Cardio - kap Flashcards
1
Q
Treatment for chronic stable angina?
A
1st line - Beta Blocker (improves exercise tolerance, relives angina by decreasing myocardial contractility/hr, improves survival in those with MI)
Can also try - Calcium channel blocker if angina persists or a nitrate acutely
Preventatives - Aspirin, statin, smoking cessation, exercise/weight loss, control blood pressure and DM
2
Q
A pt on warfarin is having excessive bruising. What is the cause?
A
CYP450 inhibition increases Warfarin Acetaminophen/NSAIDS Abs/antifungal (metronidazole) Amiodarone Cimetidine Cranberry juice, Ginkgo biloba, Vit E Omeprazole Thyroid hormone SSRI (fluoxetine)
3
Q
If a warfarin pt is having excessive clotting, what is the cause?
A
CYP 450 Inducer Carbamazepine, phenytoin Ginseng, St. John's wort Oral contraceptives phenobarbital Rifampin
4
Q
A pt with pleuritic chest pain, dyspnea, tachypnea, and tachycardia and normal CXR most likely has?
A
Pulmonary embolism
CXR can be abn with PEm but generally used to rule out PNA, pneumo, pericardial effusion, and aortic dissection
5
Q
ST elevation in leads II, III, aVF, hypotension, and JVD
A
Right Ventricular Myocardial infarction
(inferior wall MI due to occlusion of RCA)
In addition to usual MI therapy give IV fluids to improve RV preload.
6
Q
First step in managing a patient with acute arterial occlusion of the lower extremity?
A
IV heparin infusion
(Remember 6p’s of acute limb ischemia: pain, pallor, poikilothermia (cool extremity), parethesia, pulselessness, and paralysis)
Common in a fib pts
Start heparin b/c the pt is at risk of limb damage (sensory loss, pain, weakness)
7
Q
Sudden onset chest pain radiating to the back with wide mediastinum on CXR
A
Aortic dissection
Can also develop cardiac temponade - hypotension, tachycardia, JVD, irregular respiration
8
Q
Once diagnosed with Peripheral artery dz, what complication is most likely to occur in the next 5 years?
A
Cardiovascular dz (MI, stroke)
9
Q
What murmur is associated with bacterial endocarditis?
A
Systolic murmur that increases with inspiration
10
Q
A pt with chronic renal failure presents with chest pain that improves with sitting up
A
uremic pericarditis
Need to put them on dialysis
Typically have BUN >60 and diffuse ST elevation is absent on EKG due to lack of myocardial inflammation
11
Q
If you suspect dig toxicity, look for what meds in their drug regimen?
A
Amiodarone Verapamil quinidine propafenone syx = GI distress, weakness, vision changes
12
Q
ECG strip that is irregularly irregular + tachy is?
A
A fib
13
Q
According to advanced cardiac life support all pts with a pulse and persistent tachy causing hemodynamic instability (hypotension, ischemia) should be managed with?
A
Cardioversion
This will synchronize the heart
If pulseless pt has vtach - defibrilation
14
Q
What is a major complication 5 days to 2 weeks post MI?
A
Ventricular free wall rupture
Pt presents with sudden chest pain, profound shock, rapidly becomes pulseless
15
Q
Which medications improve long-term survival in pts with LV systolic dysfunction (decreased ejection fraction)?
A
Beta blockers
ACEI/ARBS
Mineracorticoid receptor antagonists (spironolactone, eplernone)
In Blacks - Hydralazine and Nitrates
16
Q
Inheritance pattern of Hypertrophic Cardiomyopathy?
A
AD
Mutation in cardiac myosin binding protein C and myosin heavy chain
17
Q
If a pt presents with SOB, tricuspid regurg (sternal border murmur increasing with inspiration), peripheral edema, and ECG findings most likely has? And how would you manage it?
A
Pulmonary HTN (most lively due to left sided HF) Give diuretics and ACEI/ARB
18
Q
Cyanide toxicity can occur in pts following an infusion of which medication?
A
Nitroprusside
Altered mental status, lactic acidosis, seizures, and coma
19
Q
What test has the highest sensitivity for dx’ing CHF?
A
BNP
Released in CHF pts in response to high ventricular filling pressures
Found in 90% of CHF pts
Physical findings are SPECIFIC for CHF (crackles, elevated JVP, edema, 3rd heart sound)
20
Q
Why does a MI pt report pain resolution following SL nitroglycerin and ASA?
A
Decreased LV volume
Systemic venodilation -> decreased LV preload/EDV, reduces wall stress and oxygen demand
21
Q
How do you manage symptomatic sinus bradycardia?
A
IV atropine
If no response IV Epi/Dopamine or transcutaneous pacing
22
Q
What are the 3 strongest predictors of AAA expansion and rupture?
A
Large aneurysm diameter
Rapid rate of expansion
Current cigarette smoking
Repair is indicated if pt is symptomatic or if diameter is over 5.5 cm
23
Q
Pt reports being very aware of his heartbeat while lying in the lateral decubitus position. Dx?
A
Aortic regurgitation
AR -> increased LV preload -> large ventricle
24
Q
How should you treat a pt with a R ventricular MI?
A
Isotonic saline Bolus
Increases RV preload and helps to prevent profound hypotenstion
ST elevation in inferior leads + clear lungs on auscultation suggest RVMI
25
Type of murmur frequently found in Marfan?
Early diastolic
Often present with aortic dissection
Aortic regurg is a complication of dissection.
AR = early diastolic murmur
26
What type of valvular insufficiency is associated with aortic dissection?
Aortic Regurgitation
Early decrescendo diastolic murmur
Typically seen in a proximal ascending aortic dissection
27
A disoriented pt presents with a NL PCWP and a Increased mixed venous oxygen saturation. Dx?
Septic shock
| Hypotensive due to reduced afterload (decreased SVR) due to peripheral vasodilation
28
What are the 3 features of Beck's triad and what does it Dx?
1. Hypotension
2. Distended neck veins
3. Muffled heart sounds
Dx = Cardiac temponade
Pulsus paradoxus is another common finding
These syx occur due to an exaggerated shift of the interventricular septum -> reduced LV preload -> reduced SV -> reduced CO
29
3 causes of acute limb ischemia?
1. Cardiac/Arterial embolus (a fib, LV thrombi) - suspect in a previously a smptomatic pt with hx of heart dz
2. Arterial thrombosis - suspect in pt with history of claudication
3. latrogenic/blunt trauma
30
Which drug classes vary in their ability to alleviate rapid heart rates depending on use dependence?
```
Class I (esp Class Ic; progressive decrease in impulse conduction leading to a wider QRS complex) - Flecainide, propafenone
Class IV (CCB's)
```
31
If you hear a diastolic continuous murmur, what should be done next?
An echocardiogram
32
What type of murmur in a healthy adult does not require further evaluation?
Midsystolic
33
When is a carotid endartectomy indicated?
```
Men:
Asymptomatic, 60-99% stenosis
Symptomatic, 50+% stenosis
Women:
70+% Stenosis regardless of symptoms
```
34
Most common complication months after an MI?
Ventricular Aneurysm
ECG often demonstrates ST elevation with deep Q waves.
Progressive ventricular enlargement
35
Noninflammatory, nonaterosclerotic condition presenting in 15-50 y/o women.
```
Fibromuscular dysplasia (arterial vessel stenosis)
primarily affects renal arteries causing HTN, can cause brain ischemia
Syx -> HTN, high renin and aldosterone (secondary hyperaldosteronism)
Dx -> CT angio of the abdomen or duplex U/S
```
36
Is a stress EKG warranted in a young pt with chest pain but no EKG changes?
No, the stress test is likely to yield a false positive and put the pt through unnecessary tests.
37
What PE and studies indicate a pericardial effusion?
Recent URI, dyspnea, elevated JVP, clear lung fields
| CXR - increased cardiac silhouette (also indicates early temponade)
38
what is the most important factor to reduce mortality in Sudden Cardiac Arrest?
Time to effective CPR, rhythem analysis, and defibrillation
| Elapsed time to effective resuscitation
39
Exertional dyspnea, orthopnea, bibasilar rales, lower extremity edema, and normal ejection fraction
HF with preserved Ejection Fraction
AKA diastolic dysfunction
Usually due to hypertensive heart dz
40
Abdominal pain + n/v?
Acute coronary syndrom. Get an ECG
41
S3 (follows S2) is indicative of?
LV failure (Ken-tuc-KY)
Normal finding in young adults
Consider IV diuretics for symptomatic relief
42
A pt presents with peripheral edema secondary to starting a new medication. What was the medication?
Amlodipine
Dihydropyriding Ca-channel agonists can cause peripheral edema due to dilation of peripheral vessels
If edema is serious d/c
43
Pt with infective endocarditis develops AV block. Dx?
Perivalvular abscess extending into cardiac conduction tissues
Found in intervenous drug users and pts with aortic valve endocarditis
Found in 40% of PWID with IE
44
Syx - decreased exercise tolerance, exertional dyspnea, angina, syncope
PE - diminished carotid pulses, soft second heart sound, mid-to-late systolic murmur with max intensity at the second right intercostal space. Dx?
Aortic stenosis
| The stenosis = outflow obstruction so increased CO cannot overcome this -> hypotension
45
Severe HTN + papilledema, retinal hemorrhages
Malignant hypertension (Hypertensive emergency >180/120)
46
Most common benign cardiac tumor?
Myxomas
Usually in Left atrium
Presents with fatigue, low grade fever, weight loss, systemic embolization, CV syx
47
If a pt is put on an electrolyte wasting diuretic, what are they at risk of developing?
Recurrent ventricular tachy
| Do a metabolic panel for hypokalemia and hypomagnesmia
48
What can cause syncope in a pt with a history of heart dz and occasional ectopic beats?
Arrythmia
| May not have prodomal syx at time of episode (ie no nausea, pallor, diaphoresis, etc.)
49
Signs of RV failure
Elevated JVP
S3
Tricuspid regurge
Hepatomegaly with pulsatile liver
Lower extremity edema, ascites, and or pleural effusions
*Often seen in Cor Pulmonale - do an echo, catheterization will most likely show elevated pulmonary a. pressure
50
Pulmonary capillary wedge estimates the pressure in the?
LV
| Elevated PCWP indicates LV failure
51
How should you manage a pt with DM, HTN, and proteinuria?
Start a ACEI to prevent the progression of diabetic nephropathy.
First line therapy for DM pts with HTN
52
Why are beta blockers traditionally contra indicated in DM's with HTN?
Thy mask hypoglycemia
| Usually use after an ACEI
53
How do you manage cardiac temponade?
Pericardiocentesis
| Use in pts with pulsus paradoxes, hypotension, and cardiomegaly on imaging
54
What is a contradiction of thrombolytic therapy in a pt that had an MI?
1. CPR for 10+ minutes
There is likely trauma to the anterior chest wall -> high bleeding risk
2. Diabetic retinopathy - high risk of retinal hemorrhage
3. Lower GI bleed if in the last 2-4 weeks
55
What stress test is appropriate in a pt with stable angina and cannot tolerate exercise?
Dobutamine stress test
| Dobutamine increases myocardial O2 demand and mimics exercise
56
When is an adenosine stress test appropriate?
Better for Coronary Artery disease because a stenosed artery cannot increase myocardial blood flow
Contraindicated in pts with asthma or COPD
57
Once elevated BP is observed at 3 visits, how do we manage this patient?
Stage I HTN with no other comorbidities:
1. Exercise
2. Diet modification
3. Thiazide (HCTZ)
58
How do you manage a pt with BP > 160?
Manage with two drug combo
| Thiazide + ACEI
59
ST elevation and T wave inversion in leads II, III, and aVF
occlusion of the RCA
| Inferior infarction
60
ST elevation in I, aVL, V5, V6
Occlusion of Circumflex
| Lateral infarction
61
What is USPSTF's recommendations for lipid screeenings?
If no RF's:
Men - 35 y/o
Women - 45 y/o
If RF's:
Men - 20 to 35
Women
20 to 45
RFS = DM, Family Hx (<50 in males, <60 in female relatives), Tobacco use, HTN
62
When is a pt a candidate for valve replacement?
EF < 60%
63
Pansystolic murmur best heard over the apex and radiating to the axilla?
Mitral regurg
64
What is the best lifestyle modification to lower the risk of cardiovascular dz?
Smoking cessation
65
A 21 y/o healthy pt presents in acute distress and ECG reveals ST elevations. What should be high on the differentials?
Amphetamine or cocaine overdose
This can cause an MI in a young healthy person due to coronary vasospasm.
Also look for hypertensive emergency and dilated pupils.
66
What is the appropriate work up for a pt with stable angina and a normal EKG?
Exercise stress test
Will identify which artery is being occluded
Indicated in a pt with anginal syx with a normal EKG, and is able to exercise at 80% of maximum. If the pt can't exercise consider dipyridamole (adenosine) - BUT contraindicated in COPD and asthma.
67
In what 3 ways does amiodarone toxicity manifest?
Pulmonary pathology
1. Organizing pneumonia
2. Chronic Interstitial pneumonitis
3. ARDS
68
If a pt with a blowing aortic murmur has both right and left sided heart failure - dx and tx?
Congestive heart failure
Can have SOB during his sleep
ACEI will decrease mortality
69
Pt has Raynaud phenomenon and antinuclear ab. Dx?
Scleroderma
70
How would you manage HTN in a scleroderma pt with renal involvement?
ACEI
BP control helps to limit the progression of the dz.
CCB's can be added if ACEI does not yield a response
71
What findings would indicate constrictive pericarditis?
CXR - calcification on pericardium
| Pericardial knock shortly after aortic valve closes (sudden cessation of ventricular filling)
72
A systolic ejection murmur is indicative of?
Mitral regurgitation
73
Crescendo- Decrescend murmur. Dx and workup?
Aortic stenosis
| Order a transthoracic echo
74
What test should be ordered for a pt suspicious for claudication?
Ankle-Brachial index (<0.9)
| Generally caused by valvular insufficiency
75
Upper thigh and buttock claudication + Impotence is suggestive of?
Leriche syndrome.
76
When would Doppler U/S be ordered for a pt?
Concersn for deep venous insufficiency or thrombosis
77
Which murmur is heard in mitral stenosis?
Increased S1 intensity (early in the dz)
MS decreases LV filling and elevates left sided atrial pressures
Can progress to pulmonary HTN
78
A pt with pulmonary edema is given furosemide and dobutamine and becomes hypotensive. Tx?
Dopamine
| Dobutamine causes hypotension by decreasing afterload, which is best corrected with DA to increase afterload
79
Which lab finding strongly correlates with risk for future coronary events
LDL > 100
80
Most common murmur in a young healthy adult?
Mitral valve prolapse
Usually asymptomatic
Associated with Marfans
81
Most likely cause of crescendo decrescendo murmur in a 80 y/o man
Calcification of the aortic valve
Calcification of a bicuspid aortic valve is more common in middle aged patients
Rheumatic fever is common cause of aortic stenosis
82
Criteria for CABG?
```
Significant left main coronary stenosis
>70% stenosis of LAD and Left circumflex
3 vessel dz
2 vessel dz in DM
Sifnificant LAD dz with LV ejection <50%
```
83
Short PR interval on EKG
Pre-excitation syndrome (Wolf-Parkinson-White)
Caused by an aberrant connection between the atria and ventricle
Digoxin, CCB, and Beta blocker further block the conduction and cause Vtach or SVT
84
Criteria for valve replacement in aortic stenosis?
Symptomatic AS
Severe AS in those undergoing CABG
AS with ejection fraction <50%
85
When should a lipid decreasing medication be initiated in a person with CAD or a equivalent (ie DM, Peripheral artery dz, AAA, carotid artery dz)
when LDL > 100
86
What is the best managment for Peripheral vascular dz (PVD)?
Calf claudication
| Cilostazol - Phosphodiesterase inhibitor - decreases platelet aggregation and is a direct arterial vasodilator
87
Pt presents with dyspnea, Right sided heart failure, hepatomegaly, DLCO 54%
Pulmonary HTN
| Significant decrease in DLCO without restrictive ventilatory abnormalities -> vascular dz
88
Pan systolic murmur 3-5 days after an MI
Papillary muscle rupture
| Get to the OR
89
Younger female with MI like syx
```
Variant angina
Transient ST segment elevations
Transient ischemia
Usually have PMH of Raynaud or Migraines
Worsened by cocaine, sumatriptan
```
90
Pt has symptomatic hypotension and bradycardia. Tx?
IV atropine
Use this first in any severe brady
Pt will most likely need pacing
91
Initial treatment for a newly diagnosed aortic stenosis?
ACE-I
92
Number 1 lifestyle modification to control HTN?
Weight loss
93
Pt presents with arthritis, abd pain, CNS changes, and papules
```
Polyarteritis nodosa (PAN)
autoimmune of medium sized
Dx with bx of lesions = focal necrotizing arteritis
```
94
3 agents that reduce mortality in CHR
ACEI/ARBS
Aldosterone inhibitors
Beta block
95
Best imaging to assess extent of valvular vegetations and damage?
Transesophageal Echo
96
Pt with pink frothy sputum from mouth
pulmonary edema, due to cardiac decomposition, due to recent arrhytmia onset.
Get an EKG
97
Most cost effective way to evaluate for a AAA?
Abdominal U/S - Sens and spec of nearly 100%
| CT of abdomen w/ contrast is more expensive and involves exposure to radiation
98
Characteristics of diastolic HF
LV hypertrophy
Normal EF
Congestion
99
Characteristics of Systolic HF
Inadequate contractility
Decreased EF
Hypotension
100
What study confirms pericarditis?
EKG
Diffuse concave ST elevation, PR depression, and somethimes flipped T waves
Echo can rule out pericardial effusion, but not able to detect pericarditis
101
What finding would make estrogen contra in a menopausal female?
endometrial cancer
Hyperplasia is ok.
Progesterone should be added to the regimen in women that still have a uterus to prevent endometrial cancer
102
Cardiac pt starts complaining of visual alterations and confuses green and yellow. Elevated BUN and Cr, EKG scooped ST segments. How do you manage?
Adjust digoxin level because she has ARI
Give atropine if bradycardic or hypoperfusing
Apparently only add Fab if she doesnt respond to adjusting dosing
103
If a pt develops ACEI angiodema what med should the be switched to?
ARB
| -sartans
104
1st line tx for a CHF pt in a fib
Beta blocker
| Decreases mortality
105
Next step in management for a DM pt with stable angina that remains symptomatic on optimal tx and has 2 vessel involvement?
CABG
* Two vessel involvement in DM's
* Three vessels in non DM's
106
Following an MI pt is hypotensive and decreased urinary output. Dx and management?
Cardiogenic shock
Give ionotropes (dobutamine) to increase CO
Be conservative with IVF due to pulmonary edema
107
Otherwise healthy person presents with stable angina that remains symptomatic despite optimal tx. Two vessels involved
Percutaneous transluminal coronary angioplasty (PTCA) with stents
108
Pt presents with acute SOB/dyspnea at rest, coughing bloodstained sputum. PE - auscultation reveals crepitations throughout the chest. EKG WNL. Dx?
Acute Pulmonary Edema - most likely caused by CHF
109
Managment of acute Pulmonary Edema secondary to HF
Support - Give O2 and sit upright
Decrease Pre load - Loop diuretics (dieresis), morphine (reduces anxiety, venodilates), and Nitrates (improve coronary flow
110
If a pt has a known GI bleed, what PE finding would indicate hypovolemia?
Orthostatic hypotension, may also see EKG changes
| Time for transfusion
111
Why is an ACEI helpful after an MI?
Prevents cardiac remodeling
(Decreases Afterload, decreases volume)
Decrease workload and O2 demand of the heart
112
Immediate management of afib with hemodynamic instability?
Synchronized cardioversion
Also indicated in unstable a flutter, a tach, SVT tach, and Vtach
Dig and diltiazem are good choices in a pt with a fib that is stable
113
1st line tx of L diastolic dysfunction in a COPD pt w/ active wheezing?
Ca Channel blocker (ie verapamil)
| Beta Block contra in active wheezing b/c it causes B2 blockage -> bronchoconstriction
114
Initial evaluation of HOCM?
Transthoracic echo followed by continuous EKG monitoring (Holter)
115
Following a cardiac catheterization through the femoral a. pt reports loss of foot perfusion. Dx?
Femoral pseudoaneurysm
| Confirm with U/S
116
Management of a woman with premature atrial contractions without syx?
Reassurance
117
Initial management of SVT?
```
Vagal maneuvers (carotid massage)
Valsava maneurver (forceful exhale over a closed mouth and nose)
```
118
If you add amiodarone to a pt, you need to decrease the doses of?
dig
| Warfarin
119
Pt is hypotensive + bradycardic
IV atropine
120
What study is needed in pt with CHF exacerbation?
Trans thoracic echo
121
When does a HCOM pt become eligible for a surgical myectomy?
After failure to be managed with BBlocker and CCB
122
Pt has vertigo when exercising, especially when his arms are overhead
Subclavian steal syndrome
123
COPD pt with abn EKG (varying P-R intervals, discrete P waves with different morphologies in multiple leads)
Multifocal atrial tachycardia
Most frequently seen in older pts with decompensated chronic lung disease
Believed to be a complication of hypoxia - get them on O2
124
BP control in a pt with HOCM
Beta block +/- CCB's (verapamil)
125
Tx for symptomatic aortic stenosis w/o carotid obstruction
Valve replacement
| Generaly with have an AV with an area <1cm and a gradient >40mmHg across the valve
126
Management of asymptomatic endocarditis due to rheumatic fever?
Reassurance
| Abx/echo not indicated
127
Best medication to reduce morbidity after an MI with preserved EF?
Beta blockers
| ACE-I - useful when EF is decreased by decreasing preload
128
What is associated with coarctation of the aorta
Bicuspid aortic valve and aortic stenosis
129
Which antihypertensive has a high risk of malignant HTN if stopped abruptly
Clonidine
Short acting sympathetic blocker (central alpha adrenergic stimulation)
Cessation -> rebound HTN, they should always be tapered
130
SLE pt on OCP's w/ severe HA's and frontal lobe infarcts
Dural sinus thromobosis
Crosses arterial territories and extends into the white mater
Dx with cerebral venogram
RF's - anything increasing coagulability (SLE, OCPs)
131
Which HOCM pts need ICDs?
Those considered high risk for sudden death (min 2 of: FHx of sudden cardiac death, Syncope, Vtach, Abn BP response to exercise, massive LVH)
132
Which pts need abx prophylaxis prior to dental work?
1. Prosthetic heart valves
2. Previous episodes of endocarditis
3. Unrepaired cyanotic heart disease
4. Valvulopathy in a transplanted heart
NOTE: rheumatic heart dz is not one of these
133
What is the target INR for pts with mechanical heart valves?
2.5-3.5
| Other pts its 2-3
134
How can you tell if peripheral edema is caused by the heart or liver?
Hepatojugular reflux
HF - + JVD and + hepatojugarly reflux
Hepatic - reduced to NL JVD, no hepatojugular reflux
HJ reflux - apply firm pressure over the upper abdomen, see elevation of JVD >3cm during abdominal compression
135
Management of first degree heart block
Observe
| NL QRS duration but PR interval is prolonged because delayed AV node conduction prevents qRS for firing on time
136
HTN in young guy
FHX + for sudden death
PE - b/l nontender upper abdominal mass
AD Polycystic kidney dz
Get a abd U/S
Hematuria, proteinuris, renal insufficiency
TX - ACEI, control cardiac RF's
137
CXR - pericardial scarring and thickening
Constrictive preicarditis
Present with decreased CO and venous overload
US etiologies - virus, cardiac surgery, chest radiation, idiopathic causes
Developing world - TB (esp Africa, India, China)
138
Management of Peripheral a. dz?
Supervised graded exercise program (improves functional capacity)
Reduce cardiovascular mortality (Aspirin, clopi)
Lower lipids in pts with abn lipid panels (statin)
139
Months after MI pt has persistent ST segment elevation w/ deep Q waves
Ventricular aneurysm
| Dyskinetic wall motion can lead to heart failure
140
Etiology of systolic HTN w/ NL diastolic (<90)
Increased stiffness or decreased elasticity of the arterial wall
Lifestyle modifications + pharma
141
Immediate tx of aortic dissection
IV beta blocker (esmolol)
| Lower heart rate and BP
142
Tx for beta blocker OD?
Glucagon IV
| Presents w/ bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, cardiogenic shock
143
Tx for CHF + pulm edema
O2
IV diuretics
Possible vasodilators (nitroglycerine, nitroprusside) if they get cardiogenic shock
144
URI + syncope
| CXR enlarged cardiac silhouette
Pericardial effusion
EKG - electrical alterans
Probably caused by viral pericarditis
145
Pericarditis + BUN>60
Uremic pericarditis
EKG - some T wave inversion
Tx - hemodialysis
146
Valvular abn in hypertrophic cardiomyopathy
ABN mitral leaflet motion (systolic ant motion blocks the aortic valve)
147
B block should be avoided in?
decompensated CHF
| Bradycardia
148
Signs of aortic regurg
Early diastolic murmur
| Bounding pulses "water hammer"
149
Most effective non pharma way to decrease blood pressure?
Weight loss
| 5-20 SBP per 10kg loss
150
Healthy pt with new dx HTN needs which tests?
UA for hematuria and urine ptorein/cr ratio
Chem panel
Lipid profile
BL EKG
151
How does stress testing work?
Causes a marked increase in blood flow in NL coronary a.'s and a relatively small increase in blood flow in stenotic a.'s. The differentce in blood flow allows diagnosis of obstructive coronary a. dz d/t reduced uptake of radioactive isotope into the ischemic myocardium
152
What causes descending aortic aneurysms?
Atherosclerosis
| CSR - wide mediastinal silhouette, increased aortic knob, and tracheal deviation
153
What causes ascending aortic aneurysms?
Cystic medial necrosis (aging)
| Connective tissue disorder (Marfan, Ehlers-Danlos)
154
First test in a person that has syx that sounds like ischemic heart disease (not an acute MI, just angina)
Exercise stress ECG
155
Pulsus paradoxus in pts that do not have tamponade
Severe asthma
COPD
PP = > 10 mmHG drop in BP during inspiration
156
What arrythmia is seen in dig toxicity?
Atrial tachycardia w/ AV block
Fairly specific for dig toxicity
dix toxicity -> increased ectopy and vagal tone
157
Best way to reduce HTN in a pt w/ BMI 20-25
DASH diet
158
Tx for v fib
Defibrillation
| us in vfib or pulseless vtach
159
Tx for a fib, a flutter, V tach w/ a pulse
Cardioversion
160
Resistant HTN despite 3 drug therapy
Unexplained rise in serum Cr
Abdominal bruit
Renovascular dz
resistant HTN, diffuse atherosclerosis (intermittent claudication), aymmetric kidney size, recurrent flash pulm edema, >30% in crease in Cr
Abd bruit is highly specific
161
Why do elderly get orthostatic hypotension?
Decreased baroreceptor responsiveness and defect in myocardial response
162
When do you start a statin according to the 10yr cardiovascular risk calculator?
>7.5%
163
Restrictive cardiomyopathy
Proteinuria
Dyspnea
Amyloidosis
Deposition of insoluble protein in oragans throughout the body
Cardiomyopathy can progress to dilated cardiomyopathy
Dx - confirm w/ tissue bx
164
10 days s/p stent placement pt presents with MI syx and ST elevation on EKG
Medication non compliance
| D/c'ing antiplatelet therapy is strongest predictor for thrombis w/in 12 months of placement
165
Tx for torsades de points
Hemodynamically unstable - defibrilation
| Stable - Mag sulfate
166
What can prolong QT interval?
Certain medications (fluconazole, moxifloxacin)
Hx of alcoholism (electrolyte imbalance)
Cardiomyopathy
HIV
167
What causes S4?
LVH from prolonged HTN
| If acute w/ MI syx = atrial gallop d/t LV stiffening and dysfunction induced by myocardial ischemia
168
young adult female w/ substernal chest pain when exercising. Told she has a childhood murmur
Supravalvular aortic stenosis -> aortic outflow obstruction -> LVH, exertional angina d/t subendocardial ischemia w/ increased myocardial oxygen demand during exercise
Can have different BPs in the upper extremities and palpable thrill in substernal notch
169
How do you manage lipids in a pt w/ DM aged 40-75
All will need a statin + lifestyle modification w/ glucose control
If 10 yr risk <7.5% - moderate intensity statin
10 yr risk >7.5% - high intensity statin
170
Depression + kidney stones + HTN
Hyperparathyroidism
171
What do you start first in ACS?
Antiplatlet tx (incl aspirin)
172
Tx for lone AF pt has converted back to sinus rhythm, VASC is 0
No tx needed
173
Papillary m. rupture can occur how many days after a MI?
3-5 days s/p MI
174
young immigrent with new dyspnea, hemoptysis and palpitations
Mitral Stenosis
| Pregressive dyspnea, nocturnal cough, hemoptysis
175
Alcoholic
| Dyspnea, S3, Bibasilar crackles, low EF
decompensated cardiomyopathy d/t alcohol (alcoholic cardiomyopathy)
dx of exclusion (dilated cardiomyopathy in alcoholic w/o other etiology)
Cessation can lead to improvement or normalization of LV fxn over time
176
Stab wound in the leg causes increased cardiac preloa by?
AV fistula -> blood leaves artery and enters vein -> increased preload
Develop HF despite NL or high CO
177
Angina that wakes a healthy young pt at night
| ST changes during pain episodees
Vasospastic angina
d/t Hyperreactivity of vascular smooth m. causing intermittent coronary a. vasospasm
Similar to Raynaud's
178
Reversible RF's for premature atrial contractions
Tobacco, alcohol use, stress, caffeine
| PAC's are usually asymptomatic but can cause "skipped" beats or palpitations. Can precede a fib
179
Peripheral edema is a common side effect of which antihypertensive?
Dihydropyrinde CCB's (amlodipine) d/t preferential dilation of precapillary vessels
addition of ACEI or ARB can reduce this
180
Upper extremity HTN
Diminished femoral pulses
Dx and CXR finding?
Coarctation of the aorta
| CXR - inferior notching of 3rd-8th ribs d/t pressure induced enlargement of the intercostal arteries
181
s/p pacemaker placement pt has holosystolic murmur at LLSB. Why?
Tricuspid regurgitation
Pacemaker leads are placed though the tricuspid valve and can cause severe regurg d/t leaflet damage or inadequate coaptation
Present as R sided HF after placement of ICD aore CDP
182
Tachycardia or a fib s/t hyperthyroidism needs?
Bblock
| Continue until pt becomes euthyroid
183
Why does niacin cause flushing an pruritis?
Prostaglandin related rxn
Peripheral vasodilation
Reduced with low dose ASA
184
Viral myocarditis can cause a?
Dilated cardiomyopathy
Echo shows dilated ventricles, diffuse hypokinesia -> systolic dysfunction
Tx - supportive
185
Tx for heat stroke
ice water immersion
Fluid resuscitation
Management of end organ complications
186
What happens to the RAAS system in CHF?
RAAS is activated
AgII causes vasoconstriction of the efferent renal arterioles -> increased intraglomerular pressure in order to maintain GFR
187
Preferred tx to prevent coronary a. dz in a pt w/ abn perfussion?
Antiplatelet therapy
188
Most common cause of a fib
ectopic foci within the pulmonary v.
189
Most common cause of flutter
Reentrant circuit around the tricuspid annulus
190
What causes Type I heart block?
Impaired AV node conduction
| Progressive prolongation of PR interval leading to a P wahve with a dropped QRS
191
What causes Wolff-Parkinson-White?
Ventricular preexcitation d/t accessory conduction conduction pathway
192
ST elevations in II, III, aVF
RCA occulusion
| Acute inferior and posterior wall myocardial infarctions
193
ST elevations V1-V6 (some or all)
LAD occlusion, anterior MI
194
Pt is pulseless, a fib on monitor
Pulseless electrical activity
Need CPR and vasopressors (epi) to maintain cerebral and coronary perfusion until underlying cause identified
No need to cardiovert or defib
195
What is cardioversion?
Energy to synchronize the QRS complex
196
What is defibrillation?
Energy randomly in the cardiac cycle without synchronization
197
Pt has orthopnea immediately after MI. Why?
MI -> papillary muscle displacement -> acute mitral regurgitation
Abrupt volume overload causes increased left sided filling pressures
No change in chamber sizes since this is an acute change
198
MOA of clopidogrel
P2y12 receptor blocker
199
Antiplatelet therapy in NSTEMI
ASA + clopi
200
DOE
afib with rapid ventricular response
LV dysfunction
Tachycardia mediated cardiomyopathy
Can be caused by hx of A fib, a blutter, V tach, AV nodal reentrant tachy
Step 1 - rate and rhythm control
201
Syncopal episode
| EKG - long PR interval, prolonged QRS
Bradyarrhythmia
202
Rheumatic heart dz wit a fib. Why the arrythmia?
Left atrial dilation
| 70% of pts with mitral steonsis develop a fib d/t LA dilation
203
Palpitations relieved by immersing face in cold water
Atrioventricular nodal reentrant tachycardia (AVNRT)
Caused by reentry d/t a dual electrical pathway (slow and fast) in the AV node
Vagal maneuvers increase parasympathetic tone and causes slowing of AV nodal conduction
204
Trauma pt in shock. Erythematoux rash with wheals over the chest and abdomen
Latex allergy
anaphylactic shock
Fat emobolism would have petechiae
be suspicious of the foley cath
205
most common cause of dilated cardiomyopathy in young adults?
Viral myocarditis
206
3 days s/p hospitalization pt presents with vague abdominal pain and blue toes, livedo reticularis
Cholesterol emolism
Complication of vascular procedures
Yellow refractile plaques in the retinal a. = hollenhorst plaques
Tx - supportive, statin therapy
207
Which medications do NOT improve survival in CHF?
Dig, furosemide
| Those that do improve survival: ACEI, ARBs, Bblock, spironolactone
208
After a trauma pt needs fluids and pressors to maintain pressure. Fingers turn gangrenous. Why?
NE induced vasospasm can cause cyanosis/gangrene
209
Tx for vasospastic angina
Calcium chanel blockers (Diltiazem, amlodipine)
210
How can you prevent ventricular remodeling in the months following MI
ACEI
211
Best way to prevent lower extremity edema in venous insufficiency?
Leg elevation (not diurectics)
212
S/p chemo/rad Hodgkin lymphoma pt presents with SOB, abd distension. Why?
Constrictive pericarditis (Inelastic pericardium)
213
Pt w/ asthma hx has MI and then develops bronchocontriction. Why?
ASA is a common trigger for bronchocontriction
214
Pt has syncope while urinating. Why?
Situational syncope
Reflex or neurally mediated syncope associate with specific triggers
Trigger -> altered autonomic response -> cardioinhibitory, vasopressor, mixed response
215
Sudden onset syncope 2wks s/p URI
| EKG - sinus tach, electrical alterans
Pericardial effusion
Beat to beat varition in QRS axis and amplitude
Need emergent pericardiocentesis
216
Prolongation of PR interval leading to non conducted P wave and dropped QRS
Mobitz type I heart block (Wenckebach), block in AV node
Genign, transient arrhythmia
Observe
217
PR interval is constant (no prolongation) and QRS drops suddently
Mobitz type II heart block
Block in His-purkinje system below the AV node
Can progress to third degree AV block and requre a pacemaker
218
Stable pt with wide QRS tachycardia needs
Amiodarone (or procainamid, sotalol, lidocaine)
219
Pt has MI syx and within minutes develops sudden cardiac arrest
Reentrant ventricular arrhytmias (ie V fib)
| most common cause of sudden cardiac arrest in the immediate post infarct time window
220
Pericarditis < 4 days s/p MI?
Peri-infarction pericarditis
Not an immune rxn - just local inflammation
NOT the same Dressler syndrome which is weeks after MI and is immune mediated
Tx - supportive, generally try to avoid NSAID's d/t impairment of collagen deposition
221
Young guy w/ palpitations
Weird FHx of cardiac stuff
PE - asked to sit up, lean forward, hold breath - decrescendo diastolic murmur over LSB
Dx?
Bicuspid aortic valve (most common cause of aortic regurg in young pt)
222
A fib with tachy but stable?
Give diltiazam
223
Predictor of poor clinical outcome in CHF?
hyponatremia
(increased renin, NE, and ADH)
Tx - fluids, ACEI, loops diuretics
224
Young guy w/ palpitations
| EKG - short PR intervals, slurred initial upstroke in QRS (delta wave), wide QRS w/ ST/T wave changes
Wolff-Parkinson-White
| Accessory pathway bypassing AV node
225
Yound pt gets syncope in high stress situations. What do you do with her?
This is vasovagal syncope
Tx - reassurance, advised to aovid triggers, use physical counterpressure maneuvers during the prodrome to abort the syncope
226
Who should be screened for AAA?
Male active of former smokers 65-75
| one time Abd U/S
227
Management of STEMI
ASA and cath lab within 90 minutes
| Fibrinolysis w/in 12 hours for those that cannot undergo cath
228
New dx of a fib would need screening for?
Hyperthyroidism
229
3-5 days s/o MI with sudden cardiogenic shock, new harsh holosystolic murmur w/ palpable thrill and LSB
Rupture of interventricular septum
| Papillary m. rupture - no thrill
230
Young pt with chest pain.
| Systolic murmur at apex that shortens w/ squatting. Dx?
Mitral valve prolapse
231
Why is B1 agonist helpful in CHF?
Decrease LV end systolic volume
Dobutamine -> increases myocardial contractility -> improved EF
Symptomatic improvement in decompensated HF
