2022 Cardiovascular Disease 14% - lipid 2% Flashcards
1
Q
Early diastolic opening snap? =
Midsystolic click? =
A
Snap - MS
Click - MVP
2
Q
What are the valves that close during:
S1?
S2?
A
- S1: A/V valves (mitral and tricuspid)
- S2: ventricular valves (aortic and pulmonic)
3
Q
Conditions a/w loud S1
A
MS, Short PR (WPW), Tachycardia, Thyrotoxicosis
4
Q
Conditions a/w soft S1
A
MR, Long PR, inc’d LVEDP
5
Q
Order of valves closing during physiologic S2 inspiration
A
A2 - AV closes first; P2 - PV closes last
6
Q
Order of valve closure during physiologic S2 during expiration?
A
both valves (aortic and pulmonic) close at same time
7
Q
When is the split between AV and PV increased during S2?
- AV closes earlier:
- PV closes later:
A
- AV closes earlier: MR, VSD
- PV closes later: PS, pulm HTN (loud P2) RBBB, PE
8
Q
Condition a/w fixed split S2?
A
ASD
9
Q
What is a paradoxical S2 split? What conditions are a/w paradoxical split S2?
A
- What: AV closes later
- Conditions: AS, HTN, LBBB
10
Q
Conditions a/w S3
A
- Can be a normal finding in healthy kids and pregnant women
- Chronic MR
- CHF
- TR, PDA
Is generally a sign of increased filling pressures/flow and increased compliance
11
Q
Conditions a/w S4
A
Decreased ventricular compliance
- LVH (e.g from longstanding HTN)
- Acute MR
- HOCM
- AS
12
Q
- Condition a/w pericardial friction rub?
- Best heard when?
- wtd next?
- Rx with?
A
- Pericarditis (scratchy sound is SPECIFIC)
- Best heard when pt upright leaning forward
- TTE to r/o effusion
- NSAIDS + colchicine
13
Q
Condition a/w sharp early diastolic sound (aka pericardial knock)
A
constrictive pericarditis
14
Q
ASD has what effect on heart sounds?
A
Fixed split S2
15
Q
HTN has what effect on heart sounds?
A
Loud A2
16
Q
Pulm HTN has what effect on heart sounds?
A
Loud P2
17
Q
Physiological split of S2: which valve closes first?
A
A2 before P2
18
Q
Pulsus tardus
A
slowly rising/late pulse –> AS
19
Q
- What is apical pulse?
- What is pulsus bisferiens?
- What conditions are a/w these
A
- apical: rapid rise
- bisferiens: single pulse with two peaks (midsystolic dip)
- a/w: think HOCM, may also be AR
20
Q
Pulsus alternans:
- Definition
- Associated conditions
A
- Alternating (beat to beat) variability in pulse strength d/t decreased ventricular performance
- a/w severe CHF
21
Q
Pulsus paradoxus
- what is it?
- conditions a/w pulsus paradoxus
A
- bp drop > 10mmHG during inspiration
- a/w: cardiac tamponade, SVC obstruction, pulmonary obstruction
22
Q
Conditions a/w holosystolic (pansystolic) blowing murmur?
A
MR, TR, VSD (flow from ventricles to atria)
23
Q
- Conditions a/w mid systolic crescendo decrescendo murmur?
- What happens when this condition is severe?
A
- a/w: AS, PS
- if AS is severe: crescendo becomes late peaking. In mild disease the murmur is early peaking
24
Q
Condition a/w midsystolic click followed by murmur
A
MVP
25
Diastolic murmurs are heard during why type of cardiac blood flow?
Diastolic murmurs are heard when blood flows into ventricles. All diastolic murmurs are pathologic.
26
Mid diastolic murmur (may have opening snap)
MS, TS (-ASD)
27
Late diastolic sound or murmur; mid systolic plop
Arial myxoma; sx a/w fever, fatigue, wt loss; tx is surgical
28
Early, blowing, diastolic murmur
AR, PR
29
Continuous murmur
PDA
30
Pt with fixed split 2nd heart sound and mid-diastolic rumble: dx?
ASD
31
1. Things that cause increased blood volume?
2. Things that cause decreased blood volume?
3. What happens to murmurs w/ increased blood volume?
1. Sitting, squatting, leg raise; hand grip and phenylephrine inc afterload and therefore inc size and volume
2. Standing, valsalva
3. increased volume increases all murmurs except HOCM and MVP
32
What happens to murmurs w/ expiration? Why?
1. All L sided murmurs increase except MVP and HOCM (these decrease)
2. Increased flow to the L side of the heart
33
What happen to murmurs during inspiration? why?
1. increase all R sided murmurs
2. increase flow to R side of heart
34
What positions cause increased volume return to heart?
1. Sitting, squatting, leg raising
2. Handgrip and phenylephrine increase afterload and therefore increase volume
35
What positions cause decreased volume return to the heart?
Standing, Valsalva
36
Handgrip and phenylephrine have what effect on afterload?
Increases which murmurs?
1. increases afterload,
2. increases flow to murmurs that flow backward (AR, MR, VSD)
37
Handgrip or phenylephrine has what effect on MR, MVP, and HOCM?
- Handgrip and phenylephrine increases afterload
Decreases HOCM (less obstruction of LVOT)
Increases intensity of MR and MVP (MVP duration decreases)
38
1. Amyl nitrate has what physiological effect?
2. What happens to MVP, MR, HOCM, and AS with amyl nitrate use?
1. Decreases afterload, so its easy for blood to be pushed into systemic circulation.
2. Decreases MVP (intensity) and MR
3. Increases HOCM (less LVOT obstruction) and AS
39
1. Kussmaul's sign: exam findings
2. associated conditions?
1. Paradoxical increased JVP on INSPIRATION
2. seen with constrictive pericarditis, cardiac tamponade, RV infarct
40
1. Physiological effect after PVCs
2. Effect on HOCM, MVP, and AS?
1. decreased afterload → rapid ventricular emptying
2. increases HOCM, MVP, and AS
41
Inspiration has what effect on R sided murmurs?
R side murmurs increase
42
Which maneuver will distinguish HOCM vs AS?
Valsalva increases HOCM; decreases AS
43
16yo comes for routine checkup - PE reveals a murmur at LSB radiating thru precordium - no change with valsalva or respiration - ekg shows mild LVH. What is the diagnosis?
VSD; MC murmur at LLSB
44
Best way to decrease CAD risk between 1. controlling BP, 2. decreasing cholesterol, and 3. quitting smoking
quit smoking
45
RCA artery obstruction
- type of MI?
- EKG leads with STE?
- sx and rx
- inferior/posterior wall MI
- leads II, III aVF; V1, V2 (early R wave progression)
- sx: clear lungs, hypotension, elevated JVP, bradycardia; rx with fluids, atropine (if HR dec), avoid nitrates, plus other usual treatments (ASA, heparin, etc)
46
LAD artery obstruction
- type of MI
- EKG leads with STE
- sx and rx
- Type: Anterioseptal /apical
- Leads: V1-4
- sx: usual pain in chest, neck and arm, pulm edema, murmur (with MVP), S4 present. dx: ASA, heparin, nitrates, beta blocker, statin, PCI
47
Circumflex artery obstruction
- type of MI
- EKG leads with STE
- type: Apical/lateral MI
- Leads: lateral V5-6
48
Pt with hx chest pain; stress EKG reveals depression in lateral leads. Nuclear imaging reveals anteroseptal ischemia. Diagnosis?
High grade LAD stenosis
49
48yo F exertional chest pain, stress test done but stopped in 50 min from CP and ST depression in V4-6. Diagnosis?
High grade LAD stenosis
50
Patients likely to present with atypical or no chest pain with MI
Elderly, women, people with diabetes
51
Risk factors for atherosclerosis
- Modifiable: tobacco use, HLD, obesity, HTN, DM, psychocsocial stressors, EtOH, low physical activity, diet low in fruits/veggies
- Unmodifiable: Age, Male, Family hx premature CAD (LP (a))
52
ACS rx for NSTEMI or UA
- ASA, heparin, beta blocker, statin, nitrates, GIIB/IIIA inh (abciximab or tirofiban) if high risk UA
- angiography w/in 48h for NSTEMI and high risk UA
- NO tPA
53
ACS rx for STEMI
- ASA, heparin, beta blocker, statin, nitrates, morphine, clopidogrel (if no CABG planned)
- PCI in 90 min, or:
- tPA if w/in 12h of start of chest pain and PCI is more than 120 min away
54
Workup for suspected CAD - middle aged woman pw chest pain, chest discomfort or atypical CP - wtd?
- If can walk and baseline EKG normal: exercise EKG
- can walk and ST-T abnl or LVH: exercise echo
- if LBBB or V-pacing: vasodilator nuc stress test
55
Max predicted HR formula and goal HR during cardiac stress test?
- Max HR: 220-age
- Stress test goal: 85% of max
56
45yo F vague CP on exertion - baseline EKG normal - exc stress non-sp changes - wtd?
Exc stress with imaging If can walk - or non-sp ST chagnes with LBBB, LAHB, repolariz change then persantine/thallium study
57
Type of stress testing for a patient with LBBB or paced rhythm
Type of stress to AVOID in pt with active COPD or asthma
1. LBBB or V paced needs: nuc stress test with vasodilator
2. COPD/asthma: AVOID vasodilators (adenosine, regadenason, dipyrimidol) as these can cause bronchoconstriction
58
Pt with peripheral vascular dz scheduled for bypass surgery: has wheezing on exam - HTN controlled to 150/90 from 170/110. Type of cardiac workup?
Dob stress test (can't use adenosine or dipyridamole with wheezing)
59
Who gets gated pool studies or MUGA scan
IN pt to determine LVEF and wall motion abnorm (dec'd LVEF poor prognostic factor on MUGA)
60
With what conditions should you NOT do stress test?
unstable angina, AS with sx
61
45yo DM2 with CP, EKG normal - stress test LEAST likely to be accurate is...
Exercise stress test
62
Obese woman with atypical CP undergoes exercise stress test - stops test after 5 min due to fatigue, no CP, HR inc'd by 50%, no EKG changes wtd?
This result is suboptimal and nonpredictive; instead schedule adenosine (vasodilator) stress EKG or echo
63
When is exercise stress test considered positive
1. Flat or down sloping ST depressions\>1mm & longer than 0.08
2. If ST elevated = high grade stenosis
64
Pt with hx of chronic angina controlled on ASA and nitrates with increasing frequency of angina. WTD?
Add beta blocker; if pt is low dose BB dose, then up titrate to max tolerated dose
65
Pt with angina previously controlled on ASA, NTG and max tolerated beta blocker has new CP after walking 2 blocks. HR 55. wtd?
Coronary angiography; PCI if needed
66
Indications for cardiac cath/angiogram (4)
1. STE or ST depression with + trop
2. Poor prognostic factor on stress test
3. Post infarct angina
4. U/A on max dose meds with ongoing or new sx
67
Pt with UA on max ASA, nitrates, beta blocker. Hgb normal, no signs of infection or stress. Increasing episodes/frequency of angina. Angio show multivessel dz no amenable to PCI. wtd?
Ranolazine. decreases frequency of angina and improved exercise tolerance. No improvement in mortality.
68
Pt with angina controlled on BB, ASA, nitrates pw inc'd freq and and duration (lasting \> 30 min) of anginal pain. EKG shows ST depression II, III, aVF. What is most likely mechanism for CP?
Atherosclerotic plaque with intermittent rupture and thromobolysis
69
65 y woman with exertional dyspnea and occasional chest pain. No relieving factors. EKG shows LBBB. wtd?
Stress test. Due to LBBB she needs adenosine PET (nuc test)
70
Pt on ASA, nitrates (with 12 hr nitrate free interval) and max BB with inc'd freq angina after walking 2 blocks; HR 55. WTD?
1. Check CBC for anemia.
2. Check for infxn
3. if no signs of either of above get PCI d/t inc'd HR-\> ischemia
71
Which one of these can get exercise EKG?
* pacemaker
* LBBB
* RBBB
RBBB is ok for exercise stress EKG
72
Antiplatelet medications: classes and examples
1. ASA
2. P2Y12 inhibitors (clopidigrel, ticagrelor, pasugrel)
3. GB IIb/IIIa inhibitors (tirofiban, eptifibitide, abciximab)
73
Pt with CP, ST depression, biphasic T wave on anteroseptal leads present. Dx? Rx?
1. Wellen's syndrome: type A = biphasic T on anteroseptal precordial leads; type B = TWI on anteroseptal precordial leads
2. Rx with trip to cath lab + LMWH + GP IIb/IIIa + Plavix + ASA
74
If angina or ST depression persists with or without troponin (+), wtd?
Cardiac cath
75
Pt stopped ASA 2 months ago 2/2 PUD - started on PPI now p/w CP, wtd?
start ASA
76
45yo M non-smoker, no DM p/w new onset CP more than 1/2 hr duration while shoveling snow - no EKG changes in ER, wtd?
Admit pt to chest pain unit. If cardiac enzymes neg, no ekg changes -\> stress test
77
65yo M with severe retrosternal CP x 40min, sweating, diaphoresis - EKG shows ST dep, TWI. Patient is started on ASA, IV nitrates, BB, LMWH gpIIb/IIIa inhib - anginal pain resolves - 24 hrs later ST dep still persists. Dx? Rx?
1. Dx: silent ischemia
2. Rx: Cardiac Cath pt -\> if angioplasty/PCI done - would decrease recurrent ischemia at 6 months (not reduce MI freq)
78
Multi-slice CT helpful to evaluate CP in what group of pts?
Exclude dx of CAD in LOW risk patients
79
Exertional dyspnea w/o chest pain may represent an anginal equivalent in absense of pulm dz in what type of patients? (4)
1. DM
2. Women (esp. post menopausal)
3. Elderly
4. Post CABG
80
1. Pathogenesis of cardiogenic SOB?
2. Diagnostic process if you suspect cardiogenic SOB?
1. Path: ischemia-\> inc'd LVEDP-\> pulmonary edema
2. Dx: empiric NTG or stress test or radionucleotide studies
81
65yo with MR murmur during exercise and disappears with rest, S4 present. Echo shows mild hyperkinesis and EF 60%. Etiology?
Ischemic
82
46yo M CP lasting 15 min - resolved in ED - HR/BP ok, No STE, only deep TWI V1-4. Dx? Rx?
Myocardial ischemia --\> Wellens syndrome (LAD TWI synd) wtd? --\> angiogram
83
Pt with CP episode at night that lasts 5-15min at rest. dx? wtd?
resting EKG neg/nonspecific ST changes → ambulatory EKG (to recreate CP) → positive → angiogram → neg → vasospastic angina
84
Pt pw CP, EKG neg - Thallium stress with reversible ischemia; cath neg, Dx? Rx?
1. Dx: microvascular angina
2. Rx: CCB, BB and nitrates
85
Elderly man with h/o syncope - he feels dizzy after dinner; EKG shows ST dep in II, III aVF - Repeat EKG after 15 min normal. Dx? Rx?
1. Dx: Post prandial ischemia
2. Rx: cardiac angio
86
Cause of STE? Causes Least likely to cause ST elevation is?
1. Transmural MI
2. LV aneursym
3. post MI Acute pericarditis
4. Prinzmetals angina
5. Takotsubo
6. least likely : unstable angina
87
Young man brought to ER with severe CP - EKG shows ST elev and MI dx.
1. This is most likely a/w which drug?
2. WTD next?
3. General rx for CP on this drug
4. General prevention of future episodes?
1. Cocaine (a/w chest pain but is also thrombogenic)
2. Next step: PCI
3. Rx of cocaine with no EKG abnormalities: benzo, nitrates, ASA
4. prevent with CCB
88
Cardiac enzymes onset, peak, duration
1. Troponin: + 3-6hrs after MI, Peak 10-25hrs, Normal 5-15 days 2. CPK-MB: + 3-8hr, Peak 10-36hrs, Normal 3 days
3. LDH: + 8 to 18hrs, Peaks 2-3 days, Returns to normal 6-10 days
4. Myoglobin: - 0-85= normal inc'd immediately peaks in 1-4 hrs and normal in 24 hrs (best to assess new MI 1 day after old MI)
89
Pt with CP, STE and trop elevated → now s/p TPA with STE and CP resolved. Next blood draw trop more elevated. wtd?
Nothing - patients who are reperfused have faster peak and higher peak of trop than pt NOT perfused
90
Pt pw CP and STE; PCI is done. Next day Pt has new chest pain: best marker to diagnose new MI?
Myoglobin (peaks 1-4 hrs, normal 24 hrs)
91
65yo M with PNA to MICU on IV abx - EKG NSR but trop 1.3. wtd?
Echo
Low level trop seen in (and poor prognostic factor in) CHF, critial illness, LVH, HOCM, coronary vasopasm, PE, CKD
92
Pt pw chest pain and low BP - you suspect RV infarct - next dx step?
R sided EKG - V3R-V4R (on R chest) with STE very diagnostic for RV infarct.
93
Acute MI Q-wave vs non Q-wave MI
Q wave MI and non-Q wave MI both similar long term survival.
Always admit pt with new onset classic CP relieved by SL nitro even if pt young or EKG normal - thrombolytics NOT given for NSTEMI
94
Indications for thrombolysis
- Chest pain typical for infarction \> 30 min with LBBB - STE 1mm in two continguous leads - \< 12 hr post MI - \< 2hrs away from PTCA center and NOT in shock
95
Contraindication for TPA
1. Absolute - Prev hemorrhagic stroke - Other CVA events \< 1 yr - IC neoplasm - Active internal bleed
2. Relative - CVA \> 1 yr - recent internal bleed or major trauma \< 2-4 wks - BP\>180/110 - Pregnancy - Active PUD
96
Indications for PTCA (PCI or angioplasty)
1. Acute ST elev MI
2. ST elevation with CP \> 12hrs
3. MI with shock and Pt is\< 2hrs away from PCI center & \< 75yr
4. STEMI post CABG pts
5. If tPA contraindicated
6. Unstable angina
97
Ticagrelor, pasugrel, clopidigrel
1. class of drugs
2. can use if allergic to ASA?
3. Use before/with PCI?
4. Use before/with CABG
1. Thienopyridine ADP Plt inhibitor (P2Y12)
2. Pt with MI allergic to ASA -\> ok to use
3. Pt going for PTCA: use ticagrelor or pasugrel
4. Pt going for CABG - NO P2Y12 inhibitors
98
When is CABG better than PCI?
1. Left Main dz
2. 3 vessel dz with dec'd LVEF
3. Two vessel dz with prox LAD and decreased LVEF \<35
4. DM with CAD (tend to have diffuse lesions no amenable to PCI)
99
Pt with CAD s/p - what antiplatelet meds on d/c?
1. MI no stent
2. MI with stent
3. no MI with stent
1. ASA for life + P2Y12 (ticagrelor or pasugrel preferred) for at least 12 months
2. ASA for life + P2Y12 (ticagrelor or pasugrel preferred) for at least 12 months
3. ASA + P2Y12 (ticagrelor or pasugrel preferred) for at least 6 months
100
60 yo pt undergoes CABG - couple months later he is doing fine but has problems keeping accounts occasionally.
Dx: neurocognitive defect
Notes: post CABG neuro cog deficit: unsure etiology but may be related to microembolism of lipids or being on card-pulm bypass. Onset and duration 1-3 months after that old cases usu resolve and fewer new cases
101
Pt with retrosternal CP\>1 hour, diaphoretic → EKG LBBB, STE in ant leads. Old EKG not availabe to compaire - CK and trop pending wtd?
Cath lab: CP with STE is enough to activate cath lab. Don't wait for trop or LDH to come back.
102
Pt with chest pain, STE anterior leads → gets tPA with BP of 90/60. 2 hrs later STE in lateral leads BP drops to 80 pt SOB - no new murmurs - CXR pulm edema. wtd?
Angiography/PCI right away if pt with new sx and unstable after tPA. Otherwise wait for 2h post tPA to do PCI
103
Elderly pt with IWMI gets PCI to proximal RCA. Pt BP down to 90/60. wtd?
Bolus of IV fluids
104
Pt has PCI 6 hr ago. Now appears diaphoretic and has clammy skin. BP 80/60, hr 116. Exam shows no swelling or erythema at puncture site. IV fluid bolus given. Hgb 14 this AM. wtd?
CT abdomen
105
Pt with 14hrs CP, taken antacids without relief - EKG with STE in anterior leads - BP 140/80. Closest PCI center 1 hr away wtd?
1. Give ASA, IV nitrates, IV BB and IV morphine
2. Transfer & do PCI
106
60 yo p/w CP to small community hospital. Found to have AWMI- nearest tertiary center is more than 2 hours away. wtd?
tPA (if no contraindications) then transfer for PCI
107
Pt p/w MI; 3 days later has new CP relieved with NTG wtd?
Cath
108
Pt has cath - 2 days later pain in R groin - exam with erythematous and pulsatile mass wtd?
US r/o pseudoaneurysm
109
Pt with MI - 9 days later with persistent CP, worse on deep breath - pericardial friction rub, pt is on DAPT, ACEi and BB, and statin. CXR with effusion - EKG diffuse ST elevation with concatvity upwards and PR depression. Dx? Rx?
1. Dx: Dressler's syndrome - secondary pericarditis
2. Rx: ASA high dose + colchicine
110
Factors shown to improve survival in MI (9)
1. PCI
2. thrombolytic therapy after Q wave MI
3. BB
4. ASA
5. ACEi
6. stop smoking
7. statins
8. ICD (40days later)
9. cardiac rehab
111
Pt p/w CP - AWMI tx'd in CCU w/o complications, EF 30%. On D/C what meds?
- DAPT- ACEi, - statin - BB; ICD ( 40 days later - if high risk for VT then wear lifevest)
112
Pt had MI, stabilized - few months later. stress test abnormal - underwent cath - 70% stenosis LCx- started on ASA - what will incr long term survival?
start Statin (NOT CABG or PTCA)
113
Sequence of ACS medical and interventional management
ASA→SL NTG→BB→statin→UFH, P2Y12→PCI
114
Complications of MI (arrythmia)
\< 48hrs: - VT (runs: observe. no incr mort. sustained=ischemic: stable --\> IV lidocaine/amio. unstable: cardioversion) then back to cath lab. - NSVT - Blocks \>48hrs: - VT (scar tisssue --\> ICD maybe in 3months - NSVT
115
Complication of MI (mechanical ruptures)
- Papillary muscle rupture -\> Acute MR - Septal rupture -\> Acute VSD - Free wall rupture -\> Tamponade
116
Ventucular arrythmias during acute MI
Ventricular ectopy or NSVT during AMI should NOT be treated VT/VFib occuring within 24 hrs of MI are independent risk factors for in house mortality BUT not risk for subsequent mortality from arrhthmia after d/c These DO NOT NEED long term antiarrhythmic therapy
117
Pt pw CP - EKG shows MI tx'd with tPA, heparin, nitrates, BB, ACEi - w/in 24 hrs pt has NSVT \<30s wtd?
Observe
118
Mechanism of reperfusion arrhythmias?
Triggered activity; change in cardiac frequency due to accumulated Ca+
119
Pt with NSVT reverts to SR and is otherwise uneventful - 5 days later pt ready for d/c does pt require long hterm anti arrythmic?
No
120
Pt with VT or VF 48hrs afte rMI - no evidence of reinfarction wtd?
tx VTACH
121
Vtach/VF 48 hrs after MI or more - independent risk factor for mortality after d/c - after acute tx wtd?
ICD \*
122
Pt has 2 discharges from ICD in 2 months wtd?
start amiodarone
123
Pt with ICD on amiodarone still getting shocks 4 months later wtd?
RF catheter ablation
124
Pt with MI refractive VT wtd?
adequate O2 and correct electrolytes Tx with amiodarone
125
Post MI surgery
elective surgeries at least 6 months post MI (risk of reinfarction highest first 3 months post MI)
126
Middle aged man clutches chest c/o severe CP - EKG diffuse STE with concavity up and PR depression wtd?
NSAIDs for pericarditis Best med for ppx - colchicine
127
If pt w/ pericarditis, has CXR showing cardiomegaly or has JVD or pulsus paradoxis. Best test to confirm dx?
echo r/o tamponade/effusion
128
Pt post CABG or AVR 4 yars ago with inc SOB for 3 months +JVD 9cm, hepatomegaly adn pedal edema, EKG and CXR normal - dx?
Pericarditis
129
MCC CHF
Ischemia\>dilated CM\>HTN, valvular dz, congential HDz \*Always r/o ischemia in pt with new onset CHF and sudden decompensation in stable CHF MC precipitant of decompensation in CHF -\> inc'd salt intake
130
CHF Systolic dysfxn
problem = dec'd contractility inc'd LVEDP dec'd LVEF Echo - dilated Tx: 1. ACEI, 2. BB - diuretics for sx: (Loop/ 3. spironolactone) - Digoxin - Hydralazine + nitrate\*\* decr mort. if cant tolerate ACEI and in black pts. - ICD/CRT
131
CHF Diastolic dysfxn
dec'd relaxation inc'd LVEDP NORMAL EF Echo: hypertrophy, early restrictive filling, E/e' \> 15 Tx: - Candesartan (good elderly & setting of systolic as well) - ACEI - BB - CCB (long acting) - Diuretics
132
What BNP is specific for acute CHF?
\<100: no chf \> 500: definate CHF
133
Elevated BNP seen in...
LHF 2/2 diastolic dysfxn LHF 22/ systolic dysfxn RHF 2/2 COPD RHF 2/2 PE
134
60yo F eval for 3 month SOB on exertion, no CP, pmhx HTN DM2, HLD for which she takes meds.. wtd?
TTE check LV fxn/WM
135
Echo with inf wall hypokinesis and EF 40% best managment?
Cath (not dob stress echo)
136
50yo M pw inc'd SOB 3 days - pmhs HTN, BMI 40, JVP 14, b/l crackles and S3 heard, b/l pitting edema, BNP 160 - management?
IV lasix
137
BNP monitoring shows what?
Dec'd mortality in pt \<75yo
138
Pt pw exc intolerance and DOE - exm JVD 10cm, few basal rales, S3+ - pt dx with CHF CE and trop normal - pt tx'd with diuretics and gts better - TTE shows EF 35% . what to proscribe at time of d/c
ACEI
139
In pt with new onset CHF - Cr up from 1.1 to 2 and potassium inc'd from 4 to 5.6 after starting ACEI.. wtd?
D/C ACEI, start hydralazine + nitrates
140
PT with CHF on lisinpril 5mg and lasix 40mg dialy pw continued fatigue, JVD 12cm, scatter rales, pitting edema , best management?
Maximize lisinopril - start IV lasix) (no diff between bolus vs infusion)
141
When to start BB in decompensated CHF
ONce volume overload corrected, start low dose BB and titrate up
142
When to f/u patient as outpt after d/c for acute decompensated CHF
F/u Appt in 1 week (not 2) decreased mortality wth early post dc monitoring
143
If CHF is taking lisinopril 10mg qd. what to add next?
carvedilol
144
Two months later pt on lasix 40mg, KCl supp, lisinopril 10 and coreg 25 bid NYHA III, EF 35% K is 5.2. waht do you start next?
D/C K supp and start low dose spironolactone
145
Pt on spironolactone at inc'd risk for what?
HyperK+ (potassium sparing diuretic)
146
Pt on spironolactone p/w L only breast enlargement 6 months later
Biospy (if unilateral)
147
CHF pt on lasix, coreg, spironolactone, lipitor prsents 6 months later with BILATERAL breast enlargment
D/C spironolactone ad start Eplerenone If can't afford Eplerenone -\> start amiloride
148
58yo F pw CHF taking lasix 20, lisinopril 5, liptor 20, coreg 6.125, spironolactone and ASA - JVP 12cm - lung with mid lung crackles, +S3, pedal edema b/l, EKG QRS 0.13 - started on IV lasix - best management?
Optimize medical therapy for CHF (all meds low doses and is overloaded now)
149
1 wk later, pt that was on suboptimal therapy now on lisinopril 30, lipitor 40, coreg 25, spironolactone 25, lasix now up to 60, asa 81 - JVP 10, lungs still with bibasilar cracksl S3+ EKG QRS 0.13 EF 35 % - beset mangement?
Start Metolazone 30min prior to lasix
150
3 months later - pt who was optimized for CHF with lasix 60mg qD, metolazone, coreg 25mg BID, lisinopril 40mg, sprionlactone 25mg and ASA 81. p/w f/u - Echo still 35%, QRS 0.13s. best managment for pt?
Start ICD with cardiac resynchroization tx optimize meds with at least three months before ICD placement
151
76yo F c/o progressive SOB x 2 months - pmhx HTN, bibasilar crackles S1,S2 no murmurs 1+ pittin gedema - EF 65% with LVH best management?
CANDESARTAN (+diuretics)
152
Apart from HTN which conditions will you get inc'd LV mass?
DM, Obesity
153
Which pt's have higer incidence of Heart failure wih prserved EF (HFpEF)
Women age \> 75 with systolic HTN
154
Poor prognostic factors for CHF
S3 Hyponatremia PCWP \>12, norm 4-12 PAP \>50, norm 10-20 Peak O2 uptake \< 14 ml/Kg
155
Drug that improve mortality in CHF
ACEI ARB Succubutril is angiotensin-r - neprilysin inhib (ARNI) Spironolactone (low dose) (for NYHA III/IV Hydralazine + nitrates BB
156
What drugs DO NOT improve survival in CHF
Digoxin (improves fxn capacity and decreases hospitalizations) CCB Lasix
157
55yo F brouht to ED onset of severe SSCP x 2 days - inc'd with breathing - recently lost custody of her grandchild - JVP normal HR 120 lungs clear with summation gallop. trop 36, EKG 1mm ST elev V1-4 - echo anter and lateral wall hypokinesis with EF 35% ballooning of LV - cath shows NO CORONARY OBSTRUCTIN dx?
Takotsubo's cardiomyopathy
158
Can you use ACEI in asx pt with LV dysfxn?
Yes
159
ACE used for all following
Sclerodermal renal crisis post acute MI CHF DM with microalbuminuria HTN with S4 Viral myocarditis IgA nephropath chemo induced NICM NOT WITH PREGNANCY
160
SE ACEI...
Cough 2/2 bradykinin First dose syncope Angioedmea/laryngela edema Dec'd constriction of efferent arterioles - renal failure in marginal patients OR, increased vasodilation of efferent w hypoperfusion of glomerulus. GFR will decr slightly Neutropenia
161
What drugs NOT to use in CHF pts
NSAIDs Glitazones insulin sensitizing agents CCB Cilostazol metformin in advanced CHF
162
Combination of ACEi and ARB shown what?
Less proteinuria WORSE renal outcomes
163
70yo F pw pulm edema, two earlier episodes - responds well to IV lasix - HTN hx with 160/95 - LUngs clear, systolic murmur II/VI at apex-\> axill a - echo mild LVH EF 60% etio?
CAD
164
65yo F new onset CHF loud S4 soft S3, JVD 12, basal crackes - EKG BBB echo EF 25% - started on iv lasix, iv acei sx improve. most appropriate next test?
coronary angio
165
Joint commision core measures for CHF
D/C instructions Use of ACEi or ARB Document EF Smoking cessation counseling Flu shot
166
Dilated CM
Etio Etoh/peripartum/doxorubicin Ischemia Hemochormatosis Tx: Similar to systolic dysfuction In severe CHF inotropic agents such as dobutamine
167
Hypertropic CM
Diastolic dysfxn Aut dom 30%
4% mortality/yr
Sudden syncope/death after vigorous excercise
Sudden death most frequent in familial form in young patient
CP/dypnea also occurs
Carotid and peripheral pulses with brisk upstroke, BISFERIENTS pulse
Early systoic murmur at LLSB inc'd with dec'd flow (standing, valsalva (Symmetric hypertrophy=athletes heart)
Etio = Asymm hypertrophy of left ventricle --\> HOCM\*\*
(symm hypertrophy of LV = athletes heart\*\*)
Dx: Echo
Tx:
1. BB, metoprolol improve sx
2. CCB for CP
3. defibrillator, Septal myotomy
one run of NSVT = ICD
168
Do HOCM pts need endocardiitis ppx?
NO
169
Poor progrnostic factors in HOCM
VT
Age \< 30
septal thickness \> 3cm
Syncope
Failure to inc BP by 20mmHg upon excerise
Familial form and
fhx of sudden death
170
T/F about HCM 18yo basketball player with suddne death after vigorous play - autopsy hyperrophied IV septum
T
171
T/F about HCM pt p./w syncope, dypena or CP
T
172
Ventricular Tach on holter monitor inc'd risk of sudden death - these pts need ICD
T
173
T/F about HCM Murmur inc'd on standing, valsalva and decreases with handshake and sitting
T
174
An asyx 18yo wants to join soccer team at PE reveals ejection murmur and brisk carotid upsstorke - echo 16mm thickened upper portion of IV septum - wtd?
No high intensity sports
Can do boweling
If the Pt has VT OR has one run of NSVT on holter & fhx of sudden death then ICD\*\*
175
Aortic Stenosis.. p/w? s/sx?
MC valvular dz in adults
p/w
* syncope, left untreated time to death 3 years
* CP - left untreated time to death 3 years
* CHF left untreated time to death \< 2 years
Signs:
* Pulsus tardus - systolic crescendo-decrescendo murmur at Right sternal border, radiating to carotids
* Delayed and slow carotid upstroke
176
Signs of severe AS
* S4,
* paradoxical split S2,
* late peaking murmur
* Echo with gradient \>40, AVA \< 1 cm2
177
WTD in an asymptomatic AS pt w/ mild disease?
echo Q 3-5 years
178
WTD in an asymptomatic AS patient with moderate disease?
Echo Q 1-2 years
179
WTD in an asymptomatic AS patient with severe disease?
echo q 6-12 months
180
75 yo w/ AS gradient 80 and syncope, has hip fx after fall. wtd?
Replace valve first.
if patient has very poor EF --\> TAVR
181
Compared to surgery the complications with TAVR are....
increased.
- vascular complications
- strokes
- heart blocks
182
AS pt going for surgical valve replacement wtd prior?
coronary angiogram
183
What is seen in pt with AS
LVH
184
AV malformation with GI bleed related to?
AS
heydes?
185
Aortic Reguritation
* Presents w/ dyspnea (backed up blood)
* Early diastolic murmur at Left sternal border
* Severe cases with AUSTIN FLINT MURMUR (mid diastolic murmur like MS)
186
AR tx:
Tx:
Even with severe AR, Asx and EF\>50% then according to LV dimentions
* End-systolic dimension: **\< 40mm**. End-distolic dimension: **\< 60**. CHF rate = 0. wtd. --\> echo in _12 months_
* End-systolic dimension: **40-50 mm**. End-distolic dimension: **60-70**. CHF rate = 6%. wtd. --\> echo in _12 months_
* End-systolic dimension: **50-55** **mm**. End-distolic dimension: 7**0-75**. CHF rate = 19%. wtd. --\> echo in _3-6 months_
* End-systolic dimension: \>**55** **mm**. End-distolic dimension: **\>75**. wtd. --\> _surgery_
Surgery IF EF\<50 with sx
187
Austin flint murmur
AR Jet hits MV open leaflets mid diastolic murmur like MS
188
25yo F with AR EF 60% wants to get pregnant - what to expect?
Normal Vaginal Deivery
189
Best candidate for sildenafil is
Pt with AR and preserved LVEF
(better than AS or pt with angina)
190
Mitral stenosis Middle aged woman born in china/india with dyspnea, hemoptysis - on exam loud S1, Loud P2, opening snap - mid diastolic rumble (decrescendo at apex)
- Swan PCWP 18, PAP 80/34, RAP 15
- CXR cardiomegaly - straightening of left heart border
dx?
Dx: Mitral stenosis
Complication = dilation of LA -\> Afib -\> thromboembolism and CHF
Tx: If valve \< 1.3cm2, then valvuloplasty
191
The reason for using diltiazem or BB in mitral stenosis
inc diastolic filling time
192
Pt with III/VI holosystolic murmur at apex , radiating to axilla. Pt is asx or mild dizziness. BP 130/84. HR: 86/min. echo = sev MR , EF 50%
LV 72mm diastolic (norm=37-57mm),
51 mm systole (norm=28-44mm).
approp mngment?
Surgery , MV repair decreased long term complications and post op mortality.
Sx even tho asympt, when:
* LV systolic dysfunction. i.e. \< 60% OR
* pulm HTN
* atrial fibrillation
* Symptoms
193
Pt h/o aortic aneurysm schedule for surgery gtting stress test - recent EKG, PFTs CXR normal - during stress test has ST dep in lat leads and 2/6 systolic murmur at apex - 5 min later no murmur dx?
Ischemic MR
194
ASD features: type, heart sounds, murmur and EKG finding:
* Secundum defect 70% (no need for abx ppx)
* Fixed split S2 (pulm valve clsoes later than aortic valve
* Parasternal impulse, prom 'a' and 'v' wave - mid systolic murmur at Left sternal border
* EKG with RV strain and partial RBBB
195
When to close ASD?
If L-\> R shunt \>1.7:1
196
What if pt ASD asx and L-\> R shunt \>2:1
Surgery
197
What if R-\> L shunt (Eisenmenger's syndrome)
NO SURGERY - denotes onset of pulm HTN
198
What is the best long term management for Atrial septal aneursym ?
nothing.
No ASA, No warfarin, no need to resect
199
PFO
* incomplete fusion of septum primum
* Bubble study for dx - 1 bubble /beat in LA (Hepatopulm syndrome 1 bubble every 4th beat)
200
Secundum ASD
* Incomplete covering of foramen ovale by septum primum
* Ideal candidate for percutanous closure
MVP
201
Primum ASD
* Septum primum does not connect to endocardial cushion
MVR
202
VSD
* common in children
* systolic murmur at LLSB -\> precordium
* Split 2nd heart sound (not fixed)
* No endocarditis ppx unless w/in 6 months of surgery
* If L-\> shunt \>1.7:1 then Do surgery
203
PDA
* Crescendo-descrecendo continuous murmur left parasternal area (Lt 3rd ICS) - Soft S3
* Percutaneous closure helps at all ages
* No abx ppx before high risk procedures needed
204
Coarctation of Aorta
* most common assoc congen. cardiac abnormality --\> 70% w bicuspid valve
* Delayed femoral-brachial pulse or absent femoral puulse Early systolic murmur
* Persistent HTN after surgical correction
* BP higher in upper than LE
* CXR rib notching 22/2 collateral vessels ("3" sign)
* No need for abx ppx
205
Marfan's syndrome
* Decrased strength and dilation of aorta with aortic regurgitation and dissection
* Monitor yearly echos, If \>4.5cm - Echo q6month
* 5.5cm or greater - repair
* Prevention of dissection = BB --\> + losartan
206
Pt with marfan's has echo q6month. you have explained 2 yrs ago, that repair should be done if it reaches 5.5cms. current echo reveals aorta of 5.3cms and you discuss the possibility for repair now and patient says he will wait another 6 months and see ... wtd?
explain pt should consider repair now and the possibility of dissection in mean time
207
Eisenmenger's syndrome
R-\> L shunt
most common presentation of eisenmenger's = Cyanosis of mucous membranes
208
HTN
Systolic BP\>disastolic BP as CVD risk factor
209
Pt normal BP, after age 18 Screen for HTN how often?
q2yr
210
what systolic bp is preferred for a pt with HTN according to SPRINT trial?
SBP \< 120 mmHg
211
Diastolic HF more common in...
Women \> 75 with systolic HTN
212
Isolated systolic HTN in elderly tx?
Thiazide diuretic 12.5-25 daily
213
Mild to mod HTN
Thiazide/chorothalaidone
214
HTN with LVH (S4+)
ACEi
215
HTN with renal insuff
ACEi
216
HTN with ischemic HDz
BB, CCB
217
HTN with DM/proteinuria
ACEi
218
HTN with CHF
ACEi, Diuretics, Carveilol
219
HTN post MI
BB, ACEi
220
HTN with gout
Losartan (ARB)
221
HTN with pregnancy
Labetolol, Methyldopa, hydralazine NO ACEi
222
Thiazide s/e
Hyper Ca+ Hyper uricemia Hypo K+ Hyponatremia Inc'd dig and lithium levels, pancreatitis, psoriasis
223
Does Angiotensin II blocker induce cough?
NO
224
Pt on HCTZ 25 daily BP still high wtd?
Restric fluid and salt
225
Pt HTN on HCTZ 25 daily - BP 160-148 Exam S4+ wtd?
add ACEi
226
18yo F 170/105 wtd?
Urine tox first
227
21yo Pt CP, cocaine + 160/100 wtdD?
benzo, nitrate, ASA Prevent CP - no cocaine, CCB
228
Thoracic aneuysm
* CP rad-\> back
* Acute AR murmur
* Widened mediastinum
* Surgery if \>6cm and asx OR
* symptoms at any size or dissections
229
Abdominal aneurysm
* Interscapular pain
* Surgery \>5cm and asx or
* Sx's at any size
* usually Dissecting AAA treat medically first with BB and nitroprusside if pain persists then surgery
230
68yo M ddmittened for urgent repair of 7.5cm AAA pt with DM and inc'd cholesterol - fhx MI at 57 next step?
No further testing
231
AAA screening
Anytime smoker age 65-75 - AAA US screening noce in MEN ONLY No screening in women
232
73yo chrnoic smoker with family hx AAA has neg abd US for AAA wtd?
No additional US needed
233
73yo ex soker no fhx of AAA has small aneursym on US wtd?
Repeat US
234
60yo M h/o CAD severe CP-\<\> back 190/100 HR 90 decresenco murmur dx?
Aortic dissection Dx: TEE - or CT scan wo contrast if no TEE available then tx with BB, IV nitropruside THEN surgery
235
A loose fitting/large fitting BP cuff will ...
UNDERestimate BP
236
Small/tight cuff will...
OVER estimate BP
237
Porcine valve
No A/C
238
Prosthetic valve
Needs A/C PT INR 2.5-3.5. warfarin not noacs
239
Valvuloplasty
Tricuspid stenosis, pulm stenosis, mitral stenosis Temporary in Aortic stenosis
240
TEE needed for...
* prostethic valve endocarditis
* Descending aortic aneurysm
* Left atrial thrombus, PFO
241
Afib
* atria fibrillating, no 'p' waves
* some imprulse conducted to the ventricles giving rise to an irregularly irregular ventricular response
* Narrow QRS except with abberant conduction
* can present as
* new onset \< 48hrs
* PAroxysmal (terminates spont.)
* Chronic \> 48hrs
242
New onset afib
w/in 48hrs
243
Paroxysmal afib
terminates spontaneously
244
Chronic
always in afib
245
Slow ventricular response in afib
* BB
* CCB
* Digoxin
246
Convert to NSR
* Amiodarone
* Ibutilide (prolongs QT)
* Dofetilide (prolonges QT)
* Electrical cardioversion
* * Dronedarone (ony med shown to decrease hospitazation -\> avoid in pt with EF\<35%)
247
Risk factors for afib
High risk -Prev stroke TIA or Embolism Mitral stenosis Prosthetic heart valve Moderate Risk factors Heart failure HTN Age\>75 LVEF\<35% DM Weaker risk factors Female Age 65-74 CAD Thyrotoxicosis
248
Afib tx
No risk factors - ASA 81 one mod risk factor ASA81 daily or wafarin INR 2-3 Any high risk factor or \>1 mod risk factor - warfarin INR 2-3
249
CHAD Vasc
C-congestive HF or LV syst. dysfxn [1]
H-hypertension, BP \> 140/90 consistently or on HTN meds [1]
A2-age \>/= 75yrs [2]
D-diabetes mellitus [1]
S2-prior stroke, TIA, or DVT [2]
V-vascular dz (PAD,MI,aortic plaque) [1]
A-age 65-74 [1]
Sc-sex category, female [1]
~1% per point. score 1 = 0.6% @1yr. \> 1 3% @1yr.
score \>/= 2 --\> AC
score =1, consider AC or ASA
250
Heart dz with one major contraindication to warfarin
tx with ASA
251
Afib with wide compplex tachy
WPW tx with procainamide NO DIG NO BB NO CCB -\> vfib
252
62yo pw palpiations EKG afib HR 100/min - started on BB - echo with no vavluar abnormalies and normal wall thickeness - BP 140/84 wtd?
ASA 81 (no risk factors)
253
76yo pt HTN pw palpitations - HR 110 HR 110, started on BB
Warfarin (one mod risk factor - HTN)
254
65yo afib h/o TIA in past
Warfarin (one high risk factor) start on 5mg daily
255
Pt chronic afib on warfarin going for MINOR surgery
continue warfarin
256
Pt with chronic afib on warfarin going for major surgery wtd?
* If CHAD score 4 or less -\> D/C warfarin 5 days prior, no need to bridge
* If CHAD score 5 or higher -\> D/C warfarin 5 days prior and bridge with:
* 1. LMWH twice daily and last dose 24 hrs prior to surgery OR
* 2. LMWH once daily last dose 1/2 morning of procedure
257
On day of surgery pt INR 1.6 wtd?
Clear for surgery
258
Rate control and A/C in afib compared to DCCV show to ?
Decrease stroke Decrease hospitalizations
259
Pt with chronic afib refractory to med tx or can't tolerate meds wtd?
AVJ ablation with PPM needs AC? - YES - atria still fibrillating
260
Young adult recurrent afib refractory to medical tx or can't tolerate meds
circumferential pulmonary vein ablation
261
Elderly pt p/w weakness on L side body - EKG shows afib IV heparin given and weakness resolves - carotid dopper shows \< 50% stenosis or right ICA & L ICA \>70%. best tx at this time?
warfarin + heparin bridge
262
how to prevent rate related cardiomyopathy (CHF) in atrial fibrillation
control resting heart rate to \<110 b/min
263
48yo M pw acute onset periumbilical pain - afib with RVR 130 bpm wtd?
arteriography r/o sequella afib emboli
heparin first, then tPA after.
acute mesenteric ischemia
264
Pt wtih afib tx'ing with diltirazem - rate control - echo structurally normal heart - pt comes back with inc'd sx palpitations - holter shows many episodes of afib where he had sx wtd?
Add BB
265
What drug will bring afib into NSR
ibutilide
266
Aflutter
* macro re-entrant circuit - EPS for RFA
* Atrial flutter rate 250-300/min
* Usually 1 in 2 flutter waves get through (2:1 block) ventricular rate 125-175 b/min.
* Etio: Cardiac or pulm dz - can have WPW
* Tx: First slow AV conduction BB, dilt then cardiovert with amiodarone/quinidine
* Low energy DCCV or atrial pacing can also be done
* Recurrent flutter - EPS/RFA
267
32yo F MS sudden palpitation - 150/min and regular - carotid massage slowed rate but then returned to 150 when stopped - dx?
Aflutter
268
MCC SVT
AVNRT 70% Tx: carotid massage Adenosine 6-\> If wheezing then CCB
269
Orthodromic reentrant tachycarida
accessory pathway EPS/RFA down AVN, up accessory pathway - narrow complex Tx: AVN blockers, vagal maneurvers
270
Antidromic re-entrant tachycardia
Accessory pathway Down accessory pathway, up AVN Wide complex Treat like VT with procainamide or cardioversion
271
22yo palpitations pounding sensation in neck for several years - now worse - gets slightly dizzy at times - sx occur without warning while restig - when she breathes slowly and deeply palpiations resolve on own - EKG normal dx?
Paroxysmal SVT
272
WPW
Impulse via accessory pathway reach ventricle earlier than AV node -\> delta wave, shortened PR on EKG WPW can pw Afib, aflutter and vfib DO EPS if aw any arrhythmia or unexplained syncope Never tx wide complex tachy with BB, CCB or digoxin
273
Pt has SVT and respods to carotid sinus massage - pt asks how to prevent future episodes
teach vagal maneuvers
274
25yo palpitations, gradual onset - during episodes sinus tach 140 notes - asx EKG normal - echo normal - pt dx with inappropriate sinus tach wtd?
start BB
275
Youn athlete on routine physical found to have EKG with WPW, asx - can he play basketball?
YES
276
Pt pw palpitaitons, EKG Afib or SVT - after BB feels bette rand repeat EKG shows shortened PR - wtd?
EPS/ablation of errant tract
277
Pt pw wide complex tachycardia HR 200 QRS 0.14 pt has h/o WPW - unable to decide if is SVT with aberration or VTach - you woudl tx this patient with ?
Procainamide
278
Multifocal Atrial Tachycardia
Three or more distinct morphological types of "p" waves Seen in COPD, result of theophylline use Tx: Oxygen, Mg, inhaled bronchodilators 2nd: CCB NO DIGOXIN
279
PVCs
3 or more PVCs = NSVT 30 S of NSVT = sustained VT
280
Pt with muultiple PVCs wtd?
Look for organic heart dz - echo, stress, gated pool studies If heart dz negative, asx - NO TX If heart dz neg but symptoms -\> BB If heard dz postiive with LOW LVEF -\> ICD Sustained VTach - ICD
281
45yo healthy man who excercises everyday and asymptomatic, is going for elective major surgery - EKG reveals multiple PVCs wtd?
Clear for surgery
282
Ventricular tachycardia
3 or more consequential PVC Diff dx: SVT with aberrancy WPW LBBB
283
VT more likely if
* AV dissociation
* QRS\>0.14s
* LAD neg.
* Fusion beats
* Capture beats (normal conducted sinus beats interrupting wide complex tacycardia)
* Presense of organic heart dz
* Cannon 'A'
* Concordance of QRS in precordial leads Rate\>100
284
30yo AA pt to ER with palpitations - found to be in arrhythmia adn hypotensive - defib twice and IV med is started - exam cervial axillary and epitrocheal LN ++
Dx: Sarcoidosis
285
Prolonged QT interval
Quinidine Disopyramide Methadone Azithro Procainagmide Hypokalmeia, hypo Mg+ Pentamidine Erythromycin Phenothiazine TCA, moxifloxacin Ariprazole
286
Torsade de points
tx: D/C offending drug Overdrive pacing Mg SO4
287
MCC sudden cardiac death
ishemia
288
What dec'd short term mortality in pt with vfib
Defibrillation
289
What is most effective timing of defib
CPR then defib
290
Pt with Vfib collapse in ER - defib x 2 but short while later vfib twice more wtd next?
epinephrine check electrolytes amiodarone
291
Best managment in pt with fhx sudden cardiac death
ICD
292
Indications for ICD
* Sudden cardiac death VT or Vfib
* EF\<35% with CHF irrespectie of etio
* NICM - 3 months fter med therapy
* ICM - 40 days after MI
* HOCM with NSVT and fhx SCD
293
21yo F wakened by alarm clock and minutes later has syncope - EKG prolongued QT and TWi - hx might be helpful is?
fhx sudden cardiac death
294
60yo F c/o recurrent excercise idued palpitations with near syncoep - pt fhx near syncope in mother and daughter - EKG QTc 460, EF 55% next step?
BB therapy (metoprolol, not sotalol)
295
42yo Asian man with sudden cardiac arrest - EKG Vfib - defib'd successfull - EKG now ST elev in V1-3 and asx - pt fhx father dying at age 40 dx?
Brugada syndorme tx: ICD
296
Pt with h/o dizziness passing out for few sesonds - h/o palpitations
Holter montior (continuous loop recorder)
297
Pt with palpitations 2-15 minutes - NO SYNCOPE
Event monitor - press button to start
298
First deg AVB
* conduction impulse to ventricles delayed
* PR\>0.2
* intranodal block with benign process
* NO NEED FOR PPM (if suspecting endocarditis -\> may have new 1st deg AVB)
299
2nd deg AVB type I (mobitz I/wenkebach)
progressively prolonging PR till dropped QRS no need for PPM unless very low HR or HD problems
ok to give low dose BB
300
Pt with inf wall MI had PCI now stable - 3 days later tele shows 2nd deg AVB type I, HR 50bpm no sx - wtd?
Close monitoring as outpt, reduce BB dose
301
2nd deg AV block type II
* PR prolonged but constant with sudden drop QRS
* If 2/2 IWMI/RV MI --\> usually transient and doesn't require pacing (may need atropine or TVP)
* If 2/2 AWMI --\> more extensive damage --\> may need PPM Infranodal block
302
3rd deg AVB
* atria and ventricles beathing at own rate - cannon A waves on JVP
* tx w/ PPM
* Acute MI with new bifasciular block -\> high risk for progression to CHB
303
Indications for PPM
* 2nd deg Mobitz II
* 3rd deg AVB
* Pause dep VT
* sinus nodes dysfxn -
* HR\<40s while awake,
* Mobitz II AVB with bifasciular block,
* post op AVB
CHF with prolonged QRS - use bivi ppm
304
75yo M intermittent palpitations denies SOB or syncope - pt on BB and ACEi for HTN - EKG NSR 66bpm - holter with HR 35-106 during day
PPM (need for tachy brady to tx palpitaitons)
305
80yo for regular checkup found to have HR 45 - holter shows rate max 55, drops to 38 during night at one point - no sx
reassurance NO PPM
306
65yo F SOB on exertion CHF EF 22% on nitrates, BB, ACEi, spironolactone and dogxoin QRS\>0.15 w LBBB what else to decrease sx?
CRT-D
307
Junctional rhythm
* Junctional tachycardia
* Vrate 70-130
* 'p' wave may be inverted - buried beneath QRS or following QRS
* Etio: Dig toxicity IWMI Myocarditis Post cardiac surgery
308
Sinus bradycardia
HR\<60 Hypothermia Hypothyroid
309
Sick Sinus syndrome
SA node problem causing bradycardia, block, arrest or tachy-brady syndrome No need for EPS -\> directly to PPM Tx: PPM if: 1. Symptomatic 2. Tx of tachyarrhythmias causing significant bradycardia
310
Digoxin
inc'd vagal tone Wt loss anemia AVN block -\> Jnc rhthym -\> regularized afib -\> dig tox
311
Digoxin effect
Scooped ST segment No tx (not dig toxicity)
312
Anti arrhythmic drugs
ClassI decrease upslope of action potential Ia: Disopyramide, Quinidine, Procainamide (Double quarter Pounder) Ib: Lidocaine, Tocainide, Mexiletine, Phenytoin (Letuce Tomato, mayo) Ic: Flecanide, Propafenone (Fries Please) Class II: decreases synpathetic activity Beta Blockeers Class III: prolongs action potential Amiodarone, Sotolol, Bretylium Class IV: CCB Others: Adenosine: slows AV conduction Digoxin
313
Toxicity of Antiarrhythmics
Quinidine -\> prolongues QT, dec'd plts Procainamide -\> Drug induced lupus (anti-histone) Lidocaine -\> seizures Amiodarone -\> Pulm fibrosis, hypo/hyperthyroid, COrneal deposits
314
LAenlargement EKG
M shaped pwave (MS)
315
RAEnlargment
Tall p wave
316
RVH
R wave V1, RADev
317
RBBB
R, R' V1-2
318
LBBB
R R' I, aVL, V6
319
Digoxin: Normal level \<1ng/mL
Toxcity - anorexia/wt loss Regularized afib - weight loss EKG Jnc Tachycardia, PAT with block, PVCs
320
Predisposing factors for dig toxicity
Low K Low Mg Low Renal Fxn Low O2
321
Drugs tha tincrease Digoxin level
Quinidine Amiodarone Verapamil Spironolactone Chlorthalidone/HCTZ
322
Treament of Digoxin toxicity
Correct electrolytes BB Lidocine/phenytoin Digoxin binding antibodies - if pt with life threatening arrythmia NO QUINIDINE, NO PROCAINAMIDE
323
Pt with afib started on Digoxin - regularized afib on EKG wtd?
D/C Digoxin
324
Elderly pt with Cr 1.3 on lisinopril, glizpiide mirtazapien and digoxin 0.25/day with gradual wt loss wtd?
lower digoxin dose
325
Pt on digoxin and amiodarone is added wtd?
Decrease digoxin dose
326
78yo M SOB with Cr 1.5 on digoxin and warfarin - EKG HR 96 looks regular with regular with retrograde pwave
Dig toxcity - check electrolytes pAT with block
327
normal BP in setting of S4?
masked BP, therore home BP monitoring
328
Pulsus paradoxus
Decr. BP, JVP incr. w/ inspiration: cardiac tamponade SVC obstruction Pulm obstruction
329
PDA
apical --\> V5-6
330
Pt w/ CP at night 5-15 min at rest. wtd?
- EKG --\> ST-T changes? yes? do angiogram. if neg? do ambulatory EKG to see if vasospastic angina - EKG --\> ST-T changes? no? do ambulatory EKG .. if positive then do angiogram.. if that is neg then vasospastic angina
331
21 yo pt w/ chest pain, cocaine positive in urine . BP 160/100. wtd?
#1 benzo #2 nitrates #3 ASA prevent chest pain in the future with CCB
332
Pt w CAD s/p PCI w stent.. 3months later with low Hb , BRBPR and EKG reveals STD. PRBCs transfused, wtd?
colonoscopy
333
pt w/ stent placed 9 months ago on ASA + plavix presnets wtih GI bleed. wtd?
d/c plavix and contin asa at 81mg qD
334
Pt w/ CP 3hrs presents to the ER w/ STE in II,III, avF. troponin neg. wtd?
PCI
335
Pt w/ 3 hours of CP, presents to the ER with STE II,III,avF. Troponin neg. PCI not available.. mangmt?
PCI after 2 hours
336
Pt w/ CP for 3 hours presents w STE V2-4. Trop +. tPA was given w/in 30 min of arrival. Pt now w crackles in lungs and dyspnea. mangmt?
PCI asap
337
65 yo M w/ AWMI w/ BP 80/60. pt was put on IABP. nearest PCI center 2.5hrs away. wtd?
tPA & then trsnsfer to do PCI
338
Pt w/ MI is treated then develops sustained VT. wtd?
if unstable (CP or low BP) --\> synchonized cardioversion, then amio/lidocaine\* if QRS and T not seen --\> defibrillation then amiodarone\* if stable --\> amiodarone/lidocaine.. wtd next ? cath\*
339
Pt with CHF NYHAII on ACEI lisinopril 20mg PO BID, coreg 25mg BID, and spironolactone. He is mildly symptomatic. wtd?
--\> switch from lisinopril to sacubril-valsartan. how? --\> dc ACEI, wait 36hr washout period and then start sacubitril-valsartan entresto = decr mortality and hospitalization ACEI + entresto is CI
340
Constrictive pericarditis...
- rigid pericardium not allowing ventricles to expand
- post cardiotomy, viral, radiation
- sx: dyspnea, fatigue, ascites
- Increased Rt/Lft sided pressures
- Normal systolic function
- diastolic fxn : yes early restrictive filling **E' \>12**
- JVP bulge: equalization of diastolic pressures
- Positive square root/dip & plateau
- Heart sounds: **knock aka early 3rd HS**
**- EKG : mostly normal**
**-murmurs less common**
**- BNP \< 100**
**- CXR --\> pericardial calcification**
**- atrial enlargement less common cardiomegally with biatrial enlargement**
**-MRI = thickened pericardium**
**- ECHO = bulging of septum to the left. Mitral annulus E' \> 12cm, respiratory variation 10-40%**
341
Restrictive cardiomyopathy..
- rigid ventricle
- etio: amyloid, endocardial fibrosis, sarcoidosis
- sx: dyspnes, fatigue, ascites
- increased rt & left sided pressures
- normal systolic function
- diastolic fxn, early restrictive filling
- JVP bulge, equalization of diastolic pressures
- Squar root/dip & plateau
- Heart sounds: **3rd HS --\> 4th HS early dz**
**- ekg: low voltage EKG, repolariz abnormalities, ST-T wave changes, AV conduction delays, afib, PACs**
**- BNP \> 400**
**- CXR: cardiomegaly due to atrial enlargement**
**- atrial enlargement: cardiomegaly with Biatrial enlargement more common**
**- MRI: ventricular wall thickening, thickened septum, refractile**
**- ECHO: mitral annulus E' \< 8cm/sec. Resp variation \< 10%**
342
A 65 yo p/w dyspnea on exertion and fatigue for the past couple of months . pmhx of MI 5yrs ago w/ CABG. exam: bulging of JVP on inspiration. early diastolic sound on auscultation. pedal edema 1+. BP 130/80. on inspiration 124/74. EKG norm. BNP 80. ECHO = early restrictive filling with septum bulging to the left on inspiration.. dx
constrictive pericarditis
343
70 yo pt p/w DOE and fatigue for the past several months. Hx of HTN. BP 140/80. Periorbital ecchymosis b/l. JVP bulges on inspiration. S3 +. Trace pedal edema, petechiae over feet, lungs clear, pansystolic murmur 2/6 at LSB. tender hepatomegaly. EKG = ST-T wave changes and 1st degree AV block. CXR = cardiomegaly. DX?
Constrictive pericarditis (can cause congestive hepatopathy and eventually cirrhosis)
344
The best management for a pt with mitral stenosis with valve surface area \< 1.5 sq cms?
Percutaneous balloon valvuloplasty; if no more than mild MR, no atrial thrombus, and no more than moderate annular calcification
345
HTN w/ systolic HTN in elderly woman
candesartan
346
HTN with aortic regurgitation
ACEI, ARB, dihydropyridine CCB
347
Frequency of AAA screening depends on size of the aneurysm.
\<3 cms --\>
3-3.4 cm --\>
3. 5 - 4.5 cm --\>
4. 5 - 5.5 cm --\>
\<3 cms --\> 5 yrs
3-3.4 cm --\> 3 yrs
3. 5 - 4.5 cm --\> 1 yr
4. 5 - 5.5 cm --\> 6 months
348
Preferred medications to maintain rhythm control in pts with afib.
NO STRUCTURAL HEART DISEASE.
* propafenone
* flecanide
* sotalol
349
Preferred medications to maintain sinus rhythm in pts with afib and a history of CHF, LVH, or CAD.
* amiodarone
* dofetilide
350
82 yo woman trips and falls and becomes unresponsive for a few mins. PMHx on non-valvular afib, w/ hx of TIA and HTN on warfarin and HCTZ. CT head shows soft tissue swelling but no fracture or bleed. wtd??
restart warfarin 2 wks later.
351
Genotyping VKORc1 +/- CYP2C9 has helped with dosing for which medication\>
warfarin
352
Initial steps in fast AVNRT
1. carotid massage
2. adenosine 6mg IV, then 12mg IV
adenosine does not work in afib/flutter
353
What condition is a/w large pulse pressure and water hammer (Corrigan) pulse?
aortic regurgitation
354
Wide QRS, STE and TWI in R precordials, with what looks like RBBB
**Brugada syndrome**, auto-dominant, sodium channel mutation. Rx with ICD in patients with syncope
355
Aortic Aneurysms
* greatest risk of expansion?
* when to do elective repair?
* screening for whom?
* greatest risk: smoking
* elective repair: at 5.5 cm size or \> 0.5cm growth/year
* men who have ever smoked \> 65yo
356
Indications for permanent pacing (5)
1. 3rd degree heart block
2. 2nd degree type II heart block
3. symptomatic 2nd degree type I heart block
4. symptomatic bradycardia
5. asystole with \> 3 sec pause
357
WTD when you have a patient with syncope and hx is consistent with vasovagal etiology (classic trigger is prolonged standing) and there are no high risk features?
discharge to home, follow up with PCP
358
Aortic dissection
* risk?
* dx modality?
* risk: HTN, smoking, Marfan, coarctation
* dx with CT angio or TEE
359
Treatment for aortic dissection with pericardial effusion?
This is a type A dissection and may lead to tamponade and cardiogenic shock. DO NOT do pericardiocentesis; get surgical consult instead
360
Monitoring for aortic aneurysm
* \< 3.0 cm
* 3.0-4.0 cm
* 4.0-5.4 cm
* screen with abdominal US
* \< 3.0cm: no surveillance
* 3.0-4.0cm: q2-3years
* 4.0-5.4cm: q6-12mo
361
PAD
* ABI value for moderate and severe
* medical rx
* surgical rx
* ABI \<0.90 = moderate; ABI \<0.40 = severe
* medical rx: ASA (+/- DAPT), statin, cilostazole (pentoxifylline has limited benefit), supervised exercise for ALL
* surgical rx: only for most severe cases (pain at rest)
*
362
Etiologies of orthostatic hypotension (3)
1. dehydration
2. medications
3. autonomic dysfunction
363
CCBs that affect the AV node and can cause bradycardia
Verapamil and diltiazem
364
NT pro-BNP
* higher average values for which patients
* lower average values for which patients
* higher average: for older people and CKD patients
* lower average: pts with higher BMI
365
Indications for CRT
EF \< 35% and QRS \> 150 and NYHA II-IV
366
Age to start lipid screening for men and women
35 for men and 45 for women; earlier if there are additional risk factors (tobacco use, DM, HTN, fam hx)
