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USMLE HY notes > Cardio internal finals 6th > Flashcards

Cardio internal finals 6th Flashcards

1
Q

מהם הטריגרים ל-
AF

6

A
  • היפרתירואידיזם
  • הרעלת אלכוהול
  • MI
  • PE
  • פריקרדיטיס
  • ניתוח לב
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2
Q

מה ההגדרה של כל אחד מהמצבים הבאים:
Paroxysmal AF
Persistant AF
long standing persistant

A
  • Paroxysmal AF- spontaneous AF lasting < 7 days
  • Persistant AF- 7 days < AF < 1 year
  • long standing persistant- > 1 year
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3
Q

Tx for acute Unstable AF

בצקת ריאות, אי יציבות המודינאמית, אנגינה ממשמעותית

A

Cardioversion- Synchronized

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4
Q

Tx for Acute stable AF
AF < 48 hours
AF > 48 hours

A

AF < 48 hours
Cardioversion- by medications (like sotalol/ amiodarone) or synchronized

AF > 48 hours / unknown age
Cardioversion only if one of the following option is present:
1. pt on anticoagulation > 3 weeks
2. complete TEE without thrombus in the left atrial “ear”

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5
Q

What is the Following Tx excepted after cardioversion?

AF

A

Anti-coagulations for 4 weeks after cardioversion

if CHA2DS2 VASc- then for life

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6
Q

What is the Tx in acute AF immidietly before cardioversion?

A
  1. Slow the rate- BB or CCB
  2. start Anti-coagulation (does not metter if CHASDS persist)

בשלב האקוטי סביב היפוך ניתן א”ק ללא קשר ל-CHADS VAS

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7
Q

How do we perform Rate control in AF
in acutic setting vs Chronic setting

A

Rate control for acute setting
BB / CCB (non-dhydro- Verpamil or dilitezam)

Rate control for chronic setting
BB and CBB (alone or in combination)
*HR target- < 80 in rest, < 100 while excersing.

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8
Q

When is the best time to perform rythm control in order to reduce the incident of CV in AF pt?

A

in early stages = less then a year since Dx

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9
Q

Which pt will most benefit early Ablation in AF?

A

Pt with Paroxysmal AF

גם בחולים שנראה שמצליחים להישאר בסינוס נמשיך לתת א”ק כל עוד
CHADS VAS מצדיק

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10
Q

AF

Which classes of Anti-arytmhic drugs are a Tx for Rythem control

A

Class I- Na channel blocker
Class III K channel blocker

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11
Q

Rythem control

Which AA Class III medication is a/w increase risk for death in pt with CHF or persistant long standing AF

A

Droendarone

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12
Q

Which AA Class IIII is consider to be a second option for pt with CHF or coronary Heart disease, with more the 40% experince sort kind of toxocitiy while taking this drug?

A

Amiodarone

נהוג לשמור לחולים שלךא יכולים לקבל תרופות אחרות . שלא עזרו = לא קו 1

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13
Q

Which AA Class III medications are a/w prolong QT

A

Dofetillide + Sotalol

שמורה לחולים שלא יכולים לקבל תרופותצ מסוג
Class I AA

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14
Q

Which conditions are C/I for using Class I AA drugs?

A

Pt without any structual heart changes

C/I in pt with coronary heart disease or CHF

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15
Q

באיזה מטופלים עם פרפור פרוזדורים היעילות של אבלציה עולה על היעילות של תרופות אנטי-אריתמיות?

A
  1. Pt with paroxysmal AF who have not treated before (as 1st line)
  2. paroxysmal AF who have failed on AA drugs (the most), (as 2nd line)
  3. HFrEF

היעילות של אבלציה עולה על היעילות של תרופות אנטי-אריתמיות

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16
Q

באיזה מטופלים אבלציה פחות יעילה מתרופות אנטי-אריתמיות
בפרפור פרוזדורים

A

Persistant AF

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17
Q

AF

What is the sucess rate after 1st ablation and the 2nd ablation

A

1st ablation -70%
2nd ablation- 90%

in contrast to atrial flatter- 90% on 1st ablation

אבלציה מגבירה את התגובתיות לטיפול אנט אריתמי

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18
Q

Which complication from Ablation in AF can present weeks to month after the procedure with dyspnea and hemoptisys?

A

Pulmonic vein stenosis

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19
Q

In which situations pt with AFib will also need Anti-coagulation (even if CA2HDS2 VAS

and which Ag treatment?

A

**MS **
becuase of RHD, HOCM, Hx of stroke

Tx
Comadin (vit K antagonist)- AF + severe RHD or mehanical valve. target INR > 2
DOACS- direct inhibitor of thrombin or Xa, C/I in Cr CL < 15

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20
Q

איפה נבצע אבלציה ומה היעילות שלה ברפרוף פרוזדורים
Atrial flutter

A

Cavotricuspid sinus, 90% success rate

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21
Q

What are Stage I and Stage II HTN

A

Stage I- 130-139/80-89

Stage II- >140 / >90

Elevated 120-129/ < 80

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22
Q

Which physical test can help us indentified psuedohypertension

A

feels radial pulse altough theres a block with the magenta

מצב נדיר במבוגרים בשל עורקים מסוידים מאוד, דורש מדידה תוך עורקית

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23
Q

Which 2 types of pt can develop Renal artery stenosis

A
  1. older pt with atherosclerosis
  2. women with fibromuscular dysplasia
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24
Q

How to Dx Renal artery stenosis?

A

Doppler of renal arteries&raquo_space; CTA/ MRA

Gold standart- Arthriography with contrast

סימנים לחסימה משמעותית- היצרות > 70%, קולטרליים, יחס <1.5 בהפרשת רנין בין שני הורידים הכלייתים

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25
Q

What the surgical and the pharmacological treatments for Renal artery stenosis?

A
  1. Pharmacological- ACEi / ARBs 1st line in unilateral atherosclerosis RAS (c/i in bi-lateral), also- statins, aspirin, smoking cessation.
  2. Surgical- no advantage over pharmecology, failed on pharmacological treatmet / severe disease mainly for Fibromuscular dyslasia
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26
Q

What are the main ceuases for secondary HTN

A

OSA
Renal artery stenosis
ADPKD
Fibromuscular dysplasia - womens 40-50 (carotid, renal- pearls of strings)
pheochromocytoma
medications- high dose estrogens (COP’s), steroids, MAOi, TCA, Psuedoheprine (nasal cogestio), Cyclosporine & Tarcolimus, NSIADS
EPO
Cocanine

Primary Aldo
Liddle syndrome- Aldo will be low
Cushing
coarctation of the aorta

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27
Q

מה הראה מחקר
Accomplish?

A

ACEi + CBB > ACEi + diuretic

in lowering the risk for CV and death in high risk pt

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28
Q

In which Subgroups ACEi showed superiority on lowering BP over other drugs?

A

DM 2
aphro-americans with hypertensive nephropathy

also reduce mortality of MI

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29
Q

Which lowering BP group showed a better protection rates against strokes?

A

CCB

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30
Q

What is the main effects of B1 anatagonist?

A
  • lowering Contractility
  • lowering renin realse from the kidney
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31
Q

all the following medication are:
Bisoprolol
Atenolol
Metoprolol
(BAM)

A

Beta1 cario selective antagonist

beta-blockers

Side effect- Hyperkalemia (b1)

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32
Q

Which 2 beta-blockers are non selevtive (b2 + b1)

A

Timolol
propranolol

Timolol = team= בקבוצה של כל הביתא

not recommend in Asthma and contrictive pulmonary disease

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33
Q

Which medications are alpha-1 + beta1+2 blockers?

A

Carvedilol
Labetalol (also a bit beta agonist “la beta LOL”= שיגועים

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34
Q

Side affects of Thiazides

A
  • Hypokalemia
  • insulin resistance
  • high cholesterol
  • could worsen hyperurecemia and gout (like loop diuretics)
  • impotence
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35
Q

how to treat Hypokalemia with thiazides?

A

Amiloride or Triametrene (eNac)

weak anti HTN , can prevent hypokalemia with combination with thiazide

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36
Q

Side effects of Spironolactone (Aldactone)

A

Gnycomastia
impotency
ammenorhea/ irrgular periods

can give Elperenone- without those side effects

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37
Q

Hypertensive urgency vs emergency
defintions

A

Urgency- BP >180/ >120
Emergency- Same BP + evidance of organ demege

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38
Q

all of the following are menefistation of ——–

Retinopathy- hemmorage, papiledemma, glomerular damage or FSGN, MicroAngiopathyic Hemolytic Anemia (MAHA), Ancephalopathy

A

Makignant HTN
Rapid change in BP&raquo_space; organ damage

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39
Q

What is the BP target when theres Encephalopathy?

and what is the Tx?

HTN crisis

A

lowering BP in 25% or till 160/110-100 in minutes to 2 hours

Tx:
Nitroprusside
Labetalol
Nicardipine

if HTN crisis + Scleroderma (renal crisis)= use of ACEi

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40
Q

What is the BP target for the following situations:
1. ischemic stroke who is candidate to tPA or Brain cathether?
2. ischemic stoke which no candidate?
3. Hemorhagic stroke?

A

**1. ischemic stroke who is candidate to tPA or Brain cathether- ** BP goal 185/ 110>
2. ischemic stoke which no candidate- Only when over 220/120 low in 15% in first 24 hours.
3. Hemorhagic stroke- only when systolic > 220, low in IV drip to 140-179 (Same medications as Malignant HTN)

Malignant HTN medications:
Nitroprusside
Labetalol
Nicardipine

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41
Q

Immidiate Tx for aortic dissection?

A

IV BB + IV Nitroprusside
BP target sys < 120 (by the hand that shows the higher BP)

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42
Q

What is the Treatment for Adrenergic Crisus?

A

Phentolamine (alpha blocker) or Nitroprusside

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43
Q

Most common cause of HF?

A

Ischemic heart disease

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44
Q

Tx for Acute decompensate HF?

A
  1. Loop diuretics until eovulemia
  2. Vasodilators- Nitroglycerin or nitropruside
  3. Ionotropes- Dubotemine / Dopamine (low dose = vasodiltor, high= constrictor), Milrinone (PDE-5 inhibitor, may cause low BP)
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45
Q

Which medications are used in HFpEF

A
  • Spironolactone- less hospital admissions
  • Candesartan- less hospital admissions
  • Sacubitril/ Valsartan- improvment of function and symptoms
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46
Q

Tx for HFrEF

first line, if symptoms persist (stage I + II)

A
  1. ACEi/ ARBS + Beta-blockers + SGLT2i

if pt symptomatic adds:
MRA (spironolactone/ elprenone) and ARNI (sacubitril/valsartan) instead of ACEi / ARBs

if symptoms persists
wide QRS + LBBB - CRT (Cardiac Resynchronization Therapy)
ICD- if indicate

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47
Q

Which medicaitons are advices for HFrEF as reduce mortality

A
  • ACEi/ ARBS- without correlation with severity of symtoms
  • BB- same
  • SGLT2i- same
  • ** MRA (mineraloreceptor antagonist)-** add on over ACEi/ARBS + BB who are still symptomatic
  • ARNI (Valsartan + scubitril)- Tx who suffer under ACEi/ ARBS
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48
Q

Which medications are the chosen to treat Supra-ventricular arrytmhias in the setting of CHF?

A

Amiodarone
Dofentilide

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49
Q

Which pt will be the optimal pt to treat with Cardiac resynchronzation therapy?

A

HFrEF, with Sinus rythem, wide QRS > 149 (but less also good), with** LBBB**

חולים שפחות מתאימים- dominant .AF, lateral wall scar RBBB, Decompensenated CHF

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50
Q

What are the indication fo ICD?

A
  1. after event of SCD w/o reversible reason
  2. NYHA II-III + EF < 35%
  3. > 40 days post MI + EF < 30%

one of the above

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51
Q

What is the 2 Treatment options for Secondary Mitral Regurgitation

A
  1. condiser CRT if candidate
  2. Replacment / repair- only in pt that either way going to CABG
  3. Mitral clip- non surgery candidate. prefferd approch

include also improving the CHF therapy given

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52
Q

Which factors elevate BNP and which decrease?

A

Elevate
1. elderly
2. womens
3. CKD
4. under ARNI treatment (niprylsin inhibitor)

Decrease
1. obesity
2. balanced CHF

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53
Q

Defenition of Cardiomypopathy

A

Heart muscle disease without stractural reasons or HTN.

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54
Q

How to Dx Infectious Myocarditis?

A
  • Clinical presentation + Echocardiogram
  • Infectious panel- adenovirus, influenza ,covid
  • biopsy- 80-90% negetive

in MRI- edema and enhence after gadolinum mainly in mid-wall

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55
Q

Non infetious myocarditis DDx

A

Sarcoidosis
Giant cell myocarditis
Polymyositis, Dermatomyositis, SLE- Eosinophilic myocarditis
Transplent rejection
Checkpoint inhibitors treatemnt

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56
Q

Heart Sarcoidosis
1. which approch will be the best for Dx?
2. Whats the Tx?

A
  1. Biopsy- mainly from mediastinal LN
  2. Tx- High dose steroids follow by MTX
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57
Q

What is Takotubo Cardiomyopathy (DCM)?

A

Acute stress induce CM- mainly women after physical / mental stress

involve intensive symphathetic activetu

Takotsubo- name of japanse octepus that the LV reasemble in this CM

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58
Q

Takotsubo CM
Dx
Treatment

A

Dx- Clinical signs (pulmonary edema, chest pain..) , Echo- global dilation of LV with decrease contraction of the apical base of the heart =** Apical ballooning apperance**

Tx- non selective alpha and beta blockers. if Prolong QT- magnesium

חולף תוך ימים עד שבועות. פרוגנוזה טובה

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59
Q

Which Chemothrapic agents are Highly a/w Toxic Cardiomyopathy?

A

Antheracyclins (Doxirubicin)
Trastuzumab- Hercptin , anti HER2

if given together highly cardiotoxicity

Dilated CM

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60
Q

What are the metabolic reasons for DCM

A
  • Thiamine def. (Beri-beri)- firstly Hyperdynamic HF&raquo_space; low output HF
  • Def. in selenium, calcium, magnesium, phosphate
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61
Q

Which cardiomyopathy will be mainly with reduce diastolic function

and what will be the clinical presenation

A

Restrictive CM

Both atrials will be enlrage

clinical presentation
mainly of right HF- peripheral edema, asictes, with both ventricles with high pressure, positive kussumel sign

DDx: constrictive pericarditis

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62
Q

DDx for restrictive CM

A

דברים שמסנינים את רקמת הלב
Amyolidosis- most common
Hemochromatosis
Fabry
Glycogen storage disease II,III

Radiation
Scleroderma

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63
Q

Which type of amyloydosis can filtrate the heart, what is a unique cherateristic of each one

A

AL/primary amyloid- MM&raquo_space; also Nephrotic syndrome may present
ATTRm- mutent ATTR, young people, afro-americans
ATTRwd- old mans > 90 (mainly), can manifest with spinal stenosis
*both can present with peripharal neuropatrhy and Carpal tunnel synd

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64
Q

When amyloidosis is suspected?

ECG + Echo

A

מיוקראד מעובה + וולטאז נמוך באק”ג

65
Q

How to Dx all types of heart amyloydosis?

Restrictive CM

A

Biopsy 100%

DPD- only for ATTR types

66
Q

Tx for Restrictive CM by Amyloydosis?

A
  1. AL- Bortezomib (proteosome inhibitors)
  2. ATTR- Tafamidis for neuropathy

C/I for digoxin
BB + ACEi / ARBs- can worsen the symptoms

for the HF- mainly diuretics and symptomatic

67
Q

Common Tx for HCM

Target- low HR + contractility, remain per-load

A
  1. **BB + CCB **(non dhydro like vermapil)- also if Afib
    if symptoms persist:
    Disopyramide- AA with negetive ionotropic effect
    if edema present- carefully diuretics
68
Q

What are the risk factors in HOCM for considering ICD?

A
  1. Hx of Heart arrest or sustained VT- most strong
  2. Syncope w/o other explaination
  3. spontanyous NSVT
  4. LV thickness > 30 mm
  5. family Hx of HCM
  6. abnormal reaction for exresice-BP drop or not elevate during exerisce

when theres 2 of the risk - ICD implantaion as long as survive > 1 year

69
Q

What are the etiologies for blood in the pericard?

A
  1. malignancy
  2. CKD
  3. after heart surgery
  4. TB
70
Q

A pt present with Friction rub and diffuse ST elevations + PR depression

A

Pericarditis

71
Q

Tx for pericarditis

1st line
2nd line
3rd line

A

1st line- NSAIDS / Aspirin+ PPI + Colchicine
2nd line- Steroids (increase risk for reccurence)
3rd line- Azathioporine or anakirna- for high reccurence > 2y and refoctroy for 1-2 line treatment

72
Q

Which Reumatological diseases are most common for pericarditis

A

SLE and Drug induce SLE

Drug induce SHIPP:
S- sulfa drugs (like SMX)
H- hidralyzine (BP mainly pregnancy)
I- Isoniazide (TB Tx)
P- procaniamide
P- phyntoin

73
Q

Tx for uremic pericarditis?

A

dialysis

w/o chest pain

74
Q

Chronic Constractive pericarditis has a similar clinical picture as right / left sided diastolyc/ systolic HF

A

Right sided diastolic HF

75
Q

What is positve kussmaul’s sign?

A

When JVP is not flattend during inspiration - means there somthing blocking the heart from getting all the blood from the RA.

in Temponade we will see positive kussmel sign

76
Q

Chronic Constractive pericarditis
how we Dx?
whats the Tx?

A

Dx- MRI/ CT
Tx- Pericardial resection

if pt > 50 yrs . Diagnostic cardiac catheterization before procedure

77
Q

What is beck’s triad

when we will see it?

A

Temponade

  1. Distant heart sound
  2. hypotension
  3. Jugular veins congestion

significant X decent w/o Y decent

78
Q

all of the following are clues for ?

CXR- increase size of heart
ECG- Electrical alternans + low QRS amplitude
Pulsus paradoxsus

79
Q

Temponade
Dx?
Tx?

A

DX- Echo
Tx- Pericardiocentesis

80
Q

Sever Aortic steosis defintion

A

narrow of Aortic valve < 1 cm
gradient > 40 mmHg
velocity > 4

81
Q

What is low flow low gradient AS

A

not meet the floe and gradient of typical Aortic stenosis

  1. low EF < 50%
  2. normal EF
82
Q

Which valve pathogly is with paradoxial split of S2 + Pulsus parvus et tardus?

83
Q

What are the 3 main indications (Class I) to replace Aortic valve?

A
  1. Symptomatic AS
  2. Asymotpmatics AS +
    EF< 50%
    Going trough cardiac procedure anyway
84
Q

When we will replave Valve to mechanic and when to biology?

A

Biology- better > 65 yrs (30% malfunction in 10 years)
Mechanical- require comadin for life

85
Q

TAVI (גישה מלעורית להחלפת מסתם)
Prons and cons

A

Prons:
less compilcations then SAVR (surgical)
Cons:
more will need ICD (AV-block)

86
Q

When we will prefferd using TAVI instead of SAVR

A
  • Older pt.
  • Fragile
  • significant co-morbidites
  • porcelain aorta

Pt < 65 yrs we will preder SAVR ,

SAVR- Bicuspid valve, reumatic disease of valve, annulus too large / small for tavi, pereferd mechanical valve, Afib, absecnt of vascular approch to TAVI (Femoral)

87
Q

When Aortic Regurgitation will be Treated surgically?

  1. Severe AR + symptomatic
  2. Severe AR + Asymptomatic
A

Class I:
1. Severe AR + symptomatic
2. Severe AR + Asymptomatic with:
EF < 55%
either way doing a cardiac surgery

class IIa:
Severe AR + Asymptomatic with LVESD > 50 mmHg
Moderate AR + either way going to a cardiac surgery

התערבות לרוב בהחלפת מסתם

88
Q

Most common cause of primary MR ?

A

MVP

mostly by the process of myxomatous degeneration

89
Q

DDx of primary MR
4 main reasons

A
  1. MVP- most common
  2. RHD
  3. congenital
  4. IE or radiations
90
Q

DDx for secondary MR?
3 main

A

Dilated CM, ishecmin CM
HOCM
Afib

91
Q

What is the most common reason for acute MR?

A

MI

rupture of the papillary muscle- most common the posterio-lateral (blood by Post. decending artery- think about it when Inf. MI )

92
Q

What will be the Tx for Primary and secondary MR?
severe symptomatic
severe- asymptomatic

A

Primary
2. 1. severe symptomatic- always surgery
2. severe- asymptomatic- must also have EF < 60% or LVESD > 40 mmHg
3. Miral clip- for high risk pt (for surgery)

93
Q

When we will preform Mitral clip in primary and secondary MR

A

Primary- very high risk pt. (for surgery)
Secondary- Severe MR + EF < 50%, remain symptomatic despite pharmacologic Tx

94
Q

In aortic dissection

which layer is ruptrue and where the blood builds up

A

Intima rupture&raquo_space; blood builds up in the intima - media layers&raquo_space; false lumen

95
Q

What is the most common risk factor for aortic dissection?

96
Q

Which drug can cause aortic dissection in a free risk pt?

97
Q

Which murmur will be found in 50% of pt with aortic disecction?

A

Diastolic murmuer - AR

98
Q

How we Dx Aortic Dissection?

A

Echo- stable/ non stable pt
CTA/ MRI- test of choice in stable pt

99
Q

What is the immidiate Tx of aortic disecction?

A

Systolic < 120 by:
1. **BB- **labetalol or Esmolol
1. **Nitropruside IV **- given in ICU setting

100
Q

What is the criteria for repairing aortic anyresums?

6 inidcations

A
  1. symptoms or complication (aka aortic dissection)
  2. aysomptomatic :
  3. קוטר > 5.5 ס”מ
  4. קצב גדילה של > 0.5 ס”מ בשנה
  5. marfan + dissection - 4-5 cm
  6. bicuspid valve who are supposed to go surgey when aorta > 4.5 cm
101
Q

AV block + inferior MI

which dagree
whats the prognosis and Tx?

A

mostly 2nd degree
mostly reversible. does not require any pacemakers

102
Q

AV block + anterior MI

which dagree
whats the prognosis and Tx?

A

2 to 3rd dagree- not stable. RBBB
temorary pacmaker needed

103
Q

When we will consider MRI in the present of AV block?

A

AVB < 60 yrs
or high clincal suspect for stractural disease

diseases: amyloidosis, myocarditis, sarcoidosis…

104
Q

PET - CT can help us diagnose which 2 conditions in the present of AVB?

A

Amyloidosis- TTR (familial)
Sarcoidosis

105
Q

Which substance will increase the AV node conduction and which will decrease?

A

increase conduction- Atrophine, Isoproterenol (beta-agonist), exresice = increase sympathetic activity
Decrease conduction- vagal manuvers, carotid massage = increase para-sym activity

תמונה הפוכה במידה ויש חסם הולכה אינפרא-נודולרי (כנראה הכוונה ל-RBBB או LBBB

106
Q

When we will do a EPS test in pt with syncope and AV block?

A

high suspiction of higher dagree AV block and non invasive methods did not helped

בודקים מהירויות הולכה:
1. AV - His > 130
2. His - ventricles > 55 always pathological, indication for Pacemaker

107
Q

Which AV block dagree will be treated with Atropine or Isoproterenol?

A

AVB II (morbitz I)

only if symptomatic

108
Q

What are the indication for persistant CDI

A
  1. non reversible Morbiz II and up
  2. non reversible Weknbach-Morbitz I only if-
    * symptomatic
    * present of progressive disease that can worsen the AVB
109
Q

What is Pacemaker syndrome?

A

disynchronization of the AV node
distendent Jugulars, syncope, myalgia, dizziness- Clinical picture of CHF

mainly when using VVI- one electrode in each room

110
Q

Which pacemaker recommend in order to prevent pacemaker syndrome

when its C/I?

A

DDD- 1 electrode in the atria, second in the ventricle
recommend for Pt with sinus and AV block

C/I- Afib

111
Q

Which pacemkaer recommend for AVB + EF < 50%

A

CRT- synchronization between the ventricles

3 total pacemkaers- VVI- one electrode in each room&raquo_space; pacmaker syn.
DDD- atria + ventricle. C/I Afib

112
Q

קווי הטיפול ב-
PSVT with nerrow complex

A

Vagal manuvers&raquo_space; Adenosine IV (C/I heart transplent)&raquo_space; BB + CBB

113
Q

Tx in pre-excited tachycardia with Afib/ Flutter

A

Tx- Cardioversion or butilide or procinamide

מצב מסכן חיים, wideQRS irregular with bizarre changed complexes

114
Q

Cannon A waves in JVP wave?

115
Q

Which electrolyte disturbance can cause prolong QT?

A

all the hypo- hypomagnesemia, hypocalcemia, hypocalemia

116
Q

Drug induce prolong QT

A

AA class IA + III, Macrolide, Flueroqionolone, resperim, clindamycin, halidol

117
Q

Pharmecological Tx for Torsa de pointes?

A

Magnesium sulfate 1-2 gram IV

if not enough&raquo_space; consider adding isoproterenol (b agonist)

118
Q

Brugada syndrome definition

A

icecream scoop ST + inverted T waves in more then 1 lead (V1-V3)
+
events of syncope or cardiac arrest (due to pleomorphic VT)

ICD- unexplain syncome / cardiac arrest
Ablation- reccurent VT

119
Q

Epsilon wave + inverted T waves + wide QR in V1-V3

which syndrome?

A

Arrythmogenic RV cardiomyopathy

הגדלת חדר ימין, אזור צלקת בהדמייה- החלפת המיוקרד ברקמה פיברו-שומנית

ICD is the Tx VT under stress- BB

120
Q

Well’s score

what does this score checking
what the meaning of above and below 4

A

the clinical likehood of PE
WS > 4 - high clinical suspect&raquo_space; proceed directly to imaging
WS < 4- low&raquo_space; proceed to Di-dimer

121
Q

Which test is the test of choine in PE and DVT with high clinical suspect

A

**PE- ** chest CTA&raquo_space; lung mismatch test&raquo_space; Venous US

DVT- Venous US

each time we move fowerd in test is when the test is non-diagnostic, unavalible or unsafe

122
Q

What is Mconnell’s sign

A

hypokinesis of the free wall of RV + hyperkinesis of apex RV
סימן עקיף לאמבוליזם בריאה

123
Q

What is the primary Tx in PR with :
1. normotensive + normal RV
2. Normotensive + hypokinesis RV
3. Hypotension

A

P1. normotensive + normal RV- Anticoagulation alone +- IVC filter
2. Normotensive + hypokinesis RV- Anti-coagulation. consider also tPA
3. Hypotension- Anti-coagulation + tPA / Embolectomy (cathter or surgical)

124
Q

Which medication are 1st line Tx in massive PE

A

hypotension present - 500 ml Normal seline

first line pressors- NE + dubotamine

other lines- VA ECMO- as bridge for definitve Tx with thrombolysis or embolectomy

125
Q

C/I for tPA in Tx of PE?

and what is the risk for major and intra-cranial bleeding

A
  1. intra-cranial disease
  2. surgery in the last 2 weeks
  3. trauma

risk for major bleeding 10%
risk for intra-cranial bleeding 2-3%

When given tPA, at first always combine with heparin

126
Q

Indications for IVC filter

A
  1. Active bleeding = prevent use of Anti-coagulation
  2. Reccurent VTE despite optimal therapy
127
Q

Dx of APLA

A

Rq 1 clinical criteria and 1 lab
Clinical:
1. at least one thrombotic event (venous/ arterial)
2. abortion (1 abortion/ early delivery < 34 weeks, or 3 abortion < 10 wks)

Lab:
high lab results in 2 seperate test (>12 hrs apart) Lupuse Anti-coagulant, Anti-cardiolipin, Beta-2 glycoprotein

LAC- not tested when using comadin

128
Q

Right atria wave pressure

what symbole the A wave ?

When we will see Cannon waves and when A will be abscent

A

Atrial Contraction

Cannon A wave- contraction infornt of closed TV (Complete AV block, SSS, VT)
Abscent- afib (atria is not contracting)

End diastole

129
Q

Right atria wave pressure

what symbole the X descent ?

when will be up and when will be down

A

Atrial Relaxation

high X descent- constrictive pericarditis
low X descent- TR

mid systole

130
Q

Right atria wave pressure

what symbole the c wave ?

A

TV Cusps bulging into RA

Early systole

131
Q

Right atria wave pressure

what symbole the v wave ?

when this V wave will be increase

A

rapid Atrial Filling

increse in TR

late systole

132
Q

Right atria wave pressure

what symbole the y descent ?

when it will elevate and when decrease

A

early ventricular filling

elevation of y desecnt- Constrictive pericarditise, RV failure
decrease- Temponade

late systole

133
Q

Which situation we will see pulsus paradoxus

A
  • Temponade
  • massive PE, Tension PTX
  • hemmoragic shock
  • severe obstractvie lung disease- asthema, COPD exc.

decrease in more then 10 mmHg in insperium

134
Q

Paradoxial splitting of S2?

A

LBBB
Right sided ICD
AS
HOCM
acute ischemic myocardium

135
Q

S3

A

early diastole sound = rapid filling
dilated room

136
Q

S4 meaning

A

end diastole
Stiff ventricle (reduce comliance)

137
Q

ECG findings

diffuse inverted T waves , prolong QT, deep T waves

which extra-cardiac situation is ?

138
Q

Which pt consider to be High risk in positve stress test

A

angina during the test or ST depression > 2mm in number of leads

need for catheraztion

139
Q

Which condition is increase the likelhood for
FP and FN results in exresice test?

A

FP- low pre-test probability for IHD
FN- condition involves only the LCX (does not show well on the ECG)

140
Q

which medication is used in Echo heart test?

A

dobutamine (b1 agonist)

141
Q

באיזה חומרים משתמשים במיפוי לב
ומה עלולים לעשות כתופעת לוואי

A

Adenosine and dipidremole
vasodilation of the coronary.

Side affect- excarsarvation of asthma

if theres ischemia there will be a “coronary steal”- which mean that more blood will go to non-ischemic area from the ischemic areas.

142
Q

What is the Calcium score

A

probability for CAD
high > 400

depends also on pt presentation

143
Q

What is the specifity and sensetivity of CT coronary and which type of pt is best for

A

Sensetivity -99%
specifity- 90%
very good for rule out CAD

good for pt with weak-mild probability for CAD

144
Q

מהי בדיקת ההדמיה המתאימה במצבים הבאים

Pain chest in a pt w/o any know coronary disease + normal ECG

A

if can do stress test&raquo_space; Stress test
if can’t&raquo_space; echo stress or heart imaging )מיפוי לב(

145
Q

מהי בדיקת ההדמיה המתאימה במצבים הבאים

Pain chest in a pt w/o any know coronary disease + pathological ECG (LBBB/ LVH)

A

echo stress or heart imaging )מיפוי לב( or CTA

146
Q

CAD imaging

Which imgaging to choose for the following pt

Atypical pain + low pre-test probability
Medium to High pre-test probaility

A

Atypical pain + low pre-test probability- coronary CTA
Medium to High pre-test probaility- Imaging under stress (מיפוי או אקו מאמץ)

147
Q

When CABG is preffered over Catheterization

A
  1. left main involvment
  2. 3 arteris
  3. 2 arteris (one is proximal LAD) + EF < 50% or DM
  4. lesions that not fit PCI
148
Q

Which type of troponing is specific for MI?

A

Troponin I + T

149
Q

Which Anti-PLT is the best choice for candiate for PCI (in the setting of ACS)

and what is the C/I

A

Prasugrel

לא לטיפול שמרני

C/I- previous CVA, High risk for bleeding

150
Q

Which Anti-coagulation from the NOAC has similar afficacy as clexane but less chande of bleeding

A

Foundaparinux

דורש החלפה להפרין בזמן צנתור כדי למנוע טרומבוס משני לפרוצדורה

151
Q

What include the long term Tx for ACS- NSTE

A

ACEi ARBS
BB
Statins- if not < 55, add PCSK9i or Ezetimibe
GLP1 or SGLT2 - in selected pt with DM2
Anti-PLT- 3 month after event / 12 month / high risk for 3 years
* adding Ribaroxoban to DAPT show improve prognosis (depsite increase probaility for bleeding)

152
Q

which medications we will give in Acute STEMI

A
  1. Bolus ASpirin
  2. P2Y12 inhibitors (plavix, bralinta, effient)
  3. GPIIb/IIIa inhibitors- for prevention of thrombotic complications
  4. Anti-coagulation- Clecxane > heparin
  5. Symptomatic Tx- Nitroglycerina / morphine
  6. BB- relieve symptoms, decrease MI size
  7. ACEi/ ARBs- in stable pt after STEMI

C/I CCB

153
Q

How medically we can provoke prinzmetal varient angina

A

injeciton of Ach to coronary- due to endothelial disfunction will lead oto vasospasm

Tx- nitrates, CBB

154
Q

PHTN (pulmonary)

Definition

A

mean pulmonary atrieal pressure > 20 mmHg

155
Q

Which test is the most importent screening test to evaluate PHTN?

A

Bubble study - Echo- when est. pressure in the pulmonary artery > 35 mmhg = caculate by the velocity in TV

also can use Echo- Large RV/ RVH - suggest PTHN

156
Q

What is the Gold standart for Dx of PHTN?

A

wedge pressure
PVR (pulmonary vascular resistance)

157
Q

Which medication are given in PAH (type I)

A
  1. CBB- when positive vaso-reactive test ( MPAP > 10 mmhg, and less then 40)
  2. if vaso reactive negetive- Prostenoids, Endothelin receptor antagonist, PDE-5 inhibitors (sildenafil)
  3. lung transplant- in severe refactory pt.
158
Q

Which arrytmia can develop after succsesful thrombolysis therapy for MI

A

AIVR
absecnt of P waves
wide QRS

USMLE HY notes (34 decks)

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