Cardio Flashcards
1
Q
What are the 2 different methods of detecting ischemia in an unclear EKG?
A
Nuclear isotope uptake or ECHO are 2 best methods for detecting ischemia and EQUAL in terms of sensitivity and specificity
2
Q
Difference between ischemia and infarction on isotope uptake and echo?
A
Ischemia is decreased perfusion and will be detected by seeing REVERSAL of the decrease uptake or wall motion that will return to normal after a period of rest
3
Q
Where must you avoid dipyridamole for medication stress test?
A
Asthmatics; PDE5 inhibitor–> Increase cAMP–>Increase bronchospasm
4
Q
What is used with nuclear isotope uptake for non-exercise stress test?
A
Dipyridamole or adenosine
5
Q
What is used with ECHO for non-exercise stress test?
A
Dobutamine
6
Q
Cardiac test workup
A
Chest pain–> EKG–>Exercise stress test–> If EKG not clear, exercise or medication thallium or echo–>Coronary angiography determines if no catheterization or catheterization (bypass vs angioplasty vs meds alone)
7
Q
Most accurate test for CAD
A
Angiography
8
Q
Management for >70% stenosis on angiography:
1) 1-2 vessel disease
2) 3 vessel disease, left main or 2 vessel disease in diabetics
A
1) PCI (stent)
2) CABG
9
Q
What is Holter monitor used for and how long?
A
Generally 24 hour period and mainly detecting rhythm disorders where it is NOT ACCURATE for evaluating ST segment or ischemia
10
Q
Chronic stable anginal medications that lower mortality
A
Aspirin, B-blockers
11
Q
Difference in Nitroglycerin administration in chronic stable angina vs. ACS (unstable, NSTEMI, STEMI)?
A
Chronic stable-patch or oral
ACS-sublingual, paste, IV forms
12
Q
What should patients with ACS receive when arriving to ER?
A
2 antiplatelet medcations-combination of aspirin and P2Y12 inhibitors (prasugrel, clopidogrel, ticagrelor)
13
Q
What P2Y12 ihibitor useful when angioplasty and stenting planned?
A
Prasugrel (best evidence) or ticagrelor (restenosis of stenting best prevented by these two compared to clopidogrel)
14
Q
When is clopidogrel used?
A
1) ACS along with aspirin
2) Aspirin intolerance such as allergy
3) Recent angioplasty with stenting (decreases restenosis from stenting but INFERIOR to other 2 antiplatelets)
15
Q
What population is prasugrel dangerous for?
A
> 75 b/c of hemorrhagic stroke risk
16
Q
Use of ticlodipine?
A
Patient INTOLERANT of both aspirin and clopidogrel
17
Q
Side effects ticlodipine?
A
Neutropenia and TTP
18
Q
Where do ACE inhibitors have best mortality benefit?
A
Low EF/systolic dysfunction w/ CHF symptoms by decreased preload AND afterload
19
Q
What can you switch someone to if ACE inhibitor not tolerable for CHF?
A
Hydralazine (decrease afterload) and nitrates (decrease preload)
20
Q
When do you use statin?
A
1) CAD with ANY LDL
2) CAD with LDL>100 and CAD w/ diabetes with LDL>70
21
Q
What are some CAD equivalents?
A
PAD, Aortic disease, carotid disease, diabetes, stroke
22
Q
What drug provides definite mortality benefit for management of hyperlipidemia?
A
Statin
23
Q
Niacin use?
A
Adjunct to statin to decrease LDL. Also, increases HDL and decreases triglycerides
24
Q
Niacin side effects?
A
Hyperglycemia (glucose intolerance), Hyperuricemia, pruritis (from histamine release)
25
Fibrates use?
Help severely decrease triglycerides
26
Fibrates side effect?
Myositis (especially with statin use)
27
Bile acid resins (eg cholestyramine) use?
Decrease LDL secondary to decreased bile acid absorption so liver must make more cholesterol to help absorb bile
28
Bile acid resins side effects?
GI upset (decrease absorption of other drugs and fat soluble vitamins)
29
Ezetimide use?
Decrease LDL w/o any evidence of actual benefit to patient.
30
What do you use if you have statin intolerance?
Ezetimibe
31
Ezetimide side effects?
Rare increase LFT, diarrhea
32
Do DHP CCB decrease mortality in CAD?
No. Might actually increase mortality from reflex tachycardia leading to increase myocardial oxygen consumption specifically in DHP type
33
When should you used non-DHP CCB for CAD?
1) Severe asthma precluding use of beta blockers
2) Prinzmental angina
3) Cocaine induced chest pain
4) Inability to control pain with maximum medical therapy
34
CCB Adverse effects?
Edema, constipation, heart block
35
Best therapy for ACS?
PCI (angioplasty) provides greatest mortality benefit
36
What two treatments are equal in chronic stable angina in terms of mortality benefit?
PCI=Maximum medical therapy (aspirin, B-blocker, ACEi, statins)
37
Two causes of PMI displacement?
1) LVH
| 2) Dilated cardiomyopathy
38
V1, V2 leads?
II, III, aVF leads?
V2-V4 leads?
1) Posterior (unique cause ST depression here would be like ST elevation elsewhere-->acute infarction)
2) Inferior
3) Anterior (30-40% mortality) associated with acute MI
39
What should treatment of PVCs be when associated with acute infarction?
Nothing. Only worsens outcome
40
Patients with MI should be given aspirin within what time and angioplasty within what time and thrombolytics?
- Aspirin 30 minutes within onset
- Angioplasty (within 90 minutes of entering door)
- Thrombolytics (within 30 minutes of entering door where benefit extends out to 12 hours from onset of chest pain)
41
Why is ICU monitoring for MI important?
Ventricular arrhythmia common post-MI and rapid performance of electrical cardioversion or defibrillation is available
42
What are complications of PCI?
1) Restenosis (thrombosis) of vessel after angioplasty
2) Rupture of coronary artery on inflation of the balloon
3) Hematoma at site of entry into the artery (eg femoral area hematoma)
43
What drugs are used in drug-eluting stent and how does it work?
Drugs-Paclitaxel, siroliumus
| MOA: Inhibit local T cell response markedly reducing rate of restenosis
44
1) Warfarin is for ___
| 2) Aspirin is for ___
1) Veins
| 2) Arteries
45
How is angioplasty superior to thrombolytics?
1) Survival/mortality benefit
2) Fewer hemorrhagic complications
3) Likelihood of developing complications of MI (less arrhythmia, less CHF, fewer septum ruptures, free all (tamponade) and papillary muscles (valve rupture))
46
Absolute contraindications to thrombolytics? (4)
1) Major bowel bleeding (melena) or brain (any CNS bleed). Heme positive NOT contraindication
2) Surgery in last 2 weeks
3) HTN >180/110
4) Non-hemorrhagic stroke in last 6 months
47
When is heparinuse good for ACS?
ST depression that helps PREVENT clot forming (best next step after aspirin). LMWH>unfractionated heparin in terms of mortality benefit
48
When is tPA (thrombolytics) use good for ACS?
STEMI or LBBB that helps BREAK clots
49
When are GPIIb/IIIa inhibitors used?
NSTEMI who are to undergo angioplasty and stenting
50
When is urgent angiography and possible angioplasty in NSTEMI ACS indicated?
- Persistent pain
- S3 gallop or CHF developing
- Worse EKG changes or sustained VTACH
- Rising troponin levels
51
Treatment of symptomatic bradycardias post-MI?
1) Atropine
| 2) Pacemaker IF atropine ineffective
52
What areas does RCA serve?
1) RV
2) AV node
3) Inferior wall of heart
53
Treatment of RV infarction and what should you avoid?
Treat-high-volume fluid replacement
| Avoid-Nitroglycerin (worsen cardiac filling)
54
Treatment of tamponade/free wall rupture?
Emergency pericardiocentesis
55
How can you tell about valve/septal rupture?
New onset of murmur (either apex (MR) or LLSternalborder(VSD) and pulmonary congestion
56
Most accurate test for valve and septal rupture?
Echocardiogram
57
What test can be used to determine septal rupture?
Oxygenation changes from right atrium increasing to right ventricle
58
What is an intraaortic balloon pump?
Contracts and relaxes in sync with natural heartbeat serving as a bridge to valve or transplant surgery
59
How do you differentiate 3rd degree AV block vs. sinus bradycardia?
Presence of cannon A waves in 3rd degree AV block
60
Why do you do post-MI stress test?
Determine those with residual ischemia and have opportunity to determine if angiography is needed for additional reversible revascularization
61
Do you give prophylactic antiarrhythmics post-MI?
NO. They just increase mortality
62
What is most common drug to cause ED post-MI
B-blocker; most common cause overall is from anxiety
63
Does patient have to wait after MI to reengate in sexual activity?
NO may begin immediately
64
What is MCC of CHF?
Hypertension
65
What are vast majority (95%) of causes of systolic CHF?
Infarction, cardiomyopathy, and valve disease
66
What is most accurate test for CHF even though it is rarely done?
Endomyocardial biopsy
67
Most common presenting sign of CHF?
Dyspnea
68
What is the significance of S3/S4 gallop?
S3-rapid filling of blood backed up into LV
| S4-Atrial systole into stiff or noncompliant ventricle.
69
What heart sound is present in CHF?
S3 gallop
70
What is circumoral numbness?
Numbness around mouth. Happens when you lower Ca2+ leading to premature depolarization and feeling of numbness around mouth
71
Presence of palpitations, syncope
Arrhythmia of almost any kind
72
Dullness to percussion at bases
Pleural effusion
73
What is most important test to CHF?
ECHO. Allows for EF evaluation
74
Best initial test for EF?
Transthoracic echo
75
Most accurate test for EF?
MUGA (multiple-gated acquisition scan) or Nuclear ventriculography
76
When should you use nuclear ventriculography?
Patients on chemo with doxorubicin. Need to give max chemo but don't want to cause cardiomyopathy
77
When is BNP testing right answer for CHF?
Acute dyspnea with unclear etiology and can't wait for echo to be done (normal BNP EXCLUDES pulmonary edema)
78
First line tx. for systolic CHF?
ACE inhibitors
79
What is MCC death in CHF?
Arrhythmia secondary to ischemia leading to death
80
What drug has been shown to decrease mortality in addition to ACE inhibitor?
Spironolactone
81
Adverse effects spironolactone?
Hyperkalemia/gynecomastia
82
What can you use instead of spironolactone to prevent anti-androgenic effects?
Eplerenone
83
Do diuretics lower mortality in CHF patients?
No. Spironolactone is technically a diuretic but not used at diuretic doses
84
Does digoxin lower mortality for CHF patients?
NO. Used to control symptoms of dyspnea and in fact no positive inotrope has been shown to lower mortality.
85
What drugs provide mortality benefit in systolic dysfunction?
ACE/ARB, B-blocker, Spironolactone/eplerenone, hydralazine/nitrates, implantable defibrillator
86
What is the indication of an implantable defibrillator?
Ischemic cardiomyopathy and EF
87
When is biventricular pacemaker indicated?
Dilated cardiomyopathy, EF120 ms
88
How do you manage diastolic CHF?
B-blockers and diuretics provide clear benefit. Digoxin and spironolactone NOT beneficial. ACE/ARB and hydralazine are uncertain.
89
What drugs can worsen HOCM?
Diuretics (Decrease preload--> Increase obstruction and worsening symptoms), positive inotropes, vasodilators
90
What symptom indicates worst, or most severe form of CHF?
Pulmonary edema
91
Why is hypoxia expected in CHF?
Presence of respiratory alkalosis because of hyperventilation
92
What is best test to do acutely for pulmonary edema?
EKG (b/c can lead to change in therapy if different underlying cause besides CHF exacerbation as cause like arrhythmias)
93
Best initial therapy for acute pulmonary edema?
IV furosemide
94
What other therapies for initial acute pulmonary edema?
Oxygen, morphine, nitrates.
95
What if initial acute pulmonary edema therapy does not work?
Dobutamine can be used in acute setting (increase contractility and decrease afterload).
96
Can digoxin be used for acute pulmonary edema in CHF?
NO. Takes several weeks to work and no role in acute setting
97
What lesions are louder with inhalation/exhalation?
Inhalation-Rt. sided lesions (increased venous return to right side of heart)
Exhalation-Lt. sided lesions (increased blood flow to left side of heart)
98
Best initial test for valvular heart disease?
Transthoracic echo, with TEE more accurate than TTE
99
Most accurate test for valvular heart disease?
Catheterization (precise measurement of valvular diameter and exact pressure gradient across valve)
100
Why will ALL valvular heart disease patients benefit from diuretics?
All of them associated with fluid overloaded state
101
Best treatment for stenosis?
Mitral stenosis-balloon because this is fibrous tissue
| Aortic stenosis-surgical removal because this is calcified tissue
102
Best treatment for regurgitant lesions?
Vasodilator therapy (ACEi/ARB, nifedipine, hydralazine)
103
When does treatment of regurgitant lesions change from medical management?
When heart dilates excessively, 55 mm for aortic and 40 mm for mitral
104
Most common symptoms in all forms of valvular heart disease
Dyspnea and CHF
105
Symptoms of MS that are unique?
Dysphagia, hoarseness, AFIB and stroke (from enormously large LA), hemoptysis (from back flow of blood into lungs bursting lung blood vessels)
106
What part of murmur signifies worsening MS?
Earlier opening snap
107
EKG findings in AFIB
Biphasic P waves in leads V1 and V2
108
Mitral stenosis treatment (4)
1) Diuretics and sodium restriction
2) Balloon valvuloplasty with catheter
3) Warfarin for AFIB (2-3 INR)
4) Rate control with (digoxin, B-blocker, Ca2+ channel blocker)
109
Aortic stenosis triad
Angina (most common presentation)
Syncope
Dyspnea (CHF)
110
Type of murmur in AS
Crescendo-decrescendo systolic ejection murmur "diamond shaped" radiating to carotid arteries
111
What maneuvers decrease AS murmur?
Valsalva, standing (both decrease preload) or handgrip (decreases ejected blood amount)
112
What maneuvers increase AS murmur?
Squatting/leg raising
113
How is cardiac enlargement defined on CXR?
Heart greater than 50% of the total transthoracic diameter.
114
What is underlying cause of MR?
Heart dilation
115
What is in MR murmur?
Holosystolic high pitched blowing murmur that obscures both S1 and S2 with radiation to the axilla.
116
What maneuvers worsen murmur?
Handgrip, squatting/leg raising (increased venous return), expiration (increased bloodflow to left heart)
117
Treatment of MR?
1) ACE/ARBi best
118
When do you replace valve in MR?
LVESD>40 mm or EF
119
Explain physiology for vasodilators (ACE/ARB) used for regurgitant lesions?
With vasodilation-->less pressure on heart-->easier for forward flow-->less regurgitation
120
Besides CHF, what other unique physical findings found for AR?
Wide pulse pressure (150-60/50-60), Water-hammer bounding pulse, quincke pulse (pulsations in nail bed), hill sign (BP in legs as much as 40 mmHg above arm BP), head bobbing (de musset sign)
121
Murmur of AR?
Diastolic, decrescendo murmur
122
What worsens AR murmur?
Handgrip
123
When do you replace valve in AR?
LVESD>55 mm or EF
124
What makes AR murmur better?
valsalva and standing (decreased preload)
125
What is unique about symptoms of MVP murmur?
Symptoms of CHF usually absent. Presents with atypical chest pain, palpitations, panic attack
126
Murmur of MVP?
Late systolic crescendo murmur with midsystolic click (due to sudden tensing of chordae dendineae)
127
What makes sound of MVP better/worse?
Better-Squatting/handgrip/leg raising
| Worsen-Valsalva and standing
128
MVP treatment
- B-blockers when symptomatic
| - Valve repair placing clip to tighten the valve.
129
Dilated cardiomyopathy has what other features?
Systolic dysfunction and low EF
130
Hypertrophic cardiomyopathy has what other features?
Diastolic dysfunction
131
What drug is involved in the treatment of all types of cardiomyopathy?
Diuretics
132
Best initial and most accurate test for cardiomyopathy?
Echocardiography
133
What drugs lower mortality in dilated cardiomyopathy?
- ACE/ARB
- B-blocker (ie metoprolol/carvedilol)
- Spironolactone
- Automated implantable cardioverter/defibrillator (some patients)
134
Why is spironolactone given?
Decrease afterload and decrease RAAS; not used as a diuretic
135
MCC hypertrophic cardiomyopathy?
HTN
136
MCC dilated cardiomyopathy?
MI/Ischemia
137
PE findings for dilated cardiomyopathy?
Symptoms of HF, S3 systolic regurgitant murmur
138
PE hypertrophic cardiomyopathy?
S4, systolic murmur
139
PE hypertrophic OBSTRUCTIVE cardiomyopathy?
dyspnea, chest pain, syncope, SCD, symptoms worsened by anything that increases heart rate or decreases left ventricular chamber size
140
What is best initial therapy for HOCM and ordinary HCM?
B-blockers (Decreasing HR is an important factor)
141
EKG changes in HOCM?
Septal Q waves in inferior and lateral leads; tall R wave in aVL + deep S wave in V3
142
Tx. of HOCM? (3 in order of best to last option)
1) Implantable defibrillator
2) Septum ablation
3) Surgial myomectomy
143
Differences in therapy with dilated and hypertrophic cardiomyopathy?
Both-B-blocker and diuretics
| Dilated-ACE/ARB, digoxin, spironolactone
144
Symptoms of Restrictive cardiomyopathy?
Dyspnea. RHF symptoms (ascites, edema, JVD, liver and spleen enlargement, Kussmaul sign)
145
How can you detect amyloid?
Speckling of septum on echo or cardiac MRI?
146
standing and valsalva are similar to using what drug?
Diuretic. So MVP and HOCM gets worse with this drug and those maneuvers.
147
Amyl nitrate acts where?
Arteriolar vasodilator
148
Handgrip and amyl nitrate have no meanigful effect on what murmur?
Mitral stenosis
149
Handgrip has what effect on MVP and HOCM?
Decreases (a bigger, fuller heart improves the symptoms)
150
MCC of pericarditis?
Viral infection
151
Tx of pericarditis and prophylaxis (for majority of cases that are viral)
Tx for other causes
Tx-NSAIDs
Prophylaxis-Cochicine
Tx for other causes: Underlying cause
152
EKG of pericarditis
- ST elevation all leads
| - PR depression (most specific finding)
153
What is most likely diagnosis with hypotension, tachycardia, distended neck veins and clear lungs?
Pericardial effusion
154
EKG of cardiac tamponade?
Electrical alternans (different heights of QRS complexes between beats)
155
What should you not give to patients during tamponade?
Diuretics (Decrease intracardiac filling--> increased chance of right side of heart to collapse)
156
What is constrictive/restrictive pericarditis?
Calcification and fibrosis due to chronic pericarditis that prevents filling of the right side of the heart. (eg TB)
157
What physical findings will be present for constrictive/restrictive pericarditis?
Kussmaul sign (increased JVD on inhalation), Pericardial knock (extra heart sound in diastole from ventricular filling against rigid pericardium), signs of RHF (peripheral edema, ascites, elevated JVP (>8 cmH20), + hepatojugular reflux )
158
Best initial test and most accurate test for constrictive pericarditis?
Best initial: CXR
| Most accurate: CT/MRI
159
Why is echo not useful in constrictive pericarditis?
Normal movement of myocardium is present
160
Tx. for constrictive pericarditis? (2)
1) Diuretics (decompress filling and relieve) symptomatic relief
2) Surgical removal of pericardium (pericardiectomy)
161
Best initial/Most accurate for PAD
Best initial-ABI
| Most accurate-Angiogram
162
Range of tests for ABI
1.3-abnormal with possible calcified and incompressible vessels
163
Tx. PAD
1) Aspirin
2) Stopping smoking
3) Cilostazol
164
Most effective PAD medication
Cilostazol (PDE inhibitor that inhibits platelet aggregation and is a direct arterial vasodilator)
165
When is surgery for PAD an option?
When maximum medical therapy is not effective
166
Key features of presence for aortic dissection
1) Pain in between scapulae
| 2) Difference in pressure between arms (>20 mmHg pressure difference)
167
Best initial test/most accurate for aortic dissection
Best initial-CXR
| Most accurate-CT angiogram w/ contrast and TEE (if patient has ARF)
168
Aortic dissection treatment
Stanford Type A-Surgery
| Stanford Type B-B-blocker followed by nitroprusside. Needs to be in this order to prevent reflex tachy
169
AAA screening guidelines
>65, male, smoker; U/S 1 time screening
170
What is most dangerous heart disease for pregnant women?
1) Peripartum cardiomyopathy (antibodies to heart in pregnancy) with LV dysfunction most commonly after pregnancy with medical management as dilated cardiomyopathy.
2) Eisenmenger syndrome (patient who has VSD)
171
What is Duke criteria for infectious endocarditis?
Gives definitive diagnosis:
- 2 major + 1 minor
- 1 major + 3 minor
- 5 minor
172
What are major criteria for Duke for endocarditis?
MAJOR
- + blood culture
- typical blood culture microorganism on 2 separate cultures (S. aureus, viridans streptococci, s pidermidis, s bovis)
- Evidence of endocardial involvement
173
What are minor criteria for Duke for endocarditis?
MINOR
- Predisposing heart condition or IV drug abuse
- Fever >38 C
- Vascular phenomenon
- Immunologic phenomenon (glomerulonephritis, osler nodes, roth spots)
- Microbiology evidence: + blood culture, but not meeting major criterion as previously noted
174
AV block with infectious endocarditis should raise suspicion for what?
Perivalvular abscess extending into adjacent cardiac conduction tissues pathways
175
Treatment of viridans group strep during endocarditis and duration?
IV penicllin or IV ceftriaxone for 4 weeks
176
Best initial test endocarditis?
Blood culture
177
Best initial empiric therapy?
Vancomycin and gentamicin
178
S. aureus endocarditis (sensitive) tx. ?
Oxacillin, nafcillin, or cefazolin
179
Fungal endocarditis tx.?
Amphotericin and valve replacement?
180
S. epidermis or resistant staph endocarditis?
Vancomycin
181
Enterococci endocarditis?
Ampicillin and gentamicin
182
When do you most commonly see viral pericarditis?
After upper URI
183
Cause of pericardial effusion in viral pericarditis?
Pericardial membrane inflammation causes extra fluid within pericardial cavity leading to effusion and compression of cardiac chambers
184
What happens with pericardial effusion pathophys?
Decreased preload-->decrease CO-->hypotension and syncope
185
Becks triad of cardiac tamponade?
Hypotension, distended neck veins and muffled heart sounds?
186
What happens to blood pressure on inspiration in tamponade and what causes it?
Pulus paradoxus (>10 mm Hg drop in systolic blood pressure during inspiration) b/c interventricular septum moves toward left ventricular cavity that reduces left ventricular preload, SV, and CO.
187
What is management of uremic pericarditis?
Urgent hemodialysis
188
Most commonly presenting sign of uremic pericarditis?
Fever
189
Cause and Clinical features of rheumatic fever?
Group A B-hemolytic streptococci. JONES (Joints (migratory arthritis), O (pancarditis), Nodules (subcutaneous), Erythema marginatum, Sydenham chorea
190
Prophylaxis for rheumatic fever?
IM benzathine penicillin G every 4 weeks
191
Prophylaxis (rheumatic fever w/o carditis)
Abx for 5 years or until 21 years old (whichever is longer)
192
Prophylaxis (rheumatic fever w/ carditis but no residual heart or valvular disease)
Abx for 10 years or until 21 years old (whichever is longer)
193
Prophylaxis (rheumatic fever with carditis and persistent heart or valvular disease)
Abx for 10 years or until 40 years old (whichever is longer)
194
Where is pulsus paradoxus seen besides tamponade?
Severe asthma/COPD
195
Findings on echocardiogram of viral myocarditis?
Dilated ventricles and diffuse hypokinesia resulting in systolic dysfunction (low EF)-->dilated cardiomyopathy
196
Why don't you see ECG changes in uremic pericarditis?
No involvement of epicardium
197
Causes of pericarditis?
Idiopathic (most common; presumed viral after URI), Viral (coxsackie B virus), autoimmune (SLE, RA), neoplasia, uremia, post-MI (Dressler), radiation
198
When does uremic pericarditis typically occur?
Patients with renal failure who have BUN>60 mg/dL
199
Dressler syndrome treatment?
NSAIDS or corticosteroids in refractor cases when NSAIDs contraindicated
200
Pain is sharp, focal, lasts for hours in center for chest and is worse with inspiration and movement?
Costochondritis
201
What are indications for urgent dialysiss?
AEIOU
- Acidosis (ph6.5) refractory to medical therapy
- Ingestion (toxic alcohols, salicylate, lithium, sodium valproate, carbamazepine)
- Overload (volume overload refractory to diurectics)
- Uremia (symptomatic (encephalopathy, pericarditis, bleeding))
202
When do you repair AAA? (3 situations)
>5.5 regardless of symptoms, >0.5 cm in 6 months or >1 cm in 1 year, presence of symptoms (abdominal, back, or flank) regardless of size
203
Most accurate test for abdominal aneurysm?
CT scan
204
What is cause of ascending vs. descending aortic aneurysms?
Ascending-cystic medial necrosis (aging) or connective tissue disorders
Descending-Atherosclerosis
205
What findings will be present for aortic coarctation?
- Brachial-femoral delay
- Upper extremity HTN, lower extremity hypotension
- Continouous cardiac murmur from large collaterals between hypertensive and hypoperfused vessels
- Rib notching (dilation of collateral chest wall vessels)
206
Tx. of aortic coarctation?
Balloon angio +/- stent
207
What studies are done for coarctation and what is the finding?
- ECG shows LVH
- CXR-notching of 3rd-8th ribs from enlarged intercostal arteries
- ECHO: diagnostic confirmation
208
What is aortic coarctation associated with? (3)
Turner, Bicuspid aortic valve, VSD
209
What happens to SVR, preload, CO with AV fistula?
- Decreased SVR
- Increased preload
- Increased CO
210
When is carotid endarterectomy indicated in men and women?
Women-70-99% for asymptomatic and symptomatic
| Men-60-99% asymptmatic, 50-69% symptomatic and 70-99%
211
How do you monitor patients with stenosis who don't need an operation?
Annual duplex U/S
212
What is PEA?
Rhythm on cardiac monitoring without a measurable BP or palpable pulse in a cardiac arrest patient in a cardiac arrest patient
213
How do you manage PEA vs. VTACH/VFIB?
PEA-CPR and vasopressor therapy for adequate cerebral and coronary perfusion (eg epinephrine). NO ROLE FOR DEFIBRILLATION!
VTACH/VFIB-CPR and defibrillation
214
Adult tachyarrhythmia
1) Hemodynamically stable (narrow) management
2) Hemodynamically stable (wide) management
3) Hemodynamically unstable (narrow or wide) managmenet
1) Vagal maneuvers (eg carotid sinus massage); IV adenosine (adenosine helps DROP) or 2nd line Ca2+ channel blockers
2) IV antiarrhythmics (amiodarone, procainaminde)
3) Immediate synchronized DC cardioversion
215
Sinus bradycardia management?
Treat reversible causes, followed by IV atropine (atropine helps TOP) if this is inadequate
216
CVP, CO, SVR in hypovolemic, cardiogenic, obstuctive, and distributive shock.
Hypovolemia-decrease CVP, decrease CO, increase SVR
Cardiogenic/Obstructive-increase CVP, decrease CO, increase SVR
Distributive-Decrease CVP, Increase CO, Decrease SVR
217
What is cardiac index?
Just a measure of pump function of the heart that correlates to CO
218
Management of exertional vs nonexertional heat stroke?
- Exertional-rapid cooling (ice water immersion)
- Nonexertional-evaporative cooling (spray luke warm water and blow fans); ice water immersion here may actually be associated with an increased mortality
219
Tx. acute decompensated HF with normal BP and adequate end organ perfusion?
1) Supplemental O2
2) IV loop diuretic (eg furosemide)
3) Consider IV vasodilator (eg nitroglycerin)
220
Tx. acute decompensated HF with hypotension or signs of shock?
1) Supplemental O2
| 2) IV furosemide, IV vasopressor (NE)
221
What electrolyte abnormality will be seen with systolic HF?
Hyponatremia (parallels to severity of HF and independent predictor of adverse clinical outcomes)
222
Fibromuscluar dysplasia arteries involved, diagnosis test, and treatment?
Arteries-Renal, carotid, vertebral
Diagnosis-CT angio abdomen or Duplex U/S
Treatment-Angioplasty w/ stent placement
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Medications to withhold for cardiac stress testing:
- 48 hours before?
- 48 hours before for vasodilator stress test?
- 12 hours before for vasodilator stress test?
- Meds to continue?
- B-blockers, Nitrates, Ca2+ channel blockers
- Dipyridamole
- Caffeine containing foods/drinks
- ACEi/ARB, statin, digoxin, diuretics
224
Tx. of HTN in ADPKD
ACEi
225
Renal bruit vs AAA bruit?
Renal-systolic diastolic abdominal bruit
| AAA-systolic bruit and pulsatile abdominal mass
226
Pulm systolic pressure in cor pulmonale?
>25 mm Hg
227
How do you differentiate liver vs heart causes of lower extremity edema?
Liver (cirrhosis/primary hepatic disease)-normal JVP and negative hepatojugular reflux
Heart-Elevated JVP and positive hepatojugular reflux
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What murmurs should be worked up and those that can be left alone?
Work up with TTE-Diastolic/continuous murmurs
| No workup needed-midsystolic soft murmurs
229
Where is AR heard best in valvular vs aortic root disease?
Valvular-best at left sternal boarder
| Aortic root-best at right sternal border
230
Indications of heparin in setting of chest pain/MI?
- Thrombus
- Unstable angina
- Severe CHF
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Tx. of idiopathic pulmonary HTN?
Prostacyclin, antiendothelin (bosentan), PDE 5 inhibitor,s and Ca2+ channel blockers
232
Murmur of HOCM?
Harsh crescendo-decrescendo systolic murmur
233
Most common location of ectopic foci that cause afib?
Pulmonary veins
234
Management of PVC if symptomatic?
B-blocker
235
Tx. of hemodynamically stable vs. unstable ventricular tachycardia?
Stable-IV amiodarone before cardioversion
| Unstable-Electrical cardioversion
236
Anterior MI: Blocked vessel and EKG involved?
Inferior MI: Blocked vessel and EKG involved?
Posterior MI: Blocked vessel and EKG involved?
Lateral MI: Blocked vessel and EKG involved?
Rt ventricle MI: Blocked vessel and EKG involved?
Anterior: LAD, V1-V6
Inferior: LCX/RCA, II,III, avF
Posterior: LCX/RCA, ST depression V1-V3, St elevation I and aVL (LCX) and ST depression I and AvL for RCA
Lateral: LCX/diagonal, ST elevation in leads I, aVL, V5, and V6; ST depression in leads II, III, aVF
Rt ventricle MI (50% of inferior MI): RCA and ST elevation in leads V4-V6R
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What is treatment of Right ventricular MI?
high flow IV fluids due to preload dependence
238
What should be given within 24 hours of MI to limit ventricular remodeling?
ACEi
239
How is situational syncope different than postural hypotension?
No orthostatic BP changes observed in situational syncope
240
Diagnosis of amyloidosis?
Abdominal fat pad aspiration biopsy
241
What can help reduced DHP Ca2+ channel blockers peripheral edema?
ACEi/ARB by causing post capillary venodilation to counteract ca2+ channel blockers causing pre capillary arteriolar dilation
242
What drugs improve mortality in CHF?
ACEi/ARB, B-blocker, spironolactone
243
Digoxin MOA?
Rate control in rapid AFIB (decrease conduction at AV node and depression of SA node) and improve symptoms in patients with CHF (increase contractility)
244
CYP450 inducers (decrease bleeding from warfarin)
Chronic Alcoholics Steal Phen Phen and Never Refuse Greasy Carbs (Chronic alcohol use, St. John wort, Phenytoin, Phenobarbital, Nevirapine, Rifampin, Griseofulvin, Carbamazepine)
245
CYP450 inhibitors (increase bleeding risk from warfarin)
AAA RACKS IN GQ (Acute alcohol use, Ritonavir, Amiodarne, Cimetidine, Ketoconazole, Sulfonamides, Isoniazid, Grapefruit juice, Quinidine, Macrolides (except azithromycin)
246
Tx for WPW
Hemodynamically stable: Use procainamide or quinidine, radiofrequency ablation
Hemodynamically unstable: DC cardioversion
247
Giving what drug to patients with RAS may percipitate acute renal failure?
ACE inhibitors
248
HTN is the #1 modifiable risk factor what what?
Strokes
249
What tests should be ordered for every patient with a diagnosis of HTN?
1) ECG-to see if heart has been affected
2) BMP
3) UA
4) Hb/Hct
5) Lipid panel
250
Do you use antiarrhythmics for asymptomatic PVC?
NO! increased risk of MI and death
251
What type of patients is multifocal atrial tachycardia seen in and what are characteristics?
MAT-severe pulmonary disease (eg COPD); variable P-wave morphology (>3 diff forms), PR interval variable depending on P wave foci, irregular
