D\'s Cardio Step 2.txt

• Mitral Regurgitation
• Tricuspid Regurgitation

Mitral valve prolapse

• Aortic regurgitation
• Pulmonic regurgitation

Mitral stenosis

CO = SV x HR

• Rate of O2 use
• ------------------
• arterial O2 - venous O2

CO x TPR

Diastolic art pressure - 1/3 pulse pressure

Systolic - Diastolic Arterial Pressure

• Contractility
• Preload
• Afterload

• 1. Catecholamonines
• 2. Inc. Intracellular Ca
• 3. Dec. Extracellular Na
• 4. Digoxin
• 5. Anxiety
• 6. Exercise
• 7. Inc preload
• 8. Dec afterload

• 1. B blockers
• 2. CCB: verapamil
• 3. CHF
• 4. Acidosis
• 5. Hypoxia

Ant wall of LV

V2, V3, V4

Ant 2/3 of IV septum

V1, V2, V3

• LA
• Lat wall LV
• Post wall LV

AvL, V5, V6

• Inf wall LV
• Post 1/3 IV septum

II, III, AVF

• RA
• RV

II, III, AVF

• SA node
• AV node

• <160 : 2 CAD risk factors
• <130 : 2 or more risk factors
• <100 : High risk of CAD
• (age, high LDL, DM, MI)

• 1. Smoking
• 2. HTN > 140/90 or on HTN med
• 3. HDL < 40
• 4. FH CAD:  < 55 yrs  < 65 yrs
• 5. Age: >45  > 55 

HDL > 60 cancels 1 risk

•  LDL
•  HDL
•  Triglycerides

S.E. Myositis, inc LFT

Do NOT give with fibrates

• LDL
• No effect on HDL or Triglyc.

S.E.: myalgia, inc LFTs, inc plaque formation

• LDL
• HDL
• Triglycerides!

S.E. Myositis, inc LFTs

Do NOT give with statins!

• Cholestyramine
• Colestipol
• Colesevelam

• LDL
• S.E. Bad taste, GI upset

• LDL
• HdL!
•  Triglycerides

S.E. Facial flushing, nausea, paresthesia, pruritis, inc LFTs, insulin resistance, worsen gout

Long term use & ASA

Cholestyramine

Triglycerides!

• ST elevation
• T-wave changes
• Possible new arrhythmia
• LBBB
• Q wave changes

Troponin I

CPK-MB

Troponin I

Ventricular Wall Rupture

• B blocker
• ACE i
• Thrombolytics

Prolonged PR > 0.2 sec (1 big box)

No tx.

Progressive PR lengthening untill skip QRS. PR progression. Then reset

Adjust med doses. No tx unless symptomatic bradycardia

B blocker, digoxin, CCB

• Randomly skipped QRS
• Normal PR

Ventricular pacemaker

Caused by infranodal conduction prob; bundle of his

No relationship b/t P and QRS.

• Ventricular Pacemaker
• Avoid meds affecting AV conduction

Absense of conduction b/t atria & ventricles

• Tachycardia 150-250
• narrow/norm QRS
• P waves hidden in T waves

• Carotid Massage/valsalva
• Cardiovert: adenosine
• CCB

Variable morphology of P waves. At least 3.

HR>100bpm

• B blockers
• CCB: nondihydro: vera, dilt
• Ablation

<60bpm

• Stop meds
• Atropine
• Glucagon
• Ca
• Insulin
• Glucose

• Irregularly irregular.
• No P waves.
• Irregular QRS

• Anticogulate
• Rate control: CCB, BB, digoxin

• Regular tachycardia
• Sawtooth p waves

• Rate control: CCB, BB, electrical or chemical
• Cardiovert
• Catheter ablation

Early and wide QRS without preceding P wave followed by brief pause in conduction.

• No tx.
• BB in py with CAD

• 3+PVCs with HR 160-240
• Regular, wide QRS independent of P waves

• Electrical cardiovert
• Antiarrhythmic
• Internal defibrillator

Totally erratic tracing. No p or QRS

• CPR
• immediate electric (+\- chemical) cardioversion

• CHF
• Dilated cardiomyopathy
• M.R.
• MI

• Aortic stenosis
• LVH
• MI
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy

L-R shunt  PH RVH  R-L shunt

• 1. Cardiac enlargement
• 2. Kerley B lines
• 3. Cephalization of pulm ves

Increased marking of lung interlobular septa caused by pulm edema.

In CHF

Increased marking of superior pulmonary vessels caused by congestion and stasis.

CHF

• Ace i
• BB
• Spironolactonr

• Loop diuretics
• ACE i /ARB
• BB
• Digoxin!
• Spironolactone
• Vasodilators!

• CCB!
• ACE i/ ARB
• BB
• K sparers

• Lasix
• Morphine
• Nitrates/Nesiritide (rBNP)
• O2
• Positioning/Pressors (dopa, dobutamine)

• A.S.:  murmur
• HOCM:  murmur

• Viral
• TB
• SLE
• Uremia
• Neoplasm
• Drug: INH, hyralazine
• Post-MI (dressler)
• Radiation
• Recent  surgery

Acute pericarditis

Fall in systolic BP >10 mmHg with inspiration.

Acute pericarditis

• Underlying cause
• Pericardiocentesis
• NSAID
• Colchicine: recurrence

If untreated can become chronic constrictive pericarditis.

Transudates protein

If exudate protein workup for neoplasm or gibrotic disease.

• Radiation
•  surgery

Chronic constrictive pericarditis.

 JVD with inspiration

• NSAID
• Colchicine
• Steriods
• Surgical excision of pericardium (high mortality)

Large pericardial effusion compressing  =  CO

• Acute pericarditis
• Chest trauma
• LV rupture from MI
• Dissecting aortic aneurysm

 tamponade

Immediate pericardiocentesis

• Idiopathic
• Etoh
• Beriberi
• Coxsackie B
• Cocaine
• Doxurubicin
• HIV
• Pregnancy

• Balloon like 
• "water bottle"

• Sarcoidosis
• Amyloidosis
• Hemochromatosis

• Cosackie
• Echo, adeno, EBV, CMV, influ
• Drugs: doxorubicin, daunorubicin, chloroquine, penicillins, sulfonamides, cocaine, radiation
• Toxin
• Endocrine

Myocarditis

• Treat infection
• Stop offending agent
• Treat CHF symptoms.

• Cardiomegaly
• Megaesophagus
• Megacolon

Assoc: acalasia

Rheumatic  dz.

Untreated group A streptoccus.

Autoantibodies attacking  valves & joints

Mitral valve

Tricispid valve

Jones

• Major: "jnes"
• Minor: peace

• Joints
• pancarditis
• Nodules: SQ, extensor
• Erythema nodusum: painless
• Sydenhams chorea

• Previous rhuematic fever
• ECG with PR prolongation
• Arthralgia
• CRP & ESR elevated
• Elevated Tenperature

• NSAID
• Steriods
• Prophylactic antibiotics

Oral: amoxicillin (before & after sx)

GU/GI: ampicillin & gentamycin (before), amoxicillin (after)

Bacterial infxn of endocardium +\- valve involvement

• Congenital  defects
• IVDA
• Prosthetic valves

Libman-Sacks endocarditis

• Staph. Aureus
• Strep. Pneumo
• Strep. Pyogenes
• Neisseria gonorrhea

• Strep viridans
• Strep mutans
• Enterococcus (VRE)
• Staph epidermidis (coag - staph)

• Haemophilus
• Actinobacillus
• Cardiobacterium
• Eikenella
• Kingella

Mitral valve

Tricuspid valve

Staph epidermis

• Major:
• Blood cx.
• Echo: vegetations/ absces
• New onset valvular regurg.
• Blood cx: + coxiella burnetii

• Minor:
• Predisposing  dz, IVDA
• Fever
• Vasc.
• Immunologic
• + cx not meeting requirements for major criteria

• Janeaway lesions: petechiae
• Osler nodes: painful nodule
• Roth spots: retinal hemorr.
• New murmur
• Fever, arthralgia
• Chills, night sweats, fatigue

Gentamycin with either ceftriaxone/vancomycin

Septic embolization

• Brain: focal neuro deficits
• Kidney: hematuria
• Spleen: abd/shoulder pain

• AV nicking
• Cotton wool spots
• Retinal hemorrhage (flame hemorrhage)

Thiazide

ACE i/ ARB

• CI:
• thiazide: impaired glucose tolerance
• BB: mask hypoglycemia

• ACE i/ ARB
• Diuretic (aldactone)

• CI: CCB-nondhydro: dilt/vera
• Lowers  contractility

• ACE i/ARB
• BB

Propanolol

Thiazide: maintains high/normal calcium level

Nonselective BB

• Labatelol
• Methyldopa
• Hydralazine
• Nifedipine

No ACE i /ARB!!

Diuretic

BB

• HTN
• Esophageal Spasm
• Prinzmetal's Angina

CN toxicity

• Renal dz
• Renal artery stenosis
• OCP
• Pheochromoctyoma
• 1* hyperaldosteronism (cushing/conns)
• Coarctation of aorta

HTN emergency

• IV Nitroprusside or
• Labetalol or
• Nicardipine or
• Fenoldapam

Once controled oral BB & ACE i

25% of presenting pressure to avoid triggering ischemic event.

• IVF
• Dobutamine
• Intra-aortic ballon pump
• PTCA

• Underlying infxn.
• IVF
• Norepi

• IVF
• Tranfusion
• SX
• Skin graft

• Airway
• Epi
• Benadryl
• Cimetidine
• IVF

• IVF
• Dobutamine or atropine

Stop at MAP 85 otherwise cord swelling.

• AAA: atherosclerosis
• Aortic dissection: HTN

AAA: localized dilation of aorta

Aortic dissection: intimal tear leads to blood entering media causing formation of false lumen.

Aortic dissection

• Symptomatic
• Rapidly enlarging
• Greater than 5.5 cm

Males 65-70 yrs with smoking hx.

Prinzmetals

Muskulosketal

Muskl.

Aortic dissection

Spont. PTX.

• Gerd
• Esophageal spasm

Pericarditis

MSKL.

Zoster

GERD

P.E.

MSKL

Aortic dissection

Do CT!!!

• Medical therapy fails
• High risk criteria

if Sig proximal L main CAD, 3v CAD with LVEf <50% CABG

• CCB
• Nitrates

No BB & ASA (worsen vasospasm)

Arrythmia- vfib.

• Statins
• Fibrates

Bile acid binding resins

Niacin

Fibrates

Statin

Thrombolytic

COX 1&2 i

Inhibit ADP receptors on platlets

Inhibit gp IIb/IIIA

Inhibit ADP r on platlets

Like clopidogrel

+ AT III

LMW heparin

3*  Block

V. Fib

Accelerated junctional rhythm.

Junctional tachycardia

Ventricular rhythm

Ventricular tachycardia

Accelerated junctional rhythm

Torades

Observe

Amiodarone

Electrical cardiovert or procainamide.

Pacemaker

Carotid massage/valsava then

IV adenosine

• LVF
• MV dz
• Lymphatic obstruction
• Lymphangitis carcinomatosis
• Asbestosis
• Sarcoidoisis

• Aortic atenosis
• Pulmonic stenosis
• M.R.
• T.R.
• VSD

• Tricuspid stenosis
• Mitral stenosis
• Aortic regurg
• Pulmonic regurg

Constrictive pericarditis > tamponade

 tamponade > pericarditis

Hemochromatosis

Restrictive  dz reversible with phlebotomy

Benign!!

If symptoms: echo

ECHO

• Renal arteriogram: gold standard
• MRA: most freq used
• Renal A duplex: bilateral but time consuming
• Helical CT of renal artery with IV contrast
• Captopril renalogram (renal US)

Alpha blockers

Minoxidil

Clonidine

Hydralazine

Aortic dissection

A: aortic dissections involving ascendimg aorta, surgery

B: aortic dissection distal to left subclavian artery, med management unless rupture or occlusion

Vascular insufficiency

Severe disease, resting pain

• Excercise
• Foot exams
• ASA
• Pentoxifylline
• Cilostazol
• PTA
• Bypass grafting
• Limb amputation

• US: locates stenosis
• Arteriography: map narrowing in arterial distribution of interest

Incompetent venous valves

• Asymptomatic
• Pain/fatigue better with elevation
• Visible/palpable veins
• Increased pigmentation
• Edema
• Ulceration

• Excercise
• Compression hose
• Leg elevation
• Surgical removal
• Sclerotherapy

Saphenous vein

Potential use in bypass grafting!

AVM

Surgicak remocal if symptomatic on brain or bowel

• Local ischemia
• Increasef risk of thrombus

Compression venous US & contrast venography

• Hepatitis B or C
•  > 
•  > 

• Kidneys, heart, gi
• (anything with vascular supply)

Angiography: numerous aneurysms

Treat: steriods & immunosuppressors

• Ca
• Vit D
• Bisphosphonates

Temporal arteritis

Polymyalgia Rheumatica

• High dose prednisone (1-2mos)
• Low dose ASA
• Vit D
• Ca

Takayasu's arteritis

• Arteriography: abnormal vessel & stenosis
• CT/MRI: vessel wall abnormalities

Causea Cerebrovasculat & myocardial ischemia.

Tx: steriods, immunosuppressives, bypass grafting obstructed vessels

Churg Strauss (allergic angiitis)

Henoch schonlein purpura

Henoch schonlein purpura

Self limited, steriods if severe GI symptoms

IgA deposition on Renal & Purpura biopsy

Kawasaki

• High dose ASA, IVIG
• No steriods!!

MI, aneurysm, sudden death

Do echo!!!

PGE2

Indomethacin

VSD

Tetralogy of Fallot

• Pansystolic at lower left sternal border
• Loud pulmonic S2

• VSD
• PDA
• ASD

• Truncus arteriosus
• Transposition of great vessels
• Tricuspid atresia
• Tetralogy of Fallot
• Total anomalous pulmonary venous return

Eisenmenger's syndrome

• Wide fixed split S2
• Systolic ejection murmur at upper left sternal border

Need antibiotic prophylaxis!

O2 desaturation at high altitudes

Decompression sickness during deep sea diving

Machinery murmur @ 2nd left intercostal space, loud S2, bounding pulses

VSD or PDA

• Aperts syndrome
• Down syndrome
• Cri-du-chat
• Trisomy 13 or 18

Persistent truncus arteriosus

• Harsh systolic murmur @ Lower left sternal border
• Loud S1 & S2
• Bounding pulses

Surgery!

Down syndrome

• Pulmonary stenosis
• RVH
• Overriding aorta
• VSD

• Down syndrome
• Cri du chat
• Trisomy 13 & 18

• Prostaglandin E
• O2
• Propanolol
• IVF
• Morphine
• Knee to chest position