Cardiovascular Flashcards
How long after drug-eluting stent is placed can dual anti-platelet therapy be withheld for surgery?
Urgent surgery: 6 months, then immediately resume afterward
Elective surgery: 12 months, then resume
Need to be on it for 12 months minimum
Cardiac myxoma in LA has what sound?
Middiastolic rumble - due to obstruction, similar sound to mitral stenosis
Alleviated by lying down
For a patient with HFrEF on beta-blocker, what should be done before a surgery?
Nothing - they are already stable on it
If about to undergo surgery, they should not start new beta-blocker due to potential for exacerbation
How is aortic dissection classified?
Type A - involves ascending aorta - surgical emergency
Type B - originates distal to subclavian artery
How does a pseudoaneurysm differ from AV fistula on auscultation?
Pseudoaneurysm: Bulging, pulsatile mass; systolic bruit
AV fistula: No mass; continuous bruit with palpable thrill
Femoral nerve injury during vascular access of femoral artery has what symptoms?
Thigh discomfort or paresthesias
Patellar tendon hyporeflexia
Ruptured abdominal aortic aneurysm - signs
Posteriorly into retroperitoneum - delayed onset
Anteriorly into peritoneum - rapid onset
Sudden, severe abdominal/back pain
Pulsatile abdominal mass
Flank or umbilical hematomas
Syncope
Abdominal aortic aneurysm - treatment
<5.5 cm (asymptomatic): serial imaging
>=5.5 cm (asymptomatic): elective repair
Symptomatic, stable: urgent repair
Symptomatic, unstable: emergency repair
Why are thrombolytics contraindicated in stroke patients with likely septic cardioembolism from IE?
20% higher risk of postthrombolytic intracerebral hemorrhage (vs other etiologies) due to pyogenic arteritis leading to vessel wall erosion and/or mycotic aneurysm formation
Fall + rapid deceleration is at risk for what injury?
Blunt thoracic aortic injury
Look for widened mediastinum or abnormal aortic contour (e.g. enlarged aortic knob), left-sided hemothorax from aortic bleeding
Confirm dx with CT angiography (stable) or TEE (unstable, hypotensive)
How does atherosclerotic occlusion at bifurcation of the aorta into common iliac arteries (aortoiliac occlusion) manifest?
Leriche syndrome triad:
1. Bilateral hip, thigh, gluteal claudication
2. Absent or diminished femoral pulses
3. Erectile dysfunction
External iliac: hip, thigh, distal lower extremity claudication
Internal iliac: superior gluteal (gluteal claudication) and internal pudendal (erectile dysfunction)
What is the difference between peri-infarction pericarditis and Dressler syndrome (post-cardiac injury syndrome)?
Dressler is immune-mediated and occurs weeks after MI
Peri-infarction is local inflammation, due to delayed reperfusion after STEMI
Peri-infarction pericarditis pain control
Acetaminophen, NOT anti-inflammatory due to increased risk of free wall rupture
DVT - when to order D-dimer vs Doppler?
D-dimer: low-moderate pretest probability
Doppler: high pretest probability
Acute severe chest pain in Turner syndrome
Aortic dissection - sharp or tearing pain in chest or back that can radiate to neck or abdomen
Should undergo regular screening with TTE and/or cardiac MRI
Prevent with antihypertensive medication and exercise restriction
Bladder rupture - signs, diagnosis, treatment
- Hematuria
- Suprapubic tenderness
- Difficulty voiding
- Associated pelvic fracture (e.g. widening of pubic symphysis)
Retrograde cystography - water-soluble contrast followed by CT imaging
Treat via surgical repair
Traumatic carotid injuries - etiology and signs
Penetrating trauma, fall with object in mouth (internal carotid located lateral and posterior to tonsillar pillars)
Signs: Gradual onset hemiplegia, aphasia, neck pain, thunderclap headache
Dx: CT scan or MR angiography
What is the most common site of blunt thoracic aortic injury?
Aortic isthmus - transition between flexible ascending and fixed descending aorta
Hereditary hemorrhagic telangiectasia - signs over time, treatment
Recurrent epistaxis in childhood (URI) –> hemoptysis early adulthood (pulmonary; multifocal, well-circumscribed, smooth nodules on chest x-ray; pulmonary bruit) –> GI angiodysplasia (blood loss IDA)
Treat with embolization
Most common peripheral aneurysms
- Popliteal
- Femoral
Watch for pulsatile masses
When is mitral valve repair indicated?
When it is primary mitral regurgitation, LVEF 30-60%
Also if asymptomatic and LVEF >60% or symptomatic and LVEF <30% if repair likely to be successful
Cholesterol embolization from coronary angiography - signs
Skin findings most common in lower extremities:
Livedo reticularis (mottled erythema)
Cyanosis
Gangrene
How would vascular dementia appear on T1-weighted MRI?
Multiple hypointense cortical and subcortical lesions corresponding to old infarcts
Flattened y descent only
Cardiac tamponade
Flattened y descent, prominent A wave
Tricuspid stenosis
Flattened x descent, prominent V wave
Tricuspid regurgitation
Carcinoid syndrome can affect which side of heart?
Right side: tricuspid regurgitation, pulmonic stenosis
Lab values and signs in recent cases of atheroembolism
Eosinophilia/uria - IL-5 activation
Hypocomplementemia - neutrophil activation
Livedo reticularis
Often happens after recent vascular procedure
What meds are avoided in periinfarction pericarditis?
Anti-inflammatory - interferes with collagen deposition, increases risk of mechanical disruptions
Primary Raynaud treatment
Dihydropyridine Ca channel blockers
How does uremic pericarditis differ from other pericarditis on ECG?
No diffuse ST elevation because does not involve the pericardium
How do CCB and ACEi affect vasodilation?
CCB: arteriolar vasodilation -> peripheral edema
ACEi: venous vasodilation
Hypertrophic cardiomyopathy - which medication if contraindication to beta blockers?
Verapamil - decreases chronotropy and inotropy
Diltiazem not preferred because of some systemic vasodilatory effect
Peripheral artery disease treatments
1A: antiplatelet and statin
1B: exercise
2: cilostazol
3: surgery
Clopidogrel potential severe reaction
TTP
Fibromuscular displagia affects which vessels most
Renal, carotid, vertebral
Ranolazine
Antianginal agent in those refractory to beta blockers and long-acting nitrates
What causes nonbacterial thrombotic endocarditis?
Hypercoagulable state - usually due to SLE or malignancy
Echo: small, mobile vegetations typically on mitral or aortic valve
Aortic valve surgical replacement - criteria
Severe aortic stenosis (aortic jet velocity >=4 m/s or mean transvalvular pressure gradient >=40 mmHg
+ >=1 of the following:
-Symptoms
-LVEF <50%
-Undergoing other cardiac surgery
What medications should be started in STEMI, NSTEMI, and unstable angina?
DAPT load and heparin drip
During hospital course, start ASA, beta-blocker, statin, ACE/ARB
In stable angina, just ASA and beta-blockers, with others based on need
Nitrates should be avoided in which MI?
Inferior wall (right ventricular function) - decreases preload
Cardiac tamponade vs pericarditis
Cardiac tamponade is more acute with hemodynamic instability (hypotension) and pulsus paradoxus
What should be initiated in all patients with established ASCVD (secondary prevention)?
Low-dose aspirin and statin
WPW syndrome treatment
Procainamide
Do NOT use AV node blockers, unlike AVRT
How does 2nd degree AV block type 2 treatment differ from type 1 or 3rd degree?
If unstable, beta-1 agonists (isoproteronol, dobutamine), rather than atropine (not necessarily indicated in type 1 unless symptomatic)
Pulmonary HTN heart sound
Loud P2 with increased splitting
ASD heart sound
Fixed split S2
Lesser causes of dilated cardiomyopathy
Ethanol, thiamine deficiency
Uremia
Catecholamine excess
Lyme, Chagas
SLE
Myocarditis from parvo, coxsackie, echo, adeno, HHV6, flu, CMV, HIV
What etiologies are cardiac MRI indicated for heart failure?
Sarcoidosis (also PET)
Radiation fibrosis
Type A aortic dissection - imaging if CTA will take too long and hemodynamically unstable
Transesophageal echo done in OR
Elevated BP during episode of CHF suggests which dysfunction?
Diastolic dysfunction
Also diabetes, female gender
Romano Ward syndrome
Congenital long QT with purely cardiac effect (unlike Jervell and Lange-Nielsen)
LBBB vs RBBB EKG
V1: LBBB has W shape (deep S)
RBBB has M shape (RSR’)
LVH vs RVH on ECG
LVH: S in V1 + R in V5/V6 >35 mm
RVH: R in V1 >7 mm
Peripheral artery aneurysm should be managed if what criteria?
Size >=2 cm diameter or symptomatic
Make sure to check other limb and abdominal aorta with US as well
Cavernous hemangioma
Dilated vessels with thin endothelial layer
Soft blue, compressible masses
Seen in VHL on viscera
What electrolyte disturbance is an independent predictor of mortality in HFrEF?
Hyponatremia <130
Most common source of atrial flutter
Tricuspid annulus
How can WPW syndrome appear on ECG?
- Normal sinus with delta wave
- AVRT (stopped by Valsalva or adenosine)
- Preexcited afib (not AV node dependent, stopped by procainamide, not adenosine due to risk of uncontrolled ventricular fibrillation)
What type of cardiotoxicity is doxorubicin?
Dilated cardiomyopathy with systolic dysfunction and decreased EF
What should be avoided within 4 weeks of MI?
Glucocorticoids - increased risk of free wall rupture
What factors increase pulse pressure vs diastolic pressure?
PP: increased SV or decreased arterial compliance
Diastolic: increased SVR or arterial blood volume
Potential abnormal causes of 1st-degree heart block
Lyme
Sarcoidosis infiltration
Nephrotic syndrome cardiovascular risk
Accelerated atherosclerosis:
Liver increases production of lipoprotein, PCSK9 (which causes LDL receptor degradation and decreased LDL clearance), and decreases endothelial lipoprotein lipase activity
Also increases thrombotic risk due to urinary loss of antithrombin III, proteins C/S
Most common cause of chronic mitral regurgitation
Resource-rich: myxomatous degeneration
Resource-poor and endemic: rheumatic heart disease
What is different about valvular Afib management (due to mitral stenosis) vs nonvalvular Afib?
Warfarin anticoagulation, regardless of Chads score - greater thrombotic risk than nonvalvular
Also, higher risk of decompensated heart failure due to impaired atrial kick
Absent A wave
Afib - no atrial contraction
Absent x and prominent V
Tricuspid regurgitation
Adenosine is particularly good for terminating what SVT?
AVNRT
Lateral ST segment depression, lateral T wave inversion
Left ventricular hypertrophy (also high-voltage QRS)
Ankle-brachial index values
1-1.4 - normal
>1.4 - calcification/stiffening
<0.9 - arterial disease
When should obstructive sleep apnea in Afib be considered?
Risk factors (e.g. BMI >30
What is the most common comorbidity associated with Afib and one of the strongest contributors to atrial remodeling?
Chronic hypertension
What must be prescribed to those with Afib?
Anticoagulation
Paroxysmal Afib (lasts short time) under rhythm control can still cause thrombus
Aortic regurgitation ausculation location
Valvular cause: left 3rd intercostal space
Aortic root dilation: right upper sternal border
What does PPV do for cardiogenic pulmonary edema in terms of pressures?
Increased intrathoracic pressure:
Decreased RV preload (decreased central venous return)
Increased RV afterload (pulmonary capillary compression)
Decreased MAP (aortic compression triggers baroreceptor reflux and decreased pressure
Decreased LV transmural pressure gradient
All of these increase SV and diastolic filling
Increased intrathoracic pressure also displaces interstitial lung water –> increased PaO2
When is preload and PCWP discordant?
Cardiac tamponade - reduced left-sided preload but PCWP paradoxically elevated due to compression of left atrium
Hypertrophic osteoarthropathy - signs
Clubbing
Joint pain and effusions
Periostosis (tender thickening of periosteum) of long bones
Use dependence in rhythm control drugs
IC (flecainide) > IA (procainamide) > IB (lidocaine)
Faster HR gives less time to dissociate from Na channels, resulting in higher blocked channels and greater effect
Flecainide - what does it prolong?
IC antiarrhythmic - Na channel blockade can lead to QRS widening
These have slowest rate of binding and dissociation
Used for Afib
Nondihydropyridine CCB - what do they prolong?
Class IV - L-type Ca channels in SA and AV nodes - prolong PR interval
Procainamide - what does it prolong?
IA antiarrhythmic - QRS and QT interval
Sotalol - what does it prolong?
PR and QT intervals
Comoare to metoprolol, which is just PR interval
Dofetilide - what does it prolong?
Other class III - QT interval prolongation
Most common vaalvular manifestation of rheumatic heart disease
Mitral stenosis - opening snap, middiastolic murmur
What problems can bicuspid aortic valve cause?
Aortic stenosis - diagnosed 10 year’s higher than regurgitation presentation (30s-40s)
Alcohol induced cardiomyopathy - pattern
Direct toxicity causes eccentric hypertrophy, dilated cardiomyopathy
Can sudden cerebral hypoperfusion from ventricular tachycardia cause brief myoclonus?
Yes
Brugada syndrome - ECG and presentation
ECG shows RBBB and ST elevation in V1-V3
Syncope, ventricular tachycardia or fibrillation
Why are ACEi and nitroprussides (arterial and venous vasodilators) and hydralazine (arterial vasodilator) contraindicated in aortic dissection?
Results in reflex sympathetic activation (HR, contractility, shear stress)
Once beta-blocker is given, then give nitroprusside preferably, or enalapril, but not hydralazine as it can still cause shear stress
What must be avoided in Prinzmetal angina?
Aspirin (aggravate ischemic attacks), beta-blockers (vasospasm)
When is carotid endarterectomy indicated?
Symptomatic in last 6 months with 70-99% stenosis
Consider if >50% or asymptomatic bit >60%
Evolocumab, alirocumab
PCSK9 inhibitor - greatly decreases LDL
Fenoldopam
D1 agonist - used in hypertensive emergency
Maintains renal perfusion and causes diuresis
Kussmaul sign
Paradoxical JVD with inhalation - constrictive pericarditis
How does Libman-Sacks endocarditis (lupus) differ from Marantic (cancer) or infectious?
Present on both sides of valve, not just one
Pulsus parvus and tardus
Weak and delayed pulse - seen in severe aortic stenosis
Bounding pulses and wide pulse pressure - which valve disease?
Aortic regurgitation
Ascending vs descending aortic aneurysm cause
Ascending - cystic medial necrosis or connective tissue disease
Descending - atherosclerosis
Chronic autonomic failure syncope - treatment
Midodrine - increase BP
Fludrocortisone - increase volume
U waves (wave after T wave)
Seen in hypokalemia, along with T-wave flattening and ST segment depression
Digitalis concern in what electrolyte abnormality?
Hypokalemia - Digitalis and K compete for same spot on Na/K pump
J point elevation (J wave) at end of QRS complex signifies…
Slow atrial fibrillation - can be seen in hypothermia <30 C
Subauricular systolic bruit
Fibromuscular dysplasia - stenosis of the internal carotid artery
Pericardial knock in diastole is seen in which condition?
Constrictive pericarditis
Cardiac resynchronization therapy indications for CHF
LVEF <35%, LBBB, and QRS >=150ms
