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1
Q

Cardiology Key points

A

Patients with symptomatic atrial flutter despite adequate medical therapy and rate control should undergo catheter ablation.

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2
Q

Cardiology Key points

A

The risk for cardiac transplant rejection is highest within the first 6 months after transplantation and then within the first year; endomyocardial biopsy should be routinely performed within the first year after cardiac transplantation to diagnose rejection.

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3
Q

Cardiology Key points

A

Patients with a non–ST-elevation acute coronary syndrome who have a high or intermediate TIMI risk score should be treated with an early invasive strategy.

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4
Q

Cardiology Key points

A

Mitral valve repair is strongly recommended for chronic severe primary mitral regurgitation in symptomatic patients with left ventricular ejection fraction greater than 30%, asymptomatic patients with left ventricular dysfunction, and patients undergoing another cardiac surgical procedure.

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5
Q

Cardiology Key points

A

The monoclonal antibody bevacizumab is associated with the development of significant but reversible hypertension

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6
Q

Cardiology Key points

A

Aortic coarctation is characterized by clinical features of upper extremity hypertension and a radial artery–to–femoral artery pulse delay as well as radiographic findings of “figure 3 sign” and rib notching

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7
Q

Diagnosis and treatment for a young woman with history of migraines, acute chest pain, and ST-segment elevation

A

Diagnosis: Coronary vasospasm (Prinzmetal angina)

Test:
Echocardiography

Treatment: Long-acting nitrate, calcium channel blocker

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8
Q

Diagnosis and treatment for a young person with chest pain following a party

A

Think Cocaine:

Dx treat:
Echocardiography; calcium channel blocker (avoid B-blockers)

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9
Q

Diagnosis and tx for a tall, thin person with long arms with acute chest and back pain (especially “tearing” sensation), a normal ECG, and an aortic diastolic murmur

A

Think: Marfan syndrome and aortic dissection

Tx: MRA, CTA, or TEE; immediate surgery for type A dissection

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10
Q

What murmur is characteristic of aortic dissection and Marfans?

A

aortic diastolic murmur

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11
Q

Dx and tx for a patient who recently traveled or with immobility, sharp or pleuritic chest pain, and nondiagnostic ECG

A

PE

Dx, Tx, CTA, UFH or LMWH

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12
Q

Dx and tx for atall thin young man who smokes with sudden pleuritic chest pain and dyspnea

A

Dx: Spontaneous pneumothorax

CXR

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13
Q

Dx and tx for a postmenopausal woman with substernal chest pain following severe emotional/ physical stress has ST-segment elevation in the anterior precordial leads, troponin elevation, and unremarkable coronary angiography

A

Dx and Tx

Stress-induced (takotsubo) cardiomyopathy. Look for characteristic apical ballooning on ventriculogram.

Treat with BB or ACE

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14
Q

What Echo feature is typical for Stress-induced (takotsubo) cardiomyopathy?

A

Look for characteristic apical ballooning on ventriculogram.

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15
Q

Dx and Tx for a young man with substernal chest pain, deep t wave inversions in V2 -V4. and a harsh systolic murmur that increases with Valsalva maneuver

A

HCM

Treatment with Echo and BB

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16
Q

Distinguish NSTEMI from unstable angina

A

Both have ST depressions or TWI, NSTEMI has positive biomarkers

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17
Q

Three EKG signs of a STEMI

A
  1. New LBBB
  2. ST elevation >1mm in 2 or more cont leads with Positive biomarkers
  3. Posterior MI (tall R waves in v1-v3)
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18
Q

How is Echo useful in ACS

A

May show regional wall abnormalities

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19
Q

EKG localization of STEMI: Which leads correspond to Inferior

A

2, 3, AVF

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20
Q

EKG localization of STEMI: Which leads correspond to Anteroseptal

A

v1-v3

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21
Q

EKG localization of STEMI: Which leads correspond to Lateral and Apical

A

v4-v6, 1 av1

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22
Q

EKG localization of STEMI: Which leads correspond to posterior wall

A

Tall R waves in v1 to v3

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23
Q

EKG localization of STEMI: Which leads correspond to R ventricle

A

V4R- 4V6, Tall R waves in V1 to V3

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24
Q

What are the 5 signs that a patient with unstable angina/NSTEMI require immediate angiography?

A
  1. hemodynamic instability
  2. HF
  3. Recurrent rest angina despite therapy
  4. new or worsening MR murmur
  5. sustained VT
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25
Q

Do all patients with unstable angina/NSTEMI require angiograph before they leave the hospital?

A

In patents with unstable angina and NSTEMI, risk stratification is used to determine whether angiography within 24 hours or predischarge stress the patient. If the stress test is positive, then and significant ischemia is seen, then angio. Use TIMI to stratify. TIMI 0-2 is low risk and 3 to 7 is high.

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26
Q

Which components makeup the TIMI risk score?

A

Age 65 or older, >3 RF (HTN, HLD, DM), CAD, EKG changes, positive biomarkers, ASA use in the last 7 days.

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27
Q

How do you manage patients with a low TIMI score vs High TIMI?

A

Low TIMI scores can be sent to stress test, high score should go to angiography

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28
Q

In post MI patients, when is cardiac catherization indicated?

A
    • exercise-induced ST-segment depression or elevation
  2. inability to achieve 5 METs during testing
  3. inability to increase SBP by 10 to 30 mm Hg
  4. inability to exercise (arthritis)
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29
Q

STEMI treatment

A

Patients with STEMI should undergo immediate cardiac angiography

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30
Q

What is the preferred strategy for tx for patients with STEMI?

A

Percutaneous coronary intervention (PCI) is the preferred strategy, with first medical contact to PCI time <90 minutes in a PCI-capable hospital

If not then 2 hours, if transferred from a non-PCI-capable hospital to a PCI- capable hospital.

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31
Q

Aside from STEMI, what are other indications for PCI?

A

Other indications for PCI are:
* failure of thrombolytic therapy (continued chest pain, persistent ST elevations on ECG)
* thrombolytic therapy is contraindicated
* new HF or cardiogenic shock

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32
Q

How long should PGY2 inhibitors be continued following MI?

A

Keep it for at least 1 year is for ACS

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33
Q

Which medicines should be started for ACS

A
  1. Aspirin
    (ASAP for all patients with
    ACS, Continue indefinitely as secondary prevention
  2. P2Y 12 inhibitor (clopidogrel, ticagrelor, prasugrel)
  3. B-Blockers (metoprolol, carvedilol)
  4. Anticoagulant (UFH, LMWH, bivalirudin)
  5. ACE/ARB
  6. Nitroglycerin
  7. High-intensity statin
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34
Q

Should you use thrombolytic therapy for patients with NSTEMI or Unstable angina?

A

NOOOOO!

  1. Do not choose thrombolytic therapy for patients with NSTEMI or for asymptomatic patients with onset of pain > 24 hours
  2. Unlike medical therapy for stable CAD, routine use of nitrates, calcium channel blockers, or ranolazine general has no role in the post-STEMI setting.
  3. Do not choose ranolazine for treatment of ACS.
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34
Q

Should you use thrombolytic therapy for patients with NSTEMI or Unstable angina?

A

NOOOOO!

  1. Do not choose thrombolytic therapy for patients with NSTEMI or for asymptomatic patients with onset of pain > 24 hours
  2. Unlike medical therapy for stable CAD, routine use of nitrates, calcium channel blockers, or ranolazine general has no role in the post-STEMI setting.
  3. Do not choose ranolazine for treatment of ACS.
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35
Q

When should thrombolytics be used vs PCI?

A

If PCI is not available and you cant get it within 2 hours.

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36
Q

When is CABG indicated acutely in STEMI patients?

A

When thrombolytics, PCI fail or if you have complications like papillary muscle rupture, VSD, oe free wall rupture

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37
Q

What is the most common presentation for patients with RV infarct?

A

Present with hypotension or may have hypotension after giving nitroglycerine or morphine. Look for JVD with clear lungs and hypotension. Treat with IV fluids

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38
Q

In STEMI patients with cardiogenic shock, acute MR, or VSD, intractable VT or refractory angina, how should we treat them?

A

Intra-aortic balloon pump

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39
Q

In what circumstances should patients with STEMI receive temporary pacing?

A
  1. Asystole
  2. Symptomatic bradycardia
  3. Alternating LBBB and RBBB
  4. New bifascicular block with first AV block
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40
Q

What is the recommended initial study for acute complications of an MI?

A

Emergency Echo

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41
Q

Which complication of acute MI is associated with SUDDEN hypotension or cardiac death with PEA

A

LV free wall rupture

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42
Q

What are the most common signs and murmurs of VSD or papillary muscle rupture?

A

Abrupt pulmonary edema, or hypotension WITH a LOUD HOLOSYSTOLIC murmur and thrill.

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43
Q

What is the recommended treatment for patients with VSD or papillary muscle rupture?

A

They should be stabilized with intra-aortic balloon pump, afterload reduction with sodium nitroprusside, and diuretics, then emergency surgery

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44
Q

What is the recommended treatment for patients with post MI and cardiogenic shock

A

Early revascularization, with support by LVAD or intra aortic balloon pumps

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45
Q

What is the recommended treatment for patients with post infarction agina

A

cardiac catherization

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46
Q

In post MI patients, in what situations are ICDs indicated?

A
  1. More than 40 days since MI
  2. EF <35
  3. > 3 months since PCI or CABG
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47
Q

When is Exercise ECG without images ok to do?

A
  1. Patients who can exercise
  2. Have normal or nonspecific baseline ECG changes (e.g., <0.5 mm ST depression)
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48
Q

When is the Exercise ECG with myocardial perfusion imaging or exercise echocardiography indicated?

A
  1. Patients who can exercise
  2. Pre-excitation (WPW) pattern
  3. > 1 mm ST depression
  4. Previous CABG or PCI
  5. LBBB
  6. L hypertrophy
  7. Digoxin use
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49
Q

When is pharmacologic stress myocardial perfusion imaging or dobutamine echocardiography indicated?

A
  1. Unable to exercise
  2. Electrically paced ventricular rhythm
  3. LBBB
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50
Q

Select coronary angiography for patients with high pretest probability of CAD. What factors make a candidate high pre-test probability for CAD?

A
  • LV dysfunction
  • class III or IV angina despite therapy
  • highly positive stress or imaging test
  • high pretest probability of left main or three-vessel CAD (a Duke treadmill score <-11)
  • uncertain diagnosis after noninvasive testing
  • history of surviving sudden cardiac death
  • suspected coronary spasm
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51
Q

Cardiology tip

A
  • Stress testing is of little value in patients with very low (e.g., <10%) or very high (e.g., >90%) pretest probabilities of CAD.
  • In patients with LBBB, do not perform exercise ECG for evaluation of possible CAD; stress echocardiography or vasodilator stress radionuclide myocardial perfusion imaging should be performed instead.
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52
Q

What are Absolute contraindications to B-blockers ?

A
  • Severe bradycardia
  • Advanced AV block.
  • Decompensated HFr
  • Severe reactive airways disease
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53
Q

Which med should be considered in patients who remain symptomatic despite optimal doses of B-blockers, calcium channel blockers, and nitrates?

A

Ranolazine

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54
Q

Which med should be initiated as first-line therapy for patients with absolute contraindications to B- blockers?

A

In the setting of continued angina despite optimal doses of B-blockers and nitrates, calcium channel blockers can be added.
Avoid short acting calcium channel blockers. Bradycardia and heart block can occur in patients with significant conduction svstem disease.

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55
Q

How can you prevent nitrate tachyphylaxis ?

A

by establishing a nitrate-free perlod of 8 to 12 hours per day during which nitrates are not used.

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56
Q

For patients using nitrates, which meds are contraindicated.

A

sildenafil, vardenafil, and tadalafil

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57
Q

Cardioprotective drugs reduce the progression of atherosclerosis and subsequent cardiovascular events. Name the three Cardioprotective drugs

A

Aspirin, ACE , statin

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58
Q

What options are available for patients with persistent angina despite maximum therapy?

A

revascularization with PCI vs CABG (go with CABG for thse that are high risk or have triple vessel dz or LV dysfunction)

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59
Q

Which two symptoms and signs that increase the likelihood of HF as a diagnosis?

A
  • paroxysmal nocturnal dyspnea
  • an S3
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60
Q

What two signs decrease likelihood of HF as a diagnosis?

A
  • absence of dyspnea on exertion
  • absence of crackles on pulmonary auscultation
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61
Q

Which BNP level is compatible with HF, which is not?

A

A BNP level >400 pg/mL. is compatible with HF, and a level 100 pg/mL effectively excludes HP as a cause of acute dyspnea.

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62
Q

Should routine testing for unusual causes of HF, including hemochromatosis, Wilson disease, multiple myeloma be performed?

A

no

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63
Q

Which factors increase BNP?

A

Kidney failure, older age, and female sex all increase BNP;

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64
Q

Which factors decrease BNP?

A

obesity reduces BNP.

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65
Q

Which BB are approved for HF?

A

only metoprolol succinate, carvedilol, and bisoprolo

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66
Q

Is there any advantage to continuous IV infusion of furosemide vs. bolus therapy in decompensated HF.

A

No. Continuous IV infusion of furosemide provides no advantage vs. bolus therapy in decompensated HF.

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67
Q

Can you start B- blocker therapy in patients with decompensated HF.

A

Do not begin B- blocker therapy in patients with decompensated HF.

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68
Q

When is ICD therapy indicated in HF?

A

For ischemic and nonischemic cardiomyopathy in patients with an EF 35% and NYHA functional class II-II or with an EF <30% and NYHA functional class I For NYHA class II-Ill symptoms

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69
Q

When should you add Entresto in HF?

A

Substitute for an ACE inhibitor or ARB in HFrEF (NYHA class ll or lI) in patients who have tolerated ACE inhibitor or ARB therapy

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70
Q

When is Cardiac resynchronization therapy indicated in HF?

A

For NYHA class I-IV, LVEF <35%, and LBBB with ORS duration >150ms

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71
Q

Who should receive cardiac transplant in HF?

A

For patients with refractory HF symptoms despite maximal medical therapy

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72
Q

In patients with chronic HF who are clinically stable, should you do an follow-up echocardiography more frequently than every 1 to 2 years

A

No! In patients with chronic HF who are clinically stable, follow-up echocardiography more frequently than every 1 to 2 years is not
recommended.

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73
Q

How is HFpEF treated?

A

The primary treatment goals in HFpEF are to treat the underlying cause (HTH, afib), to manage potentially exacerbating factors and to optimize diastolic filling (decrease HR)

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74
Q

Which pharmacologic agents have been shown to reduce morbidity and mortality in patients with HFpEF?

A

None

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75
Q

What are the most distinguising causes of Acute myocarditis

A

Associated with bacterial, viral, and parasitic infections and autoimmune disorders. Cardiac troponin levels are typically elevated; ventricular dysfunction may be global or regional. Choose supportive care in the acute phase, then standard HF

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76
Q

Which drugs can causes drug in diced cardiomyopathy?

A

Illicit use of cocaine and amphetamines has been associated with myocarditis and dilated cardiomyopathy, as well as MI, arrhythmia, and sudden death. Choose standard HF treatment. In patients with stimulant-induced acute myocardial ischemia

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77
Q

for drug induced dilated cardiomyopathy, B-blockers may exacerbate coronary vasoconstriction, which BB is preferred to have to use?

A

Labetalol, a -blocker with a-blocker activity, is preferred

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78
Q

.What is a Rare disease characterized by biventricular enlargement, refractory ventricular arrhythmias, and rapid progression to cardiogenic shock in young to middle-aged adults. Histologic examination demonstrates the presence of multinucleated giant cells in the myocardium.

A

Giant cell myocarditis

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79
Q

How is Giant cell myocarditis treated

A

Choose immunosuppressant treatment and/or LVAD placement or cardiac transplantation.

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80
Q

What is the timeline for diagnosing Peripartum cardiomyopathy?

A

Presence of HF with an LVEF <45% diagnosed between 1 month before and 5 months after delivery.

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81
Q

What is a clinical syndrome caused by excess iron deposition in the myocardium. Characterized by symptoms of heart failure and by conduction defects.

A

Hemochromatosis

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82
Q

What drugs should be avoided in Peripartum cardiomyopathy?

A

HF treatment. ACE inhibitors, ARBs, and aldosterone antagonists (e.g., eplerenone) should be avoided (teratogenicity) during pregnancy.

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83
Q

How is peripartum CM managed in pregnancy?

A

Management includes early delivery (when identified before parturition) and Anticoagulation with warfarin is recommended for women with peripartum cardiomyopathy with LVEF <35%. Women with persistent LV dysfunction should avoid subsequent pregnancy.

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84
Q

Which clinical syndrome isCharacterized by acute LV dysfunction in the setting of intense emotional or physiologic stress. May mimic acute STEMI.

A

Stress-induced (takotsubo)
cardiomyopathy

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85
Q

Which features are key for Stress-induced (takotsubo) cardiomyopathy

A

Dilation and akinesis of the LV apex occur in the absence of CAD.

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86
Q

which clinic syndrome occurs when myocardial dysfunction develops as a result of chronic tachycardia.

A

Tachycardia-mediated cardiomyopathy

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87
Q

What key features distinguish HCM from aortic stenosis?

A

In HCM, murmur increases with Valsalva and going from squatting to standing. There is no ejection sound, no radiation.

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88
Q

which EKG findings are characteristic for HCM?

A

LV hypertrophy and left atrial enlargement. Deeply inverted, symmetric T waves in leads V1 to V3 are present in the apical hypertrophic form of the disease (mimics ischemia).

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89
Q

What is the first line medical agent for HCM?

A

B- Blockers are first-line agents for patients with an EF >50%, dyspnea, and/or chest pain. Calcium channel blockers (verapamil or diltiazem) may be substituted for B-blockers. ACE inhibitors are used only if systolic dysfunction is present.

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90
Q

What is first line treatment for patients with HCM and a fib?

A

Treat all patients with HCM and AF with warfarin (first line) or one of the NOACs (dabigatran, rivaroxaban, apixaban) (second-line therapy) regardless of CHA,DS, VAS score. Surgery or septal ablation is indicated for patients with an outflow tract gradient of ›50 mm Hg and continuing symptoms despite maximal drug therapy.

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91
Q

Which HCM patients should get an ICD?

A

Patients at high risk for sudden death (one or more major risk factors) are candidates for an ICD The absence of any risk factors has a high negative predictive value (>90%) for sudden death.

Major Risk Factors for SCD in HCM:
Previous cardiac arrest
Spontaneous sustained VT
Family history of sudden death
Unexplained syncope
LV wall thickness 230 mm
Blunted increase or decrease in SBP with exercise
Nonsustained spontaneous VT

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92
Q

Which drugs should be avoided in patients with HCM?

A

Do not prescribe digoxin, vasodilators, or diuretics, which increase IV outflow obstruction for patients with HOM.

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93
Q

What advice to give to first degree relatives with HCM?

A

All first degree relatives of patients with HCM should have genetic counseling and if no mutation found should have an echo

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94
Q

What screening recommendations are for first degree relatives with HCM?

A

Ongoing screening with echo is recommended due to expression of disease at any age after 12 years

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95
Q

Clinical syndrome with abnormally rigid ventricular walls causing diastolic dysfunction in the absence of systolic dysfunction, manifesting as impaired ventricular filling and elevated diastolic ventricular pressures

A

restrictive CM

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96
Q

What echo findings are notable for restrictive CM

A

Echocardiogram shows normal ejection fraction/systolic function.

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97
Q

What Cardiac catheterization findings are notable for restrictive CM

A

Cardiac catheterization shows elevated LV and RV end diastolic pressures and a characteristic early ventricular diastolic dip and plateau.

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98
Q

Which restrictive CM is associated with Amyloidosis

A

Neuropathy, proteinuria, hepatomegaly, periorbital ecchymosis, bruising, low-voltage ECG. Little to no cardiac sxs

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99
Q

what is the best way to diagnose Amyloidosis restrictive CM

A

Diagnosis can be confirmed with abdominal fat pad aspiration.

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100
Q

which clinical syndrome restrictive CM associated with bilateral hilar lymphadenopathy; possible pulmonary reticular opacities; and skin, joint, or eye lesions.

A

Sarcoidosis

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101
Q

How is CM Sarcoidosis Diagnosed?

A

Diagnosis is supported by CMR imaging with gadolinium.

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102
Q

Which cardiac clinic syndrome characterized by Abnormal aminotransferase levels, OA, diabetes, erectile dysfunction, and HF; elevated serum ferritin and transferrin saturation level?

A

Hemochromatosis

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103
Q

Initial test needed to work up palpitations and syncope?

A

ekg

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104
Q

when should you get an echo to evaluate syncope and palpitations?

A

when structural disease is suspected

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105
Q

In evaluating syncope and arrythmias, which method can you use for frequent arrythmias that occur at least daily?

A

Ambulatory 24 hour ECG

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106
Q

In evaluating syncope and arrythmias, which method can you use for arrhythmias
provoked by exercise

A

exercise EKG

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107
Q

Clinical syndrome with postprandial dizziness, syncope, falls, or angina. The condition can be worsened by antihypertensive medications and salt and water depletion

A

postprandial hypotension (PPH)

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108
Q

In addition to adjusting potentially offending medications to treat postprandial hypotension (PPH), what nonpharmacologic measures can improve PPH?

A
  • Smaller and more frequent meals
  • Low-carbohydrate meals
  • Increased salt and water intake
  • Avoidance of alcohol
    . Custom-fit compression stockings
  • Avoidance of activities or sudden standing immediately following meals
    Octreotide may also be effective as it increases splanchnic vascular resistance and reduces pooling of blood in the gut; however, it is reserved for severely symptomatic
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109
Q

Keypoint on PPH

A

Postprandial hypotension is characterized by orthostatic symptoms within 2 hours after eating and is common in the elderly. Decreased portion sizes, increased salt/water intake, low-carbohydrate meals, and avoidance of alcohol can improve symptoms. Octreotide can be considered for severely symptomatic or refractory cases.

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110
Q

What is the treatment for Cocaine related chest pain ?

A

Cocaine related chest pain should first be treated with aspirin and nitroglycerin plus calcium channel blockers for pain control. In addition, benzodiazepines are very effective for reducing blood pressure and anxiety.

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111
Q

What drugs are contraindicated for cocaine-induced chest pain?

A

Beta blockers (even
“selective” beta blockers) can worsen coronary vasoconstriction due to unopposed as activity, and are contraindicated for cocaine-induced chest pain

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112
Q

Cardiology keypoint

A

Cocaine can cause chest pain through multiple mechanisms that simultaneously increase oxygen demand, decrease oxygen supply, and increase thrombogenicity.
Beta blockers are contraindicated in acute cocaine-induced chest pain.
Benzodiazepines, aspirin, and nitrates are first line therapy. Patients should also receive immediate cardiac catheterization with reperfusion therapy when presenting with acute ST elevation MI

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113
Q

What EKG findings are typical for complete AV block?

A
  • There is a complete failure of atrial impulses (p waves) to capture the ventricles (QRS)
    The p waves arent associated with QRS complexes
  • The escape rhythm (QRS) can be narrow (junctional escape) or wide (ventricular escape)
  • The p waves have no relation to QRS complexes (complete AV dissociation)
  • Ventricular rate is always slower than the atrial rate and is usually < 50
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114
Q

what is the treatment for complete heart block

A

Treatment is first directed at reversible causes, such as medications (eg, beta blockers). Patients who are acutely symptomatic with a narrow ORS on ECG may be treated with atropine; those with a wide QRS may require temporary pacing. Stable, asymptomatic patients usually require a permanent pacemaker, preferably with dual-chamber pacing.

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115
Q

what is the treatment for patients who are acutely symptomatic with complete heart block who have a narrow QRS on ECG

A

may be treated with atropine;

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116
Q

what is the treatment for patients WITH HEART BLOCK with a wide QRS?

A

They may require temporary pacing.

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117
Q

Treatment for complete heart block patients who are , asymptomatic patients?

A

Stable, asymptomatic patients usually require a permanent pacemaker, preferably with dual-chamber pacing.

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118
Q

What key feature is the syncope from AS associated with?

A

EXERTION

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119
Q

What key feature is the syncope from AS associated with?

A

EXERTION

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120
Q

What are signs of significant volume depletion?

A

Significant volume depletion can present with syncope and usually has associated tachycardia and hypotension

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121
Q

What symptoms are associated with vasovagal syncope

A

an identifiable trigger (eg, emotional upset, acute pain, micturition). It is characterized by a prodrome of warmth, diaphoresis, nausea and abdominal discomfort. Syncope is usually brief and frequently followed by emesis.

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122
Q

what condition is associated with an opening snap followed by a middiastolic murmur best heard at the cardiac apex.

A

Mitral stenosis

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123
Q

what is the most common cause of Mitral stenosis in young women

A

y mitral stenosis, which most commonly occurs due to underlying rheumatic heart disease.

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124
Q

What are the most distinguishing features of mitral stenosis

A

Patients experience exertional dyspnea, orthopnea, cough, and hemoptysis due to pulmonary edema

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125
Q

what is a common complication of mitral stenosis?

A

Atrial fibrillation commonly develops due to left atrial stretching and can precipitate acute worsening of symptoms.

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126
Q

what other valve disease is common with severe mitral stenosis?

A

Secondary (functional) tricuspid regurgitation is common with severe mitral stenosis because pressure backs up through the lungs to cause pulmonary hypertension and eventual right ventricular dilation with impaired coaptation of the tricuspid valve leaflets. A prominent V wave on the jugular venous pulse (JVP) waveform is characteristic of tricuspid regurgitation.

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127
Q

Which defect is associated with a harsh holosystolic murmur, along with a palpable thrill, and is best appreciated over the mid left sternal border?

A

A small ventricular septal defect

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128
Q

Whare ekg findings separates second-degree atrioventricular block features of Mobitz types I & 2?

A

Mobitz type 1 has progressive prolongation of PR interval followed by dropped QRS complex, while type 2 has Constant PR interval with randomly dropped QRS

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129
Q

WHat is treatment for Symptomatic second-degree AV block in the absence of a reversible cause?

A

necessitates placement of a permanent pacemaker regardless of whether Mobitz type I or Mobitz type II AV block is present.

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130
Q

Which patients with new HF are candidates for ICD after they have been revascularized?

A

Patients with left ventricular (LV) dysfunction due to myocardial infarction may experience recovery of LV function following coronary revascularization and treatment with optimal medical therapy. Therefore, implantable cardioverter-defibrillator placement should be reserved for patients with significant LV dysfunction that persists for 3 months following revascularization or 40 days following myocardial infarction without revascularizatidn.

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131
Q

After a new patient with depressed LV function due to MI is revascularized, how long do they have to wait to be considered for ICD?

A

Patients with left ventricular (LV) dysfunction due to myocardial infarction may experience recovery of LV function following coronary revascularization and treatment with optimal medical therapy. Therefore, implantable cardioverter-defibrillator placement should be reserved for patients with significant LV dysfunction that persists for 3 months following revascularization or 40 days following myocardial infarction without revascularizatidn.

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132
Q

whIch HF patients can get an ICD?

A

Placement of an ICD is indicated in patients with LVEF <35% with heart failure symptoms. Patients considered at high risk of SCD in the meantime may be given a temporary wearable cardiac defibrillator

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133
Q

Cardiac resynchronization therapy with placement of a biventricular pacemaker is indicated for symptomatic patients with left ventricular ejection fraction (LVEF) <35%. What other feature is needed f or them to qualify for Cardiac resynchronization therapy?

A

A left bundle branch block with QRS duration > 150 sec.

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134
Q

What is the goal for emergency cardiac catheterization and revascularization for STEMI?

A

Emergency cardiac catheterization and revascularization within 90 minutes (of first contact with medical personnel) is the goal of treatment in patients with acute ST elevation myocardial infarction.

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135
Q

What is the goal for emergency cardiac catheterization and revascularization for NSTEMI?

A

Withiin 24 hours

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136
Q

How do we manage ACS patients with high-risk features, ST-segment depression, and/or positive cardiac biomarkers ?

A

ACS patients with high-risk features, ST-segment depression, and/or positive cardiac biomarkers should be managed with an early invasive approach using coronary angiography and primary percutaneous coronary intervention (within 24 hours)

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137
Q

What is the best way to evaluate The presence of a painful, tender mass near the puncture site below the right inguinal ligament after an endovascular intervention is suggestive of hematoma with pseudoaneurysm formation.?

A

The patient should have a Doppler ultrasound to assess for the presence of hematoma and/ or pseudoaneurysm formation

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138
Q

How is an arterial pseudoaneurysm or hematoma after a cardiac procedure treated?

A

treated with ultrasound-guided compression or ultrasound-guided thrombin injection into the pseudoaneurysm

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139
Q

For a patient with a pseudoaneurysm at the catheter insertion site after a cardiac procedure, is needle aspiration a treatment option?

A

needle aspiration is contraindicated.

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140
Q

Which set of low cardiac pressures are associated with hypovolemic shocK?

A

a low right atrial and pulmonary capillary wedge pressure, reduced cardiac index and and systemic vascular resistance is increased.

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141
Q

Which set of cardiac pressures are associated with cardiogenic shocK?

A

Pulmonary artery catheterization in such patients typically reveals elevated pulmonary capillary wedge pressure, low cardiac output, and low cardiac index.

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142
Q

Which set of cardiac pressures are associated with septiic shocK?

A

increase in cardiac output in the early stages of shock. Systemic vascular resistance is typically reduced, which is useful in differentiating it from other causes of shock.

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143
Q

Which set of cardiac pressures are associated with PE?

A

Patients with pulmonary embolus have elevated right atrial, right ventricular, and pulmonary artery pressures.

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144
Q

Which set of cardiac pressures are associated with CARDIAC TAMPONADE?

A

Cardiac tamponade causes an increase in right atrial and ventricular pressures, along with a characteristic equalization of right atrial, right ventricular end diastolic, and pulmonary capillary wedge pressures.

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145
Q

Clinical syndrome associated with signs of continuous cardiac murmur, hypertension, and diminished femoral pulses, Severe hypertension can cause headaches, blurred vision, or epistaxis or can present as aortic dissection.

A

are suggestive of coarctation of the aorta.

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146
Q

what genetic syndrome is associated with coarctation of the aorta?

A

Turner syndrome

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147
Q

which 3 major cardiac defects are associated with Turners syndrome

A

-bicuspid aortic valve
-Aortic root dilation
-dissection

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148
Q

For evaluation of arrythmias, when is an event monitor used over the loop recorder?

A

Both are for infrequent arrythmias but the event monitor is mainly for symptomatic patients who have events that last at least 1 to 2 minutes. Patients have to activate the event monitor so it is not good for patients with syncope

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149
Q

can be EP study be used as an initial choice to diagnose arrythmias?

A

No

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150
Q

What are 3 common causes of sinus bradycardia?

A

Meds, hypothyroid, inferior MI

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151
Q

wHICH heart block has PR interval >0.2 s without alterations in HR or dropped beats?

A

first degree

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152
Q

which heart block has Intermittent P waves not followed by a ventricular complex?

A

2nd degree further classified Mobitz type 1 or type 2

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153
Q

which heart block has complete absence of conducted P waves (p-wave and QRS complex rates differ, and the PR interval differs for every ORS complex) and an atrial rate that is faster than the ventricular rat

A

3rd degree

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154
Q

For 2nd degree block, How can you differentiate mobitz 1 vs 2?

A

Type 1 has progressing PR interval then dropped beat, while the PR interval with type 2 is the same length and then QRS drops.

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155
Q

Which 2nd degree heart block is associated with RBBB or LBBB?

A

Type 2

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156
Q

Which 2nd degree heart block is associated with RBBB or LBBB?

A

Type 2

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157
Q

Pertaining to bradycardia, when do we consider IV atropine or transcutaneous pacing?

A

Hemodynamic instability!! Choose IV atropine and/or transcutaneous or transvenous pacing for symptoms of hemodynamic compromise caused by bradycardia or heart block

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158
Q

What 6 indications are there to consider permanent pacemaker in the event of irreversible bradycardia?

A

*symptomatic bradycardia
* asymptomatic sinus bradycardia BUT with significant pauses (>3 s) or heart rate <40/min
* AF with 5-second pauses
* complete heart block
* Mobitz type 2 second-degree AV block
* alternating bundle branch block

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159
Q

For asymptomatic bradycardia, when are the only time you place a pacemaker?

A

In the absence of a second or 3rd degree AV block, do not place a pacemaker for asymptomatic bradycardia

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160
Q

What initial 4 diagnostic studies should be obtained in new a fib?

A
  • TSH
  • Digoxin level
  • OSA evaluation
  • Echo
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161
Q

What is the treatment for a fib with hemodynamic instability?

A

emergency electrical cardioversion

162
Q

In younger patients with a fib, is Rhythm control is an appropriate management ?

A

Rhythm control is an appropriate management for younger patients with persistent symptomatic AF.

163
Q

If rhythm control is unsuccessful or not tolerated for a fib, what is the next option?

A

catheter based ablation is an option

164
Q

what treatment option is recommended for patients with rare or infrequent paroxysmal afib?

A

Patients with infrequent paroxysmal AF will benefit from the “pill-in-the-pocket” approach: flecainide or propatenone with a B-blocker or calcium channel blocker

165
Q

which anticoagulation is used for valvular a fib?

A

warfarin

166
Q

Which anticoagulation are preferred for patients with nonvalvular a fib?

A

NOACs

167
Q

in patients with a fib and WPW syndrome, what med should you use instead of CCB orBB /

A

Procainamide

168
Q

What is the most defining feature of Multifocal atrial tachycardia?

A

Irregular SVT that has 3 or more different p wave shapes

169
Q

Which cardiac SVT IS ASSOCIATED WITH copd?

A

Multifocal atrial tachycardia?

170
Q

What are the 3 narrow complex IRREGULAR tachycardias?

A

A. Flutter, a fib and MAT

171
Q

What are the 4 narrow complex REGULAR tachycardias?

A

AVNRT, ARNT, sinus tach, atrial tachycardia

172
Q

Which arrythmias should not be treated with adenosine?

A

Irregular wide complex tachycardias and polymorphic tachycardias

173
Q

What are 4 ways to terminate episodes of SVT?

A

Valsalva maneuvers
Cold water immersion face
Carotid sinus massage
Adenosine

174
Q

what is the clinical significance of terminating an SVT with adenosine z?

A

Adenosine can be used to terminate SVT and to help diagnose the cause. Termination with adenosine often suggests AV node dependence (AVNRT and AVRT), whereas continued P waves during AV block can help identify atrial flutter and atrial tachycar dia.

175
Q

what is recommended treatment For recurrent AVNRT despite drug therapy or intolerance of drug therapy?

A

For recurrent AVNRT despite drug therapy or intolerance of drug therapy, select catheter ablation therapy.

176
Q

What is treatment of MAT?

A

Treatment of MAT is directed at correcting associated pulmonary and cardiac disease, hypokalemia, and hypomagnesemia.

177
Q

Which conditions qualify a patient to receive antibiotic prophylaxis for infective endocarditis (IE)?

A

Antibiotic prophylaxis for infective endocarditis (IE) is recommended only for patients with a high-risk cardiac condition who are undergoing certain invasive procedures. This includes (Previous IE, dental procedures involving gingival manipulation)

178
Q

When performed in the setting of active underlying infection, which procedures warrant antibiotic prophylaxis for IE?

A

Genitourinary, gastrointestinal procedures, skin surgery warrant antibiotic prophylaxis in high-risk patients when performed in the setting of active underlying infection.

179
Q

What is the screening recommendation for AAA in men?

A

USPSTF recommends one-time screening for AAA with ultrasonography in men ages 65 to 75 with a smoking history.

180
Q

what size AAA is surgery indicated for a AAA?

A

Surgical repair is indicated for AAA ≥ 5.5 cm in diameter or an increase in diameter ≥ 0.5 cm in a 6-month period and in all symptomatic patients.

181
Q

which 2 EKG findings are characteristic for Wolfe Parkinson white?

A

Delta wave
short PR interval

182
Q

When doe Wolfe Parkinson white require treatment?

A
  1. Arrythmia present
  2. Symptoms present
183
Q

What is the treatment for WPW when wide complex tachycardia/or a fib are present?

A

Procainamide

184
Q

Under what circumstance is an ablation the first line treatment for WPW?

A

When a patient has pre-excitation and also symptoms

185
Q

which 3 drugs should be avoided in patients with WPW and a fib? and why

A

CCB, BB, digoxin, can convert a fib to VT or v fib

186
Q

In otherwise healthy patients without structural heart disease and non-sustained VT what should treatment begin and what options are for treatment? .

A

treatment with -blockers or calcium channel blockers, especially verapamil, should only be given if disabling symptoms are present

187
Q

what is the difference in treatment for VTACH between those who have structural heart disease and those who do not?

A

Patients with structural heart disease: -Blockers and ACE inhibitors have been shown to reduce the risk of sudden cardiac death in patients with previous MI and cardiomyopathy

188
Q

In those with recurrent VT despite B-blocker therapy and, antiarrhythmic drug therapy with amiodarone, what next option should be considered?

A

Catheter ablation should be considered in patients with recurrent VT despite medical therapy.

189
Q

when is ICD placement indicated for prevention of sudden cardiac death in patients with structural heart disease or cardiomyopathy?

A

When they have sustained VT/VF, if reversible causes have been excluded (such as acute coronary ischemia or cocaine ingestion).

190
Q

What is the recommended treatment for unstable patients with vtach?

A

immediate electrical cardioversion is indicated

191
Q

In the acute treatment of sustained VTACH, what treatment should be given to those who are hemodynamically stable with impaired LV Function?

A

IV lidocaine or amiodarone

192
Q

Patients may experience syncope or sudden cardiac death as the result of torsades de pointes. What features predispose to torsades?

A

Look for hypokalemia, hypomagnesemia, structural heart disease, medications, and drug interactions.

193
Q

Which drugs commonly predispose to torsades de pointes ?

A

Look specifically for:
* macrolide and fluoroquinolone antibiotics (especially moxifloxacin)
* terfenadine and astemizole antihistamines
* antipsychotic and antidepressant medications
* methadone
* antifungal medications
class la and class III antiarrhythmics

194
Q

Risk of torsades is greatest with a QT interval of what?

A

> 500 ms.

195
Q

Which syndrome is an inherited condition characterized by a structurally normal heart but abnormal electrical conduction associated with sudden cardiac death?

A

Classic Brugada syndrome, recognized as an incomplete RBBB pattern with coved ST- segment elevation in leads V, and V2.

196
Q

What Testing should be used for survivors of sudden cardiac death to identify anatomic abnormalities, impaired ventricular function, and/or myopathic processes

A

Select echocardiography

197
Q

What is the primary treatment for Inherited long QT syndrome?

A

may be treated with B-blockers.

198
Q

Which clinical scenarios require placement of an ICD

A

Select an ID in the following scenarios:
* for survivors of cardiac arrest resulting from VF or VT not explained by a reversible cause
* after sustained VT in the presence of structural heart disease
* after syncope and sustained VT/VF on electrophysiology study
* for ischemic and nonischemic cardiomyopathy with an EF <35%, NYHA class II or III symptoms, with guideline- directed medical therapy
* for Brugada syndrome with syncope or ventricular arrhythmia
* for inherited long QT syndrome not responding to B-blockers
* 240 days after MI with an EF 30%
* for high-risk HCM (familial sudden death; multiple, repetitive nonsustained VT; extreme LVH, a recent, unexplained syncopal episode; and exercise hypotension)

199
Q

Which clinical syndrome is characterized by acute sharp or stabbing substernal chest pain that worsens with inspiration and when lying hat and is alleviated when sitting and leaning forward?

A

Acute Pericarditis

200
Q

What medical risk factors may predispose to acute pericarditis?

A

Medical history may include.
* preceding viral symptoms
* cancer (current or in the past)
* recent trauma
* arthralgia, arthritis ( systemic rheumatic disease)
* MI
* recent thoracic surgical procedures
* use of medications, including hydralazine, phenytoin, and minoxidil

201
Q

Which physical exam component is characteristic of acute pericarditis?

A

friction rub

202
Q

Aside from friction rub, what other complication/presentation may be associated with pericarditis?

A

pericardial tamponade

203
Q

what ekg finding is present in patient with large cardiac tamponade effusions?

A

electrical alternans

204
Q

how do you define electrical alternans?

A

alternating high and low voltage QRS complexes

205
Q

Which EKG features are present that suggests acute pericarditis over MI?

A
  1. Diffuse
  2. No Q waves
  3. No reciprocal ST changes
206
Q

what is it called when trops are mildly elevated in pericarditis?

A

Myopericarditis

207
Q

what is the first line treatment for acute pericarditis?

A

Colchicine plus Aspirin or an NSAID

208
Q

When are glucocorticoids used to treat pericarditis?

A
  1. when pericarditis dOnt respond to colchicine plus aspirin or an NSAID
  2. When you suspect an autoimmune process
209
Q

When is an emergent pericardiocentesis indicated in pericarditis?

A

When a patient has tamponade and hemodynamic instability

210
Q

what 2 key EKG features occur in acute pericarditis?

A

Diffuse ST elevation and PR segment depression

211
Q

What condition is suggested in a patient with frequent episodes of nocturnal hypoxemia, a normal BMI and advanced heart failure (HF)?

A

suggest possible central sleep apnea (CSA)

212
Q

What condition is characterized by Cheyne-Stokes breathing, a crescendo-decrescendo oscillation of tidal volume, with intervals of hyperventilation separated by periods of hypopnea and apnea.

A

Central sleep apnea in Heart failure

213
Q

How is central sleep apnea tested or diagnosed

A

Polysomnography is the gold standard test for diagnosis of sleep-disordered breathing.

214
Q
A

Treatment includes optimal medical management of heart failure, positive airway pressure therapy, and supplemental oxygen.

215
Q

How is central sleep apnea treated?

A

Treatment includes positive airway pressure therapy, and supplemental oxygen.

216
Q

In a patient with high-risk features on exercise stress testing but a normal radionuclide myocardial perfusion imaging, what is the next step?

A

The presence of high-risk features on exercise stress testing and normal radionuclide myocardial perfusion imaging should raise suspicion for the presence of balanced ischemia. Such patients should be further evaluated with coronary angiography for the presence of multivessel coronary artery disease.

217
Q

What explains a discrepancy between a patient found to have ST depression in multiple leads during peak stress but no evidence of ischemia on radionuclide myocardial perfusion imaging?

A

This is suggestive of the presence of balanced ischemia. Balanced ischemia is present when coronary flow is equally or nearly equally impaired. As a result, the pattern of perfusion on the radionuclide myocardial image appears mostly homogenous, creating a false negative.

218
Q

What are 4 positive stress test findings?

A
  • Poor exercise capacity (less than 5 METs)
  • Exercise-induced angina during minimal expenditure
  • Inability to achieve 85% of age-predicted maximum heart rate with exercise
  • Fall in systolic blood pressure below baseline during exercise
  • ST elevation = 2 mm ST depression during minimal expenditure
    Early onset or prolonged duration of ST depression during exercise stress test
  • ST depression in multiple leads
  • Ventricular couplets or tachycardia during minimal expenditure or recovery
219
Q

What are 5 indications for Permanent placemaker placement?

A
  1. Complete AV block
  2. Advanced second-degree AV block (block of ≥2 consecutive P waves)
  3. Mobitz type II second-degree AV block (symptomatic or asymptomatic)
  4. Mobitz type I second-degree AV block (only if symptomatic)
  5. Symptomatic sinus bradycardia (heart rate usually <40/min)
  6. Exercise chronotropic incompetence (inability to achieve 85% of age-predicted maximum heart rate)
220
Q

Which test can help differentiate reflex from orthostatic syncope?

A

tilt table test

221
Q

In the absence of a reversible cause (eg, myocardial ischemia), patients with complete (third-degree) atrioventricular block require what treatment?

A

permanent pacemaker placement regardless of whether the block is symptomatic or asymptomatic, is persistent or transient, or occurs at rest or with exercise.

222
Q

Which high-risk cardiac conditions necessitate further evaluation and/or management prior to even low-risk surgery?

A
  • Unstable angina or recent MI
    *Decompensated heart failure
    Significant arrhythmia
  • . Symptomatic bradycardia
  • High-grade AV block
    ° Supraventricular tachycardia
  • Symptomatic or new-onset VT
  • Severe valvular disease or Severe aortic stenosis
  • Symptomatic mitral stenosis
223
Q

Which high-risk cardiac conditions necessitate further evaluation and/or management prior to even low-risk surgery?

A
  • Unstable angina or recent MI
    *Decompensated heart failure
    Significant arrhythmia
  • . Symptomatic bradycardia
  • High-grade AV block
    ° Supraventricular tachycardia
  • Symptomatic or new-onset VT
  • Severe valvular disease or Severe aortic stenosis
  • Symptomatic mitral stenosis
224
Q

Which cardiac condition is associated with late peaking 3/6 systolic murmur and paradoxical splitting of S2?

A

Severe aortic stenosis

225
Q

Prior to any noncardiac surgery, patients with severe AS should have what evaluation done?

A

TTE

226
Q

What clinical syndrome is associated with SOB, fatigue, peripheral edema, hepatosplenomegaly, hepatic dysfunction, and ascites BUT with the ABSENCE of pulmonary congestion?

A

Chronic cardiac tamponade

227
Q

What CXR finding is associated with Chronic cardiac tamponade?

A

enlarged silhouette, “Water bottle” sign

228
Q

Thee absence of what major TTE finding excludes a diagnosis of cardiac tamponade?

A

Absence of a pericardial effusion excludes a diagnosis of cardiac tamponade

229
Q

What 3 imaging findings support a diagnosis of

A

Imaging findings that support the diagnosis include:

  • calcified pericardium on x-ray (specific, but not sensitive)
  • pericardial thickening on CT or CMR imaging
  • abnormal diastolic motion on echocardiography
230
Q

What are the two main options for management of cardiac tamponade ?

A

-Drainage of pericardial fluid by percutaneous pericardiocentesis
-or surgery

231
Q

What is the best way to maintain SBP in acute cardiac tamponade ?

A

SBP should be maintained with volume resuscitation and vasopressors. In patients with chronic constrictive pericarditis, cardiac output depends on a high preload; therefore, diuretics must be used cautiously.

232
Q

What happens to R sided heart murmurs during inspiration?

A

increase

233
Q

What is the most effective tx for chronic constrictive pericarditis?

A

Pericardiectomy is the most effective treatment, but it is unnecessary in patients with early disease (NYHA functional class I) and is unwarranted in many patients with advanced disease (NYHA functional class IV).

234
Q

What happens to the murmur causes by HCM when going from squatting to standing?

A

Murmurs caused by HCM increase in intensity during the Valsalva maneuver and on standing from a squatting position. Performing the Valsalva maneuver causes an increase in intrathoracic pressure, leading to a reduction in preload to the heart.

235
Q

What happens to the murmur causes by MVP when going from squatting to standing?

A

The clicks caused by MVP may move closer to S1 and the murmur lengthens during the Valsalva maneuver and on standing from a squatting position.

236
Q

Normally, a split S2, is heard only during inspiration. Which Splitting during inspiration and expiration occurs in conditions that further delay RV ejection. Which conditions cause split S2 or delay RV ejection?

A

Conditions that further delay RV ejection, including RBBB, pulmonary valve stenosis, SD with left-to-right shunt, and ASD with left-to-right shunt.

237
Q

When does Reversed or expiratory S2 splitting occur?

A

in conditions that prolong LV ejection, including LBBB, AS, HCM, and ACS with LV dysfunction.

238
Q

What are some characteristics of innocent murmurs?

A

-Midsystolic
-Located at the base of the heart
-Grade 1/6 to 2/6
- No radiation
-Normal splitting of S2

239
Q

What are the 5 signs of a serious murmur?

A

Signs of serious cardiac disease include an
-S4,
- murmur grade 3/6 intensity OR MORE
- any diastolic murmur
- continuous murmurs
- abnormal splitting of S2

240
Q

What 4 reasons is TTE indicated for an abnormal murmur?

A

TTE is indicated in:
- symptomatic patients
- those with a systolic murmur grade 3/6 intensity
-in those with a diastolic murmur
- any continuous murmur

241
Q

During pregnancy, is it normal to have An increased P2, an S3 and an early peaking systolic murmur over the upper left sternal border?

A

An increased P2, an S3 and an early peaking systolic murmur over the upper left sternal border are normal findings during pregnancy

242
Q

What are the diastolic murmurs?

A

MS ARD
Mitral
Stenosis
Aortic
Regurgitation

243
Q

What are the systolic murmurs?

A

MR
Mitral regurgitation
Aortic stenosis

244
Q

which two murmurs radiate? and where do they radiate ?

A

AS radiates to the R clavicle, carotid, apex while MR radiates to axilla or back

245
Q

Which murmur is associated with AR?

A

Diastolic;
decrescendo

246
Q

Which murmur is associated with MS?

A

Diastolic; low pitched decrescendo

247
Q

Which murmur is associated with AS?

A

Mid-systolic; crescendo decrescendo

248
Q

Which murmurs are associated with holosystolic and where do you hear it?

A

VSD (LLSB), TR (LLSB), MR (apex)

249
Q

What is the treatment for patients with group A strep infection?

A

Penicillin (or erythromycin to those with allergy)

250
Q

How do you differentiate the murmur from ASD from AS?

A

Both have systolic crescendo decrescendo but, Atrial septal defect is also associated with flixed split s2

251
Q

What is the recommendation for prophylaxis for patients with a history of rheumatic fever?

A

Patients with a history of RF require long term prophylactic penicillin, and patients with rheumatic valvular disease should continue prophylaxis for at least 10 years after the last episode of RF or until at least 40 years of age (whichever is longer).

252
Q

What is the most commonly valved affected by rheumatic fever? and what valve abnormality?

A

Mitral valve and mistral stenosis

253
Q

If the throat culture is negative for group A streptococci, is abx required for RF? .

A

Antibiotic therapy is required even if the throat culture is negative for group A streptococci. Salicylates are the drug of choice; nonresponse to salicylates makes RF unlikely

254
Q

What valve area size and transvalve gradient are considered to be severe ?

A

less than 1 cm and more than 40mm hg

255
Q

In what circumstance can the echo UNDERESTIMATE the transvalve gradient in AS?

A

In patients with LV dysfunction

256
Q

In the absence of symptoms, what is the risk of death in patients with aortic stenosis?

A

in the absence of symptoms, patients have a low risk of death.

257
Q

In low risk, but SYMPTOMATIC patients with aortic stenosis, which method of treatment is recommended?

A

Surgical aortic valve replacement (SAVR) is recommended for symptomatic patients at low operative risk

258
Q

for intermediate risk and high-risk patients with aortic stenosis, which has a higher survival benefit TAVR or Surgical VR

A

Transcatheter aortic valve replacement (TAR) has a survival benefit similar in that oF SAVR for intermediate risk and high-risk patients and is superior to medical therapy in nonsurgical candidates.

259
Q

What are three main contraindications to TAVR?

A

1a bicuspid aortic valve
2. significant AR
3. mitral valve disease.

260
Q

For patients with AS, when is medical therapy indicated and useful?

A

Medical therapy is indicated for patients with LV dysfunction who are awaiting valve repair or replacement. Treat these patients with diuretics, digoxin, and ACE inhibitors.

261
Q

Can balloon valvuloplasty as a definitive treatment for AS in adults?

A

Do not select balloon valvuloplasty as a definitive treatment for AS in adults.

262
Q

Compared to patients with mild aortic stenosis, how often should serial echocardiography to evaluate the left aortic valve area, degree of ventricular hypertrophy, and IV function occur?

A

Use serial echocardiography to evaluate the left aortic valve area, degree of ventricular hypertrophy, and LV function every 6-12 months in asymptomatic patients with severe AS, every 1-2 years in patients with moderate AS, and every 3-5 years in those with mild AS.

263
Q

What other findings are associated with bicuspid aortic valve?

A

aortic coarctation, aneurysm of the sinuses of Valsalva, PDA, and aortic
aneurysm and dissection.

264
Q

What is first-line therapy for a stenotic bicuspid aortic valve?

A

Surgical aortic valve replacement is first-line therapy for a stenotic bicuspid aortic valve.

265
Q

What is first-line therapy for a regurge bicuspid aortic valve?

A

For a regurgitant bicuspid aortic valve, valve replacement is the treatment of choice when regurgitation is clinically significant, manifesting as symptomatic HF or asymptomatic LVEF <5O%

266
Q

At what diameter is a surgery to repair an aortic root or replace the ascending aorta in patients with additional risk factors for dissection vs patients without risk factors?

A

Surgery to repair the aortic root or replace the ascending aorta is indicated when the aortic root diameter is at least 5cm in those with risk factors but has to be >5.5 in without risk factors.

Risk factors include fam history or a rate of progression of 0.5cm per year

267
Q

What is the difference in the aortic root diameters for follow up screening vs indications for surgery for aortic stenosis?

A

for screening, the ascending aortic diameter should be assessed annually by echocardiography If the aortic root or ascending aorta dimension is >4.5 cm and every 2 years if the dimension is <4.0 cm.

For furgery,

268
Q

What is the difference in screening follow up for aortic diameter screening in those who are symptomatic and those who are asymptomatic?

A

The ascending aortic diameter should be assessed annually by echocardiography If the aortic root or ascending aorta dimension is >4.5 cm and every 2 years if the dimension is <4.0 cm.

Surgery to repair the aortic root or replace the ascending aorta is indicated when the aortic root diameter is at least 5cm in those with risk factors but has to be >5.5 in without risk factors.

269
Q

What is one of the KEY distinguishing elements of aortic regurgitation?

A

Widened pulse pressure

270
Q

What is the treatment for patients with acute AR?

A

Schedule immediate aortic valve replacement for patients with acute AR.

271
Q

What can you use in patients with acute AR for bridging therapy?

A

Bridging medical therapy includes sodium nitroprusside and IV diuretics. Dobutamine or milrinone are also indicated if the BP is unacceptably low.

272
Q

Under what circumstance is combined aortic root replacement with aortic valve replacement indicated?

A

Combined aortic root replacement with aortic valve replacement is used when an associated aortic root aneurysm is present.

273
Q

In terms of SYMPTOMATIC chronic aortic regurgitation, when is AV replacement indicated?

A

For chronic symptomatic AR, valve replacement is indicated regardless of LV systolic function.

274
Q

In patients with ASYMPTOMATIC chronic aortic regurgitation, when is valve replacement indicated?

A

Valve replacement is indicated for asymptomatic patients with LVEF <50%.

275
Q

What medical therapies should be avoided in patients with ACUTE REGURGITATION for fear of making AR worse?

A

Avoid B-blockers or intra-aortic balloon pumps for patients with acute AR because both may worsen the AR

276
Q

What meds can be given in patients with chronic severe AR and HF pending valve replacement?

A

ACE inhibitors and nifedipine may be used in patients with chronic severe AR and HF pending valve replacement.

277
Q

When is bridging indicated in patients on warfarin?

A

In patients on warfarin with a high-risk condition for perioperative thrombosis (eg, mechanical bileaflet aortic valve) it is recommended that warfarin be held until the IN is <1.5 and then the procedure may be performed; bridging therapy is not indicated.

However, patients with a very-high-risk thrombotic condition (eg, mechanical mitral valve) should undergo perioperative bridging with low-molecular-weight or unfractionated heparin.

278
Q

When is warfarin held prior to high risk procedure and when is bridging started?

A

warfarin is typically held 5 days prior to the procedure, and heparin is started once the INR is <2.0 (rather than <1.5)

279
Q

In terms of aortic stenosis, when valve gradient represent mild AS, moderate AS and severe?

A
  1. mild, gradient <20
  2. moderate, gradient 20 to 39
  3. severe, gradient >40
280
Q

Clinical syndrome associated with friction rub and onset of acute pericarditis within days after an acute myocardial infarction?

A

Peri-infarction pericarditis refers to onset of acute pericarditis within days after an acute myocardial infarction. It is usually transient, and symptomatic patients should be managed with higher doses of aspirin. The use of anticoagulants, nonsteroidal anti-inflammatory drugs, and corticosteroids should be avoided in this setting.

281
Q

How is Peri-infarction pericarditis treated?

A

Symptomatic patients should be managed with higher doses of aspirin. The use of anticoagulants, nonsteroidal anti-inflammatory drugs, and corticosteroids should be avoided in this setting.

282
Q

A prominent a wave in the jugular pulse AND
a prominent tapping apical impulse are key physical exam findings for what valve disease?

A

Mitral stenosis

283
Q

Whats the best way to visualize the presence of left atrial appendage thrombus in Mitral stenosis?

A

While TTE is used to assess disease severity of mitral stenosis by measuring valve area and transvalvular gradient, TEE provides better visualization for the presence of left atrial appendage thrombus

284
Q

For asymptomatic patients with mitral stenosis, at what valve gradient is Percutaneous balloon mitral commissurotomy indicated?

A

Percutaneous balloon mitral commissurotomy is indicated for asymptomatic patients when the valve area is <1.0 cm

285
Q

For symptomatic patients with mitral stenosis, when is Percutaneous balloon mitral commissurotomy indicated?

A

Percutaneous balloon mitral commissurotomy is indicated for symptomatic patients (NYHA functional class II, III, or [V)

286
Q

What are the 2 contraindications to valvulotomy?

A

Concurrent MR and left atrial thrombus are contraindications to valvulotomy.

287
Q

When is mitral valve surgery indicated in patients with symptomatic (NYHA functional class III IV) mitral stenosis?

A

Mitral valve surgery (repair if possible) is indicated in patients with symptomatic (NYHA functional class III IV) mitral stenosis when balloon valvotomy is unavailable or contraindicated or the valve morphology is unfavorable.

288
Q

For patients with a fib and mitral stenosis (valvular a fib), what is the treatment for MS?

A

Warfarin

289
Q

For mitral stenosis, what medical therapy is recommended to allow greater time for LV diastolic filling and relief of PH.

A

select metoprolol to allow greater time for LV diastolic filling and relief of PH.

290
Q

Which clinical syndrome is most associated with acute onset pulmonary edema, dyspnea or cardiogenic shock?

A

Acute Mitral Regurgitation

291
Q

Clinical syndrome associated with left-sided HF associated with a holosystolic murmur at the apex that radiates to the axilla and occasionally to the base?

A

Acute Mitral Regurgitation

292
Q

In the setting of an MI, what clinical syndrome is associated with mitral regurgitation?

A

In the setting of an MI, consider papillary muscle dysfunction or rupture.

293
Q

What is the main imaging modality in the evaluation and management of MR?

A

TTE serves as the main imaging modality in the evaluation and management of MR.

294
Q

Which surgical option for acute MR is the preferred method of treatment for for mitral valve?

A

Options are mitral valve repair (preferred) or mitral valve replacement.

295
Q

What type of mitral regurgitation improves?.

A

MR resulting from ischemia induced dysfunction of the papillary muscle should improve after appropriate revascularization.

296
Q

Which cardiac condition is associated with high pitch MIDSYSTOLIC CLICK loudest at the apex?

A

mvp

297
Q

For patients with MVP, which treatment options are recommended for those with mitral valve prolapse AND SYMPTOMS?

A

Treat MVP patients with SYMPTOMS of palpitations, chest pain, anxiety. or fatigue with B- blockers.

298
Q

When is Aspirin indicated for patients with mitral valve prolapse?

A

Aspirin is appropriate for patients with unexplained TIA who have sinus rhythm and and no atrial thrombi.

299
Q

When is warfarin indicated for patients with mitral valve prolapse depsite being on aspirin ?

A

Warfarin Is indicated for patients with recurrent ischemic neurologic events despite aspirin.

300
Q

What are the two primary causes of tricuspid regurgitations?

A

Primary causes of TR include Marfan syndrome and congenital disorders such as Ebstein anomaly

301
Q

Which valve abnormality is associated with prominent u waves in the neck, increased JD during inspiration, and hepatic pulsations and a A holosystolic murmur is heard at the left lower sternal border, Increasing in intensity during inspiration.

A

TR

302
Q

Which valve is associated with A holosystolic murmur is heard at the left lower sternal border, Increasing in intensity during inspiration?

A

TR

303
Q

When is surgery indicated for tricuspid regurgitation?

A

Consider tricuspid valve surgery in patients undergoing left-sided valve surgery who have severe tricuspid regurgitation or in patients with symptomatic tricuspid regurgitation unresponsive to medical management.

304
Q

Does mild or less severe TR have to be surgically treated?

A

Mild or less severe TR is common, can be easily identified by echocardiography, is physiologically normal, and does not require treatment?

305
Q

Which type of prosthetic valves require lifelong anticoagulation?

A

mechanical valves

306
Q

Prosthetic valves in which position are more likely to cause clots? aortic vs mitral?

A

Prosthetic valves in the aortic position are more durable and less prone to thromboembolism than valves in the mitral position.

307
Q

If valve dysfunction is suspected, what is the diagnostic procedure of choice?

A

If valve dysfunction is suspected, TEE is the diagnostic procedure of
choice.

308
Q

What anticoagulation is recommended for all patients with a mechanical prosthesis?

A

Anticoagulation lifelong oral anticoagulation with warfarin is recommended for all patients with a mechanical prosthesis.

309
Q

What is the Target INR for an aortic prosthetic valve without thromboembolism risk factors?

A

Target INRs
are: 2.5 for an aortic prosthetic valve without thromboembolism risk factors

310
Q

What is the Target INR for aortic prosthetic valve with thromboembolism risk factors?

A

Target INRs 3.0 for aortic prosthetic valve with thromboembolism is risk factors

311
Q

Should patients with mechanical prosthetic valves receive aspirin?

A

All patients with mechanical prosthetic valves of any type, and most patients with bioprostheses, should receive aspirin

312
Q

Can NOAC be used for mechanical heart valves?

A

Select only warfarin for anticoagulation of mechanical heart valves. Do not select a NOAC

313
Q

Should you interrupt anticoagulation in patients with a prosthetic heart valve before they undergo noncardiac or dental surgery?

A

Interrupt anticoagulation in patients with a prosthetic heart valve before they undergo noncardiac or dental surgery (but not cataract surgery).

314
Q

For aortic valve prostheses, when should you stop before the procedure?.

A

For aortic valve prostheses, stop warfarin 4 to 5 days before the procedure and restart as soon as postprocedure control of bleeding allows.

315
Q

When is IV heparin used as a bridge for patients with prosthetic valves planning to undergo surgery? .

A

In patients at high risk for thrombosis (mitral prostheses, multiple prosthetic valves, AF, or previous thromboembolic events), stop warfarin 4 to 5 days before surgery and begin bridging anticoagulation with IV heparin; resume IV heparin within 24 hours after surgery. Warfarin is also reinitiated after surgery, and heparin is discontinued when IN is therapeutic.

316
Q

What factors make a patient with prosthetic valve high risk?

A

high risk for thrombosis (mitral prostheses, multiple prosthetic valves, AF, or previous thromboembolic events)

317
Q

Do patients with prosthetic valves require lifelong anticoagulation?

A

No, ONLTY WITH MECHANICAL VALVES

318
Q

Which murmurs is associated with fixed splitting of the S, a pulmonary midsystolic murmur, and tricuspid diastolic flow murmur.

A

atrial septal defect

319
Q

Which is the most common form of ASD?

A

Ostium secundum

320
Q

a right axis deviation and a partial RBBB are associated with which ASD defect?

A

Ostium secundum

321
Q

In treating ASD, when is treatment with closure indicated ?

A

Closure is indicated for right atrial or right ventricular enlargement, large left to right shunt, or symptoms (dyspnea, paradoxical embolism).

322
Q

What is the preferred treatment for ostium secundum ASD vs ostium primum ASD ?

A

Select percutaneous device closure for ostium secundum ASD and surgical closure for ostium primum ASD and associated mitral valve defects.

323
Q

Pregnancy in patients with ASD is generally well tolerated unless they have what other cardiopulmonary condition?

A

Pulmonary hypertension

324
Q

When is it contraindicated to close an ASD ?

A
  • Closure of an ASD is contraindicated if shunt reversal (right to left) is present.
324
Q

When is it contraindicated to close an ASD ?

A
  • Closure of an ASD is contraindicated if shunt reversal (right to left) is present.
325
Q

Which ASD can just be followed clinically?

A

A small ASD with no associated symptoms or right heart enlargement can be followed clinically.

326
Q

What are the most important characteristic Findings of coarctation of the aorta?

A

hypertension, diminished femoral pulses, radial to femoral pulse delay; and a continuous murmur audible over ago back

327
Q

In patients with coarctation of the aorta, what valve abnormality is present typically?

A

bicuspid aortic valve, an ejection click or a systolic murmur

328
Q

what is the most appropriate HTN treatment for a patient with significant proteinuria and CKD?

A

The initiation of an ACE inhibitor (eg, benazepril) is most appropriate in this patient with chronic kidney disease (CKD) and significant proteinuria (ie,
> 500 mg/day). Inhibition of the renin-angiotensin-aldosterone system with ACE inhibitors or angiotensin II receptor blockers (ARBs) has been shown to reduce proteinuria and slow the progression of even advanced proteinuria CKD, likely in part due to selective vasodilation of renal efferent arterioles to decrease intraglomerular pressure.

329
Q

After ACE/ARB, which is the second line treatment for HTN in patients with significant antiproteinuric and CKD?

A

The nondihydropyridine calcium channel blockers (eg, diltiazem, verapamil) have significant antiproteinuric effects and can be used as second-line agents in patients with proteinuric CKD. However, the dihydropyridine calcium channel blockers (eg, amlodipine, nifedipine) do not have antiproteinuric effects.

330
Q

What is the treatment for Acute type A aortic dissections? And those with hemodynamic instability?

A

Acute type A aortic dissections can extend into the pericardial space and cause hemopericardium, cardiac tamponade, and shock. Such patients should be evaluated by urgent bedside transthoracic echocardiography and immediately sent for definitive surgical management. Pericardiocentesis is likely to be harmful in patients with cardiac tamponade complicating type A aortic dissection.

331
Q

In patients with coarctation of the aorta, what is the classic chest xray sign?

A

Figure 3 sign on CXR, (an indented aortic wall at the site of the coarctation with dilatation above and below the coarctation) and notching on the undersides of the posterior ribs.

332
Q

In young people presenting with unexplained hypertension, what should be the next step in evaluation?

A

Obtain BP in the legs in young people presenting with unexplained hypertension.

333
Q

Which patients with coarctation of the aorta should receive balloon dilation?

A

Schedule balloon dilation for patients with a discrete area of aortic narrowing, proximal hypertension, and a pressure gradient >20 mm Hg.

334
Q

which murmur is associated with a continuous “machinery” murmur heard beneath the left clavicle, with Bounding pulses and a wide pulse pressure may also be noted.

A

Patent Ductus Arteriosus

335
Q

Which cardiac syndrome is associated with clubbing and oxygen desaturation that affects the feet but not the hands?

A

A characteristic feature of an Elsenmenger PDA is clubbing and oxygen desaturation that affects the feet but not the hands

336
Q

When is closure of a PDA Is Indicated?

A

Closure of a PDA Is Indicated for left sided cardiac chamber enlargement in the absence of severe PH.

337
Q

When is Percutaneous PFO closure plus aspirin therapy indicated?

A

Percutaneous PFO closure plus aspirin therapy is beneficial in the prevention of recurrent stroke in patients with cryptogenic stroke.

338
Q

`How is PFO diagnosed?

A

PO is diagnosed by visualizing the interatrial septum by echocardiography, and demonstrating shunting of blood across the defect by color flow Doppler imaging or by using agitated saline.

339
Q

Do PFOs that are asymptomatic and identified incidentally require treatment?

A

PFO is usually asymptomatic and identified incidentally and, in these cases, no treatment or follow-up is needed.

340
Q

In the setting of a VSD, what features make a VSD clinically and hemodynamically significant?

A

A displaced apical LV impulse and mitral diastolic flow rumble suggest a hemodynamically important VSD.

341
Q

When should VSD be considered for closure?

A

Consider closure in adults with:
1. progressive regurgitation of the aortic or tricuspid valve
2. progressive L volume overload
3. recurrent endocarditis.

342
Q

If large VSD are not closed, what can happen as a result?

A

Without closure, large VSDs cause PH with eventual right-to-left shunt (Eisenmenger syndrome).

343
Q

When is VSD closure contraindicated?

A

When a large VSD causes PH with eventual right-to-left shunt (Eisenmenger syndrome).

344
Q

which procedures require prophylaxis for IE?

A
  1. Dental procedures that involve mucosal bleeding
  2. Procedures that involve incision or biopsy of the respiratory mucosa
  3. Procedures in patients with ongoing Gl or GU tract infection
  4. procedures on infected skin, skin structures, or musculoskeletal tissue
    5.Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials
345
Q

which risk factors are high risk and require prophylaxis for IE?

A

Provide prophylaxis for IE only in patients with the highest risk, including those with:
* prosthetic cardiac valve
* history of IE
* unrepaired cyanotic congenital heart disease
* repaired congenital heart defect with prosthesis or shunt (≤6 months post-procedure) or residual defect
* valvulopathy following cardiac transplantation
* prosthetic material used for cardiac valve repair (annuloplasty rings and chords)

346
Q

Which antibiotics for prophylactic IE is indicated for most patients in undergoing dental procedures?dental procedures?

A

Most patients requiring prophylaxis will be undergoing dental procedures, and the indicated antibiotic is oral amoxicillin 30 to 60 minutes before the procedure. If the patient is allergic to penicillin, use cephalexin, azithromycin, clarithromycin, or clindamycin.

347
Q

In a patient with Fever, malaise, and fatigue, new cardiac murmur, new-onset HF, conduction abnormalities on ECG, petechia, splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots,, which clinical syndrome should be suspected?

A

Infective endocarditis

348
Q

In a patient with suspected IE, what do conduction abnormalities on ECG suggests?

A

conduction abnormalities on ECG (suggests perivalvular abscess)

349
Q

In patients with low-probability of IE, which method of evaluation should be used?

A

TTE is sufficient to rule out IE in low-probability patients, but a TEE is indicated to rule in IE in patients with high probability of disease

350
Q

In patients with HIGHprobability of IE, which method of evaluation should be used?

A

TTE is sufficient to rule out IE in low-probability patients, but a TEE is indicated to rule in IE in patients with high probability of disease

351
Q

In the setting of Staphylococcus aureus bacteremia, which method of evaluation should be used to investigate IE?

A

Obtain a TEE particularly in the setting of Staphylococcus aureus bacteremia. TEE is the test of choice to identify a paravalvular abscess.

352
Q

Do patients with MVP or other low-risk valvular abnormalities require IE antimicrobial prophylaxis?

A

Don’t give antimicrobial prophylaxis to patients with MVP or other low-risk valvular abnormalities.

353
Q

In patients with Streptococcus bovis or Clostridium septum endocarditis, what other diagnosis should you be looking for?

A

Look for colon cancer in patients with Streptococcus bovis or Clostridium septicum endocarditis.

354
Q

What are the 3 major duke criteria for diagnosis of IE?

A
  1. Positive blood culture for endocarditis × 2 or single positive blood culture for Coxiella burnet or antiphase I gG antibody titer > 1:800
  2. Positive echocardiogram
  3. New valvular regurgitation
355
Q

What are the indications for surgery for patients with IE?

A
  • valvular dysfunction and acute HF
  • left sided IE caused by S. aureus, fungal infection, or highly resistant organisms
  • heart block
  • annular or aortic abscess
  • systemic embolization on antibiotic therapy
  • prosthetic valve endocarditis with relapsing infection or dehiscence
  • S. aureus prosthetic valve endocarditis
356
Q

Do patients with suspected IE and good cardiovascular function require empiric treatment before culture results for IE?

A

In patients with suspected IE and good cardiovascular function do not require empiric treatment before culture results. In decompensated patients, start empiric antibiotics immediately after blood cultures are obtained

357
Q

Do patients with suspected IE and decompensated cardiovascular function require empiric treatment before culture results for IE?

A

In decompensated patients, start empiric antibiotics immediately after blood cultures are obtained

358
Q

Can PO antibiotics be used for IE?

A

No

359
Q

What is the recommended empiric antibiotic regimen for patients with Community-acquired native valve IE?

A

Vancomycin or ampicillin-sulbactam plus gentamicin

360
Q

What is the recommended empiric antibiotic regimen for patients with Nosocomial-associated IE?

A

Vancomycin, gentamicin, rifampin, and an antipseudomonal B-lactam

361
Q

What is the recommended empiric antibiotic regimen for patients with Prosthetic valve IE?

A

Vancomycin, gentamicin, and rifampin

362
Q

Compared to community acquired native valve IE, what is the differenced in treatment for nosocomial IE?

A

Both use Vanc, and gentamycin, but nosocomial and prosthestic IE both adds rifampin and nosocomial adds something to cover pseudomonas

363
Q

for MSSA IE, WHAT is the recommended treatment? and for how long?

A

Uncomplicated right-sided native valve endocarditis caused by MSSA can be treated for 2 weeks with a combination of nafcillin or oxacillin,

364
Q

What is the recommended treatment DURATION for IE?

A

Continue treatment for 4 to 6 weeks except in uncomplicated right-sided native valve endocarditis caused by MSSA, which can be treated for 2 weeks with a combination of nafcillin, oxacillin

365
Q

Which patients require screening for Thoracic Aortic Aneurysm and Dissection with echocardiography?

A

Perform screening echocardiography of first-degree relatives of patients with familial thoracic aneurysm syndromes such as familial thoracic aortic aneurysms and aortic dissections (TAAD), bicuspid aortic valve, Marfan syndrome, Turner syndrome and Loeys-Dietz syndrome.

366
Q

A BP difference between the arms most likely is a sign of what clinical syndrome?

A

Aortic dissection

367
Q

What CXR findings are associated with aortic dissection?

A

A widened mediastinum is seen on chest -ray?

368
Q

What level d-dimer helps to rule out d dimer?

A

A low D dimer level (<500 ng/mL) helps rule out an acute aortic syndrome.

369
Q

What is the difference in type A, and type B dissections?

A

Dissections involving the ascending aorta are classified as type A, and all other dissections are classified as type B.

370
Q

In patients with suspected aortic dissection, and who are critically ill and cnnot be moved, what is the best diagnostic test?

A

Bedside TEE is used for critically ill patients who cannot be moved. Otherwise, The diagnosis is established by TEE, CTA, or MRA.

371
Q

For thoracic aneurysms, which meds can be used to reduce the rate of thoracic aortic dilation in patients with Marfan syndrome?

A

For thoracic aneurysms, B- blockers reduce the rate of thoracic aortic dilation in patients with Marfan syndrome.

372
Q

When is prophylactic surgery recommended for patients with ascending thoracic aortic aneurysm?

A
  • aortic diameter >5.0 cm (>4.5-5.0 cm for Marfan syndrome)
  • aortic diameter >4.5 cm and undergoing other heart surgery
  • rapid growth >0.5 cm/ yr
373
Q

For acute dissection, what is the initial treatment?

A

For acute dissection. begin IV -blocker therapy

374
Q

For acute dissection that does not respond to IV -blocker therapy, what additional med can be added ?

A

add nitroprusside if BP does not respond to IV B- blocker therapy.

375
Q

When is emergent surgery required for aortic dissection?

A

Emergent surgery is required for type A dissection (involving the ascending aorta) or intramural hematoma.

376
Q

Uncomplicated type B dissection is treated with medical therapy alone. Under what circumstance do patients with type B dissection not use medication alone?

A

Uncomplicated type B dissection is treated with continued medical therapy alone with the exception of patients with complications, including end-organ ischemia.

377
Q

For thoracic aortic aneurysm, what is the recommended interval follow up with echo for patients who have aortic diameter has been stable and <4.5 cm COMPARED to those who have aortic diameter is GREAER THAN 4.5 cm or the rate of enlargement >0.5 cm/year?

A

Annual echocardiography is recommended if the aortic diameter has been stable and <4.5 cm. If the aortic diameter is greater than 4.5 cm or the rate of enlargement >0.5 cm/year, imaging should be performed every 6 months.

377
Q

For thoracic aortic aneurysm, what is the recommended interval follow up with echo for patients who have aortic diameter has been stable and <4.5 cm COMPARED to those who have aortic diameter is GREAER THAN 4.5 cm or the rate of enlargement >0.5 cm/year?

A

Annual echocardiography is recommended if the aortic diameter has been stable and <4.5 cm. If the aortic diameter is greater than 4.5 cm or the rate of enlargement >0.5 cm/year, imaging should be performed every 6 months.

378
Q

Can hydralazine be used for acute aortic dissection?

A

Do not use hydralazine for acute aortic dissection because it increases shear stress

379
Q

When should surgery for type b dissection be considered?

A

Schedule surgery for type B dissection if major aortic vessels, such as renal arteries, are involved.

380
Q

Which population should be screened for abdominal Aortic Aneurysm?

A

One-time ultrasonographic screening is indicated to detect an asymptomatic AAA in any man between the ages of 65 and 75 years who has ever smoked and in selected men ages 65 to 75 years who have never smoked (eg., family history of AAA).

381
Q

Should women be screened for a abdominal Aortic Aneurysm?

A

No

382
Q

Which methods can and can not not be used to diagnosed ruptured AAA?

A

The diagnosis is confirmed by MRA or CT.
Ultrasonography is not accurate for diagnosing a ruptured AAA.

383
Q

Which abdominal Aortic Aneurysm requires surgical or endovascular repair?

A

Schedule surgical or endovascular repair of AAAs >5.5 cm in diameter, those growing ≥0.5 cm per year, or symptomatic AAAs. Ruptured AAA requires emergent surgery or endovascular repair.

384
Q

For patients with an unrepaired AAA what is the recommended ultrasonographic follow up?

A

monitoring at 6- to 12-month intervals if the AAA measures 4.0 to 5.4 cm and every 2 to 3 years for smaller AAAs.

385
Q

Clinical syndrome associated with livedo reticularis, gangrene of the digits (blue toe syndrome), and transient vision loss?

A

Aortic Atheroemboli

386
Q

A golden or brightly refractile cholesterol body within a retinal artery [Hollenhorst plaque] is pathognomonic for what clinical syndrome/

A

Aortic Atheroemboli

387
Q

What confirmatory test is used to diagnose Aortic Atheroemboli ?

A

Thrombocytopenia, eosinophilia, and urinary eosinophils may be present. Biopsy of muscle, skin, kidney, or other organs confirms the diagnosis.

388
Q

Patients who present with a stroke or AKI following recent cardiac or aortic surgery or other intravascular procedures should be considered for what diagnosis?

A

Aortic Atheroemboli

389
Q

What key features differentiate PAD (claudication) from spinal stenosis (psuedoclaudication)?

A

With PAD, discomfort does not occur with standing still, and the distance walked produces pain at a set distance, and with PAD the pain is usually less than 5 minutes.

390
Q

When patients have a normal or borderline resting ABI values or unexplained exertional leg symptoms, what is the next diagnostic step?

A

Exercise treadmill ABI testing

391
Q

What are the normal values for PAD?

A

0.9 to 1.4

392
Q

Which ABI values are compatible with PAD?

A

Less than 0.9

393
Q

Which ABI value is associated with ischemic rest pain?

A

less than 0.4

394
Q

Which ABI values are associated with false normal or calcified arteries?

A

greater than 1.4

395
Q

When ABI is greater than 1.4, what assessment should be ordered to better assess the lower extremities?

A

toe-brachial index

396
Q

what is the most effective treatment for improvement in functional status in patients with PAD?

A

Exercise training

397
Q

What is the treatment for patients with acute limb ischemia?

A

heparin ggt, antiplatelet agents and urgent surgery consult

398
Q

When is Cilostazol contraindicated for patients with PAD?

A

When patients have a low EF or history of HF

399
Q

Which clinical syndrome is associated with fever, anorexia weight loss and a clinical “TUMNOIR PLOP”?

A

Primary cardiac tumor, MYXOMA

400
Q

Where do cardiac myxomas typically arise?

A

Left atrium

401
Q

What is the treatment for myxomas and why?

A

Tx is resection because of the risk of embolization

ABIM (25 decks)

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