IMC/FM/EM Cards Flashcards
? is the MC type of cardiomyopathy
Half of these cases are idiopathic and MC cause of ? and the other half are d/t ?
? type of dysfunction is this MC
Dilated
Primary indication for transplant;
ETOH
Systolic- dec contractility and EF w/out abnormal loading conditions
What type of heart sound is heard w/ Dilated Cardiomyopathy
What would be seen on PE
What would be seen if severe HF was present
S3 gallop w/ low EF
Inc JVP Rales Edema Ascites MR/TR
Pallor/cyanosis
Cheyne stoke- fast/shallow then slow/heavy w/ apnea
Pulsus alternans
How is Dilated Cardiomyopathy Dx
What would be seen on EKG
What is seen on CXR
Echo showing EF <50%
LBBB
Arrhythmias
Tachy w/ non-specific ST-T-wave
Balloon heart- megaly w/ pulm congestion (R>L)
Pts w/ Dilated Cardiomyopathy and dyspnea need ? lab drawn and why
? is the imaging modality of choice for RV dysplasia
A biopsy in Dilated Cardiomyopathy is only useful for ?
BNP- establish prognosis/severity
Cardiac MRI
Transplant rejection
All PTs w/ Dilated Cardiomyopathy, regardless of etiology, need to be Tx w/ ?
If still symptomatic, how is Tx adjusted
? class drug needs to be avoided unless ? is present
ACEI, BB
Add aldosterone antagonist- Spironolactone, Eplerone
Switch ACEI/ARB for ARNI- Sacubitril/Valsartan
CCBs; Afib/flutter ventricular control
All diabetics w/ Dilated Cardiomyopathy need ? drug added if LVEF is lower than ?
What are the 3 indications to use Ivabradine to slow HR in this population
What drug is used second line but is preferred d/t?
Mineralcorticoid antagonist- Spironolactone, Eplerone;
<40%
Resting HR >70
LVEF <35%
Chronic and stable
Digoxin; Dec hospitalization
? drug combo is recommended for use in AfAm w/ Dilated Cardiomyopathy
When are Pts w/ Dilated Cardiomyopathy w/ Afib candidates for biventricular pacing
When is an ICD implant a reasonable option
Hydralazine-Nitrate
Significant MR and,
QRS >150msec
ASx ischemic cardiomyopathy w/ LVEF <35% on appropriate medical therapy and >40d post-MI
? complication is more common in Dilated Cardiomyopathy compared to Ischemic Cardiomyopathy
Dilated Cardiomyopathy w/ Afib should be anticoagulated w/ ? unless ?
What are four reversible causes of Dilated Cardiomyopathy
Emobli
DOAC; Mitral stenosis
Hypothyroid
Alcohol
Toxins
Sarcoidosis
How is Dilated Cardiomyopathy Tx
What med is added to increase cardiac contractility
Define HOCM
Loop ACEI BB
Digitalis
LV wall >1.5cm thick causing diastolic dysfunction
When is the obstruction of HOCM increased
What type of murmur is present
How is the murmur increased
Systole w/ anterior motion of MVs anterior leaflet
Medium, mid-systolic cresc-decresc
Dec ventricular volume- valsalva, stand, tachy
What is the end consequence of HOCMs hypertrophy
How is this condition inherited
How is this condition differed from athletic heart
Inc LV diastolic pressure
Autosomal dominant sarcomere defect: myosin heavy chains/Ca regulating proteins
Athletes- no diastolic dysfunction
HOCM in Asians is commonly ? type compared to the other MC
HOCM in older adults is d/t ? and differed how
HOCM can present mimicking ? but is differed by ?
Apical; MC- septal
HTN;
Sigmoid interventricular septum w/ cardiac knob below AV
AS- provoking maneuvers are opposite;
HOCM inc w/ stand/valsalva
Dec- squat, grip. leg raise
What are the three most frequent presenting Sxs of HOCM
What will be seen on PE of HOCM
? is a poor prognostic sign and what causes this to develop
Post-exertion syncope
Angina
Dysnpnea
Triple apical pulse
Bisferiens carotid pulse
JVP w/ a-wave
S4 gallop w/ lift
Afib d/t chronically elevated LA pressures
What valvular d/o is commonly seen in HOCM
What EKG finding is nearly universal in all symptomatic Pts
What else would be seen on EKG
MR
LVH
Septal Q-wave (2, 3, aVF)
High voltage precordium
What is the next step for Pts w/ HOCM identified on TTEcho
Echos must be done to r/o ? other congenital d/o
What is the initial medical management used for Tx
Ambulatory EKG
Exercise stress test
Ventricular noncompaction- trabeculation causing incomplete ventricular filling
Metoprolol; Verapamil
How can the progression of HOCM be stopped/slowed
When are Pts best managed by ICD
When is an ICD considerable
Dual biventricular pacing
Malignat ventricular arrhythmia
Unexplained syncope w/ +FamHx sudden death
LV thickness 30mm
1* relative sudden death
Unexplained syncope <6mon
How can HOCM be surgically Tx
How can HOCM non-surgically be Tx
Pregnant Pts w/ HOCM are at greater risk w/ ? measurement and are best managed w/ ?
Myotomy myomectomy w/ Alfieri
Alcohol ablation into LCA
Outflow gradient >50mmHg;
BBs
What med need to be avoided in the Tx of HOCM
What med is c/i
MCC of Restrictive Cardiomyopathy in US and world
Dec preload:
Diuretic ACEI Nitrate ARB
Digoxin
US- amyloidosis
World: tropical endomyocardial fibrosis
Define Restrictive Cardiomyopathy
This can present mimicking ? and is differentiated by ?
What two EKG findings are suggestive of a Dx
Stiff/rigid ventricle impairs diastolic filling w/ preserved contractility
Constrictive pericarditis; verify**
no ventricular accentuation w/ inhalation
Inc pulm artery pressure
S3, not pericardial knock
Low voltage, LVH
? test is used to look for amyloid deposition in the heart during Restrictive Cardiomyopathy
? imaging is used for screening
How can systemic disease involvement be confirmed but ? is needed to confirm cardiac involvement
Tech-pyrophosphate bone scan
Cardiac MRI
Rectal Adipose Gingival biopsies;
Endomyocardial biopsy
How is Restrictive Cardiomyopathy Dx
How is this Tx
What needs to be avoided
Echo w/ cath to measure atrial pressure
Loop: Furosemide
ACEI- Enalapril
CCB- Verapamil
Digoxin- precipitates arrhythmia
? medication is useful in sarcoidosis induced Restrictive Cardiomyopathy w/ conduction abnormalities
? population is more susceptible to this Dx
? are the MC forms of ASD in order
CCS
Northern European men
Ostium Secundum, mid-septum
Ostium Primum- low septum
Sinus Venosus- hole in upper atrial septum
Pulsus Bisferien seen in HOCM can also exist in ? other cardiac d/o
What would be seen on HOCM PE if there is also associated MR
What PE finding can be seen on PE of Restrictive Cardiomyopathy
Aortic regurg
Apical lift
Kussmaul Sign- JVD increases w/ inspiration
What lab result can help aid differentiating Perciarditis and Restrictive Cardiomyopathy
? is the MC arrhythmia seen in Dilated Cardiomyopathy
? chemotherapeutic medication has cardiotoxic effects and can lead to Dilated Cardiomyopathy
BNP >400: restrictive
Afib
Doxorubicin
Pts w/ Ostium Primum ASD also usually have ? other two defects
What causes a Sinus Venosus ASD to develop
What is the end results in all forms of ASD
MV/TV clefts
VSD
SVC/IVC don’t merge w/ atria properly
LA shunts blood to RV causing volume overload
? is the determining factor in the direction of shunted blood during an ASD
What is an unusual but potential cyanotic issue that can develop from ASDs
ASDs predispose the Pts to ? vascular risk
Atrial compliance
PHTN+cyanosis- Eisenmenger physiology
Paradoxic emboli
Pts w/ Patent Foramen Ovale are at increased risk for ? breathing dysfunction
? is the MC presenting Sx of ASDs
What will be heard on PE
Platypnea orthodeoxia- orthostatic hypoxemia
Afib*/flutter
Wide, Fixed, Split S2 (lub dub-dub)
Pts w/ ASDs are c/i from ? hobby
PDAs are MC in ? population
PDAs can also be d/t ? maternal infection
Diving
Premature births, more likely to spontaneously close
Rubella
ASDs can remain ASx until 30y/o but then ? presents
How are small, centrally located ASDs Tx
How are mod/large ASDs Tx
> 30: dyspnea, angina
50: Afib, RVF
<3mm close spontaneously
8mm/> or RV overload- closure at 2-6y/o w/ Pericardial/Dacron patch
? type of murmur is associated w/ PDAs
How are these Tx
How long are Pts left on endocarditis prophylaxis
Constant machinery (patent your machine)
Indomethacin/Ibuprofen w/ fluid restriction
6mon after closure
What causes PDAs
What can be the reporting c/c of PDAs
? is the MC congenital heart defect in Peds
Connection between ductus arteriosus and pulmonary artery
LE cyanosis
FTT
Tachy/Tachy
VSD- membranous
The direction of a VSD shunt depends on ?
VSD sizes are defined when compared to ? structure
? PE finding suggests increased R to L shunting in VSDs
RV pressure; smaller defect= inc gradient, louder murmur
Aortic root
Diastolic murmur
? is the classic clinical presentation of Aortic Coarctations
Half of the Pts will have ? valve defect that puts them at risk for ?
What causes these Pts to develop LV failure
Arm BP > leg BP
Bicuspid AV; Berry aneurysm
HTN
? can cause a Pt w/ VSD to present w/ acute AR and acute HF
? medication is used to reduce pulmonary pressure if Eisenmenger syndrome develops in VSDs
All VSDs w/ R-L shunts need ? intervention when in hospitals
High VSD= R-aortic cusp prolapses, reduces VSD
Bosentan- endothelial receptor blocker
IV line filters to prevent bubbles/debris from becoming systemic
? is the classic clinical presentation of Aortic Coarctations
Half of the Pts will have ? valve defect that puts them at risk for ?
What causes these Pts to develop LV failure
Arm BP > leg BP
Bicuspid AV;
Berry aneurysm
HTN
? type of aortic coarctation is associated w/ a genetic defect
What is seen on CXR
How is this Dx
Preductal- Turners, XO
Rib scalloping
Figure-3 sign
Echo w/ cath: >20mm gradient= intervention
What types of altered JVP waves may be seen in Tetrology of Fallot
What EKG finding is common in surgically repaired Tetrologies
Why do Pts need annually EKGs
Inc a-wave
C-V wave: d/t TR
RBBB
Measure QRS; >180msec d/t RVF= risk sudden death
Primary HTN is defined by ? readings
When do USPSTF screening begin and when are f/u needed
When does the AAP suggest screening Peds for HTN
SBP 130/>
DBP 80/>
2 readings, 2 visits
18y/o-
Normal: q12mon
SBP 120-129: q6mon
3/>y/o w/ RF: Q-visit
What types of altered JVP waves may be seen in Tetrology of Fallot
What EKG finding is common in surgically repaired Tetrologies
Why do Pts need annually EKGs
Inc a-wave
C-V wave: d/t TR
RBBB
Measure QRS; >180msec= risk sudden death
Primary HTN is defined by ? readings
When do USPSTF screening begin and when are f/u needed
When does the AAp suggest screening Peds for HTN
SBP 130/>
DBP 80/>
2 readings, 2 visits
18y/o-
Normal: q12mon
SBP 120-129: q6mon
3/>y/o w/ RF: Q-visit
Ranges for Normal, Elevated, Stage 1 and Stage 2 HTN
BP discrepancy of ? between arms needs further work up
Why are fundoscopic exams indicated
N: <120/880 and <80
E: 120-129 and <80
1: 130-39 or 80-89
2: 140/> or 90/>
> 15mmHg- higher mortality risk
AV nicking- arteriole crosses venule causing venous compression
When does ACC/AHA suggest starting Rx management for HTN
What are the ACC/AHA HTN targets
What are the JNC-8 HTN targets
All Stage 2 Stage 1 w/: DMT2 ASCVDz CKDz ASCVD risk 10%/>
<130/80
<60y/o/CKDz/DM: <140/90
60/>y/o: <150/90
For HTN Tx, how much sodium intake is recommended
How many alcoholic drinks can wo/men have
What are the aerobic exercise goals
<2.3g/day
Men: 2/day
Women: 1/day
Moderate x 150min (30min/day x 5d)
Vigorous x 75min (30min/day x 3d)
How are non-black/DM Pts w/ HTN Tx
How is Stage 2 HTN Tx
One of:
ACEI/ARB
CCB
Thiazide like
Two meds of different classes w/ lifestyle
How are AfAm w/ HTN Tx
When are BBx c/i for HTN Tx
What class of med is particularly indicated for angina pectoris
Two or more meds:
CCB/Thzd-like
Asthma
CCBs
S/e of using Spironolactone for HTN Tx
S/e of using BB for HTN Tx
Two s/e of using hydralazine for HTN Tx
HyperK
Impotence
Lupus-like syndrome
Pericarditis
When Tx HTN, If Pts can’t tolerate Thzd diuretic, switch for ?
3 s/e of using ACEIs
They are c/i when?
Mineralcorticoid antagonist- Spironolactone
HyperK Angioedema Cough
Pregnancy
S/e of using Spironolactone for HTN Tx
S/e of using BB for HTN Tx
Two s/e of using hydralazine for HTN Tx
HyperK
Impotence
Lupus-like syndrome
Pericarditis
? trifecta makes up the Metabolic Syndrome
? is thought to be the MCC of Secondary HTN
If Secondary HTN is thought to be d/t Pheo, the MCC or Cushings, how are these tested
3 of the 5: Obesity (M: 40", W: 35") Insulin resistance HyperTG >150 or on drug Tx HDL M: <40, W: <50 BP >130/85 or on drug Tx Fasting glucose >100 or on drug Tx
Primary Aldosteronism
Pheo: 24hr urine metanephrine and catecholamine
PA: 24hr urine aldosterone/HypoK
Cusing: dexamethasone suppression test
? lab result after starting ACEI for HTN Tx signal possible renal stenosis
Secondary HTN cause by a Pheo present w/ ? triad
Pheos are associated w/ ? FamHx
Inc creatinine
Sweating
Episodic HA
Tachycardia
MEN 2A/2B-
Medullary thyroid carcinoma, Hyperparathyroid,
What are the two different types of Hyperaldosteronism that can cause HTN
What urine lab result is Dx and
How is the Dx then confirmed
Conn Syndrome- adrenal adenoma, majority
Bilateral hyperplasia- primary hyperaldosteronism
Ald/Renin ratio >25:1
Aldosterone suppression test- PO sodium, measure urine aldosterone
Once confirmed, adrenal CT
Three meds used for HTN in pregnancy
? two meds are reserved for Pts taht fail all other medical therapy
Name of renin blocker medication
Labetalol
Methyldopa
Nifedipine
Hydralazine
Minoxidil
Aliskiren
What non-pharm methods can be used to Tx HTN and how much reduction can be expected
What needs to be monitored for when using Thzds, Loops, ACEI, ARBs and Aldosterone antagonists
Diet: 8-14 Weight: 5-20 Exercise: 4-9 Na restriction: 2-8 Alcohol: 2-4
Chem-7 (CMP): T: Hypo-K/Mg L: Hypo-K/Mg AC: Hyper-K AR: Hyper-K AA: Hyper-K
Three meds used for HTN in pregnancy
? two meds are reserved for Pts taht fail all other medical therapy
Name of renin blocker medication
Labetalol
Methyldopa
Nifedipine
Hydralazine
Minoxidil
Aliskiren
What VS readings suggest OHTON etiology was hypovolemia
What VS readings suggest a Dx of POTS
How is OHOTN Tx
HR >100bpm
Inc x 30bpm
Sxs w/out HOTN
+Sxs, no HOTN
Inc Na/Fluids
Fludrocortisone
Midodrine
? sign is seen on PE w/ TR
? is the MC systemic vasculitis
What causes the vessel occlusion during this MC
Carvalio- pansystolic increased w/ inspiration
GCA
Intimal hyperplasia remodeling
? is the greatest RF for developing GCA
? other condition is closely related to GCA’s prevalence
All Pts w/ GCA need ? PE test conducted
Age, Scandanavian women
Polymyalgia rheumatica- stiff shoulder/pelvic in AM
Fundoscopic- cotton wool spots (retinal ischemia)
What artery is involved in an anteriolateral MI
What artery is involved in a posterior MI
What artery is involved in a inferior MI
V4-6: Left main
ST depress V1-2: RCA
2, 3, aVF: RCA
MCC of Cardiogenic shock
What Sxs are present
What is seen on PE
Acute MI
Pulm congestion AMS Tachy Clammy HOTN <90
JVD
UOP <20mL
How is Cardiogenic Shock Dx
How is this Tx
Cardiogenic shock d/t free wall ruptures is MC seen after ? type of MI
Inc pulmonary capillary wedge pressure >15mmHg
Pressor: Dobutamine, NorEpi
Balloon pump
Judicious fluids
Q-wave transmural
Lateral wall
Define OHOTN
This is MCC by ? issue and MCC by ? drug
What would be seen in VS if etiology was d/t autonomic dysfunction
SBP dec x 20mm
DBP dec x 10mm
<5min repositioning
Acute MI complication;
MAOIs
HOTN w/ HR increase <10bpm
What VS readings suggest OHTON etiology was hypovolemia
What VS readings suggest a Dx of POTS
How is OHOTN Tx
HR >100bpm
Inc x 30bpm
Sxs w/out HOTN
+Sxs, no HOTN
Inc Na/Fluids
Fludrocortisone
Midodrine
Absolute c/is for fibrinolytic therapy for STEMI Tx
Suspect dissection
Active bleed/diathesis
Malignant intracranial neoplasm
Ischemic stroke <3mon
Cerebral vascular lesion
Hemorrhage, cranial
How often are cardiac markers needed during STEMI
What is the next step for all of these Pts
How is this next step different for NSTEMI/UA Pts
3 sets, q8hrs
Angiography
Delayed x 24-48hrs
Next step for all inferior wall MIs
What factors can lower the threshold for angina Sxs
How long do angina pain attacks last depending on the etiology
Right sided lead- V4R
After meals
Cold
Excitement
Exertion: <3min
Food/Emotion: <20min
What biomarkers are seen in MIs
? condition can present mimicking a STEMI but isn’t
Myoglobin
1-4h 12hr <24hrs
Troponin:
4-8hr 12-24hr 7-10d
CK-MB:
4-6hr 12-24hr 3-4d
Stress cardiomyopathy- Tako-tsubo/apical ballooning syndrome
How much stenosis is needed to cause angina Sxs w/ exercise
How much stenosis is needed to make Sxs at rest
What is the earliest stage of an atherosclerotic plaque
> 70%
> 90%
Inflammation induced foam cell (lipid laden macrophage) w/ fatty streak
HF is a syndrome of ? dysfunction
? is the dominant Sx of L-HF
? is the dominant Sxs of R-HF
Ventricular
Dyspnea
Fluid retention
What are the 4 medications withing a cardiac Vasculo-Protective Regiment
? is the only drug class proven to prevent re-infarction and increase post-MI survival
What medication is used as a last step when the preferred can ‘t be used
Antiplatelet
Statin/CSPK-9
BB
ACEI
BBs
Ranolazine- late Na channel blocker
What two meds can prevent the progression of HF for Pts in Class A and B
Define Cor Pulmonale
What are the 4 NYHA HF Classificaitons
ACEI and BB
R-HF d/t pulmonary dz
1: ASx, no limitations
2: Sx w/ mod activity
3: Sx w/ mild activity
4: Sx at rest
Absolute c/is for fibrinolytic therapy for STEMI Tx
Suspect dissection
Active bleed/diathesis
Malignant intracranial neoplasm
Ischemic stroke <3mon
Cerebral vascular lesion
HTN, cranial
How often are cardiac markers needed during STEMI
What is the next step for all of these Pts
How is this next step different for NSTEMI/UA Pts
3 sets, q8hrs
Angiography
Delayed x 24-48hrs
? is the characteristic EKG finding of anginal episodes
? is the MC used non-invasive procedure to evaluate angina pain
? is the name of the protocol used
Horizontal/down sloping ST segment, reverse when ischemia stops
Exercise stress test- unless pain at rest/minimal activity
Bruce protocol
? is a relative c/i for performing exercise stress tests to assess angina
? is the medical Tx of choice for angina pain but commonly causes ? s/e
? medication is used for chronic angina
Sx aortic stenosis
Sublingual nitro;
HA
Ranolazine
HF is a syndrome of ? dysfunction
? is the dominant Sx of L-HF
? is the dominant Sxs of R-HF
Ventricular
Dyspnea
Fluid retention
? is the MCC systolic HF
What are the 4 classifications of HF
MI induced myocardium dysfunction
A: at risk to develop d/t HTN
B: structural heart Dz w/out Sxs
C: clinical HF
D: refractory to therapy
6 causes of high output HF
What will be the first Sx of this condition
What is the best test to Dx CHF
Beriberi- dec thiamine Anemia Hyperthyroid Pregnancy AV fistula Pagets
Tachy progressing to systolic failure
Echo
How is JVP measured
? finding is abnormal
Define Hepatojugular Reflex and what this correlates to
HOB at 45*
Sternal angle to height of puslation
Add 5cm
> 8cm
Liver pressure inc JVP x 1cm;
Inc Pulm Cap Wedge pressure
? lab result is a poor prognosis for Pts w/ chronic HF
Normally BNP is used for prognosis/staging but can be artificially low in ? populations
? medication can also cause artificially low levels
Anemia w/ high RDW
Older
Female
COPD
Neprilysin inhibitors- neprilysin will degrade BNP
What are two methods to define presence/extend of CADz in HF
? medication is the most effective way to relieve HF Sxs
? drug combo is the initial Tx for most HF w/ Sxs and reduced LVEF
Left sided cath
CT angiography
Diuretics
ACEI and Diuretic;
early addition of BB
How is mild fluid retention in HF Tx
These meds tend to be ineffective when GFR is below ?
? one is best for lower GFRs
Thiazdies:
Hydrochlorothiazide
Metolazone
Chlorthalidone
<30mL/min
Metolazone: 20-30mL/min
What loop diuretics can be used in the Tx of HF
? is a common s/e across the loops
What PO K-sparing agents are used w/ Loop/Thzds and how do they work
Furosemide
Bumetanide
Torsemide
Pre-renal azotemia
Triamterene, Amiloride: reduce K secretion at distal tubules
? medication is used for HF Tx if Pt is refractory to Loop/Thzds?
How is Systolic HF Tx
When is the prevalence of Diastolic Left HF more common
Metolazone- loop/thzd combo
Loop ACEI BB
> 55y/o w/ HTN
How is Diastolic Left HF Tx
What medication can never be used
Gold standard to Dx Right HF
ACEI and BB;
Don’t use diuretic
Digoxin
Right sided cath
3 causes of high output HF
What will be the first Sx of this condition
Beriberi- dec thiamine
Anemia
Hyperthyroid
Tachy progressing to systolic failure
? is normal EF
What is seen on systolic HF
What is seen in diastolic HF
55-60;
Inc mortality <35
Dec LVEF, S3
Thick walls, S4
Why do ventricles release BNP in response to inc volume
BNP levels higher than ? make CHF likely
What are the 3 beta-1 selective used to reduce mortality from HF
Dec RAAS,
Inc Na excretion
> 100
Bisprolol
Metoprolol succinate
Carvedilol
What are the 2 MCC of Aortic Stenosis
? genetic marker is most strongly associated w/ AS
AS owns ? MC fact
Uni/Bicuspid valve
Age related calcification
Notch 1
MC surgical valve lesion in developed countries
What Triad does AS present w/
How is the murmur best heard on exam
The presence of an ejection sound suggests ?
Syncope
Angina
Dyspnea- late finding
Leaning fwd w/ expiration
Congenital cause
What lab result can indicate AS is present
Define the Gallavardin Phenomenon of AS
Usually the syncope w/ this condition is d/t ?
Helmet/Schistocytes- RBC fragments from valve calcification
Sounds like MR w/ high pitch heard at apex
V-tach
AV blocks
What medical therapy is recommended for Pts post-AS surgery
What are the 3 MCC of AR
What is a rare seronegative cause
Clopidogrel x 6mon
ASA for life
HTN
Infective endocarditis
Congenital
Ankylosing
What are the most frequent presenting Sxs of AR
What will be seen on PE in this condition
What 4 other signs are seen
Exertional dyspnea
Fatigue
Wide pulse pressure
Water hammer/Corrigan pulse
Hill: leg BP > arm BP Musset- head bob Quinke- nail bed Duroziez- to-and-fro Traubes: pistol sound over femoral/radial pulses
What extra murmur can be present w/ AR
What is the indication after load reduction is needed
What class is preferred
Austin-Flint: diastolic murmur from blood hitting anterior mitral leaflet
SBP >140
ARBs
Native tricuspid valve stenosis and MR is usually d/t ?
In the USA, TS is MC d/t ? two etiologies
TS is characterized by ? four PE findings
Rheumatic heart dz
Prior TVR
Carcinoid syndrome
Hepatomegaly
Ascites
Right HF
Dependent edema
Tricuspid stenosis will cause ? type of JVP finding
Since this valvulopathy can mimic ?, it’s differentiated by ?
? is the mainstay of Tx, particularly ? one is considerable bowel ischemia is present
Giant a-wave
MS;
Increases w/ inhalation
Loop diuretics;
Tosemide, Bumetanide
How is TS Tx if liver is engorged/ascites is present
Preferred surgical Tx is ?
? congenital and iatrogenic etiology can cause TR
Aldosterone inhibitors
Percutaneous balloon valuloplasty
TVR
Ebstein Anomaly: septal, posterior leaflets into the RV
Pacemaker lead injury
? JVP wave is altered w/ TR
Name of surgical procedure to decrease annular diameter of TR
What are the two categories of PR etiologies
X-descent fades w/ inc regurg
Large V-wave w/ rapid descent
DeVega annuloplasty
High Pressure: P-HTN (MCC)
Low Pressure: dilated annulus, congenital
What type of PE finding is heard w/ PR
What secondary murmur is also heard w/ PR
? is a common EKG finding in these Pts
Widely split S2 w/ pulmonic ejection sound
Right sided S4
Graham Steel- diastolic pulmonary murmur d/t dilated annulus; mis-Dx as AR
RBBB
How can the direction of MR murmur indicated the cause of the murmur
? do PTs need prior to MV replacement to Tx MR
Radiates anterior- posterior leaflet
Radiates posterior- anterior leaflet
Men >40/menopausal women- angiography to determine CADz
? is heard on PE during MS
? part of the valve is MC involved in MVP
? unique presentation in females can indicate underlying MVP
Accentuated S1 w/ palpable apex and opening snap
Middle cusp of posterior leaflet- if both involved= Barlow Syndrome
POTS
AR
MS
PR
TS
AS
PS
HOCM
MVP
MR
TR
VSD
Sit, lean fwd; Diaphragm at Erbs
L lat-decubits; Bell at mitral
Sit, lean fwd: Diaphragm at Pulmonic
Supine; Bell at Tricuspid
Sit; Diaphragm at Aortic
Supine; Bell at Tricuspid
Supine; Diaphragm at Mitral
Supine, Diaphragm at Mitral
Supine, Diaphragm at Mitral apex
Supine, Diaphragm at Tricuspid
Supine; Diaphragm at Tricuspid LLSB
MC Sx of MS
MCC of TS is ? and usually is seen w/ ?
Why are TS and MS difficult to differ on exam
Dyspnea
Rheumatic heart dz;
Rheumatic MS leads to TR d/t P-HTN
Both have opening snaps
Define Ortner’s Syndrome
? leaflet is affected by age and calcification the most
Hoarse voice d/t PR
Posterior
How is MS seen on EKG
Term used to describe the Echo finding of MS leaflets
? is the preferred surgical procedure
MC- p-mitrale: P-wave >2.5cm in lead 2
Fish mouth- thickened leaflets
PMBV- percutaneos mitral balloon valvotomy
How often do ASx Mitral stenosis need to f/u w/ Echo
? mitral leaflet is MC affected in MR
Severity of MR is based on ? 5 things
3-5yrs: MVA >1.5cm2
1-2yrs: MVA 1-1.5cm2
Annual: MVA <1.0cm2
Posterior
Size Pressure gradient LA and LV Systemic pressure against LV Duration LA compliance
What will be heard on PE of MR
? maneuver intensifies MR murmur
How is MVP defined by Echo
Soft S1, wide split S2
Lout P2
Hand grip
Billowing leaflet 2mm/> above annular plane
MVP is associated w/ ? 3 Dxs
Define Pulsus parvus et Tardus
Marfans
Ostegenis imperfecta
Ehlers Danlos
Weak, late rising carotid puse in Aortic Stenosis
? valvulopathy has no optimal medicat therapy for Tx/slowing disease progression
What type of surgical procedure is preferred in Peds/young adults w/ congenital AS
What is the prognosis for AS depending on ? Sx is present
AS
Balloon valvuloplasty
Syncope: <3yrs
Angina: <5yrs
Dyspnea/CHF: <2yrs
? is the hallmark PE finding of Aortic Regurg
What is the prognosis for AR depending on Sxs present
? is the MC cardiac arrhythmia
Wide pulse pressures
Angina: 4yrs
HF Sxs: 2yrs
Afib: normal SA impulse disorganized by atria/pulm vins
? is the most important lab ordered for Afib work up
? is the MC site for thrombus to develop
How is Afib Tx in unstable Pts or Sxs <48hrs old
TSH
LA
DC cardioversion:
First 100-200J in synch w/ R-wave
Second shock 360J
IV Ibutilide, rpt q10min
How is ventricular rate control in Afib best achieved
? is the drug of choice for converting Afib in Pts w/ WPW
What drugs are used for rhythm control
IV Diltiazme or SAME-olol
Procainamide
No CAD/CHF: Flecainide
CAD: Dronedarone
CHF: Amiodarone
Define Lone Wolf Afib
How is this Tx
What are the high and Moderate risk factors for Afib Pts to need Coumadin anticoagulation
Afib in Pts w/out HTN, PVD, DM and <65y/o;
Can have thyroid d/o, mild CAD
Clopidogrel
High: prior CVA, TIA, Embolus
Mod: >75, HTN, HF, LVEF <35%, DM
How is Afib Tx in Pts w/ HF and reduced LFEF
How is Afib Tx in Pts w/ no valvular d/os
Why are these two meds preferred over Warfarin and what is the risk of use
Digoxin
Rivaroxaban, Apixaban
No INR monitoring, no antidote
How is AFlutter Tx
How is Aflutter Tx different than Afib
What is the bpm goal for Tx of Afib/Flutter
Diltiazem
Flecainide
Ibutilide
Dronedarone
Anticoag necessary prior to conversion
Rate control more difficult
<110
How is the Anticoagulation need for Tx of Afib/flutter determined
What DOACs can be used
When is Warfarin used and w/ ? INR goal
CHF/LVEF <40% HTN Age >75 DM Stroke/TIA/Embolis Vasc Dz Age 65-74y/o Female
Dabigatran Edoxaban Apixaban Rivaroxaban
INR 2.5: Prosthetic valve EGFR <30 Rx: phenytoin, antiretroviral Mitral stenosis
? is the acronym for Afib etiologies
Define Paroxysmal, Persistent, Long standing and Permanent Afib
PIRATES: PE Iatrogenic Rheumatic heart Dz ACS/CAD Thyroid, hyper ETOH Sleep apnea/sick heart
Parox: <7days long
Persist: fails to self terminate in 7days
Long: >12mon
Permanent: persistent
When does Afib tend to become symptomatic
Afib is the only common arrhythmia w/ ?
? is the best imaging modality for Afib
Ventricular rate >100
Rapid ventricular rate,
Irregular rhythm
Initial: TTE
Definite: TEE
Why would ASA be used w/ DOACs when managing Afib
How is Pt w/ severe bleeding while taking Dabigatran Tx
What drug is used for reversing Facto 10a inhibitors
Coronary stents,
ACS <12mon
Reversed w/ Idarucizumab
Andexanet alfa
? IV drug has proven superior results when converting Aflutter to sinus rhythm
Aflutter that’s <48hrs old doesn’t need anticoagulation unless ? exists
? is the preferred long term Tx of choice for Aflutter but ? two meds can be used if needd
Ibutilide
MV Dz
Frequency ablation;
Class 3: Amiodarone, Dofetilide
PSVTs can be caused by what two etiologies
How are these arrhythmias Dx
What is the definitive Tx
AVNRT- rhythm from above Bundle of His
WPW: rhythm d/t abnormal pathway in Bundle of Kent
Holter monitor
Frequency ablation
How are stable Pts w/ PSVTs Tx
What is used for line Tx of symptomatic PSVT
How are regular PSVTs Tx
What needs to be avoided in WPW
Carotid massage
Valsalva/Vagal
Dive reflex
Adenosine 6mg,
Adenosine 12mg
BB/CCBs
Adenosine, CCBs
? is the MC mechanisms for PSVT to start
? Pt populations can have adverse reactions to Adenosine Tx
? medication can be used to PSVT Tx and has been shown to be as effective as Adenosine
Re-entry of impulse to AV node
Reactive airway dzs
Verapamil
How are PSVTs Tx in Pts where adenosine, BBs and CCBs are c/i
What meds are used for prevention in Pts w/ no evidence of structural heart Dz
What meds are used for prevention in Pts w/ structural heart Dz
Cardioconversion w/ 100J
Class 1c:
Flecainide, Propafenone
Class3:
Sotalol, Amiodarone
What are the two types of PSVT (pre-excitation syndrome)
Orthodromic: Conduction antegrade down AV node, retrograde up accessory pathway; narrow QRS
Antidromic: condution antegrade down accessory pathway, retrograde through AV node; wide, bizarre QRS
How is the narrwo complex of Orthodromic AVRT Tx
How is the wide complex of Antidromic AVRT Tx
What is the long term management of choice
Vagal
Adenosin
Verapamil
Class 1a: Procainamide
Class 3: Ibutilide
Frequency ablation
What are the 3 types of premature beats
How are these named based off of the frequency
PAC: abnormal P-wave
PJC: narrow QRS
PVC: wide QRS
Bi/Trigeminy
Premature Atrial Contractions are common in ? population
Pts w/ heart Dz and frequent PACs may soon develop ?
? type of premature beats are common in healthy adults
COPD
PSVT
Afib/Flutter
PVCs
If PVCs are symptomatic, what is described
What causes PJCs
How are premature beats Dx
Palpitations in throat
Irritable site in AV node fires before SA node
EKG, Holter monitor
How are premature beats Tx
Define V-tach
How is wide and regular V-tach Tx
PAC: reassure
PJC: only if >10/min or multifocal= lidocaine/antiarrhythmic
PVC: only if Sxs, BBs/ablation
Three/> consecutive premature ventricular beats
Stable: amiodarone, procainamide
Unstable: cardiovert
Pulseless: defib
V-tach can present in ? five ways
This rhythm is a frequent complication of ?
Un/sustaines
Un/stable
Pulseless
MI, Dilated myopathy
How is Stable V-Tach Tx
How is unstable Pts w/ monomorphic VTach Tx
How is unstable polymorphic V-Tach Tx
In sequence:
Amiodarone Lidocaine Procainamide
Synchronized direct current cardioversion
Dfib
Define Accelerated Idioventricular Rhythm
When is this rhythm seen
V-tach can be caused by low levels of ? E+
Regular, wide comples rhythm at 60-120bpm
Gradual onset after MI/thrombolytic reperfusion
K, Mg
Define V-Fib
How is it Tx
Small, irregular and chaotic rhyth d/t fibrillation of ventricles and no useful contraction
CPR
Defib (non-synch) 120/50/80
Epi
Amiodarone
Time frame for a Dx of Sudden Cardiac Death
? rhythm is MC the cause
? valvulopathies can predispose Pts to this
<1hr from Sx onset
VFib
AS/PS
Pts who survived Sudden Cardiac Death have better prognosis if ? protocol is enacted
What is the next step after survival
? AV blocks exist above/below the AV node
Hypothermia x 24-36hrs after arrest
Post-MI: wearable cardioverter defibrilator,
ICD
Above: 1st, 2nd Type 1
Below: 2nd Type two, 3
Define 1st* Block
Define 2nd* Block, Type 1
Define 2nd* Block, Type 2
Define 3rd* Block
PR interval >0.20 w/ regular rhythm
Longer longer drop; Wenckebach
Dropped QRS w/ P-wave
P-P/R-R is constant
PR relation is erratic
? is the MCC of AV blocks
SSS may also manifest and present as ?
What are the 4 possible presentations of SSS
Idiopathic fibrosis/sclerosis of conduction system
Chronotropic Incompetence- inappropriate HR response to exercise/stress
Brady: sinus <60bpm
Pause: <3 seconds
Arrest: >3 seconds
Tachy-Brady syndrome
? is the MCC of SSS
How are symptomatic Pts w/ SSS Tx
Infective endocarditis MC affects ? structures
SA node fibrosis
Pacemaker
Valves:
M-A-T-P in sequence of community acquired infection
? is the name of nonbacterial thrombotic growth in infective endocarditis
? is the MC underlying cardiac condition in Pts w/ Infective endocarditis
Leading cause of native, IVDA and early/late prosthetic valve endocarditis
Marantic
MVP
Native: Staph A
IVDA: Staph A
Early: Staph
Late: Strep
MCC of Subacute Bacterial Endocarditis
How does Fungal Endocarditiis develop/progress
How is this form of endocarditis Tx
Infected abnormal valve w/ Strep Viridians
Contaminated line causing large but slow growing vegetations <2mon after surgery
Amphotericin B
? group of microbes tends to grow on native heart valves and cause endocarditis
? is the MCC of endocarditis
How does this MCC present
HACEK: H aphrophilus A actinomycet C hominis E corrodens Kingella
Strep viridians
Late complication of vavle replacement w/ small vegetations/emboli
What are the peripheral stigmata of Infective Endocarditis
What is the gold standard for Dx
How else can it be Dx
Janeway lesion Roth spots Splinter hemorrhages Hematuria Osler node Petechiae, palate/conjunctiva Splenomegaly
Initial: TTE
Definitive: TEE
3 +blood culture 1hr apart
? many criteria per Modified Duke Criteria for definitive Dx
How many for a possible Dx
What are the Majors and Minors used
2 major;
1 major, 3 minor;
5 minor
1 major and 1 minor;
3 minor
Major: CSPEC Carditis Poly/Arthritis Erythema marginatum Chorea SQ nodules
Minor: EFMPP Elevated ESR/CRP Fever Monoarthralgia Polyarthralgia Prologned PR interval
Who needs Infective Endocarditis prophylaxis
How is IE in native valves w/out IVDA Tx
How is prosthetic valve IE Tx
How is IVDA IE Tx
Prosthetic material
Previous Dx IE
Unrepaired cyanotic heart dz
Transplant w/ regurg
Naficillin Ampicillin Genta
Vanc Genta Rifampin
Nafcillin (Rosh said Cefepime and Vanc)
What is used for IE prophylaxis
Heart valves w/ ? d/o are more likely to become infected w/ endocarditis
? microbe can cause culture-negative Endocarditis
Amox/Clinda
Regurgitation
Bartonella quintana
How can endocarditis be prophylactic Tx while cultures are pending
Rheumatic fever MC affects ? valve and follows ? but is technically not a ?
Vanc and Ceftriax
Mitral
Strep throat infection;
Infection, inflammatory reaction
Define Rheumatic Fever
How long does it take for Sxs to appear
How is this Dx during the first episode
Immune response to GAStrep w/ formation of antistreptolysin Abs that react w/ proteins in synovium and heart/valves
2-4wks post strep throat
Modified Jones criteria:
2 major or,
1 major and 2 minor
What are the major criteria for the Modified Jones Dx of Rheumatic Fever
What is the derm manifestation’s appearance
What are the minor criteria
Joint, polyarthritis Oh no, carditis Nodules, SQ Erythema marginatum Sydenhams chorea
Annular, non-pruritic rash w/ erythematous border on trunk/limb
Arthralgia
Inc ESR/CRP
Fever
Prolong PR on EKG
How is Rheumatic Fever Tx
When is AB prophylaxis indicated
CCS
ASA/NSAID
Pen G Benzathine
PCN allergy: Erythromycin
Peds w/out carditis: for 5yrs or until 21y/o
Peds w/ carditis and no residual damage: 10yrs
Peds w/ carditis and residual damage: >10yrs
Acute pericarditis can often progress into developing ? issue
? type of pericarditis appears 2-5d post-MI
What is the MCC of pericarditis
Pericardial effusion
Dresslers
Coxsackie
How is pericarditis Dx
What type of JVD abnormality would be seen
How is this Tx
EKG: diffuse, precordial ST elevation and PR depression in 2, aVF, V4-6
Kussmaul- inc CVP w/ inspiration
NSAIDs/ASA
CCS if Sxs >48hrs
How does a pericardial effusion present
How is it Dx
How is it Tx
Low voltage QRS
Alternans
Distant sounds
EKG: low voltage w/ alternans
Echo: swinging heart
Centesis
Window if recurrent
? triad is seen in Cardiac Effusion w/ Tamponades
? is a classic finding for this condition
? is the gold standard for Dx
Becks:
HOTN
Inc JVD
Muffles
Pulsus paradoxus
Echo showing diastolic collapse of RV
How are Cardiac Tamponades Tx
How do Aortic Aneurysms present to ED
When does USPSTF recommend screenings
Inc preload prevents RV collapse
Centesis- therapeutic
Flank pain
HOTN
Pulsatile mass
65-75y/o w/ +smoking Hx
How are Aortic Aneurysms screened for
? is the gold standard for screening
What medical therapy is used until surgical correction
Initial: US
CT- test of choice for thoracic aneurysms/eval of known AAA
Angiography
BBs
How do Aortic Dissections present to ED
What is seen on CXR
What is the gold standard for Dx
How are these Tx
Tearing chest pain radiating to scapuas and decreased pulses
Widened mediastinum
MRI angiography
Ascending: surgery
Descending: medical management (LEP-olol, morphine/dilaudid)
What are the 5 Ps of arterial occlusions
What are common causes of the thrombus formation
? is the gold standard for Dx
? is done for Tx until surgery is needed
Pallor Pulselessness Paresthesia Paralysis Poikilothermia
Afib, MS
Angiography
IV heparin
AV malformations are more likely to be located ?
How are these Dx and how are they Tx
Brain Lungs Spine
Angiography
Surgical excision
How does Peripheral Artery Dz present
If ulcers are present how do they appear on PE
How are these Dx
Intermittent claudication and ABI <0.9
Well circumscribed, lateral/distal
Angiography- gold standard
Doppler US
? is the definitive Tx of peripheral artery dz
? medical management is used
What PE finding suggests thrombo/phlebitis
Arterial bypass
Anti-platelet/lipid
Cilostazol
ASA
Clopidogrel
Palpable cord
How are thrombo/phlebitis Dx
How is phlebitis Tx
How is thrombophlebitis Tx
Venous duplex US- noncompressable vein indicates clot
NSAIDs
Elevate
Compress
Anticoagulation
How does Venous Insufficiency appear on PE
Where do ulcers appear in this condition
How does a Venous Thrombosis present
Hyperpigmentation
Atrophic shiny skin
Stasis dermatitis
Superior to medial/lateral malleolus
Unilateral, asymmetrical swelling of lower extremity
What triad is used for Venous Thrombosis Dx
What PE sign helps w/ Dx
? is first line imaging
How are these Tx
Virchows
Homans
Duplex US
Venography- gold standard
LMWH or,
Fondaparinux or,
PO Factor Xa inhibitors
ACS is defined as a group of cardiac d/os w/ ?
What 3 d/os belong to this group
ACS is defined as presence of cardiac ischemia w/ ? 4 criteria
Dec myocardium perfusion
Un/Stable angina
Acute MI- N/STEMI
Dec activity provocation
Inc frequency/duration
Angina at rest >20min
New onset limiting activity
? is the most important RF for CVDz
This RF is associated w/ ? three d/os
Next step for all inferior wall MIs
Atherosclerosis
Dyslipidemia
HTN
DM
Right sided leads, V4R
? is the MC Sx and time duration of cardiac ischemia
? c/c is highly suggestive of ischemic chest pain
EKG findings of unstable angina
Chest pain >30min
Radiating to extremities
Q waves
ST depressions
T inversions
What are the 4 initial interventions for Pts w/ ACS
All unstable angina PTs should be started on ? therapies
What 3 modifiable RFs are key for preventing CADz
Sublingual nitro
ASA
Metoprolol tartrate- unless HF
Atorvastatin
Clopidogrel ASA UFH
Sedentary Obesity Diet
Tricuspid regurgitation is MC associated w/ ? issue
What are the two MC causes of HF
When is a steroid tape indicated during the Tx of GCA and what adverse reaction can occur
R-side heart problem that increase right sided pressure:
RA dilation, RV HTN, P-HTN
CADz
Uncontrolled HTN
Taper after Tx of 2wks;
Sxs return at <20mg
Pts w/ GCA that can’t tolerate steroids are Tx w/ ?
HF MC presents w/ ? Sxs
EF below ? level is considered systolic HF
Tocillizumab
Methotrexate
Exertional dyspnea
<40%
? medication can be used in the management of stable angina to reduce contractility and increase vasodilation
What are the two MC s/e of using the above medication
? is the definitive test for determining CADz
Verapamil- negative ionotropic (dec contractility) and chronotropic (dec contraction)
Hyperplasia, Constipation
Angiography
What class of drug is Minoxidil
What is a s/e of use
? is the MC Sx of infective endocarditis
Vasodilator
Hair growth
Fever
How is MSSA infective endocarditis Tx
How is MRSA infective endocarditis Tx
How is Strep Viridians infective endocarditis Tx
Nafcillin, Oxacillin
Gentamicin
Aqueous Pen G and Gentamicin
How is native valve endocarditis d/t PCN susceptible Strep Viridians and Strep Gallolyticus (Bovis) Tx
How is this Tx if PCN is unavailable
What is used in Beta-Lactam intolerant Pts
Aqueous PCN G
Ampicillin or,
Ceftriaxone
Vanc
How is Strep Viridians induced endocarditis in a native valve Tx when Pt is hemodynamically stable
How are these Pts Tx if they are hemodynamically unstable
A-PCN-G
Vanc
When should pharmaceutical intervention for hypertriglycerides be considered
What is used for first line Tx
What are the s/e of this first line class
> 500mg/dL- consider
886- definitely start
Fibrates: Fenofibrate, Gemfibrozil, Clofibrate, Bezafivrate
Dypspepsia
Gallstone
Myopathy
? type of lipoprotein has protective effects against atherosclerosis and reverses cholesterol transport?
Superficial vein thrombosis of lower extremity involved occlusion of ?
How do these types of thrombosis present
HDL
Axial veins:
Great saphenous
Small saphenous
Erythema/pain along medial thigh w/ palpable cord
What are the deep veins of the upper extremities
Hypertriglycerides is defined as ? and categorized by ? levels
? is the MCC in Pts w/ absent primary etiologies
Axial
Brachial ulnar
Radial
Interosseous
Fasting TGC >150
Mild: 150-499
Mod: 500-886
Severe: 887 and >
Familial d/o
When Tx hypertriglyerides, ? medication dosage may need adjustment
What alternates are used for Tx if fibrates are c/i
What do VSDs sound like on exam
Warfarin
Fish oil
Nicotinic acid
Loud, harsh holosystolic at LLSB
How is Brugada’s inherited
What is the risk when Dx
Average age/population this condition is seen in
Auto-dominant mutation of Na channels
Ventricular tachydysrhythmia
Sudden death
41y/o men
Brugada pattern ECGs are significantly more common in ? populations
What is the beiggest RF
What is the MC cardiac manifestation Pts can present w/
Schizo d/t psychotropic drug use: Amytriptyline, Haloperidol, Olanzapine
1st* relative w/ sudden death or Brugada EKG
V-Fib
Polymorphic V-tach
How are Pts that are ineligible for ICD Tx managed
What are the two types of Brugada Syndrome
Varicose veins are a result of ?
Quinidine
Amlodarone
Type 1: coved
Type 2: saddle back
Valve dysfunction d/t venous HTN
? medical management can help varicose veins if lifestyle mod and pressure stocking fail
What meds can help stasis ulcers induced by venous insufficiency
What orders should be placed for ASx Pt w/ Hx of stable angina
Venoactive substances:
Flavonoid supplements
Rheologic agents:
ASA, Pentoxifylline
EKG
Lipid panel
Fasting glucose
? body position can provoke angina pectoris
HTN Emergency criteria
What are examples of end organ damage
Prone- inc venous return increases cardiac wall stress leading to Sxs
180/> or 120/> w/,
End organ damage
AMS Vision changes Angina SOB Flame hemorrhages Papilledema
How fast is BP lowered during HTN Emergency
? is the MC rhythm seen during PEs
? is the most important RF in chronic arterial insufficiency
10-20% first hour
5-15% over 23hrs
PEA
Smoking
? are the two MC presenting Sxs of arterial insufficiency
? type of aggravating and relieving factors may be present
? two arteries is MC affected in peripheral artery dz
Cramping leg pain
Intermittent claudication
Night time leg pain, MC calf;
Improved w/ standing/hanging foot off of bed
Superficial femoral in hunter canal
Aortoiliac system- thigh/butt pain
When is the QTc interval considered prolonged and at risk for Torsades
? drugs can cause Torsades when taken in OD levels
? drugs are more likely to cause Torsades when given IV
Men: >450msec
Female: >470msec
Loperamide
Ondansetron
Haloperidol
? drugs carry a moderate risk for causing Torsades
? street drug can cause Torsades
Fluoroquinolones: Moxifloxacin
Macrolides
TCAs
Fluconazole
Cocaine
Myocarditis is MC associated w/ ? cause
How is a Dx definitively made
Pts w/ new onset AV block need ? DDx r/o
Viral infection: Coxsackie B
Endomyocardial biopsy
Lyme carditis d/t Borrella bugdoferi carried by Ixodidae scapularis
How is Lyme Carditis Dx and confirmed
How is this Tx
How is Disseminated/persistent Lyme Dz Tx
ELISA then Western blot test
Adult: Doxy
Pregnant/<8y/o: Amoxicillin or Cefuroxime
IV Ceftriaxone until AV block resolves
? E+ abnormality can lead to AV blocks if left uncorrected
? endocrine d/o can cause SSS
When do AAA need elective repair
HyperK
Hypothyroid
5.5/>cm
Expands >0.5cm/6mon
? size of abdominal aorta is considered aneurysmal
? vessel is involved in anterior/septal MI
? vessel is involved in an inferior MI
? vessel is involved in a lateral MI
3.0/>cm
LAD: V1-V4
RCA or LCX; 2, 3, aVF
LCX; 1, aVL, V5-6
What hyperlipid results indicate need for full workup
What is the next order if results are abnormal
When do hyperlipid screening begin for adults w/ no RFs
Total cholesterol >250mg
HDL <40mg
Fasting lipids
Men: 35y/o
Women: 45y/o
What populations should have hyperlipidemia Tx w/ statins
When are moderate intensity statins recommended
? are the two high intensity statins and dosages
LDL 190/>
Diabetics 40-75y/o
Non-diabetic 40-75y/o w/ LDL 70-189 and 10yr risk 7.5%/>
10yr risk between 5-7.5%
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
What are the moderate intensity statins w/ dosages
What are the low intensity statins w/ dosages
Atorva 10mg Rosuva 10mg Simva 20-40mg Prava 40-80mg Lova 40mg Fluva XL 80mg Fluva 40mg Pita 2-4mg
Prava 10-20mg
Lova 20mg
What are the reversible secondary causes of asystole
What CXR findings are associated w/ CHF
Hypoxia Hypovolemia Hypothermia Hypo/per-Kalemia H+ excess
Tension pneumo Tamponade Toxin Thrombosis Thromboembolism
Linear opacities suggestive of interstitial edema: Kerley Bs
What are the 5 parts assessed during an EKG
What does each mean
P wave: atrial depolarization
PR interval: beginning of P-wave to start of QRS complex
QRS: ventricular depolarization
ST segment:
T wave: ventricular repolarization
? defines a normal sinus rhythm
? indicates sinus P-waves
? PE finding differentiates venous insufficiency from venous thromboembolism
Rate 60-100bpm
Regular rhythm
P for every QRS
PR interval 120-200
Upright P-wave Lead 2,
Biphasic P-wave V1
Lipodermatosclerosis- fibrosing pannicullitis of SQ tissue characterized by firm area of induration MC on medial ankles
? is the MC vascular d/o
What is the MCC of this MC d/o
What are the two MC Sxs
Chronic lower extremity venous dz
Valvular incompetence
Tired/heavy legs
Edema
? PE test can differentiate chronic venous insufficiency from occlusive peripheral artery dz
What are the initial Tx for chronic venous insufficiency
What is the next step if conservative therapy fails and documented venous reflux is present
Pain improves w/ walking
Elevation
Exercise
Compression
Vein ablation
? genetic condition predisposes Pts to developing chronic venous insufficiency and is a c/i for ablation therapy
What are the 5 classes of shock
What are 3 causes of LBBB
Klippel-Trenaunay syndrome
Distributive (sepsis) Cardiogenic Hypovolemic Obstructive Mixed/unknown
HTN
Cardiomyopathy
CADz
What do LBBB look like on EKG
What do RBB look like
MOA of Labetalol
? is the MC PE finding for constrictive pericarditis
Wide QRS 120msec/>
Wide R wave in Lead 1
Large QS/rS in V1
Wide S in Lead 1
RSR/Triphasic in V1
A and B-adrenergic antagonist
Elevated JVD
What two conditions can cause Kussmaul Sign
? is the first line, daily therapy for Prinzmetal Angina
? meds need to be avoided in Prinzmetal
Constrictive pericarditis
Severe TV Dz
Verapamil
Non-selective BBs
LDL Tx flow chart
LDL 190/>
Yes, w/out FamHx hypercholesterol: high dose statin therapy
LDL <190
10%/> risk: moderate dose statin, f/u 6wks
7.5-10% risk: shared decision making w/ Pt about statins
<7.5% risk: repeat screening
? are the major plasma carriers of cholesterol
Stable angina time frame vs unstable angina time frame
? layer of the aorta is torn allowing for a dissection to occur
LDLs
Stable: <5min
Unstable: 20min or >
Intima
? type of murmur can be present during an aortic dissection
? is the most important RF for developing a dissection
How much BP and HR reduction is needed during acute dissections
AR
HTN
SBP 100-120
HR <60
? is the MC predisposing condition for aortic dissection in Pts <40y/o
? is the medication of choice for Pts w/ hypertriglycerides and high LDLs
MCC of endocarditis in native, prosthetic and IVDA
Marfans syndrome
Atorvastatin
Strep V
Strep epidermis
Staph A
? is the MC site for acute arterial occlusions
? is the MC etiology
How is the cardiac tamponade triad different from tension pneumo triad
Femoral artery d/t atherosclerosis
Thrombosis in situ
Tamponade:
HOTN Inc JVD Muffled heart sounds
TPx: HOTN Inc JVD Absent lung sounds
? is the MC primary tumor of the pericardium
What are the two MCC of acquired LVH
What would be seen on EKG during angina pectoris attack
Lung Ca
HTN, AS
ST depressions
What two therapies have not shown to increase PT survival w/ HF
How much weight loss causes a BP reduction
What is the first step in Tx stable Pts w/ new Afib and ventricular rate >100bpm
Digoxin
Loop diuretics
1mmHg decrease for every 1kg
Rate control:
No heart dz: BB/CCBs
Heart dz: Digoxin, Amiodarone
? is the preferred anatomic target during radiofrequency ablation
How does the pain start and migrate during acute arterial occlusions
? PE finding suggests a severe occlusion
Cavotricuspid isthmus
Starts at site, moves proximal
Dec sensation to fine touch
3 EKG characteristics of WPW
What two medications can be used to manage WPW
What is the pre-excitation pathway of WPW named
D-wave c/ slow ventricular activation
Narrow tachycardia
Short PR interval
Procainamide
Quinidine
Bundle of Kent
COPD Pts are at inc risk for developing ? arrhythmia
How is this arrhythmia identified on EKG
? is the MCC of sudden cardiac death
WAP
P-waves w/ different morphology
CADz
What PE finding is most closely associated w/ HF
Metabolic Syndrome is a term for a group of findings that put Pts at increased risk for ?
What pharmaceutical therapy has been recommended for preventing DMT2 in Pts w/ impaired glucose tolerance?
Sustained and laterally displaced impulse
Concurrent DM and CVDz
Metformin
Where would an inferior MI have reciprocal changes seen
Inferior MIs are ? dependent and ? needs to be a part of Tx
RCA is responsible for inferior MIs in 70% of PTs, ? vessel is involved in the remaining Pts
aVL, 1, V5-6
Preload, IV fluids
LCX
What causes the lower extremity edema seen in CHF
How is a DVT worked up w/ low probability
How is a DVT w/ mod/high probability worked up
Inc venous pressures
+Ddimer- US
- US= repeat 5-7d
+ US= anticoagulate
- Ddimer= excluded DVT
US:
Neg= repeat 5-7d
Pos= antigoagulate
How are DVTs risk stratified
Wells score- Active Ca/Tx <6mon Bed x 3d/surgery <12wks Calf swelling >3cm DVT DxHx Entire leg swollen Nonvaricose veins present Alt Dx more likely Pitting edema Paralysis/paresis Localized tenderness
What is the best antiplatelet regiment for Pts going to urgent PCI
? types of stents are preferred during PCI for Pts that are expected to comply w/ dual antiplatelet therapy
What are the 4 categories of CEAP classification of venous d/os
ASA and Prasugrel
Drug eluding stent > bare metal
Clinical
Etiological
Anatomic
Pathophysiological
S/e of Nitroprusside
? medication is used prophylactically to prevent Dresslers from developing in PTs undergoing cardiac surgery
? class of drugs reduces mortality after MI
Cyanide toxicity
Colchicine
ACEI
CXR showing left apical cap is associated w/ ?
What is the cyanotic congenital heart dz mnemonic
What are the acyanotic congenital heart dzs
Aortic dissection
R to L, 5 Ts, 1-5 Truncus: joins to make 1 Transposition: 2 vessels switch Tricuspid atresia: 3 Tetrology: 4 defects Total anomalous pulm vascular return: TAPVR 5
ASD VSD PDA CoA
Sound of murmur in Tetrology
What is the MOA of a Ionotropic drug
What is the MOA of a chronotropic drug
What is the MOA of a
Harsh systolic ejection cresc/decresc
+: inc contraction
-: dec contraction
+: inc HR
-: dec HR
+: inc conduction velocity
-: dec conduction velocity
Negative ionotropic drugs
What two drugs are used for long term management of Prinzmetal
Angina may be associated w/ ? psych d/os
BB CCBs
Class 1a: quinidine, procainamide
Class 1c: flecainide
Nifidipine
Isosorbide dinitrate
Anxiety
What PE finding is specific for high output HF
What 4 populations are most likely to benefit from statin therapy
What Tx goal is aimed for
Bounding pulse w/ quick upstroke and wide pulse pressure
Any ASCVD
LDL 190/> of age
DM 40-75y/o w/ LDL 70-189
40-75y/o w/ ASCVD 7.5%/>
LDL reduction x 50%
Primary prevention for Pts 21y/o or > w/ LDL 190/>
Primary prevention in DMs w/ LDL 70-189
Primary prevention in DMs w/ LDL 70-189 and 7.5% risk score
High/max intensity statin
Moderate intensity statin
High intensity
Primary prevention in non-diabetics w/ LDL 70-189
Reduction goals for high, moderate and low intensity statins
What are the two MC dyslipidemias
Assess 10yr score:
7.5%/>: mod to high intensity statin
5-7.5%: moderate intensity statin
50%/>
30-50%
<30%
Type 2b: combines; all three elevated
Type 4: normal total/LDL, high Tgd
When does NCEP recommend starting fasting lipid panel screening
When are f/u needed
What is the next step if TG levels are found to be >150 or >1000
At 20y/o
Healthy/ASx: q5yr
RFs: q12mon
> 150: redraw after 16hr fast
1000: B-quant w/ electrophoresis to determine exact dyslipidemia
Normal amount of fluid to be in pericardial sac
? four classes of drugs improve mortality in STEMIs
Bicuspid aortic valves are more likely to develop ? two sequlae
15-30mL
BB ASA Statin ACEI
Ascending aorta dilation
Aortic stenosis
S3 is generally associated w/ ? Dx
What does an S3 sound like
What does an S4 sound like
HF
Kentucky- ventricular gallop
Tennessee- atrial gallop
? is the MCC of primary valvular dz in industrialized countries
What maneuvers move MVP click closer to systole
What maneuvers move MVP click towards diastole
Myxomatous degeneration of MV
Non-industrial: MS d/t rheumatic dz
Dec preload:
Valsalva, Standing
Inc preload:
Squatting, hand grip
? is the MC atypical c/c in elder Pts w/ ACS
Venous ulcers are more commonly seen ?
? is the preferred Tx for Pheo induced HTN emergency
Dyspnea
Medial malleolus
IV Phentolamine
What medication can be used to relieve Sxs of intermittent claudication
What is the MOA of clopidogrel
Cilostazol- PPD inhibitor
Binds to platelet ADP receptor, irreversibly inhibiting platelet activation/aggregation
3 EKG findings in HyperK situations
What BB is c/i in the Tx of Prinzmetal?
What is the desired HR for chronic stable angina when being Tx w/ BBs
Peaked T wave
Dropped P wave
Wide QRS
Propranolol
55-60bpm
What 3 EKG findings are seen w/ Digoxin use
? disease process is associated w/ sterile vegetation endocarditis on both sides of valves
What is the TIMI score used for
Down sloped ST depression
Flat/inverted T-wave
Short QT interval
Libman Sacks endocarditis
Estimates mortality for PTs w/ UA/NSTEMI in 14days
What are the points in TIMI
Aortic dissection w/ new insufficiency murmur indicates ? part of aorta is involved
What is used after IV BBs and HR is <60bpm
Age 65/> Markers EKG w/ ST depressions RFs- 3 or more CV RFs Ischemic chest pain x2/> 24hrs Coronary stenosis 50%/> ASA use in past 7days
Proximal, in arch
Pressors: Nicardipine, Nitroprusside
Define Long QT Syndrome
What are these Pts at risk for developing
How is it Tx
QTc >480ms w/ syncope
QTc > 500ms w/out syncope
Polymorphic V-Tach
Propranolol
ICD w/ exercise avoidance
Define Aschoff Body
Best study for Dx/seein PACs after a normal EKG
How are Sx PACs Tx
Characteristic histological fining in myocardium during rheumatic fever
Holter monitor
BB/CCBs
What may be seen on CXR during Mitral Stenosis
What mnemonic is used for Kawasakis
How is temp controlled during the fever stage
Straightening of left superior border d/t LA enlargement
CRASH and BURN: Burn: 5d of fever and 4/5 of: Conjunctivitis Rash Adenopathy Strawberry tongue Hand/feet swelling
IVIG and ASA
What is the mechanisms responsible for bradycardia in athletes
S/e of Prostaglandin E1 administration
MC Sx in Pts w/ Type B Aortic Dissection
Hypervagotonia
Apnea, intubate before administration
Lower back pain
When measuring aortic diameter, where is the measurement taken from
What two vagal maneuvers should not be performed in Peds
3 reflex s/e seen after Nitro administration
Outer wall to outer wall
Carotid massage
Orbital pressure
Tachycardia
Flushing
HA
What lab is also elevated w/ ESR in half of Pts w/ GCA
How is AVNRT Tx in stable PTs
AVNRT is ? MC
Elevated LFTs
VADM: Vagal Adenosine Diltiazem Metoprolol
Paroxysmal supraventricular tachycardia
MCC of myocarditis in Peds
? is usually positive in MedHx
Most specific finding for myocardial ischemia during exercise stress test for CADz
Viral infection: Coxsackie Group B
Recent URI/GI illness
2mm down sloping ST segment
What else can be used for Sx Bradycardia after atropine
? is lesion most likely in Pts w/ STEMIs in lead aVR
? are the 5 indications for emergent dialysis
Epi or Dopamine
Left main
AEIOU: Acidosis E+ disturbance Intoxication Overloaded volume Uremia
? is the most predictive RF for cardiac ischemia
When is Spironolactone used for Systolic HF Tx
What is used for Tx for all Pts w/ Systolic HF
Past MedHx of CADz
NYHA Class 3-4 and EF <35%
NYHA Class 2 and EF =30%
ACEI and BBs
Torsades can be induced by low levels of ?
How is Torsades Tx if refractory to Mg Tx
MOST suggestive and MC PE finding of an ASx AAA
K, Mg, Ca
Transvenous overdrive pacing
Abdominal mass at level of umbilicus
What are the 3 groups of CCBs
How would a venous stasis ulcer be described in words
What two conditions can lower BNP levels
Dihydropyridiines (-pine)
Benzothiazepines (Diltiazem)
Phenylalkylamines (Verapamil)
Beefy red, granulated wound bed
Obesity, Pericardial constriction
How is the stopping/bridging of anticoagulants determined prior to invasive procedures
Warfarin needs to be d/c ? far before a procedure and can be resumed ? after
How is prosthetic valve endocarditis present for >12mon Tx
CHADSVASc score 0-1 and interruption is < 1wk, no bridging needed
5 days; w/in 24hrs after
Vanc, Gentamicin and Ceftriaxone
When do expecting mothers need screening for congenital cardiac defects
? chromosome abnormality is Tetrology of Fallot associated w/
? syndrome is it also associated w/
22
DM
FamHx congenital heart dz
Indomethicin exposure
Rubella
DiGeorge syndrome
What type of appearance does Staph A have on lab results
? is the MC location for a aortoenteric fistula to form
What are the MC RFs for this fistula to form
Gram Pos cocci in clusters
Duodenum, 3rd and 4th portions
AAA+aortic surgery
Most characteristic EKG finding of PJCs
MC dysrhythmia seen in WPW
What is the direction of flow for orthodromic AVRT
Inverted P wave following QRS
Antidromic AVRT: retrograde through accessory path, returns through AV node
Anterograde through AV node
Return through accessory
Chronic Stable Angina is properly managed w/ lifestyle mods and ? meds
Pts w/ chronic stable angina and CADz need ? first line therapy
ASA is first line platelet management in stable angina except for ? cases
Statin
Anti-hypertensive
Antiplatelet
BBs
Recent MI/Coronary stent= Clopidogrel
STEMIs on the way to PCI need ? med
? is the MCC of TR
? class of DM meds are c/i in HF
GP2b/3a inhibitor: Eptifibatide or Tirofiban
Inc right heart pressure
Thiazolidinediones: -tazone
? keeps the ductus arteriosus open and ? makes it close after birth
? drug slows AV node conduction and shouldn’t be used in Pts w/ Mobitz Type 2 block
Acquired cases of aortic coractation is d/t ?
Maternal prostaglandin E1;
Bradykinin, O2, NSAIDs
Adenosine BBs CCBs Digoxin**
Inflammatory Dz: Takayasu arteritis
What EKG finding may be found in infants <1mon old and is benign
What EKG finding is seen in Pts w/ anomalous coronary artery
What score system is used for bleeding risk in Pts on anticoagulation to assss benefits of A-Fib care
RAD d/t RVH
Q-waves in lead 1 and aVL
HASBLED: HTN Abnormal kidney/liver function Stroke Bleeding Labile INRs Elderly >65y/o Drug or alcohol 0-1 Low; 2: moderate; 3/>: high
What causes Infantile Dilated Cardiomyopathy
MOA of Nitrates
What would be seen on fundoscopic exam during HTN Emergency
Duchennes dystrophy
Becker dystrophy
Dec pre and afterload
Cotton wool spots (ocular hemorrhage)
Papilledema
MOA of PD5 Inhibitors
MC murmur associated w/ Marfans
? med can be used to Tx Afib in hemodynamically stable WPW Pt
Break down cGMP, dec levels allow smooth muscle relaxation and increased blood flow
MVP
Ibutilide
MOA of ASA
How is a STEMI Dx w/ LBBB present
Two EKG findings of Brugada
Irreversibly inhibits cyclooxygenase needed to catalyze thromboxane enzymes
Sgarbossa criteria:
Pseudo RBBB
Persistent ST elevation V1-2
What makes S1
What makes S2
What vascular emergency of the legs is a result of DVTs
MV/TV closing
AV/PV closing
Phlegmasia cerulea dolens
Why would Palivizumab be given to Pt w/ cyanotic congenital heart Dz
Capture/Fusion beats confirm ? dysrhythmia dx
Indications to use glucocorticoid steroids for Tx of pericarditis
Prevent RSV infection
V-Tach
NSAIDs c/i:
Lupus, Pregnancy
How is Narrow Complex WPW Tx
Define Heyde Syndrome
Criteria for Dx Kawasaki’s
Vagal
Adenosine
CCBs
AS and GI bleed from GI angiodysplasia
Fever 5/> days and 4 of 5: Bilat conjunctiva injection Mucous membrane changes Extremity changes Polymorphous rash Cervical adenopathy
Other than Mg and Defib, how can Torsades be Tx
Normal PR interval range
Define Leriche Syndrome
Inc hHR: over drive pacing
120-200msec
Atherosclerosis in aortoiliac system causing claudication
ABI measurement of ? is seen in peripheral artery dz induced pain at rest
Define Fusion/Capture beats
Over medication w/ nitrates can lead to ? s/e
<0.4
Fusion: two different impulse locations active ventricle
Capture: normal sinus beat and beat in sinus QRS occur in wide complex tachycardia
Methemoglobinemia
? CCB has the greatest affect on AV nodes
GCA can lead to ? non-cephalic issue
MAP equation
Verapamil
Aortic valve insufficiency and/or aortic dissection
MAP= DBP + 1/3(SBP-DBP) MAP= SBP + (2 x DBP)/3
Characteristics of innocent murmurs in Peds
Lights Criteria
Grade 2/< Softer w/ sitting Short systolic duration Minimal radiation Musical/vibratory quality
Transudate: Protein = 0.5 LDH = 0.6 Pleural LDH <2/3 upper limit HF Cirrhosis Nephrotic PE
Exudate: Protein >0.5 LDH >0.6 Pleural LDH >2/3 upper limit Ca Pneumonia TB PE Pancreatitis Collagen/Vasc Dz
? is the MC tachydysrhythmia seen in WPW
Stopped
Orthodromic AVRT
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