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Step 2 CK > Cardiology > Flashcards

Cardiology Flashcards

1
Q

True or False

Menstruating women virtually never have MIs

A

True

By the time a woman is 55-60, the protective effect of menstruation and naturally-occurring estrogen have worn off, and the rates of CAD will at least equal the rates in men

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2
Q

The worse risk factor for CAD is…

The most common risk factor for CAD is…

A

Worse risk factor = DM

Most common risk factor = HTN

Others risk factors include: tobacco, hyperlipidemia, FHx of premature CAD, age >45 in men and >55 in women

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3
Q

Premature CAD is defined as…

A

CAD <55 in males

CAD <65 in females

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4
Q

FHx that increases your risk of CAD

A

CAD in first-degree relatives

Premature CAD in a family member

NOT if CAD developed in elderly relatives or if the relatives were grandparents, cousins, or aunts/uncles

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5
Q

Tako-Tsubo cardiomyopathy

A

Acute myocardial damage most often occuring in postmenopausal women immediately following an overwhelming, emotionally stressful event

Leads to “ballooning” and LV dyskinesis

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6
Q

Management of Tako-Tsubo cardiomyopathy

A

Beta blockers and ACE inhibitors

Revascularization will not help, since the coronary arteries are normal

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7
Q

Elevated homocysteine levels

Chlamydia Infection

Elevated CRP

A

Disease markers that are unreliable (unproven) risk factors for CAD

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8
Q

Within a year after stopping smoking, the risk of CAD decreases by…

A

50 %

Within 2 years, the risk is reduced by 90%

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9
Q

Ischemic pain is NOT:

A
  • Tender
  • Positional
  • Pleuritic

NPV = 95%

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10
Q

The most common cause of chest pain that is NOT ischemic in nature is…

A

GI disorders (e.g., GERD, ulcers, cholelithiasis, duodenitis, and gastritis)

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11
Q

Most likely diagnosis for chest wall tenderness

A

Costochondritis

Most accurate test = physical exam

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12
Q

Most likely diagnosis for chest pain that radiates to the back with unequal blood pressure between arms

A

Aortic dissection

Most accurate test = CXR with widened mediastinum, chest CT, MRI, or TEE

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13
Q

Most likely diagnosis for chest pain that is worse with lying flat, better when sitting up, and patient is <40

A

Pericarditis

Most accurate test = electrocardiogram with ST elevation everywhere, PR depression

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14
Q

Most likely diagnosis for chest pain that is sharp, pleuritic, and pt has tracheal deviation

A

Pneumothorax

Most accurate test = CXR

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15
Q

Stress testing is the answer when…

A

the etiology of chest pain is uncertain and the EKG is not diagnostic

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16
Q

Maximum HR =

A

220 minus the age of the patient

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17
Q

The 2 best methods of detecting ischemia without the use of EKG are:

A
  1. Nuclear isotope uptake: thallium* or sestamibi
  2. Echocardiographic detection of wall motion abnormalities (dyskinesis, akinesis, or hypokinesis)

*Abnormalities will be detected by seeing decreased thallium uptake

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18
Q

LBBB

LV hypertrophy

Pacemaker

Digoxin

A

Reasons for baseline EKG abnormalities

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19
Q

What if the patient cannot tolerate exercise (i.e., heart rate above 85% of maximum)

A

Nuclear isotope testing: give dipyridamole* or adenosine

Echo: give dobutamine to increase myocardial oxygen consumption

*Dipyridamole may provoke bronchospasm (avoid in asthmatics)

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20
Q

Angiography is used to detect…

A

the anatomic location of coronary artery disease

Angiography determines bypass surgery versus angioplasty

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21
Q

Holter monitor is used mainly for…

A

rhythm evaluation

Usually used for a 24-hour period (does NOT detect ischemia)

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22
Q

Therapeutic options for patients with chronic angina

A

ASA

Beta Blockers

Nitroglycerin*

*Nitro can be used orally or transdermally (sublingual, paste, and IV forms are only used in acute coronary syndromes)

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23
Q

All patients with ACS should receive _________ immediately upon arrival in the ER.

A

2 antiplatelet medications

  1. ASA
  2. Clopidogrel, prasugrel, or ticagrelor (inhibitors of P2Y12 receptor on platelets)
    * When angioplasty and stenting is planned, the answer is ticagrelor or prasugrel (they best prevent restenosis)*
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24
Q

Best mortality benefit in chronic angina

A

ASA and Beta Blockers

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25
Q

Side effect unique to Prasugrel

A

>75 = increased risk of hemorrhagic stroke

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26
Q

Side effects unique to Ticlopidine

A

Neutropenia and TTP*

*Clopidogrel is rarely associated with TTP

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27
Q

Pt develops hyperkalemia after starting an ACE inhibitor d/t low ejection fraction (systolic dysfunction), what is the next best step in management?

A

Switch ACE-I to hydralazine and nitrates (cannot just switch to ARB because that also leads to hyperkalemia)

Hydralazine is a direct arterial vasodilator (decreases afterload) and is used in association with nitrates to dilate the coronary arteries so that blood is not “stolen”

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28
Q

Most common adverse effect of statin medications

A

Liver dysfunction (all patients should have their AST and ALT routinely tested)

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29
Q

Why are statins first-line lipid lowering agents in patients with CAD?

A

They have an antioxidant effect on the endothelial lining of the coronary arteries

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30
Q

Adverse Effects of Second-Line Lipid-Lowering Medications

  1. Niacin
  2. Fibric acid derivatives
  3. Cholestyramine
  4. Ezetimibe
A
  1. Niacin - elevated glucose and uric acid level, pruritus
  2. Gemfibrozil (fibric acid derivatives) - increased risk of myositis when combined with statins
  3. Cholestyramine - flatus and abdominal cramping
  4. Ezetimibe - well tolerated and nearly useless
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31
Q

Use CCBs in CAD only with:

A

CCBs (verapamil/diltiazem are the only options since the others will increase HR and, subsequently, myocardial oxygen consumption)

  1. Severe asthma precluding the use of beta blockers
  2. Prinzmetal variant angina
  3. Cocaine-induced chest pain
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32
Q

Adverse Effects of CCBs

A
  1. Edema
  2. Constipation (most often with verapamil)
  3. Heart block (rare)
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33
Q

When is CABG better than PCI?

A
  • 3 vessel disease
  • Left main coronary artery occlusion
  • 2 vessel disease in a patient with diabetes
  • *Internal mammary artery grafts last on average for 10 years whereas saphenous vein grafts remain patent reliably for only 5 years*
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34
Q

What is an S4 gallop and how is it associated with Acute Coronary Syndrome

A

S4 gallop = sound of atrial systole as blood is ejected from the atrium into a stiff ventricle

ACS is associated with an S4 gallop because of ischemia leading to noncompliance of the LV

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35
Q

Pulsus Paradoxus

A

A decrease in BP >10 on inspiration (associated with cardiac tamponade)

Also seen with severe asthma or COPD

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36
Q

Kussmaul sign

A

Increase in JVP on inhalation (most often associated with constrictive pericarditis)

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37
Q

Dressler syndrome

A

Pericarditis several days to weeks after an MI

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38
Q

Displaced PMI

A

Characteristic of LVH and dilated cardiomyopathy

PMI is an anatomic abnormality that could not occur with an acute coronary syndrome

39
Q

Which EKG findings (i.e., which leads) would be associated with the worst prognosis?

A

ST elevation in leads V2-V4: corresponds to anterior wall of the left ventricle (AWMI) and has a 30-40% mortality if untreated

ST elevated in II, III, aVF: corresponds to IWMI with a <5% mortality if left untreated

ST depression in leads V1 and V2 (remember that ST depression in these leads is equivalent to ST elevation elsewhere): corresponds to a PWMI and has a very low mortality

40
Q

A patient presents with ST segment elevation in V2-V4, what two steps need to happen next?

A
  1. Give Aspirin
  2. Angioplasty
41
Q

Complications of angioplasty (aka PCI)

A
  • Rupture of the coronary artery on inflation of the balloon
  • Restenosis (thrombosis)
  • Hematoma at the site of entry into the artery (e.g., femoral area hematoma)
42
Q

What is the best way to prevent restenosis following PCI?

A

Placement of drug-eluting stents (paclitaxel, sirolimus) that inhibit the local T cell response

No stenting: 30-40% restenosis

Bare metal stent: 15-30% restenosis

Drug-eluting stent: <10% restenosis

43
Q

Absolute Contraindications to Thrombolytics

A
  • Major Bleeding into the Bowel or Brain
  • Recent Surgery (within the last 2 weeks)
  • Severe HTN (>180/110)
  • Nonhemorrhagic Stroke within the last 6 months

Blood Sure Hates Slicing

44
Q

Heparin is best for what type of MI?

GP IIb/IIIa inhibitors are best for what type of MI?

A

Heparin - NSTEMI

Abciximab/Tirofiban/Eptifibatide - NSTEMI and undergoing PCI and stenting

45
Q

Why is sinus bradycardia very common after an MI?

A

Vascular insufficiency of the SA node

46
Q

What are cannon A waves are how do they help you distinguish between sinus bradycardia and third-degree (complete) AV block?

A

Cannon A Waves = atrial systole against a closed tricuspid valve

Cannon A Waves are characteristic of complete block because the atria and ventricles are contracting separately

47
Q

Treatment of RV infarctions

A

Look for ST elevation in V4

Treat with high-volume fluid replacement (avoid nitroglycerin because it will markedly worsen cardiac filling)

48
Q

Why are acute MI patients monitored in an ICU for the first several days after the infarction?

A

To monitor for ventricular tachycardia/fibrillation and treat with electrical shock should they occur.

49
Q

Step-up in oxygen saturation

A

Diagnostic of septal rupture

(e.g., 72% O2 sat from RA and 85% O2 sat from RV)

50
Q

Postinfarction Routine Medications

A

Aspirin

Beta Blockers (metoprolol)

Statins

*ACE inhibitors

*Best for AWMI because of the high likelihood of developing systolic dysfunction

Prophylatic antiarrhythmics (amiodarone, flecainide) increase mortality

51
Q

Most likely diagnosis for dyspnea with:

  1. Sudden onset, clear lungs
  2. Slower, fever, sputum, unilateral rales
  3. Circumoral numbness, caffeine use
  4. Pallor, gradual
  5. Pulsus paradoxus, decreased heart sounds, JVD
  6. Palpitations, syncope
  7. Recent anesthetic use, brown blood, clear lungs
  8. Burn injury
A
  1. PE
  2. Pneumonia
  3. Panic attack
  4. Anemia
  5. Tamponade
  6. Arrhythmia
  7. Methemoglobinemia
  8. CO poisoning

ALL OF THESE LACK ORTHOPNEA/PND AND S3 GALLOP

52
Q

What is best initial test to determine EF?

What is the most accurate?

A

Best = TTE

Most accurate = MUGA or Nuclear Ventriculography

53
Q

When will nuclear ventriculography be the right answer on the test?

A

Example: person receiving chemo with doxorubicin (trying to give the maximum amount of chemo without causing cardiomyopathy)

54
Q

A normal BNP

A

Excludes CHF as a cause of SOB (only the answer when the etiology of dyspnea is unclear and you cannot wait for an echo to be performed)

55
Q

What medications should all patients with HF and low EF be started on?

A

ACE-I/ARB

Beta blocker

*Spironolactone

**Diuretics

**Digoxin

*Class III and IV CHF (SOB with minimal exertion or at rest)

**For symptomatic relief only

56
Q

What beta blockers are used for HF (proven benefit)?

A

Metoprolol and Bisoprolol (beta-1 antagonists)

Carvedilol (nonspecific beta blocker with alpha-1 antagonism)

57
Q

Most common cause of death from HF?

A

Arrhythmia/sudden death

58
Q

Mortality Benefit in Systolic Dysfunction

A

ACEIs/ARBs

Beta blockers (specific)

Spironolactone or eplerenone (if pt develops gynecomastia)

Hydralazine/nitrates

Implantable defibrillator

59
Q

How does management change in HFpEF compared to HFrEF?

A

HFpEF = diastolic dysfunction

Clearly beneficial: beta blockers and diuretics

Contraindicated: digoxin and spironolactone

Unclear: ACEIs/ARBs and hydralazine

60
Q

Cephalization of flow and engorged pulmonary veins on CXR

A

Pulmonary edema

AKA the worst/most severe form of CHF

61
Q

Why is EKG the most important test to do when a patient presents with signs/symptoms of pulmonary edema?

A

It guides immediate therapy

For atrial fibrillation, atrial flutter, or ventricular tachycardia the first thing to do is to perform rapid, synchronized cardioversion

62
Q

What is the best initial therapy for acute pulmonary edema

A

A loop diurectic (e.g., furosemide) to remove a large volume of fluid from the vascular space

63
Q

Lesions on the right side of the heart (tricuspid and pulmonic valve) increase or decrease in intensity with inhalation?

A

Increase

Inhalation will increase venous return to the right side of the heart

64
Q

The best initial test for all valvular heart disease is

A

echocardiogram

TEE is more sensitive and more specific than TTE

65
Q

Treatment for mitral stenosis versus aortic stenosis

A

Mitral = balloon dilation

Aortic = surgical removal

*Regurgitant lesions respond best to vasodilator therapy with ACEi/ARBs, nifedipine, or hydralazine

66
Q

Relatively unique features of mitral stenosis compared to other valvular diseases

A

Dysphagia (LA pressing on the esophagus)

Hoarseness (LA pressing on laryngeal nerve)

Atrial fibrillation (enormous LA)

Hemoptysis

67
Q

Left atrial hypertrophy shows up as what on EKG

A

biphasic P waves in leads V1 and V2

68
Q

Aortic stenosis is most commonly caused by

A

increasing calcification as people age or by a congenital bicuspid valve

69
Q

The murmur of aortic stenosis is heard best at

A

the second right intercostal space, and radiates to the carotid artery

70
Q

What is unique about the murmur of mitral regurgitation?

A

Pansystolic (obscuring both S1 and S2) and radiates to the axilla

71
Q

All left-sided murmurs except for ___________ will increase with expiration?

A

Mitral valve prolapse and HOCM

Expiration = more blood pumped to the left side of the heart

72
Q

When is surgical valve replacement indicated for mitral regurgitation

A

When the heart starts to dilate (LVESD > 40 mm or EF < 60%)

73
Q

Wide pulse pressure

Water-hammer pulse

Quincke pulse (pulsations in the nail bed)

Hill sign (BP in legs > 40 mm Hg above arm BP)

Head bobbing (de Musset sign)

A

physical findings of aortic regurgitation

74
Q

Woman presents with atypical chest pain, palpitations, and panic attacks. What valve disorder should be in your differential?

A

Mitral valve prolapse

75
Q

Cardiomyopathy is…

A

abnormal function of the heart muscle

dilated, hypertrophic, or restrictive

76
Q

Most common cause of non-obstructive hypertrophic cardiomyopathy

A

HTN (do not confuse HCM with HOCM)

77
Q

Best initial therapy for both HCM and HOCM

A

Beta blockers

78
Q

Systolic anterior motion (SAM) of the mitral valve

A

Classic for HOCM (contributes to obstruction)

79
Q

Can you use diuretics for HCM or HOCM?

A

May help in HCM, but diuretics are contraindicated in HOCM

ACEi/ARBs also do not help in HOCM (unclear benefit in HCM)

80
Q

Standing or performing Valsalva has the same effect as what type of medication?

A

A diuretic

81
Q

EKG changes for pericarditis

A

ST segment elevation in all leads

PR segment depression = most specific finding

82
Q

Treatment of idiopathic pericarditis

A

NSAID and colchicine

83
Q

Most likely diagnosis:

Hypotension

Tachycardia

Distended neck veins

Clear lungs

A

Cardiac tamponade

Perform an echo which would show RA and RV diastolic collapse (EKG would just show sinus tach and CXR would be normal)

84
Q

Single most effective medication for PAD?

A

Cilostazol

Cilostazol is a selective inhibitor of phosphodiesterase with therapeutic focus on increasing cAMP. An increase in cAMP results in an increase in the active form of PKA, which is directly related with an inhibition of platelet aggregation. PKA also prevents the activation of an enzyme (myosin light-chain kinase) that is important in the contraction of smooth muscle cells, thereby exerting its vasodilatory effect.

85
Q

Pain in-between the scapula

Difference in BP between the arms

A

Aortic dissection

86
Q

Which test does a better job at diagnosing aortic dissection?

MRA, CT angio, TEE

A

There is no difference

MRA = CTA = TEE

Angiography is the most accurate

87
Q

When is surgical repair indicated for AAA?

A

When the width exceeds 5 cm in diameter

88
Q

Which form of heart disease is the most dangerous to a pregnant woman?

A

Peripartum cardiomyopathy with persistent ventricular dysfunction

89
Q

Pulsus alternans

A

Signs of LV systolic dysfunction

90
Q

Pulsus bigeminus

A

Signs of HOCM

91
Q

Pulsus bisferiens

A

Aortic regurgitation

92
Q

Pulsus tardus et parvus

A

“delayed peak”

aortic stenosis

93
Q

Pulsus paradoxus

A

Cardiac tamponade and tension pneumo

Also seen in COPD and severe asthma

Step 2 CK (18 decks)

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