02/28/11 y Diagnosis can be made based on: o Anatomical (ie heart) o Pathophysiological (ie heart failure) o Etiological (ie

hypertension) Digoxin o If patient does not have kidney failure: give 0.5 LD and 0.25 MD o If pt has kidney failure: give only 0.125 every other day CHF vs Heart failure o CHF will have systemic congestion, ie lungs, legs, dependent edema (breast, scrotum etc.) o Cardiomegaly, abnormal apical impulse, decreased ejection fraction, S3 gallop Treat CHF with lasix and digoxin All patients >60 yo look for abdominal aortic pulsitations Pacemakers create false BBB in EKG s Patient comes with history of DVT and has SOB now do VQ scan to rule out PE

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03/01/11 y Different factors making a heart sound o S1 has aortic and pulmonic o S2 has mitral and tricuspid Mechanism of heart sound o Muscular energy in the fibers o Valvular distance the valve travels from open to close o Hemodynamic blood flows acress pulmonary artery and aorta, and blood coming in from vena cava and pulmonary veins Components of the Cardiac Cycle: o Isovolumetric contraction ventricular muscle tightening o Contraction o Ejection phase (early, maximum, late) o Relaxation (early, late) S3 and S4 can be normal in certain circumstances S3 o Generated from ventricles (R or L) o Normally present <25 yo. Physiological in pregnancy o During early passive flow of blood from atrium ventricle o Abnormal in large heart o Indicative of pending LVF S4 o From both atrium, normally not audible, but always present

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2 components: right and left Audible in everyone >34 bc muscle gets thickened, therefore no significance if pt is >34yo  Thickened ventricle makes atrium work harder, therefore atrium makes the S4 sound (thickened atrium, slow relaxation of muscle..?) o Lub (S4) .... Da (S1).... Dub (S2) o S4 LV gallop best heard on full expiration o S4 RV gallop best heard on full inspiration (bc incr volume intensifies sounds) S7 = summation gallop (S3 + S4) 30 mL is normal residual heart volume Diastolic filling: 65% passive, 35% active Ventricular premature beat decreases 19% of CO Atrial fibrillation decreases 35% of CO Increased EDPressure in aortic stenosis and IHSS o IHSS is accentuated with valsalva maneuver (know 4 stages of valsalva maneuver) EDV is decreased with mitral stenosis Reasons for poor progression of R-waves: o Obesity o Emphysema  Will have dull Baer area (triangle marked by 4th rib closer to sternum, apex of heart and 7th costovetebral junction) o Severe LVH o Bad lead placement by tech o Old MI When loose muscle mass can normalize htn o Can also normalize htn with meds and decapitated BP BP is the lateral pressure exerted by blood on walls of vessles. It is controlled by CO and TPR o CO is controlled by SV and HR  HR is controlled by muscular contraction Defibrillator is put in excessively in USA. They say if EF<45 to put one it. Indications for a Thalium Scan: o Extensive coronary artery blk o Prog of pt had MI (?) o Effect of tx to increase perfusion o To diagnosi causes of chest pain o o

03/02/11 y y y Read up on Echo s (anatomy, wall motion, abnormal echo in terms of function and anatomy) If CXR shows a pencil-like boarder of heart = pericardial effusion Obstructive nephropathy could be due to prostate antigens

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If creatinine is <1.2, you cannot give metformin. Use liposide instead, and be sure to get an acucheck every 4 hours due to possible kidney failure If pt has low ejection fraction: o Give metoprolol if also have hypertension (B2 blker) o Give corvedilol if there is no htn.  Corvedilol has alpha 1 and non-selective B blocker properties, therefore good with prostate problems. It is also an antioxidant, increases insulin sensitivity, and decreases ventricular hypertrophy. If patient has ulcers, their K and CPK levels may be increased. BUN = CREAT x 10 Correct elevated CPK with fluids and bicarb to avoid severe renal failure. EKG gets increased T waves usually at level of K>6.5/mL. (but there are exceptions) Triple vessel disease (all 3 coronary vessles occluded) Nuclear Imaging Studies/Stress Echo: o If pt cannot use treadmill, use dobutamine to exercise the heart o Use thalium, and inject it in the resting state to take pictures. It will show colour coded perfusion of the myocardium.  If perfusion defect is present in resting state could be old MI  If perfusion defect in stressed state could be an acute ischemic episode. o c/i for treadmill test:  weight >250 lbs  if EKG shows changes highly suggestive of acute arrhythmia  pts has palpitations, syncope... o indications for the testing is divided into Symptomatic and EKG indications  Symptomatic indications: chest pain, sweating, decreased BP  EKG indications: y Major= ST depressions (downslopping, J-type, horizontal) y Minor = sudden increase in amplitude of R waves, inversion of U waves, deeply inverted T waves.