Ch. 1 - Disease of the Cardiovascular System Flashcards
1
Q
Normal LV EF?
A
> 50%
2
Q
What 3 medications are typically used for a pharmacologic stress test?
A
IV
- adenosine
- dipyridamole
- dobutamine
3
Q
What is the definitive test for CAD?
A
Coronary angiography
4
Q
Coronary stenosis >__% may be significant
A
70%
5
Q
RIsk factors for CAD?
A
- smoking
- HTN
- Hyperlipidemia
- DM
- Obesity
- lack of exercise
- diet high in saturated fat and cholesterol
6
Q
What are 2 drugs administered to patients with stable angina that improve mortality?
A
- ASA
2. high intensity statins (or in some cases PCSK9 inhibitor)
7
Q
What are 4 types of drugs that relieve angina?
A
beta blockers
nitrates
calcium channel blockers
ranolazine
8
Q
What are 2 side effects of beta blockers?/
A
Erectile Dysfunction in males
Inability to increase HR in response to exercise
9
Q
What are side effects of Nitrates?
A
headache
orthostatic hypotension
tolerance
syncope
10
Q
What is the treatment for Mild CAD?
normal EF, mild angina, single vessel disease
A
Nitrates + B-blockers (Metoprolol)
+/- CCBs (Verapamil/Diltiazem) if refractory
11
Q
What is the treatment for Moderate CAD?
normal EF, moderate angina, two-vessel disease
A
Nitrates + B-blockers (Metoprolol)
+/- CCBs (Verapamil/Diltiazem) if refractory
AND Consider coronary angiography to assess for need for revascularization (PCI or CABG)
12
Q
What is the treatment for Severe CAD?
reduced EF, severe angina, three-vessel disease/left main/LAD disease
A
Coronary angiography to assess for need for CABG
13
Q
What type of medication MUST be avoided with reduced ejection fractions?
A
CCBs
14
Q
What are the indications for CABG?
A
3 vessel disease with >70% stenosis in each vessel
Left main coronary disease with >50% stenosis, left ventricular dysfunction
15
Q
Dual antiplatelet therapy includes ___ and ____
A
ASA 325
and
P2Y12 inhibitor (Clopidogrel, TIcagrelor, or Prasugrel)
16
Q
How long should DAPT be continued in patients with unstable angina?
A
9-12 months
17
Q
How long should LMWH (Enoxaparin) be continued in patients with unstable angina?
A
at least 48 hours
18
Q
The _____ score can be used to guide the decision on conservative versus more aggressive patients with stable angina.
A
TIMI risk score
19
Q
What did the CARE trial demonstrate?
A
Patients with a hx of MI had a 24% reduced risk of death, 31% reduced risk of stroke, and 27% reduced need for CABG or coronary angioplasty if they were started on a statin (regardless of LDL level).
20
Q
What is the hallmark of Variant (Prinzmetal) Angina?
Angina classically occurs at ____
A
transient ST-segment elevation (not depression) on ECG during chest pain, which represents transmural ischemia.
night
21
Q
What is the definitive test for Variant (Prinzmetal) Angina?
A
Coronary Angiography
- displays coronary vasospasm when the patient is given IV ergonovine or acetylcholine (to provoke vasoconstriction)
22
Q
What is the treatment for Variant (Prinzmetal) Angina?
A
Vasodilators - nitrates and CCBs
and risk factor modification (smoking and lipid lowering)
23
Q
MI is associated with a __% mortality rate
A
30%
24
Q
MI can be asymptomatic in 1/3 of patients and is more likely in which 4 populations?
A
post-op patients
diabetics
elderly
women
25
___ are transmural infarcts
STEMI
26
___ are subendocardial infarcts (inner 1/3-1/2 of the wall)
NSTEMI
27
Obtain Troponin I or T levels on admission and again every ___ hours for __ to __ hours.
every 6 hours
| for 18 to 24 hours
28
Troponins increase within __ to __ hours and return to normal in __ to __ days
3-5 hours
| 5-14 days
29
CKMB increases within __ to __ hours and return to normal in __ to __ hours
4-8 hours
| 48-72 hours
30
Obtain Troponin I or T levels on admission and again every ___ hours for 24 hours.
8
31
What 4 agents are the only ones shown to reduce mortality in MI?
1. ASA
2. Ticagrelor
3. B-blockers
4. ACE-inhibitors
32
What is the best statin to start before discharging a STEMI patient?
Atorvastatin 80 mg
33
The CAPRICORN study showed that ____ reduces the risk of death in patients with post-MI LV dysfunction
Carvedilol
34
What is the treatment for a patient with MI?
1. ASA
2. P2Y12 inhibitor (Clopidogrel, Ticagrelor)
3. Nitroglycerin
4. B-blocker (Atenolol or Metoprolol)
5. ACE-inhibitor
6. LMWH (Enoxaparin)
35
In acute MI, we attempt to get the HR under __ beats per minute with a systolic pressure > __ mm Hg
70 BPM
| > 90 mmHg
36
What are absolute contraindications to beta blocker therapy in MI?
- cardiogenic shock
- active bronchospasm
- severe bradycardia or heart block greater than 1st degree
- overt heart failure (including pulmonary edema)
37
What are absolute contraindications of thrombolytic therapy?
```
Trauma: recent head trauma or traumatic CPR
Previous stroke
recent invasive procedure or surgery
dissecting aortic aneurysm
active bleeding or bleeding diathesis
```
38
When is a free wall rupture most likely to occur?
90% in first 2 weeks after MI
Most 1-4 days after
(90% mortality rate)
39
What is the treatment for free wall rupture?
1. hemodynamic stabilization
2. immediate pericardiocentesis
3. surgical repair
40
When is a rupture of the interventricular septum most likely to occur?
within the first 10 days after MI
41
What is the treatment for papillary muscle rupture after MI?
```
emergency surgery for mitral valve replacement
afterload reduction (sodium nitroprusside or intra-aortic balloon pump [IABP])
```
42
What 2 treatments are contraindicated in Acute pericarditis?
NSAIDs and corticosteroids
| may hinder myocardial scar formation
43
What is the presentation of Dressler Syndrome, aka postmyocardial infarction syndrome?
fever, malaise, pericarditis, leukocytosis, and pleuritis
| occurring weeks to months after MI
44
What is the most effective therapy for Dressler syndrome?
ASA
| ibuprofen is 2nd best
45
What is the initial pharmacological therapy in patient who presents with chest pain?
If you suspect cardiac cause of pain, sublingual nitroglycerin is appropriate.
Also give aspirin if the patient does not have a bleeding disorder.
46
What are the 4 initial steps to managing a patient with chronic stable angina who presents with unstable angina?
1. ECG and cardiac enzymes
2. ASA
3. IV Heparin (If not contraindications -- active bleeding, recent life threatening bleed)
4. Admission to hospital for workup (CXR, PE workup etc.)
47
In a normal heart, increasing ___ results in greater contractility.
preload
48
Heart Failure with Reduced Ejection Fraction is defined as an EF of < __%
<40%
49
What are some causes of HFrEF?
ischemic heart disease or recent MI
idiopathic
HTN
Myocarditis (postviral, giant cell, autoimmune)
Drugs: alcohol, cocaine, meth, chemo (anthracyclines and trastuzumab)
Infiltrative disease (amyloidosis, sarcoidosis, hemochromatosis, Wilson disease)
Radiation therapy
Thyroid disease
Peripartum cardiomyopathy
Infectious disease (chagas, HIV, endocarditis causing valvular disease)
Valvular heart disease (MR, aortic stenosis or regurg)
High output HF (severe anemia, AV fistulas, pregnancy, severe thiamine deficiency)
Congenital/hereditary
50
What are some causes of HFdEF?
HTN --> myocardial hypertrophy
Valvular heart disease (Mitral stenosis, aortic stenosis or regurg)
Restrictive disease (amyloidosis, sarcoidosis, hemochromatosis in their early phases)
51
BNP levels > __ correlate strongly with the presence of decompensated CHF
>100
52
An NT-proBNP < ___ virtually excludes the diagnosis of CHF
<300
53
BNP may be falsely __ in obese patients
low
54
What is a MUGA scan?
Multigated Aquisition scan
- radionuclide ventriculography using Technitium-99m
used in assessment of CHF
55
What is the usefulness of diuretics in the treatment of CHF?
symptomatic relief; no reduction in mortality or improvement in prognosis
56
What is the #1 treatment for CHF?
Lifestyle modifications
- sodium restriction (<4g/day)
- fluid restriction (1.5-2L/day)
- weight loss
- smoking cessation
- restrict alcohol use
- exercise program
- monitor weight daily to detect fluid accumulation
- annual influenza and pneumococcal vaccine recommended
57
Which diuretics are useful in treatment of CHF symptoms?
Loop diuretics: Furosemide (Lasix) -- most common
- Bumetanide (Bumex) and torsemide
Thiazide-like diuretics are adjuncts: Metolazone, Chlorthiazide
58
Which ACE inhibitors for CHF have been proven to improve outcomes?
enalapril, lisinopril, captopril
59
Which beta blockers for CHF have been proven to improve outcomes?
Metoprolol succinate
Carvedilol
Bisoprolol
60
Which aldosterone antagonists for CHF have been proven to improve outcomes?
spironolactone, epleronone
(if EF <35%)
*** spironolactone is contraindicated in renal failure (Cr > 2)
61
In CHF patients with an EF less than __%, primary prevention of sudden cardiac death with ICD implantation is recommended
35
62
What is a good combination therapy for African American patients with HFrEF?
Hydralazine and nitrates (isosorbide dinitrate)
63
What medication can be added to a patient's therapy that is maxed out on ACEi or ARB with an EF of <35%?
Sacubatril/valsartan
| - angiotensin/neprilysin inhibitor (ARNI)
64
What medications are proven to improve mortality in patients with HFpEF?
none
65
What is the treatment for Mild CHF (NYHA Classes I to II)?
- restriction of sodium intake and physical activity
- ACE-inhibitor
- start loop diuretic if volume overload or pulmonary congestion is present
66
What is the treatment for Moderate CHF (NYHA Classes II to III)?
- ACE-inhibitor
- loop diuretic
- add B-blocker if response to above is suboptimal
(also reduces mortality)
67
What is the treatment for Severe CHF (NYHA Classes III to IV)?
- ACE-inhibitor
- loop diuretic
- Can add digoxin (for sx relief; takes several weeks to work)
- Add spironolactone or epleronone if EF <35%
68
What is the mechanism of action of ACE-inhibitors?
Cause venous and arterial dilation, decreasing preload and afterload and thus blood pressure
69
When starting ACE-inhibitors, what 3 things must you monitor?
BP, potassium, and creatinine
70
What is the treatment for Afib in a hemodynamically unstable patient?
immediate electrical cardioversion
71
What is the treatment for Afib in a hemodynamically STABLE patient?
rate control with B-blockers (preferred over CCBs)
Then,
If new (<48 hrs), Cardiovert.
```
If old (>48 hrs), TEE to determine if thrombus in left atrium...
If no--cardiovert. If yes, anticoagulate for 3 weeks then cardiovert.
```
72
what is the target rate for rate control in hemodynamically stable Afib patient?
Rate <110 BPM
73
What medications are contraindicated in patients with CHF?
Metformin
Thiazolidinediones
NSAIDs
some antiarrhythmic agents with negative ionotropic effects
74
The overall 5 year mortality in patients with CHF is about __%.
50%
75
What is the difference between cardioversion and defibrillation?
Cardioversion: delivery of a shock that is in synchrony with the QRS complex
- shock is timed NOT to hit the T wave
Defibrillation: delivery of a shock that is NOT in synchrony with the QRS complex
76
What is the goal of Cardioversion?
to terminate certain dysrhythmias such as PSVT or VT
77
What are the indications for cardioversion?
AFib
Atrial Flutter
VT with a pulse
SVT
78
What is the goal of defibrillation?
Convert a dysrhythmia to normal sinus rhythm
79
What are the indications for defibrillation?
Vfib, VT without a pulse
80
What are the 3 treatment goals of Afib?
1. rate control (<110)
2. assess need for anticoagulation
3. Rhythm control: restore normal sinus rhythm if first presentation or symptomatic
81
What is the ideal medication for treating both Afib and HFrEF?
Metoprolol succinate
| can also consider digoxin or amiodarone, useful for rhythm control
82
What scoring system can be used to assess risk of stroke in patients with Afib or Atrial flutter?
CHA2DS2-VASc score
83
When is warfarin indicated in AFib patients with a score >1?
mechanical valve
mitral valvular disease
ventricular assist devices
(otherwise DOACs can be used)
84
Which DOACs are approved for Afib?
Factor Xa inhibitors - Apixaban, Rivaroxaban, Edoxaban
Direct Thrombin Inhibitors - Dabigatran
- only one with FDA approved reversal agent
85
What is a couplet on EKG?
two successive PVCs
86
What is bigeminy on EKG?
Sinus beat followed by a PVC
87
What is trigeminy on EKG?
Two sinus beats followed by a PVC
88
How can acute warfarin-associated bleeding be reversed?
Fresh frozen plasma (FFP)
| Prothrombin Complex Concentrate (PCC)
89
Why is it important to anticoagulate a patient with Afib >48 hours 3 weeks before cardioversion and 4 weeks after?
risk of embolization during cardioversion = 2-5%
(Can obtain TEE of left atrium to rule out presence of clot to avoid waiting 3 weeks; if no clot present, start IV heparin and cardiovert within 24 hrs)
90
In Afib cardioversion, is electrical or pharmacological cardioversion preferred?
Electrical
91
How can pharmacological cardioversion be achieved in Afib patients?
Parenteral ibutilide, procainamide, flecainide, sotalol, amiodarone
92
What is the treatment for chronic AFib?
Rate control with a B-blocker or CCB
| Anticoagulation (unless <65 and without heart disease or underlying risk factors)
93
What is required to make a diagnosis of Multifocal Atrial Tachycardia?
At least 3 p wave morphologies
| in presence of tachycardia
94
If there are 3 or more p wave morphologies, but rate is between 60 and 100, what is the diagnosis?
wandering atrial pacemaker
95
What are possible treatments for multifocal atrial tachycardia with preserved left ventricular function?
```
CCBs
Beta blockers
digoxine
amiodarone
IV flecainide
IV propafenone
```
96
What are possible treatments for multifocal atrial tachycardia with decreased left ventricular function?
Digoxin
Diltiazem
Amiodarone
97
What is the most common arrhythmia caused by digoxin toxicity?
paroxysmal atrial tachycardia with 2:1 block
98
What is the treatment for paroxysmal SVT?
1. Maneuvers
- Valsalva, Carotid sinus massage, breath holding, head holding in cold water
2. IV adenosine
- alternatives: IV diltiazem (CCB), IV metoprolol (b-blocker), or digoxin
3. If refractory, DC cardioversion
99
Tachycardias with narrow QRS complexes originate _____
at or above the level of the AV node
100
Tachycardias with wide QRS complexes originate ____
outside of the normal conducting system or there is a supraventricular arrhythmia w/ coexisting abnormality in the His-Purkinje system
101
What are 5 side effects of Adenosine?
1. Headache
2. Flushing
3. SOB
4. Chest pressure
5. nausea
102
What is the treatment for WPW Syndrome?
ablation, procainamide or quinidine
Avoid drugs active on the AV node (beta blockers, CCBs, digoxin, adenosine)
103
What are risk factors for long QT?
```
hypokalemia
hypomagnesemia
hypocalcemia
drugs --antiemetics, antipsychotics, SSRIs, TCAs, macrolide and fluoroquinolone antibiotics]
congenital long QT syndrome
```
104
What is the treatment for Torsades de Pointes?
IV magnesium or if unstable --> electrical cardioversion
address underlying cause
may require Isoproterenol
105
Unlike ___, VT does NOT respond to vagal maneuvers or adenosine.
PSVT
106
What are cannon A waves?
clinical feature of VT found in the neck
| secondary to AV dissociation, which results in atrial contraction during ventricular contraction
107
What is the treatment for a hemodynamically stable patient with sustained VT?
IV amiodarone
108
Always suspect ___ in patients with a wide QRS (>.12 seconds)
VT
109
What is the most effective treatment for patient with nonsustained VT with underlying heart disease?
placement of implantable defibrillator
110
What is the treatment for VFib?
immediate defibrillation and CPR
111
What is sick sinus syndrome?
sinus node dysfunction characterized by a persistent spontaneous sinus bradycardia. Patients usually elderly.
112
What is the treatment for First Degree AV block?
benign condition that does not require treatment
113
What is the treatment for Second Degree AV block, type 1?
benign condition that does not require treatment
114
What is the treatment for Second Degree AV block, type 2?
pacemaker placement is necessary; often progresses to 3rd degree AV block
115
What is the treatment for Third Degree AV block?
pacemaker placement is necessary
116
What is the initial drug given to symptomatic patients with Hypertrophic Cardiomyopathy?
Beta blockers
117
What is the treatment for hemochromatosis?
phlebotomy or feroxamine
118
What is the treatment for Sarcoidosis?
Glucocorticoids for acute flairs
119
What are causes of myocarditis?
viruses --Coxsackie, Parvovirus B19, HHV6
bacteria --group A strep in rheumatic fever, Lyme Disease, Mycoplasma etc
SLE
Medications (eg sulfonamides)
idiopathic
120
What 4 changes are seen on ECG in the case of Acute Pericarditis?
1. DIffuse ST elevation and PR depression, with PR elevation in aVR
2. ST segment returns to normal--typically around 1 week
3. T wave may invert
4. T wave returns to normal
121
What is the treatment for Acute Pericarditis?
high dose NSAIDs (ASA, ibuprofen, naproxen, or indomethacin)
| adjunctive colchicine
122
How does ventricular filling differ in constrictive pericarditis vs cardiac tamponade?
constrictive pericarditis - unimpeded during early diastole, then halts
cardiac tamponade - impeded throughout
123
What is Kussmaul sign and what is it indicative of?
JVP (venous pressure) paradoxically increases during inspiration
124
What can be used to distinguish Constrictive Pericarditis and Restrictive Cardiomyopathy?
echo or cardiac catheterization
125
What is the imaging modality of choice for diagnosis of pericardial effusion and cardiac tamponade?
echocardiogram
126
what is the most important part of cardiac tamponade?
the RATE of fluid accumulation (not amount)
127
What are the key findings of Cardiac Tamponade?
Becks Triad -- Hypotension, muffled heart sounds, elevated JVP
Pulsus paradoxus
narrowed pulse pressure
128
What is the treatment for a nonhemorrhagic cardiac tamponade?
If hemodynamically stable -- monitor closely
| If unstable -- pericardiocentesis
129
What is the treatment for a hemorrhagic cardiac tamponade?
emergent surgery
| pericardiocentesis is only a temporizing measure until surgery
130
Almost all cases of mitral stenosis are due to ___
rheumatic heart disease
131
Patients with mitral stenosis are usually asymptomatic until the mitral valve area is reduced to approximately ____ cm^2
1.5 cm^2. (normal is 4-5)
132
What is a mitral stenosis murmur?
S2 followed by an opening snap, followed by a low-pitched diastolic rumble and presystolic accentuation
loud S1
133
How is the mitral stenosis murmur heard best?
left lateral decubitus position with bell of stethoscope
134
For the mitral stenosis murmur, what indicates a worse prognosis?
distance between S2 and the opening snap--closer to S2 = worse prognosis
135
In a patient with aortic stenosis, the development of what 3 things indicates a poor prognosis?
1. Angina - 3 yrs
2. Syncope - 2 yrs
3. Heart failure - 1.5 yrs
136
What murmur is heard for aortic stenosis?
Harsh crescendo-decrescendo murmur (2nd right intercostal space),
radiates to carotid arteries
137
What is the treatment for aortic stenosis?
If asymptomatic --> no treatment
If symptomatic --> surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR) depending on patient risk
(medical therapy has limited role)
138
What are acute causes of aortic regurg?
1. infective endocarditis
2. trauma
3. aortic dissection
4. iatrogenic as during a failed replacement therapy
139
What are chronic causes of aortic regurg (primary valvular)?
```
Rheumatic fever
bicuspid aortic valve
Marfan syndrome
Ehlers-danlos syndrome
ankylosing spondylitis
SLE
```
140
What are chronic causes of aortic regurg (aortic root disease)?
```
syphilitic aortitis
osteogenesis imperfecta
aortic dissection
Behcet syndrome
Reiter syndrome
systemic HTN
```
141
What are physical exam findings in pt with Aortic Regurg?
1. widened pulse pressure
2. DIastolic decrescendo murmur
3. Corrigan pulse
4. Austin Flint murmur
displaced PMI
murmur instensity increases with sustained handgrip
142
What is a Corrigan pulse?
rapidly increasing pulse that collapses suddenly as arterial pressure decreased rapidly in late systole and diastole; can be palpated at wrist or femoral arteries
143
What is an Austin Flint murmur?
low-pitched diastolic rumble due to competing flow anterograde from the LA and retrograde from the aorta. Similar to the murmur appreciated in mitral stenosis
144
What is the treatment for Aortic Regurg in patient that is asymptomatic with normal LV function?
no therapy indicated
145
What is the treatment for Aortic Regurg in patient that is asymptomatic with severe AR and LV dysfunction?
ACE inhibitor (or ARB) - for afterload reduction
146
What is the treatment for Aortic Regurg in patient that is symptomatic?
salt restriction, diuretics, afterload reduction (ACE-i),
HFrEF if heart failure
restriction on strenuous activity
147
What is definitive treatment for AR or for acute AR?
surgery -- aortic valve replacement
148
What murmur is seen with mitral regurgitation?
Holosystolic murmur (starts with S1 and continues on through S2) at the apex, which radiates to the back or clavicular area
149
What is the treatment for Mitral Regurg?
Afterload reduction with vasodilators is recommended for symptomatic patients only
If AFib -- chronic anticoagulation
Eventually -- surgery
150
What murmur is seen with Tricuspid regurg?
blowing holosystolic murmur
- at LLSB
- intensified with inspiration; reduced during expiration or the Valsalva maneuver
151
What type of murmur is seen with MVP?
midsystolic or late systolic click(s)
| mid-to-late systolic murmur
152
What maneuvers increase the MVP murmur?
standing and the valsalva maneuver
| reduce LV chamber size, allowing the click and murmur to occur earlier in systole
153
What maneuvers decrease the MVP murmur?
squatting (decreases LV chamber size)
154
What is the treatment for MVP?
asymptomatic --> reassurance
for chest pain --> beta blockers maybe useful
benign condition
155
How is the diagnosis of Acute Rheumatic Fever made?
2 major criteria OR 1 major criteria, 2 minor criteria
156
What are the major criteria associated with Acute Rheumatic fever?
Major criteria:
- migratory polyarthritis
- erythema marginatum
- cardiac involvement (eg pericarditis, CHF, valve disease)
- Chorea
- subcutaneous nodules
157
What are the minor criteria associated with Acute Rheumatic fever?
Minor criteria:
- fever
- elevated ESR
- polyarthralgias
- prior hx of rheumatic fever
- prolonged PR interval
- evidence of preceding streptococcal infection
158
What is the treatment for streptococcal pharyngitis?
Penicillin (penicillin or amoxicillin),
or Cephalosporin,
if penicillin allergy --> Macrolide (Azithromycin or Clarithromycin)
159
What is the treatment for Acute Rheumatic Fever?
NSAIDs
160
What is used to monitor treatment of Acute Rheumatic Fever?
C-reactive protein
161
Acute endocarditis is most commonly caused by ___
Staph aureus (highly virulent)
162
Acute endocarditis most commonly occurs on a ___ (normal/injured) heart valve
normal
163
Acute endocarditis is most commonly caused by ___
Strep viridans or enterococcus
164
Endocarditis caused by ___ is associated with increased risk of active colonic malignancy.
strep bovis
165
Prosthetic valve endocarditis: ____ is the most common cause of early onset endocarditis (<60 days after surgery).
___ is the most common cause of late onset endocarditis (>60 days after surgery).
staphylococci
| Streptococci
166
How is the diagnosis of endocarditis made?
Duke Criteria - 2 major criteria or 1 major and 3 minor criteria
167
What are the major criteria in the Duke criteria?
sustained bacteremia - by organism known to cause endocarditis
Endocardial involvement - by echocardiogram or new valve regurg
168
What are the minor criteria in the Duke criteria?
predisposing condition (abnormal valve or abnormal risk of bacteremia
fever
vascular phenomena (septic emboli, mycotic aneurysm, intracranial hemorrhage, janeway lesions)
immune phenomena (Glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor)
positive blood cultures
positive echocardiogram
169
What is Marantic Endocarditis?
sterile deposits of fibrin and platelets that form long the closure line of cardiac valve leaflets; associated with debilitating illness such as metastatic cancer
170
Characterized by the formation of small warty vegetations on both sides of valve leaflets and may present with regurgitant murmurs
Libman-Sacks Endocarditis
| assoc with SLE
171
How is atrial septal defect diagnosed?
TEE (with bubble study)
172
A late complication of atrial septal defect in which irreversible pulmonary HTN leads to reversal of shunt, heart failure, and cyanosis
Eisenmenger disease
173
When does an atrial septal defect need to be surgically repaired?
when pulmonary to systemic blood flow ratio is greater than 1.5:1 or 2:1 (or if symptomatic)
174
What is the most common congenital cardiac malformation?
ventricular septal defect
175
What type of murmur is associated with ventricular septal defect?
harsh, blowing holosystolic murmur with thrill
| - at 4th left intercostal space
176
What increases a VSD murmur? decreases?
Increased with handgrip
| decreased with standing
177
How is a coarctation of the aorta diagnosed?
CT angiogram
178
What murmur is associated with PDA?
continuous "machinery murmur" at left second intercostal space (both systolic and diastolic components)
179
What is the treatment for PDA?
if pulmonary vascular disease is absent --> surgical ligation
if severe pulmonary HTN or right-to-left shunt is present, do NOT correct the PDA -- surgery is CONTRAINDICATED
180
What 4 cardiac abnormalities make up tetrology of fallot?
1. ventricular septal defect
2. RV hypertrophy
3. pulmonary artery atresia or stenosis
4. overriding aorta
181
How is hypertensive emergency defined?
systolic BP >/= 180 or diastolic BP >/= 120
| IN ADDITION TO end-organ damage
182
What is the first step in treating a patient with severe headache and markedly elevated BP?
lower BP with antihypertensive agent
| then CT scan to rule out intracranial hemorrhage, if negative -- then lumbar puncture
183
What is the goal of treatment in pt with hypertensive emergency?
reduce mean arterial pressure by 25% in 1-2 hours
184
If hypertensive emergency is severe, with diastolic BP >130, what should be administered?
IV agents
| esmolol, nitroprusside, labetalol, or nitroglycerin
185
What are the preferred tests in the diagnosis of aortic dissection?
CTA and TEE
186
What is the treatment for aortic dissection?
IV beta blockers should be initiated immediately
- labetalol, esmolol
Goal systolic BP of 100-120
can add sodium nitroprusside
187
What triad of symptoms are indicative of a RUPTURED AAA?
abdominal pain,
hypotension
palpable pulsatile abdominal mass
188
What is the diagnostic test of choice for AAA?
Ultrasound
189
At what diameter of an AAA is surgical resection with synthetic graft placement recommended?
>5 cm
190
What is the name for an atheromatous occlusion of distal aorta just above bifurcation causing bilateral claudication, impotence, and absent/diminished femoral pulses?
Leriche syndrome
191
What is a normal ankle to brachial index (ABI)?
0.9 to 1.3
192
ABI < ___ usually means claudication
0.7
193
ABI < ___ usually presents with rest pain
0.4
194
ABI > 1.3 is due to ____
noncompressible vessels and indicates severe disease
195
What is the gold standard for diagnosing and locating PAD?
Arteriography
196
What is the most common site for an acute arterial occlusion?
common femoral artery
197
What are the 6 Ps of acute limb ischemia?
```
Pain
Pallor
Polar
Paralysis
Paresthesias
Pulselessness
```
198
Skeletal muscle can tolerate __ hours of ischemia
6
199
____ is a
- complication of syphilitic aortitis,
- aneurysm of the aortic arch with retrograde extension backwards to cause aortic regurg and stenosis of aortic branches, most commonly the coronary arteries
usually affecting men in their 4th-5th decade
Leutic Heart
200
What is the initial test for DVT and most accurate for DVT of proximal veins--Femoral and Popliteal?
Doppler analysis and Duplex ultrasound
201
What is the most accurate test for DVT of calf veins?
Vengraphy
202
What is the initial treatment for DVT?
anticoagulation with either
injectable LMWH (enoxaparin, dalteparin)
or DOACs (apixaban, rivaroxaban, edoxaban, dabigatran)
or warfarin with heparin bridge
203
When is thrombolytic therapy used as an adjunct to anticoagulation in patient with DVT?
if massive PE and hemodynamically unstable and no contraindications
204
What is the treatment for localized thrombophlebitis?
a mild analgesic (ASA or NSAIDs). elevation, and hot compresses; continue activity
205
What is the treatment for suppurative thrombophlebitis?
remove IV cannula and administer systemic abx
