PANCE Blueprint Cardiology (13%)

Lessons

1. 2019 PANCE Cardiovascular System Content Blueprint
2. Cardiology System Exam (Members Only)
3. Cardiology System Flashcards
   1. Cardiology Quick Cram Cards

4. Cardiac Murmurs With Joe Gilboy PA-C

5. Cardiac Pharmacology With Joe Gilboy PA-C (Members Only)

6. Cardiology PANCE and PANRE Content Blueprint High Yield Combined Review

   Stephen Pasquini PA-C

7. EKG Rhythm Strip Quiz
   1. EKG Interpretation (Picmonic)
   2. EKG Cram Cards
   3. EKG Pearls and Pitfalls (video)

      90 mins

8. Cardiomyopathy (PEARLS)

   1. Brian Wallace PA-C Podcast: Cardiomyopathies and Hypertension

      28 mins

      Brian Wallace PA-C

   2. Dilated Cardiomyopathy

      Stephen Pasquini PA-C

      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
   3. Hypertrophic Cardiomyopathy

      Stephen Pasquini PA-C

      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)
   4. Restrictive Cardiomyopathy

      Stephen Pasquini PA-C

      Right heart failure with a history of infiltrative process - stiff ventricles

      • Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, fibrosis, and cancer

9. Conduction Disorders (PEARLS)

   Stephen Pasquini PA-C

   1. Podcast: Arrhythmias and Murmurs

      36 mins

      Brian Wallace PA-C
   2. 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
   3. Atrioventricular block (lecture)

      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.
   4. Bundle branch block

      • Left: R and R’ (upward bunny ears) in V4-V6
      • Right: R and R’ (upward bunny ears) in V1-V3
   5. 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
   6. 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
   7. 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
   8. 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
   9. Torsades de pointes (Lecture)

      EKG: Polymorphic ventricular tachycardia that appears to be twisting around a baseline

      • Treatment: IV Magnesium sulfate
   10. Ventricular fibrillation (Lecture)

       EKG: No discernible heart contractions

       • Treatment: CPR and defibrillation (AKA non-synchronized cardioversion)
   11. 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

10. Congenital Heart Disease (PEARLS)

    1. Brian Wallace PA-C Podcast: Congenital Heart Disorders

       16.29 mins

       Brian Wallace PA-C
    2. Atrial septal defect

       5 mins

       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
    3. Coarctation of the aorta

       7 mins

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

       5 mins

       Noncyanotic - A continuous "machinery murmur" at the upper left sternal border
    5. Tetralogy of Fallot

       6 mins

       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
    6. Ventricular septal defect

       4 mins

       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.
11. Coronary Heart Disease (PEARLS)

    1. Brian Wallace PA-C Podcast: Ischemia and MI

       32 mins

       Brian Wallace PA-C
    2. 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 (Lecture)

          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
    3. Angina pectoris (PEARLS)
       1. 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
       2. Stable angina

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

          Previously stable and predictable symptoms of angina that are now more frequent, increasing or present at rest
12. 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
13. Hypertension (PEARLS)

    1. Brian Wallace PA-C Podcast: Hypertension Medications

       30 mins

       Brian Wallace PA-C
    2. Essential hypertension

       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)
    3. Hypertensive emergencies

       Hypertensive emergency: 

       • BP usually >180/120 with impending 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 > 140 mm Hg associated with papilledema and either encephalopathy or nephropathy
    4. Secondary hypertension

       22 mins

       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
14. Hypotension (PEARLS)

    1. Brian Wallace PA-C Podcast: Hypotension and CHF

       27 mins

       Brian Wallace PA-C
    2. 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.
    3. Orthostatic hypotension

       Drop of > 20 mm Hg systolic, 10 mmHg diastolic, or both 2-5 minutes after change from supine to standing

    4. Vasovagal hypotension

       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

15. Lipid disorders (PEARLS)
    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
16. Traumatic, infectious, and inflammatory heart conditions (PEARLS)

    1. Brian Wallace PA-C Podcast: Endocarditis, Pericarditis and Tamponade

       23 mins

       Brian Wallace PA-C

    2. Acute and subacute bacterial endocarditis (ReelDx)

       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
       • Classic signs of infective endocarditis
         • Osler's nodes - tender (ouchy) nodules
         • Janeway lesions - painless macules
         • Roth spots on retina
         • Splinter hemorrhages on nail bed
         • Clubbing
    3. 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
    4. 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
    5. 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
17. Valvular Disorders (PEARLS)

    1. Brian Wallace PA-C Podcast: Cardiac Valve Disorders

       28 mins

       Brian Wallace PA-C
    2. 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
    3. Aortic regurgitation (Diastolic)

       Soft early diastolic blowing murmur along left sternal border with patient sitting leaning forward after exhaling
    4. 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
    5. Mitral regurgitation

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

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

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

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

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

        High pitched early diastolic decrescendo murmur at the LUSB (pulmonic area) that increases with inspiration
18. Vascular Disease (PEARLS)

    1. Brian Wallace PA-C Podcast: Vascular Disorders

       16.25 mins

       Brian Wallace PA-C
    2. 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
    3. 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

    4. Arteriovenous malformation

       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

    5. Brian Wallace PA-C Podcast: Venous Disorders

       19.52 mins

       Brian Wallace PA-C
    6. 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
    7. Peripheral artery disease

       6 mins

       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
    8. 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
    9. Varicose veins

       5 mins

       Presentation: Dilated tortuous superficial veins, venous stasis ulcers, ankle edema, lower extremity pain after sitting/standing

       • Treatment: leg elevation and compression stockings
    10. 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.
    11. Venous thrombosis

        8 mins

        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 sign: discomfort behind the knee on forced dorsiflexion of the foot