC & echoviruses
  • Bacterial: Rickettsial (lyme dz, rocky mountain spotted fever, Q feveR)
  • Fungal: actinomycosis, coccidiomycosis, histoplasmosis, candidiasis
  • Parasitic: trichinosis, toxoplasmosis
  • toxic : scorpion envenomation, diphtheria toxins
  • Autoimmune: SLE, rheumatic fever, RA, kawasaki, UC
  • Systemic: uremia, hypothyroidism
  • Meds: methyldopa, abx (tetracycline, amph B, PCN), cyclophosphamide, acetazolamide, indomethacin, isonizid, phenytoin, sulfa, clozapine
Term
Pathophysiology of viral myocarditis
Definition
  • myocellular damage --> myocardial necrosis & dysfunction --> +- HF (d/t systolic dysfunction, cardiac enlargement & myocardial fibrosis)
Term
Clinical manifestations of myocarditis
Definition
  • viral prodrome: fever, myalgias, malaise x several days --> HF sx
  • HF sx: dyspnea @ rest, exercise intolerance, syncope, tachypnea, tachycardia, hepatomegaly.  Impaired systolic function (S3 +- S4).  Severe: hypotension, poor pulses & perfusion, AMS. GI sx: megacolon
  • +- pericarditis simultaneously: fevers & CP, pericardial friction rub, pericardial effusion
Term
Diagnostic studies for myocarditis
Definition
  1. CXR: cardiomegaly class (dilated cardiomyopathy) +- normal
  2. ECG: sinus tacy MC, +- atrial/junctional/ventricular arrhythmias. +- normal. +- show pericarditis (precordial ST elevations w/ associated PR depressions), pericardial effusion (alternans)
  3. cardiac enzymes: + CK-MB & troponin (myocardial necrosis d/t disease process - not usually occlusion) + cardiac enzymes helps distinguish myocarditis from chronic DCMP
  4. echo: ventricular dysfunction. +- pericardial effusion or MR. Echo most useful to assess cardiac fcn
  5. Endomyocardial bx: gold standard in diagnosing myocarditis.  commonly shows infiltrations of lymphs w/ myocardial tissue necrosis. Done in pts w/ new onset of HF unrelated to structural dz. helps w/ dx & prognosis
Term
Gold standard in diagnosing myocarditis
Definition
Echomyocardial bx
Term
Treatment for viral myocarditis
Definition

supportive mainstay of tx, standard regimens for HF

  • diuretics, afterload reducing agents (ex ACEI),
  • inotropic drugs if severe (dopamine, dobutamine, milrinone)

BB generally not used in management in peds

IVIG in some pts have been helpful

 

Term
systolic dysfunction --> ventricular dilation --> dilated, weak heart
Definition
dilated cardiomyopathy (95% of cardiomyopathies)
Term
disease of the heart muscle (myocardial tissue) w/ cardiac dysfunction NOT d/t other heart dz
Definition
cardiomyopathies
Term
Etiology of dilated cardiomyopathy
Definition
  • idiopathic MC cause, autoimmune
  • viral myocarditis (ex. enteroviruses)
  • toxic: ETOH, cocaine, pregnancy 
  • XRT, doxorubicin, daunorubicin 
Term
clinical manifestations of dilated cardiomyopathy
Definition
  • systolic HF sx - both right and left sided
  • embolic phenomena, arrhythmias
  • viral myocarditis: viral prodroma a few weeks --> signs of HF or CP, + cardiac enzymes, nonspp ST-T changes
Term
PE : Dilated cardiomyopathy
Definition
  • L heart failure - pulmonary congestion: rales, tachy, cough, pleural effusion
  • R heart failure - peripheral edema, increased JVP, hepatic congestion
Term
How do you diagnose dilated cardiomyopathy?
Definition
  • Echo - left ventricular dilation (thin walls), decreased EF, regional or global LV hypokinesis 
  • CXR - cardiomegaly, pul. edema, pleural effusion
Term
Treatment of dilated cardiomyopathy
Definition

standard systolic HF tx 

  • ACEI, diuretics, digoxin, BB, Na restriction

Implantable defibrillator if EF < 35% 

Term
diastolic dysfunction w/ preserved contractility

ventricular rigidity impedes ventricular filling (decreased ventricular compliance)
Definition
restrictive cardiomyopathy (1%)
Term
etiologies of restrictive cardiomyopathy
Definition

infiltrative dzs 

  • amyloidosis MCC
  • sarcoidosis, hemochromatosis
  • scleroderma, metastatic dz, idiopathic 
Term
Clinical manifestations of restrictive cardiomyopathy
Definition
  • right sided failure sx more common than left
  • poorly tolerated tachyarrhythmias
Term
PE : restrictive cardiomyopathy
Definition

Kussmauls' sign : increased JVP w. inspiration

R. heart failure: peripheral edema, increased JVP, hepatic congestion

Term
Diagnosis of restrictive cardiomyopathy
Definition

echo

  •  ventircles nondilated w/ normal wall thickness
  • marked dilation of BOTH atria
  • diastolic dysfxn w/ normal or near normal systolic fxn
Term
treatment of restrictive cardiomyopathy
Definition

no specific tx

treat underlying cause

Term
Hypertrophic cardiomyopathy definition (4%)
Definition
  • diastolic dysfunction d/t impaired ventricular relaxation/filling
  • subaortic outflow obstruction - hypertrophied septum
  • systolic anterior motion (SAM) of mitral valve & SAM is increased w/ 1. increased contractility (exertion) 2. decreased LV volume (ex decreased venous return, dehydration)
 
Term
etiologies of HCM
Definition
inherited genetic d/o of inappropriate LV and/or RV hypertrophy (esp. septal)
Term
Clinical manifestations of HCM
Definition
  1. often asymptomatic
  2. dyspnea (90%) most common initial complaint
  3. angina pectoris, syncope
  4. arrhythmias AF; VT/VF (palpitation, syncope)
  5. sudden cardiac death: esp in adolescent/preadolescent children (esp. exertion) d/t vent. fibrillation
Term
PE : HCM
Definition
  1. harsh systolic cre-decresc murmur @ LUSB similar to AS 
  2. decrease murmur intesntiy: increase venous return (ex squatting, lying down) b/c increase LV volume preserves outflow
  3. increased murmur w/ decreased venous return (valsalva & standing) & exertion (b/c decreased LV volume & increased contractility wll decrease CO) amyl nitrate
  4. usually no carotid radiation. Normal pulse, Loud S4, +- MR
Term
Diagnosing HCM
Definition
  • echo - asymmetric wall thickness (esp septal), SAM mitral valve
  • ECG: LVH
  • avoid exertion, implantable defibrillator to prevent VF
Term
treatment of HCM
Definition
  • medical: BB, verapamil, disopyramide
  • cautious use of digoxin, nitrates, & diuretics (digoxin increases contractility while nitrates & diuretics decrease volume)
  • surgical: myomectomy, ETOH ablation
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