Dr.

Alis UWorld Notes For Step 2 CK

CARDIOLOGY

Chronic venous insufficiency is a leading cause of lower extremity edema.

Thought to result from incompetence of the valves in the lower extremity
veins, venous insufficiency causes manifestations ranging from mild
varicosities to leg pain, severe edema, stasis dermatitis, skin fibrosis,
ulceration, and immobility. Risk factors for venous insufficiency include age,
female gender, obesity, a history of lower extremity surgery, and a history of
lower extremity deep vein thrombosis. Leg elevation, compression
stockings and intermittent pneumatic compression dressings can all
help to decrease the edema. Skin fibrosis and ulcerations require more
intensive medical management.
Blood pressure control and salt restriction can help alleviate edema
secondary to left heart

Failure which is indicated by crackles on lung auscultation and/or jugular

venous distention would suggest this diagnosis.
Pulmonary HTN -recurrent pulmonary infections, chronic cough, a
significant smoking history, and an increased anterior-posterior chest
diameter and wheezing on physical examination, all consistent with chronic
obstructive lung disease. The associated chronic hypoxemia causes
constriction of the pulmonary arterial system and, with time, leads to
pulmonary hypertension, right ventricular hypertrophy, and right ventricular
failure. Right heart failure has in turn caused this patient's elevated jugular
venous pressure, congestive hepatosplenomegaly, hepatojugular reflux, and
lower extremity edema.
The pulmonary capillary wedge pressure reflects the left atrial pressure. This
pressure is elevated in cases of left ventricular failure. but is not elevated in
right ventricular failure with pulmonary hypertension because the pathologic
lesion is before the pulmonary capillary bed. Crackles on lung exam suggest
volume overload in the pulmonary capillaries and pulmonary edema.
CPK levels should be checked in any patient on a stalin who presents with
myalgias. If highly elevated, the first step is to discontinue the statin.
Nonpharmacologic interventions most likely to have the greatest
impact on his high blood pressure
Lifestyle modification should be the first-line intervention for newly
diagnosed stage I hypertension. The most effective lifestyle intervention for
reducing blood pressure is weight loss in obese patients. In nonobese
patients. the greatest effect on lowering blood pressure is seen with a diet
high in fruits and vegetables. followed by a low-salt diet

Septic Shock - low pulmonary capillary wedge pressure (PCWP) and

high mixed venous oxygen saturation (Mv02) is most consistent with
septic shock. Septic shock is a form of distributive shock due to an
underlying systemic infection involving the circulatory system. The systemic
inflammatory response causes peripheral vasodilatation and decreased
systemic vascular resistance (SVR). The decreased blood flow returning to
the heart also lowers PCWP. Cardiac output is often increased to compensate
and maintain adequate tissue perfusion. Mv02 is high due to hyperdynamic
circulation, improper distribution of cardiac output, and inability of the
tissues to adequately extract oxygen. Hypotension, warm (early) I cool (late)
extremities and elevated lactate levels are common clinical findings.
Cardiogenic shock - is usually due to significant left ventricular dysfunction
and reduced pump function. There is often low cardiac output, elevated
PCWP, and increased SVR. The decreased cardiac output decreases tissue
perfusion, which signals tissues to extract more oxygen from the blood and
decrease Mv02 .
Hypovolemic shock - has reduced preload (PCWP) and reduced
cardiac output. SVR increases in an attempt to maintain adequate
perfusion to the vital organs. Mv02 is low due to reduced tissue perfusion
and increased oxygen extraction by hypoperfused tissue.

Sinus Bradycarida - EKG as a heart rate < 60 with regular rhythm and a
constant PR interval. Sinus bradycardia is associated with excellent physical
conditioning, exaggerated vagal activity, sick sinus syndrome, hypoglycemia,
and certain medications (eg, digitalis, betablockers, calcium channel
blockers). Most individuals with sinus bradycardia are asymptomatic, but
some
develop dizziness, light-headedness, syncope, fatigue, and worsened angina.
In symptomatic patients, the administration of intravenous atropine
is the proper first step in management. Atropine provides an immediate
increase in the heart rate by decreasing vagal input.
Dresslers Syndrome - Patients with Dressler's syndrome present weeks
after a myocardial infarction with chest pain that is improved by leaning
forward. EKG shows ST segment elevations in all limb and precordial leads
except in aVR, where ST depression is seen. NSAIDs are the treatment of
choice. Corticosteroids can be used in refractory cases or when NSAIDs
are contraindicated.
Cardiac Syncope - The clues for the correct diagnosis include sudden onset
of syncope without warning signs, presence of structural heart disease (postinfarction scar and probable mitral regurgitation because of the
characteristic murmur), and frequent ectopic beats. Another important clue
is the presence of the thiazide diuretic in the medication list that can cause
electrolyte disturbances predisposing to ventricular arrhythmia.
Vasovagal syncope aka Neurocardiogenic Syncope also called Common
Faint & is usually precipitated by emotional reaction and is preceded by
presyncopal dizziness, weakness and nausea and pallor. The clinical
scenario typical for this condition is a prodrome (lightheadedness, weakness,
and blurred vision), provocation by an emotional situation, and rapid
recovery of consciousness. Pain, stress, and situations like medical needles
and urination can all precipitate vasovagal syncope. Vasovagal syncope can
be diagnosed with the tilt table test.
Autonomic dysfunction or drug-induced postural hypotension may
cause syncope, but this syncope is orthostatic in nature. That means it
occurs on standing when blood is redistributed to the dependent parts of the
body. When syncope occurs without preceding change in body position (e.g.
standing), it is unlikely to be orthostatic.
Orthostatic Hypotension Syncope - Orthostatic hypotension is defined as
a drop in systolic blood pressure greater than 20 mmHg when moving from

lying down to standing. It is common in patients who are elderly, are

hypovolemic, or have autonomic neuropathy (e.g., diabetes or Parkinson's
disease). Additionally, medications such as diuretics, vasodilators, and
adrenergic blocking agents can cause orthostatic hypotension. Prolonged
recumbence increases the risk - an older person who experiences
syncope upon standing after a period of bed rest... People will often
note a pre-syncopal lightheaded sensation.
Syncope may result from valvular obstruction, particularly in patients
with critical aortic stenosis (AS). Syncope due to AS most often occurs with
activity. Patients that experience syncope secondary to AS usually have a
preceding history of exertional dyspnea, chest pain, and/or fatigue.
Hyperventilation is a rare cause of syncope. Over breathing decreases
the concentration of
Carbon dioxide in the blood and promotes vasoconstriction. In severe cases,
syncope may occur. There is usually a preceding psychological stressor or
sensation of anxiety.
Clonic jerks may occur during any syncope if it is prolonged and are due to
brain hypoxia. Absence of a previous history of seizure and the description of
syncope make the diagnosis of seizure less likely.
Digoxin Toxicity Presents with decreased appetite and nausea. Atrial
tachycardia with AV block is the arrhythmia most specific for digitalis
toxicity. Verapamil decreases the renal clearance of digoxin. The most
common side effects of digoxin toxicity are gastrointestinal (i.e.,
anorexia, nausea, vomiting). Bidirectional ventricular tachycardia and
accelerated junctional rhythms are relatively specific for digoxin intoxication.
HOCM - This condition is more common in African Americans. It shows an
autosomal dominant inheritance, so the sudden death of the patient's
brother is likely a clue to the diagnosis. The patient's physical exam is also
suggestive. A carotid pulse with dual upstroke occurs from midsystolic
obstruction that develops as the heart contracts. Hypertrophic
cardiomyopathy typically causes a systolic ejection-type crescendodecrescendo murmur along the left sternal border without carotid
radiation, and often has a strong apical impulse. Contrary to most
murmurs, the murmur of hypertrophic cardiomyopathy increases as preload
decreases since this lessens the size of the ventricular cavity and causes
increased outflow obstruction. Most murmurs will decrease with decreased
preload since there will be less flow. The Valsalva maneuver will decrease
venous return, and therefore preload.

Isolated systolic hypertension (ISH), is an important cause of

hypertension in elderly patients. The pathophysiological mechanism leading
to ISH is believed to be decreased elasticity of the arterial wall, which
leads to an increase in systolic blood pressure without a significant change in
diastolic blood pressure. During systole, the heart ejects blood at a slightly
higher pressure than the peak systolic pressure as measured in the aorta.
The elastic properties of the aorta and major arteries dampen some of this
pressure by converting it into stored elastic energy. The elastic recoil of the
arterial walls is then used to maintain diastolic blood pressure when the
heart relaxes.
As a person ages, the elastic properties of the arterial wall diminish and the
arteries become more rigid. This reduction in compliance reduces the ability
of the arteries to dampen the systolic pressure, leading to systolic
hypertension and a widened pulse pressure (the difference between systolic
and diastolic blood pressures). Increased systolic blood pressure and
widened pulse pressure are important cardiovascular risk factors in the
elderly. Monotherapy with a low-dose thiazide, an ACE inhibitor, or a longacting calcium channel blocker is the most appropriate initial treatment.
AAA - Pulsatile abdominal mass is most likely an abdominal aortic aneurysm
(AAA). AAAs are usually asymptomatic and discovered incidentally. AAA
rupture is a potentially life-threatening complication; therefore all incidentally
discovered aneurysms require close follow-up. The imaging modality of
choice for diagnosis and follow-up is abdominal ultrasound, as it has
nearly 100% sensitivity and specificity, facilitates measurement of aneurysm
size, and can show the presence of any associated thrombus. Ultrasound is
relatively inexpensive compared to CT or MRI and has the benefit of not
requiring contrast administration. Most patients with abdominal aortic
aneurysm (AAA) are initially asymptomatic and the diagnosis is made during
an imaging study performed for an unrelated cause. The risk factors
associated with development of AAA include older age (>60 years). cigarette
smoking. family history of AAA, white race, and atherosclerosis. The main
risk factors associated with aneurysm expansion and rupture
include large diameter. rate of expansion. And current cigarette
smoking.
TAA - Ascending aortic aneurysms are most often due to cystic medial
necrosis or connective tissue disorders. Descending aortic aneurysms are
usually due to atherosclerosis. Chest x-ray can suggest thoracic aortic
aneurysm by showing a widened mediastinal silhouette, increased aortic
knob, and tracheal deviation

Heat stroke is defined as a temperature above 40.5c (1 05.F). Exertional

heat stroke occurs in otherwise healthy individuals exercising in extreme
heat. Dehydration, hypotension, tachycardia and tachypnea are common.
Systemic effects like seizures, ARDS, DIC, and hepatic/renal failure may also
occur.
Chagas disease, a chronic protozoal disease caused by Trypanosoma cruzi.
The organism
is common throughout Latin America, and should be considered in a
symptomatic patient who has recently immigrated from that area. The two
primary manifestations of Chagas disease are
megacolon/megaesophagus and cardiac disease. Megacolon or
megaesophagus (focal Gl dilatation) occur secondary to destruction of the
nerves controlling the Gl smooth muscle.There is pedal edema, jugular
venous distention, S3, and cardiomegaly all point toward congestive heart
failure. The pathophysiology of Chagas heart disease is not well understood,
but probably represents a prolonged myocarditis secondary to the protozoal
infection.
Cocaine Intoxication - psychomotor agitation, Seizures, dilated pupils,
atrophic nasal mucosa, hypertension, and acute myocardial ischemia (chest
pain, electrocardiogram changes), findings highly suggestive of acute
cocaine intoxication. Cocaine potentiates sympathomimetic actions by
causing inhibition of norepinephrine reuptake into the sympathetic neuron.
This causes stimulation of alpha and beta adrenergic receptors and can
result in coronary vasoconstriction and increase in heart rate, systemic blood
pressure, and myocardial oxygen demand. It also enhances thrombus
formation by promoting platelet activation and aggregation.
All patients with acute cocaine toxicity and myocardial ischemia should be
treated initially with supplemental oxygen and intravenous
benzodiazepines. By reducing sympathetic outflow, benzodiazepines
reduce anxiety and agitation, improve blood pressure and heart rate, and
alleviate cardiovascular symptoms. Aspirin retards thrombus formation;
nitrates and calcium channel blockers, being vasodilators, are beneficial for
the cocaine-induced coronary artery vasoconstriction. Beta blockers are
contraindicated.
Cushing's syndrome is an important cause of secondary
hypertension. In addition to blood pressure elevation, high systemic cortisol
concentrations cause hyperglycemia, hypokalemia, proximal muscle
weakness, central adiposity, thinning of the skin, weight gain, and
psychiatric problems (e.g. sleep disturbances, depression, and psychosis).

Aortic dissections are life-threatening emergencies that classically present

with tearing chest pain radiating to the back. Sequelae include cardiac
tamponade, acute aortic regurgitation, stroke, and renal failure.
In patients with hyperthyroidism-related tachysystolic atrial
fibrillation, a beta-blocker is the drug of choice.
Newly Diagnosed HTN - Patients initially diagnosed with hypertension
should have a detailed history and physical examination. In addition, the
following basic testing should be performed:
1.
2.
3.
4.

Urinalysis for occult hematuria and urine protein/creatinine ratio

Chemistry panel
Lipid profile
Baseline electrocardiogram

Secondary HTN causes

Reentrant ventricular arrhythmia (ventricular fibrillation) is the most

common cause of death in patients with acute myocardial infarction.
Atrial Fibrillation - The typical ECG presentation of atrial fibrillation
includes absent P waves replaced with tiny chaotic fibrillatory waves,
irregularly irregular R-R intervals, and narrow QRS complexes. The
pulmonary veins (PVs) are the most frequent origin for the ectopic
foci that cause atrial fibrillation. Cardiac tissue (myocardial sleeves)
extends into the PVs and normally functions like a sphincter during atrial
systole. This tissue has different electrical properties than the surrounding

atrial myocytes. and is prone to ectopic electrical foci and/or aberrant

conduction which can initiate atrial fibrillation. Patients who cannot achieve
rate and/or rhythm control with medication can undergo catheter
basedradiofrequency ablation. which destroys the myocardial tissue
surrounding the PVs. electrically disconnecting the PVs from the left atrium.
Controlling the rhythm or rate in patients with prolonged tachysystolic
atrial fibrillation usually improves the LV function significantly, sometimes
even dramatically.
The causes of acute atrial fibrillation are myriad and may be divided into
cardiac, pulmonary, metabolic, and drug-related etiologies. Cardiac causes
include hypertension, acute ischemia, heart failure, myopericardial
inflammation, valve disease, and surgery. Pulmonary causes include
any acute lung disease (e.g. pneumonia), pulmonary emboli, and hypoxia.
Metabolic conditions, such as catecholamine surges or hyperthyroidism,
also may cause atrial fibrillation. Drugs that can induce atrial fibrillation
include alcohol, cocaine, amphetamines, and theophylline.
Hyperthyroidism is the most common cause of acute atrial fibrillation
Lone atrial fibrillation is defined as the presence of paroxysmal
(Recurrent (>2) episodes that terminate spontaneously in <7 days, usually
within 24 hours) persistent (Episodes lasting > 7 days), or permanent
(Persistent of> 1 year duration) atrial fibrillation with no evidence of
cardiopulmonary or structural heart disease. These patients are at low risk of
systemic
embolization and no additional therapy is indicated in those who are
asymptomatic.
The mechanism of PSVT is often due to formation of a supraventricular reentry circuit, most commonly within the AV node (AVNRT).
The most common cause of atrial flutter involves a reentrant circuit that
rotates around the tricuspid annulus, with slowing of the impulse through a
region known as the cavotricuspid isthmus. Rapid "sawtooth" flutter waves
are the characteristic ECG feature of atrial flutter.
Aortic Dissection - Intensive retrosternal pain that radiates to the back of
the chest, along with a normal EKG strongly suggests aortic dissection.
Another important clue is the presence of the early diastolic murmur,
characteristic of aortic regurgitation. Dissection of the ascending aorta may
lead to acute aortic regurgitation. Hypertension is an important risk factor
and blood pressure should be measured in both arms (there may be a
difference in inter-arm blood pressure readings due to dissection). Best
initial is CXR. Transesophageal echocardiography is the preferred
diagnostic tool. Before performing the TEE, HTN should be controlled.

Viral Myocarditis - In otherwise young healthy patients who develop

sudden CHF, myocarditis should be considered high on the differential. Viral
infection, especially with Coxsackie B virus, is the most common cause.
Ascites- Portal hypertension is the most common cause of ascites. Portal
hypertension is usually due to cirrhosis from chronic liver disease (alcoholic
or viral). Intravenous drug abuse predisposes to cirrhosis by putting
individuals at increased risk for chronic infection with hepatitis B or C.
Essential Tremor - An essential tremor is characterized by a postural
tremor (not a resting tremor unlike Parkinson's disease) and usually disturbs
the performance of fine motor tasks. Sometimes, it runs in families with
autosomal-dominant inheritance. The pathophysiologic basis of this condition
is unclear. The inhibition of the tremor by a small amount of alcohol is
typical. Propranolol, a non-selective beta-blocker, is DOC in reducing the
tremor probably by blocking beta-2 receptors. Therefore, administering
propranolol to this patient would help to control both the hypertension and
the essential tremor.
Ventricular remodeling in the weeks to months following myocardial
infarction can lead to dilatation of the ventricle. This process is lessened by
ACE inhibitors.
Pulsus paradoxus is defined as an exaggerated fall in systemic blood
pressure > 1 0 mm Hg during inspiration. It is a frequent finding in cardiac
tamponade but can also occur in conditions without pericardial effusion
such as severe asthma or chronic obstructive pulmonary disease.
Coronary Steal Phenomenon - Dipyridamole can be used during
myocardial perfusion scanning to reveal the areas of restricted myocardial
perfusion. The redistribution of the coronary blood flow to 'non-diseased'
segments induced by this drug is called coronary steal phenomenon.
DDX b/w Cardiac & Liver Edema - Lower extremity edema is a common
problem in clinical practice, and the differential diagnosis of this condition is
sometimes difficult. This patient presents with symptoms and signs
suggestive of both liver and heart disease. A history of hepatitis B favors the
diagnosis of liver disease, and tuberculosis suggests constrictive pericarditis
as a potential cause of the problem. Constrictive pericarditis can cause a
right-sided heart failure-like syndrome including lower extremity edema,
ascites, hepatomegaly, and splenomegaly. On the other side, all these signs
may occur during a liver disease, like cirrhosis. Hepato-jugular reflex is a
useful and easy method to differentiate between these conditions. Positive
hepato-jugular reflex indicates that the venous pressure is elevated and

suggests that the heart disease-related edema is present. Hepato-jugular

reflex is negative in patients with the liver disease-related edema.

Excessive alcohol intake (>2 drinks a day) or binge drinking (~5 drinks in a
row) is associated with increased incidence of hypertension compared to
nondrinkers. In such patients, reduction in alcohol intake leads to improved
blood pressure control. In contrast, moderate alcohol intake (1 or 2 drinks a
day for men and 1 drink a day for women) is associated with decreased
incidence of coronary heart disease and cardiovascular mortality.
Acute Viral Myocarditis - A history of a recent upper respiratory tract
infection followed by sudden onset of cardiac failure in an otherwise healthy
patient is suggestive of dilated cardiomyopathy, most likely secondary to
acute viral myocarditis. Dilated cardiomyopathy is the end result of
myocardial damage produced by a variety of toxic, metabolic, or infectious
agents. Viral or idiopathic myocarditis is most commonly seen following
Coxsackievirus B infection, and occurs in about 3.5 - 5% of infected patients.
Other viruses commonly implicated include parvovirus B 19, human
herpesvirus 6, adenovirus, and enterovirus. Viral myocarditis can cause
dilated cardiomyopathy via direct viral damage and as a result of humoral or
cellular immune responses to persistent viral infections. The diagnosis of
dilated cardiomyopathy is made by echocardiogram, which typically shows
dilated ventricles with diffuse hypokinesia resulting in a low ejection fraction
(i.e., systolic dysfunction). Treatment is largely supportive, involving mainly
the management of CHF symptoms.
Anaphylactic shock caused by latex - The widespread use of latex in
medical products has made it a common cause of allergy. The development
of hives after sexual intercourse in this patient was likely due to sensitization
to latex condoms. Latex gloves used by surgeons provoked the anaphylactic
reaction. Pre-existing atopic dermatitis increases the risk of latex allergy.
Health care workers and surgical patients, especially those undergoing
abdominal or genitourinary surgery, are at higher risk as well. Latex allergy
rates peaked in the 1990s and have since decreased with the use of powderfree latex gloves and latex alternatives, butthe risk remains elevated in these
populations.
Medications to Withold Prior to Stress testing

Beta blockers, calcium channel blockers, and nitrates are antianginal agents
that should be withheld for at least 48 hours prior to cardiac stress testing.
However, these medications should be continued in patients with known
coronary artery disease undergoing stress testing to assess the efficacy of
antianginal therapy.
Dehydration Indicator - Elderly patients are particularly sensitive to fluid
loss and even mild hypovolemia may predispose them to orthostatic
syncope, especially upon getting up in the morning. BUN/creatinine ratio is a
useful indicator of dehydration
Cardiac Murmur Workup - Diastolic and continuous murmurs as well as
loud systolic murmurs revealed on cardiac auscultation should always be
investigated using transthoracic Doppler echocardiography. Midsystolic soft
murmurs (grade 1-11/ VI) in an asymptomatic young patient are usually
benign and need no further work-up.
Warfarin is a vitamin K antagonist used for anticoagulation in numerous
clinical settings. Foods rich in vitamin K (e.g. dark green vegetables) will
decrease its efficacy whereas numerous other foods, supplements, and
medications will increase its activity.
Examples of agents that increase warfarin activity include alcohol, vitamin
E, garlic, ginkgo biloba, ginseng, St. John's wort, and several types of
antibiotics. These agents when taken along with Warfarin will lead to
Increased INR & Bleeding
Brussel sprouts & Spinach are high in Vit K.