Week 5 CVD & ACS

Question 1

Jugular venous pressure

A reflects pressure in the right atrium.

B Is best estimated from the carotid artery.

C should be measured with the patient positioned at 90 degrees.

D is often higher than arterial pressure.

Answer 1

A reflects pressure in the right atrium.

Pressure in the jugular veins reflects right atrial pressure giving clinicians an important clinical indicator of cardiac function and right heart hemodynamics. JVP is best estimate from the right internal jugular vein. It should be measured with the patient at 60 degrees. Systemic venous pressure is much lower than arterial pressure.

Question 2

A left-sided S4 heart sound in a 50-year-old female with hypertension suggests which of the following?

A This is a physiologic finding
B Decreased compliance of the ventricular myocardium

C Opening of a stenotic mitral valve

D Turbulent blood flow from the left ventricle into the aorta

Answer 2

B Decreased compliance of the ventricular myocardium

S4 heart sound (atrial gallop) may be heard in trained athletes or older age groups. More commonly, it is due to increased resistance to ventricular filling following atrial contraction resulting from decreased myocardial compliance. Causes include hypertensive heart disease, CAD, aortic stenosis, and cardiomyopathy.

Question 3

Lateral displacement of the point of maximal impulse (PMI) can be seen with which of the following?

A Mitral valve prolapse

B Heart failure

C Aortic dilation

D High diaphragm

Answer 3

B Heart failure

Lateral displacement occurs from cardiac enlargement. Upward displacement can occur from a high diaphragm.

Question 4

Exam findings in a patient with peripheral arterial disease (PAD) of the leg include which of the following?

A Pitting edema and decreased sensation

B Cyanosis with cold exposure and rubor with rewarming

C Hair loss and paleness

D Varicosities and stasis dermatitis

Answer 4

C Hair loss and paleness

Pitting edema, varicosities and stasis dermatitis occur with venous insufficiency. Cyanosis with cold exposure and rubor with rewarming occurs with Raynaud’s phenomenon.

Question 5

Which of the following patient populations often experience atypical symptoms of myocardial ischemia or infarction? (Select all that apply)

A Men between ages 35 and 50

B Women

C Diabetics

D Patients with hypertension

E Obese patients

Answer 5

B Women

C Diabetics

Women usually have non-chest pain symptoms such as nausea, lightheadedness, dyspnea and jaw pain. Patients with type 2 DM may have a silent MI due to autonomic neuropathy. Elderly also have atypical symptoms.

Question 6

Which of the following best describes classic anginal pain?

A Substernal tightness or pressure

B Sharp, localized left sided pain

C Right-sided chest soreness radiating to the right shoulder

D Chest pain that is worse with inspiration and movement of the left arm

Answer 6

A Substernal tightness or pressure

Classic anginal pain occurs anywhere between the epigastrum and mandible and is described as tightness, heaviness, squeezing, pressure or grip like.

Question 7

The nurse practitioner refers a patient to the emergency department with symptoms of acute ST-segment elevation MI (STEMI). The nearest hospital that can perform percutaneous coronary intervention (PCI) is three hours away. What does the nurse practitioner expect the initial treatment to be for this patient?

A Intravenous heparin

B Oral beta blocker

C Fibrinolytic treatment

D Transfer of the patient to a PCI-capable institution

Answer 7

C Fibrinolytic treatment

Fibrinolytic therapy should be administered to any patient with evolving STEMI within 30 minutes of the time of first medical contact. Patients more than 120 minutes away from a PCI-capable hospital should be given fibrinolytic therapy since PCI should be performed within 90 minutes if possible. Giving heparin or beta blockers is not helpful.

Question 8

A 65-year-old male walks into the clinical for acute chest pain and dyspnea. A STAT ECG is performed and it reveals 3 mm ST segment elevation in lead II, III, and AVF. The nurse practitioner calls ALS for transport because he suspects:

A Acute ischemia of the posterior wall

B Acute infarction of the lateral wall

C Acute infarction of the inferior wall

D Acute ischemia of the septal wall

Answer 8

C Acute infarction of the inferior wall

Leads II, III and AVF view the inferior wall of the heart. 2mm or greater ST segment elevation in 2 or more contiguous leads suggests STEMI. ST segment depression and T-wave inversion suggest ischemia.

Question 9

A patient with stable CAD who has not undergone coronary intervention should be managed with which of the following first-line agents?

A Warfarin, aspirin, and digoxinW

B Beta blocker, aspirin, and nitroglycerin

C Thiazide diuretic, calcium channel blocker, and clopidogrel

D Long acting nitrate, ACE inhibitor, and beta blocker

Answer 9

B Beta blocker, aspirin, and nitroglycerin

All patients with stable CAD should be managed with a beta blocker and aspirin unless contraindicated. Nitroglycerin can be used on an as needed basis.

Question 10

A patient experiencing heart failure with reduced ejection fraction will have which of the following?

A Increased cardiac contractility and stroke volume

B Impairment of ventricular filling and relaxation

C Left ventricular stiffness and reduced chamber size

D Pump failure from left ventricular systolic dysfunction

Answer 10

D Pump failure from left ventricular systolic dysfunction

Heart failure with reduced ejection fraction results in pump failure from ventricular systolic dysfunction. Heart failure with preserved ejection fraction may have milder symptoms and is associated with impairment of ventricular filling and relaxation. Cardiac contractility and stroke volume are decreased in HFrEF. Ventricular remodeling and dilation occurs.

Question 11

Which of the following class of medication is the considered the cornerstone of heart failure medical management unless there is an absolute contraindication?

A Hydralazine-isosrorbide

B Angiotensin-converting enzyme inhibitor (ACEI)

C Calcium channel blocker

D Ivabradine

Answer 11

B Angiotensin-converting enzyme inhibitor (ACEI)

ACEI therapy improves mortality in patients with HFrEF and improves overall clinical status. They decrease systemic and pulmonary vascular resistance. ACEI remain the cornerstone of management and should be considered priority in all patients unless there is an absolute contraindication. CCB’s should not be used in HF.

Question 12

An elderly adult patient without prior history of cardiovascular disease reports lower leg soreness and fatigue when shopping or walking in the neighborhood. The primary care nurse practitioner notes decreased pedal pulses bilaterally. Which test will the nurse practitioner order initially to evaluate for peripheral arterial disease based on these symptoms?

A Digital subtraction angiography

B Doppler ankle, arm index

C Magnetic resonance angiography

D Segmental limb pressure measurement

Answer 12

B Doppler ankle, arm index

The Doppler study may be performed easily to indicate the likelihood of PAD. Other tests are performed only if indicated.

Question 13

A patient who has been diagnosed with heart failure for over a year reports being comfortable while at rest but experiences palpitations and dyspnea when walking to the bathroom. Which classification of heart failure is appropriate based on these symptoms?

A Class I

B Class II

C Class III

D Class IV

Answer 13

B Class II

Patients with Class II heart failure (HF) will have slight limitation of activity and will be comfortable at rest with symptoms occurring with ordinary physical activity. Patients with Class I HF do not have limitations and ordinary physical activity does not produce symptoms. With Class III HF, less than usual activity will produce symptoms. With Class IV HF, symptoms are present even at rest and all physical activity worsens symptoms.

Question 14

A patient is diagnosed with peripheral arterial disease (PAD) and elects not to have angioplasty after an angiogram reveals partial obstruction in lower extremity arteries. What will the nurse practitioner recommend to help manage this patient’s symptoms?

A Daily aspirin therapy to prevent clotting

B Statin therapy with clopidogrel

C Walking slowly for 15 to 20 minutes twice daily

D Walking to the point of pain each day

Answer 14

D Walking to the point of pain each day

Studies have demonstrated that an exercise program involving walking to the point of pain is as effective as angioplasty. Medications are useful to prevent progression of plaque formation and to prevent myocardial infarction (MI).

Question 15

An 18 yo patient is here for a cardiac screening appointment to see if they can play sports in college. The diagnostic test best suited to detect hypertrophic cardiomyopathy or idiopathic left ventricular hypertrophy is

a. Echocardiogram
b. Electrocardiogram
c. Arteriogram
d. Stress test

Answer 15

a. Echocardiogram

Question 16

Your 59 yo patient has a history of hyperlipidemia, and is presenting with signs/symptoms of unstable angina. The best course of management is

a. Start aspirin therapy and schedule an exercise stress test next month
b. Initiate lipid lowering agents
c. Hospitalize the patient, with EKG monitoring and pharmacologic control of the ischemia, arrhythmias, and thrombosis as appropriate
d. Prescribe a Holter monitor and start her on a beta blocker

Answer 16

c. Hospitalize the patient, with EKG monitoring and pharmacologic control of the ischemia, arrhythmias, and thrombosis as appropriate

Question 17

You are seeing a new patient, recent move to the area, who has a diagnosis of congestive heart failure. Which of their medications should be discontinued?

a. Nifedipine (Procardia XL), taken for long term management of chronic stable angina
b. Hydrochlorothiazide (HydroDIURIL) for their hypertension
c. Enalapril (Vasotec) for his hypertension
d. Butalbital (Esgic) for his headaches

Answer 17

a. Nifedipine (Procardia XL), taken for long term management of chronic stable angina

Question 18

Which communication is your first priority when counseling a patient with ischemic arterial ulcers?

a. Increasing coffee intake will stimulate the heart rate and circulation
b. Decreasing water intake slightly will improve blood viscosity
c. Reducing risk factors will help improve tissue perfusion
d. Tell them to begin an intense aerobic exercise program to improve perfusion

Answer 18

c. Reducing risk factors will help improve tissue perfusion

Question 19

Your patient has chronic ischemic heart disease and is taking a beta blocker, which results in

a. An increase in high-density lipoprotein cholesterol
b. A reduced heart rate
c. A decreased diastolic filling time
d. An increase in oxygen demand

Answer 19

b. A reduced heart rate

Question 20

Which symptom is noted with occlusive arterial disease?

a. Pain occurring in the calves or thighs when walking, with relief upon resting
b. Pain when standing that is not relieved by sitting or lying down
c. Severe pain at rest that requires the client to raise the legs into the air to obtain relief
d. Redness and pronounced superficial veins

Answer 20

a. Pain occurring in the calves or thighs when walking, with relief upon resting

Question 21

Mr. J is a 54-year-old man who presents to primary care clinic for an initial evaluation as a new patient. He has not seen a doctor in years, because he “hasn’t needed one” and takes no medications. His chief complaint today is fatigue. He describes progressively worsening dyspnea when walking briskly and climbing stairs. He must rest several times in order to complete mowing his lawn, whereas 6 months ago he could easily complete this task without resting. He feels fine at rest. He finds himself awakening frequently at night feeling “congested” but this has improved somewhat after putting bricks under the head of his bed. He denies any chest discomfort or palpitations. He has never smoked, but he drinks “a few beers” every night. He is unaware of any family history of heart disease. On exam, he is overweight (BMI 31 kg/m2)), heart rate is 83 bpm, and blood pressure (BP) is 184/98 mm Hg. Jugular veins are nondistended without hepatojugular reflux. Lungs are clear. The point of maximal impulse (PMI) is displaced laterally. Heart sounds are regular with a 2/6 systolic murmur at the apex without gallop. Liver is nonpulsatile, and there is no lower extremity edema.

What do you suspect the dx is?

Answer 21

Suspected dx is heart failure

Major preventable causes of HF inlcude CAD, HTN, myocardititis, infiltrative dx, peripartum cardiomyopathy, HIV, connective tissue dx, substance use, chemotoxic cardiomyopathy, and idiopathic cardiomyopathy

Question 22

Mr. J is a 54-year-old man who presents to primary care clinic for an initial evaluation as a new patient. He has not seen a doctor in years, because he “hasn’t needed one” and takes no medications. His chief complaint today is fatigue. He describes progressively worsening dyspnea when walking briskly and climbing stairs. He must rest several times in order to complete mowing his lawn, whereas 6 months ago he could easily complete this task without resting. He feels fine at rest. He finds himself awakening frequently at night feeling “congested” but this has improved somewhat after putting bricks under the head of his bed. He denies any chest discomfort or palpitations. He has never smoked, but he drinks “a few beers” every night. He is unaware of any family history of heart disease. On exam, he is overweight (BMI 31 kg/m2)), heart rate is 83 bpm, and blood pressure (BP) is 184/98 mm Hg. Jugular veins are nondistended without hepatojugular reflux. Lungs are clear. The point of maximal impulse (PMI) is displaced laterally. Heart sounds are regular with a 2/6 systolic murmur at the apex without gallop. Liver is nonpulsatile, and there is no lower extremity edema.

What tests should you order?

Answer 22

● A chest x-ray (CXR) should be obtained to look for findings of HF as well as for other potential causes of the patient’s dyspnea.
● Echocardiogram
● An electrocardiogram (ECG) should be obtained to assess for evidence of structural heart disease and conduction disease. A normal electrocardiogram nearly excludes the diagnosis of systolic heart failure.
● Laboratory testing should include a hematocrit to exclude anemia and thyroid function tests to exclude thyroid disease.
● A fasting lipid profile and fasting glucose with or without hemoglobin (Hg) A1c should be obtained to assess cardiovascular risk and screen for hyperlipidemia, metabolic syndrome, and diabetes mellitus.
● A urinalysis (UA) and basic metabolic profile (BMP) should be obtained with anticipation of initiating pharmacotherapy, which will be influenced by renal function and baseline electrolyte values. Significant proteinuria may suggest an infiltrative process, although mild proteinuria is often seen in heart failure.
● A plasma brain natriuretic peptide (BNP) level can be useful in patients in whom diagnosis of HF is in question. Whereas BNP can often be elevated in processes other than HF, a normal BNP makes a diagnosis of systolic HF very unlikely.

Question 23

Meds to AVOID in HF

Answer 23

NSAIDs

CCBs (diltiazem and verapamil)

Question 24

pharmacologic tx for HF

Answer 24

meds that have demonstrated mortality benefit and offer symptomatic relief

ACE-I or ARBs

beta blockers (carvedilol, bisoprolol, long-acting metoprolol)

Aldosterone antagonists

newer drug - sacubitril/valsartan

isosorbide dinitrate and hydralazine benefits black pts

diuretics and digoxin offer symptomatic relief, no improvement in survival

Treatment should be tailored to both the symptoms and stage of HF

Question 25

Non-pharmacological tx for HF

Answer 25

``` smoking cessation minimize or abstain for alcohol use salt restriction 3g/day exercise mild-mod 30 mins/day if stable HF (not during exacerbation) weight loss cardiac rehab monitor daily weights immunizations ```

Question 26

AHA goals of tx for HF

Answer 26

``` control symptoms improve health-related quality of life patient education prevent hospitalization prevent mortality ```

Question 27

Patient w/ new dix of HF, echo results show left ventricular (LV) systolic dysfunction. The LV ejection fraction (LVEF) is 40% with global hypokinesis. The end-diastolic dimension is moderately increased. There is concentric left ventricular hypertrophy (LVH) and mitral annular dilatation with mild mitral regurgitation. The left atrium is mildly enlarged. Are there any additional tests that you would recommend at this point?

Answer 27

Exercise testing should be performed as part of the initial evaluation of systolic heart failure. This can assess for ischemic heart disease and can provide additional prognostic data. Serial evaluation can assess changes over time. Occult CAD is a common cause of systolic HF. All patients with new systolic HF and angina should be evaluated with coronary angiography. Patients without angina who have not had previous evaluation of their coronary anatomy should also be considered for coronary angiography because of the high prevalence of CAD among the older adult population. Noninvasive imaging has not yet been demonstrated as an acceptable alternative to exclude CAD in this group of patients. Additionally, angiography can exclude coronary anomalies in younger patients. Patients who have had recent prior angiographic exclusion of CAD presenting with new HF and without anginal symptoms do not need to be reevaluated by coronary angiography.

Question 28

Pt with HF returns to clinic after 6 months of regular visits and titrating medications. He is now on lisinopril, carvedilol, furosemide, and spironolactone. His dyspnea has improved, and he has used the bricks under his bed to stabilize the stationary exercise bicycle he bought with the money he saved by not drinking beer. His BP is 118/73 mm Hg. The remainder of his exam is unchanged. He met a patient in the waiting area who has a "shock box," and he wants to know if he should get one. What recommendations can you make now?

Answer 28

Implantable cardiac defibrillators (ICDs) have clearly demonstrated mortality benefit in select patient populations with increased risk for sudden cardiac death. While these populations continue to be more clearly defined, ICDs are currently recommended for patients with LVEF below 35% on optimal medical therapy, or who have had ventricular arrhythmias. Patients with left ventricular dyssynchrony may benefit from cardiac resynchronization therapy (CRT). Also termed biventricular pacing, CRT has demonstrated improvement in quality of life, functional capacity, and mortality in patients with advanced HF. Current guidelines recommend CRT for patients with LVEF less than 35%, moderate to severe symptoms, and QRS duration greater than 140 ms. These patients generally have advanced HF and will have already been referred to a cardiologist who should follow these patients and guide decisions regarding CRT. At present, this patient would not be a candidate for an ICD or CRT. He can be reassured that his risk of sudden death remains low. Symptoms of arrhythmia, such as syncope or palpitations, should be specifically elucidated at follow-up visits.

Question 29

What should follow up visits with a pt with HF involve and what should you monitor?

Answer 29

Regularly scheduled follow-up visits should include a careful history to assess changes in the patient's functional status, weight gain or fluid retention, dietary habits, salt intake, tobacco, alcohol and drug use . Physical examination should include assessment of volume status. Regular laboratory monitoring of renal function and plasma potassium levels should be performed. Plasma potassium levels should be kept between 4 and 5 mEq/L. Routine reevaluation of LVEF is not necessary, but noninvasive reassessment of LVEF is reasonable when a patient has a change in clinical status suggesting worsening HF.

Question 30

A 71-year-old man presents to the urgent care with a sudden onset of substernal chest pain 1 hour ago. He describes the pain as a heavy pressure sensation that radiates down both arms and is 10 of 10 in intensity. His pain started while he was walking and improved, but did not resolve, with rest. His medical history is significant for diabetes mellitus. He has smoked 1 pack of cigarettes per day for the past 50 years. His mother died of a myocardial infarction (MI) at age 56 years. On examination, there are both an S4 gallop and bibasilar fine crackles. His electrocardiogram (ECG) shows 3-mm ST-segment elevations in leads II, III, and aVF. What your diagnosis and how would you manage?

Answer 30

Acute coronary syndrome (ACS) includes unstable angina, non–ST-elevation MI, and ST-elevation MI; all result from myocardial ischemia caused by thrombosis at a site of coronary atherosclerosis. There are other causes of MI, but ACS is the most common. This patient has typical chest pain, meaning substernal, “pressure” or “squeezing,” exertional, and relieved by rest or nitroglycerin. Radiation to the arms correlates strongly with cardiac chest pain. To evaluate a patient with chest pain, first determine the likelihood of ACS as its cause; then stratify the risk for mortality to ensure timely intervention in high-risk patients. Here the history alone strongly suggests ACS. The patient is deemed to be at high risk because of the ST elevations on ECG. Administer aspirin, O2 and Transfer to another facility for PCI within 90 minutes or else fibrinolytic therapy.

Question 31

What are some differential diagnosis for a patient complaining of acute chest pain?

Answer 31

``` Unstable angina without MI Aortic dissection Pulmonary embolism Tension pneumothorax Pericarditis Esophageal rupture ```

Question 32

What are the laboratory, imaging, and procedures are included in the work up in acute myocardial infarction?

Answer 32

Laboratory Tests - Troponin I, troponin T, and quantitative CK-MB (creatine kinase myocardial band) elevations are seen as early as 4 to 6 hours after onset; they are almost always abnormal by 8 to 12 hours. - Troponins may remain elevated for 5 to 7 days or longer and are not generally useful for evaluating suspected early reinfarction. - High-sensitivity troponin assays • When positive, help enable myocardial infarction to be detected earlier • When negative, may be useful in excluding myocardial infarction in patients with chest pain Imaging Studies - Chest radiograph: signs of heart failure, often lagging behind the clinical findings - Echocardiography: assesses global and regional LV function, wall motion Diagnostic Procedures - ECG: classic evolution of changes is from peaked (“hyperacute”) T waves to ST-segment elevation to Q wave development to T wave inversion; this may occur over a few hours to several days. - Cardiac catheterization and coronary angiography can demonstrate coronary artery occlusions and allow PCI. - Echocardiography or left ventriculography can demonstrate akinesis or dyskinesis and measure ejection fraction.

Question 33

Patients with a drug eluting stent should be on aspirin and clopidogrel for a minimum of how long?

Answer 33

A minimum of 12 months.

Question 34

A 55-year-old man presents to the clinic complaining of chest pain. For the past 5 months, he has noted intermittent substernal chest pressure radiating to his left arm. The pain occurs primarily when exercising vigorously and is relieved with rest. He has no associated shortness of breath, nausea, vomiting, or diaphoresis. His medical history is significant for hypertension and hyperlipidemia. He is on atenolol and a low-fat diet. His father had died of a myocardial infarction (MI) at age 56 years. He has a 50-pack-year smoking history and is currently trying to quit. His physical examination is normal except for a blood pressure of 145/95 mm Hg; his heart rate is 75 beats/min. He is currently asymptomatic. What are your differential diagnosis?

Answer 34

When evaluating a patient with chest pain, first determine if the pain is acute in onset (or progressive) with features concerning for acute coronary syndrome (ACS), pulmonary embolism, aortic dissection, pneumothorax, or another emergency. Most patients with chest pain, however, do not require emergent evaluation. This patient's chest pain has characteristics of typical angina, including substernal location, exertional onset, radiation to the arm, and relief with rest. Risk factors for coronary artery disease (CAD) are weighed along with history, examination, and electrocardiogram (ECG). Although other causes (esophageal spasm or musculoskeletal pain) are possible, the symptoms, long smoking history, and family history confer a high pretest probability of CAD.

Question 35

major CAD risk factors

Answer 35

``` Age sex family history tobacco use diabetes mellitus hypertension low high-density lipoprotein [HDL] cholesterol high non-HDL cholesterol ```

Question 36

A 55-year-old man presents to the clinic complaining of chest pain. For the past 5 months, he has noted intermittent substernal chest pressure radiating to his left arm. The pain occurs primarily when exercising vigorously and is relieved with rest. He has no associated shortness of breath, nausea, vomiting, or diaphoresis. His medical history is significant for hypertension and hyperlipidemia. He is on atenolol and a low-fat diet. His father had died of a myocardial infarction (MI) at age 56 years. He has a 50-pack-year smoking history and is currently trying to quit. His physical examination is normal except for a blood pressure of 145/95 mm Hg; his heart rate is 75 beats/min. He is currently asymptomatic. What will you include in your diagnostic work up of this patient?

Answer 36

ECG (baseline status, evidence of prior MI, LV hypertrophy), CXR, ETT, echocardiogram. Consider CTA CBC, CMP, lipids, CK (if considering statin), TSH

Question 37

How is stable angina managed, both pharmacologic and nonpharmacologic?

Answer 37

``` ASA beta blocker statin therapy nitro prn Lifestyle modifications (diet, exercise, alcohol in moderation, no smoking, etc) ```

Question 38

Adult male presents with fever, chills, and malaise that are associated with subungual hemorrhages (splinter hemorrhages on nail bed) and tender violet-colored nodules on fingers and/or toes (osler's nodules). Palms and soles have tender red spots on skin (Janeway lesions). Heart murmur present. Patient has hx of prosthetic valve, congenital heart dx, cardiac device, IV drug use, and recent dental surgery. What is the dx?

Answer 38

infective endocarditis

Question 39

infective endocarditis (IE) RF

Answer 39

``` valvular/structural heart abnorms arrhythmias IV drug abuse hemodialysis implantable devices immunosuppressed hx of infective endocarditis recent dental or surgical procedure ```

Question 40

infective endocarditis (IE) most common pathogen

Answer 40

staph aureus MSSA or MRSA

Question 41

infective endocarditis (IE) presentation

Answer 41

fever, chills, fatigue, weight loss, poor appetite, cough, SOB, edema, new murmur, CHF, emboli roth spots, osler's nodes, janeway lesions , petechaie, renal failure, arthralgia, myalgia

Question 42

FROM JANE (IE)

Answer 42

F- fever R- roth spots O- osler's nodes M - murmur J- janeway lesions A- anemia N- nails - splinter hemorrhages E - emboli (vegatative)

Question 43

IE diagnostics

Answer 43

blood cultures (3 sets BEFORE antimicorbial tx) CBC, CRP, ESR EKG TTE, TEE, CT

Question 44

Duke's criteria IE

Answer 44

major criteria: - (+) blood cultures - evidence of endocardial involvement minor criteria: - predisposing factor - temp > 38C - vascular phenomena - immunologic phenomena - microbiologic evidence definite IE: 2 major OR 1 major + 3 minor

Question 45

IE management

Answer 45

refer to ED for hospitalization & IV abx | consult ID & cardio

Question 46

endocarditis prophylaxis recommended in

Answer 46

previous hx IE prosthetic heart valves unreparied/repaired cyanotic congenital heart dx cardiac transplant with valvulopathy invasive dental procedures (routine dental cleaning, tooth extractions, dental abscess drainage, etc) invasive resp tract procedures (incision or biopsy of resp mucosa) surgical procedures involving infected skin or MSK structures

Question 47

endocarditis prophylaxis med

Answer 47

1st line = amoxicillin single dose 30- 60 mins before procedure PCN allergy = clindamycin, clarithromycin, or cephalexin

Question 48

CAD RF

Answer 48

``` age gender ethnicity family hx genetics obesity smoking DM HLD HTN ```

Question 49

CAD clinical presentation

Answer 49

asymptomatic (stable) STABLE angina - tightness, pressure, heaviness w/ exertion, stress, large meals, cold weather; lasts less than 5 mins and relieved w/ rest or 1 nitro predictable pain Levine sign

Question 50

CAD atypical presentation

Answer 50

occurs in women, DM, older indigestion dyspnea jaw pain

Question 51

CAD diagnositcs

Answer 51

ECG exercise tolerance test (gold standard), if inconclusive stress test w/ ECHO, SPECT coronary angiography

Question 52

exercise tolerance test (stress test) when to perform and how

Answer 52

stress test should be performed within 72 hours of presenting symptoms of CAD exercise using Bruce protocol vs pharmacologic

Question 53

stress test w/ bruce protocol

Answer 53

start at slow speed/low incline gradually increase speed every 3 mins goal = heart working at 85% of its maximal capacity if test stopped early = inconclusive

Question 54

pharmacologic stress test

Answer 54

administer adenosine or regadenson, puts physiologic stress on heart

Question 55

positive exercise tolerance test

Answer 55

ECG changes consistent w/ ischemia horizontal or down-sloping ST depression of 1mm or more at 60- 80 msec after J point ST segment changes are indicative of viable cardiac muscle being supplied by narrowed coronary artery

Question 56

stress test should NOT be performed in

Answer 56

``` HF exacerbation uncontrolled cardiac arrhythmias severe HTN unstable angina acute MI critical aortic stenosis ```

Question 57

Duke's treadmill score (DTS) what is it

Answer 57

predicts 5-year mortality w/treadmill stress test w/ standard Bruce protocol based on duration of exercise, ST deviation, presence/severity of angina during test DTS = exercise time (mins) - (5x ST deviation in mm) - (4x angina index)

Question 58

duke's treadmill score categories

Answer 58

low risk: score > 5; 5- year survival 97% intermediate risk: score 4 and (-) 11; 5 year survival 90% high risk: score < (-) 11 5 year survival 65%

Question 59

CAD labs

Answer 59

``` lipid profile HbA1c CBC - anemia, polycythemia renal function BNP - check for evidence of HF ```

Question 60

CAD AHA/ACC secondary prevention

Answer 60

``` PREVENT major coronary event smoking cessation BP < 140/90 DM control a1c < 7% (metformin) physical activity weight management lipids: - < 75 y.o. high intensity statin - > 75 y.o. mod or high dose statin ``` ASA: daily, clopidogrel if contraindicated BB: MI, ACS, LV dysfunction, HF ACE-I: LVEF <40%, HTN, DM, CKD flu vaccine

Question 61

stable angina tx

Answer 61

sublingual nitro if NO HF q5 mins x3 doses, no relief 15 mins = ER BB - 1st line symptoms not controlled: CCB & long acting nitrate persistent angina, fail med tx = PCI or CABG

Question 62

CAD follow up

Answer 62

co manage with cardiology | every 4-6 months within 1st year , then every 4- 12 months depending on clinical situation

Question 63

Pt w/ stable CAD, when would they require dual antiplatelet tx ?

Answer 63

recent stent placement dual antiplatelet therapy (ASA plus P2y12 receptor agonist) continue for 12 months

Question 64

PAD RF

Answer 64

``` HTN DM CKD HLD smoking family hx ```

Question 65

PAD S/S

Answer 65

``` intermittent claudication - pain in calves when walking, relieved by rest sparse/absent hair LE shiny LE skin pallor when LE elevated depend rubor when LE dangling ```

Question 66

PAD diagnositcs

Answer 66

resting ABI | serum glucose, lipid profile, CRP, homocysteine

Question 67

ankle brachial index (ABI) when to perform

Answer 67

used in patients with one or more of the following: - exertional leg symptoms - nonhealing LE wounds - hx consistent with PAD in pts > 65 y.o. - symptoms in pt >/= 50 y.o. w/ DM or smoker

Question 68

ABI

Answer 68

compares systolic pressure at brachial artery with dorsalis pedis and posterior tibial arteries should be lower in affected extremity than normal one ABI = 0.9 = PAD ABI 0.75- 0.5 = claudication ABI < 0.5 = rest pain and/or tissue loss ABI > 1.4 = abnormal, can indicate calcified vessels

Question 69

normal ABI results

Answer 69

1- 1.4 if normal but high clinical suspicion of PAD, consider treadmill exercise test

Question 70

PAD management

Answer 70

smoking cessation EXERCISE low carb, low fat diet tx HTN, DM, compression stockings (ABI > 0.8) ASA or clopidogrel

Question 71

PAD red flags

Answer 71

``` severe claudication resting pain gangrene non healing wounds absent/diminished pulses blue, cold limb ``` * prolonged pain, sudden color changes, numbness = medical eval

Question 72

PAD complications

Answer 72

AAA renal artery stenosis diabetic foot ulcer infection

Question 73

acute coronary syndrome (ACS)

Answer 73

thrombus that forms in coronary arteries on plaque & occludes blood flow to areas of heart leading to muscle death life threatening condition

Question 74

ACS presentation

Answer 74

chest pain - no reproducible, not stabbing or localized, usually occurs t rest w/ minimal exertion lasts longer than 20 mins - can radiate to jaw, neck, back, arm, shoulder nausea, lightheadedness SOB

Question 75

ACS atypical presentation

Answer 75

occurs in diabetics, women, older ``` indigestion pleuritic pain dyspnea nausea lightheadedness jaw/neck pain epigastric pain ```

Question 76

ACS immediate workup

Answer 76

``` EKG within 10 mins VS ASA nitro O2 if < 90% REFER TO ED ```

Question 77

ACS diagnostics

Answer 77

EKG troponins, peaks 3- 4 hrs; serial draws 3-6 hrs CXR - r/o other causes Echocardiogram - detects wall motion abnorms coronary angiography consider: BNP for HF, CBC to exclude anemia, Mg, K, NA, BUN, Cr, TSH

Question 78

ACS ddx

Answer 78

``` aortic dissection PE MI spontaneous pneumo costochondritis PNA pulmonary HTN aortic stenosis MVP pericarditis cardiomyopathy GERD Acute cholecysitits shingles ```

Question 79

STEMI

Answer 79

ST segment elevation of 2mm or more in M; 1.5 mm in F in 2 contiguous leads = infarction new onset LBBB

Question 80

NSTEMI

Answer 80

ST-segment depression with symmetrically inverted T waves = ischemia generally present w/in mins of acute ischemic event

Question 81

STEMI management

Answer 81

reperfusion tx (PCI) vs fibrinolytic tx dual anti platelet tx anticoag: heparin 2-8 days

Question 82

NSTEMI management

Answer 82

dual antiplatelet tx up to 12 months anticoag: heparin PCI with stenting or CABG if medical management fails

Question 83

PCI must be done within

Answer 83

within 90 mins

Question 84

unstable angina vs. NSTEMI

Answer 84

both: anginal pain persists AND evidence of myocardial tissue damage (+ trops/ST depression or T wave inversion) persistence of ST segment depression > 1mm for longer than 48 hours = NSTEMI

Question 85

rehospitalization risk ACS

Answer 85

1st 30 days

Question 86

pericarditis

Answer 86

inflammation of pericardium

Question 87

pericarditis causes

Answer 87

idiopathic preceded by viral URI, bacterial infection, autoimmune dxw/ MI, meds (isoniazid or hydralazine), malignancy most common in men aged 20- 50

Question 88

pericarditis presentation

Answer 88

fever, sharp chest pain worse w/ breathing retrosternal chest pain can radiate jaw/neck, worse when supine/breathing; relieved by sitting up/leaning forward pericardial friction rub - heard full breath cycle, loudest on L sternal border

Question 89

pericarditis diagnosis

Answer 89

2 needed: - sudden onset pleuritic chest pain - diffuse ST elevation/EKG changes - pericardial friction rub - new or worse pericardial effusion on echo

Question 90

pericarditis evaluation

Answer 90

CXR (water bottle sign, liquid collects on bottom) ECHO EKG (ST elevation, PR depression, inverted T wave) CBC, ESR, troponin refer to ED

Question 91

pericarditis tx for low risk pt

Answer 91

outpatient management stable, small effusion, no fever NSAIDs @ max dose titrate over 3-4 weeks (ibuprofen, indomethacin) f/u regularly: monitor inflammatory markers/symptoms should decrease NO improvement within 7 days = refer cardio ? hospital

Question 92

What EF is diagnostic of HFREF?

Answer 92

EF < 40%

Question 93

what are the two classic presenting symptoms of HF?

Answer 93

dyspnea and fatigue

Question 94

WHAT ALWAYS NEEDS TO BE RULED OUT FIRST IN A PATIENT PRESENTING WITH NEW ONSET SYMPTOMS OF HEART FAILURE?

Answer 94

R/o ACS with EKG first

Question 95

PATIENT WITH KNOWN HF HAS LV WALL THICKENING ON HIS MOST RECENT ECHO AND AN EF OF 45%. HE IS ASYMPTOMATIC. WHAT STAGE (A,B,C,D) IS THIS PATIENT IN?

Answer 95

STAGE B – STRUCTURAL CHANGES WITH NO SYMPTOMS

Question 96

PATIENT PRESENTS TO THE CLINIC WITH NEW ONSET COUGH AND +1 LE EDEMA. HE HAS FINE BILATERAL CRACKLES ON AUSCULTATION. HIS VITAL SIGNS ARE STABLE AND HE IS IN NO ACUTE DISTRESS. EKG IS NORMAL. WHAT SHOULD THE NP DO NEXT? ADMINISTER PO LASIX AND MONITOR VS REFER TO THE ER?

Answer 96

ER – HOSPITALIZATION CRITERIA INCLUDES NEW ONSET HF CONGESTION SYMPTOMS, ACS/MI, PULMONARY EDEMA (PINK FROTHY SPUTUM), NEW ARRHYTHMIA W/ HEMODYNAMIC INSTABILITY, SPO2 <90, COMPLICATING DISEASE STATE, ? SAFE HOME MANAGEMENT, SYMPTOMS REFRACTORY TO PO TREATMENT OR HOME MANAGEMENT PLAN

Question 97

WHAT EKG FINDING WOULD YOU EXPECT IN A PATIENT WITH SUSPECTED PERICARDITIS?

Answer 97

DIFFUSE ST ELEVATION

Question 98

PATIENT PRESENTS TO THE CLINIC COMPLAINING OF NEW ONSET CHEST PAIN THAT HAS BEEN PRESENT FOR 15 MINUTES AND IS NOT ALLEVIATED WITH REST. EKG SHOWS ST DEPRESSION > 1 MM. THE PROVIDER CALLS 911. WHAT ARE 2 THINGS THAT THE PROVIDER CAN DO IN THE OFFICE WHILE WAITING FOR EMS? (TREATMENT WISE)

Answer 98

ADMINISTER ASA CHEWABLE TABLET AND NTG TABLE (IF NOT CONTRAINDICATED)

Question 99

HF RF

Answer 99

``` CAD HTN valvular heart dx aging obesity DM metabolic syndrome CKD smoking CHD ```

Question 100

systolic HF

Answer 100

HF w/ reduced EF (HFREF) = EF < 40% enlarged ventricles able to fill with blood but unable to pump it to the body, thinning of ventricular walls pump dysfunction

Question 101

diastolic HF

Answer 101

HF w/ preserved EF = EF > 50% stiff, thickened ventricles fill with less blood than normal normal CO, less amount of blood being pumped out filling dysfunction

Question 102

Left sided HF presentation

Answer 102

fatigue, dyspnea orthopnea, paroxysmal nocturnal dyspnea cough, S3 or S4 displaced apical pulse, crackles if pulmonary edema LEFT think LUNGS, so signs of congestion

Question 103

right sided HF presentation

Answer 103

usually results from advanced L-sided HF lower extremity edema, fatigue, exercise intolerance, JVD nocturia, ascites, hepatomegaly, decreased appetite, nausea S3 RIGHT think REST of the body, so starting to affect other body systems - lower extremities, liver, etc

Question 104

HF diagnostics

Answer 104

ECHO! calculates EF & structure of heart EKG (infarction, ischemia, LVH, arrhythmia) CXR (cardiomegaly) Labs: - BNP - sensitive test can r/o HF - electrolytes, Ca, Mg - CBC - BUN, Cr - UA - glucose - lipids - LFTs - TSH

Question 105

BNP vs NT-proBNP

Answer 105

if pt taking an ARNI, will need to check NT-proBNP b/c BNP is not accurate in these patients

Question 106

Framingham criteria for diagnosis of HF

Answer 106

At least 2 major or 1 major and 2 minor criteria present: Major: - acute pulmonary edema - cardiomegaly - hepatojugular reflux - JVD - paroxysmal nocturnal dyspnea/orthopnea Minor: - ankle edema - dyspnea on exertion - hepatomegaly - nocturnal cough - pleural effusion - tachycardia > 120 bpm Meet criteria = ECHO + BNP, but do not meet criteria = ECHO

Question 107

ACC/AHA HF stages

Answer 107

Stage A: at risk, no structural abnorms, no symptoms Stage B: structural heart defects but no symptoms Stage C: structural heart dx w/ prior or current symptoms Stage D: advanced structural dx w/ symptoms at rest requiring advanced interventions

Question 108

ACC Stage A HF

Answer 108

at risk, no structural abnorms, no symptoms

Question 109

ACC Stage B HF

Answer 109

structural heart defects but no symptoms

Question 110

ACC Stage C HF

Answer 110

structural heart dx w/ prior or current symptoms

Question 111

ACC Stage D HF

Answer 111

advanced structural dx w/ symptoms at rest requiring advanced interventions

Question 112

NYHA functional classification of HF

Answer 112

Class I: asymptomatic Class II: symptoms with moderate exertion; walking up stairs, fine at rest Class III: symptoms with minimal exertion; making bed, washing dishes, etc , ok at rest Class IV: symptoms at rest

Question 113

NYHA Class I HF

Answer 113

asymptomatic

Question 114

NYHA Class II HF

Answer 114

symptoms with moderation exertion

Question 115

NYHA Class III HF

Answer 115

symptoms with minimal exertion

Question 116

NYHA Class IV HF

Answer 116

symptoms at rest

Question 117

HF complications

Answer 117

``` cardiogenic shock biventricualr HF, arrhythmias end organ damage liver damage - congestive hepatopathy exacerbations ```

Question 118

HF tx goals

Answer 118

relief of S/S prevent further myocardial injury prevention of recurrence of clinical failure improvement in prognosis management depends on stage and class and which type of HF (preserved vs. reduced EF)

Question 119

Stage A HF management

Answer 119

lifestyle changes meds to control HTN, DM, HLD BP < 130 ``` ACE-I/ARB statins as appropriate smoking cessation salt reduction regular exercise limit alcohol consumption ```

Question 120

Stage B HF management

Answer 120

consider screening with BNP ACEI/ARB & BB valve repair if needed

Question 121

Stage C HF management

Answer 121

``` lifestyle changes daily weights sodium restriction reduced exercise during decompensation cardiac rehab ``` AVOID CCB & NSAIDs pharm: 4 classes - diuretic - ACE-I/ ARB/ ARNI - BB - aldosterone antagonist hydralazine w/ isosorbide in AA if cannot tolerate ACE/ARB selected pt: CRT, ICD, revascularization

Question 122

Stage D HF management

Answer 122

control S/S, improve QOL managed by cardiology inotropes - digoxin palliative care

Question 123

when to refer to cardiology in HF

Answer 123

- S/s refractory to standard tx - onset of arrhythmias, coronary ischemia or MI - young patient with ischemic or nonischemic DCM, HCM - worsening EF - NYHA class 3 or 4 - need for ICD or resynchronization - HF advanced therapies eval

Question 124

HF hospitalization considerations

Answer 124

- new onset HF w/ symptoms of congestion - evidence of ACS/MI/ischemia/infarction - pulmonary edema or acute decompensated HF - O2 < 90% - severe medical complications - PNA, renal failure - anasarca (generalized swelling throughout body) - symptomatic hypotension/syncope - hemodynamically significant arrhythmias - HF refractory to max outpatient PO tx - needed home support for safe management

Question 125

Acute HF decompensation tx

Answer 125

mnemonic: POND Position upright/ positive pressure ventilation (BiPAP) Oxygen Nitrates Diuretics

Question 126

when is an ICD appropriate in HF pt

Answer 126

Select pts between stage B or D who have an EF < 35% who are on max med therapy