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Medical > Systemic, Congenital, Pericardial > Flashcards

Systemic, Congenital, Pericardial Flashcards

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USMLE® Step 1 flashcards
1
Q

What is required for the diagnosis of acute pericarditis?

A
  • ► 2 of the following:
    • Chest pain
      • sharp, pleuritic, improved by sitting up and leaning forward
    • Pericardial friction rub
    • EKG changes
      • widespread ST-elevation or PR depression
    • New or worsening pericardial effusion
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2
Q

What are the diagnostic criteria for recurrent pericarditis?

A
  • All 3 criteria must be present:
    • Documented first attack of acute pericarditis
    • Symptom-free interval of ► 4-6 weeks
    • Evidence of subsequent recurrence of pericarditis
      • Labs (WBC, ESR, CRP)
      • pericardial friction rub
      • EKG changes
      • Echo evidence of worsening pericardial effusion
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3
Q

What are high risk features of pericarditis that warrant hospitalization?

A
  • Fever ( F > 38 C)
  • Anticoagulants
  • Trauma
  • Subacute onset
  • Large pericardial effusion
  • Immunosuppression
  • Tamponade
  • Myocarditis (concomitant)
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4
Q

What is the treatment for acute pericarditis?

A
  • NSAID x 2-4 week (taper)
  • Colchicine x 3 months
    • prevents recurrence
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5
Q

When are glucocorticoids used in pericarditis?

A
  • unable to take NSAID therapy

or

  • special conditions
    • autoimmune disease
    • renal failure
    • pregnancy
    • concomitant anticoagulant therapy
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6
Q

Describe the stepwise protocol for recurrent pericarditis

A
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7
Q

What is required for diagnosis of metabolic syndrome?

A

► 3 of the following criteria

  • abdominal obesity / waist circumference
    • men ► 102 cm
    • women ► 88 cm
  • TG > 175
  • HDL:
    • men < 40
    • women < 50
  • BP ► 130 / 85
  • Fasting plasma glucose ► 100
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8
Q
A
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9
Q

What are causes of RAD?

A
  • Dextrocardia
  • Ostium secundum ASD
  • Lead reversal
  • LPFB
  • Lateral MI
  • Vertically positioned heart
  • COPD
  • PE
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10
Q

What are causes of prominent U waves?

A
  • Most commonly found with:
    • Hypokalemia
    • Bradycardia
  • Less common causes:
    • Hypocalcemia
    • Hypomagnesemia
    • Hypothermia
    • HCM
    • Elevated intracranial pressure
    • LVH
    • Drugs
      • Digoxin
      • Class Ia (Quinidine, Procainamide)
      • Class III (Amiodarone, Sotalol)
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11
Q

Describe the findings:

A

RV VT with LBBB morphology / ARVD

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12
Q

Describe the findings and diagnosis

A

ARVD

  • Epsilon waves
  • TWI in V1-V3
  • Prolonged S-wave upstroke of 55 ms in V1-V3 (95% of patients)
  • Localized QRS widening of 110 ms in V1-V3
  • Paroxysmal episodes of VT with LBBB morphology
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13
Q

What medications used in A-fib can cause increased serum Digoxin levels when used concomitantly?

A
  • Verapamil
  • Amiodarone
  • Dronedarone
  • Quinidine
  • Rivaroxaban
  • Apixaban
  • Erythromycin, Clarithromycin
  • Cyclosporine
  • Ketoconazole
  • Itraconazole

****P-glycoprotein inhibitors (in bold)

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14
Q

Describe the findings and treatment:

  • 30 year old, healthy, relatively asymptomatic patient
A

Idiopathic LV (fascicular) VT

  • Re-entrant tachycardia involving most commonly the left posterior fascicle
  • EKG
    • mildly wide complex tachycardia
    • RBBB-like morphology
    • superior or left axis
  • Treatment:
    • Verapamil
    • rhythm is highly sensitive to verapamil
    • low-risk tachycardia –> catheter ablation of fascicle is usually curative
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15
Q

Describe the differential/algorithm for narrow QRS tachycardia (QRS < 120 ms)

A
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16
Q

What is the recommended medical therapy in a patient with:

  • Brugada syndrome
  • ICD and shocks
  • Recurrent VT
A

Quinidine or Catheter Ablation

  • Class Ia antiarrhythmic
    • Ito and IKr blocker effects
  • Class I recommendations
17
Q

Describe localization of AP using surface EKG

A
20
Q

What is the diagnosis and next best step?

  • 30 year old male with syncope (x2 in the last year while exercising)
  • No medical problems or medications
  • FH: Uncle died at 34 in drowning accident
    *
A
  • Brugada syndrome
  • EKG with high precordial leads
    • ​recording V1 and V2 in second and third intercostal space can assist in the diagnosis of borderline cases
22
Q

What are the indications for ICD placement in Brugada syndrome?

A
  • Confirmed Brugada syndrome

and

  • Cardiac arrest or Recent unexplained syncope
23
Q

Describe localization of VT site of origin on EKG

A

QRS morphology = VT circuit exit site

  • V1
    • LBBB morphology
      • RV or
      • Septum
    • RBBB morphology
      • LV

Precordial leads = sagittal plane origin

  • V3, V4, V5
    • R waves dominant
      • Basal
    • S waves dominant
      • Apical

QRS axis = coronal plane origin

  • Axis (inferior leads)
    • Inferior axis (Positive inferior leads)
      • Anterior or
      • Lateral
    • Superior axis (Negative inferior leads)
      • Inferior
24
Q

What are the recommendations for ICD placment:

  • Hypertrophic Cardiomyopathy
A
  • Class I
    • SCD (resuscitated)
    • Spontaneous VT with syncope
  • Class IIa
    • LV wall thickness ► 30 mm
    • 1st degree relative with SCD caused by HCM
    • Syncope (unexplained)
  • Class IIb
    • NSVT (on ambulatory monitoring) without other risk factors
25
Q

What are the recommendations for ICD placment:

  • ARVC
A
  • Class I
    • SCD (resuscitated)
    • RVEF or LVEF « 35%
  • Class IIa
    • Syncope (presumed due to VA)
26
Q

What are the recommendations for ICD placment:

  • Cardiac Sarcoidosis
A
  • Class I
    • SCD (resuscitated)
    • VT (sustained)
    • LVEF « 35%
  • Class IIa
    • Syncope
    • Myocardial scar by MRI or PET
    • Positive EPS for inducible VT
    • Indication for PPM
27
Q

What are the recommendations for ICD placment:

  • LQTS
A

Class I

  • SCD (reuscitated)
  • High risk patients in whom BB is ineffective or not tolerated
    • < 40 years of age
    • Females with LQTS 2
    • LQTS 2 and 3
    • onset of symptoms < 10 years of age
    • prior cardiac arrest or recurrent syncope
    • QTc > 500 ms

Class IIb

  • Asymptomatic patients, QTc > 500 ms on BB
28
Q

What are the recommendations for ICD placment:

  • CPVT
A

Class I

  • Recurrent VT or syncope while on maximal medical therapy (BB, Flecainide)
29
Q

What are the recommendations for ICD placment:

  • Brugada Syndrome
A

Class I

  • Cardiac arrest or recent unexplained syncope

+

  • spontaneous type 1 EKG pattern
35
Q

Describe the prevalence of LQTS, mutations involved and channels involved in the mutations

A

90% of cases (1:300-7,000)

  • LQT1 (KCNQ1)
    • encoding for the potassium current IKs
  • LQT2 (KCNH2)
    • encoding for the repolarizaing potassium current IKr
  • LQT3 (SCN5A)
    • encoding for the alpha subunit of the sodim channel that conducts the depolarizing sodium current INa
36
Q

What is a major distinguishing feature between Idiopathic LV and RV outflow tract VT?

A

Precordial transition point

  • LVOT VT
    • early precordial transition or
    • broad initial R wave in V1, V2
  • RVOT VT
    • late precordial transition, typically leads V3-V4

**** LBBB morphology + Inferior axis in both

38
Q

What are risk factors for arrhythmia in Brugada Syndrome?

A
  • Fever
    • SCN5A channel is temperature sensitive
  • Alcohol (heavy use)
  • Cocaine
  • Precipitating medications
    • Fluoxetine
    • Sodium channel blockers (INa)
    • Propofol
    • Lithium
    • Antihistamines
    • TCA’s
    • Trifluoperazine
    • Heavy metals
39
Q

How can you differentiate AS and HOCM on intracardiac pressure tracings?

A

Post-PVC

  • Pulse Pressure
    • HOCM –> decrease
    • AS –> increase
  • Gradient
    • ​Both –> INCREASE

Valsalva

  • Gradient
    • ​HOCM –> increase
    • AS –> decrease
  • Pulse Pressure
    • Both –> DECREASE
40
Q

What mechanical prosthetic valves require bridging anticoagulation?

A
  • Bileaflet aortic valve with increased thromboembolic risk factors
  • Caged ball or tilting disc prosthesis
  • Mitral valve prosthesis
  • Recent CVA/TIA
41
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Asymptomatic
A
44
Q

Describe the algorithm in evaluating aortic prosthesis with PV > 3 m/s

A
45
Q

Describe the frequency of monitoring in MS

A
  • Progressive (stage B)
    • MVA > 1.5 cm2 –> every 3-5 years
  • Severe (stage C)
    • MVA 1 - 1.5 cm2 –> every 1-2 years
  • Very severe
    • MVA < 1.0 cm2 –> every 1 year
46
Q

What is the severity scale for aortic prosthetic valves?

  • Peak velocity
A
  • Normal < 3 m/s
  • Possible stenosis 3-4 m/s
  • Significant stenosis > 4 m/s
47
Q

What is the severity scale for mitral prosthetic valves?

  • PHT
A
  • Normal < 130 ms
  • Possible stenosis 130 - 200 ms
  • Significant stenosis > 200 ms

Medical (69 decks)

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