Usmle Step 3 Cardiology Review

Front 1

Septic Shock

Back 1

Infection / Hypotension / Tachycardia / Tachypnea
Decreased sats
Increased capillary permeability
Pulmonary a. cath shows?

Hint 1

CO variable; PAWP: High/normal
SVR: low (<900dynes/cm2)

Front 2

Cardiogenic Shock

Back 2

Hx of MI, CAD, HLD

Hint 2

Low CO
High PAWP (RAP)
High SVR (compensates for dec CO)

Front 3

Hypovolemic shocck

Back 3

Decreased circulating blood

Hint 3

Low CO
Low PAWP (unique)
High SVR

Front 4

Extracardiac obstructive shock

Back 4

tamponade, tension pneumo, massive PE

Hint 4

Low CO
Normal/high PAWP
High SVR

Front 5

Vascular surgery risks

Back 5

MI (esp if DM, HTN, prior MI)

Front 6

Vascular Claudication - management?

Back 6

Measure ankle/brachial index. If < 1.0, peripheral artery disease is present.
1. Exercise/Diet modification
2. Cilostazol - phosphodiesterase inhibitor
3. Vascular surgeon consult
4. Percutaneous transluminal angioplasty if surgery is not option.

Front 7

Pericardial Tamponad

Back 7

SUSPECT!
Beck's Triad: Hypotension, Faint heart Sounds, JVD
- May occur late, post MI

Front 8

Blood reactions

Back 8

Acute febrile hemolysis - due to ABO mismatch, presents w/erythema, nausea, pains

Hint 8

Delayed - 3-10days later, mild course w/fever and malaise

Front 9

Hemochromatosis / etiology and risks

Back 9

Auto recessive, HFE mutation which interacts w/transferrin and alters iron absorption;

Dx: Transferrin levels most sensitive test

Hint 9

Present in 40s/50s w/elevated transaminases and cirrhotic changes. Cardiomyopathy is 2nd most common, then Arthropathy and skin bronzing.

Front 10

VSD

Back 10

Harsh Systolic Thrill, Left Sternal Border; acyanotic; Often young (2month old); echo confirms dx. complications include pulmonary vascular obstruction, CHF; Smaller defects close spontaneously

Front 11

ASD

Back 11

Common acyanotic, left-to-right shunt, typically *asymptomatic*. Wide, fixed split S2; Pulmonary hypertension, arrhythmias, heart failure are associated

Front 12

Coarctation of aorta

Back 12

Upper body hypertension, lower body hypotension & weak pulses,

Front 13

PDA

Back 13

asymptomatic if small; wide pulse pressure, machinery like murmur, apical heave, thrill may all be present.

Hint 13

blood flows directly from aorta to pulmonary artery

Front 14

Mitral Regurgitation

Back 14

Holosystolic murmur radiating to axilla

Hint 14

Need TEE. If end-systolic ventricular dimension > 45-55mm, or if EF < 55% --> cardiac surgeon referral

Front 15

Kawasaki's - pres / tx

Back 15

CRASH and BURN
Conjunctiva
Rash
Adenopathy
Swelling
Hands and Feet (rash)
Burn = Fever (high and longer than 5 days)

Hint 15

Use high dose asprin and IVIG, get echocardiogram to r/o coronary aneurysms,etc

*Influenza vaccine needed w/in one month, if receiving IVIG (prevent Reye's syndrome)

Front 16

Post-MI Meds, Activity

Back 16

Asprin
Beta-Blockers

Hint 16

Avoid strenuous phys activity and sex 1-2 weeks.
Gradually resume aerobic exercise program after that.
Submaximal Gx test before d/c (optional)
Maximal Gx test 3-5 weeks post-MI

Front 17

Hyperlipidymia Treatment
LDL
HDL
TGs

Back 17

LDL: statins
HDL: #1 nicotinic acid, gemfibrozil, statin (ranked)
TGs: nicotinic acid / fibrates
(target TGs if over 200, w/fibrates)
diet lowers HDL and LDL; Exercise may increase HDL;

Front 18

LDL
risk factors,
goals

Back 18

Risk Factors:
smoking
HDL < 40
hx of MI < 55 in 1st degree
M > 45, F > 55

Hint 18

1 or less: 160; statin at 190
2 or more: 130; 160;
CHD equiv: 100; 130;

Front 19

Potassium Sparing Diuretics

Back 19

Spironolactone
Amiloride

Front 20

Conn Syndrome

Back 20

Secondary hypertension from hyperaldosteronism, adrenal tumor.
Dx w/imaging of abdomen

Front 21

A-fib
sx?
tx?

Back 21

Sx may be present: SOB, lightheadedness, nausea, syncope.

risk:mitral stenosis --> dilated LA

Hint 21

1. Control rapid ventricular response: CCB, BBs, Digoxin; can continue for two weeks w/anticoagulation, then pursue DC Cardioversion
2. If unstable: cardioversion (after TEE)
3. Always: Heparin(Warfarin)

cardioversion can be used in combo with dofetilide, ibutilide, flecainamide, amiodarone, propafenone;

Front 22

Temporal Arteritis

Back 22

HA/Vison Changes/Jaw claudication
Dx: clinical, ESR, Bx
Manage: START prednisone if high sus, don't wait!

Front 23

HOCM

Back 23

Systolic ejection murmur at RUSB, no resp variation, (+) going to standing & w/valsalva, (-) w/handgrip

Hint 23

Suspect in younger patient
- aortic outflow obstruction is dependent on both preload and afterload. As preload (-) w/valsalva or moving to erect, the murmur increases. When afterload (+) as w/sustained handgrip, the end systolic chamber size increases and outflow obstruction decreases along w/murmur intensity.

Front 24

AS

Back 24

Systolic Ejection Murmur; cardiac base or LUSB;
Valsalva decreases preload, which decreases murmur. Standing to sitting increases preload, increasing murmur.
Lightheadedness, decreased exercise tolerance, syncope, angina

Hint 24

Signs of left heart strain: downloping ST segments in I, AVL, V5-6; axis deviation to -60
Murmur increases w/increased preload
Valve area <0.7 is considered critical

Front 25

MR

Back 25

holosystolic murmur at apex radiating to axilla.

Hint 25

Increases w/increased afterload (handgrip)

Front 26

TR

Back 26

holosystolic murmur at LLSB, increases w/inspiration

Hint 26

Right sided flows are increased with more negative intrathoracic pressures (inspiration)

Front 27

Hypertension Cutoffs / workup

Back 27

Stage
1 - 140/90 --> thiazide
2 - 160/100 --> 2 drugs
remember, need TWO readings

Hint 27

Workup - if young (e.g. <40) and extremely high (e.g >150), look for secondary causes before initiating therapy

Front 28

Infective Endo Prophylaxis Indications

Back 28

Prosthetic heart valves or shunts
Hx of IE
unrepaired cyanotic congenital HD
transplanted heart

Front 29

Lead Poisoning

Back 29

Anemia, irritability, basophilic stippling, homes before 1950, or renovated homes in 60s or 70s;
- get lead level (>70 considered very toxic)
- Dimercapol / EDTA treatment /
- XR Abdomen for Pb in bowel - if present may require bowel decontamination

Front 30

Aortitis etiology

Back 30

Salmonella - any diseased portion
Syphillis - aortic bulb

Front 31

Pericardial effusion - sx/ dx

Back 31

SOB, Diminished heart sounds, electrical alternans (P and R wave variability), cardiomegaly on XR, and effusion visible on CT

Front 32

Reentrant v. tach

Back 32

Cardioversion (w/epi - better than lidocaine) if unstable
Rate control w/beta blockers if stable

Front 33

V-fib

Back 33

Unychronized cardioversion

Front 34

Pericarditis

Back 34

follows hx of infection; chest pain - mid-sternal and non-radiating, positional and pleuritic,
Diffuse ST elevation / PR depression w/ PR elevation in aVR

Front 35

Post-MI Meds

Back 35

Asprin
Beta-blockers
Statin
+/-CCB?

Front 36

DIC

Back 36

Low Platelet count
Elevations in PT / PTT

- thrombin values are not useful
- etiology: cancers, infections, anything

Front 37

Sarcoidosis

Back 37

multiple organ manifestations - easy bruising, hypertrophic heart w/speckled pattern, CHF w/restrictive pattern, proteinuria, BL carpal tunnel - etc.

Front 38

Dissecting Aortic Aneurysm

Back 38

Excruciating CP radiating to Back; CT scan.
Type A- Operate
Type B- Beta Blockers

Front 39

CHF Drugs to Improve Mortality

Back 39

Spironolactone, ACE-i, BetaBlockers,

Front 40

Variant Angina

Back 40

Substernal chest pressrure, spontaneous pain, hx of similar pain, ST changes (e.g. 1.5mm ST elevations in II,III, aVF);
TREAT w/ MONA +
* Calcium Channel Blockers *

Front 41

Coronary Syndrome

Back 41

NSTEMI, STEMI, Unstable angina

Front 42

NSTEMI

Back 42

EKG Changes other than ST elevation;
Asprin
Heparin
gp IIb/IIIa inhibitors (aciximab)
Beta Blockers

Front 43

Infective Endo tx

Back 43

Vanc if S.Aureus

Vanc, Gent, Rifamampicin for Prosthetic Valves