1. 심혈 관계 질환 Theory

Question 1

with auscultation, what are the 5 auscultation areas?

Answer 1

Auscultation Areas / 청진 부위

1. Aortic valve area: 2nd intercostal space, right sternal border / 대동맥판 부위: 2번째 갈비사이공간 흉골 우연.
2. Pulmonary valve area: 2nd intercostal space, left sternal border / 폐동맥판 부위: 2번째 갈비사이공간 흉골 좌연.
3. Erb’s area: 3rd intercostal space, left sternal border / Erb’s area: 3번째 갈비사이공간 흉골 좌연.
4. Tricuspid valve area: 4th to 5th intercostal space, left sternal border / 삼첨판 부위: 4~5번째 갈비사이공간 흉골 좌연.
5. Mitral valve area: Apical region / 승모판 부위: 심첨부.

Question 2

with auscultation, in an adult, which heart sounds are pathological?

Answer 2

1. S1 and S2 are normal heart sounds. In adults, S3 and S4 are pathological / S1, S2는 정상 심음입니다. 성인의 S3, S4는 병적입니다.

Question 3

with auscultation, what is the sequence of ehart sounds?

Answer 3

Sequence: Contraction starts -> Mitral valve closes (S1) -> Aortic valve opens -> Relaxation starts -> Aortic valve closes (S2) -> Mitral valve opens / 수축시작 -> 승모판 닫힘(S1) -> 대동맥판 열림 -> 이완시작 -> 대동맥판 닫힘(S2) -> 승모판 열림.

Question 4

with auscultation, when you hear an S3, what is actually happening?

Answer 4

S3 is heard during the phase when atrial pressure is higher than ventricular pressure

Question 5

with auscultation, in what cases is it normal to hear and S3 and what cases is it abnormal?

Answer 5

1. Compared to adults, healthy children and adolescents have more elastic ventricular muscles, allowing them to expand more quickly during diastole / 성인과 비교할 때 건강한 소아나 청소년의 경우 심실 근육의 신축성이 좋아서 이완기에 더 빠르게 잘 늘어날 수 있다고 합니다.
2. Thus, S3 is heard during childhood and adolescence as the “a” phase deepens and widens / 따라서 소아나 청소년기에 구간 a가 더 깊어지고 넓어 지면서 S3가 들리게 됩니다.
3. In adults with stiff myocardium, hearing S3 is pathological, such as in systolic heart failure / 심근이 딱딱한 성인에서 S3가 들리면 병적인 상황입니다. 대표적인 예로 수축기 심부전이 있습니다.
4. Systolic heart failure occurs when ventricular muscles attempt to exert greater contractile force and become overstretched / 수축기 심부전은 심실 근육이 더 큰 수축력을 발휘하려고 노력하다가 뻗어버려 축 늘어진 상황이라고 생각하시면 됩니다.
5. This leads to an enlarged ventricle with increased volume but decreased myocardial contractility, known as eccentric hypertrophy / 늘어져서 더 많은 혈액이 들어오게 되고 심실이 비대해
6. In conditions like MR and AR where there is volume overload leading to eccentric LVH, S3 is naturally heard / Volume overload가 생겨 eccentric LWH가 되는 MR과 AR에서도 S3가 당연히 들리겠죠.
7. S3 can also be heard in restrictive cardiomyopathy and constrictive pericarditis as the ventricle rapidly expands until relaxation is limited / 또한 제한 심근병증과 교착 심막염에서도 이완이 제한될 때까지 급격하게 심실이 늘어나게 되므로 S3가 들릴 수 있습니다.

Question 6

with auscultation, more in general really, what is eccentric hypertrophy?

Answer 6

1. Compared to adults, healthy children and adolescents have more elastic ventricular muscles, allowing them to expand more quickly during diastole / 성인과 비교할 때 건강한 소아나 청소년의 경우 심실 근육의 신축성이 좋아서 이완기에 더 빠르게 잘 늘어날 수 있다고 합니다.
2. Thus, S3 is heard during childhood and adolescence as the “a” phase deepens and widens / 따라서 소아나 청소년기에 구간 a가 더 깊어지고 넓어 지면서 S3가 들리게 됩니다.
3. In adults with stiff myocardium, hearing S3 is pathological, such as in systolic heart failure / 심근이 딱딱한 성인에서 S3가 들리면 병적인 상황입니다. 대표적인 예로 수축기 심부전이 있습니다.
4. Systolic heart failure occurs when ventricular muscles attempt to exert greater contractile force and become overstretched / 수축기 심부전은 심실 근육이 더 큰 수축력을 발휘하려고 노력하다가 뻗어버려 축 늘어진 상황이라고 생각하시면 됩니다.
5. This leads to an enlarged ventricle with increased volume but decreased myocardial contractility, known as eccentric hypertrophy / 늘어져서 더 많은 혈액이 들어오게 되고 심실이 비대해

Question 7

with auscultation, in what cases is it normal to hear an S4 and what cases is it abnormal?

Answer 7

S4 occurs due to the atrial kick at the end of ventricular diastole / S4의 경우 심실 이완기 말 atrial kick에 의해 발생합니다.

1. In a normal heart, the ventricle can expand enough to accommodate the blood influx from the atrial kick, so S4 is not heard / 정상 심장에서는 atrial kick을 할 때 심방에서 유입되는 혈액을 수용할 만큼 더 늘어날 수 있어서 S4가 들리지 않습니다.
2. S4 occurs when the heart is stiff and cannot stretch further to accommodate the incoming blood during the atrial kick, leading to a sound from the forced entry of blood / S4는 심장이 경직되어 atrial kick 시에 유입되는 혈액을 수용할 수 없는 경우, 억지로 심방이 쥐어 짜 넣어 발생한 와류로 인한 소리라고 생각하시면 쉽습니다.
   
   1. A typical example is AS / 대표적인 예는 AS입니다.
3. To squeeze blood through the narrowed valve, a significant force is required, leading to structural hypertrophy of the ventricular muscles / 좁아진 판막을 통해서 혈액을 짜내려면 상당한 힘이 필요하겠죠.
4. This hypertrophy occurs concentrically, making the ventricle resemble the shape of a rugby ball. This type of ventricular hypertrophy is known as concentric hypertrophy / 이런 심실비대는 동심원을 그리듯이 일어나 마치 심실이 럭비공 모양처럼 변합니다. 이런 심실비대를 concentric hypertrophy라고 합니다.
5. In this case, the ventricular wall becomes very thick and stiff / 이 경우 심실 벽이 매우 두꺼워지고 딱딱해집니다.
6. Therefore, when blood is forced in during the atrial kick, a vortex occurs, leading to S4 / 따라서 atrial kick 시에 억지로 혈액이 들어가면서 와류가 발생하여 S4가 들리게 됩니다.
7. S4 can also be heard in patients with hypertension or hypertrophic cardiomyopathy (H-CMP), where pressure overload occurs / 고혈압 환자나 비대 심근병증(H-CMP)에서도 pressure overload가 발생하는 경우 S4가 들릴 수 있습니다.
8. S4 can also be heard in MR due to the massive volume of blood in the ventricle at the end of diastole, adding more pressure during the atrial kick / MR에서도 S4가 들릴 수 있는데, 이는 이완기 말에 이미 심실 내에 많은 양의 혈액이 있어 atrial kick 시에 더 많은 압력을 가하기 때문입니다.

Question 8

With the chest exam, how to you examine the apex?

Answer 8

1. Apical impulse / 심첨 박동
   
   1. Use the tips of the second and third fingers for inspection and palpation / 시진 및 촉진에는 둘째, 셋째 손가락 끝을 이용합니다.
   2. Normal location: Located inside the midclavicular line in the 4th to 5th intercostal space, palpated in supine and left lateral decubitus positions / 정상 위치: 4~5번째 늑간 쇄골중앙선 안쪽에 위치하며, 앙와위 및 좌측와위에서 촉진됩니다.

Question 9

With the chest exam, what movement of the apex indicates left ventricular enlargement

Answer 9

When displaced to the left and downward: Indicates left ventricular enlargement (e.g., AR, MR, dilated cardiomyopathy) / 왼쪽, 아래쪽으로 치우쳐 있을 때: 좌심실 확장을 나타냅니다(예: AR, MR, dilated cardiomyopathy).

Question 10

With the chest exam, what movement of the apex indicates Right ventricular hypertrophy

Answer 10

Right ventricular hypertrophy: Sustained systolic lift in the left lower sternal border, synchronous with the LV apical impulse / 우심실 비대: 흉골 좌연 하부의 sustained systolic lift, LV 심첨 박동과 동기화됩니다.

Question 11

With the chest exam, what movement of the apex indicates severe MR

Answer 11

1. Severe MR: Occurs after the LV apical impulse. Due to the RV being pushed forward by the enlarged LA / severe MR: LV 심첨 박동 뒤에 일어납니다. 확장된 LA에 의해 RV가 앞으로 밀려나기 때문입니다.

Question 12

With the chest exam, what movement of the apex indicates

Answer 12

Severe TR: Similar phenomenon as MR occurs in the right parasternal area / severe TR: right parasternal area에서 MR과 같은 현상이 일어납니다.

Question 13

With the chest exam, what grade of murmurs would you be able to hear a thrill?

Answer 13

Thrill: Palpable, low-frequency vibrations associated with heart murmurs, observed in grade I/VI or higher murmurs / Thrill: palpable하며, 저주파의 진동이며, 심잡음과 관련 있으며, grade I/VI 이상의 심잡음에서 관찰됩니다.

Question 14

With the chest exam, what is a thrill?

Answer 14

Right ventricular hypertrophy: Sustained systolic lift in the left lower sternal border, synchronous with the LV apical impulse / 우심실 비대: 흉골 좌연 하부의 sustained systolic lift, LV 심첨 박동과 동기화됩니다.

Question 15

with the JVP, how do you examine and measure the JVP

Answer 15

1. Examination method: Position the patient at an angle of 30 to 45 degrees, and shine a light at a 90° angle to the jugular vein for examination. / 검사 방법: 30~45도 정도로 기댄 자세, 경정맥(ugular vein)과 90°로 빛을 비추어 검사
2. Jugular venous pressure: Reflects central venous pressure. / 정정맥압 (jugular venous pressure): central venous pressure 반영
   
   1. Normal findings: Reference range is 3-5cm.
      
      1. Measure the vertical distance from the sternal angle to the highest point of the internal jugular vein pulsation (adding 5 to the height gives the right atrial pressure). / 정상 소견: 참고치 3-5cm. 흉골각(sternal angle)으로부터 속 목정맥(internal jugular vein) 박동의 최고점까지의 수직거리를 측정(높이에 5를 더하면 우심방압)
      2. The suprasternal notch and sternal angle are different locations. / Suprasternal notch와 sternal angle은 다른 부위입니다.
      3. The sternal angle is used as a reference point because the center of the right atrium is located about 5cm below the sternal angle in most patients, regardless of their position. / 흉골각 (sternal angle)을 기준점으로 사용하는 이유는 우심방의 중심이 환자의 체위와 무관하게 대부분의 환자에서 흉골각으로부터 약 5cm 하방에 있기 때문이랍니다.

Question 16

with the JVP, what is the normal size of the JVP?

Answer 16

Normal findings: Reference range is 3-5cm./ 참고치 3-5cm

Question 17

with the JVP, when do you use the hepatojugular refluc?

Answer 17

1. Hepatojugular reflux/ 간경정맥 역류
   
   1. Pressing the center of the abdomen of a patient lying semi-supine for 10 seconds increases jugular venous pressure, and quickly releasing the hand results in a rapid decrease in JVP by about 4cm. / 간경정맥 역류(hepatojugular reflux): 비스듬히 누운 환자의 복부 중앙을 10초간 손으로 압박하면 경정맥압이 상승, 이후 손을 재빨리 떼면 JVP가 4cm 정도 급격하게 감소
   2. Useful in patients suspected of right ventricular failure but showing normal CVP. / 우심실부전이 의심되나 정상 CVP를 보이는 환자에서 유용
   3. Also used when confirming the typical JVP findings in patients with tricuspid regurgitation. / 삼첨판 역류 환자에서 전형적인 JVP 소견을 확인하는 경우에도 쓰임

Question 18

with the JVP, how do you do the hepatojugular reflux?

Answer 18

Pressing the center of the abdomen of a patient lying semi-supine for 10 seconds increases jugular venous pressure, and quickly releasing the hand results in a rapid decrease in JVP by about 4cm. / 간경정맥 역류(hepatojugular reflux): 비스듬히 누운 환자의 복부 중앙을 10초간 손으로 압박하면 경정맥압이 상승, 이후 손을 재빨리 떼면 JVP가 4cm 정도 급격하게 감소

Question 19

with the JVP, what is the sign where Instead of decreasing during inspiration, jugular venous pressure increases.

Answer 19

Kussmaul’s sign

Question 20

with the JVP, when do you see Kussmaul’s sign?

Answer 20

Kussmaul’s sign: Instead of decreasing during inspiration, jugular venous pressure increases. / Kussmaul’s sign: 정상적으로 흡기 시에 경정맥압이 하강하는데 오히려 증가하는 경우

1. Seen in constrictive pericarditis, right ventricular infarction, etc. / 교착성 심낭염(constrictive pericarditis), 우심실 경색 등
2. Kussmaul’s sign is not present in cardiac tamponade. / cf. 심장눌림증(cardiac tamponade)에서는 Kussmaul’s sign이 나타나지 않음

Question 21

with the JVP, what are the 5 elements in the waveform of the JVP?

Answer 21

1. A-wave: Atrial contraction at the end of diastole (atrial kick just before ventricular systole). / a파: 이완기말 심방수축 (심실 수축기 직전의 atrial kick)
2. C-wave: Bulging of the tricuspid valve (TV) towards the right atrium (RA) during ventricular contraction as the TV closes. / C파: 심실 수축시 삼첨판(TV) 닫히며 RA쪽으로 TV의 bulging
3. X-descent: Decrease in atrial pressure due to atrial relaxation. / x파: 심방 이완으로 압력 감소
4. V-wave: Peak blood inflow to the right atrium (RA) from the superior vena cava (SVC) and inferior vena cava (IVC). / V파: SVC, IVC로부터 RA로 혈액 유입이 peak
5. Y-descent: Blood inflow from the right atrium (RA) to the right ventricle (RV) during ventricular relaxation. / y파: 심실 이완으로 RA로부터 RV로 혈액 유입

Question 22

with the arterial pulse, what’s the most commonly used artery to check pulse

Answer 22

The radial artery is most commonly used, palpated with the second and third fingers / 요골동맥(radial artery)을 가장 흔히 이용, 둘째와 셋째 손가락으로 촉진함

Question 23

with the arterial pulse, how do you examine the carotid pulse?

Answer 23

The carotid pulse is examined by relaxing the patient’s neck and slightly turning their head towards the examiner before palpation / 목동맥파 (carotid pulse)는 환자의 목을 이완시키고 검사자 쪽으로 고개를 살짝 돌리게 한 다음 시진함

Question 24

(3) what 3 congenital disorders are inportant to know in relation to heart diseases?

Answer 24

• Definition: A genetic disorder caused by the presence of all or part of a third copy of chromosome 21.
• Defining Features:
  
  • Facial characteristics: Flattened face, especially the bridge of the nose, almond-shaped eyes that slant up, a short neck, small ears, and a large tongue relative to the mouth size.
  • Physical growth: Short stature and low muscle tone throughout life.
  • Intellectual disability: Varies from mild to moderate.
  • Congenital heart defects, such as AVSD, VSD, and ASD, are common.

• Definition: A chromosomal disorder affecting females, where one of the X chromosomes is missing or partially missing.
• Defining Features:
  
  • Short stature: Typically noticeable by about age 5.
  • Ovarian dysfunction: Leading to infertility and lack of spontaneous puberty in most cases.
  • Physical features: Webbed neck, low-set ears, low hairline at the back of the neck, and edema of the hands and feet.
  • Cardiovascular: Coarctation of the Aorta (CoA) and other cardiovascular anomalies.

• Definition: An autosomal dominant genetic disorder that affects the body’s connective tissue.
• Defining Features:
  
  • Skeletal: Tall stature with disproportionately long arms, legs, fingers, and toes; a protruding or indented chest; and a curved spine.
  • Ocular: Lens dislocation, myopia, and increased risk of retinal detachment.
  • Cardiovascular: Aortic aneurysm and dissection, which pose the most significant risk to life. Mitral valve prolapse is also common.

Question 25

(2) In general considerations, what cardiac conditions are common in people with Down’s syndrome?

Answer 25

1. Down syndrome: Ventricular Septal Defect (VSD), Atrioventricular Septal Defect (AVSD, ECD: most common), Atrial Septal Defect (ASD) / Down 증후군: VSD, Atrio Ventricular Septal Defect(AVSD, ECD: m/c), ASD

“ECD” likely stands for “Endocardial Cushion Defect,” which is another term often used to describe Atrioventricular Septal Defect (AVSD).

Question 26

(2) In general considerations, what cardiac conditions are common in people with Turner’s syndrome?

Answer 26

Turner syndrome: Coarctation of the Aorta (CoA) / Turner 증후군: 대동맥 축착(Coarctation of Aorta, CoA)

Question 27

(2) In general considerations, what cardiac conditions are common in people with Marfan’s syndrome?

Answer 27

Marfan syndrome: aortic aneurysm, aortic dissection / Marfan 증후군: aortic aneurysm, aortic dissection

Question 28

(2) In general considerations, how does right heart failure present differently to left heart failure?

Answer 28

1. Heart failure: Can lead to severe general weakness (cachexia) depending on the progression / 심부전: 진행 정도에 따라 심한 전신쇠약(악액질, cachexia)까지 발생 가능
   
   1. Right-sided - Systemic edema, congestive hepatomegaly, jugular vein distension / Right-sided - 전신부종, 울혈성 간비대, 경정맥확장
   2. Left-sided - Dyspnea, orthopnea / Left-sided- 호흡곤란, 기좌호흡(orthopnea)

Question 29

(2) In general considerations, how does someone with a valve disorder present?

Answer 29

Valve disorders: Symptoms of heart failure & auscultation findings and heart murmurs / 판막질환: 심부전 증상 & 청진소건 및 심잡음 소견

Question 30

(2) In general considerations, how does someone with myocardial disease present?

Answer 30

Myocardial disease: Symptoms of heart failure & characteristic echocardiographic findings / 심근질환: 심부전 증상 & 특징적 초음파 소건

Question 31

(2) In general considerations, how does someone with pericardial disease present?

Answer 31

Pericardial disease: Acute pericarditis involves fever accompanied by chest pain and a friction rub, cases of cardiac tamponade or constrictive pericarditis may present with pulsus paradoxus / 심막질환: 급성 심막염의 경우 열을 동반한 흉통 및 마찰음, 심장눌림증이나 교착 심막염의 경우 기이맥 소건

Question 32

(2) In general considerations, how does someone with ischemic heart disease present?

Answer 32

Ischemic heart disease: Characteristic chest pain (worsened by exercise, after eating, or cold exposure) / 허혈성 심장질환: 특징적인(운동 시, 식후, 찬바람에 의해 악화) 흉통

Question 33

(2) In general considerations, what is cachexia?

Answer 33

Cachexia: Refers to severe malnutrition and resulting general weakness seen in patients post-surgery, those with chronic diseases, or tuberculosis patients. / 악액질(Cachexia): 수술 직후의 환자나 만성 질환자, 결핵 환자 등에서 나타나는 심한 영양실조와 그로 인한 전신쇠약을 의미합니다.

Question 34

(2) In general considerations, what heart condition does cachexia point to?

Answer 34

1. Heart failure: Can lead to severe general weakness (cachexia) depending on the progression / 심부전: 진행 정도에 따라 심한 전신쇠약(악액질, cachexia)까지 발생 가능
   - While it can appear in various diseases and is not much helpful for diagnosis on its own, if a patient’s general weakness is accompanied by additional findings suggesting cardiac abnormalities, heart failure must be suspected. / 다양한 질환에서 나타날 수 있어 그 자체로는 진단에 거의 도움이 되지 못하나, 문제에서 환자의 전신쇠약과 함께 심장의 이상을 시사하는 추가적인 소견이 주어졌을 경우 심부전을 반드시 의심해야 합니다.

Question 35

(2) With chest pain guidelines, someone presents with chest pain, what are your first steps in terms of investigations?

Answer 35

Tests that must be performed in patients with chest pain: ECG, CXR + cardiac enzymes (when myocardial infarction is suspected) / 흉통 환자에서 반드시 시행해야 하는 검사: ECG, CXR + 심근효소(심근경색이 의심될 때).

• Note: Normal cardiac enzyme levels at the time of admission do not exclude the possibility of myocardial infarction! / 주의: 내원 당시 검사한 심근효소 수치가 정상이라고 해서 심근경색의 가능성을 배제할 수 없습니다!

Question 36

(2) With chest pain guidelines, if you suspect ischemic heart disease, what are your first steps in terms of investigations?

Answer 36

ECG and cardiac enzyme tests at the time of ER visit and 4 hours later / 응급실 방문 당시와 4시간 이후의 심전도, 심근 효소 검사

Question 37

(2) With chest pain guidelines, patient comes into the ER, you’re suspecting IHD (unstable/ stable angina), what’s your first step?

Answer 37

In cases where ischemic heart disease is suspected / 허혈성 심장질환이 의심되는 경우

1. Attempt sublingual nitroglycerin administration based on history / 병력에 따라 nitroglycerin 설하 투여를 시도해 본다.
2. ECG and cardiac enzyme tests at the time of ER visit and 4 hours later / 응급실 방문 당시와 4시간 이후의 심전도, 심근 효소 검사
3. In patients with angina where there are no specific contraindications: exercise stress ECG, stress echocardiography, stress perfusion imaging / 협심증 환자에서 특별한 금기가 없을 때: 운동부하 심전도, 부하 심초음파(stress echocardiography), 부하 심근관류스캔(stress perfusion imaging)

Question 38

(2) With chest pain guidelines, what is a test you can do for CAD?

Answer 38

Provocation test for coronary artery disease

Question 39

(2) With chest pain guidelines, in what patients would you do a myocardial perfusion scan?

Answer 39

Provocation test for coronary artery disease -> Replace with rest myocardial perfusion scan in patients with

persistent chest pain,

angina at rest,

or when it is unclear whether ECG findings due to old infarct

관상동맥질환에 대한 유발검사 -> 지속적 흉통, 안정 시 충통을 호소하는 환자나 ECG 소견이 old infarct에 의한 것인지 확신하지 못하는 경우 금기 -> 휴식 시 심근관류 스캔으로 대체

so basically they have CAD but also persistentn chest pain, angina at rest and unclear ECG

Question 40

(3) With chest pain guidelines, what is a provocation test and who would you do it on?

Answer 40

A provocation test for Coronary Artery Disease (CAD) is a type of diagnostic procedure used to induce or provoke symptoms or signs of coronary artery obstruction, which may not be present at rest but become evident under conditions that increase the heart’s workload.

There are various types of provocation tests, including:

1. Exercise Stress Test (Treadmill or Bicycle Ergometry)
2. Pharmacologic Stress Test: This is used for patients who are unable to perform physical exercise. Medications like dobutamine (which stimulates the heart) or vasodilators like adenosine or dipyridamole (which increase blood flow to the heart) are administered to simulate the effects of exercise on the heart.
3. Stress Echocardiography: This combines an echocardiogram (ultrasound of the heart) with an exercise or pharmacologic stress test. The echocardiogram is performed before and immediately after the stress test to look for changes in the heart’s function when it is made to work harder.

You would do it on patients with CAD who DON’T have this criteria

1. persistent chest pain,
2. angina at rest,
3. or when it is unclear whether ECG findings due to old infarct

Question 41

(2) With chest pain guidelines, in a patient with angina, will you hospitalize or not

Answer 41

Not all patients with UNSTABLE angina need to be hospitalized, but intensive ECG monitoring is necessary / 불안정 협심증 환자 모두를 입원시킬 필요는 없지만 심전도 집중 감시 필요

Question 42

(2) With chest pain guidelines, if you suspect that a patient has an aortic dissection, what are your first steps?

Answer 42

In cases where aortic dissection is suspected, obtain a line and perform contrast-enhanced CT as soon as possible! / 대동맥박리가 의심되는 경우 line 잡고 최대한 빨리 contrast enhanced CT 시행!

Question 43

(2) With chest pain guidelines, if you suspect a PE, what are your first steps

Answer 43

Pulmonary embolism is a condition that is often missed if not suspected; perform D-dimer tests and contrast-enhanced chest CT or pulmonary angiography / 폐색전증은 의심하지 않으면 놓치는 질환으로 D-dimer 검사와 contrast enhanced chest CT 또는 폐혈관 조영술 시행

Question 44

(2) With chest pain guidelines, if you have a patient with angina, what contraindications would there be for an exercise stress ECG

Answer 44

1. Physical Inability to Exercise: This can be due to orthopedic, neurologic, or musculoskeletal conditions that impair the ability to walk or pedal.
2. Inability to Achieve Target Heart Rate: Some patients may not be able to reach the required heart rate to adequately stress the heart due to various factors like age, medications, or a sedentary lifestyle.
3. Abnormal Baseline Electrocardiogram (ECG): Conditions such as left bundle branch block (LBBB), ventricular pacing, pre-excitation, or significant ST-segment abnormalities may interfere with the interpretation of a standard exercise ECG.
4. Significant Pulmonary Disease: Severe chronic obstructive pulmonary disease (COPD) or asthma may limit exercise capacity.
5. Significant Aortic Stenosis or Hypertrophic Cardiomyopathy: These conditions can be worsened by the increased workload of an exercise test.
6. Uncontrolled Hypertension: Very high blood pressure could be dangerous during exercise.
7. Recent Myocardial Infarction or Unstable Angina: Patients with recent heart attacks or unstable chest pain should not undergo stress testing due to the high risk of provoking another event.

Question 45

(2) With chest pain guidelines, if you suspect an angina, what are your first steps

Answer 45

In patients with angina where there are no specific contraindications: exercise stress ECG, stress echocardiography, stress perfusion imaging / 협심증 환자에서 특별한 금기가 없을 때: 운동부하 심전도, 부하 심초음파(stress echocardiography), 부하 심근관류스캔(stress perfusion imaging)

Question 46

(2) WIth chest pain, in terms of aortic stenosis, how does someone present?

Answer 46

1. The three main symptoms of aortic stenosis are angina, syncope, and dyspnea / 대동맥판막 협착증의 3대 증상은 협심증, 실신, 호흡곤란입니다.

Question 47

(2) WIth chest pain, in primary pulmonary hypertension, how does someone present?

Answer 47

1. In primary pulmonary hypertension → chronic pressure overload → right ventricular hypertrophy → they get angina becasue now there’s myocardial ischemia.
2. Other symptoms include dyspnea, orthopnea, cough, hoarseness, fatigue, dizziness, syncope, and palpitations

원발성 폐동맥 고혈압에서는 만성적인 압력 부하에 의한 우심실 비대가 생기고, 이로 인해 심근 허혈에 의한 협심증 증상이 생길 수 있습니다. 이외에 호흡곤란, 기좌호흡, 기침, 신목소리, 피로, 어지러움, 실신, 심계항진 등의 증상도 나타날 수 있습니다.

Question 48

(3) with blood pressure medication and its link to syncope, tell me about valsartan

Answer 48

1. Valsartan is an antihypertensive medication that belongs to a class known as Angiotensin II Receptor Blockers (ARBs). It works by blocking the action of angiotensin II, a potent vasoconstrictor, on its receptors in the blood vessels. This action leads to vasodilation, or the widening of blood vessels, which in turn lowers blood pressure.
2. Beyond its primary use in managing hypertension, valsartan is also indicated for treating heart failure and can be prescribed following a myocardial infarction (heart attack) to improve survival and reduce hospitalization for heart failure. Its effectiveness in protecting kidney function in patients with diabetes who have proteinuria (excess protein in urine) makes it a versatile tool in cardiovascular and renal protection.
3. Valsartan is generally well-tolerated, but like all medications, it can have side effects. The most common ones include dizziness, headaches, and sometimes dizziness upon standing up due to a drop in blood pressure. It’s distinct from ACE inhibitors, another class of blood pressure medications, as it doesn’t typically cause the cough associated with ACE inhibitors but still carries a warning for angioedema, a rare but serious swelling of the deeper layers of the skin.

Question 49

(2) with vasoactive agents, draw a table with the 6 vasoactive agents and describe their effect on haemodynamics (HR, MAP, CO, SVR)

Answer 49

[picture]

Question 50

(3) with vasoactive agents, what is a lusitropic medication?

Answer 50

1. Lusitropy refers to the process that affects the relaxation of the heart muscle, specifically during the diastolic phase when the heart chambers are filling with blood. A positive lusitropic effect means enhanced relaxation and faster filling, which is crucial for efficient heart function, especially in conditions where diastolic dysfunction is present.
2. Drugs or substances that exhibit positive lusitropic effects can help improve heart relaxation and filling. For example:
   
   1. Calcium channel blockers (specific types): Certain calcium channel blockers can enhance lusitropy by reducing calcium influx during the cardiac action potential, leading to better myocardial relaxation.

Question 51

(2) with vasoactive agents, with norepinephrine, what is the principle mechanism (what receptor does it go through?)

Answer 51

alpha 1 adrenergic

less beta 1 and beta 2

Question 52

(2) with vasoactive agents, with epinephrine high dose, what is the principle mechanism (what receptor does it go through?)

Answer 52

alpha 1 adrenergic

less beta 1 and beta 2

Question 53

(2) with vasoactive agents, with dopamine high dose, what is the principle mechanism (what receptor does it go through?)

Answer 53

alpha 1 adrenergic

less dopaminergic

Question 54

(2) with vasoactive agents, with epinephrine low dose, what is the principle mechanism (what receptor does it go through?)

Answer 54

beta 1 adrenergic

beta 2 adrenergic

less alpha

Question 55

(2) with vasoactive agents, with dopamine low dose, what is the principle mechanism (what receptor does it go through?)

Answer 55

dopaminergic, beta 1 adrenergic

Question 56

(2) with vasoactive agents, with dobutamine, what is the principle mechanism (what receptor does it go through?)

Answer 56

beta 1 adrenergic

Question 57

(3) with vasoactive agents, what is the difference between inotropy and chronotropy?

Answer 57

1. Inotropy is all about the strength or force of the heart’s contractions. A positive inotropic effect means the heart is pumping harder, pushing out more blood with each beat. This is crucial when the body needs more oxygen, like during exercise or stress. Negative inotropy, on the other hand, means weaker heart contractions, which might be desirable in certain heart conditions to reduce workload and oxygen demand.
2. Chronotropy, conversely, deals with the heart rate. A positive chronotropic effect speeds up the heart rate, which can be beneficial in some situations like responding to physical activity or stress. A negative chronotropic effect slows down the heart rate, which can be therapeutic in conditions where a slower heart rate is needed to decrease oxygen consumption or to control arrhythmic conditions.
3. So, while inotropy is about the punch each heartbeat packs, chronotropy is about the tempo of the heart’s rhythm. Both are pivotal in managing cardiac function and are influenced by various drugs and the autonomic nervous system.

Question 58

(2) with vasoactive agents, what does the beta 2 adrenergic receptor do?

Answer 58

1. vasodilation
2. β2 receptors are a bit like the peacekeepers among the adrenergic family, mostly hanging out in the vasculature of skeletal muscles. They’re all about dialing down the tension, promoting vasodilation, which in turn takes a load off the SVR. Their influence on the heart is more subtle compared to the β1 squad, but the drop in SVR they orchestrate can lead to interesting shifts in MAP, usually counterbalanced by the increased efficiency in blood delivery thanks to more relaxed vessels.

Question 59

(2) with vasoactive agents, what does the beta 1 adrenergic receptor do?

Answer 59

1. inotropy and chronitropy
2. Moving on to our β1 receptors, these are the heart’s cheerleaders. Located in the myocardium and the conduction pathways, they boost both the heart rate and the contractility. It’s like turning up the volume on the heart’s performance, which naturally ups the cardiac output. And since cardiac output is a major player in the MAP equation, β1’s actions are pretty central to cardiovascular management.

Question 60

(2) with vasoactive agents, what does the alpha 1 adrenergic receptor do?

Answer 60

1. vasoconstriction
2. So, when we’re talking α1 adrenergic receptors, we’re looking at their prime real estate on vascular smooth muscles. Their modus operandi? Vasoconstriction. This bumps up the systemic vascular resistance (SVR) and, as a side effect, nudges the mean arterial pressure (MAP) northward. They’re kind of the behind-the-scenes players affecting heart dynamics more indirectly.

Question 61

(2) with vasoactive agents, what factors make up a haemodynamic response?

Answer 61

1. HR
2. MAP
3. CO
4. SVT (systemic vascular resistance)

Question 62

(3) with vasocative agents, with norepinephrine, what pathway/ receptors does it go through and how does that affect the heart?

Answer 62

1. norepinephrine
   
   1. Primarily plays in the α1-adrenergic receptor field, leading to potent vasoconstriction and hence, a spike in blood pressure. Its action on β1-adrenergic receptors is a bit more subdued but still significant, especially in the context of treating severe hypotension and shock.

Question 63

(3) with vasocative agents, with epinephrine, what pathway/ receptors does it go through and how does that affect the heart?

Answer 63

1. epinephrine
   
   1. The quintessential ‘fight or flight’ hormone, acting on both α and β-adrenergic receptors. It’s fascinating how it can both increase cardiac output and manage systemic vascular resistance, making it invaluable in anaphylaxis, cardiac arrest, and severe asthma exacerbations.

Question 64

(3) with vasocative agents, with dopamine, what pathway/ receptors does it go through and how does that affect the heart?

Answer 64

1. dopamine
   
   1. A bit of a multitasker, dopamine at low doses prefers its own receptors (dopaminergic), but as we increase the dose, it starts to engage β1-adrenergic receptors, enhancing cardiac output, and at even higher doses, it doesn’t shy away from α1-adrenergic receptors, leading to vasoconstriction. It’s a go-to in treating hypotension and shock, offering a nuanced approach depending on the dose.

Question 65

(3) with vasocative agents, with dobutamine, what pathway/ receptors does it go through and how does that affect the heart?

Answer 65

1. dobutamine
   
   1. This one’s interesting because it primarily targets β1-adrenergic receptors in the heart, boosting myocardial contractility and heart rate, which is particularly useful in heart failure management or during cardiac stress testing to assess coronary artery disease.

Question 66

(3) with vasoactive agents, what are some good examples of vasoactive agents?

Answer 66

1. dobutamine
   
   1. This one’s interesting because it primarily targets β1-adrenergic receptors in the heart, boosting myocardial contractility and heart rate, which is particularly useful in heart failure management or during cardiac stress testing to assess coronary artery disease.
2. dopamine
   
   1. A bit of a multitasker, dopamine at low doses prefers its own receptors (dopaminergic), but as we increase the dose, it starts to engage β1-adrenergic receptors, enhancing cardiac output, and at even higher doses, it doesn’t shy away from α1-adrenergic receptors, leading to vasoconstriction. It’s a go-to in treating hypotension and shock, offering a nuanced approach depending on the dose.
3. epinephrine
   
   1. The quintessential ‘fight or flight’ hormone, acting on both α and β-adrenergic receptors. It’s fascinating how it can both increase cardiac output and manage systemic vascular resistance, making it invaluable in anaphylaxis, cardiac arrest, and severe asthma exacerbations.
4. norepinephrine
   
   1. Primarily plays in the α1-adrenergic receptor field, leading to potent vasoconstriction and hence, a spike in blood pressure. Its action on β1-adrenergic receptors is a bit more subdued but still significant, especially in the context of treating severe hypotension and shock.
5. Other common examples
   
   1. nitroglycerin, used for chest pain,
   2. certain antihypertensive drugs like ACE inhibitors (enalapril) or calcium channel blockers (amlodipine/ nefidipine)
      
      1. These agents work by relaxing the smooth muscles in the blood vessel walls, allowing the vessels to expand.

Question 67

(3) with vasoactive agents, what is a vasoactive agent

Answer 67

1. substance that promotes the dilation or widening of blood vessels.
2. This action can increase blood flow and decrease blood pressure.
3. Common examples
   
   1. nitroglycerin, used for chest pain,
   2. certain antihypertensive drugs like ACE inhibitors or calcium channel blockers.
      
      1. These agents work by relaxing the smooth muscles in the blood vessel walls, allowing the vessels to expand.

Question 68

(2) in syncope like states, what are the 4 most common conditions/ presentations that present like a syncope

Answer 68

1. Anxiety or panic attacks, which can be reproduced by hyperventilation / 불안이나 공황 발작(과호흡으로 재연 가능).
2. Hypoglycemia, seizures, acute bleeding / 저혈당, 경련, 급성 출혈.
3. Acute intoxication, such as with alcohol / acute intoxication (예: 알코올).
4. Psychogenic syncope, sleep disorders / psychogenic syncope, 수면 장애.

Question 69

(3) in the general cerebrovascular causes of syncope, tell me about vertebrobasilar insufficiency - what is it and how it leads to syncope

Answer 69

• Impaired Blood Flow in the Posterior Circulation: The vertebrobasilar system supplies the brainstem, cerebellum, and occipital cortex. Insufficiency can result from atherosclerosis, arterial dissection, or other pathologies affecting these arteries.
• Clinical Presentation: Symptoms are quite distinct due to the territories supplied, including vertigo, ataxia, bilateral sensory disturbances, and even ‘drop attacks’.
• Diagnostic Approach: Imaging studies like MRI/MRA or CT angiography are key in diagnosis, alongside clinical evaluation.

Vertebrobasilar insufficiency leading to syncope is particularly intriguing because it involves the brainstem, where vital cardiovascular and respiratory control centers reside. Transient reductions in perfusion to these critical areas can result in syncope, especially in positions or conditions that exacerbate the insufficiency, like extreme head rotations that could further compromise vertebral artery flow.

Question 70

(3) in the general cerebrovascular causes of syncope, tell me about carotid artery stenosis - what is it and how it leads to syncope

Answer 70

• Narrowing of the Carotid Arteries: Typically due to atherosclerosis, where plaque buildup reduces blood flow to the brain. It’s like a narrowing highway leading to the brain’s vital regions.
• Symptoms and Risks: Can lead to transient ischemic attacks (TIAs) or strokes. Patients might experience transient weakness, difficulty speaking, or vision changes, depending on which brain territory is affected.
• Detection and Management: Often identified through duplex ultrasonography or angiography. Management can range from medical therapy to interventions like carotid endarterectomy or stenting, especially when stenosis is significant and symptomatic.

In the context of syncope, while not the most common cause, significant carotid artery stenosis can contribute to cerebral hypoperfusion, particularly if there’s a compromise in the collateral circulation or during periods of systemic hypotension.

Question 71

(3) in general cardiac causes leading to syncope, tell me about primary pulmonary hypertension - what it is and how it leads to syncope

Answer 71

• Elevated Pulmonary Arterial Pressure: Absent secondary causes, leading to right ventricular hypertrophy and potential failure. The right heart really gets put through the wringer here.
• Progressive Dyspnea: A hallmark, alongside signs of right heart failure. The increased afterload on the right ventricle can eventually compromise systemic circulation, setting the stage for syncope.

Question 72

(3) in general cardiac causes leading to syncope, tell me about cardiac tamponade - what it is and how it leads to syncope

Answer 72

• Intrapericardial Pressure Increase: Fluid accumulation compresses the heart, restricting filling. The hemodynamics get thrown off balance quickly.
• Reduced Stroke Volume: Due to impaired ventricular filling, leading to decreased cardiac output. It’s a direct pathway to syncope if not promptly relieved.

Question 73

(3) in general cardiac causes leading to syncope, tell me about pulmonary embolism- what it is and how it leads to syncope

Answer 73

• Vascular Obstruction: Typically by a thrombus, leading to increased pulmonary arterial pressure. It’s a sudden stress test for the right ventricle.
• Right Ventricular Strain: Manifests with hypoxemia and elevated biomarkers. The strain on the right heart can reduce left ventricular preload, leading to systemic hypotension and potential syncope.

Question 74

(2) in general cardiac causes, what other cardiovascular causes can lead to syncope?

Answer 74

1. Pulmonary embolism, cardiac tamponade, primary pulmonary hypertension / 폐색전, 심낭 압전, 원발성 폐동맥 고혈압 등.

Question 75

(3) in tachyarrythmias leading to syncope, tell me about Torsades de pointes- what it is and how it leads to syncope

Answer 75

• Prolonged QT Interval: A setup for Torsades, whether from congenital syndromes or acquired causes like medications. It’s all about delayed repolarization.
• Polymorphic VT: The QRS complexes twist around the isoelectric baseline, visually striking on the ECG. The unpredictability in ventricular ejection is what can precipitate syncope.

Question 76

(3) in tachyarrythmias leading to syncope, tell me about SVT - what it is and how it leads to syncope

Answer 76

• Atrial Fibrillation: Rapid, disorganized atrial depolarizations leading to irregular ventricular response. It’s the most common arrhythmia, you know, with significant stroke risk due to atrial stasis.
• Atrial Flutter: Characterized by rapid, regular atrial contractions due to a reentrant circuit, often in the right atrium. It’s like the atria are stuck on a looped track.
• AVNRT: Involves a reentrant circuit within the AV node itself. It’s fascinating how a tiny area can cause such significant rhythm issues.
• WPW Syndrome: Features an accessory pathway, leading to pre-excitation of the ventricles. The delta wave on ECG is a classic, right?

The link to syncope? Rapid heart rates compromise ventricular filling, reducing cardiac output and, thus, cerebral perfusion.

Question 77

(2) in tachyarrythmias causing syncope, what are examples of tachycardic arrythmias causing syncope?

Answer 77

1. Supraventricular tachycardia: atrial flutter/fibrillation, AV node reentry, WPW syndrome / 상심실성 빈맥(supraventricular tachycardia): 심방조동/세동, 방실결절회구(AV node reentry), WPW 증후군.
2. Ventricular tachycardia: occurs with structural heart disease / 실신빈맥(ventricular tachycardia): 구조적 심질환이 있을 때.
3. Torsades de pointes: conditions with prolonged QT interval (long QT syndrome, hypokalemia, hypocalcemia, etc.) / Torsades de pointes: QT 간격이 길어지는 조건(long QT syndrome, hypokalemia, hypocal-cemia 등).
4. Pulmonary embolism, cardiac tamponade, primary pulmonary hypertension / 폐색전, 심낭 압전, 원발성 폐동맥 고혈압 등.

*basically anything that messes with cerebral perfusion

Question 78

(3) in bradyarrythmias leading to syncope, tell me about AV block - what it is and how it leads to syncope

Answer 78

• Impaired Conduction: The electrical signals from the atria to the ventricles are delayed or blocked. It’s as if the communication lines between the two chambers are down.
• Classifications: Ranges from first-degree (delayed conduction without missed beats) to third-degree (complete block with no atrial signals reaching the ventricles).
• Variable Symptoms: Depending on the degree and the backup pacing from lower cardiac nodes. Third-degree blocks can be particularly concerning due to the reliance on slower, less effective ventricular pacemakers.

With AV block, particularly the higher degrees, the reduced ventricular rate can lead to significant drops in cardiac output, potentially leading to episodes of syncope, especially if the ventricular escape rhythms are insufficient.

Question 79

(3) in bradyarrythmias leading to syncope, tell me about sick sinus syndrome - what it is and how it leads to syncope

Answer 79

• Dysfunctional Sinoatrial Node: The pacemaker of the heart isn’t keeping time properly. It’s like the conductor of the orchestra is missing beats.
• Variety of Manifestations: Can include sinus bradycardia, sinus pauses, or even episodes of tachycardia (tachy-brady syndrome). The rhythm can swing unpredictably.
• Symptomatic Presentation: Often presents with fatigue, dizziness, or syncope due to inadequate heart rate response to physiological demands. It’s a tricky condition because the symptoms can be so variable.

The essence of SSS leading to syncope is the heart’s inability to maintain an adequate rate, compromising cardiac output and cerebral blood flow

Question 80

(2) in bradyarrythmias leading to syncope, what drugs specifically can induce the bradycardia which can induce the syncope?

Answer 80

1. Bradycardia induced by drugs/ 약물에 의한 서맥
   
   1. antiarrhythmics
   2. β-blockers
   3. calcium channel blockers
   4. digoxin

~~~

1.	**Antiarrhythmics**: These are used to treat abnormal heart rhythms (arrhythmias). Common examples include:
•	**Amiodarone** (Cordarone, Pacerone)
•	Lidocaine (Xylocaine)
•	Propafenone (Rythmol)
•	Flecainide (Tambocor)
2.	**β-Blockers** (Beta-blockers): These drugs reduce the heart rate and the heart’s workload. They are often used to treat high blood pressure, angina, and other conditions. Common examples include:
•	**Atenolol** (Tenormin)
•	Metoprolol (Lopressor, Toprol-XL)
•	Propranolol (Inderal LA, InnoPran XL)
•	Carvedilol (Coreg)
3.	**Calcium Channel Blockers**: These drugs prevent calcium from entering the cells of the heart and blood vessel walls, leading to lower blood pressure. They are used to treat high blood pressure, angina, and some arrhythmias. Common examples include:
•	**Amlodipine** (Norvasc)
•	Diltiazem (Cardizem, Tiazac)
•	Verapamil (Calan, Verelan)
•	Nifedipine (Adalat CC, Procardia XL)
4.	**Digoxin**: This is a type of cardiac glycoside, often used in the treatment of heart failure and certain types of arrhythmias. It increases the force of heart muscle contractions and can slow the heart rate. Common brand names include:
•	Lanoxin

Question 81

(2) in bradyarrythmias leading to syncope, what are examples of bradycardic arrythmias causing syncope?

Answer 81

1. Asystole, sick sinus syndrome, AV block / 동정지, 동기능부전증후군(sick sinus syndrome), 방실전도장애(AV block).
2. Bradycardia-tachycardia syndrome / 서맥-빈맥 증후군(bradycardia-tachycardia syndrome).
3. Bradycardia induced by drugs: antiarrhythmics, β-blockers, calcium channel blockers, digoxin / 약물에 의한 서맥: antiarhythmics, β-blocker, calcium channel blocker, digoxin.

*basically anything that messes with cerebral perfusion

Question 82

(2) in general arrythmias causing syncope, explain how the arrythmias lead to the syncope

Answer 82

1. Most cases occur due to arrhythmias, failing to maintain cardiac output due to regulation of stroke volume when HR < 30/min or > 180/min / 대부분 부정맥에 의해 발생, HIR < 30/min 혹은 > 180/min인 경우 1회 박출량(stroke volume) 조절에 의한 심박출량(cardiac output) 유지 실패.
2. This leads to cerebral ischemia and syncope (often without prodromal symptoms) / 뇌 허혈 및 실신(실신 전구 증상이 없는 경우가 많음).

*basically anything that messes with cerebral perfusion

Question 83

(3) in situational syncope, in a situation where you do the Valsalva manoeuvre, tell me, what are the use cases of this Valsalva manoeuvre

Answer 83

• Termination of Supraventricular Tachycardias (SVTs): Increases vagal tone to slow heart rate and interrupt reentrant circuit pathways, often effectively terminating the arrhythmia.
• Management of Atrial Fibrillation: Can transiently control heart rate in cases of atrial fibrillation, providing symptomatic relief.
• Testing for Heart Disease: Helps in diagnosing conditions like hypertrophic cardiomyopathy by observing the blood pressure response, which may vary from the norm in such patients.
• Ear Pressure Equalization: Assists in equalizing ear pressure during rapid altitude changes, such as in diving or air travel, preventing barotrauma.
• Reduction of Varicose Veins Symptoms: Briefly increases venous pressure, potentially providing temporary relief from discomfort associated with varicose veins.
• Assessment of Autonomic Function: Used in autonomic testing to evaluate the cardiovascular response, aiding in the diagnosis of autonomic dysfunction or neuropathy.

Question 84

(2) in situational syncope, in what situations does it happen?

Answer 84

1. coughing 기침
2. urinating 배뇨
3. defecating 배변
4. Valsalva maneuver - respiratory technique that involves a person attempting to exhale forcefully with the airway closed, usually by pinching the nose and closing the mouth, creating a pressure difference within the chest cavity.
5. deglutition (swallowing) 삼킴운동(deglutition)

Question 85

(2) with carotid sinus hypersensitivity, how does it happen? (signal pathway)

Answer 85

1. Mainly occurs when the baroreceptors in the carotid sinus are pressed in men over 50 years old. / 50세 이상의 남성에서 목동맥팽대 압력수용기(baroreceptor)를 압박하는 경우 주로 나타난다.
2. The signal is transmitted through the 9th cranial nerve (glossopharyngeal nerve) / 9번 뇌신경(glossopharyngeal nerve)으로 전달
3. → then through the medulla oblongata / 숨뇌를 거쳐
4. → to the vagus nerve which leans to the heart / 미주신경을 통해 심장으로 신호 전달
5. → which eventually leads to asystole, atrioventricular block / 동정지, 방실차단 유발

Question 86

(3) with carotid sinus hypersensitivity, what even is it?

Answer 86

1. Carotid sinus hypersensitivity is a condition
2. that involves an exaggerated response to stimulation of the carotid sinus.
3. The carotid sinus is a region located at the bifurcation (branching point) of the common carotid artery into the internal and external carotid arteries, primarily in the neck.
4. This area contains baroreceptors, which are specialized nerve cells sensitive to changes in blood pressure.

Question 87

(2) with postural hypotension, what is the pharmacological treatment if non-pharmacological doesn’t work?

Answer 87

1. Pharmacological treatment (if non-pharmacological treatment fails) / 약물 치료 (비약물치료 실패 시)
   
   1. Fludrocortisone / Fludrocortisone
   2. Vasoconstricting agent (midodrine, pseudoephedrine) / Vasoconstricting agent(midodrine, pseudoephedrine)
   3. If there is no effect with the above drugs, additional treatments such as pyridostigmine (cholinesterase inhibitor), yohimbine, desmopressin, and erythropoietin can be considered / 위 약물로 효과 없을 시 추가 치료로 pyridostigmine (cholinesterase inhibitor), yohimbine, desmopressin, erythropoietin을 써 볼 수 있음

Question 88

(3) with the treatment of postural hypotension, what medications do you need to remove?

Answer 88

1. Medications that induce or aggravate orthostatic hypotension
   
   1. (e.g., amitriptyline and other antidepressants, diuretics and other antihypertensive agents, alpha-blockers, sildenafil and other phosphodiesterase-5 inhibitors, centrally acting muscle relaxants such as tizanidine) should be carefully reviewed and eliminated
   2. Even “bladder-selective” alpha-blockers, such as tamsulosin, can aggravate orthostatic hypotension in older men, and may increase the risk of hip fracture

Question 89

(2) with postural hypotension, how do you treat it? / 치료

Answer 89

1. Remove inducing factors (mainly medications) / 유발 요인(주로 약물)을 제거
2. Non-pharmacological treatments: Wearing compression stockings, raising the head of the bed, increasing fluid and salt intake, etc. / 비 약물 치료: Compression stocking 착용, 침대 머리 높이기, 수분 및 염분 섭취량 늘리기 등
3. Lifestyle changes: Patients should first sit when going from a supine to a standing position. Straining during bowel movements or performing Valsalva-like maneuvers during isometric exercise may significantly reduce venous return to the heart and worsen orthostatic hypotension, leading to syncope. Constipation should therefore be treated aggressively. Eating frequent, small meals is often effective in lessening postprandial blood pressure falls.
   
   1. Patients should be aware that hot environments lead to cutaneous vasodilation to dissipate heat and may worsen orthostatic hypotension.
4. Physical measures: The use of physical counter-maneuvers when upright, such as leg-crossing, standing on tiptoes, and muscle tensing, increases venous return to the heart and enhances orthostatic tolerance. Custom-made full-length elastic stockings can be useful in preventing pooling in the lower extremities but can be difficult to use. An abdominal binder may be as effective as a vasopressor, and can be tried first.

Question 90

(2) with postural hypotension, what is the criteria for diagnosis

Answer 90

1. If the systolic blood pressure drops more than 20mmHg or the diastolic blood pressure drops more than 10mmHg within 3 minutes immediately after standing, compared to the resting blood pressure measured after lying down for 5 minutes / 누운 상태에서 5분 후에 측정한 안정 시 혈압에 비해 일어선 직후 3분 이내에 바로 측정한 혈압에서 수축기혈압 more than 20mmHg 이완기혈압 more than 10mmHg 이상 떨어지는 경우

Question 91

(2) with postural hypotension, what test do you do to confirm if there’s a sudden drop in BP specifically due to postural changes?

Answer 91

A **tilt table test **can confirm the sudden drop in blood pressure due to postural changes / Tilt table test에서 자세 변화에 따른 갑작스런 혈압의 저하를 확인할 수 있음

Question 92

(2) with postural hypotension, in what situations does it happen? (context)

Answer 92

1. Occurs when suddenly standing up from a lying or sitting position / 눕거나 앉은 자세에서 갑자기 일어설 때 발생

Question 93

(2) with postural hypotension, what are the most common causes

Answer 93

1. Decrease in circulating blood volume / 순환 혈액량의 감소
2. Chronic instability of vasomotor reflex / 혈관운동반사(vasomotor reflex)의 만성적 불안정성
3. Up to 30% of elderly people experience it/ 노인층의 30%까지 경험
4. commonly caused by antihypertensive or antidepressant drugs (ICA) / 혈압강하제나 항우울증약물(ICA) 복용이 흔한 원인

Question 94

what are the ways we can treat neurocardiogenic (vasovagal) syncope?

Answer 94

1. Treatment includes prevention through education (reassurance, avoiding triggers, increasing fluid and salt intake, etc.) / 치료는 교육을 통한 예방(안심시키기, 유발인자 회피, 수분 및 염분 섭취 증가 등)
2. safety measures when it occurs (lying down in a safe place, securing airway, loosening tight clothing, etc.) / 발생 시 안전 조치(안전한 곳에 눕기, 기도 확보, 꽉 끼는 옷 풀기 등),
3. and medication in refractory cases (Fludrocortisone, Vasoconstricting agents, β-blockers) / 난치성 경우 약물 치료(Fludrocortisone, 혈관 수축제, β-차단제)를 포함합니다.

Question 95

so patient asks, what’s happening when I get this syncope? why is this happening to me? (basically the principle of what the tilt table test is trying to test)

Answer 95

In normal individuals, a compensatory mechanism maintains blood pressure when blood pools in the legs upon standing. / 정상인의 경우, 서 있을 때 다리로 혈액이 쏠릴 때 보상 기전을 통해 혈압을 유지합니다.

In cases of neurocardiogenic syncope, there is a decrease in blood pressure and heart rate. / 신경심인성 실신의 경우 혈압과 심장 박동수가 감소합니다.

Question 96

when you’re suspecting a vasovagal syncope, what test will you do to confirm or deny your suspicions

Answer 96

Diagnosis involves a tilt table test, which is a confirmatory test for neurocardiogenic syncope. / 진단은 기립 경사 검사를 포함하며, 이는 신경심인성 실신의 확진 검사입니다.

Question 97

so someone comes with fainting, what characteristics of the fainting will tell you that this is vasovagal?

Answer 97

The degree and duration of loss of consciousness can vary, and recovery usually occurs within minutes when lying down; sphincter control is maintained, unlike in seizures. / 의식 소실의 정도와 기간은 다양할 수 있으며, 누워 있을 때 몇 분 내에 대부분 회복되며, 발작과 달리 괄약근 조절은 유지됩니다.

Question 98

in what situation specifically does nurocardiogenic syncope occur?

Answer 98

In the case of neurocardiogenic syncope, it mainly occurs in a standing position for a long time / cf. 신경심인성 실신의 경우는 주로 오래 서 있는 자세에서 발생

Question 99

what symptoms will someone experience just before they faint from a vasovagal/ vasodepressor syncope?

Answer 99

1. Prodromal symptoms can include weakness
2. nausea/ 구역질
3. sweating/ 땀
4. dizziness/ 어지럼증
5. blurred vision/ 시야 흐림
6. tachycardia 심장 박동수 증가
7. weakness for seconds to minutes in a sitting then change to standing position / 전구 증상은 수초에서 수분 동안 앉거나 서 있는 자세에서 허약함

Question 100

what are the triggers that bring on neurocardiogenic syncope? (vasovagal/ vasodrepressor related fainting)

Answer 100

1. Triggers include very hot or crowded environments/ 유발인자에는 매우 더운 혹은 혼잡한 환경
2. alcohol consumption/ 음주
3. severe fatigue/ 심한 피로
4. extreme pain/ 극심한 통증
5. fasting/ 금식
6. standing for long periods/ 오랜 시간 서 있기
7. emotional stress/ 감정적 스트레스 등이 있습니다

Question 101

what are the 2 types of neurocardiogenic syncope?

Answer 101

1. vasovagal (decrease sympathetic, increase parasympathetic) / Vasovagal syncope는 교감신경이 감소하고 부교감신경이 증가할 때 발생합니다.
2. vasodepressor (decrease sympathetic)/ Vasodepressor syncope는 교감신경이 감소할 때만 발생합니다.

Question 102

(2) what are the 4 broad groups of causes of syncope

Answer 102

1. neurogenic syncope
   
   1. neurocardiogenic (vasovagal)
   2. postural hypotension
   3. carotid sinus hypersensitivity
   4. situational
2. CVS diseases
   
   1. rbadycardic arrythmias
   2. tachycardic arrythmias
   3. PE; cardiac tamponade; primary pulmonary hyper/hypo ?? tension
3. cerebrovascular diseases
   
   1. carotid artery stenosis
   2. vertebrobasilar insufficiency
4. syncope-like states
   
   1. panic attacks
   2. hypoglycemia, seizures, bleeding
   3. acute intoxication
   4. psychogenic/ sleep disorders

Question 103

(2) What is pre-syncope?

Answer 103

1. Presyncope (= near-syncope): Prodromal symptoms before syncope (faintness) such as dizziness (different from vertigo), feeling of warmth, cold sweat, nausea, and blanching.
   Presyncope ( = near-syncope) : 실신이 일어나기 전의 전구 증상( faintness) 어지럼증 (vertigo와는 다름), 열감, 식은땀, 구역감, 눈앞이 하얘지는 현상

Question 104

(2) What is the definition of syncope (실신의 정의)?

Answer 104

1. Temporary loss of consciousness due to decreased cerebral blood flow. 뇌혈류량 감소로 인한 일시적 의식 소실

Question 105

(2) What is the morbidity of white coat/ masked hypertension? Can it lead to TOD?

Answer 105

1. Although they have less morbidity than actual hypertension patients and there is no benefit from drug treatment,
   실제 고혈압 환자보다는 morbidiy가 적고, 약물치료로 얻을 수 있는 이득은 없으나,
2. The risk of target organ damage is higher than in cases with normal blood pressure, and the likelihood of progressing to hypertension in the future is high.
   혈압이 정상인 경우보다는 target organ damage의 위험이 높고, 향후 고혈압으로 진행할 가능성이 높습니다.
3. Therefore, it is necessary to keep in mind the possibility of hypertension manifestation and target organ damage, and to conduct follow-up observations.
   따라서 고혈압 발현과 target organ damage의 가능성을 염두에 두고, 추적 관찰할 필요가 있습니다.

Question 106

(2) So what do you do if you suspect white coat hypertension or masked hypertension?

Answer 106

If white coat hypertension or masked hypertension is suspected:
백의고혈압이나 가면고혈압이 의심되는 경우:

1. Measure home blood pressure, and if it corresponds to either of the definitions,
   가정혈압을 측정해보고 1)에 해당한다면,
2. Measure 24-hour ambulatory blood pressure.
   24시간 활동혈압을 측정합니다.

Question 107

(2) In what cases would the blood pressure that you measured be higher than expected

Answer 107

1. Cases Where Blood Pressure is Measured Higher than Actual 혈압이 실제보다 높게 측정되는 경우
   
   1. Atherosclerosis: Pseudohypertension. 동맥경화증: 가성고혈압(Pseudohypertension)
   2. When measuring with the arm unsupported and hanging down. 팔을 지지하지 않고 늘어뜨린 채 측정할 경우
   3. When the air bladder of the cuff is too short. 공기주머니의 길이가 짧은 경우
   4. White coat hypertension. 백의고혈압(White coat hypertension)

Question 108

(2) In what cases would the blood pressure that you measured be lower than expected

Answer 108

When Blood Pressure Measurements Differ from Actual Values 혈압이 실제와 다르게 측정되는 경우

1. Cases Where Blood Pressure is Measured Lower than Actual 혈압이 실제보다 낮게 측정되는 경우
   
   1. When measuring blood pressure while pressing the stethoscope too firmly. 청진기를 세게 누른 상태에서 혈압을 측정하는 경우
   2. When the arm is positioned higher than the heart. 팔을 심장보다 높게 위치했을 때
   3. When the air bladder of the cuff is too long. 공기주머니의 길이가 긴 경우
   4. Masked hypertension. 가면고혈압(Masked hypertension)

Question 109

(2) What condition are you suspecting if there is a >10mmHg difference in BP between the left and right upper limbs?

Answer 109

1. Takayasu’s arteritis - the difference in blood pressure between the left and right upper limbs is more than 10mmHg. Takayasu’s arteritis - 좌우 상지 혈압 차 > 10mmHg

Question 110

(2) What condition are you suspecting if there is a >20mmHg difference in BP between the upper and lower limbs

Answer 110

1. In Coarctation of the aorta, the upper limb blood pressure is higher than the lower limb blood pressure. Coarctation of aorta-> 상지 혈압 > 하지 혈압

Question 111

(2) How much difference between the lower limb BP and upper limb BP can you expect before you start suspecting pathology

Answer 111

1. The blood pressure in the lower limbs is normally higher than in the upper limbs, but not more than 20mmHg higher. 하지의 혈압은 상지의 혈압보다 정상적으로 높지만 20mmHg 이상 높지는 않음

Question 112

(2) Just quickly, how do you measure blood pressure in the lower limbs?

Answer 112

Blood Pressure in the Lower Limbs. 하지의 혈압

1. Measure with a wider cuff wrapped around the lower part of the thigh in a prone position. 환자를 엎드린 상태에서 더 넓은 cuf를 대퇴부 아래쪽 13 부위에 감아서 측정
2. Auscultate above the popliteal artery. 오금동맥(popliteal artery) 위에서 청진

Question 113

(2) what if the difference in blood pressure between the left and right side of the limb is >10-15mmHg

Answer 113

If the difference is more than 10-15mmHg, arterial stenosis in the lower measured upper limb can be suspected. (10-15mmHg 이상의 차이가 나는 경우 -> 낮게 측정된 상지의 동맥 협착 등을 의심할 수 있음)

Question 114

(2) what’s the cutoff for the difference you can have in blood pressure from the left and right side of the limb

Answer 114

1. Normally, a difference of about 5-10mmHg can occur 양쪽 상지의 혈압을 모두 측정 : 정상적으로 5-10mmHg 정도 차이가 날 수 있음

Question 115

(2) How do you use the sphygmomanometer to measure blood pressure

Answer 115

Measurement Method: Preparation - Palpation - Stethoscope 측정방법 : 사전 준비 - 촉진 - 청진기

1. Preparation 사전 준비
   
   1. Measure in a rested state: No coffee and smoking for more than 30 minutes and rest for 5 minutes. 측정방법: 사전 준비 - 촉진 - 청진기
      
      1. 안정 상태에서 측정: 30분 이상 커피, 흡연을 삼가고 5분간 안정
   2. Patient’s posture: The upper arm (brachial artery) should be at the same height as the heart. 환자의 자세: 위팔동맥(상활동맥, brachial artery)이 심장과 같은 높이에 위치해야 함
2. Measure the approximate blood pressure through palpation. 촉진으로 대략적인 혈압을 측정
   
   1. Wrap the cuff in the correct position. 촉진으로 대략적인 혈압을 측정
      
      1. Position the air pouch about 2~3cm above the bend of the arm. 혈압대를 올바른 위치에 감음 팔오금으로부터 2~3cm 정도 위에 공기주머니를 위치시키고
      2. Ensure the brachial artery is in the center. 중앙에 위팔동맥이 오도록 함
   2. While palpating the pulse of the radial artery at the wrist, increase the pressure until the pulse is not felt, then add about 20 - 30mmHg more pressure. 손목에서 요골동맥(radial artery) 맥박을 촉진하면서, 맥박이 만져지지 않는 때부터 20 - 30mmHg 정도 압력을 더 올림
   3. Gradually decrease the pressure. 압력을 서서히 감소시킴
   4. The pressure at which the pulse of the radial artery begins to be felt again is the approximate systolic blood pressure. 요골동맥의 맥박이 만져지기 시작할 때의 압력이 대략적인 수축기 혈압

Question 116

(1) In what situations can a person’s blood pressure be higher than normal 혈압이 실제보다 높게 측정되는 경우: (so you probably won’t start these patients on treatment because you can explain their BP)

Answer 116

1. if they have arteriosclerosis 동맥경화증 → causes Pseudohypertension
   
   1. It shows higher than the invasive technique (high pressure needs to be applied to the cuff for the vessel to close. Invasive technique에 비해 높게 나옴(높은 압력 가해야 혈관이 폐쇄)
2. White coat hypertension: High office BP but normal out of office BP. d/t anxiety response that is relatively specific to the clinic setting (White coat hypertension is when the office blood pressure is 140/90mmHg or higher, but the home blood pressure or average ambulatory blood pressure is less than 135/85mmHg; 진료실혈압이 140/90mmHg 이상이고, 가정혈압 또는 평균 주간활동혈압은 135/85mmHg 미만인 경우를 백의 고혈압이라고 하고,)
3. Masked hypertension: Normal office BP but high out of office BP. d/t Lifestyle factors such as smoking, alcohol, physical inactivity, interpersonal conflicts, mental anxiety, and job stress could selectively increase ambulatory BP. (conversely, masked hypertension is when the office blood pressure is less than 140/90mmHg, but the home blood pressure or average ambulatory blood pressure is 135/85mmHg or higher; 반대로 진료실혈압은 140/90mmHg 미만이지만, 가정혈압 또는 평균 주간활동혈압은 135/85mmHg 이상인 경우를 가면 고혈압이라고 합니다.)

Question 117

(1) If someone comes in with Upper limb blood pressure > lower limb blood pressure 상지 혈압 > 하지 혈압, what are you thinking?

Answer 117

1. Coarctation of aorta
2. peripheral arterial disease in the lower limbs. 하지의 말초동맥질환.

Question 118

(1) what is a normal ankle brachial index, and what is an abnormal ABI

Answer 118

• The Ankle-Brachial index is normally above 1.0. Ankle-Brachial index는 정상적으로 1.0 이상이다
• If <0.9, there is definitely a problem. <0.9면 확실히 문제있음

Question 119

(1) What conditions should you suspect if there is more than a >10mmHg difference (좌우 상지 혈압차) between the left and right upper limbs

Answer 119

1. Takayasu’s arteritis
2. Subclavian stenosis.

Question 120

(1) What is the normal difference that you can have in blood pressure between both limbs?

Answer 120

• The blood pressure in both limbs can normally differ by about 5 to 10.양 사지 혈압은 정상적으로 5~10 가량 차이 날 수 있다.