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Step3 Uw Selfmade > Advanced Cardio1 > Flashcards

Advanced Cardio1 Flashcards

1
Q

Rhythm control agents in AF given when

A
  1. Inablity of adequate HR control by rate controlling agents
  2. Persistence of symptomatic episodes ( exacerbated HF) on rate controlling agents
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2
Q

Preferred antiarrythmic in AF pts with no any CAD or structural heart disease

A

Flecainide

Propafenone

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3
Q

Antiarrythmic for AF pts with LVH

A

Amiodarone

Dronedarone

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4
Q

Antiarrythmic for Af pts with CAD eout HF

A

Sotalol

Dronedarone

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5
Q

Antiarrythmic for AF pts with HF

A

Amiodarone

Dofetilide

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6
Q

Cocaine intoxication: physiologic effects?

A

Hypertension, tachycardia, coronary vasoconstriction, inc platelet activity, thrombus formation

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7
Q

Cocaine intoxication: CLinical effects?

A

MI, aortic dissection, neurologic ischemia or stroke

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8
Q

Cocaine intoxication: rxn?

A

Benzos and nitroglycerin, beta blockers contraindicated, CCB if persistent chest pain, pentolamine for persistent hypertension, +/- PCI for MI

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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

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10
Q

Non invasive tools for aortic dissection

A

CTA, MRA, TEE

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11
Q

MArfan syndrome pts inc risk of sudden cardiac death due to

A

Aortic root disease so echocardiography is required

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12
Q

Biscuspid aortic valve: etiology?

A

Predominant in male
30% of turner syndrome pts
Autosomal dominant e incomplete penetrance or sporadic

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13
Q

BAV: dx?

A

Screening echocardiogram for pt and 1st degree relatives

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14
Q

BAV: mxn?

A
  1. F/up echocardiogram every 1-2 yrs

2. Balloon valvuloplasty or surgery ( valve & ascending aorta replacement)

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15
Q

BAV: complications?

A

Infective endocarditis
Severe regurgitation or stenosis
Aortic root or ascending aortic dilation
Dissection

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16
Q

RV MI: CF?

A

Hypotension or shock, JVD and clear lung fields

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17
Q

RV MI: rxn?

A
  1. Similar to acute MI: dual antiplatelet, statins, anticoagulant therapy and emergency revascularization with thrombolytics or PCI
  2. Beta blockers and CCB used with caution
  3. Nitrates, diuretics, opiods avoided: dec RV preload-> dec CO-> profound hypotension
  4. Bolus of IVF -> inc RV preload
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18
Q

WPWS: ecg?

A

Short pr interval
Delta wave
Wide qrs complex

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19
Q

WPWS: cf?

A

Tachyarrhythmia

Syncope: when WPWS develop AF

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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

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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)
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22
Q

Lightning injury: asystole or VF : Rxn?

A

Continued CPR without interruption + vasopressors ( epinephrine or vasopressin)

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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
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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

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25
Q

PAD : rxn?

A

Initiation of antiplatelet (aspirin) and high intensity statin despite normal basekine cholesterol levels for secondary prevention of CV events

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26
Q

Symptomatic PAD: rxn?

A

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)

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27
Q

Supervised exercise therapy?

A

30-45 mins of supervised walking >_ 3 times a week for > 3 months

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28
Q

Indications for statin therapy: primary prevention?

A
  1. LDL >/equal 190mg/dl
  2. Age >/equal 40 e DM
  3. Estimated 10 yr ASCVD risk > 7.5-10%
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29
Q

Statin therapy: secondary prevention?

A

Established ASCVD: ACS, stable angina, arterial revascularization(CABG), stroke, TIA,PAD

Age equal 75: high intensity statin
Age > 75: moderate intensity statin

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30
Q

Hypertriglyceridemia: rxn?

A
  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
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31
Q

Acute decompensated HF: cause?

A

LV systolic/diastolic dysfunction( coronary ischemia, hypertensive cardiomyopathy), valvular disease, marked inc. in preload( excessive vol resuscitation) or afterload( severe htn)

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32
Q

ADHF: early therapaeutic goals?

A

Haemodynamic stability, improved oxygenation, optimization of vol status, IV diuretics

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33
Q

ADHF pt e inadequate initial antidiuretic response?

A

IV vasodilators( nitroglycerin: common, nitroprusside: less common due to adverse effects such as cyanide toxicity, severe hypotension)

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34
Q

IV vasodilators: MOA?

A
  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
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35
Q

Indicated urgently in flash oedema due to severe HTN

A

IV vasodilators

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36
Q

ADHF of uncertain etiology: investigation of choice?

A

TTE to identify cause & if LV dysfunction is identified then evaluation for ischemic cardiomyopathy done e stress testing & coronary angiography

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37
Q

Cardiogenic syncope: causes?

A

Aortic stenosis/HCM, ventricular tachy, sick sinus syndrome, advanced AV block, torsades de pointes

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38
Q

Cardiogenic syncope: clues to dx cause?

A
  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
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39
Q

Cardiogenic syncope: cf?

A

Absence of autonomic prodomal symptoms( nausea, pallor, diaphoresis, feeling of warmth), which are present prior to benign syncope event

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40
Q

Cardiogenic syncope due to VT: mxn?

A

Hospitalization e telemetry monitoring and echo

Rxn: combination of pharmacologic therapy( amiodarone), catheter ablation or placement of ICD

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41
Q

Diagnostic evaluation of suspected stable CAD?

A

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
Q

Exercise ecg?

A

Able to walk, no any significant abnormalities on resting ecg

43
Q

Acute pericarditis: etiology?

A

Viral/idiopathic
Autoimmune disease(SLE)
Uremia(acute or chronic RF)
Post MI ( early: peri infraction pericarditis, late: dressler stndrome)

44
Q

Acute pericarditis: cf & dx?

A

Pleuritic chest pain ( dec when sutting up) +/- fever
Pericardial rub
ECG: diffuse ST segment elevation & PR segment depression
Echo: pericardial effusion

45
Q

Acute pericarditis: rxn?

A

NSAIDS & colchicine for viral or idiopathic etiology

Variable for other etiologies

46
Q

Peri infraction pericarditis?

A

<4 days following acute MI

Delayed coronary reperfusion following ST elevated MI( >3 hrs frim symptom onset) inc. risk

47
Q

Peri infraction pericarditis: rxn?

A

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
Q

Peri infraction pericarditi: rxn contraindicated?

A

NsAIDS, glucocorticoids as they impair myocardial healing and inc. risk of ventricular septal or free wall rupture

49
Q

Coronary revascularization: indications for pts e stable angina?

A
  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
Q

DM e multivessel CAD pts?

A

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
Q

Predictors of major cardiac complications e noncardiac surgery

A

Clinical risk factors:

High risk surgery( vascular), h/o IHD, HF, h/o stroke, dm treated e insulin, preoperative cr > 2 mg/dl

52
Q

Predictors of major cardiac complications e non cardiac surgery

A 
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
Q

Perioperative cardiac events: clinical risk assessment?

A

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
Q

Preoperative cardiac evaluation for noncardiac surgery?

A

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
Q

Cardiac risk stratification for noncardiac surgical procedures?

A 
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
Q

Active cardiac condn that inc. perioperative CV risk/ require further evaluation & rxn before noncardiac surgery

A

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
Q

Mxn of HF: order of therapy?

A 
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
Q

Mxn of HF: order of therapy?

A

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
Q

Mxn of HF: order of therapy?

A

NYHA class IV ( unable to carry out any physical activity eout symptoms), can have symptoms at rest): transplant/ventricular assist device evaluation

60
Q

Pulmonary hypertension: classification?

A

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
Q

Pul. Htn: symptoms?

A

Dyspnea, fatigue/weakness, exertional angina, syncope, abdominal distension/ pain

62
Q

Pul. Htn: signs?

A

Left parasternal lift, rt ventricular heave, loud P2, rt sided S3, pansystolic murmur of TR, JVD, ascites, peripheral oedema, hepatomegaly

63
Q

Pulmonary hypertension?

A

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
Q

Idiopathic PH: rxn?

A
  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
Q

PH: investigations to find out cause?

A
  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
Q

Risk factors for CAD?

A

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
Q

Local vascular complications of cardiac catheterization?

A

Haematoma: +/- mass, no bruit
Pseudoaneurysm: bulging& pulsating mass, systolic bruit
AV fistula: no mass, continous bruit

68
Q

Paeudoaneurysm?

A

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
Q

Antiplatelet therapy after coronary stenting?

A

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
Q

Antiplatelet therapy after coronary stenting?

A

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
Q

Thrombolysis in MI risk score

A 
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
Q

Mxn of unstable or non st elevated MI

A
  • 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
Q

Persistent ST elevation despite initial medical therapy: mxn?

A

Coronary angiography e PCI dine eout delay

74
Q

AAA: risks?

A

Commonly affects infrarenal aorta (>/equal 3 cm)

Risks: smoking, male sex, older, white ethnicity, family h/o AAA, atherosclerotic disease

75
Q

AAA: screening?

A

Abdominal USG in men age 65-75 who have ever smoked

76
Q

AAA: symptoms?

A

Mostly asymptomatic
May have abdominal, back, or flank pain
Lower limb ischemia or thromboembolism
Rupture often presents e abdominal distress & shock

77
Q

AAA: mxn?

A

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
Q

AAA: follow up imaging?

A

Medium (4-5.4cm): usg every 6-12 months

Smaller: usg every 2-3 yrs

79
Q

Primary MR: cause?

A

Intrinsic defect of MV apparatus( leaflets, chordae tenidinae), Myxomatous degeneration of MV leading to MVP; common cause of chronic primary MR

80
Q

Chronic MR classified as severe if?

A

Presence of associated symptoms( dyspnea on exertion, HF) or specific echo findings( lt atrial & lt ventricular enlargement, regurgitant jet prominence).

81
Q

Severe MR & LVEF?

A

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
Q

MI: initial tests non diagnostic mxn?

A

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
Q

MI: initial tests non diagnostic mxn?

A

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
Q

Approach to adult cardiac arrest

A

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
Q

Approach to adult cardiac arrest?

A

PEA/asystole: no defibrillation other same as VT/ pulseless VT

86
Q

Reversible causes of asystole/pulseless electrical activity?

A

5Hs: hypovolumia, hypoxia, hydrogen ions( acidosis), hypo or hyperkalemia, hypothermia
5Ts: tension pneumothorax, tamponade cardiac, toxins( narcotics, benzos), thrombosis( pulmonary or coronary), trauma

87
Q

DVT: usg findings?

A

Noncompressibility of lt popliteal and femoral veins

88
Q

DVT in pts eout cancer: rxn?

A

> /equal 3 months of factor Xa inhibitors( rivaroxaban)

89
Q

DVT in cancer pts: rxn?

A

LMWH more effacious than rivaroxaban

90
Q

Rxn of acute dvt/pe?

A

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
Q

Menopausal hormonal therapy: adverse outcomes?

A

Mild inc. risk of stroke, breast cancer & DVT

92
Q

MHT caused DVT: other rxn options for hot flashes?

A

SSRI( escitalopram) or SNRI( venlafaxine)

93
Q

Dilated cardiomyopathy:cause?

A

Idiopathic: most common

CAD leading to ischemic cardiomyopathy

94
Q

Ischemic cardiomyopathy?

A

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
Q

HF: stages in development?

A

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
Q

HF: stage in development?

A

Stage C: structural heart disease e prior or current symptoms of HF
Stage D: HF symptoms at rest or refractory end stage HF

97
Q

Torsades de pointes?

A

Presence of bradyarrythmia( sinus bradycardia or pauses) associated e inc risk of developing TdP in pts e drug induced acquired LQTS

98
Q

LQTS: medications causing?

A 
Antipsychotics
Antidepressants
Macrolide
Fluoroquinolone
Antifungals
Others: electrolyte imbalance( hypomagnesemia, hypokalemia), SSRIs, hypothermia& HIV
99
Q

TdP: rxn?

A

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
Q

CVD status: pts classified into 3 categories e regard to sexual activity:

A

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
Q

CVD: 3 categories?

A 
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
Q

MI: resume sexual activity?

A

Low risk can resume within 3-4 wks( princeton guidelines) or within 1 wk( AHA guidelines)

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