Cardiology Flashcards
1
Q
PAH auscultation findings
A
Wide split S2 and prominent P2 (S3, S4, holosystolic TR)
2
Q
Wide fixed split S2
A
ASD, RV overload
3
Q
PAH definition
A
pulmonary mean arterial pressure >22mmHg, or systolic pulmonary arterial pressure >36mmHg
4
Q
PAH possible causes
A
Idiopathic, HIV, connective tissue disease, portal hypertension.
5
Q
PAH diagnosis
A
- initial workup is ECG.
- Echo.
- Conformation (gold standard) is Right heart catheterisation to assess severity.
(Decrease of mean pulmonary pressure by more than 10mmHg by using vasodilator)
6
Q
Paradoxical splitting S2
A
severe AS, LBBB, HCM, MI
7
Q
MR auscultation
A
- Holosystolic murmur
- Absence of S1
- Systolic thrill at apex
- Wide S2 split.
(S3 in case of LV dysfunction)
8
Q
AR
A
Decrescendo Diastolic murmur (bisfreiens murmur), heard at base of heart.
Increased with hand grip.
S4.
Austin flint murmur.
Widening of pulse pressure.
Increased SV
Increased LVEDV
Dilation and eccentric hypertrophy
In chronic increased preload and afterload:
- Traube sign: “pistol shot over the femoral”.
- duroziez.
9
Q
Hypertension urgency
A
Systolic > 180 or Diastolic > 120.
No sign of target organ damage.
10
Q
Hypertension emergency
A
Systolic > 180 or Diastolic > 120 + Signs end organ damage:
Papilledema, MI, Microangiopathic hemolytic anemia, eclampsia, aortic dissection, stroke and encephalopathy.
11
Q
Hypertension emergency Tx.
A
Reduction of mean arterial blood pressure in 25% in up to 2 hours -OR- Reduce to 160/100.
Drugs: Nitroprusside, Labetalol, Nicardipine.
( Labetalol & Nicardipine are good for encephalopathy ).
No encephalopathy- slower decrease in BP with Captopril, Clonidine, Labtobel.
12
Q
Ischemic stroke + hypertension: Tx indication-
A
only if BP above 220/130
13
Q
Hemorrhagic stroke + hypertension: Tx. indication-
A
only if BP above 180/130
14
Q
Contraindicated for thrombolysis
A
Systolic BP > 185
15
Q
Cardiac tamponade
A
Beck’s triad :
- Hypotension
- Muffled (distant) heart sounds.
- JVD
Additional findings:
pulsus-pardoxus, low voltage ECG, tachycardia.
Xray- enlarged heart.
16
Q
Aortic valve replacement in ASYMPTOMATIC patients with AS
A
- abnormal response to treadmill exercise. (Class IIa)
- rapid progression of AS.
- very severe AS- Jet flow >5m/s or mean gradient >60 mmHg and low operative risk. (Class IIa)
- LVH in the absence of systemic HTN.
- valve area < 1 cm2 or < 0.6 cm2/m2.
17
Q
Aortic valve replacement in patients with AR
A
- symptomatic patient.
- asymptomatic patient with LVEF <50%.
- asymptomatic patient with LVESD > 50mm
- asymptomatic patient with LVEDD > 65mm
- asymptomatic patient with previous cardiac surgery.
18
Q
Surgical indication in AS
A
- symptomatic patient. (Class I)
- asymptomatic patient with valve area < 1 cm2 or < 0.6 cm2/m2.
- asymptomatic patient with LV systolic dysfunction with EF <50%. (Class I)
- patient with bicuspid aortic valve and aortic root aneurysm.
19
Q
NSTEMI Tx.
A
Aspirin load!
Improved? PCI within 24hrs.
No improvement? immediate PCI.
20
Q
Cardiac scan test
A
Combined with stress test (exercise- treadmill or pharmacological- dipyridamole / adenosine).
These drugs will cause vasodilation, which will be limited in unhealthy coronary arteries = Steal effect.
21
Q
Stress echo (+ECG)
A
For assessment of wall motion abnormalities.
Not suitable for patient with LBBB (can mimic wall motion abnormalities).
22
Q
Cardiac CT
A
An alternative for cardiac scan, but it is performed without stress.
23
Q
Thallium stress test
A
- Pre-excitation (WPW).
- ST depression > 1mm at rest.
- LBBB.
- Paced ventricular rhythm.
24
Q
Pharmacological stress test
A
Dipyridamole / Adenosine Indications: 1. Peripheral vascular disease. 2. Dyspnea on exertion. 3. De-conditioning.
25
Risks for peri-partum cardiomyopathy
1. Increased maternal age
2. Increased parity (multiple pregnancies)
3. Twin pregnancy
4. Malnutrition
5. Tocolytics
6. Preeclampsia
26
Acute MR
Causes:
1. MI
2. IE
3. Blunt chest trauma
Tx. Nitroprusside.
27
Chronic MR
Causes:
1. Cardiomyopathy: dilated/hypertrophic
2. MVP
3. Rheumatic heart disease
4. Annular calcification
5. Congenital valve defect
Tx. Vasodilators: ACEi, Dihydropyridine CCB (e.g. nifedipine), Hydralazine.
28
MR surgical indications
1. Symptomatic patient
2. New onset a.fib + PAH
3. Asymptomatic: LVEF<60% or LVESD>40mmHg
29
PE
1. unexplained shortness of breath (most common- earliest sign is exertional dyspnea).
2. Signs and symptoms of DVT.
3. Hypoxemia (V/Q mismatch - improved with O2)
4. ECG: sinus tachycardia, S1Q3T3, T inversion V1-V4.
5. Plasma troponin can be increased due to RV microinfarctions.
6. Elevated D-dimer.
30
PE diagnosis
Low likelihood: D-dimer. If D-dimer positive>>CTA.
| High likelihood: CTA.
31
Tx. of VT after STEMI
Stable- IV Amiodarone / Procainamide.
| Unstable / failure pharmacological Tx: Synchronized electrical cardioversion.
32
Fffects of BB in MI patients
1. Reduce pain.
2. Decrease infarct size.
3. Decrease serious ventricular arrhythmia.
33
DOAC / NOAC - contraindications
1. Valvular origin a.fib.
| 2. Renal failure.
34
New onset A. fib in unstable patient
```
symptoms:
1. Hypotension
2. Pulmonary edema
3. Angina
Tx. - synchronized cardioversion.
```
35
New onset A. fib in stable patient
Tx. Rate control (BB, non-dihydropyridines: diltiazem and verapamil, digoxin).
Anticoagulation: Warfarin / NOAC.
36
Paradoxical splitting
Delay closure of aortic valve.
| Can be auscultated in: LBBB, aortic stenosis, hypertrophic cardiomyopathy, MI.
37
Kussmaul sign
increase (or no change) in JVP during inspiration (due to low RV compliance).
e.g. constrictive pericarditis, restrictive cardiomyopathy , RV-HF, massive PE, TS, right MI.
38
Constrictive pericarditis - signs
1. Kussmaul sign.
2. Pericardiac knock.
3. S3.
4. Dyspnea.
5. Paradoxical pulse.
39
Constrictive pericarditis - etiology
idiopathic, viral, TB
40
High output heart failure
1. Metabolic- thyrotoxicosis.
2. Nutritional- beriberi.
3. Excessive blood flow requirements: severe anemia, AV-shunt, paget disease, acromegaly.
41
Chemotherapeutic Drugs causing cardiomyopathy
1. Doxorubicin / Danorubicin / Hydroxyrubicin.
| 2. Cyclophosphamide (myocarditis).
42
Indications of ICD implantation for prevention of SCD
1. Septum thickness > 30mm
2. Family history of SCD
3. Non-vagal syncope with or after exertion.
4. Documented non-sustained VT
5. History of cardiac arrest or sustained VT
6. Abnormal BP response to exercise.
43
PAH due to CHRONIC thromboembolism
Dx. V/Q scan (better than CTA).
| Tx. Thrombectomy.
44
Tx for massive acute PE
Thrombolysis.
45
MS - indications for anticoagulation
1. A.fib
2. History of thromboembolism (DVT, stroke, MI).
3. Patients with sinus-rhythm and left atrial enlargement.
46
Renin secretion stimulation
1. Decrease NaCl transport to the loop of Henle.
2. Decrease pressure within the renal Afferent arterioles.
3. Stimulation of beta-1 receptor on JG apparatus via sympathetic nervous system.
leads to RAAS activation and HTN.
47
Beri-Beri
Caused by thiamin (vit B1) deficiency.
| Associated with high output HF, tachycardia and elevated bi-ventricular filling pressure.
48
Severe MS
1. Mitral valve area <1.5cm2.
49
Surgical procedures for MS
1. Percutaneous Mitral Balloon Commissurotomy (PMBC)- preferred in case of adequate valve or no clot.
2. MVR.
50
Acute HF Tx.
1. Diuretics.
2. Vasodilators.
3. Opiates.
4. Oxygen.
5. Inotropes.
51
Indications for ICD implantation
1. EF <30%
| 2. EF <35% with NYHA II-III
52
When does CRT decrease mortality?
1. NYHA III-IV
2. QRS >149ms
3. LBBB
4. HFrEF.
53
TAVR (Trans-catheter Aortic Valve Replacement) - complications
1. Arrhythmia (post procedure heart block).
2. Para-valvular aortic regurgitation.
3. Increase risk for stroke.
54
Risk stratification for SCD
Cardiac MRI
55
Poor prognosis of stress test
1. Decrease BP during exercise.
2. ST depression of 0.2mV (2mm) on low work load.
3. Chest pain with minimal exercise.
4. ST depression above 5 min after finishing.
56
Positive stress test
ST depression > 0.1mV (1mm) for 0.08 seconds, with downsloping.
57
Congenital heart diseases associated with Down syndrome
ASD, VSD
58
Congenital heart disease associated with Lithium exposure in-utero
Ebstein anomaly
59
Congenital heart disease associated with DeGeorgie syndrome
Truncus arteriosus
60
Congenital heart disease associated with Rubella
PDA
61
Congenital heart disease associated with Turner syndrome
Bicuspid aortic valve, Coarctation of aorta
62
Most common complication of STEMI that causes in-hospital death?
Pump-failure.
63
AAA - Dx.
Abdominal US: abdominal pulsatile mass.
64
Etiologies for HFpEF
1. Hypertrophy.
2. Aging.
3. Restrictive cardiomyopathies (amyloidosis, hemochromatosis, sarcoidosis).
4. Fibrosis.
5. Endomyocardial disorders.
65
Hypertrophic cardiomyopathy - associated murmur?
Holosystolic, diamond shaped (crecsendo-decrecsendo). Heard all over the pericardium.
66
Dilated cardiomyopathy - Tx.
RAAS inhibitors: ACEi / ARBs, BB, Spironolactone.
| Nitrates are not part of the Tx. for dilated cardiomyopathy
67
Prognosis (by years) of patient with AS
1. CHF (1.5-2 yrs)
2. Dyspnea (2 yrs)
3. Angina pectoris / Syncope (3 yrs).
68
Hypoparathyroidism (Hypocalcemia - ECG finding)
Prolonged QT intervals, T waves will appear at the 2nd half of RR intervals.
69
Chronic renal failure patients with highly suspicion for PE - Dx.
Lung scan.
| CTA is contraindicated!!!
70
Risk factors for A.fib
1. Age.
2. Hyperthyroidism.
3. Diabetes.
4. Cardiac disease.
5. Sleep apnea.
6. Acute alcohol intoxication.
7. Hypertension.
71
Aortic dissection - Tx.
Initial Tx. - IV BB (Metoprolol, Labetalol, Propranolol, Esmolol).
Goal- Decrease SBP to 120 and pulse to 60.
Additional Tx. - Nitrates, ACEi.
72
Tx. of normotensive patient with bilateral PE
Hepatin
73
Leading cause of descending thoracic aortic aneurysm?
Atherosclerosis
74
Aortic aneurysm in patient with Marfan syndrome (location)?
Ascending aorta.
75
LBBB + chest pain = ?
ACS.
| Tx. Aspirin (improves prognosis and decreases mortality), BB, ACEi/ARBs, P2Y12i (Clopidogrel), statins.
76
Accelerated idioventricular rhythm
Ventricular complexes + Capture beats + Fusion beats.
77
Atrial fibrillation with aberrant conduction - ECG?
Wide complex QRS.
78
TR
Systolic murmur.
| Increased with Inspiration (Carvallo sign).
79
Thiazide - SE
1. Hyponatremia.
2. Hypokalemia.
3. Insulin resistance.
4. Hyperuricemia.
5. Hypercalcemia.
6. Hypocalciuria.
80
IVC filter indications
1. CI for anticoagulation.
| 2. Recurrent venous thrombosis despite treatment.
81
MVP - murmur
1. Mid systolic click.
2. Increase with Valsalva.
3. Decrease with squatting
82
Effects of maneuvers on cardiac murmurs: Inspiration
↑ RV preload, ↓ LV preload.
1. ↑ Intensity of murmurs arising from the right side of the heart (TS, TR, PS, PR).
2. ↓ Intensity of murmurs arising from the left side of the heart (EXCEPT: HOCM, MVP - increased intensity).
83
Effects of maneuvers on cardiac murmurs: Valsalva maneuver / Standing
↓ RV preload, ↓ LV preload, ↓ LV afterload.
1. ↑ Intensity MVP (with early midsystolic click), HOCM.
2. ↓ Intensity of murmurs arising from the left side of the heart (EXCEPT: HOCM, MVP - increased intensity).
84
Effects of maneuvers on cardiac murmurs: Squatting
↑ RV preload, ↑ LV preload, (↑ LV afterload).
1. ↑ Intensity of all murmurs ((EXCEPT: HOCM, MVP - increased intensity).
2. ↓ Intensity of MVP (with late midsystolic click) and HCM murmurs
3. Tetralogy of Fallot: The severity of tet spells and the associated murmurs decrease with squatting.
85
Effects of maneuvers on cardiac murmurs: Hand grip
↑ LV afterload, No effect on RV and LV preload.
1. ↑ Intensity of murmurs resulting from backward flow of blood in the left side of the heart (e.g., AR, MR, VSD, MVP -with late midsystolic click).
2. ↓ Intensity of murmurs associated with forward flow of blood in the left side of the heart (e.g., MS, AS, HOCM).
