Cardiology Flashcards
Which main coronary supplies the following:
1) SA node
2) AV node
1) Proximal RCA (65%) or LCx (25%), both (10%)
2) RCA (80%), LCX (10%), both (10%)
Average HR drop during sleep in [1] young healthy adults and [2] elderly?
24 bpm
14 bpm
Symptoms of Bradycardia?
Asymptomatic
Fatigue
Weakness
Light-headedness
Syncope
Physical findings of bradycardia?
Slow pulse rate
Hypotension
Cool extremities
Cannon A waves (in setting of AV dissociation)
What is a junctional escape rhythm?
- Rhythm 40-60bpm
- No visible P waves before QRS
- QRS typically <120ms
Causes of sinus bradycardia? (intrinsic vs extrinsic to SA node)
1) Intrinsic to SA node
- idiopathic degeneration (aging)
- ischemia (esp. inferior)
- infiltrative (e.g., amyloidosis)
- collagen vascular disease (e.g., SLE)
- infectious (e.g., Chagas, myocarditis, Lyme)
- myotonic dystrophy
- surgical trauma (e.g., valve replacement)
2) Extrinsic to SA node
- meds (e.g., bb, ccb, digoxin, clonidine, amio, opioids)
- lytes (e.g., low/high K+)
- neurally-mediated reflexes (e.g., carotid sinus hypersensitivity)
- hypothyroidism
- hypothermia
- brainstem herniation
Common meds associated with sinus bradycardia?
- bb
- ccb
- digoxin
- clonidine
- antiarrhythmic agents (e.g., amiodarone, lidocaine)
Typically, infections leads to increase in temperature with corresponding increase in heart rate. Which infections are associated with relative bradycardia?
- Legionella
- Pscittacosis
- Q fever
- Typhoid fever
- Typhus
- Babesiosis
- Malaria
- Leptosporiasis
- Yellow fever
- Dengue fever
- Viral hemorrhagic fevers
- Rock Mountain spotted fever
How often is Mobitz II AV block associated with a wide QRS?
Wide: 80%
Narrow: 20%
ECG diagnosis of STEMI?
- > 0.1 STE in 2 contiguous leads
- EXCEPT in V2-3 - must be >0.2 (men) and >0.25 (women)
What is the typical evolution of ECG changes associated with ischemia?
- Hyperacute: tall T waves
- Acute: STE
- Hours: STE + reduced R wave + Q wave
- Day 1-2: TWI, Q-wave deeper
- Days: ST normalizes, TWI
- Weeks: ST/TW normal, Q wave persists
Which conditions make ECG interpretation of ischemia unreliable?
- early repolarization
- LVH
- LBBB
- ventricular paced rhythm
- preexcitation
- J-point elevation syndromes (e.g., Brugada)
- pericarditis/myocarditis
- SAH
- hyperK+
- stress CM
- cholecystitis
Risks associated with acute aortic dissection?
- male
- age: >60
- HTN
- prior cardiac sx (esp AV repair)
- bicuspid AV
- connective tissue (eg., marfan)
- aortitis (eg., GCA, syphilis)
Why do MVP patients who undergo repair can oftenhave persistent episodes of chest pain + palpitations after repair?
Autonomic dysfunction that persists after repair
Definitive diagnostic study for pulmonary hypertension?
- Gold: right heart cath
- Other: TTE, ECG, PFT
S3 vs S4?
1) S3
- early diastolic
- r/t rapid ventricualr filling
- DDx: ADHF, DCM, thyrotoxicosis, AR
2) S4
- late diastolic
- r/t late atrial kick against stiff ventricle
- DDx: HTN, AS, cor pulm, ischemic CM, acute MI
Heart failure symptoms: R vs L?
1) Right
- tachycardia
- low bp
- high JVP
- RV heave
- right-sided gallop
- ascites
- LE edema
2) Left
- weakness
- crackles, orthopnea, PND
- tachycardia
- low bp
- narrow PP
- left-sided gallop
- laterally displaced apical pulse
- pulsus alternans (end stage)
- cool extremities
What is the definition of ischemic CM?
LV dysfunction with at least 1 of the following:
- Hx prior MI or PCI
- >75% stenosis of LM or LAD
- 2 vessels or more with >75%
What proportion of patients with acute myocarditis will go on to develop chronic heart failure?
1/3
When does peripartum CM usually present?
- 80% present <3 months of delivery
- 10% during last month of pregnancy
- 10% present 4-5 months postpartum
What nutritional deficiencies are associated with HFrEF?
Thiamine, carnitine, selenium, zinc, copper
Which extra heart sound commonly associated with HFpEF?
S4 (concentric - stiff ventricle)
S3 (overload - typically HFrEF)
Toxic causes of heart failure?
- Alcohol
- Cocaine
- Amphetamines
- Anthracycline (chemo; Doxorubicin)
- Thyrotoxicosis
What threshold of alcohol consumption is associated with the development of cardiomyopathy?
Risk increases if consume >90g of EtOH (7-8 drinks) per day for >5 years
Which are the main categories that cause HFrEF?
- Cardiovascular
- Toxic
- Infectious
- Other
Sepsis-associated cardiomyopathy typically resolves within? Management specifics?
- 7-10 days
- Same as sepsis w/o CM, with careful attention to volume status
What TTE finding is characteristic of Takotsubo?
- Apical ballooning
- Basilar hypokinesis
How common is idiopathic dilated cardiomyopathy?
~1/2 of all dilated CM cases remain idiopathic
Quick Answers:
1. “Silent killer”
2. Right-sided heart failure 2/2 lungs
3. Associated with hypertrophic CM
4. Brachial-femoral pulse delay + rib notching on CXR
- HTN
- Cor pulmonale
- HOCM
- Coarctation of aorta
What is the final common pathway of all processes that lead to cor pulmonale?
Pulmonary HTN
Valvular lesions: which is typically associated with concentric hypertrophy in HFpEF vs. eccentric hypertrophy and HFrEF?
Bonus: right-sided valvular lesions, both stenotic/regurgitant, are generally HFpEF or HFrEF?
- Stenotic
- Regurgitant
- HFpEF
Describe murmurs:
1. AS
2. MS
3. TR
4. PS
5. TS
6. PR
- Late-peaking crescendo-decrescendo SEM at RUSB radiating into carotids - musical quality at apex “Gallavardin phenonmenon”
- Low-pitched rumbling DEM with presystolic accentuation
- Holosystolic murmur at LLSB, increases with inspiration (Carvallo’s sign)
- Similar to AS, but (+) Carvallo’s
- Late DEM with (+) Carvallo’s
- Decrescendo DEM with (+) Carvallo’s
TTE criteria for severe AS?
- aortic jet velocity >4.0m/s, or
- Ao >40mmHg
- AVA usually <1cm2 (not required)
Why is mitral stenosis often associated with embolic events? (eg., stoke, renal infarct)
- Often associated with afib (>50% cases)
- Risk of embolic events in valvular afib is higher than afib alone
Which characteristic finding of IJ waveform associated with severe TR?
- Lancisi’s sign: severe TR causes C wave to fuse with V forming a prominent wave
- Carvallo’s sign also present (worsen with inspiration)
Bullet Q’s - Infiltrative causes of HFpEF:
1. Middle-aged man with macroglossia + large shoulders?
2. Granulomatous disease
3. Infiltration of metallic element
4. Generalized lymphadenopathy + high LDH
5. Infiltration of “acid-loving” cells
- Amyloidosis
- Sarcoidosis
- Iron overload
- Lymphoma
- Eosinophilia
How does lymphoma cause heart failure symptoms?
Pericardial infiltration + effusion
What is Löffler endocarditis?
Eosinophilic myocarditis:
- Endocardial fibrosis in association with hypereosinophilic syndrome (HES) [defined as persistent hyperE with eosinophil count >1,500/microL for >6mo with evidence of organ damage
What is Fabry’s disease?
Genetic cause of HFpEF
- X-linked lysosomal storage disorder releated to deficiency of enzyme a-galactosidase A
2 signs that are seen in constrictive pericarditis?
- Kussmaul’s: paradoxical increase in JVP with inspiration
- Friedreich: sharp + deep Y descent
How does scleroderma affect the heart and lead to heart failure?
- cor pulmonale from pHTN
- acute constrictive pericarditis
- pericardial effusion
- premature CAD
- myocarditis
- nonbacterial thrombotic (marantic) endocarditis
- conduction system abnormalities
