IMC-Final Flashcards
Define Dilated Cardiomyopathy
Idiopathic dilated cardiomyopathy is the MC cause of ?
What will be seen on PE
Systolic dysfunction d/t dilation of all chambers and impaired contractility (LVEF <40%)
Indication for cardiac transplant
Heart failure
Megaly Rales S3 gallop JVP
What will be seen on EKG of Dilated Cardiomyopathy
Commonly, ? regurgitation develop and w/ ? risks
What would be seen on CXR
LBBB Arrhythmia Sinus tachycardia
MR- Afib
TR- ventricular arrhythmias
Globular megaly (balloon)
CHF
Pleural effusion R>L
Any dilated cardiomyopathy Pt w/ dyspnea needs ? lab drawn
? is the Dx modality of choice for RV dysplasia
When/why would a biopsy be most helpful
BNP- establishes prognosis/disease severity
Cardiac MRI
Transplant rejection
How is Dilated Cardiomyopathy Tx
CCBs are avoided and only used if ?
All DM w/ Dilated Cardiomyopathy need to be on ? diuretic
Loop ACEI BB
Digitalis for inc contractility
Afib/Flutter
Mineral corticoid antagonist:
Spirinolactone
Eplerenone
What 3 criteria need to be met to use Ivabradine to lower tachy rhythms in Dilated Cardiomyopathy
What medication is tradiationally used more often but is second in line for use
Normally nitric oxide therapy is avoided in AfAm Pts is avoided, however AfAm w/ Dilated Cardiomyopathy may be Tx w/ ? combo drug
LVEF <35%
Resting HR >70bpm
Chronic and stable HF
Digoxin- decreases recurrent hospitalizations and Afib rate control
Hydralazine-Nitrate
When can Pts w/ Dilated Cardiomyopathy induced Afib be converted w/ ?
When is ICD placement considered
Dilated Cardiomyopathy Pts are more at risk for ? compared to ischemic Cardiomyopathy Pts
Synchronized biventricular pacing if:
QRS >150msec w/ significant MR
Ischemic cardiomyopathy w/ LVEF >30% and on medical therapy
Emboli
Pts w/ Dilated Cardiomyopathy induced Afib should be Tx w/ ? anticoagulant unless ?
? is the MC cardiomyopathy
Half of the time this MC is caused by ? and the other half by ?
DOAC;
Warfarin if MS
Dilated- 95%
Idiopathic
Alcoholism
Define Hypertrophic Cardiomyopathy
What causes the outflow obstruction to be worse and causes ? type of dysfunction
What is the end consequence seen in Hypertrophic Cardiomyopathy
LV wall >1.5cm/15mm thick on Echo, MC in septal region
Narrowed w/ systole and
Anterior MV leaflet;
Diastolic dysfunction
Elevated LV diastolic pressure
How is Hypertrophic Cardiomyopathy acquired
This can be confused w/ athletic heart, how is it differentiated
Apical Hypertrophic Cardiomegaly is more common in ? populations
Autosomal dominant mutated genes of sarcomere/myosin heavy chains/Ca regulating proteins
Athletic heart- no diastolic dysfunction
Asian
What type of Hypertrophic Cardiomegaly seen in older adults is d/t ?
What CXR finding is specific to this type
What are the 3 common presenting Sxs if not sudden death
HTN
Sigmoid interventricular septum w/ cardiac knob below aortic valve
Postexertional syncope
Angina
Dyspnea
What is a poor prognostic sign in Hypertrophic Cardiomyopathy w/ elevated LA pressures
What would be seen on PE
? type of valvular murmur is commonly present
Afib
Bisferiens carotid pulse
Loud S4
Triple apical pulse
Prominent A-wave: atrial contraction; absent in AFib
MR
What type of murmur does HOCM cause
What causes the murmur to be louder/softer
These maneuvers are done to differentiate HOCm from ?
Loud systolic cresc-decresc murmur at LLSB
Inc: upright, valsalva (dec LV volume)
Dec: squat, hand grip, leg raise (inc LV volume)
AS- dec stroke volume= dec murmur
Inc w/ squat
Dec w/ valsalva, standing
? EKG finding is nearly universal in all HOCM Pts w/ Sxs
? EKG finding can mimic MIs
TTE is Dx for HOCM and needed to r/o ? other congenital heart dz
LVH
Inferolateral septal Q-waves- 1, aVL, V5-6 and <1 box wide
Ventricular noncompaction- ridges in cardiac walls causing LV to partially fill
? coronary artery issue is seen w/ HOCM
How is this Tx w/ meds
? type of pacing helps Tx these Pts in AFib and prevents progression of hypertrophy/obstruction
Arterial bridging- systolic squeezing of arteries
Metoprolol (initial for Sxs)
Verapamil
Dysopyramide (no mono use)
Diuretic
Short AV-delay biventricular pacing
What HOCM Pts are best managed w/ ICD
When is an ICD consideration warranted
How is HOCM Tx surgically
Any one of:
Malignant ventricular arrhythmia
Unexplained syncope w/ +FamHx sudden death
Wall thickness of 30mm
Unexplained syncope <6mon
Sudden death, 1* relative
Myotomy-myomectomy w/ Alfieri stitch (considerd best Tx w/ outflow relief)
Alcohol ablation in LCA
What are the indications for HOCM Pt to be considered for transplant
Pregnant Pts have increased issues when pressure gradient passes ?
How are these Pts medically managed
Progression to LV dilation
Intractable Sxs
> 50mmHg
Continue BB therapy
What is the next Dx step after a Dx of HOCM is made on Echo
What med classes need to be avoided in HOCM Tx
What drug is c/i in these Pts
Ambulatory ECG
Exercise stress test
Dec preload:
Diuretic ACEI Nitro ARBs
Digoxin- increased force will increase obstruction
Define Restrictive Cardiomyopathy
What is the MC cause
Restrictive Cardiomyopathy mimics ? Dx and is differentiated by ?
Impaired diastolic filling (MC- LV) d/t infiltrates w/ preserved contractile function
Amyloidosis
Constrictive pericarditis-
ventricular interaction accentuated w/ inspiration (absent in RC, which has inc pulmonary arterial pressure)
What two imaging results is suggestive of Restrictive Cardiomyopathy
? method of imaging can identify amyloid deposition in the myocardium and how is it confirmed
? imaging modality is used as a screening test method or if a Dx by Echo is uncertain
EKG w/ low voltage QRS
Echo w/ LVH
Technetium pyrophosphate imaging (bone scan), confirmed w/ biopsy
Cardiac MRI
How is Dx of Restrictive Cardiomyopathy made and w/ ? findings
How is systemic involvement of this condition confirmed
What medication has shown to decrease hospitalizations and improve quality of life
Echo w/ cardiac cath:
Normal chamber size
Reduced LVEF
Rectal, Adipose, Gingival biopsy
Tafamidis
What medication needs to be avoided in Tx of Restricted Cardiomyopathy
Why would CCS be used
How is primary cardiac amyloidosis w/out systemic involvement Tx
Digoxin- predisposes arrhythmias
Conduction abnormalities
Transplant
? is the MC etiology of Restrictive Cardiomyopathy worldwide
What type of extra heart sound does this condition have
? population is most susceptible to idiopathic Restrictive Cardiomyopathy
Tropical Endomyocarditis Fibrosis
S4
Northern European men
? is the MC type of ASD
What is a less common type
This less common type usually also has ? two defects
Ostium Secundum in mid-septum
Ostium Primum- lower septum
MV/TV clefts
VSD
? clot issue can occur in the ASD population
What will be heard on PE
ASDs are the ?MC murmur
Paradoxical embolization
Wide, fixed split S2 (lub dub-dub) w/out inspiration varying
2nd, after VSDs
ASD can remain ASx until later in life until ? c/c presents
What is seen on EKG
How are ASDs Dx
> 30- angina
50- RVF Afib Dyspnea
RAD RVH RBBB
Echo w/ bubble contrast
How are small ASDs Tx
When is surgical closure considered
How do PDAs present
<3mm spontaneously close
3-8mm spontaneously close by 3y/o
Mod/large w/ RV volume overload- surgical repair between 2-6y/o
Infant w/ FTT, tachy/tachy and machinery murmur
What causes PDAs
What will be seen on PE
How are these Tx
Persistent ductus arteriosus between aorta/PA
Wide pulse pressure w/ low DBP
Premature w/ significant shunt: Indomethicin w/ fluid restriction
Persists- surgical repair
Define VSD
What dictates the degree of shunting
When will a louder murmur be present
Left to right shunt d/t patent defect
RV pressure
Greater L-R gradient through smaller shunts
VSD sizes are made by comparing them to ? structure
What type of murmur is created in this defect
If VSD leads to P-HTN, ? valve defect will be present
Aortic root
Harsh holosystolic at 3-4LICS w/ systolic thrill
PR
? could cause for a Pt w/ VSD to suddenly present w/ AR and acute HF
VSD is ? MC
VSD that progresses to a R-L shunt is re-Dx as ?
VSD high in septum becomes blocked by prolapsed by right coronary cusp of AV
MC pathological murmur of childhood
Eisenmenger Syndrome
What medication is used for VSD induced Eisenmenger Syndrome w/ inc pulmonary pressure
When do VSD Pts need pre-dental prophylaxis from endocarditis
All Pts w/ R-L shunts need to have ? step taken when in he hospital in IV lines
Bosentan- endothelial receptor blocker
Residual VSD after patching
P-HTN and cysnosis
Filters to prevent bubbles/debris from becoming systemic
When is a VSD in infants Tx by medicine and surgery indicated
What are the 4 parts of Tetrology of Fallot
What makes this into a Pentad
CHF and retarded growth- diuretic and digoxin
Persists- surgery <6mon old
PS RVH Overiding VSD
ASD
? is the name of the procedure to reperfuse lungs w/ Tetrology of Fallot
What two types of abnormal JVP waves may be seen on PE
What will be seen on EKG prior to and after repair
Blalock Shunt
Increased A-wave
C-V wave from TR
Prior: RAD, RVH
After: RBBB
What annual screening do Pts w/ Tetrology of Fallot need
What type of spells do infants have
What is seen on CXR
EKG- QRS wider than 180msec= inc risk sudden death
Hypercyanotic tet spells
Boot-shaped heart
? is the MC cyanotic congenital heart Dz
What does this sound like on PE
How is an exacerbations and condition Tx
Tetrology of Fallot
Harsh mid-systolic ejection murmur at LUSB w/ loud S2
O2, knee to chest, fluid bolus
Morphine sulfate
Propranolol/Esmolol
Surgery
What happens if Tetrology is left untreated
Even if repaired, what are four possible complications
What is the classic Coarctation presentation
Sudden death by 20y/o-
Sudden cardiac death
HF
HF
Arrhythmia
Residual obstruction
PR
Arm BP > leg BP d/t narrowing distal to L-subclavian artery
Half of Coarcation Pts have ? deformity that puts them at risk for ?
? other presentation should signal this Dx
? type of murmur may be heard on exam
Bicuspid aortic valve;
Berry aneurysm
Young Pt w/ Secondary HTN induced LVF
Continuous murmur in superior, midline back
What is seen on CXR of Coarctation
What is seen on EKG
How is this condition Dx
Scalloping/notching of inferior ribs
Figure-3 sign
LVH
Echo w/ Doppler
? imaging result indicates intervention is needed for Aortic Coarctation
What happens if this condition is left untreated
What is a common complication seen years after surgical repair
Peak gradient >20mmHg
Death <50y/o d/t:
Rupture
Dissection
CVA
HTN d/t permanent changes to RAAS
How are Aortic Coarctations Tx
How is this condition Tx in neonates
What are 4 indications for emergent repair
Balloon angioplasty w/ stents at 2-4y/o
Prostaglandin E1- keeps dutus arteriossus open to prevent HF/shock
HTN Megaly CHF Shock
Coarctation is associated w/ ? genetic abnormality
What are the 3 types of this condition
Define Primary HTN
Turners- XO
Preductal: Turners
Ductal: when ductus closes
Post: MC in adults
SBP130/> or DBP80/> on two readings at two appts
? is a predominant predictor for CV risk
This loss is specific for ? outcome
? RF places Pt at risk for cerebral hemorrhage
Loss of nocturnal BP dip
Thrombotic stroke
Inc morning BP
How/why does alcohol cause HTN
How/why does smoking cause HTN
When do HTN screenings begin and w/ ? f/u
Inc plasma catecholamines
Inc plasma NorEpi
Start at 18y/o
q12mon: -RF
q6mon: +RF, previous SBP 120-129
What are the 4 stages of HTN
How long do Pts needs to rest prior to taking BP
? finding is associated w/ higher mortality and needs work up
ACC/AHA: <120/80 and <80: normal 120-129 and <80: elevated 130-39 or 80-89: stage 1 140/> or 90/>: stage 2
JNC-8: <120 and <80: normal 120-139 or 80-89: PreHTN 140-159 or 90-99: Stage 1 160/> or 100/>: Stage 2
> 5min and >30 after ingesting stimulant
> 15mmHg arm difference
HTN can cause ? optic PE finding
According to ACC/AHA, when does HTN need Tx
What are the Tx goals according to ACC/AHA and JNC-8
AV nicking- arteriole crosses venule causing vein to bulge
All Stage 2
Stage 1 w/ comorbidities
AHA: -/+Comorbidity: <130/80
JNC-8:
<60 w/ CKD/DM: <140/90
60/>: <150/90
Na intake limit when Tx HTN
How are non-AfAm or DM Pts w/ HTN Tx
How are AfAm w/ HTN (including DM) Tx and w/ ? Tx goal
<2.3g (1tsp)
ACEI/ARB
CCB
Thzd-like: Chlorthalidone, Indapamide
CCB and Thzd w/ goal of <130/80
When are BBs c/i in HTN Tx and may cause ? s/e
? medicatioin is particularly indicated for HTN in angina Pectoris
? medication is particularly indicated for HTN in DM w/ proteinuria
Asthma; Impotence
CCBs
ACE/ARB
HTN Tx where CCB is not tolerated d/t edema needs to be replaced w/ ?
HTN Tx where thiazide diuretic is not tolerated or c/i is replaced w/ ?
S/e and c/i for ACEI use
Non-DHP CCB
Spironolactone
Cough, angioedema;
Pregnancy
Two s/e of using Hydralazine in HTN Tx
Mild/Mod Primary HTN has ? MC presenting Sx
When should the Dx of Secondary HTN be considered
Lupus-like syndrome
Pericarditis
HA
Develops at early age
Develops after 50y/o
Refractory after previously controlled
? is the MCC of Secondary HTN
How long can lifestyle modification be used for HTN Tx before medication intervention is indicated
MCC of Cardiogenic Shock
Primary Aldosteronism
6mon
Acute MI
Define OHOTN
? VS suggests etiology is d/tPOTS
? VS suggests etiology is d/t hypovolemia
? VS suggest autonomic impairment
SBP dec >20
DBP dec >10
Both 2-5min after standing from laying
Sxs w/out HOTN
HR inc >100bpm or by >30bpm
HOTN w/out compensatory HR inc by 10bpm/>
DM w/ OHTON need ? f/u test
How is OHTON Tx
What meds may be used for Tx
Tilt table
Na/fluid increase
Fludrocortisone
Midodrine
What Tx therapy is avoided during NSTEMIs
What are the mainstays of Tx
? is the most specific EKG finding for acute coronary syndromes
Fibrinolytics
Anti-platelet/coagulation
Dynamic ST-segment shifts
ST elevation in aVR suggests ? issue
How long is ASA therapy continued after coronary syndromes
What are the P2Y inhibitors
Left main/3-vessel dz
1mon
Clopidogrel/Ticagrelor
Pts need to be off of Clopidogrel/Ticagrelor for ? days prior to CABG
What P2Y inhibitor is faster but is also c/i in ? Pts
When is Clopidogrel preferred
5 days;
7 days if on Prasugrel
Prasugrel- Hx stroke/TIA
C/i to reveive Ticagrelor/Prasugrel
What glycoprotein 2b/3a inhibitors are used for N/STEMIs
Define NSTEMI
What is seen on EKG
Tirofiban
Eptifibatide
Myocardial necrosis w/ elevated biomarkers w/out ST elevation/Q-waves
ST depression
T-wave inversion
How are NSTEMIs worked up
What markers are used for Dx
What is the next step for NSTEMI/unstable anginaI Pts after Dx
Serial cardiac markers q8hrs
Myoglobin: 1-4hrs 12hrs 24hrs Troponin 2-4hrs 12-24hrs 7-10d CK/CK-MD: 4-6hr 12-24hr 3-4d
Delayed angiography <48hrs
? is the MC used anticoagulation for UA/NSTEMI Tx
What is used if the above MC is c/i
? P2Y12 inhibitor is reversible
LMWH
Bivalirudin- if thrombocytopenia is used
Ticagrelor
? antithrombotic therapies are administered in conjunction w/ PCI Tx for UA/NSTEMI
? antithrombotic is used for UA/NSTEMI Tx if Factor Xa inhibition is needed
What is the TIMI Risk Score used for and what are the RFs used for scoring
G2b/3a:
Tirofiban
Eptifibatide
Abciximab
Fondaparinux
UA/NSTEMI-
FamHx Smoking Obesity DM Age Sex High cholesterol HTN
What is are the components of a TIMI score
Timeline for STEMI Tx
3/> considered high, angiography <72hrs: Age 65/>y/o Markers elevated ECG w/ ST-depression RFs (3/> more CV) Ischemic pain x 2 <24hr Coronary stenosis 50/> ASA use past 7days
PCI <90min
Thrombolytic <120min
All STEMI Pts must get ? Rx <24hrs of AMI onset
All N/STEMI Pts need to be started on ? class medication if not already on it
? Fibrinolytics are used for STEMI reperfusion
PO BBs
ACEI
Med/High statin
Reteplase
Alteplase
Tenecteplase
Streptokinase
? Coronary Syndrome medication has no benefit to mortality
How are NSTEMIs Tx
Define STEMI
Nitro, only Sxs
BB Nitro ASA Heparin
Cardiac necrosis w/ Q-waves and ST-elevation
Inferior MI is d/t ? vessel and seen ?
Lateral MI is d/t ? vessel and seen ?
Anterior MI is d/t ? and seen ?
Posterior MI is d/t ? and seen ?
Anteroseptal MI is d/t ? and seen ?
RCA, MC MI
2, 3, aVF
LCX,
1, aVL, V5-6
LAD,
1, aVL, V1-4
RCA/LCX,
V1-2 ST depression
LAD/septal branch,
V1-3
? type of MI is the widow maker
? is the mainstay of STEMI Tx
Absolute c/i to fibrinolytic therapy
LAD
PCI: best <3hrs but can be <12hrs from Sx onset
Suspect A-dissection Active bleeding Malignant neoplasm Ischemic stroke <3mon Cerebral vascular lesion HTN, cerebral
Define Stable Angina
This can be causes by stenosis exceeding ?
Define Bezold-Jerish reflex
Predictable chest pain <15min that’s predictable and relieved w/ rest
> 70%
HOTN causing bradycardia and ischemia
? transient murmur may be heard during Stable Angina
What is the characteristic EKG finding
? is the MC non-invasive imaging modality to evaluate inducible ischemia in angina PTs
MR d/t papillary muscle dysfuction
Reversible horizontal/down sloping ST depression
Stress test, MC w/ Bruce Protocol
? Pts w/ angina should not have stress tests
? is a relative c/i for this procedure
? is the Rx of choice for managing acute angina but it’s use may be limited by ? s/e
Pain at rest
Pain w/ minimal activity
Sx aortic stenosis
Nitro;
HA
Angina Pts taking Nitro need to avoid ? class of medication x 24hrs
? is the only antianginal medication proven to prolong life in Pts w/ coronary dz/post-MI
? medication is used for chronic angina and what is a perk and s/e of use
Phosphodiesterase inhibitors
BBs
Ranolazine- safe for use w/ ED meds;
QTc prolongation
? chemicals are used for chemical stress test
? medication needs ASAP use during CHF
? causes BNP to be released and also falsely low
Dobutamin
Adenosine
Dipyridamole
Bisprolol
ACEI
Metoprolol succinate
Carvedilol
Inc ventricular pressure,
Obesity
Pts presenting w/ acute exacerbation of CHF, what drug class is probably used first
HF is a syndrome of ?
Left HF has ? predominant and ? associated Sxs
Loops
Ventricular dysfunction
Dyspnea;
Low CO, inc pulm venous pressure
Right HF have ? predominant Sxs
? valvular heart Dzs can lead to HF
What are the 4 NYHA HF classifications
Fluid retention
Degenerative AS
Chronic AR/MR
1: ASx
2: Sx w/ ordinary activity
3: Sxs w/ mild activity
4: Sxs at rest
? is the best method to Dx CHF and w/ ? results
? is JVP measured
Why is BNP released in response to stretched ventricles
Echo,
Normal EF 55-60
Pt head at 45*
Measure pulse above sternal notch
Add 5”, >8cm- abnormal
Dec RAAS activation
Inc Na excretion
How is Systolic HF Tx
How is Diastolic HF Tx
Since diuretics are the best at relieving HF Sxs, ? one is used w/ GFR <30
Loop ACEI BB
ACEI BB/CCB w/out diuretics
Metolazone to 20-30mL/min
? are the K sparing agents
What is their MOA
Define Cor Pulmonale
Triamterene
Amiloride
Prevent K secretion from distal tubule
RVH/RVF secondary to lung d/o causing pulmonary artery HTN
How is Cor Pulmonale Dx
? ER presentation may signal this Dx is present
What are the 5 groups of etiologies for this Dx
Right heart cath- gold standard
Echo- showing inc pressure in PA/RV
Angina unrelieved by nitrates
1: PA-HTN
2: heart Dz, MC
3: lung dz/hypoxemia
4: thromboembolism
5: unclear mechanism
What are the two etiologies of Aortic Stenosis
? genetic marker has most notable associated w/ AS
AS is ? MC and can coexist w/ ? cardiomyopathy
Bicuspid/Unicuspid valve
Degenerative calcification
Notch 1
Surgical valve lesion in developed countries,
Hypertrophic
? is the characteristic murmur of Aortic Stenosis
? phenomenon may occur
These Pts present w/ ? c/cs
Systolic ejection murmur radiating to neck/apex w/ paradoxically split S2
Gallavardin- high pitch at apex w/ MR sounding murmur
SAD:
Syncope Angina Dyspnea
Aortic stenosis w/ aortic ejection sound suggests ?
? abnormal may be seen on lab results
? are the two MC presenting c/cs of Aortic Regurgitation
Congenital cause
Helmet cells- schistocytes d/t fragmented RBCs from hitting valve
Fatigue
Exertional dyspnea
What will be seen on PE of Aortic Regurgitation
Water hammer pulse
Head bobbing- de Musset sign
Nail pulses-Quinckes
Murmur heard in femoral arteries- Duroziez sign
Mid-diastolic murmur- Austin flint
When is medical therapy indicated for Aortic Regurgitation
What therapy is recommended
When is surgery indicated
SBP >140
Dec after load w/ ARB
Sxs
EF <55mm
End diastolic dimension >55mm
MCC of Mitral Stenosis
What do these Pts present w/ as c/c
What is characteristic about the murmurs origin
Rheumatic fever
Dyspnea w/ exertion
Hemoptysis
Opening snap- rheumatic origin
Pregnant Pts w/ symptomatic MS can be surgically repaired preferably ?
? is the surgical Tx of choice
? anticoagulant do Pts need if Afib develops
During 3rd Trimester
Balloon valvuloplasty w/ Maze procedure to prevent arrhythmias
Warfarin w/ INR goal 2.5-3.5
What PE findings may be seen during MS
What does MR do to the heart
What is the consequential result
Accentuated S1 w/ palpable apex
Inc preload,
Dec afterload
LVH w/ inc EF
? evaluation is needed prior to surgical repair of MR
What populations need this
What type of murmur is heard
Coronary angiography
Men >40
Menopausal w/ RF
Blowing holosystolic at apex w/ Split S2 and dec S1
Two abnormal c/c indicating MR
How is this Tx medicinally
? part of the valve is the MCC of MVP and what syndrome is this if the MC is absent
Dyspnea w/ supine
Inc urination at night
Dobutamine
Nitroprusside
Middle cusp of posterior leaflet;
Barlow- multiple cusps prolapse
? two heart d/os do Marfans have
How is this Tx
? surgical procedure is done pecutaneously
AR+MVP
BB
SSRI- OHOTN/anxiety
Alfieri
Stopped on
Tricuspid/Pulmonic
