8/13- Course Review Session 1 Flashcards
What is the differential diagnosis of “Lub Du-Dub”?
- Fixed splitting of S2 (A2-P2)
- S3 gallop (heard in decompensated heart failure)
- Opening snap: (mitral valve stenosis)
Besides S3 what are the (3) other early diastolic extra sounds?
T: tumor plop
- Extra sound that results from sudden “plopping” or “drooping” of a cardiac tumor (atrial myxoma) through the mitral valve
K: pericardial knock
- Extra sound that results from sudden “resistance” to ventricular filling by a thick calcified pericardium in constrictive pericarditis
OS: opening snap
- Results from sudden distension and bulging of the belly of MV leaflets (fused at their tips “commissures” in Rheumatic HD) in rheumatic mitral stenosis
**These are NOT S3 sounds/gallop
What are the physical findings in IHSS (HCM)?
- Spike-and-Dome or Bisferians arterial pulse
- Triple apical impulse
- Prominent palpable S4
What is a Bisferians arterial pulse/when does it occur?
- Bifid initial + wave early in systole
- Occurs before dicrotic notch
- Early LV ejection into aorta is hindered by the LV outflow obstruction; then LV overcomes it and more LV ejection occurs
What is heard in the dynamic auscultation of someone with IHSS (HCM)?
- Systolic murmur at apex/LSB
- Paradoxical A2-S2 split: late A2
- Louder and longer murmur with maneuvers that decrease EDV or increase systolic function
- Stand/Valsalva increases sound; squat decreases
Which of the following components of the atrial waveform represents active atrial systole?
A. A wave
B. C wave
C. V wave
D. X descent
E. Y descent
Which of the following components of the atrial waveform represents active atrial systole?
A. A wave
B. C wave
C. V wave
D. X descent
E. Y descent
A = atrial kick
What is the sound of pathologic atrial systole?
S4 sound
Most of the filling of the ventricles occurs during which of the phases of diastole?
A. Rapid filling phase
B. Slow filling phase
C. Atrial systole
D. None of the above
E. Possibly any of the above
Most of the filling of the ventricles occurs during which of the phases of diastole?
A. Rapid filling phase
B. Slow filling phase
C. Atrial systole
D. None of the above
E. Possibly any of the above
(Around 85% in younger people, but decreases with age)
The main difference between contractility and performance is:
A. Performance is usually load-insensitive
B. EF is load-insensitive, unlike CO
C. CO depends on SV
D. Contractility is difficult to assess at the bedside
E. Performance is an abstract concept
The main difference between contractility and performance is:
A. Performance is usually load-insensitive
B. EF is load-insensitive, unlike CO
C. CO depends on SV
D. Contractility is difficult to assess at the bedside
E. Performance is an abstract concept
The 3 key questions in diagnosing tachy-arrhythmias are all of the following except:
A. Are QRS complexes regular?
B. Are QRS complexes narrow?
C. Are P waves present?
D. Are P waves inverted in lead II?
The 3 key questions in diagnosing tachy-arrhythmias are all of the following except:
A. Are QRS complexes regular?
B. Are QRS complexes narrow?
C. Are P waves present?
D. Are P waves inverted in lead II?
The best predictor of coronary artery disease is:
A. Decreased contracility
B. Depressed EF
C. Depressed CO
D. High systemic SVR
E. Regional wall motion abnormality induced by exercise
The best predictor of coronary artery disease is:
A. Decreased contracility
B. Depressed EF
C. Depressed CO
D. High systemic SVR
E. Regional wall motion abnormality induced by exercise
(this is a stress test)
All of the following are key determinants of myocardial fiber shortening except:
A. Preload
B. Afterload
C. Contracility
D. Heart rate
E. Venous return
All of the following are key determinants of myocardial fiber shortening except:
A. Preload
B. Afterload
C. Contracility
D. Heart rate
E. Venous return
What are the determinants of cardiac function?
- Preload
- Afterload
- Contractility
- Wall stress
- (All of the above are determinants of myocardial fiber shortening)*
- Diastolic function (compliance)
All of the following are true except:
A. CO = SV x HR
B. EF of 65% is normal
C. EDV - ESV = SV
D. CI = CO/BSA
E. Vascular resistance = ratio of flow to pressure drop
All of the following are true except:
A. CO = SV x HR
B. EF of 65% is normal
C. EDV - ESV = SV
D. CI = CO/BSA
E. Vascular resistance = ratio of flow to pressure drop
VR = pressure difference/cardiac output
(SVR = [AO-RA]/CO)
- Flow (or CO) needs to be inversely proportional to vascular resistance
Normal EF is anything > 50% (normal range is 50-70%)
- Hyperkinetic: > 70%
All of the following are key determinants of wall stress except:
A. Blood pressure
B. Chamber size
C. Wall thickness
D. Hypertrophy
E. Ejection fraction
All of the following are key determinants of wall stress except:
A. Blood pressure
B. Chamber size
C. Wall thickness
D. Hypertrophy
E. Ejection fraction
WS = Pr/2h
The most common cardiac abnormality in ADULTS characterized by wide and fixed splitting of S2 is:
A. VSD
B. ASD
C. Bicuspid aortic valve
D. Hypertrophic cardiomyopathy
E. Systemic hypertension
The most common cardiac abnormality in ADULTS characterized by wide and fixed splitting of S2 is:
A. VSD
B. ASD
C. Bicuspid aortic valve
D. Hypertrophic cardiomyopathy
E. Systemic hypertension
- VSD ALSO has fixed split in S2, but does NOT commonly present and get diagnosed among adults
In the presence of ST segment depression, which morphology is most indicative of myocardial ischemia?
A. Upsloping ST
B. Downsloping ST
C. Horizontal ST
D. A and/or B
E. B and/or C
In the presence of ST segment depression, which morphology is most indicative of myocardial ischemia?
A. Upsloping ST
B. Downsloping ST
C. Horizontal ST
D. A and/or B
E. B and/or C
The following are high pitched sounds best heard with the diaphragm except:
A. First heart sound, S1
B. Second heart sound, S2
C. Third heart sound, S3
D. Pulmonary closure sound, P2
E. Mitral and tricuspid closure sounds
The following are high pitched sounds best heard with the diaphragm except:
A. First heart sound, S1
B. Second heart sound, S2
C. Third heart sound, S3
D. Pulmonary closure sound, P2
E. Mitral and tricuspid closure sounds
- S3 and S4 are fainter, low-pitched sounds that you auscultate best with the bell
In the asymptomatic diabetic with no other coronary risk factors, what is the goal LDL level?
A. LDL under 70 mg%
B. LDL under 100 mg%
C. LDL under 130 mg%
D. LDL under 160 mg%
E. LDL under 190 mg%
In the asymptomatic diabetic with no other coronary risk factors, what is the goal LDL level?
A. LDL under 70 mg%
B. LDL under 100 mg%
C. LDL under 130 mg%
D. LDL under 160 mg%
E. LDL under 190 mg%
- Anytime you have CAD, want to get under 70 (although other people may say under 70 only in very high risk pts…)
The following are useful to differentiate myocardial infarction from acute pericarditis except:
A. PR depression
B. ST elevation
C. Location of ST elevation
D. Pathologic Q waves
E. Description of chest pain
The following are useful to differentiate myocardial infarction from acute pericarditis except:
A. PR depression
B. ST elevation
C. Location of ST elevation
D. Pathologic Q waves
E. Description of chest pain
- Presence alone doesn’t really help you
- Pericarditis: sharp, localized pain that increases with coughing or inspiration
In a patient presenting with new onset oppressive chest pain, which of the following drugs would you give FIRST?
A. Metoprolol
B. Sublingual nitroglycerin
C. Heparin
D. Tissue Plasminogen Activator (t-PA)
E. Nifedipine
In a patient presenting with new onset oppressive chest pain, which of the following drugs would you give FIRST?
A. Metoprolol
B. Sublingual nitroglycerin
C. Heparin
D. Tissue Plasminogen Activator (t-PA)
E. Nifedipine
In a patient presenting with oppressive chest pain & ST elevation, you should:
A. Start an IV line first
B. Give aspirin to chew
C. Check BP then give SL NTG
D. If no change in pain and ST elevation with SL NTG, call Interventional Cardiologist
E. Check BP and HR then give metoprolol
F. All of the above
F
Start an IV line first- in case pt arrests so you can give life saving drugs
Give aspirin to chew- to reduce platelet aggregation
Check BP then give SL NTG- if BP is low (under 100) you should NOT give SL NTG
If no change in pain and ST elevation with SL NTG, call Interventional Cardiologist- now that you have excluded coronary spasm/Prinzmetal
Check BP and HR then give metoprolol- Metoprolol reduces HR and BP so you SHOULD avoid it if HR or BP are low
What is the predominant mechanism of nitroglycerin (NTG) in relieving angina?
A. Dilate coronary arteries
B. Dilate small collateral vessels
C. Reduce heart rate & blood pressure
D. Improve oxygen supply
E. Reduce venous return & preload
What is the predominant mechanism of nitroglycerin (NTG) in relieving angina?
A. Dilate coronary arteries
B. Dilate small collateral vessels
C. Reduce heart rate & blood pressure
D. Improve oxygen supply
E. Reduce venous return & preload
In a patient with prior MI & LDL of 200 mg%, the goal of lipid lowering therapy is:
A. LDL reduced by 10%
B. LDL under 130 mg%
C. LDL under 100 mg%
D. LDL under 70 mg%
E. LDL reduced by 20%
In a patient with prior MI & LDL of 200 mg%, the goal of lipid lowering therapy is:
A. LDL reduced by 10%
B. LDL under 130 mg%
C. LDL under 100 mg%
D. LDL under 70 mg%
E. LDL reduced by 20%
Once you have known CAD, the goal is under 70
A spike-and-dome (bisferiens) arterial pulse is distinctive of which cardiomyopathy?
A. Dilated
B. Hypertrophic
C. Restrictive
D. Infiltrative
E. Ischemic
A spike-and-dome (bisferiens) arterial pulse is distinctive of which cardiomyopathy?
A. Dilated
B. Hypertrophic
C. Restrictive
D. Infiltrative
E. Ischemic
Which finding is MOST reliable to confirm the diagnosis of hypertrophic cardiomyopathy?
A. Spike and dome bisferiens pulse
B. Severe concentric LVH with septal thickness greater than posterior wall thickness and outflow obstruction by echo
C. ECG evidence of LVH
D. Prominent S4 and gallop and triple apical impulse
E. Dyspnea in the absence of CAD
Which finding is MOST reliable to confirm the diagnosis of hypertrophic cardiomyopathy?
A. Spike and dome bisferiens pulse
B. Severe concentric LVH with septal thickness greater than posterior wall thickness and outflow obstruction by echo
C. ECG evidence of LVH
D. Prominent S4 and gallop and triple apical impulse
- Systolic anterior motion of the mitral valve (due to Venturi suctioning effect that pulse mitral valve into the septum and further contributes)
Which of the following best EXPLAINS Brokenbrough phenomenon?
A. Weaker beat after a pulse
B. Increased preload with more filling
C. Increased LV outflow obstruction due to a “stronger LV contraction”
D. Decreased LV outflow obstruction due to a “stronger LV contraction”
Which of the following best EXPLAINS Brokenbrough phenomenon?
A. Weaker beat after a pulse
B. Increased preload with more filling
C. Increased LV outflow obstruction due to a “stronger LV contraction”
D. Decreased LV outflow obstruction due to a “stronger LV contraction”
- Greater contractility, thus more obstruction and a weaker beeat
What is post-extrasystolic potentiation?
- Contraction after the pause that follows a premature beat is more forceful than normal
- Greater contractility and greater preload mediate stronger beat
- The Brokenbrough phenomenon contradicts this in the LVOT of HCM
What is the best approach to atrial fibrillation with a pulse rate of 190/min complicated by hypotension BP 90/50
A. IV digoxin
B. Treat underlying disease
C. Urgent cardioversion
D. IV verapamil
E. Urgent cardiac pacemaker
What is the best approach to atrial fibrillation with a pulse rate of 190/min complicated by hypotension BP 90/50
A. IV digoxin
B. Treat underlying disease
C. Urgent cardioversion
D. IV verapamil
E. Urgent cardiac pacemaker
ANY tachycardia can be helped by shocking the pt C
All of the following drugs are routinely recommended in ST elevation myocardial infarction (STEMI) except:
A. Aspirin
B. Fibrinolytics
C. Anti-Arrhythmics
D. Beta blocker
E. IIb/IIIa inhibitor
All of the following drugs are routinely recommended in ST elevation myocardial infarction (STEMI) except:
A. Aspirin
B. Fibrinolytics
C. Anti-Arrhythmics
D. Beta blocker
E. IIb/IIIa inhibitor
- IIb/IIIa inhibitor (Plavix/Clopidogrel) is only given to pts with ACS who are VERY HIGH risk Options in acute STEMI
- Aspirin (and nitrates) can be given
- Fibrinolytics if no aortic aneurysm
- Anti-arrhythmic (including beta-blocker) would be appropriate
Pre-systolic accentuation (the increase right before S1 in end diastole) of the MS murmur is absent if:
A. Cardiac rhythm is atrial fibrillation
B. Cardiac rhythm is sinus rhythm
C. Opening snap is absent
D. Opening snap is present
Pre-systolic accentuation (the increase right before S1 in end diastole) of the MS murmur is absent if:
A. Cardiac rhythm is atrial fibrillation
B. Cardiac rhythm is sinus rhythm
C. Opening snap is absent
D. Opening snap is present
- Think about what happens in end diastole at this same time (atrial systole)
- Pre-systolic accentuation corresponds to active atrial systole (or a wave on atrial waveform) which is absent if cardiac rhythm is atrial fibrillation
What is the best way to describe the classical auscultatory findings in mitral stenosis?
A. Diastolic rumble starts with pre-systolic accentuation and ends with an opening snap
B. Diastolic rumble starts with an opening snap and ends with a bow tie shaped plop
C. Diastolic rumble starts with S2 and ends with S1
D. Diastolic rumble starts with an opening snap and may end with pre-systolic accentuation
What is the best way to describe the classical auscultatory findings in mitral stenosis?
A. Diastolic rumble starts with pre-systolic accentuation and ends with an opening snap
B. Diastolic rumble starts with an opening snap and ends with a bow tie shaped plop
C. Diastolic rumble starts with S2 and ends with S1
D. Diastolic rumble starts with an opening snap and may end with pre-systolic accentuation
- May or may not end with pre-systolic accentuation (depending on sinus rhythm?)
All of the following statements are true except:
A. Tumor plop, like an opening snap, is an early diastolic extra sound
B. Pericardial knock, like a tumor plop, is an early diastolic extra sound
C. S3 gallop is an early diastolic extra sound best heard in decompensated CHF with volume overload
D. Tumor plop or pericardial knock are also referred to as S3 gallops
All of the following statements are true except:
A. Tumor plop, like an opening snap, is an early diastolic extra sound
B. Pericardial knock, like a tumor plop, is an early diastolic extra sound
C. S3 gallop is an early diastolic extra sound best heard in decompensated CHF with volume overload
D. Tumor plop or pericardial knock are also referred to as S3 gallops
