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Step 2 CK > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Axis deviation can be a sign of?

A

Ventricular hypertrophy or bundle branch block

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2
Q

How does AV block present?

A

Lengthened PR interval > 200 or a P without a QRS after it.

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3
Q

Left bundle branch block findings?

A

QRS > 120. Deep S wave and no R wave in V1. Wide, tall R waves in I, V5, V6.

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4
Q

Right bundle branch block findings?

A

RSR’ complex (rabbit ears)
Wide R wave in V1.
Wide S waves in I, V5, V6.

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5
Q

Normal axis deviation findings?

A

Positive in lead I and AvF

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6
Q

Left axis deviation findings?

A

Positive in lead I. negative in AvF.

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7
Q

Right axis deviation findings?

A

Negative in lead I. Positive in AvF.

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8
Q

Normal QT interval?

A

Less than 440

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9
Q

Long QT syndrome?

A

Underdiagnosed congenital disorder that predisposes patients to ventricular tachyarrhythmias

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10
Q

ECG change progression found with ischemia?

A

T-wave inversion, progresses to ST segment changes (depression, elevation) and finally Q waves (>40msec or more than 1/3 of the QRS amplitude)

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11
Q

Poor R wave progression can be a sign of?

A

Ischemia (although this is non-specific)

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12
Q

Findings for R atrial enlargement?

A

P-wave amplitude in lead II is > 2.5mm. (P pulmonale- peaked P waves)

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13
Q

Findings for L atrial abnormality?

A

P-wave width in lead two > 120msec or notched P waves in lead II.

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14
Q

LVH findings on ECG

A

Amplitude of S in V1 and R in V5 or V6 is >35mm.

Amplitude of R in aVL + S in V3 > 28 mm in men or 20mm in women.

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15
Q

RVH criteria?

A

right axis deviation and an R wave in V1 > 7mm.

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16
Q

Kussmaul sign?

A

increase in JVP with inspiration. Often seen in cardiac tamponade and constrictive pericarditis.

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17
Q

Name the systolic murmurs.

A 
Aortic stenosis
Mitral regurgitation
Mitral valve prolapse
Flow murmur
Tricuspid regurg
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18
Q

Aortic stenosis radiates to?

A

carotids

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19
Q

Mitral regurg character?

A

holosystolic murmur radiate to axilla

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20
Q

Mitral valve prolapse character?

A

Midsystolic or late systolic murmur with a preceding click.

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21
Q

flow murmur?

A

soft murmur. position dependent (very common and does not imply cardiac disease)

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22
Q

Name the diastolic murmurs.

A

Aortic regurg

mitral stenosis

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23
Q

Aortic regurg character?

A

Early diastolic decrescendo murmur

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24
Q

Mitral stenosis

A

mid/late diastolic, low-pitched murmur with an opening snap

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25
Q

When can an S3 gallop be normal?

A

younger patients and high output states (pregnancy)

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26
Q

S4 gallop can be normal when?

A

younger patients and athletes

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27
Q

Increased or bounding peripheral pulses are a sign of?

A

Compensated aortic regurg

Patent ductus arteriosus

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28
Q

Pulses greater in arms than legs?

A

Coarctation of aorta

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29
Q

Decreased peripheral pulses are sign of?

A

Peripheral artery disease

Late-stage heart failure

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30
Q

Pulsus paradoxus? Seen when?

A

Decreased systolic BP with inspiration. Pericardial tamponade, obstructive lung disease, tension pneumo, foreign body in airway

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31
Q

Pulsus alternans

A

alternating weak and strong pulses. cardiac tamponade, impaired left ventricular systolic function. poor prognosis.

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32
Q

Pulsus parvus et tardus.

A

weak and delayed pulses. Aortic Stenosis.

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33
Q

Management options for afib

ABCD

A

Anticoagulate
B-blockers
C-blockers/cardiovert
Digoxin (refractory cases)

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34
Q

Cha2Ds2Vasc2?

A

score used to estimate stroke risk in patients with afib

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35
Q

What Cha2ds2vasc2 score qualifies patient for anticoagulation?

A

2 or more

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36
Q

Name components of Cha2ds2vasc score and the points given to each?

A 
CHF- 1 point
HTN - 1 point
Age > 75 - 2 points
Diabetes - 1 point
Stroke/Tia hx- 2 point
Vascular dz - 1 point
Age 65-74 - 1 point
sex female- 1 point
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37
Q

ECG with slurred upstroke of QRS? Hx of patient passing out with vigorous physical activity?

A

WPW syndrome. Should advise against physical activity and sign up for electrophysiology study.

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38
Q

cause, symptoms, ecg findings, treatment:

Sinus bradycardia

A

etiology: nml- response to conditioning. sinus node dysfunction. B-blocker or CCB excess.

S: lightheaded, syncope, chest pain, hypotension. can be asymptomatic

ECG: < 60 bpm

Treatment: none if asymp. atropine to increase HR. Pacemaker is definitive treatment in severe cases.

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39
Q

cause, symptoms, ecg findings, treatment:

First-degree AV block

A

E: normal indv. increased vagal tone. b-block, c-block.

S: asymptomatic

ECG: PR interval > 200

Treatment: none

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40
Q

cause, symptoms, ecg findings, treatment:

2nd degree AV block (Mobitz type I/Wenckebach)

A

E: drug effects- digoxin, b-blockers, ccbs) or increase vagal tone, right coronary ischemia or infarction

S: usually asymptomatic

ECG: progressive PR lengthening until dropped beat. PR interval then resets

T: stop drugs. atropine when needed.

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41
Q

cause, symptoms, ecg findings, treatment:

2nd degree AV block (Mobitz type II)

A

E: fibrotic disease of conduction system or from acute, subacute, prior MI

S: syncope- frequent progression to 3rd degree AV block

Ecg: unexpected dropped beats without change in PR interval

T: pacemaker

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42
Q

cause, symptoms, ecg findings, treatment:

Third degree AV block

A

E: no electrical communication between atria and ventricles

S: syncope, dizziness, heart failure, hypotension, cannon a waves

Ecg: no relationship between P and QRS

Treatment: pacemaker

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43
Q

cause, symptoms, ecg findings, treatment:

sick sinus syndrome/tachy-brady syndrome

A

E: intermittent supraventricular tachyarrhythmias and bradyarrhythmias

S: secondary to tachy or brady -> syncope, palpitations, dyspnea, chest pain, TIA, stroke

T: most common indication for pacemaker

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44
Q

cause, symptoms, ecg findings, treatment:

sinus tachy

A

E: normal physiologic response to fear, pain, exercise. secondary to hyperthyroid, volume contraction, infection, PE.

S: palpitations, SOB

EcG: sinus rhythm. Vent rate > 100 bpm.

T: underlying cause

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45
Q

cause, symptoms, ecg findings, treatment:

Atrial fibrillation

A 
E: (PIRATES)
Pulmonary disease
Ischemia
Rheumatic heart
anemia/atrial myxoma
thyrotoxicosis
ethanol
sepsis
chronic AF- HTN, CHF

S: often asymp. SOB, CP, palpitation, irregularly/irreg pulse

ECG: no discernible P waves with variable and irregular QRS response.

T: chronic: Rate control with b-blck, ccbs, digoxin.
anticoag with warfarin for CVasc >2.

unstable or new onset of < 2 days -> cardiovert

new onset > 2 days or unclear, must get TEE to rule out atrial clot

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46
Q

cause, symptoms, ecg findings, treatment:

Aflutter

A

E: circular movement of electrical activity around atrium at 300 bpm

S: usually asymptomatic but can have palpitations, syncope, lightheadedness

Ecg: sawtooth p waves. atrial rate usually 240-320 bpm. vent rate usually 150 bpm.

T: anticoag, rate control, cardiovert guidelines as in afib.

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47
Q

cause, symptoms, ecg findings, treatment:

Multifocal atrial tachy

A

E: multiple atrial pacemakers or reentrant pathways. COPD, hypoxemia

S: may be asymp

Ecg: at least 3 diff p wave morphologies. rate > 100

T: underlying disorder. verapamil or b-block for rate control/suppression of atrial pacemakers (not very effective)

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48
Q

cause, symptoms, ecg findings, treatment:

AVNRT

A

E: reentry circuit in AV node depolarizes the atrium and ventricle nearly simultaneously

S: palpitation, SOB, angina, syncope, lightheaded

ecg: 150-200 bpm. P wave buried in QRS or shortly after

T: cardiovert if hemodynamically unstable. carotid massage, valsalva, adenosine can stop arrhythmia

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49
Q

cause, symptoms, ecg findings, treatment:

AVRT

A

E: ectopic connection between atrium and ventrical that causes reentry circuit (like WPW)

S: palpitation, SOB, angina, syncope, lightheaded

Ecg: retrograde P wave seen after normal QRS. preexcitation delta wave in WPW.

T: cardiovert if hemodynamically unstable. carotid massage, valsalva, adenosine can stop arrhythmia

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50
Q

cause, symptoms, ecg findings, treatment:

Paroxysmal atrial tachycardia

A

E: rapid ectopic pacemaker in atrium (not sinus node)

S: palpitation, SOB, angina, syncope, lightheaded

Ecg: rate > 100. P wave with unusual axis, before each normal QRS

T: adenosine

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51
Q

Name the bradyarrhythmias and conduction abnormalities?

A
  1. sinus brady
  2. first degree AV block
  3. second degree AV block (Mobitz I/Wenckebach)
  4. Second degree AV block Mobitz II
  5. Third degree AV block
  6. Sick Sinus Syndrome (tachy-brady syndrome)
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52
Q

List the supraventricular tachyarrhythmias

A
  1. sinus tach
  2. AF
  3. Aflutter
  4. multifocal atrial tachy
  5. AVNRT
  6. AVRT
  7. Paroxysmal atrial tachy
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53
Q

List the ventricular tachyarrhythmias

A
  1. PVCs
  2. WPW
  3. Vtach
  4. Vfib
  5. Torsades de pointes
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54
Q

cause, symptoms, ecg findings, treatment:

PVC

A

cause: ectopic beats arise from ventricular foci. associated with hypoxia, electrolyte abnormalities, hyperthyroid

S: usually asymp

Ecg: early, wide QRS not preceded by P wave. usually followed by a pause.

T: if symptomatic give B-block. treat underlying cause.

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55
Q

cause, symptoms, ecg findings, treatment:

WPW

A

E: abnormal fast accessory pathway from atria to ventricle

S: palpitations, SOB, dizzy, rarely cardiac death

Ecg: characteristic delta wave with wide QRS and short PR

T: obs for asymp patients

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56
Q

cause, symptoms, ecg findings, treatment:

VT

A

E: ass with CAD, MI, structural heart disease

S: < 30 sec often asymp
>30 sec- palpitation, hypotension, angina, syncope - can progress to vfib and death

Ecg: three or more consec PVCs, wide QRS in regular rapid rhythm. can see AV dissociation

T: cardioversion if unstable. amiodorone, lidocaine, procainamide

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57
Q

cause, symptoms, ecg findings, treatment:

VF

A

E: ass with CAD, structural heart disease, cardiac arrest.

S: syncope, absence of pulse and BP

ecg: totally erratic wide complex tracing

T: immediate electrical defibrillation and ACLS protocol

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58
Q

cause, symptoms, ecg findings, treatment:

Torsades

A

E: associated with long QT syndrome, proarrhythmic response to meds, hypokalemia, congenital deafness, alcoholism

E: sudden cardiac death, palpitations, dizzy, syncope

ecg: polymorphous QRS, VT with rates 150-250

T: mag initially. cardiovert if unstable. correct hypokalemia. stop drugs.

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59
Q

What is the ejection fraction in systolic heart failure?

A

EF < 50%

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60
Q

What is the earliest presenting symptom of heart failure?

A

exertional dyspnea

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61
Q

Do diuretics and digoxin have a mortality benefit for CHF patients?

A

No- symptomatic relief only

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62
Q

BNP level of __ may help support CHF?

A

> 500

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63
Q

Stages of NYHA CHF I-IV?

A

I: no limitation of activity; no symptoms with nml activity
II: slight limitation of activity, comfy at rest or with mild exertion
III: marked limitation of activity, comfy ONLY at rest
IV: any physical activity like walking brings on discomfort. symptoms at rest**

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64
Q

Acute CHF management

LMNOP

A 
L-lasix (furosemide) 
M-morphine
N-nitrates
O-oxygen
P-position upright
(dont forget ACE inhibitor or ARB)
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65
Q

Loop diuretics ____ calcium. Thiazides ____ calcium.

A

Loops lose calcium

Thiazides take calcium in

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66
Q

Pharm therapy for acute CHF

A

Loop diuretics, ACE or ARB

Avoid B-block during decompensated CHF but restart once euvolemic

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67
Q

Treatment for chronic CHF

A

Lifestyle- limit dietary sodium and fluid intake
Pharm:
-B-block, ACE/ARB (help prevent remodeling and decrease mortality for NYHA class II-IV. Avoid CCBs (can worsen edema) )
-Loops
-Spironolactone (shown to decrease mortality risk in patients with NYHA class III-IV CHF.
-Daily ASA and statin if underlying cause is prior MI

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68
Q

Advanced treatments for chronic CHF

A

Implantable cardiac defibrillator (ICD): In patients with an EF < 35%

Left ventricular assist device (LVAD) or cardiac transplant may be needed if patients are unresponsive to max medical therapy

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69
Q

Is digoxin useful in non-systolic heart failure patients?

A

NO

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70
Q

Loop diuretic side effects?

A

ototoxicity, hypokalemia, hypocalcemia, dehydration, gout

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71
Q

Thiazide diuretic side effects

A

hypokalemic metabolic alkalosis, hyponatremia, hyperglycemia, hyperlipidemia, hyperuricemia, hypercalcemia

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72
Q

K sparing diuretics (Spironolactone)

side effects

A

Hyperkalemia, gynecomastia, sexual dysfunction

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73
Q

carbonic anhydrase inhibitor (acetazolamide) side effects

A

hyperchloremic metabolic acidosis, neuropathy, NH3 toxicity, sulfa allergy

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74
Q

osmotic agents (mannitol) side effects

A

pulmonary edema, dehydration. Contraindicated in anuria and CHF.

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75
Q

3 types of cardiomyopathy?

A

Dilated, hypertrophic, restrictive

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76
Q

What must be present to make diagnosis of dilated cardiomyopathy?

A

left ventricular dilation and decreased ejection fraction.

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77
Q

Causes of dilated cardiomyopathy? What is most common cause?

A

Most idiopathic. 2dary causes are alcoholic, myocarditis, postpartum status, drugs (doxorubicin, AZT, cocaine), endocrinopathies (thyroid, acromegaly, pheochromocytoma), infection (coxsackievirus, HIV, Chagas, parasites), genetic factors, nutrition (wet beriberi), ischemia, long standing HTN

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78
Q

Most common causes of secondary dilated cardiomyopathy?

A

Ischemia, HTN

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79
Q

How to diagnose dilated cardiomyopathy?

A

Echo is diagnostic

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80
Q

Most common cause of sudden death in young healthy athletes in US?

A

HOCM

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81
Q

how is HOCM inherited

A

autosomal dominant trait in 50% of HOCM patients

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82
Q

Causes of hypertrophic cardiomyopathy?

A

HOCM, HTN, aortic stenosis

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83
Q

Key finding for hypertrophic obstructive cardiomyopathy on physical exam?

A

systolic ejection crescendo-decrescendo murmur that increases with a decrease in preload (valsalva, standing)

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84
Q

Treatment of hypertrophic obstructive cardiomyopathy

A

b-blockers are initial therapy. ccbs secondary. surgery for hocm exists

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85
Q

Restrictive cardiomyopathy

A

decreased elasticity of myocardium leading to impaired diastolic filling

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86
Q

causes of restrictive cardiomyopathy

A

infiltrative disease. amyloidosis, sarcoidosis, hemochromotosis. Or by scarring, fibrosis. 2ndary to radiation

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87
Q

Do signs/symptoms or right sided or left sided HF predominant with restrictive cardiomyopathy?

A

Right sided HF signs. Typically both left and right heart failure are occuring.

EF is normal or decreased

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88
Q

How can you further characterize cause of restrictive cardiomyopathy after diagnosing on echo?

A

C-xray, mri, cardiac cath can help identify sarcoid, amyloid, etc. cardiac biopsy.

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89
Q

What will ECG show in patients with amyloidosis?

A

low voltage ECG

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90
Q

Therapy for restrictive cardiomyopathy

A

limited. palliation only. cautious diuretic use. use of vasodilators to reduce filling pressure.

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91
Q

Risk factors for CAD

A

DM, Family history of early CAD <55 men, <65 women, smoking, dyslipidemia, abdominal obesity, htn, age (males>45, female >55), male gender

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92
Q

Major risk factors for CAD

A

age, male gender, high LDL, low HDL, HTN, family history, smoking

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93
Q

Major risk factors for CAD

A

age, male gender, high LDL, low HDL, HTN, family history, smoking

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94
Q

ST segment elevation in abscence of cardiac enzyme elevation in a young woman?

A

prinzmetal variant angina

coronary artery vasospasm

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95
Q

when is a stress test contraindicated?

A

patients with abnormal baseline ECGs.

do not perform stress tests on asymptomatic patients with low pretest probability of disease

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96
Q

Common causes of chest pain?

A

GERD, angina, esophagitis, costochondritis, trauma, pneumonia, anxiety

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97
Q

What confirms diagnosis of GERD?

A

relief of symptoms after PPI use

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98
Q

msk/costochondritis pain described as?

A

tender to palpation and movement

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99
Q

Pneumonia/pleuritis pain

A

worsening with breathing (pleuritic)

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100
Q

What 2 drugs have been shown to have mortality benefit in treatment of angina

A

ASA and B-blockers

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101
Q

Treatment for chronic/stable angina?

A

ASA, b-block, nitroglycerin

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102
Q

Is hormone replacement therapy protective against CAD in post-menopausal women?

A

NO

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103
Q

Unstable angina

A

chest pain that is
1. new onset 2. accelerating
(occurs with less exertion, lasts longer, less responsive to meds)
3. occurs at rest

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104
Q

stable angina

A

exertion only

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105
Q

unstable angina signals presence of possible ____

A

impending infarction based on plaque instability

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106
Q

NSTEMI

A

indicates myocardial necrosis marked by elevations in troponinI and CK-MB isoenzyme without ST seg elevations

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107
Q

Enzyme elevations present in unstable angina?

A

NO

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108
Q

How do you risk stratify patients for MI?

A

TIMI score

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109
Q

Treatment of acute angina symptoms

A

ASA, O2, IV nitro, IV morphine.

consider B-blockers later as hemodynamics allow.

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110
Q

What do you receive points for in the TIMI score for unstable angina/NSTEMI

A 
History
Age > 65
Three or more CAD risk factors
Known CAD stenosis > 50%
ASA use in past 7 days

Presentation
Severe angina (2 or more episodes in 24 hours)
ST deviation >.5mm
+cardiac marker

Score out of 7

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111
Q

What should you do if patients have chest pain refractory to meds and a TIMI score > 3?

A

Give IV heparin, schedule for angio and possible revasc (PCI or CABG)

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112
Q

Acute MI treatment

(MOAN)ing from an MI

A

Morphine
Oxygen
ASA
Nitro

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113
Q

What is the best predictor of survival after an ST-elevation MI?

A

left ventricular EF

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114
Q

What will ECG show with an MI?

A

ST seg elevations or new LBBB. ST seg depressions with dominant R waves in leads V1-V2 can also be reciprical changes indicating posterior wall infarct.

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115
Q

Sequence of ECG changes with MI?

A

peaked T waves, ST seg elevation, Q wave, T wave inversion, ST normalization, T wave normalization over hours/days.

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116
Q

What is the most sensitive/specific cardiac enzyme?

A

troponin I

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117
Q

Who may have clinically silent or atypical MIs

A

women, elderly, diabetics, post-heart transplant patients

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118
Q

What enzyme will help measure reinfarction?

A

CK-MB

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119
Q

Ecg findings for inferior MI?

A

ST seg elevations in II, III, avF. (RCA and PDA).

Obtain right sided ECG to look for ST elevation in right ventricle

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120
Q

Anterior MI ecg findings

A

st elevation in V1-V4 (LAD)

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121
Q

Lateral MI ecg findings

A

ST seg elevation in I, avL, V5-V6

LCX atery

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122
Q

Posterior MI

A

st seg depression in V1-V2 (anterior leads0

Obtain posterior ecg leads V7-V9 to assess for ST segment elevations

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123
Q

If patient is in heart failure post MI, what should you give instead of b-block (assuming patient not hypotensive)

A

ACE-Inh

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124
Q

In inferior wall MI, avoid?

A

nitrates

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125
Q

Indications for CABG

A

Unable to perform PCI (disease diffuse)
Left main coronary artery disease
Triple vessel disease
Depressed ventricle function

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126
Q

Interventions for MI?

A

Emergent angio and PCI should be performed if possible

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127
Q

PCI should be performed within _____ minutes?

A

90

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128
Q

contraindications to thrombolysis?

A

hx hemorrhagic stroke, ischemic stroke, heart failure, cardiogenic shock)

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129
Q

If patient presents within ____ hours of chest pain, thrombolysis with tPA, reteplase or streptokinase should be performed instead of PCI.

A

3 hours

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130
Q

Long term treatment post-MI includes?

A

ASA, AceInhibitors, B-blockers, high dose statins, (LDL < 100), clopidogrel (if PCI was performed)

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131
Q

most common complication and most common cause of death following acute MI?

A

arrhythmias

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132
Q

Timeline of common post-MI complications

A

Day 1: heart failure
Day 2-4: arrhythmia, pericarditis
5-10: left ventricular wall rupture (pericardial tamponade, papillary muscle rupture-mitral regurg)
Weeks/months: ventricular aneurysm (CHF,arrhythmia, mitral regurg, thrombus)

133
Q

Dressler Syndrome

A

autoimmune process occuring 2-10 weeks post MI

presenting with fever, pericarditis, pleural effusion, leukocytosis, elevated ESR

134
Q

Dyslipidemia?

A

Total cholesterol > 200
LDL > 130
TGs > 150
HDL < 40

135
Q

Causes of dyslipidemia?

A

obesity, alcoholism, DM, hypothyroid, nephrotic syndrome, hepatic disease, cushings, OCP use, high dose diuretics, familial

136
Q

Xanthomas

A

(eruptive nodules in skin over the tendons)- caused by very high LDL or TG

137
Q

Xanthelasmas

A

yellow fatty deposits in skin around eyes

138
Q

Lipemia retinalis

A

creamy appearance of retinal vessels

139
Q

Screening for hyperlipidemia?

A

fasting lipid screen for patients > 35 or in those > 20 with CAD risk factors.

Repeat every 5 years or sooner if lipid levels are elevated.

140
Q

Diagnosis for hyperlipidemia?

A

Total cholesterol >200 on two diff occasions.

LDL > 130 or HDL < 40 is diagnostic of dyslipidemia even if total is < 200

141
Q

treatment for hyperlipidemia is based on?

A

is based on risk stratification using risk calculator

142
Q

For patients with history of CAD, CVA or PAD use what med?

A

high intensity statin

143
Q

Patients with LDL between 70-189 without diabetes how do you treat?

A

Choose high, moderate or low intensity statin based on risk factors

144
Q

Patients with LDL between 70-189 with diabetes treat with?

A

choose high or moderate based on risk factors

145
Q

LDL > 190 treat with?

A

high intensity statin

146
Q

First intervention for hyperlipidemia for patient with no risk factors for atherosclerotic disease?

A

12 week trial of diet/exercise

147
Q

List the common lipid lowering agents

A

Statins, Fibrates, Niacin, Bile acid resins, cholesterol absorption inhibitors

148
Q

mechanism, effect, side effects? Statins

A

HMG-CoA reductase inhibitors
decrease LDL, decrease Tgs

SE: increase LFT, myositis, warfarin potentiation

149
Q

mechanism, effect, side effects? Gemfibrozil

A

Fibrate: Lipoprotein lipase stimulator. Decrease TGs, increase HDL**

SE: GI upset, cholelithiasis, myositis, increased LFTs

150
Q

mechanism, effect, side effects? Ezetimibe

A

Cholesterol absorption inhibitors. Decrease LDL.

SE: diarrhea, abdominal pain. angioedema.

151
Q

mechanism, effect, side effects? Niacin

A

Increase HDL**, lower LDL

SE: skin flushing (ASA can prevent this), paresthesias, puritis, GI upset, elevated LFTs

152
Q

mechanism, effect, side effects? cholestyramine, colestipol

A

Bile acid resins, decrease HDL

SE: constipation, GI upset, LFT elevated, myalgias. Can decrease absorption of other drugs from small Intestine.

153
Q

HTN definition/diagnosis?

A

BP > 140 and or diastolic BP > 90 based on 3 measurements separated in time in patients < 60

154
Q

How do you define HTN in patients >60 without diabetes or CKD?

A

> 150 or diastolic >90

155
Q

Risk factors for primary essential htn

A

family history htn or heart disease, high sodium diet, smoking, obesity, ethnicity (black >white), advanced age

156
Q

What labs should you order to work up patient for HTN?

A

urinalysis, BUN/Cr, electrolytes

157
Q

Treatment of HTN

A

lifestyle mod

BP goals vary by age and comorbidities

158
Q

Pharm treatment of HTN?

A

Ace/Arb
B-block
CCB
Diuretic (particularly thiazide)

159
Q

What drugs have been shown to decrease mortality in uncomplicated HTN?

A

diuretics, CCB, AceI, b-blocker

160
Q

When to initiate treatment/what are treatment goals for >60?

A

> 150 / > 90 initiate treatment

<150 / <90 treatment goals

161
Q

When to initiate treatment/what are treatment goals for <60?

A

> 140 and >90 initiate

<140 and < 90 goal

162
Q

When to initiate treatment/what are treatment goals for > 18 with CKD or diabetes?

A

> 140 / >90 initiate

<140 / <90 goal

163
Q

Woman found with pulseless electrical activity on hospital day 7 after suffering lateral wall STEMI. ACLS initiated. Next step?

A

Patient has likely suffered ventricular wall rupture with acute cardiac tamponade. emergent pericardiocentesis is next best step

164
Q

Pharm Treatment of HTN in uncomplicated patients?

A

diuretic, ccb, ace inhibitor

165
Q

Pharm Treatment of HTN in CHF?

A

diuretic, b-block, ace, arb, aldo antag

166
Q

Pharm Treatment of HTN in DM?

A

diuretics, b-block, ace, arb, ccb

167
Q

Pharm Treatment of HTN in post-MI?

A

b-block, ace, arb, aldo antag

168
Q

Pharm Treatment of HTN in CKD?

169
Q

Pharm Treatment of HTN in BPH?

A

diuretics, a-adrenergic blockers

170
Q

Pharm Treatment of HTN in isolated systolic htn?

A

diuretic, aceI, ccb

171
Q

Pharm Treatment of HTN in pregnancy?

A

b-blockers (labetalol), hydralazine

172
Q

Causes of 2ndary htn?

CHAPS

A 
C-cushing syndrome
H-hyperaldosteronism (conn)
A- aortic coarctation
P-pheo
S- stenosis of renal artery
173
Q

htn emergencies are diagnosed based on?

A

extent of end organ damage. NOT BP

174
Q

When to worry about htn crises

A

BP > 180/120

175
Q

how will patients with htn emergency present?

A

end organ damage revealed by acute kidney injury, chest pain (ischemia, MI), back pain (dissection), changes in mental status (hypertensive encephalopathy)

176
Q

htn urgency

A

elevated BP with mild to moderate symptoms (headache, chest pain) without end organ damage

177
Q

htn emergency

A

elevated BP with signs/symptoms of impeding organ damage

178
Q

Treatment for htn urgency?

A

oral anti-htn (b-block, clonidine, Ace) with goal of gradual lowering over 24-48 hours

179
Q

treatment for htn emergency?

A

IV meds (labetalol, nitroprusside, nicardipine) with goal of lowering MAP by no more than 25% over first 2 hours to prevent cerebral hypoperfusion

180
Q

Cause of renal artery stenosis in younger patients?

A

fibromuscular dysplasia

181
Q

Why dont we give ACE-Inh in patients with bilateral renal artery stenosis?

A

can accelerate kidney failure by preferential vasodilation of efferent arteriole.

182
Q

Causes of pericarditis?

A

most common- idiopathic

viral, TB, SLE, uremia, drugs, radiation, neoplasm, post-mI, Dressler syndrome, aortic dissection, rheumatic fever

183
Q

Presentation of pericarditis?

A

pleuritic chest pain, dyspnea, cough, fever

184
Q

How does position affect pain in pericarditis?

A

Pain worsens in supine position and with inspiration. classic patient seen sitting up and bending forward.

185
Q

Physical exam findings for pericarditis?

A

pericardial friction rub. elevated JVP and pulsus paradoxus (decrease in systolic BP >10 on inspiration)

186
Q

Initial tests in diagnosis of pericarditis?

A

CXR, ECG, echo to rule out MI and pneumonia

187
Q

ECG changes for pericarditis?

A

diffuse ST-segment elevation and PR-segment depressions followed by T wave inversions

188
Q

How to treat pericarditis?

A

underlying cause

steroids for SLE
dialysis for uremia
ASA for post- MI
ASA NSAIDs for viral

189
Q

why avoid steroids within a few days after MI?

A

predispose to ventricular wall rupture

190
Q

when is pericardiocentesis required?

A

evidence of cardiac tamponade. effusions without symptoms can be monitored.

191
Q

cardiac tamponade

A

excess fluid in pericardial sac leading to compromised ventricle filling and decreased cardiac output.

192
Q

risk factors for tamponade

A

pericarditis, malignancy, SLE, TB, trauma (stab wounds medial to left nipple)

193
Q

What triad can diagnose acute cardiac tamponade?

A

Beck triad

JVD, hypotension, distant heart sounds

194
Q

For cardiac tamponade what do echo, cxray and ecg show?

A

echo: right atrial and right ventricle diastolic collapse
cxr: enlarged, globular, water-bottle heart
ecg: electrical alternans

195
Q

Treatment of cardiac tamponade

A

aggressive volume expansion with IV fluids
urgent pericardiocentesis
decompensating patient -> go to pericardial window

196
Q

When does a triple AAA require surgical repair?

197
Q

Aortic aneurysm

A

greater than 50% dilatation of all three layers of aortic wall.

198
Q

Aneurysms are most commonly associated with what vascular pathology?

A

Atherosclerosis

199
Q

Most aortic aneurysms originate?

A

abdominal, below renal arteries

200
Q

Are aortic aneurysms typically symptomatic?

201
Q

on physical exam?

A

pulsatile abdominal mass or abdominal bruits

202
Q

risk factors for aortic aneurysm

A

htn, high cholesterol, fam hx, smoking, male, age

203
Q

ruptured aneurysm signs/symptoms?

A

hypotension and severe tearing abdominal pain that radiates to back

204
Q

screening for AA?

A

all men 65-75 with history of smoking

205
Q

surgical repair for thoracic AAA is indicated for ____ cm?

A

6 cm or smaller but rapidly enlarging

206
Q

aortic aneurysm is most often linked to ______ where as aortic dissection is most often linked to _____?

A

aneurysm: atherosclerosis
dissection: HTN

207
Q

What are indications for valve replacement in patients with aortic stenosis?

A

symptoms of ACS, angina, CHF, syncope

208
Q

most common etiology of mitral valve stenosis

A

rheumatic fever

209
Q

primary cause of mitral valve prolapse

A

rheumatic fever or chordea tendineae rupture post MI. also infectious endocarditis.

210
Q

Causes of acute aortic regurg?

A

infective endocarditis, aortic dissection, chest trauma

211
Q

causes of chronic aortic regurg?

A

valve malformation, rheumatic fever, connective tissue disease

212
Q

head bob and water hammer pulses are seen with?

A

aortic regurg

213
Q

treatment for aortic regurg?

A

vasodilator therapy (dihydropyridines or ACE-In)

214
Q

treatment for mitral valve regurg?

A

antiarrhythmics if necessary as afib is common with LAE. nitrates and diuretics to decrease preload

215
Q

most common sites for aortic dissection?

A

above aortic valve and distal to left subclavian artery

216
Q

presentation of aortic dissection?

A

sudden tearing, ripping pain in chest or back. typically htn. asymmetric pulses and BP measurements. aortic regurg murmur may be heard. neuro deficits possible if aortic arch or spinal arteries involved

217
Q

presentation of ruptured aortic aneurysm

A

hypotension, severe, tearing abdominal pain radiating to back

218
Q

gold standard for imaging for aortic dissection?

A

CT angiography

219
Q

Treatment for dissection?

A

manage BP and heart rate. avoid thrombolytics. begin B-blockade before vasodilators to prevent reflex tachycardia.

220
Q

If dissection involves ascending aorta?

A

surgical emergency

221
Q

Virchow triad

A

hemostasis, trauma(endothelial damage), hypercoaguability

222
Q

diagnosis of DVT?

A

dopplar ultrasound

223
Q

diagnosis of PE?

A

spiral CT or V/Q scan

224
Q

How can d-dimer be used to eval for PE?

A
  • d-dimer test can be used to rule out possibility of PE in a low risk patient
225
Q

treatment for DVT?

A

anticoagulate with IV unfrac heparin or subcu low molecular weight heparin followed by PO warfarin for a total of 3-6 months

226
Q

For patients with DVT and contraindications to anticoagulation what should you do?

A

IVC filters

227
Q

The 6 P’s of acute ischemia

A 
Pain
Pallor
Paralysis
Pulse deficit
Paresthesias
Poikilothermia
228
Q

rest pain usually occurs with an ABI of ?

229
Q

ABI =

230
Q

normal ABI?

231
Q

pharm treatment for peripheral vascular disease?

A

ASA, cilostazol, thromboxane inhibitors

232
Q

immigrant presents with progressive swelling of lower extremities bilaterally with no cardiac abnormalities?

A

lymphedema. filariasis infection

233
Q

children present with progressive bilateral swelling of extremities

A

primary (congenital) lymphedema

234
Q

Are diuretics effective for lyphedema?

235
Q

patients with lyphedema are at higher risk for?

A

cellulitis infection. prophylactic antibiotic coverage will be helpful

236
Q

cardiac related syncope is associated with 1 year sudden cardiac death rates of up to?

237
Q

amiodorone

A

class III antiarrhythmic used for management of ventricular arrhythmias in patients with coronary artery disease and ischemic cardiomyopathy

238
Q

side effects of amiodorone

A

chronic interstitial pneumonitis, hypo/hyperthyroidism.
GI/hepatic- elevated transaminases, hepatitis. corneal microdeposits. optic neuropathy. blue-gray skin discoloration. peripheral neuropathy. heart block, sinus brady, prolong QT-torsades.

239
Q

Pulmonary toxicity from amiodorone use correlates with total cumulative dose. True or false?

240
Q

What tests should be done before initiating amiodorone?

A

PFT, cxray

241
Q

westermark’s sign

A

sign seen in cxray of patient with PE. collapse of a vessel distal to PE

(peripheral hyperlucency due to oligemia (hypovolemia))

242
Q

hampton’s hump sign

A

peripheral wedge of opacity in lung due to pulmonary infarct likely from PE.

243
Q

Fleischner sign

A

enlarged pulmonary atery

244
Q

peptic ulcer perforation presents with?

A

acute abdominal pain with radiation to the back or the shoulder with signs of peritonitis and likely to see free air under diaphragm on cxray

245
Q

Marfans

A

autosomal dominant due to mutations in extracellular matrix protein fibrillin-1

246
Q

cardiac manifestations of marfans

A

aortic dissection, aortic regurg, mitral valve prolapse

247
Q

wide fixed splitting of S2

248
Q

Holt-Oram (heart-hand syndrome)

A

Upper limb defects (radius, carpal deformities and ASD)

249
Q

All patients with new onset afib should have what hormone checked?

250
Q

Management of STEMI

A
  1. Oxygen for O2 sat < 90%
  2. Nitrates
  3. ASA / Clopidogrel
  4. Anticoag
  5. B-block (not in heart failure)
  6. Prompt perfusion with PCI (ideal if less than 90 minutes to balloon)
  7. statin
251
Q

Current guidelines recommend PCI for patients with acute STEMI as follows:

A
  • within 12 hours of symptom onset
  • within 90 minutes door to balloon at PCI facility
  • within 120 minutes from first medical contact at non-PCI facility
252
Q

systemic atheroembolism

systemic crystal embolism

A

aortic atherosclerotic plaques can lead to systemic emboli (can be spontaneous but is more common with vascular procedures)

253
Q

Typical symptoms of systemic cholesterol emobilization

A

acute/subacute renal failure, GI pain, skin manifestations (livedo reticularis

254
Q

What will labs show for systemic atheroembolism?

A

EOSINOPHILIA, hypocomplementemia

elevated BUN/Cr with few cells/casts

255
Q

What is the sensitivity of BNP for diagnosing CHF?

256
Q

Most patients with CHF have plasma BNP levels greater than ?

257
Q

BNP levels less than ____ have a negative predictive value for CHF

258
Q

sensitivity of cardiomegaly on cxray?

259
Q

Clinical signs of CHF (JVD, lower ext edema, lung crackles) have high sensitivity or specificity?

A

specificity

260
Q

systolic murmur at sternal border that increases with inspiration?

A

tricuspic regurg

261
Q

Isolated systolic hypertension

A

systolic BP > 140 with normal diastolic <90

262
Q

ISH is associated with?

A

severalfold increase in risk of cardiovascular morbidity/mortality

263
Q

Pathophysiology of isolated systolic BP?

A

increased stiffness, decreased elasticity of aortic and arterial walls in elderly patients

264
Q

tachy-mediated cardiomyopathy

A

variety of tachyarrhythmias can cause structural changes in the heart if they are prolonged. including LV dilation and myocardial dysfunction

265
Q

how do you treat tachy-mediated cardiomyopathy?

A

aggressive rate control and restoration of normal sinus rhythm

266
Q

An important side effect to keep in mind for dihydropyridine Ca channel antagonists like amlodipine?

A

Peripheral edema! due to dilation of peripheral blood vessels

267
Q

cardiac non caseating granulomas?

A

sarcoidosis

268
Q

most common complication of cardiac sarcoidosis?

A

conduction defects. complete AV block is most common.

269
Q

Who is at increased risk of developing peri-infarction pericarditis?

A

patients with delayed coronary reperfusion following ST-elevation MI

270
Q

Treatment of peri-infarct pericarditis?

A

supportive

271
Q

Inability to palpate the PMI is consistent with?

A

Large pericardial effusion

272
Q

Pulsus bisferiens (biphasic pulse)

A

2 strong systolic peaks of the aortic pulse from the left ventricular ejection separated by midsystolic dip. (patients with siginificant AORTIC REGURG)

273
Q

enlarged water bottle shaped cardiac silhouette

A

pericardial effusion

274
Q

Presentation of fibromuscular dysplasia

A

90% women (adults)

  1. internal carotid artery stenosis
    - recurrent HA
    - pulsatile tinnitus
    - TIA
    - stroke
  2. Renal artery stenosis
    - 2ndary htn
    - flank pain
275
Q

What may you find on PE in women with fibromuscular dysplasia?

A
  • subauricular systolic bruit

- abdominal bruit

276
Q

how to diagnose fibromuscular dysplasia?

A

duplex US, CTA, MRA

catheter based arteriography

277
Q

treatment for fibromuscular dysplasia?

A

ACE or ARB - 1st line
PTA (percutaneous transluminal angioplasty)
Surgery (if PTA doesn’t work)

278
Q

fibromuscular dysplasia may lead to?

A

arterial stenosis, aneurysm, dissection

279
Q

aortic coarctation presents with?

A

upper extremity htn. HA. LE claudication.

280
Q

SLE is a known risk factor for?

A

accelerated atherosclerosis and premature coronary heart disease

281
Q

______ is recommended as an initial test for diagnosis and risk stratification of most patients with suspected stable angina

A

Exercise ECG

282
Q

_______ is performed in patients with high risk findings on cardiac stress testing

A

coronary angiography

283
Q

Secondary amyloidosis can be caused by the following conditions:

A 
Inflammatory arthritis
Chronic infection 
IBD
Malignancy
Vasculitis
284
Q

Amyloidosis diagnosis

A

abdominal fat pad aspiration

285
Q

amyloidosis presentation

A
  • asymptomatic proteinuria or nephrotic syndrome
  • restrictive cardiomyopathy
  • hepatomegaly
  • peripheral neuropathy
  • visible organ enlargement (macroglossia)
  • bleeding diathesis
  • waxy thickening, easy bruising of skin
  • orthostatic hypotension
286
Q

Cardiac amyloidosis should be suspected in patients with ____ findings on ECG? echo?

A

low voltage ECG

Echo shows increased ventricular wall thickness with normal LV cavity

287
Q

Be particularly suspicious of amyloidosis in patients with

A

CHF, diastolic dysfunction and without HTN

288
Q

Alcoholic cardiomyopathy is dilated or concentric?

289
Q

patients with hemochromatosis can develop dilated or concentric cardiomyopathy?

290
Q

Systemic symptoms of hemochromotosis

A

cardiomyopathy (dilated)
liver disease hepatomegaly, LFT elevated, cirrhosis
Arthropathy
Skin pigmentation
DM
hypogonadism
decreased libido and erectile dysfunction in men

291
Q

systemic symptoms of sarcoidosis

A 
heart failure (systolic or diastolic)
hilar adenopathy
reticular opacities
erythema nodosum
uveitis
292
Q

Common causes of cor pulmonale

A

COPD
ILD
Pulm vasc disease (thromboembolic)
Obstructive sleep apnea

293
Q

What might you find on ECG for a patient with cor pulmonale

A
  • partial or complete RBBB
  • right axis deviation
  • RVH
  • Right atrial enlargement
294
Q

Echo findings in cor pulmonale?

A
  • Pulm HTN
  • dilated right ventricle
  • tricuspid regurg
295
Q

Gold standard for diagnosis of cor pulmonale?

A

Right heart catheterization - showing right ventricular dysfunction, pulm htn, no left heart diease

296
Q

cor pulmonale

A

impaired function of right ventricle caused by pulmonary htn (right ventricular heart dysfunction due to left heart disease or congenital disease is not cor pulmonale)

297
Q

holosytolic murmur at left sternal border that changes with inspiration?

A

tricuspid regurg

298
Q

Right heart cath in patient with cor pulmonale will show?

A

elevated pulmonary artery pressure >25

299
Q

PCWP is an estimation of?

A

left ventricular end diastolic pressure

300
Q

PCWP is elevated in patients with? Will have what physical exam finding typically>

A

LV systolic or end diastolic dysfunction.

Pulmonary edema

301
Q

In addition to standard MI therapy, patients with inferior wall MIs are also typically treated with? Why?

A

IV fluid boluses due to decreased preload and resulting hypotension with RV dysfunction

302
Q

S1Q3T3 pattern?

A

Pulmonary embolism

303
Q

Ascending aortic aneurysms are most often due to?

A

cystic medial necrosis that occurs with aging or connective tissue disorders (marfan, ehlers danlos)

304
Q

What is more common- ascending aortic aneurysms or descending?

A

Ascending (60%)

Descending (40%)

305
Q

Descending aortic aneurysms are usually due to?

A

atherosclerosis

htn, hypercholesterolemia, smoking are risk factors

306
Q

Risk factors for aortic dissection?

A

HTN
Marfan
Cocaine

307
Q

Type A ascending aortic dissections can lead to aortic rupture into the?

A

pericardial space-> can rapidly progress to cardiac tamponade and cardiogenic shock

308
Q

pulse differential blood pressure should make you think of?

A

aortic dissection

309
Q

Diagnostic study of choice in hemodynamically stable patients without kidney injury where you suspect aortic dissection?

A

CT angiography

310
Q

What test should you order for suspected aortic dissection in patients with hemodynamic instability and kidney injury?

A

transesophageal echo

311
Q

Should you use B-blockers in patients with acute aortic dissection?

A

YES- to lower systolic blood pressure

312
Q

Should you use anticoagulation in patients with aortic dissection?

313
Q

Three most common causes of aortic stenosis in general population?

A
  1. senile calcific aortic stenosis
  2. bicuspid aortic valve
  3. rheumatic heart disease
314
Q

Myxomatous valve degeneration causes?

A

mitral valve prolapse

315
Q

regular narrow complex tachycardia =

A

supraventricular tachycardia

316
Q

All patients with persistent tachyarrhythmia (narrow or wide) causing hemodynamic instability should be managed with?

A

immediate synchronized direct current cardioversion

317
Q

For patients with stable, recurrent or refractory wide-complex tachy what therapy can be used?

A

procainamide, amiodorone

318
Q

When is unsynchronized cardioversion (defibrillation) used?

A

resuscitation efforts in patients with pulseless cardiac arrest (with vfib, vtach)

319
Q

Leriche syndrome

A

Aortoiliac occlusion (characterized by triad of bilateral hip, thigh, buttock claudication, impotence, symmetric atrophy of bilateral lower extremities due to chronic ischemia)

320
Q

Pacemaker placement can cause complications to which valve?

A

Tricuspid valve

321
Q

most common organism for infectious endocarditis?

A

staph aureus

322
Q

Which valve is most common for endocarditis in IV drug users?

A

Tricuspid valve

323
Q

numerous round alveolar infiltrates on cxray in an IV drug user with cough, chest pain, hemoptysis should make you suspicious for?

A

Tricuspid endocarditis -> septic pulmonary emboli

324
Q

cardiac index =

A

cardiac output/body surface area

325
Q

how do you treat viral or idiopathic pericarditis?

A

NSAIDs + colchicine

326
Q

Which type of pericarditis does not typically cause diffuse ST elevation?

A

Uremic pericarditis

327
Q

how to differentiate pericardial friction rub from pleuritic friction rub due to viral pleurisy?

A

pleural friction rub will disappear with breath holding

328
Q

Advanced renal failure- BUN is?

A

BUN > 60 requires dialysis

Step 2 CK (26 decks)

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