CARDIOLOGY Flashcards

1
Q

Location of sinus node

A

Superior aspect of the crista terminalis

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2
Q

Ridge of muscle where the posterior smooth atrial wall derived from the sinus venosus meets the trabeculated anterior portion of the right atrium

A

Crista terminalis

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3
Q

Sinus rate increases spontaneously at rest or out of proportion to physiologic stress or exertion

A

Inappropriate sinus tachycardia

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4
Q

Symptomatic sinus tachycardia that occurs with postural change from supine to standing position

A

Postural orthostatic tachycardia syndrome (POTS)

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5
Q

Postural orthostatic tachycardia syndrome (POTS) is defined as:

A

Rate increases by 30 bpm or to >120 bpm within 10 min of standing, with no hypotension

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6
Q

Factors that plays prominent roles in the development of coronary atherosclerosis in women than in men (4)

A

Inflammation
Obesity
Type 2 DM
Metabolic syndrome

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7
Q

Exercise ECG has a higher diagnostic accuracy in the prediction of epicardial obstruction in women than in men. True or false.

A

False. Lower.

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8
Q

Mechanism of myocardial ischemia

A

Imbalance between the heart’s oxygen supply and demand

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9
Q

NYHA Class I definition

A

No limitation of physical activity.

No symptoms with ordinary exertion

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10
Q

NYHA Class II definition

A

Slight limitation of physical activity

Ordinary activity causes symptoms

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11
Q

NYHA Class III definition

A

Marked limitation of physical activity
Less than ordinary activity causes symptoms
Asymptomatic at rest

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12
Q

NYHA Class IV definition

A

Inability to carry out any physical activity without discomfort
Symptoms at rest

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13
Q

Pitfalls in cardiovascular medicine (3):

A
  1. Failure by the noncardiologist to recognize important cardiac manifestations of systemic illnesses
  2. Failure by the cardiologist to recognize underlying systemic disorders in patient with heart disease
  3. Overreliance on and overutilization of laboratory tests, particularly invasive techniques, for the evaluation of cardiovascular system
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14
Q

Asymptomatic or mildly symptomatic patients with VHD that is anatomically severe should be evaluated periodically, every _______.

A

6-12 months

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15
Q

Dysplastic pulmonic valves due to mutation in chromosome 12

A

Noonan syndrome

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16
Q

Mutation in the PTPN1 gene

A

Noonan syndrome

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17
Q

RV dysfunction from afterload mismatch occurs earlier in the course of PS. True or false.

A

True. RV adapts less well to this type of hemodynamic burden

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18
Q

Definition of severe PS

A

Peak systolic gradient across the pulmonic valve of >50 mmHg

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19
Q

Definition of moderate PS

A

Peak systolic gradient across the pulmonic valve of 30-50 mmHg

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20
Q

Higher pressures needed to fill a noncompliant, hypertrophied RV in pulmonic stenosis causes this wave change

A

RA a wave elevates (Prominent a wave may be seen in the jugular venous pulse)

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21
Q

This wave change/characteristic signifies functional TR from RV and annular dilation in pulmonic stenosis

A

Prominent RA v wave

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22
Q

Crescendo-decrescedo, mid-systolic, heard best in the left 2nd ICS

A

Pulmonic stenosis

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23
Q

The only right-sided murmur that decreases in intensity with inspiration

A

The ejection sound/ click that precede the murmur of pulmonic stenosis. The PS murmur increase in intensity during inspiration

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24
Q

Percutaneous pulmonic balloon valvotomy indications (2):

A

 Symptomatic patients with a domed valve and a peak gradient > 50 mmHg (or mean gradient > 30 mmHg)
 Asymptomatic patients with with a peak gradient > 60 mmHg (or mean gradient > 40 mmHg)

(used only in less than moderate PS)

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25
Q

High-pitched, decrescendo diastolic murmur, along the left sternal border

A

Graham Steell murmur

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26
Q

4 other terms for MVP

A

a. Systolic click-murmur syndrome
b. Barlow’s syndrome
c. Floppy-valve syndrome
d. Billowing mitral leaflet syndrome

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27
Q

Most common abnormality leading to primary MR

A

MVP

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28
Q

One of the causes of MVP is the reduction of production of what type of collagen?

A

III

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29
Q

MVP is a frequent finding in patients with heritable disorders of connective tissue, such as: (3)

A

a. Marfan syndrome
b. Osteogenesis imperfecta
c. Ehlers-Danlos syndrome

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30
Q

Which mitral leaflet is mostly affected in MVP

A

Posterior mitral leaflet

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31
Q

MVP is more common in what population (gender and age group)?

A

a. Women

b. Ages of 15 and 30 years

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32
Q

In older (>50 years) patients, MVP is more common in what gender?

A

Men

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33
Q

Mid- or late-(nonejection) systolic click is seen in what valvular abnormality?

A

MVP

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34
Q

Systolic click followed by a high-pitched, mid-late systolic crescendo–decrescendo murmur is a feature of

A

MVP

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35
Q

Leaflet involved in MVP when the radiation of the murmur is to the base of the heart

A

Posterior leaflet prolapse (Jet of MR is directed anteriorly)

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36
Q

Leaflet involved in MVP when the radiation of the murmur is to the axilla and the back

A

Anterior leaflet prolapse (Jet of MR is directed posteriorly)

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37
Q

Earlier with standing, MVP murmur is increased or decreased?

A

Increased

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38
Q

During the train phase of the Valsalva maneuver, MVP murmur is increased or decreased?

A

Increased

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39
Q

During any intervention that decreases LV volume (preload), MVP murmur is increased or decreased?

A

Increased

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40
Q

During squatting, MVP murmur is increased or decreased?

A

Decreased

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41
Q

During isometric exercises, MVP murmur is increased or decreased?

A

Decreased

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42
Q

Indications for MVP repair (5):

A

a. Symptomatic severe MR
b. LV systolic dysfunction
c. Pulmonary artery hypertension
d. Recent onset AF
e. Flail mitral leaflet

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43
Q

Can be considered for treatment of symptomatic patients at high surgical risk with severe primary MR due to MVP

A

Transcatheter edge-to-edge repair

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44
Q

Mortality of NYHA FC IV

A

30-70%

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45
Q

Mortality of NYHA FC IV

A

5-10%

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46
Q

Compensatory mechanisms become activated in the presence of cardiac injury and/or LV dysfunction allowing patients to sustain and modulate LV function for a period of months to years. What are the 2 known mechanisms

A

(1) activation of the renin-angiotensin-aldosterone system (RAAS) and the adrenergic nervous system (which are responsible, respectively, for maintaining cardiac output through increased retention of salt and water )
(2) increased myocardial contractility

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47
Q

Refers to the changes in LV mass, volume, and shape and the composition of the heart that occur after cardiac injury and/or abnormal hemodynamic loading conditions

A

Ventricular remodeling

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48
Q

The cardinal symptoms of HF (2)

A

fatigue and shortness of breath

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49
Q

The most important mechanism of cardiac dyspnea is pulmonary congestion with accumulation of interstitial or intra-alveolar fluid, which activates ___________, which in turn stimulate the rapid, shallow breathing characteristic of cardiac dyspnea

A

juxtacapillary J receptors

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50
Q

T or F: Dyspnea may become less frequent with the onset of right ventricular (RV) failure and tricuspid regurgitation

A

True

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51
Q

It results from redistribution of fluid from the splanchnic circulation and lower extremities into the central circulation during recumbency, with a resultant increase in pulmonary capillary pressure.

A

Orthopnea

Nocturnal cough is a common manifestation of this process and a frequently overlooked symptom of HF

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52
Q

acute episodes of severe shortness of breath and coughing that generally occur at night and awaken the patient from sleep, usually 1–3 h after the patient retires

A

paroxysmal nocturnal dyspnea

with persistent coughing and wheezing
even after they have assumed the upright position

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53
Q

Periodic respiration or cyclic respiration that is present in 40% of patients with advanced HF and usually is associated with low cardiac output

A

Cheyne-Stokes respiration

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54
Q

Cheyne-Stokes respiration is caused by (2)

A

an increased sensitivity of the respiratory center to arterial Pco2 and a lengthy circulatory time

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55
Q

Electrical diastole is slowing of what action potential phase

A

slow diastolic depolarization (phase 4)

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56
Q

Phase of action potential upstroke of nodal cells

A

Phase 0

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57
Q

Phase 0 of nodal cells is mediated by

A

calcium rather than Na

L-type Ca current

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58
Q

Mechanisms causing bradycardia (2)

A
  1. Failure of impulse initiation due to depressed automaticity
  2. Failure in impulse conduction that is may be due to exit block or fibrosis
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59
Q

The only reliable therapy for symptomatic bradycardia in the absence of extrinsic and reversible etiologies

A

Permanent pacemaker

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60
Q

SA nodal artery arises from either of these 2

A
  • RCA – 55-60%

* LCx – 40-45%

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61
Q

Membrane potential of SA node

A

-40 to -60 mV

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62
Q

T or F. SA node has slow phase 0 and rapid phase 4

A

True

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63
Q

Heritable form of sinus node disease caused by autosomal dominant mutations in the If subunit gene HCN4 on chromosome 15

A

Tachycardia-bradycardia variant of sick sinus syndrome 2

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64
Q

Heritable form of sinus node disease caused by autosomal recessive mutations in cardiac Na channel gene, SCN5A on chromosome 3

A

Sick sinus syndrome 1

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65
Q

Heritable form of sinus node disease that presents as ophthalmoplegia, pigmentary degeneration of the retina, and cardiomyopathy

A

Kearns-Sayre syndrome

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66
Q

Failure of the SA node to discharge, producing a pause without P waves visible on ECG up to 3 s

A

Sinus pauses

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67
Q

Intermittent failure of conduction from the SA node

A

Sinus exit block

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68
Q

intermittent conduction from the SA node and a regularly irregular atrial rhythm characterized by intermittent absence of P waves

A

2nd degree SA block

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69
Q

Progressive prolongation of SA node conduction with intermittent failure of the impulses originating in the SA node to conduct to the surrounding atrial tissue

A

2nd degree SA block type 1

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70
Q

SA block with no change in SA node conduction before the pause

A

2nd degree SA block type 2

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71
Q

SA block characterized by no P waves on the ECG

A

Complete or 3rd degree SA block

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72
Q

Most common tachycardia in the tachycardia-bradycardia in SSS

A

Atrial fibrillation

Also, atrial flutter and atrial tachycardia

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73
Q

Inability to increase the HR in response to exercise or other stress appropriately

A

Chronotropic incompetence

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74
Q

Chronotropic incompetence is defined as failure to reach ___ of predicted maximal heart rate at peak exercise or failure to achieve a HR ____ with exercise or a maximal heart rate with exercise less than ___ standard deviations below that of an age-matched control population

A

85%
> 100 bpm
2 SD

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75
Q

Diagnostic test for carotid sinus hypersensitivity

A

ANS testing

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76
Q

Normal intrinsic heart rate in ANS testing? And measured after giving these 2 medications (with dose)

A

117.2-(0.53 x age) bpm

After administration of 0.2 mg/kg propranolol and 0.04 mg/kg atropine

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77
Q

Low IHR in ANS testing is indicative of

A

SA disease

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78
Q

Longest pause after cessation of overdrive pacing of the RA near the SA node in the electrophysiologic testing

A

Sinus node recovery time (SNRT)

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79
Q

In EPS testing, ½ the difference between the intrinsic sinus cycle length and a noncompensatory pause after a premature atrial stimulus

A

Sinoatrial conduction time (SACT)

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80
Q

Drug that shorten SNRT and may improve SA node dysfunction

A

Digitalis

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81
Q

1st letter in the nomenclature of permanent pacemakers is the

A

chamber(s) that is paced

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82
Q

2nd letter in the nomenclature of permanent pacemakers is the

A

chamber(s) in which sensing occurs

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83
Q

3rd letter in the nomenclature of permanent pacemakers is the

A

response to a sensed event

  • O – none
  • I – inhibition
  • T – triggered
  • D – inhibition plus triggered
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84
Q

4th letter in the nomenclature of permanent pacemakers is the

A

programmability or rate response

R – rate responsive

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85
Q

5th letter in the nomenclature of permanent pacemakers is the

A

existence of anti-tachycardia functions if present

  • O – none
  • P – anti-tachycardia pacing
  • S – shock
  • D – pace + shock
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86
Q

Most commonly programmed modes of implanted single-chamber pacemakers

A

VVIR

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87
Q

Most commonly programmed modes of implanted dual-chamber pacemakers

A

DDDR

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88
Q

Permanent pacemakers are most commonly implanted via

A

subclavian-SVC venous system

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89
Q

Rotation of the pacemaker pulse generator in its subcutaneous pocket can wrap the leads around the generator and produce dislodgement with failure to sense or pace the heart causing

A

Twiddler’s syndrome

Rare complication in small-sized and light weight pacemakers

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90
Q

Achilles heel of permanent pacing systems

A

Transvenous leads

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91
Q

Constellations of signs and symptoms due to interruption and failure to restore AV synchrony by the pacing modes

A

Pacemaker syndrome

Neck pulsation, fatigue, palpitations, cough, condusion, exertional dyspnea, dizziness, syncope, elevation in JVP, canon A waves, and signs and symptoms of CHF

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92
Q

This will minimize the sequelae of pacemaker syndrome

A

Maintenance of AV synchrony

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93
Q

Class I indications for pacemaker implantation in SA node dysfunction (4)

A
  1. SA node dysfunction with symptomatic bradycardia or sinus pause
  2. Symptomatic SA node dysfunction as a result of essential long-term drug therapy with no acceptable alternatives
  3. Symptomatic chronotropic incompetence
  4. Atrial fibrillation with bradycardia and pauses >5 s
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94
Q

Class IIa indications for pacemaker implantation in SA node dysfunction (3)

A
  1. SA node dysfunction with heart rates <40 beats/min without a clear and consistent relationship between bradycardia and symptoms
  2. SA node dysfunction with heart rates <40 beats/min on an essential long- term drug therapy with no acceptable alternatives, without a clear and consistent relationship between bradycardia and symptoms
  3. Syncope of unknown origin when major abnormalities of SA node dysfunction are discovered or provoked by electrophysiologic testing
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95
Q

Class IIb indication for pacemaker implantation in SA node dysfunction

A

Mildly symptomatic patients with waking chronic heart rates <40 beats/min

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96
Q

Class III indications for pacemaker implantation in SA node dysfunction (3)

A
  1. SA node dysfunction in asymptomatic patients, even those with heart rates <40 beats/min
  2. SA node dysfunction in which symptoms suggestive of bradycardia are not associated with a slow heart rate
  3. SA node dysfunction with symptomatic bradycardia due to nonessential drug therapy
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97
Q

Initiating event for cardiac contraction

A

Depolarization of the heart

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98
Q

Atrial repolarization waveforms in ECG

A

ST-Ta

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99
Q

Phase of rapid upstroke of action potential

A

Phase 0

Onset of QRS

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100
Q

Plateau phase of action potential

A

Phase 2

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101
Q

Isoelectric ST segment corresponds to what phase of action potential

A

Phase 2

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102
Q

Phase of active repolarization

A

Phase 3

T wave

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103
Q

Amiodarone effect on QT interval

A

increase the QT interval

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104
Q

Hypocalcemia effect on QT interval

A

increase the QT interval

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105
Q

Hypercalcemia effect on QT interval

A

shorten QT

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106
Q

Digoxin effect on QT interval

A

shorten QT

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107
Q

Activation of the atria from an ectopic pacemaker in the lower part of either atrium or in the AV junction region causes these p waves

A

Retrograde P waves

Negative in II, positive in aVR

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108
Q

ECG marker (in terms of U wave) of increased susceptibility to torsades de pointes

A

Very prominent U waves

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109
Q

RA overload is defined as P wave of

A

≥2.5 mm

P-pulmonale

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110
Q

Most common arrhythmia in pulmonary embolism

A

Sinus tachycardia

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111
Q

ECG abnormality typical of pulmonary embolism

A

S1Q3T3

  • Prominent S wave in Lead I
  • Q wave in Lead III
  • T wave inversion in Lead III
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112
Q

LVH Sokolow lyon and Cornell criteria

A
  • S in V1 + R in V5 or V6 = > 35 mm

* R in aVL + S in V3 > 20 mm in women or >28 mm in men

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113
Q

ECG findings that is a major noninvasive marker of increased risk of cardiovascular morbidity and mortality rates, including sudden cardiac death

A

ECG evidence of LVH

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114
Q

In RBBB, terminal QRS is oriented to the

A

Right and anteriorly

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115
Q

In LBBB, terminal QRS is oriented to the

A

Left and posteriorly

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116
Q

BBB that is more common in subjects without structural heart disease

A

RBBB

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117
Q

LBBB is the marker of one of 4 underlying conditions associated with increased risk of cardiovascular morbidity and mortality rates

A
  • CAD
  • Hypertensive heart disease
  • Aortic valve disease
  • Cardiomyopathy
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118
Q

Fascicular block where QRS axis is more negative than -45 degrees

A

LAFB

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119
Q

Fascicular block where QRS axis is more rightward than +110-1200

A

LPFB

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120
Q

Most common cause of marked LAD in adults

A

LAFB

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121
Q

Fascicular block that is more common

A

LAFB

LPFB is extremely rare as an isolated finding

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122
Q

In early transmural ischemia, the T wave is

A

hyperacute

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123
Q

Subendocardial ischemia manifests as _____ in the ECG

A

ST segment depression with ST elevation in aVR

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124
Q

Reciprocal ST depressions in leads V1 to V3 is seen in

A

Posterior wall ischemia

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125
Q

Reversible transmural ischemia due to coronary vasospasm

A

Prinzmetal’s angina

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126
Q

Ischemic chest pain with deep T-wave inversions in multiple precordial leads (e.g. V1-V4, I and aVL) with or without cardiac enzyme elevations is caused by severe obstruction in

A

LAD

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127
Q

CVA T wave pattern

A

Deep, wide T wave inversions

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128
Q

Scooping of the ST-T wave complex is an effect seen in what drugs

A

Digitalis

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129
Q

Relatively a specific ECG sign of pericardial effusion, usually with cardiac tamponade

A

Total electrical alternans (P-QRS-T) with sinus tachycardia

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130
Q

Gold standard in the assessment of the anatomy and physiology of the heart and its associated vasculature

A

Coronary angiography

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131
Q

T or F: Coronary angiography is mandatory prior to cardiac surgery in young patients who have CHD or VHD

A

False. as long as well-defined by non-invasive imaging or no CAD symptoms

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132
Q

Risk of MI in elective cardiac catheterization

A

<0.1

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133
Q

Risk of stroke in elective cardiac catheterization

A

0.01%

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134
Q

Risk of death in elective cardiac catheterization

A

0.1%

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135
Q

Most common complication of cardiac catheterization

A

Significant access-site bleeding – 1.5-2.0%

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136
Q

Contrast-induced AKI is defined as

A

increase in Crea >0.5 mg/dL or 25% above baseline that occurs 48-72 hrs after contrast

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137
Q

Prior to cardiac catheterization, you have to stop Metformin when?

A

24 hrs prior to the procedure until 48 hrs after – limit risk of lactic acidosis

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138
Q

In order to prevent CIN, when will you give NaHCO3? And dose?

A

3mL/kg per hour 1 hour prior and 6 hours

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139
Q

Prior to coronary angiography, how much Aspirin will you give patient?

A

325 mg Aspirin

Additional antiplatelet if procedure is likely to progress to PCI
• Clopidogrel – 600mg loading and 75 mg daily
• Prasugrel – 60 mg LD and 10 mg OD
• Ticagrelor – 180 mg LD and 90 mg BID

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140
Q

In patients who will undergo cardiac catheterization, you hold warfarin how many days prior? And target INR should be?

A

2-3 days prior

INR <1.7

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141
Q

In patients who will undergo cardiac catheterization, you hold NoAC how many days prior?

A

1-2 days

24-48 hrs

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142
Q

Vascular access for left heart catheterization (2)

A

Femoral or radial artery

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143
Q

Vascular access for right heart catheterization (3)

A

Femoral, brachial, or internal jugular vein

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144
Q

Test that confirm dual blood supply to the hand prior to radial approach of cardiac catheterization

A

modified Allen’s test or Barbeau test

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145
Q

Preferred access sites for cardiac catheterization to the right heart when IVC filter in place or requires prolonged hemodynamic monitoring

A

Internal jugular or antecubital veins

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146
Q

Direct thrombin inhibitors that may given instead of heparin for prolonged cardiac catherization (2)

A

Bivalirudin 0.75 mg/kg bolus, 1.75 mg/kg per hour for the duration of the procedure

Argatroban 350 ug/kg bolus, 15 ug/kg per min for duration of the procedure

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147
Q

During cardiac catheterization, if without VHD (based on pressure tracings), atria and ventricles are “one chamber” during what part of cardiac cycle?

A

Diastole

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148
Q

During cardiac catheterization, if without VHD (based on pressure tracings), ventricles and their respective outflow tract are “one chamber” during what part of cardiac cycle?

A

systole

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149
Q

During the hemodynamic study, if there is systolic pressure gradient between LV and aorta, it indicates

A

Aortic stenosis

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150
Q

During the hemodynamic study, if there is diastolic pressure gradient between the pulmonary capillary wedge (LA) pressure and the LV, it indicates

A

Mitral stenosis

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151
Q

During the hemodynamic study, a dynamic intraventricular pressure gradient during ventricular systole

A

HOCM

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152
Q

During a hemodynamic study, following a premature ventricular contraction, there is an increase in the LV-aorta pressure gradient with a simultaneous decrease in the aortic pulse pressure. What do you call this sign? And in what condition is it present?

A

Brockenbroigh-Braunwald sign

HOCM

Absent in AS

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153
Q

During hemodynamic study, if RA pressure is increased with decreased or absent y descent with diastolic equalization of pressures in all cardiac chambers, it is indicative of what condition?

A

Cardiac tamponade

Due to impaired RA emptying during diastole

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154
Q

During hemodynamic study, if there is elevated RA pressure with prominent y descent, it is indicative of what condition?

A

Constrictive pericarditis

Due to rapid filling of the RV during early diastole

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155
Q

Most specific hemodynamic phenomenon for constriction

A

Discordant pressure changes in the RV and LV with inspiration
• RV systolic pressure increases
• LV systolic pressure decreases

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156
Q

During hemodynamic study, marked increase in RV and pulmonary artery systolic pressures (>60 mmHg), separation of the LV and RV diastolic pressures by > 5 mmHg and concordant changes in the LV and RV diastolic filling pressures with inspiration (both increase) is indicative of

A

Restrictive cardiomyopathy

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157
Q

The amount of oxygen consumption by an organ is equal o the product of its blood flow (cardiac output) and the difference in the concentration of the substance in the arterial and venous circulation (A-V oxygen difference).

A

Fick method

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158
Q

Indicator for Fick method

A

Oxygen

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159
Q

Indicator for thermodilution method

A

Temperature

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160
Q

Mean pressure gradient / mean flow (cardiac output) =

A

Ohm’s law

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161
Q

Equates the area to the flow across the valve divided by the pressure gradient between the cardiac chambers surrounding the valve

A

Gorlin formula

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162
Q

Valve area and mean gradient indicative of severe aortic stenosis

A

Area <1.0 cm2 and a mean gradient of >40 mmHg

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163
Q

Valve area and mean gradient indicative of moderate-to-severe MS

A

Area <1.5 cm2 and a mean gradient >5-10 mmHg

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164
Q

Difference in O2 saturation of 5-7% between adjacent cardiac chambers is indicative of

A

Intracardiac shunts

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165
Q

Determine severity of the intracardiac shunt

A

Qp/Qs

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166
Q

For ASD, a Qp/Qs ratio of ___ is considered significant

A

1.5

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167
Q

For VSD, a Qp/Qs ratio of ___ with evidence of LV volume overload is a strong indication for surgical correction

A

≥2

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168
Q

Should be suspected in patients with subtherapeutic anticoagulation with a low mean INR, a prothrombotic state, recent onset heart failure, cardiogenic shock, cardiac arrest, thromboembolic event or, in asymptomatic patients, an increasing gradient across the prosthetic valve.

A

Prosthetic valve leaflet dysfunction

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169
Q

Three major coronary vessels evaluated in coronary angiography

A

Left anterior descending artery
Left circumflex artery
Right coronary artery

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170
Q

It is termed as right dominant when the ____ is the origin of what 3 arteries_____

A

RCA

AV nodal branch, the posterior descending artery, and the posterior lateral vessels

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171
Q

In terms of coronary circulation, 85% of individuals are right or left dominant?

A

Right dominant

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172
Q

It is termed as left dominant when the ____ is the origin of what 3 arteries_____

A

LCx

AV nodal branch, the posterior descending artery, and the posterior lateral vessels

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173
Q

Posterior descending vessel arise from both the right coronary and the posterior lateral vessels from left coronary circulation. This circulation is called _____ and seen in how many % of people?

A

Codominant circulation

10%

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174
Q

Most common coronary artery anomaly

A

Separate ostia for the LAD and LCx

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175
Q

Coronary stenosis that is considered significant

A

> 50%

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176
Q

Percent stenosis is determined visually by

A

comparing the most severely diseased segment with a proximal or distal “normal segment”

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177
Q

A portion of the vessel dips below the epicardial surface into the myocardium and is subject to compressive forces during ventricular systole

A

Myocardial bridge – most commonly involves the LAD

returns to normal during diastole unlike the stenosed part

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178
Q

A measure of the relative duration of time that it takes for contrast to opacify the coronary artery fully

A

Thrombolysis in myocardial infarction (TIMI) flow grade

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179
Q

TIMI flow grade 1

A

minimal filling of contrast

severe stenosis

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180
Q

TIMI flow grade 2

A

delayed filling of contrast

severe stenosis

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181
Q

Provides a more accurate anatomic assessment of the coronary artery and the degree of coronary atherosclerosis if with intermediate stenoses (40–70%), indeterminate findings, or anatomic findings that are incongruous with the patient’s symptoms

A

Intravascular ultrasound (IVUS)

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182
Q

A catheter-based imaging technique that uses near-infrared light to generate images with better spatial resolution than intravascular ultrasound, and image characteristics of the atherosclerotic plaque (lipid, fibrous cap) with high definition and assess coronary stent placement, apposition, and patency

A

Optical coherence tomography

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183
Q

Provides a functional assessment of the coronary stenosis and is more accurate in predicting long-term clinical outcome than imaging techniques

A

Fractional flow reserve

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184
Q

Ratio of the pressure in the coronary artery distal to the stenosis divided by the pressure in the artery proximal to the stenosis at maximal vasodilation

A

Fractional flow reserve

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185
Q

Fractional flow reserve that indicates hemodynamically significant stenosis that would benefit from intervention

A

<0.8

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186
Q

Bed rest duration for femoral and radial approach

A

6 hours

2 hours

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187
Q

For narrow QRS-complex tachycardia, ventricular activation is from the

A

Purkinje system

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188
Q

For wide QRS-complex tachycardia, ventricular activation is from the

A

Accessory pathway

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189
Q

Most common SVT

A

Sinus tachycardia

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190
Q

First step in diagnosis of SVT

A

Consider the possibility of sinus tachycardia

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191
Q

Among SVT, using AV nodal maneuvers or drugs may terminate tachycardia except for

A

Atrial flutter

Increased AV block with continueation of atrial flutter exposes underlying flutter waves

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192
Q

tachycardia from the normal sinus node area that occurs without an identifiable precipitating factor as a result of dysfunctional autonomic regulation

A

Inappropriate sinus tachycardia

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193
Q

Regular atrial tachycardia with defined p wave; may be sustained, nonsustained, paroxysmal, or incessant. Frequent sites of origin occur along the valve annuli of left or right atrium, pulmonary veins, coronary sinus musculature, superior vena cava

A

Focal atrial tachycardia (AT)

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194
Q

organized reentry creates organized atrial activity, commonly seen as sawtooth pattern at rates typically faster than 200 beats/min

A

Atrial flutter

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195
Q

chaotic rapid atrial electrical activity with variable ventricular rate

A

Atrial fibrillation

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196
Q

the most common sustained cardiac arrhythmia in older adults

A

Atrial fibrillation

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197
Q

multiple discrete p waves often seen in patients with pulmonary disease during acute exacerbations of pulmonary insufficiency

A

Multifocal atrial tachycardia

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198
Q

paroxsymal regular tachycardia with P waves visible at the end of the QRS complex or not visible at all

A

AV nodal reentry tachycardia (AVNRT)

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199
Q

the most common paroxysmal sustained tachycardia in healthy young adults

A

AV nodal reentry tachycardia (AVNRT)

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200
Q

paroxysmal sustained tachycardia similar to AV nodal reentry; during sinus rhythm, evidence of ventricular preexcitation may be present (Wolff-Parkinson-White syndrome) or absent (concealed accessory pathway)

A

Orthodromic AV reentry tachycardia (AVRT)

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201
Q

Either has no discernible p-waves because they are synchronous with the QRS, or p-waves that are negative in II, III, aVF immediately following the QRS (referred to as short R-P tachycardia)

A

AV nodal reentry tachycardia (AVNRT)

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202
Q

The most abundant superfamily of ion channels expressed in the heart

A

Voltage-gated channels

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203
Q

the primary carriers of depolarizing current in both the atria and the ventricles

A

Na and Ca channels

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204
Q

In cardiac physiology, this is a time when little current is flowing, and relatively minor changes in depolarizing or repolarizing currents can have profound effects on the shape and duration of the action profile

A

Plateau phase

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205
Q

underlies the property of automaticity characteristic of pacemaking cells in the SA and AV nodes, His-Purkinje system, coronary sinus, and pulmonary veins

A

Spontaneous (phase 4) diastolic depolarization

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206
Q

Normal or enhanced automaticity of subsidiary latent pacemakers if there is failure of more dominant pacemakers

A

Escape rhythms

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207
Q

Abnormal automaticity may produce what arrhythmias (3)

A
  • Atrial tachycardia
  • Accelerated idioventricular rhythms
  • Ventricular tachycardia
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208
Q

membrane voltage oscillations that occur during or after an action potential

A

Afterdepolarizations

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209
Q

most common arrhythmia mechanism

A

Reentry

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210
Q

Class I antiarrhythmic drugs blocks

A

Na

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211
Q

Class II antiarrhythmic drugs blocks

A

β-adrenergic receptor

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212
Q

Class III antiarrhythmic drugs blocks

A

K

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213
Q

Class IV antiarrhythmic drugs blocks

A

Ca

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214
Q

Class I antiarrhythmic drug that have moderate potency and intermediate kinetics

A

Ia – quinidine, procainamide

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215
Q

Class I antiarrhythmic drug that have low potency and rapid kinetics

A

Ib – lidocaine, mexiletine

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216
Q

Class I antiarrhythmic drug that have high potency and slowest kinetics

A

Ic – flecainide, propaferone

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217
Q

Antiarrhythmic drugs that have both Class I and Class III actions (3)

A

Quinidine
Procainamide
Ranolazine

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218
Q

Antiarrhythmic drugs that have the actions of the all 4 classes (2)

A

Amiodarone

Dronedarone

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219
Q

Dofetilide is what class of antiarrhythmic drugs?

A

Class III

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220
Q

Ibutilide is what class of antiarrhythmic drugs?

A

Class III

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221
Q

Class Ia antiarrhythmics

A

quinidine, procainamide

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222
Q

Class Ib antiarrhythmics

A

lidocaine, mexiletine

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223
Q

Class Ic antiarrhythmics

A

flecainide, propaferone

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224
Q

Most common cause of imbalance between myocardial oxygen supply and demand leading to NSTEMI

A

Plaque rupture

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225
Q

% of NSTEMI patient that has left main coronary artery stenosis

A

10%

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226
Q

% of NSTEMI patient that has 3-vessel CAD

A

30%

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227
Q

% of NSTEMI patient that has 2-vessel CAD

A

20%

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228
Q

% of NSTEMI patient that has single-vessel CAD

A

20%

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229
Q

% of NSTEMI patient that has no apparent critical epicardial coronary artery stenosis

A

15%

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230
Q

May show an eccentric stenosis with scalloped or overhanging edges and a narrow neck on coronary angiography and is composed of a lipid-rich core with a thin fibrous caps

A

Vulnerable plaques

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231
Q

Chest discomfort in NSTEMI is severe and has at least one of 4 features:

A
  • Occurrence at rest (or with minimal exertion)
  • lasting >10 min
  • Relatively recent onset (i.e., within the prior 2 weeks)
  • Crescendo pattern, i.e., distinctly more severe, prolonged, or frequent than previous episodes
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232
Q

Anginal equivalents (4)

A
  • Dyspnea
  • Epigastric discomfort
  • Nausea
  • Weakness
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233
Q

Anginal equivalents are more common in (3)

A
  • Women
  • Elderly
  • Diabetes mellitus
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234
Q

2 ECG findings in NSTEMI and which of the 2 is the most common?

A
  • New ST-depression – in 1/3 of the patients

* T wave inversion – more common

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235
Q

Preferred markers of myocardial necrosis

A

Cardiac troponin I or T

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236
Q

Serial ECG and cardiac markers monitoring are done after how many hours of presentation of NSTEMI?

A

4-6 hours and 12 hours after presentation

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237
Q

Risk of early (30-day) mortality of NSTEMI

A

1-10%

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238
Q

Risk of recurrent ACS rate during 1st year:

A

5-15%

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239
Q

7 independent factors for Thrombolysis in Myocardial Infarction Trial:

A
  • Age ≥ 65 years
  • 3 or more of the traditional risk factors for coronary heart disease
  • Known history of CAD or coronary stenosis of at least 50%
  • Daily aspirin use in the prior week
  • More than 1 anginal episode in the past 24 h
  • ST segment deviation of at least 0.5 mm
  • Elevated cardiac specific biomarker above the upper limit of normal
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240
Q

4 additional risk factors for Thrombolysis in Myocardial Infarction Trial (aside from the independent factors)

A
  • Diabetes mellitus
  • LV dysfunction
  • Renal dysfunction
  • Elevated BNP
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241
Q

Ambulation in NSTEMI is permitted if

A

No recurrence of ischemia or no elevation of cardiac biomarker for 12-24 h

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242
Q

In NSTEMI, initial anti-ischemic treatment should include these 4

A
  • Bed rest
  • Nitrates
  • Beta blockers
  • Inhaled oxygen in patients with O2 sat <90% and/or in those with heart failure and rales
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243
Q

Absolute contraindications for Nitrates (2)

A
  • Hypotension

* Recent use of PDE-5 inhibitors

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244
Q

Target heart rate for NSTEMI

A

50-60

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245
Q

Recommended for patients with persistent symptoms or ECG signs of ischemia after treatment with full-dose nitrates and beta blockers

A

Calcium channel blockers (Verapamil and Diltiazem)

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246
Q

Second major cornerstone of treatment of NSTEMI

A

Antithrombotic therapy

Major cornerstone: anti-ischemic therapy

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247
Q

Initial dose of Aspirin in NSTEMI

A

162 mg of a rapidly acting preparation (oral non-enteric coated or IV)

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248
Q

Platelet P2Y12 receptor blocker that is rarely used due to poor tolerability

A

Ticlodipine

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249
Q

Thienopyridine that has irreversible blockade of the platelet P2Y12 receptor

A

Clopidogrel

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250
Q

Loading dose of Clopidogrel in NSTEMI

A

600 mg or 300 mg

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251
Q

2 newer P2Y12 inhibitors that are superior to clopidogrel in preventing recurrent cardiac ischemic events in randomized double-blind studies

A

Prasugrel

Ticagrelor

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252
Q

A thienopyridine that has higher level of platelet inhibition than clopidogrel

A

Prasugrel

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253
Q

Loading dose and maintenance dose of Prasugrel in NSTEMI

A

60 mg

10 mg/day

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254
Q

Loading dose and maintenance dose of Ticagrelor in NSTEMI

A

180 mg

90 mg/day

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255
Q

A novel, potent, reversible platelet P2Y12 inhibitor

A

Ticagrelor

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256
Q

A P2Y12 inhibitor that may have dyspnea early after administration (most often transient and infrequently serious)

A

Ticagrelor

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257
Q

Dual antiplatelet therapy (DAPT) have ___% relative reduction in cardiovascular death, MI or stroke compared to aspirin alone

A

20%

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258
Q

Triple antiplatelet therapy for NSTEMI is composed of

A

Aspirin + P2Y12 inhibitor + Glycoprotein IIb/IIIa inhibitors

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259
Q

Direct thrombin inhibitor that has similar in efficacy to either UFH and LMWH in treatment of NSTEMI

A

Bivalirudin

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260
Q

Indirect factor Xa inhibitor that has similar in efficacy to LMWH in treatment of NSTEMI

A

Fondaparinaux

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261
Q

Patient is closely observed and coronary arteriography is carried out if rest pain or ST-segment changes recur, positive biomarker, or evidence of severe ischemia on a stress test. This approach is called

A

Selective invasive approach

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262
Q

Severe ischemic pain that occurs at rest that is associated with transient ST-segment elevation

A

Prinzmetal’s variant angina

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263
Q

Caused by focal spasm of an epicardial coronary artery with resultant transmural ischemia and abnormalities in the LV function

A

Prinzmetal’s variant angina

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264
Q

Cause of spasm in Prinzmetal’s variant angina is

A

the hypercontractility of vascular smooth muscle due to adrenergic vasoconstrictors, leukotrienes, or serotonin

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265
Q

Transient coronary spasm on coronary angiography is the diagnostic hallmark of

A

Prinzmetal’s variant angina

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266
Q

Main therapeutic agents used for Prinzmetal’s variant angina (2)

A
  • Nitrates

* Calcium channel blockers

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267
Q

May increase severity of ischemic episodes in Prinzmetal’s angina

A

Aspirin

due to sensitivity of coronary tone to modest changes in the synthesis of prostacyclin

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268
Q

5-year survival of Prinzmetal’s angina

A

~90-95%

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269
Q

How many % of Prinzmetal’s variant angina will experience MI?

A

20%

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270
Q

In stress myocardial perfusion imaging, which is preferred, exercise stress or pharmacologic stress?

A

Exercise stress

Downside: submaximal exercise or people unable to exercise

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271
Q

Pharmacologic stress that is used in stress myocardial perfusion imaging (2)

A
  1. Coronary vasodilators (adenosine, dipyridamole, regadenoson) – most commonly used
  2. ß1-receptor agonist (dobutamine)
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272
Q

Simplest application of cardiac CT

A

CT calcium scoring

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273
Q

Scoring that quantify coronary calcium

A

Agatson score

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274
Q

Based on Agatson scoring, define minimal, mild, moderate, and severe scores

A
  • Minimal – 0-10
  • Mild – 10-100
  • Moderate – 100-400
  • Severe - >400
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275
Q

T or F. CT calcium scoring has high cardiac prognostic value

A

True

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276
Q

Techniques for better image in CT coronary angiography (3)

A
  • Breath holding
  • Slowing of HR to 60 bpm – using IV or oral ß-blocker
  • SL nitroglycerin – to enlarge the coronary lumen just prior to contrast injection
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277
Q

Primary imaging method to assess cardiac structure and function

A

Echocardiography

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278
Q

How to compute for EF based on EDV and ESV

A

(EDV – ESV)/EDV

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279
Q

Primary method in the assessment of the diastolic function

A

Echocardiography

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280
Q

Most accurate noninvasive technique to evaluate structure and ejection fraction of the RV

A

CMR

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281
Q

Specific pattern of regional RV dysfunction in acute PE wherein there is preservation of the RV wall motion in the basal and apical regions, and dyskinesis in the region of the mid RV free wall

A

McConnell sign

Highly specific for acute PE

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282
Q

In CIN, renal function usually returns to baseline within ____, without progressing to chronic renal failure

A

7-10 days

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283
Q

Diagnostic test used to assess the cadiac shunts

A

Agitated saline / Bubble study

+ bubbles in the left side of the heart – shunt
If it remains on the right chamber, no shunt

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284
Q

Hallmark of myocardial ischemia in stress echocardiography (2)

A

New regional wall motion abnormalities and reduced systolic wall thickening

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285
Q

Most common form of stress radionuclide imaging tests for CAD evaluation

A

SPECT myocardial perfusion imaging

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286
Q

One of the most valuable clinical applications of radionuclide perfusion imaging is for

A

risk stratification

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287
Q

CAC score that is predictive of a higher likelihood of obstructive CAD

A

High CAC scores (Agatson score > 400)

Agatson score < 400 – less effective in excluding CAD especially in symptomatic patients

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288
Q

For symptomatic patients without prior history of CAD and normal or nearly normal resting ECG who are able to exercise, what test should be used according to ACC/AHA recommendation?

A

exercise treadmill test

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289
Q

Low risk by exercise treadmill test is defined as those

A

Achieving >10 METS without chest pain or ECG changes

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290
Q

In patients who are categorized as low risk by exercise treadmill test but with CAD symptoms, what is ACC/AHA recommendation?

A

treat with medical therapy

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291
Q

High-risk Exercise Treadmill Testing findings (4)

A
  1. Typical angina with > 2 mm ST depression in multiple leads
  2. ST elevation during exercise
  3. Drop in BP
  4. Sustained V-tach
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292
Q

In patients who are categorized as high risk by exercise treadmill test, what is the next step based on ACC/AHA recommendations?

A

coronary angiography

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293
Q

Intermediate-high risk Exercise Treadmill Testing findings (3)

A
  1. Low exercise capacity
  2. Chest pain
  3. ST depression without high risk features
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294
Q

In patients who are categorized as intermediate-high risk by exercise treadmill test, what is the next step based on ACC/AHA recommendations?

A

additional testing (stress imaging or coronary CTA)

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295
Q

In patients who are unable to exercise and/or with abnormal resting ECGs (e.g. LVH with strain pattern and LBBB), what is recommended testing strategy?

A

imaging strategy

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296
Q

In patients who have intermediate-high likelihood of CAD (e.g. diabetics and renal impairment), what is recommended testing strategy?

A

imaging strategy – due to increased overall sensitivity for diagnosis of CAD and improved risk stratification

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297
Q

Justification of stress imaging

A

identification of which patients may benefit from a revascularization strategy rather than angiography-derived anatomic stenoses

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298
Q

First imaging test for the assessment of valvular heart disease

A

Echocardiography

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299
Q

Most cost-effective screening method for VHD

A

Echocardiography

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300
Q

Indications of echocardiography in VHD (4)

A
  1. Cardiac murmurs
  2. DOB
  3. Syncope or presyncope
  4. Preoperative exams in patients undergoing bypass surgery
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301
Q

Tethering of the leaflet tips and relative pliability of the leaflets themselves (hockey stick-type deformation particularly of anterior leaflet) is and echocardiographic finding of

A

Rheumatic MS

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302
Q

Best technique for imaging for presence or the extent of infarcted myocardium in MI patients

A

Late gadolinium enhancement imaging by CMR

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303
Q

Why not do echocardiography immediately after MI who underwent reperfusion therapy?

A

There is partial or complete recovery of ventricular function within several days (EF may be misleading at this time) – myocardial stunning

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304
Q

Best method in the assessment of patients with suspected mechanical complications after MI

A

Echocardiography

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305
Q

Thrombus in the pericardial space after MI raise suspicion of

A

cardiac rupture

306
Q

When should you do a follow-up echocardiography post MI?

A

1-6 months post MI – assess cardiac function and regional wall motion

307
Q

First line test in patients presenting with new-onset heart failure

A

Echocardiography

308
Q

Cardiotoxicity from drug is defined as a ____ reduction in LVEF to ____ with symptoms of heart failure or _____ drop in LVEF to ____ in patients who are asymptomatic

A

> 5%
<55%

> 10%
<55%

309
Q

Distance from the parietal to visceral pericardium for it to be considered a significant effusion

A

> 1 cm

310
Q

Cardiac tamponade echocardiographic features (2)

A
  1. Diastolic collapse of the RV free wall – pericardial pressures exceed RV filling pressures
  2. Doppler evidence of respiratory flow variation – equivalent of pulsus paradoxus
311
Q

Modality that first detects a cardiac mass

A

Echocardiography

312
Q

Majority of the cardiac malignancy is

A

Metastatic

  • Direct invasion (lung and breast)
  • Lymphatic spread (lymphomas and melanomas)
  • Hematogenous spread (renal cell carcinoma)
313
Q

Atrial myxoma is more common in what chamber

A

LA

314
Q

Best technique to assess vegetations because it allows visualization of the typical oscillating motions

A

Echocardiography

315
Q

Best method to view both vegetation and abscess, esp in patients with prosthetic valves

A

TEE

316
Q

Most common adult congenital cardiac abnormalities

A

Abnormalities in the interatrial septum

317
Q

Best way to assess PFO or ASD

A

Agitated saline (Bubble study)

Use maneuvers such as Valsalva or sniff maneuver – to increase RA pressure since PFO is a one-way flap

318
Q

Most common ASD in adults

A

Secundum-type (in the fossa ovalis)

319
Q

In the dyslipidemia guideline, for non-diabetic individuals aged ____ with LDL-C _____ AND ___ risk factors, without atherosclerotic cardiovascular disease, statins are RECOMMENDED for the prevention of cardiovascular events.

A

≥ 45 years
≥ 130 mg/ dL
≥ 2

320
Q

According to the Dyslipidemia guidelines, risk factors for cardiovascular disease include (9)

A
  1. male sex
  2. postmenopausal women
  3. smoker
  4. hypertension
  5. BMI > 25 kg/m2
  6. family history of premature CHD
  7. microalbuminuria
  8. proteinuria
  9. left ventricular hypertrophy
321
Q

According to the Dyslipidemia guidelines, for diabetic individuals without evidence of atherosclerosis (ASCVD), are statins recommended for primary prevention of cardiovascular events?

A

Yes

322
Q

In general, the 2015 CPG recommends a _____ reduction in LDL-C for appropriate treatment goal with statin therapy

A

30% or greater

323
Q

According to Dyslipidemia CPG, what is the treatment goal LDL-C level

A

<70 mg/dl

324
Q

According to the Dyslipidemia CPG, for individuals without evidence of ASCVD but aged_____ AND with ____ risk factors*, the use of lipid profile for screening is RECOMMENDED

A

> 45 years

2 or more

325
Q

According to the Dyslipidemia CPG, is serial liver function test monitoring recommended in asymptomatic individuals prior to treatment with statin therapy?

A

No

326
Q

According to the Dyslipidemia CPG, if patient has elevated AST/ALT while on statin therapy that is ≥ 3x ULN, will you continue the statin or not?

A

Discontinue. In individuals with very high risk for CVD, may use othe non-statins to lower LDL-C while off statins. Recheck AST/ALT after 2 weeks

327
Q

According to the Dyslipidemia CPG, if patient has elevated AST/ALT while on statin therapy that is ≤ 3x ULN, will you continue the statin or not?

A

Continue statin then work up for other possible causes of elevated LFTs especially if with high index of suspicion for other etiologies.

328
Q

According to the Dyslipidemia CPG, if a patient on statin therapy had myalgias, what diagnostic test should you do?

A

Creatine kinase. If elevated at 5x ULN, and patient can tolerate the symptom, may continue or reduce statin dose. if cannot tolerate the symptom and no organ damage, discuss the importance of of discontinuing statin treatment. Then may resume at a lower dose or with other statin once symptom resolves

329
Q

According to the Dyslipidemia CPG, if a patient on statin therapy had myalgias and was noted to have >5xULN elevation of the CK and elevated creatinine, what is the possible diagnosis?

A

statin-induced rhabdomyolysis

stop the statin for 6 weeks then reassess for possible combination therapy with ezetimibe and low dose statin with alternate or weekly dosing

330
Q

According to the Dyslipidemia CPG, for diabetic and non-diabetic individuals with or without evidence of ASCVD, are the the use of fibrates and poly-unsaturated fatty acids (PUFA) or omega 3 fatty acids recommended as alternative to statins for the secondary prevention of cardiovascular events?

A

NOT recommended

The use of fibrates may be considered among patients with a high baseline TG > 204 mg/dl and low HDL-C < 34 mg/dl once LDL-C has been reached on a maximally dosed statin

331
Q

Infectious disease that has a cardiac involvement in up to 50% of cases with 10% developing AV conduction block that is generally reversible but may require temporary pacing support

A

Lyme disease

332
Q

More persistent AV conduction disturbances is seen in these infectious diseases (2)

A

Chagas disease

syphilis

333
Q

Cause of AV conduction block which are accelerated forms with mutations i the cardiac sodium channel gene (SCN5A) and other loci in chromosomes 1 and 19

A

Progressive familial heart block

334
Q

Congenital AV block in the setting of structurally normal heart is seen in children born to mothers with

A

SLE

335
Q

Coronary vasospasm of what artery will cause transient AV block

A

right coronary artery distribution

336
Q

MI that predisposes to 2nd or higher grade AV block with more stable, narrow escape rhythms

A

inferior MI

337
Q

MI that cause block in distal AV nodal complex, His bundle, or bundle branches and produces wide complex unstable escape rhythms with worse prognosis and high mortality

A

Anterior MI

338
Q

In the AV block has normal QES, the site is ____. If with wide QRS, the site is ____

A

normal: intranodal
wide: distal conduction system

339
Q

Intermittent failure of conduction of atrial impulses to the ventricles

A

second degree AV block

340
Q

progressive increase in PR interval, decrease in RR interval, pause that is less than 2 times the immediately preceding RR interval

A

Mobitz type 1 (wenckebach block)

341
Q

Mobitz type 1 block is almost localized to the

A

AV node (intranode)

342
Q

Sudden unexpected failure of conduction from atria to ventricles without preceding change in PR interval

A

Mobitz type 2

343
Q

Mobitz type 2 is localized at

A

distal or infra-His conduction system (infranodal)

344
Q

second degree AV block that is associated with intraventricular conduction delays and is more likely to proceed to higher grades of AV block

A

Mobitz type 2

345
Q

due to a large reentry circuit, often associated with areas of scar in the atria

A

Macroreentrant atrial tachycardia

346
Q

Arrhythmia due to a circuit that revolves around the tricuspid valve annulus, bounded anteriorly by the annulus and posteriorly by functional conduction block in the crista terminalis

A

Common or typical right atrial flutter

The wavefront passes between the inferior vena cava and the tricuspid valve annulus, known as the sub-Eustachian or cavotricuspid isthmus, where it is susceptible to interruption by catheter ablation. Thus, common atrial flutter is also known as cavotricuspid isthmus-dependent atrial flutter

347
Q

Atrial rate of atrial flutter is typically

A

240–300 beats/min

but may be slower in the presence of atrial disease or antiarrhythmic drugs

It often conducts to the ventricles with 2:1 AV block, creating a regular tachycardia at 150 beats/min

348
Q

Some patients with atrial fibrillation treated with an antiarrhythmic drug, particularly_____, _____, or _____, will present with atrial flutter rather than fibrillation, since these agents slow atrial conduction velocity and can promote reentry.

A

flecainide, propafenone, or amiodarone

349
Q

Atrial flutter can occur in either atrium and are almost universally associated with areas of

A

atrial scar

350
Q

T or F. The risk of thromboembolic events in atrial flutter is lower than with atrial fibrillation

A

False. Similar

351
Q

For recurrent episodes of common atrial flutter, catheter ablation of the ____ abolishes the arrhythmia in >90% of patients with a low risk of complications that are largely related to vascular access, and rarely heart block.

A

cavotricuspid isthmus

352
Q

Management of first episode of atrial flutter

A

Conversion to sinus rhythm with no antiarrhythmic drug therapy

353
Q

Antiarrythmic for recurrent atrial flutter (4)

A

Sotalol
Dofetilide
Disopyramide
Amiodarone

354
Q

Multifocal AT (MAT) is characterized by a rhythm with at least ____ distinct P-wave morphologies with rates typically between _____

A

Three
100 and 150 beats/min

It is usually encountered in patients with chronic pulmonary disease and acute illness

355
Q

Management of Multifocal AT

A

treating the underlying disease and correcting any metabolic abnormalities

CCB (verapamil and diltiazem) - may slow the atrial and ventricular rate

Amiodarone

356
Q

T or F. Electrical cardioversion is ineffective in MAT

A

True

357
Q

MAT may respond to amiodarone, but long-term therapy with this agent is usually avoided due to its toxicities, particularly

A

pulmonary fibrosis

358
Q

CHA2DS2-VASc risk factors

A
C—congestive heart failure 
H—hypertension 
A- Age ≥75 y.o
D—diabetes mellitus 
S – stroke or TIA, embolus
V—vascular disease 
A- Age 65 - 75 y.o
Sex—female
359
Q

Among the CHA2DS2-VASc risk factors, which of them is scored 2 points?

A

A- Age ≥75 y.o

S – stroke or TIA, embolus

360
Q

Annual stroke rate for each CHA2DS2-VASc risk factors

A
0 – 0
1 - 1.3% 
2 – 2.2%
3 - 3.2% 
4 – 4.0%
5 - 6.7% 
6-9 - >9%
361
Q

Dabigatran is an inhibitor of

A

Thrombin

362
Q

Rivaroxaban is an inhibitor of

A

Factor Xa

363
Q

Apixaban is an inhibitor of

A

Factor Xa

364
Q

Central cyanosis is caused by

A

significant right-to-left shunting at the level of the heart or lungs

365
Q

Reduced extremity blood flow due to small vessel constriction

A

Peripheral cyanosis / Acrocyanosis

366
Q

Peripheral cyanosis / Acrocyanosis can be aggravated by what drugs

A

ß-blockers – due to unopposed ⍺-mediated vasoconstriction

367
Q

Unusually tan or bronze discoloration of the skin that may be seen in systolic HF

A

Hemochromatosis

368
Q

Pigeon chest

A

Pectus carinatum

369
Q

Funnel chest

A

Pectus excavatum

370
Q

Loss of the normal kyphosis of the thoracic spine. This is seen in what cardiac problem?

A

Straight back syndrome

Seen in patients with MVP

371
Q

Tender, raised nodules on the pads of the finger and toes

A

Osler’s nodes

372
Q

Linear petechiae in the midposition of the nail bed

A

Splinter hemorrhages

373
Q

Posterior calf pain on active dorsiflexion of the foot against resistance. This is present in what condition?

A

Homan’s sign

DVT

374
Q

Single most important bedside measurement to estimate volume status

A

JVP

375
Q

In the measurement of JVP, which vein is preferred?

A

Internal jugular vein

External jugular vein is valved and not directly in line with the SVC and RA

376
Q

Venous pressure is the vertical distance between the

A

top of the jugular venous pulsation and the angle of Louis

377
Q

Normal JVP

A

≤4.5 cm at 30º angle

378
Q

Part of the body that is a better reference for measurement of the JVP

A

Clavicle

379
Q

Difference between carotid pulse and venous waveform (2)

A

Carotid pulse is not easily obliterated with palpation and is monophasic

Venous waveform change with changes in posture or inspiration (unless quite elevated) and is biphasic

380
Q

Venous waveform that corresponds to the right atrial presystolic contraction

A

ɑ - wave

381
Q

Prominent ɑ - wave indicates

A

Reduced RV compliance

382
Q

Venous waveform of AV dissociation and right atrial contraction against a closed tricuspid valve

A

Cannon ɑ wave

383
Q

In patients with wide complex tachycardia, appreciation of cannon ɑ wave in the JV waveform identifies the rhythm as _____ in origin

A

Ventricular

384
Q

ɑ wave is not present in what arrhythmia

A

Atrial fibrillation

385
Q

Venous waveform that represents fall in the right atrial pressure

A

X descent

after inscription of the ɑ wave

386
Q

Venous waveform that representing closed tricuspid valve pushed into the RA during early ventricular systole

A

c wave

Interrupts the x descent and followed by further descent

387
Q

Venous waveform that represents atrial filling or atrial diastole

A

v wave

Occurs during ventricular systole

388
Q

Venous waveform that is accentuated in TR

A

v wave

389
Q

Venous pressure should _____ by ______ with inspiration

A

fall by at least 3 mmHg

390
Q

Rise or a lack of fall of the JVP with inspiration is called ____. This is usually seen in what condition.

A

Kussmaul’s sign

Constrictive pericarditis

391
Q

Abdominojugular reflux maneuver is elicited by firm and consistent pressure over the _____ of the abdomen, preferably over the_____, for _____, and reassessment of ____

A

upper portion
RUQ
15 s
JVP

392
Q

Positive response of abdominojugular reflux maneuver

A

sustained rise of > 3 cm in the JVP

Response should be assessed after 10 s of continuous pressure

Venous hypertension

393
Q

Positive response of abdominojugular reflux maneuver is seen in pulmonary artery wedge pressure

A

> 15 mmHg in patients with HF

Indicates a volume-overloaded state with limited compliance of an overly distended or constricted venous system

394
Q

Very low (even 0 mmHg) diastolic BP is seen in what condition (2)

A
  • chronic, severe AR

- large AV fistula

395
Q

Difference of the BP between the 2 arms must be

A

< 10 mmHg

396
Q

Systolic leg pressure is usually _____ than the arm pressure

A

20 mmHg higher

Higher in chronic severe AR or in PAD

397
Q

White-coat hypertension is defined as at least ___ separate clinic-based measurements ____ and at least ___non-clinical-based measurements _____ in the absence of any evidence of ______

A

3
> 140/90 mmHg

2
<140/90 mmHg

target organ damage

398
Q

Orthostatic hypotension is defined as a fall in the SBP _____ or DBP _____ in response to assumption of the upright posture from a supine position within _____

A

> 20 mmHg
10 mmHg

3 mins

399
Q

Aortic pulse is best appreciated in the

A

epigastrium, just above the umbilicus

400
Q

Asses the integrity of the arcuate system of the hand

A

Allen’s test

401
Q

Performed routinely before instrumentation of the radial artery

A

Allen’s test

402
Q

Character of the pulse is best appreciated at the

A

carotid level

403
Q

A weak and delayed pulse seen in severe AS

A

Pulsus parvus et tardus

404
Q

Slow, notched, or interrupted upstroke seen in AS

A

Anacrotic pulse

405
Q

Sharp rise of carotid upstroke and rapid fall-off that is seen in chronic severe AR

A

Corrigan’s or water-hammer pulse

406
Q

Bifid pulse

A

Bisferiens pulse

Seen in advanced AR and HOCM

407
Q

Fall in systolic pressure > 10 mmHg with inspiration

A

Pulsus paradoxus

Measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each heartbeat, independent of the respiratory phase

408
Q

Pulsus paradoxus is fall in systolic pressure _____ with _____

A

> 10 mmHg

inspiration

409
Q

Beat-to-beat variability of the pulse amplitude. This is usually seen in what condition?

A

Pulsus alternans

Seen in severe LV systolic dysfunction

410
Q

Cervical bruit is a weak indicator of

A

carotid artery stenosis

411
Q

Visible right upper parasternal pulsation is indicative of

A

ascending aortic aneurysm

412
Q

Normal splitting of S1 is seen in young patient with

A

RBBB

Tricuspid valve closure is relatively delayed

413
Q

Narrowly split S2 or a single S2

A

pulmonary hypertension

414
Q

Fixed splitting of S2

A

Secundum ASD

415
Q

Reversed or paradoxical splitting is the pathologic delay in AV closure that is seen in these conditions (5)

A
  1. LBBB
  2. RV pacing
  3. Severe AS
  4. HOCM
  5. Acute MI
416
Q

High-pitched early systolic sound that corresponds in timing to the upstroke of the carotid pulse

A

Ejection sound

417
Q

The only right-sided acoustic event that decreases in intensity with inspiration

A

Pulmonic ejection sound

418
Q

S3 corresponds to

A

Rapid filling phase of the ventricular diastole

Normal finding in children, adolescents, and young adults
Heart failure in older patients

419
Q

Low-pitched sound best heard at the LV apex that is predictive of cardiovascular morbidity and mortality in CHF

A

Left-sided S3

420
Q

S4 corresponds to

A

atrial filling phase of the ventricular diastole

421
Q

Thrill is present in what grade of murmur

A

grade 4 murmurs or above

422
Q

Early systolic murmur that may increase in intensity with inspiration heard at the left lower sternal border

A

Acute TR

423
Q

Most common cause of midsystolic murmur in adult

A

Aortic Stenosis

424
Q

Midsystolic murmur that is loudest in the 2nd right interspace with radiation to the carotids

A

Aortic Stenosis

425
Q

Increase in intensity of murmur of TR with inspiraton

A

Carvallo’s sign

426
Q

Decrescendo, blowing diastolic murmur at left sternal border with wide pulse pressure and bounding arterial pulses

A

Chronic, severe AR

427
Q

Signs of diastolic run-off (2):

A
  • Wide pulse pressure

* Bounding arterial pulses

428
Q

Low-pitched mid- to late apical diastolic murmur that sometimes can be confused with MS. This murmur is heard in what condition?

A

Austin Flint murmur

Chronic, severe AR

429
Q

Low-pitched mid- to late diastolic rumbling best heard at apex on left lateral decubitus position

A

Mitral stenosis

430
Q

Continuous murmur at

A

2nd or 3rd interspace at a slight distance from the sternal border

431
Q

Continuous murmur heard at supraclavicular fossa that can be obliterated with firm pressure applied to the diaphragm of the stethoscope

A

Cervical venous hum

Benign
children or adolescents

432
Q

Enhanced arterial blood flow through engorged breasts causes this continuous murmur

A

Mammary soufflé of pregnancy

433
Q

Right-sided events increase in intensity with inspiration and decrease with expiration except

A

pulmonic ejection sound

434
Q

Left-sided events _____ in intensity with inspiration and _____ with expiration

A

Decrease

Increase

435
Q

Increase murmur in response to maneuvers that increase LV afterload (i.e. hand grip and vasopressors) (3)

A

MR
VSD
AR

436
Q

In older patients, murmur of AS may be well transmitted to the apex. What do you call this?

A

Gallavardin effect

437
Q

Most heart murmurs decrease in intensity and duration during the strain phase of Valsalva, except (2)

A

MVP
HOCM

After release of the Valsalva maneuver, right-sided murmurs tend to return to control intensity earlier than do left-sided murmurs

438
Q

First clue that prosthetic valve dysfunction may contribute to recurrent symptoms

A

Change in the quality of the heart sounds or the appearance of a new murmur

439
Q

Prosthetic valves that has same heart sounds with the native valves

A

Bioprosthetic valves

440
Q

In patients with prosthetic valve, this may present clinically with signs of shock, muffled heart sounds, and soft murmurs

A

Prosthetic valve thrombosis

441
Q

3 components of pericardial friction rub

A
  • Ventricular systole
  • Rapid early diastolic filling
  • Late presystolic filling after atrial contraction
442
Q

Pulsus paradoxus that exceeds ____ is seen pericardial tamponade

A

12 mmHg

443
Q

With standing, most murmurs______ , with two exceptions: ______ and ______

A

HOCM – become louder

MVP – lengthens and often is intensified

444
Q

With squatting, most murmurs become____, except for ______ and ______

A

Louder

HOCM and MVP usually soften and may disappear

Passive leg raising usually produces the same results.

445
Q

Murmur often decreases with nearly maximum hand grip exercise

A

HOCM

446
Q

Most common primary tumor of the heart

A

Myxoma

Primary tumors of the heart are rare. Approximately three-quarters are histologically benign

447
Q

Most common malignant tumor of the heart

A

Sarcomas

Malignant tumors, almost all of which are sarcomas, account for 25% of primary cardiac tumors

448
Q

Gender predilection of myxoma

A

Female

449
Q

a syndrome of myxomas (cardiac, skin, and/or breast), lentigines and/or pigmented nevi, and endocrine overactivity (primary nodular adrenal cortical disease with or without Cushing’s syndrome, testicular tumors, and/or pituitary adenomas with gigantism or acromegaly)

A

Carney complex

450
Q

Inactivating mutations in the tumor-suppressor gene PRKAR1A, which encodes the protein kinase A type I-α regulatory subunit, have been identified in ~70% of patients with

A

Carney complex

451
Q

Difference between sporadic and familial myxoma

A

Sporadic: solitary, arise in interatrial septum in the vicinity of fossa ovalis, pedunculated

Familial: syndromic, younger individuals, multiple, may be ventricular in location, more likely to recur after initial resection

452
Q

The most common clinical presentation of myxoma mimics that of

A

mitral valve disease

either stenosis owing to tumor prolapse into the mitral orifice or regurgitation resulting from tumor-induced valvular trauma or distortion

453
Q

Characteristic auscultation finding in myxoma

A

Low-pitched sound, a “tumor plop,” during early or mid-diastole

454
Q

Management of myxoma

A

Surgical excision using cardiopulmonary bypass

indicated regardless of tumor size
generally curative

455
Q

Cardiac tumors that may grow as large as 15 cm, may present as an abnormality of the cardiac silhouette on chest x-ray

A

Cardiac lipomas

456
Q

Friable cardiac tumors with frond-like projections that are usually solitary

A

Papillary fibroelastomas

457
Q

Most common tumors of the cardiac valves

A

Papillary fibroelastomas

458
Q

Remnants of cytomegalovirus have been recovered from these cardiac tumors, raising the possibility that they arise as a result of chronic viral endocarditis

A

Papillary fibroelastomas

459
Q

The most common cardiac tumors in infants and children (2)

A

Rhabdomyomas and fibromas

usually occur in the ventricles

460
Q

Cardiac tumors that are considered haramartomatous growths are multiple in 90% of cases, and are strongly associated with tuberous sclerosis

A

Rhabdomyomas

461
Q

Single cardiac tumor that is universally ventricular in location, often calcified, tend to grow and cause arrhythmias and obstructive symptoms,

A

Fibromas

462
Q

Rare chromaffin cell tumors that represent extra- adrenal pheochromocytomas

A

Paragangliomas

Most are located in the roof of the left atrium

463
Q

Almost all malignant primary cardiac tumors are

A

Sarcomas

isolated cardiac lymphomas have been rarely described, but usually occur in the context of more systemic disease

In general, sarcomas are characterized by rapid progression that culminates in the patient’s death within weeks to months from the time of presentation as a result of hemodynamic compromise, local invasion, or distant metastases.

464
Q

most common type of cardiac sarcoma in adults

A

angiosarcomas

465
Q

most common type of cardiac sarcoma in children

A

Rhabdomyosarcomas

466
Q

Most common metastatic site of cardiac sarcoma

A

lung

467
Q

Cardiac tumors that commonly involve the right side of the heart, are rapidly growing, frequently invade the pericardial space, and may obstruct the cardiac chambers or venae cavae

A

Sarcomas

Sarcomas also may occur on the left side of the heart and may be mistaken for myxomas.

468
Q

Most common tumors of the heart

A

Tumors metastatic to the heart

469
Q

Although cardiac metastases may occur with any tumor type, the relative incidence is especially high in _____ and, to a somewhat lesser extent, _____ and ____

A

Malignant melanoma

Leukemia and lymphoma – somewhat lesser extent

470
Q

The most common primary sites from which cardiac metastases originate are (2)

A

Breast CA

Lung CA

471
Q

Most often involved part of the heart in cardiac metastases

A

Pericardium

Followed by myocardium of any chamber, and, rarely, by involvement of the endocardium or cardiac valves

472
Q

The most common cause of myocardial ischemia

A

Atherosclerotic disease of an epicardial coronary artery

473
Q

Central to the pathophysiology of myocardial ischemia

A

myocardial supply and demand

474
Q

Major determinants of myocardial oxygen demand (3)

A
  1. Heart rate
  2. Myocardial contractility
  3. Myocardial wall tension (stress)
475
Q

Determinants of oxygen supply to the myocardium (2)

A
  1. Oxygen-carrying capacity of the blood

2. Adequate level of coronary blood flow

476
Q

Major determinants of coronary resistance (2)

A

Prearteriolar vessels

Arteriolar and intramyocardial capillary vessels

477
Q

Condition that increases the myocardial oxygen demand causing ischemia

A

Severe left ventricular hypertrophy (LVH) due to aortic stenosis

Can present with angina that is indistinguishable from that caused by coronary atherosclerosis largely owing to subendocardial ischemia

478
Q

T or F. Severe anemia often cause myocardial ischemia

A

False. Rarely causes myocardial ischemia by itself but may lower the threshold for ischemia in patients with moderate coronary obstruction

479
Q

Abnormal constriction or failure of normal dilation of the coronary resistance vessels causing angina

A

Microvascular angina

480
Q

Major site of atherosclerotic disease

A

Epicardial coronary arteries

Branch point of epicardial artery - increased turbulence; predilection for atherosclerotic plaques

481
Q

Major risk factors of coronary atherosclerosis (5)

A
  1. High level of LDL
  2. Low level of HDL
  3. Cigarette smoking
  4. Hypertension
  5. Diabetes mellitus
482
Q

Limitation of the ability to increase flow to meet increased myocardial demand is seen in stenosis of how many percent

A

~50%

483
Q

Blood flow at rest may be reduced and further minor decreases in the stenotic orifice area can reduce coronary flow dramatically to cause myocardial ischemia at rest or with minimal stress. This is seen in stenosis of how many percent

A

~80%

484
Q

Most common cause of segmental atherosclerotic narrowing of epicardial coronary arteries

A

Plaque

485
Q

Duration of total occlusion of coronary arteries in the absence of collaterals where in damage is reversible

A

≤20 min

> 20min of occlusion – permanent damage with subsequent myocardial necrosis

486
Q

Cardiomegaly and heart failure secondary to ischemic damage of the LV myocardium that may have caused no symptoms before the development of heart failure

A

Ischemic cardiomyopathy

487
Q

Stable angina pectoris is due to

A

transient myocardial ischemia

488
Q

Patients with angina localizes pain by placing hand over the sternum with a clenched fist. What do you call this sign?

A

Levine’s sign

489
Q

Description of angina in terms of
Characteristic:
duration:
Radiation

A

Characteristic: crescendo-decrescendo
duration: 2-5 min
Radiation: shoulder and to both arms (ulnar surfaces of forearm and hand), back, interscapular region, root of the neck, jaw, teeth, and epigastrium

Rarely localized below the umbilicus or above the mandible

490
Q

T or F. Angina can radiate to trapezius muscle

A

False

491
Q

Angina that occur while patient is recumbent

A

angina decubitus

492
Q

Patient may be awakened at night by typical chest discomfort and dyspnea

A

Nocturnal angina

Due to episodic tachycardia, diminished oxygenation, or expansion of the intrathoracic blood volume that occurs during recumbency. Recumbency causes an increase in cardiac size (EDV), wall tension, and myocardial oxygen demand

493
Q

Anginal equivalents (4)

A
  1. Dyspnea
  2. Nausea
  3. Fatigue
  4. Faintness
494
Q

Most widely used test for both the diagnosis of IHD and the estimation of risk and prognosis

A

Treadmill test

495
Q

Treadmill test is discontinued if with (7)

A
  1. Chest discomfort
  2. Severe shortness of breath
  3. Dizziness
  4. Severe fatigue
  5. ST-segment depression >0.2 mV (2mm)
  6. Fall in SBP >10 mmHg
  7. Ventricular tachyarrhythmia
496
Q

Ischemic ST segment response in treadmill test

A
  1. Flat ST

2. Downsloping depression of the ST >0.1 mV below the baseline (i.e. PR segment lasting longer than 0.08 s.

497
Q

Target heart rate in treadmill test

A

85% of maximal predicted heart rate for age and sex

498
Q

T or F. Negative test for treadmill test will rule out CAD.

A

False.

Does not exclude CAD but makes likelihood of 3-vessel or left main CAD is extremely unlikely

499
Q

Contraindications of treadmill test (7)

A
  1. Rest angina within 48 h
  2. Unstable rhythm
  3. Severe aortic stenosis
  4. Acute myocarditis
  5. Uncontrolled heart failure
  6. Severe pulmonary HPN
  7. Active IE
500
Q

Failure of the BP to increase or an actual decrease with signs of ischemia during the treadmill test

A

Ischemia-induced global LV dysfunction

important adverse prognostic sign

501
Q

Indicative of severe IHD and high risk of future adverse events (2)

A
  1. Angina and or severe (>0.2 mV) ST-segment depression at a low workload (before completion of stage II of the Bruce protocol)
  2. ST-segment depression that persists >5 min after termination of exercise
502
Q

IV pharmacologic challenge in cardiac imaging uses (3)

A

Dipyridamole
Adenosine
Dobutamine

503
Q

IV pharmacologic challenge in cardiac imaging create a coronary “steal” by temporarily increasing flow in nondiseased segments of the coronary vasculature at the expense of diseased segments

A

Dipyridamole or adenosine

504
Q

T or F. One of the indication for coronary arteriography is as a routine exam for patients with careers that involve the safety of others

A

False. Patients with careers that involve the safety of others (e.g., pilots, firefighters, police) who have questionable symptoms or suspicious or positive noninvasive tests and in whom there are reasonable doubts about the state of the coronary arteries.

505
Q

Coronary arteriography is indicated in male patients ____ old and females ____ old who are to undergo a cardiac operation such as valve replacement or repair and who may or may not have clinical evidence of myocardial ischemia

A

> 45 years

>55 years

506
Q

Principal prognostic indicators of IHD (4)

A
  1. Age
  2. Functional state of the LV
  3. Location and severity of coronary artery narrowing
  4. Severity of myocardial ischemia
507
Q

Location of obstruction that has greater risk for coronary events (2)

A
  1. Left main (>50% luminal diameter)

2. LAD coronary artery proximal to the origin of the 1st septal artery

508
Q

Side effect of long-acting nitrates (2)

A

headache and dizziness

509
Q

Minimum effective dose of long-acting nitrates should be used and a minimum of 8 h each day kept free of the drug to restore any useful response. Why?

A

minimize the effects of nitrate tolerance

510
Q

Therapeutic aim of beta blockers in IHD

A

relief of angina and ischemia

511
Q

Piperazine derivative that is useful for patients with chronic stable angina despite standard medical therapy

A

Ranolazine

Inhibit the late inward sodium current (INa) resulting to limitation of the Na overload of ischemic myocytes and prevention of Ca2+ overload via the Na-Ca exchanger

512
Q

T or F. Ivabradine has no benefit for patients with IHD with no clinical HF

A

True

513
Q

Most common clinical indication for PCI

A

Symptom-limiting angina pectoris, despite medical therapy, with evidence of ischemia during stress test

514
Q

Vessels used in CABG (3)

A
  1. internal mammary arteries
  2. radial artery
  3. Saphenous vein
515
Q

Preferred procedure in CABG

A

Anastomosis of one or both of the internal mammary arteries or a radial artery to the coronary artery distal to the obstructive lesion

516
Q

T or F. In CABG, saphenous vein grafts have higher long-term patency rates compared in internal mammary and radial artery implantations

A

False.

517
Q

T or F. In CABG, internal mammary and radial artery implantations are better used for LAD obstruction than saphenous vein

A

True

518
Q

T or F. CABG is superior to PCI in preventing death, myocardial infarction, and repeat revascularization

A

True

519
Q

Noncontractile or hypocontractile myocardial segments that are viable but are chronically ischemic

A

Hibernating myocardium

Treated with revascularization

520
Q

T or F. Stroke risk is higher in PCI than in CABG

A

False. Lower

521
Q

PCI is chosen over CABG in patients with (3)

A
  1. 1- or 2-vessel CAD
  2. Normal LV function
  3. Anatomically suitable lesion
522
Q

CABG is chosen over PCI in patients with (6)

A
  1. 3-vessel CAD
  2. 2-vessel CAD that includes proximal LAD
  3. Impaired global LV function (LV EF <50%)
  4. DM
  5. Left main CAD
  6. Lesions unsuitable for catheter-based procedures
523
Q

CCD functional class I

A

Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina present with strenuous or rapid or prolonged exertion at work or recreation.

524
Q

CCD functional class II

A

Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or when under emotional stress or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions.

525
Q

CCD functional class III

A

Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing more than one flight of stairs in normal conditions.

526
Q

CCD functional class IV

A

Inability to carry on any physical activity without discomfort— anginal syndrome may be present at rest.

527
Q

Nitrates is contraindicated in what cardiac condition

A

HOCM

528
Q

Nondihydropyridines CCB

A

Verapamil and diltiazem

529
Q

An index of both sodium and potassium intakes that is a stronger correlate of BP than is either sodium or potassium alone

A

Urine sodium-to-potassium ratio

530
Q

Determinants of arterial pressure (2)

A

Cardiac output – determined by SV and HR
Peripheral resistane - determined by functional and anatomic changes in small arteries (lumen diameter 100–400 μm) and arterioles

531
Q

T or F. Non-chloride salts of sodium has little or no effect on BP

A

True

532
Q

An extreme example of volume-dependent hypertension

A

ESRD

533
Q

Play important roles in tonic and phasic cardiovascular regulation (3)

A

Norepinephrine, epinephrine, and dopamine

534
Q

Mediators of activities of all adrenergic receptors

A

G proteins

Second messengers

535
Q

α receptors is occupied and activated more avidly by

A

Norepinephrine > epinephrine

536
Q

Adrenergic receptors that are found in the postsynaptic cells in smooth muscle

A

α1 Receptors

537
Q

Action of α1 Receptors in the vessel wall and in kidney

A

Vasoconstriction

In kidney, increase renal tubular absorption of sodium

538
Q

Adrenergic receptor that is found in presynaptic membranes of postganglionic nerve terminals that synthesize norepinephrine

A

α2 Receptors

539
Q

Adrenergic receptor that act as negative feedback controllers when activated by catecholamines

A

α2 Receptors

Inhibit further norepinephrine release

540
Q

β receptors is occupied and activated more avidly by

A

Epinephrine > norepinephrine

541
Q

Effect of β1 receptor stimulation in cardiovascular and in the kidney

A

Stimulates the rate and strength of cardiac contraction leading to increase in cardiac output

Stimulates renin release from the kidney

542
Q

Effect of β2 receptor stimulation in cardiovascular

A

Relaxation of vascular smooth muscle leading to vasodilation

543
Q

Phenomenon that is characterized by decreasing responsiveness to catecholamines

A

Tachyphylaxis

Caused by downregulation of receptors due to sustained high levels of catecholamines

544
Q

Most blatant example of hypertension related to increased catecholamine production

A

Pheochromocytoma

545
Q

Treatment of pheochromocytoma

A
  1. Surgical excision of the tumor
  2. a1 receptor antagonist
  3. inhibitor of tyrosine hydroxylase
546
Q

Rate-limiting step in catecholamine biosynthesis

A

tyrosine hydroxylase

547
Q

Centrally acting a2 agonist that inhibits sympathetic outflow

A

Clonidine

Abrupt cessation of this drug will cause rebound hypertension due to upregulation of a1 receptors

548
Q

Arterial baroreflex is mediated by stretch-sensitive sensory nerve endings in the

A

carotid sinuses and aortic arch

Increase BP will cause increase firing of baroreceptors and result to decrease in sympathetic outflow eventually leading to decrease in arterial pressure and heart rate

549
Q

Most renin in the circulation is synthesized in the

A

afferent renal arteriole

550
Q

3 primary stimuli for renin secretion:

A
  1. Decrease NaCl transport in Macula densa
  2. Baroreceptor mechanism
  3. Sympathetic nervous system stimulation of renin-secreting cells via β1 adrenoreceptors
551
Q

Angiotensin I is converted to angiotensin II in the

A

Lung

552
Q

Primary tropic factor for the secretion of aldosterone by the adrenal zona glomerulosa

A

Angiotensin II

553
Q

Obstruction of the renal artery causes decreased renal perfusion pressure and renin secretion leading to

A

Renovascular hypertension

554
Q

Effect of aldosterone in the kidney

A

Increases sodium reabsorption by amiloride-sensitive epithelial sodium channels (ENaC) on the apical surface of the principal cells of the renal cortical collecting duct

May cause hypokalemia and alkalosis since electrical neutrality is maintained by exchanging Na for K and H ions

555
Q

Adrenal aldosterone synthesis and release are independent of renin-angiotensin is seen in what condition

A

Primary aldosteronism

556
Q

A compelling example of mineralocorticoid-mediated hypertension

A

Primary aldosteronism

557
Q

Resistance to blood flow varies inversely with the ____ power of the radius of the vessel

A

Fourth

558
Q

Geometric alterations in the vessel wall without a change in vessel volume

A

Remodeling

559
Q

The most common cause of death in hypertensive patients

A

Heart disease

560
Q

The strongest risk factor for stroke

A

Elevated blood pressure

561
Q

The most common etiology of secondary hypertension

A

Primary renal disease

562
Q

The renal lesion associated with malignant hypertension

A

Fibrinoid necrosis of the afferent arterioles

563
Q

Macroalbuminuria is a random urine albumin/creatinine ratio of

A

> 300 mg/g

564
Q

Microalbuminuria is a random urine albumin/creatinine ratio of

A

30–300 mg/g

565
Q

ABI that is diagnostic of PAD

A

ABI <0.90

Associated with >50% stenosis in at least one major lower limb vessel

566
Q

The classic symptom of PAD

A

Intermittent claudication

567
Q

Cardiovascular disease risk doubles for every _____ increase in systolic and _____ increase in diastolic pressure

A

20-mmHg

10-mmHg

568
Q

T or F. Diastolic blood pressure and pulse pressure are more powerful predictors of cardiovascular disease than systolic blood pressure among older individuals

A

False. Systolic blood pressure and pulse pressure are more powerful predictors of cardiovascular disease than diastolic blood pressure among older individuals.

569
Q

More comprehensive assessment of the vascular burden of hypertension

A

Ambulatory blood pressure recordings

570
Q

T or F. BP tends to be lower in the early morning hours, soon after waking, than at other times of day

A

False. Higher.

MI and stroke are more common in the early morning hours

571
Q

Recommended criteria for a diagnosis of hypertension based on 24-h BP monitoring:
Average awake blood pressure
Average asleep blood pressure

A

Average awake blood pressure ≥135/85 mmHg
Average asleep blood pressure ≥120/75 mmHg

These levels approximate a clinic blood pressure of 140/90 mmHg

572
Q

High renin patients may have a _____ form of hypertension

A

vasoconstrictor

573
Q

Low-renin patients may have _____ form of hypertension

A

volume-dependent

574
Q

Hypertension due to an occlusive lesion of a renal artery

A

Renovascular hypertension

A potentially curable form of hypertension

575
Q

Large majority of patients with renovascular hypertension have a plaque obstructing mostly the

A

origin of renal artery

in older arteriosclerotic patients

576
Q

Patients with renovascular hypertension secondary to fibromuscular dysplasia have an obstruction in the

A

distal portions of the renal artery

577
Q

PE finding that is seen in 50% of patients with renovascular hypertension

A

Abdominal or flank bruit

More likely to be hemodynamically significant if it lateralizes or extends throughout systole into diastole

578
Q

“Gold standard” for evaluation and identification of renal artery lesions

A

Contrast arteriography

No single test is sufficiently reliable to determine a causal relationship between a renal artery lesion and hypertension

579
Q

Functionally significant lesions is defined as lesions that generally occlude _____ of the lumen of the affected renal artery

A

> 70%

Presence of collateral vessels to the ischemic kidney

580
Q

T or F. Laboratory evaluation for renal artery stenosis and stent placement should be considered only in those arteriosclerotic patients in whom medical therapy fails to control blood pressure or preserve renal function

A

True

581
Q

Most effective medical therapies for renovascular hypertension

A

ACE inhibitor or an angiotensin II receptor blocker

582
Q

A useful screening test in primary aldosteronism

A

PA/PRA

The ratio of plasma aldosterone to PRA

Recommendation: withdraw aldosterone antagonists for at least 4-6 weeks before obtaining the measurements

583
Q

PA and PA/PRA values that indicates an aldosterone-producing adenoma

A

Ratio >30:1
PA >555 pmol/L (>20 ng/dL)

A high ratio in the absence of an elevated plasma aldosterone level is considerably less specific for primary aldosteronism since many patients with primary hypertension have low renin levels in this setting

584
Q

Diagnosis of primary aldosteronism can be confirmed by demonstrating failure to __________after IV infusion of _______ over _____

A

suppress plasma aldosterone to <277 pmol/L (<10 ng/dL)

2 L of isotonic saline

4 h

Post-saline infusion plasma aldosterone values between 138 and 277 pmol/L (5–10 ng/dL) are not determinant

585
Q

2 most common causes of sporadic primary aldosteronism

A

Aldosterone-producing adenoma

Bilateral adrenal hyperplasia

586
Q

Most accurate means of differentiating unilateral versus bilateral forms of primary aldosteronism

A

Bilateral adrenal venous sampling for measurement of plasma aldosterone

587
Q

Catecholamine-secreting tumors (2)

A

Pheochromocytoma

Paraganglioma

588
Q

Most common congenital cardiovascular cause of hypertension

A

Coarctation of the aorta

Occurs in 35% of children with Turner’s syndrome

589
Q

Causes diastolic hypertension, hypo or hyperthyroidism?

A

Hypothyroidism causes diastolic hypertension

Hyperthyroidism causes systolic hypertension

590
Q

Monogenic hypertension cause wherein synthesis of sex hormones and cortisol is decreased

A

17α-hydroxylase deficiency

Decreased cortisol  diminished cortisol-induced negative feedback on pituitary ACTH production  increase ACTH  increase ACTH-stimulated adrenal steroid synthesis proximal to the enzymatic block  increase mineralocorticoids (i.e. desoxycorticosterone)  Hypertension, hypokalemia

591
Q

Enzyme deficiency that results in a salt-retaining adrenogenital syndrome

A

11β-hydroxylase deficiency

Increased mineralocorticoid synthesis (e.g. desoxycorticosterone)
Decreased cortisol synthesis

Acne, hirsutism, and menstrual irregularities – may be the presenting features when the disorder is first recognized in adolescence or early adulthood

592
Q

Syndrome caused by constitutive activation of amiloride-sensitive ENaC on the distal renal tubule

A

Liddle’s syndrome

Excess sodium reabsorption
Cause of monogenic hypertension

593
Q

Pregnancy can exacerbate hypertension by:

A

Activation of the mineralocorticoid receptor by progesterone

594
Q

Average blood pressure reductions of 6.3/3.1 mmHg for every reduction of mean body weight of

A

9.2 kg

595
Q

Lowering systolic blood pressure by ____ and diastolic blood pressure by _____ confers relative risk reductions of 35–40% for stroke and 12–16% for CHD within 5 years of the initiation of treatment

A

10–12 mmHg

5–6 mmHg

596
Q

The single most effective intervention for slowing the rate of progression of hypertension-related kidney disease

A

Hypertension control

597
Q

Anti-HPN that inhibit the Na+/Cl– pump in the distal convoluted tubule and hence increase sodium excretion

A

Thiazides

598
Q

Anti HPN that inhibit ENaC in the distal nephron

A

Potassium-sparing diuretics (Amiloride and triamterene)

Potassium-sparing diuretics

599
Q

Anti HPN that target the Na+-K+-2Cl– cotransporter in the thick ascending limb of the loop of Henle

A

Loop diuretics

Reserved for hypertensive patients with reduced GFR (reflected in serum creatinine >220 μmol/L [>2.5 mg/dL]), CHF, or sodium retention and edema

600
Q

Why does ACE inhibitors causes cough?

A

It increases the bradykinin levels

601
Q

ARBs act on what receptors?

A

AT1 receptors

AT1 receptors – constriction
AT2 receptors – dilation

602
Q

ARB that is proven to reduce the risk of developing diabetes in high-risk hypertensive patients

A

Valsartan

ACE and ARBS improve insulin action and ameliorate the adverse effects of diuretics on glucose metabolism

Modest impact on the incidence of diabetes

603
Q

T or F. ACEi/ARB combinations are less effective in lowering blood pressure than is the case when either class of these agents is used in combination with other classes of agents

A

True

604
Q

Oral, nonpeptide competitive inhibitors of the enzymatic activity of renin

A

Aliskiren

As effective as ACEIs and ARBs if used as monotherapy
More complete blockade
Not considered first-line antihypertensive agent

605
Q

A nonselective aldosterone antagonist

A

Spironolactone

606
Q

Side effects of spironolactone (2)

A

Gynecomastia (binds to progesterone receptors)

Impotence (binds to androgen receptors)

607
Q

Selective aldosterone antagonist

A

Eplerenone

Lesser side effects

608
Q

T or F. There is no difference in the antihypertensive potencies of cardioselective and nonselective beta blockers

A

True

609
Q

T or F. Beta blockers with intrinsic sympathomimetic activity decrease the rate of sudden death, overall mortality, and recurrent myocardial infarction

A

False. Without ISA

610
Q

Block both β receptors and peripheral α-adrenergic receptors (2)

A

Carvedilol and labetalol

611
Q

Cardioselective beta blocker and has additional vasodilator actions related to enhancement of nitric oxide activity

A

Nebivolol

612
Q

CCBs reduce vascular resistance through blockade of what channel

A

L-channel blockade

613
Q

A potent direct vasodilator that has antioxidant and NO-enhancing actions and may induce a lupus-like syndrome

A

Hydralazine

614
Q

Direct vasodilator that can be used to treat malignant hypertension and life-threatening LV heart failure

A

IV Nitroprusside

615
Q

Standard doses of most antihypertensive agents reduce BP by

A

8-10/4-7 mmHg

616
Q

Younger patients are more responsive to this anti-HPN drugs (2)

A

beta blockers and ACEIs

617
Q

> 50 year old patients are more responsive to this anti-HPN drugs (2)

A

diuretics and calcium antagonists

618
Q

____ are inferior to other classes of anti-HPN agents for prevention of cardiovascular events, stroke, renal failure, and all-cause mortality

A

Beta blockers

619
Q

_____ may be inferior than diuretics but superior to other classes of agents for the prevention of heart failure

A

Calcium channel blockers

620
Q

T or F. ACEIs or ARBs provide better coronary protection than CCB

A

True

621
Q

T or F. ACEIs or ARBs provide more stroke protection than other anti-HPN

A

False. CCBs

622
Q

Combination treatment with an ACEI (benazepril) plus a calcium antagonist (amlodipine) was superior to treatment with the ACEI plus a diuretic (hydrochlorothiazide) in reducing the risk of cardiovascular events and death among high-risk patients with hypertension. What is this trial

A

Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH Trial)

623
Q

The maximum protection against combined cardiovascular endpoints is achieved with pressures _____ for systolic blood pressure and _____ for diastolic blood pressure

A

<135–140 mmHg

<80–85 mmHg

624
Q

Intensive blood pressure control (systolic blood pressure <120 mmHg) reduced the risk of cardiovascular events and mortality by 25% compared with less intensive control (systolic blood pressure 135–139 mmHg). More intense control may also be associated with a higher incidence of adverse events (e.g., syncope, electrolyte abnormalities, deterioration of renal function). This trial is the

A

SPRINT trial

625
Q

Failed to find superiority of intensive blood pressure lowering (<120 mmHg) over standard blood pressure control (<140 mmHg) in reducing the risk of the study’s primary outcome (a composite endpoint of myocardial infarction, stroke, and cardiovascular death) in diabetic patients. This trial is the

A

ACCORD Trial

Demonstrate a significant reduction of stroke and left ventricular hypertrophy with more intensive therapy

626
Q

Refers to patients with blood pressures persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic

A

Resistant hypertension

More common in patients aged >60 years

627
Q

Maneuver done in patients with severely sclerotic arteries wherein radial pulse is palpated despite occlusion of the brachial artery by the cuff

A

Osler maneuver

Pseudoresistant hypertension

628
Q

In hypertensive emergencies, this determines the rapidity with which blood pressure should be lowered

A

degree of target organ damage

629
Q

A syndrome associated with an abrupt increase of blood pressure in a patient with underlying hypertension or related to the sudden onset of hypertension in a previously normotensive individual

A

Malignant hypertension

Associated with diffuse necrotizing vasculitis, arteriolar thrombi, and fibrin deposition in arteriolar walls

630
Q

In patients suspected with malignant hypertension, intake of these drugs must be investigated first.

A

Use of monoamine oxidase inhibitors

Use of recreational drugs (e.g., cocaine, amphetamines)

631
Q

T or F. In hypertensive encephalopathy, BP must be lowered rapidly

A

True. BP must be lowered rapidly but inherent risks of overly aggressive therapy is present.

In hypertensive individual, the upper and lower limits of autoregulation of cerebral blood flow are shifted to higher levels of arterial pressure. Rapid lowering of BP to below the lower limit of autoregulation may precipitate cerebral ischemia or infarction due to decreased cerebral blood flow

632
Q

Initial goal of therapy in hypertensive encephalopathy

A

Decreased MAP by no more than 25% within minutes to 2 h or to a BP range of 160/100-110 mmHg

633
Q

T or F. In malignant HPN without encephalopathy, BP must be reduced slowly

A

True. May be effectively be achieved initially with frequent dosing of short-acting oral agents such as captopril, clonidine, and labetalol

634
Q

In patients with acute, transient blood pressure elevations after thrombotic stroke that is not candidate for thrombolytic therapy, institute antihypertensive therapy only for patients with SBP _____ or DBP of _____

A

> 220 mmHg

> 130 mmHg

635
Q

In patients with acute, transient blood pressure elevations after thrombotic stroke that is candidate for thrombolytic therapy, target SBP and DBP are

A

SBP is <185 mmHg

DBP is <110 mmHg

636
Q

In patients with acute, transient blood pressure elevations after hemorrhagic stroke, target SBP is

A

140-179 mmHg

637
Q

Treatment of adrenergic crisis as cause of hypertensive emergency

A

phentolamine or nitroprusside

Pheochromocytoma, cocaine or MAP overdose, clonidine witrawal, acute spinal cord injuries, and interaction of tyramine-containing compounds with monoamine oxidase inhibitors

638
Q
SBP and DBP of:
Normal
Prehypertension
Stage I
Stage II
Isolated systolic HPN
A
Normal: <120, <80
Prehypertension: 120-139; 80-89
Stage I: 140-159; 90-99
Stage II: ≥160; ≥ 100
Isolated systolic HPN: ≥140; <90
639
Q

Dietary salt reduction for hypertension

A

<6 g NaCl/d

640
Q

Moderation of alcohol consumption for hypertension

A

For those who drink alcohol, consume ≤2 drinks/d in men and ≤1 drink/d in women

641
Q

Cardioselective beta blockers (2)

A

Atenolol

Metoprolol

642
Q

Nonselective beta blocker

A

Propanolol

643
Q

Nonselective alpha antagonist used in pheochromocytoma

A

Phenoxybenzamine

644
Q

Direct vasodilators used in HPN (2)

A

Hydralazine

Minoxidil

645
Q

Normal quantity of pericardial fluid

A

15–50 mL

646
Q

Most common pathologic process involving the pericardium

A

Acute pericarditis

647
Q

Chest pain that is intensified by lying supine, and relieved by sitting up and leaning forward

A

Acute pericarditis

648
Q

rasping, scratching, or grating sound heard most frequently at end expiration with the patient upright and leaning forward

A

pericardial friction rub

649
Q

Stage of acute pericarditis where there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2–V6, with reciprocal depressions only in aVR and sometimes V1

A

stage 1

Also, depression of the PR segment below the TP segment, reflecting atrial involvement

Stage 2: ST segments return to normal

650
Q

Stage of acute pericarditis where T waves become inverted

A

Stage 3

Stage 4: Weeks or months after the onset of acute pericarditis, the ECG returns to normal

651
Q

Difference between the ST elevation in MI and pericarditis

A

MI – convex, reciprocal depression is usually more prominent

Acute pericarditis – concave

652
Q

Patch of dullness and increased fremitus beneath the angle of the left scapula that is audible when base of the left lung may be compressed by pericardial fluid

A

Ewart’s sign

653
Q

Chest xray finding of “water bottle” configuration

A

Massive pericardial effusion

654
Q

Management of acute pericarditis (4)

A
  1. Aspirin 2-4 g/day
  2. NSAIDs (ibuprofen 600-800 mg tid or indomethacin 25–50 mg tid)
  3. Gastric protection (omeprazole)
  4. Colchicine 0.5 mg qd [<70 kg] or 0.5 mg bid [>70 kg] for 3 months

Glucocorticoids (e.g., prednisone 1 mg/kg per day) usually suppress the clinical manifestations of acute pericarditis in patients who have failed therapy with or do not tolerate NSAIDs and colchiine. However, since they increase the risk of subsequent recurrence, full-dose corticosteroids should be given for only 2–4 days and then tapered.

655
Q

Drug that enhances the response to NSAIDs and also aids in reducing the risk of recurrent pericarditis

A

Colchicine

656
Q

predictors of poor prognosis in acute pericarditis (3)

A

fever >38°C
subacute onset
large pericardial effusion

657
Q

three principal features of tamponade

A
  1. Hypotension
  2. soft or absent heart sounds
  3. jugular venous distention with a prominent x (early systolic) descent but an absent y (early diastolic) descent
    Beck’s triad

The limitations to ventricular filling are responsible for reductions of cardiac output and arterial pressure

658
Q

Beck’s triad is seen in

A

Cardiac tamponade

659
Q

The quantity of fluid necessary to produce cardiac tamponade may be as small as ____ when the fluid develops rapidly to as much as _____ in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume

A

200 mL

>2000 mL

660
Q

greater than normal (10 mmHg) inspiratory decline in systolic arterial pressure or palpating weakness or even disappearance of the arterial pulse during inspiration

A

Paradoxical Pulse

important clue to the presence of cardiac tamponade

Paradoxical pulse also occurs in approximately one-third of patients with constrictive pericarditis, and in some cases of hypovolemic shock, acute and chronic obstructive airway disease, and pulmonary embolism

661
Q

May resemble cardiac tamponade with hypotension, elevated jugular venous pressure, an absent y descent in the jugular venous pulse, and, occasionally, a paradoxical pulse

A

Right ventricular infarction

662
Q

Doppler ultrasound shows that tricuspid and pulmonic valve flow velocities increase markedly during inspiration, whereas pulmonic vein, mitral, and aortic flow velocities diminish

A

Cardiac tamponade

663
Q

Most common approach for pericardiocentesis

A

Subxiphoid approach

664
Q

The most frequent complication of acute idiopathic pericarditis

A

recurrent (relapsing) pericarditis

665
Q

Post cardiac injury syndrome is characterized by acute pericarditis that follows (4)

A
  1. cardiac operation (postpericardiotomy syndrome)
  2. blunt or penetrating cardiac trauma
  3. perforation of the heart with a catheter
  4. AMI.
666
Q

The principal symptom of post cardiac injury syndrome is the pain of acute pericarditis, which usually develops ____ after the cardiac injury

A

1–4 weeks

667
Q

This syndrome is probably the result of a hypersensitivity reaction to antigen(s) that originate from injured myocardial tissue and/or pericardium.

A

Post cardiac injury syndrome

668
Q

Treatment of Post cardiac injury syndrome

A

aspirin and analgesics

669
Q

pericarditis that is usually secondary to cardiothoracic operations, by extension of infection from the lungs or pleural cavities, from rupture of the esophagus into the pericardial sac, or from rupture of a valvular ring abscess in a patient with infective endocarditis

A

Pyogenic (purulent) pericarditis

670
Q

2 forms of pericarditis seen in CKD patient

A
  1. Pericarditis of renal failure (uremic pericarditis)
  2. dialysis-associated pericarditis

When the pericarditis of renal failure is recurrent or persistent, a pericardial window should be created or pericardiectomy may be necessary.

671
Q

Pericarditis due to neoplastic diseases results from extension or invasion of metastatic tumors, most commonly (5)

A
  1. lung
  2. Breast
  3. malignant melanoma
  4. lymphoma
  5. leukemia
672
Q

Most common cause of chronic pericardial effusion (2)

A
  1. Tuberculosis
  2. Myxedema

Neoplasms, SLE, rheumatoid arthritis, mycotic infections, radiation therapy to the chest, and chylopericardium may also cause chronic pericardial effusion and should be considered and specifically sought in such patients

673
Q

Management of chronic pericardial effusion

A

Pericardiectomy

Intrapericardial instillation of sclerosing agents may be used to prevent reaccumulation of fluid

674
Q

This disorder results when the healing of an acute fibrinous or serofibrinous pericarditis or the resorption of a chronic pericardial effusion is followed by obliteration of the pericardial cavity with the formation of granulation tissue

A

Chronic constrictive pericarditis

675
Q

Common cause of constrictive pericarditis

A

TB

676
Q

Difference between the constrictive pericarditis and cardiac tamponade in terms of ventricular filling

A

Ventricular filling is unimpeded during early diastole but is reduced abruptly when the elastic limit of the pericardium is reached, whereas in cardiac tamponade, ventricular filling is impeded throughout diastole

677
Q

The right and left atrial pressure pulses display an M-shaped contour, with prominent x and y descents

A

constrictive pericarditis

678
Q

Difference between the constrictive pericarditis and cardiac tamponade in terms of y descent

A

y descent is absent or diminished in cardiac tamponade

y descent is prominent in constrictive pericarditis

679
Q

In constrictive pericarditis, the ventricular pressure pulses in both ventricles exhibit characteristic ____ signs during diastole.

A

“square root”

680
Q

In constrictive pericarditis, the apical pulse is reduced and may retract in systole. This is called

A

Broadbent’s sign

681
Q

The apical pulse is reduced and may retract in systole The heart sounds may be distant; an early third heart sound occurring at the cardiac apex with the abrupt cessation of ventricular filling is often conspicuous

A

Constrictive pericarditis

The early third sound is the pericardial knock

682
Q

Pericardial calcification is most common in

A

Tuberculous pericarditis

Pericardial calcification may, however, occur in the absence of constriction, and constriction may occur without calcification

683
Q

Diagnostic test for constrictive pericarditis

A

CT or MRI

echocardiography cannot definitively establish or exclude the diagnosis of constrictive pericarditis

684
Q

only definitive treatment of constrictive pericarditis

A

Pericardial resection

should be as complete as possible

685
Q

In pericardial resection, coronary arteriography should be carried out preoperatively in patients aged ____ to exclude unsuspected accompanying coronary artery disease

A

> 50 years

686
Q

This form of pericardial disease is characterized by the combination of a tense effusion in the pericardial space and constriction of the heart by thickened pericardium

A

Subacute Effusive-Constrictive Pericarditis

Wide excision of both the visceral and parietal pericardium is usually effective therapy

687
Q

Tuberculous pericardial disease may present as (3)

A
  1. pericardial effusion
  2. chronic constrictive pericarditis
  3. subacute effusive constrictive pericarditis
688
Q

If the etiology of chronic pericardial effusion remains obscure despite detailed analysis including culture of the pericardial fluid, a______ should be performed

A

pericardial biopsy, preferably by a limited thoracotomy

689
Q

T or F. If definitive evidence of tb pericarditis is still lacking but the specimen shows granulomas with caseation, antituberculous chemotherapy is indicated.

A

True

690
Q

If the biopsy specimen shows a thickened pericardium after 2–4 weeks of antituberculous therapy, ______ should be carried out

A

Pericardiectomy

to prevent the development of constriction

691
Q

Duration of acute, subacute, and chronic pericarditis

A

Acute: <6 weeks
Subacute: 6 weeks to 6 months
Chronic: > 6 months

692
Q

Five functional components of the mitral valve apparatus

A
  1. Leaflets
  2. Annulus
  3. Chordae tendineae
  4. Papillary muscles
  5. Subjacent myocardium
693
Q

Acute MR can occur in the setting of (3)

A
  1. Acute myocardial infarction (MI) with papillary muscle rupture
  2. Blunt chest wall trauma
  3. During the course of infective endocarditis (IE) owing to leaflet perforation or destruction
694
Q

Papillary muscle of the mitral valve that is most often involved in acute MI

A

posteromedial papillary muscle

because of its singular blood supply

695
Q

Can result in “acute-on- chronic MR” in patients with myxomatous degeneration of the valve apparatus

A

Rupture of chordae tendineae

696
Q

MV leaflets and/or chordae tendineae are primarily responsible for abnormal valve function

A

primary MR

697
Q

MV leaflets and chordae tendineae are usually normal but the regurgitation is caused by left ventricular (LV) remodeling with annular enlargement, papillary muscle displacement, leaflet tethering, or their combination

A

secondary (functional) MR

698
Q

MR may occur as a congenital anomaly, most commonly as a

A

defect of the endocardial cushions (atrioventricular cushion defects)

699
Q

Chronic MR is frequently secondary to

A

ischemia

may occur as a consequence of ventricular remodeling, papillary muscle displacement, and leaflet tethering, or with fibrosis of a papillary muscle, in patients with healed MI(s) and ischemic cardiomyopathy

700
Q

Chronic, severe MR is defined by a regurgitant volume_____, regurgitant factor ____, and effective regurgitant orifice area ____

A

≥60 mL/beat

≥50%

≥0.40 cm2

701
Q

most prominent complaints in patients with chronic severe MR (3)

A

Fatigue, exertional dyspnea, and orthopnea

702
Q

Holosystolic murmur, grade III/VI, most prominent in the apex and radiates to the axilla

A

MR

703
Q

Systolic murmur that is transmitted to the base of the heart with cooing or “seagull” quality

A

MR secondary to ruptured chordae tendineae

704
Q

Systolic murmur that is transmitted to the base of the heart with musical quality

A

MR secondary to flail leaflet

705
Q

The systolic murmur of chronic MR not due to MVP is _______ by isometric exercise (handgrip) but is _____ during the strain phase
of the Valsalva maneuver

A

Increased

Decreased

because of the associated decrease in LV preload

706
Q

Direct anticoagulants is contraindicated in this valve conditions (2)

A
  1. Rheumatic MS

2. Mechanical prosthetic heart valves

707
Q

MV surgery that is preferred and has lower risk

A

Mitral valve repair

Repair usually consists of valve reconstruction using a variety of valvuloplasty techniques and insertion of an annuloplasty ring

708
Q

Indications for mitral valve repair for chronic severe primary MR: (6)

A
  1. Symptomatic
  2. Asymptomatic patients with LV dysfunction characterized by an EF <60%
  3. Asymptomatic patients with an LV end-systolic dimension (LV ESD) >40 mm
  4. recent-onset AF (duration <3 months)
  5. pulmonary hypertension (defined as a systolic PA pressure ≥50 mmHg at rest or ≥60 mmHg with exercise)
  6. progressive decrease in LV EF or increase in LV ESD on serial imaging
709
Q

leading cause of mitral stenosis

A

Rheumatic fever

Other less common etiologies of obstruction to left ventricular inflow include congenital mitral valve stenosis, cor triatriatum, mitral annular calcification with extension onto the leaflets, systemic lupus erythematosus, rheumatoid arthritis, left atrial myxoma, and infective endocarditis with large vegetations

710
Q

Pure or predominant MS occurs in ____ of all patients with rheumatic heart disease and a history of rheumatic fever

A

~40%

711
Q

“fish-mouth” valve

A

Rheumatic MS

712
Q

Normal MV orifice

A

4-6 cm2

713
Q

In the presence of significant obstruction, i.e., when the MV orifice area is reduced to ____, blood can flow from the LA to the left ventricle (LV) only if propelled by an abnormally elevated left atrioventricular pressure gradient

A
714
Q

hemodynamic hallmark of MS

A

abnormally elevated left atrioventricular pressure gradient

715
Q

When the mitral valve opening is reduced to <1.5 cm2, referred to as “severe” MS, an LA pressure of ____ is required to maintain a normal cardiac output (CO).

A

~25 mmHg

716
Q

Severe MS has orifice of

A

1-1.5 cm2

717
Q

The LV diastolic pressure and ejection fraction (EF) are ____ in isolated MS

A

normal

718
Q

In patients with severe MS (mitral valve orifice 1–1.5 cm2), the CO is

A

normal or almost so at rest, but rises subnormally during exertion

In patients with very severe MS (valve area <1 cm2), particularly those in whom pulmonary vascular resistance is markedly elevated, the CO is subnormal at rest and may fail to rise or may even decline during activity

719
Q

Very severe MS has orifice of

A

<1 cm2

720
Q

Causes of pulmonary hypertension in MS (4)

A
  1. passive backward transmission of the elevated LA pressure
  2. pulmonary arteriolar constriction (the so-called “second stenosis”), which presumably is triggered by LA and pulmonary venous hypertension (reactive pulmonary hypertension)
  3. interstitial edema in the walls of the small pulmonary vessels
  4. end stage, organic obliterative changes in the pulmonary vascular bed
721
Q

The development of ____ in MS often marks a turning point in the patient’s course and is generally associated with acceleration of the rate at which symptoms progress

A

persistent AF

722
Q

Presents as a malar flush with pinched and blue facies, with prominent a waves, with normal or low BP

A

Severe MS

723
Q

Auscultatory finding that is most readily audible in expiration at, or just medial to, the cardiac apex. This sound generally follows the sound of aortic valve closure (A2) by 0.05–0.12

A

Opening snap

MS
The time interval between A2 and OS varies inversely with the severity of the MS

724
Q

Low-pitched, rumbling, diastolic murmur, heard best at the apex with the patient in the left lateral recumbent position; it is accentuated by mild exercise (e.g., a few rapid sit-ups) carried out just before auscultation

A

MS

725
Q

Pansystolic murmur along the left sternal border that is louder during inspiration and diminishes during forced expiration is the murmur of _____. What do you call this sign?

A

TR

Carvallo’s sign

In severe pulmonary hypertension

726
Q

A high-pitched, diastolic, decrescendo blowing murmur along the left sternal border, results from dilation of the pulmonary valve ring and occurs in patients with mitral valve disease and severe pulmonary hypertension

A

Graham Steell murmur of PR

727
Q

Eariest chest X-ray changes in MS (4)

A
  1. straightening of the upper left border of the cardiac silhouette
  2. prominence of the main PA
  3. Dilation of the upper lobe pulmonary veins
  4. Posterior displacement of the esophagus by an enlarged LA
728
Q

Target INR for patients with MS with AF or history of thromboembolism

A

2-3

729
Q

Usually, cardioversion in MS with AF (recent onset) should be undertaken after the patient has had at least _____ of anticoagulant treatment to a therapeutic INR

A

3 consecutive weeks

If cardioversion is indicated more urgently, then intravenous heparin should be provided and TEE performed to exclude the presence of LA thrombus before the procedure

Conversion to sinus rhythm is rarely successful or sustained in patients with severe MS, particularly those in whom the LA is especially enlarged or in whom AF has been present for more than 1 year.

730
Q

Indication of mitral valvotomy in MS

A

Symptomatic (NYHA FC II-IV) with isolated severe MS whose effective orifice is < ~1 cm2/m2 body surface area, or <1.5 cm2 in normal- sized adults

Asymptomatic patients or mild/moderate MS with recurrent systemic embolization or severe pulmonary hypertension

731
Q

Successful valvotomy is defined by a ____ reduction in the mean mitral valve gradient and a ____ of the mitral valve area

A

50%

doubling

732
Q

Preferred procedure for pregnant patient with MS

A

PMBV

Valvotomy should be carried out if pulmonary congestion occurs despite intensive medical treatment

733
Q

Management of patients with MS and significant associated MR

A

Mitral valve replacement (MVR)

734
Q

Indications for mitral valve replacement (MVR)

A
  1. Orifice area ≤1.5 cm2

2. NYHA Class III

735
Q

Sex predilection of AS

A

Male

~80% of adult patients with symptomatic, valvular AS are male.

736
Q

Most common causes of AS in adults (3)

A

Degenerative calcification occurs most commonly on a substrate of

  1. congenital disease (BAV)
  2. chronic (trileaflet) deterioration
  3. previous rheumatic inflammation.
737
Q

T or F. Rheumatic AS is almost always associated with involvement of the mitral valve and with aortic regurgitation (AR).

A

True

738
Q

Most common congenital heart valve defect

A

Bicuspid aortic valve (BAV)

Occurs in 0.5–1.4% of the population with a 2–4:1 male-to-female predominance
autosomal dominant with incomplete penetrance

739
Q

Bicuspid aortic valve (BAV) is prominent in what chromosomal disorder

A

Turner’s syndrome

740
Q

most common bicuspid AV variant

A

right-left cusp fusion

associated with enlargement of the ascending aorta along its greater curvature

741
Q

AS associated with severe obstruction to LV outflow (2)

A
  1. Mean systolic pressure gradient >40 mmHg with a normal CO
  2. Effective aortic orifice area of ~<1 cm2 (or ~<0.6 cm2/m2 body surface area in a normal-sized adult)
742
Q

AS is rarely of clinical importance until the valve orifice has narrowed to

A

~1 cm2
because of the ability of the hypertrophied LV to generate the elevated intraventricular pressures required to maintain a normal stroke volume
Once symptoms occur, valve replacement is indicated

743
Q

T or F. Most patients with pure or predominant AS have gradually increasing obstruction over years but do not become symptomatic until the fourth decade.

A

False. 6th to 8th decade

744
Q

Causes of exertional syncope in AS

A
  1. Decline in arterial pressure caused by vasodilation in the exercising muscles and inadequate vasoconstriction in nonexercising muscles in the face of a fixed CO
  2. Sudden fall in CO produced by an arrhythmia
745
Q

three cardinal symptoms of AS

A
  1. Exertional dyspnea
  2. angina pectoris
  3. syncope
746
Q

AF occurrence in AS should suggest the possibility of

A

associated mitral valve disease

Though it may also occur as a complication of AS at the late course of the disease

747
Q

In the late stages of AS, when stroke volume______ , the systolic pressure may ____ and the pulse pressure ____.

A

declines
fall
narrow

748
Q

Carotid arterial pulse rises slowly to a delayed peak

A

Pulsus parvus et tardus

Seen in AS

749
Q

Low-pitched murmur, rough and rasping in character, and loudest at the base of the heart, most commonly in the second right intercostal space, and is transmitted upward along the carotid arteries

A

AS

750
Q

The murmur of AS occasionally is transmitted downward and to the apex, where it may be confused with the systolic murmur of mitral regurgitation (MR). This is called

A

Gallavardin effect

751
Q

Severe AS is defined by a valve area

A

<1 cm2

752
Q

Moderate AS is defined by a valve area of

A

1–1.5 cm2

753
Q

Mild AS by a valve area of

A

1.5–2 cm2

754
Q

Aortic valve sclerosis is accompanied by a jet velocity of

A

<2.5 m/s (peak gradient <25 mmHg)

755
Q

Catheterization is useful in three distinct categories of AS patients:

A

(1) patients with multivalvular disease, in whom the role played by each valvular deformity should be defined to aid in the planning of operative treatment
(2) young, asymptomatic patients with noncalcific congenital AS, to define the severity of obstruction to LV outflow, because operation or percutaneous aortic balloon valvuloplasty (PABV) may be indicated in these patients if severe AS is present, even in the absence of symptoms
(3) patients in whom it is suspected that the obstruction to LV outflow may not be at the level of the aortic valve but rather at the sub- or supravalvular level.

756
Q

Calcific AS is a progressive disease, with an annual reduction in valve area averaging ____ and annual increases in the peak jet velocity and mean valve gradient averaging ____ and____, respectively

A
  1. 1 cm2
  2. 3 m/s

7 mmHg

757
Q

T or F. In patients with severe AS (valve area <1 cm2), strenuous physical activity and competitive sports should be avoided once with symptoms.

A

False. Should be avoided even on asymptomatic stage

758
Q

T or F. Medications used for the treatment of hypertension or CAD, including beta blockers and angiotensin-converting enzyme (ACE) inhibitors, are generally safe for asymptomatic AS patients with preserved LV systolic function.

A

True

759
Q

Surgical management of AS is indicated in patients with

A

severe AS (valve area <1 cm2 or 0.6 cm2/m2 body surface area) who are symptomatic

  1. LV systolic dysfunction (EF <50%)
  2. BAV disease and an aneurysmal root or ascending aorta (maximal dimension >5.5 cm)
760
Q

Bioprostheses for AS valve replacement are favored for patients age

A

> 65 years

761
Q

Ross procedure

A

Its use has declined considerably in the United States because of the technical complexity of the procedure and the incidence of late postoperative aortic root dilation and autograft failure with AR

762
Q

This procedure is preferable to operation in many children and young adults with congenital, noncalcific AS

A

Percutaneous aortic balloon valvuloplasty

It is not commonly used as definitive therapy in adults with severe calcific AS because of a very high restenosis rate (80% within 1 year) and the risk of procedural complications, but on occasion, it has been used successfully as a “bridge to operation” in patients with severe LV dysfunction and shock who are too ill to tolerate surgery. It is performed routinely as part of the TAVR procedure