Cardio Block 1

Question 1

Location, Quality, Duration, Worse/Better, S/Sxs of Angina

Answer 1

L: retrosternal; radiates to neck, jaw, arm, shoulder, “elephant on chest”, Levine Sign
Q: pressure/burn/squeeze/heavy
D: 2-10min
A/R: exercise, cold, stress / rest, nitro
S/Sxs: S3 or papillary muscle dysfunction murmur during pain episode, sweating (SNS), Nausea (PNS), Tachy

Question 2

Location, Quality, Duration, Worse/Better, S/Sxs of Rest or Unstable angina

Answer 2

L: same as angina
Q: same as angina but more severe
D: <20min
A/R: same as angina, dec tolerance for exertion/at rest
S/Sx: transient heart failure can occur

Question 3

Location, Quality, Duration, Worse/Better, S/Sxs of MI

Answer 3

L: substernal, radiates similar to angina
Q: heavy, pressure, burning, burning, constriction
D: >30min, but variable
A/R: unrelieved by nitro/rest
S/Sx: N/V, SoB, sweating, weak

Question 4

Location, Quality, Duration, Worse/Better, S/Sxs of Pericarditis

Answer 4

L: over sternum/apex, radiates to neck or L shoulder
Q: sharp, stabbing, knife-like
D: hrs to days w/ waxing/waning
A/R: deep breath, rotating chest, supine / sitting, leaning
S/Sxs: friction rub (best heard LLD)

Question 5

Location, Quality, Duration, Worse/Better, S/Sxs of Aortic Dissection

Answer 5

L: anterior chest, radiates to back
Q: excruciating, tearing, knife-like
D: sudden and unrelenting
A/R: HTN, Marfan Syndrome
S/Sxs:aortic murmur, HTN, BP asymmetry, large/displaced PMI

Question 6

Location, Quality, Duration, Worse/Better, S/Sxs of PE

Answer 6

L: substernal or over site of PE
Q: pleuritic or angina-like
D: sudden onset, lasts minutes-hrs
A/R: breathing worsens it
S/Sxs: tachy, dyspnea, Signs of RVFailure

Question 7

Location, Quality, Duration, Worse/Better, S/Sxs of PHTN

Answer 7

L: substernal
Q: pressure, oppressive
D: similar to angina
A/R: worse w/ effort
S/Sxs: pain w/ dyspnea, signs of PHTN

Question 8

What are the key terms associated with the quality of pain for non-cardiac causes of chest pain?

Answer 8

Pneumo w/ pleurisy- pleuritic, local
Spot Pneumo- sharp, very local
MSK d/o- ache
Herpes- burning, itch
Esophageal reflux- burning, visceral discomfort
Ulcer- visceral burning, ache
Gallbladder- visceral
Anxiety- variable and transient

Question 9

What can be heard/best assessed in the aortic area?

What can be heard/best assessed in the pulmonic area?

Answer 9

Ascending aorta
Aortic valve
Ejection clicks
Aortic aneurysms

Pulmonic valve, artery, regurgitation
Lungs

Question 10

What can be heard/best assessed at Erb’s Point?

Answer 10

Aortic/pulmonic origins
HOCM
Aortic insufficiency (blowing)

Question 11

What does it mean if cardiac pulsations are visible laterally to the LMCL?

What does a sustained apex impulse mean?

Answer 11

Cardiac enlargement

LVH

Question 12

How does aortic dissection effect the PMI?

What else can cause these changes to PMI?

Answer 12

Enlarged and displaced

Volume overload, cardiac dilation, hyper-dynamic apical pulse
Pressure overload- hypertrophy, sustained apical pulses

Question 13

Blocked arteries have what characteristics?

Blocked veins have what characteristics?

Answer 13

Diminished/absent pulse, swelling, pain, cold to touch

Swelling, pain

Question 14

What forms the anterior border of the heart on a lateral view?

What forms the posterior border?

Answer 14

Inferior- RV, Superior- pulmonary trunk

LV and part of IVC

Question 15

Characteristics of the S1

Answer 15

Heard at Apex
Forced closure of M/T valves from ventricles in sequence w/ carotid pulse Onset of systole
Mitral= S1 but Tricuspid happens at the same time

Question 16

Characteristics of the S2

Answer 16

Closure of A/P valves from aortic/pulmonary artery pressure
Onset of diastole
A- R2IC, more intense
P- L2ICS

Question 17

Characteristics of S3 heart sounds

Answer 17

Most of the time= pathologic
occurs after S2 during ventricle filling as a dull/low pitched sound indicating a volume overload
Indicative of ventricular failure
Systolic HF

Question 18

What can cause a volume overload and lead to an S3?

Pathological S3 is AKA ? and usually associated w/ ?

Answer 18

CHF, M/T insufficiency

Ventricular gallop- blood entering ventricle during rapid filling phase of diastole creating an early diastole sound and seen w/ swollen lower extremities

Question 19

Characteristics of S4 heart sounds

Answer 19

Low pitch from HTN of any type late in diastole when atria contract before S1, atrial filling against stiff/non-compliant ventricle

Question 20

What type of PT positioning is needed to listen for an S4?

What is a pathologic S4 AKA ? and is from ?

Answer 20

Apex with PT in left lateral decubitus

Atrial gallop from pressure overload from HTN of any type

Question 21

Define Physiological S2 Splitting

Answer 21

Aortic valve closes before pulmonic valve and can be exaggerated by inspiration causing more blood return to RV and prolonging the emptying of the chamber and delay in pulmonic valve closure
Pulmonic region between 2-3LICS

Question 22

When viewing heart valves from a superior view, what is the sequence of valves from anterior to posterior?

Congenital bicuspid valves are especially linked with what syndrome?

Answer 22

Pulmonic Aortic (Ant), Tricuspid Mitral (Post)

Marfan Syndrome

Question 23

Where is the Mitral Valve located and how many leaflets does it have?

Answer 23

Between LA and LV

2: anteromedial, posterolateral

Question 24

Where is the Tricuspid Valve located and how many leaflets does it have?

Answer 24

RA and RV

Anterior, Medial and Posterolateral

Question 25

What does the RCA supply blood to?

Answer 25

``` PRAIS P; II, III, aVF Posterior 1/3 of septum R atrium/ventricle AV node Inf/Post LV SA Posterior descending artery- supplies part of septum and accounts for 85% of PTs having right dominant circulation ```

Question 26

What does the Left Main Coronary artery turn into and supply blood to?

Answer 26

LAD- ABA; V1-V4 anterior 2/3 of septum, bundle branches, anterior LV (bulk of ventricle) ``` LCX- SLAP P; V5-V6 1st diagonal=I, aVL= high lateral SA node Lateral LV Atrium, L Posterior LV PDA 8-10% of PTs= Left Dom Circulation ```

Question 27

Right dominant circulation means supply from ? Left dominant circulation means supply from ? Codominant circulation receives blood from ?

Answer 27

RCA LCX (LMCA) RCA and Circumflex

Question 28

What is K role in cardiac action? What is Ca role in cardiac action?

Answer 28

Repolarization of AP Released from sarcoplasma reticulum from ryanodine receptor/Ca release channel to activates muscle contraction by binding to Troponin C to allow actin-myosin cross bridge to occur to shorten sarcomere.

Question 29

What is the sequence of structures signals pass through in the hearts conduction system?

Answer 29

``` SA Node Inter-atrial/nodal pathways AV node AV junction/Bundle of His Intraventricular septum- bundle branches Left Anterior/Posterior fascicles Purkinje fibers Myocardial cells in ventricles ```

Question 30

Define Cardiac Output

Answer 30

Measurement of the heart's primary function of delivering oxygenated blood to tissues CO= SV x HR

Question 31

# Define Preload What are the 4 components?

Answer 31

Load from IVC/SVC that stretches the heart muscle prior to contraction, the ventricle wall tension at end of diastole Total blood volume, Distribution of blood volume, Atrial contraction, Compliance

Question 32

What is used is Preload measured? How is it measured?

Answer 32

Ventricular End Diastolic Volume/Pressure DIRECTLY measured by L Heart Catheterization ESTIMATED during R Heart Catheterization from Pulmonary Wedge Pressure

Question 33

# Define Afterload It is determined by what two factors?

Answer 33

Force that LV must pump against ``` Aortic pressure (mean BP) Volume of ventricular cavity/thickness of wall ```

Question 34

How do the adrenergic NS and catecholamines inc/dec myocardial contractility? What positive inotropic drugs increase myocardial contractility?

Answer 34

Inc Ca by stimulating B1 receptor Digoxin, Isoproterenol, Dopamine, Dobutamine, Caffeine

Question 35

What substances decrease myocardial contractility?

Answer 35

Negative ionotropic drugs Anti-arrhythmics- Quinidine, Procainamide, Disopyramide CCB/BBs

Question 36

What physiological changes/effects can initially cause tachycardia but at toxic levels/times cause bradycardia?

Answer 36

``` Hypoxia Hypercapnea Ischemia/Infarct Acidosis ETOH ```

Question 37

What are the H's of ACLS?

Answer 37

Hypovolemia- tachy, narrow QRS; Saline Hypoxia- brady, cyanosis H+ excess- low amplitude QRS; Sodium BiCarb Hypoglycemia- Dextrose Hypo/perkalemia- po=flat T and origin of U, Mg infusion; per= peaked T, wide QRS; CaCl, NaBiCarb Hypothermia

Question 38

What are the T's of ACLS?

Answer 38

Tension Pneumo- brady, narrow QRS Tamponade- tachy, narrow QRS Toxins- prolonged QRS Thrombus- pulmonary= tachy, narrow QRS; acute MI= abnormal ECG

Question 39

What are the causes of PEA narrow complexes? What will be seen on EKG? What type of issues cause it? What imaging can be done and r/o a DDx?

Answer 39

Tamponades, Tension Pneumo, Mechanical hyperinflation, PE Narrrow QRS, mechanical/RV issue Acute MI, myocardial rupture Bedside US: LV hyperdynamic, pseudo-PEA

Question 40

What are the causes of PEA wide complexes? What will be seen on EKG? What kind of issue causes it?

Answer 40

Severe hyperkalemia, Na channel blocker toxicity Wide QRS, metabolic/LV problem Acute MI pump failure LV hypo/akinetic, true PEA

Question 41

Where are baroreceptors located? What drug influences both inotropic and chronotropic results?

Answer 41

Carotid sinus, Aortic bodies, Base of heart Epi- inc HR, inc contractility

Question 42

Define Ejection Fraction

Answer 42

End diastolic volume ejected from ventricles during systolic contractions used to assess primary cardiac function Normal= 55-75% EF= SV/end diastolic volume

Question 43

How is ejection fraction measured?

Answer 43

``` Echo- done most of the time Nuclear Ventriculography (MUGA) MRI Gold Standard- cardiac catheterization (R sided is best, exact done w/ L sided) ```

Question 44

Cardiac hypertrophy causes what heart sounds that can be heard on physical exam? What are the disadvantages of this hypertrophy?

Answer 44

S3 and S4 Increased stiffness and heart O2 demand

Question 45

What effects can cause hypertrophy? What effects can cause dilation?

Answer 45

Chronic contraction against high after load Prolonged increase of EDV/EDP from high preloads

Question 46

What type of heart performance change occurs with cardiac dilation? What are the disadvantages of this dilation?

Answer 46

Initially, increased Frank Starling that tops out and results in decreased CO Increased wall stress- LaPlace Increased myocardial O2 demand

Question 47

PTs presenting with chest pain need x-rays done within ? time frame? What types of issues can be seen/identified?

Answer 47

30min Chamber enlargement, Cardiomegaly, Enlarged pericardial sac, Ventricular aneurysms

Question 48

How long does it take for ventricular aneurysms to appear post-MI? What are the three types of holosystolic murmurs?

Answer 48

7 days MR*, TR, VSD Systolic murmurs from papillary muscle rupture

Question 49

What four issues can be identified in the great vessels on a chest x-ray?

Answer 49

Calcification- severity (measured w/ continuous wave Doppler) Aortic aneurysms Pulmonary artery dilation Pulmonary venous congestion

Question 50

What are the primary indications for ordering a CT for cardiac issues?

Answer 50

Gold standard- chronic constrictive pericarditis Assess great vessels- aortic dissection of STABLE PT Pericardial abnormalities

Question 51

CT images of the heart can be used to evaluate what four structures?

Answer 51

Great vessels Pericardium Myocardium Coronary arteries

Question 52

What are Electron Beam CT scanner used for?

Answer 52

AKA "ultra fast" TOC to evaluate pericardial disease and cardiac tumors Coronary artery calcification- Ca within a vessel

Question 53

Define Agatstan score

Answer 53

Data from EBCT that correlates to atherosclerotic plaque burden, shows CA calcification Considered cardiac risk predictor independent of other risk factors

Question 54

MRI of the heart are AKA and best used for ? What type of material is used the dye?

Answer 54

CMR, differentiating tissues even w/out contrast Gadolinium- find infarcted/viable myocardium

Question 55

What is a CMRA? What are they utilized for?

Answer 55

Coronary angiography- non=invasive, contrast free image High sensitivity/accuracy for CAD in LMCA, proximal points of coronary vessels and congenital coronary abnormalities

Question 56

What are the five modes of an Echo What are the two types of Echos?

Answer 56

1D (M-mode), 2D, 3D, 4D (animations), Doppler- blood flow, function Trans-Thoracic Trans-Esophageal- Gold Standard

Question 57

What are the indications for ordering an echo?

Answer 57

Valve lesions- quantifies regurgitation and stenosis Ventricular assessment- thickness, mass, estimate EJF CAD- post-MI motion abnormalities, quality of RV function Cardiomyopathy Pericardial disease

Question 58

What type of test would be ordered to assess a suspected stenotic heart valve? What do all post-MI PTs receive prior to discharge home?

Answer 58

Doppler Echo Echo

Question 59

What are the 3 types of cardiomyopathy? What test is always ordered for any type?

Answer 59

Dilated, HCM, Restricted Echo

Question 60

What is the pay off and down side of using a TTE?

Answer 60

Visualize anterior heart- RV Can't see posterior heart Bad window from "fluffy"

Question 61

What info does TTE provide?

Answer 61

``` B PLEAV Blood flow direction (regurg) Paradoxical septum motion LA size Estimated EF Assess LV/RV dilation Valve structure assessment ```

Question 62

If exact, definitive LV EF is needed, what test? What if an estimate is needed?

Answer 62

L sided cath TTE

Question 63

What is the primary advantage of doing TEEs?

Answer 63

Increased sensitivity/specificity anatomic abnormality detection Highly specific for aortic dissection, endocarditis, prosthetic/mechanical valve dysfunction LA thrombus prior to cardioversion

Question 64

What additional test can be performed with either TEE or TTE? TEEs are performed if ? is suspected in the PT?

Answer 64

Venous saline agitation- Bubble Study: identifies intracardiac shunt (ASD/VSD) Thrombus

Question 65

What is the only study that can be used to visualize/assess the appendage on the LA? Why is this capability unique/important?

Answer 65

TEE Majority of cardiac thrombus originate from here

Question 66

TEEs allow for user to focus on one structure at a time in a specific pattern in what sequence?

Answer 66

``` Mitral valve and L chambers Aortic valve L atrial appendage*** R side structures Interatrial septum Base Transgastric area Aorta- asc and desc ```

Question 67

Other than CTs, what is the only other test that allows for visualization and assessment of the aorta, both ascending and descending? If a PTs BP is below ?/? do NOT put them in scanners, instead order ? study

Answer 67

TEE- used for unstable PTs w/ sedation 90/60, TEE

Question 68

Normal HR for EKG Normal P wave duration Normal PR Interval

Answer 68

50-100 <0.12 msec 90-200 msec

Question 69

Normal QRS duration Normal QTCs Normal QRS axis

Answer 69

75-110 msec M: 390-450; F: 390-460 msec -30 - +90*

Question 70

What are the HR for newborns, 2, 4 and 6yrs old?

Answer 70

New: 110-150 2: 85-125 4: 75-115 6: 60-100

Question 71

What is the criteria for the LAFB and LPFB?

Answer 71

LAFB- <0.12 sec, -45 - -90*, delayed precordium transition qR aVL, normal QRS LPFB- <0.12sec, +90 - +180*, delayed precordium transition rS I, aVL, aR in III and aVF, normal QRS

Question 72

EKGs must be done within ? minutes of PTs presenting? What is the dose of MgSulfate used in V-Fib or pulseless V-Tach?

Answer 72

10m, same as triage time frame 1-2f IV for polymorphic VT

Question 73

What is the TOC for assessing the LV function? What is the TOC for assessing myocardial perfusion?

Answer 73

MUGA (AKA Radionuclide Ventriculography)- determines L/R ventricular ejection fraction through T-99m labeling to show blood passing through heart/vessels, ischemia/infarction, and assesses myocardial metabolism PET scan

Question 74

Most CA cells work in ? environments EF from MUGA are usually similar to EJ estimates from ? test?

Answer 74

Anaerobic Echos

Question 75

What are the advantages of MUGA tests? What are the disadvantages of MUGA tests?

Answer 75

30 FAV Accuracy, RV /LV info simultaneously, No habitus limitations, 30m or less RAV Radiation No info on valves Less accurate for PTs w/ arrhythmias

Question 76

What tags are used in cardiac PET scans?

Answer 76

Assessment of perfusion and viability with N-13, Fl-18 or Ru-82 to show areas of impaired flow or injury

Question 77

When are Holter Monitors used on PTs? When is an Event/Loop monitor used on PTs?

Answer 77

Continuous ECG for 24-48hrs for suspected frequent arrhythmias/syncope or dizzy Usually the FIRST non-invasive cardiac rhythm assessment ordered 3 days to 3wks for infrequent arrhythmia Sxs or PTs w/ non-Dx Holter evaluation

Question 78

When is an Implantable Loop recorder used?

Answer 78

PTs w/ infrequent but concerning Sxs that suggest pathological arrhythmia/unexplained syncope

Question 79

What test is ordered for all post-MI PTs prior to starting rehab? Other reasons for ordering a stress test can include ? four things?

Answer 79

Cardiac stress test Prognosis, Function, Therapy effectiveness, Evaluate exercise induced arrhythmia

Question 80

What are the absolute contraindications for ordering stress tests?

Answer 80

``` SPAM HEADS STEMI <2 days Physically disables Acute pericarditis (less than 2wks) Myocarditis ``` ``` Sx HOCM Endocarditis High ACS risk HF- decompensated Severe aortic stenosis ```

Question 81

If PT has high risk of ACS, no stress tests can be done. What test needs to be ordered? What Dx can PT have and STILL do a stress test?

Answer 81

Coronary angiogram Chronic pericarditis (more than 2wks)

Question 82

Define Baye's Theorem

Answer 82

Probability of a PT having a Dz after a Dx test is completed (Post-Test probability) related to disease probability before the test (Pre-Test Probability) and probability the test provides a true result Post Test Prob= Pre-Test x Likelihood ratio

Question 83

When do PTs have a high probability of having CAD

Answer 83

>85% Angina in older PTs- >40 M; >60 F Angina in PTs w/ combination of risk factors- DM, Smoking, Hyperlipidemia

Question 84

When do PT have an intermediate risk of CAD?

Answer 84

15-85% Younger PTs, <40 M; <60 F Angina or non-angina in older PTs >40 M; >60 F PTs with multiple risk factors

Question 85

When do PTs have a low probability of CAD?

Answer 85

<15% | Possible angina in PTs w/out combo of risk factors

Question 86

What baseline EKG abnormalities which preclude EKG based testing?

Answer 86

``` WALL WPW Any ST depression 1mm or more LVH/Digoxin therapy w/ any ST depression LBBB, paced rhythm or non spcifiv IVCD ```

Question 87

What is the most common treadmill protocol?

Answer 87

Bruce protocol- requires PT to reach 85% of max HR w/ 60-65% sensitive/80-85% specific for CAD Max= 240 - Age

Question 88

Cardiac stress tests are performed and continued until one of what four events occur?

Answer 88

``` PAST PT is fatigued Angina Signs of myocardial ischemia in ECG Target HR reached ```

Question 89

Treadmill stress tests are done to provide info on what 5 things?

Answer 89

``` Local TREP Localize areas of ischemia for Tx via Echo, EKG or PET Therapy decision making Risk of CV event Exercise capability Prognosis ```

Question 90

What are the markedly positive test findings of a treadmill stress test?

Answer 90

``` V SIPS Ventricular arrhythmia develops SBP decreases during exercise Ischemia on EKG within 3min of starting/lasting 5min after stopping PT can't exercise for 2min ST depression >2mm ```

Question 91

How do pressures change as blood progresses through the heart?

Answer 91

``` *Low Press RA: 2-8 RV: 15-30/2-8 PA: 15-30/4-12 PCW: 2-10 *Start of high press LA: 2-10 LV: 100-140/3-12 Aorta: 100-140/60-90 ```

Question 92

When measuring wedge pressure via R-sided cath, what is it AKA?

Answer 92

Swan Gams R sided cath

Question 93

What are the therapeutic and diagnostic indications for a L-sided cath?

Answer 93

Access through F, B, A and is most common type Balloon- CAD, C Shock, V stenosis Intracardiac shunt closure ``` Cant Left w/ Painful Heart Coronary anatomy in PUNCS LV function Prox aorta dz Hemodynamics pericardial con/restriction ```

Question 94

Where is access for a R-sided cath obtained?

Answer 94

Subclavian, Internal Jugular, Brachial or Femoral vein w/ balloon tipped catheter (Swan Ganz) w/out need of fluoroscope

Question 95

What measurement is indicative of the pressure in the Left Atrium? When are they done?

Answer 95

Pulmonary Capillary Wedge Pressure provides estimation Admitted ICU, not done on Out-PT basis

Question 96

What does an elevated wedge pressure mean? What does a reduced pressure mean?

Answer 96

Volume overload- wet (S3 sound, 3rd spacing) Volume depletion- dry (give fluids)

Question 97

What are the indications for a R-sided cath?

Answer 97

AH AS ES ED PM Assess filling pressures and CO in PTs w/ HF Volume/vascular resistance in PTs w/ sepsis Evaluate intracardiac shunts Evaluate pericardial disease Peri-operative monitoring PTs w/ high risk of HF during procedures

Question 98

What are the relative contraindications for doing caths?

Answer 98

``` DIPS BARS Digitalis toxicity Infection Psych illness Stroke in past month Bleeding Anemia Renal impairment Systemic HTN ```

Question 99

What are the primary diagnostic indications for electrophysiologic studies? What are the primary therapeutic indications?

Answer 99

Recurrent/difficult arrhythmia including SVT, V-Tach, sudden death Assess pharmacologic/implanted device efficacy Ablation of recurrent arrhythmias unresponsive to medical therapy

Question 100

What tests can be done for PTs 4 days post-MI to test function? What are the four steps of the clinical approach to a cardiac PT?

Answer 100

Echo, MUGA, Stress test Anatomic/Physiologic Etiology Function

Question 101

What are the cardinal Sxs of heart dz?

Answer 101

D FACES | Palpitations, Dyspnea** Fatigue, Angina, Claudication, Edema, Syncope

Question 102

``` Sxs of MI Sxs of Angina Sxs of Pericarditis Sxs of Aortic Dissection Sxs of Valve Dz Sxs of CHF Sxs of Tamponade ```

Answer 102

Pressure radiating into L arm Pain resolving w/ rest: pressure, squeeze, tight, heavy Feels better when leaning fwd Sharp or ripping/tearing Associated w/ Sxs: Aortic stenosis= syncope Swollen extremities Dyspnea, inability to move fatigue

Question 103

Atypical MIs can happen in female, elder, or diabetic PTs and can have pain located where or accompanied ? Any PT with ? pain needs to be worked up as an MI until proven otherwise

Answer 103

Neck, Back, Jaw, Head, Belching Jaw

Question 104

What two CV causes of chest pain present with dyspnea? What three non-CV causes of chest pain present w/ dyspena?

Answer 104

Angina: 2-10min of pain MI: +30min of pain PE, Pneumonia w/ pleurisy, Spot Pneumo

Question 105

What would be seen on an EKG if PT had PHTN? What type of EKG axis deviation is seen w/ PEs?

Answer 105

Lead 2, Large P-wave +2.5mm w/ dyspnea Q1S3T3, RAD/ERAD

Question 106

Pink frothy sputum is usually associated w/?

Answer 106

PE or MS

Question 107

What cardiac issues can cause palpitations? What are the non-cardiac causes of palpitations?

Answer 107

V CAPS Valve Dz, Cardiomopathy, A-Fib/Flutter, , Prematures, SVT Anxiety, Stimulants, ETOH Hyperthyroid- Low TSH, High T3/4, isolated systolic HTN

Question 108

What are the 3 types of edema? What is the sequence of edema accumulation?

Answer 108

Peripheral Abdominal (ascites) Dependent- pitting (3rd spacing) Lower extremities, neck, ascites

Question 109

What are the 8 (5 modifiable, 3 non-modifiable) traditional atherosclerotic risk factors? What is the limit for defining HTN? What are the ages for m/w when risks increase?

Answer 109

Smoking, HTN, Dyslipidemia, DM, Obese/Dec PT Adv Age, Male, FamHx (consider high risk if adopted) >140/90 on three different visits M:>45; W: >55

Question 110

Diabetics have a ___ increase for CVDz What risk factors contribute to metabolic syndrome and which one is omitted?

Answer 110

3-5x higher HTN, Hypertriglyceridemia, Low HDL, Insulin resistance, Visceral obesity (NO LDL)

Question 111

What type of FamHx is of concern for cardiac PT risk factors?

Answer 111

M: 1* relative w/ CAD Dx before 55 W: 1* relative w/ CAD Dx before 65

Question 112

What are the Non-Traditional risk factors for cardiac PTs?

Answer 112

``` Homocysteine Lipoprotein Small LDL size Pro-inflammatory markers Subclinical atherosclerosis Coronary calcification- seen on EBCT End stage renal Dz Chronic inflammatory dz (Chrons, Lupus) HIV/AIDS ```

Question 113

Where does homocysteine come from? What does it require?

Answer 113

Methionine metabolism B12 and Folate

Question 114

PTs w/ congenital deficiencies related to homocysteine metabolism will be at early risk of ? What happens when the AA rises to dangerous levels and what is done about it?

Answer 114

Premature atherosclerosis CV events, PO folate is given but no evidence showing decreased events

Question 115

What is the circulating lipoprotein that is similar to LDL Lipoprotein A levels are highly dependent on ? factor

Answer 115

Lipoprotein A- B100 Inheritance, >20mg/dl= inc risk of CVDz

Question 116

LDL numbers are correlated with the levels of ? What is the acute phase reactant?

Answer 116

Insulin resistance CRP- reflects instability rather than burden and not independently reliable unless PT has INTERMEDIATE risk

Question 117

What imaging modality is used as a screening tool for CAD in ASx PTs What is a bad score from this test?

Answer 117

CT scan EBCT score +100= atherosclerotic

Question 118

Normal chest is ____ than it is _____ Abnormalities of the chest shape can lead to secondary cardiac conditions including ?

Answer 118

Wider than deep PHTN

Question 119

# Define Pectus Excavatum Define Pectus Carinatum

Answer 119

AKA Funnel Chest; lower sternum is depressed causing heart/great vessel compression Sternum displaced anterior which increases A/P diameter and compresses costal cartilages (COPD/Barrel, Obese, Age)

Question 120

# Define Thoracic Kyphoscoliosis What leads are Septal, Anterior, Lateral

Answer 120

Abnormal spinal curvature and vertebrae rotation deforms the chest, possible abnormal lung sounds 1, 2- Septal 3, 4- Ant 5, 6- Lat

Question 121

What causes Regularly Irregular HRs What causes irregular irregular HR?

Answer 121

Cadence ie- ventricular trigeminy A-fib/flutter

Question 122

What is cyanosis usually associated with? What is abnormal/different about PTs presentation that are in septic shock?

Answer 122

Increased levels of reduced/unsaturated Hgb HOTN but warm

Question 123

What are the 3 things that primarily cause peripheral cyanosis? What causes central cyanosis?

Answer 123

Cold/vasoconstriction response, HF, Shock- circulatory failure, PT will be cold w/ HOTN Complex etiologies causing impaired oxygenation (cardiac/pulmonary R to L shunting

Question 124

# Define Eisenmenger Syndrome Define Erythrocytosis and when is it seen

Answer 124

Condition that causes increased pressure from R side to L side of heart through ASD/VSD Too many RBCs, seen in PTs w/ chronic etiologies that are compensating to their cyonotic state (CA, Heart Dz/F)

Question 125

What does Pallor of the sclera indicate What three areas can be checked?

Answer 125

Anemia- inadequate Hgb Check conjunctiva, lips and mucous membranes

Question 126

What are causes of bilateral edema? Severe systemic edema due to cardiac causes may manifest as ? or ?

Answer 126

``` CV Dz (most commonly HF, especially R sided) Kidney Dz associated w/ proteinuria, hypoalbuminemia ``` Sacral edema or Hepatomegaly

Question 127

What conditions can cause an enlarged PMI?

Answer 127

HTN, HCM, LVH, Atrial Myxoma (benign tumor in L atrium that enlarges and act like mitral stenosis, causes shifting of heart, most common benign tumor)

Question 128

JVP is usually associated with ? Why is measuring JVP in PTs w/ visible JVD not routinely done?

Answer 128

Volume overload like in CHF (+S3) Little/no benefit since JVD= abnormal increase of CVP

Question 129

What is the difference between the arterial and venous pulses in the neck? Where does the JVP fill from?

Answer 129

``` Arterial= single upstroke Venous= two peaks and two troughs per cycle ``` Above from SVC

Question 130

How does inspiration or posture alter the JVP?

Answer 130

Resp- volume of atria increases, dec w/ inspiration Post- dec as PT sits up and if they're healthy

Question 131

Interpretation of the JVP waveform determines ? 3 things What are the 5 elements of the wave form?

Answer 131

Structure, function, electrical abnormalities of heart, primarily on R side ``` A wave X descent C wave V wave Y descent ```

Question 132

Characteristics of JVP "a wave"

Answer 132

Atrial contraction Precedes S1 in diastole Inc A= any condition causing increased resistance to R atrial emptying No a waves in A-Fib (no S4)

Question 133

Characteristics of JVP "x descent"

Answer 133

Atrial relaxation Prominent X waves in- constrictive pericarditis, pericardial tamponade Eliminated by tricuspid regurgitation (pan/holosystolic systolic, blowing murmur)

Question 134

What is the most common PE finding in PTs w/ constrictive pericarditis? What other condition also has this finding?

Answer 134

Pericardial knock Cardiac tamponade

Question 135

Most common PE Dx finding for pericarditis? Most common PE Dx finding for tamponades and constrictive pericarditis?

Answer 135

Friction rub (pericarditis, tamponade, myocarditis) Pericardial knock

Question 136

Characteristics of JVP "c wave"

Answer 136

Bulging tricuspid valve/ventricular contraction during systolic contraction, mostly not present in every PT

Question 137

Characteristics of JVP "v wave"

Answer 137

Increased atrial pressure during venous return after systole | Especially prominent in PTs w/ tricuspid regurg

Question 138

Characteristics of "y descent"

Answer 138

Reduced pressure w/ tricuspid valve opening and atrial emptying during diastole Impacted by factors impairing atrial emptying (like a waves)

Question 139

What will Pericardial Effusion, Constrictive Pericarditis and/or Pericardial Tamponade change to JVP?

Answer 139

Parodoxical JVP | Kussmaul sign: JVP rises w/ inspiration

Question 140

# Define Cannon A Waves What can cause these?

Answer 140

Aria contracting against a closed tricuspid valve A-flutter, Premature atrial rhythm/tachy, 3* block, Ventricular ectopics/tachycardia, Junctional rhythm

Question 141

# Define Large A Waves What causes them?

Answer 141

Increased atrial contraction pressure Tricuspid stenosis, R HF, PHTN

Question 142

Someone with a prominent JVP "c wave" has what issue? What does a Precipitous X Descent mean?

Answer 142

Tricuspid Regurgitation Pericardial constriction or Cardiac tamponade

Question 143

What causes large V Waves?

Answer 143

C-V waves: tricuspid regurg (raised JVP, large V wave, rapid Y descent) or ASD

Question 144

What causes a Slow, Rapid or Sharp Y descent?

Answer 144

Slow- tricuspid stenosis Rapid- tricuspid regurgitation Sharp- constrictive pericarditis

Question 145

Total JVP measurement can also be AKA ? Normal JVP ____ w/ inspiration

Answer 145

H2O JVP Falls

Question 146

Kussmaul sign is seen w/ ? JVP finding? Kussmaul findings suggest ? issues

Answer 146

JVP rising w/ inspiration Impaired filling of RV due to fluid in pericardial space or, Poorly compliant myocardium/pericardium

Question 147

What are the DDx for Kussmaul JVP findings Define the Hepato-Jugular Reflux and who is it seen in

Answer 147

Constrictive Pericarditis, Restrictive Cardiomyopathy PE technique to visualize JVP by pressing on RUQ in PTs w/ RHF or passive hepatic congestion

Question 148

# Define Pulse Pressure What can cause this to increase or decrease?

Answer 148

Difference between Systolic and Diastolic arterial pressures Inc- aortic regurgitation, conditions that increase SV/contraction Dec- hypovolemia, severe LVF, mitral stenosis

Question 149

A full pulse exam includes assessing pulses where? Palpating pulses has what two purposes

Answer 149

Carotid, radial, brachial, femoral, popliteal, posterior tibial and dorsalis pedis Patency and contraction of LV

Question 150

Which pulse location is the most accurate reflection of the aortic pulse? All pulses are assessed for what 5 things?

Answer 150

Carotid Rate, Rhythm, Strength, Contour, Symmetry

Question 151

A normal pulse is characterized by what 3 things? Define the Dicrotic Notch

Answer 151

Rapid rise in early systole, Short Plateau, Gradual descent Interrupts descending limb and represents aortic closure

Question 152

# Define Hypokinetic pulse Define Hyperkinetic pulse

Answer 152

Hypo- decreased LV pressure, SV, outflow obstruction Hyper- increased LV pressure, SV w/ decreased peripheral resistance (hyperthryroid, Epi)

Question 153

# Define Bisferiens Pulse Define Pulsus Alternans

Answer 153

Bis- pulse w/ two palpable beats during systole (HOCM, AS/insufficiency, ejection of inc SV like exercise, fever, PDA) PA- variation in pulse amplitude from changing systolic pressure, confirmed w/ BP (Systolic HF, LV failure-S3)

Question 154

# Define Pulsus Parvus et Tardus Define Pulsus Paradoxus

Answer 154

PPT- slow rate of pressure increase, small pulse pressure, late associated w/ severe aortic stenosis (2RICS, old PTs, young congenital) PP- exaggerated decrease 10mm or more of SBP during inspiration (tamponade, constrictive pericarditis, HOTN shock, obstructive pulmonary dz- asthma/COPD, large PEs)

Question 155

What are the three things that cause restrictive cardiomyopathy? Stethoscope diaphragm and bell are used for what sounds?

Answer 155

Amyloidosis, Sarcoidosis, Hemochromatosis D- high S1/2, AR, MR, pericardial friction rubs, through precordium B- more sensitive, low S3/4, MS

Question 156

# Define Thrills Define Heave/Lift

Answer 156

Palpable low frequency murmurs most commonly associated w/ grades 4-6 Movement of precordium that's associated w/ large ventricle or HF

Question 157

What can cause widened splitting of S2 What causes fixed spitting of S2?

Answer 157

Delayed P/Early A closures through expiration from RBBB or Pulmonic Stenosis Constant splitting through exp/inspiration from ASD

Question 158

# Define Paradoxical splitting What part of the cardiac cycle would the tightening of the tendon chordae happen?

Answer 158

Reversed splitting- P closes before A from LBBB, AS (dec A), chronic HTN (inc A) S3

Question 159

What can cause an increased intensity of S3? Most common etiologies of S4 sounds are from ?

Answer 159

Increased venous return to heart- leg raise Increased arterial press/CO- hand grip, brief exercise LVH from any cause (HTN)

Question 160

Characteristics of opening snaps

Answer 160

Early diastolic high pitched heard between apex and L sternal border most commonly due to MS causing doming of leaflets during diastole Not changed by respiration Disappears w/ worsening MS Reduced interval between A2 and Snap= worsening MS

Question 161

Define the Austin Flint murmur

Answer 161

Severe AS Mitral valve leaflet displacement and turbulent mixing of antegrade mitral and retrograde aortic flow Mid-diastolic, low pitched rumbling murmur best heard at Apex "Not a true MS"

Question 162

Characteristics of Ejection Clicks

Answer 162

Early Systolic high pitched sound usually from valve dz (AS, PS, Pulmonic Stenosis) Mid systolic- sudden opening/regurg of M/T valves during systole (MV prolapse)

Question 163

Nearly all diastolic murmurs are ? Systolic murmurs are either ? or ?

Answer 163

Pathologic- MS/TS Pathologic or benign- AS/PS

Question 164

What info is used to describe murmurs? Two continuous murmurs

Answer 164

TIPS Time/Duration, Location, Intensity, Pitch/Quality, Shape/Configuration Venous hum, PDA

Question 165

MR will radiate and be heard ? AS will radiate and be heard ?

Answer 165

Axilla Neck

Question 166

What are the Grade 1-6 criteria for grading murmurs

Answer 166

1- barely audible 2- faint-med intensity 3- easily heard, no thrill 4- easily heard, possible thrill (vibration in stethoscope) 5- easily heard but requires stethoscope to touch chest, possible thrill 6- no stethoscope needed Grade 3-4= worrisome

Question 167

High frequency pitch/quality implies ?

Answer 167

High- increased velocity | Low- reduced velocity

Question 168

Harsh pitch= ? Blowing pitch= ? Rumbling pitch= ?

Answer 168

Associated w/ severity Regurgitation murmur Diastolic in nature- Austin Flint, AR, MR

Question 169

# Define Crescendo Defie Decrescendo Define Crescendo/Decrescendo

Answer 169

Builds intensity Reducing intensity- early diastolic of AR Diamond shaped murmur of AS

Question 170

Any factor that increases blood volume/preload will increase murmur intensity w/ ? exception? How is preload inc/dec

Answer 170

MV Prolapse and Hypertrophic Cardiomyopathy- more affected by pressure gradient across valve Inc w/ venous return, dec w/ less venous return

Question 171

What causes after load to inc/dec? After load generally augments ? murmurs and reduces ? murmurs

Answer 171

Inc- inc systemic vascular resistance (BP at aorta) Dec by reduced systemic resistance (BP at aorta) Augments regurg Reduces stenotic

Question 172

How does inspiration change the action of the heart?

Answer 172

Increases preload, augments R sided murmurs and S2 splitting, Decreases venous return to L side of heart/murmurs

Question 173

How does standing change load on the heart?

Answer 173

Reduces preload Augments intensity of MVP (mid systolic click) and HOCM from widened pulse gradient at R atrium Minimal effect on other systolic murmur

Question 174

How does squatting change load on the heart?

Answer 174

Increases preload and afterload Reduces MVP/HCM intensity Limited effect on other murmurs- regurg/stenotic

Question 175

How does leg elevations alter blood to the heart? How can you inc/dec HOCM/MVP?

Answer 175

Increases preload, reduces MVP and HOCM Inc- stand, valsalva Dec- squat, leg elevate

Question 176

How does valsalva alter blood flow to the heart?

Answer 176

Inc then dec afterload and preload | Augments MVP and HOCM intensity from widened pressure gradients to R Atrium

Question 177

How does hand grips alter blood flow to the heart?

Answer 177

Increases afterload Augments MR, MVP, AR, and VSD Reduces AS, HCM

Question 178

How does amyl nitrate alter blood flow to the heart? How does phenylephrine alter blood flow?

Answer 178

Reduces preload and afterload from vasodilation Inc HOCM and AS Reduces MR, AR Inc afterload Inc MR, AR Red HOCM, AS

Question 179

How does amyl nitrate alter blood flow to the heart? How does phenylephrine alter blood flow?

Answer 179

Reduces preload and afterload from vasodilation Inc HOCM and AS Reduces MR, AR Inc afterload Inc MR, AR Red HOCM, AS Stops prolonged erection

Question 180

``` Why and when are the following drugs taken through the day? Lisinopril Simvastatin Metformin Gabapentin Aspirin ```

Answer 180

``` L- BP in morning S- Cholesterol at bed M- DM at morning and evening dinner G- nerve pain, breakfast, lunch and bed Aspirin- heart health at breakfast ```

Question 181

What are the two major lipids of plasma How are they transported?

Answer 181

Cholesterol and Triglycerides Lipoproteins

Question 182

What is the most common clinical manifestation of lipid d/o? Severe hypertriglyceridemia is primarily associated w/ increased risk of ? but not linked to ?

Answer 182

Atherosclerotic cardiovascular dz from inc levels of B-100s Pancreatitis, but CVDz risk CV score +5%= statin, don't worry about TGL

Question 183

Cholesterol is precursor for ? What are TGLY made of?

Answer 183

Fat soluble vitamins Steroid hormones- cortisol, estradiol, progestins, testosterone 3 FA on glycerol molecule

Question 184

What is the importance of Apolipoproteins

Answer 184

Amphipathic molecules on lipoproteins that act as keys to receptors

Question 185

What drugs work in the liver? How do statins exert their needed effect?

Answer 185

Niacin, Statin, Fibrates Inhibit the rate limiting step in cholesterol synthesis: HMGCoA Reductase which binds ACoA to free cholesterol to make cholesterol esters

Question 186

Where are chylomicrons retrieved from? What anti-oxidant is found in the blood stream?

Answer 186

Lymph system Apo-B and Apo-C transfer from HDL to chylomicrons Apo-E

Question 187

Liver uses ? and ? to make VLDL What medication can be injected to lower cholesterol?

Answer 187

Cholesterol and TGLY PCSK-9i

Question 188

What type/class of drug is used for management of TGLY levels? What does Niacin do?

Answer 188

Fibrates Cholesterol and TGLY management

Question 189

Macrophages eat bad cholesterol until they die and turn into ? What are the 3 layers of vessels?

Answer 189

Foam cells= atherosclerosis Intima, Media, Adventicia

Question 190

What is it called when a vessel needs its own blood supply?

Answer 190

Vasovasorum- located in adventitia

Question 191

Sequence of events to make atherosclerosis

Answer 191

Tear in endothelial layer LDL/cholesterol enters tear Monocyte turns in macrophage and eats LDL/cholesterol Inflammation occurs Death to foam cells leading to necrosis between intima and media layer Necrotic area turns into fibrous cap Cap ruptures and becomes thrombus until dislodged and made into an embolis

Question 192

Difference between exo/indogenous pathways of lipoprotein transport system

Answer 192

Slide 16 Lect 5

Question 193

What's the difference between Primary and Secondary dyslipidiemia Start checking cholesterol levels in kids at ? age?

Answer 193

Primary- genetics Secondary- weight, DM, renal/thyroid disease 9-11y/o FamHx- 5y/o BPs @ 5-6y/o

Question 194

What would a PTs BUN levels be if they have liver dz? AKAs for HDL, LDL and Chylomicrons

Answer 194

0 HDL- Apo-A1 LDL- Apo-B100 Chylomicrons- Apo B-48

Question 195

How often are PTs cholesterol levels screened? When/how often are PS ASCVD scores calculated?

Answer 195

Once every 5yrs starting @ 20y/o, done w/ fasting lipids, LDL levels are NOT included 40-75yrs old Q4-6yrs w/out ASCVD or DM w/ LDL 70-189

Question 196

What lab finding is our marker for identifying PTs what are not responding/handling Statin therapy?

Answer 196

ALT elevations

Question 197

What are the 3 areas on the body where excess cholesterol can build up and be externally visible? What are the two high intensity statins?

Answer 197

Xanthelasma, Tendon Xanthomata, Arcus senilus Atorvastatin- 40-80mg Rosuvastatin- 20mg

Question 198

What are themoderate intensity statins?

Answer 198

``` Ator- 10mg Rosu- 10mg Simva- 20-40mg Prava- 40-80mg Lova- 40mg Fluva- XL 80mg/ 40mg BID Pita- 2-4mg ```

Question 199

What are the two low intensity statins? Why is statin therapy discontinued?

Answer 199

Prava- 10-20mg Lova- 20mg Severe muscle Sxs/Fatigue Work up for possible Rhabdo- order CK, creatinine and UA for myoglobinuria

Question 200

What pre-existing conditions can signal PT will be increased risk for muscle symptoms while using statins? How long can PTs have muscle Sxs before secondary causes need to be searched for?

Answer 200

Hypothyroid, Dec renal/hepatic function, Polymyalgia reheumatica, Steroid myopathy, Vit D deficient, Primary muscle dz 2mon

Question 201

What are the 4 statin benefit groups?

Answer 201

Pts w/ clinical ASCVD LDL 190 or higher 40-75y/o diabetics w/ LDL 70-189 40-75y/o w/ LDL 70-189 AND ASCVD of 7.5% or higher

Question 202

Clinical ASCVD includes ? conditions

Answer 202

``` TIA Revascularization Acute coronary syndromes- MI Hx, angina Peripheral artery dz Stroke ```

Question 203

What type of effects do HMG-CoA reductase inhibitors (AKA Statins) exert? What type of effects do Bile Acid Sequestrants exert?

Answer 203

Dec LDL and TGLY, Inc HDL Adverse- transaminitis, myopathy Dec LDL, Inc HDL and TGLY Adverse- constipation, bloating

Question 204

What type of effects do Cholesterol Absorption Inhibitors exert? What type of effects does Niacin exert?

Answer 204

Dec LDL and TGLY, Inc HDL Adverse- rare allergic Rxn Dec LDL and TGLY, Inc HDL Adverse- flushing (reduced w/ Aspirin, don't use Naperson)

Question 205

What types of effects do Fibric Acid Derivatives exert? Don't treat Triglyceride levels unless they're above what amount?

Answer 205

Dec LDL, Inc HDL and TGLY Adverse- Nausea, Gallstone 500 or higher (Tx w/ Fibrates, Nicotinic acid, Omega 3 Acids)

Question 206

What are the risk factors for PTs to develop metabolic syndrome?

Answer 206

``` Abd obesity- +40"/35" High TGLY- 150 or higher HDL- less than 40m/50w BP- 130/85 or higher Fasting glucose- 110 or higher (not LDL) ```

Question 207

What adjunct is given to PTs when treating metabolic syndrome and they have intermediate/high CV risk? 90% of metabolic syndrome treatment errors are primary care issues that include what issues?

Answer 207

ASA and lipid management Wrong drug/dose PT needs combo Tx Non-compliant PT

Question 208

What two PCSK9 monoclonal antibodies have shown to further reduce ASCVD risks when added to statin therapies in high risk PTs? What bile sequestrant and fibrate combo have shown progress in reducing CV events in male populations?

Answer 208

Alirocumab and Evolucamab and Ezetimibe Cholestyramine and Gemfibrozil

Question 209

Which fibrate is contraindicated to use w/ statins?

Answer 209

Gemfibrozil- 30x increased risk of myopathy

Question 210

EKG ST elevation means? ST depression/inversion means?

Answer 210

Transmural Ischemia and/or injury Subendocardial Ischemia w/ abnormal repolarizatiton or death

Question 211

Stable angina= ? compensation Acute coronary sydrome= ? compensation

Answer 211

70% or less occlusion 71% or above 90%= pain at rest

Question 212

While walking, coronary blood flow represents ?% of total CO

Answer 212

5%

Question 213

# Define Ischemic Heart Dz Define Angina Pectoris

Answer 213

Imbalance between myocardial blood supply and demand leads to hypoxia and increased waste metabolites Uncomfortable chest sensation from ischemia, most common clinical presentation and most commonly from atherosclerosis

Question 214

# Define Stable Angina Define Variant Angina

Answer 214

Transient midline/left anterior angina precipitated w/ activity/emotions causing temporary ST depression and relieved w/ rest Angina at rest from coronary spasm causing transient ST elevation between midnight and 4am, not ruled out with troponins, r/o by PCI

Question 215

# Define Silent Ischemia Define Unstable Angina

Answer 215

ASx ischemia detected by EKG and labs Increased angina from less exertion or at rest; all PTs are admitted Change of baseline, first time/new onset, any pain at rest Time is not issue but typically beyond 20min

Question 216

What is the Fatty Streak

Answer 216

Endothelial dysfunction between 17-25y/o Allows LDL entry and modification and monocyte aggregation Monocytes-> macrophages and foam cell formation

Question 217

What is needed for oxidation to transform LDL to fatty streaks? What 3 factors affect coronary vascular resistance?

Answer 217

Inflammation Accumulation of metabolites Endothelial derived substances (NO- dilation; Endothelin 1- constrictor) Neural innervation- A adrenergic and B2 adrenergic

Question 218

What drug has positive inotropic effect and utilized as last resort when heart is failing? One medication that can be given that decreases morbidity and mortality

Answer 218

Digoxin Aspirin

Question 219

What are the 3 major clinical consequences of HDz

Answer 219

Myocardial injury- stunned or hibernating Acute Sxs- un/stable, variant, cardiac syndrome X Necrosis leading to MI- irreversible, Sx or silent

Question 220

What is cardiac syndrome X Define Stunned myocardium

Answer 220

Young/healthy PT that have heart attack without atherosclerosis and is usually genetically linked Short term near/total reduction of coronary flow re-established by PCI and followed w/ subsequent, limited LV dysfunction

Question 221

Define Hibernating Myocardium

Answer 221

Persistently impaired myocardial and LV function at rest from chronically reduced coronary blood flow but is reversible This is a chronic stable angina PT* Conduct PET or Dobutamine Echo to determine perfusion and possible angiography if cells are viable

Question 222

What are the anginal equivalent Sxs? The mortality rate of stable angina is best predicted by?

Answer 222

Dyspnea, Sweating, Fatiuge, Dizzy/Light headed, Gastric urtications Degree of LV function assessed by Echo (CO, EF), exercise capacity and severity of Sxs

Question 223

What are the 3 anginal equivalents of stable/classic angina?

Answer 223

Dyspnea, LV dysfunction (light headed, dizzy), Fatigue

Question 224

Prinzmetal angina spasm is thought to be a combo of what two factors? What meds can be given?

Answer 224

Sympathetic activity and Endothelial dysfunction Stress test will produce normal test results CCBs preferred, DO NOT use BB Nitro can be given acutely

Question 225

Of the 3 major clinical presentations of heart disease, where do the atypicals fall in? What 3 questions are asked during a diagnostic evaluation of stable angina?

Answer 225

Myocardial necrosis leading to MI Is chest pain substernal, retrosternal, or epigastric? Sxs brought on predictably by stress or exertion? PTs Sxs relieved by nitro or within 5min of rest? 3 yes= typical angina 2 yes= atypical angina Less than 2 yes= non-anginal

Question 226

What are the 5 questions/point scale used for determining risk factor points of CAD?

Answer 226

``` 55 or older male/65 or older female CAD or CV Dz Pain not reproducible by palpitation Pain worse w/ exercise PT assumes pain is cardiogenic ```

Question 227

What are the 4 cardinal features of angina How is it typically described by PTs?

Answer 227

Character of discomfort, Site and distribution, Provocation, Duration Pressure w/ feeling of strangling/anxiety Atypical PTs describe as vague and atypical

Question 228

What does a peaked P-wave in Lead II mean? What labs/rads are ordered and in what time frame?

Answer 228

PHTN ``` EKG- 10m, if not diagnostic, repeat 5-10m intervals CXR- 30m Fibrinolytics- 30m PCI- 90m, 120min if transfer is needed Labs- CBC, Chem-7, Troponin, UA, glucose, lipids Treadmill test- low/mod risk Nuclear test- if EKG abnormalities OR, Exercise echo Rx Stress Test if PT can't exercise Coronary angiography if PT is high risk ```

Question 229

What is the difference between Coronary Angiography and Revascularization

Answer 229

CA- dye injection | ReVasc- stent placement

Question 230

What are the 3 criteria are are the end points for stress tests?

Answer 230

Sxs limit continuation Ischemia 0.10mV or more or horizontal ST depression/elevation BP decrease by 10mmHg or more during exercise

Question 231

What are the 3 criteria for a positive stress test?

Answer 231

``` Pos= 0.10mV or more horizontal ST depression Neg= no exercise abnormalities at 85% max HR Non-Dx= <85% max HR w/ no EKG evidence of ischemia ```

Question 232

What are the 3 goals of therapy in chronic ischemic heart Dz? How is stable angina managed?

Answer 232

Dec anginal attacks Prevent acute coronary syndromes-MI Prolong survival Type of episode- acute or chronic First line- nitrates, sublingual Rest/stop doing activity

Question 233

All PTs with stable ischemic heart disease can get which immunization? What is the pharmacological treatment for them?

Answer 233

Influenza- possible reduced inflammation processes ``` AKA Vasculo Protective Regiment Anti-platelet therapy (ASA, Clopidogrel) Lipid lowering- statin/CSPK9 BBs- meto/? ACEIs- if high risk PT- lisinopril Rarely CCBs- last resort ```

Question 234

What are the uses and perks of using BBs

Answer 234

Primary preventinon/first line therapy of anti-angina therapy Only drug proven to prevent re-infarct and increase survival chances post-MI HR goal 55-60 Beta 1- pos ion/chornotropic Beta 2- vaso/broncho dilators

Question 235

What 4 BBs can be selected for use and the perks of use

Answer 235

Non-Sel: Propanolol B1 Sel: Meto/Atenolol Intrinsic sympathomimetic activity Alpha/Non-Sel: Carvedilol, Labetolol

Question 236

PTs with ischemia +65y/o get ? BB PTs under 65 get ? one?

Answer 236

Carvedilol Metoprolol

Question 237

Which BB can be used in pregnancy? What are the contraindications for using BBs?

Answer 237

Labetolol ``` Brady, below 50bpm PRI > 0.24, 2* or 3* block Decomp HF Hx of asthma Caution w/ diabetics ```

Question 238

Don't use ? class drug in PTs on cocaine? What CCBs are used?

Answer 238

BBs- causes coronary spasms Diltiazem, Verapamil, Amlodipine preferred Non-DHPs: Dec ion/chronotropy and after load; C/I in brady or systolic HF DHPs: dilators that decrease afterload, A/F/N-dipine

Question 239

What is the first line medication for treating PTs/ with ischemic heart dz but have bradycardia or AV blocks What is a new medication that can be used in place of BB or w/ BB therapy?

Answer 239

DHPs- Amlo/Felo/Nifedipine Ranolazine- late Na channel blocker

Question 240

What are the adverse effects of Organic Nitrates? What are the adverse effects of BBs

Answer 240

HA, HOTN, Reflex Tachy Brady cardia, dec LV contraction, Bronchoconstriction, masks hypoglycemia, fatigue

Question 241

What are the adverse effects of CCBs What are the adverse effects of Ranolazine

Answer 241

HA, flushing, dec LV contractility on V/D Bradycardia on V/D Edema on N/D Constipation, especially on V Dizzy, HA, constipation, nausea

Question 242

Post MI, what two meds can be used in combo for anti-platelet therapy? PTs w/ HTN, previous MI or exertional angina should be placed on ?

Answer 242

Aspirin and Clopridgel BB

Question 243

When art PTs placed on ACEI therapy

Answer 243

No benefit to angina, helps reduce remodeling of heart | Benefit for HTN, DM, CKD< LVEF <40% require ACEI

Question 244

Usually monitoring is done on PTs who remain Sx on medical therapy, however revascularization is considered and pursued if ?

Answer 244

Angina Sxs don't respond adequately to drug therapy Unacceptable s/e on meds PT is high risk coronary dz and revascularization is known to improve survival

Question 245

What is the CABG to PCI ratio What determines if a PT gets a PCI or CABG?

Answer 245

1 CABG : 3 PCIs One or two vessel involvement, +70%= PCI 3 vessels or LMain disease w/ intermediate/complex anatomy or impaired left ventricular systolic function= CABG DM with 2 vessels Significant LV failure

Question 246

Revascularization by any technique does not reduce MI/death risk from CAD in PTs w/ ? and ? What was the COURAGE trial and what did it show?

Answer 246

Chronic stable angina and preserved left ventricle function, medical management is key Clinical Outcomes Utilizing Revascularization and AGgressive drug Evaluation- showed PCI was no better than max medical therapy at reducing mortality and cardiac events in PTs w/ stable CAD but may be more effective at long term Sx relief

Question 247

PCI is AKA ? What drugs are given during this procedure? What two are given prior to procedure?

Answer 247

Percutaneous Transluminal Coronary Angiography- places drug eluding stents in PTs w/ 1 or 2 vessel disease and is Procedure of CHOICE Abciximab, Eptifibatide, Tirofiban ASA, Clopidogrel

Question 248

When is a CABG procedure preferred? When do you do PCIs?

Answer 248

Large amount of myocardium is at risk (3 vessels or LM) STEMI, NSTEMIs not responding to max medical therapy

Question 249

What does CABG stand for? What are the two types done?

Answer 249

Corornary Artery Bypass Grafts Native veins- section of saphenous "superfluous" vein and sutured from base of aorta to RCA segment down stream of stenosis, high re-occlusion rate Arterial graft- most common, uses internal mammary "superfluous" branch of subclavian and anastomosed distally to LM/LCX, more resistant/long lasting

Question 250

For revascularization, ALL STEMIs get _____ In order to revascularize a PT, one of what two criteria must be present?

Answer 250

Angiography- PCI Severe/refractory angina Severe ischemia on stress testing

Question 251

What two meds are always given to PTs prior to PCIs?

Answer 251

ASA and Clopidogrel

Question 252

What are the 3 benefits of PCI What are the 3 benefits of CABG

Answer 252

Less invasive, Shorter In-PT and easier recovery, Superior to Rx therapy to relive angina More effective for long term, Most complete revascularization, Greater survival in PTs w/ greater than 50% LM stenosis or w/ impaired LV function

Question 253

Prinzmetal angina is also associated with what other two issues? All PTs with DM and CAD are placed on ? med?

Answer 253

Raynauds and Migraine HAs ACEI

Question 254

LDL lowering therapy in PTs w/ Dx or suspected CAD are placed on what 3 meds What drug is used during the MI algorithm but has not mortality/morbidity benefit?

Answer 254

High potency statin, Ezetimibe, PCSK9 inhibitors Nitro

Question 255

What meds are used when BBs are contraindicated for the prevention of MI and reduce Sxs? What factor Xa inhibitor can be combo'd with ASA or Clopidogrel?

Answer 255

CCBs, Long acting Nitrates Rivaroxaban, not good for non-compliant PTs

Question 256

When is fibric acid derivatives considered for use? What are the four functional changes that occur to the heart as scarring?

Answer 256

High risk PTs w/ elevated triglycerides and LDL is at target on statin therapy, don't combine Stunning, Hibernation, Reconditioning, Remodeling

Question 257

What is the one med we use to stop ventricular remodeling? What two chemicals are naturally secreted by vessels in response to damage to inhibit platelet aggregation and activation?

Answer 257

BBs, ACEIs Prostacyclin- aggregation and activation NO- activation and dilation In presence of injury, become constrictive

Question 258

What are 3 drugs that can decrease anti-thrombotic effects? Partial occlusion of a vessel leads to ? or ? Full occlusion leads to ? or ?

Answer 258

TPA, NO, Prostacyclin UA or NSTEMI STEMI

Question 259

When considering the rupture of a plaque, how do you know if it's superficial or deep? There is never a serum biomarker with what heart issue?

Answer 259

Superficial/minor- self limiting Deep w/ obstruction- ACS syndrome UA, no troponin Always have one w/ NSTEMI

Question 260

You can't Dx PT with STEMI if they have a normal ? How are NSTEMIs initially treated?

Answer 260

EKG, must have ST elevation Medical management for 24-72hrs

Question 261

What are some causes coronary thrombus N/STEMI appearing issues but are non atherosclerotic issues? What is the one exception?

Answer 261

Anemia, HOTN, Stenosis, Aortic Dissection, Procedure complication, Embolic phenomenon, Blunt trauma Coronary artery spasm- variant or Printzmetal

Question 262

What are some non-atherosclerotic conditions that can be used as DDx for N/STEMI issues? Acute Coronary Syndrome encompasses ? 3 issues?

Answer 262

Lupus, Takayasus, Kawasakis, Giant Cell Arteritis, Polycythemia, Sickle Cell, Cocaine UA, NSTEMI, STEMI

Question 263

What will a transmural entire thickness MI, what will MI show? How to distinguish between UA or NSTEMI?

Answer 263

STEMI, transmural= entire thickness of wall Lab test for troponin

Question 264

What are the early changes during trasnmural infarctions

Answer 264

2m: ATP decrease 10m: Irreversible injury- VT/VF 24min: Wavy myofibrils 12hr: Hemorrhage, edema 24hrs: Coagulation necrosis- eosinophils 2-4d: Total coagulation necrosis- monocytes Stopped w/ BB/ACEIs

Question 265

What are the late changes during a transmural infarct?

Answer 265

5-7d: yellow softening by macrophages 7+d: granulation/ventricular remodel 7wks: fibrosis and scarring complete, PT can start PT

Question 266

What functional changes can occur during transmural events?

Answer 266

Impaired contractility/compliance- hyokinetic, akinetic, dyskinetic seen on echo Myocardial stunning- limited LV dysfucntion Ischemic precondition- MI w/ recent angina experience less morbidity/mortality Ventricular remodel- thinning/dilation of wall

Question 267

What is the most common Sx of cardiac ischemia +85y/o? What two meds used in combo improve LV function and long term survival?

Answer 267

Dyspnea BB and ACEI, PTs need to be on these upon d/c

Question 268

Every PT with suspected MI is treated the same in what steps?

Answer 268

O2, Monitor, IV, Hx, PE, EKG, CXR, Labs- Chem 7 (CK, E+), CBC (anemia), lipids, UA, troponin, CKMB, myoglobin

Question 269

How to diagnose ACS from UA/NSTEMI What med is not used in PTs w/ UA?

Answer 269

Sxs, EKG abnormalities, serum markers of myocardial necrosis CCBs

Question 270

All inferior wall acute MIs need ? prior to Nitro administration? What vessel supplies lateral, inferior, septal, anterior areas on EKG

Answer 270

Right sided EKG V4R 2, 3, AvF- inf, RCA 1, AvL- LCX or 1st diagonal branch V1, V2- first 1/3= PDA, bottom 2/3=LAD

Question 271

Pos AVR and V1 mean one of what 2 things? What vessels supply SA, AV, Bundle, RBB, LBB

Answer 271

LM occlusion, PE ``` SA- RCA in 70% AV- RCA in 85% Bundle of His- LAD RBB- Prox= LAD, Distal= RCA LBB- Ant= LAD, Post= LAD and PDA ```

Question 272

How long does it take to rule out a MI w/ no troponin results on labs? What are the two Troponin Cardiac markers?

Answer 272

12hrs= 100% r/o, this is why troponins are never ordered on outpatient basis I and T, I is most sensitive Inc of either is Dx for MI

Question 273

What is the use of CKMG for MIs? What is the first marker to rise and fall within 24hrs?

Answer 273

Proves MI re-infarction, rise 5x above baseline is Dx Myoglobin, CKMB and troponin are second

Question 274

What are the timelines for cardiac biomarkers to rise, peak and return to baseline?

Answer 274

Troponin: R 3-4hrs, P 18-36hrs, B 7-10 days CK: R 3-8hrs, P 24hrs, B 2-3 days

Question 275

How often are repeat EKGs ordered post-MI while inpatient? On an echo, heart wall motion that is waving =? If it's no moving then it's ?

Answer 275

Every day Dyskinetic Akinetic

Question 276

How do you rule in/out MIs in pregnant PTs? What if PE is suspected?

Answer 276

CT angiogram Creatinine >1.5- order VQ scan to r/o PE but don't order CT angiogram, will kill kidneys

Question 277

What are the 4 classes of drugs used in ischemic heart disease? What is the trifecta sequence of EKG changes during STEMIs?

Answer 277

Anti-platelet, BB, CCB, ACEI Hyper acute T wave, Depression, Elevation, Q waves

Question 278

What two fibrinolytics are used for MI PTs? For testing purposes, give MI PTs O2 if puls-ox is below ?

Answer 278

TPA (Tenecte,Alte/Reteplase) or Streptokinase 90%

Question 279

What are the 3 steps of UA and NSTEMI treatment plans?

Answer 279

Anti-ischemis: BB, nitrates, +/- CCB or ACEI Anti-thrombotic: anti platelet- ASA/Clopanti,coagulant- LMWH, unfractionated heparin Adjuncts: statin, ACEIs for ALL Pts

Question 280

Why do we give all PTs w/ MIs BB? What CCBs do we give for anti-ischemic therapy?

Answer 280

Lower mortality rate and sets HR goal of 60bpm, don't use if less than 50bpm Non-DHPs: Diltiazem, Verapamil; caution w/ edema and constipation Don't use for LV dysfunction

Question 281

Don't use nitrates as anti-ischemic therapy if it's ? type of failure What P2Y12 inhibitors are used for UA/NSTEMI antithrombotic therapy? What GP2b/3a inhibitors are used?

Answer 281

RV failure Clopidogrel (cheaper, higher bleed risk), Prasugrel, Ticagrelor (lowest chance of causing bleeding, expensive, reversible), Cangrelor Abciximab, Eptifibatide, Tirofiban E/T= small molecule agents, don't induce immune response

Question 282

What anti-coagulants are used in UA/NSTEMI therapy?

Answer 282

LMWH- most commonly used, no lab testing, Enoxaparin UFH- slow onset, monitor PTT, preferred for PCI since it's reversible Bivalirudin- used if heparin induced thrombocytopenia occurs

Question 283

What is the MOA and benefit of Bivalirudin use When/why is Fondaparinux used?

Answer 283

Direct thrombin inhibitor Less associated bleeding Conservative management of UA/NSTEMI to decrease bleeding Similar to LMWH, indirect 10a inhibitor but no Thrombin inhibit

Question 284

UA/NSTEMI treatment is conservatively managed w/ meds unless ? Early invasive management (within 24-48hrs) of UA/NSTEMI is based on ?

Answer 284

Ischemic episodes return Stress test indicates residual inducible ischemia TIMI risk

Question 285

What are the parts of the Thrombolysis in Myocardial Infarction risk score

Answer 285

+65y/o 3 or more risk factors: Age, Sex, FamHx, Smoking, HTN, Hypercholesterol, DM, Obese Coronary stenosis of 50% or more by angiography ST deviation on presenting EKG 2 anginal episodes in 24hrs ASA use in prior 7 days Elevated troponin or CKMB 0-1: ASA and d/c 3 or more- bad

Question 286

How is STEMI clinically defined on EKG? When does a MI PT NOT receive nitro?

Answer 286

ST elevation in 2 contiguous/precordial leads (2,3,AvF; 1, AvL; V5,V6; V3,V4; V1,V2) New LBBB Consistent presentation of ACS Hemodynamic instable, HF, decreased neurologic function

Question 287

All STEMI PTs get an PO BB within ?? hrs of onset of AMI? What statin is started ASAP?

Answer 287

Within 24hrs unless c/i Atorvastatin

Question 288

STEMI PTs get Fibrinolytics within ? time frame and under ? condition What are the absolute contraindications for using Fibrinolytics in MI?

Answer 288

90-120min and Sxs are <12hrs old ``` Prior intracranial hemorrhage Structural cerebral vascular lesion Intracranial neoplasm Ischemic stroke in past 3mon Active internal bleeding (doesn't include menses) Suspected dissection/pericarditis ```

Question 289

? drugs is a venodilator? What aer the long term management and secondary prevention steps of STEMI

Answer 289

Nitro ACEI w/in 24hrs- includes ASx and EF >40%, all CHF, reduced EF <40%, Anterior wall MI or ARB if can't tolerate ARB (-sartan)

Question 290

What drugs are not given for long term management/secondary prevention of STEMI? What type of STEMI PTs get an Aldosterone antagonist?

Answer 290

CCBs HF, Spirinolactone

Question 291

What medicatoin must be stopped in all STEMI PTs What do all STEMI PTs get prior to d/c

Answer 291

NSAID- avoid in HF and reduced LVEF except for ASA Echo

Question 292

When do STEMI PTs get anti-coag w/ Warfarin?

Answer 292

Large anterior MI LV aneurysm on TEE or Echo(7days post-MI) LV thrombus

Question 293

What is the dispostion for PTs with likelihood/risks for ACS?

Answer 293

Low L/Low R= out PT eval Intermediate L/Low R= out PT eval Intermediate/Intermediate= in PT w/ telemetry Intermediate/high L/High R= Cardiac care unit

Question 294

What are the 5 scenarios that require admission for PTs w/ ACS?

Answer 294

``` Continuous chest pain Positive serum makers Significant/new ST abnormalities Wellens T-waves- new/deep inversions Hemodynamically unstable High risk stress test results- +/- ```

Question 295

How is Wellens treated/managed?

Answer 295

Deep inverted/biphasic T waves due to LAD occlusion, seen in V2/V3, get to PCI due to poor medical management outcomes PT may be pain free at time of EKG w/ normal/barely elevated enzymes but are at extremely high risk for massive anterior MI in following days

Question 296

If no cardiologist is present, who manages Wellen Syndrome PTs? What about STEMI, NSTEMI or angina?

Answer 296

Internal Med STEMI- cardiology or Internal Med NSTEMI- Internal med, may end at cardiology Angina- internal med

Question 297

What dosage of aspirin is given to PTs upon arrival? What anti-depressant can be used for depressed PTs post-MI?

Answer 297

81-325mg, 325 preferred and chewed 81mg at discharge Sertraline or any SSRI

Question 298

PTs presenting with one of these 5 NSTEMI characteristics are sent to cath lab immediatley?

Answer 298

Hemodynamic instable/cardiogenic shock(BP 90/60, cold and clammy, AMS, chest pain, "sick" looking" Severe LV dysfunction/HF Recurrent/persistent rest angina despite medical therapy New/worsening MR or new VSD Sustained ventricular arrhythmias

Question 299

Fibrinolytics AKA thrombolytics have no clear survival benefit for ? cardiac PTs? When is the use of firbrinolytic preferred?

Answer 299

UA or NSTEMI, never ever give Small area of ischemia will be made worse by swelling Contraindicated for PCI, no PCI available within next 90min

Question 300

No PT ever goes to CABG without going through ? first How long after MI does LV aneurysm take to development?

Answer 300

PCI 7 days

Question 301

What two meds are used for treating MI induces pericarditis/Dressler's? What anti-coag can cause cardiac tamponade if given to these PTs but prevents transmural thrombus

Answer 301

ASA, Colchicine (viral= high dose NSAIDs) Warfarin

Question 302

MI Sinus Brady causes ? MI Sinus Tachy causes?

Answer 302

RCA/Inf Wall- Inc vagal tone, dec SA node perfusion Ant wall- Pain, Anxiety, volume depletion (dopamine)

Question 303

MI APBs, A-Fib causes ? MI VPBs, VT and VF causes?

Answer 303

HF, Atrial ischemia HF, Ventricle ischemia

Question 304

MI AB Blocks 1, 2, 3 cause?

Answer 304

IMI= inc vagal tone, dec AV perfusion AMI= destruction of conduction tissue

Question 305

# Define Cardiogenic Shock How is it treated?

Answer 305

Dec CO and HOTN w/ poor peripheral perfusion due to >40% LV death Ionotropic drugs (Dobutamine) but cycle continues until LVAD implant or transplant

Question 306

What test is done prior to all post-MI PT discharge and is is used to gather the most useful prognostic indicator? PEs are _% sensitive and _% specific for detecting valve Dz

Answer 306

Echo to get LVEF 70% and 98%

Question 307

What are the Systolic murmurs by position? When do the get Echos?

Answer 307

``` AS- RUSB PS/PDA- LUSB HCM- Erb's TR, VSD- LLSB MR, MVP- Apex ``` Grade 3 or higher

Question 308

What are the Diastolic murmurs by postition? What do all diastolic murmurs gert?

Answer 308

PI, Split S2- LUSB AI- Erb's TS- LLSB MS- Apex Echos

Question 309

What are the 3 continuous murmurs? What is the sequence of interventions for brady/BLS?

Answer 309

PDA- LUSB Arteriovenous malformation Venous hum Atropine, Transcutaneous Pacing, Dopamine, Epi

Question 310

What vision change can occur w/ Digitalis toxicity? Pancarditis is AKA ?

Answer 310

Yellow vision Myocarditis

Question 311

What are the 2 types of WPW? How is it treated?

Answer 311

Orthodromic- narrow QRS, symptomatic, Delta waves Antodromic- wide QRS Tx w/ Procainimide or conversion Definitive Tx- ablation

Question 312

What type of BBB is equivalent to STEMI? VSD is most commonly associated w/ ? and ASDs are most commonly associated w/ ?

Answer 312

LBBB VSD- LBBB ASD- RBBB, PEs most commonly associated here

Question 313

Sequence of treatment of PSVT 3 PVCs in a row is called ?

Answer 313

Stable- vagal, adenosine 6mg/flush, 12mg/flush, V-tach

Question 314

What are the causes behind Sinus Brady?

Answer 314

``` BB, CCBs, Digoxin Inc vagal tone Hypo thyroid, temp, sugar SSS Obstructive apnea ```

Question 315

If blood glucose is less than 60, what is the Tx? How many Joules are used for defib on Vfib?

Answer 315

Glucose 200J biphasic

Question 316

PT on hydrochlorothizide and develops U-waves, what is the cause? How is V-tach treated?

Answer 316

Hypokalemia Stable= amiodarone, lidocaine, procainamide Unstable= cardioversion Pulseless- defib

Question 317

What meds can cause Torsades? How is it treated?

Answer 317

Antipsychotics, Methadone (SSRIs preferred for depressed MI PTs) Unstable- defib Stable- IV MgSulfate and d/c offender

Question 318

What is the most common cause of R sided HF?

Answer 318

L sided HF

Question 319

What are the grading scales for systolic murmurs?

Answer 319

``` 1- barely audible 2- faint but immediately audible 3- easily heard 4- easily heard and w/ palpable thrill 5- loud, hear w/ light tough of stethoscope 6- audible w/out stethoscope ```

Question 320

What are the grading scales for diastolic murmurs?

Answer 320

1- barely 2- faint but audible 3- easily heard 4- very loud

Question 321

Murmurs of what characteristics are classified as benign murmurs?

Answer 321

``` Early/mid systolic- MVP Soft, grade 1 or 2 Vary w/ respiration Normal exam/work up No FamHx ```

Question 322

What are pathologic murmurs and what do all get for imaging?

Answer 322

``` All diastolic- MS TS, AR, PR All pansystolic- MR TR VSD Late systolic- AS/PS Loud Continuous- venous hum, PDA, AV malformation ``` ALL GET ECHOS

Question 323

Systolic ejection murmurs Pansystolic murmurs

Answer 323

AS- 2RICS and neck PS- 2-3LICS MR- apex to axilla TR- LLSB to RLSB

Question 324

Late systolic murmurs Early diastolic murmurs

Answer 324

MVP- apex to axilla AR- L sternum PR- upper R of sternum

Question 325

Mid to Late diastolic murmurs Define Acute Rheumatic Fever

Answer 325

MS- apex 2-3 wk delayed sequel of pharyngeal infection w/ Group A Strep w/ scarlet fever but not from GAS skin infections

Question 326

What physical response occurs during ARF?

Answer 326

Aschoff nodule- source problem of all issues High fever Valvulitis, usually mitral Non-itching pruritis- erythema modulotum Joint pain starting one at a time PAINLESS subcutaneous nodules (endocarditis= painful) Rapid involuntary muscle movement of face

Question 327

What would bee seen on physical exam in PTs presenting weeks after infection but now with ARF?

Answer 327

Throat exudates and high fever | No runny nose, cough= GAS don't cause these

Question 328

What are the major Jones Criteria

Answer 328

Joints- migratory polyarthritis in large joints of UE w/ Rubor, Palor, Calor and Tumor O- myocarditis w/ pericardial effusion Nodules, subcutaneous Erythema marginatum Sydenhams chorea- AKA St Vitus Dance, stops during sleep, rare in adults, rarer in males

Question 329

What imagine modality is used to view Jones Criteria Firm/painless nodules nearly always occur due to ?

Answer 329

Echo, no scanners Carditis

Question 330

ARF erythema marginatum presents with what characteristics?

Answer 330

Non pruritic, non-painful serpentinous eruption on trunk, proximal trunk and center returns to normal before margins

Question 331

What are the minor Jones criteria

Answer 331

Arthralgia w/out arthritis Fever 101-104 Elevated ESR and CRP Prolonged PR interval**

Question 332

What are the diagnostic tests for RF show on labs/rads

Answer 332

Strep culture or Rapid Strep Strep Ab Titer- ASO or AntiDNase B w/ elevated CRP and ESR CXR w/ cardiomegaly and/or HF ECG- blocks

Question 333

What type of diagnostic info is used for making a Dx of ARF

Answer 333

GAS pharyngitis infection + throat culture + rapid strep Ab test Elevated/rising strep Ab test- ASA, Anti-DNase B, or Antistreptozyme

Question 334

How many major/minor criteria are needed from Jones Criteria to make a Dx When can a presumptive Dx of ARF be made?

Answer 334

Two major or, One major and two minor criteria Chorea as only manifestation Indolent carditis- PTs failing to seek early Tx Recurrent RF PT w/ Hx of ARF are presumed to have recurrence w/ any manifestation

Question 335

What are the DDx of RF

Answer 335

``` Bacterial endocarditis- painful nodules Viral myocarditis- cultures, low myocytes/lymphocytes Lupus Serum Sickness RA Infectious arthritis ```

Question 336

What part of ARF can't be treated/slowed? What are the major goals of treatment

Answer 336

Valve damage Relief of acute Sxs Eradication of GAS Prophylaxis from future GAS infections Most PTs are admitted

Question 337

How is ARF Treated?

Answer 337

ABX- PCN x 10 days regardless of pharyngitis presence HF management and anti-inflammatory- ASA 80-100mg kids/4-8g in adults Therapy is continued until all Sxs are gone and/or ESR/CRP are normal Bed rest

Question 338

How is ARF Carditis treated? How is the rash treated?

Answer 338

HF and Blocks Tx w/ conventional therapy Valve repair/replacement for non-reponsive HF No specific Tx needed

Question 339

What ABX are used for treating ARF

Answer 339

``` Therapy x 10 days Kids under 27kg= Penicillin VK 250mg b/tid +28kgs= Penicilin VK 500mg b/tid Bicillin LA IM- once in lieu of PO PCN Kids- 600K units Adults 1.2M units ``` PCN Allergic- Azithromycin, Clarithromycin, Clindamycin (Macrolides)

Question 340

What is RF prevention therapy

Answer 340

Primary= Dx and ABX Tx of GAS tonsillopharyngitis Secondary= Hx of Dx increases PTs risk, limit Dz severity w/ prophylaxis

Question 341

How long after illness does it take RF TPs to develop heart issues?

Answer 341

10-20yrs Mitral stenosis- most common Aortic valve Rarely Tricuspid

Question 342

What is Carvallo's sign? What are the 3 Diastolic murmurs

Answer 342

Pansystolic murmur that is louder w/ inspiration and helps distinguish from MR Austin AR MS at rest

Question 343

Large P wave over 2.5 in lead 2 more than 4mm in height is due to ? What are the 4 atypical MI presenters

Answer 343

Cor pulmonale- chronic from COPD, acute from PE. PTs presents w/ edema, fatigue and signs of R sided HF DM, Old, Female, CHF

Question 344

Dx HTN What decreases after load but can be treated with?

Answer 344

3 separate visits of 140/90 Dantrolene

Question 345

Difference Pitting and Non-Pitting edema What is the difference between a low and high output HF

Answer 345

Pitting- CV cause Non- lymph High- due to high metabolic state or shunting of blood that inc O2 demand- hyperthyroid, Beriberi, AV fistula, Paget's, Anemia, Pregnancy Low- depressed Ejection Fraction; dilated cardiomyopathy, chronic HTN, Valvular HDz

Question 346

What are the four stages of HF Staging/Classification

Answer 346

A- high risk w/out Sxs or Dz B- structural Dz w/out Sxs C- structural Dz and Sxs D- refractory HF

Question 347

What are the 4 classifications of the New York Heart Association?

Answer 347

1- ASx 2- Sx w/ ordinary activity 3- ASx only at rest 4- Sxs at rest

Question 348

What are the JNC 8 Guidelines of HTN?

Answer 348

Under 60 or Diabetic= 140/90 Over 60= 150/90 Tx: 1st line always lifestyle mod. Non Af.Am.= Thiazide, ACEI, or ARB or CCB Af.Am= Thiazide or CCB CKD, with or w/out DM= ACEI or ARB

Question 349

For HTN PTs, when are the re-evaluated, referred and what are not used together? What PE finding proves a PT has renal artery stenosis?

Answer 349

Titrate up or add therapy after 1mon if not at goal Don't combine ACE/ARB If more than 3 drugs are needed= referral to HTN specialist Bruis

Question 350

PTs presenting w/ MI Sxs need to have what drug use r/o prior to giving nitro? Other than inferior MI, what other cardiac issue needs to avoid Nitro use?

Answer 350

Phosphodiesterase inhibitors (Viagra) in past 24hrs RV Infart and Severe Aortic stenosis

Question 351

All PTs with ACS get ? med despite lab baseline levels?

Answer 351

High intensity statin (Atorva/Rivustatin)- LDL +190 or ASCV risk +7.5%

Question 352

Long term STEMI care How are aneurysms seen?

Answer 352

ASA/Clopidogril Warfarin- large Anterior MI TEE, Echo

Question 353

What risk does the combo of smoking and contraceptives have? What HTN emergency drug is metabolized into cyanide?

Answer 353

Venous thrombosis Sodium Nitroprusside

Question 354

Caution before giving Clarithromycin (macrolide ABX) to PTs taking what class of medication? Class 1A/B/C, 2 3 and 4 drugs

Answer 354

Statins- QT prolongation and hearing loss

Question 355

Rebound HTN emergencies occur w/ sudden d/c of what anti-HTN drug? Imaging choices for suspect DVT?

Answer 355

Clonidine/Methyldopa Duplex US to Venography

Question 356

What two murmurs increase w/ valsalva? How can HOCM present and be confused for something else?

Answer 356

HOCM, MVP Large amplitude QRS Deep na`rrow Q in inf/lat leads mimicking lat/inf MI Tall R in V1-V2 mimicking post MI/RVH

Question 357

PACs can be signs of ? Do you stop CPR to place AED?

Answer 357

Atherosclerosis Yes

Question 358

PT with anemia, low Hct/Hgb and is suffering from MI has what type of MI? If PT is getting hypoglycemia on BBs, what diuretic can be given to counteract the effect?

Answer 358

High out put Thiazide diuretic

Question 359

Which diuretic causes Ca to go up? PT w/ MI and HTN emergency, EKG shows ST elevation in V2-4, what drug can be used for HTN?

Answer 359

Thiazide- up Loop- down Nitro Avoid Enalaprilat

Question 360

PTs w/ LV failure need to receive Enalaprilat, how do you know it's LVF? What is the DOC for aortic dissections?

Answer 360

Rales/crackles, leg edema, no JVD, fatigue, dyspnea, EJF <40% Esmolol

Question 361

What drug is the DOC for excess catecholamine excess states such as phenochromocytoma? If troponin is greater than ___ it's always a MI

Answer 361

Phentolamine; Pts presents Sx/transient HTN for 10-15m then self resolves 10

Question 362

What blood thinner can be used in STEMIs? What class drug is not used in UA?

Answer 362

UFH CCBs

Question 363

Statin use is contraindicated for use in ? PT population?a What time of day is it used?

Answer 363

Pregnant/feeding At night, when cholesterol synthesis is highest

Question 364

What are the 3 bile acid sequestrants? Don't use them if ? is normal in the PT

Answer 364

Cholestyramine Colestipol- must use w/ statin In PTs w/ normal TG levels

Question 365

How are PSK9 inhibitors administered? What drug can be given to PTs for asthma/steroid reasons but may reverse anti-HTN med effects?

Answer 365

IM only Naprosyn

Question 366

What causes RAD? Hypo K causes ? ekg findings?

Answer 366

LPFB, RVH, Lateral MI, PE, COPD U waves, ST depression, Flat T wave

Question 367

What drugs are likely to causes orthostasis and present with warning of first dose syncope? Criteria for HTN urgency/emergency

Answer 367

A1 blockers- Doxa/Terazosin

Question 368

RF causes what type of heart murmur? Squatting/hand grips effect on murmur

Answer 368

Mitral stenosis >???

Question 369

Valsavla effect on murmurs ECG finding of L atrial enlargement

Answer 369

AS dec w/ valsalva HOCM inc Greater negative deflection/at least 1mm wide and deep in V1

Question 370

Factor 5 Layden

Answer 370

Pregnant | Not contraindicated in fibrolytics

Question 371

R sided HF Tx Which mechanism best explains why excess adipose tissue leads to atherosclerosis?

Answer 371

``` BiPap Nitrate Furosimide Dobutamine- not in shock NorEpi- shock ``` Production of proinflammatory cytokines