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CK IM > Cardio > Flashcards

Cardio Flashcards

1
Q

Myocardial infarction is associated with pain that lasts______

A

> 20–30 minutes in duration.

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2
Q

Wide physiologic splitting of the second heart sound (splitting wider with inspiration)
can be found in ______

A

right bundle branch block or in right ventricular infarction

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3
Q

New paradoxical splitting is most often due to _______

A

left bundle branch block (LBBB), or anterior or lateral infarction.

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4
Q

A new fourth heart sound can occur with _____

A

angina or infarction.

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5
Q

An S3 is more likely due to underlying___

A

heart failure

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6
Q

aortic regurgitation occurs in over half of patients with_____, while mitral regurgitation can occur in patients with angina or infarction and is due to ______

A

aortic dissection

papillary muscle dysfunction.

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7
Q

_____is the single most important test for the evaluation of the cause of chest pain

A

ECG

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8
Q

In patients presenting with acute chest

pain who have normal ECG, the chance of acute MI is _____

A

much less than 10% (in some studies

1–2.6%).

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9
Q

_____ is cardiac specific and is useful for the early diagnosis of acute myocardial infarction.

A

CK-MB

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10
Q

the peak CK-MB level does not predict infarct size; however, it can be used
to detect ______

A

early reinfarction.

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11
Q

Unlike troponin I levels, troponin T levels may be elevated in patients with _____

A

renal disease,

polymyositis, or dermatomyositis

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12
Q

Patients with a normal CK-MB level but elevated troponin levels are considered to have ________

A

sustained minor myocardial damage, or microinfarction

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13
Q

patients with elevations of both CK-MB and troponins are considered to have had ___

A

acute myocardial

infarction.

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14
Q

Subtle findings such as loss

of lung volume or unilateral decrease in vascular markings may suggest _____

A

pulmonary embolism

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15
Q

Dyspnea, tachycardia, and hypoxemia are prominent; pain is usually pleuritic, especially when pulmonary infarction develops

A

Pulmonary Embolism

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16
Q

ECG of Pulmo Embo

A

S wave in lead I, Q wave in lead III, or inverted T wave in lead III

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17
Q

May be preceded by viral illness; pain is sharp, positional, pleuritic, and relieved by
leaning forward; pericardial rub often present

A

Pericarditis.

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18
Q

Pericarditis ECG

A

diffuse ST elevation occurs without evolution of Q waves;

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19
Q

Pericarditis CKs

A

CK level usually normal; responds to anti-inflammatory agents

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20
Q

What condition?

Total CK and MB fraction of CK (CK-MB) are often elevated; conduction abnormalities and Q waves may occur.

A

Myocarditis

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21
Q

Pain is sharp and increases on inspiration; friction rub or dullness may be present;
other respiratory symptoms and underlying pulmonary infection usually present

A

Pleuritis.

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22
Q

Cause of life-threatening acute coronary syndromes

A

When the atherosclerotic plaque ruptures, there is superimposed thrombus formation that acutely occludes the artery

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23
Q

_____ is the single most important subgroup

that carries risk for IHD,

A

LDL cholesterol

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24
Q

Cigarette smoking is an important factor for IHD because a smoker’s risk of heart
attack is ____ that of a nonsmoker

A

> 2x

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25
Q

______ have a higher risk of death from IHD, though less than cigarette
smokers

A

Cigar or pipe smokers

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26
Q

Studies in the general population have

shown that the risk for cardiovascular events increases at BP _____

A

> 110/75 mm Hg

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27
Q

All-cause mortality in diabetic patients is comparable to that of all-cause mortality in patients with prior myocardial ischemia; hence, diabetes is now considered
an _______

A

“IHD equivalent.

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28
Q

______as women age may contribute to a

higher risk of heart disease after menopause

A

the decrease of natural estrogen

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29
Q

Manifestations of myocardial ischemia

A
  • Anginal chest discomfort
  • ST-segment deviation on ECG
  • Reduced uptake of tracer during myocardial perfusion scanning
  • Regional or global impairment of ventricular function
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30
Q

In the presence of coronary obstruction, an
increase of myocardial oxygen requirements caused by exercise, tachycardia, or emotion
leads to a transitory imbalance. This condition is frequently termed _______

A

“demand ischemia”

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31
Q

In other situations, the imbalance is caused by acute reduction of oxygen supply secondary to marked reduction or cessation of coronary flow as a result of platelet aggregates or thrombi. This condition, termed ______

A

“supply ischemia,

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32
Q

____ occurs when the myocardium becomes ischemic. This occurs during periods of increased demand for oxygen, such as exercise, or decreased supply, such as hypotension or anemia

A

Stable angina

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33
Q

In Angina,

A new_____ may be heard, suggesting a stiff ventricle due to ischemia

A

S4

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34
Q

Most patients with angina will have ECG changes during an attack. Most commonly,________is seen

A

ST segment

depression

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35
Q

In stable angina, ST segment elevation occurs in ____ or ____

A

variant angina (Prinzmetal angina) where coronary artery spasm is responsible and rarely during ischemia caused by stable angina (where atherosclerotic disease is responsible).

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36
Q

The ______is the most useful test for evaluating the cause of chronic chest pain when there is concern about IHD (stable angina)

A

exercise treadmill test (exercise stress test)

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37
Q

Stress test

In order to do an appropriate analysis, a target heart rate must be reached which is computed as?

A

• Target heart rate is 85% of predicted maximum heart rate: 85% × (220 – patient’s age)

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38
Q

Interpretation of Stress test

A

Significant fixed stenoses of the coronary arteries will result in ECG evidence of ischemia.

Low-grade stenoses (<50%) may not produce sufficient impairment of blood flow to affect
the ECG; in these cases the stress test will be normal

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39
Q

An exercise stress test is considered positive for myocardial ischemia ______

A

when large (>2 mm) ST-segment depressions or hypotension (a drop of >10 mm Hg in systolic pressure) occur either alone or in combination.

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40
Q

Patients who are unable to exercise or walk should be considered________

A

for chemical stress testing, such as dipyridamole (Persantine) or dobutamine stress test

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41
Q

Stress test

_____ may blunt the heart rate during exercise and thus should be held 24
hours prior to the test

A

Beta blockers

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42
Q

____ may depress the ST segments, so if ST-segment depression of ≥1 mm is present on
baseline ECG, the stress test results will be difficult to interpret

A

Digoxin

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43
Q

A radioactive substance is injected into the patient and perfusion of heart tissue is visualized. An abnormal amount of thallium will be seen in those areas of the heart that
have a decreased blood supply.

A

Nuclear stress test

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44
Q

Compare nuclear vs regular stress test

A

Compared to regular stress tests, the nuclear stress tests have higher sensitivity and specificity (92% sensitivity, 95% specificity vs. 67% sensitivity, 70% specificity).

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45
Q

Used in people who are unable to exercise. A

drug is given to induce tachycardia, as if the person were exercising

A

Dobutamine or adenosine stress test:

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46
Q

______Combines a treadmill stress test and an echocardiogram (ECHO).

The latter can recognize abnormal movement of the walls of the left ventricle
(wall motion abnormalities) that are induced by exercise.

A

Stress echocardiogram:

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47
Q

______ is also used in patients with stable angina for (1) diagnosis and (2) prognosis/risk stratification

A

Cardiac catheterization

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48
Q

Target goals for hyperlipidemic patients with
coronary artery disease include:

1
2
3

A
  • LDL <100 mg/dL
  • HDL ≥40 mg/dL
  • Triglycerides <150 mg/dL
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49
Q

The optimal LDL-cholesterol goal is considered to be______ for patients considered to be very high risk

A

<70 mg/dL

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50
Q

What intervention for these pts:

Patients with left main disease or triple-vessel disease and low ejection fraction. In addition, patients with angina refractory to medical therapy

A

Coronary bypass graft

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51
Q

How is CABG done

A

The procedure involves the construction of 1 or more grafts between the arterial and coronary circulations.

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52
Q

Potential consequences of graft failure (loss of patency) include the_____

A

development of angina, myocardial

infarction, or cardiac death.

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53
Q

PCI is most useful in ______

A

acute coronary syndrome (ACS)

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54
Q

Classification of ACS

A

Acute coronary syndrome (ACS) is used to describe a range of thrombotic coronary diseases, including unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI

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55
Q

ACS is due to _____

A

coronary vessel atherosclerotic obstruction with superimposed thrombotic occlusion

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56
Q

_____considered to have occurred if ischemia produces damage detectable by biochemical markers of myocardial injury (troponin I or CK-MB).

A

NSTEMI

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57
Q

If there are no detectable serum markers of myocardial injury 12–18 hours after
symptom onset, the patient should be diagnosed with ______

A

UA

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58
Q

Unstable angina is sometimes referred to as _______ angina

A

“crescendo” or “preinfarction”

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59
Q

untreated UA progresses to ____ in 50% of cases, thus the patient with new-onset or unstable angina should be hospitalized for intensive medical treatment

A

MI

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60
Q

High-risk features for patients with presumed UA/NSTEMI include:

A
  • Repetitive or prolonged chest pain (>10 min)
  • Elevated cardiac biomarkers
  • Persistent ECG changes of ST depression >0.5 mm or new T-wave inversion
  • Hemodynamic instability (SBP <90)
  • Sustained ventricular tachycardia
  • Syncope
  • LV ejection fraction <40%
  • Prior angioplasty or prior CABG
  • Diabetes
  • Chronic kidney disease
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61
Q

Avoid______in patients likely to require emergency coronary bypass surgery.
Prasugrel and ticagrelor are alternatives

A

clopidogrel

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62
Q

Give_____along with the recommended antiplatelet therapy for UA/NSTEMI

A

heparin

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63
Q

This class of antithrombotic agents inhibits platelet function by blocking a key receptor involved in platelet aggregation.

A

Glycoprotein (GP) IIb/IIIa inhibitors

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64
Q

Glycoprotein (GP) IIb/IIIa inhibitors

_____is particularly recommended in high-risk patients in whom an invasive strategy is planned

A

Tirofiban or eptifibatide

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65
Q

Concomitant_____ is particularly beneficial and recommended in patients with
diabetes.

A

tirofiban

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66
Q

Early coronary angiography (within 48 hours) and revascularization are recommended in
patients with_______

A

NSTEMI and high-risk features, except in patients with severe comorbidities

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67
Q

The symptoms of MI last >20 minutes and do not respond completely to_____

A

nitroglycerin

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68
Q

A fourth heart sound (S4) is common due to a ______

A

stiffened ventricle

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69
Q

The second heart sound may be

paradoxically split as the left ventricular contraction time increases due to_____

A

LBBB and weakened left ventricle

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70
Q

ECG of STEMI

A
  • Persistent ST-segment elevation of ≥1 mm in two contiguous limb leads
  • ST-segment elevation of ≥2 mm in two contiguous chest leads
  • New LBBB pattern
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71
Q

Patients with STEMI usually have a _____

A

completely occluded coronary artery with thrombus at the site of a ruptured plaque

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72
Q

Patients with STEMI who present within 12 hours of the onset of ischemic symptoms should have ______

A

a reperfusion strategy implemented promptly

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73
Q

Reperfusion may be obtained with ___

A

fibrinolytic therapy or percutaneous coronary intervention (PCI).

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74
Q

Artery involved

Inferior infarction

A

Right coronary

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75
Q

Artery involved

Anteroseptal

A

Left anterior descending

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76
Q

Artery involved

Anterior

A

Left anterior descending

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77
Q

ECG changes with Lateral infarction

A

I, aVL, V4, V5, and V6

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78
Q

Artery involved with Lateral infarction

A

Left anterior descending

or circumflex

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79
Q

EKG: posterior infarction

A

V1–V2: tall broad initial R wave, ST depression, tall upright T wave; usually occurs in association with inferior or lateral MI

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80
Q

Artery: : posterior infarction

A

Posterior descending

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81
Q

Hyperacute T waves (tall, peaked T waves in leads facing infarction)

Onset: ______
Disappearance: _______

A

Immediately

6–24 hours

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82
Q

ST-segment elevation

Onset: ______
Disappearance: _______

A

Immediately

1–6 weeks

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83
Q

Q waves longer than 0.04 seconds

Onset: ______
Disappearance: _______

A

One to several days

Years to never

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84
Q

T wave inversion

Onset: ______
Disappearance: _______

A

6–24 hours

Months to years

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85
Q

Thrombolysis benefits patients with all types of ST elevation infarction, but the benefit is
several times greater in those with _____

A

anterior infarction.

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86
Q

Prolonged persistence of antibodies to streptokinase may reduce the effectiveness of subsequent treatment; therefore, streptokinase should not be used if ______=

A

if used within the previous 12 months in the same patient.

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87
Q

consider a thrombolytic agent as an alternative to primary PCI in suitable candidates with:

A
  • ST-elevation MI (>1 mm ST elevation in 2 contiguous leads)

* New LBBB

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88
Q

Reperfusion therapy with either PCI or

fibrinolysis is not routinely recommended in patients who are_______

A

asymptomatic and hemodynamically

stable, and who present >12 hours after symptom onset

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89
Q

CABG surgery may also be considered in patients with____ or______

A

cardiogenic shock or in association with mechanical repair

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90
Q

______ should be prescribed in addition to aspirin for patients undergoing PCI with a stent

A

Clopidogrel or prasugrel

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91
Q

IV unfractionated heparin should be given as an initial bolus, adjusted to attain the_____

A

activated partial thromboplastin time (APTT) at 1.5 to 2 times control

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92
Q

Emergency bypass surgery should be considered in patients with STEMI and

A

(1) failed PCI with persistent pain or hemodynamic instability and coronary anatomy suitable for surgery or
(2) persistent or recurrent ischemia refractory to medical therapy and suitable anatomy

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93
Q

BB

____ and _____ particularly should
be used in patients after ACS who have heart failure

A

Metoprolol and carvedilol

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94
Q

Bradycardia in ACS examples: ________. These are treated acutely with atropine and temporary pacing if severe

A

sinus, atrioventricular junctional, idioventricular

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95
Q

Examples of Tachyarrhythmias (supraventricular) in ACS

A

atrial tachycardia, atrial fibrillation, atrial flutter, AV junctional; are seldom caused by ischemia

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96
Q

Conduction Abnormalities in ACS
• Atrioventricular nodal: ________
• Intraventricular:_______

A

first-, second-, and third-degree block

hemiblocks (left anterior, left posterior), bundle branch block, thirddegree
atrioventricular block

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97
Q

Examples of contractile dysfn in ACS

A

left ventricular, right ventricular, and biventricular failure; true ventricular aneurysm; infarct expansion

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98
Q

Examples of ischemic Cx of ACS

A
  • Postinfarction ischemia: ischemia in the infarct and ischemia distant to the infarct
  • Early recurrent infarction or infarct extension
  • Postinfarction angina after thrombolytics or PCI should be treated with bypass surgery
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99
Q

Mx of Pericarditis—Dressler syndrome (late)

A

Treated with aspirin, NSAIDs, and later steroids if there is no response.

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100
Q

MCC of sudden death in ACS

A
  • Ventricular fibrillation (most commonly)

* Ventricular tachycardia

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101
Q

Selective serotonin reuptake
inhibitors (SSRIs) such as ______ and ____ have been found to be both effective in reducing depression and relatively safe for use in patients with coronary heart disease

A

sertraline and citalopram

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102
Q

_____ has also been found to be effective in treating depression.

A

Cognitive behavior therapy

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103
Q 
Erectile dysfunction (ED) is prevalent among patients with CAD and post-MI (in some
series\_\_\_\_\_
A

~ 40%).

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104
Q

Sildenafil should be used cautiously in men post-MI who are taking nitrates of up to
55 mm Hg, because _____

A

it can cause a drop in BP. Due to this synergistic effect, it is therefore
contraindicated in patients taking nitrates

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105
Q

ED is a complication of the conditions that are primary risk factors for developing
CAD, in particular, ______

A

diabetes, hypertension, dyslipidemias, and arteriosclerosis

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106
Q

Who are at HR for sexual activity in CAD

A 
those with unstable angina, MI within 2 weeks, poorly controlled hypertension,
severe CHF (New York Heart Association class III/IV), significant arrhythmias, severe cardiomyopathies;
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107
Q

What to do for HR CAD

A

patients should be referred for cardiovascular evaluation and stabilization prior to recommending resumption of sexual activity

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108
Q

_____ use has been documented to induce coronary vasoconstriction in nondiseased coronary segments but is more
pronounced in atherosclerotic segments

A

Cocaine

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109
Q

_____is a very uncommon condition in which episodes of severe angina are triggered when one of the major coronary arteries suddenly goes into spasm.

A

Prinzmetal angina, or variant angina,

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110
Q

SSx of Prinzmetal angina, or variant angina,

A

Prinzmetal angina usually occurs during periods of rest, most often at night and in the early morning hours.

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111
Q

Prinzmetal: _____ has been used to trigger coronary artery spasm in susceptible patients, confirming the diagnosis.

A

Ergonovine

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112
Q

Prinzmetal

Treatment with ______ or _____eliminates spasm in most of these patients.

A

calcium channel blockers or nitrates

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113
Q

Cardiac changes during HF include

A
  1. increased end-diastolic volume;
  2. ventricular dilatation or hypertrophy; 3. decreased stroke volume and cardiac output; 4. reduced ejection fraction
    (systolic dysfunction) or 5. impaired filling (diastolic dysfunction).
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114
Q

Compensatory changes in HF

  • Cardiac: _____
  • Neuronal:______
  • Hormonal: ______
A

Frank-Starling mechanism, tachycardia, ventricular dilatation

increased sympathetic adrenergic activity, reduced cardiac vagal activity

activation of angiotensin-aldosterone system, vasopressin, catecholamines,
and natriuretic peptides

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115
Q

Systolic HF (systolic dysfunction) is due_____

A

to a loss of contractile strength of the myocardium accompanied by ventricular dilatation.

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116
Q

Systolic HF (systolic dysfunction) is accompanied by a ______

A

decrease in normal ventricular emptying (usually ejection fraction <45%)

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117
Q

Examples of systolic HF include _____

A

ischemic cardiomyopathy and dilated cardiomyopathy

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118
Q

_______occurs when the filling of one or both ventricles is impaired while the emptying capacity is normal (echocardiogram
confirms that the ejection fraction is normal

A

Heart failure with preserved ejection fraction (diastolic dysfunction)

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119
Q

Heart failure with preserved ejection fraction (diastolic dysfunction) examples

A

The infiltrative cardiomyopathies (amyloidosis

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120
Q

In heart failure, intravascular congestion occurs with elevation of left ventricular diastolic and pulmonary venous pressures that eventually causes_____

A

transudation of fluid from the pulmonary

capillaries into the interstitial space

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121
Q

____ develops when the rate of fluid

accumulation goes above the rate of lymphatic absorption.

A

Pulmonary edema

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122
Q

Precipitating factors for HF

A

• Cardiac ischemia and myocardial infarction
• Infections (especially pulmonary infections)
• Arrhythmias (especially atrial fibrillation)
• Excessive dietary salt (commonly after holiday meals)
• Uncontrolled hypertension (especially after abrupt cessation of anti-hypertensive
medication)
• Thyrotoxicosis
• Anemia

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123
Q

Most Common Causes of Acute Pulmonary Edema

A 
Ischemia
Arrhythmia
Non-adherence with medication
Dietary indiscretion
Infection
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124
Q

______is the test-of-choice to confirm the diagnosis of HF and to classify the type (systolic vs. diastolic

A

Echocardiography

125
Q

Chest x-rays are also used to aid in the diagnosis of heart failure. They may show _______

A

cardiomegaly, vascular redistribution, Kerley B-lines, and interstitial edema.

126
Q

_____ is a polypeptide secreted by the heart in response to excessive stretching of the myocytes. It is a valuable tool in the evaluation of patients with presumed HF
or decompensated HF in the acute setting.

A

Brain Natriuretic Peptide (BNP)

127
Q

The BNP is almost always elevated ____ sensitivity) in patients with decompensated HF

A

(97%

128
Q

_____are the basis of therapy and recommended for all patients with HF (especially systolic HF), irrespective of blood pressure status

A

ACE inhibitors

129
Q

MOA of ACEi

A

ACE inhibitors through vasodilation reduce preload and afterload, thereby reducing right atrial, pulmonary arterial, and pulmonary capillary wedge pressures

130
Q

______is the treatment of choice for the relief of acute

pulmonary edema symptoms

A

Diuretic therapy, especially loop diuretics,

131
Q

ACE inhibitors MOA _____

A

through vasodilation reduce preload and afterload, thereby reducing right atrial, pulmonary arterial, and pulmonary capillary wedge pressures.

132
Q

Thiazide diuretics (hydrochlorothiazide) are useful only in _____

A

mild HF

133
Q

_____ and _____ have been used as add-on therapy to ACE inhibitors in severe heart failure to prolong survival by presumed aldosterone inhibition.

A

Spironolactone and eplerenone (aldosterone antagonists)

134
Q

Where is the site of action?

Captopril
Enalapril
Lisinopril

A

Arteriolar and venous ACE

inhibitor

135
Q

Where is the site of action?

Nitroprusside

A

Arteriolar and

venous

136
Q

Where is the site of action?

Nitroglycerin

A

Venous (arteriolar

at high doses IV)

137
Q

Where is the site of action?

Isosorbide
dinitrate

A

Venous

138
Q

Where is the site of action?

Hydralazine

A

Arteriolar

139
Q

Chronic adrenergic activation has been implicated in the pathogenesis of HF and thus
_______are an important part of HF therapy

A

b-adrenergic blocking agents

140
Q 
beta blockers have been demonstrated to 
1
2
3
4
5
A

decrease mortality,
reduce hospitalizations,
improve functional class, and improve ejection fraction in several large-scale, randomized,
placebo-controlled trials.

141
Q

Site of action

Thiazides (inhibits NaCl cotransport); used mostly for treatment of hypertension
• Hydrochlorothiazide
• Chlorothiazide

A

Distal tubule

142
Q

Site of action

Indapamide
direct vasodilator

A

Distal tube

143
Q 
Loop diuretics (inhibitors Na/K, 2Cl cotransport); most commonly used diuretics in
heart failure
• Furosemide
• Ethacrynic acid
• Bumetanide
A

Loop of Henle

144
Q

Site of action

Potassium-sparing diuretics
• Spironolactone
aldosterone antagonist

A

Distal tubule

145
Q

Other vasodilators, such as a combination of ______, may be used when ACE inhibitors and ARBs are not tolerated or contraindicated (renal failure).

A

hydralazine and isosorbide

146
Q

The addition of spironolactone in patients with severe CHF significantly reduces (about ____ relative risk) death and hospitalizations among treated patients.

A

30%

147
Q

Spironolactone is used in patients with NYHA class _____

A

III-IV

148
Q

Once the patient is started on spironolactone, ______ levels have to be monitored closely

A

serum potassium

149
Q

_____ is an alternative to spironolactone that does not cause gynecomastia

A

Eplerenone

150
Q

The addition of inotropic agents to patients with severe HF improves symptoms and quality of life and reduces hospitalizations but does not improve survival. The most commonly used inotropic agent is_____

A

digitalis

151
Q

What is the MOA of digitalis

A

Digitalis inhibits Na+/K+ - ATPase pump which results in increased
intracellular concentration of Na+ and decreased exchanges of intracellular Ca2+. The end
result is an increase in intracellular concentration of Ca2+ which results in improved cardiac
contractility.

152
Q

Remember that K+ and digitalis compete for myocardium binding sites. Hyperkalemia will
_____ whereas hypokalemia results in _____

A

decrease digitalis activity,

toxicity

153
Q

Digitalis indications

A
  • CHF
  • Atrial fibrillation/flutter
  • Paroxysmal atrial tachycardia/SVT
154
Q

Conditions which predispose to digitalis toxicity are:

A
  • Renal insufficiency
  • Electrolyte disturbances (hypokalemia, hypercalcemia, hypomagnesemia)
  • Advanced age
  • Sinoatrial and atrioventricular block
  • Thyroid disease, especially hypothyroidism
155
Q

Decreases digoxin

Binds digoxin in GI tract; interferes with
enterohepatic circulation

A

Cholestyramine, colestipol

156
Q

Toxic Effects of Digitalis

A
  • Nausea and vomiting
  • Gynecomastia
  • Blurred vision
  • Yellow halo around objects
  • Arrhythmias—
157
Q

Arrhythmias of Digitalis—commonly

A

paroxysmal atrial tachycardia (PAT) with block, PVCs (premature ventricular contractions), and bradycardia

158
Q

_____ are sometimes used in the management of severe acute HF (hospitalized patients).

A 
Sympathomimetic amines (dopamine, doputamine) and phosphodiesterase inhibitors (amrinone,
milrinone)
159
Q 
In refractory HF (defined as progression of HF despite standard treatment), the patient may
be considered for: 
1
2
3
A

biventricular pacing, implantable defibrillator, and heart transplantation

160
Q

The automatic implantable cardioverter/defibrillator (AICD) is a standard therapy for_______

A

ischemic

dilated cardiomyopathy

161
Q

How does an IACD lower mortality?

A

Since the most common cause of death in CHF is an arrhythmia, it is logical that a device which interrupts arrhythmia will lower mortality

162
Q

A______ will “resynchronize” the heart when there is dilated cardiomyopathy and
a QRS >120 mSec.

A

biventricular pacemaker

163
Q

• Dilated cardiomyopathy with a persistent ejection fraction <35%. What mechanical device?

A

AICD?

164
Q

Dilated cardiomyopathy with a QRS wider than 120 mSec

A

biventricular pacemaker

165
Q

CXR findings of Pulmo edema

A
  • Prominent pulmonary vessels
  • Effusions
  • Enlarged cardiac silhouette
  • Kerley B lines
166
Q

Most common lesion caused by rheumatic fever consisting of thickened mitral valve
leaflets, fused commissures, and chordae tendineae. It may result in right ventricular failure. It often becomes clinically symptomatic during pregnancy

A

MS

167
Q

In Pulmo edema

____ (due to rupture of pulmonary vessels)
______ (due to stagnation of blood in an enlarged left atrium)
______ (due to impingement of an enlarged left atrium on the recurrent laryngeal
nerve)

A
  • Hemoptysis
  • Systemic embolism
  • Hoarseness
168
Q

Signs of MS

A
  • Decreased pulse pressure
  • Loud S1
  • Opening snap following S2
  • Diastolic rumble (low-pitched apical murmur)
  • Sternal lift (due to right ventricular enlargement)
169
Q

ECG findings

A
  • May show signs of right ventricular hypertrophy

* May show left and right atrial abnormalities

170
Q

CXR of MS

A

Large left atrium (indicated by a double-density right heart border, posterior displacement of esophagus, and elevated left mainstem bronchus), straightening of the left
heart border

171
Q

MS

May show signs of pulmonary hypertension, including _______

A

Kerley B lines and increased

vascular markings

172
Q

MS Echocardiography

A

• Shows thickening of mitral valve leaflets and a reduction in the excursion and area of
the valve leaflets
• May also show left atrial enlargement

173
Q

_____is the standard of care for MS

A

Balloon valvulotomy

174
Q

When to do Sx in MS

A

Indicated when patient remains symptomatic (functional class III) despite medical therapy

175
Q

_____if balloon dilation fails

A

Mitral commissurotomy or valve replacement,

176
Q

Backflow of blood from the left ventricle into the left atrium, due to inadequate
functioning (insufficiency) of the mitral valve. Most commonly from ischemia

A

Mitral Regurgitation

177
Q

MCC of MR

A

Common causes are hypertension, CHF, ischemic heart disease, rheumatic fever, and
any cause of dilation of the left ventricle

178
Q

Pathogenesis of MR

• Volume overload occurs, increasing _____
• _____ is decreased as the left ventricle empties part of its contents into the relatively
low-pressure left atrium

A

preload.

Afterload

179
Q

Signs of MR

A
  • Carotid upstroke diminished in volume but brisk
  • Holosystolic apical murmur radiating to the axilla and often accompanied by a thrill
  • S3 heard with a soft S1 and widely split S2
  • Distended neck veins when severe or acute
180
Q

Echocardiography: The mitral valve can prolapse into the left atrium during systole in
cases of a ______

A

ruptured chordae or mitral valve prolapse.

181
Q

____is the single most accurate test for MR

A

Catheterization

182
Q

MR Tx

With medical therapy, the goal is to relieve symptoms by______

A

increasing forward cardiac output and reducing pulmonary venous hypertension

183
Q

Tx of MR

A
  • ARBs or hydralazine
  • Arteriolar vasodilators (ACE inhibitors)
  • Digitalis
  • Diuretics
184
Q

Criteria for Sx of MR

A

Criterion is an ejection fraction <60% or left ventricular end systolic diameter >40 mm.

185
Q

The most common congenital valvular abnormality (2–3% population) typically
seen in young women

A

Mitral Valve Prolapse

186
Q

Mitral valve prolapse may occur with greater frequency in those with _____

A

Ehler-Danlos syndrome, polycystic kidney disease, and Marfan syndrome

187
Q

Signs of MVP

A
  • Mid-to-late systolic click and a late systolic murmur at the cardiac apex
  • Worsens with Valsalva or standing
  • Improves with squatting or leg raise
188
Q

CX of MVP

A
  • Serious arrhythmias
  • Sudden death
  • CHF
  • Bacterial endocarditis (but does not mean routine dental prophylaxis is indicated)
  • Calcifications of valve
  • Transient cerebral ischemic attacks
189
Q

2D echo findings for pts with MVP

A

Marked systolic displacement of mitral leaflets
with coaptation point at or on the left atrial side of the annulus; moderate systolic displacement of the leaflets with at least moderate mitral regurgitation.

190
Q

MCC of AS

A

Calcification and degeneration of a congenitally normal valve; more common in the elderly population. This is the most common cause

191
Q

Pathophysio of AS

A

Aortic stenosis results in elevation of left ventricular systolic pressure, and the resultant left ventricular hypertrophy maintains cardiac output without dilation of the ventricular cavity. Therefore, the stroke volume is normal until the late stages of the disease

192
Q

AS

Forceful atrial contraction augments filling at the thick, noncompliant ventricle and generates a prominent ____ that elevates the left ventricular end-diastolic pressure.

A

S4 gallop

193
Q

How does angina occur in AS

A

Left ventricular hypertrophy and high intramyocardial wall tension account for the increased oxygen demands and, along with decreased diastolic coronary blood flow, account for the occurrence of angina pectoris

194
Q

SSx of AS

A

• Pulsus tardus et parvus
• Carotid thrill
• Systolic ejection murmur in aortic area, usually with thrill, harsh quality, radiates to
carotids
• S4 gallop
• A2 decreased, S2 single or paradoxically split
• Aortic ejection click

195
Q

AS

  • Chest x-ray may present with______.
  • Echocardiography shows ______
A

calcification, cardiomegaly, and pulmonary congestion

thick aortic valve leaflets with decreased excursion and LVH.

196
Q

AS

Surgery (valve replacement) is advised when symptoms develop, which is when the
valve area is reduced_______.

A

below 0.8 cm2 (normal aortic orifice, 2.5–3 cm2)

197
Q

AS

_____may be useful in those too ill to tolerate surgery.

A

Balloon valvuloplasty

198
Q

DDx of AS

  • Systolic murmur does not peak late
  • Carotids do not have delayed upstrokes
  • No left ventricular hypertrophy by EKG
  • Echocardiographic visualization of excursion of valve leaflets usually normal or mildly reduced, but valves may not be visualized
A

Aortic valve sclerosis of the elderly, without stenosis

199
Q

DDx of AS

  • Brisk bifid carotid upstrokes
  • Murmur usually does not radiate into neck
  • Characteristic change in murmur with various maneuvers
  • Pseudoinfarct pattern (large septal Q waves) on EKG
A

Hypertrophic obstructive cardiomyopathy

200
Q

DDx of AS

  • Murmur is holosystolic and radiates to axilla and not carotids
  • Carotid upstroke may be normal
  • Dilated left ventricle
  • Aortic valve normal on echocardiogram unless there is associated aortic valve disease
A

Mitral regurgitation

201
Q
  • Murmur does not radiate into neck; loudest along the left sternal border; increases with inspiration
  • Physical examination, chest x-ray, and EKG may reveal enlarged right ventricle
  • Echocardiogram reveals right ventricular enlargement and hypertrophy
A

Pulmonic stenosis

202
Q

____ and ____are the most common causes of aortic regurgitation

A

Systemic hypertension and ischemic heart disease

203
Q

Conditions that may affect the ascending aorta and cause aortic regurgitation

A 
–– Syphilis
–– Ankylosing spondylitis
–– Marfan syndrome
–– Rheumatic fever
–– Aortic dissection
–– Aortic trauma
204
Q

Aortic regurgitation results in a volume overload of the left ventricle.
• The ventricle compensates by increasing its end-diastolic volume according to the
________

A

Frank-Starling mechanism.

205
Q

Acute aortic regurgitation results in a ______than does chronic aortic regurgitation.

A

lower cardiac output, narrower aortic pulse pressure, and a smaller left ventricle

206
Q

Aortic regurgitation can cause 3 different murmurs

  1. Systolic flow murmur
  2. ______ Systolic and/or diastolic thrill or murmur heard over the femoral arteries
  3. _____
A

Duroziez sign:

Austin-Flint murmur

207
Q

ECG of AR

A

LV hypertrophy often with volume overload pattern (narrow deep Q waves in left precordial leads)

208
Q

2D Echo of AR

A

Dilated LV and aorta; left ventricular volume overload; fluttering of anterior mitral valve leaflet

209
Q

AR

Endocarditis prophylaxis is no longer recommended.

A

T

210
Q

AR

Vasodilators such as an ______ are the standard of care

A

ACE, ARB, or nifedipine

211
Q

AR when to do Sx

A

Perform surgery when the ejection fraction is <55% or left ventricular systolic diameter
is >55 mm.

212
Q

MC Etiology of DCM

A

• Idiopathic: most common

213
Q

Other Etiologies of Dilated (Congestive) Cardiomyopathy

A
  • Alcoholic
  • Peripartum
  • Postmyocarditis due to infectious agents (viral, parasitic, mycobacterial, Rickettsiae)
  • Toxins (cobalt, lead, arsenic)
  • Doxorubicin hydrochloride, cyclophosphamide, vincristine
  • Metabolic: chronic hypophosphatemia, hypokalemia, hypocalcemia, uremia
214
Q

ECG of DCM

A

sinus tachycardia, arrhythmias, conduction disturbances

215
Q

2D echo of DCM

A

dilated left ventricle, generalized decreased wall motion, mitral valve regurgitation;

216
Q

DCM

Catheterization: ______

A

dilated hypocontractile ventricle, mitral regurgitation

217
Q

Tx of DCM

A

Patients are treated as those with systolic heart failure. ACE, beta blockers, and
spironolactone lower mortality

218
Q

DCM

_______ may decrease risk of sudden death when the ejection fraction is <35%.

A

Implantable defibrillator

219
Q

Hypertrophic Obstructive Cardiomyopathy

An abnormality on _____ has been identified in the familial form of the disease.

A

chromosome 14

220
Q

Hypertrophic Obstructive Cardiomyopathy

The distinctive hallmark of the disease is unexplained myocardial hypertrophy, usually
with________

A

thickening of the interventricular septum.

221
Q

What is the pathophysio in HOCM

A

Diastolic dysfunction is characteristic, resulting in decreased compliance and/or inability for the heart to relax

222
Q

USual EF of pts with HOCM

A

Ejection fractions are often 80–90% (normal is 60%, ±5%), and the left ventricle may
be virtually obliterated in systole.

223
Q

Characteristic murmurs of HOCM

A

Large jugular A wave, bifid carotid pulse, palpable S4 gallop, systolic murmur and
thrill, mitral regurgitation murmur

224
Q

2Deco of HOCM

A

It typically shows hypertrophy, systolic

anterior motion of mitral valve, and midsystolic closure of aortic valve

225
Q

Tx of HOCM

A
  • Beta-blockers
  • Calcium channel blockers that reduce heart rate: diltiazem, verapamil
  • Disopyramide, occasionally
226
Q

the least common of the causes of cardiomyopathy.

It is myocardial disorder characterized by rigid noncompliant ventricular walls.

A

Restrictive Cardiomyopathy

227
Q

Restrictive Cardiomyopathy etiologies

A
  • Infiltrative: sarcoidosis/amyloidosis; hemochromatosis; neoplasia
  • Scleroderma
  • Radiation
228
Q

PAthophysio of RCM

A

Systolic performance is often reduced, but the overriding problem is impaired diastolic filling, which produces a clinical
and hemodynamic picture that mimics constrictive pericarditis.

229
Q

SSx of RCM

A

Elevated jugular venous pressure, edema, hepatomegaly, ascites, S4 and S3 gallop,
Kussmaul sign

230
Q

ECG of RCM

A

EKG: low voltage, conduction disturbances, Q waves

231
Q

2D Echo of RCM

A

Echo: characteristic myocardial texture in amyloidosis with thickening of all cardiac
structures

232
Q

Cath findings of RCM

A

square root sign; elevated left- and right-sided filling pressures

233
Q

Tx of RCM

A

There is no good therapy; ultimately results in death from CHF or arrhythmias;
consider heart transplantation

234
Q

Etiology of acute pericarditis

A
  • Idiopathic
  • Infections (viral)
  • Vasculitis—connective tissue disease group
  • Disorders of metabolism
  • Neoplasms
  • Trauma
  • Inflammation—uremia
235
Q

CP of Acute Pericarditis

A

Chest pain, often localized substernally or to the left of the sternum, is usually worsened by lying down, coughing, and deep inspiration (which helps in the differential
diagnosis with MI) and is relieved by sitting up and leaning forward

236
Q

Pericardial friction rub (diagnostic of pericarditis) is a scratchy, high-pitched sound that has 1 to 3 components corresponding to
1
2
3

A

atrial systole, ventricular systole, and early diastolic ventricular filling

237
Q

How to enhance friction rub?

A

The rub is often transient and is best heard with the diaphragm of the stethoscope as the patient sits forward at forced-end expiration.

238
Q

CHaracteristic ECG of friction rub?

A

EKG may be diagnostic and reveals a diffuse ST-segment elevation with upright
T waves at the onset of chest pain. PR segment depression is very specific.

239
Q

In idiopathic pericarditis, treatment with ________ is appropriate.

A

anti-inflammatory medications (NSAIDs, aspirin, corticosteroids)

240
Q

Pericarditis

Adding_______to an NSAID decreases recurrence

A

colchicine

241
Q

Serosanguineous pericardial fluid is a classic sign in ___ and _____

A

tuberculosis and neoplastic diseases.

242
Q

Echo findings in pts with small effusions

A

The presence of pericardial fluid is recorded as a relatively echo-free space between the posterior pericardium and the posterior left ventricular epicardium in patients with small effusions

243
Q

In patients with large effusions, the heart may swing freely within the pericardial sac, and this motion may be associated with______

A

electrical alternans

244
Q

CXR of perdicardial effusion

A

Chest x-ray may show a “water-bottle” configuration of the cardiac silhouette

245
Q

A life-threatening condition in which a pericardial effusion has developed so rapidly
or has become so large that it compresses the heart.

A

Cardiac tamponade

246
Q

SSx of cardiac tamponade

_____ characterized by a decrease in systolic blood pressure >10 mm Hg with normal inspiration, frequently is present

A

Pulsus paradoxus,

247
Q

Paradoxical pulse is not diagnostic of cardial tamponade and can occur in

A

chronic lung disease, acute asthma, severe CHF, and in some cases of hypovolemic shock

248
Q

_____is associated with acute tamponade; it includes low blood pressure, distended
neck veins, and decreased heart sounds

A

Beck’s triad

249
Q

Mx of cardiac tamponade

A
  • Pericardiocentesis

* Subxiphoid surgical drainage

250
Q

The diffuse thickening of the pericardium in reaction to prior inflammation, which results in reduced distensibility of the cardiac chambers

A

Constrictive Pericarditis

251
Q

Constrictive Pericarditis

The fundamental hemodynamic abnormality is ______

A

abnormal diastolic filling.

252
Q

Constrictive Pericarditis PE

A

Heart sounds are distant, and an early diastolic apical sound, or “pericardial knock,” is often present and can be confused with an S3 gallop

253
Q

Constrictive Pericarditis CT/MRI

A

Shows thickened pericardium; pericardial calcifications may be seen in tuberculous constriction

254
Q

Cardiac cath findings of Constrictive Pericarditis

A

A marked “y” descent is present in the right atrial pressure tracing.

Left and right ventricular pressure tracings demonstrate a characteristic “dip
and plateau” or “square root” sign

255
Q

Basis of anatomical AV block

A

based on the site of block as determined by His bundle electrocardiography.

256
Q

Clinical AV block

A

The 3 classic clinical types are first-, second-, and third-degree (or complete) AV block.

257
Q

Pulse rate (PR) interval >0.20 s at a heart rate of 70 beats/min.

A

First-Degree AV Block

258
Q

Causes of first degree AV block

A 
–– Aging
–– Digitalis
–– Exaggerated vagal tone
–– Ischemia (diaphragmatic infarction)
–– Inflammation (myocarditis, acute rheumatic fever)
259
Q

Types of Second-Degree AV Block

A 
Type I (Mobitz I, Wenckebach)
Type II (Mobitz II)
260
Q

Progressive prolongation of the PR interval until a P wave is completely blocked and a ventricular beat is dropped. PR interval of the next conducted beat is shorter than preceding PR interval.

A

Type I (Mobitz I, Wenckebach)

261
Q

Type I (Mobitz I, Wenckebach)

location of block

A

Usually AV nodal (supra-Hisian)

262
Q

Type I (Mobitz I, Wenckebach)

Effect of carotiid sinus pressure

A

May increase degree of block

263
Q

Type I (Mobitz I, Wenckebach)

Effect of atropine

A

Frequently shortens PR interval and increases AV conduction

264
Q

Type I (Mobitz I, Wenckebach)

Consequences of progression to complete heart block

A

Escape focus usually junctional; narrow QRS
complex; rate >45 beats/min; Adams-Stoke
attacks uncommon

265
Q

Blocked beat occurs suddenly and is not preceded by a change in duration of the PR interval. Patient is equipped with a pacemaker, which cuts in to sustain a regular ventricular rhythm.

A

Type II (Mobitz II)

266
Q

Type II (Mobitz II)

Site of block

A

Infranodal (intra- or infra-Hisian)

267
Q 
Type II (Mobitz II)
QRS complex
A 
Usually wide (bundle branch block) with infra-
Hisian block; narrow with intra-Hisian block
268
Q

Type II (Mobitz II)

Effect of carotid sinus pressure/atropine

A

none

269
Q

Type II (Mobitz II)

Consequences of progression to complete heart block

A

Escape focus infrajunctional (usually ventricular) wide QRS complex; rate <45 beats/min; Adams-Stoke attacks common

270
Q

all atrial beats are blocked, and the ventricles are driven by an escape focus distal to the site of block

A

Third-Degree (Complete) AV Block

271
Q

Third-Degree (Complete) AV Block

Most common cause in adults is simple fibrous degenerative changes in the conduction system that results from aging ______

A

(Lenègre disease)

272
Q

Third-Degree (Complete) AV Block

SSx

A

Symptoms are associated with Adams-Stoke attacks and occasionally CHF.

273
Q

_______ are caused by either sudden asystole or the development of
ventricular tachyarrhythmias, such as transient ventricular tachycardia or ventricular
fibrillation, that lead to circulatory arrest.

A

Adams-Stoke attacks

274
Q

The bradycardia associated with complete heart block may lead to ______n patients with myocardial disease

A

congestive heart

block i

275
Q

In ______ HR greater than 100, the ventricular complexes are of normal width, evenly spaced, and a P-wave precedes
a QRS complex

A

sinus tachycardia,

276
Q

Transient sinus tachycardia is occasionally the result of a rebound phenomenon following the discontinuation of ____

A

beta-adrenergic blocking drugs

277
Q

______ is a group of ectopic tachyarrhythmias characterized by sudden onset and abrupt termination. They are usually initiated by a supraventricular premature beat (includes paroxysmal atrial tachycardia)

A

Paroxysmal supraventricular tachycardia

278
Q

Paroxysmal supraventricular tachycardia

80% are caused by_____

A

re-entry, mainly in the AV node

279
Q

Paroxysmal supraventricular tachycardia

Initial Tx

A

Initial therapy consists of maneuvers aimed at increasing vagal tone, particularly right
carotid sinus massage. Carotid sinus massage is followed by adenosine

280
Q

Meds for Paroxysmal supraventricular tachycardia

A
  • IV propranolol or esmolol, verapamil

* IV digitalis

281
Q

Morphology in MFAT

A

The morphology of the P waves (at least 3 different P wave forms) varies from beat to
beat, as does the PR interval. Each QRS complex, however, is preceded by a
P wave

282
Q

Where is MFAT usually seen

A

Generally seen in elderly patients or those with chronic lung disease who are experiencing respiratory failure

283
Q

Tx of MFAT

A

Use diltiazem, verapamil, or digoxin; avoid beta blockers because of lung disease

284
Q

_____ generally presents as an absolutely regular rhythm with a ventricular rate of
125–150 beats/min and an atrial rate of 250–300 beats/min (i.e., 2:1 block).

A

Atrial flutter

285
Q

Atrial flutter

It has been associated with

A
  • Chronic obstructive lung disease
  • Pulmonary embolism
  • Thyrotoxicosis
  • Mitral valve disease
  • Alcohol
286
Q

Atrial flutter

Therapy is _______ if hemodynamically unstable (e.g., hypotension), digitalis,
verapamil, diltiazem, and beta-blockers

A

cardioversion

287
Q

AF

The synchronization ensures that _____

A

electrical stimulation does not occur during the vulnerable phase of the cardiac cycle

288
Q

Drugs proven effective for pharmacologic cardioversion of atrial fibrillation include:

A

amiodarone, dofetilide, flecainide, ibutilide, propafenone, and quinidine

289
Q

Drugs used to maintain sinus rhythm in patients with atrial fibrillation include

A

amiodarone, disopyramide, dofetilide, flecainide, propafenone, and sotalol

290
Q

______ has been defined as a condition in which all or some portion of the ventricle is activated by atrial impulses earlier than if the impulses were to reach the ventricles by way of the normal cardiac conduction pathways

A

Pre-excitation

291
Q

Pre-excitation is achieved by the _____

A

use of accessory pathways (Kent bundle).

292
Q

WPW is associated with:
1
2

A

–– Paroxysmal supraventricular arrhythmias alternating with ventricular arrhythmias
–– Atrial fibrillation and flutter

293
Q

WPW

If the patient is hemodynamically stable, then _______is the best medication.

A

procainamide

294
Q

WPW

What Tx to avoid

A

Avoid digoxin, beta blockers and calcium-channel blockers, as they can
inhibit conduction in the normal conduction pathway

295
Q

_______is defined as 3 or more consecutive beats of ventricular origin at a rate >120 beats/min. QRS complexes are wide and often bizarre

A

Ventricular tachycardia (VT)

296
Q

VT causes

Cardiomyopathies and rarely seen in patients with ______

Metabolic derangements, such as ___

A

mitral valve prolapse

hypokalemia, hypercalcemia, hypomagnesemia, and
hypoxia

297
Q

PE of VT

A

–– Variation in systolic blood pressure, as measured peripherally
–– Variation in the intensity of the heart sounds
–– Intermittent cannon A waves in the jugular venous pulses caused by the simultaneous
contraction of the atrium and the ventricles
–– Extra heart sounds

298
Q

Characterized by undulating rotations of the QRS complexes around the electrocardiographic
baseline.

A

Torsade de Pointes

299
Q

Antiarrhythmic drugs that prolong ventricular repolarization include

A
  • Quinidine
  • Procainamide
  • Disopyramide
300
Q

drugs that prolong ventricular repolarization include

A

–– Phenothiazines
–– Thioridazine
–– Tricyclics
–– Lithium

301
Q

conditions that prolong ventricular repolarization include

A

especially hypokalemia and hypomagnesemia

302
Q

Sudden auditory stimuli, such as the ringing of the telephone at night, may initiate Torsade de Pointes in a vulnerable individual with a ______

A

long QT interval syndrome

303
Q

TX of Torsade

______ or _____may suppress episodes of tachycardia and may be useful for emergency treatments

A

Cardiac pacing or an isoproterenol infusion

304
Q

______ is a very effective antiarrhythmic drug, and can be used in ventricular tachycardia, AF, and atrial flutter. Because it has a very long half-life (>50 days), drug interactions are possible for weeks after discontinuation.

A

Amiodarone

305
Q

The most severe side effects of amiodarone therapy are related to _____

A

the lungs and present as

cough, fever, or painful breathing

306
Q

What should be avoided in pts on amiodarone

A

many patients experience an exaggerated response to the harmful
effects of sunlight,

307
Q

Long-term administration of amiodarone may occasionally result in a______

A

blue-gray discoloration

of the skin

308
Q

Nitrates

  • In low doses, nitrates ______.
  • In medium doses, ______
  • In high doses, nitrates ____
A

increase venous dilation and subsequently reduce preload

nitrates increase arteriolar dilatation and subsequently decrease afterload and preload.

increase coronary artery dilatation and subsequently increase oxygen supply

CK IM (9 decks)

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