Cardiology Flashcards
In the context of CAD, MI
Metoprolol is contraidicated in
Cardiogenic shock
May reduce BP and HR
In the context of CAD
Nitro glycerin is contraindicated when
- Rright ventricular MI
- hypotension
- bradycardia
- Recent use of phosphodiesterase inhibitors.
CAD, MI
How do nitrates work
Venous dilation (venous pooling) –> decreased end-diastolic pressure (i.e., decreased preload), reduced myocardial wall tension, and improved myocardial perfusion.
Substernal chest pain + ST-segment elevations that spontaneously resolves is consistent with
Prinzmetal angina.
Coronary artery vasospasm
1st line Tx are CCBs (diltiazem)
STEMI
Door to ballon time
Angioplasty
< 90 mins
PCI, Angioplasty
If PCI fails or > 120 mins–> fibrinolysis
What to discontinue before stress test
BBs
CCBs
Caffeine
Theophyline
Renal compensatory mechanism on context of CHF
Reduced renal blood flow leads to compensatory activation of the RAAS system.
Angiotensin II causes vasoconstriction of the afferent and efferent arterioles within the kidney, decreasing the net renal blood flow. Vasoconstriction is, however, more pronounced in the efferent arteriole, which results in an increase in intraglomerular pressure to maintain the glomerular filtration rate
Hepatojugular reflux indicates…
JVP increases on applying pressure over the liver
Right heart failure, an increase in JVP that is > 3 cm H₂O occurs and it persists for > 15 seconds.
Can help distinguish cardiac disease from hepatic disease in a patient presenting with bilateral lower extremity edema and ascites.
CHF
Hyponatremia due to fluid dilution in the extracellular fluid compartmen is associated with
Poor prognosis
A decrease in Na is associated with a decrease in CO in CHF
cardiac biomarker that is useful for detecting reinfarction following acute MI
CK-MB
Atypical symptoms associated with MI are more common in
women, the elderly, and people with diabetes
Dressler syndrome is a(n)
autoimmune phenomenon that results in fibrinous pericarditis following a myocardial infarction (MI) (2-10 weeks)
What is the likely diagnosis in a post-MI patient that presents a few weeks later with chest pain that improves while leaning forward and diffuse ST elevation on ECG?
Dressler syndrome
a type of pericarditis
Papillary muscle rupture will present with findings of […] heart failure
Interventricular septum rupture will present with findings of […] heart failure
Papillary muscle rupture will present with findings of left heart failure
Interventricular septum rupture will present with findings of left and right heart failure
In acute mitral regurgitation, how do the following left ventricular hemodynamics change?
- Preload
- Afterload
- Ejection fraction
- Forward stroke volume
In acute mitral regurgitation, how do the following left ventricular hemodynamics change?
- Preload = significantly increase
- Afterload = decrease
- Ejection fraction = significantly increase
- Forward stroke volume = decrease
One complication that may occur 2 - 7 days post-MI, which often causes mitral regurgitation
Papillary muscle rupture
CHF, HTN
Meds which are good for both hypertension and heart failure as they help prevent cardiac remodeling
ACE inhibitors
β-blockers (compensated HF)
aldosterone antagonists
What class of drugs should be administered within 24 hours of an MI to limit ventricular remodeling?
ACE inhibitors
What effect do ACE inhibitors have on levels of
renin
angiotensin I
angiotensin II
renin: Increased
angiotensin I: Increase
angiotensin II: Decreased
JVD, crackles, and SOB post-arteriovenous (AV) conduit formation is suggestive of
high output heart failure
What type of heart failure does severe anemia cause?
High-output heart failure
What is the likely diagnosis in a patient on dialysis via AV fistula that develops progressive weakness and exertional dyspnea with widened pulse pressure, tachycardia, and brisk carotid upstroke?
High-output heart failure (secondary to AV fistula formation)
Preload: Increased
Afterload: Decreased
CO: Increased
Why are NSAIDs contraindicated in heart failure?
↓ Renal perfusion → ↑ RAAS → Na+/H2O retention
Left heart failure causes decreased forward perfusion to the kidneys, resulting in
activation of the renin-angiotensin system
preferential vasoconstriction of efferent renal arterioles
How do the following parameters change in LV systolic dysfunction (CHF)?
* Cardiac output:
* Systemic vascular resistance:
* Left ventricular EDV:
- Cardiac output: Decreased
- Systemic vascular resistance: Increased
- Left ventricular EDV: Increased
How are the following diagnostic parameters affected in congestive heart failure?
* Cardiac index:
* Left ventricular end-diastolic volume:
* Systemic vascular resistance:
- Cardiac index: elevated
- Left ventricular end-diastolic volume: elevated
- Systemic vascular resistance: elevated
Meds that improve prognosis in patients with CHF
- BBs
- ACE inhibitors
- Mineralocorticoid receptor antagonists (MRAs): Eplerenone
- Angiotensin receptor-neprilysin inhibitors (ARNIs)
- hydralazine with isosorbide nitrate: BiDil
- SGLT2 inhibitors.
low frequency, late diastolic sound
S4
What is the likely diagnosis in a hypertensive patient with symptoms of CHF with LV hypertrophy and an ejection fraction of 55% on echocardiography?
Diastolic heart failure with preserved %EF (HFpEF)
What is the most common cause of heart failure with preserved ejection fraction (HFpEF)?
Chronic uncontrolled hypertension
Heart sound on cardiac auscultation that occurs during early diastole
S3
symmetric arthropathy of the 2nd and 3rd metacarpophalangeal joints, a feature suggestive of
hemochromatosis.
Complications of MI
Patients with Marfan syndrome often have XXXXXXX as a consequence of cystic medial degeneration.
Patients with Marfan syndrome often have aortic disease (e.g., aortic regurgitation) as a consequence of cystic medial degeneration.
Bicuspid valve predisposes to what valvular disease?
aortic stenosis (older patients) and aortic regurgitation (young adults)
What is the likely underlying cause of an early decrescendo diastolic murmur in a young patient in the U.S. with a family history of heart disease?
Congenital bicuspid aortic valve
Opening snap, diastolic murmur 5th intercostal space midclavicular line
Mitral stenosis
most commonly due to chronic rheumatic heart disease
Decrescendo early diastolic murmur, left sternal border
Aortic insuficiency
What is the most common heart valve affected by rheumatic heart disease?
Mitral valve
But also could affect aortic valve
What pathology is associated with scoliosis, long tapering fingers and toes (arachnodactyly), and upward subluxation of lenses?
Marfan syndrome
Four associated cardiac problems with Marfan syndrome:
- MVP
- Thoracic aortic aneurysm
- Aortic dissection
- Aortic regurgitation
Holosystolic murmur, left lower sternal border, that increases with inspiration
Tricuspid valve regurgitation
Acquired tricuspid valve regurgitation and signs of right-sided heart failure in a previously healthy patient suggest a diagnosis of
Tricuspid valve endocarditis.
intravenous drug use (IVDU) is the strongest predisposing factor
What demographic is most commonly affected by aortic stenosis?
Older adults (> 60)
What is the likely diagnosis in an elderly patient with syncope, dyspnea, and a slow-rising/delayed pulse?
Aortic stenosis
Which heart valve is most frequently involved in infective endocarditis in IV drug users?
Tricuspid valve
What is the likely diagnosis in a young adult with a month-long history of fever and malaise that develops symptoms of CHF with cardiomegaly on imaging?
Viral myocarditis
What is the likely diagnosis in a child that presents with fever and signs of heart failure after several days of a URI (runny nose and nasal congestion)?
Viral myocarditis
What is the treatment for HOCM? -
Avoiding dehydration (preserving preload) - Beta blockers (increased diastolic time to maximize preload)
What effect does the hand grip maneuver have on the intensity of hypertrophic cardiomyopathy murmurs?
Decreased intensity
Diuretics, nitrates, ACE inhibitors, and dihydropyridine Ca2+ channel blockers are contraindicated in
hypertrophic obstructive cardiomyopathy
Meds contraindicated
strongest predictor of a poor prognosis in Aortic Stenosis
Dyspnea is the strongest predictor of a poor prognosis in Aortic Stenosis
What can alcohol cause on the heart?
Dilated cariomyopathy
Tx: Alcohol abstinence
Complications of mitral stenosis?
One possible complication of mitral stenosis is dysphagia and hoarseness due to left atrial dilatation and compression of surrounding structures and esophagus
a brief, high frequency, precordial sound heard in early diastole in patients with
pericardial knock
constrictive pericarditis
What is the likely diagnosis in a patient with peripheral edema, ascites, JVD without inspiratory decline, and pericardial calcifications on CXR?
Constrictive pericarditis
Kussmaul sign (increased JVP on inspiration) may be seen with
constrictive pericarditis and restrictive cardiomyopathies
Constrictive pericarditis is treated first with
diuretics, then pericardiectomy
What is the treatment for acute pericarditis?
NSAIDs and colchicine
Acute pericarditis commonly presents with sharp chest pain that is aggravated by XXXXX and relieved by XXXXX
Acute pericarditis commonly presents with sharp chest pain that is aggravated by inspiration and relieved by sitting up and leaning forward
In cardiac tamponade, cardiac output decreases due to
In cardiac tamponade, cardiac output decreases due to decreased left ventricular preload
- Hypotension
- Distended neck veins
- Distant heart sounds
Cardiac tamponade
Beck triad
One ECG change associated with cardiac tamponade
electrical alternans
“swinging” movement of the heart in a large effusion
ECG pattern characterized by alternations in the appearance of the QRS complex between beats
Cardiac tamponade may be associated with pulsus paradoxus, which is
a decrease in amplitude of systolic BP > 10 mmHg during inspiration
Chest X-ray of a patient with aortic dissection shows
a widened mediastinum
markedly unequal blood pressure in the arms
a widened mediastinum
Aortic dissection
What imaging study is used for the definitive diagnosis of pericardial effusion / cardiac tamponade?
Echocardiography
Late systolic murmur (with midsystolic click) at the apex
Mitral valve prolapse
Mitral valve prolapse is caused by
myxomatous degeneration of the valve, making it floppy
What is the most likely diagnosis in a patient with dilated cardiomyopathy, supraventricular tachyarrhythmia, and no murmur?
Tachycardia-induced cardiomyopathy
Dilated cardiomyopathy and supraventricular tachyarrhythmias often occur concomitantly
Dilated cardiomyopathy and supraventricular tachyarrhythmias often occur concomitantly
Dilated cardiomyopathy and supraventricular tachyarrhythmias often occur concomitantly
Late (chronic) VS early (acute) lesions of rheumatic heart disease
Late (chronic) lesions of rheumatic heart disease cause mitral stenosis
Early (acute) lesions of rheumatic heart disease cause mitral regurgitation
Patients with HCM may also have an accompanying murmur of
Mitral regurgitation (i.e., a holosystolic murmur best heard at the apex)
Caused by systolic anterior motion of the mitral valve (SAM) leaflets into the left ventricular outflow tract
A sustained decrease in systolic BP by ≥ 20 mm Hg and/or diastolic BP by ≥ 10 mm Hg from the supine to standing position is consistent with
orthostatic hypotension.
1st line Tx: fluid and sodium intake; 2nd line: alpha-1 adrenergic agonist (e.g., midodrine)
Patient with orthostatic hypotension.
Fluid and sodium intake fails to resolve symptoms.
Next step?
alpha-1 adrenergic agonist (e.g., midodrine)
Multiple system atrophy (MSA) involves 2/3 of:
- Motor abnormalities (Parkinsonian)
- “S”erebellar (cerebellar) ataxia
- Autonomic insufficiency (orthostatic hypotension, incontinence)
Aortic regurgitation murmurs due to valvular disease are best heard at
the left sternal border (Erb’s point / left 3rd ICS)
Most likely echo finding in patient with hypertrophic cardiomyopathy
Besides septal wall thickness of >15 mm
Abnormal movement of mitral valve
echocardiography which typically shows systolic anterior motion of the anterior mitral valve leaflet
Medication that can cause hypertensive crisis after recent ingestion of foods rich in tyramine (e.g., cured meats, dried fruits, red wine).
Monoamine oxidase inhibitors (MAOIs), e.g., phenelzine
As MAOIs inhibit monoamine oxidase, the consumption of tyramine-rich foods (e.g., red wine, certain nuts, aged cheeses, cured meats, dried fruits) can lead to an accumulation of tyramine. This, in turn, results in a release of norepinephrine, which can induce a hypertensive crisis.
Tx of major depression
Jugular venous distention on inspiration
Kussmaul sign
Seen in patients with constrictive pericarditis, restrictive cardiomyopathy and right atrial or ventricular tumors
Cause of wide pulse pressure with elevated systolic blood pressure and normal diastolic pressure.
Decrease in arterial compliance
Syncope within 2–5 minutes of rising from a seated or supine position
Orthostatic syncope
Caused by Autonomic dysfunction
The first-line agents for management of essential hypertension during pregnancy are
labetalol and methyldopa
A sustained decrease in systolic BP by ≥ 20 mm Hg and/or diastolic BP by ≥ 10 mm Hg from the supine to standing position is consistent with
orthostatic hypotension.
Situational vs vasovagal syncope
- Situational: Syncope after coughing, straining while defecating, or even after a meal.
- Vasovagal syncope: triggered by seeing blood, pain, emotional stress, or prolonged standing
Routine test in HTN
HELP CUT blood pressure:
* HbA1c/Fasting glucose
* ECG (baseline)
* Lipid Profile
* Chemistry panel
* Urinalysis
* TSH
Dx in a young patient with:
- hypertensive emergency
- papilledema
- severe headache
- confusion
- abdominal bruit on examination that is best heard at the right costovertebral angle
Fibromuscular dysplasia (FMD)
Stenoses of the renal arteries
A disease characterized by stenosis of the small and medium-sized arteries as a result of proliferation of connective tissue and muscle fibers within the arterial vessel walls.
- Confusion
- headache
- flushed skin
- bright red retinal veins
- high anion gap (AG = Na - (Cl + HCO3) (Normal value 4-12)
- elevated lactate levels
Cyanide poisoning
Nitroprusside is associated with
Tx of HTN crisis
Cyanide poisoning
Renal changes in HTN
nephrosclerosis/glomerulosclerosis leading to chronic kidney disease
Tx of HTN in african american patients
THZ (e.g., Chlorthalidone)
xanthelasma
Increased risk of CAD
HMG-CoA reductase inhibitor
Statins
How to calculate LDL
LDL (mg/dL) = total cholesterol - HDL - (triglycerides/5)
Cholestatic jaundice + sicca syndrome (e.g., dry eyes, dry mouth) are highly suggestive of .
Primary biliary cholangitis (PBC)
Associated to dramatic hypercholesterolemia, autoimmune thyroiditis, CREST syndrome, and rheumatoid arthritis.
Dyslipidemia
Niacine
Flushing
Tx et PPx with ASA
caused by prostaglandin-induced peripheral vasodilation
Which three statins have the lowest risk of statin-associated myopathy?
- Pravastatin
- Pitavastatin
- Fluvastatin
Indications of statins
- Vascular disease (MI, carotid stenosis, peripheral vascular disease, cerebrovascular disease)
- LDL > 190 mg/dL (10 mmol/L)
- LDL 70 mg/dL (4 mmol/L)-190 mg/dL (10 mmol/L) + age 40-75 + Diabetes
- LDL 70 mg/dL (4 mmol/L)-190 mg/dL (10 mmol/L) + age 40-75 + cardiovascular risk factors (Hypertension, smoking, obesity, family Hx, XY > 45 y-o/XX > 55 y-o
Hemodynamically stable patients with sustained monomorphic VT.
Next step?
Prompt pharmacologic cardioversion with intravenous antiarrhythmics such as procainamide, sotalol, or amiodarone
**Hemodynamically unstable patients with sustained monomorphic VT.
WITH pulse
Next step
Cardioversion
**Hemodynamically unstable patients with sustained monomorphic VT.
WITHOUT pulse
Next step
Defibrilation
Then CPR for 2 mins
Stable + narrow QRS tachycardia > 150 bpm =
Stable + wide QRS tachycardia > 150 bpm =
Tx?
Stable + narrow QRS tachycardia > 150 bpm = Adenosine
Stable + wide QRS tachycardia > 150 bpm = Amiodarone
Underlying cause of splenic infarction
In patients < 40 years of age:
In patients > 40 years of age:
Underlying cause of splenic infarction
In patients < 40 years of age: hypercoagulable state
In patients > 40 years of age: thromboembolic
What is the most common location of ectopic foci that cause atrial fibrillation?
Pulmonary veins
Tx with ablation: Pulmonary vein isolation
A conduction abnormality (e.g. AV block) in the setting of infective endocarditis suggests what?
Perivalvular abscess
What is the likely diagnosis in an IV drug abuser with fever, an early diastolic murmur (left sternal border), and 2nd-degree AV block?
Perivalvular abscess
What is the recommended management for a patient with first-degree AV block and a normal QRS duration (< 120 msec)?
Observation
What is the recommended treatment for neurologic or cardiac manifestations of Lyme disease?
IV ceftriaxone
long-term adverse effect of amiodarone
Chronic interstitial pneumonitis
patients with tertiary syphilis are at risk of developing
- thoracic aortic aneurysm (TAA) from aortitis
- Tabes dorsalis: ataxia, lower extremity pain, impaired sensation in the lower extremities
- Argyll Robertson pupil: pupils that react to accomodation but do nit react to light
Patients with recurrent DVTs may be treated with a(n) ????? if they have contraindications to anticoagulation
Patients with recurrent DVTs may be treated with a(n) IVC filter if they have contraindications to anticoagulation
absolute contraindications to anticoagulation (e.g., recent surgery, intracranial hemorrhage, active bleeding),
Restritive cardiomyopathy + macroglosia
Multiple myeloma (MM)
AL amyloidosis
most common cause of viral myocarditis in children and adolescents.
Coxsackie B virus is the most common cause of viral myocarditis in children and adolescents.
Absent jugular venous pulse y descent indicates…
Pericardial tamponade
High pitched grating sound between S1 and S2
Pericarditis
ST elevations in all leads
Always suspect a XXXXXX in patients with Infective endocarditis who develop a new conduction abnormality
Always suspect a perivalvular abscess in patients with infective endocarditis who develop a new conduction abnormality
