High Yield IM CARDIOVASCULAR Review for Step 2 CK & Shelf Exam

Summary

This script offers an in-depth look at diagnosing and treating cardiovascular diseases, focusing on stable and unstable angina, stress tests, and pharmacological interventions. It covers various diagnostic methods like EKG, echo, and nuclear perfusion studies, and treatments including nitrates, aspirin, and beta blockers. The script also addresses acute coronary syndrome, differentiating unstable angina from STEMI, and outlines treatments for each. Additionally, it touches on Dressler syndrome, restrictive cardiomyopathy, and the management of hypertensive emergencies and peripheral vascular disease.

Takeaways

• 🏥 Stable angina is characterized by chest pain during exertion that improves with rest, and is assessed with stress tests like EKG, echo, or nuclear perfusion study.
• 💓 A positive stress test indicates ST depression, hypotension, pain, abnormal wall motion, or decreased nuclear isotope uptake.
• 🚑 Pharmacologic stress tests are used for those unable to exercise, utilizing drugs like adenosine to induce cardiac stress.
• 🩺 Angiography is the definitive diagnostic method for coronary artery disease but is invasive, hence stress tests are conducted first.
• 💊 First-line treatments for stable angina include nitrates, aspirin, and beta blockers, while unstable angina is treated with a broader regimen including morphine and heparin.
• 🆘 Acute coronary syndrome encompasses unstable angina, NSTEMI, and STEMI, and is initially assessed with EKG and cardiac enzymes.
• 🩹 In STEMI, cardiac enzymes aren't necessary for diagnosis if there's ST elevation or new left bundle branch block with chest pain.
• 🩩 Unstable angina is differentiated from stable by rest pain and worsening symptoms, without troponin elevations.
• 🌡️ Stress tests are indicated for chest pain assessment, with exercise tests preferred unless contraindicated by abnormal EKG or physical limitations.
• 🛑 Cardiac tamponade presents with Beck's triad (hypotension, JVD, muffled heart sounds) and is treated by draining the pericardial fluid.
• 🩸 Peripheral artery disease is diagnosed with ankle-brachial index, with treatment ranging from exercise to interventional procedures based on severity.

Q & A

What is stable angina and how is it typically managed?

Stable angina is a condition where substernal chest pain occurs with exercise or exertion and is relieved by rest. It is managed by stress tests such as EKG, echo, or nuclear perfusion study, and pharmacological stress tests if the patient is unable to exercise.

What are the three types of stress tests mentioned in the script?

The three types of stress tests mentioned are EKG stress test, echo stress test, and nuclear perfusion study.

How is a positive stress test indicated in the script?

A positive stress test is indicated by ST depression, hypotension, pain, abnormal wall motion in an echo, or decreased uptake of nuclear isotope in a nuclear perfusion study.

What is the first-line treatment for stable angina according to the script?

The first-line treatment for stable angina is nitrates, aspirin, and beta blockers.

What is the difference between stable and unstable angina as described in the script?

Stable angina occurs with exertion and is relieved by rest, while unstable angina is worsening, evolving, or occurs at rest without troponin elevations. Unstable angina with troponin elevations is considered NSTEMI.

What are the three types of acute coronary syndrome mentioned in the script?

The three types of acute coronary syndrome mentioned are unstable angina, STEMI, and NSTEMI.

How is STEMI diagnosed in the script?

STEMI is diagnosed with one millimeter ST elevations in two continuous leads or a new left bundle branch block with chest pain on an EKG.

What is the treatment for Dressler syndrome as per the script?

Dressler syndrome is treated with aspirin, which is an NSAID used specifically for this autoimmune pericarditis that occurs after an MI.

What are the conditions associated with restrictive cardiomyopathy according to the script?

The conditions associated with restrictive cardiomyopathy are hemochromatosis, amyloidosis, and sarcoidosis, which cause deposits in the myocardium leading to diastolic heart failure.

What is the first-line treatment for hypertensive emergency as mentioned in the script?

The first-line treatments for hypertensive emergency are IV hydralazine, nitroprusside, or labetalol, with the necessity of end organ damage for it to be considered an emergency.

How is aortic dissection differentiated into Type A and Type B in the script?

Aortic dissection is differentiated into Type A, which is anything proximal to the left subclavian, and Type B, which is distal to the left subclavian. Type A requires immediate surgery, while Type B is treated with beta blockers.

Outlines

00:00

🩺 Cardiology Overview: Stable Angina and Diagnostic Testing

This paragraph discusses stable angina, characterized by chest pain during exertion that subsides with rest. It emphasizes the importance of stress tests, which include EKG, echo, and nuclear perfusion studies. A positive stress test may show ST depression, hypotension, or pain. The necessity of a pharmacologic stress test for those unable to exercise is highlighted, using drugs like adenosine or dipyridamole. The paragraph also touches on the first-line treatments for stable and unstable angina, the latter being a more severe condition with pain at rest and no troponin elevations. The text transitions into the diagnosis of acute coronary syndrome, focusing on EKG and cardiac enzymes, and differentiates between unstable angina and NSTEMI based on troponin levels. It concludes with the importance of ruling out STEMI, which is diagnosed with specific EKG changes and chest pain.

05:01

🏥 Advanced Cardiac Conditions and Treatments

The second paragraph delves into the management of various cardiac conditions. It starts with the use of the TIMI score to determine the urgency of a stress test or a trip to the cath lab for patients with chest pain. The paragraph then explores specific conditions like Prinzmetal's angina, which involves coronary vasospasm, and the treatment of inferior wall MI, where nitrates are contraindicated due to right ventricular issues. It also discusses the use of drugs like dobutamine and atropine in cardiogenic shock and the importance of certain drugs in reducing mortality in MI. The paragraph further covers Dressler's syndrome, restrictive cardiomyopathy, and the treatment of different types of heart block. It ends with a discussion on CHF, highlighting the use of loop diuretics and the difference in treatment between supraventricular and ventricular tachycardia.

10:04

🩹 Cardiac Emergencies and Their Management

This section focuses on the diagnosis and treatment of acute cardiac conditions. It begins with the identification of cardiac tamponade through Beck's triad and pulsus paradoxus, and the use of imaging to detect pericardial fluid. The text then moves on to discuss mitral stenosis, its causes, and the diagnostic value of cardiac catheterization and echocardiograms. It also covers the complications of hypertension and aortic stenosis, including angina and syncope. The paragraph further addresses tricuspid valve issues related to IV drug use and carcinoid syndrome, and the diagnosis of infective endocarditis through fever, leukocytosis, and new murmurs. It concludes with the treatment of hypertensive emergencies with IV drugs and the differentiation between type A and type B aortic dissections, their symptoms, and appropriate treatments.

15:05

🚑 Peripheral Vascular Disease and Its Clinical Presentations

The fourth paragraph discusses peripheral vascular disease, emphasizing the importance of the ankle-brachial index for diagnosis. It describes the symptoms of claudication and the treatment options ranging from exercise to interventions like stenting or bypass surgery. The text also covers acute limb ischemia, its symptoms, and the use of heparin or embolectomy in treatment. It mentions LaRouche syndrome, a variation of peripheral vascular disease, and the use of IVC filters in cases where anticoagulants are contraindicated. The paragraph concludes with a discussion on the diagnosis and treatment of pulmonary embolism, highlighting the importance of heparin and CT angiography. It also touches on the signs of venous insufficiency and the differentiation from other conditions like CHF and cardiogenic shock.

20:06

🏋️‍♂️ Exercise and Interventional Treatments for Vascular Conditions

The final paragraph focuses on the role of exercise in managing peripheral vascular disease, especially in the early stages. It discusses the progression to more severe disease and the need for interventions like stenting or bypass surgery when patients experience pain at rest. The text also covers acute limb ischemia and its management with heparin and embolectomy. Additionally, it mentions LaRouche syndrome, its symptoms, and the importance of IVC filters in specific cases. The paragraph concludes with a discussion on the diagnosis and treatment of pulmonary embolism, emphasizing the use of heparin and CT angiography. It also addresses the signs of venous insufficiency and the differentiation from other conditions like CHF and cardiogenic shock.

Keywords

💡Stable Angina

Stable angina is a type of chest pain that occurs with physical exertion or stress and is relieved by rest. It is a sign of reduced blood flow to the heart muscle, typically due to coronary artery disease. In the script, stable angina is discussed as a condition that prompts a stress test to evaluate the heart's function further. The video emphasizes the importance of diagnosing and treating stable angina to prevent more severe heart conditions.

💡Stress Test

A stress test is a non-invasive medical test that helps doctors evaluate how well a person's heart works during physical activity. It's often used to diagnose coronary artery disease by measuring the heart's response to exertion. The script outlines three types of stress tests: EKG, echo, and nuclear perfusion study, and explains when each type is appropriate, such as when a patient has an abnormal EKG that might interfere with the test results.

💡EKG (Electrocardiogram)

An EKG is a test that records the electrical activity of the heart, which can show how fast the heart is beating and its rhythm (steady or irregular). It can also detect problems with the size, shape, and position of the heart's chambers. In the context of the video, an EKG is the first diagnostic step for patients with chest pain to rule out conditions like STEMI (ST-elevation myocardial infarction).

💡Pharmacologic Stress Test

A pharmacologic stress test is a type of stress test performed on patients who cannot exercise. It involves the use of drugs like adenosine or dipyridamole to induce stress on the heart, which is then monitored using EKG, echo, or nuclear perfusion studies. The script mentions this test as an alternative for patients who are unable to exercise due to conditions like wheelchair-bound status or osteoporosis.

💡Angiography

Angiography is a medical imaging technique used to visualize the inside of blood vessels and arteries, typically to diagnose a blocked or narrowed artery. It is considered the definitive method to diagnose coronary artery disease. The video script explains that angiography is typically performed after less invasive tests like stress tests because of its invasive nature.

💡Unstable Angina

Unstable angina is a form of chest pain that occurs at rest or with minimal exertion, signaling a higher risk of heart attack. It is considered more severe than stable angina because it does not improve with rest. The script describes unstable angina as a condition that requires immediate medical attention and may lead to an NSTEMI (non-ST-elevation myocardial infarction) if there are troponin elevations.

💡Acute Coronary Syndrome

Acute coronary syndrome (ACS) is an umbrella term for conditions that involve a sudden reduction in blood flow to the heart muscle, including unstable angina, STEMI, and NSTEMI. The script emphasizes the importance of quickly identifying ACS in patients presenting with chest pain, as it can be life-threatening and requires urgent treatment.

💡Cardiogenic Shock

Cardiogenic shock is a life-threatening condition in which the heart is unable to pump enough blood to meet the body's needs. It is typically caused by severe heart muscle damage from a large heart attack. The script mentions cardiogenic shock as a potential complication of heart conditions like inferior wall MI, where treatment may involve drugs like dobutamine or atropine.

💡Restrictive Cardiomyopathy

Restrictive cardiomyopathy is a heart muscle disease that prevents the heart's normal filling and relaxation. It is often caused by conditions like amyloidosis, sarcoidosis, or hemochromatosis. The script associates restrictive cardiomyopathy with these 'O.C.'s' and explains that they lead to diastolic heart failure with reduced ejection fraction due to deposits in the myocardium.

💡Congestive Heart Failure (CHF)

Congestive heart failure (CHF) is a condition in which the heart can't pump enough blood to meet the body's needs. The script discusses CHF in the context of acute decompensation, where the heart failure worsens, and the treatment involves diuretics, oxygen, and other measures to reduce the workload on the heart and improve circulation.

💡Supraventricular Tachycardia (SVT)

Supraventricular tachycardia is a rapid heart rate originating from the atria or the junction between the atria and ventricles. It is typically regular and can be caused by various factors, including stress and certain medical conditions. The script mentions adenosine as a treatment for stable SVT, while unstable cases may require cardioversion.

Highlights

Stable angina is indicated by substernal chest pain that occurs with exercise and is relieved by rest.

Three types of stress tests are available: EKG, echo, and nuclear perfusion study.

A positive stress test shows ST depression, hypotension, pain, or abnormal wall motion.

Pharmacologic stress tests are used when patients are unable to exercise.

Angiography is the definitive method to diagnose coronary artery disease, but it is invasive.

First-line treatment for stable angina includes nitrates, aspirin, and beta blockers.

Unstable angina is characterized by worsening chest pain at rest without troponin elevation.

STEMI is diagnosed with ST elevation on EKG and is a type of acute coronary syndrome.

Treatment for STEMI includes immediate cath lab intervention without waiting for cardiac enzymes.

Unstable angina treatment includes nitroglycerin, morphine, oxygen, aspirin, clopidogrel, beta blockers, ACE inhibitors, statins, and heparin.

For chest pain, an EKG is the first diagnostic step to rule out STEMI.

If no ST elevations are present, serial troponin and EKGs are used to diagnose unstable angina or NSTEMI.

Indications for cath lab include three-vessel disease, proximal left anterior descending disease, Prinzmetal angina, and inferior MI.

Treatment for inferior wall MI may include fluids instead of nitrates to avoid exacerbating hypotension.

Only three drugs have been shown to decrease mortality in MI: aspirin, beta blockers, and ACE inhibitors.

Dressler syndrome is an autoimmune pericarditis treated with aspirin, distinct from viral pericarditis.

Restrictive cardiomyopathy is associated with conditions like hemochromatosis, amyloidosis, and sarcoidosis.

Treatment for CHF includes loop diuretics, inotropes, and positioning, with loop diuretics being the first line.

Supraventricular tachycardia is treated with adenosine if stable, and with cardioversion if unstable.

Ventricular tachycardia is treated with amiodarone and cardioversion if unstable.

Cardiac tamponade presents with Beck's triad and is associated with pulsus paradoxus and electric alternans.

Mitral stenosis is often caused by previous rheumatic fever and can lead to left ventricular hypertrophy.

Aortic stenosis can be diagnosed with cardiac catheterization or echocardiogram and may require valve replacement.

Peripheral artery disease is diagnosed with the ankle-brachial index and is treated with exercise or interventions like stenting.

Acute limb ischemia in peripheral artery disease is treated with heparin or embolectomy.

Suspected PE is treated with heparin before diagnostic imaging with CT angio.

Transcripts

[Music]

so we're gonna start cardiovascular

disease so people who have stable angina

which means that they have substernal

chest pain that occurs with exercise or

exertion and is alleviated by rest then

this is a sign of stable angina because

it improves with rest people with this

you the next thing you want to do is a

stress test right and there's three

types of stress tests and EKG an echo or

a nuclear perfusion study so you would

do an echo if that or a nuclear

perfusion study if that person is uh has

any abnormalities on EKG so the actual

so a positive stress test would be

anything that shows ST depression or

hypotension or pain and then you know

the echo you might see abnormal wall

motion that would be a positive stress

test or and then nuclear perfusion

studies would show decreased uptake of

nuclear isotope and that'd be a positive

stress test as well so and then remember

if they are unable to exercise then

that's when you do a pharmacologic

stress test so there's two ways to

induce stress on the heart either

exercise or using drugs such as

adenosine or die period them all so most

of the time the correct answer will be

as exercise stress test using EKG if

they have an abnormal EKG which will

mask the results of that stress EKG then

you either do an echo or nuclear

perfusion studies if they can exercise

then they will exercise on the treadmill

if they can't exercise as an they are

wheelchair-bound

or have osteoporosis or some other thing

that is a contraindication to exercise

then that's when you do a pharmacologic

test

test and with the pharmacologic test it

can be observed either on EKG echo or

nuclear perfusion study as well so and

then remember that the definitive way to

actually diagnose coronary artery

disease is through angiography so the

reason why you do these stress tests

first is because angiography is very

invasive so that's why you do the others

first so um the first thing you want to

do first test you want to do with chest

pain as EKG the first-line treatment for

stable angina is nitrates aspirin and

beta blockers first-line treatment for

unstable angina is lemonis II - mnemonic

which is morphine oxygen nitrates

aspirin clopidogrel beta blockers ACE

inhibitors statin and heparin and

remember that the first thing you want

to give is aspirin and remember if the

person has unstable angina which means

if definition of unstable angina means

that their angina is worsening or

evolving or occurs at rest now which is

different than stable angina but

unstable angina also has no troponin

elevations if you have unstable angina

with troponin elevations and so

basically unstable angina becomes NSTEMI

as soon as there are any troponin if

there are opponents with st elevations

then this is what we call a STEMI what

alright so when someone comes in with

chest pain the first thing you want to

do is rule out acute coronary syndrome

acute coronary syndrome is unstable

angina and STEMI or STEMI so those are

the three types of acute coronary

syndrome so when someone comes in with

chest pain you want to roll that out so

we first you do an EKG and cardiac

enzymes but the thing is cardiac enzymes

can take a while to come

so first thing you want to do is what

the EKG is luck to see if this is STEMI

or not so it fits

dami if it's STEMI then to diagnose

Tammy you don't even need cardiac

enzymes all you need is one millimeter

st elevations and two continuous leads

or a new left bundle branch block with

chest pain and that's considered STEMI

you don't even need the enzymes if you

see those they go straight to cath lab

and then see you do the EKG but there

are no st elevations but they do have

the characteristic chest pain that they

were describing then you want to do

serial troponin and serial EKGs to see

if this is evolving or changing so then

it's either going to be unstable angina

or n STEMI if the troponin is come back

updated with elevated troponin then

that's now called an N STEMI as a non ST

elevation mi

if there are no troponin yet and after

serial troponin measurements and it

stays low then this is called unstable

angina and remember it the conditions

also have to be satisfied where the

chest pain has been evolving recently

and been getting worse and this person

has been having chest pain at rest this

is called unstable angina if they have

unstable angina or and STEMI then you

want to apply the Tammy's core if it's 0

to 2 this person will get a stress test

if it's 3 or more than this person will

go to cath lab anyone who has chest pain

who has has unstable vitals as well that

you suspect my they also go straight to

cath lab so those are some exceptions

main indications for a cabbage are three

vessel disease or proximal left anterior

descending disease with 70% plus

stenosis

next is prinzmetal angina which is

basically coronary vasospasm

so the angiography will show this so

spasm when given organ a vine or

Sedo : and you'll also see st-elevation

on EKG during these painful episodes and

you want to treat this with calcium

channel blockers or nitrates you only do

TPA and MMI if there's no access to PCI

Center inferior mi when you have an ro

cardial infarction of the inferior wall

which is 2/3 and a VF and this is the

only mi that has an exception where you

don't want to give nitrates because

because they have a right ventricular mi

it's already the heart is already having

problems pumping blood to the left side

of the heart so if you give nitrates

this will exacerbate the hypotension

so actually in an inferior wall mi you

actually want to give fluids sometimes

an inferior wall mi can because because

the right coronary artery supplies blood

to the SA node this can cause and then

that sinus bradycardia can cause

cardiogenic shock and usually first when

for cardiogenic shock is dobutamine

which is the beta 1 agonist but in the

case of inferior wall mi that has

bradycardia and cardiogenic shock this

is due to injury of the SA node so in

this special case you want to give

atropine remember that there's only

three drugs shown to decrease mortality

in MI and this is very high yield is

aspirin beta blockers and ACE inhibitors

and nitrates work in two ways but the

predominant way it works by for my eyes

is that it decreases preload it's a V no

die later and that decreases stress on

the myocardium due to excess blood so

when you minimize the preload there's

less stress on the heart muscle and also

it's secondary effect as it dilates the

coronary arteries so treatment of

first-degree and second-degree heart

block mobitz one is no treatment but mo

it's two and the complete heart block

you want to treat with pacemaker

Dressler syndrome is an autoimmune

pericarditis that happens two weeks

later after an mi host MI two weeks with

fever and symptoms of pericarditis with

leukocytosis you want to treat with

aspirin this is contrasted with other

causes of pericarditis such as viral

pericarditis those will be treated with

NSAIDs

this Dressler syndrome is specifically

treated with aspirin and then you have

restrictive cardiomyopathy I just

remember the o C's so hemochromatosis

amyloidosis sarcoidosis this creates a

diastolic heart failure with reduced

ejection fraction this is due to

deposits in the myocardium

so like amyloid deposits or granulomas

or iron deposits in the myocardium what

I'm trying to say is remember that humor

chrome mitosis amyloidosis and

sarcoidosis

or if associated with restrictive

cardiomyopathy and then remember

hemochromatosis is bronze diabetes and

iron overload so they'll have diabetes

bronze gaming don't have elevated liver

enzymes amyloidosis is think of like

protein deposits you're gonna have

deposits in the heart and the kidney and

in the joints and in the kidney you'll

see proteinuria versus sarcoidosis is

where you'll see heart and lung stuff so

bilateral hilar adenopathy a dry cough

uveitis erythema nodosum and also

restrictive cardiomyopathy there are

three CHF drugs shown to decrease

mortality and that's ace inhibitors beta

blockers and spironolactone which is a

potassium sparing their diuretic which

should be contrasted with the three

drugs that decrease mortality and mi

which is ace inhibitors as well and beta

blockers as well but the third is

aspirin remember met four

which is first-line treatment for type 2

diabetes remember its contraindications

which is it's contraindicated in renal

disease and CHF because it can cause

metabolic acidosis remember for CHF

acute decompensation of CHF which means

the heart failure is getting worse then

you want to treat it with them mnemonic

no lit nitrates oxygen loop diuretics

inotropes

and positioning such as elevating the

head of the bed but the first thing you

want to treat what is a loop diuretics

such as furiosa might you need to know

supraventricular tachycardia versus

ventricular tachycardia so a

supraventricular tachycardia will have

narrow QRS s you know it'll look like

QRS TQ r st qrst

and if they're stable you treat with

adenosine and if they're unstable then

you want to treat with cardioversion and

then ventricular tachycardia which has

wide bizarre qrs complexes after one

after another then you want to treat

with amiodarone and if they're unstable

then you want to treat with

cardioversion versus v-fib and pulseless

v-tach

first-line treatment for that is

different relation verses asystole and

pulseless electrical activity pulseless

electrical activity means that the EKG

shows any rhythm but when you feel for

the pulse there's no pulse that means P

e a and then to treat with that is CPR

and by the way remember that the

first-line treatment for a super

ventricular tachycardia before you

progress with an adenosine is vagal

maneuvers such as carotid massage so

torsades de pointes can lead to v-fib

and this is treated with IV magnesium

which stabilizes the cardiac membranes X

is constrictive pericarditis which is

idiopathic fibrous scarring replacing

the entire

pericardial space the key here I want

you to look for is when they do imaging

like a chest x-ray of the heart you'll

see calcifications calcifications is key

and it's usually caused by TB or lupus

and it can present similarly to

restrictive cardiomyopathy it can have

equal diastolic pressures and all

chambers and it can also have by atrial

enlargement and treatment is peri

cardiac t'me acute pericarditis causes

the main causes coxsackievirus and you

treat it with the NSAID versus Jess lair

which is treated with aspirin aspirin is

a type of NSAID but remember Dressler's

aspirin and on EKG you'll see diffuse St

elevations and it's improved with

leaning forward so cardiac tamponade is

just remember Beck's triad which is

hypotension jvd and muffled heart sounds

it's also associated with pulsus

paradoxus which means when you inspire

this increases filling to the right

ventricle which causes the

interventricular septum to bow over to

the left side which decreases the left

ventricular preload and because of this

the stroke volume is decreased and

because of this the systolic pressure

will drop by greater than 10 and that's

called pulsus paradoxus which means a

systolic pressure dropping by greater

than 10

upon inspiration you will see that in

cardiac tamponade it's also associated

with electric alternates which means the

QRS voltages kind of the amplitude kind

of becomes alternating between big and

small big and small big and small and

that's because the heart is literally

swinging within the pericardial fluid

which distorts the qrs measurements and

then you'll also see low-voltage QRS and

a KU small sign coos

sign which means when you inhale that

the jugular venous distention increases

because with cardiac tamponade shelling

of the right side of the heart is more

difficult because it's not as compliant

so then the venous blood tends to

overflow faster remember mitral stenosis

the majority of the causes of mitral

stenosis our previous episode of acute

rheumatic fever or rheumatic heart

disease hypertension or aortic stenosis

can over time lead to left ventricular

hypertrophy and if this is prolonged

this can become dilated cardiomyopathy

and people with hypertension or aortic

stenosis tend to get angina because of

decreased perfusion to the coronary

arteries another complication as syncope

due to decreased perfusion of the brain

another complication is left ventricular

hypertrophy because of increased

afterload another complication is

dilated cardiomyopathy from chronicity

and then you'll hear a soft s2 because

the valve doesn't move well and then

definitive diagnosis for aortic stenosis

is cardiac catheter to measure the valve

area what an echocardiogram can also

measure the valve diameter if it's less

than one square centimeter or if they

have any symptoms at all such as an

angina syncope or CHF then you want to

treat with valve replacement the

tricuspid valve remember that it's

associated with IV drug use and

carcinoid syndrome carcinoid syndrome is

a tumor that produces too much serotonin

and that creates bronchospasm flushing

diarrhea and right-sided heart murmurs

three causes of holosystolic murmur or

mitral regurg tricuspid regurge and VSD

so if someone has infective endocarditis

the easiest way to diagnose this is

one who has a fever with leukocytosis

and new onset of murmur and you don't

know the bugs it before you find out

from your blood culture which is the

first thing you want to do you treat it

empirically with vancomycin and an

aminoglycoside hypertensive emergency is

defined as 180 over 120 and the

first-line treatments for hypertensive

emergency is IV hydralazine

nitroprusside or labetalol and remember

that for it to be considered an

emergency there has to be evidence of

end organ damage

so encephalopathy or acute kidney injury

or liver injury where versus

hypertensive urgency is high blood

pressure over 180 over 120 but no end

organ damage so the difference is if

it's an emergency you treat IV but if

it's urgency you treat with oral

medications subarachnoid hemorrhage the

Thunder Clap headache worst headache of

your life first thing you want to do is

a CT head without contrast and if that's

negative and you still suspect oh so

brackenreid hemorrhage the next step is

lumbar puncture and you're gonna look

for positive xantho chromia which is the

presence of bilirubin in the CSF a or

DIC dissection is substernal chest pain

that is described as tearing and

radiates to the back and you have two

types type A and type B type B is

anything just fill to the left

subclavian and type a is anything

proximal to that and you treat them

differently a goes to surgery right away

and B you give beta blockers to treat it

and you diagnose an aortic dissection

with a CT angio or a transesophageal

echo and remember any type of CT imaging

make sure to always check the patient's

kidneys because anyone with kidney

disease it's contraindicated to you see

see with contrast which is the majority

of CT imaging next is peripheral

vascular disease or peripheral artery

disease and so the number one risk

factor is smoking and to diagnose it you

want to do something called the ankle

brachial index which is measuring the

differences in blood pressures from the

ankle and the arm and if the ratio in

the ankle to arm is less than 0.9 then

that's disease and if it's less than 0.4

then this is severe disease which will

most likely have pain at rest as well

and people with peripheral artery

disease will describe themselves as

having claudication and their legs while

walking so they'll walk a certain

distance and then feel pain in their

legs and then it improves with rest it's

sort of like stable angina of the legs

due to stenosis of the ephemeral or

popliteal arteries the ones that are

current rest would be synonymous to like

unstable angina and then sometimes they

can make clots which is called acute

limb ischaemia which would be synonymous

to like an MI so if someone has a ratio

between 0.4 to 0.9 which would be like

stable angina this is the initial stages

of peripheral vascular disease the

first-line treatment is an exercise

program

if it starts if they start to have

problems at rest and their ratio is

below point 4 now you have to do an

intervention such as a stand or a bypass

if if they have acute limb ischemia

which is due to some sort of thrombosis

that cuts off the circulation in the

legs where everything just still did

that starts getting cold and pulseless

and in a lot of pain then you want to

treat that with heparin or an

embolectomy

sometimes there's a variation of

peripheral vascular disease known as

LaRouche syndrome which is caused by

atherosclerosis proximal to the aortic

bifurcation if

or they become the iliac arteries and

this person will complain a bilateral

leg pain as well as the key here is

impotence and buttock pain and this is

us like a sub-type a variation of the

same thing

remember that IVC filters are placed if

contraindicated to heparin or warfarin

or if they've failed previous therapy

with heparin or warfarin if you suspect

a PE in a patient which is basically

acute sudden onset of tachypnea

tachycardia and hypoxemia the first

thing you want to do is give heparin

before you even do the CT angio so

heparin and then CT angio if you had to

pick what is the best next step and they

both of those are the options pick

heparin first and then low molecular

weight heparins remember they're

contraindicated and renal disease

someone who has venous insufficiency

looked for the medial malleolus ulster

which is a sign of venous insufficiency

which can be contrasted to other similar

presentations such as CHF cardiogenic

shock first-line treatment is the ina

trope such as dobutamine

septic shock first-line treatment is IV

antibiotics plus IV fluids and

potentially vasopressors neurogenic

shock remember everything is down

cardiac output is down heart rate is

down total peripheral resistance is down

wedge pressure is down and the jvd is

down and you treat this with IV fluids