IMC-Final Flashcards by brandon lovin

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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? 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

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? 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

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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

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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

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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

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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)

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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

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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

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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

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? 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

Northern European men

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? 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

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? 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

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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