Hobb's Study Questions Flashcards
According to JNC-7 findings, what 2 classes of recommended BP medications are given in a patient with angina?
B-blockers
ACE inhibitors
What is the most common cause of secondary hypertension?
renal artery stenosis
What are the antihypertensive agents that are recommended for management of HF according to JNC-7 guidelines?
B-blockers
ACE inhibitors
aldosterone antagonists
loop diuretics
What two antihypertensive medication classes are suggested for patients with cerebrovascular dz, according to JNC-7?
ACE inhibitors
thiazide diuretics
What is the most common blood test order in a patient who is suspected of having occult HF?
BNP
Name 3 causes of acute onset HF
- acute MI
- papillary muscle rupture
- infective endocarditis
Name 4 causes of chronic HF
- cardiomyopathies
- infiltrated processes
- HTN
- valvular heart dz
What physical examination sign signifies cardio medley in a patient with heart failure?
displaced PMI
What is the New York heart Association heart failure classification for a patient who has symptoms associated with moderate exertion?
Class II. The New York heart Association heart failure classification is as follows: class I no symptoms, class II moderate symptoms, class III symptoms with minimal exertion, class IV symptoms at rest
What type of new heart sound may occur in a patient with either angina or myocardial infarction and why does this occur?
New S4 is due to a stiff and left ventricle making ventricular filling more difficult
Name three ECG findings that may occur in a patient with angina.
ST segment depression, T-wave in version and T-wave flattening
What is the typical finding on a nuclear stress test for a patient who has angina but has not had a heart attack?
Decreased ventricular filling
A patient with well-controlled angina presents with the change in his symptom pattern with chest pain. These symptoms occur sooner than expected and last longer than usual. The diagnostic workup reveals no ECG findings and cardiac enzymes are negative. What is the diagnosis?
unstable angina
What is the most common pathologic mechanism for a patient who has an acute MI?
rupture of an unstable plaque
What is the most common mechanism for a patient with acute MI who develops a new onset heart murmur?
rupture of papillary muscle resulting in acute mitral regurgitation (typically, it is the posterior papillary muscle since it has a single artery supply from the right coronary artery)
How soon can they troponin I cardiac enzyme become elevated and how long does it stay elevated?
rises in approximately 4 to 5 hours and can stay elevated for up to 14 days
What echocardiogram findings can be used to indentify in acute MI?
ventricular wall hypo-kinesis or akinesis; may also see acute decrease in left ventricular ejection fraction
What is the typical heart rate in a patient who has supraventricular tachycardia?
greater than 150 beats per minute
What is the significance of the large biphasic P wave in the lead V1 and AVR on the ECG?
right and left atrial enlargement
What is the most common sustained cardiac arrhythmia?
atrial fibrillation
What is the recommended treatment for a patient with premature atrial complexes?
generally none, as this is a self-limited condition
What is the differentiation between ventricular couplets and ventricular bigeminy?
couplets are two PVCs in a row while bigeminy is a PVC alternating with a normal complex
What is the expected adverse outcome of the R on T phenomenon?
ventricular tachycardia, this may occur because the PVC is firing on a very susceptible portion of the T wave
Name the accepted treatments of Torsades de pointes.
magnesium sulfate, overdrive pacing, and correction of any underlying cause or medication
What is the treatment of choice for third degree heart block?
Immediate pacing
What are the two lateral precordial heart leads?
V5 and V6
What are the three heart leads used in a patient suspected of having inferior wall damage?
Leads II, III, and aVF
What heart vessel is most commonly involved in a patient having a lateral wall myocardial infarction?
Circumflex artery
What is the most common heart vessel involved in a patient having an inferior wall myocardial infarction?
Right coronary artery
What is the most common heart vessel involved in a patient having an anterior wall myocardial infarction?
Left anterior descending artery
What is the most common symptom of left-sided heart failure?
Dyspnea—initially on exertion but will later progress to occurring at rest
What is the most common symptom of ischemic heart disease?
chest pain
What is the most common cardiac cause of dependent pitting edema?
Right-sided HF, though progressive left-sided HF can do this as well
What heart sound corresponds to the carotid pulse?
S1 heart sound
What causes the S-1 heart sound?
Closure of the mitral and the tricuspid heart valves (“Many Things Are Possible” is the pneumonic used to remember the closing sequence of the heart valves)
What are the causes of an accentuated S-1 heart sound?
Sinus tachycardia
mitral stenosis
increased cardiac output states such as severe anemia, hyperthyroidism and exercise
What is the effect of respiration on the S2 heart sound?
respiration widens the S2 because inspiration causes increased venous return to the right side of the heart which further delays closure of the pulmonic valve widening the split
What is the most common cause of fixed splitting of S2?
Atrial septal defect, caused by left to right shunting of blood in the atria resulting in equalization of blood in the chambers
What is the most common patient type in whom an S3 is normal?
Adults over 40 years of age who have a hyper dynamic circulation; pregnant women in their third trimester due to increased plasma volume
What is the most common heart sound that is initially heard in LV failure?
S3
What is the most common mechanism producing an S4 heart sound?
Atria contracting in the late diastole against a noncompliant or poor filling ventricle; ventricles do not fill well when hypertrophied or when pericardial fluid restricts filling or at times where there is a volume overload; left-sided S-4 sound increases with expiration
what is the most common reason for an opening snap?
mitral stenosis
What are the most common causes of a physiologic heart murmur?
anemia – decreased viscosity of the blood along with an increase in the rate causes the blood flow to increase through these normally structured valves; other causes include fever which results in increased rates and force of contraction and hyperthyroidism
What are the most common causes of an innocent heart murmur?
aortic systolic ejection murmur; this murmur is most commonly heard in children and usually classified as grade 1 or 2 and heard best in the second left intercostal space when the patient is supine
What causes a diastolic rumble?
a diastolic rumble is due to excessive blood rushing into the ventricle from the volume overloaded atria
What is the effect of squatting on heart valve sounds?
Squatting increases the left ventricular volume by increasing systemic vascular resistance. Squatting also increases venous return of blood to the right heart. Squatting will decrease the murmur of hypertrophic obstructive cardiomyopathy because when more blood is present in the heart the obstruction is lessened.
What is the effect of inspiration on heart murmurs?
Inspiration will increase the intensity of right-sided heart murmurs due to increased flow of blood into the right heart; this is due to an increase in negative intrathoracic pressure
What are the most common causes of left ventricular hypertrophy?
Essential hypertension causes concentric hypertrophy due to increased afterload.
~Other causes include aortic stenosis, aortic regurgitation, and left to right shunts.
What is the most common cause of right ventricular hypertrophy?
Pulmonary hypertension; due to increased afterload of the right ventricle which may be caused by hypertrophy of pulmonary vessels
~other causes include pulmonic valve stenosis and left to right shunts
What are the most common causes of a pericardial friction rub?
fibrous pericarditis secondary to viral pericarditis; it may also occur several weeks after myocardial infarction, this is called Dressler’s syndrome
~other causes include uremia rheumatic fever and lupus
What is the most common valvular cause of a narrow pulse pressure?
Aortic Stenosis
what is the effect of aging on heart rate?
Decreased heart rate due to decreased beta adrenergic response
What causes pulsus paradoxus to occur?
restricted filling of the right ventricle along with concomitant reduction in the stroke volume of the left ventricle; less blood going into the right ventricle means less blood into the pulmonary circulation and less blood going to the left ventricle; inspiration results and even less blood going into the right ventricle and so on; resulting in decreased systolic blood pressure
Name the two most common mechanisms for pulsus paradoxus to occur.
pericardial effusion and severe bronchial asthma with increased pulmonary pressure
Describe pulsus alternans.
A pulse that has a high volume accompanied by a low amplitude beat; amplitude changes occur as a result of stroke volume changes in the heart due to decreased contractility.
What is the most common cause of pulsus alternans?
severe left ventricular failure as seen in severe congestive heart failure
What test is best to evaluate for left atrial enlargement?
Transesophageal echocardiogram (TEE); this is due to the posterior location of the left atrium
What are the two lipid tests that are most commonly used in the screening for coronary heart disease in an asymptomatic patient?
Total cholesterol and HDL levels; risk is based on a comparison ratio between these two levels; LDL is also important
What lipid fraction is most commonly used to follow in the management of coronary artery disease in a patient with known heart disease?
LDL; new guidelines suggest a level under 70 in patients with established disease
what is the primary effect of lipoprotein A?
it enhances atherosclerosis
What is the difference between Apoprotein A and Apoprotein B?
Apoprotein A is a good marker as it consists primarily of HDL while type B primarily accompanies LDL
What are way to increase HDL cholesterol?
exercise, moderate alcohol intake, estrogen, niacin, weight loss, and statin drugs
What do triglyceride levels over 1000 put a patient at risk for ?
acute pancreatitis
How does DM affect lipids>
increase total cholesterol especially LDL and triglycerides; decrease HDL
What are the lipid effects of nephrotic syndrome?
increase total cholesterol and LDL
What are the acute effects on lipids in a patient who has had an acute MI?
cholesterol levels decreased by 40% after 48 hours and don’t return to baseline for another 2 to 3 months therefore measurements of lipids immediately after a myocardial infarction will be falsely low
What classes of antihypertensive medications adversely affect lipids?
thiazide diuretics if given in large dosages increased triglyceride and cholesterol levels; beta blockers increased total cholesterol and decrease HDL
What are the lipid effect of taking corticosteroids?
increase total cholesterol
Which is the most common type of familial hypercholesterolemia?
Type II hyperlipidemia
How do statins work?
They decrease delivery ability to produce cholesterol and up regulate receptors that increase clearing of LDL from the blood
what are the most worrisome side effects of statin drugs?
liver toxicity is the primary concern though myopathy can also occur
What is the mechanism of action for nicotinic acid
this drug inhibits lipolysis in adipose tissue which decreases the release of fatty acids and subsequent synthesis of LDL
What are the side effects of nicotinic acid?
Flushing caused by prostaglandin mediated vasodilation; hyperglycemia and hyperuricemia are less common
how do bile acid resins work?
These agents by bile salts resulting in an increased uptake of cholesterol, specifically LDL, from the bloodstream
What are two coexisting physical exam finding in a patient with coarctation of the aorta?
bicuspid aortic valve and rib notching
What are the BP goals for a patient with DM?
At or less than 130/80
What are the most common side effects associated with ACE inhibitors?
chronic cough and angioedema
What is the most common location of a Pheochromocytoma?
adrenal medulla
What is considered to be the gold standard test for the evaluation of renal vascular HTN?
renal angiography
What is a high pitched diastolic decrescendo murmur that is heard early after A2 at the LSB?
Aortic insufficiency
What is the most common cause of aortic stenosis?
senile degradation of a bicuspid aortic valve
What is the classic triad of symptoms for a patient with aortic stenosis?
DOE, chest pain syncope
What is the classic type of pulse associated with aortic stenosis?
parvus & tardus (weak & delayed)
What mode of inheritance occurs and HOCM?
autosomal dominant
What clinical condition associated with dyspnea and acute pulmonary congestion occurs due to a sudden increase in the left ventricular end diastolic pressure and left atrial pressure?
acute mitral regurgitation
What heart valve abnormality classically is the most common cause of cardiogenic pulmonary edema?
mitral stenosis
What disorder presents with substernal chest pain that worsens with inspiration and lying supine but lessens with setting up and leaning forward?
pericarditis
What are the classic EKG signs that are associated with acute pericarditis?
Diffuse ST segment elevation and PR depression; also in inverted t waves in some instances
Excruciating, tearing chest pain that radiates into the jaw or back end is acute and onset is associated with what condition?
aortic dissection
What drug class is the TOC for costochondritis?
NSAIDS
What are the minimum ST segment elevation criteria for diagnosing an acute MI?
ST elevation in two contiguous leads of at least 0.1 mm and limb leads &/or 0.2 mm in precordial leads
What is the most common mechanism for the occurrence of MI?
disruption or rupture of an atherosclerotic plaque leading to platelet aggregation, thrombus formation and occlusion of a coronary artery
What single medication is proven to be effective in both primary and secondary prevention of MI?
Aspirin
What medications have been proven to be beneficial to improve long-term prognosis after an acute myocardial infarction?
Aspirin, B-blockers, ACE inhibitors statins
Other than supportive measures what is the definitive treatment class used for ST segment elevation myocardial infarction?
thrombolytic therapy
What disorder causes wide complex polymorphic ventricular tachycardia with QRS complexes that progressively change direction or axis and may be seen in the setting of prolonged QT interval?
Torsades de pointes
What is one of the most common risk factors for the development of ventricular fibrillation?
Left ventricular dysfunction secondary to CAD
What are the two most common presenting signs or symptoms for ventricular fibrillation?
sudden cardiac death &/or syncope
What is the appropriate definition of what constitutes a significant Q wave?
One square wide and 1/3 of the height of the R wave
