Cardiology Flashcards
On a lateral view CXR, extension of the heart border posteriorly and inferiorly indicates enlargement of which ventricle?
Extension of the heart border posteriorly and inferiorly on lateral view CXR indicates enlargement of the left ventricle.
On a lateral view CXR, extension of the cardiac shadow of the lower part of the anterior clear space behind the sternum indicates enlargement of which ventricle?
Extension of the heart shadow into the retrosternal airapsce indicates right ventricular enlargement.
What conditions is a TEE useful for evaluating?
TEE is useful for evaluating the left atrium (left atrial appendage), valvular disease, endocarditis, aortic dissection, cardiac masses, and intracardiac shunts.
What are absolute indications for terminating an ETT?
Absolute indications for terminating an ETT include: ST segment elevation>1mm in leads without Q waves, decrease in SBP >10mmHg, Moderate-to-severe angina, CNS symptoms, signs of poor perfusion, sustained 2nd or 3rd degree AV block, patient requests to stop, severe arrhythmias.
When are stress imaging studies done instead of an ETT?
Stress imaging is done when the patient is unable to exercise on the treadmill or has baseline ECG changes that would confound interpretation of the ECG.
When are exercise stress echo and MPI indicated instead of ETT?
Stress imaging is done when the patient is able to exercise on the treadmill or has baseline ECG changes that would confound interpretation of the ECG.
Which stress imaging tests are used in patients with LBBB? With paced ventricular rhythm?
A patient with LBBB needing stress imaging should do a vasodilator MPI or dobutamine stress echo. A patient with a pacemaker should have a vasodilator MPI as treadmill or dobutamine may not elevate heart rate in such patients.
Which patients may benefit from cardiopulmonary exercise testing?
Cardiopulmonary testing should be performed to evaluate patients with systolic heart failure, patients undergoing a pre-transplant evaluation, and for patients with unexplained dyspnea.
When is PCWP increased?
PCWP increased with LV systolic and diastolic failure, mitral stenosis, aortic and mitral insufficiency, tamponade, and constrictive pericarditis.
At which PCWP do you expect to see frank pulmonary edema?
The PCWP in a patient with frank pulmonary edema should be >35mmHg.
When is diastolic pressure equal in all 4 chambers?
Equalization of diastolic pressure in all 4 chambers is seen with pericardial tamponade and constrictive pericarditis.
Name 1 indication for doing endomyocardial biopsy.
Endomyocardial biopsy is usually used to monitor for heart transplant rejection. It is also used to evaluate the cause of a cardiomyopathy or myocarditis in patients where the diagnosis is uncertain and would change management.
True or false? Pulsus paradoxus can be seen in cardiac tamponade.
True,pulsus paradoxus is seen in cardiac tamponade. It can also be seen in constrictive pericarditis, asthma, and tension pneumothorax.
What is pulsus bisferiens? What does it indicate?
Pulsus bisferiens is a pulse with 2 systolic peaks per cardiac cycle. It is seen in aortic regurgitation and hypertrophic cardiomyopathy.
What does pulsus alternans indicate?
Pulsus alternans is a varying pulse pressure with regular pulse rate and is seen in severely depressed systolic function from any cause.
True or false? Sustained handgrip increases the murmur of mitral valve prolapse, but decreases the murmur of HCM.
True. Sustained handgrip increases systemic vascular resistance and decreases the murmurs of HCM and aortic stenosis while prolonging the murmur of MVP.
When is a persistently split S2 heard?
Persistent splitting of S2 is seen in pulmonic stenosis, acute pulmonary embolism, and rhythms arising in the left ventricle (due to pacemaker or RBBB).
What causes a paradoxically split S2?
Paradoxical splitting of S2 is seen with delay in aortic closure as is seen with LBBB and pacemaker beats originating in the right ventricle.
When is an S3 important?
S3 is common before age 40 years but is abnormal after that and often indicates LV systolic dysfunction with early filling of the LV.
When are large v waves seen on the left side? Right side?
Large v waves on the left side are seen with mitral regurgitation. Right sided large v waves are seen with tricuspid regurgitation.
When is rapid x and y descent seen?
Rapid x and y descents are seen in restrictive cardiomyopathy.
When is the y descent absent?
The y descent is slow or absent with tricuspid stenosis.
When are large, right-sided a waves seen?
Large, right sided a waves are seen in tricuspid stenosis, severe pulmonic stenosis, and severely noncompliant RV.
When are large, left-sided a waves seen?
Large, left sided a waves are seen in mitral stenosis.
When are “cannon” a waves seen?
“Cannon” a waves are seen with AV dissociation such as complete AV block, VT, and asynchronous ventricular pacing.
When does a slow y descent occur?
Slow y descent occurs in tricuspid stenosis.
In which patients should you suspect secondary HTN?
Suspect secondary HTN in patients who develop HTN before age 30, who have drug-resistant HTN, or who develop uncontrolled HTN that was previously controlled.
True or false? A systolic abdominal bruit without a diastolic bruit suggests renal vascular HTN.
True, a systolic abdominal bruit without diastolic bruit suggests renal vascular HTN.
What disorder should you think of if a patient presents with HTN, hypokalemia, and low renin?
Patients with HTN, hypokalemia, and low renin should be evaluated for primary hyperaldosteronism.
True or false? Digoxin prolongs survival.
False. Digoxin may improve symptoms and reduce hospitalizations in heart failure, but it does not improve survival in heart failure or post-MI.
Which medications have been shown to prolong survival both post-MI and for patients with heart failure?
Only beta-blockers, ACEIs, and ARBs have been shown to prolong survival in both post-MI and heart failure patients.
With which medication should a nitrate be paired to improve survival in heart failure patients?
Hydralazine paired with a nitrate has been shown to improve survival in African American heart failure patients.
What is the most common cause of acute coronary syndrome?
Plaque rupture or erosion with thrombosis is the most common cause of acute coronary syndrome.
What is the cause of Prinzmetal angina?
Prinzmetal angina is caused by spasm of a coronary artery.
What does ST-segment elevation suggest on an exercise ECG stress test?
ST-segment elevation in >3 leads on ETT suggest significant ischemia. It can also be seen in coronary vasospasm.
What causes resting ST-segment elevation?
Resting ST-segment elevation is caused by acute MI, coronary spasm, pericarditis, LV aneurysm, LBBB, LV pacing, LVH, and early repolarization.
Explain the similarities and differences between hibernating myocardium, reperfusion injury, and stunned myocardium.
Hibernating myocardium is chronically underperfused myocardium which has no irreversible injury. If reperfused it can return to normal function. Reperfusion injury is irreversible myocardial injury that occurs if reperfusion occurs after 1 hour. Stunned myocardium is the result of acute ischemia. From time of reperfusion it can take 7-10 days for ventricular function to return to normal.
What are the main drugs used to treat angina?
Beta-blockers and nitrates are the mainstays of antianginal therapy with calcium channel blockers also playing a role.
Which patients might benefit from ranolazine (Ranexa)?
Ranolazine can be used for antianginal effect in those on maximal standard therapy including beta-blockers or in those who cannot tolerate beta-blockers.
Which antianginal drugs decrease myocardial oxygen demand?
Beta-blockers, nitrates, and calcium channel blockers all decrease myocardial oxygen demand. Beta-blockers decrease myocardial oxygen demand by decreasing heart rate, blood pressure, and contractility.
Which antianginal drugs decrease afterload?
Calcium channel blockers predominantly reduce afterload.
Which antianginal drugs decrease preload?
Nitrates reduce preload and to a lesser extent afterload.
Which antianginal drug do you not give to a patient with RV infarct? Why?
Nitrates should not be used in RV infarct as they can reduce RV preload and lead to reduced cardiac output and hypotension.
Why should you determine the probability of CAD in a person with intermittent chest pain?
History and physical along with baseline ECG are the first steps to determine the pre-test probability of CAD.
What is the most important test for risk stratification in patients with stable ischemic heart disease?
Exercise treadmill testing is the most important test for risk stratification in patients with stable ischemic heart disease.
For which patient with chronic stable angina do you do an echocardiogram? Why?
Use echocardiogram to assess the patient with chronic stable angina if they have prior MI, pathologic Q waves, symptoms or signs of heart failure, arrhythmias, or heart murmur as this will help guide treatment.
A patient undergoing a workup for chronic stable angina is determined to be at high risk for death. What is the next step?
High risk patients with chronic stable angina should be referred for coronary angiography to determine coronary artery anatomy.
What is the goal for blood pressure management in a patient with stable ischemic heart disease?
Blood pressure should be kept <140/90 in patients with chronic stable angina.
Would you recommend aspirin in a healthy woman <65 years of age for primary prevention of MI?
There is no clear evidence of benefit of preventive aspirin in women <65 years of age.
What are the 2 major categories of ACS?
The two major categories of ACS are ST-segment elevation ACS and non-ST-segment elevation ACS.
How are troponin I and T used? How long do they stay elevated after an MI?
Troponins I and T are the gold standard for detection of myocardial necrosis. They start to elevate 4 hours after event, peak at 44 hours, and may remain elevated for 10-14 days.
What are the prehospital guidelines for chest pain?
Prehospital guidelines for chest pain include: call 911, take an aspirin 162-325mg chewed and swallowed, give a nitrate times up to three doses, in-field ECG by EMS, monitoring and preparing to manage ventricular arrhythmias.
What are the major things you should do in early risk stratification of a patient who presents with ACS in the emergency department?
ECG, aspirin, measuring of cardiac markers, and directed history and physical should be done early in management of patient with ACS. If initial ECG is non-diagnostic, this should be repeated q15-30 minutes to evaluate for changes.
Based on early stratification of ACS, to what groups can a patient be assigned?
Based on early stratification, patients should be assigned to 1) noncardiac chest pain, 2) possible ACS, and 3) definite ACS.
What anti-ischemic measures are done initially for all patients with ACS?
Initial anti-ischemic measures for all patients with ACS include: aspirin, nitrates, morphine is unrelieved by nitrates, and beta-blockers and ACEI if still hypertensive or evidence of LV dysfunction.
Which patients should receive a platelet GP IIb/IIIa inhibitor?
GP IIb/IIIa inhibitors should be considered in high risk ACS patients including those with elevated troponin, hemodynamic instability, or dynamic ECG changes. Since the advent of dual antiplatelet therapy, GP IIb/IIIa inhibitors are used less frequently.
Of those with ACS, what group gets considered for fibrinolytic therapy and what group definitely does not?
Fibrinolytic therapy should not be given to those without ST-segment elevation. Those with ST-segment elevation should be given fibrinolytic therapy if immediate PCI is not available and they do not have contraindications.
Which NSTE-ACS patients should be considered for an early invasive strategy?
Indications for an early invasive strategy include heart failure, hemodynamic instability, recurrent or refractory angina. Other indications for invasive therapy include: elevated cardiac markers, dynamic ST changes, diabetes, EF <40%, PCI within the last 6 months, prior MI, prior CABG, intermediate/high risk patients based on scoring such as TIMI scoring.
What are the reperfusion therapies you give to (or consider for) those with STEMI or new LBBB/ Who gets what?
All patients who present within 12 hours of symptom onset with STEMI or new LBBB should be considered for emergent reperfusion with PCI or fibrinolysis (if PCI is not available).
What are the absolute and relative contraindications to fibrinolytic therapy?
Absolute contraindications to fibrinolytic therapy include any prior cerebral hemorrhage, other cerebrovascular events within 1 year, intracranial neoplasm, active internal bleeding, or suspected aortic dissection. Relative contraindications include BP >180/110, remote nonhemorrhagic CVA >1 year ago, current use of anticoagulants with INR >2-3, bleeding diathesis, recent major trauma or surgical procedure (2-4 weeks), noncompressible vascular puncture, previous exposure to streptokinase/anistreplase, pregnancy, active peptic ulcer.
How does management of RVI differ from LV infarction?
RV infarcts are preload dependent. They should not receive nitrates. Fluid support is often needed to maintain preload in RV infarct.
Which patients with tachyarrhythmias after an MI get DC cardioversion?
Ventricular fibrillation and pulseless VT should be treated with unsynchronized DC cardioversion. Sustained VT with pulse but with hemodynamic instability is treated with synchronized DC cardioversion.
What are the medical options for hemodynamically stable MI patients with VT?
Amiodarone is the drug of choice for the hemodynamically stable MI patient with VT. Hypokalemia and hypomagnesemia should be corrected as well.
When do the major mechanical complications tend to occur after an MI? How do they present? What is the best initial test to diagnose such a complication?
Papillary muscle rupture presents 3-7 days after inferior MI and presents with rapid development of shock and pulmonary edema. Ventricular septal defect presents 3-7 days after anteroseptal MI and presents with shock and a loud holosystolic murmur. Both papillary muscle rupture and post-MI VSD are diagnosed by echocardiogram. Free wall rupture occurs 3-7 days after large, anterior MI and presents with sudden syncope, distended neck veins, tachycardia, pulsus paradoxus, and hypotensions. This complication almost always results in death.
When should a patient with STEMI be referred for consideration of an ICD?
ICD placement is indicated in STEMI patients with sustained VT or V-fib >48 hours after MI. It is also indicated in those patients with post-MI EF <30-35% when reevaluated by echo >40 days after MI.
What are the primary risk factors for CAD?
The primary risk factors for CAD are age, male gender, family history of early CAD, smoking, HTN, diabetes, elevated LDL, and low HDL.
What lab tests should general lipid screening include?
General lipid screening should include measurement of total cholesterol, HDL cholesterol, and triglyceride with a calculation of LDL cholesterol.
In what situations are LDL receptors down-regulated? Up-regulated?
LDL receptors are down-regulated when dietary cholesterol or saturated fats are high, with increasing age, and in patients with familial hypercholesterolemia (50% in heterozygotes, 0% in homozygotes). LDL receptors are up-regulated when diet is low in cholesterol and saturated fats, by estrogen, by thyroxine, by statins, by a decrease in bile acid uptake for the intestines (as with use of bile acid binding resins).
Which familial dyslipidemia is the most common? What lipoproteins are elevated?
Familial combined hyperlipidemia is the most common familial dyslipidemia. In FCHL there is increased production of both apoB100 and VLDL, and the increased VLDL stresses the pathway toward increased LDL production.
What lipid test results suggests the need to work up familial hypoalphalipoproteinemia?
Isolated low HDL should prompt consideration of familial hypoalphalipoproteinemia, an autosomal dominant condition resulting from a mutation in the gene for apoA1 or for the gens ABCA1 or LCAT. It is found in 6% of Japanese patients with low HDL.
What is the primary endpoint of lipid screening done for primary prevention of CHD?
The primary endpoint for lipid screening to prevent CHD is the LDL.
Explain the ATPIII treatment priority for lipid abnormalities?
The ATPIII priority levels for treatment of dyslipidemia are 1) lower elevated LDL, 2) treat elevated non-HDL, then 3) raise low HDL.
List the CHD-equivalent diseases.
CHD-equivalent diseases include diabetes, carotid artery disease, peripheral artery disease, TIA or stroke, AAA, chronic kidney disease, and 10 year risk of CHD >20% using Framingham risk calculator.
Per ATPIII what are the non-LDL risk factors for CHD that are considered when you stratify patients for primary prevention of CHD?
Per ATPIII the non-LDL risk factors to consider in risk stratification of patients include age, family history, smoking, HTN, and low HDL cholesterol.
Per ATPIII, at what LDL level if TLC started on a 38yo man with diabetes? At what level do you start drug therapy?
A 38yo man with diabetes has a CHD-equivalent, so TLC should be initiated with LDL >100 and drug therapy should be started if LDL > 130.
Per ACC/AHA ASCVD guidelines, name the 4 statins benefit groups.
The 4 statin benefit groups per ACC/AHA ASCVD guidelines are clinical atherosclerotic cardiovascular disease, LDL>190, diabetes 40-75 years of age with LDL 70-189 and no evidence of atherosclerotic CV disease, and those without atherosclerotic CV disease or diabetes with 10-year risk of CV disease >7.5%.
How is high-intensity statin defined? A moderate-intensity statin?
High intensity statin therapy reduces LDL >50%. Moderate intensity statin therapy reduces LDL 30-50%.
Which fats are the “good fats”? The “bad fats”?
Monounsaturated fats such as olive/peanut/canola oils and omega-3 fatty acids are considered good fats. Hydrogenated vegetable oils (“trans fats”), saturated fats, and polyunsaturated fats are considered “bad fats”.
What class of drugs is recommended 1st line to reduce LDL?
Statins are considered first line to reduce LDL.
What are the major side effects of statins?
Major side effects of statins include myalgias, elevated glucose, memory loss and confusion.
What are the side effects of colesevelam?
Colesevelam and the other bile acid binding resins may cause nausea, vomiting, constipation and bloating. They can also interfere with absorption of other medications, so other medicines should be given one hour before or 4 hours after bile acid binding resins.
What is the main action of the fibrate drugs?
The main action of fibrates is to increase the activity of LPL on VLDL thus increasing the rate of conversion of VLDL to IDL.
What are the relative contraindications to niacin?
Niacin may contribute to hyperuricemia and insulin resistance, so relative contraindications to niacin include gout and diabetes.
What activities increase HDL? Lower HDL?
Moderate alcohol intake, exercise, smoking cessation, weight loss if obese, and reducing intake of trans fats all increase HDL levels. Smoking, weight gain, diets high in trans fats or polyunsaturated fats all decrease HDL levels.
What happens to the lipid panel in ACS?
A recent MI or any serious illness can lower LDL and HDL cholesterol and variably affect triglycerides, so a lipid panel should be checked 8 weeks after illness to better determine patient’s lipid abnormalities.
