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board review cards Flashcards

1
Q

rare syncope associated with palpitations.

A

frequency of sx determines choice
-wearable loop recorder– useful for palpitations accompanied by syncope/presyncope or short-lived episodes that may not be captured by patient triggered recorder.
-if sx spaced out in time-needs implantable loop recorder (2-3y)

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2
Q

patient with palpitations and WPW. Next best management

A

EP study– EPS+ablate the pathway. no ICD.

if asymptomatic with incidental WPW – exercise stress test. If they develop pre-excitation, then need EP study due to high risk of progression. if delta wave disappears it is reasssuring.

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3
Q

symptomatic with frequent PVCs (>20% burden) and bigeminy. EF drops to 40% from normal despite BB therapy.

note: no ischemia on cardiac MR.

A

PVC ablation for non-ischemic PVCs.

tx 1st line: BB/CCB
if persistent sx of LV dysfunction–> PVC ablation

PVCs can cause sx and cardiomyopathy if >10% PVC burden.

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4
Q

STEMI s/p PCI
following PCI–develops cannon a waves, otherwise asymptomatic and has accelerated idioventricular rhythm. vitals fine. next step.

A

observe.
No P waves, ventricular rhythm with rate 60-100. transient in 1st 24h after reperfusion.

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5
Q

grade 1/6 decrescendo diastolic murmur heard best over apex.

A
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6
Q

when and how to evaluate a murmur

A

always get eval when:
-diastolic murmur
-systolic 3/6 or greater
-holosystolic
-late systolic (MVP)
-symptomatic

get TTE

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7
Q

when not to evaluate a murmur

A
  1. no sx
  2. soft
  3. short but not diastolic
  4. systolic
  5. S1 and S2 normal
  6. standing or sitting (no positional component)

must meet all 6- reassure

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8
Q

management of HCM

A

stop diuretics

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9
Q

management of HCM

A

stop diuretics/avoid hypovolemia
start BB/CCB for negative inotropic effect
avoid vasodilators (such as ACEi) – worsen pressure gradient

consider:
-surgery for treatment refractory sx
-ICD for SCD prevention (not for sx)

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10
Q

murmurs with valsalva

A

decreases venous return

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11
Q

murmurs with valsalva/sit to stand

A

decrease VR

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12
Q

murmurs with stand to squat

A

increase VR/increase preload, increase AL

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13
Q

hand grip

A

ie, increases vascular resistance

increase LV afterload

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14
Q

AS

A

decrease with standing/valsalva, decrease handgrip, increase with squatting

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15
Q

HCM

A

increase with standing/valsalva and handgrip and decrease with squatting

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16
Q

MVP

A

increase with standing/valsalva
decrease with handgrip and squatting

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17
Q

ICD indications in HCM

A

prior hx of cardiac arrest or sustained VT.

Do not do this if no concerning sx, family hx, or LV wall thickness >30mm or recent unexplained syncope.

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18
Q

hx of rheumatic fever
severe MR with sx
hx of GI bleeding

A

can do medical therapy with afterload reduction for symptoms early on but ultimately needs bioprosthetic MV replacement

19
Q

severe MR

A

indications for surgery
-symptomatic (class II-IV)
-LVEF <60% or LVESD >40mm
-asymptomatic who can get it done at an experienced center

repair v replacement
repairable valve has no calcification in leaflet and no calcium in annulus. Do not pick if calcium is listed in stem.

Bioprosthetic v mechanical
-bio – recommended in patients >70 or any age for whom AC is contraindicated, cannot be managed appropriately, or not desired by patient.
-mechanical - younger (<50), or those who have other indication for AC already.
-Age 50-70 – shared decision making

20
Q

AS in asymptomatic 68yo - management
AV area 0.8cm
mean gradient of 44mmHg
EF 55%
peak gradient of 53mmHg

A

f/u ECHO in 6-12 months as asymptomatic

severe AS criteria
-AVA <1cm
-peak velocity >4m/s
-mean gradient >40
-absent A2 and late peaking murmur

Surgery performed when
-sx by hx or with exercise-testing
-LVEF>50%
-at the time of other cardiac surgery, eg if getting aortic aneurysm repaired

If not met with severe AS – f/u in 6-12 months for sx

21
Q

surveillance for bicuspid AV

A

Get CT chest for full thoracic aorta eval once bicuspid AV diagnosed
f/u after diagnosis:
-ECHO if adequate windows. If not – get CT or MRI

bAV with only mild AS without ascending aortic aneurysm – TTE every 3-5 yr
bAV and asc aortic aneurysm >4,5cm – annual TTE
more frequent if changes in sx or pregnancy – risk of increased aortic dilation and dissection in late pregnancy or postpartum.

22
Q

AR

A

diastolic decrescendo murmur at end-expiration when leaning forward.
widened pulse pressure, bounding carotid and peripheral pulses.
Austin flint murmur – low pitched mid to late diastolic rumble heard best at apex and ass with severe AR caused by AR jet abutting LV endocardium.

23
Q

MS

A

opening snap, low-pitched, mid-diastolic murmur
hx of rheumatic fever

24
Q

acute dCHF management in HFpEF

A

HFpEF
-treat underlying factors – HTN, afib/flutter, OSA, overweight, no role for mortality reducing Rxs.

25
Q

chronic HFrEF – role of device therapy
ICD

A

ICD indications
-EF <35%
-Class II-IV NYHA sx (exception is ICM with EF <30% who can get ICD even if NYHA class I)
-must be on GDMT as tolerated
-must meet timeline criteria:
-ICM:
-40d post MI if no revascularisation
-3 months if revascularisation performed

  -NICM: 3 months after diagnosis
26
Q

chronic HFrEF – role of device therapy
CRT

A

CRT – LBBB with QRS >150, EF 35% or less, sx, GDMT

27
Q

clinical pericarditis dx

A

need 2/4
-chest pain
-pericardial rub
-diffuse ST elevation, PR depression, and PR elevated in aVR
-pericardial effusion
-elevated inf markers

28
Q

pericarditis tx

A

post MI – high dose ASA

otherwise
-NSAIDs
-colchicine 0.6mg daily if <70kg or BID if >70kg x3 months
-steroids only if no other options or recurrent (increases risk of recurrence so last-line)

29
Q

tamponade

A

becks triad
pulsus paradoxus – fall of SBP >10 during inspiration
and electrical alternans on EKG
TTE:
-Diastolic RA/RV collapse
-REsp variation in MV and TV inflow - significant
-IVC dilated//plethoric

pericardiocentesis is tx, can increase preload acutely

30
Q

constrictive pericarditis

A

long-standing hx of RV failure
pericardial knock
rapid y descent
kussmaul sign – no fall in JVD on inspiration

31
Q

most appropriate test to diagnose an intrapulmonary shunt

A

TTE with bubble study

RHC with shunt run can also diagnose but not 1st step

32
Q

ASCVD risk 5-7.5%

A

CAC score – greater than 300 or greater than 75%for age should start statin
-hsCRP - above 2
-ABI below 0.9

33
Q

ordering stress test in patient with stable CP in patients with obstructive CAD

A

consider..
age
and sex

CP classification (typical, atypical or non-anginal)
-substernal of characteristic quality
-provoked by exertion or stress
-relief with rest/nitrate
–note: in women, elderly or diabetics – shoulder, epigastric pain and belching are considered chest pain

low to int: stress test
high risk: LHC

34
Q

diamond forrester classification

A

men >40 with typical CP: high risk –> LHC
women >60 with typical: high risk–>LHC
women <60 and non-anginal = low risk
otherwise intermediate

35
Q

which stress test to choose

A

can they exercise?
is EKG readable for ischemia?
-ie, no LBB, V pacing, WPW/pre-excitation, LVH with baseline 1 mm or more ST seg abnormality
-is there no need to localize the ischemic vessel or territory
-ie, if no prior stent/cabg–no need to assess viability

if all yes –> exercise treadmill ECG
if any = no –> imaging
-if able to exercise –> imaging with exercise
-otherwise, pharmacologic agents (adenosine v dobutamine)

choice between depends on contraindication profile

36
Q

tx stable angina

A

asa/statin/smoking cessation

anti-anginal meds (by line of therapy):
BB + sublingual nitro
long-acting nitrate can improve functional capacity
CCB
Ranolazine

when PCI:
change in sx or high risk stress test (ie, ST changes, hypotension on exercise)
ongoing lifestyle limiting angina despite two anti-anginal meds

37
Q

takotsubo

A

STEMI/NSTEMI mimic – Diagnosis of exclusion (ie, R/O ACS)

Dx: question stem includes recent stressor
EKG/trop suggestive of ACS/STEMI
LHC with no obstruction
APical ballooning on ventriculogram but apex akinetic and baloons out

Tx: like systolic HF if EF low
–diuretic prn
–BB/ACEi/ARB
–no heparin/ASA/antiplatelets/statins
–no role of ACs without evidence of LV thrombus
–treat underlying inciting issue

38
Q

DAPT indications

A

ACS class 1 - STEMI or NSTEMI regarless of stent type = 12 months

Stable ischemic heart disease
-DES - at least 6 months
-BMS at least 1 month

39
Q

Afib/AC

A

0/1 chadvasc - no AC
1/2-shared decision making
2/3-needs AC

AC determined by chadsvasc even after ablation

warfarin if mechanical or mod-severe MS

40
Q

antimicrobial ppx for IE

A

indications for abx ppx:
1. prior endocarditis
2. prosthetic valve or prosthetic material used for valve repair
3. cardiac trasnsplant with valvulopathy
4. unrepaired cyanotic congenital diseases
5. repaired congenital cyanotic within 1st 6 months of repair
6. repaired congenital cyanotic with residual shunt

procedures using abx pppx
-only dental work wtih gingival manipulation or perforation of oral mucosa (include routing cleaning)

amoxicillin preferred but clinda if allergic.

41
Q

tx of PAD/claudication

A

asa/statin/stop smoking
1st line for int claudication: EXERCISE program
2nd line: cilostazol (PDE3 inh which can decrease sx) but not if EF <40%/HFrEF
-similar action as milrinone which can increase mortality rates in HF patients with chronic use.

conservative medical therapy» surgery

42
Q

congenital heart disease associations

A

repaired TOF –> pulm regurgitation
-pay attention to TOF repair as child – diastolic murmur which increases with inspiration

Noonan syndrome –> pulmonary stenosis

Turner syndrome –> bAV and AC

Down: complete AV canal defect (primum ASD, inlet VSD, AV regurg).

43
Q

white coat HTN v masked HTN

A

white coat
-24h ambulatory home monitor

masked HTN
-EKG with LVH, normal office BP

board review (11 decks)

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