CARDIOLOGY Flashcards

Question

What is dx for LBBB

Answer 1

1) left axis deviation (I, avf) 2) wide QRS (>3 boxes) 3) V1: neg QRS, with pos ST 4) V6: pos QRS, with neg ST

Answer 2

1) avl: R >12mm 2) V1 Swave + R wave in V5/V6 > 35mm 3) avL R wave + V3 s wave >28mm M/20 mm F

Answer 3

HCM -autosomal dominant -thickened left ventricle -murmur (like AS): crescendo descrendo systolic murmur along LEFT sternal border -Louder w/standing or Valsalva -Decr with sustained handgrip -Tx: BB, CCB -ICD: arrhythmia, SCD in two 1st family members, myocardium thickness >30mm (>3cm) anywhere in left ventricle, unexplained syncopal episode EKG findings: -LVH, left atrial enlargement -deeply inverted T waves (V3-V6) mimics ischemia

Answer 4

Description: tear in DESCENDING aorta only (distal to the subclavian artery) Dx: CTA Tx: IV BB (1st line) -->CCB (if BB contraindicated 2/2 reactive airway dx)

Answer 5

-tear in ascending aorta, arch -Dx: CTA 1st (or TEE) Tx: emergent surgery;

Answer 6

Goal <130/80. There are TWO exceptions: (1) low risk pt w/ASCVD <10% and stage 1 HTN, goal can be <140/90 (also w/pre-eclampsia, pheo) (2) CKD pts, SBP goal <120 (also w/aortic dissection)

Answer 7

Severe incr in BP BUT pt is otherwise stable. -Tx: incr meds w/close outpt followup

Answer 8

THIS requires hospitalization. See sx/symptoms of end-org damage -blood pressire: >180/120

Answer 9

(1) LDL ≥ 190 : high-intensity statin (2) LDL 70-189 AND 40-75yrs and ASCVD ≥ 20%: high-intensity (3) LDL 70-189 AND 40-75yrs and DM : mod/high (4) Clinical ASCVD*: high *Clinical ASCVD: ACS, stable or unstable angina, coronary artery revascularization, stroke/TIA, or PAD HIGH intensity statin: 40-80mg atorvastatin, 20-40mg rosuvastatin **The 10-year risk for ASCVD can be categorized as low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%).

Answer 10

10-20mg atorvastain, 20-40mg simvastatin

Answer 11

Secondary HTN -seen in young female, fibromuscular dysplasia -Tx: ACE-I/ARB -Dx: renal u/s; definitive angio

Answer 12

(1) ACE-I/ARB (2) BB (3) Diuretics (4) SLG-2 inhibitor (5) Spironolactone **Blk pts: hydralazine+ isosorbide dinitrate

Answer 13

**BP control + diuresis (1) ACE-I/ARB (2) Diuretics (3) SLG-2 inhibitor

Answer 14

No, unless pt has h/o MI or angina.

Answer 15

1) renovascular: elevated renin, abd bruit, renal u/s for dx, ACE-I/ARB for tx 2) hyperaldostronism: low k, metab alk, low renin

Answer 16

-thiazide diuretics (chlorthalidone), ACE-I/ARB, CCB (amlodipine)

Answer 17

1st line tx is amoxicillin (2g po 15mins prior to dental procedure) IF PCN allergy, then: -clindamycin -cephalexin -azithromycin or clarithyromycin

Answer 18

- Innocent murmur -Brief, vibratory, grade 1-3 midsystolic low-pitched murmur -heard at LL sternal border, sometimes radiates to cardiac apex -Louseds in supine and diministhes in intenstity w/sitting or standing up -Seen in young adult (often before they participate in comeptitice sports, get hx )

Answer 19

nonselective alpha-blockers--relax smooth muscle in bladder and prostate, often rx for BPH --BUT orthostatic hypotension esp common with 2 agents--> doxazosin, terazosin *Other alpha blockers (tamsulosin, silodosin) are mor selective for prostate tissue **NOTE: BB may case bradycardia or exacerbate hypotension BUT does not generally cause profound orthostatic HTN

Answer 20

Vasovagal: syncope caused by reflex-mediated reduction in vascular tone, heart rate, or both.

Answer 21

No. Guidelines recommend no perioperative testing in pts who's functional capacity is >4 METS (metabolic equivalents). Pts who can climb 1 flight of steps are considered to be at this level. Of note, do exclude active cardiac issues ( unstable coronary dx, HF with volume overload BUT if surgery emergency, can bypass)

Answer 22

-Sx: angina, HF, syncope (w/exercise) -Murmur: mid-to late peaking (diamond shaped) ejection murmur +/- ejection click; decr absent S2 (2/2 decr mobility of aortic valve leaflets), paradoxical S2 split (becs stenotic valve closes AFTER pulmonary valve) -PE: carotid pulse (parvus et tardus--weak amplitude and delayed), S4 gallop, **murmur transmits to carotids--think AS. IF normal, consider aortic sclerosis -Prognosis: pt's w/symptomatic severe AS have 10% risk of suddent death. -Dx: echo (as w/all valvular heart dx) Tx: SAVR >> RAVR. Medical tx NOT effective

Answer 23

-chronic AR, MR -Use ACEI/ARBs for afterload reduction. You can use diuretics to tx sx od volume overload NOTE Surgery indicated for: (1) AR: Aortic valve REPLACEMENT (AVR) if (1) symptomatic severe AR (2) asx severe defined as LVEF <55% or LV enlargement with LV end-systolic diameter ≥ 50 mm (2) MR: valve REPAIR surgery if (1) symptomatic severe MR (2) Asx severe defined as LVEF <60% or LV enlargement with LV end-systolic diameter ≥ 40mm

Answer 24

Syncope -Definition: sudden transient loss of consciousness w/loss of postural tone followed by SPONTANEOUS recovery. Different from other types of loss of consciousness such as seizures or narcolepsy. CAUSES (1) neurocardiogenic (2) Cardiac (3) Orthostatic hypotension (4) Meds **a-blockers for BPH -->terazosin, prazosin

Answer 25

Neurocardiogenic syncope: (1) SX: dizziness/ prodromal featuers (n/w etc_ +/- myoclonic jerks mimicking seizure SUBTYPES: (1) Vasovagal. most common. Triggered by intense emotion, standing, ETOH, heat. Typically have prodrome (ie nausea/vomitting) (2) Situational. brought by SPECIFIC scenarios-cough, micturition, straining (3) Caroid sinus hypersensitivity. Dx with pause of >3sec during carotic sinus massage

Answer 26

Tilt=table used to diagnose neurocardiogenic syncope

Answer 27

Type A dissection (acending aorta) can cause =new AR =hemopericardium with TAMPONADE =inferior MI (due to invovlement of right coronary artery). -Dissection typically presents w/severe anterior chest pain +/- severe interscapulary back pain Don't be fooled --treat AS (CTA for dx, emergent surgery ) FIRST. NOT AR or MI....

Answer 28

1) Stroke -hemorrhagic ever/any -ischemic (past 3mos) 2) intracranial neoplasm 3) suspect aortic dissection 4) active bleeding 5) severe face/head trauma 6) neurosurgery/spine surgery (past 2 mos) 7) persistent severe HNT unresponsive to medical tx 8) active bleeding

Answer 29

(1) Acute STEMI (2) Coronary vasopastic (Prinzmetal) angina (3) Pericarditis (will also see PR DEPRESSIONS) **Don't forget about (1) early repolarization variant (<40yrs, J wave) (2) stress-induced (takotsubo) cardiomyopathy (3) LBBB (4) hypothermia (J wave aka Osborn wave)

Answer 30

Prinzmetal angina (aka coronary spasms_ -Def: coronary spasms cause vasospastic angina -Transient ST elevations -Tx: CCB, nitrates Microvascular angina -Def: Angina w/ischemic changes on cardiac stress test BUT visually normal coronary arteries on angiogram. Type of ischemia with No Obstructive Coronary Artery Disease (INOCA) -Dx: adenosine or acetylcholine provocation via intracoronary injection. Cardiac MRI perfusion imaging and cardiac PET can also be helpful REVIEW 1) DIFFUSE ST changes -->think pericarditis. LOOK for PR depressions 2) TRANSIENT ST changes-- > think prinzmetal. LOOK for coronary distribution BUT transient 3) ST elevations that are CONCAVE up (happy face) -IF diffuse (with PR depressions) --> pericarditis -IF young (<40yrs) and no reciprocal ST depressions + notching (V4/V5) think : EARLY repolarization 4) ST elevations CONCAVE dwn - -> STEMI -->IF visually normal angio -->microvascular angina

Answer 31

Use warfarin only Aortic: av INR 2.5 Mitral: INR 3.0

Answer 32

ACLS--for non shockable rhythm--give epinephrine ASAP. Remember to used CLOSED LOOP communication https://img.grepmed.com/uploads/10756/acls-management-adult-lifesupport-aha2020-original.jpeg

Answer 33

Atrial myxoma. Often composed of gelatinous material w/irregular borders Sx:stroke, TIA, syncope, arrithyma Definitive tx: surgical excision

Answer 34

AORTIC REGURGE (1) Chronic AR -2/2 valve deformity, Marfan -decsrendso diastolic, high-pitched -1st: afterload reduc: ACE-I/ARB -surgery(AV replacement): LVEF <55% (2) Acute AR -2/2 endocarditis, dissection -short diastolic murmur (NO bounding pulse); CO/BP LOW -1st: Urgent Surgery MITRAL REGURGE (1) Chronic MR -holosystolic murmur, heard @ apex, radiates to axilla -1st: afterload reduc: ACE-I/ARB -surgery(AV replacement): LVEF <60% (2) Acute MR -descrescrendo, systolic murmur @ apex -Urgent surgery **Note AS: murmur @ RUSB and radiates to carotids and also apex. MR heart @ apex and radiates to axilla

Answer 35

coronary thrombus **The most dangerous complication of Kawasaki is coronary aneurysm which over time can cause myocardial infarction 2/2 thrombosis. Rare complication men >>women KAWASAKI -rash (childhood) involves MOUTH -febrile illness, affects medium-sized vessels, manifests with: (1) fever (2) lymphadenopathy (3) conjunctivitis (4) RASH (palms & soles ) (5) erythematous mucosa (strawberry tongue)

Answer 36

With prolonged Qtc there is a tendency to develop polymorphic Vtach. If prolonged Qtx is from bradycardia, the polymorphic Vtach called Torsades.

Answer 37

Prolonged QTC: >450 ms 1) HYPOcalcemia 2) HYPOmagenesium 3) HYPOkalemia 4) TCA overdose 5) Several meds -antipsychotics -abx -antihistamies -opiods

Answer 38

Targeted temperature management

Answer 39

IF STABLE: amiodarone IF UNSTABLE -->cardioversion!! -hypotension -change in mental status -angina -PULMONARY EDEMA

Answer 40

Leads V1, V6 https://i.pinimg.com/originals/20/f4/b7/20f4b7c478c3a77bb083d0edc69bf843.jpg

Answer 41

WPW: - symptomatic AVRT with evidence of preexcitation on resting ECG (delta wave) -delta wave becs of "early conduction" via accessory path. -the accessory/bypass track conducts faster than AV node -AF occurs in 1/3 of pts TX -1st line therapy: ablation -Asymptomatic WPW conduction without arrhythmia (WPW pattern) does not require investigation or treatment. -AVOID SVT meds --BB/CCB/adenosine

Answer 42

1. V tach--most common Tx: IF unstable--cardioconvert. If stable-->amiodarone 2. SVT w/aberracncy. Expect to see LBBB or RBBB. Tx: AV nodal blocking meds: BB/CBB/adenosine 3. A fib with WPW. Rhythm is IRregular (becs of afib.) QRS wide becs of delta wave. NEVER give AV-nodal blocking meds (BB/CCB) becs can cause vfib.Tx: procainamide, synchronize cardioversion.

Answer 43

LBBB -conduction block of left bundle branch-->takes longer for left ventricle to contract -QRS> 120 ms (3 sm squares), widened EKG FINDINGS: -V1: NEGative QRS + ST elevation -V6: reverse of V1

Answer 44

EKG FINDINGS: -V1: Rabbit Ears 'RsR

Answer 45

(1) MITRAL VALVE PROLAPSE -mid-systolic CLICK +/- MR (2) MITRAL STENOSIS - diastolic rumble **MITRAL REGURGE -chronic: holo SYSTOLIC, constant murmur -acute: pan SYSTOLIC, decrescendo murmur @ apex

Answer 46

Assess LEVF after 40 days (~6wks) . AFter 40 days, if LEVF continues to be low (LEVF <=30%, then ICD may be useful)

Answer 47

Surgical repair indicated for: -aneurysm ≥ 5.5 cm OR - growing ≥ 5cm/year

Answer 48

(1) Lifestyle modifcations -low wt, exercise-->for all afib pts -Tx of OSA, DM, HTN, HLD for all pts (2) Anticoagulation -Use CHA2 DS2 VASc to risk stratify -(A) 65-74 is 1 pt; A2>=75 is 2 pts -Men >=2, Women >= start, usu DOACs (unless bare metal stent) (3) Rhythm vs Rate control

Answer 49

1) Exercise stress testing preferred -no if LBBB, pacemaker,can't excercise 2) Pharmacological stress testing -Dobutamine-->no if pacemaker -adenosine -->MPI only. no if brochospams

Answer 50

AV: 2.5 MV: 3.0

Answer 51

1) hemodynamically unstable-->cardioversion (electrical/pharmocologic) *IF duration unknown or afib >48hrs-->r/o thrombus by (1) TEE >> (2) anticoagulate 3wksprior 2) stable afib: rate vs rhythm control +/- anticoagulation (risk stratification using CHA2 DS2 VASc) *valvular always use warfarin 3) Afib +PCI: dual therapy ONLY -clopidogrel +DOAC (NO aspirin)

Answer 52

1) hypokalemia 2) digitalis intoxication

Answer 53

-numerous studies have demonstrated superior symptom treatment with rate PLUS rhythm control compared with rate control alone. -because the long-term effects of rate-only control are unknown, rhythm control is often pursued in younger patients (aged <50 years) - A strategy of early rhythm control (within 1 year of diagnosis) among patients at high risk for adverse cardiovascular events was tested in the randomized EAST-AFNET 4 trial. -High risk was defined as age older than 75 years or a previous transient ischemic attack or stroke, or meeting two of the following criteria: age older than 65 years, female sex, heart failure, hypertension, diabetes, severe CAD, chronic kidney disease, and LV hypertrophy. -Early rhythm control (drugs or ablation) +RATE control superior in this population

Answer 54

1) Afib + PCI -DOAC +clopidogrel (NO aspirin) 2) Afib + CAD -rivoxaban (NO aspirin) 3) Afib in HF pts -rhythm control

Answer 55

-NARROW complex tachycardia. Can be grouped into: (1) REGULAR rhythm -sinus tachy: p b4 every QRS -AVNRT: p after/buried in QRS *sinus tachy usu 2/2 stress/fever/exercise etc -1st line tx: IV adenosine. IF recurrent CCB/BB (2) IRREGULAR rhythma -afib: irregular irregular -aflutter: see in VI, II, III, avF -MAT: diff p waves TX: -BB/CCB, adenosine, vagal *if STOPS w/adenosine--usu AVNRT/AVRT

Answer 56

TETRALOGY OF FALLOT (TOF) -most common congenital cause of cyanosis -4 defects: (1) large VSD (2) overriding aorta (3) RVH (4) pulmonary valve stenosis - pulmonary stenosis: RV hypertrophy, prominent jugular a wave, palpable right ventricular lift -Increased risk of endocarditis EISENMENGER -Severe PH with cardiac shunt reversal (right-to-left shunting) caused by long-standing, unrepaired VSD, PDA, or ASD. -Pregnancy absolute contraindication -Tx: heart-lung transplant

Answer 57

COARCTATION -Associated with bicuspid aortic valve (AS) -hear a systolic murmur in left infraclavicular region or over back -SX: diminished femoral pulses -DX: continuous murmur over back, "3 sign" CXR, LVH on ekg

Answer 58

1) HYPERkalemia 2) MI 3) intercerebral hemorrage **INVERTED T waves seen w/HCM.

Answer 59

1) digoxin 2) amiodarone 3) HYPOkalemia 4) bradycardia **Best seen in leads V1, V2 and after T wave**

Answer 60

1) No p waves 2) Inverted p waves -after QRS -before QRS

Answer 61

1) REGULAR wide complex -Vtach (tx amiodarone) 2) IRREGULAR wide complex -afib (WPW, w/aberrancy), aflutter 3) METABOLIC -TCA overdose (tx: IV bicarbonate) -hyperkalemia -severe acidosis **https://rushemergencymedicine.org/2019/08/09/wide-complex-tachycardia/

Answer 62

CARDIAC TAMPONADE (obstructive shock) *fluid in the pericardial sac, compresses heart -JVP: rapid x, blunted y descent -Sx: hypotension, elevated JVP, muffled heart sounds, CLEAR Lungs -Pulsux paradoxus: inspiratory fall in SBP CONSTRICTIVE PERICARDITIS (obstructive shock) *result of scarring and consequent loss of the normal elasticity of the pericardial sac -JVP: rapid x, y descent -Kussmaul sign: elevated JVP w/inspiration REMEMBER: 1) diastolic pressure equal in all 4 chambers for Tamponade and constrictive pericarditis 2) How do you tell the 2 apart--look at inspiration (JVP up/Kussmal/Constrictive vs SBP exaggerated dec/Pulsus paradoxus/tamponade); look at JVP waves (x descent only-tamponade; x and y descent- constrictive)

Answer 63

1) constricted pupils 2) neck pain 3) unilateral head pain *hypertensive patient, lk for cholesterol emboli on fundoscopic exam

Answer 64

ASD -fixed splitting of S2 -EKG: RBBB, r axis deviation -CXR: r heart enlargement

Answer 65

3rd pregnangy can be predisposing factor for aortic dissection -Dx: cTA -Tx: surgery, IV BB (labetalol)

Answer 66

-labetalol -CCB -meythldopa

Answer 67

AMYLOIDOSIS -restrictive sx (dyspnea, fatigue, HF--elevated JVD, edema,wet lungs) -increased wall thickness (low amplitude on ekg) -Dx: CMR imaging

Answer 68

Takotsubo CARDIOMYOPATHY -SPECIFIC CARDIOMYOPATHY: clinical syndrome associated with reduced LVEF, elevated cardiac enzyme levels, and signs of ischemia on ECG. typically occurs in older women and is usually precipitated by a stressful physical or emotional event -aka APICAL balloon syndrome w/preservation of basal wall -Cardiac imaging shows wall motion abnormalities that do not follow a coronary artery territory (typically, apical dyskinesis or ballooning) -Tx: symptomatic. Resolves in days to weeks with supportive care. PHEOCHROMOCYTOMA -also p/w apical wall ballooning w/preserved function of the base

Answer 69

ACUTE LIMB ISCHEMIA -akin to ACS -6 Ps -Tx: surgery PERIPHERAL ARTERY DX (PAD) -akin to CAD -Sx: claudication w/exercise -Dx: ABI (abn; =<0.9). >1.4 requires toe brachial index -Tx: ASA, statin + cilostazol (to improve EXCERCISE tolerance) + low-dose rivaroxaban (improve CARDIAC outcomes)

Answer 70

ICD CRITERIA FOR POST-MI PATIENTS: 1) >40 days since MI 2) or >3 months since PCI or CABG

Answer 71

1) RIGHT ventricular infarction -hypotension + CLEAR lungs + elevated JVP -dx: ekg (elevated ST in leav V4) -tx: IVFs 2) MECHANICAL complications -VSD, papillary wall, LV free wall rupture -->VSD/papillary wall: hypotension + PULMONARY edema +loud holosytolic murmur/thrill -->LV free wall rupture: SUDDEN hypotension + PEA -dx:echo (emergency) -tx: inatra-arotic balloon pump + afterload reductin (sodium nitroprusside) + diuretics -->emergency surgery 3)CArdiogenic shock -Tx: intra aortic ballon 4)

Answer 72

Urgent invasive treatment (within 2 hours) -indicated for: 1) hemodynamic instability 2) refractory chest pain 3) HEART FAILURE 4) ventricular arrhythmias.

Answer 73

TRUE. Fevers in pt w/ bioprosthetic valve-->be suspicious for ENDOCARDITIS -Order TEE to eval further. *Why ppx abx used for high-risk individuals

Answer 74

MAJOR -Positive blood clx - new valvular murmur - positive echo findings MINOR -heart condition/drug use -fever -embolic vascular phenomena -immunologic phenomena -positive blood clx not meeting major criteria DIAGNOSIS: -2 major -1 major, 3 minor - 5 minor

Answer 75

1) ATRIAL Myxomas ~ 50 yrs -usu in LEFT atrium -systemic sx (fever wt loss) +vascular occlusive sx -Tx: surgery 2) Papillary fibrolelastoma ~80 yrs -usu on surface of aortic or mitral valve -globular appearance on echo 3) ANGIOSARCOMA -MOST common -usu in RIGHT atrium +pericardial effusion -sx: dyspnea, SOB, poor survival

Answer 76

SCAD -MOST common cause of pregnancy-associated MI -Usu during 1st mo postpartum -Sx: chest pain + ekg findings -Echo: Regional wall motion abnormalities

Answer 77

eft ventricular systolic dysfunction recognized toward the end of pregnancy or in the months following delivery MEDS -Women with peripartum cardiomyopathy should be promptly treated with medical therapy that may include β-blockers, digoxin, hydralazine, nitrates, and diuretics. -ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists are teratogenic and should be avoided until after delivery

Answer 78

TRUE *In pregnant patients with a mechanical valve prosthesis, warfarin anticoagulation is preferred during the first trimester if the daily dose is 5 mg or less; intravenous unfractionated heparin or dose-adjusted low-molecular-weight heparin is preferred if the warfarin dose is more than 5 mg daily. CARDIAC MEDS CAN USE: BB, CCB, hydralazine, digoxin, adenosine, diuretics CONTRAINDICATED -ACE-I/ARBS, spironolactone

Answer 79

Permanent Pacemaker: -symptomatic bradycardia -high grade block (3rd degree, 2nd degree Type 2) ICD: (1)PRIMARY prevention: Post MI/ non-ischemic HF (≥40 days after MI) - EF ≤ 30% +optimal tx + HF sx (NHA II/III) - EF ≤ 35% +optimal tx + regardless of HF sx (2) SECONDARY prevention: -Sustained ventricular arrhythmias (>30 seconds) --VT/VF cardiac arrest (without a reversible cause) (3) Specific medical conditions: -Brugada syndrome w/syncope -inherited long QT syndrome not responding to β-blockers -Hypertrophic cardiomyopathy (IF Previous sudden cardiac death or sustained VT should receive an ICD CRT: *pacing both left/right ventricles -EF ≤ 35% + LBBB w/prolonged QT AND HF sx

Answer 80

The key difference between ICD and pacemaker: ICD - implantable device that sends out a shock when the heart beats way too FAST rate PACEMAKER - implantable device that sends out electrical pulses when the heart beats way too SLOW.

Answer 81

-Long QT syndrome may be inherited, but most are acquired. Patients may experience syncope or SCD as the result of ventricular arrhythmia. -Look for HYPOkalemia, HYPOmagnesemia, structural heart disease, medications, and drug interactions. -LOOK specifically for: (1) macrolide and fluoroquinolone antibiotics (especially moxifloxacin) (2) terfenadine and astemizole antihistamines (3) antipsychotic and antidepressants (4) methadone (5) antifungal medications (6) class Ia and class III antiarrhythmics

Answer 82

(1) HCM -Syncope, VF during exercise -EKG: LVH, inverted T waves (V3-V6) -Tx: BB/CCB, ICD, surgical myectomy (2) Brugada -Syncope during sleep -EKG: coved ST-elevation (V1-V3) Tx: ICD, catheter ablation (3) Long QT syndrome -Syncope during sleep, auditory triggers, and/or during exercise (depending on subtype) -EKG: QTc usually >460 ms; torsades de pointes -Tx: BB, avoidance of QT-prolonging drugs, ICD in selected patients (4) arrhythmogenic right ventricular cardiomyopathy/dysplasia -Syncope, palpitations -EKG: inverted T-waves (V1-V3), monomorphic VT, frequent PVCs -Echo: abnl RV size and function -Tx: BB, antiarrhythmic medications, catheter ablation, exercise abstinence (uniform)

Answer 83

1) hypotension 2) bradycardia 3) hyperglycemia 4) metabolic acidosis (2/2 inc lactate from tissue hypoperfusion) *lisinopril overdose:hypotension but NO bradycardia

Answer 84

-fatigue, n/v, headache -hyponatremia -tremor -xerstomia

Answer 85

DIAGNOSIS - ankle branchial index (<0.9 diagnostic for PAD) -IF ABI >1.4, toe brachial index -IF ABI nl but sx, exercise ABI TREATMENT -ASA -cilostazol: improve exercise tolerance -low-dose rivaroxaban: improve cardiac outcomes

Answer 86

-Any wide QRS tachycardia should be considered to be VT until proven otherwise. -In the presence of known structural heart disease, especially a previous MI, the diagnosis of VT is almost certain.

Answer 87

-Torsades de pointes is a specific form of polymorphic VT associated with long QT interval. -Torsades de pointes episodes are typically short-lived and terminate spontaneously, but multiple successive episodes may result in syncope or VF.

Answer 88

1) Idiopathic VT (NO identifiable structural heart disease): -1st line: BB, CCB 2) Structural heart disease (MOST common) -angiography and revascularization -catheter ablation if reccurrent -ICD if sustained or to prevent SCD 3) Acute treatment of sustained VT: -IF unstable: electrical cardioversion -IF Pulseless VT: electrical cardioversion -IF stable: IV amiodarone (also procainamide sotalol).

Answer 89

SCAD - MOST common cause of pregnancy-associated MI -Usus occurs in 1st month postpartum Coronary vasospasm -DIFFUSE and TRANSIENT ST elevations -CP at rest -Trop usu normal -can be assoc w/hemodynamic instability -Tx: CCB Microvascular angina -Angina w/ischemic changes on cardiac stress test BUT visually normal coronary arteries on angiogram. -Type of ischemia with No Obstructive Coronary Artery Disease (INOCA) -Dx: adenosine or acetylcholine provocation via intracoronary injection. CMR or cardiac PET also helpful to visualize MICRO lesions

Answer 90

Heart Transplant! - acceptable candidates for cardiac transplantation are generally younger than 65 to 70 years with no medical contraindications and have good social support and adherence -ICD placement is currently indicated in patients with ejection fraction less than 25% and poor exercise tolerance despite maximally tolerated therapy, with either a high predicted 1- or 2-year mortality or inotrope dependency, who still want aggressive restorative care.

Answer 91

CONTRAINDICATED -ACE-I/ARBS, spironolactone -for peripartum cardiomyopathy have to use HF drugs but NOT the ones above! -Management includes early delivery

Answer 92

Cardiac stress testing is best used in patients with an intermediate pretest probability of coronary artery disease. 1) Exercise ECG is a reasonable diagnostic test in patients who can exercise and have normal findings on a baseline ECG *ekg abnormalities (LBBB, ST depression >1mm, LVH, WPW) 2) IF patient can exercise and no major ekg abnormalities (LBBB, pacemaker) --> stress induced ETT + imaging (CMR, echo, MPI) 3) IF pt has major ekg abnormalities (LBBB, pacemaker) and/or can't exercise --> pharmacological + imaging -adenosine: esp if LBBB on ekg. NO for respiratory airway dx -dobutamine: NO for Aortic stenosis or pacemaker

Answer 93

**for BOTH atrial fib and PAF--use CHA2 DS2 VASc.** -DOAC preferred if criteria met (>=2 men, >=3 female) - WARFARIN preferred if pt has mod/severe Mitral Stenosis OR mechanical valve -IF pt also has ACS indication for antiplatelet tx, use DOAC/wafarin + clopidogrel.

Answer 94

PDE-5 inhibitors (sildenafil, meds often used for erectile dysfunction) contraindicated with Nitrates (isorbide dinitrate) 2/2 significant hypotension

Answer 95

Pulmonary regurge

Answer 96

(1) Pericarditis -inflammation of pericardial sac (can result in effusion). diffuse ST depressions -Tx: NSAIDS + colchine (2) Pericardial effusion -->tamponade -elevated JVP/muffled heart sounds/pulsus paradoxus, exaggerated SBP dec w/inspiration, x descent/blunted y descent -tx: urgent drainage of pericardial fluid with either pericardiocentesis or surgery. (3) constrictive pericarditis -resolution of effusion, leaves pericardial thickening, fibrosis -elevated CVP, prominent x & y descent, Kussmaul (elevated JVP w/inspiration) -tx: IF transient, same as acute pericarditis. IF chronic, surgical pericardiectomy.

Answer 97

one-time screening with DUPLEX U/S in all men aged 65 to 75 years who have smoked at least 100 cigarettes in their lifetime

Answer 98

aortic aneurysm is defined as an increase in the aortic diameter. Surgery indicated for: (1) Aortic diameter >5.5 cm (general pop) (2) Aortic diameter >4.5 cm (Marfan (4-5), Pregnancy, requires surgery for CAD or valve repair--LOWER threshold) (3) Rapid growth >0.5 cm (5 mm) per year Medical therapy for asymptomatic aortic aneurysm includes lowering BP to <130/80 mm Hg; β-blockers are the preferred antihypertensive agent. In patients with Marfan syndrome, β-blockers and losartan reduce the rate of aneurysm growth

Answer 99

(1) SMALLER than 4.0 cm -duplex u/s q 2-3 yrs (2) 4.0 to 5.5 cm - CT angiography or duplex u/s q6 to 12 mos

Answer 100

(1) CT angiography to identify the location of AAA (suprarenal, juxtarenal, or infrarenal) (2) The choice between open surgical repair and endovascular repair (EVAR) is driven by LOCATION -Open surgical repair: suprarenal and juxtarenal aneurysms -Endovascular repair: infrarenal aneurysms often can be treated with EVAR. .

Answer 101

CTA >> TEE

Answer 102

Conditioms -pregnancy, uncontrolled HTN, MArfan's Murmur: AR

Answer 103

Flecainide is a class IC antiarrhythmic agent and, along with propafenone, is absolutely contraindicated in patients with ischemic heart disease,

Answer 104

1) bradycardia 2) hypotension 3) hyPerglcymeia 4) metabolic acidosis

Answer 105

ASAP -ASA high dose -antiplatelet (clopidogrel/ ticagrelor) -heparin (UFH only for PCI, any for thrombolytic) -nitro/morphine prn 24HRS -BB (not hypotensive) -high dose statin -ACE-I (if intolerant ARB) * Eplerenone: 3 to 14 days after MI if LVEF ≤40% and clinical HF or diabetes

Answer 106

ASD - defect in the atrial septum resulting in a left-to-right shunt w/eventual right-sided cardiac chamber dilatation -Adults p/w dyspnea, atrial arrhythmias, and/or right heart enlargement -elevated central venous pressure, a right ventricular lift, and fixed splitting of the S2 -Large left-to-right shunt causes a pulmonary midsystolic flow murmur and a tricuspid diastolic flow rumble owing to increased flow. -EKG: right axis deviation, incomplete right bundle branch block, and right ventricular hypertrophy

Answer 107

Ostium SECUNDUM ASD -RBB, RVH, right atrial enlargement Ostium primum ASD -LAD, first-degree AV block

Answer 108

-BB [ONLY bisoprolol, carvedilol, metoprolol succinate) -ARNI valsartan-sacubitril (instead of ACE-I); contraindicated in pt with angioedema! -SLG2 inhibitor -EF <30%: Aldosterone antagonists-NO CKD! (spironolactone, eplerenone--more selective an assoc w/fewer gynecomastia) -Blk pts: isosorbide dinitrate–hydralazine -diuretics *Reduce hospitalizations -digoxin -Ivabradine: EF <30%, HR >70, max BB use

Answer 109

(1) ACUTE DISSECTION -SBP to <120 mm Hg in first hour -IV β-blocker therapy ± nitroprusside -pain control with opioids (2) EMERGENT SURGERY -cardiogenic shock -type A dissection/ intramural hematoma (3) Uncomplicated type B dissection is treated with continued medical therapy alone, except in patients with complications, including end-organ ischemia.

Answer 110

Most thoracic aortic aneurysms are asymptomatic. Surveillance and treatment depend on aneurysm size and subsequent rupture risk. Surveillance intervals for asymptomatic thoracic aortic aneurysm of the aortic root and ascending aorta are: 1) Annual imaging: 3.5 to 4.4 cm 2) q 6mos: 4.5 to 5.4 cm (4.5 - 5.0 if Marfan)

Answer 111

(1) ICD - EF =< 35% + symptomatic on meds (2) Cardiac resynchronization therapy - EF =< 35% + symptomatic on meds+ LBBB + QRS >150 ms

Answer 112

Indications for surgery include: (1) valvular dysfunction and acute HF (2) left-sided IE caused by Staphylococcus aureus, fungal infection, or highly resistant organisms (3) complete heart block (4) perivalvular abscess or fistula formation (5) positive blood clx despite >5days IV abx (6) prosthetic valve endocarditis

Answer 113

(1) control of hypertension (2) Diuretics --relief of volume overload (3) AND SLG2-inhibitor

Answer 114

Mobitz TYPE 2 -dizziness and syncope Complete HB -fatigue, dyspnea, chest pain, presyncope or syncope, and cardiac arrest.

Answer 115

Junctional rhythms are regular supraventricular rhythms in which the P wave in lead II is negative (preceding or following the QRS complex) or absent (arrows).

Answer 116

(1) cardiac arrest 2/2 VF or VT (2) sustained VF or VT (3) HF with EF ≤35% + symptomatic on meds (4) Brugada syndrome with syncope (5) Inherited long QT syndrome not responding to β-blockers (6) ≥40 days after MI with an EF ≤30%

Answer 117

HYPERTENSIVE URGENCY: -BP>180/120 w/NO evidence of organ damage -SBP should be lowered no more than 25% within 1st hr, then to <160/100 mm Hg w/in 2-6 hrs, then cautiously to target w/in 24-48 hrs -IF on meds: and not adherent--slowly resume -IF on med: and adherent--slowly add 1 med -IF newly diagnosed: captopril, clonidine, furosemide--want 20-30bp drop to be slow HYPERTENSIVE EMERGENCY: -BP 180/120 AND e/o organ damage( acute HF, myocardial damage--elevated trop) -Tx: IV nitroglycerin (IV BB if NO HF)

Answer 118

True-severe LF-LG aortic stenosis is amenable to valve replacement, whereas pseudo-severe aortic stenosis requires management of the underlying cardiomyopathy.

Answer 119

HCM -AD -echo, ekg, genetic counseling (if sacromere mutation identified) for all first-degree relatives of patients with HCM

Answer 120

Athlete's Heart -wall thickness <13mm HCM - ≥15 mm in any LV region or > 13 mm in person w/ 1st degree relative

Answer 121

1) BB or CCB 2) ICD indication - cardiac arrest, sustained VT -.risk factors for sudden cardiac death: (1) death in 2 1st degree relatives (2) LVH > 30 mm (3) syncope (4) EF < 50% 3) Surgical myomectomy -severe obstructive sx + a resting or provoked LVOT gradient of 50 mm Hg or greater

Answer 122

TRUE; for HCM pts Also genetic testing if genetic variant found in 1st degree relatve (AD!)

Answer 123

AS -EF <50% AR -EF ≤55% MR -EF ≤60% -LV end-systolic diam ≥40mm AS/MS: a discrepancy between resting echocardiographic findings and clinical symptoms, exercise echocardiograph

Answer 124

respiratory---COPD

Answer 125

-mechanical valves: warfarin -HCM: warfarin

Answer 126

TREATMENT 1) BB or CCB 2) avoid competitive sports 3) IF afib: warfarin 4) IF outflow gradient> 50mm HG: Surgery or septal 5) IF h/o sustaintained VT, 2 st degree relatives w/SCD: ICD SCREENING -TEE + EKG q1-2 yrs to eval for MR and LVH -genetic counseling (if sarcomeric mutation is identified in index case).

Answer 127

Hypertensive emergency -target organ damage (ex: ischemia, HF) TREATMENT -acute Aortic dissection: IV Esmolol, labetalol -acute HF/pulmonary edema: IV nitroglycerin, nitroprusside. NO BB -ACS: IV Esmolol, nitroglycerin -acute kidney injury: CCB --Nicardipine -Eclampsia or preeclampsia: IV Hydralazine, labetalol, nicardipine. NO ACE inhibitors, ARBs, renin inhibitors, nitroprusside contraindicated

Answer 128

1) metop succinate 2) carvedilol 3) bisoprolol

Answer 129

IF EF < 40% +/- DM (regardless of volume overload) CAVEATS: 1) Aldosterone antagonists should NOT used for diuretic therapy, and patients with volume overload should be treated with a loop or thiazide diuretic. 2) do NOT use with kidney failure (GFR of at least 30 mL/min/1.73 m2.) 3) Of the two agents, eplerenone is a more selective aldosterone antagonist and is associated with lower incidence of gynecomastia and breast tenderness.

Answer 130

When he shaded area separating the LAP from the LVP during diastole represents the elevated pressure gradient that is characteristic of mitral stenosis https://www.cvphysiology.com/Heart%20Disease/HD004

Answer 131

RHEUMATIC FEVER -Multisystem dx (joints, carditis, nodes, erythema marginatum, chorea) -caused by untreated pharyngitis 2/2 grp A strep -Dx: Jones criteria (1) Major criteria include carditis, arthritis, chorea, erythema marginatum, and subcutaneous nodules (2) minor criteria include prolonged PR interval, arthralgia, fever, and elevated inflammatory markers. - recent history of group A streptococcal infection + 2 major criteria OR 1 major and two minor criteria. -Tx: PCN ENDOCARDITIS -inflammatory dx that affects abnl valves (congenital, prosthetic, mostly 2/2 staph >> or strep) -Dx: Duke's criteria (1) 2 major (bld clx, echo, new murmur) (2) 1 major + 3 minor (embolic, fever, immunologic) (3) 5 minor criteria -Tx: IV abx +/- surgery. -Dental ppx

Answer 132

- NORMAL: I (+) aVF (+) - Right axis deviation: I (-) aVF (+) - Left axis deviation: I (+) aVF (-)

Answer 133

CVP=measure of right atrial pressure. -Elevated with RV infarct **RV infarct: Look for JVD with clear lungs, hypotension, and tachycardia **Remeber: PCWP is measure of LEFT atrial pressure

Answer 134

1st: Cardioselective β-blockers (NO if reactive airways disease/wheezing) 2nd: CCB (amlodipine) -Avoid short-acting CCB 3rd: Nitrates (isosorbide mononitrate) are as effective as β-blockers and calcium channel blockers in reducing angina. -IF using nitrates THEN NO sildenafil, vardenafil, tadalafil - Ranolazine: FINAL: after BB-CCB-nitrate -Ranolazine should be considered in patients who remain symptomatic despite optimal doses of β-blockers, calcium channel blockers, and nitrates.

Answer 135

ADENOSINE -NO for respiratory airway dx DOBUTAMINE -NO for Aortic stenosis or pacemaker

Answer 136

Ezetimbe-->PCSK9 monoclonal antibodies (alirocumab and evolocumab) **Lipophilic statins (atorvastatin, simvastatin, and lovastatin) have a higher propensity to cause statin myopathy compared with hydrophilic statins (fluvastatin, pravastatin, and rosuvastatin).

Answer 137

STATIN-->ezetimibe-->evolocumab

Answer 138

(1) initiate intravenous anticoagulation with unfractionated heparin, (2) perform angiography, and (3) establish a plan for reperfusion of the l