Cardiology Flashcards
What medications can you not give a patient with aortic stenosis?
- Beta Blockers
- Calcium Channel Blockers
- Nitroglycerin
An elderly patient presents with dyspnea, angina, and syncope on exertion. The EKG is normal. What is the most likely diagnose?
Aortic Stenosis
On physical exam you hear a harsh systolic murmur along the right sternal border. What is the most likely diagnosis?
Aortic Stenosis
A diastolic rumble should make you think of what diagnosis?
Mitral Valve Stenosis and Tricuspid Stenosis
Is the murmur of aortic stenosis stystolic or diastolic?
Systolic (the blood is trying to get through the valve)
A wide split and fixed S2 should make you think of what diagnosis?
Atrial Septal Defect
Rheumatic fever may be associated with waht two cardiac valve issues?
Mitral and Aortic Stenosis
How does body position affect the murmur of hypertrophic cardiomyopathy?
Louder with valsalva, quieter and squatting
What is the most common cardiomyopathy?
Does it cause diastolic or systolic dysfunction?
Dialated
Systolic
What is the pathophysiology behind Tako-subo?
Extreme stress to the heart due to high emotional state causes a release of norepinephrine and epinephrine causing the cordae tendinae to rupture
Describe Still’s Murmur?
Occurs at around age 2-10. High pitched early systolic that diminishes with Valsalva.
The majority of atrial septal defects are secondary to what pathologic opening remaining open?
The ostium secundum
Rheumatic fever develops in children and adolescents following what infection?
Pharyngitis with group A strep
What is the treatment for rheumatic heart disease?
PCN in the acute phase + Asparin
What congenital heart defect can present with diaphoresis during feeds?
Is the murmur systolic or diastolic?
Ventricular Septal Defect
Holosystolic murmur best heard at lower left sternal border
What genetic pattern is hypertrophic cardiomyopathy?
Autosomal Dominant
What are the hallmark signs of Kawasaki’s Disease?
Strawberry Tongue and persistent fevers
What medication is first-line for chronic stable angina?
Beta-blockers (metoprolol)
What is the mechanism of nitroglycerin in relieving angina?
It causes venodilation, reducing preload and myocardial oxygen demand
What is the first lab to elevate in a STEMI?
Myoglobin
What is the treatment for a carotid disection?
Anticoagulants
What medication should be avoided in right ventricular infactions?
Nitroglycerin
What is the most common valve associated with bacterial endocarditis in drug users?
What murmur is most often heard?
Tricuspid valve
Tricuspid regurgitation
Which valve abnormality is most commonly associated with Marfan’s syndrome?
Mitral valve prolapse
What is the test of choice for evaluation of a known abdominal aortic aneurysm in an asymptomatic patient?
Abdominal Ultrasound
What is the most common electrolyte that can affect the initiation of ventricular tachycardia?
Magnesium
What is the most common cause of atrial fibrillation?
Hypertension
What is the first-line treatment for stable supraventricular tachycardia?
Vagal maneuvers –> adenosine
What is the drug of choice for stable ventricular tachycardia?
Amiodarone
What auscultation finding is classic for heart failure?
S3 gallop (ventricular gallop)
What is the first-line treatment for acute decompensated heart failure?
Loop diuretics (furosemide) + oxygen
What is the first-line medication for hypertension in African American patients?
Thiazide diuretics or calcium channel blockers (amlodipine)
What valvular disease is associated with a diastolic “opening snap”?
Mitral Stenosis
What is the mainstay of treatment for chronic peripheral artery disease (PAD)?
Aspirin, statin, smoking cessation, cilostazol
What is the first-line medical treatment for aortic dissection?
IV beta-blockers (esmolol, labetalol)
What is the primary pathophysiology of ventricular fibrillation?
Chaotic, uncoordinated ventricular depolarization preventing effective contraction and cardiac output.
Why does left-sided heart failure lead to pulmonary congestion?
Increased left atrial pressure → pulmonary venous hypertension → pulmonary edema
What neurohormonal mechanisms exacerbate heart failure?
RAAS activation, sympathetic nervous system activation, and ADH release, all leading to vasoconstriction, sodium retention, and increased afterload.
What cardiac complication is associated with hyperthyroidism?
High-output cardiac failure
What medication is recommended for the treatment of atrial dysrhythmias associated with hyperthyroidism?
Propranolol
What is the most common chronic arrhythmia?
A. Fib
When are beta-blockers and calcium channel blockers contraindicated in A. Fib?
In CHF and severe hypotension
What medications are used for rate control in A. Fib?
When is digoxin used in the treatment of A. Fib?
Beta Blockers (Metoprolol, Atenolol, Esmolol)
Non-dihydropyridine Calcium Channel Blockers (Diltiazem, Verapamil)
What medications should be avoided in Wolf-Parkinson-White?
Avoid AV nodal blocking agents (Adenosine, Beta blockers, CCB, digoxin) because they can lead to preferential conduction down the Bundle of Kent, worsening the tachycardia
What is the preferred treatment of stable (wide complex tachycardia) in WPW?
Procainamide
What is the preferred therapy for the prevention of recurrent preexcited atrial fibrillation?
Ablation of the accessory pathway
What is the definitive treatment for Wolf-Parkinson-White?
Radiofrequency ablation
You are evaluating a newborn for an episode of cyanosis, shortness of breath, and agitation. On cardiac exam, a harsh cresendo-decrescendo systolic ejection murmur is appreciated. Chest x-ray shows a boot shaped heart. What is the most likely diagnosis?
Tetralogy of fallot
Which arrhythmia is characterized by a “sawtooth” pattern on the ECG?
Atrial Flutter
What is the first-line treatment for symptomatic bradycardia?
Atropine
Which medication is commonly used for rate control in atrial fibrillation?
Beta-Blockers (motoprolol)
What is the definitive treatment for patients with recurrent ventricular tachycardia or ventricular fibrillation?
Implantable cardioverter-defibrillator (ICD)
What is the most appropriate first step in the management of a stable patient with paroxysmal supraventricular tachycardia (PSVT)?
Vagal Meneuvers
What heart arrhythmia is associated with EKG patterns that bradycardia alternates with tachycardia?
Sick Sinus Syndrome
Which class of medication is typically first-line in the management of symptomatic dilated cardiomyopathy?
ACE Inhibitors
What is Dressler’s Syndrome?
What is the treatment?
What should be avoided to prevent pericardial wall thinning?
Pericarditis following a myocaridal infarction
ASA or Colchacine
NSAIDs and corticosteroids
The treatment for a pulmonary embolism is low molecular weight heparin plus warfarin. What are the low molecular weight agents?
- Enoxaparin
- Daltaparin
- Tinzaparin
What are common signs and symptoms of congestive heart failure?
- Exertional dyspnea (SOB), then with rest
- Chronic nonproductive cough, worse in a recumbent position
- Fatigue
- Orthopnea (late), night cough, relieved by sitting up or sleeping with additional pillows
- Paroxysmal nocturnal dyspnea
- Nocturia
What adventatous breath sound is associated with congestive heart failure?
What will be seen on CXR?
Rales
Kerley B Lines
What is the BEST test for working up congestive heart failure?
Echocardiogram
What tick-borne disease is most likely to be associated with an atrioventricular heart block?
Lyme Disease
What psychiatric disorder has a high association with Burgada Syndrome?
Schizophrenia
What are some common manifestations of endocarditis?
- Osler Nodes: painful raised red lesions on the hands and feet
- Janeway Lesions: non-tender, flat, small lesions on hands/feet
- Petechiae: palate or conjunctiva
- Clubbing
- Roth Spots: retinal hemorrhages with pale centers
What is the USPSTF recommendation for high cholesterol screening?
USPSTF recommends screening for patients with NO evidence of CVD and NO other risk factors should begin at 35 years of age
What is the targeted LDL in a patient with diabetes?
LDL < 70; anything above 70 should be treated with statin therapy
What are some side effects of ACE inhibitors?
Ace inhibitors are associated with cough, angioedema, and can cause hyperkalemia.
They are contraindicated in pregnancy
What are the rate controlling calcium channel blockers?
Verapamil and Diltiazam
What medication class should be used to treat high triglycerides?
Fibrates (Fenofibrate and Gemfibrizil)
What is the goal LDL for patients with diabetes and coronary artery disease?
LDL < 55 mg/dL
High intensity statin therapy is warranted. Add Ezitimibe if not controlled with statin alone.
What is the first line therapy for hypertriglyceridemia?
Fibrates (Fenofibrate) are the most potent medications to decrease trigylcerides - can reduce TG level as much as 50% or greater
What manuvers can be done to increase venous return?
Does increase venous return increase most murmur intenstities?
- Supine Position
- Squatting
- Leg elevation
Yes, except hypertrophic cardiomyopathy and the click of mitral prolapse
In which ECG leads can a myocardial infarction in the anteroseptal portion of the heart be seen?
Leads V1-V4
ECG Lead Distribution for Anteroseptal MI:
V1-V2: Septal wall infarction
V3-V4: Anterior wall infarction
V1-V4: Anteroseptal infarction (involves both regions)
What ankle-brachial index (ABI) ratio suggests a degree of arterial obstruction often associated with claudication?
What is a normal ABI?
ABI of 0.4-0.9
0.9 - 1.4
What is a helpful physical exam finding that can differentiate peripheral artery disease from chronic venous insufficiency?
Leg swelling/edema; PAD does not have leg swelling
What is Pancoast Syndrome and what type of lung cancer is it associated with?
Pancoast syndrome involves a lung malignancy in the superior sulcus. These tumors can cause nerve impingement that leads to arm or shoulder pain and hand muscle atrophy. They can also disrupt the sympathetic nerve chain, which innervates the eye, leading to ptosis, miosis, and anhidrosis of the ipsilateral side (Horner syndrome).
Non-Small Cell Lung Cancer
What type of birth control should be avoided in women with a history of deep vein thrombosis?
Contraceptives containing estrogen
Which heart valve is most commonly affected by infective endocarditis in intravenous drug users?
Tricuspid Valve
What is the most common organism responsible for acute bacterial endocarditis?
What is the most common organism responsible for subacute endocarditis?
S. aureus
Strep Viridans
Which imaging modality is the gold standard for diagnosing endocarditis?
Transesophageal echocardiogram (TEE)
Name one major criterion from the Duke criteria used for the diagnosis of endocarditis
- Blood cultures: S. aureus, S. viridans, S. bovis or other typical species x 2, 12 hours apart
- Echocardiogram: vegetations are seen (tricuspid-IV drug users, mitral-non drug users)
- New regurgitant murmur
What is the initial empiric antibiotic therapy for native valve endocarditis?
Vancomycin and ceftriaxone
At what anatomical sites does the abdominal aorta begin and end?
The abdominal aorta begins at the level of the diaphragm and ends at the level of the umbilicus, where it bifurcates into the left and right iliac arteries.
What is the Levine sign?
Clenched fist placed over the heart in the setting of chest pain
What are other causes of elevated troponin in addition to acute myocardial infarction?
- Myocarditis
- Pericarditis
- Rapid atrial fibrillation
- Heart failure
- Pulmonary embolism
- Aortic dissection
- Sepsis
What are the first-line antihypertensive agents in patients with acute aortic dissection?
Esmolol or labetalol
What medication class should be initiated imediately in patients with an NSTEMI?
High-dose statins (atorvastatin) are recommended in all patients with NSTEMI as they improve outcomes and delay death or major cardiovascular events by up to three months
What is the most common risk factor for the development of abdominal aortic aneurysm?
What is the USPSTF’s recommendation for screening of AAA?
Smoking
One time screening via ultrasound for men 65-75 who have smoked
At what diameter is an abdominal aortic aneurysm considered surgical?
Generally, surgical repair is considered when the aneurysm is ≥ 5.5 cm or if it is rapidly expanding. Some sources say > 5.0 cm for women.
What imaging modality is most commonly used for initial screening of an abdominal aortic aneurysm?
Abdominal Ultrasound
What is the primary pathological change leading to the formation of an abdominal aortic aneurysm?
Which layer of the aortic wall is most commonly affected?
Degeneration and weakening of the aortic wall, primarily due to loss of elastin and collagen in the tunica media
Tunica media
What genetic disorder is associated with an increased risk of aortic aneurysm due to connective tissue defects?
Marfan Syndrome, which affects fibrillin, leading to a weakened aortic wall
What heart valve is most commonly affected in rheumatic heart disease?
The mitral valve (mitral stenosis is the most common consequence)
What is the long-term prevention strategy for patients with rheumatic heart disease?
Long-term antibiotic prophylaxis, usually with penicillin, to prevent recurrent Group A streptococcal infections
What medication classes are contraindicated in patients with right ventricular infarction?
Nitrates and Diuretics
What is the heparin antidote (reversal agent)?
Protamine Sulfate
What anti-hypertensive drug class can lower melatonin therefore causing fatigue and sleep disturbances?
Beta-Blockers
What artery is occluded in an anterior wall STEMI and what leads will the infarct be?
Why is this called the “widow maker”
Anterior wall infarction is caused by an occlusion of the LAD.
Infarct will appear in leads V3 and V4.
It involves a large area of the left ventricle and has a bad prognosis
What is the most common side effect with statin medications?
Myalgias (muscle pain or soreness)
Upon discharge from an acute heart failure exacerbation patients should be instructed on what to prevent readmission?
How many grams of sodium can one eat per day on a low sodium diet?
Monitor daily weights and adhere to all prescribed medications
Under 2 grams
List the major criterion for the revised Jones Criteria for Acute Rheumatic Fever?
What are some minor criterion?
- Carditis
- Polyarthritis
- Chorea
- Subcutaneous nodules
- Erythema marginatum
Fever, polyarthralgia, elevated ESR or CRP, prolonged PR interval on EKG
What is the name of the short, mid-diastolic murmur heard best at the apex of the heart, which is associated with acute rheumatic fever?
Carey Coombs murmur, which indicates inflammation of the mitral valve
What is the diagnostic criteria for Kawasaki Disease?
What is the treatment?
Kawasaki Disease Criteria (Need ≥5 days of fever + 4/5 of the following):
- Conjunctivitis (bilateral, nonexudative)
- Rash (polymorphous, no vesicles or bullae)
- Extremity changes (swelling, erythema, later desquamation)
- Adenopathy (cervical, unilateral, >1.5 cm)
- Mucosal changes (strawberry tongue, cracked lips)
IVIG + ASA
Why is aspirin apart of the treatment for Kawasaki disease?
To prevent coronary artery aneurysms - Kawasaki disease effects medium sized vessels
Tall peaked P-waves should make you think of what diagnosis?
Right atrial enlargement - can be associated with Cor Pulmonale
A U wave on EKG should make you think of what diagnosis?
Hypokalemia
In heart failure with preserved ejection fraction the EF is greater than what percent?
> 50%
Why can’t you lower blood pressure too quickly in the setting of hypertensive crisis?
Hypoperfusion
What is the name of the syndrome that involves pericarditis several days after an MI?
Dressler’s syndrome
What is the accessory pathway associated with Wolff-Parkinson-White syndrome?
The Bundle of Kent
What are the inferior leads?
II, III, and avF
Define pulse pressure?
The difference between systolic and diastolic pressure
An opening snap is an indication of what valvular disease?
Mitral valve stenosis
MONA is a common mnemonic used to remember treating acute coronary syndrome. What does it stand for?
Morphine, Oxygen, Nitroglycerin, Aspirin
Which lab should be tightly monitored in a patient taking an aldosterone antagonist?
Potassium, they may have hyperkalemia
Diffuse ST elevation on a 12 lead ECG should make you think of what diagnosis?
Pericarditis
What causes the second heart sound (S2)?
The closure of the aortic and pulmonic valves
Mitral stenosis patients will usually go on to develop what other cardiac issue?
A. Fib
Why do you get pulses paradoxus with cardiac tamponade?
The heart is squeezed by the tamponade. It’s squeezed more with inspiration and the left ventricle can’t fill.
An elderly patient presents with dyspnea, angina, and syncope on exertion. The EKG is normal. What is the most likely diagnosis?
What will be heard on exam?
Aortic stenosis
Harsh, crescendo-decrescendo, heard best at the 2nd intercostal space
Can radiate to carotids
Following an MI, what medication should you be using to treat hypertension?
Beta-Blocker
A diastolic rumble should make you think of what diagnosis?
Mitral valve stenosis
What medication can you use to treat digitalis toxicity?
Atropine
What are the first line medications for cardiogenic shock?
Norepinephrine or dobutamine
What is the imaging of choice to diagnose an abdominal aortic aneurysm?
Ultrasound
What are Roth Spots and what diagnosis do they indicate?
Exudates in the retina. Endocarditis.
An elevated brain natiuritic peptide (BNP) is indicative of what disease?
Heart Failure
What is the primary goal of long-term management to reduce the risk of complications and recurrent aortic dissection?
What layer lining does a disection occur?
Strict BP Control
Intima, the internal lining of the aorta
What dysrhythmia commonly occurs in patients with tricuspid stenosis?
Atrial Fibrillation
A 57-year old patient is found to be unresponsive and pulseless. CPR is started, and the defibrillator is attached. EKG shows asystole. What is the next best step?
Administer 1mg intravenous epinephrine
What syndrome is associated with a VSD that results in right-to-left shunting?
Eisenmenger Syndrome. Progressive high pulmonary vascular pressure alters flow from left to right through the VSD to right to left, leading to cyanosis.
What is the American Academy of Pediatrics recommendation for the initial work-up of pediatric persistent hypertension?
- BMP
- Urinalysis
- Lipid Panel
