Cardiology Flashcards
______ is a very common in association with MI because of vascular insufficiency of the sinoatrial (SA) node. There are NO cannon A waves.
Sinus Bradycardia
____ will have cannon A waves. Cannon A waves are produced by atrial systole against a closed tricuspid valve.
Third-degree (complete) AV block
How do you treat Right Ventricular Infarctions?
High-volume fluid replacement.
Avoid nitroglycerin, they markedly worsen cardiac filling,
What complication of Acute MI present with new onset of a murmur and rales/pulmonary congestion?
Valve Rupture
What is the most accurate test for both valve rupture and septal rupture?
Echocardiogram
What is a temporary device that can be placed when there is an acute pump failure from an anatomic problem? It serves as a bridge to surgery for valve replacement or transplant for 24 to 48 hours.
Intraaortic balloon pump (IABP)
When a patient presents with either an inferior or anterior infarction, it is common for a second event to infarct a second geographic area of the heart. What are the things you need to look for?
- Recurrence of pain
- New rales on PE
- Elevated CK-MB
- Sudden onset of Pulmonary Edema
How do you treat a mural thrombi?
Treat with Heparin followed by Warfarin
What complication of Acute MI present with new onset of a murmur and increase oxygen saturation on entering the right ventricle?
Septal rupture
What complication of Acute MI present with Inferior Wall MI in history, clear lungs, tachycardia, hypotension with nitroglycerin?
Right Ventricle Infarction
What complication of Acute MI present with sudden loss of pulse and jugulovenous distention?
Tamponade/Wall Rupture
What complication of Acute MI present with loss of pulse that would need an EKG to diagnose?
Ventricular Fibrillation
What do you need to do to a patient diagnosed with Acute MI prior to discharge?
Stress Test
It determines if angiography is needed. Angiography determines the need for revascularization such as angioplasty or bypass surgery.
DO NOT do a stress test if the patient remains symptomatic
What are the routine medications you should discharge your patients with?
- Aspirin
- Beta blockers (Metoprolol)
- Statins
- ACE inhibitors
What medication is NEVER the right choice for coronary artery disease?
Dipyridamole
A 48-year old woman comes to the office with chest pain that has been occurring over the last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of the pain is retrosternal. The pain is associated with nausea. There is no shortness of breath and the pain does not radiate beyond the chest. She has no past medical history. What is the most likely diagnosis?
A. GERD B. Unstable Angina C. Pericarditis D. Pneumothorax E. Prinzmental Angina
A. GERD
What are the risk factors of Coronary Artery Disease?
Diabetes Mellitus (WORST risk factor) Tobacco smoking Hypertension (MOST COMMON) Hyperlipidemia Family history of premature coronary artery disease Age: >45 men >55 women
Which of the following is the most dangerous to a patient in terms of risk for CAD?
A. Elevated triglycerides
B. Elevated total cholesterol
C. Decreased high density lipoprotein (HDL)
D. Elevated low density lipoprotein (LDL)
E. Obesity
D. Marked elevation in LDL - most dangerous portion of a lipid profile for a patient
A postmenopausal woman develops chest pain immediately on hearing the news of her son’s death in a war. She develops acute chest pain, dyspnea, and ST segment elevation in leads V2 to V4 on electrocardiogram. Elevated levels of troponin confirm an acute myocardial infarction. Coronary angiography is normal including an absence of vasospasm on provocative testing. Echocardiography reveals apical left ventricular “ballooning.”
What is the presumed mechanism of this disorder?
A. Absence of estrogen B. Massive catecholamine discharge C. Plaque rupture D. Platelet activation E. Emboli to the coronary arteries
B. Massive Catecholamine Discharge
Disease: Tako-Tsubo Cardiomyopathy
Correcting which of the following risk factors for CAD will result in the most immediate benefit for the patient?
A. Diabetes Mellitus B. Tobacco Smoking C. Hypertension D. Hyperlipidemia E. Weight loss
B. Smoking cessation results in the greatest immediate improvement in patient outcomes for CAD
What are the features of chest pain that tell that it is NOT ISCHEMIC in nature?
Changes with:
Respiration (Pleuritic)
Position of the body
Touch of the chest wall
Remember: PPT
Pleuritic, Positional, Tender
What is the difference in duration of stable angina from ACS?
Stable angina: >2 to <10 min
ACS: >10 to 30 min
What are the provoking factors of Ischemic Pain?
Physical activity, cold, emotional stress
What are the usual quality of Ischemic Pain?
Squeezing, tightness, heaviness, pressure, burning, aching
NOT sharp, pins, stabbing, knifelike
Where does ischemic pain usually radiates?
Neck, lower jaw and teeth, arms, shoulders
What is the diagnosis and most accurate test if the case describes chest pain with Chest Wall Tenderness?
Costochondritis
Physical Exam
What is the diagnosis and most accurate test if the case describes chest pain with Radiation to back and unequal blood pressure between arms?
Aortic Dissection
Chest X-Ray with widened mediastinum, Chest CT, MRI, or TEE
What is the diagnosis and most accurate test if the case describes chest pain with pain worse with lying flat, better when sitting up, young (<40)?
Pericarditis
Electrocardiogram with ST elevation everywhere, PR depression
What is the diagnosis and most accurate test if the case describes chest pain with epigastric discomfort and pain better when eating?
Duodenal ulcer
Endoscopy
What is the diagnosis and most accurate test if the case describes chest pain with bad taste, cough, hosarseness?
GERD
Response to PPIs; aluminum hydroxide and magnesium hydroxide, viscous lidocaine
What is the diagnosis and most accurate test if the case describes chest pain with cough, sputum, hemoptysis?
Pneumonia
Chest X-Ray
What is the diagnosis and most accurate test if the case describes chest pain with sudden onset shortness of breath, tachycardia, hypoxia?
Pulmonary embolus
Spirat CT, V/Q Scan
What is the diagnosis and most accurate test if the case describes chest pain with sharp, pleuritic pain, tracheal deviation?
Pneumothoroax
Chest X-Ray
What is the best initial test for all forms of chest pain?
Electrocardiogram (ECG)
What is the indispensable tool to evaluate chest pain when the etiology is not clear and the EKG is not diagnostic.
Stress (Exercise Tolerance) Testing
2 Factors to consider:
- You can read the EKG
- The patient can exercise
What is the formula to determine maximum heart rate?
220 - age of patient
What are the two best methods of detecting ischemia without the use of EKG?
1) Nuclear isotope uptake: thallium or sestamibi
2) Echocardiographic detection of wall motion abnormalities
Give reasons for baseline EKG abnormalities
- Left bundle branch block
- Left ventricular hypertrophy
- Pacemaker use
- Effect of Digoxin
What is the difference of Ischemia versus Infarction?
Ischemia gives reversible wall motion or thallium uptake between rest and exercise
Infarction is irreversible or “fixed”
What if the patient cannot exercise/ cant do stress testing? What alternate method can you do?
Increase Myocardial Oxygen Consumption by
1) Persantine (Dipyridamole) or Adenosine in combination with the use of nuclear isotopes such as thallium or sestamibi
2) Dobutamine in combination with Echocardiography
A man with atypical chest pain is found to have normal nuclear isotope uptake in his myocardium at rest. On exercise, there is decreased uptake in the inferior wall. Two hours after exercise, the uptake of nuclear isotope returns to normal.
What is the right thing to do?
A. Coronary angiography B. Bypass Surgery C. Percutaneous coronary intervention (e.g angioplasty) D. Dobutamine echocardiography E. Nothing, it is an artifact
A. Coronary Angiography
The patient has reversible ischemia on stress test
A 48-year old woman comes to the office with chest pain that has been occurring over the last several weeks. The pain is not related to exertion. She is comfortable now. The location of the pain is retrosternal. She has no hypertension, and the EKG is normal.
What is the most appropriate next step in management?
A. CK-MB B. Troponin C. Echocardiogram D. Exercise tolerance testing E. Angiography F. CT Angiography G. Cardiac MRI H. Holter Monitor
D. Exercise tolerance testing is to evaluate stable patients with chest pain whose diagnoses are not clear
Give 3 treatment for chronic angina that can lower mortality
- Aspirin
- Beta-blockers
- Nitroglycerin
What should a patient with acute coronary syndromes (ACS) receive immediately upon arrival in the ER?
Asprin and either Clopidogrel, Prasugrel, Ticagrelor
*This does not apply to chronic or stable CAD
Give 3 uses for Clopidogrel
- Combination with Aspirin in all ACS
- Aspirin intolerance such as allergy
- Recent angioplasty with stenting
What is the adverse effect of Prasugrel?
dangerous in 75 and older patients because of an increased risk of HEMORRHAGIC STROKE
Give the indication, contraindication, mode of action, and side effects of Ticlopidine
I: For Aspirin and Clopidogrel Intolerance
CI: If reason for aspirin/clopidogrel intolerance is BLEEDING
MOA: Inhibit platelets
SE: Neutropenia, TTP
A 64-year-old man is placed on lisinopril as part of managing CAD in association with an ejection fraction of 24% and symptoms of breathlessness. Although he sometimes has rales on lung examination, the patient is asymptomatic today. Physcial examination reveals minimal edema of the lower extremities. Blood tests reveal an elevated level of potassium that is present on a repeat measurement. EKG is unchanged.
How would you best manage the patient?
A. Add kayexalat B. Insulin and Glucose C. Stop lisinopril D. Switch lisinopril to Candesartan E. Switch lisinopril to hydralazine and nitrates
E.
ACEIs may also cause hyperkalemia aside from cough
Hydralazine
- direct-acting arterial vasodilator
- will decrease afterload and has been shown to have a clear mortality benefit in patients with systolic dysfunction
- should be used in association with nitrates to dilate the coronary arteries
What is the goal of LDL in the use of statins for CAD patients?
LDL < 70
Which of the following is the most common adverse effect of statin medications?
A. Rhabdomyolysis B. Liver dysfunction C. Renal failure D. Encephalopathy E. Hyperkalemia
B.
AST and ALT should be part of routine monitoring
check CPK levels if with symptoms
What is an excellent drug to add to statins if full lipid control is not achieved by statins?
Niacin
These are fibric acid derivatives that lower triglyceride levels more than statins.
What is the side effect of this drug if used together with statins?
Gemfibrozil
S.E: Myositis
What are the clear indications for the use of statins?
Acute Coronary Syndrome
MI or Stenting
Any arterial disease
10-year risk of CAD >7.5%
What is the adverse effect of Cholestyramine?
Flatus and abdominal cramping
Do we give Calcium Channel Blockers to patients with CAD?
When do we use CCB in CAD?
What are the adverse effects of CCBS?
NO! It increase mortality.
Use only with:
Severe asthma
Prinzmetal variant angina
Cocaine-induced chest pain
Adverse Effect:
Edema
Constipation (Verapamil)
Heart block (rare)
This is a sodium channel-blocking medication that treats angina. It is added to those who still have pain despite aspirin, beta blockers, nitrates, and calcium blockers
Ranolazine
Give 4 indications for Coronary Artery Bypass Grafting (CABG)?
- 3 vessels with at least 70% stenosis in each vessel
- Left main coronary artery occlusion
- 2-vessel disease in a patient with diabetes
- Persistent symptoms despite maximal medical therapy
What is the best therapy in acute coronary syndromes, particularly those with ST segment elevation?
Percutaneous Coronary Intervention (PCI)
A 70-year-old woman comes to the emergency department with crushing substernal chest pain for the last hour. The pain radiates to her left arm and is associated with anxiety, diaphoresis, and nausea. She describes the pain as “sore” and “dull” and clenches her fist in front of her chest. She has a history of hypertension.
Which of the following is most likely to be found in this patient?
a. >10 mm Hg decrease in BP on inhalation
b. Inc. in JVP on inhalation
c. triphasic scratchy sound on auscultation
d. continuous “machinery” murmur
e. S4 gallop
f. Point of maximal impulse displaced toward axilla
E. S4 gallop associated with Acute Coronary Syndromes
What sign is an increase in jugulovenous pressure on inhalation?
Give 2 diseases that is associated with this sign.
Kussmaul sign
Constrictive Pericarditis
Restrictive Cardiomyopathy
A 70-year-old woman comes to the emergency department with crushing substernal chest pain for the last hour. Which of the following EKG findings would be associated with the worst prognosis?
a. ST elevation in leads II, III, avF
b. PR interval >200 milliseconds
c. ST elevation in leads V2-V4
d. Frequent premature ventricular complexes (PVCs)
e. ST depression in leads V1 & V2
f. Right bundle branch block (RBBB)
C.
Leads V2-V4: anterior wall of the left ventricle
Leads II, III, aVf: inferior wall
A 70-year-old woman comes to the emergency department with cushing substernal chest pain for the last hour. An EKG shows ST segment elevation in V2 to V4, What is the most appropriate next step in the management of this patient?
a. CKCK-MB level
b. Oxygen
c. Nitroglycerin sublingual
d. Aspirin
e. Thrombolytics
D.
Aspirin lowers mortality with acute coronary syndromes, and it is critical to administer it as rapidly as possible.
Do we treat PVCs and APCs (atrial premature complexes)? Why?
PVCs and APCs should not be treated, even when associated with an acute infarction. Treatment only worsens outcome.
What happens when you combine nitrates with sildenafil?
Hypotension. They are both vasodilators.
What is the essential feature of congestive heart failure?
Shortness of breath (dyspnea)
Differentiate systolic dysfunction and diastolic dysfunction in CHF.
Systolic dysfunction is a low ejection fraction (less blood pumped) and dilation of the heart
Diastolic dysfunction is the inability of the heart to “relax” and receive blood. Ejection fraction is PRESERVED and sometimes above normal.
What is the most common cause of CHF?
Hypertension
Enumerate the events leading to CHF.
Infarction -> Dilation -> Regurgitation -> CHF
In addition to dyspnea on exertion, what other things should you look for in CHF?
Orthopnea Peripheral edema Rales JVD Paroxysmal nocturnal dyspnea (PND) (sudden worsening at night, during sleep) S3 gallop rhythm
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… sudden onset, clear lungs
Pulmonary embolus
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… sudden onset, wheezing, increased expiratory phase
Asthma
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… slower, fever, sputum, unilateral rales/rhonchi
Pneumonia
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… decreased breath sounds unilaterally, tracheal deviation
Pneumothorax
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… circumoral numbness, caffeine use, history of anxiety attack
Panic attack
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… pallor, gradual over days to weeks
Anemia
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… pulsus paradoxus, decreased heart sounds, JVD
Tamponade
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… palpitations, syncope
Arrhythmia of almost any kind
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… dullness to percussion at bases
Pleural effusion
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… long smoking history, barrel chest
COPD
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… recent anesthetic use, brown blood not improved with oxygen, clear lungs on auscultation, cyanosis
Methemoglobinemia
What is the MOST LIKELY diagnosis for dyspnea if the case mentions… burning building or car, wood-burning stove in winter, suicide attempt
Carbon monoxide poisoning
What is the most important of all tests in CHF?
Echocardiography
What is the best initial test in CHF?
Transthoracic echo
What is the most accurate test in CHF?
Multiple-gated acquisition scan (MUGA) or nuclear ventriculography.
In a patient with acute shortness of breath in whom the dyspnea is not clear and you cannot wait for an echo to be done, what should you order?
BNP level
A normal BNP excludes CHF as a cause of the shortness of breath
What test will you order if the etiology of CHF is MI, heart block?
EKG
What test will you order if the etiology of CHF is Dilated cardiomyopathy?
Chest X-Ray
What test will you order if the etiology of CHF is Paroxysmal Arrhythmias?
Holter monitor
What test will you order if the etiology of CHF is Precise valve diameters, septal defects?
Cardiac catheterization
What test will you order if the etiology of CHF is Anemia?
CBC
What diagnostic test can distinguish CHF from ARDS?
Swan-Ganz right heart catheterization (not routine)
These agents should be given to all patients with systolic dysfunction at any stage of disease.
ACEI and ARBs
The beneficial effects of ACEI and ARBs occur with any drug in the class.
Which of the following is the most common cause of death from CHF?
a. Pulmonary edema
b. Myocardial infarction
c. Arrythmia / sudden death
d. Emboli
e. Myocardial rupture
C.
Ischemia provokes ventricular arrhytmias leading to sudden death. Over 99.9% of patients with CHF are at home, not acutely short of breath.
What are the side effects of Spironolactone?
Hyperkalemia and Gynecomastia
What is the management of a patient with severe CHF who develops gynecomastia?
Switch Spironolactone to Eplerenone
Do diuretics lower mortality in CHF?
No.
They control symptoms of CHF.
Do digoxin lower mortality in CHF?
Not proven.
It controls symptoms of dyspnea and will decrease the frequency of hospitalizations.
A 74-year old African American man with a history of dilated cardiomyopathy secondary to MI in the past is seen in the office for routine evaluation. He is asymptomatic and is maintained on lisinopril, furosemide, metoprolol, aspirin, and digoxin. Lab tests reveal a persistently elevated potassium level. The EKG is unchanged.
What is the best management?
a. Switch lisinopril to candesartan
b. Stop lisinopril
c. Start kayexalate
d. Refer for dialysis
e. Switch lisinopril to hydralazine and nitroglycerin
E. Hydralazine is a direct-acting arteriolar vasodilator. There is a definite survival advantage with the use of hydralazine in combination with nitrates in systolic dysfunction. Candesartan is associated with hyperkalemia as well. Dialysis is sometimes used in hyperkalemia, but only if associated with renal failure as the cause.
What is the answer if the patient is still dyspneic after using ACE inhibitors, beta blockers, diuretics, digoxin, and mineralocorticoid inhibitors?
Ivabradine: SA nodal inhibitor of “funny channels” that slows the heart rate. Add it to systolic dysfunction if the pulse is over 70 bpm or beta blockers can’t be used. Ivabradine decreases symptoms.
Sacubitril/Valsatran: Used instead of an ACE inhibitor. Sacubitril is added only to an ARB. This neprilysin inhibitor does provide a mortality benefit for systolic dysfunction.
Hydralazine/Nitrates: Used when neither an ACE inhibitor nor an ARB can be used as vasodilator therapy. May add efficacy to ACE inhibitor or ARB in some patients.
What to do when maximal therapy (ACEI, BB, Spironolactone, Diuretics, Digoxin) and possibly the biventricular pacemaker fail to control symptoms of CHF
Cardiac Transplantation
What are the drugs the have CLEAR benefit in diastolic dysfunction in CHF?
Beta blockers and diuretics
What are the drugs the have NO CLEAR benefit in diastolic dysfunction in CHF?
Digoxin and Spironolactone
This is a congenital disease with an asymmetrically enlarged (hypertrophic) septum leading to an obstruction of the left ventricular outflow tract.
Hypertrophic Obstructive Cardiomyopathy (HOCM)
______ are contraindicated in HOCM because they will increase the obstruction.
Diuretics
This is the worst, most severe form of CHF
Pulmonary Edema
If acute pulmonary edema is from an arrhythmia, what is the fastest way to fix it?
Cardioversion
A 47-year old woman comes to the ER with the acute onset of shortness of breath, respiratory rate of 38 per minute, rales to her apices, S3 gallop, and jugulovenous distention. What is the best initial step in the management of this patient?
a. Oximeter
b. Echocardiography
c. Intravenous furosemide
d. Ramipril
e. Metoprolol
f. Nesiritide
C.
The best initial test for acute pulmonary edema is to remove a large volume of fluid from the vascular space with a loop diuretic
Give 4 initial therapy in acute pulmonary edema
Oxygen
Loop diuretics such as furosemide or bumetanide (best)
Morphine
Nitrates
This is a positive inotropic agent that can be used in the acute setting of patients placed in the ICU when their shortness of breath does not respond to therapy acutely with preload reduction.
Dobutamine
In patients with systolic dysfunction and low ejection fraction, what can you give on discharge for long-term use?
ACEIs and ARBs
Should we give Heparin in Acute Pulmonary Edema?
No.
Heparin is always WRONG for acute pulmonary edema management in the absence of a clot.
Give the difference of right sided and left sided lesions of the heart in terms of valvular heart disease.
Lesions on the right side of the heart (tricuspid and pulmonic valve) increase in intensity or loudness with INHALATION.
Left-sided lesions (mitral and aortic valve) increase with EXHALATION.
What is the best initial test for all valvular heart disease?
Echocardiogram
Transesophageal echo is generally both more sensitive and more specific than transthoracic echo
What is the most accurate test for all valvular heart disease?
Catheterization
Mitral stenosis is most often caused by _______.
Rheumatic Fever
What 2 things should you look for in the history if you’re thinking of Mitral Stenosis as a diagnosis?
Pregnancy and Immigrant
Mitral stenosis often presents in
a. Childhood
b. Teenage years
c. Young adult
d. Adult
e. Elderly
C. Young adult
Give 4 unique features of Mitral Stenosis
- Dysphagia - from left atrium pressing on the esophagus
- Hoarseness - left atrium pressing on laryngeal nerve
- Atrial fibrillation and stroke from enormous LA
- Hemoptysis
How do you describe the murmur in mitral stenosis?
Diastolic murmur, just after an opening snap
What do you see in a chest x-ray of mitral stenosis?
Left Atrial Hypertrophy
> Straightening of the left heart border
Elevation of the left heart border
Second “bubble” behind the heart
Enumerate treatments done in Mitral Stenosis
- Diuretics and sodium restriction when fluid overload is present in the lungs
- Balloon valvuloplasty done with a catheter
- Valve replacement only when catheter procedure cannot be done, or fails
- Warfarin for atrial fibrillation to an INR of 2 to 3
- Rate control with digoxin, beta blockers, or diltiazem/ verapamil
_____ can be caused by a congenital bicuspid valve or with increasing calcification as people age
Aortic Stenosis
What is the most common presentation of Aortic Stenosis?
Angina
Describe the murmur of Aortic Stenosis.
Systolic, crescendo-decrescendo murmur
heard best at the second right intercostal space, and radiates to the carotid artery
Valsalva and standing IMPROVE or decrease the intensity of the murmur
Handgrip SOFTENS the murmur
What is the truly effective therapy for Aortic Stenosis?
Valve replacement
_______ is an abnormal backward flow of blood through a mitral valve that does not fit together.
Mitral Regurgitation
What is the murmur of Mitral Regurgitation (MR)?
Pansystolic (Holosystolic), obscuring both S1 and S2
Handgrip WORSEN the murmur
Squatting and leg raising will also WORSEN murmur
What are the BEST medications used in Mitral Regurgitation?
ACEIs or ARBs
Give 6 causes of Aortic Regurgitation.
- MI
- Hypertension
- Endocarditits
- Marfan syndrome or cystic medial necrosis
- Inflammatory disorders such as ankylosing spondylitis or Reiter syndrome
- Syphilis
Enumerate physical findings found in Aortic Regurgitation
> Wide pulse pressure
Water-hammer (wide, bounding) pulse
Quincke pulse (pulsations in the nail bed)
Hill sign (BP in legs as much as 40 mm Hg above arm BP)
Head bobbing (de Musset sign)
Describe the murmur of Aortic Regurgitation.
Diastolic, decrescendo murmur heard best at lower left sternal border
Valsalva and standing makes it BETTER
Handgrip makes it WORSE
Medical management for Aortic Regurgitation
ACEIs/ARBs or Nifedipine
What is the most common complication of a Bicuspid Aortic Valve?
Aortic Stenosis
If patient under age 30 with bicuspid aortic valve is asymptomatic, what do you do?
Monitor with Echo every 1-2 years
Treat hypertension
If a patient with bicuspid aortic valve shows LV dysfunction and symptoms, what do you need to do?
Surgical replacement
Give 2 congenital causes of Mitral Valve Prolapse.
Marfan and Ehlers-Danlos syndrome
Give 3 most common presentation of Mitral Valve Prolapse.
Atypical chest pain
Palpitations
Panic attack
Describe the murmur of Mitral Valve Prolapse
Midsystolic click
Valsalva and standing WORSEN MVP
Squatting or Handgrip IMPROVE MVP
What is the medical management for MVP?
Beta blockers if symptomatic
What is the best initial test for Cardiomyopathy?
Echocardiography
What is the common treatment for all types of Cardiomyopathy?
Diuretics
except HOCM-> contraindicated
What are the two murmurs that DO NOT increase with EXPIRATION?
HOCM
MVP
What treatment can be used in Dilated Cardiomyopathy?
a. ACEIs and ARBs
b. Beta blockers
c. Spironolactone
d. Diuretics
e. Digoxin
f. Hydralazine with nitrates
g. Biventricular pacemaker
h. Automated implantable cardioverter/defibrillator
i. All of the above
I. All!
What is the most common cause of Hypertrophic Cardiomyopathy
Hypertension
What are the differences between HCM and other forms of Cardiomyopathy?
S4 gallop
Fewer signs of right heart failure such as ascites and liver and spleen enlargement
What triggering factor worsens the symptoms of HOCM?
Anything that INCREASES HEART RATE (exercise, dehydration, diuretics)
Anything that DECREASES left ventricular chamber size (ACEIs, ARBs, digoxin, hydralazine, Valsalva, and standing suddenly)
What type of cardiomyopathy typically presents with sudden death, particularly in healthy athletes
Hypertrophic Obstructive Cardiomyopathy
What is the best initial therapy for both HOCM and ordinary HCM?
Beta blockers
Verapamil and Disopyramide can also be useful
Systolic anterior motion (SAM) of the mitral valve is classic for _____.
a. DCM
b. HCM
c. HOCM
C. HOCM
It contributes to obstruction
Do we give digoxin and spironolactone in HCM?
NO.
They are always WRONG.
What are two medical management that DO NOT help in HOCM?
Diuretics and ACEIs
This is the major difference between HOCM and HCM
________ combines the worst aspects of both dilated and hypertrophic cardiomyopathy. The heart neither contracts nor relaxes normally because it is infiltrated with substances creating immobility.
Restrictive Cardiomyopathy
Give 5 causes of Restrictive Cardiomyopathy
Sarcoidosis Amyloid Hemochromatosis Endomyocardial fibrosis Scleroderma
Standing and Valsalva will increase/decrease venous return to the heart
decrease
Handgrip increase/decrease left ventricular emptying
decrease
Amyl nitrate increase/decrease left ventricular emptying
increase
Handgrip and Amyl nitrate has no effect in:
a. Aortic stenosis
b. Mitral stenosis
c. Aortic regurgitation
d. Mitral regurgitation
e. Mitral valve prolapse
f. HOCM
B. Mitral Stenosis
Handgrip increases murmur in:
a. Aortic stenosis
b. Aortic regurgitation
c. Mitral regurgitation
d. Mitral valve prolapse
e. a and b
f. b and c
g. c and d
F. B and C
What is the only truly accurate test for myocarditis?
Biopsy of the heart
What will echocardiography show in a patient with Myocarditis?
Decrease in ejection fraction
What is the most common infection in Pericarditis?
Viral
_________ is associated with sharp chest pain that changes in intensity with respiration as well as the position of the body. The pain is worsened by lying flat and improved by sitting up.
Pericarditis
What medication decreases the recurrences of pericarditis?
Colchicine
A 78-year old man with a history of lung cancer comes to the ER with several days of increasing shortness of breath. He became somewhat lightheaded today, and that is what has brought him to the hospital. On physical examination, he has a blood pressure of 106/70; pulse of 112; jugulovenous distention; and the lungs are clear to auscultation. The blood pressure drops to 92/59 on inhalation. Which of the following is the most appropriate to confirm the diagnosis?
a. EKG
b. Chest X-Ray
c. Echocardiogram
d. Right heart catheterization
e. Cardiac MRI
C: Echocardiogram
Patient has edema, ascites, enlargement of the liver and spleen, JVD, and calcification on Chest X-Ray. What is the most likely diagnosis?
Constrictive Pericarditis
Patient has hypotension, tachycardia, distended neck veins, clear lungs. What is the most likely diagnosis?
Pericardial Tamponade
What is the best initial test in Constrictive Pericarditis?
Chest X-Ray
It’ll show calcification and fibrosis
In Constrictive Pericarditis, what will you give first to decompress the filling of the heart and relieve edema and organomegaly
Diuretics
Patient has leg pain in the calves upon exertion and is relieved by rest. It occurs when walking up or down hills. The skin appears to be smooth and shiny. What is the most likely diagnosis?
Peripheral Artery Disease
What is the best initial test in PAD?
Ankle-brachial index
If ABI less than 0.9 or difference between ankle and brachial BP is greater than 10%, then disease is present
What is the most accurate test in PAD?
Angiogram
What is the best initial therapy for PAD?
Aspirin or vorapaxar
Stop smoking
Cilostazol (single most effective medication)
A 67-year-old man comes to the ER with the sudden onset of chest pain. He also has pain between his scapulae. He has a history of hypertension and tobacco smoking. His blood pressure is 169/108. What is the best initial test?
a. Chest X-Ray
b. Chest CT
c. MRA
d. Transesophageal echocardiogram
e. Transthoracic echochardiogram
f. CT angiogram
g. Angiography
A. Chest X-Ray
might show widening of the mediastinum, which is an excellent clue as to the presence of aortic dissection
Patient has pain in between scapulae and difference in blood pressure between the arms, what is the most likely diagnosis?
Aortic Dissection
A 67-year-old man comes to the ER with the sudden onset of chest pain. He also has pain between his scapulae. He has a history of hypertension and tobacco smoking. His blood pressure is 169/108. What is the most accurate test?
a. MRA
b. Transesophageal echocardiogram
c. Transthoracic echocardiogram
d. CT angiogram
e. Angiogram
E. Angiography is more accurate than any other choices
MRA = CTA = TEE (No difference in accuracy)
Treatment for Aortic Dissection
- Beta blockers
- Nitroprusside
- Surgical correction
*BB must be started before nitropusside to protect against reflex tachycardia of nitroprusside which will worsen shearing forces
Which of the following is the most appropriate screening for aortic aneurysm?
a. Everyone above 50 with CT angiography
b. Men who ever smoked above 65 with ultrasound
c. Everyone above 50 with ultrasound
d. Everyone above 65 with ultrasound
e. Men above 65 with ultrasound
B.
AAA > 5 cm –> surgical or catheter-directed repair
New-onset back pain in elderly patients (>65) should have ultrasound of aorta to rule out AAA
Which of the following is the most dangerous to a pregnant woman?
a. Mitral stenosis
b. Peripartum cardiomyopathy
c. Eisenmenger phenomenon
d. Mitral valve prolapse
e. Atrial septal defect
B
Peripartum cardiomyopathy develops after delivery in most cases; that is why ACEIs/ARBs are acceptable to use
Give 5 medical treatment for Peripartum Cardiomyopathy
- ACEIs/ARBs
- Beta blockers
- Spironolactone
- Diuretics
- Digoxin
This is the development of a right-to-left shunt from pulmonary hypertension
Eisenmenger Syndrome
