Valve diseases
what heart sound marks the end of diastole/start of systole? which valves are closing?
S1 - Tricuspid and Mitral valves closing
Which murmur is the only one that gets louder with valsalva maneuvers?
murmurs related to mitral valve prolapse.
What are the 2 main ways the body decompensates into heart failure?
SNS and RAAS
decreased CO -> kidneys sense hypoperfusion -> activation of RAAS -> Increase BP/PVR.
SNS senses hypoperfusion -> brain secretes ADH, catecholamines -> fluid retention, increase in HR.
What are signs of a patient being unstable hemodynamically?
Hypotension, diaphoresis, tachycardia, AMS, pulselessness.
Which two antiarrhythmics should you not pair?
BBs and Non-DHP CCBs
A systolic murmur is heard at the PMI, and this radiates upwards to the neck/axilla. which valve is likely involved?
Likely mitral valve regurgitation
Describe where and when you'd hear a murmur for aortic stenosis?
systolic murmur heard at right upper sternal border.
A patient has had a previous diagnosis of HFrEF, but she has improved so much that her ejection fraction is close to 55% now. She has no limitations with physical activity anymore. What stage and NYHA class is she in?
Still Stage C since she had HF before, but now in NYHA class I
A patient presents with palpitations and ECG shows afib. He's never had this before. He says that he thinks it started yesterday but he was also quite drunkypoo and can't quite remember. Hes stable... how should we proceed?
Chemical cardioversion with BB or CCB as we can't trust him that onset was <48 hrs ago (for electrical cardioversion) -> risk of sending clot to brain.
Whats something we can give for patients who have frequent/bothersome PACs/PVCs?
Beta blockers to slow HR (low dose)
A murmur is heard at the left lower sternal border during diastole, and increases with respiration. What valve disorder is likely?
Tricuspid valve stenosis
What P wave change on ECG can happen with tricuspid stenosis?
P wave increases amplitude d/t enlarged RA d/t backup.
What is BNP mostly used for?
Used for supporting diagnosis of HF or to r/o HF, or as a prognostic factor in known HF patients (higher = worse prognosis)
what is the hallmark of WPW on ECG? What's happening physiologically?
Delta waves (sloping of QR segment)
Pre-excitation of ventricles via accessory pathway other than the AV node.
What medications are primarily used for ventricular arrythmias s/p MI?
Lidocaine or Mexiletine (Na channel blockers)
You hear a significantly split S2 sound that is louder with inspiration, and a systolic murmur is heard as well. What is your likely diagnosis? What is your treatment?
Pulmonic valve stenosis - 95% are congenital. Likely patient is asymptomatic until late in course (can develop HF symptoms).
Most people don't need treatment unless showing signs of HF. Then treat like HF.
a patient presents to you for the first time, and reports a PMHx of rheumatic heart disease which caused "some type of heart murmur". Where would you likely hear this murmur best?
What arrythmia is associated with this heart murmur?
Apex - MCC of mitral stenosis is rheumatic heart disease. Would hear a diastolic murmur at the PMI.
Strong association with AFIB!
How does an ARNI work?
ARNI is an angiotensin receptor blocker and neprilysin inhibitor. ARNIs work similarly to ARBs and decrease PVR/BP, but also blocks neprilysin -> block breakdown of BNP/ANP -> more diuresis.
What is brugada syndrome? When does it usually happen? What is the treatment?
Brugada syndrome is a ventricular arrythmia, ST elevation in a structurally normal heart.
Normally happens during rest/sleep
Tx: Quinidine (Na channel blocker) or ICD.
are Non-DHP calcium channel blockers used for primarily atrial or ventricular arrythmias?
Atrial arrythmias. If ventricular, use lido or mexiletine or amiodarone.
Contraceptives -> pregnancy can worsen stenosis.
A patient comes in for a wellness check and has no complaints. On exam, you notice his BP is 145/59. He also unexpectedly has pulses palpable over his RUQ and fingertips. What type of murmur are you potentially worried about?
What are the pillars of treatment for HF? What is the mechanism for each?
Beta Blockers - slow HR
ACEi/ARBs/ARNIs - Decrease PVR by inhibiting vasoconstriction. ARNIs also promote diuresis.
MRAs - Aldosterone antagonist -> more diuresis
SLGT2i - increase glucose excretion in urine -> more diuresis.
+/- diuretics
Which antiarrythmic has a black box warning for potentially causing resistant ventricular tachycardia?
Flecanide (Na channel blocker)
BP (causes peripheral dilation), ECGs (can cause heart block, QT prolong) Thyroid (blocks conversion of T4->T3)
All K CHANNEL BLOCKERS (CLASS 3) CAUSE QT PROLONGATION (risk of Torsade's)