Cholesterol / Dyslipidemia
Screening:	·       If ≥35 q5 years ·       If ≥20 w/ CAD RF q5 ys
Dx	·       Total > 200 ·       LDL >130 ·       TG >150 ·       HDL <40
Tx	1˚: 12-week diet & exercise 2˚ Meds When it is an option, the right answer is always: 1. Lifestyle = Diet / Exercise 2. Adherence = Medication and Lifestyle ·       So, you wanna 1) start those who need statin on HIGH-INTENSITY Statins –> if they are intolerant (hepatitis, renal, myositis) –> 2) reduce the intensity for them and be MODERATE-Intensity
Who Needs a Statin?	1. Vascular Disease = MI, CVA, PVD, CS 2. LDL > 190 3. LDL 70-189 + Age + Diabetes 4. LDL 70-189 + Age + Calculated Risk = “Risk Factors” Risk Factors for Coronary Artery Disease 1. Diabetes 2. Smoking 3. Hypertension 4. Dyslipidemia 5. Age > 55 for women, > 45 for men
Drugs

Benign Vs Pathologic murmurs
	Benign	Pathologic
Hx	•      Normal appetite, energy, activities and growth •      No important Family Hx	•      Diaphoresisi and fatigue with feeding or workout, poor weight gain, chest pain, dizziness, syncope, shortness of breath •      Family Hx of sudden cardiac death, heart defects, etc
Feature	•      Early or mid-systolic •      Grade I or II intensity that decrease on standing and Valsalva maneuver  •      Low pitched, musical, pure, or squeeky tone at LLSB (still’s murmur) or high pitched at LUSB (Pulmonary flow murmur)	•      Harsh, holosystolic, diastolic •      Grade III intensity or higher •      ⤴️ with standing and Valsalva maneuver
Other findings	•      None	•      Loud, fixed split, or single S2 •      ⤵️ or absent femoral pulses
Workup	•      None indicated	•      ECG (to assess for hypertrophy) •      Echocardiogram (to assess for structural abnormalities) •      Cardiology Referral

	Murmur	Location	Leg Raise	Valsalva	Tx	Path	Presentation	Def Tx
Mitral Stenosis	diastolic w/ openin snap	Apex	Get worse	Improves	Preload Reduction	Rheumatic Fever	Afib, CHF SOB	Replace
Aortic Stenosis	Systolic / Crescendo-decrescendo	Aortic w/ radiation to Carotids	Get worse	Improves	Preload Reduction	Calcification Bicuspid	Angina, CHF Syncope	Replace
Mitral Regurg	Systolic	Apex to Axilla	Get worse	Improves	Preload Reduction	Infxn Infarction	CHF	Replace
Aortic Regurg	Diastolic	Aortic	Get worse	Improves	Preload Reduction	Infxn Infarction	CHF	Replace
HCOM	Systolic	Apex	Improves	Get worse	Increase Preload	Congenital	SOB, Sudden Death	Replace
Mitral Valve Prolapse	Systolic	Apex	Improves	Get worse	Increase Preload	Congenital	CHF	Replace

	Venous Return / Preload		Afterload		Drugs
	Increase (leg raise/ squat)	Decrease (Valsalva/standing)	Increase	Decrease	Diuretics	ACEIs
			(Handgrip)	(amyl Nitrate)
MS, AS	⤴️	⤵️	⤵️(AS)	⤴️(AS)	Yes, but better
			Negligible Effect in (MS)		AS (Replace)	⊖
MR, AR	⤴️	⤵️	⤴️	⤵️	⊕	⊕
VSD	⤴️	⤵️	⤴️	⤵️	⊕	⊕
HOCM	⤵️	⤴️	⤵️	⤴️	⊖	⊖
MVP	⤵️	⤴️	⤵️	⤴️	⊖	⊖

Innocent murmur	·       3-7 yo ped ·       systolic, grade 2, never diastolic ·       can happen when ⤴️ CO (fever) ·       best heard @ Left Lower sternal border ·       reassure
Pulmonary flow murmur	·       also innocent murmur ·       heart at 2nd left intercostal ·       while pt laying down ·       high-pitch, early systolic
Venous hum	·       why? ·       heard in neck / anterior chest ·       disappear w/ compression of jugular v
Machinary murmur	·       PDA
ASD	·       Ejection murmur ·       Wide fixed spilitting of P2

Prosthetic Valve Dysfunction
?	•      Transvalvular regurgitation (cusp degeneration) •      Paravalvular leak (annular degeneration, IE) •      Obstruction/stenosis of the valve (valve thrombus)
Clx	•      New murmur (regurgitant or stenotic) •      Macroangiopathic hemolytic anemia •      HF symptoms, thromboembolism
Dx	•      Echocardiography

Chronic AR
?	•      Congenital bicuspid aortic valve •      Post inflammatory (rheumatic heart disease, endocarditis) •      Aortic root dilation (Marfan syndrome, syphilis)
Path	•      Backflow from aorta into LV à ⤴️ LV EDV •      LV compensates w/ eccentric hypertrophy à ⤴️ SV & CO •      Eventual LV dysfunction à ⤵️  SV & COà HF
Clx	•      Diastolic decrescendo murmur (best heard w/ pt sitting up, leaning forward, full expiration + at 3rd-4th left intercostal space) •      Widened pulse pressure (⤴️ SBP & ⤵️ DBP) •      Rapid rise-rapid fall (“water-hammer”) pulsation •      Abrupt carotid distension & collapse, “pistol-shot” femoral pulses

	MS
🔉	·       Holosystolic murmur ·       Apex ·       S3
S/S	·       SOB ·       pHTN ·       Eccentric LV hypertrophy ·       ⤴️ LA pressure → HF
Dx	TTE

Aortic dissection
Approach	·       1st: look at the vitals ·       if hypertensive –> Labetalol (keep systolic 120-100) ·       if BP is not controlled w/ labetalol –> Add nitroprosside o   never give it w/o BB → since it induces reflexive tachycardia → causing more damage
Dx Work-up
Spiral CT w/ contrast	·       Pt is Clx stable ·       Often 1˚ & done in ER
TEE	·       Clx unstable (VS UNSTABLE) ·       Allergic to contrast ·       has kidney failure ·       Must intubuate
MRI	·       Chronic ·       Clx stable

Acute Aortic Dissection
Clx	·       PMHx: Hypertension, genetic do (Marfan) ·       intense, sharp, tearing chest or back pain ·      >20 difference in Systolic BP bw arms
Dx	·       ECG: ⓝ ·       CXR: mediastinal widening ·      CT angiography or TEE for final diagnosis
Tx	·       Pain control (morphine) ·       IV BB (Esmolol) ·       ± Sodium nitroprusside (if SBP >120 mm Hg) ·       Emergent surgical repair for ascending dissection

	AAA
RF	·       Advanced age (eg, >60) ·       Smoking, male 🤵🏻, HTN ·       Hx of atherosclerosis or Autoimmune
S/S	Mostly Asx Rapid expansion ·       Dull abdominal/back pain (can be referred) ·       Distal embolization Rupture ·       Sudden, severe abdominal/back pain ± shock ·       Umbilical/flank hematoma ·       Syncope
Tx	·       Smoking cessation ·       Elective repair for size >5.5 cm (Asx) ·       Urgent repair for sx & HD stable ·       EMERGENT repair for sx & HD unstable

	AAA	Aortic Dissection
S/S	·       Pulstile abdomenal mask, ·       Can present as back pain, ·       Incidentally found on CT. ·       >65 male ·       Atherosclerotic ·       RF: SMOKING	·       HTN ·       TEARING Chest pn radiating to back ·       Asymmetric BP in arms ·       Widened mediastinum
Dx	·       US ·       X-ray: prevertebral aortic calcification ·       NOT CT ·       NOT ARTERIOGRAM	BEST? CT ARTERIOGRAM NOT ARTERIOGRAM
Tx	Strategy: If VS stable: CT If VS unstable → SURGERY + US If small AAA –> wait & screen. If big AAA or growing fast, I shall operate. >3.5 cm –> screen q1 year >4.5 cm –> screen q6 months >5.5 / growin fast (0.5 per 6 m) –> SURGERY	Type A (Ascending): OR –> offer aortic valve replacement Type B (Descending): IV BB

Traumatic carotid injuries
Mechanism	·       Penetrating trauma ·       Fall with object in mouth (eg, toothbrush, pencil) ·       Neck manipulation (eg, yoga, sports)
Clx	·       Gradual-onset hemiplegia ·       Aphasia ·       Neck pain ·       “Thunderclap” headache
Dx	·       CT or MR angiography

	Mobitz type I	Mobitz type II
Level of block	Usually AV node	Below the level of AV node (Bundle of His)
ECG	Progressive prolonged PR interval leads to a nonconducted P wave (“group beating”)	PR interval remains constant with intermittent nonconducted P waves
QRS complex	Narrow	Narrow
Exercise or atropine	Improves type I AV block	Worsens type II AV block
Vagal maneuvers	Worsens	Paradoxically improves
Risk of complete heart block	Low risk	Higher risk, indication for pacemaker

Dilated
Features	Etiologies of Dilated (Congestive) Cardiomyopathy • Idiopathic: most common • Alcoholic (dx of exclusion / complete abstinence from alcohol leads to NORMALIZATION) • Peripartum • Postmyocarditis due to infectious agents • Doxorubicin • Metabolic: chronic hypophosphatemia, hypokalemia, hypocalcemia, uremia
S/S	HF
Dx	·       Clx ·       X-ray: cardiomegaly / pulmonary congestion ·       Echo
Tx	Tx just like HF

HOCM
Features	·       Chromosome 14 ·       Sarcomere gene mutation ·       AD (variable penetration)
S/S	·       Can be Asx ·       Systolic Ejection murmur that ⤴️ by ⤵️ preload / afterload ·       Fatigue, chest pain, SOB, Syncope ·       Sudden death.
Dx	·       ECG: LV hypertrophy ·       Echo: ⤴️ LV outflow tract gradient, Systolic anterior motion of Mitral valve ·       Family screening
Tx	·       BB ·       CCB ·       Surgery Avoid: • Digitalis • Diuretics (do not ⤵️ PRELOAD) • Vasodilators • Exercise

Restrictive
Features	• Infiltrative: ·       sarcoidosis/amyloidosis; ·       Hemochromatosis; ·       Neoplasia • Scleroderma • Radiation
S/S	HF
Dx	Echo
Tx	There is no good therapy; ultimately results in death from CHF or arrhythmias; consider heart transplantation.

Viral Myocarditis
Clx	•      Relatively young adults (age <60) •      Viral prodrome (Fever, malaise, myalgias) •      CHF → can lead to dilated heart •      Chest pain •      Sudden cardiac death
Dx	•      ECG: Nonspecific •      Echo: 4-chamber dilation •      Cardiac MRI: Late improvement of the epicardium •      Biopsy: Lymphocytic infiltration, viral DNA or RNA
Tx	•      CHF 💊 (Diuretics, ACEI, 8B) •      Temporary ventricular assist device, if needed •      If no recovery → Heart transplant

Etiology for Pericarditis
Infections	Viral (coxsackie) Bacterial (Strep/Staph) Tuberculosis Fungus
Autoimmune	Lupus, Rheumatoid, Scleroderma Procainamide, Hydralazine Uremia
Trauma	Blunt, Penetrating
Cancers	Lung, Breast, Esophagus Lymphoma
Others	Many

Pericardial Disease Treatment
Pericarditis	NSAIDs + Colchicine
Pericardial effusion	Pericarditis
Recurrent Effusion	Pericardial Window
Tamponade	Pericardiocentesis
Constrictive Pericarditis	Pericardiectomy

	Acute Pericarditis
Features	many causes (check table)
S/S	Pleuritic chest pain
Dx	ECG
Tx	NSAID + Colchicine

Constrictive pericarditis Features
Etiology	•      Idiopathic or viral pericarditis •      Cardiac surgery or RTx •      Tuberculosis (in endemic areas)
Pathogenesis	•      Thickened, rigid pericardium forms a noncompliant casing surrounding the heart, limiting ventricular expansion during diastolic filling
Hemodynamic signs	•      ⤴️ Jugular venous pressure •      Kussmaul sign •      Pulsus paradoxus •      Pericardial knock

	Pericardial Effusion
Features	·       Fluid may accumulate in the pericardial cavity in virtually all forms of pericardial disease.
S/S	JVP / SOB / Pulsus Paradoxus (exagerated BP fall during inspiration by >10)
Dx	ECHO
Tx	·       Fluid aspiration ·       Management of acute pericarditis etiology ·       If recurrent: pericardial window

Post-pericardiotomy syndrome
?	Inflammation → reactive pericarditis
S/S	·       Infants: abdominal pain / vomiting ·       Older children: pericarditis ·       Can progress to temponade (beck’s triad)
CXR	Cardiomegaly
Tx	Pericardiocentesis

Generalized SZ	Trigger: • Fever • Hypoglycemia • Sleep deprivation Clx: • +/- Aura • Loss of consciousness & tone, tonic-clonic convulsions • Postictal state
Vasovagal Syncope	Trigger: standing Physical/emotional Clx: -Presyncope (lightheadedness, pallor, diaphoresis) -Immediate retum to baseline
Cardiogenic Syncope	Trigger: • Exertion • Dehydration Clx: -Sudden loss of consciousness without prodrome – Immediate retum to baseline after event

Syncope	Path	Hx	Physical	Dx
VV (Vaso Vagal)	– Visceral Organs (micturition, defecation, cough) – Carotid Stimulus (turning head, shaving) – Psychogenic (see blood)	– Situation- related – Prodrome (eg, pallor, nausea, diaphoresis)	Vagal stimulation produces asystole or a ⤵️SYS BP of 50 mmHg	Tilt table
Orthostatics	– ⤵️ Volume – Autonomic Nervous Dysfunction	Orthostatic hypotension	Defined as ⤵️SYSBP by 20 ⤵️DIA BP by 10 ⤴️HR by 20 Sxs of orthostasis	Volume and Reassess, chase causes of hypotension if refractory to fluid
Mechanical Cardiac		Exertional syncope	Murmur	Echo
Arrhythmia		Onset is sudden, unprovoked,	None	24-hour Holter
Neuro (vertebrobasilar insufficiency		Onset is sudden, unprovoked, very rare	Focal Neurologic Deficit	CTA
Pulmonary Embolism Electrolytes (bG, TSH)		PE None	PE None	Wells criteria, CT scan BMO

Vasovagal syncope
Clx	•      Inciting event (stress, prolonged standing) •      Prodrome (pallor, nausea, diaphoresis) •      Rapid regain of consciousness (<1 minute)
Dx	•      Primarily clinical diagnosis •      Upright tilt table testing in uncertain cases
Tx	•      Reassurance •      Triggers avoiding •      Counterpressure techniques for recurring episodes

Types of syncope
Types	Causes	Characteristic
Cardiogenic	Mechanical (AS. PS, HOCM…) Arrhythmias	No prodome
Vasomotor (the most common)	• Excessive vagal tone • Impaired reflex control of the peripheral circulation	Has prodome: Lightheadness. nausea, sweating, ringing ears. Trigger: stressful situation
Orthostatic Hypotension	• Hypovolemia • Decrease BP > 20/10 mmHg	Think in elderly. blood loss. use of diuretics, vasodilators
Neurogenic	• Loss of sympathetic nervous system tone	Decrease BP due to vasodilation

Start w/	Thiazide
African-American	Thiazide
Essential Tremor	BB
Perioperative HTN	BB
Hyperthyroidism	BB
Migraine	BB/CCB
Raynaud’s	CCB
DM	ACEI
Osteoporosis	Thiazide
BPH	alpha 1 blocker

Malignant HTN	Hypertensive Encephalopathy
·       PMHx: Long standing uncontrolled HTN ·       End-organ damage (but no CNS Sx)	·       PMHx: Long standing uncontrolled HTN ·       Cerebral edema d/t breakthrough vasodilation from failure of autoregulation
·       Eye: retinal FLAME hemorrhage, Papilledema, exudates ·       AKI: nephrosclerosis (∆ AKF, Hematuria, Proteinuria) ·       NO CNS Sx	·       Headache ·       N/V ·       Non-localizing neurologic Sx (restlessness, confusion, SZ, coma) ·       can develop ICH/SAH

Antihypertensive that can cause hyperprolactinemia?

·       Methyldopa ·       Reserpine ·       Verapamil

Secondary HTN DDx
Renal Disease	⤴️ Cr
Renal a. Stenosis	SEVERE HTN + Abdominal bruit
Hyperaldosteronism	HTN + ⤴️ Na + ⤵️ k+
Pheochromocytoma	Episodic SEVERE HTN + HEADACHEs
Cushing	Typical Sx
Hypothyroidism	Fatigue, dry skin, cold intolerance
HyperPTH	Sx of hypercalcemia (kidney stones)
CoA	difference in BP b/w arms & legs

Clx Features of Acute decompensated heart failure
S/S	•      Acute SOB, orthopnea, paroxysmal noctumal dyspnea •      HTN is common; hypotension suggests severe disease •      Accessory muscle use, tachycardia, tachypnea •      Diffuse crackles with possible wheezes (cardiac asthma) •      Possible S3, JVP distention, peripheral edema
Tx	ⓝ or ⤴️ BP: •      O2 •      IV loop diuretic (Furosemide) •      Consider IV vasodilator (Nitroglycerin) Hypotension/Shock ·       O2 •      IV loop diuretic (Furosemide) •      IV vasopressor (Norepinephrine)

HF w/ preserved EF
?	·       LV diastolic dysfunction: HTN / Restrictive / Hypertrophic cardiomyopathy ·       Valvular heart disease: Aortic / Mitral valves ·       Pericardium: Constrictive pericarditis ·       Systemic disorders (high-CO): Thyrotoxicosis, severe anemia, large AV fistula
Tx	·       Control BP & HR ·       Address concurrent conditions: AF & Ml ·       Tx hypervolemia w/ diuretics ·       Exercise / cardiac rehabilitation

Pt	Tx
Everybody	Salt <2g per day H2O < 2L, per day ACEI or ARB (best mortality benefit) Beta -Blocker
Preload Reduction	Diuretics such as Furosemide Nitrates such as Isosorbide Dinitrate Dietary Modifications (NaC1, H20)
Afterload Reduction	ACEI or ARB Hydralazine Spironolactone
Special Considerations
EF < 35%	AICD (must be Class I-III)
Ischemic	ASA and Statin
Class IV	Inotropes like Dobutamine (ICU) VAD bridge to transplant Transplant

💊 that improve mortality in LV systolic failure/CHD

BB

ACEI

Minalocorticoid receptor blocker (eplerenone, spironolactone)

Statin

Dual Antiplatelets (Aspirin + Clopidogril)

In African-american pt 👨🏾‍⚖️: Hy nigga (Hydralazine +  Nitrate)

When a CHF pt comes w/ acute pulmonary edema?
Everyone	·      Lasix (Furosemide) ·      Morphine ·      Nitrates ·      O2 ·      Position
If it fails →	·       Dobutamine o   If fails + no hypotension → Hydralazine o   If fails + hypotension → Dopamine

Poor prognostic factors in systolic heart failure
Clx	• Higher NYHA functional class • Resting tachycardia • Presence of S3 • JVP Elevation • Low BP (<100/60) • MR
Lab	• Hyponatremia • Elevated BNP levels • Renal insufficiency
ECG	• QRS duration >120 msec
Echo	• Severe LV dysfunction • Concomitant diastolic dysfunction • Reduced right ventricular function • Pulmonary hypertension
Association	• Anemia • Atrial fibrillation • DM

	Cor Pulmonale
?	·       PULMONARY-RELATED ·       COPD ·       Interstitial Lung dz ·       PE ·       OSA
Sx	·       SOB ·       Syncope on exertion (d/t ⤵️ CO) ·       Angina on exertion (d/t ⤴️ heart demand)
PEx	·       Peripheral edema (LL, Ascites) ·       ⤴️ JVP ·       Loud S2 ·       Right-sided Heave ·       Hepatomegaly ·       TR Murmur
Dx	·       ECG: RBBB / RV hypertrophy / Right axis deviation ·       Echo: pHTN, dilated RV, TR ·       Ⓡ heart catherization: gold standard: RV failure.

Digoxin toxicity
Cardiac	·       severe arrhythmias
GI	·       Anorexia ·       Nausea & vomiting ·       Abdominal pain
Neuro	·       Confusion ·       Faintness ·       Color vision changes

Notes from OME (Provided for free)

Treatment of chronic stable angina
Beta blockers	•      1st -line therapy •      ⤵️ Myocardial contractility & HR
Nondihydropyridine CCBs	•      Alternative to beta blocker •      ⤵️ Myocardial contractility & HR
Dihydropyridine CCBs	•      Added to beta blocker when needed •      Coronary artery vasodilation •      ⤵️ Afterload by systemic vasodilation
Nitrates	•      Long-acting added for persistent angina •      ⤵️Preload by dilation of capacitance veins
Ranolazine	•      Alternative therapy for refractory angina •      ⤵️Myocardial calcium influx

Stable angina	Unstable Angina/NSETMI	STEMI
·       Most patients with angina will have ECG changes during an attack? ST depression ·       Dx: Stress test: o   Target: 85%*(220-age) o   Contraindication: MI, dissection, AS, HOCM, uncontrolled HTN o   Stop BB 24 h prior to procedure o   Digoxin causes ST depression –> make it hard to interpret the results o   ⊕ Stress test in young females? False positive ·       Tx: o   OP: BASA – BB / Aspirin / Statin / ACEI (everybody gets statin) –> if there’s pain (NGT) / If there’s stent (clopidogril) o   For episodes: NTG o   Long-term: NGT + BB –(no contraindications)–> Aspirin + Statins o   Modify RFs o   Cath –> to see if they need bypass o   When to give antihyperlipidemia? ·       Bottom line: almost all patients with chronic stable coronary artery disease will likely need to be on statin therapy, unless contraindicated. ·       Target: LDL <100 / <70 if IHD + DM / ACS	·       If there are no detectable serum markers of myocardial injury 12–18 hours after symptom onset, the patient should be diagnosed with UA. ·       At the time of presentation, UA and NSTEMI may be indistinguishable and can be identically managed. ·       Thrombolytic therapy is beneficial in patients with STEMI, but is not effective in UA or NSTEMI and may be harmful. ·       In fact, untreated UA progresses to MI in 50% of cases –> Tx is IP ·       In NSTEMI –> ECG can be normal ·       Tx: BANC Cath o   NGT o   Aspirin for all pts + another antiplatelets: Clopidogrel + Heparin o   BB o   Take them to cath lab (ASAP)	·       Cardiac exam will usually be normal. ·       Tx: 1.     MONA BASH C ·       M: Morphine ·       O: O2 ·       N: NGT ·       A: ASA ·       B: BB ·       A: ACEI ·       S: Statins ·       H: Heparin ·       C: Clopidogrel (or other antiplatelets) 2.     REPERFUSION: ·       EMERGENT CATH –> PCI ·       Fibrinolytics (within 60 min + no near facility to transfer) o   Late presentation (>12 hours after symptom onset): Reperfusion therapy with either PCI or fibrinolysis is not recommended in patients who are asymptomatic and hemodynamically stable, and who present >12 hours after symptom onset. o   Drugs to use w/ reperfusin: ·       Clopidogrel or prasugrel should be prescribed in addition to aspirin for patients undergoing PCI with a stent / Fibrinolytics. Ticagrelor is an alternative to clopidogrel or prasugrel. ·       If CABG –> NO Clopidogrel ❌❌❌❌ ·       if Stent: keep clopidogrel for 12 m / if fibrinolytics: keep for 1 m ·       Give unfractionated heparin to all ·       GP IIb/IIIa inhibitors should be avoided with fibrinolytic therapy as there is evidence of excessive bleeding o   If Left main coronary (or equivelant: 70% proximal LAD + LCX) –> CABG o   If DM –> CABG Absolute Contraindications to tPA Relative ICH Poorly controlled HTN Structural vascular lesion Ischemic stroke > 3 months Intracranial mass Dementia Ischemic stroke w/i 3 months Major surgery w/i 3 weeks Hemorrhagic stroke anytime Internal bleeding w/i 3 weeks Aortic dissection Active bleeding Hx of diabetic retinopathy

Notes from UW:

Complications of Femoral a. Cath
Cholesterol embolism	·       Pain + skin changes ·       livedo reticularis ·       Ischemic ulcers ·       Cyanosis ·       Gangrene ·       Eø
Femoral pseudoaneurysm	·       loss of distal pulses ·       pulsitile mass post-cath ·       Systolic bruit
Retroperitoneal bleeding	·       back pain ·       sudden drop in Hct ·       purpura in lower back