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Old cardio board review Qs > Deck 2 > Flashcards

Deck 2 Flashcards

0
Q

45M is referred for asymptomatic diastolic murmur. Echo shows mild AI, aortic root diameter 3.6 cm, bicuspid AV, maximum ascending aortic diameter 5.3 cm.

What to do next?

A

Refer for surgery of aortic root

Bicuspid AV and ascending aorta >5.0 cm should be referred for surgery (due to high risk of rupture)

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1
Q

65F with h/o CVA 4 months ago, HTN, DM p/w AWSTEMI. You are 100 mins away from PCI capable center. What to do next?

A

Give lytic therapy

She has no absolute contra-indications to lytic therapy and she is >90 mins away from PCI capable center.

Absolute contra-indications to lytics - history of ANY of the following:

ischemic CVS within 3 mos
Closed-head/facial trauma within 3 mos
IC Vascular lesion (eg aneurysm)
Hemorrhagic CVA
Malignant Intracranial neoplasm
Suspected aortic dissection
Acute bleeding or bleeding d/o
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2
Q

72M h/o CABG (including LIMA to LAD), DM p/w exertional CP. O/e (+) diminished pulses in Lt radial artery. What to do next? (2)

A

Check BP in both arms and send for CT thorax to evaluate for subclavian stenosis

diminished pulses in Lt arm and exertional CP post LIMA graft –> think of subclavian stenosis

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3
Q

Describe the characteristic carotid artery lesion that usually arises post RT treatment.

A

RT-induced CA dz usually Involves long segments of CCA +/- ICA

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5
Q

Name four conditions that predict a poor outcome in patients with chronic HF.

A
  1. Tachycardia at rest
  2. Low serum cholesterol (correlates with poor nutritional status)
  3. Escalating doses of diuretics
  4. Hyperuricemia
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6
Q

58F with h/o HCM p/w class II HF symptoms. Subsequent stress echo demonstrates (+) dynamic LVOT obstruction & exercise-induced moderate MR. What to do next?

A

start beta blockade

1st-line treatment of HF symptoms a/w dynamic LVOT gradient is medical therapy

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7
Q

65F h/o HOCM p/w dyspnea with minimal exertion. She takes a beta blocker. Last echo showed exercise-induced moderate MR. What to do next?

A

obstructive HCM w/ class III HF symptom despite medical therapy -> refer for surgical myomectomy

*indication surgical myomectomy: obstructive HCM that fails medical therapy (AND has class III or IV HF)

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8
Q

What is the ventilatory efficiency of CO2 removal? What is its significance with regard to evaluation of patients with chronic HF?

A

ventilatory eff of CO2 removal = VE/VCO2 (measured during cardiopulmonary testing)

where VE = pulmonary ventilation & VCO2 is carbon dioxide extraction from blood

VE/VCO2 > 35 correlates with poor prognosis

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9
Q

Pt with end-stage HFpEF undergoes cardiopulmonary exercise stress testing as part of workup. He has O2 consumption of 9 cc/kg/min, VE/VCO2 of 25. What to do next?

A

refer for transplant

VO2 of less than 12-14 cc/kg/min is a potent predictor of poor outcome –> patient should be sent for cardiac transplant

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10
Q

48M a/w ADHF, found with newly-diagnosed severe LVSD (EF 25%) and 3rd degree HB. What to do next?

A

Send for endomyocardial bx (EMB)

New-onset-HF with HB –> class I indication for EMB to r/o infiltration dz

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11
Q

55M h/o pAFib recently started on dofetilide presents to CCU after episode of VF in ED. His EKG shows sinus bradycardia. He wants to know why he had VF. What to tell him?

A

he likely went into VF because dofetilide is more potent at slower rates (and he has sinus bradycardia)

above property is called “reverse use-dependence”

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12
Q

65M is a/w ADHF & VT to CCU. He has been on normal-dose lidocaine gtt one day and now develops acute delirium. What to do next?

A

drop his lidocaine dose to half

patients with ADHF are at risk of lidocaine toxicity due to hepatic congestion –> they should get half the regular dose to avoid toxicity

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13
Q

discuss the metabolism of lidocaine

A

lidocaine is:

  1. metabolized by liver
  2. excreted by kidney
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14
Q

presentation of postural tachycardia syndrome? (POTS) (3)

A
  1. young female
  2. p/w: near-syncope, exercise intolerance
  3. o/e: excessive orthostatic tachycardic response with mild hypotension
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15
Q

38F p/w palpitations and fatigue ever since she had a severe flu-like illness 3 mos ago. o/e, sitting vitals show BP 110/70 & HR 80, standing vitals are BP 100/60 & HR 120. Most likely diagnosis?

A

POTS

in order to diagnose POTS you must have BOTH of the following:

  1. symptomatic (pre-syncope, etc..)
  2. upon standing HR is: increased by 30+ bpm OR >120 bpm
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16
Q

64M h/o HTN is r/w abnormal EKG. He is asymptomatic. EKG shows NSR with narrow QRS and 2:1 AVB. What to do next?

A

dx is asymptomatic 2:1 HB

perform vagal maneuver while he is hooked up to EKG -> if block is in the AVN, conduction will worsen with vagal maneuver

in asymptomatic 2:1 AVB, PPM is only indicated if block is distal (infra-nodal)

17
Q

52F h/o HTN & pAFib is r/w symptomatic episodes of Afib lasting 2-3 hours at at time, but only occurring once monthly. o/e HR 51. Treadmill stress echo shows no ischemia and normal cardiac structure. What to do next?

A

start her on anti-arrhythmic agent (class 1c or III) prn –>”pill in the pocket” approach

ideal candidate for pill-in the pocket: paroxysmal symptomatic episodes in young pt with no contra-indication to ARD agent

18
Q

3 absolute contra-indications to starting a pt on dofetilide?

A
  1. LVH on echo
  2. concurrent usage of HCTZ (risk of hypokalemic-induced tornadoes)
  3. QTc > 440 ms
19
Q

Pt with CPVT on nadolol 0.5 mg/kg/day has EST which is significant for 2 runs of NSVT at maximal exercise capacity. What to do next?

A

increase nadolol dose (max dose is 2.5 mg/kg/day)

20
Q

Pt with CPVT is taking maximum nadolol dosage per day and still has episodes of NSVT on holter monitor. What to do next?

A

start flecainide

21
Q

Pt is r/w newly-diagnosed CPVT. Which therapy should you start her on?

A

non-selective beta blocker (nadolol at 1-1.5 mg/kg/day)

22
Q

45M p/w palpitations to ED, found with monomorphic VT with superior axis and RBBB pattern. After cardioversion his EKG demonstrates NSR w/ 1st deg AVB. LHC shows normal coronaries with moderate global hypokinesis. What will cardiac MRI likely show?

A

MRI will likely show delayed enhancement of anterior wall consistent with cardiac sarcoid

when see conduction dz + scar-related VT from LV + normal coronaries –> think of cardiac sarcoid

23
Q

Pt h/o Afib on max lopressor dose, ICM (EF 25%) undergoes BiV/ICD implant for heart failure sx. He has persistent NYHA class III symptoms following the procedure and is noted to be paced 25% of time. What to do next?

A

Persistent tachycardia and AV dysynchrony 2/2 Afib despite pharmacotherapy trial

–> send for AV junction ablation

24
Q

Name the 8 types of regular SVT (use RP length to classify them).

A
  1. short RP tachycardias: non-paroxysmal junctional tachycardia (NPJT), typical AVNRT, orthodromic AV re-entry tachycardia (OAT), sinus tach with 1st degree AVB
  2. long RP tachycardias: permanent junctional reciprocating tachycardia (PJRT), PAT, sinus tach, atypical AVNRT
25
Q

Pt p/w regular narrow QRS tachycardia. Esophageal electrode shows 1:1 atrial-to-ventricular relationship during tachycardia. VA interval is 55 ms. Most likely diagnosis?

A

regular SVT w/ very short VA conduction time -> most likely dx is AVNRT

note: AVNRT usually has VA conduction time < 70ms

26
Q

differential diagnosis of narrow complex tachycardia with short RP, VA conduction time > 70 ms? (2)

A
  1. non-paroxysmal junctional tachycardia (NPJT)

2. orthodromic AV re-entry tachycardia (OAT)

27
Q

Pathophysiology of permanent junctional reciprocating tachycardia (PJRT)?

A

accessory pathway in muscular posteroseptal region that has AVN properties (slow & decremental conduction)

  1. PVC occurs and is conducted up the above accessory pathway to atria
  2. conduction continues down slow AVN pathway
28
Q

17M with h/o WPW p/w regular narrow complex tachycardia w/ cycle length of 375 ms that occurred with sudden-onset. RP interval is 100 ms. There is 1:1 relationship between A & V depolarization. Best initial treatment?

A

dx = probable orthodromic AV re-entry tachycardia (short RP, h/o WPW)

best treatment = AVN blockade (verapamil is a good choice)

29
Q

3 class I recommendations of CONSENSUS TRIAL?

A
  1. ACE-I for all patients w/ HF & reduced EF & current/prior symptoms (will reduce m&m)
  2. ACE-I for all patients with h/o ACS & reduced EF (reduces m&m)
  3. ACE-I for all patients w/ reduced EF (will prevent symptomatic HF, even if NO h/o ACS)
30
Q

Best anti-arrhythmic for Afib in pt with renal failure?

A

propafenone

99% hepatic clearance

31
Q

Pt with ESRD on HD develops hemodynamically-unstable sustained VT. He is due for dialysis later today. Which anti-arrhythmic is ideal?

A

amiodarone (it is NOT cleared by HD, so it will prevent VT even after dialysis is performed)

32
Q

Which anti-arrhythmic agents can increase serum levels of digoxin? (4)

A
  1. flecainide
  2. propafenone
  3. quinidine
  4. CCBs
33
Q

Which cardiac medication is contra-indicated for use with dofetilide?

A

verapamil

verapamil may lead to dofetilide toxicity in the following ways:

  1. blocks renal excretion of tykosin
  2. blocks hepatic metabolism of tykosin
34
Q

Class III anti-arrhythmic that is considered to have the LEAST negative inotropic effect?

A

dofetilide

35
Q

Pt with acute MI has multiple PVCs. The intern in the CCU calls to tell you that pt is having run of vtach x several seconds. Intern wants to give propafenone to prevent further arrhythmia. What to tell the tern?

A

do not give propafenone to pt in post-infarction period

CAST I & II trials: class IC agents promote arrhythmogenic death in post-infarct period

36
Q

Which anti-arrythmics are the most POTENT sodium channel blockers?

A

class IC agents are the most potent sodium channel blockers

class IB drugs are the WEAKEST Na blockers

37
Q

Pt with h/o systolic HF & Afib is admitted for Afib/RVR. He is loaded with amiodarone & his HR decreases to 70s. One day later he goes into bidirectional Vtach. Likely diagnosis?

A

bidirectional VT is characteristic of digoxin toxicity

dx = digoxin toxicity 2/2 amiodarone

**amiodarone increases serum concentrations of digoxin

38
Q

Which medication is the only FDA-approved drug for acute cardioversion of AFib to sinus rhythm?

A

ibutilide

Old cardio board review Qs (5 decks)

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