Cardiology 2 Flashcards
Cardiac monitoring of patient on herceptin
- Baseline TTE
- Repeat TTE a 3,6,9 months after herceptin initiation
RF’s for cardiotoxicity with herceptin
- old age
- previous or concurrent anthracycline use
Management of patient on herceptin with asymptomatic decline in EF of 15% or more
Hold herceptin for 4 weeks
Angiosarcomas clinical features
- Right atrium
- Associated with pericardial effusions, tamponade
- increased vascularity
Typical origin of cardiac tumors
Metastatic
Tumor commonly associated with cardiac mets
Melanoma
atrial myxoma clinical features
- typically left atrium
- have a stalk
- lack of vascularity
Rhabdomyomas clinical features
- tuberous sclerosis
- kids
Management of patient with AF who has bleed on multiple AC
Left atrial appendage (Watchman)
Digoxin toxicity clinical features
- arrhythmia (every rhythm abnormality can be seen with dig toxicity)
- nausea, anorexia, fatigue, vision changes, AMS
- often happens with AKI
- have a low threshold for stopping and checking a level
VTE management in patient with valvular AF (secondary to mitral stenosis)
Warfarin (regardless of CHADS-VASc score)
Score indicating need for AC from CHADS-VAs
- Men = 2 or greater
* Women = 3 or greater
Antithrombotic therapy for patient with AF after PCI and stent with elevated bleeding risk
Double therapy: Plavix + low-dose rivaroxaban or dose-adjusted warfarin (no aspirin/triple therapy)
Next step after emergent cardio version for new AF
Anticoagulation ASAP then continued for at least 4 weeks if CHADSVASC 1 or indefinitely if CHADSVASC 2 or greater (there is high risk of thromboembolism after cardio version)
Primary evidence for clinical benefit from SGLT2 inhibitors or GLP-1 agonists
- primarily in patients with atherosclerotic CV disease
- less benefit in CHF patients
Initial step following diagnosis of symptomatic mild or moderate mitral stenosis
IF symptoms are not consistent with valve grade –> Exercise echo (need to ensure symptoms are attributed to mitral stenosis)
management of mild to moderate mitral stenosis in asymptomatic patients
annual clinic apt + TTE q5 years
Medical therapy for mitral stenosis
- diuretics
- long acting nitrates
- beta-blockers or non-dihydropiridine CCBs (to lower HR and improve LV diastolic filling time)
When do you use medical therapy for mitral stenosis?
Only when patient is not a surgical candidate
Antithrombotic therapy in patient with mechanical prosthetic valve
Lifelong Aspirin + warfarin (for at least 3 months)
ASD clinical features
dyspnea, paroxysmal atrial fibrillation, and features of right heart volume overload with elevation of the central venous pressure and a right ventricular lift (due to left to right shunt)
ostium primum ASD clinical features
Fixed splitting of the S2, a mitral regurgitation murmur, and left-axis deviation on electrocardiogram
ostium primum vs. secundum clinical features
Secundum = *no mitral regurgitation. *No Left axis deviation.
Papillary fibroelastomas vs. atrial myxoma
Left atrial myxoma = Both can embolize. LA myxomas are larger than fibroelastomas, causing obstructive symptoms + typically attach to the fossa ovalis, not the valve (look at where it’s attached).
Left atrial myxoma presentation
fatigue, low-grade fever, athralgia
left atrial myxoma vs endocarditis
both can cause fever but myxomas often cause obstructive symptoms
Atrial myxoma treatment
urgent surgical excision
Nonbacterial thrombotic endocarditis clinical features
hypercoagulable state (malignancy, or connective tissue disease), small/irregularly shaped/wart like vegetations
Indication for entresto
Include symptomatic hypotension/orthostasis as contraindication
Ivabradine mechanism
Inhibits the If or I-funny channel of the SA node, resulting in a reduction in heart rate
Ivabradine indication
Sinus rhythm with HR greater than 70 on GDMT, addition to maximal dose betablocker has been shown to reduce CHF hospitalizations
What is GDMT
ACE inhibitor, beta-blocker, and aldosterone antagonist
Indication for pacer in CHF
EF less than or equal to 35% + NYHA class II to IV CHF despite GDMT + sinus rhythm + left bundle branch block with QRS complex of 150 ms or greater
Management of patient with severe AR who is asymptomatic
No echo, or exercise testing if patient has an indication for surgery (treadmill stress echo is used for patients with equivocal symptoms
Recommended echo interval for severe MR surveillance
q6-12 months
Indications for surgery with severe primary MR
- 1) symptomatic with LVEF greater thna 30%
- 2) asymptomatic with LV dysfunction
- 3) undergoing another cardiac surgery
- 4) AF or pHTN
Management of CAD + AF
Discontinue antiplatelet therapy, and do only oral anticoagulation unless patient has recent active CAD (ACS or revascularization in past 12 months)
Initial step in management of bicuspid aortic valve
CT angiography of the aorta (even in asymptomatic patients, aortopathy (aneurysm, dissection, coarctation) is life threatening so these pathologies need to be ruled out)
RBBB on ECG
- widened QRS complex (>120 ms); an RSR′ pattern in lead V1; and a wide negative S wave in leads I, V5, and V6.
- M and W pattern
LAFB on ECG
positive QRS complex in lead I and a negative QRS complex in lead aVF.
Management of asymptomatic bifascicular block
No further evaluation
When are pacemakers indicated for symptomatic bradycardia?
Always indicated in the *absence of a reversible cause.
Management of patient with a thoracic aortic aneurysm who is requiring CABG
IF greater than 4.5 cm –> aneurysm repair at time of surgery (so concomitant surgery)
Management of acute limb ischemia
urgent invasive angiography
Indications for device closure with ostium secondum ASD
- Right heart enlargement
- Symptomatic
AFib with aberrancy management
Beta-blocker + anticoagulation
*standard AF management
Indications for cardiac rehab
Everyone following hospitalization for ACS and PCI
First step in aortic dissection management
Differentiate Type A from Type B
Management of acute Type A aortic dissection
emergent open surgical repair (high mortality rate)
Indications for TTE with murmurs
- systolic murmurs grade 3/6 or higher,
- late or holosystolic murmurs
- diastolic or continuous murmurs
- symptomatic
Management of suspected peri valvular abscess
If high pretest –> proceed directly to TEE
Symptoms suggesting severe mitral stenosis
Progressive exertional dyspnea
Biggest risk factor for cardiovascular disease in nonsmokers or patients who’ve quit smoking more than 10 years ago
Hyperlipidemia
ABI interpretation
- Less than or equal to 0.90 = PAD
- Greater than 1.40 = uninterpretable (calcified, non compressible arteries in lower extremities), thus need to calculate toe-brachial index
ABI calculation
Higher ankle pressure divided by Higher brachial pressure
Workup of new heart failure diagnosis
CMP, TSH
*Cath only if angina or significant ischemia
noonan syndrome clinical features
pulmonary stenosis, particularly those with short stature, variable intellectual impairment, unique facial features, neck webbing, hypertelorism, and other cardiac abnormalities, including hypertrophic cardiomyopathy, atrial septal defect, and ventricular septal defect
Treatment of effusive constrictive pericarditis
NSAIDS + colchicine (pericardiectomy if not responding to medical therapy)
Management of severe myxomatous degeneration of mitral valve
- Mitral valve repair
- NOT mitral valve replacement (worse survival compared to valve repair)
Indications for surgery with mitral regurg
1) Symptomatic with LVEF greater than 30%
2) Asymptomatic with LV dysfunction (EF less than ***60% and or **LV end systolic diameter greater than 40 mm)
3) Patients undergoing another cardiac surgical procedure
4) AF or pHTN
Indications for surgery with Severe AR
- symptomatic
- LVEF less than **50%
- significant LV dilation
Management of severe AR not requiring surgery
- TTE in 6-12 months
- NOT medical management (uncertain benefit, beta-blockers useful when comorbid CHF)
BNP levels in heart failure
- Greater than 400 = high likelihood
Lower than 100 = good NPV for excluding CHF
*In between is indeterminate.
Initial management of symptomatic or frequent PVCs
Exercise stress testing (evaluate for ischemia, assess response of PVCs to exercise) + TTE
Treatment of symptomatic or frequent PVCs
beta-blockers or CCBs
IF persistent, despite medical therapy OR LV dysfunction – catheter ablation
Cardiac tamponade clinical features
- hypotension
- pulsus paradoxus
- enlarged cardiac silhouette on CXR
- electrical alternans on EKG
Definition of pulsus paradoxus
Fall in systolic pressure of 10 mm Hg with inspiration
Management of type 1 NSTEMI in patient declining cath
Aspirin + ticagrelor for at least 1 year
How to titrate beta-blockers in CHF
Uptitrate every 2 weeks until patient achieves resting HR of approximately 60
Hydralazine + isosorbide dinitrate indication
Black + MAXIMAL GDMT + class III-IV CHF
First step in management of cryptogenic stroke
30 day-event monitor (NOT hotter monitor)
- if inconclusive, loop recorder is reasonable
Management of AS with discrepancy between symptoms and TTE
Cath to determine severity before valve replacement
Initial step in WPW
EP study
Valve disease management in general
- surgical, rarely ever medical
cutoff for severe mitral stenosis
Less than 1.0 cm2
Other general indication for valve surgery
Patient is getting other cardiac surgery
Management of MR – repair or replace?
Always repair if possible
Management of severe MR in patient who isn’t a surgical candidate
Mitral clip
EF cutoff with MR for repair
*60 (higher because ejection fraction looks better but blood is going backward)
monitoring frequency of valves
Mild - 3 years
moderate - 1 yrs
severe – 6-12 months
indications for antibiotic prophylaxis with dental procedures
- prosthetic valve
- prior endocarditis
- cardiac transplant with new valve disease (immunosuppressed)
Indications for surgery with left sided endocarditis
- CHF
- highly resistant organism
- complications (block, abscess)
- failed abx
Indications for surgery with right sided endocarditis
- same indications but you should avoid surgery if possible (more likely to heal)
pulmonary stenosis repair vs replacement
- only replace if severely dysplastic valve
Indications for valve replacement surgery in asymptomatic patients with bicuspid aortic valve and severe AR
LVEDP of 50 mm or LVEF of less than 50%
S3 is associated with
CHF
Management of Type B dissection
- initial medical management, surgery reserved for patients who develop complications of dissection
Cause of S4
atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophsic ventricle.
indications for pacemakers with second degree heart block
Type 1 = Pacer only if symptomatic
Type 2 = Pacer alway
Pulsus paradoxes how to measure
Just measure BP during expiration and inspiration (it is an abnormally large decrease in BP during inspiration)
tetralogy of fallot clinical features
Angel with wings and belted wrapped around her neck on one door (pulmonic stenosis code) + heart man with huge right leg + train riding over aorta + one of the doors is a wall with a hole in it/4 components = Pulmonic stenosis + Right ventricular hypertrophy + Overriding aorta + Ventricular septal defect. Have to PROVe TOF.
Indications for pacers with AV block
- third degree block with or without symptoms
- Symptomatic second degree block (I and II)
- Advanced second degree AV block (block of 2 or more consecutive P waves)
Left bundle branch block on ECG
- W and M
- wide QRS (greater than 120 (3 small boxes)) + deep and broad s wave in V1 + broad notched R in V6
antithrombotic therapy for mechanical prosthetic valves
- warfarin + *aspirin
CHADS-VASc scoring
C-CHF = 1 H-HTN = 1 A2-Age = over 75 = 2 D-DM2 = 1 S2 = Prior stroke or TIA or VTE = 2 A = Age 65-74 Sc = sex (female) = 1
Timing of complications post-MI
- Ventricular septal rupture and free wall rupture are only pathologies that can happen in hours
- Papillary muscle rupture – 2 days to 1 week
- LV aneurysm only pathology that can happen months out
Presentation of LV aneurysm post MI
- subacute heart failure
- stable angina
Free wall rupture vs inter ventricular septal rupture
- Free wall rupture = effusion on TTE
- Interventricular septal rupture = new holosystolic murmur
Papillary muscle rupture clinical features
- new holosystolic murmur
- severe pulmonary edema
Brugada syndrome ECG features
Huge bundle of sticks in the right corner + mountains on backwall with hat bone on left and hambone on right/ECG pattern of pseudo-right bundle branch block + ST elevations in V1-V3.
Brugada syndrome management
He has an implanted cardioverter-defibrillator/prevent SCD with implantable cardioverter-defibrillator (ICD).
Brugada syndrome clinical features
Jonny kenser dead on the floor in front of him + heart hanging above with ventricles oscillating rapidly/increased risk of ventricular tachyarrhythmias + SCD (sudden cardiac death).
WPW treatment
Long term = catheter ablation
Short term of acute STABLE tachyarrythmia = Vagal maneuvers, Verapamil, adenosine are first line. Second line are procainamide and beta blockers.
Differential for regular, narrow complex tachycardia
Sinus tach
A flutter
AVNRT
Differential for irregular, narrow complex tachycardia
AFib
MAT
AFlutter with variable conduction
Differential for regular, wide complex tachycardia
V tach
SVT with aberrancy (BBB)
Differential for irregular, wide complex tachycardia
AFib with BBB
Polymorphic VT
Differential for irregular, wide complex tachycardia
AFib with BBB
Polymorphic VT
Key ECG feature of MAT
p waves of multiple morphologies
CABG indications
1) Triple-vessel disease
2) Severe left main stem artery stenosis
3) Left main equivalent disease (70% or greater stenosis of LAD and proximal left circumflex)
4) Multivessel disease and Diabetes
Indication for aldosterone antagonist in systolic heart failure
- NYHA II-IV + EF less than or equal to 35% + normal potassium level + normal renal function (defined as Cr less than 2.5 and 2.0 in women)
