panre and pance review cardiovascular i

21
Cardiovascular I oooooooooalooooooaoooooaoaoaooaoooooooooooaaooaooaooaoo Dr. Donald Sefcik Donald J. Sefcik is the Associate Dean at the Chicago College of Osteopathic Medicine (CCOM), Midwestern University (MWU), in Downers Grove, IL. He is a tenured professor and board certified in both Emergency Medicine and Family Medicine. From June L997 through May 2000, Dr. Sefcik served as Medical Director for the Physician Assistant Program, College of Health Sciences (CHS), at MWU. Dr. Sefcik's lectures are based upon his experiences as a clinician and preceptor, tenure as a medical school faculty member, and his student assessment research. Dr. Sefcik has practiced with physician assistants since 1988 and been involved in the clinical training of physician assistants since 1990. Prior to joining lVlidwestern Universrty's faculty, Dr. Sefcik was a faculty member in the Pharmacology Department at Butler University and in the Nursing Department at Marian College, both in Indianapolis, Indiana. Dr. Sefcik has a Bachelor of Science in Pharmacy (1981), a Master of Science in Pharmacology (1994), both from Butler University, ffid an MBA (May 2004) from Purdue University. CME Resources Certification & Recertification Exam Review www.thepalife.com

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Page 1: PANRE and PANCE Review Cardiovascular I

Cardiovascular I

oooooooooalooooooaoooooaoaoaooaoooooooooooaaooaooaooaoo

Dr. Donald Sefcik

Donald J. Sefcik is the Associate Dean at the Chicago College ofOsteopathic Medicine (CCOM), Midwestern University (MWU), inDowners Grove, IL. He is a tenured professor and board certified in bothEmergency Medicine and Family Medicine. From June L997 through May2000, Dr. Sefcik served as Medical Director for the Physician AssistantProgram, College of Health Sciences (CHS), at MWU. Dr. Sefcik's lecturesare based upon his experiences as a clinician and preceptor, tenure as a

medical school faculty member, and his student assessment research.

Dr. Sefcik has practiced with physician assistants since 1988 and beeninvolved in the clinical training of physician assistants since 1990. Prior tojoining lVlidwestern Universrty's faculty, Dr. Sefcik was a faculty member inthe Pharmacology Department at Butler University and in the NursingDepartment at Marian College, both in Indianapolis, Indiana. Dr. Sefcik hasa Bachelor of Science in Pharmacy (1981), a Master of Science inPharmacology (1994), both from Butler University, ffid an MBA (May2004) from Purdue University.

CME ResourcesCertification & Recertification Exam Review

www.thepalife.com

Page 2: PANRE and PANCE Review Cardiovascular I

CertiJication & RecertiJication Exam ReviewCME Resources

2004

Cardiovascular Medicine - IDiagnostic Modalities and Murmurs

Donald J. Sefcik, D.O., FACOEPLearning Objectives

Upon completion of this portion of the review course, the participant should be able to:

L Discuss the following common cardiovascular diagnostic tools:Chest x-rays

o Electrocardiographs(EKC). ExerciseElectrocardiography(StressTests). Echocardiography. CardiacCatheterizationo Ultrafast CT scans

2. Differentiate left-sided and right-sided heart murmurs.3. Compare and contrast the following systolic and diastolic murmurs:

r Aortic stenosise Aortic regurgitationo Mitral stenosiso Mitral regurgitation (including MVP; Barlow's syndrome). Right-sided valvular defects

4. Define and describe Rheumatic heart disease.o Discuss Jones criteria.

5. Discuss endocarditis and its classic features.6, Compare and contrast Roth spots, Osler's nodes and Janeway lesions.

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Page 3: PANRE and PANCE Review Cardiovascular I

Certification and Recertification Exam ReviewCardiology - I

2004

Case 1

A 64 year-old female presents complaining of crushing chest pain. She also advises youthat she is nauseous and is experiencing indigestion. She is notably diaphoretic. Herblood pressure is 124178 mm Hg. Her 12lead EKG reveals regional ST segmentelevation, Her rhythm strip is included for your interpretation.

Case 1 .1

Which one of the following myocardial infarctions is most likely?

A. anterior aspect of the left ventricleB. posterior aspect of the right ventricleC. inferior aspect of the left ventricleD. lateral aspect of the left ventricleE. anteriolateral aspect of the left ventricle

Case 1.2Which one of the following best describes the rhythm strip?

A. first degree AV blockB. second degree AV block, Mobitz type I - i,"., tl ir'' tr'"r'ir:'t L{'*

C. second degree AV block, Mobitz type llD. complete heart blockE. Wolf-Parkinson-White syndrome

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Page 4: PANRE and PANCE Review Cardiovascular I

Certification and Recertification Exam ReviewCardiology - I

2004

Gase 2

A 36 year-old male presents complaining o{lgft-qggq ngrnlgqs for the past severalhours. He relates that he is in excellent heailh-?ndmsnTseen a clinician since highschool. His examination reveals murmurs, loudest at the aortic listening post,grades lllA/l systolic and llful diastolic.

Case 2.1Which one of the following would most expeditiouslydiagnosis?

A. echocardiogramB. fundoscopic examinationC. examination of peripheral pulses /D. complete neurological examinationE. CT scan of his brain

provide support for your initial

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\ ff tfre patient began to complain of a headache during your evaluation and then became'obtunded, which of the following would you suspect as the most likely cause?

a

laCUnar infarCtion l- s,rrr.\\ r*tv.{ ( I

rupture of a berry aneurysmcw^. ,n :;;Ze- -- c.[*t,'*E;c rX \{10 \

marked ischemia of the left parietal lobemarked ischemia of the right occipitat loUet) nr + .\e{ie *,9West Nile Viral encephalopathy

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Page 5: PANRE and PANCE Review Cardiovascular I

Certification and Recertification Exam ReviewCardiologY - I

2004

Case 3

A 62 year-old female presents complaining of palpitations. She has experienced two

previous episodes that lasted only a few minutes. This episode has lasted two hours' She

is mildly short of breath, mostly because of anxiety. She denies chest pain. Her rhythm

strip is included for your interpretation.

A. quinidine t ^B. lidocaine - c^\ *!f..'\rz -*'C. amiodarone'v*-*..-r,aD. diltiazem r\1:,'yllr,'n'ta:.E. digoxin "

Case 3.1Wnic-f' one of the following therapeutic choices would be LEAST effective

this arrhythmia?

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Case 3.2Which one of the following diagnostic tests would be the most

definitive diagnosis underlying her arrhythmia?

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at controlling

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likely to provide the

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A. complete blood countB. free serum Ta levelC. 24 hour holter monitorD. HDL cholesterol levelE. serum potassium level

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c,.to st o6 '4 Ci

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Page 6: PANRE and PANCE Review Cardiovascular I

Certification and Recerti{ication Exam ReviewCardiology - I

2004

Gase 4

A 56 year-old male presents complaining of severe tightness in his chest for 45 minutes. Heis a smoker, with longstanding hypertension, diabetes mellitus type 2 and hyperlipidemia.His EKG reveals ST segment elevation (4 mm) and T wave changes.

Case 4.1Which one of the following, if identified on this patient's EKG, supports the diagnosis ofacute myocardial infarction with a positive predictive value of greater than 90%?

A. R waves greater than 11 mm in height in tead avf {LV qA asymmetric T wave inversionLeJ reciprocal sr segment depression ,i;f e\zurr\r-:,,-r =D. multifocal premature atrial complexes v I . r

E. unifocal premature ventricular complexes 'Tt.,r.,,;murA ric\'\c"r','c.

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Case 4.2lf this patient is not having an acute myocardial infarction, which one of the following isLEAST likely the correct diagnosis?

@ rate-related event - g€o e$ w''\ S,\"e-B. myocarditis

1 *r*., c, {\ . (\ .-.-i -_\c. hiperkalemia ls{.-Y\.-rr\'r: T.-T g.\e-rt{ansD' bundle-branch block

-E. acute pericarditis c/

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Page 7: PANRE and PANCE Review Cardiovascular I

Certification and Recertification Exam ReviewCardiology - I

2004

Case 5

A 62 year-old male presents complaining of_sho of breath on exertion for thepast several weeks; now he is short of breath at resl congestiveheartfaiIure.HisexaminationlffiS,SinuStachycardia,bilate-rallowerextremity edema (3+/4+), indirect (bedside) evidence of elevated right atrial pressureand a heart gallop.

Case 5.1Which one of the following is the most specific manifestation supporting a currentdiagnosis of congestive heart failure in this patient?

A. bibasilar ralesB. atrialgallopC. ventricular gallopD. jugular venous distentionE. peripheral edema

@such patients are preload dependent.B. most diuretics are negative inotropes.C. most diuretics are positive chronotropes.D, the ensuing vasoconstriction will reduce peripheral resistance.E. the baroreceptor reflexive response will be bradycardia.

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Case 5.2This patient has documented diastolic dysfunction. Aggressive diuresis in this patientmight cause hypotension because:

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Page 8: PANRE and PANCE Review Cardiovascular I

C e rtificatio n and Recertificatio n Exam ReviewCardiology - I

2004

Gase 6

A 64 year-old female presents to your practice for her first visit. She had a myocardialinfarction two years ago. She currently is asymptomatic, just wants to establish rappotlwith a clinician in her new neighborhood. Her blood pressure is 122174 mm Hg and herpulse is 64. Her total cholesterol is 230, with an LDL of 130. Her BMI is 24. She has noother medical problems. She follows a low fat diet and walks briskly in the mall every day.

Case 6.1

Which one of the following is the most appropriate at this time?

A. no intervention is required

@tart lovastatinC. start cholestyramineD. start metoprololE. order an echocardiogram

Case 6.2Six weeks later the patient presents to the Emergency Depadment complaining of 45minutes of crushing chest pain. She has 4 mm of ST segment elevation in leads ll, llland aVF. Her blood pressure is 142182 mm Hg and pulse is 72. Based only upon whatis known, which of the following should NOT be administered to this patient?

A. aspirin

@diltiazemC. metoprololD. oxygen (2 liters)E. a thrombolytic agent

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Page 9: PANRE and PANCE Review Cardiovascular I

Certificatio n and Recertifrcation Exam ReviewCardiology - I

2004

Case 7

A 68 year-old female presents to your practice complaining of dyspnea on exertion.She advises you that the symptoms began about four weeks ago. She denies chestpain, dizzine_sq qnd orthopnea. During her examination, you auscultate a grade lllA/lelectiorGvsto.l*urmur that radiates into her carotids and into her axilla (loudest in theleft-lateral decubitus position). \

\ [\os- s\erorn

cause of the murmur that you hear?Case 7.1Which one of the following is most likely a

A. aorlic regurgitation -b,tr>tB. mitral regurgitatiop - -slsrui',L-C. pulmonic regurgitation rr nD. iricuspid ste-nos-is ) l)'cn'sotlcE. Austin-Flint murmur

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Case 7 .2Which of the following sets of EKG findings would you expect to find on her EKG?

A. low voltage and sinus tachycardiaB. R waves in lead V5 less than 10 mm in height and right axis deviationC. S waves in lead V2 less than 5 mm in height and left axis deviationD. right atrial enlargement and right axis deviationE. P waves in lead ll greater than 3 mm in width and P waves in lead V1

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Page 10: PANRE and PANCE Review Cardiovascular I

Certification and Recertification Exam ReviewCardiology - I

2004

Case 8

, SNI_A patient is noted tofauera'grade lllA/l crescendo-decrescendo systolic murmur thatbegins well after th{S1 heart sound. The murmur is most notable at the lower leftsternal border. The cErotid pulsation rapidly rises.

Case 8.1Which of the following is the most likely cause of this murmur?

n*-mitral-stenosis - c\B, mitral regurgitation 3

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E. hypertrophic cardiomyopathy -.$-f,1

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Case 9

A 76 year-old male presents after a syncopal episode. He is currently asymptomatic.Historically, he advises you thai he has suffered from exertional dyspnea and anginalchest pain. His blood pressure is 114196. 1. e1,ri_.

a 3D$3' r-v13',.'q

Case 9.1 r_t C +t FWhich of the following is most likely to be discovered during his examination?

j4raOe llA/l @pmurmur at lower left sternal border iff;::: llifll :fiHi:illi;li:liiijil::htsterna'|

border : sec.'r ,n^rn.,th l n"o*-fropening snap .- v,^.'k'\ S kar)-, )-E-+ridsystolic click - p1\,1p)<-

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Page 11: PANRE and PANCE Review Cardiovascular I

,Selecferl Cardiovas cular Diagnostic Tools

I. Chest X-Ray (CXR) q

o Pulmonary veins - more horizontalr Pulmonary arteries - more vertical

b, Aortic coarctation. Absence of aortic knob. Rib notching (secondary to elevated intercostal arterial pressure) , . \

r Ml Consider in younger patients refractory to therapy ( <\',c' 5lur I h 1U )

6.inn\o''-

- t '/ Brachial-femoral blood pressure and pulse disparities

nctfa t .a tc. Pulmonarv edema' L Fl {'*\/J\d}'-'

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:, n- ) . [email protected] lines in basal periphery; interstitial fluid)

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d. pericardial .tirion \- us:'\ [q \-*-Y " J.

o "water bottle " heart (not an acute chanee)^ .-^,f::=),^-^lr]l --,-- --;,. nol{lechocardiographyj confirms; quantifies fluid

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2. Exercise Electrocardiography fStress Tests]

a. assesstnent for coronary artery disease (70% sensitive detection; 75Yo specifieity exclusion)

b. various protocolsr Bruce - degree of eievation and speed changed every 3 minutes. Naughton - degree of elevation changes every 2 minutes. Echocardiogram (check for wall motion changes - hypokinesis)

c. Interpretation:o How farllong did the patient go ? [< 3 minutes - high risk]

' Symptoms ?

. EKG Changes ?** ST segment changes - horizontal or down-sloping ST segments = very suggestive CAD

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a. General usefulnessRapidly assesses cardiac silhouette and occasionally individual chamber changeso Heafi:thoracic ratio > 0.5 - cardiomegaly on upright posterior-anterior (pA) film,/ Cardiac silhouette - measured from midline to the right and to the left,/ Transthoracic diameter measured at height of right hemidiaphragm

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II. Patient Conditions

-" t' $'J [k'dt' f h ''s1. Electrocardiogram (EKG) ? i'ct

Discussed in Chest Pain and Myacardial Infarction section

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Page 12: PANRE and PANCE Review Cardiovascular I

Ar..,-{\"^I Juas n;* Ptffi:*e '

d. Perfusion Scintigraphyr Thallium-2}| (apotassiumanalog)

- Injected at peak exercise; images ASAP afterwards and at 2 - 6 hours* infarcted - "cold" spot; stays cold* Ischemic - "cold" spot; reperfuses

. Usdul: Abnormal resting EKGs (BBB); Equivocal Treadmill stress tests

. More accurate for determining extent and dislribution of ischemia

tkl7" r L+\s*rrs5Lrn\ Lrr (;-)

".,c r-frH- coronary arterial anatomy- hernodynamics

b. Significant narowing - defined as at least 70% luminal narrowingr Note: 70% luminal narrowing corresponds to 50Yo reduction in cross-sectional area

c. Therapeuticstratification. Low risk - Single vessel disease (usually do well with medical therapy). High risk - Triple vessel disease (with decreased left ventricular function)

Left Main Coronary artery disease

II,/Y

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3. Cardiac Catheterization

a. Best test to "get the answer"

4. Ultrafast CT Scans

a. identifies coronary arterial "calcifrcation,,b. Does not visualize (quantify) all "blockage"c. Noninvasived. Role as a "Screening Test"?

B, Valvular Heart Disease

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1. Echocardiography (Transthoracic - adequate for - 90 % ofcases)a. assessment of valvular disordersb. assessment of cardiac ejection fractionsc. assessment of charnbers/wall motiond. quantifies pericardial effirsionse. Doppler echocardiography measures blood flow velocityf. assessment of ventricular thrombusg. can coupie with Exercise Electocardiography

r Transesophageal approach: rA- better views of left atrium; mitrai valve and thoracic (ascending) aorta ( PqSfCta,n

C;\n)'rlxz'r

2. Cardiac Catheterization

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Page 13: PANRE and PANCE Review Cardiovascular I

C. Anltythmias

1. Electrocardiogram (EKG)

a. If patient symptomatic at the time:. may provide definitive diagnosis or rule out anhythmia

b. If done between symptomatic episodes, may provide ,,clues',:

. Long QT interval

2. Ambulatory Monitorsa. Holter Monitor - 24 hoursb, Event Recorder - days - weeks - months... ...

(

.Pre.excitationsyndromes(shortPRinterval)A.,v,y\+f4/^\<i. Wolf-Parkinson-White $MpW) - delta wave pre$entii. Long-Ganong-Levine o-cl.) -no delta;;*' [

- 'i g F -a - e\4d ,tv\'u\^ii. Long-Ganong-Levine 0-GL) - no delta wave \

;

-ong QT interval I I sVnabi

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3. Signal-Averaged EKGMonitors high-frequency, low-amplitude signal from terminal portion of QRS complexThe presence of late potentials is suggestive of a risk for ventricular anhythmias

4. Electrophysiologic (EP) Studies

Intracardiac catheters - stimulate and record cardiac events

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Page 14: PANRE and PANCE Review Cardiovascular I

Valves

* Afrioventicuiar: fught - TricusPidLeft - Mitral

* Semilunar: Left - AorticRight - Pulmonic

Heart Solutds

Mechanisms:1. Valve Vibrations2. Walis of Chambers3. Vessels

Diaphraqm:

S1 (Lubb) - onset of systole (AV Valves)

52 (Dubb) - onset of diastole (SL Valves)

,-+ * solit s2\t-\-(--A2- Aortic Valve Closwe

\ Pz- Pulmonic Valve Closure

* Venticular Hyperrophy (LVH)

AUSCULTATE: (first with diaphragm' then bell)

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**-GALLyEE- * Di**obtL hect* Lt)-nvt

C\\ f S3) Vent'icular Gallop (Passive Venticular Filling)

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Enhanced bv.' +Dilated Venticte(cnrLj

*w\._ RapidFilling(anemia'thyrotoxicosis) R 5ro"gs oF pe.)pr- ;

f;t\r,.\*.-^:#. s4-AtrialGallop(ActiveVentricularFilline) P\rrv\"'''t S 3'L'()

-tqw,r- J ,lurrr-., Enhancedby, ofiance ts\€\d.$ft?I\ Y,]*5

L Act,rc- pir-,r*rr) ffi'-F-4'-birn\?te- fuJ\r.rtr1Przgr*Jt,

C"\Aortic area (2nd right ICS, RSB)Pulmonic area (2nd left ICS, LSB) -

Second pulmonic area (3rd left ICS' LSB)Tricuspid area (4th and 5th left ICS' LSB)Apex or mitral area (5 left ICS in MCL)

Ct.> f\

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Page 15: PANRE and PANCE Review Cardiovascular I

:6MURMURS

A. What ????

a. Relatively prolonged exta heart soundsb. Heard in Systole or Diastole or Bothc. Caused by turbulent blood flow into/through/out ofthe heartd. May be benign or pathologic

B. Descriptions ????

a. Timing & DurationEarly Systolic, Midsystolic (Ejection), Late SystolicEarly Diastolic, Middiastolic, Late Diastolic (Presystolic)Holosystolic (Pansystolic)Holodiastolic (Pandiastolic)Continuous

b, Intensity

Grade IGrade IIGrade IIIGrade IVGrade VGrade VI

c. Location

Jugular Venous PulsationsC4. ir.re^W: !\)ne- =B,f;- Ld(^\'t- '=

Barely AudibleQuiet, but clearly audibleModerately Loud

--.Loud and Associated witrr ffiiD- rnt r[ 6t t ( , r ' 6Very Loud, Thrill easily pu$E5t/Audible with Stethoscope not in contact with chest and thrill is visible

Auscultatory area - area ofgreatest intensity

"x" Slope: RA relaxation duringRV Systole(TV is closed)

"a" wave = right atial contraction

c" wave = closure tricuspid valvecarotid activity

'ar-' ('\2'p, J, *'*\r'icrs' S, \4

wave = venous filling(volume) of RA

"y" slope = RA emptying duringRV Diastole

(TV is open)

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Page 16: PANRE and PANCE Review Cardiovascular I

gS'L rcrur.^\^ts

C/rfe_

Left s'*"JSYSTOLE

DIASTOLE

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Page 17: PANRE and PANCE Review Cardiovascular I

aLeft-Sided Valvular Problems

Aortic Stenosis (AS)

Symptoms:

Signs:

c. If symptomatic - sugery, generally - therapy of choice

----*--

A o rtic Re g urg it ati o n (AR)

u. Oft .fu!gg-ut!!g rdgid congenital, infl ammatory/infectiousb. Blood retums to left venticle during diastole

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a. one(gggenqln origin (bicuspid), calcific changes tn@ rheumatic feverb. Causes left ventricular outflow obstruction (during systole)

DJpryu, Angina, Syncope, Fatigue, Weakness

sro* ririnJ.-oron*.frr.. t*"r **r .t tardus;f,Diffuse left ventricular impulse 'r( *-Systolic murmur (often diamond shaped) /'Left venticular hyperlrophy )r

Symptoms: Dyspnea on exertion (DOE), Angina, SyncopePalpitations, Orthopnea/PND, Chest Pain

Signs:

N\'=--\B1 \i

S1\i b' *'h- ? fuHrr"a..

.-.d Mitrat stenosis (MS) '{: }az '..*' : 5fl,^ ,KAtf,'

)t-v .-s\.a. Often\rheurnatic in origin\more common in women (- 3F:lM)b. ElevatidTEft-atriffiGEiil. \p F

Symptoms: DyspneaiDoE, orthopneai?ND, Pulmonary edema, Angina He^t'r\" '*}T-Y--It)!r *uu\> \

Signs: ffi*' (9 [""*-)Pulmonaryhypertension/edema

(-\atrial arrhythmias ._\. - , \J

c. Medicai: Atrial fibrillation - anticoagulation and digitalis * ?' ?-^ J,^,fSurgical: Valvuloplasty, Commissurotomy, Replacement {-xr ) tn

Diastolic murmur (Often 53; occasioni

c, Ifacute - surgeryIf chronic - sugery, once symptomatic

Often 53; occasionally 54

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Page 18: PANRE and PANCE Review Cardiovascular I

,$"Mitr al Re g ur g itatio n (M R)

a. Many etiologies:

kArutq infective endocarditis, chorda tendinae rupture, papillary muscle infarction...

Chronic: Blsumatic-dsease, congenital, calcification of annulus....* generally - best tolerated of valwlar iesions

P)I--Z.ZIa '{g^q \* Commofr-Sp-to T0Tlo of females ?)* Most common cause of MR* Myxomatous changes (may be part of Marfan's syndrome)* Floppy valve - Click* Barlow's syndrome - MVP + Quasicardiologic symptoms

- - 80 % of all patients may be symptomatic- nonspecific chest pain, palpitations, shorfness of breath....

b. Syrnptomatology -

Symptoms (acute): Dyspnea/PNDSymptoms (chronic): Waxing/Waning Shortness of Breath and Fatigue

Signs (acute): Pulmonary edema

Signs (chronic): LVH, Pulmonary hypertensionatrial fibrillation

c. Ifsevere - surgery

f);rpncrr. un t'{tl um'

v

O;"r'dk'

Lesion Sy Signs Notes

UUbAnginaSyncopeOrthopnealPND

Earlv drastollc murmurD-ggssggrrdoWide oulse DressureBoundins pulses-Siffiff ;i- -"r, r

^,l'\'o L.\r

54 (occasionally)LV Heave

Louddf-> 7Cslttlngleaning forwardfull exhalation

AS DOEChest Pain (angina)Syncope

Late-peaking Systolic murmur(Pulsus parvus et tardusLV HeaveS4

\-.Loufrr", '}f--s-min-g

leaning forward

MR AcuteDyspnea, pulmonary edemaChronicWaxingAVaning dyspnea

Holosystolic murmurWide splits 52Atrial fibrillation

RadiatesAoex to axilla

DOEPND

,ll*-=. r,.r i \ C^ C

Diastolic Rumble-,,.+( ODenrns snaD-\iilaff

I-nr&+l9!-1aleraldecubitusoosition

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Page 19: PANRE and PANCE Review Cardiovascular I

@turmurs of Childhood

A. Stills Murmur-_. 2-8yearsoid

. low pitched; musical quality

. systolic - grade II - III / VI .r. loudest iftuap.fiil;simfr-\ f

Deep Inspiration* Increases TR

Y Continuous - Patent Ductus Arteriosus (PDA)

"--$

itiorir loudest - midway from low left sternal border to apexr caused by turbulent flow in left ventricular outflow

B. Venous Hum

---5yearsoldr continuous- gradel-III/VI

avicular ion; radiates i neckind or head turned

caused by turbulent flow jugular veins, as pass clavicle

Miscellaneous Murmur Notes

a

a

2. When to worry about Childhood murmurso Loud and Harsh. Holosystolic. Diastolic 4(. Suspiciousassociation:

Loud 52GallopsCyanosisClicksAlteration in pulsesFailure to thrive

3. Murmur Characteristtcs

Diagnostic Maneuvers

:t AR..

fn(

a €"; $e,^\ Res*u At L

($l-

l0

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Page 20: PANRE and PANCE Review Cardiovascular I

Rheumatic I{eart Disease

DefinitionAn inflammatory disease, possibly autoimmune, involving the:

Heart, joints, skin and CNS

Aschoffbody - focal, interstitial myocardial inflammation

Foliows Streptococcal infections - 7 - 35 days (mean - 18 days)

IncidenceMost common in 5 - 15 year oldsRecurrences are common, if not treated with antibiotics (- 20 %)

Clinical Presentation

Joints: Arthralgias -75%-- Migratory LL'lgl*h

Cardiac: Myocarditis, PericarditisValvular VS*MR-60-80 %;Ar-30% 0{:8, Av b\ot

Skin: Erythema marginatum < 5 7o )kSerology: Evidence of Streptococcal infection (4SO tb BUT, negative in up to 10 %)

Jones Criteria(Must have Two Major or One Major and Two Minor)

fplus evidence of Streptococcal infection, recently]

MajorS-gbgg[aneous nodules - 5 - I0 %P-olyarthritis - 75 %E-ryhqma marginatum - < 5 Yo

earditis --65%Chorea-2-3%

** Sydenham's - rare, but very diagnosticPurposeless, rapid, involuntary movementsEmotionally labile

MinorFeverArtkalgias ? !, ^ ^ , \Acute phase reactants - elevated C t \ R' ' g -ig ^t &rrc \Prolonged PR interval (increase of 0.04 seconds or more, over baseline)Previous rheumatic fever

11

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Page 21: PANRE and PANCE Review Cardiovascular I

Infective Endocarditis

Definitionusually an infection ofthe valvular endocardium

r'--:.Valves Q.@t Aortic >> Tricuspid> Pulmonic

al: 1; MVP = , - tf Rh-eumatic Heart Disease =

100F

Be suspiciozts of the NEW cardiac murmur; especially in febrile patients

Special PatientsiSpecial OrganismsIDU - Staphylococcus aureus ('ricuspid valve) { ' -"-.

"- '-, r O' tru G\ s.tL s{ na#t'

Predisposing Risk

- Prosthetic Valves

- MVP* Congenital heart malformations-- Dental procedures (transient bacteremia)

Rheumatic valvular disease

IDUMiscellaneous

NOTE - Reduced risk with Secundum Atriol SePtal Defects

Classic Findine2r' gp5,\ ,.^;" )\ oodo*ri-f - ,o %) - alsoknown as:Litten's sign

ophthalmic (retinal) hemorrhages with central white spots

Osler Nodes (- 5 - 25 %)tender lesions, digital pads

Janeway Lesions (- 2 - 10 %)nontender, nonpalpable, nonblanching - violet colored

Splinter Hemorrhages (- 5 - 15 %)linear streaks subungually

Clubbing (- 10 - 50 %)

DiagnosticsTransthoracic echocardiogam - 45 - 75 %Transesophageal echocardiogram - 90 %

Blood cultures - negative in 5 - 15 % (commonly secondary to antibiotic previously prescribed or HACEK)

[Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella]

tt1

t2

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