congestive heart failure occurs when the heart's pumping action is not able to meet the body's metabolic demands either because of increased demands, dysfunction of the heart itself, or both. the heart can compensate for this discrepancy in various ways such as tachycardia, hypertrophy; but with enough time none of these adaptations will suffice. "compensated" refers to such a case of chronic heart failure where increased heart rate or other factors have allowed the heart to maintain adequate CO and perfusion. similarly, "high output" failure refers to congestive heart failure with tachycardia to compensate, which results in peripheral vasodilation and warm extremities.
heart failure affects and is affected by many other systems of the body. generally, the sympathetic nervous system is overactive, causing peripheral vasoconstriction which shunts blood away from extremities. systemic venous congestion will also affect the renal system by way of diminished hepatic metabolism of aldosterone which will lead to increased fluid retention which will unfortunately negatively feed back into creating more pressure for the heart (note that the same heart stressing effect can happen with a patients sudden cessation of diuretics). in the lungs, heart failure cells might appear, which are macrophages full of hemosiderin.
left sided CHF, as we learned in CPD, involves dysfunction of receiving blood from the pulmonary system and thus presents with symptoms of pulmonary congestion such as pulmonary edema. on the other hand, RCHF involves dysfunction of receiving venous blood from the body and thus can present with signs of systemic congestion such as peripheral edema. LCHF is usually caused by infarction/ischemia of the left ventricle, hypertension, or mitral dysfunction whereas RCHF is most commonly caused by LCHF.
cardiomyopathies come in three flavors, dilated (90%), restrictive, and hypertrophic. dilated is when all four chambers are enlarged but not hypertrophic and can be caused by severe alcoholism. hypertrophic is severe hypertrophy of myocardium, especially the ventricular septum, which is generally caused by a genetic defect that causes a mutation in the proteins within sarcomeres. restrictive cardiomyopathy is generally due to hemochromatosis (excess Fe deposition) or amyloidosis (excess amyloid deposition) within the myocardium which renders it dysfunctional.
infectious endocarditis is an infection of the myocardium or heart valves, characterized by formation of "vegetations"- made up of platelets, fibrin, and bacteria. these have a high potential for embolization; septic emboli can manifest as Roth spots in the eye, petechiae on the skin, splinter hemorrhages in the fingernails. the main risk factors for infectious endocarditis include artificial valves, immunocompromise, IV drug abusers, alcoholics, procedures with catheters / grafts. endocarditis can also occur from an inflammatory origin, as in the case of Libman-Sacks endocarditis, which results in the case of SLE.
questions
introduction to CHF...
1. what is congestive heart failure?
2. how does the heart typically respond to heart failure initially?
3. why does frank starling's law not apply in cases of severe heart failure?
4. how many americans does CHF affect per year?
5. what is "compensated" or "decompensated" CHF?
6. describe the sympathetic response in acute CHF which compensates for decreased CO.
7. how can systemic venous congestion lead to fluid retention?
8. what are heart failure cells?
CHF types...
9. what is the difference between primary and secondary CHF?
10. what is a common cause of CHF related to drugs?
11. what are some common underlying conditions that can lead to CHF?
12. what can left sided CHF lead to and why?
13. what is left sided CHF usually caused by?
14. what is the most common cause of right sided CHF?
15. what is cor pulmonale?
16. describe the difference in symptom presentation between RCHF and LCHF.
high and low output failure...
17. what is the difference between high and low output heart failure?
18. what are some causes of high output heart failure?
19. how can Paget's disease cause high output heart failure?
20. what are some causes of low output heart failure?
cardiomyopathies...
21. what are the three types of cardiomyopathies and which is most common?
22. what is dilated cardiomyopathy characterized by? what is the most common cause?
23. what is hypertrophic cardiomyopathy characterized by? what is it caused by?
24. what is restrictive cardiomyopathy characterized by? what are the most common causes?
endocarditis...
25. what are "vegetations" in the context of endocarditis?
26. most common cause of endocarditis is...
27. what are some potential portals of entry for bacteria that might cause endocarditis?
28. what is the difference between acute and sub-acute infectious endocarditis?
29. the most consistent sign of endocarditis is...
30. what is a serious danger of vegetations besides their disruption of blood flow in the heart?
31. septic emboli from endocarditis can manifest in...
32. main risk factors for endocarditis.
most likely organism to cause IE in...
33. patient with native valves...
34. prosthetic valves...
35. IV drug abusers...
36. alcoholics...
37. after a cystoscopy/prostatectomy/catheters...
38. patients with colon cancer...
non-infectious endocarditis...
39. culture negative endocarditis may indicate...
40. what is the endocarditis of SLE called?
41. what is Marantic endocarditis?
answers
1. inability of the heart to pump out enough blood to meet the body's metabolic requirements.
2. increased contractility or increased heart rate.
3. if the myocardium is stretched beyond a certain point as in severe CHF, the optimum length for contractility is surpassed and the ventricles are overstretched; CO begins to decrease again.
4. 2 million.
5. compensated is CHF with adequate CO and decompensated is CHF with inadequate CO.
6. increased catecholamine activity causes peripheral vasoconstriction and shunting of blood away from extremities to internal organs.
7. systemic venous congestion leads to diminished hepatic perfusion which leads to diminished metabolism of aldosterone which leads to fluid retention.
8. hemosiderin laden macrophages in the alveoli.
9. primary is a dysfunction of the heart itself while secondary is a dysfunction of the heart due to the stress placed on it by other systems in the body.
10. cessation of certain heart medications; in particular diuretics, causes a sudden increase in fluid retention and thus stress placed on the heart.
11. conditions that cause myocardial dysfunction: coronary atherosclerosis, arterial hypertension, myocardial ischemia, infarction, inflammatory / degenerative muscle disease.
12. pulmonary congestion because of the increased pressure in the left ventricles (end-diastolic) and atrium.
13. left ventricular infarction / ischemia, hypertension or mitral dysfunction.
14. LCHF.
15. heart failure that results from an underlying lung disorder such as COPD.
16. RCHF presents with symptoms of systemic venous congestion and LCHF presents with symptoms of pulmonary congestion.
17. high output failure characterized by peripheral vasodilation / warm extremities while low output failure characterized by peripheral vasoconstriction / cold extremities.
18. hyperthyroid, stimulants, anemia, Paget's disease.
19. in Paget's, abnormal bone mass is formed with high vascularity, increasing the demand for O2 and thereby increasing the heartrate.
20. infarction, ischemia, endocarditis.
21. dilated restrictive and hypertrophic. dilated 90%.
22. all four chambers enlarged, chronic alcoholism.
23. hypertrophy of chambers (especially ventricular septum), abnormal diastolic filling, intermittent ventricular outflow obstruction. caused by a genetic defect that affects sarcomere function.
24. abnormal tissue that obstructs blood flow. hemochromatosis (excess iron deposition) and amyloidosis are two main causes.
25. infected thrombotic masses on myocardium or valves in infectious endocarditis.
26. bacteria: chlamydia, rickettsiae.
27. dental health, GU tract infection, skin infection, pulmonary infection, any infection in blood, IV drug users.
28. sub-acute is a gradual onset and usually takes place in a heart that already has damage, whereas acute is a sudden infection with a virulent organism with a poor prognosis.
29. fever.
30. their potential for embolization.
31. roth spots in the eye, petechiae, splinter hemorrhages.
32. artificial valves, immunocompromised patients, IV drug abusers, alcoholics, catheters, grafts.
33. strep viridans.
34. staph epidermitis.
35. staph aureus.
36. anaerobes and mouth bacteria.
37. gram- microbes such as ecoli.
38. strep bovis
39. endocarditis with inflammatory origin.
40. Libman-Sacks endocarditis.
41. endocarditis that results from the hypercoagulable state resulting from Trousseau's syndrome.
Showing posts with label CHF. Show all posts
Showing posts with label CHF. Show all posts
Wednesday, January 20, 2010
Sunday, January 10, 2010
CPD II: cardiovascular pathologies
in the second lecture of the cardiac pathologies series we began with the different cardiac tests used to diagnose heart conditions, then went into specific cardiac pathologies. there are several different tests for diagnosing cardiac pathologies, each with their own advantages and disadvantages. the ECG is a measure of the electrical activity of the heart and is best in discerning arrhythmias, ischemia, enlarged chambers. the electrical impulse of the beating heart are manifested on a realtime graph, which can be dissected into several components: PQRST, where the P wave represents atrial depolarization, QRS represents ventricular depolarization, and T represents ventricular repolarization. deviations of shape/rhythm in the ECG wave can indicate various cardiac pathologies (for example, pericarditis induces an elevated ST wave). the echocardiogram is an ultrasound of the heart that is best for determining valvular dysfunction, chamber hypertrophy, cardiomyopathies. EBCT is electron bean computed tomography, useful in determining coronary artery dysfunction. the PET test measures myocardial perfusion by means of radionuclides such as thallium and technitium. finally, stress testing is a ECG measured concurrently with exercise or chemical stimulation of the heart; the best way to measure coronary artery dysfunction.
there are countless pathologies available to the heart and circulatory system. arterial hypertension is high blood pressure either from a multitude of factors (primary) or from a single underlying disease (secondary). atherosclerosis results from high LDL levels which causes plaque formation in arteries and is exacerbated by diabetes mellitus. angina pectoris is chest pain generally caused by ischemia caused by coronary artery dysfunction and can be stable (worse upon exertion, better with rest) or unstable (happens at rest). acute coronary syndromes result from more severe coronary artery ischemia leading to infarction and necrosis, and include unstable angina, NSTEMI, STEMI. congestive heart failure is the dysfunction of the right or left ventricle and have symptom pictures that appear as fluid overload (right) or respiratory problems (left). cor pulmonale is right ventricular hypertrophy that is secondary to a lung disorder such as COPD. finally, cardiomyopathies are dysfunctions of myocardium that are diagnosed when other main etiologies such as valvular, HTN, pulmonary are ruled out. there are three types: dilated, restrictive, hypertrophic.
questions
cardiac testing...
1. what are ECG's used to assess?
2. what do the different components of the PQRST wave represent in the ECG?
3. which test is better to assess valvular dysfunction, the ECG or echocardiography?
4. what is the echocardiogram useful for assessing?
5. describe the difference between the TTE and TEE.
6. what does the EBCT test stand for and what does it measure?
7. what are MRI/MRA tests useful in determining?
8. PET measures...
9. examples of myocardial perfusion nuclides...
10. stress testing is a good way to assess....
arterial hypertension...
11. describe the demographic / racial trends for arterial hypertension.
12. what is the most common cause of arterial hypertension in children?
13. what are some risk factors for arterial hypertension?
14. what is the difference between primary and secondary hypertension?
15. what are some possible etiologies for primary arterial hypertension?
16. what are some examples of diseases that can cause secondary hypertension?
17. arterial hypertension patients are usually...
18. describe the symptom picture of patients with arterial hypertension.
19. what is an early sign of arterial hypertension?
20. what are some signs in a patient with arterial hypertension that might indicate an emergency situation?
21. what would you ask in a medical history of a patient with arterial hypertension?
22. what are some important aspects of the physical examination of a patient with arterial hypertension?
23. how might the specific lab tests differ for a patient who was newly diagnosed with HTN vs. a patient who has left ventricular hypertrophy or ST depression?
24. what are some blood tests that one might perform to aid in the diagnosis of arterial hypertension?
atherosclerosis...
25. describe the role of LDL in the pathogenesis of atherosclerosis.
26. what are the risk factors for developing atherosclerosis?
27. relationship of diabetes and pathophysiology of atherosclerosis.
28. describe the symptom picture/timeline for a patient with atherosclerosis.
29. what are some tests to screen for atherosclerosis?
angina...
30. angina is the result of...
31. describe the general location and sensation of the symptoms in angina pectoris.
32. unique aspects of symptom picture of angina pectoris?
33. what heart sound might be heard in a patient with angina pectoris?
34. how does the way that women experience angina pectoris differ from that of men?
35. what is variant / prinzmetal angina?
36. what is microvascular angina?
37. what is a silent ischemia?
38. what are some clues from the physical exam of a patient with chest pain that indicate coronary artery disease?
39. point tenderness over the chest wall indicates...
40. angina EKG characteristics.
41. possible differential diagnoses for angina pectoris.
acute coronary syndromes...
42. what are the hallmarks of unstable angina?
43. define NSTEMI.
44. define STEMI.
45. in general what is the etiology of acute coronary syndromes?
46. describe the symptom picture of a patient with NSTEMI or STEMI.
47. what are the tests that are diagnostic of these conditions?
48. what are some sounds one might hear upon auscultation of heart in a NSTEMI or STEMI patient?
49. blood tests.
50. ECG characteristics.
51. prognosis of the three types of acute coronary syndromes.
52. complications of MI?
53. what is the "post MI syndrome"?
left congestive heart failure...
54. what is congestive heart failure?
55. what are some possible etiologies for congestive heart failure?
56. LCHF causes...
57. what is the relationship between renal failure and CHF?
58. what is the relative difference in overall presentation of LCHF and RCHF?
59. general/systemic S/SX of LCHF.
60. respiratory S/SX of LCHF.
61. cardiac S/SX of LCHF.
62. etiologies of LCHF?
63. what are some complications of LCHF?
64. what are the differential diagnoses for LCHF?
right congestive heart failure...
65. general S/SX of RCHF.
66. cardiac S/SX of RCHF.
67. what are some possible etiologies of RCHF?
68. what are some possible differential diagnoses of RCHF?
69. what are the classes of CHF as defined by the New York Heart Association?
70. what would the chest xray of a CHF patient show?
71. what is a blood test that might aid in the diagnosis of CHF?
72. what is the best test for diagnosis of CHF and what might the test show?
73. ∂escribe the utility of a stress test in congestive heart failure.
74. what are some blood markers that might be abnormal in CHF?
75. why must water intake/output be monitered in CHF patients?
cor pulmonale...
76. what is cor pulmonale?
77. what is the etiology of cor pulmonale?
78. S/SX of cor pulmonale.
79. a chest xray of a patient with cor pulmonale might show...
80. tests that aid in the diagnosis of cor pulmonale are...
cardiomyopathies...
81. when are cardiomyopathies suspected?
82. what are the three types of cardiomyopathies?
83. describe the symptom picture dilated cardiomyopathy?
84. prognosis for dilated cardiomyopathy?
85. what is hypertrophic cardiomyopathy?
86. etiology of hypertrophic cardiomyopathy?
87. describe the typical patient and symptom picture of hypertrophic cardiomyopathy.
88. hypertrophic cardiomyopathy might result in...
89. what is a typical heart sound of hypertrophic cardiomyopathy?
90. which tests aid in the diagnosis of hypertrophic cardiomyopathy?
91. what is the least prevalent form among the types of cardiomyopathies and what is it characterized by?
92. what does restrictive cardiomyopathy result in?
93. what are common symptoms of a patient with restrictive cardiomyopathy?
94. what are the cardiac symptoms of a patient with restrictive cardiomyopathy?
answers
1. arrhythmias, myocardial ischemia, enlarged chambers.
2. P=atrial depolarization, QRS=ventricular depolarization, T=ventricular repolarization
3. echocardiography-- ECG cannot assess valvular dysfunction.
4. valvular disorders, chamber hypertrophy or dilation, blood flow, cardiomyopathies, heart failure, pericarditis.
5. TTE is more common and less invasive. TEE is used for more posterior structures of the heart, pacemaker implantation, prosthetic valves.
6. electron beam computed tomography, useful for assessing coronary artery disease.
7. mediastinal evaluation, dysfunction of aorta, muscles, non-coronary vessels.
8. myocardial perfusion via radionuclides.
9. thallium and technitium.
10. coronary artery disease.
11. more prevalence in african americans (32%) than european or mexican americans.
12. kidney disease.
13. genetic predisposition, poor lifestyle, diet (high salt intake in particular), stress, obesity.
14. primary is due to multiple factors whereas secondary is caused by a single underlying disease.
15. alcohol, OCP's, corticosteroids, cocaine, licorice (extreme, ridiculous amounts).
16. renal disease, pheochromocytoma, cushing's, primary aldosteronism, hyperthyroidism, myxedema, aortic coarctation.
17. asymptomatic.
18. associated with very high blood pressure: dizziness, flushing, headache, fatigue, epistaxis,
19. the 4th heart sound (S4).
20. diastolic BP above 120mmHg, JVD, CNS disorders, lung crackles (might indicate the pulmonary edema associated with heart failure), severe retinopathy.
21. history of heart disease, any lifestyle risk factors, DM, hyper/dyslipidemia, salt intake, stimulant use (especially cocaine), known duration of HTN.
22. besides vitals: fundoscopic exam to assess for retinopathy, ausculation of neck and abdominal bruits, CVP and neuro exam.
23. new dx- urinalysis and resting ECG. left ventricular hypertrophy: echocardiogram.
24. creatinine, BUN, K, Na, Mg, Calcium, glucose, lipids, TSH, homocysteine, CRP-hs, fibrinogen, fractionated lipids.
25. oxidized LDL uptake into subendothelial layers of blood vessels causes inflammation and atheroma formation, increasing risk for ischemia or stenosis.
26. obesity, atherogenic dyslipidemia, HTN, insulin resistance, prothrombic states, pro-inflammatory states, smoking, hyperhomocysteinemia.
27. diabetes can increase "advanced glycation end products" which damage endothelial cells and increase inflammation.
28. might be asymptomatic for years or decades, then symptoms of ischemia (angina, TIA, IC), then progress to acute symptoms such as unstable angina, stroke, limb pain, sudden death.
29. besides history and risk factor screening: blood tests (lipid profile, blood sugar, homocysteine, CRP-hs, fibrinogen, CBC), stress testing, imaging tests (fast CT, carotid ultrasound, catheterization) can be helpful.
30. myocardial ischemia.
31. a "substernal heaviness or pressure" that may radiate to jaw, neck, left shoulder/arm.
32. pain lasts 15-30 seconds, worse in cold weather, after a meal, or contact with cold air.
33. S4 gallop.
34. various differences: for women, angina pectoris occurs more often with diabetes, is accompanied by more muscular discomfort, nausea, shortness of breath, fatigue, and is more often mistaken for indigestion.
35. angina that is due to coronary artery spasm as opposed to arteriosclerosis.
36. angina that develops from small vessel dysfunction- which results in a normal arteriogram.
37. coronary artery dysfunction that has no symptoms, most often occuring in diabetics.
38. decreased peripheral pulses, bruits in femoral/carotid arteries, xanthomas.
39. indicates that angina probably not due to CAD.
40. usually normal between attacks. during attacks: visible Q waves, T wave inversion, maybe ST depression. possible: smaller R wave, bundle branch disturbances.
41. cervicothoracic spine abnormalities, costochondral separation, Gi disease, pulmonary disease, pericarditis, mitral valve prolapse.
42. prolonged chest pain at rest, increasing/worsening symptoms, transient ECG changes.
43. Non ST Elevation MI: "myocardial necrosis without ST elevation of Q waves"
44. myocardial necrosis with ST elevation (and possible Q waves)
45. acute obstruction of an artery, usually a coronary artery thrombus.
46. deep, intense substernal pain that is not relieved by anything. restlessness, apprehension, dyspnea, diaphoresis, nausea, vomiting.
47. ECG within 10 minutes of MI and cardiac marker tests are diagnostic.
48. murmurs, S4 gallop, split S2, soft heart sounds, tachy/bradycardia, ventricular arrhythmias.
49. cardiac markers: troponin I/T, CK-MB, myoglobin, CBC, ESR.
50. inverted T wave, ST elevation, Q waves greater than 1mm wide or 1/3 QRS height.
51. unstable angina: 30% have MI in 3 months. STEMI/NSTEMI: mortality is ~30%.
52. heart failure, myocardial disorders and rupture, arrhythmias, aneuryism, cardiogenic shock, pericarditis.
53. pericarditis, pleural effusion, pneumonitis, fever. [pppf]
54. ventricular dysfunction which leads to reduced pumping action of the heart, ventricular hypertrophy and catecholamine elevation.
55. cardiomyopathies, valvular disease, MI, ischemia, CAD, HTN, PDA, VSD, arrhythmias.
56. RCHF, renal insufficiency, liver disease.
57. renal failure causes volume overload which contributes to HTN which contributes to CHF.
58. RCHF looks more like fluid buildup, whereas LCHF looks like respiratory problem.
59. dyspnea/fatigue upon exertion, intolerance to cold, cyanosis.
60. due to pulmonary edema: dyspnea, mb bronchospasm/wheezing, cough, right sided pleural effusions with basilar rales.
61. displaced apical impulse due to hypertrophy, S3 and S4.
62. CAD, ischemia, MI, HTN, aortic stenosis, cardiomyopathy, PDA, VSD, valvular dysfunction.
63. acute p. edema and associated symptoms, abnormal serum proteins (sudden onset cases).
64. p. edema, ARDS, COPD, IPF, cancer, chronic bronchitis.
65. fatigue, peripheral cyanosis, pitting edema, JVD, hepatomegaly, nocturia, light headedness. [i'm tired because my pee is swollen swollen swollen and blue]
66. tricuspid murmur, systemic HTN, low cardiac output. [tri murmuring "COHTN"]
67. LCHF, cor pulmonale, multiple p.edema, infarction, primary pulmonary HTN, stenosis of mitral valve, pulmonary valve, pulmonary artery. [look left, right: many die; one blocked]
68. edema: peripheral, idiopathic, myedema, angioneurotic, lymphedema. nephrotic syndrome, liver cirrhosis, hemiplegia, pericarditis. [edema, kidney/liver, stroke, heart protector]
69. class I: no physical activity limitation, no dyspnea/fatigue/palpitations. class II: slight limitation, dyspnea upon normal physical activity. class III: moderate limitation, dyspnea upon "less than ordinary" activities. class IV: severe limitation, dyspnea at rest.
70. enlarged cardiac silhouette, kerly-b lines, pleural effusion.
71. B natriuretic peptide, which is released in the body during excessive fluid release in general.
72. echocardiography, will show that ejection fraction less than 50%.
73. never do one of those things.
74. high BUN, creatinine, proteinuria, abnormal liver enzymes, electrolytes.
75. because excess water intake will exacerbate edema and contribute to volume overload.
76. right ventricular hypertrophy due to lung disease.
77. COPD, lung tissue loss, p. emboli, scleroderma, obesity.
78. that of underlying lung disorder, right ventricular hypertrophy or failure. in chronic cases: slight dyspnea at rest, syncope, chest pain, S3.
79. right heart and proximal pulmonary artery enlargement.
80. echocardiogram (most helpful), CXR, ECG.
81. when valve disease, HTN, lung disease are ruled out as etiologies.
82. dilated, hypertrophic, restrictive.
83. related to ventricular dilation/systolic dysfunction: dyspnea/fatigue/edema, mb atypical chest pain, tachyarrythmias.
84. poor without transplant.
85. ventricular hypertrophy with diastolic dysfunction.
86. mostly inherited.
87. aged 20-40, =pain/dyspnea/palpitation/syncope upon exertion.
88. sudden death.
89. systolic ejection murmur that is increased with Valsalva.
90. ECG/echocardiogram/chest xray. chest xray might not show hypertrophy.
91. restrictive cardiomyopathies, characterized by low ventricular compliance.
92. pulmonary hypertension.
93. exertional dyspnea, orthopnea, p. edema, JVD.
94. S4, S3, mitral/TC regurgitation murmur, quiet heart sounds, rapid carotid pulse, arrhythmias.
there are countless pathologies available to the heart and circulatory system. arterial hypertension is high blood pressure either from a multitude of factors (primary) or from a single underlying disease (secondary). atherosclerosis results from high LDL levels which causes plaque formation in arteries and is exacerbated by diabetes mellitus. angina pectoris is chest pain generally caused by ischemia caused by coronary artery dysfunction and can be stable (worse upon exertion, better with rest) or unstable (happens at rest). acute coronary syndromes result from more severe coronary artery ischemia leading to infarction and necrosis, and include unstable angina, NSTEMI, STEMI. congestive heart failure is the dysfunction of the right or left ventricle and have symptom pictures that appear as fluid overload (right) or respiratory problems (left). cor pulmonale is right ventricular hypertrophy that is secondary to a lung disorder such as COPD. finally, cardiomyopathies are dysfunctions of myocardium that are diagnosed when other main etiologies such as valvular, HTN, pulmonary are ruled out. there are three types: dilated, restrictive, hypertrophic.
questions
cardiac testing...
1. what are ECG's used to assess?
2. what do the different components of the PQRST wave represent in the ECG?
3. which test is better to assess valvular dysfunction, the ECG or echocardiography?
4. what is the echocardiogram useful for assessing?
5. describe the difference between the TTE and TEE.
6. what does the EBCT test stand for and what does it measure?
7. what are MRI/MRA tests useful in determining?
8. PET measures...
9. examples of myocardial perfusion nuclides...
10. stress testing is a good way to assess....
arterial hypertension...
11. describe the demographic / racial trends for arterial hypertension.
12. what is the most common cause of arterial hypertension in children?
13. what are some risk factors for arterial hypertension?
14. what is the difference between primary and secondary hypertension?
15. what are some possible etiologies for primary arterial hypertension?
16. what are some examples of diseases that can cause secondary hypertension?
17. arterial hypertension patients are usually...
18. describe the symptom picture of patients with arterial hypertension.
19. what is an early sign of arterial hypertension?
20. what are some signs in a patient with arterial hypertension that might indicate an emergency situation?
21. what would you ask in a medical history of a patient with arterial hypertension?
22. what are some important aspects of the physical examination of a patient with arterial hypertension?
23. how might the specific lab tests differ for a patient who was newly diagnosed with HTN vs. a patient who has left ventricular hypertrophy or ST depression?
24. what are some blood tests that one might perform to aid in the diagnosis of arterial hypertension?
atherosclerosis...
25. describe the role of LDL in the pathogenesis of atherosclerosis.
26. what are the risk factors for developing atherosclerosis?
27. relationship of diabetes and pathophysiology of atherosclerosis.
28. describe the symptom picture/timeline for a patient with atherosclerosis.
29. what are some tests to screen for atherosclerosis?
angina...
30. angina is the result of...
31. describe the general location and sensation of the symptoms in angina pectoris.
32. unique aspects of symptom picture of angina pectoris?
33. what heart sound might be heard in a patient with angina pectoris?
34. how does the way that women experience angina pectoris differ from that of men?
35. what is variant / prinzmetal angina?
36. what is microvascular angina?
37. what is a silent ischemia?
38. what are some clues from the physical exam of a patient with chest pain that indicate coronary artery disease?
39. point tenderness over the chest wall indicates...
40. angina EKG characteristics.
41. possible differential diagnoses for angina pectoris.
acute coronary syndromes...
42. what are the hallmarks of unstable angina?
43. define NSTEMI.
44. define STEMI.
45. in general what is the etiology of acute coronary syndromes?
46. describe the symptom picture of a patient with NSTEMI or STEMI.
47. what are the tests that are diagnostic of these conditions?
48. what are some sounds one might hear upon auscultation of heart in a NSTEMI or STEMI patient?
49. blood tests.
50. ECG characteristics.
51. prognosis of the three types of acute coronary syndromes.
52. complications of MI?
53. what is the "post MI syndrome"?
left congestive heart failure...
54. what is congestive heart failure?
55. what are some possible etiologies for congestive heart failure?
56. LCHF causes...
57. what is the relationship between renal failure and CHF?
58. what is the relative difference in overall presentation of LCHF and RCHF?
59. general/systemic S/SX of LCHF.
60. respiratory S/SX of LCHF.
61. cardiac S/SX of LCHF.
62. etiologies of LCHF?
63. what are some complications of LCHF?
64. what are the differential diagnoses for LCHF?
right congestive heart failure...
65. general S/SX of RCHF.
66. cardiac S/SX of RCHF.
67. what are some possible etiologies of RCHF?
68. what are some possible differential diagnoses of RCHF?
69. what are the classes of CHF as defined by the New York Heart Association?
70. what would the chest xray of a CHF patient show?
71. what is a blood test that might aid in the diagnosis of CHF?
72. what is the best test for diagnosis of CHF and what might the test show?
73. ∂escribe the utility of a stress test in congestive heart failure.
74. what are some blood markers that might be abnormal in CHF?
75. why must water intake/output be monitered in CHF patients?
cor pulmonale...
76. what is cor pulmonale?
77. what is the etiology of cor pulmonale?
78. S/SX of cor pulmonale.
79. a chest xray of a patient with cor pulmonale might show...
80. tests that aid in the diagnosis of cor pulmonale are...
cardiomyopathies...
81. when are cardiomyopathies suspected?
82. what are the three types of cardiomyopathies?
83. describe the symptom picture dilated cardiomyopathy?
84. prognosis for dilated cardiomyopathy?
85. what is hypertrophic cardiomyopathy?
86. etiology of hypertrophic cardiomyopathy?
87. describe the typical patient and symptom picture of hypertrophic cardiomyopathy.
88. hypertrophic cardiomyopathy might result in...
89. what is a typical heart sound of hypertrophic cardiomyopathy?
90. which tests aid in the diagnosis of hypertrophic cardiomyopathy?
91. what is the least prevalent form among the types of cardiomyopathies and what is it characterized by?
92. what does restrictive cardiomyopathy result in?
93. what are common symptoms of a patient with restrictive cardiomyopathy?
94. what are the cardiac symptoms of a patient with restrictive cardiomyopathy?
answers
1. arrhythmias, myocardial ischemia, enlarged chambers.
2. P=atrial depolarization, QRS=ventricular depolarization, T=ventricular repolarization
3. echocardiography-- ECG cannot assess valvular dysfunction.
4. valvular disorders, chamber hypertrophy or dilation, blood flow, cardiomyopathies, heart failure, pericarditis.
5. TTE is more common and less invasive. TEE is used for more posterior structures of the heart, pacemaker implantation, prosthetic valves.
6. electron beam computed tomography, useful for assessing coronary artery disease.
7. mediastinal evaluation, dysfunction of aorta, muscles, non-coronary vessels.
8. myocardial perfusion via radionuclides.
9. thallium and technitium.
10. coronary artery disease.
11. more prevalence in african americans (32%) than european or mexican americans.
12. kidney disease.
13. genetic predisposition, poor lifestyle, diet (high salt intake in particular), stress, obesity.
14. primary is due to multiple factors whereas secondary is caused by a single underlying disease.
15. alcohol, OCP's, corticosteroids, cocaine, licorice (extreme, ridiculous amounts).
16. renal disease, pheochromocytoma, cushing's, primary aldosteronism, hyperthyroidism, myxedema, aortic coarctation.
17. asymptomatic.
18. associated with very high blood pressure: dizziness, flushing, headache, fatigue, epistaxis,
19. the 4th heart sound (S4).
20. diastolic BP above 120mmHg, JVD, CNS disorders, lung crackles (might indicate the pulmonary edema associated with heart failure), severe retinopathy.
21. history of heart disease, any lifestyle risk factors, DM, hyper/dyslipidemia, salt intake, stimulant use (especially cocaine), known duration of HTN.
22. besides vitals: fundoscopic exam to assess for retinopathy, ausculation of neck and abdominal bruits, CVP and neuro exam.
23. new dx- urinalysis and resting ECG. left ventricular hypertrophy: echocardiogram.
24. creatinine, BUN, K, Na, Mg, Calcium, glucose, lipids, TSH, homocysteine, CRP-hs, fibrinogen, fractionated lipids.
25. oxidized LDL uptake into subendothelial layers of blood vessels causes inflammation and atheroma formation, increasing risk for ischemia or stenosis.
26. obesity, atherogenic dyslipidemia, HTN, insulin resistance, prothrombic states, pro-inflammatory states, smoking, hyperhomocysteinemia.
27. diabetes can increase "advanced glycation end products" which damage endothelial cells and increase inflammation.
28. might be asymptomatic for years or decades, then symptoms of ischemia (angina, TIA, IC), then progress to acute symptoms such as unstable angina, stroke, limb pain, sudden death.
29. besides history and risk factor screening: blood tests (lipid profile, blood sugar, homocysteine, CRP-hs, fibrinogen, CBC), stress testing, imaging tests (fast CT, carotid ultrasound, catheterization) can be helpful.
30. myocardial ischemia.
31. a "substernal heaviness or pressure" that may radiate to jaw, neck, left shoulder/arm.
32. pain lasts 15-30 seconds, worse in cold weather, after a meal, or contact with cold air.
33. S4 gallop.
34. various differences: for women, angina pectoris occurs more often with diabetes, is accompanied by more muscular discomfort, nausea, shortness of breath, fatigue, and is more often mistaken for indigestion.
35. angina that is due to coronary artery spasm as opposed to arteriosclerosis.
36. angina that develops from small vessel dysfunction- which results in a normal arteriogram.
37. coronary artery dysfunction that has no symptoms, most often occuring in diabetics.
38. decreased peripheral pulses, bruits in femoral/carotid arteries, xanthomas.
39. indicates that angina probably not due to CAD.
40. usually normal between attacks. during attacks: visible Q waves, T wave inversion, maybe ST depression. possible: smaller R wave, bundle branch disturbances.
41. cervicothoracic spine abnormalities, costochondral separation, Gi disease, pulmonary disease, pericarditis, mitral valve prolapse.
42. prolonged chest pain at rest, increasing/worsening symptoms, transient ECG changes.
43. Non ST Elevation MI: "myocardial necrosis without ST elevation of Q waves"
44. myocardial necrosis with ST elevation (and possible Q waves)
45. acute obstruction of an artery, usually a coronary artery thrombus.
46. deep, intense substernal pain that is not relieved by anything. restlessness, apprehension, dyspnea, diaphoresis, nausea, vomiting.
47. ECG within 10 minutes of MI and cardiac marker tests are diagnostic.
48. murmurs, S4 gallop, split S2, soft heart sounds, tachy/bradycardia, ventricular arrhythmias.
49. cardiac markers: troponin I/T, CK-MB, myoglobin, CBC, ESR.
50. inverted T wave, ST elevation, Q waves greater than 1mm wide or 1/3 QRS height.
51. unstable angina: 30% have MI in 3 months. STEMI/NSTEMI: mortality is ~30%.
52. heart failure, myocardial disorders and rupture, arrhythmias, aneuryism, cardiogenic shock, pericarditis.
53. pericarditis, pleural effusion, pneumonitis, fever. [pppf]
54. ventricular dysfunction which leads to reduced pumping action of the heart, ventricular hypertrophy and catecholamine elevation.
55. cardiomyopathies, valvular disease, MI, ischemia, CAD, HTN, PDA, VSD, arrhythmias.
56. RCHF, renal insufficiency, liver disease.
57. renal failure causes volume overload which contributes to HTN which contributes to CHF.
58. RCHF looks more like fluid buildup, whereas LCHF looks like respiratory problem.
59. dyspnea/fatigue upon exertion, intolerance to cold, cyanosis.
60. due to pulmonary edema: dyspnea, mb bronchospasm/wheezing, cough, right sided pleural effusions with basilar rales.
61. displaced apical impulse due to hypertrophy, S3 and S4.
62. CAD, ischemia, MI, HTN, aortic stenosis, cardiomyopathy, PDA, VSD, valvular dysfunction.
63. acute p. edema and associated symptoms, abnormal serum proteins (sudden onset cases).
64. p. edema, ARDS, COPD, IPF, cancer, chronic bronchitis.
65. fatigue, peripheral cyanosis, pitting edema, JVD, hepatomegaly, nocturia, light headedness. [i'm tired because my pee is swollen swollen swollen and blue]
66. tricuspid murmur, systemic HTN, low cardiac output. [tri murmuring "COHTN"]
67. LCHF, cor pulmonale, multiple p.edema, infarction, primary pulmonary HTN, stenosis of mitral valve, pulmonary valve, pulmonary artery. [look left, right: many die; one blocked]
68. edema: peripheral, idiopathic, myedema, angioneurotic, lymphedema. nephrotic syndrome, liver cirrhosis, hemiplegia, pericarditis. [edema, kidney/liver, stroke, heart protector]
69. class I: no physical activity limitation, no dyspnea/fatigue/palpitations. class II: slight limitation, dyspnea upon normal physical activity. class III: moderate limitation, dyspnea upon "less than ordinary" activities. class IV: severe limitation, dyspnea at rest.
70. enlarged cardiac silhouette, kerly-b lines, pleural effusion.
71. B natriuretic peptide, which is released in the body during excessive fluid release in general.
72. echocardiography, will show that ejection fraction less than 50%.
73. never do one of those things.
74. high BUN, creatinine, proteinuria, abnormal liver enzymes, electrolytes.
75. because excess water intake will exacerbate edema and contribute to volume overload.
76. right ventricular hypertrophy due to lung disease.
77. COPD, lung tissue loss, p. emboli, scleroderma, obesity.
78. that of underlying lung disorder, right ventricular hypertrophy or failure. in chronic cases: slight dyspnea at rest, syncope, chest pain, S3.
79. right heart and proximal pulmonary artery enlargement.
80. echocardiogram (most helpful), CXR, ECG.
81. when valve disease, HTN, lung disease are ruled out as etiologies.
82. dilated, hypertrophic, restrictive.
83. related to ventricular dilation/systolic dysfunction: dyspnea/fatigue/edema, mb atypical chest pain, tachyarrythmias.
84. poor without transplant.
85. ventricular hypertrophy with diastolic dysfunction.
86. mostly inherited.
87. aged 20-40, =pain/dyspnea/palpitation/syncope upon exertion.
88. sudden death.
89. systolic ejection murmur that is increased with Valsalva.
90. ECG/echocardiogram/chest xray. chest xray might not show hypertrophy.
91. restrictive cardiomyopathies, characterized by low ventricular compliance.
92. pulmonary hypertension.
93. exertional dyspnea, orthopnea, p. edema, JVD.
94. S4, S3, mitral/TC regurgitation murmur, quiet heart sounds, rapid carotid pulse, arrhythmias.
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