Ch 10: Heart Disease Flashcards
Roughly how many adults in the US have congenital heart disease?
about 2 million (p. 322)
Severe pulmonary valve stenosis may present with signs of…
…right-sided heart failure. (p. 322)
In severe pulmonary valve stenosis, P2 may be…
…delayed and soft or absent. (p. 322)
The ejection click of pulmonary valve stenosis is the only right heart sound that…
…decreases with inspiration. All other right heart sounds increase. (p. 322)
What test is used to diagnose pulmonary valve stenosis?
echocardiography or doppler (p. 322)
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.
60 40 (p. 322)
Pulmonary stenosis can occur in two major forms, which are…
…valvular pulmonary stenosis, and infundibular stenosis. (p. 322)
Pulmonary stenosis is often __________ and associated with other _______ _______.
congenital cardiac lesions (p. 322)
In valvular pulmonic stenosis, pulmonary blood flow preferentially goes to the…
…left lung. (p. 322)
(Not from this text), but in general, what is an infundibulum?
a funnel-shaped cavity or structure. (medical dictionary)
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…
…conus arteriosus. …supraventricular crest and terminates in the pulmonary trunk. (medical dictionary)
Infundibular stenosis can be so severe that the right ventricle is…
…divided into a low-pressure and high-pressure chamber (i.e. double-chambered RV) (p. 322)
What is the Ross procedure for aortic valve disease?
Transfer of the pulmonary valve to the aortic position with a homograft pulmonary valve placed in the pulmonic position. (p. 322)
In patients who have had the Ross procedure, noncongenital postoperative pulmonic stenosis can result from an…
…immune response in the homograft. (p. 322)
What EKG findings may be present in pulmonary stenosis?
right axis deviation peaked P waves (p. 323)
What are the “essentials of diagnosis” of coarctation of the aorta?
–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)
How could you explain coarctation of the aorta to a patient?
A narrowing of the large blood vessel (aorta) that leads from the heart. Mayo Clinic
Coarctation is a cause of _________ ____________ and should be considered in _____ ________ with elevated blood pressure.
secondary hypertension young patients (p. 324)
In coarctation of the aorta, if cardiac failure does not occur in infancy, there are usually no symptoms until…
…the hypertension produces left ventricular failure.
(p. 324)
What are the essentials of diagnosis for atrial septal defect and patent foramen ovale?
- Often asymptomatic and discovered on routine examination.
- RV life; S2 widely split and fixed.
- Echocardiography/Doppler is diagnostic.
- All atrial septal defects (ASD) should be closed if there is any evidence of an RV volume overload regardless of symptoms.
- 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.
What does cryptogenic mean?
Of obscure or uncertain origin.
The most common form of ASD (80% of cases) is…
…persistence of the ostium secundum in the mid-septum.
Right-to-left PFO shunting may be more prominent when the patient is upright, leading to…
…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
How can you explain a patient foramen ovale to a patient (PFO)?
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
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.
ezetimibe, simvastatin
simvastatin
(p. 353)
In the RCT’s reviewed by expert panels regarding ASCVD and statins, what 2 drugs and dosages were considered “high-intensity statin therapy”?
Atorvastatin 40 - 80 mg
Rosuvastatin 20 - 40 mg
(p. 355).
What would cause a transient apical systolic murmur during a period of chest pain?
mitral regurgitation from papillary muscle dysfunction
(p. 356)
What is the Bruce protocol in stress testing?
The protocol increases the treadmill speed and elevation every 3 minutes until the patient is limited by symptoms.
(p. 357)
What percent of people with anatomically significant coronary disease will have a positive stress test?
60 - 80%
(p. 357)
What percent of people without significant coronary disease will have a positive stress test? (false positive)
10 - 30%
(p. 357)
How is the fractional flow reserve measured?
A pressure wire is used to measure the relative change in pressure across a coronary lesion after adenosine-induced hyperemia.
(p. 359)
See Lehne’s pharmacology flashcards (Chapter 52) for info regarding P2Y12 ADP receptor antagonists:
clopidogrel (Plavix)
prasugrel
ticlopidine
ticagrelor
The EARLY-ACS trial involved use of eptifibatide. What were its findings?
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)
What kind of drug is fondaparinux?
Guidelines recommend fondaparinux as especially favorable in people who are…
a specific factor Xa inhibitor, that comes as a subcutaneous injection
…at high risk for bleeding, such as the elderly.
(p. 368)
What are the guidelines for short-term discontinuation of P2Y12 ADP inhibitors for procedures?
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)
What is the starting and maximum doses for IV nitroglycerin?
10 mcg/min
200 mcg/min
(p. 368)
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?
diltiazem or verapamil are preferred
nifedipine and other dihydropyridines are more likely to cause reflex tachycardia or hypotension
(p. 368)
What is Kussmaul sign?
What does it indicate?
lack of decrease in jugular venous pressure with inspiration
it indicates RV infarction
(p. 371)
An S3 is referred to as….
An S4 is referred to as…
Which is more common?
….a ventricular gallop
…an atrial gallop
S4
Which cardiac biomarker is more useful for evaluating possible reinfarction?
CK-MB
(p. 371)
Q waves do not occur in what percent of MIs?
30 - 50%
(p. 371)
What is meant by the phrase “concordant ST elevation”?
ST elevation in leads with an overall positive QRS complex
(p. 371)
Concordant ST elevation with left BBB is a specific finding indicating…
…STEMI.
(p. 371)
What is the most sensitive test to detect and quantify extent of infarction?
MRI with gadolinium contrast enhancement
(p. 371)
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…
aspirin, 162 mg or 325 mg
(p. 371)
a P2Y12 inhibitor. (p. 372)
Prasugrel is contraindicated in patients who…
…have a history of stroke or who are older than 75 years.
(p. 372)
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 _ ___.
14 days
1 year
(p. 372)
Patients with STEMI who seek medical attention within 12 hrs of onset of symptoms should receive…
Patients with NSTEMI…
…reperfusion therapy, either primary PCI or fibrinolytic therapy.
…do not benefit. (p. 372)
Primary PCI stenting is done with bivalirudin, a ______ ________ _________, or heparin, with or without glycoprotein IIb/IIIa inhibitors.
direct thrombin inhibitor
The Heat PPCI trial showed…
…increased stent thrombosis and more adverse cardiovascular events with bivalirudin compared to unfractionated heparin.
(p. 373)
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.
3 hours
50%
(p. 374)
What are the absolute contraindications to fibrinolytic therapy?
- 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)
Alteplase is also known as…
…recombinant tissue plasminogen activator.
(p. 374)
following fibrinolytic therapy for STEMI, what anticoagulation should the patient be on?
For how long?
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)
NSAIDs should be avoided during hospitalization for STEMI due to increased risk of…
…mortality, myocardial rupture, hypertension, heart failure, and kidney injury
(p. 375)
ACE inhibitors have shown the greatest benefit for STEMI patients with…
…an EF of 40% or less, large infarctions, or clinical evidence of heart failure.
(p. 375)
Accelerated idioventricular rhythm following MI should NOT be treated with…
…antiarrhythmics, which could cause asystole.
(p. 377)
Why should inotropic agents be avoided in acute LV failure if possible?
If necessary, which drug has the best hemodynamic profile? Dosage?
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
What is the risk of having a patient receive both CPR and thrombolytic therapy??
pericardial tamponade due to hemorrhagic pericarditis
(p. 378)
What were the findings of the IABP-SHOCK II trial?
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)
Which drug has been shown to be as effective at terminating SVT in the acute setting (approx 90%) as adenosine?
Verapamil
(p. 386)
What is the difference between orthodromic and antidromic reentrant tachycardia?
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)
What are the 5 risk factors addressed by the CHADS2 Risk Score?
C - Cardiac - Heart failure or LVEF < 40%
H - Hypertension
A - Age > 75 years
D - Diabetes mellitus
S2 - Stroke or TIA
What are the risk factors addressed in the CHA2DS2 - VASc Risk Score?
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)
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?
dagibatran (Pradaxa)
rivaroxaban (Xarelto)
apixaban (Eliquis)
edoxaban (Savaysa, Lixiana)
What are several reasons NOT to use the DOAC’s?
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)
What is the reversal agent for dabigatran?
idarucizumab (pronounced eye-da-roo-SIZ-uh-mab)
What is the general half-life of the DOAC’s in a patient with normal kidney function?
10 - 12 hours
(p. 393)
An advantage of DOAC’s is that when stable anticoagulation is desired before elective cardioversion…
…it is achieved faster than with warfarin.
(p. 393)
The normal pulmonary bed offers about what fraction of the resistance to blood flow as the systemic arterial system?
one-tenth
(p. 429)
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…
…25 mm Hg
…a PCWP of less than 16 mm Hg at rest.
(pp. 429)
What are the early symptoms of pulmonary hypertension?
Late symptoms?
exertional dyspnea, chest pain, fatigue, lightheadedness
syncope, abdominal distention, ascites, and peripheral edema
(p. 430)
The Fourth World Symposium on Pulmonary Hypertension divided the disorder based on causes. What is group 1 made up of?
Pulmonary arterial hypertension related to an underlying pulmonary vasculopathy. This includes what we formerly called “idiopathic pulmonary arterial hypertension”.
In the clinical classification of PH, what is Group 2 made up of?
All cases in which the PH is due to left heart disease.
(p. 430)
In the clinical classification of PH, what is Group 3 made up of?
Those cases of PH which are due to lung disease and/or hypoxia (this includes those with COPD and interstitial lung disease)
(p. 430)
In the clinical classification of PH, what is Group 4 made up of?
cases of PH due to chronic thromboembolic pulmonary hypertension
(p. 430)
In the clinical classification of PH, what is Group 5 made up of?
Cases of PH due to unclear multifactorial mechanisms.
(p. 430)
What 5 features in the Jones Criteria are considered major criteria?
C - A - C - E -S (think C-Aces)
carditis
arthritis (polyarthritis only)
chorea
erythema marginatum
subcutaneous nodules
(p. 423)
What are the 5 features in the Jones Criteria which are considered to be minor criteria?
Fever
Arthralgia
Elevated ESR or CRP or both
prolonged PR interval
(p. 423)
What establishes the diagnosis of rheumatic fever?
the presence of two major criteria - or one major and two minor criteria
(p. 422)
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.
autosomal-dominant
myosin heavy chains
