Cardiology Flashcards
What features suggest cardiac syncope and how should it be evaluated?
- suggested by a sudden loss of consciousness and sudden regaining of consciousness
- begin with a cardiac exam
- those with abnormalities should have an echo while those with a normal exam should get ECG, telemetry, and cardiac enzymes
What is the most likely cause of chest pain?
GI disorder
What is the worst risk factor for coronary artery disease?
What is the most common risk factor?
What is the most dangerous lipid profile abnormality?
Which, if changed, provides the fastest benefit?
- worst is diabetes
- most common is hypertension
- elevated LDL is the worst
- smoking cessation provides the quickest risk reduction
What family history of coronary artery disease is considered a personal risk factor for CAD?
must be a first degree relative with premature CAD; either a male less than 55 or a female less than 65
Describe the pathogenesis, presentation, and treatment of Takotsubo cardiomyopathy.
- a massive catecholamine discharge causes acute myocardial damage, ballooning and left ventricular dyskinesias, leading to acute heart failure and death
- presents as chest pain, typically in a postmenopausal women who has just undergone immense stress
- treat with beta blockers and ACE inhibitors; revascularization plays no role since the arteries are fine
What features of chest pain are not consistent with ischemic heart disease?
it should not be positional, pleuritic, or reproducible on palpation
For those with chest pain, what accompanying symptom conveys the worst prognosis?
shortness of breath
What is the best initial test for chest pain?
always an ECG
When is “get cardiac enzymes” the right answer?
- for cases of acute chest pain presenting to the ED
- do not get for chronic pain or patients in the office
What role does stress testing play in the evaluation of chest pain?
stress testing is used to evaluate chest pain where the etiology is unclear and ECG is not diagnostic
For patients undergoing evaluation of chest pain, when are the following indicated:
- ECG
- exercise tolerance test
- exercise thallium
- exercise echo
- dipyridamole thallium
- dobutamine echo
- angiogram/cath
- ECG: always the best first test
- exercise ECG: used when the ECG is non-diagnostic
- exercise thallium: used when an exercise ECG can’t be read due to baseline abnormalities
- exercise echo: used when an exercise ECG can’t be read due to baseline abnormalities
- dipyridamole thallium: used when an exercise ECG can’t be done because the patient can’t exercise
- dobutamine echo: used when an exercise ECG can’t be done because the patient can’t exercise
- angio: used to decide on CABG versus angioplasty; it is also the most accurate test for detecting CAD and can be used if non-invasive testing is equivocal
What is dipyridamole testing? When can and when can’t it be used?
- it is a nuclear scan used in the evaluation of chest pain if a patient can’t exercise and the ECG was non-diagnostic
- may induce bronchospasm so avoid in asthmatics
What is a dobutamine echo? When can and when can’t it be used?
- it is an echo done following injection of dobutamine, which increases myocardial oxygen demand to provoke any inducible ischemia
- performed when an ECG was non-diagnostic and a patient can’t exercise
- contraindicated for ventricular arrhythmias, severe hypertension, LV outflow obstruction, and concurrent beta-blocker use
When is cardiac catheterization or angiogram used?
- typically used to evaluate patients in whom reversible ischemia has been demonstrated to decide on CABG versus angioplasty
- may also be used in some instances to diagnose CAD if non-invasive testing was equivocal since it is the most accurate test
What is the most accurate test for coronary artery disease?
catheterization
At what point does coronary stenosis become significant and at what point does it become surgically correctable?
- not significant until greater than 50%
- not surgically correctable until greater than 70%
Describe the workup for cardiac chest pain.
- ECG
- Stress Test
> exercise or chemical ECG if initial ECG normal
> exercise or chemical echo if initial ECG abnormal - angiography
- medical therapy or intervention
What medications lower mortality for those with chronic angina?
only aspirin and beta-blockers
What formulations are used for the treatment of chronic angina versus acute coronary syndrome?
- for chronic angina, oral and transdermal formulations are used
- for ACS, rapid acting sublingual, paste, and IV are used
How do beta blockers reduce mortality in those with chronic angina?
they reduce isotropy and heart rate thereby decreasing oxygen demand and prolonging diastole which increases coronary perfusion
What is the LDL goal for those with CAD and equivalents?
less than 70
What is the most common adverse effect of statin medications?
liver dysfunction, which is why patients should undergo routine monitoring of LFTs
What side effects are associated with:
- statins
- niacin
- fibrates
- cholestyramine
- statins: transaminitis and myositis
- niacin: flushing/pruritis, hyperglycemia, and hyperuricemia
- fibrates: myositis when combined with statins
- cholestyramine: GI upset
What is evolovumab?
a PCSK9 inhibitor which disinhibit hepatic clearance of LDL but do not have any mortality benefit
How are calcium channel blockers used in the treatment of coronary artery disease and chronic angina?
- dihydropyridines should be avoided because they cause a reflex tachycardia, increasing oxygen demand
- verapamil and diltiazem do not increase heart rate; however, and can be used in asthmatics who can’t tolerate beta-blockers therapy
- verapamil and diltiazem also play an important role in the treatment of Prinzmetal angina and cocaine-induced chest pain for which beta-blockers are contraindicated
What are the indications for CABG?
- three vessel disease with greater than 70% stenosis
- two vessel disease in those with diabetes
- one vessel dais if it is the left main coronary artery
How should chronic angina be treated?
- all patients should be put on aspirin and beta-blockers which are the only two shown to improve mortality
- all patients should also be started on a statin with goal of LDL less than 70
- add an ACEi for patients with reduced EF
- for asthmatics who can’t tolerate beta-blockers, use verapamil or diltiazem
- consider CABG for three vessel disease, two vessel disease in diabetics, or involvement of the left main coronary
What is the Kussmaul sign?
a rise in JVP with inhalation, which is most often suggestive of constrictive pericarditis
What is pulses paradoxus?
a more than 10mmHg drop in SBP on inspiration, which is indicative of cardiac tamponade
For those with ACS, ST elevation in which leads has the worst prognosis?
V4-V6, which involves the anterior wall of the left ventricle
What is the best first step in treating someone with an acute coronary syndrome?
dual anti-platelet therapy
What is the most common cause of death in the days following an MI?
ventricular arrhythmia
Describe anti-platelet therapy in the treatment of acute coronary syndromes.
- all patients should be started on dual anti platelet therapy
- aspirin and clopidogrel are the preferred agents
- prasugrel or ticlopidine are use in place of clopidogrel for those undergoing angioplasty and stenting because they lower the incidence of restenosis
How long do you have to perform PCI or give thrombolytics in patients with an acute coronary syndrome?
- 90 minutes to complete PCI
- 12 hours to give thrombolytics, although preference is for less than 30 minutes
Why are drug-eluting stents preferred to bare metal?
because the drugs that are eluted inhibit the local T cell response and reduce the rate of restenosis
What are absolute contraindications to thrombolytics in patients with ACS?
- major GI bleed or any CNS bleed
- blood pressure greater than 180/110
- surgery in the last 2 weeks
- ischemic stroke in the last 6 months
When is LMWH used in the treatment of acute coronary syndrome?
- it is part of initial therapy for those with NSTEMI and unstable angina to prevent clot expansion and transition to STEMI
- for those with STEMI, it is used after stenting to prevent restenosis
What is the treatment for unstable angina and NSTEMI?
- dual anti-platelet therapy
- beta-blockers
- nitrates for pain relief
- LMWH to prevent clot expansion
- GPIIb/IIIa inhibitors (abciximab)
- angiography and PCI if patients fail to improve
What is the treatment for STEMI?
- dual anti-platelet therapy
- beta-blockers
- nitrates for pain relief
- PCI or thrombolytics
- heparin after stenting if performed
How does the treatment of unstable angina and NSTEMI differ from that for STEMI?
- both get dual anti-platelet therapy, beta-blockers, and nitrates
- NSTEMI/unstable angina get LMWH and abxicimab, a GPIIb/IIIa inhibitor, at the time of presentation
- STEMI gets PCI or thrombolytics and then heparin after stenting
When is PCI used in the treatment of acute coronary syndrome?
- preferred intervention for those with STEMI if it can be completed within 90-120 minutes
- used for unstable angina or NSTEMI in patients who fail to improve with medical therapy
What does sinus bradycardia occur secondary to MI? Which types of MI specifically?
because of vascular insufficiency of the SA node, typically from involvement of the right coronary?
Describe the pathogenesis, presentation, and treatment of third-degree AV block in the post-MI setting.
- due to involvement of the right coronary which perfuses the AV node
- presents with bradycardia, an abnormal ECG, and cannon A waves
- treat with atropine for bradycardia and then place a pacemaker
What are cannon A waves?
bounding jugular venous pulses at the time of atrial systole due to third-degree heart block which causes the right atria to contract against a closed tricuspid valve
What ECG findings are suggestive of a right ventricular infarction and how does the treatment differ from those involving the left ventricle?
- signified by ST elevation in leads II, III, and aVF
- treat with fluids and avoidance of nitrates
How does the presentation of septal rupture differ from that of free wall rupture in post-MI patients?
- septal rupture produces a new VSD murmur and pulmonary congestion
- free wall rupture produces cardiac tamponade with pulseless electrical activity and pulsus paradoxus
How can septal rupture and valvular dysfunction be differentiated in the post-MI setting?
- both will present with a new murmur and pulmonary congestion
- however, mitral valve dysfunction produces an MR murmur whereas septal rupture produces a VSD murmur
How is re-infarction of the myocardium diagnosed and treated?
diagnose with ECG and CK-MB if initial infarction was recent then treat with angioplasty
Every patient who suffers an acute MI should be discharged with what medications?
- dual anti platelet therapy (90 days of clopidogrel if no stent was placed, 12 months if stent was placed)
- beta-blocker
- statin
- ACEi/ARB and spironolactone if EF is less than 40
Post-MI erectile dysfunction is most often due to what?
anxiety although the most common medication causing it are beta-blockers
When can MI patients return to sexual activity?
after 2-4 weeks of being symptom free
Describe the pathogenesis of ischemic cardiomyopathy.
infarction leads to dilation and regurgitation which produces CHF
Describe the pathogenesis of hypertensive cardiomyopathy.
hypertension leads to hypertrophy, which manifests as restrictive heart disease, eventually causing dilation and CHF
What is the best initial test for CHF? What is the most accurate?
- a TTE is the most important initial test
- MUGA is the most accurate measure of EF
When should you get a BNP?
in patients with acute shortness of breath for whom the etiology is not clear and an echo cannot be performed
What is patiromer? What is it used for?
- an oral potassium binder that exchanges calcium for potassium in the bowel
- helpful in those taking ACEi/ARBs who develop hyperkalemia
What benefit does digoxin offer to those with HFrEF?
it reduces symptoms and the frequency of hospitalization; it offers no mortality benefit
What medical devices offer a mortality benefit for those with HFrEF? For whom are they indicated?
- ICD for those who have ischemic cardiomyopathy and EF less than 35
- biventricular pacemaker for those with dilated cardiomyopathy, EF less than 35, and QRS above 140
What interventions provide a survival benefit in those with HFrEF?
- all patients should be put on beta-blockers, an ACEi/ARB, and spironolactone
- an ICD improves mortality for those with ischemic cardiomyopathy and an EF less than 35
- biventricular pacemakers improve mortality for those with dilated cardiomyopathy, an EF less than 35, and QRS less than 140
What is the only medication shown to improve mortality for those with HFpEF?
spironolactone
What is the most important test to do if a patient arrives with acute pulmonary edema?
an ECG to see if a shockable arrhythmia is contributing
Describe the diagnosis and management of acute pulmonary edema.
- the best first step is an ECG to see if a convertible arrhythmia is contributing
- the best medication to then start is a loop diuretic
- patients should later receive oxygen, nitrates, and morphine as well as undergo a TTE
What is the general rule about left- and right-sided heart murmurs?
- right sided murmurs are loudest while lying back and with inhalation
- left sided increase when sitting up and exhaling
What is the best initial and what is the most accurate test for valvular heart disease?
- best initial test is a TTE
- the most accurate is a cardiac cath
Generally speaking, how are regurgitant and stenotic valves treated?
- regurgitant respond to vasodilator therapy, preferable ACEi/ARBs but nifedipine or hydralazine also work; replacement is indicated when the heart begins to dilate
- stenotic don’t respond to medical therapy and require replacement or angioplasty once they become symptomatic
Describe the etiology, presentation, diagnosis, and treatment of mitral stenosis.
- most cases are due to rheumatic heart disease and exacerbated by increased volume, so they present in pregnant immigrants
- typically presents with dyspnea and diastolic murmur just after the opening snap
- best initial test is a TTE but you should also get an ECG to look for a secondary atrial rhythm disturbance
- treat with diuretics, balloon valvuloplasty, and management of any resulting atrial fibrillation
Describe the presentation of aortic stenosis.
- typically presents in younger patients with a bicuspid valve or older individuals with calcifications
- earliest symptom is angina followed by syncope and CHF
- presents with a systolic, crescendo-decrescendo murmur and LVH hypertrophy seen on ECG
How do we define LVH on an ECG?
based on an R wave greater than 35mm in lead V5
Which murmur has an opening snap and which has a mid-systolic click?
- an opening snap indicates mitral stenosis
- a mid-systolic click indicates mitral prolapse
A wide pulse pressure, pulsations of the nail bed, and bounding pulse are suggestive of what heart disease?
aortic regurgitation
How do we manage bicuspid aortic valves?
- monitor with echo every 1-2 years for asymptomatic patients under age 30
- control any hypertension and then replace surgically if patient becomes symptomatic or develops LV dysfunction
Describe the presentation and treatment of mitral valve prolapse.
- presents with atypical chest pain, palpitations, and panic attacks
- a mitral regurgitation murmur follows a mid-systolic click and is exacerbated by anything that decreases left ventricular size
- treat with beta blockers if symptomatic
What are potential etiologies for dilated, hypertrophic, and restrictive cardiomyopathy?
- dilated: ischemia, alcohol, postviral myocarditis, radiation, doxorubicin, Chagas disease
- hypertrophic: hypertension
- restrictive: sarcoidosis, amyloidosis, hemochromatosis, scleroderma
Describe the pathophysiology, presentation, diagnosis, and treatment of HOCM.
- due to an asymmetrically hypertrophied interventricular septum which obstructs the LV outflow tract
- worse with anything that increases heart rate or reduces left ventricular chamber size
- presents with chest pain, syncope, and sudden death
- diagnose with echocardiogram
- treat with beta-blockers, ICDs, ablation, and myomectomy; diuretics and ACEi are contraindicated because they reduce LV preload
How is restrictive cardiomyopathy diagnosed?
- TTE is the best initial test
- biopsy is the most accurate
Which anatomic abnormalities of the heart produce symptoms and a murmur that worsen when preload is reduced?
mitral valve prolapse and HOCM
Standing will worsen which two murmurs?
mitral valve prolapse and HOCM because these are preload dependent abnormalities
What effect does valsalva have on the heart and murmurs?
- it increases intrathoracic pressure, reducing venous return to the heart
- this effectively improves all murmurs except HOCM and mitral valve prolapse
What effect does amyl nitrate have on heart murmurs?
- it is a direct arterial vasodilator and has the opposite effect as handgrip
- it will improve regurgitant murmurs
Describe the etiology, presentation, diagnosis, and treatment of pericarditis.
- most commonly due to coxsackie B virus but can be caused by any organism
- presents with chest pain that is better when sitting up and worse with deep inspiration
- an ECG will show diffuse ST elevation and PR depression
- treat with NSAIDs and colchicine
What will each of the following show in someone with a pericardial tamponade:
- CXR
- ECG
- Echo
- Cath
- CXR: globular heart
- ECG: electrical alternans
- Echo: right atrial and ventricular diastolic collapse
- Cath: diastolic equalization of pressures
What is the treatment for pericardial tamponade?
- pericardiocentesis or pericardial window
- fluids since patients are preload dependent
Describe the diagnosis and treatment of constrictive pericarditis.
- the best initial test is CXR showing calcifications and fibrosis; CT and MRI are more accurate; echo helps rule out other causes since the myocardium moves normally
- treat with diuretics and then surgical removal of the pericardium
Describe the presentation, diagnosis, and treatment of peripheral vascular disease.
- presents with crampy leg pain in the calves on exertion that is relieved by rest; often the legs are smooth, shiny, and hairless
- the best initial test is an ABI less than 0.9; the most accurate is angiogram used before surgical intervention
- treat with cilostazol, aspirin, smoking cessation, and a supervised exercise program
Describe the diagnosis and treatment of aortic dissection.
- the best initial test is CXR showing a widened mediastinum; angiogram is the most accurate but rarely used; confirm the diagnosis with TEE or CTA
- treat with beta-blockers then nitroprusside to a systolic pressure less than 190; surgery indicated for those involving the ascending aorta
What three heart diseases are likely to be exacerbated by pregnancy?
- peripartum cardiomyopathy
- Eisenmenger syndrome
- mitral stenosis
Describe the pathogenesis, presentation, and treatment of peripartum cardiomyopathy.
- due to antibodies against the myocardium, which produce damage and LV dysfunction
- presents as a HFrEF but is usually self-limited
- treat with ACEi/ARB if postpartum, beta-blockers, spironolactone, diuretics, and digoxin
