Cardiac Miscellaneous Notes

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    Cardiac Miscellaneous Notes

1. Chest Pain – Cardiac vs Esophageal

  • Pain radiation is unreliable for distinguishing cardiac vs esophageal pain.

  • Both share overlapping visceral afferents → pain can radiate to arms, jaw, neck, back.

  • Clue:

    • Angina/vasospastic angina pain = lasts minutes.

    • Pain lasting hours → more likely non-cardiac (eg, esophageal).

2. Syncope

  • Orthostatic syncope: impaired vasoconstriction (eg, amlodipine use, autonomic dysfunction).

    • On standing → venous pooling → baroreceptors fail → ↓ cerebral perfusion → syncope.

  • Tilt-table test: helps distinguish orthostatic vs vasovagal syncope if recurrent.

  • CT head: not needed in typical vasovagal syncope, only if neuro symptoms present.

  • Conversion disorder: can mimic syncope (psychogenic pseudosyncope) but involves prolonged unresponsiveness (>5–10 min).

3. Postthrombotic Syndrome

  • Seen in >50% of patients after DVT.

  • Due to chronic venous insufficiency distal to clot.

  • Symptoms: leg pain, edema, fatigue, venous dilation, ulcers.

  • Treatment: compression stockings + exercise.

  • IVC filter: for DVT with contraindication to anticoagulation (eg, GI bleed, brain bleed).

4. Norepinephrine in Septic Shock

  • MOA:

    • α1 → vasoconstriction → ↑ SVR, ↑ perfusion.

    • β1 → supports cardiac output.

  • Use: First-line vasopressor after fluids in septic shock.

  • Pathophysiology: cytokines/NO → vasodilation + capillary leak → distributive shock.

5. Skin Disorders in Cardiac/Metabolic Context

  • Necrobiosis Lipoidica Diabeticorum (NLD):

    • Seen in diabetics (pretibial areas).

    • Multifocal brown lesions, telangiectasias, central atrophy.

    • May precede diabetes → check A1c/glucose.

  • Allergic Contact Dermatitis:

    • Localized, itchy, lichenified dermatitis at allergen exposure sites (eg, footwear).

    • Patch testing if chronic & resistant.

6. Uremic Pericarditis

  • Seen in renal failure with BUN >60 mg/dL.

  • Presentation: Pericarditis-like pain, friction rub.

  • Difference: ECG usually does NOT show diffuse ST elevation/PR depression, since myocardium not inflamed.

  • Treatment:

    • NSAIDs or colchicine + NSAID.

    • Steroids if NSAID contraindicated (renal disease).

    • Dialysis = best treatment.

    • Avoid anticoagulation (risk of hemorrhagic pericardial effusion).

7. Restrictive Cardiomyopathy

  • Cause: amyloidosis, sarcoidosis, hemochromatosis, radiation fibrosis.

  • Pathology:

    • Thick stiff LV walls → ↓ filling, restrictive physiology.

    • Small LV cavity, large atria.

  • Associated findings: proteinuria, neuropathy, hepatomegaly, GI bleeding (eg, amyloidosis).

8. Special Cardiovascular Mimics

  • IVC thrombosis: LE edema + ascites, but normal JVP and no proteinuria (distinguish from HF/nephrotic).

  • Thiamine deficiency (wet beriberi): dilated cardiomyopathy + high-output HF, not hypertrophic.

9. Pulsus Paradoxus

  • Defined: Fall in SBP >10 mmHg on inspiration.

  • Seen in: cardiac tamponade, severe asthma/COPD.

  • Mechanism in tamponade: inspiration → ↑ RV filling → septal shift into LV → ↓ LV stroke volume.

  • Absent in severe AR + tamponade: because ↑ LVEDP prevents septal shift.

10. Costochondritis

  • Most common musculoskeletal chest pain.

  • Localized, sharp, reproducible with palpation of costochondral joints.

  • Tx: reassurance, NSAIDs.

11. Chronic Venous Insufficiency (CVI)

  • Cause: valve incompetence in deep veins → venous HTN.

  • Symptoms: evening leg swelling, pain, heaviness, improved with elevation.

  • Signs: pitting edema, varicosities, telangiectasias, skin changes (hyperpigmentation, lipodermatosclerosis, medial malleolus ulcers).

  • Treatment: compression, leg elevation, exercise; duplex US if resistant.

12. Arrhythmia Emergency

  • Unstable patient (eg, hypotension, chest pain, confusion) + ventricular rate >150/min → emergency synchronized electrical cardioversion.

🔑 High-Yield Pearls from File

  • Pain radiation is not reliable for angina vs esophageal pain; duration is more helpful.

  • Orthostatic syncope = failure of baroreflex; tilt-table test if unclear.

  • Post-thrombotic syndrome is common after DVT, managed with compression.

  • NE is first-line vasopressor in septic shock (α1, β1).

  • Uremic pericarditis = pericarditis without ECG changes; treat with dialysis.

  • Pulsus paradoxus = tamponade, COPD/asthma; absent in AR + tamponade.

  • CVI = evening edema + ulcers (medial ankle).

  • Any unstable tachyarrhythmia (>150/min) → cardioversion.

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