Cardiovascular

Question 1

Treatment for systolic CHF

Answer 1

beta-blockers (metoprolol, bisopropol, carvedilol); ACEI or ARB (for afterload reduction); spironolactone (if K+ not high & pt on optimal dosage of beta-blocker & ACEI/ARB); digoxin (to decrease hospitalizations & improve symptoms, but does NOT improve mortality)

hydralazine & long-acting nitrates may be used in AAs

Question 2

EF in systolic heart failure

Answer 2

low

Question 3

EF in diastolic heart failure

Answer 3

normal to elevated

Question 4

treatVT/VF

Answer 4

automatic implantable cardiac defibrillator (AICD)–decrease mortality from VT/VF

Question 5

causes of diastolic heart failure

Answer 5

most common: HTN with LVH

others: hypertrophic cardiomyopathy, sarcoidosis, amyloidosis, hemochromatosis, scleroderma

Question 6

causes of systolic heart failure

Answer 6

ischemic heart disease, long-standing HTN, viral or idiopathic cardiomyopathy in younger patients

Question 7

causes of dilated cardiomyopathy

Answer 7

ischemia, tachycardia, HTN, EtOH, Chagas’ disease (in S. America)
*Cardiomyopathy 2/2 tachycardia & EtOH are almost completely reversible if remove offending agent

Question 8

treatment of dilated cardiomyopathy

Answer 8

ACEIs, ARBs, beta-blockers, spironolactone, digoxin (improves symptoms, but not mortality)

Question 9

causes of restrictive cardiomyopathy

Answer 9

sarcoid, amyloid, hemochromatosis, cancer, glycogen storage disease

Question 10

treatment of restrictive cardiomyopathy

Answer 10

treat underlying cause, diuretics

Question 11

autosomal dominant; associated with sudden death; echo may reveal normal EF & an asymmetrically thickened ventricle

Answer 11

hypertrophic cardiomyopathy

Question 12

treatment for hypertrophic cardiomyopathy

Answer 12

beta-blockers, CCBs, disopyramide

***inotropes (e.g. digoxin), vasodilators, & excessive diuresis should be avoided

Question 13

signs/symptoms of pericarditis

Answer 13

CP/SOB that worsens with cough/deep inspiration and improves with sitting up or leaning forward; pain may radiate to back; pericardial friction rub on auscultation (a leathery sound that is inconstant)

Question 14

ECG findings of pericarditis

Answer 14

diffuse ST elevation; PR segment depression

Question 15

causes of pericarditis (inflammation of pericardial sac)

Answer 15

viral infxn (esp. enterovirus), mediastinal radiation, post-MI (Dressler’s syndrome), cancer, rheumatologic diseases (SLE, RA), uremia, TB, prior cardiac surgery

Question 16

types of pericarditis (based on duration)

Answer 16

acute (6 months)

Question 17

treatment of pericarditis

Answer 17

NSAIDs
colchicine, aspirin
treat underlying disorder
***avoid NSAIDs in post-MI pericarditis (interfere w/ scar formation)

Question 18

possible complications of pericarditis

Answer 18

pericardial effusion & tamponade

Question 19

pt p/w hypotension, JVD, muffled heart sounds, SOB, pulsus paradoxus (>10 mmHg drop in systolic BP during inspiration)

Answer 19

pericardial effusion –> cardiac tamponade

Question 20

diagnostic procedure of choice when tamponade suspected

Answer 20

echo

Question 21

treatment for acute tamponade

Answer 21

pericardiocentesis

Question 22

treatment for recurrent or malignant effusions

Answer 22

pericardial window

Question 23

indications for cardiac stress testing (not exhaustive)

Answer 23

diagnosis of CAD/eval of symptoms
preop eval
risk stratification in pts w/ known disease
decision making about need for revascularization

Question 24

Contraindications to stress testing

Answer 24

severe aortic stenosis, acute coronary syndrome, decompensated heart failure

Question 25

patients p/w sudden onset of severe chest pain that radiates to back. What do you suspect & what test do you want to do?

Answer 25

Aortic dissection. Do a CT scan with IV contrast--diagnostic & shows extent of dissection. If pt has CI to contrast, can do TEE. MRI can be used, but it is time-consuming & not optimal for unstable pts.

Question 26

Risk factors for aortic aneurysm

Answer 26

age >60, smoking, HTN, fam h/o aortic aneurysm, hypercholesterolemia ***risk of rupture low for aneurysms <4cm

Question 27

treatment of aortic dissection

Answer 27

initial medical stabilization: aggressive HR & BP control 1st w/ b-blockers (e.g. IV esmolol) & then IV nitroprusside if needed * Ascending dissection (Stanford type A, involves ascending aorta): emergent surgical repair * Descending dissection (Stanford type B, distal to L subclavian a.): medical mgmt unless intractable pain, progressive dissection in pts w/ CP, or vascular occlusion of aortic branches

Question 28

presentation of acute endocarditis

Answer 28

fever, rigors, heart failure from valve destruction, & symptoms related to systemic emboli (neurologic impairment, back pain, pulmonary symptoms)

Question 29

presentation of subacute bacterial endocarditis

Answer 29

characterized by weeks to months of fever, malaise, & weight loss; also p/w symptoms of systemic emboli

Question 30

presentation of noninfectious endocarditis (i.e. nonbacterial thrombotic endocarditis or marantic endocarditis, verrucous endocarditis or Libman-Sacks encocarditis)

Answer 30

gen. asymptomatic, can cause heart failure by destroying valves

Question 31

exam findings for infective endocarditis

Answer 31

fever, new murmur, findings a/w emboli including focal neuro deficits & TTP over spine), Osler's nodes (painful nodules on fingers & toes), Janeway lesions (small skin infarctions), Roth's spots (retinal exudates)

Question 32

diagnosis of infective endocarditis

Answer 32

blood cultures plus TTE or TEE

Question 33

treatment of infective endocarditis

Answer 33

* prolonged antibiotic therapy (4-6 wks)--begin w/ empiric gentamicin & antistaphylococcal penicillin (oxacillin or nafcillin; vanc for MRSA) * Valve replacement for fungal endocarditis, heart failure from valve destruction, valve ring abscess, or systemic emboli despite adequate antibiotic therapy

Question 34

Supraventricular tachycardia

Answer 34

Can p/w weakness, dizziness ECG shows narrow QRS complex tachy Tx: valsalva to increase pt's vagal tone or give adenosine