Cardiovascular System

Heart Murmurs

• Result from turbulent blood flow through major vessels or heart valves.
• Classified by timing (systolic vs. diastolic) and location (aortic vs. mitral).

Systolic Murmurs – “MR Peyton Manning AS MVP”

1. Mitral Regurgitation – Holosystolic (pan-systolic) murmur.
   • Location: Best heard at the apex of the heart.
   • Radiation: Extends to the axilla.
   • Sound: High-pitched, blowing murmur.
   • Best Heard With: Diaphragm of stethoscope.
2. Physiologic Murmur – Occurs due to temporary conditions like severe anemia or dehydration.
   • Louder when lying down.
3. Aortic Stenosis – Harsh, noisy murmur.
   • Location: 2nd intercostal space (ICS), right of sternum.
   • Radiation: Extends to the neck.
   • Considerations:
     • Increased risk of sudden cardiac death—avoid strenuous activity.
     • Monitored via echocardiogram; may require valve replacement.
     • Common causes: Congenital defect (in children), previous rheumatic fever.
     • Symptoms: Chest pain (angina), fainting (syncope), heart failure.
4. Mitral Valve Prolapse (MVP) – Mid-to-late systolic murmur with a mid-systolic click.

Diastolic Murmurs – “ARMS”

1. Aortic Regurgitation – High-pitched blowing murmur.
   • Location: 2nd ICS, right of sternum.
   • Best Heard With: Diaphragm.
2. Mitral Stenosis – Low-pitched murmur.
   • Location: Apex (apical area).
   • Also Called: “Opening snap,” “crescendo murmur”.
   • Best Heard With: Bell of the stethoscope.

Key Point: All diastolic murmurs are abnormal.

Valve Locations (APETM)

• Aortic Valve – 2nd ICS, right upper sternal border.
• Pulmonic Valve – 2nd ICS, left upper sternal border.
• Erb’s Point – 3rd ICS, left of sternum (often used for S2 sounds).
• Tricuspid Valve – 4th ICS, left lower sternal border.
• Mitral Valve – 5th ICS, left midclavicular line (PMI or apical area).

Murmur Radiation

• Axilla: Likely a mitral valve issue.
• Neck: Likely an aortic valve issue.

Valve Dysfunction

• Stenotic valves fail to open properly.
• Incompetent (regurgitant) valves fail to close properly.

Murmur Grading Scale

1. Grade I/VI – Very faint, barely audible.
2. Grade II/VI – Clearly audible but soft.
3. Grade III/VI – Moderate volume, as loud as S1.
4. Grade IV/VI – Loud, often accompanied by a palpable thrill.
5. Grade V/VI – Very loud, heard with the stethoscope partially lifted off the chest.
6. Grade VI/VI – Loudest, can be heard even without a stethoscope.

Using a Stethoscope

• Bell – Best for low-pitched sounds (S3, S4, mitral stenosis).
• Diaphragm – Best for mid-to-high pitch sounds (lung sounds, mitral regurgitation, aortic stenosis).

Heart Sounds

Mnemonic: “Motivated Apples”

• S1 (“lub”) – Occurs during systole (AV valve closure).
  • M – Mitral valve.
  • T – Tricuspid valve.
  • AV – Atrioventricular valves.
• S2 (“dub”) – Occurs during diastole (semilunar valve closure).
  • A – Aortic valve.
  • P – Pulmonic valve.
  • S – Semilunar valves.

Additional Heart Sounds

• S3 (“ventricular gallop”) – Suggests congestive heart failure (CHF) in patients >35 years old.
  • Can be normal in adolescents, pregnancy, and thyrotoxicosis.
  • Sounds like “Kentucky”; best heard at pulmonic area.
• S4 (“atrial gallop”) – Indicates left ventricular hypertrophy (LVH), uncontrolled hypertension, or unstable angina.
  • Common in elderly patients.
  • Sounds like “Tennessee”; best heard at apex with the bell.
• Split S2 – Heard best at the pulmonic area, normal in young athletes.

Fibrinolysis Contraindications

Absolute Contraindications (High Risk – Avoid Use)

• History of intracranial hemorrhage (previous brain bleed).
• Cerebral vascular abnormalities (aneurysms, arteriovenous malformations).
• Brain tumors (primary or metastatic).
• Ischemic stroke within the past 3 months.
• Suspected aortic dissection.
• Active internal bleeding (excluding menses).
• Recent intracranial or intraspinal surgery (within 2 months).
• Severe, uncontrolled hypertension (posing a risk of hemorrhage).

Relative Contraindications (Consider Risks vs. Benefits)

• Chronic uncontrolled hypertension or marked hypertension upon presentation.
• Recent ischemic stroke (< 3 months ago).
• Prolonged or traumatic CPR.
• Major surgery within the past 3 weeks.
• Recent internal bleeding (within 2-4 weeks).
• Non-compressible vascular punctures (e.g., subclavian or jugular vein access).
• Pregnancy.
• Active peptic ulcer disease.
• Current use of oral anticoagulants (warfarin, DOACs).

Key Cardiovascular Concepts

• Blood Pressure Formula:
  BP = HR x SV x PVR
  • HR – Heart Rate
  • SV – Stroke Volume
  • PVR – Peripheral Vascular Resistance
• Left vs. Right Heart Pressures:
  • Left side of the heart operates at higher pressures (arterial system).
  • Right side of the heart functions at lower pressures (venous system).
  • Most abnormalities originate from left-sided heart disease.
• Blood Flow Through the Heart:
  Deoxygenated Blood Pathway:
  Superior vena cava → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary arteries → Lungs
  (RBCs exchange CO2 for O2 in alveoli)Oxygenated Blood Pathway:
  Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Systemic circulation

Hypertrophy & Cardiac Changes

• Left Ventricle: Most likely chamber to hypertrophy.
  • Common in hypertension (HTN) target organ damage (TOD).
  • PMI shifts downward & laterally in left ventricular hypertrophy (LVH).
  • Normal PMI location: 5th ICS, midclavicular line (MCL).
• Left Atrium: Second most common chamber to hypertrophy.
• Aortic Stenosis:
  • Most common pathological murmur associated with aging.
• Mitral Regurgitation (MR):
  • Most common regurgitant murmur (caused by mitral valve failing to close properly).
  • Leads to reduced cardiac output.

Signs of Low Cardiac Output

• Dyspnea on exertion (shortness of breath with activity).
• Chest pain.
• Orthopnea (shortness of breath when lying flat; often indicates heart failure rather than lung disease).
• Syncope or near-syncope (often due to aortic stenosis or hypertrophic obstructive cardiomyopathy).

Hypertrophic Obstructive Cardiomyopathy (HOCM)

• Genetic condition (autosomal dominant inheritance).
• Also known as idiopathic hypertrophic subaortic stenosis.

Mitral Regurgitation (MR) – Clinical Exam Findings

• Murmur Characteristics:
  • Holosystolic murmur (persists throughout systole with consistent intensity).
  • Blowing quality (soft or whooshing sound).
  • Grade II-III/IV murmur.
  • Radiates to the axilla.

Assessing Unexpected Cardiac Findings

• If a sudden, unexpected murmur or symptom is discovered, ask:
  • Onset – When did it begin?
  • Location & Radiation – Where is it heard, and does it spread elsewhere?
  • Duration – How long has it been present?
  • Character – What does it sound like?
  • Aggravating Factors – What makes it worse?
  • Relieving Factors – What improves it?
  • Timing – When does it occur (rest vs. exertion)?
  • Severity – How intense is it?

Target Organ Damage in Hypertension

• Eyes: Hypertensive retinopathy, increasing the risk of blindness.
  • Findings: Silver or copper wiring of arterioles, AV nicking, flame-shaped hemorrhages (appearing as black spots in vision), and papilledema.
• Kidneys: Signs of renal damage include:
  • Microalbuminuria & proteinuria
  • Elevated creatinine & decreased GFR
  • Edema due to fluid retention
• Cardiovascular System:
  • S3 heart sound (congestive heart failure)
  • S4 heart sound (left ventricular hypertrophy)
  • Carotid bruits (suggesting atherosclerosis)
  • Conditions: CAD, MI, LVH, PAD/PVD
• Brain: Increased risk of TIA (transient ischemic attack) & stroke (CVA).

Lifestyle Modifications for Hypertension & Dyslipidemia

• Quit smoking & reduce stress levels.
• Weight loss (if overweight/obese):
  • 5–20 mmHg reduction per 10 kg lost.
• DASH diet:
  • Increase fruits, vegetables, potassium, and calcium.
  • Reduce sodium intake.
  • Consume fatty cold-water fish at least 3 times per week.
• Sodium intake: Limit to <2.4 g/day.
• Exercise:
  • Aerobic activity (40 minutes, 3-4 days per week).
• Alcohol moderation:
  • Men: <2 drinks/day
  • Women: <1 drink/day

Aldosterone Antagonist Diuretics

Mechanism of Action:
Blocks the effects of aldosterone, promoting sodium and water excretion while conserving potassium. Also exhibits anti-androgenic effects.

Indications:

• Hypertension (HTN)
• Congestive Heart Failure (CHF)
• Hirsutism and precocious puberty (off-label use due to anti-androgenic activity)

Common Side Effects:

• Gynecomastia (more common with spironolactone)
• Hyperkalemia

Contraindications:
Avoid use in combination with:

• Other potassium-sparing diuretics
• ACE inhibitors (ACEIs) or potassium supplements
• Renal insufficiency
• Diabetes with microalbuminuria (increased risk of hyperkalemia)

Examples:

• Spironolactone (Aldactone)
• Eplerenone (Inspra)

JNC-8 Hypertension Guidelines

While JNC 8 previously recommended a target of <150/90 mmHg for adults ≥60, more recent guidelines from the ACC/AHA 2017 now define:

Blood Pressure Categories:

• Normal: <120/80 mmHg
• Elevated: 120–129/<80 mmHg
• Stage 1 Hypertension: 130–139/80–89 mmHg
• Stage 2 Hypertension: ≥140/90 mmHg

Treatment Goals:

• Most adults, including healthy older adults: Target <130/80 mmHg
• Consider individualized targets in frail or high-risk elderly patients

First-Line Antihypertensive Medications:

• Non-Black adults: Thiazide diuretics, ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or calcium channel blockers (CCBs) — used alone or in combination
• Black adults: Thiazide diuretics or CCBs — alone or in combination
• Chronic Kidney Disease (CKD): ACEI or ARB preferred, alone or with other agents

Treatment Strategy:

• Begin with lifestyle modifications for all patients
• Initiate medication based on BP level and cardiovascular risk
• Maximize first drug dose or add a second agent from a different class if needed
• Consider combination therapy upfront for Stage 2 HTN or significantly elevated BP

Note: While JNC 8 can be referenced historically, the <130/80 mmHg goal is now the standard target for most patients according to ACC/AHA guidelines.

Thiazide Diuretics

• MOA: Reduces blood volume, venous pressure, and preload.
• Most effective in Black patients.
• May cause erectile dysfunction (ED).
• Beneficial in osteoporosis:
  • Calcium-sparing effect lowers fracture risk.
• High doses (>25 mg/day) increase risks:
  • Hyperglycemia, hyperlipidemia, hyperuricemia (gout)
• Monitor: Sodium (Na+), potassium (K+), and magnesium (Mg++) levels.
• Example: Hydrochlorothiazide (HCTZ) – contraindicated in sulfa allergy.

Calcium Channel Blockers (CCBs) – “-ipine” Drugs

• MOA: Causes systemic vasodilation and slows heart rate.
• Most potent BP-lowering medication.
• Types:
  • Dihydropyridines (DHPs) → Lower BP without affecting HR
    • Example: Amlodipine
  • Non-Dihydropyridines (Non-DHPs) → Lower BP & HR slightly
    • Examples: Diltiazem, Verapamil
• First-line treatment for Black patients with HTN.
• Side Effects: Headache, ankle edema, bradycardia, reflex tachycardia.
• Contraindications:
  • Heart block, bradycardia, CHF.
• Avoid: Grapefruit, macrolide antibiotics.
• More effective when taken at night.

Digoxin

• ECG in therapeutic range: Prolonged PR interval, depressed/cupped ST segment.
• ECG in toxicity: AV heart block.
• Signs of toxicity: Anorexia.
• Drug interactions: Amiodarone, diltiazem, macrolides, antifungals, cyclosporine, verapamil.

Loop Diuretics

• Examples:
  • Furosemide (Lasix)
  • Bumetanide (Bumex)
• MOA: Inhibits the sodium-potassium-chloride pump in the kidneys, increasing urine output.
• Side Effects:
  • Electrolyte imbalances: Hypokalemia, hyponatremia, hypomagnesemia.

Alpha-1 Blockers (“-ozin” Drugs)

• Indications: Benign prostatic hyperplasia (BPH) & hypertension.
• Side Effects: Orthostatic hypotension, dizziness, postural hypotension (especially with the first dose).
• Dosing Strategy: Start low, titrate up, and give at bedtime.
• Examples:
  • Terazosin (Hytrin)
  • Tamsulosin (Flomax)
• Carvedilol: Acts as both an alpha- and beta-adrenergic antagonist.

Beta-Blockers (“-olol” Drugs)

• MOA: Blocks beta-1 receptors in the heart, reducing heart rate and stroke volume.
• Indications:
  • Post-MI, migraines, glaucoma, resting tachycardia, angina, hyperthyroidism.
• Caution:
  • May worsen asthma, COPD.
  • Contraindicated in heart block, bradycardia.
• Efficacy:
  • More effective in White patients for BP control (4th-line antihypertensive).
  • Primarily used for heart failure rather than BP control.
• Reduces effects of circulating catecholamines.

ACE Inhibitors (“-pril”) & ARBs (“-sartan”)

• MOA: Blocks the conversion of angiotensin I to angiotensin II.
• First-line choice for:
  • Hypertension with diabetes or kidney disease.
• Side Effects:
  • Dry hacking cough (more common with ACE inhibitors).
  • Hyperkalemia, angioedema.
• Dosing Adjustments: Needed in renal insufficiency.
• Contraindications:
  • Pregnancy, renal artery stenosis, acute renal insufficiency.

Dyslipidemia

Screening & Detection

• Lipid profile recommended for individuals with cardiovascular risk factors, including:
  • Diabetes mellitus (DM)
  • Hypertension (HTN)
  • Strong family history of dyslipidemia or early cardiovascular disease
  • Obesity
• 12-hour fasting required before testing.
• Key lipid panel components:
  • Total cholesterol (TC)
  • Low-density lipoprotein (LDL) – “bad” cholesterol
  • High-density lipoprotein (HDL) – “good” cholesterol
  • Triglycerides (TG)

Dietary Modifications to Lower LDL (5-10% Reduction)

• Increase plant sterols (found in cholesterol-lowering margarine):
  • Take Control, Benecol
• Consume fiber-rich foods:
  • Oatmeal, oat bran

Reduce Intake of Saturated Fat & Cholesterol

• Avoid trans fats (found in processed and fried foods).
• Keep total cholesterol intake below 200 mg/day.

Increase Omega-3 Fatty Acids for Heart Health

• Eat fatty fish at least twice per week (e.g., salmon, mackerel, sardines).
• Other sources:
  • Flaxseed
  • Walnuts
  • Canola and soybean oils
• For those with coronary heart disease (CHD):
  • Consume 1 gram of EPA + DHA daily (via 4 oz salmon daily or fish oil supplements).

Statin Therapy Overview

Category	High-Intensity	Moderate-Intensity	Low-Intensity
Usage Considerations	Avoid in individuals over 80, those with impaired kidney function, frailty, multiple comorbidities, or when combined with fibrates	Preferred for patients at higher risk of adverse effects	Generally not recommended
LDL Reduction	Reduces LDL by approximately ≥50%	Reduces LDL by 30-49%	Reduces LDL by <30%
Medications & Dosages	– Atorvastatin 40-80 mg – Rosuvastatin 20-40 mg	– Atorvastatin 10-20 mg – Rosuvastatin 5-10 mg – Simvastatin 20-40 mg – Pravastatin 40-80 mg – Lovastatin 40 mg	– Pravastatin 10-20 mg – Lovastatin 20 mg – Simvastatin 10 mg

Cholesterol Management: Additional Considerations

Statin therapy is now guided primarily by cardiovascular risk categories rather than specific LDL targets. The focus is on risk-based treatment, as supported by the ACC/AHA, USPSTF, and ADA 2023 guidelines.

When to Use Statins:

• Clinical ASCVD (e.g., prior MI, stroke, or PAD):
  → Recommend high-intensity statin
• LDL ≥190 mg/dL (regardless of risk):
  → Recommend high-intensity statin
• Diabetes (age 40–75 years):
  → Recommend moderate-intensity statin
  → Consider high-intensity statin if additional risk factors or 10-year ASCVD risk ≥20%
• 10-year ASCVD risk ≥7.5% (no ASCVD or diabetes):
  → Recommend moderate- to high-intensity statin, based on shared decision-making
• Ages >75:
  → Statin use should be individualized, as evidence is more limited

Key Notes:

• The goal is to reduce overall cardiovascular risk, not necessarily to reach a specific LDL number (e.g., LDL <100 mg/dL is no longer a universal treatment target)
• Diabetic patients aged 40–75 are generally treated with at least moderate-intensity statins, per ADA 2023 guidelines
• Statins are often taken at night, especially shorter-acting ones (e.g., simvastatin), though some newer agents can be taken at any time
• If prescribed, baby aspirin may be used alongside statins for secondary prevention, but not routinely for primary prevention

Weight and Obesity

• Body Mass Index (BMI): Measurement comparing weight and height
  • Formula: Weight (kg) ÷ Height (m²)
  • May overestimate BMI in muscular individuals
• BMI Categories:
  • Underweight: Below 18.5
  • Healthy Weight: 18.5 – 24.9
  • Overweight: 25 – 29.9
  • Obese: 30+
• Waist and Hip Measurements:
  • Men: Waist > 40 inches
  • Women: Waist > 35 inches
  • Waist-to-Hip Ratio: >1.0 (men), >0.8 (women)
• Metabolic Syndrome Diagnosis: Requires three of the following:
  • Abdominal obesity (waist circumference)
  • High blood pressure
  • Abnormal lipid levels (elevated triglycerides, low HDL, insulin resistance)
  • Fasting glucose > 100 mg/dL or diabetes diagnosis

Statins (HMG-CoA Reductase Inhibitors)

• Effects on Lipids:
  • Reduces LDL by 18–55%
  • Increases HDL by 5–15%
  • Lowers triglycerides by 7–30%
• Monitoring: Baseline liver enzyme test; no ongoing checks needed
• Cautions: Avoid grapefruit juice with simvastatin, atorvastatin, lovastatin
• Potential Side Effects:
  • Rhabdomyolysis, muscle inflammation (myositis)
  • Risk Factors for Myositis: Older age, low body weight, high-dose statins

Bile Acid Sequestrants

• Effects on Lipids:
  • Decrease LDL by 15–30%
  • Slightly raise HDL by 3–5%
  • May increase triglycerides if levels exceed 400 mg/dL
• Examples: Cholestyramine, colestipol, colesevelam
• Side Effects: Constipation, reduced absorption of other medications

Niacin (Vitamin B3)

• Effects on Lipids:
  • Lowers LDL by 5–25%
  • Increases HDL by 15–35%
  • Reduces triglycerides by 20–50%
• Side Effects:
  • Flushing (can be minimized with aspirin 1 hour before)
  • Increased blood sugar, uric acid, digestive discomfort, liver toxicity

Fibrates

• Effects on Lipids:
  • Reduces LDL by 5–20%
  • Increases HDL by 10–20%
  • Decreases triglycerides by 20–50%
  • May raise LDL in individuals with very high triglycerides
• Side Effects: Indigestion, gallstones, muscle issues
• Contraindications: Not recommended for severe kidney or liver disease
• Example: Fenofibrate

Omega-3 Fatty Acids (Fish Oil)

• Recommended Dose: 4 grams per day
• Effects on Lipids:
  • Lowers triglycerides by 20–30%
• Side Effects:
  • Increased bleeding risk
  • Gastrointestinal discomfort (fishy aftertaste) – can be reduced by freezing capsules, taking with meals, and avoiding hot drinks immediately after

Causes of Secondary High Triglycerides

• Underlying Conditions:
  • Uncontrolled or untreated hypothyroidism
  • Poorly managed diabetes
  • Excessive alcohol consumption

Cholesterol Absorption Inhibitors

• Effects on Lipids:
  • Reduces LDL by 15–20%
  • Slightly increases HDL by 3–5%
• Examples: Ezetimibe (Zetia) – often used in combination therapy (e.g., Vytorin)

Cardiovascular System

Condition	Causes	Signs & Symptoms	Diagnostics	Treatments	Concerns
Acute Coronary Syndrome (STEMI, NSTEMI, Unstable Angina)	Unstable angina caused by vasoconstriction, non-occlusive thrombus, inflammation, or infection	Central chest pain (squeezing, tightness, crushing pressure), numbness/tingling in left jaw/arm, cold/clammy sweating. Pain triggered by exertion or heavy meals, persists at rest. Women may experience fatigue, sleep disturbances, anxiety, weakness, nausea, dyspnea, syncope, back pain	EKG	Beta-blockers, ACE inhibitors, aldosterone antagonists	STEMI: full-thickness MI with Q waves. NSTEMI: partial occlusion. Stable angina: predictable pain pattern.
Congestive Heart Failure (Left-Sided)	MI, CAD, HTN, fluid retention, valvular disease, arrhythmias	Bilateral lung crackles, S3 heart sound, cough, dyspnea, dullness to percussion, nocturnal dyspnea, orthopnea, non-productive cough, wheezing (“left = lung”)	Chest X-ray (Kerley B lines), EKG, troponin, BNP, CMP, echocardiogram	Monitor weight, avoid alcohol, quit smoking, diuretics, ACEI/ARB, beta-blockers (if HFrEF), aldosterone antagonists, sodium restriction (2-3g), fluid restriction (1.5-2L)	Ejection Fraction (EF): HFrEF <40% (systolic failure), HFpEF >40% (diastolic failure). Medications contributing to HF: NSAIDs, amlodipine, metoprolol (still needed), glitazones (Actos/Avandia). NYHA classification: Class I (no limits) – Class IV (symptoms at rest).
Congestive Heart Failure (Right-Sided)	MI, CAD, HTN, fluid retention, valvular disease, arrhythmias	Jugular venous distension (>4cm), enlarged spleen/liver causing nausea, anorexia, abdominal pain, lower extremity edema (“right = GI”)	Same as left-sided HF	Same as left-sided HF	Same as left-sided HF
Bacterial Endocarditis	Gram-positive bacteria (Viridans streptococcus, Staphylococcus aureus)	Fever, chills, new murmur, sudden CHF. Subungual hemorrhages, petechiae on palate, painful Osler nodes (fingers/toes), non-tender Janeway lesions (palms/soles), Roth spots (retinal hemorrhages), hematuria	Blood cultures (x3), CBC, ESR >20 mm/hr	Refer to cardiology. Prophylaxis: no longer needed for MVP/GU/GI, but required for prior endocarditis, prosthetic valves, congenital heart disease. Antibiotics: Amoxicillin 2g PO (adult) or 50mg/kg (peds) 1 hr pre-procedure. If allergic: Clindamycin 600mg, Biaxin 500mg, Keflex 2g, macrolide alternative	Risks: valve destruction, myocardial abscess, emboli
Dissecting Abdominal Aortic Aneurysm		Pulsating abdominal mass, severe sharp back/chest pain, hypotension, distended abdomen	Abdominal ultrasound. CXR may show widened mediastinum, tracheal deviation, obliteration of aortic knob	Surgical repair. If <4cm, monitor annually via CT scan	Risk factors: male >60, smoker, uncontrolled HTN, white race, genetic conditions (Marfan syndrome)
Atrial Fibrillation	HTN, CAD, ACS, caffeine, nicotine, hyperthyroidism, alcohol, HF, LVH, PE, COPD, sleep apnea	May be asymptomatic or present with HR >110 bpm. If unstable: chest pain, hypotension, heart failure, clammy skin, acute kidney injury	12-lead EKG, TSH, electrolytes, renal function, 24-hour Holter, echocardiogram	Avoid stimulants. Identify underlying cause. Refer to cardiology if CHA₂DS₂-VASc score >2 (anticoagulation needed: Warfarin INR 2-3, for valves 2.5-3.5). HR control: CCB, beta-blockers, digoxin	Most common arrhythmia (SVT class), increases stroke risk. Paroxysmal AF: lasts <7 days. INR >4-5: hold dose, adjust maintenance dose.
Paroxysmal Supraventricular Tachycardia (PSVT)	Digitalis toxicity, alcohol, hyperthyroidism, caffeine, stimulant drugs	Sudden onset palpitations, rapid pulse, lightheadedness, dyspnea, anxiety (HR 150-250 bpm)	EKG	Vagal maneuvers, carotid massage, cold water to face. If WPW syndrome or symptomatic: emergency intervention (911)	May occur in Wolff-Parkinson-White syndrome

Cardiovascular

Condition	Causes	Signs & Symptoms	Diagnostics	Treatments	Concerns
Pulsus Paradoxus	Asthma, emphysema, cardiac tamponade, pericarditis, pericardial effusion	Apical pulse remains audible while the radial pulse disappears; detected via stethoscope and BP cuff. Heart chamber compression causes an exaggerated drop in systolic BP (>10 mmHg)	Clinical assessment	Identify and treat underlying condition	Indicates severe cardiac or respiratory dysfunction
Hypertension	Changes in peripheral vascular resistance (PVR) or cardiac output (CO) alter BP	Often asymptomatic. Normal: <120/80 mmHg. Prehypertension: 120-139/80-89. Stage 1: 140-159/90-99. Stage 2: ≥160/100. Secondary HTN: Suspect in patients <30 years old, severe HTN, acute BP rise, resistant HTN (on 3 meds). Possible causes: Renal (renal artery stenosis, polycystic kidney disease, CKD), Endocrine (hyperthyroidism, hyperaldosteronism, pheochromocytoma), Other (sleep apnea, aortic coarctation)	Confirm elevated BP on 2 separate visits. BP goals: <140/90 if <60 years old; <150/90 if >60 years old with no comorbidities. Tests: Creatinine, GFR, UA (kidneys), TSH, glucose (endocrine), K+/Na+/Ca2+ (electrolytes), cholesterol, CBC, baseline EKG, CXR	Hypertensive emergency: Diastolic BP >120 with symptoms (N/V, stroke, MI, renal failure, retinopathy, aortic dissection). Treatment: Thiazides, CCBs, ACEI/ARBs	Isolated systolic HTN: SBP >160 due to arterial stiffness and increased PVR. Younger patients have higher renin levels; pregnancy reduces vascular resistance.
Deep Vein Thrombosis (DVT)	Blood clot formation due to stasis, trauma, inflammation, or hypercoagulation	Gradual unilateral leg swelling, pain, redness, warmth. If pulmonary embolism (PE): Sudden chest pain, dyspnea, dizziness, syncope	Tests: +Homan’s sign (33% of cases), CBC, platelets, PT/PTT, INR, D-dimer, chest X-ray, EKG, ultrasound	Treatment: Refer to Wells Criteria. Warfarin takes 3-5 days for full effect; maintain INR 2-3. Interactions: Clarithromycin ↑ warfarin effect, cholestyramine ↓ warfarin effect. Consider direct thrombin inhibitors (Pradaxa)	Risk factors: Prolonged immobility (bed rest, long travel), CHF, clotting disorders (Factor V Leiden, protein C deficiency), estrogen use (OCPs, pregnancy), trauma, malignancy
Superficial Thrombophlebitis	Inflammation of superficial veins due to trauma or secondary infection (Staphylococcus aureus)	Localized redness, swelling, tenderness, vein feels hardened (indurated). Usually in extremities. Afebrile, normal vitals	Clinical exam: palpable, cord-like, warm, tender vein without edema	NSAIDs, warm compress, elevate limb	Usually self-limiting; treat underlying cause
Peripheral Artery Disease (PAD)	Narrowing or occlusion of medium-to-large arteries in the lower extremities (arterial insufficiency)	Leg pain worsens with walking, relieved by rest (claudication – “angina of the legs”). Thin, hairless skin, thickened/discolored toenails, absent dorsalis pedis pulse, possible toe gangrene	Check dorsalis pedis/posterior tibial pulses, ABI <0.9, Doppler ultrasound, refer to vascular specialist	Management: Smoking cessation, daily walking. Medications: Cilostazol (Pletal) with aspirin or Plavix (caution with grapefruit juice, diltiazem, omeprazole); Pentoxifylline (Trental) (limited benefit)	Complications: Foot gangrene, CAD, carotid artery plaque, increased risk with HTN, smoking, diabetes, hyperlipidemia. May lead to osteomyelitis.
Raynaud’s Phenomenon	Reversible vasospasm of peripheral arterioles in fingers/toes	Episodic color changes: white (pallor) → blue (cyanosis) → red (reperfusion). Numbness, tingling, episodes lasting hours. Associated with autoimmune diseases (thyroid disorders, pernicious anemia, rheumatoid arthritis). More common in women (8:1), secondary Raynaud’s linked to scleroderma	Check distal pulses	Lifestyle changes: Avoid cold exposure, stimulants, and smoking. Medications: CCBs (Nifedipine, Amlodipine), ACE inhibitors. Avoid vasoconstrictors (beta-blockers, decongestants, ergotamines).	Complications: Small fingertip/toe ulcers, usually occurs between ages 15-45.

Condition	Causes	Signs & Symptoms	Diagnostics	Treatments	Concerns
Mitral Valve Prolapse (MVP)	Structural valve abnormality, systolic murmur	Fatigue, palpitations, chest pain, lightheadedness (worsens with exertion). May be asymptomatic. Linked to pectus excavatum, joint hypermobility, and Marfan’s syndrome (arm span > height)	Auscultation: Mid-to-late systolic click and murmur Imaging: Echocardiogram with Doppler	Asymptomatic: No treatment needed Symptomatic: Beta-blockers for palpitations, avoid caffeine, alcohol, and smoking Holter monitor: For arrhythmia detection	Complications: Increased risk of thromboembolism, TIA, atrial fibrillation, and ruptured chordae tendineae
Hyperlipidemia (HLD)	Risk factors: Hypertension, premature heart disease (women <65, men <55), diabetes, smoking, obesity, microalbuminuria, CAD, PAD	Lipid Levels: – Total cholesterol: Normal <200, Borderline 200-239, High >240 – HDL: >40 (Low HDL often due to high-carb, low-fat diet) – LDL: <100 – Triglycerides: <150 (Risk of pancreatitis if >1000) – If triglycerides >500: Treat first with fenofibrate, niacin, or omega-3s. May be due to metabolic syndrome, diabetes, alcohol abuse, hyperthyroidism, kidney disease, or medications	Screening: – Start fasting lipid tests at 20, repeat every 5 years – If >40, screen every 2-3 years – If diagnosed, screen annually	Lifestyle changes: Exercise, weight loss, healthy fats, no trans fats, reduce junk food, DASH diet, smoking cessation Medications: Focus on lowering LDL unless triglycerides >500 (use statins) Statin interactions: Avoid grapefruit, fibrates, antifungals, macrolides, amiodarone	Risks: Monitor for muscle pain (myalgias), possible memory loss or confusion Elderly: Consider stopping statins at 80+ if symptomatic, though they help prevent MI/CVA by stabilizing atherosclerosis
Rhabdomyolysis	Acute skeletal muscle breakdown leading to renal failure	Classic triad: Muscle pain, weakness, and dark urine. Persistent muscle aches without exertion	Tests: – Creatine kinase (CK) – Urinalysis (myoglobinuria, proteinuria) – BUN, creatinine, potassium – EKG (if electrolyte abnormalities suspected)	Management: IV fluids, electrolyte correction, treat underlying cause	Risk factors: Obesity, metabolic disorders, certain medications
Nonalcoholic Fatty Liver Disease (NAFLD)	Accumulation of triglycerides in liver	Often asymptomatic, but possible hepatomegaly. If symptomatic: Fatigue, malaise, RUQ pain. Associated with obesity, metabolic syndrome, diabetes, hyperlipidemia	Lab findings: Elevated ALT/AST, negative viral hepatitis (A, B, C) Gold standard: Liver biopsy	Treatment: Weight loss, diet modification, alcohol cessation, avoid hepatotoxic drugs (acetaminophen, statins). Refer to GI for further evaluation	Concerns: Can progress to cirrhosis Most common liver disease in the U.S. Leading cause of liver transplants
Varicose Veins	Inherited venous valve defects, prolonged standing, leg crossing, tight clothing, heavy lifting	Enlarged, tortuous superficial veins. Leg aching and mild swelling (worse at the end of the day and in warm weather). Great saphenous vein is most commonly affected	Clinical exam	Treatment options: Laser ablation, sclerotherapy, surgery	Risk factors: Women affected twice as often as men

Heart Block

• First-Degree AV Block: The PR interval is prolonged (>0.2 seconds) but remains consistent without dropped beats.
  • Mnemonic: “If the R is far from P, then you have First Degree.”
• Second-Degree Type I (Wenckebach): The PR interval gradually lengthens until a QRS complex is dropped.
  • Mnemonic: “Longer, longer, longer, drop—then you have Wenckebach.”
• Second-Degree Type II (Mobitz II): The PR interval remains constant, but some QRS complexes are intermittently dropped.
  • Mnemonic: “If a QRS doesn’t get through, then you have Mobitz II.”
• Third-Degree (Complete Heart Block): No correlation between P waves and QRS complexes; atria and ventricles beat independently.
  • Mnemonic: “If Ps and Qs don’t agree, then you have Third Degree.”