Master the Boards: Cardiology Flashcards
What is Tako-Tsubo cardiomyopathy and the presumed mechanism?
Myocardial infarction occurring in relation to extremely stressful events, common in postmenopausal woman and presumed due to massive catecholamine release. Coronary arteries are normal and patients don’t benefit from revascularization. There is evidence of LV hypokinesis.
In order for CAD in a parent to be a risk factor for a patient what other information must you know?
The age of onset in that pattern. CAD will only be a risk factor if it occurs early in the parents (males
What risk factor lifestyle modification leads to the greatest reduction in CAD risk?
Quitting smoking
If the nature of chest pain changes with respiration, bodily position, or upon palpation is it more or less likely ischemia?
Less likely
What are EKG findings of pericarditis?
ST elevation throughout
PR depression
If the etiology of chest pain is not certain and the EKG is non-diagnostic what should be the next test employed?
Stress test
If a patient cannot exercise for a stress test then what other options do yo have for inducing mild ischemia during testing?
Dipyridamole combined with nuclear isotopes (e.g. thallium ,sestamibi)
Dobutamine with echocardiography
What is the most accurate method of detecting CAD?
Coronary angiography
Surgically correctable levels of coronary stenosis begin at what percentage?
70%
What drugs offer the best mortality benefit in chronic angina (3)?
Aspirin
Beta-blocker
Nitrate
What is prasugrel?
Thienopyridine (similar to clopidogrel) with best evidence in use for angioplasty and stenting
Ticlodipine inhibits platelets and is used in the rare situation when both aspirin and clopidogrel cannot be used.
What are two side effects of ticlodipine?
Neutropenia
TTP
What drug has the best mortality benefit in CAD with low ejection fraction(systolic dysfunction)?
ACE inhibitors
In CAD, what is the goal of LDL according to national guidelines?
What is the most common side effect of statin medications?
Elevated transaminases
Rhabdomyolysis is not as common as the above
Niacin predominantly has what effect on the lipid profile?
What are three side effects seen?
Increases HDL
Glucose intolerance (hyperglycemia), increased uric acid, itchiness related to histamine release
Fibrates have what effect on lipid profile?
When used with statins what are patients at increased risk for?
Lower TGs
Increased risk of myositis
Name a bile acid sequestrant medication
Cholestyramine
Flatus and abdominal cramping are side effects of what lipid lowering medication?
Cholestyramine
Should CCBs be routinely used in CAD, why?
Which two may be used in select situations?
No, they can cause a reflex tachycardia which can increase myocardial oxygen demand in CAD and lead to INCREASED mortality.
Verapamil and diltiazem may be used in those with severe asthma which can’t receive beta-blockers, cocaine users, or those with Prinzmetal variant angina
Edema, constipation, and heart block may be the side effects of what class of medications?
Calcium channel blockers
Constipation is especially common with verapamil
In bypass grafting, which vessel usually lasts longer internal mammary artery or saphenous vein?
Internal mammary artery (10 years) Saphenous vein (5 years)
What is the best intervention for acute coronary syndrome?
Percutaneous coronary intervention (i.e. angioplasty)
Increased jugulovenous pressure on inhalation = ?
What is it associated with?
Kussmaul sign
Associated with constrictive pericarditis or restrictive cardiomyopathy
A displaced point of maximal impulse is suggestive of what two disease entities?
LVH
Dilated cardiomyopathy
ST elevations in V2 - V4 suggest STEMI of what location?
Anterior wall of left ventricle
ST elevations in II, III, and aVF suggest STEMI of what location?
Inferior wall
Should PVCs be treated?
No, treating them (even in setting of ACS) only worsens outcomes
ST depression in leads V1 and V2 suggests of MI of what location?
Posterior wall MI (low mortality)
What medication should be given immediately during acute coronary syndrome since it reduces mortality?
Aspirin
Beta-blocker, nitrate, oxygen, morphine all help but do not lead to reduced mortality as much
How long after an MI does troponin rise and how long does it remain elevated?
4-6 hours post-MI
Remains elevated for 10-14 days so not helpful in determining reinfarction
What is better, angioplasty or thrombolytics?
What is the gold standard in terms of time?
Angioplasty (i.e. PCI) should be done within 90 minutes of arriving to ED with chest pain
Does warfarin have any utility in CAD?
During PCI, what helps reduce the risk of restenosis?
No, warfarin is really only helpful on the venous circulation
Placement of a drug-eluting stent with PCI reduces the risk of restenosis
If a patient is brought to a hospital without a cath lab and they have ACS what should be done, thrombolytics or transfer for PCI?
Thrombolytics, attempt to give within 30 minutes
If there is ST depression on EKG of a patient with suspected ACS can thrombolytics be used?
No, they should only be used in cases of ST elevation
What type of MI is heparin best used in?
NSTEMI
A cannon A wave is an indicator of what pathological cause of bradycardia?
Third degree AV block. They represent atria contracting against a closed tricuspid valve since the atria and ventricles are out of sync.
What artery supplies the inferior wall of heart?
Right coronary artery?
How should RV infarctions be treated compared to LV infarctions?
They should be fluid resuscitated (Nitrates and other venodilators may worsen cardiac filling in RV infarction)
Sudden loss of pulse a few days after an MI is from what complication?
Free wall rupture/tamponade
A patient presents a few days after an MI with new onset murmur and pulmonary congestion, what are the two possible causes?
Septal rupture (often present with "step-up" in oxygenation) Valve rupture (causing mitral regurgitation)
What is the utility of an intra-aortic balloon pump?
It is a temporizing measure to help induce blood flow in a heart with poor output due to anatomic causes. It is not a permanent solution and is often done for 24-48 hours prior to valve replacement or transplant.
What should be done before discharging a patient from the hospital with myocardial ischemia?
A stress test to determine residual areas in need of revascularization. If the patient remains symptomatic do not do the stress test, likewise if they don’t have signs of reversible ischemia.
Should patients receive prophylactic antiarrhythmics upon discharge from the hospital after an MI?
NO!
Do patients have to wait after an MI to have sex?
Erectile dysfunction post-infarction is most commonly due to?
No, they can go for it.
Anxiety
What is the most common cause of CHF?
HTN
Name as many causes of cardiomyopathy leading to CHF you can
Alcohol, postviral myocarditis, hemochromatosis, thiamine, radiation, Chagas disease, thyroid disease, peripartum cardiomyopathy, adriamycin/doxorubicin
Name the cause of dyspnea
Brown blood, not improving with oxygen supplementation, cyanosis, and clear lungs on auscultation
Methemoglobinemia
What are specific H + P findings leading you to consider CHF?
Orthopnea
Paroxysmal Nocturnal Dyspnea
S3
Every patient with CHF must undergo what test to evaluate for either systolic or diastolic dysfunction?
Echo
What is the best initial test to evaluate EF in CHF?
What is the most accurate test?
Transthoracic Echo Nuclear ventriculography (TEE is even more accurate)
In what situation should you be checking a BNP on a patient?
They present with SOB and CHF is suspected and you don’t have immediate access to an echo
What disturbance on the lipid profile is the biggest risk factor for CAD?
Elevated LDL
What is the benefit of eplerenone over spironolactone?
Doesn’t have the antiandrogenic effects of spironolactone
Does digoxin (or any positive inotropic agent for that matter) have an effect on mortality in CHF?
What does digoxin have an effect on in CHF?
No effects on mortality
Digoxin does however reduce the frequency of hospitalizations
What are the indications for an implantable pacemaker in CHF? (2)
Ischemic cardiomyopathy
Ejection fraction
What treatments of systolic-dysfunction CHF have a proven mortality benefit (4 pharmacologic, 1 procedural)?
ACEi/ARB Beta-blocker Spironolactone/Eplerenone Hydralazine/Nitrate Implantable pacemaker
Are diuretics recommended in hypertrophic obstructive cardiomyopathy?
No. They worsen the obstruction
What medications have a clear benefit in the treatment of diastolic CHF?
Beta-blockers
Diuretics
Amrinone and milrinone function how?
What effects do they have?
PDE inhibitors
Increase contractility, reduce afterload
What valvular disease is Rheumatic fever most commonly associated with?
Mitral stenosis
What effect does inspiration and expiration have on murmurs on the right and left sides of the heart, respectively? Explain.
Inspiration causes negative intrathoracic pressure which draws increased venous return to the right (increased preload on right) which increases intensity of tricuspid and pulmonic murmurs.
Expiration “pushes” blood out of the lungs and into the left heart, thus accentuating mitral and aortic murmurs.
Regurgitant valvular lesions respond best to which type of medical therapy?
ACEi/ARB
Nifedipine
Hydralazine
What valvular abnormality may present with dysphagia and hoarseness?
What do squatting and leg raising do to the murmur?
Mitral stenosis; it may compress esophagus and also recurrent laryngeal nerve
Squatting and leg raising increase preload and increase the intensity of the murmur
What do Valsalva, standing, and handgrip all do the murmur of aortic stenosis and why?
They all decrease it.
Valsalva and standing both decrease venous return which reduces volume of blood flowing by the valve.
Handgrip increases afterload which also reduces the amount of blood which will pass through the valve.
What is a procedural treatment which can be done for mitral stenosis?
Balloon valvoplasty
What will handgrip, squatting, leg raising, standing, valsalva, and expiration do to mitral regurgitation murmur?
Handgrip: Increase afterload therefore increase
Squat/Leg raise: Increase preload therefore increase
Standing/Valsalva: Decrease preload therefore decrease
Expiration: Increases left-heart volume and thus increases
What are the only two left-sided murmurs which will decrease with expiration?
Hypertrophic cardiomyopathy
Mitral valve prolapse
What medical management is recommended for mitral regurgitation?
What is an indication for surgical valve replacement?
ACEi/ARB
Dilation of heart because that can lead to irreversible damage
Marfan syndrome may lead to which type of heart murmur?
Aortic regurgitation (via cystic medial necrosis)
Which murmur is heard as a diastolic, decrescendo murmur at the lower left sternal border that can also present with head bobbing?
What different maneuvers will change the quality of the murmur?
Aortic regurgitation
Valsalva and standing improve. Handgrip worsens. Squatting and straight leg worsen.
What murmur may present with atypical chest pain, palpitations, and a panic attack?
MVP
What is the murmur of MVP?
What effects do typical movements have on the murmur?
Midsystolic click murmur that may have a systolic component afterwards from a degree of mitral regurgitation.
Behaves in opposite way of most left-sided murmurs.
Expiration: decreases
Valsalva/standing: increase
Handgrip/Squat/Straight leg raise: decrease
Symptomatic MVP is treated with what?
Beta-blocker
Symptoms would include atypical chest pain, palpitations, and panic attack
What is the main treatment for cardiomyopathy?
Diruetics
What medications lower mortality in dilated cardiomyopathy?
Which help control symptoms?
ACEi/ARB
Beta-blocker
Spironolactone
Symptom control: diuretics and digoxin
Anything that decreases left ventricular size or increases heart rate will worsen __________.
Hypertrophic obstructive cardiomyopathy
What is the best medication for initial therapy in HOCM?
What medication is contraindicated in HOCM and why?
Beta-blockers is best initial therapy
Diuretics are contraindicated because they will lower ventricular size and worsen obstruction
A patient with HOCM presents with a syncopal episode. He is admitted in the hospital. What procedure should he be scheduled for?
Implantable defibrillator placement
Are spironolactone and digoxin used in hypertrophic cardiomyopathy?
No
What are causes of restrictive cardiomyopathy?
Amyloidosis Scleroderma Hematochromatosis Sarcoid Endomyocardial fibrosis
How do standing and Valsalva maneuvers reduce venous return to the heart?
Standing: opens venous capacitance of legs
Valsalva: Increases intrathoracic pressure and reduces return
What effect does handgrip and amyl nitrate have on afterload?
Handgrip: increases afterload so a “fuller” LV
Amyl nitrate: arterial vasodilator which decreases afterload so an “emptier” LV
What are medical treatment options for pericarditis of idiopathic origin?
NSAIDs, including indomethacin
Colchicine can reduce recurrences
Equalization of pressures in diastole seen in a right heart catheterization may indicate what pathology?
Cardiac tamponade
In suspected constrictive pericarditis, what is the best initial test?
Chest X-ray which may show calcification and fibrosis
How do the legs appear in severe types of peripheral artery disease?
Smooth and shiny due to loss of hair follicles, sweat glands, and sebaceous glands
An ABI less than ____ indicates a degree of PAD
What is the single most effective medication in peripheral artery disease and how does it work?
Cilostazol: PDE3 inhibitor which leads to arterial vasodilation
What medications are used to control BP in patients presenting with aortic dissection?
Beta-blockers first
Others include nitroprusside (but beta-blocker must be used before because it guards against a reflex tachycardia associated with nitroprusside)
What is the pathophysiologic mechanism of peripartum cardiomyopathy?
What drugs can be used for this?
Antibodies made against the myocardium (usually develops AFTER giving birth)
ACEi/ARB, beta-blocker, diuretic, spironolactone, digoxin
What is Eisenmenger syndrome?
A person with VSD eventually develops pulmonary hypertension severe enough to switch the shunt through the VSD so that it is right to left
