Internal Med EOR: CARDIOVASCULAR

CAD Inad. tissue perfusion/ischemia d/t imbalance between blood supply/demand Atherosclerosis MC cause Risk factors: DM worst, smoking (most imp. modifiable risk factor). Also hyperlipidemia , HTN, males, age (>45 men, > 55 women). FHx of CAD. Obesity. Patho: formation of fatty streaks = lipid deposition in WBCs

Causes myocardial ischemia when a fatty streak becomes a fibrous plaque (prolif. sm. muscle and connective tissue are incorporated into the plaque) = narrowing. Symptoms at ≥70%reduction

Long-term management of HF Diet/exercise: Na+, fluid restrictions, exercise, stop smoking Drugs: ACE-I (1st line) - potentiate vasodilators ↓preload and afterload, ↓mortality (post-MI) Watch for 1st dose hypotension, renal insufficiency, hyperkalemia, cough, angioedema. No ACE-I in hypotension or pregnancy If can't take ACE-I go to: ARBs B-blockers added after ACE-I or ARB, ↓ mortality by 35% by ↑ EF and ↓ventricle size. No b-blockers in decompensated CHF Hydralazine + nitrates Consider if can't tolerate ACE-I or B-blocker. Good for AA, safe in preggos. Hydralazine ↓afterload, NTG ↓ preload AND afterload

Diuretics Most effective in mild-moderate CHF, also HTN, severe edema, mild renal dz - watch out for hypokalemia/calcemia/natremia, hyperglycemia, hyperuricemia K+-sparing diuretics Spironolactone assoc. w/↓ mortality, added in class III/IV HF Watch hyperkalemia Not for renal failure, hyponatremia Sympathomimetics Short term in CHF (except digoxin) For HF + A-fib to ↓hospitalizations/symptoms + inotrope, -chronotrope Prolongs intracellular Ca2+/contraction by inhibiting Na+/K+ pump S/e: arrhythmias, visual disturbances (halos/blurred/green/yellow), gynecomastia *Dig toxicity = ↓ST, junctional rhythms Dobutamine, dopamine

PAD Atherosclerotic dz of lower extremities, vessels outside heart and brain S/s: Intermittent claudication MC Resting leg pain, acute arterial embolism (6 Ps: paresthesias, pain, pallor, pulselessness, paralysis, poikilothermic). Gangrene Exam: ↓/absent pulses, +/- bruits, ↓ cap refill Atrophic skin changes: thin/shiny, hair loss, thick nails cool limbs, usu. no edema Color: pale on elevation, dusky red w/dependency, cyanosis

Dx: Ankle-brachial index (ABI): simple, quick non-invasive, most useful for chronic PAD Arteriography gold standard Doppler to assess pulses Tx: Platelet inhibitors - cilostazol (Pletaal). Also ASA, plavix, ADP inhibitor Pentoxifylline Revascularization - PTA, bypass grafts, endarterectomy Supportive: foot care, exercises Acute arterial occlusion = heparin, thrombolytics if thrombus, embolectomy. Amputation if severe or gangrene

Myocarditis Inflammation of heart muscle. MC in children MC d/t viral infection. Also postviral damage. Viral = enteroviruses MC cause, also adenovirus, PVB19, HHV6, EBV (HHV4), HIV, VZV. Bacterial = Lyme dz, RMSF, Q fever), Chagas, diptheria Also fungal, parasitic, scorpions Autoimmune: SLS, rheumatic fever, Kawasaki, UC Meds can also cause (methyldopa, abx (tetracycline, Ampho-B, PCN), isoniazid, indomethacin, phenytoin, sulfanomides Myocellular damage = myocardial necrosis & dysfunction = S/sx: Viral prodrome HF s/sx +/- Pericarditis

Dx: CXR - cardiomegaly classic EKG - sinus tach MC + CKMB, trop Echo - vent. dysfn ↑ ESR Endomyocardial biopsy = GOLD standard - will show infil. of lymphocytes w/myocardial tx necrosis Tx: Supportive - diuretics, afterload reduction, inotropes if severe No BBs for peds IV immune globulin may help some

Pericardial effusion (critical care topic) ↑ fluid in pericardial space Etiologies: Pericarditis, malignancy, infection, radiation tx, dialysis/uremia S/s: Distant muffled heart sounds

Dx: ECG: Low voltage QRS complexes Electrical alternans (heart swinging) Echo: to assess for tamponade CXR: Cardiomegaly Tx: Observation if small and no tamponade, treat underlying cause +/- pericardiocentesis if tamponade or large; pericardial window if recurrent

ACS: NSTEMI and unstable angina Atherosclerosis MC cause Etiologies: 1) plaque rupture --> acute coronary thrombosis w/platelet adhesion/activation/aggregation w/fibrin formation 2) Coronary artery vasospasm - cocaine, Prinzmetal angina S/s: Anginal pain = retrosternal pressure > 30 mins Unstable angina = pain @ rest = > 90% occlusion Sympathetic stimulation: anxiety, diaphoresis, tachy/palp, N/V, dizziness Silent MI -women, DBM, elderly, obese: atypical symptoms (abd/jaw pain, dyspnea W/O CP) Physical exam usu normal S4 esp w/inferior MI hyper/hypotension CP + Brady could be inferior MI May have new onset murmur

Dx: ECG: NSTEMI & unstable angina +/- ST depression and/or T wave inversions Troponin - peaks @ 12-24 hrs, may be falsely elevated in RF, advanced HF, acute PE, CVA Tx: MONA, heparin, antithrombotics, angiography/PTC, Clopidogrel (Plavix) if can't have ASA, statins, Bblockers (careful with HF and brady), CCBs (esp vasospastic) NO B-BLOCKERS IN COCAINE INDUCED MI No nitrates for inferior MI or Viagara use B-blockers post MI

Acute Pericarditis Fibrinous inflammation of the pericardium. May cause effusion. Etiologies: MC idiopathic, viral: coxsackie, echovirus. Also neoplastic, post-MI (Dressler syndrome: occurs weeks-months post MI, s/s: typical CP, fever, malaise, leukocytosis), autoimmune, systemic, uremia, bacterial, radiation tx, drugs S/s: Sharp pleuritic CP relieved by sitting forward, may radiate. Fever Pericardial friction rub heard best @ expiration while leaning forward.

Dx: ECG: diffuse ST elevation, PR depression that is diagnostic in aVR view T wave inversions --> resolution +/- + troponin Echo: to assess for effusion or tamponade Tx: ASA or NSAIDS x 7-14 days Colchicine 2nd line, Dressler ASA or colchicine

Aortic stenosis Obstruction of LV outflow across aortic valve. MC valvular dz, symptoms MC begin when AoV < 1 term-32cm2 (normal 3-4 cm2) Etiologies 1) Degenerative heart dz: calcifications common in >70 yo 2) CHD (bicuspid AoV) common in <70 yo 3) Rheumatic heard dz: usually w/AR or mitral dz Patho Stenosis > LV outflow obstruction (fixed CO) > incr. afterload (pressure overload) > LVH > LV failure S/s Dyspnea MC "Aortic Stenosis Complications" - angina (5 yr survival), syncope (exertional, 3 yr survival), CHF* (2 yr survival, worst prognosis) Exam Systolic ejection crescendo-decrescendo murmur @ RUSB, radiates to carotids Valsalva, standing = decr. venous return = decr. murmur squat, leg raise = incr. venous return = incr. murmur Late peaking murmur = incr. severity Narrowed pulse pressure

Dx: Echo ECG: LVH CXR nonspecific Cardiac cath definitive dx Management Surgery - AoV replacement only effective tx, tx of choice for symptomatic AS 1. Mechanical valve - lasts longer (10+ yrs), but have to be on anticoags for life 2. Bioprosthetic valve - doesn't last a long, no anticoags 3. Intra-aortic balloon pump - for temporary stabilization No truly effective medical therapy, avoid venodilators/negative inotropes (NO CCBs, NO b-blockers)

Mitral regurg Etiologies: MVP MC cause rheumatic heart dz, endocarditis, annulus dilation, valvulitis, marfan's, papillary muscle dysfunction, ruptured cords Patho: Retrograde blood from from LV to LA, then back to LV = volume overload --> LA dilation, incr. pulmonary pressures --> decr. cardiac output S/s: Acute: pulmonary edema, hypotension, dyspnea, fatigue Chronic: Afib, progressive dyspnea w/exertion, fatigue, CHF, pulmonary HTN Exam: Blowing, holosystolic murmur @ apex with radiation to axilla, wide split S2 Decr. intensity: decr. venous return (valsalva, standing), inspiration Incr. intensity: incr. venous return (supine, squatting), inspiration, handgrip, LLR Displaced PMI, S3 gallop (LV dysfunction)

Dx: Echo may show hyperdynamic LV, EF < 60% = LV impairment ECG (LAE, LVH), CXR (cardiomegaly, pulm congestion) pretty much nonspecific Tx: Surgical: repair preferred over replacement - acute or symptomatic; asymptomatic MR with LV decompensation/dilation (EF <55-60%) Drugs (for non-operative stable pt): , ACEI, hydralazine/nitrates ((decr. afterload), *diuretics (decr. preload), dig (for afib or + inotropy)

Mitral Stenosis Etiologies: Rheumatic heart dz MC cause leading to fish mouth valve, MC in 3rd-4th decade Patho: Obstruction of flow from LA to LV --> incre. L atrial pressure/volume overload --> pulmonary congestion --> pulmonary HTN --> CHF S/s: Pulmonary: dyspnea MC, pulmonary edema, hemoptysis, cough, bronchitis, pulmonary HTN (20s-30s if rheumatic), afib, mitral facies = ruddy cheeks w/facial pallor Exam: Opening snap, early-mid diastolic rumble Decr. intensity: decr. venous return (valsalva, standing), inspiration Incr. intensity: incr. venous return (lying supine, squatting), exercise, LLR position Loud S1, +/- split S2 prior to OS

Dx: Echo, cardiac cath, ECG: LAE, afib, RVH, CXR Tx: Surgical - percutaneous balloon valvuloplasty: best in younger pts Open mitral valvotomy, mitral repair/replacement if symptomatic Meds: WILL NOT ALTER PROGRESSION OR DELAY NEED FOR SURGERY: loop diuretics, Bblockers, digoxin (if afib)

Pericardial Tamponade (critical care topic) Pericardial effusion causing significant pressure on the heart → restricts filling →↓CO The faster it develops, the worse it is - can have chronic PT that doesn't cause hemodynamic compromise S/s: Beck's Triad: muffled heart sounds, hypotension, JVD Pulsus paradoxus: > 10 mm Hg ↓ in SBP with inspiration, ↓ pulses w/inspiration (d/t ↑filling in right heart that ↓ LV filling) Dyspnea, fatigue, periph. edema, shock, hypotension, tachycardia

Dx: Echo: effusion + diastolic collapse of cardiac chambers d/t pressure outside heart being higher Tx: Pericardiocentesis

Dilated cardiomyopathy 95% of cardiomyopathies BIG, BAGGY HEART Systolic dysfunction --> ventricular dilation MC men 20-60 Idiopathic - MC viral Viral myocarditis - enteroviruses MC, Lyme dz, Chagas dz Toxic: ETOH abuse, cocaine, anthracylines (Doxorubicin), radiation tx Other: pregnancy, infiltrative, autoimmune, metabolic (hyper/hypothyroid d/o) Clinical manifestations Heart failure (systolic): fatigue, L and R CHF, lateral displaced PMI, +/- mitral or tricuspid regurg, embolisms, arrhythmias, CP with exertion

Dx: Echocardiogram: L ventricular dilation (thin ventricle walls), large ventricular chambers, decreased EF CXR: cardiomegaly, pulmonary edema, pleural effusion ECG: sinus tach, arrhythmias Tx: Standard heart failure tx: ACEI, BB (if not in decompensated CHF), Aldosterone Antagonists, diuretics Na+ restriction, AICD if EF < 30-35%, cardiac xplant Ddx: dilated HF d/t cardiac dz Takotsubo cardiomyopathy - apical LV ballooning following an event that causes a catecholamine surge (stress, broken heart syndrome, surgery) postmenopausal

AAA Dilation of aortic diameter at least 1-1.5x diameter measured @ level of renal aa. > 3.0 = aneurismal, MC infrarenally Risk factors: atherosclerosis MC, CAUCASIAN MEN age > 60 yrs Smoking, hyperlipidemia, connective tx d/o, syphilis, HTN Patho: proteolytic degeneration of aortic wall S/s: Most asymptomatic until rupture, often incidental Acute leakage/rupture: Classic = older male (>60 yo) with severe back/abd pain who presents with syncope or hypotension and a tender, pulsatile abdominal mass +/- flank ecchymosis. < 5 cm = ↑ rupture risk

Dx: abd ultrasound CT - for thoracic Gold standard = angiography, often before surgery MRI/MRA instead of angiography Tx: ≥ 5.5 cm or > 0.5 cm expansion in 6 months = immediate surgical repair even with asymptomatic > 4.5 cm = surgical referral 4-4.5 cm = monitor via US q6 months 3-4 cm monitor via US q1 year B-blockers ↓ shearing forces and risk factors

Restrictive cardiomyopathy (1% of cardiomyopathies) Impaired diastolic function with relatively preserved contractility. *Ventricular rigidity impedes filling (dec. compliance). STIFF HEART _Etiologies_ Infiltrative dz: amyloidosis MC cause, sarcoidosis, idiopathic myocardial fibrosis, hemochromatosis, metastatic dz, scleroderma, chemo, radiation therapies Manifestations: R-sided HF sx more common than L-sided, poorly tolerated tachyarrythmias

Exam: Kussmaul's sign - JVP ↑ w/inspiration. Stiff RV = impaired filling = ↑ blood flow backing up in venous system = signs of HF, +/- S3 Dx: CXR: normal ventricular chamber size, enlarged atria, maybe pulmonary congestion ECG: low voltage +/- arrhythmias Echo: non-dilated ventricles with normal wall thickness, marked dilation of atria, diastolic dysfunction Tx: Treat underlying d/o, symptomatic tx

Heart failure Inability of heart to pump sufficient blood to meet metabolic demands of the body @ normal filling pressures MC causes are: LEFT sided: CAD and HTN, others = valvular dz, cardiomyopathies RIGHT sided: pulmonary dz (COPD, pulm htn), mitral stenosis Systolic HF MC form of HF Thin vent walls, dilated chamber ↓ EF, +/- S3. Etiologies: Post MI, dilated term-25cardiomyopathy, myocarditis Diastolic HF Thick vent walls, small chamber Associated w/normal cardiac size normal/incr. EF, +/- S4 = forced atrial contraction into a stiff ventricle Etiologies: HTN, LVH, elderly, valvular heart dz, cardiomyopathies (hypertrophic, restrictive), constrictive pericarditis

High output HF = metabolic demands of body exceed normal cardiac function. Low output HF = inherent problem of myocardial contraction, ischemia, chronic HTN Acute HF = mostly systolic (ex. HTN crisis, acute MI, papillary muscle rupture) Chronic HF = typically seen in dilated cardiomyopathy or valvular dz Dx: Echo EF most imp Normal EF = 55%-70% EF < 35% = ↑risk mortality - place AICD CXR: useful in CHF (Kerley B Lines) ↑ BNP may ID CHF (> 100 = CHF likely) Tx: HR/BP control, relief of ischemia (B-blockers, ACE-I, CCBs), diuretics

Murmurs - in general Harsh/rumble think stenosis: AS, MS → pressure overload Blowing think regurgitation: AR, MR. → volume overload ARMS rest = Aortic Regurg & Mitral Stenosis hearing during diastole (rest) Accentuation Maneuvers Position: Sitting up, leaning forward = AS, AR louder Lying on L side = MS, MR louder Squat, leg raise, lying down = ↑venous return = ↑all murmurs EXCEPT: ↓ in HCOM, ejection click of MVP Valsalva, standing = ↓ venous return = ↓ all murmurs EXCEPT: ↓ in HCOM, ejection click of MVP

Inspiration: ↑ all R side murmurs ↓ all L side murmurs Expiration: ↑ all L side murmurs - best heard after max expiration ↓ all R side murmurs Handgrip: ↑ afterload → ↓ LV emptying = ↓forward flow and ↑backward flow AS, MVP, HCOM = ↓ murmur AR, MR, MS = ↑ murmur

Rheumatic fever Acute autoinflammatory multi-systemic illness mainly affecting children 5-15 Symptomatic or asymptomatic infection w/GABHS (strep pyogenes) stimulates antibody production to host tissues and damages organs. Precedes onset of rheumatic fever by 2-6 wks. Affects mitral valve (MC) (75-80%), aortic valve (30%), tricuspid/pulmonic 5% Dx JONES criteria - major: 1) Joints (migratory polyarthritis) - 2+ joints, large joints, MUST have heat/redness/swelling w/pain. Medium/large joints MC. 3-4 weeks 2) Oh my heart -active carditis - can affect valves esp. mitral and aortic, myo/pericardium 3) Nodules (subcu) - over joints, scalp, spinal column; rare 4) Erythema marginatum - often w/carditis. Red, macular, non-pruritic w/central clearing, spares face. Annular w/sharply demarcated borders on trunk/extremities 5) Sydenham's chorea - sudden involuntary jerky mvmts of head/arms ("Saint Vitus dance"), may occur 1-8 months after initial infection. MC in females, resolves spontaneously

Minor: Fever (>101.3), arthralgia, incr. ESR, CRP, leukocytosis, long PR interval PLUS supporting evidence of a recent GAS infection Dx: ↑ ESR, CRP, leukocytosis. ECG = prolonged PRI Management: 1. ASA 2-6 weeks w/taper, corticosteroids severe cases & carditis 2. PCN-G (erythromycin if PCN allergy) in both acute phase and after prevention

Aortic regurg Etiologies: Valve dz: rheumatic heart dz, endocarditis, bicuspid AoV, aortic root dz/dilation, HTN, marfan's, syphilis, RA, lupus, aortic dissection ankylosing spondylitis Patho: LV volume overload --> LV dilation --> CHF S/s: Acute: pulmonary edema, +/- hypotension Chronic: clinically silent while LV dilates --> LV decompensation --> CHF Exam: Diastolic, decrescendo, blowing murmur loudest @ LUSB ↑ intensity: ↑ venous return (squat); sitting forward, handgrip (except late), displaced PMI, most prominent during expiration Decr. intensity: decr. venous return (valsalva, standing), inspiration Bounding pulses 2ry to incr. SV Wide pulse pressure

Pulsus Bisferiens: double pulse carotid upstroke, seen w/combined AR + AS or severe AR Dx: Echo, ECG, CXR Tx: Afterload reduction: ACEI, ARBS, Nifedipine, Hydralazine (incr. forward flow) Surgical: definitive: ind. in severe or symptomatic AR, asymptomatic with LV decompensation, EF < 55% - bc pts need a hyperdynamic LV to maintain CO

Atrial fibrillation MC chronic arrhythmia, most pts asymptomatic Regularly irregular rhythm w/narrow QRS, no P waves, vent rate 80-140 May cause thrombi that can embolize Etiologies: Incr. age, hemodynamic stress, meds, drugs/EGOH, men > women, whites > blacks Types: Paroxysmal (go away w/in 7 days, usu. < 24 hrs) Persistent (last > 7 days, require termination) Permanent (persistent AF > 1 yr, refractory to cardioversion) Lone (paroxysmal, persistent or permanent w/out evidence of heart dz) Tx: Stable afb: Rate control - preferred over rhythm control: Bblockers (caution in reactive airway dz) CCBs (nondihydropyridines - Diltiazem, Verapamil) Digoxin - preferred for pts w/hypotension or CHF

Rhythm control: younger pts with lone afib Synchronized cardioversion can be done if: 1) AF present < 48 hrs, or 2) after 3-4 weeks of anticoags and a TEE that shows no atrial thrombi. Or start IV heparin, cardiovert w/in 24 hrs and anticoag for 4 weeks Drugs for rhythm control Ablation Unstable afib: synchronized cardioversion Anticoagulation All pts: Asses risk via CHA2DS2-VASc score, determine benefits vs risks: Anticoagulants: NOACS (non-vit K antagonist coagulants) pref over Warfarin - Dabigatran, Apixaban (factor Xa inhibitor) Warfarin: for CKD, poor, on antiepileptics with CYP450 clearance. *Goal INR 2-3

Hypertension Elevated BP ≥ 2 readings on ≥ 2 diff visits. Etiologies: Essential MC, idiopathic Secondary: HTN d/t an underlying, often correctible cause. Suspect if: HTN refractory, severely elevated, young/older onset Renovascular MC cause: renal artery stenosis Fibromuscular dysplasia MC in young pts, atherosclerosis in elderly Other causes: endocrine (1ry aldosteronism, pheochromocytoma, Cushing's), coarc, obstructive sleep apnea, thyroid d/o Think 2ry if: HTN unresponsive to treatment (usually Grade II) Abdomen bruit Cushing's appearance Low K+, increased Creatinine, abnormal TSH Hx: What to ask: Last known BP Prior treatment Other meds that incr. BP (e.g. estrogen, decongestant) +FH hypertension--at what age ? Symptoms of target organ damage (cp, dyspnea) Comorbidities (e.g. DM, CAD) Smoking, ETOH, Drug use, Diet, Exercise Exam: BP: both arm, manual -vs- automated, cuff size BMI Fundi: AV nicking, hemorrhages, edema Neck: thyromegaly and bruits Heart: rate, rhythm, murmur, extra sounds (e.g. S4) Lungs: adventitious sounds Abd: aortic pulsations, bruits, masses Neuro: weakness, speech, confusion Exts: edema, pulses

Routine Labs: ECG (LVH, old infarct) Urinalysis (proteinuria) Glucose or A1C (diabetes) Hemoglobin (anemia or polycythemia) Electrolytes Creatinine (and estimated GFR) Lipids (additional risk factors) TSH (thyroid disease) Systolic more predictive of cardiovascular events - target systolic bp Tx HTN Goal < 140/90, < 150/90 if < 60 yo Lifestyle mod: weight loss, diet, exercise, ↓ ETOH Thiazide diuretics(AA), ACE-I (esp if DBM, renal dz, DBM, post-MI), ARBs if ACE-I not tolerated, CCBs (AA), B-blockers, a-1 blockers Hypertensive urgency tx: ↓ BP (MAP) by 25% over 24-28 hours w/oral meds: clonidine, captopril, furosemide, labetalol, nicardipine Hypertensive emergency: ↑ BP + end organ damage Usually SBP ≥ 180 and/or DBP ≥ 120 Neuro damage (encephalopathy, stroke, seizure), cardiac damage (ACS, aortic dissection, HF/pulm edema), renal damage (AKI, proteinuria, hematuria), papilledema Tx: ↓ BP (MAP) by 25% over 24-28 hours w/IV meds

CHF Acute decompensated HF w/worsening baseline symptoms, pulm congestion CXR: cardiomegaly, cephalization of flow (↑vasc. flow to apices 2ry to ↑ pulm venous pressure, occurs when PCWP is 12-18 mm Hg, normal = 6-12 mm Hg), Kerley B lines, pulm. edema, peribronchial cuffing, cardiomegaly, perihilar congestion Batwing appearance - pulm edema

S/Sx: Dyspnea, rales, pink frothy sputum Sympathetic activation Management: LMNOP: Lasix (removes fluids), Morphine (reduces preload and heart strain), Nitrates (venodilators - reduce preload and afterload), Oxygen, Position (place up right to ↓ venous return). +/- inotropes

Aortic dissection Tear in innermost layer of aorta (intima) d/t cystic medial necrosis - false lumen created Type A dissection — tear begins in the ascending aorta and progresses throughout the vessel Type B - tear is located only in the descending aorta, but may extend into the abdomen MC ascending (65%) , 20% ascending, 10% aortic arch ASCENDING = HIGH MORTALITY Risk factors: HTN Age: MC 50-60 yo, Marfan's pts may present earlier, men 2x risk, cocaine use

S/s: CP (96%): sudden onset, severe, tearing, chest/upper back, N&V, diaphoresis ↓ periph. pulses, variation in BP arm to arm > 20 mmHg HTN: MC in distal/type B Ascending dissections = acute new onset AR, acute MI, cardiac tamponade Descending dissections = back pain Dx: CT w/contrast MRI angiography = gold standard, TEE CXR = widened mediastinum (esp. distal dissection) Tx: Surgical in acute proximal or acute distal with complications Meds: for descending with no complications Esmolol, Labetolol 1st line Sodium nitroprusside if needed

Patho of HF Initial insult causes: ↑ afterload, ↑ preload and/or ↓contractility. Injured ♡ tries to compensate (sympathetic NS activation, RAAS system, myocyte hypertrophy/remodeling) = causes cardiovascular deterioration over time

S/s: Left HF ↑ pulmonary venous pressure from fluid backing up into lungs 1. Dyspnea MC - initially exertion, becomes orthopnea, also PND, dyspnea at rest 2. Pulm congestion/edema = CHF 3. HTN, tachypnea, Cheyne-Stokes, S3 (in systolic), S4 (in diastolic), lateral PMI 4.↑ adrenergic activation (dusky pale skin, diaphoresis, sinus tach, cool extremities, fatigue, AMS

ACS: STEMI Atherosclerosis MC cause Etiologies: 1) plaque rupture --> acute coronary thrombosis w/platelet adhesion/activation/aggregation w/fibrin formation Unstable Anginal pain = retrosternal pressure > 30 mins *not relieved w/rest or nitro. May radiate to back/arms/shoulders/epigastrum/jaw. Levine's sign. Dyspnea. Sympathetic stimulation: anxiety, diaphoresis, tachy/palp, N/V, dizziness Silent MI -women, DBM, elderly, obese: atypical symptoms (abd/jaw pain, dyspnea W/O CP) Physical exam usu normal S4 esp w/inferior MI hyper/hypotension CP + Brady could be inferior MI May have new onset murmur

STEMI = ST elevations > 1 mm in >2 contiguous leads; reciprocal changes in opposite leads New LBBB = STEMI equivalent STEMI progression: Peaked T --> ST elevation --> pathologic Q Pathologic Q = > .03 s and 0.1 mV deep (at least 25% of assoc. R wave) Tx: PCI - reperfusion most imp Thrombolytics indicated ASA lowers mortality MONA Bblockers, ACEI, nitrates Statins NO B-BLOCKERS IN COCAINE INDUCED MI No nitrates for inferior MI or Viagara use B-blockers post MI

Dyslipidemia Hypercholesterolemia: hypothyroidism, pregnancy, kidney failure Hypertriglyceridemia: DBM, ETOH, obesity, steroids, estrogen S/s: Most asymptomatic, may develop Xanthomas (Achilles tendon) or Xanthelasma (lipid plaques on eyelids) Goals: ↓ weight, ↑ exercise Restrict cholesterol, carbs, ↓ trans fats Drug goals: plaque stabilization, reversal of endothelial dysfunction, thrombogenicity reduction, atherosclerosis regression Screening: Based on risk: sex, age, risk factors: smoking, HTN, FHx of CAD Adults 20-79 free of CVD assess risk every 4-6 yrs to calc. 10 yr risk Higher risk > 1 risk factor (HTN smoking, FHx) = start screening @ 20-25 for males, 30-35 for females Lower risk = 35 for males, 45 for females

Statins: Det. by 10-yr lifetime risk: age, gender, race, smoking, BP, cholesterol, DBM. Treat: DBM I or II between 40 and 75 No cardio dz age 40-75 and ≥ 7.5% risk of heart attach or stroke in 10 yrs ≥ 21 yo with LDL ≥ 190 mg/dL Anyone with CAD Statins lower LDL Fibrates lower triglycerides, also Omega 3 fatty acids Niacin to ↑ HDL Type II DBM = fibrates, statins, caution w/niacin Goals: *LDL < 100 mg/dL Total < 200 mg/dL HDL > 60 mg/dL*

Angina Stable = fixed plaque Class I: only with strenuous acticity. No limitations Class II: with more prolonged/rigorous activity. Slight limitations Class III: angina w/ADLs. Marked limitation Class IV: angina at rest. Unable to be physical S/s: Primarily a HISTORICAL DX Substernal CP, nonpleuritic, poorly localized, exertional. Radiates to arm, teeth, lower jaw, back, usu. short in duration (< 30 mins). Levine's sign: fist clenched over chest Pain relieved w/rest or nitro Dsypnea, nausea, diaphoresis, numbness, fatigue May have epigastric pain Exam: Often normal S4 gallop, signs of LV failure (S3, pulm. edema) during attack. May see xanthelasma. Dx: ECG: *ST depression classic Resting ECG may be normal LVH = incr. adverse outcome

Stress testing most useful noninvasive screening tool If unclear can do an exercise echo to locate ischemia, or MRI Coronary angiography = gold standard for dx PCTA if 1 or 2 vessel dz not including L main coronary and near-normal vent. function- should be candidate for CABG Stents CABG if left main coronary dz, symptomatic or critical stenotic (<70%), 3-vessel dz or deer. LVEF < 40% Meds: Incr. myocardial blood supply, decr. demand Nitro (if BP > 90 mmHg), Bblockers, CCBs (nondihydropyridines) for its who can't use Bblockers (Prinzmetal angina), ASA, statins Reduce risk factors

CHA2DS2-VASc score for anticoag therapy

To determine who needs coagulation in tx of afib C= CHF (1) H= HTN (1) A2= age > 75 (2) D= DBM (1) S2= Stroke/TIA/thrombus (2) V= Vascular dz (1) A= age 65-74 (1) S2 = Stroke (2) 0 = low risk (none or ASA), 1 = moderate risk (coags), 2 = high risk (coags)

Thromboangitis obliterans (Buerger's dz) Nonatherosclerotic inflammatory dz of small/medium arteries/veins - segmental vascular inflammation and vasooclusive phenomena Strongly assoc. w/tobacco MC men 20-45, India, Asia, Middle East Suspect in young smokers w/distal extremity ischemia/ischemic ulcers/gangrene of digits Abnormal Allen test

Tx: Tobacco cessation only definitive mgmt Wound care CCB for Raynaud's

Infective endocarditis An inflammatory process of the valvular or endocardial surface of the heart. Almost always on mitral valve, except IVDA (tricuspid) Acute endocarditis: infection of normal valves with an organism (S. auerus MC) Subacute endocarditis: infection of abnormal valves with less virulent organism (S. viridians MC) S/s: fever, new/changed murmur MC Roth spots (petechiae) Janeway lesions (Painless, Erythematous Macular lesions on palms and soles) Osler's nodes (Painful, Voilacious Raised lesions on fingers and toes) Splinter hemorrhages of proximal nail bed Dx: TEE gold standard Blood cx, ECG Diagnosis: Modified Duke Criteria Minor criteria Predisposition: Heart condition/IV drug abuse Fever > 100.4

Vascular phenomena (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions) Immunologic phenomena (glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor) Microbiologic evidence (+ blood cx not meeting major criteria) Echo findings that do not meet major criteria 2+ major criteria, 1 major + 3 minor, or 5 minor Major criteria Positive blood cultures (Typical microbe in 2 cultures, Persistently + cultures, Single + culture for Coxiella burnetii) Evidence of endocardial involvement (Definite vegetation, Myocardial abscess, New partial dehiscence of prosthetic valve) New or worsening regurgitation murmur 2+ major criteria, 1 major + 3 minor, or 5 minor Tx: cover with Vanco and ceftriaxone while awaiting blood cxs Surgery: refractory CHF, persistent/refractory/invasive infection, prosthetic valve, recurrent emboli, fungal May delay abx in subacute Therapy usu. 4-6 weeks Prophylaxis if have prosthetic heart valve, CHD: amoxicillin, or clinda if allergy

MORE MURMURS!!! Aortic stenosis = Systolic ejection crescendo-decrescendo murmur @ RUSB, radiates to carotids Mitral stenosis = diastolic rumble @ apex in left lat. decub - +/- preceded by opening SNAP Aortic regurg = diastolic decrescendo blowing @ LUSB. ↑ w/handgrip, ↓ with amyl nitrate. Mitral regurg = blowing holosystolic murmur @ apx. ↑ w/handgrip in left lat. decub, ↓ with amyl nitrate MVP = mid-to-late systolic ejection CLICK @ apex; ↓ venous return (valsalva/standing/insp) = earlier click/longer murmur

↓ with Valsalva = ✔ Diuretics ↓ with Amyl Nitrate = ✔ ACEIs