Cardiology Flashcards
1
Q
What is chronic primary mitral valve regurgitation with impaired left ventricle systolic function?
A
Mitral valve insufficiency that results in intrinsic defect in mitral valve apparatus (Leaflets, Chordae tendinae). Patient with ejection fraction less than 60.
2
Q
What is the most common cause of mitral valve prolapse?
A
Myxomatous degeneration leading to chronic primary MR
3
Q
How does the effective left ventricular ejection fraction get affected with patients with severe MR
A
Large portion of the LVEF gets injected into the left atrium which decreases the effective EF. Mitral valve repair or replacement of the surgery if less than 60 app
4
Q
What is the cause of acute MR? What can it lead to?
A
Rupture of chordae tendonae or papillary muscle following a myocardial infarction; Because the left ventricle doesn’t have time to dilate (to compensate for the rapid increase in LV preload) this can lead to rapidly progressive pulmonary edema, cardiogenic shock or hemodynamic instability.
5
Q
What is secondary or functional MR? What is the approach in treatment?
A
MR caused by a disease process involving the left ventricle (myocardial infarction, dilated cardiomyopathy); The mitral valve is intrinsically normal furthermore treatment involves Optimizing left ventricle function such as cardiac resynchronization therapy therapy [MI] or medication [Dilated Cardiomyopathy]rather than mitral valve surgery
6
Q
Athletes who undergo intense training can develop what non-pathogenic cardiac change?
A
Resting sinus bradycardia with or without 1st degree atrioventricular block, Left ventricular hypertrophy
7
Q
What is that inheritance pattern for bicuspid aortic valve?
A
30% in patients with Turner’s syndrome. Autosomal dominant with incomplete penetration. Sporadically
8
Q
What are the complications for aortic bicuspid valve?
A
Aortic dissection, aortic root or ascending aortic dilation, Severe regurgitation or stenosis, infectious endocarditis
9
Q
Explain the anti-thrombotic therapy for patients with mechanical heart valves?
A
Aspirin and warfarin; INR of 2-3 if aortic valve replacement without risk factors. 2.5-3.5 If mitral valve replacement or aortic valve replacement with risk factors.
10
Q
If patient cannot tolerate warfarin post mechanical valve placement, what should be done?
A
Increased dosage of aspirin.
11
Q
What is considered high risk factors for mechanical valve patients in regards antithrombotic therapy?
A
Atrial fib, LV systolic dysfunction EF less than 30, hypercoagulable state, prior thromboembolism
12
Q
What is the caution for giving nitrates to unstable angina/non-STEMI patients⁉️ BBs⁉️
A
Hypotension especially in patients with right ventricular infarction; heart failure (patients with crackles or pulmonary Edema), Can be used cautiously in decompensated heart failure but never in pulmonary edema post MI
13
Q
What are the cardioselective beta blockers that can be given to ACS patients? How does this differ in hypertensive patients?
A
Metoprolol, atenolol; intravenous for hypertensive patients
14
Q
When are beta blockers used in hypertension? When is it not used?
A
Hypertension with compensated heart failure. Not used in cardiogenic shock or decompensated heart failure
15
Q
What medications are use for hypertension?
A
Thiazide diuretics, ACEi/ARBs, Dihydropyridine calcium channel blocker
16
Q
What medications can be used for hypertension with heart failure?
A
Diuretics, ACEi/ARB, BB (compensated), aldosterone antagonist
17
Q
Medications use for hypertension with diabetes?
A
ACEi/ARB( Prevent diabetic nephropathy) thiazide diuretics, CCB, BBs
18
Q
Medication utilized in Hypertension in pregnant patients?
A
Hydralazine, methyldopa,Labetalol, Nifedipine
19
Q
What are the calcium channel blocker’s that is used for smooth muscle and vessels?heart?
A
Amlodipine,nimodipine; Diltiazem, verapamil
20
Q
What are the two examples of antiplatelet therapy?
A
Aspirin (inhibit TXA2 synthesis), Clopidogrel (inhibit GpIIb/IIIa)
21
Q
What are the benefits of low molecular weight heparin, and fondaparinux?
A
Longer half-life, administered subcutaneously, no weekly INR check necessary
22
Q
What are the low molecular weight heparin medications?
A
Enoxaparin and dalteparin
23
Q
What is the direct thrombin inhibitor?
A
Bivalirudin. Venus thromboembolism, atrial fibrillation, Can be used in HIT, does not require lab monitoring
24
Q
What are the anticoagulation medications that can be given to patient with ACS?
A
UFH, LMWH, fondaparinux, bivalirudin
25
What is the treatment for ACS patients?
Nitrate for long-standing chest pain, dual antiplatelet therapy, High intensity Staten, Anticoagulation, beta blockers
26
When is rhythm control treatment necessary for patients who have AFib?
When Rate control (BBS, CCBs) treatment Doesn’t work.
27
What is the preferred antiarrhythmic treatment for Atrial fibrillation patients with heart failure?
Amiodarone or Dofetilide
28
Atrial fibrillation without CAD or structural heart disease?
Flecainide or Propafenone.
29
Atrial fib treatment in patients with left ventricular hypertrophy?
Amiodarone
30
What medications can be use for Atrial fib relation with coronary artery disease without heart failure?
Sotalol
31
Dronedarone Medication can be is used for which a fib patients?
Left ventricular hypertrophy and CAD
32
What can be done for patients with atrial fib refractory to medication?
Radio frequency ablation
33
STEMI requires urgent revascularization via?
PCI within 90 minutes of medical contact (not symptom) or 120 minutes if Requires transfer
34
In what instance is CABG surgery superior to PCI with drug eluding stents⁉️
Diabetes with multi vessel CAD
35
What is a conservative treatment for patients with varicose veins? How was does this change is the patient has arterial insufficiency?
Leg elevation, compression stockings, weight loss, Sclerotherapy, Surgical ligation; Compression stocking should not be used
36
What should be given in cocaine induced chest pain? What is contraindicated acute cocaine ingestion?
Benzodiazepines should be given to decrease sympathetic outflow, psychomotor agitation, hypertension in cardiac demand, Myocardio ischemia. Nitroglycerin can also be used to aid in hypertension. Beta blockers are contraindicated Due to the risk of excessive alpha one vasoconstriction
37
Cocaine related chest pain can result from what? What else should be included as possible affect with cocaine?
Myocardial infarction, ACS, stroke, aortic dissection, pneumothorax, hemorrhagic alveolitis
38
What would be the signs of a workday section any patients with cocaine related chest pain?What should be done?
Persistent chest pain and right extremity weakness, CT angiogram for your chest should be done
39
What are the signs for extremity PAD?
Leg pain with activity, Foot and leg shiny ended devoid of here, brachial angle index
40
What should PAD be prescribed On diagnosis? What should not be given in a patient with a PAD? Why?
Statin and aspirin; Warfarin Increase the risk for bleeding
41
What is the initial/1st step in PAD?
Step 1a: Risk factor management including smoking cessation, hypertension, diabetes antiplatelets and statins. Step 1b: Exercise program
42
After initial management and persistence of symptoms in PAD patients, What it should be considered?
Cilostazol then Revascularization (angioplasty with/without stent, autogenus or synthetic bypass graft)
43
What will confirm non ST elevation MI? Unstable angina?
Troponin elevation with or without ECG changes; Typical angina pain in the absence of troponin elevation
44
In patients with initial troponin and ECG negative but have reasonable suspicion for ACS (typical angina for greater than 20 minutes, or resolve with nitroglycerin) What should be done?
Serial troponins (3 levels 6 hours apart); repeat ECGs every 30 minutes
45
What can exercise stress testing predict?
Low risk of cardiac events in the near future. Can screen for occlusive CAD not non occlusive CAD
46
What is multifocal atrial tachycardia? Who does that usually occur in?
Usually occurs in elderly patient hospitalized for COPD exacerbation. Can also occur in hypokalemic patients.
47
What should be screened for in patients who have Marfan syndrome?
Aortic root dilation leading to set in cardiac death
48
What are the etiology of multifocal atrial tachycardia?
Catecholamine surge (sepsis), COPD exacerbation or other pulmonary disease, electrolyte disturbances (hypokalemia)
49
What is the severe chronic mitral regurgitation ass. with?
Associated with symptoms such as dyspnea on exertion or heart failure or specific echocardiogram findings such as left atrial and left ventricular enlargement regurgitant jet Prominence
50
What LVEF is considered normal in most patients?
>50%
51
What is the cause of resting/sinus bradycardia in athletes heart?
Heightened the vagal tone
52
What is Sudden Cardiac Death (SCD)?
Leading cause of mortality in young <35 athletes most commonly due to ventricular arrhythmias triggered by intense exertion and is setting of undiagnosed structural heart disease hypertrophic cardio myopathy, anomalous origin of a coronary artery, arrhythmic genic right ventricular cardiomyopathy.
53
When is treadmill exercise testing is for young patients?
Used for risk stratification in patients with known structural heart disease
54
When should an echocardiogram be performed in young athletes?
Unexplained symptoms, cardiac murmur’s, family history of SCD or inherited structural heart disease, or abnormal ECG not consistent with athletes heart
55
When negative affects can performance-enhancing drugs such as androgens have on younger athletes?
Increases the risk of SCD, cardiac Hypertrophy not Bradycardia
56
When is a 24 hour ECG monitor indicated for young patients? When is it not?
Patient with unexplained symptoms such as palpitations or syncope. It’s not indicated in young athletes with asymptomatic sinus bradycardia
57
What is positive for uncomplicated bicupsid valve in a physical examination?
Ejection Murmur with a sound or click at the lower left sternal border
58
What are the findings of bicupsid aortic valve in chest x-ray?
Chest x-ray can reveal AV calcification, aortic enlargement due to aneurysm, rib notching due to coarctation
59
What is used to diagnose bicupsid AV and for follow up?
Transthoracic echocardiogram.
60
Why are first-degree relative screened for bicupsid AV?
To avoid complications including severe regurgitation, stenosis, ascending aortic or aortic root dilation, dissection, and increased risk for endocarditis
61
When is AV replacement appropriate for a bicupsid of valve patients?
For patients with severe aortic stenosis or regurgitation associated with symptoms of the left ventricular dysfunction
62
When is balloon valvuloplasty indicated for Bicupsid AV patients?
If symptomatic or asymptomatic but plan to become pregnant or participate in competitive sports: criteria must be met 1) Aortic stenosis, 2) no significant AV calcification or aortic regurgitation 3) peak gradient > 50mmHg
63
How do you compare the risk for systemic thromboembolism in patients with mechanical mitral valve as opposed to a aortic valve prosthesis?
Mechanical mitral valve has twice to risk compared to aortic
64
Beta blockers are contraindicated in what acute patient? How?
Acute decompensated heart failure (ADHR) patients leading to ischemic left ventricular dysfunction and pulmonary edema. Beta blockers may worsen pulmonary edema by decreasing contractility and heart rate
65
How should beta blockers be given to ADHF patients?
Initially held, once patient is stabilized can be given low-dose therapy
66
Explain to management for ACS patients?
Dual antiplatelet therapy (aspirin and P2Y12 receptor blocker), nitrates for CP, anticoagulation, beta blocker, high intensity Statins
67
Is upper gastrointestinal bleeding like me to H pylori peptic ulcer disease they contraindication for antiplatelet for anticoagulation therapy in ACS?
No can still use aspirin and or heparin
68
What should be done for patients who exhibit and tolerance for Simba Staten therapy?
Close monitoring, every other day dosing, reduction of statin intensity maybe pravastatin. But she be tolerable Statin regimen
69
What is nitroglycerin used for?
Decreased cardiac preload what a relief of persistent chest pain and ACS patients. Alleviation of pulmonary edema in a DHF and hypertensive patients
70
How does a patient with an exacerbation of systolic heart failure triggered by uncontrolled atrial fibrillation with rapid ventricular response present?
Lower extremity edema, palpitations, shortness of breath, dizziness
71
How can a patient with Afib be managed?
Anticoagulation (eg. rivaroxaban)and rate control with a atrioventricular nodal blocking agents (eg. BBs) or rhythm control with anti arrhythmic agents
72
Cocaine related chest pain may be due to what?
Cocaine related chest pain may be due to cardiovascular or non-cardiac causes; pneumothorax hemorrhagic alveolitis or crack lung, Cardiovascular is more common
73
What is the mechanism for the cardiovascular adverse effects of cocaine?
Inhibition of presynaptic uptake of norepinephrine overstimulates adrenergic receptors alpha one in beta one in the CNS. Causing tachycardia increase our contract Hillary, vasoconstriction, hypertension.
74
What makes myocardial ischemia and acute coronary syndrome common in cocaine related chest pain?
Increase in myocardial oxygen demand and decrease in supply
75
How does cocaine promote thrombus formation? Which increases the risk for what?
Cocaine activates platelets increasing the risk for the robbers formation, MI, stroke
76
How can cocaine cause aortic dissection?
Cocaine induced hypertension
77
Why are benzodiazepines used for cocaine related chest pain?
Reduce sympathetic sympathetic Outflow (alleviate tachycardia and hypertension and improve MI).
Also carbs patient decreasing hard actually is in demand
78
What can be used for cocaine related chest pain treatment?
Benzodiazepines and nitroglycerin both alleviates the hypertension in different ways
79
When should aspirin and Clopidogrel be given to CRCP patient?
Aspirin should be given for early management except if Contraindication like high suspicion for aortic dissection. Clopidogrel When diagnosis of ACS has been established through EKG or biomarkers
80
What drug is contraindicated in patients with cocaine related chest pain? Why?
Beta blockers are contraindicated, because of unopposed alpha one receptor mediated a Vasoconstriction
81
What should be given to lower hypertension in CRCP patients if not responding to benzos and nitro?
Phentolamine Alpha receptor antagonist
82
What should be given for persistent chest pain in CRCP?
CCBs
83
What should be done for myocardial infarction in CRCP?
PCI
84
What is the most common cause of a cute aortic dissection in younger patients?
Severe hypertension due to cocaine ingesting
85
What is highly suspicious for acute dissection of the ascending aorta CRCP For patients?
Adequately controlled heart rate and blood pressure and no evidence of ischemia and EKG however chest pain persisting in combination of new neurologic findings right side weakness)
86
What is the difference in presentation for type A and type B dissections?
Type a dissection involve type A is ascending aorta typically has sharp anterior chest pain, back pain is more common in type B dissections.
87
How can cerebral ischemia and subsequent focal neurologic deficit occur in CRCP patients?
Carotid artery involvement, obstruction by intimal flap, extension of dissection into carotids
88
What type a dissection is considered a surgical emergency?
Ascending aorta a cute dissection
89
How is aortic dissection diagnosed?
CT Angiography (or MRA, transesophageal ECHO)
90
What is the normal ankle brachial index? When is it seen?
1 to 1.4. Peripheral vascular disease
91
Where does the atherosclerotic narrowing of PAD occur?
Proximal end of the large peripheral vascular arteries (iliac Popliteal)
92
What are the symptoms of PAD in order of severity of disease?
Pain with exertion (claudication), rest pain, tissue alteration, gangrene
93
What PAD patients should get high intensity Statin therapy? What are they?
All patients equal to or younger than 75 regardless of their baseline cholesterol levels; (atorvastin 40-80 mg daily, rosuvastatin 20-40)
94
Why aren’t calcium channel blocker is used for a PAD?
Arteries with atherosclerotic disease are unable to dialate in significantly
95
Is dual antiplatelet therapy recommended for PAD patients? What about Warfarin?
No, No
96
What is the first step for treatment of the symptomatic peripheral artery disease?
Risk factor management: Smokes the station, diabetes and hypertension management, supervised exercise therapy, antiplatelet and Statin therapy
97
What is the 2nd step for treatment of the symptomatic peripheral artery disease?
Cilostazol (preferred over phentoxifylline)
98
What is the last step for treatment of the symptomatic peripheral artery disease?
Revascularization for persistent symptoms : angioplasty with or without stent placement, Autogenous or synthetic bypass graft
99
What can cause multifocal atrial tachycardia?
Atrial conduction abnormalities triggered by right atrial enlargement, catecholamines surge (sepsis) or electrolyte in balance
100
What type of patients does multifocal atrial tachycardia mostly occur in? That is the typical presentation?
Elderly patients greater than 70 with acute exacerbation of underlying pulmonary disease such as COPD. Patient typically presents with underlying illness symptoms such as cough wheezing or shortness of breath and tachycardia which is asymptomatic (unless to palpitations)
101
Explain the cardiac examination of MAT? How is it diagnosed?
Irregular rhythm with rapid rate. EKG showing distinct P waves of at least three different morphologies irregular are are intervals atrial rate greater than 100
102
How is MAT differentiated from wandering atrial PageMaker?
ECG shows elevated atrial rate in MAT
103
What is the proper treatment for MAT?
Management of inciting illness, administration of bronchodilators systemic steroids and noninvasive ventilation if significant respiratory distress
104
Where is amiodarone use for?
Pharmacological cardioversion in atrial fibrillation patient
105
What is a common laboratory abnormality for MAT? What could be the cause of it?
Electrolyte disturbances e.g. hyperkalemia, hypomagnesemia; Diarrhea, diuretic use, etc. for hypokalemia
106
What will lead to conversion to sinus rhythm and patients with MAT?
Repletion of depleted electrolytes and resolve an underlying disease
107
What are common transit complications of acute inferior wall myocardial infarction? How is this explained? What can treat this?
Sinus bradycardia and atrioventricular block; Increase in vagal tone; atropine intravenously can be responsive sometimes, temporary transcutaneous followed by transvenous cardiac pacing if persistent bradycardia
108
What can nonpharmacologic measures do for patients who are at risk for hypertension?
delay onset of hypertension and reduce the overall risk of cardiovascular events, and patients who already have hypertension they can allow for fewer medications and a lower dosage of anti-hypertensive medication
109
What is the most effective non-pharmacological measure in decreasing blood pressure for overweight individuals?
10% Weight loss
110
T-wave inversion in inferior Leads is suggestive of what?
Right heart strain that can occur in acute PE
111
What EKG findings are indicative of a cute pericarditis?
PR depression, ST elevations, diffuse
112
What is the recommendation for exercise DASH diet and dietary, Alcohol, sodium in order to lower hypertension blood pressure
I30 minutes a day for 5 to 7 days a week, less than 3 g a day, diet high in fruits and vegetables low in fat, two drinks a day in men one drink a day in women,
113
What is the amount of systolic blood pressure decrease for weight loss patients?
5-20 per 10 kg lost
114
What is a common cause for refractory hypertension?
Daily alcohol consumption greater than recommended
115
What individuals show the best outcomes for high blood pressure in sodium restriction?
Older individuals especially post menopausal women, African-Americans, and overweight individuals
116
We should be done to STE am I patients who symptoms are improved but not relieved with nitro glycerin? What should be done if no access to PTI capable facility?
Urgent coronary revascularization in the form of a percutaneous coronary intervention, PCI within the first 90 minutes of contact or 120 minutes if must transfer. Fribinolytic therapy within 30 minutes of hospital arrival
117
What is seen in acute pericarditis on EKG?
Diffuse ST elevation with PR depression
118
What is T wave inversion in inferior leads indicative of?
Right heart strain that can occur with acute PE
119
When is fibrinolytic therapy indicated for PE patients?
Acute PE with persistent hypotension or shock
120
What are the high intensity Statin therapy?
Atorvastatin 40-80
| Rosuvastatin 20-40
121
What patients should get the high intensity Statin therapies? Moderate intensity?
ASCVD patients 75 or younger; Patient younger than 75
122
Which patients should get Statin therapy?
All diabetic patients 40-75
LDL 190 or greater
10year ASCVD risk 7.5 or greater
123
What does Nictinic acid or niacin do? Fibrates?
Raise HDL; decrease triglycerides and increase HDL
124
Patients who have symptoms and risk factors that are suggestive of stable CAD should get what done?
Exercise ECG or pharmacologic stress testing then if positive should be given medical management with coronary angiography
125
What medication should be discontinued for patients who have osteoporosis? Why?
Selective estrogen receptor modulators such as raloxifene and tamoxifen because it increases the risk for Venus thromboembolism and should be discontinued four weeks prior to surgical procedures
126
What are the risk associated with ACEi and ARBs?
Peri andPostoperative hypotensive episodes, Should be withheld 10 hours before surgery Unless the patient is taking them for heart failure
127
What are the medications that can be continued during surgery?
Calcium channel blocker, statins, beta blockers, alpha two agonist such as clonidine
128
What are the medications in which withdrawal can cause hypertension during surgery?
Beta blockers and alpha two agonist
129
How should diuretics administered peri and postoperation? What are the adverse possibilities?
Continue up to the day of surgery and hold that morning; possibility for hypervolemia and hypotension
