MKSAP Board Basics Cardiology Flashcards
Who presents with atypical symptoms of angina?
- Women
- Older adults
- People with diabetes mellitus
If a patient has a new mitral regurgitation (MR) murmur and S3 and S4 gallop - what is this a sign of?
Cardiac ischemia
What should you consider in a patient presenting with pulmonary edema, hypotension, confusion and dysrhythmias, with risk factors such as diabetes mellitus and/or hypertension?
Acute coronary syndrome
Young woman, with history of migraines, acute chest pain, and ST-segment elevation.
Diagnosis?
Coronary vasospasm (Prinzmetal angina)
What is the investigation of choice for coronary vasospasm?
Echocardiography
What is the treatment for coronary vasospasm?
Long-acting nitrate
Calcium channel blocker
Young person with chest pain following a party.
Diagnosis?
Cocaine
What is the investigation of choice for chest pain secondary to cocaine?
Echocardiography
What is the treatment of chest pain secondary to cocaine?
Calcium channel blockers
Should you give beta blockers to someone who has taken cocaine?
No
A tall, thin person with long arms with
acute chest and back pain (especially
“tearing” sensation), a normal ECG, and an aortic diastolic murmur.
Diagnosis?
Marfan syndrome and aortic dissection
What is the treatment for a type A aortic dissection?
Immediate surgery
What investigations are done when an aortic dissection is suspected?
- MR angiography
- CT angiography
- Trans-esophageal echocardiogram
A patient who recently traveled or with
immobility, sharp or pleuritic chest pain,
and nondiagnostic ECG.
Diagnosis?
Pulmonary embolism
A tall, thin young man who smokes with sudden pleuritic chest pain and dyspnea.
Diagnosis?
Spontaneous pneumothorax
A postmenopausal woman with substernal chest pain following severe emotional/physical stress has ST-segment elevation in the anterior precordial leads, troponin elevation, and unremarkable coronary angiography.
Diagnosis?
Stress-induced (takotsubo)
cardiomyopathy. Look for characteristic
apical ballooning on ventriculogram.
What do you see on ventriculogram in case of stress-induced (takotsubo) cardiomyopathy?
Apical ballooning
What is the treatment of stress-induced (takotsubo) cardiomyopathy?
- Beta-blockers
- ACE inhibitors
A young man with substernal chest pain, deep T-wave inversions in V2-V4, and a harsh systolic murmur that increases with Valsalva maneuver.
Diagnosis?
Hypertrophic cardiomyopathy
What investigations are done when hypertrophic cardiomyopathy is suspected?
Echocardiography
What is the treatment for hypertrophic cardiomyopathy?
Beta-blockers
What is the difference between unstable angina and NSTEMI?
Unstable angina has negative biomarkers (troponin) and NSTEMI has positive biomarkers (troponin).
What are ST-elevation equivalents on an EKG?
- New LBBB
- Posterior MI (tall R waves and ST-depressions in V1 - V3)
ST-elevation in EKG leads II, III and aVF.
Diagnosis?
Inferior MI
ST-elevation in EKG leads V1 - V3.
Diagnosis?
Anteroseptal MI
ST-elevation in EKG leads V4 - V6, possibly I and aVL.
Diagnosis?
Lateral and apical MI
ST-elevation in EKG leads V4R - V6R, tall R waves in V1 - V3.
Diagnosis?
Right ventricular MI
EKG with ST-depression and tall R waves in leads V1 - V3.
Diagnosis?
Posterior wall MI
What is considered a low TIMI (Thrombolysis in Myocardial Infarction) risk score?
0 - 2
What is considered a high TIMI (Thrombolysis in Myocardial Infarction) risk score?
3 - 7
Which unstable angina/NSTEMI patients should get early angiography (within 24 hrs) followed by revascularization?
Those with a high TIMI risk score of 3 - 7.
Which unstable angina/NSTEMI patients should get predischarge stress testing and angiography if testing reveals significant myocardial ischemia?
Those with a low TIMI risk score of 0 - 2.
Does acute pericarditis cause ST elevation?
Yes
Does a STEMI cause ST elevation?
Yes
Does a left ventricular aneurysm cause ST elevation?
Yes
Does stress (tokotsubo) cause ST elevation?
Yes
Does coronary vasospasm (Prinzmetal angina) cause ST elevation?
Yes
Does acute stroke cause ST elevation?
Yes
Can ST-segment elevation be a normal variant?
Yes
What should happen with all STEMI patients?
They should undergo immediate cardiac/coronary angiography.
How long is aspirin continued for acute coronary syndrome?
Indefinitely
(Secondary prevention)
How long is a P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) continued for acute coronary syndrome?
For about 1 year following the MI
How soon after diagnosis should you give beta-blockers in ACS?
Within 24 hours
How long do you continue beta-blockers for in ACS?
Indefinitely
(Secondary prevention)
What are the indications to give ACE inhibitor or ARB in ACS?
- Reduced LV ejection fraction
- Clinical heart failure
- Diabetes mellitus
- Hypertension
- Chronic kidney disease
How soon after diagnosis should you give ACE inhibitors or ARBs in acute coronary syndrome?
Within 24 hours
When should you give spironolactone or eplerenone in ACS?
- If LVEF is 40% or less.
- Clinical heart failure
- Diabetes mellitus
How soon after diagnosis should you give spironolactone or eplerenone in acute coronary syndrome?
3 - 14 days after the MI
How long do you continue statin for in ACS?
Indefinitely
(Secondary prevention)
When are GP IIb/IIIa antagonists (abciximab, eptifibatide, tirofiban) given in ACS?
Generally reserved for short-term infusion after difficult or failed PCI in patients at high risk with a large clot burden.
What is the treatment of choice for acute STEMI?
Percutaneous coronary intervention
What is the target time for PCI in STEMI patients?
- 90 min or less in a PCI-capable hospital
- 120 min or less if transferred from another hospital to a PCI-capable hospital
What are four indications for PCI (percutaneous coronary intervention) in ACS patients?
- Failure of thrombolytic therapy
- Thrombolytic therapy contraindicated
- New heart failure
- Cardiogenic shock
What blood pressure is a relative contraindication for thrombolytic agents?
> 180/110 mmHg
When should you administer thrombolytics instead of PCI for STEMI?
When PCI is not available or cannot be achieved within 120 minutes even with transfer.
When is CABG indicated acutely for STEMI?
In the presence of thrombolytic PCI failure or mechanical complications (papillary muscle rupture, VSD, free wall rupture).
Where is the infarct if a patient develops hypotension after nitrates for STEMI?
Right ventricular infarction
What do patients with right ventricular infarcts need in addition to the standard STEMI treatment?
IV fluids
What intervention needs to be performed in a STEMI patient with cardiogenic shock?
Placement of an intra-aortic balloon pump
Should patients with NSTEMI get thrombolytic therapy?
No
Should you give thrombolytic therapy to patients who had onset of chest pain more than 24 hours ago?
No
Should ranolazine be used to treat acute coronary syndrome?
No
Routine use of which (three) medications used in stable angina do not have a role in the post STEMI setting?
- Nitrates
- Calcium channel blockers
- Ranolazine
How long after a myocardial infarction do mechanical complications (VSD, papillary muscle rupture, and LV free wall rupture) typically occur?
2 - 7 days
Which initial diagnostic study is used to evaluate a mechanical complication of an MI?
Emergency echocardiogram
What do you think of if a patient with an MI develops abrupt pulmonary edema or hypotension and a loud holosystolic murmur and thrill?
- VSD (ventricular septal defect)
- Papillary muscle rupture
What do you think of if a patient with an MI develops sudden hypotension or
cardiac death associated with pulseless electrical activity?
Left ventricular free wall rupture
What is the treatment of VSD or papillary muscle rupture after an MI?
- Stabilize with aortic balloon pump
- Sodium nitroprusside (afterload reduction)
- Diuretics
- Emergency surgical intervention
What is the next step in a patient with post-infarction angina?
Coronary angiography
Is the following a criterion (along with others) for placing an ICD in a post-MI patient?
More than 40 days since MI
Yes
Do all these criteria need to be met to place an ICD in a post-MI patient?
- More than 40 days since MI
- LVEF of 30% or less with NYHA functional class I or LVEF 35% or less with NYHA functional class II or III
- More than 3 months since PCI/CABG
Yes
Is the following a criterion (along with others) for placing an ICD in a post-MI patient?
LVEF of 30% or less with NYHA functional class I
Yes
Is the following a criterion (along with others) for placing an ICD in a post-MI patient?
More than 3 months since PCI/CABG
Yes
Is the following a criterion (along with others) for placing an ICD in a post-MI patient?
LVEF 35% or less with NYHA functional class II or III
Yes
All post-MI patients should be screened for depression, because it is associated with increased hospitalization and
death.
True or false?
True
What should you arrange for after discharge from hospital after a myocardial infarction?
Cardiac rehabilitation
What is the definition of stable angina pectoris?
Reproducible, stable anginal symptoms of at least 2 months’ duration precipitated by exertion
or stress and relieved by rest.
Is stress testing of value in patients with very low (e.g., <10%) or very high (e.g., >90%) pretest probabilities of CAD?
No
Which stress test should you perform in angina patients with LBBB?
- Stress echocardiography
- Vasodilator stress radionuclide myocardial perfusion imaging
Which stress test should you not perform in angina patients with LBBB?
Exercise EKG
What should you do for stable angina patients who have a high probably of coronary artery disease?
Coronary angiography
What should you do for stable angina patients who have evidence of left ventricular dysfunction?
Coronary angiography
What should you do for stable angina patients who have evidence of class III or IV angina despite therapy?
Coronary angiography
What should you do for stable angina patients who have evidence of highly positive stress or imaging test?
Coronary angiography
What should you do for stable angina patients who have high pretest probability of left main or three-vessel CAD (a Duke treadmill score ≤−11)?
Coronary angiography
What should you do for stable angina patients who have uncertain diagnosis after noninvasive testing?
Coronary angiography
What should you do for stable angina patients who have history of surviving sudden cardiac death?
Coronary angiography
What should you do for stable angina patients who have suspected coronary spasm?
Coronary angiography
What is the most important treatment for all patients with chronic stable angina?
Intensive lifestyle modification
What are the 4 classes of anti-anginal medications?
- Beta blockers
- Nitrates
- Calcium channel blockers
- Ranozaline
What is the first line treatment of chronic stable angina?
Cardio-selective beta blockers
What is the goal heart rate in chronic stable angina?
Less than 60 beats/min
What are absolute contraindications to beta-blockers?
- Severe bradycardia
- Advanced AV block
- Decompensated heart failure
- Severe reactive airway disease.
What is the first line treatment of chronic stable angina if beta-blockers are absolutely contraindicated?
Calcium channel blockers
How do you prevent nitrate tachyphylaxis?
Nitrate-free period of 8 to 12 hours per day
When is ranolazine considered in chronic stable angina?
Patients who remain symptomatic despite optimal doses of β-blockers, calcium channel
blockers, and nitrates.
Which non-prescription medication reduces the risk of stroke, MI, and vascular death in patients with CAD?
Aspirin
Which medications reduce cardiovascular and all-cause mortality in patients with diabetes, hypertension, CKD, LVEF ≤40%, HF, or a history of MI?
ACE inhibitors
Which lipid medications reduce cardiovascular events, including MI and death?
High-intensity statins
What is the treatment for chronic stable angina in patients who are symptomatic on maximal medical therapy?
Revascularization therapy with PCI or CABG
CABG reduces mortality in which patients?
- Triple vessel disease
- Left-main disease with LV dysfunction
Should you treat elevated
serum homocysteine levels with folic acid or vitamin B12 in angina patients?
No
Should you use antioxidant vitamins (vitamin E) in angina patients?
No - no indication.
Should you give hormone replacement therapy to female patients with angina?
No
What is the likely diagnosis in a patient with paroxysmal nocturnal dyspnea and an S3?
Heart failure
NYHA Functional Class I
Structural disease but no symptoms)
NYHA Functional Class II
Symptomatic; slight limitation of physical activity
NYHA Functional Class III
Symptomatic; marked limitation of physical activity
NYHA Functional Class IV
Inability to perform any physical activity without symptoms
What BNP level excludes heart failure as a cause of dyspnea?
Less than 100 pg/mL
What BNP level is compatible with heart failure as a cause of dyspnea?
More than 400 pg/mL
When is endocardial biopsy indicated?
Diagnosis of:
- Giant cell myocarditis
- Amyloidosis
- Hemochromatosis
What study should be performed on symptomatic NYHA class II-IV HFrEF patients with excessive daytime sleepiness?
Sleep study
Should you order serial BNPs in hospitalized patients to monitor heart failure?
No
Does the BNP increase or decrease in obesity?
Decrease
Does the BNP increase or decrease in kidney failure?
Increase
Does the BNP increase or decrease in older adults?
Increase
Does the BNP increase or decrease in women?
Increase
Which HFrEF patients are treated with ACE inhibitors?
All (to reduce mortality)
Which HFrEF patients are treated with beta blockers?
All (to reduce mortality)
Which two drugs are used in HFrEF black and select non-black patients (low output syndrome, hypertension) with EF < 40% to reduce mortality?
Hydralazine plus nitrates
Which NYHE class HFrEF patients are treated with hydralazine plus nitrates?
- NYHA class III - IV
Which HFrEF patients are treated with aldosterone antagonists (spironolactone and eplerenone)?
NYHA class III - IV (to reduce mortality)
Which HFrEF patients are treated with digitalis?
Still symptomatic despite guideline directed therapy
Which HFrEF patients are treated with diuretics?
Volume overloaded patients
Which HFrEF patients are treated with ivabradine?
EF ≤35% who are in sinus rhythm with a heart rate ≥70/min
Which NYHA class HFrEF patients are treated with valsartan-sacubitril?
NYHA class II or III
Which HFrEF patients are treated with ICD?
- EF ≤35% and NYHA class II - III
- EF ≤30% and NYHA class I
- NYHA class II - III symptoms
HFrEF patients with what ECG findings should be treated with cardiac resynchronization therapy?
LBBB with QRS duration >150 ms
HFrEF patients with what LVEF should be treated with cardiac resynchronization therapy?
- LVEF ≤35%
HFrEF patients with which NYHA class should be treated with cardiac resynchronization therapy?
NYHA class II - IV
Which HFrEF patients are treated with cardiac transplantation?
Refractory HF symptoms despite maximal medical therapy
Which HFrEF patients are treated with exercise training?
All
Should you begin β-blocker therapy in patients with decompensated heart failure?
No
Is IV furosemide better than bolus furosemide in heart failure?
No - no advantage
Which two common drug classes worsen heart failure?
NSAIDS
Thiazolidinediones
Which calcium channel blockers should not be used in heart failure?
Nondihydropyridine calcium channel blockers (diltiazem or verapamil)
How often do you need follow-up echocardiography in heart failure?
Every 1 - 2 years
Do pharmacologic agents (β-blockers, ACE inhibitors, ARBs, aldosterone antagonists) decrease morbidity and mortality in patients with HFpEF?
No
What is the most common cause of non-ischemic cardiomyopathy?
Idiopathic (~ 50%)
Associated with bacterial, viral, and parasitic infections and autoimmune disorders. Cardiac troponin levels are typically elevated; ventricular dysfunction may be global or regional. Can cause cardiogenic shock and ventricular arrhythmias.
Diagnosis?
Acute myositis
What are the principles of treatment of acute myositis?
- Supportive care in acute phase
- Standard heart failure treatment
Associated with chronic heavy alcohol ingestion, but other manifestations of chronic alcohol abuse may be absent. Typically, the LV (and frequently both ventricles) is dilated and hypokinetic.
Diagnosis?
Alcoholic cardiomyopathy
Treatment of alcoholic cardiomyopathy.
- Abstinence from alcohol
- Standard heart failure treatment
Which drugs have been associated with drug-induced cardiomyopathy (myocarditis and dilated cardiomyopathy, as well as MI, arrhythmia, and sudden death)?
Cocaine and amphetamines
Should you use beta blockers in stimulant-induced acute myocardial ischemia?
No
Which beta blockers can you consider in stimulant-induced acute myocardial ischemia?
Labetalol (because it has some alpha activity)
Rare disease characterized by biventricular enlargement, refractory ventricular arrhythmias, and rapid progression to cardiogenic shock in young to middle-aged adults. Histologic examination demonstrates the presence of multinucleated giant cells in the myocardium.
Diagnosis?
Giant cell myocarditis
How do you treat giant cell myocarditis, short and long term?
Immunosuppressant treatment
and/or
LVAD placement/Cardiac transplantation.
Caused by excess iron deposition in the myocardium. Characterized by symptoms of heart failure and by conduction defects.
Diagnosis?
Hemochromatosis
(as a cause of cardiomyopathy)
Presence of HF with an LVEF <45% diagnosed between 1 month before and 5 months after delivery.
Diagnosis?
Peripartum cardiomyopathy
What are the principles of treatment of peripartum cardiomyopathy.
- Early delivery
- Standard heart failure therapy
- Anti-coagulation with warfarin in women with LVEF less than 35%
What do you do for women with LVEF less than 50% with peripartum cardiomyopathy?
Anti-coagulation with warfarin
Should women with persistent left ventricular dysfunction after peripartum cardiomyopathy get pregnant again?
No
Characterized by acute LV dysfunction in the setting of intense emotional or physiologic stress. May mimic acute STEMI. Dilation and akinesis of the LV apex occur in the absence of CAD.
Diagnosis?
Stress-induced (takotsubo) cardiomyopathy
Treatment of stress-induced (takotsubo)
cardiomyopathy.
Supportive care
Occurs when myocardial dysfunction develops as a result of chronic tachycardia.
Diagnosis?
Tachycardia-mediated cardiomyopathy
Principle of treatment of tachycardia-mediated cardiomyopathy.
To slow or eliminate the arrhythmia.
How is hypertrophic cardiomyopathy inherited?
Autosomal dominant in 60% of patients
ECG shows LV hypertrophy and left atrial enlargement. Deeply inverted, symmetric T waves in leads V3-V6 are present in the apical hypertrophic form of the disease (mimics ischemia).
Diagnosis?
Hypertrophic cardiomyopathy
What is the diagnostic test of choice for hypertrophic cardiomyopathy?
Echocardiography
What the first line treatment for hypertrophic cardiomyopathy with EF of 50% or more?
Beta-blockers
What is the first line anti-coagulant treatment of patients with hypertrophic cardiomyopathy and atrial fibrillation?
Warfarin
What is the second line anti-coagulant treatment of patients with hypertrophic cardiomyopathy and atrial fibrillation?
Novel Oral Anticoagulants (NOACs)
e.g. dabigatran, rivaroxaban, apixaban
What is the treatment for hypertrophic cardiomyopathy patients with an outflow tract gradient of >50 mm Hg and continuing symptoms despite maximal drug therapy?
Surgery
Septal ablation
Are patients with hypertrophic cardiomyopathy are at risk of sudden cardiac death if they have had a previous cardiac arrest?
Yes
Are patients with hypertrophic cardiomyopathy are at risk of sudden cardiac death if they have blunted increase or decrease of systolic blood pressure with exercise?
Yes
Are patients with hypertrophic cardiomyopathy are at risk of sudden cardiac death if they have unexplained syncope?
Yes
Are patients with hypertrophic cardiomyopathy are at risk of sudden cardiac death if they have a family history of sudden death in a first-degree relative?
Yes
In patients with hypertrophic cardiomyopathy, what kind of ventricular tachycardia puts them at risk of sudden cardiac death?
- Spontaneous sustained VT
- Non-sustained spontaneous VT ≥ 3 beats
In patients with hypertrophic cardiomyopathy, what left ventricular wall thickness puts them at risk of sudden cardiac death?
- LV wall thickness ≥ 30 mm
What is the treatment for hypertrophic cardiomyopathy patients at risk of sudden cardiac death?
ICD
The absence of any risk factors has a high negative predictive value (>90%) for sudden death in hypertrophic cardiomyopathy patients.
True or false.
True
Are electrophysiologic studies useful in predicting sudden cardiac death in hypertrophic cardiomyopathy?
No
Which medications are contra-indicated in hypertrophic cardiomyopathy?
- Digoxin
- Vasodilators
- Diuretics
(increase LV outflow obstruction)
How should relatives of hypertrophic cardiomyopathy patients be screened?
- Genetic counseling
- If no genetic mutation in proband then echocardiographic screening
At what age is echocardiographic screening started in relatives of patients of hypertrophic cardiomyopathy?
12 years
Cardiac catheterization shows elevated LV and RV enddiastolic pressures and a characteristic early ventricular diastolic dip and plateau.
Diagnosis?
Restrictive cardiomyopathy
Neuropathy, proteinuria, hepatomegaly, periorbital ecchymosis, bruising, low-voltage ECG.
Diagnosis?
Amyloidosis
How is the diagnosis of amyloidosis confirmed?
Abdominal fat pad aspiration.
Bilateral hilar lymphadenopathy; possible pulmonary reticular opacities; and skin, joint, or eye lesions. Cardiac involvement is suggested by the presence of arrhythmias, conduction blocks, or HF.
Diagnosis?
Sarcoidosis
How is the diagnosis of sarcoidosis causing restrictive cardiomyopathy supported (which imaging study)?
Cardiac MR imaging with gadolinium.
Abnormal aminotransferase levels, OA, diabetes, erectile dysfunction, and HF; elevated serum ferritin and transferrin saturation level.
Diagnosis?
Hemochromatosis
What cardiac test do you do first in a patient with palpitations and syncope?
ECG
How would you evaluate frequent arrhythmias?
Ambulatory 24-hr ECG monitoring
How are arrhythmias precipitated by exercise evaluated?
Exercise ECG
What is the test of choice for infrequent, symptomatic arrhythmias?
If they last > 1 - 2 min then event monitor.
If they last less than 2 min then loop recorder.
What is the test for very infrequent arrhythmias?
Implanted recorder
ECG shows PR interval > 0.2 s without alterations in heart rate.
Diagnosis?
First-degree heart block
ECG shows intermittent P waves not followed by a ventricular complex.
Diagnosis?
Second-degree heart block
(can be Mobitz type 1 or type 2)
ECG shows complete absence of conducted P waves (P-wave and QRS complex rates differ, and the PR interval differs for every QRS complex) and an atrial rate that is faster than the ventricular rate; most common
cause of ventricular rates 30-50/min.
Diagnosis?
Third-degree block
(complete heart block)
ECG shows absent Q waves in leads I, aVL, and V6; large, wide, and positive R waves in leads I, aVL, and V6; QRS > 0.12 s.
Diagnosis?
Left bundle branch block (LBBB)
ECG shows rsR′ pattern in lead V1 (“rabbit ears”), wide negative S wave in lead V6, QRS > 0.12 s.
Diagnosis?
Right bundle branch block (RBBB)
ECG shows right bundle branch and one of the fascicles of the left bundle branch are involved.
Diagnosis?
Bifascicular block
ECG characterized by bifascicular block and prolongation of the PR interval.
Diagnosis?
Trifascicular block
ECG shows left axis usually –60°, upright QRS complex in lead I, negative QRS complex in aVF, and normal QRS duration.
Diagnosis?
Left anterior hemiblock
ECG shows right axis usually +120°, negative QRS complex in lead I, positive QRS complex in lead aVF, and normal QRS duration.
Diagnosis?
Left posterior hemiblock
ECG shows constant P-P interval with progressively increased PR interval until the dropped beat; grouped beating is classic.
Diagnosis?
Mobitz type 1 (Wenckebach block)
EKG shows constant PR interval in the conducted beats; R-R interval contains the nonconducted (dropped) beat equal to two P-P intervals; usually associated with LBBB or RBBB.
Diagnosis?
Mobitz type 2
Do you usually treat asymptomatic patients with bradycardia?
No
What is the treatment of bradycardia or heart block with symptoms of hemodynamic compromise?
- IV atropine
- Transcutaneous or transvenous pacing
Should you place a pacer for asymptomatic bradycardia in the absence of second- or third degree AV block?
No
What is the treatment of hemodynamically unstable atrial fibrillation?
Emergency electrical cardioversion
Is there mortality benefit of rhythm control compared to rate control in atrial fibrillation?
No
Who should get rhythm control for atrial fibrillation?
Younger patients with persistent symptoms
Who should get rate control for atrial fibrillation?
Older patients with chronic atrial fibrillation or atrial fibrillation of unknown duration.
How do you assess stroke risk in patients with atrial fibrillation?
CHA2DS2-VASc score
Can you give warfarin in pregnancy?
No
Which anticoagulant is indicated for valvular atrial fibrillation?
Warfarin
Which anticoagulant is indicated for nonvalvular atrial fibrillation?
Novel Oral Anticoagulants (NOACs)
What is the treatment of atrial fibrillation in patients with Wolff-Parkinson-White syndrome?
Procainamide
Which drugs are contra-indicated in the treatment of atrial fibrillation in patients with Wolff-Parkinson-White syndrome?
- Calcium channel blockers
- Beta-blockers
- Digoxin
Can adenosine cardiovert atrial fibrillation?
No
Is medical therapy or radiofrequency catheter ablation superior in the treatment of atrial flutter?
Radiofrequency catheter ablation
How can you terminate an episode of SVT?
- Valsalva maneuvers
- Carotid sinus massage
- Cold water on face
- Adenosine
Adenosine is contra-indicated in which type of tachycardia?
- Irregular wide complex tachycardia
- Polymorphic tachycardia
What is atrial fibrillation associated with Wolff-Parkinson-White syndrome a risk factor for?
Ventricular fibrillation
What is the preferred treatment for unstable patients with Wolff-Parkinson-White syndrome?
Cardioversion
Does asymptomatic WPW conduction without arrhythmia need investigation or treatment?
No
What is the first line treatment of patients with Wolff-Parkinson-White who have pre-excitation and symptoms?
Ablation of accessory bypass tract
What should wide QRS tachycardia be considered unless proven otherwise?
Ventricular tachycardia
What tests are indicated in all patients with ventricular tachycardia?
- ECG
- Exercise treadmill testing
- Cardiac imaging/echocardiogram
What is the treatment of non-sustained ventricular tachycardia in patients without identifiable structural heart disease and debilitating symptoms?
- Beta-blockers
- Calcium-channel blockers
What is the treatment of non-sustained ventricular tachycardia in patients with identifiable structural heart disease?
- Beta-blockers
- ACE inhibitors
What is the treatment of recurrent non-sustained ventricular tachycardia?
Amiodarone
What is the treatment of patients with recurrent non-sustained ventricular tachycardia despite medical therapy?
Catheter ablation
What is the treatment of sustained ventricular tachycardia in patients with structural disease or cardiomyopathy, if reversible causes (e.g. cocaine or acute coronary ischemia) have been excluded?
ICD
Does therapy to suppress PVCs affect outcomes in patients with structural heart disease?
No
What is the acute treatment of sustained ventricular tachycardia in unstable patients?
Cardioversion
What is the acute treatment of sustained ventricular tachycardia in stable patients with impaired left ventricular function?
IV amiodarone
IV lidocaine
Procainamide
Sotolol
What raises suspicion of an inherited arrhythmia syndrome?
- Sudden cardiac death before age 35 years
- Sudden death in first degree relative
Patients with this may experience syncope or sudden cardiac death as the result of torsades de pointes. Look for hypokalemia, hypomagnesemia, structural heart disease, medications, and drug interactions (especially moxifloxacin or methadone).
Diagnosis?
Long QT syndrome
An inherited condition characterized by a structurally normal heart but abnormal electrical conduction associated with sudden cardiac death. ECG shows an incomplete RBBB pattern with coved ST-segment elevation in leads V1and V2.
Diagnosis?
Brugada syndrome
What (three) investigations are ordered for survivors of sudden cardiac death?
- ECG
- Echocardiography for structural disease.
- Electrophysiologic studies
How is inherited long QT syndrome treated?
Beta-blockers
What is the treatment for survivors of cardiac arrest resulting from VF or VT not explained by a reversible cause?
ICD
What is the treatment after sustained VT in the presence of structural heart disease?
ICD
What is the treatment after syncope and sustained VT/VF on electrophysiology study?
ICD
What is the treatment for ischemic and nonischemic cardiomyopathy with an EF ≤35%, NYHA class II or III symptoms, on guideline-directed medical therapy?
ICD
What is the treatment for Brugada syndrome with syncope or ventricular arrhythmia?
ICD
What is the treatment for inherited long QT syndrome not responding to β-blockers?
ICD
What is the treatment for a patient who is ≥ 40 days after MI with an EF ≤ 30%?
ICD
What is the treatment for high-risk HCM (familial sudden death; multiple, repetitive non-sustained VT; extreme LVH; a recent, unexplained
syncopal episode; and exercise hypotension)?
ICD
Acute sharp or stabbing substernal chest pain that worsens with inspiration and when lying flat and is alleviated when sitting and leaning forward.
Diagnosis?
Acute pericarditis
Does absence of a pericardial effusion on echocardiography rule out pericarditis?
No
What is the first line treatment of acute pericarditis?
- Colchicine and aspirin
- NSAIDS
How do you treat acute pericarditis that does not respond to colchicine or NSAIDS?
Glucocorticoids
What is the treatment of acute pericarditis associated with cardiac tamponade or hemodynamic instability?
Emergent pericardiocentesis
Can acute pericarditis cause elevated troponin?
Yes
Patient with metastatic lung and breast cancer presents with dyspnea, fatigue, peripheral edema, hepatomegaly, hepatic dysfunction, and ascites in the absence of pulmonary congestion. Physical examination shows JVD, pulsus paradoxus, tachycardia, reduced heart sounds, and/or hypotension.
Diagnosis?
Chronic cardiac tamponade
CXR shows an enlarged cardiac silhouette (“water bottle sign”).
Diagnosis?
Pericardial effusion/cardiac tamponade
Does absence of a pericardial effusion exclude a diagnosis of cardiac tamponade?
Yes
Patient with cirrhosis has a pericardial knock (a loud third heart sound that occurs earlier in diastole than a normal S3), Kussmaul sign (increased JVD on inspiration), and pericardial friction rub.
Diagnosis?
Constrictive pericarditis
Is chronic constrictive pericarditis necessary to treat in patients with early disease (NYHA functional class I) and selected patients with advanced disease (NYHA functional class IV)?
No
What is the most effective treatment for chronic constrictive pericarditis?
Pericardiectomy
A pregnant woman has an increased P2, an S3, and an early peaking systolic murmur over the upper left sternal border.
Diagnosis?
Normal findings during pregnancy
Mid-systolic; crescendo decrescendo murmur at right upper sternal border. Enlarged, nondisplaced apical impulse; S4.
In severe cases decreased A2; high-pitched, late-peaking murmur; diminished and delayed carotid upstroke.
Diagnosis?
Aortic stenosis
Diastolic; decrescendo murmur at left or right lower sternal border. Enlarged, displaced apical impulse. Increased pulse pressure; bounding
carotid and peripheral pulses.
Diagnosis?
Aortic regurgitation
Diastolic; low pitched, decrescendo at apex. Loud S1; tapping apex beat. Intensity of murmur
correlates with transvalvular gradient.
Diagnosis?
Mitral stenosis
Systolic; holo-, mid-, or late systolic murmur at apex. S3, hyperdynamic apical pulse. Valsalva
maneuver moves onset of clicks and murmur closer to S1; handgrip increases murmur intensity.
Diagnosis?
Mitral regurgitation
Holosystolic murmur at left lower sternal border that increases during inspiration. Merged and prominent c and v waves in jugular venous pulse. Right ventricular impulse below sternum. Pulsatile, enlarged liver with possible ascites.
Diagnosis?
Tricuspid regurgitation
Diastolic; low pitched, decrescendo murmur at left lower sternal border; increased intensity during inspiration. Elevated CVP with prominent a wave, signs of venous congestion (hepatomegaly, ascites, edema).
Diagnosis?
Tricuspid stenosis
Systolic; crescendo decrescendo murmur at right upper sternal border. Pulmonic ejection click after S1 (diminishes with inspiration). Increased intensity of murmur with late peaking.
Diagnosis?
Pulmonary stenosis
Diastolic; decrescendo murmur at left lower sternal border. Loud P2 may be present.
Diagnosis?
Pulmonary regurgitation
Systolic; crescendo decrescendo murmur at right upper sternal border. Fixed split S2; right ventricular heave. May be associated with pulmonary hypertension with increased intensity of P2, pulmonary valve regurgitation.
Diagnosis?
Atrial septal defect
Holosystolic murmur at left lower sternal border; palpable thrill. Increases with hand-grip,
decreases with amyl nitrite.
Diagnosis?
Ventricular septal defect
What is the treatment of a group A streptococcal infection?
Penicillin
What is the treatment of a group A streptococcal infection in patients with penicillin allergy?
Erythromycin
How long should rheumatic valvular heart disease patients take prophylaxis?
10 years after last episode of rheumatic fever or age 40 years whichever is longer.
What medication should you use for prophylaxis in patients with rheumatic fever?
Penicillin
Which is the most common valve effected in rheumatic fever?
Mitral valve
What is the treatment for culture negative rheumatic fever?
- Penicillin
- Salicylates
Should symptomatic patients with aortic stenosis get exercise stress testing?
No
What is the treatment of symptomatic aortic stenosis patients?
Surgery - aortic valve replacement (SAVR)
What is the treatment of symptomatic aortic stenosis patients who are at high operative risk?
Transcatheter aortic valve replacement (TAVR)
What is the survival benefit of SAVR (surgical aortic valve replacement) vs TAVR (transcatheter aortic valve replacement) vs medical therapy?
SAVR and TAVR are similar in intermediate and high-risk patients; and superior to medical therapy.
What are contraindications to TAVR (transcatheter aortic valve replacement)?
- Biscuspid aortic valve
- Significant aortic regurgitation
- Mitral valve disease
What is the medical therapy of aortic stenosis?
- Diuretics
- Digoxin
- ACE inhibitors
Does medical therapy stall progression of aortic stenosis?
No
When is medical therapy used to treat aortic stenosis?
When patients are waiting for SAVR (surgical aortic valvular replacement) or TAVR (transcatheter aortic valve replacement).
Should you use balloon valvuloplasty as definitive treatment for aortic stenosis?
No
Do statins alter the natural history of aortic stenosis?
No
What do you monitor with serial echocardiography in patients with aortic stenosis?
- Left aortic valve area
- Degree of ventricular hypertrophy
- Left ventricular function
How often do you do serial echocardiography in asymptomatic patients with severe aortic stenosis?
Every 6 - 12 months
How often do you do serial echocardiography in asymptomatic patients with moderate aortic stenosis?
Every 1 - 2 years
How often do you do serial echocardiography in asymptomatic patients with mild aortic stenosis?
Every 3 - 5 years
What is most common congenital heart abnormality?
Bicuspid aortic valve
What is the first line therapy for a stenosed bicuspid aortic valve?
Surgery - aortic valve replacement (SAVR)
What is the first line therapy for a regurgitant bicuspid aortic valve in a symptomatic patient or one with LVEF < 50%?
Surgery - aortic valve replacement (SAVR)
What are the indications for surgery in a regurgitant bicuspid aortic valve?
- Symptomatic (heart failure symptoms).
- Left ventricular ejection fraction less than 50%
When is surgery indicated to repair aortic root or replace ascending aorta?
Aortic root diameter > 5 cm with risk factors for dissection (family history, progression > 0.5 cm/year)
Or
Aortic root diameter > 5.5 cm without risk factors
How often is the aortic root assessed by echocardiogram in patients with bicuspid aortic valve?
If aortic root or ascending aorta diameter is more than 4 cm then every 2 years, if more than 4.5 cm then every year.
Name two conditions that cause acute severe aortic regurgitation.
- Infective endocarditis
- Aortic dissection
What diagnosis should you think of in case of widened pulse pressure?
Aortic regurgitation (severe)
What is the treatment for acute aortic regurgitation?
Surgery - aortic valve replacement
What is the bridging medical therapy for patients with acute aortic regurgitation who need aortic valve replacement?
- Sodium nitroprusside
- IV diuretics
How do you treat the hypotension in patients with aortic regurgitation?
- Dobutamine
- Milrinone
What is the bridging medical therapy for patients with chronic aortic regurgitation and heart failure who need aortic valve replacement?
- ACE inhibitors
- Nifedipine
What therapies are contra-indicated in acute aortic regurgitation?
- Beta-blockers
- Intra-aortic balloon pumps
Does medical therapy delay need for surgery in asymptomatic patients with chronic aortic regurgitation?
No
What is the treatment for patients with symptomatic mitral valve stenosis?
Percutaneous balloon mitral commissurotomy
What is the treatment for patients with asymptomatic mitral valve stenosis with valve area < 1 cm3?
Percutaneous balloon mitral commissurotomy
What is a contraindication to valvulotomy in case of patients with mitral stenosis?
Concurrent mitral regurgitation
Left atrial thrombosis
When is surgery (repair) for mitral valve stenosis indicated?
When balloon valvotomy is unavailable or contra-indicated.
What is the medical treatment of mitral stenosis?
- Diuretics
- Long-acting nitrates
Should patients with mitral stenosis and atrial fibrillation with a low CHA2DS2-VASc score be treated with anti-coagulation?
Yes
Which medication is used for anti-coagulation in mitral stenosis patients with atrial fibrillation?
Warfarin
What is the first line treatment for mitral valve regurgitation?
Surgery - repair preferred, otherwise replacement
What is the medical treatment of decompensated heart failure patients with mitral regurgitation?
- Nitrates
- Diuretics
How do you treat patients with severe mitral regurgitation who are hypotensive?
- Inotropic agents
- Intra-aortic balloon pump
Do ACE inhibitors or ARBs prevent progression of left ventricular dysfunction in patients in chronic mitral regurgitation?
No
What is the treatment of symptomatic patients with mitral valve prolapse?
Beta-blockers
What is the treatment of patients with mitral valve prolapse who have unexplained TIAs with sinus rhythm and no atrial thrombi?
Aspirin
What is the treatment for mitral prolapse patients with recurrent ischemic neurologic events despite aspirin?
Warfarin
What is the treatment for mild tricuspid regurgitation?
No treatment needed.
(Physiologically normal)
What is the treatment for symptomatic severe tricuspid regurgitation?
Surgery
Which artificial heart valves, mechanical or bioprosthetic, are more durable?
Mechanical valves
Do mechanical valves require lifelong anticoagulation?
Yes
Prosthetic valves in which position are more durable and less prone to thromboembolism?
Aortic valves are more durable and less prone to thromboembolism than valves in the mitral position.
What is the diagnostic procedure of choice if cardiac valve dysfunction is suspected?
Echocardiography
What is the target INR for an aortic prosthetic valve without thromboembolism risk factors?
2.5
What is the target INR for an aortic prosthetic valve with thromboembolism risk factors?
3
Should patients with mechanical heart valves receive aspirin?
Yes
Should you use a NOAC (e.g., dabigatran, rivaroxaban) for anticoagulation in patients with a mechanical heart valve?
No
Should you use warfarin for anticoagulation in patients with a mechanical heart valve?
Yes
When is closure of an ASD contra-indicated?
Shunt reversal from right to left.
Is coarctation of the aorta congenital?
Yes
When you check blood pressure in legs in young people presenting with unexplained hypertension, what diagnosis are you suspecting?
Coarctation of aorta
When is treatment for coarctation of aorta indicated?
- Discrete area of aortic narrowing
- Proximal hypertension
- Pressure gradient > 20 mmHg
What is the treatment of coarctation of aorta?
Balloon dilation
What percentage of patients have recurrent or persistent hypertension after repair of coarctation of aorta?
Up to 75%
Patient has clubbing and oxygen desaturation that affects the feet but not the hands (differential cyanosis).
Diagnosis?
Eisenmenger syndrome in patent ductus arteriosus (PDA)
When is closure of PDA (patent ductus arteriosus) indicated?
Left-sided cardiac chamber enlargement in the absence of severe pulmonary hypertension.
In what percentage of the population does the foramen ovale not close?
25 - 30%
When is patent foramen ovale treated?
In patients with cryptogenic stroke (prevents recurrent stroke). These patients also need aspirin.
What is Eisenmenger syndrome?
Pulmonary hypertension with eventual right-to-left shunt.
When is closure of VSD (ventricular septal defect) contra-indicated?
Eisenmenger syndrome - when there is pulmonary hypertension with right-to-left shunt.
Do dental procedures that involve mucosal bleeding need prophylaxis against infective endocarditis?
Yes - if the patient has risk factors.
What medication is used for prophylaxis against infective endocarditis?
Amoxicillin 30 - 60 min before the procedure.
Osler nodes are found in which disease?
Infective endocarditis
Janeway lesions are found in which disease?
Infective endocarditis
Roth spots are found in which disease?
Infective endocarditis
What should you do if a patient has Staphylococcus bacteremia?
Transesophageal echocardiogram (TEE)
What is the test of choice to identify a paravalvular abscess?
Transesophageal echocardiogram (TEE)
What criteria do you use to diagnose infective endocarditis?
Duke criteria
Should you give antibiotic prophylaxis to patients with mitral valve prolapse?
No
What should you look for in patients with infective endocarditis caused by Streptococcus bovis or Clostridium septicum?
Colon cancer
Should you wait for culture results before treating infectious endocarditis?
Yes.
However, decompensated patients should be treated immediately (prior to culture results).
What is the empiric treatment for community-acquired native valve infective endocarditis?
Vancomycin or ampicillin-sulbactam + Gentamycin
What is the empiric treatment of nosocomial-associated infective endocarditis?
- Vancomycin
- Gentamycin
- Rifampin
- Anti-pseudomonal beta-lactam
What is the empiric treatment of prosthetic valve infective endocarditis?
Vancomycin
Gentamycin
Rifampin
How long is the treatment of infectious endocarditis typically?
4 - 6 weeks
How is right-sided native valve endocarditis caused by MSSA treated?
Nafcillin
Oxacillin
Flucloxacillin
For 2 weeks.
Are oral antibiotics recommended for infective endocarditis?
No
What is a type A dissection?
Aortic dissection involving the ascending aorta
What is a type B dissection?
All aortic dissections that do not involve the ascending aorta
What is a risk factor for aortic dissection in older patients?
Uncontrolled hypertension
What medications reduce the rate of aortic dilation in patients with Marfan syndrome?
Beta-blockers
How is uncomplicated type B dissection treated?
Medical therapy:
- Beta-blockers
- Nitroprusside
Which medication should not be used in aortic dissection because it increases shear stress?
Hydralazine
When should surgery be scheduled for type B dissection?
When major arteries are involved e.g. renal arteries.
Who should get a screening ultrasound for abdominal aortic aneurysm?
One time screening:
- Men between 65 - 75 years who have ever smoked
- Men between 65 - 75 years who have risk factors (family history of AAA)
Should you screen women for AAA?
No
Can ultrasonography accurately diagnose a ruptured abdominal aortic aneurysm?
No
Patient presents with livedo reticularis, gangrene of digits, transient vision loss with golden or highly refractile within a retinal artery (Hollenhorst plaque).
Diagnosis?
Embolic stroke secondary to aortic atheroemboli.
Is asymptomatic aortic atheroma treated?
Yes
What is the treatment of asymptomatic aortic atheroma?
- Antiplatelet agents
- Statins
(to reduce risk of cardiovascular events)
Should you screen routinely for peripheral artery disease (PAD)?
Either way.
No - USPTF - insufficient evidence
Yes - ACC/AHA - reasonable in high-risk patients (atherosclerosis)
What do you think of in patients with intermittent claudication?
Peripheral artery disease
What is the initial diagnostic test to evaluate suspected peripheral artery disease (PAD)?
Resting ABI
What is the next step in patients with intermittent claudication and normal or borderline resting ABI?
Exercise treadmill ABI testing
When is noninvasive angiography with duplex ultrasonography, CTA or MRA performed in patients with peripheral artery disease (PAD)?
When anatomic delineation is needed for patients with PAD who need surgical or endovascular intervention
What is the best test to perform in patients with acute limb ischemia?
Diagnostic angiography
When should you do a toe-brachial index?
If the ankle-brachial index is > 1:40 - to provide a better assessment of lower extremity perfusion
What is the most effective treatment for improvement in functional status in patients with PAD?
Exercise training
Is peripheral artery disease an indication for anti-coagulation?
No
Should you use cilostazol in patients with a low LVEF or history of HF?
No
Are β-Blockers contraindicated in patients with peripheral artery disease (PAD)?
No
What is the medical treatment of peripheral artery disease (PAD)?
- Aspirin
- Statin
- Cilostazol
What is the treatment of acute limb ischemia?
- Antiplatelets
- Heparin
- Surgery (embolectomy)
What valvular heart disease do the auscultatory findings in atrial myxoma mimic?
Mitral stenosis
What is the treatment of a cardiac myxoma?
Surgical resection
Does a STEMI cause ST elevation?
Yes
Does a left ventricular aneurysm cause ST elevation?
Yes
What are the criteria for placing an ICD in a post-MI patient?
Must meet all of the following:
- More than 40 days since MI
- LVEF of 30% or less with NYHA functional class I or LVEF 35% or less with NYHA functional class II or III
- More than 3 months since PCI/CABG
