Cardiovascular (15%)

Question 1

Pericarditis

Answer 1

• Inflammation of pericardium
• Usually d/t infection (non-infectious causes include post-MI, autoimmune, uremia)
• Characterized by non-radiating, sharp, stabbing, knife-like chest pain over PMI
• Friction rub may be present
• 12-lead ECG may show global concave ST elevation
• Pain relieved by leaning forward
• Treatment – NSAIDs for mild; corticosteroids for severe

Question 2

Endocarditis

Answer 2

• Inflammation of endocardium
• Caused by bacteria (Staph. Aureus) or fungi
• Increased risk in patients with valve disease and those with increased risk of pathogen introduction
• Changing cardiac murmur is diagnostically significant
• Physical exam typically shows a septic patient
• Other findings – Osler’s nodes (painful nodules on distal fingers), Janeway lesions (macules on palms and soles), splinter hemorrhages
• Treatment – Gram+ coverage (Vanco + Gentamicin)

Question 3

Myocarditis

Answer 3

• Inflammation of the myocardium
• Usually caused by viruses, but can also be from bacteria and other causes
• Chest pain, fever, sweats, recent flu-like symptoms or recent URI
• Supportive therapy for s/s of acute HF – diuretics, nitro, ACE-I, inotropes
• Avoid NSAIDs in acute phase

Question 4

Coronary Artery Disease (CAD)

Answer 4

• Develops d/t several factors including endothelial damage and infiltration of fatty deposits
• Management centers around decreasing myocardial workload or increasing oxygen supply

Question 5

Stable Angina

Answer 5

• Earliest stages of clinically significant CAD
• Symptoms occur with activity and end with rest and/or nitrates
• No cardiac enzyme elevation, rarely see EKG changes
• Treatment – prophylactic therapy (lower lipids, nitrates, ASA, lifestyle modification)

Question 6

Unstable Angina

Answer 6

• Partial coronary thrombosis
• Symptoms with activity and/or rest and isn’t easily relieved with rest or nitrates (< 30 minutes)
• No cardiac enzyme elevation, may have ST depression
• Treatment – nitrates, beta blockers, morphine, oxygen, aspirin 16-324 mg once then 81 mg daily, ADP receptor blocker (clopidogrel, ticareglor), heparin therapy (if admitted), cardiology consult

Question 7

NSTEMI

Answer 7

• Subtotal coronary thrombosis with partial thickness infarction
• Symptoms with activity and/or rest and isn’t easily relieved with rest or nitrates (> 30 minutes)
• Cardiac enzyme elevation, ST depression
• Treatment – nitrates, beta blockers, morphine, oxygen, aspirin 16-324 mg once then 81 mg daily, ADP receptor blocker (clopidogrel, ticareglor), heparin therapy (if admitted), cardiology consult

Question 8

STEMI

Answer 8

• Total coronary thrombosis with full thickness infarction
• Symptoms at rest, not improved with rest, may improve with nitrates
• Cardiac enzyme elevation, ST elevations
• Treatment – ASA 325 mg once, nitrates, beta blockers, antiplatelet, heparin therapy, cardiac catheterization/PCI or fibrinolysis (if delayed PCI)

Question 9

TIMI Scoring for UA/NSTEMI

Answer 9

• 0-2: low risk

* 3-7: high risk

Question 10

Cardiac interventions - Fibrinolysis

Answer 10

• Symptoms > 15 minutes but < 12 hours
• Goal (if presenting to PCI facility) door to balloon < 90 minutes
• Goal (if presenting to non-PCI facility) door to balloon < 120 minutes
• Absolute contraindications – hx of cerebrovascular event (ICH, intracranial tumor, aneurysm), non-hemorrhagic stroke or head trauma < 3 months ago, cranial or spinal trauma < 2 months ago, known bleeding disorder, active internal bleeding

Question 11

Cardiac Tamponade

Answer 11

 Accumulation of fluid in the pericardial space
 Emergency!
 Etiology – blunt/penetrating chest trauma, s/p cardiac surgery or cath., pericarditis, acute MI, infection
 Symptoms – Beck’s triad (elevated JVP, hypotension, distant/muffled heart tones), signs of shock, narrowing pulse pressure, tachycardia
 Diagnostics – TTE
 Treatment – IVF to maintain preload, O2, inotrope, mainstay = percutaneous or open pericardiocentesis

Question 12

Dilated Cardiomyopathy

Answer 12

• Ventricular chamber enlargement causes progressive dilation leading to overstretching and failure
• Symptoms – gradual heart failure – fatigue, DOE, dyspnea, orthopnea, edema, weight gain
• Management – heart failure management (rest, daily weight, Na restriction, diuretics, ACE INHIBITORS (-PRILs), beta blockers

Question 13

Hypertrophic Cardiomyopathy

Answer 13

• Increased LV wall thickness which restricts ventricular filling leading to diastolic HF
• Symptoms – dyspnea (most common), syncope, palpitations, orthopnea, dizziness, sudden cardiac death
• TTE is diagnostic
• Management – restrain from highly strenuous activity, BETA BLOCKERS (METOPROLOL IS 1ST LINE), ICD

Question 14

Restrictive Cardiomyopathy

Answer 14

• Rigid ventricular walls causing impaired diastolic filling and diastolic HF
• Can be caused by amyloidosis or sarcoidosis
• Symptoms – gradually worsening SOB, fatigue, weakness, chest pain, right-sided HF s/s
• Management – treat cause (if known – amyloidosis or sarcoidosis), nitrates, beta-blockers (carvedilol), inotropes (digoxin)

Question 15

Dyslipidemia Causes - primary vs. secondary

Answer 15

• Primary – familial hypercholesterolemia

* Secondary – SEDENTARY LIFESTYLE with excessive intake of fats and cholesterol

Question 16

Dyslipidemia Screening

Answer 16

• ACCE recommends screening all adults 20-44 years every 5 years, 45-65 every 1-2 years, 65+ years annually

Question 17

Dyslipidemia Treatment

Answer 17

• Lifestyle recommendations – weight reduction, DASH diet, Na restriction, physical activity, moderate consumption of alcohol
• Statin therapy – initiate high-intensity statin (can down-titrate of not tolerated (atorvastatin 40-80 mg or rosuvastatin 20-40 mg)
• Contraindications to high-intensity statin therapy – age > 80, impaired renal function, frailty, multiple comorbidities

Question 18

Left-sided vs. Right-sided Heart Failure

Answer 18

• Left – involves left ventricle, pulmonary symptoms are most common (i.e., SOB, DOE, pulmonary edema, etc.)
• Right – involves right ventricle, systemic symptoms are most common (i.e., hepatosplenomegaly, edema, etc.)

Question 19

Systolic vs. Diastolic Heart Failure

Answer 19

• Systolic – decreased forcefulness of contraction, decreased EF
• Diastolic – inability of full relaxation, normal EF

Question 20

Assessing degree of congestion and adequacy of perfusion in HF (cold vs. warm; wet vs. dry)

Answer 20

No congestion, good perfusion: warm & dry
– outpatient treatment
No congestion, poor perfusion: cold & dry
– inpatient, inotropes
Congestion, good pefusion: warm & wet
– inpatient, diuresis
Congestion, poor perfusion: cold & wet
– ICU, diuresis, inotropes, and/or vasodilators

Question 21

Treatment for Congestion in HF

Answer 21

• “LMNOP”
• Lasix – give IV at 1-2.5x total daily PO dose
• Morphine – for refractory symptoms, SOB
• Nitrates – vasodilation
• Oxygen – consider non-invasive mechanical ventilation
• Position – upright with legs over side of the bed

Question 22

Treatment for Poor Perfusion in HF

Answer 22

• IV vasodilators – nitro
• Inotropes – dobutamine, Milrinone
• Mechanical circulatory support – IABP (inflates in diastole and deflates in systole, decreases O2 demand and increases coronary perfusion), LVAD (bridge to recovery or transplant)

Question 23

ACC/AHA Stages of HF

Answer 23

• Can only progress down
• Stage A – high risk of HF without structural changes or presence of symptoms
• Stage B – structural changes but no s/s of HF
• Stage C – structural changes with s/s of HF
• Stage D – refractory HF

Question 24

NYHA Symptom Classification of HF

Answer 24

• Can move up or down
• Class I – no limitation on activity
• Class II – slight physical limitation, comfortable at rest, normal activity causes symptoms
• Class III – marked physical limitation, comfortable at rest, less than normal activity causes symptoms
• Class IV – unable to perform any activity without symptoms, symptoms present at rest

Question 25

Hypertension

Answer 25

 Elevated BP is 120-129/<80
• No pharmacologic therapy, reassess BP in 3-6 months
 HTN is ≥ 140/≥90
• Non-pharmacologic therapy and BP-lowering meds, reassess BP in 1 month
• Consider initiating 2 first-line agents of different classes: thiazide diuretics (HCTZ), CCBs (amlodipine, diltiazem), and ACE (-pril) or ARB (-sartan)

Question 26

Hypertensive Urgency

Answer 26

• HTN with minimal or no acute target organ damage, can also be asymptomatic
• SBP > 180 mmHg and/or DBP > 120 mmHg
• Lower BP over a few hours with oral antihypertensives with goal to return BP to normal within 1-2 days
• Captopril 12.5-100 mg 3x daily, labetalol 200-800 mg 3x daily, clonidine 0.2 mg loading then 0.1 mg hourly
• Monitor for decreased urine output, increased creatinine, and decreased mental status – may indicate that the lower BPs aren’t tolerated by that BP has dropped to fast

Question 27

Hypertensive Emergency

Answer 27

• HTN (of any degree) with acute target end organ damage and ischemia
• Neuro – encephalopathy, strokes, papilledema
• Cardio – acute coronary syndrome, HF, pulmonary edema, aortic dissection
• Renal – proteinuria, hematuria, acute renal failure
• Lower MAP by 25% within minutes to 2 hours with IV agents
• Consider arterial line monitoring
• Goal is DBP < 110 within 2-6 hours, as tolerated
• Nitroprusside 0.25-10 mcg/kg/min., labetalol 20-80 mg IVP, nicardipine 5-15 mg/hr, nitro 5-1000 mcg/min
• Monitor for decreased urine output, increased creatinine, and decreased mental status – may indicate that the lower BPs aren’t tolerated by that BP has dropped to fast

Question 28

Adult Congenital Heart Diseases (ACHD)

Answer 28

• Most common birth defect
• Lifetime expert surveillance is needed
• Nearly all have some degree of HF (Grade A or NYHAC I or worse)
• Higher risk for endocarditis, thrombus formation, and premature degeneration and calcification of prosthetic materials
• Consult cardiology specialist

Question 29

Murmurs - systolic vs. diastolic

Answer 29

Systolic - MR. ASS is MVP
– Mitral Regurg, Aortic Stenosis = Systolic is Mitral Valve Prolapse
– mitral regurg is classically holosystolic
Diastolic - MS. ARD
– Mitral stenosis, Aortic Regurg = Diastolic

Question 30

Benign vs. Pathologic Murmurs

Answer 30

• Benign – no cardiac history, low grade, S1 and S2 intact, normal PMI, softens or disappears with supine to standing position change
• Pathologic – abnormal history, higher grade, S1 and S2 obliterated, PMI displaced, increases in intensity with supine to standing
• Consider pathologic if at least 1 criteria met; if pathologic, echo is next step

Question 31

Postural Orthostatic Tachycardic Syndrome (POTS)

Answer 31

 Lightheadedness, fainting, and a rapid increase in HR that comes on when standing up from a reclining or laying position
 Diagnostics – tilt table test is gold standard for diagnosis
 Treatment – POTS diet (drink fluids throughout the day, increase salt intake); physical therapy; combination of meds to retain Na (ex: fludrocortisone), beta blockers, and/or meds to improve constriction (ex: midodrine)

Question 32

Peripheral Artery Disease (PAD)

Answer 32

o Intermittent claudication (exacerbated by exercise, relieved by rest)
o 6 Ps – pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
o Skin ulcerations – well defined, punched out appearance, painful
o Loss of hair over lower extremities, shiny skin, thin skin
o Ankle-Brachial Index (ABI) – systolic pressure of ankle divided by systolic pressure of arm; number > 0.9 is diagnostic of peripheral artery disease
o Management – smoking cessation, exercise, foot care, weight reduction, statin, beta blocker, antiplatelets

Question 33

Chronic Venous Insufficiency

Answer 33

o Symptoms – dull ache in legs, leg swelling or tightness, hyperpigmentation
o Ulcerations – sloping, gradual edges, minimal pain, slough
o Management – elevate legs, compressive stockings, skin care, exercise, weight reduction

Question 34

Aortic Dissection

Answer 34

o Occurs when a tear develops in the inner layer (tunica interna) of the aorta and blood dissects into the media
o Stanford classifications
 Type A – upper ascending aorta, more common, emergency
 Type B – lower descending aorta, acute < 14 days or chronic > 14 days
o Risk factors – HTN!, genetics (ex: common in Marfan’s syndrome), aortic coarctation, atherosclerosis
o Symptoms – acute “tearing” chest/back pain, pulse deficit/absent pulses, JVD, hypotension, tachycardia
o Clinical triad – abrupt onset of tearing back/chest pain, variation in pulse, mediastinal and/or aortic widening on CXR
o Type A management – immediate surgical intervention
o Type B management – stable is ICU for pain and HTN monitoring (labetalol); unstable is stenting and medication therapy

Question 35

Aortic Aneurysm

Answer 35

o Most are asymptomatic until rupture!
o Risk factors – COPD, previous aneurysm repair, CAD, HTN, male
o Symptoms – asymptomatic (until rupture), back/flank/groin pain, n/v, abdominal pain, pulsing sensation in abdomen, progressive symptoms, shock symptoms
o Diagnostics – CTA (USPSTF =screen men 65-75 years old who have smoked)
o Management – consult vascular or cardiac surgery, BP control (beta blockers are first line – labetalol)

Question 36

DVT

Answer 36

o Risk factors – PRIOR DVT, CANCER, immobility, post-op, major surgery, pregnancy or post-partum
o Virchow’s triad – inflammation, hypercoagulability, and endothelial injury
o Symptoms – pain, cramp, or “charley horse”, unilateral or bilateral swelling, redness, cyanosis
o Diagnostics – duplex is diagnostic; CT or MRI is not necessary; D-dimer is nonspecific (use only to rule out DVT)
o Wells Criteria Score:
 ≤ 0: low likihood of DVT
 1-2: moderate likelihood of DVT
 ≥ 3: high likelihood of DVT
o Management – first line therapy is direct oral anticoagulation (rivaroxaban, dabigatran, apixaban) for 3 months if provoked or indefinitely if unprovoked

Question 37

PE

Answer 37

o Risk factors – venous stasis, immobility, recent surgery, malignancy, hx of VTE
o Virchow’s triad – inflammation, hypercoagulability, and endothelial injury
o Symptoms – abrupt onset of chest pain, SOB, and hypoxia are classic symptoms
 Other – anxious, wheezing, hemoptysis, tachypnea, diaphoretic
o Diagnostics – CTA (PE protocol)
o Management
 Respiratory support
 Hemodynamic support – cautious IVF (can overload RV), levophed, ECMO?
 Anticoagulation
 Reperfusion
 Chronic phase – 3 months anticoagulation if provoked or indefinite anticoagulation if unprovoked (rivaroxaban, dabigatran, apixaban)

Question 38

Intra-Aortic Balloon Pump (IABP)

Answer 38

• Inserted in femoral artery and sits in descending thoracic aorta
• Decreases afterload, decreases myocardial demand, increases coronary artery perfusion, enhances cardiac output
• Indications – low CO syndromes (ex: septic shock), LV overload, bridge to CABG or LVAD

Question 39

Ventricular Assist Device (VAD)

Answer 39

• An electromechanical pump that is implanted to with assist with cardiac circulation
• Indications – destination therapy, bridge to transplant, bridge to recovery
• Contraindications – extreme BMI, RV UNABLE TO SUPPORT LV FLOWS

Question 40

Extracorporeal Membrane Oxygenation (ECMO)

Answer 40

• Indications – cardiogenic shock, pulmonary HTN, PE with hemodynamic compromise, reversible respiratory failure (ARDS), cardiac arrest, bridge to decision (transplant or VAD)
• Contraindications – irreversible pulmonary or cardiac disease, > 65 years, metastatic malignancy, significant brain injury, terminal disease, inability to tolerate systemic anticoagulation

Question 41

Heart Transplant

Answer 41

• Signs of rejection – most are asymptomatic, signs of left ventricular dysfunction (dyspnea, syncope, orthopnea), tachydysrhythmias
• Dilated cardiomyopathy is most frequent reason for heart transplant