ABIM 2015 - Cardio Flashcards
Pt presents with c/o occasional sensation of a “skipped beat” or an “extra strong beat” ?
Premature Ventricular Contractions (PVC)
MURMUR: Mid-SYSTOLIC, Crescendo-Decrescendo, S4 present, Diminished and Delayed Carotid Upstroke, diminished, late A2 best heard at the RIGHT upper sternal border?
AORTIC STENOSIS
Absence of a RV impulse, pulmonary ejection CLICK that DECREASES with INSPIRATION, prominent “a” wave on the jugular venous pressure waveform, pulmonic component of S2 (P2) is delayed with a RV S4 and a RV lift are present in patients with?
MODERATE-to-SEVERE PULMONARY Valve STENOSIS
Pt presents with Dyspnea, Peripheral Edema, A-fib, Jugular Venous Engorgement on Inspiration, Pericardial Knock, Hepatomegaly and Ascites however WITHOUT pulmonary congestion?
CONSTRICTIVE Pericarditis
What Cardiac DEFECTS do Down Syndrome (Ostium Primum, Holt-Oram Syndrome (b/l UE abnormalitis) and FAMILIAL occurence (chromosome #5 - with complete heart block - Type III AV block) have in common?
ASD
What is the purpose of Bi-Ventricular pacemaker placement?
To restore cardiac synchronization and effective ventricular contraction
What are the common, reversible causes of BRADYCARDIA?
LYME disease, HYPO/HYPERkalemia, Drugs, HYPOthyroidism, HYPOglycemia
Extensive damage to the myocardium, Ventricular Septal Defect (VSD), RV infarction, papillary muscle rupture with severe MITRAL regurgitation, LV free wall rupture or LV thrombus WILL result in what s/p STEMI?
CARDIOGENIC SHOCK
What type of Valve abnormality is seen in patients with Marfan Syndrome, Williams Syndrome, Patent DUCTUS Arteriosus, Turner Syndrome
BICUSPID Aortic Valve
Although these antiarrhythmic agents have greater antiarrhythmic effects than Classes II and IV (ß-blockers & Ca-channel blockers), they can cause ventricular arrhythmias and toxicities?
Class I (Sodium-channel blockers) & Class III (Potassium-channel blockers)
Should patients with MECHANICAL valves get ANTIBIOTIC PROPHYLAXIS prior to DENTAL procedures?
YES!!!
What does the maneuver “HANDGRIP” do and what valve disease is it useful to detect?
Acute decrease in AFTERload with and INTENSIFIED MITRAL REGURGITATION murmur
Fibrofatty infiltration of RV causing RV-caused VT with RV dysfunction with T-wave inversions in V1-V3 and >500 PVCs in 24-HOURS?
Arrhythmogenic RV Cardiomyopathy w/Dysplasia (ARVC/D)
What procedure is required in cardiogenic shock to assess filling pressures and cardiac output to guide therapy?
Pulmonary Artery Catheter (PA cath)
What do maneuvers such as VALSALVA or STANDING from a seated or squatting position do and what valve disease are they useful to detect?
ACUTELY REDUCE Cardiac PREload; MITRAL valve prolapse
PFO and PFO associated with an atrial ANEURYSM pose an increased risk for what?
STROKE
In patients whom are HYPOVOLEMIC, what medication should NOT be started?
ACE-I (will exacerbate or precipitate HYPOtension)
Which are the SEPTAL LEADS on the ECG?
V1-V2
ALL patients with Chronic Stable Angina should carry what with them for emergency use?
NITROGLYCERIN
Why are the findings of a WIDE QRS (≥180 msec) and NON-sustained VENTRICULAR TACHYCARIDA important?
Because these are risk factors for SUDDEN Cardiac DEATH
What is the LEADING cause of DEATH in WOMEN?
Cardiovascular disease
What medications used to treat systolic dysfunction CANNOT be used in pregnancy?
ACE-I (-“pril”), ARBs (-“sartan”), Aldosterone antagonists (-“renone” or “lactone”)
This medication REDUCES the risk of STROKE, MI and CAD-related vascular DEATH and should be used in ALL patients with Chronic Stable Angina?
ASPIRIN
When should a MEDIUM Patent DUCTUS ARTERIOSUS be closed and how?
In ALL patients, Percutaneously vs surgery
Can you treat WPW+A-fib with AV nodal blocking agents (ß-blockers and Ca-channel blockers)?
NO!! (will cause sudden death due to VF) - use Procainamide or Amiodarone ONLY
If ABI must use the great toe for measurments because of vessel calcification, what is considered normal and what is considered PAD?
Great Toe SYSTOLIC BP ≥40 mm Hg is NORMAL and an ABI (great toe) 0.70 is diagnostic for PAD
Autoimmune myocardial injury from VIRAL infection and is NOT treated with immunosuppressive medication, rather same as SYSTOLIC HF?
Acute Myocarditis
What are the common yet ATYPICAL symptoms that WOMEN present with when experiencing ACS?
Fatigue, Dyspnea, Nausea
Left Ventricular DIASTOLIC dysfunction can be caused by these two (2) systemic inflammatory diseases?
RA, Ankylosing Spondylitis
Should you use Ca-channel blockers in the treatment of SYSTOLIC HF?
NO!! (cause decompensation) - use only for Chronic Stable Angina WITHOUT HF
Which patients develop symptoms during pregnancy, those with obstructive (stenosis, etc.) or those with regurgitant valve lesions?
Those with OBSTRUCTIVE Valve lesions
Is a patient with an ASD, WITHOUT Pulmonary HTN safe to become pregnant?
YES!!
This SVT has a pre-excitation feature of the ventricles as well as a DELTA wave (a slurred initial segment of the QRS complex)?
AV Reciprocating Tachycardia (AVRT)
Are ACE-I and DIURETICS recommended in the treatment of patients with ACUTELY decompensated HF?
YES!!!
When DO you want to perform STRESS testing in patients with HIGH Pretest Probability for CAD?
When defining prognosis, establishing effectiveness of current medical therapy, measuring exercise capacity and defining extent and severity of ischemia to identify patients appropriate for surgery as well as assessing surgical risk for NON-cardiac surgery
What is the most common CONGENITAL heart defect that is DETECTED at birth?
VSD (LARGE)
What is considered NORMAL Cardiac septal wall thickness?
When is it OK to use Corticosteroids to treat PERICARDITIS?
If REFRACTORY to ASPIRIN, NSAIDS and colchicine (last resort)
Allergic reaction is possible to REPEAT thrombolytic therapy exposure ONLY with one agent, which is it?
Streptokinase (decreased risk of ICH with this agent)
What organism is the PREDOMINANT cause of Infective Endocarditis affecting native/prosthetic valves and cardiac devices?
STAPAHYLOCOCCUS Aureus
What is the FIRST LINE therapy for VASOSPASTIC (Prinzmetal) ANGINA “VARIANT ANGINA”?
Ca-channel blockers (because they dilate coronary arteries)
What syndrome is caused by AV-node Accessory Pathway RECIPROCATING Tachycardia therefore with VENTRICULAR PRE-EXCITATION and appearance of DELTA waves on ECG?
WolfF-Parkinson-White (WPW)
What is the BEST predictor of long-term survival post SURGICAL REPAIR of Coarctation of the AORTA?
AGE at time of REPAIR (clearly, the earlier the better)
Should you use a Pulmomary Artery catheter in a hemodynamically STABLE patient for monitoring?
ABSOLUTELY NOT!!
In what type of patients are Pulmonary Artery (PA) catheters most useful?
Hemodynamically UNSTABLE patients, REMOVE PROMPTLY when no longer needed!!
Pts with a STEMI should be given ASPIRIN 325 mg (chewed rapidly), morphine, nitrates, oxygen, ACE-I, ß-blockers, clopidogrel, heparin (unfractionated or LMWH) and what else? UNLESS!!?
Sublingual nitroglycerin; UNLESS INFERIOR WALL STEMI (presumed RIGHT ventricular infarction)
For REFRACTORY Symtpoms of SVT, although potential fetal risk exists in pregnant women, this medication is used?
AMIODARONE
In what patients are the DOBUTAMINE Stress tests (ECHO and NUCLEAR perfusion) used rather than any of the EXERCISE stress tests?
In those whom CANNOT exercise
How are Cholesterol Emboli (arterial instrumentation) without Acute Limb Ischemia (ALI) treated?
Supportive ONLY
What are the four (4) PHARMACOLOGIC agents used in PHARMACOLOGIC Stress testing?
Dobutamine, Vasodilators (Adenosine, Dipyridamole, Regadenoson)
What is the most common type of VSD, which is located in the LV outflow tract, just below the AORTIC Valve ?
PERIMEMBRANOUS
Hypertrophy of the heart is asymmetric in what condition?
HCM (not Athlete’s heart)
What indicates successful reperfusion after thrombolytic therapy in a patient with STEMI?
> 50% ST-segment elevation IMPROVEMENT on ECG 60 minutes after administration of thrombolytic therapy
Once shunt reversal is present (LEFT-to-RIGHT becomes RIGHT-to-LEFT: Eisenmenger syndrome) should VSDs be closed?
ABSOLUTELY NOT!! (clinical deterioration)
MITRAL VALVE PROLAPSE, MI with Papillary Muscle rupture or Dysfunction, Rheumatic Heart Disease, LV SYSTOLIC Dysfunction and Infectious Endocarditis can cause what valvular disease?
MITRAL REGURGITATION
Negative sawtooth waves in the inferior leads (II, III, aVF) and a positive sawtooth wave in V1?
Atrial Flutter
Patients with Chronic Stable Angina and LEFT MAIN disease, >2-3 vessel disease with involvement of the PROXIMAL LAD and reduced systolic function will benefit from what intervention?
SURGICAL revascularization (CABG)
What maneuver decreases PREload and ENHANCES the MID-SYSTOLIC murmur of HYPERTROPHIC Cardiomyopathy so it can be heard better?
Valsalva maneuver
What is considered a “NORMAL” BNP in ambulatory patients with clinically stable HF?
500 pg/mL
What is screening is recommended for 1st degree relatives of patients with HCM?
ECHO yearly for adolescents, every 3-5 years for adults
Should NYHA 4 HF patient pursue SURGICAL Pericardiectomy for CONSTRICTIVE Pericarditis?
NO!! (high mortality with low benefit)
What are the three most common causes of Restrictive Cardiomyopathy?
Amyloidosis, Sarcoidosis, Hemochromatosis
If successful thrombolytic therapy occurs after STEMI, what patients still get coronary angiography?
Those with clinically significant ischemia and EF
What is the MOST common AUSCULTATORY presentation of HYPERTROPHIC Cardiomyopathy (HCM) and why?
MID-Systolic murmur caused by LV outflow tract obstruction due to asymmetric SEPTAL hypertrophy
The END pressure that stretches the ventricle, the initial stretching of the ventricle wall PRIOR to contraction?
PREload
CPR for Sudden Cardiac Arrest?
30 compressions (>2 in rate of 100/min) + 2 breaths x 5 cycles
Can you use Flecainide or Propafenone (Class Ic antiarrhythmic agents - Sodium-Channel Blockers) to treat a-fib and a-flutter in patients with CAD or s/p MI? Why?
NO!!!; can cause VT
In a patient with NEW-onset a-fib >48 HOURS, PRIOR to ELECTRICAL or PHARMACOLOGIC cardioversion, what MUST be done first?
ACUTE anticoagulation (HEPARIN) - NOT NECESSARY if
If patient took an ED medication (sildenafil, vardenafil or tadalafil) how long before its ok to take nitroglycerin?
24 hours
Which STEMI type causes 10-20% chance of LEFT Ventricular (LV) thrombus and how do you treat?
Anterior STEMI; treat with 3-6 months of warfarin
What happens to the LEFT Atrium and LV in pt with Mitral Regurgitation?
Volume overload and hence DILATION (ECCENTRIC HYPERtrophy - dilation)
What consists MEDICAL treatment of AAA if not appropriate for surgery?
Treat for HTN and Hyperlipidemia as well as SMOKING cessation
What is the average Pulmonary Artery Pressure?
15 mm Hg (3-30)
What can be used INSTEAD of Aspirin to reduce the risk of STROKE, MI and CAD-related vascular DEATH in patients whom cannot tolerate Aspirin?
CLOPIDOGREL
What are the risk factors for intracerebral hemorrhage to consider prior to thrombolytic therapy?
Age >65, Low Weight, Female, SBP >160
What should be monitored after initiation or dose increase of an ACE-I?
K (for HYPERkalemia) and Kidney function (Cr, GFR)
What must be HELD 24 hours prior to a NUCLEAR Perfusion Vasodilator (Adenosine, Dipyridamole and Regadenoson) Stress tests?
CAFFEINE
No clear P-waves with IRREGULAR Ventricular response (QRS complexes)
a-fib
What condition causes HIGHT Blood Pressure in the UEs and LOWER Blood Pressure in the LEs?
Coarctation of the AORTA
This medication is used ACUTELY for a-fib or a-flutter, does NOT have the adverse effect profile of amiodarone (liver toxicity, thyroid dysfunction, pulmonary fibrosis) and although it raises the Cr level, it DOES NOT affect GFR?
DRONEDARONE
What two (2) inflammatory rheumatological conditions cause major morbidity and mortality via atherosclerosis?
SLE and RA
What determines whether or not a patient should undergo cardiac STRESS testing?
INTERMEDIATE Pretest Probability for CAD
MURMUR: SYSTOLIC, Crescendo-Decrescendo, Carotid Impulse BOTH with Systole and Diastole, INTENSITY increased with VALSALVA or Standing from Sitting/Squatting Position?
HOCM
What are the ONLY medications patients with Pre-Excitation (DELTA waves - AVRT and WPW) be given?
Procainamide or Amiodarone ONLY!!
What meds MUST be withheld for 24-48 hours prior to any type of EXERCISE Stress test?
ß-blockers
These medications work by blocking the FINAL pathway of platelet aggregation?
G2b3a inhibitors (tirofiban, eptifibatide, abciximab)
Why is EXERCISE Stress testing recommended over pharmacologic if possible?
Because it gauges a patient’s FUNCTIONAL CAPACITY
What should be done if an agent (typically Class III - Potassium-Channel Blocker) such as sotalol or amiodarone increases the to QTc >500 msec total or more than 15% (60 msec) from baseline?
STOP the agent to prevent Torsades de Pointes
By INCREASING the pressure in your chest during a valsalva maneuver, PREload is decreased because it does not allow more blood to fill the heart. This maneuver is used to ENHANCE the MID-SYSTOLIC murmur of what condition?
HYPERTROPHIC Cardiomyopathy
The following signs: JVD, S3 gallop, Hepatojugular reflux, Ascites, laterally displaced apical impulse, Narrow Pulse Pressure (small difference between SBP and DBP), Cool extremities, Tachycardia with pulsus alternans (alternating strong and weak beats) are associated with?
Heart Failure (HF)
What is considered blood “HYPERVISCOSITY” which is often seen in chronic CYANOSIS (causes headaches, concentration difficulties) and how is it treated?
Hb ≥20 mg/dL AND Hct ≥65% in the ABSENCE of DEHYDRATION; treated with phlebotomy (2-3 times per year ONLY followed by IVF)
What evaluation and medical treatments are MOST important when treating Heart Failure (HF, CHF)?
Evaluate for LEFT Ventricular SYSTOLIC Dysfunction; ACE-I or ARBs and Smoking Cessation
Do statins prevent progression of CAD in patients with inflammatory diseases such as SLE?
NO!
Besides the holoSYSTOLIC murmur that occurs with VSD, in MODERATE-to-SEVERE VSDs, what other murmur is heard?
MITRAL DIASTOLIC Rumble (increased flow accross the MITRAL Valve)
“RIB Notching” and “Figure 3 Sign” on chest radiographs suggest?
Coarctation of the AORTA
Disease within the AV node that causes PROGRESSIVE lengthening of the PR interval until a QRS complex is ABSENT?
SECOND-DEGREE AV-Block TYPE-1 (Mobitz 1-Wenckebach)
ECG with VT and LBBB in the inferior leads (II, III, aVF) presenting only with palpitations in a 20-40 yo woman provoked with exercise or emotional stress?
Idiopathic VT (normal heart)
Which patients with acute myocarditis have a better prognosis?
Those that present with FULMINANT myocarditis (rapid onset, fever, severe hemodynamic compromise)
Marfan syndrome, Ankylosing Spondylitis and Giant Cell Arteritis can all cause this valvular disease?
AORTIC REGURGITATION (progressive)
What are MULTIFOCAL Atrial Tachycardias and what are these caused by?
Three (3) or more P-wave morphologies, caused by underlying pulmonary disease (treat that and electrolytes)
After quitting smoking, when is MOST of the cardiovascular risk decreased and when does the risk return to same as for a non-smoker?
2 YEARS; 3-5 YEARS
Some patients with HYPERTROPHIC Cardiomyopathy develop LV Outflow Obstruction (syncope, CP, dizziness, fatigue) only during exercise, how do you test these patients?
Exercise ECHO and Valsava maneuver
What should be done with ALL myxomas?
Surgical resection, especially if LEFT sided (to avoid embolic events) or Anticoagulation if surgery not tolerated
Anthracycline exposure (>550 mg/m2 for doxorubicin) cause what type of cardiac injury?
Myocardial necrosis with dilated cardiomyopathy
Restrictive Cardiomyopathy (RIGHT heart failure) with concomitant pulmonary disease, low QRS voltage and can be seen on CMR?
Sarcoidosis
Besides being risk factors for CAD, advanced age, HTN, DM, dyslipidemia and smoking are all risks for what else?
Chronic Kidney Disease (CKD)
What effect does radiation therapy have on the heart?
Fibrosis (can occur YEARS after exposure)
Which are the LATERAL LEADS on the ECG?
V5-V6
What EF% on STRESS testing confers a poor prognosis?
Women, intense emotional stress, apical ballooning of LV that MIMICS ACS (CP, mildly elevated enzymes, ischemic ECG changes) diagnosis made by ECHO?
Takotsubo Cardiomyopathy (supportive treatment only)
How should patients with WPW and symptoms be treated?
ABLATION!!
Findings of Left Axis Deviation, 1st Degree AV Block (Wenckebach), Right heart enlargement, a-fib and Mitral Valve Regurgitation are found in which congenital heart disease?
Ostium Primum ASD
Which pharmacologic agents, part of the NUCLEAR Perfusion Vasodilator (Adenosine, Dipyridamole and Regadenoson) Stress tests are associated with symptoms of CHEST PAIN, DYSPNEA or FLUSHING?
ADENOSINE and DIPYRIDAMOLE
What can be used and what should NEVER be used for ACUTE AORTIC REGURGITATION or for patients who are NOT surgical candidates?
Vasodilators (nitrates, ca-channel blockers); NEVER use Intra Aortic Balloon Pump (IABP) to treat AORTIC REGURGITATION (increases diastolic flow and regurgitant volume because it INFLATES during diastole forcing the volume above it to flow through the regurgitant valve back into the LV further increasing its volume exacerbating the condition)
Cardiac transplant patients are generally treated with one of these two medications which can cause DM, dyslipidemia, HTN, Kidney disease as well as interact with other medications?
Calcineurin inhibitors (cyclosporine or tacrolimus)
What are UNSTABLE ANGINA, NSTEMI and STEMI called?
Acute Coronary Syndrome (ACS)
What are the indications for ASD closure?
When there is evidence of RIGHT to LEFT SHUNT AND Ostium Primum, Sinus Venosus, SYMPTOMS AND a Pulmonary (Qp) to Systemic (Qs) blood flow ratio ≥1.5-2.0 (to avoid long-term complications), BEFORE a PACEMAKER is placed (increased risk of tromboembolism) and IF there is any other reason to perform cardiac surgery - then at time of THAT surgery
Chromosome 22q11.2 microDELETION?
Tetralogy of Fallot (DOWN Syndrome)
HOLOSYSTOLIC murmur 3-7 days post MI heard best along the LEFT sternal border WITH palpable chest wall thrill?
VENTRICULAR SEPTAL DEFECT (VSD)
What are the BEST antiarrhythmic agents to use for VT in patients with HF?
Amiodarone or Sotalol
When is SURGERY recommended to correct Coarctation of the AORTA and why?
When the gradient across the coarctation is ≥20 mm Hg or less with evidene of COLLATERAL formation; because high risk of dissection, CAD, Stroke, Systemic HTN and REDUCED SURVIVAL
What is the LEADING cause of DEATH in Americans ≥65 years of age?
Coronary Artery Disease (CAD)
Once endotracheal tube is placed for sudden cardiac arrest patient, what should be done next?
Capnography to check placement then breath every 6-8 seconds
Prior to hospital discharge, HF patients should be on BOTH of these medications?
ß-blockers AND ACE-I (or ARBs)
CONTINUOUS (when severe) murmur heard over the back?
Coarctation of the AORTA
What is the utility of a Coronary Artery Calcium (CAC) imaging test?
Predictive of cardiovascular risk in patients whom were determined to be at an INTERMEDIATE risk on pretest probability testing for CAD
SINUS tachycardia is a very common presentation after successful reperfusion of this type of STEMI?
ANTERIOR WALL (ST-elevation in V1-V6) - LAD occlusion, worst prognosis - LV infarction)
What illicit drugs affect the heart significantly?
Cocaine and Amphetamines
Does using medications (folic acid/niacin) to lower levels of elevated homocysteine and Lp(a) lipoprotein reduce the risk of CAD?
NO!
Two (2) or more non-conducted P waves occur for each QRS complex?
HIGH-GRADE AV-Block (advanced SECOND-DEGREE Heart Block)
What do you do for a patient with HGH-risk STEMI features whom presents at a non-PCI capable center?
Immediate transfer to a PCI-capable facility OR full-dose THROMBOLYTIC therapy followed by immediate transfer
Which types of cardiac shunts result in hypoxemia and cyanosis?
RIGHT-to-LEFT shunts (deoxygenated blood mixes with oxygenated blood in LV)
How is an ACUTE Cardiac TAMPONADE treated?
Volume resuscitation, vasopressors, inotropes or Intra Aortic Balloon Pump (IABP) + SURGERY (or pericardiocentesis)
Pt presents with AR, EF
Aortic Valve Replacement
How do you treat LONG QT-Syndrome and what meds MUST be avoided to prevent Sudden Cardiac Death?
ß-blockers; MUST avoid Sotalol, Haldol, Erythromycin)
When is the NUCLEAR Perfusion Vasodilator (Adenosine, Dipyridamole and Regadenoson) Stress test used?
In patients whom CANNOT exercise AND have a CONTRAINDICATION to DOBUTAMINE (severe baseline HTN or ARRHYTHMIAS)
What other heart ANOMALIES are associated with Coarctation of the AORTA and what genetic condition has both?
BICUSPID AORTIC Valve, CEREBRAL ARTERY ANEURYSMS; Turner Syndrome (female 45,X)
Jugular venous engorgement with inspiration is called and seen in?
Kussmaul Sign (CONSTRICTIVE Pericarditis)
Patients with HF, SBP
ß-blockers
JVD, parasternal impulse, SYSTOLIC murmur at SECOND intercostal space and FIXED splitting of S2 are all characteristics of?
ASD
Why does onset of a-fib in patients with DIASTOLIC DYSFUNCTION cause dyspnea?
Because of the LOSS of the ATRIAL “Kick” needed for LV filling
What is the RECOMMENDED intervention for MITRAL or CONGENITAL PULMONIC STENOSIS?
Balloon Valvotomy
What method is used to determine TYPE of LONG-TERM anticoagulation for a-fib patients WITHOUT significant valvular disease?
CHADS-2 score
Wall motion abnormalities, valve function and pulmonary pressures can be assessed in what type of cardiac stress testing?
EXERCISE STRESS ECHO
MURMUR: HoloSYSTOLIC, best heard at the Left Lower Sternal Border, Increases during INSPIRATION, Prominent C and V waves, Pulsatile Enlarged Liver?
TRICUSPID REGURGITATION
In patients with REFRACTORY Chronic Stable Angina who do not optimally respond to a combination of ß-blockers, Ca-channel blockers and nitrates, what is the ONLY other medication that can be used BEFORE coronary ANGIOGRAPHY?
RANOLAZINE (sodium-channel inhibitor)
Why is BRUGADA syndrome important to recognize?
Causes VF and Sudden Cardiac Death - ACID
Biventricular diastolic failure with RV failure predominating, fatigue, EDEMA, anorexia, hepatomegaly, ascites, pulmonary edema?
Restrictive Cardiomyopathy (RIGHT heart failure)
When should a SMALL Patent DUCTUS ARTERIOSUS be closed and how?
In a patient with previous history of Infectious ENDOCARDITIS; Percutaneously vs surgery
How is the presence of Pulmonary Valve REGURGITATION after Tetralogy of Fallot repair noted?
By the presence of a-fib/flutter
HCM patients with PRESERVED systolic function BUT LV outflow tract obstruction whom are refractory to medical treatment for HF (NYHA 3-4) what can be done?
Septal myectomy or Alcohol septal ablation (for poor surgical candidates)
Patients with a HIGH TIMI (≥3) risk score should be treated how?
Early INVASIVE treatment AND G2b3a Inhibitors
Athlete that presents with angina, dyspnea, palpitations, fatigue, dizziness and syncope should be checked for what else besides a-fib, diastolic dysfunction, ischemia, outflow obstruction and MR?
HYPERTROPHIC Cardiomyopathy (HCM)
Should patients admitted with ACUTE decompensated HF on ACE-I and ß-blockers be continued on these?
YES!!!! unless contraindicated (significant HYPOtension, cardiogenic shock or acute kidney failure)
What is done for Sudden Cardiac Arrest where the rhythm is NOT VF or VT but rather Symptomatic Bradycardia?
Atropine first, if no effect, Dopamine + EPI until can pace
What are the only patients whom would benefit from PFO closure?
Those who also have SEVERE TRICUSPID Valve REGURGITATION or RECURRENT “cryptogenic stroke”
BNP
NOT HF
Turner Syndrome, Coarctation of the Aorta are associated with?
Bicuspid Aortic Valve
What type of IV lines are needed in hospitalized patients with RIGHT-to-LEFT cardiac shunts?
FILTERED (to avoid paradoxical air embolism - the obstruction of a systemic artery by an embolus that originates in the venous system and reaches the arterial system through a septal defect or an open oval foramen of the heart such as seen in RIGHT-to-LEFT cardiac shunts)
How do you treat CONSTRICTIVE Pericarditis?
Treat edema and dyspnea with Diuretics then SURGICAL Pericardiectomy in patients with NYHA 2-3 (Paracentesis does NOTHING)
In what patients does controlling the rhythm in a-fib become important?
Those who continue to be SYMPTOMATIC
What is the therapeutic INR for a patient anticoagulated for a-fib?
2.0-3.0
Women who are multiparous, >30, black, multifetal pregnancy, gestational HTN, pre-eclampsia or had been treated with tocolytic agents are at risk of?
Peri-partum cardiomyopathy
How should HTN be treated in patients with CKD, DM and CHF?
AGGRESSIVELY!! (multiple meds if necessary)
What is the preferred revascularization method for a patient with HIGH-risk STEMI features?
PCI
What is the DEFINITIVE treatment of a STEMI (ACS)?
RAPID initiation of reperfusion via thrombolytic therapy or PCI
MURMUR: DIASTOLIC, Low-pitched, Decrescendo, Increases in Intensity during INSPIRATION, venous congestion (ascites, edema, hepatomegaly), Prominent A wave?
TRICUSPID STENOSIS
Why should a patient who has undergone REVASCULARIZATION and requires STRESS testing, NOT have the EXERCISE ECG Stress test?
Because EXERCISE ECG Stress testing does NOT accurately localize the site OR extent of ischemia
BEST ß-blockers (2) to use in pregnancy because of lowest possible risk?
LABETALOL, METOPROLOL
In NUCLEAR SPECT Stress testing, which radioactive agent is preferred for patients with breasts and whom are obese?
Technetium (takes longer ~2 days to complete)
MURMUR: holo-or-late-SYSTOLIC, S3, Apical Impulse, heard best at the APEX?
MITRAL REGURGITATION
What is the purpose of ACE-I use within 24-hours post MI?
Inhibit post-MI remodeling
TOXIC cardiomyopathies such as systolic dysfunction (late), diastolic dysfunction (early) , reduced contractile reserve (early - lack of significant increase in EF% during stress echo) can be confirmed with which testing methods?
ECHO
Due to its elevation of homocysteine levels leading to potentially FATAL lactic acidosis in patients with CHF or recent MI, this DM medication should NOT be used in those patients?
METFORMIN
What can conditions that increase LV PREload or cardiac output (sepsis, anemia, pregnancy) OR tachycardia (a-fib) do to a previously asymptomatic patient with SEVERE valvular regurgitation or stenosis?
Cause an ACUTE exacerbation of their symptoms
Inflammatory disease causing accelerated atherosclerosis cause a significant increase of what type of cardiovascular event?
MI
When is BRIDGING with Heparin/LMWH required when stopping warfarin for a procedure?
CHADS-2 >5, mechanical or rheumatic mitral valve or interruption is for >1 week
What two CHEMOTHERAPEUTIC agents can cause MI during treatment?
5-FU and IL-2
What should be suspected in ANY patient who presents with a NEW or INCREASED REGURGITANT heart murmur?
Infective endocarditis
What agents can patients WITHOUT sinus or AV-node dysfunction, BBB, long QT or structural heart problems use PRN for symptomatic a-fib rather than all the time?
Flecainide and Propafenone (use ß-blocker or Ca-channel blockers 30 min prior to taking this)
Abciximab, Eptifibatide, Tirofiban?
G2b3a-Inhibitors
Pt presents with MITRAL STENOSIS or REGURGITATION either WITH symptoms OR Pulmonary HTN, EF
MS - EITHER Percutaneous Mitral Balloon VALVOTOMY or Mitral Valve Replacement; MR - EITHER Mitral Valve REPAIR or Replacement
In patients whom are VOLUME OVERLOADED or in LOW OUTPUT states (decompensated HF), what medication should NOT be started?
ß-blockers
What can a PERIMEMBRANOUS VSD cause?
Ventricular Septal Aneurysms, TRICUSPID/AORTIC Valve REGURGITATION - spontaneous closure UNCOMMON
What is the RISK with Coronary ANGIOGRAPHY?
Allergy to contrast and contraindication in patients with kidney dysfunction
Outpatient monitoring of this LAB in patients with HF, allows for titration of ACE-I and ß-blockers?
BNP
What are some of the cardiovascular risks that present and should be checked for annually after exposure to CHEST RADIATION therapy?
Premature coronary atherosclerosis, pericardial constriction, cardiac (RV > LV) and valvular (L > R) function abnormalities
MURMUR: DIASTOLIC, Decrescendo, Loud P2, best heard at the Left Lower Sternal Border?
PULMONIC REGURGITATION
This cardiac imaging test is the MOST accurate test available for myocardial viability as it can identify viable and infarcted myocardium as well as anomalous coronary arteries however its contrast agent is contraindicated in patients with kidney disease?
Cardiac Magnetic Resonance (CMR) imaging (requires gadolinium contrast agent)
ANY degree of albuminuria means what?
Increased risk factor for cardiovascular events, heart-failure hospitalizations and all-cause mortality
When and why is WARFARIN used in pregnant women?
Although risks of possible teratogenicity and miscarriage exist, it is the BEST agent to prevent thrombosis of MECHANICAL VALVES
What can be done if peri-partum HF is refractory to therapy?
Ventricular-Assist Devices or Transpant
When are ASDs usually diagnosed?
In adulthood (fatigue, exertional dyspnea, a-fib, pulmonary HTN, embolism - RIGHT heart failure due to dilation)
What is seen on ECG/CXR of a patient with Eisenmenger Syndrome (reversal of LEFT-to-RIGHT shunt to a RIGHT-to-LEFT shunt with digital clubbing)?
RV hypertrophy and RA enlargement with RIGHT heart failure
When can a patient after SUCCESSFUL cardioversion be safely taken off warfarin?
4-weeks
What does a SECOND-DEGREE AV-Block TYPE-2 (Mobitz 2) carry a risk of?
Progression to COMPLETE HEART BLOCK (THIRD-DEGREE AV-Block)
What are the TWO (2) most common causes of AS?
ATHEROSCLEROTIC Calcification OR BICUSPID Valve
What are THE two (2) indications for using DIGOXIN?
a-fib rate control AND symptom reduction in SYSTOLIC HF
What can occur if a patient with HIGH CAD pretest probability undergoes a cardiac STRESS test?
FALSE NEGATIVE results may occur leading to a false sense of security and missed diagnosis
Pt presents with chest pain and has Non-specific ECG changes with NORMAL troponin and CK-MB, diagnosis?
UNSTABLE ANGINA (part of ACS)
For clinically stable HF patients, how often should routine monitoring of electrolytes and kidney function be done?
Every 6 months (earlier with changes in therapy)
Findings of RV/LV Hypertrophy with EVENTUAL Left heart enlargement are found in which congenital heart disease?
Large VSD
How do you diagnose pericardial effusion?
ECHO
How does Aortic Regurgitation affect the LV?
Hypertrophy (both eccentric and concentric) with LV SYSTOLIC dysfunction (EF
Would surgically repairing AORTIC REGURGITATION reverse LV dysfunction?
YES!! (can’t become too chronic as pts would be symptomatic)
How do you treat sarcoidosis that affects the heart?
Corticosteroids + Chloroqine (hydroxychloroquine, cyclosporine, methotrexate)
What patients with ACS can present with symptoms of only shortness of breath?
Elderly or Diabetics
When should REVASCULARIZATION (Endovascular Stenting) be considered for patients with PAD?
When medical therapy (exercise + cilostazol) fails or pt has symptoms that LIMIT their LIFESTYLE or EMPLOYMENT
Are most patients with PULMONARY Valve STENOSIS symptomatic?
NO
In the ABSENCE of AFTERload, diffuse or focal LV hypertrophy, familial AD disease, can present with SYNCOPE, ARRHYTHMIA, ISCHEMIA, HF, STROKE?
HYPERTROPHIC Cardiomyopathy (HCM)
When should TRICUSPID REGURGITATION be surgically repaired?
When there is evidence of RIGHT heart failure OR refractory to medical therapy
What DM medications are CONTRAINDICATED for patients with NYHA 3 or 4?
Thiazolidinediones (-“glitazone”) ESPECIALLY ROSIGLITAZONE
Young athlete passes out or dies suddenly?
HYPERTROPHIC Cardiomyopathy (HCM)
Which valve lesion is associated with EXERTIONAL angina and SYNCOPE?
AORTIC STENOSIS
What are the nine (9) MODIFIABLE risk factors for CAD identified in the INTERHEART study?
Cholesterol, Smoking, Stress, DM, HTN, Obesity, Alcohol (moderate), Exercise, Daily fruits & vegetables
What medication can be used INSTEAD of heparin or LMWH for patients undergoing PCI that presented with ACS and achieved an INTERMEDIATE or HIGH TIMI risk score ?
Bivalirudin
In which patients is a CT CAC diagnostic test for assessment of atherosclerotic burden indicated?
Patients with an INTERMEDIATE pretest probability for CAD (NOT those with low risk or existing CAD or DM)
What is the preferred treatment method for MITRAL VALVE REGURGITATION?
Surgical Repair/Replacement
What is recommended for ALL patients with Tetralogy of Fallot whom wish to become pregnant?
GENETIC Screening for microDELETION of chromosome 22q11.2 (associated with 50% risk of congenital heart disease)
What patients benefit the most from G2b3a inhibitors?
Those with an INTERMEDIATE or HIGH TIMI risk score and those post PCI therapy
This SVT involves a SLOW and a FAST pathway within the AV node with pseudo R and pseudo S waves in the inferior leads (II, III, aVF)?
AV Nodal Reentrant Tachycardia (AVNRT)
What genetic Syndrome that also affects the aorta has also the feature of translucent skin?
Ehlers-Danlos Syndrome
In what patients should a BNP level be drawn (Brain Natriuretic Peptide)?
In those in whom HF is suspected to differentiate between dyspnea due to HF vs. pulmonary disease
How do you treat amyloidosis that affects the heart?
Chemotherapy
SPIRONOLACTONE (and ALL other aldosterone antagonists) CANNOT be used in pregnancy, can it be used during BREASTFEEDING?
YES
In a patient with active ANGINA, what ECG changes are expected?
Conduction abnormalities or ST-T wave changes
In HYPERTROPHIC Cardiomyopathy with SEPTAL hypertrophy (most common type), what is seen besides increased QRS segments?
Q-waves in the Infero-lateral leads (II, III, aVF, V5-V6) where the T-WAVES are UPRIGHT in the leads with Q-waves (VERY important)
What patient population is at risk for Infective Endocarditis without having had surgical valve replacement or prior Infective Endocarditis episodes and REQUIRE prophylactic antibiotics prior to DENTAL procedures?
ALL those with CONGENITAL heart defects
What type of QRS features does AV Reciprocating Tachycardia (AVRT), a type of SVT?
NARROW QRS (If orthodromic - 95%) or wide (if antidromic - 5%)
Where does a-flutter typically originate?
RIGHT atrium
MURMUR: holo-SYSTOLIC, Palpable THRILL, Increases with HANDGRIP, CYANOSIS with Eisenmenger Syndrome?
VSD (ventricular septal defect)
What is considered PAD, what is considered SEVERE PAD?
≥0.90; ≥0.40
This systemic inflammatory disease can cause Sudden Death?
Sarcoidosis
When a pt presents with MITRAL STENOSIS, what MUST you also treat to improve function and symptoms?
a-fib
LEFT ATRIAL tumor (80% of cardiac tumors), benign? How is it diagnosed?
Myxoma; TTE
HCM with EF
AICD placement
What is the most COMMON complication after SURGICAL REPAIR of Coarctation of the AORTA?
HTN (75% of patients)
What is considered peri-partum cardiomyopathy how many of these women improve 6 months post delivery?
Previously unrecognized LV SYSTOLIC dysfunction identified toward the end of pregnancy or in the months following delivery; 50% (half)
When the LV is affected by a valve dysfunction, this is an indication for what treatment?
Valve SURGERY
HCM patient with a-fib and CHADS score of ≥2 should be treated with?
Warfarin
Pt presents with TRICUSPID REGURGITATION with REFRACTORY RIGHT HF, or RV ENLARGEMENT, or SYSTOLIC Dysfunction, what should be the management?
TRICUSPID REPAIR or REPLACEMENT
If a-fib duration (diagnosis) is UNKNOWN and pt presents with associated HYPOtension, angina or HF, what MUST be done?
Emergent Cardioversion AFTER intracardiac clot has been r/o (TEE)
This genetic Myocardial “Storage” condition can present as HYPERTROPHIC Cardiomyopathy (HCM) and is x-linked?
Fabry Disease (alpha-galactosidase deficiency)
What does a low/high TIMI risk score mean?
Low TIMI (
What is the preferred treatment of Symptomatic SVT during pregnancy? What if recurrent?
ADENOSINE; ß-blockers + DIGOXIN
What are the three (3) major risk factors for developing PAD?
Age ≥65, DM, Smoking
What test should be done for ALL patients with arrhythmias prior to ablation?
EPS study
Pericardial effusion on ECHO?
Pericarditis
How do you treat HCM WITH systolic dysfunction and NO outflow obstruction (HF)?
Same as HF patients
What pharmacologic agent is used to QUICKLY stop a SupraVentricular Tachycardia?
ADENOSINE
What causes the UE HTN and LE LOW Blood Pressure and the reduced pulses in the LEs to progressively and SPONTANEOUSLY improve in patients with Coarctation of the AORTA?
Formation of COLLATERALS
What is it about rheumatological conditions such as SLE, RA, Ankylosing Spondylitis, Systemic Sclerosis, Takayasu Arteritis, Giant Cell Arteritis, Polyarteritis Nodosa, Kawasaki Disease, Behçet syndrome and Sarcoidosis that causes accelerated atherosclerosis?
INFLAMMATION
Are Ca-channel blockers ok to use in patients with SEVERE SYSTOLIC DYSFUNCTION?
NO!! (can precipitate/worsen heart failure)
3-7 days s/p STEMI, a patient develops HYPOtension, JVD and distant heart sounds?
LV free wall rupture; EMERGENCY pericardiocentesis and SURGERY
Why is acute PERICARDITIS that does not respond to NSAIDS or Corticosteroids significant?
Because it has a high risk of RECURRENCE
Degree of coronary occlusion in STEMI? NSTEMI/UNSTABLE ANGINA?
STEMI - COMPLETE; NSTEMI/UNSTABLE ANGINA - PARTIAL
What antiarrhythmic agent (Class III - Potassium-Channel Blocker) is typically used in patients with HF or LV hypertrophy?
AMIODARONE
What are the goals of treating a-fib (HR/EF%)?
HR 40%
Findings of an Abnormal P axis with Right heart enlargement and a-fib are found in which congenital heart disease?
Sinus Venosus ASD
WHY is surgery preferred over pericardiocentesis for malignant effusions and aortic dissections causing the tamponade?
Because slows reaccumulation and because CONTRAINDICATED in DISSECTION
How can you tell on physical examination that a patient with known VSD has a MODERATE-to-LARGE VSD with VOLUME OVERLOAD?
There will be a DISPLACED LV IMPULSE
Resistance LEFT VENTRICLE (LV) must overcome to circulate blood is known as?
Afterload
What is recommended for alleviation of SYMPTOMS in patients with PAD?
Exercise (supervised 30-45 minutes 3x/wk) + Cilostazol
What test can determine reversibility (if Eisenmenger Syndrome has NOT set in) of a Patent DUCTUS Arteriosus?
Cardiac Catheterization
What four (4) cardiac STRESS tests have NO radiation exposure?
EXERCISE ECG, EXERCISE STRESS ECHO, Dobutamine ECHO and CMR (Cardiac Magnetic Resonance)
This systemic inflammatory disease causes PAD, Stroke and MI?
Giant Cell Arteritis
What do elevated levels of homocysteine and Lp(a) lipoprotein mean?
Elevated risk of CAD
How is PAD diagnosed if ABI results are borderline (0.91-0.99)?
Performe an EXERCISE STRESS Test and if post exercise, ABI decreases by ≥20%, it is PAD
Occlusion of what blood vessel results in RV-infarction with resultant HYPOtension, CLEAR lungs and JVD?
RIGHT CORONARY artery
What can be seen on ECHO in PERICARDITIS?
PERICARDIAL Effusion
Which revascularization method is preferred in patients with DM and CAD with MULTI-vessel disease?
CABG
What method is employed to calculate the PULMONARY to SYSTEMIC blood flow ration in ASDs?
Cardiac catheterization
What is the form of cardiac STRESS testing most recommended if possible?
EXERCISE Stress testing (ECG, ECHO, Nuclear SPECT perfusion)
What electrolyte do BOTH DIGOXIN and Spironolactone interfere with?
POTASSIUM (K)
How do you treat patients with AS with acute pulmonary edema or LV systolic dysfunction?
AFTERload reduction (vasodilators: nitrites, Ca-channel blockers)
How is PERICARDITIS treated?
HIGH-dose Aspirin or NSAIDS and tapered over 4 weeks + PPI thrapy (can also use colchicine)
What electrical abnormality can occur after both INFERIOR and ANTERIOR wall STEMIs requiring pacemaker use?
COMPLETE heart block
If a structural source of a life-threatening arrhythmia is strongly suspected such as cardiomyopathy or sarcoidosis but cannot be found on ECG or ECHO, what adjunctive test can be used with the ECHO to obtain superior imaging?
CMR
Placing a MAGNET over a pacemaker does what?
Causes it to pace in ASYNCHRONOUS mode so as not to inhibit pacemaker function
Which are the ANTERIOR LEADS on the ECG?
V3-V4
