Cardiology for Studs

Studly Overview

Congenital Heart Disease
Percardial Disease
Ischemic Heart Disease
Cardiomyopathies
Ventricular Septal Defect
Congestive Heart Failure
Valvular Heart Disease
Endocarditis

Cardiac Arrhythmias

Atrial Tachyarrhythmias

Regular Atrial Tachycardias

Sinus Tachycardia
Paroxysmal Atrial Tachycardia
Atrial Flutter with Constant Conduction

Irregular Atrial Tahycardias

Atrial Fibrillation
Multifocal Atrial Tachycardia
Atrial Flutter with Irregular Conduction

Wolf Parkinson White Syndrome

VASCULAR DISEASE

Ischemic Heart Disease

Chest Pain

Chest pain reproducible by palpation --> Costochondritis

Tearing chest pain radiate to back --> Dissecting aortic aneurysm

Angina Pectoris

Levine's sign: clenched fist over sternum

ST depression, T wave inversion

Treatment of angina: acute --> sublingual nitroglycerine

Prinzmetal's (variant) angina

chest pain at rest

ST elevation (rather than depression)

Treatment:

Acute --> sublingual nitroglycerine

Chronic --> calcium channel blockers

Acute Myocardial Infarction

'Angor Animi' --> patients have feeling of impending doom

EKG: differentiate ST elevation (Q wave, transmural) from non-ST elevation (non-Q wave, subendocardial) MI

Anterior wall MI [LAD]: V2 – V4

Reperfusion arrhythmia: accelerated idioventricular rhythm

Treatment

for ST elevation (Q wave) MI: 'MONA'

Congestive Heart Failure

Cardiac Arrhythmias

Ischemic Heart Disease

Angina Pectoris

Levine's sign: clenched fist over sternum

ST depression

Treatment of angina: acute --> sublingual nitroglycerine

Prinzmetal's (variant) angina

ST elevation (rather than depression)

Treatment:

Acute --> sublingual nitroglycerine

Chronic --> calcium channel blockers

Acute Myocardial Infarction

'Angor Animi' --> patients have feeling of impending doom

EKG: differentiate ST elevation (Q wave, transmural) from non-ST elevation (non-Q wave, subendocardial) MI

Reperfusion arrhythmia: accelerated idioventricular rhythm

Valvular Heart Disease

Cardiomyopathies

Pericardial Disease

Pericarditis

Treatment: NSAIDS, aspirin

Congenital Heart Disease In The Adult

Venous Thrombosis

Cardiovascular Syncope

Cardiac Tamponade

Increased JVP

Second Take

Myocardial Ischemia / Myocardial Infarction: Substernal squeezing chest pain

[pressure / heavy feeling on chest]

Pericarditis: chest pain relieved by leaning forward

Costochondritis: chest pain reproduce by palpation

Dissecting aortic aneurism: tearing chest pain radiate to back

 Pneumonia: pleuritic (increase on inspiration) chest pain
 Pulmonary embolism: pleuritic chest pain, dyspnea, tachypnea
 Esophageal spam (“nut cracker disease”): h/o GERD, gastritis, pain occur after
eating, normal EKG

Stable angina: chest pain after exertion

 Unstable angina: chest pain at rest [ST Depression] [D ® E]

 Myocardial Infarction: chest pain at rest [ST Elevation]

 Prinzmetal angina: chest pain at rest [ST elevation – Transmural Ischemia][due to coronary artery spam. Pain may relieve by little exercise like patient gets up and walking and pain relieve because exercise causes increase in Adenosine
which is a potent coronary vasodilator] [Best diagnostic test – Angiography – shows No atherosclerosis] [Treatment: Ca++ channel blockers (CCB), Nitrates] [Not Aspirin and b-blockers]
 How will you differentiate unstable / Prinzmetal angina and MI? Angina
means chest pain comes and goes so even though chest pain occur at rest in unstable
/ Prinzmetal angina, you can easily diagnose from the presentation in the question.
 Patient with Stable/Unstable angina and MI should receive Aspirin, Nitrates
and b-blockers (if no contraindications like Asthma, etc.)
 Patient should also receive oxygen (if oxygen saturation is low) and morphine (if patient is still having chest pain)
 Unstable Angina (vessel blockage is due to plaque so clot is forming ): above 2 steps + Heparin (not thrombolytics) + Statins
 MI (vessel blockage is due to disrupted plaques so clot is already form ed ): above
2 steps + Thrombolytics (If certain criteria meets) + Statins + Low molecular
weight Heparin (If not contraindicated) + ACE inhibitors (only If CHF due to
acute MI) + Lidocaine (only If ventricular arrhythmias)
Thrombolytics (If it is not contraindicated, if Angioplasty is not readily available)
 Within 12 hrs of the onset of MI.
 > 1 mm ST segment elevation in two contiguous EKG.
 New LBBB (Left Bundle Branch Block).
 Best Initial test: EKG; Stress test for Stable angina
 Most accurate diagnostic test: Angiography (Ischemia) /
Cardiac Troponin & CK-MB (Infarction) [Both begin to elevate in 4-6 hrs] [Cardiac Troponin remains elevated for 1-2 wks] [CK-MB remains elevated for 2-3 days] [best test to check
re-infarction within a week – CK-MB because it disappears in 2-3 days]
 Most accurate treatment for MI / Unstable angina: Angioplasty
 Most important is to know when you will do diagnostic test and when you
will start treatment. Answer what they asked like best initial / most accurate
 If patient comes with chest pain for last 1-hr and still having pain, best initial
test? – EKG
 If patient comes with chest pain for last 1-hr and still having pain, EKG shows
ST depression / ST elevation, what will you do now? – Start treatment [Aspirin,
Nitrates….] (all patient should receive above treatment depends upon what they
have like Unstable angina or MI or stable angina or Prinzmetal angina)
 If patient comes with c/o chest pain off & on but no pain at present, what will
you do first? – Stress test (EKG may not show anything cause no pain now)
 Patient with past medical h/o CAD & other comorbidities (which restrict from
exercise) present with symptoms suggestive of ischemia (i.e. c/o chest discomfort
or feeling heavy in chest for few mins and goes away, etc), next step? – Adenosine myocardial perfusing scan (to see the progression of ischemia and risk stratification of CAD) [Adenosine and Dipyridamole scan are C/I in patient with
COPD / Asthma. Use Dobutamine in those patient]

 If above scenario but patient is able to exercise, next step? – exercise stress test
 Different scenario : Patient present with typical / atypical intermittent chest pain
(exercise stress test); Patient present with typical / atypical intermittent chest pain
with comorbidities which restrict patient from doing exercise (Adenosine scan);
Patient present with typical / atypical intermittent chest pain with comorbidities
which restrict patient from doing exercise and has Asthma / COPD (Dobutamine scan); Patient with previous Unstable angina / MI / bypass present with typical intermittent chest pain, EKG show changes (depression) or Stress test show ST
depression (Angiography – useful in further Mx – Angioplasty / Bypass)
 Any male patient present with chest pain (usually 2-3 hrs after dinner to confuse us on the exam), next step? – EKG. If EKG is done & is normal and patient’s pain relieved by sub-lingual nitroglycerine, next step? – admit the patient and serial monitoring of cardiac enzymes (always rule out cardiac problem first)

 Any male present with chest pain which didn’t relieve by nitroglycerine & EKG is non-specific, next step? – admit the patient and serial monitoring of cardiac enzymes (always try to rule out cardiac cause first)
 Cocaine induced transmural ischemia (ST elevation on EKG), next step? – initial management of ischemia (Oxygen, Aspirin, Nitroglycerin, Morphine) and Benzodiazepines; If patient continues to have pain after administration of
benzodiazepines, next step? – Give Phentolamine [alpha1-blocker] [cocaine causes increase in Norepinephrine which causes HTN by prominent alpha1 action] – If still c/o pain, next step? – Angiography
* Complication of MI : Ventricular Arrhythmia (MCC of Death)
˗ Rupture (Ant Wall, Papillary muscles, Interventricular Septum) – 3-7 days

˗ Autoimmune Pericarditis (Dressler’s Syndrome) – 6-8 weeks Post–MI – Tx: NSAIDs

- Sexual activity can be resumed after 2-4 weeks post-MI
- Management of bradycardia following acute MI – IV Atropine. If bradycardia persists for more than 24-hrs – Transcutaneous pacemaker
- Alternate tachycardia and bradycardia in a patient who had MI – Sick sinus syndrome – Tx: Pacemaker
- Acute right ventricular infarction – IV normal saline bolus (first step); then if
it fails to improve hypotension, give ionotropic agents like dobutamine
at 70% of target rate (after 5-7 days)
· Stress Test Post–MI
at 80% of target rate (after 2-3 weeks)
 EKG changes in Acute MI: Peak tall T-wave → ST elevation → T-wave inversion
→ Q-wave
 Inferior wall MI [RC]: II, III, aVF
 Anterior wall MI [LAD]: V2 – V4
 Anteroseptal [LAD]: V1 – V3
 Lateral wall MI [LAD / Circumflex]: I, aVL, V4 – V6
 Posterior wall MI [Posterior Descending]: V1 – V2
LIPID MANAGEMENT
¯

¯ ¯
Coronary artery disease Coronary artery disease
or +
Diabetes, Hypertension, Tobacco Diabetes, HTN, Tobacco
Risk Factors
½
One ¯ More than One
½ ½
¯ ¯ ¯ ¯
LDL > 160 mg/dl LDL > 190mg/dl LDL > 130 mg/dl LDL > 160 mg/dl
· Diet · Statins · Diet · Statins
· Two main factors that reduce risk of CAD – reduce LDL & HTN (in DM patient)
* Unstable Angina ( Acute Coronary Syndrome) : Stress Test ® Contra indicated
(C/I) [Other C/I of stress test – acute myocardial infarction within 48 hours,
symptomatic severe aortic stenosis, uncontrolled arrhythmia, aortic dissection,
pulmonary embolism, and pericarditis]
 Statins are best initial drugs for management of high LDL.
 Generalized aches & pain with extremely high CPK in patient taking Statins,
next step?  stop Statins

Congestive Heart Failure
½
¯ ¯
Right Sided Left Sided
· JVD · Pulmonary Edema
· Hepatomegaly · Paroxysmal nocturnal dyspnea (PND)
· Ascites · Orthopnea
· Pedal edema · S3 gallop & murmurs
· Positive Hepato jugular reflex is seen in right side heart failure is helpful in
differentiate cause of lower extremity edema from Heart problem / Liver problem
· Diagnosis :
- History & Physical Examination
- CXR , Echocardiography
- MUGA scan / radionuclide ventriculography for measurement of ejection fraction
(most accurate test)
· Treatment :
- Acute CHF (c/o short of breath, etc) – 1 s t step – give Oxygen – Next step – Diuretics
(reduce pre-load) [Nitrates, Morphine are helpful too] – If still no improvement
– give Dobutamine (ionotropic agent) [Digoxin takes time; Dopamine increase
after-load by vasoconstriction]
- After stabilization – ACE inhibitor (reduce after-load) / Angiotensin II receptor
antagonist (those who don’t tolerate ACE inhibitors), b -blockers (Studies have
shown decrease in mortality by beta blockers in patient with CHF)
- Chronic CHF patients should be on Diuretics, ACE inhibitors, b -blockers,
Digoxin
- Spironolactone have been shown to reduce mortality when added with all of the
above chronic CHF drugs
- Asymptomatic patient with low ejection fraction (means heart is failing), next
step? – find out etiology (IHD most common cause so order a stress test)

- Management of acute pulmonary edema due to any cause – Oxygen, Morphine, Loop Diuretics

If it is due to hypertensive crisis –> Tx: Nitroglycerin or Nitroprusside

If it is due to acute heart failure – Dobutamine. Next step after
stabilization of patient with acute pulmonary edema of unknown etiology –
echocardiography (to rule out MS or AI)
· Pt on multiple drugs for multiple problems including digoxin, furosemide, next
step?  serum electrolyte measurement (furosemide cause hypokalemia which
may cause digoxin toxicity)
■ Mitral valve Prolapse : Mid-late Systolic Click
- Presentation ® Asymptomatic, Palpitation (most common presentation), Chest
pain, Syncope, Sudden death

- Marfan Syndrome / Asymptomatic
- Most common cause of mitral regurgitation in U.S.
* Treatment ® No specific treatment in most cases
- Endocarditis Prophylaxis ® Only If murmur present
- b - blockers ® if chest pain occurs, palpitation and autonomic symptoms
- Anti–arrhythmic ® if arrhythmia occurs
■ Infective Endocarditis : Splinter hemorrhages , Roth’s spot in eye , Janeway
lesions, Valve regurgitation
- Pathophysiology of Roth’s spot & Osler’s node – immune vasculitis; Janway lesion
– septic emboli
- Strep. Viridians ® most common overall cause (previously damage valve )
- Staph. Aureus ® IV drug abuse ( Normal / Previously damage valve ) Tricuspid
Valve
- Staph. Epidermidis ® Prosthetic devices
- Strep. bovis ® ulcerative colitis / colorectal cancer patient
- Conditions that do not require infective Endocarditis Prophylaxis
· pt. with cardiac pacemaker and defibrillation
· Mitral valve prolapsed without regurgitation (without murmur)
· Surgically repaired ASD, VSD, PDA
· h/o Rheumatic fever without valvular dysfunction
· h/o Kawasaki disease without valvular dysfunction
· h/o isolated bypass surgery
· h/o isolated ostium secondum ASD
˗ Prophylaxis of Infective Endocarditis in patient allergic to Penicillin:
Dental, oral, respiratory, esophageal procedure  Clindamycin, Azithromycin
GI & genitourinary  High risk  Vancomycin + Gentamycin
Low risk  Vancomycin
˗ First step – start empiric antibiotics after drawing blood for culture
Next step – Transesophageal echocardiography to see vegetation
˗ Empiric antibiotic for IE in IV drug abuser – Vancomycin + Gentamycin
˗ In general – Nafcillin + Gentamycin

- Loeffler Endocarditis –> prominent Eosinophil infiltrates, restricive cardiomyopathy –
leading to the fibrotic thickening of portions of the heart

■ Valvular Heart Disease :
· Stenosis ® Problem in opening of valve therefore murmur occurs during opening
of the valve
· Regurgitation ® Problem in closing of valve therefore murmur occurs during
closing of the valve
Mitral Stenosis Aortic
Regurgitation
Mitral
Regurgitation
Aortic Stenosis
· Diastolic murmur · Diastolic
decrescendo
· Holosystolic
radiate to the Axilla
· Systolic ejection
radiate to carotid
· Opening snap · Austin Flint
murmur
· CXR ® double
density Right heart
Border.
·Echocardiography ·Echocardiography ·Echocardiography ·Echocardiography
Treatment Treatment Treatment Treatment
· Diuretics (best
initial)
· Endocarditis
Prophylaxis
· Digitalis · Endocarditis
Prophylaxis
· Balloon
valvuloplasty (if
diuretics don’t help)
· Diuretic, ACE
inhibitors
· Diuretics , ACE
inhibitors
· Surgery if valve
area < 0.8 cm2
( Normal 2.5-3 cm2 )
· Valve replacement
(If both of above fail
to relieve
symptoms)
· Valve replacement
( Presence of Austin
Flint murmur
indicates the need
for replacement of
the valve )
· Anticoagulant · Balloon
valvuloplasty
· Digitalis(if AF)
· Anticoagulant (if
AF)
· Valve replacement · Indication for
surgery – chest pain
/ Syncope during
exercise in elders;
Stable angina due to
stenosis next step?
Echocardiography
[not stress test]
· Austin Flint murmur : regurgitant stream from incompetent Aortic valve hits anterior
mitral valve leaflet producing a diastolic murmur.
· Right sided murmur increase in intensity with Inspiration

* Cardiomyopathies *
Dilated Hypertrophic Restrictive
· Echocardiography · Echocardiography · Echocardiography
· CHF following
URTI
· Autosomal Dominant
chromosome 14
· Catheterization: square
root sign on tracing
ventricular pressure
· Treatment · thickening of Interventricular
septum
· Mimic Constrictive
Pericarditis
- Diuretics · Mechanism of mitral
regurgitation – systolic anterior
motion of mitral leaflet
· No good treatment
- Vasodilators · ejection fraction 80-90 %
( Normal 60% ± 5% )
· Consider Heart transplant
- Digoxin · Sudden Death in athletes · EKG – low voltage
· If Arrhythmia Treatment
¯ · b- blockers
Procainamide /
Quinidine
· Ca+ 2 channel blockers
· Anticoagulants · Disopyramide
· “speckled pattern” on
echocardiography 
cardiac amyloidosis
· Valsalva / Standing: ¯ Preload® Obstruction
· Squatting / Hand grip: Preload ® ¯ Obstruction
· Increase in Pre-load – decrease murmur in Mitral valve prolapse and Hypertrophic
cardiomyopathy.

* Pericardial Diseases *

Acute Pericarditis Cardiac Temponade Constrictive Pericarditis
· Chest pain · Pulsus paradoxus · Kussmaul’s Sign
¯ ¯ ¯
Relieved by leaning forward

¯ SBP more than 10 mmHg
on normal inspiration
jugular venous distension
with inspiration
· Pericardial friction rub
(Diagnostic)
· Neck vein distension
with clear lung
· Pericardial knock
· EKG – diffuse ST
segment elevation (In MI –
ST elevation is in different
leads according to
involvement of heart and it
is convex)
· Shock [Beck’s triad –
Hypotension, JVP, muffled
heart sound], next step? ®
Pericardiocentesis. If no
blood on pericardiocentesis,
next? ® Thoracotomy
(blood is clotted in
pericardial sac)
· EKG – low voltage
· Treatment involves
treating its etiology
· Echocardiography
¯
small Heart
· Catheterization: square
root sign
· Treatment
¯
· D/D: Restrictive
cardiomyopathy
- Pericardiocentesis · CT scan - best choice to
demonstrate thickened
Pericardium
- Subxiphoid Surgical
drainage.
· Treatment
¯
- Diuretics
- Pericardiectomy
■ Pericardial Effusion :
· Serosanguineous ® TB / neoplasm
· CXR – “water – bottle” configuration of cardiac silhouette
· Echocardiography (Best test)
· Treatment : Fluid Aspiration, Treat etiology

* Arrhythmias *
* Heart Block *
1 s t Degree 2 nd Degree 3 rd Degree
· PR interval > 0.2 sec. ¯ ¯
Type – 1 Type -2
· All atrial beasts are
blocked.
· usually asymptomatic ¯ ¯
( Wenckebach ) dropped
beat occur
suddenly
No PR
lengthening
· Ventricles beat by a focus
distal to the site of block.
(Automaticity of heart)
· Tx: usually none. If
Symptomatic ®
Atropine.
¯ ¯
Progressive Tx:
Prolongation of Pace -
PR until a P wave maker
is completely (no resp-
Blocked & onse to
Dropped Atropine)
Beat
¯
· Tx : Pacemaker
· Tx: usually none. If
Symptomatic ® give
Atropine.
˗ Premature atrial beats and PVC (premature ventricular contraction)  observe
(never required any treatment)

Sinus Bradycardia Sinus Tachycardia PSVT
· Rate <> 100 / min · Rate 130-220 / min
· QRS complex – Normal · QRS complex - Normal · Regular rhythm
Treatment
· None if asymptomatic
Treatment
· Right carotid sinus
massage
Treatment
· IV Adenosine.
· Atropine ( 1 st choice )
· Pacemaker
10
Atrial Arrhythmias
Multifocal Atrial Tachycardia
Atrial Flutter Atrial Fibrillation ( AF )
· Irregular rhythm · Regular rhythm · Irregular rhythm
· morphology of P wave
varies from beat to beat
· 2 : 1 block · 300-500 impulse / min
· Cardioversion if
hemodynamically unstable
· Tx : cardioversion if
hemodynamically
unstable
Tx : cardioversion if
hemodynamically
unstable or AF is due
to angina / MI
· If hemodynamically
stable then give Digitalis /
Calcium Channel Blockers (CCB)
· If hemodynamically stable then give
· Digitalis / b-blockers (IV Metoprolol) / CCB (IV Diltiazam) to lower the HR [below 100] and then elective cardioversion
· Patient with following
sign / symptoms should
consider as hemodynamically
unstable:
- Hypotension
- Chest pain
- Confusion
· If AF for› 48 hrs then give Warfarin 3 weeks before elective cardioversion and continue 4 wks after normal sinus rhythm or do echocardiography to see if there is any clot or not and then do cardioversion
· Digoxin – preferred if
poor LV function
· CCB & b-blockers are C/I
in patient with poor LV function
- DOC for Paroxysmal Atrial fibrillation – Amiodarone
- First step in management (Mx) of stable patient with Multifocal Atrial
Tachycardia – rule out etiology [hypoxia, hypokalamia, hypomagnesemia]

Wolff – Parkinson – White Syndrome ( WPW ):
- Short PR interval followed by a wide QRS complex with a Slurred initial deflection,
or delta wave, that represent early ventricular activation (Pre–excitation Syndrome)
- Tx : Cardioversion if hemodynamically unstable
- Procainamide is DOC for WPW
– Digoxin & Ca + 2 channel blockers are contraindicated

Torsade de Pointes:
- Prolong QT interval, wide QRS complex
- Drugs : Quinidine
¯ Procainamide
which Disopyramide
block K+ channel Anti- Psychotics
[Phenothiazine & Thioridazine]
- Tx : Magnesium
- First step in management of patient with Torsade de pointes – immediate defibrillation. DOC for Tx & prevention – IV Mg (give Mg regardless of patient’s Mg level)

Ventricular Arrhythmias
Ventricular Tachycardia Ventricular Fibrillation
· Rate > 120 beats / min · Significant electrical activity on EKG
with no signs of an organized pattern
· IHD – (most commonly seen)
· QRS complexes are wide and often
bizarre
VT (Pulse)
Pulseless VT / VF
¯
Cardioversion
Stable unstable

IV lidocaine 1 mg/kg cardioversion
or Amiodarone / Procainamide
(Amiodarone is preferred when poor LV
function)

* Asystole : 1mg Epinephrine every 3-5 mins
¯
1 mg Atropine every 3-5 mins
¯
2-5 mg Epinephrine every 3-5 mins

 Patent ostium primum (patent foramen ovale) – failure of septum primum to
fuse with endocardial cushions

 Atrial Septal Defect (ASD) – incomplete adhesion b/w septum primum &
septum secondum – Wide fixed split S2

 VSD – defect in membranous interventricular septum

 PDA – machinery murmur – associated with congenital rubella – PGE2 keep it
open – it shunts pulmonary artery blood to aorta in fetus

· Coarctation of Aorta :
˗ Turner’s syndrome
˗ Rib notching on CXR, MRI of chest (best test)
˗ Tx : surgery
˗ Endocarditis prophylaxis required
· Tetralogy of Fallot (TOF) :
˗ Pulmonary stenosis, VSD, RVH and Over riding of aorta
˗ Boot shaped hert on CXR
˗ Murmur disappears & cyanosis improves when child squats
˗ Single or soft S2
˗ Tx : Surgery
˗ Endocarditis prophylaxis required
· Transposition of great vessels :
- Cyanosis in first 24-hrs of life, Infants of diabetic mothers
- Give PGE1 to keep open PDA until surgical correction done

■ Acute Rheumatic fever :
- Aschoff bodies (pathognomic) [central area of necrosis surrounded by reactive
Histiocytes (Anitschkow cells)]
- Pericarditis, Polyarthritis, Chorea, Erythema marginatum and subcutaneous
Nodules (Jones criteria)
- Usually occur 1-3 weeks after a preceding Strep. Pyogens pharyngitis
- ASO titers
- Treatment of acute infection and monthly Penicillin prophylaxis then after.
- Tx of Sydenham’s Chorea (seen several months after acute attack of Rheumatic fever; carditis and arthritis manifest within 21 days) – Oral penicillin for 10 days immediately

· Young child with Mitral stenosis due to Acute Rheumatic fever without any symptoms, next step?  Penicillin prophylaxis; If AF develop then consider anticoagulation

Location of Murmur Conditions
Upper Rt sternal border AS, IHSS
Upper Lt sternal border PS, PDA
Lower Lt sternal border VSD
Apex MVP

 Cardiac Myxoma – left atria – mesenchymal tumor – embolic episode in young
person (next step? Send thrombus for pathologic examination, order echo), syncopal episode – young adult

 Rhabdomyoma – children – associated with tuberous sclerosis – hemartoma

 Best step in management of patient with Acute Aortic Dissection – emergent surgery. First step – give IV beta blockers [Type A – Ascending aorta (emergent surgery) Type B – Descending aorta (IV beta blockers)]

 Diagnostic test for Aortic dissection  Transesophageal echocardiography or CT scan

 Abdominal Aortic Aneurysm pulsatile abdominal mass, next step? USG (first step) / CT scan (before repair) <> 6 cm (elective repair)

● Tender AAA / Excruciating back pain, fainting episodes, unequal femoral pulses in patient with known case of AAA ® Emergency surgery [Retroperitoneal bleed causes fainting attacks]

● Complication of AAA repair ® Ischemic colitis [30% of cases IMA is the only artery which supply sigmoid colon and by repairing AAA obstruct IMA which present as severe abdominal pain, foul smelling diarrhea 2-3 days afterrepair, next step? ® Sigmoidoscopy followed by exploration]

 Peripheral Arterial Disease (PVD) : Intermittent claudication / Rest pain, first step? ® Ankle-Brachial pressure index measurement ® Arteriogram (most accurate test) ® stop smoking, stop beta-blockers ® start Aspirin, Cilostazol (Antiplatelet vasodilator) ® stent / Bypass (most effective treatment)

 Lerich Syndrome : Aortoillio atherosclerosis – atherosclerosis of hypogastric artery – c/o impotence and claudication

 Deep vein thrombosis : Duplex USG (Best initial test) ® Venography (most accurate test) ® If Duplex USG positive, next step? ® LMW Heparin (sc) for 5-7
days followed by Warfarin for 3-6 months (INR 2-3) [only in patient with metallic heart valve keep INR at 3-4]

· Sign & Symptoms of DVT, next step?  Compression UGS to confirm diagnosis before anticoagulation treatment (to avoid potentially serious side effects of anticoagulation therapy in unnecessary pt.)

 Fludrocortisone is the first line medicine for orthostatic hypotension but should be tried after non-pharmacologic trial fail like discontinue dugs causing orthostatic hypotension [Nitrates, CCB, TCA, Opiates analgesics]

 Best initial test / next step in management of patient with acute syncope – EKG

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Pediatric

Pericardial Disease

Atherosclerosis

Ischemic Heart Disease

Complications of MI

Tafford

Aortic Stenosis

Aortic Regurgitation

Mitral Valve

Cardiac Myxoma

Endocarditis

Cardiomyopathy

WPW(Wolf Parkinson White syndrome)

Heart Block

Ventricular Arrhythmias

Torsades de Pointes

Hypertension

VASCULAR DISEASE

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