Cardiology, Harrison Flashcards
Estimates risk of ischemic stroke in patients with non-rheumatic/non-valvular Afib
CHADS2 Score: 1) CHF 2) Htn 3) Age >75 4) DM 5) Previous stroke; Each corresponds to 1 point, except for previous stroke which corresponds to 2 points; A score >2 = oral anticoagulation advised
Estimates 10-year risk of coronary disease, cerebrovascular disease, peripheral vascular disease, and heart failure
Framingham Cardiovascular Risk: 1) Age 2) SBP 3) Total cholesterol 4) HDL 5) BP treatment 6) Smoking status 7) DM 8) Gender
Chest discomfort precipitated by emotion/exertion; rapidly resolves (within 5-10 mins) with resting/nitrates
Chronic stable angina
MCC of chronic stable angina
Atherosclerotic epicardial Hcoronary artery disease
Accelerates coronary atherosclerosis in both sexes at all ages
Smoking
Family history of coronary artery disease, significant ages within genders
Male less than 55; Female less than 65 (must be FIRST DEGREE relatives)
Chest pain of chronic stable angina lasts for
2-10 minutes
Atypical chest discomfort of angina is common in
1) Elderly >75 2) Women 3) Diabetics; may present with anginal equivalents
T/F Pain of chronic stable angina may radiate to the back/interscapular region
T
Chest pain of chronic stable angina RARELY localises where
Below umbilicus or above mandible
Angina that occurs at rest is referred to as
Unstable angina
Angina at night while the patient is recumbent
Angina decubitus
Symptoms of myocardial schema (MI) other than angina
Anginal equivalents: Dyspnea, nausea, fatigue, faintness, epigastric discomfort
MI without chest discomfort but detectable by continuous ECG (Holter monitoring) or during stress test
Silent ischemia
Mitral regurgitation is best appreciated with the patient in ___ position
Left lateral decubitus
T/F Localization of chest discomfort with a single fingertip on the chest makes angina unlikely
T
Unstable angina lasts for
10-20 minutes
Angina of acute MI lasts for
> 30 minutes
Angina that cannot be relieved by nitroglycerin
Acute MI
Late-peaking systolic murmur radiating to the carotid arteries
Aortic stenosis
Condition that can cause chest pain that closely mimics angina
Esophageal spasm
Simplest test for diagnosis and risk stratification of ischemic heart disease
Treadmill ECG (exercise stress test)
Used to diagnose ischemic heart disease when resting ECG is abnormal
Stress myocardial perfusion imaging: Thallium or sestamini is infused IV during exercise/pharmacologic stress testing; imaged after cessation of exercise and 4 hours later
Substances that may be used for pharmacologic stress testing
1) Dobutamine 2) Adenosine 3) Dipyridamole
Definitive test for assessing severity of CAD
Coronary arteriography
Target heart rate in exercise stress testing
85% of maximal heart rate for age and gender
Exercise stress testing is discontinued when
1) Chest discomfort 2) Severe shortness of breath 3) Dizziness 4) Severe fatigue 5) ST depression >0.2mV 6) Decrease in SBP by >10mmHg 7) Vtach
Baseline (0mV) in ECG
PR segment
Contraindications to stress testing
1) Rest angina within 48 hours 2) Unstable rhythm 3) Severe aortic stenosis 4) Acute myocarditis 5) Uncontrolled heart failure 6) Severe pulmonary htn 7) Active infective endocarditis
Vitamins that improve outcomes of patients with IHD
Vitamin C and E
Indications for coronary artery bypass surgery (CABG)
1) Significant left main CAD 2) 3-vessel CAD 3) 2-vessel CAD that includes LAD 4) Require revascularization but vessels unsuitable for PCI 5) Angina refractory to medical therapy 6) Medical therapy not tolerated 7) Diabetic with at least 2-vessel disease
Drugs that can be used to increase HDL and decrease TAG
1) Niacin (Vitamin B6) 2) Fibrates
T/F Unstable angina and NSTEMI have similar mechanisms, clinical presentations, and treatment strategies
T
Angina that occurs with a crescendo pattern
Unstable angina
Difference between NSTEMI and Unstable angina
NSTEMI: With evidence of myocardial necrosis (elevated cardiac markers
Age risk factors per gender
Male - 50 or older; Female - 60 or older
Clinical hallmark of unstable angina
Chest pain
Cardiac marker: First to elevate
Myoglobin
Myoglobin remains elevated up to
24 hours
CK-MB and Troponin elevate when
3-12 hours
CK-MB remains elevated until
1.5-3 days
Cardiac marker: Last to decline
Troponin (remains elevated for 1-2 weeks
Cardiac marker: Assist with determination of coronary risk
1) High sensitivity C-reactive protein (hsCRP) 2) Homocysteine
Cardiac marker: Aids in diagnosis, management, prognosis, and monitoring therapy of congestive heart failure (CHF)
B-type natriuretic peptide (BNP)
A marker of long-term cardiac risk produced by all nucleated cells, unaffected by acute phase reactants, body or muscle mass, and diet
Cystatin C
When is ambulation permitted in patients with UA and NSTEMI
1) No recurrence of schema 2) No elevation of cardiac biomarkers at 12-24 hours
Pain reliever used in UA/NSTEMI in patients whose symptoms are not relieved after 3 serial sublingual nitroglycerin tablets
Morphine sulfate
Antithrombin of choice for UA/NSTEMI; superior to unfractionated heparin in reducing recurrent cardiac events
Enoxaparin
Drugs shown to have benefit for long-term therapy in UA/NSTEMI patients
1) Beta blockers (helps decrease triggers for MI) 2) Statins and ACEIs (long-term plaque stabilisation 3) Antiplatelet (prevents/reduces severity of thrombosis if a plaque ruptures
Tearing or ripping knife-like chest pain radiating to the back between the shoulder blades
Aortic dissection
Grading of heart murmurs
1-very faint; 2-faint; 3-moderately loud; 4-loud with thrill; 5-stethoscope lightly pressed on skin; 6-stethoscope slightly above chest wall
Posterior calf pain on active dorsiflexion of foot against resistance
Homan’s sign
Rise or lack of fall of JVP with inspiration
Kussmaul’s sign
Venous pressure should fall by at least ___ mmHg with inspiration
3
Abdominojugular reflex
Pressure over the RUQ for 10 seconds results in a sustained rise of >3 cm in JVP for at least 15 seconds after release of hand
Uncontrolled htn with NO end-organ damage
Hypertensive urgency/hypertensive crisis
Uncontrolled htn with end-organ damage
Hypertensive emergency/malignant hypertension
Hypertensive urgency: Treatment
Oral drugs first; lower BP within 24 hours
Hypertensive emergency: Treatment
IV medications; lower BP by not >20-25% within the first hour
Drug class that should be avoided in patients with congestive heart failure
Beta blockers
Criteria for white coat hypertension
1) At least 3 clinic measurements >140/90 2) At least 2 non-clinic measurements less than 140/90 3) No target organ damage
Orthostatic hypotension is a fall in SBP by ___ mmHg or DBP by ___ mmHg from supine to upright within ___ minutes
> 20, >10, 3
Leading cause of death and disability in the developed world
Atherosclerosis
Enzyme inhibited by statins
HMG-CoA reductase
Characteristic of LDL in diabetic dyslipidemia
Levels near average but smaller and denser particles thus more atherogenic
Gravest complication of atherosclerosis
Acute thrombosis
5 A’s of behavioural counselling framework in smoking cessation
Ask about tobacco use; Advise to quit; Assess willingness to quit; Assist to quit; Arrange follow-up and support
BP goal for patients with diabetes or kidney disease
Less than 130/80 (140/90 for all others)
Metabolic syndrome describes a constellation of metabolic derrangements that typically includes 3 or more of the following
1) Abdominal obesity (>102 cm in men, >88 cm in women) 2) TG 150 mg/dL or greater 3) HDL Less than or equal to 40 mg/dL in males and 50 mg/dL in females 4) BP 130/85 5) Fasting glucose 100 mg/dL or greater
Fasting lipid profile should be done for all adults ___ of age; to be repeated every ___ years if values are acceptable
> 20, 5
Components of lipid profile
1) Total cholesterol 2) TAG 3) LDL 4) HDL
___ treatment has been shown to reduce risk of first MI in men
Low-dose aspirin
Risk factors that modify LDL goals
1) Smoking 2) Htn 3) Low HDL 4) DM 5) Family history of premature CAD 6) Age >45 in males >55 in females 7) Emerging risk factors (e.g. homocysteine)
Metabolic syndrome is aka
1) Insulin-resistance syndrome 2) Syndrome X
Metabolic syndrome places the individual at increased risk for
1) Coronary artery disease 2) Stroke 3) Peripheral vascular disease 4) TIIDM 5) NASH
Common key underlying abnormality in metabolic syndrome
Insulin resistance
Antihypertensive regimen for patients with metabolic syndrome should include
ACEI and ARBs
ATP III recommends at least ___ minutes of moderate-intensity physical activity on a daily basis for weight reduction
30
First-line drug for LDL reduction in metabolic syndrome
Statin
Inability of ventricle to contract normally, with symptoms resulting from inadequate cardiac output; depressed EF
Systolic failure (EF less than 40%)
Inability of the ventricle to relax and fill normally, with symptoms from elevated filling pressures; preserved EF
Diastolic failure (EF >50%)
High- vs low-output heart failure: After MI, htn, dilated cardiomyopathy, valvular or pericardial disease
Low-output
High- vs low-output heart failure: Hyperthyroidism, anemia, pregnancy, AV fistula, beriberi, Paget disease
High-output
T/F Low-output heart failure is often accompanied by vasoconstriction and cold extremities
F, vasodilation and warm extremities
Systolic vs diastolic heart failure: More common in women and seen especially in elderly women with hypertension
Diastolic
Hypertrophy brought about by PRESSURE overload
Concentric
Hypertrophy brought about by VOLUME overload
Eccentric/dilated
Ascites is most commonly seen in what etiology of heart failure
1) Constrictive pericarditis 2) Tricuspid valve disease
Abdominojugular reflex is positive in
Congestive hepatomegaly
Criteria to establish a clinical diagnosis of CHF
Framingham criteria
At least ___ major and ___ minor Framingham criteria are required to establish a diagnosis of CHF
1 major, 2 minor
Major Framingham criteria
1) Cardiomegaly 2) S3 gallop 3) Acute pulmonary edema 4) Rales 5) PNDn 6) Neck vein distention 7) (+) hepatojugular reflex 8) Increased venous pressure
Minor Framingham criteria
1) Extremity edema 2) Night cough 3) Dyspnea on exertion 4) Hepatomegaly 5) Pleural effusion 6) Vital capacity reduced by 1/3 from normal 7) Tachycardia of 120 or greater
Major or minor Framingham criterion
Weight loss of 4.5 kg or greater over 5 days of treatment
Cardiac marker that helps in differentiating between cardiac and pulmonary causes of dyspnea
BNP
CHF Stage: At high risk of HF but no evident structural heart disease or symptoms of HF
A
CHF Stage: Structural heart disease without symptoms of HF
B
CHF Stage: Structural heart disease with prior or current symptoms of HF
C
CHF Stage: Refractory HF requiring specialized interventions
D
Sudden death in CHF is most commonly due to
Vfib
Suspect ___ in middle-aged or elderly who develop asthma for the first time
Heart failure (HF)
Cornerstone of modern HF treatment
ACEI and beta blockers
Cor pulmonale is caused by ___ in >50% of cases
COPD
RV heave is characteristic of
Cor pulmonale
JVP waves prominent in for pulmonale
a and v
MC symptom of for pulmonale
Dyspnea
This is the increased intensity if holosystolic murmur of tricuspid regurgitation with inspiration
Carvallo’s sign
The main premise in the treatment of for pulmonale is
Treat the underlying disorder
Hand placed over sternum with a clenched fist to indicate a squeezing, central, substernal discomfort
Levine’s sign
Form of angina pectoris caused by intermittent focal spasm of a major epicardial coronary artery
Prinzmetal/variant angina
T/F Prinzmetal angina is more severe than classic angina and occurs typically at rest but usually not increased by exercise
T
T/F Prinzmetal angina is associated with ST elevation
T, transient
Substances that places a person at high risk for prinzmetal angina
1) Alcohol 2) Cocaine 3) 5-FU 4) Sumatriptan
T/F Prinzmetal angina promptly responds to sublingual nitrates
T
Most common artery involved in prinzmetal angina
Right coronary artery
Spasm of coronary artery usually occurs within __ cm of luminal obstruction
1
Cardiac marker: Taken only once, at least 12 hours after chest pain
Trop I or T
Cardiac marker: Increased sensitivity with serial sampling (q6-8)
CK-MB
Generally occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis
STEMI
Prohibited drug implicated in STEMI
Cocaine
Mc etiology of STEMI
Atherosclerotic plaque rupture > formation of a mural thrombus at site of rupture > occlusion
Coronary plaques that are prone to rupture
Rich lipid core and fibrous cap
Circadian variations of STEMI have been reported with clusters seen ___
In the morning, within a few hours of awakening
MC presenting symptom of STEMI
Chest pain
~___% of MIs are clinically silent
25
Anterior vs inferior infarction: Sympathetic hyperactivity (tachycardia or hypertension)
Anterior
Anterior vs inferior infarction: PSY hyperactivity (bradycardia or hypotension)
Inferior
Heart disease that may present with radiation of discomfort to trapezius
Acute pericarditis
When to request for cardiac markers
At presentation, 6-9 hours later, 12-24 hours later if diagnosis remains uncertain
T/F Echo can distinguish acute STEMI from old myocardial scar
F, cannot
Sequence of ECG changes in typical STEMI
ST elevation > T wave depression > Q wave development
T/F Absence of Q wave = no STEMI
F, STEMI may be present in the absence of Q waves
Initial therapy for STEMI
Aspirin, chewed
In the absence of ___, fibrinolysis is not helpful and may be harmful in patients with MI
ST elevation
Preferable symptoms-to-needle (PCI) time
Less than 2-3 hours
Door-to-needle time for maximum benefit
Less than 30 minutes
Patients who suffered from MI should be placed on bed rest for how long
First 12 hours; ambulate in room by 2nd to 3rd day in the absence of complications
Correlates CHF mortality with severity of pump failure
Killip class
Killip class: No signs of pulmonary or venous congestion
I
Killip class: Moderate heart failure; R-sided heart failure
II
Killip class: Severe heart failure; pulmonary edema
III
Killip class: Shock with systolic pressure less than 90 mmHg
IV
MCC complication of STEMI developed during hospitalization
Cardiogenic shock
MC complication associated with transmural STEMI
Pericarditis
Most out-of-hospital deaths from STEMI are due to
Sudden ventricular fibrillation
Fibrinolysis is preferred over PCI in STEMI if patient presents ___ from onset
Less than 3 hours
PCI is preferred over fibrinolysis in STEMI if patient presents ___ from onset
> 3 hours
Resumption of work and sexual activity in post STEMI patients
2 weeks
T/F Acute rheumatic fever (ARF) commonly develops in patients after untreated group A streptococcal infection
F, only ~3% develop ARF
T/F ARF is more common after a GABHS pharyngitis than after a GABHS skin infection
T
Used to detect GABHS after a throat infection
ASO
Used to detect GABHS that is more sensitive to streptococcal pyoderma
Anti-DNAse-B
Peak age of ARF
5-15 yo
Most initial attacks of ARF in ADULTS occur at
End of second and beginning of 3rd decades of life
Valve most often affected in ARF
Mitral
Criteria for diagnosis of rheumatic fever
Jones criteria
To fulfil the Jones criteria, either ___ OR ___ must be fulfilled
2 major; 1 major and 2 minor; + supporting evidence of a recent GABHS infection
[USMLE] Order of affectation of heart valves in RF
Mitral > aortic»_space; tricuspid
Early cardiac lesion of RF
MR
Late cardiac lesion of RF
MS
RHD is what type of hypersensitivity reaction
II
Carditis in RF involves what layer of the wall of the heart
All 3 (peri-, myo-, and endocardium); it is a pancarditis
