Cardiology Flashcards
The single most important bedside measurement from which to estimate the volume status
JVP
wave that occurs with atrioventricular (AV) dissociation and right atrial contraction against a closed tricuspid valve
cannon a wave
a wave is not present in AF
waves that are present in progressive TR
C-V waves
Abdominojugular reflux is produced with firm and consistent pressure over the upper portion of the abdomen, preferably over the right upper quadrant, for >___ s.
A positive response is defined by a sustained rise of > __ cm in the JVP during the application of firm abdominal pressure
15s
>3 cm
indicates presence of >15 pulmonary artery wedge pressure
Blood pressure should be measured in both arms, and the difference should be < __mmHg
10
Systolic leg pressures are usually as much as ___ mmHg higher than systolic arm pressures.
20
A weak and delayed pulse (pulsus parvus et tardus) defines what dse ?
severe aortic stenosis (AS)
Abnormal pulse oximetry (a >__% difference between finger and toe oxygen saturation) can be used to detect lower extremity peripheral arterial disease and is comparable in its performance characteristics to the ankle-brachial index.
2
Reversed or paradoxical splitting refers to a pathologic delay in aortic valve closure, such as that which occurs in patients with ______ (5)
left bundle branch block, right ventricular pacing, severe AS, HOCM, and acute myocardial ischemia
With standing, most murmurs diminish, with two exceptions being the murmur of , which becomes louder ___, and that of ___, which lengthens and often is intensified.
HOCM
MVP
Classic triad of findings ECG for pericardial effusion with cardiac tamponade
(1) sinus tachycardia
(2) low QRS voltages
(3) electrical alternans
In CTA, Coronary what calcium scores are considered
moderate ?
severe ?
moderate (100–400)
severe (>400).
considered the most accurate noninvasive technique to evaluate the structure and ejection fraction of the right ventricle
CMR
most common congenital anomaly of the heart
bicuspid aortic valve
An important predictor of outcome in patients with mitral regurgitation of any cause.
Ventricular dilatation
in a patient with significant mitral regurgitation, a large portion of the blood being ejected from the left ventricle with every beat is regurgitant, thus artificially increasing the ejection fraction.
Thus, an ejection fraction of 55% in a patient with severe mitral regurgitation may actually represent substantial reduction in myocardial systolic function
Definition of cardiotoxicity
The accepted standard for clinical diagnosis of cardiotoxicity is defined as a >5% reduction in LVEF to <55% in symptomatic patients or a 10% drop in LVEF to <55% in patients who are asymptomatic.
Most common type of ASD
Secundum
occur most commonly in the region of the fossa ovalis
Warfarin is held starting ___ days prior to the cardiac catheterization to allow the international normalized ratio (INR) to fall to ___ and limit access-site bleeding complications.
2-3
<1.7
What sign is demonstrated by an increase in the left ventricular–aorta pressure gradient with a simultaneous decrease in the aortic pulse pressure following a premature ventricular contraction?
Hypertrophic obstructive cardiomyopathy is confirmed by the Brockenbrough-Braunwald sign
What disease condition/s is/are square root sign seen?
Constrictive pericarditis, restrictive cardiomyopathy
Cardiomyopathy that has amarked increase in right ventricular and pulmonary artery systolic pressures (usually >60 mmHg),
Restrictive
What disease condition has prominent x and y descent?
Constrictive pericarditis
A coronary stenosis of __ % is considered significant
50%
A sinus rate of < ___ beats/min in the awake state in the absence of physical conditioning generally is considered abnormal
40
Treatment options for POTS
Volume expansion with salt supplementation, oral fludrocortisone, compression stockings, and the α-agonist midodrine, often in combination, can be helpful. Exercise training has also been purported to improve symptoms.
Most likely mechanism of MAT
triggered automaticity
The risk of developing VT is greatest in _____ of acute MI.
the first hour
The cardinal symptoms of HF are ____ and ___
fatigue and shortness of breath
Most impt mechanism of dyspnea in HF
The most important mechanism is pulmonary congestion with accumulation of interstitial or intra-alveolar fluid, which activates juxtacapillary J receptors, which in turn stimulate the rapid, shallow breathing characteristic of cardiac dyspnea.
A normal ECG in HF virtually excludes _____
LV systolic dysfunction
For HFreF beta blockers should ideally be restricted to
carvedilol, bisoprolol, and metoprolol succinate
The single most important association of extent of dyssynchrony is ______ on ECG
a widened QRS interval on the surface electrocardiogram, particularly in the presence of a left bundle branch block pattern
Cardiomyopathy that has EF > 60%
Hypertrophic
cardiomyopathy that has LV dimension >60 mm
Dilated
Cardiomyopathy related to valve septum interaction
Hypertrophic
Cardiomyopathy related to endocardial involvement
Restrictive
The most commonly recognized genetic causes of DCM are truncating mutations of the ___
ogiant protein titin, encoded by TTN, which maintains sarcomere structure and acts as a key signaling molecule
Define possible subclinical, probable and definite myocarditis
(1) Possible subclinical acute myocarditis is diagnosed when a typical viral syndrome occurs without cardiac symptoms, but with elevated biomarkers of cardiac injury, ECG suggestive of acute injury, reduced left ventricular ejection fraction or regional wall motion abnormality.
(2) Probable acute myocarditis is diagnosed when the above criteria are met and accompanied by cardiac symptoms, such as shortness of breath or chest pain, which can result from pericarditis or myocarditis.
(3) Definite myocarditis is diagnosed when there is histologic or immunohistologic evidence of inflammation on endomyocardial biopsy and does not require any other laboratory or clinical criteria.
most common infective cause of cardiomyopathy
Chaga’s dse
The most common cause NONinfective inflammation of the heart is
granulomatous myocarditis, including both sarcoidosis and giant cell myocarditis.
most common toxin implicated in chronic DCM
Alcohol
Estimates of the alcohol intake necessary to cause cardiomyopathy have been 4–5 ounces or 80–100 g of pure ethanol daily for 5–10 years, about 1 L of wine, 8 beers, or ½ pint of hard liquor. Frequent binge drinking may also be sufficient
The most common current reason for thyroid abnormalities in the cardiac population is the ______
treatment of tachyarrhythmias with amiodarone, a drug with substantial iodine content
Treatment for HOCM
β-Adrenergic blocking agents and L-type calcium channel blockers slow AV nodal conduction and improve symptoms
cardiac glycosides should be avoided, as they may increase contractility and worsen obstruction
Major risk factors for SCD in HOCM
see table
T-wave changes are more common but are less specific signs of ischemia, unless they are new and deep T-wave inversions ( ____ mV).
≥0.3
Thrombolysis in Myocardial Infarction (TIMI) Trials, which includes seven independent risk factors which include
age ≥ 65 years
3 or more of the traditional risk factors for coronary heart disease
known history of coronary artery disease or coronary stenosis of at least 50%
daily aspirin use in the prior week
more than one anginal episode in the past 24 h
ST segment deviation of at least 0.5 mm
elevated cardiac specific biomarker above the upper limit of normal
The only absolute contraindications to the use of nitrates are _____ and ____
hypotension or the recent use of a phosphodiesterase type 5 (PDE-5) inhibitor, sildenafil or vardenafil (within 24 h), or tadalafil (within 48 h).
Target HR for NSTEMI
50-60
DAPT should continue for at least ____ in patients with NSTEACS, especially those with a drug-eluting stent, to prevent stent thrombosis.
1 year
When is immediate invasive strategy indicated in NSTEMI
see table
Cut off GRACE score to qualify for early invasive strategy in NSTEMI
> 140
Treatment for Prinzmetal angina
Nitrates and calcium channel blockers
Aspirin may actually increase the severity of ischemic episodes, possibly as a result of the sensitivity of coronary tone to modest changes in the synthesis of prostacyclin.
Statin therapy has been shown to reduce the risk of major adverse events, although the precise mechanism is not established
The pain of STEMI may radiate as high as the _____ but not below the ____.
as high as the occipital area but not below the umbilicus.
in STEMI, The nonspecific reaction to myocardial injury is associated with polymorphonuclear leukocytosis, which appears within a few hours after the onset of pain and persists for ___ days; the white blood cell count often reaches levels of 12,000–15,000/μL.
3–7
How do you differentiate Type 1 -5 MI
see table
An idiosyncratic reaction to nitrates, consisting of sudden marked hypotension, sometimes occurs but can be reversed promptly by the rapid administration of intravenous _____
atropine
FMC - device time
<=90 mins if PCI not capable
***but if capable, 60 mins (not from garrisons)
Transfer to PCI capable hospital should be done in ____ mins
120min
Administration of fibrinolytics should be done in ____ mins if transfer to PCI capable hospital would take > 120 mins
30m
Clear contraindications to the use of fibrinolytic agents include
a history of cerebrovascular hemorrhage at any time
a nonhemorrhagic stroke or other cerebrovascular event within the past year
marked hypertension (a reliably determined systolic arterial pressure >180 mmHg and/or a diastolic pressure >110 mmHg) at any time during the acute presentation
suspicion of aortic dissection
active internal bleeding (excluding menses)
Because of the risk of emesis and aspiration soon after STEMI, patients should receive either nothing or only clear liquids by mouth for the first ___ h.
4–12
patients with STEMI should be kept at bed rest for the first
6–12 h.
patients with STEMI resume an upright posture by dangling their feet over the side of the bed and sitting in a chair within .
the first 24 h
for patients with STEMI, by the _____ day, patients typically are ambulating in their room with increasing duration and frequency, and they may shower or stand at the sink to bathe.
second or third
The typical coronary care unit diet for STEMI px should provide ___ of total calories as fat and have a cholesterol content of ≤300 mg/d. Complex carbohydrates should make up ____ of total calories.
≤30%
50–55%
for patients with STEMI, By day 3 after infarction, patients should be increasing their ambulation progressively to a goal of ___ m at least three times a day.
185 m (600 ft)
primary cause of in-hospital death from STEMI
Pump failure
Most patients who had STEMI will be able to return to work within ___ weeks.
2–4
For STEMI px normal sexual activity may be resumed during this period.
1-2w
How do you define angiographic success in PCI
A successful procedure (angiographic success), defined as a reduction of the stenosis to less than a 20% diameter narrowing, occurs in 95–99% of patients.
most common complication of angioplasty
restenosis
occurs in 20–50% of patients with balloon angioplasty alone, 10–30% of patients with bare metal stents, and 5–15% of patients with drug-eluting stents within the first year.
The primary reason for being considered inoperable with CABG is
the presence of severe comorbidities such as advanced age, frailty, severe chronic obstructive pulmonary disease (COPD), poor left ventricular function, or lack of suitable surgical conduits or poor distal targets for bypass
three cardinal symptoms of AS
Exertional dyspnea, angina pectoris, and syncope
Describe the murmur of AS
The murmur of AS is characteristically an ejection (mid) systolic murmur that commences shortly after the S1 , increases in intensity to reach a peak toward the middle of ejection, and ends just before aortic valve closure.
In AS, average time to death after the onset of various symptoms was as follows
angina pectoris, ___
syncope, ____
dyspnea ____
angina pectoris, 3 years;
syncope, 3 years;
dyspnea, 2 years;
in AR A rapidly rising “water-hammer” pulse, which collapses suddenly as arterial pressure falls rapidly during late systole and diastole is called ______
(Corrigan’s pulse)
In AR, capillary pulsations, an alternate flushing and paling of the skin at the root of the nail while pressure is applied to the tip of the nail is called ______
(Quincke’s pulse)
in AR, A booming “pistol-shot” sound can be heard over the femoral arteries is called _____
(Traube’s sign)
in AR to-and-fro murmur that is audible if femoral artery is lightly compressed with steth is called _____
(Duroziez’s sign)
Leading cause of MS
Rheumatic fever
With severe pulmonary hypertension, a pansystolic murmur produced by functional TR may be audible along the left sternal border. This murmur is usually louder during inspiration and diminishes during forced expiration and is called _____
(Carvallo’s sign)
most characteristic auscultatory finding in chronic severe MR
systolic murmur of at least grade III/VI intensity
It is usually holosystolic , but as previously noted, it is decrescendo and ceases in mid-to-late systole in patients with acute severe MR.
The systolic murmur of chronic MR is usually most prominent at the apex and radiates to the axilla
most common abnormality leading to primary mitral regurgitation
MVP
ECG finding in MVP
most commonly normal but may show biphasic or inverted T-waves in leads II, III, and aVF, and occasionally supraventricular or ventricular premature beats
The physical examination hallmark of PR is a high-pitched, decrescendo diastolic murmur also called ______ is heard along the left sternal border
(Graham Steell murmur)
most common form of cyanotic CHD, occurring in 0.5 per 1000 live births.
Tetralogy of Fallot (TOF)
The base of the left lung may be compressed by pericardial fluid, producing _____ sign, a patch of dullness and increased fremitus beneath the angle of the left scapula.
Ewart’s sign
Treatment for pericarditis
There is no specific tx for acute idiopathic pericarditis, but bed rest and anti-inflammatory tx with aspirin (2–4 g/d), with NSAIDs, such as ibuprofen (600–800 mg tid) or indomethacin (25–50 mg tid), and should be administered along with gastric protection (e.g., omeprazole 20 mg/d)
colchicine (0.5 mg qd [70 kg]), should be administered for 3 months. Colchicine enhances the response to NSAIDs and also aids in reducing the risk of recurrent pericarditis
However, since they increase the risk of subsequent recurrence, full-dose corticosteroids should be given for only 2–4 days and then tapered. Anticoagulants should be avoided because their use could cause bleeding into the pericardial cavity and tamponade.
What constitutes Beck’s triad?
hypotension
soft or absent heart sounds
jugular venous distention
What constitutes an important feature in the differentiation of acute pericarditis from AMI
The almost simultaneous development of fever and precordial pain, often 10–12 days after a presumed viral illness
in AMI chest pain precedes fever.
What in the JVP wave form is absent or diminished in cardiac tamponade, is the most prominent deflection in constrictive pericarditis
y descent
In acute pericarditis, the apical pulse is reduced and may retract in systole AKA
(Broadbent’s sign)
the most common type of primary cardiac tumor in adults
Myxoma
In absolute terms, the most common primary sites from which cardiac metastases originate are carcinoma of the______ and _____ , reflecting the high incidence of those cancers
breast and lung
major site of atherosclerotic disease
Epicardial coronary arteries
Example of anginal equivalents
Anginal “equivalents” include dyspnea, nausea, fatigue, and faintness and are more common in the elderly and in diabetic patients
When a stenosis reduces the diameter of an epicardial artery by __%, there is a limitation of the ability to increase flow to meet increased myocardial demand.
When the diameter is reduced by ~___%, blood flow at rest may be reduced
50%, 80%
Contraindications for Ranolazine?
hepatic impairment
QTc prolongation
drugs that inhibit the CYP3A metabolic system (e.g., ketoconazole, diltiazem, verapamil, macrolide antibiotics, HIV protease inhibitors, and large quantities of grapefruit juice
MOA of nicorandil
opens ATP-sensitive potassium channels in myocytes
most common clinical indication for PCI is _____
symptom-limiting angina pectoris
the most common etiology of secondary hypertension
Primary renal disease
An ankle-brachial index <___ is considered diagnostic of PAD and is associated with >50% stenosis in at least one major lower limb vessel.
0.90
ABIs >1.40 indicate noncompressible arteries secondary to vascular calcification
Cardiovascular disease risk doubles for every __ mmHg increase in systolic and __mmHg increase in diastolic pressure.
20 mmHg
10 mmHg
Recommended criteria for a diagnosis of hypertension, based on 24-h blood pressure monitoring, are average awake blood pressure ≥ _____ mmHg and asleep blood pressure ≥___ mmHg.
135/85
120/75
A ratio >___ in conjunction with a plasma aldosterone concentration >____ pmol/L (>20 ng/dL) reportedly has a sensitivity of 90% and a specificity of 91% for an aldosterone-producing adenoma
30:1
555
______ is the most common congenital cardiovascular cause of hypertension
Coarctation of the aorta
for hypertensive urgency The initial goal of therapy is to reduce mean arterial blood pressure by no more than % within minutes to 2 h or to a blood pressure in the range of mmHg
25%
160/100–110
The two most common autosomal dominant genetic mutations are ____ and ____ for inherited thrombophilias
factor V Leiden
prothrombin gene mutation
most common acquired cause of thrombophilia and is associated with venous or arterial thrombosis.
Antiphospholipid antibody syndrome
in PEThe most common gas exchange abnormalities are ____ and ____, which represents the inefficiency of O2 transfer across the lungs.
arterial hypoxemia and an increased alveolar-arterial O2 tension gradient
Hallmarks of massive PE
Dyspnea, syncope, hypotension, and cyanosis
most common symptom of DVT
“charley horse” in the lower calf that persists and intensifies over several days
Signs of PE on CXR
Well-established abnormalities include focal oligemia (Westermark’s sign), a peripheral wedged-shaped density usually located at the pleural base (Hampton’s hump), and an enlarged right descending pulmonary artery (Palla’s sign).
Finding on chest on chest CT indicates an increased likelihood of death within the next 30 days
RV enlargement
pressure required for compression stockings for acute DVT
30-40 mmhg
Define McConnell’s sign
The best-known indirect sign of PE on transthoracic echocardiography is McConnell’s sign: hypokinesis of the RV free wall with normal or hyperkinetic motion of the RV apex
PE= apical sparing
For life-threatening or intracranial hemorrhage due to heparin or LMWH, what can be administered?
protamine sulfate can be administered
Antidote for dabigatran
idarucizumab
The only Food and Drug Administration–approved indication for PE fibrinolysis is ____
massive PE
Approximately 90% of syphilitic aneurysms are located in ______
ascending aorta or aortic arch
What are the indications for operative repair for ascending aorta aneurysm?
Operative repair with placement of a prosthetic graft is indicated in patients with symptomatic ascending thoracic aortic aneurysms and for most asymptomatic aneurysms, including those associated with bicuspid aortic valves, when the aortic root or ascending aortic diameter is ≥5.5 cm, or when the growth rate is >0.5 cm per year.
In patients with Marfan’s syndrome, ascending thoracic aortic aneurysms of 4–5 cm should be considered for surgery.
What are the indications for operative repair for descending aorta aneurysm?
Operative repair is indicated for patients with degenerative descending thoracic aortic aneurysms when the diameter is >6 cm, and endovascular repair should be considered if feasible when the diameter is >5.5 cm.
Target BP and HR for px with acute dissection
<= 120 mmHg
<60 bpm
What is a phosphodiesterase inhibitor with vasodilator and antiplatelet properties, increases claudication distance by 40–60% and improves measures of quality of life
Cilostazol
most common peripheral artery aneurysms
popliteal artery
Compression of a large arteriovenous fistula may cause reflex slowing of the heart rate AKA as ____ sign
(Nicoladoni-Branham sign)
principal diagnostic test to evaluate patients with chronic venous disease
venous duplex ultrasonography.
Graduated compression stockings with pressures of ____ mmHg are suitable for most patients with simple varicose veins, although pressures of ____ mmHg may be required for patients with manifestations of venous insufficiency such as edema and ulcers.
20–30
30–40
The most common etiology of secondary lymphedema worldwide is _______
lymphatic filariasis
Thickening of the skin in lymphedema is detected by ______sign, which is the inability to tent the skin at the base of the toes
Stemmer’s
Stage of lymphedema wherein fluid subsides with limb elevation
Stage I
Stage of lymphedema wherein fluid does not subside with limb elevation
Stage II
How do you define resistant hypertension?
BP persistently >140/90 despite use of 3 or more
antihypertensives including a diuretic
parameters is indicative of worse outcomes in
patients with acute decompensated heart failure
BUN
Crea
troponin levels
SBP
BUN > 43 mg/dL
Crea > 2.75 mg/dl
troponin levels- elevated
SBP < 115 mmHg
In acute MI, which papillary muscle is most commonly involved?
Posteromedial papillary muscle of the left ventricle
Patients who have angina when under emotional stress are classified under the Canadian Cardiovascular Society (CCS) as functional class:
II
MOA of Nicorandil
Stimulates K adenosine triphosphate channels
How long should you stop smoking before surgery to reduce perioperative pulmonary complications
8 weeks before and 10 days after
Most common cause of mid systolic murmur in adults
AS
Right sided sounds increase with inspiration except for ____
pulmonic eejction sounds
Most impt component of acute management of ADHF with high BP
Vasodilator since likely no due to volume overload
if normal bp likely due to volume overload hence need to give diuretics
What is the principal determinant of the clinical course, manifestation and feasibility of repeair in px with VSD
status of the pulmonary vascular bed
Pathologic finding in arterioles of target organs in malignant hypertension
fibrinoid necrosis
Recommended criteria for diagnosis of hypertension in 24 hr ambulatory bp
Average awake BP >= 135/85
Asleep BP >=120/70
approximate a clinic bp of 140/90
Anti anginal drug that should be avoided in HOCM
Nitroglycerin
Most commonly implicated drugs in toxic cardiomyopathy
Chemotherapeutic drugs
Threshold transferrin saturation for hemochromatosis induced cardiomyopathy
> 60% for men
45-50% for women
The usual first symptom in restrictive cardiomyopathy
Subtle exercise intolerance
Leading cause of SCD in the young
HOCM
Tuberculous aneurysm usually affects which segment of the aorta
Thoracic
T-B, T-horacic
Drug indicated in AAA to reduce cardiovascular events related to atherosclerosis
Statins
90% of AAA > 4cm are related to atherosclerotic dse
How do you differentiate the different Debakey types of aoric dissection
How do you differentiate the different Stanford types of aoric dissection
Most frequently cited ecg abnormality in PE
Sinus tachy
S1Q3T3
Most common ecg abnormality in PE
t wave inversion in v1-v4
Most typicl symptom of PAOD
intermittent claudication
Characteristic murmur of VSD
Holosystolic murmur heard best over 3rd and 4th interspaces along the sternal border
increases with hand grip
Characteristic murmur of PDA
Small: silent
Large: continuous machinery like murmur heard best below the left clavicle
Imaging of choice for follow up repaired TOF
Cardiac MRI
Associated valvular abnormality in straight back syndrome
MVP
which cardiac imaging modality has the highest sensitivity and specificity in diagnosing coronary artery disease?
CT angio
NT pro BNP can be falsely elevated in which circumstances?
older age
renal impairment
women
right HF
use of ARNIs
What drug therapy is useful across all types of
the most common valvular heart diseases?
diuretics
Triad of Buerger’s dse
Raynauds, claudication, migratory superficial vein phlebitis
What BP should you start treating the following
acute ischemic stroke
For thrombolysis
Hemorrhagic stroke
acute ischemic stroke: SBP >220 or DBP >130
For thrombolysis: lower to < 185/110
Hemorrhagic stroke: if SBP > 180 or DBP >130
How long is the target time from Door In to provincial hospital to Door Out of provincial hospital (DIDO) (to a PCI capable hospital)
30 mins
At which diameter of thoracic aortic aneurysm should a marfan’s syndrome patient be considered for operative repair
4-5 cm
Among patients receiving aggressive fluid resuscitation for extensive fluid losses, a decrease in renal output with rise in serum creatinine may indicate which complication of managemen
renal vein compression
in a patient with PAD what the best test to objectively assess his functional limitations?
Treadmill stress test
Sodium intake limit in px with hypertension
1500 mg/day
BP target for px with DM and hypertension
< 130/80
What electrolyte abnormality is predictive of worse outcome in HF?
Hyponatremia
Characteristics of vulnerable plaque
Vulnerable Plaques may show:
1. Eccentric Stenosis with scalloped or overhanging edges
2. Narrow neck on coronary angiography
3. Lipid-rich core and THIN Fibrous cap
Mid systolic click is associated with what condition
MVP
A frequent finding is the mid- or late (nonejection) systolic click, which occurs 0.14 s or more after S1 and is thought to be generated by the sudden tensing of slack, elongated chordae tendineae or by the prolapsing mitral leaflet when it reaches its maximal excursion. Systolic clicks may be multiple and may be followed by a high-pitched, mid-late systolic crescendo–decrescendo murmur, which occasionally is “whooping” or “honking” and is heard best at the apex. Radiation of the murmur will depend on the involved leaflet.
What medications can cause increased amplitude of u waves?
An abnormal increase in U-wave amplitude is most commonly due to drugs (e.g., dofetilide, amiodarone, sotalol, quinidine) or to hypokalemia.
the most common cause of marked left axis deviation in adult
Left anterior fascicular block (QRS axis more negative than –45°) is probably the most common cause of marked left axis deviation in adult
which diseases do you see differential cyanosis?
Differential cyanosis refers to isolated cyanosis affecting the lower but not the upper extremities in a patient with a large patent ductus arteriosus (PDA) and secondary pulmonary hypertension with right-to-left to shunting at the great vessel level.
What are the contrainidcations to stress testing?
What features during stress testing indicate severe IHD and high risk of future events?
Contraindications of prasugrel
prior stroke or transient ischemic attack or at high risk for bleedin
Most common cause of aortic stenosis
degenerative calcification
Observational studies show increased risk of CVD beginning with systolic blood pressures (SBPs) >_____- mmHg
110–115
NYHA classification
When should you request for 2d echo in px with murmur?
Asymptomatic or mildly symptomatic patients with valvular heart disease that is anatomically severe should be evaluated periodically, every _____ months, by clinical and noninvasive examinations
6–12
Conditions that prolong phase 2 or 3 increase/decrease the QT interval.
increase
eg. (amiodarone, hypocalcemia)
most common arrhythmia
sinus tachycardia
Biventricular pacing usually produce LBBB or CRBBB?
CRBBB
most common cause of marked left axis deviation in adults
LAFB
Prevention of contrast induced AKI
For all patients, adequate intravascular volume expansion with intravenous 0.9% saline (1.0–1.5 mL/kg per hour) for 3–12 h before and continued 6–24 h after the procedure limits the risk of contrast-induced acute kidney injury by >50%.
Pretreatment with N-acetylcysteine (Mucomyst) has not reduced the risk of contrast-induced acute kidney injury consistently and, therefore, is no longer recommended routinely.
Diabetic patients treated with metformin should stop the drug 24 h prior to the procedure and not restart until 48 h after contrast administration to limit the associated risk of lactic acidosis.
Other strategies to decrease risk include the administration of sodium bicarbonate (3 mL/kg per hour) 1 h before and 6 h after the procedure (similar outcome to saline infusion); use of low- or iso-osmolar contrast agents; and limiting the volume of contrast to <50 mL per procedure.
Cardiac catheterization is performed after the patient has fasted for _ h and has received intravenous conscious sedation to remain awake but sedated during the procedure
6
Test to do to confirm dual blood supply to the hand
A normal modified Allen’s test or Barbeau test confirming dual blood supply to the hand from the radial and ulnar arteries is recommended prior to access at this site
Systolic pulsations over the liver signify what valvular abnormality
severe tricuspid regurgitation (TR)
Clubbing implies the presence of central right-to-left shunting, although it has also been described in patients with ________
endocarditis
What sign signifies posterior calf pain on active dorsiflexion of the foot against resistance?
A Homan’s sign (posterior calf pain on active dorsiflexion of the foot against resistance) is neither specific nor sensitive for deep venous thrombosis
Why is IJV preferred over EJV for measuring JVP?
The internal jugular vein is preferred because the external jugular vein is valved and not directly in line with the superior vena cava and right atrium
Abnormal JVP
A distance >4.5 cm at 30° elevation is considered abnormal
Normally, the venous pressure should fall by at least ___ mmHg with inspiration.
3
Kussmaul’s sign is defined by either a rise or a lack of fall of the JVP with inspiration and is classically associated with constrictive pericarditis, although it has been reported in patients with restrictive cardiomyopathy, massive pulmonary embolism, right ventricular infarction, and advanced left ventricular (LV) systolic heart failure
Abdominojugular reflux is produced with firm and consistent pressure over the upper portion of the abdomen, preferably over the right upper quadrant, for >__s.
A positive response is defined by a sustained rise of >3 cm in the JVP during the application of firm abdominal pressure
15
The response should be assessed after 10 s of continuous pressure to allow for respiratory artifacts and tensing of the abdominal muscles to subside.
Kussmaul’s sign is defined by either a rise or a lack of fall of the JVP with inspiration and is classically associated with constrictive pericarditis, although it has been reported in patients with restrictive cardiomyopathy, massive pulmonary embolism, right ventricular infarction, and advanced left ventricular (LV) systolic heart failure.
It is also a common, isolated finding in patients after cardiac surgery without other hemodynamic abnormalities.
When taking the BP, The cuff should be inflated to __ mmHg above the expected systolic pressure and the pressure released at a rate of ___ mmHg/s
30
2-3
Very low (even 0 mmHg) diastolic blood pressures may be recorded in patients with ___________ because of enhanced diastolic “run-off.”
chronic, severe AR or a large arteriovenous fistula
Blood pressure should be measured in both arms, and the difference should be <___ mmHg
10
Systolic leg pressures are usually as much as 20 mmHg higher than systolic arm pressures. Greater leg–arm pressure differences are seen in patients with chronic severe AR as well as patients with extensive and calcified lower extremity peripheral arterial disease
Definition of white coat hypertension
“White coat hypertension” (elevated clinic blood pressure and normal out of clinic blood pressure) is defined by at least three separate clinic-based measurements >130/80 mmHg and at least two non-clinic-based measurements <130/80 mmHg in the absence of any evidence of target organ damagef
Definition of orthostatic hypotensio
Orthostatic hypotension is defined by a fall in systolic pressure >20 mmHg or in diastolic pressure >10 mmHg in response to assumption of the upright posture from a supine position within 3 min
The aortic pulse is best appreciated in the _______
The aortic pulse is best appreciated in the epigastrium, just above the level of the umbilicus
A bifid pulse is also described in patients with _______, with inscription of percussion and tidal waves
hypertrophic obstructive cardiomyopathy (HOCM)
A bifid pulse is easily appreciated in patients on intraaortic balloon counterpulsation (IABP), in whom the second pulse is diastolic in timing
Also seen in advanced AR
Definition of pulsus paradoxus
Pulsus paradoxus refers to a fall in systolic pressure >10 mmHg with inspiration that is seen in patients with pericardial tamponade but also is described in those with massive pulmonary embolism, hemorrhagic shock, severe obstructive lung disease, and tension pneumothorax.
Sustained apex beat is present in which conditions
A sustained apex beat is a sign of pressure overload, such as that which may be present in patients with AS or chronic hypertension
An unusually narrowly split or even a singular S2 is a feature of ______
pulmonary arterial hypertension
Fixed splitting of S2 , in which the A2 –P2 interval is wide and does not change during the respiratory cycle, occurs in patients with a
secundum atrial septal defect
The pericardial knock (PK) is also high-pitched and occurs slightly later than the OS, corresponding in
timing to the abrupt cessation of ventricular expansion after tricuspid valve opening and to an exaggerated y descent seen in the jugular venous waveform in patients with constrictive pericarditis
two types of benign continuous murmurs.
The cervical venous hum is heard in children or adolescents in the supraclavicular fossa. It can be obliterated with firm pressure applied to the diaphragm of the stethoscope, especially when the subject turns his or her head toward the examiner.
The mammary soufflé of pregnancy relates to enhanced arterial blood flow through engorged breasts
No further work ups needed
Right-sided murmurs and sounds generally increase with inspiration, except for
Pulmonary ejection sounds
A change in the intensity of a systolic murmur in the first beat after a premature beat or in the beat after a long cycle length in patients with atrial fibrillation suggests valvular AS rather than MR, particularly in an older patient in whom the murmur of the AS may be well transmitted to the apex AKA ______ effect
(Gallavardin effect)
a potent vasoconstrictor peptide with growth-promoting effects that may play an important role in pulmonary hypertension and right ventricular failure
Endothelin
chronic anemia is associated with high CO when hemoglobin reduces significantly, for example, to a level that is ≤
8 g/dL.
Definition of cardiac cachexia
In patients with chronic HF on guideline-directed medical therapy, resting heart rate ideally should be <___ beats/min, and blood pressure should be in the normal to low-normal range
70–75
T/F You should screen px with HF for anxiety
False
Depression
Depression is an independent risk factor for adverse outcomes in HF , especially in older women.
The AHA recommends screening for depression among patients with cardiovascular disease including HF using validated patient health questionnaires. Selective serotonin reuptake inhibitors are safe for treating depression in HF but do not appear to affect the natural history of disease
What is the CHARM trial about?
The Candesartan in Heart Failure—Assessment of Mortality and Morbidity (CHARM) Preserved study showed a statistically significant reduction in HF hospitalizations but no difference in all-cause mortality in patients with HFpEF who were treated with the ARB candesartan
What is the I-PRESERVE trial about?
Irbesartan in Heart Failure with Preserved Systolic Function (I-PRESERVE) trial demonstrated no differences in the composite of cardiovascular death or HF hospitalization during treatment with the ARB irbesartan compared with placebo.
What is the PEP-CHF trial about?
Apparent early benefits of the ACE inhibitor perindopril on HF hospitalizations and functional capacity in the Perindopril in Elderly People with Chronic Heart Failure (PEP-CHF) study were attenuated over longer-duration follow-up
What is the DIG trial about?
The Digitalis Investigation Group (DIG) Ancillary Trial found no impact of digoxin on all-cause mortality or on all-cause or cardiovascular hospitalization among patients with chronic HF, ejection fraction (EF) >45%, and sinus rhythm, although a modest reduction in HF hospitalizations was noted.
What is the SENIORS trial about?
the subgroup of elderly patients with prior hospitalization and HFpEF enrolled in the Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with Heart Failure (SENIORS) trial of nebivolol, a vasodilating beta blocker, did not appear to experience significant reductions in all-cause or cardiovascular mortality.
What is the TOPCAT trial about?
Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial explored the potential benefit of spironolactone compared to placebo in HFpEF. This trial demonstrated no improvement in the primary composite endpoint of cardiovascular death, HF hospitalizations, or aborted cardiac arrest but did show a reduction in HF hospitalizations among those allocated to spironolactone
What is the RELAX trial about?
This finding led to the phase 2 trial, Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart Failure (RELAX), in HFpEF patients (left ventricular EF [LVEF] >50%) with New York Heart Association (NYHA) functional class II or III symptoms, who received sildenafil at 20 mg three times daily for 3 months, followed by 60 mg three times daily for another 3 months, compared with a placebo. There was no improvement in functional capacity, QOL, or other clinical and surrogate parameters in those allocated to sildenafil compared to placebo.
What is the NEAT-HFpEF trial about?
On the premise that nitrates, which are NO donors, might improve preload, coronary perfusion, endothelial function, and exercise tolerance, the Nitrate’s Effect on Activity Tolerance in Heart Failure with Preserved Ejection Fraction (NEAT-HFpEF) study was conducted. Isosorbide mononitrate did not improve QOL or submaximal exercise capacity and decreased overall activity levels in treated patients
What is the INDIE-HFpEF trial about?
Inorganic nitrate compounds have also been shown to enhance NO signaling but did not improve functional capacity compared to placebo among patients with HFpEF randomized in the Inorganic Nitrite Delivery to Improve Exercise Capacity in Heart Failure with Preserved Ejection Fraction (INDIE-HFpEF) trial.
What is the PARAGON-HF trial about?
The PARAGON-HF trial randomized 4822 patients with symptomatic HFpEF (LVEF ≥45%), elevated natriuretic peptides, and structural heart disease to treatment with either sacubitril-valsartan or valsartan with the novel composite primary endpoint of cardiovascular death and total hospitalizations for HF. Although there was a 13% reduction in the rate of the primary composite endpoint in those allocated to sacubitril-valsartan, this result narrowly missed the margin for statistical significance in the primary statistical analysis (p = .06).
Directional benefits in secondary endpoints including QOL, NYHA class, and renal function favoring sacubitril-valsartan support a possible modest benefit of neprilysin inhibition in this population, particularly among patients with lower (i.e., mildly reduced or mid-range) EF and women, subgroups who appeared to derive greater benefit.
What is the DAPA-HF trial about?
Addition of the SGLT-2 inhibitor dapagliflozin to guideline-directed medical therapy of HFrEF was associated with reductions in cardiovascular mortality and HF hospitalization among patients with and without diabetes enrolled in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) study
T/F
Predischarge measurement of natriuretic peptide levels, which are highly correlated with risk for postdischarge mortality and readmission, may also be useful in assessing the adequacy of therapy and stratifying risk.
True
What is the CARRESS-HF trial about?
In the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF) trial, 188 patients with ADHF and worsening renal failure were randomized to stepped pharmacologic care or UF. The primary endpoint was a change in serum creatinine and change in weight (reflecting fluid removal) at 96 h. Although similar weight loss occurred in both groups (~5.5 kg), there was a rise in serum creatinine among patients allocated to the UF group. Deaths and hospitalizations for HF were no different between groups, but there were more adverse events in the UF group, mainly due to kidney failure, bleeding complications, and intravenous catheter-related complications. This investigation argues against using UF as a primary strategy in patients with ADHF who are diuretic-responsive.
What is the ASCEND-HF trial about?
Clinical utilization of nesiritide has waned due to concerns raised regarding heightened risks of renal insufficiency and mortality identified in early trials. The Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) study randomizing 7141 patients with ADHF to nesiritide or placebo did not confirm this risk, but also identified no clear clinical benefit with regard to subsequent HF admissions, mortality, or symptom relief (reduction in dyspnea)
A smaller study of low-dose nesiritide in acute HF (Renal Optimization Strategies Evaluation Acute Heart Failure Study [ROSE-AHF]) also showed no incremental benefit over intravenous diuretics for relief of congestion or preservation of renal function.
What is the RELAX-AHF trial about?
In the Relaxin in Acute Heart Failure (RELAX-AHF) trial, 1161 patients hospitalized with ADHF, evidence of congestion, and systolic pressure >125 mmHg were randomized to treatment with serelaxin or placebo in addition to standard HF therapy. Serelaxin improved dyspnea, reduced signs and symptoms of congestion, and was associated with less early worsening of HF. A positive signal of reduced mortality identified in an exploratory analysis prompted a second study (RELAX-AHF2), which did not confirm an effect on cardiovascular death or worsening HF. Accordingly, this agent was not approved for use in clinical practice
What is the TRUE-AHF trial about?
the Trial of Ularitide Safety and Efficacy in Acute Heart Failure (TRUE-AHF) randomly allocated 2157 patients with acute HF to early treatment with the synthetic natriuretic peptide ularitide (at a dose sufficient to reduce ventricular wall stress) or placebo. Despite a very short duration between initial clinical presentation and pharmacologic intervention (<6 h) and early hemodynamic benefits, no improvement in clinical outcomes was observed in patients allocated to ularitide at 6 months. Ularitide was associated with a higher rate of hypotension and worsening serum creatinine
Dose of dopamine which exhibit
a. vasodilatory effects
b. beta adrenergic effects
c. alpha adrenergic effects
Dopamine exhibits dose-dependent effects on dopaminergic, α-, and β-adrenergic receptors, with vasodilatory effects predominating at lower doses (<2 μg/kg per min), β-adrenergic (inotropic) effects at moderate doses, and α-adrenergic effects (vasoconstriction) at higher doses (typically >10 μg/kg per min)
What is the OPTIME-CHF trial about?
Routine, short-term use of milrinone in patients hospitalized with ADHF in the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) trial was associated with increased risk of atrial arrhythmias and prolonged hypotension, but no benefit with regard to subsequent mortality or HF hospitalization. Accordingly, routine use of inotropic support in ADHF is discouraged, and these agents are currently indicated principally for short-term use as bridge therapy (to either left ventricular assist device support or to transplant) in cardiogenic shock or as selectively applied palliation in end-stage HF
a calcium sensitizer that provides inotropic activity but also possesses phosphodiesterase-3 inhibition properties that are vasodilatory
Levosimendan
Two trials, the second Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy (REVIVE II) and Survival of Patients with Acute Heart Failure in Need of Intravenous Inotropic Support (SURVIVE), have tested this agent in ADHF. SURVIVE compared levosimendan with dobutamine, and despite an initial reduction in circulating B-type natriuretic peptide levels in the levosimendan group compared with patients in the dobutamine group, this drug did not reduce all-cause mortality at 180 days or affect any secondary clinical outcomes.
The second trial compared levosimendan against traditional noninotropic therapy and found a modest improvement in symptoms with worsened short-term mortality and ventricular arrhythmias. Although levosimendan has been approved for use to support management of HF in several countries worldwide, it is not approved for use in the United States, largely owing to the lack of compelling data for incremental efficacy in comparison with conventional inotropic drugs or standard HF therapies
What is the PROTECT trial about?
Among patients with acute HF and renal dysfunction enrolled in the Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function (c) trial, no cardiovascular or renal benefit was observed.
What is the EVEREST trial about?
Similarly, despite compelling theoretical benefit of vasopressin receptor antagonism in acute HF (based on the central role of vasopressin in mediating the fluid retention that contributes to worsening HF), no benefit of the oral selective vasopressin-2 antagonist tolvaptan was seen with regard to mortality or HF-associated morbidity in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial.
What is the PIONEER trial about?
Comparison of Sacubitril-Valsartan Versus Enalapril on Effect on NT-proBNP in Patients Stabilized from an Acute Heart Failure Episode (PIONEER-HF) study of patients with HFrEF stabilized after hospital admission for ADHF, predischarge initiation of sacubitril-valsartan compared with enalapril was associated with greater reductions in natriuretic peptides as well as lower rates of composite death and HF readmission at 8 weeks.
What vasodilator is associated with Thiocyanate toxicity in renal insufficiency (>72 h)
Nitroprusside
** Also Requires arterial line placement for titration for precise blood pressure
management and prevention of hypotension
What is the CIBIS trial about?
Whether beta blockers or ACEIs should be started first was answered by the Cardiac Insufficiency Bisoprolol Study (CIBIS) III, in which outcomes did not vary based on the sequence of drug initiation. Thus, it matters little which agent is initiated first; what does matter is that optimally titrated doses of both ACEIs and beta blockers be established in a timely manner.
What trials were the basis for aggressive titration of HF medications to target doses?
Prospective trials of high- versus low-dose ACEIs (ATLAS), ARBs (HEAAL), and beta blockers (MOCHA) consistently favor the higher dose, with lower rates of death and HF hospitalization seen in the higher-dose group. Clinical experience suggests that, in the absence of symptoms to suggest hypotension (fatigue and dizziness), pharmacotherapy may be uptitrated every 2 weeks in stable ambulatory patients as tolerated
What is the RALES trial about
Spironolactone is the most commonly utilized agent in this class based on efficacy demonstrated in the Randomized Aldactone Evaluation Study (RALES) in patients with HFrEF and NYHA class III–IV symptoms. Eplerenone (studied principally in patients with milder NYHA class II symptoms and those with HF or left ventricular dysfunction complication myocardial infarction) lacks the antiandrogen effects of spironolactone and may be a suitable alternative for patients who experience sexual side effects (gynecomastia, erectile dysfunction, diminished libido)
Trials for HF about dual RAAS blockade
In both the Valsartan Heart Failure Trial (Val-HeFT) and the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM-Added) trial, addition of an ARB to an ACEI and other HF therapy was associated with a lower risk of HF hospitalizations
Subsequent data from the Valsartan in Acute Myocardial Infarction (VALIANT) trial suggested that the addition of the ARB valsartan to an evidence-based dose of the ACEI captopril in patients with HF complicating myocardial infarction was associated with an increase in adverse events without any added benefit compared with monotherapy for either group.
The findings of the VALIANT trial are buttressed by more recent data from the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure (ATMOSPHERE), which randomly allocated 7016 patients with HFrEF to treatment with enalapril (targeted dose 10 mg twice daily as recommended by guidelines), the plasma renin inhibitor aliskiren, or the combination on top of standard HF therapy. In that study, combination treatment with aliskiren and enalapril was associated with higher rates of hyperkalemia, hypotension, and worsening renal function, but no incremental benefit with regard to HF hospitalization or cardiovascular mortality
What is the A-HeFT trial about?
A trial conducted in self-identified African Americans, the African-American Heart Failure Trial (A-HeFT), studied a fixed dose of isosorbide dinitrate with hydralazine in patients with advanced symptoms of HFrEF who were receiving standard background therapy including an ACEI and beta blocker. The study demonstrated improvements in survival and hospital admission for HF in the treatment group. Adherence to this regimen is limited by the thrice-daily dosing schedule
What is the OVERTURE trial about?
The combined drug omapatrilat hybridizes an ACEI with a neutral endopeptidase (neprilysin) inhibitor, and this agent was tested in the Omapatrilat Versus Enalapril Randomized Trial of Utility in Reducing Events (OVERTURE) trial. This drug did not favorably influence the primary outcome measure of the combined risk of death or hospitalization for HF requiring intravenous treatment compared with enalapril alone, and notably, the risk of angioedema was increased in patients assigned to omapatrilat
Indications for surgery in MS
Unless there is a contraindication, mitral commissurotomy is indicated in symptomatic (New York Heart Association [NYHA] Functional Class II–IV) patients with isolated severe MS, whose effective orifice (valve area) is <~1 cm2 /m2 body surface area, or <1.5 cm2 in normal-sized adults.
Successful commissurotomy is defined by a 50% reduction in the mean mitral valve gradient and a doubling of the mitral valve area
Indications for surgery for AR
Aortic valve replacement (AVR) is indicated for the treatment of severe AR in symptomatic patients irrespective of LV function. In general, the operation should be carried out in asymptomatic patients with severe AR and progressive LV dysfunction defined by an LVEF <55% on serial studies, an LV end-systolic dimension >50 mm (>25 mm/m2 ), or an LV diastolic dimension >65 mm
Indications for surgery in px with TR
Tricuspid valve surgery is recommended for patients with severe TR who are undergoing left-sided valve surgery and is also undertaken frequently for treatment of even moderate TR in patients undergoing left-sided valve surgery who have tricuspid annular dilation (>40 mm), a history of right heart failure, or PA hypertension.
Surgical indication for AS
Operation is indicated in patients with severe AS (valve area <1 cm2 or 0.6 cm2 /m2 body surface area) who are symptomatic, those who exhibit LV systolic dysfunction (EF <50%), and those with AS due to BAV disease and an aneurysmal root or ascending aorta (maximal dimension >5.5 cm).
Operation should be carried out promptly (1–3 months) after symptom onset
Factors which favor SAVR vs TAVI
Disorder with pericardial knock and pericardial calcification
constrictive pericarditis
Activities requiring 5-7 METS
What CCB has constipation as side effect?
nifedipine
How do you classify CVI based on clinical classification
Based on CPG 2020, how do you classify hypertension among adult Filipinoes
Observational studies have shown that for every 10 mmHg increase in the blood pressure from 115/75mmHg, there is doubling of cardiovascular risk thus, the rationale of setting the BP of < 120/80mmHg as the optimal level at which cardiovascular risk is set at the minimum.
Definition of hypertension based on ABPM vs HBPM
Definition of preeclampsia
Definition of severe preeclampsia
Parenteral medications for hypertensive emergencies
Diagnosis of familial hypercholesterolemia
Target LDL based on CPG 2020
Based on CPG 2020, when should you hold statins?
Based on CPG 2020, how long should you advise statin holiday if the px develops rhabdomyolysis?
6 weeks
What constitutes Wells score?
Anticoags that may be used for VTE
VTE prophylaxis
** note: enox 40 mg daily NOT 1mg/kg/day OD
Aspirin may be used as prophylaxis as per harrisons
high risk for recurrent VTE
take note:
minor surgery - intermediate risk
major surgery - low risk
Stages of HF
Tx for symptomatic HFref and HFpef
HFpef trials
Mananagement of different stages of HF
RAAS blockers class 1 in stage B but 2b only in HFmref and HFpef even if stage D
4 pillars are all class 1 for Class D with HFrefs
Duration of anticoag for STEMI
Risk stratification of ACS NSTEMI
Max time FMC to ECG diagnosis of STEMI
** not from harrisons
What is May thurner syndrome?
Compression of the left iliac vein by the right iliac artery
Target LDL for px with familial cholesterolemia
Drugs associated with edema
Mechanisms include renal vasoconstriction (nonsteroidal anti-inflammatory drugs and cyclosporine), arteriolar dilation (vasodilators), augmented renal sodium reabsorption (steroid hormones), and capillary damage.
early, decrescendo systolic murmur best heard at or just medial to the apical impulse
Acute, severe MR into a normal-sized, relatively noncompliant left atrium results in an early, decrescendo systolic murmur best heard at or just medial to the apical impulse. These characteristics reflect the progressive attenuation of the pressure gradient between the left ventricle and the left atrium during systole owing to the rapid rise in left atrial pressure caused by the sudden volume load into an unprepared, noncompliant chamber, and contrast sharply with the auscultatory features of chronic MR
Causes of continuous murmurs
When is TTE indicated when a px has a grade 2 -3 midysystolic murmur?
TTE is indicated to evaluate a grade 2 or 3 midsystolic murmur when there are other signs of cardiac disease.
62/M, smoker, diabetic, came for consult due to 1 month history of intermittent left calf pain which worsens after his early morning walk. He denied trauma, back pain, fever and leg weakness. VS were normal. Femoral pulses were diminished bilaterally; the left dorsalis pedis and posterior tibialis pulses were not palpable. Which is the best test to objectively assess his functional limitations?
a. Duplex ultrasonography
b. Computed Tomographic Angiography (CTA)
c. Magnetic resonance angiography
d. Treadmill testing
d. Treadmill testing
60/F with hypertension and CAD complaining of 2 month history of pain, cramps and sensation of heaviness and fatigue of left lower extremity when walking in her garden, previously relieved by resting but lately noted to be associated with cold sensation and numbness of toes. She was started on intensive statin therapy, losartan and carvedilol for BP control as well as rivaroxaban and ASA. However, despite these interventions, symptoms progressed even at rest. What is the next best step?
a. 2D echo with doppler
b. Duplex ultrasonography
c. Magnetic resonance angiogram
d. Treadmill stress test
c. Magnetic resonance angiogram
54/M with no vices or known comorbidities, was noted to have BP readings of 122/82, 120/84 and 126/85 in 3 separate clinic visits respectively. He has:
a. Normal blood pressure
b. Borderline hypertension
c. Hypertension stage I
d. Hypertension stage II
b. Borderline hypertension
69/M with T2DM and hypertension, consulting for easy fatigability. He noted palpitations, chest heaviness and shortness of breath when climbing up his 3-storey house the past month. Symptoms are relieved with rest. He also noted bipedal edema in the late afternoons relieved with leg elevations. VS stable with BP 120/80 HR 84bpm, regular RR 18 cpm Afebrile with O2 at 99% On PE, there is note of a palpable precordial third heart sound. Pertinent findings on initial labs are as follows: ECG: NSSTTWCs CXR: mild cardiomegaly with no haziness or effusion Abd UTZ: mild hepatomegaly 2D echo: mildly enlarged LV with EF 59% (NV >/= 55%) ALT 42 (NV 4-36 U/L)
HbA1c 6.7% Crea 1.1 mg/dl (GFR 73) Na 136 K 4.0 CBC normal TSH normal U/A unremarkable He is maintained on perindopril 10mg OD and sitagliptin + metformin 50/1000mg BID.
According to the available clinical trials, what will be your best advise?
a. Shift perindopril to irbesartan to decrease risk of cardiovascular death or HF hospitalization based on the I-PRESERVE trial
b. Start digoxin to decrease all-cause mortality or cardiovascular hospitalization based on the DIG ancillary trial
c. Start nebivolol to decrease cardiovascular death and hospitalization based on the SENIORS trial
d. Advise exercise training to improve functional capacity and quality of life
d. Advise exercise training to improve functional capacity and quality of life
The acute decompensated heart failure (ADHF) phenotype associated with pulmonary edema is caused a. cardio-renal syndrome and hepatomegaly
b. renal insufficiency and hypoxia
c. pulmonary embolism and infection
d. new onset arrhythmia and CNS injury
d. new onset arrhythmia and CNS injury
60/F with long standing diabetes, hypertension and chronic heart failure NYHA II to III secondary to CAD came to the clinic with the following recent lab results: Crea 1.8 mg/dl (previously 1.2 mg/dl K 5.5 (previously 4.8) Na 136 (previously 138) +3 proteinuria on urinalysis HbA1c 7.2% (previously 7.5%) Her BP ranges 120-140/70-80. She is maintained on Valsartan 160mg OD, linagliptin 5mg OD, Insulin degludec 20 units SC OD, and furosemide 40mg prn. What is your best treatment approach?
a. Shift valsartan to hydralazine + ISDN
b. shift valsartan to spironolactone + nebivolol
c. Shift valsartan to perindopril + carvedilol
d. shift valsartan to amlodipine + metoprolol
a. Shift valsartan to hydralazine + ISDN
A 25/F came for evaluation of syncope. She has no co morbid condition. Physical examination and 2d echocardiogram are within normal limits.
Her ECG showed the following: What is the next best diagnostic test to request?
a. Treadmill stress test
b. Treadmill stress echocardiogram
c. Myocardial perfusion can
d. Cardiac magnetic resonance imaging
d. Cardiac magnetic resonance imaging
Targeted advanced imaging—magnetic resonance imaging (MRI): amyloidosis, myocarditis, hemochromatosis, sarcoidosis, congenital heart disease (CHD), sinus of Valsalva aneurysm, aortic dissection, arrhythmogenic right ventricular cardiomyopathy
A 55/M, hypertensive, diabetic was brought to the emergency room. Troponin is elevated. Vital signs: BP 80/50 mmHg ; HR 41 bpm ; RR 23 cpm. How should the patient be managed?
a. Give amiodarone
b. Give atropine
c. Pacemaker implantation
d. No treatment is needed at this time
b. Give atropine
Since with hypotension
A 25/M came in for his annual executive examination. His vital signs and physical examination were unremarkable. ECG and other laboratory tests were normal. 2D echocardiogram showed presence of multiple trabeculations in the left ventricle distal to the papillary muscles with evidence of systolic dysfunction. What should be the treatment plan for this patient?
a. Early implantable defibrillator as this patient is high risk for ventricular arrhythmias
b. Antiplatelets prevent embolic event
c. Reassurance with frequent visits
d. Fluid restriction
a. Early implantable defibrillator as this patient is high risk for ventricular arrhythmias
evaluated for chest pain which started 1 month ago. Pain is at rest and is intermittent. Troponin is elevated. ECG showed STE. Coronary angiogram showed transient coronary spasm without obstruction. What is the main treatment for the patient?
a. Aspirin
b. Low molecular weight heparin
c. Calcium channel blocker
d. Statins
Which of the following procedures is considered higher risk for mortality during non-cardiac surgical procedures?
A. Major thoracic surgery
B. Major abdominal surgery
C. Emergent major operation
D. Carotid endarterectomy
C. Emergent major operation
Which of the following findings in the cardiac nuclear scan is high risk for ischemia?
A. Three ischemic zones seen in the myocardium imaging.
B. Change in left ventricular ejection fraction during exercise
C. Positive ECG changes in the inferior wall
D. 0.1 mV ST segment depression in leads II and III
B. Change in left ventricular ejection fraction during exercise
In which of the following case would be most appropriate to use coronary CT angiography?
A. 60/M with complete right bundle branch block
B. 70/F amputee, hypertensive and diabetic
C. 72/M with no known comorbidities and does walking everyday for exercise
D. 51/M with ongoing chest pain
C. 72/M with no known comorbidities and does walking everyday for exercise
CT calcium scoring –> high cardiac prognostic value in ASYMPTOMATIC px
A 50/M came to the clinic with a referral from a dentist asking for possible antibiotic prophylaxis for his heart condition prior to tooth extraction. He has mitral valve prolapse with moderate regurgitation with no history of endocarditis. He is maintained on Losartan 50 mg once a day along with Diabetes Mellitus type 2 medications (Insulin Glargine, Metformin and Glipizide). Which of the statements is appropriate?
A. Give Amoxicillin 500 mg single dose prior to dental extraction
B. Give Cefixime 200 mg single dose prior to dental extraction
C. Give Cephalexin 500 mg single dose prior to dental extraction
D. No prophylaxis is needed
Answer: D. No prophylaxis is needed
A 3A 78/M known hypertensive, consulted for progressive shortness of breath upon exertion. Physical examination findings: BP 110/70 mmHg, HR 95 bpm, RR 18 cpm. JVP = 3 cm H20. Clear breath sounds. Adynamic precordium, Apex beat 6th ICS LMCL, distinct S1, silent S2, Grade 3/6 Systolic ejection murmur with late peaking over the 2nd intercostal space, right parasternal border with radiation to the carotids. The carotid impulse rises slowly with late peaking. What is the most likely etiology of the patient’s condition?
A. Calcific
B. Congenital
C. Hypertensive Heart Disease
D. Rheumatic
A. Calcific
53/F public school teacher consulted due to 8-month history of worsening swelling of the legs, not associated with pain. She has hypertension and has good functional capacity. She mentioned that she usually noticed leg swelling after teaching in class and improves upon waking up in the morning. What is the next best step to diagnose the condition of this patient? A. Review patient’s medication
B. Do conventional venography
C. Request for venous duplex ultrasound
D. Request for 2D Echocardiography
C. Request for venous duplex ultrasound
68/F hypertensive and diabetic consulted due to bilateral leg swelling and “ulcer-like” lesion near the left ankle. Which of the following findings is associated with venous insufficiency?
A. Nonpitting edema
B. Hypopigmentation
C. Hypertrophic skin
D. Eczema
D. Eczema
38/F with no known co-morbids came in at the ER due to sudden onset severe abdominal pain and unexplained breathlessness. She takes OCP and is a tennis player. She underwent surgery for PCL tear repair 1 month ago but had decreased mobility since after surgery. At the ER, VS are: BP 80/50 mmHg, HR 125 bpm, RR 26cpm, Temp 36.7C, O2 sats 82% at room air, improved to 85% at 5LPM. Lungs are clear
What diagnostic examination will you do to confirm your assessment?
A. D Dimer
B. Echocardiography
C. Pulmonary angiography
D. Chest CT scan with IV contrast
D. Chest CT scan with IV contrast
79/M stroke patient and bedridden for 1 year was sent to ER due to sudden onset difficulty breathing. The home care giver reported that oxygen saturation is 80%. At the ER, VS are as follows: BP 70/40, HR 132, RR 30, Temp 36.6C, O2 sats 83% at 10LPM. A bedside 2D Echo was done showing: RV enlargement, hypokinetic RV free wall with hyperkinetic RV apex and interventricular septal flattening. What is the best management for this patient?
A. Fibrinolytic therapy
B. Embolectomy
C. IVC filter
D. Anticoagulation
B. Embolectomy
Which of the following patients has a class I indication for open heart surgery
a.80M Symptomatic severe aortic regurgitation with poor life expectancy less than 6 months
b.55M Asymptomatic severe aortic regurgitation with LV ejection fraction 40 % LV end diastolic dimension 61mm
c.60F Asymptomatic severe aortic regurgitation with LV ejection fraction 53% LV end diastolic dimension 55mm
d.None of the above
b.55M Asymptomatic severe aortic regurgitation with LV ejection fraction 40 % LV end diastolic dimension 61mm
Which of the following conditions can lead to heart failure with either reduced or preserved ejection fraction?
A. Aging
B. Chronic anemia
C. Infiltrative disorders
D. Regurgitant valvular disease
C. Infiltrative disorders
A 51-year-old woman comes to the ER for progressive worsening dyspnea over the past 4 hours. She has hypertension, and is on carvedilol, amlodipine, and enalapril with a usual home BP of 120/80 mmHg. She arrived last night from a weekend trip and forgot to take her medications. BP is 170/100 mmHg, HR 110/min, RR 28/min, SpO2 97% on room air. On physical exam, there is no jugular venous distention, with minimal bibasal crackles and an S3 heart sound on chest auscultation. Labs are pending. Which of the following suggested drugs will you give your patient?
A. Diuretics
B. Inotropic therapy
C. Opiates
D. Vasodilators
B. Inotropic therapy
Which of the following has been demonstrated to improve clinical outcomes among patients with heart failure with reduced ejection fraction (HFrEF)?
A. Amlodipine
B. Diltiazem
C. Fish oil
D. Rosuvastatin
C. Fish oil
Which of the following is TRUE about the auscultatory findings in patients with mitral valve prolapse?
A. A frequent finding is a mid- or late-systolic ejection click.
B. Squatting and isometric exercises increase the intensity of the clickmurmur complex.
C. Systolic clicks may be multiple and may be followed by a mid-late systolic crescendo-decrescendo murmur. D. The murmur will radiate to the axilla and back with posterior leaflet prolapse.
C. Systolic clicks may be multiple and may be followed by a mid-late systolic crescendo-decrescendo murmur.
A 56-year-old presents to the ER with chest pain of 20 minutes duration. He is subsequently diagnosed with anterior wall STEMI and received thrombolytic therapy with tPA. Soon after administration of tPA, the ECG changes revert to baseline. He is monitored on telemetry for 48 hours without any arrhythmias. He is able to walk around the ward without difficulty. Further diagnostic tests during the immediate discharge period should include which of the following?
A. Heart rate-limited exercise treadmill test, 1 week post-MI
B. Nuclear imaging with pharmacologic stress C. Stress echocardiogram
D. Symptom-limited exercise treadmill test, 1 week post-MI
A. Heart rate-limited exercise treadmill test, 1 week post-MI
D is done 4-6 weeks after
A 56-year-old man comes to the emergency room for chest discomfort. He reports working on his car 2 hours ago when he felt some heaviness over his left chest. He says that this has not happened before. Medical history is pertinent for hypertension controlled on enalapril. He is a non-smoker. On PE, BP 120/70 mmHg, HR 77/min. Rest of systemic PE is unremarkable. A baseline ECG is non-diagnostic, and biomarkers on admission are not elevated. You decide to observe him in the ER. After 12 hours, he asks if he can go home as the chest discomfort did not recur. A repeat troponin level remains low. What is the next step in the management of this patient?
A. Observe the patient for a total of 24 hours with serial troponin measurements.
B. Do a stress study to provoke ischemia.
C. Admit the patient for coronary angiogram.
D. Discharge the patient.
B. Do a stress study to provoke ischemia.
A 45-year-old man comes to the emergency room due to chest pain. He has hypertension and is on losartan and carvedilol. He presents with a 4-hour history of chest pain associated with dyspnea and diaphoresis. On arrival, he is hypotensive and has bibasal crackles. He is started on dobutamine and is given morphine sulfate for the pain. ECG showed ST-segment depression on leads V5-V6. His troponins are elevated. What is the best management option for this patient? A. Early invasive strategy
B. Delayed invasive strategy
C. Immediate invasive strategy
D. Trial of optimal medical management prior to invasive strategy
C. Immediate invasive strategy
Among patients with suspected or confirmed aortic dissection, which of the following drugs can be used to lower systolic BP if sodium nitroprusside is unavailable?
A. IV verapamil
B. IV hydralazine
C. Oral metoprolol
D. Sublingual clonidine
A. IV verapamil
Which of the following is the most appropriate management at this time?
A. Obtain cardiac magnetic resonance imaging
B. Perform coronary angiography
C. Proceed with mitral valve repair
D. No further management is required; she may proceed with pregnancy without interventions
C. Proceed with mitral valve repair
A 58-year-old is referred to you for preoperative risk assessment prior to colorectal surgery. He is recently diagnosed with colorectal adenocarcinoma. He had a myocardial infarction 3 years prior and underwent revascularization with a drug-eluting stent. He is on lowdose aspirin, rosuvastatin, lisinopril and carvedilol. He has no other comorbid illnesses and no other medications. He reports being able to walk 4 blocks to work, and is able to exercise most days of the week by jogging up a hill.
What is the next step in this patient’s management?
A. Perform coronary angiography with intent to revascularize if needed
B. Perform pharmacologic stress testing
C. Perform a resting echocardiogram
D. No further testing is needed, patient may proceed with surgery
D. No further testing is needed, patient may proceed with surgery
Which of the following is the most important component of acute management for a typical type of acute decompensated heart failure with elevated blood pressure?
A. Noninvasive ventilator support
B. Vasodilator therapy
C. Inotropic therapy
D. Diuretic therapy
B. Vasodilator therapy
Typical ADHF with normal BP are usually volume overloaded so will require diuretic therapy while those with HTN are usually NOT volume overloaded thus should be managed with vasodilators
Which of the following is a component of management of patients with cardiogenic type of acute decompensated heart failure?
A. Inotropic therapy
B. Vasodilator therapy
C. Anti-arrhythmic therapy
D. Opiates
A. Inotropic therapy
§ Inotropic support and mechanical circulatory support § Diuretic therapy for congestion and renal failure
Based on the 2020 Philippine CPG for dyslipidemia, which of the following individuals without ASCVD and DM, would you start on statin therapy to prevent cardiovascular events?
A. 40-year-old man, hypertensive, with LDL-C 140mg/dL B. 45-year-old woman, pre-menopausal, non-hypertensive, with LDL-C 135mg/dL
C. 46-year-old man, hypertensive, with LDL-C 135mg/dL D. 60-year-old woman, non hypertensive, BMI 24 kg/m2, with LDL-C 140mg/dL
C. 46-year-old man, hypertensive, with LDL-C 135mg/dL
Recommend statins among Non-DM and without ASCVD:
if age ≥ 45 with LDL-C ≥ 130mg/dL + ≥ 2 risk factors
Risk factors:
§ Male sex
§ Postmenopausal women
§ Smoker
§ Hypertension
§ BMI >25 kg/m2
§ Family history of premature CHD
§ Proteinuria
§ Left ventricular hypertrophy
Which of the following types of cardiac murmurs will NOT require further evaluation with transthoracic 2D echo?
A. Grade 2 early systolic murmur in a 30-year-old woman
B. Grade 2 middiastolic murmur in a 20-year-old
C. Continuous murmur that disappears when the patient turns head towards examiner
D. Continuous murmur in a 3-month pregnant woman heard with the diaphragm of a stethoscope applied with a rm pressure
D. Continuous murmur in a 3-month pregnant woman heard with the diaphragm of a stethoscope applied with a rm pressure
A male patient with tachycardia and palpitations has the following ECG tracing with atrial flutter. He was given Adenosine IV. What will be the eect of this intervention?
A. Increase in the AV block
B. Increase in the cardiac rate
C. Termination of the tachycardia
D. No effect
A. Increase in the AV block
Which of the following is a feature of typical acute decompensated HF
A. Hypotension
B. Features of hypoperfusion
C. Presence of biomarkers of injury
D. Pulmonary congestion with hypoxia
C. Presence of biomarkers of injury
D = cardiogenic shock
