Cardiology

Front 1

pediatric with holosystolic mumur LL sternal border and rumbling diastolic murmur or cardiac apex. Sx: failure to thrive, easy fatigability and and heart failure. Think? Dx how?

Back 1

most common congenital heart malformation. ventricular septal defect with left to right shunt. Diastolic murmur is due to increased flow across the mitral valve
* echocardiogram with bubble study

Front 2

most common congenital heart malformation.

Back 2

ventricular septal defect

Front 3

atrial fibrillation. How do you choose anti coag choice

Back 3

CHADS2:
* CHF
* HTN
*Age >75
*DM
*stroke = 2 pts
0pts -> aspirin
>3pts->warfarin
1-2 - either is ok

Front 4

pt with arrythmia on long term amiodarone treatment presenting chronic interstitial pneumonitis (nonproductive cough, fever, pleuritic chest pain, weight loss, dyspnea on exerticion and focal or diffuse intersitial opacity on CXR, organizing pneumonia, ARDS, or solitary pulmonary mass. Dx? tx?

Back 4

amiodarone toxicity
- stop amiodarone

Front 5

palpitations w/ regular, Narrow QRS, tachycardia (150-200). Think? Dx how?
1. tx if unstable?
2. tx stable 1st line?
3. ***if this fails?
4. best long term management?

Back 5

supraventricular tachycardia (SVT)
dx: EKG, holter monitor
1. tx if unstable: synchronized cardioversion
2. incrase vagal tone
3. IV adenosine. Both allow the rhythm to slow so that it can be recognized.
4. radiofrequency ablation

Front 6

recurrence of chest pain 1-4 days after MI, which gets worse with position changes and deep inspiration. Pericardial friction rub (scratchy sound that is more pronounced when the patient leans over). EKG: sinus tach, diffus ST segment elevations with PR segment depressions "q waves)" Think? Dx how? tx?

Back 6

infarction paricarditis
- clinical
- high dose aspirin as it manages the pain . Other NSAIDs may increase the risk of myocaridial rupture after transmural MI

Front 7

depressed pt with hypotension, anticholinergic effects, change in mental status, EKG with widened QRS and sinus tachy. Think? Tx

Back 7

TCA overdose and TCA induced ventricular arrhythmia
- 1. sodium bicard counters the TCA cardio toxic effect.
2. lidocaine is the best drug for TCA ventricular arrhythmias

Front 8

cardiotoxic chemo agents like doxorubicin. How monitor

Back 8

radionuclide vetriculography

Front 9

smoking cessation: buproprion or nicotine

Back 9

nicotine
nicotine patch is preferred to buproprion in the early statges of nicotine cessations

Front 10

Back 10

Afib

Front 11

Back 11

atrial flutter
*slow down with cardizem and call cards

Front 12

Back 12

left bundle branch block
The QRS duration must be ≥ 120 ms[2]
There should be a QS or rS complex in lead V1
There should be a RsR' wave in lead V6.

Front 13

cocaine induced myocardial ischemia. Tx?

Back 13

benzo for sedation and nitro and calcium channel blockers for pain relief
* beta blockers: avoid due to unopposed alpha stimulation

Front 14

It worsens after dilt or digoxin.
1. dx?
2. sequelae?
3. best initial tx?
4. best long term therapy

Back 14

1. wolf parkinson white syndrome
- caused by an accessory pathway that connects atria to ventricles bypassing the av node
- has a short PR interval with a DELTA wave (P-R gradual up slope before the spike), and a wide >0.12s QRS complex
2. can deveolop tachyarrhythmias
3. procainamide
4. catherter ablation if they have symptomatic arrhythmias or

Front 15

patient with 3 vessel disease or left main disease. Tx

Back 15

CABG

Front 16

what drugs do they use for a pharmacologic stress test?

Back 16

adenosine myocardial perfusion imaging

Front 17

bradycardia in anterior wall MI. Tx symptomatic? asymptomatic

Back 17

if symptomatic: IV atropine sulfate
if asymp: no tx, usually transient

Front 18

artery that supplies the lateral wall of left ventricle

Back 18

left circufelx

Front 19

artery that supplies the right ventricle and infereoposterior wall of left ventricle

Back 19

right coronary

Front 20

artery that supplies the left ventricle anterior wall

Back 20

left anterior descending

Front 21

comorbidity that is the single poorest predictor of future CV outcomes

Back 21

DM

Front 22

cocaine induced transmural MI not improved with drugs. Next step

Back 22

coronary angiography to look for coronary thrombus

Front 23

on digoxin and has nausea, vomiting, anorexia, fatigue, confusion, visual disturbances, and cardiac problems. ? antiarrythmic Drugs responsible

Back 23

dig toxicity:
amiodarone
verapamil
quinadine

Front 24

P waves of different morphology and tachycardia, variable RR and PR segments. Think? Caused by?

Back 24

multifocal atrial tachycardia:
1. hypoxia
2. COPD
… check arterial blood gas

Front 25

hemoptysis with low pitched rumbling diastolic murmur, with prominent pulmonary arteries at the hilum, elevation of the left mainstem bronchus, left arterial enlargement with flattening of the left heart border

Back 25

mitral stenosis usually 2/2 rhumatic fever

Front 26

AAA what's more important, better control of DM or smoking cessation?

Back 26

smoking cessation

Front 27

code: fast and wide, regular w/ pulse. Dx? tx

Back 27

V-tach
- Amiodarone 150mg IV

Front 28

code: fast and wide, regular w/ no pulse. Dx? tx

Back 28

pulseless V-tach
shock
CPR

Front 29

fast and wide, irregular w/o pulse. Dx? tx

Back 29

V-fib
shock
CPR

Front 30

fast and narrow w/o pulse

Back 30

PEA
CPR

Front 31

code: no waveform

Back 31

asystole

Front 32

EKG: sinus brady. what next?

Back 32

check leads II and V1 for P waves
* medication likely cuase
tx: non-symptomatic -> bening
- if elderly w/ enlarged ventricles, investigate further

Front 33

px w/ palpitations, syncope, chest pain, or sudden death.
1. dx
2. hemodynamically stable tx?
3. hemodynamically UNstable tx?

Back 33

1. Vtach
2. stabilize with lidocaine, amiodarone, procainamide, or mag
3. Synchornized cardioversion (premedicate with benzo)

Front 34

Back 34

Vtach
* stabilize with lidocaine
* premedicate with benzo
* Synchornized cardioversion

Front 35

Back 35

pericarditis
Electrocardiogram in acute pericarditis showing diffuse upsloping ST segment elevations seen best here in leads II, III, aVF, and V3 to V6. There is also subtle PR segment deviation (positive in aVR, negative in most other leads). ST segment elevation is due to a ventricular current of injury associated with epicardial inflammation; similarly, the PR segment changes are due to an atrial current of injury which, in pericarditis, typically displaces the PR segment upward in lead aVR and downward in most other leads.

Front 36

Back 36

Electrocardiogram in typical complete LBBB. The asynchronous activation of the two ventricles increases the QRS duration (0.14 sec). The abnormal initial vector results in loss of normal septal forces as manifested by absence of physiologic q waves in leads I, aVL, and V6. The late activation of the left ventricle prolongs the dominant leftward progression of the middle and later depolarization forces, leading to a positive and widened R wave in the lateral leads. Both the ST segment and T wave vectors are opposite in direction from the QRS, a "secondary" repolarization abnormality.

Front 37

what electrolyte abnormality?

Back 37

Prolonged QT interval due to hypocalcemia
The QT interval in this case is quite prolonged (0.50 sec) at a heart rate of 55 beats/min. The rate corrected QT (QTc) interval can be calculated from: QT interval ÷ sqrt (RR interval). The RR interval is 1.05 sec leading to a QTc of 0.48 sec which is longer than the normal value of ≤0.44 sec. A long QT interval with a "stretched out" ST segment and normal T wave is most consistent with hypocalcemia. In contrast, hypercalcemia shortens the QT, hyponatremia usually has no effect on the ECG, and hypokalemia prolongs repolarization with flattened or broad T waves and prominent U waves.

Front 38

What is the cause of the wide QRS complex?

Back 38

Wolff-Parkinson-White pattern
Precordial leads in a patient with preexcitation due to the WPW syndrome. The three characteristic findings are the short PR interval (0.09 sec in this case), the wide QRS, and the delta wave (slurring of the QRS upstroke) that is best seen in leads V5 and V6 (arrows).

Front 39

chronic lung disease

Back 39

Multifocal atrial tachycardia
* Electrocardiogram showing multifocal atrial tachycardia in a woman with severe pulmonary disease. The diagnostic criteria include an average atrial rate above 100 beats/min and at least three different consecutive non-sinus P waves in the same lead. Note the multiple P wave morphologies - inverted (I), upright (U), and biphasic (B)

Front 40

electrolyte abnormalities

Back 40

hyperkalemia
Lateral precordial leads showing peaked, narrow (tented) T waves and prolongation of the QRS complex (0.14 to 0.16 seconds) associated with moderate to severe hyperkalemia.

Front 41

Back 41

Atrial flutter with 2:1 block
Typical atrial flutter with 2:1 atrioventricular block. The flutter rate is approximately 300/min with a ventricular rate of 150/min. The flutter waves are best seen in leads II, III, and V1 (arrows). This patient also has low QRS voltage in the limb leads, a non-specific finding.

Front 42

Back 42

Hypercalcemia
Shortened QT interval in hypercalcemia that results from shortening of the duration of the ventricular action potential. (Hypocalcemia has the opposite effect.) Note how the T waves appear to take off directly from the end of the QRS due to abbreviation of the ST segment. The slight J point elevation in leads V1 to V3 may also be seen with hypercalcemia in the absence of ischemia.

Front 43

hx of syncope

Back 43

Sick sinus syndrome and atrial fibrillation
Rhythm strip showing sick sinus syndrome. The initial part of the tracing reveals coarse fibrillation with a slow ventricular response in the absence of drugs that slow AV nodal conduction. The atrial fibrillation breaks and is followed by a sinus escape beat with a long escape inverval of nearly four seconds and then another escape beat at a similar interval (not shown).

Front 44

pt has an MI. what do your order a few days latter if he has new chest pain?

Back 44

CK-MB. Troponins will stay elevated for a couple of weeks.

Front 45

Which cardiac enzyme rises first?

Back 45

myoglobin rises in 1-4 hours. Troponins rise in 3-6 hours

Front 46

ACS initial tx. What reduces mortality? if acute MI?

Back 46

1. ASA - reduces mortality
2. morphine and nitrates do not reduce mortality
3. O2 if hypoxic
4. clopidogrel (plavix) or prasugrel if acute MI

Front 47

STEMI. What reduces mortality? <90min? >90min>

Back 47

1. thrombolytics if >90 min
2. primary angioplasty (a type of percutaneous coronary intervention) - perform w/in 90 minutes
benefit decreases as time increases

Front 48

stable angina tx

Back 48

asa, beta blocker, and statin
angioplasty does not improve mortality beyond this

Front 49

ACS tx after initial tx? decrease mortality and under what conditions?

Back 49

1. beta blockers decrease mortality and are not time sensitive
2. ACE I/ARB. Lower mortality ONLY IF left ventricular dysfunction or systolic dysfunction
3. Statin if LDL >100. Lower mortality

Front 50

post MI discharge meds

Back 50

ASA
clopidogrel
metoprolol, carvedilol, or bisoprolol
statin,
ACEI/ARB

Front 51

How does NSTEMI management differ from STEMI? Coagulation?

Back 51

No thrombolytic use
- LMWH - lowers mortality
- Glycoprotein IIb/IIIa inhibitors lower mortalitiy
- PCI also used

Front 52

stable angina tx

Back 52

- ASA and metoprolol lower mortality
- nitrates - do not lower mortality
- coronary angiography to see if they are a CABG candidate

Front 53

what vessel should be used for CABG

Back 53

internal mammary artery remains open for 10 years
saphenous vein remains open for 5 years

Front 54

indications for CABG: number of vessels? % stenosis

Back 54

-3 vessel dz and >70% stenosis
OR left MAIN coronary w/ >70% stenosis

Front 55

LDL goal for pt w/ CAD and DM

Back 55

<70

Front 56

MI risk factors: BP, cholesterol, fam hx, age

Back 56

- tobacco
- HDL<40
- primary fam hx of CAD F<65 or M<55
- age: M>=45 and F>=55

Front 57

60F w/ acute severe dyspnea, rales, S3 gallop, and orthopnea. dx? tx? work up?

Back 57

- CHF w/ acute pulmonary edema
- tx w/ O2, furosemide, nitrates, morphine
- CXR, EKG, oximeter, echo
- admit to ICU

Front 58

pulmonary edema; gave O2, furosemide, nitrates, morphine. Now pt still dyspneic. tx?

Back 58

positive ionotrope: dobutamine,
2nd line: amirone, milrinone

Front 59

rales

Back 59

crackles

Front 60

Rhonchi

Back 60

coarse rattling sound somewhat like snoring, usually caused by secretion in bronchial airways

Front 61

pulm edema w/ vtach, afib, a flutter, or SVT. tx?

Back 61

synchronized cardioversion

Front 62

what does a normal BNP mean?

Back 62

CHF is ruled out

Front 63

Digoxin benefits for CHF

Back 63

- decreases symptoms if EF reduced as has inotropic effects
- decreases frequency of hospitalizations
- DOES NOT decrease mortality

Front 64

Which bb have been shown to reduce mortality for CHF?

Back 64

carvedilol and metoprolol

Front 65

systolic CHF - what medications? which ones lower mortality?

Back 65

1. ACEI/ARB - lower mortality
2. metoprolol or carvedilol: lower mortality
3. Spironolactone - use if px EF<35%. lower mortality
4. digoxin if symptomatic - lower symptoms and hospitalizations.
5. diuretics - do not lower mortality

Front 66

diastolic CHF tx? which ones should not be used

Back 66

BB and lasix (or other diuretics)
ACE I - unsure if it helps
Digoxin and spironolactone do NOT help

Front 67

Most common cause of death in CHF? What can you do to prevent this?

Back 67

* sudden death from arrhythmia
* ACEI, BB, spironolactone.
* if EF<35% -> cardioverter/defibulator

Front 68

which mumurs increase with inspiration? expiration?

Back 68

R
Inspiration
g
H
T

L
Expiration
F
T

Front 69

which murmurs increase w/ valsalva

Back 69

HOCM, and MVP

Front 70

2nd RUS border systolic crescendo decrescendo murmur

Back 70

aortic stenosis

Front 71

2nd LUS border systolic murmur

Back 71

pulmonic valve

Front 72

LLS border systolic murmur

Back 72

aortic regurg
tricuspid murmur
VSD

Front 73

murmur workup

Back 73

1. echo (TTE. if not diagnostic, then order TEE), ecg, and CXR
- left heart catheterization is most accurate

Front 74

valsalva effect on heart

Back 74

decreases preload

Front 75

handgrip effect on heart

Back 75

increases afterload

Front 76

ACEI effect on heart?

Back 76

decreases afterload

Front 77

tx of regurg lesions (handgrip makes it worse; amyl nitrate improves it)

Back 77

1. vasodilator therapy (ACEI/ARB or nifedipine) - It decreases afterload which decreases regurgitation.
2. if regurg progresses -> valve replacement

Front 78

diastolic murmurs are most commonly?

Back 78

aortic regurg or mitral stenosis

Front 79

stenotic valvular lesion tx

Back 79

anatomic repair
- mitral ballon valvuloplasty
- aortic stenosis: valve replacement

Front 80

diuretic effects on heart

Back 80

decrease preload

Front 81

murmur w/ valvular disease; valsalva improves murmur. tx

Back 81

diuretic as it decreases preload

Front 82

murmur w/ valvular disease: amyl nitrate improves murmur or hand grip makes it worse

Back 82

ACE I

Front 83

no pulse
1. dx?
2. tx?

Back 83

1. v-fib
2. UNsynchronized cardioversion

Front 84

syncope w/ sudden loss of consciousness. etiology (2)

Back 84

neurologic (seizures)
cardiac etiology?