MKSAP14 Flashcards
A flutter classically has an atrial rate of _________ and a ventricular rate of ______
300;150 i.e. 2:1
How is DAPT affected by history of stroke?
If pt has had ischemic stroke then cannot have prasugrel as it is contraindicated
What is the concern for a pt with COPD who has RAD/RBBB
May have cor pulmonale (WHO III pulmonary HTN)
How many PVCs make up VT? When is VT considered to be sustained?
more than 3 PVCs, if VT lasts >30 sec
In a pt with inferior MI, what is an indicator that the pt may have concomittant RV involvment?
Development of hypotension with the administration of SLNTG
In a pt who has had several heart surgeries who presents with elevated JVP, ascites, LE edema with normal LV systolic fxn the most likely dx is __________. What is the low-pitched early diastolic sound that can be heard?
Constrictive pericarditis (would need R heart cath); Pericardial Knock
What is the likely etiology of a pt with myocardial ischemia who has symmetric, deep TWIs in V2-V3 with flat ST segment?
Proximal LAD occlusion (Wellen Syndrome)
What should you think if a pt on digoxin develops atrial tachycardia with a 2:1 AV block?
Digoxin toxicity, increased risk if hypokalemic
What are signs of cardiac involvment with pts who have systemic sarcoidosis?
Development of AV block or bundle branch blocks and heart failure; tx with steroids; Dx often with Bx of something else as endomyocardial bx may be nl due to patchy distribution of granulomas
What is endomyocardial fibroelastosis? ARVC?
A restrictive cardiomyopathy seen predominately in West Africa; ARVC is infiltration of fibrofatty tissue into the RV; assoc. with plakoglobin gene mutation
What may be the etiology of a pt who has afib on digoxin who develops a junctional rhythm (no p waves but regular rhythm)?
Digoxin toxicity
Tx of a pt with frequent PVCs who develops cardiomyopathy __________
Catheter Ablation
A cardiac physical exam of a sustained apical impulse suggests _______
LVH
What is the efficacy of aldosterone antagonists in HFpEF?
No benefit per TOPCAT study
The classic presentation of RV infarction is what?
CP, distended neck veins, hypotension, and CLEAR LUNGS
What is the hemodynamic variable most likely to be elevated in RV infarction?
CVP as it is a measure of RA pressure; PCWP is measure of LA pressure
Possible etiology of refractory HTN in young woman?
Fibromuscular dysplasia causing renal artery stenosis
When is intervention needed in pulmonic stenosis?
Anytime that there is pulmonic stenosis, regardless of whether or not there are symptoms; usual Tx of choice is balloon valvuloplasty but NOT if there is dysplasia or if there is a concomittant regurgitation component
In what situation is an endomyocardial bx likely to be useful?
In a newly diagnosed acute heart failure exacerbation that is associated with conduction abnormalities (AV block) and ventricular tachyarrhythmias to look for giant cell myocarditis (can add steroids)
What is the concern for a pt with acute CP and sx of CHF who has a mechanic AV?
Valve thrombosis i.e. INR is 1.6; it basically can lead to obstructive shock type picture
What findings are consistent with an acute posterior MI on EKG?
Prominent R waves with ST depression in the septal and anterior precordial leads V1-V3); the abnormally tall R waves in V1-V2 are a clue as they are reciprocal changes
What is a systolic crescendo-decrescendo murmur that becomes louder with valsalva?
HOCM; the murmur will become louder with things that decrease the preload; AS does not really change with valsalva
Best mgmt of afib with RVR in COPD?
CCB > BB due to bronchospasm
How do you decide on anticoagulation in a pt with Afib due to hyperthyroidism?
Still CHADSVASC i.e. if 0 then no need to AC there is no increased risk just bc it is due to hyperthyroidism
What is the dose of clopidogrel for NSTEMI?
300-600 mg load then 75 mg daily but careful as you don?t know if the pt will need a CABG
What is a normal ABI? Borderline low? Low? Uninterpretable?
Normal is 1-1.4; Borderline low is 0.91-1, Low is <0.9; uninterpretable is >1.4
How long should a stent, whether BMS or DES be kept on DAPT after being placed for ACS?
1 year; if a BMS was placed for reason other than ACS then can be on DAPT for 1 month or if need surgery
What is the most appropriate next step to further evaluate a pt with pleuritic CP, a pericardial rub and a nonspecific EKG?
TTE as it can show a pericardial effusion to help with the Dx of pericarditis; the classic EKG has diffuse ST elevation and PR depression
What did the FREEDOM trial show?
That DM pts with reduced systolic fxn with multivessel dz do better with CABG than with PCI
What is the best anticoagulant to give to a pt with NSTEMI who is to be treated in a non-invasive, ischemia directed way? What about early invasive?
LMWH (lovenox); if planning intervention i.e. early invasive approach (within 24 hours) then UFH is better bc can shutoff
What is the murmur of diastolic decrescendo with diastolic rumble?
Austin Flint murmur of AR; diastolic decrescendo is the AR then the rumble is the functional MS due to the regurgitant jet
How does subclavian steal present?
Often after a CABG with LIMA-LAD in a pt with arm pain, angina, and vertebrobasilar insuff
What should be added to the usual tx of HFrEF in black patients?
Hydralazine + Nitrates (Isosorbide dinitrate) if NYHA III-IV (added to ACE-I, BB, and aldosterone antagonist)
What should you do for a pt with a STEMI at a PCI incapable hospital 3 hours from a PCI capable center who had an ischemic stroke 2 months ago?
ASA and thienopyridine, fibrinolytics are contraindicated
What is the mgmt of cyanotic heart dz with erythrocytosis?
No intervention unless the hematocrit is >65% or there is evidence of hyperviscosity sx
What is the Tx of most pt with structural heart dz who have PVCs or NSVT (<30 sec)?
Their presence does NOT predict sudden cardiac death (the EF is better for predicting that) and their suppression is not useful; however, if symptomatic can be on BB and if >10% of all beats can do catheter ablation
What is theoretically a good tx for a pt with HTN emergency with acute heart failure?
IV nitroglycerin
What is the appropriate surveillance of aortic root dilation in Marfan syndrome?
One time 6 months after Dx then annually assuming that the size remains stable
What is the Tx of Dressler Syndrome?
High dose ASA and Colchicine (avoid NSAIDS)–of note NSAIDs ok in pericarditis NOT assoc with MI
What is the most appropriate mgmt of a pt with suspected PAD who has an ABI of >1.4
Since that is an uninterpretable ABI the measurement of GREAT TOE SYSTOLI PRESSURE can establish the Dx
What is the most likely cause of a new mid-late systolic murmur that develops after an acute inferior MI in a clinically stable pt without sx of CHF?
Papillary muscle displacement (the old papillary muscle dysfxn); diff from papillary muscle rupture which would have acute heart failure or cardiogenic shock
What is the best diagnostic test for a patient with infrequent palpitations a couple of times per month?
Cardiac Event Recorder (30 day recorder)
Best dx test for a woman from Guatemala with conduction abnormalities, CHF and GERD
T. cruzi IgG levels
What is the most likely Dx for unexplained syncope, RV dysfxn, and TWI in V1-V3 with FMHx sudden cardiac death
ARVC (plakoglobin)–fibrofatty infiltration of RV myocardium
What are the best initial drugs to start a pt on with HFrEF once they are euvolemic/compensated?
ACE/ARB first then a beta blocker; ACE are typically started first due to beneficial hemodynamic effects; BBs then started and titrated up q1-2 weeks or so until target dose
What is the first line mgmt of a pt with intermediate risk of CAD?
Exercise stress test (w/ exercise EKG stress preferred unless LBBB, pre-excitation, or baseline ST-T wave changes) second line pharmacologic
What are clinical markers of reperfusion in pt who have received lytics for STEMI?
Improvement in CP, improvement >70% in ST elevation, reperfusion arrhythmias i.e. accelerated idioventricular rhythm
What is the treatment of high degree AV block in Lyme dz?
IV CTX and possibly temporary transvenous pacing if needed for stability but rarely need a PPM
What is the most appropriate mgmt for a pt with suspected constrictive pericarditis who has an uninterpretable TTE?
Right Heart Catheterization (look for square root sign)
How do you risk stratify for anticoagulation after catheter ablation for afib?
Still based on CHADSVASC and NOT based on their rhythm status
What medication should be added to a pt with STEMI who has undergone thrombolysis?
Clopidogrel 300 mg PO (CLARITY-TIMI-28 study); other thienopyridines have not been studied in the post-fibrinolytic setting; otherwise for STEMI, ticagrelor and prasugrel are better
What is Wellen Syndrome?
A proximal LAD occlusion manifested by CP with deep symmetric TWIs in V2-V3 with flat ST segment
What is the best test for a pt presenting with Amaurosis fugax?
Carotid US to look for extracranial dz, could consider CTA or MRA if negative for intracranial stenosis
What is a specific finding on TTE for cardiac tamponade? What may be seen on EKG?
Early RV collapse; R heart cath showed equilization of pressures and EKG shows electrical alternans
How frequently should patients with asymptomatic bicuspid AoV undergo surveillance TTE?
Yearly if the aortic root or ascending aorta is >4.5 cm
When is a baby aspirin indicated in DM pts?
If clinical ASCVD or if ASCVD risk >10%
What can improve LV EF in pt with HFrEF due to iron overload?
Iron chelation therapy; if primary hemochromatosis then maintenance phlebotomy as well but not if secondary (i.e. due sickle cell etc)
Why might you place a Holter monitor on a pt with newly diagnosed, asymptomatic atrial fibrillation?
Because if the average HR is >110 bpm would consider rate-controlling the pt
A patient who has had a catheter ablation of AF with unexplained dyspnea raises concern for what?
Pulmonary Vein Stenosis; several diagnostic modalities: CT angio, MRI, etc
What is the best mgmt for a pt with recurrent malignant pericardial effusions?
Subxiphoid Pericardotomy (Pericardial Window)
What are 3 indications for AICD in HOCM?
If pt has hx of cardiac arrest, spontaneous sustained VT (>30 sec) or syncope, or >2 family members with sudden cardiac death
How can you differentiate the murmur of HOCM from that of AS?
HOCM gets louder with things that decrease the preload i.e. valsalva and softer with squatting as it increases preload; AS does not really change and if anything would get softer with a decrese in preload
What is considered frequent PVCs? What is the complication? Tx?
Frequent PVCs are ones that are >10% of all beats or >10,000 beats per day; if symptomatic tx is BB; if they are causing a cardiomyopathy then need to perform ablation
What can tell you the likelihood that a person has a DVT?
Well’s criteria
What is the difference between a massive and submassive PE?
A massive PE is one with HoTN; a submassive PE is normotensive but has evidence of R heart strain on TTE, EKG (S1Q3T3), or elevated trop
What are the creatinine cutoffs for starting aldosterone antagonists?
sCr >2 in women, 2.5 in men
Who gets tendinous xanthomas?
Pathognomonic for Familial Hypercholesterolemia (Palmar xanthomas are in abetalipoproteinemia)
What two meds are the cornerstone of any pt with depressed LV fxn even if there are no sx?
ACE/ARB and BB (bisoprolol, metop succ, coreg)
What are the 4 general indications for moderate-high intensity statin?
Clinical ASCVD (high), primary LDL elevation >190, DM age 40-75 with LDL 70-189 and >7.5% risk, anyone with >7.5% risk
A pt with HFrEF and EF <35% should be one what meds?
BB (metop succ, bisoprolol, carvedilol), ACE/ARB, and aldosterone antagonist (assuming K <5 and sCr <2.5 in men, 2.0 in women)
When it comes to surgery in mitral regurgitation explain the pros and cons of repair vs. replacement
Repair is usually the preferred mgmt if possible; however, if there is extensive calcification of the annulus or destruction of the chordal apparatus may need replacement; then prefer mechanical vs. bioprosthetic unless C/I to anticoagulation etc.
What is the best Tx of Prinzmetal’s Angina?
CCB (nondihydropyridine dilt or verapamil)
What is the treatment of choice for an HD stable pt with WPW who develops acute Afib with RVR? What if unstable?
Procainamide or ibutilide as BB/CCB or digoxin are CI; if unstable answer is always cardiovert
What is tilt table testing used for and when is it useful?
To diagnose vasovagal syncope (neurocardiogenic) when the etiology of syncope is unclear based on history alone
What is the most appropriate mgmt for stable monomorphic VT
Antiarrhythmic such as amiodarone or lidocaine; i.e. bolus followed by drip
An EKG with tall R waves in leads V1-V3 with ST depressions in a pt with CP should make you think of _______
Acute Posterior Wall MI
What is the most appropriate mgmt to a patient who needs a mitral valve replacement that has contraindications to anticoagulation?
Place a bioprosthetic valve rather than a mechanical one; a bioprosthetic is also reasonable if it is in an older person
What is a bifascicular block?
A Left Anterior Fascicular block and a RBBB
What is a good clinical way to differentiate a bicuspid AoV murmur from a HOCM murmur (i.e. young person with systolic murmur)
HOCM will get louder with valsalva whereas bicuspid AoV likely unaffected
What is the most appropriate mgmt of a pt with an ischemic but viable lower extremity (i.e. acute limb ischemia)?
Urgen angiography to define the anatomy and decide what intervention i.e. stent vs bypass vs BKA/AKA is best
Most appropriate mgmt of DM pt with triple vessel dz and depressed LV fxn
CABG (FREEDOM Trial)
This is the test of choice for patients with known endocarditis who now have a prolonged PR interval
Repeat TEE for perivalvular abscess
What distinguishes an Austin-Flint murmur from mitral stenosis?
There is no opening snap with Austin Flint plus there is the AR diastolic decrescendo component along with the diastolic rumble
What is the appropriate workup of a pt with new onset CHF and EKG showing LBBB and regional WMAs (but no trop leak)
Coronary angiography as they likely have ICMO; of note, could do a stress test for pts but not if LBBB then would want a cath and if find multivessel dz may need CABG
What is the best mgmt of acute pericarditis?
ASA + Colchicine (combo tx is better at reducing the risk of recurrence); use of steroids can actually INCREASE RISK OF RECURRENCE
What is the preferred mgmt for severe symptomatic mitral stenosis?
Percutaneous Balloon Mitral Valvuloplasty (different from MR where it is surgical repair or replacement) and it is indicated in all pt with MS who have class III-IV sx; MVR is done if the valve morphology is unfavorable
What is the most effective anti-HTN med in DM?
ACE/ARB
What are 2-3 presentations that can occur with a subtherapeutic INR in a pt with mechanical valve?
Either embolic phenomena or sx of heart failure; i.e. AV obstruction could cause CHF and CP; if severe could lead to obstructive shock
This is the most appropriate initial mgmt for a symptomatic, HD stable pt with a regular narrow complex tachycardia
Adenosine 6 mg - it can terminate a re-entry tachycardia or slow down AV conduction to identify aberrant P waves or F waves
What is the tx of a pt with native valve endocarditis with conduction block?
Surgery, may need to do TEE first to confirm perivalvular abscess; the effectiveness of cure with abx alone is markedly diminished
What is long term therapy following an MI? (5)
Aspirin, high intensity statin (rosuva 20-40, atorva 40-80), BB, ACE/ARB, and for one year–a thienopyridine (clopidogrel, ticagrelor, prasugrel); however, based on the EPHESUS trial, an aldosterone antagonist could be added if the EF is <40%
What is the most appropriate mgmt for a pt with NSTEMI who is at risk for recurrent ischemia/death (i.e. TIMI/GRACE score)?
i.e. Grace score >3% is high risk; pt needs an angiography within 24 hours (early invasive vs. ischemia-guided i.e. medical)
For both MR and MS when is mitral valve replacement performed?
If the valve morphology is unfavorable; i.e. for severe MR would repair and for severe MS w/ III-IV sx would do balloon valvuloplasty
When should a type B dissection be treated surgically?
If it is a complicated type B dissection: end-organ ischemia (spinal artery, renal failure due to renal arterial involvement), persistent severe HTN, rupture or propagation of the pain
What abnormality can possibly be seen on CXR in PE?
Hampton’s Hump, an opacity that can be seen
This is the preferred antihypertensive for a pt with HFrEF
ACE/ARB (could then also add one of the 3 BBs; however, all HFrEF should be on these 2 classes anyway)
What are the 3 beta blockers that have shown mortality benefit in HFrEF?
Carvedilol, metoprolol succinate, and bisoprolol
How do atrial myxomas present and what is the feared complication?
Often with constitutional sx due to tumor cytokine production, and fatigue/dyspnea; diastolic tumor plop; embolization to brain etc; tx is surgical; recall that MC cardiac tumor is metastasis
In whom is flecainide to be avoided in?
Avoid in CAD, significant structural heart dz, and LV dysfxn (recall CAST Trial showed that flecainide harmed pts who had PVCs after MI)
What are RCTs showing regarding PFO closure as of march 2018 in cryptogenic stroke?
Some studies showed a better outcome than aspirin alone
What is the most sensitive EKG indicator for RV infarction?
ST segment elevation in V4R (need R sided leads)
What are the tx options for pt with stable angina that is not relieved by BB? What other meds should these pts be on by virtue of having ASCVD?
long acting CCB (dilt/verapamil) or nitrate isosorbide mononitrate; ranolazine can be given; high intensity statin and low dose aspirin
Acute ST segment elevation within several days of placing a stent is most likely due to _________
Stent thrombosis
What do you do if a pt has an acute uncomplicated type B dissection but has contraindications to beta blockers?
Give a CCB such as diltiazem or verapamil; then give a vasodilator (goal HR <60, goal BP <120); note that inability to control the BP could be indication for surgical repair
What is the appropriate add on therapy for a pt with ongoing HTN on a thiazide diuretic?
Add on CCB or ACE/ARB- if pt has DM or has had MI/CHF then ACE or ARB is preferred to CCB
Does a pt who develops VT/VF after an MI need an AICD?
Only if the VF/VT occurred > 24 hours after the MI; the other indication for AICD s/p MI is if EF <35% on GDMT after 40 days
What is the best mgmt of acute HF with severely depressed LV, and poor CO with evidence of renal hypoperfusion?
Inotropes with milrinone (PDE3 inhib) or dobutamine (B1 agonist) and hold the BB
Who should be screened for HOCM?
All first degree relatives of patients with HOCM and this would include their parents (i.e. a kid is dx, father and mother should be screened)
What is the best tx for HD instablity in pt with suspected cardiac tamponade?
Give IVF and do urgent TTE followed by pericardiocentesis vs. pericardial window if confirmed
What is the likely etiology of syncope in a pt with bifascicular block?
Transient complete heart block (i.e. symptomatic bradyarrhythmia)
In a pt who has had a DES or BMS placed and needs a nonurgent surgery when can DAPT be held?
DES 6 months, BMS 1 month; if placed for ACS, DAPT should generally be continued for 1 year for EITHER a BMS or DES
When is CRT indicated?
Recommended in patients with EF <35%, NYHA III-IV sx on GDMT who have LBBB with QRS >150 msec
When it comes to DC cardioversion for afib that is HD stable (bc if unstable you always shock) when could you do it?
If they have been on AC for at least 4 weeks or if there has been a TEE showing that there is no LA thrombus
A young person who had Kawasaki dz as a child now presenting with a STEMI may have what?
Coronary aneurysm with subsequent thrombosis
What is the best mgmt of postinfarction VSD (i.e. ischemic VSD)?
Urgent cardiac surgery with VSD repair offers the only chance of survival particularly in those who have been complicated by cardiogenic shock
What did the PLATO trial show?
That ticagrelor > clopidogrel with 1.9% ARR for a COMPOSITE ENDPOINT of stroke, MI, and death
What is the mgmt of new-onset afib with RVR still tachy despite multiple attempts at rate control who is starting to have decreased LV fxn?
TEE followed by cardioversion if no LA thrombus; can also cardiovert after 4 weeks AC; the pts can develop a tachycardia mediated CMO
What is the best mgmt of pt with bicuspid AoV and ascending aortic aneurysm >5.5 cm?
Surgical repair of the aorta
What drugs are contraindicated in Afib with preexcitation?
Cannot give digoxin, BB, or CCB; can give procainamide or ibutilide as they will not only slow the AV conduction but also the accessory pathway
What is the most appropriate initial mgmt of an acute uncomplicated type B dissection? Goal HR/BP?
IV beta blocker labetalol or esmolol BEFORE vasodilator (i.e. nitroprusside or nicardipine) with goal HR <60 and SBP <120 ; Type B dissection takes place distal to L subclavian vein
A patient needs to achieve _______ % of their maximum predicted heart rate to be considered to have had an adequate stress test
85%
What is the issue with endomyocardial biopsy for cardiac sarcoidosis?
The granulomas are patchy and so you should make the dx based on pt having systemic sarcoidosis with evidence of heart involvement i.e. heart failure and conduction issues
In a pt who has been transferred s/p lytics for STEMI, what is the best mgmt?
Early invasive approach within 24 hours assuming they did not have lytic failure (i.e. deterioration with ongoing CP) in which case would do it right away
What is the most likely dx in a pt with angina following CABG who has arm pain and dizziness?
Subclavian Steal- only happens if a LIMA graft is used; Dx with physical exam showing SBP >15 mmHg diff between the arms and doppler showing flow reversal in vertebral arteries
Per the 2017 ACC/AHA HTN guidelines what is stage I HTN and stage II HTN?
Stage I is 130/80-89 and Stage II is >140/90
What are the thresholds to AC for various CHADSVASC scores?
0 no AC; 1 aspirin, 2 or more AC
What is the most useful clinical test to use when evaluating for coarctation of the aorta?
A systolic BP difference >20 mmHg between arms and legs
5 cardiac conditions requiring endocarditis ppx
Prosthetic valves (both bioprosthetic and mechanical), prior valve repair WITH prosthetic material, heart xplant with valvulopathy, prior endocarditis, unrepaired cyanotic congenital heart dz
What do you do for a patient with normal LDL, DM and an ASCVD risk of >7.5%?
High intensity Statin (rosuvastatin 20-40; atorvastatin 40-80)
How may a post-infarction VSD manifest itself?
A new holosystolic murmur in the setting of a recent MI or, worse yet, cardiogenic shock
In a pt with a V-paced rhythm, ischemia can be diagnosed by what?
ST depression that is > 1 mm and is concordant with the QRS complex
What is the most appropriate next step in pt with sx of claudication with a borderline-low resting ABI (i.e. 0.91 to 1)?
Exercise ABI; recall great toe systolic pressure is for pt with ABI >1.4 which is uninterpretable
What are two physical exam findings for a pt with AS that can indicate that it is severe AS?
Either lack of an S2 or delayed and diminished pulses (pulsus parvus et tardus)
What are the indications for MV repair in mitral regurgitation in symptomatic and asymptomatic patients?
Symptomatic MR with LV EF >30% or asymptomatic severe MR with EF 30-60%. In essence, it should always be replaced if there is severe MR as long as the EF is >30%
What cardiac disorder is associated with the Carney complex?
Atrial myxomas; AD disorder with pigmentation abnormalities i.e. Blue nevi, schwannomas, and endocrine issues such as Cushing
What is the target ventricular rate for a pt with chronic afib?
HR <110, if unsure of baseline HR could do a Holter monitor
A patient with elevated CVP and progressive liver dz should raise concern for what?
Constrictive pericarditis; primary liver dz would rarely be associated with elevated CVP so in a pt with volume overload, elevated CVP and new ascites etc. concern for constrictive pericarditis
What is the mgmt of a wide complex bradyarrythmia?
Probably transcutaneous or transvenous pacing as the site of the block is below the AV node so atropine not useful
What is the mgmt of a pt with stable angina and an abnormal stress test with a small reversible defect?
Tx medically i.e. aspirin and statin for the clinical ASCVD and BB for the stable angina (or can add CCB/nitrate/ranolazine if not working)
When should AAAs be repaired in men and women?
>5 cm in women, >5.5 cm in men or rapidly expanding
What is the most appropriate mgmt of paroxysmal afib that is symptomatic despite multiple cardioversions and rate controlling meds?
Catheter Ablation- pulmonary vein isolation with possible AE being pulmonary vein stenosis; recall that aflutter often cavotricuspid isthmus with afib being pulmonary vein
Describe the murmur of HOCM
Crescendo-Decrescendo murmur that increases with valsalva whereas AS or Bicuspid AoV do not
What is the utility of high sensitivity CRP and cardiac calcium scoring?
Best used in patients with intermediate ASCVD risk 5-7.5% as it may bump them into the next strata
In a patient with high risk NSTEMI the timing of angiography should be __________
Within 24 hours (this is an early invasive approach); In studies comparing this to a delayed angio approach i.e. >24 hours there were better outcomes
Which trial showed that ticagrelor was superior to clopidogrel for a composite endpoint of stroke, death, or MI?
PLATO trial
What are the symptoms of severe AS?
Syncope, Angina, and Dyspnea (SAD); tx is with SAVR or if high risk then TAVR
What is the most appropriate mgmt of pt with congential long QT syndrome without hx of syncope?
Beta blocker
What is an important secondary cause of new CHF to rule out in a pt with tachycardia
Hyperthyroidism, just check a TSH in any newly Dx person with CHF
Best next step for HFrEF pt on ACE/ARB who is euvolemic and asymptomatic
Beta blocker: bisoprolol, metoprolol succinate, or carvedilol
What sorts of baseline EKG abnormalities can affect the ability to interpret a stress EKG?
LVH with ST depressions > 0.5 cm (or other repolarization abnormalities), pre-excitation, LBBB, paced rhythm
What should you think if pt has had an ablation procedure and now has sinus tachycardia, hypotension, and elevated CVP? Dx? Tx?
Could be iatrogenic tamponade; do a bedside TTE and/or pulsus paradoxus assessment and then pericardiocentesis
In a pt with suspected cardiac sarcoid what should you bx– hilar LAD or endomyocardial tissue?
Hilar node as there is patchy granuloma distribution in cardiac sarcoid so bx may be falsely nl
What is the deal with AICD placement after MI?
If EF <35% after GDMT within 40 days of an MI (about 6 weeks) as this allows stunned myocardium to “wake up”; OR if VT/VF GREATER than 24 hours after MI
What is the window of sx that a pt with STEMI at a non-PCI capable center should fall in to receive lytics? How far does the nearest PCI capable center have to be?
Less than 12 hours of sx; more than 120 min away
What drug has been shown to improve walking distance in pt with PAD? Contraindictaions?What is the first line tx for walking in PAD?
Cilostazol (PDE-3 inhibitor); Contraindicated if EF <40% due to similar MOA as milrinone which has worse outcomes with CHRONIC use in HFrEF; supervised walking program
What medications should be held prior to a stress test?
Beta blockers because they can blunt the HR response and pt may not meet 85% MPHR to have an adequate test; hold 24-48 hours prior
What is the tx of severe MR with LV dysfunction?
Assuming that the valve is suitable for repair, mitral valve repair is the treatment of choice if there is LV dysfunction, even if asymptomatic (Of note, EF should be at least 30%)
MC cardiac anomaly associated with Turner Syndrome?
Bicuspid AoV
When is CABG best for CAD?
Patients who are symptomatic despite optimal medical tx and who have specific angiographic findings of L main dz, multivessel dz with pLAD involvement; or DM pts with triple vessel dz and concomittant reduced LV fxn (FREEDOM)
When is a moderate to high intensity statin indicated in a pt with DM?
Age 40-75 with DM whose CV risk is >= 7.5%
What is a diagnostic consideration in a pt with newly diagnosed Afib i.e. on random EKG to determine if they may need rate control?
Can do a Holter monitor to see if the average HR is >110 bpm as the goal should be less than 110
What is a likely etiology of acute heart failure with atrial arrhythmias in a pt within 2 years of heart transplant?
Acute Allograft Rejection (development of afib and aflutter common); allograft vasculopathy more common and may just have the HF sx and is SLOWER TO PROGRESS and needs angio
In what cases of acute heart failure are steroids useful?
If it is due to sarcoidosis, giant cell myocarditis, or eosinophilic myocarditis; it is not helpful for viral myocarditis; note that NSAIDS, colchicine, and asa are options for pericarditis do NOT pick this for myocarditis
What is the appropriate mgmt of thrombolytic therapy failure for MI? What may indicated that pt has had failure of thrombolytics?
Transfer to a PCI capable center for rescue PCI; Failure to resolve CP, lack of improvement in ST elevations, no reperfusion arrhthmias, or clinical deterioration/cardiogenic shock
In addition to aspirin and a statin, the typical med started in a pt with symptomatic CAD (i.e. stable angina) is __________
BB; BB is first line then can try long-acting CCB (dilt/verapamil) or nitrate then ranolazine
How do you diagnose subclavian steal syndrome?
See reversal of flow in the vertebral arteries with doppler US, can see BP diff of >15 mmHg between the arms
The INTERHEART study assessed 9 modifiable risk factors for MI, which one was the worst?
Dyslipidemia; Dyslipidemia > smoking > psycho stress > DM > HTN > obesity > EtOH > physical inactivity > diet low in fruits/veg
Explain an Austin Flint murmur
It is a diastolic decrescendo aortic regurgitation murmur with a diastolic rumble due to premature closure of the MV from the regurgitant jet causing functional MS
What are some evidence of severe AS on TTE? Tx?
Aortic valve area <1 cm2, mean transvalvular pressure gradient >40, Vmax (flow) >4 m/s or AVA by BSA index <0.6 cm2/m2
