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STEP 3 > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Criteria for severe aortic stenosis and indications for valve replacement

A

Aortic jet velocity > 4m/sec or mean transvalvular pressure gradient >40 mm Hg
Replace if meets severe AS criteria and one or more:
-Onset of sxs (angina, syncope)
-LVEF <50%
-Undergoing other cardiac surgery (CABG)

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2
Q

Positive stress testing criteria

A 
Clinical variables: 
1. Poor exercise capacity
2. Exercise-induced angina at low workload
3. Fall in systolic BP from baseline
4. Chronotropic incompetence (no HR increase w/ exercise
ECG variables:
1. >1mm ST depression
2. ST depression at low workload
3. ST elevation in leads without Q waves
4. Ventricular arrhythmias
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3
Q

Medical tx for CAD

A

Aspirin
High-intensity statin
Beta-blocker
Optimization of risk factors (smoking cessation, BP control, glucose control)

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4
Q

Primary mitral regurgitation

A

Caused by intrinsic defect of valve (vs secondary which is due to disease process involving left ventricle such as myocardial ischemia or dilated cardiomyopathy)
LVEF <60% considered to be impaired in primary mitral regurgitation
Holosystolic murmur at apex following a click

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5
Q

Marfan syndrome

A

AD, defect in fibrillin-1
Tall stature (height percentile >95%)
Lens subluxation or dislocation (ectopia lentis), tall (usu. >95% percentile)
Aortic root disease, screen with echo on dx and annually thereafter

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6
Q

Statin - primary prevention

A

LDL >190mg/dL: high-intensity statin
Age 40 or more w/ DM and 10-year risk 20% or more: high-intensity statin
Age 40 or more w/ DM and 10-year risk <20%: moderate-intensity statin
10-year risk >7.5-10%: moderate-to-high intensity statin

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7
Q

Statin - secondary prevention

A

Anyone with established ASCVD (ACS, stable angina, arterial revascularization like CABG, stroke, TIA, PAD)
If age 75 or less: high-intensity statin
If age >75: moderate-intensity statin

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8
Q

High intensity statins

A

Atorvastatin 40-80mg

Rosuvastatin 20-40mg

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9
Q

Moderate intensity statin

A

Rosuvastatin 5-10mg
Simvastatin 20-40mg
Pravastatin 40-80mg
Lovastatin 40mg

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10
Q

Tx of PAD

A
  1. Risk factor management: Aspirin (1st line) or clopidogrel, statin (PAD qualifies for secondary prevention), smoking cessation, BP and glucose control
  2. Supervised exercise program
  3. After lifestyle changes, can consider cilostazol (PDE3 inhibitor) 100mg bid
  4. Revascularization (stent vs bypass) if persistent symptoms
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11
Q

Six Ps of acute limb ischemia and tx

A 
Pain
Pallor
Pulselessness
Poikilothermia
Paresthesia
Paralysis
Tx with IV heparin and emergency surgical revascularization if limb threatened (no arterial doppler)
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12
Q

Most important modifiable risk factor for AAA

A

Smoking

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13
Q

AAA screening and management

A

Screen men age 65-75 who have ever smoked
Tx w/ smoking cessation, aspirin and statin therapy
Elective repair if >5.5cm, rapidly enlarging (0.5cm or more in 6mo) or AAA associated with PAD or aneuryssm
F/u imaging: if 4-5.4cm, U/S q6-12mo, if smaller q2-3 years

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14
Q

Asymptomatic left ventricular systolic dysfunction (LVSD) definition and tx

A

Ejection fraction 40% or less

Tx w/ ACE-i/ARB (start low and increase as tolerated), then add beta blocker

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15
Q

Multifocal atrial tachycardia

A

Caused by exacerbation of lung dz (COPD), electrolyte disturbances or catecholamine surge (sepsis)
P waves of at least 3 different morphologies and atrial rate >100/min
Tx: correct underlying disturbance, AV nodal blockade with nondihydropyridine CCBs (verapamil, diltiazem) or BBs (esmolol) if persistent

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16
Q

Management of unstable angina and NSTEMI

A
  • Nitrates prn (caution with hypotension, right ventricular infarct)
  • Cardioselective BB such as metoprolol or atenolol. Contraindicated in HF and bradycardia, IV for hypertensive patients
  • DAPT: ASA 325mg + P2Y12 receptor blocker
  • Anticoagulation: unfractionated heparin, enoxaparin, bivalirudin, or fondaparinux
  • High-intensity statin
  • Coronary reperfusion within 24h
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17
Q

ECG criteria for STEMI

A

-New ST elevation at the J point in 2 or more anatomically contiguous leads:
>1mm in all leads except V2 and V3
1.5mm or more in women, 2mm or more in men age 40 and more, 2.5mm or more in men <40 in leads V2 and V3
-New LBBB with clinical presentation consistent with ACS

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18
Q

Acute Decompensated Heart Failure

A

IV diuretics
Can add IV vasodilator if inadequate response to diuretics; leads to rapid decrease in cardiac preload, resulting in reduced intracardiac filling pressure and improvement in pulmonary edema

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19
Q

Pulmonary hypertension findings and initial eval

A

Left parasternal lift, right ventricular heave
Loud P2, right-sided P3
Pansystolic murmur of tricsupid regurgitation
JVD, ascites, peripheral edema, hepatomegaly
CXR: prominent pulmonary arteries
Eval: initially with TTE, then right heart cath with mean pulmonary arterial pressure >25mmHg is diagnostic

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20
Q

Tx for idiopathic pulmonary hypertension (group 1)

A

Endothelin receptor antagonists (bosentan, ambrisentan)
PDE5 inhibitors (sildenafil, tadalafil)
Prostacyclin pathway agonists (epoprostenol)
If positive vasoreactive test during right heart cath, CCBs are another option

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21
Q

Most effective nonpharmacologic measure to decrease BP in overweight individuals

A

Weight loss (next is DASH diet)

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22
Q

Perioperative risk stratification

A

Ok to proceed if (in that order):

  • No active cardiac conditions (unstable angina, recent MI, decompensated HF, significant arrhythmia or valvular disease)
  • Low risk surgery (ambulatory or superficial procedure, endoscopic, cataract, breast)
  • Patient has RCRI 1% or less (1 or less of following: high-risk surgery, hx of ischemic heart disease, HF, hx of stroke, DM on insulin, creatinine >2)
  • Able to perform 4 METS (climb 2 flights of stairs)
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23
Q

Tx of sinus bradycardia from inferior wall MI

A

IV atropine sulfate if hemodynamically significant (hypotension, cold extremities, pulmonary edema)

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24
Q

Down’s syndrome: malformations and later complications

A

Malformations: endocardial cushion defect (harsh holosystolic murmur), duodenal atresia, Hirschsprung’s disease, atlanto-axial instability and hypothyroidism
Later complications: acute leukemia, Alzheimer-like dementia, autism, ADHD, depressive disorder and seizure disorder

25
Q

Hypertrophic cardiomyopathy

A

Systolic murmur that increases w/ valsalva, asymmetric septal hypertrophy, systolic anterior motion of mitral leaflets, increased left ventricular outflow tract gradient
If sxs of HF and increased LVOT gradient, tx with negative inotropic agents (start w/ BB, add verapamil or disopyramide if persistent symptoms)
If sxs refractory to medical therapy, alcohol septal ablation
Do NOT use vasodilators (amlodipine, nifedipine), ACE-i/ARBs or nitrates in HCM

26
Q

Indications for ICD placement

A

Primary prevention:
-Prior MI and LVEF 30% or less
-NYHA class II or III sxs and LVEF 35% or less
Secondary prevention
-Prior VF or unstable VT without reversible cause
-Prior sustained VT with underlying cardiomyopathy

27
Q

Tx cocaine-related chest pain

A

Benzo and nitroglycerin
Do NOT use BBs (unopposed alpha 1 mediated vasoconstriction)
CCBs if persistent chest pain
Phentolamine if persistent hypertension
Monitor for complications: acute dissection of aorta

28
Q

Criteria for biventricular pacing device

A

LVEF <35%
NYHA class II, III, or IV HF sxs (i.e. any sxs)
LBBB with QRS duration >150 msec

29
Q

List the 3 coronary heart disease (CHD) equivalents

A
  1. Noncoronary atherosclerotic disease (eg, carotid, peripheral artery, AAA)
  2. Diabetes mellitus
  3. Chronic kidney disease
30
Q

Aortic coarctation

A 
Claudication
Upper extremity hypertension and lower extremity hypotension
Brachiofemoral pulse delay
May have continuous vs systolic murmur
Confirm dx with echocardiogram
31
Q

Antiarrhythmic tx in patients with atrial fibrillation

A

No CAD or structural heart disease: flecainide, propafenone
Left ventricular hypertrophy: amiodarone, dronaderone
CAD w/o HF: sotalol, dronaderone
HF: amiodarone, dofetilide
Refractory to meds: radiofrequency ablation

32
Q

CHA2DS2-VASc

A 
CHF 1
Hypertension 1
Age 75 or greater 2
Diabetes 1
Stroke/TIA/Thromboembolism 2
Vascular disease 1
Age 65-74 1
Sex 1 if female
33
Q

Discontinuing statin therapy

A

If symptomatic, discontinue

If asymptomatic and CK >10x ULN, discontinue

34
Q

Vasovagal syncope

A

Pallor, nausea, diaphoresis before (and/or after) syncopal event
Regain consciousness rapidly (<1min)
Tx with reasurrance and counterpressure techniques (leg crossing with tensing of muscles, tensing of arm muscles with clenches fists)

35
Q

WPW pattern on ECG, criteria for WPW syndrome and tx

A

Short PR interval with delta wave and widened QRS

Pattern on ECG + symptomatic tachyarrythmia = WPW syndrome, treat w/ catheter ablation

36
Q

Acute aortic dissection management

A

Pain control
IV BBs (esmolol preferred due to short half life) +/- sodium nitroprusside if SBP >120mmHg
Emergent surgical repair of ascending

37
Q

Bicuspid aortic valve

A

Screening echocardiogram for patient and 1st degree relatives
F/u echo q1-2 years
Evaluate all patient for aortic root or ascending aortic dilation w/ echo, CT or MRI
Balloon valvulosplasty in patients with:
-Aortic stenosis
-No sign AV calcification or aortic regurgitation
-Peak gradient >50mmHg

38
Q

Acquired long QT syndrome

A

Meds: diuretics, zofran, antipsychotics, TCAs, SSRIs, antiarrhythmics, antianginal (ranolazine), anti-infective
Metabolic disorders: electrolyte imbalance (low K/Mg/Ca), starvation. hypothyroidism
Bradyarrhythmias: sinus node dysfunction, 2md or 3rd degree AV block
Others: hypothermia, MI, intracranial disease, HIV

39
Q

Tx per-infarction pericarditis

A

High-dose aspirin. If still bad, can add colchicine or narcotic analgesics

40
Q

Indications for ICD placement in HCM

A

Primary prevention
-Family history of SCD
-Syncope (recurrent and/or associated with exercise)
-Nonsustained VT on Holter
-Hypotension during exercise
-Extreme left ventricular hypertrophy (>3cm septal wall thickness)
Secondary prevention
-Survivors of cardiac arrest
-Sustained spontaneous ventricular arrhythmias

41
Q

Perioperative medications to stop

A

ACE inhibitors: continue if HF patient, otherwise hold the night before surgery
Diuretics: hold on morning of surgery
SERMs: hold 4 prior to surgery (risk of thromboembolism)

42
Q

Cardiogenic syncope etiologies

A

AS/HCM: exertional syncope, systolic murmur on exam
VT: no preceding symptoms, cardiomyopathy or previous MI
Sick sinus: preceding fatigue or dizziness, sinus pauses on ECG
Advanced AV block: bifascicular block or incr. PR interval on ECG, dropped QRS complexes
Torsades de pointes: no preceding symptoms, QT prolonging meds, hypo-K/Mg

43
Q

When should INR goal be 2.5-3.5 in valve replacements.

A

Mitral valve replacement, AVR with risk factors (Afib, severely decreased LVEF <30%, prior thromboembolism, hypercoagulable state)
Otherwise goal 2-3
Everyone gets ASA

44
Q

Indications for coronary revascularization

A
  • Patients with refractory angina despite maximal medical therapy
  • To improve long-term survival: left main coronary stenosis; multivessel CAD (esp. involving proximal LAD) with left ventricular systolic dysfunction
45
Q

Management of unstable angina/NSTEMI

A

Hemodynamic instability, HF or new MR, recurrent chest pain or ventricular arrhythmia: immediate coronary angiography

Otherwise stratify with Thrombolysis in Myocardial Infarction (TIMI) score - 1 pt for each:

  • Age 65 or greater
  • 3 or more CAD risk factors (HTN, HLD, diabetes, family hx of CAD or current smoker)
  • Known CAD (stenosis 50% or greater)
  • ASA use in past 7 days
  • Severe angina (2 or more episodes in 24h)
  • EKG ST changes 0.5mm or greater
  • Positive cardiac marker (troponin)

If score 0-2: stress test
If score 3 or more: early coronary angiography (within 24h)

46
Q

Local vascular complications of cardiac cath

A

Hematoma: no bruit, +/- mass, hemodynamic instability and ipsilateral flank/back pain; get CT A/P
Pseudoaneurysm: bulging pulsatile mass, systolic bruit; get U/S of groin
AV fistula: no mass, continuous bruit; get lower extremity angiography if initial U/S ambiguous

47
Q

Optimal medical therapy for HF

A

ACE-i/ARB for everyone

If NYHA II (slight limitation with physical activity, ordinary activity causes fatigue, palpitation or dyspnea): -BB w/ EF 40% or less once euvolemic

  • spironolactone if EF 35% or less with stable renal function and potassium
  • Diuretic therapy (does not improve mortality)

When getting close to NYHA III (marked limitation with physical activity, less than ordinary activity causes fatigue, palpitations, dyspnea):

  • Isosorbide dinitrate (hydralazine if AA)
  • Digoxin if symptomatic with spironolactone
  • Cardiac resynchronization therapy if QRS>150msec
48
Q

Digoxin toxicity toxidrome, medications that cause it

A

Nausea, anorexia, confusion, vomiting, fatigue, visual disturbances, cardiac abnormalities
Caused by verapamil (inhibits renal tubular secretion of digoxin, resulting in 70-100% increase in serum digoxin levels), quinidine, amiodarone, spironolactone

49
Q

Features of compartment syndrome, dx, tx and complications

A
  • Pain out of proportion to injury
  • Pain increased on passive stretch
  • Rapidly increasing and tense swelling
  • Paresthesia (early)

Dx w/ tissue pressures: >30mmHg or delta pressure (DBP - compartment pressure <20-30mmHg)

Tx w/ fasciotomy (timing of surgical intervention is most important prognostic factor)

Complications include rhabdomyolysis, released myoglobin is nephrotoxic leading to acute renal failure

50
Q

Ejection click followed by crescendo-decrescendo systolic murmur

A

Aortic or pulmonic valve stenosis

51
Q

Nonejection click followed by a continuous systolic murmur

A

Mitral regurgitation

52
Q

Harsh holosystolic murmur with palpable thrill

A

VSD

53
Q

Holosystolic murmur that increases with inspiration

A

Tricuspid regurgitation

54
Q

Opening snap then low-pitched diastolic murmur

A

Mitral stenosis

55
Q

Movements that increase venous return

A

Squatting, supine leg raise (increases intensity of most murmurs except MVP and HOCM)

56
Q

Movements that decrease venous return

A

Standing, valsalva (decrease intensity of most murmurs except MVP and HOCM)

57
Q

Presentation and tx of cyanide toxicity

A

Presentation: flushing, AMS, metabolic acidosis
Often caused by nitroprusside
Tx w/ sodium thiosulfate

58
Q

Constrictive pericarditis dx

A

Hx of viral infection, cardiac surgery or radiation therapy
Present with edema, ascites and hepatic congestion
Pericardial thickening and calcifications seen on CXR

59
Q

Tx of ADHF

A

If normal/elevated BP w/ adequate end-organ perfusion:

  • Supplemental oxygen
  • IV loop diuretic
  • Consider IV vasodilator (nitroglycerin)

If hypotension or signs of shock:

  • Supplemental O2
  • IV loop diuretic as appropriate
  • IV vasopressor (norepi)

STEP 3 (12 decks)

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