cardiology 5 Flashcards
What is the most appropriate procedure for diagnosing aortic dissection in hemodynamically unstable patients?
CT angiography
Does suppression of PVCs and non-sustained VT improve survival in asymptomatic patients?
No, it has not shown to improve survival in asymptomatic patients.
What is the most likely cause of an acute MI following stent placement?
Stent thrombosis
What does arteriovenous nicking on fundoscopic exam indicate?
Chronic uncontrolled hypertension
What arrhythmia is characterized by an atrial HR rate of 280 to 300 beats per minute with a 2:1 conduction through the AV node?
Atrial flutter
When should IV medications be used for severe hypertension?
Reserved for symptomatic patients (i.e. heart failure, coronary ischemia, or hypertensive encephalopathy)
What are the 3 typical signs of right-sided heart failure?
Elevated JVP, pedal edema, and tricuspid regurgitation
When is an ICD indicated after an MI?
If the patient has a left ventricular EF of 35% or less at least 40 days after the infarction.
How should postcardiac injury syndrome (Dressler syndrome) be treated?
With high-dose aspirin, analgesics, and colchicine.
What is the most appropriate initial medication for a symptomatic hemodynamically stable patient with a regular narrow complex tachyarrhythmia?
Adenosine
Adenosine should terminate reentrant tachyarrhythmias that involve the AV node.
What does ST segment depression typically indicate?
Reversible myocardial ischemia
What is the first-line treatment in hypertensive emergency and heart failure?
IV nitroglycerin
What happens to the murmur in aortic and pulmonary stenosis with the Valsalva maneuver?
The murmur becomes softer due to decreased preload.
What is the treatment for high degree AV block due to Lyme disease?
Typically reversible with antibiotic therapy.
When should an ascending aortic aneurysm be surgically repaired?
When it exceeds 5.5 cm in diameter or enlarges more than 0.5 cm/year.
What is a characteristic finding in patients with subclavian steal?
A systolic pressure difference of at least 15 mmHg between the left and right arms.
What should be the goal of targeted temperature management (TTM)?
Avoidance of hyperthermia rather than the induction of hypothermia.
What is the most appropriate management for a patient with a bicuspid aortic valve and an ascending aortic aneurysm >5.5 cm?
Surgical repair of the aneurysm.
What are the stages of EKG abnormalities of acute pericarditis?
- Widespread ST elevation and PR depression
- Normalization of ST and PR segment
- Development of widespread T wave inversion
- ECG normalizes or indefinite persistence of T wave inversion
What are the three main components of a right bundle branch block (RBBB)?
- An rsr complex in leads V1 and V2
- Tall secondary R wave in lead V1
- Wide slurred S wave in leads I, V5, V6
What is the hallmark clinical finding of subclavian steal syndrome?
Systolic BP difference of 15 mmHg between right and left arm.
What is the management for a type II diabetic with multivessel coronary disease and reduced systolic dysfunction?
CABG
What is the most sensitive EKG finding for right ventricular infarction?
ST elevation in lead V4 on the right side.
What is indicated in adults with congenital cyanotic heart disease and erythrocytosis if hematocrit exceeds 65%?
Phlebotomy
What are clear indications for valve repair in chronic mitral regurgitation?
- Symptoms
- Reduction in ejection fraction to less than 60%
- Left ventricular end-systolic dimension greater than 40 mm
What is the next step to confirm cardiac sarcoidosis with bilateral hilar lymphadenopathy?
Perform lymph node biopsy.
What is the treatment for a patient with hypertensive urgency and no symptoms?
Adjustment of long-acting medications.
What is the management for a patient with hypertensive urgency and no symptoms?
Adjustment of long-acting medications and prompt outpatient follow-up.
What is the likely medication class for a patient experiencing orthostatic hypotension secondary to a recently started medication?
Alpha blocking agent.
What is the first-line therapy for a patient with hypertensive emergency and acute heart failure?
IV nitroglycerin.
What antihypertensive therapy is indicated for a patient with type 2 diabetes and CKD with blood pressure > 130/80?
ACE or ARB.
How often should an adult aged 40 to 75 with no ASCVD and not on statins have their lipid levels measured?
Every 4 to 6 years.
What are the classic presentations of Kawasaki disease?
Fever, lymphadenopathy, conjunctivitis, rash with redness of palms and soles.
What is the most useful physical exam technique for coarctation of the aorta?
Taking blood pressure readings in all four extremities.
Are amoxicillin and cephalexin indicated in the treatment of acute GAS pharyngitis?
True.
What are the three main components of a right bundle branch block (RBBB)?
An rsr complex, tall secondary R wave in lead V1, wide slurred S wave in leads I, V5, V6.
What is the most appropriate treatment for acute uremic pericarditis?
Hemodialysis.
If a patient with chronic stable angina is on max dose BB and nitrate, what is the next step?
Add a CCB.
False; if already on max BB, no need to add CCB, should instead add ranolazine.
What are the indications for an ICD in congenital long QT syndrome?
Survivors of cardiac arrest, patients with recurrent syncope while on beta blockers, patients with QTC intervals greater than 500 msec.
What does hypotension and elevated JVP after a cardiac ablation procedure suggest?
Cardiac tamponade.
What is the diagnostic test for cardiac tamponade?
Echocardiography.
What is the treatment for cardiac tamponade?
Pericardiocentesis.
What is the treatment of choice in a hemodynamically stable patient with acute atrial fibrillation and preexcitation?
Intravenous procainamide or ibutilide.
Why does adenosine have no role in controlling ventricular response in atrial fibrillation?
Adenosine has a very short half-life.
Do embolic events occur in one-third of cases of atrial myxomas?
True.
What indicates a pseudoaneurysm after cardiac catheterization?
A tender pulsatile mass and an audible systolic bruit.
What is the purpose of the tilt table test?
To distinguish between different types of reflex syncope.
Where is a pericardial friction rub best heard in acute pericarditis?
At the left sternal border at end expiration while leaning forward.
What is characteristic of atrial flutter?
An atrial HR rate of 280 to 300 beats per minute with 2:1 conduction through the AV node.
What is the most effective strategy for perioperative anticoagulation in a patient with a mechanical mitral valve and CKD?
Discontinue warfarin 5 days before surgery and initiate therapeutic dose of IV unfractionated heparin when INR falls below 2.5.
What are EKG abnormalities consistent with RV strain?
Right bundle branch block, SI-QIII-TIII pattern, ST elevation in inferior leads (especially III, aVF), ST elevation in aVR, T-wave inversion in V1-V3.
What is lipoprotein lipase deficiency characterized by?
An elevated triglyceride level but low HDL and LDL.
What does transient painless complete monocular vision loss indicate?
TIA.
What is the most appropriate anticoagulant for NSTEMI-ACS managed noninvasively?
Subcutaneous low-molecular-weight heparin.
What do Type B aortic dissections involve?
The descending aorta or the arch distal to the origin of the left subclavian artery.
What is the typical treatment for Dressler syndrome?
High-dose aspirin, analgesics, and colchicine.
What labs should be ordered for a PE workup?
INR, PTT, fibrinogen, D-dimer, troponin, lactate.
What is the likely diagnosis for acute chest pain, symptoms of heart failure, and a mechanical aortic heart valve with low INR?
Valve thrombosis.
What is the diagnostic test to order for valve thrombosis?
Echocardiogram.
What indicates tricuspid regurgitation?
A holosystolic murmur at the left lower sternal border that increases with inspiration.
What should be assessed in a patient presenting for follow-up of recent myocardial infarction reporting fatigue?
Depression.
What does DAPT typically consist of?
Aspirin and a P2Y12 inhibitor such as clopidogrel, ticagrelor, or prasugrel.
What should be considered in patients presenting with an acute inferior wall MI?
Right ventricular infarction.
What is the most common cause of left ventricular hypertrophy (LVH)?
Primary hypertension.
What should patients with HFrEF be treated with?
A beta-blocker and either an ACE-I, ARB, or ARNI. If symptoms persist, add an MRA or an SGLT2 inhibitor.
What are three typical indications for biventricular pacing?
LVEF of less than 35%, sinus rhythm with LBBB morphology, QRS complex duration of greater than 149 ms.
What are the goals of initial treatment for type B aortic dissection?
Reduce blood pressure to less than 120 mmHg and heart rate to about 60 bpm.
Is endovascular repair for thoracic aortic aneurysms routinely recommended?
False.
Are most cases of hypertension primary or secondary in nature?
Primary.
What is the most appropriate management for stable angina and an abnormal stress test indicating low cardiovascular risk?
Aspirin, a statin, and at least one of the following: a beta-blocker, a CCB, or long-acting nitrate.
What do patients typically report with stent restenosis?
Progressive exertional angina.
What is considered low-intensity statin therapy?
Simvastatin 10 mg, Pravastatin 10-20 mg, Lovastatin 20 mg, Fluvastatin 20-40 mg.
What is surgical subxiphoid pericardiotomy also called?
Pericardial window.
What is severe aortic stenosis typically associated with?
A mean transvalvular pressure gradient of >40 mmHg or a peak velocity > 4 m/sec.
What is the most likely cause of rising serum creatinine after treatment with ACE inhibitor in a young woman with hypertension?
Renal artery stenosis secondary to fibromuscular dysplasia.
In wide-complex bradyarrhythmias, where is the level of the block in relation to the atrioventricular node?
Above the level of the atrioventricular node.
In wide-complex bradyarrhythmias, what is the level of the block in relation to the atrioventricular node?
Below the level of the atrioventricular node.
What is the level of the block in relation to the atrioventricular node?
The level of the block is below the level of the atrioventricular node.
What has iron chelation therapy shown in patients with secondary hemochromatosis?
Iron chelation therapy has been shown to improve ventricular function, reduce mortality, and prevent ventricular arrhythmias.
What is the most concerning vascular risk for atrial myxoma?
Embolization.
What is sometimes used for blood pressure control in patients of African descent who cannot tolerate ACEi or ARBs?
Isosorbide Dinitrate + Hydralazine.
What is preferred for anticoagulation in A-fib cases of severe mitral stenosis or a mechanical heart valve?
Warfarin would be preferred over a DOAC.
What are the three main components of a Right Bundle Branch Block (RBBB)?
- An rsr complex forming a characteristic ‘rabbit ears’ or M shape in leads V1 and V2.
- Tall secondary R wave in lead V1.
- Wide slurred S wave in leads I, V5, V6.
What are the ECG findings of Left Ventricular Hypertrophy (LVH)?
- Tall R waves.
- Deep S waves.
- +/- QRS widening.
- +/- left axis deviation.
- +/- ST-T changes.
- +/- LAE (left atrial enlargement).
What typically results from Dressler syndrome?
Pleuritic chest pain, fever, and occasionally a pericardial effusion.
When is an ICD appropriate for heart failure patients?
An ICD is appropriate as primary prevention for patients with heart failure whose LVEF is less than 35%.
What is the initial management of acute viral pericarditis?
High-dose NSAID and colchicine.
When does post MI pericarditis typically occur?
Typically occurs in 1-3 days after a transmural infarct.
What indicates low risk in patients with stable angina?
Patients are low risk if they do not have significant coronary artery disease.
What is the likely diagnosis for a patient with type A aortic dissection and acute aortic regurgitation who develops acute hypotension and distended neck veins but has clear lungs?
Likely diagnosis: cardiac tamponade.
What do current ACC/AHA guidelines state about aspirin for primary prevention of ASCVD?
Aspirin should not be used for primary prevention of ASCVD in adults older than 70 or any age who are at increased risk of bleeding.
What are typical manifestations of Chagas disease?
Esophageal dysfunction, conduction system abnormalities, and dilated cardiomyopathy.
What should a patient with severe symptomatic mitral regurgitation referred for elective valve surgery have?
Preoperative cardiac catheterization with coronary angiography to assess for coronary artery disease.
When is an ICD indicated after an MI?
An ICD is indicated if the patient has an EF of 35% or less at least 40 days after the infarction.
What are the typical beta blockers used in GDMT for heart failure patients?
Metoprolol succinate, Coreg, and bisoprolol.
What is the most common physical finding on cardiac auscultation in patients with hypertension?
S4 gallop.
What is likely indicated by a hollow diastolic rumbling murmur at the apex with pre-systolic accentuation?
Mitral stenosis.
What should be the first-line therapy for a patient with hypertensive emergency and acute heart failure?
IV nitroglycerin.
What is a common side effect of alpha 1 adrenergic antagonists?
Orthostatic hypotension.
What are the two common auscultation findings in aortic regurgitation?
- Low pitched diastolic rumble at the apex.
- Decrescendo diastolic murmur at the left sternal border.
When can conventional troponin assays detect serum troponin levels?
At least 2 hours after infarction.
What do Type A aortic dissections involve?
The ascending aorta, the aortic arch, or both.
What is the typical treatment for hypertensive emergency and heart failure?
IV nitroglycerin due to its effects on preload reduction, afterload reduction, and coronary arterial dilation.
What is another name for Dressler syndrome?
Postcardiac injury syndrome.
What are the EKG abnormalities consistent with RV strain?
- Right bundle branch block.
- SI-QIII-TIII pattern.
- ST elevation in inferior leads (especially III, aVF).
- ST elevation in aVR.
- T-wave inversion in V1-V3.
How is pain from acute pericarditis relieved?
Pain from acute pericarditis is relieved by leaning forward.
What is the typical oscillatory description of the pericardial knock?
High-pitched early diastolic heart sound.
What should a STEMI patient who has undergone thrombolytic therapy and shows signs of heart failure do?
Undergo percutaneous coronary intervention.
What does renal-cell carcinoma have a predilection for?
Vascular invasion.
What causes of symptomatic sinus bradycardia should be ruled out?
- Medications.
- Sleep apnea.
- Hypothyroidism.
- MI.
- Electrolytes.
What is the likely diagnosis for a patient with dyspnea on exertion and deep symmetric T-wave inversions in leads V2 and V3?
Likely diagnosis: unstable angina.
What should be the immediate step for a patient with acute NSTEMI when PCI is more than 2 hours away?
Fibrinolytic therapy.
What is indicative of Wolff-Parkinson-White syndrome?
A young patient with palpitations, a short PR interval, and a delta wave.
What is the most worrisome sign for massive PE?
Bradycardia.
What is the first-line therapy for right ventricular infarction and hypotension?
IV normal saline.
What should patients with HFrEF be treated with?
A beta blocker and either an ACE-I, ARB, or ARNI. If symptoms are persistent, add an MRA or an SGLT 2 inhibitor.
Are BNP elevations associated with both heart failure exacerbations and acute coronary syndromes?
True.
What is the relationship between BNP levels in acute coronary syndromes and outcomes?
The higher the levels in acute coronary syndromes, the worse the outcomes.
What are the signs of calcium channel blocker overdose?
Hypotension, bradycardia, hyperglycemia, and metabolic acidosis.
What do current guidelines for STEMI recommend regarding aspirin and primary PCI?
Administer aspirin before primary PCI and a loading dose of the P2Y12 inhibitor as early as possible or at the time of PCI.
What is Cilostazol?
A phosphodiesterase inhibitor with antiplatelet properties.
What is Ibutilide used for?
Cardioversion of suitable patients with A-fib or a flutter.
What are T wave inversions in V1-V3 and right axis deviation indicative of?
RV strain.
What are leads V1 and V2 considered?
Anterior-septal leads.
What is the recommended amount of exercise per week?
At least 150 minutes of moderate intensity exercise per week or 75 minutes of vigorous exercise per week.
What are conduction-system abnormalities often the earliest indicators of?
Chagas cardiomyopathy.
What leads are typically involved in an Anterior MI?
Leads V1-V6.
What is the most appropriate management for stable angina with an abnormal stress test indicating low cardiovascular risk?
Aspirin, a statin, and at least one of the following: a beta-blocker, a CCB, or long-acting nitrate.
What is recommended for STEMI patients presenting within 12 hours after symptom onset when PCI cannot be performed within 2 hours?
Thrombolytic therapy.
What should be added in chronic stable angina despite use of aspirin, BB, ACE-I, and a statin?
A long-acting nitrate or a CCB.
What is the heart rate in an arrhythmia with a rate of 280 to 300 beats per minute and a 2:1 conduction through the AV node?
Atrial HR rate of 280 to 300 beats per minute.
What is thrombolytic therapy used for in STEMI patients?
Thrombolytic therapy is used for STEMI patients presenting within 12 hours after symptom onset when PCI cannot be performed within 2 hours after first medical contact.
What should be added to chronic stable angina treatment despite use of aspirin, BB, ACE-I, and a statin?
A long-acting nitrate or a CCB.
What is characteristic of atrial flutter?
An arrhythmia with an atrial HR rate of 280 to 300 beats per minute and a 2:1 conduction through the AV node resulting in a ventricular rate of around 150.
What are the criteria for successful thrombolysis in STEMI patients?
Relief of pain, >50% resolution in the magnitude of ST segment elevation, and reperfusion.
What can a small subset of patients with PE experience?
An exuberant release of epinephrine which leads to hypertension.
What changes typically occur in an acute myocardial infarction?
Changes in T waves, ST segments, and Q waves.
What is the typical presentation of T waves in lead aVR?
T waves are typically inverted in lead aVR.
What cardiac conditions need antibiotic prophylaxis for bacterial enteritis before dental procedures?
Prosthetic heart valves, valve repair with prosthetic material, heart transplant with valvulopathy, prior infective endocarditis, and certain types of congenital heart disease.
What is Dabigatran?
Dabigatran is a direct thrombin inhibitor.
What troponin value would rule in ACS?
A very high initial high sensitivity cardiac troponin value (typically >52 ng/L) or a significant increase on one hour serial assessment (typically >5 ng/L).
When should an echocardiogram be performed for evaluation of LV systolic function for an ICD?
No earlier than 3 months after PCI or CABG.
What is the initial treatment for Dressler syndrome?
High-dose aspirin, analgesics, and colchicine.
What is Type IV RTA associated with?
Hypoaldosteronism and is characterized by hyperkalemia and associated with low plasma renin activity.
Who are most likely to have nonclassic presentations of angina?
Older patients, diabetes mellitus, and women.
What are the recommended antibiotics for secondary prevention of rheumatic fever?
Long-acting Penicillin G Benzathine IM every 3 to 4 weeks, daily oral penicillin V, sulfadiazine, or a macrolide.
Is preoperative workup indicated for non-cardiac mid-risk surgery in patients with long-standing stable angina and good functional status?
False.
