cardiology 6 Flashcards
What is the typical treatment for renal cell carcinoma with venous tumor thrombus?
IV beta blockers
What complication occurs in up to 10% of affected patients with renal cell carcinoma?
Formation of venous tumor thrombus extending into the renal vein or inferior vena cava
What is the most useful physical exam technique for coarctation of the aorta?
Take blood pressure readings in all four extremities
What is the minimum duration of DAPT for a bare-metal stent?
1 month
Where is a pericardial friction rub best heard in acute pericarditis?
At the left sternal border while leaning forward
What may patients display in the first week after cholesterol embolization?
Peripheral eosinophilia and eosinophiluria
What are the most appropriate procedures for diagnosing aortic dissection in hemodynamically stable patients?
CXR, TTE, or POCUS
What should patients with HFrEF be treated with?
A beta-blocker and either an ACE-I, ARB, or ARNI
What labs are typical to order for a PE workup?
INR, PTT, fibrinogen, D-dimer, Troponin, Lactate
What is indicated for all patients with an inferior MI?
A right-sided EKG
What characterizes lipoprotein lipase deficiency?
Elevated triglyceride level but low HDL and LDL
What should be done for a patient with symptomatic amiodarone-induced pulmonary toxicity?
Stop amiodarone and start an oral steroid plus an alternative antiarrhythmic medication
What is first-line treatment in hypertensive emergency and heart failure?
IV nitroglycerin
What should be given if atropine is ineffective in reversing symptomatic bradycardia?
Chronotropic drugs such as dopamine or epinephrine
What antihypertensive therapy is indicated for a patient with type 2 diabetes, CKD, and blood pressure > 130/80?
ACE or ARB
What do SGLT2 inhibitors reduce in patients with HFrEF?
Hospitalization and mortality rates
What is the prognosis for aortic stenosis once symptoms develop?
Median survival of 5 years or less
When is aortic valve replacement indicated for severe aortic stenosis?
For patients undergoing other cardiac surgery, with a left EF <50%, or with symptoms from severe outflow obstruction
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
What is the typical treatment for early nondisseminated Lyme disease?
Oral doxycycline or oral amoxicillin
What cholesterol levels are typically seen in familial hypercholesterolemia?
Total cholesterol level of 350 to 550 or an LDL level of 200-400
What is a typical sign of coarctation of the aorta?
Radiofemoral pulse delay
What defines a massive PE in the setting of hypotension?
Systolic BP < 90 mm for 15 minutes, fall in systolic BP by >40 mm for 15 minutes, or requirement for vasopressors
What is the most likely cause of complete heart block in a young patient from Latin America?
Chagas cardiomyopathy
What is recommended for men aged 65-75 who have ever smoked?
A one-time ultrasound of the abdominal aorta to evaluate for AAA
Which beta-blockers reduce long-term mortality in patients with HFrEF?
Bisoprolol, carvedilol, and long-acting metoprolol
What is the antibiotic of choice for the prevention of endocarditis in a patient having a dental procedure?
Amoxicillin
What are myxomas?
The most common primary cardiac tumors; the most frequent site is the left atrial cavity.
What disease can thiazide diuretics trigger?
Gout
When are patients with HFrEF considered for an MRA?
If serum potassium levels are <5 mEq/L and creatinine is <2.5 mg/dL for men or 2 mg/dL for women.
What is most suggestive of Prinzmetal angina?
Chest pain and ST-segment elevation that resolve with administration of nitroglycerin.
What does a new RBBB or LBBB after an MI indicate?
It depicts a large MI and a poor prognosis.
Does aortic rupture lead to neck vein distention?
Typically does not.
What are the criteria for successful thrombolysis in STEMI patients?
Relief of pain, >50% resolution in the magnitude of ST segment elevation, and reperfusion arrhythmias (accelerated idioventricular rhythm).
What are the most common clinical signs of cholesterol crystal embolism?
Livedo reticularis and blue toe syndrome.
Who are the patients deemed to be at greatest risk for infective endocarditis?
- Patients who have prosthetic cardiac valves
- Patients who have prosthetic material used for cardiac valve repair
- Patients with previous infective endocarditis
- Patients with unrepaired cyanotic congenital heart disease
- Patients who have a cardiac transplant with valve regurgitation.
What are the indications for an ICD in a patient with hypertrophic cardiomyopathy?
History of cardiac arrest due to V-fib, spontaneous sustained V. tach, family history of sudden cardiac death in at least 2 first-degree relatives who had HCM.
What are the common auscultation findings in aortic regurgitation?
Low pitched diastolic rumble at the apex and decrescendo diastolic murmur at the left sternal border.
What can catecholamine induced cardiomyopathy manifest as?
Severe diffuse apical wall motion abnormalities with preserved base function.
How can goal TTM be achieved?
With early management of fevers and interventional cooling as necessary.
What is the typical target INR for a patient with a mechanical aortic valve?
2.0-3.0, increasing to 2.5-3.5 with any additional risk factors for thromboembolism.
What is the best management for patients with low risk stable angina?
Optimal medical therapy including aspirin, statin, beta-blocker, CCB, and nitrate.
What class of medications is associated with orthostatic hypotension in older men with hypertension?
Alpha-blockers.
What are the three main components of a 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 is the typical presentation of anterior MI?
Usually due to a blockage of the LAD artery.
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 is low intensity statin therapy?
Simvastatin 10 mg, Pravastatin 10-20 mg, Lovastatin 20 mg, Fluvastatin 20-40 mg.
What is the likely diagnosis for a patient with high JVP, ascites, peripheral edema, and normal EF?
Constrictive pericarditis.
What does pulsus alternans refer to?
Beat to beat variation in arterial pulse related to severe LV systolic dysfunction or tamponade.
What is cholestyramine used for?
A bile-acid sequestrant used to decrease LDL.
Do Q waves persist or heal after an MI?
Q waves typically persist after an MI.
What is the most effective strategy for perioperative anticoagulation in a patient with 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 is cholestyramine?
Cholestyramine is a bile-acid sequestrant used to decrease LDL.
What typically happens to Q waves after an MI?
Q waves typically persist after an MI.
What is the most effective strategy for perioperative anticoagulation bridging?
Discontinue warfarin 5 days before surgery and initiate therapeutic dose of IV unfractionated heparin when INR falls below 2.5.
Why should ACE inhibitors and ARBs not be used together?
Due to concern for renal damage and hyperkalemia.
What is the recommended treatment for patients with CKD and NSTEMI with no chest pain?
IV unfractionated heparin.
What is the most common peripheral vascular complication after cardiac catheterization?
A pseudoaneurysm.
What leads are considered the inferior leads of the heart?
Leads II, III, and aVF.
How is digoxin cleared from the body?
Digoxin is cleared by the kidneys.
What is a widened pulse pressure indicative of?
It is not detected in patients with acute aortic insufficiency.
What is the next step for a patient with NSTEMI with a high TIMI or Grace risk score?
Cardiac catheterization with coronary angiography within 12 to 24 hours.
Does an S4 gallop in a patient with hypertension warrant further work-up?
No, it does not warrant further work-up.
What is the target blood pressure for patients with type 2 diabetes?
The target blood pressure is <130/80 mm Hg.
What is the goal for lipid-lowering therapy in patients with type 2 diabetes?
To reduce the LDL level by ≥50% from baseline to a target level of <70 mg/dL.
How do cholesterol emboli typically manifest after a procedure?
As a petechial rash after a procedure performed via arterial access.
What are typical cardiac involvements with sarcoidosis?
AV block, bundle branch block, and arrhythmias.
What are the initial symptoms of Lyme disease?
Fever, myalgias, arthralgias, and erythema migrans.
When is phlebotomy indicated in adults with congenital cyanotic heart disease?
If hematocrit exceeds 65% with symptoms of hyperviscosity in the absence of volume depletion.
What can a prolonged PR interval in a young adult with fevers and pulmonary edema indicate?
It can be indicative of aortic valve endocarditis with acute aortic insufficiency.
What do current ACC/AHA guidelines state about aspirin for primary prevention of ASCVD?
Aspirin should not be used for primary prevention in adults older than 70 or any age who are at increased risk of bleeding.
What describes an innocent still murmur?
A brief vibratory grade 1-3 midsystolic low pitched murmur at the left lower sternal border that may radiate to the cardiac apex.
Which medications are useful in managing stable patients with SVT?
Metoprolol, verapamil, and diltiazem.
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, and T-wave inversion in V1-V3.
What is an indication for early valve replacement in heart failure due to endocarditis?
Heart failure resulting from valve dysfunction.
What is the treatment for situational syncope?
Education and reassurance.
What often transiently improves the ventricular rate if the site of block is in the atrioventricular node?
Atropine.
What is the mnemonic for reciprocal ECG changes?
PAILS: P-posterior, A-anterior, I-inferior, L-lateral, S-septal.
What medication classes should be avoided in decompensated heart failure and an MI?
Beta-blockers and CCBs.
What are the indications for an ICD in a patient with hypertrophic cardiomyopathy?
History of cardiac arrest due to V-fib, spontaneous sustained V. tach, and family history of sudden cardiac death in at least 2 first-degree relatives who had HCM.
What is the most appropriate prophylaxis for sudden cardiac death with syncope and severe septal hypertrophy from HCM?
ICD placement.
What indicates a low risk for stable angina?
Imaging does not identify features of left main or multivessel CAD.
What is the classic auscultatory sign of constrictive pericarditis?
A pericardial knock.
What is recommended if initial therapy with aspirin/NSAIDs plus colchicine fails in acute pericarditis?
Steroids are recommended.
What is first-line therapy for RV infarction complicated by hypotension?
IV normal saline.
What does a shock index (HR/SBP) >1 suggest in massive PE?
It suggests poor hemodynamic reserve and a worse prognosis.
Where is a pericardial friction rub best heard in acute pericarditis?
At the left sternal border at end expiration while leaning forward.
What is the minimum duration of DAPT for a drug-eluting stent in stable ischemic heart disease?
6 months.
What would rule in ACS regarding high sensitivity cardiac troponin values?
A very high initial value (typically >52 ng/L) or a significant increase on one hour serial assessment (typically >5 ng/L).
What is the first-line lipid management approach for patients ≤75 with CAD?
Treatment with a high intensity statin (atorvastatin 40 to 80 daily or rosuvastatin 20 to 40 daily).
What is the most appropriate long-term treatment for refractory psoriatic arthritis?
Methotrexate therapy plus a biologic agent.
What should be done when initiating a sodium-glucose cotransporter-2 inhibitor in a patient on a low-dose diuretic?
The next step is to discontinue the diuretic.
How often should an adult 40 to 75 with no ASCVD and not on statins have their lipid levels measured?
Every 4 to 6 years.
When is stent thrombosis most likely to occur?
In the first six months after placement.
What is the next step for an adult aged 40 to 75 with no ASCVD, not on statins, and an LDL of 70 to 189?
The next step is to discontinue the diuretic.
How often should lipid levels be measured in adults aged 40 to 75 with no ASCVD?
Lipid levels should be measured every 4 to 6 years.
When is stent thrombosis most likely to occur?
Stent thrombosis is most likely to occur in the first six months after placement.
What is a characteristic finding in patients with acute aortic insufficiency?
A widened pulse pressure is not detected in patients with acute aortic insufficiency.
What is the minimum duration for dual antiplatelet therapy (DAPT) after placement of a drug-eluting stent following an NSTEMI?
The minimum duration for DAPT is currently 12 months.
What is the minimum duration for DAPT after placement of a bare-metal stent?
The minimum duration for DAPT is 1 month.
What is the first-line therapy for RV infarction complicated by hypotension?
IV normal saline is the first-line therapy.
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
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 three typical signs of right-sided heart failure?
- Elevated JVP
- Pedal edema
- Tricuspid regurgitation
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 does increased JVP with inspiration describe?
Increased JVP with inspiration describes Kussmaul sign.
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 symptoms are highly suggestive of vasovagal syncope?
Tunnel vision and diaphoresis prompted by an emotional stimulus.
What should be done for a patient with symptomatic amiodarone-induced pulmonary toxicity?
Stop the amiodarone and start an oral steroid plus an alternative antiarrhythmic medication.
What does a shock index (HR/SBP) >1 suggest in a patient with massive PE?
It suggests poor hemodynamic reserve and a worse prognosis.
What are indicators of aortic coarctation?
Diminished and delayed pulses of the femoral arteries relative to the brachial arteries.
What are the criteria for successful thrombolysis in STEMI patients?
- Relief of pain
- > 50% resolution in the magnitude of ST segment elevation
- Reperfusion arrhythmias (accelerated idioventricular rhythm)
What are the characteristics of left bundle branch block (LBBB)?
- No R wave in lead V1
- Deep S waves (forming a characteristic W shape)
- Wide notched R waves in leads I, aVL, V5, V6 (forming a characteristic M shape)
- Loss of Q waves in the lateral leads
How soon can high sensitivity cardiac troponin sense serum troponin levels after infarction?
High sensitivity cardiac troponin can sense serum troponin levels as soon as one hour after infarction.
How long should secondary antibiotic prophylaxis continue for a patient with a history of rheumatic heart disease?
Secondary antibiotic prophylaxis should continue for 10 years or until age 40, whichever is longer.
What is the most common inherited bleeding disorder worldwide?
Von Willebrand disease.
When should BP medications be adjusted for patients with elevated BP during hospitalization?
BP medications should not be adjusted until BP has been reassessed outpatient.
What should be on your differential for weight gain, edema, orthopnea, and dyspnea on exertion in a patient?
Heart failure should immediately be on your differential.
What do current guidelines recommend for thrombolytic therapy in STEMI?
Thrombolytic therapy is recommended for STEMI patients who present within 12 hours after symptom onset when PCI cannot be performed within 2 hours.
When should a patient who has undergone PCI for MI undergo an assessment for ICD?
The assessment for ICD should occur no earlier than 3 months after PCI.
What are the normal T wave characteristics in leads V1 and V2?
Normal T waves are upright in leads V1 and V2.
What does DAPT with aspirin and a P2Y12 inhibitor help minimize?
DAPT helps to minimize the risk for stent thrombosis following stent placement.
What are the signs of cardiac tamponade?
- Tachycardia
- Pulsus paradoxus
- Elevated jugular venous pressure
- Faint heart sounds
What is the physical finding most indicative of severe aortic stenosis?
A soft or absent aortic component of the second heart sound.
What is hereditary hemorrhagic telangiectasia?
It is an inherited autosomal dominant disorder associated with AVMs of the brain, skin, liver, and lungs.
What is the initial treatment for nearly all acute idiopathic or viral pericarditis?
NSAIDs with colchicine.
What are the typical leads for T wave inversions and right axis deviation in RV strain?
T wave inversions in leads V1-V3 and right axis deviation are typical of RV strain.
What does intermittent nonconducted P waves with unchanging PR intervals describe?
It describes Mobitz type 2 heart block.
What type of murmur does a VSD have?
A VSD has a harsh systolic murmur at the lower sternal border.
What should be considered for a HFrEF patient at less than 30 percent EF on GDMT for roughly 3 months with minimal or no improvement?
An ICD should be considered.
What do type B aortic dissections involve?
Type B aortic dissections involve the descending aorta or the arch distal to the origin of the left subclavian artery.
What is recommended for patients with severe symptomatic mitral valve regurgitation and CAD?
Concomitant CABG at the time of valve repair surgery is recommended.
What is the risk of sudden cardiac death in Wolff-Parkinson-White patients compared to the general population?
Wolff-Parkinson-White patients have an equal risk of sudden cardiac death as the general population (False).
