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                                                                                  CORONARY                TREATMENT OF                DEFINITION OF              TREATMENT OF
       CAUS ES                      RIS KS          CHARACTERISTICS            ARTERIOGRAPHY              STAB LE ANGINA                UNS TAB LE                 UNS TAB LE
                                                                                 INDICATIONS                                             ANGINA                     ANGINA

1. coronary                 1. elevated LDL;        1. v isceral pressure      1. unresolved chest       1. control avoidance of    1. recent onset of          1. hospitalizat ion
atherosclerosis             deceased HDL;                                      pain                      precipitating factors      progressive angina
                            elevated TAGs           2. t ightness                                                                   pectoris                    2. Nitrates
2. unknown cause w/                                                            2. potential coronary     2. pay attn to risk
normal arteriograms         2. hypertension         3. pain begins             artery bypass graft       factors                    2. acceleration of pre-     3. B-blockers
(syndrome X)                                        substernally and may       (CA BG) or                                           existing stable state of
                            3. cigarette smoking    radiate to arms, jaw, or   percutaneous              3. Nitrates                chronic angina              4. Ca b lockers
3. coronary artery                                  back                       transluminal coronary                                pectoris
spasms                      4. lack of exercise                                angioplasty (PTCA)        4. B-Blockers                                          5. Heparin
                                                    4. precipitated by                                                              3. pro longed chest
4. mit ral valve            5. genetic factors      physical or emot ional     3. markedly positive      5. Ca b lockers            pain up to 20-30 mins       6. Glycoprotein Iib-
prolapse                                            stress, relieved by rest   stress tests                                         w/out infarction (it’s      IIIa inhib itors (only if
                            6. personality traits                                                        6. Anti-p latelet agents   rare if angina lasts > 2-   pt conutes to have
5. myocard ial bridg ing                            5. Exercise stress test:   4. post resuscitation     esp w/previous             3 mins)                     chest pain in bed)
(involves LAD going         7. d iabetes              -at least 1 mm right                               infarct ion
down into the epi, then                             angle or down sloping      5. catheterizat ion for                              4. vasospastic angina       7. anti-platelet agents
makdes loop into myo        8. obesity              ST depression develops     other reasons in older    7. A CE inhibitors         (prin zemetal angina =      (ASA, Clopidogrel)
                                                    in the setting of a        age group (for silent                                rare)
6. hypertorphic                                     normal resting EKG=        coronary disease)         8. PTCA and stenting                                   8. PTCA
cardio myopathy                                     ischemia
                                                      -stress imaging                                    9. CA BG                                               9. CA BG
7. aort ic valve d isease                           w/radionuclide or
                                                    ECHO is necessary of                                                                                        (6&7= very expensive)
8. hypertension                                     baseline EKG is
                                                    abnormal or
                                                    pharmacological stress
                                                    testing is necessary

 PATHOPHYS              PHYS ICAL EXAM                       LAB TES TS                    NON-                  TX OF NON-TRANS MI                     COMPLICATIONS
                           FINDINGS                                                   TRANS MURAL MI

1. p laque           1. pt appear sweaty &           1. EKG                          -nonQ wave MI              1. Hospitalize                 1. tachyarrhythmias including VF
disruption           ashen                             -Ant surface: V leads
                                                       -Post surface: II, III, aVF   -flow restricted and       2. pain relief w/narcotics     2. Bradyarrhythmias including heart
2. vasospasm         2. hypotension                                                  only subednocardial                                       block
                                                     2. Elevated En zy mes:          necrosis has ocured        3. o xygen
3. p latelet         3. abnormal apical pulse          * CPK:                                                                                  3. LV failure  pulmonary edema
acivation                                               -rises in 8 hrs             -EKG: ST depression        4. bed rest
thrombosis           4. S4 gallop                        -peaks by 24 hrs                                                                      4. Cardiogenic shock
                                                         -normal in 72 hrs           -modest enzyme             5. clear liquids progressing     -destroyed 40% o f LV due to infarct
(death related to    5. d iminished heart                -elevation of myocard ial   elevation                  to a mild sodium restricted      -occlusion of pro x LA D
vulnerable plaque)   sounds due to                   band of CPK about 5%                                       diet
                     decreased contracitlity         inidcates myocardial            -prolonged pain                                           5. mit ral regurg b/o rupture of papillae
                                                     necrosis                                                   6. stood softeners             and cordae tendinae
                     6. parado xical splitting of      *Troponin                     -vessel totally occluded
                     2nd heard sound (LV has             -rises in 2 hrs             then thrombolytic          7. avoid b ladder distension   6. Rupture of IV septum if occlude
                     delayed contraction, P2           * LDH                         process opens plaque                                      LAD
                     delayed and moves on top            -rises in 12 hours          up again                   8. anti-coagulants (CT scan
                     of A2 in inspiration)               -peaks at 48-72 hrs                                    done 24-48 hrs after MI        7. Pulmonary embo lis m
                                                         -normal 7-10 days                                      shows that pts develop
                     7. Tachy/Brady                                                                             thrombus at site of            8. Cardiac rupture (if rupture into
                                                     3. Leu kocytosis                                           infarct ion)                   pericardiu m, get bradycardia and
                     8. Premature contractions                                                                                                 hypotension
                                                     4. Elevated sedimentation                                  9. t x of arrhythmias
                     9. slight fever                 ate                                                                                       9. Dressler’s syndrome: post op
                                                                                                                10. IV n itroglycerine         pericardotomy; autoimmune chronic
                     10. pericardial friction rub                                                                                              chest pain; difficult to manage
                                                                                                                11. aspirin

                                                   1.Increases coronary blood flow by increasing aortic root perfusion pressure
1. ASA-Clopidogrel if ASA is intolerant            2. Reduces afterload by distending peripheral arteries
2. Beta blockers
                                                    HOSPITAL AND POST HOSPITAL ACTIVITIES AFTER UNCOMPLICATED, ACUTE MI
3. Statin drugs                                      1. In coronary care unit: Unrestricted motion in bed (bedside commode, feeding self)
4. A CE inhibitors                                   2. Ambulatory unit:
5. Anti-o xidants                                            a. Up in chair and shaving
6. Folic Acid
                                                             b. walk about room and hall if no complications
                                                             c. discharge in 4 days for uncomplicated infarctions

       DRUGS                            US E                          MARKERS OF REPERFUS ION                           US E OF THROMBOLYTIC THERAPY
Streptokinase        -lease expensive
                     -infused slowly
                     -can have anaphylaxis
                     -never give 2x                                                                             1. EKG findings consistent w/acute mI
                     -vessel opening rate is almost as good as   1. accelerated chest pain resolution             -ST elevation of at least 1 mm in any two adjacent leads
                     TPA                                                                                        which persist after ad ministration of nitroglycerine
Tissue plasminogen                                               2. accelerated ST segment return to baseline
activator                                                                                                       2. Chest pain or symptoms typical of MI of < 12 hrs
Tenectaplase         -TPA                                        3. presence of ‘reperfusion dysrrhythmias’     duration
                     -US market                                  (accelerated id ioventricular rhythm,
                     -does not have to be given by infusion      bradycardia, nonsustained VT, PVCs ,           3. EKG should be repeated in 30 mins for pt w/symto ms
                     -works just as well as slow TPA             ventricular fibrillat ion                      but only equivocal EKG changes
Retevase             -use for pulmonary emboli, thro mbolic,
                     embolic stroke                                                                             (6-12 hrs = relative to give pt thro mbolytic)
                     -better improvement in mo rtality w/ DVT
                     than TPA
                     -high cost

    1. AKA: Idiopathic hypertrophic subaortic stenosis (IHSS)
    2. Normal LVEF
    3. Valsalva:
          a. Reducing preload will decrease diameter of LV outflow tract and make systolic murmur louder
          b. Increasing preload will increase diameter of LV outflow tract and make systolic murmur soft

  1. Arthritis
  2. Carditis
  3. Chorea (self- healing)
  4. Subcutaneous nodules
  5. Erythema marginatum
  6. Major manifestions:
        a. Fever
        b. Prolonged PR interval on EKG
        c. Elevated sedimentation rate and ASO titer

         DIS EAS E            MURMUR                 PYS/LAB FINDINGS                EKG FINGINGS                         TREATMENT                     OTHER
Mitral regurgitation   Pansystolic regurg murmur   -a-fib                                                  -if pt develops hrt failure fix valve and
                                                   -LA gets larger b/c holding                             plug up hole
                                                   a huge amt of b lood                                    -rheu m: leaflets fuse so put in new valve
                                                                                                           -coronary repair: leaflets ok, so fix
                                                                                                           w/synthetic cordae tendinae and tx
                                                                                                           comorbid ity
Mitral stenosis        Diastolic murmur                                                                    W/non calcified valve and no MR
                                                                                                           balloon valve
                                                                                                           -opens valve and also gives some degree
                                                                                                           of MR
                                                                                                           -surgery, replace valve
Aortic regurg          Decrescendo murmur          LV has to pump 2x as                                    Tx; heart failure; put in new valve
                                                   much blood  volu me
                                                   overload                                                Vasodilatory to help blood get to organs
                                                   -PP wide
                                                   -DBP decreased
                                                   -SBP may increase or stay
                                                   the same
                                                   -TPR decreased
                                                   -hammer pu lse felt
                                                   -digital puse felt
                                                   -murmur in fem artery 
Aortic Stenosis        Systolic ejection murmu r                                 R in V6 plus S in V1 >>   -mechanical fixing
                       Crescendo, decrescendo                                    35mm due to LV            -removing obstruction
                       murmur                                                    hypertrophy               -valvuloplasty
                                                                                                           -replace valve

     DIS EAS E            DEFINITION                PHYS/LAB FINDINGS                EKG CHANGES             TREATMENT                       OTHER
                      Co mbination of :        -clubbing                             -V1 =big/tall R     -hrt/lung transplant      -rt-lft shunt  no murmur
                       -VSD                                                          wave                (rarely done b/o high
                       -pulm hyperTN           Polycythemia:                         (majo r strain on   mortality                 -dilated pulmonary artery
                       -consequent rt-lft        -respond to cyanosis by  O2        right heart  rt                              may cause ejection murmu r
                      shunt thru defect w/or   capacity                              vent hypertrophy    -Prostacycline by
Eisenmenger           w/out overriding aorta     -Hb: 20-25                                              infusion:                 -pt can live until 40 w/
Syndrome                                         -HCT: 50-55                                               *help pulm hyperTN      Eisenmingers
                                                 -mo re susceptible to coagulation                         *imp rove hypoxia
                                                 -pulm hemorrhage is mode of                               * exercise tolerance
                                                 -pulm arterio les pop easily b/c
Tetralogy of Fallot   1. IV septal defect
                      2. Pulm stenosis         -clubbing, but disappears when        -V1 =big/tall R     -fix IV septal defect     Systolic Ejection Murmu r:
                      (subvalvular or of rt    fixed                                 wave                                            -mu rmur of aort ic
                      vent outflow tract)                                            (majo r strain on                             stenosis
                      3. Rt vent hypertrophy                                         right heart  rt                                -best heard at 2nd left
                      4. overrid ing aorta                                           vent hypertrophy                              interspace
Tricuspid Atresia     Congenital lack o f
                      tricuspid orfice
Transposition of
great vessles
Truncus Arteriosus

  DIS EAS E                MURMUR                 PHS Y/LAB FINDINGS           EKG CHANGES                  TREATMENT                             OTHER
Pulmonary                                                                                           -balloon to pop valve (can’t be
stenosis         Diastolic ejection mu rmur       -Pulmonary valve closure                          used w/aortic stenosis due to      Pulsus tartus: plateau pulse
                  -loud                           a bit delayed                                     type of pressure the aorta deals
                  -2nd left intercostal space                                                       w/)                                No mixing of vent blood
                                                                                                    -50 mm of pressure difference      w/atrial blood
                                                                                                    btwn rt vent and pulm art is
                                                                                                    significant enough to do
Aotric           Systolic ejection murmu r        -left vent hypertrophy       V6 R + V1 S = 35     -mechanical fixing                 -in adult it’s always calcified
stenosis           -when LVP exceeds aortic                                    mm or >>             -remove obstruction                -sudden death may occur
                 P, get’s louder then descends                                                      -valvuloplasty
                 crescenco, decrescendo                                                            -replace valve
Ventricular      Pancystolic regurg murmur
Septal Defect      -heard best at lower left      -bivent hypertrophy due      V1 and V6 have big   -fix surgically                    -P in lft vent = 120
                 sternal border                   to  in P in both            R wave                                                  -P in rt vent=25
                   -4th intercostal space         ventricles
Atrial septal    Pulm ejection mu rmur            -fixed split P2: doesn’t
defect             -soft                          vary w/respiration (stays                         -fixed when found b/c right
                   -sounds physiological          widely split due to rt                            ventricular failure results
                   -2nd left intercoastal space   ventricle always being
Patent ductus    Continuous murmur                -those living at high                                                                Differentials for continuous
arteriosus        -infraclav icular @ left side   altitudes have more                               -anchor by cathetor and it         murmurs:
                                                  chance of getting PDA                             thromobsis off                      -Trau ma (stab in neck)
                                                                                                                                        -A V fistulas
                                                  -P in aorta is 120/ 80                                                                   *coronary artery A V fist
                                                  -commun ication at                                                                       *pulm art A V fist
                                                  beginning of left
                                                  pulmonary artery
                                                  -P in pulm art in systole
                                                  and diastole are < then P
                                                  in aorta  flow goes fro m
                                                  aorta to pulm arter
Coarctation of                                    -only have HTN in
the Aorta                                         young/mid aged                                    -put in a balloon
                                                  -unexpected in those w/no
                                                  fam history

 Acute Idi opathic           Infecti ous        Ass w/generalized         Invol vement of     Neopl astic   Trauma   Radi ation   Drugs
                                                     disease                 contiguous
Most probably viral     -bacterial              -rheu matic fever       -acute myocardial
(Co xsackie B)          -viral                  -rheu m arthritis       infarct ion
                        -TB                     -SLE                    -post infarction
                        -fungal                 -uremia b4 d ialysis    syndrome
                        -Parasitic              -My xedema (hear        -dissecting
                                                pericardial rub)        aneurysm
                                                                        -esophageal disease
                                                                        -pulmonary disease

-Generalized ST elevation except in aVR = acute pericard itis
-in repairing you can get much calcification on pericard iu m therefore this is restricted

       1. Increased CO (to about 7-8 L/ min )
       2. decreased afterload

     1. Basilar ejection murmu r
              a. rt/lft 2nd intercostal space
              b. around 32 weeks when blood volu me is most confused w/atrial septal defect
     2. W ide pulse pressure