PANCE Blueprint Cardiology (16%)

PANCE Blueprint Cardiology (16%)

PANCE Blueprint Cardiology (16%)

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

  • 52 PANCE and PANRE Cardiology Content Blueprint Lessons (see below)
  • Cardiology Pearls Flashcards
  • Ten Cardiology Content Blueprint high-yield summary tables
  • 147 Question Cardiology Exam (available to paid subscribers)
  • ReelDx integrated video content (available to paid subscribers)

Lessons

  1. Cardiology Comprehensive Exam (Members Only)

  2. Cardiology Flashcards (Members Only)

    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

      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)

      • 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

      • 1st degree: PR interval > .2 seconds
      • 2nd degree:
        • 2nd degree type 1- longer, longer, drop now you've got a Wenckebach
        • 2nd degree type 2- some get dropped some get through now you've got Mobitz 2
      • 3rd degree: P’s and Q’s don’t agree now the block is 3rd degree
    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

      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. Ventricular tachycardia (ReelDx)

      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
    8. Ventricular fibrillation

      EKG: No discernible heart contractions
      • Treatment: CPR and defibrillation (AKA non-synchronized cardioversion)
    9. Torsades de pointes

      EKG: Polymorphic ventricular tachycardia that appears to be twisting around a baseline
      • Treatment: IV Magnesium sulfate
    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. Tetralogy of Fallot

      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.
  3. 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
  4. Hypertension (PEARLS)

    1. Primary hypertension (formerly essential)

      Primary hypertension is elevated blood pressure > 140/90 with no identifiable cause
      • Normal: < 120/80 mmHg
      • Prehypertension: 120–139/80–89 mmHg
      • Stage 1: 140–159 mmHg (systolic) or 90–99 mm Hg (diastolic)
      • Stage 2:  ≥ 160 mm Hg (systolic) or ≥ 100 mm Hg (diastolic)
    2. 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
    3. Hypertensive emergencies

      Hypertensive emergency: 
      • BP usually >180/120 with impeding or progressing end organ damage
        • End organ damage: encephalopathy, nephropathy, intracranial hemorrhage, aortic dissection, pulmonary edema, unstable angina or MI (except papilledema which = malignant HTN)
      • BP must be reduced within 1 hour to prevent progression of end organ damage or death
      • Treatment: IV labetalol or calcium channel blocker (dihydropyridine), Sodium Nitroprusside (drug of choice) 
      Hypertensive Urgency: 
      • BP usually 180/120 without signs of end organ damage
      • Immediate BP reduction is not required
      • Treatment: oral antihypertensive Clonidine (drug of choice)
      Malignant HTN
      • Characterized by diastolic reading greater than 140 mm Hg associated with papilledema and either encephalopathy or nephropathy
  5. Hypotension (PEARLS)

    1. Cardiogenic shock

    2. Orthostatic hypotension

      Drop of > 20 mm Hg systolic, 10 mmHg diastolic, or both 2-5 minutes after change from supine to standing
  6. Coronary Heart Disease (PEARLS)

    1. Acute myocardial infarction (PEARLS)

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

        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 (STEMI)

        ST segment elevations > 1mm 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
        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 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
    2. Angina pectoris (PEARLS)

      1. Stable angina

        Predictable, relieved by rest and/or nitroglycerine
      2. Unstable angina

        Previously stable and predictable symptoms of angina that are now more frequent, increasing or present at rest
      3. Prinzmetal variant 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
  7. Vascular Disease (PEARLS)

    1. Aortic aneurysm/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. 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
    4. 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
    5. 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
    6. Varicose veins

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

    8. Venous thrombosis

      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
  8. Valvular Disorders (PEARLS and Flashcards)

    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
    2. Aortic regurgitation (Diastolic)

      Soft early diastolic blowing murmur along left sternal border with patient sitting leaning forward after exhaling
    3. Mitral stenosis (Diastolic)

      Diastolic low pitched decrescendo rumbling murmur with opening snap heard best at the apex (mitral area) with patient in lateral decubitus position
    4. Mitral regurgitation

      Holosystolic high-pitched blowing murmur at apex (mitral area) that radiates to axilla with a split S2
    5. Mitral valve prolapse

      Midsystolic ejection click heard best at the apex (mitral area)
    6. Tricuspid stenosis (Diastolic)

      Diastolic rumbling murmur at the LLSB (tricuspid area) with an opening snap
    7. Tricuspid regurgitation

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

      Harsh, loud, medium pitched systolic murmur heard best at the 2nd /3rd left intercostal space (pulmonic area) that may decrease with inspiration
    9. Pulmonary regurgitation (diastolic)

      High pitched early diastolic decrescendo murmur at the LUSB (pulmonic area) that increases with inspiration
  9. Other Forms of Heart Disease (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)
    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

      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)