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ChicKen Review > 2. Cardiovascular > Flashcards

2. Cardiovascular Flashcards

1
Q

Patients with aortic outflow obstruction from supravalvular aortic stenosis develop LVH and can have exertional angina due to what?

A

Subendocardial ischemia with increased myocardial OXYGEN DEMAND during exercise.
Can also have coronary artery stenosis

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2
Q

What causes isolated systolic HTN in the elderly?

A

Increased stiffness or dec elasticity of the arterial wall.

Note: tx = lifestyle modification and primary HTN pharm

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3
Q

What is the best next step in management when an aortic dissection (intense chest and neck pain that radiates to interscapular area and PMH of HTN) is suspected?

A

Transesophageal echo - excellent sensitivity and specificity for aortic dissection, and is preferred in patients with hemodynamic instability or renal insufficiency
Note: Cr may be elevated and aortic regurg can be seen with aortic dissection

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4
Q

Describe mobitz type I second degree AV block.

A

Impaired AV node conduction
Increasing PR interval leading to non-conducted P wave and dropped QRS complex.
Mobitz II: PR interval constant with intermittent nonconducted P waves

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5
Q

What is the MCC of isolated AR in young adults?

A

Congenital bicuspid aortic valve - best heard w/diaphragm along L sternal border at the 3rd and 4th intercostal spaces when sitting up and leaning forward and holding in full expiration.

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6
Q

Describe first degree AV block. Management?

A

Delayed impulse transmission from the atria to the ventricles –> prolongation of the PR interval on an ECG to more than 200 msec
management - observation

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7
Q

A small pulsatile mass in the groin area is most likely what?

A

Femoral artery aneurysm

Note: popliteal artery aneurysms are also common and can be assoc with AAA

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8
Q

What can cause SOB, “pounding” heart esp while lying on L side?

A

Aortic regurg - inc LVEDV, wide pulse pressure, “water hammer” pulse, and LV enlargement. LLD position brings enlarged LV closer to chest wall, causing pounding sensation and inc awareness of heart beat

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9
Q

Patients initially diagnosed with HTN should have a detailed hx and PE. In addition, what 4 basic tests should be performed?

A
  1. UA for occult hematuria and urine protein/creatinine ratio
  2. Chemistry panel
  3. Lipid panel
  4. Baseline ECG
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10
Q

What common medication in women can cause hypertension?

A

OCPs

Discontinuing it can correct HTN in most patients.

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11
Q

Severe hypocalcemia can present how on ECG?

A

QT-interval prolongation

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12
Q

How do you treat torsades de pointes in hemodynamically stable vs unstable patients?

A

Stable - IV magnesium sulfate

Unstable - immediate defibrillation

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13
Q

How can you differentiate between peripheral edema due to cardiac vs liver disease by physical exam?

A

Hepatojugular reflux
Cardiac - elevated JVP and positive hepatojugular reflux.
Liver - reduced or normal JVP and neg hepatojugular reflux

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14
Q

What can present with bilateral midfield lung opacities, and cause serious arrhythmia, cardiomyopathy, HF, and sudden cardiac death?

A

Cardiac sarcoidosis

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15
Q

What should you suspect in patients with unexplained CHF, proteinuria, and LVH in the absence of hx of HTN?

A 
Amyloid cardiomyopathy (type of restrictive cardiomyopathy)
Amyloidosis is a multisystem disease that also manifests with proteinuria, hepatomegaly, pulm nodules, etc.
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16
Q

Elevated BNP and audible 3rd heart sounds are signs of what?

A

Increased cardiac filling pressures - noted in patients with CHF d/t LV systolic dysfunction
BNP - natriuretic hormone released from ventricular myocytes in response to high ventricular filling pressures and wall stress in patients with CHF.

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17
Q

Acute mediastinitis can occur following cardiac surgery - fever, chest pain, leukocytosis, mediastinal widening on CXR. Management?

A

Drainage, surgical debridement, prolonged abx

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18
Q

Patients with cardiac myxomas can develop what constitutional, systemic, and cardiovascular sx?

A

Constitutional: fatigue, fever, wt loss
Systemic embolization: TIA, ischemic stroke, acute embolic arterial occlusion
CV sx: mitral valve disease

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19
Q

How can positive pressure mechanical ventilation cause sudden cardiac death in a patient with hypovolemic shock?

A

Increases intrathoracic pressure –> acute loss of right ventricular preload and loss of cardiac output

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20
Q

In patients with mitral stenosis, what causes development of atrial fibrillation?

A

Significant left atrial dilatation

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21
Q

Pulseless electrical activity (PEA) or asystole should be managed how?

A

uninterrupted CPR and vasopressor therapy to maintain adequate cerebral and coronary perfusion.
Note: defibrillation or synchronized cardioversion has no role in management

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22
Q

What abnormal heart sound can be heard during the acute phase of MIs?

A

Fourth heart sound (atrial gallop) - due to LV stiffening and dysfunction induced by MI

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23
Q

What are possible early complications of operation on the abdominal aorta (eg AAA repair)?

A

Bowel ischemia and infarction (1-7% incidence). Presents with abdominal pain and bloody diarrhea

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24
Q

Patient with history and RF for coronary artery disease and Atypical presentation of acute coronary syndrome: abdominal pain, nausea/vomiting should be first tested how?

A 
ECG
Other tests (eg abdominal US, amylase, lipase, GI endoscopy) should be done after bc they evaluate less immediately life-threatening conditions.
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25
Acute digoxin toxicity = (GI sx) and possible weakness and confusion Chronic digoxin toxicity = less severe GI sx but more neuro sx (lethargy) and visual changes. How does amiodarone, verapamil, quinidine, and propafenone cause digoxin toxicity?
Increase serum levels of digoxin.
26
What are the guidelines for AAA screening?
USPSTF recommends screening a male active or former smokers aged 65-75 years with a one-time abdominal US to eval for AAA
27
Dobutamine has what physiologic effects on the heart?
Inotropic agent for B1 receptors and weak B2 and A1 receptors. Inc contractility --> improved EF, dec LV end SYSTOLIC vol, and improves sx of decomp HF
28
What is the MCC of pediatric myocarditis (fever, lethargy, signs of HF)?
viruses - tends to occur after a viral prodrome. Monitor in ICU bc risk of acute decompensation and fatal arrhythmias. Note: acute rheumatic fever can cause myocarditis but is uncommon in kids <3 bc they have fewer epithelial cell attachment sites for strep pharyngitis to occur.
29
What should you suspect in patients with acute renal failure, livedo reticularis, nausea, abd pain, and history of atherosclerosis and recent coronary angiogram?
Cholesterol emboli | Can occur after recent arteriography or cardiac catheterization
30
Patients with aortic dissection involving the ascending aorta (type A) can have retrograde extension of the tear resulting in what? Sx include sudden onset of worsening chest pian, hypotension and pulmonary edema
Tear involves aortic valve --> Aortic regurgitation (decrescendo diastolic murmur)
31
What is the strongest predictor of AAA expansion and rupture?
Active smoking Note: current indications for operative or endovascular repair include aneurysm size >5.5cm , rapid rate of aneurysm expansion (>0.5cm in 6mo or >1 cm per year), and presence of sx regardless of size
32
What is the MCC of sudden cardiac arrest int he immediate post-infarction period in patients with acute MI?
Reentrant ventricular arrhythmias
33
What anatomic site is the most likely origin of afib?
Ectopic foci within the Pulmonary veins
34
What pharm can help manage hypertrophic cardiomyopathy?
neg inotropic agents (bb, verapamil, disopyramide) | inotrope = agent that modifies the force or speed of contraction of muscles.
35
AV block in a patient with infective endocarditis is suspicious for what?
Perivalvular abscess extending into the adjacent cardiac conduction tissues. Aortic valve endocarditis and IV drug abuse are assoc with inc risk of periannular extension of endocarditis
36
How do you treat vasospastic angina?
CCB (diltiazem/amlodipine)
37
How can you differentiate tricuspid regurg from other murmurs?
Holosystolic murmur that Inc in intensity with inspiration | IV drug user
38
How does fibromuscular dysplasia cause headaches and hypertension?
Causes internal carotid artery stenosis and secondary HTN due to renal artery stenosis
39
Marked HTN and AKI in the setting of systemic sclerosis (scleroderma) suggests what?
Scleroderma renal crisis
40
Raynaud phenomenon affects digital arteries in a similar mechanism as what cardiac condition?
Vasospastic angina - recurrent chest discomfort from hyperreactivity of vascular smooth mm
41
What lab finding has the greatest sensitivity for diagnosing HF?
Elevated BNP levels.
42
Electrical alternans with sinus tachy is highly specific for what? How should you manage it?
Large pericardial effusion --> emergency pericardiocentesis
43
Define resistant HTN
persistent HTN despite use of >=3 antihypertensive agents of different classes. renal artery stenosis is a potential cause
44
How do you manage a patient with 3rd degree AV blok?
Temporary pacemaker insertion.
45
What nonpharm intervention is most likely to have greatest impact on blood pressure?
Dietary modification to DASH diet (Dietary Approaches to Stop HTN). Losing weight has an even larger effect
46
Water bottle heart with clear lung fields is suggestive of what?
pericardial effusion. If it presents without cardiac tamponade have exam findings of dec heart sounds and max apical impulse that is difficult to palpate.
47
What heart defects are assoc with Turner syndrome
Bicuspid aortic valve Coarctation of the aorta aortic root dilation
48
How do you interpret ankle-brachial index? <=0.9, 0.91-1.3, >=1.3
<=0.9 (abnormal) 0.91-1.3 (normal) >=1.3 (calcified and uncompressible vessels)
49
What heart defects are assoc with Trisomy 18? What should be performed to assess this defect?
VSD - holosystolic murmur at L lower sternal border Other features: micrognathia, overlapping fingers, rocker-bottom feet, microcephaly Echo - determine location and size of the VSD. if small, requires no tx
50
What murmur is associtaed with bound "water hammer" peripheral pulses?
Aortic regurg - early diastolic murmur.
51
Dual antiplatelet therapy leads to reduction in recurrent MI and CV death. What are the 2 drugs?
Aspirin P2y12 receptor blocker. Note: aspirin is the only antipatelet that is effective in reducing risk of early recurrence of ischemic stroke.
52
Rheumatic mitral stenosis may be asymptomatic until pregnancy because of hemodynamic changes. These patients are at increased risk of what?
Atrial fib with RVR (pulse >100/min) --> pulm congestion and pulm edema
53
Acute limb ischemia after MI suggests what? Management?
Arterial embolus from LV thrombus. | Immediately anticoagulate, consult vascular surgery, transthoracic echo to screen for LV thrombus and eval LV function
54
What murmur is a complication of aortic dissection?
Aortic regurg - presents with early diastolic murmur
55
Acute MI does what to the cardiac index (Cardiac output) and pulmonary capillary wedge pressure (PCWP)?
CI: low (dec myocardial contractility --> hypotension, and reflex tachy) PCWP: elevated (estimates LA pressure) bc of failure of blood to flow forward
56
High-energy, blunt, rapid decel trauma to the chest commonly causes what cardiac injury?
Aortic rupture - death is immediate. If rupture is contained, see widened mediastinum, L hemothorax on CXR
57
MC heart defect with Down syndrome
Complete AV septal defect. Heart failure in early infancy, systolic ejection murmur (inc pulm flow from ASD), and holosystolic murmur d/t VSD
58
Best way to manage stable patients with wide-complex tachy?
Antiarrhythmics (eg amiodarone, procainamide, sotalol, lidocaine) Electrical cardioversion is for patients with persistent tachyarrhythmia and severely symptomatic or hemodynamically unstable
59
Study of choice for dx and follow-up of AAA?
Abdominal US
60
General tx for vasovagal syncope?
Reassurance. Avoid triggers and use physical counterpressure maneuvers (squatting, arm tensing) to abort or delay an episode of syncope
61
Sharp and pleuritic chest pain, pericardial friction rub, BUN >60 suggests what?
uremic pericarditis - occurs in 6-10% of renal failure patients. Do NOT present with classic EKG changes of pericarditis. Hemodialysis leads to rapid resolution of chest pain
62
Treatment of choice for initial medical management of patients with acute aortic dissection?
IV beta blockers - lower HR and BP, and reduce LV contractility
63
After central venous catheter placement, what should be done?
CXR prior to catheter use to confirm location bc complications due to inapprop placement are common.
64
What are the main reasons for inc incidence of orthostatic hypotension in the elderly?
Progressively decreasing baroreceptor sensitivity and defects in the myocardial response to this reflex
65
What causes signs/sx of high-output HF in a patient after a traumatic injury ?
Arteriovenous fistula - abnormal connection bw arterial and venous systems that bypass the capillary beds. Shunting of blood through the fistula dec SVR, inc preload, and inc CO. Widened pulse pressure, brisk carotid upstroke
66
Bradycardia, hypotension, WHEEZING, hypoglycemia, delirum, seizures, and cardiogenic shock are signs of what drug OD?
Beta blocker. IV fluids and atropine are firstline IV glucagon should be admin in pts with profound or refractory hypotension
67
How do pressors such as norepinephrine can cause ischemia of the distal fingers and toes (dusky and cold fingers and toes)?
Norepinephrine-induced vasospasm. A1 agonist --> vasoconstriction. Can also occur in intestines --> mesenteric ischemia.
68
Patients with symptomatic sinus bradycardia should be treated initially with what drug?
IV atropine - if inadequate response, further treat with IV epinephrine or dopamine, or transcutaneous pacing
69
Differentiate symptoms of vascular rings from laryngomalacia
Vascular ring can encircle the trachea and or esophagus so presents with resp (biphasic stridor not affected by position) and esophageal sx (dysphagia) Laryngomalacia - d/t collapse of supraglottic structures during inspiration (inspiratory stridor that improves with prone position)
70
All patients with hypotension/shock after MVA should be presumed to have what shock? What should you suspect if PCWP is elevated?
Hypovolemic shock from hemorrhage. | Elevated PCWP = myocardial dysfunction d/t cardiac contusion and prompt urgent echo
71
Patients with persistent tachyarrhythmia (narrow- or wide-complex) causing hemodynamic instability should be managed how?
immediate synchronized cardioversion | Note: IV antiarrhythmics can be used in pts with STABLE recurrent or refractory wide-complex tachy
72
Left axis deviation on neonatal EKG is never normal. What cyanotic congenital heart defect is characterized by LAD and dec pulm markings on CXR?
Tricuspid valve atresia - hypoplasia of RV and pulm outflow tract
73
What should be given first in a patient with acute coronary syndrome?
Aspirin (early antiplatelet therapy reduces rate of MI and overall mortality)
74
What are the most important factors in improving patient survival if presenting with sudden cardiac arrest?
Prompt resuscitation with adequate CPR, prompt rhythm analysis and defibrillation (if in vfib)
75
Blue toe syndrome, livedo reticularis, gangrene, and ulcers may be a sign of what complication of cardiac catheterization/other vascular procedures?
Cholesterol embolism
76
How does mitral stenosis predispose to afib and systemic thromboembolic complications like strokes?
MS -- inc pulm pressures and pulm vascular congestion (dyspnea, orthopnea, PND, hemoptysis), L atrial enlargement --> afib and systemic thromboembolisms
77
Acute MR does what to LVEDP?
Increases LVEDP. Does not cause significant change in L atrial or ventricular size or compliance unlike chronic MR
78
Use dependance is most freq assoc with class IC antiarrhythmics. Class IA less and class IB drugs rarely. What is seen on EKG?
widening of the QRS complex - faster HR --> drug has less time to dissociate from Na channels --> higher number of blocked channels --> dec impulse conduction and wider QRS complex
79
Common causes to inadequate antihypertensive therapy?
Non-adherence to lifestyle changes and diet med noncompliance use of meds that inc BP or reduce response of antihypertensives (NSAIDs, decongestants, glucocorticoids) Excess alcohol.
80
What valvular diseases are most commonly associated with infective endocarditis. Sx of IE (Janeway lesions, OSler nodes, roths pots in eyes, splinter hemorrhages)
MVP and assoc MR have 5-8x higher risk of IE than those with a normal valve The aortic valve is the 2nd MC cardiac valve involved (eg pt with hx of congenital bicuspid aortic valve w/assoc AS)
81
Loop diuretics cause what electrolyte abnormalities?
HYPOkalemia and HYPOmagnesemia --> ventricular tachycardia | can also potentiate SE of digoxin
82
What drug can lesson ventricular remodeling in the weeks to months following MI?
ACE inhibitors
83
What are the MC complications of cardiac cath for MI management? How do you dx?
bleeding, hematoma (local or retroperitoneal), arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula. Hematoma presents with hemodynamic instability and flank or back pain. Dx w/non-contrast CT
84
Patients with blunt chest trauma who present with persistent JVD, tachy, and hypotension despite aggressive fluid resuscitation should be suspected to have what? What does CXR show? Tx?
acute cardiac tamponade. CXR shows normal cardiac silhouette without tension PTX Decompress with pericardiocentesis or surgical pericardiotomy
85
Hypertrophic cardiomyopathy genetic inheritance?
Auto dom
86
Patients with new-onset afib should get what tested bc ___ is the MC and likely cause of this?
free T4 and TSH | Hyperthyroidism
87
A patient with CHF, and proteinuria and easy bruisability points to what condition as the etiology of the CHF?
Cardiac Amyloidosis - echo shows inc ventricular wall thickness with normal LV cavity dimensions. Note: Sarcoidosis or constrictive pericarditis can present similar but doesn't cause proteinuria.
88
A relatively young patient with signs of decompensated HF, dilated cardiomyopathy, and may have several weeks of viral prodrome prior to this may have what?
Viral myocarditis
89
Why does pharm vasodilator stress testing (eg adenosine) show a difference in blood flow between normal and ischemic myocardium?
marked inc in blood flow in normal coronary arteries and relatively small inc in blood flow in stenotic coronary arteries.
90
Edema, stasis dermatitis and venous ulcerations result from lower extremity venous insuff due to what?
Valve incompetence. Usually occurs on the medial leg superior to the medial malleolus
91
What arrhythmia is most specific for digitalis toxicity
Atrial tachy with AV block
92
What is Leriche (aortoiliac occlusion) syndrome?
Triad of bilateral hip, thigh, and but claudication, impotence, and symmetric atrophy of bilateral lower extremities d/t chronic ischemia. RF atherosclerosis, smokers.
93
In Afib with RVR, rate control should be attempted initially with what pharm?
BB or CCB (eg diltiazem)
94
What does CHA2DS2-VASc score stand for?
``` C: CHF H: HTN A2: age >=75 (2 points) D: DM S2: Stroke/TIA/Thromboembolism (2 points) V: vascular disease A: age 65-74 Sc: sex category (female = 1 pt) Max score = 9 ```
95
Patients with RV MI can experience profound hypotension d/t inadequate RV preload. How should these pts be initially managed/
IV saline bolus to inc RV preload and improve cardiac output. Avoid nitrates bc venous dilation causes abrupt dec in RV preload.
96
In addition to starting low-dose aspirin and statin therapy, what should be done in all patients with intermittent claudication from peripheral vascular disease?
Supervised Exercise program Note: cilostazol and percutaneous or surgical revascularization should be done for those with persistent sx despite adequate supervised exercise therapy
97
In hypovolemic shock, what happens to ejection fraction?
Increases! (compensatory for dec in LV size due to low fillin vol)

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