Advanced Cardio1 Flashcards
1
Q
Rhythm control agents in AF given when
A
- Inablity of adequate HR control by rate controlling agents
- Persistence of symptomatic episodes ( exacerbated HF) on rate controlling agents
2
Q
Preferred antiarrythmic in AF pts with no any CAD or structural heart disease
A
Flecainide
Propafenone
3
Q
Antiarrythmic for AF pts with LVH
A
Amiodarone
Dronedarone
4
Q
Antiarrythmic for Af pts with CAD eout HF
A
Sotalol
Dronedarone
5
Q
Antiarrythmic for AF pts with HF
A
Amiodarone
Dofetilide
6
Q
Cocaine intoxication: physiologic effects?
A
Hypertension, tachycardia, coronary vasoconstriction, inc platelet activity, thrombus formation
7
Q
Cocaine intoxication: CLinical effects?
A
MI, aortic dissection, neurologic ischemia or stroke
8
Q
Cocaine intoxication: rxn?
A
Benzos and nitroglycerin, beta blockers contraindicated, CCB if persistent chest pain, pentolamine for persistent hypertension, +/- PCI for MI
9
Q
Persistent chest pain in cocaine induced pts with adequate HR and BP control and normal ecg
Persistent chest pain with new neurologic symptoms
A
Aortic dissection
10
Q
Non invasive tools for aortic dissection
A
CTA, MRA, TEE
11
Q
MArfan syndrome pts inc risk of sudden cardiac death due to
A
Aortic root disease so echocardiography is required
12
Q
Biscuspid aortic valve: etiology?
A
Predominant in male
30% of turner syndrome pts
Autosomal dominant e incomplete penetrance or sporadic
13
Q
BAV: dx?
A
Screening echocardiogram for pt and 1st degree relatives
14
Q
BAV: mxn?
A
- F/up echocardiogram every 1-2 yrs
2. Balloon valvuloplasty or surgery ( valve & ascending aorta replacement)
15
Q
BAV: complications?
A
Infective endocarditis
Severe regurgitation or stenosis
Aortic root or ascending aortic dilation
Dissection
16
Q
RV MI: CF?
A
Hypotension or shock, JVD and clear lung fields
17
Q
RV MI: rxn?
A
- Similar to acute MI: dual antiplatelet, statins, anticoagulant therapy and emergency revascularization with thrombolytics or PCI
- Beta blockers and CCB used with caution
- Nitrates, diuretics, opiods avoided: dec RV preload-> dec CO-> profound hypotension
- Bolus of IVF -> inc RV preload
18
Q
WPWS: ecg?
A
Short pr interval
Delta wave
Wide qrs complex
19
Q
WPWS: cf?
A
Tachyarrhythmia
Syncope: when WPWS develop AF
20
Q
WPW: rxn?
A
Catheter ablation: SCD can occur in WPWs pt with AF which can progress to VF to obliterate the accessory pathway
21
Q
Lightning injury?
A
Thermal burns( superficial, partial or full thickness) Cardiac arrythmias ( asystole, VF) Rhabdomyolysis e RF Neurologic dysfunction ( loss of consciousness, temporary weakness/paralysis, autonomic dysfunction, respiratory depression)
22
Q
Lightning injury: asystole or VF : Rxn?
A
Continued CPR without interruption + vasopressors ( epinephrine or vasopressin)
23
Q
Hypertension control nonpharmacologic measures?
A
Modification Dec systolic BP Wt loss 5-20 per 10 kg loss DASH diet. 8-14 Exercise. 4-9 Dietary Na. 2-8 Limit alcohol intake. 2-4
24
Q
HTN control nonpharmacologic measures
A
Wt loss: BMI < 25 kg/m2
DASH diet: diet high in fruits and veg & low in saturated & total fats
Exercise: 30 mins/day for 5-6 days/ week
Dietary Na: <3g/day
Limit alcohol intake: _< 2 drinks/day men, _< 1 drink/day in women
25
PAD : rxn?
Initiation of antiplatelet (aspirin) and high intensity statin despite normal basekine cholesterol levels for secondary prevention of CV events
26
Symptomatic PAD: rxn?
Step 1A: smoking cessation, control of DM & HTN, antiplatelet& statin therapy
Step1B: supervised exercise therapy
Step 2: cilostazol preferred over pentoxifylline
Step3: revascularization for persistent symptoms (1. Angioplasty +/- stent placement 2. Autogenous or aynthetic bypass graft)
27
Supervised exercise therapy?
30-45 mins of supervised walking >_ 3 times a week for > 3 months
28
Indications for statin therapy: primary prevention?
1. LDL >/equal 190mg/dl
2. Age >/equal 40 e DM
3. Estimated 10 yr ASCVD risk > 7.5-10%
29
Statin therapy: secondary prevention?
Established ASCVD: ACS, stable angina, arterial revascularization(CABG), stroke, TIA,PAD
Age equal 75: high intensity statin
Age > 75: moderate intensity statin
30
Hypertriglyceridemia: rxn?
1. 150-500mg/dl
A. Lifestyle modifications: wt loss, moderate alchol intake, inc. exercise
B. Known CV disease or high risk: statin therapy
2. > 1000mg/dl: fibrates, fish oil, abstinence from alcohol
31
Acute decompensated HF: cause?
LV systolic/diastolic dysfunction( coronary ischemia, hypertensive cardiomyopathy), valvular disease, marked inc. in preload( excessive vol resuscitation) or afterload( severe htn)
32
ADHF: early therapaeutic goals?
Haemodynamic stability, improved oxygenation, optimization of vol status, IV diuretics
33
ADHF pt e inadequate initial antidiuretic response?
IV vasodilators( nitroglycerin: common, nitroprusside: less common due to adverse effects such as cyanide toxicity, severe hypotension)
34
IV vasodilators: MOA?
1. Nitroglycerin Dec. Preload-> dec intracardiac filling pressure-> improvement in pul oedema
2. Nitroprusside Dec intracardiac filling pressures through balanced vasodilation and reductions in both cardiac preload & afterload
35
Indicated urgently in flash oedema due to severe HTN
IV vasodilators
36
ADHF of uncertain etiology: investigation of choice?
TTE to identify cause & if LV dysfunction is identified then evaluation for ischemic cardiomyopathy done e stress testing & coronary angiography
37
Cardiogenic syncope: causes?
Aortic stenosis/HCM, ventricular tachy, sick sinus syndrome, advanced AV block, torsades de pointes
38
Cardiogenic syncope: clues to dx cause?
1. AS/HCM: exertional syncope, systolic murmur on examination
2. VT: no preceding symptoms, cardiomyopathy or previous MI
3. Sick sinus syndrome: preceding fatigue/dizziness, sinus pauses on ecg
4. Advanced AV block: bifascicular block or inc. PR interval on ecg, dropped qrs complexes on ecg
5. Torsades de pointes: no preceding symptoms, medications that prolong qt interval, hypokalemia or hypomagnesemia
39
Cardiogenic syncope: cf?
Absence of autonomic prodomal symptoms( nausea, pallor, diaphoresis, feeling of warmth), which are present prior to benign syncope event
40
Cardiogenic syncope due to VT: mxn?
Hospitalization e telemetry monitoring and echo
| Rxn: combination of pharmacologic therapy( amiodarone), catheter ablation or placement of ICD
41
Diagnostic evaluation of suspected stable CAD?
Symptoms and risk factors suggest stable CAD:
1. Able to exercise: exercise ecg stress testing
2. Unable to exercise: pharmacologic stress testing
•if -ve: no significant CAD, risk factor redn
•if +ve: CAD present; medical mxn +/- CA e revascularization( high risk pts)
42
Exercise ecg?
Able to walk, no any significant abnormalities on resting ecg
43
Acute pericarditis: etiology?
Viral/idiopathic
Autoimmune disease(SLE)
Uremia(acute or chronic RF)
Post MI ( early: peri infraction pericarditis, late: dressler stndrome)
44
Acute pericarditis: cf & dx?
Pleuritic chest pain ( dec when sutting up) +/- fever
Pericardial rub
ECG: diffuse ST segment elevation & PR segment depression
Echo: pericardial effusion
45
Acute pericarditis: rxn?
NSAIDS & colchicine for viral or idiopathic etiology
| Variable for other etiologies
46
Peri infraction pericarditis?
<4 days following acute MI
| Delayed coronary reperfusion following ST elevated MI( >3 hrs frim symptom onset) inc. risk
47
Peri infraction pericarditis: rxn?
Usually self limited
Pt e significant discomfort, high dose aspirin for symptomatic relief compared to NSAIDS or glucocorticoids
Persistent symptoms despite high dose aspirin, colchicine or narcotics analgesics( oxycodone) used
48
Peri infraction pericarditi: rxn contraindicated?
NsAIDS, glucocorticoids as they impair myocardial healing and inc. risk of ventricular septal or free wall rupture
49
Coronary revascularization: indications for pts e stable angina?
1. Pts e refractory angina despite maximal medical therapy
2. Pts in whom revascularization improve long term survival including those e left main coronary stenosis or multivessel CAD e LV systolic dysfunction
50
DM e multivessel CAD pts?
CABG is superior than PCI e drug eluting stents because of lower rate of all cause mortality
CABG also associated e lower rates of repeat revascularization than PCI
51
Predictors of major cardiac complications e noncardiac surgery
Clinical risk factors:
| High risk surgery( vascular), h/o IHD, HF, h/o stroke, dm treated e insulin, preoperative cr > 2 mg/dl
52
Predictors of major cardiac complications e non cardiac surgery
```
Rate of cardiac death, nonfatal cardiac arrest or nonfatal MI
No risk factors: 0.4%
1 risk factor: 1%
2 risk factors: 2.4%
>/equal 3 risk factors: 5.4%
```
53
Perioperative cardiac events: clinical risk assessment?
Type of surgery, pt comorbidities, functional status( exercise capacity >4 METS: able to climb 2 flight of stairs)
• <4 METS and >1% risk of significant cardiac event should undergo further cardiac evaluation prior to surgery
54
Preoperative cardiac evaluation for noncardiac surgery?
Active high risk cardiac condn, if yes: stabilization prior to surgery, if no -> low risk surgery, if yes: proceed e surgery, if no -> revised cardiac risk index( RCRI) equal 1%, if yes: proceed e surgery, if no -> able to perform >/equal 4 METS, if yes: proceed e surgery, if no -> further cardiac evalution prior to surgery( TTE, stress testing)
55
Cardiac risk stratification for noncardiac surgical procedures?
```
High risk(>5%): aortic or other major vascular, peripheral vascular
Intermediate risk(1-5%): carotid endarterectomy, head&neck, intraperitoneal& intrathoracic, orthopedic, prostrate
Low risk(<1%): ambulatory or superficial procedures, endoscopic procedure, cataract, breast
```
56
Active cardiac condn that inc. perioperative CV risk/ require further evaluation & rxn before noncardiac surgery
Unstable angina or recent MI
Decompensated HF
Significant arrythmia: symptomatic bradycardia, high grade AV block, SVT, symptomatic or new onset VT
Severe valvular disease: severe AS, symptomatic MS
57
Mxn of HF: order of therapy?
```
NYHA class I ( no limits e physical activity): ACEIs, ARB if ACEI not tolerated
NYHA class II ( slight limitation e physical activity, ordinary activity causes fatigue, palpitation or dyspnea): Diuretics, beta blockers e EF equal 40% once euvolemic, spironolactone if EF
```
58
Mxn of HF: order of therapy?
NYHA class III (marked limitation e physical activity, less than ordinary activity causes fatigue, palpitations or dyspnea): Isosirbide dinitrate/hydralazine if African american, digoxin if symptomatic e spironolactone, cardiac resynchronization therapy if QRS > 150msec
59
Mxn of HF: order of therapy?
NYHA class IV ( unable to carry out any physical activity eout symptoms), can have symptoms at rest): transplant/ventricular assist device evaluation
60
Pulmonary hypertension: classification?
Pul. arterial htn, due to lt sided heart disease, due to chronic lung disease, due to chronic thromboembolic disease, due to other causes (sarcoidosis)
61
Pul. Htn: symptoms?
Dyspnea, fatigue/weakness, exertional angina, syncope, abdominal distension/ pain
62
Pul. Htn: signs?
Left parasternal lift, rt ventricular heave, loud P2, rt sided S3, pansystolic murmur of TR, JVD, ascites, peripheral oedema, hepatomegaly
63
Pulmonary hypertension?
Chest xray: enlargement of main pulmonary arteries e attenuation of peripheral arteries
Suspected PH: initial evaluation e transthoracic echo that evaluates the cause
Definitive dx e rt heart catheterization e mean pul arterial pressure >/equal 25mm hg confirm
64
Idiopathic PH: rxn?
1. Endothelin blockers: delay disease progression in symptomatic idiopathic PH
2. Phosphodiesterase 5 inhibitors( sildenafil, tadalafil)
3. Prostacycline pathway agonists( epoprostenol, treprostinil, ilolrost)
4. Pts e +ve vasoreactive test during rt heart catheterization: CCB another option
65
PH: investigations to find out cause?
1. Rt heart catheterization: due to lt heart failure
2. PFT: chronic lung diseases
3. V/Q scan: thromboembolic diseases
4. Polysomnography: sleep disorder
5. If all normal then idiopathic cause
66
Risk factors for CAD?
CHD risk equivalent: noncoronary atherosclerotic disease( carotid, perioheral artery, abdominal aortic aneurysm), DM, CKD
CHD established risk factors: age( > 50 in men & menopause in women), male gender, family h/o CHD in 1st degree relatives age(<50 in men & <60 in women), htn, dyslipidemia, smoking, obesity
67
Local vascular complications of cardiac catheterization?
Haematoma: +/- mass, no bruit
Pseudoaneurysm: bulging& pulsating mass, systolic bruit
AV fistula: no mass, continous bruit
68
Paeudoaneurysm?
Bleeding from artery confined eun periarterial connective tissue
Exam: tender, pulsatile mass e systolic bruit
Dx confirmed: USG
Rx: Small treated e usg guided compression or thrombin inj; large or rapidly expanding: surgical repair due to risk of rupture
Main risk factor for pseudoaneurysm: inadequate post procedural manual compression
69
Antiplatelet therapy after coronary stenting?
Recommended duration of therapy
• DAPT for min 6-12 months after BMS or DES placement
• DAPT for min 4 wks in select pts after BMS
• Continue DAPT for total 30 months if possible( low bleeding risk)
• Continue aspirin immediately
BMS: bare metal stent, DES: drug eluting stent
70
Antiplatelet therapy after coronary stenting?
Perioperative mxn:
• Elective surgery: defer surgery until after min DAPT duration
• Urgent surgery: continue P2Y12 receptor blocker or hold for shortest duration possible
• Continue aspirin unless high risk of severe surgical bleeding
71
Thrombolysis in MI risk score
```
Clinical variables( 1 point for each)
age >/equal 65
>/equal 3 risk factors for CAD
Known CAD e > 50% stenosis
Use of aspirin in past 7 days
>/equal 2 anginal eoisodes ein preceding 24 hrs
Elevated cardiac biomarkers
ST segment deviation > 0.5 mm on admission ECG
```
72
Mxn of unstable or non st elevated MI
* Low risk (0-2): stress test
* Intermediate (3-4) or high (5-7) risk: early coronary angiography (ein 24 hrs)
* Haemodynamic instability, HF or new MR, recurrent chest pain, ventricular arrythmia: immediate coronary angiography
73
Persistent ST elevation despite initial medical therapy: mxn?
Coronary angiography e PCI dine eout delay
74
AAA: risks?
Commonly affects infrarenal aorta (>/equal 3 cm)
| Risks: smoking, male sex, older, white ethnicity, family h/o AAA, atherosclerotic disease
75
AAA: screening?
Abdominal USG in men age 65-75 who have ever smoked
76
AAA: symptoms?
Mostly asymptomatic
May have abdominal, back, or flank pain
Lower limb ischemia or thromboembolism
Rupture often presents e abdominal distress & shock
77
AAA: mxn?
Smoking cessation
Aspirin & statin therapy
Elective repair recommended for:
• large( >/equal 5.5cm) aneurysms
• rapidly enlarging aneurysms (>/equal 0.5 cm in 6 months)
• AAA associated e peripheral artery disease or aneurysm
78
AAA: follow up imaging?
Medium (4-5.4cm): usg every 6-12 months
| Smaller: usg every 2-3 yrs
79
Primary MR: cause?
Intrinsic defect of MV apparatus( leaflets, chordae tenidinae), Myxomatous degeneration of MV leading to MVP; common cause of chronic primary MR
80
Chronic MR classified as severe if?
Presence of associated symptoms( dyspnea on exertion, HF) or specific echo findings( lt atrial & lt ventricular enlargement, regurgitant jet prominence).
81
Severe MR & LVEF?
In severe MR: large portion of LVEF flows back to lt atrium so LVEf much lower than estimated by echo so pts e severe chronic primary MR and LVEF <60%: MV repair or replacement is indicated
82
MI: initial tests non diagnostic mxn?
Initial ecg can be nondiagnostic & troponin levels remain undetectable for 6-12 hrs following MI symptoms. If ecg and troponin unremarkable and have reasonable suspicion for ACS then further observation e serial ecg and troponin done.
83
MI: initial tests non diagnostic mxn?
3 troponin levels 6 hrs apart & several ecg 30 mins apart
Elevation of troponin e normal ecg findings: non st elevated MI, reoccurrence of typical anginal pain eout troponin elevation: unstable angina
84
Approach to adult cardiac arrest
Initial: start CPR, give oxygen & attach monitor/ defibrillator
If VF/ pulseless VT: defibrillation shock-> CPRxmin, airway, IV/IO access, epinephrine every 3-5 min-> pulse& rhythm check every 2min, treat reversible causes-> if shockable rhythm start again e defibrillation shock and continue, if undhockable rhythm then treat as PEA/asystole, or return of spontaneous circulation
Amiodarone given after 3rd defibrillation shock
85
Approach to adult cardiac arrest?
PEA/asystole: no defibrillation other same as VT/ pulseless VT
86
Reversible causes of asystole/pulseless electrical activity?
5Hs: hypovolumia, hypoxia, hydrogen ions( acidosis), hypo or hyperkalemia, hypothermia
5Ts: tension pneumothorax, tamponade cardiac, toxins( narcotics, benzos), thrombosis( pulmonary or coronary), trauma
87
DVT: usg findings?
Noncompressibility of lt popliteal and femoral veins
88
DVT in pts eout cancer: rxn?
>/equal 3 months of factor Xa inhibitors( rivaroxaban)
89
DVT in cancer pts: rxn?
LMWH more effacious than rivaroxaban
90
Rxn of acute dvt/pe?
Oral factor xa inhib. Warfarin
MOA. Direct xa inhibit. VitKblock
Ther.onset 2-4hrs. 5-7days
Overlap. No. Yes UFHorLMWH 5 days
Labmonit. No. Yes, PT/INR
91
Menopausal hormonal therapy: adverse outcomes?
Mild inc. risk of stroke, breast cancer & DVT
92
MHT caused DVT: other rxn options for hot flashes?
SSRI( escitalopram) or SNRI( venlafaxine)
93
Dilated cardiomyopathy:cause?
Idiopathic: most common
| CAD leading to ischemic cardiomyopathy
94
Ischemic cardiomyopathy?
Most pts do not have typical anginal symptoms & initially present e symptoms of HF( dyspnea, vol overload) so all pts e new onset HF e LV systolic dysfunction should be evaluated for CAD e stress testing or coronary angiography
Such pts, coronary revascularization lead to improvement of symptoms, systolic function & long term mortality
95
HF: stages in development?
Stage A: high risk of HF but eout structural heart disease or symptoms of HF( pts e risk factors for DM or HTN, pts exposed to cardiotoxic drugs)
Stage B: structural heart disease, but eout signs or symptoms of HF ( pts e prior MI or valvular heart disease e lt ventricle enlargement or low EF)
96
HF: stage in development?
Stage C: structural heart disease e prior or current symptoms of HF
Stage D: HF symptoms at rest or refractory end stage HF
97
Torsades de pointes?
Presence of bradyarrythmia( sinus bradycardia or pauses) associated e inc risk of developing TdP in pts e drug induced acquired LQTS
98
LQTS: medications causing?
```
Antipsychotics
Antidepressants
Macrolide
Fluoroquinolone
Antifungals
Others: electrolyte imbalance( hypomagnesemia, hypokalemia), SSRIs, hypothermia& HIV
```
99
TdP: rxn?
IV magnesium sulfate: first line therapy in concious & haemodynamically stable pts. Used for acute rxn and prevention of recurrent TdP episodes. Effective and should not be withheld in pt e normal baseline magnesium levels
100
CVD status: pts classified into 3 categories e regard to sexual activity:
Low risk pts can perform light intensity exercise eout symptoms & should be able to initiate or resume sexual activity. Eg: few CVD risk factors, controlled htn, asymptomatic LV dysfunction, successful revascularization of clinically significant lesions (> 50-60%)
101
CVD: 3 categories?
```
High risk pts should be referred for detailed assessment prior to advising on activity. Eg: include those e refractory angina, NYHA class IV HF, significant arrythmias or severe valvular disease
Intermediate risk, stress testing recommended to reclassify them as low or high risk & to help guide decisions
```
102
MI: resume sexual activity?
Low risk can resume within 3-4 wks( princeton guidelines) or within 1 wk( AHA guidelines)
