Cardiovascular Flashcards
62 yo male presents with CP; Labs show NML troponin; EKG shows ST segment depression – diagnosis?
Unstable angina
62 yo male presents with CP; Labs show elevated troponin; EKG shows ST segment depression – diagnosis?
NSTEMI
When does Troponin T begin to rise in ACS?
4-6 hours
How long does Troponin T stay elevated in ACS?
10 days
When does Troponin I begin to rise in ACS?
4-6 hours
How long does Troponin I stay elevated in ACS?
10 days
When does CK-MB begin to rise in ACS?
4-6 hours
How long does CK-MB stay elevated in ACS?
48-72 hours
Patient recently had MI about 3-4 days ago; Begins to experience CP again – what is best test to evaluate for repeat MI?
CK-MB
Metabolic disturbance associated with PE?
Respiratory alkalosis
Best management of NSTEMI and Unstable Angina?
Anti-ischemic medications; Anti-platelet medication; Anti-coagulant medication
Best management of STEMI?
Anti-ischemic medications; Anti-platelet medication; Anti-coagulant medication + Reperfusion therapy
4 anti-ischemic medications?
Morphine, O2, NTG, b-blockers
Which anti-ischemic medication has been shown to improve survival in patients with MI?
b-blockers
4 anti-platelet + anti-coagulant medications?
ASA, Clopidogrel, LMW Heparin, GPIIb/IIIa
Event that will increase morality in patients with Unstable Angina + NSTEMI?
Thrombolytic therapy
Which reperfusion drug is contraindicated in patients who are also treated with heparin?
Streptokinase
4 absolute contraindications to fibrinolytic therapy in ACS?
Hemorrhagic CVA, Active bleeding, Suspected aortic dissection (order CXR), Intracranial tumor
When does post-MI VSD typically occur?
3-7 days after MI
When does post-MI papillary muscle rupture typically occur?
3-7 days after MI
Test used to distinguish between post-MI VSD and papillary muscle rupture?
ECHO
Next step of workup for patient who experiences massive MI, when develops pulseless legs?
Angiogram + Embolectomy
Most common cause of death in acute MI?
Ventricular fibrillation
Risk of giving lidocaine to patient with ventricular fibrillation in acute MI?
Asystole
3 DOC for treatment of CP in patient with HX of cocaine use?
Benzodiazepines, NTG, ASA
Which medication should be avoided in treatment of CP in patient with HX of cocaine use?
b blockers
2 aspects of clinical presentation for RV infarction?
Hypotension, JVD
Best treatment for RV infarction?
IV fluids
Which treatment is contraindicated in RV infarction?
NTG
Why is NTG contraindicated in patients with RV infarction?
Further decreases preload
Alternate name for RV infarction?
Inferior wall MI
3 arrhythmias that are common in patients with inferior wall MI?
Sinus bradycardia, Prolonged PR, 3rd degree AV block
When may patients resume sexual activity after acute MI?
6 weeks after MI
Patient presents with bradycardia; EKG shows no p waves – diagnosis?
SA node problem
Patient presents with bradycardia; EKG shows p waves – diagnosis?
AV node problem
Appearance of EKG in Sick Sinus Syndrome?
Loss of P wave
Clinical presentation for Sick Sinus Syndrome?
Syncope
Best treatment for Sick Sinus Syndrome?
Pacemaker
How can you differentiate between cardiac and vagal etiologies of syncope?
Cardiac = sudden, NO prodrome; Vagal = prodrome (fainting)
Description of 1st degree AV block?
Prolonged PR interval … PR > 0.20
Treatment for 1st degree AV block?
Observation
Description of 2nd degree AV block – Type 1?
Progressively prolonged PR interval
Treatment for 2nd degree AV block – Type 1?
Observation … discontinue digoxin
Condition associated with 2nd degree AV block – Type 1?
Inferior MI … affects AV node
Description of 2nd degree AV block – Type 2?
Unequal ratio of P waves : QRS complexes
Treatment for 2nd degree AV block – Type 2?
Pacemaker
Location of defect in 2nd degree AV block – Type 1?
His-Purkinje system
Description of 3rd degree AV block?
Complete dissociation between P waves, QRS complexes
Best treatment for 3rd degree AV block?
Pacemaker
Location of defect in 3rd degree AV block?
His-Purkinje system
DOC for SVT?
Adenosine, 6 mg IV … if no response to vagal maneuvers
Appearance of EKG in SVT?
Tachycardia, Narrow QRS complex
Definitive treatment of SVT?
Catheter ablation of AV node
18 yo female presents for sports physical; Reports occasional palpitation – what should you look for on EKG?
Delta wave
In addition to delta wave, what is another EKG finding associated with WPW?
Short PR interval
Complication of WPW?
V-Fib
Location of accessory pathway in WPW?
Connects atria directly with ventricles via conduction across AV groove
DOC for acute management of reentrant tachycardia in WPW?
Adenosine
DOC for acute management of atrial fibrillation with rapid ventricular response?
Procainamide, Amiodarone
Treatment of choice for WPW patient who is hemodynamically unstable?
Emergent cardioversion
Definitive treatment for WPW?
Catheter ablation
1st step of treatment for A-Fib?
Anticoagulation
2nd step of treatment for A-Fib?
Rate control
2 DOC for rate control in patient with A-Fib?
b blockers, CCBs
DOC for patient with A-Fib, HX of COPD?
CCBs … avoid b blockers
Best treatment for patients with A-Fib lasting more than 48 hours?
Anticoagulation for 2-3 weeks, before attempting cardioversion
DOC for atrial flutter?
Same as A-Fib … b blockers, CCBs
Additional step of workup for patient with Atrial Flutter?
Radiofrequency ablation
In patient with chronic hypoxemia and decompensated COPD – what changes should you expect on EKG?
Multifocal atrial tachycardia … P waves all look different
Which drug is typically associated with Multifocal atrial tachycardia?
Theophylline
Best treatment for patient with Multifocal atrial tachycardia?
Supplemental O2
38 yo male presents for wellness exam; EKG shows PVCs; He is asymptomatic – next step?
Reassurance
Torsades de pointes is a type of …
Ventricular fibrillation
2 electrolyte imbalances that might lead to Toursade de pointes?
Hypo-Mg2+, Hypo-K+
6 medications that may lead to QT prolongation?
Fluoroquinolones, Lithium, Azoles, Macrolides, TCA, Methadone
Best treatment for Toursade de pointes?
Mg2+ infusion; Defibrillation
Description of Ebstein’s anomaly seen in setting of Lithium use during pregnancy?
Atrialization of RV
Change in position of Tricuspid valve in setting of Ebstein’s anomaly?
Displaced towards RV
3 additional AE of lithium?
Nephrogenic DM, Torsades de pointes, Hypercalcemia
3 AEs of quinidine?
Prolonged QT, Tinnitus, Hemolytic anemia
2 AEs of procainamide?
SLE, Prolonged QT
1 AE of lidocaine?
Seizures
2 AEs of b blockers?
Asthma, Decreased libido
5 AEs of Amiodarone?
Hyper/hypothyroidism, Corneal deposits, Pulmonary fibrosis, Gray skin, Photosensitivity
5 risk factors for development of coronary atherosclerosis?
LDL > 100, BP > 140/90, HBA1c > 7, Low HDL, Homocystinuria
Etiology of Prinzmetal angina?
Vasospasm of coronary vessels
Best treatment for Prinzmetal angina?
CCBs
EKG change associated with stable angina?
ST depression
56 yo male presents with intermittent CP, related to exercise; HX of smoking; Which condition is not considered to be a contraindication to workup with exercise stress test?
RBBB
6 conditions that contraindicate exercise stress test?
WPW, Pacemaker, LVH, LBBB, Digoxin use, T-wave abnormalities
Alternative workup in patients who cannot undergo exercise stress test?
ECHO
3 conditions that might cause resting ST elevation?
Acute MI, Pericarditis, LV aneurysm
5 medications that decrease risk of MI in patients with CAD?
ASA, ACEIs, b blockers, Statins, Gemfibrozil
Value of giving b blockers to patients with CAD?
No mortality benefit for patients with chronic CAD; Beneficial for patients with HTN + stable angina
68 yo male presents with stable CAD, EF = 40%, class 3 angina despite pharmacologic therapy – best therapy to improve survival and decrease need for later revascularization?
CABG
Indication for PCI in patients with CAD?
Patients with 1- or 2-vessel CAD, NML LV function
3 indications for CABG in patients with CAD?
Patients with 3-vessel CAD, decreased LV function, LAD disease
Etiology of acute Mitral Regurgitation murmur?
Rupture of papillary muscles post-MI
Clinical presentation of acute Mitral Regurgitation murmur?
Immediate-onset pulmonary edema in post-MI stage
What are the 3 types of holosystolic murmurs?
MR, TR, VSD
Which medication may be cause of chronic MR murmur?
Phen-Fen … used for OB
Most common etiology of Mitral Stenosis murmur?
Chronic rheumatic fever
Change to heart structure in setting of MS murmur?
LA dilation
Clinical presentation of Mitral Stenosis in pregnant females?
Hemoptysis … overload on L heart
CXR appearance of Mitral Stenosis murmur?
Straightening of L heart border
Best treatment of Mitral Stenosis in pregnant females?
Balloon valvotomy
Most common primary heart tumor?
Atrial myxoma
Most common location of atrial myxoma tumor?
LA
Heart sound associated with atrial myxoma?
Loud S1
Best tool for diagnosis of atrial myxoma?
ECHO
Best treatment for atrial myxoma?
Surgical excision
3 most common etiologies of AR murmur?
Bicuspid aorta, Syphilis, Marfan
Description of Quincke’s Sign in setting of AR?
Throbbing nailbed pulses
Description of Hill’s Sign in setting of AR?
Difference between popliteal-brachial pulses > 20
3 steps of treatment for asymptomatic patients with AR?
ACEI, Diuretics, Vasodilators (hydralazine)
Best treatment for symptomatic AR?
Surgery
Change to pulses measured in aortic dissection?
Good UE pulses; Diminished LE pulses
Change to pulses measured in aortic coarctation?
High BP in RUE; Low BP in LUE; Diminished pulses in LE
Description of pulsus paradoxus?
Systolic BP drop > 10 mmHg during inspiration
Pulsus paradoxus is associated with which condition?
Pericardial tamponade
Description of Pulsus biferiens?
Pulse with 2 systolic peaks
Pulsus biferiens is associated with which condition?
Aortic regurgitation
Pulsus tardus is associated with which condition?
Aortic stenosis
Pulsus alternans is associated with which condition?
PVCs, Severe LV disease
In which 2 conditions does standing/Valsalva increase intensity of murmur?
MVP, HCM
How can you distinguish between MVP and HCM murmurs?
MVP intensifies with hand squeeze; HCM softens with hand squeeze
Murmur associated with MVP?
Isolated mid-systolic click
Should patients with MVP receive endocarditis prophylaxis?
No
In which 5 conditions is prophylaxis recommended for endocarditis?
Prosthetic valves, Previous bacterial endocarditis, Unrepaired cyanotic heart disease, Repaired congenital heart defect (first 6 months), Cardiac transplant patients who develop valvulo-pathology
2 types of procedures that require endocarditis prophylaxis?
Respiratory, Dental
2 heart sounds associated with NML pregnancy?
S3, Increased P2 … due to increased blood volume
During pregnancy, any ___ murmur is considered pathologic
Diastolic
2 conditions that decrease intensity of S1?
Aortic regurgitation; Mitral stenosis
What is the physiologic splitting of S2?
A2, then P2
Physiologic splitting of S2 is increased with ___
Inspiration
Physiologic splitting of S2 is decreased with ___
Expiration
Condition associated with fixed splitting of S2?
ASD
Which PE finding has the greatest SPECIFICITY to rule out aortic stenosis?
Physiologic splitting of S2 … If there is NO splitting of S2, think aortic stenosis
Appearance of ASD on CXR?
Pulmonary congestion
3 conditions associated with paradoxical splitting of S2 (P2, then A2)?
Left BBB, Advanced HCM, Pacemaker beats from RV
Etiology of S3 heart sound?
Tensing of chordae tendinae
S3 heart sound is considered normal in which group of patients?
Pediatric
Condition associated with S3 heart sound?
LV systolic dysfunction
Etiology of S4 heart sound?
Atrial contraction against non-compliant LV
3 conditions associated with S4 heart sound?
Aortic stenosis, Cardiac ischemia, HCM
2 most common infectious causes of dilated cardiomyopathy?
Coxsackievirus, Chagas disease
Most common hereditary disorder responsible for dilated cardiomyopathy?
Hereditary hemochromatosis
CTX drug associated with dilated cardiomyopathy?
Doxorubicin
When can peripartum cardiomyopathy occur?
3rd trimester … Up to 6 months postpartum
3 DOC for dilated cardiomyopathy?
ACEIs, b blockers, Diuretics
Patient diagnosed with dilated cardiomyopathy; PE shows no JVD, no leg edema; Labs show BP = 138/79; Currently on terazosin 4 mg for BPH – which drug should be added to regimen?
ACEI
What causes HCM murmur to intensify?
Valsalva
What causes HCM murmur to soften?
Hand grip, Squat
Best diagnostic tool for HCM?
ECHO
DOC for treatment of HCM?
b blockers
2 medications that should be avoided in HCM?
Diuretics, Nitrates … want to give heart a chance to fill
Inheritance pattern for HCM?
AD
Which group of patients should be screened for HCM?
All 1st-degree relatives (AD)
Treatment for HCM that reduces the risk of sudden cardiac death/
Cardioverter-defibrillator
3 contraindications to sports participation?
HCM, Infectious mononucleosis (with splenomegaly), Congenital QT prolongation
Patient presents with cardiac symptoms; PE shows enlarged + tender liver, neuropathy, petechiae – diagnosis?
Amyloidosis
Change to EKG in setting of Amyloidosis?
Reduced voltage … thick walls on ECHO
Change to ECHO that is characteristic for Amyloidosis?
Speckled pattern on ECHO
Drug that should be avoided in Amyloidosis?
Digoxin … increased risk of arrhythmias
Treatment in hemochromatosis that can improve cardiac function and prolong life expectancy?
Phlebotomy
3 indications for use of digoxin in CHF?
Severely-low EF, S3 gallop, enlarged heart
Contraindication to use of digoxin in CHF?
AV block
5 indications for implantable cardioverter-defibrillator in CHF?
EF < 30%, Syncope, Ventricular tachycardia/fibrillation, Cardiac arrest, HCM
Indication for cardiac transplant in patients with CHF?
End-stage CHF
3 examples of L-to-R shunts?
ASD, VSD, PDA
3 examples of R-to-L shunts?
Tetralogy of Fallot, Transposition of Great Vessels
L-to-R shunts are associated with ___ heart conditions
Non-Cyanotic
R-to-L shunts are associated with ___ heart conditions
Cyanotic
In setting of L-to-R shunts, movement of unoxygenated blood to systemic circulation is called …
Eisenmenger Syndrome
Alternate name for Eisenmenger Syndrome?
Irreversible pulmonary vascular sclerosis
Most common ASD etiology?
Ostium secundum
Location of sinus venosus ASD?
Near entrance of SVC
What is the most common congenital cardiac malformation at birth?
VSD
What is the most common congenital cardiac malformation to be first diagnosed in adults?
ASD
What is the most common cardiac abnormality seen in Down Syndrome?
ASD
What is the most common etiology of paradoxical embolism?
PFO
3 systemic manifestations of paradoxical embolism?
CVA, Kidney infarction, Acute limb ischemia infarct … embolisms SHOULD be going to the lungs
3 conditions associated with VSD?
Trisomy 13, Trisomy 18, Cri du Chat
Murmur associated with VSD?
Holosystolic murmur heard best over L sternal border
Congenital PDA is associated with which pathogen?
Rubella
Description of murmur heard in PDA?
Machinery murmur
Pattern of cyanosis seen in PDA?
LE cyanosis
Remnant of PDA that is present after birth?
Ligamentum arteriosus
What is the most common cyanotic congenital heart disease?
Tetralogy of Fallot
4 components of Tetralogy of Fallot?
RV outflow obstruction; VSD; RV hypertrophy; Overriding aorta
Condition associated with Tetralogy of Fallot?
DiGeorge Syndrome
DiGeorge Syndrome is associated with abnormal development of …
Pharyngeal arches 3 and 4
When does cyanosis typically develop in baby with Tetralogy of Fallot?
Few weeks after delivery
Which cardiac defect is always present in viable baby with Transposition of Great Vessels?
PDA
Best treatment for Transposition of Great Vessels?
Prostaglandin E1 … keeps PDA patent
When does cyanosis typically develop in baby with Transposition of Great Vessels?
Immediately after delivery
Appearance of Transposition of Great Vessels on CXR?
“Egg on String” heart
Maternal exposure that increases risk of baby developing Transposition of Great Vessels?
Maternal use of anti-epileptic drugs
Clinical presentation of Aortic Coarctation?
HTN in UE; Reduced BP in LE
In setting of Aortic Coarctation, which vessels maintain circulation in UE?
Intercostal arteries
CXR manifestation of collateral flow through intercostal arteries in Aortic Coarctation?
Rib notching
Appearance of Aortic Coarctation on CXR?
Figure 3 sign
Description of Figure 3 sign seen in Aortic Coarctation on CXR?
Dilation of aorta above/below coarctation
More than 50% of patients with Aortic Coarctation also have which cardiac abnormality?
Bicuspid aorta
Which genetic condition is associated with Aortic Coarctation?
Turner’s Syndrome
Patients with Aortic Coarctation have greater risk of developing …
Berry aneurysm … Higher pressure above heart
Condition associated with Pulmonary Stenosis?
Noonan Syndrome
1 clinical manifestation of Noonan Syndrome?
Neck webbing
What type of coagulopathy is associated with Noonan Syndrome?
Hemophilia C
Hemophilia C results from deficiency in …
Factor XI
Clinical manifestation of Pulmonary Stenosis?
Prominent JVD
On JVD mapping, which portion of curve is prominent in setting of Pulmonary Stenosis?
a wave
Appearance of EKG in setting of Pulmonary Stenosis?
RA enlargement
Treatment of choice for Pulmonary Stenosis?
Balloon valvuloplasty
Description of cardiac changes seen in setting of Ebstein anomaly?
Atrialization of RV
Exposure associated with Ebstein anomaly?
Lithium
2 cardiac abnormalities associated with Marfan Syndrome?
Aortic dissection, AR
What causes aortic dissection in setting of Marfan Syndrome?
Cystic medial necrosis
1 cardiac abnormality associated with Ehler-Danlos Syndrome?
Aortic dissection
1 cardiac abnormality associated with Ehler-Cystic Fibrosis?
Aortic stenosis
1 cardiac abnormality associated with maternal rubella?
PDA
Electrolyte abnormality that might cause QT prolongation?
Hypocalcemia
DOC for atrial flutter?
Diltiazem
BP that should be diagnosed as HTN?
Sustained BP > 140/90
Best treatment for Conn Syndrome?
Spironolactone
Thyroid condition that causes HTN?
Hypothyroidism
Parathyroid condition that causes HTN?
Hyperparathyroidism … increased Ca2+ causes vessel constriction
Most common case of HTN in young females?
OCP use
EKG findings associated with acute pericarditis?
Diffuse ST elevations
Most common cause of acute pericarditis?
Viral infection
Which treatment for Dressler Syndrome should be avoided?
Corticosteroids
Best treatment for acute pericarditis?
NSAIDs, Corticosteroids
Best treatment for recurrent pericarditis?
Colchicine
Characteristic of pericardial effusion that can cause symptoms?
Rapid accumulation
Triad of symptoms seen in pericardial tamponade?
Pulsus paradoxus, Hypotension, JVD (jugular venous distension)
Change to EKG in setting of pericardial tamponade?
Decreased voltage
When should you collect samples of pericardial aspirate in setting of pericardial effusion?
Suspected TB
Appearance of pericardial tamponade on PA cath?
Equalization of pressure in RA, RV, Pulmonary artery
Change to JVD curve in pericardial tamponade?
Attenuated Y descent
Heart sound associated with constrictive pericarditis?
Pre-systolic knock
In setting of constrictive pericarditis, when does pericardial knock occur?
Just after S2
Change to JVD curve in constrictive pericarditis?
Sharp Y descent
Change to JVD appearance on PE in setting of constrictive pericarditis?
Kussmaul sign … Increased JVD during inspiration
Best treatment for constrictive pericarditis?
Pericardiectomy
