Cardiology

Question 1

Stable Angina

Answer 1

Chest discomfort due to myocardial ischemia. Occurs with exacerbation, relieved by rest.

Question 2

What determines myocardial demand for O2?

Answer 2

HR, SBP, contractility, LV wall stress

Question 3

Why does subendocardium get ischemic during tachycardia?

Answer 3

Because it receives its blood during diastole, so when tachycardia occurs, diastole preferentially shortens

Question 4

Most common cause of stable angina

Answer 4

Vasospasm, AS, HOCM, HTN

Question 5

How to treat asymptomatic patients with moderate framingham risk?

Answer 5

Daily aspirin

Question 6

Is it recommended to treat women with hormone replacement to prevent heart disease?

Answer 6

No

Question 7

Is it recommended to test homocysteine?

Answer 7

No

Question 8

How to screen for CAD?

Answer 8

Dont do it.

Question 9

How to determine typical vs atypical vs nonanginal cp?

Answer 9

Retrosternal
Relieved by rest/nitro
Exacerbated by activity or stress

1 is nonanginal
2 is atypical
3 is typical

Question 10

How to use stress testing to diagnose angina?

Answer 10

Patients with low probability don’t require stress test, patients with high probability should be started immediately on medical management. Patients with intermediate pretest probability should receive stress test.

Question 11

How to choose a stress test?

Answer 11

Patients with baseline changes in EKG shouldn’t get EKG stress, patient’s who can’t exercise need chemical stress.

Dipyridamole for nuclear perfusion, dobutamine for echo

Question 12

Contraindications for EKG exercise stress

Answer 12

LBBB, ST depressions, WPW, LVH or on digoxin

Question 13

Contraindications for echo

Answer 13

LVOT obstruction
Wall motion abnormalities
Obese

Question 14

Contraindications for nuc perfusion

Answer 14

Asthma
hypotension
conduction disease

Question 15

Goal of exercise or chemical stress

Answer 15

To achieve 80% of max heart rate.

Question 16

Coronary angiography

Answer 16

Goal standard for patients at high risk or abnormal stress tests. Though patients with abnormal stress tests can be managed medically.

Question 17

Therapy for chronic stable angina

Answer 17

1) lifestyle modifications

2) Antianginal meds + vascular protective meds

Question 18

Initial medication regimen for chronic stable angina

Answer 18

Beta blocker, aspirin, long acting nitrate, statin (high intensity for >75, moderate intensity for

Question 19

How to manage chronic stable angina if symptoms persist on first pass?

Answer 19

Increase B blocker dose, increase nitrate dose, add CCB.

Question 20

How to manage chronic stable angina if symptoms persist on second pass?

Answer 20

consider ranolazine, refer for angio

Question 21

Should antiplatelet agents besides aspirin be used in chronic stable angina?

Answer 21

No, only if contraindication to aspirin

Question 22

Is PCI effective in chronic stable angina?

Answer 22

Not effective in reducing mortality, but effective in controlling symptoms and increasing quality of life.

Question 23

How to follow up patients with stable angina?

Answer 23

Repeat EKG’s not recommended if there hasn’t been a change in symptoms or meds.
Repeat stress test contraindicated unless there is a change in symptoms

Question 24

How to work up a patient with anginal chest pain

Answer 24

Get an ekg, if positive, stemi, then cath or TPA
If negative, then get biomarkers, if those are positive, then NSTEMI, cath if TIMI 3-7. If negative then eventually get a stress test.

If biomarkers are negative, then UA. Geta stress test eventually.

Question 25

How to treat ACS patients

Answer 25

``` MONA BASH Morphine O2 Nitro Aspirin + clop ``` Beta blocker Acei Statin Heparin

Question 26

Sinus arrest

Answer 26

2 or more seconds of pause on EKG

Question 27

Sick sinus syndrome

Answer 27

AKA brady tachy. SA nodal disease where bradycardia or pauses are followed by SVT or Afib

Question 28

Indications for pacing

Answer 28

``` Symptomatic bradycardia (5sec Alternating bundle branch blocks ```

Question 29

How to treat AV blocks with bradycardia?

Answer 29

Atropine

Question 30

First degree heart block

Answer 30

PR>200ms. Usually asymptomatic but associated with heart failure and death.

Question 31

Second Degree heart blocks

Answer 31

Mobitz I - wenchybach Mobitz II - Dropped beats without Pr elongation, defect is within ventricular conduction system Pace

Question 32

Third degree heart block

Answer 32

Complete P and Q dissociation. QRS can be wide or narrow. Pace.

Question 33

SV arrhythmias

Answer 33

Can be regular (SVT) or irregular (Afib/aflutter/mat)

Question 34

SVT

Answer 34

Patient has palps, syncope, dyspnea, fatigue HR usually >150, no P or T waves. Tx: adenosine or shock

Question 35

Afib

Answer 35

``` No p waves If unstable: shock If stable: rhythm control = rate control For rhythm: if Afib for cardiovert If afib >48 hours, TTE ->TEE, cardiovert if no LA thrombus ```

Question 36

Torsades

Answer 36

Wide complex, give mag

Question 37

Vtach

Answer 37

Wide complex, treat with shock or amio

Question 38

How to work up heart failure

Answer 38

EKG, Echo, BNP, LH cath if new and acute

Question 39

How to treat CHF (everybody)

Answer 39

H2O

Question 40

How to treat NYHA class III or IV

Answer 40

Add spironolactone, add furosemide, add ISDN or hydralazine

Question 41

How to treat CHF if EF

Answer 41

Defibrillator placement

Question 42

How to treat CHF if in ICU?

Answer 42

Dobutamine

Question 43

How to work up CHF exacerbation

Answer 43

``` Get EKG, Echo, BNP, Trop If stemi, LH cath +MONABASH If negative, not CHF If positive, its a true exacerbation and treat with LMNOP Lasix, morphine, O2, Nitro, Position ```

Question 44

How to conduct ACLS if patient has a pulse?

Answer 44

Arrhythmia (everything but sinus tach or NSR)? Symptomatic? No? Give IVF, O2 and Tele. If symptomatic, check if stable. If SBP>90 and no AMS or CP, then stable. Give drugs: Amiodarone for wide and fast, adenosine for narrow and fast, atropine for slow. If not stable, then shock or pace.

Question 45

Diastolic murmurs

Answer 45

Mitral stenosis, aortic regurgitation

Question 46

Mitral stenosis (Path, sxs, murmur, tx)

Answer 46

Path: Rheumatic heart disease Sxs: CHF, Afib Murmur: Diastolic rumble with opening snap Tx: Balloon valvuloplasty, then replace

Question 47

Aortic regurgitation

Answer 47

Path: Infection, infarction, aortic dissection. Acute presentation: Cardiogenic shock, flash pulm Chronic: CHF, Chest pain Murmur: Diastolic at base Tx: Acute: Emergent replacement Chronic: Urgent replacement

Question 48

Systolic murmurs

Answer 48

Mitral insufficiency, aortic stenosis

Question 49

How to treat carotid stenosis if asymptomatic?

Answer 49

Surgery or stent if stenosis >70%

Question 50

How to treat carotid stenosis?

Answer 50

Surgery or stent if stenosis >50%