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225 Cards in this Set

  • Front
  • Back

Risk factors for Coronary Artery Disease

DM


Tobacco smoking


HTN


Hyperlipidemia


Family history of premature CAD


Age above 45 in men and above 55 in women

Acute MI in post-menopausal woman, immediately following a very emotionally stressful event



What is the treatment

Tako-Tsubo cardiomyopathy



BB, ACEI

Correcting which of the following risk factors for CAD gives the most immediate benefit?


1. DM


2. Smoking


3. HTN


4. Hyperlipidemia


5. Wt loss

Smoking cessation.



Within a year after smoking cessation, the risk of CAD decreases by 50%. After 2 yrs, the risk reduces by 90%

Symptoms of Ischemic Chest pain?

Dull or sore


Squeezing or pressure feeling

Pain worse with lying flat and better when sitting up:


1. Most likely diagnosis


2. Most accurate test

1. Pericarditis


2. ECG with ST Elevation everywhere,


PR depression

Sudden onset of SOB, Tachycardia, hypoxia


1. Most likely diagnosis


2. Most accurate test

1. Pulmonary embolus


2. Spiral CT, V/Q scan

Ischemia shows ST _______ on the EKG

Depression

Perform ______ when the etiology opf chest pain is uncertain and the EKG is not diagnostic

Stress testing

Reasons for baseline EKG abnormalities (4) ?

1. LBBB


2. Left ventricular hypertrophy


3. pacemaker use


4. Effect of Digoxin

If patient is not able to perform a stress test, what alternate method can be performed to increase myocardial oxygen consumption?

1. Dipyridamole or adenosine in combination with the use of nuclear isotopes e.g. thallium or sestamibi



2. Dobutamine in combination with use of echocardiography

Indications for use of Holter monitor

To check for Rhythm disorders e.g


- Atrial fib


- flutter


- Ectopy e.g premature beats


- V-tach

1. In chronic angina, nitroglycerin is given either ___ or by ______



2. In ACS, nitroglycerin is given

1. orally or by transdermal patch


2. sublingually, paste or IV form

Indications for Clopidogrel (2)

Aspirin intolerance


Recent angioplasty with stenting

Prasurgel (Effient) is an _________ medication



a) Indications (1):


b) Contraindications (2) :

- anti- platelet


a) people undergoing angioplasty and stenting


b) > 75 yr old (increased risk of hemorrhagic stroke


- abnormal bleeding (e.g. stomach ulcers, etc)

If patient is intolerant to both aspirin and Clopidrogel, give ______



Most common SE:

Ticlopidine (inhibits platelets)



- Neutropenia


SE of ACEI

Cough (7%)


Hyperkalemia - because ACEI and ARBs both inhibit aldosterone


Pt on ACEI for low EF (24%) and sx of breathlessness. Pt develops hyperkalemia. How will you manage?

Switch ACEI to hydralazine and nitrates.



Hydralazine is an arterial vasodilator and must be given with nitrates.

LDL goal

Atleast < 100

Most common SE of Statins

Liver dysfunction.
- Elevated transaminases

1. Use CCB (Verapamil, Diltiazem)


a) Use in CAD only when (3):



2. Dihydropyridine CCB (nifedipine, nicardipine, nitrendipine) increase mortality in patients with CAD because of _____________

1. Severe asthma precluding the use of BB


Prinzmetal variant angina


Cocaine induced chest pain



2. raising HR

CABG lowers mortality in these 4 circumstances

1. Three vessels with at least 70% stenosis in each vessel


2. Left main coronary artery occlusion


3. Two vessel disease in patients with DM


4. Persistent sx despite medical therapy

ACS is assoc w/ ____ gallop

S4.

Due to ischemia leading to noncompliance of the LV. The S4 gallop is the sound of atrial systole as blood is ejected from the atrium into a stiff ventricle.

Define pulsus paradoxus? What is it associated with?

A decrease of BP of greater than 10 mm Hg on inhalation is a pulsus paradoxus and is a/w cardiac tamponade

What is Kussmaul sign? What is it associated with?

An in crease in jugulovenous pressure on inhalation



It is a/w constrictive pericarditis or restrictive cardiomyopathy.

Displaced PMI is characteristic of ____

LVH as well as dilated cardiomyopathy.



A displaced PMI cannot occur with ACS because it is an anatomic abnormality

1. ST Elevation signifies


Acute MI

Describe location of MI: ST Elevation in leads?


a) V2 - V4


b) II, III, aVF


c)

a) Anterior wall of the Left ventricle. Untreated mortality b/w 30-40%



b) Inferior wall MI. Untreated mortality < 1% at one year after the event

70 yr old woman comes to the ED w/ crushing substernal chest pain for the last hour. EKG shows ST elevation in V2-V4. What is the most appropriate next step?

Administer aspirin

70 yr old woman comes to the ED w/ crushing substernal chest pain for the last hour. EKG shows ST elevation in V2-V4. Aspirin has been administered, what is the next step?

Angioplasty

PVC. What is the treatment?

No treatment necessary

______ can cause false positive troponins

Renal insufficiency

a) Time to become abnormal


b) Duration of abnormality



Give a, and b for:



1. Myoglobin


2. CK-MB


3. Troponin

1 a) 1-4 hours b) 1-2 days


2 a) 4-6 hours b) 1-2 days


3 a) 4-6 hours b) 10-14 days

____ is given as initial therapy for ST Depression and NON-ST elevation MI

Low molecular wt heparin.



Heparin is bet for NSTEMI


GP IIb/IIIa inhibitors e.g. Abciximab, are best for NSTEMI and those undergoing PCI and stenting


______ is very common in MI due to vascular insufficiency of the SA node

Sinus bradycardia (does not present with cannon A waves)

________ will have cannon A waves

Third degree (complete) AV block i.e. atria and ventricles are pumping independent of each other.

RCA supplies (3):

RV


AV node


Inferior wall of the heart



This is why up to 40% of people with inferior wall MI will have RV infarction

Treat RV infarctions with _____



Avoid ______ to RV infarction

high volume fluid replacement



Nitroglycerin (worsen cardiac filling)

Most accurate test for valve and septal rupture

Echocardiogram

Most likely diagnosis



a) IWMI in history, clear lungs, tachycardia, hypotension with nitroglycerin


b) New murmur, rales, congestion


c) New murmur, increase in oxygen saturation on entering the right ventricle


d) Sudden loss of pulse, JVD

a) RV infarction


b) Valve rupture


c) Septal rupture


d) Tamponade/ wall rupture

ACEI are best for ____ wall infarctions because of the high likelihood of developing systolic dysfunction

Anterior wall infarction

Post infarction routine meds:
Everyone should go home on (4):

Aspirin


BB (e.g. Metoprolol succinate)


Statins


ACEI or ARBS if intolerant to ACEI


In CHF, ___ gallop may be heard

S3


S3 appears right after S2


S4 appears right before S1

Dyspnea, What is the most likely diagnosis?


a) Sudden onset, clear lungs


b) Sudden onset, Wheezing, increased expiratory phase


c) pallor, gradual over days to weeks


d) Pulsus paradoxus, Decreased heart sounds, JVD

a) Pulmonary embolus


b) Asthma


c) Anemia


d) Tamponade



All of these will lack a) Orthopnea/PND b) S3 gallop

Systolic Heart Failure (EF < 40%) . What is the pharmacological treatment?

ACEI for all patients [A*].
BB for all patients except those who are hemodynamically unstable, or those who have rest dyspnea with signs of congestion.
Aldosterone antagonist (low dose) for patients with rest dyspnea or for symptomatic patients who have suffered a recent myocardial infarction
Isosorbide dinitrate-hydralazine combination for symptomatic HF patients who are African-American [A*].


Loop diureticsInitial therapy of CHF w/ LEF is loop diuretics in combinations with ACEI or ARBs:



Digoxin only for patients who remain symptomatic despite diuretics, ACE inhibitors and beta blockers or for those in atrial fibrillation [A*].






Systolic Heart Failure: What are the devices (2)?

1. Implantable defibrillators: For pts with EF < 35



2. Bi-ventricular pacemakers considered for patients requiring defibrillators who have
symptomatic HF and QRS durations ≥ 120 msec

Which therapies provide mortality benefit in Systolic dysfunction? (5)

ACEi/ ARBs


BB


Spirinolactone


Hydralazine/nitrates


Implantable defibrillator

Heart failure with preserved EF -


a) What treatments are clearly beneficial


b) what treatments are clearly not beneficial

a) BB and Diuretics


b) Digoxin and spirinolactone



Uncertain: ACEi, ARBs, hydralazine

Acute Pulmonary Edema may cause this acid base disturbance? _________ ?
alkalosis - due to hyperventilation

If acute pulmonary edema is due to arrhythmia than ________ is the fastest way to fix it

cardioversion

The best initial therapy in the management of patient with Acute Pulmonary Edema is (4)?
Preload Reduction:
Oxygen
Loop diuretics
Morphine
Nitrates

Right sided valvular arrhythmias _______ in intensity with inhalation



Left sided valvular arrhythmias ______ in intensity with exhalation.

Increase. Inhalation will increase venous return to the right side of the heart.



Increase. Exhalation will squeeze blood out of the lungs and into the left side of the heart

a) Treatment of all valvular diseases requires _____


b) Correction of mitral stensosis requires ___


c) ____ is the MCC of mitral stenosis


d) Critical narrowing is defined as valve surface area < _____ cm^2.

a) Diuretics


b) dilation with a balloon


c) Rheumatic fever


d) 1 cm^2

What is the presentation of Mitral Stenosis

Mitral stenosis usually presents in young adult patients:


1. Shortness of breath and CHF is a/w all forms of valvular heart disease


2. Dysphagia from LA pressing on the esophagus - LA Hypertrophy


3. Hoarseness - LA pressing on laryngeal nerve


4. Atrial fib (very common) and stroke from enormous LA


5. Hemoptysis


6. Mid Diastolic murmur - just after opening snap. Increased S1 sound


7. Squatting and leg raising increases intensity due to increased venous return to the heart

1. What are the common EKG findings in Mitral Stenosis



2. What are the late findings of MS after pulmonary HTN has indued?

1. - Atrial rhythm disturbance esp. atrial fibrillation


- Left atrial hypertrophy -shows up as biphasic P wave in leads V1 & V2



2. Increased P2 heart sound

What is the presentation of Aortic Stenosis

AS is usually due to congenital bicuspid valve or with increased calcification due to aging



Angina: most common presentation


Syncope:


CHF: poorest prognosis with 2 year average survival

Describe the murmur in AS?



What maneuvers decrease the intensity?

a) Systolic, crescendo-decrescendo murmur peaking in a diamond shape in mid-systole.



b) Valsalva and standing decrease the intensity due to decreased venous return to the heart


Handgrip softens the murmur because of decreased ejection of blood

1. What are the EKG findings of AS?



2. What is the treatment for AS

1. LVH. S wave in V1 plus an R wave in V5 greater than 35 millimeters



2. Valve replacement

Whats the etiology of Mitral Regurg?

HTN, Endocarditis, myocardial infarction with papillary muscle rupture or any other reason that the heart dilates will lead to MR.

1. Describe the murmur in MR?



2. What happens to the murmur in MR with


a) Handgrip


b) Squatting and leg raising


c) Expiration

1. Pansystolic (holosystolic) obscuring both S1 and S2


The murmur of MR radiates to the axilla


2. Handgrip worsens because more blood is pushed backwards through the valve. Handgrip increases afterload and worsens the murmurs of both aortic regur and MR.


Squatting and leg raising also worsen the murmur due to increased venous return


Expiration worsens/increases the murmur

What is the treatment for mitral regurg?

1. Vasodilators: ACEi or ARBs. Decrease the rate of progression of regurgitation lesion



2. Digoxin and diuretics:



3. Valve replacement is indicated when the heart starts to dilate.

What is the indication for valve replacement in MR?

1. LV End Systolic Diameter (LVESD) above 40 mm


2. EF < 60%

Etiology of Aortic Regurg

AR is caused by anything that makes the heart or aorta dilate in size:


- MI


- HTN


- Endocarditis


- Marfan syndrome or cystic medial necrosis


- Inflammatory disorders e.g. ankylosing spondylitis or Reiter syndrome


- Syphilis

What are the physical findings of Aortic regurg (5)?

Besides CHF, AR has the following physical findings:
-
Wide pulse pressure


- Water-hammer (wide, bounding) pulse


- Quincke pulse (pulsations in the nail bed)


- Hill sign (BP in legs as much as 40 mm Hg above arm BP


- Head bobbing (de Musset sign)

Describe the murmur in Aortic regurg

AR gives a


- diastolic


- decrescendo murmur


- heard best at lower left sternal border

Describe the effect of the following on the murmur or AR?


a) Valsalva and standing


b) Handgrip

a) Valsalva and standing improves the murmur


b) Handgrip increases afterload by compressing the arteries of the arm makes it worse


Note: Standing or Valsalva has same effect as diuretic use


Amyl Nitrate is a direct arteriolar vasodilator and stimulates the effect of ACEi/ARBs on the heart. Any valvular ds that is treated ACEi will improve with amyl nitrate.


Therefore, Amyl nitrate = ACEi = Emptier LV

Treatment of Aortic regurg?

1. ACEi or ARBs as vasodilators will increase forward flow of the blood and delay progression



2. Digoxin and diuretics have little benefit



3. Surgical valve replacement

What is the indication for surgical valve replacement in AR?

EF < 55% or



Left Ventricular End Systolic Diameter greater than 55m



In MR


1. LV End Systolic Diameter (LVESD) above 40 mm


2. EF < 60%

What is the presentation of Mitral Valve Prolapse

MVP is usually asymptomatic


Symptoms of CHF are usually absent.



The most common presentation is:
- Atypical Chest pain


- Palpitations


- Panic attack

Describe the murmur of MVP.

- Midsystolic click


What is the effect of the following on MVP murmur?


a) Valsalva and standing


b) Squatting or handgrip

a) Valsalva or standing decrease venous return to the heart and worsens MVP



b) Squatting or handgrip increases LV chamber size Improve or diminish the murmur of MVP.

What is the treatment of MVP?

BB are used when the patient is asymptomatic



Surgical repair of the valve is rarely necessary.

What is the presentation of Cardiomyopathies (4) ?

All cardiomyopathy present with


- SOB


- Edema ,


- Rales, and


- JVD


Which murmurs do no increase with expiration (2) ?



What is the effect of handgrip in these two conditions?

1. Hypertrophic obstructive cardiomyopathy (HOCM)


Mitral Valve Prolapse (MVP)



Because less blood decreases all murmurs except MVP and HOCM.



2. Handgrip decreases ventricular emptying by increasing afterload. This will improve the lesions of MVP and HOCM.


Amyl nitrate worsens these two lesions, because it causes an emptier heart.


Dilated Cardiomyopathy can arise due to (6):

1. MI and ischemia


2. Alcohol


3. Post viral myocarditis


4. Radiation


5. Toxins such as doxorubicin


6. Chagas disease

What is the treatment of Dilated Cardiomyopathy?

1. ACEi or ARBs


2. BB such as metoprolol or carvedilol


3. Spirinolactone


4. Diuretics and digoxin are used to control symptoms


5. Biventricular pacemaker if QRS >120 ms

What worsens Hypertrophic Obstructive Cardiomyopathy (HOCM)

Worsened by anything that decreases LV chamber size:


- ACEi or ARB


- digoxin


- hydralazine


- Valsalva and standing suddenly

______ may help in Hypertrophic cardiomyopathy (HCM) but is contraindicated in Hypertrophic obstructive cardiomyopathy



_____ is the best initial therapy for both HOCM and ordinary HCM.

Diuretics



BB



Note: Negative inotropic agents like verapamil and disopyramide can also be helpful.

1. _____ motion of the mitral valve is classic for HOCM, causing obstruction



2. ____ waves in the inferior and lateral leads are common in HOCM. They are not common in MI.



3. (T or F) Giving Digoxin and Spirinolactone is always wrong in hypertrophic cardiomyopathy


1. Systolic anterior motion of the mitral valve



2. Septal Q waves



3. True

What is the major therapeutic difference between HCM and HOCM?

In HOCM, ACEi and diuretics do not help.

What is the etiology of Restrictive cardiomyopathy?

The heart neither contracts nor relaxes normally because it is infiltrated with substances creating immobility. Causes are:


- Sarcoidosis


- Amyloidosis


- Hemochromatosis


- Endomyocardial fibrosis


- Scleroderma

What is the presentation of Restrictive Cardiomyopathy

Dyspnea is the most common complaint w/ signs of Right Heart Failure (JVD, Ascites, edema, and hepatosplenomegaly)



Pulmonary HTN is common because of an increase in wedge pressure



Kussmaul sign, an increase in jugulovenous pressure on inhalation is common.

1. The pain in pericarditis is _____ by lying flat and _____ by sitting up.


2. EKG in pericarditis shows ST _____ in _____ leads. and the most significant finding is ____.

1. worsened, improved



2. Elevation in all leads, PR segment depression



Note: Most common cause of Pericarditis is idiopathic and these cases are generally presumed to be viral in etiology with Coxsackie B virus. These cases treated with NSAIDs.

What is the EKG presentation of Pericardial Tamponade

1. Electrical alternans (Diff heights of QRS complexes b/w beats


However, EKG often shows nothing except sinus bradycardia.

What is the tx for Pericardial Tamponade

Pericardiocentesis


IV Fluids



Note: Diuretisc will decrease intracardiac filling pressure and may worsen the collapse of the right side of the heart.

What is the most likely diagnosis given:


- Edema


- Ascities


- Hepatosplenomegaly


- JVD



Constrictive Pericarditis is a combo of Physical findings + calcification on CXR



In this patient, Kussmaul sign: increase in JVD on inhalation (Normally the neck veins should go down on inhalation)

What is the most likely diagnosis given:


- Hypotension


- Tachycardia


- Distended neck veins


- Clear lungs

Pericardial tamponade.



What is the best initial test in constrictive pericarditis



2. What is its treatment

1. CXR - shows calcification and fibrosis



2. Diuretics - used first to decompress the fillings of the heart and relieve edema and organomegaly



Surgical removal of the pericardium

1. Leg pain in the calves on exertion, occurs when walking up or down hills.



2. What is the best initial test?

1. Peripheral artery disease: causative factors include DM, Hyperlipidemia, HTN, Smoking


Note: Spinal stenosis pain is worse when walking down hill



2. Ankle-brachial index (ABI). - ratio of BP in ankles to the brachial arteries. If difference b/w > 10% i.e ABI less than 0.9 then disease is present.



3. Aspirin, Smoking cessation, Cilostazol. (Cilostazol is the single most effective medication.



1. In AAA, the most important step in initial treatment is ______ and its done by giving ___ and ____.



2. In AAA, the aneurysm needs to be > ___ cm to require surgical correction

1. BP, BB and nitroprusside. BB must be given before nitroprusside to protect against reflex tachycardia.



2. Aneurysm > 5cm

Tx for peripartum cardiomyopathy?

Same drugs asmused for dilated cardiomyopathy
ACEi/ARBs, BB


Spirinolactone


Diuretics


Digoxin


Peripartum cardiomyopathy develops after delivery in most cases, thats why ACEi/ARBs are ok to use. After Peripartum cardiomyopathy, Eisenmenger syndrome is worst cardiac disease of pregnancy.

1. Fever, pericarditis, and increased ESR 2-4 weeks post-MI. Dx?



2. Most common valvular ds?



3. Pansystolic murmur, heard best at apex, radiates to the axilla. Whats the best tx.

1. Dressler syndrome



2. MVP. Often asymptomatic



3. Mitral regurg - valvel repair is the best option when EF < 60%

1. The most accurate test to determine a patients systolic function is _____



2. Tx of costochondroitis?



3. ___ is the most common presentation of patients with Hypertrophic obstructive Cardiomyopathy. Define the murmur?

1. MUGA scan (multigated acquisition)



2. NSAIDs and rest



3. Shortness of breath.


S4. Harsh Crescendo-Decrescendo murmur at the apex which gets louder with Valsalva and better with squatting.

1. Which drugs have shown to reduce mortality in patients who have CHF?



2. (T or F): Diabetic retinopathy is an absolute Contraindication to the use of thrombolytics?



3. Treatment of LV dysfunction resulting in pulmonary edema?

1. ACEI or ARBS , Spirinolactone, and BB


2. True



3. Dobutamine.


- Reduces afterload and is a positive inotropic.

1. What is De Musset sign?



2. A large c-v wave is seen in this murmur?



3. T or F: Post MI, in pt with normal EF, ACEI are more efficacious than BB?

1. Head bobbing seen in pts with Aortic regurg due to increased pulse pressure



2. Tricuspid regurg



3. Post MI with preserved EF, BB are more effective. ACEI improve survival in post MI pts when the EF < 40. However, in low EF both BB are ACEI are equally effective.

1. ___ is the best way to reduce BB in pts with aortic dissection


2. A boot shaped heart on Xray is seen in___ (2)?

1. Labetolol


2. Tetralogy of fallout, HOCM

MI AND EKG



1. Earliest evidence of myocardial injury?


2. Followed by?


3. What is the latest EKG finding of an MI?


1. Hyperacute T waves


2. Elevation of ST segments, inversion of T waves


- followed by return of ST segment to normal


3. Development of Q waves

1. ___ is the TOC for idiopathic hypertrophic sub aortic stenosis


1 (b) its murmur intensity is ______ by valsalva maneuver?

1. BB - slow ventricular rate allowing more filling time.


1 (b) increased. Valsalva decreases the flow of blood to the LV, which increases the intensity of the murmur



This presents w/carotid upstroke with double impulse palpable. There is a loud S4 and a harsh systolic murmur heard along the left sternal border

1. Amiodorone _______ (inhibits, accelerates) warfarin metabolism?


2. Anke-brachial Index(ABI) < ____ is an indication for surgery


3. TOC for HOCM?

1. Inhibits


2. <0.4


3. BB or CC- Have a negative inotropic effect.


HOCM presents with harsh crescendo-decrescendo murmur


HOCM is an autosomal dominant disorder characterized by asymmetric hypertrophy of the LV.

1. ____ is the MCC of non-thrombocytopenic purpura in children.

1. HSP

PSVT


1. What is the treatment for AV re-entry type of Paroxysmal Supraventricular tachycardia as found in WPW?


2. What are the ECG findings of PSVT?


3. First line medical management of pt w/ PSVT?


4. PSVT w/ AV nodal reentry + hemodynamically stable


5. PSVT w/ AV nodal reentry + NOT hemodynamically stable

1. AV reentry as found in Wolff-Parkinson White syndrome is Rx: Amiodorone or Procainamide (type 1A or 1C antiarrythmiac)



2. P waves hidden in T waves; 150-250 bpm HR; normal QRS


3. Vagal maneuver


4. AV nodal reentry with hemodynamic stability: Rx w/ BB or CCB


5. AV Nodal reentry NOT hemodynamic stablity: Rx w/ Cardioversion or adenosine

MAT


1. How do you diagnose Multifocal atrial tachycardia in EKG


2. How do you treat it? Acutely and long-term?

1. Variable morphology of P waves at least 3 diff. This is due to the P waves originating from differing foci.



2. BB or CCB(Verapamil or diltizem) acutely. BB Preferred. Keep K > 4 and Mg > 2 may be curative.
Catheter ablation or surgery to eliminate abnormal pacemakers.

1. What is the treatment of BB induced bradycardia or verapamil induced bradycardia(4) ?



2. What is the tx for PVC (2(b)): What is the ECG finding?



3. When do PVC become concerning? How do you define a V-Tach?

1. Atropine, Ca, Glucagon, Insulin w/glucose


2. Tx: none if pt is healthy;


BB or amiodorone in pts with CAD


ECG: early and wide QRS (wide b/c ventricular) w/o preceding P wave


followed by brief pause in conduction


3. PVC become concerning when > 3 PVC in a minute


VTach = > 3 PVC in a row

1. What are the pansystolic murmurs


2. What are the Crescendo decrescendo murmurs?


3. What are the early diastolic murmurs?


4. Mid-late diastolic murmur?


5. Which murmur may cause syncope?

1. Mitral and tricuspid regurg.


2. Aortic and Pulmonic Stenosis


3. Aortic regurg (decrescendo), Late diastolic murmur (Austin flint)


and Pulmonic regurg


4. Mitral Stenosis (heard at apex) - opening snap after S2


5. Aortic stenosis

1. What is Beck's Triad?



2. Diabetes, HF, elevated LFT?

1. Cardiac tamponade


- Hypotension


- distant heart sounds


- JVD



2. Hemochromotosis

Cardiomegaly, Megaesophagus, Megacolon

Chagas disease

Jones criteria for Rheumatic heart ds?

Joints


Heart (Pancarditis)


Nodules (subcutaneous, extensor surfaces)


Erythema nodosum (painless rash)


Sydenham chorea

MVP w/ regurg: Is abx prophylaxis required?

Yes. Not required if MVP w/o regurg.

Negative culture endocarditis can result from these bacteria (5)?

HACEK:


Hemophilus,


Actinobacillus


Cardiobacterium


Eikenella


Kingella

What is the tx for infective endocarditis?

Long Term IV Abx


- Gentamycin + Ceftriaxone


OR


- Gentamycin + Vancomycin

_____ is the first HTN medicine prescribed unless comorbid condition says otherwise?

Thiazides

Non-dihydropyridine CCB are: _______ and ______ and they work at ________

Diltiazem and Verapamil



Heart

Dihydropyridine CCB are: (5) ?

nifedipine


amlodipine


Felodipine


Nicardipine


Nisoldipine



Act as vasodilators at the veins

For Prinzmetal angina and esophageal spasms use _______ CCB

Dihydropyridine

Hydralazine works on the ______

Arterioles

What the effect of ACEI on Preload and Afterload?

Decreases both preload and afterload

Hydrazaline's effect on preload and after load?

Decreases afterload only.



- Thats why Hydralazines are often given with nitrates so that both preload and after load are decreased.

Nitroprusside: where does it work? Whats the main SE?

Both arteries and veins



SE = Cyanide toxicity

Whats the effect of ACEI on GFR?

Decreases GFR ==> therefore slight increase in BUN and Cr

What is the effect of ACEI and ARBs on fetus?

Damages kidneys

What HTN meds can be given in pregnancy?

Labatalol


M-dopa


Hydralazine


Nifedipine



Can't give: Thiazides(relative CI) , ACE and ARB

What's the definition of HTN Urgency?

BP > 200/120 w/o systemic signs of end organ damage


Pressor of choice for cardiogenic shock?

Dobutamine - B1 effect

Whats the mechanism of Septic shock

Decreased TPR

Whats the pressor to use for Septic shock?

Norepi

What's the pressors used in Neurogenic shock?

Dobutamine or Atropine


What's the limitation guidelines for IVF in neurogenic shock?

Stop giving once MAP = 85 to prevent spinal cord swelling

HTN, Kidney stones, depression,

Hyperparathyroidism

Pt comes with pulsatile abdominal mass, whats the next step?

Ultrasound

What are the screening guidelines AAA?

If confirmed AAA, screen every 6 months if < 5 cm in diameter.



All males btw 65-75 yo and hx of smoking

What is the indication for surgical repair in AAA?

If symptomatic


>5.5cm in diameter


Increase in size > 0.5cm in a 6 month period

DOC for Aortic dissection?

BB are DOC.


Also, nitroprusside.

What are the categories of Aortic dissection?

Stanford A: Involves ascending aorta


Stanford B: Distal to subclavian


What is the indication for surgery for Aortic dissection?

Stanford A dissection

What labs are used for PVD/PAD (Peri Art ds)?

Ankle brachial index (ABI)


ABI < 1 = vascular insufficiency


ABI < 0.4 = severe disease (frequently seen in resting pain)

What Rx are given in PVD/PAD?



Cilostazol (Makes RBC more pliable. CI= HF pts)



Pentoxifylline (Cilostazol is better)

What is Virchow's triad for DVT?

Blood stasis


Hypercoagulability


Vascular damage



These increase patient's risk of DVT

Half of patients with Temporal arteritis also have this condition?

Polymyalgia rheumatica

Any patient on Steroids for more than 3 months should be taking ____, _____, and ______.

Ca, Vit D, prophylactic bisphosphonate

Churgg-Strauss, what ab are positive?

p-ANCA

Asthma is a/w with which vasculitis?

Churgg-Strauss (allergic angiitis)


- will show eosinophilia

Vasculitis: biopsy of vessel shows plasma cells and lymphocytes in media and adventitia. Dx?

Takayasu's arteritis


- Inflammation of aorta and its branches

Upper resp tract infection, arthritis, palpable purpura, abdominal pain with possible bleeding, renal disease? Dx?

Henoch Schonlein Purpura aka


anaphylactoid purpura, aka


purpura rheumatica



IgA deposition in renal biopsy.

Fever >104 + 4 of the following 5 sx:


1. Conjunctivitis (bilateral, painless)


2. Rash (truncal)


3. Adenopathy (of cervical lymph nodes)


4. Strawberrty tongue


5. Hands and feet (edema, erythema or desquamation


Dx = ?

Kawasaki disease



Note: commonly in young children


coronary vasculitis seen in 25% of patients

Which congenital heart defect?


a) Wide fixed S2


b) Pansystolic murmur at lower left sternal border, Loud pulmonic S2, systolic thrill


c) Machine murmur


d)Harsh systolic murmur at lower left sternal border, Loud S1 and S2, bounding pulses

a) ASD


b) VSD


c) PDA


d) Persistant truncus arteriosus

Which congenital heart defect requires abx?

ASD

Most common cyanotic heart disease?

Tetralogy of fallot

Boot shaped heart on Xray?

Seen in right ventricular hypertrophy


e.g TOF


What are Q wave infarction?

Involves full thickness of the myocardium

Contraction band necrosis seen in _____

Reperfusion injury

In AMI:


a) ______ is present within 12-24 hours


b) ______ is present 1-3 days


c) Heart is softest from days ___ to ____ post MI


a) Coagulation necrosis


b) Neutrophils


c) Softest from days 3-7

_____ is MCC of death in acute MI

V-fib

Autoimmune pericarditis develops in _____ weeks following an MI

6-8 weeks



- Fever and precordial friction rub are present

When ventricular aneurysm following an MI detected ?

Within 4-8 weeks.


- Begins developing in the first 48 hours

What is the histological finding of myocarditis due to coxsackie

Lymphocytic infiltrate with focal areas of necrosis

____ is the most consistent sign of endocarditis

Fever

MCC of myocarditis

Coxsackie virus

____ form of Trypanosoma Cruzi infect cardiac muscle

amastigotes - w/o flagella



- Trypanosomes (w/ flagella) circulate in blood

Fever


Chest pain


Pericardial friction rub
Biventricular heart failure


Heart murmur - Mitral regurg most common



Dx = ?

Myocarditis

MCC of pericarditis

Coxsackie

Young with pericarditis and effusion. Most likely dx?

SLE

MCC of Constrictive pericarditis in the U.S.

Idiopathic


2/2 scarring from previous open heart surgery

1. MCC of dilated cardiomyopathy



2. What are the other causes of dilated cardiomyopathy

1. myocarditis - MCC



2. - Alcohol 2nd most common cause (15-40%)


- Drugs - doxorubicin, daunorubicin, cocaine


- Post partum state - Last trimester or within 6 months post partum


- Organic solvents - e.g. sniffing glue


- Acromegaly


- Myxedema heart in severe hypothyroidism

Most common cardiomyopathy

Dilated

MCC of sudden death in young individuals

Hypertrophic cardiomyopathy

What drugs should be avoided in HCM

Drugs that decrease preload


- Diuretics


- Positive inotropics (Digitalis)

Tx for HCM

BB

_____ is the Most common site for tumor metastasis to the heart

Pericardium

MCC of primary heart tumor in adults is ______and 90% arise from the _____

cardiac myxoma


LA

MCC of primary heart tumor in children is ____ and is often a/w _______

Rhabdomyoma


tuberous sclerosis

MCC of secondary pulmonary HTN

COPD

Whats the definition of Pulmonary HTN?

At Rest: Mean Pulmonary Artery Pressure > 25mm Hg



With Exercise: Mean Pulmonary Artery Pressure > 25mm Hg

XRay findings in Pulmonary HTN

Enlargement and tapering of Pulmonary arteries


Right heart dilatation


ECG findings of Pulmonary HTN

Right axis deviation and


RV hypertrophy

MCC of aortic regurg

Infective endocarditis

Indication for dopamine

To correct hypotension IF induced after administration of dobutamine.


- Dobutamine reverses afterload, which may occur so drastically to cause severe hyptotension


- Dopamine reverses hypotension through its pressor effects ---> increasing after load

Indication for MUGA scan

- To determine EF in patients who present with s/s of CHF


- To determine baseline LV fxn before chemo or radiation


- To evaluate COPD pt for CAD



Basically when echo is inconclusive for EF

Pt with Pulmonary edema due to HF. Furosemide, nitrates and morphine don't work. What's the next step

Hydralazine


- Smooth muscle relaxant working on arteries and arterioles


- Reduces afterload ---> improves CO

Indications for CABG

1. 3 or more stenotic vessels


2. Diabetic pt and more than 2 vessels involved


3. Left main coronary artery involved



Stenotic --> Greater than 70% occlusion

Pt is a cocaine user, what rx MUST NOT be given?

BB - can cause severe HTN

Short PR inteval


Widening of QRS


Delta wave



Dx = ?


Tx = ?

Wolff Parkinson White Syndrome



Tx = Procainamide or Amiodorone (if hemodynamically stable)


Synch. cardioversion (if not hemo. stable)



Definitive Tx = radio-ablation

What drugs must be avoided WPW syndrome?

1. Digoxin, BB, CCB(e.g. diltiazem)

Mid-diastolic rumble heard best at apex

- MS



- Atrial myxoma may also cause this. Remember pieces of myxoma may get embolized


MCC of diatolic heart dysfunction

Chronic HTN ---> Concentric hypertrophy

1. 1st line tx for pulmonary edema 2/2 Acute CHF



2. What if no relief in sx after tx in (1)

1. IV loop diuretic


Nitrates


Morphone



2. Add Dobutamine



Hydralazine if no response to Dobutamine as well and adequate BP

Most effect 1st line tx for diastolic HF

BB

Muffled heart sounds, Pulsus paradoxes, hypotension.



Dx?

Cardiac tamponade

Murmur of HOCM?

Either S4 or


Harsh crescendo-decrescendo murmur

Most common anatomic feature in patients with a-fib is _____

Enlarged LA


- Dilated LV is also commonly seen in pts with AFib and CHF

Hypotension


Equilization of pressure in all chambers of the heart (near PCWP)


Narrow pulse pressure



a) Dx


b) Tx

a) Cardiac tamponade



b) Pericardiocentesis

Indications for Aortic Valve replacement

- Symptomatic Severe AS


- Severe AS in pts who are undergoing CABG or other valvular repair


- Severe AS with LVEF < 50%

After cardiac cath. via femoral arterty, pt develops pulsatile mass, femoral bruit, and compromised distal pulses.



Dx = ?

Femoral pseudoaneurysm

______ is a PDE antagonist which suppresses platelet aggregation and is a direct arterial vasodilator.


It is indicated in the medical management of intermittent claudication especially if anti-platelet agents and exercise therapy have been ineffective and revascularization cannot be offered.

Cilastozol

Vascular embolectomy is indicated in patients who have _____

Arterial thrombosis

In patients being treated for DVT, what is the target INR?

INR 2-3

Pts with DVT remain on anticoag for ______ months

3-6 months

Varying P-wave morphology in 3 or more leads


Varying P-R intervals


Most often related to severe COPD



a) Dx


b) Tx

a) Multifocal (Chaotic) Atrial Tachycardia (MAT)



b) Check O2 sat, then



Non-dihydropyridine CCB


- e.g. Verapamil or Diltiazem

How is STEMI diagnosed

- ST elevations > 1mm in two contiguous leads


- New onset LBBB

How is NSTEMI diagnosed

- Chest pain at rest, new onset


- Elevated cardiac enzymes


- No ST elevations

After angioplasty and stent placement what Rx is given?

Glycoprotein IIb/IIIa inhibitor


- e.g Abciximab or tirofiban



- Given during and after stent placement


- IV drug


- Given along with heparin and ASA

Pt has been diagnosed with NSTEMI, that occurred about one hour ago. What is the next step?

Coronoary angiogram


- to determine if pt needs PTCA or CABG



Note: TPA has not proven benefit in NSTEMI


TPA can be used for STEMI

Pansystolic murmur maximum at the apex

MR

Crescendo, Decrescendo systolic murmur in precordial regino

AS

Syncope after emptying a distended bladder or after prolonged coughing

Reflex syncope

Syncope usually in young adults. Pain, apprehension, emotional shock are the usual triggers

Vasovagal syncope

Beaded appearance of renal artery in angiograph

Fibromuscular hyperplasia

1. Tx for Malignant HTN


2. Tx for Malignant HTN in pt with renal insufficiency



3. Malignant HTN + s/s of ischemic heart ds

1.IV Nitroprusside, or


Labetolol - rapid onset of action <5 min


- no effect on heart rate


- avoid in COPD, asthma, HF, bradycardia


2. IV Fenoldepam



3. IV nitroglycerin

1st step in the management of patients with ACS

Aspirin 325 mg

What is the cardinal sign of cardiac tamponade

Pulsus paradoxus


-Decrease in systolic BP > 10 on inspiration

ACS due to STEMI.



1) Within in 90. tx?


2) Initial tx of patient with ACS


3) Alteplase, mech of action?


4) If > 90 mins

1. Revascularization. Angio + stent



2. ASA, Sublingual nitrates, IV morphine



3. Thrombolytic



4. Thrombolytics, ASA, LMWH

1. Pts who have CHF (Systolic or diastolic) are initially tx with?



2. What if pt continues to have SOB, and low-mod BP?

1. O2, Morphine, nitrates, IV furosemide



2. Add dobutamine

T or F: Digoxin no longer used in acute CHF

True

Indications for intubation (3)

1.Inability to oxygenate (SO2< 90, PaO2 < 55)



2. Inability to ventilate (increased PaO2, Resp acidosis, mental status change)



3. Pt unable to protect airway

Imbalance of this electrolyte may result in digoxin toxicity

Hypokalemia

1. What antibodies can be checked for group A strep (3)



2. Which of these is the most sensitive and specific

1. Anti-DNase B ab


Anti-Streptolysin O


Anti-hyaluronidase




2. Anti-Dnase B ab


Variant angina presents with transient ST _____ and occasional flipped T waves

Elevation

What is the goal of therapy for Malignant HTN

The initial goal of therapy is to reduce the mean arterial pressure by approximately 25% over the first 24-48 hours.

What constitutes Tetralogy of Fallot

1. Pulmonary Stenosis


VSD


Dextraposition of the aorta


Right ventricular hypertrophy

_______ is the most useful test in Dx Pericarditis

ECG

Pt with suspected ACS. Next step will be an echocardiogram under which conditions (4) ?

These conditions make an ECG difficult to interpret:


1) LBBB


2) Previous MI


3) Pacemaker


4) Digoxin

Pulmonary regurgitation causes a ______ murmur which gets ________ with inspiration

Diastolic murmur


Louder



- Decreases with valsalva

ST elevation in leads: Give the artery and area of heart



a) V2, V3, V4


b) V1, V2, V3


C) aVL, V5, V6


d) II, III, aVF


a) LAD, Anterior wall of LV


b) LCA --> LAD --> Septal branch, Ant 2/3 of IV Septum


c) LCA--> Circumflex branch,


LA, Lateral wall of LV, Posterior wall of LV


d) RCA --> Posterior descending br (80%)


Inferior wall of LV, Post 1/3 of IV septum

Name the GP IIb/IIIa inhibitors

Abciximab


Tirofiban


Eptifibatide

Pt presents with chest pain suggestive of ACS. What drugs be given immediately

MONA:


- Morphone


- Oxygen


- Nitrates


- Aspirin

Thrombolytics are given for ______ and GP IIb/IIIa are given for _______

STEMI - thrombolytics should be given w/in 12h


NSTEMI -

Fever, Pericarditis, Increased ESR 2-4 weeks post MI. Dx?

Dressler syndrome