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Step3 > Cardiology > Flashcards

Cardiology Flashcards

1
Q

IHD

The single most dangerous factor for cad

A

The single most dangerous factor for cad is diabetes

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2
Q

Physical exam for cp

A

CV: S3: dilated left ventricle
S4: LVH
Jugulovenous distention**
Holosystolic murmur of mitral regurgitation

Chest rakes
General. Distressed, sob, clutching chest
Ext Edema

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3
Q

CAD

the best initial diagnostic test

A

EKG is Always the best initial diagnostic test but

But if you had to choose btw ekg or meds. You do meds.

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4
Q

What is the most accurate test for cp

A

CK-MB Or troponon

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5
Q

WhAt is the best test for reinfarction

A

Ck mb

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6
Q

What is always the wrong answer

A

LDH level

LDH isoenzymes

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7
Q

Which of the following cardiac enzymes rise first

A

Myoglobin.

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8
Q

When is stress test the answer

A
  • when the case is NOT acute

- when the initial ekg and or enzyme do NOT establish the dx

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9
Q

When do I Answer dipyramidole stress test or adenosine thallium stress test or dobutamine echo

A 
Ppl who can not exercise > 85% maximin
COPD
amputation 
Deconditioning
Obesity 
Dementia
Lower extremity ulcer 
Weakness of previous stroke

No caffeine 24 hours before dypiramidole

The adverse s/e of dypiramidole (HA, cp, bronchoconstriction) can be reversed with aminophylline

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10
Q

When use Sestamibi nuclear stress. Test

A

Obesity

Large breasts

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11
Q

Reversible ischemia next dx step

A

Angiography

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12
Q

When is coronary bypass the answer

A

When angiography has been done

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13
Q

Most accurate test to evaluate EF

A

Nuclear ventriculogram

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14
Q

Clopidogrl And ticagrelor given when

A

Added to aspirin for acute mi

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15
Q

When give prasugrel

A

When angioplasty is done

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16
Q

prasigrel
Clopidogrel
Ticagrelor
Added when

A

When people get an angioplasty or stent

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17
Q

Which treatments lower mortality in stemi

A

Thrombolytics
Primary angioplasty

-**they are Very dependent on time

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18
Q

Clopidogrel
Ticagrelor
Prawugrel* also a little tidbit
They are used when

A

Aspirin allergy
Pt undergoes angioplasty and stenting

PrAsugrel has more efficacy than clopidogrel but causes more BLEEDING

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19
Q

Prasugrel increases bleeding in

A

Age > 75

Weight <60 kg

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20
Q

When is pacemakers the answer for acute MI

A 
Third degree block
Second degree AV block, Mobitz type II 
Bifascicular block
New LBBB
Sympyomatic bradycardia
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21
Q

When is Lidocaine or Amiodarone the answer for acute MI

A

ONLY when there is v tach or v fib

Do not give them to prevent v arrhythmia

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22
Q

Complications of MI

Cardiogenic shock
Valve rupture 
Septal rupture 
Myocardial wall rupture 
Sinus bradycardia 
Third degree complete heart block 
Right ventricular infarction
A

Complications of MI

Cardiogenic shock( echo; swan ganz catheter. ACE I and urgent revascularization
Valve rupture : Echo. Ace, nitroprisside, intra aortic balloon pump as a bridge to Sx
Septal rupture : Echo, right heart caty. Ace, nitroprusside, urgent Sx
Myocardial wall rupture : Echo. Periocardecentisis and urgent cardiac repairing ir
Sinus bradycardia - EakG. Atropine followed by pacemaker if still symptomatic
Third degree complete heart block - ekg, canon “a” waves… atropine and pacemaker even if still symptomatic
Right ventricular infarction -( e fluid load

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23
Q

NSTEMI

A

No thrombolytic use

LMWH»> unfractionated heparin

GpIib/IIIa inhibitors like abciximab
Tirofiban
Eptifibitide lower mortality especially in those undergoin angioplasty

The single greatest benefit of these meds come with a combination of angioplasty and stents

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24
Q

Difference between saphenous vein graft and ima

A

Svg only good for 5 years

Ima good for 10 yesrs

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25
Q

Indications for CABG

A

Three coronary vessels >70%

Left MCA with >50-70% stenosis

2 vessels in diabetics

2-3 vessels with low EF

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26
Q

Ranolazine

A

Anti angina med

Added if other meds do not control pain

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27
Q

Give lipids! Strongest indication

A

CAD + LDL> 100

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28
Q

Diabetic LDL goal

A

< 70

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29
Q

Risk Fx for Lipid Tx

A 
Cigarette smoke 
Family Hx ( male<55, women <65)
High BP 140/90
Low HDL< 40
Age >55 females , <45 in males
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30
Q

CAD equivalentS

A

Diabetes
PAD
Aortic disease
CArotid disease

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31
Q

Sex and the heart

A

Anxiety&raquo_space; bb as the mcc of ED post infarction

Stop nitrates if starting sildenafil

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32
Q

CHF sounds

A

S3; splash

S4: bang

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33
Q

Pulmonary edema

CCS tip

A

Tx: Oxygen, furosemide; nitrates and morphine

This is the worst manifestation of CHF

Ccs; move clock forward only 15-30 and this is a perfect example that all tests and Tx should be ordered at the same time minutes if there is no response to Tx after moving forward the clock, add a
Positive inotrope like dobutamine, inamrinone Or milrinone

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34
Q

Blue box for pulmonary edema

A

All cases of pulmonary edema and MI need to be placed in the ICU

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35
Q

Important question *

What to do when you have v tach assd with pulmonary edema

A

Synchronized cardioversion—> v tach assd with pulmonary edema
Or Afib, flutter or svt

Unsyncuronized cardioversion•”—> v fib or v tach with no pulse

Anti arrhythmic•> v tach in someone who is hemodynamics stable

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36
Q

When nesitiride the answer?

A

Acute pulmonary edemaa
Preload reduction.
It’s a synthetic version of anp

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37
Q

Pulmonary edema parameters

A

CO is decreased
SVR is increased
Wedge pressure is increased
RAP music is increased

38
Q

Hypovolemic shock parameters

A

Decreased CO
Increased SVR
Decreased wedge pressure
Decreased rap

39
Q

Septic shock parameters

A

Increased co
Decreased SVR
Decreased wedge pressure
Decreased rap

40
Q

Pulmonary hypertension parameters

A

Decreased co
Increased SVR
Decreased wedge pressure
Increased rAp

41
Q

Spirinolone gives gynecomastia and ED. Anti androgenic

Switch to what?

A

Epleronone

42
Q

Diastolic dysfunctions Tx?

A

Bb and diuretics

ACe I have not been shown to help do not give spirinolactone or digoxin

43
Q

EF below 35

A

Implantahle cardioverterz/ defribillayor

44
Q

Systolic dysfunction with low EF

A 
Ace I
Bb
Spirinolactone / epleronone
Diuretics 
Digoxin
45
Q

Mcc death in CHF

A

arrhythmia

46
Q

Single most important fact about CHF inv further mgmt

A

Mortality decreased by ace, B.B., and spirinolactone

Digoxin decrees Sx but not lower mortality

47
Q

When is biventricular pacemaker the answer

A

When EF <35 and qrs> 120 msec

48
Q

When is warfarin the answer for CHF

A

Never

Wrong answer

49
Q

What is an absolute CI to use of bb

A

Symptomatic bradycardia

50
Q

Systolic murmurs
Diastolic murmurs
Right sided murmurs
Left sided

A

Systolic murmurs; As, MR, mvp, and HOCM

Diastolic murmurs: AR and MS

Right sided murmurs : Inc with inhalation

Left sided murmurs: inc with exhalation

51
Q

Maneuvers on valvular disorders

A

Most murmurs get louder with squatting or leg raise. You increase venous return
Like … AS, AR, MS, MR and right sided lesions m
Only 2 that become softer! Is hocm and mvp

Opposite for valsava and standing

52
Q

Effect of handgrip on murmurs

A

Increases afterload which is what ace does

So…
AR, MR, murmurs worsen and get louder
VSD same thing

53
Q

Table of handgrip vs amyl nitrate

A 
They have the opposite effect 
Handgrip (? Increased aftefload)
- AS decreased 
-AR increased 
- MS negligible 
-  MR increased m
- VSD increased
- HOCM and Mvp decreased 
Amyl nitrate ( decreased afterload)
AS increased 
AR decreased 
MS negligible 
MR decreased 
VSD decreased 
HOCM and mvp increased
54
Q

Valvular lesions

Best initial test

Most accurate test

A

Echo… order TTE first on CCS then tee

Left heart cath

For ccs, order CXR and ekg

55
Q

Regurgitate lesions tx

Stenotic lesions tx

A

Vasodilator therapy like ace, ARBs or nifedipine

Stenotic lesions need anatomical repair
MS needs balloon valvuloppasty even if pregnant

Valsava Improves murmur—> diuretics
Amyl nitrate improves murmur —> ACe

56
Q

AS

A

Presents with cp*, CHF Sx And syncope

Old patient with HTN

Coronary disease—> 3-5 year survival
Syncope: 2-3 year survival
CHF: 1.5-2 year survival

Increased intensity with leg raises, squatting and amyl nitrate

Decreased intensity with vAlsava, handgrip and standing

Also case may describe delayed carotid upstroke

Dx: best initial is TTE
More accurate is tee and left heart cath is most accurate test. Good for aortic pressure gradient

57
Q

Normal aortic valve gradient is…

A

Zero

58
Q

AR

A

Causes: HTN, rheumatic heart disease, endocarditis, cystic medial necrosis
Mmc presentation: sob and fatigue

Diastolic decresxendo murmur beard best at the left sternal border

Quinckes pulse: capillaries pulsations in the fingernails
Mussets sigh: head bobbing up and down with each pulse
Hill sign: bp gradient much higher in Le
Corrigans pulse: high bounding pulse . Aka water hammer pulse
Duroziez sign: murmur heard over femoral artery

Dx:  
Best initial test TTE 
More accurate is tee 
Most accurate app is left heart cath
For ccs, choose CXR and ekg

Tx:
Ace arbs and nifedipine are best initial therapy
For ccs, add loops
EF>55 Or LVESD <55= surgery

59
Q

MS

A

MCC is rheumatic fever
Pregnant immigrant

Sx:
dysphagia
Hoarseness
A fib

Diastolic rumble after an opening snap

Murmur increases in intensity with leg raising, squatting and expiration 
DX
Best initial TTE 
More accurate is tee
Most accurate left heart cath
Ccs, order ekg and cxr (LAH, straights of the left heart border and elevation of the left main stem bronchus
Tx:best initial diuretics 
Most effective is balloon valvuloplasty
60
Q

MR

A

HTN, IHD,And any condition that dilates the heart

Mc Sx is DOE

Holosystolic murmur that obscures S1 And S2. Best heArd at the apex and radiates to the axilla

S3 gallop- when fluid overload states like CHF it MR*

Murmur increases in intensity with leg raising, squatting or handgrip ( same as AR)

Standing valsava And amyl nitrate decrease intensity

Best initial test TTE
More accurate tee

Treatment is same as A Regurgitation
Ace, arbs, and nifedipine
Inc ccs, Add loops
Sx when EF< 60 or lvesd > 40 mm

61
Q

VSD

A

Asymptomatic: holosystolic murmur At LLSB
Large defects: sob

Murmur increases in intensity with leg raising squatting and exhalation ( just like MS)

Dx first test echo
More accurate cath

Tx mild defects don’t need mechanical closure

62
Q

ASD

A

Small ASDs are asymptomatuc
Large ones—> sob and parasternAl heave

*** fixed splitting of S2. Most important * step 3 tests this

Dx with echo

Tx percutaneous or catheter devices
Repair — >1.5:1

63
Q

Wide P2 delayed

A

RBBB
PS
RVH
Pulmonary HTN

64
Q

Paradoxical A2 delayed

A

LBBB
LVH
AS
HTN

65
Q

Dilated cardiomyopathy

A

Presents And managed just like CHF so treat with ace, ARBs, B.B. and spirinolactone

MCC: ischemia , Alcohol, Adriamycin, radiation and chagas

66
Q

HOCM

A

Sob and S4 gallop ( LVH and decreased compliance of Ventricle)

Echo shows normal EF

Tx B.B. and diuretics

67
Q

Restrictive cardiomyopathy

A

Sob, as with All cardiomyopathy And kussmauls sign

Mainstay of diagnosis: - Echo

  • Most accurate is endomyocardial biopsy
  • Cath shows rapid x and y descent

Amyloid: low voltage on ekg
Speckled pattern on echo

Tx: diuretics abd treat the underlying cause.

68
Q

Pericarditis

Dx
Tx

A

Best initial test EKG
- shows diffuse ST elevTion
And PR depression

Tx is with nsaids+ colchicine

Advance the clock 1-2 daysand go to the office and add prednisone orally *
advance clock again 1-2 days

69
Q

Pericardial tamponade

A

On ccs, also examine the lungs
Pulsus paraxodus!
Electric Alternans on ekg!

Dx
Best initial : EKG shows low voltage and electric alternans
Most accurate echo
Right heArt cAth shows equalization of pressures during diastole

Tx
Best initial therapy pericardiocentesis
Most effective therapy is pericardial window placement
Most dangerous therapy diuretics

70
Q

Constrictive pericarditis

A 
Sob and sign of righ heart failure like…
Edema
Hepatodplenomegaly
Ascites
Jvd

Pericardial knock!
Kussmaul sign!

Dx test
CXR
EKG
CT and mri

Tx
Best initial: diuretic
Most effective: surgical removal of the pericardium

71
Q

Aortic dissection

A

Best initial test CXR
Most accurate test ct angio

Tx
B.B.
Order B.B. with ekg and CXR. Move the clock forward then and order…

No matter what the ekg shows order…

Ct angio = tee= mra
Then give Nitroprusside! to control the bp

All cases need to go to the icu and a surgical consultation will be needed

72
Q

PAD

Dx
Tx
Ccs tip

A

Best initial test ABI
Most accurate test angio

Tx Aspirin
ACEi
Cilolastazol
Exercise as tolerated lipid control with goal <100

Ccs tip: move the clock forward several weeks to see if meds are working and if the pain progresses—> surgical bypass

Marginally effective Pentoxifylline
Not helpful ca blockers

73
Q

Spinal stenosis

A

Pain that’s worse walking downhill and better when walking uphill or sitting or cycling

Pulses and skin exam are normal

74
Q

Arterial occlusion

A

Pain + pallor. + pulseless = Arterial occlusion

75
Q

arterial embolus

Which 2 condition seen with this

A

AS and A fib

76
Q

A fib

Dx
Ccs tip
Tx

A

Dx
EKG
IP—> telemetry
OP—> holter

Ccs tip
Order: Echo, TSH and T4, electrolÿtes, trop Or ck-mmb

Tx:
Stable—>rate control with iV B.B., diltoazem or digixin
Once rAte is controlled—> anticoagulation with warfarin, dabigatran to INR 2-3

Unstable ( bp less than 90, CHF, or confusion or cp

Use chads score
C: CHF
H: HTN
A: Age > 75
D/: diabetes 
S: stroke/TIA

Score 0-1—> Aspirin
Score >_ 2•> warfArin, dabihAtran, rivaroxoban, apixAvban

** bridging with heparin is the WRONG answer

77
Q

Multfocal Atrial Tachycardia (MAT)

A

Polymorphic p waves in association with COPD/emphysema.

Tx
oxygen first then diltiazem
Do not give B.B. **

78
Q

SVT

Dx
Tx
Ccs tip

A

Dx if ekg doesn’t show svt—> holter monitor or telemetry

Best initial Tx
unstable patients —> synchronized cardioversion

Stable_-> vagal maneuvers
If vAgal maneuvers don’t work —> IV adenosine
**
Best long term treatment —> radiofrequency catheters ablAtion

Ccs—> all causes of dysrhythmia need TTE

79
Q

WPW

A

Svt that can alternate with v tach
* worsening of svt with Ca channel blockers or digoxin

Best initial test ekg showing delta waves!

Most accurate test electrophysiological studies

Best initial therapy procainamide!!! IF the svt or v tach is from wpw

  • best long term therapy is radio frequency catheter ablation
80
Q

V tach

Presentation
Dx
Tx

A

Palpitations
Syncope
Cp
Sudden death

Best initial test ekg
If ekg doesn’t show —> telemetry
Most accurate is electrophysiological studies

Tx
unstable—> synchronized cardioversion
Stable _—> amiodarone, lidocaine, procainamide
Magnesium

81
Q

V fib

Presents
Dx
Tx

A

Presents as sudden death

Dx ekg

Tx unsynchronized cardioversion!!

82
Q

Syncope

What to order

A
  • CBC (anemia)
  • bmp (glucose): hypoglycemic seizure
  • pulse ox ( hypoxia)
  • cardiac enzymes (ck mb or troponin
  • ekg!
  • echo
  • head ct
  • cardiac and neurological exams
83
Q

Syncope

Ccs tip

A

Move the clock forward to get initial test results

OP—> holter monitory
IP—> telemetry
Repeat ck mb or troponin
Urine and blood tox screen

If etiology is not clear, move the clock forward and order:

Holter
Telemetry 
urine tox 
repeat cardiac enzymes 
Tilt table
Electrophysiological studies 
Bottom line on ccs, order:
EKG
Echo
Cardiac enzymes
Head ct
84
Q

PAD Tx

A 
Aspirin 
ACE inhibitor
Exercise 
Cilostazol
Statins

Marginally effective: pentoxifylline!
Ineffective: Ca channel blocker

85
Q

S3 atrial gallop

A

S3—> fluid overload like … CHF or MR
But
Normal in patients <30

86
Q

MR Rx

A

Ace, arbs And nifedipine
For ccs add a loop
Surgery —>LVEF is < 60 or LVESD > 40 mm

87
Q

AR Tx

A

Ace, arbs And nifedipine
For ccs add a loop
Surgery —>LVEF is < 55% or LVESD > 55 mm

88
Q

ASD Tx

A

Percutaneous or catheter devices

Repair—> if shunt ratio exceeds 1.5 to 1

89
Q

Dilated cardiomyopathy Dx and Tx

A

Echo is best initial
MUGA Or nuclear ventriculogram is most accurate

Ace
Arbs
BB
Spirinolactone

90
Q

When Synchronized cardioversion

Unsynchronized

A

Synchronized cardioversion —> anything other than v fib and pulse less v tach

Unsynchronized—> v fib, pulseless v tach

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