Cardiovascular

Question 1

What is the first line drug management for mitral valve prolapse?

Answer 1

A beta-blocker such as propranolol

Question 2

What herbal supplement is useful in the treatment of varicose veins?

Answer 2

Horse chestnut seed extract has been shown to have some effect when used orally for symptomatic treatment of chronic venous insufficiency, such as varicose veins. It may also be useful for relieving pain, tiredness, tension, and swelling in the legs. It contains a number of anti-inflammatory substances, including escin, which reduces edema and lowers fluid exudation by decreasing vascular permeability.

Question 3

What are the risk factors for a AAA?

Answer 3

Cigarette smokers are five times more likely than nonsmokers to develop an abdominal aortic aneurysm (AAA). The risk is associated with the number of years the patient has smoked, and declines with cessation. Diabetes mellitus is protective, decreasing the risk of AAA by half. Women tend to develop AAA in their sixties, 10 years later than men. Whites are at greater risk than African-Americans. Hypertension is less of a risk factor than cigarette smoking.

Question 4

What patients with cardiac pathology are indicated to take antibiotics prophylactically prior to dental or gastrointestinal procedures?

Answer 4

Indicated only for high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who develop valvular disease.
Note that patients with mitral valve prolapse do not have to take prophylactic antibiotics.

Question 5

How often should patients with mild aortic stenosis that are asymptomatic undergo an echocardiogram?

Answer 5

Every 3-5 years

Question 6

What arrhythmias can IV magnesium treat?

Answer 6

A well-known use of intravenous magnesium is for correcting the uncommon ventricular tachycardia of torsades de pointes. Results of a meta-analysis suggest that 1.2–10.0 g of intravenous magnesium sulfate also is a safe and effective strategy for the acute management of rapid atrial fibrillation.

Question 7

What is the recommendation for dual anti-platelet therapy following placement of a drug-eluting coronary artery stent?

Answer 7

The recommended dosages of dual antiplatelet therapy are aspirin, 162–325 mg, and clopidogrel, 75 mg, or prasugrel, 10 mg for 1 year.

Question 8

What heart malformation is associated with hereditary hemorrhagic telangiectasia?

Answer 8

Pulmonary arteriovenous malformations

Question 9

What drug is recommended for persistent ventricular fibrillation?

Answer 9

In addition to electrical defibrillation and CPR, patients should be given a vasopressor, which can be either epinephrine or vasopressin.

Question 10

What does the CHADS score stand for?

Answer 10

C (congestive heart failure), H (hypertension), A (age 75), D (diabetes mellitus), and S (secondary prevention for prior ischemic stroke or transient attack—most experts include patients with a systemic embolic event). Each of these clinical parameters is assigned one point, except for secondary prevention, which is assigned 2 points. Patients are considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high risk with a score 3.

Question 11

What are the treatment guidelines a CHADS score of 0 in a patient for A-fib?

Answer 11

Experts typically prefer treatment with aspirin rather than warfarin when the risk of stroke is low.

Question 12

What is the treatment for acute pericarditis?

Answer 12

NSAIDs such as aspirin or ibuprofen. There is some evidence that adding cochicine to aspirin may be beneficial.

Question 13

In an African American patient with CHF unable to tolerate an ACE inhibitor, what medications should be used?

Answer 13

For patients who cannot tolerate an ACE inhibitor, especially African-Americans, a combination of direct-acting vasodilators such as isorbide and hydralazine is preferred plus a beta-blocker.

Question 14

What is the drug of choice to manage Raynaud’s?

Answer 14

Nifedipine

Question 15

What are the characteristics of unstable angina that is high risk for death or MI?

Answer 15

Unstable angina patients at high risk include those with at least one of the following:
• Angina at rest with dynamic ST-segment changes 1 mm
• Angina with hypotension
• Angina with a new or worsening mitral regurgitation murmur
• Angina with an S3 or new or worsening crackles
• Prolonged (>20 min) anginal pain at rest
• Pulmonary edema most likely related to ischemia

Question 16

What does syncope with exertion indicate?

Answer 16

Organic heart disease with a fixed obstruction (e.g. aortic stenosis)

Question 17

What is the normal ejection fraction?

Answer 17

55%-75%

Question 18

What are some treatments that have been shown to be beneficial for managing the symptoms of peripheral artery disease (e.g. claudication)?

Answer 18

Routine exercise up to near-maximal pain on a regular basis has been shown to be one of the most effective treatments for symptoms of PAD. Smoking cessation and aspirin are also standard recommendations. Statins and ACE inhibitors have also been shown to decrease symptoms. *Side note - the combination of nifedipine and atenolol has been shown to worsen PAD symptoms.

Question 19

What is cilostazol (Pletal) used for?

Answer 19

A trial of cilostazol is recommended by the American College of Cardiology and the American Heart
Association as initial treatment for peripheral arterial disease (PAD) that limits the lifestyle of patients
without heart failure

Question 20

What does an ankle-brachial index of >1.4 indicate?

Answer 20

Noncompressable calcified arteries

Question 21

What does an ankle-brachial index of <0.9 indicate?

Answer 21

Peripheral vascular disease

Question 22

What BNP level helps to rule out heart failure?

Answer 22

BNP < 100

Question 23

What are the USPSTF guidelines for carotid artery ultrasonography?

Answer 23

The USPSTF and the American Heart Association/American Stroke Association recommend not performing carotid artery screening with ultrasonography or other screening tests in patients without neurologic symptoms because the harms outweigh the benefits.

Question 24

What clinical findings have a specificity >90% for heart failure?

Answer 24

A third heart sound (S3 gallop), displaced point of maximal impulse, interstitial edema or venous congestion on a chest radiograph, jugular vein distention, and hepatojugular reflux.

Question 25

What EKG abnormality makes an exercise stress test uninterpretable, and instead requires a pharmacologic stress test?

Answer 25

Left bundle branch block makes the EKG uninterpretable during an exercise stress test, and can also interfere with nuclear imaging performed during the test. It is associated with transient positive defects in the anteroseptal and septal regions in the absence of a lesion within the left anterior descending coronary artery. This leads to a high rate of false-positive tests and low specificity. Pharmacologic stress tests using vasodilators such as adenosine with nuclear imaging have a much higher specificity and positive predictive value for LAD lesions, and the same is true for dobutamine stress echocardiography.

Question 26

What medication should be started 4 weeks prior to scheduled coronary revascularization?

Answer 26

A statin. It should be continued after the surgery as well.

Question 27

Above what blood pressure is it considered hypertensive urgency/emergency?

Answer 27

180/120

Question 28

What is cilostazol and what does it treat?

Answer 28

It is a phosphodiesterase inhibitor that has anti-platelet activity used as a vasodilator to treat the symptoms of LE claudication (does not improve underlying disease process).

Question 29

What are the guidelines around screening for a AAA?

Answer 29

Men who have ever smoked (defined as 100 or more cigarettes) should be screened once for abdominal aortic aneurysm (USPSTF B recommendation) between the ages of 65 and 75

Question 30

What is the management for a asymptomatic patient found to have mild aortic stenosis on echo?

Answer 30

Repeat echo in 3-5 years unless symptoms develop sooner.