Cardiology

1. Clear lung fields
2. Elevated CVP
3. Hypotension

ST segment elevation of V4R

Inferior infarction

1. Normal Saline Bolus
2. Dobutamine if not responsive to fluids alone
3. Beta blockers cause AV node blockade which will actually worsen the situation and nitroglycerin is contraindicated because of the potential for venodilation and hypotension

1. Left main coronary artery disease
2. Severe three vessel disease with reduced left ventricular systolic function
3. Severe three vessel disease with involvement of the proximal left anterior descending artery
4. Diabetics with three vessel disease

1. If mitral regurgitation is present patient needs valve replacement surgery
2. If no MR, then can proceed to balloon valvuloplasty (keep in mind balloon (percutaneous) valvuloplasty can make MR worse)

1. Transmitral pressure gradient > 10 mm Hg
2. Enlargement of the left atrium
3. Mitral valve area less than 1.5 cm2
4. Pulmonary pressures > 50 mmHg

Defined as heart failure with a left ventricular EF < 45% that is diagnosed between 3 months before and 6 months after delivery in the absence of any identifiable cause; usually diagnosed during the first month postpartum

1. NHYA class III or IV heart failure
2. EF less than or equal to 35%
3. QRS > 120 msec

1. JVP demonstrates prominent a wave
2. RV lift and thrill present
3. Ejection click noted close to S1
4. Sound decreases in intensity with inspiration (only right sided sound that decreases with inspiration)

1. Dyspnea, angina, and exertional syncope
2. Small and late carotid pulsations
3. Late peaking systolic murmur loudest at 2nd RICS
4. Absent splitting of S2
5. Sustained apical impulse
6. Murmur radiates to one or both carotids

1. Fixed splitting of S2
2. Equal a and p jugular venous waves
3. RV impulse is present

1. Holosystolic murmur
2. Murmur heard at apex and radiates to axilla without respiratory variation

1. Holosystolic murmur at the left sternal border
2. Increases with inspiration
3. Prominent v wave

Surgical myomectomy

NHYA class II or III and either ishemic or nonischemic cardiomyopathy with a EF 35% or less; ScD-HeFT trial

1. ACEI or ARB
2. Beta-blocker

1. CHF exacerbation
2. Bronospastic airway disease
3. Low BP

1. Beta Blocker - note beta blockers do cross the placenta so fetuses should be monitored
2. ACEIs and ARBs are contraindicated in pregnancy

1. Aneursym diameter 5.5 cm or larger
2. Expansion rate of more than 0.5 cm /year

1. If less 4 cm then every 24 months
2. If 4-5.5 cm then every 6 months

1. PCI
2. Thrombolytic therapy in pts presenting at > 12 hrs has not shown to be of any benefit

1. Hemodynamic instability
2. Paravalvular extension
3. Heart failure
4. Resistant infections
5. Large mobile vegetations

1. Flushing
2. Nausea
3. Poor glucose control

1. Phlebotomy only if they do not have a significant anemia
2. if cannot tolerate phlebotomy proceed to iron chelation therapy

Aortic sclerosis

1. Prosthetic cardiac valves
2. Known history of infective endocarditis
3. Unrepaired congenital heart disease
4. Complex congenital heart disease with residual abnormalities
5. Cardiac transplant recipients with valve abnormalities

p=4v^2

Exercise stress test

1. Adenosine or dobutamine nuclear imaging
2. Dobutamine echo

Adenosine nuclear imaging

Dobutamine nuclear imaging
Dobutamine echo

CT angio or coronary angio

V1-V4 corresponds to LAD
I, AVL, V5, V6 corresponds to Left circumflex
II, III, AVF corresponds to Right coronary artery

Evaluate:
1. Myocardium viability for CABG
2. LV function
3. Tissue characterization (i.e. infiltrative, cardiomyopathies)
4. Myocardial masses

1. RA pressure = 0-5 mmHg
2. RV systolic pressure < 30 mmHg
3. 13-28/3-13
4. PCWP < 12 mmHg

Cardiac Tamponade - tamponade and constrictive pericarditis produce equal pressures throughout the heart

In setting of inferior MI, represents RV infarction

Cardiogenic Shock

Mitral stenosis

Pulmonary hypertension

Pulsus Paradoxus
1. Pericardial tamponade
2. Asthma
3. Tension pneumothorax

Bifid aortic pulse.
1. Aortic regurgitation
2. Hypertrophic cardiomyopathy

Alternating arterial pulse
1. Aortic stenosis
2. Severe LV dysfunction

Anything that blocks blood flow to the lungs from teh right heart

1. Tricuspid stenosis
2. Severe pulmonic stenosis
3. Severe noncompliant RVH
4. Mitral Stenosis

Tricuspid regurgitation

Tricuspid stenosis

Atrial septal defect

Prolonged PR interval, aortic regurgitation, severely calcified mitral valve

Type A (involvement of ascending aorta) require surgery; Type B (descending aortic dissections) do worse with surgery and their BP should be controlled with a beta blocker and a vasodilator (nitroprusside, fenoldopam, or enalaprilat)

In a patient to be evaluated for arrythmias that has infrequent events thorughout the year where a 24 holter may not capture the abnormality

Rheumatic heart disease

1. Mitral stenosis
2. Rheumatic fever

1. NSAIDs i.e. ibuprofen
2. Colchicine as long as no CKD

Vasodilator therapy with Nitroglycerin or Calcium channel antagonsits. Should be treated with benzodiazepines.

HR 55-60 bpm

1. Aspirin
2. ACEI
3. BB
4. Long Acting nitrate
5. Statin

Coronary angiography to see if bypass surgery can be done during valve surgery if needed

Place magnet on chest and it will suscpend the ICDs abiltiy to detect arrhythmias

If they can bring pt to a place that does PCI within 90 mins then proceed with PCI if not then thrombolytics

Constrictive pericarditis

Atrial septal defect

Must meet all of the following:
1. EF less than or equal to 35%
2. QRS duration greater than 120 msec
3. NYHA class III or IV symptoms (symptoms with mild activity or rest) on optimal medical therapy

Criteria for valve replacement:
Pulm valve gradient > 50 or when RV hypertrophy is present

Treatment is via pulmonary valve stenosis

If considering a RV infarction can obtain a right sided EKG and should see ST elevation in leads V3R and V4R.

Pericardial Effusion

1. Rib notching
2. Loss of aortic knob

CT angio

p=4v^2
p = pressure
v = velocity

Exercise stress test

Adenosine or dobutamine nuclear imaging or a dobutamine echo

Adenosine nuclear imaging

Dobutamine nuclear imaging

CT angio or coronary angio

1. Due to closure of the mitral valve leaflets
DDX: Prolonged PR interval, AR, Calcified MV

1, Caused by closure of mitral valve leaflets when they are far apart
DDx: Short PR interval, Hyperdynamic LV function, Mitral stenosis

Delayed RV emptying
DDx: pulmonic stenosis, Pulmonary embolism, RBBB

Caused by delayed LV emptying
DDx: Severe AS, LBBB, HCM

ASD

LV or RV dysfunction, TR, MR< or AR

AS, MR, HCM, LVH

Consider stress tests in patients with low probability of an ACS that have LV EF > 40%

PPI should be added to ASA and clopidogrel

If can undergo PCI in 90 mins then proceed with PCi but if not pt needs reperfusion therapy in 30 minutes

An ACEi should be given if the LVEF is less than or equal to 40%

If pt took sildenafil within 24 hrs, tadalafil in 48 hrs, or vardenafil in past several days

1. Within first half an hour of arrival
2. Within 6 hrs since the onset of chest pain
3. With no contraindications

Contraindications: previous hemorrhagic stroke, cerebrovascular events within 1 year, intracranial neoplasm, active internal bleeding, and suspected aortic dissection

Medications: Streptokinase, tPA, alteplase

If a pericardial effusion is present for at least 3 months with no improvement then a pericardiocentesis needs to be performed

1. In asymptomatic aortic stenosis can proceed with hip surgery
2. In symptomatic aortic stenosis, elective surgery should be postponed until after valve replacement

Hydralazine and isosorbide dinitrate

Pts with NYHA class II or III with an EF of 40% despite optimal medical therapy with an ACEI and Beta-blocker
- Digoxin decreases symptoms and decreases hospitlizations but does not improve survival

Transesophageal echocardiogram

1. Evidence of a left to right shunt with a pulmonary flow to systemic flow ration that is greater than 1.5:1.0
2. Volume overload of right sided cardiac chambers
3. Symptomatic related to defect

1. Myocarditis
2. Supportive care

1. Plavix for at least one month; continued ASA therapy
2. Plavix and ASA for at least one year

Persistent Patent Ductus Arteriosus

1. Beta blocker
2. If symptomatic with Beta blocker consider defibrillator

Pseudo right bundle branch block pattern with ST segment elevation on the EKG and ventricular arrhythmias

Endomyocardial biopsy

BP goal is less than 130/80

Valve replacement is reccomended for asymptomatic pts with a bicuspid aortic valve and severe aortic regurgitation when the left ventricular end systolic diameter reaches 55 mm or the LV EF < 60%; If does not meet the above criteria serial echocardiograms are needed for monitoring

If within 48 hrs does not affect prognosis; If > 48 hrs then associated with poor prognosis

1. Free Wall Rupture
2. Heroic saves with CT surgery

1. Papillary muscle dysfunction
2. CT surgery

1. VSD
2. CT surgery

1. Cardiogenic shock
2. Supportive measures, PCI

1 - 1.29 Normal
0.91 -0.99 Borderline
0.41 - 0.90 Mild to Moderate Disease
Less than or equal to 0.4 Severe disease

1. Smoking cessation
2. Treatment of HTN to JNC 7 goals
3. Beta blockers are not contraindicated
4. Decrease LDL < 100
5. Treat diabetes aggressively
6. ASA for all patients
7. Clopidogrel 75 mg/day is an alternative for ASA
8. Cilostazol (100 mg bid) improves symptoms and increases walking distance (contraindicated in heart failure)
9. Pentoxifyline (400 mg tid) is a 2nd line alternative
10. Most important: Walking to near maximal claudication

1. Lack of response to exercise therapy and claudication pharmacotherapies
2. Presence of severe disability
3. Favorable lesion morphology
4. Acceptable overall prognosis

1. PTA for ilial, femoral, and popliteal lesions < 3 cm in length
2. Stenting is reccomended for iliac lesions

1. Symptomatic patients with stenoses of 50-99% as long as surgical mortality risk is < 6%
2. Asymptomatic patients with stenoses of 60-99% as long as surgical mortality risk is < 3%

1. Aorta > 5 cm
2. Fam Hx of dissection at < 5 cm
3. Rapidly expanding aneurysm
4. Significant AR

1. Loeys-Dietz
2. Aortic surgery if: Aorta > 4.2 cm by TEE; Aorta > 4.4 cm to 4.6 cm by CT or MR

Bicuspid aortic valve, aortic dissection, aortic coarctation, HTN,

EKG, CXR. TEE

1. Beta blockers to keep HR < 60l can give diltiazem or verapamil if BBs are contraindicated
2. If systolic BP is > 120 after BBs then begin ACEIs or other vasodilators
3, Goal is a MAP of 70 mmHg
4. Do not use beta blockers in acute AR
5. Do not use vasodilators prior to beta blockade

Type A - involvement of the ascending aorta
Type B - descending aorta alone

1. If Type A needs surgery as can casue AR, hemopericardium, tamponade, and severe, anterior chest pain
2. Type B can be medically managed as long as there are no complications

1. thoracic aneurysm > 6 cm or an expanding aneurysm
2. If the aneurysm is putting pressure on other structures
3. If the aneurysm is traumatic in origin
4. Any abdominal aneurysm > 5 cm or any expanding aneurysm regardless of size

1. Staph, Strep, HACEK organisms
2. Staph epidermidis

Need 2 majors, 1 major and 3 minor, or 5 minor for diagnosis

Major;
1. Positive blood cultures
2. Evidecne of endocardial involvement (new murmur, echo)

Minor:
1. Predisposing cardiac lesion
2. Fever
3. Vascular phenomena (emboli, aneurysm)
4. Immunologicla pheomena (osler nodes, roth spots, glomerulonephritis)
5. < 2 blood cultures positive
6. Mild echo abnormalities

Painful red lesions on the hands and feet associated with endocarditis

retinal hemorrhages with white centers associated with endocarditis

1. New heart failure
2. Annular involvement or abscesses
3. Fungal endocarditis
4. Antibiotic resistant organisms

1. Prosthetic cardiac valve
2. Previous infective endocarditis
3. Cynotic congenital heart disease that is unrepaired or repaired with a prosthesis
4. Cardiac transplant pts with valvular disease

Need 2 major vs.1 major and 2 minor; either way must have either a positive strep tests or positive ASO

Major: PECCS
1. Polyarthritis
2. Erythema marginatum
3. Chorea
4. Carditis
5. Sibcutaneous nodules

Minor: PEAP
1. Previous rheumatic fever
2. ESR elevated, CRP elevated
3. Arthralgias
4. Prolonged PR interval

Mitral stenosis

Aortic aneurysm - all pts with aortic stenosis should be evaluated for an aortic aneurysm

1. Evaluate for aortic aneurysm
2. Need LHC due to high prevalence of CAD

1. Symptomatic
2. No elective surgeries should be performed on severe aortic stenosis patients without aortic valve replacement

1 - 1.29 Normal
0.91 - 0.99 Borderline
0.41 - 0.910 Mild to moderate disease
<0.4 Severe disease

1. Smoking cessation
2. Tx HTN
3, Beta blockers are not contraindicated
4. Treat diabetes aggresively
5. ASA for all patients with clopidogrel being an effective alternative
6. Cilostazol improves symptoms (contraindicated in heart failure); Pentoxifylline
7. Exercise therapy improves walking distance

1. Lack of response to exercise therapy and claudication pharmacotherapy
2. Severe disability
3. Acceptable overall prognosis

1. PTA is recommended for ilial, femoral, and popliteal lesions < 3 cm in length
2. Stenting is recommended for iliac lesions
3. Surgery is recommended for long or multiple lesions

Claudication of the arch of the foot with walking but not running

Coronary angiography

Pulse delay between upper and lower extremities
Blood pressure in the lower extremities less than the upper extremities
Ejection click and systolic murmur
Systolic and diastolic murmurs heard over the back due to collaterals
rib notching

1. Headaches
2. Palpitations
3. Profuse sweating

1. V/Q scan to rule out PE as cause of pulm HTN
2. Right heart cath to demonstrate elevated pulmonary vascular resistance

Graded exercise to provoke symptoms
IF ABIs in exercise fall by 20% indicates PAD

Pulmonary artery hypertension

Cardiopulmonary symptoms

Lyme carditis. Ceftriaxone till block resolves then oral therapy for 3 weeks. Penicillin is also first line therapy. Third line therapy is oral erythromycin.

1. Prior intracerebral hemorrhage
2. Cerbrovascular lesion (arteriovenous malformation)
3. Ischemic stroke within 3 months
4. Suspected aortic dissection
5. Active bleeding
6. Significant closed head trauma or facial trauma in the past 3 months

Dobutamine or Milrinone

1. symptomatic patients
2. asymptomatic patients: LVEF > 50%, LVESD > 55 mm or LVEDD > 75 mm; LVEF < 55%

Endocarditis
Trauma
Aortic dissection

Tachycardia, hypotension, pulmonary edema
High-pitched decrescendo murmur
No bounding pulses of chronic AR

Cardiothoracic surgery consult
Dobutamine (inotrope)
Nitroprusside (peripheral vasodilation)

rheumatic disease

opening snap heard at the apex
S1 may be loud
Low pitched diastolic rumble heard at apex

Pulmonary artery revascularization
Large left atrium
Normal sized lV

Pts with class 2 to 4 symptoms should have a balloon valvuloplasty or surgery if PBV is not possible
Asymptomatic pts should have a PBV if PA pressure is > 50 mmHg

Rheumatic heart disease
Endocarditis
Connective tissue disease
Ischemia of the papillary muscles

Symptomatic patients
1. LVEF > 30% and LVESD < 55 mm
Asymptomatic patients
1, LVEF < 60% and LVESD > 40 mm
2. LVEF > 60% and LVESD < 40 mm

1. Rupture of a myxomatous chordae
2. Endocarditis
3. Trauma
4. Acute ischemia of the papillary muscle

Tx: Cardiothoracic consult, Dobutamine, Nitroprusside

Rheumatic heart disease

Pulmonic ejection sound in pulmonic stenosis

Anything that increases RV pressure causing dilation of the tricuspid annulus
1. Left heart failure
2. Chronic lung disease
3. Pulmonary emboli
4. IVDA leading to tricuspid endocarditis

Holosystolic murmur heard at the LLSB that increases with inspiration

Valsalva manuever: Increases AS and MR but decreases HOCM

Handgrip: Decreases HOCM, AS but increases MR

1. Poor V relaxation
2. Raised LVEDP (Norm < 10 mmHg)

Involves both decreased systolic function and an elevated LVEDP

Viral, EtOH, Cocaine, Chemotherapy

Signs of right and left heart failure

1. ACE inhibitors / ARBs
2. Beta blockers
3. Spironolactone / Eplerenone
4. Hydralazine/Nitrates in African Americans

Pts with EF < 35% with sy,ptoms but has a complex side effect profile

1. Harsh nonradiating midsystolic murmur
2. Murmur is louder with manuevers that decrease LV volume like valsalva
3. Rapid carotid upstroke

1. Beta blockers, verapamil
2. Resynchronization therapy
3. Septal myomectomy
4. Antiarrythmic therapy
No drug prolongs survival

1. Pulsus paradoxus present in tamponade but not constrictive pericardiits
2. Kussmaul' sign is absent in tamponade but present in constrictive pericarditis
3. Thickened pericardium present in constrictive pericarditis
4. Jugular waveforms: x descent in tamponade but and y descents in constrictive
5. Constrictive affects only filling but tamponade affects both

Primary pulmonary hypertension
Eisenmeger's syndrome

1. Mitral stenosis
2. Secundum ASD

5 Ps
Pain, Pallor, Parasthesias, absent pulses, paralysis

No. Indicates developing neuropathy due to lack of blood flow in severe limb ischemia.

Pacemaker - even if the BB is causing the bradycardia; BB should be continued to prevent rapid HR of afib

Development of rapid atrial fibrillation interspersed with episodes of bradycardia at rest

Pacemaker

1. Hypertension
2. Preserved EF
3. Treat the underlying cause

Decreases hospitlizations but does not improve mortality

They increase venous return decreasing degree of obstruction and decreasing the intensity of the murmur

Hand grip decreases pressure gradient leading to a decreased murmur intensity

22q11; There is a 50% cahnce of their offspring developing heart related abnormalities

Rupture of AAA
Pancreatitis

1. if BB therapy fails then proceed to ablation
2. AV node and His bundle ablation should be done if this fails proceed to MAZE procedure

Pulmonary regurgitation

Can hold for 3-5 days prior to surgery without a heparin bridge given the low risk of aortic valve replacements

If it was a mitral valve replacement or pt had a history of thromboembolism then would use a heparin bridge

Sodium nitroprusside, hydralazine to reduce MAP to less than 60; pressors; IABP

1. Symptomatic
2. EF < 55%
3. LV dilation > 45 mm

Mitral valve repair is preferred over replacement
Do not do mitral valve surgery if LVEF is < 30%