Uworld Cardiology Good

7/25/2019 Uworld Cardiology Good

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Cardiology UWORLD

1. Orthostatic Hypertension: common in patients who are elderly, defned as adrop in systolic B ! "#mm$g. %lso in hypo&olemic, or a'tonomic ne'ropathy. %lsomeds: di'retics, &asodilators, and adrenergic (loc)ing agents.

". Dilated cardiomyopathy due to alcohol: throm(ocytopenia, macrocytosis, andele&ated transaminases all s'ggest alcoholism.

*. Mitral regurgitation: +ertional dyspnea, dry co'gh and holosystolic m'rm'r,

decreased cardiac o'tp't and increased le-t atrial press're, $eard (est o&er theape with radiation to the ailla.

. ACE Inhibitors: prolong the li-e o- the C$/0. Aortic Stenosis: high resistance ca'ses concentric hypertrophy and stiening o-

the &entricle, res'lting in 2.3. Perivalvular abcess: needle trac) mar)s, early diastolic m'rm'r 4%R5 %lso ":1 %6

Bloc).7. PAD: leads to myocardial in-arction in 0 years.8. Mobitz ype ! "loc# : Constant 9 nter&al, Increasing P$ Interval, Decreasing

R9R nter&al, %rouped beating 4repeating cl'sters o- (eats -ollowed (y adropped &$S'

;. Cardiac arrest( 2tart CR!)* In+ective endocarditis: 2tart appropriately on empiric vancomycin -or

staph. 2trep 6iridans: ntra&eno's a<'eo's penicillin % or I, ce+tria-one*!!* Acute MI. papillary muscle rupture. M$ Increased le+t ventricular

/lling pressure. inc 0,EDP. re=ected (ac) in le-t atri'm and is responsi(le -orthe ac'te symptoms o- p'lmonary edema and signs o- C$/.

!1* Aortic Dissection 21) systolic "P dierence in each arm >ransthoracicechocardiogram. E. C3$ 4idened mediastinum

!5* %raves Disease: atrial f(rillation, Beta Bloc) is the DOC!6* In+ective Endocarditis( 2ystolic m'rm'r that increases on inspiration10. remat're atrial f(rillation: Observation13. %c'te lim( ischemia -rom arterial occl'sion: Echocardiogram17. 7irst degree heart (loc)( Observation18. Atrial /brillation( DC Cardioversion1;. PS,: mmerse -ace in cold 4ater wor)s (y aecting %6 ?ode Cond'cti&ity"#. Cor Pulmonale: ele&ated p'lmonary artery press're1!* orsades de Pointes: type o- polymorphic ventricular tachycardia

@agnesi'm 2'l-ate"". Orthostatic hypertension: decreased (aroreceptor responsi&eness"*. S elevation in+erior in+arct 1A* are Right 6entricle". Rayna'ds is &asospastic li)e migraines, and rinmetals 4&ariant5 angina"0. Late allergy, s'rgical glo&es, condoms, %naphylais"3. Pericarditis: ?2%D2"7. achycardia8mediated cardiomyopathy can de&elop in patients who

ha&e persistent or rec'rrent tachyarrhythmia with prolonged periods o- rapid&entric'lar rate. nitial treatment is aimed at restoration o- sin's rhythm oraggressi&e control o- &entric'lar rate and can lead to signifcant impro&ement inle-t &entric'lar -'nction.

"8. Pericardial e9usion( an enlarged water (ottleE shaped cardiac silho'etteon chest ray. hysical eam fndings o- e'sion witho't cardiac tamponade

1



incl'de diminished heart so'nds on a'sc'ltation and a maimal apical imp'lse thatis diFc'lt to palpate.

";. ,iral Myocarditis( %'di(le 2* with p'lmonary &asc'lar congestion*#. Cardiogenic shoc# d'e to ac'te right &entric'lar myocardial in-arction

hypotension, shoc), and G'g'lar &ein distension and clear l'ng felds in the settingo- in-erior wall @U. atients with e&idence o- low CO and hypotension sho'ld (etreated initially with a (ol's o- I, :uid to improve right ventricular preload.Bitrates, di'retics, and opioids can red'ce R6 preload and sho'ld (e a&oided in

R6@.*1. $igh dose niacin therapy prod'ces c'taneo's ='shing: prostaglandin

induced c'taneo's ='shing. Can (e red'ced (y low dose aspirin.*". %miodarone: 'lmonary toicity**. WW: rocainamide*. %trial f(rillation with rapid &entric'lar response: nitial rate control with (eta

(loc)ers, or dilitaem*0. %rrhythmias within 1# min'tes o- coronary occl'sion are )nown as

immediate; or phase !a ventricular arrhythmias. %c'te ischemia ca'sesheterogeneity o- cond'ction with areas o- mar)ed cond'ction slowing and delayed&entric'lar acti&ation, which in t'rn predisposes to reentrant arrhythmias. On

the contrary delayed; or phase !b arrhythmias occ'r a(o't 1#93# min'tesa-ter ac'te in-arction are tho'gh to res'lt -rom abnormal automaticity*

*3. $ypertrophic cardiomyopathy H Beta Bloc)ers*7. CIR is o(tained in all patients who 'ndergo central &eno's catheteriation*8. +le&ated B? le&els and an a'di(le 2* are (oth signs o- increased cardiac

flling press'res*;. HI%H <IE0D ==== hiazide diuretics have un+avorable metabolic

side e9ects including hyperglycemia. increased 0D0 cholesterol. andplasma triglycerides* Electrolyte abnormalities that can be induced bythiazide diuretics include hyponatremia. hypo#alemia. andhypercalcemia*

#. ressors s'ch as ?+ can ca'se ischemia o- the distal fngers and toessecondary to &asospasm. >he diagnosis is s'ggested (y symmetric dus#inessand coolness o- all fngertips.

1. atients with symptomatic sin's (radycardia sho'ld (e reated initially with 6%tropine. n patients with inade<'ate response, -'rther treatment options incl'de6 epinephrine or dopamine, or transc'taneo's pacing.

". %/B @C ca'sed (y ectopic -oci in the p'lmonary &eins.65* Atrial 7lutter. MC caused the reentrant circuit around the tricuspid

annulus*. Bradycardia, atrio&entric'lar (loc), hypotension and di'se wheeing is

s'ggesti&e o- (eta (loc)er o&erdose. >reatment J Kl'cagon0. eripheral edema is a common side eect o- the treatment with

dihydropyridine Ca8channel antagonists li#e amlodipine. t is ?O> an allergicreaction.

3. Digoin and /'rosemide does not impro&e s'r&i&al in C$/7. %-ter central &eno's catheter orta(le chest 9ray8. +le&ated le&els o- B? and an a'di(le 2* are signs o- increased cardiac flling

press'res.;. Leg ele&ation, compression therapy and eercise are initial treatment o-

&eno's ins'Fciency.

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0#. solated systolic hypertension is d'e to decreased elasticity o- arterial wall.nitial treatment in&ol&ed monotherapy with low dose thiaide, an %C+ inhi(itor, orlong acting CCB.

01. Coronary 2teal henomenon: Dipyridamole can (e 'se d'ring myocardialper-'sion scanning to re&eal the areas o- myocardial restricted per-'sion. >heredicstri('tion o- coronary (lood =ow to non diseasedE segments.

0". %theroemol(ism 4cholesterol em(olism5 is a complication o- cardiaccatheteriation and other &asc'lar proced'res. ts characteried (y c'taneo's

fndings 4ie (l'e toe syndrome, li&edo retic'lares5, cere(ral or intestinal ischemia,ac'te )idney inG'ry, and Hollenhorst pla<'es. >reatment is s'pporti&e andincl'des statin therapy -or ris) -actor red'ction and pre&ention -o rec'rrentcholesterol em(oli.

0*. %scending aortic ane'rysm is most o-ten d'e to cystic medial necrosis orconnecti&e tiss'e disorders. Descending aortic ane'ryms are 's'ally d'e toatherosclerosis. CIR can s'ggest thoracic aortic ane'rysm (y showing widenedmediastin'm silho'ette, increased aortic )no(, and tracheal de&iation.

0. >reatment o- choice -or f(ro m'sc'lar dysplasia is perc'taneo's angioplastywith stent placement.

00. $ypertensi&e emergency ?itropr'sside, parenteral &asodilator,

meta(olism releases ?O ions and C? ions. ?O ind'ces &eno's and arteriolar&asodilation.

03. /lecainide and propa-enone are class 1C antiarrhythmics. >hey (loc) ?achannels and are 'sed in treatment o- atrial f(rillation.

07. Dilated cardiomyopathy can (e seen -ollowing &iral myocarditis a-ter aCosac)ie B in-ection. Diagnosis is made (y echocardiogram, which typically showsdilated &entricles and di'se hypo)inesia res'lting systolic dys-'nction 4low +/5. >reatment is largely s'pporti&e in&ol&ing managing the C$/ symptoms.

08. %ortic Reg'rgitation: Bo'nding p'lses, or peripheral water hammer p'lses.0;. +CK with an irreg'larly irreg'lar rhythm and los o- wa&es descri(es atrial

f(rillation. %trial f(rillation ca'ses a lac) o- an atrial )ic)E which co'ld ca'seworsening =ow thro'gh the stenotic mitral &al&e and increased congestion in thel'ngs, th's leading to the patients ac'te onset o- dyspnea.

3#. >he meas'rement o- ser'm B? can help disting'ish (etween C$/ and otherca'ses o- dyspnea. % &al'e o- !1## diagnoses C$/ with a sensiti&ity, specifcity,and predicti&e acc'racy o- ;#, 73, and 8* percents, respecti&ely. Use-'l indierentiating dyspnea -rom C$/ or COD. t is released -rom the &entricles inresponse to &entric'lar &ol'me o&erload and press're o&erload. B? !10#correlate strongly with the presence o- decompensated C$/. ?9terminal pro9B? isa new assay with similar predicti&e &al&e as B?. >he normal range -or this &al'edepends on the age o- the patient, ('t a ?>9pro9B? M*## &irt'ally ecl'des thediagnoses o- $/.

31. 2ystolic dys-'nction +/ M#N, reser&ed L6 /'nction +/!#N detected (y+C$O

3". % s'per&ised eercise program sho'ld recommend as part o- an initialtreatment regimen in all patients with intermittent cla'dication. harmacologictherapy with ciolstazol and perc'taneo's or s'rgical re&asc'lariation sho'ld (ereser&ed -or those with persistent symptoms despite ade<'ate s'per&ise eercisedtherapy. Low dose aspirin and station therapy frst

3*. %OR>C 2>+?O22a. +I+R>O?%L 2@>O@2, C$+2> %?, D2?+%, DPP?+22, %?D 2?CO+

*



(. D+L%+D %?D D@?2$+D C%RDO>D UL2+ 4UL2U2 %R6U2 +> >%RDU25c. 2?KL+ %?D 2O/> 2", %UDBL+ 2d. $%R2$ +Q+C>O? 4CR+2C+?DO9D+CR+2C+?DO5 22>OLC @UR@UR ? >$+

2+CO?D +/$ R?>+RCO2>%L 2%C+ W>$ R%D%>O? >O >$+ C%RO>D264. Herediatary hemochromatosis $yperpigmentation, arthralgia,

arthropathy, +le&ated hepatic enymes and increased ris) o- $CC, Dia(etesmellit's, secondary hypogonadism, and hypothyroidism Restricti&e or dilatedcardiomyopathy and cond'ction a(normalitiesA ncreased s'scepti(ility to Listeria,

Vibrio Vulnifcus & Yersinia enterocolitica.30. %2D can (e isolated or pate o- $olt O Ram 4heart hand syndrome533. ntra&eno's adenosisne is 'se-'l in the initial diagnosis and management

with narrow9R29comple tachycardia. t slowa the sin's rate, increase %B nodalcond'ction delay or can a transient (loc) in the %6 node cond'ction. t can alsoterminate paroysmal s'pra&entirc'lar tachycardia (y interr'pting the %6 ?odalreentry circ'it.

37. Costochondritis: pain is sharp, -ocal, lasts -or ho'rs, and worsens withinspiration and mo&ement all s'ggest @2S etiology

38. +ertional heat stro)e is defned as (ody temperat're !# C 41#/5 with C?2dys-'nction 4encephalopathy5. t is most commonly ind'ced (y streno's eercise

d'ring hot and h'mid weather. Dehydration, hypotension and tachycardia andcommon. 2ystemic eects s'ch as sei'res, %RD2, DC, and hepaticArenal -ail'remay also occ'r. >reatment consists o- rapid cooling and s'pporti&e management

3;. Loop di'retics can hypo)alemia and hypomagnesmia. >he electrolytea(normailities can ca'se &entric'lar tachycardia and also potentiate the sideeects o- digoin.

7#. /re<'ent epigastric pain ('rn not relie&ed (y antacids. 2ensation (ro'ght on(y hea&y li-ting at wor), 1#910 min'te goes away. ?o associated arm or nec) pain,co'gh 2OB, 2L+ diagnosed 0 years go, ta)es low does prednisone +ercise +CKstress test witho't imaging is the most reasona(le frst step is the (aseline resting+SK is normal. -or ischemic heart disease, 2L+ and chronic steroid 'se are ris)-actors -or coronary artery disease. Baseline +CK is normal and he is a(le toeercise, stress test is 'nnecessary. - the stress test is normal, then -'rther wor)'p-or the ca'se o- the ('rning sensation co'ld (e done, possi(le K etiology.

71. Coronary angiography is the gold standard -or detecting coronary arterydisease, ('t is pro(a(ly more aggressi&e than is necessary at this time. / thepatients stress test is positi&e, coronary angiography may (e necessary.

>1* Hyponatremia in patients 4ith CH7 parallels the severity o+ heart+ailure and is an independent predictor &al'e o- ad&erse o'tcome. ncreasedle&els o- renin. norepinephrine and ADH ca'se it* reatment in&ol&es :uidrestriction. ACE Inhibitors. and loop diuretics

7*. 2it'ational syncope: >ypical scenario is middle age or older male who losesconscio'sness immediately a-ter 'rination, or a man who loses his conscio'snessd'ring co'ghing fts.

7. atients with cardiac tamponade ha&e "ec#s riad( hypotension,distended nec) &eins, and m'Ted heart so'nds. >hese symptoms are d'e to aneaggerated shi-t o- inter&entric'lar sept'm toward the le-t &entric'lar ca&ity,which red'ces le-t &entric'lar preload, stro)e &ol'me, and cardiac o'tp't.

70. K+RD: $" Receptor antagonists: ranitidine, or omepraole73. %%% %(dominal 'ltraso'nd is st'dy o- choice -or diagnosis and -ollows 'p.

1##N sensiti&ity and specifcity.



77. >hree maGor mechanical complications o- myocardial in-arction: mitralreg'rgitation d'e to papillary m'scle r'pt're, &entric'lar -ree wall r'pt're andinter&entric'lar sept'm r'pt're. While all three o- these de&elopments can res'ltin hypertension, a pansystolic m'rm'r heard lo'dest at the ape with radiation tothe ailla is classic -or mitral reg'rgitation.

78. 26> can (e slowed (y carotid sin's massage and adenosine.7;. n atrial f(rillation with rapid &entric'lar response, calci'm channel (loc)ers

sho'ld attempt rate control initially. mmediate synchronied electrical

cardio&ersion is indicated in hemodynamically 'nsta(le patients with rapid atrialf(rillation.

8#. %D: smo)ing cessation, aspirin, statin, eercise therapy81.8". Reentrant &entric'lar arrhythmias 4eg &entric'lar tachycardia5 are the @CC

o- s'dden cardiac arrest in the immediate post in-arction period in patients withac'te @.

8*. %R increased L6 end diastolic &ol'me d'e to lea)age o- (lood -rom theaorta (ac) into the le-t &entricle. /eat'res o- aortic reg'rgitation incl'de a widep'lse press're, water hammer p'lse and L6 enlargement. >he le-t lateral dec'(it'sposition (rings the enlarged le-t &entricle closer to the chest wall and ca'ses a

po'nding sensation and increased awareness o- heart(eat.?6* %c'te @ anterolateral: S Segment elevation in leads !. a,0 and ,18,@

and S Segment depression in leads II. III. a,7*?* Chest pain that is reproducible 4ith palpation suggests MSB

etiology*83.

O$0D CA$DIO0O0%<

0ate Presentation o+ Aortic Coarctationresentation %symptomatic: $ypertension @C

Chest pain, cla'dication, headache. epista-is,heart -ail're, aortic dissection in se&ere cases

+amination "rachial 7emoral Delay. pper e-tremityhypertension. lo4 e-tremity hypotensionContin'o's cardiac m'rm'r -rom large collaterals

Diagnostic 2t'dies +CK: L6$CSR: otching o+ the 5rd F ?th ribs +romenlarged ntercostal arteriesG5 sign; +rom aortic indentation+cho: Diagnostic confrmation

>reatment Balloon %ngioplasty%ssociatedConditions

Bic'spid aortic &al&e62D >'rner 2yndrome

0



,ascular and Immunologic Mani+estations o+ In+ectiveEndocarditis IE'

,ascular Phenomena9 2ystemic arterial em(olic 4-ocal ne'rologic defcits, renal or

splenic in-arcts59 2eptic p'lmonary in-arcts9 @ycotic ane'rysm9 ConG'ncti&a $emorrhages

8 ane4ay 0esions F Macular erythematous. non8tenderlesion on the palms and soles

Immunologic Phenomena8 Osler odes F Pain+ul. violaceous nodules seen on the

/ngertips and toes8 $othJs Spots F Edematous K hemorrhagic lesions o+ the

retina9 Klomer'lonephritis9 %rthritis or positive rheumatoid +actor

In+ective Endocarditis in I, drug users9 $6 in-ection increases + ris) in intra&eno's

dr'g 'sers9 2taphylococco's a're's the most common

organism9 >ric'spid &al&e in&ol&ement 4right9sided5 more

common than aortic &al&e8 Holosystolic murmur that increases 4ith

inspiration indicating tricuspidinvolvement

9 2eptic p'lmonary em(oli common

9 /ewer peripheral + mani-estation 4splinterhemorrhages, Qaneway lesions59 $eart -ail're more common in aortic &al&e

in&ol&ement ('t rare with tric'spid &al&edisease

3



E9ect o+ maneuvers on Hypertrophic CardiomyopathyPhysiologic E9ect Change in Murmur

Intensity,alsalva Straining

Phase'

reload

Abrupt standing

+rom sitting orsupine position'

itroglycerinadministration

Sustained hand grip %-terload

SLuatting7rom standing

position'

%-terload and reload

Passive 0eg $aise reload

Mechanicalcomplicationo+ acute MI

imeCourse

Coronaryartery

typicallyinvolved

Clinical 7indings Echocardiography

$ight,entricle

7ailure

%c'teRC%

$ypotension andclear l'ngs

Bussmaul sign

$ypo)inetic R6

Papillarymusclerupture

%c'te andwithin *90

daysRC%

%c'te, se&erep'lmonary edema?ew holo9systolic

m'rm'r

2e&ere @R with=ail lea=et

I, septumrupturede+e

ct

%c'te andwithin *90

days

L%D

apical septalr'pt're

RC% (asal

septalr'pt're

2hoc) and chestpain

e4 holo8systolic murmur

"iventricular+ailure

Le-t to rightsh'nt at le&el o- &entricle 2tep 'p

oygen le&el

(etween R% and&entricle

7ree allrupture

Within/rst days8 14ee#s

L%D2hoc) and chest

pain Q'g'lar &eno's

distensionDistant heart

so'nds

ericardiale'sion withtamponade

7



ormal Hypovolemic Shoc#

CardiogenicShoc#

SepticShoc#

$A Pressurepreload'

@ean o- mm$g

?ormalA

PCPpreload'

@ean o- ; mm$g

?ormalA

CardiacInde-

".89."LAminAm"

S,$a+terload'

@ean o- 110#dynes

secAcm"

Mi-ed,enous O1

Saturation

3#98#N

Cardiac My-oma

umorcharacteristics 8#N located in the le-t atri'm

Clinical 7eatures Constitutional Symptoms 4-e&er, weight loss,Rayna'ds phenomenon5C,S Complications

9 6al&'lar a(normalities 4eg mitral disease59 $eart -ail're d'e to anatomic o(str'ction9 @yocardial in&asion ca'sing arrhythmias, heart

(loc), or pericardial e'sionEmbolization0ung invasion ca'sing respiratory symptoms

mimic)ing (ronchogenic carcinomaDiagnosis andManagement

9 +chocardiogram9 rompt s'rgical resection

Diagnosis o+ orthostatic postural' hypotensionWithin "90 min'tes o- standing -rom s'pine position:

9 Drop is 2B ! "# mm$g9 Drop in DB !1# mm$g

8



;



Poor prognostic +actors in systolic heart +ailureClinical $igher ?$% -'nctional class

Resting tachycardiaresence o- S5 gallopElevated Nugular venous pressure0o4 blood pressure !))@) mm Hg'@oderate to se&ere mitral regurgitation0o4 maimal oygen cons'mption pea# ,O1'

0aboratory HyponatremiaElevated pro8"P levelsRenal ins'Fciency

Electrocardiography

&$S duration 2 !1) msecLe-t B'ndle Branch Cloc) attern

Echocardiography

2e&ere L6 dys-'nctionConcomitant Diastolic Dys-'nctionRed'ced right &entric'lar -'nction'lmonary $ypertension

AssociatedConditions

%nemia%trial f(rillationDia(etes @ellit's

$eversible causes o+ AsystolePulseless Electrical Activity HJs Js

Hypovolemia ension Pneumothora-Hypo-ia amponade. cardiac

Hydrogen ions acidosis' o-ins narcotics.benzodiazepines'

Hypo8hyper#alemia hrombosis pulmonary orcoronary'

Hypothermia rauma

1#



7eatures o+ Constrictive PericarditisEtiology diopathic or &iral pericarditis

Cardiac s'rgery or radiation therapy >'(erc'lo's pericarditis 4in endemic areas5

ClinicalPresentatio

n

/atig'e and dyspnea on eertioneripheral edema and ascitesIncreased ,P

Pericardial #noc# may be heardPulsus parado-usBussmaulJs Sign

Diagnostic7indings

+CK may (e non9specifc or show atrial f(rillation orlow &oltage R2 compleesmaging shows pericardial thic)ening andcalcifcation Q'g'lar &eno's p'lse tracing shows prominent -and y descents

%uidelines +or lipid8lo4ering therapyIndication $ecommended herapy

Clinically signi/cantatherosclerotic disease%C2, @2ta(le or 'nsta(le anginaCoronary or other arterial&asc'lariation2tro)e, >%, %D

Age less than >( $igh intensitystatin

Age 2 >( @oderate intensitystatin

0D0 2!) mgd0 $igh intensity statin

Age 6)8> 4ith diabetes !) year ASC,D ris# 2 >*Q

$igh intensity statin!) year ASC,D ris# >*Q@oderate intensity statin

11



Causes o+ AcLuired long & Syndrome

Medication

Diuretics due to electrolyte imbalances'%ntiemetics 4ondansetron5%ntipsychotics 4haloperidol. Luetiapine.risperidone' >C%s22Rs 4citalopram5%nti9arrhythmics 4amiodarone. sotalol. :ecainide5

%nti9anginal dr'gs 4ranolazine5%nti9in-ecti&e dr'gs 4macrolides, /l'oro<'inolones,anti-'ngals5

MetabolicDisorders

+lectrolyte m(alances 4S V, @gV", CaV"52tar&ation$ypothyroidism

"radyarrhythmias

2in's node dys-'nction%6 Bloc), "nd or *rd degree

Others $ypothermia@ntracranial disease$6 n-ection

1"



Acute dyspnea in the hospitalized patientMechanism $is# 7actors Clinical 7eaturesArrhythmia Cardiac disease

+lectrolytea(normalities

Diiness, palpitations >achycardia or(radycardia

"ronchoconstriction %sthma@edications 4aspirin,(eta (loc)ers5

heezingRRRrolonged epiration

CH7Hypervolemia Cardiac DiseaseChronic SidneyDiseaseatrogenic 4='ids,(lood prod'cts5

Crac)les+le&ated G'g'lar &eno'spress're 4!8cm $"O5Lower9etremity edema

In+ection.pneumonia.aspiration

Chronic l'ng diseasemm'nos'ppressionmpaired mentalstat's2tro)eAdysphagia

Fever Leukocytosis

Pleural E9usion C$/Chronic SidneyDisease@alignancy

Decreased (reath so'ndsD'llness to erc'ssion

Pulmonaryembolism

rolonged immo(ility2'rgery 4hipA)neereplacements5

>achycardia, tachypnea$ypoemia2igns o- D6>

An-iety DementiaChronic mental illness2leep Depri&ation

>achycardia, tachypnea?ormal oygenation,l'ng eamination

Etiologies o+ Pericarditis 8 HemodyialysisIn+ection 6iral, 4most common,5 (acterial

Iatrogenic 2'rgery, tra'ma, radiation, dr'g related

CD R%, 2L+Cardiac Dressler syndrome 4post9myocardial pericarditis,

's'ally 193 wee)s a-ter @5remic 2er'm BU? !3# mgAdL, ('t degree o- pericarditis

does not always correlate with degree o- ele&ationMalignancy Can (e d'e to cancer 4l'ng, (reast, $odg)ins5 or

treatment 4radiation, chemotherapy5

1*



reatment o+ hypertensionRRRModi/cation $ecommended plan Appro-imate

decrease in systolic"P

eight loss Red'ce B@ M"0)gAm"

09"# per 1# )g loss

DASH Diet Diet high in -r'its and&egeta(les and low insat'rated -at and total

-at

891

E-ercise *# minAday -or 093daysAwee)

9;

Dietary sodium M* gAday "98

Alcohol inta#e " drin)sA day in men 1 drin)Aday in women

"9

Myocardial in+arction based on coronary vessel involvementInvolved

myocardium"loc#ed ,essel EC% 0eads involved

%nterior @ L%D 9 2ome or all o- leads 61963

n-erior @ RC% or LCI 9 2> ele&ation in leads ", *,a6/

osterior @ LCI or RC% 9 2> depression in leads 6196*9 2> ele&ation in leads a6L

4LCI59 2> depression in leads

a6L 4RCI5Lateral @ LCI, diagonal 9 2> ele&ation in leads , a6L,

60 and 639 2> depression in leads ,

a6/Right &entric'lar

@ 4occ'rs in Xo- in-erior @5

RC% 9 2> ele&ation in leads 6963R

1



Clinical +eatures o+ acute decompensated heart +ailureClinical

Presentation9 %c'te dyspnea, orthopnea, ?D9 $ypertension commonY hypotension

s'ggests se&ere disease9 %ccessory m'scle 'se, tachycardia,

tachypnea9 Di'se crac)les with possi(le wheees

4cardiac asthma59 ossi(le 2*, G'g'lar &eno's distension,

peripheral edema

reatment ormal or elevated blood pressure 4ithadeLuate end organ per+usion

9 2'pplemental oygen9 6 loop di'retic 4-'rosemide59 Consider 6 &asodilator 4nitroglycerin5

Hypotension or signs o+ shoc# 9 2'pplemental oygen8 I, loop diuretic +urosemide' as

appropriate9 6 &asopressor 4eg ?orepinephrine5

7actors associated 4ith poor outcomea+ter 4itnesses out8o+8hospital sudden

cardiac arrest

10



9 >ime elapsed prior to eecti&eres'scitation 4delayed (ystander CR,delayed def(rillation5

9 nitial rhythm o- p'lseless electricalacti&ity or asystole

9 rolonged CR 4!0 min'tes59 %(sence o- &ital signs9 %d&anced age

9 rior history o- cardiac disease9 !* chronic illnesses9 ?eed -or int'(ation or &asopressors9 ne'monia or renal -ail're a-ter CR9 2epsis, C6%, or Class or class 6

heart -ail're

reatment +or stable chronic anginaAntianginal "eta "loc#er

9 !st line therapy -or angina symptoms, impro&es

eercise tolerance9 Relie&es angina (y decreasing myocardial

contractility and heart rate9 mpro&es s'r&i&al in those with myocardial in-arction

Calcium Channel "loc#er9 Can com(ine with (eta (loc)er i- angina persists or

as alternate therapy9 mpro&es angina (y ca'sing peripheral and coronary

&asodilationitrates

9 2hort9acting -orm is 'sed in the acute setting

9 Long9acting -orm is an ass9on therapy -or persistentangina

Preventive 9 %spirin9 2tatin9 2mo)ing cessation9 Reg'lar eercise weight loss9 Control o- (lood press're and dia(etes

Auscultation o+ cardiac murmurs

13



Maneuver hat it does Murmur thatgets louder

Murmur thatgets so+ter

,alsalva 6eno's ret'rn4d'ring strainYd'ring relaation5

$C@@6

%ll others

Standing 6eno's ret'rn $C@@6

%ll others

SLuatting 6eno's ret'rn %-terload Reg'rgitant-raction

A$

M$,SD

$C@

@6

Handgrip %-terload Blood press're Reg'rgitate-raction

A$M$,SD

$C@%2

Classi/cation o+ Atrial 7ibrillation7irst Detected nitial diagnosis, independent o- d'ration

Paro-ysmal Rec'rrent 4!"5 episodes that terminatespontaneo'sly in M7 days, 's'ally within " ho'rs

Persistent +pisodes lasting !7 days0ongstanding

persistentersistent o- !1 year d'ration

Permanent ersistent with no -'rther plans -or rhythm control

0one atrial /brillation is defned as the presence o- paroysmal,persistent, or permanent atrial f(rillation with no e&idence o-cardiop'lmonary or str'ct'ral heart disease. >hese patients are lo4 ris#

o+ systemic embolization and no additional therapy is indicated inthose who are asymptomatic

Anticoagulation in atrial /brillationCHADS 1 Score Stro#e $is# Antithrombotic therapy

# Low ?o anticoag'lation 4pre-erred5 or%spirin

1 ntermediate %nticoag'lation 4pre-erred5 or %spitin

17



"93 $igh %nticoag'lation

Common causes o+ aortic regurgitationAortic valve lea:et disease Rhe'matic heart disease

+ndocarditisBic'spid aortic &al&e >ra'ma

@yomato's degeneration%n)ylosing spondylitis%cromegaly@edications 4-en='ramine,phenteramine5

Ascending aorta or aortic rootdisease

$ypertension%ortitis 4syphilis5%n)ylosing spondylitisDissecting ane'rysm+hlers9DanlosBDReacti&e %rthritis@ar-ans 2yndrome

%allop heart sounds7eatures ormal AbnormalAssociat

ed ConditionsS5 9 6entric'lar

gallop so'ndsa-ter 2"

9 $eard d'ringrapid flling o-

&entricles indiastole9 >'r('lent

(lood =ow tothe &entricled'e toincreased&ol'me

9 Children9 o'ng

ad'lts9 regnancy

%ge ! #$eart -ail'reRestricti&eCardiomyopathy$igh o'tp't states

S6 9 %trial gallopso'nd (e-ore

$ealthy older ad'lts

o'nger ad'lts,children

18



219 $eard

immediatelya-ter atrialcontractionphase as (loodis -orced into asti &entricle.

6entric'larhypertrophy%c'te myocardialin-arction

Syncope0i#ely etiology Clinical clues to diagnosis

,asovagal or neutrally mediatedsyncope

>riggers: rolonged standing oremotional distress, pain-'l stim'lirodromal symptoms: na'sea,warmth, diaphoresis

Situational Syncope >riggers: Co'gh, mict'rition,de-ecation

Orthostatic hypotension ost'ral changes in heart rateA(loodpress're a-ter standing s'ddenly

Aortic stenosis. hypertrophiccardiomyopathy. anomalous

coronary arteries

2yncope with eertion or d'ringeercise

,entricular arrhythmias rior history o- coronary arterydisease, myocardial in-arction,cardiomyopathy, or red'ced eGection-raction

Sic# sinus syndrome. bradyarrhythmias. A, "loc#

2in's pa'ses on monitor, prolongedR inter&al or R2 d'ration

orsade de Pointes AcLuiredlong & Syndrome' $ypo)alemia, hypomagnesmia,medication ca'sing prolonged >nter&al

Congenital long & Syndrome /amily history o- s'dden death,prolonged > inter&al on +CK,syndrome with triggers 4eercise,swimming, s'dden noise, d'ringsleep5

Causes o+ peripheral edemaPrimary Mechanism Clinical E-amples

Increased capillary hydrostaticpressure

9 $eart -ail're 4le-t &entric'lar cor p'lmonale5

9 rimary renal sodi'm retention4renal disease dr'gs5

9 6eno's o(str'ction 4cirrhosis &eno's ins'Fciency5

1;



Decreased capillary oncoticpressure hypoalbuminemia'

9 rotein loss 4nephroticsyndrome protein9losingenteropathy5

9 Decrease al('min synthesis4cirrhosis maln'trition5

Increased capillary permeability 8 "urns. trauma K sepsis8 Allergic reactions8 A$DS

8 Malignant ascites0ymphatic obstructionincreased

interstitial oncotic pressure8 Malignant ascites8 Hypothyroidism8 0ymph ode Dissection

"#



Secondary causes o+ hypertension

Condition Clinical clues+eatures$enal parenchymal

disease9 +le&ated ser'm creatinine9 %(normal 'rinalysis 4protein'ria, RBC

Casts5

$enovascular disease

9 2e&er hypertension 4!18# mm$g andAor1"# mm$K diastolic5 a-ter age 00

9 ossi(le rec'rrent =ash p'lmonary edemaor resistant heart -ail're

9 Uneplained rise in ser'm creatinine9 %(dominal (r'it

Primary Aldosteronism9 +asily pro&o)ed hypo#alemia9 2lightly hypernatremia9 $ypertension with adrenal incidentaloma

Pheochromocytoma

9 aroysmal ele&ated (lood press're withtachycardia

9 o'nding headaches, palpitation,diaphoresis

9 $ypertension with adrenal incidentaloma

CushingJs Syndrome

9 Central o(esity9 /acial lethora9 roimal m'scle wea)ness, abdominal

striae9 +cchymosis, amenorrhea, erectile

dys-'nction9 $ypertension with adrenal incidentaloma

Hypothyroidism 9 /atig'e, dry s)in, cold intolerance9 Constipation, weight gain, (radycardia

Primary

hyperparathyroidism

9 $ypercalcemia 4poly'ria, polydipsia

9 Sidney stones9 ?e'ropsychiatric presentation, 4con-'sion,depression, psychosis5

Coarctation o+ theaorta

8 De-erential hypertension with brachial8+emoral pulse delay

"1



Approach to 4ide comple- tachycardiaide comple- tachycardia with " -'sion (eats which are essentiallydiagnostic -or s'stained monomorphic &entric'lar tachycardia. 42@6>5

%6 dissociationZ

/'sionAcapt're (eatsZ <ES

O

Diagnosis o-6entric'lar tachycardia

Consider 26>With a(errancy

Stablenstable

9 $ypotension9 %ltered mentation9 Respiratory

distress

Stable

6 %miodarone 2ynchroniedCardio&ersion

@ane'&ers todetermine rhythm 4eg,carotid massage, rate

control5 treat+lectrical cardio&ersion is indicated -or 2@6> patients who arehemodynamically unstable, p'lseless, or se&erely symptomatic.Hemodynamically stable patients can frst (e gi&en antiarrhythmic 46%miodarone5 as these may lead to sin's rhythm and a&oidance o- the need-or cardio&ersion.

""



eurogenic K ,ascular Claudicationeurogenic Claudication

pseudoclaudication',ascular claudication

Symptoms 8 Posture dependentpain

8 0umbar e-tension4orsens pain

4al#ing do4nhill'8 0umbar :e-ion

relieves pain4al#ing 4hile bent+or4ards'

8 0o4er8e-tremitynumbness Ktingling

8 0o4er8e-tremity4ea#ness

9 0o4 bac# pain

9 +ertional dependentpain

9 ain relie&ed withrest, ('t not with

(ending -orwardwhile wal)ing

9 Lower9etremitycrampingAtightness

9 ?o signifcant lower9etremity wea)ness

9 ossi(le ('ttoc),thigh, cal-, or -ootpain

E-amination 8 ormal pulses8 7reLuently normal

e-amination

9 Decreased p'lses9 Cool etremities9 Decreased hair

growth9 allor with leg

ele&ation

Diagnosis M$I o+ the spine %n)le9(rachial inde

"*



Clinical 7eatures o+ 7ibromuscular DysplasiaPatients to

screenomen age ) 4ith ! o+ the +ollo4ing(

9 2e&ere or resistant hypertension

9 Onset o- hypertension (e-ore age *09 2'dden increase in (lood press're -rom (aseline9 ncrease in creatinine 4!#.091 mgAdL5 a-ter starting

angiotensin#con&erting enyme inhi(itor or %RB witho't signifcant eect on (lood press're

8 2ystolic9diastolic epigastric (r'it

ClinicalPresentation

9 $esistant hypertension -rom renal arteryin&ol&ement

9 Cere(ro&asc'lar /@D with symptoms o- brainischemia eg amaurosis +uga-. $orners syndrome,transient ischemic attac), stro)e'

9 ?onspecifc symptoms 4eg headache, p'lsatiletinnit's, diiness5 -rom carotid or vertebral arteryinvolvement

9 Can also in&ol&e iliac, s'(cla&ian &isceral arteries

Diagnosis K7ollo4 up

9 ?onin&asi&e testing pre-erred 4eg comp'tedtomography angiography, d'ple 'ltraso'nd5

8 Catheter9(ased digital s'(traction arteriography -orpatients with inconcl'si&e nonin&asi&e testing

8 @edically treated patient need -ollow9'p (loodpress're creatinine e&ery *9 months renal'ltraso'nd e&ery 391" months

reatment 8 OC is percutaneous coronary angioplasty 4ithstent placement

8 Plasma renin increased. Aldorenin !)

Overvie4 o+ vasovagal syncopeIncitingevents

Age @) years(9 +motionalAorthostatic stress 4eg, &enip'nct're,

prolonged standing, heat epos're, eertion5

Age 2 @) years:9 @ay also (e triggered (y mict'rition, co'gh de-ecation

Symptoms 9 rodrome o- pallor, diiness, na'sea, anddiaphoresis

9 2hort d'ration o- syncope 4seconds to -ew min'tes59 2ymptoms impro&e with s'pine position

Diagnosis 9 @ainly clinical diagnosis9 Upright tilt ta(le testing in 'ncertain cases

"



reatment 9 re&enti&e meas'res to a&oid triggering acti&ities4eg, prolonged standing5

Indications +or carotid endarectomyMen Asymptomatic(

9 3# H ;;N stenosisSymptomatic(

9 0#93;N 2tenosis 4Krade"%5

9 7#9;;N 2tenosis 4Krade1%5

omen "oth symptomatic Kasymptomatic:

9 7#9;;N 2tenosis

Decreased renal per+usion seen in CH7 and subseLuent $AASactivation lead to increase angiotensin 1 levels* Angiotensin 1causes numerous e9ects including(

!* 6asoconstriction o- (oth the aerent and eerent glomer'lar arterioles,

leading to an increase in renal &asc'lar resistance and a net decreasein renal blood :o4". Pre+erential vasoconstriction o+ e9erent renal arterioles, which

increases intraglomer'lar press're in attempt to maintain ade<'ateglomer'lar fltration rate 4K/R5

*. Direct stim'lation o- sodi'm resorption in the proimal t'('les andincreased secretion o- aldosterone -rom the adrenal glands, which int'rn promotes -'rther sodi'm resorption in cortical collecting t'('le. >hese actions lead to decreased sodium delivery to the distalt'('le and an increase in etracell'lar ='id &ol'me

"0



Di9erential diagnosis K +eatures o+ chest painCoronary artery

disease9 2'( sternal9 Radiation to arm, sho'lder, or Gaw9 recipitated (y e-ertion9 Relie&ed (y nitroglycerin or rest

PulmonarypleuriticPleurisy.

pneumonia.Pericarditis. PE'

9 2harpAsta((ing pain9 Worse with inspiration

9 Pericarditis: Worse when lying =at9 PE. Pneumothora-: Respiratory distress,

hypoia

AorticDissection.intramural.hematoma'

9 Sudden. severe tearingE pain9 Radiates to bac# 9 +lderly men9 $ypertension ris) -actors -or atherosclerosis

%astrointestinalEsophageal

9 ?oneertional, relie&ed (y antacids9 Upper a(dominal s'(sternal9 %ssociated with reg'rgitation, na'sea,

dysphagia8 octurnal pain

Chest 4allMusculos#eletal

9 ersistent andAor prolonged pain9 Worse with mo&ement or change in position9 O-ten -ollows repetitive activity

Conditions associated 4ith atrial /brillation8 EB% o+ A8/bCardiac 9 $ypertensi&e heart disease 4most common5

9 Coronary artery disease9 Rhe'maticA6al&'lar heart disease 4egY @2, @R5

9 Congesti&e heart -ail're9 $ypertrophic cardiomyopathy9 Congenital heart disease 4egY atrial septal de-ect59 ost cardiac s'rgery

Pulmonary 9 O(str'cti&e sleep apnea9 'lmonary em(olism9 COD9 %c'te hypoia 4eg, pne'monia5

Miscellaneous

9 O(esity9 +ndocrine 4eg, hyperthyroidism, dia(etes59 %lcohol a('se

9 Dr'gs 4eg, amphetamines, cocaine, theophylline5

"3



Clinical +eatures o+ Cocaine seClinical /eat'res

Complications@anagement o- Chestpain

Benodiaepenes -or B and aniety%spirin?itrogycerin CCB -or painBeta Bloc)ers are contraindicated/i(rinolytics not pre-erred d'e to increased ris) -o intracranialhemorrhagemmediate cardiac catherteriation with reper-'sion whenindicated

"7



Clinical 7eatures o+ Aortic Dissection 8 EE$is# +actorsassociations

8 Hypertension MC'8 Mar+an Syndrome9 Cocaine use

Clinical+eatures

9 2e&ere sharp, tearing chest or (ac) pain9 !"# mm $g &ariation in systolic B (etween arms

Complications involved

structure'

9 2tro)e 4carotid arteries59 %c'te aortic reg'rgitation 4aortic &al&es5

9 $orners 2yndrome 4superior cervical sympatheticganglion5

9 %c'te myocardial ischemiaAin-arction 4coronaryartery5

9 ericardial e'sionAcardiac tamponade 4pericardialca&ity5

9 $emothora 4ple'ral ca&ity59 Lower9etremity wea)ness or ischemia 4spinal or

common iliac arteries59 %(dominal pain 4mesenteric artery5

Initial stabilization o+ acute8S elevation MI

9 2'pplemental oygen 4i- 2aO"M;#N or dyspnea59 Aspirin *"0 mg9 P1<!1 inhibitor 4eg, clopidogrel59 ?itrates 4s'(ling'al59 "eta8bloc#er 4'nless hypotension, (radycardia, chronic heart -ail're

or (loc)5

9 $igh dose statin 4eg, ator&astatin 8#mg59 Anticoagulation 4dr'g depends on planned re&asc'lariation5

ersistent pain,hypertension, or

heart -ail're

ersistent se&erepain

Unsta(le sin's(radycardia

'lmonaryedema

Intravenousnitroglycerin

4not i- hypotension,

right &entric'larin-arct, or se&ereaortic stenosis

occ'rs5

Intravenousmorphine

Intravenousatropine

Intravenous+urosemide 4not

i- patient ishypotensi&e or

hypo&olemic5

$eper+usion(9 Percutaneous transluminal coronary angioplasty PCA' within

;# min pre-erred

"8



9 >hrom(olysis 4i- >C% not a&aila(le within 1"# min5

Side e9ects o+ AmiodaroneCardiac 2in's (radycardia, heart (loc)

Ris) o- proarrhythmias H >prolongation ris) o- torsadesde pointes

Pulmonary Chronic interstitial pne'monitis4co'gh, -e&er, dyspnea,p'lmonary infltrates5

Endocrine $ypothyroidism$yperthyroidism

%IHepatic +le&ated transaminases

Ocular Corneal micro depositions

Optic ne'ropathyDermatologic Bl'e9gray s)in discoloration

eurologic eripheral ne'ropathy

Indications +or urgent dialysis AEIO'Acidosis @eta(olic acidosis

9 p$ M7.1 re-ractory to medicaltherapy

Electrolyte Abnormalities 2ymptomatic hyper)alemia9 +CK change or &entric'lar

arrhythmias2e&ere hyper)alemia

9 S!3.0 m+<AL re-ractory tomedical therapy

Ingestion >oic alcohols 4methanol, ethyleneglycol52alicylateLithi'm2odi'm &alproate, car(amaepine

Overload 6ol'me o&erload re-ractory todia(etics

remia 2ymptomatic9 +ncephalopathy9 ericarditis9 Bleeding

";



AmyloidosisEpidemiology +tracell'lar deposit o- insol'(le polymeric protein

f(rils in tiss'es and organsCan (e primary 4%L >ype5 or 2econdary 4%%5 tochronic in=ammatory conditions s'ch as

9 n=ammatory %rthritis 4R%59 Chronic n-ections 4Bronchiectasis, >B,

Osteomyelitis59 n=ammatory Bowel Disease 4Crohns Disease59 @alignancy 4Lymphoma59 6asc'ltis

ClinicalPresentation

9 %symptomatic protein'ria or ?ephrotic2yndrome

9 Restricti&e cardiomyopathy9 $epatomegaly9 eripheral ne'ropathy Aor a'tonomic

ne'ropathy9 6isi(le organ enlargement 4eg macroglossia59 Bleeding diathesis9 Way thic)ening, easy (r'ising o- s)in

Diagnosis 9 >iss'e (iopsy 4a(dominal -at pad5

Characteristic 7indings o+ cor pulmonale F Pulmonary artery systolicpressure

CommonEtiologies

9 COD 4@C59 nterstitial L'ng Disease9 'lmonary &asc'lar Disease 4eg thromem(olic59 O(str'cti&e sleep apnea

Symptoms

9 Dyspnea on eertion, -atig'e, lethargy

9 +ertional syncope 4d'e to [ CO59 +ertional angina 4d'e to \ myocardial demand5

E-amination

9 eripheral +dema9 Q6 with a prominent a wave8 0oud S19 Right sided hea&e9 'lsatile li&er -rom congestion9 >ric'spid Reg'rgitation @'rm'r9 EC%: artial or complete RBBB, R%D, R6$, R%+9 Echocardiogram: 'lmonary $>?, Dilated R6, >R

*#



Imaging 9 $ight heart catheterization: Kold standard -ordiagnosis showing right &entric'lar dys-'nction,p'lmonary hypertension, and no le-t heart disease

Hypertensive ComplicationsHypertensive urgency

9 2e&ere hypertension 4's'ally 18#A1"# mm$g5 with no symptoms o-ac'te end9organ damage

Hypertensive

emergency

2e&ere hypertension with ac'te, li-e9threatening, end9organcomplications:

9 Malignant hypertension: 2e&ere hypertension with retinalhemorrhages, e'dates, papilledema

9 Hypertensive Encephalopathy( 2e&ere hypertension withcere(ral edema non9localiing ne'rologic symptoms signs

Cholesterol crystal embolism Atheroemboli'$is# 7actors 9 Comor(id conditions 4hypercholesterolemia, hypertension,

type " D@59 Cardiac catheterization or &asc'lar proced'res

Clinical 7eatures 9 Dermatologic 4livedo reticularis, 'lcers, gangrene, bluetoe syndrome5

9 Renal 4acute or subacute #idney inNury59 Central ner&o's system 4stro)e, amaorosis -'ga59 Oc'lar in&ol&ement 4Hollenhorst plauLes59 K 4intestinal ischemia, pancreatitis5

Diagnosis 0aboratory 7indings9 +le&ated ser'm creatinine, eosinophilia,

hypocomplementemia9 Urinalysis H typically (enign with -ew cells or casts, may ha&e

eosinophiluriaS#in or $enal "iopsy

9 Bicon&e, needle9shaped cle-ts within occl'ded &essels

9 eri&asc'lar in=ammation with eosinophils

*1



Adult tachycardia algorithm 4ith pulse' F 1)!) AC0S %uidelines[

denti-y treat 'nderlying ca'se9 @aintain patient airway, assist (reathing i- needed9 Oygen9 Cardiac monitor to identi-y rhythm, monitor (lood press're oimetry

[ersistent tachyarrhythmia ca'sing:

9 $ypotension9 %ltered mental stat's9 2igns o- shoc)9 schemic chest discom-ort9 %c'te heart -ail're

es2ynchronied Cardio&ersion

9 2edation9 - reg'lar, narrow comple, consider

adenosine

[?oR2 D'ration ! #.1" seconds es

9 6 access 1" +CK9 Consider adenosine i- reg'lar monomorphic

9 Consider antiarrhythmic in-'sion9 Consider epert cons'ltation

[?o6 access 1"9lead +CK6agal mane'&ers%denosine 4i- reg'lar rhythm5Beta9(loc)er or CCBConsider epert cons'ltation

High output heart +ailure F increased cardiac preloadCO%EIA0 AC&I$ED

atent D'ct's %rterios's >ra'ma at popliteal or iliac artery%ngiomas atrogenic 4eg, -emoral catheteriation5'lmonary %6/ %therosclerosis 4eg, aortoca&al fst'la5C?2 %6/ Cancer

*"



Clinical signs incl'de widened p'lse press're, strong peripheral arterial p'lsation 4eg,(ris) carotid 'pstro)e5, systolic =ow m'rm'r, tachycardia, and 's'ally ='shedetremities. >he le-t &entricle hypertrophies, and the point o- maimal imp'lse isdisplaced to the le-t. %n +CK 's'ally shows the le-t &entric'lar hypertrophy.

Aortic $egurgitationCommon causes 9 %ortic root dilation 4@ar-ans 2yndrome, 2yphilis5

9 ost in=ammatory 4rhe'matic heart disease, endocarditis58 Congenital (ic'spid aortic &al&e

Pathophysiology

9 Bac)=ow -rom aorta into L6 L6+D6 Compensatorymyocardial hypertrophy &entric'lar enlargement initiallymaintain stro)e &ol'me and cardiac o'tp't

9 +cessi&e L6 stretching later leads to [stro)e &ol'me,[-orward (lood =ow systolic heart -ail're

8 \Le-t &entric'lar end diastolic press're p'lmonarycongestion

Clinical7eatures

8 Diastolic decrescendo murmur TTTTU8 Widened pulse pressure Vsystolic blood pressure.

Wdiastolic blood pressure'9 $eart -ail're signsAsymptoms

Autosomal Dominant Polycystic Bidney DiseaseSymptoms 9 @ost patients are asymptomatic

9 $emat'ria9 /lan) pain 4nephrolithiasis, in-ection, cyst r'pt're,

hemorrhage5

Clinical signs 9 $ypertension9 alpa(le a(dominal masses 4's'ally (ilateral59 rotein'ria9 Chronic Sidney disease

E-trarenal +eatures 9 Cere(ral ane'rysms

9 $epatic and pancreatic cysts9 Cardiac &al&e disorders 4@6, %R59 Colonic di&ertic'losis9 6entral and ing'inal hernias

Diagnosis 9 Ultrasonography 4alternate: C>, @R5 shows m'ltiple renalcysts

Management 9 /ollow (lood press're and renal -'nction9 %ggressi&e control o- cardio&asc'lar ris) -actors9 %C+ nhi(itors pre-erred -or high (lood press're

**



9 +nd9stage renal disease, dialysis, renal transplant

Modi/ed ells criteria +or pretest probability o+ D,Score X! Points

0e+t leg sho4s4armth.tenderness. and

s4elling 26cm'

8 Previously documented D,8 Active cancer8 $ecent immobilization o+ the legs8 $ecently bedridden +or 25 days8 0ocalized tenderness along vein distribution

8 S4ollen leg8 Cal+ s4elling 25cm compared to other leg8 Pitting edema8 Collateral syper/cial nonvaricose veins8 Alternate diagnosis more li#ely 81 points'

otal score +orclinicalprobability

8 0ess than or eLual to ! D, unli#ely8 %reater than or eLual to 1 D, li#ely

Management o+ S8segment elevation MI SEMI'8 O-ygen +or arterial saturation )Q8 itrates9 Ca'tion with hypotension, right &entric'lar in-arction or se&ere aortic stenosis8 Antiplatelet therapy9 %spirin V"1" receptor (loc)er8 Anticoagulation9 Un-ractionated heparin, low molec'lar weight heparin, or (i&alr'din8 "eta "loc#ers9 CA in o&ert heart -ail're9 $igh ris) -or cardiogenic shoc)

9

Bradycardia8 Prompt reper+usion 4ith PCI9 deal frst medical contact to C M;# min'tes8 Statin therapy as soon as possible

1. Complete heart (loc) H Cardiac pacing 4diiness and worsening angina54>emporary pacema)er5

". 2* )en9t'c9)yE, associated with L6 -ail're, treatment di'retics*. +ect o- nitroglycerin: Dilation o+ capacitance vessels. 2, a low -re<'ency heart so'nds at the end o- diastole commonly associated with

L6 $ypertrophy -rom prolonged hypertension0. 2'pra&entric'lar arrhythmias: %denosine, retrograde wa&es3. $ypo&olemic 2hoc): CO Dec, CW: Dec, >R nc B Dec7. %ortic 6al&e Replacement

a. 2ymptomatic patient with %2(. atients with se&er %2 'ndergoing C%BK or other 6al&'lar s'rgeryc. %symptomatic patient with se&ere %2 and either poor L6 systolic dys-'nction,

L6 $ypertrophy!10 mm, &al&e area M#.3 cm" or a(normal response toeercise

*



?* Cyanide toicity can occ'r in patient recei&ing prolonged in-'sions or higher does o-nitropr'sside and is most common in patients 4ith renal insuYciency*

;. PAD, a-ter smo)ing cessation and lipid lowering therapy eercise program1#. @itral reg'rgitation: displaced apical imp'lse, holosystolic m'rm'r, and third heart

so'nds11. 2creening -or a(dominal aortic ane'rysm H 0.0 cm or greater aged 30970 who ha&e

smo)ed cigarettes1". ndications -or 'rgent dialysis

1*. 6ariant anginaArinmetals angina same as Rayna'ds phenomenon1. @'rm'r +chocardiography10. Orthostatic $ypotension13. >he three maGor mechanical complications o- @ incl'de mitral reg'rgitation d'e to

papillary m'scle r'pt're, le-t &entricle -ree wall r'pt're, and inter&entric'larsept'm r'pt're. While all three o- these de&elopments can res'lt in hypotension, apan9systolic m'rm'r heard lo'dest at the ape with radiation to the ailla is theclassic characteriation o- mitral reg'rgitation.

!>*eople who ha&e an @ sho'ld ha&e Aspirin. "eta "loc#ers. 0ipid 0o4eringdrugs. ACE inhibitors. and clopidogrel*

!?*B? is released -rom the &entricles in response to &ol'me o&erload, correlated

4ith 5rd heart sound1;. Class 1 anti9arrhythmic dr'gs wor) (y (loc)ing sodi'm channels."#. /lecainide and pepa-enone are class 1C."1. Electrical alternans with sin's tachycardia is specifc -or ericardial +'sion."". Crescendo9Decrescendo systolic m'rm'r along the le-t sternal (order witho't

carotid radiation is the description o- the m'rm'r present in $OC@."*. atient with na'sea, &omiting, and -atig'e, common with digoin toicity.". @itral stenosis as a conse<'ence o- rhe'matic heart disease. >he frst heart so'nds

is lo'd and a mid9diastolic r'm(le is heard at the ape. Crac)les are present in (othl'ng felds. +CK shows an irreg'lar irreg'lar heart rhythm and the a(sence o- Wa&es. @ost li)ely ca'se is Le-t atrial dilation.

"0. atient with C$/, and the etra9cardiac mani-estations 4protein'ria and easy(r'isa(ility5 point to amyloidosis as the etiology. t can also present with way s)in,macroglossia, hepatomegaly, and peripheral 4carpel t'nnel5 and or a'tonomicne'ropathy 4orthostatic hypotension5

1@*"eta8bloc#ade is the most appropriate initial intervention +or acute aorticdissection* ype A dissection involved the ascending aorta and are treated4ith medical therapy and surgery. 4hile type " dissections involves onlydescending aorta and are treated 4ith medical therapy alone*

1>*$epatoG'g'lar re=' is a 'se-'l clinical tool that can dierentiate (etween cardiacand li&er disease related ca'ses o- lower etremity edema. atient with peripheraledema d'e to heart -ail're ha&e ele&ated Q6 and positi&e hepatoG'g'lar re='. >hose with peripheral edema -rom primary hepatic disease and cirrhosis ha&ered'ced or normal G'g'lar &eno's press're and negati&e heaptoG'g'lar re='.

1?* % (ic'spid aortic &al&e is the ca'se o- aortic stenosis in the maGority o- patients'nder 7# years o- age.

1*@6, systolic m'rm'r that shortens with s<'atting5)* "ec#Js triad( Decreased le+t ventricular preload5!* "eta bloc#er overdose presents 4ith bradycardia. hypotension.

4heezing. hypoglycemia. delirium. seizures. and cardiogenic shoc#* I,

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:uids and atropine are the /rst line treatment options* I, glucagon shouldbe administered in patients 4ith pro+ound or re+ractory hypotension*

51* iacin :ushing( prostaglandin induced peripheral vasodilation and canbe reduced by lo4 dose aspirin*

55*Evaluation o+ chest pain :o4 chat56*Characteristic o- R6@

a* 2ymptoms o- myocardial inG'ry 4chest pain, diaphoresis, dyspnea5b* $ypotension 4d'e to decreased le-t heart flling5 > with ormal Saline

"olusc* Distended G'g'lar &eins with clear l'ng felds 4d'e to R6 o(str'ction5

5*Diagnostic approach s'spected aortic dissection5@* atient presentation: recent 'pper respiratory tract in-ection, dyspnea, ele&ated

G'g'lar &eno's press're, clear l'ng felds, and increased cardiac silho'ette on CIR His s'ggesti&e o- cardiac tamponade d'e to a large pericardial e'sion. H ?on9palpa(le point o- maimal imp'lse

*7. @o(it type 1 heart (loc)*8. Lidocaine is a class 1B anti9arrhythmic dr'g that is eects against a &ariety o-

&entric'lar arrhythmias. t is 'sed prophylactically to pre&ent 69/i( in patients withac'te @. >he pro(lem is lidocaine increases the ris) o- asystole.

*;. $ypertrophic cardiomyopathy H >reatment Beta Bloc)ers#. Basilar crac)les that etend hal-way 'p the l'ng felds (ilaterally H /'rosemide6!* $ereditary hemochromatosis: Cardiac conduction abnormalities61*%pproach to sin's (radycardia65* ellow e'date with high amylase content: +sophageal per-oration66*K+RD H omepraole, +CK stress testing re&eals 1 mm 2> segment depression in

the in-erior leads at ;#N o- predicted maimal heart rate,6* >his patients presentation 4eertional dyspnea, paroysmal noct'rnal dyspnea,

p'lmonary and peripheral edema5 and history o- @ s'ggest decompensationsystolic C$/. Decreased renal per-'sion seen in C$/ and s'(se<'ent R%%2acti&ation leads to increased %ngiotensin " le&els. %ngiotensin ca'sed n'mero'seects incl'ding:

a* 6asoconstriction o- (oth the aerent and eerent glomer'lar arterioles,leading to an increased in renal &asc'lar resistance and a net decrease inrenal blood :o4

b* Pre+erential vasoconstriction o+ the e9erent renal arterioles, whichincreases intraglomer'lar press're in an attempt to maintain ade<'ateglomer'lar fltration rate.

c. Direct stim'lation o- sodi'm rea(sorption in the proimal t'('les andincreased secretion o- aldosterone -rom the adrenal glands, which in t'rnpromotes -'rther sodi'm resorption in the cortical collecting t'('le. >heseactions lead to decreased sodium delivery to the distal t'('le and anincrease in the etracell'lar ='id &ol'me.

6@* When a patient eperience rec'rrent 6>, the frst thing to do a-ter sta(iliing apatient is to search -or an 'nderlying ca'se. +lectrolyte im(alance d'e to thedi'retics.

7. @ar-ans 2yndrome J early diastolic m'rm'r8. +ertional heat stro)e, temp a(o&e 1# degrees;. +&al'ation o- Chest pain in the +mergency Department0#. atients with possi(le %C2 sho'ld recei&e %spirin, it inhi(its throm(oane %"!*$enovascular hypertension( Angioplasty 4ith stent placement

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1*Syncope re+ers to an abrupt and transient loss o+ consciousness 4ith losso+ postural tone. +ollo4ed by spontaneous and complete recovery*

5*he clinical presentation F pleuritic chest pain. dyspnea. tachypnea. andtachycardia in a long8distance truc# driver is most consistent 4ith PE*

6* Pulmonary capillary 4edge @ @8!1'. Mi-ed venous O1 Saturation >?Q(@8>Q' F Spetic Shoc#

*$enovascular hypertension should be suspected and evaluated in the+ollo4ing situations(

a. +le&ation in ser'm creatinine !*#N -rom (aseline a-ter starting %C+ inhi(itoror %RB (loc)er

(. 2e&ere hypertension in patients with recurrent :ash pulmonary edemac. 2e&ere hypertension in patients with di9use atherosclerosisd. O(set o- se&ere hypertension a-ter age 00e. $ypertension in a patient with asymmetric #idney sie or a small atrophic

'nilateral )idney-. resence o- an a(dominal (r'it

03. War-arins eect is increased (y %cetaminophen and 22Rs increased (leeding ris)07. Costochondritis: @2S pain tenderness to palpation o&er the stern'm, pain worsens

somewhat with inspiration

?* >hiaide di'retics ca'se hyperglycemia, increased LDL cholesterol, and plasmatriglycerides. +lectrolyte a(normalities that can (e ind'ced (y thiaide di'reticsincl'de hyponatremia. hypo#alemia. and hypercalcemia*

*Possible ischemic heart disease E-ercise EB%@)*+lectrical cardio&ersion is indicated -or s'stained monomorphic &entric'lar

tachycardia who are hemodynamically unstable, p'lseless, or se&erelysymptomatic. Hemodynamically stable patients can frst (e gi&en antiarrhythmic4, Amiodarone5 as these may leads to sin's rhythm and a&oidance o- the need-or cardio&ersion.

@!*Digitalis toicity: %trial tachycardia with %6 (loc) is the arrhythmia most specifc -ordigitalis toicity.

@1*+tremely ele&ated CS: 2top sim&astatin@5* >his patients mar)ed hypertension and ac'te )idney inG'ry in the setting o-

systemic sclerosis 4scleroderma5 s'ggests scleroderma renal crisis 42RC5 2histocytes

@6*%R J wide p'lse press're@*PS, is most common paroysmal tachycardia in people witho't str'ct'ral heart

disease, immersion in cold ice 4ater, increase &agal tone, and decreased %6node cond'cti&ity.

@@* >he pulmonary veins are most common +ocus o+ atrial /brillation. %trial='tter commonly in&ol&es a reentrant circ'it aro'nd the tric'spid ann'l's.%trio&entric'lar nodal reentry circ'it -ormed (y " separate cond'cting pathwayswith the %B node. %trio&entric'lar re9entrant tachycardia is d'e to a reentrantcirc'it in&ol&ing an accessory atrio&entric'lar (ypass tract.

@>*P Syndromea* $+@OD?%@C%LL 2>%BL+: 6 BU>LD+ OR ROC%?%@D+ 2 R+/+RR+Db* $+@OD?%@C%LL U?2>%BL+: +L+C>RC%L C%RDO6+R2O?

@?* Acute limb ischemia -rom arterial occl'sion. @aGor so'rces o- arterial em(oliincl'de

a* L6 >$RO@BU2

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b* >$RO@BU2 4U2U%LL L+/> %>R%L5 /ORO@%>O? DU+ >O %>R%L/BRLL%>O?

c* %OR>C %>$+RO2CL+RO22@*,E$ICC0A$ A$$H<HMIAS, incl'ding &entric'lar premat're (eats, non9

s'stained &entric'lar tachycardia, and &entric'lar f(rillation, are <'ite common inthe immediate post9myocardial in-arction period. 6entirc'lar f(rillation is the most-re<'ent 'nderlying arrhythmia responsi(le -or s'dden cardiac arrest.

7#. %-ter inserting central &eno's catheter, a chest ray sho'ld (e done right away.

Complications incl'de arterial p'nct're, pne'mothora, hemothora, throm(osis,air em(olism, sepsis, &asc'lar per-oration, and myocardial per-oration leading totamponade. Q6 is lateral to the CC%.

71. 'ls's parado's: a -all in systolic B !1#mm$K d'ring inspiration. 2een inasthma and COD.

7". Restore coronary (lood =ow, >C% door to (alloon time o- ;# min'tes, whenf(rinolytic are 's'al, door to needleE time o- *# min'tes is the goal.

7*. B greater in the right than in the le-t in patient with cooarctation.7. Orthostatitics drop in "# systolic, 1# diastolic, decreased age phenomenon o-

(aroreceptor responsi&enesss70. Despite ad&ances in therapy, the o&erall s'r&i&al rate -or patient with s'dden

cardiac arrest remains <'ite poor. >he most important -actors in impro&ing ]patientss'r&i&al are prompt eecti&e res'scitation with adeLuate bystander CP$prompt rhythm analysis. and de/brillation in patient -o'nd to (e in &entric'larf(rillation.

73. %ge depended idiopathic sclerocalcifc changes are the most -re<'ent ca'se o-isolated aprotic stenosis in elderly patients. >he changes are common and 's'allyha&e minimal hemodynamic signifcance, ('t sometimes may (e se&ere.

77. eipheral edema is a common side eect o- CCB therapy, with a reported incidento- approimately "N a-ter 3 months o- therapy. >he edema is li)ely related topre-erential dilation o- precapillary &essels 4arteriolar dilation5, which leads toincrease capillary hydrostatic press're and ='id etra&asation into the interstitial.D$ CCBs s'ch an amlodipine and ni-edipine are potent arteriolar dilators andca'se more peripheral edema the non9D$ CCBs incl'de headache, ='shing anddiiness.

78. " wee)s wea)ness, low grade -e&ers, and eertional shortness o- (reath, he alsohas fngertip pain, and say that his 'rine has (een dar) and clo'dy recently, On A+se&eral o- his proimal and distal interphalangeal Goints are swollen. Which o- the-ollowing diagnoses is most consistent with his presentationZ Rhe'matic /e&er

7;. $yponatremia in patients with congesti&e heart -ail're parallels the se&erity o-heart -ail're and is an independent predisctor o- ad&erse clinical o'tcomes. t isca'sed (y increased le&els o- renin, norepinephrine, and %D$. >reatment in&ol&es='id restriction, %ntgiotensin con&erting enyme inhi(itors, and loop di'retics.

8#. Chagas Disease H >rypansoma Cr'i CIR re&eals prominent cardiomegaly,presence o- an 2*

81. Dipyridamole can (e 'sed d'ring myocardial per-'sion scanning to re&eal theareas o- restricted myocardial per-'sion. >he redistri('tion o- the coronary (lood=ow to non9diseaseE segments ind'ced (y this dr'g is called coronary stealphenomenon.

8". ost'ral or orthostatic hypotension is a common ca'se o- syncope in elderlypatients d'e to impaired (aroreceptor sensiti&ity 4a'tonomic -ail're5 or &ol'medepletion* "lood urea nitrogenserum creatinine ratio increases with

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increasing se&erity o- hypo&olemia and is a sensiti&e 4('t not specifc5 indicator o-hypo&olemia.

8*. solated systolic hypertension is a important ca'se o- hypertension in elderlypatients, and it is ca'sed (y decreased elasticity o- the arterial wall. 2$ sho'ldalways (e treated d'e to its association with an increased ris) -or cardio&asc'lare&ents. nitial treatment in&ol&es monotherapy with a low dose thiaide, an %C+inhi(itor, or a long9acting calci'm channel (loc)er.

8. /eat'res o- atrial f(rillation on +SK incl'de an irreg'larly irreg'lar R9R inter&al with

a(sent wa&es and narrow R2 complees. n 'nsta(le patient immediate DCcardio&ersion sho'ld (e per-ormed.

80. War-arin or target specifc oral anticoag'lants 4ri&aroa(an, apia(an, da(igatran5sho'ld (e 'sed to red'ce the ris) o- systemic throm(oem(olism in patients withatrial f(rillation 4%/5 and moderate to high ris) o- throm(oem(olic e&ents 4C$%D2 "2core 6%2C 2core !"5 atient with lone %/ 4score #5 are at low ris) o- systemicem(oliation and anticoag'lant therapy is not indicated.

83. ressors s'ch as ?+ 4alpha91 agonist properties5 can ca'se ischemia o- the digitalfngers and toes secondary to &asospasm. >he diagnosis is s'ggested (y symmetricd's)iness and coolness o- all fngertips.

87. $emodynamics in heart -ail're: Low C, $igh 26R, $igh L6+D6

88. +chocardiogram H %28;. % patients le-t lower etremity is cool and pale (elow the )nee. ?either the

posterior ti(ial or the dorsalis pedis p'lse is palpa(le. Which medication co'ld ha&epre&ented thisZ War-arin

;#. %n a(normal 2 4atrial gallop5 can (e heard in most patients d'ring the ac'tephase o- o- myocardial in-arction d'e to ischemia ind'ced myocardial in-arction.42'(sternal discom-ort, le-t9sided nec) pain, diaphoresis, and dyspnea is consistentwith %C25

;1. Dia(etic patients age #970 sho'ld (e treated with statin therapy in addition toli-estyle modifcation and gl'cose control. >hose with a 1# year ris) o-atherosclerotic cardio&asc'lar disease M 7.0N sho'ld recei&e moderate intensitystatin therapy, and those with a ris) o- ! 7.0N sho'ld recei&e high intensity statintherapy.

;". $ypertrophic Cardiomyopathy H %D;*. %lcohol and to(acco and re&ersi(le ris) -actors -or %Cs. Beta (loc)ers are o-ten

help-'l in patients who are symptomatic.;. C$/: Dilated &entricles with di'se hypo)inesia;0. %ssymetric septal hypertrophy is present in hypertrophic cardiomyopathy.;3. Concentric hypertrophy o- the heart is seen -ollowing chronic press're o&erload

incl'ding aortic stenois and 'ntreated hypertension.;7. +ccentric hypertrophy de&elops -ollowing chronic &ol'me o&erload as seen in

&alc'lar reg'rgitation.;8. @itral stenosis is characteried (y a mid9diastolic m'rm'r and an opening snap.;;. Dilated cardiomyopathy can (e seen -ollowing &iral myocarditis, partic'larly a-ter

Cosac)ie B in-ection. Diagnosis is made (y echocardiogram, which typically showsdilated &entricles and di'se hypo)inesia res'lting in systolic dys-'nction 4loweGection -raction5 >reatment is largely s'pporati&e in&ol&ing mainly themanagement o- C$/ symtpoms.

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