Cardio

Question 1

Acute autoimmune inflammatory multi-systemic illness sequela of a beta-hemolytic streptococcal infx of the pharynx

Answer 1

Rheumatic fever

Question 2

Pathophys of Acute rheumatic fever

Answer 2

Symptomatic or asymptomatic infection with Group A Streptococcus (aka Strep pyogenes) stimulates antibody production to host tissues & damages organs directly

Children 5-15 years old

Question 3

Major criteria for acute rheumatic fever

Answer 3

JONES = Joint (migratory polyarthritis), Oh (active carditis), Nodules (Subcutaneous), Erythema marginatum (macular erythematous non pruritic annular rash), Sydenham’s chorea

Question 4

Minor criteria for acute rheumatic fever

Answer 4

Arthralgia

Fever 101.3 +

EKG = prolonged PR

Elevated CRP/ESR

Leukocytosis

Question 5

Dx of acute rheumatic fever

Answer 5

Jones criteria for rheumatic fever – 2 Major OR 1 Major + 2 Minor PLUS Supporting evidence of recent strep infx

Question 6

Tx of rheumatic fever

Answer 6

Anti-inflammatory: Aspirin (2-6 weeks with taper) +/- corticosteroids in severe cases & carditis

Penicillin G – antibiotic of choice (or erythromycin if PCN allergic) both in acute phase & after acute episode

Prevention is the most important therapeutic course – therefore all patients should be treated w/ abx

Question 7

Biggest complication from rheumatic fever

Answer 7

Rheumatic valve dz = mitral (75-80%), aortic (30%), tricuspid & pulmonic (5%)

Question 8

Abnormal opening in the atrial septum between the right & left atrium → volume overload of right atrium & ventricle

Answer 8

Atrial septal defect

Question 9

MC type of atrial septal defect

Answer 9

ostium secundum

Question 10

2nd MC congenital heart dz

Answer 10

Atrial septal defect

Question 11

Sx of atrial septal defect

Answer 11

Infants & young children: recurrent respiratory infx, failure to thrive, DOE

Adolescents & young adults: exertional dyspnea, easy fatigability, palpitations, atrial arrhythmias, syncope, heart failure

Over 30 – dyspnea & chest pain, over 50 – afib & RVF

Question 12

PE findings of atrial septal defect

Answer 12

Systolic ejection crescendo-decrescendo flow murmur @ pulmonic area (LUSB – 2nd or 3rd intercostal space)

Wide, fixed split S2 that does not vary with respirations, loud S1 & hyperdynamic right ventricle

Question 13

Dx of Atrial septal defect

Answer 13

Echo = best test

Question 14

Tx of ASD

Answer 14

Small ASD < 5mm may be observed (most small ASD spontaneously close in the first year of life)

Symptomatic treatment: Diuretics, ACE inhibitors, digoxin

Surgical correction: 1cm+/symptomatic (between 2-4 y/o) → perQ transcatheter closure v. surgical intervention

Question 15

Persistent communication between the descending thoracic aorta & main pulmonary artery after birth

Answer 15

Patent ductus arteriosus

Question 16

Pathophys for PDA

Answer 16

Continued prostaglandin E1 production & low arterial oxygen content promotes patency

Question 17

Acyanotic vs cyanotic heart disease

Answer 17

Acyanotic = defect in which oxygen levels delivered to the body remain normal = VSD, PDA, ASD, AV Canal

*VSD = MC Acyanotic type

Cyanotic= Transposition of great arteries, terat of fallot, tricuspid valve abnormalities

Question 18

Continuous machine-like or “to and fro” murmur loudest @ pulmonic area (LUSB – 2nd intercostal space)

Answer 18

PDA

Question 19

Congenital narrowing of the aortic lumen at the distal arch &/ descending aorta, 2x M>F

Answer 19

Coarctation of aorta

Question 20

Coarctation associated with

Answer 20

Often associated with bicuspid aortic valve (supposed t be 3 not 2) (50% of patients), mitral valve defects, patent ductus arteriosus & Turner syndrome

Question 21

Sx of coarctation of aorta

Answer 21

Bilateral claudication, dyspnea on exertion, syncope

Neonatal presentation: failure to thrive in infants, poor feeding 1-2 weeks after birth

Question 22

Late systolic ejection murmur/continuous murmur radiating to the left back, left scapula or chest, heard in the aortic area

Answer 22

Coarctation of aorta

Question 23

Upper extremity systolic HTN with lower extremity hypotension &/ diminished/delayed lower extremity pulses (femoral & dorsalis pedis pulse)

Answer 23

Coarctation of aorta

Question 24

Tx of coarctation of aorta

Answer 24

Corrective surgery or transcatheter-based intervention (eg. Balloon angioplasty w/ or w/out stent placement) preferably in early childhood (between 2 and 4 years)

Emergent surgical repair performed in cases of circulatory shock, cardiomegaly, severe HTN, severe CHF

Prostaglandin E1 (Alprostadil) preoperatively to stabilize the condition – maintains a patent ductus arteriosus, reducing symptoms @ improves lower extremity blood flow

Untreated? Most adults die by 50 y/o d/t aortic rupture, CVA, or aortic dissection

Question 25

MC cyanotic congenital heart disease (associated with a right-to-left shunt d/t pulmonary stenosis)

Answer 25

Teratology of fallot

Question 26

Pathophys of tetralogy of fallot

Answer 26

**Constellation of:** **1) pulmonary stenosis (RV outflow obstruction)** **2) RV hypertrophy** **3) large unrestrictive VSD** **4) overriding aorta**

Question 27

RF of tetralogy of fallot

Answer 27

Risk factors: genetic & environmental factors – associated with **chromosome 22 deletion**

Question 28

Sx of teratology of fallot

Answer 28

**Infancy: cyanosis most common presentation (blue baby syndrome)** **Tet spells relieved with putting knees to chest in infancy** **Older children: exertional dyspnea, cyanosis that worsens with age** Tet spells – paroxysms of cyanosis relieved with squatting (squatting decreases rightto-left shunting, improving oxygenation); develop during crying/feeding

Question 29

harsh systolic murmur @ left mid to upper sternal border (VSD), right ventricular heave (RVH), digital clubbing, cyanosis

Answer 29

Tetralogy of fallot

Question 30

Tx of Tet of fallot

Answer 30

**Surgical repair – ideally in first 4-12 months of life** Prostaglandin infusion prior to surgery to maintain a patent ductus arteriosus – improve circulation Prophylaxis for bacterial endocarditis

Question 31

MCC of sudden cardiac death in young athletes in the US

Answer 31

Hypertrophic cardiomyopathy

Question 32

Tx of hypertrophic cardiomyopathy

Answer 32

Focus on early detection, medical tx, surgical tx, & or ICD placement ## Footnote **Medical: beta blockers 1st line medical management**

Question 33

Hole in the ventricular septum, assoc. w/ left-to-right shunt

Answer 33

**Ventricular septal defect**

Question 34

MC type of congenital heart dz in childhood

Answer 34

VSD

Question 35

What is Eisenmenger syndrome

Answer 35

VSD with large (unrestricted) defects may eventually develop a right to left shunt

Question 36

MC type of VSD

Answer 36

**Perimembranous: most common type – hole in the LV outflow tract near the tricuspid valve** Muscular: usually multiple holes in a “swiss cheese” pattern Inlet (posterior): located posterior to the septal leaflet of the tricuspid valve Supracristal (outlet): beneath the pulmonic valve, may have aortic valve insufficiency

Question 37

PE findings of VSD

Answer 37

**High-pitched harsh holosystolic murmur best heard @ lower left sternal border** Smaller VSDs usually louder & associated w/ more palpable thrills than larger ones

Question 38

Dx and Tx of VSD

Answer 38

**Dx = Echo** Tx = Observation: in small, symptomatic VSDs (must close within 12 months) Patch closure: symptomatic infants or uncontrolled CHF, growth delay, recurrent respiratory infections **Large shunts repaired by 2 years to prevent pulmonary HTN**

Question 39

Medium & small vessel necrotizing vasculitis including the coronary arteries

Answer 39

Kawasaki dz

Question 40

Pathophys Kawasaki

Answer 40

**Mucocutaneous vasculitis d/t vessel wall infiltration w/ mononuclear cells & later IgA secreting plasma cells** → destruction of tunica media & formation of aneurysms Unknown cause: increased risk with **advanced maternal age, mother of foreign birth**, group B strep, early infancy hospitalization d/t infx for bacterial cause, an unidentified respiratory agent/viral pathogen with propensity towards vascular tissue

Question 41

Sx of Kawasaki - Warm + Cream

Answer 41

**Warm + CREAM** = Fever \>5 days + 4 out of 5 of the following: **Conjunctivitis** **Rash** (erythematous or morbilliform or macular) **Extremity changes:** edema, erythema, or desquamation of palms & soles; Beau’s lines (transverse nail grooves), arthritis **Adenopathy** (cervical) **Mucositis:** strawberry tongue, lip swelling, fissures, pharyngeal erythema

Question 42

Tx of Kawasaki

Answer 42

**IV immunoglobulin** + aspirin for fever, joint pain, & prevention of coronary complications; Recurrent: 2nd dose IVIG +CS x3d

Question 43

Complications of Kawasaki

Answer 43

Coronary vessel arteritis: coronary artery aneurysm (20% of pts not given tx), MI, pericarditis, myocarditis