PANCE Blueprint Cardiology (13%)

PANCE Blueprint Cardiology (13%)

PANCE Blueprint Cardiology (13%)

Follow along with the NCCPA™ PANCE and PANRE Cardiology Content Blueprint

Lessons

  1. Cardiovascular 145 Question Comprehensive Exam (Members Only)

    Comprehensive PANCE/PANRE Cardiovascular System Blueprint Exam
  2. Smarty PANCE Cardiology System Flashcards and Cheat Sheet

    Flashcards covering all Cardiology PANCE/PANRE NCCPA Content Blueprint topics. Download and print the flashcard cheat sheet and access our premium Quizlet flashcard sets.
    1. Additional Cardiology Flashcards

    1. EKG Interpretation (Picmonic)

    2. EKG Cram Cards

    3. EKG Pearls and Pitfalls (video)

    1. Most common cardiomyopathy - reduced contraction strength, large heart, systolic dysfunction
      • Etiology: Genetics, excess alcohol, postpartum, chemotherapy, endocrine disorders
      • Physical exam: Dyspnea, S3 gallop, rales, jugular venous distention
    2. Hypertrophic Cardiomyopathy (HOCM)

      Hypertrophic portion of septum - Young athlete with a positive family history has sudden death or syncopal episode
      • High pitched mid systolic murmur at LLSB. Increased with valsalva and standing (less blood in chamber). Decreased with squatting (more blood in chamber)
    3. Restrictive Cardiomyopathy

      Right heart failure with a history of infiltrative process - stiff ventricles
      • Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, fibrosis, and cancer
    1. Atrial fibrillation/flutter (ReelDx + Lecture)

      • Atrial Fibrillation: Low-amplitude fibrillatory waves without discrete P waves and an irregularly irregular pattern of QRS complexes
      • Atrial Flutter: Regular, sawtooth pattern, atrial rate 250-350 BPM, narrow QRS complex
    2. Atrioventricular block (lecture + ReelDx)

      First degree AV block: PR interval > .2 seconds.
      • First-degree heart block is actually a delay rather than a block. It is caused by a conduction delay at the AV node or bundle of His. This means that the PR Interval will be longer than normal (over 0.20 sec.).
      Second degree AV block Type 1 (Wenckebach) and Type 2 (Mobitz)
      • Second degree type 1 (Wenckebach)Longer, longer, drop now you've got a Wenckebach.
        • With second-degree heart block, Type I, some impulses are blocked but not all. More P waves can be observed vs QRS Complexes on a tracing. Each successive impulse undergoes a longer delay. After 3 or 4 beats the next impulse is blocked.
      • Second degree type 2 (Mobitz)Some get dropped some get through now you've got Mobitz 2.
        • With Mobitz Type II blocks, the impulse is blocked in the bundle of His. Every few beats there will be a missing beat but the PR Interval will not lengthen.
      Third degree AV block: P’s and Q’s don’t agree now the block is 3rd degree.
      • With this block, no atrial impulses are transmitted to the ventricles. As a result, the ventricles generate an escape impulse, which is independent of the atrial beat. In most cases, the atria will beat at 60-100 bpm while the ventricles asynchronously beat at 30-45 bpm.
    3. Bundle branch block

      • Left: R and R’ (upward bunny ears) in V4-V6
      • Right: R and R’ (upward bunny ears) in V1-V3
    4. Paroxysmal supraventricular tachycardia

      A SVT with abrupt onset and offset:
      • Atrioventricular nodal reentrant tachycardia (AVNRT): Any tachydysrhythmia arising from above the level of the Bundle of His
      • Wolff-Parkinson-White (WPW) syndrome: Caused by the presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles (Bundle of Kent fibers). hallmarks on EKG include a shortened PR interval, widened QRS, and delta waves
    5. Premature beats

      • PVC: Early wide "bizarre" QRS, no p wave seen
      • PAC: Abnormally shaped P wave
      • PJC: The QRS complex will be narrow, usually measured at 0.10 sec or less, no p wave or inverted p wave
    6. Sick sinus syndrome (sinus node dysfunction)

      Collective term used to describe dysfunction in the sinus node's automaticity and impulse generation
      • Sinus bradycardia: Sinus rhythm with a resting heart rate of < 60 bpm in adults, or below the normal range for age in children
      • Sinus pause: pause < 3 seconds
      • Sinus arrest: pause > 3 seconds
      • Tachy-Brady Syndrome: Episodes of alternating sinus tachycardia and bradycardia
    7. Sinus arrhythmia

      Sinus arrhythmia represents normal, minimal variations in the SA Node's pacing rate in association with the phases of respiration. Heart rate frequently increases with inspiration, decreases with expiration
    8. Torsade de pointes (Lecture)

      EKG: Polymorphic ventricular tachycardia that appears to be twisting around a baseline
      • Treatment: IV Magnesium sulfate
    9. Ventricular fibrillation (Lecture)

      EKG: No discernible heart contractions
      • Treatment: CPR and defibrillation (AKA non-synchronized cardioversion)
    10. Ventricular tachycardia (ReelDx + Lecture)

      EKG: Wide complex tachycardia with three or more consecutive ventricular premature beats
      • Stable: Treat with amiodarone → lidocaine → procainamide (in this order)
      • Unstable: Treat with CPR and defibrillation synchronized direct current (DC) cardioversion
    1. Atrial septal defect

      Noncyanotic - Foramen ovale fails to close. Wide fixed split second heart sound (S2). Systolic ejection murmur at second left intercostals space with an early to mid-systolic rumble
    2. Coarctation of the aorta

      Noncyanotic - Higher blood pressures in the arms than in the legs and pulses are bounding in the arms but decreased in the legs.
    3. Patent ductus arteriosus

      Noncyanotic - A continuous "machinery murmur" at the upper left sternal border
    4. Failure to thrive. "tet spells", baby with cyanosis and loss of consciousness with crying
      • Cyanotic - Four features "PROVe":Pulmonary Stenosis, Right ventricular hypertrophy, Overriding aorta, Ventricular septal defect
    5. Ventricular septal defect

      Noncyanotic - VSD is the most common pathologic murmur in childhood.
      • Loud, harsh, pansystolic murmur at the lower left sternal border.
      • Most close by age 6, surgery if large.
  3. Coronary Heart Disease (PEARLS)

    1. Acute myocardial infarction (PEARLS)

      1. Non-ST-Segment Elevation MI (NSTEMI) ReelDx

        Evidence of myocardial necrosis (cardiac markers in blood; troponin I or troponin T and elevated CK) without acute ST-segment elevation or Q waves
        • ECG changes such as ST-segment depression, T-wave inversion, or both may be present
      2. ST-Segment Elevation Myocardial Infarction (Lecture)

        ST segment elevations > 1 mm in > 2 contiguous leads on ECG and evidence of myocardial necrosis (cardiac markers in blood; troponin I or troponin T and elevated CK)
        • ST elevation: acute ischemia
        • T wave depression: myocardial injury
        • Q wave: Infarct
        Characteristic symptoms of myocardial infarction include pain in the substernal region of the chest that radiates to the left armshortness of breath, and diaphoresis
        • The underlying pathologic process of myocardial infarction is plaque rupture with the adhesion of platelets and platelet aggregation
        Location of heart:
        • Lateral (I, aVL, V5, V6): Left circumflex
        • Anterior (V2-V4): Left anterior descending
        • Septal (V1, V2): Left anterior descending
        • Anterolateral (V4, V5, V6): Left main
        • Posterior (V1, V2: ST depression): Right coronary artery
        • Inferior (II, III, aVF): Right coronary artery
        Serial cardiac enzymes:
        • Troponins: Most specific test, appears at 4-8 hours, peaks at 12-24 hours, and lasts for 7-10 days
        • Myoglobin: Elevate in 1- 4 hours
        • CK-MB: Appears at 4-6 hours, peaks at 12-24 hours, and lasts for 3-4 days
        Treatment includes Beta Blockers + NTG + Aspirin + Heparin + ACEI + REPERFUSION
        • PCI (Percutaneous Coronary Intervention) GOLD STANDARD - best if within 3 hours of sx onset (especially 90 minutes), PCI is superior to thrombolytics
        • Thrombolytic therapy - Done if no access to cath lab or surgery is contraindicated
          • TPA
          • Streptokinase
        Absolute contraindications for fibrinolytic use in STEMI include the following:
        • Prior intracranial hemorrhage (ICH)
        • Known structural cerebral vascular lesion
        • Known malignant intracranial neoplasm
        • Ischemic stroke within 3 months
        • Suspected aortic dissection
        • Active bleeding or bleeding diathesis (excluding menses)
        Upon discharge - ACE inhibitors have been shown to decrease left ventricular hypertrophy and remodeling to allow for a greater ejection fraction.
    2. Angina pectoris (PEARLS)

      1. Prinzmetal variant angina (vasospastic angina)

        Coronary artery vasospasms causing transient ST segment elevations, not associated with clot
        • Look for a history of smoking (#1 risk factor) or cocaine abuse
        • EKG may show inverted U waves
      2. Stable angina

        Predictable, relieved by rest and/or nitroglycerine
      3. Unstable angina (ReelDx)

        Previously stable and predictable symptoms of angina that are now more frequent, increasing or present at rest
  4. Heart Failure (ReelDx)

    Right sided: causes peripheral and abdominal fluid accumulation -  jugular venous distention, edema, hepatomegaly, no rales
    • Diagnose with echo and doppler, gold standard is right heart cardiac catheterization
    Left sided: causes shortness of breath and fatigue - paroxysmal nocturnal dyspnea, cough, orthopnea, rales
    • Systolic: Decreased ejection fraction, S3 (Rapid ventricular filling during early diastole is the mechanism responsible for the S3)
    • Diastolic: Ejection fraction is usually normal, S4
    Chest radiograph: Kerley B lines, ↑ BNP
  5. Hypertension (PEARLS)

    1. Essential hypertension

      Primary hypertension is defined as a resting systolic BP ≥ 130 or diastolic BP ≥ 80  on at least two readings on at least two separate visits with no identifiable cause
      • ACC/AHA classification of BP
        • Normal: < 120/80 mmHg
        • Elevated: 120–129 mmHg and < 80 mmHg
        • Stage 1: 130–139 mmHg or 80-89 mm Hg
        • Stage 2: ≥ 140 mm Hg or ≥ 90 mm Hg
        • Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage
    2. Hypertensive emergencies (ReelDx)

      Hypertensive Urgency (severe asymptomatic hypertension)
      • Very high blood pressure (systolic ≥ 180 or diastolic ≥ 120) WITHOUT target-organ damage
      • BP at these levels can be worrisome; however, acute complications are unlikely, so immediate BP reduction is NOT required. However, patients should be started on a 2-drug oral combination, and close evaluation (with an evaluation of treatment efficacy) should be continued on an outpatient basis
      Hypertensive Emergency
      • Severe hypertension (SBP ≥ 180 and/or DBP ≥ 120) WITH signs of damage to target organs - retinal hemorrhages, papilledema, encephalopathy, acute and subacute kidney injury, intracranial hemorrhage, aortic dissection, pulmonary edema, unstable angina or MI.
      • BP must be reduced within 1 hour by approximately 10 to 20 percent to prevent the progression of end-organ damage or death and a further 5 to 15 percent over the next 23 hours.
      • This often results in a target blood pressure of <180/<120 mmHg for the first hour and <160/<110 mmHg for the next 23 hours
      Hypertensive emergencies can be further classified into these two clinical syndromes:
      • Hypertensive retinopathy (formerly called malignant HTN)
        • Characterized by retinal hemorrhages, exudates, and papilledema
      • Hypertensive encephalopathy 
        • Hypertensive encephalopathy refers to the presence of signs and/or symptoms of cerebral edema caused by severe and/or sudden rises in BP
        • S&s include the insidious onset of headache, nausea, and vomiting, followed by nonlocalizing neurologic symptoms such as restlessness, confusion, and if the hypertension is not treated, seizures and coma.
    3. Secondary hypertension

      Systolic BP ≥ 140 diastolic BP ≥ 90 or both with an identifiable cause
      • Sleep apnea, pheochromocytoma, coarctation of the aorta, parenchymal renal disease, renal artery stenosis, Cushing syndrome, primary hyperaldosteronism (Conn’s disease)
      • Reduce BP to < 140/90 mm Hg for everyone < 60, including those with a kidney disorder or diabetes
      • Reduce BP to < 150/90 mm Hg for everyone ≥ 60
  6. Hypotension (PEARLS)

    1. Cardiogenic shock

      Common causes include acute MI, heart failure, cardiac tamponade.
      • Hypotension (SBP <90mmg), cyanosis, cool extremities, altered mental status, and crackles.
      • Treatment includes fluid resuscitation, pressors (dopamine), and treat underlying cause.
    2. Orthostatic hypotension (ReelDx)

      Drop of > 20 mm Hg systolic, 10 mmHg diastolic, or both 2-5 minutes after change from supine to standing
    3. A sudden drop in heart rate and blood pressure leading to fainting, often in reaction to a stressful trigger
      • Upright tilt-table study can reproduce the symptoms in susceptible people
      • Treatment usually involves trigger avoidance, but may on rare occasions include β-blockers and disopyramide or a pacemaker
    1. Hypercholesterolemia

      Four groups most likely to benefit from statin therapy are identified:
      • Patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
      • Patients with primary LDL-C levels of 190 mg per dL or greater.
      • Patients with diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL.
      • Patients without diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
    2. Hypertriglyceridemia

      Obtain fasting lipid panel beginning at age 20 and repeated every 5 years
      • Normal <150 mg/dL
      • Mild hypertriglyceridemia  150 to 499 mg/dL
      • Moderate hypertriglyceridemia 500 to 886 mg/dL
      • Very high or severe hypertriglyceridemia 886 mg/dL
      Treatment
      • Triglyceride level should be reduced to < 500 mg/dL to prevent this pancreatitis
      • Isolated triglycerides are treated with Fibrates (gemfibrozil and fenofibrate) and Niacin
      • Niacin may cause hyperglycemia so caution in patients with DM
      • Flushing treated with daily aspirin, will have a beneficial effect on HDL cholesterol
  7. Traumatic, infectious, and inflammatory heart conditions (PEARLS)

    1. Acute bacterial endocarditis: Infection of normal valves with a virulent organism (S. aureus) Subacute bacterial endocarditis: Indolent infection of abnormal valves with less virulent organisms (S. viridans)
      • Duke's criteria (major and minor), staph aureus in acute and IV drug users, strep viridans in subacute
      • The four classic peripheral stigmata of infective endocarditis are:
        • Osler's nodes - tender (ouchy) nodules
        • Janeway lesions - painless macules
        • Roth spots on the retina
        • Splinter hemorrhages on the nail bed
      The Four Classic Peripheral Stigmata of Infective Endocarditis
    2. Acute pericarditis (ReelDx)

      Chest pain that is relieved by sitting and/or leaning forward worse when lying down
      • Dressler's syndrome is pericarditis 2-5 days after an acute myocardial infarctions
      • Pericardial friction rub heard best with patient upright and leaning forward
      • EKG will demonstrate diffuse, ST segment elevations in the precordial leads
    3. Cardiac tamponade (ReelDx)

      Beck’s triad on physical exam: jugular venous distention, hypotension, muffled heart sounds
      • Pulsus paradoxus is a classic finding (drop 10 mmHg in systolic pressure on inspiration), narrow pulse pressure
      • EKG will show electrical alternans (when consecutive, normally-conducted QRS complexes alternate in height) and low voltage QRS complex
      • Chest x-ray finding – water bottle heart - heart shaped like a canteen
      • Treatment: Pericardiocentesis
    4. Pericardial effusion (ReelDx)

      Same symptoms as acute pericarditis except patient will now have signs of fluid buildup around the heart which include low voltage QRS complexes, electrical alternans, distant heart sounds and an echocardiogram showing a collection of pericardial fluid.
      • EKG showing low voltage QRS along with electric alternans
      • Echocardiogram with increased pericardial fluid
      • Radiograph: Water bottle heart
      • Treatment: Underlying cause, pericardiocentesis if effusion is large
    5. Acute myocarditis

  8. Valvular Disorders (PEARLS)

    1. Aortic stenosis (ReelDx)

      • Harsh systolic ejection crescendo-decrescendo murmur at the right upper sternal border (aortic area) with radiation to the neck and apex heard best by leaning forward with expiration and squatting. Associated with a split S2
      Aortic Stenosis (AS) Murmur Auscultation
    2. Aortic regurgitation (Diastolic)

      • Soft, high-pitched, blowing, decrescendo murmur along the 3rd intercostal space on the left (Erb's point). Loudest with the patient sitting, leaning forward after exhaling, squatting, and with hand grip.
      Aortic Regurgitation Murmur Auscultation
    3. Mitral stenosis (Diastolic)

      • Diastolic low-pitched decrescendo rumbling murmur with opening snap heard best at the apex (mitral area) with a patient in a left lateral decubitus position.
      Mitral Stenosis (MS) Murmur Auscultation
    4. Mitral regurgitation

      • Blowing holosystolic murmur heard best at the apex (mitral area) with a SPLIT S2 that radiates to the left axilla.
      Mitral Regurgitation (MR) Murmur Auscultation
    5. Mitral valve prolapse

      • Midsystolic ejection click heard best at the apex. The murmur is noticeably longer and often louder with standing and Valsalva.
      Mitral Valve Prolapse (MVP) Murmur Auscultation
    6. Tricuspid stenosis (Diastolic)

      • Mid diastolic rumbling murmur at the LLSB (tricuspid area) with an opening snap that increases with inspiration.
      Tricuspid Stenosis (TS) Murmur Auscultation
    7. Tricuspid regurgitation

      • High-pitched holosystolic murmur at the LLSB (tricuspid area) that radiates to the sternum and increases with inspiration.
    8. Pulmonary stenosis

      • Harsh, loud, medium-pitched systolic murmur heard best at the 2nd left intercostal space (pulmonic area) that radiates to the left shoulder and neck and may increase with inspiration. Associated with split S2.
      Pulmonary Valve Stenosis (PS) Murmur Auscultation
    9. Pulmonary regurgitation (diastolic)

      • High-pitched early diastolic decrescendo murmur at the LUSB (pulmonic area) that increases with inspiration.
      Pulmonary Regurgitation (PR) Murmur Auscultation
  9. Vascular Disease (PEARLS)

    1. Aortic aneurysm and aortic dissection

      Abdominal Aortic Aneurysm: Flank pain, hypotension, pulsatile abdominal mass

       
      • Surgical repair if >5.5 cm or expands >0.6 cm per year
      • Monitor annually if >3 cm. Monitor every 6 months if >4 cm
      • Beta blockers
      Aortic Dissection: Sudden onset tearing chest pain, between scapulas.Diminished pulses
      • Chest radiograph: Widened mediastinum
      • Ascending aorta- Surgical emergency
      • Descending aorta- Medical therapy (beta blockers) unless complications are present
    2. Arterial embolism/thrombosis

      Caused by a sudden arterial occlusion - The P's of arterial emboli: PAIN, PALLOR, PULSELESSNESS, PARESTHESIA, PARALYSIS, POIKILOTHERMIA
      • Atrial fibrillation and mitral stenosis are common causes of thrombus formation
      • Angiography is considered the gold standard for diagnosis
      • Treat with IV heparin then call vascular surgeon
    3. Arteriovenous malformation is an abnormal connection between arteries and veins, bypassing the capillary system.
      • In about half of all brain AVMs, intracranial hemorrhage is the first sign
      • Signs and symptoms may also include seizure, headache and focal neurologic deficit
      • Angiography is the diagnostic gold standard
      • Surgical excision is the mainstay of treatment along with radiosurgery and endovascular embolization
    4. Giant cell arteritis

      Inflammation of large and medium vessels: Jaw claudication and headache, thickened temporal artery scalp pain elicited by touching the scalp or combing the hair, acute vision disturbances  Amaurosis fugax (temporary monocular blindness) secondary to anterior ischemic optic neuritis
      • ESR > 100
      • Diagnosed with Temporal artery biopsy
      • Treat with high dose prednisone – do urgently to prevent blindness (Do not wait for biopsy results)
      • Associated with polymyalgia rheumatica
    5. Peripheral artery disease

      Intermittent claudication, atrophic skin, rubor, hair loss, decreased pulses or non healing ulcers
      • Diagnosis with ankle/brachial index (< 0.9)
      • angiography is gold standard
      • βblockers are contraindicated in isolated PAD – it will worsen claudication
    6. Phlebitis/thrombophlebitis

      Spontaneous or after trauma, IV/PICC lines - dull pain, erythema, induration of vein, palpable cord
      • Venous duplex ultrasound Gold Standard for diagnosis
      • NSAIDs, warm compress
    7. Varicose veins

      Presentation: Dilated tortuous superficial veins, venous stasis ulcers, ankle edema, lower extremity pain after sitting/standing
      • Treatment: leg elevation and compression stockings
    8. Venous insufficiency (ReelDx)

      Edema, atrophic shiny skin, brawny induration, stasis dermatitis, brown hyperpigmentation, varicosities, and venous stasis ulcers above medial malleolus.
      • ABI, Trendelenburg tests, ultrasound.
      • Treatment: Sclerotherapy, vein stripping, compression hose.
    9. Venous thrombosis (ReelDx)

      Unilateral (ASYMMETRICAL) swelling of lower extremity
      • Virchow’s triad: stasis, vascular injury, hypercoagulable state (OCP, cancer, surgery, factor V Leiden)
      • D-dimer, venous duplex ultrasound first line imaging, venography gold standard
      • Homan signdiscomfort behind the knee on forced dorsiflexion of the foot

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