Cardiology

Pericardium

Fluid filled sac around the heart, protect against infection and lubricates the heart

Epicardium

Outer layer of the heart, protects inner layers of heart and produced pericardial fluid

Myocardium

Composed of cardiac muscle fibers, enables heart contractions, thickest in LV

Endocardium

Inner layer of the heart, covers chambers, valves and great vessels

Semilunar Valves

Aortic Valve & Pulmonary Valve

Semilunar Valves (SAP)

Maintains blood flow from ventricles to main arteries.

Atrioventricular Valves

Tricuspid Valve & Mitral (Bicuspid) Valve

Atrioventricular Valves (MAT)

Maintains blood flow from the atria to the ventricles.

Deoxygenated Blood (Blood Flow)

IVC/SVC -> RA -> TV -> RV -> PV -> Pulm. Artery -> Lungs

Oxygenated Blood (Blood Flow)

Lungs -> Pulm. Vein -> LA -> MV -> LV -> AV -> Aorta -> Body

Veins

carries deoxygenated blood to the heart

Arteries

carries oxygenated blood away from the heart

Coronary Arteries

the two arteries that supply blood to the heart muscle

Electrical Conduction System

SA node -> LA and RA -> meets at AV node -> traverses through bundle of His -> branches off into left and right bundle branches -> Purkinje fibers

Sinoatrial (SA) Node

pacemaker of the heart

Atrioventicular (AV) Node

Small mass of specialized cardiac muscle fibers, located in the wall of the right atrium of the heart, that receives heartbeat impulses from the sinoatrical node and directs them to the walls of the ventricles. AV node delays electrical impulse from SA before allowing it to move on to ventricles. Directs impulses to walls of ventricles.

Cardiac Risk Factors

-Hypertension (HTN) -Obesity -Diabetes (DM) -Hyperlipidemia (HLD) -Familial/Genetic -Smoking -Alcohol (ETOH) -Illicit drug use -Chemotherapy -Excessive caffeine -Stress -Being physically inactive -Diet -Age (55 or older in woman) -Sex (men)

Angina

May indicate myocardial infarction (MI) or coronary artery disease (CAD). -Described as tightness, squeezing, or heaviness in chest. -Occurs when heart muscle doesn't receive enough blood. -Made worse with exertion and better with rest. -Other chest pain (CP) may also be caused by respiratory, gastrointestinal (GI) or musculoskeletal issues.

Dyspnea

Shortness of breath (SOB) common in patients with heart failure (HF). -Occurs when fluid seeps into lungs, may be heard through stethoscope as wheezing. -In early stages of HF, ___ only occurs during exertion. As HF progresses, SOB occurs with less activity until it occurs even at rest. -Orthopnea, Paroxysmal Nocturnal Dyspnea (PND) -Other SOB may also be caused by respiratory dysfunction, arrhythmias, anemia, or overactive thyroid.

Orthopnea

Dyspnea when lying flat, feels more comfortable sitting up.

Paroxysmal Nocturnal Dyspnea (PND)

Sudden gasping or coughing during sleep.

Fatigue

Can occur due to HF, arrhythmias, deconditioning, thyroid dysfunction, etc.

Arrhythmias

irregular heart rhythms; can cause people to pass out

Palpitations

Awareness of heart beat or rhythm. -Described as skipping, pounding, sudden, gradual, tapers, forceful, catch my breath. -May have many causes which range in severity from benign to dangerous. -Associated with SOB, CP, weakness, fatigue,or syncope.

Lightheadedness/Syncope

Inadequate blood flow resulting from arrhythmias or poor pumping function. May also occur with neurological dysfunction.

Pre-syncope

About to pass out/feeling

Lower Extremity Edema

Commonly seen in HF or peripheral vascular disease. -Occurs when blood pools in the legs and fluid cannot be redistributed. -Described as tight, heavy, painful gait, tingling, restless leg; often worse at night. -Conservative therapy: Increase walking, compression stockings, elevating legs.

Electrocardiogram (ECG/EKG)

Great diagnostic tool to determine many heart diseases including arrhythmias, ischemia, and hypertrophy. Uses 12 leads to measure electrical conduction of heart.

P Wave

Activation of SA node and contraction of atria

QRS Wave

Activation of AV node and contraction of ventricles

T Wave

Recovery of ventricles

Monitors

An ECG that can be worn from 24 hours up to 3 years to evaluate arrhythmias.

24 hour/48 hour Holter monitors

Uses leads with sticky pads to monitor heart rhythm.

Event Monitor

A Holter monitor that can be worn up to one month

ZioPatch

A leadless monitor that can be used from 3-14 days

Loop Recorder

A small implanted monitor that can be used up to 3 years

Electrophysiological Study (EPS)

Used to evaluate rhythm or electrical conduction dysfunction by inducing arrhythmias, can have ablations performed during ____

Computer Tomography (CT)

Used to detect structural abnormalities in heart, pericardium, and major vessels. Uses XR to create cross sectional images. Uses radiation and too much exposure can b dangerous.

Echocardiogram (Echo)

Uses ultrasound (high frequency sound) that bounce off structures to produce moving images; most commonly used due to non-invasiveness, no radiation, and good images. Useful for evaluating structure (valves, chambers, vessels), wall motion abnormalities, hypertrophy, and ejection fraction (EF). Can use Doppler to produce colored images of turbulent blood flow. Useful in determining valve regurgitation. -Transthoracic Echo (TTE), Transesophageal Echo (TEE), Stress Echo

Transthoracic Echo (TTE)

Over the chest, least invasive

Transesophageal Echo (TEE)

Behind esophagus through throat, more invasive

Stress Echo

Similar to stress test, echo are done before and after exercise/dobutamine

Dobutamine Stress Echo

Used in patients who cannot run on treadmills

Magnetic Resonance Imaging (MRI)

Uses strong magnetic fields that vibrate protons and excites the atom. This gives off radio waves which is picked up by sensors and creates images. -Often used when physician suspects cardiac amyloidosis. -Not compatible in patients with certain ICDs or pacemakers.

Nuclear Imaging

Uses radioactive tracers and gamma cameras to evaluate CP with unknown etiology and CAD. -Can be coupled with stress test to evaluate for ischemia and previous MI.

Cardiac Catheterization

Uses a thin catheter that is inserted in the groin or arm to evaluate inside the heart. From there, many procedures can be performed. -Left Heart Cath (LHC) & Right Heart Cath. -Useful in measuring hemodynamic pressures, ejection fraction, obtaining cardiac biopsies, and performing ablations and coronary angiogram and percutaneous coronary interventions (PCI/stent).

Left Heart Cath (LHC)

Uses artery

Right Heart Cath (RHC)

Uses vein

Angiotensin-converting-enzyme (ACE) inhibitor

Treatment of HTN, CHF, and MI. -Helps relax blood vessels (more area=less pressure) and decrease blood volume (reduces oxygen demand from heart) by inhibiting ACE which regulate BP and fluid balance in RAAS (renin-angiotension-aldosterone) system. -Common side effects: dry cough (ACE induced cough), hyperkalemia. -Nomenclature: ends in -pril, Lisinopril, Benazepril, Enalapril.

ACE inhibitors

-pril Lisinopril, Benazepril, Enalapril, Fosinopril, Captopril, Perindopril, Moexipril, Quinapril, Ramipril, Trandolapril

Beta Blockers (BB)

Treatment of arrhythmias and protection from second MI, can be used for HTN but is usually not the first line of treatment. -BB inhibit receptors meant for catecholamines (epinephrine, norepinephrine). This reduces stress response of heart. -Common side effects: bradycardia, fatigue, hypotension. -Nomenclature: ends in -lol, Carvedilol, Metoprolol (tartrate, succinate).

Beta Blockers

-lol Carvedilol, Metoprolol, Acebutolol, Atenolol, Betaxolol, Bisoprolol, Nadolol, Propranolol, Sotalol

Ca Channel Blockers (CCB)

Treatment of HTN -Blocks Ca channels which helps vasodilate, reduce contraction of muscle, and slow heart beat. -Common side effects: dizziness. -Nomenclature: most end in -pine, but not all, Amlodipine, Nifedipine, Diltiazem, Verapamil.

Calcium Channel Blockers

most end in -pine Amlodipine, Nifedipine, Felodipine, Nimodipine, Nisoldipine, Diltiazem, Verapamil

Angiotensin II Receptor Blockers (ARB)

Treatment of HTN & CHF. -Blocks angiotensin II, a key component in RAAS System, leads to vasodilation and reduces vasopressin (reduces fluid in circulatory system). -Common side effects: dizziness, hyperkalemia. -Nomenclature: ends in -sartan, Losartan, Valsartan.

Angiotensin II Receptor Blockers

-sartan Losartan, Valsartan, Candesartan, Eprosartan, Irbesartan, Telmisartan

Angiotensin-Receptor Neprilysin Inhibitor (ARNI)

Sacubitril/Valsartan (Entresto)

SGLT2 Inhibitors

Dapagliflozin (jardiance), Empagliflozin (farxiga)

Statins (HMG-CoA Reductase Inhibitor)

Treatment of HLD, elevated trig/LDL levels -Blocks HMG CoA Reductase which helps reduce LDL levels, also useful in plaque stabilization in patients with CAD. -Common side effects: myalgia, liver dysfunction. -Nomenclature: ends in -statin, atorvastatin, simvastatin, rosuvastatin.

Statins

Atorvastatin, Simvastatin, Rosuvastatin, Lovastatin

Nitrovasodilator (Vasodilators)

Treatment and prevention of angina. -Causes vasodilation, useful for people with stable and acute angina. -Common side effects: headaches, dizziness, flushed. -Nomenclature: nitroglycerin sublingual (NTG SL), isosorbide mononitrate (Imdur), isosorbide dinitrate (Isordil)

Nitrovasodilators (Vasodilators)

Nitroglycerin sublingual (NTG SL), Isosorbide mononitrate (Imdur), Isosorbide dinitrate (Isordil), Nesiritide, Hydralazine, Nitrates, Minoxidil

Oral Anticoagulants (OACs)

Prophylaxis from blood clot related diseases such as cerebrovascular accidents (CVA), deep vein thrombosis (DVT), and pulmonary embolism (PE). -Commonly used in patients who have atrial fibrillation, newly placed PCI and CABG, valve replacements. -Prolongs clotting time, most don't have a reversing antidote. -Warfarin requires regular INR checks to make sure it's working optimally. -Common side effects: chronic bleeding, bruising. -Nomenclature: Warfarin (coumadin), Eliquis (apixaban), Xarelto (rivaroxaban), Pradaxa (dabigatran).

Oral Anticoagulants

Warfarin, Apixaban, Rivaroxaban, Dabigatran

Antiplatelet

Prophylaxis for platelet aggregation and inhibit thrombus formation, commonly used in patients who had PCI placed, PVD/PAD, recent stroke from Afib and cardiac surgery (especially valve replacements). -Dual Anti-platelet Therapy (DAPT) -Common side effects: chronic bleeding, bruising. -Nomenclature: aspirin 81 mg (ASA), clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta), cilostazol (Pletal).

Dual Antiplatelet Therapy (DAPT)

Combination of Aspirin + Clopidogrel/Prasugrel/Ticagrelor (Plavix, Effient, Brilint) to help reduce risk of restenosis of PCI, typically on DAPT for one year.

Antiplatelet Therapy

ASA (Aspirin), Clopidogrel (plavix), Prasugrel (effient), Ticagrelor (brilinta), Cilostazol (pletal), Dipyridamole

Aspirin

Acetylsalicylic acid (ASA)

Antiarrhythmic

Suppresses abnormal heart rhythms such as atrial fibrillation. -There is a wide range of medications classified as ____. This includes Na channel blockers, beta blockers, Ca channel blockers, K channel blockers. -Common side effects: dizziness, fatigue, lethargy, hypotension. -Nomenclature: Amiodarone, Flecainide, Propafenone, digoxin, Sotalol, Mexiletine.

Antiarrhythmics

Amiodarone, Flecainide, Propafenone, Digoxin, Sotalol, Mexiletine

Diuretic

Increase excretion of water from body which helps reduce edema and lower blood pressure, commonly used in HF and kidney dysfunction. -Also has a wide range of classes acting on different pathways. -Common side effects: muscle weakness and cramping, hypo/hyperkalemia. -Nomenclature: Furosemide (Lasix), Torsemide, Bumetanide (Bumex), Metolazone, Hydrochlorothiazide (HCTZ), Spironolactone

Diuretics

Furosemide, Amiloride, Torsemide, Bumetanide, Metolazone, Chlorothiazide, Chlorthalidone, Indapamide, Hydrochlorothiazide, Spironolactone

Labs

CBC, CMP, BMP, Lipid Panel, Thyroid Panel (TSH, T3, T4), Pro BNP (Brain Natriuretic Peptide), PT/INR (Prothrombin Time/International Normalized Ratio), ESR.

Pro BNP

more specific to left ventricular dysfunction; Ventricular natriuretic peptide or brain natriuretic peptide, also known as B-type natriuretic peptide, is a hormone secreted by cardiomyocytes in the heart ventricles in response to stretching caused by increased ventricular blood volume. Helps diagnose and monitor heart failure.

PT/INR

prothrombin time/international normalized ratio

Hypertension (HTN)

High blood pressure, has many causes; BP > 130/80. -Most common, caused by lifestyle or genetic factors. -Preventative measures: exercise, low sodium diet, abstain from smoking and EtOH, reducing obesity. -Secondary: high blood pressure caused by another source, renal or endocrine dysfunction, illicit drug use, sleep apnea, etc. -Malignant: rapid development of HTN, causing organ damage. -Primary Pulmonary: increased BP in pulmonary artery. -Measure with blood pressure cuff, typically asymptomatic. -Can cause many structural deformation because heart and vessels are overworked. This includes LV hypertrophy, valve regurgitation, aortic aneurysms, atherosclerosis. -Medications: ACE inhibitors, ARB, Ca Channel Blockers, Diuretics

1. Essential

2. Secondary

3. Renovascular

4. Primary Pulmonary

Dyslipidemia

Abnormal amounts of lipids in the blood, most common is HLD, elevated lipids. -Evaluated with lipid profile, shows increased LDL, and decreased HDL. -Can cause coronary artery disease, peripheral artery disease, myocardial infarction, atherosclerosis. -Medications: statins, Praluent and Repatha

Pulmonary HTN

when the pressure in the blood vessels leading from the heart to the lungs is too high, and blood vessels to the lungs develop an increased amount of muscle in the wall of the blood vessels

Aortic Valve Regurgitation

Blood flow in the opposite direction, most common in mitral and aortic valves. -Prevention: control BP. -Monitor with echo with Doppler or cardiac MRI

Aortic Valve Stenosis

Valve narrowing/stiffness making blood flow difficult. -Caused by congenital bicuspid valves, calcified valves. -Also monitored with echo and cardiac MRI

Aortic Regurgitation & Stenosis

Common symptoms: SOB Intervention: procedures and surgeries can be performed to reduce symptoms. -Mitral clip -Transcatheter aortic valve replacement (TAVR) -Open heart surgery valve replacement.

Mitral clip

Mitral valves are clipped together to reduce regurgitation

Transcatheter aortic valve replacement (TAVR)

Uses catheters to place a new valve over the old aortic valve, must meet certain criteria to have this performed.

Patent Forman Ovalis (PFO)

Flap between left and right atrium, present as a fetus (Forman Ovale), and closes once the baby is born. -Common symptoms: SOB -Evaluated with TEE because you can get a better view of PFO from posterior side. -Large PFO's can lead to stroke due to mixing of oxygenated with deoxygenated blood.

Atrial Septal Defect (ASD)

Hole between RA and LA. -Less serious than PFO. -Can be plugged with use of a catheter.

Coronary Artery Disease (CAD)

Typically occurs due to plaque formation in coronary arteries, limiting blood flow and increasing risk of rupture. This can lead to acute myocardial infarction. -Evaluated with coronary angiograms. -Risk factors: smoking, obesity, diet, sedentary lifestyle, uncontrolled DM. -MI causes cell death and reduces heart function. When this is an emergency, the cardiologist will do an angiogram and perform a percutaneous coronary intervention (PCI) and place a stent in the affected artery. -If occlusion is severe and in multiple locations, cardiothoracic surgery will get involved for a CABG. -Medical Therapy: DAPT, beta blockers, Ca Channel blockers, statins, nitrovasodilators. -Prevention: exercise, low fat diet, low sugar diet, quit smoking, control diabetes.

Chronic venous insufficiency/Hypertension (HTN)

Valve dysfunction in legs causing the vessel to swell and blood and fluid to pool. -Evaluated by ultrasound (US) of the veins and physical exam (LE edema, varicose veins) to r/o venous insufficiency -Common symptoms: leg pain, burning sensation, edema, restless leg, tingling. -Conservative therapy: leg elevation, compression stocking, regular walking. -Procedures: radio-frequency ablation (RFA)

Peripheral Artery Disease

Plaque formation in peripheral arteries. -Evaluated by US of arteries and ankle-brachial index (ABI). -Common symptoms: claudication (cramping/pain when walking), decreased pulses in foot. -Similar medical therapy and intervention as CAD. -Medical therapy: Cilostazol (Pletal)

Premature Atrial/Ventricular Contractions (PAC, PVC)

Common and typically benign, if severe, may require beta blocker and RFA

RFA

radio-frequency ablation

Supraventricular Tachycardia (SVT)

An umbrella term for Paroxysmal ___, atrial fibrillation/flutter (Afib/Aflut), and Wolff-Parkinson-White (WPW) syndrome. -Dysfunction in atria and AV node from re-entry or automaticity.

Reentry

Electrical conduction reenters the nodes

Automaticity

Random electrical impulses. -On EKG, the QRS wave is narrow

Atrial Fibrillation

Quivering atrium from automaticity causing irregularities in atrial and ventricular rhythm and rate. -Detected through ECG, monitors, and devices. -Physical Exam: irregularly irregular. -Symptoms: fatigue, palpitations, SOB. -Atrial Flutter: reentrant conduction, irregular contractions of atrium and ventricles. -Physical exam: regular rate, irregular rhythm. -Complications: can cause blood to pool in atrium, typically in the left atrial appendage which can lead to stroke. -Medical therapy: anticoagulation, beta blockers, antiarrhythmics. -Procedures: RFA or cryoablation, cardioversion

Ventricular Ectopic Beats

-Typically not seen in clinic setting. -Ventricular tachycardia and ventricular fibrillation are life threatening heart rhythms that require immediate medical attention. -Having an ICD will shock patient and bring them back to normal rhythm.

Bundle Branch Block (BBB)

Elongated QRS > 120 ms -Right BBB -Left BBB: typically may cause dyssynchrony of ventricle; requires pacemaker to resynchronize heart beat. -Heart block: faulty SA node, varying degrees; causes palpitations, lightheadedness, and syncope

Sick Sinus Syndrome (SSS)

Sinoatrial node dysfunction. -Caused by many different causes including amyloidosis & cardiomyopathy. -Requires pacemaker to beat heart for the patient.

Pacemaker

Utilized in patient with bradycardia, SSS, heart block and dyssynchrony.

Internal Cardiac Defibrillator (ICD)

Utilized in patients at risk for sudden cardiac death (SCD), indicated with echocardiogram with EF <35%

Device interrogation

To check the function of pacemakers or other devices; required by PM and ICD devices