Cardiovascular Flashcards
What heart sound might you hear with Mitral valve regurgitation?
Mitral valve regurgitation may cause a wide split of the second heart sound.
Mitral valve regurgitation can be caused by mitral valve prolapse, rheumatic heart disease, ischemic cardiomyopathy, myocarditis or endocarditis. This condition places a pathophysiological volume overload on the heart. Symptoms include fatigue, weakness and exertional dyspnea. Heart failure and pulmonary edema can occur in the acute or chronic setting.
Echocardiography is diagnostic and treatment consists of medical management of secondary conditions (i.e. congestive heart failure, atrial fibrillation, etc.) and surgical repair. Because the deterioration of left ventricular function is progressive and irreversible the latter should be done prior to the onset of symptoms and early operation is indicated in asymptomatic patients with a reduced ejection fraction (less than 60%) and/or left ventricular dilation.
Acute therapy for NSTEMI
Medical treatment for NSTEMI includes: anti-ischemic therapy (oxygen, nitroglycerin, beta blocker), antiplatelet therapy (aspirin, clopidogrel or brilinta, platelet glycoprotein IIb/IIIa inhibitor), and antithrombotic therapy (heparin, low-molecular-weight heparin).
Describe Heart Failure due to diastolic dysfunction
Diastolic dysfunction is an important mechanism of heart failure with a preserved ejection fraction, which causes nearly 50% of cases of heart failure in the United States. It is most commonly seen among women and older patients. Additional risk factors include obesity, hypertension, diabetes mellitus, coronary disease, and tobacco use.
Clinically, this is suspected in patients with typical signs and symptoms of heart failure and a left ventricular ejection fraction that is >50%. It is most often due to left ventricular hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax or fill adequately, leading to decreased cardiac output and increased diastolic pressures that put pressure on the pulmonary venous system and resulting in high mean pulmonary capillary wedge pressures.
Palpitations associated with ___________ have increased risk of a cardiac etiology
Patients with a history of cardiovascular disease, palpitations that affect their sleep, or palpitations that occur at work have an increased risk of an underlying cardiac cause (positive likelihood ratio 2.0–2.3)
How is AS followed?
The American Heart Association and the American College of Cardiology recommend that asymptomatic patients with mild aortic stenosis undergo repeat echocardiography every 3–5 years.
most effective drug for treating allergic rhinnitis?
steroid nasal spray
what are the 3 phases of scalp hair follicle rotation
The actively growing anagen-phase hairs give way to the catagen phase, during which the follicle shuts down, followed by the resting telogen phase, during which the hair is shed.
describe telogen effluvium
a nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.
Describe anagen effluvium
diffuse hair loss that occurs when chemotherapeutic medications cause rapid destruction of anagen-phase hair
round patches of hair loss, thought to have an autoimmune etiology.
Alopecia areata
Best medication to prevent osteoporotic hip and back fx
treatment with bisphosphonates to prevent osteoporotic hip and vertebral fractures is the only one supported by consistent patient-oriented, high-quality clinical evidence
foods that have cross reactivity with latex allergy
avocados, bananas, chestnuts, and kiwi
sequence for testing for hepatitis C
Hepatitis C testing should be initiated with an antibody test ( anti‑HCV test). People testing anti‑HCV positive/reactive should have follow-up testing for detection of HCV RNA. If that is positive- confirmed
If negative, it was false positive.
If the third test, quantitative RNA is neg, it is an old infection resolved.
Can hepatitis C resolve on its own
Yes, 15-20%
Features of a benign pulmonary nodule on CXR
Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year.
Two most common causes of hypercalcemia
Malignancy and hyperparathyroidism
What is the recommendation for low dose Aspirin?
Do not recommend routinely for primary prevention.
The ADA guidelines recommend low-dose aspirin for diabetic patients with 10-year CVD risk ≥10%
Recommended to all for secondary prevention
Non modifiable Cardiovascular risk factors
Age, sex, family hx DM/CAD
What is used to reverse heparin (UFH)
Protamine zinc
T or F. Only STEMI patients with stents should be discharged on statins
All MI patients should be discharged on high dose statins.
do STEMi or NSTEMI have better long term outcomes
About the same, NSTEMI slightly worse
what are the 3 more commonly used glycoprotein inhibitors -
abciximab (abcixifiban) (ReoPro)
eptifibatide (Integrilin)
tirofiban (Aggrastat)
when is the special circumstance for use of gycoprotein inhibitors
Patients undergoing stenting
What drug category is clopidogrel and brilinta
Both anti platelet aggregation through binding of ADP/P2Y12 sites
50 yr old male with classic Angina symptoms has what percent chance of it being cardiac
90%
Female 73%
What type of patient is best suited for cardiac stress tesing
those with intermediate pretest probability of cardiac dx
Which is most sensitive and specific regarding stress testing MPI vs Stress echo
MPI is more sensitive
Stress echo more specific
Guidelines for recommending CABG
3 vessel disease with LV dysfunction, LAD >50% occlusion
Problem with coronary stents in diabetics
Much higher rate of re-occlusion. Overall do better with CABG
Drug Eluding stents have more early reocclusions, T or False
True. It takes longer to epithelialize
Drug eluding stents should have what for a year
clopidogrel or ticagrelor (ASA for life)
Bare stents 6 months
For patients with multivessel dx, unstable angina or previous MI, STENT vs CABG
they overall have better outcomes CABG
Drugs for pericarditis
Colchicine, NSAIDS and if fail consider prednisone
pure rt heart failure with JVD, hypotension is preload dependent T or F
True. Needs IV fluids
Pulsus paradoxus occurs with tamponade. Define it
Pulsus paradoxus refers to an exaggerated fall in a patient’s blood pressure during inspiration by greater than 10 mm Hg. On physical examination, one can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse.
Is RHF synonymous with RV dysfunction
NO. Some patients have asymptomatic RV dysfunction, and not all RHF is caused by RV dysfunction.
CCTA is better at ruling out CAD than ruling it in T/F
True. Negative predictive value is 93% as opposed to PPV of 82% May slow HR with B-blocker to improve images
What is the BP goal of treatment in diabetic patients 30-59y?
<140/90 Tighter control does not have better results.
if >60 yr old make goal <150/90
Holiday heart syndrome
Afib from a binge of Alcohol
Uncontrolled AF can be cardioverted if
Has been present < 48hrs
Or clear of clots by TEE
DOAC vs NOAC
Direct vs New oral anticoagulant
• Apixaban (Eliquis®)
• Dabigatran (Pradaxa®)
• Rivaroxaban (Xarelto®)
How long does it take for the anti-coagulant effect of Apixaban and Rivaraxaban vs Dabigatran
Immediate vs required heparin bridging with pradaxa
Reversal agent for Apixaban and Rivaroxaban (aksi
Andexxa (Andexanet alfa)
What is pulsus alterans
alternating strong and weak pulses seen in decreased Ejection fraction of severe LVHF
Classification of LVHF. Based on activity level
Class I strenuous activity causes sx
Class II moderate activity
Class III mild
Class IV at rest
Treatment that is included for all 4 NY Heart Ass classes
Salt intake < 2g for moderate to severe, otherwise <3g
Fluid intake <2L
ACE/ARB, Betablocker
What is added to Class II HF patients and beyond
A diuretic
What is added to Class III HF patients and beyond
Aldosterone antagonist like spironolactone or vasodilator like hydralazine or isosorbide
What may be added to a Class IV HF patient?
inotrope like digoxin
What are the 3 broad categories of Rt sided heart failure
- decreased right ventricular contractility (e.g. right ventricle infarction and myocarditis),
- increased right ventricular pressure due to increased resistance
to flow (e.g. pulmonary embolism
and left-sided heart failure), - and right ventricular volume overload (e.g. tricuspid regurgitation).
The majority of atrial thrombus from A-fib forms where
Left atrial appendage
Where does most A-fib originate
The pulmonary veins appear to be the most frequent source of these automatic foci
Tx of non-valvular Afib
Chad score 0 - none
1 - consider DOAC or coumadin
2+ - DOAC (preferred) or coumadin
Can you interrupt anticoagulation in A-fib pt for surgery?
Yes. If non valvular, up to 1 wk. If coumadin, stop several days before surgery and then restart
When to bridge stopping of Coumadin for surgery in A-fib pt
If valvular A-fib or if Chad score >5
At what INR should your routinely treat the coumadin coagulopathy with vitamin K
10
What is the risk of non-sustained asymptomatic
V-Tachy
None. Starting antiarrhythmics has more risk
All heart failure patients with an EF < 30% should get…
Implantable defibrillator
Next step if a patient is having syncope sx with intermittent ventricular tachy
EP study. Many of these, if not related to cardiac disease like Ischemic dx or LV dysfunction etc., can be fixed with ablation.
T/F Mitral valve prolapse is no longer considered a cause of PAC’s
True. Mitral STENOSIS is a cause of PAC
Should pt’s with severe Mitral or Aortic regurgitation get surgery before symptoms start?
Yes. Monitor with yearly Echo. Decision for surgery based on valvular anatomy, valve hemodynamics, LV dilation, systolic function etc.
Persistent atrial fibrillation is defined as atrial fibrillation rhythm that lasts more than ___ days.
7
__ is the most common risk factor for atrial fibrillation.
hypertension
how many leaflets does aortic valve have
How many leaflets results in increased risk of stenosis
- Semi lunar. Each leaflet looks like a half moon
2- more stress and inury
What are the new terms for systolic dysfunction and diastolic dysfunction heart failure
HF with reduced EF
HF with preserved EF
What is the test of choice to diagnose HF? Why
Echo. You get lots of information about degree as well as etiology
Most common cause of HFrEF?
Ischemic Heart disease
how often weight checks in CHF
daily
What drugs have been shown to decrease mortality in HFrEF?
Best is ACE/ARB. Beta Blockers
Combo long acting nitrate + hydralazine
How does Hydralazine (apresoline) work
PO or IV …. q6hr dosing
Direct arteriol vasodilator- little effect on veins. Primarily afterload reducer. Exact mechanism unknown
Hydralazine apparently lowers blood pressure by exerting a peripheral vasodilating effect through a direct relaxation of vascular smooth muscle.
Hydralazine vs Nitrate mechanism of action
hydralazine, a primary afterload-reducing agent, and nitrates, primarily preload-reducers.
do diuretics reduce mortality in HFrEF
No
Which Beta blockers reduce mortality in HFrEF
Metoprolol, carvedolol, bisoprolol
Add spironolactone to which HF pt’s?
NYHA class III and IV
name 4 drugs that can raise potassium
ACE, ARB, spironolactone, Trimethoprim-sulfa
Never prescribe bactrim if on these other meds.
T/F Not all HF patients are fluid overloaded
T Therefore, just diuretic is not the best choice for a patient with acute fluid overload from HF
At what level of Hgb should transfusion be considered in a patient that is anemic with symptomatic heart disease
8-10
ACC/AHA HF staging
A- at risk for HF
B- structural HD but no symptoms
C- symptoms
D- Bad- needs advanced therapies
Roughly what percent of patients with HF have HFpEF
50%
the problem with HFpEF is therefore the best drug class to use is
Not enough muscle relaxation, filling
Beta-blocker- it allows longer filling time
What is the 5 yr survival rate for HF
50%
What is Cor Pulmonale
Cor pulmonale is defined as an alteration in the structure and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory system. Pulmonary hypertension is often the common link between lung dysfunction and the heart in cor pulmonale.
An echocardiogram shows hypertrophied RV with paradoxical bulging into septum. Suspect what?
Cor Pulmonale
T/F 10% of pts with sickle cell dx will get pulmonary HTN
T
enlarged, peaked P-wave think …
Cor Pulmonale
One of the best treatments for Cor Pulmonale, esp in smokers, and those with sleep apnea is
Low-flow oxygen
Follow up US for AAA guidlines
< 4cm yearly
4-5cm q 6 months
over 5cm - repair
What does elevated LDH indicate
Cellular injury/tissue damage. All cells have LDH, which helps convert Lactate to Pyruvate
15: 2
30: 1
Breaths to compression 2 and 1 person CPR
Second degree HB Mobitz type I
If PR spaces out then blocks, it must be Wenki bach.
Wink with one eye
Second degree Mobitz type II
if PR stays normal then QRS quits, it’s 2 stroke Mobitz
Which second degree AV block is most likely to go on to third degree block
Mobitz II. The block is below the AV node
Ankle brachial index
Ankle BP / brachial index
sensitive and specific for PAD in lower extremities.
.95-1.29 = normal
.9 or below is 95% sensative for some degree of
occlussive dx
.4 and below is severe dx
Medication of choice for Claudication
First choice of treatment however….
Pletal (cilostazol) Trental (pentoxifylline) if not HF patient. First step in treatment is graduated walking program
PAD is considered a CAD equivalent…
with the same 10-year attendant cardiac risk.
Indications for surgery for PAD
1) Limb salvage- ulcer, gangrene 2) Persistant pain that interferes with daily life
AS surgery indicated when
becomes symptomatic or just before symptomatic or if asymptomatic and severe, when another heart surgery is done
any of the valve diseases, if mild, should have echo every
3-5 yrs
Is Valvulotomy (balloon) a long term solution
No, only lasts 3-6 months. TAVR (transthoracic Valve Replacement) is definitive tx
What age group is White coat HTN more prevalent
Elderly
what beta blocker is least preferred currently
atenolol
What is a class side effect of Calcium channel blockers?
dependent edema
Does a third degree heart block always have a wide QRS?
No, it depends on where the escape comes from
Describe electrical alternans and when you would see it
QRS voltage alternate in height beat to beat. May see it late stage pericardial effusion
Acute pericarditis can look like STEMI but…
Classic findings of sinus tachy, diffuse ST elevation, and PR depression
Regular narrow complex tachycardia does not convert with adenosine and HR worsens with diltiazem. what may be happening?
WPW
Use procainamide
General rule of thumb usually holds true in LBBB and RBBB in regards to where you find R-R prime
On Right side of ECG in RBBB (V1V2V3)
On Left side of ECG in LBBB (lead I)
What are the primary valves that are involved with endocarditis?
Aorta
Mitral
Who qualifies for High dose statin
LDL> 190, Hx of CAD or equivalent, DM age 40-75
Who qualifies for Moderate dose statin (Non-diabetic)
Use risk calculator. If > 7.5% risk AND LDL 70-190 and age is 40-75. Must look at risk enhancers if falls below this
Goal of statin therapy
Reduce LDL by 50% from baseline. No fixed LDL goals any longer- used to be below 100
what is considered high dose statin
atorvastatin 40-80mg or rosuvastatin 20-40mg
What is considered low -medium dose statin
atorvastatin 10-20mg daily, pravastatin 40-80mg BID, rosuvastatin 5-10mg QD
Aortic regurgitation murmur description
Aortic regurgitation, also known as aortic insufficiency, is a decrescendo blowing diastolic murmur heard best at the left lower sternal border
Who always gets statin treatment
Secondary prevention- Post cardiac event patients
What 3 main groups of patients need consideration for primary prevention statin therapy
1- LDL > 190 (consider Familial Hyperlipidemia) -high dose
2- 40-75 yr olds with DM get mod to high intensity
3 - 40-75yr non diabetics - do risk assessment
What cardiac condition has a murmur that increases in intensity with valsalva
Valsalva increases the strength of murmurs due to hypertrophic obstructive cardiomyopathy and mitral valve prolapse.
It decreases the intensity of aortic stenosis, mitral stenosis, aortic regurgitation, mitral regurgitation, and ventricular septal defects.
