Cardiology Flashcards
T/F: High-intensity statin therapy can induce new/worsen existing diabetes and should be stopped in such patients
False. True about the sugars, benefit of statins outweighs harm so you don’t stop the statin
How do you manage cocaine-induced chest pain?
- if STEMI, cath lab
- 1st line meds: Aspirin + Nitroglycerin, Benzos, Calcium Channel Blocker
- Contraindicated: Beta blocker (unopposed alpha)
How do you manage patients with long QT syndrome?
Beta blocker! reduces arrythmias and SCD. If syncope or arrythmia on BB, ICD
Physical exam
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)
EKG changes hyperkalemia
PR prolongation, p wave flattening/loss, bradyarrhythmias, peaked T waves
Milrinone MOA
Phosphodiesterase inhibitor that decreases cAMP degradation = inc cAMP = arterial and venous vasodilator and + inotropy. Improves HF sxs. Watch for hypotensive episodes and arrythmias.
Anticoagulation for cardioversion
If TEE confirms no thrombus, continue for 4 weeks following (stunning); if TEE does not definitively rule it out, 3 weeks of anticoag beforehand
Management of AAA
<4cm: US q 2-3 years
4-4.9cm: US q 6-12 months
>5.5cm: surgery
>0.5cm growth/6 months: surgery
cardiac abnormality associated with Marfan Syndrome
Aortic root dilation causing aortic regurgitation. Watch for aortic dissection. MVP present in marfans as well as ehlers danlos
T/F: OSA is an important cause of arrythmias. HF can cause central sleep apnea.
true
When to give fluids in cardiogenic shock?
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.
common medications causing sinus bradycardia
digoxin, beta blockers, CCB, clonidine, amiodarone, donepezil
lipid mgmt after statin-induced myopathy
discontinue offending agent. Switch to a different statin (i.e. rosuvastatin)
good hypertension meds in patients with gout
losartan, CCB (amlodipine). Others (diuretics, ACE-i, BB increase risk of gout)
Grading of aortic stenosis, f/u
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
Definition of HCM
LV thickness > 15mm (1.5cm) at any location
Mgmt of HCM
- 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)
how is a VSD distinguishable?
palpable thrill. usually 3rd to 4th left ICS
Bicuspid aortic valve PE findings
prominent ejection click, mid-systolic murmur of R 2nd ICS
T/F: Patients with severe MR require MV repair
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
unexplained rise >30% in serum Cr after initiation of ACE-i
Renovascular disease (i.e. renal artery stenosis )
Severe HTN with diffuse atherosclerosis
Renovascular disease (i.e. renal artery stenosis )
Adrenal cortex producing tumor
Cushing syndrome. Secondary HTN with cushingoid features
How do Valsalva, standing affect LV cavity size
Decreases
How does Valsalva/standing affect HCM patients?
Causes hypertrophied septum to obstruct further and make the murmur louder
How does Valsalva/standing affect aortic stenosis patients?
Quieter murmur b/c less preload = less flow across fixed obstruction
Parvus et tardus
delayed pulses seen in aortic stenosis
Bifid pulse
Seen in HCM because ejection –> obstruction –> ejection during systole
2 main causes of aortic stenosis
Senile (bicuspid valve) = sxs @ 40
Fibrocalcific (normal calcification) = sxs @ 70
Murmur seen in Ebstein’s anomaly
TR
what decreases murmur in HCM
increasing preload (squatting, leg raise) and increase afterload (hand grip)
what increases murmur of MVP
reducing LV filling (valsalva, standing)
anti-hypertensives that increase risk for diabetes
Thiazides»_space; BB
how does DASH diet compare to american diet?
High in fruits and vegetables, plant protein, fiber
Low in saturated/total fats, sodium
Indications for intervention for mitral stenosis
- Sx rheumatic MS
- Moderate-severe MS (valve area < 1.5 cm2)
- pHTN @ rest or w/exercise
Tx options for mitral stenosis
Percutaneous mitral balloon valvotomy vs surgical commissurotomy.
PMBV is CI if LA thrombus or moderate-severe MR
3 broad causes for orthostatic hypotension
- Volume depletion (i.e. hyperglycemia, diuretics)
- Medication side effect (vasodilators)
- Autonomic dysfunction (Parkinson, LB dementia)
Hypertension with hypokalemia and metabolic alkalosis
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
High aldosterone, low renin in hypertension with metabolic alkalosis
Primary hyperaldosteronism
High aldosterone, high renin in hypertension with metabolic alkalosis
Fibromuscular dysplasia (younger female) or renovascular (older male with comorbidity) hypertension
Hyponatremia and osmolality
If low: true hypoosmolar state/clinical hyponatremia
If Normal: Pseudohyponatremia –> protein, liipds
If high –> related to hyperglycemia
objective assessment of volume status
Urine sodium <20 and Feurea <35 = low volume state.
Urine sodium >20 = no volume depletion
Urine Osmolality>100-200 = ADH floating around
Euvolemic hyponatremia, how does urine osm help you differentiate?
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)
SIADH pearls
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
Hypernatremia, best next test
Urine osmolarity
If high: problem with access to free water (elderly in nursing home)
If low: Central/Nephrogenic Diabetes Insipidus
How do you differentiate nephrogenic vs central DI
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
What is low urine osmolality
<250. If sodium low/normal, polydipsia. if hypernatremia, DI
Hypercalcemia, first test
PTH.
Low PTH:
- Malignancy:
- MM: SPEP/UPEP
- Lymphomas: increased 1, 25 vit D
- Solid tumors (squamous, lung CA): PTHrP - Granulomatous disease: 1, 25 vit D
- Milk alkali syndrome or excessive Ca and Vit D intake
High PTH:
- Primary Hyperparathyroidism (bones, stones, moans, groans)
- high Ca, low Phos
- even normal PTH is inappropriate in high Ca!
- urine calcium high! - FHH
- asx
- low urine calcium
Primary vs Secondary Hyperparathyroidism
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.
2 pearls for hypocalcemia
always check mg
long QT
T/F: PPI associated with refractory hypomagnesemia
true
for PAD, no cilostazol (PDE inhibitor) if:
any LV dysfunction (HF)
T/F: In heyde syndrome, treating the AS improves the GI AVMs
true
T/F: TAVR is indicated for bicuspid aortic valve
False, TAVR is contraindicated in this case and you would need SAVR for sx
most common causes of acute AR (tachy, hypotension, decompensated, shock)
endocarditis
aortic dissection
trauma
bridging therapy for acute AR
peripheral vasodilation (Nitroprusside), diuretics and positive inotropy (dobutamine).
Avoid BB and IABP
These folks need CT surgery asap
indications for surgery for asymtomatic chronic MR
LVEF <60% or LV end-systolic diameter >40mm
Repair favored over replacement
mechanical valve vs prosthetic valve
mechanical: younger patient. requires lifelong AC
bioprosthetic: older patients or younger who can’t tolerate AC
AC for prosthetic valves
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)
AC interruption for prosthetic valves
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)
T/F: All mechanic prosthetic valves and most bioprosthetics should get aspirin
true. and for mechanical, lifelong coumadin.
Thrombosed prosthetic valve
Mechanical (AV or MV): SURGERY
Bioprosthetic: Can start with vitamin K antagonist
tx of Afib if WPW
use Procainamide for wPw
Not BB, CCB, Dig
T/F: If on both dig and amio, reduce doses
true, by up to 50%
valvular afib vs nonvalvular afib ac
valvular: coumadin
Nonvalvular: chadvasc
Chadsasc
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
T/F: Patient unstable angina/nstemi but lower TIMI score still gets aspirin and plavix
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
how long is asa and plavix continued for nstemi/stemi
ASA: indefinitely
Plavix: at least 1 year of DAPT!!
T/F: Patients with ACS should not receive BB
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
abrupt pulmonary edema with loud holosystolic murmur/thrill 2-7 days post-MI
VSD or Papillary mm rupture
Tx: IABP, afterload reduction (nitroprusside), diuretics + emergent surgery
when would you perform exercise ECG without imaging as stress test for LBBB patient?
Never. use this modality for those who can exercise with normal baseline ECG
4 main classes of meds for stable angina
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
what role does Hydralazine + nitrates (isosordil dinitrate) play in HF?
For HFrEF (EF<40), especially in black patients this lowers mortality. can also use in patients who don’t tolerate ace or arb.
T/F: ICD is only beneficial in ischemic cardiomyopathy
false, both ICM and NICM <35%
who gets CRT?
LBBB + EF <35
Which diabetes meds should be avoided in HF?
Thiozolidinediones ( i.e. pioglitazone).
NSAIDS, Dilt/verapamil also harmful to HF patients
how often echo in stable HF
not more than q 1-2 years
T/F: ACEi, bb and aldosterone antagonists reduce mortality in HFpEF
False, this has not been show. they do in HFrEF
Multinucleated giant cells in myocardium of young patient with rapid development of cardiogenic shock. may have biventricular enlargement.
Giant cell myocarditis. Tx with immunosuppression and/or LVAD placement or cardiac transplant
T/F: Hemochromatosis causes a dilated CM
true
What to look out for during peripartum cardiomyopathy?
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.
ECG shows LVH, LA enlargement, deeply inverted t waves leads V3-V6
HCM
T/F: HCM patients with AF need AC regardless of chadvasc
true
Meds for HCM
BB and CCB (dilt/verapamil) ok. ACE-i if systolic dysfunction. In general, do not Rx vasodilators, diuretics or digoxin which will worsen LVOT.
T/F: Termination of SVT with adenosine suggests AVRT or AVNRT
True. AVNRT will have Pseudo R wave in V1
If you kept seeing p waves, suggest atrial tach or flutter
Tx of recurrent AVNRT
Use CCB or BB to prevent. If recurrent despite meds, catheter ablation therapy
Tx for MAT
- treat underling lung heart dz, correct electrolytes
- can use metoprolol followed by verapamil with bronchospastic dz
what kind of tachycardia is WPW an example of
symptomatic AVRT (usually antegrade to the ventricles = delta wave, short PR interval. QRS normal or prolonged)
What happens if you give bb, ccb or digoxin to WPW patient with afib?
converts to VT or VF so don’t do it
Tx of acute VT in hemodynamically stable patient
IV Lidocaine or Amiodarone (or procainamide, sotalol)
Vs unstable need cardioversion
Tx of NSVT in patient with no structural heart disease
BB or Verapamil
Incomplete RBBB with Coved ST-segment elevation V1, V2
Brugada
tx for inherited long QT syndrome (not wpw)
BB, ICD
When does an MI patient get the ICD?
40 days after if EF still <30
meds for pericarditis
colchicine + asa (preferred after MI) or nsaid
if autoimmune related, glucocorticoids
T/F: bicuspid aortic valve will have systolic ejection click followed by murmur. MS has opening snap. MVP has systolic click
true
JONES criteria is for?
Rheumatic Fever
pulsus parvus et tardus
Aortic Stenosis
T/F: All patients with MS and AF get coumadin regardless of chadvasc
true
most common cause of significant MR
MVP
most common type of ASD
ostium secundum. will have partial RBBB and RA deviation
Why might you check BP in legs of young patient with unexplained hypertension?
Screen for coarctation of the aorta
continuous murmur @ left clavicle, bounding pulses and a wide pulse pressure
PDA, machine-like murmur. If clubbing then eisenmenger syndrome
abx for prosthetic valve IE
Vanc, Gent and Rifampin
meds for acute aortic dissection
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)
T/F: Screening is not recommended for abdominal aortic aneurysm
False. One time US screen for men 65-75 with any smoking hx (don’t screen women)
when would you select toe-brachial index to assess le perfusion?
if your ABI is >1.4
(0.9-1.4 is a normal ABI,
tx for intermittent claudication from PAD
cilostazol (don’t use if low EF or CHF)
LA and RA cardiac tumors
LA: myxoma (can sound like MS)
RA: angiosarcoma
contraindications to MS balloon commissurotomy
LA thrombus or concurrent MR
contraindications to TAVR
bicuspid AV
significant AR
mitral valve disease
T/F: Bicuspid aortic valve is associated with aortic aneurysm and dissection
true
Stress test for patients with LBBB or pacemaker
Pharmacologic with adenosine or dipyridamole (don’t use this for reactive airway disease). It dilates coronary arteries with inc BP or HR
T/F: BB and ACE-i improve mortality in HFpEF
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
T/F: Patients discovered to have WPW need ICD
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
What kind of supraventricular arrythmia does WPW syndrome develop?
AVRT (narrow complex)
mgmt if typical claudication sxs but normal ABI
exercise testing with repeat ABI to confirm occlusive PAD (before starting meds)
tx for chronic venous stasis
- leg elevation
- leg exercises (calf strengthen)
- compression stockings
- aspirin to accelerate ulcer healing
*topical antibiotics, zinc sulfate and HBOT not effective
T/F: Pericarditis aspirin dosing is much higher than baby dose
true (650-1000mg tid)
