Cardiology Flashcards
1
Q
BB CIs
A
1- Asthma
2- HR <50 without pacemaker
3- Recent <4w or acute CHF exacerbation PLUS Cardiogenic shock or flash Pulmonary edema
- Use with caution (not preferred) in patients with BP <90/60 or HR 50-59
2
Q
Peripartum Cardiomyopathy Treatment
A
1- Ferusmide till euvolemic
2- BB once euvolemia established
3
Q
Pulse pressure definition
A
Systolic - Diastolic
4
Q
Pulse pressure in advanced HF
A
Narrow
5
Q
Pulse pressure range
A
40-60 mmHg
6
Q
Weight in advanced HF
A
Weight loss ( catabolic state )
7
Q
HFpEF >40%, best medication for mortality
A
MRA (spironolactone), with careful attention to serum K+
8
Q
Carvedilol maximum therapeutic dosage
A
25mg BID
9
Q
BNP
A
NT-proBNP and BNP ranges differes across age groups
10
Q
Five drug classes may worsen CHF and therefore should be avoided?
A
1- CCB (except amlodipine)
2- NSAIDs
3- TZD (pioglitazone)
4- inhaled anesthetics
5- Some antidepressants (SSRI may be used judiciously )
11
Q
Whats the most common type of Paroxysmal SVT?
A
AVNRT [Atrioventricular Nodal Reentrant Tachycardia]
- common among women and young adults
12
Q
Second most common type of Paroxysmal SVT?
A
- AVRT ( Atrioventricular Reciprocating Tachycardia )
Most common type in childrens
13
Q
Acute pericarditis most common cause
A
More than 90%: idiopathic or viral
14
Q
First line treatment for acute pericarditis
A
- NSAIDS
- Indomethacin may reduce myocardial perfusion, therefore not preferred in patients with CCS OR ACS
- 2nd line: Colchicine, alone or in combination with NSAIDs
Steriod: shown to increase risk of recurrent pericarditis
Therefore, not preferred, unless indicated
15
Q
JNC 8, when to start Anti-htn according to age
A
Older than 60: 150/90
Younger, DM, or CKD: 140/90
16
Q
When to decide to add on or increase dose of anti HTN?
A
- if target BP not reached within 1 month
17
Q
First line antihypertensive in CKD and DM nephropathy
A
ACEI
18
Q
Anti htn for COPD patients
A
Selective BB is the agent of choice. Reduce mortality and COPD exacerbation
19
Q
Mention two selective B1 BB?
A
- Bisoprolol
- Metoprolol
20
Q
BB B1 Selective safer in whom?
A
- Diabetic with PAD
- Asthma and COPD
21
Q
Anti HTN in pregnancy
A
- labetalol 1st line
- Nifedipine, methyldopa
22
Q
Anti HTN for recurrent stroke prevention
A
ACEI and thiazide diuretic
23
Q
When to stop ACEI in CKD?
A
Raise in creatinine >30% > should prompt investigations to renal artery stenosis
24
Q
Strongest clinical evidence among Thiazide diuretics?
A
- Chlorthalidone
- All thiazide most effective when combined with ACEI
Monitor for Hypokalemia
Loop diuretic may be needed if eGFR <40
25
Preferred ARBS in gout and hyperuricemia
- Losartan
26
Preferred ARBS in migraine patients
Candesartan
27
BB for DM SE
Mask hypoglycemia awareness
Adversly affect glucose
28
CCB classes
Di-hydro-pyridine: Amlodipine, nifedipine,
Non- Di-hydro-pyridine: diltiazem, verapamil
29
Can di-hydro-pyridine combined with BB?
YES
But Non dhp ccb is CI, due to redueced HR and heart block SE
30
Vasodilators in HTN
Hydralazine and Minoxidil: may cause reflex tachycardia (needs BB), and fluid retention (needs diuretic)
Alpha blockers as doxazosin, terazosin: orthostatic hypotension
31
Centrally acting agent for HTN
Clonidine (available as weekly patch). Methyldopa, guanfacine
32
What features suggest secondary HTN
1- <40 yo with grade 2.
2- Childhood with any grade
3- Resisitant
4- Extensive HMOD
33
BB in pheochromocytoma?
Will increase BP
34
When to initiate high intensity statin?
1- LDL 190
2- ASCVD 10year risk 20%
35
When to initiate moderate intensity statin?
- 40-75 and Diabetic
- 40-75 and LDL 70-189 and ASCVD risk is 7.5-<20% “intermediate risk” + risk enhancers favoring statin
- 40-75 and LDL 70-189 and ASCVD risk is 5-<7.5% “borderline risk” + risk enhancers favoring statin then DISCUSS “class 2b (mainly lifestyle and risk factors management)
Low risk (<5%) is always for lifestyle risk factors decreasing
USPTF: 40-75 + ASCVDA RISK >10%
36
What is risk decision is uncertain?
Consider measuring CAC in selected patients
CAC: 100 initiate statin
CAC: 1-99 Favoring statin specially after age 55
CAC: zero no statin (unless family history of premature CHD or smoker)
37
What are high intensity statins?
Atorva 40
Rosuva 20
38
What are moderate intensity statin
- Lova 40
- Atorva 20
- Simva 20
- Rosuva 10
39
Mention the ASCVD Risk enhancers?
- Family history of premature ASCVD (55 MALE, 65 FEMALE)
- CKD
- Metabolic syndrome
- Premature menopause
- Preeclampsia
- inflammatory disease ( specially HIV, RA, PSORIASIS)
- Ethnicity
Lab:
- Persistently elevated TG 175. Or LDL 160
40
Age 0-19 with dyslipidemia
- lifestyle
- statin if familial
41
Age 20-39 with dyslipidemia
- lifestyle
- Consider statin if FH of premature CVD PLUS LDL 160
42
Mechanism of action of statin?
Inhibit HMG-CoA Reductase > this leads to increase activity of LDL receptors on liver
43
Mechanism of action of Fibrates?
- Increase Lipprotein lipase activity
44
PE in dyslipidemia
1- Orange large tonsils, intermittent neuropathy, hepatosplenomegaly, very low HDL and TC, yellow mucosa, conreal opacitiy: Tangier disease
2- Eruptive xanthoma: chylomicronemia syndrome “TG from 1500 to 2000”
3- Tendinous xanthoma, arcus juvelinis: Familial hypercholesteremia
45
JNC-8 BP targets
60 years old: 150/90
<60 even if CKD or DM: 140/90
46
When to refer HTN?
uncontrolled on more than THREE drugs
47
Orthostatic hypotension definition
Fall in systolic 20mmHG
Fall in diastolic 10mmHG
5 minutes set or supine
Then 2-3 minutes upright
48
Orthostatic hypotension causing medications?
Antihypertensive and diuretics
49
Hypertension emergency goals?
- MAP 10-20% in the first hour
- MAP 5-15% over 23 hours
MAP REDUCTION >25% may cause end organ ischemia
50
Exception for gradual reduction of BP over a course of one day in hypertension emergency
1- Ischemic stroke
2- ICH
3- Aortic dissection
51
What IV antihypertensive increase renal perfusion?
FENOLDOPAM ( Dopamine-1 reception agonist)
52
USPSTF HTN screening
18 years old, every 3-5 years
At least yearly IF: Age >40, risk factors (obesity) or prehypertensive (120-129 systolic) twice a year
53
Elbow Xanthoma versus Eruptive Xanthoma
Elbow Xanthoma: LDL >300
Eruptive Xanthoma: LDL >1000
54
First line agent to prevent Pancreatitis In HyperTriglycermia of 500mg/dL or more
FIBRATE (Gemfibrozil)
Mild to moderate elevation (>150 but >500): lifestyle and consider statin based on ASCVD risk assessment
Severe elevation (>500): FIBRATE
If still uncontrolled FIBRATE + OMEGA3 FATTY ACID
55
What age group more responsive to ACEI and ARBS?
<50 YEARS OLD
56
Clonidine mechanism of action
Centerally acting presynaptic Alpha-2 adrenergic agonist
Decrease sympathitic response
57
Calcium channel blockers
NON-DiHydroPyridine is Dilitizam and veraprimil
NON = NON BEAT = HEART BLOCK
58
Most frequent electrolyte abnormality with thiazides diuretic?
Hypokalemia
59
First line antihypertensive in CKD?
ACEI or ARBS
REGARDLESS OF AGE (EVEN IF BLACK)
The only exception is those who aged 75 or older with reduced renal function ( fear of Hyperkalemia and increased creatinine )
60
Cardiogenic shock
Narrow pulse pressure
LOW cardiac index
HIGH pulmonary capillary wedge
61
The only shock with HIGH Mixed venous oxygen (SvO2) IS?
SEPTIC SHOCK
62
Most common cause of cardiogenic shock
ACUTE MI
63
Best antihypertensive for GOUT?
- Losartan
Diuretics (thiazide and ferusmide) increase urate reabsorption
64
Most common cause of drug-resistant hypertension?
Primary hyperaldosteronism
65
Treatment of Conn?
Adenoma: surgery
Hyperplasia: sprinolactone
66
Septic shock treatment
Measure and follow lactate level
1- fluid (30cc/kg)
2- Norepenphrine if MAP still <65
3- vasopressin
Septic: Norepenphrine, Dopamine
Cardiogenic: Dubtamine
67
SIRS?
Temp: >38, <36
HR: >90
RR: >20
WBC: >12000 or less than 4000
68
First line for orthostatic hypotension
Lifestyle: water intake, smaller meal with less carbs, avoid alcohol, isometric and lower extremities exercise, stand up slowly, avoid overheating
Fludrocortisone, Midodrine (alpha-1 agonist), Pyridostigmine
69
CCB with greater effect on AV node?
Verapamil
70
Polycystic kidney disease
- AD
- ACEI or ARBS
- Family history
- PKD1 gene
- U/S
- flank pain or hematuria
- Most common inherited cause of CKD
- Tolvaptan (large kidney volume or decline in GFR)
- Increased risk of liver involvement, berry aneurysm, and inctracerebral haemorrhage
71
Postural tachycardia syndrome
Raise in HR >30bpm with standing
Absence of orthostatic hypotension
Treatment: fluid and salt intake and structured exercise therapy, usually resolved within 6 weeks
72
When to start combined antihypertensive?
Systolic >20mmHg or diastolic >10mmHG above target
Meaning:
18-59: >160/100
60: >170/100
73
RAS management ( renal artery stenosis )
- ACEI or ARBS are first line
- Percutanous angioplasty
- Surgical revasculization
74
Compelling indications?
Stable angina: BB, CCB
Atrial flutter/fibrillation rate control: BB, NON-CCB
Systolic HF, POST MI, CKD: ACEI
BPH: ALPHA BLOCKERS
ESSENTRIAL TERMOR: NON SELECTIVE BB
HYPERTHYRODISM: BB
75
Antihypertensive CI
Angioedema: ACEI
Asthma: BB
Depression: Reserpine
Liver disease: Methyldopa
Pregnancy: ACEI, ARBS
Second or third degree Heart block: BB, NON-CCB
76
Antihypertensive adverse effect on comorbid conditions
Depression: BB, and colondine
Gout: diuretics
Hyperkalemia: ACEI and ARBS
Hypokalemia and Hyponatermia: Thiazide
Renovascular disease: ACEI and ARBS
77
Hypertensive emergency special drug indication
- Vasodilators:
Nitruprusside: combine with BB to avoid reflex tachycardia
Nicradipine: caution with CAD and CHF
FENOLDOPAM: Caution with glaucoma
Nitroglycerin: PREFERRED IN CORONARY ISCHEMIA
Hydralazine: ECLAMPSIA
Enalaprilat: preferred in Acute HF. Avoid in Acute MU
- Adrenergic inhibitors:
Labetalol: Caution in AHF
Esmolol: AORTIC DISSECTION
Phentolamine: PHEOCHROMOCYTOMA
78
Goal of BP in Ischemic stroke?
- <220/120 if not candidate for tPA
- <185/110 if candidate for tPA
79
What BB doesn’t carry risk of Predm and dm?
Carvedilol and Nebivolol
80
What condition necessitates the most RAPID correction of blood pressure?
AORTIC DISSECTION
WITH A GOAL OF 100-120 SYSTOLIC WITHIN 20 MINTUES
BB first to reduce HR <60.
81
HF classification
HFrEF: EF of 40% or lower
HFpEF: EF of 50% or more
(HF with borderline preserved ejection fraction is 41 to to 49, it is a definition, but treatment and outcome is the same HFpEF)
82
Most common cause of HF?
IHD
83
Most common cause of right HF
Left HF
84
Rule of BNP
Distinguish cardiac from pulmonary etiology of dyspnea
85
Gold standard test for HF?
TTE
86
Most common cause of HFpEF?
Hypertension
87
Advanced HF laboratory marker?
Hyponatermia
88
NT Pro-BNP
Also elevated in CKD
89
Albumin in advanced HF
LOW (<3.4mg/dl)
90
NYHA classes
Class 1: No limitation - Asymptomatic
Class 2: Slight limitation - Mild symptoms with ordinary activities
Class 3: Moderate limitation: Symptoms with minimal activity
Class 4: Severe limitation - Symptoms at rest
91
HFrEF classes guided treatment
ACEI:
Class 1 or more
BB:
Class 2 or more
Spirnolactone:
Class 3 or more if EF<35%
Hydralazine plus nitrate:
- Class 2 or more
- Black or cannot tolerate ACEI and ARBS
92
Does SGLT-2 have mortality benefit in HFrEF?
Reduced hospitalization
93
Initially diagnosed HFrEF and volume overload
- Ferusmide is mandatory
- Initiate ACEI during or after optimization of Ferusmide
94
HFrEF and CCB?
Amlodipine, and felodipine are particularly safe if given for HF but with other indication (HTN, Angina)
95
BB that carry mortality benefit in HFrEF?
- Metoprolol Succinate ER
- Bisoprolol
- Carvedilol
96
Ferusmide mechanism of action?
- Inhibit reabsoprtion of Na+, K+, and Cl-
- Common electrolytes abnormalities with Loop Diueretics: Hypo N+, k+, Mg+
97
BNP for HF, High positive or negative predictive value?
High Negative predictive value
So a low BNP helps to r/o heart failure
Sensitive, but not specific
Strong predictor of mortality in 2-3 months, but monitoring in OPD is useless
All cardiac disease can elevate BNP and NT-proBNP
Non cardiac causes:
- advanced age
- anemia
- renal failure
- pulmonary; OSA, severe pneumonia, embolism, P.HTN
- Sepsis or critical illness
- severe burn
98
S3 versus S4 in heart failure?
S3 early diastole: Systolic HF (HFrEF) - may be normal
S4 late diastole: Diastolic HF (HFpEF) - always abnormal
99
Medications used for HFpEF?
- SGLT-2: Mortality benefit, and reduce hospitalization
- MRA (spirnolactone): reduce hospitalization, with less clear mortality benefit
Others are usually not indicated since there’s no benefit including (ACEI, BB, Nitrate and hydralazine)
100
Recommendations for SGLT-2i in HFrEF??
Reduce hospitalization in patients with HFrEF + DM + established or high risk ASCVDs
101
Diastolic HF versus Systolic HF?
Diastolic: Reduce active ventricular relaxation and Reduce passive ventricular compliance
102
Three most common causes of HFpEF?
IHD
HTN
VHD
103
Pericardial effusion versus Cardiac temponade
- Can occurs from right sided HF
- ECG:
Start with effusion > sinus tachycardia with low voltage QRS complex > effusion progress > Cardiac tamponade > Electrical alternans ( alternating high and low QRS complex amplitudes between beats )
- Echo in cardiac tempondae:
Diastolic collapse of right ventricles ( HIGHLY SENSITIVE AND SPECIFIC )
Early systolic collapse of Right atrium (less sensitive but very specific)
Plethoric IVC
- Management:
Saline bolts (cuz patient is preload dependant)
Pericardiocentesis
Pericardial window
104
Two non-pharmacological treatments help to reduce mortality in HFrEF?
Disease management and Telemonitoring
105
AHA/ACC HF classification
Stage A: High risk - No symptoms or structural disease
Stage B: Structural disease - No symptoms
Stage C: Structural disease + Symptoms
Stage D: Refractory HF
106
How to estimate left atrial pressure?
Swan Ganz Catheter ( Pulmonary Artery Catheter )
107
Leading cause of 2ndry healthcare-associated bacteremia?
UTI associated with Urinary Catheter
108
CCB and HF?
Non-hydropyridine is not permitted “negative iontropic effects”
Hydropyridine, such as amlodipine, has no rule in HF, but can be used if additional management of HTN is needed. Not indicated if EF is 30% or less
109
Hydrochlorothiazide and HF?
If patients has insuffienct response to loop “inhibit sodium reabsorption at loop of henle”
Thiazide combined to loop have increased efficacy “inhibit remaining sodium reabsoprtion at distal tobules”
*Monitor for Hypokalemia if combined
110
Which Antiobiotics should be avoided or carefully monitored in patients with HF?
- TRI-Sulphate (BACTRUM)
Risk of HYPERKALEMIA
111
Prinzmetal angina
Occur without precipitating factor and associated with ST ELEVATION
112
Premature CVD
Men <55
Women <65
113
ACEI in ACS?
STEMI: Yes
Non-STEMI: Controversial
114
When nitrate is CI in ACS?
Inferior MI
115
ST elevation arteries
Inferior MI:
- aVF, II, III
- RIGHT CORONARY ARTERY
Anterior MI:
- V1-V4
- Left anterior descending artery
Lateral MI:
- aVL, V5-V6
Posterior MI:
- ST DEPRESSION V1-V3
- ST ELEVATION V8-V9
116
Criteria for ST elevation
>1mm in more than two contiguous leads
Anterior leads (V2-3): 1.5mm in females, 2mm in male >40, 2.5mm in male <40
117
Most common atypical feature of MI?
- DYSPNEA
118
Medical therapy for Acute Coronary Syndrome
MONA BAAS
M ( Morphine ):
- Relieve pain and reduce work of breathing in setting of Pulmonary edema
- Only used if Nitro failed to relieve pain
O (Oxygen):
- given if O2 <90, dyspnea, or HF
N (Nitroglycerin):
- Relieve ongoing chest pain, reduce BP
A (Antiplateles):
- Reduce recurrent thrombosis, and stent thrombosis
- PCI? So DUAL NEEDED
- Aspirin before PCI and continued indefinitely
- PGY12I continue for 1 year if stent placed
- GPIIB/IIIA antagonist for PCI “abciximab, eptifibatide” IN HIGH RISK ONLY
B(BB):
- Prevent recurrent ischemia and arrhythmia
A (ANTICOAGULANT):
- If LV thrombus OR Afib OR receiving thrombolytics OR undergoing PCI
- Unfractioned heparin
- Direct thrombin inhibitor (BIVALIRUDIN)
A (ACEI):
- in STEMI
S (Statin)
- High intensity
119
Reperfusion management for ACS?
- PCI:
PCI Center with door to ballon time <90m
Non-PCI Center with door to ballon time <120m
- Thrombolysis:
Can be given up to 12 hours from symptoms onset
CI: ICH, IC malignancy, ischemic stroke within 3 months, Aortic dissection
120
Percentage present with atypical MI symptoms?
33%
121
First line in stable angina?
- BB
- Nitro usually In more acute settings
122
Which class of Angina does BB is CI?
Primenzal angina
123
Most sensitive and specific cardiac bio marker?
- Troponin T&I
Detected at 3 hours, return to normal in 2 weeks
Rise more rapidly than CK-MB
Highest sensitivy and specific
- CK-MB
Detected at 3 hours, return to normal in 2-3 days
Useful for Dx of reinfarction
- Myoglobin
Detected at 1 hour, return to normal in 1-2 days
First to appear, first to peak, first to decline
Not specific
124
First aid in ACS
Chewable aspirin, non enteric coated, 162-325 mg
125
Erliest change in ECG in STEMI?
Hyperacute T wave
126
Risk stratification for unstable Angina / NSETMI patients
TIMI SCORE:
Age 65 OR Older
3 CAD risk factors
Known coronary artery stenosis 50%
Aspirin use in last 7 days
Severe angina (2episodes in 24 hours)
ECG ST elevation 0.5mm
Positive troponin
PCI if:
- hemodynamicly unstable
- continued angina despite anti-ischemic therapy
- CHF symptoms ( s3, pulmonary edema, crackles, mitral regurgitation, elevated BNP “not ANP"”, new ST depression)
- EF <40%
- History of CABG
- History of PCI within the past 6 months
- Elevated troponin
127
Initial intervention for ACS
- ABC
- IV line and cardiopulmonary monitor
- Aspirin 325 orally, or rectally
- History and PE and LABS ( cbc, cardiac enzymes, electrolytes, coagulation profile)
- Pain control with NTG (0..4mg, sublingual three tablets)
- Start dual antiplateles
- Start Anticoagulant
- Give BB
- persistant pain give Morphine
- Statin as early as possible, before PCI in patients not on statin
128
In addition to BB, what antihypertensive medications has also mortality benefit in ACS, but is BEST for patients with HF, EF40% OR LESS, STEMI (SPECIALLY ANTERIOR)
ACEI
129
Cocaine induces ischemic symptoms, what medication to avoid?
BB
130
Cardiomyopathy types
1- Dilated CM
2- Hypertrophic CM
3- Restrictive CM
131
What is the most common cardiomyopathy?
Dilated cardiomyopathy
132
What is the most common cause of dilated cardiomyopathy
Idiopathic
ECG findings of: LVH, Low limb lead voltage
133
Idiopathic dilated cardiomyopathy and family screening
A lot of familial dilated cardiomyopathy was initially diagnosed as idiopathic.
So, history taking of family is imp (3-4 generations)
Screening for first degree relatives is imp
Consider genetic testing (AD)
How to screen?
- HX
- PE
- ECG
- ECHO
- CK and MM isoenzyme
134
ACLS protocol for cardiac arrest
Start CPR:
1- Shockable rhythm?
Shock > continue CRP 2m > Shock > CPR 2m > Epinephrine every 3-5m > amiodarone
Initiate targeted temperature management after ICU admission (maintain normothermia, and avoid hyperthermia)
2- Asystole/PEA?
CPR 2m and Epinephrine every 3-5m
CPR QUALITY
Push hard (5cm) and fast (100-120/m)
Allow full chest recoil (1/3 AP chest diameter in child)
If no advanced airway 30:2 compression to ventilation ratio
If there’s advanced airway (endotracheal intubation or supraglottic advanced airway), give 1 breath every 6 seconds = 10 breath/m
135
What is the most metabolic cause of cardiac arrest?
Hyperkalemia
136
Most common cause of restrictive cardiomyopathy?
Amylodosis
137
Restrictive cardiomyopathy VERSUS Constructive pericarditis?
- Constructive pericarditis present similarly in term of symptoms
- pericardial calcification, knob, no palpable impulse, absence of S3 gallop, and lower BNP <400. Are all suggestive of constructive pericarditis rather than restrictive cardiomyopathy
138
Most common primary cardiomyopathy?
Hypertrophic cardiomyopathy
139
Hypertrophic cardiomyopathy meds?
- BB
- Verapamil for patients without left ventricular outflow obstruction (Non-DHP)
Used only for symptomatic patients, or with HTN
140
Primary treatment of hypertrophic cardiomyopathy at risk of sudden death?
ICD
Implantable cardioverter-defibrillator
First line if:
1- documented ventricular arrhythmia
2- High risk for SCD
Risk factors for SCD?
1- Age <30 with evidence of nonsustained ventricular tachycardia
2- Thickness of ventricular wall or septum In echo is 3cm or above
3- family history of SCD
4- recent unexplained syncope
5- hypotension during stress testing
If had history of syncope due to heart block?
Evaluate for implantation of dual chamber permenant pacemaker with ICD
Septal myoectomy?
Doesn’t prevent SCD, it usually used if the patient develop heart failure that is referactory to medical management
141
Takotsubo (stress) cardiomyopathy
Broken heart syndrome
More common in women, specially postmeopause
Mimics STEMI
Diagnostic criteria:
1- ECG abnormalities or modest cardiac enzymes elevation
2- left ventricular systolic dysfunction on echo ( apical ballooning of the left ventricure)
3- absence of atherosclerosis on angiography
4- absence of pheochromoctyoma or myocarditis (by cardiac MRI)
142
Acute MI, when can he do stress test?
Two days
143
Familial dilated cardiomyopathy treatment?
- ACEI and diuretics
- Cardiac transplant
- LVAD (LEFT VENTRICULAR ASSIST DEVICE) if not candidate for transplant
Implantable cardioverter defibrillator should be considered in patients with +ve family history of sudden cardiac death. Even if EF >35% ( the usual cutoff for prophylactic placement)
144
Restrictive cardiomyopathy
MOST COMMON CAUSE IS AMYLODOSIS
ECG: low voltage
Echo: impaired diastolic filling, and preserved systolic function
TREATMENT OF CARDIAC AMYLODOSIS: LOOPS +- SPIRONOLACTONE
145
DVT, most appropitate and gold standard?
Duplex U/S
Gold: Venography (CT or MR)
MR VENOGRAPHY HAVE 100% SENSITIVITY
146
Aortic dissection Stanford classification
A: involve ascending aorta and most common. Most common. Require emergency surgical intervention
B: No involvement of ascending aorta (distal to left subclavian artery = descending)
147
Aortic dissection Medical management
1- Decrease HR to <60 with IV BB (Esomolol)
2- Maintain SBP 100-120mmHg with IV Nitroprusside (vasodilator) only after HR is controlled
148
Aortic aneurysm definition of smoker in recommendations
Lifetime 100 ciggrates
149
AAA diagnostic cut-off and monitoring
AAA diagnostic cutoff: 3cm dilatation
Monitoring:
3 - 3.9: US every 2-3 years
4 - 4.9: US annualy
5 - 5.4: US every 6 months (MRI,CT can be used)
5.5cm: surgery
Rapidly expanding (>0.5cm over 6m): surgery
Symptomatic: surgery
Repair if going for another cardiac surgery if: >4.5cm
Women: higher risk of rupture so >5cm is a safe approach to consider surgery
150
Most common complication of Bicuspid aortic valve?
Aortic stenosis
151
PAD testing
ABI:
High: >1.4 ( suggest calcified artery )
Normal (1.01-1.4)
Borderline-low: 0.91-1
Low: 0.90 or less
Mild 0.9-0.75
Moderate PAD 0.75-0.4
Severe PAD <0.4
ABI interpretation and next step:
If high: toe-brachial index (normal if >0.65)
If normal or borderline- low with highly suspicious history > Exercise ABI testing
If low: PAD is the most likely diagnosis, further testing as necessary
0.9 or less: indicated 50% stenosis
0.4 or less: indicated ischemia
Conventional arteriography:
The gold standard
If the limb is threatening (rest pain, ischemic ulcer, gangrene):
Contrast angiography
For lesion localization and planning for intervention:
Contrast angiography
152
Most common symptom in Aortic dissection
Chest pain
Back pain: more common in those with descending aortic dissection
153
Imaging for Aortic dissection
Initial: CXR
Best imagining: CTA
Hemodynamic unstable: CTA (gold standard), or TEE
154
AAA is more common in men, but risk of. Rupture and negative surgical outcome is more common in?
Females
155
Aortic dissection physical findings?
- Wide pulse pressure
- 20mmHG difference in SBP between left and right arm
- Can cause aortic regurgitation > diastolic decrescendo murmur
156
CVI > Varicose veins > superficial phlebitis, superficial thrombophlebitis, superficial vein thrombosis
For superficial phlebitis:
- NSAIDS, warm moist compressor
——————————
For superficial thrombophlebitis, or superficial vein thrombosis, same
If at increased risk of DVT:
- 5cm thrombosis
- thrombosis with proximity to the deep venous system (5cm from saphenofemoral or saphenopopliteal junction)
USE LMWH or fondaparinux for 45 days
157
Modified wells score (Pretest probability of DVT):
Each point for:
History:
- Active cancer ( on treatment or palliative, or within 6 months of treatment )
- Paralysis or plaster immobilization
- Bedridden >3days, or major surgery <3m )
- previous documented DVT
PE:
- Entire leg swelling
- Calf swelling more than 3cm when compared to the other leg “measured 10 cm below tibial tubersity”
- pitting edema
- Localized tenderness along the distribution of deep venous system
- collateral superficial veins (no varicose)
# if alternative diagnosis is As likely or More likely than that of DVT > -2 points
SCORE:
High probability
1-2: Moderate probability
Low probability
—————————————
Low- Moderate probability > D-dimmer > if positive > U/S > if negative U/S> repeat in 1 week
(Some experts recommend initial U/S if moderate probability)
High probability > U/S
158
Aortic dissection and BP
Type A: Hypotensive
Type B: Hypertensive
159
Tender nodule in lower extremities?
1- Polyarteritis nodule
2- Erythema nodusm
160
Pathognomonic feature of Polyarteritis nodusa?
Startburst livedo
161
Upper extremity venous thrombosis criteria
One point of each:
- subclavian or jugular vein catheter or device
- unilateral pitting edema
- localized pain in that extremity
- minus one point if other diagnosis is suspectible
2 scores = high probability for upper extremity DVT
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DVT haemodynamically stable management
Isolated distal calf vein:
Anticoagulant only if symptomatic, or high risk for proximal extension.
F/u after two weeks to monitor extention, if extended, anticoagulant is indicatied
- deep veins involvement ( popliteal, femoral, iliac ):
Oral anticoagulant unless contraindicated (plt <70.000, severe liver or renal diseases)
- DOAC is the threatment of choice
Factor XA INHIBITORS ( apixiban, rivaroxaban, edoxaban)
Direct thrombin inhibitor (Dabigatran)
Rivaroxaban, 15mg BID with food for 3 weeks, then 20mg OD
If warfarin would be used, should be bridged with IV heparin for 5 days
Duration:
First episode; 3 months
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PAD most common artery involved?
- Common iliac artery > External iliac artery > common femoral artery > superficial femoral artery > popliteal > anterior tibial
- Internal iliac artery: buttock
- Common femoral artery: Thigh pain
- Superficial femoral artery
(Calf pain) IS THE MOST COMMON ( upper 2/3 of the calf )
- Popliteal artery: Lower 1/3 of the calf
- anterior tibial artery: foot pain
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Aortic stenosis, When to refer to a cardiologist?
1- Symptomatic (SAD)
2- Severe stenosis: defines as mean pressure gradient is more or equal to 40mmhg, Or, Maximum transaortic volecity more or equal to 4m/s, Or aortic valve area less than or equal to 1 cm
3- Reduced ejection fraction (<50%)
4- going to other cardiac surgery
Surgical valve replacement is preferred. However, if the patient is high surgical risk, trans catheter aortic valve replacement may be considered
- Hints for severe aortic stenosis: soft, inaudible aortic component of S2
165
Preferred anti HTN for aortic stenosis
- ACEI
- Diuretics
Try to avoid ( BB, CCB, alpha blockers )
166
Most common cause of Aortic stenosis
Degenerative calcification
167
Sublingual nitroglycerin mechanism of action?
- convert to Nitric oxide
- dilate all blood vessels and decrease preload to the heart > decrease myocardial oxygen demand
168
Antianginal medications?
- BB: first line
- Nitroglycerin
- CCB
169
Algorithm for vascular testing in symptomatic PAD
If Critical limb ischemia (ANY OF THE FOLLOWING), refer to vascular specialist for contrast angiography and management:
- Rest pain and dependant rubor
- Tissue loss
- Non healing ulceration (>2w)
- Gangrene
If Claudication/ atypical leg symptoms, measure ABI:
>1.3: calcification
0.91 to 1.3: Normal
0.90 or less: Abnormal
- Calcified > refer
- Normal-borderline > exercise ABI if typical claudication
- Abnormal: treat risk factor for mild >0.8, refer for revasculrization for moderate to severe
170
Ankle and Arterial insuffiency versus venous insuffiency?
- skin change or ulcer to the lateral aspect of ankle (lateral malleolus) > arterial
- skin change or ulcer to the medial aspect of ankle (medial malleolus) > venous
171
Marfan and aortic aneurysm/dissection
Thoracic aortic aneurysm once become sympatomic surgery is indicated!
5cm is the cut off for surgery in Marfan
Mostly ascending
Marfan:
- AD
- Mutation of fibrillin-1 gene
- Pectus deformities
- Wrist sign: thumb overlap terminal phalanx of the fifth digit
- Thumb sign: thumbnail projects beyond the border of the hand
- Ectopia lentils: dislocation of ocular lens
- Scoliosis/ kyphosis
- Aortic root dilation > aortic dissection
Annual echo is required: Aortic root dilation, aortic regurgitation, mitral proplase with or without regurgitation
Patient with Marian + dilated aortic root: should be restricted from competitive sport, contact sport, isometric exercise.. but light regular activity is advised
Marfan female should be counseled by cardiologist about: risk of aortic dissection at pregnancy, and risk of uterine rupture at delivery
Stimulants ( as for ADHD ) should not be used in marfan with cardiac involvement
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Pulmonary venous stenosis
- Complication of catheter ablation for atrial fibrillation
- dyspnea, cough, hemoptysis, recurrent chest infection
- usually 2-5 months after the procedure
- treated with angioplasty
173
Highest RF for PAD
- Smoking and Diabetes
174
Medical management of PAD:
- Smoking casseation
- structured exercise program
- statin
- Antiplatelet
Cilostazol can be given if no heart failure.
175
Definition of ABI borderline PAD
0.91 to 0.99
176
Spider veins/ reticular vein/ varicose vein
Spider: <1mm
Reticular: 1-3mm
Varicose: >3mm, bulge above the skin
177
Sinus node dysfunction
- Formerly known as sick sinus syndrome
- Most commonly caused by SA node dysfunction
- Medications causing sick sinus dysfunction (BB, CCB, digitalis, LITHIUM, anti arrhythmic drugs), Hyperthyrodism
- ECG: Tachycardia (Afib most commonly, SVT, atrial flutter) followed by bradycardia. May required Holter monitor to detect ( Tachy,Brady syndrome )
- Treatment:
If on offending medications: D/C to check if it was medication-induces sick sinus dysfunction
If not meds induces: PACEMAKER FOR BRADY who developed symptoms, FOLLOWED BY MEDICATIONS FOR TACHYCARDIA (BB, CCB,ANTIDYSRHYTHAMIC)
Surgery? Radiofrequency ablation around AV NODE
178
Carotid sinus hypersenstivity
- Carotid sinus massage: sinus pause more than 3 seconds, or symptomatic drop in blood pressure upon massage
179
Heart block
ECG:
First degree
- Prolonged PR interval (>200m/s) (more than 5 small square)
2nd degree Mobtiz I
- Progressive prolongation of PR interval, then QRS drop
2nd degree Mobtiz II
- No prolonged PR, QRS dropped
3rd degree (complete heart block)
- No relation between P and QRS
Management
IV atropine OR IV dopamine OR temporary pacing to Any unstable defined as:
- Hypotensive
- Unstable bradycardia: altered mental status, ischemic chest pain, acute heart failure
Ongoing management:
- can investigate as outpatient if stable for 1st degree, or 2nd degree Mobtiz I
- Plan for permenant pacemaker in Mobtiz II AND 3rd degree heart block without reversible causes.
- Plan for permenant pacemaker in low risk ( 1st degree and Mobtiz I ) If symptomatic, neurmuscular disease, infranodal block
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Afib
Types:
Paroxysmal:
Terminate within a week, with or without intervention
Persistant:
Fails to terminate within a week, often require pharmacological or electrical cardio version
Long standing:
More than a year
Permanent:
Joint decision to no longer pursue a rhythm control strategy
Treatment:
- unstable: cardioversion
- Stable: rate control ( BB, or Non-CCB as diltiazem ) versus rhythm control. Around 110bpm is acceptable
- >48hours, anticoagulate 3 weeks prior to cardioversion (DOAC), cause warfarin may take up to 6 weeks for patients to be effectively coagulated
- CHADS,VASC score (used to determine risk of embolization “specifically stroke”in non vulvular Afib patients)
- HAS-BLED score to asses risk of bleeding
CHF or LV dysfunction (EF40or less): +1
Hypertension: 1
Age 75: +1
DM: +1
Stroke, TIA, or thromboembolism: +2
Vascular disease (MI, PAD, aortic plaque): +1
Age 65-74: +1
Female: +1
2 male, or 3 women: initiate DOAC
Indications for warfarin:
- Vulvular Afib (moderate to severe mitral stenosis “is defined as valve area <1.5cm", mechanical heart valve, Hypertrophic cardiomyopathy)
- APL
Reversal agents for bleeding:
- Direct thrombin inhibitor ( Dabigatran ): Idarucizumab
- Factor Xa inhibitor ( Apixiban, rivaroxaban ): andexanet Alfa
- Since most of thrombus formed within left atrium appendage, chronic anticoagulation is considered according to chadvascs score
Contraindication to anticoagulant:
Unacceptable high risk of bleeding, thus include
- Thrombocytopenia
- Prior severe bleeding (ICH)
- recurrent bleeding
- High risk of fall, or previous fall resulting in injury
- poor medication complainance
Those, referral for a placement of percutanoues left atrial appendage occlusion device should be considered
Radiofrequency catheter ablation: beneficial for symptoms improvement, but doesn’t reduced risk of embolism stroke
Therapeutic INR in non Vulvular Afib: 2-3
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Supraventricular Tachycardia (SVT)
Unstable: Cardioversion
Stable: Vagal maneuver (to increase parasympathetic tone) first, if cannot performed or failed, Adenosine.
Iv metoprolol, or verapamil if vagal and adenosine ineffective
IV Digoxin if all above failed
182
DOAC and antiepleptics?
-Phentyoin
-phenobarbital
-carbamazepine
Contraindicated with:
- Dabagrtan
- Abixiban
- Rivarxiban
183
Prolonged QT syndrome
Causes:
Most common: medications
Familial
Hypokalemia
Hypocalcemia
Hypomaganesmia
Offending medications:
- antiarrhythmic
Class IA: procainamide, quinidine
Class IC: Propafenone, flecaindine
- older generations antipsychotic (haloperidol, droperidol), phenothiazine
- Cyclic antidepressant
- certain antiobiotics
Fluoroquinolone
Macrolide
Antifungal/ antiviral
- Nonsedating antihistamine
- Gastric motility agents
- methadone
- ECG:
Men QT interval >440 msec
Women QT interval > 460 msec
- treatment:
Symptomatic: Propranolol or Nadolol
ICD for high risk of sudden death
Congenital: BB even if asymptomatic (propranolol). Cardiology consultation, consider genetic testing and counseling
Acquired: Stop offending medication, correct electrolytes imbalance
Torsades de pointes: IV Magnesium sulphate or pacing
ICD indications:
1- syncope”specially if recurrent”
2- aborted cardiac arrest
3- ventricular tachycardia (eg. torsade de pointes ) on BB
184
Torsades de pointes
Most common caused by: acquired or congenital prolonged QT syndrome
ECG: wide complex tachycardia with QRS polymorphism
Management:
Unstable: Defibrillation
Stable: IV Mg and stop offending drug
185
Right bundle branch block
Wide QRS complex
((((Triphasic QRS complex in lead V1))))
Wide S wave in leads I, v5, or V6
186
Valsalva maneuver
Vagal stimulation by:
- cold stimulants to the face
- Valsalva maneuver: blow through a closed mouth or into straw/ syringe
- stimulate gag reflex
Thus will increase pressure in IVC > decrease preload > increase periphral vascular resistance > sudden termination the Manuver > sudden increase in the preload while the periphral vascular resistance is still high > rise in MAP > parasympathetic response that decrease the heart rate
** Carotid massage is CI in childrens
187
Verapamil contraindications
WW
- WIDE QRS
- SUSPECTED WPW SYNDROME
188
Premature ventricular contractions (PVCs)
Occur in general population
Specially lying on left side
Frequent ventricular premature beats: identify cardiac etiology; echo, holster, ecg, stress ecg
Risk factors:
- HTN WITH LVH
- MI
- HF
- HCM
- CHD
- idiopathic ventricular tachycardia
ECG:
- Earlier than the next expected normal QRS
- Wider than normal QRS, morphology is bizarre
- No preceding P wave
- followed by Pause
Asymptomatic: none
Symptomatic: BB- ccb
189
Basic ECG
P: depolarization of atria
PR: conduction through AV node
QRS: depolarization of ventricles
ST: between de, and re, POLRIZATION
T wave: ventricular repolarization
Normal HR: 60-100
PR: 120-200
QRS: 60-100
190
Normal P wave in ECG in normal sinus rhythm
Upright in leads I, II, aVF, V1 to V6
Inverted in avR
191
Ventricular Tachycardia
- Most common cause: previous MI
- Pulsless: immediate defibrillator
- Unstable: Cardioversion
- Stable: Amiodarone
192
Amiodarone Monitoring and Recommendations
- Chronic interstitial pneumonitis is the Most common complication
- Pulmonary toxicity is the most common cause of death among long term amiodarone users
Others:
- Pulmonary ( fibrosis )
- Nephrotoxic
- Hepatotoxic
- Metabolic (thyroid disorders, dyslipidemia )
- neurogenic ( tremor, neuropathy, ataxia )
- skin ( photosensitivity, bluish skin discoloration )
- Eyes: corneal micro deposits, optic neuropathy
- Cardiac: QT prolongation and Torsades de pointes, symptomatic SA or conduction system impairment
Baseline investigations:
- ECG
- TFT
- LFT
- CXR and PFT
- PE (neurological, eye examination, skin examination)
Follow up:
- TFT, LFT : every 6 months
- CXR and ECG: annually
- Derma, neuro, eye exam, PFT: PRN
When to discontinue amiodarone?
- Hyperthyrodism
- Optic neuropathy
- Any pulmonary disease
When to continue amiodarone?
- hypothyroidism: continue and treat
- corneal micro deposit
- Photosenstivity: avoid sunlight, use sunblock
When to reduce dose or discontinue?
- CNS complications (ataxia, dizziness, fatigue )
- Skin blue gray discoloration
- ECG changes
- Hepatotoxicity
193
Aortic valve replacement complications
- AV block ( heart block ) > Pacemaker
194
Wolff Parkinson White Syndrome
Most commonly caused by accessory pathway (BUNDLE OF KENT)
ECG:
1- Delta wave: slurred upstroke of QRS complex
2- Wide QRS
3- Short PR
Associated with; atrioventricular nodal reentrant
Acute treatment?
Orthodromic (down): vagal manuver > adenosine > bb > ccb
Antidromic (up): procainamide
Unstable: cardioversion
Definitive: Radiofrequency ablation
Concommunit Afib : Ibutilide ( BB- CC is contraindicated )
195
The most frequent mechanism of sudden cardiac death in acute MI is?
Ventricular fibrillation
Immediate treatment:
Non-Synchorized Cardioversion (defibrillation)
using Biphasic Waveform defibrillator
Defibrillation = Ventricular tachycardia or V fib
196
Anticoagulants
We are preferring to treat thromboembolism generally with DOAC (Direct Oral AntiCoagulant) previously known as NOAC (New Oral AntiCoagulant)
EXCEPT in those situations you should treat with WARFARIN!
1- Antiphospholipid syndrome
2- Left atrium thrombus
3- Moderate to severe mitral stenosis (including valvular A fib which is A fib with moderate to severe MS)
4- Cardiac prosthesis
5- Creatinine clearance less than 30 (except for Apixaban can be used till Crcl 15)
6- Cerebral venous thrombosis
7- Hypertrophic cardiomyopathy
197
Non vulvular afib, doesn’t want anticoagulant for reasons other than bleeding
Aspirin + clopdigrel
198
Multifocal atrial tachycardia (MAT)
Associated with COPD
ECG:
- HR >100
- P wave: variable morphology “at least three”
Treatment:
- Treat underlying cause + CCB
199
Approach to narrow QRS tachycardia
Q1- is it regular or irregular?
Regular: P wave visibility
Not visible: AV nodal reentry tachycardia (AVNRT)
Visible: atrial flutter, sinus tachycardia (same p wave) , focal atrial tachycardia (different p wave than baseline, RP prolonged)
Irregular: Afib, atrial flutter with variable AV block, Multifocal atrial tachycardia, Sinus tachycardia with premature atrial complex
200
Focal atrial tachycardia
Rhythm control if not hypotensive
BORDERLINE HYPOTENSIVE: IV AMIODARONE
NORMOTENSTIVE: IV BB OR NON-CCB
Types of heart block can appear with focal atrial tachycardia?
- 2nd degree heartblock
201
Sinus bradycardia
Causes:
- Medications ( BB, CCB, Digoxin)
- IHD
- Hyperkalemia
- Hypoglycemia
- Hypothyorism
- Hypothermia
- OSA
- Sick sinus syndrome
- Increased vagal tone (athletes)
Treatment:
Symptomatic: Atropine > epinephrine, dopamine > transcutaneous pacing
Asymptomatic: observation
202
Paroxysmal SVT
- most common type?
AV- Nodal Reentrant Tachycardia
- Hormone?
Progesterone
-ECG?
No P wave, Narrow qrs and regular
- Treatment?
Vagal > adenosine > cardioversion if unstable
203
Troponin non cardiac causes?
- Renal failure
- Sepsis
- Drug toxicity
- Stroke
- SAH
204
Sinus bradycardia, what to exclude?
Sinus node dysfunction (Sick sinus syndrome)
With Hother monitor
205
Definitive treatment for SVT?
Ablation
206
A fib caused by acute or alcohol use?
Holiday heart
207
Left bundle branch block
- LAD artery
- Widenend QRS
- lead I: Large wide R wave
- Lead V1: negative wave
Indications for cardiac resynchronization therapy (biventricular pacemaker) to pass the ventricular conduction system entirely:
Left bundle branch block + HF NYHA class 2-3
208
Ethanol toxicity and cardiac
- associated with development of atrial arrhythmia, specially Afib
- Ataxia, gait instability, slurred speech
- severe intoxication 4H ( hypothermia, hypotension, hypoglycemia, hypoventilation )
- Supportive, In severe cases; glucose and thiamine
209
Afib initial labs and imaging
- CBC
- Kidney function
- Renal function
- TSH
- CXR and ECHO
Drugs: only if suspected (ventolin, lithium, alcohol, diet pills)
Sleep study: if OSA is suspected as the cause
210
V tachy
Shock
Sock
Before the third shock: consider amiodarone
211
VULVULAR HEART DISEASES
REFER TO PDF EXPERT
212
Acute Rheumatic Fever
Type two hypersenstivity reaction, where is the Antibodies against GAS crossely reacting with host cell protein.
History: recent GAS infection
Diagnosis: Revised Jones Criteria
Labs: antistreptolysin O, anti-DNase B, Throat culture, rapid antigen test.
Treatment is AB and NSAID
Antibiotic for GAS doesn’t prevent against PSGN
The goal is to prevent GAS and recurrent rheumatic fever, which may worsen already existing rheumatic heart disease, or induce it
- drugs:
Penicillin G (IM) is the first line. Every 21d or 28d (21d is preferred in high risk situation such as acute recurrence of Rheumatic fever despite adherence to 28d injections)
Penicillin V (oral) is the second line, usually due adherence issue
Penicillin allergy?
1- desensitization
2- Azithromycin
3- Erythromycin ( more side effects and more daily doses)
4- clarithromycin
Duration (whichever longer):
Without carditis: 5 years, or till 21
With carditis: 10 years, or till 21
With carditis + residual heart disease (VHD): 10 years or till 40 years, sometimes lifelong prophylaxis is indicated ( higher risk to exposed to GAS; teacher, crowdy, healthcare worker )
213
Mitral stenosis and anticoagulants?
- Afib
- Left atrial thrombus
- Prior embolic event
214
Congenital Heart Diseases
1- VSD:
- Most common pathological murmur in childhood
- Types:
Infundibular
Memberanous “MOST COMMON"
Inlet
Muscular
Rare type: Gerbode defect, defiency of AV septum separating left ventricle from right atrium, needs periodic screening for sinus node dysfunction And tricuspid regurgitation
- Small: often asymptomatic aside from murmur
- Moderate: FTT, diaphoresis with feeding, tachypnea,..
- Large: risk of Eisenmenger syndrome
- Loud harsh PANSYSTOLIC murmur, lower left sternal border
- diagnosis: Echo. Moderate-to-large VSD can be detected in utero “16-18w”
- Treatment:
small: monitoring without intervention
Moderate, large: monitoring, diuretics for symptoms
Moderate, large unresponsive to medical therapy: surgery
Surgery should be avoided in severe pulmonary HTN
Down: A-V septal defect is the most common, followed by VSD
2- Coarocation of aorta:
- Narrowing of descending aorta
- Associated with Turner, intracranial aneurysm, bicuspid aortic valve”
- Bicuspic AV, and VSD are the most common cardiac defected associated with coarocation of aorta
- Systolic BP in upper limbs, and femoral delay
- ECG: LVH
- CXR: Ribs notching
- Diagnosis: Echo
- treatment: ballon angioplasty with stent, or surgical correction
3- ASD:
- Wide fixed split S2
- Most commonly caused by persistant Ostium SECUNDOM “septum primum, septum SECUDUM, AV septum"”
- Osteum Secondum caused by growth arrest or osteum secondum, or excessive absorption of the septum primum
- small: usually asymptomatic
- large: FFT, diaphoresis,… and recurrent pulmonary infection
- CXR with large ASD: Cardiac enlargement AND increase pulmonary vascularity
- ECG: incomplete right bundle branch block
- treament:
Often close spountanously during childhood
If persistant: Percutanous closure or surgery
4-: Teratology of Fallot
- Most common CYANOTIC CHD
- Associated with trisomy 21 “down”
- Cresencendo decrescendo harsh systolic ur ur
- Echo PROV: Pulmonary valve stenosis, RVH, Overrding aorta, VSD
- Cyanosis with exertion called hyper cyanotic spells or tet spells “with feeding, crying..” and squatting for relieve
CXR: Boot shaped heart
5- Brugada syndrome
- AD conduction disorder
- ECG: V1-V2 coved or saddleback ST segment
- Schizophrenia can be associated with brugada pattern ECG
- Nocturnal agonal breathing with gasping breaths during sleep, represent aborted cardiac dysrhythmia, common presentation to Brugada
- Amiodarone, most effective medication to prevent tachyarrhythmia in those patient
- BEST management: ICD “for symptomatic (preceding syncope or V dysrhthmia”or family history of sudden cardiac death
6- PDA
- RF: birth at high amplitiude, prematurity, rubella, female, genetics
- hemodynamic close 10-15h soon after birth. And histological obliteration by the third week
- bounding pulse, wide pulse pressure
- continuous machinery like flow murmur radiated to the back, best heart left upper sternal border 2nd ics below the clavicle
- indeomethacin or ibuprofen in premature infants, surgery
- can leads to Eismenger
7- Ttransoprtation of great vessels
- Aorta raised from RV
- pulmonary artery arise form LV
- typically, no murmur heart unless concumient VSD
8- Pantology of Fallot:
- Teratolgy of Fallot + ASD
215
Infective Endocarditis
- Risk factors:
VHD (mitral valve prolapse or regurgitation)
History of RHD or IE
Congenital cyanotic heart disease
Intracradiac or intravascular device
Indwelling venous catheter
IV drug use
DM
HIV
Age greater than 60
Male
Poor dentition
Hemodialysis
- most common symptoms: fever > malaise
- PE: FROM JANE ( Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, anemia, nail bed haemorrhage, embolism
- Diagnosis: Echo and Duke criteria
- Most common caused by (REFER TO UTD)
Most common worldwide: staph aureus
Most common in US and developed conurry: Staph aureus
Staph aureus 1/3 of cases and more important in hospital acquired. Strept in more important in community
IV drug abusers: Staph aureus, typically tricuspid valve
Native valve: Staph aureus, typically mitral
Previously diseased native valve (CHD, degeneration, calcified, RHD): Strep viridans, typically mitral
GI malignancy: strep Bovis
Murmur: most often not presented on initial presentation
IV drug Endocarditis carries a lower mortality rate than prosthetics valve endocarditis
Tranthoracic echo carries a sensitivity only 60% for endocarditis. If the transthoracic is negative, and clinical suspection is high > TRANSESOPHAGEAL ECHO
Treatment:
Microbiological response to treatment assessed every 1-2 days with blood culture until bacterimia cleared
Duration is 6 weeks
Empiric antiobiotic should cover MRSA, so it’s always VANCOMYCIN
AB can be ulcer once we have the culture results
Indications for valve replacement surgery:
1- New onset Heart failure
2- perivalvular abcess
3- persistent positive culture despite 7 days of Antibiotic
4- Persistent embolic event despite treatment with Antibiotic
Criteria for prophylaxis AB:
Both of the following
1- high risk patient for IE
2- high risk procedure
High risk patents:
1- Prosthetic heart valve, prosthetic material used in valve repair
2- Prior IE
3- Unrepaired cyanotic congenital heart disease, including palliative shunts or conduits
4- Repaird CHD with prosthesis during the first 6 months after procedure. OR. Repaired CHD with residual defect at or adjacent to the site of prosthesis device or patch
5- Heart transplant with valvulopathy
High risk procedures:
1- Dental: include routine dental cleaning
2- Respiratory: Incision or biopsy of respiratory mucosa
3- Skin or soft tissue: infected tissue surgical management
4- Cardiac surgery with prosthesis
Other procedure (trans esophageal echo, GI AND GU) doesn’t require AB, except if active infection is present at the site of the procedure
Choose of Antibiotics:
Amoxicillin, 2g, 30-60m prior to procedure
If pencillin allergic > azithromycin, clarithromycin, doxycycline,, cephalexin
216
MODIFIED DUKE CRITERIA
Modified Duke criteria:
Pathological
- from tissue culture or histology ( from vegetation including embolism, or intracardiac abcess )
Major
- Positive blood culture ( 2, 12 hours apart, typical organisms as staph, strept, HÁČEK, Ecoli, or single culture of coxiella burnetii )
- Echo ( evidence of endocardial vegetation - new valve regulation - abcess - prosthetic valve dehiscence )
- Minor “TIMER”
T: Temp >38
I: Immunological phenomena (Osler nodes, Roth spot, positive RF, Glumeronephritis)
M: Microbiological not meeting major,
E: Embolic phenomenal ärterial or septic emboli, conjunctival haemorrhage, mycotic aneurysm, Janeway lesion),
R: Risk factor
DEFINITIVE:
2 Major
1 Major + 3 Minor
5 Minor
1 pathological
POSSIBLE:
1 Major + 1 Minor
3 Minor
REJECTED DIAGNOSIS:
Not definitive or possible
Firm alternative diagnosis present
Absence of surgical or autopsy evidence of IE in the period of first three days of AB
Resolution of clinical characteristics of IE in 4 days or less of AB
217
Acute pericarditis / Pericardial effusion
MCC:
- Idiopathic or viral
- Uremic: BUN >60mg/dL, no st elevation
- Pleurtic chest pain ( worse on supine, inspiration, or coughin - improve on sitting or leaning forward )
- Pericardial friction rub, best heard on leaning forward and inspire
- ECG:
PR depression
PR elevation in lead aVR
widespread ST elevation
In ongoing non treated condition: PR and ST may normalize, and T wave flattening or inversion may develop
- CXR: cardiomegaly “200ml required for cardiomegaly to appears"
- ECHO: should be performed after cardiac surgery, or haemodynamcally unstable patients r/o pericardial effusion or temponade. OTHERWISE: ECG IS THE BEST BUT SHOULD BE FOLLOWED BY ECHO. Echo usually normal in patients with pericarditis, so ECG is best, and then evaluate for effusion by echo
Treatment:
- NSAIDs “Aspirin for Dressler, and Ibuprofen for others pericarditis”
- Colchicine “prevent recurrence, so add it to NSAIDs"
- Steroid have the higher recurrence rate ( refractory / cannot use primary medications / certain rheumatological disorders )
NSAIDS
- Indomethacin may reduce myocardial perfusion, therefore not preferred in patients with CCS OR ACS
- 2nd line: Colchicine, alone or in combination with NSAIDs
Steriod: shown to increase risk of recurrent pericarditis
Therefore, not preferred, unless indicated
Criteria to admission:
1- fever
2- subacute presentation
3- high troponin
4- immunocompromised
5- anticoagulant use
- presence of pericardial effusion or temponade
- trauma
- failure to outpatient tx
—————-
Pericardial effusion:
- Most commonly after episode of Acute pericarditis
- Usually asymptomatic, but if cocomminet with acute pericarditis, presented typically with fever, fatigue, sob, elevated JVP, edema
- highly suggestive physical sign of pericardial effusion is dullness to percussion at the point of maximal impulse
Ecg: Sinus tachycardia with low QRS voltage
Treatment:
Acute affecting hemodynamic stability: Pericardiocentesis
Chronic/ stable:
Treat underlying etiology
Pericardiocentesis: if there’s symptomatic pericardial effusion, or greater than 20mm effusion
218
Most common primary cardiac tumor?
Atrial Myxoma
Most commonly involve left atrium
Echo is initial
MRI is gold standard
Most serious complication: emboli
219
Myocarditis
Etiology: most commonly viral
Most common cause worldwide is: Chagas’ disease “protocol; trypanosoma Cruzi"
PE: Tachycardia disapproptane to degree of fever or discomfort, s3 or s4 gallop
Echo and MRI
Gold standard is Endomyocardial Biopsy
Treatment is supportative
Chronic myocarditis: immunosuppressant
Giant, esionophilic myocarditis: IVIG
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Modified Jones criteria for Acute Rheumatic fever
Evidence of GAS infection, PLUS:
First episode: 2 major, or, 1 major + 2 minors
Recurrent: 2 major, or 1 major + 2 minors, OR, 3 minors
Evidence of GAS infection, (any of the following):
1- increased Antistreptolysin O or anti DNase
2- Positive throat culture of GAS
3- positive rapid antigen test
4- Recent scarlet fever
Major ( JONES)
J (JOINT): migrating Polyarteritis, or mono in mod-high risk groups “knee/ankle/wrist/elbow”
O (Ouch, my heart, Carditis): Echo valvulitis, or new or changing murmur (mitral regurgitation), both clinical and subclinical
N(Nodule): subcutaneous, painless, firm, usually over bone or tendon
E (Erythema marginatum): Nonpruritic rash over the trunk and extremities, sparing the face
Minor:
Fever
Poly/monoarthrlagia
High ESR or CRP
Prolonged PR interval on ECG
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Some causes of sudden cardiac arrest?
- Congenital long QT syndrome
- Short QT syndrome
- Commito cord is
- Idiopathy ventricular tachycardia
- idiopathic ventricular fibrillation
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Innocent heart murmur
7S:
Short duration (not holosystolic)
Single (no clicks or gallops)
Small (not radiated)
Soft (low amplitude)
Sweet sounding (not harsh)
Sensitive (change with positing and respiration) > murmur that are loudest in supine, disappear in standing or valsalva are usually innocent
SYSTOLIC
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Pulsus paradoxus definition and DDx
Drop in SBP with inspiration more than 10 mmHG
O/E: feel the pulse while auscultation > listen to the beat without feeling the pulse
Differential diagnosis:
- Constructive pericarditis
- Cardiac temponade
- Croup
- Obstructive lung disease
- Pulmonary embolism
- Vena cava thrombus
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Electrical alternans
Beat to beat difference in QRS axis or amplitude
Seen in temponade, or effusion
The cause is the heart swing in the pericardial fluid, usually with large effusion
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Heart valves
Prosthetic heart valve:
Biological: Last 10 years, No anticoagulant, No click
Mechanical: Last >20 years, Anticoagulant, Click
Mechanical valve require anticoagulant because they are MORE thrombogenic and hemolysis than Biological valve.
In auscultation: Mechanical ( loud metallic closure sound, softer opening click ). Biological ( same sounds at native, but louder )
Paravalvular leaks: more common with mechanical valve than biological
Recommended INR?
Mitral: 3
Aortic: 2.5-3
2-3 in general. If the patient have additional risk factors for thromboembolism such as; Afib, LV dysfunction, previous embolism> THE TARGET WOULD BE 2.5-3.5
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Mechanical complications of acute MI?
Mechanical complication of acute MI
1- LV free wall rupture
2- VSD
3- Papillary muscle rupture (acute mitral regurgatioin)
VSD: Holosystolic murmur, thrill
Mitral regurgitation: Holosystolic murmur, No thrill, radiated to axilla
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Safest ACEI in patient taking simvastatin?
Ramipril, can take 40mg daily
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Stable angina medications
BB is the first line
If not relieving
Long acting nitrate “isosorbide mononitrate” NOT dinitrate (short acting)
If not releving
CCB
Amlodopine or EXTENDED release nifedipine if the patient taking BB
Non-DHT if the patient not taking BB
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Minimum amount of dual antiplateles after stenting
Drug eluting stent [DES]:
- 6 months for stable angina
- 1 year for ACS
Bare metal stent:
- 1 month
STOPDAPT trial and SMARTCHOICE trial
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Dual antiplatelets and surgery
Aspirin: can be continued safely, except if very high risk bleeding procedure [ neurosurgery, posterior eye surgery]
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Atrial arrhythmias
Atrial flutters “saw tooth pattern”: regular
SVT: regular
Afib: irregular
MAT: irregular
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Rate versus rhythm control in Afib
- it is patient specific, no significant difference of all causes of mortality between the two approaches
- patients who tend to benefit more from rhythm control are: YOUNGER, HIGHLY SYMPTOMATIC, LESS RESPONSIVE TO RATE CONTROL, RISK FOR TACHYCARDIA MEDIATED CARDIOMYOPATHY
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Sinus bradycardia causes?
1- Medications ( BB, Non-DHP CCB, antiarrhythmic, cholinestrase inhibitors )
2- OSA
3- hypothyroidism
4- acute mi
5- electrolytes abnormalities
If all the above causes are ruled out, you’re left with Sinus Node Dysfunction (cause of bradycardia in elderly) > pacemaker if symptomatic
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Hypertensive emergency ( Heart failure )
First line: IV Nitroglycerin
IV nicradipine > may cause reflux tachycardia > harmful for CAD
IV Labetalol > CONTRAINDICATED IN ACUTE HEART FAILURE
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Pediatrics HTN
- other arm and one leg measurement of BP > to evaluate coarocation of aorta
- from the age of 13 years old, don’t use precentile, use table ( grade 1 is 130/80 - grade 2 140/90 ) according to American Academy of pediatrics
- cuff blade ( 80-100% length, and 40% width ) of arm circumference
- age of BP measurement: 3 years
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VHD and EF!!
- Aortic stenosis: <35%
- Mitral regurgitation: <60%!!!!!!!!!!!!!! (Associated with rapidly declining 10 years survival)
Don’t forget symptomatic; surgery
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Varicose veins
Conservative management
Interventional treatment ( sclerotherapy, endovenous laser ablation, surgical vein ligation ) if;
- Severe symptoms or skin changes, or failure of conservative
- saphenous vein reflux in Doppler “as this is the primary target in most procedures ”
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Preoperative management for Cardiac Conditions
1- Afib
Target ventricular rate is: <110
For elective surgery, if >110, postpone the surgery until adequate rate control
2- Aortic sclerosis
Right sternal systolic murmur with otherwise no symptoms or signs
3- stable CAD, no symptoms, and good functional capacity (exercise capacity is 4 or more metabolic equivalent”
No cardiac investigations needed for low risk surgeries [ including cataract, endoscopic, superficial procedures, breast surgery, ambulatory surgeries ] AND medium risk non-cardiac surgeries [ including colonectomy, rotator cuff tear ]
4- Active cardiac conditions
This include [ unstable angina, decompensated heart failure, concerning arrhythmia, severe VHD ]
Cardiac evaluation is required
5- Post PCI elective surgeries:
Metal stent: 1m
DES: 6m
DAPT: continue aspirin if possible, and restart pgy12 Inhibitors ASAP after surgery
If delaying surgery is inadviseable > cardiology consultation
6- Urgent and Emergent: Proceede
7- Unstable CAD and not on BB:
Never start before surgery to avoid significant bradycardia and hypotension. Start low dose and titrate up slowly weeks before the surgery
8- Mechanical heart valve on warfarin
Stop warfarin 5 days before surgery, and, initiate IV heparin “THERAPUTIC DOSAGE” or LMWH infusion when INR is less than 2.5 (2-2.5)
IV: for end stage CKD
LMWH: for normal-borderline CKD
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Pleural friction rub versus pericardial friction rub
Pericardial friction rub: Acute pericarditis, best listened when the patient end of expiration and leaning forward, PERSIST when the patient hold his breath
Pleural friction rub: PE, absent when the patient hold his breath
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Adultscent with ST elevation and history of Kawasaki
Long term squeal of Kawasaki is: Coronary Artery Aneurysm > can lead to thrombosis OR stenosis > Acute MI
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Spironlactone indications and contraindications
Indications
EF <35% AND NYHA class3-4
EF <30 AND NYHA class2
CI:
Advanced renal disease ( baseline creatinine 2 for female and 2.5 for male, or eGFR <30 )
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Indications for ICD and biventricular pacing for cardiac resynchorization for prevent sudden cardiac death?
ICD:
Non-ischemic cardiomyopathy and LVEF <35% and NYHA 2-3
If left bundle branch block and QRS >150msec add biventricular pacing CRT
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Kawasaki disease
Criteria [ CRASH BURN ]
Fever met the criteria + at least 4/5:
Burn: fever for 5 days
C: conjunctivitis ( non exudative, spare the limbus )
R: Rash (erythema or polymorphous exanthem )
A: Adenopathy ( Anterior cervical, >1.5cm )
S: Strawberry tongue ( erythema of lib and oral cavity )
H: Hand and feet swelling
Treat to prevent cardiac complications: Coronary artery aneurysm > stenosis or thrombosis > SCD, IHD
IVIGg + IV high dose Aspirin
Treatment should started within 7 days, or 10 days maximammily
After 10th day, treatment reserved for those with ongoing unexplained fever or signs of ongoing inflammation
Glucocorticoids? > can be used along with IVIG for patients with high risk of CAA, but not alone
ALL children should undergone BASELINE ECHO, but this should not delay treatment > to look for coronary artery morphology, left ventricular and valvular function, and evidence of pericardial effusion
ECG? Not required unless arrhythmia symptoms
Incomplete Kawasaki disease? As patients with a major and 3 or 2 minor; other etiology should be suspected as EBV ( respiratory virus panel, serology for viruses )
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HF and ivabardine and Carvidalol and Dapagliflozin
BEAUTIFUL TRIAL
Showed increase cardiovascular event if resting HR >70
So used if the patient on maximum tolerated BB + HR >70
Carvidalol
25mg BID for <85kg
50mg BID for >85kg
Data showed a lower moratily than Empa in HF
Hydralazine and isosobide-denitrate
If ACEI or ARBS is not tolerated
Or; add on if persistant symptoms despite full guideline directed medical therapy (ACEI-ARNI-ARBS, BB, Spironalctone, SGLT-2)
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Myocarditis most common cause
Viral
Specifically enteroviral ( coxacki virus )
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Aortic stenosis
Soft or absent aortic sound of 2nd heart sound
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Lyme cardiac disease
History of Camping in US
Organism: Borrelia burgdoferi
Characteristic circular rash (erythema migrants)
Heart: Conduction disorders
Early non disseminated disease: oral “doxy, amoxi”
late disseminated: IV Ceftriaxone
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ACS and dual antiplatelets timing
STEMI: immediate
NSTEMI AND UA: often P2Y12i added after angiography
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Acute management of ACS contraindications
BB: CI in bradycardia and CARDIOGENIC SHOCK
Nitrate: CI in inferior MI
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OSA-mediated bradycardia
CPAP is the treatment
Permenant pacemaker is not indicated
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Post operative Afib
Frequently seen
Self limiting
80% resolve within the first 24 hours
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Approach to pediatrics HTN
Definition: systolic or diastolic 95th percentile or above for age,sex,height On 3 separate visits
Echo should be included as an initial workup
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Carotid hypersensitivity syndrome
Test is recommended in patients age >40 with syncope of uncertain etiology
Diagnostic criteria after carotid sinus message:
1- syncope + asystole >3seconds
2- fall in SBP >50mmHg
Contraindications to carotid sinus massage:
1- ipsilateral carotid artery stenosis or bruits
2- History of TIA or stroke within the past 3 months
Treatment:
Permanent pacing
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Lidocaine and arrhythmia?
For wide complex QRS and not first line
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Primary goals in HFpEF
1- Maintain euvolemia
2- Maintain targeted BP
3- Check for CAD by stress testing
4- revasculrize documented ischemia
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Atypical MI symptoms
Typical are sub sternal heavy/squeezy sensation
Atypical (elderly, DM, women):
Burning sensation, vague discomfort, fullness in the chest
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BNP interpretation in dyspnea patients
Normal (<100): no cardiac dyspnea / obesity
Intermediate (100-400): Possible CHF, AKI/CKD or others; pulmonary HTn, advanced age, stroke or ICH
Elevated (>400): likely CHD(95% liekhood), could be sepsis or hematologyical malignancy
NT prop BNP:
<300 unlikely
more: likely
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Vasovagal syncope
Often preceded by nausea, diaphoresis, bradycardia, pallor
Management: reassurance, avoid trigged, assuming supine position at onset of symptoms. Physical counterpressure manutvers can abort or delay the episode of syncope
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Streptococcus gallolyticus ( S bovis ) and colon
Colonscopy for underlying malignancy
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Acute decompnesated HF management
1- IV diuretics 40mg ferusmide
2- supplemental oxygen
3- vasodilators ( nitroprusside, nitroglycerin): if severe HTN not responding to diuretica
4- iontropes: short term treatment with hypotension and signs of hypoperfusion: dubtamine, milrinone
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Carotid artery stenosis management
Medical as secondary prevention in patients with TIA or stroke should include; Antiplatets, statin, and control BP
Endarterectomy:
>50% if symptomatic
>70% if asymptomatic
Complete occlusion (100%): no benefit of surgery
No need for warfarin/DOACs here
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Statins and hypothyroidism
Hypothyroidism can precipitate statin myopathy
Statin can aggravate hypothyroid myopathy
Any statin myopathy? Screen for TSH
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Peri infarction pericarditis
High dose aspirin
Use of anticoagulants/steriod/NSAIDs should be avoided in that sitting
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Thrombolysis contraindications
1- History of ICH
2- History of ischemic stroke within 3 months
3- History of recent intracranial, intraxial surgery
4- History of intraaxial neoplasm
5- BP >185/110
6- Platelets <100,000
7- Glucose <60
8- INR >1.7, PT >15sec, high PTT
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Dyslipidemia screening
Men 35 years old
Women 45 years old
Younger with additional CVD risk factors
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Hyperkalemia ECG changes
1-Prolonged PR interval and tall t wave
2- ST depression, loss of P wave
3- Wide QRS
4- Asystole
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High risk procedure?
Aortic and other major vascular surgeries
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Pericardial effusion and hypothyroidism
Incidence: 25%
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ABC or CAB for cardiac arrest?
CAB
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Aortic stenosis and monitoring
Mild (Every 3-5 years):
Mean gradient <20
Moderate (Every 1-2 years)
Mean gradient 20-39
Severe (Every 6 months if asymptomatic, surgery if symptomatic)
Mean gradient >40
Aortic area<1cm
Surgery Recommended for asymptomatic if severe + LVEF <50%
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Post prandial hypotension التخمة
Dropped SBP >20mmHg
Treatment:
Increase fluid intake
Decrease meal size and carbs
Standing up slowly
Compression stocking
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Is Ejection fraction reduce with aging?
NO
Aging
Atrial: increase in size and volume
Ventricular: increase mass and wall thickness
Resting LVEF doesn’t change in healthy older individuals
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Syncope etiologies
1- Vasovagal syncope (cardioneurogenic syncope):
- triggers: prolonged standing, emotional distress, painful stimuli
- prodromal symptoms: nausea, warmth, diaphoresis
2- situational syncope:
- triggers: cough, micturation, defecation
3- Orthostatic syncope:
Postural changes in HR/BP upon standing suddenly
4-: Aortic stenosis/ HOCM/ anomalous coronary arteries:
Syncope with exertion or exercise
5- Ventricular arrhythmias:
Prior history of CAD, cardiomyopathies, or HF
6- Sick sinus syndrome/ AV block/ Bradyarrhthmia:
Increased QRS and PR durations
7- Torsades de pointes (congenital/acquired long QT syndromes):
Hypokalemia, hypomagensemia, medications, family Hx of SCD, syncope with triggers “ëxercise, sleeping)
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PAD
Smoking
Antiplatet
Statin
Dm and HTn
Structured exercise program
Failed?
Cilostazol
Revascularization ( per cutaneous or surgical )
Usually for ABI <0.5 or limb threatening ischemia
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Risk factors for resistant HTN
- Black
- Elderly
- Male
- Obese
- LVH
- DM / CKD-albumiuria / high CVD risk
- OSA
- Insomnia
- genetics
- hyperuricemia
- hyperaldosternism
- vascular disease
- genetica
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Modified framingham ciriteria of HF
2 major / or 1 major and 2 minors
Majors:
- PND
- orthopnea
- JVP elevated
- pulmonary rales
- 3rd heart sound
- Caridomegaly on CXR
- Pulmonary edema on CXR
- weight loss 4.5kg in 5 days in response to treatment of presumed HF
Minor:
- bilateral leg edema
- nocturnal cough
- dyspnea on ordinary exertion
- hepatomegaly
- pleural effusion
- tachycardia, HR 120
- wight loss 4.5kg in 5 days
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CXR in HF
ABCDE:
A: alveolar edema “bat wings”
B: karely B lines “intersitial edema”
C: Cardiomegaly
D: dilated prominent upper lobe vessels
E: effusion “pleural effusion”
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TEE in HF?
- pregancy and severe obesity
- patients on mechanical ventilation
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ARNI versus ACEI and ARBS
ARNI = ARBS + neprilysin = Valsartan+secubitril
Symptomatic HFrEF class 2/3 recommended to change to ARNI for further reduce morbidity and mortality
Allor 36hr between stopping ACEI and switch to ARNI “concerns of angiodedma
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Empa or dapa?
Dapa better a little bit in studies
eGFR: 30 for dapa, and 20 for empa
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Medications to avoid in HF patients
1- non selective NSAIDS + selective COX-2 inhibitors
2- CCB: nifedipine, verapamil, dilitizam
3- most antiaarhthmic ( except class 3 )
4- Thiazolidibediones
5- Saxagliptin, Alogliptib
6- alpha1 blockers; doxazosin
