Cards2 Step2

  1. Murmurs inc in intensity with inhalation
    • Right side, inc venous return
    • Tricuspid and pulmonic valves
  2. Valvular heart disease tests
    • initial: echo
    • accurate: catheterization
  3. Tx of valvular lesions
    • All get diuretics
    • Mitral stenosis - balloon dilation
    • Aortic stenosis - surgical removal
    • Regurgitant - vasodilators (ACEi, nifedipine, hydralazine) and surgical replacement
  4. 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%
  5. Mitral stenosis tx
    Tx if symptomatic or valve area is <1 cm2
  6. 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
  7. Mitral stenois murmur
    • Opening snap
    • Diastole
    • Inc with squatting and leg raising
  8. Aortic stenosis presentation
    • Older
    • Angina, syncope, CHF (2yr survival)
    • Systolic, crescendo-decrescendo
    • Dec with valsalva, standing, handgrip
    • LVH
  9. Mitral regurg presentation
    • Dilation of heart from HTN, MI etc
    • CHF
    • Holosystolic
    • Worse with handgrip, squatting, leg raise
  10. 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
  11. 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
  12. MVP management
    • Echo, no cath
    • Bblockers for symptoms, valve repair but rare
    • No ppx
  13. Handgrip
    • Increases afterload (via compressing arteries)
    • Inc AR, MR
    • Dec AS, MVP, HOCM
    • No effect on MS
  14. Amyl nitrate effect on murmurs
    • Arteriolar vasodiltors. Like ACEi
    • Inc AS, MVP, HOCM
    • Dec AR, MR
    • No effect on MS
  15. Squatting/leg raise
    • Inc venous return
    • Inc MS, AS, MR, AR
    • Dec MVP, HOCM
  16. 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)
  17. Cardiomyopathy presentation
    • SOB, edema, rales, JVD
    • Dilated - gallop, CHF
    • Hypertrophic - s4 gallop, fewer right heart failure signs
  18. 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
  19. Dilated cardiomyopathy causes
    • MI
    • etoh
    • postviral myocarditis
    • radiation
    • Roxorubicin
    • Chagas
  20. Hypertrophic cardiomyopathy cause
  21. 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
  22. Restrictive cardiomyopathy causes
    • sarcoidosis
    • amyloid
    • hemochromatosis
    • fibrosis
    • scleroderma
  23. 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
  24. Pericarditis most common cause
    • Viral - coxsackie B (tx with NSAIDs)
    • SLE is most common CT disorder. the rest can do it too
  25. Pericarditis EKG
    • ST elevation in all leads
    • Most specific is PR depression
  26. Pericardial tamponade presentation
    • If fast, sx at 50mL, if slow 2L
    • Right side first
    • Hypotension, tachycardia, distended neck veins, clear lungs, pulsus paradoxus
  27. Pericardial tamponade tests
    • Globular heart
    • Electrical alternans
    • Echo - ri atrial and ventricular diastolic collapse
    • Cath - Equalization of pressures in diastole
  28. Tamponade tx
    • IVF (not diuretics)
    • pericardiocentesis
  29. Constrictive pericarditis presentaion
    • Rt heart failure
    • Kussmal sign
    • Knock in diastole from vent filling
  30. Constrictive pericarditis dx and tx
    • initial: CXR with Ca
    • Accurate: CT and MRI
    • Diuretics first. Surgical removal of pericardium
  31. 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
  32. Aortic dissection tx
    • bblockers
    • Then nitroprusside (second to dec reflex tachycardia)
    • surgery
  33. Peripartum cardiomyopathy
    • Ab to myocardium
    • LV dysfunction after pregnancy - reversible and short term. Worse 2nd time
    • Tx as dilate cardiomyopathy
  34. Pregnancy worsening CV disease
    • Worst is peripartum cardiomyopathy
    • Eisenmenger
    • Mitral stenosis
Card Set
Cards2 Step2