-
Murmurs inc in intensity with inhalation
- Right side, inc venous return
- Tricuspid and pulmonic valves
-
Valvular heart disease tests
- initial: echo
- accurate: catheterization
-
Tx of valvular lesions
- All get diuretics
- Mitral stenosis - balloon dilation
- Aortic stenosis - surgical removal
- Regurgitant - vasodilators (ACEi, nifedipine, hydralazine) and surgical replacement
-
Assessment of ventricular size with indication for valve replacement
- End systolic diameter and EF
- If diameter expands, replace valve.
- MR: Above 40mm or EF <60%
- AR: 55mm or 55%
-
Mitral stenosis tx
Tx if symptomatic or valve area is <1 cm2
-
Mitral stenosis presentation
- Immigrants, pregnant, young adults
- SOB, CHF
- Dysphagia
- Hoarseness
- AFib
- Hemoptysis
- CXR with second bubble behind heart, elevation of left bronchus, and straigh left heart border
-
Mitral stenois murmur
- Opening snap
- Diastole
- Inc with squatting and leg raising
-
Aortic stenosis presentation
- Older
- Angina, syncope, CHF (2yr survival)
- Systolic, crescendo-decrescendo
- Dec with valsalva, standing, handgrip
- LVH
-
Mitral regurg presentation
- Dilation of heart from HTN, MI etc
- CHF
- Holosystolic
- Worse with handgrip, squatting, leg raise
-
Aortic regurgitation presentation
- MI, HTN, marfan, alkylosing spondylitis, syphilis
- CHF, wide pulse pressure, bounding pulse (water hammer), quincke pulse (pulse in nail bed), Hill sign (BP in legs 40+ arms), de Musset (head bobbing)
- Diastolic, decrescendo
- Better with valsalva and standing
- Inc by handgrip
-
MVP presentation
- normal variant, Marfan, Ehlers-Danlos
- CP, palpitations, panic attack. No CHF
- Midsystolic click, can have murmur after it
- Worse with valsalva and standing
- Better with squatting and handgrip
-
MVP management
- Echo, no cath
- Bblockers for symptoms, valve repair but rare
- No ppx
-
Handgrip
- Increases afterload (via compressing arteries)
- Inc AR, MR
- Dec AS, MVP, HOCM
- No effect on MS
-
Amyl nitrate effect on murmurs
- Arteriolar vasodiltors. Like ACEi
- Inc AS, MVP, HOCM
- Dec AR, MR
- No effect on MS
-
Squatting/leg raise
- Inc venous return
- Inc MS, AS, MR, AR
- Dec MVP, HOCM
-
Valsalva/standing
- Dec venous return (via inc thoracic pressure or inc venous capacity)
- Similar to diuretic use
- Inc MVP, HOCM
- Dec MS, AS, MR, AR (all else)
-
Cardiomyopathy presentation
- SOB, edema, rales, JVD
- Dilated - gallop, CHF
- Hypertrophic - s4 gallop, fewer right heart failure signs
-
Cardiomyopathy management
- Echo
- All but HOCM tx with diuretics
- Dilated: Acei, bblockers, spironolactone dec mortality. Diuretics and digoxin for sx. Defib if wide QRS
- Hypertrophic: bblocker is best initial. verapamil. disopyramide
- HOCM: bblocker, verapamil. disopyramide. No diuretics. Defibrillator if syncope. Ablation or myomectomy
-
Dilated cardiomyopathy causes
- MI
- etoh
- postviral myocarditis
- radiation
- Roxorubicin
- Chagas
-
Hypertrophic cardiomyopathy cause
HTN
-
Hypertrophic Obstructive cardiomyopathy
- abnormal septum, genetic
- Dyspnea, CP, syncope, sudden death, worse with inc HR
- Systolic anterior motion of mitral valve
- Worse with dec LV size such as ACEi, digoxin, hydralazine, valsalva, standing suddenly
- Nonspecific ST and T wave changes, septal Q waves in inf and lateral leads
-
Restrictive cardiomyopathy causes
- sarcoidosis
- amyloid
- hemochromatosis
- fibrosis
- scleroderma
-
Restrictive cardiomyopathy presentation and dx
- dyspnea, right sided heart failure, pulm HTN
- Kussmaul sign
- initial: echo
- Amyloid speckling on echo
- Accurate: endomyocardial bx but rare. do bx elsewhere
-
Pericarditis most common cause
- Viral - coxsackie B (tx with NSAIDs)
- SLE is most common CT disorder. the rest can do it too
-
Pericarditis EKG
- ST elevation in all leads
- Most specific is PR depression
-
Pericardial tamponade presentation
- If fast, sx at 50mL, if slow 2L
- Right side first
- Hypotension, tachycardia, distended neck veins, clear lungs, pulsus paradoxus
-
Pericardial tamponade tests
- Globular heart
- Electrical alternans
- Echo - ri atrial and ventricular diastolic collapse
- Cath - Equalization of pressures in diastole
-
Tamponade tx
- IVF (not diuretics)
- pericardiocentesis
-
Constrictive pericarditis presentaion
- Rt heart failure
- Kussmal sign
- Knock in diastole from vent filling
-
Constrictive pericarditis dx and tx
- initial: CXR with Ca
- Accurate: CT and MRI
- Diuretics first. Surgical removal of pericardium
-
PAD dx and tx
- ABI <0.9
- Angiogram is more accurate but only used if plant to revascularize
- ASA, stop smoking, cilostazol (most effective), bypass
-
Aortic dissection tx
- bblockers
- Then nitroprusside (second to dec reflex tachycardia)
- surgery
-
Peripartum cardiomyopathy
- Ab to myocardium
- LV dysfunction after pregnancy - reversible and short term. Worse 2nd time
- Tx as dilate cardiomyopathy
-
Pregnancy worsening CV disease
- Worst is peripartum cardiomyopathy
- Eisenmenger
- Mitral stenosis
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