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SmPc IMC Flashcards

1
Q

What does the definition of Cardiomyopathy broadly mean?

Define the three types and general issue of each

A

Heart Muscle Dz

Dilated: large, weak ventricles

Hypertrophic: large, thickened heart muscle

Restrictive: stiff ventricle

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2
Q

How may a Pt w/ dilated cardiomyopathy present to clinic

What MedHx can be there

What may be found on PE

What could be seen on CXR?

A

Older w/ SoB, worse in PM

HTN, ETOH abuse

Pan-systolic murmur radiating to axilla
Apex beat,
Normal breath sounds,
S3 gallop

CXR: enlarged LV shadow

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3
Q

What is the MC type of cardiomyopathy

What process usually causes this MC

A

Dilated

Process/Event/Trauma damages myocardium leading to decreased ventricular contraction and LV dilation

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4
Q

What are possible etiologies of Dilated Cardiomyopathy

1/3 of cases will be d/t ?

A 
GP-CEVICHE
Genetic
Post-partum
Chemo
Endocrine d/o
Viral infections
Ischemic: MI CADz Arrythmia
Cocaine
Heavy metals
ETOH abuse

Inherited

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5
Q

How is Dilated Cardiomyopathy Dx

What will be seen on EKG

What can be seen on CXR

A

Echo- most definitive; shows dilation and dysfunction

Nonspecific ST/T changes

Balloon like heart- cardiomegaly/pulm congestion

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6
Q

How is Dilated Cardiomyopathy Tx

Why is the ABCD mnemonic used for Tx

What medication is used to increase cardiac contractility

A

BB + ACEI+ Loop

Anti-Coag
ACEI
BB
CCBs
Diuretic/Digoxin

Digitalis

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7
Q

Extreme cases of Dilated Cardiomyopathy may need ? for Tx

What part of the heart becomes hypertrophied during HOCM

Where is this murmur heard and what makes it worse?

A

Transplant, LVAD

Septum, impedes into LV outflow tract during systole

LLSB mid-systolic
Worse w/ contractility (Valsalva, standing)

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8
Q

How will HOCM present

How is this condition passed down genetically

What can this condition be confused w/ and how is it differentiated?

A

Young athlete w/ +FamHx of sudden death/syncopal episodes

Autosomal dominant

Athletic heart- won’t have diastolic dysfunction

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9
Q

What will be seen on PE during HOCM

How is this condition Dx

What would be seen on an EKG?

A

Bifid pulse
S4 gallop

Echo- LVH w/ thick septum, small LV and diastolic dysfunction

LVH and non-specific ST/T-wave changes

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10
Q

How is HOCM Tx

What needs to be avoided during Tx

What medication is contraindicated during Tx?

A
  • Metoprolol and/or Verapamil- dec contractility/HR to dec outflow obstruction
  • ICD implant consideration
  • No high intensity athletics
  • Surgical/alcohol ablation of hypertrophy section

Nitrates, or any drug that decreases preload (diuretic, ACEI, ARBs)

Digoxin- increases force of contraction and increase obstruction

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11
Q

Define Restrictive Cardiomyopathy

What are the etiologies of this condition

A

Right HF w/ Hx of infiltrative process

Ca- radiation/chemo
Hemochromatosis
Fibrosis
Amyloidosis
Sarcoidosis
Scleroderma
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12
Q

What abnormals may be seen on PE of Restrictive Cardiomyopathy

What would be seen on Echo

What would an EKG show

What would CXR show

A

P-HTN
Large atria
Early diastolic filling

Normal LVEF, dilated atria, hypertrophied myocardium

Non-specific abnormals:
ST/T-wave abnormalities
Low voltage

Pulm vascular congestion
Normal heart size

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13
Q

If a Dx is still uncertain after Echo/EKG, what is the next step?

Although not necessary for Dx, what result would be seen if catheterization is done?

Since this condition’s Tx is focused at the underlying cause, what management step can be taken w/ caution

A

MRI- abnormal cardiac textures

High atrial pressures

Diuretics if +edema/pulmonary congestion- caution, don’t lower preload

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14
Q

What type of murmur does ASD create?

What causes a non-cyanotic ASD

What is the MC type of non-cyanotic ASD

A

ULSB systolic rumble w/ wide, fixed, split S-2 during in/expiration

Foramen ovale fails to close

Ostium Secundum- defect in middle of septum (primum occurs in lower atrial septum)

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15
Q

Other than a murmur, what else may be noted on PE during an ASD exam

What is the best method to Dx this condition

How is this condition Tx Sx and definitively

A

Failure to thrive

Placing catheter through shunt

Sxs: Diuretics ACEI Digoxin
Def: surgical closure

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16
Q

How does a PDA defect present

What type of murmur is heard

Normally, this structure is kept open d/t ?

A

Young infant w/ red/pink UE and blue LE

Machinery-like of LSB at pulmonic space late in systole make loud S2

Prostaglandin E-2- why NSAIDs Tx condition and c/i in pregnancy

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17
Q

How is PDA Dx

How is it Tx

What type of murmur does VSA create

A

Echo

Indomethacin

Holosystolic at LLSB w/out radiating into axila

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18
Q

? is the MC pathologic murmur found in childhood

How is this MC Dx

How is this Tx

A

VSD

Echo

If not self-resolving by age 6- surgery

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19
Q

What systemic issue is often present w/ CAAortas?

What key PE finding may be noted in teen/early adulthood exams?

What type of murmur may be appreciated

A

HTN- kidneys can’t sense normal pressures

Normal UE pressure,
Dec LE pressures

Ejection murmur at aortic area, radiates to axilla/back

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20
Q

What anatomical defect is present in half of Coarctation of Aorta cases

These pts are at increased risk for ? issue

What are the 3 methods to Dx this condition

A

Bicuspid valve

Cerebral berry aneurysm

1st- echo
EKG- LVH
CXR- rib notching, Figure-3 sign

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21
Q

How is Coarctation of Aortas Tx

What are the 4 issues seen in Tetralogy of Fallot

How does this condition present

A

Prostaglandin- E1s
Surgery- balloon dilation

Pulm stenosis
RVH
Over riding aorta
VSD

Difficult feeding
Failure to thrive
LoC w/ crying

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22
Q

What type of murmur is head during TOFallot

What will be seen on CXRs

? RF places Pts at risk for Stable Angina w/ Pts that have atherosclerosis

A

Crescendo-decrescendo, holosystolic murmur at LSB and radiates to back

Boot shaped heart

DM

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23
Q

Pts w/ classic Sxs of aninga need ? test as the most widely used test to Dx ischemic heart Dz

Define Stable Angina

What would be seen on EKG

A

Nuclear stress test

Precordial discomfort/pressure that is predictably relieved by rest/nitro and worse w/ activity

ST depression during episodes, can be normal; Flat/inverse T-waves

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24
Q

How is Stable Angina Dx

What is the definitive method to Dx

How is this condition Tx

A

Exercise stress test- most useful/effective non-invasive test; ST depression 1mm= Dx

Coronary angiography

Bypass surgery
ACEI/BB/CCBs
Nitrates
Angioplasty
ASA
Statins
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25
Q

Define NSTEMI

What type of EKG changes may be seen

What type of infarct can cause this presentation

A

Myocardial necrosis w/: +troponin/CK
But w/out:
ST elevation, Q-waves

ST depression
T-wave inversion

Subendocardial infarct

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26
Q

What does the typical workup for NSTEMI include

What cardiac marker is most sensitive and what time frames does it follow

What other two markers can be used, but less often, and what time lines do they follow

A

CXR CBC/CMP
BNP EKG Troponin I

Troponin:
Appears 2-4hrs
Peaks 12-24hrs
Lasts 7-10days

CK/MB:
Appear: 4-6hrs
Peak: 12-24hrs
Normal: 48-72hrs

Mb:
Appear: 1-4hrs
Peak: 12hrs
Baseline: 24hrs

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27
Q

How are NSTEMIs Tx

A 
BBs 
ASA 
Reperfusion- PCI   
Clop 
Heparin 
ACEI 
NTG
Statin
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28
Q

Define STEMI

How are these worked up

A

Myocardial necrosis w/: +troponin/CK AND
ST elevation/Q-wave

CXR CBC/CMP
BNP EKG Troponin I

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29
Q

What EKG findings indicated the location of an MI

A

Anterior:
1, aVL, V2-6

Inferior:
2,3,aVF

Lateral:
ST elevation 1, aVL, 5-6 w/ reciprocal changes in 3, aVF

Posterior:
ST depression V1-3

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30
Q

How are STEMIs Tx

A

ASA/Clop at once
PCI <90min
Thrombolytics <180min if PCI unavailable

BBs 
ASA 
Reperfusion- PCI   
Clop 
Heparin 
ACEI 
NTG
Statin
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31
Q

What are the absolute c/i for performing fibrolytic therapy for STEMI Tx

What absolutes don’t include ? ongoing issue

A 
Prior intracranial hemorrhage
Cerebral vascular lesion
Malignant intracranial neoplasm
Ischemic stroke <3mon
Suspected aortic dissection
Active bleeding/diathesis

Menses

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32
Q

How does LV failure present

How does RV failure present

A

SOB Fatigue w/ exertion SoB
S3
Crackles
Displaced to left apical impulse

SoB Ankle swelling
JVD Hepatojugular reflex
Hepatomegaly
Lung will be CTA

33
Q

HF is a syndrome of ?

Left sided Systolic HF is d/t ?

How is this form of HF Tx

How is an acute worsening of this type of HF Tx

A

Ventricular dysfunction- dilated w/ EF <40%

Rapid ventricular filling during early diastole causing S3

ACEI + BB _ Loop
O2, ACEI
D/c BB
Start Nitro 
Double IV diuretic
34
Q

How is a Diastolic left HF identified on PE

What causes this condition/form of HF

This form is common in Pts w/ ? MedHx

A

Diastolic S4 w/ normal EF

Hypertrophic thick wall of LV w/ impaired relaxation

HTN

35
Q

How is Diastolic L-HF Tx

What two forms of Tx are avoided

How are acute exacerbation Tx

A

ACEI BB/CCB

No diuretic if stable chronic failure
Digoxin

Same as Systolic LFH:
ACE 
IV Loop 
Nitro 
O2
36
Q

What causes RV right sided HF

What is the MC cause of R-HF

What is the Gold standard method for Dx and how is this Tx

A

Pulm-HTN

Left sided HF

R sided heart cath
Tx: underlying condition

37
Q

What causes High Output Cardiac Failure

What Sx will appear first but then the Pt will progress into ?

How is this form Tx

A

Inc metabolic demand:
Hyperthyroid
Anemia, severe
BeriBeri/THiamine deficient

Tachy leading to systolic failure

Llike HF and acute CHF;
Tx underlying condition

38
Q

What is the best method to Dx CHF

What is the most important determinant in the prognosis

A

Echo

EF
Norm 55-60
<35: inc mortality, place defib

39
Q

What are the 4 classes of NYHA HF

A

1: no limitations on activity
2: slight limitations; ordinary activity leads to fatigue, palpitations, dyspnea, angina but conformable at rest
3: marked limitations of activity; less than ordinary activity leads to palpitations, dyspnea, angina but are comfortable at rest
4: unable to carry out activity w/out discomfort but also have Sxs at rest that worse w/ any activity

40
Q

When Tx S/D-HF, what part of the Tx needs to be used ASAP and why

What 3 specific drugs are used in Tx

A

ACEI: dec comorbidity and mortality

Beta-1 selective:
Bisoprolol
Metoprolol succinate
Carvedilol

41
Q

Aortic regurg

A

Early blowing, decrescendo diastolic murmur at LSB

Pt sits, leans fwd and exhales

Diaphragm at Erbs

42
Q

MS

A

Split S1 after opening snap at apex

Rumble loudest at beginning of diastole

heard best LSB/apex

Pt position: supine, left side down w/ bell on mitral position

43
Q

Pulm Regurg

A

High pitch decrescendo murmur at LUSB

Inc w/ inspiration

Pt sits, leans fwd

Diaphragm on pulmonic

44
Q

TS

A

Diastolic rumble best heard at LLSB/xiphoid

Pt supine w/ bell at Tricuspid position

45
Q

? are the MC types of heart murmurs

What are the 3 types

How are these MC differentiated from pansystolic murmurs

A

Mid-systolic ejection

Pathologic: structural abnormalities (pansystolic)
Physiologic: physiological alteration in body
Innocent: no detectable abnormalities

Gap between murmur and S2

46
Q

AS

A

Late systolic ejection murmur at 2nd ICS, RSB that radiated to carotids/apex

Dec w/ valsalva

EKG shows LVH

Pt sits, diaphragm on RUSB aortic position

47
Q

PS

A

Harsh systolic murmur at 2/3rd ICS radiating to left shoulder

Early systolic sound precedes murmur during expiration

EKG: right axis deviation

Wide split S2

Pt supine w/ bell at tricuspid locaiton

48
Q

HCM

A

Med-pitched mid-systolic murmur; dec w/ squat, inc w/ strain

Pt supine w/ diaphragm over mitral

49
Q

MVP

A

Mid-systolic click

Pt supine w/ diaphragm over mitral position

50
Q

MR

A

Blowing holosystolic murmur at apex/mitral w/ split S2 and radiates to axilla

Pt supine w/ diaphragm on mitral/apex location

51
Q

TR

A

Hx rheumatic fever

Blowing holosystolic murmur on LSB; inc w/ valsalva and inspiration

EKG: afib

Pt supine w/ diaphragm over tricuspid position

52
Q

VSD

A

Loud, harsh holosystolic murmur at LLSB w/out axila radiation

Wide, fixed S2

Pt supine w/ diaphragm over tricuspid

53
Q

Primary HTN is defined as ?

A

SBP 130 or >
DBP 80 or >
On two readings during two different visits w/out obvious cause

Norm: <120/80 and <80
Elevate: 120-29 and <80
Stage 1: 130-39 or 80-89
Stage 2: 140or> or 90 or >

54
Q

What does the ACC/AHA define as a target blood pressure regardless of w/ or w/out comorbidity

What are the JNC8 Tx targets

A

<130/80

<60y/o, even w/ DM/Kidney D/o: <140/90
>60y/o: <150/90

55
Q

How is Primary HTN Tx

A

Normal: yearly eval

Elevated: lifestyle change, re-eval 3-6mon

Stage 1: assess ASCVD risk
<10%: lifestyle mod, reassess 3-6mon
>10%, CVD, DM, CKD: lifestyle mod, 1 medication, re-eval 1mon
Met goal: reassess 3-6mon
Not met: different med/titrate
Monthly f/u until goal reached

Stage 2: lifestyle mod w/ 2 medications, reassess 1mon
Met goal: re-eval 3-6mon
Not met: change med/titrate
Monthly f/u until goal reached

56
Q

How are Non-Black Pts, including those w/ DM Tx for Primary HTN

How is Tx changed if they’re at Stage 2 HTN

How are black adults Tx and w/ ? goal in mind

A

ACEI or ARB
CCB: Amlodipine
Thz: Chlorthalidone/Indapamide

2 BP meds from different classes

Two or more med (Thx and CCB) for target <130/80

57
Q

When are CCBs c/i as an anti-hypertensive

Why are ACEI/ARB c/i in diabetic HTN control

When are ACEIs c/i

When are BBs c/i during anti-hypertensive therapy

A

Angina pectoris

Proteinuria

Pregnancy

DMs

58
Q

S/e of using Spironolactone for antihypertensive therapy

S/e of CCBs

What two CCBs are rate controlling

A

HyperK

Edema

Verapamil/Diltiazem

59
Q

A-blockers can be used to Tx HTN and ? simultaneously

What are two possible s/e of using Hydralazine for antihypertensive therapy

Criteria for a HTN emergency and the next step that determines Tx

A

BPH

Lupus-like syndrome
Pericarditis

SBP >180 and/or DBP 120 or>
End organ damage
New/Worse/Progressive

60
Q

Once an HTN emergency is admitted to ICU, what 3 conditions have to be r/o

What is the Tx plan if these condition are or are not present

A

Aortic dissection
Pre/Eclampsia
Pheo crisis

Are:
SBP <140 w/in first hr
Dec to <120 if dissecting

Not:
Max reduction 25% w/in first hour
Then to 160/110-100 w/in 2-6hrs,
Then to normal w/in 24hrs

61
Q

Criteria for HTN urgency

How are these PTs managed

What Dx count as end organ damage for HTN Emergencies

What doesn’t count as an end organ damage

A

> 180/120 w/out end organ damage

Start on 2 PO drugs w/ close f/u

Encephalopathy
Nephropathy
ICH
Aortic dissection
Pulm Edema
Unstable angina
MI

Papilledema- HTN retinopathy

62
Q

Define Malignant HTN

What is the drug of choice for Tx of HTN urgency

What is the drug of choice for HTN emergencies

What is the recommended drug combo for Tx of Malignant HTN

A

HTN Retinopathy; diastolic >140 w/ papilledema and either encephalopathy or nephropathy

Clonidine- RxoC

Sodium nitroprusside

Clevidipine/Sodium nitroprusside

63
Q

Define Secondary HTN

What are the red flags for secondary HTN

This Dx needs to be suspected in ? presentation

A

SBP 130 or >
DBP 80 or >
Both w/ identifiable and correctable cause

HTN <25y/o w/out FamHx
HTN starting >50
Previously controlled, now refractory

Refractory to antihypertensives

64
Q

What is believed to be the MC cause of Secondary HTN

If Pts HTN is newly Dx, what is the next step

How is Secondary HTN Tx

A

Primary aldosteronism

UA
Spot albumin/Cr ratio
EKG
Cr K Na Fasting glucose Lipids TSH

Underlying condition Tx w/ aim for BP treatment targets

65
Q

What class drug can accidentally cause HTn Urgency

How does occur

A

MAOI

Eating wrong at Holiday buffets: cheese sausage wine

66
Q

Define Cardiogenic Shock

What are the 3 MC causes

What will be seen on PE

A

Impaired contractility and overall pump failure; heart can’t generate enough output to sustain perfusion

MI HF Tamponades

JVD
BP <90mm
AMS

67
Q

How is Cardiogenic Shock Dx

How is this Tx

A

Echo: wedge pressure >15mm

Fluids: 250-500ml NS w/ frequent auscultations
Pressers: Dobutamine NorEpi Balloon pump

68
Q

Define O-HOTN

If PT is diabetic, what is a common cause of this condition

What test do they then need

A

Excessive drop of BP while upright
SBP drop >20mm
DBP drop 10mm
Both 2-5min after supine to standing

Autonomic dysfunction

Tilt table test: HR >15 bpm= low volume

69
Q

How is O-HOTN Dx

What result suggests autonomic impairment as the cause

What result suggests dec volume as the cause

How is this Tx

A

BP/HR measured after 5min supine and 1-3min after standing

HOTN w/out compensatory inc HR

HR inc >100bpm or inc by >30bpm

Fluids/Na intake
Fludrocortisone/Midodrine

70
Q

Define Vasovagal HOTN

How is this Dx

What test can reproduce these Sxs

A

Paradoxical w/drawl of sympathetic stimulation replaced by parasympathetic/vagal activity causing dec BP/cerebral perfusion

Hx PE Carotid massage EKG

Upright tilt table test

71
Q

Vasovagal HOTN can occur at anytime but if it first episode occurs after 40y/o, ?

How is this Tx

A

Reluctant to make Dx

Supine w/ legs elevated
BBs
Disopyramide
Pacemaker

72
Q

What type of lesions may be seen on the hands of Pts w/ infected cardiology Dxs

What are the two MC microbes to cause infectious endocarditis

What is the MC microbe to cause Acute/Subacute endocarditis, drug user endocarditis and valvular endocarditis

A

Janeway: painless

Staph/Strep

Acute: Staph A
Sub: S Viridians
Drug: Staph A
Valve: Staph epidermis

73
Q

What is the MC cause of fungal endocarditis

What does this form usually cause to develop

How is this Tx

A

Candidiasis: contaminated lines <2mon from valve replacement surgery

Large vegetations

Amphotericin B

74
Q

? types of microbes cause vegetation to grow on native valves

? microbe is the MC cause of endocarditis

How does this MC present

A

HACEK

S veridians

Late complication of valve replacement w/ small vegetations and emboli

75
Q

What peripheral PE finding suggest infective endocarditis

What neuro findings are consistant w/ this Dx

A 
Splinter hemorrhages
Osler nodes- painful on extremity
Roth spot- retinal hemorrhage
Janeway lesion
Petichae: palate/conjunctiva
Splenomegaly
Hematuria

Visual loss
Motor weakness
Aphasia

76
Q

How is infectious endocarditis Dx

What labs are needed

What frequency are these labs drawn

A

TEE: gold standard

RF ESR CBC

3 sets, 1hr apart

77
Q

What are the major and minor criteria needed for Dx infectious endocarditis

A

Major:

Minor:

78
Q

How is infectious endocarditis Tx based on etiology

A

Native valve and no IVDA: IV Ampicillin + Nafcillin + Gentamicin

Prostethic valve: Vanc + Gentamicin + Rifampin

IVDA: Nafcillin

PCN allergy= Van substitute

79
Q

What is used for infective endocarditis prophylaxis

A

2g Amoxicillin 60min or less before procedures

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