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Uworld + ABIM blueprint > Cardiovascular Disease > Flashcards

Cardiovascular Disease Flashcards

1
Q

what are the pharmacologic stress tests available

A

dobutamine echo, dobutamine nuclear perfusion, vasodilator nuclear perfusion (adenosine, dipyrimadole, regadenoson), PET/CT

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2
Q

first line therapy in patients with stable angina

A

Aspirin (or clopidogrel on ASA intolerante pts), BB, Statin

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3
Q

Indications for thrombolytics (streptokinase, alteplase, reteplase, tenecteplase) in STEMI cases

A

if STEMI symptom onset within 12 hr-24 hr prior to presentation and PCI not available within 120 mins of first medical contact

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4
Q

absolute contraindications to thrombolytic therapy for STEMI

A

any previous intracerebral hemorrhage, known cerebrovascular lesion (AVM), ischemic stroke w/in 3 months, suspected aortic dissection, active bleeding or bleeding diathesis,, significant closed head or facial trauma within 3 months

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5
Q

Contraindications of BB in ACS

A

evidence of cardiogenic shock, heart failure on presentation, bradycardia, PR>240ms or heart block

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6
Q

nitrates during ACS contraindicated in patients who had received ______ within 24-48 hrs

A

PDE5 inhibitors such as sildenafil

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7
Q

TIMI score for Non-STE ACS

A

age >65, >3 traditional CAD risk factors (HTN, Cholesterolemia, DM, current smoker, family hx of CAD), documented CAD >50% stenosis, ST segment deviation, >2 anginal episodes in 24 hrs, ASA use w/in 1 week, elevated cardiac biomarkers

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8
Q

TIMI risk score and corresponding invasive v. ischemia guided treatment

A

TIMI score 0-2 -> ischemia guided tx
TIMI score 3-4 -> delayed invasive tx (24-72 hrs)
TIMI score 5-7 -> early invasive tx (within 24 hrs)

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9
Q

care after ACS

A

low dose ASA indefinitely, Statin indefinitely, DAPT for a year; BB and ACEI indefinitely in those with LV dysfunction
Avoid NSAIDs if possible due to increased CV risk associated with these drugs

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10
Q

Cardiac X syndrome

A

frequent cause of chest pain syndromes in women and present without traditional risk factors for CAD. most common theory: microvascular dysfunction.
Tx with BB, CCB and nitrates
seen in patients with chronic inflammatory dieases or neuromuscular disease with elevated Troponin T (present in skeletal muscles) but cardiac Troponin I is wnl.

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11
Q

Aspirin is recommended as ______prevention in all patients with ______ and CAD

A

secondary; diabetes

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12
Q

True or False: tight glycemic control reduces microvascular complications but does not reduce risk for MI

A

true

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13
Q

treatment for symptomatic bradycardia and hemodynamic distress

A

atropine first; if ineffective, dopamine or epinephrine infusion until transcutaneous pacing or temporary pacing wire placed;

Temporary pacing indicated in those with hemodynamically unstable bradycardia

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14
Q

In hemodynamically stable, permanent pacing indications are?

A
  • symptomatic bradycardia without reversible cause
  • asymptomatic brady with pauses >3 seconds in sinus rhythm or heart rate <40
  • afib with pauses of 5 secs or longer
  • alternating Bundle branch block
  • asymptomatic complete heart block or Mobitz Type 2 second degree heart block
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15
Q

wide complex tachycardia

A

qrs>120ms; QRS either all pos or neg in precordial leads

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16
Q

multifocal atrial tachycardia

A

irregular rhythm, p wave shape varies, atrial rate >100; seen with Chronic COPD and can be seen with digitalis toxicity in patients with heart disease

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17
Q

wandering pacemaker

A

p wave shape varies as pacameker center moves within atria, irregular rhythm, atrial rate <100

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18
Q

afib

A

continuous rapid firing of multiple atrial automaticity foci; no single impulse depolarizes both of the atria completely, so no P waves; occasional random atrial depolarization reaches the AV node -> irregular ventricular rhythm

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19
Q

escape beat/rhythm…atrial, junctional and ventricular

A

SA node misses one cycle (sufficient pause for an atrial/junctional/ ventricular automaticity focus to escape overdrive suppression –> escape beat).
atrial escape beat: pause, then different p wave with associated QRS, rate 60-80

junctional escape beat: pause, QRS complex with no p waves, rate 40-60 or if retrograde atrial depolarization, then inverted p wave after the QRS

ventricular escape beat: pause, enormous QRS complex; rate 20-40

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20
Q

PVC

A

PVC depolarize only the ventricles, not the SA node; originate suddenly in an irritable ventricular automaticity focus and produces giant ventricular complex ; irritable usually because of hypoxia;

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21
Q

how many runs of PVCs equals a run of VT

A

3 or more

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22
Q

definition of sustained VT

A

VT lasting >30 secs

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23
Q

inherited arrhythmia syndrome

A

long QT syndrome, short QT syndrome, Brugada syndrome, early repolarization syndrome, catecholaminergic polymorphic VT, HCM

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24
Q

Long QT syndrome

A

men QTc>440, women QTc>460; can progress to torsades-> Vfib;
tx: BB as first line therapy
but if recurrent events (syncope or VT) or refractory to BB tx, then ICD placement

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25
Q

Short QT syndrome

A

QTC<340ms; inherited, ADominant;
can present with atrial or ventricular arrhythmias (afib or VT)
at VERY high risk of SCD
Tx: ICD in ALL patients

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26
Q

Brugada syndrome

A

R precordial ECG changes (V1 - V3, concave or linear downsloping ST segment +/- RBBB)
M>W; Asians
arrhythmias more common at night during sleep
Tx: ICD

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27
Q

early repolarization syndrome

A

should strongly suspect in patients with unexplained VF arrest, particularly when provoked during exercise.
J point elevation >1mm in lateral and inferior leads in a patient with VF/cardiac arrest
Tx: ICD

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28
Q

class I recommendation for ICD placement as secondary prevention

A

sustained VT (>30secs) or cardiac arrest without reversible cause

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29
Q

what are the indications for ICD placement as primary prevention

A

HF with EF

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30
Q

Cardiac resynchronization therapy (biventricular pacing) indicated in which patients

A

HF with EF < or = 35%, NYHA class II to IV symptoms despite guideline directed medical therapy, sinus rhythm, LBBB with QRS >150ms or greater

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31
Q

most common cause of severe aortic stenosis

A

degeneration of aortic valve

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32
Q

definition of severe aortic stenosis

A

small valve area <1.0 cm2 and either high peaking velocity (>4m/s) or high mean gradient (>40mm Hg).

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33
Q

Indications for Aortic valve replacement

A

1) symptomatic patients (dyspnea, angina, presyncope/syncope)
2) LV dysfunction (Ef<50%) in asymptomatic patient
3) concomitant cardiac surgical procedure (such as simultaneous CABG or ascending aorta surgery)

considered in asymptomatic patients with abnormal results on supervised exercise testing: poor exercise tolerance, abnormal EG changes or hypotension during testing

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34
Q

TAVR indications

A

Trileaflet aortic stenosis who are at intermediate to high surgical risk and those who dont have severe concomitant aortic regurgitation

35
Q

characteristic physical finding of severe aortic stenosis

A

late peaking systolic murmur, diminished/absent S2, weak/delayed carotid upstroke

36
Q

characteristic aortic stenosis murmur

A

mid-systolic, crescendo-descrescendo; at RUSB; radiates to neck (carotids) or apex

37
Q

characteristic aortic regurgitation murmur

A

diastolic; decrescendo; at LLSB (3rd intercostal space?)

38
Q

parvus et tardus

A

pulses weaker than compared to heart sounds; a/w aortic stenosis

39
Q

characteristic mitral stenosis murmur

A

diastolic, decrescendo; at apex no radiation

loud opening snap;late rumble

40
Q

characteristic mitral regurgitation murmur

A

systolic murumr/holosystolic murmur at apex with radiation to axilla or back

41
Q

characteristic tricuspid stenosis murmur

A

diastolic, at LLSB with no radiation

42
Q

characteristic tricuspid regurgitation murmur

A

holosystolic at LLSB

43
Q

characteristic pulmonic stenosis murmur

A

systolic, crescendo - decrecendo; LUSB

44
Q

characteristic pulmomic regurgitation murmur

A

diastolic at LLSB

45
Q

most common cause of aortic stenosis

A

valve degeneration; other causes: rheumatic disease and chest radiation (mantle therapy for non Hodgkin lymphoma)

46
Q

rheumatic disease involves which valves

A

mitral valve in isolation

rheumatic aortic valve disease never occurs without mitral valve involvement.

47
Q

how does aortic stenosis lead to heart failure

A

it results in chronic pressure overload of LV -> concentric LV hypertophy and myocardial interstitial fibrosis. Diastolic dysfunction follows with eventual systolic heart failure and pulmonary congestion

48
Q

severe aortic stenosis definition and murmur

A

late peaking systolic murmur, diminished or absent aortic component of S2 and delay in carotid upstroke (pulsus tardus) with pulsus parvus (due to low cardiac output)

mean gradient>40mm Hg, AVA <1.0 cm2, Vmax>4m/s

49
Q

dobutamine echo or invasive hemodynamic study to distinguish between true aortic stenosis and pseudostenosis indicated when?

A

2 subsets of patients with severe aortic stenosis might have small valve are and low velocity/gradient:

1) patients with severe LV dysfunction and low CO
2) patients preserved LV dysfunction and paradoxical low-flow, low gradient aortic stenosis

50
Q

causes of chronic aortic regurgitation

A

ascending aortic dilation, valve abnormalities due to bicuspid disease, calcific degeneration, rheumatic involvement or chest radiation

51
Q

causes of acute aortic regurgitation

A

endocarditis, blunt chest trauma, iatrogenic (balloon aortic valvuloplasty) and aortic dissection

52
Q

physical findings of chronic aortic regurgitation

A

dyspnea, bounding peripheral pulses due to large stroke volume and LV dilatation; displacement of LV apex, diastolic decrescendo murmur along RUSB (if root pathology), LUSB (if valvular path)

53
Q

physical findings of acute aortic regurgitation

A

abrupt onset of volume overload is not tolerated well and can present with acute heart failure or cardiogenic shock, +/- bounding pulse

54
Q

management of acute aortic regurgitation

A

if due to aortic dissection: surgical emergency

for other acute causes, surgical indication depends on symptoms, hemodynamic stability

55
Q

management of chronic aortic regurgitation

A

indications for surgery with OPEN aortic valve REPLACEMENT:

  • symptomatic patients with LV EF<50%
  • patients undergoing other cardiac surgery
  • significant LV dysfunction
56
Q

medical therapy for chronic aortic regurgitation

A

with dihydropyridine CCB (nifedipine, amlodipine), ACEI or ARBs in those with AR with HTN

if no HTN, then medical tx for symptomatic patients who are not surgical candidates

57
Q

what type of lesion does bicuspid aortic valve lead to and during what decade of life?

A

predisposes to early degeneration –> aortic stenosis mostly

progresses to severe disease during 5th or 6th decade of life

58
Q

management of bicuspid aortic valve disease

A

follows recommendation for predominant valve lesion (aortic stenosis or regurgitation) and severity of valvular disease

59
Q

leading cause of mitral stenosis

A

rheumatic heart disease, W>M

60
Q

symptoms of mitral stenosis

A

arise from low cardiac output (fatigue), pulmonary congestion (dyspnea) and pulmonary hypertension with R sided HF (lower extremity edema).

61
Q

severe mitral stenosis definition

A

mitral valve area 15cm2 or less, MV gradient 5-10 mmHg at normal heart rate.

62
Q

management of significant rheumatic mitral stenosis

A

percutaneous balloon mitral commissurotomy (PBMC)

63
Q

indications for Percutaneous balloon mitral commissurotomy

A

symptomatic patients with severe mitral stenosis

asymptomatic patients with critical mitral stenosis when valve area <1.0 cm2

64
Q

patients with mitral stenosis are at incerased risk for what? and whats the tx for it?

A

Afib

Anticoagulation with warfarin with goal INR of 2.0-3.0

65
Q

warfarin tx is indicated in patients with mitral stenosis with hx of what?

A

afib, LA thrombus or systemic embolization

66
Q

most common cause of CHRONIC primary mitral valve regurgitation

A

mitral valve prolapse

67
Q

indications for surgery for chronic severe primary mitral valve regurgitation

A

symptomatic pts with EF>30%

  • asymptomatic patients with VEF 30-60% or LV end diastolic diameter>40mm
  • patients undergoing concomitant cardiac surgery
  • asymptomatic patients with new onset Afib or pulmonary HTN (PASP>50mmHg)
68
Q

surgical replacement or repair is preferred in patients with mitral valve regurgitation

A

surgical repair in all patients and paatients should be referred to surgical center with expertise with valve repair

69
Q

management of chronic secondary mitral regurgitation

A

guideline directed medical therapy for ventricular dysfuncton; surgical repair or replacement benefits in chronic secondary mitral regurgitation are less certain;
but surgery beneficial if undergoing concomitant cardiac surgery

70
Q

physical exam for chronic mitral regurgitation

A

blowing holosystolic murmur at apex

71
Q

what is the medical therapy in acute severe mitral regurgitation (surgery is indicated promptly)

A

vasodilator therapy with titratable drug such as nitroprusside (decreases aortic impedance and mitral regurgitation, thereby improving cardiac output)

intra-aortic balloon pump can be used to decrease afterload and augment systemic and coronary perfusion pressures

72
Q

management of patients who meet criteria for mitral valve repair but are not surgical candidates?

A

catheter based clip device

73
Q

management of patients with significant tricuspid regurgitation

A

loop diuretics and aldosterone antagonists to improve symptoms

Tricuspid valve surgery for those with severe TR undergoing left sided valve surgery

74
Q

goal INR for warfarin anticoagulation in mechanical aortic valve prosthesis

A

2.5 for those with no additional risk factors for thromboembolism (LV dysfunction, afib, hx of embolization, hypercoaguable disorder)

in those with risk factors for thromboembolism, target INR 3.0

75
Q

whats the duration of oral AC with warfarin after mitral or aortic bioprosthesis

A

at least 3 months and as long as 6 months

76
Q

mechanical valve prosthesis requires what type of AC and for how long

A

lifelong warfarin AC

77
Q

are antiplatelets recommended with mechanical or bioprosthesis?

A

antiplatelets with aspirin is strongly recommended with mechanical prosthesis along with warfarin

78
Q

when is yearly TTE recommended in patients with bioprosthetic valves?

A

starting at 10 years after surgery;

immediately after implantation, alll patients should have tte to document baseline hemodynamics and repeat evaluations based on signs/symptoms of prosthetic dysfunction

79
Q

Infective Endocarditis prophylaxis, patients who are at risk

A
  • hx of endocarditis
  • prosthetic valves
  • unrepaired cyanotic CHD
  • repaired CHD using prosthetics in the first 6 months after procedure
  • repaired CHD with residual defects
  • heart transplant with valvular disease
80
Q

IE high risk procedures requiring ppx

A

dental manipulation of gingival tissue or perforation of oral mucosa, resp procedure with biopsy or incision, GI/GU procedures with GI/GU ongoing infection, cardiac surgery

81
Q

low risk procedures that do NOT require ppx

A

ERCP, GI procedres, GU procedres (prostatectomy catheter insertions), vaginal or C-section

82
Q

IE ppx

A

denta/respiratory procedures:
oral: amoxicillin, cephalexin, clinda or azithromycin
IV: ampicillin, ceftriaxone, clinda

Gi/GU prodecures (enterococcus): amoxicillin, ampicillin, or vancomycin

Skin/musculoskeletal tissue ppx: (staph or strep): vancomycin or clindamycin for suspected MRSA

83
Q

IE dx with Modified Duke criteria

A
  • 2 major
  • 1 major + 3 minor
  • 5 minor

Major:
-2 +blood cultures, 12 hrs apart with typical organisms: viridans strep, strep bovis/gallolyticus, HACEK, staph aureus, CA enterococcus
Single positive culture for coxiella burnetti or IgG ab titer

  • Evidence of endocardial involvement with +TTE showing intracardial mass/abscess or new partial dehiscence of prosthetic valve
  • new valvular regurgitation

Minor:

  • predisposing heart condition or IVDU
  • fever
  • vascular phenomenon (major arterial embolis, septic pulmonary infarcts, mycotic aneurysm, ICH, conjunctival hemorrages, janeway lesions)
  • immunologic phenomenon: glomerulonephritis, osler nodes, roth spots, rheumatoid factor
  • microbiologic evidence: +blood culture that does not meet major criteria

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