Cardiology Flashcards
A 55 year old man presents for an initial eye exam. He feels well, has no complaints and has not seen any doctors for at least 5 years
You check his blood pressure and find it is 152/94
A) Make the diagnosis of hypertension
B) Examine his eyes and be alert for hypertensive findings
C) Send him to an emergency room now
D) Call his PCP and demand that he get seen today
B) Examine his eyes and be alert for hypertensive findings
To make a diagnosis of HTN you should have a series of elevated blood pressures from his history over time,
one blood pressure reading isn’t enough to diagnose for HTN. He could be anxious which is why there is a spike in high blood pressure. You do want him to have a f/u to have the blood pressure repeated since 152/94 is pretty high.
If you see A/V nicking or EKG findings with this patient, it may be due to HTN then you can make the diagnosis for hypertension
There are three things where you can make a diagnosis for HTN:
- Mild-moderate degree of a series high blood pressure
- sky high blood pressure
- when there is end organ effects of HTN + the reading
BP level is not at an emergency level
Should be seen by PCP in a few weeks
A 55 year old man presents for an initial eye exam. He feels well, has no complaints and has not seen any doctors for at least 5 years
You check his blood pressure and find it is 152/94
He finds a PCP with the help of your office staff and is seen 5 days later. His BP is 146/92. Which of
the following does his PCP do?
A) Diagnose whitecoat HTN
B) Obtain an EKG to look for LVH
C) Call you to ask about your funduscopic findings
D) Discuss lifestyle management
B) Obtain an EKG to look for LVH
C) Call you to ask about your funduscopic findings
D) Discuss lifestyle management
White coat HTN- If there are no end organ effects then you can have them check their blood pressure out of the office. Patients can self test their blood pressure with a arm blood pressure cuff and then have a f/u in the office. This person has two high BP that is consistent in the office so it’s not a whitecoat HTN. It may be HTN.
If there is a LVH then that can conclude that this pt does have HTN. EKG is a simple office test and worth doing
You should send a summary report to PCP. It is never too early to discuss lifestyle management especially HTN - think about sodium. You should consider healthy eating and calories. Sodium should be kept at 2000mg a day
A 55 year old man presents for an initial eye exam. He feels well, has no complaints and has not seen
any doctors for at least 5 years
You check his blood pressure and find it is 152/94
The patient asks why he developed hypertension. You explain that causes of HTN can include:
A) Renal artery stenosis
B) Undetermined factors (essential HTN)
C) Pheochromocytoma
A) Renal artery stenosis
B) Undetermined factors (essential HTN)
C) Pheochromocytoma
Explanation
HTN deals with two types:
Essential hypertension- combination of factors : lifestyle, genetic factors, environmental, physiological factors.
No one thing will reverse it in a targeted way
Secondary hypertension- single items/issues, that can contribute to elevated bp due to hormonal factors, stimulants, antidepressants, OTC meds
Renal artery stenosis- The kidney is not getting a normal blood flow so it senses volume deficit and it responds as if you are dehydrated to respond and do everything it can to increase BP. But in fact the adequate pressure is getting through and the kidney can’t see that proper pressure. So often fixing the artery
stenosis can fix the secondary hypertension.
Pheochromocytoma- Due to catecholamine surge from adrenal tumor that can also trigger elevated blood pressure- facial flushing and headache can occur. You want to elicit a the history that can be concerning
A 55 year old man presents for an initial eye exam. He feels well, has no complaints and has not seen
any doctors for at least 5 years
You check his blood pressure and find it is 152/94
The patient has additional evaluation to look for end organ effects of HTN which can include
A) Electrocardiogram (EKG) to assess for left ventricular hypertrophy
B) Echocardiogram to assess for LVH
C) Creatinine blood test to assess for renal disease
D) Eye exam to evaluate for focal arteriolar narrowing
E) Blood testing for hyperglycemia
A) Electrocardiogram (EKG) to assess for left ventricular hypertrophy
B) Echocardiogram to assess for LVH
C) Creatinine blood test to assess for renal disease
D) Eye exam to evaluate for focal arteriolar narrowing
A) True
B) Good to access True. but not ideal because it is expensive
C) Renal can be both secondary or chronic kidney disease creatinine blood test for CKC is needed.
Creatinine can access for end organ effects and secondary effects to HTN
D) True
E) False; folks with DM do have a tendency to develop HTN. Hyperglycemia with DM is associated with
risk of heart attacks and strokes, but HTN is also a risk factor for heart attacks and strokes.
Hyperglycemia by itself however does not cause HTN
A 55 year old man presents for an initial eye exam. He feels well, has no complaints and has not seen
any doctors for at least 5 years
You check his blood pressure and find it is 152/94
You discuss medication to treat high blood pressure. Consideration by key drug classes are.
Regarding beta blockers:
A) Useful for patients with angina
B) Useful for patients with bradycardia
C) Useful for patients with congestive heart failure
D) Useful for patients with HTN
E) Useful after MI
F) Useful for patients with asthma
G) Should never be used in diabetes
A) Useful for patients with angina
D) Useful for patients with HTN
E) Useful after MI
A) (decrease myocardial oxygen demand) beta blockers will slow down your heart rate,
B) patients who start out with slow heart rate, beta blockers can cause bradycardia so it would probably
be best to not put patients with slow heart rates on beta blockers
C) Congestive heart failure- squeezes everything it can to help the failing heart (sympathetic overdrive and works too hard) and sometimes it can go too far and will stop or slow down – staying in diastole for a longer time. So beta blockers will decrease contractility too much and slow it down too much (so if beta blockers were to be used with patients ith congestive heart failure it’ll have to be used carefully, however it’s not an ideal treatment)
D) Beta blockers are effective anti hypertensives but not first line blockers, there are better first line therapies out there: ace inhibitors, diuretics. Useful if patients have multiple symptoms as well as HTN that can be solved with a beta blocker (example MI + High HTN).
E) Helps decrease reinfarction after MI
F) When patients have asthma they have airway bronchoconstriction. There is constriction of the airways,
the narrow airways have a whistling sound. Beta agonist inhalers can open up the airways. But beta blockers should be used carefully with people who have asthma. If someone has asthma but has MI that’s when you should need a beta blocker if you use it carefully, however avoided if possible.
G) With someone with DM or is insulin dependent : Insulin increases risk of hypoglycemia. The counter regular hormones are basically activated to increase glucose output to counteract hypoglycemia. If you have a catecholamine surge– when you get scared for example or running at a gym you are jumpy–
these may be hypoglycemic symptoms. Beta blockers block the sympathetic system, so people who are hypoglycemic will be unaware that they have it because the symptoms for it will be blocked –
(causes hypoglycemia unawareness)
There is a slight decrease in heart rate with beta blockers but it is on a case by case basis. When putting a
patient on beta blockers make sure to monitor carefully and include the PCP.
Ace inhibitors are effective for:
A) Aortic regurgitation
B) Post-MI management
C) Hypertension
D) Diabetic renal disease
E) Reducing afterload
A) Aortic regurgitation
B) Post-MI management
C) Hypertension
D) Diabetic renal disease
E) Reducing afterload
Explanation
A) Pressure in your aorta is your bp – aortic afterload, ace inhibitors decrease this. The higher the pressure in the aorta the more blood pushed back into that aortic regurgitation. It will decrease afterload and help with forward flow. Ace inhibitors however are not helpful with aortic stenosis.
B) Helpful after MI since there is heart muscle death after MI. The heart will remodel after the infarction (creates scars). Remodeling can be harmful and cause aneurysms but ace inhibitors can help with remodeling and decrease risks and harm.
C) True
D) Decreases progression of diabetic renal disease with ace inhibitors.
E) Decreases pressure as the heart is in systole injecting blood, helps aortic regurgitation
Diuretics
A) Can cause edema
B) Should not be used in HTN with DM
C) Require electrolyte monitoring
D) Cannot be combined with other antihypertensives
C) Require electrolyte monitoring
A) Treats edema does not cause it
B) Diuretics are antihypertensives and can be used with people who also have DM
C) Need to be monitored for kidney function as well as monitoring creatinine
D) Diuretics are good add on therapies
Consider the calcium channel blocker family of drugs; clinical effects may include:
A) Bradycardia
B) Tachycardia
C) Lower BP
D) Edema
A) Bradycardia
C) Lower BP
D) Edema
A) True for verapamil and dilitiazem
B) Overall false only limited are true; increases myocardial oxygen demand
C) Antihypertensive, lowers BP so true
D) True for dihydropiridines
Alpha adrenergic blockers can be used to treat:
A) HTN
B) Congestive heart failure
C) Urinary symptoms in men with prostatic hyperplasia
D) Orthostatic hypotension
A) HTN
C) Urinary symptoms in men with prostatic hyperplasia
Can improve urinary flow in men, antihypertensive, relaxes vascularature and peripheral vessels can’t constrict. Orthostatic htn can happen with alpha blockers, and can cause light headedness from the peripheral vessels not being able to constrict.
A) True
B) False
C) These people placed on alpha blockers can
D) It causes orthostatic hypotension and does not treat it. False
This 55 yo patient has now been diagnosed with High blood pressure which is a cardiovascular risk factor.
Which of the following data are also important for cardiovascular risk assessment?
A) Ask him about family history
B) Ask about smoking status
C) Check blood glucose
D) Check a cholesterol level
E) Check his BMI
A) Ask him about family history
B) Ask about smoking status
C) Check blood glucose
D) Check a cholesterol level
E) Check his BMI
Explanation
A) Always ask about a patient’s family history to see what can be past down especially heart disease
B) Smoking is a high risk for cardiovascular disease, stopping smoking is the best to help with a patient’s health. Stop and counsel them at that moment
C) Make sure they are screened for dm since its a comorbidity for cardiovascular issues. Can be helpful to provide counsel and treatment
D) Definitely comorbidity for cardiovascular disease and stroke
E) Very important because it is strongly correlated with cardiovascular risk. Patient with obesity/ elevated BMI can increase risk for many diseases.
Cholesterol treatment goals:
A) Depends upon the initial (pre-treatment) cholesterol level-
B) Should be based upon the individual patient’s cardiovascular risk profile
C) Can be influenced by the presence of diabetes
D) Will determine the dose of drug used in treatment
A) Depends upon the initial (pre-treatment) cholesterol level- (partially true)
B) Should be based upon the individual patient’s cardiovascular risk profile
C) Can be influenced by the presence of diabetes
D) Will determine the dose of drug used in treatment
A) Kind of depends if it’s true or not. This depends on the different risk factors and risk profiles that this patient has.
You can have two groups - cholesterol treatment is dependent on risk factors and other group where it depends on their sky high cholesterol
B) Depends on the patient’s cardiovascular risk profile
C) DM increases the risk factor
D) someone who is at high risk will need to be at high dose of medication for lipid lowering
His PCP initiates a statin (HMG CoA reductase inhibitor) drug. WHich of the following is/are true:
A) Useful to lower LDL cholesterol
B) Useful to decrease cardiovascular risk for secondary prevention
C) Useful to decrease cardiovascular risk for primary prevention
D) Have few drug interactions
E) Require monitoring for muscle pain and soreness
A) Useful to lower LDL cholesterol
B) Useful to decrease cardiovascular risk for secondary prevention
C) Useful to decrease cardiovascular risk for primary prevention
E) Require monitoring for muscle pain and soreness
Secondary prevention - patient already had heart attack
Primary prevention - patient who does have high cholesterol but no previous heart attacks
E. side effects of statin - muscle inflammation and soreness. Monitoring is important
Thinking about cardiovascular risk…
Artherosclerotic risk factors can present with findings in other organ systems. Select true if the finding below is
a manifestation of an atherosclerotic risk factor:
A) AV nicking on eye exam
B) Roth spots on eye exam
C) Xanthelasma
D) non - proliferative diabetic retinopathy
E) Hollenhorst plaques
A) AV nicking on eye exam
C) Xanthelasma
D) non - proliferative diabetic retinopathy
E) Hollenhorst plaques
B) roth spots classically associated with endocarditis- leukemia as well. However not exclusively endocarditis.
D) presence of diabetic retinopathy would should cardiac risk since dm itself is a risk
E) manifestations of arterio emboli
A 55 year old man presents for an initial eye exam. He feels well, has no complaints and has not seen
any doctors for at least 5 years
You check his blood pressure and find it is 152/94
He asks about taking aspirin, which:
A) Has been demonstrated to prevent heart attack in all individuals at risk
B) Has few adverse effects and should be considered for prophylactic therapy by most of the american
population
C) Reversibly inhibits platelet aggregation
D) Has no effects on the gastric mucosa (lining)
E) Can prevent hemorrhagic stroke
A) Has been demonstrated to prevent heart attack in all individuals at risk
C) Reversibly inhibits platelet aggregation
B) false because aspirin is well tolerated but if gastric bleeding occurs that is still a big risk, with low dose it is still going to cause side effects
C) main difference is aspirin is irreversible as compared to ibuprofen where anti platelet effects from ibuprofen will usually disappear
Aspirin can prevent colon cancers and strokes. Major harm is bleeding, especially GI bleeding, causing gastric
ulcers.
E) only prevents thrombotic stroke, aspirin actually increases hemorrhagic strokes
A 55- year old male presents to an emergency room with chest pressure radiating to his left arm with
nausea
A) Sounds like heartburn, begin outpatient treatment and he should follow up in 24-48 hours
B) Obtain an electrocardiogram
C) Administer aspirin
D) Assess for cardiovascular risks
B) Obtain an electrocardiogram
C) Administer aspirin
D) Assess for cardiovascular risks
B) will look at the risk for ischemia , can be heartburn but you wont know that unless you do an
electrocardiogram to rule it out.
C) acute thrombotic crisis aspirin will help
In diagnosing myocardial infarction:
A) ST segment elevation is associated with acute myocardial infarction
B) Atrial fibrillation is always seen in acute MI
C) Non- Q wave MI is associated with with risk for further extension of the MI and aggressive
treatment may be appropriate
A) ST segment elevation is associated with acute myocardial infarction
C) Non- Q wave MI is associated with with risk for further extension of the MI and aggressive
treatment may be appropriate
A) ST segment elevation = acute MI
B) Not always seen in acute MI, just sometimes
C) Non- Q wave MI - region with blood vessel that has been blocked, some tissue has died there so there’s a MI , but luckily an artery opened up and not all the tissue died. However, the artery can be closed up again. A stent should be used to save the surrounding tissues that are still alive
Signs of angina
A) Don’t occur in patients with diabetes
B) Include anterior chest pressure
C) Can differ between men and women
D) Can radiate to the arm or jaw
E) May be relieved with nitroglycerine
F) Often get worse with deep breaths
G) Ischemia (or infarction) of papillary muscles can lead to acute mitral regurgitation
B) Include anterior chest pressure
C) Can differ between men and women
D) Can radiate to the arm or jaw
E) May be relieved with nitroglycerine
G) Ischemia (or infarction) of papillary muscles can lead to acute mitral regurgitation
Chest pressure or jaw pain improving with nitroglycerine can be relieved with angina Chest wall abnormalities or lung tissue around the blood pressure is what is occuring if it gets worse with deep
breath- not a acute cardiac ischemia
Unstable angina
A) Represents slow growth of an arterial atherosclerotic plaque
B) Can be safely managed at home
C) Includes chest pressure at rest
D) May progress to MI and requires aggressive management
C) Includes chest pressure at rest
D) May progress to MI and requires aggressive management
A)in stable angina there is a plaque that is stable, given the level of exertion it max the level of the artery
unstable angina - rapid growth of the plague, less exertion is max the amount of blood flow passing through.
The artery is so unstable you don’t need exertion to trigger it.
B) high risk for vascular occlusion and may progress to MI
Atherosclerotic lesions
A) Are unlikely to trigger a heart attack until they exceed 90% of the lumen diameter
B) Consist entirely of cholesterol and triglyceride
C) Trigger platelet adhesion when rupture
D) Can develop early in life when risk factors are present
C) Trigger platelet adhesion when rupture
D) Can develop early in life when risk factors are present
Explanation
There is lipid and plaque in the artery, a plaque occluding 30% of the lumen and ruptures with platelet
deposited and clots can cause occlusion 100% causing MI. Ruptures can cause MI even if the lesion is small.
C) aspirin inhibits the platelet adhesions
Bacterial endocarditis:
A) Can manifest with a new cardiac murmur
B) Can contribute to aortic valve disease
C) Can result in fever
D) Can manifest with Roth spots on exam
E) Can be treated with beta blockers
F) Is often caused by gram positive bacteria (like staph or strep)
G) Is always acquired in a health care setting
A) Can manifest with a new cardiac murmur
B) Can contribute to aortic valve disease
C) Can result in fever
D) Can manifest with Roth spots on exam
F) Is often caused by gram positive bacteria (like staph or strep)
Bacterial endocarditis can cause an infection and erode the valve of the heart causing a murmur.
Can be acquired in the health care setting but also community settings.
Regarding arrhythmias ( true /false)
A) Atrial fibrillation usually causes bradycardia
B) In some situations, ventricular fibrillation can be treated with medications and anticoagulations if monitored closely
C) Acute myocardial infarction can trigger an arrhythmia
D) Stroke risk in Atrial fibrillation can be assessed with a scoring system (e.g. CHA2DS2VASc) to determine optimal therapy
E) Ventricular fibrillation results in a rapid, irregular pulse
C) Acute myocardial infarction can trigger an arrhythmia
D) Stroke risk in Atrial fibrillation can be assessed with a scoring system (e.g. CHA2DS2VASc) to
determine optimal therapy
A)False – usually tachycardia
B) False– venetricular fibrillation seen with sudden death so you need to shock the heart, theres no medical
way to treat it, you need defibrillation
C)True- can trigger a lot of arrhyhmias
D)True scoring system helps assess what degree of stroke they have to treat it
E)False - ventricular fibrillation is not a perfusing rhythm they are pulseless– they are at sudden death (fatal
arrhythmia most of the time)
Select the correct association(s):
A) Rheumatic fever- mitral stenosis
B) Marfan syndrome- mitral regurgitation
C) Aortic stenosis- ace inhibitor
D) Mitral stenosis- atrial fibrillation- stroke
A) Rheumatic fever- mitral stenosis
B) Marfan syndrome- mitral regurgitation
D) Mitral stenosis- atrial fibrillation- stroke
A)true- can cause a lot of valve syndromes
B)true
C)false counter productive, decreases the pressure that the body needs to perfuse the brain
D)true- need an anticoagulant to help
Regarding heart failure:
A) Heart failure with reduced EF (HRrEF) and heart failure with preserved EF (HFpEF) cannot occur in
the same individual
B) Left and right heart failure can occur in the same individual
C) Heart attack is associated with HFpEF
D) LVH is associated with HFrEF
E) Pulmonary edema is a complication of heart failure
B) Left and right heart failure can occur in the same individual
E) Pulmonary edema is a complication of heart failure
**C and D are true IF you need to flip the heart failure types
A)False- people can have other risks factors that cause heart failure
B)true
C)false - heart attack is myocardial tissue death - impaired squeezing of the heart you have reduced EF,
D)false- LVH without infarction the thick heart muscle with years of untreated HTN , the heart can’t relax well,
heart can’t be filled and results in preserved EF
E)true- left ventricle not filling or working well can cause lung edema
Treatments for atrial fibrillation can include:
A) Digoxin for rate control
B) Beta blockers to prevent stroke
C) Aspirin when seen with mitral valve disease or hypertension
D) Calcium channel blockers for rate control
A) Digoxin for rate control
D) Calcium channel blockers for rate control
B)false- slow downs heart rate but does not prevent stroke- need a anticoagulant
C)false- aspirin - anticoagulant and decrease risk for clotting events. Aspirin however is not strong enough
anticoagulant to prevent stroke when there is mitral valve disease - only good for low afib.
