Cardiovascular II Flashcards
The CHA2DS2-VASc score is useful for assessing thromboembolic risk in patients with […]:
C: Congestive heart failure
H: Hypertension
A2: Age > 75* (2 points)
D: Diabetes mellitus
S2: Stroke/TIA/thromboembolism* (2 points)
V: Vascular disease (prior MI, PAD, or aortic plaque)
A: Age 65-74
Sc: Sex category (female)
The CHA2DS2-VASc score is useful for assessing thromboembolic risk in patients with non-valvular atrial fibrillation:
C: Congestive heart failure
H: Hypertension
A2: Age > 75* (2 points)
D: Diabetes mellitus
S2: Stroke/TIA/thromboembolism* (2 points)
V: Vascular disease (prior MI, PAD, or aortic plaque)
A: Age 65-74
Sc: Sex category (female)
The combination of atrial tachycardia with AV block is fairly specific for […] toxicity.
The combination of atrial tachycardia with AV block is fairly specific for digitalis toxicity.
digitalis causes both an increased ectopy in the atria or ventricles (atrial tachycardia) and an increased vagal tone (AV block)
The current indications for operative/endovascular repair of an AAA include rapid rate of expansion, presence of symptoms, and aneurysm size > […] cm.
The current indications for operative/endovascular repair of an AAA include rapid rate of expansion, presence of symptoms, and aneurysm size > 5.5 cm.
rapid rate of expansion is considered > 0.5 cm in 6 months or > 1 cm per year
The murmur of pulmonic stenosis is characterized by an ejection click followed by a crescendo-decrescendo systolic murmur over the […] space.
The murmur of pulmonic stenosis is characterized by an ejection click followed by a crescendo-decrescendo systolic murmur over the left second intercostal space.
versus aortic stenosis, which is typically heard over the right second intercostal space
The presence of a continuous abdominal bruit has a high specificity for the presence of […] hypertension.
The presence of a continuous abdominal bruit has a high specificity for the presence of renovascular hypertension.
The strongest predictors of abdominal aortic aneurysm rupture are large aneurysm diameter, rapid rate of expansion, and […].
The strongest predictors of abdominal aortic aneurysm rupture are large aneurysm diameter, rapid rate of expansion, and current cigarette smoking.
True ventricular aneurysm is a complication that may occur months after an MI and increases risk for mural […].
True ventricular aneurysm is a complication that may occur months after an MI and increases risk for mural thrombus.
echocardiogram typically reveals a thinned and dyskinetic myocardial wall
What abnormal heart sound is associated with a stiff left ventricle (e.g. LV hypertrophy due to prolonged hypertension)?
S4
often referred to as “ten-nes-see” a sound, which corresponds to S4-S1-S2
What abnormal heart sound is associated with volume overload (e.g. CHF with LV dysfunction)?
S3
often referred to as “ken-tuc-ky” a sound, which corresponds to S1-S2-S3
What abnormal heart sound is often heard during the acute phase of myocardial infarction?
S4 (atrial gallop)
due to left ventricular stiffening and dysfunction
What abnormal RBC may be seen in patients with scleroderma renal crisis?
Schistocytes
due to microangiopathic hemolytic anemia
What adrenergic receptor is the primary target of dobutamine?
Beta-1 receptors (agonist)
also has a weak affinity for beta-2 and alpha-1 receptors
What age range of diabetic patients should be started on statin therapy?
40 - 75 years old
high-intensity if 10-year ASCVD risk > 7.5%; moderate intensity if < 7.5%
What analgesics are associated with decreased metabolism of warfarin (i.e. increased bleeding risk)?
acetaminophen and NSAIDs
other notable CYP450 inhibitors include amiodarone and some antibiotics/antifungals (e.g. metronidazole)
What anti-hypertensive medication is commonly associated with peripheral edema as an adverse effect?
Dihydropyridine Ca2+-channel blockers
due to preferential dilation of precapillary vessels (arteriolar dilation), which increases capillary hydrostatic pressure
What area of the myocardium is likely involved in an MI with ST elevations in leads I and aVL?
Lateral (typically LCX obstruction)
What area of the myocardium is likely involved in an MI with ST elevations in leads II, III, and aVF?
Inferior (typically RCA obstruction, or less commonly LCX)
What area of the myocardium is likely involved in an MI with ST elevations in leads V1 - V4?
Anterior (typically LAD obstruction)
What arrhythmia commonly develops in patients with mitral stenosis?
Atrial fibrillation
due to significant left atrial dilatation
What artery is likely obstructed given the ECG below?
Right coronary artery
What class of drugs should be administered within 24 hours of an MI to limit ventricular remodeling?
ACE inhibitors
except in patients with a contraindication; ventricular remodeling often results in dilatation of the ventricle
What classes of medications (3) should be held for 48 hours prior to cardiac stress testing?
beta blockers, calcium channel blockers, and nitrates
exception: continue these medications in patients with known CAD undergoing stress testing to assess the efficacy of anti-anginal medication
What CXR finding is often found in patients with coarctation of the aorta?
Notching of the ribs
also may have a “3” sign due to indentation of the aorta with pre- and post-stenotic dilation
What drug classes (2) are used as first-line therapy for chronic stable angina?
beta-blockers (preferred) and non-dihydropyridine CCBs
these drugs decrease myocardial O2 demand by reducing myocardial contractility and heart rate
What drug classes are useful for reducing Ca2+ channel blocker-induced peripheral edema?
ACE inhibitors and ARBs
dihydropridine Ca2+ channel blockers cause edema due to pre-capillary vasodilation; ACE inhibitors relieve edema via post-capillary venodilation
What ECG finding is fairly specific for pericardial effusion?
Electrical alterans
diagnosis of pericardial effusion can be more definitely made using echocardiogram
What electrolyte abnormality may potentiate the effects of digoxin?
Hypokalemia
What electrolyte abnormality parallels the severity of heart failure and is an independent predictor of adverse clinical outcomes?
Hyponatremia
caused by increased levels of renin, norepinephrine, and ADH; treatment involves fluid restriction, ACE inhibitors, and loop diuretics
What hypertensive complication is defined as severe hypertension (> 180/120 mmHg) with no symptoms or acute end-organ damage?
Hypertensive urgency
What hypertensive complication presents as severe hypertension (> 180/120 mmHg) with cerebral edema and non-localized neurologic signs/symptoms (e.g. confusion)?
Hypertensive encephalopathy (hypertensive emergency)
What hypertensive complication presents as severe hypertension (> 180/120 mmHg) with retinal hemorrhages, exudates, or papilledema?
Malignant hypertension (hypertensive emergency)
What imaging study is used for the definitive diagnosis of cardiac tamponade?
Echocardiography
management includes immediate percutaneous or surgical drainage of pericardial fluid
What imaging study should be considered in a patient with acute limb ischemia after an MI?
Transthoracic echocardiogram
to screen for LV thrombus and evaluate LV function; patients also require immediate anticoagulation and vascular surgery consult
What intervention is most likely to improve cardiovascular and overall long-term mortality in patients with acute STEMI?
Restoration of coronary blood flow (e.g. PCI, fibrinolysis)
What is preferred treatment to prevent coronary artery disease in a patient with inducible ischemia?
Anti-platelet therapy (e.g. aspirin)
a decreased tracer uptake with stress but normal at rest indicates inducible ischemia
What is the best initial management for a hemodynamically stable patient with palpitations and the ECG findings below?
IV amiodarone
What is the first-line therapy for conscious and stable patients with torsades de pointes?
IV magnesium
if patient is hemodynamically unstable, immediate defibrillation is indicated
What is the imaging modality of choice for diagnosis and follow-up of abdominal aortic aneurysms?
Abdominal ultrasound
cheap and does not require contrast (vs. CT and MRI)
What is the initial management for a patient with pulmonary hypertension that presents with JVD, peripheral edema, bibasilar crackles, and an ejection fraction of 30%?
Loop diuretics and ACE inhibitors (or ARBs)
the pulmonary hypertension is due to LV systolic dysfunction and thus treatment involves addressing the underlying cause; beta-blockers and occasionally aldosterone antagonists may be used for long-term management as well (note: endothelin-1 receptor antagonists and PDE-5 inhibitors are used for idiopathic pulmonary hypertension)
What is the initial management for a patient with suspected acute arterial occlusion leading to an immediately-threatened limb (e.g. sensory loss, weakness)?
Anticoagulation (e.g. IV heparin)
should be done prior to further evaluation with non-invasive or invasive imaging
What is the initial management for a patient with suspected acute limb ischemia?
Anticoagulation (e.g. IV heparin)
should be initiated empirically, prior to further evaluation with other imaging studies
What is the initial management for hypotension in a patient with a right ventricular MI that has low-normal JVP?
IV saline bolus (nitrates should be avoided)
RVMI often creates high sensitivity to intravascular volume depletion; hypotension with low JVP suggests inadequate RV preload
What is the initial management of choice (besides pain control) for patients with type B aortic dissection?
IV beta blockers (e.g. labetalol, esmolol, propanolol)
results in decreased HR, BP, and LV contractility (less aortic wall stress)
What is the initial therapy for patients with atrial fibrillation due to hyperthyroidism?
Beta blockers
helps control heart rate and hyperadrenergic symptoms; should be continued until the patient becomes euthyroid with thionamides, radioiodine, and/or surgery
What is the initial treatment for a hemodynamically stable patient with atrial fibrillation with rapid ventricular response?
Rate control (e.g. beta blockers or CCBs)
rhythm control should be considered in patients unable to achieve adequate HR control or in those with recurrent symptomatic episodes
What is the initial treatment for chronic venous insufficiency?
Conservation measures (e.g. leg elevation, exercise, compression therapy)
patients who do not respond to conservative measures should have diagnosis of CVI confirmed by identification of venous reflux in the deep venous system on duplex ultrasound
What is the initial treatment for symptomatic sinus bradycardia?
IV atropine
in patients with inadequate response, further treatment options include IV epinephrine or dopamine, or transcutaneous pacing
What is the initial treatment for tachycardia-mediated cardiomyopathy?
Rate or rhythm control
presents with progressive dyspnea, decreased exercise tolerance, and LV systolic dysfunction secondary to chronic tachycardia (e.g. chronic A-fib)
What is the initial treatment of choice for a patient with atrial fibrillation that develops asystole or pulseless electrical activity (no palpable pulse but electrical activity on ECG)?
CPR with vasopressor therapy (e.g. epinephrine)
potentially reversible causes of PEA should also be investigated (see below)
What is the initial treatment of choice for a patient with persistent tachyarrhythmia with associated hemodynamic instability?
Immediate synchronized cardioversion
energy delivered is synchronized to the QRS complex to minimize the likelihood of the shock occuring during repolarization, which can precipitate ventricular fibrillation; hemodynamically stable patients may be managed with rate control (e.g. beta-blockers, non-dihydropyridine CCBs)
