Cardiology Exam 4

what is the most frequently injured area on the heart with traumatic cardiac penetration? why?

right ventricle

bc of its anterior position

what is the diagnostic gold standard for penetrating trauma?

subxiphoid window

most cardiac penetrating trauma wounds can be repaired how?

left thoracotomy

severe/sudden abdominal compression can acutely increase pressure/blood flow to the heart --> resulting in RT sided rupture

blunt trauma

what arrhythmias are UNcommon in pts with blunt trauma who are surviving to the hospital?

vfib and vtach

if a pt with blunt trauma is stable, how should they be treated?

observe w/ supportive care

pts with blunt trauma who have severe ventricular dysfunction and low CO should be given what to avoid a primary ischemic event?

inotropic support

a large majority of thoracic great vessel injuries are caused by what?

penetrating trauma

_____ can cause cardiac rupture involving any chamber or great vessel

survival is likely if injury is to Atria or RV

blunt trauma

2 of what 4 criteria must be present for acute pericarditis to be diagnosed?

pericardial chest pain

pericardial rub

new widespread STE or PR depression

new/worsening pericardial effusion

what are the 3 infectious forms of pericarditis? specifically?

viral*** (coxsackie and echovirus)

purulent (s. aureus, s. pneumoniae)

TB (m. tuberculosis)

what are the 2 main causes of drug-induced pericarditis?

hydralazine

isoniazid

symptoms of what condition?

- substernal, sharp CP

- improves with sitting upright // worsens with laying down

- poss fever

- early friction rub

- poss pulsus paradoxus

pericarditis

what is the tx for viral pericarditis?

NSAIDs/aspirin

+

colchicine x 3 mos

what is the tx for purulent pericarditis? (2)

emergent surgical drainage

+

IV abx (vanc)

what is the tx for TB pericarditis?

RIPE

+

prednisone

elevated intrapericardial pressure > 15 mmHg

restricts venous return and ventricular filling --> HR and venous pressure rise --> shock/death

tamponade

what assesses the size of pericardial effusions and is the main form of diagnosis?

TTE

symptoms of what condition?

- dyspnea**

- pleuritic chest pain

- cough

- hoarseness

- hiccups

- syncope

pericardial effusions and tamponade

what makes up Beck's Triad?

JVD + hypotension + muffled heart sounds

what may be seen on a CXR in pericardial effusions/tamponade?

water bottle heart (enlarged silhouette)

when should pericardiocentesis procedure be performed with pleural effusions?

cardiac tamponade

large effusion

symptoms of what condition?

- slowly progessive dyspnea

- ascites (often out of proportion to degree of peripheral edema)

- elevated JVP

- kussmaul sign

- pericardial "knock" in early diastole

constrictive pericarditis

what is the definitive dx for constrictive pericarditis?

cardiac catheterization

what will show on an ECHO with constrictive pericarditis?

septal "bounce"

what is the tx for constrictive pericarditis if there is venous congestion/edema?

aggressive diuretics

what is the tx for constrictive pericarditis if diuretics are not working?

surgical pericardiectomy

what are the components of the "major" jones criteria (5)

carditis

arthritis

subq nodules

EM

chorea

what are the heart valves most commonly involved in endocarditis?

most commonly involved if pt is an IV drug user?

MV and AV

TV

infection of previously normal heart valve by highly virulent organism (s. aureus) that rapidly produces necrotizing/destructive lesions

acute infective endocarditis

T/F in subacute infective endocarditis, death can occur within days-weeks of onset despite appropriate abx tx and surgery

false - ACUTE

underlying valvular disease in which there is a decrease in pressure when blood flows through a stenosed vessel at a high velocity

venturi effect

with the venturi effect, where does bacteria accumulate if there is aortic valve insufficiency/regurg?

on ventricular side

with the venturi effect, where does bacteria accumulate if there is mitral valve insufficiency/regurg?

on atrial side

which endocarditis?

< 6 weeks

- s. aureus or B strep

- highly virulent

- normal valves

- invasive/destructive lesions on valves

acute

which endocarditis?

> 6 weeks

- strep

- less virulent

- damaged valves

- no lesions on valves

- splenomegaly, clubbing, petechiae

subacute

which endocarditis?

- acute malaise

- shaking/chills

- fever

- tachy

- leukocytosis

- normal gamma globulins

- pos rheum factor

actue

which endocarditis?

- weight loss

- night sweats

- low/no fever

- normal WBCs or leukopenia

- elevated gamma globulins

- pos rheum factor

subacute

which type of native valve IE?

- indolent course with variable symptoms

- s. viridans is MC

- s. bovis is 2nd most common

- can affect damaged heart valves

subacute

infective endocarditis signs/sx

FROM JANE

fevers

roth spots

osler nodes

murmur

janeway lesions

anemia

nail bed hemorrhage

emboli

which echo is used first for infective endocarditis?

which echo is confirmatory for IE?

transthoracic

transesophageal

uses microbiological data, evidence of endocardial involvement, and other phenomenon associated w/ IE to estimate the probability of IE in a given pt

dukes criteria

when treating IE, how long should abx usually be given for?

when does the number of days of tx START?

2-6 wks

at the 1st negative blood/culture specimen

what tx therapy is contraindicated in NVE and is controversial in PVE?

what is the recommended tx regimen for NVE?

anticoagulation

vanc + ceftriaxone

what has become the primary modality of therapy for AVRNT, tachy w/ accessory pathways, PAT, and atrial flutter?

catheter ablation

what are the 2 types of treatment for sinus brady?

atropine

external pacing (TCP or perm pacemaker)

what is the type of external pacing for sinus brady that is contraindicated in hypothermic pts and asystole?

what is the other external pacing tx?

TCP

permanent pacemaker

disorder of the SA node caused by impaired pacemaker function and impulse transmission

can also be seen as chronotropic incompetence (inappropriate HR response to exercise)

SSS

what is the tx for SSS?

permanent pacemaker (usually dual chamber)

>= 3 distinct P wave morphologies on EKG

100-150 bpm

seen in severe COPD and lung disease

MAT

A-Fib and what condition usually go hand-in-hand?

HF

what are the 4 A-Fib classifications and their recurrent episode timeframes?

paroxysmal (<= 7 days)

persistant (> 7 days)

lonstanding persistant (> 12 mos)

permanent (>12 mos despite attempts to restore NSR)

what are the CCBs that can be used for IV RATE control of A-Fib?

what are the BBs?

what else can be used?

diltiazem, verapamil (Non-DHP)

esmolol, metoprolol, propranolol

digoxin

what meds are often used for RHYTHM control of A-Fib?

for anticoagulation?

amiodarone

dabigatran, -xaban, warfarin/heparin

what are the components of CHADS-VASc

CHF

HTN

age > 75 yro (2)

DM

stroke (2)

vascular disease

age 65-74

sex

CHADS-VASc stroke risk score should be used to identify ______ pts who should NOT be offered antithrombotic therapy

low-risk

_____ is recommended for stroke prevention in A-Fib pts with CHADS-VASc score >=2 in men or >=3 in women

oral anticoagulation (OAC)

where is the MC place for a clot to form due to A-Fib?

LT atrial appendage (LAA)

if the duration of A-Fib is < 48 hrs or pt is hemodynamically UNstable, what tx may you proceed with?

in all other cases, this tx must be preceded by what?

cardioversion

TEE

with post "stunning" phenomenon there is an increased CVA risk for _____, therefore, pt MUST take ____ treatment for at least 4 weeks

30 days

OAC

what are the 2 tx's for atrial flutter?

cardioversion

ibutilide

what is the MC narrow complex SVT?

AVNRT

what can cause SCD due to rapid conduction of A-Fib thru the accessory pathway (bundle of kent)?

WPW (AVRT)

antegrade conduction thru AV node

orthodromic AVRT

retrograde conduction thru AV node // wide QRS complex often mistaken for VTach

antidromic AVRT

which is more concerning, orthodromic or antidromic AVRT?

antidromic

what is the non-pharm tx for SVT?

what is the pharm tx? (3)

vagal maneuvers (valsalva)

IV adenosine, CCBs, BBs

what tx may be indicated if SVT is refractory or unstable?

synchronized cardioversion

fixed prolonged PR interval (> 0.20 sec)

1st deg AVB

some P waves fail to conduct to ventricles, so ratio of P waves to QRS is greater than 1:1

2nd deg AVB

extra P waves with dropped QRS // PR interval may be normal or prolonged but is fixed

mobitz 2

complete absence of conduction from the atria to ventricles (ventricles at rate of 20-40bpm)

3rd deg AVB

what are the 6 indications for a permanent pacemaker?

pauses > 3 sec

sinus brady < 35 bpm

sinus brady 36-40 bpm + symptomatic

chronotropic incompetence

mobitz type 2

3rd deg AVB

occurs when a focus in the ventricle generates an AP before the next scheduled SA nodal AP

what is the 1st line tx if pt is symptomatic?

PVC

BB or non-dhp CCB

>= 3 consecutive PVCs at a rate > 100 bpm that can be sustained (>= 30sec) or non-sustained (< 30 sec)

V-Tach

what is the drug of choice for VTach pts W/ pulse and more stable?

IV amiodarone

what are the 3 tx's for torsades? (multifocal VTach with prolonged QT interval)

CPR/ACLS

IV magnesium

defibrillate

results in SCD from polymorphic VTach or V-Fib in the setting of a structurally normal heart

brugada syndrome

what is the tx for brugada syndrome?

ICD

who is syncope most common in?

elderly females

what are the 3 causes for neurally-mediated syncope (NMS)?

vasovagal**

carotid sinus syndrome

situational

which type of NMS?

- provoked by triggers such as sight of blood, needles, extreme emotional distress

vasovagal

which type of NMS?

- specific localized stimuli (coughing, prolonged standing, heat, defecation, swallowing)

- lack of sleep

- hunger

situational

NMS diagnosis is made how?

specifically? (3)

by exclusion of cardiogenic cause of syncope

tilt table test, holter monitoring, loop recorder

how is carotid sinus syncope diagnosed?

czermak-hering test (carotid massage)

avoid in elderly

what are the pharm tx's for orthostatic hypotension?

fludrocortisone

midodrine

coved ST in V1-V3 followed by a negative T wave =

brugada syndrome

what is the most important part of initial eval for syncope?

HPI