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ABIM > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Opening

A

Snap - MS

Click - MVP

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2
Q

Closure

A

S1

S2

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3
Q

Loud S1

A

MS
Short PR (WPW)
Tachycardia
Thyrotoxicosis

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4
Q

Soft S1

A

MR
Long PR
inc’d LVEDP

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5
Q

S2 inspiration

A

A2 - AV closess first

P2 - PV closes last -> physiologist split

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6
Q

S2 expiration

A

both valves close at same time

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7
Q

S2 split inc’d

A

closese earlier - MR, VSD

Closes later PS, pulm HTN (loud P2) RBBB

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8
Q

Fixed S2 split

A

ASD

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9
Q

paradoxical S2 split

A

AS, HTN, LBBB

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10
Q

S3

A 
inc'd flow
chronic MR
CHF
TR, PDA
BENIGN IN KIDS
pregnancy
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11
Q

Inspiration

A

MORE BLOOD IN R HEART

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12
Q

S4

A 
Decreased compliance
Acute MR
HOCM
LVH
AS
Ischemia
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13
Q

Pericardial friction rub

A

Superficial scratch sound best heard when pt upright leaning forward and deep breath in pericarditis

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14
Q

Pericardial knock

A

constrictive pericarditis - sharp early diastolic sound (early 3rd sound)

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15
Q

Physioligc during expiration

A

Single S2

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16
Q

HTN/AS/LBBB

A

Paradoxical S2 split

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17
Q

ASD

A

Fixed split

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18
Q

Calcified AS

A

Single S2 (soft A2)

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19
Q

HTN

A

Loud A2

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20
Q

Pulm HTN

A

Loud P2

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21
Q

Physiologist split

A

A2 before P2

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22
Q

Pulsus tardus

A

slowly rising pulse

AS

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23
Q

Pulsus bisferients

A

rapid upstroke - bifid/trifid

HCM

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24
Q

Pulsus alternans

A 
one heart snd normal, one abn
severe HF
cardiac tamponade
SVC obstruction
Pulm obstruction
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25
Q

Hyperkinetic

A

High output state
PDA
Thyrotoxicosis

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26
Q

Hypokinetic

A

Low output states

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27
Q

Kusmal

A

deep breath more blood into R heart - taemponade - R septum bulges into LV, dec’d BP on inspiration, JVP bulges

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28
Q

Auscultation

A

R IInd IC space (Aortic Area)
AS
AI

Left II IC Space (Pulm area)
PS, PR, AI, PDA

LLSB (Tricuspid area)
TS, TR
ASD, VSD
HOCM

Apex (Mitral Area)
MS
MR
AR

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29
Q

Palpation

A

Left parasternal area
Hyperdynamic implse (inc’d RV volume (ASD or TR)
Sustained L parasternal heave - RVH, (MS, pHTN, PS)

Apical area
Hyperdynamic impulse
Inc'd LV vol (Hyprthyroid, Anemia, preimary MR, AR with nl EF, PDA VSD)
Susptained Apex lift/impulse
LVH (HTN, Dil CM)
IHD, AR with low EF
Bifid/trifid apical impulse - HOCM
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30
Q

AV Valve Holosystolic murmur

A

MR, MR, VSD

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31
Q

V valves Mid systolic murmur

A

AS, PS

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32
Q

AV Valves Late systolic murmur

A

MVP - mid systolic click

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33
Q

Diastolic mumur

A

All in-flow to ventricles creates diastolic murmurs

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34
Q

AV valves Mid diastolic murmur

A

MS, TS

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35
Q

AV valve - late diastolic murmur, mid systolic plop

A

Arial Myxoma - > surgery

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36
Q

V valves Early diastolic murmur

A

AR, PR

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37
Q

Continuous murmur

A

PDA

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38
Q

Pt with fixed split 2nd heart sound and mid systolic -diastolic rumble dx?

A

ASD

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39
Q

Inspiration

A

inc’d flow to R side of heart, all R sided murmurs increase

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40
Q

Expiration

A

Inc’d flow to L side of heart - all L sided murmurs increase

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41
Q

Inc’d flow INCREASES all murmurs EXCEPT

A

HOCM/MVP (decrease)

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42
Q

Inc’d flow

A

Sitting, squatting, leg raising

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43
Q

Dec’d flow

A

Standing, Valsalva

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44
Q

Handgrip

A

increases afterload, increases flow to murmurs that flow backward (AI, MR, VSD)

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45
Q

What happens to murmur during handgrip or phenylephrine

A

Handgrip inc’d afterload, LV cavit size inc’s so ALL murmurs increase including MR
Except: dec’s HOCM, MVP, AS

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46
Q

What happens to murmurs with amyl nitrate use

A 
Decreaes afterload, so its easy for blood to be pushed into systemic cir, LV cavity decreased
MR dec's
MVP inc's
HOCM inc's
AS inc's
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47
Q

What happens to murmur post PVC

PVC=inc’d volume, dec’d afterload

A

HOCM/AS increase

MVP dec’s

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48
Q

What happens to blood that returns to heart during valsalva maneuver

A

Increases intrathoracic pressure and DEcreases blood return to heart

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49
Q

Kussmaul’s sign

A

Neck vins DISTENTION on INSPIRATION
constrictive pericarditis
cardiac tamoponade
RV infarct

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50
Q

Application of pressure in the RUQ causes engorged Right jugular vein - rapidly improved upon release of pressure - indicates…

A

Increased jugular venous pressure

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51
Q

inspiration

A

inc’d R side murmurs

Dec’d L side murmurs

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52
Q

Expiration

A

inc’d L side murmurs

Dec’s R sided murmurs

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53
Q

Standing/valsalva

A

Inc’d HOCM, MVP

Dec’d all other murmurs

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54
Q

Squatting/Sitting

A

Dec’d HOCM, MVP

Inc’d All other murmurs

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55
Q

Hand grip

A

Dec’d HOCM, AS, MVP

Inc’d MR, MVP

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56
Q

Post PVC

A

Inc’d HOCM, AS

Dec’d MVP

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57
Q

AS

A

inc’d standing, valsalva, post-PVC

dec’d with handgrip

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58
Q

MR

A

inc’d standing, valsalva

Dec’d Post=PVC, handgrip

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59
Q

MVP

A

Dec’d standing, valsalva, post-PVC

Inc’d with handgrip

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60
Q

HOCM

A

Dec’d Standing, valsalva, handgrip

Inc’d Post-PVC

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61
Q

16yo pw routine checkup - PE reveals a murmur at LSB radiating thru pre-cordium - no change with valsalva or respiration - exam LVH dx?

A

VSD

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62
Q

RCA

A

inferior
II, III aVF
Posterior V1, V2 (early R wave progression)
RV -> V3R-V4R (no nitrates - IVF + atropine if HR dec)

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63
Q

LAD

A

Anterioseptal V2-4

Anterior V3-5

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64
Q

Cirumflex

A

Apicolateral V5-6

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65
Q

Circumflex branch (OM1) or LAD branch (diag)

A

High lateral

I, aVL

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66
Q

Pt h/o CP EKG stress reveals depression in lateral leads - nuclear iaging reveals anteroseptal ischemia

A

High grade LAD stenosis

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67
Q

48yo F exertional CP, stress done - stopped in 50 min from CP and ST dep V4-6

A

High grade LAD stenosis

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68
Q

Epidemiology

A

900,000 deaths/yr
1/3 from CAD
smoking doubles risk
INc’d LDL and total chol risk factor
1% dec LDL = 2-3% ec risk of CAD
Every 1mm dec in BP - 2-3 % dec in r/o MI
Death rates with heart dz MORE in females

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69
Q

Risk factors for atherosclerosis

A 
Modifiable
HLD
tob
Psychocsocial stressors
DM
HTN
Obesity
Etoh
Physical activity
Diet low in fruits/vegies

Unmodifiable:
Age
Male
Family h/o premature CAD (LP (a))

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70
Q

Pt no meds - wants advice on dec’ing CAD risk - smoker, HTN, LDL 100 wtd?

A

Quit smoking

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71
Q

ACS

A

ST elev -> Q wave MI - TPA or PCI
NSTEMI - w+CE - ASA, plavix +- IIb/IIIa
no CE (U/A) - no TPA - hep gtt, ASA, plavix

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72
Q

Workup for suspected CAD - middle aged woman pw chest pain, chest discomfort or atypical CP - wtd?

A

EKG - if normal stress test (exc if can walk)

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73
Q

If pt with COPD then

A

Dobutamine stress (no adneosine, dyprimadole)

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74
Q

45yo F vague CP on exertion - EKG normal - exc stress non-sp changes - wtd?

A

Exc stress with imaging

If can’t walk - or non-sp ST chagnes with LBBB, LAHB, repolariz change then persantine/thallium study

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75
Q

Which can under EKG stress?

A

RBB (not LBBB or paced)

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76
Q

Pt with peripheral vascular dz scheduled for bypass surgery - wheezing on exam - HTN controlled to 150.90 from 170/110

A

Dob stress test (can’t use adenosine or dipyridamole with wheezing)

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77
Q

Who gets gated pool studies or MUGA scan

A

IN pt to dtermine LVEF and WMA (dec’d LVEF poor prognostic factor on MUGA

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78
Q

When NOT to do stress test

A

U/A

AS with sx

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79
Q

45yo DM2 with CP, EKG neg - test LEAST likely to be accurate is…

A

Exercise stress test

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80
Q

Obese woman with atypical CP undergoes EST - stops test after 5 min due to fatigue, no CP, HR inc’d by 50%, no EKG chagnes wtd?

A

Adenosine stress or stress echo

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81
Q

When is EST positive

A

Flat or down sloping ST depressions>1mm & longer than 0.08s
If ST elevated then high grade stenosis

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82
Q

When do you stop a stress test

A

ST dep >2mm
SBP dec >15mm Hg
VT
Chest pain/SOB

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83
Q

Poor prognostic factors on stress test

A 
>2mm ST depression
Persistant ST dep 5 min post excercise
Fall in BP > 15mmHg
ST elev
Vent ectopy/VT
global ischemic changes
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84
Q

Who gets cardiac cath/angiogram

A

Presence of poor prognostic factor on stress test
Post infarct angina
U/A on med tx still with sx or ST dep or troponin +

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85
Q

Unstable Angina

A

New onset severe angina < 2 months
Angina at rest
Recent inc’d freq
Post infarct angina

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86
Q

Pt with angina controlled on BB, ASA, nitrates pw inc’d freq and now chest pain lasting > 30 min -> EKG ST dep II, III, aVF - most likley mechanism for CP

A

Atherosclerotic plque with intermittent rupture and thomobolysis

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87
Q

Pt h/o chornic angina controlled on ASA, nitrates with inc freq angina wtd?

A

Add BB

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88
Q

Pt now on ASA, nitrates (with 12 hr nitrate free interval) and BB with inc’d freq angina

A

Check CBC for anemia

Check for infxn (in’d HR-> ischemia)

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89
Q

Abv pt with low Hg and EKG with ST dep - PRBC tx’d wtd?

A

Coronary angiogram

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90
Q

Pt on ASA, nitrates, BB, statin, Hg normal - no signs infxn or stress with increasing episodes angion a on exertion - angiogram MV dz not amenable to revascularization - wtd?

A

Ranoxazine (ranexa)

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91
Q

Antiplts

A

ASA - thromboxane
Plavix ADP
GB IIb/IIIa

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92
Q

Pt with CP, ST depression present

A

Welen’s syndrome -> persistent twi on EKG - cath lab

LMWH + GP IIb/IIIa + Plavix + ASA

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93
Q

If angina or ST depression perissts with or without troponin (+)

A

Cardiac cath

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94
Q

Pt stopped ASA 2 months ago 2/2 PUD - started on PPI now pw CP wtd?

A

start ASA

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95
Q

45yo M non-smoker, no DM pw new onset CP more than 1/2 hr duration while shoveling snow - no EKG changes in ER wtd?

A

Admit pt to chest pain unit

If CE neg, no ekg chages o/n -> stress test

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96
Q

65yo M woke up early AM with severe retrosernal CP x 40min, sweating, diaphoresis - EKG ST dep, Twi, started on ASA, IV nitrates BB, LMWH gpIIb/IIIa inhib - anginal pain resolves - 24 hrs later ST dep still persists

A

Dx: silent ischemia
Cardiac Cath pt
-> if angioplasty/PCI done - would decrease recurrent ischemia at 6 months (not reduce MI freq)

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97
Q

Multislice CT helpful to evaluate CP in what group of pts

A

Exclude dx in LOW risk patients

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98
Q

Exertiona dyspnea w/o chest pain in a pt may represent and anginal equivalent in absenseof pulm dz - mc seen in…

A

DM
Women
Elderly
Post CABG

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99
Q

Pathogenesis of SOB

A

Ischemia-> inc’d LVEDP-> Pulmonary edema

Dx: Empiric NTG or stress test or radionuclide studies

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100
Q

65yo with murmur MR during excercise and disappers post exc - S4 + echo shows mild hypkinesisa and EF 60% etio?

A

Ischemic

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101
Q

46yo M CP lasting 15 min - resolved in ED - HR/BP ok, no ST elev - deep Twi 1-4 - wellen’s sign wtd?

A

Check echo, cath

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102
Q

The followin gare true in pts with DM

A

CAD lesions are proximal
CABG better tha PTCA in pt with CAD
DM patients more likely to have silent ischemia
Among DM - more women athan men die of CAD
DM more prone to CAD than non-DM

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103
Q

Pt pw CP, EKG neg - Thalimum stress with reversible ischemia, cath neg dx?

A

microvascular angina

Tx: CCB, BB, nitrates

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104
Q

Elderly man with h/o syncope - EKG on prsenation normal - feels dizzy after dinner - ST dep in II, III aVF - EKG after 15 min normal dx?

A

Post prandial ischemia

tx: cardiac cath

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105
Q

Least likely to cuase ST elevation is?

A

Unstable angina

Transmural MI, LV aneursym post MI, acute pericarditis, Prinzmetals angina ll aan cause ST elev

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106
Q

Young man brought to ER with severe CP - EKG shows ST elev and MI dx - caused by which drug?

A

Cocaine

tx: PCI

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107
Q

Cardiac enzymes

A

Troponin - + 3-6hrs after MI
Peak 10-25hrs
Normal 5-15 days

CPK-MB + 3-8hr
Peak 10-36hrs
Normal 3 days

LDH + 8 to 18hrs
Peaks 2-3 days
Returns to normal 6-10 days

Myoglboin - 0-85= normal
inc’d immediately peaks in 1-4 hrs and normal in 24 hrs

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108
Q

Pt with CP, ST elv trop elevated - s/p TPA ST resolve - CP resolved - next blood draw trop more elevated wtd?

A

Nothing - pt who reperfused have faster peak and higher peak of trop than pt NOT perfused

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109
Q

Pt pw CP and ST elev - PTCA done next day has CP best marker?

A

Myoglobin (peaks 1-4 hrs, normal 24 hrs)

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110
Q

65yo M aw PNA to MICU on IV abx - EKG NSR - trop 1.3 wtd?

A

Echo
Low level trop see in
CHF, critial illness, LVH, coronary vasopalsm, pulm embolism, CKD

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111
Q

Pt pw chest pain and low BP - you suspect RV infarct - next dx step?

A

R EKG - V3R-V4R

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112
Q

Acute MI

A

Q wave MI and non-Q wave MI both similar long term survival
Always admit pt with new onset classic CP - relieved by SL nitro even if pt young or EKG normal
PTCA better than TPA
thrombolytics NOT given for non-Q wave MI - instead give gpIIb/IIIa inhibitors just like for U/A and ST depression

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113
Q

INdications for thrombolysis

A

Chest pain typical for infarction > 30 min with LBBB
ST elev 1mm in two continguous leads
2hrs away from PTCA center and NOT in shock

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114
Q

Contraindication for TPA

A 
Absolute
Prev hmorrhagic stroke
Other CVA events < 1 yr
IC neoplasm
Active internal bleed
Relative
CVA> 1 yr
recent internal bleed or major trauma < 2-4 wks
BP>180/110
Pregnancy
Active PUD
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115
Q

Indications for PTCA (PCI or angioplasty)

A 
Acute ST elev MI
ST elevation with CP > 12hrs
MI with shock and Pt is < 75yr
STEMI post CABG pts
If tPA contraindicated
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116
Q

Plavix

A

Thienopyridine ADP Plt inhibitor
Pt with MI allergic to ASA -> use plavix
Pt going for PTCA needs plavix
Pt goign for CABG - NO PLAVIX

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117
Q

When is CABG better than PTCA

A

Left Main dz
3 vessel dz with dec’d LVEF
two vessel dz with prox LAD and decreased EF
DM with CAD

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118
Q

Pt with CAD s/p PTCA with stent palcement - what meds on d/c

A

ASA + Plavix

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119
Q

60yo pt undergoes CABG - couple months later he is doing fine but has problems keep ing accounts occasionally

A

Dx: neurocognitive defect

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120
Q

Pt with retrosternal CP>1, diaphoretic -> EKG LBBB, ST elev in ant leads - old EKG not availabe to compaire - CK and trop pending wtd?

A

Cath lab

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121
Q

Pt with Chest pain, ST elev ant leads - s/p tPA with BP of 90/60 - 2hrs later ST elev in lateral leads BP drops to 80 pt SOB - no new murmurs - CXR pulm edema wtd?

A

Cath - IABP-> PIC

If allergic to ASA then desensitization

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122
Q

Elderly pt with IWMI gets tPA - pt becomes hypotensive and HR 38 wtd?

A

atropine

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123
Q

HR 74, BP stable, pt confused, both puils dilated - dx?

A

ANtichoinergic delierum

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124
Q

Pt with 14hrs CP, taken antacids without relief - EKG with ST elevatins in anterior leads - BP 140/80 - given ASA to chew - IV nitrates, IV BB and IV morphine - closest PTCA at least 1 hr away wtd?

A

Transfer for PTCA

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125
Q

60yo pw CP AWMI to small community hospital - nearest PTCA 2 hours away wtd?

A

TPA then tx for PTCA

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126
Q

Pt aw MI - 3 day slater Cp relieved with NTG wtd?

A

Cath

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127
Q

Pt has cath - 2 days later pain in R groin - exam with erythematous and pulsatile mass wtd?

A

US r/o pseduoaneurysm

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128
Q

Pt with MI - 9 days later with persistent CP, worse on deep breath - pericardial friction rub - CXR with effusion - EKG diffuse ST elevation with concatvity upwards

A

Dressler’s syndrome - secondary pericarditis

Indomethacin, ASA

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129
Q

Factors shownto improve survival in MI

A 
PTCA
thrombolytic therapy after Q wave MI
BB
ASA
ACE in EF < 35%
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130
Q

Pt with CP, ST elev in II, III, avF all are true

A

ACEi improve survival
BB imporove survival
statins improve survival
(CCB DO NOT improve survival)

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131
Q

Pt p/w CP - AWMI tx’d in CCU wihtout complciations EF 30%, on D/C what meds

A

ASA, plavix, BB, ACEi, warfarin 3-6 months, Statin, ICD 40 days later - if high risk for VT then wear lifevest

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132
Q

65yo with angina CVABG 2ya HR BP ok, no DM, EF normal wtd to reduce chance of another cardiac event

A

ACEi (ramipril)

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133
Q

Pt had MI, stabilized - few months later stress tes ab - underwent cath - 70% Cx - started on ASA - what will inc survival?

A

Statin (NOT CABG or PTCA)

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134
Q

Complications of MI (arrythmia)

A

48hrs
VT (scar tissue -> need amiodarone-> ICD
NSVT

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135
Q

Complication of MI (ruptures)

A

Papillary muscle rupture -> Acute MR
Septal rupture -> Acute VSD
Free wall rupture -> Tamponade

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136
Q

Ventucular arrythmias during acute MI

A

Ventricular ectopy or NSVT during AMI should NOT be treated
VT/VFib occuring within 24 hrs of MI are independent risk factors for in house mortality BUT not risk for subsequent mortality from arrhthmia fter d/c
These DO NOT NEED long term antiarrhythmic therapy

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137
Q

Pt pw CP - EKG shows MI tx’d with tPA, heparin, nitrates, BB, ACEi - w/in 24 hrs pt has NSVT <30s wtd?

A

Observe

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138
Q

Mechanism of reperfusion arrhythmias?

A

Triggered activity; change in cardiac frequency due to accumulated Ca+

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139
Q

Reperfusion arrythmia

A

If unstable (dec’d BP, CP) - DCCV
If stable - amiodarone
wtd next - cath

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140
Q

Pt with NSVT reverts to SR and is otherwise uneventful - 5 days later pt ready for d/c does pt require long hterm anti arrythmic?

A

No

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141
Q

Pt with VT or VF 48hrs afte rMI - no evidence of reinfarction wtd?

A

tx VTACH

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142
Q

Vtach/VF 48 hrs after MI or more - independent risk factor for mortality after d/c - after acute tx wtd?

A

ICD

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143
Q

Pt has 2 discharges from ICD in 2 months wtd?

A

start amiodarone

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144
Q

Pt with ICD on amiodarone still getting shocks 4 months later wtd?

A

RF catheter ablation

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145
Q

Pt with MI refractive VT wtd?

A

O2 and correct electrolytes

Tx with amiodarone

146
Q

Post MI surgery

A

elective surgeries at least 6 months post MI (risk of reinfarction highest first 3 months post MI)

147
Q

Middle aged man clutches chest c/o severe CP - EKG diffuse ST elev with concavity up and PR depression wtd?

A

NSAIDs for pericarditis

Best med for ppx - colchicine

148
Q

If pt’s CXR (pericarditis) shows cardiomegaly or has JVD o rpulsus paradoxis wtd?

A

echo r/o tamponade/effusion

149
Q

Constrictive pericarditis

A

Rigid pericardium - impaired cardiac filling
Cl features - gradual onset dypnea, fatigue, ascites, Kussmauls sign +
Sharp early diastolic snd following S2 (early S3)
JVP - > inc’d with prominent x and y descent (Sqrt sign)
EKG normal
CXR - 50% show pericardial calcification
Echo - thickened pericardium =- early diastolic filling of ventricles and pressures >15 adn within 5mm of each other
Swan - RA=RV=PAP=PCWP
tx: pericardial stripping

150
Q

Risk factors for contrictive pericarditis

A

Post cardiotomy (CABG/AVR)
INfections Viral, TB, fungal
Radiation exposure to chest in past

151
Q

Most sensitive test to measure pericardial thickness

A

MRI

152
Q

Pt post CABG or AVR 4 yars ago with inc SOB for 3 months +JVD 9cm, hepatomegaly adn pedal edema, EKG and CXR normal - dx?

A

Pericarditis

153
Q

T/F in pericarditis JVP inc’d on inspiration

A

T

154
Q

T/F in pericarditis pericardial knock also knowna as sharp early 3rd heard snd can be heard

A

T

155
Q

T/F in pericarditis Echo can reveal pericardial thikening

A

T

156
Q

T/F in pericarditis CXR can show pericardial calcification

A

T

157
Q

T/F in pericarditis Treatment is surgical streipping

A

T

158
Q

T/F in pericarditis MRI is most sensitive to detect thickness of pericardium

A

T

159
Q

MCC CHF

A

Ischemia>dilated CM>HTN, valvular dz, congential HDz
Always r/o ischemia in pt with new onset CHF and sudden decompensation in stable CHF
MC precipitant of decompensation in CHF -> inc’d salt intake

160
Q

CHF Systolic dysfxn

A 
dec'd contractility
inc'd LVEDP
dec'd LVEF
Echo - dilated
Tx:
ACEi, BB, ACEi
diuretics (Loop/spironolactone)
Digoxin
Hydralazine + nitrate
ICD/CRT
161
Q

CHF Diastolic dysfxn

A 
dec'd relaxation
inc'd LVEDP
NORMAL EF
Hypertrophy on echo
Tx:
Candesartan
BB, CCB (long acting)
Diuretics
162
Q

BNP

A

inc’d in CHF
100-250 - significant LV dysfxn with compensated congestion
250-500 - CHF with both systolic and diastolic dysfxn
500-1000 decompenstaed CHF
>1000 - severe CHF

163
Q

Elevated BNP seen in…

A

LHF 2/2 diastolic dysfxn
LHF 22/ systolic dysfxn
RHF 2/2 COPD
RHF 2/2 PE

164
Q

60yo F eval for 3 month SOB on exertion, no CP, pmhx HTN DM2, HLD - takes meds wtd?

A

TTE check LV fxn/WM

165
Q

Echo with inf wall hypokinesis and EF 40% best managment?

A

Cath (not dob stress echo)

166
Q

50yo M pw inc’d SOB 3 days - pmhs HTN, BMI 40, JVP 14, b/l crackles and S3 heard, b/l pitting edema, BNP 160 - management?

A

IV lasix

167
Q

BNP monitoring shows what?

A

Dec’d mortality in pt <75yo

168
Q

Pt pw exc intolerance and DOE - exm JVD 10cm, few basal rales, S3+ - pt dx with CHF
CE and trop normal - pt tx’d with diuretics and gts better - TTE shows EF 35% wtd at d/c

A

ACEi

169
Q

In pt with new onset CHF - Cr up and K inc’d from 4 to 5.6 after starting ACEi wtd?

A

D/C ACEi

start hydralazine

170
Q

PT with CHF on lisinpril 5mg and lasix 40mg dialy pw continued fatigue, JVD 12cm, scatter rales, pitting edema - wtd?

A

Maximize lisinopril - start IV lasix) (no diff between bolus vs infusion)

171
Q

When to start BB in decompensated CHF

A

ONce volume overload corrected, start low dose BB and titrate up

172
Q

When to f/u patient as outpt after d/c for acute decompensated CHF

A

F/u Appt in 1 week (not 2)

173
Q

If CHF pt on lasix and lisinopril what to add next?

A

carvediolol

174
Q

Two months later pt on lasix, KCl supp, lisiopril 10 and coreg 25 bid NYHA III, EF 35% wtd?

A

D/C K supp and start low dose spironolactone

175
Q

Pt on spironolactone at inc’d risk for what?

A

HyperK+ (potassium sparing diuretic)

176
Q

Pt on spironolactone pw L only breast enlargement 6 months later

A

Biospy (if unilateral)

177
Q

CHF pt on lasix, coreg, spironolactone, lipitor prsents 6 months later with BILATERAL breast enlargment

A

D/C spironolactone ad start Eplerenone

If can’t afford Eplerenone -> start amiloride

178
Q

58yo F pw CHF taking lasix 20, lisinopril 5, liptor 20, coreg 6.125, spironolactone and ASA - JVP 12cm - lung with mid lung crackles, +S3, pedal edema b/l, EKG QRS 0.13 - started on IV lasix - best management?

A

Optimize medical therapy for CHF (all meds low doses and is overloaded now)

179
Q

1 wk later, pt that was on suboptimal therapy now on lisinopril 30, lipitor 40, coreg 25, spironolactone 25, lasix now up to 60, asa 81 - JVP 10, lungs still with bibasilar cracksl S3+ EKG QRS 0.13 EF 35 % - beset mangement?

A

Start Metolazone 30min prior to lasix

180
Q

9 months later - pt who was optimized for CHF with lasix, metolazone, coreg, lipiotr sprionlactone and asa for f/u - Echo still 35%, QRS 0.13 -

A

Start ICD with cardiac resynchroization tx

181
Q

54yo M CHF - echo reveals ejection fraction 35% - what target BP will prevent any coronary event in pt?

A

BP < 120/80

182
Q

76yo F c/o progressive SOB x 2 months - pmhx HTN, bibasilar crackles S1,S2 no murmurs 1+ pittin gedema - EF 65% with LVH best management?

A

CANDESARTAN (+diuretics)

183
Q

Apart from HTN which conditions will you get inc’d LV mass?

A

DM, Obesity

184
Q

Which pt’s have higer incidence of Heart failure wih prserved EF (HFPEF)

A

Women age > 75 with systolic HTN

185
Q

Poor prognostic factors for CHF

A 
S3
Hyponatremia
PCWP >12
PAP >50
Peak O2 uptake < 14ml/Kg
186
Q

Drug that improve mortality in CHF

A 
ACEi
ARB
Spiroolactone (for NYHA III/IV
Hydralazine+nitrates
BB
187
Q

What drugs DO NOT improve survival in CHF

A

Digoxin (improves fxn capacity and decreases hospitalizations)
CCB
Lasix

188
Q

55yo F brouht to ED onset of severe SSCP x 2 days - inc’d with breathing - recently lost custody of her grandchild - JVP normal HR 120 lungs clear trop 36, EKG 1mm ST elev V1-4 - echo anter and lateral wall hypokinesis with EF 35% ballooning of LV - cath shows NO CORONARY OBSTRUCTIN dx?

A

Takotsubo’s cardiomyopathy

189
Q

Can you use ACEI in asx pt with LV dysfxn?

A

Yes

190
Q

ACE used for all following

A 
Sclerodermal renal crisis
post acute MI
CHF
DM with microalbuminuria
HTN with S4
Viral myocarditis
IgA nephropath
NOT WITH PREGNANCY
191
Q

In pt taking ACEi least likely to follow

A

Serum Ca+

Do need to f/u BP, K, Cr

192
Q

S/E ACEi

A 
Cough 2/2 bradykinin
First dose syncope
Angioedmea/laryngela edema
Dec'd consstriction of efferent arterioles - renal failure in marginal patients
Neutropenia
193
Q

What drugs NOT to use in CHF pts

A

NSAIDs
Glitazones
CCB
Cilostazol

194
Q

Combination of ACEi and ARB shown what?

A

Less proteinuria

WORSE renal outcomes

195
Q

70yo F pw pulm edema, two earlier episodes - responds well to IV lasix - HTN hx with 160/95 - LUngs clear, systolic murmur II/VI at apex-> axill a - echo mild LVH EF 60% etio?

A

CAD

196
Q

65yo F new onset CHF loud S4 soft S3, JVD 12, basal crackes - EKG BBB echo EF 25% - started on iv laxi, iv ace sx improve next test?

A

cath

-if 3 vessel dz? -> CABG

197
Q

Joint commision core measures for CHF

A 
D/C instructions
Use of ACEi or AR
Document EF
Smoking cessation counseling
Flu shot
198
Q

Dilated CM

A 
Etio
Etoh/peripartum/doxorubicin
Ischemia
Hemochormatosis
Tx: Similar to systolic dysfuction
In severe CHF inotropic agents such as dobutamine
199
Q

Restrictive cardiomyopathy (Diastolic dysfxn)

A

Secondary to Fibrosis or
Amyloid - thickened septum refractile on echo - normal systolic fxn
Diastolic dysfxn (early restrictive filling)
Hemochormatosis
CHF/arrhythmias
Endomyocardial fibrosis

200
Q

Hypertropic CM

A

Diastolic dysfxn
Aut dom 30%
4% mortality/yr
Sudden syncope/death after vigorous excercise
Sudden death most frequent in familial form in young patient
CP/dypnea also occurs
Carotid and peripheral pulses with brisk upstroke, BISFERIENTS pulse
Early systoic murmura t LLSB inc’d with dec’d flow (standing, valsalva
(Symmetric hypertrophy=athletes heart)
Etio Asymm hypertrophy of LV = HOCM
Dx: Echo
Tx: BB improve sx
CCB for CP
ICD/Septal myotomy

201
Q

Do HOCM pts need endocardiitis ppx?

A

NO

202
Q

Poor progrnostic factors in HOCM

A 
VT
Age 3cm
Syncope
Failure to inc BP by 20mm upon excerise
Familial form and fhx of sudden death
203
Q

T/F about HCM 18yo basketball player with suddne death after vigorous play - autopsy hyperrophied IV septum

A

T

204
Q

T/F about HCM pt p./w syncope, dypena or CP

A

T

205
Q

Ventricular Tach on holter monitor inc’d risk of sudden death - these pts need ICD

A

T

206
Q

T/F about HCM Murmur inc’d on standing, valsalva and decreases with handshake and sitting

A

T

207
Q

An asyx 18yo wants to join soccer team at PE reveals ejection murmur and brisk carotid upsstorke - echo 16mm thickened upper portion of IV septum - wtd?

A

No high intensity sports
Can do boweling
tx: sx - CP - BB, long acting CCB
if no response - AV seq pacing or sugical myotomy
If Pt VT or NSVT on holter and fhx sudden death then ICD

208
Q

Aortic Stenossi

A

MC valvular dz in adults
pw
Sncope - left untreated time to death 3 years
CP - left untreated time to death 3 years
CHF left untreated time to death < 2 years
Signs: Pulsus tardus - systolic crescendo-decrescendo murmura t Right sternal border rad to carotid
Delayed and slow carotid upstroke

209
Q

Signs of severe AS

A

S4, paradoxical split S2, late peaking murmur Echo with gradient >50, valve <0.5cm sq

210
Q

WTD in asx AS pt

A

f/u serial echos

211
Q

WTD if progressive deterioration with sx

A

Replace valve

212
Q

75yo AS gradient 80 and syncope - falls has hip fx after fall

A

replace valve first
If poor EF then
Balloon valvuloplasty prior to hip surgery

213
Q

If pt has asx AS and hip fx with echo gradient 0.5 then wtd?

A

Swan during surgery

214
Q

AS pt going for surgical valve replacement wtd prior?

A

Cath

215
Q

What is seen in pt with AS

A

LVH

216
Q

AV malformation with GI bleed related to?

A

AS

217
Q

Aortic Reguritation

A

Presents w/ dyspnea (backed up blood)
Early diastolic murmur at Left sternal border
Sever cases with AUSTIN FLINT MURMUR (mid diastolic murmur like MS)

218
Q

AR tx:

A

Tx: Even with severe AR, Asx and EF>50% then according to LV dimentions
ES 55, ED >75 -> Surgery
IF EF<50 with sx then DO SURGERY!

219
Q

Austin flint murmur

A

AR Jet hits MV open leaflets mid diastolic murmur like MS

220
Q

25yo F with AR EF 60% wants to get pregnant - what to expect?

A

Normal Vaginal Deivery

221
Q

Best candidate for sildenafil is

A

Pt with AR adn preserved LVEF (better than AS or pt with angina)

222
Q

Mitral stenosis
Middle aged woman born in china/india with dyspnea, hemoptysis - on exam loud S1, Loud P2, opening snap - mid diastolic rumble (decrescendo at apex - Swan PCWP 18, PAP 80/34, RAP 15 - CXR cardiomegaly - straighteing of left heart border

A

Dx: Mitral stenosis
COmplciation - dilation of LA -> Afib -> thromboembolism and CHF
Tx: If valve

223
Q

The reason for using diltiazem or BB in mitral stenosis

A

inc diastolic filing time

224
Q

Pt with III/VI holosystolic murmur at apex->axilla asx or mild diziness echo sev MR BP/HR ok EF 50% LV 72mm diastolic, 51 mm systole wtd?

A 
Surgery for mitral regurgitation: Repair>Replacement
Asx - LV systomic dysfxn (EF<60)
Pulm HTN
afib
Symptoms
225
Q

Pt h/o aortic aneurysm schedule for surgery gtting stress test - recent EKG, PFTs CXR normal - during stress test has ST dep in lat leads and 2/6 systolic murmur at apex - 5 min later no murmur dx?

A

Ischemic MR

226
Q

ASD

A

Secundum defect 70% (no need for abx ppx)
Fixed S2 (pulm valve clsoes later than aortic valve
Parasternal impulse, prom a and v wave - mid systolic murmur at Left sternal border
EKG with RV strain and partial RBBB

227
Q

When closure

A

If L-> R shunt >1.7:1

228
Q

What if pt ASD asx and L-> shunt >2:1

A

Surgery

229
Q

What if R-> L shunt (Eisenmenger’s syndrome)

A

NO SURGERY - denotes onset of pulm HTN

230
Q

Atrial septal aneursym management

A

No ASA, No warfarin, no need to resect

231
Q

PFO

A

incomplete fusion of septum primum
Bubble study for dx - 1 bubble /beat in LA
(Hepatopulm syndrome 1 bubble every 4th beat)

232
Q

Secundum ASD

A

Incomplete covering of foramen ovale by septum primum

Ideal candidate for percutanous closure

233
Q

Primum ASD

A

Septum primum does not connect to endocardial cushion

234
Q

VSD

A 
common in children
systoic murmur at LLSB -> precordium
Split 2nd heart sound (not fixed)
No endocarditis ppx unless w/in 6 months of surgery
If L-> shunt >1.7:1 then Do surgery
235
Q

PDA

A

Crescendo-descrecendo continuous murmur left parasternal area (Lt 3rd ICS) - Soft S3
Surgery helps at all ages
No abx pps needed

236
Q

35yo Asx man for routine physical - brisk carotid upstrokes and ejection click followed by stystolic ejection murmur at base of heart, also II/VI diastolic murmur at LSB wtd?

A

Echo -
mild dilation of LV wtd?
nifedipine/ACEi revent further dilation and systolic dysfxn

237
Q

Coarctation of Aorta

A

Aw bicuspid AV
Delayed femoral-brachial pulse or absent femoral puulse
Early systolic murmur
Persistent HTN after surgical correction
BP higher in upper than LE
CXR rib notching 22/2 collateral vessels (“3” sign)
No need for abx ppx

238
Q

Marfan’s syndrome

A 
Decrased strength and dilation of aorta with aortic regurgitation and dissection
Monitor yearly echos
If >4.5cm - Echo q6month
5.5cm or greater - repair
Prevention of dissection - BB
239
Q

Pt with marfan’s has echo q6month - current echo 5.3cm - pt wants to wait

A

explain pt should consider repair now and the possibility of dissection in mean time

240
Q

Eisenmenger’s syndrome

A

R-> L shunt

Cl ft - Cyanosis of mucous membranes

241
Q

HTN

A

Systolic BP>disastolic BP as CVD risk factor

242
Q

HTN screenings

A

Pt normal BP after age 18

Screen for HTN q2yr

243
Q

What systoic BP aim for in elderly

A

SBP < 150

244
Q

Diastolic HF more common in…

A

Women > 75 with systolic HTN

245
Q

Isolated systolic HTN in elderly tx?

A

Thiazide diuretic 12.5-25 daily

246
Q

Mild to mod HTN

A

Thiazide/chorothalaidone

247
Q

HTN with LVH (S4+)

A

ACEi

248
Q

HTN with renal insuff

A

ACEi

249
Q

HTN with ischemic HDz

A

BB, CCB

250
Q

HTN with DM/proteinuria

A

ACEi

251
Q

HTN with CHF

A

ACEi, Diuretics, Carveilol

252
Q

HTN post MI

A

BB, ACEi

253
Q

HTN with gout

A

Losartan (ARB)

254
Q

HTN with pregnancy

A

Labetolol, Methyldopa, hydralazine

NO ACEi

255
Q

Thiazide s/e

A 
Hyper Ca+
Hyper uricemia
Hypo K+
Hyponatremia
Inc'd dig and lithium levels
256
Q

Does Angiotensin II blocker induce cough?

A

NO

257
Q

Pt on HCTZ 25 daily BP still high wtd?

A

Restric fluid and salt

258
Q

Pt HTN on HCTZ 25 daily - BP 160-148 Exam S4+ wtd?

A

add ACEi

259
Q

Ma huang (ephedra) causes

A

HTN

260
Q

18yo F 170/105 wtd?

A

Urine tox first

261
Q

21yo Pt CP, cocaine + 160/100 wtdD?

A

benzo, nitrate, ASA

Prevent CP - no cocaine, CCB

262
Q

Thoracic aneuysm

A 
CP rad-> back
Acute AR murmur
Widened mediastinum
Surgery if >6cm and asx
OR symptoms at any size
or dissections
263
Q

Abdominal aneurysm

A

Interscapular pain
Surgery >5cm and asx
or Sx’s at any size
Dissecting AAA treat medically first with BB and nitroprusside if pain persists then surgery

264
Q

68yo M ddmittened for urgent repair of 7.5cm AAA pt with DM and inc’d cholesterol - fhx MI at 57 next step?

A

No further testing

265
Q

AAA screening

A

Anytime smoker age 65-75 - AAA US screening noce in MEN ONLY

No screening in women

266
Q

73yo chrnoic smoker with family hx AAA has neg abd US for AAA wtd?

A

No additional US needed

267
Q

73yo ex soker no fhx of AAA has small aneursym on US wtd?

A

Repeat US in 6 months

268
Q

60yo M h/o CAD severe CP-<> back 190/100 HR 90 decresenco murmur dx?

A

Aortic dissection
Dx: TEE - or CT scan wo contrast if no TEE available
then tx with BB, IV nitropruside THEN surgery

269
Q

A loose fitting/large fitting BP cuff will …

A

UNDERestimate BP

270
Q

Small/tight cuff will…

A

OVER estimate BP

271
Q

Porcine valve

A

No A/C

272
Q

Prosthetic valve

A

Needs A/C

273
Q

Valvuloplasty

A

Tricuspid stenosis, pulm stenosis, mitral stenosis

Temporary in Aortic stenosis

274
Q

TEE needed for…

A

prostethic valve endocarditis
Desceding aortic aneurysm
Left atrial thrombus
PFO

275
Q

Afib

A

atria fibrillating, no p waves
some imprulse conducted and cnotract ventricles - irregularly irregular ventricular response
Narrow QRS except with abberant conduction

276
Q

New onset afib

A

w/in 48hrs

277
Q

Paroxysmal afib

A

terminates spontaneously

278
Q

Chronic

A

always in afib

279
Q

Slow ventricular response in afib

A

BB
CCB
Digoxin

280
Q

Convert to NSR

A 
Amiodarone
Ibutilide (prolongs QT)
Quinidine
Procainagmide
Dofetilide (prolonges QT)
Electrical cardioversion
Dronedarone (ony med shown to decrease hospitazation -> avoid in pt with EF<35%)
281
Q

Risk factors for afib

A 
High risk
-Prev stroke
TIA or Embolism
Mitral stenosis
Prosthetic heart valve
Moderate Risk factors
Heart failure
HTN
Age>75
LVEF<35%
DM
Weaker risk factors
Female
Age 65-74
CAD
Thyrotoxicosis
282
Q

Afib tx

A

No risk factors - ASA 81
one mod risk factor ASA81 daily or wafarin INR 2-3
Any high risk factor or >1 mod risk factor - warfarin INR 2-3

283
Q

CHAD Vasc

A

Vasc dz 1 point
Age 65-75 1 point
Sc=female=1 point

284
Q

Heart dz with one major contraindication to warfarin

A

tx with ASA

285
Q

Afib with wide compplex tachy

A 
WPW
tx with procainamide
NO DIG
NO BB
NO CCB -> vfib
286
Q

62yo pw palpiations EKG afib HR 100/min - started on BB - echo with no vavluar abnormalies and normal wall thickeness - BP 140/84 wtd?

A

ASA 81 (no risk factors)

287
Q

76yo pt HTN pw palpitations - HR 110 HR 110, started on BB

A

Warfarin (one mod risk factor - HTN)

288
Q

65yo afib h/o TIA in past

A

Warfarin (one high risk factor)

start on 5mg daily

289
Q

Pt chronic afib on warfarin going for MINOR surgery

A

continue warfarin

290
Q

Pt with chronic afib on warfarin going for major surgery wtd?

A

If CHAD score 2 or less -> D/C warfarin 5 days prior no bridge
If CHAD score 3 or higher -> D/C warfarin 5 day sprior and bridge with:
1. LMWH twice daily and last dose 24 hrs prior to surgery OR
2. LMWH once daily last dose 1/2 morning of procedure

291
Q

On day of surgery pt INR 1.6 wtd?

A

Clear for surgery

292
Q

Rate control and A/C in afib compared to DCCV show to ?

A

Decrease stroke

Decrease hospitalizations

293
Q

Pt with chronic afib refractory to med tx or can’t tolerate meds wtd?

A

AVJ ablation with PPM

needs AC? - YES - atria still fibrillating

294
Q

Young adult recurrent afib refractory to medical tx or can’t tolerate meds

A

Afib ablation - pulm vein isolation

295
Q

Elderly pt pw weakness on L side body - EKG shows afib IV heparin started weakness resolves - carotid dopper hows L ICA >70% best tx?

A

warfarin + heparin bridge

296
Q

Afib rate control goal

A

<110 (resting)

297
Q

48yo M pw acute onset periumbilical pain - afib with RVR 130 bpm wtd?

A

arteriography r/o sequella afib emboli

298
Q

Pt wtih afib tx’ing with diltirazem - rate control - echo structurally normal heart - pt comes back with inc’d sx palpitations - holter shows many episodes of afib where he had sx wtd?

A

Add BB

299
Q

What drug will bring afib into NSR

A

ibutilide

300
Q

Aflutter

A

macro re-entrant circuit - EPS for RFA
Atrial flutter rate 250-300
Usually 2:1 block HR 125-175
Etio Cardiac or pulm dz - can have WPW
First slow AV conduction BB, dilt then cardiovert with amiodarone/quinidine
Low energy DCCV or atrial pacing can also be done
Recurrent flutter - EPS/RFA

301
Q

32yo F MS sudden palpitation - 150/min and regular - carotid massage slowed rate but then returned to 150 when stopped - dx?

A

Aflutter

302
Q

MCC SVT

A

AVNRT 70%
Tx: carotid massage
Adenosine 6->
If wheezing then CCB

303
Q

Orthodromic reentrant tachycarida

A

accessory pathway
EPS/RFA
down AVN, up accessory pathway - narrow complex
Tx: AVN blockers, vagal maneurvers

304
Q

Antidromic re-entrant tachycardia

A

Accessory pathway
Down accessory pathway, up AVN
Wide complex
Treat like VT with procainamide or cardioversion

305
Q

22yo palpitations pounding sensation in neck for several years - now worse - gets slightly dizzy at times - sx occur without warning while restig - when she breathes slowly and deeply palpiations resolve on own - EKG normal dx?

A

Paroxysmal SVT

306
Q

WPW

A

Impulse via accessory pathway reach ventricle earlier than AV node -> delta wave, shortened PR on EKG
WPW can pw Afib, aflutter and vfib
DO EPS if aw any arrhythmia or unexplained syncope
Never tx wide complex tachy with BB, CCB or digoxin

307
Q

Pt has SVT and respods to carotid sinus massage - pt asks how to prevent future episodes

A

teach vagal maneuvers

308
Q

25yo palpitations, gradual onset - during episodes sinus tach 140 notes - asx EKG normal - echo normal - pt dx with inappropriate sinus tach wtd?

A

start BB

309
Q

Youn athlete on routine physical found to have EKG with WPW, asx - can he play basketball?

A

YES

310
Q

Pt pw palpitaitons, EKG Afib or SVT - after BB feels bette rand repeat EKG shows shortened PR - wtd?

A

EPS/ablation of errant tract

311
Q

Pt pw wide complex tachycardia HR 200 QRS 0.14 pt has h/o WPW - unable to decide if is SVT with aberration or VTach - you woudl tx this patient with ?

A

Procainamide

312
Q

Multifocal Atrial Tachycardia

A 
Three or more distinct morphological types of "p" waves
Seen in COPD, result of theophylline use
Tx: Oxygen, Mg, inhaled bronchodilators
2nd: CCB
NO DIGOXIN
313
Q

PVCs

A

3 or more PVCs = NSVT

30 S of NSVT = sustained VT

314
Q

Pt with muultiple PVCs wtd?

A

Look for organic heart dz - echo, stress, gated pool studies
If heart dz negative, asx - NO TX
If heart dz neg but symptoms -> BB
If heard dz postiive with LOW LVEF -> ICD
Sustained VTach - ICD

315
Q

45yo healthy man who excercises everyday and asymptomatic, is going for elective major surgery - EKG reveals multiple PVCs wtd?

A

Clear for surgery

316
Q

Ventricular tachycardia

A 
3 or more consequential PVC
Diff dx:
SVT with aberrancy
WPW
LBBB
317
Q

VT more likely if

A 
QRS>0.14
LADev
Fusion beats
Capture beats
Prsense of organic heard dz
Cannon A
Concordance of QRS in precordial leads
Rate>100
318
Q

30yo AA pt to ER with palpitations - found to be in arrhythmia adn hypotensive - defib twice and IV med is started - exam cervial axillary and epitrocheal LN ++

A

Dx: Sarcoidosis

319
Q

Prolonged QT interval

A 
Quinidine Disopyramide
Methadone
Azithro
Procainagmide
Hypokalmeia, hypo Mg+
Pentamidine
Erythromycin
Phenothiazine
TCA, moxifloxacin
Ariprazole
320
Q

Torsade de points

A

tx: D/C offending drug
Overdrive pacing
Mg SO4

321
Q

MCC sudden cardiac death

A

ishemia

322
Q

What dec’d short term mortality in pt with vfib

A

Defibrillation

323
Q

What is most effective timing of defib

A

CPR then defib

324
Q

Pt with Vfib collapse in ER - defib x 2 but short while later vfib twice more wtd next?

A

epinephrine
check electrolytes
amiodarone

325
Q

Best managment in pt with fhx sudden cardiac death

A

ICD

326
Q

Indications for ICD

A 
Sudden cardiac death VT or Vfib
EF<35% with CHF irrespectie of etio
NICM - 3 monthas fter med therapy
ICM - 40 days after MI
HOCM with NSVT and fhx SCD
327
Q

21yo F wakened by alarm clock and minutes later has syncope - EKG prolongued QT and TWi - hx might be helpful is?

A

fhx sudden cardiac death

328
Q

60yo F c/o recurrent excercise idued palpitations with near syncoep - pt fhx near syncope in mother and daughter - EKG QTc 460, EF 55% next step?

A

BB therapy (sotolol)

329
Q

42yo Asian man with sudden cardiac arrest - EKG Vfib - defib’d successfull - EKG now ST elev in V1-3 and asx - pt fhx father dying at age 40 dx?

A

Brugada syndorme

tx: ICD

330
Q

Pt with h/o dizziness passing out for few sesonds - h/o palpitations

A

Holter montior (continuous loop recorder)

331
Q

Pt with palpitations 2-15 minutes - NO SYNCOPE

A

Event monitor - press button to start

332
Q

First deg AVB

A 
conduction impulse to ventricles delayed
PR>0.2
intranodal block with benign process
NO NEED FOR PPM
(if suspecting endocarditis -> may have new 1st deg AVB)
333
Q

2nd deg AVB type I (mobitz I/wenkebach)

A

prolonguing PR till dropped QRS

no need for PPM unless very low HR or HD problems

334
Q

Pt with inf wall MI had PCI now stable - 3 days later tele shows 2nd deg AVB type I 50bpm no sx - wtd?

A

Close monitoring as outpt
reduce BB dose
Block in AVN

335
Q

2nd deg AV block type II

A

PR prolonged but constant with sudden drop QRS
If 2/2 IWMI/RV MI usually transient and doesn’t required PPM (may need atropine or TVP)
If 2/2 AWMI - more extensive damage - may need PPM
Infranodal block

336
Q

3rd deg AVB

A

atria and ventricles beathing at own rate - cannon A waves on JVP
PPM needed
Acute MI with new bifasciular block -> high risk for progression to CHB

337
Q

Indications for PPM

A 
2nd deg Mobitz II
3rd deg AVB
Pause dep VT
sinus nodes dysfxn - HR3s, Mobitz II AVB with bifasciular block, post op AVB
CHF with prolonged QRS - use bivi ppm
338
Q

75yo M intermittent palpitations denies SOB or syncope - pt on BB and ACEi for HTN - EKG NSR 66bpm - holter with HR 35-106 during day

A

PPM (need for tachy brady to tx palpitaitons)

339
Q

80yo for regular checkup found to have HR 45 - holter shows rate max 55, drops to 38 during night at one point - no sx

A

reassurance NO PPM

340
Q

65yo F SOB on exertion CHF EF 22% on nitrates, BB, ACEi, spironolactone and dogxoin QRS>0.12 what else to decrease sx?

A

BIVICD

341
Q

Junctional rhythm

A 
Junctional tachycardia
Vrate 70-130
p wave may be inverted - buried beneath QRS or following QRS
Etio: 
Dig toxicity
IWMI
Myocarditis
Post cardiac surgery
342
Q

Sinus bradycardia

A

HR<60
Hypothermia
Hypothyroid

343
Q

Sick Sinus syndrome

A

SA node problem causing bradycardia, block, arrest or tachy-brady syndrome
No need for EPS -> directly to PPM
Tx: PPM if:
1. Symptomatic
2. Tx of tachyarrhythmias causing significant bradycardia

344
Q

Digoxin

A

inc’d vagal tone
Wt loss
anemia
AVN block -> Jnc rhthym -> regularized afib -> dig tox

345
Q

Digoxin effect

A 
Scooped ST segment
No tx (not dig toxicity)
346
Q

Anti arrhythmic drugs

A

ClassI decrease upslope of action potential
Ia: Disopyramide, Quinidine, Procainamide (Double quarter Pounder)
Ib: Lidocaine, Tocainide, Mexiletine, Phenytoin (Letuce Tomato, mayo)
Ic: Flecanide, Propafenone (Fries Please)

Class II: decreases synpathetic activity
Beta Blockeers

Class III: prolongs action potential
Amiodarone, Sotolol, Bretylium

Class IV: CCB

Others: Adenosine: slows AV conduction
Digoxin

347
Q

Toxicity of Antiarrhythmics

A

Quinidine -> prolongues QT, dec’d plts
Procainamide -> Drug induced lupus (anti-histone)
Lidocaine -> seizures
Amiodarone -> Pulm fibrosis, hypo/hyperthyroid, COrneal deposits

348
Q

LAenlargement EKG

A

M shaped pwave (MS)

349
Q

RAEnlargment

A

Tall p wave

350
Q

RVH

A

R wave V1, RADev

351
Q

RBBB

A

R, R’ V1-2

352
Q

LBBB

A

R R’ I, aVL, V6

353
Q

Digoxin: Normal level <1ng/mL

A

Toxcity - anorexia/wt loss
Regularized afib - weight loss
EKG Jnc Tachycardia, PAT with block, PVCs

354
Q

Predisposing factors for dig toxicity

A

Low K
Low Mg
Low Renal Fxn
Low O2

355
Q

Drugs tha tincrease Digoxin level

A 
Quinidine
Amiodarone
Verapamil
Spironolactone
Chlorthalidone/HCTZ
356
Q

Treament of Digoxin toxicity

A 
Correct electrolytes
BB
Lidocine/phenytoin
Digoxin binding antibodies - if pt with life threatening arrythmia
NO QUINIDINE, NO PROCAINAMIDE
357
Q

Pt with afib started on Digoxin - regularized afib on EKG wtd?

A

D/C Digoxin

358
Q

Elderly pt with Cr 1.3 on lisinopril, glizpiide mirtazapien and digoxin 0.25/day with gradual wt loss wtd?

A

lower digoxin dose

359
Q

Pt on digoxin and amiodarone is added wtd?

A

Decrease digoxin dose

360
Q

78yo M SOB with Cr 1.5 on digoxin and warfarin - EKG HR 96 looks regular with regular with retrograde pwave

A

Dig toxcity - check electrolytes

pAT with block

ABIM (14 decks)

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