Outpatient Arrhythmias

normal sinus rhythm (NSR) =

bradycardia =

tachycardia =

Normal Sinus Rhythm (NSR) = 60 - 100 bpm

bradycardia = < 60bpm

tachycardia = > 100bpm

hypothermia

hypothyroidism

electrolyte abnormalities

infiltrative disease

CAD/HTN/old age

cause...

sinus node dysfunction (decreased automaticity)

also caused by cardiomyopathies

HR of 60-80bpm

node in arrest:

automaticity foci:

type of rhythm:

HR of 60-80bpm

node in arrest: SA node

automaticity foci: atria

type of rhythm: atrial escape rhythm

HR of 40-60bpm

node in arrest:

automaticity foci:

type of rhythm:

HR of 40-60bpm

node in arrest: SA node

automaticity foci: AV junction

type of rhythm: junctional escape rhythm

HR of 20-40bpm

node in arrest:

automaticity foci:

type of rhythm:

HR of 20-40bpm

node in arrest: SA and AV node

automaticity foci: ventricles

type of rhythm: ventricular escape rhythm

Pain

Drugs

Hyperthyroid

Anemia

Fever

Anxiety

Exercise

Can cause...

STRUCTURAL cause of atrial fibrillation:

STRUCTURAL cause of atrial fibrillation:

• cardiomyopathies
• valvular pathology
• infiltrative diseases
• HTN
• Pericardial disease

METABOLIC causes of atrial fibrillation:

METABOLIC causes of atrial fibrillation:

• electrolyte imbalances
• endocrine abnormalities
• drugs

Valvular Heart Disease Lecture

What type of aortic stenosis would you expect if the pt was 50-65 yrs old?

possible associated findings?

bicuspid aortic stenosis: 

possible associated findigs:

• dilated ascending aorta
• coarctation of the aorta

what are the most common types of aortic stenosis?

causes?

congenital:  unicuspid or bicuspid** valve

**occurs in 50% of AS in pts < 70y

degenerative:  tricuspid aortic stenosis

due to calcium deposits on the leaflets similar to atherosclerosis

Name the disease:

Inspection:  sustained PMI, prominent atrial filling wave

Palpation:  powerful, heaving PMI displaced below MCL, systolic thrill, weak carotid pulse, **When do you check for radial-femoral delay**

Heart sounds:  Prominent S4, A2 normal/soft/absent, normal SBP, high DBP

Aortic Stenosis

Inspection:  sustained PMI, prominent atrial filling wave

Palpation:  powerful, heaving PMI displaced below MCL, systolic thrill, weak carotid pulse, **When do you check for radial-femoral delay**

Heart sounds:  Prominent S4, A2 normal/soft/absent, normal SBP, high DBP

**Bicuspid valve AS:  radial-femoral delay is seen in coarctation of the aorta but must be r/o with bicuspid valve AS

Name the disease:

Inspection:  hyperdynamic PMI to the left of the MCL, visible carotid pulsation, pulsating nailbeds, head bob

Palpation:  apical impulse forceful and displaced to the left and downward, prominant carotid pulse, rapidly rising and collapsing pulses

Heart sounds:  loud A2, S1 normal or reduced, wide pulse pressure with DBP<60mmHg

Aortic Regurgitation

Inspection:  hyperdynamic PMI to the left of the MCL, visible carotid pulsation, pulsating nailbeds, head bob

Palpation:  apical impulse forceful and displaced to the left and downward, prominant carotid pulse, rapidly rising and collapsing pulses

Heart sounds:  loud A2, S1 normal or reduced, wide pulse pressure with DBP<60mmHg

Name the disease:

Inspection:  malar flush, precordial bulge, diffuse pulsation (young patients)

Palpation:  "tapping" sensation over area of expected PMI, possible palpable P2

Heart sounds:  S1 loud, opening snap after S2**

Mitral Stenosis

Inspection:  malar flush, precordial bulge, diffuse pulsation (young patients)

Palpation:  "tapping" sensation over area of expected PMI, possible palpable P2

Heart sounds:  S1 loud, opening snap after S2**

**The S2-opening snap interval will be shorter the worse the disease

Name the disease:

Inspection:  usually prominant and hyperdynamic apical impluse to left of MCL

Palpation:  forceful, brisk PMI, systolic thrill over PMI, pulse normal, small or slightly collapsing

Heart sounds:  S2 normal or burried in early part of murmur, prominent 3rd heart sound in severe cases, midsystolic clicks, normal BP

Mitral Regurgitation

Inspection:  usually prominant and hyperdynamic apical impluse to left of MCL

Palpation:  forceful, brisk PMI, systolic thrill over PMI, pulse normal, small or slightly collapsing

Heart sounds:  S2 normal or burried in early part of murmur, prominent 3rd heart sound in severe cases, midsystolic clicks, normal BP

Name the disease:

Location of murmur:  localized near the apex.  Diastolic rumble in left decubitus position.

Mitral Stenosis

Location of murmur:  localized near the apex.  Diastolic rumble in left decubitus position.

Name the disease:

Location of murmur:  loudest over PMI.  Transmission sounds can be left axilla or anterior precordium.

Mitral Regurgitation

Location of murmur:  loudest over PMI.  Transmission sounds can be left axilla or anterior precordium.

Name the disease:

Location of murmur:  Right 2nd ICS parasternally or at apex, heard in carotid arteries, may sound like mitral regurg. at apex but murmur occurs after S1 and stops before S2.

Aortic Stenosis

Location of murmur:  Right 2nd ICS parasternally or at apex, heard in carotid arteries, may sound like mitral regurg. at apex but murmur occurs after S1 and stops before S2.

Name the disease:

Location of murmur:  Diastolic:  louder alond LSB in 3rd-4th ICS.  Heard over aortic area and apex, may be associated with low-pitched middiastolic murmur at apex

Aortic Regurgitation

Location of murmur:  Diastolic:  louder alond LSB in 3rd-4th ICS.  Heard over aortic area and apex, may be associated with low-pitched middiastolic murmur at apex

1. Degenerative (48%)
2. Bicuspid (27%)
3. Post-inflammatory/Rheumatic (23%)

chest pain? = 6yrs survival

angina, syncope?  = 3yrs survival

SOB, CHF? = 2 yrs survival

Aortic Regurg: 

What diseases are associated with the following..

Aortic Root Dilation/Distortion =

Cusp Retraction/Fibrosis =  

Cusp Perforation/Tears =

Lack of Cusp Support =

Aortic Regurg: 

Aortic Root Dilation/Distortion = Aortopathy, Aortitis, HTN**(most common cause)

Cusp Retraction/Fibrosis =  Chronic Rheumatic, Inflammatory

Cusp Perforation/Tears = Bacterial Endocarditis, Trauma

Lack of Cusp Support = Dissection of the Aorta, VSD (venticular septal defect)

What is your Dx?

Sx:

Fatigue

Dyspnea

Chest Pain

Lightheadness

Signs: 

Decrescendo early diastolic murmur

Displaced PMI

Soft S2

Wide pulse pressure (90mmHg)

What two medications are recommended to delay they need for surgery in aortic regurgitation?

Why?

ACE-Inhibitors

CCB (amlodipine)

Reduction in afterload

prolapse, endocarditis, flail, myxoma, rheumatic, perforation, and mycomatousus degeneration are diseases of the                        that cause                          

prolapse, endocarditis, flail, myxoma, rheumatic, perforation, and mycomatousus degeneration are diseases of the mitral leaflets that cause mitral regurgitation

dyspnea

paroxysmal nocturnal dyspnea

fatigue

palpitations

atrial fibrillation

edema

orthopnea

clinical manifestations of...

mitral stenosis

**key point**

left atrial pressure overload

atrial fibrillation

embolization

congenital or degenerative causes

cause...

prophylactic ABX Tx for mitral valve endocarditis

(need to fill in slide)

Management of Mitral Stenosis:

Pharm (2)

Procedures (2)

Management of Mitral Stenosis:

Pharm:  anticoagulation, diuretics

Procedures: baloon valvuloplasty, mitral valve replacement

Aortic Stenois vs. HCOM

how do you tell apart?

Valsalva:  HCOM inc

Squatting:  AS inc

Endo-, Myo-, Peri-carditis

Native infective endocarditis (IE) is most commonly caused by what?

what will the clinical signs be with this bug?

What about with IV drug users?

Native IE = S. aureus

(also S. epidermis, S. viridans, enterococci)

S. aureus = acure febrile illness

IV drug users = gram (-)

congenital heart disease

rheumatic heart disease

mitral valve prolapse

degenerative lesions

are risk factors for what?

Native Valve Infective Endocarditis (IE)

congenital heart disease:  30-40% of IE in kids **(common in Downs Syndrome)

rheumatic heart disease

mitral valve prolapse:  risk inc 10-100x with regurg

degenerative lesions:  common in elderly, 50% of pts >60y w/ IE

infective endocarditis is most likely to be found in

1. 

2. 

1.  left sided valves

2.  L to R shunts** (most common sites of IE)

dental work

Note:

Transient bacteremia, low grade and short duration-less than 10 minutes after dental extraction

central venous lines, pulmonary artery catheters, and pacemakers are assocatied with IE in which side of the heart?

Right sided IE

**Nosocomial infections have a 50% mortality rate

symptoms (most common to less common)

fever

chills

arthralgia/myalgias

back pain

pleuritic chest pain

disease?

Endocarditis

Roth's spots are retinal hemorrhages with white or pale centers composed of coagulated fibrin.

Osler's nodes are painful, red, raised lesions on the palms and soles

Janeway lesions are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter

cardiac murmur

petechia

splinter hemorrhages

palpable spleen

CNS problems

renal insufficiency

are clinical signs on PE for                   

1.  prosthetic cardiac valve

2.  previous infectious endocarditis

3.  congenital heart disease

4.  cardiac transplantation recipients who develop valvulopathy

which of these procedures require prophylaxis for endocarditis?

1. dental procedures w/ manipulation of the gingival tissue
2. genitourinary tract procedures
3. respiratory tract procedures
4. GI tract procedures
5. procedures on infected skin or musculoskeletal tissue

1. dental procedures w/ manipulation of the gingival tissue  YES
2. genitourinary tract procedures  NO
3. respiratory tract procedures  YES
4. GI tract procedures  NO
5. procedures on infected skin or musculoskeletal tissue  YES

how is infective endocarditis diagnosed?  (2)

blood cultures

echocardiogram (transesophageal to find vegetation 90% specific test...then sample vegetation if pt has surgery)

Name the causative bugs...

Oropharyngeal:

GI or GU:

Skin:

Oropharyngeal:  streptococci

GI or GU:  enterococci

Skin:  staphylococci

infection

allergic reaction

drug reaction (name 2 ABX)

systemic inflammatory disease (name 3)

insect bites

are all causes of ...

myocarditis

drug reaction:  sulfonamides, tetracycline

systemic inflammatory disease:  SLE, RA, sarcoidosis, sclerosis, Kawasaki

children have a higher rate of                      due to naive immune systems

approx 50% of                 pts have this same disease at autopsy

myocarditis

50% of AIDS pts.

myocarditis

borrelia burgdorferi = spirochetes

tachycardia

muffled heart sounds, extra beats, transient murmurs

cardiomegally (severe cases)

leukocytosis

EKG changes (what does this tell you?)

PE signs of what?

myocarditis

EKG changes:  conduction defects mean systemic illness, ST and T wave MI changes after 2 months of illness

tx of myocarditis is similar to tx of what disease?

what would the tx be then?

tx of CHF symptoms and complications

tx:  O2, diuretics, digoxin, Na+ restriction, maybe ACE-I

**NSAIDS may make damage worse and steroids are not effective

most common cause of pericarditis is                  .

what is post-MI pericarditis called?

viral

Dressler's Syndrome

pleuritic chest pain that is relieved by sitting that is substernal and may radiate to the back, shoulders, neck, or epigastic area along with pericardial friction rub, dyspnea and fever

S/S of what?

tx of pericarditis

usually viral, so palliative tx

aspirin or indomethacin (NSAID)

dyspnea

edema

fatigue/weakness

hepatic congestion/ascites

increaed JVP

Kussmail sign (what is this?)

Sx of what?

pericarditis

Kussmail sign:  failure of JVP to fall with inspiration

septal "bounce" on an ECHO scan may be seen with what?

diuretics

surgical pericardectomy may be necessary if diuretics don't work (15% mortality)

                     is when pericardial effusion increases intrapericardial pressure >15mmHg

What happens to the SV, pulse pressure, HR, and venous pressure?

what can occur as a result?

cardiac tamponade

SV and pulse pressure fall

HR and venous pressure rise

shock and death can occur

large, slow effusions may have what effect?

what about small, fast effusions?

large, slow effusions may have no hemodynamic effect

small, fast effusions can cause tamponade

dyspnea and cough (common)

friction rub

tachycardia

tachypnea

narrow pulse pressure

edema/ascites (what do they indicate)

pulses paradoxus**

S/Sx for what disease?

cardiac tamponade

edema/ascites (rate, but indicate a chronic process, not fast occuring tamponade)

pulses paradoxus** classic sign

ECHO

urgent pericardiocentesis to drain fluid

may need to repeat if from malignancy