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RC Study Cards > Cardiology > Flashcards

Cardiology Flashcards

1
Q

List 3 indications for infective endocarditis prophylaxis

A
  1. Prosthetic cardiac valve or prosthetic material used for valve repair
  2. Previous Infective Endocarditis
  3. Cardiac transplant recipients who develop valvulopathy
  4. Unrepaired CHD (including palliative shuts and conduits)
  5. Completely repaired CHD with prosthetic material/device during first 6mo after procedure
  6. Repaired CHD with residual defects at site or adjacent to site of patch/device
  7. Significant residual valvular disease 2˚ rheumatic heart disease
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2
Q

What is the most common underlying condition that predisposes patients to infective endocarditis?

A

Mitral valve prolapse

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3
Q

Is the mortality risk in infective endocarditis higher with prosthetic valves or native valves?

A

Prosthetic valves

(20% vs 5% with native)

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4
Q

List 2 instances where infective endocarditis prophylaxis is required

A
  1. Dental procedures involving manipulation of gingival tissue, periapical region of teeth or perforation of oral mucosa (not required for dental XR, routine anethestic [non-infected tissue], placing or adjusting orthodontic appliances or brackets, shedding deciduous teeth, bleeding from trauma to lips or oral mucosa)
  2. Incision or biopsy of respiratory mucosa (like a T+A) (not required for bronchoscopy unless incision of mucosa planned)
  3. Procedures on infected skin, skin structure or MSK tissue

Consider for UTI procedure (cystoscopy etc) that is not elective.

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5
Q

You decide your patient requires infective endocarditis prophylaxis. Provide instructions on how to take.

What if they cannot tolerate oral antibiotics?

A

Administer dose of amoxicillin (cephalexin, clinda or azithro if allergic) 30-60 minutes before the procedure or up to 2 hours afterwards.

If unable to tolerate PO antibiotics, give IV ampicillin, ceftriaxone or cefazolin. (can also consider clindamycin if ampicillin allergic)

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6
Q

Describe one way that individuals can decrease their incidence of bacteremia from daily activities.

A

Maintenance of optimal oral health and hygiene

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7
Q

Which of the following are indications for prophylaxis?

  • Bicuspid aortic valves
  • Mitral valve prolapse
  • Previous infective endocarditis
  • Patent ductus arteriosus
  • Significant residual valvular disease 2˚ rheumatic heart disease
  • Cardiac transplant recipients with cardiac valvulopathy
  • Hypertrophic cardiomyopathy
  • Calcified aortic stenosis
  • Prosthetic cardiac valves
A
  • Previous infective endocarditis
  • Cardiac transplant recipients with cardiac valvulopathy
  • Prosthetic cardiac valves
  • Significant residual valvular disease 2˚ rheumatic heart disease
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8
Q

Which of the following are indications for prophylaxis?

  • Palliative shunt
  • Coarctation of the aorta
  • Previous Kawasaki disease
  • Rheumatic heart disease if prosthetic valves or prosthetic material used in valve repair
  • Implanted defibrillator
  • CHD repaired with prosthetic material 3 months ago
  • Previous CABG
  • ASD/VSD
  • Repaired CHD with residual defect next to prosthetic patch
  • Pulmonic stenosis
  • Cardiac pacemaker
  • Appendectomy
A
  • Palliative shunt
  • Rheumatic heart disease if prosthetic valves or prosthetic material used in valve repair
  • CHD repaired with prosthetic material 3 months ago
  • Repaired CHD with residual defect next to prosthetic patch
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9
Q

List 4 risk potential cardiac risk factors for sudden cardiac death among children starting stimulant medication.

A
  1. SOBOE or poor exercise tolerance without alternative explanation
  2. Fainting or seizures with exercise, startle or fright
  3. Palpitations brought on by exercise
  4. Family history (1+2˚) of sudden unexplained death in <35yo (SIDS, unexplained drowning, unexplained MVCs)
  5. Personal or Family history (1+2˚) of nonischemic heart disease, long QT syndrome, familial arrhythmia, WPW, cardiomyopathy, heart transplant, pulmonary HTN, ICD
  6. Hypertension
  7. Sternotomy incision
  8. Pathologic sounding murmur
  9. Absent or delayed femoral pulses
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10
Q

Which structural CHD conditions are associated with sudden death?

A
  1. Tetralogy of Fallot
  2. Dextro-transposition of the great arteries (d-TGA) - particularly after Mustard or Senning procedures
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11
Q
  1. To what gestational age does the CCHD Screen apply?
  2. When should CCHD screening be performed?
  3. Where should the pulse oximeters be placed?
A
  1. ≥34 weeks being cared for in locations outside the NICU
  2. Between 24-36 hours postbirth
  3. Right hand and either foot
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12
Q

List 5 conditions that are detectable using pulse oximetry screening in newborns (CCHD)

A

Most consistently cyanotic

  • 5Ts
    • Truncus arteriosus (1 big trunk)
    • Transposition of the great arteries (2 interchanged vessels)
    • TRIcuspid atresia
    • TETRAlogy of Fallot
    • TAPVR (total anomalous pulmonary venous return) - 5 words
  • Pulmonary atresia with intact ventricular septum
  • Hypoplastic left heart syndrome

May be cyanotic

  • Coarctation of the aorta
  • DORV (double outlet right ventricle)
  • Ebstein’s anomaly
  • Interrupted aortic arch
  • Defects with single ventricle physiology
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13
Q

What is considered NORMAL, BORDERLINE and ABNORMAL on a CCHD test?

What do you do if you have each of these results?

A
  • NORMAL = ≥95% AND ≤3% difference
    • Continue with normal newborn care
  • BORDERLINE = 90-94% OR >3% difference
    • Repeat in 1 hour x 2, if BORDERLINE a 3rd time = FAILED screen
  • ABNORMAL = <90%
    • FAILED screen
      • assessment by MRP including 4 limb BP, ECG and CXR
      • If most likely cause appears to have cardiac origin or remains unclear, consult paediatric cardiology followed by echocardiogram
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14
Q

List 3 “red flags” for cardiac-related syncope

A
  1. Loss of consciousness without prodromal symptoms
  2. Syncope in response to loud noise, surprise or emotional distress (suspicious for long QT)
  3. Syncope during exercise
  4. Syncope while lying flat
  5. FMHx sudden death, LQTS/arrthymias, cardiomyopathy
  6. Syncope with an abnormal ECG

Additional from Hamilton Review

  1. Prolonged loss of consciousness (>5 min)
  2. Associated with palpitations or chest pain
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15
Q

List 3 features concerning for a pathologic murmur

A
  1. History concerning for cardiac disease
  2. Systolic murmur that intensifies with standing
  3. Presence of holosystolic or diastolic murmur
  4. ≥3/6
  5. Abnormal S2 or audible click
  6. Young age (neonate or young infant)
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16
Q

List 4 different types of innocent murmurs of childhoos

A
  1. Still’s murmur
  2. Venous hum (~3-8yo, louder when sitting up, disappears when lies down)
  3. Pulmonary flow murmur
  4. Peripheral pulmonic stenosis (0-6mo)
  5. Aortic systolic murmur
  6. Supraclavicular or brachiocephalic systolic murmur
  7. Mammary artery soufflé (teens/pregnancy)
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17
Q

Describe why a hyperoxia test is performed, how to perform the test and what the results indicate.

A

Hyperoxia test determines whether the presence of cyanosis is due to lung disease or CHD.

An ABG is obtained while the infant is breathing room air and then is repeated after 10min of receiving 100% FiO2.

  • >300 = Normal
  • ≥150-300 = likely respiratory disease, CNS disorder or methemoglobinemia
  • ≥100-150 = PPHN or cardiac mixing lesion w/increased pulmonary blood flow
  • <100 = cardiac mixing lesion with restricted pulmonary blood flow OR cardiac conditon with parallel circulation
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18
Q

What are common complications associated with PDA ligation?

A
  1. Vocal cord paralysis (injury to recurrent laryngeal nerve)
  2. Diaphragm paralysis (injury to phrenic nerve)
  3. Chylothorax (injury to thoracic duct)
  4. Later-onset scoliosis related to thoracotomy
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19
Q

Match the following murmurs to their condition

A
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20
Q

What condition does this demonstrate?

A

Coarctation of the aorta

Classic “3” sign.

Cardiomegaly

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21
Q

What condition does this demonstrate?

A

Transposition of the Great Arteries

“egg on a string” CXR

22
Q

What condition does this demonstrate?

A

Total anomalous pulmonary venous return

“snowman” sign

23
Q

What condition does this demonstrate?

A

Tetralogy of Fallot

“boot-shaped” heart

24
Q

List 4 risk factors for persistent pulmonary hypertension of the newborn.

A
  1. Polycythemia
  2. C-section delivery
  3. Postterm delivery
  4. Meconium aspiration syndrome
  5. Maternal SSRI use
  6. Hypoglycemia
  7. Cyanotic heart disease (especially obstructed TAPVR)
  8. Sepsis
25
Q

What is the most common cause of infective endocarditis?

A

1st: Group A streptococcus (Streptococcus viridans)
2nd: Staphylococcus aureus

26
Q

What is required to clinically diagnose infective endocarditis?

A

MODIFIED DUKE CRITERIA

Must have (one of) for Clinical Diagnosis:

  • 2 MAJOR
  • 1 MAJOR, 3 MINOR
  • 5 MINOR

MAJOR CRITERIA:

  1. Blood culture positive for IE
    • 2 positive BCx
    • Persistently positive BCx
    • 1 positive BCx for Coxiella burnetii
  2. Evidence of endocardial involvement
  3. Positive Echo
    • Vegetation
    • Abscess
    • New partial dehiscence of prosthetic valve
  4. New valvular regurgitation

MINOR CRITERIA

  1. Predisposing condition (indications for prophylaxis, IVDU)
  2. Fever ≥38˚C
  3. Immunologic signs
    • Glomerulonephritis
    • Osler nodes
    • Roth spots
    • Positive RF
  4. Vascular phenomena
    • Major arterial emboli
    • Septic pulmonary infarcts
    • Mycotic aneurysm
    • Intracranial hemorrhage
    • Conjunctival hemorrhage
    • Janeway lesions
  5. 1 positive blood culture (not meeting major criteria)
  6. Positive Echo (not meeting major criteria)
27
Q

Identify the following dermatological features and the diagnosis they are associated with.

A

INFECTIVE ENDOCARDITIS

28
Q

What is required to clinically diagnose rheumatic fever?

A

REVISED JONES CRITERIA

Must have:

  • Evidence of recent GAS infection (+rapid strep antigen test, throat culture, rising ASOT or DNase B titre)
  • Either
    • 2 MAJOR
    • 1 MAJOR+2 MINOR
  • Recurrent: as above or 3 MINOR

MAJOR

  1. Polyarthritis
  2. Carditis (MR most common, AI usually in combo w/MR)
  3. Sydenham chorea
  4. Erythema marginatum
  5. Subcutaneous nodules

MINOR

  1. Prolonged PR interval (only if no evidence of carditis)
  2. Fever ≥38.5˚C
  3. Polyarthralgia (only if no arthritis)
  4. ESR ≥60 (≥30 in endemic areas) or CRP ≥30
29
Q

Describe your management plan for rheumatic fever

A
  • Eradicate streptococcal infection
    • IM pen G x 1
    • PO pen V BID-TID OR amoxicillin daily x 10 days
  • High-dose ASA for mild-moderate carditis
    • PO prednisone for severe carditis
  • Consider need for long-term prophylaxis
    • Carditis w/valvular disease = 10y or until 40yo, sometimes lifelong (whichever is longer)
    • Carditis w/o valvular disease = 10y or until 21yo (whichever is longer)
    • No carditis = 5y or until 21yo (whichever is longer)
30
Q

What is the most common cause of myocarditis

A

Viral infection

31
Q

Describe features associated with Long QT syndromes

A
  1. Family history of sudden death (including Romano-Ward)
  2. Sensorineural hearing loss (Lange-Neilsen)
  3. Triggers
    • Stress or exertion, especially swimming (LQT1)
    • Auditory triggers (horns, alarms) (LQT2)
    • Postpartum (LQT2)
    • Sleep (LQT3)

FYI

  • tx beta-blockers + avoidance of QT prolonging medications
  • Schwartz score can be used
32
Q

Describe symptoms associated with CHF

A
  • Inadequate CO: Cool extremities, exercise intolerqnce, fatigue, gallop rhythm
  • Pulmonary Overload: Tachypnea, coarse breath sounds, feeding difficulties
  • Systemic Overload: Edema, hepatomegaly
  • Acute heart failure: Hypotension, tachycardia, poor perfusion
33
Q

Match the cardiac defect with the associated syndrome

A
34
Q

A child presents with SVT and poor perfusion.

  1. Describe your initial management.
  2. What pharmacological intervention is indicated (be specific)?
A
  1. Initial Management
    • Maintain open/patent airway, assist breathing and provide O2 as needed
    • Attach monitors for cardiac rhythm, O2 saturation and blood pressure
    • Establish IV/IO access
    • Obtain 12-lead ECG
  2. Adenosine (0.1mg/kg, max 6mg) as bolus with rapid flush technique using 2 syringes
    • If not effective, can try Adenosine (0.2mg/kg, max 12mg) with same technique
    • If not effective, attempt synchronized cardioversion (0.5-1J/kg) while recording and monitoring the ECG continuously before, during and immediately after each cardioversion attempt
    • If not effective, provide synchronized cardioversion (2J/kg)
    • If not effective, consult cardiology
      • Prepare amiodarone or procainamide
35
Q

Name 2 genetic conditions associated with secundum-type ASDs

A
  1. Noonan syndrome
  2. Treacher Collins syndrome
  3. TAR (thrombocytopenia with absent radius) syndrome
  4. Holt-Oram syndrome
36
Q

What structural heart lesion is associated with this ECG finding? Name 3 auscultatory findings AND 2 long-term complications seen with it if not repaired

A

Atrial Septal Defect

  • RSR’ pattern in V1

Auscultatory findings

  • Wide, fixed split S2
  • Systolic ejection murmur loudest to LUSB
  • Diastolic rumble at LLSB

Long-term complications

  • Atrial arrhythmias (particularly AFib [also AFlutter and SVT])
  • Pulmonary HTN and Eisenmenger syndrome
  • Paradoxical embolization → stroke
37
Q

List 4 ductal-dependent congenital heart defects

A
  1. Hypoplastic left heart syndrome
  2. Critical Aortic Stenosis
  3. Critical Coarctation of the Aorta
  4. Interrupted Aortic Arch
  5. Tetralolgy of Fallot w/ pulmonary atresia
  6. Pulmonary atresia w/intact interventricular septum
  7. Critical Pulmonic Stenosis
  8. Transposition of the Great Arteries
38
Q

What condition is associated with this ECG?

A

ALCAPA

(Anomalous Left Coronary Artery from the Pulmonary Artery)

ECG appears as a anterolateral wall MI (QR pattern followed by inverted T waves in I and aVL, Q waves in V5, V6)

39
Q

What is the most common cardiac lesion in an infant of a diabetic mother?

A

1st: Hypertrophic cardiomyopathy (resolves in weeks to months)
2nd: VSD

40
Q

What is the diagnostic criteria for Postural Orthostatic Tachycardia Syndrome (POTS)?

A
  • REQUIRES
    • Symptoms while upright
    • DAILY orthostatic symptoms
  • HR increase >40bpm during 1st 10min of upright tilt test without associated hypotension while replicating orthostatic symptoms that occur when upright
  • Improvement of symptoms in supine position

Symptoms associated with POTS: lightheadedness, orthostatic nausea, fatigue, tunnel vision, brain fog, 20-30% have syncope

41
Q

What comorbidities are associated with Postural Orthostatic Tachycardia Syndrome (POTS)? List 2.

A
  1. Sleep issues (usually delayed onset of sleep)
  2. Frequent awakening, not feeling refreshed in morning
  3. Aches in different parts of the body
  4. Abdominal pain
  5. Headaches and migraines
  6. Nausea and vomiting
  7. Raynaud-like symptoms
42
Q
  1. Describe the BEST investigation to diagnose Postural Orthostatic Tachycardia Syndrome (POTS)
  2. Provide treatment recommendations for POTS
A
  1. Head-up tilt table test for at least 10 min
    • Requires replication of day-to-day symptoms while upright, not just increased HR
  2. Nonpharmacologic
    • Regular aerobic exercise program
      • Start with water exercises + recumbent aerobic activities (rowing or recumbent bike)
      • Slowly increase time to 45min at least 5X/wk
      • When tolerance increases, advance to more upright aerobic activities + combine with light core- limb-strengthening activities
    • Fluids (>80oz/day)
    • Salt supplementation (2g in morning and early afternoon)
    • Compression garments (thigh or waist high)

Medications (if nonpharmacologic not sufficient)

  • Fludrocortisone
  • Midodrine
  • Metoprolol
  • Propranolol
  • Pyridostigmine - very useful if consipation present
43
Q

Describe the mechanism causing infants with VSD to present after 1 month of life.

A

PVR initially elevated→ falls in the first few weeks→ increase of L-R shunt

Pulmonary HTN due to large communication allowing exposure of pulmonary circulation to systemic pressure → pulmonary vascular obstructive disease

Once PVR/SVR ratio approaches 1:1, bidirectional shunt occurs →heart failure symptoms lessen → Eisenmenger physiology →cyanosis

44
Q
  1. Hypermetabolic demand
  2. Unable to feed adequately due to increased tachypnea + WOB during feeds
  3. Decreased suck strength due to fatigue from hypoxia
  4. Hypoxia leading to decreased ability to coordinate suck-swallow reflex
A

4 reasons a child has FTT with congenital heart disease

45
Q

List 3 causes of a prolonged QT interval.

List 2 genetic disorders that are associated with prolonged QT interval.

A

CAUSES

  1. Electrolyte disturbances
    • Hypocalcemia
    • Hypomagnesemia
  2. Medications
    • Antimicrobials (TMP/SMX, Macrolides, Fluoroquinolones, azoles)
    • SSRI (also seen in neonates with maternal SSRI use)
    • Cisapride
    • Amiodarone
    • Antipsychotics
    • Loperamide
    • Methadone
    • Sotalol
  3. Arsenic poisoning
  4. Starvation (including bulimia and anorexia nervosa)

ASSOCIATIONS

  1. Long QT syndrome
  2. Marfan syndrome
  3. Duchenne Muscular Dystrophy
46
Q

What is an association with Wolff-Parkinson-White syndrome?

Explain the pathophysiology of WPW?

A
  1. Hypertrophic cardiomyopathy
  2. Epstein’s anomaly
  3. L-TGA or CCTGA (congenitally corrected)

Accessory AV pathway allows “early” depolarization of ventricles (pre-excitation).

Can cause:

  • SVT (retrograde conduction through accessory pathway)
  • Sudden death (rapid antegrade condultion of atrial arrhythmia)
47
Q

You are seeing a patient with “repaired” CHD in your office. List 5 concerns associated with this population.

A
  1. Ongoing disease (AS)
  2. Growth and nutrition
  3. Arrhythmia (scar acts as a focus)
  4. Genetics (for family planning; recurrence ~4% (up to 10% w/left sided lesions; higher when part of syndrome)
  5. Development
    • Increased risk of specfic learning disorders, ADHD (especially if open heart surgery in 1st year of life)
  6. Dental hygiene (may require SBE prophylaxis)
  7. Scoliosis (if thoracotomy)
  8. Post-pericardiotomy syndrome (first 4 weeks) - associated with fever, pericardial and pleural effusions
  9. If Fontans procedure:
    • Protein losing enteropathy
    • Plastic bronchitis
48
Q

When is the highest risk of coronary aneurysm with Kawasaki disease?

What are 2 risk factors for coronary artery involvement and treatment resistance.

A

Weeks 4-6 after onset of fever.

RISK FACTORS

  1. Young age (<6mo)
  2. Abnormal echocardiogram at presentation
  3. Severe disease (MAS, shock)
49
Q

List 3 causes of cyanosis in an infant

A
  1. Cyanotic congenital heart disease
  2. Severe congestive heart failure
  3. Intrapulmonary R→L shunt
    • Parenchymal
      • RDS
      • Pneumonia
      • Pulmonary hemorrhage
    • Non-parenchymal (space occupying issues)
      • Pleural effusion
      • CPAM
      • CDH
  4. Central hypoventilation
  5. Polycythemia
  6. Methemoglobinemia
50
Q

Describe your initial management of an infant with cyanosis.

A
  • Maintain open/patent airway, assist breathing and provide O2 as needed
  • Attach monitors for cardiac rhythm, O2 saturation and blood pressure
  • Establish IV access
  • Obtain 12-lead ECG
  • Transilluminate if air entry discrepancy
  • Obtain a CXR
  • Obtain bloodwork: CBC/diff, culture, glucose, lytes, extended lytes
  • Start antibiotics
  • If no response to oxygen and no other obvious cause, start prostaglandin (0.05mcg/kg/min)
    • Monitor continuously for apnea
    • Intubate if necessary
  • URGENT consult to cardiology
51
Q

What is the most common cause of pericarditis?

Describe classic features on history and physical exam.

What are the expected ECG findings?

Outline management for pericarditis.

A

Most common cause = viral infection

Other causes: idiopathic, leukemia/lymphoma, JIA, SLE

  • History:
    • Sharp, stabby or squeezing chest pain
    • Worse lying down, better sitting
    • Often pleuritic
  • Physical Examination
    • Pericardial friction rub
    • Narrow pulse pressure
    • Pulsus paradoxus ≥15mmHg
  • ECG (4 stages):
    • ST elevation
    • PR depression
    • T wave flattening
    • T wave inversion
    • Resolution
  • Management
    • If stable: NSAIDs with regular echo follow-up
    • If persistent: steroids, colchicine
    • Pericardiocentesis if tamponade or persistence on medication
    • Antibiotics if suppurative pericarditis (would be VERY sick)
52
Q

Describe non-pharmacological and pharmacological strategies in the management of CHF.

A
  • Non-pharmacological
    • Keep head elevated (↓respiratory distress)
    • Tube feeds (↓cardiac workload)
    • high caloric formula (limits free water)
    • salt restriction in older children (avoids excess preload)
    • fluid restriction - if severe
  • Pharmacological
    • Improve contractility
      • Dopamine, dobutamine, milrinone, epinephrine, norepinephrine
    • Decrease preload
      • Diuretics (spironolactone and furosemide)
    • Decrease afterload
      • ACEi/ARBs
    • Minimize ongoing damage
      • Beta blockers
  • Preventative
    • Immunizations - RSV, influenza
  • Surgical correction

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