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Infective endocarditis in IV drug use
- Staph aureus is the most common
- Tricuspid valve involvement (right-sided) more common than aortic
- Holosystolic murmur increases with inspiration = tricuspid involvement
- septic pulmonary emboli
- Heart failure more common in aortic valve involvement
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Acute atrial fibrillation
- Cardiac: hypertension, acute ischemia, heart failure, myopericardial inflammation, valve disease, surgery
- Pulmonary: acute lung disease (pneumonia), pulmonary emboli, hypoxia
- Metabolic: Catecholamine surges, hyperthyroidism
- drug-related: alcohol, cocaine, amphetamines, theophylline
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Sinus bradycardia
Causes
- physical conditioning
- exaggerated vagal activity
- sick sinus syndrome
- hypoglycemia
- medications (digitalis, beta-blockers, calcium channel blockers
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Sinus bradycardia
symptomatic: treatments
- dizziness, light-headedness, syncope, fatigue, worsened angina
- Tx: intravenous atropine (decreases vagal input)
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Hypertrophic cardiomyopathy
- carotid pulse dual upstroke
- systolic ejection murmur along left sternal border
- Murmur: increases as preload decreases (valsalva maneuver)
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Suspected aortic disection
- Risk factors: Marfan syndrome, connective tissue disease, hypertension
- Tearing chest/abdominal pain radiating to the back
- Perfusion deficits (pulse deficit, >20mmHg blood pressure difference between right and left arm; aortic regurgitation murmur)
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Aortic disection
workup
- Chest X-ray or ECG (for other diagnosis)
- Imaging: TEE, chest CT with contrast, MRI (only if nonemergency)
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Atrial fibrillation
- ventricular rates as high as 150/min
- Tx: beta blockers or calcium channel blockers (in hemodynamically stable patients)
- digoxin; only in patients with AF due to heart failure (or those who can't tolerate BBs or CCBs)
- cardioversion: only in patients who have had AF of <48hrs, or must receive rate control with 3-4 weeks anticoagulation
- common complication of CABG (40% of patients)
- tx of hemodynamically unstable (hypotension, AMS): immediate cardioversion
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hypertrophic cardiomyopathy
- autosomal dominant
- murmur decreases with increased pre-load
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Prinzmetal angina
variant angina
- coronary vasospasm
- presentation: variant angina, typically at night; transient ST elevations on ECG
- Risk factors: young females, smokers
- Tx: calcium channel blockers or nitrites
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Cause of death in acute MI
complex ventricular arrhythmias (i.e. reentry, such as vfib
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Cushing's syndrome
- cortisol: vasoconstriction, insulin resistance, mineralocorticoid activity
- result: high BPs, hyperglycemia, hypokalemia
- proximal muscle weakness, central adiposity, thinning of the skin
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hypothyroidism
weight gain, fatigue, bradycardia, depression, skin and hair changes
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COPD --> lower extremity edema
- COPD leads to chronic hypoxemia --> vasoconstriction
- pulmonary hypertension --> RV hypertrophy and failure
- Right heart failure: elevated JVP, congestive hepatosplenomegaly, hepatojugular reflux, lower extremity edema
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arteriovenous fistula
congenital vs acquired
- Congenital: PDA, angiomas, pulmonary AVF, CNS AVF
- Acquired: Trauma, iatrogenic (fem cath), atherosclerosis (aortocaval fistula), cancer
- Complication: increases cardiac output through increased preload
- signs: wide pulse pressure, strong peripheral arterial pulse, systolic flow murmur, tachycardia, flushed extremities
- Dx: doppler ultrasonography
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high output heart failure
causes
- AVMs or AVFs
- thyrotoxicosis
- Paget disease
- anemia
- thiamine deficiency
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aortic stenosis
- increased intensity of apical impulse
- narrow pulse pressure
- typical systolic murmur
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venous insufficiency
- normal jvp
- dilated lower-extremity veins
- worse with prolonged standing
- pitting edema
- skin discoloration
- dermatitis/eczema
- lipodermatosclerosis
- skin ulceration
- tx: leg elevation, exercise, compression stockings
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CHF symptoms
- paroxysmal nocturnal dyspnea
- DOE
- peripheral edema
- hepatomegaly
- cardiomegaly
- bilateral pleural effusion
- third heart sound
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CHF
causes in young individuals
viral myocarditis: coxsackie B virus
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Secondary causes of hypertension
- Renal parenchymal disease: elevated Cr, abnormal UA
- Renovascular disease: severe HTN, recurrent flash pulmonary edema or resistant heart failure, abdominal bruit
- Primary aldosteronism: easily provoked hypokalemia, slight hypernatremia, hypertension with adrenal incidentaloma
- Pheochromocytoma: paroxysmal elevated blood pressures with tachycardia, pounding headache, palpitations, hypertension with adrenal incidentaloma
- Cushing's syndrome: central obesity, facial plethora, proximal muscle weakness, abdominal striae, ecchymosis
- Hypothyroidism: fatigue, dry skin, cold intolerance, constipation, weight gain
- Primary hyperparathyroidism: hypercalcemia (polyuria, polydypsia), kidney stones, neuropsychiatric
- COarctation of the aorta: differential hypertension with brachial femoral pulse delay
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subacute bacterial endocarditis
causes
viridans group streptococci, enterococci, and coagulase-negative staph (staph epidermidis)
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electrical alternans, sinus tachycardia
- highly specific for pericardial effusion
- can also see low voltages
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Pericarditis
etiologies
- infection: viral (most common), bacterial
- Iatrogenic: surgery, trauma, radiation & drug-related
- Connective tissue disease: RA, SLE
- Cardiac: Dressler's syndrome (post-myocardial pericarditis), usually 1-6 wks after MI
- Uremic: serum BUN >60mg/dL
- Malignancy: cancer or treatemnt
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Statins
- inhibit HMG-CoA reductase, rate limiting enzyme in the intracellular biosynthesis of cholesterol
- reduces serum LDL with minimal change in liver LDL
- myalgias: 2-10% of patients, symmetric proximal muscle weakness or tenderness
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Thoracic aortic aneurysm
- asymptomatic, or chest, back, flank, or abodminal pain
- 60% are ascending aorta aneurysms
- Ascending aortic aneurysms: associated with cystic medial necrosis or connective tissue disorders (Marfan, Ehlers-Danlos syndrome)
- Descending: 40%, arise distal to the left subclavian artery. risk factors include hypertension, hypercholesterolemia, smoking
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most common cause of secondary hypertension
renovascular hypertension
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renovascular hypertension
suspect if...
- elevated Cr >30% baseline after starting ACE inhibitor or ARB
- Severe hypertension in pts with recurrent flash pulmonary edema
- diffuse atherosclerosis
- severe onset after age 55
- asymmetric kidney size
- abdominal bruit
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chagas disease
- chronic protozoal disease caused by trypanosoma cruzi
- megacolon/megaesophagus: destruction of the nerves controlling the GI smooth muscle
- cardiac disease: prolonged myocarditis
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Digitalis toxicity
- arrhythmia: Atrial tachycardia with AV block
- slower atrial rate than atrial flutter (150-250)
- increases vagal tone, decrease conduction through AV node = potentially causing AV block
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nitroglycerin
MOA
- venodilatory effect
- blood pools in the systemic venous circulation, decreasing the preload and left ventricular volume (decreases work of heart)
- also cause some arterial vasodilation
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Lidocaine
- class IB anti-arrhythmic drug
- use: ventricular arrhythmias (v-tach)
- decreases frequency of VPBs, but increases mortality in patients with acute MI
- asystole, therefore not used prophylactically in patients with ACS
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Flecainide
- Class IC antiarrhythmic: blocks sodium channels
- elongates the period of depolarization
- use: ventricular arrhythmias, SVTs (such as a-fib)
- increases the QRS complex duration
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Thiazide diuretics
side effects
- decreased tolerance to glucose
- increase LDL cholesterol
- Increase plasma triglycerides
- increase risk of acute gout arthritis (uric acid retention)
- hyponatremia
- hypokalemia
- hypercalcemia
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constrictive pericarditis
- elevated JVP with hepatojugular reflux
- kussmaul's sign: lack of decrease or an increase in JVP on ispiration
- pericardial knock
- pericardial calcifications on chest radiograph
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pulsus paradoxus
- >10mmHg fall in systolic pressure during inspiration
- Ddx: cardiac tamponade, asthma, COPD
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hypertrophic cardiomyopathy
treatment
- sx: 15-25% report syncope, chest pain on exertion
- inheritance: autosomal dominant
- murmur: systolic, left sternal border; worsens with maneuvers that decrease preload
- complication: diastolic heart failure
- Tx: beta blockers, CCB if patient cannot tolerate beta blocker
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wide complex tachycardias
- AV dissociation, Fusion/capture beats: Ventricular tachycardia
- -stable: IV amiodarone
- No AV dissociation: SVT with aberrancy
- -Stable: Maneuvers to determine rhythm (carotid massage, rate control)
- Unstable: hypotension, AMS, respiratory distress
- - synchronized cardioversion
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Sustained monomorphic ventricular tachycardia
- occurs 6 to 48 hours post MI
- tx in stable: antiarrhythmics (amiodarone, lidocaine, procainamide)
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