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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

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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)
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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
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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

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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.

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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)

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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

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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)

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9
Q

What murmur is associated with bacterial endocarditis?

A

Systolic murmur that increases with inspiration

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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

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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
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12
Q

ECG strip that is irregularly irregular + tachy is?

A

A fib

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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

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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

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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

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16
Q

Inheritance pattern of Hypertrophic Cardiomyopathy?

A

AD

Mutation in cardiac myosin binding protein C and myosin heavy chain

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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
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18
Q

Cyanide toxicity can occur in pts following an infusion of which medication?

A

Nitroprusside

Altered mental status, lactic acidosis, seizures, and coma

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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)

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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

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21
Q

How do you manage symptomatic sinus bradycardia?

A

IV atropine

If no response IV Epi/Dopamine or transcutaneous pacing

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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

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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

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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

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25
Q

Type of murmur frequently found in Marfan?

A

Early diastolic
Often present with aortic dissection
Aortic regurg is a complication of dissection.
AR = early diastolic murmur

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26
Q

What type of valvular insufficiency is associated with aortic dissection?

A

Aortic Regurgitation
Early decrescendo diastolic murmur
Typically seen in a proximal ascending aortic dissection

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27
Q

A disoriented pt presents with a NL PCWP and a Increased mixed venous oxygen saturation. Dx?

A

Septic shock

Hypotensive due to reduced afterload (decreased SVR) due to peripheral vasodilation

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28
Q

What are the 3 features of Beck’s triad and what does it Dx?

A
  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
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29
Q

3 causes of acute limb ischemia?

A
  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
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30
Q

Which drug classes vary in their ability to alleviate rapid heart rates depending on use dependence?

A 
Class I (esp Class Ic; progressive decrease in impulse conduction leading to a wider QRS complex) - Flecainide, propafenone
Class IV (CCB's)
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31
Q

If you hear a diastolic continuous murmur, what should be done next?

A

An echocardiogram

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32
Q

What type of murmur in a healthy adult does not require further evaluation?

A

Midsystolic

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33
Q

When is a carotid endartectomy indicated?

A 
Men:
Asymptomatic, 60-99% stenosis
Symptomatic, 50+% stenosis
Women:
70+% Stenosis regardless of symptoms
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34
Q

Most common complication months after an MI?

A

Ventricular Aneurysm
ECG often demonstrates ST elevation with deep Q waves.
Progressive ventricular enlargement

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35
Q

Noninflammatory, nonaterosclerotic condition presenting in 15-50 y/o women.

A 
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
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36
Q

Is a stress EKG warranted in a young pt with chest pain but no EKG changes?

A

No, the stress test is likely to yield a false positive and put the pt through unnecessary tests.

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37
Q

What PE and studies indicate a pericardial effusion?

A

Recent URI, dyspnea, elevated JVP, clear lung fields

CXR - increased cardiac silhouette (also indicates early temponade)

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38
Q

what is the most important factor to reduce mortality in Sudden Cardiac Arrest?

A

Time to effective CPR, rhythem analysis, and defibrillation

Elapsed time to effective resuscitation

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39
Q

Exertional dyspnea, orthopnea, bibasilar rales, lower extremity edema, and normal ejection fraction

A

HF with preserved Ejection Fraction
AKA diastolic dysfunction
Usually due to hypertensive heart dz

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40
Q

Abdominal pain + n/v?

A

Acute coronary syndrom. Get an ECG

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41
Q

S3 (follows S2) is indicative of?

A

LV failure (Ken-tuc-KY)
Normal finding in young adults
Consider IV diuretics for symptomatic relief

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42
Q

A pt presents with peripheral edema secondary to starting a new medication. What was the medication?

A

Amlodipine
Dihydropyriding Ca-channel agonists can cause peripheral edema due to dilation of peripheral vessels
If edema is serious d/c

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43
Q

Pt with infective endocarditis develops AV block. Dx?

A

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

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44
Q

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?

A

Aortic stenosis

The stenosis = outflow obstruction so increased CO cannot overcome this -> hypotension

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45
Q

Severe HTN + papilledema, retinal hemorrhages

A

Malignant hypertension (Hypertensive emergency >180/120)

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46
Q

Most common benign cardiac tumor?

A

Myxomas
Usually in Left atrium
Presents with fatigue, low grade fever, weight loss, systemic embolization, CV syx

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47
Q

If a pt is put on an electrolyte wasting diuretic, what are they at risk of developing?

A

Recurrent ventricular tachy

Do a metabolic panel for hypokalemia and hypomagnesmia

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48
Q

What can cause syncope in a pt with a history of heart dz and occasional ectopic beats?

A

Arrythmia

May not have prodomal syx at time of episode (ie no nausea, pallor, diaphoresis, etc.)

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49
Q

Signs of RV failure

A

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

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50
Q

Pulmonary capillary wedge estimates the pressure in the?

A

LV

Elevated PCWP indicates LV failure

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51
Q

How should you manage a pt with DM, HTN, and proteinuria?

A

Start a ACEI to prevent the progression of diabetic nephropathy.
First line therapy for DM pts with HTN

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52
Q

Why are beta blockers traditionally contra indicated in DM’s with HTN?

A

Thy mask hypoglycemia

Usually use after an ACEI

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53
Q

How do you manage cardiac temponade?

A

Pericardiocentesis

Use in pts with pulsus paradoxes, hypotension, and cardiomegaly on imaging

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54
Q

What is a contradiction of thrombolytic therapy in a pt that had an MI?

A
  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
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55
Q

What stress test is appropriate in a pt with stable angina and cannot tolerate exercise?

A

Dobutamine stress test

Dobutamine increases myocardial O2 demand and mimics exercise

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56
Q

When is an adenosine stress test appropriate?

A

Better for Coronary Artery disease because a stenosed artery cannot increase myocardial blood flow
Contraindicated in pts with asthma or COPD

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57
Q

Once elevated BP is observed at 3 visits, how do we manage this patient?

A

Stage I HTN with no other comorbidities:

  1. Exercise
  2. Diet modification
  3. Thiazide (HCTZ)
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58
Q

How do you manage a pt with BP > 160?

A

Manage with two drug combo

Thiazide + ACEI

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59
Q

ST elevation and T wave inversion in leads II, III, and aVF

A

occlusion of the RCA

Inferior infarction

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60
Q

ST elevation in I, aVL, V5, V6

A

Occlusion of Circumflex

Lateral infarction

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61
Q

What is USPSTF’s recommendations for lipid screeenings?

A

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

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62
Q

When is a pt a candidate for valve replacement?

A

EF < 60%

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63
Q

Pansystolic murmur best heard over the apex and radiating to the axilla?

A

Mitral regurg

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64
Q

What is the best lifestyle modification to lower the risk of cardiovascular dz?

A

Smoking cessation

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65
Q

A 21 y/o healthy pt presents in acute distress and ECG reveals ST elevations. What should be high on the differentials?

A

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.

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66
Q

What is the appropriate work up for a pt with stable angina and a normal EKG?

A

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.

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67
Q

In what 3 ways does amiodarone toxicity manifest?

A

Pulmonary pathology

  1. Organizing pneumonia
  2. Chronic Interstitial pneumonitis
  3. ARDS
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68
Q

If a pt with a blowing aortic murmur has both right and left sided heart failure - dx and tx?

A

Congestive heart failure
Can have SOB during his sleep
ACEI will decrease mortality

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69
Q

Pt has Raynaud phenomenon and antinuclear ab. Dx?

A

Scleroderma

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70
Q

How would you manage HTN in a scleroderma pt with renal involvement?

A

ACEI
BP control helps to limit the progression of the dz.
CCB’s can be added if ACEI does not yield a response

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71
Q

What findings would indicate constrictive pericarditis?

A

CXR - calcification on pericardium

Pericardial knock shortly after aortic valve closes (sudden cessation of ventricular filling)

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72
Q

A systolic ejection murmur is indicative of?

A

Mitral regurgitation

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73
Q

Crescendo- Decrescend murmur. Dx and workup?

A

Aortic stenosis

Order a transthoracic echo

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74
Q

What test should be ordered for a pt suspicious for claudication?

A

Ankle-Brachial index (<0.9)

Generally caused by valvular insufficiency

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75
Q

Upper thigh and buttock claudication + Impotence is suggestive of?

A

Leriche syndrome.

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76
Q

When would Doppler U/S be ordered for a pt?

A

Concersn for deep venous insufficiency or thrombosis

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77
Q

Which murmur is heard in mitral stenosis?

A

Increased S1 intensity (early in the dz)
MS decreases LV filling and elevates left sided atrial pressures
Can progress to pulmonary HTN

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78
Q

A pt with pulmonary edema is given furosemide and dobutamine and becomes hypotensive. Tx?

A

Dopamine

Dobutamine causes hypotension by decreasing afterload, which is best corrected with DA to increase afterload

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79
Q

Which lab finding strongly correlates with risk for future coronary events

A

LDL > 100

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80
Q

Most common murmur in a young healthy adult?

A

Mitral valve prolapse
Usually asymptomatic
Associated with Marfans

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81
Q

Most likely cause of crescendo decrescendo murmur in a 80 y/o man

A

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

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82
Q

Criteria for CABG?

A 
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%
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83
Q

Short PR interval on EKG

A

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

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84
Q

Criteria for valve replacement in aortic stenosis?

A

Symptomatic AS
Severe AS in those undergoing CABG
AS with ejection fraction <50%

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85
Q

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)

A

when LDL > 100

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86
Q

What is the best managment for Peripheral vascular dz (PVD)?

A

Calf claudication

Cilostazol - Phosphodiesterase inhibitor - decreases platelet aggregation and is a direct arterial vasodilator

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87
Q

Pt presents with dyspnea, Right sided heart failure, hepatomegaly, DLCO 54%

A

Pulmonary HTN

Significant decrease in DLCO without restrictive ventilatory abnormalities -> vascular dz

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88
Q

Pan systolic murmur 3-5 days after an MI

A

Papillary muscle rupture

Get to the OR

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89
Q

Younger female with MI like syx

A 
Variant angina
Transient ST segment elevations
Transient ischemia
Usually have PMH of Raynaud or Migraines
Worsened by cocaine, sumatriptan
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90
Q

Pt has symptomatic hypotension and bradycardia. Tx?

A

IV atropine
Use this first in any severe brady
Pt will most likely need pacing

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91
Q

Initial treatment for a newly diagnosed aortic stenosis?

A

ACE-I

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92
Q

Number 1 lifestyle modification to control HTN?

A

Weight loss

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93
Q

Pt presents with arthritis, abd pain, CNS changes, and papules

A 
Polyarteritis nodosa (PAN)
autoimmune of medium sized
Dx with bx of lesions = focal necrotizing arteritis
94
Q

3 agents that reduce mortality in CHR

A

ACEI/ARBS
Aldosterone inhibitors
Beta block

95
Q

Best imaging to assess extent of valvular vegetations and damage?

A

Transesophageal Echo

96
Q

Pt with pink frothy sputum from mouth

A

pulmonary edema, due to cardiac decomposition, due to recent arrhytmia onset.
Get an EKG

97
Q

Most cost effective way to evaluate for a AAA?

A

Abdominal U/S - Sens and spec of nearly 100%

CT of abdomen w/ contrast is more expensive and involves exposure to radiation

98
Q

Characteristics of diastolic HF

A

LV hypertrophy
Normal EF
Congestion

99
Q

Characteristics of Systolic HF

A

Inadequate contractility
Decreased EF
Hypotension

100
Q

What study confirms pericarditis?

A

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
Q

What finding would make estrogen contra in a menopausal female?

A

endometrial cancer
Hyperplasia is ok.
Progesterone should be added to the regimen in women that still have a uterus to prevent endometrial cancer

102
Q

Cardiac pt starts complaining of visual alterations and confuses green and yellow. Elevated BUN and Cr, EKG scooped ST segments. How do you manage?

A

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
Q

If a pt develops ACEI angiodema what med should the be switched to?

A

ARB

-sartans

104
Q

1st line tx for a CHF pt in a fib

A

Beta blocker

Decreases mortality

105
Q

Next step in management for a DM pt with stable angina that remains symptomatic on optimal tx and has 2 vessel involvement?

A

CABG

  • Two vessel involvement in DM’s
  • Three vessels in non DM’s
106
Q

Following an MI pt is hypotensive and decreased urinary output. Dx and management?

A

Cardiogenic shock
Give ionotropes (dobutamine) to increase CO
Be conservative with IVF due to pulmonary edema

107
Q

Otherwise healthy person presents with stable angina that remains symptomatic despite optimal tx. Two vessels involved

A

Percutaneous transluminal coronary angioplasty (PTCA) with stents

108
Q

Pt presents with acute SOB/dyspnea at rest, coughing bloodstained sputum. PE - auscultation reveals crepitations throughout the chest. EKG WNL. Dx?

A

Acute Pulmonary Edema - most likely caused by CHF

109
Q

Managment of acute Pulmonary Edema secondary to HF

A

Support - Give O2 and sit upright
Decrease Pre load - Loop diuretics (dieresis), morphine (reduces anxiety, venodilates), and Nitrates (improve coronary flow

110
Q

If a pt has a known GI bleed, what PE finding would indicate hypovolemia?

A

Orthostatic hypotension, may also see EKG changes

Time for transfusion

111
Q

Why is an ACEI helpful after an MI?

A

Prevents cardiac remodeling
(Decreases Afterload, decreases volume)
Decrease workload and O2 demand of the heart

112
Q

Immediate management of afib with hemodynamic instability?

A

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
Q

1st line tx of L diastolic dysfunction in a COPD pt w/ active wheezing?

A

Ca Channel blocker (ie verapamil)

Beta Block contra in active wheezing b/c it causes B2 blockage -> bronchoconstriction

114
Q

Initial evaluation of HOCM?

A

Transthoracic echo followed by continuous EKG monitoring (Holter)

115
Q

Following a cardiac catheterization through the femoral a. pt reports loss of foot perfusion. Dx?

A

Femoral pseudoaneurysm

Confirm with U/S

116
Q

Management of a woman with premature atrial contractions without syx?

A

Reassurance

117
Q

Initial management of SVT?

A 
Vagal maneuvers (carotid massage)
Valsava maneurver (forceful exhale over a closed mouth and nose)
118
Q

If you add amiodarone to a pt, you need to decrease the doses of?

A

dig

Warfarin

119
Q

Pt is hypotensive + bradycardic

A

IV atropine

120
Q

What study is needed in pt with CHF exacerbation?

A

Trans thoracic echo

121
Q

When does a HCOM pt become eligible for a surgical myectomy?

A

After failure to be managed with BBlocker and CCB

122
Q

Pt has vertigo when exercising, especially when his arms are overhead

A

Subclavian steal syndrome

123
Q

COPD pt with abn EKG (varying P-R intervals, discrete P waves with different morphologies in multiple leads)

A

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
Q

BP control in a pt with HOCM

A

Beta block +/- CCB’s (verapamil)

125
Q

Tx for symptomatic aortic stenosis w/o carotid obstruction

A

Valve replacement

Generaly with have an AV with an area <1cm and a gradient >40mmHg across the valve

126
Q

Management of asymptomatic endocarditis due to rheumatic fever?

A

Reassurance

Abx/echo not indicated

127
Q

Best medication to reduce morbidity after an MI with preserved EF?

A

Beta blockers

ACE-I - useful when EF is decreased by decreasing preload

128
Q

What is associated with coarctation of the aorta

A

Bicuspid aortic valve and aortic stenosis

129
Q

Which antihypertensive has a high risk of malignant HTN if stopped abruptly

A

Clonidine
Short acting sympathetic blocker (central alpha adrenergic stimulation)
Cessation -> rebound HTN, they should always be tapered

130
Q

SLE pt on OCP’s w/ severe HA’s and frontal lobe infarcts

A

Dural sinus thromobosis
Crosses arterial territories and extends into the white mater
Dx with cerebral venogram
RF’s - anything increasing coagulability (SLE, OCPs)

131
Q

Which HOCM pts need ICDs?

A

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
Q

Which pts need abx prophylaxis prior to dental work?

A
  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
Q

What is the target INR for pts with mechanical heart valves?

A

2.5-3.5

Other pts its 2-3

134
Q

How can you tell if peripheral edema is caused by the heart or liver?

A

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
Q

Management of first degree heart block

A

Observe

NL QRS duration but PR interval is prolonged because delayed AV node conduction prevents qRS for firing on time

136
Q

HTN in young guy
FHX + for sudden death
PE - b/l nontender upper abdominal mass

A

AD Polycystic kidney dz
Get a abd U/S
Hematuria, proteinuris, renal insufficiency
TX - ACEI, control cardiac RF’s

137
Q

CXR - pericardial scarring and thickening

A

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
Q

Management of Peripheral a. dz?

A

Supervised graded exercise program (improves functional capacity)
Reduce cardiovascular mortality (Aspirin, clopi)
Lower lipids in pts with abn lipid panels (statin)

139
Q

Months after MI pt has persistent ST segment elevation w/ deep Q waves

A

Ventricular aneurysm

Dyskinetic wall motion can lead to heart failure

140
Q

Etiology of systolic HTN w/ NL diastolic (<90)

A

Increased stiffness or decreased elasticity of the arterial wall
Lifestyle modifications + pharma

141
Q

Immediate tx of aortic dissection

A

IV beta blocker (esmolol)

Lower heart rate and BP

142
Q

Tx for beta blocker OD?

A

Glucagon IV

Presents w/ bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, cardiogenic shock

143
Q

Tx for CHF + pulm edema

A

O2
IV diuretics
Possible vasodilators (nitroglycerine, nitroprusside) if they get cardiogenic shock

144
Q

URI + syncope

CXR enlarged cardiac silhouette

A

Pericardial effusion
EKG - electrical alterans
Probably caused by viral pericarditis

145
Q

Pericarditis + BUN>60

A

Uremic pericarditis
EKG - some T wave inversion
Tx - hemodialysis

146
Q

Valvular abn in hypertrophic cardiomyopathy

A

ABN mitral leaflet motion (systolic ant motion blocks the aortic valve)

147
Q

B block should be avoided in?

A

decompensated CHF

Bradycardia

148
Q

Signs of aortic regurg

A

Early diastolic murmur

Bounding pulses “water hammer”

149
Q

Most effective non pharma way to decrease blood pressure?

A

Weight loss

5-20 SBP per 10kg loss

150
Q

Healthy pt with new dx HTN needs which tests?

A

UA for hematuria and urine ptorein/cr ratio
Chem panel
Lipid profile
BL EKG

151
Q

How does stress testing work?

A

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
Q

What causes descending aortic aneurysms?

A

Atherosclerosis

CSR - wide mediastinal silhouette, increased aortic knob, and tracheal deviation

153
Q

What causes ascending aortic aneurysms?

A

Cystic medial necrosis (aging)

Connective tissue disorder (Marfan, Ehlers-Danlos)

154
Q

First test in a person that has syx that sounds like ischemic heart disease (not an acute MI, just angina)

A

Exercise stress ECG

155
Q

Pulsus paradoxus in pts that do not have tamponade

A

Severe asthma
COPD
PP = > 10 mmHG drop in BP during inspiration

156
Q

What arrythmia is seen in dig toxicity?

A

Atrial tachycardia w/ AV block
Fairly specific for dig toxicity
dix toxicity -> increased ectopy and vagal tone

157
Q

Best way to reduce HTN in a pt w/ BMI 20-25

A

DASH diet

158
Q

Tx for v fib

A

Defibrillation

us in vfib or pulseless vtach

159
Q

Tx for a fib, a flutter, V tach w/ a pulse

A

Cardioversion

160
Q

Resistant HTN despite 3 drug therapy
Unexplained rise in serum Cr
Abdominal bruit

A

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
Q

Why do elderly get orthostatic hypotension?

A

Decreased baroreceptor responsiveness and defect in myocardial response

162
Q

When do you start a statin according to the 10yr cardiovascular risk calculator?

A

> 7.5%

163
Q

Restrictive cardiomyopathy
Proteinuria
Dyspnea

A

Amyloidosis
Deposition of insoluble protein in oragans throughout the body
Cardiomyopathy can progress to dilated cardiomyopathy
Dx - confirm w/ tissue bx

164
Q

10 days s/p stent placement pt presents with MI syx and ST elevation on EKG

A

Medication non compliance

D/c’ing antiplatelet therapy is strongest predictor for thrombis w/in 12 months of placement

165
Q

Tx for torsades de points

A

Hemodynamically unstable - defibrilation

Stable - Mag sulfate

166
Q

What can prolong QT interval?

A

Certain medications (fluconazole, moxifloxacin)
Hx of alcoholism (electrolyte imbalance)
Cardiomyopathy
HIV

167
Q

What causes S4?

A

LVH from prolonged HTN

If acute w/ MI syx = atrial gallop d/t LV stiffening and dysfunction induced by myocardial ischemia

168
Q

young adult female w/ substernal chest pain when exercising. Told she has a childhood murmur

A

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
Q

How do you manage lipids in a pt w/ DM aged 40-75

A

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
Q

Depression + kidney stones + HTN

A

Hyperparathyroidism

171
Q

What do you start first in ACS?

A

Antiplatlet tx (incl aspirin)

172
Q

Tx for lone AF pt has converted back to sinus rhythm, VASC is 0

A

No tx needed

173
Q

Papillary m. rupture can occur how many days after a MI?

A

3-5 days s/p MI

174
Q

young immigrent with new dyspnea, hemoptysis and palpitations

A

Mitral Stenosis

Pregressive dyspnea, nocturnal cough, hemoptysis

175
Q

Alcoholic

Dyspnea, S3, Bibasilar crackles, low EF

A

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
Q

Stab wound in the leg causes increased cardiac preloa by?

A

AV fistula -> blood leaves artery and enters vein -> increased preload
Develop HF despite NL or high CO

177
Q

Angina that wakes a healthy young pt at night

ST changes during pain episodees

A

Vasospastic angina
d/t Hyperreactivity of vascular smooth m. causing intermittent coronary a. vasospasm
Similar to Raynaud’s

178
Q

Reversible RF’s for premature atrial contractions

A

Tobacco, alcohol use, stress, caffeine

PAC’s are usually asymptomatic but can cause “skipped” beats or palpitations. Can precede a fib

179
Q

Peripheral edema is a common side effect of which antihypertensive?

A

Dihydropyrinde CCB’s (amlodipine) d/t preferential dilation of precapillary vessels
addition of ACEI or ARB can reduce this

180
Q

Upper extremity HTN
Diminished femoral pulses
Dx and CXR finding?

A

Coarctation of the aorta

CXR - inferior notching of 3rd-8th ribs d/t pressure induced enlargement of the intercostal arteries

181
Q

s/p pacemaker placement pt has holosystolic murmur at LLSB. Why?

A

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
Q

Tachycardia or a fib s/t hyperthyroidism needs?

A

Bblock

Continue until pt becomes euthyroid

183
Q

Why does niacin cause flushing an pruritis?

A

Prostaglandin related rxn
Peripheral vasodilation
Reduced with low dose ASA

184
Q

Viral myocarditis can cause a?

A

Dilated cardiomyopathy
Echo shows dilated ventricles, diffuse hypokinesia -> systolic dysfunction
Tx - supportive

185
Q

Tx for heat stroke

A

ice water immersion
Fluid resuscitation
Management of end organ complications

186
Q

What happens to the RAAS system in CHF?

A

RAAS is activated
AgII causes vasoconstriction of the efferent renal arterioles -> increased intraglomerular pressure in order to maintain GFR

187
Q

Preferred tx to prevent coronary a. dz in a pt w/ abn perfussion?

A

Antiplatelet therapy

188
Q

Most common cause of a fib

A

ectopic foci within the pulmonary v.

189
Q

Most common cause of flutter

A

Reentrant circuit around the tricuspid annulus

190
Q

What causes Type I heart block?

A

Impaired AV node conduction

Progressive prolongation of PR interval leading to a P wahve with a dropped QRS

191
Q

What causes Wolff-Parkinson-White?

A

Ventricular preexcitation d/t accessory conduction conduction pathway

192
Q

ST elevations in II, III, aVF

A

RCA occulusion

Acute inferior and posterior wall myocardial infarctions

193
Q

ST elevations V1-V6 (some or all)

A

LAD occlusion, anterior MI

194
Q

Pt is pulseless, a fib on monitor

A

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
Q

What is cardioversion?

A

Energy to synchronize the QRS complex

196
Q

What is defibrillation?

A

Energy randomly in the cardiac cycle without synchronization

197
Q

Pt has orthopnea immediately after MI. Why?

A

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
Q

MOA of clopidogrel

A

P2y12 receptor blocker

199
Q

Antiplatelet therapy in NSTEMI

A

ASA + clopi

200
Q

DOE
afib with rapid ventricular response
LV dysfunction

A

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
Q

Syncopal episode

EKG - long PR interval, prolonged QRS

A

Bradyarrhythmia

202
Q

Rheumatic heart dz wit a fib. Why the arrythmia?

A

Left atrial dilation

70% of pts with mitral steonsis develop a fib d/t LA dilation

203
Q

Palpitations relieved by immersing face in cold water

A

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
Q

Trauma pt in shock. Erythematoux rash with wheals over the chest and abdomen

A

Latex allergy
anaphylactic shock
Fat emobolism would have petechiae
be suspicious of the foley cath

205
Q

most common cause of dilated cardiomyopathy in young adults?

A

Viral myocarditis

206
Q

3 days s/p hospitalization pt presents with vague abdominal pain and blue toes, livedo reticularis

A

Cholesterol emolism
Complication of vascular procedures
Yellow refractile plaques in the retinal a. = hollenhorst plaques
Tx - supportive, statin therapy

207
Q

Which medications do NOT improve survival in CHF?

A

Dig, furosemide

Those that do improve survival: ACEI, ARBs, Bblock, spironolactone

208
Q

After a trauma pt needs fluids and pressors to maintain pressure. Fingers turn gangrenous. Why?

A

NE induced vasospasm can cause cyanosis/gangrene

209
Q

Tx for vasospastic angina

A

Calcium chanel blockers (Diltiazem, amlodipine)

210
Q

How can you prevent ventricular remodeling in the months following MI

A

ACEI

211
Q

Best way to prevent lower extremity edema in venous insufficiency?

A

Leg elevation (not diurectics)

212
Q

S/p chemo/rad Hodgkin lymphoma pt presents with SOB, abd distension. Why?

A

Constrictive pericarditis (Inelastic pericardium)

213
Q

Pt w/ asthma hx has MI and then develops bronchocontriction. Why?

A

ASA is a common trigger for bronchocontriction

214
Q

Pt has syncope while urinating. Why?

A

Situational syncope
Reflex or neurally mediated syncope associate with specific triggers
Trigger -> altered autonomic response -> cardioinhibitory, vasopressor, mixed response

215
Q

Sudden onset syncope 2wks s/p URI

EKG - sinus tach, electrical alterans

A

Pericardial effusion
Beat to beat varition in QRS axis and amplitude
Need emergent pericardiocentesis

216
Q

Prolongation of PR interval leading to non conducted P wave and dropped QRS

A

Mobitz type I heart block (Wenckebach), block in AV node
Genign, transient arrhythmia
Observe

217
Q

PR interval is constant (no prolongation) and QRS drops suddently

A

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
Q

Stable pt with wide QRS tachycardia needs

A

Amiodarone (or procainamid, sotalol, lidocaine)

219
Q

Pt has MI syx and within minutes develops sudden cardiac arrest

A

Reentrant ventricular arrhytmias (ie V fib)

most common cause of sudden cardiac arrest in the immediate post infarct time window

220
Q

Pericarditis < 4 days s/p MI?

A

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
Q

Young guy w/ palpitations
Weird FHx of cardiac stuff
PE - asked to sit up, lean forward, hold breath - decrescendo diastolic murmur over LSB
Dx?

A

Bicuspid aortic valve (most common cause of aortic regurg in young pt)

222
Q

A fib with tachy but stable?

A

Give diltiazam

223
Q

Predictor of poor clinical outcome in CHF?

A

hyponatremia
(increased renin, NE, and ADH)
Tx - fluids, ACEI, loops diuretics

224
Q

Young guy w/ palpitations

EKG - short PR intervals, slurred initial upstroke in QRS (delta wave), wide QRS w/ ST/T wave changes

A

Wolff-Parkinson-White

Accessory pathway bypassing AV node

225
Q

Yound pt gets syncope in high stress situations. What do you do with her?

A

This is vasovagal syncope
Tx - reassurance, advised to aovid triggers, use physical counterpressure maneuvers during the prodrome to abort the syncope

226
Q

Who should be screened for AAA?

A

Male active of former smokers 65-75

one time Abd U/S

227
Q

Management of STEMI

A

ASA and cath lab within 90 minutes

Fibrinolysis w/in 12 hours for those that cannot undergo cath

228
Q

New dx of a fib would need screening for?

A

Hyperthyroidism

229
Q

3-5 days s/o MI with sudden cardiogenic shock, new harsh holosystolic murmur w/ palpable thrill and LSB

A

Rupture of interventricular septum

Papillary m. rupture - no thrill

230
Q

Young pt with chest pain.

Systolic murmur at apex that shortens w/ squatting. Dx?

A

Mitral valve prolapse

231
Q

Why is B1 agonist helpful in CHF?

A

Decrease LV end systolic volume
Dobutamine -> increases myocardial contractility -> improved EF
Symptomatic improvement in decompensated HF

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