Internal Medicine: Cardiology

The Electrocardiogram (ECG)

o *know the parts of the ECG tracing

ECG Component Normal Values and Interpretation

P wave 1. Less than 2 mm
2. Equal or less than to 3 small boxes
3. Duration: less than 0.12 secs or
less than 120 msecs.
4. Atrial depolarization, atrial
activation
PR interval 1. Duration: 0.12 to 0.20 secs or 120
to 200 msecs (or 0.22 secs)
2. 3 to 5 small boxes
3. Atrium to AV node; conduction
within AV node
QRS Complex 1. Duration: less than 0.11 to 0.12
secs or less 110 to 120 msecs
2. Less 3 small boxes
3. Ventricular activation
ST Segment 1. Phase 2 of transmembrane
potential
2. Isoelectric- level of PR segment
T wave 1. Ventricular repolarization
2. Upright after the age of 16
QT interval 1. Males: 0.35 to 0.43; Fem: 0.45
2. Beginning of QRS; end of T wave
3. Ventricular activation and
Recovery

Hypertension
o Read on BP Classification
o Causes of HTN:
 Renal Arterty Stenosis
 Atherosclerosis
 Fibromuscular dysplasia
 (+) abd bruit
 Renal Parenchymal dse
 Inc crea
 Abn UA
 COA
 35% in turner syn
 Diminished delayed femoral pulse

God Bless you! – Cabrera, NM

  CXR shows indentation of the aorta at the level of the coarctation and
rib notching
 Pheochromocytoma
 Cathecolamines; adrenal; VMA
 Tx: surgery
 Hyperaldostronism
 Tumor
 Hyperthyroid
o Drug
 Monoxidil-a vasodilator; not ideal for MI pt
 Hydralazine- ok in preggy; not ideal in MI patient
 Verapamil- contraindicated in 3rd deg AV block (this is a CCB; Mnemonics: VERY
NICE DRUGS- VND- Verapamil, Nifedipine, Diltiazem; Amlodipine)
 Beta blocker- not ok in pt w/ pulmo edema (OLOL drugs; Atenolol, propranolol,
metoprolol; know which is cardio-selective)
 ACE Inhibitors- for proteinuria; not ok in preggy; inc in bradykinin: what is the
side effect?; caution in pt with Renal artery sten (PRIL: Captopril; Enalapril)
 ARBS- for proteinuria; not ok for preggy; caution in pt with renal artery sten
(SARTAN: Losartan, Telmisartan)
 Methydopa- ok in preggy
o Laboratory


o Other treatment modalities

God Bless you! – Cabrera, NM

 ST Segment Elevation MI
o Review ECG (correlate): ST elevation, followed (if acute reperfusion is not achieved) by
T-wave inversion, then Q-wave development over several hours.
o Chest pain same w/ angina (review types of angina) MORE INTENSE AND PERSISTENT
o NOTE: NOT RELIEVED BY REST and NITROGLYCERINE (Read the MOA; Doc loves Pharma;
in some patients, this might cause hypotension)
o w/ nausea, sweating, apprehension
o Pallor, diaphoresis, tachycardia, S4, dyskinetic cardiac impulse may be present. If CHF
exists, rales and S3 are present. Jugular venous distention is common in right ventricular
infarction
o For precautionary measures during exam: memorize the cardiac biomarkers and its
normal values
o Initial Management: ASPIRIN 162 to 325 mg (important); Next: probably fibrinolysis
(again, pharma. Read me)
o Morphine for pain in STEMI; contraindicated in pt w/ pancreatitis (haha my favorite
question. Why bawal? Because it causes spasm sa sphincter of oddi)
o You may also read reperfusion therapy
UA and NSTEMI
o UA includes (l) new onset of severe angina, (2) angina at rest or with minimal activity,
and (3) recent increase in frequency and intensity of chronic angina. NSTEMI is
diagnosed when symptoms of UA are accompanied by evidence of myocardial necrosis
(e.g., elevated cardiac biomarkers). Some pts with NSTEMI present with symptoms
identical to STEMI-the two are differentiated by ECG findings
o ECG: May include ST depression and/or T-wave inversion; unlike STEMI, there is no Q-
wave development
o Cardiac biomarkers
Heart Failure
o Memorize NYHA Classification
o C/C: Dyspnea, fatigue
o Accompanied with edema and rales
o Includes (1) states that depress systolic ventricular function with reduced ejection
fraction (HFrEF; e.g., coronary artery disease [CAD], dilated cardiomyopathies, valvular
disease, congenital heart disease); and (2) states of heart failure with preserved ejection
fraction (HFpEF; e.g., restrictive cardiomyopathies, hypertrophic cardiomyopathy,
fibrosis, endomyocardial disorders), also termed diastolic failure. (you may also read me
in IM Plat, CHF Section; know the normal and abnormal Ejection fraction)
o Know the findings in every laboratory and imaging (helpful literature: Harrison’s manual;
I did not include cz its too long huhu.)
o Pharmacology is shortened in Harrison’s Manual. But I guess I could give you an
overview
 Fluid retention: Na Restriction (less 2g per day); fluid restriction; diuretic: loop
are most potent (furosemide); monitor weight, monitor urine output.
 ACEI: standard initial therapy; may cause hypotension in pt w/ volume depletion
 Beta blockers

God Bless you! – Cabrera, NM

  Aldosterone antagonist: caution in pt taking ACEI or ARBS: HYPERKALEMIA
(spironolactone)
 Digoxin: Not indicated in CHF due to pericardia( disease, restrictive
cardiomyopathy, or mitral stenosis
PAD
o C/C: intermittent claudication- Intermittent claudication is muscular cramping with
exercise, quickly relieved by rest.
o PE: Decreased peripheral pulses (ankle:brachial index <l.0, <0.5 with severe ischemia),
blanching of affected limb with elevation, dependent rubor (redness). Ischemic ulcers or
gangrene of toes may be present.
o Read: Ankle Brachial Index
AS
o Etiology: congenital (Unicuspid), pneumatic, degenerative (calcification, elderly)
o Football shaped opening
o Patho
 (+) pressure gradient: LA vs LV
 LV fxn maintained by hypertrophy
 LV Exhaustion: dec fxn
 Concentric LV hypertrophy
o S/sx: usually, dyspnea angina, syncope
o PE: pulsus tardus et parvus, soft split s2; s4 gallop; systolic ejection murmur (crescendo
decrescendo)
o Know the BEST test to be employed (usually 2D Echo)
o Important MGT: infective endocarditis prophylaxis; surgical REPLACEMENT is DEFINITIVE
AR
o Mechanism: ineffective coaptation
o PE: Wide Pulse pressure (40 or more); diastolic murmur
o You may read IM Plat Page 80 Section B

God Bless you! – Cabrera, NM