April/May 2021

Question 1

What is the gold standard the diagnosis of myocarditis?

Answer 1

Cardiac MRI is the gold standard noninvasive diagnostic imaging for myocarditis in combination with troponin elevation

Clinical tip: good diagnostic tool to distinguish between myocardial infarction and myocarditis

Question 2

What is the treatment for immune checkpoint inhibitor associate myocarditis?

Answer 2

Steroids

This patient is unstable, IVIG or ATG and plasma exchange

Question 3

Lesson

Answer 3

Apixaban is NOT renally dosed. THE ONLY DOAC! So can be used for ESRD

Question 4

Where is VGS normally colonized?

Answer 4

Oropharynx, GI tract and skin

Question 5

Which group within VGS is known to cause abscesses?

Answer 5

Strep anginosus

Question 6

What is the criteria for RBBB?

Answer 6

CLINICAL TIP: Look for “M” in V1-V3, “W” in lateral leads (I, aVL, V5-V6)

1) Wide QRS (>120)
2) RSR’ pattern (M) in V1-V3
3) Wide slurred S wave in the lateral leads (I, aVL, V5-V6)

Question 7

What is the axis in RBBB?

Answer 7

NORMAL! Normal activation of the left ventricle leads to normal axis since normal activation leads to a predominant vector in the down and left direction

Question 8

Explain the pathophysiology (aka sequence of activation) of the findings on EKG from RBBB?

Answer 8

1) Left ventricle is activated via the left bundle branch
2) Septal activation is normal, so Q wave is unchanged ( review: septal activation goes from left to right, hence Q waves (negative) )
3) Right ventricle depol is delayed as it originate from the LV, across the septum, going form a down and RIGHT direction. Hence, away from the lateral leads (producing a negative Slurring S wave) and toward the precordial leads (producing R’)

Question 9

How to measure R peak time?

Answer 9

Earliest sign of Q wave or R wave to the peak of R wave in aVL, V5 or V6

Question 10

What does R peak time represent?

Answer 10

Time to excitation from endocardium to epicardium in the LV

Question 11

Lesson:

Answer 11

Panoptogram good XR to eval for tooth abscesses, cause of bacteremia from oral sources e.g. strep viridans

Question 12

Lesson:

Answer 12

When holding 1604, determine if appropriate work up has been completed or consultant services have been called prior to putting pt on board

Question 13

What is the fluid resuscitation for prevention of CIN in patients at risk of CIN?

Answer 13

NS: 1ml/kg/hour for 12 hours prior and then post procedure

OR

Bicarb: 3ml/kg/hour x 1 hour prior, then 3ml/kg/hour x 6 hours post procedure

Question 14

What is the fluid of choice for prevention of CIN?

Answer 14

Bicarb or NS

Question 15

What is considered a “high grade AV Block” or “Advanced heart block”?

Answer 15

Block of 2 consecutive impulses

Question 16

What cardiac related medications should be DIScontinued for patients undergoing non-cardiac surgery?

Answer 16

Diuretics - stop day prior to surgery

ACEi and ARBS - most guidelines say stop day prior to surgery

Question 17

What are the components of the RCRI ?

Answer 17

DM on insulin
History of CVA
History of Ischemic heart disease (CAD)
History of heart failure
Cr > 2
High risk surgery (intraperitoneal, intrathoracic and suprainguinal vascular)

Question 18

What does the RCRI predict?

Answer 18

Predict 30 day risk of MI, Death and Cardiac arrest?

Question 19

What patients undergoing non cardiac surgery may it be reasonable to obtain a EKG?

Answer 19

Highest level of evidence: DO NOT obtain in low risk surgeries

Known CAD, arrhythmia, PAD, CVA or other structural heart disease that are undergoing at least intermediate risk surgery

Lowest level of evidence: asympt patients having non-low risk surgeries (aka simply all patients getting a non-low risk surgery)

Question 20

What patients undergoing non cardiac surgery may it be reasonable to obtain an ECHO?

Answer 20

Known HF and new, worsening symptoms

Known HF that is stable, but no ECHO within 1 year

Suspected valvular heart disease

Question 21

What does evaluating a patient’s MET’s help determine in regards to pre-operative testing?

Answer 21

MET < 4 and high risk surgery -> pharmacologic stress test

Question 22

What is the basic steps in evaluating a patient for preop risk assessment prior to non-cardiac surgery?

Answer 22

Is patient having ACS?

Is patient having acute cardiac emergency e.g. acute valvular disease, heart failure, etc?

Is surgery low or high risk?

What is patient’s MET?

Between 4-10: no
< 4 MET: stress test

Question 23

What are the 4 cutaneous emergencies that are always a part of each other’s differential diagnosis?

Answer 23

DRESS
AGEP (acute generalized exanthematous pustulosis)
SJS/TEN
Erythroderma

Question 24

The presence of what clinical finding makes a possible cutaneous emergency unlikely SJS/TEN?

Answer 24

Lymphadenopathy

Question 25

Of all the cutaneous emergencies, which one presents the soonest after drug exposure?

Answer 25

AGEP – can present after 48 hours

Question 26

What cutaneous emergency has the longest window of exposure after initiation of an offending drug to be at risk of developing symptoms?

Answer 26

DRESS – anywhere between 2 weeks to 6 weeks after drug intake

Question 27

What are the indications for aortic valve replacement in ASYMPTOMATIC patients with severe aortic stenosis?

Answer 27

Asymptomatic severe aortic stenosis + LVEF < 50%

Asymptomatic severe aortic stenosis + receiving cardiac surgery for another reason

Question 28

What are the indications for aortic valve replacement in SYMPTOMATIC patients with severe aortic stenosis?

Answer 28

High-gradient severe aortic stenosis

Low flow/low gradient severe aortic stenosis + LVEF < 50%

Question 29

What is considered “high gradient” in aortic stenosis?

Answer 29

If the gradient is > 40mmHg

Question 30

What is the definition of “severe aortic stenosis”?

Answer 30

Maximum aortic velocity > 4 m/second OR mean pressure gradient > 40 mmHg

OR

Aortic valve area < 1cm2 OR aortic valve area indexed to body surface area < 0.6cm2

Question 31

What is the definition of “very severe aortic stenosis”?

Answer 31

Maximum aortic velocity > 5 m/sec or mean pressure gradient > 60mmHg

TIP: the diff between mild, moderate, severe and very severe aortic stenosis is dependent on max velocity and mean gradient

HOWEVER: not always.

Question 32

What distinguishes mild, moderate, severe and very severe aortic stenosis from each other?

Answer 32

TIP: the diff between mild, moderate, severe and very severe aortic stenosis is dependent on max velocity and mean gradient - NOT just the aortic valve area

Normal: < 2 m/s and NO gradient  
Mild: 2-2.9 m/s and <20mmHg gradient  
Mod: 3- 3.9 m/s and 20-39 gradient  
Severe: > 4m/s and >40 mmHg gradient 
            - TIP: "4 and 4" rule
Very severe: > 5m/s and > 60 mmHg gradient

Question 33

What is the suggested INR range for prosthetic heart valves?

Answer 33

TIP: Mechanical requires life long (regardless of mitral vs aortic) and bioprosthetic requires initial 3-6 months of anticoagulation

Mechanical

INR 1.5-2 Mechanical On-X AVR
INR 2-3 Mechanical AVR without additional risk factors
INR 3: Mechanical AVR w/ additional risk factors OR Mechanical mitral valve

Biosprosthetic: Doesn’t matter if Mitral vs Aortic valve, INR goal 2.5 for 3-6months after placement

Question 34

How does carotid artery stenosis lead to acute CVA?

Answer 34

Breaching of the fibrous cap that overlies the atherosclerotic plaque leads to formation of thrombosis which itself can cause arterial occlusion or can be a source of emboli. These are the 2 ways that carotid artery stenosis leads to acute CVA

Question 35

What degree of carotid stenosis would warrant intervention if symptomatic for stroke?

Answer 35

70-99% if by non invasive testing

50-69% if by catheter-based imaging

Question 36

What is the difference between the antiplatelet therapy for prevention of strokes in patients with symptomatic carotid artery stenosis vs large artery ICAS (IntraCranial Atherosclerotic Stenosis)

Answer 36

CAS - mono therapy with aspirin 81 mg daily vs clopidogrel vs cilostazol

ICAS - consider DAPT - Asa 325 mg daily and Clopidogrel from Sammpris trial

Question 37

Patient’s blood culture comes back with preliminary read of “gram positive rods”. What are the 5 major genera to keep in mind when trying to guess the possible causes?

Answer 37

Bacillus e.g. B. Anthrax or B. Cereus

Clostridium e.g. C. tetani, C. Perfringens, C. Botulinum and C. Difficile

Listeria

Corynebacterium

Gardnerella

Clinical tip: Clostridium is the only anaerobic one, rest are aerobic. 2 spore forming ones are bacillus and Clostridium

Question 38

What patients with cholecystitis are candidates for percutaneous cholecystostomy (PTC)?

Answer 38

Clinical tip: too sick and high risk surgical candidate

Clinical tip: can be diagnostic of acalculous chole if patient improves after drain

Moderate acute cholecystitis - aka Grade II

• WBC > 18k
• Duration > 72 hours
• “marked inflammation”
  - biliary peritonitis
  - pericholecystic abscess
  - hepatic abscess
  - gangrenous cholecystitis
  - emphysematous cholecystitis

Severe acute cholecystitis -aka Grade III, simply requiring ICU care

    - Pressures - on pressors  
    - Brain - Loss of consciousness 
    - Kidney - Oliguria or Cr > 2 
    - Lungs - respiratory failure