Cardiology Flashcards
1
Q
Common symptoms of stable CAD in elderly patients?
A
SOB, lightheadedness, fatigue (without CP) during exertion
2
Q
Best next test for patients with suspected stable CAD?
A
Non-invasive stress testing … Pharmacologic or Exercise
3
Q
2 options for pharmacologic stress testing for patients with suspected stable CAD?
A
Dobutamine ECHO, Adenosine myocardial perfusion
4
Q
Initial evaluation of choice in patients with suspected stable CAD?
A
Non-invasive stress testing
5
Q
DOC for patients with stable CAD (+) non-invasive stress testing?
A
ASA + statin + b blocker
6
Q
What is considered a high-risk feature on stress-testing for patient with suspected stable CAD?
A
ST depression
7
Q
In addition to medical treatment (ASA + statin + b blocker), what is an additional treatment for patients with (+) stress test and high-risk features?
A
Percutaneous coronary angiogram … to assess for stent placement + CABG
8
Q
72 yo male presents with arrythmia and pulmonary symptoms – diagnosis?
A
MAT … Multifocal Atrial Tachycardia
9
Q
Appearance of MAT on EKG?
A
Distinct P waves with different morphologies; Irregular rhythm (variable PR and RR segments); Tachycardia
10
Q
Best treatment for MAT?
A
Treat underlying pulmonary disease
11
Q
Patient with MAT does not show improvement of arrhythmia on EKG after treatment of underlying pulmonary disease – what is next step in treatment?
A
Check for electrolyte disturbances .. then correct electrolyte disturbances
12
Q
Patient with MAT does not show improvement of arrhythmia on EKG after treatment of underlying pulmonary disease and electrocyte disturbances – what is next step in treatment?
A
b blockers, CCBs
13
Q
2 DOC for patients with A-Fib with RVR?
A
b blockers, Non-DHP CCBs
14
Q
2 examples of Non-DHP CCBs?
A
Diltiazem, Verapamil
15
Q
Best management of hypertrophic cardiomyopathy (HCM)?
A
Implantable cardioverter-defibrillator (ICD)
16
Q
Optimal medical therapy for patient with systolic CHF with severe LV dysfunction?
A
b blocker, ACEI, Aldosterone antagonist, Diuretics
17
Q
Next step of management for patient with systolic CHF + severe LV dysfunction who is unresponsive to b blocker, ACEI, Aldosterone antagonist, Diuretics?
A
Add isosorbide dinitrate + hydralazine
18
Q
Best pharmacologic management for patients with suspected Acute Coronary Syndrome (ACS)?
A
ASA 325mg + NTG (if experiencing active CP)
19
Q
Best workup for patients with suspected Acute Coronary Syndrome (ACS)?
A
Troponin I levels … 3 hours apart
20
Q
Clinical presentation of acute mitral valve prolapse, due to mitral chordae tendinae rupture?
A
Sudden-onset hypotension, pulmonary edema
21
Q
Cardiac PE finding in setting of acute mitral valve prolapse, due to mitral chordae tendinae rupture?
A
Hyperdynamic precordium
22
Q
Auscultation PE finding in setting of acute mitral valve prolapse, due to mitral chordae tendinae rupture?
A
Decrescendo holosystolic murmur at cardiac apex
23
Q
Diagnosis of acute mitral valve prolapse, due to mitral chordae tendinae rupture is confirmed via …
A
Bedside ECHO
24
Q
Which patients are at increased risk of acute mitral valve prolapse, due to mitral chordae tendinae rupture?
A
Connective tissue disease
25
ECHO findings for patients with acute mitral valve prolapse, due to mitral chordae tendinae rupture?
Rapid equalization of LA and LV pressures
26
What clinical feature can be used to distinguish Ehlers-Danlos from Marfans?
EDS is much more likely to present with skin findings (unhealed scars)
27
There is a bidirectional link between depression and ___ … Depression is an independent risk factor for increased morbidity/mortality in ___
CAD
28
Best management of patient with Acute Coronary Syndrome (unstable angina, or NSTEMI)?
Dual antiplatelet therapy (ASA + clopidogrel), b blockers, NTG, Statin, Heparin
29
Best management of patient with STEMI?
Cardiac catheterization + revascularization within 90 minutes of presentation
30
Highly specific finding of cardiac tamponade, requiring immediate intervention?
Early diastolic collapse of RA/RV on ECHO
31
Additional specific finding of cardiac tamponade, requiring immediate intervention?
JVD plethora, with lack of inspiratory collapse
32
Best intervention for acute cardiac tamponade?
Catheter pericardiocentesis
33
Consequence of acute cardiac tamponade?
Impaired diastolic filling of R heart
34
Definition of elevated BP?
Systolic 120-129
35
Best management of elevated BP?
Lifestyle changes
36
Definition of Stage 1 HTN?
Systolic 130-139, Diastolic 80-89
37
Best management of Stage 1 HTN?
Lifestyle changes + 1 antihypertensive drug
38
Definition of Stage 2 HTN?
Systolic > 140, Diastolic > 90
39
Best management of Stage 2 HTN?
Lifestyle changes + 2 antihypertensive drugs
40
4 options for monotherapy in Stage 1 HTN?
ACEIs, ARBS, CCBs, Thiazide diuretics
41
Best combination therapy of 2 antihypertensive drugs in management of Stage 2 HTN?
ACEI + CCB
42
Which drug is NOT recommended in initial management of HTN?
B blockers
43
2 conditions in which B blockers would be indicated for initial management of HTN?
CAD, CHF
44
6 additional studies that should be ordered in patient with newly-diagnosed HTN?
Fasting lipid profile, BG, UA, serum electrolytes, creatinine, EKG
45
Best treatment for STEMI?
Percutaneous coronary intervention (PCI) within 90 minutes of first medical contact
46
Alternative best therapy for STEMI in patients who require transfer to PCI facility?
PCI within 120 minutes for patients
47
Best therapy for STEMI in rural setting where PCI is not possible?
Fibrolytic therapy
48
3 EKG findings that are diagnostic for STEMI?
New left BBB; > 1 mm ST elevation in all leads except V2 and V3; > 1.5 mm (in women) and > 2 mm (in men) ST elevations and leads V2 and V3
49
Hallmark of 2nd degree AV block type 2?
Intermittent non-conducted P waves
50
Best treatment of 2nd degree AV block type 2?
Pacemaker placement
51
How long should DVTs due to underlying surgery, pregnancy, trauma, OCP use be treated with anticoagulation therapy?
3-6 months
52
How long should idiopathic DVTs be treated with anticoagulation therapy?
> 6 months
53
Name the murmur … mid-systolic murmur at L upper sternal border; ECHO shows RA and RV dilation?
ASD
54
Additional heart sound heard in setting of ASD?
Wide and fixed splitting of S2
55
ASD is a type of ___ shunt
L-to-R
56
Most common congenital heart defect in adults?
Bicuspid aortic valve
57
2nd most common congenital heart defect in adults?
ASD
58
Clinical presentation of papulopustular rosacea?
Erythema in central face, flushing, telangiectasia, pustules
59
Best management for patients with papulopustular rosacea?
Topical metronidazole
60
Patients with rosacea also experience ___ symptoms
Ocular
61
3 ocular manifestations of rosacea?
Foreign body sensation, recurrent chalazion, conjunctivitis
62
Etiology of chalazion?
Inflammation of meibomian gland
63
Clinical presentation of chalazion?
Painless pea-sized nodule within eyelid
64
What accounts for cocaine-related chest pain?
Overstimulation of b1 and alpha1 receptors
65
MOA of cocaine?
Inhibition of presynaptic reuptake of norepinephrine
66
Initial DOC for management of cocaine-related chest pain?
Benzodiazepine
67
Role of Benzodiazepine in treatment of cocaine-related chest pain?
Reduce sympathetic outflow
68
Medication that is contraindicated in treatment of cocaine-related chest pain?
b blockers
69
Why are b blockers contraindicated in treatment of cocaine-related chest pain?
Can lead to excessive alpha-1 receptor vasoconstriction
70
35 yo female presents with cocaine-related chest pain; 2 hours after presentation, she reports persistent CP with new-onset R-sided weakness – diagnosis?
Aortic dissection
71
What accounts for Aortic dissection in setting of cocaine use?
Severe HTN after cocaine ingestion
72
Diagnostic test for Aortic dissection?
CT angiography, MRI, Transesophageal ECHO
73
Amiodarone is a CYP450 ___
Inhibitor … (SICKFACES.COM when I Am drinking GFJ)
74
How should a patient’s dose of warfarin be altered when Amiodarone is added to their drug regimen?
Amiodarone = CYP450 inhibitor … Slows metabolism of warfarin … Reduce warfarin dose by 25-50%
75
Best strategy for discontinuing amlodipine in a patient with well-controlled HTN, who has recently lost a healthy amount of weight?
Amlodipine is a long-acting medication … discontinuation can be achieved by taking the medication every-other-day … OR in lower lose tablets
76
Best strategy for discontinuing lisinopril in a patient with well-controlled HTN?
Lisinopril is a short-acting medication … discontinuation can ONLY be achieved by taking the medication every day in a smaller dose
77
How can you calculate a CHADS2-VASC score for a patient with newly-diagnosed A-Fib?
CHF, HTN, Age > 75 (2 points), DM, Stroke (2 points), Vascular disease, Age 65-74, Sex (female)
78
What is the role of CHADS2-VASC score in newly-diagnosed A-Fib?
Estimate thromboembolic risk
79
Best treatment for A-Fib patients who are hemodynamically unstable?
Emergency cardioversion
80
Best treatment for A-Fib patients who are hemodynamically stable?
Medical therapy
81
2 DOC for A-Fib rate control?
Diltiazem, b blockers
82
Best additional management for patients with CHADS2-VASC score <2?
Periodic follow-up
83
Best additional management for patients with CHADS2-VASC score >2?
Anticoagulation
84
62 yo male presents with new-onset, RLE pain; Reports CABG performed 3 months ago; Presented to ED 2 nights ago for recurrent CP; Troponin = elevated, angiogram was (+) for coronary artery stenosis; Patient was treated with heparin, anti-platelet agents, b blocker, NTG; Stenting was performed; ECHO was (-); PE shows RLE that is cool to touch, diminished pulses; Labs show thrombocytopenia – diagnosis?
Type 2 HIT
85
3 hallmark clinical findings for Type 2 HIT?
Thrombocytopenia, Onset after Heparin administration, Thrombosis
86
Etiology of Type 2 HIT?
Auto-Ig directed against heparin-platelet factor 4 complexes
87
Difference between Type 1 HIT and Type 2 HIT?
Type 1 = non-immune mediated; Type 2 = immune mediated
88
Diagnostic test for Type 2 HIT?
HIT antibody testing
89
Best management of Type 2 HIT?
Discontinue all heparin-containing products; Begin non-heparin anticoagulants … Don’t wait for (+) HIT antibody testing to return
90
2 types of non-heparin anticoagulants that can be used in setting of Type 2 HIT?
Argatroban, Fondaparinux
91
Approach to future heparin use in a patient diagnosed with Type 2 HIT?
Avoid all forms of heparin for life
92
2 long-term treatment options for patients with A-Fib?
Rate control + Anticoagulation; Rhythm control
93
2 clinical settings in which Rhythm control is the preferred treatment for patients with A-Fib?
Inability to maintain HR control with rate-control agents; Persistence of symptomatic CHF episodes while on rate-control agents
94
2 anti-arrhythmic agents used in treatment of A-Fib for patients with no CAD or structural heart disease?
Flecainide, Propafenone
95
1 anti-arrhythmic agent used in treatment of A-Fib for patients with LV hypertrophy?
Amiodarone
96
1 anti-arrhythmic agent used in treatment of A-Fib for patients with CAD?
Sotolol
97
2 anti-arrhythmic agents used in treatment of A-Fib for patients with CHF?
Amiodarone, Dofetilide
98
3 classes of anti-HTN drugs that affect lithium levels?
Thiazide diuretics, ACEIs/ARBs, Spironolactone
99
1 additional drug that affects lithium levels?
NSAIDs
100
2 classes of anti-HTN drugs that affect do NOT lithium levels?
CCBs, Loop diuretics
101
Lithium is metabolized by which organ?
Kidney
102
In a patient with existing AAA, control of which risk factor is most important for decreasing likelihood of AAA expansion/rupture?
Smoking cessation … (not HTN control)
103
Etiology of early post-MI acute pericarditis?
Peri-infarction pericarditis
104
Typical time-frame of post-MI acute pericarditis?
Within 4 days of MI
105
Etiology of late post-MI acute pericarditis?
Dressler Syndrome
106
EKG findings associated with post-MI acute pericarditis?
Diffuse ST segment elevations, PR depression
107
Cardiac auscultation results for post-MI acute pericarditis?
Friction rub
108
Best treatment for post-MI acute pericarditis?
High-dose ASA
109
Best treatment for acute pericarditis … viral OR idiopathic etiology?
NSAIDs + colchicine
110
Why are NSAIDs + colchicine + corticosteroids NOT recommended as treatment for post-MI acute pericarditis?
NSAIDs ma impair cardiac healing, increase risk of septal/free wall rupture
111
Best test for initial diagnostic evaluation of stable CAD?
Exercise EKG … (stress test)
112
What might account for a holosystolic heart murmur heart in patient with acute decompensated heart failure?
Holosystolic murmur = dilated cardiomyopathy causing MR
113
3 initial tests that should be ordered for patient with acute decompensated heart failure?
Pulse Ox, CXR, ECG
114
Most important initial step in treatment of acute decompensated heart failure?
Decrease preload … diuretics (furosemide)
115
Alternative medication used to decreased preload in patients with acute decompensated heart failure (not furosemide)?
Vasodilators (nitroprusside, NTG)
116
3 characteristic heart sounds heard in aortic stenosis?
Single A2, Delayed carotid pulse, Crescendo-Decrescendo systolic murmur
117
___ refers to Delayed carotid pulse seen in aortic stenosis?
Parvus et tardus
118
What accounts for Single A2 heard in aortic stenosis?
Delayed closure of aortic valve
119
If a patient is preparing to undergo cardiac catheterization, which home medication should be discontinued?
Metformin
120
Why should Metformin be discontinued prior to cardiac catheterization?
Increased risk of lactic acidosis … huge amount of iodine contrast exposure
121
Creatinine level that contraindicates use of metformin?
Creatinine > 1.5
122
Change to RA pressure in setting of hypovolemic shock?
Decreased
123
Change to PCWP in setting of hypovolemic shock?
Decreased
124
Change to cardiac index in setting of hypovolemic shock?
Decreased
125
Change to SVR in setting of hypovolemic shock?
Increased
126
Change to venous O2 saturation in setting of hypovolemic shock?
Decreased
127
Change to RA pressure in setting of cardiogenic shock?
Increased
128
Change to PCWP in setting of cardiogenic shock?
Increased
129
Change to cardiac index in setting of cardiogenic shock?
Decreased
130
Change to SVR in setting of cardiogenic shock?
Increased
131
Change to venous O2 saturation in setting of cardiogenic shock?
Decreased
132
Change to RA pressure in setting of septic shock?
Decreased
133
Change to PCWP in setting of septic shock?
Decreased
134
Change to cardiac index in setting of septic shock?
Increased
135
Change to SVR in setting of septic shock?
Decreased
136
Change to venous O2 saturation in setting of septic shock?
Increased
137
Change to RA pressure in setting of cardiac tamponade?
Increased
138
Change to RV pressure in setting of cardiac tamponade?
Increased
139
Characteristic of RA, RV, PCWP in cardiac tamponade?
Equalized
140
Change to RA pressure in PE?
Increased
141
Change to RV pressure in PE?
Increased
142
Change to PCWP pressure in PE?
Increased
143
Best management of NSTEMI or unstable angina in low-risk patients?
Exercise stress test
144
Best management of NSTEMI or unstable angina in high-risk patients?
Coronary artery angiogram
145
57 yo male presents with new-onset extreme HTN; BP was previously controlled with HCTZ + amlodipine; PE shows R-sided carotid bruit, L-sided diminished popliteal pulses – diagnosis?
Renal Artery Stenosis (RAS)
146
3 additional PE findings associated with RAS?
Abdominal bruit, Recurrent flash pulmonary edema, Unilateral renal atrophy
147
1 lab value associated with RAS?
Elevated creatinine
148
Diagnostic step for RAS?
Imaging with MRA, CTA, Doppler US
149
DOC for secondary prevention in patients with known atherosclerotic cardiovascular disease (ASCVD)?
High intensity statin (atorvastatin, rosuvastatin)
150
Which patients should receive high-intensity statin therapy as primary prevention for ASCVD?
LDL > 190, Age > 40 with DM, 10-year risk of ASCVD > 7.5%
151
EKG finding that might result from interaction of sotalol and azithromycin?
QT prolongation
152
EKG complication of QT prolongation?
Toursade de Pointes
153
Additional EKG event that might provoke Toursade de Pointes (not hypokalemia)?
Bradycardia
154
Best management of Toursade de Pointes?
Magnesium … even in patients with NML Mg2+ levels
155
Next step of management for patients with Toursade de Pointes, who do not respond to Mg2+ supplementation?
Transvenous pacing
156
Most common cause of dilated cardiomyopathy is idiopathic; What is most common secondary cause?
Ischemic cardiomyopathy
157
Screening test that should be performed for all patients with new-onset heart failure?
Stress testing, or coronary angiography … to rule out ischemic cardiomyopathy
158
Indication for amiodarone?
Ventricular and supraventricular arrhythmia
159
6 AEs of amiodarone?
Photosensitivity, skin discoloration, bone marrow suppression, thyroid dysfunction, abnormal LFTs, pulmonary toxicity
160
What is the most common manifestation of amiodarone-induced pulmonary toxicity?
Chronic interstitial pneumonitis
161
Appearance of Chronic interstitial pneumonitis on CXR?
Diffuse interstitial opacities
162
Best management of amiodarone-induced Chronic interstitial pneumonitis?
Discontinue amiodarone
163
Best initial management of patient with suspected Acute Decompensated Heart Failure (ADHF)?
Furosemide + O2 supplementation
164
Next management of patient with suspected Acute Decompensated Heart Failure (ADHF), who shows inadequate response to initial diuretic therapy?
IV vasodilator (NTG)
165
Beneficial effect of IV vasodilator (NTG) in patients with Acute Decompensated Heart Failure (ADHF)?
Decreased cardiac preload; Reduced intracardiac filling pressures, improvement in pulmonary edema
166
Diagnostic test to include in workup for Acute Decompensated Heart Failure (ADHF)?
Transthoracic ECHO … to assess LV function, valvular abnormalities
167
Most common cause of acute limb ischemia?
Embolism from a cardiac source
168
Best management of acute limb ischemia?
Anticoagulation + Emergency surgical intervention
169
Why is emergency surgical intervention required for acute limb ischemia?
Increased risk for irreversible myonecrosis
170
Common vasopressor therapy?
Norepinephrine
171
3 aspects of initial management for STEMI in the setting of cocaine use?
Benzodiazepine, NTG, ASA
172
Role of Benzodiazepine, NTG, ASA in initial management for STEMI in the setting of cocaine use?
Reduction in myocardial O2 demand, Improvement in myocardial O2 supply
173
Which medication is contraindicated in the management for STEMI in the setting of cocaine use?
b blockers … due to unopposed a activity … HTN
174
Best management of persistent STEMI in patients with recent cocaine use?
Coronary angiogram + percutaneous coronary intervention (PCI)
175
Patient undergoes L heart catheterization, which shows “step up” in oxygenation between RA and RV – diagnosis?
VSD … L-to-R shunt
176
Description of murmur heard in VSD?
Harsh holosystolic murmur over 3rd-4th ICS … with palpable thrill
177
L heart catheterization results for ASD?
“step up” in oxygenation between SVC+IVC and RA
178
Best management of patient with stable angina; Coronary angiogram shows stenosis of LAD, LCX, and RCA?
CABG … CABG is superior to PCI with drug-eluting stent for patients with multi-vessel disease
179
3 groups of people with stable angina who would benefit from coronary revascularization?
Refractory angina, LAD stenosis, multivessel disease
180
Common post-operative complication of cardiac surgery?
A-Fib (post-operative A-fib … POAF)
181
Most likely prognosis for POAF?
Spontaneous conversion to sinus rhythm within few days of surgery
182
3 complications of POAF?
Increased long-term mortality, Embolic CVA, heart failure
183
Describe the murmur - holosystolic murmur at L 4th intercostal space close to sternal border?
VSD
184
Description of ASD?
Wide, fixed splitting of S2
185
Description of MVP?
Late systolic click
186
4 characteristics of Tetralogy of Fallot?
RV outflow obstruction, VSD, RV hypertrophy, overriding aorta
187
Description of Triscuspid Stenosis?
Mid-diastolic rumble
188
50 yo male presents with substernal CP; BP 84/52, HR 34; PE shows crackles at BL bases; EKG shows ST elevation in II-III-aVF; Best treatment?
IV atropine
189
Change in vital signs associated with inferior wall MI?
Sinus bradycardia
190
3 EKG changes associated with hyperkalemia?
Peaked T waves, PR prolongation, widening of QRS complex
191
Best management of SVT without HD instability?
Vagal massage, IV adenosine
192
Best management of SVT with HD instability?
Synchronized cardioversion
193
Best management of PEA?
CPR
194
What is best diagnostic test for patients with stable angina?
Stress testing
195
68 yo male is about to undergo urgent laparotomy for intestinal perforation; Prior to surgery, develops A-Fib with HR 112-118; what is next best step in management?
In a HD-stable patient, administer IV B blocker for rate control, proceed with surgery
196
48 yo female presents for chest pain; Was in a MVC yesterday, husband is still hospitalized; HR 102, BMI 31; EKG shows ST segment elevation in leads V3-V6, QTc 509 - what is most likely finding on ECHO?
LV wall abnormalities
197
48 yo female presents for chest pain; Was in a MVC yesterday, husband is still hospitalized; HR 102, BMI 31; EKG shows ST segment elevation in leads V3-V6, QTc 509 - diagnosis?
Takotsubo cardiomyopathy
198
Typical finding of Takotsubo cardiomyopathy on coronary angiogram?
Absence of CAD
199
Etiology of Takotsubo cardiomyopathy?
Catecholamine surge
200
Which pathology is associated with RV dilation and hypokinesis?
Acute PE
201
55 yo female presents with exertional dyspnea for 3 months; HX of HTN and CKD; Current meds include furosemide, amlodipine, lisinopril; PE shows trace BL pitting edema; Labs show Hgb 10.8, Cr 2.2, GFR 28 - what is next step in workup?
Stress ECHO … stable angina
202
66 yo female presents after recent diagnosis of CHF with EF 30%; Reports mild exertional fatigue ; Current medications include sacubitril-valsartan, metoprolol succinate, furosemide; HR 62; PE shows pnsystolic murmur at apex; Labs show no significant e+ abnormalities - what is next step in pharmacotherapy?
Add spironolactone
203
Best medication regimen for HF with EF < 40%?
ARB, B blocker
204
Best medication regimen for HF with EF < 40% with signs of volume overload?
ARB, B blocker + Diuretic
205
Best medication regimen for HF with EF < 35%?
ARB, B blocker + Aldosterone antagonist
206
3 EKG changes seen in athletes participating in high-intensity training?
Resting sinus bradycardia, 1st degree AV block, LVH
207
Most common cause of SCD in young patients?
Structural heart defects
208
Most common terminal event in SCD in young patients?
V-tach
209
2 most common Anomalous Aortic Origin of Coronary Artery (AAOCA) responsible for SCD?
LCA originating from R aortic sinus, RCA originating from L aortic sinus
210
Typical appearance of resting EKG in SCD?
NML
211
Diagnostic study for AAOCA?
CT coronary angiogram, MRA
212
What is the most common structural defect that causes SCD?
HoCM
213
65 yo male presents for syncope; HX of MI; Current medications include ASA, carvedilol, atorvastatin, ramipril, tansulosin; EKG shows Q waves; ECHO shows apical wall abnormality, EF 40% - etiology of syncope?
V-tach
214
Clue that suggests aortic stenosis as cause of syncope?
Systolic murmur on PE
215
Clue that suggests V-tach as cause of syncope?
Previous MI or cardiomyopathy
216
Clue that suggests Sick Sinus Syndrome as cause of syncope?
Sinus pause on EKG
217
Clue that suggests AV block as cause of syncope?
Prolonged PR interval, dropped QRS complexes
218
Clue that suggests Toursades as cause of syncope?
HypoK, HypoMg, Medications that prolong QT interval
219
34 yo female presents for palpitations; HX of HoCM, hypothyroidism; Currently on metoprolol, levothyroxine; PE shows thyroid gland that is symmetrically enlarged, nontender; EKG shows T wave inversions that are unchanged from 6 months ago; Next best step?
Ambulatory EKG monitoring
220
2 heart arrythmias that patients with HoCM are predisposed to?
A-Fib, V-tach
221
67 yo male presents with fatigue, LE edema; HX of CABG and MV repair; Recently developed A-Fib, requiring amiodarone and anticoagulation; PE shows JVD, ascites, LE edema; ECHO shows enlarged LA, NML LV wall thickness and RV size, EF 65%; Mild MR; CXR shows nromal heart size, but spotty calcifications along the L heart border - diagnosis?
Constrictive pericarditis
222
2 most common etiologies of Constrictive pericarditis?
Viral pericarditis, Cardiac surgery
223
EKG finding for Constrictive pericarditis?
A-Fib, low-voltage QRS complex
224
Imaging of Constrictive pericarditis?
Pericardial thickening and calcification
225
Appearance of Constrictive pericarditis on JVP tracing?
Prominent X/Y descent
226
Of the following EKG findings, which warrants further workup – Deep Q waves in V1-V4, 1st degree AV block with PR interval 230 ms, Left BBB with QRS duration 160 ms, QTC interval prolongation of 480 ms?
Left BBB
227
3 criteria for pacemaker placement in patient with CHF?
EF < 35%, Left BBB with QRS > 150 ms, Symptomatic CHF
228
63 yo male with HTN, HLD presents for wellness exam; PE shows ejection-type systolic murmur at R 2nd ICS; ECHO shows EF 35% - what is best management of patient?
ACEI
229
___ is the first-line therapy for patients with asymptomatic ventricular systolic dysfunction
ACEI, then b blocker
230
Most common congenital heart abnormality in adults?
Bicuspid aorta
231
Risk associated with bicuspid aortic valve?
Thoracic aortic aneurysm, Aortic dissection
232
Diagnosis of femoral artery pseudoaneurysm after cardiac catheterization is confirmed by …
Ultrasound
233
31 yo male presents for exertional SOB; BP is 147/90, apical impulse is hyperdynamic; ECHO shows increased IV thickness; EF is 75% - diagnosis?
Hypertrophic cardiomyopathy
234
Best initial management of Hypertrophic cardiomyopathy?
b blocker
235
Change to motion of mitral valve in setting of Hypertrophic cardiomyopathy?
Anterior motion of mitral leaflets during systole
236
2 additional medications than can be added to b blocker for patients with Hypertrophic cardiomyopathy?
Verapamil, Disopyramide
237
62 yo male presents with CP; Adenosine stress test shows moderate perfusion defect in lateral wall of LV – which coronary vessel is most likely involved?
LCX
238
Which coronary vessel supplies the anterior wall of LV?
LAD
239
Which coronary vessel supplies the anterolateral wall of LV?
LAD’s diagonal branches
240
Which coronary vessel supplies the inferoposterior wall of LV?
RCA
241
64 yo male presents with CP; He underwent RCA stenting 2 weeks ago; On presentation today, EKG shows ST elevations in leads II-III-aVF – which additional piece of history is most helpful in diagnosis?
Medication non-compliance
242
What is the strongest risk factor for development of stent thrombosis after coronary stent placement?
Premature discontinuation of dual antiplatelet therapy
243
What does dual antiplatelet therapy after stent placement include?
ASA, P2Y12 receptor blocker (clopidogrel)
244
When is the most common time for stent thrombosis to occur after placement of coronary artery stent?
Within 30 days of stent placement
245
68 yo male presents for nausea, anorexia, AMS; Recently admitted for uncontrolled HTN and palpitation; started on new medication; Prior to that, his meds included digoxin, warfarin, simvastatin, HCTZ; HR 50, otherwise VSS - diagnosis?
Digoxin toxicity
246
68 yo male presents for nausea, anorexia, AMS; Recently admitted for uncontrolled HTN and palpitation; started on new medication; Prior to that, his meds included digoxin, warfarin, simvastatin, HCTZ; HR 50, otherwise VSS - which medication is contributing?
Verapamil
247
How does verapamil induce digoxin toxicity?
Inhibits renal tubule secretion of digoxin
248
5 classic findings of digoxin toxicity?
AMS, nausea, vomiting, anorexia, visual changes
249
4 medications that can induce digoxin toxicity?
Verapamil, amiodarone, spironolactone, quinidine
250
46 yo male presents with PE and RLE DVT; He is started on a heparin drip, but develops bradycardia, without a pulse; CPR and intubation still do not yield a pulse – what is best next step in management?
PEA … chest compressions + epinephrine
251
60 yo male presents with fatigue and dyspnea on exertion; HX of HTN and CKD; PE shows cardiac lateral + downward displacement of apical impulse; EKG shows LVH; Labs show Hgb 8.3, MCV 88, ferritin 320 (high) – what is role of treatment with EPO in this patient?
Positive impact on LVH
252
Cardiac complication commonly seen in CKD?
Mixed concentric + eccentric LVH
253
Major contributor to concentric hypertrophy in CKD?
Systemic HTN
254
60 yo male presents with CP, SOB; HX of Hodgkin lymphoma treated with CTX and XRT; PE shows diastolic murmur at L sternal border; ECHO shows enlarged LA, NML LV, EF 60%, moderate diastolic dysfunction; Mitral and aortic valves appear sclerotic, calcified; Aortic root appears normal size but ECHO bright; Moderate AR – diagnosis?
XRT cardiotoxicity
255
Hallmark features of XRT cardiotoxicity?
Leads to restrictive cardiomyopathy, diastolic dysfunction, preserved EF
256
Hallmark features of anthracycline cardiotoxicity?
Leads to dilated cardiomyopathy with decreased EF
257
45 yo male presents for follow-up of HTN; Reports 25 pack-year history; Vitals show BP 140/88, BMI 30; Labs show Total cholesterol 255, TG 340 – what is best next step of workup?
Calculate 10-year atherosclerotic CVD risk
258
2 indications for prescription of new statin?
LDL > 190, Patients age > 40 yo with DM
259
When should patients with LDL < 190, age > 40 without DM be started on statin?
If 10-year CVD risk > 7.5%
260
23 yo male presents for murmur discovered recently at a health fair; PE shows mid-systolic murmur at L sternal border; ECHO shows bicuspid aortic valve – diagnosis?
Bicuspid aortic valve
261
Inheritance pattern of bicuspid aortic valve?
AD with incomplete penetrance
262
74 yo male presents after MVA with blunt chest trauma; BP 98/65, HR 105; PE shows bruises to anterior chest, otherwise unremarkable exam - next step of workup?
Bedside US (FAST exam)
263
Most common manifestation of blunt chest trauma?
Cardiac contusion … decreased cardiac contractility, arrhythmia, myocardial rupture
264
70 yo male presents for fatigue; PE reveals crescendo-decrescendo murmur at cardiac base, S2 has inaudible A2 component; ECHO shows LVH, severe aortic valve calcification; Estimated aortic valve diameter is 0.78 cm, transvavlular gradient is 50 mmHg - what is best management for this patient?
Aortic valve replacement
265
Indications for aortic valve replacement?
Gradient > 40, Valve area < 1cm, aortic jet velocity > 4.0
266
25 yo male presents for sudden-onset L foot pain; Reports fatigue and weight loss over 2 months; Mother developed blood clot in leg after elective surgery; PE shows diastolic murmur over apex, absent pulses in L foot, pale/cool L foot - diagnosis?
L atrial myxoma
267
Most common location for atrial myxoma?
LA
268
Murmur associated with atrial myxoma?
Diastolic murmur over apex
269
Factor V Leiden typically presents as …
DVTs
270
62 yo female presents with unstable angina; Stress testing reveals no symptoms during exercise for 8 minutes, no abnormal ST changes on EKG - how should these stress test results be interpreted?
Low risk (<1%) for cardiovascular events in the near future (1 year)
271
Wolfe-Parkinson White (WPW) syndrome is a type of …
Tahyarrhythmia
272
3 EKG findings associated with WPW syndrome?
Short PR interval, Delta wave, Wide QRS
273
What is next best step in suspected WPW syndrome in a patient with (+) EKG findings, recurrent synope?
Catheter ablation
274
82 yo female presents with stable angina; BP 152/92; PE shows JVD, diffuse lung crackles, LE edema; EKG shows ST depression in leads I, aVL, V3-V6 - diagnosis?
Acute decompensated heart failure
275
82 yo female presents with stable angina; BP 152/92; PE shows JVD, diffuse lung crackles, LE edema; EKG shows ST depression in leads I, aVL, V3-V6 - which medication should be avoided at this time?
Metoprolol
276
Why are B-blockers contraindicated in Acute decompensated heart failure?
May exacerbate pulmonary edema
277
NTG is contraindicated in which type of heart problem?
Inferior MI
278
49 yo male presents for poor sexual performance, inability to have erections at night; HX of DM, HLD, exertional pain in buttocks + thighs; HX of tobacco use; BMI 32 - what is best next step?
Measure ABI
279
Role of ABI?
Diagnosis of PAD
280
Triad of symptoms seen in Leriche syndrome?
LE claudication, absent/diminished pulses, ED
281
Result of ABI that suggests PAD?
ABI < 0.9
282
Next step of workup for patient with PAD and atherosclerotic risk factors?
Screening for CAD with stress test
283
62-year-old male is hospitalized for CABG; other medical history includes stage III CKD, 50-pack-year smoking history; patient is extubated, but develops drowsiness, lethargy on day 3 of admission, physical exam reveals tachycardia, RR 9, bibasilar lung crackles; EKG shows atrial fibrillation with RVR; what is best next step in management of patient's altered mental status?
Naloxone
284
62-year-old male is hospitalized for CABG; other medical history includes stage III CKD, 50-pack-year smoking history; patient is extubated, but develops drowsiness, lethargy on day 3 of admission, physical exam reveals tachycardia, RR 9, bibasilar lung crackles; EKG shows atrial fibrillation with RVR; diagnosis?
Acute opioid intoxication
285
Which opioid is associated with high risk of opioid toxicity in the setting of CKD?
Morphine
286
60-year-old male with hypertension and HLD presents for follow-up visit; antihypertensive agent is added to his current medication list; while vacationing in Florida, developed erythematous rash on exposed parts of body - which medication is responsible?
HCTZ
287
72-year-old male presents for preoperative evaluation for AAA repair; AAA was initially detected on routine screening 7 years ago; most recent study demonstrated aneurysm with diameter 5.5 cm, increased from 5.1 cm approximately 1 year ago; current medications include aspirin, valsartan, amlodipine, atorvastatin, Metformin, insulin; former smoker, quit 15 years ago; vitals show BP 142/80; BMI 30, PE shows pulsatile mass, trace pitting edema bilaterally; creatinine 1.3, EKG with nonspecific T wave changes; CXR demonstrates tortuous thoracic aorta, otherwise normal -what is most appropriate course of action?
Proceed with AAA repair
288
For medications that are indicated in patient with CAD and prior MI?
Beta-blocker, statin, antiplatelet therapy, ACE inhibitor
289
53-year-old female presents for hemoptysis, fatigue, shortness of breath, palpations; JVD at 9 cm, BMI 20; loud first heart sound, short apical low pitched diastolic rumbling; bilateral crackles, EKG shows notched P wave in lead II, RAD; CXR shows pulmonary edema, prominent pulmonary arteries, elevation of left mainstem bronchus, left atrial enlargement -diagnosis?
Rheumatic heart disease, chronic mitral stenosis
290
What is most common cause of mitral stenosis?
Chronic rheumatic heart disease
291
What is typical heart sound heard in setting of mitral stenosis?
Loud S1, mid diastolic rumble best heard at the cardiac apex
292
61-year-old female presents with exertional dyspnea; history of current HER-2 positive breast cancer, treated with paclitaxel, carboplatin, trastuzumab; prior to mastectomy, EF was 60%, but now 30% -diagnosis?
Trastuzumab associated cardiotoxicity
293
What is best advice for patient regarding Trastuzumab associated cardiotoxicity?
Most patients completely recover heart function after discontinuation of trastuzumab
294
What is most typical heart sound heard in the setting of mitral valve prolapse?
Nonejection click and systolic murmur that varies in timing depending on body position
295
57-year-old female presents after aortic valve replacement approximately 6 months ago; history also significant for HTN; current medications include aspirin, warfarin, amlodipine, ARB; what is best treatment recommendation for this patient?
Continue aspirin and warfarin with goal INR 2-3
296
What is the target INR for mechanical aortic valves with high risk features (A. fib, LVEF < 30%, prior thromboembolism, hypercoagulability)?
2.5-3.5
297
72 yo female presents with 4 hours of chest pain; EKG shows ST segment elevation in II-II-avF; while waiting for interventional cardiology, BP 75/45, HR 60; PE shows diaphoresis, cold extremities - what is best next step?
Optimize preloaf with IVF ... inferior wall MI
298
76 yo male presents with PE findings consistent with varicose veins; PE shows leg heaviness, cramping, worse with prolonged standing - what is best management?
Conservative measures with leg elevation and compression stockings
299
28 yo female presents with exertional shortness of breath; From Cambodia, Hx of rheumatic mitral stenosis; 1.5 cm2 area of mitral valve on ECHO 4 months ago - what is next best step in management?
Pregnancy test
300
6 yo male presents for annual PE; Reports intermittent pain in legs; BP is 135/88 in UE, HR 110; PE reveals continuous murmur over L interscapular area - diagnosis?
Aortic coarctation
301
Additional PE finding associated with Aortic coarctation?
Lower extremity hypotension
302
76-year-old male presents with nausea, vomiting, generalized abdominal distention; history of type II DM; diagnostic work-up is consistent with complicated SBO; undergoes exploratory laparotomy, extubated in ICU; several hours later, BP 84/50, HR 32; EKG shows sinus bradycardia with ST elevation in inferior leads; CXR shows increased interstitial markings bilaterally; patient treated with IV fluids and atropine, without significant improvement -- what is next best step in management?
Temporary cardiac pacing
303
76-year-old male presents with nausea, vomiting, generalized abdominal distention; history of type II DM; diagnostic work-up is consistent with complicated SBO; undergoes exploratory laparotomy, extubated in ICU; several hours later, BP 84/50, HR 32; EKG shows sinus bradycardia with ST elevation in inferior leads; CXR shows increased interstitial markings bilaterally; patient treated with IV fluids and atropine, without significant improvement -- diagnosis?
Inferior lateral STEMI complicated by sinus bradycardia
304
What accounts for development of bradycardia in the setting of inferior lateral STEMI?
AV block
305
Initial treatment for acute inferior wall MI, complicated by sinus bradycardia?
IV atropine
306
Prognosis for patients with hypertrophic cardiomyopathy?
Will achieve normal life expectancy with appropriate therapy
307
2 factors in hypertrophic cardiomyopathy that indicate favorable prognosis?
Lack of symptoms, diagnosis during adulthood
308
1 factor in hypertrophic cardiomyopathy that indicates poor prognosis?
LV systolic dysfunction
