Cardiology 6

  1. Chronic renal dz & HTN: MOA
    expanded plasma volume & peripheral vasoconstriction
  2. Renal artery stenosis prevalence in HTN pts
    less than 2%
  3. HTN pts w/ renal artery stenosis: proportions
    75% unilateral stenosis; 25% bilateral
  4. Problem w/ renovascular HTN
    Renal artery stenosis causes 30% of medically refractory HTN
  5. Catecholamine-producing large tumors of adrenals
  6. HTN & CPAP use for OSA
    CPAP improves risk of developing HTN & CV dz
  7. HTN prevalence in DM pts
    75% of diabetics have HTN
  8. Aldosterone-like effect precipitates persistent HTN in:
    Cushing Syndrome
  9. Leading cause of death worldwide
    arterial HTN
  10. Using std size cuff on obese pt:
    Gives falsely elevated result
  11. Ambulatory BP monitor can detect:
    Lack of nocturnal dip (assoc w/higher CVD risk)
  12. BP & substances
    Avoid tobacco/caffeine 30 min prior; document if pt took meds
  13. Ambulatory BP monitor & TOD
    Better TOD predictor than office measurements
  14. Those that develop HTN before 50 yrs:
    SBP > 140 mmHg & DBP > 90 mmHg
  15. What symptom must be present for a dx of Malignant Hypertension?
  16. Most patients who develop HTN after 50 yrs have:
    Isolated Systolic HTN
  17. Defn Isolated Systolic HTN
    systolic BP over 140 mmHg with diastolic BP <90 mmHg
  18. Isolated Systolic HTN: hemodynamic fault =
    decreased distensibility of the large conduit arteries
  19. Majority of uncontrolled HTN occurs among:
    older pts with isolated systolic HTN.
  20. JNC: SBP opinion
    In pts over 50, SBP over 140 is a more important CVD risk than DBP
  21. DHP CCBs: AEs
    Ankle edema; Flushing; HA; Increased HR
  22. Diltiazem/Verapamil: AEs
    Bradycardia; Constipation
  23. Most common cause of Hypertensive Emergency
    Acute CHF with pulm edema (37%)
  24. JNC7: tx of uncomplicated HTN for most pts
    thiazide diuretic
  25. HTN lifestyle mods
    Wt; ETOH; aerobic activity; Na+ to 2.4 mg/day; K+; DASH diet
  26. Most single HTN meds lower BP:
    at most 20/10 mm Hg (so most pts on more than 1 drug)
  27. Compelling Indications: CHF
    Diuretic; Beta-blocker; ACEI; ARB; AA
  28. Compelling Indications: High Coronary Dz Risk
    Beta; ACEI; CCB; Diuretic
  29. Compelling Indications: Post-MI
    Beta; ACEI; AA
  30. Compelling Indications: DM
    Beta; ACEI; Diuretic; ARB
  31. Compelling Indications: Chronic Kidney Dz
  32. Compelling Indications: Recurrent Stroke Prevention
    ACEI; Diuretic
  33. HTN eval labs
    UA; serum Cr, glu, K+, Na+ ; Lipids (TC, trigs, HDL, LDL); 12-Lead EKG (LVH)
  34. HTN TOD
    Neuro; Ophthalmologic; CV; Renal; Vascular
  35. First Line Tx for HTN
    *Thiazide* ; beta; ACEI; ARB; other diuretics; CCB
  36. ACEIs
    Block formation of angiotensin II; blocking Angiotensin II results in vasodilatation and Na+ loss
  37. Excessive Na+-K+ exchange which results in hypokalemia; associated with HTN
  38. Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood (systolic or diastolic)
  39. Clinical syndrome caused by a variety of underlying conditions that lead to inadequate cardiac output
  40. Clinical syndrome of CHF =
    Body’s maladaptive response to a low-flow state which produces symptoms of dyspnea and volume overload
  41. 3 major adaptive mechanisms to compensate for CHF
    Frank-Starling mechanism (rapid); Neurohumoral system activation (rapid); Myocardial remodeling (slow)
  42. Frank-Starling mechanism
    Increased ventricular filling during diastole results in increased volume of ejected blood during systolic contraction (CO = HR x SV; norm is about 5L/min)
  43. Neurohumoral release
    Norepinephrine stimulates cardiac contraction & activation of renin-angiotensin-aldosterone system; fn = to maintain arterial pressure & perfusion of vital organs
  44. Cardiac Remodeling (decline in function)
    Compensatory response following injury to cardiac tissue; LV dilates, damaged area forms scar (over time progresses to noncompliance of ventricle, inhibiting relaxation & filling)
  45. ACEI effect on heart remodeling
    Decrease (reverse) remodeling, improving cardiac performance
  46. Diastolic Left Heart Failure:
    Relaxation or Filling: heart does not relax normally, filling pressures are high but EF is normal (over 55%)
  47. Systolic Dysfunction
    Defect is in the expulsion of blood from the left ventricle, leading to inadequate cardiac output
  48. Causes of Systolic Left Heart Failure
    Ischemic heart dz (most common) due to MI hit or chronic ischemia; Longstanding HTN; Valvular Heart Dz; Idiopathic; Myocarditis (L & R); Toxins (ETOH, Cocaine, Thyroid, Pb); Sepsis
  49. Relationship: CHF & age
    HF incidence due to Diastolic dysfunction increases with age (due to increasing noncompliance of LV from long-standing HTN)
  50. Systolic component of CHF caused by:
    chronic loss of contracting myocardium due to prior MI & acute loss of myocardial contractility induced by transient ischemia
  51. Diastolic component of CHF is due to:
    ventricles reduced compliance due to chronic scarring & acute loss of distensibility during ischemia
  52. Rare instances of high output HF is assoc with:
    Elevated cardiac index but low SVR; chronic activation of symp N.S. & RAA systems; chronic volume overload and remodeling; heart cannot meet the metabolic demands; ultimately result in same neurohormonal imbalances as low output HF
  53. Sudden triggers for Acute HF
    Massive MI; Tachyarrhythmia with a very rapid rate; rupture of valve secondary to infective endocarditis
  54. Causes of Right HF
    Left HF; Congenital Heart Lesion (ASD); Right Valve Dz (Tricuspid, Pulmonic); Pulmonary Dz
  55. Pulmonary Dz =
    COPD, Interstitial Lung Dz; Pulmonary emboli; Pulmonary HTN (idiopathic, connective tissue dz)
  56. Why do initial CHF S/S occur w/ exertion?
    Exertion: Decrease ventricular filling time; Increase HR; Inability to increase CO (end result = supply & demand mismatch); ischemia may worsen situation
  57. CHF S/S
    SOB/dyspnea on exertion; edema (LE, abdomen (ascites), sacral/low back if bedbound); PND; orthopnea; fatigue, weakness, anorexia, nausea, wt change; tachycardia/palpitations
  58. CHF Phys Exam findings
    Skin (pallor, cyanosis, cool/moist); Tachypnea/ accessory mx use?; JVP elevation; HJR, hepatomegaly
  59. Cardiac Exam: Right HF:
    Right sided S3 or S4; TR murmur, loud P2 (delayed closing of pulmonic valve
  60. CHF: Systemic Findings
    Hepatomegaly; Pulsatile liver, tender RUQ; Ascites, Abd Swelling; edema (Low Back or sacrum if in bed); diminished or bounding pulses; Pulse, Pressure, 02 sat, weight
  61. CHF: Cardiac Cath consists of:
    Left ventriculogram; Arch shot; Coronary angiography to assess for blockages
  62. Left ventriculogram:
    Evaluate LV fn w/ calculated EF, assess wall motion, look for evidence of Mitral Regurgitation
  63. Arch shot:
    Assess for Aortic Insufficiency, defects in aorta (dissection/aneurysm)
  64. CHR: Echo: Assess:
    Assess for EF (LV function); for LVH; RV & Pulmonary pressures; Cardiac valves/murmurs; diastolic fn/ relaxation; WMAs; Pericardium (for effusion or mass)
  65. Management Algorithm
    S/S; H&P; EKG /Labs (assess etiology); Echo (MRI): preserved EF (diastolic) or poor EF (Systolic); cardiac cath (r/o ischemia, assess valve gradients, filling pressures, consider bx; start acute or chronic tx; reduce concomitant risk factors
  66. Pharm mgmt of CHF
    ACEI; ARBs; Beta Blockers; Nitrates + hydralazine; AAs; diuretics; digoxin; statins
  67. CHF: Pharm mgmt w/ proven mortality benefit
    ACEI; ARBs; Beta Blockers; Nitrates + hydralazine; AAs
  68. CHF: Non-Pharm chronic tx
    Multi-disciplinary team approach; Wt mgmt (Na+ / Fluid balance; ETOH/Toxin avoidance; Behavioral/ Risk modification; Palliative Care/ Hospice when appropriate
  69. Exercise in CHF pts
    Pts limited in even daily activity by poor functional status; even if cannot fix heart make body more efficient at given work load to allow independence; allows for wt Loss, mx strength, rehab enough to be able to get transplant
  70. Resynchronization therapy (Biventricular pacing): indications
    If low EF, Wide QRS > 130 ms and Class III or IV
  71. Anticoagulation for CHF
    Consider Coumadin (chronically) for Low EF; Hosp pt: prophylactic anticoag; aspirin if CAD (but no evidence for non-ischemic)
  72. Anticoagulation for CHF: Chronic Definite Use (Unless CI)
    A-fib; LV Thrombus; Previous thrombo-embolic CVA; Coagulopathy; LV Aneurysm
  73. Decompensated CHF:
    Pt is clinically deteriorating or unstable; begin early & aggressive tx as sort out Etiology
  74. Acute CHF S/S
    Severe SOB, Rales, Hypoxic, Cyanotic, Pale; CP; Tachy, BP may be hyper or hypo; cool or not perfused, poor pulses; distress (tachypneic, accessory mx); poor mental status
  75. Tests to determine cause of Decompensated CHF
    EKG (ischemia), HTN, atrial or other arrhythmia; Echo to assist dx; CXR to assess pulmonary edema
  76. Acute Decompensated CHF: Tx
    Diuretics (Natriuretics); O2 (CPAP or BiPAP); morphine? ; Nitrates (Vasodilators); Inotropes (Dobutamine, Milrinone); Hold/Do not start Beta; ACE/ ARB or other afterload reduction; Balloon pump; ID & tx underlying cause
  77. Acute Pulmo Edema (flash Pulmo Edema)
    Overcome fluid balance btw vascular bed & lung interstitium; pts are tachypneic, tachycardic, hypertensive, hypoxemic, crackles; if hypotensive, grave sign
  78. Causes of Acute Pulmo Edema:
    MI; Acute Valvular lesion (MR, AI); HTN/Renovascular dz; End stage valvular dz (AS, MS); Systemic illness (sepsis, anemia, thyrotoxicosis, severe resp illness); poss other causes (PE, MI)
  79. Acute Pulmonary Edema: Rx
    IV Diuretics, nitrates, inotropes (or BNP nesiritide), pressors (BP support), ACE/ARB or hydralazine + nitrate; HOLD beta in acute phase; O2, Morphine, Anti-arrhythmics if indicated
  80. % of people with LV dysfn who are symptomatic
  81. Heart Contraction & Relaxation wrt energy
    Both are energy requiring
  82. Classifications of Left Heart Failure:
    Systolic & diastolic
  83. Systolic Left Heart Failure
    Contraction: heart does not squeeze well, low EF (<55%)
  84. CHF with preserved systolic function
    Clinical S/S similar to systolic dysfunction
  85. CHF risk factors
    Age; HTN; Tobacco; DM; Obesity; ETOH/Substance abuse
  86. Most common cause of Systolic Left Heart Failure
    Ischemic heart dz
  87. Can Systolic & Diastolic CHF coexist?
  88. Most common form of HF is caused by:
    chronic ischemic heart dz
  89. Prior histories most often assoc w/ systolic CHF
    CAD; valvular heart dz
  90. Prior histories most often assoc w/ diastolic CHF
  91. Diagnostic features of systolic CHF
    Echo reduced EF; CXR Cardiomegaly; CXR Pulm edema
  92. Diagnostic features of diastolic CHF
    Echo LVH; EKG LVH; CXR Pulm edema
  93. Echo features present in systolic HF & absent in diastolic HF
    Reduced EF; LV dilation
  94. CHF & output
    Most right/ left heart failure is low output
  95. Most common cause of Right HF
    Left HF
  96. CHF pts w/low EF (<35%) are at risk of devt of:
    v-tach or v-fib
  97. JVP elevation:
    Assess R int jugular vein; Reflects right atrial pressure elevations
  98. HJR =
    Hepatojugular reflux
  99. CHF PE: First assess:
    Acute distress or chronically ill?
  100. Lung Exam: Left HF
    Crackles/Rales; poss wheezing; dullness at bases; sputum (frothy/pink)
  101. Lung Exam: Right HF
    Possibly clear; dullness at bases (consider pleural effusion)
  102. Cardiac Exam: Left HF:
    S3 or S4 or Summation gallop; MR murmur
  103. CHF: dx tests help to:
    classify dz; assess etiology
  104. What % of CHF patients have LVH?
  105. CHF: EKG
    Global low voltage possible in end stage CHF; Evidence of Ischemia or prior infarction (Q waves)
  106. CHF: Cardiac Biomarkers
    (CK/MB, Troponin levels): indicated if suspect ischemic etiology
  107. Cardiac Cath: Indicated in:
    MI, USA
  108. CHF: on CXR (PA/Lateral), what is important?
    Size & Shape of cardiac silhouette
  109. CHF: CXR findings
    Kerley B lines; Pleural effusions
  110. Kerley B lines =
    sharp, linear densities of interlobular interstitial edema
  111. Pleural effusions in CHF: caused by:
    increase in interstitial edema
  112. Pleural effusions most often assoc with:
    LV dysfunction
  113. CHF = most common cause of what pulmonary outcome?
    Pleural effusion
  114. Describe pleural effusions:
    Typically transudative, small to moderate in size, & free flowing (LLD view may be helpful)
  115. CHR: Echo provides:
    structural, anatomic & physiologic info about the heart
  116. BNP: CHF
    BNP secreted from ventricles under stress in CHF
  117. BNP Levels
    Levels vary dependent on alterations in intracardiac filling pressure
  118. BNP = proposed marker for :
    severity of CHF & potentially useful for Rx management
  119. BNP may be falsely elevated in:
    renal failure
  120. CHF Device Tx
    AICD; IABP; Ultrafiltration/hemofiltration to remove fluid; LVAD
  121. AICD criteria
    EF < 35% for most CHF etiologies
  122. AICD Purpose:
    Prevention of sudden death; also for some HCM
  123. IABP =
    Intra-aortic balloon pump, temporary measure for acute CHF in hospital
  124. AICD =
    Automatic Implantable Cardioverter Defibrillators
  125. CHF: Nonpharm tx
    Behavioral; Devices (AICDs, Pacing, LVADS or pumps); Transplant
  126. LVAD =
    Left Ventricular Assist Device
  127. LVAD is considered a ____ tx
    bridge therapy prior to heart transplantation
  128. Placement of LVAD
    May be internal or external
  129. Frequency of heart transplants for CHF
    2500/yr for CHF
  130. CHF Device Tx
    AICD; IABP; Ultrafiltration/hemofiltration to remove fluid; LVAD
  131. AICD for CHF = what type prevention?
    Primary or Secondary Prevention
  132. AICD indicated if:
    Previous V-Tach, SCD
  133. Effect of antiarrhythmics for VT/VF
    (Amiodarone, Dofetilide) do not improve survival
  134. Limitation in OHT (transplant) for CHF =
    donor organs
  135. OHT for CHF: Late Survival post one year:
    Determined by devt CAD or vasculopathy
  136. OHT for CHF: median survival =
    10 years
  137. OHT for CHF: one-year mortality predicted by:
    need for post-op dialysis or ventilation
  138. OHT for CHF: Hx of sepsis, CAD, DM, CVA predict:
    decreased 5 year survival
  139. Decompensated CHF: types
    Acute or Acute on Chronic
  140. Acute CHF: hypotension is:
    Ominous (if bradycardia this may be cause, as is inappropriate)
  141. Decompensated CHF: Phys Exam
    New murmur of MR or AI, worsened AS , rales
  142. Decompensated CHF: tx
    Tx early & aggressively; eliminate or control inciting factors
  143. Acute (flash) Pulmo Edema:
    S/S of rapid clinical deterioration
  144. Cause of pericarditis
  145. Cardiomyopathy
    dilated cardiomyopathy (MC due to CAD or ischemia)
  146. Congenital heart defect
    ventricular septal defect
  147. Cyanotic congenital heart defect
    tetralogy of fallot (VSD, RVH, pulmonary stenosis, & overriding aorta)
  148. Cause of chest pain in outpatient setting
    musculoskeletal cause
  149. Ulcer location in chronic venous insufficiency
    proximal to medial malleolus
  150. Ulcer location in chronic arterial insufficiency
    distal toes or lateral aspect of affected extremity
  151. Site for an acute embolic occlusion
    femoral artery
  152. Cause of renovascular hypertension
  153. Chest x-ray finding with traumatic thoracic aortic injury
    widened mediastinum
  154. Inherited condition associated with pulmonary embolism
    Factor V leiden mutation (expressed as resistance to anticoagulant protein C)
  155. Cause of atrial fibrillation
    HTN & Coronary arthrosclerosis
  156. Valvular abnormalities in adults
    Aortic stenosis
  157. Valve abnormality in rheumatic heart disease
    Mitral stenosis
  158. Valvular heart defect in US
    mitral valve prolapse
  159. Cause of CHF
    Artherosclerotic coronary disease & HTN
  160. Cause of arterial occlusive disease
  161. Aortic catastrophe
    aortic dissection
  162. Cause of secondary HTN
    Renal disease
  163. Test for arterial insufficiency
    Ankle-brachial index
  164. Cause of sudden cardiac death in adolescents
    hypertrophic cardiomyopathy
  165. Osler nodes (painful, violaceous, raised lesions of the fingers, toes or feet)
  166. Janeway lesions (painLESS erythematous lesions of the palms or sole)
  167. Roth spots (exudative lesions in the retina)
  168. Pain relieved by sitting forward
  169. Young person passes out & dies playing a sport
    hypertrophic cardiomyopathy
  170. Delta wave
    Wolff-Parkinson White
  171. Machine like murmur
    patent ductus arteriosus (close w/ indomethacin, open w/ prostaglandin E1)
  172. Kussmaul sign (↑ in JVP during inspiration)
    Constrictive pericarditis
  173. Homan’s sign
    calf pain on forced dorsiflexion (DVT)
  174. Punched out appearance with pale or necrotic base
    ulcers secondary to chronic arterial insufficiency
  175. Lower extremity edema & pigmentation changes
    chronic venous insufficiency
Card Set
Cardiology 6
Cardiology flashcards made by previous students