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Internal Medicine > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

How long after drug-eluting stent is placed can dual anti-platelet therapy be withheld for surgery?

A

Urgent surgery: 6 months, then immediately resume afterward
Elective surgery: 12 months, then resume

Need to be on it for 12 months minimum

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2
Q

Cardiac myxoma in LA has what sound?

A

Middiastolic rumble - due to obstruction, similar sound to mitral stenosis

Alleviated by lying down

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3
Q

For a patient with HFrEF on beta-blocker, what should be done before a surgery?

A

Nothing - they are already stable on it
If about to undergo surgery, they should not start new beta-blocker due to potential for exacerbation

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4
Q

How is aortic dissection classified?

A

Type A - involves ascending aorta - surgical emergency
Type B - originates distal to subclavian artery

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5
Q

How does a pseudoaneurysm differ from AV fistula on auscultation?

A

Pseudoaneurysm: Bulging, pulsatile mass; systolic bruit
AV fistula: No mass; continuous bruit with palpable thrill

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6
Q

Femoral nerve injury during vascular access of femoral artery has what symptoms?

A

Thigh discomfort or paresthesias
Patellar tendon hyporeflexia

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7
Q

Ruptured abdominal aortic aneurysm - signs

A

Posteriorly into retroperitoneum - delayed onset
Anteriorly into peritoneum - rapid onset

Sudden, severe abdominal/back pain
Pulsatile abdominal mass
Flank or umbilical hematomas
Syncope

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8
Q

Abdominal aortic aneurysm - treatment

A

<5.5 cm (asymptomatic): serial imaging
>=5.5 cm (asymptomatic): elective repair
Symptomatic, stable: urgent repair
Symptomatic, unstable: emergency repair

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9
Q

Why are thrombolytics contraindicated in stroke patients with likely septic cardioembolism from IE?

A

20% higher risk of postthrombolytic intracerebral hemorrhage (vs other etiologies) due to pyogenic arteritis leading to vessel wall erosion and/or mycotic aneurysm formation

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10
Q

Fall + rapid deceleration is at risk for what injury?

A

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)

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11
Q

How does atherosclerotic occlusion at bifurcation of the aorta into common iliac arteries (aortoiliac occlusion) manifest?

A

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)

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12
Q

What is the difference between peri-infarction pericarditis and Dressler syndrome (post-cardiac injury syndrome)?

A

Dressler is immune-mediated and occurs weeks after MI

Peri-infarction is local inflammation, due to delayed reperfusion after STEMI

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13
Q

Peri-infarction pericarditis pain control

A

Acetaminophen, NOT anti-inflammatory due to increased risk of free wall rupture

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14
Q

DVT - when to order D-dimer vs Doppler?

A

D-dimer: low-moderate pretest probability
Doppler: high pretest probability

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15
Q

Acute severe chest pain in Turner syndrome

A

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

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16
Q

Bladder rupture - signs, diagnosis, treatment

A
  1. Hematuria
  2. Suprapubic tenderness
  3. Difficulty voiding
  4. Associated pelvic fracture (e.g. widening of pubic symphysis)

Retrograde cystography - water-soluble contrast followed by CT imaging

Treat via surgical repair

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17
Q

Traumatic carotid injuries - etiology and signs

A

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

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18
Q

What is the most common site of blunt thoracic aortic injury?

A

Aortic isthmus - transition between flexible ascending and fixed descending aorta

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19
Q

Hereditary hemorrhagic telangiectasia - signs over time, treatment

A

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

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20
Q

Most common peripheral aneurysms

A
  1. Popliteal
  2. Femoral

Watch for pulsatile masses

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21
Q

When is mitral valve repair indicated?

A

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

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22
Q

Cholesterol embolization from coronary angiography - signs

A

Skin findings most common in lower extremities:
Livedo reticularis (mottled erythema)
Cyanosis
Gangrene

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23
Q

How would vascular dementia appear on T1-weighted MRI?

A

Multiple hypointense cortical and subcortical lesions corresponding to old infarcts

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24
Q

Flattened y descent only

A

Cardiac tamponade

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25
Q

Flattened y descent, prominent A wave

A

Tricuspid stenosis

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26
Q

Flattened x descent, prominent V wave

A

Tricuspid regurgitation

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27
Q

Carcinoid syndrome can affect which side of heart?

A

Right side: tricuspid regurgitation, pulmonic stenosis

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28
Q

Lab values and signs in recent cases of atheroembolism

A

Eosinophilia/uria - IL-5 activation
Hypocomplementemia - neutrophil activation
Livedo reticularis

Often happens after recent vascular procedure

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29
Q

What meds are avoided in periinfarction pericarditis?

A

Anti-inflammatory - interferes with collagen deposition, increases risk of mechanical disruptions

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30
Q

Primary Raynaud treatment

A

Dihydropyridine Ca channel blockers

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31
Q

How does uremic pericarditis differ from other pericarditis on ECG?

A

No diffuse ST elevation because does not involve the pericardium

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32
Q

How do CCB and ACEi affect vasodilation?

A

CCB: arteriolar vasodilation -> peripheral edema
ACEi: venous vasodilation

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33
Q

Hypertrophic cardiomyopathy - which medication if contraindication to beta blockers?

A

Verapamil - decreases chronotropy and inotropy
Diltiazem not preferred because of some systemic vasodilatory effect

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34
Q

Peripheral artery disease treatments

A

1A: antiplatelet and statin
1B: exercise
2: cilostazol
3: surgery

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35
Q

Clopidogrel potential severe reaction

A

TTP

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36
Q

Fibromuscular displagia affects which vessels most

A

Renal, carotid, vertebral

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37
Q

Ranolazine

A

Antianginal agent in those refractory to beta blockers and long-acting nitrates

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38
Q

What causes nonbacterial thrombotic endocarditis?

A

Hypercoagulable state - usually due to SLE or malignancy
Echo: small, mobile vegetations typically on mitral or aortic valve

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39
Q

Aortic valve surgical replacement - criteria

A

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

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40
Q

What medications should be started in STEMI, NSTEMI, and unstable angina?

A

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

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41
Q

Nitrates should be avoided in which MI?

A

Inferior wall (right ventricular function) - decreases preload

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42
Q

Cardiac tamponade vs pericarditis

A

Cardiac tamponade is more acute with hemodynamic instability (hypotension) and pulsus paradoxus

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43
Q

What should be initiated in all patients with established ASCVD (secondary prevention)?

A

Low-dose aspirin and statin

44
Q

WPW syndrome treatment

A

Procainamide
Do NOT use AV node blockers, unlike AVRT

45
Q

How does 2nd degree AV block type 2 treatment differ from type 1 or 3rd degree?

A

If unstable, beta-1 agonists (isoproteronol, dobutamine), rather than atropine (not necessarily indicated in type 1 unless symptomatic)

46
Q

Pulmonary HTN heart sound

A

Loud P2 with increased splitting

47
Q

ASD heart sound

A

Fixed split S2

48
Q

Lesser causes of dilated cardiomyopathy

A

Ethanol, thiamine deficiency
Uremia
Catecholamine excess
Lyme, Chagas
SLE
Myocarditis from parvo, coxsackie, echo, adeno, HHV6, flu, CMV, HIV

49
Q

What etiologies are cardiac MRI indicated for heart failure?

A

Sarcoidosis (also PET)
Radiation fibrosis

50
Q

Type A aortic dissection - imaging if CTA will take too long and hemodynamically unstable

A

Transesophageal echo done in OR

51
Q

Elevated BP during episode of CHF suggests which dysfunction?

A

Diastolic dysfunction

Also diabetes, female gender

52
Q

Romano Ward syndrome

A

Congenital long QT with purely cardiac effect (unlike Jervell and Lange-Nielsen)

53
Q

LBBB vs RBBB EKG

A

V1: LBBB has W shape (deep S)
RBBB has M shape (RSR’)

54
Q

LVH vs RVH on ECG

A

LVH: S in V1 + R in V5/V6 >35 mm
RVH: R in V1 >7 mm

55
Q

Peripheral artery aneurysm should be managed if what criteria?

A

Size >=2 cm diameter or symptomatic

Make sure to check other limb and abdominal aorta with US as well

56
Q

Cavernous hemangioma

A

Dilated vessels with thin endothelial layer
Soft blue, compressible masses
Seen in VHL on viscera

57
Q

What electrolyte disturbance is an independent predictor of mortality in HFrEF?

A

Hyponatremia <130

58
Q

Most common source of atrial flutter

A

Tricuspid annulus

59
Q

How can WPW syndrome appear on ECG?

A
  1. Normal sinus with delta wave
  2. AVRT (stopped by Valsalva or adenosine)
  3. Preexcited afib (not AV node dependent, stopped by procainamide, not adenosine due to risk of uncontrolled ventricular fibrillation)
60
Q

What type of cardiotoxicity is doxorubicin?

A

Dilated cardiomyopathy with systolic dysfunction and decreased EF

61
Q

What should be avoided within 4 weeks of MI?

A

Glucocorticoids - increased risk of free wall rupture

62
Q

What factors increase pulse pressure vs diastolic pressure?

A

PP: increased SV or decreased arterial compliance
Diastolic: increased SVR or arterial blood volume

63
Q

Potential abnormal causes of 1st-degree heart block

A

Lyme
Sarcoidosis infiltration

64
Q

Nephrotic syndrome cardiovascular risk

A

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

65
Q

Most common cause of chronic mitral regurgitation

A

Resource-rich: myxomatous degeneration
Resource-poor and endemic: rheumatic heart disease

66
Q

What is different about valvular Afib management (due to mitral stenosis) vs nonvalvular Afib?

A

Warfarin anticoagulation, regardless of Chads score - greater thrombotic risk than nonvalvular

Also, higher risk of decompensated heart failure due to impaired atrial kick

67
Q

Absent A wave

A

Afib - no atrial contraction

68
Q

Absent x and prominent V

A

Tricuspid regurgitation

69
Q

Adenosine is particularly good for terminating what SVT?

A

AVNRT

70
Q

Lateral ST segment depression, lateral T wave inversion

A

Left ventricular hypertrophy (also high-voltage QRS)

71
Q

Ankle-brachial index values

A

1-1.4 - normal
>1.4 - calcification/stiffening
<0.9 - arterial disease

72
Q

When should obstructive sleep apnea in Afib be considered?

A

Risk factors (e.g. BMI >30

73
Q

What is the most common comorbidity associated with Afib and one of the strongest contributors to atrial remodeling?

A

Chronic hypertension

74
Q

What must be prescribed to those with Afib?

A

Anticoagulation

Paroxysmal Afib (lasts short time) under rhythm control can still cause thrombus

75
Q

Aortic regurgitation ausculation location

A

Valvular cause: left 3rd intercostal space
Aortic root dilation: right upper sternal border

76
Q

What does PPV do for cardiogenic pulmonary edema in terms of pressures?

A

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

77
Q

When is preload and PCWP discordant?

A

Cardiac tamponade - reduced left-sided preload but PCWP paradoxically elevated due to compression of left atrium

78
Q

Hypertrophic osteoarthropathy - signs

A

Clubbing
Joint pain and effusions
Periostosis (tender thickening of periosteum) of long bones

79
Q

Use dependence in rhythm control drugs

A

IC (flecainide) > IA (procainamide) > IB (lidocaine)

Faster HR gives less time to dissociate from Na channels, resulting in higher blocked channels and greater effect

80
Q

Flecainide - what does it prolong?

A

IC antiarrhythmic - Na channel blockade can lead to QRS widening
These have slowest rate of binding and dissociation

Used for Afib

81
Q

Nondihydropyridine CCB - what do they prolong?

A

Class IV - L-type Ca channels in SA and AV nodes - prolong PR interval

82
Q

Procainamide - what does it prolong?

A

IA antiarrhythmic - QRS and QT interval

83
Q

Sotalol - what does it prolong?

A

PR and QT intervals

Comoare to metoprolol, which is just PR interval

84
Q

Dofetilide - what does it prolong?

A

Other class III - QT interval prolongation

85
Q

Most common vaalvular manifestation of rheumatic heart disease

A

Mitral stenosis - opening snap, middiastolic murmur

86
Q

What problems can bicuspid aortic valve cause?

A

Aortic stenosis - diagnosed 10 year’s higher than regurgitation presentation (30s-40s)

87
Q

Alcohol induced cardiomyopathy - pattern

A

Direct toxicity causes eccentric hypertrophy, dilated cardiomyopathy

88
Q

Can sudden cerebral hypoperfusion from ventricular tachycardia cause brief myoclonus?

A

Yes

89
Q

Brugada syndrome - ECG and presentation

A

ECG shows RBBB and ST elevation in V1-V3

Syncope, ventricular tachycardia or fibrillation

90
Q

Why are ACEi and nitroprussides (arterial and venous vasodilators) and hydralazine (arterial vasodilator) contraindicated in aortic dissection?

A

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

91
Q

What must be avoided in Prinzmetal angina?

A

Aspirin (aggravate ischemic attacks), beta-blockers (vasospasm)

92
Q

When is carotid endarterectomy indicated?

A

Symptomatic in last 6 months with 70-99% stenosis

Consider if >50% or asymptomatic bit >60%

93
Q

Evolocumab, alirocumab

A

PCSK9 inhibitor - greatly decreases LDL

94
Q

Fenoldopam

A

D1 agonist - used in hypertensive emergency
Maintains renal perfusion and causes diuresis

95
Q

Kussmaul sign

A

Paradoxical JVD with inhalation - constrictive pericarditis

96
Q

How does Libman-Sacks endocarditis (lupus) differ from Marantic (cancer) or infectious?

A

Present on both sides of valve, not just one

97
Q

Pulsus parvus and tardus

A

Weak and delayed pulse - seen in severe aortic stenosis

98
Q

Bounding pulses and wide pulse pressure - which valve disease?

A

Aortic regurgitation

99
Q

Ascending vs descending aortic aneurysm cause

A

Ascending - cystic medial necrosis or connective tissue disease
Descending - atherosclerosis

100
Q

Chronic autonomic failure syncope - treatment

A

Midodrine - increase BP
Fludrocortisone - increase volume

101
Q

U waves (wave after T wave)

A

Seen in hypokalemia, along with T-wave flattening and ST segment depression

102
Q

Digitalis concern in what electrolyte abnormality?

A

Hypokalemia - Digitalis and K compete for same spot on Na/K pump

103
Q

J point elevation (J wave) at end of QRS complex signifies…

A

Slow atrial fibrillation - can be seen in hypothermia <30 C

104
Q

Subauricular systolic bruit

A

Fibromuscular dysplasia - stenosis of the internal carotid artery

105
Q

Pericardial knock in diastole is seen in which condition?

A

Constrictive pericarditis

106
Q

Cardiac resynchronization therapy indications for CHF

A

LVEF <35%, LBBB, and QRS >=150ms

Internal Medicine (23 decks)

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