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
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
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
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
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
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
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
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
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
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
