Diagnostic Methods

Diagnostic Test

Measures

Radiograph

Uses X-rays to view a

non-uniformly composed
object

Indications
Acute aortic syndromes

Chest pain
Intramural hematoma

Aortic trauma

Aortic aneurysm

Test Interpretation
Other
Result
Parameters
Intramural
Not great at detailing vessel damage
Widen mediastinum
Hematoma
Aortic arch segment is
Aortic Trauma
too wide
Aortic Aneurysm

Wide aorta

Tunica intima flap visible

within lumen
Dissection present in
Type A Dissection
ascending aorta and
aortic arch
Aortic Dissection

Aortic dissection

Computed
Tomography Scan

Computer-processed
x-rays produce
tomographic images
of specific areas in an
object

Aortic trauma

Annuloaortic ectasia

Mycotic aneurysm

Intramural hematoma
( aortic rupture)

Type B Dissection

Dissection only present

in descending aorta

Intramural
Hematoma

Crescent-moon shape in
the aorta

Aortic Rupture

Opaque cloud surrounds

and extends from aorta

Aortic Trauma

Outcropping pocket
on aorta

Aoritis

Aortic aneurysm

Takayasu arteritis

Ascending Aortic
Aneurysm
Descending Aortic
Aneurysm
Abdominal Aortic
Aneurysm
Aneurysm
Rupture
Annuloaortic
Ectasia
Takaysu Arteritis

Ambulatory
Blood Pressure
Monitoring

Portable blood pressure cuff that

automatically measures BP every
30 minutes during the day and
every 60 minutes at night

Holter Monitor

Ambulatory electrocardiography
monitoring

Borderline HTN
Refractory HTN
Episodic HTN
Hypotensive symptoms
from medications

White coat HTN

Autonomic dysfunction

Apparent HTN drug

resistance
Evaulation of
Circadian patterns of BP antihypertensive efficacy
and dosing time
Frequent palpitations

Arrhythmias

> 4 cm
> 3.5 cm
> 3.0 cm
Blood surrounding and
outside of aorta
Dilated annulus
Dilated valsalva
Wall thickening
Narrowing of aorta
Advantages
Multiple readings
R/O white coat syndrome
No placebo effect
Disadvantages
Cost
Disruption of daily activities
Lack of long-term studies
Only useful if patients actually
experience palpitations while the
holter monitor is worn

Compiled by Drew Murphy, Duke Phsyician Assistant Class of 2015

Diagnostic Methods
Diagnostic Test

Measures

Event Monitor

Ambulatory electrocardiography
monitoring that stores specific
symptomatic episodes

Ankle Brachial
Index

Ratio of the blood pressure

in the lowers legs to the
blood pressure in the arms

Excerise Doppler
Stress Test

Exercise testing that assess functional

capacity of blood vessels and the
magnitude of physical limitations

Indications
Episodic palpitations

Result

Test Interpretation
Parameters

Other
Can be activated by patient when
symptoms arise

Syncope

Continuous EKG monitoring

Claudication
> 70 years old

Noncompressible
Normal
Mild-To-Moderate
> 50 years old with
PAD
smoking and/or diabetes
Severe PAD
Non-healing wounds

> 1.30
0.91 - 1.30

ABI = Systolic ankle pressure

Systolic arm pressure

0.41 - 0.90
0.00 - 0.40

Claudication
Pseudoclaudication
PVD

Compiled by Drew Murphy, Duke Phsyician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Atrial
Tachycardia

Arrhythmias caused
by increased atrial
pulse rates

Bradycardia

Decreased heart rate

Sinus Arrhythmia

Cyclic changes in heart

rate during breathing

Multifocal Atrial
Tachycardia

Different clusters of
cells outside the SA
node take control of
heart rate

Atrial Fibrillation

Rapid, disorganized
electrical signals
causes the atria to
quiver

Signs and Symptoms

Test

Laboratory
Result

EKG

Wolff-ParkinsonWhite Syndrome

No cardiovascular symptoms

Palpitations

Chest pain

EKG

Pulse rate

Rhythm

P Wave
Rhythm
Rate

Irregular
LOW
Variable
1:1
Irregular
100 bpm

P Wave

3 Morphologies

Rate

P-P
P-R
R-R
Rate

st

1 Degree
Atrioventricular Block

Fainting

Rate
Delta Wave
Delta Wave

Present

CHF
P Wave

Patients can feel the atrial fibrillation rhythm

when their heart is in it

Echo
Holter

Rhythm
P Wave

Supraventricular tachycardic
rhythm that occurs due to the Very brief episodes that are typically only captured
by a holter monitor
formation of a reentry circuit next
to the AV node

Slowed conduction
through the normal
conduction pathway

Class IA/IC
Antiarrhythmics
Class III
Antiarrhtyhmics

Medications

Palpitations
Shortness of breath

P Wave

Pacemaker Indications
HR < 40 bpm WITH symptoms
Pause > 3.0 seconds (while awake)
Symptomatic bradycardia from
required drug therapy
Symptomatic chrontropic
incompetence
Common in young patients

Seen in elderly people with

pulmonary disease.

Variable
Atrial HR
Irregularly
irregular
Random and
chaotic
A-fib
A-fib
Atrial HR
150 bpm
(ventricular HR w/
2:1 a-flutter)
Regular
Saw-tooth
Distroted
(2:1 a-flutter)
Near or hidden
in QRS
Retrograde
after QRS
140 - 200 bpm
Absent

Rhythm

Rapid and rhythmic

atrial impulses

Pre-excitation syndrome caused by

an abnormal accessory conduction
pathway between the atria and
ventricles

Artial HR

Cardioversion (hemodynamically
unstable or stable)
Rate control atttempt (borderline or
hemodynamically stable)
Anti-coagulation
(hemodynamically stable)

Ablation (with symptomatic)

Vagal maneuvers or adenosine

(2:1 a-flutter)
Adenosine therapy
Vagal maneuvers
Rate control
Ablation of slow pathway

Dizziness
Cardioversion

Syncope

High vagal tone

Ischemia

Electrolyte
abnormalities

History of beta blockers

or calcium channel
blockers

Other

AV Nodal Blockers

Ablation

QRS

Atrioventricular
Node Reentry
Tachycardia

Medications

Find the cause of cause.

Rate

Atrial Flutter

Treatment

Triggers
Ischemia
Warfarin
Alcohol
Beta Blockers Thyroid disease
Calcium Channel Lung disesae
Blockers
Caffeine
Digoxin
Cold drinks

Anti-Arrhythmics

Adenosine

Anti-Arrhythmics

Adenosine
Beta Blockers
Calcium Channel
Blockers
AV node blockers should be avoided
in a-fib and a-flutter with a history
of WPW

200 ms
PR Interval

No therapy required
Constant

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

2nd Degree
Atrioventricular Block
Type I (Wenckebach)

Progressively lengthening
conduction between the atria
and ventricles continues until a
beat is dropped

2nd Degree
Atrioventricular Block
Type II (Mobitz)

Delayed conduction between

the atria and ventricles
usually due to a block in the
Bundle of His

Conduction between
3rd Degree
the atria and
Atrioventricular
ventricles is
Block (Complete) completely severed

Ventricular
Tachycardia
Torsades de
Pointes
Ventricular
Fibrillation

Potentially lethal
accelerated
ventricular rate
Life-threatening polymorphic
ventricular tachycardia
Quivering ventricles produce
no net blood flow through
the heart

Signs and Symptoms

Aortic Stenosis

Any of a set of
diseases that cause
valvular dysfunction

Narrowing or
obstruction to
forward flow while
the aortic valve is
open

Laboratory
Result

Rhythm

Regularly irregular

PR Interval

Progessively
lengthing
Resets after
failed beat

Usually asymptomatic

Light-headedness

Dizziness

Syncope

Regular
Rhythm

PR Interval

Age

Ischemia

Post-Surgery

Congenital

Electrolytes

Digoxin toxicity

Rates

P Waves
P-P
Q-Q

High vagal tone

Common cardiac symptoms

Rhythm
QRS
P Waves

Can be asymptomatic
Chest pain

Dizziness
Syncope

You will know it when it happens.

Mitral valve prolapse

Valvular Heart
Disease

Test

Axis
Rhythm
P Waves
QRS
Q-T
Rhythm
Rate
QRS
P Waves

Dropped
ventricular beats
Constant

Treatment

Medications

Stop all nodal blockers

Pacemaker

Atrial and
ventricular rates
completely
independent
Pacemaker
Independent of
QRS
Constant
Constant
Cardioversion
Regular
(hemodynamically unstable)
Anti-arrhythmic therapy
Wide
Treat underlying disease
Hidden
ICD (if EF 35%)
After QRS
Ablation
Unusual
Irregular
Absent
Cardioversion
Polymorphic
Prolonged
Irregular
Cardioversion
Unknown
Chaotic
Treat underlying problem
Absent

Can be lethal
Anti-Arrhythmics

Lethal
IV Magnesium
Lethal

Systolic Murmurs
Aortic and pulmonic stenosis
Mitral and tricuspid regurgitation
Diastolic Murmurs
Mitral and tricuspid stenosis
Aortic and pulmonic regurgitation

Regurgitant lesions
Hypertrophy
(stenotic disease)

Congenital Malformation Murmurs

Dilatation
(regurgitant disease)
Angina

Typical age > 60 years

Shortness of breath

EKG

CHF

Orthopnea

Exertional chest pain

(end-stage symptom)

S4 murmur

Displaced apical impulse

Radiation to neck, subclavian artery, or abdomen

LVH
Cardiomegaly

CXR

Syncope or presyncope
symptoms

Often progresses to complete heart

block

Symptomatic
Exerciseinduced
HR < 40
Pause > 3 sec

Stenosis

Asymptomatic with
murmur

Other
Common in athletes, elderly,
ischemic patients, or patients taking
beta blockers, calcium channel
blockers, or anti-arrhythmics.

Echo

Cath

Aortic valve replacement

Post-stenotic
dilation
Abnormal valvular
morphology
Aortic ballon valvotomy
(high risk of complications and disease
recurrence)
Assess

Septal defects
Tetralogy of Fallot
Septal coarctation
Normal
Area = 3.0 - 4.0 cm2
Mild
Area > 1.5 cm2
Pressure gradient < 25 mm Hg
Moderate
Area > 1.0 cm - 1.5 cm2
Pressure gradient = 25 - 40 mm Hg
Severe
Area < 1.0 cm2
Pressure gradient > 40 mm Hg
No beneficial medical therapy

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Acute Aortic
Regurgitation

Chronic Aortic
Regurgitation

Mitral Stenosis

Cause

Sudden onset of
backflow from the aortic
valve

Slowly progressing
leakage of the aortic
valve

Narrowing or
obstruction to
forward flow while
the mitral valve is
open

Acute Mitral
Regurgitation

Sudden onset of
backflow from the
mitral valve

Chronic Mitral
Regurgitation

Slowly progressing
leakage of the mitral
valve

Mitral Valve
Prolapse

Leaflets of the mitral valve

invert into the left atrium
causing leakage of blood

Tricuspid Valve
Stenosis

Narrowing and calcification of the

tricuspid valve causing diastolic
pressure gradient between the right
atrium and right ventricle

Signs and Symptoms

Bacterial endocarditis
Acute pulmonary edema

Laboratory
Result

EKG

No LVH

Prosthetic valve
dysfunction
Aortic dissection

No classical physical exam findings present

Asymptomatic for
Fatigue
many years
Angina
Exertional dyspnea
Wide pulse pressure
Pulmonary edema
Diastolic BP
Soft, decrescendo
diastolic murmur at left
sternal border

Test

S3 gallop murmur

Quincke's pulse
(nail bed)
Fatigue

Water-hammer (or
Corrigan's) pulse
Musset's sign
(head bob)
Dyspnea

Orthopnea

Hemoptysis

Peripheral edema

Palpitaiton / a-fib

Pulmonary venous
congestion

10 - 20 years after acute

rheumatic fever

Embolic events

LA Pressure

Cardiac output

Pulmonary HTN

Right-sided heart failure

Left atrial enlargement

High-pitched, opening
Loud, palpable S1
snap after S2
Low-pitched, diastolic
Accentuated P2 and
rumble near apex
RV heave
New systolic murmur
Prior acute MI
Bacterial endocarditis Papillary muscle rupture
or dysfunction
Chordae rupture
Acute pulmonary
Abscess / necrosis
edema
Cardiogenic shock
Holosystoic murmur
JVD
at apex
Soft S1
Visible, palpable LV
Laterally displaced
heave at apex
apical impulse
S3 murmur
CHF
Asymptomatic
Fatigue
Atypical chest pain
Palpitations
Sympathetic
Anxiety disorders
hyperactivity
Postural orthostasis
Mid-systolic click MR murmur
Symptoms of right
Edema
atrium pressures
Weakness
Ascites
Fatigue
Hepato-splenomegaly
JVD
Diastolic murmur at sternal border that increases
with inspiration

Treatment

Medications

Other

Medications
Nitroprusside
Surgery
LVH

Medications (afterload reduction)

EKG / CXR
LV enlargment
Echo

Assess

Cath

Assess CAD prior

to surgery and
aortic root
involvement
Velocity

Echo
Pressure
gradient

Aortic Valve
Replacement

LVESD > 5.0 cm

Infective endocarditis prophylaxis
(asymptomatic patients)
Diuretics / salt restriciton
A-fib management through rate
control and anticoagulation (high
embolic risk)
Medications
Exercise
Capacity
Surgery Criteria

Cath

Symptoms of
heart failure
Acute AI with
hemodynamic
compromise
LVEF < 55%

Echo

Cath

Echo

Assess MR
severity

Hydralazine +
nitrates

Diuretics

Nitrates

A-fib
Mitral valve replacement (combined
stenosis and regurgitation)

EKG

ARBs

Pulmonary HTN

Directly measure
pressures

LVH
Left atrial
enlargement
Hyperdynamic,
dilated LV
Abnormal valve
morphology
Doppler study
Assess MR
severity

ACE Inhibitors

Balloon valvuloplasty
Medications
Endocarditis prophylaxis

Beta Blockers

Diuretics
Acute MR

Chronic MR with
LV function
Surgery Criteria
Chronic MR with
end-systolic left
ventricular
diameter > 4.0 cm
Reassurance of patient
SBE prophylaxis
Medications
Surgery (when there is severe MR)

Causes
Fibrosis or thickening of leaflets
Commissural fusion
Chordae fusion and shortening
Orifice size
Normal
Valve area = 4.0 - 6.0 cm2
Pressure gradient = 0 mm Hg
Mild
Valve area > 2.0 cm2
Pressure gradient < 8 mm Hg
Moderate
Valve area = 1.0 - 2.0 cm2
Pressure gradient = 8 - 12 mm Hg
Severe
Valve area < 1.0 cm2
Pressure Gradient > 12 mm Hg
Repair surgery is favored over
replacement.

ACE Inhibitors
Digoxin

Antibiotics
Beta Blockers

Common in young females

Aspirin
>
Uncommon in adults

Ballon valvuloplasty
Surgical valve replacement (pressure
gradient > 5 mm Hg)

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Tricuspid
Regurgitation

Backflow of the
tricuspid valve

Symptoms of right
C-V waves in
ventricular failure
jugular veins
Pulsatile liver
Hepatojugular reflux
Holosystolic murmur at left sternal border that
increases with inspiration
Pulmonary HTN
A-fib (possible)

Pulmonic Stenosis

Narrowing or obstruction
of blood flow through the
pulmonic valve

Pulmonic
Insufficiency

Rheumatic Fever

Exertional dyspnea
Pre-syncope Sx
Cyanosis
JVP with prominent A
wave

Laboratory
Result

S4 murmur

Systemic immune
response to Group A
-hemolytic Strep
infections of the
pharynx

Other

Diuretics

Digoxin

Repair surgery (preferred over

replacement)

Echo

Splitting of S2

Right ventricular
hypertrophy
Systolic doming
of PV
Transpulmonic
gradient

Balloon valvotomy

RV failure symptoms (if pulmonary HTN present)

Mitral (75%) or aortic

(30%) valvulitis

No specific therapy for inflammatory

reactions

Pulmonic and tricuspid

valvulitis (5%)

Salicyclates
Bedrest if significant cardiac disease is
present

Valvular regurgitation
or stenosis

Transient bacteremias

Microbal invasion of
the endocardium

Medications

Treatment of pulmonary HTN

Hyperdynamic RV with
Fairly asymptomatic
Failure of the pulmonic valve due
palpable heave
to the dilation of the valve ring Low-pitched diamond-shaped diastolic murmur in
the 3rd and 4th intercostal spaces
from pulmonary hypertension or

dilation of the pulmonary artery

Treatment
Usually only treat severe TR
Medications

Fatigue

Post-surgery

Medications

Symptoms appear
2 - 3 weeks after
infection

History of turbulence, trauma, or inflammation of

the endocardium

Infective
Endocarditis

Test

History of intravascular
device

Fever

New cardiac murmur

Weight loss

Petechiae / rash

Osler nodes

Splinter hemorrhages

Janeway lesions

Roth spots

Steroids
Heart failure management
Blood Culture

Positive

CBC

Anemia
Leukocytosis
ESR

UA

Proteinuria

Rheumatoid
Factor
Antibody

Echo

Positive

Prolonged IV antibiotics
Failure to clear
infection
Fungal organism
Surgical Valve
Replacement
Criteria

Severe, refractory
CHF
Intramyocardial
abscess
Recurrent embolic
events

Oscillating
vegetations
Abscesses
Unstable
Valvular
prosthetic devices
regurgitation
Predisposing heart
NO ANTICOAGULATION THERAPY
condition

Antibiotics

Typical age = 5 - 15 years

Major Jones Criteria
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor Jones Criteria
Arthralgia
Fever
Acute phase reactants
Prolonged P-R interval
Previous Hx of Group A Strep
Etiologies
Viridans Streptococci (50%)
S. aureus/epidermidis (25%)
Enterococci (10%)
Gram (-) species (5 - 10%)
Fungal / TB / Culture (-) (5 - 10%)
Major Criteria
(+) blood cultures for IE
Evidence of of endocardial
involvement
Minor Criteria
Fever
Valvular phenomena
Immune phenomena
Microbiologic indications
IV drug users are more commonly
infected by S. aureus

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Asymptomatic
(usually found on a routine exam)

Pulmonary congestion

Dilated
Cardiomyopathy

Enlargement of the
ventricles

Fatigue / Weakness

Dyspnea

Chest pain

CXR

Blood Tests
Right-sided heart failure
(late symptom)

Apex displaced

S3 (once symptomatic)
Cath

BP

Interventricular
conduction delays
Anterior
precordial Q
waves
Cardiomyopathy
Electrolytes
Thyroid Fx
ESR / ANA
Ferritin
HIV

Systolic murmur
MRI

Identify and treat correctable cause

Vasodilators
Treat heart failure symptoms
(salt and fluid reduction and
medications)
Diuretics
Arrhythmia management (ICDs)

Cardiac rehabilitation
Exclude pericardial
diseases
Assess cardiac and
pulmonary
Transplant evaluation
pressures
Assess

Peripartum
Cardiomyopathy

Pregnancy causes
cardiomyopathy
slightly pre-partum or
post-partum

Pregnancy or
post-partum

Typical cardiomyopathic
symptoms

Heart failure management

Alcohol
Cardiomyopathy

Cardiomyopathy due to
prolonged consumption of
alcohol (> 10 years)

History of alcohol

Typical cardiomyopathic
symptoms

Alcohol cessation

Dynamic pressure
gradient

Hypertrophic
Cardiomyopathy

Portion of the
myocardium is
hypertrophied with
no apparent cause

Other
Most common form of
cardiomyopathy.

Assess
Echo

Enlarged PMI

Medications

Sinus tachycardia
EKG

Exercise intolerance

Treatment

Diastolic dysfunction
Ischemia

Mitral regurgitation

Asymptomatic

Dyspnea

Angina

Fatigue

Syncope

Forceful, displaced apical

impulse

Harsh, crescendo
systolic murmur

EKG

LVH
ST-T changes
Gaint T wave
inversion
Prominent Q
waves in
precordium
LVH
ASH 1.5x thickness
of post. wall

Echo

Outflow tract
narrowing

Beta Blockers

Risk Factors
Age > 30
African-American
Multiparous
Twin pregnancy
History of HTN
Preeclampsia / eclampsia
Reversible
Mechanisms
Direct toxic effect on myocytes
Nutritional deficiencies
Toxic additives in EtOH product

Manage symptoms
Medications
Beta Blockers
Treat tachyarrhythmias

Pacemaker
aICD
Surgery

Calcium Channel
Blockers

Dynamic gradient

Restrictive
Cardiomyopathy

Cardiomyopathy in which
the cardiac walls are rigid

Systolic thrill

S4 Murmur

Right heart failure

symptoms
Hemochromatosis
Amyloid
Eosinophilic disease

Abnormal diastolic
function
Sarcoidosis
Glycogen storage
diseases

Cath

Evaluate

Transplant
Rarest of all cardiomyopathies

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Asymptomatic that can turn into fulminant and

fatal heart failure

Myocarditis

Inflammation of the
myocytes, intersitium,
vasculature, and/or
pericardium

Arrhythmias

Tachycardia

Fever

Chest pain

Chest pain

Dyspnea

Laboratory
Result
ST / T wave
EKG
abnormalities
Left ventricle
Echo
dysfunction
Coxsackie
Hepatitis
Serology
HIV
T. cruzi
Stool
Viral Cultures
Throat
Pericardial fluid
Endocardial
Biopsy
Confirmatory
Endocardial
MRI
Serial EKGs are
really helpful
Diffuse ST
elevation
Test

EKG

Acute Pericarditis

Acute inflammation of
the pericardium

Symptoms of underlying
Pericardial friction rub
disease

Recurrent symptoms

Fever

Cardiac
Enyzmes
Echo

Hemorrhagic Pericarditis

Pericarditis caused by TB that is

characterized by loss of blood

Purulent
Pericarditis

Pus forms at the

inflammed pericardium

Post-Infarction Pericarditis

Pericarditis that appears 1 day to 6

weeks after an infarction

Dressler's
Syndrome

Secondary form of pericarditis

that occurs with injury to the
myocardium or pericardium

Neoplastic
Pericarditis

Tumor growth causes

pericarditis

ST segments
return to baseline

Treatment

Medications

Treat infections

Treat underlying diseases

Often in young people

Pericardiocentesis to confirm or
exclude purulent pericarditis

NSAIDs

Treatment of underlying disease

Aspirin

Admission
TW inversion
Reversion of TW
Pain relief
inversion
PR segment
Antibiotic treatment
depression
Positive
(sometimes)
IV anticoagulant therapy (use caution)
Effusion
(sometimes)

Coricosteroids

Colchicine

S. aureus
Blood Cultures
S. pneumoniae
Friction rub

Pain
History of infarction

Malaise

Fever

Anticoagulation (with caution)

Pericardial discomfort

Pericardial effusion

Lung
Breast
Leukemia
Source of Tumors
Hodkins and nonHodgkins lymphoma
Metastatic melanoma
Often asymptomatic during life

Aspirin

Leukocytosis
CBC

Other
Etiologies
Infections (most common)
Allergic reactions
Drugs
Inflammatory diseases
Toxins
Mechanisms
Invasion of the myocardium
Myocardial toxin
Immune-mediated

Aspirin

Routes of Infection
Hematogenous
Contiguous spread
Endocarditis
Post-operative
Avoid NSAIDs and corticosteroids
Avoid NSAIDs and corticosteroids if
< 4 weeks since MI

ESR
Mechanisms
Extension / attachment
Nodular tumor deposits
Diffuse pericardial infiltration
Local infiltration

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Hypotension
Beck's Triad

Systemic venous
pressures
Small quiet heart

Cardiac
Tamponade

Fluid accumulates in
the pericardium

JVP

Tachypnea

Friction rub

Tachycardia

EKG

CXR

Early echo if

Treatment

Medications

Other

Acute pericarditis
or effusion signs
Electrical
alternanas
No changes
Pericardial
effusion

Volume resuscitation

Diastolic collapse
Pericardiocentesis
of the RV and RA
Pulsus paradoxus
RA pressures

Cath
Diminished heart sounds

RV and LV
diastolic pressures Pericardial window

Pulsus paradoxus
Pulsus paradoxus

Asymptomatic (acute episode)

Fibrin deposition
Calcification

Constrictive
Pericarditis

Thick, fibrotic
pericardium restricts
diastolic filling

Aneurysm

Localized, blood-filled ballonlike bulge in the wall of a

blood vessel

Pseudoaneurysm

Collection of blood and connective

tissue located outside the vessel wall

Abdominal Aortic
Aneurysm

Localized dilation of
the abdominal aorta
exceeding the normal
diamater by more
than 50%

Symmetrical contriction Equalization of pressures

of the heart
in ALL chambers
Unimpeded, rapid early
diastolic filling
Kussmaul's sign
( JVP)
Pericardial knock

Describers

Stroke volume
Cardiac output
Systemic congestion
Non-palpable impulse
Pulsus paradoxus
Location
Size
Morphological
appearance
Origin

EKG

Low voltage

CXR

Calcification
Effusion

Echo

Cath

Etiologies
Idiopathic
TB
Connective tissues diseases
Post-operatively
Uremia
Post-purulent pericarditis

Pericardial stripping

Hepatic vein
plethora
Assess

Collection of blood and connective tissue with

defined borders outside a blood vessel
Abdominal aorta
diameter > 5 cm
Mid-abdominal
discomfort
Palpable abdominal
mass (when ruptured)

Risk Factors

Risk Factors for Rupture

Asymptomatic
Mild pain
Severe pain
(when ruptured)
Hypotension
(when ruptured)
Tobacco abuse
Age
HTN
Hyperlipidemia
Atherosclerosis

Family history
5 cm or 6 cm
> 1 cm growth / year

Family history
Uncontrolled HTN
Smoking

5.5 cm

95% Sensitivity

4.5 - 5.0 cm
Abdominal
Ultrasound

100% Specificity

Endovascular
Repair Criteria

Patient preference

Cost

Risk patients
with appropriate
anatomy

Pre-op study
CT Scan

Tobacco cessation
Indeterminate
ultrasound

Aortography

Rapid expansion

Saccular Aneurysm
Outpocket from a vessel
Fusiform Aneurysm
Expansion of a section of a blood
vessel
Ruptured Aneurysm
Erupted aneurysm (usually saccular
aneurysm)
Infrarenal AAAs = 90% of AAAs
Suprarenal AAAs = 10% of AAAs
80% of contained rupture goes into
the left retroperitoneum
Free rupture into the peritoneal
cavity is a lethal event.

Underestimates
diameter

Risk Factor
Modification

Aggressive HTN
therapy
Lipid medications

Open repair
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Asymptomatic
Lower extremity or
mesenteric ischemia

Thoracic Aortic
Aneurysm

Ballooning of the
upper aspect of the
aorta

Ascending
Thoracic
Aneurysm

Aneurysm in the
ascending aorta

Aortic Arch and

Descending
Thoracic
Aneurysm

Localized dilation of
the aortic arch or
descending aorta

Aortic Dissection

Spontaneous intimal
tear in the aorta
creates a false lumen
between the tunica
media and adventitia

Thromboembolism
Renal infarct
SVC syndrome

Tracheal deviation

Cough

Hemoptysis

Dysphagia

Steady, deep, severe

substernal / back /
neck pain

Etiologies

Etiologies

Test

Hoarseness

CXR

Laboratory
Result
Widened
mediastinum
Enlarged aortic
knob
Tracheal
displacement
Differentiate from
anterior
mediastinal mass

Echo
CT / MRI

Severe hypotension
(when ruptured)

Coronary
Angiography

Cystic medial necrosis

Bicuspid aortic valve
Aortic insufficiency
Arteritis / vasculitis
Collagen vascular
diseases
Hypertension
Syphilis (rare)
Atherosclerosis (rare)
ARCH

Assess
Most sensitive
diagnostic test
If surgery is
required

Treatment

Surgery (TEVAR)
Criteria

Medications

5.5 cm
ascending aorta
5.0 cm bicuspid
valve or Marfan's
Syndrome
4.5 cm aortic
valve replacement
6.0 cm
descending aorta

Treatment of possible pulmonary

complications
Aortic root replacement

Other
Extent I
Distal left subclavian artery
above renal arteries
Extent II
Distal left subclavian artery
aortic bifurcation
Extent III
6th intercostal space aortic
bifurication
Extent IV
Diaphgram aortic bifurcation
Extent V
6th intercostal space above renal
arteries

See Thoracic Aorta Aneurysm

Extension of ascending
or descending
aneurysms

See Thoracic Aorta Aneurysm

Hx of trauma or
deceleration injury
Atherosclerosis
Hypertension

Vasculitis

Congenital cardiac
disease

Hereditary connective
tissue disease

Trauma

(+) Cocaine

Tachycardia

Tachypenia

Acute ripping chest or

scapular pain

Neurological deficits

Shock

Hypotension (later)

JVD

Pulsus paradoxus

CHF

Acute aortic insufficiency

CXR

TEE

EKG

CT
MRA / MRI

Widened
Type A
mediastinum
Rupture
Widened aortic
Limb or visceral
silhouette
ischemia
Left-sided pleural
Saccular
effusion
morphology
Surgical Repair
Pericardial
Ongoing pain
(TEVAR) Criteria
effusion
Uncontrolled
hypertension
98% sensitive
Marfan's
99% specific
syndrome
LVH
Non-specific or
Aortic
inferior
insufficiency
abnormalities
Type B
Medical Therapy
Helpful when
Chronic
Criteria
acute
Asymptomatic
Aggressive BP control
Follow up

Debakey Classification
I - Ascending and descending
aorta
II - Ascending aorta only
III - Descending aorta only
Stanford Classifcation
A - Any involvement of ascending
aorta
B - No involving ascending aorta

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Peripheral
Arterial Disease

Systemic
atherosclerosis distal
to the aortic arch

Acute Arterial
Occlusion

Sudden blockage of an artery

due to an embolism or
thrombus

Giant Cell
Arteritis

Inflammatory disease of
blood vessels typically
involving the medium and
large vessels in the head

Raynaud's
Phenomenon

Excessively reduced blood

flow in response to cold or
emotional stress

Chronic Venous
Insufficiency

Dysfunctional venous values

in the lower extremities
cause irregular venous blood
flow

Varicose Veins

Dilated, tortuous superficial veins of

the lower extremities due to valve
incompetence and venous reflux

Superficial
Thrombophlebitis

Localized thrombosis
due to sluggish blood
flow

Laboratory
Treatment
Medications
Result
Smoking
PAD
Smoking cessation
Risk Factor
Diabetes
(< 0.9)
Intermittent
Modification
HTN
Exercise
Risk Factors
claudication
Hyperlipidemia
Ankle /
Sedentary lifestyle
(< 0.7)
Antiplatelet therapy
Brachial Index
Obesity
Rest pain
Ischemic rest pain
(< 0.4)
Intermittent claudication
(frequently nocturnal)
Impending tissue
(muscular pain in the
necrosis
Ischemic ulcers
Percutaneous revascularization
lower extremities)
Tissue necrosis
(< 0.1)
Diminished peripheral
Femoral bruits
Reduced blood
pulses
Cool skin
Angiography
flow through
Surgery
Abdnormal skin color
Poor hair growth
peripheral arteries
Sexual dysfunction
Revascularization
Pain
Pulselessness
Pallor
Paresthesia
Intra-arterial thrombolytic therapy
IV Heparin
Paralysis
Poikilothermia
Surgical thromboembolectomy
A-fib
Valvular disease
Ischemic disease
Surgical bypass
ESR
Headache
Scalp tenderness
Prevention of blindness
CRP
Prednisone
Blood Work
IL-6
Visual symptoms
Jaw claudication
Mild anemia
Thrombocytosis
Anti-inflammatory therapy
Blindness (opthalmic
Throat pain
Aspirin
Temporal
Diagnostic
artery occlusion)
Artery Biopsy
Lifestyle changes (gloves or warmer
Calcium Channel
Digital ischemia
Pallor
climate)
Blockers
Sympathectomy
Nitrates
Cyanosis Rubor
Subsequent vasodilation
Treat underlying condition
Leg elevation
History of DVT
Hx of leg trauma
Compression stockings
Medical therapy
Brawney skin
Edema
Exercise
pigmentation
NSAIDs
Leg massage
Venostasis ulcerations Puritic, dull discomfort
Weight loss
Vein Stripping
Varicose veins
Heavy, achy, tired legs
Endovenous laser ablation
Spider veins
Compression stockings
Asymptomatic
Dull, aching leg
Leg elevation
Endovenous ablation
Mild skin browning
Mild edema
Sclerotherapy
Visible dilated, tortous veins
Great saphenous vein stripping
Signs and Symptoms

Inflammation

Induration

Linear erythema

Tenderness

Fever
(septic phlebitis)

Chills
(septic phlebitis)

Test

Prevention (no long-term standing)

Local heat and elevation
Bed rest
Ligation surgery (with recurrence)
Anticoagulation therapy
Antibiotic therapy

NSAIDs

Other
Pain Location Related to Vessel
Buttock / Hip - Aortoiliac disease
Thigh - Common femoral artery
Upper Calf - Superficial femoral
artery
Lower Calf - Popliteal artery
Foot - Tibial / peroneal artery

TAAs are 17x more frequent in

patients with this disease

Primarily affects young

Etiologies
Genetics
Standing
Pregnancy
DVT
Trauma
Obesity
Sedentary lifestyle
Thrombophlebitis rare occurs due to
varicose veins

Septic phlebitis is most likely a

S. aureus infection.

Aspirin
Antibiotics

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Deep Venous
Thrombosis

Cause

Thromboembolus
involving deep veins
of lower extremities
or pelvis

Signs and Symptoms

Asymptomatic

Dull, aching pain in

calf / leg

Edema

Painful ambulation

Fever

Tachycardia
Homan's sign
Age
Cancer
Prior VTE

DVT Risk Factors in

Surgical Patients

Laboratory
Result
NEGATIVE
D-Dimer
(helpful)
LE Doppler /
Diagnostic
Ultrasound

Treatment

Test

VQ Scan or
Spiral CT

Thrombolytic therapy

If pulmonary
emboli suspected
DVT evidence
(3 points)
PE diagnosis
(3 points)
HR > 100 bpm
(1.5 points)

Medications

Heparin

Embolectomy

Immobilization /
Wells Criteria Surgery < 4 weeks
(1.5 points)
for PE

Obesity
Heart Failure
Paralysis
Hypercoaguable state

Warfarin

Previous DVT / PE
(1.5 points)
Cancer
(1 point)
Hemoptysis
(1 point)

IVC filter (trauma)

Other
80% deep veins of calf
20% femoral or iliac vein
Etiologies
Virchow's Triad
Preciptators
Hypercoarguable syndromes
Complications
Pulmonary embolism
Varicose veins
Chronic venous insufficiency
Ischemic limb
> 6 Wells score = highly likely
< 2 Wells score = highly unlikely
DVT Prevention with Surgery
Risk - < 40 yo + no additional
risk factors
Med. risk - < 40 yo + risk factor
40 - 60 yo
Risk - > 60 yo
40 - 60 yo + risk factors
Risk - > 40 yo + risk factors
Hip / knee arthroplasty
Major spinal trauma

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Generic Examples /
Brand Name
procanamide

Class IA

quinidine

Mechanism of Action

Indications

Pharmacokinetics
E: Hepatic or renal

Modulation of Na channels
to inhibit phase 0
Atrial tachyarrhythmias
depolarization

disopyramide

K+ channel blocker

lidocaine

Modulation of Na+
channels to inhibit
phase 0 depolarization

Contraindications

Adverse Effects

Heart failure

Blood dyscrasias
GI effects
Heart failure
Hypoglycemia

QT interval
Least used antiarrhythmic
drugs

CNS effects
Seizures
Aggravation of underlying conduction
disturbance
GI effects
Psychosis
Blurred vision
Dizziness
GI effects
Aggravation of heart failure
Aggravation of underlying conduction
disturbances
Fatigue
Bradycardia
Exercise intolerance
Erectile dysfunction
Pulmonary disorder exacerbation

QRS and PR interval (occurs

with toxic concentrations)

Ventricular
tachyarrhythmias

E: Hepatic

Class IB
mexiletime

flecainide

Class IC
propafenone

Class II

Class III

Class IV

Procainamide

Quinidine

Disopyramide

Ventricular arrhythmias

Modulation of Na+ channels

to inhibit phase 0
Atrial tachyarrhythmias
depolarization

E: Hepatic or renal
Ventricular
tachyarrhythmias

K+ channel blocker
Phase IV inhibitor

Atrial tachyarrhythmias

Ventricular
tachyarrhythmias

Sympathetic nervous
system inhibitor

Rate control

Polymorphic sustained
VT

E: Variable

Beta Blockers

dofetilide
ibutilide
sotalol
amiodarone
dronedarone

K+ channel blocker that

Atrial tachyarrhythmias
prolongs the AP palteau,
repolarization, and refactory (dofetilide and ibutilide)
period

Calcium Channel
Blockers

Ca2+ channel blocker to slow

conduction velocity through
the AV node and prolong
the refractory period

Procan

Na+ channel blocker that

prolongs the cardiac AP to
slow conduction

Quinidex

Norpace

Na+ channel blocker

that prolongs the
cardiac AP to slow
conduction
Modulation of Na+ channels
to inhibit phase 0
depolarization

E: Hepatic or renal
Ventricular
tachyarrhythmias
E: Hepatic

Rate control

A-fib / A-flutter
Monomorphic or
polymorphic sustained
VT

Atrial arrhythmias

M: Hepatic
Hemodynamically stable
E: Renal
VT
WPW
M: Hepatic
E: Renal

Chronic a-fib / a-flutter (not first line)

E: Renal (primarily) and

hepatic
Maintenance of sinus rhythm in patients with
a-fib / a-flutter

K+ channel blocker

Lidocaine

Xylocaine

Modulation of Na+ channels

to inhibit phase 0
depolarization

Sustained ventricular
tachycardia

Pulseless VT / V-fib

A: IV
t: Up to 12 hours in
cirrhosis and CHF

Structural heart disorders

Monitoring / Other

PR and QRS intervals

QT interval

Bradycardia
Complex, multi-organ effects
Nonsustained polymorphic VT
GI effects
AV block
Bradycardia
Heart failure exacerbation
Hypotension

Drug-induced lupus
Agranulocytosis
Torsades
Ventricular arrhythmias
Aggravation of heart failure
GI effects
Cinchonism
Hypotension
Torsades
Ventricular arrhythmias
Hemolytic anemia
Digoxin concentration
(when prescribed together)
GI effects
Anticholinergic symptoms
Heart failure
Aggravation of underlying conduction
abnormalities
Ventricular arrhythmias
Tosades
Confusion
Tremors
Paresthesias
Seizures

No adequate studies in
management of a-fib or aflutter

Significant (-) iontropic effects

Dose is determine by hepatic

function and cardiac output

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Generic Examples /
Brand Name

Mechanism of Action

Indications

Pharmacokinetics

Mexiletine

Mexitil

Modulation of Na
channels to inhibit
phase 0
depolarization

Flecainide

Tambocor

Modulation of Na+ channels to

inhibit phase 0 depolarization

Rythmol

Modulation of Na+
channels to inhibit
phase 0 depolarization

Propafenone

Dofetilide

Sotalol

Tikosyn

Betapace

K channel blocker
that prolongs the AP
palteau,
repolarization, and
refactory period

Ventricular arrhythmias

Maintenance of sinus
rhythm in patients with
a-fib / a-flutter

Pharmacologic
cardioversion of a-fib
Maintenance of sinus
rhythm

E: Renal and hepatic

Maintenance of sinus
E: Hepatic
rhythm in patients with Potent (-) inotropic agent
a-fib / a-flutter
Maintenance of sinus
rhythm

Pharmacologic
cardioversion of a-fib

Pharmacologic
cardioversion of
symptomatic
a-fib / a-flutter

Maintenance of sinus
rhythm in patients with
a-fib / a-flutter

E: Renal

Maintenance of sinus rhythm

K+ channel blocker that

prolongs the AP palteau,
repolarization, and refactory
period

Maintenance of sinus
rhythm

Chemical cardioversion

Monomorphic or
polymorphic
sustained VT

A-fib

Adrenergic inhibitor

Monomorphic or
polymorphic sustained
VT

Maintenance of sinus
rhythm

V-fib

Pulseless VT

Cordarone

Pacerone

Prolongs AP and
refractory period

D: tissue
accumulation
t: than amiodarone

Ibutilide

Structural heart disease

History of CAD

Systolic dysfunction

Maltaq

Derivative of
amiodarone

Corvet

K+ channel blocker that

prolongs the AP palteau,
repolarization, and refactory
period

CV hospitalization in patients with

persistant a-fib / a-fib / a-flutter
with a recent episode

Adverse Effects

Proarrhythmias
Dofetilide concentrations
QT prolongation
(with phenothiazines or
erythromycin)

QTc > 450 msec

LV dysfunction (use caution)
History of MI (use caution)

Bradycardia (with blockers)

QT prolongation
(with phenothiazines)
Electrolytes (with diuretics)

Class IV heart failure

2 and 3 AV block
Sick sinus syndrome
3A4 inhibitors
QT-prolonging drugs
QTc 500 msec
PR > 280 msec
Severe heaptic impairment
Pregnancy / lactation
Liver / lung toxicity

Monitoring / Other

CNS effects
Psychosis
GI effects
Aggravation of underlying conduction
abnormalities or ventricular
arrhythmias
Blood dyscrasias (rare)
EKG changes
Ventricular arrhythmias
GI effects
Blurred vision
GI effects
Aggravation of CHF
Ventricular arrhythmias

Cimetidine
Ketoconazole
Verapamil
Trimethoprim
Prochlorperazine
Megestrol
CrCl < 20 mL/min

AV node conduction
and sinus node function

Amiodarone

Dronedarone

Contraindications

A: oral bioavailability
M: Hepatic
t: 8 - 15 hours

QT prolongation
Pulmonary fibrosis (3 - 10%)
Hypothyroidism (20%)
Hyperthyroidism (5 - 10%)
Optic neuritis (1%)
Photophobia (75 - 90%)
Hepatic transaminases (5 - 20%)
Digoxin concentrations
INR (with warfarin)
Phenytoin toxicity
Proarrhythmic effects
(with sotalol)
GI disorders
Severe liver injury
Pulmonary toxicity
QT prolongation
(with erythromycin)
Bradycardia (with blockers)
Dematological disorders
10% serum creatinine
Digoxin concentrations

EKG
QT interval
Renal function
Electrolytes
Concomitant medications
3-day hospitalization to initiate
Baseline QTc < 440 msec
EKG
QTc
Electrolytes
Renal function

EKG
QT interval
Liver function
Pulmonary function
Thyroid function
Ophthalmic exam
Concomitant medications

EKG
QT interval
Electrolytes
Concomitant medications
Liver / renal function
Contains a lot less iodine than
amiodarone

A: IV
Maintenance of sinus
rhythm in patients with
a-fib / a-flutter

Pharmacologic
conversion of a-fib

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Antiarrhythmics
Type
1A
1B
1C

Generic Name
disopyramide
lidocaine
flecainide
propafenone
amiodarone

dronedarone
sotalol
dofetilide
ibutilide
digoxin
adenosine

Brand Name
Norpace
Xylocaine
Tambocor
Rythmol
Cordarone
Pacerone
Maltaq
Betapace
Tikosyn
Corvet
Lanoxin
Adenocard