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MKSAP - Internal > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

what is the difference between NSTEMI and unstable angina?

A

NSTEMI has elevations of cardiac biomarkers whereas unstable angina does not

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2
Q

pt presents with angina at rest or new onset / increased angina

A

unstable angina or NSTEMI

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3
Q

chronic stable angina

A

chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved by rest or nitroglycerin

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4
Q

sharp, pleuritic chest pain worsened in the supine position and radiates to top of shoulder

A

acute pericarditis

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5
Q

dx. criteria for acute pericarditis (3)

A
  1. pleuritic chest pain
  2. friction rub
  3. diffuse ST elevation on ecg, w/ PR depression
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6
Q

pt presents with abrupt onset, severe pain in thorax; there may be a pulse deficit on P/E, murmur of aortic regurgitation and widening of mediastinum of CXR - dx?

A

aortic dissection

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7
Q

ST elevation in II, III and aVF

A

inferior wall MI

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8
Q

preferred tx. for pts with STEMI

A

PCI with stent placement

- most effective if done w/in 12 hrs of onset of pain

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9
Q

C/I to thrombolytic therapy

A

prior intracerebral hemorrhage
ischemic stroke w/in 3 months
suspected aortic dissection
active bleeding

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10
Q

next diagnostic step in suspected aortic dissection

A

chest CT

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11
Q

when is echocardiogram useful in emergency setting?

A

pts presenting with chest pain and non-diagnostic ECG

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12
Q

classic triad of RV MI

A

hypotension
clear lung fields
elevated estimated CVP

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13
Q

most predictive findings of RV-MI

A

ST-segment elevation on right-sided electrocardiogram lead V4R

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14
Q

what test should all patients with inferior wall MI have done?

A

right sided ECG

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15
Q

primary supportive tx. in RV MI

A

volume expansion with normal saline

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16
Q

pts with RV-MI whose hypotension is not corrected after 1 L of saline should get what drug?

A

IV dobutamine (inotropic)

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17
Q

what two drugs are impaired in RV-MI?

A

b-blockers }bradycardia

nitrates } makes hypotension worse, inhibiting right heart filling

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18
Q

Tx of pt with GERD-related chest pain

A

rule out cardiac ischemia (i.e. exercise stress test) and then tx. empirically with PPI

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19
Q

prolongation of PR interval > 0.2 sec; not assoc with alterations in HR

A

first degree AV block

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20
Q

progressive prolongation of PR interval until there is a dropped beat

A

Mobitz Type I - Wenkebach

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21
Q

dropped beat without progressive prolongation of PR interval

A

Mobitz Type II block

- usually assoc. with BBB and progresses to third degree block

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22
Q

complete absence of conduction of atrial impulses with ventricular bradycardia (30-50 bpm)

A

third degree heart block

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23
Q

pt presents with recurrent, unexpected episodes of palpitations, sweating, dyspnea, chest pain, nausea, dizziness and numbness; sx. peak w/in 10 min and last 15-60 minutes - dx?

A

consider panic attacks

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24
Q

Tx. of panic acttacks

A

CBT

SSRI- paroxetine

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25
Q

pt presents with sudden severe headache, diaphoresis and palpitations; he is very pale

A

pheochromocytoma - episodic or sustained HTN

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26
Q

AV block characterizes by regularly dropped beat (nonconducted P wave every 2nd or 3rd beat)

A

Mobitz Type II block

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27
Q

causes of Mobitz Type I block

A

absence of heart disease - athletes, elderly
underlying heart disease - ischemia
drugs - CCBs, beta blockers, digoxin

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28
Q

Tx of mobitz type II block

A

pacemaker

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29
Q

anti-anginal therapy for chronic stable angina

A

B-blockers
CCBs
nitrates

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30
Q

vascular protective therapy for chronic stable angina

A

aspirin
statin
ACE inhibitor

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31
Q

Ranolazine

A

novel antianginal agent approved for tx. of chronic stable angina
- should only be used in addition to baseline therapy of BB, CCB and long-acting nitrate

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32
Q

when is coronary angiography useful in assessment of chronic stable angina?

A

when pt still has symptoms despite max medical therapy

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33
Q

pt complains of chest pain and dyspnea with asymmetric leg edema, elevated CVP, tachypnea and tachycardia - dx? what test should you do?

A

suspect PE

- do a CT pulmonary angiography

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34
Q

normal wall motion on echocardiography during chest pain excludes…

A

coronary ischemia or infarction

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35
Q

adenosine nuclear perfusion stress test is C/I in what patients?

A

those with asthma or sig. bronchospastic dz

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36
Q

primary approach to diagnosis of CAD in pts who can exercise and have normal resting ECG

A

exercise ECG testing

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37
Q

multiple P waves in a sawtooth pattern with 2:1 ventricular conduction

A

atrial flutter

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38
Q

absence of discernable P waves which are replaced by fibrillatory waves that vary in amplitude, shape and frequency; ventricular rate is irregular

A

atrial fibrillation

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39
Q

symptomatic sinus bradycardia with alternating atrial tachyarrhythmias (A.fib)

A

sick sinus syndrome

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40
Q

wide QRS morphology (QRS > 0.12 sec) and HR > 100/min

A

ventricular tachycardia

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41
Q

when do you add a CCB to a pt with chronic stable angina?

A

if pt is unable to tolerate BB or they can be added to BB for difficult to control sx

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42
Q

should you give clopidogrel to a pt with stable angina?

A

no - increased risk of bleeding

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43
Q

LDL cholesterol target range for CAD

A

< 100 mg/dL (2.6 mmol/L)

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44
Q

what studies should at the very minimum be done in dx. Atrial Fibrillation? 2

A

transthoracic echo - exclude occult valve or structural heart disease
TSH to exclude hyperthyroidism

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45
Q

who is coronary angiography reserved for?

A

lifestyle limiting angina despite tx
positive results on stress testing
successful resuscitation from sudden cardiac death
ventricular tachycardia

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46
Q

coronary calcium testing - who gets this test?

A

asx. pts with a 10-20% 10 yr risk category

young pts with strong family history of premature CVD

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47
Q

how do you diagnose pre-excitation?

A

short PR interval
presence of delta wave
- if tachycardia - dx. is WPW syndrome

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48
Q

wide QRS complex and HR between 60-100/min

A

idioventricular or slow ventricular tachycardia

49
Q

three or more p-wave configurations on ECG w/ assoc. tachycardia; commonly seen in chronic lung disease patients

A

multifocal atrial tachycardia

50
Q

what test is indicated in a pt with chronic stable angina who is experiencing lifestyle limiting angina despite optimal medical therapy?

A

coronary angiography

51
Q

coronary revascularization is beneficial in stable angina pts who meet the following conditions:

A
  • refractory to medical tx
  • large area of ischemic myocardium and high risk criteria on stress testing
  • high risk coronary anatomy (Left main or 3-vessel dz)
52
Q

what 3 conditions are “cannon waves” present in?

A

3rd degree heart block
pulmonary HTN
ventricular tachycardia

53
Q

a wide QRS tachycarida, in the presence of known structural heart disease (esp prior MI) is almost certainly…

A

ventricular tachycardia

54
Q

what is important drug to initiate in NSTEMI?

A

BB - reduces infarct size, decreases frequency of recurrent MI and improves short/long term survival

55
Q

indications for intra-aortic balloon pump

A

cardiogenic shock unresponsive to med. tx
acute mitral regurg. secondary to papillary mm. dysfunction
ventricular septal rupture
refractory angina

56
Q

how does an intra-aortic balloon pump work?

A

reduces afterload during systole and increases coronary perfusion during diastole

57
Q

what type of infarct predisposes to papillary muscle rupture and acute mitral regurg?

A

inferior wall infarcts

58
Q

signs of ventricular aneurysm

A

intractable ventricular tachyarrrhythmia
systemic emboli
heart failure

59
Q

how does ventricular free wall rupture manifest?

A

pericardial tamponade, cardiovascular collapse or pulseless electrical activity

60
Q

new systolic murmur with palpable thrill 2-7 days following STEMI

A

ventricular septal defect or ischemic mitral regurgitation

- next steps: echo and surgery

61
Q

pt presents with severe, sharp, tearing chest pain; pain radiates widely and is assoc. with syncope, systemic ischemia or heart failure

A

aortic dissection

62
Q

physical findings assoc. with aortic dissection

A

acute aortic regurg (diastolic murmur at base)
myocardial ischemia
cardiac tamponade/hemopericardium
hemothorax/exsanguination

63
Q

sick sinus syndrome consists of…

A

sinus bradycardia
sinus arrest
sinus exit block

64
Q

tachycardia-bradycardia syndrome

A

rapid ventricular conduction during episodes of atrial fibrillation with resting bradycardia between episodes

65
Q

symptomatic sinus dysfunction is an indication for what?

A

pacemaker implantation

66
Q

effects of Donepezil on heart

A

Achesterase inhibitor - causes increased vagal tone, bradycardia and AV block

67
Q

cardiac effects of Trazodone

A

palpitations and ventricular ectopy

68
Q

next best step in pt with cardiac arrhythmia who is unstable

A

electrical cardioversion

69
Q

what test should you order in pt with sinus tachycardia?

A

TSH level to test for hyperthyroidism

70
Q

what is adenosine used for?

A
  1. terminates AV nodal re-entrant tachycardia

2. can reveal flutter waves during adenosine-induced AV block

71
Q

elevated resting sinus rate in the absence of recognized cause and an exaggerated rate response to exercise

A

inappropriate sinus tachycardia

72
Q

Tx. inappropriate sinus tachycardia

A

CCB or BB

- refractory cases - sinoatrial node ablation

73
Q

CHA2DS2 ASc risk score

A 
CHF
HTN
age > 75- 2 pts
Diabetes
Stroke or TIA - 2 points
Vascular disease (prior MI, PAD, Aortic plaque)
Age 65-74
Sex (F)
74
Q

what do you do with a 25 yo patient with PVCs and structurally normal heart

A

no additional investigation or tx. needed

75
Q

first-line therapy for PVCs

A

beta blocker - metoprolol OR CCB - verapamil

76
Q

medical therapy of sustained ventricular tachycardia

A

amiodarone, procainamide, flecainide

- does not improve survival in pts with VT or structural disease

77
Q

primary eligibility criterion for ICD implantation

A

EF < 35%, regardless of presence or absence of coronary disease or arrhythmias

78
Q

ICD implantation is not indicated for whom?

A

pts who experience ventricular arrhythmias less than 48 hours after acute STEMI - these should be managed medically

79
Q

indications for pacemaker placement

A

symptomatic sinoatrial node dysfunction

symptomatic bradycardia due to 2nd or 3rd degree block

80
Q

pt presents with recurrent syncope as well as a family history of syncope triggered by activity or sudden death/cardiac arrest due to torsades - dx?

A

long QT syndrome - most likely congenital

81
Q

acquired long QT syndrome

A 
female sex
hypokalemia, hypomagnesemia
structural heart disease
previous QT interval prolongation
history of drug-induced arrhythmia
82
Q

when is digoxin used in HF treatment?

A

added to other therapy in pts with NYHA class III/IV heart failure - strictly for symptom control (no survival benefit)

83
Q

HF with EF < 45% diagnosed between 3 months before and 6 months after delivery (usually first month post-partum)

A

peripartum cardiomyopathy

84
Q

what do you suspect in pt with elevated CVP, pulmonary crackles, S3 and S4 heard, any cardiac murmus and LE edema

A

heart failure

85
Q

next best step in pt with new-onset heart failure

A

cardiac angiography

86
Q

what is radionuclide ventriculogram useful for?

A

confirming the EF if clarification is needed

87
Q

what test should be ordered in all patients with newly suspected heart failure?

A

echocardiography

88
Q

BNP > 500 suggests what?

A

acute heart failure

89
Q

what drugs are recommended for all NYHA class 1 and 2 patients, regardless of symptoms or functional status?

A

B-blocker (carvedilol)
ACE-i (lisinopil)
- improve mortality

90
Q

when do you initiate spironolactone and digoxin in HF?

A

NYHA III-IV patients

91
Q

what can you give a patient with HF who is intolerant of an ACEi (hyperkalemia, renal insufficiency)?

A

hydralazine + nitrate

- also improve survival but not as much as ACEi

92
Q

eplerenone - indications

A

HTN
LV dysfunction after MI
instead of spironolactone in CHF

93
Q

contraindications to spironolactone

A

serum creatinine > 2.5 md/dL

K+ > 5 mmol/L

94
Q

what two CCBs can be used in HF patients if symptoms are not adequately controlled by BB or ACEIs?

A

amlodipine

felodipine

95
Q

failure of a bioprosthetic aortic valve leads to …

A

aortic insufficiency

96
Q

widened pulse pressure, bounding peripheral/carotid pulses, holodiastolic murmur on left upper sternal border best heard when pt is leaning forward

A

aortic regurgitation

97
Q

fixed splitting of S2 and ventricular heave

A

ASD

98
Q

what do you do with murmurs that are grade 2/6 sysolic murmur or less

A

if asymptomatic, these are considered benign and require no further testing

99
Q

indications for transthoracic echocardiography (murmurs)

A
  • grade 3/6 or louder systolic murmus
  • any diastolic or continuous murmur
  • new murmur diagnosed
100
Q

accentuated P2, opening snap and low-pitched, diastolic rumble

A

mitral stenosis - usually due to Rheumatic disease

101
Q

systolic murmur best heard at left lower sternal border that increases with intensity during inspiration

A

tricuspid regurgitation

102
Q

what maneuvres increase the murmur of hypertrophic cardiomyopathy

A

valsalva manuevre

squat-to-stand

103
Q

rapid upstrokes of carotid arteries with a systolic murmur?

A

hypertrophic cardiomyopathy

104
Q

Acute A-fib Rx in unstable patient

A

Immediate electrical cardioversion to sinus rythym

105
Q

Acute A-fib Rx in stable patient (3)

A
  1. Rate control (DOC: B-blockers; CCB’s, in LVSD- digoxin, amiodarone)
  2. Cardioversion E>Pharm (ibutilide, procainamide, flecainide, sotalol, amiodarone)
  3. Anticoagulation
106
Q

Atrial flutter rx

A

similar to A-fib

107
Q

multifocal atrial tachycardia dx

A

vagal maneuvers or adenosine to show av block w/out disrupting the atrial tachycardia

108
Q

multifocal atrial tachycardia Rx

A

improving oxygenation and ventilation
LV function ok: CCBs, B-Blockers, Digoxin, amiodarone, IV flecainide and IV propafenone
LV not preserved: Digoxin, diltiazem or amiodarone

109
Q

Paroxysmal Supraventricular Tachycardia Rx maneuvers (4)

A

Stimulate the vagus delay AV conduction and thus re-entry mechanism: Valsalva, carotid sinus massage, breath holding, head immersion in cold water

110
Q

Paroxysmal Supraventricular Tachycardia Acute Rx

A

DOC: adenosine 6 mg rapid IV push
Iv Verapamil or IV esmolol or Digoxin
Cardioversion if unaffective

111
Q

Paroxysmal Supraventricular Tachycardia prevention

A

DOC: Digoxin
Verapamil or B-blocker
Ablation of AV node

112
Q

Rx W-P-W

A

Ablation
Consider amiodarone 150 mg IV over 10 min.
Pharm(esp if patient goes into a-fib): procainamide or quinidine

113
Q

Avoid drugs active on AV-node in W-P-W

A

Digoxin, B-Blocker, CCB, Adenosine

may accelerate conduction

114
Q

Rx: Sustained VT with hemodynamically stable patients

A

ACLS guidelines: IV amiodarone 150 mg IV over 10 min; IV procainamide or
IV sotalol > IV lidocaine or IV bretylium

115
Q

Rx: Sustained VT with hemodynamically unstable patients

A

Immediate synchronous DC cardioversion

Follow with Amiodarone to maintain sinus rhythm

116
Q

Rx: Nonsustained VT

A

No underlying heart condition: NO treatment
Underlying heart disease: order electrophysio study
- if inducible S-VT give amiodarone

117
Q

V-fib Rx

A

Immediate Defibrillation and CPR indicated

continues after shock EPI (1 mg bolus initially)

118
Q

Pulseless electrical Activity causes

A

5H’s and 5T’s (due cpr)
Hypovolemia, hypoxia, H+ (acidosis), hypo/hyperkalemia, hypothermia
Tension Pneumo, Tamponade, Toxins (Narcs, BZ), Thrombosis (Pulm/cardiac), Trauma

MKSAP - Internal (11 decks)

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