cardiology review group 2: lauren montemayor ivanna sorych dharti patel gabriela almeida mark dunbar...

CARDIOLOGY REVIEW

GROUP 2:Lauren MontemayorIvanna Sorych Dharti PatelGabriela Almeida Mark DunbarMike KayalObaid AhmadJoon Jun

Anatomy of the Heart

Cardiac Terminology

Preload: amount of blood heart must pump with each beat largely determined by venous return to the heart and the stretch of muscle fibers.

Afterload: the pressure the heart must generate to move blood into the aorta.

Pulse pressure: the difference between the systolic pressure and diastolic pressure.

Mean arterial pressure: the average pressure in arterial system during ventricular contraction and relaxation. This is a good indicator of tissue of profusion.

Cardiac Terminology

Cardiac Output: the amount of blood the heart pumps each minute. Maximal Cardiac output is = Maximal Heart

Rate X Stroke volume

Stroke Volume: the volume of blood ejected from the left ventricle with each beat.

Myocarditis

Myocarditis and Cardiomyopathies

A man presents with flu like symptoms and chest pain.

PE reveals Soft S1, Mitral Regurg and S3 & S4 present.

CXR reveals Pulmonary Venous Markings and enlarged heart;

Transvenous endomyocardial biopsy reveals Cocksackie B virus.

EKG reveals Bi-Basalar Rales. Tests show an increase in all Cardiac Enzymes.

Diagnosis? Myocarditis

Myocarditis and Cardiomyopathies

An Alcoholic with a history of Cocaine abuse presents c/o SOB, DOE, Orthopnea indicating that he has already had a heart transplant.

PE reveals Mitral and Tricuspid Regurgitation Murmurs. The ECHO cardiogram reveals Dilated Chambers and Thin

Walls. Diagnosis?

Dilated Cardiomyopathy

Treatment?1. ACE Inhibitors – use 1st, 31% reduction in mortality

by using2. Digitalis – use

Myocarditis and Cardiomyopathies A 25 year old male collapses of SOB and DOE playing

basketball, but still alive. PE reveals Heaves and Lifts over PMI and Mitral Regurg

Murmur. CXR reveals enlarged heart. Echo reveals Thick Walls with Small Chambers.

Diagnosis? Hypertrophic Cardiomyopathy;

aka: IHSS, Idiopathic Hypertrophic Subaortic Stenosis

Treatment?1. Medical: Beta-Blockers & Calcium Channel

Blockers2. Surgical: Transaortic Ventriculomyotomy

Hypotension & Shock

Myocarditis and Cardiomyopathies A 40 year old woman presents with symptoms of congestion, edema,

SOB, DOE. PE reveals JVD, S3, Gallops, Mitral and Tricuspid Regurg but NO

Cardiomegaly. CXR reveals Atrial enlargement. Echocardiogram reveals Thick Walls with Slightly Enlarged Ventricles

and some Dilation of the Aorta. Biopsy reveals either Sarcoidosis, Amyloidosis or Hemochromatosis.

Diagnosis? Restrictive Cardiomyopathy

Treatment for above patient? Not a lot to do. – Do not give any medicine. Only Tx. is

Transplant.

Cardiomyopathies

A pt comes in with a complaint of chest pain for about a week now. Pt admits using multiple pillows at night for elevation which relieves the chest pain. The pt has a fever of 101. ECG findings indicate PR depression. What is the BEST diagnosis for the above clinical findings? (a) Myocardial infarct (b) Myocarditis (c) Pericardial effusion (d) Acute pericarditis

Explanation:PR depression is a specific finding of an acute pericarditis.

Cardiomyopathies

The MOST common pathogen that causes inflammation of the myocardium: (a) E.coli (b) Echovirus (c) Poliovirus (d) Cocksackie

Cardiomyopathies

Myocarditis can cause all of the following except: (a) shortness of breath (b) chest pain (c) sudden death (d) bradycardia

Hypotension & Shock

Shock is a failure of blood circulation that can happen quickly such as in a gunshot wound or over a period of days as in the case of vomiting or diarrhea for days. In both cases, Organ Dysfunction may result.

Hypotension & Shock

Name 4 areas of the body where life-threatening hemorrhage may occur:

1. Thighs2. Chest3. Abdomen4. Pelvis

Which two organs when diseased radiate painfully to the back?

1. Pancreas2. Aorta

Hypotension & Shock

Woman presents with cool, clammy, mottled hands, anxious with dizziness, weak pulse and no bowel sounds and has bulimia saying that yesterday, after gagging herself and throwing up her big meal she vomited blood for the first time in her life.

Diagnosis? Mallory Weiss Syndrome – Tear of LES at GI

Junction

What type of shock is this woman at risk for? Hypovolemic Shock due to GI Bleed or Internal

bleed.

Hypotension & Shock

Other Risk Factors for Hypovolemic Shock include: Borhaave’s Syndrome Hemophilia Aortic Aneurism Vaginal Bleed Hemorrhage Burns Stab wounds

What is the treatment for the Hypovolemic Shock? Vasopressin and Saline

Hypotension & Shock

A man presents with Chest Pain, (a diabetic may not have pain), Sweating and Nausea and Vomiting.

He also shows a positive Levine Sign and his EKG shows ST elevation.

Diagnosis? Acute MI, (if ST was depressed – Ischemia)

Most commonly after surviving an acute MI, the heart may have a decrease in function where cardiac output is lowered and over 40% of the left ventricular muscle dies.

What is this? Cardiogenic Shock

Hypotension & Shock

Cardiogenic Shock results in either of 2 conditions: Myocardial Stunning or Hibernating Myocardium. In the case of Myocardial Stunning, if Ionotropes are

given, the stunned tissue will heal itself and regenerate.

In the case of Hibernating Myocardium, the ischemia will reverse after the tissue has revascularized.

Treatment: Morphine, Oxygen, Nitrogen and Antiplatelets given

simultaneously

Hypotension & Shock Name 4 causes of Obstructive Shock and their treatments:

1. Pericardial Tamponade – Pericardial Effusion Beck’s Triad: JVD, Hypotension, Muffled Heart Sounds Treatment: Pericardialcentesis – stab the heart

2. Tension Pneumothorax This pushes on the heart and reduces its output Treatment: Needle Decompression

3. Pulmonary Embolism DVT is the MCC Treatment: Heparin

4. Aortic Dissection Ripping tearing pain that radiates to back Treatment: Surgery

The general treatment for Obstructive Shock is: Oxygen, IV fluids, Ionotropes (Epinephrine, Norepinephrine).

Hypotension & Shock

A man, with a history of eating shellfish developed an allergic reaction, he went outside to vomit and was mugged and hit by a baseball bat to his head, fell to the ground.

He presents with increased pulse pressure, decreased diastolic blood pressure, high cardiac output, warm extremities, (not clammy) and good capillary refill.

Diagnosis? Distributive Shock – blood going to the wrong place and

decreased vasomotor tone.

Cardio Rx

DOC for pregnant women with HTN? Methyldopa.

Methyldopa (A2 agonist) reduces the SNS outflow from brainstem to heart, but severe rebound HTN can occur so taper slowly over 1-2 weeks.

DOC for HTN pt. after LSM failed to work in stage 1 HTN? Thiazide diuretics. HCTZ, Chlorthalidone.

DOC after ACE I fails to work? ARB. ADR for ACE I and ARBs?

Cough, angioedema, Hyper K+. CI in renal stenosis, failure.

Cardio Rx

CCB work better on arteriole smooth muscle by blocking Ca++ channel ions. This relaxes vascular smooth muscle, decreases PVR, BP.

Which drugs should not be combined b/c of severe bradycardia, and hypotension? CCB and B blockers.

DOC for pt. w/ BPH, HTN and hyperlipidemia? A1 blockers “azosin”

Hypertension

Hypertension

Which of the following anti-hypertension drug is appropriate for a patient with diabetes?

A) Ace inhibitor B) Alpha blocker C) CCB D) Diuretics

Hypertension

What is a common side effect of Ace inhibitor?

A) ED B) Coughing C) Syncope D) Blurry vision

Hypertension

Which of the following anti-hypertensive drug would you prescribe for a patient with BPH?

A) Ace inhibitor B) CCB C) Beta blocker D) Alpha1 blocker

Hypertension

Hypertension is more common among?

A) Asians B) Whites C) African Americans D) Greeks

Heart Murmurs

Heart Murmurs

A mid or late systolic murmur that may be preceded by a systolic click describes this valvular abnormality: (a) aortic stenosis (b) mitral valve prolapse (c) aortic regurgitation (d) mitral valve stenosis

Explanation: Mitral valve prolapse may be preceded by a systolic click. It usually occurs in mid or late systole and lasts until the beginning of the S2.

Heart Murmurs

A systolic crescendo-decrescendo murmur most likely is: (a) aortic stenosis (b) mitral valve prolapse (c) mitral stenosis (d) aortic regurgitation

Explanation: A systolic crescendo-decrescendo murmur (one that rises in intensity and then falls) is heart with aortic stenosis. This type of murmur may also be heard with an innocent flow of murmur.

Heart Murmurs

An S4 may be found in all of the following conditions EXCEPT: (a) aortic stenosis (b) atrial fibrillation (c) cardiomyopathy (d) hypertensive heart disease

Explanation: S4 is an atrial sound occurring just before S1. It is auscultated best with the bell of stethoscope. It occurs most commonly because of increased resistance to ventricular filling following an atrial contraction. This increased resistance is due to the decreased compliance or stiffness of the myocardium of the ventricle. S4 is never heard in the absence of atrial contraction, so it will never exist with atrial fibrillation.

Heart Murmurs

A 40 year old male presents with chest pain and a low-grade fever. When the patient’s chest is auscultated, a high-pitched murmur is noted when the patient is asked to lean forward. The most likely cause of this murmur is: (a) pericardial friction rub associated with

pericarditis (b) obstructive hypertrophic cardiomyopathy (c) patent ductus arterious (d) mtral valve prolapse

Explanation: A pericardial friction rub is best ascultated when the patient leans forward an inhales. It is a scratchy murmur heard during diastole and systole.

Peripheral Vascular Disease

Peripheral Vascular Disease

Which arterial disease most commonly presents with pain, pallor, polar, paresthesia, paralysis, pulselessness and can lead to cyanosis and necrosis? Acute Arterial OcclusionAcute Arterial Occlusion Buerger’s Disease Deep Venous Thrombosis Chronic venous insufficiency

Peripheral Vascular Disease

Thromboangitis Obliterans (Buerger’s Disease) is idiopathic and characterized by chronic ulcers, superficial nodules, Reynaud's phenomenon, pain and gangrene requires the patient to: Stop EtOH intake Stop smokingStop smoking Stop walking None of the above

Peripheral Vascular Disease

Virchow’s Triad that is assosiated with Deep Venous Thrombosis includes all of the above except: Venous stasis Hypercoagulable state Endothelial injury Warm extremitiesWarm extremities

Peripheral Vascular Disease

Which of the following is NOT a risk factor for Chronic Peripheral Arterial Occlusive Disease? Diabetes Cigarette smoking Daily ExercisingDaily Exercising Age CAD

Peripheral Vascular Disease

In regard to Varicose Veins – long saphenous vein and its tributaries are most commonly involved? TrueTrue False

Coronary Artery Disease

Coronary Artery disease

Coronary arterial disease, or atherosclerosis, is the accumulation of lipid deposits within the walls of coronary arteries resulting in obstruction and ischemia of myocardial cells.

CAD

1- What is a collection of foam cells and the earliest pathologic lesion of atherosclerosis?

Fatty streak

2- What are some major risk factors of CAD? Increasing age Tobacco use Hypertension (> 140/ 90) Diabetes mellitus Hypercholesterolemia/ hyperglyceridemia Elevated lipoprotein Obesity Family History of Premature CAD

CAD

3- What diagnostic tests are often used to screen for CAD?

Exercise or pharmacologic stress test or imaging

4- What is the gold standard for the diagnosis of CAD?

Coronary angiography

CAD

5- Which groups of patients commonly do not exhibit classic anginal symptoms in the setting of myocardial ischemia?

1. Elderly2. Women 3. Diabetics (due to diabetic neuropathy)

6- What is the common presentation of a patient with symptomatic CAD?

Angina pectoris +/- radiation to jaw, left shoulder, or arm; Exacerbated by exertion Relieved by rest Relived by nitroglycerin

CAD

7- Which type of angina is characterized by chest pain and dyspnea at rest?

Unstable angina

8- (T or F) A normal EKG rules out MI False

CAD

9- Which antianginal drug must be used with caution in patients with asthma and COPD?

Beta-blockers

10 – What is the common presentation of MI? Crushing retrosternal chest pressure occurring at

rest and radiating to the left arm, neck or jaw, diaphoresis, nausea/ vomiting, dyspnea, anxiety.

CAD

11- What serologic markers are typically used to diagnose and follow an MI?

Troponin I and L, and CK-MB

12- What long-term medications have been shown to improve mortality in patients with MI?

ASA, Beta blockers, and ACE- Inhibitors

Happy Studying!