Cardiovascular Flashcards
Acute treatment of Atrial Fibrillation in Wolff-Parkinson-White syndrome. What do you have to avoid?
Goals: control ventricular response and termination of AF
- Hemodynamically unstable: immediate electrical cardioversion
- Stable: Rythm control➡Procainamide, Ibutilide, Amiodarone
*Avoid AV nodal blocking agents: adenosine, beta-blockers, CCB (especially verapamil), digoxin▶AF into Ventricular fibrillation (⬆conduction through accessory pathway)
What is “pulsus parvus and tardus” and when do you expect to find it?
- Delayed (slow-rising) and diminished (weak) carotid pulse
- Severe aortic stenosis
*Outflow tract obstruction syncope
Which are the two aberrant electrical pathways of the Wolff-Parkinson-White (WPW) syndrome?
- Pre-excitation→involves the node itself►Supraventricular tachycardias (atrial fibrillation or atrial flutter)
- Electrical pathway→reaches out of the AV node, connects to the bundle of His in the ventricles→early electrical impulse to the ventricles while bundle of His is in refractory period►Ventricular tachycardia
Gold standard treatment for chronic WPW syndrome
Radiofrequency ablation
How do you differentiate cardiac tamponade vs right ventricle failure?
- Pulsus paradoxus►Cardiac tamponade, NO in right ventricle failure
- Both have Beck’s triad►muffled cardiac sounds, hypotension, jugular venous distention
Most likely ECG pattern expected in a pulmonary embolism
Non-specific ST segment and T waves abnormalities, and sinus tachycardia→70% of PE
*S1 Q3 T3, right axis deviation, Right bundle branch block, atrial fibrillation [right heart strain]→may suggest PE, but absence does not rule out (20% of PE)
Most useful test for diagnosing pericarditis, which finding is more specific?
ECG→Diffuse concave ST elevation, PR depression (more specific finding), occasionally flipped T waves
*Echocardiogram→to rule out coexisting pericardial effusion or tamponade, often normal in acute pericarditis alone. Find small amount of fluid is not specific, seen in variety of conditions
When beta-blocker and ACEIs are more efficient between them to reduce mortality in post-myocardial infarction patients?
- Beta-blockers→post-MI patients with normal ejection fraction (↓O2 demand and ventricular arrhythmias)
- ACEI→post-MI in patients with reduced ejection fraction
Which Beta-blockers you should avoid when treating Heart Failure and why?
Pindolol and Acebutolol→have sympathomimetic activity
How do you identify a pericardial effusion at chest x-ray?
Enlarged and globular cardiac silhouette (“water bottle” heart shape)
Important physical examination finding to suspect pericardial effusion
- Clear lung fields
- Inability to palpate the point of maximal apical impulse
- If large pericardial effusion→cardiac tamponade►Beck’s triad (hypotension, elevated JVP, muffled heart sounds)
Physical examination findings on coarctation of the aorta
- Simultaneous palpation of the brachial and femoral pulses→assess for brachial-femoral delay
- Bilateral upper extremities (supine position) and lower extremities (prone position) blood pressure measurement→evaluate blood pressure differential
Confirmatory diagnostic test for coarctation of the aorta
Echocardiogram
Embolism that more commonly occur during vascular procedures such as peripheral angiography or interventions, guidewire or catheter manipulations during cardiac catheterization, intraaortic balloon pump insertion
Cholesterol crystal embolism→disruption of atherosclerotic aortic plaques►systemic atheroembolism
Most common high-dose Niacin side effect. Why does it happen?
- Flushing and pruritus
- Drug-induced release of Histamine and Prostaglandin (no true hypersensitivity)
*Give low-dose ASA 30 minutes before niacin
What is Inferior Vena Cava plethora and what does it mean?
- Lack of the normal inspiratory collapse of a dilated IVC on echocardiography (Normally the IVC diameter decreases about 50% during inspiration)
- Right heart failure and constrictive pericarditis (cardiac tamponade)
Hemodynamic changes on cardiac tamponade (most asked variables)
- Pulmonary capillary wedge pressure ⬆
- Cardiac Index ⬇
- Right atrial pressure ⬆
- Systemic vascular resistance ⬆
Diagnostic gold standard for viral myocarditis. Most frequently, which study does assist the diagnosis in a regular basis?
- Endomyocardial biopsy (lymphocytic infiltration) aided by viral polymerase (DNA or RNA)
- Cardiac MRI▶️late enhancement of the epicardium
What is the indication for mineralocorticoid receptor antagonists on heart failure?
- Left ventricular ejection fraction <40% with recent ST-elevation myocardial infarction
- Symptomatic heart failure
Differences between ascending and descending aortic aneurysms in location and etiology
- Ascending aneurysm→60% cases, origin anywhere from aortic valve to the innominate artery, cystic medial necrosis (aging) or connective tissues disorders (Marfan sx or Ehler-danlos sx)
- Descending aneurysm→40% cases, origin distal to the subclavian artery, atherosclerosis
Chest X-ray findings suggesting thoracic aortic aneurysm
- Widened mediastinal silhouette
- Increase aortic knob
- Tracheal deviation
ECG finding on acute pericarditis due to renal failure
Nonspecific T wave abnormalities
*Classic diffuse ST elevations are typically absent due to lack of myocardial inflammation
What does hyponatremia suggest in a patient with acute heart failure?
Severe congestive heart failure➡independent predictor of adverse clinical outcomes
Which electrolyte disturbance is associated with increase susceptibility of digoxin toxicity? Why?
Hypokalemia (may be associated with excessive diuretic use)→permissive for digoxin binding at K+ binding site on Na+/K+ ATPase
Best initial tests to diagnose pulmonary embolism. Which is most often the best next step or test to do after them?
- Chest x-ray, ECG, Arterial Blood Gas
- CT Angiogram (Spiral CT Scan)→standard of care to confirm PE
*Angiography is most accurate but 0,5% mortality (rarely done)
If you suspect a pulmonary embolism and the V/Q and spiral CT don’t give a clear diagnosis, what do you do next?
Lower Extremity Doppler study
- Positive→no further test is needed (80% of PEs come from legs and the therapy won’t change)
- Negative→Withhold Heparin
First choice test to confirm pulmonary embolism in pregnancy
V/Q scan
*Completely normal scan excludes a clot
When do you use thrombolytics in a pulmonary embolism?
- Hemodynamically unstable→hypotension (systolic BP<90, tachycardia, etc)
- Acute right ventricular dysfunction
*There is no specific time limit as in stroke or MI
What is the first step to confirm the diagnosis of peripheral artery disease?
Ankle-Brachial Index (ABI)→<0,9►diagnostic of occlusive PAD with a 90% sensitivity and 95% specificity in symptomatic patients
*Arterial ultrasound of the lower extremities→less sensitive and specific than ABI►localize site and severity of vascular obstruction
Most common indications for surgery in infectious endocarditis
- Acute heart failure (acute aortic/mitral valve regurgitation)
- Extension of infection (abscess, fistula, heart block)
- Difficult to treat pathogen (fungus, muti drug-resistant pathogen)
- Persistent bacteremia on antibiotics
- Large vegetation/persistent septic emboli
Neurologic complications of infective endocarditis
- Embolic stroke
- Cerebral hemorrhage
- Brain Abscess
- Acute encephalopathy or meningoencephalitis
Ventricular apical ballooning, history of myocardial infarction after a stressful situation and normal coronary angiography. Disease and its mechanism?
- Tako-Tsubo cardiomyopathy
- Massive catecholamine discharge
When do you use Exercise Tolerance Testing to evaluate chest pain?
Etiology is not clear and EKG is not diagnostic
Why the EKG in an Exercise Tolerance Testing may not be suitable to read and interpret?
Baseline EKG abnormality→Left bundle branch block, left ventricular hypertrophy, pacemaker use, effect of digoxin
Which antiplatelet drugs are preferred in addition to aspirin in a patient undergoing angioplasty and stenting? and why?
- Prasugrel or Ticagrelor
- Restenosis of stenting is best prevented
Medication that offers the best mortality benefit in chronic angina
Aspirin and Beta blockers
Which other medications can be used instead of ACEI/ARB in systolic dysfunction to decrease mortality? in what situation could you switch them?
- Hydralazine (arterial vasodilator→↓ afterload) and Nitrates (dilate coronary arteries) - Reduce mortality in african-american
- Hyperkalemia by ACEI or ARB
Which EKG finding in the context of acute coronary syndrome has the worst prognosis?
ST elevation in V2-V4 leads or Anterior Wall Miocardial Infarction
*If untreated - 30 to 40% mortality in 1 year
Most important measure in decreasing the risk of restenosis of the coronary artery after PCI
Placement of drug-eluting stent (paclitaxel, sirolimus)
When do you suspect a perivalvular abscess?
Symptoms of infective endocarditis + New conduction abnormalities (ex, 2:1 second-degree atrioventricular block with syncope)
Which symptom is more specific when suspecting beta-blocker intoxication?
- Beta-blocker intoxication→bradycardia, atrioventricular block, hypotension (ex, present also in CCB, digoxin, cholinergic intoxication)
(+) Wheezing more specific
In an ST-segment depression acute coronary syndrome, which is the best next step in the management after aspirin is given? Which of them is best in terms of mortality?
- Heparin
- Low molecular weight heparin superior to unfractionated heparin
Most accurate test in diagnosing congestive heart failure. In which case do you use it?
- Multiple-gated acquisition scan (MUGA) or nuclear ventriculography
- Ex: Patient receiving chemotherapy with doxorrubucin
Best initial treatment for beta-blocker poisoning. Best next step if there is no improvement after the initial treatment.
- Initial Tx→secure airway, isotonic fluids, atropine
- Next best step→Glucagon (⬆cAMP➡Tx for BB and CCB toxicity) in profound refractory hypotension
Presumed etiology of idiopathic pericarditis
Coxsackie B virus
What is “Lone Atrial Fibrilation”? Treatment.
- Paroxysmal, persistent or permanent AF + No evidence of cardiopulmonary or structural heart disease
- Usually <60 years, CHA2DS2VASc=0→No treatment needed
Therapy for hemodynamically stable atrial fibrillation with rapid ventricular response
Beta blockers, Calcium channel blockers (Diltiazem), Digoxin
How do you identify by auscultation the tricuspid valve compromised by infective endocarditis? Why?
- Tricuspid valve endocarditis (Regurgitation)→⇧holosystolic murmur with inspiration (differentiates right sided murmurs from all others)→Carvallo’s sign
- ↑Venous blood flow on inspiration→↑stroke volume of right ventricle in systole→↑blood from right ventricle to the right atrium
Measure of aortic valve area on echocardiogram to cause left ventricular hypertrophy and symptoms of angina
Aortic valve area <1 cm2→severe stenosis
Measure of aortic valve area to diagnose aortic stenosis
Valve area <3cm2
When do you suspect Renovascular Hypertension?
Patients with resistant hypertension and:
- Diffuse atherosclerosis
- Asymmetric kidney size
- Recurrent flash pulmonary edema
- ↑Creatinine >30% from baseline after initiate ACEI or ARB’s
- Continuous abdominal bruit (high specificity)
Auscultations findings of severe mitral regurgitation
- Blowing and high-pitched holosystolic murmur at the apex
- S3 gallop→sudden cessation of blood flow into dilated LV during filling phase of diastole
*Absence of S3 helps rule out severe chronic MR
Most common cause of mitral and aortic stenosis
- Mitral stenosis→rheumatic fever (most common immigrants in USA)
- Aortic stenosis→congenital bicuspid valve or calcification by aging
Treatment of mitral and aortic stenosis
- Mitral stenosis→dilation through balloon valvuloplasty with catheter
- Valve replacement when ballon cannot be done or fails
- Aortic stenosis→surgical replacement
Unique features of mitral stenosis clinical presentation
Dysphagia, Hoarseness, Atrial fibrilation (stroke) [Big LA], Hemoptisis
Etiology of Mitral Regurgitation
- Any reason that dilated the heart
- Hypertension
- Endocarditis
- MI with papillary muscle rupture
First line of treatment of regurgitant lesions (mitral and aortic regurgitation)
Vasodilators: ACEIs or ARBs or nifedipine→delay the progression
Valve replacement indication for mitral regurgitation
When heart starts to dilate→LVESD>40mm or EF<60% *Operatively or with catheter placing a clip or sutures
Most common presentation of mitral valve prolapse
Atypical chest pain, palpitations and panic attack
Heart compensatory mechanisms of the asymptomatic phase of chronic volume overload (AR, MR, Ischemic disease, dilated cardiomyopathy)
Eccentric hypertrophy→↑Left ventricle compliance (have additional LV volume) and ↑Left ventricle contractility (sustain stroke volume)
Most common cause of sick sinus syndrome
Age-related degeneration of the cardiac conduction system→fibrosis of the sinus node
ECG findings of sick sinus syndrome
- Sinus bradycardia
- Sinus pauses (delayed P waves)
- Sinoatrial nodal exit block (dropped P waves)
Clinical presentation of sick sinus syndrome
- Bradycardia→fatigue, dyspnea, dizziness, syncope
- Palpitations:
+Bradycardia-tachycardia syndrome→bradycardia alternating with supraventricular tachycardia
+Atrial arrhythmias (ex, atrial fibrillation)
Most common arrhythmia on hyperthyroidism and its treatment
- Thyroid hormone ↑beta-adrenergic receptor expression ↑sympathetic activity→Atrial fibrillation (5-15%)
- Beta-blockers (propranolol, atenolol)→continue until hyperthyroidism is well treated
Pathologic causes of sinus bradycardia
Sick sinus syndrome, myocardial ischemia, obstructive sleep apnea, hypothyroidism, ↑intracranial pressure, medications (b-blockers, CCB excess)
Best initial therapy for hypertrophic obstructive cardiomyopathy and ordinary hypertrophic cardiomyopathy
Beta-blockers
*Strong negative inotropic drugs are useful - Verapamil, Disopyramide
Contraindicated medications in HOCM
Diuretics, ACEIs do not help (may worsen symptoms), digoxin, hydralazine
*Diuretics may help in ordinary hypertrophic cardiomyopathy symptoms
Distinctive feature of chronic constrictive pericarditis
Chronic pericarditis→fibrosis and calcification of pericardium►Calcification on x-ray (Best initial test)
Treatment of idiopathic pericarditis
NSAID and colchicine
What is the Kussmaul sign and when it is most likely associated?
- ↑JVD on inhalation (normally neck veins go down on inspiration)
- Constrictive pericarditis
Most appropriate study for pericardial tamponade
Echocardiogram→right atrial and ventricular diastolic collapse
EKG findings on pericadial tamponade
Electrical alternans→different heights of QRS complexes between beats
Best initial test for aortic dissection
Chest x-ray→widening of the mediastinum
*Source MTB2
What is peripartum cardiomyopathy? In which stage during pregnancy is most commonly developed?
- LV dysfunction secondary to antibodies against the myocardium in a pregnant woman
- After delivery in most cases
Best initial test for hemodynamically stable and unstable patients in those who suspect aortic dissection
- Stable→CT angiography, MRA if contrast is contraindicated
- Unstable→Transesophageal echocardiogram (also for renal insufficiency)
*Source First aid 2CK
Differences between the treatment of the type A and B aortic dissection
- Type A (ascending)→proximal to left subclavian artery (may involve descending aorta)►all patients should have surgery
- Type B (descending)→distal to left subclavian artery (no involve ascending aorta)►BP, heart rate control; surgery if leakage, rupture, or compromised organs
Emergency and optimal treatment for decompression sickness
- IV hydration
- Trendelenburg position
- 100% Oxygen➡facilitates absorption of nitrogen gas from the bloodstream
- Optimal management: Hyperbaric oxygen
Screening for abdominal aortic aneurysm
Abdominal ultrasound for men age 65-75 who have ever smoked (lifetime tobacco use>100 cigarettes)
Definition of severe aortic stenosis
- Aortic jet velocity ≥4 m/sec
- Mean transvalvular pressure gradient ≥40 mmHg
- Valve area usually ≤1 cm2, but NO required
Indications of aortic valve replacement
Severe AS and ≥1 of the following:
- Onset of symptoms (angina, syncope)
- Left ventricular ejection fraction <50%
- Undergoing other cardiac surgery (CABG)
Most common form of paroxysmal supraventricular tachycardia (PSVT)
Atrioventricular nodal reentrant tachycardia (AVNRT)➡reentry mechanism▶slow and fast pathways form a looped circuit
*Impulses traveling in antegrade direction through the slow pathway and returning through the fast pathway
Most common cause of chronic mitral regurgitation in developed countries
Mitral valve prolapse: myxomatous degeneration of the mitral valve leaflets and chordae
Major driver of AKI in cardiorenal syndrome
Elevated central venous pressure
*Reduced effective arterial blood volume (EABV)➡Heart failure, cirrhosis
Most accurate test for aortic dissection
Angiogram
*Source MTB2
Which is the triad of aortoiliac disease?
Leriche syndrome→hip, thigh, buttock claudication; impotence; symmetric atrophy of bilateral lower extremities
How nitrates relieve ischemic symptoms of angina?
Systemic venodilation→↓cardiac preload→↓LV systolic wall stress→↓myocardial oxygen demand
New onset hypertension in a young patient with epistaxis, tachycardia and tremor. Which test do you run?
Secondary hypertension due cocaine intoxication→urine drug screen
Treatment for Dressler’s syndrome
- NSAIDs first line
- Corticosteroids in refractory cases or NSAIDs contraindication
*Avoid anticoagulation to prevent hemorrhagic pericardial effusion
Most common adverse effect of statins
- Liver inflammation
2. Myopathy
What do you suspect in a patient with acute limb ischemia after a myocardial infarction?
Embolization of a left ventricular thrombus
*Perform transthoracic echocardiography➡screen LV aneurysm and/or residual thrombus
Specific arrhythmia (diagnostic) caused by digoxin toxicity
Atrial tachycardia (⬆automaticity) with atrioventricular (AV) block (⬆vagal tone)
Physical findings of severe aortic stenosis
- Pulsus parvus et tardus
- Late peaking, crescendo-decrescendo systolic murmur
- Soft and single S2 during inspiration➡Soft and delay aortic valve closure (A2) to the point that during inspiration is simultaneous with pulmonic valve closure (P2)▶Narrowed splitting
*Expiration delays A2 closure even further and paradoxical splitting may be appreciated
First-line antihypertensive therapy for a patient with osteoporosis
Thiazide diuretic (eg, Clorthalidone)➡⬆calcium reabsorption in distal tubule▶⬇rate of bone loss
Which clinical clue may aid in the differentiation of organic vs psychogenic erectile dysfunction?
- Nocturnal and early morning nonsexual erections➡suggest psychogenic (intact vascular and nerve function in the penis)
- Sudden onset, situational➡psychogenic
How do you reverse the effect of Rivaroxaban, Apixaban and Edoxaban?
Andexanet➡recombinant modified factor Xa protein▶decoy and sequesters anticoagulants, inhibiting them from binding to natural factor Xa
How do you reverse the effect of dabigatran?
Idarucizumab➡antibody fragment (Fab)▶binds to and inactivates dabigatran
Physical examination with prominent, high amplitude jugular venous pulsations, intermittently and irregular; with ECG: regular, wide-complex tachycardia. Explanation of these findings.
Ventricular tachycardia➡Atrioventricular dissociation▶Right atrial contraction against a closed tricuspid valve
*Also seen in complete AV block, frequent premature ventricular contractions
Most common source of pulmonary embolism
Proximal/thigh deep (iliac, femoral, popliteal) leg veins➡>90% of acute PE
*Distal/calf most DVT but less likely to embolize. More likely to spontaneously resolve.
Most common cause of secondary hypertension. Typical findings.
- Primary hyperaldosteronism (Conn syndrome)➡Adrenal adenoma or bilateral adrenal hyperplasia
- Hypokalemia, metabolic alkalosis, ⬇renin activity
Cardiovascular physical examination findings in pulmonary artery hypertension
- Right ventricular heave➡impulse palpated immediately to the left of the sternum suggesting RV enlargement
- Loud pulmonary component of S2 + right heart failure (peripheral edema, hepatomegaly)
Most likely etiology of secondary hypertension when associated with hypercalcemia, muscle weakness, kidney stones and neuropsychiatric symptoms
Primary hyperparathyroidism➡[proposed mechanisms] ⬆renin secretion, sympathetic hyperresponsiveness, peripheral arterial vasoconstriction
*Other CV manifestations: LVH, arrhythmias, vascular and valvular calcification
Most characteristic EKG findings of hypokalemia
- U waves
2. Ventricular ectopy, Flattened T waves, ST depression
What is the most common cause of aortic stenosis and aortic regurgitation in developed countries and young adults?
Bicuspid aortic valve
Best management in an adult patient with 3 weeks of DVT treated with warfarin that presents to the ER with life-threatening bleeding
- Retrievable inferior vena cava filter
- Therapeutic anticoagulation is contraindicated (warfarin, heparins, rivaroxaban)
Indication to place Inferior vena cava filter
- Complication from anticoagulation: significant active bleeding, recent surgery, acute hemorrhagic stroke
- Anticoagulation fails: new or recurrent thrombosis while on anticoagulation
Which lesions or structures may you listen to during auscultation at the left upper sternal border?
Pulmonic area
- Pulmonary stenosis
- Atrial septal defect
A young patient with hypertension, several hemangiomas (retinal and cerebellar, and presented with painless vision loss), and family history of father HTN, significant hearing impairment, and death of an intracranial hemorrhage at his 40s
Von Hippel-Lindau syndrome (VHL tumor supressor gene, chromosome 3, autosomal dominant)
- Cerebellar and retinal hemangioblastomas
- Pheochromocytoma
- Renal cell carcinoma (clear cell subtype)
*Hearing loss in father - endolymphatic sac tumors of the middle ear
The quickest way to reduce pain by myocardial infarction
Venodilation with nitrates➡⬇preload▶⬇ventricular wall stress and ventricular volume
