Cardiology Flashcards
1
Q
Which new murmur is a sign of cardiac ischemia?
A
new MR murmur
2
Q
In a history of a young woman with h/o migraines, acute chest pain, and ST elevation, what etiology of chest pain do you suspect? What is the work up and treatment?
A
coronary vasospasm (Prinzmetal angina) w/u: echo tx: long acting nitrate, CCB
3
Q
What is the treatment for takotsubo cardiomyopathy?
A
BB, ACE-I
4
Q
What would you suspect in a young man with substernal chest pain, deep T waveinversions in V2-V4 and a harsh systolic murmur that increases with Valsalva maneuver? What is the w/u and treatment?
A
HCM
w/u: echo
tx: BB
5
Q
T/F: posterior MI also counts as STEMI
A
T (tall R waves and ST depressions in V1-V3)
6
Q
Where is the STEMI on EKG?
1) II, III, aVF
2) V1-V3
3) V4-V6, possibly I and aVL
4) depressions with tall R waves in V1-V3
5) V4R-V6R; tall R waves in V1-V3
A
1) inferior
2) anteroseptal
3) lateral and apical
4) posterior
5) right ventricle
7
Q
What are 5 situations where the unstable angina/NSTEMI needs immediate angiography?
A
1) HD instability
2) HF
3) recurrent rest angina despite therapy,
4) new/worsening MR murmur
5) sustained VT
8
Q
How do you approach UA/NSTEMI with TIMI score of:
1) 0-2
2) 3-7
A
1) ASA, BB, nitrates, heparin, statin, clopidogrel with predischarge stress test and angio if needed
2) ASA, BB, nitrates, heparin, statin, clopidogrel with angio
9
Q
What are 4 situations that a cardiac cath is needed following post-MI stress test results?
A
1) exercise-induced ST depressions/elevations
2) inability to achieve 5 METs
3) inability to increase SBP by 10-30mmHg
4) inability to exercise
10
Q
What medications are started for STEMIs:
1) ASAP (3)
2) within 24 hours (2)
3) early (1)
4) within 3-14 days if LVEF <40% and clinical HF or DM
A
1) ASA, P2Y12 inhib (continue for 1 year), anticoagulant
2) BB, ACE-I (continue if reduced LVEF, clinical HF, DM, HTN, CKD)
3) statin
4) eplerenone/spironolactone
11
Q
What is the first medical contact to PCI time in:
1) PCI-capable hospital
2) transfer
A
1) <90 min
2) <120min
12
Q
What are 3 indications for PCI other than STEMI?
A
1) failure of thrombotic therapy (CP, persistent ST elevations)
2) thrombolytic contraindicated
3) new HF or cardiogenic shock
13
Q
When are the 3 contraindications for thrombolytic therapy in STEMI?
A
1) active bleeding
2) risk of bleeding
3) BP >180/110
14
Q
When is CABG indicated for STEMI? (4)
A
1) PCI failure
2) papillary muscle rupture
3) VSD
4) free wall rupture
15
Q
What happened when you get hypotension following nitroglycerin or morphine?
A
RV/posterior infarction
16
Q
What is the treatment for patients with cardiogenic shock, acute MR or VSD, intractable VT or refractory angina?
A
intra-aortic balloon pump
17
Q
What are 4 situations that would require temporary pacing?
A
1) asystole
2) symptomatic bradycardia
3) alternating LBBB and RBBB
4) new or indeterminate-age bifasicular block with first degree AV block
18
Q
Complications of acute MI 2-7 days later?
A
mechanical complications (VSD, papillary muscle rupture, LV free wall rupture)
VSD/papillary muscle rupture sx: pulm edema, hypotension, loud holosystolic murmur and thrill
LV free wall rupture sx: hypotension, cardiac death 2/2 PEA
tx: papillary muscle rupture and VSD-intra-aortic balloon pump with afterload reduction with nitroprusside and diuretics then surgery
19
Q
What do you need to support cardiogenic shock? 2 surgical things
A
intra-aortic balloon pump and LVAD
20
Q
What is the treatment of postinfarction angina? ventricular arrhythmia?
A
1) cardiac cath
2) ICD therapy
21
Q
What is the indication for ICDs post-MI? It needs to meet all 3 criteria
1) ___ days since MI
2) LVEF ____ and NYHA functional class __ &__ or LVEF ____ and NYHA functional class __
3) ___ months since PCI or CABG
A
1) >40 days
2) <35% with NYHA II &III or <30% with NYHA I
3) >3 months
22
Q
What is the appropriate stress test for the following situations?
1) can exercise, normal/nonspecific EKG changes
2) can exercise, WPW pattern, ST depression, previous CABG/PCI, LBBB, LVH, digoxin
3) unable to exercise, electrically paced V rhythm, LBBB
A
1) exercise EKG w/o imaging
2) exercise EKG with myocardial perfusion imaging or exercise echo
3) pharmacologic stress myocardial perfusion imaging or dobutamine echo
23
Q
What stress test should be done on patients with high prtest probability of disease or: LV dysfunction, class III or IV angina despite therapy, highly positive stress or imaging test, high pretest prob of left main or 3v CAD, uncertain diagnosis after noninvasive testing, h/o sudden cardiac death, suspected coronary spasm?
A
coronary angio
24
Q
T/F: Do a stress test if pretest probability of CAD is <10% or >90%
A
False
25
What stress test should be done for patients who have LBBB?
stress echo or vasodilator stress radionucleotide myocardial perfusion imaging
26
What BP is the target for chronic stable angina?
<130/80
27
What are 4 contraindications for BB therapy?
1) bradycardia
2) advanced AV block
3) decompensated HF
4) severe RAD
28
How do you prevent nitrate tachyphylaxis?
nitrate-free period of 8-12 hours overnight
**do NOT use sildenafil, vardenafil, tadalafil**
29
When do you consider using ranolazine in chronic angina therapy?
when already on optimal doses of BB, CCB and nitrates
30
T/F: Use ACE-I in chronic angina and if htey have DM, HTN, CKD, LVEF<40, HF or h/o MI
T
31
What other medications (3) that are cardioprotective and not targeting angina symptoms?
ASA, ACE-I, high intensity statin
32
What are 2 signs and symptoms that increase likelihood of HF as diagnosis?
paroxysmal nocturnal dyspnea
| S3
33
What are 2 signs and symptoms that decrease the likelihood of HF as a diagnosis?
abscence of dyspnea on exertion and abscence of crackles on pumonary auscultation
34
What level of BNP is compatible with HF and what rules it out?
>400 rules it in
| <100 rules it out
35
What are 4 unusual causes of heart failure? (don't test for this)
1) hemochromatosis
2) wilson disease
3) multiple myeloma
4) myocarditis
36
What 3 factors will increase BNP? What will reduce BNP?
increase: kidney failure older age, female
decrease: obesity
37
What medication should be given for NYHA class III-IV and EF <40% in black and pts with low output syndrome/HTN? (only for when they cannot be on ACE/ARB)
hydralazine+nitrates
38
What medication should be given for NYHA III-IV HF to reduce mortality?
aldosterone antagonist
39
What medication is given when patient continue to be symptomatic HF despite GDMT
digitalis
40
What medication is given to EF <35% in SR with HR >70 with HRrEF?
Ivabradine
41
What NYHA class do you substitute valsartan-scubitril for ACE/ARB?
II/III
42
When do you place an ICD for HrEF?
EF<35% and NYHA II-III or EF <30% and NYHA class I
or NYHA II-III w/ symptoms
43
When do you perform cardiac resynchronization therapy in HFrEF?
NYHA class II-IV, LVEF <35% and LBBB with QRS >150ms
44
T/F: Begin BB with decompensated HF
False
45
T/F: NSAIDs or thiazolidinediones do not worsen HF
False; don't prescribe!
46
T/F: nondihydropyridine CCB (diltiazem or verapamil) is harmful for patients with HF
True
47
If patinent has biventricular enlargement, refactory ventricular arrhythmias, rapid progression to cardiogenic shock in young/middle-aged adults, what disease should you think of?
giant cell myocarditis
Histology: multinucleated giant cells in myocardium
tx: immunosuppressant treatment or LVAD or transplant
48
T/F: warfarin in recommendation for women with peripartum cardiomyopathy with LVEF <35%
True
49
T/F: HOCM will have an increase in murmur when valsalva or squatting
T
50
What EKG finding will you see with HOCM
Deeply inverted, symmetric T waves in V3-V6 with LVH and LAE
51
What is the treatment for HOCM?
BB or CCB, ACEI only if systolic dysfunction, anticoagulation, surgery if outflow tract gradient >50mmHg and sx despite meds
52
What are the major risk factors for sudden death in HOCM-->needing ICD (7)
1) previous cardiac arrest
2) spontaneous sustained VT
3) fhx of sudden death
4) unexplained syncope
5) LV wall thickness >30mm
6) blunted increase/decrease in SBP with exercise
7) nonsustained spontaneous VT >3 beats
53
At what age do you screen for HOCM if there is a family history?
12 years old
54
What is Kussmaul sign?
jugular veins engorge with inspiration
55
Cardiac cath of restrictive CM will show elevated LV and RV end diastolic pressures and characteristic early ventricular ___ __ and ___
diastolic dip and plateau
56
How can you confirm diagnosis of amyoidosis?
neuropathy, proteinuria, hepatomegaly, periorbital ecchymosis, bruising, low voltage EKG, abdominal fat pad aspiration
57
How do you confirm diagnosis of sarcoidosis?
bilateral hilar lymphadenopathy, pulm reticular opacities, skin/join/eye lesions, arrythmias, conduction blocks, HF, CMR imaging with gad
58
When does sinus brady occur?
| ___ impulses fire at a rate lower than expected
AV node
59
What is a bifascicular block?
RBB and one of the fascicles of the LBBB
60
What is a trifascicular block?
bifascicular block (RBB and one of fasicles of LBBB) with prolongation of PR interval
61
What is left anterior hemiblock?
left axis -60 degrees, upright QRS complex in lead I, negative QRS in aVF, normal QRS duration
62
What is left posterior hemiblock?
R axis +120 degrees, neg QRS complex in lead I, positive QRS in aVF, normal QRS duration
63
What are 6 indications for pacemaker for bradycardia?
1) symptomatic bradycardia
2) asymptomatic sinus brady with significant pauses >3s or HR <40
3) AF with 5 second pauses
4) complete heart block
5) Mobitz type 2 second degree AV block
6) alternating BBB
64
Patients with infrequent paroxysmal AF will benefit from what medication therapy "pill in the pocket" approach?
flecainide or propafenone with BB or CCB
65
What does CHA2DS2VASC stand for?
CHF, HTN, age >75 (2), DM, Sex, stroke/TIA/thromboembolic disease (2)
anticoagulate in men >1, women >2
66
avoid which factor Xa inhib for CrCl<30
rivaroxaban
67
Which medication should be used in a patient with AF and WPW?
procainamide (do not use, CCB, BB, digoxin)
68
Which tachycardia can be seen in COPD?
MAT-irregular SVT with 3+ different P wave morphologies
69
Which narrow complex tachycardia are these:
1) P wave just after QRS or buried in QRS
2) P wave with short RP interval
3) P wave with long RP interval
1) AVNRT (AV nodal reentrant tachycardia)
2) AVRT (AV reciprocating tachycardia)
3) atrial tachycardia
70
What tachyarrthymic rhthms are solved by adenosine? (2) Which 2 are not?
solved: AVNRT and AVRT
| not solved: atrial flutter and atrial tachycardia
71
What 2 medications can prevent recurrent AVNRT?
CCB and BB, can also use catheter ablation therapy
72
What is the treatment for multifocal atrial tachycardia?
treat underlying pulm/cardiac disease, hypokalemia, hypomagnesemia
If symptomatic or have complications 2/2 cardiac ischemia, then use metoprolol followed by verapamil
73
AF associated with WPW is a risk factor for what arrhythmia?
VF (irregular, wide complex tachycardia)
74
What is the treatment for WPW?
```
procainamide or another class I or III agent
cardioversion if unstable
ablation of accessory bypass tract is first line therapy
```
75
T/F: Asymptomatic WPW conduction without arrhythmia requires treatment
F
76
Ventricular tachyarrhythmias have prolonged or narrow QRS?
prolonged
77
T/F: any wide QRS tachycardia should be considered to be VT until proven otherwise
T
78
What can torsades de pointes turn into?
syncope or VF
79
How do you treat VT without structural heart disease if disabling symptomatic?
BB, CCB (like verapamil)
80
How do you treat VT with structural heart disease?
BB, ACEI, amiodarone if need, catheter ablation if recurrent VT despite medical therapy, ICD if have sustained VT/VF
81
How do you treat hemodynamically stable patients with impaired LV function with sustained VT?
IV lidocaine or amiodarone, can also use procainamide and sotalol
82
Long QT syndrome can put someone at risk for syncope or sudden cardiac death 2/2 torsades de pointes if they take 6 classes of meds
1) macrolide and fluroquinolone abx (especially moxifloxacin)
2) terfenadine and astemizole antihistamines
3) antipsychotic and antidepressant meds
4) methadone
5) antifungal meds
6) class Ia and class III antiarrhythmics
83
What is an inherited condition characterized by structrually normal heart but abnormal electrical conduction associated with sudden cardiac death? EKG is an incomplete RBB with coved ST segment elevation in V1 and V2
Brugada syndrome
84
How do you treat long QT syndrome?
BB
85
What are 8 situations that an ICD is indicated?
1) survivors of cardia carrest from VF/VT not explained by reversable cause
2) sustained VT in presence of structural heart disease
3) syncope and sustained VT/VF on EP study
4) ischemic and nonischemic CM with EF <35, fNYHA class II or III symptoms with GDMT
5) brugada syndrome with syncope or ventricular arrhtymia
6) inherited long QT syndrome not responding to BB
7) >40 days after MI with EF <30%
8) high risk HCM (familiarl sudden death, multiple repeititve nonsuustained VT, extreme LVH, recent, unexplained syncopal episode, exercise hypotension
86
What 3 medications is associated with pericarditis?
hydralazine, phenytoin, minoxidil
87
What is the first line treatment for pericarditis?
colchicine + ASA (especially after MI) or NSAID
glucocorticoids if not responsive to colchicine + ASA/NSAID or is related to auotimmune process
88
What heart sound is characterized by loud third heart sound that occurs earlier in diastole than a normal S3?
pericardial knock
89
What is the most effective treatment for chronic constrictive pericarditis?
pericardiectomy, but not needed for NYHA functional class I or late disease NYHA functional class IV
90
Which side murmurs will increase in intensity with inspiration?
right sided heart murmurs
91
Which murmur will increase in intensity during valsalva maneuver and from squatting to standing?
HOCM
92
What valvular abnormality can move click closer to S1 and murmur lengthens during valsalva and from standing from squatting?
MVP
93
Abnormal splitting of ___ helps differentiate heart murmurs. If it s
S2
94
If you have a reversed or expiratory splitting of S2, then what heart problems is it indicating? occurs with
prolonged LV ejection like LBBB, As, HOCM, ACS with LV dysfunction
95
If you have a S2, splits during inspiration AND expiration, then it occurs in what heart conditions?
conditions that delay RV ejection like RBBB, pulm valve stenosis, VSD with L to R shunt, ASD with L to R shunt
96
What are 5 heart findings on exam that are signs of serious cardiac disease?
S4, >3 grade, diastolic, continuous, abnormal splitting of S2
97
T/F: increased P2, S3 and early peaking systolic murmur over the upper left sternal border are normal in pregnancy
T
98
Which murmur is mid-systolic, RUSB with radiation to right clavicle, carotid, apex
aortic stenosis
99
Which murmur is diastolic decrescendo located LLSB or RLSB without radiation best heard in sitting and leaning forward
aortic regurgitation
100
Which murmur is diastolic with low pitch, decrescendo best heard in lateral decubitus position in the apex without radiation? there is a loud S1 and opening snap after S2
mitral stenosis
101
Which murmur is systolic, holo-mid or late systolic that is best heard at tha apex and radiates to the axilla or back? the murmur will move closer to S1 with valsalva and handgrip will increase murmur intensity
mitral regurgitation
102
Which murmur is holosystolic heard at the LLSB with radiation to the LUSB? murmur increases with inspiration and can see with enlarged liver
tricuspid regurgitation
103
Which murmur is diastolic with low pitch, decrecendo, increased intensity during inspiration located at LLLSB that does NOT radiate? Have elevated CVP and signs of venous congestion
tricuspid stenosis
104
Which murmur is systolic, crescendo-decrescendo located at the LUSB and radiates to the left clavicle with a pulmonic ejection click after S1
pulm stenosis
105
Which murmur is midsystolic grade 1-2 in intesnsity that is located at the RUSB
innocent flow murmur
106
Which murmur is systolic, crescendo-decrescendo located in the LLSB without radiation; it does increase with valsalva or squatting to standing
HOCM
107
Which murmur is systolic, crescendo-decrescendo located at the RUSB without radiation with a fixed split S2
ASD
108
Which murmur is holosystolic at the LLSB without radiation with a palpable thrill and increases with hand grip and decreases with amyl nitrite?
VSD
109
Patient with rheumatic fever should be given PCN for how long?
at least 10 years after the last episode of Rf or until at least 40 years (whichever is longer)
110
What are 2 heart conditions that are consequences of RF?
mitral stenosis and regurgitation
aortic valve is the second most affected valve
111
What is the Jones criteria for RF?
Major: carditis, polyarthritis, chorea, subcutaneous nodules, erythema marginatum
minor: arthralgia, fever, elevated ESR/CRP, GAS infection proof, prolonged PR on EKG
dx: 2 major or 1 major and 2 minor
112
T/F: nonrepsonse to salicylates make RF unlikely
T
113
What is considered severe aortic stenosis?
| 1) valve area ___
1) <1cm^2
| 2) >40mmHg
114
What are 3 contraindications for a TAVR?
1) bicuspid valve
2) significant AR
3) mitral valve disease
115
What are 3 meds that are tried in AS?
diuretic, digoxin, ACEI
116
What is the follow up time for AS?
1) asymptomatic severe AS
2) moderate AS
3) mild AS
1) q6-12m
2) q1-2 years
3) q3-5 years
117
What is the first line therapy for a stenotic bicuspid aortic valve?
surgical AV replacement
118
What is the first line therapy for a regurgitant bicuspid aortic valve when symptomatic HR or asx LVEF <50%
surgical valve replacement
119
When is it indicated to repair the aortic root?
>5cm with risk factors of dissection (fhx, rate of progression >0.5cm/year) or >5.5cm without risk factors
120
How often do you need to repeat echo for bicuspid aortic valve?
1) asx severe AV stenosis or regurg
2) mild stenosis or regurgitation
1) q6-12 months
| 2) 3-5 years
121
How often do you need to monitor ascending aortic diameter?
1) if aorta dimension is >4.5 cm
2) if aorta dimension is <4
1) every year
| 2) every 2 years
122
What type of severe aortic regurg does infective endocarditis or aortic dissection cause? acute vs chronic?
acute
123
What type of severe aortic regurg is associated with dilated ascednding aorta from HTN or primary aortic disease, calcific AS, bicuspid aortic valve or rheumatic disease? acute vs chronic?
chronic
124
What are 7 features of severe, chronic AR?
1) 3 symptoms
2) narrow vs wide pulse pressure
3) __S1, __ A2, ___ S3
4) what does the murmur sound like?
5) how can you hear it better?
6) findings on EKG
7) findings on CXR
1) angina, orthopnea, exertional dyspnea
2) widened pulse pressure
3) soft S1, soft or absent A2, loud S3
4) diastolic murmur immediately after A2 along the LSB (2/2 primary aortic valvular disease) or RSB (2/2 aortic root dilatation)
5) enhanced auscultation when leaning forward and exhaling
6) left axis deviation and LVH on EKG
7) cardiomegaly and aortic root dilatation a n dcalcification on CXR
125
What are features of acute AR?
1) what does murmur sound like?
2) narrow vs wide vs normal pulse pressure?
3) CXR findings
1) short, soft diastolic murmur
2) normal
3) normal heart size
126
What is the treatment for acute AR?
immediate arotic valve replacement?
127
What is the bridging medical therapy to surgery for AR?
1) 2 meds
2) 2 meds if BP is low
3) 2 meds if chronic severe AR and HF
1) sodium nitroprusside and IV diuretics
2) Can also use dobutamine or milrinone if BP low
3) ACEI and nifedepine can be used in chronic severe AR and HF
128
What are 2 indications for aortic valve replacement in AR?
1) chronic sympomatic AR
| 2) asympomtaic with LVEF <50%
129
T/F: BB or intra-aortic balloon pumps in acute AR can worsen AR
T--so don't use!
130
What are 4 symptoms of mitral stenosis
1) fatigue
2) orthopnea
3) paroxysmal noturnal dyspnea
4) lower extremity swelling
131
What are 5 physical exam findings for mitral stenosis?
1) prominent __ wave in the jugular pulse
2) prominent __ apical impulse
3) signs of ___ HF
4) accentuation of ___ and ___ ___
5) murmur sound
1) a
2) tapping
3) right sided
4) P2 and opening snap
5) low-pitched, rumbling diastolic murmur with presystolic accentuation
132
What does the CXR look like for mitral stenosis?
enlarged pulmonary artery, left atrium, right ventricle, right atrium
133
What does EKG show for mitral stenosis?
RV hypertrophy and notched P-wave duration >0.12 s in lead II (P mitrale)
134
What is the treatment for sympomatic patients with mitral stenosis?
percutaneous balloon mitral commissurotomy
135
When does an asympomatic patient with mitral stenosis need to get a percutaneous balloon mitral commissurotomy?
valve area <1cm^2
136
What is the treatment if unable to do a percutaneous balloon mitral commissurotomy in a patient with sympomatic mitral stenosis?
mitral valve surgical repair
137
What is the medical therapy for mitral stenosis?
diuretics or long acting nitrates, BB and nondihydropyridine CCB
138
T/F: treat all patients with mitral stenosis and AF with warfarin
T
139
Which murmur occurs due to cordae tendineae rupture 2/2 myxomatous valve disease or endocarditis?
mitral regurgitation
140
What are 3 symptoms of acute MR?
dyspnea, pulmonary edema, cardiogenic shock
141
What is the murmur of acute MR?
left sided HF associated with holosystolic murmur at apex that radiates to axilla and occasionally to the base
can hear soft S3 and P2
142
What are 6 causes of chronic MR?
1) MVP
2) infectious endocarditis
3) HOCM
4) ischemic heart disease
5) ventricular dilatation
6) marfan syndome
143
What are 6 indications for surgery for MR?
1) acute MR
2) chronic sympomatic MR
3) asympomatic MR with LVEF <60% or LV end systolic diameter >40
4) PH caused by MR
5) new AF
6) chronic severe primary MRwhen another cardiac surgery is planned
144
What is preferred: mitral valve repair or mitral valve replacement?
repair
145
What are medications used to stabilize decompensated HF in patients with acute or chronic MR?
nitrates and diuretics
can use intra-aortic balloon pump if hypotensive
146
T/F: ACEI and ARBs are effective in preventing progression of LV dysfunction in chronic MR
F
147
What is the most common cause of MR?
MVP
148
T/F: MVP can cause embolic phenomena
T
149
What is the murmur of MVP?
high pitched midsystolic click followed by late systolic murmur loudest at the apex
standing from sitting and valsalva causes click and murmur to occur earlier
squatting from standing delays the click and murmur and decreases intensity
150
What is the treatment for MVP?
BB with palpitations, CP, anxiety, fatigue
ASA if have TIA
warfarin is have recurrent ischemic events
surgery for significant MR
151
What 2 things characterizes severe MVP 2/2 severe MR?
flail leaflet caused by ruptured chorda or marked chordal elongation
152
What are 3 causes for tricuspid regurgitation?
Marfan syndrome, congenital disorders like Ebstein anomaly (abnormalities of tricuspid valve and right ventricle) and AV canal malformations
other causes: IE, carcinoid syndrome, PH and RF
153
What kind of features do you see with tricuspid regurg?
1) prominent __ waves in the neck
2) ___ JVD during inspiration
3) ___ pulsations
1) v
2) increased
3) hepatic (can have ascites and pedal edema)
154
What does the murmur of a TR sound like?
holosystolic murmur at the LLSB increasing in intensity during inspiration
155
When do you consider surgery for TR?
severe tricuspid regurg or sympomatic tricuspid regurg refractory to medical management
156
Which prosthetic valve is more durable and less prone to thromboembolism? aortic or mitral?
aortic
157
What should be suspected in a patient who develops acute HF after receiving a prosethetic heart valve?
valve dehiscence or dysfunction characterized by new cardiac symptoms, embolic phenomena, hemolytic anemia with schistocytes, new murmurs
if suspected, do a TEE
158
1) Which prosthetic valves need anticoagulation? mechanical or bioprosthetic?
2) What is the INR goal for aortic prosthetic valve w/o thromboembolism risk factors?
3) What is the INR goal for aortic prosthetic valve w/ thromboembolism risk factors?
1) mechanical
2) 2.5
3) 3.0
159
T/F: Hold ASA if patient is receiving warfarin for anticoagulation for a mechanical valve
F; all mechanical prosthetic valves and most with bioprostheses should receive ASA
160
What type of surgery does not need to have interruption in anticoagulation for prosthetic heart valve?
cataract
161
When do you stop warfarin for an aortic valve prostheses for surgery? When do you restart?
stop warfarin 4-5 days prior and restart ASAP after control of bleeding
162
When do you stop warfarin for a mitral prostheses/multiple prosthetic valves/AF/previous thromboembolic event for a procedure? When do you restart?
stop wararin 4-5 days prior to srugery and bridge with IV heparin; resume IV heparin within 24 hours after surgery with warfarin to bridge to therapeutic INR
163
What is the murmur for ASD
fixed splitting of S2, pumonary midsystolic murmur and tricuspid diastolic flow murmur
164
What is the most common form of ASD? EKG finding?
ostium secundum defect; right axis deviation and partial RBBB
165
Which ASD is associated with cleft in mitral or tricupsid valve and with associated valve regurgitation? May have VSD association too
ostium primum ASD
166
When is ASD closure indicated?
right atrial or right ventircular enlargement, large left to right shunt or symptoms of dyspnea, paradoxical embolism
167
What is the proper closure for ostium secundum ASD? ostium primum and associated mitral valve defects
ostium secundum-percutaneous device closure
| ostium primum-surgical
168
When is ASD closure contraindicated?
if shunt is R to L
169
What on CXR will you see with a coarctation of the aorta?
figure 3 sign
170
What work up do you need for coarctation of the aorta?
TTE, CMR and CT, cath if thinking intervention
171
When is intervention needed for coarctation of aorta?
proximal HTN, pressure gradient >20mmHg
172
aortic coarctation and bicupsid aortic valve will have what extra sounds on exam?
ejection click or systolic murmur
173
Where is the PDA murmur heard?
continuous mahcinery murmur heard beneath left clavicle; bounding pulses with wide pulse pressure
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What symptoms/consequences can be seen with PDA?
sx of dyspnea and HF, large L to R shunt causing PH with shunt reversal from R to L (Eisenmenger syndrome)
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What are some features of an Eisenmenger PDA?
clubbing and oxygen desaturation that affects feet but not hands
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When is closure of PDA indicated?
left sided cardiac chamber enlargement in the abscence of severe PH
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How can a PFO be closed in a patient with recurrent cryptogenic strokes?
percutaneous PFO closure plus ASA
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What is a VSD murmur
holosystolic murmur that obliterates S2
If displaced apical LV impulse and mitral diastolic flow rumble->hemodynamically significant VSD
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When should VSD be closed?
preogressive regurgitation of aortic or tricuspid valve, progressive LV volume overload, recurrent endocarditis
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How are VSD closed?
device closure with muscular VSD
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When is it contraindicated to close VSD?
PH with R ot L shunt (Eisenmenger syndrome)
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When do you provide prophylaxis for infective endocarditis?
prosthetic heart valve, h/o IE, unrepaired cyanotic congenital heart disease, repeard congenital heart defect with prosthetsis or shunt, valvulopathy following cardiac transplantation, prosthetic materal used for cardiac valve repair
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Which procedures require IE prophylaxis?
dental procedures that involve mucosal bleeding, procedures that involve incision or biopsy of respiratory mucosa, procedures with GI/GU tract infection, procedures on infected skin, skin structures or MSK tissue, surgery to place prosthetic heart valves or intravascular intracardiac materials
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What is the antibiotic used used prophylaxis for IE?
amoxicillin 1 hour prior to procedure, if allergic, then use cephalexin, azithroycin, clarithromycin, clindamycin
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How do you diagnose endocarditis?
2 major, 1 major and 3 minor, 5 minor, or pathological confirmation
major: 2 positive blood cultures or single culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800; positive echo; new valvular regurgitation
minor: predisposing hear tcondition or injection drug use, fever, embolic vascular phenomena, immunologic phenomena (GN or RF), positive blood culture not meeting major criteria
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What cancer should be looked for if have strep bovis or clostridium septicum endocarditis?
colon cancer
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What are 7 indications for surgery for endocarditis?
1) valvular dysfunction and acute HF
2) left sided IE caused by S aureus, fungal infection or highly reisstant organism
3) heart block
4) annular or aortic abscess
5) systemic embolizationon antibiotic therapy
6) prosthetic valve endocarditis with relapsing infection or dehiscence
7) S aureus prosthetic valve endcarditis
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T/F: if suspect IE and have good CV function, don't need empiric treatment before culture results
T
189
treatment for endocarditis:
1) community-acquired native valve IE
2) nosocomial-associated IE
3) prosthetic valve IE
1) vancomycin or unasyn + gentamicin
2) vancomycin, gentamicin, rifampin and an antipseudomonal B-lactam
3) vancomycin, gentamicin and rifampin
4-6 weeks except if uncomplicated right sided native valve endoccarditis caused by MSSA which can be treated for 2 weeks with nafcillin, oxacillin or flucloxacillin
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What 5 familial syndromes should you screen first degree relatives with an echo to detect thoracic aneurysms?
1) familial thoracic aortic aneurysms and aortic dissections (TAAD)
2) bicuspid aortic valve
3) Marfan syndrome
4) Turner syndrome
5) Loeys-dietz syndrome
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What are 3 risk factors for thoracic aortic aneurysm in young people? 1 risk factor in old people?
young: Marfan, cocaine abuse, bicuspid aortic valve
old: poorly controlled HTN
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T/F: A low D dimer level will rule out acute aortic syndrome
T, if <500
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What type of dissection involves the ascending aorta?
A
| all others are B type
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How do you medically treat thoracic aneurysm?
BB to reduce the rate of dilation in Marfarn
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When is prophylactic surgery recommended for thoracic aneurysms? (3 situations)
1) aortic diameter >5 (or >4.5 in Marfarn)
2) aortic diameter >4.5 and going to have other heart surgery
3) rapid growth >0.5cm / year
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What is the treatment for an acute aortic dissection?
IV BB with nitroprusside if needed
type A: emergent surgery
intramural hematoma: emergent surgery
uncomplicated type B: medical therapy unless have end organ ischemia
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How often do you do follow up echo for aortic aneurysm?
annual if stable and <4.5
| If >4.5 or enlarging >0.5cm/year, then q6m
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T/F: Use hydralazine in acute aortic dissection to bring down BP
F! It can increase shear stress
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When is a type B aortic dissection needing surgery?
if major aortic vessels like renal arteries, are involved
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T/F: Use US to diagnose a ruptured AAA
F, it's not accurate
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When do you schedule a repair of a AAA?
>5.5 or growing >0.5/year or symptomatic
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How often do you follow up a AAA?
q6-12m if AAA 4.0-5.4cm
| q2-3 years if AAA <4.0
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Holenhorst plaque (golden or brightly refractile choleesterol body within retinal artery) is pathognomonic for what?
aortic atheroemboli
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What other lab findings can you see with aortic atheroemboli?
thrombocytopenia, eosinophilia, urinary eosinophils
need biopsy to confirm
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What type of testing is needed for patients with normal or borderline resting ABI values and unexplained exertional leg symptoms?
exercise treadmill ABI teesting
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1) What is a normal ABI?
2) What is ABI compatible with PAD?
3) what is ABI associated with ischemic rest pain?
4) What ABI is associated with false normal in diabetes with calcified, noncompressible arteries?
1) 0.9-1.4
2) <0.9
3) <0.4
4) >1.4
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What is the next testing if ABI is >1.4
toe-brachial index
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What is the medical therapy for PAD? BP goal?
BP <130/80
| ASA (over clopidogrel), high intensity statin, cilostazole if have intemrittent claudication
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When is cilostazol contraindicated?
low LVEF or h/o HF
210
Patient with acute limb ischemia require what 3 things?
antiplatelet, heparin, surgery
211
t/F: most common cardiac tumors are metastatic (melanoma, malignant thymoma, germ cell tumors)
T
212
What is the most common primary cardiac tumor?
myxoma
sx: fever, anorexia, weight loss
mitral stenosis murmur wiht a tumor plop
213
Where is myxomas usually located? angiosarcomas?
myxoma: left atrium with stalk adherent to fossa ovalis
| angiosarcoma-right atrium
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What is the treatment for myxoma?
take it out! risk of embolization and CV complications like sudden death
