Cardiovascular System

Abdominal Aortic Aneurysm

• Definition: AAA; majority of patients are asymptomatic until rupture.

• If symptomatic without rupture: abdominal, back, or flank pain.

• Ruptured AAA: suspected with classic triad of acute abdominal pain, abdominal distention, and hemodynamic instability.

• Risk factors: older, white male; current or former smoker; hypertension (HTN).

• Incidental finding on chest x-ray may show widened mediastinum, tracheal deviation, and obliteration of the aortic knob (note: thoracic aortic dissection considerations).

• Initial imaging: abdominal ultrasound; CT often used for further evaluation.

• Clinical tip: Rule out AAA in older male with pulsatile abdominal mass > 3 cm; next step: ultrasound then CT.

Acute Coronary Syndrome (ACS)

• Spectrum includes STEMI, NSTEMI, and unstable angina.

• Classic presentation: middle-aged to older man with onset of constant chest or substernal discomfort > 15 minutes; described as squeezing, tightness, crushing, knot in the center of the chest, heavy pressure ("elephant on my chest"); may radiate to arms, shoulders, neck, jaw, back.

• Triggers: exertion, emotional upset, or heavy meals.

• Women, older adults, and diabetics may have atypical presentations (epigastric discomfort, indigestion, nausea, vomiting, fatigue, dizziness).

• Some chest pain may be rest-related or unpredictable (unstable angina).

• Diagnostic test: 12-lead EKG; some MI presentations may have normal or nonspecific EKG.

• Immediate actions: assess airway, breathing, circulation; give aspirin 162–325 mg to chew and swallow unless contraindicated; call 911.

Bacterial Endocarditis (Infective Endocarditis)

• Risk factors: valvular abnormalities; IV drug use; indwelling cardiac devices; immunosuppression; recent dental or surgical procedure.

• Common pathogens: Staphylococcus aureus; streptococci; enterococci.

• Presentation: fever and chills with new-onset murmur, anorexia, weight loss; skin findings on fingers/hands and toes: splinter hemorrhages, Osler nodes (tender violet lesions), Janeway lesions (painless red spots on palms/soles); Roth spots (retinal hemorrhages).

• Fundoscopy and other signs may aid diagnosis.

• First test for suspected bacterial endocarditis: transthoracic echocardiogram (TTE).

• Diagnostic plan often includes blood cultures and echocardiography; CBC may show elevated WBC and ESR > 20 mm/h.

• Management: hospitalization for IV antibiotics; consult cardiology/infectious disease; monitor valve function; consider surgical intervention if indicated.

• Complications: cardiologic and neurologic events, valvular destruction, myocardial abscess, septic emboli, metastatic infection, immune reactions, death.

• Prophylaxis: for high-risk settings (dental procedures, etc.).

  • Preferred oral prophylaxis: Amoxicillin 2 g PO 1 dose for adults 1 hour before procedure.

  • IV options: Ampicillin 2 g IM/IV or cefazolin/ceftriaxone 1 g IM/IV.

  • High-risk conditions include prosthetic valves, prior endocarditis, implanted devices, congenital heart disease, and certain surgeries.

  • For penicillin allergy: oral cephalexin 2 g or clarithromycin; IV cefazolin or ceftriaxone 1 g.

• Cardiac arrhythmias may coexist with endocarditis.

Heart Failure (HF)

• Presentation: older adults with dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea; fatigue; fluid overload signs.

• Physical findings: lung crackles, wheezing, tachypnea, tachycardia, S3 gallop; JVD; edema; ascites; hepatomegaly; hypoxia.

• Etiologies include LV dysfunction, RV dysfunction, valvular disease, pericardial disease, obstructive lesions, high-output states.

• Decompensation factors: high sodium intake, nonadherence to meds.

• LV systolic function categories by EF:

  • HF with reduced EF (HFrEF): EF \,\le\; 40\%

  • HF with mid-range EF: 41\% \le EF \le 49\%

  • HF with preserved EF (HFpEF): EF \ge 50\% (diastolic HF)

• Right-sided HF may accompany LV failure and show hepatomegaly, splenomegaly, ascites.

Stable vs Unstable Angina

• Stable angina: chest discomfort predictably provoked by exertion; brief (2–5 minutes); relieved by rest or nitroglycerin.

• Unstable angina: occurs with less activity or at rest; episodes more frequent, severe, or prolonged; may not respond to rest or nitroglycerin.

• Distinction from NSTEMI: unstable angina has ischemic symptoms with no troponin elevation; NSTEMI has troponin elevation.

Normal Findings and Cardiac Anatomy (Key Reference Data)

• Heart position: right ventricle lies closest to the sternum.

• Apical impulse: PMI at the apex, 5th intercostal space (ICS), left midclavicular line.

• PMI displacement:

  • Severe LVH/ cardiomyopathy: PMI displaced laterally, >3 cm wide, more prominent.

  • Pregnancy: uterus enlarges, diaphragmatic elevation moves heart left/up; PMI displaced upward; may hear S3 in pregnancy.

• Circulation flow:

  • Deoxygenated blood: SVC/IVC → RA → tricuspid → RV → pulmonic valve → pulmonary artery → lungs (gas exchange) → pulmonary veins → LA → mitral → LV → aortic valve → aorta → systemic circulation.

  • Oxygenated blood returns from lungs via pulmonary veins to the LA.

• Systole/diastole mnemonic: "motivated apples" for S1/S2 sound production and valve types.

  • Motivated (S1): Mitral (M) and Tricuspid (T); AV valves.

  • Apples (S2): Aortic (A) and Pulmonic (P); semilunar valves.

• Heart sounds:

  • S1: closure of AV valves; the lub component; AV valves close; semilunar valves open.

  • S2: closure of aortic and pulmonic valves; the dub; AV valves open.

  • S3: early diastole; ventricular gallop; heard as Kentucky; abnormal after age 40; normal in children/pregnant athletes >35.

  • S4: late diastole; atrial kick; Tennessee; usually abnormal; LVH; best heard at apex with bell.

• Stethoscope skills:

  • Bell: low-pitched sounds (S3/S4, mitral stenosis).

  • Diaphragm: higher-pitched sounds (lung sounds, MR, AS).

• Benign variants:

  • Physiologic S2 split: best at left upper sternal border; splits during inspiration, disappears on expiration.

  • S4 in older adults may be normal variant if no disease signs.

• Abnormal findings: pathologic murmurs; echocardiography indicated for symptomatic murmur or diastolic murmur, diastolic murmur with other signs, or high-grade murmurs.

Heart Murmurs: Identification and Mnemonics

• Murmurs: timing (systolic vs diastolic) and location (auscultatory area).

• Key mnemonics:

  • MR. PASS (Systolic murmurs): Mitral Regurgitation (MR), Physiologic (MR/P) murmur, Aortic Stenosis (AS), Systolic murmurs typically louder and radiate to neck or axilla; best heard at apex for MR; AS heard at right second ICS.

  • MS. ARD (Diastolic murmurs): Mitral Stenosis (MS), Aortic Regurgitation (AR) diastolic murmur; AR heard best with patient leaning forward, held expiration; AR location may be Erb’s point or right upper sternal border depending on cause.

• Murmur locations:

  • Mitral area (apex): fifth left ICS at the midclavicular line; PMI is here.

  • Aortic area: second ICS, right sternal border; base of heart.

  • Erb’s point: third to fourth ICS, left sternal border.

• Murmurs: grading scale

  • Grade I: very soft, only under optimal conditions.

  • Grade II: mild to moderately loud.

  • Grade III: loud, easily heard.

  • Grade IV: loud with palpable thrill.

  • Grade V: very loud with edge of stethoscope off chest; thrill easily palpable.

  • Grade VI: heard with stethoscope off chest; thrill obvious.

• Tips:

  • The first thrill is detectable at Grade IV.

• Common pathologic murmurs:

  • Mitral regurgitation: MR; holosystolic murmur; best at apex; may radiate to base or axilla; soft/low-pitched; heard with diaphragm.

  • Aortic stenosis: harsh, harsh-sounding, midsystolic ejection murmur; best at right 2nd ICS; may radiate to neck; avoid overexertion; serial echocardiograms with Doppler; possible surgical valve replacement if worsens.

  • Aortic regurgitation: high-pitched diastolic murmur; best heard sitting up and leaning forward with expiration; Erb’s point if valve disease; right upper border for root disease.

• Diastolic murmurs (MS ARD): see MS (opening snap at apex with diastolic rumble); AR at left sternal border; AR may be at right 2nd ICS.

Bacterial Endocarditis: Prophylaxis and Management

• Prophylaxis indications include high-risk conditions: prosthetic valves, prior endocarditis, certain congenital defects, and durable mechanical circulatory support devices; invasive dental or oral procedures.

• Regimens:

  • Amoxicillin 2 g PO 1 dose (adult, oral) 1 hour before procedure.

  • IV options: Ampicillin 2 g IM/IV; cefazolin or ceftriaxone 1 g IM/IV.

  • If penicillin allergy: cephalexin 2 g PO; clarithromycin; or IV cefazolin/ceftriaxone 1 g.

• Pathogens: Staphylococci; streptococci; enterococci.

• Classic clinical signs: subungual hemorrhages, Osler nodes, Janeway lesions, Roth spots; fever, murmur;

• Diagnostic approach: blood cultures; echocardiography (TTE or TEE as indicated).

• Complications: valvular destruction, abscess, embolization, metastatic infection, immune phenomena.

• Management plan: hospitalization and IV antibiotics; cardiology + infectious disease consult; monitor valve function; consider surgical repair if indicated.

End-User Practical Notes: Antimicrobial/Anticoagulation Context

• Warfarin management basics:

  • Target INR depends on indication; common targets include 2.0–3.0 for nonvalvular AF; 2.5–3.5 for mechanical valves or certain high-risk states.

  • Initiation dose often ≤ 5 mg daily; adjust for frailty or age > 70 years (e.g., 2.5 mg).

  • Full anticoagulation effect may take up to 3 days; monitor INR every 2–3 days until stable; then every 1–4 weeks.

  • Drug interactions exist; DOACs are first-line for nonvalvular AF in many settings.

  • If bleeding occurs, adjust therapy: stop anticoagulants, give vitamin K, PCC, or FFP as indicated.

• Direct-acting anticoagulants (DOACs): dabigatran, rivaroxaban, edoxaban, apixaban.

  • Do not require INR monitoring; fewer dietary interactions; easier adherence.

  • Specific reversal agents: dabigatran → idarucizumab (Praxbind); rivaroxaban/apixaban → andexanet alfa (Andexxa).

  • Warfarin preferred with mechanical valves, rheumatic MS, or certain drug interactions.

• Lipid management overview:

  • First-line: lifestyle changes; statins for ASCVD risk or established disease; high-intensity statin therapy for very high risk ASCVD, diabetes, or LDL elevations; goal LDL often <70 mg/dL for very high risk; <100 mg/dL otherwise.

  • High-intensity statins: Atorvastatin 40–80 mg/d; Rosuvastatin 20–40 mg/d; Simvastatin 20–40 mg/d; Pravastatin 40–80 mg/d; Lovastatin 40 mg/d; Fluvastatin 40 mg BID.

  • Ezetimibe (Zetia) and PCSK9 inhibitors (evolocumab, alirocumab) are used if LDL-C remains above goal despite statins.

  • Niacin and fibrates have limited cardiovascular benefit when used alone; niacin not routinely recommended due to side effects.

  • Lifestyle strategies: Mediterranean/DASH diets, soluble fiber, omega-3 fatty acids for triglycerides; aim to reduce ASCVD risk with dietary measures (salt reduction, balanced fats).

• Hypertension management: ACC/AHA 2017–2018 guideline framework (summary)

  • BP stages (office): Normal <120/80; Elevated 120–129/<80; Stage 1: 130–139 or 80–89; Stage 2: ≥140 or ≥90.

  • Goals: <130/80 mmHg for most adults, with consideration of risk factors and comorbidities.

  • Initiation of pharmacotherapy guided by ASCVD risk; multiple guidelines exist (ACC/AHA vs JNC 8). In high-risk patients, treatment may begin earlier.

  • First-line options: thiazide diuretics, ACE inhibitors, ARBs, or certain CCBs; combinations may be necessary to reach goals.

  • Special populations: diabetic, CKD, African American, older adults; adjust choices accordingly.

  • Nonpharmacologic: weight loss, sodium restriction (<2–3 g/day), physical activity, moderation of alcohol, smoking cessation, DASH diet, potassium intake (if kidney function permits).

• Hypertension diagnosis and out-of-office management:

  • Diagnosis requires multiple readings and appropriate technique; ambulatory BP monitoring is the gold standard for out-of-office measurement.

  • Self-measured BP (SMBP) guidance: use validated devices, cuff size appropriate for arm; maintain a BP diary.

  • Recognize hypertensive emergencies (SBP > 180 or DBP > 120 with target organ damage) and urgencies (similar BP without organ damage).

  • Pregnancy-related HTN: avoid ACE inhibitors/ARBs in pregnancy; use methyldopa, nifedipine, or labetalol; screen for preeclampsia at prenatal visits.

• Anatomic and physiologic notes relevant to HTN risk:

  • Retinopathy signs (copper/silver wiring, AV nicking, hemorrhages, cotton-wool spots).

  • CKD signs: edema, proteinuria, elevated creatinine/CR, abnormal eGFR.

  • Atherosclerotic disease signs: carotid bruits, PAD, CAD, MI.

Atrial Fibrillation (AF) and Atrial Flutter

• AF: most common cardiac arrhythmia in the U.S.; irregularly irregular rhythm with absence of discrete P waves on ECG.

• AF with rapid ventricular response (RVR) can destabilize hemodynamics in critical illness.

• Atrial flutter: regular atrial rate with faster atrial impulse; sawtooth-like ECG tracing.

• Paroxysmal AF: episodes terminate within 7 days (usually <24 hours); often asymptomatic.

• Diagnostic workflow for new AF: 12-lead ECG; assess thyroid function (TSH), electrolytes (Ca, K, Mg, Na), renal function, BNP, troponin; consider 24-hour Holter; echocardiography to assess valves.

• Anticoagulation decisions: CHA2DS2-VASc score used to determine need for anticoagulation.

  • CHA2DS2-VASc components: CHF, HTN, age >75 (2 points), diabetes, stroke/TIA (2 points), vascular disease, age 65–74, female sex.

  • Scoring guidance: 0 = low risk; 2+ = anticoagulation recommended; some treat at 1 depending on context.

• Anticoagulation options:

  • Warfarin (Coumadin): INR target 2.0–3.0; daily initial dose often ≤ 5 mg; lower dose for frail/old >70.

  • DOACs: dabigatran, rivaroxaban, edoxaban, apixaban; advantages include not needing INR monitoring; reversal agents available (idarucizumab for dabigatran; andexanet alfa for rivaroxaban/apixaban).

  • Vitamin K antagonist monitoring: INR monitoring schedule after initiation or dose changes; interactions with numerous drugs.

• Other AF management considerations:

  • Rate control: beta-blockers (e.g., metoprolol), non-DHP CCBs (diltiazem, verapamil), or digoxin.

  • Rhythm control: amiodarone for maintaining sinus rhythm; monitor for adverse effects (pulmonary toxicity, hepatic injury, thyroidism, visual issues, neuropathy).

  • Lifestyle: avoid stimulants; limit caffeine; alcohol moderation; treat underlying conditions.

• Complications: thromboembolism (stroke, PE), HF, angina; warfarin-associated intracerebral hemorrhage risk higher; DOACs often preferred in older adults due to lower intracranial bleeding risk.

• DOAC specifics and cautions: ensure adherence; not all patients are candidates (renal function, drug interactions); avoid in mechanical valves (current guidance).

Acute ST-Elevation Myocardial Infarction (STEMI) and Non-STEMI (NSTEMI)

• STEMI: hyperacute T waves; ST-segment elevation in contiguous leads; potential development of Q waves and T-wave inversions; tombstone appearance on wide QRS in V2–V4.

• NSTEMI: T-wave changes; ST depression; often no Q waves early; troponin may be elevated.

• Acute management considerations (from ACS context across notes): immediate evaluation, analgesia, antithrombotic therapy, revascularization as indicated.

Peripheral Vascular and Venous Conditions

• Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE): Virchow’s triad – stasis, hypercoagulability, endothelial injury.

• Risk factors for DVT: prior VTE, immobilization, surgery, cancer, pregnancy, estrogen therapy, long travel.

• Diagnostic approach: CBC, platelets, PT/PTT/INR, D-dimer, chest X-ray, ECG; Wells score; compression ultrasonography with Doppler.

• Treatment: outpatient vs inpatient depending on stability; anticoagulation with LMWH (enoxaparin) or heparin; transition to warfarin; or DOACs.

• Complications: PE, recurrent DVT, post-throke syndrome; stroke risk with emboli; recurrent embolic events possible.

• Ankle-Brachial Index (ABI): diagnostic for PAD.

  • Interpretation: ABI ≤ 0.9 indicates PAD; 0.91–1.3 generally excludes PAD.

  • Measurement protocol: rest 15–30 minutes; measure dorsalis pedis and posterior tibial pressures; measure brachial SBP; calculate ratio of higher ankle pressure to higher brachial SBP.

• PAD clinical course: intermittent claudication; progression to severe ischemia and possible ulcers or gangrene; skin changes; diminished pulses; bruits.

• Cilostazol (Pletal): phosphodiesterase inhibitor for symptomatic walking improvement; avoid grapefruit juice; can be combined with aspirin or clopidogrel.

• Revascularization: percutaneous angioplasty or surgical bypass when indicated.

Raynaud’s Phenomenon

• Vasospastic color change in fingers/toes with cold/emotional triggers.

• Classic color sequence: white (pallor) → blue (cyanosis) → red (reperfusion).

• Primary Raynaud’s: no autoimmune disease; secondary Raynaud’s associated with conditions like lupus or scleroderma.

• Management: avoid cold exposure and stimulants; maintain warmth; smoking cessation; stress management.

• Treatments: CCBs (nifedipine, amlodipine); alternative options include PDE-5 inhibitors, losartan, or fluoxetine.

• Avoid vasoconstrictive drugs (e.g., sumatriptan, ergots, pseudoephedrine).

• Tips: remember the color sequence with a flag mnemonic (American flag colors).

Superficial Thrombophlebitis

• Inflammation and thrombosis of superficial veins; risk factors include varicose veins, recent vein procedures, pregnancy, estrogen therapy, prior DVT, cancer, hypercoagulable states.

• Presentation: acute onset of indurated, warm, tender vein with surrounding erythema; often a palpable nodular cord.

• Management: NSAIDs, warm compresses, limb elevation; ultrasound to rule out DVT if suspected; anticoagulation decision based on risk.

Pulsus Paradoxus

• Definition: fall in systolic blood pressure > 10 mmHg during inspiration; classic sign of cardiac tamponade.

• Other causes: pulmonary and cardiac conditions that impair diastolic filling (e.g., asthma, COPD; pericarditis, effusion).

Miscellaneous: Additional Cardiac Concepts and Practical Pearls

• Vitamin K antagonist (Warfarin) notes:

  • FDA category X; teratogenic; monitor INR; interactions with many drugs and foods.

  • INR targets and monitoring schedules summarized in therapeutic guidelines.

• Echocardiography is a key diagnostic tool for many cardiac conditions (valvular disease, endocarditis, HF).

• Electrocardiography (ECG/EKG) key appearances to memorize for exams:

  • AF: irregularly irregular rhythm; no P waves.

  • Anterior STEMI: ST elevation in V2–V4.

  • Ventricular tachycardia: wide, irregular QRS complexes.

  • Normal sinus rhythm and sinus arrhythmia as common variants.

Summary of Key Guidelines and Practice Points (Condensed)

• Aneurysm and vascular:

  • AAA risk and imaging pathway; consider ultrasound first.

• ACS pathophysiology and initial management:

  • Aspirin for suspected ACS; EKG-first approach; promptly assess airway and circulation.

• Endocarditis:

  • Recognize classic skin signs; use TTE first line; prophylaxis for high-risk scenarios including dental procedures; IV antibiotics and specialist involvement.

• Heart failure:

  • EF-based classification; NYHA functional classification; management includes diuretics, RAAS blockade, beta-blockers, and consideration of ARNI in HFrEF; handle acute decompensation in ED.

• Murmurs and auscultation:

  • Master MR. PASS and MS. ARD mnemonics; know apex, aortic, and Erb’s point locations; grade murmurs; distinguish systolic vs diastolic.

• Arrhythmias:

  • AF/AFlutter management workflows including CHA2DS2-VASc scoring and anticoagulation strategies; DOACs vs warfarin.

• Hyperlipidemia:

  • ACC/AHA 2018 framework; statin intensity; when to add ezetimibe or PCSK9 inhibitors; CAC scoring as a risk modifier.

• Hypertension:

  • 2017 ACC/AHA stages and goals; emphasis on lifestyle modifications (DASH, sodium restriction, potassium intake); risk-based pharmacotherapy; ambulatory monitoring; hypertensive emergencies vs urgencies.

• Weight and metabolic health:

  • Obesity prevalence data, abdominal obesity thresholds; management through lifestyle modification and weight loss strategies; avoid unproven diets and procedures.

Key Quantitative References (LaTeX-formatted)

• LV ejection fraction categories:

  • EF \le 40\%\quad(HFrEF)

  • 41\% \le EF \le 49\%\quad(mid-range)

  • EF \ge 50\%\quad(HFpEF)

• CHA2DS2-VASc components (summary):

  • C: CHF, H: HTN, A: Age\;>\;75\%\, (2\text{ points}), D: Diabetes, S2: Stroke/TIA\,(2\text{ points}), V: Vascular disease, A: Age\;65-74, S: Sex\;female

• Anticoagulation targets:

  • Warfarin INR target: 2.0\le INR \le 3.0

  • If certain mechanical valves or high-risk features: 2.5\le INR \le 3.5

• ASCVD risk-based statin guidance (high-risk notes):

  • Very high risk ASCVD goal: LDL < 70\text{ mg/dL}

• Hypertension thresholds (2017 ACC/AHA):

  • Stage 1: \text{BP} = 130-139/80-89\text{ mmHg}

  • Stage 2: \text{BP} \ge 140/\ge 90\text{ mmHg}

• Triglyceride levels (risk thresholds):

  • Very high triglycerides: \text{TG} \ge 1000\text{ mg/dL}

• Ankle-Brachial Index (ABI) interpretation:

  • PAD if ABI \le 0.9; otherwise PAD unlikely if 0.91 \le ABI \le 1.3

• LV dysfunction and HFpEF/HFrEF summary: use guideline-directed medical therapy (GDMT) including diuretics, ACEI/ARB/ARNI, beta-blockers; SBP target < 130/80 mmHg in HF contexts.

• Systolic ejection murmur localization: AS best heard at the right 2nd ICS; MR best heard at the apex; AR/Erb’s point considerations depend on etiology.

Note: The above notes condense and organize the content from the transcript into a study-friendly, bullet-point format. Where numerical thresholds or pharmacologic regimens are given, they are represented with standard units and LaTeX formatting for precision.