5. Cardiology Flashcards
(105 cards)
1
Q
Risk factors of MI ?
A
- DM. “Worst risk factor”
- Hyperlipidemia. “elevated LDL”
- HTN. “most common”
- smoking.
- Age (men>45, women>55)
- Family hx of premature CAD or MI in 1st degree.
- Low levels of HDL.
2
Q
Prognostic indicators of CAD ?
A
A. Left ventricular function (EF):
- Normal >50%.
- If <50%, associated with increased mortality.
B. Vessels involved (severity/extent of ischemia):
- LMA, poor prognosis coz it covers 2/3 of heart.
- 2 or 3 vessels or CAD, worse prognosis.
3
Q
Typical chest pain ?
A
- Characterized as discomfort/pressure rather than pain.
- Time duration >2 mins.
- Provoked by activity/exercise.
- Radiation (i.e. arms, jaw)
- Does not change with respiration/position.
- Associated with diaphoresis/nausea.
- Relieved by rest/nitroglycerin.
4
Q
Atypical chest pain ?
A
- Pain that can be localized with one finger.
- Constant pain lasting for days.
- Pain lasting for a few seconds.
- Pain reproduced by movement/palpation.
5
Q
The detection of ischemia on an ECG stress test is
based on presence of ?
A
- ST segment depression.
- or chest pain, hypotension or significant arrhythmias.
- Patients with a positive stress test result should undergo cardiac catheterization
6
Q
What is the definitive test for CAD?
A
Coronary angiography.
7
Q
Standard care for stable angina “ chronic coronary syndrome” ?
A
- Aspirin.
- B-blockers.
- only 2 above lowers mortality.
- Statin.
- Nitrates “for pain”
- Risk factors modifications .
8
Q
The distinction between USA and NSTEMI is based entirely on ?
A
- Cardiac enzymes.
- NSTEMI has elevation of troponin or CK-MB
9
Q
Treatment of acute coronary syndrome ?
A
- Aspirin (300 mg).
- Heparin. (LMWH or Enoxaparin)
- Ticagrelor 180 mg (P2Y12 inhibitors).
- O2 (if <95%)
- Morphine.
- Nitro (always check BP)
10
Q
What is the Thrombolysis in Myocardial Infarction (TIMI) Score ?
A
Is used to determine the likelihood of ischemic events or mortality in patients with unstable angina or non–ST-segment elevation myocardial infarction (NSTEMI)
11
Q
(TIMI) Score factors ?
A
- Hx:
- Age>65 -> 0-1.
- > 3 CAD risk fsctors -> 0-1.
- Known CAD -> 0-1.
- ASA use in past 7 days -> 0-1.
- Presentation:
- Severe angina (> 2 episodes in last 24 hrs) -> 0-1.
- ST changes -> 0-1.
- Positive cardiac marker -> 0-1.
12
Q
Ticagrelor use in post ACS ?
A
- 180 mg (P2Y12 inhibitors).
- for 12 months but depends on the type of stent. if drug stent -> 6 months.
13
Q
Complications of acute MI ?
A
- Pump failure (CHF).
- Arrhyrhmias.
14
Q
Transradial approach: Benefits ?
A
- Stay in bed not required
- Shortening of hospitalization
- Decreased costs of hospitalization
- Decreased risk of complication
- Lower need for blood transfusion.
15
Q
Transradial approach: Benefits
• Mainly useful in ?
A
– Peripheral artery disease
– Abdominal aorta aneurysm
– Obese people
– Blood clotting problems increased INR
16
Q
SYNTAX scale ?
A
Anatomical assessment of lesion in coronary areteries in patient with multivessel disease or with lesion in Left Main
17
Q
Risk factors of Restenosis ?
A
- Long lesion.
- Narrow vessel.
- Amount and lenght of implanted stents. (multiple stenosis).
- Inappropriate stent deployment.
- DM
18
Q
Stent thrombosis is ?
A
Sudden occlusion of previously treated vessel that usually leads to ST-elevation myocardial infarction.
19
Q
New York Heart Association (NYHA) Classification ?
A
- NYHA class I: nearly asymptomatic
- NYHA class II: symptoms after prolonged or moderate exertion.
- NYHA class III: symptoms occur with usual activities.
- NYHA class IV: symptoms occur at rest.
20
Q
Common Symptoms of Heart Failure ?
A
- Dyspnea on exertion
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Fatigue
- Lower extremity edema
- Cough, usually worse at night
- Nausea, vomiting, anorexia, ascites
- Nocturia
- Sleep disorders
21
Q
Common Physical Findings of Heart Failure ?
A
§ Elevated jugular venous pressure § Hepatojugular reflux § Displaced apical impulse § S3 gallop § Pulmonary rales § Hepatomegaly § Peripheral edema § Ascites § Signs of cardiac cachexia
22
Q
Tests to order for a new patient with CHF ?
A
- CXR (pulmonary edema, cardiomegaly, rule out COPD).
- Echocardiogram (estimate EF, rule out pericardial effusions).
- ECG.
- Cardiac enzymes (to rule out MI).
- CBC (anemia).
- Natriretic peptides (BNP)
23
Q
Echocardiogram rule in CHF ?
A
A. Initial test of choice—should be performed whenever CHF is suspected based on history, examination, or CXR.
B. Useful in determining whether systolic or diastolic dysfunction predominates, and determines whether the cause of CHF is due to a pericardial, myocardial, or valvular process.
C. Estimates EF (very important): Patients with systolic dysfunction (EF <40%) should be distinguished from patients with preserved left ventricular function (EF >40%).
24
Q
Standard ttt of CHF ?
A
- Treatment should be according to NYHA classification.
- all patient should decrease sodium and water intake.
- All patient should take B-blockers and ACE inhibitors.
- Then we add drugs according to NYHA classes:
- NYHA II: Add Loop diuretics “for symptoms”and Thiazide diuretics.
- NYHA III: Add Spironolactone and vasodilators (hydralazine).
NYHA IV: Inotrops (Digitalis (useful in patient with EF <40%, severe CHF, or severe AFib)).
………… - Valsartan/sacubitril
25
Killip classification ?
Designed to provide a clinical estimate of the severity of circulatory derangement in the treatment of acute MI.
- Stage I: No heart failure.
- Stage II: HF.
- Stage III: Severe heart failure.
- Stage IV: Cardiogenic shock.
26
What is the difference between ACC/AHA classification and NYHA ?
- ACC/AHA stages of HF based on structure and damage to heart muscle.
- NYHA Functional Classification: severity based on symptoms and physical activity.
27
ACE inhibitors in HF should be uptitrated to
- The dosages shown to be effective in large trials.
| - They should not be titrated based on symptomatic improvement
28
Virchow's Triad - Causes of Thrombosis ?
* Changes in the blood vessel wall
* Changes in the blood flow
* Changes in the blood composition
29
Strong predisposing factors of PE?
- Fracture (hip or leg).
- Hip or knee replacement.
- Major general surgery.
- Major trauma.
- Spinal cord injury.
30
What are principal markers of high risk of early death in acute PE ?
Shock and hypotension.
31
What is related to intermediate risk of short-term mortality in PE ?
- RV dysfunction.
| - Myocardial injury.
32
Symptoms of PE ?
- Dyspnoea 80%
- Chest pain 52%
- Cough 20%
- Hemoptysis
- Cyanosis
- Collapse.
33
Signs of PE ?
- Tachypnoea (>20/min) 70%
- Tachycardia (>100/min) 26%
- Pulmonary component of the second tone
- Raised jugular venous pressure
34
Assesment of clnical probability of PE ?
* Wells score:
1. Previous DVT or PE -> +1.5
2. Recent surgery or immobilization -> +1.5
3. Caner -> +1
4. Hemoptysis -> +1.
5. HR>100 -> +1.5.
6. Clinical signs/symptoms -> +3.
7. PE is most likely -> 3
35
Wells score results interpretation ?
* Clinical probability (3 level):
- Low: 0-1
- Intermediate: 2-6
- High: >7
* Clinical probability (2 level):
- PE unlikely: 0-4
- PE likely: >4
36
D-dimer ?
- The product of a cross-linked fibrin.
- Very high negative predictive value.
- Very low positive predictive value.
- Negative D-dimer result in a highly sensitive assay safely excludes the PE in a patients with low or moderate clinical risk.
37
Compression ultrasonography (CUS) ?
• 90% of PE is due to DVT in lower limb.
• CUS has 90% sensitivity and 95% specificity for
diagnosing proximal DVT
• Thus finding a proximal DVT in patients with suspected PE is sufficient to start anticoagualnt treatment
38
TTT of Acute AFib in a hemodynamically unstable patient ?
Immediate electrical cardioversion to sinus rhythm
39
TTT of Acute AFib in a hemodynamically stable patient ?
```
A. Rate control -> B-blockers (Metoprolol)
- u can also use amiodarone.
B. Check TEE.
C. Anticoagulation.
D. Cardioversion.
```
40
Treatment approach of AFib depends on which scores ?
- CHA2-DS2-VAS score.
| - HAS-BLED score.
41
CHA2-DS2-VAS score :
* Estimate the risk of stroke for patients with atrial fibrillation.
- Age: 0-1-2.
- Sex: F 1. M 0
- CHF hx: 0-1.
- HTN hx: 0-1.
- Stroke/TIA/TE: 0-2.
- Vascular disease history: 0-1.
- DM hx: 0-1
42
HAS-BLED score ?
* Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.
- HT (uncontrolled): 0-1.
- Renal disease: 0-1
- Liver disease: 0-1.
- stroke hx: 0-1.
- Prior bleeding: 0-1.
- INR: 0-1
- Age: >65
- Meds: 0-2
- Alcohol: 0-1
43
Pacemaker types?
- AAI.
- VVI.
- DDD.
44
Pacemaker indications ?
- Sinus bradycardia WITH symptoms. (AAI)
- Sinus sick syndrome. (AAI)
- AV block II advanced. (VVI)
- AV Block III. (DDD)
- Premature AFib. (VVI)
45
Wolff–Parkinson–White Syndrome treatment ?
- Radiofrequency catheter ablation of one arm of the reentrant loop.
- Medical options include procainamide or quinidine.
46
Atrial flutter therapy ?
- electrical cardioversion.
- Catheter ablation.
- Antiarrhymic drugs. (risk of 1:1 conduction).
- Amiodarone, Sotalol, Flecainide.
47
Cardiomyopathies is ?
A Myocardial disorder in which the heart muscle is structurally and functionally abnormal, in the absence of coronary artery disease, hypertension, vulvular diseases and congenital heart disease sufficient to cause the observed myocardial abnormality.
48
WHO Classification for Cardiomyopathies ?
* Unknown cause (Primary):
- Dilated.
- Hypertrophic.
- Restrictive.
- Unclassified.
* Specific heart muscle disease (secondary):
- Infective.
- Metabolic.
- Systemic disease.
- Heredofamilial.
- Sensitivity.
- Toxic.
49
Dilated Cardiomyopathy ?
- A disease of unknown etiology that principally affects the myocardium.
- LV dilation and systolic dysfunction.
50
Pathology of Dilated Cardiomyopathy ?
- Increased heart size and weight.
- Ventricular dilation, normal wall thickness.
- Varying degree of myocyte degeneration.
51
What is the Most common type of cadiomyopathy?
Dilated Cardiomyopathy (90%).
52
Diagnostic criteria of Dilated Cardiomyopathy?
- 4 chamber dilation of unknown cause.
| - NO ischemic heart disease, HTN, vulvular disease or other 2ndary causes.
53
Clinical features of Dilated Cardiomyopathy?
* Slowly developing CHF.
* Murmurs:
- mitral or tricuspid regurge.
* Thromboembolic disease:
- Thrombus formation in both ventricules and atria.
- Due to stasis of blood.
54
Symptoms of heart failure (may be gradual in onset) ?
- pulmonary congestion (lLeft HF):
dyspnea (rest, exertional, nocturnal), orthpnea.
- Systemic congestion (Right HF): edema, nausea, abdominal pain, nocturia.
- Low CO: fatigue, weakness.
- Hypotension, tachycardia, tachypnea.
55
Definitive Clinical indications for endomyocardial biopsy in dilated cardiomyopathy?
- Monitoring of cardiac allograft rejection.
| - Monitoring of anthracycline cardiotoxicity.
56
Possible Clinical indications for endomyocardial biopsy in dilated cardiomyopathy?
- Detection and monitoring of myocarditis.
- Diagnosis of secondary cardiomyopathies.
- Differentiation between restrictive and constrictive heart disease.
57
Management of dilated cardiomyopathy?
* Limit activity based on functional status.
* Meds:
- ACE inhibitors.
- B-blockers.
- MRA.
- Angiotensin receptor blockers.
- Digoxin.
- Diuretics.
- Hydralazine / nitrates combination.
* Salt restriction.
* Fluid restriction for significant low Na+.
* Anticoagulation for EF <30%, history of thromboemoli, presence of mural thrombi.
* CRT.
* ICD.
* Left ventricle asisst device (LVAD).
* Cardiac transplantation.
58
Hypertrophic Cardiomyopathy ?
- 2nd most common type of cardiomyopathy.
| - More than 50% are inherited as autosomal dominant condition.
59
Risk of complications after ICD implantation in HCM ?
- Inappropriate ICD discharge: 25%.
- Lead complications (fracture, disoldgment, oversensing): 6-13%.
- Device-related infection: 4-5%.
- Bleeding or thrombosis: 2-3%
60
Cardinal manifestation of acute pericarditis ?
* Chest pain (most common findings):
- pain is severe and pleuritic.
- Positional.
- Pain is relieved by sitting up and leaning forward.
* Pericardial friction rub. (Not always but very specific for pericarditis)
* ECG changes. (diffuse ST elevation: PR depression)
* Pericardial effusion(with or without tamponade)
61
How to differentiate between chest pain in acute pericarditis and MI ?
In acute pericarditis pain is pleuritic, associated with breathing.
62
Management of acute pericarditis ?
- Most cases are self limited and resolve in 2-6 wks.
- NSAIDs are the mainstay of therapy.
- Colchicine is also often used.
- GS if no response to NSAIDs
63
Constrictive Pericarditis ?
Fibrous scarring of the pericardium. leads to rigidity and thickening of the pericardium, with obliteration of the pericardial cavity.
64
Diagnosis of Pericardial Effusion ?
* Echocardiogram:
- Confirms the presence or absence of a significant effusion.
- Most sensitive and specific method; can show as little as 20 ml.
- Should be performed in all patients with acute pericarditis to rule out an
effusion.
65
Cardiac Tamponade ?
* Defined as accumulation of pericardial fluid.
* It is the rate of fluid accumulation that is important, not the amount:
- 200 ml of fluid that develops rapidly (i.e., blood secondary to
trauma) can cause cardiac tamponade.
- 2 L of fluid may accumulate slowly before cardiac tamponade occurs.
- COZ, When fluid accumulates slowly, the pericardium has the opportunity to stretch
and adapt to the increased volume (i.e., related to a malignancy)
66
Clinical features of Cardiac Tamponade ?
| beck triad
- JVD.
- Hypotension.
- Muffled heart sounds.
67
What are the most typical signs and symptoms for aortic stenosis ?
Which signs does indicate poor prognosis of Aortic stenosis?
- Angina.
- Syncope.
- HF.
* AKA cardinal symptoms.
68
Management of Aortic stenosis ?
- If symptomatic -> NO treatment.
| - If symptomatic -> Surgery (aortic valve replacment)
69
Additional physical findings in Aortic insufficiency ?
- De Musset sign: Head bobbing (rhythmical jerking of head).
- Müller sign: Uvula bobs.
- Duroziez sign: Pistol-shot sound heard over femoral artieries.
70
Physical findings in Aortic insufficiency ?
- Widened pulse pressure. (increased systolic and decrease diastolic).
- Diastolic decrescendo murmur best heard at left sternal border.
- Corrigan pulse (water-hammer pulse).
- Austin flint murmur.
71
Mitral Valve Prolapse ?
MVP is defined as the presence of excessive or redundant mitral leaflet tissue due to myxomatous degeneration of mitral valve leaflets and/or chordae tendineae.
72
Classification of aortic stenosis ?
- Mild: area >1.5 cm2
- Moderate: 1-1.5 cm2.
- Severe: area <1 cm2.
* normal adult valve orifice is 3.0 to 4.0
cm2.
73
Mitral valve prolapse (MVP) ?
- 3-5% of the population.
- Usually a primary condition.
- Majority asymptomatic.
- Patients may complain of syncope, presyncope, palpitation, chest discomfort.
- Patients with MVP and severe MR should be treated as are other patients with severe MR.
74
What is the auscultatory finding in MVP ?
Systolic click
75
Eisenmenger syndrome ?
- Caused by increased flow through pulmonary vascular system due to left to right shunt.
- Pulmonary hypertension develops.
- Which leads to reversal of the shunt (Right to left)
76
Signs and symptoms of Eisenmenger syndrome ?
```
– Cyanosis
– High red blood cell count
– Nail clubbing of fingers.
– Syncope
– Heart failure symptoms
– Arrhythmia
```
77
Artial Septal Defect (ASD) ?
* It may remain undiagnosed until adulthood.
* Most common types:
- Ostium primum (15% of
ASD).
- Ostium secundum (80% of ASD).
78
Clinical presentation of ASD ?
- Majority develop sympthoms >40 years old.
- Reduced funtional capacity.
- Shortness of breath on excercise.
- Palpitation.
- Pulmonary infections.
- Sings of right heart failure.
79
Ebstein’s anomaly ?
- Abnormally formed and apically displaced leaflets of the tricuspid valve.
- The apical displacement of the tricuspid valve means that the right heart consists of an RA, an atrialized portion of the RV, and the remaining functional RV.
- The tricuspid valve is often regurgitant.
80
Marfan syndrome ?
- Autosomal dominant disorder of connective tissue.
| - Mutations in the FBN1 gene on chromosome 15q21 encoding fibrillin-1, a glycoprotein in the extracellular matrix.
81
Diagnosis of Aortic dissection ?
- CT (1st line)
| - TEE – second line; good for proximal, cannot visualize descending aorta well.
82
Risk factors of of Aortic dissection ?
- Male.
- HTN.
- Connective tissue disease.
- Cocaine use.
- Syphilis.
- Inflammatory conditions affecting aorta.
- Bicuspid aortic valve.
- Aortic coarction.
- Hx of CABG.
- high intensity weight lifting.
- Trauma.
83
clinical presentation of Aortic dissection ?
```
– 85% have chest or back pain
– “Ripping” or “tearing” in 50%
– Neurologic symptoms in 20%
– Hematuria
– Asymmetric pulses and BP
```
84
Aortic dissection management of type A ?
* Surgery!
* Do not delay surgery, even for LHC
* Beta blockers, titrate to HR 50-60 (labetalol, esmolol)
* BP control (nitroprusside)
85
Aortic dissection management of type B ?
• Beta blockers, titrate to HR 50-
60 (labetalol, esmolol)
• BP control – add nitroprusside or similar agent to SBP goal 100-120mmHg
• Surgery for those with end organ damage or those who do not respond to medical therapy
• Watch for hypotension – give fluids if needed, consider tamponade, MI, or rupture as complications if hypotensive
86
Aortic valve auscultation area is located in the ?
2nd right intercostal space on the right sternal border.
87
First heart sound is produced by?
The Closing of the mitral and tricuspid valve leaflets
88
Second heart sound caused by ?
The Closing of the Aortic Pulmonary/Pulmonic valve leaflets
89
Please indicate markers of pulmonary embolism severity ?
- Hypotension.
| - Elevated NTproBNP and/or troponins.
90
Which device is the best method of treatment for 85 years old female with permanent atrial fibrillation, a few symptomatic pauses 4-5 seconds max in Holter ECG and ejection fraction 55% ?
DDD type
91
Which of the following combination treatment for hypertension is CI?
ACE inhibitors + angiotensin receptor blocker.
92
The typical LBBB in ECG ?
QRS > 120 ms. QS or rS complex in lead V1, notched R wave in lateral leads.
93
GRACE score ?
is a prospectively studied scoring system to risk stratifiy patients with diagnosed ACS to estimate their in-hospital and 6-month to 3-year mortality.
94
Which of the anticoagulants can be used as a thromboembolic complications prevention in 45 years old patient with prosthetic mechanical aortiv valve and resuced creatinine clearance?
Warfarin
95
Diagnostic criteria for HFpEF (Heart failure with preserved ejection fraction) is ?
EF > 49%
96
Third heart sound ?
- is caused by rapid ventricular filling.
- best heard with the bell over the apex.
- may be confused with a split second sound or opening snap.
- Heard in failure of either ventricle.
97
What is a target LDL cholesterol level in a patient with stable coronary artery disease?
< 70 mg/dl (<1.8 mmol/l)
98
Which antithrombotic treatment is most appropriate in patient with a STEMI undergoing primary PCI ?
ASA, Ticagrelor, UFH
99
Which interrupt me as require thromboembolic risk stratification ?
- A Fib.
| - A flutter.
100
20 year old man with a history of a cardiac arrest and preexcitation in resting ECG, which of the following is the best long term treatment ?
Ablation of accessory pathway.
101
Q. Which of the following would NOT be an indication for an immediate in invasive approach (<2 hrs) in a patient with NSTEMI ?
Left ventricular ejection fraction <40% or congestive heart failure.
102
Criteria for Myocardial Infarction ?
* Detection of a rise and/or fall of cardiac biomarker (preferably troponin) with at least one value above the 99 percentile upper reference limit and with one of the following:
- Symptoms of ischaemia
- New ST-segment – T-wave changes or new LBBB
- Pathological Q waves in the ECG
- Imaging evidence of new loss of viable myocardium
or new regional wall motion abnormality
- Intracoronary thrombus by angiography or autopsy
103
Murmur of aortic regurgitation ?
Diastolic murmur, heard best in the 3rd left intercostal space, charactersized as blowing, decrescendo, irradiating widely along left sternal border.
104
S4 is and what is the most common causes?
* powerful atrial contraction filling an abnormally stiff ventricle.
- Stenosis.
- Hypertension/ Heart block.
- Ischemic HD.
- Tamponade.
105
S3 is and what is the most common causes?
* Rapid ventricular filling in early diastole.
- Failure.
- Incompentence (mitral/trcuspid)
- Pregnancy/pill.
- PE/Pericarditis. (constrictive)
- Youth/Athletic.
