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Sunday, October 19, 2014

Cardiology List of Most Commons for Physician Assistant Students


Dear Readers,

Below are the most commons in cardiology that I’ve put together from this block. I’m sure once I enter rotations I will be adding many more. Can I just say that one of my biggest pet-peeves right now is the incorrect pronunciation of medical terms? For example, angina. This word has been produced in two ways by various professors, but there must be a correct way to pronounce it, so naturally, I looked it up. “An-jen-uh” is the correct pronunciation, while “an-jine-ah” is colloquially used, but incorrect.

Cardiology Most Commons
  • Most common pathologic process of the pericardium - Pericarditis
    • Most common etiology of Acute Pericarditis - coxsackievirus A and B
  • Most common cause of death in the U.S. - Coronary Artery Disease (CAD)
    • Coronary microcirculation disease more common in women - this is why CAD affects more women than men annually
    • Exercise electrocardiography less accurate in women
    • More women die each year of CAD
  • Most common cause of sudden cardiac death: ventricular fibrillation
  • Most common cause of sudden cardiac death in young athletes: hypertrophic obstructive cardiomyopathy (HOCM)
  • Hypertension
    • More common in women as age increases
    • More common in men in young and middle aged people
    • More common in African Americans and lower socioeconomic groups
      • African Americans develop at earlier age compared to other races
    • Secondary HTN - more common in children
  • White coat HTN - affects more treated women than men
  • HTN is the SECOND most common cause of CKD
  • Obesity most common in African Americans, Hispanics, and Native Americans than Caucasians in US
  • Resistant HTN - most common reason for referral to hypertension specialist
    • Persistent BP 140/90+ despite treatment with full doses of 3+ classes of meds
  • The most common cause of CAD is HTN
  • The most common cause of right ventricular heart failure is left ventricular heart failure!
  • Most common reason patients 65+ are hospitalized each year: congestive heart failure (CHF)
  • Most common etiology of LV systolic dysfunction: CAD
  • Most common secondary cause of dyslipidemia: diabetes/insulin resistance
  • Most common etiology of mitral stenosis: rheumatic heart disease
  • Most common etiology of endocarditis: staph aureus
    • More common in males living in urban areas
  • Native valve infective endocarditis (IVDU) most commonly
    • Affects the tricuspid valve +/- mitral or aortic
    • Affects normal valves
    • Most common microbe: staph aureus
  • Native valve infective endocarditis (non-IVDU) most commonly
    • Affects the mitral and aortic valves
    • Abnormal valves affected (RF and bicuspid aortic valve)
    • Most common microbe: strep mutans

Other Most Commons and Tips for Memorization!
  • While automaticity is greatest at the SA node, conductivity is greatest in the Purkinje Fibers (4000 mm/s) and slowest in the AV node (200 mm/s)
  • Pericardial Friction Rub - hallmark finding of acute pericarditis
  • “Water bottle” configuration - CXR finding of pericardial effusion
  • Clinical Presentation of Constrictive Pericarditis
    • WADE (heart failure symptoms)
      • Weakness
      • Ascites
      • Dyspnea
      • Edema
    • Increased JVP (without decrease upon inspiration)
    • +/- Pericardial “knock” - early diastole, L sternal border
  • Beck’s Triad - classic presentation of Cardiac Tamponade
    • Decreased arterial pressure
    • Distended neck veins
    • Faint heart sounds
  • Pulsus Paradoxus - decrease in pulse and systolic pressure (10 mmHg+) with inspiration; seen in cardiac tamponade, but also seen in hypovolemic shock, COPD, and pulmonary embolism; thus, it is non-specific and not good to rule in or out
  • Order of Heart Sounds
    • SEM-SOSS “some-sauce”
    • S1, Ejection click, Midsystolic click, S2, Opening snap, S3, S4
  • Mid-systolic (HAPI) Murmurs
  • Holosystolic (MTV) Murmurs
  • Diastolic (ARMS) Murmurs
      • “Austin Flint Murmur” - a diastolic rumble heard with chronic aortic regurgitation
      • Peripheral Pulses (Chronic Aortic Regurgitation)
        • Waterhammer pulse (Corrigan’s pulse) - rapid increase in pulse
        • Bobbing of head (de Musset’s sign) or uvula (Muller’s sign) with each heartbeat
        • Quincke’s pulses (capillary pulsations)
        • Traube’s Sign (“pistol shots” over femoral arteries)
        • Duroziez’s sign (systolic and diastolic femoral murmurs)
      • “Rule of 55” - operate before LVEF <55% or LV end-systolic dimension >5.5 cm
  • For more advanced learning, the American College of Cardiology has Heart Songs for purchase available through their website. While it is expensive, you might consider purchasing this one as a group and sharing it amongst students.
  • 2007 European Guidelines for treating HTN: “It is not important how treatment is started, but very important that BP goals are achieved”
  • CHADs2 Score - Atrial Fibrillation Stroke Risk
    • CHF = 1 Pt
    • HTN = 1 Pt
    • Age 74 + = 1 Pt
    • DM = 1 Pt
    • Secondary Embolic (stroke) Event: 2 Pts
  • Cardiac Tamponade
    • +/- in Pericardial effusion
  • Medical Emergencies in Cardiology
    • Cardiac Tamponade
    • Ventricular Tachycardia - sudden cardiac death
    • Ventricular Fibrillation - sudden cardiac death
    • Hypertrophic Obstructive Cardiomyopathy (HOCM)
    • Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
    • Wolff-Parkinson-White Syndrome
    • QT Prolongation
    • Severely elevated BP (HTN) + acute or rapid organ dysfunction
  • Various EKG Findings (keep in mind this is from a very basic understanding)
    • Atrial Flutter - “sawtooth pattern” or “rapid regular”
    • Atrial Fibrillation - “wavy baseline” “rapid irregular” “CHF promotes A-fib, A-fib aggravates CHF”
    • PVC - “wide, bizarre QRS complex”; inverted wide-QRS; inverted T-wave; no p-wave;
    • Wolff-Parkinson-White Syndrome - delta wave
    • Idioventricular rhythm - “slow v-tach”
    • Chronic Unstable Angina - 1 mm horizontal or down sloping ST segment depression in V5
    • NSTEMI - ST segment depression + T-wave inversion
    • STEMI - ST elevation
    • Acute Myocardial Infarction
      • Active injury: ST elevation, wide/deep Q wave, R wave normal, T-wave peaked
      • As heart necroses: deeper Q-waves
      • Post-injury: ST very elevated, R wave notching and loss of amplitude
      • T-wave inversion within hours and before ST segment isoelectric
      • ST elevation returns to normal within hours
      • Depressed PR segment
    • Acute Pericarditis - ST elevation/T-wave inversion (lasts days), decreased QRS amplitude
    • Pericardial Effusion: decreased QRS voltage, QRS alterans
    • Chronic Pericarditis - decreased QRS voltage, T-wave inversion
    • Cardiac Tamponade - decreased QRS voltage
    • Left Ventricular Hypertrophy (LVH) - thick lines, increased QRS voltage
    • Hyperkalemia - tall T-wave, sine-wave
    • ST depressions + deep T-wave inversions - HCM (apical variant)
    • ARVD (arrhythmogenic right ventricular dysplasia) - Epsilon waves
  • Takotsubo “octopus trap” Cardiomyopathy is sometimes referred to as the “broken heart syndrome” or “stress cardiomyopathy” - mimics MI without CAD present
  • Obviously patient history and physical exam are going to be more important in these cases, but here is a comparison that can be useful for remembering labs. This will especially be helpful in your ED rotation.
  • Remember for sensitivity and specificity:
    • SNOUT (SeNsitivity - rules OUT)
    • SPIN (SPecificity - rules IN)
Diagnosis
Identification/
Detection
Extras
Acute Pericarditis
TTE

Chronic Constrictive Pericarditis
R-heart Catheterization

CHF
BNP (rule IN)
Increases with sepsis, pulmonary emboli
Decreases with obesity
AMI
Myoglobin (rule OUT)
CK-MB (rule OUT)
Troponin (rule IN)
If all 3 elevated - acute phase of MI
NSTEMI
CK; CK-MB
Troponin




Sources:

2 comments:

  1. pronunciations of umbilicus. I am still not sure which one is correct as I have heard both from multiple different preceptors!

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    Replies
    1. So actually, the medical dictionaries are saying this: ŭm-bil′i-kŭs..which in laymen's sounds like um-bill-EYE-cuss. Merriam Webster and other literary dictionaries use the pronunciation: um·bi·li·cus, which is how most people pronounce it - um-bill-eh-cuss.

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