PANCE - PREP PEARLS

systolic "ejection" crescendo-decrescendo harsh murmur at RUSB that radiates to carotids

aortic stenosis

harsh diastolic rumble murmur at apex (low) in LLD that may be preceded by OPENING SNAP and is MCC by ________

mitral Stenosis

rheumatic heart disease

what is a diastolic decrescendo blowing murmur @ LUSB and is associated with hammer rumble

aortic regurgitation

note:

wide pulse pressure

increases with handgrip

decreases with amyl nitrate

+/- austin flint murmur = mid-late diastolic rumble at apex

aortic regurgitation + head bobbing

DeMussets

aortic regurgitation + nailbed pulsations

Quincke pulses

blowing holosystolic murmur @ apex that radiates to axilla

mitral regurgitation

note:

increases with handgrip

decreases with amyl nitrate

midsystolic ejection click at apex is caused by what

mitral valve prolapse

note: reassurance and good prognosis in asymptomatic pts or with mild sx

systolic ejection crescendo-decrescendo flow murmur at PULMONIC AREA

atrial septal defect

note:

ostium secundum most common

left to right shunt (noncyanotic)

continuous machinery murmur that is loudest at pulmonic area

patent ductus arteriosus

note: left to right shunt (noncyanotic), continued PGE2 production promotes patency, IV indomethacin if preterm to close PDA

systolic murmur that radiates to the back/scapula/chest

increase BP upper > lower extermities

delayed/weak femoral pulses

coarctation of aorta

along with coarctation of aorta, 70% also have ____

bicuspid aortic valves

coarctation of aorta

CXR

rib notching

note:

"3 sign" on barium swallow

angiogram gold standard

Tx balloon angioplasty, PGE1

tetralogy of fallot is what type of shunt?

What are the defects

1.

2.

3.

4.

right to left

1. VSD

2. R ventricular hypertrophy

3. overriding aorta

4. pulmonic stenosis (RV outflow obstruction)

(photo: boot-shaped heart)

anti-arrhythmic classes

I

II

III

IV

V

I- Na+ channel blockers (slow conduction velocity)

Ia- procainamide, prolongs repolarization

Ib- lidocaine, shortens repolarization

II- beta blockers (propranolol, metoprolol, esmolol)

III- K+ channel blockers (K+ prevents efflux)

IV- CCB (verapamil, diltiazem)

V- others, adenosine

atropine is first line treatment in _________________

bradycardia

adenosine is used for treatment in ________

tachycardia

causes transient heart block in AV node

class V

amiodarone is used as treatment for ___________

supraventricular arrhythmias (class III)

blocks SA/AV node

EKG: how can we calculate rate

300-150-100-75-60-50

EKG: which lead to look at for atrial enlargement

lead II

left atrial enlargement- "m-shaped" P wave

right atrial enlargement- tall P

how do bundle branch blocks present on EKG

leads V1* and V6

left bundle branch block- downward deflection; deep S in V1...when you turn left, you pull the steering wheel down

right bundle branch block- upward deflection; RsR' in V1...

when you turn right, you pull the steering wheel/turn signal up

epinephrine and norepinephrine are _______ hormones that __________ HR

sympathetic, increase

acetylcholine (secreted by vagus n) is _________ hormone and causes ______ HR

parasympathetic, decereased

note: vagal maneuvers do the same; hold breath, bear down, carotid massage

what is normal sinus rate

60-100 bpm

sinus arrest w/ alterations of paroxysms of atrial tachy and bradyarrhythmias, caused by sinoatrial node disease is called ________________. how is it treated

sick sinus syndrome aka brady-tachy syndrome

permanent pacemaker

EKG: prolonged PR-interval is criteria for _______________

first degree AV block

PR interval > 0.20 sec

describe second degree AV block (mobitz I)

aka wenckebach

increased lengthnening of PR interval with dropped QRS

describe second degree AV block (mobitz II)

constant/prolonged PR interval w/ dropped beat

P waves are not related to QRS in what type of AV block? what is the treatment for this

third degree AV block

permanent pacemaker

what is the atrial flutter rate and how does it look on EKG

250-350 bpm

note: sawtooth pattern

irregularly irregular rhythm defines ______________. What is the treatment

atrial fibrillation

rate vs rhythm control...

rate

-vagal

-CCB

-BB

rhythm

-DC cardioversion

-DCC may also be done after 3-4 weeks of anticoagulation or TEE showing no atrial thrombi

pts w/ atrial fibrillation are on warfarin or aspirin for prophylaxis for ____ based on ____ score

stroke

CHADS2 = CHF, HTN, age > 75 yo, DM, Stroke/TIA

note:

high risk (score > 2)-on warfarin (INR 2.0-3.0)

moderate risk (score 1) -on warfarin or aspirin

low risk (score 0)- none or aspirin

describe wandering atrial pacemaker

> 3 P wave morphologies w/ rate under 100

multifocal atrial tachycardia (MAT) is associated with severe ______

COPD

definitive tx for paroxysmal supraventricular tachycardia (PSVT) is _______________

radiofrequency catheter ablation

delta wave (slurred QRS upstroke) and a short PR interval is present in ______________. What is the accessory pathway called

wolff-parkinson white

kent bundle

why must we avoid A-V nodal blocking agents in wolff-parkinson white? Sooo then what is the tx

may cause preferential conduction through accessory pathway

vagal maneuvers

antiarrhythmics (ex: procainamide, amiodarone)

radiofrequency ablation *definitive tx

most common rhythm seen with digitalis toxcity

AV junctional dysrhythmia

what is the junctional rhythm rate

40-60 bpm

wide, bizarre QRS occurring earlier than expected, usually the T wave is in the opposite direction of the R, associated with compensatory pause. this describes what?

premature ventricular complexes

describe ventricular tachycardia

> 3 consecutive PVCs at a rate of > 100 bpm

electrolyte status with torsades

hypomagnesium

hypokalemia

what is tx for stable sustained VT

anti-arrhythmics (Amiodarone*, lidocaine, procainamide)

what is treatment for unstable VT with a pulse

synchronized (direct current) cardioversion (DCC)

what is tx for VT withOUT a pulse

defibrillation/CPR (tx as ventricular fibrillation)

tx for torsades de pointes is ____________

IV magnesium

electrical activity that is not coupled with mechanical contraction is called ____________

pulseless electrical activity

note: no mechanical contraction aka no pulse

asystole rhythm (ventricular standstill) Tx

CPR

epinephrine

checks for shockable rhythm q 2 mins

______ leads and _____ (vessel)

II, III, aVF

inferior

right coronary artery

______ leads and _____ (vessel)

V1-V4

anterior

left anterior descending artery

______ leads and _____ (vessel)

I, AVL, V5, V6

lateral

circumflex artery

sokolow-lyon:

S in V1 + R in V5 = 35 mm (men)

S in V1 + R in V5 = 30 mm (women)

criteria for left ventricular hypertrophy

ST depression usually indicates ______________

ischemia

ST depression

horizontal-

upslope-

downslope-

horizontal-pathological

upslope-may be benign

downslope-pathological

ST elevation CONCAVE precordial leads

PR depression seen in the same leads with the ST elevations

no reciprocal changes

acute pericarditis

describe brugada syndrome

right bundle branch syndrome

ST elevation V1, V2, V3 (often downsloping pattern)

T wave inversion in V1, V2

+/- S wave in lateral leads

most common in Asian males

may cause syncope, ventricular fibrillation, sudden cardiac death

prevented by implantable cardiodefribrillator

equation for cardiac output

CO = HR X SV

note: normal physiologic variation....during inspiration, left sided stroke volume decreases

_____-sided murmurs are best heard at end expiration

Left

_____-sided murmurs are best heard at end inspiration

Right

don't use nitrogen and morphine in ____-sided (inferior) myocardial infarction

Right-sided

(because right-sided heart failure is preload dependent and nitrogen and morphine decrease preload via vasodilation)

3 ways renin increases BP

1. increases ACE > increase BP

2. increases ADH > increase H2O > increase BP

3. increases aldosterone > increase sodium > increase BP

note:

ACE = angiotension converting enzymes

ADH = antidiuretic hormone

what makes a positive stress test and what is it most useful for?

ST depressions

exercise-induced hypertension/hypotension

arrhythmias

Sx

abnormalities in heart rate

suspected coronary disease

what is the benefit of radionuclide myocardial perfusion imaging

localize region of ischemia

what drugs used in pharmacologic stress testing

adenosine or dipyridamole

dobutamine (2nd line)

what is gold standard diagnostic test for definitive diagnosis of coronary artery disease/angina

coronary angiography aka "cath"

what is the most useful test to dx heart failure

echocardiogram

what is the primary noninvasive test for assessing cardiac anatomy and fx

transthoracic echocardiogram

(transesophageal echocardiogram is more invasive but better at imaging)

what drugs are used in pharmacologic stress stressing, why are they used, and what are they CI in?

adenosine, dipyridamole

pts unable to exercise to localize area of ischemia

bronchospastic disease

why is a dobutamine stress echo used for

localize area of ischemia in patients that are CI for vasodilators

define coronary artery disease

inadequate tissue perfusion due to imbalance bt decreased coronary blood supply and increased demand

what is MCC of coronary artery disease

atherosclerosis

what are the major risk factors for coronary artery disease

DM, smoking, hyperlipidemia, HTN, male, increased age, FH

what are the 3 phases of formation of atherosclerotic plaque

fatty streak: lipid deposits in WBC

early plaque: LDL is oxidized attracting macrophages/smooth muscle cells to ingest harmful LDL

fibrous plaque: narrowing of arterial lumen and calcification

define myocardial ischemia

narrowing of arterial lumen reduce cardiac blood flow in conditions of increased demand

usually >70% of lumen reduction

define angina and the classes

substernal chest pain brought on by exertion that is poorly localized and relieved with rest/nitro

I: angina w/ only unusually strenuous activity

II: angina w/ more prolonged activity

III: angina w/ daily activity

IV: angina at rest

what is Levine's sign

present in angina

what are the percutaneous transluminal coronary angiography indications

1 or 2 vessels NOT involving main left coronary artery

near/normal left ventricular function

(definitive tx for angina)

coronary artery bypass graft (CABG) indications

left main coronary artery disease

symptomatic 3 vessel disease

left ventricular ejection fraction < 40%

(definitive tx for angina)

nitroglycerin MOA and contraindications

MOA: increase myocardial blood supply and decrease in demand

CI: PDE5 inhibitors, R ventricular MI, SBP<90mmHg

1st line drug for chronic management of stable angina

beta blockers (increase myocardial blood supply and decrease in demand)

note: reduces mortality

____ play a major role in preventing/terminating ischemia induce by coronary vasospasm (Prinzmetal's angina)

calcium channel blockers (increase myocardial blood supply and decrease in demand)

aspirin: MOA

prevents platelet activation/aggregation

(by inhibiting cyclooxygenase)

reduced risk of thrombosis

prevents progression of from chronic stable angina to ACS

what is classic outpatient regimen for angina

aspirin, sublingual nitro, daily B-blocker and statin

who is at risk for a silent MI

women, elderly, diabetics, obese

what defines chronic stable angina?

caused by fixed stenosis (coronary plaque)

relieved by rest/NTG

chronic stable angina Tx

aspirin

beta blocker

statin

PRN sublingual NTG

what makes it unstable angina?

fixed stenosis

negative cardiac enzymes

NOT relieved by rest/NTG

new onset angina

note: > 90% occlusion can cause anginal Sx at rest aka pian at rest indicates 90% blockage!

what defines NSTEMI?

positive cardiac enzymes

no ST elevations on EKG

what defines STEMI

ST elevations >1mm in >2 contd leads + reciprocal leads

new LBBB

most common cause of MI

atherosclerosis

most common causes of coronary artery vasospasm

cocaine

prinzmetal's variant angina

troponin vs CK/CK-MB

troponin

-most sensitive and specific for cardiac ischemia

-appears 4-6 h

-peaks 12-24 h

-returns to baseline 7-10 d

CK/CK-MB

-appears 4-6 h

-peaks 12-24 h

-returns to baseline 3-4 d

what is anti-thrombotic tx in UN/NSTEMI

1. aspirin

2. unfractionated heparin

3. enoxaparin (Lovenox)

4. clopidogrel (Plavix)

5. GP IIb/IIIa inhibitors (eptifibatide, tirofiban, abciximab)

6. Fondaparinux (factor Xa inhibitor)

what is the MOA and indiction for unfractionated heparin

binds and potentiates antithrombin III's ability to inactivate factor Xa , inactivates thrombin

ACS pts w/ EKG changes or + cardiac markers

what is enoxaparin (Lovenox), what is the MOA, and what is the SE

define: low molecular weight heparin

MOA:binds to antithrombin III to inhibit factor Xa

SE: thrombocytopenia

____ is useful in initial tx of acute coronary syndrome in pts with aspirin allergy

clopidogrel (Plavix)

what is adjunctive anti-ischemic therapy in UA or NSTEMI

B blockers: metoprolol

nitrates

morphine

Ca channel blockers

how does morphine contribute to relief of UA or NSTEMI

decreases pain

venodialation to reduce preload

what is the 3 part approach to treatment of STEMI

reperfusion therapy: PCI or thrombolytics (used if PCI unavailable)

antithrombotics

adjunctive therapy

(additional: replinish Mg and K, monitor glucose and bp, reduce risk factors, statin therapy)

(page 28***)

percutaneous coronary intervention is best w/in _____ of sx onset

3hr

describe clot formation

factor Xa converts prothrombin (II) > thrombin (factor IIa)

thrombin activates fibrinogen > fibrin clot