Cardio Flashcards
1
Q
Myocardial infarction is associated with pain that lasts______
A
> 20–30 minutes in duration.
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
3
Q
New paradoxical splitting is most often due to _______
A
left bundle branch block (LBBB), or anterior or lateral infarction.
4
Q
A new fourth heart sound can occur with _____
A
angina or infarction.
5
Q
An S3 is more likely due to underlying___
A
heart failure
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.
7
Q
_____is the single most important test for the evaluation of the cause of chest pain
A
ECG
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%).
9
Q
_____ is cardiac specific and is useful for the early diagnosis of acute myocardial infarction.
A
CK-MB
10
Q
the peak CK-MB level does not predict infarct size; however, it can be used
to detect ______
A
early reinfarction.
11
Q
Unlike troponin I levels, troponin T levels may be elevated in patients with _____
A
renal disease,
polymyositis, or dermatomyositis
12
Q
Patients with a normal CK-MB level but elevated troponin levels are considered to have ________
A
sustained minor myocardial damage, or microinfarction
13
Q
patients with elevations of both CK-MB and troponins are considered to have had ___
A
acute myocardial
infarction.
14
Q
Subtle findings such as loss
of lung volume or unilateral decrease in vascular markings may suggest _____
A
pulmonary embolism
15
Q
Dyspnea, tachycardia, and hypoxemia are prominent; pain is usually pleuritic, especially when pulmonary infarction develops
A
Pulmonary Embolism
16
Q
ECG of Pulmo Embo
A
S wave in lead I, Q wave in lead III, or inverted T wave in lead III
17
Q
May be preceded by viral illness; pain is sharp, positional, pleuritic, and relieved by
leaning forward; pericardial rub often present
A
Pericarditis.
18
Q
Pericarditis ECG
A
diffuse ST elevation occurs without evolution of Q waves;
19
Q
Pericarditis CKs
A
CK level usually normal; responds to anti-inflammatory agents
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
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.
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
23
Q
_____ is the single most important subgroup
that carries risk for IHD,
A
LDL cholesterol
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
25
______ have a higher risk of death from IHD, though less than cigarette
smokers
Cigar or pipe smokers
26
Studies in the general population have
| shown that the risk for cardiovascular events increases at BP _____
>110/75 mm Hg
27
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 _______
“IHD equivalent.
28
______as women age may contribute to a
| higher risk of heart disease after menopause
the decrease of natural estrogen
29
Manifestations of myocardial ischemia
* Anginal chest discomfort
* ST-segment deviation on ECG
* Reduced uptake of tracer during myocardial perfusion scanning
* Regional or global impairment of ventricular function
30
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 _______
“demand ischemia”
31
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 ______
“supply ischemia,
32
____ 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
Stable angina
33
In Angina,
A new_____ may be heard, suggesting a stiff ventricle due to ischemia
S4
34
Most patients with angina will have ECG changes during an attack. Most commonly,________is seen
ST segment
| depression
35
In stable angina, ST segment elevation occurs in ____ or ____
variant angina (Prinzmetal angina) where coronary artery spasm is responsible and rarely during ischemia caused by stable angina (where atherosclerotic disease is responsible).
36
The ______is the most useful test for evaluating the cause of chronic chest pain when there is concern about IHD (stable angina)
exercise treadmill test (exercise stress test)
37
Stress test
In order to do an appropriate analysis, a target heart rate must be reached which is computed as?
• Target heart rate is 85% of predicted maximum heart rate: 85% × (220 – patient’s age)
38
Interpretation of Stress test
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
39
An exercise stress test is considered positive for myocardial ischemia ______
when large (>2 mm) ST-segment depressions or hypotension (a drop of >10 mm Hg in systolic pressure) occur either alone or in combination.
40
Patients who are unable to exercise or walk should be considered________
for chemical stress testing, such as dipyridamole (Persantine) or dobutamine stress test
41
Stress test
_____ may blunt the heart rate during exercise and thus should be held 24
hours prior to the test
Beta blockers
42
____ 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
Digoxin
43
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.
Nuclear stress test
44
Compare nuclear vs regular stress test
Compared to regular stress tests, the nuclear stress tests have higher sensitivity and specificity (92% sensitivity, 95% specificity vs. 67% sensitivity, 70% specificity).
45
Used in people who are unable to exercise. A
| drug is given to induce tachycardia, as if the person were exercising
Dobutamine or adenosine stress test:
46
______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.
Stress echocardiogram:
47
______ is also used in patients with stable angina for (1) diagnosis and (2) prognosis/risk stratification
Cardiac catheterization
48
Target goals for hyperlipidemic patients with
coronary artery disease include:
1
2
3
* LDL <100 mg/dL
* HDL ≥40 mg/dL
* Triglycerides <150 mg/dL
49
The optimal LDL-cholesterol goal is considered to be______ for patients considered to be very high risk
<70 mg/dL
50
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
Coronary bypass graft
51
How is CABG done
The procedure involves the construction of 1 or more grafts between the arterial and coronary circulations.
52
Potential consequences of graft failure (loss of patency) include the_____
development of angina, myocardial
| infarction, or cardiac death.
53
PCI is most useful in ______
acute coronary syndrome (ACS)
54
Classification of ACS
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
55
ACS is due to _____
coronary vessel atherosclerotic obstruction with superimposed thrombotic occlusion
56
_____considered to have occurred if ischemia produces damage detectable by biochemical markers of myocardial injury (troponin I or CK-MB).
NSTEMI
57
If there are no detectable serum markers of myocardial injury 12–18 hours after
symptom onset, the patient should be diagnosed with ______
UA
58
Unstable angina is sometimes referred to as _______ angina
“crescendo” or “preinfarction”
59
untreated UA progresses to ____ in 50% of cases, thus the patient with new-onset or unstable angina should be hospitalized for intensive medical treatment
MI
60
High-risk features for patients with presumed UA/NSTEMI include:
* 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
61
Avoid______in patients likely to require emergency coronary bypass surgery.
Prasugrel and ticagrelor are alternatives
clopidogrel
62
Give_____along with the recommended antiplatelet therapy for UA/NSTEMI
heparin
63
This class of antithrombotic agents inhibits platelet function by blocking a key receptor involved in platelet aggregation.
Glycoprotein (GP) IIb/IIIa inhibitors
64
Glycoprotein (GP) IIb/IIIa inhibitors
_____is particularly recommended in high-risk patients in whom an invasive strategy is planned
Tirofiban or eptifibatide
65
Concomitant_____ is particularly beneficial and recommended in patients with
diabetes.
tirofiban
66
Early coronary angiography (within 48 hours) and revascularization are recommended in
patients with_______
NSTEMI and high-risk features, except in patients with severe comorbidities
67
The symptoms of MI last >20 minutes and do not respond completely to_____
nitroglycerin
68
A fourth heart sound (S4) is common due to a ______
stiffened ventricle
69
The second heart sound may be
| paradoxically split as the left ventricular contraction time increases due to_____
LBBB and weakened left ventricle
70
ECG of STEMI
* 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
71
Patients with STEMI usually have a _____
completely occluded coronary artery with thrombus at the site of a ruptured plaque
72
Patients with STEMI who present within 12 hours of the onset of ischemic symptoms should have ______
a reperfusion strategy implemented promptly
73
Reperfusion may be obtained with ___
fibrinolytic therapy or percutaneous coronary intervention (PCI).
74
Artery involved
Inferior infarction
Right coronary
75
Artery involved
Anteroseptal
Left anterior descending
76
Artery involved
Anterior
Left anterior descending
77
ECG changes with Lateral infarction
I, aVL, V4, V5, and V6
78
Artery involved with Lateral infarction
Left anterior descending
| or circumflex
79
EKG: posterior infarction
V1–V2: tall broad initial R wave, ST depression, tall upright T wave; usually occurs in association with inferior or lateral MI
80
Artery: : posterior infarction
Posterior descending
81
Hyperacute T waves (tall, peaked T waves in leads facing infarction)
Onset: ______
Disappearance: _______
Immediately
6–24 hours
82
ST-segment elevation
Onset: ______
Disappearance: _______
Immediately
1–6 weeks
83
Q waves longer than 0.04 seconds
Onset: ______
Disappearance: _______
One to several days
Years to never
84
T wave inversion
Onset: ______
Disappearance: _______
6–24 hours
Months to years
85
Thrombolysis benefits patients with all types of ST elevation infarction, but the benefit is
several times greater in those with _____
anterior infarction.
86
Prolonged persistence of antibodies to streptokinase may reduce the effectiveness of subsequent treatment; therefore, streptokinase should not be used if ______=
if used within the previous 12 months in the same patient.
87
consider a thrombolytic agent as an alternative to primary PCI in suitable candidates with:
* ST-elevation MI (>1 mm ST elevation in 2 contiguous leads)
| * New LBBB
88
Reperfusion therapy with either PCI or
| fibrinolysis is not routinely recommended in patients who are_______
asymptomatic and hemodynamically
| stable, and who present >12 hours after symptom onset
89
CABG surgery may also be considered in patients with____ or______
cardiogenic shock or in association with mechanical repair
90
______ should be prescribed in addition to aspirin for patients undergoing PCI with a stent
Clopidogrel or prasugrel
91
IV unfractionated heparin should be given as an initial bolus, adjusted to attain the_____
activated partial thromboplastin time (APTT) at 1.5 to 2 times control
92
Emergency bypass surgery should be considered in patients with STEMI and
(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
93
BB
____ and _____ particularly should
be used in patients after ACS who have heart failure
Metoprolol and carvedilol
94
Bradycardia in ACS examples: ________. These are treated acutely with atropine and temporary pacing if severe
sinus, atrioventricular junctional, idioventricular
95
Examples of Tachyarrhythmias (supraventricular) in ACS
atrial tachycardia, atrial fibrillation, atrial flutter, AV junctional; are seldom caused by ischemia
96
Conduction Abnormalities in ACS
• Atrioventricular nodal: ________
• Intraventricular:_______
first-, second-, and third-degree block
hemiblocks (left anterior, left posterior), bundle branch block, thirddegree
atrioventricular block
97
Examples of contractile dysfn in ACS
left ventricular, right ventricular, and biventricular failure; true ventricular aneurysm; infarct expansion
98
Examples of ischemic Cx of ACS
* 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
99
Mx of Pericarditis—Dressler syndrome (late)
Treated with aspirin, NSAIDs, and later steroids if there is no response.
100
MCC of sudden death in ACS
* Ventricular fibrillation (most commonly)
| * Ventricular tachycardia
101
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
sertraline and citalopram
102
_____ has also been found to be effective in treating depression.
Cognitive behavior therapy
103
```
Erectile dysfunction (ED) is prevalent among patients with CAD and post-MI (in some
series_____
```
~ 40%).
104
Sildenafil should be used cautiously in men post-MI who are taking nitrates of up to
55 mm Hg, because _____
it can cause a drop in BP. Due to this synergistic effect, it is therefore
contraindicated in patients taking nitrates
105
ED is a complication of the conditions that are primary risk factors for developing
CAD, in particular, ______
diabetes, hypertension, dyslipidemias, and arteriosclerosis
106
Who are at HR for sexual activity in CAD
```
those with unstable angina, MI within 2 weeks, poorly controlled hypertension,
severe CHF (New York Heart Association class III/IV), significant arrhythmias, severe cardiomyopathies;
```
107
What to do for HR CAD
patients should be referred for cardiovascular evaluation and stabilization prior to recommending resumption of sexual activity
108
_____ use has been documented to induce coronary vasoconstriction in nondiseased coronary segments but is more
pronounced in atherosclerotic segments
Cocaine
109
_____is a very uncommon condition in which episodes of severe angina are triggered when one of the major coronary arteries suddenly goes into spasm.
Prinzmetal angina, or variant angina,
110
SSx of Prinzmetal angina, or variant angina,
Prinzmetal angina usually occurs during periods of rest, most often at night and in the early morning hours.
111
Prinzmetal: _____ has been used to trigger coronary artery spasm in susceptible patients, confirming the diagnosis.
Ergonovine
112
Prinzmetal
Treatment with ______ or _____eliminates spasm in most of these patients.
calcium channel blockers or nitrates
113
Cardiac changes during HF include
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).
114
Compensatory changes in HF
* Cardiac: _____
* Neuronal:______
* Hormonal: ______
Frank-Starling mechanism, tachycardia, ventricular dilatation
increased sympathetic adrenergic activity, reduced cardiac vagal activity
activation of angiotensin-aldosterone system, vasopressin, catecholamines,
and natriuretic peptides
115
Systolic HF (systolic dysfunction) is due_____
to a loss of contractile strength of the myocardium accompanied by ventricular dilatation.
116
Systolic HF (systolic dysfunction) is accompanied by a ______
decrease in normal ventricular emptying (usually ejection fraction <45%)
117
Examples of systolic HF include _____
ischemic cardiomyopathy and dilated cardiomyopathy
118
_______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
Heart failure with preserved ejection fraction (diastolic dysfunction)
119
Heart failure with preserved ejection fraction (diastolic dysfunction) examples
The infiltrative cardiomyopathies (amyloidosis
120
In heart failure, intravascular congestion occurs with elevation of left ventricular diastolic and pulmonary venous pressures that eventually causes_____
transudation of fluid from the pulmonary
| capillaries into the interstitial space
121
____ develops when the rate of fluid
| accumulation goes above the rate of lymphatic absorption.
Pulmonary edema
122
Precipitating factors for HF
• 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
123
Most Common Causes of Acute Pulmonary Edema
```
Ischemia
Arrhythmia
Non-adherence with medication
Dietary indiscretion
Infection
```
124
______is the test-of-choice to confirm the diagnosis of HF and to classify the type (systolic vs. diastolic
Echocardiography
125
Chest x-rays are also used to aid in the diagnosis of heart failure. They may show _______
cardiomegaly, vascular redistribution, Kerley B-lines, and interstitial edema.
126
_____ 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.
Brain Natriuretic Peptide (BNP)
127
The BNP is almost always elevated ____ sensitivity) in patients with decompensated HF
(97%
128
_____are the basis of therapy and recommended for all patients with HF (especially systolic HF), irrespective of blood pressure status
ACE inhibitors
129
MOA of ACEi
ACE inhibitors through vasodilation reduce preload and afterload, thereby reducing right atrial, pulmonary arterial, and pulmonary capillary wedge pressures
130
______is the treatment of choice for the relief of acute
| pulmonary edema symptoms
Diuretic therapy, especially loop diuretics,
131
ACE inhibitors MOA _____
through vasodilation reduce preload and afterload, thereby reducing right atrial, pulmonary arterial, and pulmonary capillary wedge pressures.
132
Thiazide diuretics (hydrochlorothiazide) are useful only in _____
mild HF
133
_____ and _____ have been used as add-on therapy to ACE inhibitors in severe heart failure to prolong survival by presumed aldosterone inhibition.
Spironolactone and eplerenone (aldosterone antagonists)
134
Where is the site of action?
Captopril
Enalapril
Lisinopril
Arteriolar and venous ACE
| inhibitor
135
Where is the site of action?
Nitroprusside
Arteriolar and
| venous
136
Where is the site of action?
Nitroglycerin
Venous (arteriolar
| at high doses IV)
137
Where is the site of action?
Isosorbide
dinitrate
Venous
138
Where is the site of action?
Hydralazine
Arteriolar
139
Chronic adrenergic activation has been implicated in the pathogenesis of HF and thus
_______are an important part of HF therapy
b-adrenergic blocking agents
140
```
beta blockers have been demonstrated to
1
2
3
4
5
```
decrease mortality,
reduce hospitalizations,
improve functional class, and improve ejection fraction in several large-scale, randomized,
placebo-controlled trials.
141
Site of action
Thiazides (inhibits NaCl cotransport); used mostly for treatment of hypertension
• Hydrochlorothiazide
• Chlorothiazide
Distal tubule
142
Site of action
| Indapamide
direct vasodilator
Distal tube
143
```
Loop diuretics (inhibitors Na/K, 2Cl cotransport); most commonly used diuretics in
heart failure
• Furosemide
• Ethacrynic acid
• Bumetanide
```
Loop of Henle
144
Site of action
| Potassium-sparing diuretics
• Spironolactone
aldosterone antagonist
Distal tubule
145
Other vasodilators, such as a combination of ______, may be used when ACE inhibitors and ARBs are not tolerated or contraindicated (renal failure).
hydralazine and isosorbide
146
The addition of spironolactone in patients with severe CHF significantly reduces (about ____ relative risk) death and hospitalizations among treated patients.
30%
147
Spironolactone is used in patients with NYHA class _____
III-IV
148
Once the patient is started on spironolactone, ______ levels have to be monitored closely
serum potassium
149
_____ is an alternative to spironolactone that does not cause gynecomastia
Eplerenone
150
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_____
digitalis
151
What is the MOA of digitalis
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
Remember that K+ and digitalis compete for myocardium binding sites. Hyperkalemia will
_____ whereas hypokalemia results in _____
decrease digitalis activity,
toxicity
153
Digitalis indications
* CHF
* Atrial fibrillation/flutter
* Paroxysmal atrial tachycardia/SVT
154
Conditions which predispose to digitalis toxicity are:
* Renal insufficiency
* Electrolyte disturbances (hypokalemia, hypercalcemia, hypomagnesemia)
* Advanced age
* Sinoatrial and atrioventricular block
* Thyroid disease, especially hypothyroidism
155
Decreases digoxin
Binds digoxin in GI tract; interferes with
enterohepatic circulation
Cholestyramine, colestipol
156
Toxic Effects of Digitalis
* Nausea and vomiting
* Gynecomastia
* Blurred vision
* Yellow halo around objects
* Arrhythmias—
157
Arrhythmias of Digitalis—commonly
paroxysmal atrial tachycardia (PAT) with block, PVCs (premature ventricular contractions), and bradycardia
158
_____ are sometimes used in the management of severe acute HF (hospitalized patients).
```
Sympathomimetic amines (dopamine, doputamine) and phosphodiesterase inhibitors (amrinone,
milrinone)
```
159
```
In refractory HF (defined as progression of HF despite standard treatment), the patient may
be considered for:
1
2
3
```
biventricular pacing, implantable defibrillator, and heart transplantation
160
The automatic implantable cardioverter/defibrillator (AICD) is a standard therapy for_______
ischemic
| dilated cardiomyopathy
161
How does an IACD lower mortality?
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
A______ will “resynchronize” the heart when there is dilated cardiomyopathy and
a QRS >120 mSec.
biventricular pacemaker
163
• Dilated cardiomyopathy with a persistent ejection fraction <35%. What mechanical device?
AICD?
164
Dilated cardiomyopathy with a QRS wider than 120 mSec
biventricular pacemaker
165
CXR findings of Pulmo edema
* Prominent pulmonary vessels
* Effusions
* Enlarged cardiac silhouette
* Kerley B lines
166
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
MS
167
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)
* Hemoptysis
* Systemic embolism
* Hoarseness
168
Signs of MS
* Decreased pulse pressure
* Loud S1
* Opening snap following S2
* Diastolic rumble (low-pitched apical murmur)
* Sternal lift (due to right ventricular enlargement)
169
ECG findings
* May show signs of right ventricular hypertrophy
| * May show left and right atrial abnormalities
170
CXR of MS
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
MS
May show signs of pulmonary hypertension, including _______
Kerley B lines and increased
| vascular markings
172
MS Echocardiography
• 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
_____is the standard of care for MS
Balloon valvulotomy
174
When to do Sx in MS
Indicated when patient remains symptomatic (functional class III) despite medical therapy
175
_____if balloon dilation fails
Mitral commissurotomy or valve replacement,
176
Backflow of blood from the left ventricle into the left atrium, due to inadequate
functioning (insufficiency) of the mitral valve. Most commonly from ischemia
Mitral Regurgitation
177
MCC of MR
Common causes are hypertension, CHF, ischemic heart disease, rheumatic fever, and
any cause of dilation of the left ventricle
178
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
preload.
Afterload
179
Signs of MR
* 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
Echocardiography: The mitral valve can prolapse into the left atrium during systole in
cases of a ______
ruptured chordae or mitral valve prolapse.
181
____is the single most accurate test for MR
Catheterization
182
MR Tx
With medical therapy, the goal is to relieve symptoms by______
increasing forward cardiac output and reducing pulmonary venous hypertension
183
Tx of MR
* ARBs or hydralazine
* Arteriolar vasodilators (ACE inhibitors)
* Digitalis
* Diuretics
184
Criteria for Sx of MR
Criterion is an ejection fraction <60% or left ventricular end systolic diameter >40 mm.
185
The most common congenital valvular abnormality (2–3% population) typically
seen in young women
Mitral Valve Prolapse
186
Mitral valve prolapse may occur with greater frequency in those with _____
Ehler-Danlos syndrome, polycystic kidney disease, and Marfan syndrome
187
Signs of MVP
* 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
CX of MVP
* Serious arrhythmias
* Sudden death
* CHF
* Bacterial endocarditis (but does not mean routine dental prophylaxis is indicated)
* Calcifications of valve
* Transient cerebral ischemic attacks
189
2D echo findings for pts with MVP
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
MCC of AS
Calcification and degeneration of a congenitally normal valve; more common in the elderly population. This is the most common cause
191
Pathophysio of AS
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
AS
Forceful atrial contraction augments filling at the thick, noncompliant ventricle and generates a prominent ____ that elevates the left ventricular end-diastolic pressure.
S4 gallop
193
How does angina occur in AS
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
SSx of AS
• 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
AS
* Chest x-ray may present with______.
* Echocardiography shows ______
calcification, cardiomegaly, and pulmonary congestion
thick aortic valve leaflets with decreased excursion and LVH.
196
AS
Surgery (valve replacement) is advised when symptoms develop, which is when the
valve area is reduced_______.
below 0.8 cm2 (normal aortic orifice, 2.5–3 cm2)
197
AS
_____may be useful in those too ill to tolerate surgery.
Balloon valvuloplasty
198
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
Aortic valve sclerosis of the elderly, without stenosis
199
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
Hypertrophic obstructive cardiomyopathy
200
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
Mitral regurgitation
201
* 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
Pulmonic stenosis
202
____ and ____are the most common causes of aortic regurgitation
Systemic hypertension and ischemic heart disease
203
Conditions that may affect the ascending aorta and cause aortic regurgitation
```
–– Syphilis
–– Ankylosing spondylitis
–– Marfan syndrome
–– Rheumatic fever
–– Aortic dissection
–– Aortic trauma
```
204
Aortic regurgitation results in a volume overload of the left ventricle.
• The ventricle compensates by increasing its end-diastolic volume according to the
________
Frank-Starling mechanism.
205
Acute aortic regurgitation results in a ______than does chronic aortic regurgitation.
lower cardiac output, narrower aortic pulse pressure, and a smaller left ventricle
206
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. _____
Duroziez sign:
Austin-Flint murmur
207
ECG of AR
LV hypertrophy often with volume overload pattern (narrow deep Q waves in left precordial leads)
208
2D Echo of AR
Dilated LV and aorta; left ventricular volume overload; fluttering of anterior mitral valve leaflet
209
AR
Endocarditis prophylaxis is no longer recommended.
T
210
AR
Vasodilators such as an ______ are the standard of care
ACE, ARB, or nifedipine
211
AR when to do Sx
Perform surgery when the ejection fraction is <55% or left ventricular systolic diameter
is >55 mm.
212
MC Etiology of DCM
• Idiopathic: most common
213
Other Etiologies of Dilated (Congestive) Cardiomyopathy
* 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
ECG of DCM
sinus tachycardia, arrhythmias, conduction disturbances
215
2D echo of DCM
dilated left ventricle, generalized decreased wall motion, mitral valve regurgitation;
216
DCM
Catheterization: ______
dilated hypocontractile ventricle, mitral regurgitation
217
Tx of DCM
Patients are treated as those with systolic heart failure. ACE, beta blockers, and
spironolactone lower mortality
218
DCM
_______ may decrease risk of sudden death when the ejection fraction is <35%.
Implantable defibrillator
219
Hypertrophic Obstructive Cardiomyopathy
An abnormality on _____ has been identified in the familial form of the disease.
chromosome 14
220
Hypertrophic Obstructive Cardiomyopathy
The distinctive hallmark of the disease is unexplained myocardial hypertrophy, usually
with________
thickening of the interventricular septum.
221
What is the pathophysio in HOCM
Diastolic dysfunction is characteristic, resulting in decreased compliance and/or inability for the heart to relax
222
USual EF of pts with HOCM
Ejection fractions are often 80–90% (normal is 60%, ±5%), and the left ventricle may
be virtually obliterated in systole.
223
Characteristic murmurs of HOCM
Large jugular A wave, bifid carotid pulse, palpable S4 gallop, systolic murmur and
thrill, mitral regurgitation murmur
224
2Deco of HOCM
It typically shows hypertrophy, systolic
| anterior motion of mitral valve, and midsystolic closure of aortic valve
225
Tx of HOCM
* Beta-blockers
* Calcium channel blockers that reduce heart rate: diltiazem, verapamil
* Disopyramide, occasionally
226
the least common of the causes of cardiomyopathy.
It is myocardial disorder characterized by rigid noncompliant ventricular walls.
Restrictive Cardiomyopathy
227
Restrictive Cardiomyopathy etiologies
* Infiltrative: sarcoidosis/amyloidosis; hemochromatosis; neoplasia
* Scleroderma
* Radiation
228
PAthophysio of RCM
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
SSx of RCM
Elevated jugular venous pressure, edema, hepatomegaly, ascites, S4 and S3 gallop,
Kussmaul sign
230
ECG of RCM
EKG: low voltage, conduction disturbances, Q waves
231
2D Echo of RCM
Echo: characteristic myocardial texture in amyloidosis with thickening of all cardiac
structures
232
Cath findings of RCM
square root sign; elevated left- and right-sided filling pressures
233
Tx of RCM
There is no good therapy; ultimately results in death from CHF or arrhythmias;
consider heart transplantation
234
Etiology of acute pericarditis
* Idiopathic
* Infections (viral)
* Vasculitis—connective tissue disease group
* Disorders of metabolism
* Neoplasms
* Trauma
* Inflammation—uremia
235
CP of Acute Pericarditis
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
Pericardial friction rub (diagnostic of pericarditis) is a scratchy, high-pitched sound that has 1 to 3 components corresponding to
1
2
3
atrial systole, ventricular systole, and early diastolic ventricular filling
237
How to enhance friction rub?
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
CHaracteristic ECG of friction rub?
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
In idiopathic pericarditis, treatment with ________ is appropriate.
anti-inflammatory medications (NSAIDs, aspirin, corticosteroids)
240
Pericarditis
Adding_______to an NSAID decreases recurrence
colchicine
241
Serosanguineous pericardial fluid is a classic sign in ___ and _____
tuberculosis and neoplastic diseases.
242
Echo findings in pts with small effusions
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
In patients with large effusions, the heart may swing freely within the pericardial sac, and this motion may be associated with______
electrical alternans
244
CXR of perdicardial effusion
Chest x-ray may show a “water-bottle” configuration of the cardiac silhouette
245
A life-threatening condition in which a pericardial effusion has developed so rapidly
or has become so large that it compresses the heart.
Cardiac tamponade
246
SSx of cardiac tamponade
_____ characterized by a decrease in systolic blood pressure >10 mm Hg with normal inspiration, frequently is present
Pulsus paradoxus,
247
Paradoxical pulse is not diagnostic of cardial tamponade and can occur in
chronic lung disease, acute asthma, severe CHF, and in some cases of hypovolemic shock
248
_____is associated with acute tamponade; it includes low blood pressure, distended
neck veins, and decreased heart sounds
Beck’s triad
249
Mx of cardiac tamponade
* Pericardiocentesis
| * Subxiphoid surgical drainage
250
The diffuse thickening of the pericardium in reaction to prior inflammation, which results in reduced distensibility of the cardiac chambers
Constrictive Pericarditis
251
Constrictive Pericarditis
The fundamental hemodynamic abnormality is ______
abnormal diastolic filling.
252
Constrictive Pericarditis PE
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
Constrictive Pericarditis CT/MRI
Shows thickened pericardium; pericardial calcifications may be seen in tuberculous constriction
254
Cardiac cath findings of Constrictive Pericarditis
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
Basis of anatomical AV block
based on the site of block as determined by His bundle electrocardiography.
256
Clinical AV block
The 3 classic clinical types are first-, second-, and third-degree (or complete) AV block.
257
Pulse rate (PR) interval >0.20 s at a heart rate of 70 beats/min.
First-Degree AV Block
258
Causes of first degree AV block
```
–– Aging
–– Digitalis
–– Exaggerated vagal tone
–– Ischemia (diaphragmatic infarction)
–– Inflammation (myocarditis, acute rheumatic fever)
```
259
Types of Second-Degree AV Block
```
Type I (Mobitz I, Wenckebach)
Type II (Mobitz II)
```
260
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.
Type I (Mobitz I, Wenckebach)
261
Type I (Mobitz I, Wenckebach)
location of block
Usually AV nodal (supra-Hisian)
262
Type I (Mobitz I, Wenckebach)
Effect of carotiid sinus pressure
May increase degree of block
263
Type I (Mobitz I, Wenckebach)
Effect of atropine
Frequently shortens PR interval and increases AV conduction
264
Type I (Mobitz I, Wenckebach)
Consequences of progression to complete heart block
Escape focus usually junctional; narrow QRS
complex; rate >45 beats/min; Adams-Stoke
attacks uncommon
265
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.
Type II (Mobitz II)
266
Type II (Mobitz II)
Site of block
Infranodal (intra- or infra-Hisian)
267
```
Type II (Mobitz II)
QRS complex
```
```
Usually wide (bundle branch block) with infra-
Hisian block; narrow with intra-Hisian block
```
268
Type II (Mobitz II)
Effect of carotid sinus pressure/atropine
none
269
Type II (Mobitz II)
Consequences of progression to complete heart block
Escape focus infrajunctional (usually ventricular) wide QRS complex; rate <45 beats/min; Adams-Stoke attacks common
270
all atrial beats are blocked, and the ventricles are driven by an escape focus distal to the site of block
Third-Degree (Complete) AV Block
271
Third-Degree (Complete) AV Block
Most common cause in adults is simple fibrous degenerative changes in the conduction system that results from aging ______
(Lenègre disease)
272
Third-Degree (Complete) AV Block
SSx
Symptoms are associated with Adams-Stoke attacks and occasionally CHF.
273
_______ 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.
Adams-Stoke attacks
274
The bradycardia associated with complete heart block may lead to ______n patients with myocardial disease
congestive heart
| block i
275
In ______ HR greater than 100, the ventricular complexes are of normal width, evenly spaced, and a P-wave precedes
a QRS complex
sinus tachycardia,
276
Transient sinus tachycardia is occasionally the result of a rebound phenomenon following the discontinuation of ____
beta-adrenergic blocking drugs
277
______ 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)
Paroxysmal supraventricular tachycardia
278
Paroxysmal supraventricular tachycardia
80% are caused by_____
re-entry, mainly in the AV node
279
Paroxysmal supraventricular tachycardia
| Initial Tx
Initial therapy consists of maneuvers aimed at increasing vagal tone, particularly right
carotid sinus massage. Carotid sinus massage is followed by adenosine
280
Meds for Paroxysmal supraventricular tachycardia
* IV propranolol or esmolol, verapamil
| * IV digitalis
281
Morphology in MFAT
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
Where is MFAT usually seen
Generally seen in elderly patients or those with chronic lung disease who are experiencing respiratory failure
283
Tx of MFAT
Use diltiazem, verapamil, or digoxin; avoid beta blockers because of lung disease
284
_____ 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).
Atrial flutter
285
Atrial flutter
It has been associated with
* Chronic obstructive lung disease
* Pulmonary embolism
* Thyrotoxicosis
* Mitral valve disease
* Alcohol
286
Atrial flutter
Therapy is _______ if hemodynamically unstable (e.g., hypotension), digitalis,
verapamil, diltiazem, and beta-blockers
cardioversion
287
AF
The synchronization ensures that _____
electrical stimulation does not occur during the vulnerable phase of the cardiac cycle
288
Drugs proven effective for pharmacologic cardioversion of atrial fibrillation include:
amiodarone, dofetilide, flecainide, ibutilide, propafenone, and quinidine
289
Drugs used to maintain sinus rhythm in patients with atrial fibrillation include
amiodarone, disopyramide, dofetilide, flecainide, propafenone, and sotalol
290
______ 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
Pre-excitation
291
Pre-excitation is achieved by the _____
use of accessory pathways (Kent bundle).
292
WPW is associated with:
1
2
–– Paroxysmal supraventricular arrhythmias alternating with ventricular arrhythmias
–– Atrial fibrillation and flutter
293
WPW
If the patient is hemodynamically stable, then _______is the best medication.
procainamide
294
WPW
What Tx to avoid
Avoid digoxin, beta blockers and calcium-channel blockers, as they can
inhibit conduction in the normal conduction pathway
295
_______is defined as 3 or more consecutive beats of ventricular origin at a rate >120 beats/min. QRS complexes are wide and often bizarre
Ventricular tachycardia (VT)
296
VT causes
Cardiomyopathies and rarely seen in patients with ______
Metabolic derangements, such as ___
mitral valve prolapse
hypokalemia, hypercalcemia, hypomagnesemia, and
hypoxia
297
PE of VT
–– 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
Characterized by undulating rotations of the QRS complexes around the electrocardiographic
baseline.
Torsade de Pointes
299
Antiarrhythmic drugs that prolong ventricular repolarization include
* Quinidine
* Procainamide
* Disopyramide
300
drugs that prolong ventricular repolarization include
–– Phenothiazines
–– Thioridazine
–– Tricyclics
–– Lithium
301
conditions that prolong ventricular repolarization include
especially hypokalemia and hypomagnesemia
302
Sudden auditory stimuli, such as the ringing of the telephone at night, may initiate Torsade de Pointes in a vulnerable individual with a ______
long QT interval syndrome
303
TX of Torsade
______ or _____may suppress episodes of tachycardia and may be useful for emergency treatments
Cardiac pacing or an isoproterenol infusion
304
______ 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.
Amiodarone
305
The most severe side effects of amiodarone therapy are related to _____
the lungs and present as
| cough, fever, or painful breathing
306
What should be avoided in pts on amiodarone
many patients experience an exaggerated response to the harmful
effects of sunlight,
307
Long-term administration of amiodarone may occasionally result in a______
blue-gray discoloration
| of the skin
308
Nitrates
* In low doses, nitrates ______.
* In medium doses, ______
* In high doses, nitrates ____
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
