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17 Cards in this Set

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What percentage (15,33,50) of patients with inferior wall MI develop right ventricular infarction?
E: About 1/3
A: 33
What are the five categories of causes of cardiopulmonary syncope?
E:List the common cardiovascular causes of syncope. Show answer Hide answer

* Tachyarrhythmias, such as VT or SVT (AF, atrial flutter, or paroxysmal SVT).
* Bradyarrhythmias, such as second- or third-degree AV block, AF with a slow ventricular response rate, or sinus bradycardia due to sick sinus syndrome.
* LV outflow obstruction due to fixed lesions (valvular, subvalvular, or supravalvular aortic stenosis) or dynamic obstruction such as hypertrophic cardiomyopathy. Characteristically, these patients present with syncope during or immediately after exercise.
* LV inflow obstruction due to severe mitral stenosis or a large LA myxoma.
* Primary pulmonary hypertension

A: tachy,brady,outfl,infl,(pph)|(pulm)
A 68-year-old man with hypertension presents with a 2-week history of progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. What is the differential diagnosis of congestive heart failure in hypertensive patients?
E:A 68-year-old man with hypertension presents with a 2-week history of progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. What is the differential diagnosis of congestive heart failure in hypertensive patients?
* CAD
* Diastolic dysfunction associated with hypertension
* Dilated cardiomyopathy (idiopathic or alcoholic)
* Valvular heart disease (mitral regurgitation, aortic stenosis, aortic insufficiency)
* Restrictive heart disease (amyloidosis)
* Hypertrophic cardiomyopathy (idiopathic hypertrophic subaortic stenosis)
A: CAD, diastol, IHSS, cardiomy, restri
What is the differential diagnosis of an abnormal early diastolic sound heard at the apex and lower left sternal border?
E:What is the differential diagnosis of an abnormal early diastolic sound heard at the apex and lower left sternal border?
1. Loud P2
2. S3 gallop
3. Opening snap
4. Pericardial knock
5. Tumor plop (atrial myxoma)

An early diastolic sound may be due to wide splitting of S2, with or without a loud pulmonic closure sound. An atrial septal defect (ASD) causes wide and fixed splitting of S2.
A:P2,knock, plop,S3,snap
A red blood cell and fibrin rich clot is seen in (STEMI/non-STEMI).
E: The pathophysiologic mechanism of acute non-ST elevation coronary syndrome is intermittent and/or incomplete coronary occlusion by platelet-rich "white" recent thrombus resulting from platelet aggregation at the site of a damaged inner surface of a coronary artery. The trigger for this platelet aggregation is usually rupture of an atherosclerotic plaque. This type of thrombus is in sharp contrast to the mature red blood cell and fibrin-rich "red" or "mature" thrombus, which is the hallmark pathologic finding in patients with acute ST elevation MI. Unlike the platelet-rich "white" thrombus, a mature "red" thrombus results in a complete and/or persistent coronary artery occlusion resulting in severe transmural ischemia characterized by acute ST segment elevation. An intermittent or incomplete occlusion of a coronary artery usually causes acute subendocardial ischemia, which presents with ST segment depression or T wave changes that are transient or dynamic in nature.
A: non-STEMI
A patient presents with non-STEMI or unstable angina. What antiplatelet agent should be given other than aspirin?
E: The American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend clopidogrel in patients admitted with acute coronary syndromes with no ST segment elevation in addition to aspirin therapy. This class I recommendation is based on the CURE trial which showed a significant reduction in recurrent cardiac events with the addition of clopidogrel to standard therapy including aspirin, beta blockers, and statins.
A: Clopidogrel
Which trial demonstrated that the addition of clopidogrel improved outcomes in non-STEMI/unstable angina?
E: The CURE trial
Braunwald E, Antman EM, Beasley JW, et al, for the American College of Cardiology/American Heart Association Committee on the Management of Patients with Unstable Angina: ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: A report of the ACC/AHA Task Force on Practice Guidelines. Circulation 106:1893-1900, 2002.
The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial investigators: Effects of clopidogrel in addition to aspirinView drug information in patients with acute coronary syndrome without ST segment elevation. N Engl J Med 345:494-502, 2001.
A: cure
The combination of GP2B3A inhibitors and thrombolysis shows reduction in mortality. True/False
E: Three clinical trials have evaluated the angiographic results of thrombolytics in combination with an inhibitor of the platelet glycoprotein 2b/3a receptor: the TIMI 14, SPEED GUSTO, and INTRO-AMI trials. All three specifically evaluated angiographic outcome at 60 and 90 min after thrombolytics when combined with a platelet glycoprotein 2b/3a receptor. The TIMI 14 and GUSTO SPEED trials revealed that the proportion of patients who completely reperfuse (as evidenced by a TIMI flow grade 3) is significantly higher with the combination of half-dose t-PA or r-PA with the platelet glycoprotein 2b/3a receptor inhibitor abciximab(Reopro). The INTRO-AMI trial confirmed these results using the platelet glycoprotein 2b/3a receptor inhibitor eptifibatide information (Integrelin) and showed a similar increase in rate and extent of thrombolysis at 90 min after thrombolysis is initiated. However, despite these promising angiographic results, none of the mortality trials showed any survival advantages for the combination of lysis + 26/3a inhibitors. This combination is not routinely recommended.
Antman EM, Giugliano RP, Gibson CM, et al, for the TIMI 14 Investigators: Abciximab facilitates the rate and extent of thrombolysis: Results of the Thrombolysis in Myocardial Infarction (TIMI) 14 trial. Circulation 99:2720-2732, 1999.
Trial of abciximab with and without low-dose reteplaseView drug information for acute myocardial infarction: Strategies for Patency Enhancement in the Emergency Department (SPEED) Group. Circulation 101:2788-2794, 2000.
A:F
What are the four advantages of primary angioplasty over pharmacologic reperfusion?
E: The primary angioplasty in myocardial infarction (PAMI) trial is the first published clinical trial designed specifically to compare balloon angioplasty with t-PA as the primary reperfusion therapy in patients with acute ST-elevation MI. Survival rates (at 30 days and at 2 years) after primary angioplasty were similar to those with t-PA in acute MI, but angioplasty conferred greater freedom from recurrent ischemia, reinfarction, and need for readmission to the hospital. Another important advantage of balloon angioplasty over thrombolytic drug therapy is freedom from intracranial hemorrhage, a dreadful complication of thrombolysis, particularly in elderly patients.
Nunn CM, O'Neill WW, Rothbaum D, et al: Long-term outcome after primary angioplasty: Report from the primary angioplasty in myocardial infarction (PAMI-I) trial. J Am Coll Cardiol 33:640-646, 1999.
A: reinfarct, readmis, isch, hemorr
Nitrates are equally efficacious in vasospastic and effort angina. True/False?
E: Patients with both forms of angina respond promptly to nitrates
A:T
What is the treatment of choice in Prinzemetal's angina?
E: In contrast to beta blockers, calcium blockers are quite effective in reducing the frequency and duration of episodes of variant angina. Along with nitrates, calcium blockers are the mainstay of treatment of Prinzmetal's angina because of their proven efficacy and safety.
A: (calc)|(CCB)
A 78-year-old asthmatic man has stable exertional angina of 3 years' duration. His past medical history reveals intermittent claudication after walking 50 yards. What is your approach to medical management of his anginal symptoms?
E: This elderly man has three medical problems: asthma, intermittent claudication, and chronic stable angina. Of the available antianginal drugs, beta blockers are contraindicated because of the presence of asthma. Cardioselective beta blockers, such as metoprololView drug information (Lopressor) or atenololView drug information (Tenormin), may be used cautiously in low doses in asthma, but noncardioselective beta blockers are not safe in this patient. However, the presence of peripheral vascular disease, as manifested by intermittent claudication, also is a contraindication for the use of any beta blocker. Calcium antagonists or nitrates are thus the antianginal drugs of choice in this patient.
A: (calc)|(CCB), nitrate
What are the risk factors for death and reccurrent MI in ACS?
E:The risk of death or recurrent non-fatal MI is highest in patients with acute coronary syndrome complicated by any of the following features:

1. Ongoing prolonged chest pain; more than 20 min in duration
2. Acute pulmonary edema (by physical exam or chest x-ray)
3. New or worsening mitral regurgitation murmur
4. Rest angina with dynamic ST-segment changes more than 1 mm
5. S3 gallop or rales.
6. Hypotension
7. Positive enzymes

A: edema, hypotension,rales
What are the five indications for cardiac catheterization in patients with unstable angina?
E: Cardiac catheterization should be entertained in patients with unstable angina and any of the following features:

1. Refractory unstable angina.
2. Prior revascularization
3. Ejection fraction less than 50 per cent.
4. Life-threatening ventricular arrhythmias
5. Inducible myocardial ischemia (provoked by exercise, dobutamine, adenosine, or dipyridamole) at a low exercise level.
A:refrac,revasc,inducib, EF, arrhythm
Name three thrombolytic drugs.
E: The effect of IV thrombolytic therapy on MI mortality is well established. In the GISSI trial published in 1986, 11,806 patients with acute MI presenting within 12 hours of symptom onset were randomly assigned to receive IV streptokinaseView drug information or placebo. The hospital mortality was significantly reduced in patients treated with streptokinase within the first 6 hours. Most importantly, there was a remarkable 50% reduction in hospital mortality in patients treated within 1 hour of symptom onset. Subsequent clinical trials of various thrombolytic drugs including streptokinase(SK), t-PA (Activase), r-PA (Retavase), and the most recent FDA-approved thrombolytic TNK-t-PA (Tenectaplase) confirmed the consistent improvement in survival with thrombolytic therapy in patients with acute ST elevation MI.
A: t-PA,r-PA, TNK-t-PA
What is the NTT for thrombolysis?
E: Thrombolysis is the most effective life-saving pharmacologic therapy in acute MI. It saves about 40 lives for every 1000 treated patients and reduces 30-day and 1-year mortality by about 25%.
A:20
What are the contraindications to thrombolysis?
E:The current standard of care for patients with acute ST-elevation (or transmural) MI includes administration of IV thrombolytic therapy in all patients admitted within 12 hours of symptom onset. Contraindications include:
1. Bleeding disorders
2. Severe uncontrolled hypertension (BP:180/120+mmHg).
3. Recent history of thromboembolic cerebrovascular accident (within 2 months).
4. Any prior history of a hemorrhagic cerebrovascular accident.
5. Prolonged cardiopulmonary resuscitation (over 10 min), 6. Active bleeding from a peptic ulcer.
7. Other noncompressible source.
8. Known brain metastasis.
9. Cerebral AVM
10. Aneurysm.
GISSI Trial: Effect of time to treatment on reduction in hospital mortality observed in streptokinase-treated patients. Lancet 1:397-401, 1986.
AHA/ACC Task Force: Guidelines for management of acute myocardial infarction. Circulation July 2004, accessed via ACC or NIH Web sites
A: active, recent CVA, hemorrhagic CVA, AVM, aneurysm,mets,hyperten