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USMLE Step 3 MTB > Cardiology > Flashcards

Cardiology Flashcards

1
Q

most common cause of death in US

A

CAD

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2
Q

CAD risk factors (8)

A
  1. diabetes mellitus
  2. hypertension
  3. tobacco use
  4. hyperlipidemia
  5. peripheral arterial disease (PAD)
  6. obesity
  7. inactivity
  8. family history
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3
Q

what is considered “significant” in the family history of CAD?

A
  • females > 65 years of age

- males > 55 years of age

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4
Q

chest pain that changes with RESPIRATION

A

pleuritic pain

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5
Q

causes of PLEURITIC chest pain

A
  1. PE
  2. pneumonia
  3. pleuritis
  4. pericarditis
  5. pneumothorax
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6
Q

cause of chest pain that is tender to palpation

A

costochondritis

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7
Q

causes of POSITIONAL chest pain

A

pericarditis

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8
Q

clues that chest pain is ISCHEMIC in nature

A
  1. dull pain
  2. last 15-30 minutes
  3. exertional
  4. substernal location
  5. radiates to jaw or left arm
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9
Q

S3 gallop indicates

A

DILATED left ventricle

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10
Q

mechanism of S3 gallop

A

rapid ventricular filling during diastole

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11
Q

mechanism of S4 gallop

A

atrial systole into a stiff or noncompliant left ventricle

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12
Q

S4 gallop indicates

A

left ventricular HYPERTROPHY

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13
Q

best INITIAL step in presentation of chest pain

A

ASPIRIN

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14
Q

which test is best to detect REINFARCTION a few days after initial infarction?

A

CK-MB

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15
Q

which cardiac enzyme rises first?

A

myoglobin

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16
Q

if initial EKG and/or enzymes do NOT establish diagnosis of CAD, next step

A

stress test

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17
Q

when should you order a dipyridamole or adenosine thallium stress test, or dobutamine echocardiogram?

A

patient can’t exercise to target HR of > 85% of maximum

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18
Q

situations where patient won’t be able to do an exercise stress test

A
  1. COPD
  2. amputation
  3. deconditioning
  4. weakness/previous stroke
  5. LE ulcer
  6. dementia
  7. obesity
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19
Q

when should you answer exercise thallium testing, or stress echocardiography?

A

EKG is unreadable for ischemia

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20
Q

situations where EKG may be unreadable for ischemia

A
  1. LBBB
  2. digoxin use
  3. pacemaker
  4. LVH
  5. baseline ST segment abnormality
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21
Q

next diagnostic test to evaluate an abnormal stress test

A

angiography

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22
Q

mechanism of thallium (nuclear isotope)

A

decreased uptake = damage

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23
Q
  • causes acute chest pain
  • can occur with exertion or at rest
  • ST segment elevation, depression, or normal EKG
  • NOT based on enzyme levels, angiography, or stress test results
  • BASED ON h/o chest pain with features suggestive of ischemic disease
A

definition of acute coronary syndrome (ACS)

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24
Q

best initial therapy for all cases of ACS

A

ASPIRIN

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25
Q

benefit of using aspirin in ACS

A

instant effect of inhibiting platelets

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26
Q

can be given in ACS, but do NOT lower mortality

A

nitrates and morphine

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27
Q

added to aspirin for patients with ACUTE MI

A

clopidogrel or ticagrelor

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28
Q

only given when angioplasty is done

A

prasugrel

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29
Q

MOA of clopidoGREL, ticaGRELor, and prasuGREL

A

inhibit ADP activation of platelets

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30
Q

what LOWER MORTALITY in STEMI and are TIME DEPENDENT?

A

thrombolytics and PCI

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31
Q

PCI should be done within what timeframe of reaching the ER?

A

90 MINUTES

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32
Q

what if PCI cannot be done within 90 minutes?

A

thrombolytics

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33
Q

indications for thrombolytics

A
  1. cannot perform PCI

2. chest pain for

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34
Q

thrombolytics should be done within what timeframe of reaching the ER?

A

30 MINUTES

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35
Q

mechanism of thrombolytics

A

ACTIVATE plasminoGEN into PLASMIN

chops up fibrin strands into D-dimers
(does nothing if already stabilized by factor XIII)

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36
Q

lower mortality in ACS, but is NOT time critical

A

beta blockers

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37
Q

should be given to ALL patients with ACS, but only lower mortality if there is LEFT VENTRICULAR DYSFUNCTION, or SYSTOLIC DYSFUNCTION

A

ACE inhibitors

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38
Q

should be given to ALL patients with ACS, regardless of EKG/enzyme levels

A

statins

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39
Q

ALWAYS lower mortality in ACS

A
  1. aspirin
  2. thrombolytics
  3. angioplasty
  4. metoprolol
  5. statins
  6. clopidoGREL/ticaGRELor/prasuGREL
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40
Q

lower mortality in ACS in CERTAIN CONDITIONS

A
  1. ACE/ARBs inhibitors IF EF is LOW
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41
Q

do NOT lower mortality in ACS

A
  1. oxygen
  2. morphine
  3. nitrates
  4. calcium channel blockers (actually INCREASE; avoid!)
  5. lidocaine
  6. amiodarone
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42
Q

clopidoGREL or ticaGRELor is used in ACS when

A
  • aspirin allergy
  • patient undergoes angioplasty/stenting
  • acute MI
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43
Q

calcium channel blockers are used in ACS when

A
  • intolerance to beta blockers (e.g. asthma)
  • cocaine-induced CP
  • coronary vasospasm/Prinzmetal’s angina
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44
Q

when do you use a pacemaker for AMI?

A
  • 3rd degree AV block
  • Mobitz II, second degree AV block
  • bifasicular block
  • NEW LBBB
  • symptomatic bradycardia
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45
Q

when is lidocaine or amiodarone used for AMI?

A
  • ONLY in Vtach, or Vfib
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46
Q

complications of myocardial infarction

A
  1. cardiogenic shock
  2. valve rupture
  3. septal rupture
  4. myocardial wall rupture
  5. sinus bradycardia
  6. third degree (complete) heart block
  7. right ventricular infarction
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47
Q

diagnostic tests for cardiogenic shock

A
  • echo

- Swan-Ganz (right heart) catheter

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48
Q

treatment for cardiogenic shock

A
  • ACE inhibitor

- urgent revascularization

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49
Q

diagnostic test for valve rupture

A

echo

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50
Q

treatment for valve rupture

A
  • ACE inhibitor
  • nitroprusside
  • intra-aortic balloon pump as bridge to surgery
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51
Q

diagnostic tests for septal rupture

A
  • echo

- right heart cath showing STEP UP IN SATURATION FROM RIGHT ATRIUM TO RIGHT VENTRICLE

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52
Q

treatment for septal rupture

A
  • ACE inhibitor
  • nitroprusside
  • urgent surgery
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53
Q

diagnostic test for myocardial wall rupture

A

echo

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54
Q

treatment for myocardial wall rupture

A
  • pericardiocentesis

- urgent cardiac repair

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55
Q

diagnostic test for sinus bradycardia

A

EKG

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56
Q

treatment for sinus bradycardia

A
  • atropine

- pacemaker IF there are STILL symptoms

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57
Q

diagnostic test for third-degree (complete) heart block

A
  • EKG

- canon “a” waves

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58
Q

treatment for third-degree (complete) heart block

A
  • atropine

- pacemaker EVEN IF symptoms resolve

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59
Q

diagnostic test for RIGHT ventricular infarction

A

EKG showing right ventricular leads

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60
Q

treatment for RIGHT ventricular infarction

A

fluid loading

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61
Q

ALL post-MI patients should go home on

A
  1. aspirin
  2. clopidoGREL, or prasuGREL
  3. beta blocker
  4. statin
  5. ACE inhibitor
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62
Q

CAD + LDL > 100

A

give statins

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63
Q

LDL goal in ACS patient with DIABETES

A

< 70

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64
Q

CAD equivalents

A
  1. DM
  2. PAD
  3. aortic disease
  4. carotid disease
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65
Q

MC adverse effect of statins

A

LIVER TOXICITY

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66
Q

MC of post-MI erectile dysfunction

A

anxiety

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67
Q

MC of post-MI erectile dysfunction d/t medication

A

beta blockers

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68
Q

contraindicated with sildenafil (PDI’s)

A

nitrates

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69
Q

CHF presentation

A
  • SOB, especially on exertion, and…
  • edema
  • rales
  • ascites
  • jugular venous distention
  • S3 gallop
  • orthopnea (SOB when lying flat)
  • paroxysmal nocturnal dyspnea (SOB attacks at night)
  • fatigue
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70
Q

standard of care for pulmonary edema

A
  1. oxygen
  2. furosemide (preload reduction)
  3. nitrates
  4. morphine
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71
Q

non-ST segment elevation myocardial infarction treatment

A
  1. no thrombolytics
  2. low molecular weight heparin
  3. glycoprotein IIb/IIIa inhibitors (lower mortality)
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72
Q

MOA of heparin

A

potentiates effect of antithrombin

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73
Q

improve mortality of chronic angina

A

aspirin and metoprolol

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74
Q

which medications should only be used in congestive heart failure, systolic dysfunction, or low ejection fraction?

A

ACE inhibitors or ARBs

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75
Q

AE of ACEI and ARBs

A
  • hyperkalemia with both

- cough with ACEIs

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76
Q

when do you add ranolazine?

A

persistent chest pain

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77
Q

indications for CABG

A
  1. THREE coronary vessels > 70% stenosis
  2. left main coronary artery > 50-70% stenosis
  3. TWO vessels in a DIABETIC
  4. 2 or 3 vessels with LOW EF
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78
Q

mechanism of rales

A

increased HYDROSTATIC pressure in pulmonary capillaries –> transudation of liquid into alveoli –> “popping” sound during inhalation

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79
Q

MOA of carvedilol

A

antagonist of B1, B2, and a1 receptors

  1. antiarrhythmic
  2. anti-ischemic
  3. antihypertensive
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80
Q

initial diagnostic tests for CHF patient

A
  1. CXR
  2. EKG
  3. oximeter (maybe an ABG)
  4. echo
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81
Q

what CXR shows in CHF patient

A
  1. pulmonary vascular congestion
  2. cephalization of flow
  3. effusion
  4. cardiomegaly
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82
Q

what EKG shows in CHF patient

A
  1. sinus tachycardia

2. atrial and ventricular arrhythmia

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83
Q

what oximeter shows in CHF patient

A
  1. hypoxia

2. respiratory alkalosis (from tachypnea)

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84
Q

what echo shows in CHF patient

A

distinguishes systolic vs diastolic dysfunction

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85
Q

possible causes of CHF

A
  1. HTN
  2. valvular heart disease
  3. MI
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86
Q

MOA of imamRINONE and milRINONE

A
  • PDE inhibitors
  • increase contractility
  • vasodilators= decrease AFTERload
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87
Q

MOA of dobutamine

A
  • increase contractility

- vasoconstriction= increases AFTERload

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88
Q

clinical diagnosis of acute pulmonary edema

A
  1. SOB
  2. rales
  3. S3 (splash)
  4. orthopnea
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89
Q

right heart catheter results in acute pulmonary edema

A
  • CO = decreased
  • SVR = increased
  • wedge pressure = increased
  • RA pressure = increased

(wedge pressure = indirect LA pressure measurement)

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90
Q

treatment for SYSTOLIC dysfunction (low EF)

A
  1. ACEI or ARB
  2. metoprolol/carvedilol/bisoprolol
  3. spironolactone/eplerenone
  4. diuretic
  5. digoxin
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91
Q

treatment for DIASTOLIC dysfunction (normal EF)

A
  1. metoprolol/carvedilol/bisoprolol

2. diuretic

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92
Q

decreases mortality in patients with

  • EF 120ms
A

biventricular pacemaker

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93
Q

exertional SOB: young female, general population

A

MVP

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94
Q

exertional SOB: healthy young athlete

A

HCM

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95
Q

exertional SOB: immigrant, pregnant

A

MS

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96
Q

exertional SOB: Turner’s syndrome, coarctation of aorta

A

BICUSPID aortic valve

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97
Q

exertional SOB: palpitations, atypical chest pain NOT with exertion

A

MVP

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98
Q

possible PE findings in valvular heart disease

A
  • peripheral edema
  • carotid pulse findings
  • gallops
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99
Q

all RIGHT-sided murmurs increase in intensity with

A

INhalation

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100
Q

all LEFT-sided murmurs increase in intensity with

A

EXhalation

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101
Q

ONLY 2 murmurs that become SOFTER with SQUATTING/leg raise

A
  1. MVP

2. HCM

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102
Q

ONLY 2 murmurs that LOUDER with STANDING/Valsalva

A
  1. MVP

2. HCM

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103
Q

which maneuver increases afterload?

A

handgrip

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104
Q

which murmurs are LOUDER with handgrip maneuver?

A
  1. AR
  2. MR
  3. VSD
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105
Q

which murmurs are SOFTER with handgrip?

A
  1. MVP

2. HCM

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106
Q

which medications decrease afterload?

A
  1. amyl nitrate

2. ACEIs

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107
Q

which murmurs are LOUDER with amyl nitrate?

A
  1. MVP
  2. HCM
  3. AS
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108
Q

effect of handgrip on aortic stenosis

A

SOFTENS murmur

less blood travels from LV to aorta

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109
Q

effect of amyl nitrate on aortic stenosis

A

makes it LOUDER

decreases afterload

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110
Q

AS is best heard where and radiates where?

A
  • 2nd RIGHT intercostal space

- carotid arteries

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111
Q

pulmonic valve murmurs are best heard where?

A

2nd LEFT intercostal space

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112
Q

AR, tricuspid murmurs, and VSD are best heard where?

A

LLSB

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113
Q

MR is best heard where and radiates where?

A
  • apex (5th intercostal space)

- axilla

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5
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114
Q

best INITIAL test for valvular heart disease

A

ECHO

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115
Q

MOST ACCURATE test for valvular heart disease

A

left heart catheterization

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116
Q

best treatment for REGURGITANT lesions

A

VASODILATORS

ACEIs, ARBs, or nifedipine

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117
Q

best treatment for STENOTIC lesions

A

anatomic repair

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118
Q

Valsalva improves murmur than ___ medicine is indicated

A

diuretics

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119
Q

handgrip makes it worse/amyl nitrate improves murmur

A

ACEI indicated

120
Q

best treatment for mitral stenosis

A

balloon valvuloplasty

121
Q

best treatment for severe aortic stenosis

A

aortic valve replacement

122
Q
  • chest pain/syncope
  • older
  • h/o HTN
123
Q

prognosis of AS

A
  • CAD = 3-5-year average survival
  • syncope = 2-3-year average survival
  • CHF = 1.5-2-year average survival
124
Q

mechanism of syncope/angina in AS

A

blocked flow with increased demand = chest pain

125
Q

AS murmur description and location it’s best heard

A
  • crescendo-decrescendo

- 2nd RIGHT intercostal space radiating to CAROTIDS

126
Q

mechanism of crescendo-decrescendo murmur of AS

A
  • isovolumetric contraction = no blood moving = no murmur

- mid-systole = peak flow = peak noise

127
Q

best INITIAL test for AS

128
Q

MORE ACCURATE test for AS

129
Q

MOST ACCURATE test for AS

A

left heart catheterization

130
Q

normal aortic valve pressure gradient

131
Q

mild AS pressure gradient

132
Q

moderate AS pressure gradient

133
Q

severe AS pressure gradient

134
Q

best INITIAL therapy for AS

A

diuretics

don’t improve long-term prognosis
OVERDIURESIS IS DANGEROUS

135
Q

treatment of choice for AS

A

valve replacement

136
Q

when do you balloon dilate AS?

A

ONLY when patient can’t tolerate surgery

137
Q

how long do bioprosthetic valves last?

A

about 10 years

138
Q

how long do mechanical valves last?

A

15-20 years

need to be on warfarin with INR of 2-3

139
Q

causes of AR

A
  • HTN
  • rheumatic heart disease
  • endocarditis
  • cystic medial necrosis
140
Q

MC presentation of AR

A
  1. SOB

2. FATIGUE

141
Q

AR murmur description and location it’s best heard

A
  • diastolic decrescendo murmur

- LEFT sternal border

142
Q

Quincke pulse

A

arterial or capillary pulsations in FINGERNAILS

143
Q

Corrigan’s pulse

A

high bounding pulses

“water-hammer” pulse

144
Q

Musset’s sign

A

head bobbing with pulse

145
Q

Duroziez’s sign

A

murmur heard over femoral artery

146
Q

Hill’s sign

A

BP gradient much higher in LE’s

147
Q

best INITIAL test for AR

148
Q

MORE ACCURATE test for AR

149
Q

MOST ACCURATE test for AR

A

left heart catheterization

150
Q

best INITIAL therapy for AR

A
  • ACEI/ARB, or nifedipine

- and loop diuretic

151
Q

when do you do SURGERY for AR?

EVEN IF PATIENT IS ASYMPTOMATIC

152
Q

why does high pressure dilate aortic valve?

A

LaPlace’s law

tension = radius x pressure

153
Q

MCC of MS

A

rheumatic fever

154
Q

special features of MS

A
  1. dysphagia (LA pressing on esophagus)
  2. hoarseness (pressure on recurrent laryngeal nerve)
  3. a-fib (stroke)
155
Q

mechanism of increased MS symptoms in pregnancy

A
  • 50% increase in plasma volume
  • more volume = more pressure, backflow, and symptoms
  • ADH levels higher
156
Q

MS murmur description

A

diastolic RUMBLE after OPENING SNAP

opening snap moves closer to S2 as mitral stenosis worsens

157
Q

mechanism of opening snap earlier in worsening MS

A

worse MS = higher LA pressure = mitral valve opens earlier

mitral valve opens when LA pressure > LV pressure

158
Q

best INITIAL test for MS

159
Q

MORE ACCURATE test for MS

160
Q

MOST ACCURATE test for MS

A

left heart catheterization

161
Q

CXR findings for MS (mitral stenosis)

A
  • straightening of left heart border

- elevation of left mainstem bronchus

162
Q

best INITIAL therapy for MS

163
Q

most effective therapy for MS

A

balloon valvuloplasty

164
Q

is pregnancy a contraindication to do balloon valvuloplasty in MS?

165
Q

causes of MR

A
  1. HTN
  2. ischemic heart disease
  3. any condition leading to dilation of heart
166
Q

S3 gallop can be normal in which patients?

167
Q

MC complaint in MR

A

exertional dyspnea

168
Q

MR murmur description and location it’s best heard

A
  • holosystolic murmur that obscures S1 and S2

- apex radiating to axilla

169
Q

best INITIAL test for MR

170
Q

MORE ACCURATE test for MR

171
Q

best INITIAL treatment for MR

A
  • ACEI/ARB, or nifedipine
172
Q

when do you do SURGERY for MR?

EVEN IF PATIENT IS ASYMPTOMATIC

173
Q

VSD murmur description

A
  • holosystolic murmur

- LLSB

174
Q

complaint in VSD

175
Q

diagnostic test for VSD

176
Q

used to determine degree of left-to-right shunting

A

catheterization

177
Q

VSD treatment

A

mechanical closure if severe

178
Q
  • holosystolic murmur at LLSB
  • SOB
  • parasternal heave
179
Q
  • FIXED splitting of S2
  • SOB
  • parasternal heave
180
Q

mechanism of fixed splitting of S2 in ASD

A

equal pressure between LA and RA = no change in splitting

181
Q

test for ASD

182
Q

treatment for ASD

A

percutaneous or catheter repair

183
Q

when is ASD repair most often indicated?

A

if shunt ratio exceeds 1.5:1

184
Q

WIDE splitting of S2 (P2 delayed) causes

A
  • RBBB
  • pulmonic stenosis
  • RVH
  • pulmonary HTN
185
Q

PARADOXICAL splitting of S2 (P2 delayed) causes

A
  • LBBB
  • AS
  • LVH
  • HTN
186
Q

FIXED splitting of S2

187
Q

best INITIAL test for DILATED cardiomyopathy

A

echo

check EF and wall motion abnormality

188
Q

MC causes of dilated CMP

A
  • ischemia (MOST COMMON)
  • alcohol
  • adriamycin
  • radiation
  • Chagas’ disease
189
Q

treatment for DCMP

A
  1. ACEI/ARB
  2. BB
  3. spironolactone/eplerenone (decrease work of heart)
190
Q
  • exertional SOB

- S4 gallop

A

hypertrophic cardiomyopathy

191
Q

best INITIAL test for HYPERTROPHIC cardiomyopathy

A

echo

shows normal EF

192
Q

treatment for HCMP

A
  1. BB

2. diuretics

193
Q

possible causes of RESTRICTIVE cardiomyopathy

A
  • sarcoidosis
  • amyloidosis
  • hemochromatosis
  • cancer
  • myocardial fibrosis
  • glycogen storage diseases
194
Q
  • exertional SOB

- Kussmaul’s sign (increase in jugular venous pressure on inhalation)

A

restrictive cardiomyopathy

195
Q
  • low-voltage EKG

- speckled pattern on echo

A

amyloidosis

196
Q

what does cardiac catheterization show in RCMP?

A

rapid x and y descent

197
Q

what does EKG show in RCMP?

A

low voltage

198
Q

mainstay of diagnosis of RCMP

199
Q

MOST ACCURATE test for RCMP

A

endomyocardial biopsy

200
Q

treatment for RCMP

A
  1. diuretics

2. correct underlying cause

201
Q
  • pleuritic chest pain (changes with respiration)
  • positional chest pain (better when sitting up/leaning forward)
  • pain is SHARP, and BRIEF
A

pericarditis

202
Q

only pertinent positive PE finding for pericarditis

A

FRICTION RUB

203
Q

best INITIAL diagnostic test for pericarditis

A

EKG

GLOBAL ST elevation
(PR segment depression in lead II is pathognomonic)

204
Q

best INITIAL treatment for pericarditis

205
Q

treatment for pericarditis if pain persists after NSAID

A

prednisone

206
Q
  • SOB
  • hypOtension
  • jugular venous distention
  • lungs CTA
  • PULSUS PARADOXUS (BP decrease > 10mmHg on INhalation)
  • ELECTRICAL ALTERNANS (alternating QRS complex heights)
A

pericardial tamponade

207
Q

mechanism of pulsus paradoxus

A

inhale = big RV = smaller LV = BP drop > 10mmHg

208
Q

MOST ACCURATE test for pericardial tamponade

209
Q

finding on echo in pericardial tamponade

A

diastolic collapse of RA and RV

210
Q

right heart catheterization findings of pericardial tamponade

A

EQUALIZATION of ALL pressures in heart during systole

211
Q

best INITIAL treatment for pericardial tamponade

A

pericardiocentesis

212
Q

MOST EFFECTIVE treatment for pericardial tamponade

A

pericardial window placement

213
Q

MOST DANGEROUS thing to give a patient with pericardial tamponade

214
Q
  • SOB
  • signs of chronic right heart failure (edema, JVD, hepatosplenomegaly, ascites)
  • Kussmaul’s sign (increase in JVD on INhalation)
  • PERICARDIAL KNOCK (extra diastolic sound from heart hitting calcified thickened pericardium)
A

constrictive pericarditis

215
Q

what does CXR show in constrictive pericarditis?

A

calcification

216
Q

what does EKG show in constrictive pericarditis?

A

low voltage

217
Q

what does CT and MRI show in constrictive pericarditis?

A

thickening of pericardium

218
Q

best INITIAL treatment for constrictive pericarditis

219
Q

MOST EFFECTIVE treatment for constrictive pericarditis

A

surgical removal of pericardium

220
Q
  • chest pain radiating to back between scapula
  • CP is INITIALLY very severe and “ripping”
  • difference in BP between RIGHT and LEFT arms
A

dissection of thoracic aorta

221
Q

best INITIAL test for dissection of thoracic aorta

A

CXR showing WIDENED MEDIASTINUM

222
Q

MOST ACCURATE for dissection of thoracic aorta

223
Q

INITIAL treatment for dissection of thoracic aorta

A

beta blocker, and get EKG/CXR

224
Q

further management of dissection of thoracic aorta

A
  1. order CTA = TEE = MRA

2. start nitroprusside

225
Q

MOST EFFECTIVE treatment for dissection of thoracic aorta

226
Q

screening US of abdominal aorta should be done in?

A

MEN OVER 65 who are current or were former SMOKERS

227
Q

when do you repair AAA?

228
Q
  • claudication (pain in calves on exertion)
  • “smooth, shiny skin” with loss of HAIR and SWEAT GLANDS
  • loss of pulses in feet
229
Q

best INITIAL test for PAD

A

ankle-brachial index (ABI)

230
Q

what is a NORMAL ankle-brachial index (ABI)?

A

greater than or equal to 0.9

> 10% difference = OBSTRUCTION

231
Q

MOST ACCURATE test for PAD

A

angiography

232
Q

best INITIAL treatment for PAD

A
  1. aspirin
  2. BP control with ACEI
  3. exercise as tolerated
  4. cilostazol
  5. statin with LDL goal
233
Q

PAIN + PALLOR + PULSELESS =

A

ARTERIAL OCCLUSION

234
Q
  • SUDDEN onset loss of pulse and COLD extremity
  • painful
  • can have h/o AS or atrial fibrillation
A

acute arterial embolus

235
Q

are beta blockers contraindicated with PAD?

236
Q

mechanism of why CCB don’t work in PAD

A

CCB dilate muscular layer EXterior to atherosclerotic clot which is INterior

237
Q

perform surgical bypass in PAD when

A

signs of ischemia:

  • gangrene
  • pain at REST
238
Q
  • palpitations
  • IRREGULAR pulse
  • h/o HTN, ischemia, or CMP
239
Q

initial test for atrial fibrillation

A
  • telemetry monitoring as INpatient

- Holter monitoring as OUTpatient

240
Q

other tests to order once atrial fibrillation is diagnosed

A
  1. echo: looking for clots, valve function, LA size
  2. TFT: TSH, T4
  3. electrolytes: K+, Mag2+, Ca2+
  4. troponin/CK
241
Q

UNSTABLE patient with atrial fibrillation

(unstable = SBP

A

SYNCHRONIZED electrical cardioversion

242
Q

STABLE patient with atrial fibrillation

A

slow ventricular HR if > 100-110

243
Q

which medications can be given for atrial fibrillation to control the rate?

A
  • beta blockers (metoprolol/esmolol)
  • calcium channel blockers (diltiazem)
  • digoxin

should be given IV

244
Q

next best step in patient with a-fib, that’s rate controlled

A

warfarin with goal INR of 2-3

245
Q

other PO AC’s for a-fib besides warfarin

A
  • dabigatran (direct THROMBIN inhibitor)
  • rivaroxaban (factor Xa inhibitor)
  • apixaban (factor Xa inhibitor)
246
Q

CHADS2Vasc

indicates need for warfarin

A 
CHF +1
HTN +1
Age
≥ 75 +2
DM +1
Stroke/TIA/Thromboembolism +2
Vascular Disease +1
Age
> 65-74 +1
Female +1
247
Q
  • palpitations

- REGULAR rhythm

A

atrial flutter

248
Q

atrial fibrillation/atrial flutter WITH:

  • ischemic heart disease
  • migraines
  • Graves disease
  • pheochromocytoma
A

beta blockers (metoprolol)

249
Q

atrial fibrillation/atrial flutter WITH:

  • asthma
  • migrains
A

calcium channel blockers (diltiazem)

250
Q

atrial fibrillation/atrial flutter WITH:

  • borderline hypOtension
251
Q
  • atrial arrhythmia IN ASSOCIATION WITH COPD/EMPHYSEMA

- tachycardia (HR > 100)

A

multifocal atrial tachycardia (MAT)

252
Q

MAT EKG finding

A

POLYMORPHIC P waves

253
Q

treatment for MAT

A
  1. oxygen FIRST

2. THEN diltiazem

254
Q

do NOT use what in MAT?

A

beta blockers

255
Q
  • palpitations and tachycardia
  • occasionally syncope
  • NOT associated with ischemic heart disease
  • REGULAR RHYTHM WITH VENTRICULAR RATE OF 160-180
A

supraventricular tachycardia (SVT)

256
Q

diagnostic tests for MAT

A
  • EKG first

- if EKG is negative, Holter monitor or telemetry

257
Q

best INITIAL management for UNSTABLE patients

A

synchronized cardioversion

258
Q

best INITIAL management for STABLE patients

A

vagal maneuvers

  • carotid sinus massage
  • ice immersion of the face
  • Valsalva
259
Q

NEXT BEST step in management if vagal maneuvers do NOT work

A

IV adenosine

most frequently asked SVT question

260
Q

best long-term management

A

radiofrequency catheter ablation

261
Q
  • SVT that can alternate with ventricular tachycardia

- WORSENING of SVT after use of CCB or digoxin

A

Wolff-Parkinson-White syndrome (WPW)

262
Q

diagnosis of WPW

A

DELTA WAVE on EKG

263
Q

MOST ACCURATE test for WPW

A

electrophysiologic studies

264
Q

best INITIAL treatment for WPW

A

procainamide

265
Q

best long-term treatment for WPW

A

radiofrequency catheter ablation

266
Q

mechanism of WPW

A

neutralized cardiac muscle going around AV node creating aberrant pathway

267
Q
  • palpitations
  • syncope
  • chest pain
  • sudden death
A

ventricular tachycardia (VT)

268
Q

if EKG does not detect VT then

A

telemetry monitoring

269
Q

MOST ACCURATE diagnostic test for VT

A

electrophysiologic studies

270
Q

treatment for VT in patient that hemodynamically STABLE

A
  • amiodarone
  • lidocaine
  • procainamide
  • magnesium
271
Q

treatment for VT in patient that hemodynamically UNSTABLE

A

synchronized cardioversion

272
Q

sudden death

A

ventricular fibrillation (VF)

273
Q

diagnosis of loss of pulse/VF

274
Q

treatment for VF

A

ALWAYS UNsynchronized cardioversion first

275
Q

mechanism for need of synchronization

A
  • T-wave represents refractory period

- electrical shock delivered during the T-wave can set off a WORSE rhythm; VF, and ASYSTOLE

276
Q

BLS for VF

A
  1. continue CPR
  2. defibrillate (UNsynchronized cardioversion)
  3. IV epinephrine/vasopressin
  4. defibrillate (UNsynchronized cardioversion)
  5. IV amiodarone/lidocaine
  6. defibrillate (UNsynchronized cardioversion)

repeat CPR between each shock

277
Q

management of syncope is based on 3 criteria

A
  1. was the loss of consciousness SUDDEN or GRADUAL?
  2. was the regaining of consciousness SUDDEN or GRADUAL?
  3. is the cardiac exam NORMAL or ABNORMAL?
278
Q

if syncope onset was GRADUAL, possible causes could be?

A
  • toxic-metabolic
  • hypoglycemia
  • anemia
  • hypoxia
279
Q

if syncope onset was SUDDEN, next question is?

A

was the regaining of consciousness SUDDEN or GRADUAL?

280
Q

if return to consciousness onset was GRADUAL, possible causes could be?

A

neurological etiology (seizures)

281
Q

if return to consciousness onset was SUDDEN, next question is?

A

is the cardiac exam NORMAL or ABNORMAL?

282
Q

if cardiac exam is ABNORMAL, possible causes could be?

A

structural heart disease:

  • aortic or mitral stenosis
  • HCM
  • mitral valve prolapse (rare)
283
Q

if cardiac exam is NORMAL, possible cause could be?

A

ventricular arrhythmia

284
Q

diagnostic tests for syncope evaluation

A
  • cardiac/neurological exam
  • EKG
  • chemistries (looking at glucose, and electrolytes)
  • oximeter
  • CBC (looking for anemia)
  • cardiac enzymes
285
Q

in evaluation of syncope, if murmur is present

A

order an echo

286
Q

in evaluation of syncope, if the neuro exam is FOCAL, or there’s h/o head trauma

287
Q

in evaluation of syncope, if headache is described

288
Q

in evaluation of syncope, if seizure is described, OR SUSPECTED

A

order CTH and EEG

289
Q

mechanism of syncope

A

ONLY BRAINSTEM stroke can cause syncope (controls sleep/wake in brain)

290
Q

further evaluation of syncope if diagnosis is still unclear after INITIAL tests

A
  • Holter monitor as outpatient
  • telemetry monitor as inpatient
  • repeat cardiac enzymes
  • urine/blood toxicology
291
Q

if etiology of syncope is STILL NOT clear

A
  • tilt table test (to diagnose neurocardiogenic (vasovagal) syncope)
  • EP testing
292
Q

treatment for syncope

A

based on etiology

but most cases lack specific diagnosis

293
Q

if ventricular dysrhythmia is diagnosed as etiology of syncope, what is indicated?

A

implantable cardioverter/defibrillator

294
Q

role of colchicine in pericarditis

A

adds efficacy to NSAIDs and prevents recurrent episodes

295
Q

at what CHADS2Vasc score should a pt be started on warfarin, and should the pt be bridged on heparin?

A
  • 2, or more points

- NO!

296
Q

heart failure is primarily a clinical diagnosis:

name the MAJOR criteria

need either, 2 major criteria, or 1 major and 2 minor

A
  1. paroxysmal nocturnal dyspnea (PND)
  2. orthopnea
  3. raised jugular venous pressure (JVP)
  4. third heart sound
  5. increased cardiac silhouette on CXR
  6. pulmonary vascular congestion on CXR
297
Q

heart failure is primarily a clinical diagnosis:

name the MINOR criteria

need either, 2 major criteria, or 1 major and 2 minor

A
  1. B/L LE edema
  2. nocturnal cough
  3. exertional dyspnea
  4. tachycardia
  5. presence of pleural effusion
  6. hepatomegaly

USMLE Step 3 MTB (20 decks)

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