Cardiology

Question 1

When you cant read the EKG and the person can Exercise, what test to order?

Answer 1

Exercise thallium Echo/Stress Exercise Echo (Sestamibi scan (infarcted tissue wont pick up thallium and ischemic tissue will eventually pick up thallium)

Question 2

When you cant read the EKG and the person CANT Exercise: What 2 test can be done?

Answer 2

Pharmacological Stress Test: (Persantine)Dipyridamole Echo with thallium uptake works by coronary steal (Causes bronchospasm in asthmatics) and Dubotamine Echo with thallium uptake .

Question 3

When is Clopidegrol(Plavix) used? (3)

Answer 3

1. For all MI 2. When patient has aspirin allergy 3. After stenting, coated with stent (used in combination with aspirin)

Question 4

Adverse effect of Ticlopidine?

Answer 4

Neutropenia and TTP.

Question 5

When a patient suffers from hyperkalemia on ACEI and/or ARB while being treated for angina. What is the next step in management?

Answer 5

Stop the ACE-I or ARB (these are given in CAD when pt has low EF and/or regurgitant valve disease) and switch to Hydralazine and Nitro.

Question 6

Name the adverse effect: 1. Statins 2. Niacin 3. Fibric Acid 4. Cholestyramine 5. Ezetimibe

Answer 6

1. Raise AST and ALT 2. Can help raise HDL but raises glucose, uric acid levels and cause itchiness. 3. Can lower triglycerides but Cause myositis with statins (increase risk when used in combination) 4. GI upset 5. Good for help to lower LDL only with STATIN, well tolerated.

Question 7

How do the dihydropyridine CCBs increase mortality in patients with CAD?

Answer 7

(Amlodipine, Nifedipine, Nimodipine) They cause peripheral vasodilation which can cause reflex tachy of the HR and precipitate ischemic episodes.

Question 8

When are the non-dihydropyridine CCBs used? (Diltiazem and Verapamil)

Answer 8

Severe asthma, Prinzmetal angina, Cocaine induced CP

Question 9

When is Angiography done?

Answer 9

To assess extent of disease or when EKG and Echo are equivocal.

Question 10

Name (4) indications for CABG.

Answer 10

1. 3 vessel dz 2. Left main coronary artery occlusion 3. 2 vessel dz + DM 4. Symptoms do not respond to maximal medical therapy.

Question 11

Person presents with crushing substernal chest pain and EKG shows ST Elevation in leads V2 to V4. Next step in management?

Answer 11

Give Aspirin or clopidegrol if there is an aspirin allergy. After that can give 02, Morphine, Nitrates. Get to Cath lab within 90 minutes for angioplasty.

Question 12

What is the next step in management when a patient develops new chest pain after suffering from ST elevation a few days ago?

Answer 12

EKG and check CK-MB levels ( best marker for reinfarction they rise and decrease within 2 days)

Question 13

Name 2 indications when Heparin is used?

Answer 13

After Angioplasty and tPA to prevent restonsis. First line for NSTEMI/UA (helps prevent clot formation)

Question 14

When a patient after suffering from NSTEMI/UA and is not better ( persistent pain, S3 gallop, Worsened EKG, Rising Troponin levels) after ALL meds have been given, what is the next best step in management?

Answer 14

Angiography followed by angioplasty.

Question 15

Complications of MI: Bradycardia and cannon A waves Dx? Rx?

Answer 15

Third Degree AV Block. Atropine then pacemaker.

Question 16

Complications of MI: Bradycardia but no cannon A waves + Symptoms. Dx? Rx?

Answer 16

Sinus Brady. Atropine.

Question 17

Complications of MI: After post-MI 5 days to 2 weeks post MI. Sudden loss of pulse/Shock, pulseless electrical activity, JVP, muffled heart sounds, lungs clear. Dx? What artery is involved? Rx?

Answer 17

Tamponade 2/2 Free Wall rupture. LAD. Pericardiocentesis.

Question 18

Complications of MI: Acute Hypotension, Clear lungs, Kussmaul sign. Echo shows Hypokinetic valve. Dx? Which artery is involved?

Answer 18

Right ventricular failure. RCA

Question 19

Complications of MI: 3-5 days Post-MI. New murmur that is heard at the lower left sternal border, Left to Right shunt, Increase in 02 sat on cath going from RA to RV. Dx? What Artery is involved? Rx?

Answer 19

Septal Wall rupture. RCA. Intraaortic Balloon Pump.

Question 20

Complications of MI: 3-5 days post-MI. Loss of pulse, can lead to sudden death, need EKG to answer question. Dx? Rx?

Answer 20

V Fib. Cardiovert/Defribrillate.

Question 21

Complications of MI: Weeks to months post-MI. Management of aneurysm/mural thrombus.

Answer 21

Most aneurysm do not need specific therapy. Mural thrombi can be treated with heparin followed by warfarin.

Question 22

Pt presents with dysphagia, hoarseness, hemoptysis. On physical exam you can here a fib or opening snap with worsened with exhalation. Dx? Best initial test? Most accurate test? Rx?

Answer 22

Mitral Stenosis associated with rheumatic fever and pregnancy. Transthoracic echo then confirm with cauterization (best to check for diameter of chambers and difference in pressures) Non specific testing: EKG will show bi- phasic “P” waves and CXR will show hypertrophy, straightening of left heart border and bubble sign due to enlarged left atrium. If symptomatic rx with diuretics then do ballon valvuloplasty. Warfarin for those with a fib.

Question 23

Pt presents with angina, syncope and CHF. On physical exam you hear a crescendo- decrescendo murmur at the second R intercostal space that decreases with valsava, standing and handgrip. Worsens with squatting and leg raising. Dx? What is the most common presentation of this dz? Best initial test? Most accurate test? Rx?

Answer 23

Aortic stenosis most common associated with anginal symptoms. Can be cause by rheumatic fever. In US due to age or bicuspid aortic valve. Transthoracic echo. Heart cauterization. Surgical removal of valve.

Question 24

Pt presents with murmur that is pancystolic and radiates to R axilla. Murmur worsens with Handgrip, squatting and leg raising and exhalation. Improves with Valsava and standing. Dx? Etiology? Best initial test? Most accurate test? Rx?

Answer 24

Mitral Regurgitation. Can be caused by HTN, MI, Endocarditis) Transthoracic. Catherization. Rx: ACE-I/ARBS. If EF 40 mmHg then surgery is indicated.

Question 25

Pt presents with wide pulse pressure, bounding pulses, head bobbing, pulse in nail bed, Hill sign (Bp in arm much greater than leg.) On physical exam the murmur is a diastolic decrescendo heard at the lower left sternal border. Murmur worsens with Handrip, squatting, leg raising and exhalation. Valsava and standing make it better. Dx? Etiology? Best initial test? Most accurate test? Rx?

Answer 25

Aortic Regurgitation. Can be caused by HTN, MI, Endocarditis and Marfans, and cystic medial necrosis. Transthoracic. Catherization. Rx: ACE-I/ARBs. if EF is 55 mm then surgery is indicated. 55/55

Question 26

Female presents with atypical CP, palpitations and panic attack. On physical exam a mid systolic click is heard. Murmur worsens with Valsava and standing (decreased preload) and improves with squatting, leg raising and exhalation. Dx? Etiology? Best initial test? Most accurate test? Rx?

Answer 26

MVP. Marfans and Ehlers-Danlos Syndrome. Transthroacic. Catherization. Beta blockers if symptomatic.

Question 27

Name 5 causes of dilated cardiomyopathy. Best initial test? Rx?

Answer 27

1. Alochol 2. Chagas disease 3. doxirubucin 4.Post viral coksackie myocarditis 5. Radiation. Echo. ACE-I/ARBs. Diuretics and digoxin help with symptoms. If wide QRS present (>120 milliseconds) then place biventricular pacemaker. Can place Automated implantable cardioverter/defibrillator.

Question 28

Can presents with dyspnea/SOB, CP, syncope, lightheadedness, sudden death. Dx? What is the most common presentation? Best initial test? Rx?

Answer 28

Hypertrophic Obstructive cardiomyopathy HCOM - genetic . Most common presentation is SOB. Echo. 1. Beta blockers. Do NOT GIVE Diuretics which reduces pre-load and the cardiac return to the heart. 2. Implantable defibrillator 3. Ablation of septum 4. Surgical myomectomy of septum.

Question 29

On physical exam there is an S4 gallop and fewer right sided heart failure signs (hepatosplenomegaly) Dx? Best initial test? Rx?

Answer 29

Hypertrophic Cardiomyopathy HCM. Echo. 1. Beta blockers. ACE/ARBs have unclear benefit in hypertrophic cardiomyopathy. 2. CCBs 3. Diuretics (ok in HCM and not HOCM). 4.Implantable defibrillator. 5. Ablation of Septum. 7. Myomectomy.

Question 30

What 2 heart diseases are Diuretics not given?

Answer 30

HOCM and Tamponade. They can worsen venous return to heart.

Question 31

Pt presents tachycardia, hypotenion, JVD and clear lungs. Pulsus paradoxus. Dx? Most specific finding associated with this disease? Best initial and Most accurate? Rx?

Answer 31

Pericardial tamponade. Pulsus paroduxus is the most significant finding associated with tamponade. Best initial and most accurate test is Echo (R atrial and ventricle diastolic collapse.) CXR (Globular heart after a week). EKG (Electrical alterans.) R heart cauterization (equal pressures in diastole.) Rx: Pericardiocentesis, Fluids and Hole or “window” placed in pericardium.

Question 32

Pt has hx of HTN, DM, Smoking and Hyperlipidemia. Pts can present with leg pain that worsens with walking and improves with rest. Leg looks hairless, smooth and shiny on physical exam. Dx? Best initial test? What is considered bad? Most accurate test? Rx?

Answer 32

Peripheral Artery Disease (PAD.) Pt has Claudication. ABI (if there is a > 10 % difference between arm and leg that is significant. (ABI

Question 33

Pt presents with sudden onset of chest pain. There is pain btw the scapulae. Hx of HTN, Tobacco smoking and blood pressure is 169/108. Dx? Best initial test? Most accurate test? Rx?

Answer 33

Aortic dissection. CXR (shows widened mediastinum) Most accurate is anagram. Beta blockers (reduces shearing forces), Nitroprusside and surgical correction.

Question 34

Name the 2 major criteria for infective endocarditis.

Answer 34

2 Major: 1. Blood cultures positive for S. aureus, S. viridians or enterroccus. 2. Major vegetations seen on valve.

Question 35

What is the management once you diagnosed a pt with infective endocarditis?

Answer 35

Obtain blood cultures from at least 3 separate sites. and empirically rx with vancomycin and gentamicin. Then specify rx when blood cultures come back.

Question 36

Increase R atrial pressure, increase PCWP, DECREASE CI, increase SVR, decrease MVO2. What type of shock?

Answer 36

Cardiogenic Shock

Question 37

Young healthy patient develops pitting edema, ascities, bibasilar crackles, elevated JVP after having a URI. Dx? What will the test show? Rx?

Answer 37

Acute Congestive heart failure 2/2 dilated cardiomyopathy 2/2 viral myocarditis 2/2 s/p URI. Echo will show dilated ventricles and hypokinesis. - common cause of acute heart failure in adults. Rx is supportive -diuresm, beta blockers and acei.

Question 38

Block in the purkinjie system leads to constant PR interval and dropped beat. Dx? Rx ?

Answer 38

Mobitz type 2. No treatment.

Question 39

PR interval greater than 200ms

Answer 39

First degree AV block

Question 40

Intermittent AV nodal block. That leads to longer and longer PR interval with dropped beat

Answer 40

Wankebach. Mobitz type 1

Question 41

Family Hx of sudden death, prolong QT with triggers such as emotion, stress, exercise causing syncope. Dx?

Answer 41

Congenital long QT syndrome, can have a Torsades de pointes.

Question 42

Sinus pauses, prolonged PR interval and prolong ORS interval causing syncope. Dx? (2)

Answer 42

Sick Sinus Syndrome, AV block

Question 43

Complication of MI: After 3-5 days post MI Pt develops serve Pulmonary Edema and New ONSET Holosystolic murmur. What artery is involved?

Answer 43

Papillary muscle rupture. RCA.

Question 44

Difference between sustained and nonsustained VTach?

Answer 44

Nonsustained is asymptomatic. Sustained can lead to palpitations, hypotension, angina and syncope. Can progress to Vfib. Pulseless Vfib you cardioconvert.

Question 45

Early wide QRS not proceded by a P wave. Usually asymptomatic.

Answer 45

PVC, premature ventricular contraction.

Question 46

A reentry circuit in the AV node depolarizes the atrium and ventricle nearly simultaenously.

Answer 46

Atrioventricular Nodal Reentry Tachycardia. AVNRT

Question 47

Circular movement of an impulse between the AV node and the atrium through a bypass tract. Which condition is this seen in?

Answer 47

Atrioventricular reciprocating tachycardia. AVRT seen in WPW- Rx wth Procainamide.

Question 48

Rapd ectopic pacemaker in the atrium.

Answer 48

Paroxysmal Atrial Tachycardia.