CV 2

Question 1

Individuals with AS are typically asymptomatic for a LONG time until you have severe AS….how long after becoming symptomatic doe typically live untreated?

Answer 1

2-3 years.

Question 2

What is the genetics of Hypertrophic Obstructive Cardiomyopathy?

How can HOCM affect Mitral valve motion?

Answer 2

Autosomal Dominant mutation of Cardiac Sarcomere muscles, causing septal hypertrophy and LV outlet obstruction.

SAM - Systolic anterior motion of mitral leaflet.

Question 3

What is the treatment for HOCM?

When should you consider ICD implantation?

Answer 3

Medical treatment = Negative IONOTROPICS
- BB (preferred)

ICD if:

1. FamHx of cardiac arrest or Vtach
2. Exertional Syncope
3. HYPOTN with exercise
4. LV septal wall great than 3 cm.

Question 4

What does the murmur of HOCM sound similar to? How can differentiate between these two?

Answer 4

Similar to AS BUT maneuvers that increase venous return to heart will DECREASE murmur of HOCM, while increasing AS.

Question 5

How does hand grip (increased Afterload) affect the following murmurs?

AS
AR
MS
MR
VSD
HOCM
MVP

Answer 5

AS - decrease
AR- Increase
MS - No change
MR - Increased 
VSD - Increased 
HOCM - Decreased
MVP - Decreased 

(Amyl Nitrate, which decreased the afterload has exactly the opposite effect)

Question 6

What do you need to do regarding family members after dx HOCM?

Answer 6

SCREEN every 1st degree relative with Echo.

Question 7

What kinds of Heart Abnormalities do you see in Marfans vs Elhers Danlos?

Answer 7

Marfans:

• Progressive Aortic root dilation
• MVP (can lead to acute MR if chordeae tendoniea rupture)

ELHERS DANLOS:
- MVP (can lead to acute MR if chordeae tendoniea rupture)

Question 8

What is the genetic mutation in Marfans vs Elhers Danlos?

Answer 8

Marfans:

• Autosomal Dominant
• Fibrillin 1 gene mutation

ED:
- CoL5A1 and CoL5A2 mutation

Question 9

A patient presents with CP to the ED…What tests would you first ORDER?

How do these tests dictate further management?

Answer 9

EKG
–> ST elevation = EMERGENT Cath

Troponins
–> +ve = Urgent Cath

IF EKG shows no ST elevation and TROPONIN negative –> Stress Test (Exercise vs Dobutamine)

Question 10

A patient comes to the ED with CP, has not ST elevation on EKG, and Toponins are negative.. You admit them to do a Stress test the next day…

How do you choose between exercise vs Dobutamin/Adenosine?

How do you choose between EKG, Echo, Nuclear myocardial perfusion imaging, while during the stress test?

Answer 10

Exercise is always preferred unless for some reason can’t tolerate exercise.

EKG - if initial EKG normal
Echo - if initial EKG abnormal or prior abnormal EKG
Nuclear - if HF or prior bypass.

Question 11

What does a negative a negative Stress test signify?

How should you manage a positive stress test?

Answer 11

Negative = No clinically significant CAD

Positive Stress test–> Determine risk

• LOW RISK –> medically manage (ASA, high statin, BB)
• High RISK –> Cath
• Cont CP despite medical management X 3 month –> Cath

Question 12

Paroxysmal Supraventricular Tachycardia presents as intermittent abrupt onset of tachycardia +/- dyspnea, rarely syncope.

What is the cause of PSVTs?

What is the TRX?

Answer 12

Eiotlogy = secondary conduction pathway that allows abnormal cycling of cardiac conduction through a formation of re-entry circuit.

(GOOGLE PICTURE)

TRX:

• Vagal maneuvers
• Adenosine
• IF HD instability –> Cardioversion

Question 13

Wolff- Parkinson- White presents as transient episodes of tachyarrhythmias (SVT or VT) .

What is the cause of WPW?

What are the 3 classic EKG findings?

TRX?

Answer 13

Caused by development of an extra nodal accessory conduction ptwy that bypasses AV node.

EKG:

1. Delta wave (slurred upstroke of QRS)
2. Shortening PR
3. Widening QRS

TRX:

• PROCAINAMIDE for SVT or VT
• Radiofrequency Ablation of Accessory Pathway.

Question 14

What is the most common cause of Dilated Cardiomyopathy? Second most common cause?

Everyone diagnosed with dilated cardiomyopathy requires what test? Why?

Answer 14

Most common cause is IDEOPATHIC
ISCHEMIC is 2nd most common…

Stress Test, to evaluate for CAD since ischemic myopathy is 2nd most common cause.

Question 15

Atrial Myxomas are the most common primary cardiac tumors…

Where are they usually located?

What 3 complications are they associated with?

How dx and trx?

Answer 15

Location = L atrium.

3 MAJOR COMPLICATION:

1. MV obstruction and rapidly worsening HF
2. New onset Afib
3. Tumor emboli (tumor is friable and bits break off)

DX- Echo
TRX - Surgical resection.