Cardiology

Question 1

How will the ejection fraction differ in diastolic and systolic heart failure?

Answer 1

Diastolic dysfunction will have a normal ejection fraction. The problem here is poor relaxation leading to impaired filling. Systolic dysfunction will have a decreased ejec- tion fraction. The problem here is poor contraction.

Question 2

What is the most common etiology in CHF?

Answer 2

Coronary artery disease. ALL patients get aspirin, beta blockers, and a statin.

Question 3

What is the first test that should be ordered in the evaluation of CHF?

Answer 3

Echocardiogram. Remember, this is a clinical diagnosis, but the echocardiogram
is used to give added information, such as: estimatating ventricular size and ejection fraction. It is NOT used to diagnose CHF.

Question 4

Which drugs lower mortality in heart failure?

Answer 4

ACE/ARBs and beta blockers lower mortality in all patients with CHF. Spiranolac- tone and eplerenone lower mortality in those who have class 3 or class 4 disease. Diuretics and digoxin reduce symptoms only - they do not reduce mortality!

Question 5

Which beta blockers lower mortality?

Answer 5

The only beta blockers that have proven benefit in CHF are carvedilol, bisoprolol, and metoprolol succinate (think succinate like survival - both start with “s”).

Question 6

What is the medication of choice for hypertrophic cardiomyopathy?

Answer 6

Beta blockers. Do not confuse this with HOCM (also treated with beta blockers). Hypertrophic cardiomyopathy is a type of diastolic dysfunction. Diuretics are CON- TRAINDICATED in HOCM, but not hypertrophic cardiomyopathy.

Question 7

What sound will you hear in a patient with an ASD?

Answer 7

Systolic ejection murmur with wide splitting of S2.

Question 8

What classic x-ray finding will you see in coarctation of the aorta?

Answer 8

You will either see “rib notching” or a “3 sign”.

Question 9

What classic murmur will be heard in patients with PDA?

Answer 9

Machine like continuous murmur.

Question 10

What are TET spells?

Answer 10

These are found in patients with tetralogoy of fallot and are episodes of hyper cya-
nosis. Classically, the child will bend down bringing their knees to their chest. This will decrease venous return, increase vascular resistance making the child more comfortable.

Question 11

What is Eisenmenger syndrome?

Answer 11

This is seen in patients with a VSD, meaning a shunt connecting both ventricles.
Normally, the pressure is greatest in the left ventricle, which will push oxygenated blood to the right ventricle. Over time, this excess blood pushed to the right ventri- cle is too much for the lungs to handle. This will lead to pulmonary congestion. Eventually, this leads to increased pressure in the pulmonary vasculature, and in turn to the right ventricle (more so than the left ventricle). This will lead to a re- versal of blood flow, from the right ventricle to the left. Deoxygenated blood will then leave the heart into the systemic circulation - this is bad!

Question 12

What is the most common cause of secondary hypertension?

Answer 12

Renovascular disease

Question 13

What are the first line medications for hypertension in patients who are otherwise healthy?

Answer 13

Diuretics, ACE/ARBs, or Amlodipine (long acting dihydropyridine).

Question 14

What is the difference between hypertension urgency and emergency?

Answer 14

They will both have a blood pressure >180/120. The difference is that
hypertension emergency will also have end organ damage.

Question 15

What is the classic clinical presentation for a patient in cardiogenic shock?

Answer 15

Hypotensive, altered mental status, and cool/clammy skin.

Question 16

How will atrial flutter and atrial fibrillation present on EKG?

Answer 16

Atrial flutter will have a regular rhythm with a saw tooth pattern. Atrial fibrillation
will have an irregularly irregular rhythm without p waves.

Question 17

What will happen if a patient who presents with WPW is accidentally given adeno- sine?

Answer 17

This may place the patient into ventricular tachycardia or fibrillation.

Question 18

What is the classic presentation for a patient presenting with angina?

Answer 18

The patient will have chest pain that is relieved with rest or nitroglycerin. The chest pain is predictable and reproducible. New chest pain or worsening chest pain can never be classified as stable angina - this is unstable angina.

Question 19

What are the medications of choice for patients with stable angina?

Answer 19

All patients should receive a beta blocker, aspirin, and nitroglycerin. The beta
blocker will increase filling time and decrease oxygen demand. The nitroglycerin is used on an as needed bases for chest pain relief.

Question 20

What is the treatment of choice for prinzemtal angina?

Answer 20

Give these patients calcium channel blockers. Their pain is due to smooth muscle spasm. Avoid beta blockers, as this will result in unopposed alpha stimulation and worsen the their symptoms.

Question 21

What will differentiate unstable angina from NSTEMI?

Answer 21

Both will clinically present the same. Both will have similar EKG findings. The only difference will be that NSTEMI will have elevated cardiac enzymes, while unstable angina will not. Most MIs can reliably be excluded after 6 hours, but if clinical sus- picion is high, continue to monitor for 12 hours. The most specific cardiac marker will be troponin I. Troponin I is also now used to diagnose reinfarction - look for the trend.

Question 22

Why should you proceed with caution in administering nitrates in patients with an inferior MI?

Answer 22

If the right ventricle is involved, nitrates will cause a sudden and severe drop in blood pressure, as this area is preload dependent.

Question 23

What medications should be given to all patients post MI?

Answer 23

Everyone leaves with an aspirin, beta blocker (metoprolol or atenolol), ACE
inhibitor, and a statin. Clopidogrel is given to patients with aspirin allergy.

Question 24

What do the guidelines say about screening for AAA?

Answer 24

Screen males over the age of 65 who have ever smoked. Only a one time screen- ing with ultrasound is indicated.

Question 25

Why should steroids be given to a patient with suspected GCA before doing a bi- opsy?

Answer 25

Optic nerve ischemia can develop leading to blindness. Saving the patients eye sight is more important then confirming the diagnosis.

Question 26

What is the only medication with proven benefit in peripheral artery disease?

Answer 26

Cilostazol

Question 27

What is the most common vein affected in patients with superficial thrombophlebi- tis?

Answer 27

Saphenous vein

Question 28

What are risk factors for DVT?

Answer 28

Know Virchows triad: hypercoagulability, stasis, and endothelial injury. If risk fac- tors are not present, this is termed unprovoked DVT.

Question 29

When should a D-Dimer be ordered for DVT?

Answer 29

D-dimer is only ordered when there is a low clinical suspicion. If DVT is highly sus-
pected, this should never be ordered. DVT has a high sensitivity, but horrible speci- ficity. This means many things can elevate the value, but it is almost always ele- vated in patients with DVT. Remember, only order if the clinical suspicion is low.

Question 30

How does respiration affect murmurs?

Answer 30

Inspiration will increase right sided murmurs. Expiration will increase left sided mur- murs. Inspiration will increase right ventricular filling, but decrease left ventricular filling.

Question 31

What are the most common symptoms in a patient with aortic stenosis?

Answer 31

Dyspnea, angina, and dizziness.

Question 32

Which valvular abnormality will present with a water hammer pulse?

Answer 32

Aortic regurgitation

Question 33

What are the most common etiologies in endocarditis?

Answer 33

Streptococcus viridans and staphylococcus aureus. Staphylococcus aureus is as- sociated with patients who are injection drug users.

Question 34

How will patients with endocarditis present?

Answer 34

They will have a new murmur or a change in murmur with a fever.

Question 35

What is the first test to order in patients with suspected endocarditis?

Answer 35

Blood cultures! The echocardiogram is done after blood cultures have been col- lected. Antibiotics are given after three blood cultures separated by one hour have been collected.

Question 36

What is the classic EKG finding present in patients with pericarditis?

Answer 36

Diffuse ST elevations with PR depression. An MI will have ST elevations, but they will not be diffuse.

Question 37

What is Becks triad and when will it be found?

Answer 37

Becks triad is found in patients with cardiac tamponade. The classic triad consists of hypotension, muffled heart sounds, and distended neck veins.