Internal Medicine Essentials Questions: Cardiovascular Medicine Flashcards
A patient presents with persistent chest pain that is worse when lying down and has diffuse ST-elevations on electrocardiogram. What should you recommend and tell the patient?
These findings are suggestive of pericarditis, often seen after a recent URI. The pain will likely go away on its own, and NSAIDs can be used in the meantime.
Why is asking about pain radiation important in taking a history in chest pain?
Cardiac pain often radiates to the arm or shoulder, while costochondritis doesn’t –it remains in the anterior chest wall.
How is the onset of chest pain different in costochondritis?
Costochondritis usually has an insidious onset, whereas angina is usually sudden.
Describe the ways to distinguish between pericarditis and costochondritis.
•Pericarditis:
- presents with a friction rub
- causes pleuritic pain
- often follows a URI or MI or is found in someone with a connective tissue disease
•Costochondritis:
- worse with lateral bending
- reproducible with palpation
Discuss the presentation of a patient with spontaneous pneumothorax.
- History: pleuritic chest pain of sudden onset; SOB
- Physical exam: decreased chest expansion on affected side; midline trachea (because it is not a tension pneumothorax); decreased breath sounds on affected side; distant heart sounds; hyperresonance
If a patient has nonanginal chest pain and a cardiac workup is negative, _____________ is a reasonable diagnostic/therapeutic option.
PPI trial
A man has chronic stable angina (verified by stress ECG) that has not responded to his initial dose of metoprolol. What should you do?
Increase the metoprolol until no longer tolerate (HR 60).
If a patient has chronic stable angina –meaning they have already had a stress test and have not had a change in symptoms – that is refractory to medical therapy, then you should refer them to ________________.
coronary angiography; doing this can both diagnose and treat perfusion defects
Note: percutaneous intervention should only be done in cases of angina that are refractory to medicine.
What history questions can you ask to help decide if chest pain is reflux-related?
- “Is it worse with lying down?”
* “Is it worse after eating?”
The medical treatment for MI comprises what six drugs?
- Aspirin
- Clopidogrel
- Thrombolytics (tPA)
- Heparin
- IV nitroglycerin
- Beta-blocker
Review the contraindications to beta-blockers?
- Heart block
- SBP less than 90 mm Hg
- HR less than 50 BPM
Percutaneous intervention has been shown to benefit MI patients up to ___________ hours after the onset of symptoms.
12
If a patient cannot get the door-to-balloon time of 90 minutes, start them on thrombolytics and do PCI if possible within 12 hours of symptom onset.
A patient has an MI and develops hematologic instability with a new-onset holosystolic murmur at the lower-left sternal border. What happened?
VSD due to infarction
Why are the dihydropyridine CCBs contraindicated in acute coronary syndrome?
Reflex tachycardia
__________ presents with bradycardia and sinus pauses.
Sick sinus syndrome
Differentiate type I and II second-degree heart block.
- I: progressive lengthening of PR interval until a beat is lost
- II: sudden loss of beat without changes in PR interval
(“oNE is leNgthEning. 2 you get in2rupted with a lost beat.”)
Review the ECG findings of LBBB.
- Absent Q in I, aVL, and V6
* Wide, positive R wave in I, aVL, and V6
True or false: the heart block caused by Lyme disease is reversible.
True!
Intravenous ceftriaxone for 21 days can reverse it.
A score of _____ or more on the CHA2DS2VAS indicates anticoagulation.
2
WPW can cause _______________.
ventricular preexcitation syndrome
Atrial flutter classically has the atrial rate of _________.
300 beats/min
A fib beats at 600 beats/min.
Multifocal atrial tachycardia most often presents in ______________.
patients with chronic lung disease (because the vasoconstriction of lung disease leads to right atrial enlargement)
Review the treatment of asymptomatic HCM.
- Advise that the patient avoids strenuous physical activity
- Beta-blockers
- Implantable cardioverters
Which factors can make a BNP falsely low?
- Obesity (the most influential factor)
- Female sex
- Old age
In a patient with a high pretest probability of CAD –such as multiple risk factors and an echo demonstrating hypokinesis –then the correct diagnostic should be _____________.
coronary angiography
A stress test is so likely to be positive in a patient with hypokinesis on echo that you should proceed to coronary angiography.
How do you treat peripartum cardiomyopathy?
The same as non-pregnant cardiomyopathy: beta-blockers, diuretics, and (after delivery) ACE-inhibitors
What murmur suggests that a prosthetic aortic valve is dysfunctional?
An early diastolic murmur
Prosthetic valves are designed to move during systole, so a systolic click or systolic ejection murmur is normal. A diastolic murmur, on the other hand, indicates that the valve is allowing backflow –not normal.
List the characteristics that indicate that murmur is benign and does not require further workup.
- Patient is asymptomatic
- Normal physical exam with exception of murmur (i.e., no edema, thrills, heaves, lung crackles, etc.)
- Murmur is 1/6 or 2/6 in intensity
- Murmur does not radiate
- ECG (if done for another reason) is normal
Explain the role of balloon valvuloplasty.
In patients with aortic stenosis causing heart failure, the definitive treatment is valve replacement. Balloon valvuloplasty can be done as a bridge treatment in hemodynamically unstable patients.
How should you manage a patient with bicuspid aortic valve who has no symptoms and evidence of mild aortic regurgitation?
Follow-up in 1 year
Bicuspid aortic valve does confer an increased risk of endocarditis and aortic stenosis, but if the patient is asymptomatic and lacks signs of progressive disease then follow-up is all that is needed.
The proper treatment for hypertension secondary to fibromuscular dysplasia is ________________.
angioplasty of the renal vasculature
To bridge to warfarin, you need to give LMWH for _____ days and reach an INR of _____.
5; 2
Which of the heparins is not renally cleared?
Unfractionated
It is cleared by the reticuloendothelial system.
Do not give fondaparinux to those with GFRs less than 30.
