Cardiology

Question 1

What are the Brugada criteria used for?

Answer 1

Differentiation of V tach vs. SVT with aberrancy

Question 2

What are the Brugada criteria? (what questions are asked in the algorithm?)

Answer 2

Question 3

ACE inhibitors also inhibit ________ and increase levels of __________, which can induce cough but also may contribute to their beneficial effect through ____________.

Answer 3

kininase

bradykinin

vasodilation

[from 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline]

Question 4

In angiotensin receptor–neprilysin
inhibitors (ARNIs) (e. g. valsartan/sacubitril), an ARB is combined with an inhibitor of neprilysin.

What is neprilysin?

Answer 4

An enzyme that degrades natriuretic peptides, bradykinin, adrenomedullin, and other vasoactive peptides.

[from 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline]

Question 5

What is the general rule regarding calcium channel blocker use in HFrEF?

Answer 5

Calcium channel blockers should generally be avoided in patients with heart failure with HFrEF (except amlodipine and felodipine) since they provide no functional or mortality benefit and some first generation agents may worsen outcomes [1].

Calcium channel blockers have a better defined role in the treatment of HF due to diastolic dysfunction.

[from UpToDate “Calcium channel blockers in heart failure with reduced ejection fraction”]

Question 6

Two frequently confused drugs are verapamil and enalapril. What is the pharmacological classification of these drugs?

Answer 6

Verapamil is a nondihydropyridine calcium channel blocker.

Enalapril is an ACE inhibitor.

(Board Vitals)

Question 7

Define platypnea-orthodeoxia.

Answer 7

Platypnea-orthodeoxia syndrome is positional dyspnea and hypoxemia that occurs when the patient is upright and resolves when they lay flat.

[Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591898/]

Question 8

If a patient has a mechanical valve, is on Coumadin, and is being treated for life-threatening bleeding, what therapy should you NOT use to reverse the INR?

Answer 8

vitamin K

Instead, use only FFP to reverse the INR.

–Dany Ghannam

Question 9

What is the only antipsychotic (that is commonly used at our facility), that does NOT prolong the QT interval?

Answer 9

aripiprazole (Abilify)

[Dany Ghannam; Lehne’s Pharmacology, p. 330]

Question 10

How does fenofibrate work?

Answer 10

Fenofibrate mainly works by activating receptors in the body, called peroxisome proliferator-activated nuclear receptors. When the receptor is activated, the rate that the fats in the body are broken down increases, leading to more elimination of triglyceride-rich particles from the plasma.

[From medicinehow.com/fenofibrate]

Fenofibric acid, an agonist for the nuclear transcription factor peroxisome proliferator-activated receptor-alpha (PPAR-alpha), downregulates apoprotein C-III (an inhibitor of lipoprotein lipase) and upregulates the synthesis of apolipoprotein A-I, fatty acid transport protein, and lipoprotein lipase resulting in an increase in VLDL catabolism, fatty acid oxidation, and elimination of triglyceride-rich particles; as a result of a decrease in VLDL levels, total plasma triglycerides are reduced by 30% to 60%; modest increase in HDL occurs in some hypertriglyceridemic patients.

[From LexiComp]

Question 11

Concentric LV hypertrophy with severe biatrial enlargement suggests that HF is caused by an ____________ process such as amyloidosis, particularly in the absence of a prior diagnosis of ____________.

Answer 11

infiltrative

hypertension

[Clinical Key, from Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine]

Question 12

Diastolic function is assessed using Doppler measurements, including analyses of the ______ _____ ______ pattern (early [E] and atrial [A] waveforms), tissue velocities at the mitral valve annulus, pulmonary vein flow, and the left atrial volume indexed to body surface area. Diastolic dysfunction can be further classified as grades _ to _ based on these measurements, with incremental prognostic importance in HF as worsening grades of diastolic dysfunction are noted.

Answer 12

mitral valve inflow

I to III

[Clinical Key, from Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, “Approach to the Patient with Heart Failure”]

Question 13

Ratio of early mitral valve inflow to mitral valve annulus velocity determined using tissue Doppler (E/e′) is particularly helpful to determine presence and severity of diastolic dysfunction; a ratio of __ or greater is abnormal. Pulmonary hypertension in patients without significant systolic dysfunction or pulmonary disease suggests that _________ __________ may be present.

Answer 13

15

diastolic dysfunction

[Clinical Key, from Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, “Approach to the Patient with Heart Failure”]

Question 14

What are the general terms used to describe the 3 major patterns of abnormal mitral inflow? (i.e. diastolic dysfunction)

Answer 14

Impaired relaxation pattern, “pseudonormal” pattern, and restrictive filling

[From UpToDate: “Echocardiographic evaluation of left ventricular diastolic function”]

Question 15

Another advantage of echocardiography is the ability to estimate right-sided heart pressures noninvasively. For example, right atrial (RA) pressures are estimated by the inferior vena cava (IVC) diameter and the relative change in diameter on ___________. Normal IVC diameter and inspiratory collapse of at least __% are associated with normal RA pressures, whereas increased IVC diameter and smaller inspiratory changes indicate elevated RA pressure.

Answer 15

inspiration

50%

[Clinical Key, from Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, “Approach to the Patient with Heart Failure”]

Question 16

Antiphospholipid syndrome is present if at least ___ of the clinical criteria and ___ of the laboratory criteria are met.

Answer 16

one, one

[From Osmosis and UpToDate: “Diagnosis of antiphospholipid syndrome”]

Question 17

The clinical criteria for antiphospholipid syndrome are:

Answer 17

1. Vascular thrombosis
   One or more clinical episodesΔ of arterial, venous, or small vessel thrombosis◊, in any tissue or organ. Thrombosis must be confirmed by objective validated criteria (ie, unequivocal findings of appropriate imaging studies or histopathology). For histopathologic confirmation, thrombosis should be present without significant evidence of inflammation in the vessel wall.
2. Pregnancy morbidity
   a. One or more unexplained deaths of a morphologically normal fetus at or beyond the 10th week of gestation, with normal fetal morphology documented by ultrasound or by direct examination of the fetus; or

b. One or more premature births of a morphologically normal neonate before the 34th week of gestation because of: (i) eclampsia or severe preeclampsia defined according to standard definitions, or (ii) recognized features of placental insufficiency§; or

c. Three or more unexplained consecutive spontaneous abortions before the 10th week of gestation, with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded.
In studies of populations of patients who have more than one type of pregnancy morbidity, investigators are strongly encouraged to stratify groups of subjects according to a, b, or c above.

[From UpToDate: Diagnosis of antiphospholipid syndrome]

Question 18

The laboratory criteria for antiphospholipid syndrome are:

Answer 18

1. Lupus anticoagulant present in plasma, on two or more occasions at least 12 weeks apart, detected according to the guidelines of the International Society on Thrombosis and Haemostasis (Scientific Subcommittee on LAs/phospholipid-dependent antibodies).
2. Anticardiolipin antibody of IgG and/or IgM isotype in serum or plasma, present in medium or high titer (ie, >40 GPL or MPL, or >the 99th percentile), on two or more occasions, at least 12 weeks apart, measured by a standardized ELISA.
3. Anti-beta-2 glycoprotein-I antibody of IgG and/or IgM isotype in serum or plasma (in titer >the 99th percentile), present on two or more occasions, at least 12 weeks apart, measured by a standardized ELISA, according to recommended procedures.

[From UpToDate “Diagnosis of antiphospholipid syndrome”]

Question 19

When writing the HPI on a patient with symptomatic bradycardia, what key piece of information needs to be included?

Answer 19

The time and date of the last heart rate-slowing medication dose.

Question 20

Regarding the presentation of aortic dissection, what is the most common presenting symptom?

Answer 20

The most common presenting symptom of acute aortic dissection is pain (located in the back, abdomen, or chest), reported in more than 93% of patients, with 85% specifying an abrupt onset.

[From “Rutherford’s Vascular Surgery and Endovascular Therapy”, Ninth Edition]

Question 21

Where do patients with aortic dissection usually complain of pain? How do the presentations vary depending on type A vs type B dissection?

Answer 21

While the pain is typically described as anterior in location in type A dissections, for type B dissections, pain is more often experienced in the back (78% vs. 64%, respectively).

[From “Rutherford’s Vascular Surgery and Endovascular Therapy”, Ninth Edition]

Question 22

Pain has been localized to the abdomen in up to 21% of patients with type A and 43% of patients with type B dissections. In such patients, a high index of suspicion for mesenteric vascular compromise is warranted. Typically the pain is severe, causing the patient to seek medical attention within minutes to hours of onset, and has been described as “the worst ever” by nearly __% of patients.

Answer 22

90

[From “Rutherford’s Vascular Surgery and Endovascular Therapy”, Ninth Edition]

Question 23

What is the Sokolow-Lyon criterion for LVH on an EKG?

Answer 23

If measurement of the [R wave in V5 or V6], + [S wave in V1] > 35 mm, then the patient has LVH.

Question 24

What is the Cornell criteria for LVH on an EKG?

Answer 24

If measurement of the R in aVL and S in V3 > 28 mm (in men; or > 20 mm in women), then the patient has LVH.

Question 25

What is the modified Cornell criteria for LVH?

Answer 25

If the R wave in aVL > 12 mm, LVH is present

Question 26

What does BRASH syndrome stand for?

Answer 26

bradycardia

renal failure

AV blockade

shock

hyperkalemia