Cardiology 2 Flashcards
Pt s/p cardiac transplant 10 months ago now presents with exertional dyspnea and abdominal pain cannon a waves on EKG. What will help establish diagnosis?
Endomyocardial biopsy (these are formed routinely, some pts asymptomatic) to evaluate for Acute Rejection.
Common within the first year after transplant associated with heart failure and complete heart block (cannon a waves)
Pt presents with Right Sided Weakness, hx of Heart Failure with LVAD placed 2 years ago. CT head shows sulcal effacement and loss of gray-white differentiation in territory of the left MCA. What is the cause of the stroke?
LVAD thrombosis
Indications for Therapy in HF
- Beta Blockers
- Spironolactone
- Ivabradine
- Valsartan-Sacubitril
- ICD
- Cardio Resynchronization therapy
- Cardiac Tranplant
- All classes
- NY HA Class III-IV
- With LVEF < 35% and HR still 70bpm on beta blocker
- Substitute for ACE or ARB
- Ischemic and Non-ischemic cardiomyopathy in its with EF < 35% and NYHA II-III or EF < 30% in NYHA Class I
- NYHA Class II-IV, LVEF 35% and LBBB with QRS > 150ms
- Refractory symptoms despite maximal medical therapy
What initial lab test should be ordered in a patient with new onset heart failure?
- CBC
- BMP and kidney function BNP
- TSH
- Liver chem
What is the management of beta blockers and heart failure?
Titrate every 2 to 4 week until HR 60 or patient symptomatic hypotension
Difference btw restrictive cardiomyopathy and constrictive pericarditis?
Why is this difference important?
Restrictive Cardiomyopathy - Has Elevated BNP due to Very large heart (HTN, AS, Sarcoid, Amyloid, Hemachromatosis, Cancer and Fibrosis.)
Constrictive Has Pericardial Knock. (Skull Around heart) - In USA Radiation #1 Cause.
Surigical pericardiectomy can relieve symptoms and prolong life with patients with Constriction.
- When pt presents with constitutional Symptoms, Embolic Phenoma and Vegetation found on Echo. Pt has no risk factors for Thrombus (catheter, afib). Dx? Rx?
- Cardiac tumor that is attached to left-sided valvular endocardium by stalk, maybe associated with stroke, TIA, angina, MI. Dx?
- Atrial Myxoma
Surgical excision
- Papillary fibroelastoma
What should be excepted in black patients older than 50 who have left ventricular wall thickening that is not explained by HTN or AS and present with heart failure and features of diastolic dysfunction?
Q waves in anteroseptal leads without regional wall motion abnormalities “ pseudo-infarct”
Cardiac Amyloidosis (Cause of Restrictive Cardiomyopathy - Pts will have elevated BNP due to diastolic heart failure, No pericardial Knock).
Endomyocardial biopsy is more sensitive than Abdominal fat pad biopsy
- Management of patients with HCM who have risk of sudden cardiac death?
- Management of symptoms of ventricular outflow tract obstruction?
- How often should they be monitored ?
- When is genetic testing indicated?
- ICD
- Non-vasodilating B-blockers
- Echo every 1 to 2 years
- Testing in individuals who have Sarcomeric mutation
Who is considered for Percutaneous Closure of patent foramen ovale?
Pt with Cryptogenic Stroke after thorough evaluation for alternative causes of stroke.
No treatment or follow up is needed in Asymptomatic patients.
Pt presents with elevated BP, radial-femoral pulse delay, systolic murmur over left sternal border, left clavicle and left posterior chest. rib notching noted on CXR. Dx?
Coarctation of the aorta
Continuous murmur heard beneath the left clavicle?
PDA
Management of a patient with Eisenmenger Syndrome and Symptomatic post op Anemia?
Short course Iron Therapy
Management of pt with Pulmonary Valve Stenosis with peak gradient > 50 mmhg?
Balloon valvuloplasty
Fixed splitting S2, Mitral Regurgitation, EKG. Dx?
Ostium primum ASD
Ostium secundum ASD DOES NOT include Mitral Regurgitation and pt have first degree AV block and incomplete RBBB
Management of patients with Small Uncomplicated VSD?
Periodic follow up
After TOF repair pt develops diastolic murmur heard at the left sternal border that increases with inspiration. Dx?
Pulmonary valve regurgitation due to relief of R ventricular outflow tract obstruction during repair.
Management of a patient with Ostium Secundum ASD and palpitations with RAD and incomplete RBBB
Device closure of the ASD
When is surgical mitral valve repair (generally preferred over replacement) indicated? (6 reasons)
- Acute MR
- Chronic Symptomatic
- Asymptomatic LVEF < 60%, LV diameter > 40mm
- PH
- New onset AF
- When it is severe and another surgery is planned
Next step in management with a patient with Syncope and EKG showing short runs of Vtach? Pt has hx of Nonischemic Cardiomyopathy.
ICD
What is the preferred AC agent in patients who are pregnant with mechanical mitral valves?
Warfarin, it is preferred in the 1st, 2nd and EARLY 3rd trimester.
- Best test for patients able to reach target HR but not for LBBB or pacemaker?
- Best test for LBBB and Pacemaker and patients unable to reach target HR, but not for Reactive airway disease or patients on dipyridamole or theophylline?
- Best test for patients with Reactive Airway Disease and unable to reach target heart rate but not for tachyarrhythmias?
- Exercise ECG
- Pharmacologic Stress test with Adenosine or Dipyridamole.
- Dobutamine Stress Echo
- Management of a patient getting a High Bleeding Risk Procedure (joint replacement, endoscopy w/ FNA) + CHADS VASC> 6, (Very High Thrombotic risk - Mechanical Mitral Valve) ?
- Management of a patient getting a High Bleeding Risk Procedure with Moderate/High Thrombotic Risk (CHADSVASC>5) ?
- Management of a patient doing a low breeding risk procedure (Cataract, Endoscopy w/o Needle Biopsy, Carpal Tunnel)) but Moderate/High thrombotic risk ( CHADSVASC > 5 or High thrombotic Risk)?
- Hold Coumadin for 5 days until INR < 2 then bridge with heparin, Stop morning of procedure then RESTART Heparin + Coumadin 24-48 hrs after hemostasis is achieved.
- Hold Coumadin for 5 days until
INR < 1.5 then perform procedure
then resume Coumadin evening following procedure (No bridging Needed) - Continue warfarin with no change in dosing or INR Target.
Name 2 drugs linked to increase Diabetes Risk.
- Statins
- Thiazides (also cause Gout flare)
Peri-operative thrombotic risk:
Name the VERY High Thrombotic Risk ( The ones that need bridging) Conditions:
1) Valve
2) VTE
3) AF
- Mechanical Mitral Vale
Cage-ball or tilting disc Aortic
Valve - VTE within 3 months
Severe Thrombophilia - AF CHADSVASC > 6
AF with TIA/Stroke within 3 months
AF with Rheumatic Valve Disease
- Management of a patient who is High Risk Sudden Death post MI with LVEF < 30% or < 35% with heart failure symptoms?
- Management of a patient that is not High Risk of Sudden Death with LVEF 35% post MI
- Placement of Life Vest
- Receive optimal medical therapy and wait 3 months to see if improvement in EF before ICD
- Seen in the elderly. Associated with Episodic dizziness, syncope or angina or sometimes falls after eating.
Rx? Rx for Refractory Symptoms.
Postprandial Hypotension
Small frequent meals.
Increase in Salt and Water intake.
Compression Stockings
Octreotide if no improvement
- Indication for Implantable cardioverter-defibrillator after MI?
- What is the Heart Failure indication?
- Primary prevention of SCD for patients with persistent LVEF < 30% following MI who are at least 40 days post-MI and 3 months post-revascularization.
- LVEF < 35% and Class II or III Heart Failure symptoms.
Management of Aortic Dissection?
- Morphine, Esmolol/labetolol/propanolol
if SBP not < 120 with Beta blocker than add Nitroprusside
Emergency Surgical Repair for Ascending Aortic Dissecton
Type B - strictly medical therapy
Abx for Prevention of infective Endocarditis?
Amoxicillin, Cephalexin, Azithromycin, Doxycycline
ACAD
Management of a patient with hx of Rheumatic Fever?
Penicillin G Benzathine every 4 weeks continuously (depending on severity of Rheumatic heart disease.
What is the TIMI Risk score?
AMERICA
(1 pt for each)
1. Age > 65
2. Markers
3. EKG
4. Risk factors
5. Ischemia}angina
6. CAD
7. Aspirin
A: Age
M : Elevated Cardiac Markers
E: EKG (ST Elevation)
R: Risk factors for CAD
I: Recent Angina/Ischemia
C: KNOWN 50% Coronary disease
A: Aspirin use within last 7 days
3-4 Intermediate risk
> 5 high risk
What are the high risk features for Acute Coronary Syndrome?
- Elevated troponin
- New ST segment depression
- Recurrent angina at rest or low level activity despite intensive therapy
- Hemodynamic Instability
- Sustained ventricular arrhythmias
- Primary PCI within 6 months
- Left ventricular EF < 40%
- TIMI risk score > 2
Management of chronic venous stasis?
Leg Elevation, Weight loss, Exercise, Compression Stockings, Aspirin (helps accelerate ulcer healing)
Type of Angina that occurs in the absence of Coronary artery stenosis. Coronary artery vasospasm leads to Transient segment elevation even at rest.
Variant Angina (Prinzmetal Angina.)
