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Cardiology Flashcards

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USMLE® Step 1 flashcards
1
Q

What is the clinical presentation of aortic dissection and how to confirm the diagnosis ?

A
  • Sharp , tearing and extremly sever pain.
  • Pain is radiatin to the back.
  • Loss of pulses or aortic insufficiency
  • CXR: wide mediastinum.
  • MI may occur if dissection extends into coronary artery.
  • Dx is confirmed by either MRI, CT or transesophageal echocardigram.
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2
Q

What is the clinical presentation of pulmonary embolism and how to confirm the diagnosis ?

A
  • Dyspnea, tachycardia and hypoxemia
  • Pleuritic pain.
  • ECG : S wave in lead 1 and Q wave in lead III or inverted T wavein lead III.
  • Dx is confirmed by CT angiogram.
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3
Q

What is the clinical presentation of pericarditis ?

A
  • Maybe preceded by viral illness.
  • pain is sharp, positional, pleuritic, relieved by leaning forward.
  • Pericardial rub may be present
  • Diffuse ST elevation without evolution of Q waves.
  • CK level is normal
  • Responds to Anti-inflammatory agents.
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4
Q

What is the treatment of STEMI ?

A

Immediate coronoray reperfusion therapy is indicated:
- Primary Percutaneous coronary intervention PCI:
* within 12 hours of symptoms onset AND
* within 90 min from first medical contact to device time at a PCI - capable facility OR
* within 120 mins from first medical contact to device time at a NON- PCI - capable facility
OR
- Fibrinolytic therapy (E.g Atleplase).

Following initial measures whichincludes:

  • Oxygen
  • Full dose Aspirin (chewed to enter bloodstream quickly).
  • Platelet P2Y12 receptor blocker ( Clopidogrel - Ticagrelor )
  • Nitroglycerin (use morphine if nitroglycerin is inadequate)
  • Beta blocker
  • Anticoagulation ( i.e Heparin).
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5
Q

What is the Management of unstable angina &

non–ST-segment elevation myocardial infarction ?

A
  • Nitrates:
    Caution with hypotension(eg, right ventricular infarction)
  • Beta blockers
    Cardioselective (eg, metoprolol, atenolol)
    Contraindicated in heart failure & bradycardia
    Intravenous for hypertensive patients.
  • Antiplatelet therapy:
    Aspirin & P2Y12 receptor blocker(eg, clopidogrel)
  • Anticoagulation:
    Unfractionated heparin, enoxaparin, bivalirudin, or fondaparinux.
- Statin therapy:
High intensity (eg, atorvastatin, rosuvastatin)
  • Coronary reperfusion
    Percutaneous coronary intervention within24 hours
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6
Q

what are the leads of the following area of infarction _ which artery is involved?

  • Inferior
  • Anteroseptal
  • Anterior
  • Lateral
  • Poterior ?
A
  • Inferior:
    leads : II , III, aVF
    Right coronary
  • Anteroseptal:
    V1 - V3
    Left anterior descending
  • Anterior:
    V2-V4
    Left anterior descending
  • Lateral:
    I , aVL , V4, V5 , V6
    Left anterior descending or circumflex

Posterior:
V1 , V2
Posterior descending

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7
Q

What are the precipitating factors of heart failure ?

A

HEART MAY DIE :

HTN
Embolism 
Anemia 
Rhuematic heart disease 
Thyrotoxicosis

MI
Arrhythmias
Y

Diet and lifestyle
Infections
Endocarditis

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8
Q

How to classify the severity of heart failure ?

A

Using the New York Heart Association Functional Classification (NYHA):

  • Class I : Pt have no limittaion of activity, they suffer no Sx from ordinary activites.
  • Class II: Pt with slight, mild limitation of activity, they are comfortable with rest or with mild exertion.
  • Class III: Pt with marked limitation of activity, they are comfortable only at rest.
  • Class IV: Pt are confined to bed or chair, any physical activity brings on discomfort and Sx occur at rest.
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9
Q

What is the management of heart failure ?

A
  • Reduction of salt intake
  • ACE inhibitort
  • Diuretics:
    • loop diuretics (Furosemide)
    • Thiazide diuretics (Hydrochlorothiazide)
  • Beta - adrenergic bloking agents: (Carvedilol or metoprolol).
  • +/- Spironolactone (K- sparing diuretics)
  • +/- Digitalis (Inotropic agent) reduce hospitalization but not survival.
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10
Q

What are the agents that lower mortality in systolic dysfunction ?

A
  • ACEI (or ARBs)
  • Beta blockers
  • Spironolactone (or eplerenone).
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11
Q

What are the conditions that Digitalis can be used in treatment ?

A
  • Congestive heart failure
  • Atrial fibrillation / flutter
  • Paroxysmal atrial tachycardia/SVT
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12
Q

What are the conditions which predispose to digitalis toxicity ?

A
  • Renal insufficiency
  • Electrolyte disturbances (hypoK - hypoCa- hypoMg)
  • Advanced age
  • Sinoatrial and atrioventricular block
  • Thyroid disease. (Hypothyroididm)
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13
Q

Agents which improve heart failure Sx but do not reduce mortality?

A
  • Digoxin

- Diuretics

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14
Q

What are the toxic effects of Digitalis ?

A
  • N/V
  • Gynecomastia
  • Blurred vision
  • Yellow halo around objects
  • Arrhythmias : Paroxysmal atrial tachycardia with block, Premature ventricular contractionsm bradycardia.
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15
Q

How to treat Digitalis intoxication ?

A
  • Stop drug
  • Lidocaine or Phenytoin (for arrythmia)
  • Digibond for acute overdose
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16
Q

When to use Automatic Implantable Cardioverter/defibrillator (AICD) and when to use biventricular pacemaker ?

A
  • Automatic Implantable Cardioverter/defibrillator (AICD):
    Dilated cardiomyopathy with a persistent ejection fraction <35 %
  • Biventricular pacemaker:
    Dilated cardiomyopathy with a QRS > 120 mSec.
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17
Q

How to treat cardiogenic pulmonary edema?

A
  • O2
  • Diuretic therapy (Furosemide) reduces preload
  • Morphine sulphate
  • sitting the pt upright
  • Nitroglycerin to reduce preload
  • Digoxin if atrial fibrillation
  • IV ACEI
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18
Q 
What are the : 
- Causes 
- Pathogenesis
- clinical picture 
- Diagnosis methods 
- Tx 
of Mitral stenosis ?
A

Causes :

  • Secondary to Rhuematic fever (MOST COMMON)
  • Congenital defect
  • Calcification of the valve
  • Post - radiation treatmnet to the chest

Pathogenesis :

  • Impredes LV filling
  • Increased LA pressure.
  • Pulmonary congestion
  • Cardiac output becomes reduced.
  • Secondary pulmonary vasoconstriction
  • RV failure.

Clinical pic:

  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Fatigue
  • Hemoptysis ( due to rupture of pulmonary vessels)
  • Systemic embolism ( due to immobility of blood in an enlarged left atrium).
  • Hoarsness ( due to impingement of enlarged LA to the recurrent laryngeal nerve.
  • Rt sided HF Sx : Heptomegaly - ascitis - peripheral edema.
  • Atrial fibreillation
  • Pulmonary rales
  • Decreased pulse pressure
  • Loud S1
  • Opening snap following S2
  • Diastolic rumble
    Sternal lift
Dx: 
- ECG: 
   RV hypertrophy - LT and RT atrial abnormalities - S-Fib
- CXR
- Echo
Tx: 
Medical: 
- Diuretics + salt restriction diet 
- Digitalis to control ventricular rate  if A-Fib 
- Anticoagulation if A-fib 
- Balloon valvulotomy

Surgical:
- Mitral commissurotomy or valve replacement

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19
Q

What is the single most accurate test for mitral regurgitation ?

A

Catheterization

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20
Q

How to treat mitral valve regurgitation ?

A 
Medical treatment: 
Relieve Sx by increasing forward output + reducing pulmonary venous hypertension: 
- ARBs or Hydralazine
- ACEI (arteriolar vasodilator)
- Digitalis 
- Diuretics.

Surgical:

  • Mitral valve repair/ replacement (Repair is preferrable)
  • Indication for surgery:
    • Persistence of Sx despite medical Tx
    • EF < 60% or Lt ventricular end systolic diameter >40 mm
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21
Q

What is the most common congenital valvular abnormality?

A

Mitral valve prolapse .

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22
Q

What is the Tx of Aortic stenosis ?

A

Valve replacement when Sx develps, which is when the valve area is < 0.8 cm

Normal aortic valve area is (2.5 - 3 cm)

Balloon valvuloplasty if pt is too ill to tolerate the surgery.

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23
Q

What are the most common causes of aortic regurgitation ?

A

systemic HTN + ischemis heart disease.

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24
Q

What is Duroziez sign ?

A

It is a systolic and/or diastolic thrill or murmur heard over the femoral arteries in aortic regurgitation

25
Q

When to perform surgery in aortic regurgitation ?

A
  • EF < 55 %

- Left ventricular systolic diameter > 55mm.

26
Q

What is the:

  • Etiology
  • Clinical manifestations
  • Treatment

of Acute Pericarditis ?

A
  • Etiology:
    • Idiopathic
    • Infections
    • Vasculitis
    • Metabolism disorders
    • Neoplams
    • Trauma
    • Inflammation (Uremia).
  • Clinical manifestations:
    • Substernal/left of the sternum chest pain.
    • Worsened by lying down, coughing, deep inspiration.
    • Relived by leaning forward and sitting up.
    • Pericardial fricition rub
  • Treatment:
    • NSAIDs
    • Aspirin
    • Corticosteriods ( + Colchicine).
27
Q

How to differentiate between MI and acute pericarditis ?

A

The diffuseness of the ST-segment elevation + absence of reiprocal leads + absence of development of Q waves.

28
Q

What does a (Water -bottle) sign of the cardiac silhouette in CXR represent ?

A

Pericardial Effusion

29
Q

What is pulsus paradoxus ?

A

Decraese in systolic blod pressure > 10 mmHg with normal inspiration.

30
Q

What is Beck’s triad ?

A

Triad that is associated with cardiac tamponade:

  1. Hypotension
  2. Distended neck veins.
  3. Decreased heart sounds. (muffled heart sound).
31
Q

How to diagnose abd treat cardiac tamponade?

A

Dx:

  • Echocardiography
  • Cardiac catheterization

Tx:
- Pericardiocentesis + subxiphoid surgical drainage.

32
Q

What is Kussmaul sign ?

A

Jugular venous distension increases with inspiration.

33
Q

What is the procedure of choice to demonstrate the thickened pericardium ?

A

CT

34
Q

What is the Tx of sinus bradycardia ?

A
  • Nothing if no Sx
  • Atropine if Sx present
  • Consider pacemaker if bradycardia is resistent.
35
Q

What is the usual heart rate in Paroxysmal Supraventricular tachycardia?

A

130 - 220 beats/min
Average: 160
Regular Rythm

36
Q

What is the Tx of Paroxysmal Supraventricular tachycardia?

A
  • Increase vagal tone by right carotid massage.
  • Adenosine (IV)
  • IV Propranolol or Esmolol , Verapamil
  • IV Digitalis
  • Synchronized external cardioversion if pt is unstable.
37
Q

What is the heart rate in Multifocal atrial tachycardia ?

A

Irregular beats

100 -200 bpm

38
Q

How to Tx Multifocal atrial tachycardia ?

A
  • Diltiazem
  • Verapamil
  • Digoxin

Avoif BB if lung disease occur

39
Q

How to Tx atrial flutter ?

A
  • Cardiversion if pt is unstsble
  • Digitalis
  • Verapamil
  • Diltiazem
  • Beta blockers
40
Q

What is CHADS score ?

A

It is a clinical prediction rule for estimating the risk of stroke in a patient with AF.

C - CHF
H - HTN
A - Age > 75 
D - DM
S - Stroke Hx or TIA

Each condition gets 1 point except stroke gets 2 points

0 - Give Aspirin
1- Aspirin + Warfarin
> 2 or more - Warfarin

41
Q

Which drugs are proven effective for Atrial fibrillation ? abd which are used to maintain sinus rhythm in pts with AF ?

A

Proven effective:

  • Amiodarone
  • Dofetilide
  • Flecainide
  • Ibutilide
  • Propafenone
  • Quinidine

Maintain sinus rhythm:

  • Amiodarone
  • Disopyramide
  • Dofetilide
  • Flecainide
  • Propafenone
  • Sotalol
42
Q

What are the ECG features of Wolff- Parkinson - White syndrome ?

A

Short PR interval followed by a wide QRS complex with a slurred initial deflection or delta wave, representing early ventricular activation.

43
Q

What is the Tx of Wolff- Parkinson - White syndrome ?

A

If unstable :
- Immediate electrical cardioversion (synchronized cardioversion)

If stable:
- Procainamide

Avoid BB - CCB and Digoxin as it will inhibit conduction in the normal conduction pathway

44
Q

What are the conditions in which the QRS complex is >0.12 s (wide) and regular ?

A
  • Ventricular tachycardia
  • Supraventricular tachycardia
  • Wolff - Parkinson - White syndrome
45
Q

What are the conditions in which the QRS complex is >0.12 s (wide) and irregular ?

A
  • Atrial fibrillation
46
Q

What are the conditions in which the QRS complex is <0.12 s (narrow) and regular ?

A
  • Sinus tachycardia
  • Paroxusmal supraventricular tachycardia
  • Atrial flutter
47
Q

What are the conditions in which the QRS complex is <0.12 s (narrow) and irregular ?

A
  • Atrial fibrillation

- Multifocal atrial tachycardia

48
Q

How to Tx unstable pt with ventricular tachycardia ?

A
  • O2
  • IV access
  • Consider sedation
  • Cardiovert 100 J
  • CArdiovert 200 J
  • Cardiovert 300 J
  • Cardiovert 350 K
49
Q

How to Tx stable pt with ventricular tachycardia ?

A
  • O2
  • IV access
  • Amiodarone or Lidocaine
  • Lidocaine until VT resolves
  • Precainamide until VT resolves
  • Cardiovert if pt becomes unstable
50
Q

What is Amiodarone ?
Short - term side effects?
Long - term side effects ?

A

It is an Antiarrhythmic drug

Short term side effects:

  • Lung effects: cough , fever and painful breathing.
  • Nerve toxicity: Imbalance, change in gait, tremor, numbness in the fingers and toes, dizziness, muscle weakness, loss of coordination.
  • Hypo/hyperthyroidism.
  • Harmful effects of sunlight

Long- term side effects:

  • Blue - grey discoloration of the skin
  • Visual impairment: Halo lights and blurred vision
  • Corneal deposits.

other:
- very long half life (20 - 40 days)
- Increase Digoxin level.

51
Q 
What is the effect of Nitrates in : 
- Low dose 
- Medium dose 
- High dose 
\+ what is the side effects and what are the contraindications of the drug ?
A

In low dose: Increase venoud dilation => Reduce preload.

In medium dose: Increase arteriolar dilatation => decreses afterload and preload

In high dose: increases coronary artery dilation => increase O2 supply.

S/E: 
- Orthostatic hypotension 
- Refelx tachycardia 
- Throbbing headache
- Blushing 
All caused by vasodilation

Contraindicated if systolic BP < 90 mmHg.

52
Q

What is the side effects of Phenytoin ?

A
  • CNS: Ataxia, Nystagmus, drowsiness.
  • Hypotension
  • Heart block with rapid IV injection
53
Q

What are the side effects of Adenosine ?

A
  • Transient dyspnea
  • Noncardiac chest pain
  • rarely, Hypotension
54
Q

What are the side effects of lidocaine ?

A
  • CNS (drowsiness, agitation , seizures)

- Heart block

55
Q

What is the mechanism of action of beta blockers ?

What is their side effects ?

A

Decrease heart rate + BP + contractility => Decreases myocardial O2 requirement.

S/E:

  • Fatigue/insomnia
  • mental depression
  • lipid abnormalities
  • hallucinations
  • Raynaud phenomenon
  • Bronchoconstriction
  • Mask signs / symptoms of insulin-induced hypoglycemia
  • Sexual dysfunction (Except Nebivolol).
56
Q

Name the cardio- selective beta blockers ?

A
  • Metoprolol (Lopressor)
  • Atenolol (Tenormin)
  • Acebutolol (Sectral)
  • Esmolol (IV)
57
Q

What are the calcium channel blockers ?

A

Cardiac:

  • CHF
  • Reflex tachycardia
  • Hypotension
  • Lightheadedness
  • AV block

Noncardiac:

  • Flushing
  • Headache
  • Weakness
  • Constipation
  • Nasal congestion
  • Wheezing
  • Peripheral edema
  • Gingival hyperplasia
58
Q

Explain the heart sounds (S1) and (S2).

A

Fisrt heart sound (S1):

  • Corresponding to mitral and tricuspid valve closure.
  • Indicates the beginning of ventricular systole.

Second heart sound (S2):

  • Corresponding to aortic and pulmonary valve closure.
  • Indicates the end of aortic and pulmonary closure.

Medical (6 decks)

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