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UWORLD ABIM > Cardiology > Flashcards

Cardiology Flashcards

1
Q

T/F: High-intensity statin therapy can induce new/worsen existing diabetes and should be stopped in such patients

A

False. True about the sugars, benefit of statins outweighs harm so you don’t stop the statin

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2
Q

How do you manage cocaine-induced chest pain?

A
  • if STEMI, cath lab
  • 1st line meds: Aspirin + Nitroglycerin, Benzos, Calcium Channel Blocker
  • Contraindicated: Beta blocker (unopposed alpha)
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3
Q

How do you manage patients with long QT syndrome?

A

Beta blocker! reduces arrythmias and SCD. If syncope or arrythmia on BB, ICD

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4
Q

Physical exam

A

Aortic Regurg: patient sitting up, leaning forward and holding breath
Mitral stenosis: left lateral decubitus, bell at apex
S3: left lat dec
MVP: Standing/valsava lengthens murmur, squatting/leg elevation = delayed and shorter murmur (inc LV V)

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5
Q

EKG changes hyperkalemia

A

PR prolongation, p wave flattening/loss, bradyarrhythmias, peaked T waves

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6
Q

Milrinone MOA

A

Phosphodiesterase inhibitor that decreases cAMP degradation = inc cAMP = arterial and venous vasodilator and + inotropy. Improves HF sxs. Watch for hypotensive episodes and arrythmias.

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7
Q

Anticoagulation for cardioversion

A

If TEE confirms no thrombus, continue for 4 weeks following (stunning); if TEE does not definitively rule it out, 3 weeks of anticoag beforehand

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8
Q

Management of AAA

A

<4cm: US q 2-3 years
4-4.9cm: US q 6-12 months
>5.5cm: surgery
>0.5cm growth/6 months: surgery

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9
Q

cardiac abnormality associated with Marfan Syndrome

A

Aortic root dilation causing aortic regurgitation. Watch for aortic dissection. MVP present in marfans as well as ehlers danlos

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10
Q

T/F: OSA is an important cause of arrythmias. HF can cause central sleep apnea.

A

true

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11
Q

When to give fluids in cardiogenic shock?

A

If inferior wall/RV MI. Lungs will be clear but otherwise cardiogenic shock. Fluids improves RV preload and forward flow to LV. Nitrates avoided because decrease RV preload. Can use Dopamine for inotropy.

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12
Q

common medications causing sinus bradycardia

A

digoxin, beta blockers, CCB, clonidine, amiodarone, donepezil

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13
Q

lipid mgmt after statin-induced myopathy

A

discontinue offending agent. Switch to a different statin (i.e. rosuvastatin)

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14
Q

good hypertension meds in patients with gout

A

losartan, CCB (amlodipine). Others (diuretics, ACE-i, BB increase risk of gout)

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15
Q

Grading of aortic stenosis, f/u

A

Mild: Velocity 2-2.9 m/s, Gradient <20 mmHG, echo q 3-5 years
Mod: Velocity 3-3.9 m/s, Gradient 20-39 mmHg, echo q 1-2 years
Severe: Velocity >4 m/s, gradient >40 mmHg, echo q 6-12 months

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16
Q

Definition of HCM

A

LV thickness > 15mm (1.5cm) at any location

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17
Q

Mgmt of HCM

A
  • asymptomatic: avoidance of high-intensity physical exercise
  • sxs of HF: try BB or verapamil/diltiazem
  • refractory HF: septal ablation/myomectomy
  • ICD: if fhx of SCD from HCM or LV thickness >30mm (3 cm)

Avoid: amlodipine/nifedipine and ACE-I/ diuretic (any vasodilator will worsening LVOT sxs because afterload reduction)

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18
Q

how is a VSD distinguishable?

A

palpable thrill. usually 3rd to 4th left ICS

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19
Q

Bicuspid aortic valve PE findings

A

prominent ejection click, mid-systolic murmur of R 2nd ICS

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20
Q

T/F: Patients with severe MR require MV repair

A

false, depends on symptoms and function.

  • LVEF >60 and asx: echo 6-12 mo
  • sxs, pHTN , new afib or LVEF 30-60: MV surgery, repair > replacement
  • LVEF <30: medical optimization, consider surgery
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21
Q

unexplained rise >30% in serum Cr after initiation of ACE-i

A

Renovascular disease (i.e. renal artery stenosis )

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22
Q

Severe HTN with diffuse atherosclerosis

A

Renovascular disease (i.e. renal artery stenosis )

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23
Q

Adrenal cortex producing tumor

A

Cushing syndrome. Secondary HTN with cushingoid features

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24
Q

How do Valsalva, standing affect LV cavity size

A

Decreases

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25
Q

How does Valsalva/standing affect HCM patients?

A

Causes hypertrophied septum to obstruct further and make the murmur louder

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26
Q

How does Valsalva/standing affect aortic stenosis patients?

A

Quieter murmur b/c less preload = less flow across fixed obstruction

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27
Q

Parvus et tardus

A

delayed pulses seen in aortic stenosis

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28
Q

Bifid pulse

A

Seen in HCM because ejection –> obstruction –> ejection during systole

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29
Q

2 main causes of aortic stenosis

A

Senile (bicuspid valve) = sxs @ 40

Fibrocalcific (normal calcification) = sxs @ 70

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30
Q

Murmur seen in Ebstein’s anomaly

A

TR

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31
Q

what decreases murmur in HCM

A

increasing preload (squatting, leg raise) and increase afterload (hand grip)

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32
Q

what increases murmur of MVP

A

reducing LV filling (valsalva, standing)

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33
Q

anti-hypertensives that increase risk for diabetes

A

Thiazides&raquo_space; BB

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34
Q

how does DASH diet compare to american diet?

A

High in fruits and vegetables, plant protein, fiber

Low in saturated/total fats, sodium

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35
Q

Indications for intervention for mitral stenosis

A
  • Sx rheumatic MS
  • Moderate-severe MS (valve area < 1.5 cm2)
  • pHTN @ rest or w/exercise
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36
Q

Tx options for mitral stenosis

A

Percutaneous mitral balloon valvotomy vs surgical commissurotomy.

PMBV is CI if LA thrombus or moderate-severe MR

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37
Q

3 broad causes for orthostatic hypotension

A
  • Volume depletion (i.e. hyperglycemia, diuretics)
  • Medication side effect (vasodilators)
  • Autonomic dysfunction (Parkinson, LB dementia)
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38
Q

Hypertension with hypokalemia and metabolic alkalosis

A

check Aldosterone and Renin (PRA) ratio!!!

  • If ratio A to R >20, next step is confirmation: 24 hour urine for aldo and creatinine on a high salt diet (which would normally suppress aldo)
  • Then imaging (CT with adrenal cut). in the case of the bilateral lesions, you do adrenal vein sampling. if still no lateralization and not surgery, then eplerenone or spironolactone
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39
Q

High aldosterone, low renin in hypertension with metabolic alkalosis

A

Primary hyperaldosteronism

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40
Q

High aldosterone, high renin in hypertension with metabolic alkalosis

A

Fibromuscular dysplasia (younger female) or renovascular (older male with comorbidity) hypertension

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41
Q

Hyponatremia and osmolality

A

If low: true hypoosmolar state/clinical hyponatremia

If Normal: Pseudohyponatremia –> protein, liipds

If high –> related to hyperglycemia

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42
Q

objective assessment of volume status

A

Urine sodium <20 and Feurea <35 = low volume state.
Urine sodium >20 = no volume depletion
Urine Osmolality>100-200 = ADH floating around

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43
Q

Euvolemic hyponatremia, how does urine osm help you differentiate?

A

It tells you if ADH works normal or not.

In Primary Polydipsia, you’re drinking a lot of water and ADH works so your urine is SUPER dilute (Urine Osm 50-100)

In SIADH/hypothyroid/cortisol def/adrenal insuff, ADH is not working normal so your urine will be concentrated (Urine Osm >300)

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44
Q

SIADH pearls

A

Urine sodium >20 which rules out volume depletion

urine osmolarity >100-200 suggests presence of ADH

Always rule out CORTISOL deficiency and THYROID disease. Do not miss adrenal insufficiency as a cause of hypo-osmolar hyponatremia

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45
Q

Hypernatremia, best next test

A

Urine osmolarity

If high: problem with access to free water (elderly in nursing home)

If low: Central/Nephrogenic Diabetes Insipidus

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46
Q

How do you differentiate nephrogenic vs central DI

A

Central DI: Problem making ADH. Give Desmopressin (ADH analogue) and the urine osmolarity will improve
–>Tx: Desmopressin

Nephrogenic DI (b2 receptors don’t respond to ADH): Give desmopressin won’t fix anything

  • ->Main offenders = lithium, Sjogren, hypercalcemia
  • ->Tx: Thiazide diuretics
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47
Q

What is low urine osmolality

A

<250. If sodium low/normal, polydipsia. if hypernatremia, DI

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48
Q

Hypercalcemia, first test

A

PTH.

Low PTH:

  1. Malignancy:
    - MM: SPEP/UPEP
    - Lymphomas: increased 1, 25 vit D
    - Solid tumors (squamous, lung CA): PTHrP
  2. Granulomatous disease: 1, 25 vit D
  3. Milk alkali syndrome or excessive Ca and Vit D intake

High PTH:

  1. Primary Hyperparathyroidism (bones, stones, moans, groans)
    - high Ca, low Phos
    - even normal PTH is inappropriate in high Ca!
    - urine calcium high!
  2. FHH
    - asx
    - low urine calcium
49
Q

Primary vs Secondary Hyperparathyroidism

A

Primary and secondary both have high PTH (“phosphate-trashing hormone”)

Primary: High Ca, low Phos

Secondary:

  • Calcium low (this is the driver), Phos high. usually CKD.
  • If calcium and phos both low and PTH high, secondary from vitamin D deficiency.
50
Q

2 pearls for hypocalcemia

A

always check mg

long QT

51
Q

T/F: PPI associated with refractory hypomagnesemia

A

true

52
Q

for PAD, no cilostazol (PDE inhibitor) if:

A

any LV dysfunction (HF)

53
Q

T/F: In heyde syndrome, treating the AS improves the GI AVMs

A

true

54
Q

T/F: TAVR is indicated for bicuspid aortic valve

A

False, TAVR is contraindicated in this case and you would need SAVR for sx

55
Q

most common causes of acute AR (tachy, hypotension, decompensated, shock)

A

endocarditis
aortic dissection
trauma

56
Q

bridging therapy for acute AR

A

peripheral vasodilation (Nitroprusside), diuretics and positive inotropy (dobutamine).

Avoid BB and IABP

These folks need CT surgery asap

57
Q

indications for surgery for asymtomatic chronic MR

A

LVEF <60% or LV end-systolic diameter >40mm

Repair favored over replacement

58
Q

mechanical valve vs prosthetic valve

A

mechanical: younger patient. requires lifelong AC
bioprosthetic: older patients or younger who can’t tolerate AC

59
Q

AC for prosthetic valves

A

Mechanical: Lifelong warfarin + ASPIRIN. INR 2.5 for AV w/o clot risks, 3.0 for AV w/ clot risk of MV (b/c lower flow state)

60
Q

AC interruption for prosthetic valves

A

AV: Stop 4-5 days before and restart after

MV or orther high risk clot: Stop 4-5 days and bridge (either IV heparin or subq LMW heparin)

61
Q

T/F: All mechanic prosthetic valves and most bioprosthetics should get aspirin

A

true. and for mechanical, lifelong coumadin.

62
Q

Thrombosed prosthetic valve

A

Mechanical (AV or MV): SURGERY

Bioprosthetic: Can start with vitamin K antagonist

63
Q

tx of Afib if WPW

A

use Procainamide for wPw

Not BB, CCB, Dig

64
Q

T/F: If on both dig and amio, reduce doses

A

true, by up to 50%

65
Q

valvular afib vs nonvalvular afib ac

A

valvular: coumadin
Nonvalvular: chadvasc

66
Q

Chadsasc

A 
CHF
HTN
Age >75 (2 points)
DM
Stroke/tie/thromboembolism (2 points)
Vascular dz 
Age 65-74
Sex category (female +1, male 0)

Do nothing: 0 men, 1 women
AC >2 men, 3 women

67
Q

T/F: Patient unstable angina/nstemi but lower TIMI score still gets aspirin and plavix

A

True. Meds for all nstemi patients = ASA, BB, Clopidogrel, Hperain, Nitrates, Statin.

If low TIMI, do predischarge stress test. Intermediate to high risk same meds but benefit from early angiography and revascularization

68
Q

how long is asa and plavix continued for nstemi/stemi

A

ASA: indefinitely
Plavix: at least 1 year of DAPT!!

69
Q

T/F: Patients with ACS should not receive BB

A

False. Should be given within 24 hours for ACS and continued indefinitely as secondary prevention. Watch out for patients who come in intoxicated, would avoid with any cocaine ingestion

70
Q

abrupt pulmonary edema with loud holosystolic murmur/thrill 2-7 days post-MI

A

VSD or Papillary mm rupture

Tx: IABP, afterload reduction (nitroprusside), diuretics + emergent surgery

71
Q

when would you perform exercise ECG without imaging as stress test for LBBB patient?

A

Never. use this modality for those who can exercise with normal baseline ECG

72
Q

4 main classes of meds for stable angina

A

BB
CCB
Nitrates (tachyphylaxis, so have 8-12 hour period daily without use usually overnight)
Ranolazine

–>these patients will still benefit for ASA, ACI-I, high intensity statin for cardioprotection

73
Q

what role does Hydralazine + nitrates (isosordil dinitrate) play in HF?

A

For HFrEF (EF<40), especially in black patients this lowers mortality. can also use in patients who don’t tolerate ace or arb.

74
Q

T/F: ICD is only beneficial in ischemic cardiomyopathy

A

false, both ICM and NICM <35%

75
Q

who gets CRT?

A

LBBB + EF <35

76
Q

Which diabetes meds should be avoided in HF?

A

Thiozolidinediones ( i.e. pioglitazone).

NSAIDS, Dilt/verapamil also harmful to HF patients

77
Q

how often echo in stable HF

A

not more than q 1-2 years

78
Q

T/F: ACEi, bb and aldosterone antagonists reduce mortality in HFpEF

A

False, this has not been show. they do in HFrEF

79
Q

Multinucleated giant cells in myocardium of young patient with rapid development of cardiogenic shock. may have biventricular enlargement.

A

Giant cell myocarditis. Tx with immunosuppression and/or LVAD placement or cardiac transplant

80
Q

T/F: Hemochromatosis causes a dilated CM

A

true

81
Q

What to look out for during peripartum cardiomyopathy?

A

It can be dx 1 month before delivery, however don’t use ACE-i, ARB or aldosterone antagonists during the pregnancy due to teratogen. AC with coumadin if LVEF <35. Avoid subsequent pregnancy if persistent LV dysfunction.

82
Q

ECG shows LVH, LA enlargement, deeply inverted t waves leads V3-V6

A

HCM

83
Q

T/F: HCM patients with AF need AC regardless of chadvasc

A

true

84
Q

Meds for HCM

A

BB and CCB (dilt/verapamil) ok. ACE-i if systolic dysfunction. In general, do not Rx vasodilators, diuretics or digoxin which will worsen LVOT.

85
Q

T/F: Termination of SVT with adenosine suggests AVRT or AVNRT

A

True. AVNRT will have Pseudo R wave in V1

If you kept seeing p waves, suggest atrial tach or flutter

86
Q

Tx of recurrent AVNRT

A

Use CCB or BB to prevent. If recurrent despite meds, catheter ablation therapy

87
Q

Tx for MAT

A
  • treat underling lung heart dz, correct electrolytes

- can use metoprolol followed by verapamil with bronchospastic dz

88
Q

what kind of tachycardia is WPW an example of

A

symptomatic AVRT (usually antegrade to the ventricles = delta wave, short PR interval. QRS normal or prolonged)

89
Q

What happens if you give bb, ccb or digoxin to WPW patient with afib?

A

converts to VT or VF so don’t do it

90
Q

Tx of acute VT in hemodynamically stable patient

A

IV Lidocaine or Amiodarone (or procainamide, sotalol)

Vs unstable need cardioversion

91
Q

Tx of NSVT in patient with no structural heart disease

A

BB or Verapamil

92
Q

Incomplete RBBB with Coved ST-segment elevation V1, V2

A

Brugada

93
Q

tx for inherited long QT syndrome (not wpw)

A

BB, ICD

94
Q

When does an MI patient get the ICD?

A

40 days after if EF still <30

95
Q

meds for pericarditis

A

colchicine + asa (preferred after MI) or nsaid

if autoimmune related, glucocorticoids

96
Q

T/F: bicuspid aortic valve will have systolic ejection click followed by murmur. MS has opening snap. MVP has systolic click

A

true

97
Q

JONES criteria is for?

A

Rheumatic Fever

98
Q

pulsus parvus et tardus

A

Aortic Stenosis

99
Q

T/F: All patients with MS and AF get coumadin regardless of chadvasc

A

true

100
Q

most common cause of significant MR

A

MVP

101
Q

most common type of ASD

A

ostium secundum. will have partial RBBB and RA deviation

102
Q

Why might you check BP in legs of young patient with unexplained hypertension?

A

Screen for coarctation of the aorta

103
Q

continuous murmur @ left clavicle, bounding pulses and a wide pulse pressure

A

PDA, machine-like murmur. If clubbing then eisenmenger syndrome

104
Q

abx for prosthetic valve IE

A

Vanc, Gent and Rifampin

105
Q

meds for acute aortic dissection

A

IV beta blocker

  • add nitroprusside if BP does not respond
  • intramural hematoma or type a = surgery

-don’t use hydralazine for acute dissection (increases shear stress)

106
Q

T/F: Screening is not recommended for abdominal aortic aneurysm

A

False. One time US screen for men 65-75 with any smoking hx (don’t screen women)

107
Q

when would you select toe-brachial index to assess le perfusion?

A

if your ABI is >1.4

(0.9-1.4 is a normal ABI,

108
Q

tx for intermittent claudication from PAD

A

cilostazol (don’t use if low EF or CHF)

109
Q

LA and RA cardiac tumors

A

LA: myxoma (can sound like MS)
RA: angiosarcoma

110
Q

contraindications to MS balloon commissurotomy

A

LA thrombus or concurrent MR

111
Q

contraindications to TAVR

A

bicuspid AV
significant AR
mitral valve disease

112
Q

T/F: Bicuspid aortic valve is associated with aortic aneurysm and dissection

A

true

113
Q

Stress test for patients with LBBB or pacemaker

A

Pharmacologic with adenosine or dipyridamole (don’t use this for reactive airway disease). It dilates coronary arteries with inc BP or HR

114
Q

T/F: BB and ACE-i improve mortality in HFpEF

A

False, this has only been shown for HFrEF. For HFpEF, focus on reducing volume overload, managing other conditions (CAD, HTN, Afib) and afterload reduction (aldosterone antagonists here) + exercise training in cardiac rehab

115
Q

T/F: Patients discovered to have WPW need ICD

A

False, no ICD in WPW if anything ablation. Asymptomatic patients can be risk stratified with exercise ECG, if speeding up HR makes it go away they’re fine

116
Q

What kind of supraventricular arrythmia does WPW syndrome develop?

A

AVRT (narrow complex)

117
Q

mgmt if typical claudication sxs but normal ABI

A

exercise testing with repeat ABI to confirm occlusive PAD (before starting meds)

118
Q

tx for chronic venous stasis

A
  • leg elevation
  • leg exercises (calf strengthen)
  • compression stockings
  • aspirin to accelerate ulcer healing

*topical antibiotics, zinc sulfate and HBOT not effective

119
Q

T/F: Pericarditis aspirin dosing is much higher than baby dose

A

true (650-1000mg tid)

UWORLD ABIM (10 decks)

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