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UWORLD ABIM > Cardiology > Flashcards

Cardiology Flashcards

1
Q

How to diagnose carotid sinus hypersensitivity?

A

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

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2
Q

Indications for ICD for primary prevention of SCD

A

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

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3
Q

How to first treat acute aortic dissection

A

IV beta blocker

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4
Q

cardiac side effects of donepezil

A

sinus bradycardia

heart blocks

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5
Q

what has been found to improve functional capacity and quality of life in HFpEF patients?

A

exercise training/cardiac rehab

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6
Q

when is surgical repair of AAA indicated?

A 
>=5.5 cm 
OR 
increase of 0.5 cm in 6 mos 
OR 
in all symptomatic pts
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7
Q

BP meds that have risk of new onset diabetes due to effect on glucose metabolism

A

Thiazide diuretics

Beta blockers - except carvedilol

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8
Q

use warfarin with goal INR of 2.5 in all patients with mitral stenosis and 1 of the following:

A
  • afib (paroxysmal, persistent or permanent)
  • left atrial thrombus
  • prior embolic event

DOACs are not yet approved for valvular afib

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9
Q

Cardiac resynchronization therapy indications

A

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

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10
Q

Asymptomatic mild aortic stenosis. parameters and follow up echo

A

velocity: 2-2.9 m/s
mean gradient < 20 mmhg

f/u echo every 3-5 years

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11
Q

Asymptomatic mod aortic stenosis. parameters and follow up echo

A

velocity: 3-3.9 m/s
mean gradient 20-39 mmhg

f/u echo every 1-2 years

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12
Q

Asymptomatic severe aortic stenosis. parameters and follow up echo

A

velocity: >=4 m/s
mean gradient >=40 mmhg

f/u echo every 6-12 mos

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13
Q

when to put in an ICD in a HCM patient to prevent SCD

A

one or more of the following:

family hx of sudden cardiac death
recurrent or exertional syncope
NSVT
hypotension during exercise
massive LVH >3 cm
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14
Q

Who needs endocarditis prophylaxis for high risk procedures?

A

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
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15
Q

What are the high risk procedures that require endocarditis prophylaxis for some patients?

A
  • 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

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16
Q

What procedures do you not need endocarditis prophylaxis for?

A

Vaginal/c-section delivery

Colonoscopy/endoscopy/ERCP

GU procedures - prostatectomy, catheter insertion

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17
Q

Infective endocarditis - modified Dukes criteria

A

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

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18
Q

When can you hear an S3

A

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
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19
Q

When can you hear an S4

A
  • can be normal in older adults due to decreased ventricular compliance with aging
  • HOCM
  • pulmonic stenosis
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20
Q

how to treat peri-infarction pericarditis? PIP

A
  • 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
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21
Q

indications for early surgical management in native valve infective endocarditis

A

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
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22
Q

What does Valsalva maneuver do to murmurs?

A
  • 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
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23
Q

What does standing do to murmurs?

A
  • decreases venous return
  • HCM and MVP louder
  • all other murmurs are softer due to less flow over stenotic or regurgitant valves
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24
Q

What does squatting do to murmurs?

A
  • 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)
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25
Q

What does handgrip do to murmurs?

A
  • 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)
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26
Q

characteristics of cardiac myxoma

A
  • 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
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27
Q

Indications of percutaneous MV balloon valvotomy

A

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

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28
Q

Contraindications of percutaneous MV balloon valvotomy

A

left atrial or left appendage thrombus

mod-severe mitral regurg

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29
Q

What is Pickering syndrome?

A

flash pulm edema in patients w/ bilateral renal artery stenosis

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30
Q

When induction of anesthesia ex. midazolam, causes hypertension and tachycardia, this could be unmasking an undiagnosed ________?

A

pheochromocytoma

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31
Q

Peripheral edema from CCBs like amlodipine can be reduced with combination therapy with which other antihypertensive?

A

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
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32
Q

all patients with congenital long qt syndrome should be treated with:

A

beta blockers

  • put in an ICD if patient has syncope, or VT on BB therapy, or those w/ aborted cardiac arrest
33
Q

postprandial hypotension in the elderly, occurs within 2 hours after eating- how do you manage it?

A

decreased portion sizes

increased salt/water intake

low carb meals

avoidance of alcohol

34
Q

postprandial hypotension in the elderly, occurs within 2 hours after eating- how do you manage it?

A

decreased portion sizes

increased salt/water intake

low carb meals

avoidance of alcohol

  • can use octreotide for severely symptomatic or refractory cases
35
Q

Brugada syndrome

A

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

36
Q

Causes of culture-negative endocarditis

A

Fastidious bacteria- Coxiella/Q fever, Bartonella

Streptococcus spp if abx already given

Fungal organisms

Non-infectious causes- rheum disease, malignancy

37
Q

what type of aortic valve is coarctation of the aorta associated with?

A

bicuspid valve- 40% of cases

38
Q

what arrhythmia occurs in elderly patients with an exacerbation of pulmonary disease? what are the features?

A

multifocal atrial tachycardia

atrial rate >100
irregular RR intervals
>= 3 distinct p wave morphologies

39
Q

which is higher risk for thrombosis w/o AC, mechanical mitral valve, or mechanical aortic valve?

A

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

40
Q

Aortic valve replacement criteria in chronic severe AR?

A

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

41
Q

Describe the NYHA Classes

A

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

42
Q

Patient with symptomatic heart failure and EF <35% is on Entresto + BB. Adding what medication reduces morbidity and mortality?

A

Spironolactone/aldosterone antagonist

43
Q

EKG findings in WPW

A

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.

44
Q

What anticoagulation/antithrombotic therapy do you need for patients with mechanical mitral or aortic valves?

A

aspirin and warfarin

45
Q

What is target INR for pt with mechanical mitral valve?

A

2.5-3.5

46
Q

What is the target INR for pt with mechanical aortic valve?

A

2-3, or 2.5-3.5 if there are additional risk factors including afib, EF <30, prior VTE, hypercoaguable state

47
Q

what is balanced ischemia?

A

when coronary flow is equally or nearly equally impaired. pattern on perfusion imaging comes up as homogenous- a false negative.

48
Q

VSD murmur?

A

holosystolic murmur best heard over 3rd and 4th intercostal space at left sternal border, accompanied by a palpable thrill

49
Q

ASD murmur?

A

mid systolic pulmonic ejection murmur, best heard at 2nd left intercostal space, associated with wide split S2

50
Q

bicuspid aortic valve murmur?

A

midsystolic murmur with ejection click, best heard at 2nd right intercostal space

51
Q

Anatomical features of Ebstein anomaly?

A

Apical displacement of the tricuspid leaflets
Decreased volume of the right ventricle
Atrialization of the right ventricle

Assoc with tricuspid regurgitation

52
Q

Mitral regurg murmur?

A

Holosystolic
best heard at apex
radiates to axilla

53
Q

Tricuspid regurg murmur?

A

holosystolic murmur best heard over 2nd and 3rd intercostal spaces, with NO palpable thrill. Increases with inspiration

54
Q

Limitations in stress testing for patients with paced rhythm?

A

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

55
Q

If ICD is infected, you remove the entire device if:

A
  • 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
56
Q

which cardiac med is associated w/ increased risk of new onset diabetes?

A

statins

57
Q

in patients w/ mechanical prosthetic valve undergoing low risk surgical procedures (dental, cateract, skin biopsy, cath, etc), what do you do with warfarin?

A

continue

58
Q

When do you do elective surgery on the aortic root in a pt with Marfans?

A

aortic root diameter >50 mm

59
Q

mitral stenosis murmur?

A

accentuated first heart sound- S1
opening snap after S2
mid-diastolic murmur or rumble with presystolic accentuation

60
Q

normal pregnancy - potential murmur?

A

due to increased blood flow, cardiac output

short and soft systolic ejection murmur

61
Q

define orthostatic hypotension

A

drop systolic BP >20

drop diastolic >10

62
Q

is mitral valve repair or replacement preferred for prolapse + regurg?

A

repair

63
Q

how do you treat asymptomatic patients with severe primary mitral valve regurg?

A

if EF >60%, monitor echos q 6-12 mos
if EF 30-60%- repair
if EF 30%- medical optimization, possible repair case-by-case

64
Q

what is milrinone?

A

phosphodiesterase inhibitor- arterial and venous dilator.

also an inotrope

65
Q

DAPT patients should be on PPI for ppx IF:

A
  • prior GI bleed
  • over age 65
  • hx PUD
  • active h pylori
66
Q

Signs of Right Ventricular MI, and distribution of blockage?

A

Sx: hypotension/shock, JVD, clear lung fields

RCA/Inferior wall MI

67
Q

Treatment of RV MI and med to avoid?

A

Avoid nitrates as these will decrease the right ventricular preload and worsen hypotension

tx with IV fluids to replenish preload, anticoag, antiplatelets, emergent cath

68
Q

Antibiotic of choice for secondary prevention of rheumatic fever?

A

IM penicillin G benzathine q3-4 weeks

69
Q

Duration of abx therapy for secondary prevention of rheumatic fever (following last attack)?

A

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

70
Q

What is Cheyne Stokes breathing? When does it occur?

A

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

71
Q

What medication for pericarditis is associated with higher rates of recurrence?

A

glucocorticoids

72
Q

Exam and diagnostic findings of cor pulmonale

A

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

73
Q

Superior vena cava syndrome- common causes

A

Most common: tumor compression

Other cause: ICD lead thrombosis/occlusion

74
Q

HCM definition

A

LV wall thickness >=15 mm, in any location, in absence of other causes ex. HTN, valvular disease

75
Q

What is a normal ABI?

A

1-1.3

76
Q

What can cause a falsely elevated ABI?

A

calcified and non-compressible arteries in patients with advanced PAD in DM or CKD

77
Q

What ABI defines occlusive PAD?

A

<=0.90

78
Q

Outline pharmacotherapy for patients with PAD (used AFTER risk factor modification and graded exercise program)

A
  • 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
79
Q

When do PAD patients meet criteria for revascularization?

A

patients who fail medical and exercise therapy
disabling claudication
limb threatening ischemia, usually ABI <0.5

UWORLD ABIM (11 decks)

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