Cardiology

Question 1

First degree block

Answer 1

Constant prolonged PRI >0.20 sec
Management: none, observation

Associated with: aging, ischemia, inflammation, cardiomyopathies, digitalis

Question 2

2nd degree Mobitz I Heart Block

Answer 2

Wenckebach
Progressive PRI lengthening —> dropped QRS
Management: Asx: observation, +/- cardiac consult
Sx: ATROPINE (anticholinergic), epinephrine, +/- pacemaker

Question 3

2nd degree Mobitz II heart block

Answer 3

Constant, prolonged PRI —> dropped QRS
Usually block in bundle of HIS
Management: atropine or temporary pacing
Definitive treatment: permanent pacemaker

Question 4

3rd degree AV block

Answer 4

AV dissociation: P waves not related to QRS
Decreased output (since all P waves not followed by QRS)
Management: temporary pacing —> permanent pacemaker
Definitive txt: permanent pacemaker

Question 5

Treatment of choice in antidromic atrioventricular reciprocating tachycardia

Answer 5

Wolff-Parkinson White
Wide-complex tachycardia (>120ms)
Stable: procainamide, amiodarone
Unstable: cardioversion
Definitive treatment: ablation of the accessory pathway.

Do NOT use drugs that slow conduction through the AV node, such as adenosine, calcium channel blockers, and beta blockers. May enhance conduction through the accessory tract, leading to vfib.

Question 6

Mitral stenosis

Answer 6

History of rheumatic heart disease
Sx: exertional dyspnea, hemoptysis
On auscultation: loud S1, opening snap, low-pitched, rumbling diastolic apical murmur

Question 7

Aortic stenosis

Answer 7

Patient will be older
History of diabetes, hypertension
Sx: dyspnea, chest pain, syncope
PE: harsh crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop
Most commonly caused by degenerative calcification
Treatment is aortic valve replacement
Comments: murmur decreases with Valsalva

Question 8

Which murmur is most commonly associated with Marfan’s syndrome?

Answer 8

Mitral valve prolapse

Question 9

Mitral regurgitation

Answer 9

Patient with a history of ischemic heart disease, endocarditis, MI, trauma

Acute sx: dyspnea, pulmonary edema, cardiogenic edema
Chronic sx: asymptomatic until CHF onset, S3

PE: blowing holosystolic murmur, best heard at apex with radiation to axilla, pulmonary edema, cardiogenic edema

Diagnosis: TTE echo

Acute txt: nitroprusside, dobutamine, intra-aortic balloon pump, emergency surgery
Chronic txt: anticoagulation, CHF rx, valve replacement

Question 10

LBBB

Answer 10

large wide R wave in lead I
negative wave (QS or rS) in lead V1.
ST elevation V1-V3

New LBBB + Chest Pain = MI until proven otherwise

Question 11

RBBB

Answer 11

wide S wave in lead I

Triphasic QRS pattern in lead V1

Question 12

Acute Rheumatic Fever

Answer 12

Patient with a history of GAS infection
Complaining of fever, red skin lesions on the trunk and proximal extremities, and small, non-tender lumps located over the joints

JONES:
Strep: anti-streptolysin O, anti-DNase B, positive throat culture or positive rapid antigen test
Major: carditis, migrating Arthritis, chorea, subcutaneous nodules, erythema marginatum (non-pruritic rash sparing face)
Minor: fever, arthralgia, elevated ESR or CRP, prolonged PR interval

Txt: abx, NSAIDs

Question 13

Bacterial Endocarditis

Answer 13

Patient will be complaining of fever, rash, cough, and myalgias
PE: Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE)
Dx: echocardiography and Duke criteria

Most commonly caused by:
IVDA: S. aureus, tricuspid
Native valve: Staphylococcus aureus, Streptococcus viridans (m/c in previously diseased), mitral

Treatment is antibiotics
Comments: GI malignancy: S. bovis
Dental prophylaxis in some cases (amoxicillin)

Question 14

Dx of endocarditis

Answer 14

1. Blood cultures: 3 sets 1 hour apart
2. EKG
3. Echo (TTE first, TEE more sensitive)
4. Labs: CBC - leukocytosis, anemia; elevated ESR/RF

Duke Criteria:
Major: 1)sustained bacteremia with 2 + blood cultures by organism known to cause endocarditis; 2)endocardial involvement via echo or new valvular regurgitation (AR or MR)
Minor: 1)Predisposing condition (abnormal valves, IVDA, indwelling catheters, etc); 2)Fever; 3)vascular and emboli phenomena; 4)immunologic phenomena; 5)+ blood dx not meeting major criteria; 6)echo not meeting major criteria (worsening of existing murmur)

Question 15

Tetralogy of Fallot

Answer 15

Patient with a history of episodes of cyanosis (tet spells) and squatting for relief
PE: harsh holosystolic murmur LUSB, RV heave
Echo: gold standard: pulmonic stenosis, RVH, overriding aorta, and VSD (PROVe)
CXR: “boot-shaped” heart
Txt: PGE1 infusion followed by surgery
Comments: Most common cyanotic congenital heart disease

Question 16

Acute Pericarditis

Answer 16

Sx: pleuritic persistent chest pain radiating to the back, worse when lying back, improved when leaning forward
PE: tachycardia and pericardial friction rub
ECG: PR depression, PR elevation (aVR and V1), diffuse ST-segment elevation (concave)
Most commonly caused by idiopathic, then viral (Coxsackie)
Treatment is NSAIDs, colchicine

Question 17

Hypertrophic Cardiomyopathy

Answer 17

Sx: dyspnea on exertion (most common presenting symptom)
PE: harsh crescendo-decrescendo systolic murmur which increases in intensity with Valsalva maneuver and decreases with squatting
Diagnosis: echocardiography
Most commonly caused by an autosomal dominant genetic defect
Treatment: refraining from vigorous physical activity, beta-blockers or calcium channel blockers

Question 18

Hyperkalemia

Answer 18

Patient with a history of renal failure, DKA, rhabdomyolysis, tumor lysis
Complaining of lethargy, weakness, paralysis
PE will show bradycardia, hypotension, cardiac dysrhythmia
ECG will show peaked T waves, prolonged PR, wide QRS
Treatment is calcium gluconate, insulin, albuterol, bicarbonate

Question 19

Mitral valve prolapse

Answer 19

Patient will be complaining of palpitations, dyspnea, non-exertional CP, and fatigue. Most cases are asymptomatic.
PE will show midsystolic click and late systolic murmur
↑ Preload → ↓ murmur; ↓ preload → ↑ murmur
Marfan syndrome, Ehlers-Danlos
Diagnosis is made by echo

Question 20

Tricuspid regurgitation

Answer 20

Patient will be complaining of signs of right-sided heart failure - ascites, edema, RUQ pain
PE will show JVD and a blowing holosystolic murmur best heard at the left sternal border that become louder during inspiration
Diagnosis is made by echo
Most commonly caused by RV dilatation
Associated with Ebstein’s Anomaly

Question 21

Atrial septal defect

Answer 21

PE will show wide, fixed split S2
Most commonly caused by persistent ostium secundum
Comments: May lead to Eisenmengers syndrome

Question 22

Myocarditis

Answer 22

Patient will be complaining of fatigue, fever, chest discomfort, dyspnea, and palpitations
PE will show tachycardia that is disproportionate to fever or discomfort
Echocardiogram will show decreased ventricular ejection fraction with hypokinesis and wall motion abnormalities
Gold standard for diagnosis is an endomyocardial biopsy

Question 23

Ventricular tachycardia

Answer 23

> 3 consecutive ectopic ventricular beats
Monomorphic, polymorphic
Bidirectional: digoxin toxicity
Wide complexes
Pulseless: immediate defibrillation
Unstable: synchronized cardioversion
Stable: procainamide, amiodarone, synchronized cardioversion (refractory)
If unsure, manage all wide complex tachycardias as ventricular tachycardia

Question 24

Acyanotic congenital heart disease

Answer 24

ASD: fixed split S2
VSD: most common congenital heart defect, harsh holosystolic murmur at LLSB, complication: Eisenmenger syndrome (longstanding left-to-right shunt becomes a right-to-left shunt)
PDA: machine-like murmur, Rx: indomethacin
Coarctation of the aorta: upper extremity > lower extremity BP/pulse, CXR: rib notching, Rx: PGE1
Diagnosis is made by echocardiography

Question 25

Constrictive pericarditis

Answer 25

PE will show a pericardial knock on cardiac auscultation, Kussmaul sign, and pulsus paradoxus
Most commonly caused by fibrous thickening of the pericardium
Treatment is pericardiectomy

Question 26

Pericardial tamponade

Answer 26

Patient will be complaining of dyspnea and chest pain
PE will show muffled heart sounds, JVD, hypotension (Beck triad), pulsus paradoxus
ECG will show low voltage QRS, electrical alternans
Echocardiography will show
Diastolic collapse of RA (highly sensitive and specific)
Early diastolic collapse of RV (less sensitive, but is very specific)
Treatment is pericardiocentesis

Question 27

Tricuspid stenosis

Answer 27

Most common cause: rheumatic heart disease
almost always occurs with mitral stenosis (MS)
Murmur:
Diastolic murmur along left sternal border
Louder than MS during inspiration
JVP: giant “a” waves