Cardiology Flashcards
How to diagnose carotid sinus hypersensitivity?
With carotid sinus massage, in patients >40 with syncope of unknown etiology.
Diagnostic if patient gets syncope w/ asystole >3 seconds or drop in systolic BP by 50 mmhg.
Avoid massage in pts with carotid bruits/stenosis on same side, or w/ hx TIA/stroke within 3 mos
Indications for ICD for primary prevention of SCD
EF <=30% after MI, at least 40 days post MI and 3 mos post revascularization
EF <=35% and NYHA Class II or III in ALL patients regardless of if they have had an MI
How to first treat acute aortic dissection
IV beta blocker
cardiac side effects of donepezil
sinus bradycardia
heart blocks
what has been found to improve functional capacity and quality of life in HFpEF patients?
exercise training/cardiac rehab
when is surgical repair of AAA indicated?
>=5.5 cm OR increase of 0.5 cm in 6 mos OR in all symptomatic pts
BP meds that have risk of new onset diabetes due to effect on glucose metabolism
Thiazide diuretics
Beta blockers - except carvedilol
use warfarin with goal INR of 2.5 in all patients with mitral stenosis and 1 of the following:
- afib (paroxysmal, persistent or permanent)
- left atrial thrombus
- prior embolic event
DOACs are not yet approved for valvular afib
Cardiac resynchronization therapy indications
In patients with all three of the following criteria:
EF <=35% and sinus rhythm
NHYA class III-IV
QRS >150 msec
-optional for QRS 120-150
OR
EF <30%
NYHA class I or II
QRS >150 msec with LBBB
Asymptomatic mild aortic stenosis. parameters and follow up echo
velocity: 2-2.9 m/s
mean gradient < 20 mmhg
f/u echo every 3-5 years
Asymptomatic mod aortic stenosis. parameters and follow up echo
velocity: 3-3.9 m/s
mean gradient 20-39 mmhg
f/u echo every 1-2 years
Asymptomatic severe aortic stenosis. parameters and follow up echo
velocity: >=4 m/s
mean gradient >=40 mmhg
f/u echo every 6-12 mos
when to put in an ICD in a HCM patient to prevent SCD
one or more of the following:
family hx of sudden cardiac death recurrent or exertional syncope NSVT hypotension during exercise massive LVH >3 cm
Who needs endocarditis prophylaxis for high risk procedures?
patients with:
- prosthetic valves
- hx of endocarditis
- unrepaired cyanotic congenital heart defect
- repaired congenital heart defect using prosthetic material in first 6 mos after procedure
- repaired congenital heart defect with residual defects
- heart transplant w/ valvular disease
What are the high risk procedures that require endocarditis prophylaxis for some patients?
- dental manipulation of gingival tissue or periapical region, or perforation of oral mucosa
- respiratory tract procedures with incision or biopsy
- cardiac surgery
- procedures in patients with ongoing GI or GU infection
- GI procedures for cirrhosis and variceal bleeding, biliary obstruction and cholangitis, pancreatic cyst and PEG tube placement
- procedures in patients with infected skin or muscle tissue
usually amoxicillin or clindamycin
What procedures do you not need endocarditis prophylaxis for?
Vaginal/c-section delivery
Colonoscopy/endoscopy/ERCP
GU procedures - prostatectomy, catheter insertion
Infective endocarditis - modified Dukes criteria
Major:
- blood culture positive for typical organism- staph, strep viridans, enterococcus
- echo showing vegetation on valve
Minor:
- fever
- IV drug use
- predisposing cardiac lesion
- embolic phenomena
- immunologic phenomena ex. glomerulonephritis
- positive blood culture not meeting above criteria
Definite IE:
2 major OR 1 major and 3 minor criteria
Possible IE:
1 major and 1 minor OR 3 minor criteria
When can you hear an S3
chronic severe mitral regurg
chronic aortic regurg
HF assoc with dilated cardiomyopathy
high cardiac output states- pregnancy, thyrotoxicosis
- can be normal in young adults <40
When can you hear an S4
- can be normal in older adults due to decreased ventricular compliance with aging
- HOCM
- pulmonic stenosis
how to treat peri-infarction pericarditis? PIP
- usually self limited, but tx with higher doses of aspirin in symptomatic patients: 650 mg to 1000 mg TID
- do not use NSAIDS or steroids
- can add colchicine / narcotic analgesics if needed
- occurs within days of MI
indications for early surgical management in native valve infective endocarditis
Valvular/conductive failure:
- acute heart failure due to valvular regurgitation
- valve leaflet fistula formation
- new heart block
Uncontrollable infection:
- paravalvular abscess formation
- infection w/ difficult to treat pathogen ex. fungi
- fever or persistent bacteremia despite >7 days abx
Embolic complications:
- systemic emboli despite appropriate antibiotics
- left-sided, mobile vegetation >10 mm and prior embolic event
What does Valsalva maneuver do to murmurs?
- decreases venous return in the strain phase
- HCM and MVP louder
- all other murmurs are softer due to less flow over stenotic or regurgitant valves
- increase venous return in the release phase, which will increase all R sided murmurs
What does standing do to murmurs?
- decreases venous return
- HCM and MVP louder
- all other murmurs are softer due to less flow over stenotic or regurgitant valves
What does squatting do to murmurs?
- increases venous return
- increases afterload due to kinking of femoral arteries
- increases reverse flow
- AR, MR and VSD become louder
- HCM and MVP softer (increases preload in HCM, decreases the gradient across obstruction)
What does handgrip do to murmurs?
- increases afterload
- increases blood pressure
- reverse flow across valve
- AR, MR, VSD become louder
- HCM and AS become softer (HCM increased LV volume, AS decreased transvalvular pressure gradient)
characteristics of cardiac myxoma
- benign tumor
- 80% located in left atrium
- position dependent mitral valve obstruction, resulting in mid diastolic murmur, dyspnea, lightheadedness, syncope
- can get embolization of tumor fragments, ex. stroke
- can get constitutional symptoms- fever, wt loss
Indications of percutaneous MV balloon valvotomy
symptomatic rheumatic MS
asymptomatic pts with amenable valve morphology- non-calcified, pliable
mod-to-severe MS (valve area <1.5 cm) and pulm HTN at rest or w/ exercise
palliation in non surgical patients
Contraindications of percutaneous MV balloon valvotomy
left atrial or left appendage thrombus
mod-severe mitral regurg
What is Pickering syndrome?
flash pulm edema in patients w/ bilateral renal artery stenosis
When induction of anesthesia ex. midazolam, causes hypertension and tachycardia, this could be unmasking an undiagnosed ________?
pheochromocytoma
Peripheral edema from CCBs like amlodipine can be reduced with combination therapy with which other antihypertensive?
ACE inhibitors (increases venule dilation)
- diuretics do not effectively decreased edema from CCBs as it is not due to salt/water retention, but rather due to preferential arterial dilation, which changes the pressure gradient between capillaries and interstitium
all patients with congenital long qt syndrome should be treated with:
beta blockers
- put in an ICD if patient has syncope, or VT on BB therapy, or those w/ aborted cardiac arrest
postprandial hypotension in the elderly, occurs within 2 hours after eating- how do you manage it?
decreased portion sizes
increased salt/water intake
low carb meals
avoidance of alcohol
postprandial hypotension in the elderly, occurs within 2 hours after eating- how do you manage it?
decreased portion sizes
increased salt/water intake
low carb meals
avoidance of alcohol
- can use octreotide for severely symptomatic or refractory cases
Brugada syndrome
Can cause syncope and sudden cardiac death
> 2 mm of coved ST elevation in the right precordial leads with associated T wave inversion and RBBB appearance
ICD placement indicated in patients with syncope
Causes of culture-negative endocarditis
Fastidious bacteria- Coxiella/Q fever, Bartonella
Streptococcus spp if abx already given
Fungal organisms
Non-infectious causes- rheum disease, malignancy
what type of aortic valve is coarctation of the aorta associated with?
bicuspid valve- 40% of cases
what arrhythmia occurs in elderly patients with an exacerbation of pulmonary disease? what are the features?
multifocal atrial tachycardia
atrial rate >100
irregular RR intervals
>= 3 distinct p wave morphologies
which is higher risk for thrombosis w/o AC, mechanical mitral valve, or mechanical aortic valve?
due to stagnant blood flow around a mechanical mitral valve, this is very high risk for thrombosis, more so than aortic valve that has higher rate of flow, and is only high risk for thrombosis.
prior to high bleeding risk procedures- hold warfarin, but with mitral valves you also have to bridge with heparin as it is very high risk for thrombosis without AC
Aortic valve replacement criteria in chronic severe AR?
Symptomatic?
If YES-> replace
If NO-> get echo. If EF <50% or LVSD > 55 mm or LVDD > 75 mm then replace. If not, repeat in 6-12 mos
Describe the NYHA Classes
I: no symptomatic limitation of physical activity
II: Slight limitation- ex. dyspnea climbing stairs
III: Marked limitation- ex. dyspnea with house chores
IV: Inability to perform activities without discomfort
Patient with symptomatic heart failure and EF <35% is on Entresto + BB. Adding what medication reduces morbidity and mortality?
Spironolactone/aldosterone antagonist
EKG findings in WPW
WPW Pattern: Short PR, delta waves, wide QRS
- occurs from pre-excitation of ventricles
Patients develop symptomatic supraventricular arrhythmias involving the accessory pathway when a re-entry circuit is formed back to atria. This is WPW Syndrome. Converts to a narrow-complex tachycardia- AVRT is the most common in 80% of pts.
What anticoagulation/antithrombotic therapy do you need for patients with mechanical mitral or aortic valves?
aspirin and warfarin
What is target INR for pt with mechanical mitral valve?
2.5-3.5
What is the target INR for pt with mechanical aortic valve?
2-3, or 2.5-3.5 if there are additional risk factors including afib, EF <30, prior VTE, hypercoaguable state
what is balanced ischemia?
when coronary flow is equally or nearly equally impaired. pattern on perfusion imaging comes up as homogenous- a false negative.
VSD murmur?
holosystolic murmur best heard over 3rd and 4th intercostal space at left sternal border, accompanied by a palpable thrill
ASD murmur?
mid systolic pulmonic ejection murmur, best heard at 2nd left intercostal space, associated with wide split S2
bicuspid aortic valve murmur?
midsystolic murmur with ejection click, best heard at 2nd right intercostal space
Anatomical features of Ebstein anomaly?
Apical displacement of the tricuspid leaflets
Decreased volume of the right ventricle
Atrialization of the right ventricle
Assoc with tricuspid regurgitation
Mitral regurg murmur?
Holosystolic
best heard at apex
radiates to axilla
Tricuspid regurg murmur?
holosystolic murmur best heard over 2nd and 3rd intercostal spaces, with NO palpable thrill. Increases with inspiration
Limitations in stress testing for patients with paced rhythm?
Exercise nuclear imaging stress test- false positive
Exercise EKG cant be used in paced rhythm
Exercise echo has paradoxical septal motion due to early activation of RV, can lead to false positive results
**should use pharmacological radionuclide perfusion testing
If ICD is infected, you remove the entire device if:
- evidence of valve or lead vegetation on TEE
- positive blood cx with an organism that is high risk for endocarditis
- evidence of pocket infection (localized pain/tenderness, erythema, swelling, purulent discharge or skin erosion)
- in all of the above cases, you remove then tx abx. 2 weeks if only pocket infection, 6 weeks if concerned for endocarditis due to TEE or bcx
which cardiac med is associated w/ increased risk of new onset diabetes?
statins
in patients w/ mechanical prosthetic valve undergoing low risk surgical procedures (dental, cateract, skin biopsy, cath, etc), what do you do with warfarin?
continue
When do you do elective surgery on the aortic root in a pt with Marfans?
aortic root diameter >50 mm
mitral stenosis murmur?
accentuated first heart sound- S1
opening snap after S2
mid-diastolic murmur or rumble with presystolic accentuation
normal pregnancy - potential murmur?
due to increased blood flow, cardiac output
short and soft systolic ejection murmur
define orthostatic hypotension
drop systolic BP >20
drop diastolic >10
is mitral valve repair or replacement preferred for prolapse + regurg?
repair
how do you treat asymptomatic patients with severe primary mitral valve regurg?
if EF >60%, monitor echos q 6-12 mos
if EF 30-60%- repair
if EF 30%- medical optimization, possible repair case-by-case
what is milrinone?
phosphodiesterase inhibitor- arterial and venous dilator.
also an inotrope
DAPT patients should be on PPI for ppx IF:
- prior GI bleed
- over age 65
- hx PUD
- active h pylori
Signs of Right Ventricular MI, and distribution of blockage?
Sx: hypotension/shock, JVD, clear lung fields
RCA/Inferior wall MI
Treatment of RV MI and med to avoid?
Avoid nitrates as these will decrease the right ventricular preload and worsen hypotension
tx with IV fluids to replenish preload, anticoag, antiplatelets, emergent cath
Antibiotic of choice for secondary prevention of rheumatic fever?
IM penicillin G benzathine q3-4 weeks
Duration of abx therapy for secondary prevention of rheumatic fever (following last attack)?
Whichever is longer:
Uncomplicated rheumatic fever: for 5 years or until age 21
With carditis but no valve disease: 10 years or until age 21
With carditis and valvular disease: 10 years or until age 40
What is Cheyne Stokes breathing? When does it occur?
crescendo-decrescendo oscillation of tidal volume with intervals of hypoventilation separated by periods of hypopnea and apnea.
occurs in central sleep apnea in heart failure patients
What medication for pericarditis is associated with higher rates of recurrence?
glucocorticoids
Exam and diagnostic findings of cor pulmonale
JVD
peripheral edema
palpable RV heave, loud P2, TR murmur
hepatomegaly, pulsatile liver
EKG: RBBB , R axis deviation, RV hypertrophy, RA enlargement
Echo: pulm HTN, RV dilation/dysfunction, TR
Catheterization:
gold-standard
Elevated filling pressures, decreased cardiac output, pulmonary hypertension
Superior vena cava syndrome- common causes
Most common: tumor compression
Other cause: ICD lead thrombosis/occlusion
HCM definition
LV wall thickness >=15 mm, in any location, in absence of other causes ex. HTN, valvular disease
What is a normal ABI?
1-1.3
What can cause a falsely elevated ABI?
calcified and non-compressible arteries in patients with advanced PAD in DM or CKD
What ABI defines occlusive PAD?
<=0.90
Outline pharmacotherapy for patients with PAD (used AFTER risk factor modification and graded exercise program)
- first line is aspirin
- plavix in pts who cannot tolerate aspirin
- patients who are still symptomatic on antiplatelet therapy can add cilostazol- a PDE inhibitor and vasodilator that inhibits platelet aggregation and improves pain-free walking distances
When do PAD patients meet criteria for revascularization?
patients who fail medical and exercise therapy
disabling claudication
limb threatening ischemia, usually ABI <0.5
