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
How should a patient suspected to have an acute aortic syndrome (dissection) be treated if NOT in shock?
Reduce HR to 60-80 with IV ß-blockers and Reduct SBP with IV nitroprusside or fenoldopam to 70 mm Hg (sufficient for organ and cerebral perfusion)
How is SHORT QT-Syndrome (QTc
AICD!!!
Should Milrinone (INOTROPIC agent) or Cilostazol (used to treat symptoms of PAD be used in patients with HF?
NO!! (associated with increased mortality)
A pt with NYHA 2 or 3 on proper meds and expected to survive >1 year, with ischemic cardiomyopathy ≥40 days s/p MI OR non-ischemic cardiomyopathy with EF≤35% OR h/o hemodynamically significant VENTRICULAR arrhythmia or cardiac arrest OR severely reduced systolic function with unexplained syncope OR a patient with NYHA 1-3 with ischemic cardiomyopathy with EF ≤30% would benefit from what?
AICD placement
What treatments should ALL patients with PAD be recommended?
Smoking cessation, initiation of STATIN therapy to lower LDL ≥100 mg/dL AND if concomitant DM to ≥70 mg/dL, treatment of HTN to BP of ≤140/90 mm Hg with ß-blockers or other agents (if w/DM or Kidney disease (≤130/80 mm Hg), ASPIRIN (75-150 mg) OR Clopidogrel (75 mg) IF cannot tolerate aspirin
What agents used to treat Chronic Stable Angina IF ß-blockers are ABSOLUTELY contraindicated?
Ca-channel blockers
In the setting of HTN and severe aortic atherosclerosis, what type of aortic injury can occur?
Penetrating atherosclerotic ulcer in the aortic media causing a contained pseudoaneurysm
What is WPW Syndrome?
The Pre-Excitation Pattern on ECG of AV Reciprocating Tachycardia (AVRT) WITH presence of symptoms (palpitations, etc)
Initiating a Valsalva maneuver, Massaging the Carotid Sinus or Dunking of your Face into ICE water can have what effects on a SupraVentricular Tachycardia?
STOP it
Pts with this condition typically present with exertional headaches, LEG fatigue, CLAUDICATION with Upper Extremity HTN and reduced blood pressure and pulses in the Lower Extremities?
Coarctation of the AORTA
What is the medication of choice for treatment of ventricular arrhythmias in pregnancy?
Lidocaine
What agents are ABSOLUTELY contraindicated in patients taking nitrates (for angina, etc.) daily or intermittently?
Erectile Dysfunction meds (sildenafil, vardenafil, tadalafil)
Should women use postmenopausal hormone replacement therapy (HRT) for prevention of future cardiovascular events?
ABSOLUTELY NOT!!
What should ALL women with CONGENITAL heart disease do prior to considering pregnancy?
Consult a specialist
Rare, fatal myocarditis, immune mediated, rapid onset with ventricular arrhythmias and only treatment is VAD as a bridge to transplant (can recur in transplanted heart)?
Giant Cell Myocarditis
RIGHT ATRIAL Pressure elevation with atrial flutter and systemic congestion (edema, hepatomegaly, ascites) caused by sequela of Rheumatic Heart Disease, Infective Endocarditis, Carcinoid Tumor, Congenital Ebstein Anomaly, Radiation Therapy or Trauma from placement of Pacemaker/AICD?
TRICUSPID REGURGITATION
What medication should BLACK patients with NYHA 3-4 OR ANY patient whom CANNOT be on ACE-I/ARBs due to HYPERkalemia or kidney dysfunction?
Hydralazine-Isosorbide Dinitrate
What is the PRIMARY reason to use an ARB rather than an ACE-I?
Tolerability (Cough)
PR interval >200 msec, asymptomatic, represents a delay in the impulse conduction in the AV node?
FIRST-DEGREE AV-Block
ALL patient with a CONTINUOUS cardiac murmur OR ANY DIASTOLIC murmur OR >3/6 SYSTOLIC murmur should undergo what diagnostic test?
ECHO
BEFORE initiating an exercise program in a patient with DM and CAD without a STRESS test in the past 2 years OR with chest pain, PAD, abnormal resting ECG?
STRESS testing
What are the two (2) cardiac STRESS tests that are BEST for patients whom have LBBB?
The NUCLEAR SPECT Perfusion and the NUCLEAR Perfusion Vasodilator (Adenosine, Dipyridamole, Regadenoson) Stress tests
What does the presence of Q-waves indicate on an ECG performed on a RESTING patient?
Previous MI
MURMUR: SYSTOLIC, Crescendo-Decrescendo, Ejection Click after S1, Decreased with INSPIRATION, best heard at the Left Upper Sternal Border?
PULMONIC STENOSIS
Which anticoagulants should be used in the treatment of ACS? How do you decide?
Heparin or LMWH; Heparin (pts about to undergo early invasive procedure, at higher bleeding risk or have kidney disease), LMWH (no kidney disease, non-emergent SURGICAL revascularization and in those undergoing an early invasive approach
These two systemic inflammatory diseases can cause Aortic Aneurysms?
Takayasu arteritis and Kawasaki disease (Japanese)
Acute Limb Ischemia due to embolus is likely to come from where?
A-fib, LV thrombus, L-sided Endocarditis
What is the recommended diagnostic testing modality for FREQUENT arrhythmias or ASYMPTOMATIC arrhythmias?
Continuous Ambulatory ECG Monitors (HOLTER)
Does Percutaneous Coronary Intervention (PCI) reduce future cardiovascular events or improve survival?
NO!! (it improves quality of life by reducing angina symptoms)
What are the goals of evaluation of a patient with HF?
Severity, Cardiac structure and function, potentially REVERSIBLE causes, risk for LIFE THREATENING arrhythmias
What are ACE-I replaced with in patients s/p MI whom cannot tolerate them?
ARB’s (-“sartan”)
Is BNP elevated in CONSTRICTIVE Pericarditis?
NO
In extremely high-risk AAA patients, what is the BEST interventional modality?
EndoVascularAneurysmRepair (EVAR)
What is the purpose of the DUKE Treadmill Score?
To stratify patients whom underwent EXERCISE Stress testing into Mild, Moderate and High risk for CAD
What is the recommended surveillance imaging for AAA 1. 2.6-2.9 cm? 2. 3.0-3.4 cm? 3. 3.-4.4 cm? 4. ≥4.5 cm
- Every 5 years
- Every 3 years
- Every 1 year
- Every 6 months
How does LEG elevation affect the heart?
It INCREASES PREload
What pretest probability result is BEST suited for a patient to undergo cardiac STRESS testing?
INTERMEDIATE
What do WIDENING of the Mediastinum on a CXR, Migratory pain, differences in arm blood pressure all indicate?
Aortic DISSECTION (acute tearing-ripping pain)
How is a ventricular free wall rupture treated?
EMERGENT pericardiocentesis + SURGERY
After thrombolytic therapy, a patient stops having chest pain, ST-segent elevation improves but they begin having an accelerated idioventricular rhythm.
SUCCESSFUL thrombolytic therapy
The difference in the rate of a condition between EXPOSED and UNEXPOSED population
ATTRIBUTABLE RISK
This VSD type is common in ASIANS (33%) but NOT in everyone else?
Sub-PULMONARY VSD - spontaneous closure UNCOMMON
Recurrent angina 6-9 months post PCI indicates what?
Restenosis (dramatically reduced with drug-eluting stents)
How do you gauge which patients to perform specific tests for whom present with Chronic Stable Angina?
Based on their Pretest Probability of CAD (INTERMEDIATE for STRESS testing)
How soon after hospital discharge should a pt follow-up as an outpatient?
WITHIN 7 days
What type of stress testing should be used in patients with LBBB?
Vasodilator Stress testing (Adenosine, Dipyridamole and Regadenoson)
What do cardiac ventricles secrete in response to increased wall stress due to volume or pressure overload?
proBNP (cleaved to BNP)
Class Ic antiarrhytmic agents (Sodium-Channel Blockers) Flecainide and Propafenone) are typically used for what?
A-fib and A-flutter HOWEVER NOT in patients with CAD or s/p MI - can cause VT
A NUCLEAR Stress test that shows a perfusion defect BOTH at rest and after stressor is positive for what?
INFARCT
Age >65, ≥3 CAD risk factors, CAD with ≥50% stenosis, ST-segment DEVIATION, ≥2 anginal episodes over past 24 hours, Aspirin use in the past week, elevated troponin or CK-MB)?
Components of TIMI risk score (each worth 1 point)
What cardiac test is the MOST effective at RULING OUT CAD in patients with low to intermediate pretest disease probability?
CT ANGIOGRAPHY
Is routine genetic testing recommended for HCM?
NO
In patients with PHENOTYPIC (visible, expressed) features of HCM what should be recommended?
ß-blockers & NO vigorous exercise (risk of sudden death)
After DYSLIPIDEMIA and SMOKING (1st and 2nd) what is the THIRD most significant risk factor associated with MI?
Psychosocial STRESS (depression, anxiety, anger)
A pt with NYHA class 3 or 4 AND EF≤35% AND QRS ≥120 msec would benefit from what?
Bi-VENTRICULAR Pacemaker
What is Eisenmenger syndrome and when does it occur?
Reversal of an initial LEFT-to-RIGHT VSD shunt to a RIGHT-to-LEFT VSD shunt due to chronic Pulmonary artery HTN
Which three (3) new cardiomyopathy agents have been shown to benefit treatment of peri-partum cardiomyopathy?
IVIG, Pentoxifylline and Bromocriptine
In NUCLEAR SPECT (Single Photon Emission CT) Stress testing, which radioactive agent used leads to FALSE-POSITIVE image artifacts when patients have breasts or are obese?
Thallium
What is typically used for LONG-term management of a-fib for RATE control?
AMIODARONE (can cause pulmonary fibrosis, thyroid dysfunction, liver toxicity and skin hypersensitivity)
What does LOW VOLTAGE in a patient WITHOUT obesity or emphysema suggest on ECG?
Infiltrative Cardiomyopathy (amyloid, sarcoidosis)
MURMUR: DIASTOLIC, Low-pitched Decrescendo, Opening SNAP after S2, heard best at APEX in the Left Lateral Decubitus position?
MITRAL STENOSIS
Do small ASDs, small VSDs and small Patent DUCTUS ARTERIOSUS require restriction from exercise?
NOT without Pulmonary Artery HTN
When is SURGERY (endovascular, percutaneous technique) recommended for a Stanford Type B aortic dissection?
When there is occlusion of a major aortic branch with visceral or limb ischemia, progressive extension and dilation, rupture, large penetrating atherosclerotic ulcer (≥20 mm diameter and ≥10 mm depth), penetrating atherosclerotic ulcer with hematoma
What does cardiac stress testing actually do?
It provokes transient myocardial ischemia
What non-specific marker of inflammation is another important independent risk factor for adverse cardiovascular events in patients with an INTERMEDIATE risk for CAD?
hsCRP (high sensitivity CRP)
How long post ABLATION (pulmonary vein) for a-fib must a pt continue to take anticoagulation?
2-3 MONTHS
All patients at risk for SUDDEN Cardiac Death should be treated with?
AICD implantation
HYPOkalemia and HYPOmagnesemia are seen with the use of these medications in patients with HF?
Diuretics (loop + thiazides)
What two (2) other medications should be used in conjunction to the standard Chronic Stable Angina medications (ß-blockers, Ca-channel blockers, Nitrates)?
ASPIRIN (at least 75-162 mg) and STATINS
What should be a part of treatment of RECURRENT PERICARDITIS?
COLCHICINE (then ADD ASPIRIN and/or NSAIDS)
After a RESTING ECG, what should be the next diagnostic testing modality for an arrhythmia and why?
ECHO, because arrhythmias have the greatest clinical significance if they occur due to underlying structural heart disease
When is the CLOSURE of a VSD indicated?
When the Pulmonary (Qp) to Systemic (Qs) blood flow ratio is ≥1.5-2.0 AND evidence of LV volume overload OR history of ENDOCARDITIS
Pt presents with symptoms of HF, a continous “machinery” murmur best heart below the LEFT CLAVICLE with BOUNDING Pulses and a WIDE PULSE PRESSURE and mentions that his mother had Rubella when she was pregnant with him and he was a prematurely-delivered baby?
MODERATE Patent DUCTUS ARTERIOSUS
What conditions should DRONEDARONE NOT be used for?
NYHA 2&3 WITH recent decompensation or NYHA 4 or as a rate control agent in those with PERMANENT a-fib
What are the two (2) common conditions that can result in persistence of the DUCTUS ARTERIOSUS?
Maternal RUBELLA infection and Premature Delivery
What people can have NORMAL sinus bradycardias of as little as 40 bpm awake and 30 bpm asleep?
Highly-conditioned athletes
EXCEPT with SEVERE valve STENOSIS, in the ABSENCE of symptoms, can patients participate in competitive sports?
YES!
After a patient undergoes PCI, how soon should the undergo ELECTIVE surgeries?
Drug-eluting stent - 1 YEAR; Bare metal stent - 6 weeks
What is consider a NORMAL ABI?
1.0-1.40
What signs and symptoms in a patient s/p REPAIR of Tetralogy of Fallot suggest the need for PULMONARY Valve Replacement?
Severe REGURGITATION (decreased exercise tolerance, RIGHT heart enlargement with dysfunction and the development of atrial or ventricular ARRHYTHMIAS - a-fib)
What causes TRICUSPID VALVE STENOSIS?
Rheumatic Heart Disease
Pt has a Patent DUCTUS ARTERIOSUS with Pulmonary Artery HTN, should it be closed?
NO!!
Patients presenting with presumed ischemic chest pain and either NSTEMI or UNSTABLE ANGINA should be treated with what meds?
ASPIRIN (325 mg, decreased to 81 mg after 1 month), ß-blockers and NITRATES, CLOPIDOGREL (300 mg)
What can be done for REFRACTORY HF?
Implantation of VADs as bridge to transplant or until death
What cardiac STRESS test has the highest combination of SENSITIVITY and SPECIFICITY for diagnosing CAD especially in OBESE patients?
PET/CT (expensive)
Which anticonvulsant used also for cardiac arrhythmias CANNOT be used in pregnancy?
Phenytoin
MURMUR: SYSTOLIC, FIXED-SPLIT S2 with RV Heave, Increased P2 and associated with Pulmonary HTN?
ASD (atrial septal defect)
ACS (UNSTABLE ANGINA/NSTEMI) - low TIMI (0-2) Rx?
Aspirin, ß-blocker, nitrates, statin, clopidogrel, either heparin or LMWH AND pre-discharge stress test (if positive - coronary angiography)
What should be done for women with previous cardiac events or arrhythmias, baseline NYHA 3-4 or cyanosis, LEFT-sided heart obstruction (stenotic valves), congenital heart disease or an EF
Pre-conception cardiac intervention, frequent follow-up, referral to regional specialty center for ongoing care
What are the three SupraVentricular Tachycardias?
AV Nodal Reentrant Tachycardia (AVNRT) and AV Reciprocating Tachycardia (AVRT)
For patients s/p STEMI whom require PCI reperfusion, what is recommended for anticoagulation for ease of control?
Unfractionated heparin (Heparin) or Bivalirudin, NOT LMWH
What vascular abnormality can present with symptoms of chest pain, hoarseness, stridor, back pain or dysphagia AND what MUST be URGENTLY done for this?
Thoracic Aortic Aneurysm (due to compression); Urgent REPAIR regardless of aortic size
THORACIC Aortic Aneurysm is associated with with Syndrome most commonly?
MARFAN Syndrome (can rupture at smaller sizes than in patients without this syndrome)
What disease risks are there with a BICUSPID AORTIC Valve?
AORTIC STENOSIS, Infective ENDOCARDITIS, AORTIC Dilation (connective tissue disease, NOT associated with valve dysfunction) - REQUIRES SERIAL MONITORING of the ASCENDING AORTA (ECHO or CT/MR angiography)
What three (3) conditions MUST be ruled out prior to treating a STEMI?
Pericarditis, PE, Aortic Dissection (all can present as a STEMI)
Is Coronary Artery Calcification (CAC) testing recommended and good for CAD testing?
NO! the test sucks
ANY previous ICH, known cerebrovascular lesion (AVM/tumor), Ischemic stroke within 3 months, suspected aortic dissection, active bleeding, significant closed head/facial trauma within 3 months?
ABSOLUTE contraindications to thrombolytic therapy
For HCM patients with HF symptoms (exertional dyspnea) due to outflow obstruction but preserved systolic function what meds are beneficial?
ß-blockers and Verapamil (DO NOT USE if outflow obstruction with SEVERE symptoms)
What does a QRS duration of ≥120 msec suggest?
Poor cardiac synchronization and ineffective ventricular contraction with significant HF (NYHA class 3 or 4) and low EF%
What should be done for the first 12-24 hours for comatose patients who survive cardiac arrest?
Therapeutic hypothermia
What is the goal heart rate that MUST be achieved during an EXERCISE Stress test for best results?
85% of maximum predicted hear rate (220 - age)
When would an EXERCISE NUCLEAR SPECT Perfusion STRESS test be used instead of an EXERCISE ECG Stress test or EXERCISE STRESS ECHO?
When the baseline ECG is abnormal and there is a LBBB
What is the LEADING cause of DEATH in patients with CKD?
CAD
What is done with the ACUTE finding of RV Ischemia/Infarct?
AGGRESSIVE IVF and INOTROPIC support with DOPAMINE or DOBUTAMINE
CONTINUOUS “machinery” murmur heard best below the LEFT CLAVICLE?
Patent DUCTUS ARTERIOSUS
What are PVCs treated with IF SYMPTOMATIC?
AV nodal blocking agents (ß-blockers or Ca-channel blockers)
Should a patient with cardiac TAMPONADE be sedated and mechanically intubated?
NO!!! (potentiate hemodynamic compromise)
Coronary disease of a newly-transplanted heart (Cardiac Allograft Vasculopathy - CAV) which is NOT amenable to standard revascularization interventions (PCI or CABG) and typically presents with syncope, new HF, dyspnea, heart block but NOT angina (no innervation of transplanted heart) is only treatable how?
New transplant
What must the SHARP and SEVERE chest pain of PERICARDITIS be distinguished from?
MI, dissection, PE
Which valves are associated with systemic venous CONGESTION, LE EDEMA, abdominal distention and ASCITES?
RIGHT-sided valves (TRICUSPID and PULMONIC)
LEFT-sided valves can also cause this if they cause LV systolic dysfunction or Pulmonary HTN
ACS (UNSTABLE ANGINA/NSTEMI) - intermediate or high TIMI (≥3) Rx?
Aspirin, ß-blocker, nitrates, statin, clopidogrel, either heparin or LMWH, G2b3a-inhibitor AND coronary angiography
This cardiac STRESS test is ONLY used in conjunction with a pharmacologic STRESS test when BEST images and ABSOLUTE myocardial blood flow measurements are needed especially in LARGE patients?
PET/CT
In a patient who is NOT a surgical candidate but presents with SEVERE, SYMPTOMATIC AS, what can be done?
VALVULOPLASTY (short term benefit only)
If a patient with a-fib has a MECHANICAL heart valve, what is the INR range recommended?
2.5-3.5
Is anticoagulation recommended for patients with low EF% without previous thrombus or a-fib?
NO!!
Pt presents with mottled lower extremity skin and purple toe discoloration after coronary angiography?
Lower extremity embolism from dislodged atheromatous aortic plaque
Low QRS voltage ECG is seen in this cause of Restrictive Cardiomyopathy in patients with neuropathy, proteinuria and macroglossia?
Amyloidosis (gingival or abdominal fat pad biopsy)
EARLY Peaking SYSTOLIC murmur?
AS
How do you treat Premature Atrial Contractions (PAC)?
ONLY if symptomatic (ß-blockers or Ca-channel blockers)
Should PFO’s be closed in asymptomatic patients and those patients whom had a prior stroke?
NO!! (no benefit demonstrated)
When is the DOBUTAMINE NUCLEAR Perfusion Stress test used instead of the DOBUTAMINE ECHO?
When the DOBUTAMINE ECHO images are suboptimal
Do patients with ENDOVASCULAR STENT Aortic Aneurysm Repair require warfarin anticoagulation/antiplatelet therapy and antibiotic prophylaxis prior to dental procedures?
NO!!
If a ß-blocker is needed in a patient with reactive airway disease s/p ACS, what can be considered and why?
ESMOLOL - Short acting
What are the cardiac sequelae of MITRAL STENOSIS?
Dilated LEFT ATRIUM - therefore A-fib, Increased Pulmonary VEIN and ARTERY pressures
ST-elevation in II, III, aVF; Q-wave in II, III, aVF; Reciprocal ST-depression in aVL
Inferior STEMI (RV infarction)
What is the treatment method recommended for MITRAL VALVE PROLOAPSE?
NONE, by itself, this is benign
A pt with Chronic Stable Angina wishes to begin medical treatment, has NO contraindication to medications and reports that his quality of life, ability to exercise and normal sexual function are of utmost importance to them, what agent do you prescribe?
Ca-channel blocker
A patient presents with an asymptomatic grade 1/6 or 2/6 midsystolic murmur, what’s the next step?
Nothing, benign murmur
Physiologically Significant Atherosclerosis of the AORTIC BIFURCATION OR ARTERIES of the LOWER LIMBS
Peripheral Artery Disease
What is the recommended test for assessing hemodynamic shock, finding the location of intra-cardiac shunts and guiding therapy?
Pulmonary Artery catheterization (PA)
What vascular abnormality can be seen with pregnancy and ESPECIALLY in women with MARFAN Syndrome?
Aortic DISSECTION
J-point elevation >2 mm, concave ST-elevation and inverted T-wave in V1-V3?
Brugada Syndrome
What two (2) medication types are most important when treating Left Ventricular SYSTOLIC dysfunction?
ACE-I or Angiotensin Receptor Blockers (ARBs - “-sartan”)
Pt undergoes SURGICAL revascularization (NOT PCI), how low an LDL level should their prescribed statin get them to?
What is the prognosis of LATE-developing anthracycline-induced cardiomyopathy and HF (due to dilated cardiomyopathy)?
Poor (high mortality)
Pt with valve disease develops ventricular dilation or systolic dysfunction, hemodynamic abnormalities and dyspnea with little exertion, whats the next step?
SURGICAL Repair or REPLACEMENT
When a patient with AS develops SYMPTOMS such as angina, syncope or HF (dyspnea), what is their expected survival WITHOUT surgical valve REPLACEMENT?
2-3 years ONLY (which is why, regardless of AS severity, a pt with SYMPTOMS must have surgery
What is the recommended screening modality for presence of AAA in men 65-75 yo with h/o smoking?
One-time Ultrasound
In what patients is Ventricular Tachycardia (VT) dangerous?
Those with LOW EF% and rapid tachycardia (cardiac arrest)
What are the three (3) MAJOR classes of medications used to treat Chronic Stable Angina?
ß-blockers, Nitrates, Ca-channel blockers
What toxic effects do ANTHRACYCLINES (-“rubicin”) have on the heart?
Dilated or Restrictive disease
What OTHER valve disease is FREQUENTLY seen with SVERE AS?
MITRAL REGURGITATION (due to annular calcification)
Should patients with UNREPAIRED Coarctation of the AORTA participate in contact sports, isometric exercises and become pregnant?
NO!!
When is warfarin preferentially used during pregnancy for DVT, A-fib and Ventricular dysfunction?
1st-trimester but ONLY up to 6 weeks, can be used after that but NOT before delivery
What DIRECT THROMBIN INHIBITOR (no lab monitoring needed) is SUPERIOR to warfarin BUT can cause GI bleed?
Dabigatran
Regardless of whether patient received a bare metal stent or drug-eluting stent, if they presented with ACS (Unstable Angina or NSTEMI or STEMI) how long should they be on CLOPIDOGREL for?
1 YEAR
This Risk Score Calculator is OPTIMIZED for WOMEN unlike the Framingham risk score calculator?
The REYNOLDS risk score calculator
What benefit does Percutaneous PULMONIC VEIN ISOLATION confer to patients with HCM and refractory a-fib whom do NOT have marked LEFT atrial enlargement?
Maintains sinus rythm
Whom do you continue giving IV nitroglycerin to?
Patients s/p STEMI with CONTINUED chest pain after initial sublingual administration
What medications are used to treat Restrictive Cardiomyopathy?
Diuretics, ß-blockers and Ca-channel blockers (verapamil, diltiazem - vasodilators)
What abnormality is seen in HYPERTROPHIC Cardiomyopathy?
Increased QRS
What are the indications for Peripheral Artery Disease (PAD) screening?
- Age ≥50 + DM/Smoking
- Age ≥65
- Exertional leg symptoms OR NON-healing LE ulcers
When performing AORTIC Valve REPLACEMENT for a BICUSPID AORTIC Valve, what other surgery should be performed?
Ascending AORTA replacement IF diameter >4.5 cm with Continued SERIAL MONITORING
Sudden death (young patients), HF, Stroke, a-fib dilated cardiomyopathy are all associated with this cardiac condition?
HCM
What is the ESSENTIAL test used in evaluating HF to determine etiology, clinical status, comorbidities and prognosis?
ECHO
How is VT treated initially?
ß-blockers
What is the recommended diagnostic testing modality for assessing cardiac masses?
Chest CT
WHAT should be done and WHEN for patients with Chemotherapy-Induced Cardiotoxicity?
Aggressive treatment of NEW or WORSENING DIASTOLIC or SYSTOLIC dysfunction and for HF and routine surveillance for CAD
How is Acute Limb Ischemia (ALI) BELOW the knee treated?
COMBINED anti-platelet therapy AND THIENOPYRIDINE with Endovascular placement of a DRUG-ELUTING Stent
After an Acute MI, what are the SIX (6) most important treatments that showed the most improvement?
Early ASPIRIN, Early ß-blockers, ACE-I use, Smoking Cessation Counseling, treatment of LDL cholesterol to
Under what circumstances should AAAs be repaired?
When SYMPTOMATIC (regardless of dimension) OR when ≥5.5 cm (measured perpendicularly to vertical descending aorta) OR when expanding ≥0.5 cm/yr BY open surgery or endovascular repair IF life expectancy is ≥2 years
Severe bradycardia, advanced AV block, decompensated CHF and SEVERE reactive airway disease are all contraindications to what medication?
ß-blockers
Are there any Pregnancy or Exercise RESTRICTIONS for patients with PULMONARY Valve STENOSIS?
Only if SEVERE
LV diastolic wall thickness ≥30 mm, Blunted increase or decrease in SBP on exercise, spontaneous sustained/non-sustained VT?
Risk factors for SUDDEN DEATH in HCM patients warranting an AICD placement
When is JVD NOT seen in TAMPONADE?
When pt is HYPOvolemic
What is the MAJOR risk for patients with WPW who develop A-Fib with h/o AVRT or Ebstein anomaly (congenitally abnormal tricuspid valve with pulmonary valve stenosis)?
SUDDEN DEATH due to Ventricular Fibrillation (VF) because of BYPASS PATHWAY conduction of a-fib
What chemotherapeutic agents carry the highest risk of cardiotoxicity?
Anthracyclines, Mitoxantrone, Alkylating agents (Cyclophosphamide, Cisplatin, Mitomycin), 5-FU, Paclitaxel, Trastuzumab, IL-2 and Interferon-alpha
In patients whom suffered what type of a STEMI do you NOT give nitrates, especially nitroglycerine?
Inferior wall MI (RV infarct) - II, III, aVF
Why and for WHOM is ANTICOAGULATION recommended during PREGNANCY?
Pregnancy is a HYPERcoagulable state; women with a-fib, mechanical valves, antiphospholipid-Ab Syndrome and DVT (venous thromboembolism)
What generally causes HF with PRESERVED EF%?
Uncontrolled HTN
How do certain cancers, anthracyclines (-“rubicin”) and uermia affect the heart similarly?
PERICARDITIS
HCM with a-fib Rx?
Cardioverion and Amiodarone to reverse; ß-blockers, verapamil and digoxin (only if no outflow obstruction) for rate control
Should DIGOXIN be withdrawn in clinically STABLE patients with HF?
NO!! (can precipitate HF decompensation)
Pts with Chronic Stable Angina and LEFT MAIN disease, REDUCED LV Systolic function, extensive and severe CAD and symptomatic despite optimal medical therapy?
REVASCULARIZATION (PCI or surgery)
Increased central venous pressure with SEVERE BI-ATRIAL enlargement?
Restrictive Cardiomyopathy (RIGHT heart failure)
Systemic Illness, Kidney Dysfunction, Eosinophilia and Livedo Reticularis can all be caused by what process?
Cholesterol Embolus from arterial instrumentation
What is the recommended treatment for FUNCTIONAL MITRAL VALVE REGURGITATION (LV Dilation or Dysfunction)?
CABG or PCI (NOT SURGERY)
Findings of normal ECG but with Paradoxical Embolism are found in which congenital heart disease?
Patent Foramen Ovale
Findings of an incomplete RBBB (delayed RV activation - due to dilation produces RR’ waves in V1-V3 and a wide S wave in V5-V6), RA enlargement a-fib and prominent pulmonary artery are found in which congenital heart disease?
Ostium Secundum ASD
Cleft Mitral and Tricuspid valves, VSDs, SubAortic Stenosis (endocardial cushion defect) are seen in?
Down Syndrome
When is Invasive Angiography used to evaluate PAD?
As part of an INTERVENTIONAL procedure
If a patient presents with palpitations s/p MI or has ischemic heart disease (Q-waves, T-wave abnormalities), what is the likely arrhythmia etiology seen on the ECG?
Ventricular arrhythmia
Why should you try to NOT use corticosteroids for acute PERICARDITIS unless refractory to treatment (ASPRIN, NSAIDS and colchicine)?
Because it can cause RECURRENT PERICARDITIS
What meds/procedures can be used to REDUCE AICD shocks?
ß-blockers, Sotalol, Amiodarone and ablation
Are the following findings normal during pregnancy: SOB with orthopnea/cough, a-fib/flutter, VT, Chest Pain Heavyness or Pressure, SYSTOLIC murmur ≥3/6 or ANY DIASTOLIC Murmur, HR >100 bpm, Symptomatic low BP, Pulmonary Edema or an S4?
NO!!
What do you do if you perform a cardiac angiography on a patient who presented with ACS and found multi-vesel disease and needs surgery however is on CLOPIDOGREL?
STOP CLOPIDOGREL and delay surgery for 5-7 days
What is the OPTIMAL diagnostic method for infective endocarditis?
Trans ESOPHAGEAL ECHO
What structure is affected by the Sinus Venosus ASD?
RIGHT upper PULMONARY VEIN - anomalous drainage
When is a EXERCISE STRESS ECHO indicated rather than an EXERCISE ECG stress test?
When baseline ECG is abnormal OR when DETAILED information on an area of MYOCARDIUM at risk is needed
Why should you wait a FEW DAYS after an MI to place a pacemaker for bradycardia or heart block?
Because post-MI a patient may have only a TRANSIENT heart block
When is Cardiac Catheterization GENERALLY used?
When INTERVENTION is considered
What are the risk factors for an Abdominal Aortic Aneurysm (AAA)?
Age, Male, Long H/O Smoking, Family H/O AAA, vascular form of Ehlers-Danlos Syndrome
Should DIGOXIN be used to treat ACUTELY decompensated HF?
NO!!
In ALL patients with Chronic Stable Angina, unless contraindicated, this medication should ALSO be used as it has also been found to reduce future cardiovascular events including MI and DEATH?
STATINS
What is the NEXT step after a “markedly positive STRESS test”?
Coronary Angiography
Detection of a LEFT ATRIAL thrombus, prosthetic valve dysfunction, aortic dissection or endocarditis is best assessed with?
Trans Esophageal Echocardiography (TEE)
What are the possible EARLY post STEMI complications?
ARRHYTHMIA, HF, Vascular complications s/p PCI
Can sodium nitroprusside be used in pregnancy or breastfeeding?
NO!!
Besides PCI intervention with stenting, patients with Chronic Stable Angina and LEFT MAIN disease may need what additionally during the procedure?
Intra-Aortic Balloon Pump (IABP) or percutaneous ventricular assist device
How is a post-MI Ventricular Septal Defect (VSD) treated?
Intra Aortic Balloon Pump (IABP) + Vasopressors + URGENT SURGICAL REPAIR
What should be done for patients with a AORTIC or MITRAL mechanical valve on warfarin prior to elective surgical procedures?
BRIDGED with unfractionated HEPARIN or LMWH
What should be done in the case of MECHANICAL Valve?
EMERGENCY IV fibrinolytic therapy or SURGERY
A patient presents with palpitations, dizziness, syncope and decreased exercise tolerance, what is the problem?
Cardiac arrhythmia
Can moderate-to-large VSDs adversely affect the heart (LEFT heart enlargement or Pulmonary Artery HTN)?
YES!! eventually will present with HF (due to LV volume overload)
If patient with cardiogenic shock does NOT show improvement with medical therapy (inotropic agents), what ELSE can be done?
Intra Aortic Balloon Pump (IABP) OR Ventricular Assis Devices (VAD)
What agent is used to RAPIDLY terminate REENTRANT SVTs?
ADENOSINE
How is a post-MI Papillary muscle rupture treated?
Intra Aortic Balloon Pump (IABP) + AFTERload reduction (sodium nitroprusside and diuretics) + EMERGENT SURGICAL REPAIR
Inpatient treated for decompensated HF demonstrates evidence of HYPOtension or HYPOperfusion, what do you do?
Start INOTROPIC agents (dobutamine, dopamine, Epi, Norepi, Vasopressin)
Which Stanford Type of Aortic Dissection is considered an EMERGENCY?
Type A (ORIGINATING in the ascending aorta or its arch)
In a RIGHT-sided ECG (not conventional placement of leads), what do ST-elevations in V3R and V4R mean?
RIGHT VENTRICULAR Ischemia
Besides HF, in whom else can you hear an S3 gallop?
Normal people up to age of 40, Athletes
What is the FIRST LINE therapy for patients with Chronic Stable Angina and what is the goal of treatment?
ß-blockers (cardio-selective); HR of 55-60, improve functional capacity, decrease angina attacks
Patients who develop HF EARLY post STEMI benefit from PREload and AFTERload reduction with what agents?
PREload reduction - DIURETICS; AFTERload reduction - ACE-I & NITRATES
What does a prolonged QRS duration indicate?
The degree of RIGHT Ventricular Dilation
Which cancers (tumors) metastasize to the heart?
Lung and Breast
What is the treatment of SYMPTOMATIC Bradycardia/SECOND-DEGREE Heart Block Type 1 or 2, ASYMPTOMATIC COMPLETE Heart Block or ADVANCED SECOND-DEGREE Heart Block, A-Fib with pauses ≥5 seconds OR Heart Block WITHOUT reversible causes?
Pacemaker Implantation
What meds should be given for sudden cardiac arrest patient and how often?
EPI every 3-5 min or Vasopressin (ONCE, then EPI); AFTER 3rd shock, give AMIODARONE then repeat cycle
For CHADS-2 score of 0-1, what is typically used as anticoagulation for a-fib? ANYTHING above CHADS-2 score of 1 (1-6), what is used for anticoagulation for a-fib?
Aspirin; WARFARIN
What are the symptoms of MITRAL STENOSIS?
Dyspnea on exertion, pulmonary edema (in pregnancy and a-fib)
What are the three recommended diagnostic testing modalities for assessing congenital heart disease?
TTE, Cardiac Catheterization, CMR
What can be used as ACUTE rate-control agents in a-fib, to maintain HR 60-110 bpm?
Verapamin, Diltiazem, Metoprolol or Esmolol
What ADDITIONALLY should be done for a patient with STEMI and CARDIOGENIC SHOCK besides thrombolytic therapy and prior to PCI?
Intra Aortic Balloon Pump (IABP)
What are life/functional restrictions for patients with Eisenmenger Syndrome?
NO PREGNANCY, NO CONTACT SPORTS (strenuous exercise, weight lifting), NO HIGH ALTITUDES (less oxygen at >1,500 meters/5,000 feet), NO DEHYDRATION, NO EXPOSURE TO EXCESS HEAT (sauna, outdoors, etc.)
In asymptomatic patients following revascularization SURGERY, the development of vein-graft disease can be identified prior to graft occlusion using what?
STRESS Imaging
What part of the heart is mostly affected by HYPERTROPHIC cardiomyopathy if the Anterior Leads show T-waves that are deeply inverted and symmetric?
Apical Hypertrophy of the LV
Are the following findings normal during pregnancy: Mild exertional SOB, PVCs, PACs, SYSTOLIC murmur 1-2/6, asymptomatic decrease in BP, mild PERIPHERAL Edema or and S3?
YES!!
What are the most common causes (2) of pericarditis?
VIRAL infection, post MI
What can be done to distinguish between the very similar symptoms of PERICARDITIS and PE?
PERICARDITIS is relieved by leaning forward and exacerbated by lying down (recumbent)
Pt presents with AS, EF
Aortic Valve Replacement
Which type of heart valves require anticoagulation and what type? For how long?
BOTH biologic and mechanical; Warfarin: BIOLOGIC for 3 MONTHS, MECHANICAL for LIFETIME Aspirin: LIFETIME for BOTH (75-100 mg)
What are the typical anatomic findings of a patient with cyanosis?
Digital clubbing, scoliosis, arthritis
In a patient with a-fib in whom CARDIOVERSION is NOT planned, how would you treat?
ORAL anticoagulation
When should a LARGE Patent DUCTUS ARTERIOSUS associated with SEVERE Pulmonary Artery HTN (adult) be closed?
NEVER
When is warfarin acceptable to use during pregnancy for MECHANICAL Valves?
ALL times EXCEPT before delivery
What is the vasodilator of choice for use in pregnancy?
Hydralazine
What are the three NON-pharmacologic treatments for refractory a-fib?
Pulmonary vein ablation, AV-node ablation + Pacemaker and MAZE surgery at time of OPEN-HEART surgery
How do you anticoagulate prior to cardioversion in a patient with NEWLY-diagnosed a-fib >48 HOURS duration or UNKNOWN duration?
3-weeks on warfarin OR fully anticoagulate and perform TEE to r/o intracardiac thrombus
Cardiotoxicity (ventricular dysfunction) by which agent is reversible?
TRASTUZUMAB
Pregnancy changes such as increase in plasma volume with a lesser increase in erythrocyte mass resulting in relative ANEMIA, decreased systemic vascular resistance, rise in cardiac output (40% by week 32 and 80% during delivery) are known as what?
Normal, physiological changes of pregnancy
In patients with what abnormalities is use of DOBUTAMINE contraindicated?
Severe baseline HTN and ARRHYTHMIAS
What is the most common symptom associated with SEVERE valve regurgitation OR stenosis?
A slow progression of dyspnea with exertion and reduced functional capacity
Large, sub-AORTIC VSD, PULMONARY Valve STENOSIS, AORTIC OVERRIDE, RV Hypertrophy with CYANOSIS due to DECREASED blood flow to the LUNGS after birth?
Tetralogy of Fallot (DOWN Syndrome)
What thyroid disorder can cause pericardial effusion?
HYPOthyroidism
This VSD is associated with DOWN syndrome and occurs by the ventricular INLET adjacent to the TRICUSPID valve?
INLET VSD
The following: Pt with PDA with LA or LV enlargement in the ABSENCE of Pulmonary Artery HTN and if the SHUNT is still LEFT-to-RIGHT, are indications for what?
Surgical/Percutaneous closure
What FURTHER testing is performed if an arrhythmia is potentially life-threatening?
Cardiac STRESS testing, angiography and EPS testing
Forceful apical impulse with S3?
Restrictive Cardiomyopathy (RIGHT heart failure)
What must be monitored when treating a patient with DIGOXIN?
K (potassium) and KIDNEY function (renally cleared)
Urine and peripheral eosinophilia after cardiac angiography indicates?
Cholesterol embolism (a complication of the procedure)
Pt undergoes PCI, what medications should they be on for the stent placed and for how long?
LIFELONG ASPIRIN; CLOPIDOGREL, Drug-eluting stent - 1 YEAR; Bare metal stent - 1 MONTH
What cardiovascular finding is common to both Syphilis AND Takayasu Arteritis?
THORACIC Aortic Aneurysm (Untreated Syphilis causes ASCENDING aortic aneurysm)
These four (4) systemic inflammatory diseases can cause pericarditis and non-infective endocarditis?
SLE, RA, Systemic Sclerosis, Behçet syndrome
In order to save the MOTHER, ACE-I should be used in PREGNANCY ONLY in this condition?
Renal Crisis due to SCLERODERMA
Angina that occurs at REST with TRANSIENT ECG changes and elevated cardiac biomarkers in near NORMAL coronary artery segments and can be seen with some diseases as well as with COCAINE and METHAMPHETAMINE use?
Vasospastic (Prinzmetal) Angina
Besides THORACIC Aortic Aneurysm and a BICUSPID Aortic Valve what other Valvular abnormality is seen in MARFAN Syndrome?
Mitral Valve REGURGITATION
What alternative to Spironolactone can be used in a pt with NYHA 3-4 who developed gynecomastia on spironolactone?
Eplerenone
How does the Valsalva maneuver affect the heart?
It DECREASES PREload
Post-Operative Neurologic Dysfunction can be seen in patients undergoing what surgery? why?
Open CABG (due to prolonged hospital stay)
This VSD COMMONLY closes, is therefore usually NOT seen in adults, it can occur in single or multiples anywhere along the INTRAVENTRICULAR Septum?
Muscular VSD
SINUS bradycardia and HYPOtension is a very common presentation after successful reperfusion of this type of STEMI? How do you treat?
INFERIOR WALL (ST-elevation in II, III, aVF - RV infarction) STEMI; treat with IVF, atropine/dopamine
How do you treat a STEMI?
REPERFUSION (thrombolitic or angioplasty)
How do you treat a NSTEMI?
RISK STRATIFICATION (for death/MI) with TIMI risk score FIRST!!
Which of these medications, ALL of which CAN be used in PREGNANCY has special restrictions and what are they? (Warfarin, unfractionated HEPARIN, LMWH)
Warfarin (contraindicated in first trimester AND before delivery)
What should be done for ACUTE valve regurgitation?
MEDICAL EMERGENCY - stabilize with afterload reduction and inotropic agents, then URGEN SURGERY (cardiogenic shock)
What is the recommended testing modality when suspecting pathological structural heart disease?
Trans Thoracic Echocardiography (TTE)
Which valve disease is associated with A-fib?
MITRAL valve stenosis and regurgitation
Is PERICARDIECTOMY effective for PERICARDITIS?
NO!! (not for acute OR recurrent - keeps using Aspirin, NSAIDS and colchicine)
Asymptomatic for HCM but phenotypic, no major risk factors for sudden death, how do you manage?
Annual follow-up with ECHO, avoid VIGOROUS exercise
How does Coarctation of the AORTA affect the LV?
HYPERTROPHY
Noonan Syndrome: short-stature, intellectual impairment, facial abnormalities, neck webbing and hypertelorism (wide distance between the eyes) is associated with what heart defect?
PULMONARY Valve Stenosis
What are the possible causes of ACUTE aortic regurgitation?
Dissection, Infective Endocarditis, Trauma
What measures help prevent or reduce contrast associated nephropathy?
Use of N-acetylcysteine, decreased contrast load, good periprocedural hydration and use of low-osmolar contrast
What is the most commonly used ß-blocker for ACS?
Metoprolol
QTc >500 msec?
LONG QT-Syndrome (a genetic channelopathy)
Dysfunction of the Sinus node, the AV node or the His-Purkinje system can cause what?
BRADYCARDIA (HR
These anatomical features are associated with CAD INDEPENDENTLY of BMI and conventional CAD factors?
Waist Circumference and Waist-to-Hip ratio
Which is the ONLY ß-blocker which should NOT be used during Pregnancy OR Breastfeeding?
ATENOLOL (low birth weight, early delivery, small fetal size)
Which are the Class I (Sodium-Channel Blockers)
Quinidine, Procainamide, Lidocaine, Phenytoin, Flecainide, Propafenone
LV Hypertrophy and DIASTOLIC Dysfunction causing dyspnea and angina and SYNCOPE with EXERCISE due to FIXED LV Stroke Volume is seen with this valvular disease?
AS
What should be done for a patient with HIGH Pretest Probability of CAD?
Initiate empiric treatment
What causes a RIGHT-to-LEFT cardiac shunt?
ASD (Ostium Primum, Ostium Secundum, Sinus Venosus)
The TENSION in the wall of the ventricle DURING ejection, the LOAD against the heart as it contracts to eject blood?
AFTERload
Which ASD is most commonly seen in Down Syndrome?
Ostium Primum
How do you treat PVC’s?
You DON’T, unless structural heart disease, family h/o sudden death or SYNCOPE
When should you perform SURGICAL intervention in patients with ASYMPTOMATIC, MODERATE valvular disease?
When they are undergoing OTHER cardiac surgery for something else
What is the preferred INTERVENTION for PULMONARY Valve STENOSIS when ASYMPTOMATIC (with PEAK Instantaneous Doppler gradient ≥60 mm Hg OR a MEAN Doppler gradient ≥40 mm Hg) AND for SYMPTOMATIC (with PEAK Instantaneous Doppler gradient ≥50 mm Hg OR a MEAN Doppler gradient ≥30 mm Hg)?
Percutaneous VALVULOPLASTY; (SURGERY when SEVERE Pulmonary Valve Regurgitation, SUB/SUPRA Valvular Stenosis or Small Pulmonary Valve Annulus)
Should you do ROUTINE or SERIAL BNP level checks in patients with valvular heat disease? CHF?
NO!!!; YES!!!
Patients who develop CAD after RADIATION Therapy are treated medically the SAME however increased SURGICAL risks are higher with?
CABG - mediastinal fibrosis makes this more difficult
STENTING - much higher restenosis rates
Pericardiectomy - more difficult due to adherent epicardial fibrosis
If inpatient treatment with increased LOOP diuretics isn’t enough for a patient with decompensated HF, what should be added?
Thiazide diuretic
A pt presents with a LOUD holoSYSTOLIC murmur best heart at the LEFT LOWER STERNAL BORDER (LSB) that is palpable and obliterates the S2 heart sound?
VS (small or large)
Are Prinzmetal Angina and Unstable Angina the same entity?
NO! Unstable angina is Acute Coronary Syndrome (ACS)
How long post CARDIOVERSION for a-fib MUST warfarin be used for WITHOUT interruption?
4 WEEKS
Are there ANY ECG or CXR abnormalities with a small VSD or Patent DUCTUS ARTERIOSUS?
NO (more susceptible to endocarditis in adulthood)
What are BP and LDL goals for patients with CAD and DM?
BP
In which patients are the NUCLEAR Perfusion Vasodilator (Adenosine, Dipyridamole and Regadenoson) Stress tests contraindicated?
In those whom have BRONCHOSPASTIC (asthma) airway disease or use THEOPHYLLINE
What should be recommended for treatment and why when a patient is found to have an aortic ARCH atheroma >4 mm?
STATIN therapy, because high risk for STROKE
Why do patients with SupraVentricular Tachycardias have visible neck pulsations?
Because their atria pump against a closed TRICUSPID valve
A common manifestation of CAD due to FIXED coronary stenosis?
Chronic Stable Angina
Why are coughing and Valsalva manuvers used when diagnosing a PFO?
Because upon RELEASE of valsalva or end of cough, the RIGHT atrial pressure is transiently elevated demonstrating a RIGHT-to-LEFT shunt with saline bubbles on TTE
ST-segment elevation and Q-waves only in leads III and/or aVF with T-wave inversion in II, aVF, V1-V4 with SEVERE chest pain and shortness of breath?
PE
How is PAD diagnosed and quantified?
Using the Ankle-Brachial Index (ABI)
What does the ABI mean when it’s >1.40?
Nothing, suggests inability to test due to CALCIFIED vessels
What is the MOST COMMON type of TACHYCARDIA?
SINUS-NODE tachycardia (>100 bpm due to pain, fever, anxiety, anemia)
Regardless of whether RATE (ß-blockers, Ca-channel blockers or digoxin) or RHYTHM (antiarrhythmics) are used for a-fib, what MUST be done for all pts with CHADS-2 score >1?
Anticoagulation with warfarin
What complication can be seen with ENDOVASCULAR STENT Aortic Aneurysm Repair?
STROKE (dislodged atheromatous plaques)
What should be done during pregnancy or lactation for women who are taking ß-blockers?
Monitor BOTH maternal and Fetal HR as well as newborn BLOOD GLUCOSE
Are AICD/ICD devices recommended in patients with NYHA class 4?
NO!!!
Pregnant women with cardiovascular disease are recommended VAGINAL delivery EXCEPT?
If on Warfarin (risk of fetal intracranial hemorrhage) or SEVERE Pulmonary HTN or markedly dilated AORTA
Why should you use ASPIRIN instead of NSAIDS in a post-MI PERICARDITIS?
To avoid ventricular wall rupture
Reduced QRS voltage, Dullness to percussion, muffled heart sounds, chest pain?
Pericardial EFFUSION
A reversible cardiomyopathy that presents LIKE an MI WITHOUT obstructive coronary lesions following a STRESSFUL event or CRITICAL ILLNESS?
TAKOTSUBO or STRESS Cardiomyopathy
What are the dangers of cardiac catheterization such as with angiography or percutaneous revascularization, stent placement or angioplasty?
Atheroma dislodgement with embolisation causing kidney dysfunction, MI, ischemia, stroke and lower extremity embolism
What is Wolff-Parkinson-White pattern on ECG?
The Pre-Excitation pattern with DELTA waves seen in patients with AV Reciprocating Tachycardia (AVRT)
What can HEPARIN be substituted with in patients with a reaction to it (HIT: thrombocytopenia)?
BIVALIRUDIN
Antiarrhythmic Medications Classes II (ß-blockers) and IV (Ca-channel blockers) are CONTRAINDICATED in patients with what two (2) conditions?
Decompensated SYSTOLIC HF or WPW
MURMUR: DIASTOLIC, Decrescendo, S3 or S4, Bounding Carotid Pulse, best heard at the Lower Left or Lower Right Sternal Border?
AORTIC REGURGITATION
This cardiac imaging test, like the Coronary Artery Calcium (CAC) test, is used in patients whom were determined to be at an INTERMEDIATE risk on pretest probability testing for CAD, and can visualize in DETAIL coronary artery vessel lumen and atherosclerotic lesions as well as anomalous coronary arteries?
Coronary CT Imaging
What are the ONLY types of patients in which SCREENING for abnormalities of the AORTA is recommended?
Those with UNDERLYING vascular pathology (Marfan Syndrome, Giant Cell Arteritis) or a family h/o aortic disease
WHAT is the MAJOR cause of MITRAL Valve STENOSIS?
Rheumatic Heart Disease ESPECIALLY in women (unlike with AS - atherosclerotic calcification although rarely it can occur in the elderly)
Are ANY other meds (disopyramide, digoxin, vasodilators, diuretics) recommended for HCM WITH outflow obstruction?
NO!!! (ONLY ß-blockers and sometimes Verapamil)
How long should ß-blocker therapy be used for in patients with reduced LV systolic function, previous MI or ACS?
Indefinitely
How are patients with Eisenmenger Syndrome treated?
Pulmonary Vasodilators (epoprostenol and iloprost)
What is considered a NORMAL QTc-interval?
What does a-fib cause even if it is rate-controlled?
Stasis of blood in the LEFT atrium with risk of clot formation an thus stroke
Ho should a patient with an aortic ARCH atheroma and h/o unexplained stroke be treated?
STATIN + Warfarin (INR 2.0-3.0)
What is the recommended diagnostic test for assessing detailed mitral valve imaging and for interatrial septum evaluation for guidance of percutaneous ASD closure?
3D ECHO
What is the management ECHO frequency recommended post valve surgery?
TTE ECHO every 2-3 MONTHS after, NO ANNUAL ECHO needed if NO change in CLINICAL status
How is Tetralogy of Fallot treated, what is the expected survival and how often is cardiology follow-up recommended?
SURGICAL Repair; Normal Survival; YEARLY follow-up
What should the GLUCOSE be kept under for best outcome s/p MI (whether in ICU setting or not)?
What two tests should be done for a symptomatic patient with benign Idiopathic VT?
ECG and EXERCISE Stress test
How should patients with PFO and first incidence of “cryptogenic stroke” be managed?
Antiplatelet therapy (Aspirin or Clopidogrel)
Do small VSDs require restriction from exercise?
NO, unless Pulmonary Vascular Resistance is present
What two studies allow for more precise and detailed diagnosis of HCM which is particularly important in young athletes and can prevent undiagnosed progression of hypertrophy?
Tissue Doppler ECHO and CMR
What types of pericarditis-causing infections require pericardial drainage?
Bacteria and Fungi
How do magnets affect AICD’s?
Turn off shock function (such as during a procedure) but doesn’t affect pacing
How is Arrhythmogenic RV Cardiomyopathy w/Dysplasia treated?
AICD and NO EXERCISE
What is the ONLY test that can provide DEFINITIVE diagnosis of the PRESENCE and SEVERITY of CAD?
Coronary ANGIOGRAPHY
Can small VSDs adversely affect the heart (LEFT heart enlargement or Pulmonary Artery HTN)?
NO!!
Which pharmacologic agent, part of the NUCLEAR Perfusion Vasodilator (Adenosine, Dipyridamole and Regadenoson) Stress tests is CONTRAINDICATED in patients with Sick Sinus Syndrome or High-Degree AV-Block?
ADENOSINE
What can be done for patients with VT at risk for sudden cardiac death (structural heart disease or hemodynamically unstable VT)?
AICD placement
Pt undergoes SURGICAL revascularization (NOT PCI), what medications should they be on and for how long?
LIFELONG ASPIRIN; ADD CLOPIDOGREL if P/W Unstable Angina/NSTEMI and continue for 1 YEAR
What is the ONLY indication for ANTIBIOTIC PROPHYLAXIS against Infective Endocarditis for patients with NATIVE VALVE disease?
Previous Infective Endocarditis episode
In a patient with SEVERE THORACIC PAIN what must be considered and done emergently?
Acute Aortic Syndrome (dissection); Imaging (color flow doppler ECHO or CT with IV contrast)
What are the two Aortic Dissection types by the Stanford Classification?
Type A: (originating in ASCENDING Aorta or the ARCH); Type B: (originating DISTAL to the SUBCLAVIAN Artery)
INFERIOR STEMI is associated with which two infarcted areas?
RIGHT VENTRICLE and POSTERIOR WALL
What are reversible causes of COMPLETE HEART Block?
Medications (ß-blockers, Ca-channel blockers, digoxin) and LYME disease
What are some of the HIGH-risk features in patients with STEMI?
LBBB, ANTERIOR wall MI, CHF
If a cause for pericarditis cannot be determined, or effusion persists >3 months, what should be done?
Pericardiocentesis with culture, cytology and adenosine deaminase activity
In CAD patients with DM, REDUCED LV EF% or HTN, the addition of this medication class REDUCES DEATH, MI and ALL-CAUSE MORTALITY?
ACE-I
Which are the best ß-blockers to use for HF?
Metoprolol, Carvedilol, Bisoprolol
Is a patient with a VSD, WITHOUT Pulmonary Artery HTN safe to become pregnant?
YES!!!
Disease within the His-Purkinje System causing a drop in the QRS complex WITHOUT a change in the preceding PR interval?
SECOND-DEGREE AV-Block TYPE-2 (Mobitz 2)
How likely it is for an event to OCCUR vs how likely it is for an event NOT TO OCCUR, (a measure of association between an exposure and an outcome)?
ODDS RATIO
OR=1 Exposure does not affect odds of outcome
OR>1 Exposure associated with higher odds of outcome
OR
Why is an ANTERIOR MI more likely to have permanent conduction defects?
Because of larger infarct size
What must be infarcted to a large degree to cause Heart Failure (HF)?
LEFT VENTRICLE (LV)
DROP in PEAK LV FILLING during inspiration with “to-and-fro” diastolic motion of the ventricular septum with ELEVATED and EQUALIZED DIASTOLIC LEFT and RIGHT VENTRICULAR PRESSURES?
CONSTRICTIVE Pericarditis
What valvular disease accounts for the majority of a-fib?
MITRAL valve (with resultant dilation of the LEFT atrium), especially Rheumatic Mitral Stenosis
What is the BEST method to quit smoking?
Combination of COUNSELING & MEDICATION
What two diagnostic tests can differentiate between Restrictive Cardiomyopathy and Pericarditis?
Doppler ECHO and >800 BNP (Restrictive Cardiomyopathy)
What non-medical intervention is the MOST important for a patient presenting with Acute Coronary Syndrome (ACS)?
Primary Percutaneous Coronary Intervention within 90 minutes of hospital arrival
What thrombolytic agent has the LOWEST risk of intracerebral hemorrhage?
Streptokinase
What conditions MIMIC the Brugada Syndrome pattern (J-point elevation >2 mm, concave ST-segments and T-wave inversion in V1-V3?
Cocaine use, Alcohol, Fever, K-abnormalities, TCAs
Volume of blood in the ventricles at the end of diastole (end diastolic pressure) is known as?
Preload
Contrast induced nephropathy occurs in 2% of patients after radio-contrast is administered for any testing (angio), when does PEAK Cr elevation typically occur and when does the Cr return to baseline?
Peaks at 3-5 days post test and returns to baseline several days later
If warfarin CANNOT be used in a patient with a-fib and CHADS-2 score of ≥2 (high-risk), what can be used?
ASPIRIN + CLOPIDOGREL combination
What type of cardiac risk do women with SEVERE Pulmonary HTN (Pulmonary Artery Pressure ≥2/3 Systemic Pressure) or NYHA class 3 or 4 HF (EF
Very high mortality risk (HF, thromboembolism, arrhythmia), pregnancy is contraindicated
When is EXERCISE ECG Stress testing NOT useful?
When BASELINE ECG is abnormal (LVH, LBBB, pacemaker, WPW, >1 mm ST-depression)
Ventricular tachycardia is COMMON and transient in the first 24-hours post STEMI, what does it mean when it occurs DAYS later?
Poor prognosis - large infarct size
In patients with INFECTIVE ENDOCARDITIS with Severe Hemodynamic Abnormality (LEFT sided valve involvement or Heart Failure), Fistula formation, Persistent Infection despite antibiotic therapy, Intracardiac Abscess, Involvement of a Prosthetic device OR Presence of Vegetation, besides antibiotic therapy, what is recommended?
SURGERY
What can occur if a patient with LOW CAD pretest probability undergoes a cardiac STRESS test?
FALSE POSITIVE results may occur leading to unnecessary further testing and intervention/treatment
If tolerant, ALL patients with HF (NYHA 1-2) should be on what meds?
ß-blocker + ACE-I
What patients should undergo Coronary Angiography and PCI?
Those whom remain symptomatic despite optimal medical therapy, unable to tolerate meds and those with HIGH-RISK findings on non-invasive imaging (STRESS testing)
How is an infected pacemaker or AICD handled?
Blood Cultures + TTE, if positive, take out completely and treat with antibiotics
Patients presenting with acute HF decompensation present most often with THIS symptom?
HYPOtension (due to volume overload and end-organ HYPOperfusion - kidney failure, AMS)
What are cardiovascular surveillance recommendations for patients s/p radiation therapy?
Annual evaluation by physical exam and blood work, ECHO every 10 years and in patients with CAD PRIOR to radiation therapy, NUCLEAR perfusion tests ever 5 years
Systemic HYPOtension AND END-organ HYPOperfusion suggest what?
Cardiogenic SHOCK
Pt presents with symptoms of Pulmonary Artery HTN with shunt reversal (R-to-L) with Eisenmenger Syndrome and CLUBBING of the FEET, NOT HANDS (desaturated blood reaches the lower part of the body preferentially)?
LARGE Patent DUCTUS ARTERIOSUS
What is the most POWERFUL MODIFIABLE risk factor for development of cardiovascular disease?
Dyslipidemia (High LDL and Low HDL)
What are the risk factors of having PAD?
MI, Stroke, Vascular death
Class III antiarrhythmic agents (Potassium-Channel Blockers - sotalol, amiodarone) are used for ATRIAL and VENTRICULAR arrhythmias and are known to cause this electrical adverse effect?
QT-prolongation (Torsades de Pointes)
Pt presents with SHARP, SEVERE chest pain with a pleuritic component, a friction rub is heard (LSB) during breath hold and leaning forward, WORSENS in the recumbent position (lying down) AND ECG shows DIFFUSE ST-elevation?
PERICARDITIS
How does one easily obtain information regarding Cardiac Output, preload (pulmonary capillary wedge pressure), afterload (systemic vascular resistance) and Mixed Venous Oxygen Saturation (SVO2)?
PA (pulmonary artery) catheterization
A rhythm of >100 bpm that lasts >30 seconds that originates in the ventricles?
Ventricular Tachycardia (VT)
This score estimates the 10-year risk of MI or coronary death based on AGE, SEX, CHOLESTEROL, SMOKING and BP?
FRAMINGHAM score
What is a contraindication for use of COLCHICINE for the treatment of PERICARDITIS?
Kidney disease
CLOPIDOGREL is continued for 1 YEAR post ANY ACS (Unstable Angina, NSTEMI, STEMI), what medications are continued INDEFINITELY after a STEMI?
Aspirin (325–>81 mg after 1 month); ß-blockers; ACE-I (or ARBs if not tolerated); Statins (goal LDL of at least 100 mg/dL)
Is EARLY exposure to G2b3a-Inhibitors beneficial for patients with INTERMEDIATE of HIGH risk TIMI scores for ACS (UNSTABLE ANGINA/NSTEMI)?
NO, it causes more risk of bleeding
What patient populations is the FRAMINGHAM risk score not appropriate for?
Women and Minorities
How is a Stanford Type B Aortic dissection treated?
Medically (reduction of HR: ß-blockers & SBP with nitroprusside/fenoldopam) OR Surgically IF: there is occlusion of a major aortic branch with visceral or limb ischemia, progressive extension and dilation, rupture, large penetrating atherosclerotic ulcer (≥20 mm diameter and ≥10 mm depth), penetrating atherosclerotic ulcer with hematoma
If tolerant, ALL patients with HF (NYHA 3-4) should be on what meds?
ß-blocker + ACE-I + Spironolactone (WHITES) + (Hydralazine-Isosorbide Dinitrate for BLACKS)
Below what EF% are pregnant women recommended Warfarin?
≤35%
How is PAD of the COMMON FEMORAL ARTERY revascularized as Endovascular Stenting cannot be performed there (stent fracture due to flexion)?
Surgical endarterectomy with patch repair
What maneuver INCREASES PREload and DIMINISHES (softens) the MID-SYSTOLIC murmur of HYPERTROPHIC Cardiomyopathy so it can’t be heard?
Leg Elevation
HCM with bradycardia Rx?
Pacemaker
What is the most COMMON reason for RE-Operation for Tetralogy of Fallot that causes progressive RIGHT Heart Enlargement (with resultant increased risk of atrial and ventricular arrhythmias) with Tricuspid REGURGITATION (due to the increased RV pressure) and EXERCISE limitation? Why does this occur?
PULMONARY Valve REGURGITATION; due to repair of the STENOTIC RV Outflow tract to the lungs and STENOTIC PULMONARY Valve with Dilating Patch placement
What are CLINICAL contraindications to any type of EXERCISE (ECG, ECHO, NUCLEAR SPECT Perfusion) Stress testing?
MI
Concentric Cardiac hypertrophy, less marked hypertrophy than HCM (wall thickness ≤15 mm), enlarged LV cavity (>55 mm end diastolic diameter) no marked L atrial enlargement, normal diastolic function?
Athlete’s heart
What occurs to the red blood cells in a patient with CYANOSIS?
Increased RED CELL MASS (estimated by the Hematocrit - Hct)
What score is used to determine the risk for death or MI in patients presenting with UNSTABLE ANGINA or NSTEMI so as to recommend proper treatment approach?
TIMI risk score
What does it mean when sinus tachycardia occurs several DAYS post STEMI?
Development of HF and poor prognosis
ACUTE dyspnea, tachycardia, JVD, hemodynamic instability, hypotension with PULSUS PARADOXUS (abnormally large >10 mm Hg drop in SBP and Pulse Wave amplitude during INSPIRATION)?
TAMPONADE
What is the SURVIVAL of an ASYMPTOMATIC patient with SEVERE AS?
NORMAL (however symptoms WILL develop)
Am I going to finally PASS this motherfucking test?
YES!!
How do you medically treat SEVERE MITRAL STENOSIS?
ß-blockers (slow down filling of the ventricle), diuretics (for congestion) and RATE CONTROL of a-fib
What is “Claudication” and where does it present in patients with PAD?
Exertional muscle CRAMPING relieved by REST, occurs just DISTAL to the level of obstruction
Should pregnant women and patients with advanced CKD use ACE-I?
NO!!!
What medication should ALL patients with MARFAN Syndrome be placed on?
ß-blockers (to reduce the rate of aneurysm expansion) OR ARBs (-“sartan”)
Rupture or erosion of a CORONARY plaque with exposure of subendothelial matrix to circulating blood resulting in formation of a CLOT resulting in PARTIAL or COMPLETE occlusion on a coronary artery?
Acute Coronary Syndrome (ACS) - UNSTABLE ANGINA or NSTEMI or STEMI
What valve disease can PULMONARY HTN cause?
TRICUSPID REGURGITATION
Why is warfarin recommended after ASD closure?
Due to common development of A-fib post closure
What is the ONLY type of mechanical valve that does NOT require BRIDGING prior to elective surgical procedures?
BI-Leaflet AORTIC VALVE
How is Acute Limb Ischemia (ALI) treated?
COMBINED anti-platelet therapy AND systemic HEPARIN, vascular surgery consultation and non-invasive arteriography
How long should CPR occur for prior to checking rhythm?
2 MINUTES
What valve(s) are typically replaced LATER in life in a patient with REPAIRED Tetralogy of Fallot?
PULMONARY Valve (due to severe regurgitation) and if not done soon enough, TRICUSPID Valve as well (as this will develop regurgitation due to resulting RIGHT heart enlargement)
Several days s/p MI with acute pulmonary edema, loud HOLOsystolic murmur at LEFT sternal border and apex radiating to axillae without a thrill (vibration felt by examiner on palpation) with rapid progression to cardiogenic shock?
Papillary muscle rupture
This endomyocardial disorder causes hyperEOSINOPHILIA, organ infiltration with fibrosis of the endomyocardium?
Loffler Endocarditis
Which are the Class III (Potassium-Channel Blockers)
Sotalol, Amiodarone
Normal resting ECG in a patient
Catecholaminergic Polymorphic VT (treat with ß-blockers or AICD) and NO exercise
Which are the ONLY patients is the COMBINATION of ASPIRIN+CLOPIDOGREL is indicated?
Recent MI or Recent STENTING
What happens to the LV in patients with AS?
Concentric Hypertrophy (THICKENED WALLS WITHOUT dilation)
NO relationship between P waves and the QRS complexes as the P wave generated by the SINUS node is NOT conducted through the AV node and the AV node depolarizes on its own?
THIRD-DEGREE AV-Block (COMPLETE HEART BLOCK)
