Board Basics Flashcards
EKG changes seen with unstable angina and NSTEMI?
- ST segment depression
- T wave inversions
Acute coronary syndromes occur due to what pathological situations?
- Coronary blood flow was disrupted
- Metabolic requirements exceed supply
Chest pain during the peripartum period
Spontaneous coronary artery dissection
What are other presentations besides chest pain that indicate ACS?
HF, pulmonary edema, shock, dysrhythmias
What are 2 signs (PE) of cardiac ischemia?
New MR murmur and S4 sound
ST-elevation equivalents?
- New LBBB
- Posterior MI (tall R waves and ST depression in V1-V4)
Indications for immediate angiography?
1) Hemodynamic instability
2) HF
3) sustained VT
4) New or worsening MR murmur
5) Refractory pain
What of the other causes of ST elevation?
- Acute pericarditis
- LV aneurysm
- Takotsubo’s cardiomyopathy
- Coronary vasospasm
- Acute stroke
- Normal variant
What is a scoring indicate and a TIMI score?
0–2: Low risk, likely will need stress test
3–7: Intermediate to high risk, will need early revascularization
What is a tool used for restratification to determine early angiography in patients with unstable angina and NSTEMI?
TIMI
Was indication for thrombolytic agents in setting of ACS? What is a “treatable” contraindication for thrombolytic therapy?
If PCI not available and will not be able to be performed within under 120 minutes. BP must be below 180/110
What is the timeline for PCI?
- 90 minutes from first medical contact and a PCI capable Health Center
- 120 minutes for first medical contact if transferred from a facility that does not have PCI capabilities
Reportedly 2 other indications for PCI in setting of ACS?
- Failure of thrombolytic therapy
- Cardiogenic shock or new HF
When should the patient not be given thrombolytic therapy if ACS suspected?
- NSTEMI
- Asymptomatic patients with onset of pain greater than 24 hours ago
A 58-year-old man with acute chest pain has ST segment elevation in leads II, III, and aVF. Blood pressure is 82/52 mmHg, and pulse rate is 54/M IN. Physical examination shows JVD, clear lungs, and no murmur or S3.
Visit diagnosis? What is the management of this patient?
RV Infarction
IV Fluids, ECG lead V4R tracing, and cardiac catheterization
Ordered further recommendations for temporary pacing the setting of acute MI?
- Symptomatic bradycardia (including complete heart block)
- Alternating LBBB and RBBB
- New or intermediate age bifascicular block with first-degree AV block
Patient recently suffered an MI approximately 4 days ago and then suddenly became hypotensive and went into cardiac arrest associated with PEA
LV free wall rupture
Post MI patient developed abrupt pulmonary edema and hypotension. Patient is noted to have a loud holosystolic murmur and thrill on physical exam.
VSD or papillary muscle rupture
All complications of acute MI occur approximately 2-7 days?
Mechanical complications (VSD, papillary muscle rupture, and LV free wall rupture)
What is the management of papillary muscle rupture and VSD?
Stabilize patient. Intra-aortic balloon pump, afterload reduction with sodium nitroprusside, diuretics followed by emergency surgical intervention
Which should post MI patient’s be screened for?
Depression
ICDs are indicated PostMI patients meeting all the following criteria:
- Greater than 40 days since MI or greater than 3 months since PCI or CABG
- LVEF less than 35% in setting of NYHA class II or III
- LVEF less than 30% in setting of NYHA class I
Symptoms and signs that increase likelihood of HF include:
1) PND
2) S3 (11 fold likelihood)
The likelihood of HF is decreased 50% by:
1) absence of dyspnea on exertion
2) absence of crackles on pulmonary auscultation
A BNP level of what is compatible with HF? What level rules out HF?
> 400; <100 unlikely to be CHF
What would the indication for endomyocardial biopsy be in setting of CHF?
If you suspect, giant cell myocarditis and sarcoidosis
Symptomatic patients with CHF and excessive daytime sleepiness should be evaluated for?
OSA
Cardiac MRI can assess for what?
hemochromatosis, sarcoidosis, and amyloidosis
What can increase BNP?
What decreases BNP?
Kidney failure, age, and female sex
Obesity
Medications to avoid in CHF?
NSAIDs
Thiazides (glitazones)
Do not implant ICD until when?
3 months of guideline directed medical therapy (or 40 days after MI)
Preferred Beta Blocker in drug-induced cardiomyopathy?
Labetalol (due to alpha blocker activity to prevent coronary vasospasm); regular beta blockers can exacerbate
Rare disease characterized by biventricular enlargement, Refractory ventricular arrhythmias, and rapid progression to cardiogenic shock and young to middle-aged adults.
Giant Cell Myocarditis
Histologic examination of giant cell myocarditis demonstrates what?
Presence of multinucleated giant cells in the myocardium
Treatment for giant cell myocarditis?
Immunosuppression and/or elevated
Definitive treatment is by cardiac transplantation
When his peripartum cardiomyopathy diagnosed?
1 month for 5 months after delivery
What medications should be avoided in Partum cardiomyopathy?
ACE inhibitors, ARB, aldosterone antagonist (eplerenone)
What other medications are indicated in peripartum cardiomyopathy if LVEF is less than 35%?
Anticoagulation with heparin to warfarin
Should valsalva maneuver increase or decrease a murmur in HCM?
Increase (increase systemic resistance and afterload)
Screening for HCM?
1st degree relatives:
1) echo
2) EKG
3) genetic testing
medications to be avoided in HCM?
- Avoid vasodilating beta-blockers (carvedilol, labetalol, and nebivolol)
- Avoid digoxin, vasodilators, or diuretics which increased LV outflow obstruction for
The LV is preload dependent
What is the indication for surgery or septal ablation in patients with HCM?
- Outflow tract gradient of greater than 50 mmHg
- Continue symptoms despite maximal drug therapy
What medication be added if significant symptoms related to LVOT obstruction remain in hypertrophic cardiomyopathy?
Disopyramide
What are the indications for beta-blockers in patients with hypertrophic cardiomyopathy?
1 ejection fraction greater than 50%
2. Dyspnea
3. Chest pain
What findings on ECG may mimic ischemia in patients with HCM?
deeply inverted, symmetric T waves in leads V3 to V6; In the apical hypertrophic form of the disease
The two categories and etiologies of restrictive cardiomyopathy?
1) normal wall size
2) increased wall thickness
Three types of restrictive CM that have normal wall thickness?
1) Hemochromatosis
2) Radiation induced fibrosis
3) Eosinophilic diseases
Heart Failure symptoms with neuropathy and signs of proteinuria, hepatomegaly, periorbital ecchymosis, bruising, and low voltage ECG
AL amyloid cardiomyopathy
Most common extrinsic causes of sinus bradycardia or what medications?
- Beta-blockers
- Donepezil
- Neostigmine
- pyriDistigmine
Common causes of inappropriate sinus bradycardia are?
- Age-related myocardial fibrosis
- Hypothyroidism
- Inferior ischemia
Indications for pacemaker?
1) Symptomatic bradycardia
2) Permanent AF with bradycardia
3) Heart Block (Mobitz II and above)
4) Alternating LBBB and RBBB
What consists of the CHADSVASC score?
2 points: prior stroke or age >75
1 point: HTN, HF
1 point: DM, Vasc
1 point: female, ages 65-74
What medication is started for atrial fibrillation control if they have comorbid, WPW syndrome?
procainamide
When is warfarin indicated in AF?
valvular AF
Definitive treatment for typical atrial flutter?
catheter ablation
What is the classic ventricular rate of atrial flutter?
150 bpm due to 2:1 conduction ratio
When is VTE prophylaxis used post-discharge from hospital?
Postdischarge prophylaxis (up to 5 weeks)
1) Hip Fracture
2) Knee and Hip Replacement
3) Major Cancer Surgery
What score of zero eliminates the need for D-dimer testing or CTA?
PERC (Pulmonary Embolism Rule-Out) Score
What score from Well’s criteria indicates further testing for thrombus?
Well’s DVT (>1) or Well’s PE (>4) will need Duplex US or CTA, respectively
Low probability <1, <4 = D-dimer
Treatment of Superficial Vein Thrombophlebitis?
Supportive Care (Analgesia, warm compresses, and NSAIDs); if symptoms persist, image
When to A/C for superficial vein thrombosis?
> 5cm, close to deep venous system, or other risk factors exist
Distal Leg DVT
Asymptomatic
- Monitor with serial duplex US within 1-2 weeks
- 3-6 months of Eliquis or Xarelto
Proximal Leg DVT or PE
-Provoked tx duration?
-Unprovoked?
-Recurrent?
-3-6 months
-Extended
-Depends (whether provoked or unprovoked)
Indications for tPA in DVT/PE
1) massive DVT with either acute limb ischemia, severe edema, and/or venous insufficiency
Right-sided heart murmurs increase in intensity with work?
Inspiration
Hypertrophic cardiomyopathy murmurs increase intensity with what?
valsalva and on standing from squatting position
What heart murmur is described as a clinic and moves closer to S1 with a murmur lengthening with Valsalva maneuver and on standing from a squatting position?
Mitral valve prolapse
Fixed splitting occurs with ASD, VSD, and what other 2 causes?
RBBB, pulmonary valve stenosis
Paradoxical splitting occurs under what 3 manifestations?
LBBB, HCM, and severe AS
Signs of serious cardiac disease on cardiac physical exam include: (For characteristics)
- S4
- Murmur grade greater than 3/6 intensity
- Continues murmurs
- Any diastolic murmur
- Abnormal splitting of S2
What are the 3 different criteria that constitutes severe aortic stenosis?
- Aortic area of less than 1 cm²
- Aortic jet velocity (Vmax) greater than 4 m/s
- Mean transaortic pressure gradient greater than 40 mmHg
What are the 3 indications for aortic valve replacement and severe AS?
- Symptomatic: Syncope, presyncope, angina, and dyspnea
- Ejection fraction less than 50%
- A contaminant cardiac surgical procedure further indications
When is TAVI preferred over SAVR for symptomatic patients with severe AS?
- Age greater than 80 years
- Neuner patients with less than 10 years life especially
- Any age with a higher probability of surgical risk
MCC of hypercalcemia in the outpatient setting?
Primary Hyperparathyroidism
MCC of hypercalcemia in the inpatient setting?
Malignancy
Symptom presentations of hypercalcemia (non-incidental findings)?
1) Kidney Stones
2) Osteoporosis
3) Fractures (Osteopenia)
4) Pancreatitis
