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Current Medical Diagnosis and Treatment 2017 > Ch 10: Heart Disease > Flashcards

Ch 10: Heart Disease Flashcards

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USMLE® Step 1 flashcards
1
Q

Roughly how many adults in the US have congenital heart disease?

A

about 2 million (p. 322)

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2
Q

Severe pulmonary valve stenosis may present with signs of…

A

…right-sided heart failure. (p. 322)

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3
Q

In severe pulmonary valve stenosis, P2 may be…

A

…delayed and soft or absent. (p. 322)

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4
Q

The ejection click of pulmonary valve stenosis is the only right heart sound that…

A

…decreases with inspiration. All other right heart sounds increase. (p. 322)

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5
Q

What test is used to diagnose pulmonary valve stenosis?

A

echocardiography or doppler (p. 322)

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6
Q

In general, operation on a stenotic pulmonic valve should be done based on symptoms, however, if the peak pulmonic valve gradient is greater than __ mm Hg or a mean of __ mm Hg is found by echo/doppler, the patient should undergo intervention regardless of symptoms.

A

60 40 (p. 322)

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7
Q

Pulmonary stenosis can occur in two major forms, which are…

A

…valvular pulmonary stenosis, and infundibular stenosis. (p. 322)

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8
Q

Pulmonary stenosis is often __________ and associated with other _______ _______.

A

congenital cardiac lesions (p. 322)

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9
Q

In valvular pulmonic stenosis, pulmonary blood flow preferentially goes to the…

A

…left lung. (p. 322)

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10
Q

(Not from this text), but in general, what is an infundibulum?

A

a funnel-shaped cavity or structure. (medical dictionary)

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11
Q

The right ventricular infundibulum is also known as the… It is the left or anterosuperior, smooth-walled portion of the cavity of the right ventricle of the heart, which begins at the…

A

…conus arteriosus. …supraventricular crest and terminates in the pulmonary trunk. (medical dictionary)

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12
Q

Infundibular stenosis can be so severe that the right ventricle is…

A

…divided into a low-pressure and high-pressure chamber (i.e. double-chambered RV) (p. 322)

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13
Q

What is the Ross procedure for aortic valve disease?

A

Transfer of the pulmonary valve to the aortic position with a homograft pulmonary valve placed in the pulmonic position. (p. 322)

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14
Q

In patients who have had the Ross procedure, noncongenital postoperative pulmonic stenosis can result from an…

A

…immune response in the homograft. (p. 322)

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15
Q

What EKG findings may be present in pulmonary stenosis?

A

right axis deviation peaked P waves (p. 323)

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16
Q

What are the “essentials of diagnosis” of coarctation of the aorta?

A

–Usual presentation is systemic hypertension.

–Echocardiography/Doppler is diagnostic; a gradient of more than 20 mm Hg may be significant due to collaterals around the coarctation reducing gradient despite severe obstruction.

–Associated bicuspid aortic valve (in 50 - 80% of patients).

–Systolic pressure is higher in upper extremities than in lower extremities; diastolic pressures are similar. (p. 323)

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17
Q

How could you explain coarctation of the aorta to a patient?

A

A narrowing of the large blood vessel (aorta) that leads from the heart. Mayo Clinic

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18
Q

Coarctation is a cause of _________ ____________ and should be considered in _____ ________ with elevated blood pressure.

A

secondary hypertension young patients (p. 324)

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19
Q

In coarctation of the aorta, if cardiac failure does not occur in infancy, there are usually no symptoms until…

A

…the hypertension produces left ventricular failure.

(p. 324)

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20
Q

What are the essentials of diagnosis for atrial septal defect and patent foramen ovale?

A
  1. Often asymptomatic and discovered on routine examination.
  2. RV life; S2 widely split and fixed.
  3. Echocardiography/Doppler is diagnostic.
  4. All atrial septal defects (ASD) should be closed if there is any evidence of an RV volume overload regardless of symptoms.
  5. A patent foramen ovale (PFO), present in 25% of the population, rarely can lead to paradoxic emboli. Suspicion should be highest in patients who have cryptogenic stroke before age 55 years.
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21
Q

What does cryptogenic mean?

A

Of obscure or uncertain origin.

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22
Q

The most common form of ASD (80% of cases) is…

A

…persistence of the ostium secundum in the mid-septum.

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23
Q

Right-to-left PFO shunting may be more prominent when the patient is upright, leading to…

A

…orthostatic hypoxemia. This is also referred to as platypnea orthodeoxia. Platypnea-orthodeoxia is an uncommon syndrome of dyspnea and hypoxemia induced by upright posture, which is subsequently relieved by recumbency.

https://www.ncbi.nlm.nih.gov/pubmed/16042142

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24
Q

How can you explain a patient foramen ovale to a patient (PFO)?

A

A patent foramen ovale (PFO) is a hole in the heart that didn’t close the way it should after birth.

During fetal development, a small flap-like opening — the foramen ovale — is normally present in the wall between the right and left upper chambers of the heart (atria). It normally closes during infancy. When the foramen ovale doesn’t close, it’s called a patent foramen ovale.

http://www.mayoclinic.org/diseases-conditions/patent-foramen-ovale/basics/definition/con-20028729

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25
Q

The IMPROVE-IT study showed that _________ combined with ___________ was superior to ___________ alone in reducing LDL cholesterol and risk of MI and ischemic stroke (but not mortality) in stabilized patients following ACS.

A

ezetimibe, simvastatin

simvastatin

(p. 353)

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26
Q

In the RCT’s reviewed by expert panels regarding ASCVD and statins, what 2 drugs and dosages were considered “high-intensity statin therapy”?

A

Atorvastatin 40 - 80 mg

Rosuvastatin 20 - 40 mg

(p. 355).

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27
Q

What would cause a transient apical systolic murmur during a period of chest pain?

A

mitral regurgitation from papillary muscle dysfunction

(p. 356)

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28
Q

What is the Bruce protocol in stress testing?

A

The protocol increases the treadmill speed and elevation every 3 minutes until the patient is limited by symptoms.

(p. 357)

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29
Q

What percent of people with anatomically significant coronary disease will have a positive stress test?

A

60 - 80%

(p. 357)

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30
Q

What percent of people without significant coronary disease will have a positive stress test? (false positive)

A

10 - 30%

(p. 357)

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31
Q

How is the fractional flow reserve measured?

A

A pressure wire is used to measure the relative change in pressure across a coronary lesion after adenosine-induced hyperemia.

(p. 359)

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32
Q

See Lehne’s pharmacology flashcards (Chapter 52) for info regarding P2Y12 ADP receptor antagonists:

A

clopidogrel (Plavix)

prasugrel

ticlopidine

ticagrelor

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33
Q

The EARLY-ACS trial involved use of eptifibatide. What were its findings?

A

It found no benefit from eptifibatide started at the time of admission, compared with starting it at the time of invasive coronary angiography.

(p. 368)

34
Q

What kind of drug is fondaparinux?

Guidelines recommend fondaparinux as especially favorable in people who are…

A

a specific factor Xa inhibitor, that comes as a subcutaneous injection

…at high risk for bleeding, such as the elderly.

(p. 368)

35
Q

What are the guidelines for short-term discontinuation of P2Y12 ADP inhibitors for procedures?

A

Patients who have had bare metal stents placed should not stop taking them for at least one month following placement, and 3 - 6 months for drug-eluting stents. However, aspirin should generally be continued throughout the period of the procedure.

(p. 368)

36
Q

What is the starting and maximum doses for IV nitroglycerin?

A

10 mcg/min

200 mcg/min

(p. 368)

37
Q

Ca channel blockers have NOT been shown to favorably affect outcomes of unstable angina. However, if unable to tolerate nitrates and/or beta blockers, they are third-line therapy. Which two drugs are preferred, and which drug and drug sub-class should be avoided and why?

A

diltiazem or verapamil are preferred

nifedipine and other dihydropyridines are more likely to cause reflex tachycardia or hypotension

(p. 368)

38
Q

What is Kussmaul sign?

What does it indicate?

A

lack of decrease in jugular venous pressure with inspiration

it indicates RV infarction

(p. 371)

39
Q

An S3 is referred to as….

An S4 is referred to as…

Which is more common?

A

….a ventricular gallop

…an atrial gallop

S4

40
Q

Which cardiac biomarker is more useful for evaluating possible reinfarction?

A

CK-MB

(p. 371)

41
Q

Q waves do not occur in what percent of MIs?

A

30 - 50%

(p. 371)

42
Q

What is meant by the phrase “concordant ST elevation”?

A

ST elevation in leads with an overall positive QRS complex

(p. 371)

43
Q

Concordant ST elevation with left BBB is a specific finding indicating…

A

…STEMI.

(p. 371)

44
Q

What is the most sensitive test to detect and quantify extent of infarction?

A

MRI with gadolinium contrast enhancement

(p. 371)

45
Q

All patients with definite or suspected acute MI should receive _______ at a dose of ___ mg or ___ mg at once, regardless of whether fibrinolytic therapy is being considered or the patient has been taking it before.

If they have an allergy, they should receive…

A

aspirin, 162 mg or 325 mg

(p. 371)

a P2Y12 inhibitor. (p. 372)

46
Q

Prasugrel is contraindicated in patients who…

A

…have a history of stroke or who are older than 75 years.

(p. 372)

47
Q

Guidelines call for a P2Y12 inhibitor to be added to aspirin for all patients with STEMI, regardless of whether reperfusion is given, and continued for at least __ ____ and generally for _ ___.

A

14 days

1 year

(p. 372)

48
Q

Patients with STEMI who seek medical attention within 12 hrs of onset of symptoms should receive…

Patients with NSTEMI…

A

…reperfusion therapy, either primary PCI or fibrinolytic therapy.

…do not benefit. (p. 372)

49
Q

Primary PCI stenting is done with bivalirudin, a ______ ________ _________, or heparin, with or without glycoprotein IIb/IIIa inhibitors.

A

direct thrombin inhibitor

50
Q

The Heat PPCI trial showed…

A

…increased stent thrombosis and more adverse cardiovascular events with bivalirudin compared to unfractionated heparin.

(p. 373)

51
Q

The greatest benefit of thrombolytic therapy occurs if treatment is initiated within the first _ hours after the onset of presentation, when up to a __% reduction in mortality rate can be achieved.

A

3 hours

50%

(p. 374)

52
Q

What are the absolute contraindications to fibrinolytic therapy?

A
  • Previous hemorrhagic stroke
  • Other strokes or CVAs within the last year
  • Known intracranial neoplasm
  • Recent head trauma, including minor trauma
  • Active internal bleeding, excluding menstruation
  • Suspected aortic dissection

(p. 374)

53
Q

Alteplase is also known as…

A

…recombinant tissue plasminogen activator.

(p. 374)

54
Q

following fibrinolytic therapy for STEMI, what anticoagulation should the patient be on?

For how long?

A

Asprin (81 - 325 mg/day) and low-molecular weight heparin is preferable (either enoxaparin or fondaparinux)

until revascularization, or for the duration of the hospital stay, up to 8 days

(p. 375)

55
Q

NSAIDs should be avoided during hospitalization for STEMI due to increased risk of…

A

…mortality, myocardial rupture, hypertension, heart failure, and kidney injury

(p. 375)

56
Q

ACE inhibitors have shown the greatest benefit for STEMI patients with…

A

…an EF of 40% or less, large infarctions, or clinical evidence of heart failure.

(p. 375)

57
Q

Accelerated idioventricular rhythm following MI should NOT be treated with…

A

…antiarrhythmics, which could cause asystole.

(p. 377)

58
Q

Why should inotropic agents be avoided in acute LV failure if possible?

If necessary, which drug has the best hemodynamic profile? Dosage?

A

Because they often increase heart rate and myocardial oxygen demand, thus worsening outcomes.

Dobutamine, starting at 2.5 mcg/kg/min, up to a maximum of 20 mcg/kg/min

59
Q

What is the risk of having a patient receive both CPR and thrombolytic therapy??

A

pericardial tamponade due to hemorrhagic pericarditis

(p. 378)

60
Q

What were the findings of the IABP-SHOCK II trial?

A

In patients with cardiogenic shock, the use of an IABP does not offer a mortality benefit at 30 days or 1 year compared with routine care with rapid revascularization.

(p. 378)

61
Q

Which drug has been shown to be as effective at terminating SVT in the acute setting (approx 90%) as adenosine?

A

Verapamil

(p. 386)

62
Q

What is the difference between orthodromic and antidromic reentrant tachycardia?

A

Orthodromic reentrant tachycardia conducts antegrade down the AV node and retrograde up the accessory pathway, normally resulting in a narrow QRS.

Antidromic reentrant tachycardia conducts antegrade down the accessory pathway and retrograde through the AV node, resulting in a wide and often bizarre QRS which may be mistaken for V tach.

(p. 387)

63
Q

What are the 5 risk factors addressed by the CHADS2 Risk Score?

A

C - Cardiac - Heart failure or LVEF < 40%

H - Hypertension

A - Age > 75 years

D - Diabetes mellitus

S2 - Stroke or TIA

64
Q

What are the risk factors addressed in the CHA2DS2 - VASc Risk Score?

A

C - Cardiac - Heart failure or LVEF < 40% - 1 pt

H - Hypertension - 1 pt

A - Age > 75 years - 2 pt

D - Diabetes mellitus - 1 pt

S2 - Stroke or TIA - 2 pt

V - Vascular Disease (previous MI, PAD, or aortic plaque) - 1 pt

A - Age 65 - 74 - 1 pt

Female sex (but NOT a risk factor if female sex is the only factor) - 1 pt

Maximum score is 9

(p. 390)

65
Q

What are the 4 DOACs that have been shown to be at least as effective as warfarin for stroke prevention in patients with atrial fib?

A

dagibatran (Pradaxa)

rivaroxaban (Xarelto)

apixaban (Eliquis)

edoxaban (Savaysa, Lixiana)

66
Q

What are several reasons NOT to use the DOAC’s?

A

Those with mechanical prosthetic valves

advanced kidney disease (Cr Cl < 30 mL/min)

moderate or severe mitral stenosis

patients who can’t afford the newer medications

(p. 392)

67
Q

What is the reversal agent for dabigatran?

A

idarucizumab (pronounced eye-da-roo-SIZ-uh-mab)

68
Q

What is the general half-life of the DOAC’s in a patient with normal kidney function?

A

10 - 12 hours

(p. 393)

69
Q

An advantage of DOAC’s is that when stable anticoagulation is desired before elective cardioversion…

A

…it is achieved faster than with warfarin.

(p. 393)

70
Q

The normal pulmonary bed offers about what fraction of the resistance to blood flow as the systemic arterial system?

A

one-tenth

(p. 429)

71
Q

Experts recommend that a diagnosis of idiopathic pulmonary hypertension should be firmly based on a mean PA pressure of __ mm Hg or higher in association with…

A

…25 mm Hg

…a PCWP of less than 16 mm Hg at rest.

(pp. 429)

72
Q

What are the early symptoms of pulmonary hypertension?

Late symptoms?

A

exertional dyspnea, chest pain, fatigue, lightheadedness

syncope, abdominal distention, ascites, and peripheral edema

(p. 430)

73
Q

The Fourth World Symposium on Pulmonary Hypertension divided the disorder based on causes. What is group 1 made up of?

A

Pulmonary arterial hypertension related to an underlying pulmonary vasculopathy. This includes what we formerly called “idiopathic pulmonary arterial hypertension”.

74
Q

In the clinical classification of PH, what is Group 2 made up of?

A

All cases in which the PH is due to left heart disease.

(p. 430)

75
Q

In the clinical classification of PH, what is Group 3 made up of?

A

Those cases of PH which are due to lung disease and/or hypoxia (this includes those with COPD and interstitial lung disease)

(p. 430)

76
Q

In the clinical classification of PH, what is Group 4 made up of?

A

cases of PH due to chronic thromboembolic pulmonary hypertension

(p. 430)

77
Q

In the clinical classification of PH, what is Group 5 made up of?

A

Cases of PH due to unclear multifactorial mechanisms.

(p. 430)

78
Q

What 5 features in the Jones Criteria are considered major criteria?

A

C - A - C - E -S (think C-Aces)

carditis

arthritis (polyarthritis only)

chorea

erythema marginatum

subcutaneous nodules

(p. 423)

79
Q

What are the 5 features in the Jones Criteria which are considered to be minor criteria?

A

Fever

Arthralgia

Elevated ESR or CRP or both

prolonged PR interval

(p. 423)

80
Q

What establishes the diagnosis of rheumatic fever?

A

the presence of two major criteria - or one major and two minor criteria

(p. 422)

81
Q

Hypertrophic cardiomyopathy is inherited as an _________-_________ trait with variable penetrance and is caused by mutations of one of a large number of genes, most of which code for ______ _____ ______ or proteins regulating calcium handling.

A

autosomal-dominant

myosin heavy chains

Current Medical Diagnosis and Treatment 2017 (41 decks)

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