cardiology 2 Flashcards
What happens to inverted T Waves formed after an MI?
They become upright.
What is hypertensive urgency?
Severe hypertension without symptoms or evidence of acute organ dysfunction.
What are typical signs of RV strain?
T wave inversions in V1-V3 and right axis deviation.
What is the diagnosis for a patient with flow reversal in the left vertebral artery after CABG?
Subclavian steal syndrome.
Who should receive antibiotic prophylaxis for procedures?
Patients at greatest risk for infective endocarditis.
Who are the patients at greatest risk for infective endocarditis?
- Patients who have prosthetic cardiac valves.
- Patients who have prosthetic material used for cardiac valve repair.
- Patients with previous infective endocarditis.
- Patients with unrepaired cyanotic congenital heart disease or repaired congenital heart disease.
- Patients who have a cardiac transplant.
What is HFrEF classified as?
An EF less than 40 percent.
What are low-risk surgeries?
Surgeries that carry a cardiac risk of less than 1%.
What should be added to treatment for chronic stable angina?
A long-acting nitrate or a CCB.
When does papillary muscle rupture typically occur after an inferior myocardial infarction?
3 to 7 days.
What is the next step for a patient with NSTEMI with a high TIMI or Grace risk score?
Cardiac catheterization with coronary angiography within 12 to 24 hours.
What do fibrates do?
Increase lipoprotein lipase activity by activating PPAR alpha receptor.
What is the target INR for patients with mechanical mitral valve prosthesis?
Typically 2.5-3.5.
What class of medication is associated with orthostatic hypotension in older men with hypertension and BPH?
Alpha blockers.
What is the most appropriate immediate treatment for symptomatic complete heart block?
Transcutaneous or transvenous pacing.
What is the likely diagnosis for a young patient with periodic palpitations?
Wolff-Parkinson-White.
What is the recommended treatment for suspected TCA overdose with wide QRS complex?
Sodium bicarbonate.
What antibiotics are recommended for secondary prevention of rheumatic fever?
Long-acting Penicillin G Benzathine IM every 3 to 4 weeks, daily oral penicillin V, sulfadiazine, or a macrolide.
What is the addition of spironolactone to GDMT for HFrEF patients indicated for?
Once the EF drops below 35%.
What is the initial management of cocaine-associated chest pain?
Benzodiazepine and nitroglycerin.
What is the diagnosis for a patient with a very high initial high sensitivity cardiac troponin value?
Would rule in ACS.
What is the murmur location for acute mitral valve insufficiency?
Will be at the apex.
What is the murmur location for aortic valve insufficiency?
At the base.
What are the typical manifestations of Chagas disease?
Esophageal dysfunction, conduction system abnormalities, and dilated cardiomyopathy.
What is a Bifascicular block?
An RBBB with either left anterior or left posterior fascicular block.
What are common clinical signs of cholesterol crystal embolism?
Livedo reticularis and blue toe syndrome.
What is the management for patients with renal cell carcinoma and venous tumor thrombus extending into the renal vein?
Surgical intervention may be required.
What is a thrombus?
A thrombus is a blood clot that can extend into the renal vein or inferior vena cava.
What is the typical oscillatory description of a pericardial knock?
High-pitched early diastolic heart sound.
What is the first-line therapy for a patient with hypertensive emergency and acute heart failure?
IV nitroglycerin.
What is recommended for STEMI patients presenting within 12 hours after symptom onset?
Thrombolytic therapy when PCI cannot be performed within two hours after first medical contact.
What should be considered in patients presenting with an acute inferior wall MI?
A right ventricular infarction.
What are the clinical findings in hypertrophic cardiomyopathy that would benefit from an ICD?
Septal wall thickness greater than 3 cm and left ventricular outflow obstruction greater than 30 mmHg.
What should a patient with severe symptomatic mitral regurgitation have before elective valve surgery?
Preoperative cardiac catheterization with coronary angiography to assess for coronary artery disease.
What does a fixed split second heart sound suggest?
It is suggestive of an ASD.
What qualifies as low cardiovascular risk?
Stable angina and evidence of myocardial ischemia at high workload.
What is recommended if initial therapy with aspirin/NSAIDs plus colchicine fails in acute pericarditis?
Steroids are recommended.
What can frequent ventricular ectopy be associated with?
Reversible cardiomyopathy if the ectopic beats represent more than 10 to 20% of overall heartbeats.
What are typical imaging studies for pulmonary embolism (PE)?
CT angiography, EKG, and echocardiography.
What is a likely diagnosis for a young patient with a short early systolic sound at the apex followed by a soft ejection murmur?
Bicuspid aortic valve.
What are tendinous xanthomas pathognomonic for?
Familial hypercholesterolemia.
What EKG findings can be present in a patient with catecholamine induced cardiomyopathy?
ST-segment elevation or diffuse T wave inversion throughout the precordial leads.
What is familial hypercholesterolemia?
An autosomal dominant genetic disorder.
What should patients with Dressler syndrome avoid?
Non-aspirin NSAIDs and steroids.
What is the most dangerous complication of Kawasaki disease?
Formation of coronary artery aneurysms which can result in thrombosis or stenosis.
What is the normal range for ejection fraction (EF)?
55-70 percent.
What is the most common physical finding on cardiac auscultation in patients with hypertension?
An S4 gallop.
What is the recommended screening test for men 65 to 75 years of age who have ever smoked?
Ultrasound of the abdominal aorta.
What is indicated in a patient with atrial fibrillation of unknown or more than 48 hours duration?
TEE is indicated to exclude thrombus before cardioversion.
What is the total cholesterol level typically seen in familial hypercholesterolemia?
350 to 550, or an LDL level of 200-400.
What mechanism describes vasovagal syncope?
Trigger activates vagus nerve leading to increased parasympathetic nervous tone, decreased heart rate, blood pressure, and cardiac contractility, and increased peripheral vasodilation.
What medications limit the maximum daily dose of simvastatin?
Verapamil or diltiazem.
What is diagnostic for congenital long QT syndrome?
A QTC of >460 msec in women and >440 msec in men.
What is cardiac sarcoidosis often associated with?
Conduction abnormalities such as complete heart block, bundle branch block, and ventricular arrhythmias.
When is an echocardiogram most useful?
In preoperative assessment when a patient exhibits symptoms of heart failure.
What is a sign of pulmonic valve stenosis?
A harsh systolic crescendo decrescendo murmur in the second left intercostal space radiating to the neck.
What is audible in roughly 85% of patients with acute pericarditis?
A pericardial friction rub.
What EKG abnormalities are consistent with right ventricular strain?
Right bundle branch block, SI-QIII-TIII pattern, ST elevation in inferior leads (especially III, aVF), ST elevation in aVR, and T-wave inversion in V1-V3.
What is the next diagnostic step for a young patient with significantly elevated blood pressure and an S4 gallop?
No additional testing needed unless there is evidence of a specific secondary cause of hypertension.
What are the criteria for defining hypotension in the setting of PE?
Any of the following criteria would generally be defined.
What is the most effective strategy for perioperative anticoagulation bridging in a patient with a mechanical mitral valve and CKD?
Discontinue warfarin 5 days before surgery and initiate therapeutic dose of IV unfractionated heparin when INR falls below 2.5.
How should hemodynamically unstable ventricular arrhythmias be treated?
With unsynchronized cardioversion.
What are nonclassical symptoms of myocardial infarction?
Jaw, neck, ear, arm, and epigastric pain.
When is anticoagulation indicated based on the CHA2DS2-VASc score?
A score of greater than or equal to 2 in men or 3 in women.
How should hemodynamically unstable ventricular arrhythmias be treated?
They should be treated with unsynchronized cardioversion.
What are nonclassical symptoms of myocardial infarction (MI)?
Jaw, neck, ear, arm, and epigastric pain.
When is anticoagulation indicated based on the CHA2DS2-VASc score?
When the score is greater than or equal to 2 in men or 3 in women.
What defines a massive pulmonary embolism (PE) in terms of hypotension?
Systolic BP < 90 mm for 15 minutes, fall in systolic BP by >40 mm for 15 minutes, or requirement for vasopressors.
What are indicators of aortic coarctation?
Diminished and delayed pulses of the femoral arteries relative to the brachial arteries.
What mechanical complication of an inferior myocardial infarction is most likely to cause cardiogenic shock?
Papillary muscle rupture.
How is scleroderma renal crisis optimally treated?
With an ACE inhibitor.
What are the EKG findings consistent with left bundle branch block (LBBB)?
No R wave in lead V1, deep S waves forming a characteristic W shape, wide notched R waves in leads I, aVL, V5, V6 forming a characteristic M shape, and loss of Q waves in the lateral leads.
How should patients with heart failure with reduced ejection fraction (HFrEF) be treated?
With a beta-blocker and either an ACE inhibitor, ARB, or ARNI. If symptoms are persistent, add an MRA or an SGLT2 inhibitor.
What is indicative of Wolff-Parkinson-White syndrome?
A young patient with palpitations, a short PR interval, and a delta wave.
What typically causes vasovagal syncope?
Prolonged standing or intense pain.
Do CHF exacerbations typically manifest with acute chest pain?
No, they usually manifest with dyspnea and are not typically associated with acute chest pain.
What is DAPT typically composed of?
Aspirin and a P2Y12 inhibitor such as clopidogrel, ticagrelor, or prasugrel.
What should all patients with an inferior MI have performed?
A right-sided EKG.
How is hemodynamically stable monomorphic VT typically treated?
With an anti-arrhythmic drug such as amiodarone, procainamide, or lidocaine.
What is the target INR for patients with a mechanical aortic valve?
Typically 2-3.
What is the first-line class of anticoagulation agents for atrial fibrillation?
Typically a DOAC.
Is anticoagulation therapy necessary in a patient with atrial fibrillation associated with hypothyroidism and no other thromboembolic risk factors?
No, it is not necessary.
What should a patient with CAD be managed with?
Aspirin, a statin, and at least one of the following: a beta-blocker, a CCB, and/or a long-acting nitrate.
What type of pulses are typically seen in Takayasu arteritis?
Diminished pulses.
What is the QRS complex pattern in patients with LBBB or a paced rhythm?
QRS complexes that are discordant with the ST segments and T waves.
What should all patients with NSTEMI receive?
DAPT involving aspirin and a P2Y12 inhibitor.
What does acute coronary syndrome (ACS) involve?
The suspicion or confirmed presence of acute myocardial ischemia.
Why would we not initiate a beta-blocker in a newly diagnosed A-fib patient?
If the patient is asymptomatic or has a heart rate within normal limits.
What should raise concern for postviral myocarditis?
Tachycardia, abdominal pain, and a new cardiac murmur in a patient with recent viral illness and fevers.
What is low intensity statin therapy typically composed of?
Simvastatin 10 mg, Pravastatin 10-20 mg, Lovastatin 20 mg, Fluvastatin 20-40 mg.
Does dapagliflozin have a greater mortality benefit in heart failure than empagliflozin?
Yes, it does.
Do patients with stable angina who are proven low risk by initial imaging and clinical signs require further workup?
No, they do not require further workup.
What are the inferior leads of the heart?
Leads II, III, and aVF.
What is a common initial symptom in adults with severe aortic stenosis?
A decrease in exercise capacity.
What are EKG abnormalities consistent with RV strain?
Right bundle branch block, SI-QIII-TIII pattern, ST elevation in inferior leads (especially III, aVF), ST elevation in aVR, and T-wave inversion in V1-V3.
What is the target INR for patients with a mechanical mitral valve?
Typically 2.5-3.5.
What are the common auscultation findings in aortic regurgitation?
Low pitched diastolic rumble at the apex and decrescendo diastolic murmur at the left sternal border.
What is the echocardiographic appearance of catecholamine induced cardiomyopathy?
Similar to that seen in stress induced cardiomyopathy (apical ballooning syndrome or takotsubo cardiomyopathy).
What are the classic clinical findings of severe aortic stenosis?
Slow rising carotid pulse, diminished S2, and late peaking systolic ejection murmur.
What is the classic triad of RV infarction in the setting of an inferior MI?
Hypotension, distended neck veins, and clear lungs.
What is indicated for ACS or after PCI?
DAPT with aspirin and a P2Y12 inhibitor.
What is giant cell myocarditis?
A rare form of myocarditis that has an acute and severe presentation.
When is an ICD indicated for congenital long QT syndrome?
For survivors of cardiac arrest, for patients who have recurrent syncope while on beta blockers, and for patients with QTC intervals greater than 500 msec.
What are the stages of EKG abnormalities of acute pericarditis?
Widespread ST elevation and PR depression, normalization of ST and PR segment, development of widespread T wave inversion, and ECG normalization or indefinite persistence of T wave inversion.
What type of MI is typically seen in leads V1-V6?
Anterior MI.
When is aortic valve replacement indicated for patients with severe aortic stenosis?
For patients undergoing other cardiac surgery, those with a left EF <50%, or those with symptoms from severe outflow obstruction such as dyspnea, chest pain, or syncope.
What should sudden onset of leg pain with swelling, purple color, arterial ischemia signs, and loss of distal pulses raise concern for?
Massive proximal deep vein thrombosis.
What is the treatment of choice for chronic symptoms of constrictive pericarditis refractory to conservative management?
Pericardiectomy.
What does Dressler syndrome typically result in?
Pleuritic chest pain, fever, and occasionally a pericardial effusion after an MI.
What is recommended for STEMI patients presenting within 12 hours after symptom onset when PCI cannot be performed within two hours after first medical contact?
Thrombolytic therapy.
What are the two categories of NSTE-ACS?
NSTEMI (positive myocardial injury biomarkers) and unstable angina (absence of detectable myocardial injury biomarkers).
What should be the next steps for an older adult, overweight, with newly diagnosed asymptomatic A-fib?
Begin anticoagulation as well as lifestyle change.
What should be considered in all patients presenting with acute inferior wall MI?
Right ventricular infarction, especially in the setting of hypotension.
What is the best way to determine cardiovascular risk in an asymptomatic 50-year-old man?
To calculate a global risk score for atherosclerotic cardiovascular disease.
What is the development of complete heart block associated with?
It is associated with various cardiac conditions.
What is a class I indication for permanent pacemaker implantation?
Development of complete heart block in a patient with a chronic bifascicular conduction abnormality.
What is an absolute contraindication to thrombolytic therapy?
An ischemic stroke in the 3 months prior to an acute ST-segment elevation myocardial infarction.
Which beta-blockers reduce long-term mortality in patients with HFrEF?
Bisoprolol, carvedilol, and long-acting metoprolol.
What murmur is associated with hypertrophic cardiomyopathy?
A systolic crescendo-decrescendo murmur that becomes louder with the Valsalva maneuver.
What is the goal of targeted temperature management (TTM) in hypertrophic cardiomyopathy?
The avoidance of hyperthermia rather than the induction of hypothermia.
What is a prerequisite for either submassive or massive pulmonary embolism?
Right ventricular dilation.
When is transesophageal echocardiography (TEE) indicated?
In a patient with atrial fibrillation of unknown or more than 48 hours duration to exclude thrombus before cardioversion.
What is the typical dosing for Apixaban?
5 mg twice daily.
Should aspirin be used for primary prevention of ASCVD in adults older than 70 or at increased risk of bleeding?
No, aspirin should not be used for primary prevention in these populations.
Who should receive antibiotic prophylaxis for infective endocarditis?
Patients with prosthetic cardiac valves, prosthetic material used for cardiac valve repair, previous infective endocarditis, unrepaired cyanotic congenital heart disease, repaired congenital heart disease, and cardiac transplant recipients.
What should be considered in all patients presenting with acute inferior wall myocardial infarction?
Right ventricular infarction, especially in the setting of hypotension.
What is the next step in management for an asymptomatic patient with PVCs and non-sustained VTs?
Observation.
What is the classic triad of right ventricular infarction?
Hypotension, distended neck veins, and clear lungs in the setting of an inferior myocardial infarction.
What does the tilt table test distinguish between?
Different types of reflex syncope, such as vasovagal and orthostatic hypotension.
What are the ECG findings of left ventricular hypertrophy (LVH)?
Tall R waves, deep S waves, possible QRS widening, left axis deviation, ST-T changes, and left atrial enlargement.
What is the solution to the first dose effect in alpha blockers?
Starting treatment at a low dose.
What is the risk for orthostatic hypotension and syncope after the first dose of doxazosin or terazosin?
It is considered highest after the first dose.
When is thrombolytic therapy recommended for STEMI?
For patients who present within 12 hours after symptom onset when PCI cannot be performed within 2 hours.
What is the recommended diameter for elective surgical repair of an abdominal aortic aneurysm in men and women?
Greater than or equal to 5.5 cm in men or 5 cm in women.
What does GDMT refer to in the context of HFrEF treatment?
Initial medical therapy with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA).
What is the most likely cause of renal artery stenosis in a young woman with hypertension and rising serum creatinine after treatment with an ACE inhibitor?
Renal artery stenosis secondary to fibromuscular dysplasia.
What are the indications for an ICD in a patient with hypertrophic cardiomyopathy?
History of cardiac arrest due to V-fib, spontaneous sustained V-tach, and family history of sudden cardiac death in at least 2 first-degree relatives who had HCM.
What is the treatment for bradycardia directly attributed to sinus node dysfunction?
Pacemaker.
What typically triggers vasovagal syncope?
Prolonged standing or intense pain.
What is acute type A aortic dissection?
A serious condition requiring immediate medical attention.
What are the indications for myopathy?
History of cardiac arrest due to V-fib, spontaneous sustained V. tach, and family history of sudden cardiac death in at least 2 first-degree relatives who had HCM.
What is the treatment for bradycardia attributed to sinus node dysfunction?
Pacemaker.
What typically results in vasovagal syncope?
Vasovagal syncope typically results after prolonged standing or intense pain.
What is an acute type A aortic dissection?
An acute type A aortic dissection involves the ascending aorta or aortic arch.
What is the minimum duration for DAPT after a drug-eluting stent placement following an NSTEMI?
The minimum duration for DAPT is currently 12 months.
