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USMLE Step 2 CK Flash Cards > Cardiovascular > Flashcards

Cardiovascular Flashcards

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USMLE® Step 1 flashcards
1
Q

Acute treatment of Atrial Fibrillation in Wolff-Parkinson-White syndrome. What do you have to avoid?

A

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)

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2
Q

What is “pulsus parvus and tardus” and when do you expect to find it?

A
  • Delayed (slow-rising) and diminished (weak) carotid pulse
  • Severe aortic stenosis

*Outflow tract obstruction syncope

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3
Q

Which are the two aberrant electrical pathways of the Wolff-Parkinson-White (WPW) syndrome?

A
  • 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
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4
Q

Gold standard treatment for chronic WPW syndrome

A

Radiofrequency ablation

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5
Q

How do you differentiate cardiac tamponade vs right ventricle failure?

A
  • Pulsus paradoxus►Cardiac tamponade, NO in right ventricle failure
  • Both have Beck’s triad►muffled cardiac sounds, hypotension, jugular venous distention
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6
Q

Most likely ECG pattern expected in a pulmonary embolism

A

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)

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7
Q

Most useful test for diagnosing pericarditis, which finding is more specific?

A

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

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8
Q

When beta-blocker and ACEIs are more efficient between them to reduce mortality in post-myocardial infarction patients?

A
  • Beta-blockers→post-MI patients with normal ejection fraction (↓O2 demand and ventricular arrhythmias)
  • ACEI→post-MI in patients with reduced ejection fraction
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9
Q

Which Beta-blockers you should avoid when treating Heart Failure and why?

A

Pindolol and Acebutolol→have sympathomimetic activity

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10
Q

How do you identify a pericardial effusion at chest x-ray?

A

Enlarged and globular cardiac silhouette (“water bottle” heart shape)

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11
Q

Important physical examination finding to suspect pericardial effusion

A
  • 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)
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12
Q

Physical examination findings on coarctation of the aorta

A
  1. Simultaneous palpation of the brachial and femoral pulses→assess for brachial-femoral delay
  2. Bilateral upper extremities (supine position) and lower extremities (prone position) blood pressure measurement→evaluate blood pressure differential
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13
Q

Confirmatory diagnostic test for coarctation of the aorta

A

Echocardiogram

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14
Q

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

A

Cholesterol crystal embolism→disruption of atherosclerotic aortic plaques►systemic atheroembolism

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15
Q

Most common high-dose Niacin side effect. Why does it happen?

A
  • Flushing and pruritus
  • Drug-induced release of Histamine and Prostaglandin (no true hypersensitivity)

*Give low-dose ASA 30 minutes before niacin

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16
Q

What is Inferior Vena Cava plethora and what does it mean?

A
  • 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)
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17
Q

Hemodynamic changes on cardiac tamponade (most asked variables)

A
  • Pulmonary capillary wedge pressure ⬆
  • Cardiac Index ⬇
  • Right atrial pressure ⬆
  • Systemic vascular resistance ⬆
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18
Q

Diagnostic gold standard for viral myocarditis. Most frequently, which study does assist the diagnosis in a regular basis?

A
  • Endomyocardial biopsy (lymphocytic infiltration) aided by viral polymerase (DNA or RNA)
  • Cardiac MRI▶️late enhancement of the epicardium
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19
Q

What is the indication for mineralocorticoid receptor antagonists on heart failure?

A
  • Left ventricular ejection fraction <40% with recent ST-elevation myocardial infarction
  • Symptomatic heart failure
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20
Q

Differences between ascending and descending aortic aneurysms in location and etiology

A
  • 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
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21
Q

Chest X-ray findings suggesting thoracic aortic aneurysm

A
  • Widened mediastinal silhouette
  • Increase aortic knob
  • Tracheal deviation
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22
Q

ECG finding on acute pericarditis due to renal failure

A

Nonspecific T wave abnormalities

*Classic diffuse ST elevations are typically absent due to lack of myocardial inflammation

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23
Q

What does hyponatremia suggest in a patient with acute heart failure?

A

Severe congestive heart failure➡independent predictor of adverse clinical outcomes

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24
Q

Which electrolyte disturbance is associated with increase susceptibility of digoxin toxicity? Why?

A

Hypokalemia (may be associated with excessive diuretic use)→permissive for digoxin binding at K+ binding site on Na+/K+ ATPase

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25
Q

Best initial tests to diagnose pulmonary embolism. Which is most often the best next step or test to do after them?

A
  • 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)

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26
Q

If you suspect a pulmonary embolism and the V/Q and spiral CT don’t give a clear diagnosis, what do you do next?

A

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
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27
Q

First choice test to confirm pulmonary embolism in pregnancy

A

V/Q scan

*Completely normal scan excludes a clot

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28
Q

When do you use thrombolytics in a pulmonary embolism?

A
  • Hemodynamically unstable→hypotension (systolic BP<90, tachycardia, etc)
  • Acute right ventricular dysfunction

*There is no specific time limit as in stroke or MI

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29
Q

What is the first step to confirm the diagnosis of peripheral artery disease?

A

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

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30
Q

Most common indications for surgery in infectious endocarditis

A
  • 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
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31
Q

Neurologic complications of infective endocarditis

A
  • Embolic stroke
  • Cerebral hemorrhage
  • Brain Abscess
  • Acute encephalopathy or meningoencephalitis
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32
Q

Ventricular apical ballooning, history of myocardial infarction after a stressful situation and normal coronary angiography. Disease and its mechanism?

A
  • Tako-Tsubo cardiomyopathy

- Massive catecholamine discharge

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33
Q

When do you use Exercise Tolerance Testing to evaluate chest pain?

A

Etiology is not clear and EKG is not diagnostic

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34
Q

Why the EKG in an Exercise Tolerance Testing may not be suitable to read and interpret?

A

Baseline EKG abnormality→Left bundle branch block, left ventricular hypertrophy, pacemaker use, effect of digoxin

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35
Q

Which antiplatelet drugs are preferred in addition to aspirin in a patient undergoing angioplasty and stenting? and why?

A
  • Prasugrel or Ticagrelor

- Restenosis of stenting is best prevented

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36
Q

Medication that offers the best mortality benefit in chronic angina

A

Aspirin and Beta blockers

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37
Q

Which other medications can be used instead of ACEI/ARB in systolic dysfunction to decrease mortality? in what situation could you switch them?

A
  • Hydralazine (arterial vasodilator→↓ afterload) and Nitrates (dilate coronary arteries) - Reduce mortality in african-american
  • Hyperkalemia by ACEI or ARB
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38
Q

Which EKG finding in the context of acute coronary syndrome has the worst prognosis?

A

ST elevation in V2-V4 leads or Anterior Wall Miocardial Infarction

*If untreated - 30 to 40% mortality in 1 year

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39
Q

Most important measure in decreasing the risk of restenosis of the coronary artery after PCI

A

Placement of drug-eluting stent (paclitaxel, sirolimus)

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40
Q

When do you suspect a perivalvular abscess?

A

Symptoms of infective endocarditis + New conduction abnormalities (ex, 2:1 second-degree atrioventricular block with syncope)

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41
Q

Which symptom is more specific when suspecting beta-blocker intoxication?

A
  • Beta-blocker intoxication→bradycardia, atrioventricular block, hypotension (ex, present also in CCB, digoxin, cholinergic intoxication)
    (+) Wheezing more specific
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42
Q

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?

A
  • Heparin

- Low molecular weight heparin superior to unfractionated heparin

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43
Q

Most accurate test in diagnosing congestive heart failure. In which case do you use it?

A
  • Multiple-gated acquisition scan (MUGA) or nuclear ventriculography
  • Ex: Patient receiving chemotherapy with doxorrubucin
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44
Q

Best initial treatment for beta-blocker poisoning. Best next step if there is no improvement after the initial treatment.

A
  • Initial Tx→secure airway, isotonic fluids, atropine

- Next best step→Glucagon (⬆cAMP➡Tx for BB and CCB toxicity) in profound refractory hypotension

45
Q

Presumed etiology of idiopathic pericarditis

A

Coxsackie B virus

46
Q

What is “Lone Atrial Fibrilation”? Treatment.

A
  • Paroxysmal, persistent or permanent AF + No evidence of cardiopulmonary or structural heart disease
  • Usually <60 years, CHA2DS2VASc=0→No treatment needed
47
Q

Therapy for hemodynamically stable atrial fibrillation with rapid ventricular response

A

Beta blockers, Calcium channel blockers (Diltiazem), Digoxin

48
Q

How do you identify by auscultation the tricuspid valve compromised by infective endocarditis? Why?

A
  • 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
49
Q

Measure of aortic valve area on echocardiogram to cause left ventricular hypertrophy and symptoms of angina

A

Aortic valve area <1 cm2→severe stenosis

50
Q

Measure of aortic valve area to diagnose aortic stenosis

A

Valve area <3cm2

51
Q

When do you suspect Renovascular Hypertension?

A

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)
52
Q

Auscultations findings of severe mitral regurgitation

A
  • 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

53
Q

Most common cause of mitral and aortic stenosis

A
  • Mitral stenosis→rheumatic fever (most common immigrants in USA)
  • Aortic stenosis→congenital bicuspid valve or calcification by aging
54
Q

Treatment of mitral and aortic stenosis

A
  • Mitral stenosis→dilation through balloon valvuloplasty with catheter
  • Valve replacement when ballon cannot be done or fails
  • Aortic stenosis→surgical replacement
55
Q

Unique features of mitral stenosis clinical presentation

A

Dysphagia, Hoarseness, Atrial fibrilation (stroke) [Big LA], Hemoptisis

56
Q

Etiology of Mitral Regurgitation

A
  • Any reason that dilated the heart
  • Hypertension
  • Endocarditis
  • MI with papillary muscle rupture
57
Q

First line of treatment of regurgitant lesions (mitral and aortic regurgitation)

A

Vasodilators: ACEIs or ARBs or nifedipine→delay the progression

58
Q

Valve replacement indication for mitral regurgitation

A

When heart starts to dilate→LVESD>40mm or EF<60% *Operatively or with catheter placing a clip or sutures

59
Q

Most common presentation of mitral valve prolapse

A

Atypical chest pain, palpitations and panic attack

60
Q

Heart compensatory mechanisms of the asymptomatic phase of chronic volume overload (AR, MR, Ischemic disease, dilated cardiomyopathy)

A

Eccentric hypertrophy→↑Left ventricle compliance (have additional LV volume) and ↑Left ventricle contractility (sustain stroke volume)

61
Q

Most common cause of sick sinus syndrome

A

Age-related degeneration of the cardiac conduction system→fibrosis of the sinus node

62
Q

ECG findings of sick sinus syndrome

A
  • Sinus bradycardia
  • Sinus pauses (delayed P waves)
  • Sinoatrial nodal exit block (dropped P waves)
63
Q

Clinical presentation of sick sinus syndrome

A
  • Bradycardia→fatigue, dyspnea, dizziness, syncope
  • Palpitations:
    +Bradycardia-tachycardia syndrome→bradycardia alternating with supraventricular tachycardia
    +Atrial arrhythmias (ex, atrial fibrillation)
64
Q

Most common arrhythmia on hyperthyroidism and its treatment

A
  • Thyroid hormone ↑beta-adrenergic receptor expression ↑sympathetic activity→Atrial fibrillation (5-15%)
  • Beta-blockers (propranolol, atenolol)→continue until hyperthyroidism is well treated
65
Q

Pathologic causes of sinus bradycardia

A

Sick sinus syndrome, myocardial ischemia, obstructive sleep apnea, hypothyroidism, ↑intracranial pressure, medications (b-blockers, CCB excess)

66
Q

Best initial therapy for hypertrophic obstructive cardiomyopathy and ordinary hypertrophic cardiomyopathy

A

Beta-blockers

*Strong negative inotropic drugs are useful - Verapamil, Disopyramide

67
Q

Contraindicated medications in HOCM

A

Diuretics, ACEIs do not help (may worsen symptoms), digoxin, hydralazine

*Diuretics may help in ordinary hypertrophic cardiomyopathy symptoms

68
Q

Distinctive feature of chronic constrictive pericarditis

A

Chronic pericarditis→fibrosis and calcification of pericardium►Calcification on x-ray (Best initial test)

69
Q

Treatment of idiopathic pericarditis

A

NSAID and colchicine

70
Q

What is the Kussmaul sign and when it is most likely associated?

A
  • ↑JVD on inhalation (normally neck veins go down on inspiration)
  • Constrictive pericarditis
71
Q

Most appropriate study for pericardial tamponade

A

Echocardiogram→right atrial and ventricular diastolic collapse

72
Q

EKG findings on pericadial tamponade

A

Electrical alternans→different heights of QRS complexes between beats

73
Q

Best initial test for aortic dissection

A

Chest x-ray→widening of the mediastinum

*Source MTB2

74
Q

What is peripartum cardiomyopathy? In which stage during pregnancy is most commonly developed?

A
  • LV dysfunction secondary to antibodies against the myocardium in a pregnant woman
  • After delivery in most cases
75
Q

Best initial test for hemodynamically stable and unstable patients in those who suspect aortic dissection

A
  • Stable→CT angiography, MRA if contrast is contraindicated
  • Unstable→Transesophageal echocardiogram (also for renal insufficiency)

*Source First aid 2CK

76
Q

Differences between the treatment of the type A and B aortic dissection

A
  • 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
77
Q

Emergency and optimal treatment for decompression sickness

A
  • IV hydration
  • Trendelenburg position
  • 100% Oxygen➡facilitates absorption of nitrogen gas from the bloodstream
  • Optimal management: Hyperbaric oxygen
78
Q

Screening for abdominal aortic aneurysm

A

Abdominal ultrasound for men age 65-75 who have ever smoked (lifetime tobacco use>100 cigarettes)

79
Q

Definition of severe aortic stenosis

A
  • Aortic jet velocity ≥4 m/sec
  • Mean transvalvular pressure gradient ≥40 mmHg
  • Valve area usually ≤1 cm2, but NO required
80
Q

Indications of aortic valve replacement

A

Severe AS and ≥1 of the following:

  • Onset of symptoms (angina, syncope)
  • Left ventricular ejection fraction <50%
  • Undergoing other cardiac surgery (CABG)
81
Q

Most common form of paroxysmal supraventricular tachycardia (PSVT)

A

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

82
Q

Most common cause of chronic mitral regurgitation in developed countries

A

Mitral valve prolapse: myxomatous degeneration of the mitral valve leaflets and chordae

83
Q

Major driver of AKI in cardiorenal syndrome

A

Elevated central venous pressure

*Reduced effective arterial blood volume (EABV)➡Heart failure, cirrhosis

84
Q

Most accurate test for aortic dissection

A

Angiogram

*Source MTB2

85
Q

Which is the triad of aortoiliac disease?

A

Leriche syndrome→hip, thigh, buttock claudication; impotence; symmetric atrophy of bilateral lower extremities

86
Q

How nitrates relieve ischemic symptoms of angina?

A

Systemic venodilation→↓cardiac preload→↓LV systolic wall stress→↓myocardial oxygen demand

87
Q

New onset hypertension in a young patient with epistaxis, tachycardia and tremor. Which test do you run?

A

Secondary hypertension due cocaine intoxication→urine drug screen

88
Q

Treatment for Dressler’s syndrome

A
  • NSAIDs first line
  • Corticosteroids in refractory cases or NSAIDs contraindication

*Avoid anticoagulation to prevent hemorrhagic pericardial effusion

89
Q

Most common adverse effect of statins

A
  1. Liver inflammation

2. Myopathy

90
Q

What do you suspect in a patient with acute limb ischemia after a myocardial infarction?

A

Embolization of a left ventricular thrombus

*Perform transthoracic echocardiography➡screen LV aneurysm and/or residual thrombus

91
Q

Specific arrhythmia (diagnostic) caused by digoxin toxicity

A

Atrial tachycardia (⬆automaticity) with atrioventricular (AV) block (⬆vagal tone)

92
Q

Physical findings of severe aortic stenosis

A
  • 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

93
Q

First-line antihypertensive therapy for a patient with osteoporosis

A

Thiazide diuretic (eg, Clorthalidone)➡⬆calcium reabsorption in distal tubule▶⬇rate of bone loss

94
Q

Which clinical clue may aid in the differentiation of organic vs psychogenic erectile dysfunction?

A
  • Nocturnal and early morning nonsexual erections➡suggest psychogenic (intact vascular and nerve function in the penis)
  • Sudden onset, situational➡psychogenic
95
Q

How do you reverse the effect of Rivaroxaban, Apixaban and Edoxaban?

A

Andexanet➡recombinant modified factor Xa protein▶decoy and sequesters anticoagulants, inhibiting them from binding to natural factor Xa

96
Q

How do you reverse the effect of dabigatran?

A

Idarucizumab➡antibody fragment (Fab)▶binds to and inactivates dabigatran

97
Q

Physical examination with prominent, high amplitude jugular venous pulsations, intermittently and irregular; with ECG: regular, wide-complex tachycardia. Explanation of these findings.

A

Ventricular tachycardia➡Atrioventricular dissociation▶Right atrial contraction against a closed tricuspid valve

*Also seen in complete AV block, frequent premature ventricular contractions

98
Q

Most common source of pulmonary embolism

A

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.

99
Q

Most common cause of secondary hypertension. Typical findings.

A
  • Primary hyperaldosteronism (Conn syndrome)➡Adrenal adenoma or bilateral adrenal hyperplasia
  • Hypokalemia, metabolic alkalosis, ⬇renin activity
100
Q

Cardiovascular physical examination findings in pulmonary artery hypertension

A
  • 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)
101
Q

Most likely etiology of secondary hypertension when associated with hypercalcemia, muscle weakness, kidney stones and neuropsychiatric symptoms

A

Primary hyperparathyroidism➡[proposed mechanisms] ⬆renin secretion, sympathetic hyperresponsiveness, peripheral arterial vasoconstriction

*Other CV manifestations: LVH, arrhythmias, vascular and valvular calcification

102
Q

Most characteristic EKG findings of hypokalemia

A
  1. U waves

2. Ventricular ectopy, Flattened T waves, ST depression

103
Q

What is the most common cause of aortic stenosis and aortic regurgitation in developed countries and young adults?

A

Bicuspid aortic valve

104
Q

Best management in an adult patient with 3 weeks of DVT treated with warfarin that presents to the ER with life-threatening bleeding

A
  • Retrievable inferior vena cava filter

- Therapeutic anticoagulation is contraindicated (warfarin, heparins, rivaroxaban)

105
Q

Indication to place Inferior vena cava filter

A
  • Complication from anticoagulation: significant active bleeding, recent surgery, acute hemorrhagic stroke
  • Anticoagulation fails: new or recurrent thrombosis while on anticoagulation
106
Q

Which lesions or structures may you listen to during auscultation at the left upper sternal border?

A

Pulmonic area

  • Pulmonary stenosis
  • Atrial septal defect
107
Q

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

A

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

108
Q

The quickest way to reduce pain by myocardial infarction

A

Venodilation with nitrates➡⬇preload▶⬇ventricular wall stress and ventricular volume

USMLE Step 2 CK Flash Cards (17 decks)

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