Cardiology

Question 1

Presents post re-vascularization with cardiogenic shock, pulmonary edema, hyperdynamic precordium and a systolic murmur

Answer 1

Acute papillary muscle rupture with subsequent mitral regurgitation. Murmur may be very faint due to early equalization of pressures

Question 2

EKG findings in hyperkalemia

Answer 2

peaked T waves, wide complex QRS without p waves

Question 3

Murmur best heard by sitting up, leaning forward, holding breath in full expiration and using diapharagm of stethoscope with firm pressure

Answer 3

Aortic regurgitation

Question 4

Affect on mitral valve prolapse murmur with standing or valsava

Answer 4

Earlier click with longer murmur

Question 5

Affect on mitral valve prolapse murmur with squatting

Answer 5

Later click with shorter murmur

Question 6

Murmur best heard in left lateral decubitus with bell of stethoscope

Answer 6

Mitral stenosis

Question 7

DAPT management in CABG perioperative period

Answer 7

Stop clopidogrel 5-7 days prior to CABG as these are associated with increased bleeding risk. Continue aspirin through surgery as it has been shown to significantly reduce the risk of early graft occlusion

Question 8

Periprocedural anticoagulation management in mechanical aortic valves

Answer 8

If high risk of bleed procedure - stop warfarin 5 days prior to procedure until INR < 1.5 , proceed with procedure and then restart warfarin the night of procedure. No need to bridge as high flow through the aortic valve

Question 9

Periprocedural anticoagulation management in mechanical mitral valves

Answer 9

If high risk of bleed procedure - stop warfarin 5 days prior to procedure. Start heparin bridge when INR <2, hold the morning of the procedure and restart 24-48 hours post procedure in combination with warfarin. Low flow through mitral valve increases thrombotic risk

Question 10

Late peaking systolic murmur with paradoxical S2 splitting

Answer 10

Aortic stenosis - typically severe. Paradoxical split due to delayed closure of aortic valve

Question 11

Exercise EKG stress testing is non diagnostic in these patients:

Answer 11

Patients with LBBB, pacemakers, or inability to reach target heart rate 85% of 220-age

Question 12

Cannot use pharmacologic stress testing in these patients:

Answer 12

With reactive airway disease, on dipyramidole or theophylline

Question 13

Cannot use dobutamine stress echocardiography in these patients

Answer 13

with tachyarrhythmias

Question 14

Anticoagulation in mitral stenosis

Answer 14

Should anticoagulate with warfarin (DOAcs not studied for this indications) if moderate to severe mitral stenosis + 1 of the following: atrial fibrillation, atrial thrombus, or prior embolic event

Question 15

Kidney function cut off for DOAcs

Answer 15

CrCl >30 can use DOAcs, CrCl < 30 should use warfarin

Question 16

General first line atrial flutter treatment preference

Answer 16

radiofrequency ablation over long term anti-arrhythmics

Question 17

Follow up interval of mild aortic stenosis (mean gradient <20)

Answer 17

Every 3-5 years with TTE

Question 18

Follow up interval of moderate aortic stenosis (mean gradient 20-39)

Answer 18

Every 1-2 years with TTE

Question 19

Follow up interval of severe aortic stenosis (mean gradient >40)

Answer 19

Every 6-12 months with TTE

Question 20

Severe mitral regurgitation that is asymptomatic next steps

Answer 20

Clinical follow up with echo every 6-12 months to monitor for symptom development or cardiac dysfunction leading to an indication for repair

Question 21

Indications for repair (preferred)/replacement in severe mitral regurgitation

Answer 21

Symptomatic. New onset atrial fibrilllation, LVEF <60, end diastolic systolic dimension >40, PAP >50

Question 22

Drug that interacts with statins making statin myopathy more likely

Answer 22

Verapamil

Question 23

Initial tests to send when suspicious of statin myopathy

Answer 23

CK, vitamin D and thyroid function tests

Question 24

Preferred antiarrhythmic agent in patients with atrial fibrillation without structural heart disease or ischemic heart disease

Answer 24

flecainide or propafenone

Question 25

ST depression on multiple leads in exercise EKG testing, but no evidence of ischemia on radionucleide testing

Answer 25

Balanced ischemia - this is a false negative on imaging and concerning for significant multivessel disease. Should go to cath lab.

Question 26

Absolute contraindications to thrombolytics for STEMI

Answer 26

any prior, ICH, ischemic stroke in last 3 months, known cerebrovascular lesion, suspected aortic dissection, active bleeding, significant closed head or facial trauma within last 3 months

Question 27

Relative contraindications to thrmbolytics for STEMI

Answer 27

history of chronic severe, poorly controlled HTN, severe HTN on presnetation (SBP >180, DBP >110), history of ischemic stroke >3 months, dementia, or intracranial lesion, traumatic/prolonged (>10 minutes) CPR or major surgery in last 3 weeks, internal bleeding within last 4 weeks, pregnancy, allergy to thrombolytics, current anticoagulation use (higher risk with higher INR), and active peptic ulcer disease

Question 28

When to use thrombolytics?

Answer 28

If present within 12 hours of STEMI symptom onset and will take >120 minutes to get to PPCI. CAn consider in 12-24 hours since onset if sig. myocardial injury

Question 29

When do you start screening for hyperlipidemia?

Answer 29

Men >35, women >45, can do younger if sig. family history (male relative with disease <50, female relative with disease <60), smoking, HTN, diabetes

Question 30

RCRI clinical risk factors

Answer 30

high risk surgery (vascular), history of ischemic heart disease, heart failure, history of stroke, diabetes treated with insulin, preoperative Cr >2

Question 31

Future pregnancy advise for patients with history of peripartum cardiomyopathy and persistent LV dysufnction

Answer 31

Have high risk of further decline of LV function, recurrent heart failure and death with subsequent pregnancies. Advise avoiding future pregnancies.

Question 32

Earliest and most sensitive echo finding of cardiac tamponade

Answer 32

Right atrial collapse during end diastole.

Question 33

Presents with LV failure wiht continuous murmur, wide pulse pressure and bounding pulses. Can have pulmonary HTN and in severe cases Eisenmenger syndrome

Answer 33

Unrepaired PDA

Question 34

Treatment for patients with congenital long QT syndrome

Answer 34

Initial treatment is beta blockers to decrease potential for V tach. If syncopal despite beta blocker therapy then should have ICD placed

Question 35

Timing for placement of an ICD after myocardial ischemia

Answer 35

3 months after event if revascularized. 40 days after event if not revascularized

Question 36

Indications for giving Dig Fab fragments in digoxin toxicity?

Answer 36

life threatening cardiac arrhythmia, end organ dysfunction due to hypoperfusion, hyperkalemia. Dig Fab treat the hypokalemia - do not also need to give K lowering medications

Question 37

Most common cause of unexpected mortality post cardiac cath

Answer 37

Retroperitoneal hemorrhage

Question 38

Indications for early valvular surgery (prior to completion of IV abx course) in endocarditis

Answer 38

Acute heart failure due to valvular regurgitation (though not valve disease alone), new heart block, infection with difficult to treat pathogen (fungi), paravalvular abscess, persistent fever/bacteremia (>7 days) despite appropriate abx, systemic emboli AFTER appropriate abx, left sided lesion >10mm with prior embolic event

Question 39

ECG abnormalities in ASDs

Answer 39

first degree AV block, right axis deviation, incomplete or complete RBBB

Question 40

Contraindications to mitral balloon vavlulotomy

Answer 40

Moderate to severe mitral regurgitation and patients with a left atrial thrombus

Question 41

Next steps once pre-excitation indicative of WPW is found on EKG

Answer 41

Exercise EKG to risk stratify. If pre-excitation is lost on exercise EKG then lower risk and low likelihood of rapid AF conduction leading to VF. These patients need nothing further. If pre-excitation not lost then should proceed with albation of accessory pathway

Question 42

> or =2mm coved ST segments elevation in right precordial leads (V1-V3) with RBBB and syncope

Answer 42

Brugada syndrome

Question 43

Hypertensive crisis and flash pulmonary edema during anesthesia induction

Answer 43

Suggestive of pheochromocytoma

Question 44

Anti HTN meds associated with increased risks of gout flares

Answer 44

diuretics, beta blockers, ACEi, ARBs (EXCEPT losartan - can use losartan in patients with gout)

Question 45

MEdication in myopericarditis that tends to have recurrence of symptoms

Answer 45

Prednisone - used for refractory, but shouldn’t be used as first line (first line is NSAIDs)

Question 46

Treatment of peri-infarction pericarditis

Answer 46

Increase dose of aspirin to 650mg to 1000mg TID. Avoid NSAIDs and steroids.

Question 47

Increased ventricular mass on echocardiogram, but low voltage on EKG - mass/voltage discrepancy

Answer 47

Consider infiltrative cardiomyopathy such as amyloidosis or sarcoidosis