Term
| What is the primary physiologic purpose of the heart? |
|
Definition
| CO, EF, compensatory mechanisms |
|
|
Term
| What happens during inspiration |
|
Definition
| Intrathoracic pressure is lowered; blood flow into chest is augmented; P2 is delayed (splitting of S2); R sided heart murmurs become louder |
|
|
Term
| What happens when the patient is standing? |
|
Definition
| Decreases heart size; accentuates murmurs of hypertrophic cardiomyopathy and mitral valve prolapse |
|
|
Term
| What reponse occurs in handgrip exercises |
|
Definition
| ^ BP & HR; accentuates AR,MR,& MS; decrease AS and hypertrophic cardiomyopathy |
|
|
Term
| What does Amyl Nitrate inhalation do? |
|
Definition
| reduces BP, increases stenosis murmurs, and decreases regurg murmurs |
|
|
Term
| Change in "a" wave indicates |
|
Definition
| change in atria associated with JVP |
|
|
Term
| What is pulsus Alternans? |
|
Definition
| Sign of failing ventricle; manifestation of decreased myocardial contractility; beat to beat variation in the pressure tracing using a Swan-Ganz cath |
|
|
Term
| What is Bisferiens pulse? |
|
Definition
| Combination of low rising and collapsing pulse occurring when aortic stenosis and incompetence are present |
|
|
Term
| What is pulsus Parvus et Tardus? |
|
Definition
| Small pulse with low pressure that rises and falls gradually; occurs in aortic stenosis |
|
|
Term
|
Definition
| Abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration |
|
|
Term
| What color tube do you use when drawing cardiac enzymes? |
|
Definition
|
|
Term
| What are the cardiac enzymes tested? |
|
Definition
| CK (CPK), Troponin T and I, Myoglobin, and Lactic Dehydrogenase (LD or LDH) |
|
|
Term
|
Definition
Heart, brain, and skeletal muscle, released in blood when muscle is damaged
CK-MB (heart); CK-BB (Brain); CK-MM (skeletal muscle) |
|
|
Term
| When does CK-MB appear with MI? |
|
Definition
serum withn 6-12 hours, peaks around 24hrs
nl in 3-4 days |
|
|
Term
|
Definition
| Unique to heart muscle and highly concentrated in cardiomyocytes |
|
|
Term
| when is troponin detectable |
|
Definition
serum in 1-3 hrs
stays for 14-15 days
Useful for the eval of small MI and later in the course of an MI |
|
|
Term
| Where is myoglobin found? |
|
Definition
| In striated muscle, damage to skeletal muscle or cardiac muscle releases myoglobin into circulation |
|
|
Term
| When is it myoglobin detectable? |
|
Definition
Rises fast (2 hours) after MI
Peaks at 6-8 hours
Normal in 20-36 hours |
|
|
Term
| Where is lactic dehydrogenase found? |
|
Definition
Heart muscle, skeletal muscle, liver, erythrocytes, kidney, neoplasms
Increased in over 90% of MI |
|
|
Term
| When is it LDH detectable? |
|
Definition
Begins to rise in 24 hours
Peaks in 3 days
Normal in 8-9 days |
|
|
Term
| What is the indication for chest xray? |
|
Definition
| To find info about the condition of the heart and lungs |
|
|
Term
| What is the indication for ambulatory cardiac monitoring? |
|
Definition
| Document suspected arrythmias, minor treatment effectiveness |
|
|
Term
| What is an echocaridiogram? |
|
Definition
| Noninvasive technique to examine the heart to provide info about its position, size, movement of valves, chambers, and velocity of blood flow |
|
|
Term
| What is the indication for an echo? |
|
Definition
| Suspected valve, chamber disturbances, eval of pericardial effusion |
|
|
Term
| What is the echo procedure? |
|
Definition
| Pt lies in left lateral decubitis, skin is lubricated with gel and transducer is held over various regions of the chest wall to obtain appropriate views of the heart |
|
|
Term
| What is Doppler ultrasound? |
|
Definition
Non-invasive test to evaluate a pt with calf pain, a + Homan’s sign, and the calf is
tender, warm and has modest swelling |
|
|
Term
|
Definition
| Measures the efficiency of the heart during a dynamic exercise stress period |
|
|
Term
| What are the indications for stress testing? |
|
Definition
| Suspicion of ischemia or physiologic mechanism underlying cardiac symptoms |
|
|
Term
| Describe the stress test procedure. |
|
Definition
Resting rhythm/echo pictures obtained
Pt put under stress either physiologic or pharmacologic
Stress rhythm/echo pictures obtained
Test ends when pt reaches max performance, develops S/S, or reaches a predetermined point |
|
|
Term
| What can the stress test findings tell you? |
|
Definition
| Both sets of data are compared to determine if abnormality is present and the extent of the disease process |
|
|
Term
| What are the complications as a result of stress test? |
|
Definition
|
|
Term
| When is a MRI of the heart indicated? |
|
Definition
| When it is necessary to examine the size and thickness of the chambers of the heart, and determine the extent of damage caused by a heart attack or progressive heart disease |
|
|
Term
| What is the MRI procedure? |
|
Definition
Patient is placed on table and asked not to move
Technician leaves the room but can communicate with the pt
Takes 15-30 minutes |
|
|
Term
| What is the caution for MRI? |
|
Definition
Watch for implanted devices
Generally avoided in first 12 weeks of pregnancy |
|
|
Term
| What is Multiple Gated Acquisition Scan (MUGA)? |
|
Definition
| Synchronized test using imaging equipment to assess the function of the heart |
|
|
Term
| What is Multiple Gated Acquisition Scan (MUGA)procedure? |
|
Definition
| Radiolabeled RBCs are injected into the patient, EKG signals camera to take images at different points in cardiac cycle |
|
|
Term
| What are the MUGA findings? |
|
Definition
| Gives info about cardiac output, ejection fraction, velocity and wall motion abnormalities |
|
|
Term
| What is the indication of tilt table testing? |
|
Definition
| To identify cause of syncope |
|
|
Term
| What is the tilt table procedure? |
|
Definition
Pt is hooked up to EKG and BP cuff
Keep pt at 60-80 degrees for 20-60 minutes
Monitor for symptoms and change in HR and BP
May involve injection of isoproterenol |
|
|
Term
| What do the tilt table findings tell you? |
|
Definition
| If the pt exhibits syncope during these maneuvers, it is assessed to be neural mediated and not cardiogenic |
|
|
Term
| What do electrophysiologic studies do? |
|
Definition
| Allows analyzation of EKG in different areas of the conduction |
|
|
Term
| What is the indication for electrophysiologic studies? |
|
Definition
| To detect and analyze arrhythmias and their origins |
|
|
Term
| What is the electrophysiologic studies procedure? |
|
Definition
Catheter with electrode is placed into R atrium and Ventricle
Recording and stimulation takes place to ID arrhythmias and exact location or origin |
|
|
Term
| What do the electrophysiologic findings tell you? |
|
Definition
| Helps to differentiate different arrhythmias and efficacy of therapy |
|
|
Term
|
Definition
| Invasive testing to assess pt hemodynamics and perform coronary angiography |
|
|
Term
| What is the indication for a cardiac cath? |
|
Definition
| Suspected MI and/or valvular abnormalities |
|
|
Term
| What is the procedure of a cardiac cath? |
|
Definition
| Catheter placed into coronary vessels and chambers while pressures are measured and fluoroscopy takes pictures |
|
|
Term
| What are the complications of a cardiac cath? |
|
Definition
| Bleeding; hematoma; arrhythmias, MI, CVA |
|
|
Term
| What is the best test to obtain info on pts with PVD? |
|
Definition
|
|
Term
| What is a Swann-Ganz cath? |
|
Definition
| Hemodynamic monitoring device |
|
|
Term
| What are the indications for a Swan-Ganz? |
|
Definition
| Diagnosis shock, monitor hemodynamics in critically ill pts |
|
|
Term
| What is the procedure for a Swan-Ganz? |
|
Definition
Under sterile technique, insert catheter into L subclavian or R internal jugular veins; through R atrium and ventricle into pulmonary artery
PCWP = LAP = LVEDP |
|
|
Term
| What are the complications in a Swan-Ganz? |
|
Definition
|
|
Term
|
Definition
| Causes obstruction to forward flow causing an increased pressure in the ventricle |
|
|
Term
|
Definition
| backward flow which causes a volume overload on the heart |
|
|
Term
| Which are benign murmurs? |
|
Definition
Early to midsystolic
Soft (I-II/VI)
Vary with respiration
Normal with exam and workup |
|
|
Term
| Which are pathologic murmurs? |
|
Definition
All diastolic murmurs
All pansystolic murmurs
Late systolic murmurs
Very loud murmurs
Continuous murmurs |
|
|
Term
| What are some clues to ID benign murmurs? |
|
Definition
Absence of associated symptoms
Absence of family hx
Assoc with normal, physiologic splitting of S2; absence of other abnormal heart sounds
Early to midsystolic
Crescendo-decrescendo murmur
Normal BP, pulse contour, electrocardiography, precordial exam
Often heard best or pulmonic area or mid-left sternal border
Soft murmur (grade 1 or 2) |
|
|
Term
| What are some clues to ID pathologic murmurs? |
|
Definition
Assoc arrhythmia
Assoc L ventricular apical or R ventricular parasternal heave
Assoc with abnormal jugular venous pulse; wide pulse pressure; or brisk, rapidly rising pulse or weak, slowly rising pulse
Change in intensity with physiologic maneuvers (especially if murmur becomes louder with valsalva or squat-to-stand maneuvers)
Diastolic murmur
Family hx of sudden death or cardiac disease
Long duration (mid or late peak or holosystolic murmur)
Loud murmur (grade 3 or more)
Other abnormal heart sounds (loud S1, fixed or paradoxically split S2, midsystolic click)
Presence of assoc symptoms (CP, dyspnea on exertion ,syncope
Radiation to axilla or carotids |
|
|
Term
|
Definition
| Very soft, only detected after very careful auscultation |
|
|
Term
|
Definition
| Soft murmur that is readily evident |
|
|
Term
|
Definition
| Moderately intense murmur not associated with palpable precordial thrill (vibration |
|
|
Term
|
Definition
| Loud; palpable precordial thrill is not present or is intermittent |
|
|
Term
|
Definition
| Loud; assoc with a palpable precordial thrill; the murmur is not audible when the stethoscope is lifted from the thoracic body wall |
|
|
Term
|
Definition
| Loud; assoc with a palpable precordial thrill and audible even when the stethoscope is lifted from the thoracic wall |
|
|
Term
| What is aortic stenosis in the bicuspid valves? |
|
Definition
Congenital abnormality; affects 1% of population
1/3 are stenotic; 1/3 are regurgitant; the remainder cause only minor hemodynamic abnormalities
Symptoms usually develop when pt is 40-60 |
|
|
Term
| What is aortic stenosis in the tricuspid valves? |
|
Definition
Thickening and calcification develops from an inflammatory process similar to coronary heart disease
Symptoms develop in 60-80
Angina; syncope; and heart failure are classic symptoms |
|
|
Term
| What is the etiology of aortic stenosis? |
|
Definition
Normal valvular area is 3-4 cm
Pressure gradient develops when valvular area is reduced to 1/3 normal
LVH occurs as a compensatory response to increased pressure gradient
LVH maintains CO and preserve EF |
|
|
Term
|
Definition
| Symptoms occur due to limited coronary blood flow reserve or due to inadequate hypertrophy allowing increased wall stress and O2 consumption to increase |
|
|
Term
|
Definition
In aortic stenosis syncope is due to exertion
Exertion causes a fall in total PR that cannot be compensated by increased CO
CO is limited by the obstruction to L ventricular flow
Reduced systemic BP and cerebral perfusion causes syncope |
|
|
Term
|
Definition
Contractile dysfunction (systolic failure) and failure of normal relaxation (diastolic failure) both occur
Contractility is reduced – excessive afterload inhibits ejection
Increased wall thickness increases diastolic stiffness; higher pressures decrease relaxation
Increased collagen deposition also stiffens the myocardium and adds to diastolic dysfunction |
|
|
Term
| What does your PE show with aortic stenosis? |
|
Definition
Systolic ejection murmur
Loudest in aortic area and radiates to neck
Apical impulse is enlarged and are forceful
S1 usually normal
S2 may be single or split
S4 gallop is common
Signs of R sided heart failure are common |
|
|
Term
| What diagnostic testing can be done for aortic stenosis? |
|
Definition
ECK shows signs of LVH and LAA
Chest x-ray shows a boot shaped heart
May see calcification of aortic valve and/or cardiomegaly
Echocardiography is indispensible to asses extent of LVH; systolic ejection performance; aortic valve anatomy
Cardiac cath to determine extent of CAD prior to surgery |
|
|
Term
| What is the treatment for aortic stenosis? |
|
Definition
Antibiotic prophylaxis to prevent bacterial endocarditis
Balloon aortic valvotomy relative ineffective and is only palliative in cases where replacement is not possible due to comorbidity
Valve replacement is only proven treatment |
|
|
Term
| What are the aortic leaflet abnormalities? |
|
Definition
Bicuspid aortic valve
Infective endocarditis – most common
Rheumatic heart disease
Anorexigenic drugs |
|
|
Term
| What are the aortic root abnormalities? |
|
Definition
Marfan syndrome
HTN – induced annuloaortic ectasia
Aortic dissection
Syphilis
Ankylosing spondylitis
Psoriatic arthritis |
|
|
Term
| What is aortic regurgitation? |
|
Definition
Volume overload on L ventricle
L ventricle is pumping forward flow from L atrium and the regurgitant volume from the aorta
Resultant cardiac hypertrophy compensates for volume overload |
|
|
Term
| What are the clinical manifestations of aortic regurgitation? |
|
Definition
Consistent with L heart failure
Dyspnea on exertion (DOE)
Orthopnea
Fatigue
Less commonly angina |
|
|
Term
| What are the clinical manifestations of aortic regurgitation? |
|
Definition
Consistent with L heart failure
Dyspnea on exertion (DOE)
Orthopnea
Fatigue
Less commonly angina |
|
|
Term
| What do you find on PE with aortic regurg? |
|
Definition
Hyperactive impulse on palpation of the precordium
Displacement of PMI down and L
Diastolic blowing murmur following S2, best heard along L sternal border |
|
|
Term
| What are the noninvasive methods in evaluation of aortic regurg? |
|
Definition
ECK – non specific but almost always shows LVH
CXR – enlarged heart with enlargement of aortic root
Echo – most important for assessing severity of aortic insufficiency and its impact on LV geometry and function; color flow Doppler provides most info |
|
|
Term
| What is the treatment of aortic regurg? |
|
Definition
Treat asymptomatic pts with nifidipine and other vasodilators such as ACE inhibitors and hydralazine to reduce afterload.
Symptomatic pts should undergo surgical treatment with valve repair or most commonly valve replacement |
|
|
Term
|
Definition
Usually the cause is rheumatic fever- occasionally severe calcification of the mitral annulus can lead to mitral stenosis in the absence of rheumatic involvement; 3x more common in women; usually in 40-50; rarely seen in
developed countries
obstruction to L ventricle filling increases the L atrial pressure and produces a persistent pressure gradient between the L atrium and the L ventricle
increased L atrial pressure and the restricted flow into the L ventricle cause a decrease in CO |
|
|
Term
| What are the signs of mitral stenosis? |
|
Definition
1/3 of pts have decreased EF due to decreased preload (inflow obstruction) and increased afterload as a result of reflex vasoconstriction
As mitral stenosis worsens, RV failure develops as a result of pressure overload |
|
|
Term
| What may your history look like in mitral stenosis? |
|
Definition
Asymptomatic until valve area is reduced to 1/3 normal size
Symptoms lf LV failure – DOE, orthopnea, and PND
Hemoptysis is common
If RV failure occurs, ascites and edema are common |
|
|
Term
| What should PE find in a mitral stenosis? |
|
Definition
Palpation of precordium reveals a quiet apical impulse
Parasternal life may be present if pulmonary HTN and RV HTN are present
Loud S1, S2 is followed by an opening snap
No S3 or S4
Murmur follows opening snap and is low pitched early diastolic mitral stenosis rumble |
|
|
Term
| What noninvasive methods of eval can be used in mitral stenosis? |
|
Definition
ECG – a-fib is common
If pulmonary HTN has developed there is often evidence of RVH
CXR – L atrial enlargement produces straightening of the L heart border; double density of the R heart border may be present as a result of combined silhouettes of R & L atrium
Echo – transthoracic or transesophageal makes diagnosis nearly 100% of time; produces excellent images of mitral valve; most important in making diagnosis |
|
|
Term
| What are the invasive methods of eval can be used in mitral stenosis? |
|
Definition
Cardiac cath – usually unnecessary to assess the severity of mitral stenosis
Many pts are of the age when coronary disease may be present; if surgery is anticipated or if there is coexistent angina a R & L cath should be performed |
|
|
Term
| How can it be mitral stenosis prevented? |
|
Definition
| Appropriate use of antibiotic treatment of B hemolytic strep infections |
|
|
Term
| What is the treatment for mitral stenosis? |
|
Definition
Asymptomatic pts do not require therapy
Symptoms of mild dyspnea and orthopnea can be treated with diuretics alone
A-fib and other arrhythmias must be controlled
Anticoagulation to a target INR of 2.5-3.5
Balloon valvotomy or complete valve replacement |
|
|
Term
| What are the causes of mitral regurgitation? |
|
Definition
Mitral valve prolapse – most common cause in US (2/3)
MI which leads to papillary muscle dysfunction or infarction (1/4)
Annular calcification, endocarditis, collagen vascular disease, rheumatic heart disease |
|
|
Term
| What is the pathophys in mitral regurg? |
|
Definition
Regurgitant and forward flow cause volume overload of L ventricle
Decreased SV due to regurgitant flow into L atrium
Increased L atrial pressure causes pulmonary congestion
Overall result is decreased CO and heart failure |
|
|
Term
| How is mitral regurg diagnosed? |
|
Definition
Investigate cause and symptoms of L heart failure (rheumatic heart disease, endocarditis, MI)
Thorough H & P |
|
|
Term
| What should you find on PE in mitral regurg |
|
Definition
Apical impulse displaced down and L
S1 may be softer; S2 usually physiologically split; S2 followed by S3
Murmur is a holosystolic apical murmur that radiates to the axilla |
|
|
Term
| What are the noninvasive evaluation techniques for mitral regurg? |
|
Definition
ECG – LVH and L atrial abnormality
CXR – cardiomegaly
U/S – determine extent of mitral valve damage
Doppler Echo – most info about extent of damage and flow abnormality |
|
|
Term
| What is the treatment for mitral regurg? |
|
Definition
| Surgical repair/replacement of valve |
|
|
Term
| What is mitral valve prolapse? |
|
Definition
Occurs when one or both leaflets prolapse into the L atrium superior to the mitral valve annular plane during systole
Symptoms are variable from pt to pt depending on the amount of damage to the valve |
|
|
Term
| How is mitral valve prolapse diagnosed? |
|
Definition
Most pts are asymptomatic
Symptoms typically include: palpitations, syncope, CP |
|
|
Term
| What should you find on PE in mitral valve prolapse? |
|
Definition
Mid systolic click and late systolic murmur
Valsalva maneuver causes the click to occur earlier and the murmur to be more holosystolic and louder |
|
|
Term
|
Definition
| As with other valvular abnormalities; echo is best |
|
|
Term
|
Definition
| As with other valvular abnormalities; echo is best |
|
|
Term
| What is the treatment of MVP? |
|
Definition
Most pts only need to observe standard endocarditis prophylaxis
B-blockers help relieve symptoms of palpitations
Low dose ASA (81 mg) recommended for pts with redundant leaflets to reduce risk of CVA |
|
|
Term
| What is pulmonic stenosis? |
|
Definition
Congenital disease resulting from the fusion of the pulmonic valve cusps
Usually detected and treated in childhood
Symptoms of R sided heart failure develop
Echo confirms diagnosis
Pressure gradient < 25 mm HG, no treatment
Pressure gradient > 50 mm Hg or symptoms develop; valve ballon commissurotomy is effective treatment |
|
|
Term
| What is tricuspid regurgitation TCR? |
|
Definition
Usually caused by a hemodynamic load on the R ventricle, rather than a structure valve deformity
Anything that increases L ventricular filling pressure will increase R ventricular load |
|
|
Term
| What is the most common cause of TCR? |
|
Definition
|
|
Term
| What are the other causes of TCR? |
|
Definition
Carcinoid syndrome
Rheumatic involvement of tricuspid valve
Myxomatous degeneration
RV infarct
Mishaps during endomyocardial biopsy |
|
|
Term
|
Definition
Symptoms of R sided heart failure: ascites, edema, RUQ
PE: JVD, hepatic enlargement, liver pulsations, parasternal lift
Echo – method of choice for definitive diagnosis |
|
|
Term
|
Definition
If cause is LV failure – treatment toward LV failure (DOE, orthopnea, fatigue, edema, dyspnea)
If cause is pulmonary disease – treatment towards improving lung function
Treatment usually medical in nature
Surgical treatment not usually required but could be valve repair rather than replacement |
|
|
Term
| Define Infective Endocarditis |
|
Definition
Vegetations usually affecting the valves
Nonbacterial (marantic) endocarditis |
|
|
Term
| How is infective carditis classified? |
|
Definition
Clinical course Host (native valve vs prosthetic vs IVDU)
Infectious organism |
|
|
Term
| What is the epidemiology of infective endo? |
|
Definition
Community acquired
IV drug users
Preexisting valvular heart disease (prosthetic valves; AS, AI, MR, MVP)
Indwelling catheters
Congenital heart disease
Increasing S. aureus prevalence, especially in tertiary care centers |
|
|
Term
| What is the pathogenesis of infective card? |
|
Definition
Endocardial surface injury
Thrombus formation
Bacteremia
Bacterial adherence |
|
|
Term
|
Definition
Local destruction
Embolization
Hematogenous seeding
Immune injury |
|
|
Term
| What is subacute bacterial endocarditis? |
|
Definition
Develops gradually over a period of weeks to months
Usually affects an already damaged heart: congenital heart conditions, prosthetic valves, rheumatic heart disease
Most common cause – Strep viridans |
|
|
Term
| What is acute bacterial endocarditis? |
|
Definition
Develops rapidly causing significant valve damage
Occurs in patients with normal hearts as well as already damaged hearts: drug abusers, prosthetic valves, septic conditions
Most common cause Staph aureus |
|
|
Term
| What is the course of the acute bacterial endo? |
|
Definition
Organism travels in the bloodstream and attach to the endocardial lining of a normal heart or to the area of defect of an abnormal heart
The organisms enmesh in deposits of fibrin and platelets and create vegetations which settle on the valves
These vegetations prevent complete closure of the valve, leading to new onset of a valvular murmur
As vegetations grow they break off and embolize into the systemic and cerebral circulation |
|
|
Term
| What are the symptoms of acute bacterial endo? |
|
Definition
Fever
Chills
Sweats
Anorexia
Weight loss
Malaise
Cough
H/A
Muscle aches |
|
|
Term
| Signs of acute bact. endo |
|
Definition
Fever
Pallor
Heart murmur
Petechiae
Subungual “splinter” hemorrhages
Osler’s nodes (small tender nodules on the finger and toes)
Janeway lesions (small hemorrhages on the palms and soles)
Splenomegaly |
|
|
Term
| What will you find with diagnostic studies in acute bact. endo.? |
|
Definition
Leukocytosis
Hematuria
Positive blood cultures – should be obtained every 24-48 hours for 7-10 days
Echo – useful to detect vegetations on valve leaflets |
|
|
Term
| What are the major Duke criteria? |
|
Definition
2 positive blood cultures
Evidence on echo of vegetations; abscess; dehiscence of a prosthetic valve |
|
|
Term
| What are the minor Duke criteria? |
|
Definition
Predisposing condition
Fever > 38 C
Immunologic signs (glomerulonephritis, Osler’s nodes, Roth spots, rheumatoid factor)
1 positive blood culture
Positive echo not meeting major criteria |
|
|
Term
| What is diagnostic using Duke criteria? |
|
Definition
| 2 major; 1 major and 3 minor; 5 minor |
|
|
Term
|
Definition
Empirical regimen until blood culture results are final
Nafcillin 1.5 g q4 plus PCN 2-3 million units q4 plus gentamycin 1 mg/kg q8
Give vanco 15 mg/kg q 12 x 4 weeks for PCN allergy
Streptococci:PCN G 2-3 million units IV q4 x 4 weeks
Cefriazone 2 g qd IV or IM x 4 weeks
Enterococci:
PCN with streptomycin or gentamycin
Staphylococci:Naficillin or oxicillin |
|
|
Term
| What are the complications of asute bact. endo. |
|
Definition
Valvular dysfunction
Abscess formation
Peripheral embolization |
|
|
Term
| How can acute bact. endo. be prevented? |
|
Definition
| Prophylactic antibiotics should be given to patients with predisposing congenital or valvular abnormalities who undergo invasive procedures |
|
|
Term
| Which pt’s are at highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is reasonable? |
|
Definition
| Prosthetic cardiac valve or prosthetic material for valve repair; previous infective endocarditits; CHD (unrepaired cyanotic CHD including palliative shunts and conduits; completely repaired CHD with prosthetic material or device whether by surgery or cath within 6 months; repaired CHD with residual defects at the site or adjacent to the site of the prosthectic patch or device); cardiac transplant pts who develop cardiac valvulopathy |
|
|
Term
| When is antibiotic prophylaxis reasonable? |
|
Definition
For all dental procedures that involve manipulation of gingival tissue or periapical region of teeth or perforation of oral mucosa, but only for pts with underlying cardiac conditions
For procedures on the respiratory tract or infected skin, skin sutures, or musculoskeletal tissue only for pts with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis |
|
|
Term
| For which procedures is prophylaxis not recommended? |
|
Definition
Dental procedures: anesthetic injection through non-infected tissues; dental x-rays; placement, adjustment, or removal of orthodontic or prosthodontic applicancs; shedding of deciduous teeth; bleeding from trauma to the lips and oral
Mucosa
GI procedures: endoscopy of the upper GI and colonoscopy
GU procedures: cystoscopy, hysterectomy, vaginal delivery
Tattooing |
|
|
Term
|
Definition
| Blood clot that forms inside a blood vessel or cavity of the heart |
|
|
Term
|
Definition
| Blood clot that moves through the bloodstream until it lodges in a narrowed vessel and blocks circulation |
|
|
Term
| What are the risk factors for thrombus/embolus? |
|
Definition
A-fib
Hx of PE/DVT
Post-op lower extremity surgery
OC
Blunt trauma
Hypercoaguable states
Obese
Sedentary |
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Term
| What does thrombus formation depend on? |
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Definition
Blood stasis
Blood coagulation
Change in vessel wall |
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Term
| What does an anticoagulant do? |
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Definition
| Inhibits blood coagulation |
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Term
| What does an antithrombotic do? |
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Definition
| Inhibits platelet aggregation |
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Term
| What does a thrombolytic agent do? |
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Definition
| Degrade clots that have already formed |
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Term
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Definition
Aka Lovenox (LMWH)
Anticoagulant
Binds to antithrombin III, inhibiting Factor Xa which inhibits formation of thrombin |
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Term
| What are the indications for heparin use? |
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Definition
| Prevent DVT/PE, immediate anticoagulation |
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Term
| What is the dosage of heparin? |
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Definition
| IV (bolus then maintenance) 80 U/kg bolus then 18 U/kg/hr or SQ (5,000 U q 12) |
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Term
| How should you monitor the levels of heparin |
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Definition
| aPTT q 4-6 hours until therapeutic |
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Term
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Definition
Bleeding
Thrombocytopenia |
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Term
| What is the treatment for heparin OD? |
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Definition
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Term
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Definition
Aka Coumadin
Anticoagulant
Antagonize Vit K, inhibits Vit K dependent factors (II, VII, IX, X) |
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Term
| What are the indications for Coumadin use? |
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Definition
DVT
Long term anticoagulation therapy (post MI, mechanical valves, A-fib) |
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Term
| What is the dosage for coumadin? |
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Definition
| 5 mg daily for 4-6 days then adjust to therapeutic levels |
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Term
| How do you monitor the levels of coumadin? |
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Definition
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Term
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Definition
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Term
| What is the treatment for Coumadin OD |
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Definition
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Term
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Definition
Antithrobotic
Prevents formation of thromboxane A2 and prostaglandins which inhibits platelet aggregations |
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Term
| What are the indications for ASA use? |
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Definition
| Hx or risk of TIA, MI, CVA |
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Term
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Definition
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Term
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Definition
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Term
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Definition
Aka Ticlid
Antithrombotic
Blocks platelet binding to fibrogen |
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Term
| What are the indications for Ticlopidine use? |
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Definition
| Hx of CVA or MI, prescribed post cardiac intervention |
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Term
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Definition
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Term
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Definition
Bleeding
GI upset
Neutropenia
Abnormal LFTs |
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Term
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Definition
Plavix
Antithrombotic
Blocks platelet binding to fibrogen |
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Term
| What is the indication for plavix use |
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Definition
| Hx of CVA or MI; prescribed post cardiac intervention |
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Term
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Definition
| 75 mg qd, may give 300 mg loading dose |
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Term
| What are the complications of plavix? |
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Definition
Bleeding
GI upset
Abnormal LFTs |
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Term
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Definition
Aggrastat
Antithrombotic
Antagonist of the platelet glycoprotein IIa/IIb, inhibits platelet aggregation |
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Term
| What are the indications for Tirofiban use |
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Definition
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Term
| What is the route for Tirofiban? |
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Definition
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Term
| What are the complications of tirofiban? |
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Definition
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Term
| What is a similar medto tirofiban? |
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Definition
| Eptifibatide (integrilin) |
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Term
| What questions do you need to ask when evaluating for congenital heart disease in the adult? |
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Definition
Is the pt cyanotic?
Is pulmonary arterial blood flow increased?
Does the malformation originate on the L or R side of the heart?
Which is the dominant ventricle?
Is pulmonary HTN present? |
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Term
| What are the abnormalities associated with a L R shunt? |
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Definition
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Term
| What develops with acyanotic pt’s with LR shunts? |
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Definition
| Reversal of the shunt (now RL) along with pulmonary vascular occlusive disease – Eisenmenger Syndrome |
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Term
| What are the clinical features of Eisenmenger’s syndrome |
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Definition
Consequences of chronic cyanosis
Disappearance of murmurs
Clubbing
SOB |
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Term
| What is the therapyof Eisenmenger’s syndrome ? |
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Definition
Limited
Activity limitations
Phlebotomy
Endocarditis prophylaxis
Surgery – best option is heart/lung transplant
Poor prognosis |
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Term
| What are the acyanotic congenital heart diseases without a shunt? |
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Definition
Valvular – congenital aortic stenosis (valvular, subvalvular, supravalvular)
Coarctation of the aorta |
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Term
| What are the cyanotic diseases that have decreased pulmonary blood flow (RL)? |
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Definition
Tetralogy of Fallot
Tricuspid atresia
Ebstein anomaly
Pulmonary atresia |
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Term
| What are the cyanotic diseases with increased pulmonary blood flow (LR) |
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Definition
Persistent truncus arteriosus
Transposition of the great arteries w/without VSD or PDA
Total anomalous venous return
Single or common ventricle
Hypoplastic left heart syndrome |
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Term
| Describe the fetal and transitional circulations at birth |
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Definition
Inflation of lungs produces a dramatic drop in pulmonary vasculature
Blood from IVC and SVC flows into RV and is ejected into pulmonary artery
Increased LA blood volume results in increased LA pressure and closure of foramen ovale (bradykinin)
Increased PaO2 and changes in local prostaglandin production results in constriction of ductus arteriosus (functional closure in 72 hours; anatomic closure in 4-8 weeks) |
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Term
| What is Ebstein’s anomaly? |
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Definition
“atrialized” RV (R atria is enlarged, making the RV very small
May have RL shunt
Associated with ASD or PFO and WPW |
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Term
| What is the pathophys of ebsteins? |
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Definition
Related to degree of tricuspid valve displacement
EKG has R axis deviation |
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Term
| What is the treatment for ebsteins anomaly? |
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Definition
Endocarditis prophylaxis
Possible surgical repair |
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Term
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Definition
Most often 2ndary to bicuspid aortic valve
Up to 20% of affected persons have associated cardiovascular abnormalities (PDA, coarctation of aorta)
Most affected persons develop symptoms during 5th and 6th decades |
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Term
| What are the symptoms of valvular AS |
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Definition
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Term
| complications of valvular AS? |
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Definition
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Term
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Definition
Often first diagnosed in adulthood
Characterized by a discrete fibrous diaphragm encircling the LV outflow tract
Outflow murmur but no systolic ejection click |
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Term
| Describe Supravalvular AS |
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Definition
Characterized by variable degrees of ascending aortic root stricture
Usually diagnosed in childhood and associated with hypercalcemia and multiple skeletal, vascular and developmental abnormalities |
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Term
| Describe coarctation of the aorta |
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Definition
Fibrotic narrowing of the aortic lumen, usually distal to the L subclavian artery
25% have associated bicuspid valve
Most common extra-cardiac abnormality is aneurysm of the circle of Willis
Most remain undiagnosed until adulthood, when they have a workup for HTN |
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Term
| What does the obstruction LV outflow cause? |
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Definition
Rise in BP in proximal aorta and great vessels relative to distal aorta and lower extremities
LVH develops to maintain SV in face of increased afterload |
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Term
| complications of LV outflow |
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Definition
Untreated, 2/3 will develop CHF by 4th decade
Aortic dissection or rupture
CVA
Endocarditis |
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Term
| What does PE reveal in LV outflow |
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Definition
Forceful carotid and upper extremity pulses with weak and delayed lower extremity pulses
Ejection murmur if bicuspid AV present
Systolic murmur originating from the coarctation typically heard over L upper back |
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Term
| How is obstruction LV outflow diagnosed? |
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Definition
In infants and children – 2D echo and Doppler
What iIn adults – MRI and cardiac cath preferred |
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Term
| What's tx for obstr.Lv outflow |
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Definition
Surgical repair recommended in adults, although only 50% become normotensive
SBE (sub-acute bacterial endocarditis) prophylaxis recommended |
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Term
| What is tetralogy of Fallot? |
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Definition
| Most common cyanotic congenital heart lesion in adults |
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Term
| What are the 4 components of Tetraloy of Fallot |
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Definition
RV outflow obstruction secondary to pulmonic valve or infundibular stenosis
Membranous VSD
Overriding aorta across the VSD
RVH |
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Term
| What determines the severity of RL shunt? |
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Definition
Severity RV outflow obstruction?
Mild – shunting is minimal and patient relatively acyanotic (pink tetralogy)
Cyanosis worsens with exercise as SVR falls |
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Term
| complications of Tetralogy of Fallot? |
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Definition
Severe erythrocytosis
Paradoxical emboli
SBE
Ventricular arrhythmias – due to stretching |
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Term
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Definition
Surgical correction usually performed in infancy or childhood
SBE prophylaxis |
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Term
| What are the 4 types of ASD? |
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Definition
Ostium secundum defects involve fossa ovalis (most common)
Ostium primum defects involve AV junction
Sinus venosus defects involve superior septum
Female:male 3:1
Inferior Vena cava |
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Term
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Definition
asymp. until adult
sx's are 2° to RV dys.(fatigue,dsypnea)
A-fib common in ASD(ALWAYS check for ASD in new A-fib onset) |
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Term
| What may you find on PE in ASD? |
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Definition
Wide & fixed S2 split
RV heave
Pulm. mid-syst. flow thru the R side valves from aL-R shunt
Absence of nl sinus rhythm |
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Term
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Definition
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Term
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Definition
surgical closure w/ large defects
OSD may be closed percutaneously |
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Term
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Definition
Rarely encountered in adults: 50% spontaneously during childhood; most large defects are surgically correct at an early age
Oxygenated blood from the LV is shunted through the VSD into the RV (LR shunt)
If defect large, RV dilates and pulmonary blood flow increases (if uncorrected, pulmonary vasculature obstruction Eisenmenger’s complex RL shunt) |
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Term
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Definition
location w/in IVS
membranous/muscular IVS VSDS
AV canal VSDS(common in Down's,asso. w/ OSD ASD |
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Term
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Definition
hyperdynamic precordium (heaves,lifts,thrills)
holosystolic L parasternal murmur w/ thrill |
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Term
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Definition
2D echo & doppler
Cardiac cath necessary before surgical repair to document severity of shunt and determine PAP and PVR
Pts with Eisenmenger’s are not surgical candidates (heart-lung transplant)
Closure of VSD indicated with LR shunt > 2:1 without irreversible pulmonary HTN |
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Term
| Where is Patent Ductus Arteriosus(PDA) seen? |
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Definition
premies
asso. w/ Coarc. & VSD |
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Term
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Definition
| Arterial duct that connects the aorta and pulmonary artery during fetal life fails to close with 24-48 hours |
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Term
| What are hemodynamic consequences of PDA? |
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Definition
Consequences depend on size of ductus
Large ductus – LV volume overload and pulmonary vascular congestion result
Persistent – pulmonary vascular obstruction with Eisenmenger’s complex may develop |
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Term
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Definition
Loud, continuous machinery-like murmur in L infraclavicular region
Differential cyanosis with LE cyanosis and clubbing of toes more the UE |
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Term
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Definition
Confirmed by 2D echo and Doppler
Cardiac cath to confirm and exclude irreversible pulmonary vascular obstruction |
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Term
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Definition
Surgical closure unless irreversible pulmonary HTN
SBE prophylaxis |
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Term
| What is Acute Rheumatic Fever (ARF)? |
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Definition
Post infections inflammatory disease
Follows group A strep pharyngitis
Unknown if caused by AI or toxin
No single symptom makes the diagnosis |
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Term
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Definition
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules |
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Term
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Definition
Arthralgias
Fever
Eleveated ESR or C-reactive protein
Prolonged PR interval
Prior hx of ARF or RHD |
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Term
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Definition
Children > adults
Varying course
Undetected in vast majority |
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Term
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Definition
Appearance of/change in organic murmur
Definite increase in heart size
Pericardial friction rub or effusion
Signs of CHF |
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Term
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Definition
Endocardium-endocarditis
Myocardium – aschoff body
Pericardium - pericarditis |
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Term
| What is the Jones criteria? |
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Definition
| Firm diagnosis requires 2 major or 1 major and 2 minor criteria in addition to the evidence of recent strep infection |
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Term
| What are the criteria of carditis? |
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Definition
All layers of cardiac tissue are affected
New or changing murmur: mitral regurgitation the most common, followed by aortic insufficiency |
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Term
| What is criteria of polyarthritis |
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Definition
Migrating arthritis that typically affects the knees, ankles, elbows, wrists
Joints are very painful and symptoms are very responsive to anti-inflammatory meds |
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Term
| What are the criteria of chorea? |
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Definition
Aka Syndenham’s chorea or St. Vitus’ dance
Abrupt purposeless movements
May be the only manifestation of ARF and its presence is diagnostic
May also include emotional disturbances and inappropriate behavior |
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Term
| What are the criteria of erythema marginatum? |
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Definition
Non-pruritic rash that commonly affects the trunk and proximal extremities, but spares the face
Rash typically migrates from central areas to periphery, well-defined borders
Nonindurated, blanches on pressure, clear centers |
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Term
| What are the criteria for subcutaneous nodules? |
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Definition
Usually located over bones or tendons, these are painless and firm
Characteristically on: extensor tendons of hands, scalp, scapulae, spinous processes
Pea sized |
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Term
| What is the epidemiology of ARF? |
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Definition
Most common 5-15 y/o
Morbidity and mortality decreased in last 30 years but may be significant in undeveloped areas
Increased incidence among Pacific ancestry and Polynesians |
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Term
| what is the attack of ARF |
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Definition
After Group A pharyngitis: 3% epidemic, 0.3% endemic
10% chronic recurrence with repeated Group A strep infections |
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Term
| What are the lab findings in ARF? |
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Definition
Strep antibody titers: ASO (antistreptolysin O), Anti-DNase B, AH (antihyaluronidase), ASTZ (antistreptozyme)
Isolation of group A strep
Acute phase reactants
Best diagnosed by echo |
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Term
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Definition
75% subside in 6 weeks
90% subside in 12 weeks
<5% persist for more than 6 months |
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Term
| What is the prognosis for chronic cases of RF? |
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Definition
Mitral valve affected most commonly
4% develop mitral stenosis
Addition 25% with AS or AR along with MS |
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Term
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Definition
Determine portal of entry and treat
Acute therapy and primary prevention: antibiotics (PCN, can sub macrolides or cephalosporins if PCN allergy); anti-inflammatory (ASA, prednisone)
Secondary prevention of recurrences: monthly PCN shots, duration of prophylaxis uncertain
Prior hx of RF is no longer an independent indication for antibiotic prophylaxis against endocarditis infection |
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Term
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Definition
| Pulmonary Artery (Swan-Ganz) Cath |
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Term
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Definition
Stroke volume – preload, afterload, contractility
HR |
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Term
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Definition
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Term
| What are the determinants of preload? |
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Definition
| Total blood volume, distribution of blood volume, atrial contraction, compliance |
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Term
| What is afterload dependent on? |
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Definition
| Aortic pressure, volume of ventricle cavity/thickness of ventricular wall |
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Term
| What factors affect ventricular performance? |
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Definition
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Term
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Definition
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Term
|
Definition
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Term
| What compensatory mechanisms increase CO? |
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Definition
Acute: Frank-Starling, Sympathetic Stimulation
Chronic: Ventricular Hypertrophy, Ventricular Dilatation |
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Term
| What is Frank-Starling Law? |
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Definition
Greater the volume of blood entering the heart during diastole (EDV), the greater the volume of blood ejected during systolic contraction (SV)
Allows the CO to be synchronized with venous return, arterial blood supply, and humeral length without depending upon external regulation to make alterations |
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Term
| When you inspect the chest what are you looking for? |
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Definition
| Chest configuration; central/peripheral cyanosis; pallor; edema; hyperpigmentation; xanthomas |
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Term
| What are some signs of R heart failure? |
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Definition
Cyanosis, engorgement of jugular veins, enlargement of liver, ascites, dependent edema, elevated venous pressure
Marked dilatation of R ventricle due to mitral valvular disease resulting in R heart failure |
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Term
| When you palpate the chest what are you looking for? |
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Definition
Symmetry; arterial pulses (patency, magnitude of LV contraction), pulse pressure
Apical impulse (PMI), lifts, thrills |
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Term
| What are the variations of pulses? |
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Definition
| Hypokinetic “Pulsus Parvus”; Hyperkinetic; Bisferiens pulse, Pulsus Alternans; Pulsus Parvus et Tardus; Pulsus Paradoxus |
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Term
| What is hypokinetic “Pulsus Parvus”? |
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Definition
| Decrease in SV, increase in PVR |
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Term
| What is hyperkinetic “Pulsus Parvus”? |
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Definition
| Increase in SV, decrease in PVR |
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Term
| What is important to know about murmurs? |
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Definition
| , location/duration, intensity, configuration/shape, pitch/quality, special maneuvers |
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Term
| What are you listening for in an S1 heart sound? |
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Definition
Mitral-tricuspid
Increased/reduced S1 |
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Term
| What are you listening for in an S2 heart sound? |
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Definition
Aortic-pulmonic
Inspiration vs expiration effects; normal splitting; widened splitting; fixed splitting; paradoxical splitting |
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Term
| What are you listening for at S3? |
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Definition
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Term
| What are you listening for at S4? |
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Definition
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Term
| What are some other abnormal heart sounds? |
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Definition
| Opening snap (OS), ejection clicks (EC), mid-systolic click, friction rubs |
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Term
| What is the mechanism of murmurs? |
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Definition
Abnormal flow across normal structures or normal flow across abnormal structures
Nearly all diastolic murmurs are pathologic
Most systolic murmurs are benign |
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Term
| What are the systolic murmurs? |
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Definition
| Mitral regurgitation; tricuspid regurgitation, VSD, aortic stenosis, pulmonic stenosis |
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Term
| What are the diastolic murmurs? |
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Definition
| Aortic regurgitation, pulmonic regurgitation, mitral valve stenosis, tricuspid valve stenosis |
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Term
| What maneuvers affect murmurs? |
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Definition
| Inspiration, standing, squatting, lying with legs elevated, valsalva, handgrip, amyl nitrate, phenylephrine |
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