Cardiac - Recall

What is preload?

What is EDV?

What is SV?

What is EF?

Dilated

• What are the causes of dilated cardio myopathy?

• What kind of hypertrophy is associated with ↑ preload?

• Stretching the heart can ➔ _________ & ________ problems ➔

• What type of HF is associated with dilated?

• Which heart sound is associated with filling a dilated chamber?

  • What is causing it?

  • When do you hear it?

• What is the tx?

  • When does an AICD go?

Takotsubo (stress induced)

• MC in post __________ __________

• An acute __________ ➔ release of __________ ➔ apex __________

• They present with __________ so you work it up like MI

  • There may be ST elevation but unlike an MI there are no __________ __________

  • PCI shows __________ coronary arteries and ECHO shows apex __________

Hypertrophic

• The classic pt:

• Explain SAM

• What important stuff lives in the septum and can mess with conduction when there is ↑ septal growth?

• What type of dysfunction?

• Which heart sound is associated with filling a hypertrophic chamber?

  • What is causing it?

  • When do you hear it?

• What is the murmur and when do you hear it?

  • Explain why squat/hand grip ➔ ↓ murmur and why valsalva/standing ➔ ↑ murmur (click here to review maneuvers)

• If you were going to tx with CCB... would you pick dihydropyridine or non-dihydropyridine?

  • Why?

• Surgical ________ if refractory to meds and install an _______ after their arrest

Restrictive

• Deposits in myocardium ➔ ↓ __________

  • The deposits come from what disorders?

• What sided HF is associated with restrictive?

  • What is Kussmaul sign?

• Which heart sound is associated with filling a non-compliant chamber?

• Echo shows ______________ dysfunction with __________ enlargement - but not __________ enlargement

• To dx the underlying you see apple ________ with congo _______ (thankfully, I only like green apples)

What is the conduction pathway?

• What are the intrinsic rates?

What many ms is normal a p-wave?

How many ms is a normal PR interval?

• So how many small boxes should be between the end of a P and the start of the Q/R

How many small boxes are 1 big box?

• How many ms is 1 big box?

• If a PR interval is bigger than 1 big box then you have __________

Atrial fibrillation/flutter

• A-fib = ____________ __- waves

  • Chronic a-fib tx involves:

• What is the atrial rate in A-flutter?

  • This causes the typical __________ pattern

    • What determines the ventricular rate?

Atrioventricular block

• Explain the longer, longer, drop...

  • What ° block, what type?

  • Explain the difference between type 1 and type 2

• What is a third ° block?

Bundle branch block

• LBB: QRS is _________ in V1 and _________ in V6

  • It has _________ and ________ R waves

  • New LBB and CP should be worked up as ________

• RBB: The ___________ of the QRS is normal-ish (since the signal is conducted down the left bundle normally)

  • The T-wave is _______ in V1

Paroxysmal supraventricular tachycardia

• PSVT is typically synonymous with ________

  • AVNRT is a reentry within the _________

• What is the difference between AVNRT and AVRT?

  • AVRT with orthodromic tachycardia has __________ QRS complexes

  • AVRT with antidromic tachycardia has __________ QRS complexes

• WPW has an ____________ accessory pathway ➔ pre-excited ventricles ➔ delta waves

Premature beats

• A PAC is a __________ QRS complex and a PVC is a _________ QRS complex

Sick sinus syndrome

• Can have SA _________ and/or _________-_________ syndrome

• What diagnostic tool can you use to catch sick sinus?

• What is the definitive tx for sick sinus?

Sinus arrhythmia

• Inspiration ⊣ vagal tone ➔ _______ rate

• Expiration ↑ vagal tone ➔ _______ rate

  • Something is wrong if this isn't present

Torsades de pointes

• Is a type of ________-morphic v-tach

• It is associated with ___________ syndrome

  • Explain R on T

• What is the tx for unstable? What is tx for stable?

Ventricular fibrillation

• Does V-fib have a pulse?

Ventricular tachycardia

• Can v-tach have a pulse?

Create a mega code for yourself

• Pt with CP becomes brady...

  • Good pressure:

  • Bad pressure:

• Goes into asystole:

  • Do you shock asystole?

  • How often and how much epi?

• After a round of CPR you see a vfib

  • Do you do synchronized or desynchronized shock?

• What if instead of CP with brady the pt was tachy (175bpm)

  • Narrow complex

    • Good pressure:

    • Bad pressure:

  • Wide complex

    • Good pressure:

    • Bad pressure:

Atrial septal defect

• Murmur:

• Wide fixed spilt S2 means ___________ with inspiration

Coarctation of aorta

• Where is the narrowing in infants?

• Where is the narrowing in adults?

  • Where is there HTN and where is there hypotension?

    • How do these present?

  • What will you see on CXR?

Patent ductus arteriosus

• What viral infxn in the 1st trimester can cause this?

• Murmur:

• What is the tx once Eisenmenger syndrome develops

Tetralogy of Fallot

• What are the 4 components of TOF?

• Explain tet spells

• What will you see on CXR?

Ventricular septal defect

• Murmur:

• What age/complications warrant surgery?

Acute myocardial infarction

• Non–ST-segment elevation

  • Can be subendocardial or reciprocal changes (like in a ___________ MI)

  • Does it have cardiac biomarkers?

• ST-segment elevation

  • Which are the inferior leads?

    • The reciprocal?

  • Which are the lateral leads?

    • The reciprocal?

  • Which are the anterior leads?

  • Which vessels are associated with which leads?

  • Initial STEMI tx:

    • PCI in ______ mins and if not feasible

    • Thrombolytics in _____ mins

  • MI pts go home on what meds?

Angina pectoris

• Prinzmetal variant

  • Does it relief with rest?

  • How do you dx vasospastic angina?

• Stable

  • Does it relieve with rest?

  • How do you dx stable angina?

• Unstable

  • If they don't have cardiac biomarkers then you just send them home... right?

  • It isn't like it can be an MI if they have weird EKG changes and no markers... right?

Explain the ssx behind LHF vs RHF

How can you have preserved EF (HFpEF)?

Explain the difference between systolic vs diastolic HF

Concentric remodeling is associated with ↑ ___________ and eccentric remodeling is associated with ↑ __________

The gold standard dx test is _______ (gives you EF)

BNP is _______ in HF

↓ CO causes:

• NE to bind β receptors on heart ➔ ↑ ________ & ______

• NE to bind β receptors kidney ➔ ↑ ________ secretion

• Renin converts angiotensinogen into AG1 which is converted into AG2 by ______

  • AG2 stimulates ___________ and _________ reabsorption

  • AG2 stimulates ___________ which ➔ ↑ _______ reabsorption and ↑ ________ excretion

• ACEi and ARB ➔ ____ preload and ____ afterload

  • ADR:

    • ACEi can ➔ cough because of ↑ _________

• Diuretics

  • Loops and thiazides ➔ metabolic ___________, hypo___________, hypo__________

  • Thiazides ↑ _________ reabsorption

  • K sparring diuretics are _______________

    • They can cause metabolic ___________, hyper___________

• Acute HF in a dry pt is likely because of ____________

• Acute HF in a wet pt is like because of __________ __________

Essential hypertension

• Primary HTN patho poorly understood but mostly genetic and environment

• Which systems will end organ damage manifest in? (four)

• What is elevated HTN?

• What makes it stage 1 or stage 2?

Hypertensive urgency/emergency

• What is systolic or diastolic number for urgency?

  • What makes it emergency?

  • What systems have end organ damage and what ssx will you see in each?

• What is mean arterial pressure (MAP)?

  • How do you calculate it?

• Why can't you lower the BP too quickly?

• What determines IV vs PO anti-HTN meds?

• How much do you want to lower BP?

  • Unless what?

• What are the PO meds for HTN urgency?

• What are the IV meds for HTN emergency?

  • For neuro ssx:

  • For ACS:

  • For acute CHF:

  • For dissection:

    • Why do you want to give β-blockers before vasodilators?

Secondary hypertension

• What is secondary HTN?

  • What two systems should you think of for secondary HTN?

  • What pt presentation should make you think secondary HTN?

Shock

• Is a shocky pt always hypotensive?

• Why is there an elevation in lactate?

• What is shock index?

• Hypovolemic, cardiogenic, and obstructive all have _____ systemic vascular resistance

• Distributive shock has _____ systemic vascular resistance

  • Three distributive shocks are:

    • Which one has ↑ CO?

• What happens to hemoglobin/hematocrit with ↓ fluid (not ↓ blood)

Cardiogenic shock

• What do you want to avoid in tx of cardiogenic shock

Orthostatic hypotension

• How do you dx orthostatic hypotension?

• Can depleted volume ➔ orthostatic hypotension?

• Why would you pick tilt table as an answer?

• How can you tx orthostatic hypotension?

• What are the options for refractory orthostatic hypotension?

Vasovagal hypotension

• Is the MCC of ___________

• Which nerve is responsible? (this is a tough one)

Hypercholesterolemia

• Is defined as:

Hypertriglyceridemia

• Is defined as:

What do you want levels below?

• Total, LDL, HDL, Triglycerides

Why do we care about ↑ cholesterol?

What are things you can see on PE in pts with lipid disorders?

If someone had MI, stroke, PAD (or any other manifestation of ASCVD) what do you start them on?

If someone is 40-75 and has DM, what do you start them on?

If someone has LDL > 190, what do you start them on?

If someone has LDL < 190 what do you estimate?

• Who doesn't get what you put all those people👆 on?

What is best to:

• ↓ LDL

  • How does it work?

• ↑ HDL

  • How does it work?

• ↓ Triglycerides

  • How does it work?

• What are the three other medications used to ↓ LDL

Acute and subacute bacterial endocarditis

• MC organism in acute:

• MC organism in recent (< 2mo) prosthetic valve or catheter:

• MC organism in older prosthetic valve:

• Which valve is MC affected?

  • What about in IVDA?

• FROM JANE:

What criteria is used to dx endocarditis?

• If you get 2 positive cultures and positive echo (... you have your dx

• If echo has signs of endocarditis but your cultures haven't grown anything, you're thinking what organisms are responsible?

  • What else would you need to make dx?

What empiric ABX are given to critical pts after getting cultures?

Acute pericarditis

• What are the causes?

  • What can happen after MI?

• What ssx are present in acute pericarditis?

  • What is pleuritic CP?

  • What does EKG show in pericarditis?

    • What is the difference between these EKG findings and what is seen in MI on EKG?

• What ssx are present in constrictive pericarditis?

  • What is Kussmaul's sign?

  • What does echo show in constrictive pericarditis?

• What is a pericardial effusion?

  • What can you see on EKG in effusion?

• What is the tx for acute pericarditis?

  • Unless...

• What is the tx for constrictive pericarditis?

Pericardial effusion/Cardiac tamponade

• What is a pericardial effusion?

  • What happens when an effusion happens too fast?

• What is Beck triad?

• What is pulsus paradoxus?

• Do you need to get echo if they are boxing?

• What do you do if they are circling the drain?

  • Where?

What are the systolic murmurs?

What are the diastolic murmurs?

Aortic

• Stenosis

  • SSX:

  • Murmur:

    • Maneuver:

  • Echo:

  • TX

  • Complications:

• Regurgitation

  • SSX:

  • Murmur:

    • Maneuver (handgrip ➔ ↑ afterload):

  • Echo:

  • TX:

  • Complications:

Mitral

• Stenosis

  • MCC:

  • SSX:

  • Murmur:

    • Maneuver:

  • Echo:

  • TX:

  • Complications:

• Regurgitation

  • MCC:

    • Other cause (_____ ➔ acute MR)

  • SSX:

  • Murmur:

    • Maneuver:

  • Complications:

    • Why would enlarged LA ➔ dysphagia/hoarseness?

  • Echo:

  • TX:

Pulmonary

• Pulmonic stenosis

  • Usually from ________

  • PV stenosis ➔ RV outflow obstruction ➔ ______

  • Murmur:

    • What does CXR show?

  • TX:

Tricuspid

• Stenosis

  • The pt has a hx of _______

  • SSX of which sided HF?

  • Murmur:

• Regurgitation

  • Murmur:

Maneuvers

• Inspiration ➔ ↑ ______ preload & ↓ _______ preload

  • Right sided murmurs _____

  • Left sided murmurs _____

  • Except in _____ & ______

    • In this case

• What is a split S2?

  • Is it normal?

  • When would it be wide?

  • What is a fixed split?

    • When does this occur?

  • What is a paradoxical split?

    • When does this occur?

Aortic aneurysm

• ↑ risk of ______

• __________ abd mass = AAA

• What would you see if they ruptured?

• How many mm of dilation to dx aneurysm (not cm... mm)

• Dx/screen with ____________ but the definitive dx is ____________

• Who gets screened for AAA?

  • How big does the dilation have to be if you're going to follow up in 3yrs, 1yrs, 6mos

    • What can you give the pts that are getting f/u US?

  • How big or how much of an ↑ in diameter ➔ surgery?

    • What is the surgery?

Aortic dissection

• DeBakey type 1 starts in ____________ and moves to/beyond arch

• DeBakey type 2 starts and stays in ____________

  • DeBakey 1 & 2 are ____________ A

• ____________ B doesn't affect __________

  • DeBakey 3

• Is Stanford A or B more at risk for rupture?

• Classic SSX of aortic dissection:

• What causes unequal BPs

• What is gold standard dx?

• Which Stanford doesn't go right to surgery?

  • What do you start tx with?

    • Which do you give first?

What is a thrombus? What is an embolus?

Arterial embolism

• ↓ perfusion ➔ 6 p's:

• DX: First __________, best __________

• TX:

Arteriovenous malformation

• Where are they MC?

• The initial ssx are:

  • Eventually ➔

• DX: First __________, best __________

• TX:

Traumatic AV fistula

• MCC: (pt has hx of...)

• The initial ssx are:

  • Eventually ➔

  • DX: First __________, best __________

  • TX:

Giant cell arteritis

• __________ vasculitis of __________ & __________ arteries

  • Unlike _____________________ , which affects __________ & __________ arteries

• Constitutional sx include:

  • 50% of pts with GCA also have _______________________

• Cranial ssx include:

• Labs show ↑ ____/____

• Doppler US shows stenotic __________________ artery

  • Definitive dx is temporal __________ that shows _____________

• Why don't you want to delay tx?

• What is the tx?

Peripheral artery disease

• SSX

• DX

• TX

Phlebitis/thrombophlebitis

• Do we just give the pt with superficial thrombophlebitis a warm & wet towel and d/c them?

Varicose veins

• Cosmetic

Venous insufficiency

• SSX

• DX

• TX

Venous thrombosis

• DVT classic ssx:

• PE classic ssx:

• Meyers sign:

• Payr sign:

• Homans sign:

• Wells score - 8 components worth 1 point each:

  • (1-2 points = moderate pre-test probability; 3-8 points = high pre-test probability)

  • D-dimer is helpful for _________ DVT in Wells score < ___

  • Compression US shows a vein that is ______________

  • TX with ____________ for how long?

    • What medication do you not start with?

      • Why?

Differentiate between PAD and VI:

• Pain with walking

  • PAD

  • VI

• Dependent foot ➔

  • PAD

  • VI

• Leg looks like

  • PAD

  • VI

• Acute occlusion ➔

  • PAD

  • VI