Dd [Music] so we're gonna start cardiovascular disease so people who have stable angina which means that they

have substernal
chest pain that occurs with exercise or exertion and is alleviated by rest then this is a sign of stable angina because it improves with
rest people with this you the next thing you want to do is a stress test right and there's three types of stress tests and EKG an echo or
a nuclear perfusion study so you would do an echo if that or a nuclear perfusion study if that person is uh has any abnormalities on
EKG so the actual so a positive stress test would be anything that shows ST depression or hypotension or pain and then you know
the echo you might see abnormal wall motion that would be a positive stress test or and then nuclear perfusion studies would show
decreased uptake of nuclear isotope and that'd be a positive stress test as well so and then remember if they are unable to exercise
then that's when you do a pharmacologic stress test so there's two ways to induce stress on the heart either exercise or using drugs
such as adenosine or die period them all so most of the time the correct answer will be as exercise stress test using EKG if they have
an abnormal EKG which will mask the results of that stress EKG then you either do an echo or nuclear perfusion studies if they can
exercise then they will exercise on the treadmill if they can't exercise as an they are wheelchair-bound or have osteoporosis or some
other thing that is a contraindication to exercise then that's when you do a pharmacologic test test and with the pharmacologic test it
can be observed either on EKG echo or nuclear perfusion study as well so and then remember that the definitive way to actually
diagnose coronary artery disease is through angiography so the reason why you do these stress tests first is because angiography is
very invasive so that's why you do the others first so um the first thing you want to do first test you want to do with chest pain as
EKG the first-line treatment for stable angina is nitrates aspirin and beta blockers first-line treatment for unstable angina is lemonis
II - mnemonic which is morphine oxygen nitrates aspirin clopidogrel beta blockers ACE inhibitors statin and heparin and remember
that the first thing you want to give is aspirin and remember if the person has unstable angina which means if definition of unstable
angina means that their angina is worsening or evolving or occurs at rest now which is different than stable angina but unstable
angina also has no troponin elevations if you have unstable angina with troponin elevations and so basically unstable angina
becomes NSTEMI as soon as there are any troponin if there are opponents with st elevations then this is what we call a STEMI what
alright so when someone comes in with chest pain the first thing you want to do is rule out acute coronary syndrome acute coronary
syndrome is unstable angina and STEMI or STEMI so those are the three types of acute coronary syndrome so when someone
comes in with chest pain you want to roll that out so we first you do an EKG and cardiac enzymes but the thing is cardiac enzymes
can take a while to come so first thing you want to do is what the EKG is luck to see if this is STEMI or not so it fits dami if it's
STEMI then to diagnose Tammy you don't even need cardiac enzymes all you need is one millimeter st elevations and two
continuous leads or a new left bundle branch block with chest pain and that's considered STEMI you don't even need the enzymes if
you see those they go straight to cath lab and then see you do the EKG but there are no st elevations but they do have the
characteristic chest pain that they were describing then you want to do serial troponin and serial EKGs to see if this is evolving or
changing so then it's either going to be unstable angina or n STEMI if the troponin is come back updated with elevated troponin then
that's now called an N STEMI as a non ST elevation mi if there are no troponin yet and after serial troponin measurements and it
stays low then this is called unstable angina and remember it the conditions also have to be satisfied where the chest pain has been
evolving recently and been getting worse and this person has been having chest pain at rest this is called unstable angina if they have
unstable angina or and STEMI then you want to apply the Tammy's core if it's 0 to 2 this person will get a stress test if it's 3 or more
than this person will go to cath lab anyone who has chest pain who has has unstable vitals as well that you suspect my they also go
straight to cath lab so those are some exceptions main indications for a cabbage are three vessel disease or proximal left anterior
descending disease with 70% plus stenosis next is prinzmetal angina which is basically coronary vasospasm so the angiography will
show this so spasm when given organ a vine or Sedo : and you'll also see st-elevation on EKG during these painful episodes and
you want to treat this with calcium channel blockers or nitrates you only do TPA and MMI if there's no access to PCI Center inferior
mi when you have an ro cardial infarction of the inferior wall which is 2/3 and a VF and this is the only mi that has an exception
where you don't want to give nitrates because because they have a right ventricular mi it's already the heart is already having
problems pumping blood to the left side of the heart so if you give nitrates this will exacerbate the hypotension so actually in an
inferior wall mi you actually want to give fluids sometimes an inferior wall mi can because because the right coronary artery
supplies blood to the SA node this can cause and then that sinus bradycardia can cause cardiogenic shock and usually first when for
cardiogenic shock is dobutamine which is the beta 1 agonist but in the case of inferior wall mi that has bradycardia and cardiogenic
shock this is due to injury of the SA node so in this special case you want to give atropine remember that there's only three drugs
shown to decrease mortality in MI and this is very high yield is aspirin beta blockers and ACE inhibitors and nitrates work in two
ways but the predominant way it works by for my eyes is that it decreases preload it's a V no die later and that decreases stress on
the myocardium due to excess blood so when you minimize the preload there's less stress on the heart muscle and also it's secondary
effect as it dilates the coronary arteries so treatment of first-degree and second-degree heart block mobitz one is no treatment but mo
it's two and the complete heart block you want to treat with pacemaker Dressler syndrome is an autoimmune pericarditis that
happens two weeks later after an mi host MI two weeks with fever and symptoms of pericarditis with leukocytosis you want to treat
with aspirin this is contrasted with other causes of pericarditis such as viral pericarditis those will be treated with NSAIDs this
Dressler syndrome is specifically treated with aspirin and then you have restrictive cardiomyopathy I just remember the o C's so
hemochromatosis amyloidosis sarcoidosis this creates a diastolic heart failure with reduced ejection fraction this is due to deposits
in the myocardium so like amyloid deposits or granulomas or iron deposits in the myocardium what I'm trying to say is remember
that humor chrome mitosis amyloidosis and sarcoidosis or if associated with restrictive cardiomyopathy and then remember
hemochromatosis is bronze diabetes and iron overload so they'll have diabetes bronze gaming don't have elevated liver enzymes
amyloidosis is think of like protein deposits you're gonna have deposits in the heart and the kidney and in the joints and in the
kidney you'll see proteinuria versus sarcoidosis is where you'll see heart and lung stuff so bilateral hilar adenopathy a dry cough
uveitis erythema nodosum and also restrictive cardiomyopathy there are three CHF drugs shown to decrease mortality and that's ace
inhibitors beta blockers and spironolactone which is a potassium sparing their diuretic which should be contrasted with the three
drugs that decrease mortality and mi which is ace inhibitors as well and beta blockers as well but the third is aspirin remember met
four which is first-line treatment for type 2 diabetes remember its contraindications which is it's contraindicated in renal disease and
CHF because it can cause metabolic acidosis remember for CHF acute decompensation of CHF which means the heart failure is
getting worse then you want to treat it with them mnemonic no lit nitrates oxygen loop diuretics inotropes and positioning such as
elevating the head of the bed but the first thing you want to treat what is a loop diuretics such as furiosa might you need to know
supraventricular tachycardia versus ventricular tachycardia so a supraventricular tachycardia will have narrow QRS s you know it'll
look like QRS TQ r st qrst and if they're stable you treat with adenosine and if they're unstable then you want to treat with
cardioversion and then ventricular tachycardia which has wide bizarre qrs complexes after one after another then you want to treat
with amiodarone and if they're unstable then you want to treat with cardioversion versus v-fib and pulseless v-tach first-line
treatment for that is different relation verses asystole and pulseless electrical activity pulseless electrical activity means that the EKG
shows any rhythm but when you feel for the pulse there's no pulse that means P e a and then to treat with that is CPR and by the way
remember that the first-line treatment for a super ventricular tachycardia before you progress with an adenosine is vagal maneuvers
such as carotid massage so torsades de pointes can lead to v-fib and this is treated with IV magnesium which stabilizes the cardiac
membranes X is constrictive pericarditis which is idiopathic fibrous scarring replacing the entire pericardial space the key here I
want you to look for is when they do imaging like a chest x-ray of the heart you'll see calcifications calcifications is key and it's
usually caused by TB or lupus and it can present similarly to restrictive cardiomyopathy it can have equal diastolic pressures and all
chambers and it can also have by atrial enlargement and treatment is peri cardiac t'me acute pericarditis causes the main causes
coxsackievirus and you treat it with the NSAID versus Jess lair which is treated with aspirin aspirin is a type of NSAID but
remember Dressler's aspirin and on EKG you'll see diffuse St elevations and it's improved with leaning forward so cardiac
tamponade is just remember Beck's triad which is hypotension jvd and muffled heart sounds it's also associated with pulsus
paradoxus which means when you inspire this increases filling to the right ventricle which causes the interventricular septum to bow
over to the left side which decreases the left ventricular preload and because of this the stroke volume is decreased and because of
this the systolic pressure will drop by greater than 10 and that's called pulsus paradoxus which means a systolic pressure dropping by
greater than 10 upon inspiration you will see that in cardiac tamponade it's also associated with electric alternates which means the
QRS voltages kind of the amplitude kind of becomes alternating between big and small big and small big and small and that's
because the heart is literally swinging within the pericardial fluid which distorts the qrs measurements and then you'll also see low-
voltage QRS and a KU small sign coos sign which means when you inhale that the jugular venous distention increases because with
cardiac tamponade shelling of the right side of the heart is more difficult because it's not as compliant so then the venous blood tends
to overflow faster remember mitral stenosis the majority of the causes of mitral stenosis our previous episode of acute rheumatic
fever or rheumatic heart disease hypertension or aortic stenosis can over time lead to left ventricular hypertrophy and if this is
prolonged this can become dilated cardiomyopathy and people with hypertension or aortic stenosis tend to get angina because of
decreased perfusion to the coronary arteries another complication as syncope due to decreased perfusion of the brain another
complication is left ventricular hypertrophy because of increased afterload another complication is dilated cardiomyopathy from
chronicity and then you'll hear a soft s2 because the valve doesn't move well and then definitive diagnosis for aortic stenosis is
cardiac catheter to measure the valve area what an echocardiogram can also measure the valve diameter if it's less than one square
centimeter or if they have any symptoms at all such as an angina syncope or CHF then you want to treat with valve replacement the
tricuspid valve remember that it's associated with IV drug use and carcinoid syndrome carcinoid syndrome is a tumor that produces
too much serotonin and that creates bronchospasm flushing diarrhea and right-sided heart murmurs three causes of holosystolic
murmur or mitral regurg tricuspid regurge and VSD so if someone has infective endocarditis the easiest way to diagnose this is one
who has a fever with leukocytosis and new onset of murmur and you don't know the bugs it before you find out from your blood
culture which is the first thing you want to do you treat it empirically with vancomycin and an aminoglycoside hypertensive
emergency is defined as 180 over 120 and the first-line treatments for hypertensive emergency is IV hydralazine nitroprusside or
labetalol and remember that for it to be considered an emergency there has to be evidence of end organ damage so encephalopathy
or acute kidney injury or liver injury where versus hypertensive urgency is high blood pressure over 180 over 120 but no end organ
damage so the difference is if it's an emergency you treat IV but if it's urgency you treat with oral medications subarachnoid
hemorrhage the Thunder Clap headache worst headache of your life first thing you want to do is a CT head without contrast and if
that's negative and you still suspect oh so brackenreid hemorrhage the next step is lumbar puncture and you're gonna look for
positive xantho chromia which is the presence of bilirubin in the CSF a or DIC dissection is substernal chest pain that is described as
tearing and radiates to the back and you have two types type A and type B type B is anything just fill to the left subclavian and type
a is anything proximal to that and you treat them differently a goes to surgery right away and B you give beta blockers to treat it and
you diagnose an aortic dissection with a CT angio or a transesophageal echo and remember any type of CT imaging make sure to
always check the patient's kidneys because anyone with kidney disease it's contraindicated to you see see with contrast which is the
majority of CT imaging next is peripheral vascular disease or peripheral artery disease and so the number one risk factor is smoking
and to diagnose it you want to do something called the ankle brachial index which is measuring the differences in blood pressures
from the ankle and the arm and if the ratio in the ankle to arm is less than 0.9 then that's disease and if it's less than 0.4 then this is
severe disease which will most likely have pain at rest as well and people with peripheral artery disease will describe themselves as
having claudication and their legs while walking so they'll walk a certain distance and then feel pain in their legs and then it
improves with rest it's sort of like stable angina of the legs due to stenosis of the ephemeral or popliteal arteries the ones that are
current rest would be synonymous to like unstable angina and then sometimes they can make clots which is called acute limb
ischaemia which would be synonymous to like an MI so if someone has a ratio between 0.4 to 0.9 which would be like stable angina
this is the initial stages of peripheral vascular disease the first-line treatment is an exercise program if it starts if they start to have
problems at rest and their ratio is below point 4 now you have to do an intervention such as a stand or a bypass if if they have acute
limb ischemia which is due to some sort of thrombosis that cuts off the circulation in the legs where everything just still did that
starts getting cold and pulseless and in a lot of pain then you want to treat that with heparin or an embolectomy sometimes there's a
variation of peripheral vascular disease known as LaRouche syndrome which is caused by atherosclerosis proximal to the aortic
bifurcation if or they become the iliac arteries and this person will complain a bilateral leg pain as well as the key here is impotence
and buttock pain and this is us like a sub-type a variation of the same thing remember that IVC filters are placed if contraindicated
to heparin or warfarin or if they've failed previous therapy with heparin or warfarin if you suspect a PE in a patient which is
basically acute sudden onset of tachypnea tachycardia and hypoxemia the first thing you want to do is give heparin before you even
do the CT angio so heparin and then CT angio if you had to pick what is the best next step and they both of those are the options
pick heparin first and then low molecular weight heparins remember they're contraindicated and renal disease someone who has
venous insufficiency looked for the medial malleolus ulster which is a sign of venous insufficiency which can be contrasted to other
similar presentations such as CHF cardiogenic shock first-line treatment is the ina trope such as dobutamine septic shock first-line
treatment is IV antibiotics plus IV fluids and potentially vasopressors neurogenic shock remember everything is down cardiac
output is down heart rate is down total peripheral resistance is down wedge pressure is down and the jvd is down and you treat this
with IV fluids