EXAM 2- ADH 2

Angina

chest pain caused by myocardial ischemia

Myocardial ischemia

reduced blood flow to the heart muscle prevents it from receiving enough oxygen and nutrients

Stable angina

predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin

Symptoms of stable angina

Chest pain or discomfort, possibly described as pressure, squeezing, burning or fullness.

Pain in your arms, neck, jaw, shoulder or back accompanying chest pain

Nausea

Fatigue

Shortness of breath

Sweating

Dizziness

Unstable angina

chest pain at rest or chest pain of increasing frequency

Symptoms of unstable angina

prolonged pain at rest, change in character, frequency or duration of stable angina, unrelieved by nitro

Silent ischemia

heart blood flow is interrupted, but there is no pain involved

confirmed by ECG

Prinzemtal variant angina

a rare form of angina that often occurs at rest and not with increased physical demand

caused by spasms of the coronary artery

Symptoms of Prinzmetal variant angina

angina during REM sleep or when exposed to cold

cyclic, short bursts of angina at usual times each day

pain can be relieved by moderate exercise or with SL nitro

Microvascular angina

chest pain occurs in the absence of significant CAD or coronary spasm of a major coronary artery

related to myocardial ischemia associated with atherosclerosis or spams of the small distal branch vessels of the coronary microcirculation

Symptoms of microvascular angina

angina is prolonged and brought on by physical exertion (positive stress test results)

Inconsistent response to nitrates

Medications for stable angina

Short-acting nitrates are first-line therapy!

SL or translingual nitro

Long-acting nitrates (isosorbide dinitrate, isosorbide mononitrate)

Nitropaste: topical or transdermal

ACE inhibitors, ARBs, beta blockers, calcium-channel blockers, and ranolazine

Coronary Artery Disease (CAD)

a condition affecting the arteries of the heart that reduces the flow of blood and the delivery of oxygen and nutrients to the heart; most often caused by atherosclerosis

Atherosclerosis

condition in which fatty deposits called plaque build up on the inner walls of the arteries

Atherosclerosis risk factors

-Age (more common in elderly)

-Gender (more common in men)

-High blood cholesterol levels

-High blood pressure

-Cigarette smoking

Atherosclerosis symptoms

Usually asymptomatic until late stages of disease

Severe pain near the heart

Pain or numbness down the left arm

Leg pain when walking

Dizziness

Nausea, weakness, sudden perspiration

CAD symptoms

Angina, SOB, palpitations, tachycardia, nausea, sweating, tachycardia

Symptoms of CAD

chest pain or pressure, worse with exertion, improved with rest

dyspnea

fatigue

dizziness

palpitations

CAD risk factors

HTN, HLD, DM, smoking, family hx,

Management of CAD

managing risk factors, exercise/weight loss, smoking cessation, manage stress

Medications for CAD

beta blockers, aspirin, statins, nitrates

PAD

any disease process affecting the arteries; common manifestation of atherosclerosis

Main cause of PAD

hardening of arteries with plaque build-up in arteries, which narrows and blocks blood flow (atherosclerosis)

Risk factors for PAD

smoking, DM, obesity, HTN, high cholesterol, older age, family hx

Symptoms of PAD

mostly asymptomatic

intermittent claudication

cool/pale extremities

unequal pulses

leg numbness/weakness

sores on toes/feet that wont heal

hair loss/slower growth on feet or legs

shiny skin on legs

ED in men

Management of PAD

Modifying or eliminating risk factors

Medications such as Trental (pentoxifylline), Pletal (cilostazol), and Plavix (clopidogrel), or Aspirin

Lipid lowering drugs

Peripheral interventional procedures such as balloon angioplasty (PTCA) and stenting

Surgical vascular bypass for severe or diffuse arterial obstruction

intermittent claudication

pain in the leg muscles that occurs during exercise and is relieved by rest

Infective endocarditis

inflammation of endothelium that lines heart and cardiac valves. most commonly damages mitral valve, then aortic and tricuspid valves

Risk factors for IE

Congenital heart defects, hx of endocarditis, damaged heart valves, rheumatic fever or infection, hx of IV illegal drug use

Manifestations of IE

anorexia or weight loss

myalgia

fever/chills

back/joint pain

night sweats

acute: rapid onset, high fever, chills

subacute: gradual onset, low-grade fever, malaise, lethargy

Treatment of IE

- high dose antibiotics (up to 6 weeks worth)

- heart surgery

- long term hospitalization

Myocarditis

inflammation of the heart muscle (myocardium)

can be acute or chronic

Symptoms of myocarditis

fever

myalgias

ventricular arrhythmias

cardiogenic shock

S3 gallop

tachycardia

JVD

peripheral edema

palpitations

HF

Treatment for myocarditis

Same as heart failure (ACE, diuretics, BB)

Pericarditis

inflammation of the sac surrounding the heart (pericardium)

Causes of pericarditis

viral

acute MI

chest trauma/surgery

autoimmune disorders

medications, malignancy

Symptoms of pericarditis

Chest pain- most common! Aggravated by deep inspiration, coughing, lying down, or turning

Friction rub

mild fever

high WBC

anemia

nonproductive cough

dyspnea

Treatment of pericarditis

NSAIDS and ASA- first line!

Colchicine

Surgical removal of the pericardium

Cardiac tamponade

acute compression of the heart caused by fluid accumulation in the pericardial cavity

Medical emergency!

Symptoms of cardiac tamponade

SOB

chest tightness

dizziness or restlessness

pulsus paradoxus (a decrease of 10 mm Hg or more in the systolic blood pressure during inspiration)

tachycardia

JVD

Rheumatic heart disease

Condition in which permanent damage to the heart valves occurs from a prior episode of rheumatic fever

Rheumatic carditis

Inflammation of the pericardium, myocardium, and endocardium, separately or in combination

Temporarily weakens the pumping ability of the heart

Stenosis

The opening of the valve is narrowed, and the forward flow of blood through the valve is reduced

Regurgitation

when valves do not close completely, and blood flows backward through the valve

Mitral stenosis

calcified mitral valve impedes the forward flow of blood into the left ventricle

major risk factor of rheumatic fever!

Symptoms of mitral valve stenosis

Loud S1 snap

Dyspnea on exertion- primary symptom!!

orthopnea

A-fib or palpitations

fatigue

HTN

JVD

pitting edema

hemoptysis/hoarseness

dry cough

PND

heptamegaly

Treatment of mitral valve stenosis

controlling symptoms

surgical repair: valve replacement, repair, or percutaneous mitral balloon valvuloplasty

Mitral valve prolapse

A portion of one or both mitral valve leaflets bulges into the left atrium- causes regurgitation

most common form of valvular heart disease in the US

Symptoms of mitral valve prolapse

usually asymptomatic:

palpitations

angina

dyspnea

dizziness or numbness

Mitral valve regurgitation

A backflow of blood caused by failure of the heart's mitral valve to close tightly from the LV into the LA

Causes of mitral valve regurg

congenital

rheumatic heart diagnosis

acute IE

MVP

MI

Symptoms of mitral valve regurg

Prolonged asymptomatic period before symptoms occur:

fatigue

tachycardia

weakness

orthopnea

DOE

PND

Treatment for mitral valve regurg

medications

annuloplasty

valve leaflet repair

chordoplasty

Acute mitral regurg

cardiac emergency!

severe SOB, pallor, tachycardia, crackles, hypotension, JVD, peripheral edema, and ascites

Occurs abruptly, when papillary muscle rupture occurs as a complication of MI, infective endocarditis, or trauma

Aortic stenosis

the narrowing of the aortic valve between the LV and aorta, resulting in obstruction of blood flow

Symptoms of aortic stenosis

Prolonged asymptomatic period then rapid deterioration at onset of symptoms:

angina

dyspnea

syncope

heart failure

murmur

S4

Aortic regurgitation

the backward flow of blood into the LV from the aorta during diastole

causes volume overload

Causes of aortic regurg

rheumatic heart disease

congenital deformity

syphilis

Symptoms of aortic regurgitation

Prolonged asymptomatic period even while exercising, then decreased exercise tolerance

CHF (very late sign)

angina

dizziness

palpitations

Murmurs

sounds created by abnormal, turbulent flow of blood in the heart

the valve involved is where the murmur is heard!

Systolic murmur

heart murmur heard during systole (active pumping)

mitral regurg

aortic stenosis

mitral valve stenosis

Diastolic murmur

heart murmur heard during diastole (rest/active filling)

aortic regurg

mitral stenosis

Valvuloplasty

repair of a cardiac valve surgically or percutaneously

general term for repairing a stenosed or regurgitant valve by commissurotomy, annuloplasty, leaflet repair, or chordoplasty

Valve replacement

surgical replacement of a valve with a biologic or mechanical device

mechanical valve replacement

long lasting

will require long-term anticoagulation

Tissue valve replacement

Can be *human* (homograft, autograft) or *animal* (bioprosthesis)

Lasts about 10-15 years (less durable than mechanical)

Lower need for anticoagulant

Cardiomyopathy

A disorder of the myocardium (heart muscle) associated with mechanical and/or electrical dysfunction

results in impaired CO

Causes of cardiomyopathy

autoimmune disorders

excessive alcohol

pregnancy

chemotherapy

viral infection

Dilated Cardiomyopathy (DCM)

Irreversible dilation of the ventricles and systolic dysfunction w/out hypertrophy

most common type!

(floppy heart)

Symptoms of Dilated Cardiomyopathy (DCM)

dyspnea

fatigue

weight gain

volume overload

arrythmias

Hypertrophic cardiomyopathy (HCM)

leading cause of sudden death in athletes; involves an abnormally enlarged left ventricle

leads to obstruction of LV outflow

(enlarged, thickened heart)

Symptoms of Hypertrophic cardiomyopathy (HCM)

usually asymptomatic

dyspnea

angina

fatigue

palpitations

dizziness

presyncope

syncope

sudden death

end-stage HF

Restrictive Cardiomyopathy (RCM)

heart muscle becomes stiff and unable to expand or contract effectively

rare!

(stiff, rigid heart)

Symptoms of Restrictive Cardiomyopathy (RCM)

Dyspnea

orthopnea

nonproductive cough

angina

peripheral edema

fatigue

hepatomegaly

Arrhythmogenic right ventricular cardiomyopathy (ARVC)

Disease of the RV = ventricular tachycardia and R HF

inherited

Accounts for 20% of sudden death in athletes (2nd leading cause)

(arrhythmia-prone heart)

Symptoms of Arrhythmogenic right ventricular cardiomyopathy (ARVC)

usually present in early childhood

palpitations

syncope

supraventricular and ventricular arrhythmias

R-sided HF

ventricular tachycardia

Stress-induced (Takotsubo) cardiomyopathy

Acute, reversible LV dysfunction commonly precipitated by profound emotional, psychological, or physical distress

Predominantly in white, postmenopausal women

(stressed heart)

Symptoms of Stress-induced (Takotsubo) cardiomyopathy

symptoms similar to a STEMI

life-threatening arrhythmias

pulmonary edema

HF

cardiogenic shock

sudden death

substernal chest pain

SOB

Medications for cardiomyopathies

ACE inhibitors

aldosterone antagonists

diuretics

beta blockers

calcium channel blockers

Contraindications for heart transplantation

Irreversible pulmonary HTN- would lead to RV failure of the new heart

Malignancy

Active infection

Complications of mitral prolapse

MR, IE, SCD, HF, cerebral ischemia

Treatment for MVP

Beta-blockers (symptomatic - for chest pain and palpitations)

Valve repair for developed MR

Encourage the patient to stay hydrated, exercise regularly, and avoid caffeine

Acute AR

caused by IE, trauma, or aortic dissection

Life-threatening emergency!

Manifestations of acute AR

severe dyspnea

angina

hypotension

cardiogenic shock

Chronic AR

Caused by rheumatic heart disease, congenital bicuspid aortic valve, syphilis, or chronic rheumatic conditions

Manifestations of chronic AR

exertional dyspnea, orthopnea, paroxysmal dyspnea

angina

water-hammer pulse

soft or absent S1

S3 or S4

murmur

Tricuspid valve stenosis

Occurs in patients with RF and IVDA

causes R atrial enlargement and elevated systemic venous pressures

Manifestations of tricuspid valve stenosis

peripheral edema

ascites

hepatomegaly

diastolic low-pitched murmur

Pulmonary Valve stenosis

almost always congenital

results in RV HTN and hypertrophy

Manifestations of pulmonary valve stenosis

fatigue and loud murmur

Valve repair

surgical procedure of choice- lower mortality

may not restore total valve function

commissurotomy, valvuloplasty, annuloplasty

Treatment for dilated cardiomyopathy

meds to control HF (nitrates, diuretics, ACE inhibitors, BBs, aldosterone antagonists)

ventricular assist device

nutritional therapy

heart transplant

cardiac rehab

Treatment for hypertrophic cardiomyopathy

Beta-blockers initially for symptomatic relief, CCBs for 2nd line tx.

Avoid intense athletic training

elevate feet to promote venous return

Cholecystitis

inflammation of the gallbladder, usually associated with gallstones

can be acute or chronic

Symptoms of cholecystitis

Pain varying in frequency and intensity- can mimic chest pain but isnt!

pain that radiates to R shoulder

pain that occurs after a large or high-fat meal

anorexia, N/V, dyspepsia, flatulence

feeling of ABD fullness

rebound tenderness

jaundice

fever

Cholecystectomy

surgical removal of the gallbladder

ducts are explored for stones

Open chole- T tube is placed to drain

Laparoscopic- no tube!

Cholelithiasis

gallstones form when bile in the gallbladder hardens into stone-like material

very common!

Causes of cholelithiasis

increased cholesterol in bile

Increased bile salts

slowed emptying rate

more concentrated or stagnant in the gallbladder

Procedures for cholelithiasis

Lithotripsy- delivers shock waves to break up stones

Cholecystectomy - open or lap

Treatment for cholelithiasis

diet- low fat, take fat-soluble vitamins and bile salts

drugs- opioids for pain, anticholinergics, bile acid therapy

may need NGT to decompress the stomach and empty