Term
What condition is associated with an "opening snap" followed by a low-pitched diastolic rumble? How would you confirm your suspicion?
hint (also find a loud S1) |
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Definition
1) Mitral Stenosis
- opening snap follows S2 (the shorter the time between S2 and snap, the worse the stenosis)
2) Order an Echo
- left atrial enlargement
- thick calcified MV
- signs of RVF in advanced disease |
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Term
| How would you treat a patient that presents with mitral stenosis? What are the medical, surgical and management options? |
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Definition
1) Medical
- Diuretic (for pulmonary congestion and edema)
- Beta blocker (decrease HR and CO)
2) Surgical (for severe disease)
- percutaneous balloon valvuloplasty
- can replace value if balloon contraindicated
3) Management
- Diuretics if symptomatic
- If Afib develops, need to treat (rate control with beta blocker and anti-coagulate) |
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Term
Why can atrial stenosis lead to mitral regurgitation?
What are the common causes of AS? |
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Definition
1) Progressive dilation of LV can stretch MV leaflets
2) Causes
- Congenital abnormal valve becomes calcified
- Rheumatic fever
- Elderly calcification |
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Term
Patient presents with exertion syncope and complaints consistent with angina.
You detect a harsh crescendo-decrescendo systolic murmur that radiates to the carotid arteries. You also notice that S2 is soft and splitting cannot be detected.
What is the most appropriate diagnostic approach and treatment for this condition? |
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Definition
Presentation and murmur is consistent with Aortic Stenosis. S2 is single because aortic component is delayed and merges into pulmonic component.
- Confirm with cardiac cath (usually detectable with Echo too)
- Treatment of choice is Aortic valve replacement (indicated in all symptomatic patients- high mortality rate of 75%). If asymptomatic, watchful waiting is indicated. |
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Term
What are the most common causes of the condition associated with a widened pulse pressure, a Muller sign (uvula bobbing) and De Musset sign (head bobbing)?
How would you treat? When is treatment a medical emergency? |
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Definition
Aortic insufficiency due to regurgitation.
1) Acute causes include by infectious endocarditis, trauma, aortic dissection
- Chronic causes include rheumatic fever, bicuspid aortic valve, Marfan syndrome, and multipel forms of aortic root disease.
2) Treat
- Conservative options include salt restriction, diuretics, vasodilators, after load reduction (ACE inhibition)
- Surgical treatment is valve replacement
- Acute AR after an MI is a MEDICAL EMERGENCY (perform emergent valve replacement) |
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Term
Patient presents with dyspnea on exertion, PND and orthopnea, as well as signs of pulmonary edema.
You detect a holoystolic murmor at the heart apex, which radiates to the back.
How would you treat? |
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Definition
This is a symptomatic patient with mitral regurgitation.
You treat only symptomatic patients, and this case treatment might involve after load reduction with vasodilators and chronic anticoagulation if Afib is present. |
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Term
Patient presents with ascites, a pulsatiile liver and pitting edema in the lower extremities.
You detect a blowing holosystolic murmur at the LLSB that is intensified with inspiration.
What test(s) do you order and how would you treat? |
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Definition
This sounds like signs of right heart failure and the murmur is consistent with Tricuspid regurgitation.
- Diagnose with Echocardiogram
- Treat underlying etiology if possible.
- Volume control with diuretics and surgery if necessary |
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Term
What condition with associated with mid/late systolic clicks and mid-to-late systolic murmurs? What conditions is it associated with? What is the major concern?
Hint (this murmur decreases with squatting) |
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Definition
Sounds like mitral valve prolapse (click and murmur due to extra leaflet tissue moving into left atrium).
Associated with Marfan's, osteogenesis imperfect and ED syndrome.
Concern is that emboli from MV can cause TIA's (rare)
Condition is generally benign, but beta blockers can be used if chest pain is present. |
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Term
| Describe the diagnostic criteria for Rheumatic Heart Disease. |
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Definition
Need 2 Major or 1 Major and 2 Minor
Major
- Migratory polyarthritis
- Erythema marginatum
- Cardiac involvement
- Chorea
- Sub-q nodules
Minor
- Fever
- Elevated ESR
- Polyarthralgias
- Prior history of RF
- Prolonged PR interval
- Evidence of preceding strep infection. |
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Term
| How do you treat a patient with Rheumatic fever? |
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Definition
1) Treat strep (PCN or erythromycin)
2) Acute fever treated with NSAIDS (monitor CRP)
3) Treat valvular pathology as needed. |
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Term
What are you worried about in a patient with a new onset murmur and an unexplained fever?
How is it diagnosed? |
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Definition
Infective Endocarditis
Need 2 major, 1 major and 3 minor, or 5 minor (Duke)
Major
- Sustained bacteremia by organism known to cause it
- Endocardial involvement or new valvular regurgitation.
Minor
- Predisposing condition (IV drug user, abnormal valves)
- Fever
- Vascular phenomena (Janeway lesions?)
- Immune phenomena: Osler nodes, Roth spots, rheumatoid factor, glomerulonephritis
- Positive blood culture (not meeting major)
Positive echo (not meeting minor).
**Trans-esophogeal echo is better than transthoracic echo** |
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Term
| What are the major organisms associated with acute and subacute infectious endocarditis? |
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Definition
Native valves are affected by HACEK organisms
- Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
Prosthetic valves are affected by Staph (early) and Strep (late)
1) Acute (occurs on normal valve and fatal in 6 weeks if not treated)
- S. aureus (virulent)- also most common in IV users (right)
2) Subacute (occurs on abnormal valves and less fatal)
- Enterococcus, S. viridans |
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Term
How is infectious endocarditis treated?
How qualified for prophylaxis? |
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Definition
1) Parenteral antibiotics for 4-6 weeks based on culture
- if culture negative, give PCN (or vanc) and amino glycoside until organism is isolated
2) For prophylaxis, must have both a qualifying cardiac indication AND procedure to warrant antibiotic prophylaxis
- Cardiac indications include prosthetic valve, history of inf. endocarditis, congenital heart disease, or previous cardiac transplant with valvuloplasty
- Procedures include dental surgery, biopsy or incision of respiratory mucosa and procedures involving infected skin or MSK tissue.
NOT FOR native valve prolapse/stenosis or routine GI or GU procedures. |
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Term
| What are the 2 major types of nonbacterial endocarditis? |
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Definition
1) Thrombotic (Marantic)
- associated with metastatic cancer (20% of patients)
- Sterile deposits of fibrin and platelets along valve leaflets
- Vegetations can embolize (may use heparin)
2) Verrucous (Libman-Sacks)
- typically involves aortic valves in LSE patients
- formation of small warty vegetations on both sides of valve leaflets and can lead to AR murmurs
- Treat SLE and anti coagulate |
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Term
What congenital heart disease is associated with a fixed split S2? How could you confirm?
How does this condition become detected in adults and what are the important associated complications? |
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Definition
ASD- shunt prevents separation of A and P portions of S2 during inspiration/expiration. Confirm with TEE
- Adults typically are asymptomatic until 40, and then exhibit exercise intolerance, dyspnea on exertion and fatigue.
- Complications are rare but can include Pulm HTN (increased pulmonary blood flow from shunt) and Eisenmenger's syndrome (pulmonary htn leads to reversal or shunt and causes heart failure and cyanosis). |
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Term
What is the most common congenital heart defect and what is the associated murmur?
How would you formally diagnose and when is treatment required? |
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Definition
- VSD with a harsh, blowing holosystolic murmur with thrill
- Diagnose with echo
- Treat with surgery IF pulmonary flow to systemic flow ratio is greater than 1.5:1 or 2:1, as well as patients with infective endocarditis. |
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Term
| Which congenital heart defect is associated with woman with Turner syndrome? What are the clinical features? |
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Definition
Coarctation of aorta (usually where left subclavian artery originates near ligamentum arteriosum). Can lead to LVH
- HTN in upper extremities (well developed) and Hypotension in lower extremities (underdeveloped)
- Femoral pulses are delayed relative to radial pulses |
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Term
What is the leading cause of death in adults with PDA?
What is the murmur? |
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Definition
Communication between aorta and pulmonary artery stays open. L to R shunt causes volume overlaid, pulmonary HTN and right-sided heart failure with late cyanosis.
1) Heart Failure
2) Infective Endocarditis
BUT adults with PDA usually have normal pulmonary pressures
Murmur is a continuous machine-like murmur at left second intercostal space (both systolic and diastolic components). |
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Term
| How does treatment with PDA in adults differ depending on pulmonary vascular disease? |
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Definition
1) If absent, surgical ligation indicated
2) If PVD present (either severe pulmonary hypertension or right-left shunt), surgery CONDRAINDICATED
- Can still use indomethicin to inhibit prostaglandins and close it. |
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Term
| What are the cardiac abnormalities in TOF? How is it diagnosed? |
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Definition
Typically sporadic, but can be associated with syndrome
1) VSD
2) RVH
3) Pulmonary artery stenosis
4) Overriding aorta
- Diagnosed with Echo, but CXR finding of boot-shaped heart is also characteristic |
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Term
| Patient presents with blood pressure of 230/110. What do you do? |
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Definition
Hypertensive urgency (sys > 220 or dias > 120)-
1) need to determine if it is an "emergency" by checking for end-organ damage.
- Look in eyes (papiledema)
- CNS (mental status or ICH, or encephalopathy)
- Kidneys
- Lungs (pulmonary edema?)
- Heart (USA, MI, CHF with pulmonary edema, aortic dissection)
2) If emergency is detected
- Reduce MAP by 25% in 1-2h
- Can use IV agents such as hydrazine, esmolol, nitroprusside if encephalopathy is present and/or htn is severe
3) If urgency present
- Lower BP over 24h using ORAL agents |
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Term
| Patient presents with headache and markedly elevated BP. What do you do? |
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Definition
Concerned about hypertensive emergency with encephalopathy (perhaps posterior reversible encephalopathy syndrome).
- First, lower BP with antihypertensive agent (maybe hydrazine)
- Second, order CT of head to rule out IC bleeding
- If CT is negative for SAH, proceed to a lumbar puncture |
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Term
| What are the two major types of aortic dissection and how does their treatment differ? |
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Definition
In both cases, immediately start IV beta blocker (lower HR) and sodium nitroprusside (lower systolic BP < 120)
1) A is proximal/ascending, and treatment is surgical
- open surgery
2) B is distal/descending (after takeoff of subclavian artery) and treatment is medical
- IV beta blocker
- pain control
- consider surgery if unrelenting |
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Term
| Patient presents with complaints of "tearing pain" in back. What do you do? |
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Definition
Worried about aortic dissection
- Order CXR (widened mediastinum (>8mm on AP view)
- Order TEE
If diagnosis is met, start medical therapy immediately (IV nitroprusside and beta-blocker) |
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Term
Patient presents with complaints of sudden onset pain in back radiating to the groin, buttocks and legs. They also exhibit ecchymoses on back and flanks as well as around the umbilicus.
What do you do? |
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Definition
Sounds like a AAA is about to rupture.
- Grey Turner sign (echymoses on back and flanks) and Cullen sign (ecchymoses around umbilicus)
- Order ultrasound to confirm
- If enraptured, management depends on size of AAA
- If >5cm or symptomatic, surgery is indicated with synthetic graft placement (placed endovascularly via femoral)
- If <5cm and asymptomatic, management is controversial |
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Term
| What is Leriche syndrome? |
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Definition
| Atheromatous occlusion of distal aorta just above bifurcation causing bilateral claudication, impotence and absence/diminished femoral pulses. |
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Term
| What is the classic triad of a ruptured AAA? |
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Definition
1) Hypotension
2) Severe abdominal pain
3) Palpable pulsatile abdominal mass.
EMERGENT LAPORATOMY indicated (no further diagnosis required) |
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Term
| What is the proper evaluation strategy for a patient who presents with peripheral vascular disease? |
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Definition
PVD usually effects superficial femoral, popliteal and/or aortioiliac arteries.
1) Evaluate CVS (HTN, bruits, murmurs, AAA)
2) Assess arterial pulses
3) Inspect lower extremities for color change, curlers, musle atrophy, hair loss, thickened toenails, ect.
4) Consider ordering ECG, CBC, renal function tests, and coagulation profile (factor V leiden, antithrombin III, protein C and S) |
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Term
| What are the most common locations for PVD and how do they present? |
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Definition
Intermittent claudication with same distance walking, as well as rest pain (often at night) that is improved by standing or resting feet over bed
1) Peripheral femoral and 2) Popiteal artery disease causes claudication in CALF
3) Aortoiliac disease causes buttock and hip claudication (in addition to calves) |
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Term
| What is the diagnostic workup for suspected PVD? |
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Definition
1) Ankle-to-brachial index (ABI)- systolic blood pressure ratio
- >1.3 indicated noncompressive vessels (severe disease)
- <.7 found with intermittent claudication
- <.3 found with rest pain
2) Pulse volume recordings
3) Arteriography (contrast in vessels and radiographs) is gold standard |
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Term
| How is a patient with intermittent claudication due to PVD treated? |
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Definition
Conservative
1) Stop smoking
2) Exercise program
3) Foot care
4) Risk factor reduction (weight, HTN, etc)
5) Aspring and Clopidogrel can be used
6) Cilostazol is a PDE inhibition which suppresses platelet aggregation and dilates arterioles. |
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Term
| What is the management of patients with PVD associated with severe resting pain? |
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Definition
1) Angioplasty
- try a few times before bypass
2) Surgical bypass |
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Term
Where is the most common location with embolic arterial occlusion?
Where do the emboli typically come from? |
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Definition
1) Common femoral artery
2) Heart (85%), Anuerysms and Atheromatous Plaques |
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Term
| What are the 6 Ps of acute arterial occlusion? |
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Definition
Pain
Pallor
Polar (cold)
Paralysis
Parasthesias
Pulselessness (use Doppler)
Order Arteriogram, ECF (MI or Afib) and Echo |
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Term
| How is acute arterial occlusion treated? |
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Definition
1) immediately anti coagulate with IV heparin.
2) Surgery can include Fogarty balloon, and instead of Surgery thrombolytics like Urokinase can be used. |
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Term
| What is the diagnostic test of choice to distinguish between PVD and acute arterial occlusion? |
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Definition
Arteriogram
- Remember, PVD is associated with intermittent claudication (conservative management) or resting pain (surgery), while AAO is associated with Pallor, Paralysis, Polar, Parasthesia, Pulslessness, and localized pain (treatment is anticoagulation and emergent surgery) |
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Term
| True or false: Anticoagulation therapy is indicated in patients with cholesterol embolization syndrome. |
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Definition
False!
Treatment is supportive. Control BP |
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Term
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Definition
Complication of Syphilitic Aortitis
- Aneurysm of aortic arch with retrograde extension causes AR and AS
- Give IV PCN and surgical repair. |
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Term
| What is the "Virchow Triad" and why do only 50% of patients with DVT show this? |
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Definition
1) Endothelial injury, venous stasis, hypercoagulability
2) IF superficial venous system is patent, blood will effectively drain from these patent veins.
**Only 50% of patients with triad actually have DVT!** |
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Term
How would you treat each of these three diseases of the Venous system?
1) Local tenderness, erythema along course of a superficial vein
2) Aching of lower extremities, worse at end of day, relieved by elevation of legs and worsened by recumbency, edema, pigmentation
3) DVT |
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Definition
1) Superficial thrombophlebitis
- Analgesics and monitor for spread or cellulitis.
2) Chronic venous insufficiency
- Leg elevation, avoid long standing, stockings
3) Diagnose with duplex and d-dimer and treat with anticoagulation. |
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Term
Patient presents with lower extremity pain and swelling and you note calf pain upon ankle dorsiflection.
What do you do next? |
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Definition
Homan's sign indicative of DVT
1) Order Doppoer and Duplex US (good for proximal, but not distal thrombi). Can order Venography, Impedance plethysmography and D-dimer testing (high sensitivity, but low specificity).
2) If Doppler is positive
- Patient with intermediate-high pre-test probability- begin anticoagulation (LMW Heparin)
- Patient with low-to-intermediate probability- observe and repeat US in 2 days |
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Term
| How do you anti-coagulate a patient with DVT (high pre-test probability)? |
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Definition
1) Start herparin bolus followed by constant infusion to maintain PTT at 1.5 to 2 times aPTT
2) Start warfarin once aPTT is therapeutic and continue for 3-5 months, anti coagulating INR to 2-3
3) Continue heparin until INR is therapeutic for 48 hours. |
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Term
In patients with massive PE who are hemodynaptically unstable, rapid thrombolysis is often indicated.
What medications are available? What would you do if there was a failure of adequate anticoagulation as well? |
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Definition
1) Streptokinase/urokinase/tPA
2) Inferior vena cava filter (Greenfield filter)
- prevents PE, but not DVT |
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Term
| What are the major methods of post-surgical anticoagulation prophylaxis? |
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Definition
1) Mechanical
- elevate legs, compression stockings, early ambulation
- pneumatic compression boots
- possibly IVC filter for patients with high risk and absolute contraindication
2) Pharmacology
- Heparin or LMWH: until patient is ambulatory
- LMWH has longer half life, can be given outpatient, no need to follow aPTT, but is more expensive. |
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Term
Most patients with DVT history eventually develop chronic venous insufficiency (80%).
Why is this and how can it be handled? |
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Definition
1) Damage to venous valves in deep and perforating systems leads to ambulatory venous HTN, which leads to interstitial fluid accumulation/edema and extravasation of plasma proteins and RBCs into sub-Q tissues (brown-black coloring)
- Eventually can lead to hypoxia of tissues, swelling and venous ulcers (the more swelling, the more ulcers)
2) Management
- leg elevation
- avoid long periods of standing
- if ulcers develop, deliver wet-to-dry saline dressings and Unna venous boot (compression stockings)
- If ulcers do not heal, apply split-thickness skin grafts with or without ligation or perforated veins. |
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Term
| How are cellulitis and lymphangitis differentiable from superficial thrombophlebitis? |
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Definition
1) The later involve widespread swelling and erythema
2) In thrombophlebitis, palpable, indurated vein is usually present. |
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Term
| How is Superficial Thrombophlebitis treated? |
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Definition
DO NOT ANTICOAGULATE
1) For localized disease, mild analgesia and elevation/hot compress
2) For Suppurative thrombohlebitis, administer systemic antibiotics |
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Term
| What is the major concern with atrial myxomas? |
|
Definition
Embolization
Commonly present with fatigue, fever, syncope, palpitations and a low-pitched diastolic murmur (plot)
Surgically excise these. |
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Term
| What are the common signs and symptoms of shock? |
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Definition
Underperfusion of tissues
1) Hypotension
2) Oliguria (renal failure)
3) Tachycardia
4) Altered mental status
**also lactic acidosis) |
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Term
| Describe the initial approach to a patient in shock. |
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Definition
1) Focused history and PE
- Fever and site of infection (septic)
- Trauma, GI bleeding, Vom/Diarhea? (hypovolemic)
- History of MI, angina, heart disease, JVD? (cardiogenic)
- Brain or spinal chord injury? (neurogenic)
2) Stabilize patient hemodynamically and determine source of shock
- 2 large bore venous catheters, a central line and an arterial line
- A fluid bolus
- Draw blood: CBC, electrolytes, renal function, PT/PTT
- ECG, CXR
- Continuous pulse ox
- Vasopressors (dopamine, NE, phenylephrine) if patient remains hypotensive |
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Term
Which types of shock are associated with the following findings?
1) Decreased CO, increased SVR and increased PCWP
2) Decreased CO, increased SVR and decreased PCWP
3) Decreased CO, decreased SVR and decreased PCWP
4) Increased CO, decreased SVR and decreased PCWP |
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Definition
1) Cardiogenic
2) Hypovolemic
3) Neurogenic
4) Septic |
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Term
| What is the basic treatment for shock? |
|
Definition
1) ABCs!
2) Generous IV fluids are usually required (except cardiogenic) |
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Term
| What is the most common cause of cardiogenic shock and how is it diagnosed? |
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Definition
1) After acute MI (most common)
- Also tamponade, tension pneumo (compression of heart)
2) systolic BP<90 with urine output <20 mL/hr with adequate ventricular filling pressure
**Engorged neck veins (elevated JVP) are common with pulmonary congestion**
- ECG/ Echo/ Hemodynamic monitoring with Swan-Ganz catheter |
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Term
| How does an intra-aortic balloon pump assist in treatment of cardiogenic shock? |
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Definition
Reduce afterload and myocardial oxygen demand and increase CO.
- Balloon positions in descending thoracid aorta, just distal to subclavian artery.
- Inflates at onset of diastole (increases diastolic pressure) and deflates before onset of systole (reduced after load) |
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