Fa: Step 2 Ck. Cardiology.

Front 1

Describe determination of ECG axis.

Back 1

normal (-30 to +105): positive QRS in leads I, II

left-axis deviation (<-30): positive QRS in I, negative QRS in II

right-axis deviation (>+105): negative QRS in I, positive QRS in II

Front 2

Distinguish ECG characteristics of AV block, LBBB, RBBB.

Back 2

AV block: PR >200 msec, or P with no QRS

LBBB: QRS >120 msec, no R wave in V1, wide and tall R waves in I, V5, V6

RBBB: QRS >120 msec, RSR' complex (rabbit ears), wide S in I, V5, V6

Front 3

ECG changes with ischemia

ECG changes with infarction (transmural)

Back 3

ischemia: inverted T waves, poor pre-cordial R-wave progression, ST-segment elev/depr

infarction (transmural): Q wave higher/longer, ST elevation, T-wave inversion

Front 4

What is an elevated JVD?

What leads to elevated JVD?

Back 4

>7 cm above sternal angle

R heart failure
pulmonary HTN
volume overload
tricuspid regurgitation
pericardial disease

Front 5

What is Kussmaul's sign?

Back 5

increased JVP with inspiration

signifies RV infarction, postoperative cardiac tamponade, tricuspid regurg, constrictive pericarditis

Front 6

What is signified by hepatojugular reflux?

Back 6

fluid overload
impaire RV compliance

Front 7

Describe the following systolic murmurs:

1. aortic stenosis
2. mitral regurgitation
3. mitral valve prolapse
4. flow murmur

Back 7

1. harsh systolic ejection murmur, radiation to carotids
2. holosystolic murmur, radiation to axillae or carotids
3. midsystolic or late-systolic click
4. does not imply cardiac disease

Front 8

Describe the following diastolic murmurs:

1. aortic regurgitation
2. mitral stenosis

Back 8

1. early decrescendo
2. mid to late, low-pitched murmur

Front 9

causes of peripheral edema (10)

Back 9

R heart failure
bi-ventricular failure
peripheral venous disease
constrictive pericarditis
tricuspid regurgitation
hepatic disease
lymphedema
nephrotic syndrome
hypoalbuminemia
drugs

Front 10

increased peripheral pulses in what conditions?

Back 10

compensated aortic regurg
coarcation (arms > legs)
PDA

Front 11

Define pulsus paradoxus.

What is the DDx for pulsus paradoxus?

Back 11

decreased systolic BP with inspiration

pericardial tamponade
asthma or COPD
tension pneumothorax
foreign body in airway

Front 12

What is the DDx for pulsus alternans (alternating weak and strong pulse)?

Back 12

cardiac tamponade
impaired LV systolic function

(poor prognosis)

Front 13

What condition is implied by pulsus parvus et tardus (weak and late)?

Back 13

aortic stenosis

Front 14

What is the management of atrial fibrillation?

Back 14

"A, B, C, D"

Anticoagulate
Beta-blockers to control rate
Cardiovert/Ca2+-channel blockers
Digoxin

Front 15

Give the ECG findings for each type of bradyarrythmia/conduction abnormality:

1. sinus brady
2. 1st degree AV block
3. 2nd degree, Mobitz I
4. 2nd degree, Mobitz II
5. 3rd degree (complete)
6. sick sinus syndrome/tachy-brady

Back 15

1. rate <60, normal P before every QRS
2. PR >200 msec
3. progressive PR lengthening until dropped beat
4. unexpected dropped beats without change in interval
5. no relationship between P waves and QRS complexes
6. intermittent SV tachy and brady

Front 16

Give the Tx for each type of bradyarrythmia/conduction abnormality:

1. sinus brady
2. 1st degree AV block
3. 2nd degree, Mobitz I
4. 2nd degree, Mobitz II
5. 3rd degree (complete)
6. sick sinus syndrome/tachy-brady

Back 16

1. none if no Sx (atropine or pacemaker if Sx)
2. none
3. stop drug (atropine or pacemaker as indicated)
4. pacemaker
5. pacemaker
6. pacemaker (most common indication)

Front 17

Give the ECG findings for each type of atrial tachyarrhythmia:

1. sinus tachy
2. atrial fib
3. atrial flutter
4. multifocal atrial tachycardia

Back 17

1. >100, normal P waves before every QRS
2. no discernible P waves, variable QRS response
3. sawtooth P waves
4. three or more P wave morphologies; rate >100

Front 18

Give the Tx for each type of atrial tachyarrhythmia:

1. sinus tachy
2. atrial fib
3. atrial flutter
4. multifocal atrial tachycardia

Back 18

1. treat underlying cause
2. anticoagulate if old, cardiovert if new i.e. <48 hours (use CHAD2 to estimate stroke score)
3. anticoagulation and rate control, cardiovert accordingly
4. treat underlying disorder; verapamil or beta-blockers for rate

Front 19

Give the ECG findings for each type of AV junction tachyarrhythmia:

1. AV nodal re-entry tachycardia
2. AV reciprocating tachy (WPW syndrome)
3. Paroxysmal atrial tachy
4. PVC
5. V tach
6. V fib
7. torsades de pointes

Back 19

1. 150-250; P waves buried in QRS
2. retrograde P wave after QRS
3. rate >100; P wave with unusual axis before each normal QRS
4. early, wide QRS not preceded by P wave
5. three or more consecutive PVS, wide, regular, rapid QRS
6. totally erratic, wide complex
7. polymorphous QRS; VT @ 150-250

Front 20

Give the Tx for each type of AV junction tachyarrhythmia:

1. AV nodal re-entry tachycardia
2. AV reciprocating tachy (WPW syndrome)
3. Paroxysmal atrial tachy
4. PVC
5. V tach
6. V fib
7. torsades de pointes

Back 20

1. carotid massage, Valsalva, adenosine (cardiovert if unstable)
2. same as #1
3. adenosine for temporary AV block helps unmask underlying atrial activity
4. treat underlying cause; beta-blockers for Sx
5. cardioversion + amiodarone, lidocaine, or procainamide
6. immediate cardioversion and ACLS protocol
7. correct hypokalemia/withdraw offending drug; give Mg initially and cardiovert if unstable

Front 21

features of L-sided heart failure

Back 21

Left-sided CHF: dyspnea predominates!

L S3/S4
bilateral basilar rales
pleural effusions
pulmonary edema
orthopnea
paroxysmal nocturnal dyspnear

Front 22

features of R-sided heart failure

Back 22

Right-sided CHF: fluid retention predominates!

R S3/S4
JVD
hepatojugular reflex
peripheral edema
hepatomegaly, ascites

Front 23

What is the treatment for different stages of heart failure?

Back 23

Stage A. manage risk factors (HTN, smoking, lipids, obesity, exercise, alcohol); ACE-Is for vascular disease, DM, or HTN

Stage B: ACE-Is, beta-blockers

Stage C: diuretics, ACE-Is, beta-blockers, digitalis, dietary Na+ restriction

Stage D: assist devices, xplant, continuous IV inotropes, hospice

Front 24

What is the Tx for acute pulmonary congestion due to CHF?

Back 24

"LMNOP"

Lasix
Morphine
Nitrates
Oxygen
Position (upright)

Front 25

For each class of diuretic, give mechanism of action:
1. loop
2. thiazide
3. K+-sparing
4. carbonic anhydrase inhibitors
5. osmotic agents

Back 25

1. decrease Na/K/2Cl cotransporter in loop of Henle; decrease urine concentration; increase Ca2+ excretion

2. decrease NaCl absorption in early distal tubule leading to decreased dilution

3. spironolactone: aldosterone antagonist; triamterene and amiloride block Na channels

4. bicarbonate diuresis decreases total body bicarb

5. increases tubular osmolarity, leading to increased urine flow

Front 26

For each class of diuretic, give side effects:

1. loop
2. thiazide
3. K+-sparing
4. carbonic anhydrase inhibitors
5. osmotic agents

Back 26

1. ototoxicity, hypo-K+, hypo-Ca2+, dehydration, gout

2. hypo-K+ metabol acidosis, hypo-Na+, hyper-(glucose, lipids, urea, Ca2+)

3. hyper-K+, gynecomastia, hirsutism, sexual dysfunction

4. hyperchloremic metabolic acidosis, neuropathy, NH3 toxicity, sulfa allergy

5. pulmonary edema, dehydration (contraindicated in anuria and CHF)

Front 27

dilated cardiomyopathy: causes

Back 27

idiopathic
ischemia
long-standing HTN
alcohol
myocarditis
postpartum status
drugs (doxorubicin, AZT, cocaine)
endocrinopathies
infection
wet beriberi

Front 28

dilated cardiomyopathy: Dx

Back 28

echo

CXR shows enlarged heart and pulmonary congestion

Front 29

dilated cardiomyopathy: Tx

Back 29

treat underlying cause
ACE-Is, beta-blockers, aldosterone antagonist (spironolactone)
consider ICD if EF <35%

treat CHF Sx with diuretics

Front 30

hypertrophic cardiomyopathy: causes

Back 30

50% AD inheritance in congenital form
HTN
aortic stenosis

Front 31

hypertrophic cardiomyopathy: Dx

Back 31

echo shows asymmetrically thickened LV wall and dynamic blood flow obstruction

Front 32

hypertrophic cardiomyopathy: Tx

Back 32

beta-blockers initially

then CCBs

Front 33

restrictive cardiomyopathy: causes

Back 33

decreased elasticity of myocardium due to:

infiltrative diseases (amyloidosis, sarcoidosis, hemochromatosis)

scarring/fibrosis (secondary to radiation or doxorubicin)

Front 34

restrictive cardiomyopathy: Dx

Back 34

echo shows rapid early filling with normal or near-normal EF

Front 35

restrictive cardiomyopathy: Tx

Back 35

limited, palliatve (vasodilators and anticoagulation if not contraindicated)

Front 36

Describe Prinzmetal's (variant) angina

Back 36

mimics angina pectoris, but caused by vasospasm of coronary vessels

clasically affects young women at rest in the early morning; associated with ST-elevation with NO cardiac enzyme elevation