Rapid Acquisition Of Key Concepts - Cardiovascular

Inotropes

Vasodilators

Diuretics

• Dobutamine
• Milrinone
• Levosimendan

• NTG
• Nesiritide
• Nitroprusside
• Serelaxin
• Ularitide

• Furosemide
• Torsemide
• Bumetanide
• Adjuvant Diuretics

Drug

Dose

Special Caution

Comments

Inotropic drugs

Dobutamine

2 to 20 μg/kg/min

• Increase myocardial oxygen demand. 
• Increase risk of arrhythmias.

• Short acting drug.
• Tendency of Development of tolerance over long term use.

Milrinone

0.375 to 0.75 μg/kg/min

• Hypotension
• Arrhythmias 

• Decrease its dose in renal insufficiency. 

Levosimendan

0.1 μg/kg/min

• Hypotension 
• Arrhythmias 

• Long acting
• No usage in hypotension.
• Effectiveness is similar to dobutamine. 

Vasodilators

Nitroglycerin

• 10 to 20 μg/min
• Max dose - 200 μ/min.
• Reduce preload and after load.

• Headache
• Tolerance
• Flushing

• Most common vasodilator but often underused.
• High dose is used to treat hypertension.

Nesiritide

• Bolus - 2 μg/kg

+

• Infusion - 0.01 μg/kg/min 

Hypotension

• It is not given with low BP.
• Adjust the dose in renal failure.

Sodium nitroprusside

• 0.3 μg /kg/min
• Can be titrated up to 5 μg/kg/min 

Thiocyanate toxicity - high in renal failure

• Given in arterial line.
• Can cause significant hypotension.

Serelaxin

30 μg/kg/day

Give when SBP > 125 mmHg 

• Not widely commercially available.
• Ineffective according to trials.

Ularitide

15 ng/kg

Given when SBP > 116 mmHg. 

• Causes hypotension. 
• Decrease renal perfusion and Increases serum creatinine 

Diuretics

Furosemide

20 to 240 mg/day

• Electrolyte monitoring 
• Associated with hypokalemia

• Used in severe congestion. 
• Give bolus followed by infusion.

Torsemide

10 to 100 mg/day

Monitor for hypokalemia 

• Given orally.
• High bioavailability 

Bumetanide

0.5 to 5 mg/day

Monitor for hypokalemia 

• Given orally.
• Intermediate bioavailability 

Peripheral signs 

Description 

Mayne's Sign

• Decrease in the diastolic blood pressure: 15 mmHg 
• Arms held above the head

Corrigan's Sign: Head

• Dancing carotid within the neck

De musset's Sign:Head 

• To and Fro movement of the head

Landolfi's Sign: Face

• Change in the pupil size with each cardiac systole

Lighthouse Sign: Face

• Flushing and blanching over the forehead 

Becker's Sign: Face

• Pulsations in the retinal artery

Muller's Sign: Face

• Pulsations over the uvula

Rosenbach's sign and Gerhardt's Sign: Abdomen

• Rosenbach's sign: Pulsations in the liver
• Gerhardt's Sign: Pulsations over the spleen

Traube's Sign: Lower limbs

• Pistol shot sounds
• Basically, booming sounds
• Heard over the femoral artery by placing the stethoscope

Duroziez's murmur and Duroziez's sign: Lower limbs

• Systolic murmur: Diaphragm is compressed proximally
• Diastolic murmur: Diaphragm is compressed distally

• Other Name: Duroziez's murmur

• Duroziez's sign: Systolic murmur + Diastolic murmur

Hill's Sign: Lower limbs

• Systolic blood pressure of bronchial artery, Systolic blood pressure of femoral artery: 10 mmHg
• Difference is >20 mmHg
• Detect the severity of the aortic regurgitation 
• Severe AR:>60 mmHg
• Specific sign of aortic regurgitation 

Shelley's Sign: Cervix

• Observed in females
• Pulsations over the cervix

Causes of Collapsing Pulse

Cardiac

High cardiac output states

Physiologic

A PDA Must Be Repaired

• Aortic regurgitation (most common cause)
• Patent ductus arteriosus (PDA)
• Defect (VSD: large)
• Aortopulmonary window
• Mitral regurgitation (severe)
• Block (complete heart block)
• Rupture of sinus of Valsalva

ABCD

• Anemia (Severe/AV fistula)
• Beriberi
• Cor pulmonale/ Cirrhosis
• Diseases (Paget’s, Grave’s)

• Fever 
• Pregnancy 

Paroxysmal AF

Persistent AF

Long Standing AF

Definition 

• Self-terminating or require cardioversion.
• Duration is <7 days

• No self-termination
• Duration >7 days

• >1 year

LA Size

• Normal or mild enlarged left atrium.
• Abnormal Focus is in the pulmonary vein generating abnormal impulse causing atrial fibrillation.

• Mild or severely enlarged left atrium 

• Severely enlarged LA

LA Scar Burden

• Low

• Moderate

• High due to arrhythmogenicity 

Efficacy- AAD

(Anti arrhythmic drugs)

• Often Effective

• Not as effective 

• Refractory

Ablation

• 1st line therapy 

• In case of AAD failure 

• After AAD failure 

Ablation technique 

• Origin of arrhythmogenicity – Pulmonary vein
• Pulmonary vein isolation 

• Pulmonary vein isolation + Ablation of Non pulmonary vein source

• Pulmonary vein isolation + additional ablation for LA scar 

Early Diastolic Murmur 

Mid-Diastolic Murmur 

Late Diastolic Murmur

• Heard in Aortic regurgitation, pulmonary regurgitation 

• Heard in Mitral stenosis, Tricuspid stenosis

• Rare

• AR murmur is heard better at 2nd right intercostal space/ 3rd left intercostal space.

• Increase on expiration.

• PR murmur is heard at 2nd left intercostal space- para sternal line. 

• Increase on inspiration

• MS heard at apex.
• TS heard at 4th/5th left intercostal space-para sternal line

Cardiac tamponade

Constrictive pericarditis

Paradoxical pulse

Present

⅓rd

Equal RT and LT sided pressure

Present

Present

Systemic venous morphology

Absence of Y wave

Prominent X and Y waves

Inspiratory change in SVP

Decreased

Increased presence of Kussmmaul sign

Square root sign

Absent

Present

Condition

Prophylaxis Strategy

High-risk nonorthopedic surgery 

Unfractionated heparin 5000 units SC bid or tid 

Enoxaparin 40 mg daily 

Dalteparin 2500 or 5000 units daily

Medical oncology 

Enoxaparin or dalteparin 

Rivaroxaban or apixaban 

Cancer surgery, including gynecologic 

cancer surgery 

Enoxaparin 40 mg daily, consider 1 month of prophylaxis

Major orthopedic surgery 

Warfarin (target INR 2.0-3.0) 

Enoxaparin 40 mg daily 

Dalteparin 2500 or 5000 units daily 

Fondaparinux 2.5 mg daily 

Rivaroxaban 10 mg daily, beginning 6-10 h postoperatively 

Aspirin 81-325 mg daily