Cardiac

Question 1

Why is it important to determine the duration of the angina that the patient has been experiencing?

Answer 1

angina lasting <20 minutes = myocardial ischemia angina

> 20 minutes = acute coronary syndrome (i.e. unstable angina or myocardial infarction)

Question 2

CCS classification of angina

Answer 2

class 1 = no limitation of ordinary activity; angina with strenuous, rapid or prolonged exertion

class 2 = slight limitation of ordinary activity; angina with ordinary activity (walking stairs, walking uphill) after meals, in cold, in wind or under emotional stress

class 3 = marked limitation of ordinary activity; angina on walking or climbing short distances under normal condition and at normal pace

class 4 = inability to carry on ordinary activity; angina at rest

Question 3

Stable angina pathophysiology

Answer 3

atherosclerotic plaque narrowing of coronary artery plus endothelial dysfunction decrease blood supply to heart causing ichemia

Question 4

Stable angina clinical presentation

Answer 4

typical angina for <20 minutes

Question 5

Stable angina management

Answer 5

lifestyle

anti-anginal therapy: nitrates PRN, beta blocker

anti-platelet therapy: aspirin or clopidogrel

lipid lowering therapy: statin

if decreased quality of life despite medication or high risk feature on stress testing or significant angina or acute change in angina, mechanical revascularization: percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG)

Question 6

ACS pathophysiology

Answer 6

unstable angina: rupture of atherosclelrotic plaques of coronary arteries causing increased ischemia

STEMI & NSTEMI: disruption of atherosclerotic plaque of coronary arteries causing platelet aggregation and clot formation, causing high grade stenosis or occlusion of coronary artery with or without associated emboli entering microciriculation downstream, resulting in ischemia and infarction of myocardium

Question 7

ACS clinical presentation

Answer 7

typical angina that is severe and prolonged (>20 minutes)

unstable angina can present with any of the following ways

1. crescendo pattern with increase in frequency, duration or intensity
2. angina at rest without provocation
3. new onset of severe angina (CCS class 3) without previous angina

Question 8

Diagnosis of different ACS types

Answer 8

ECG: no ST elevation
Enzyme test: normal
= unstable angina

ECG: no ST elevation
Enzyme test: elevated
= NSTEMI

ECG: ST elevation
Enzyme test: elevated
= STEMI

Question 9

STEMI management

Answer 9

PCI or tPA

Question 10

Non ST elevated (unstable angina and NSTEMI) ACS management

Answer 10

1. Everyone gets ASA, statin and nitro
2. Risk stratify

Low Risk Group:
ECG normal
TIMI score 0-2

Intermediate Risk Group
ECG: Normal or T wave inversion
TIMI 3-4
Previous CABG or PCI

High Risk Group
ECG ST shift or deep T wave inversion
TIMI 5-7
Refractory ischemia, heart failure or hypotension

3. Treatment

Low Risk
Beta blocker
early discharge with follow up

Intermediate risk
Heparin
Clopidogrel
Observation

High risk 
Beta blocker 
Heparin 
GPIIb/IIIa inhibitor or bivalirudin with clopidogrel 
Early cath

Question 11

How to calculate the TIMI score

Answer 11

age >65

> 3 CAD risk factor

prior stenosis

ST depression

elevated cardiac markers

multiple angina within 24 hours

aspirin in last 7 days

Question 12

Aortic dissection diagnosis

Answer 12

Chest CT

Question 13

What is Tietze syndrome

Answer 13

pain accompanied by inflammation (swelling, erythema, heat) is named Tietze syndrome, which is a more severe case of costochondritis

Question 14

What is dead space

Answer 14

Ventilation but no perfusion (ex. PE)

Question 15

Pretest probability of PE based on Well’s score

Answer 15

+1
Active cancer
Hemoptysis

+1.5
Past history of DVT or PE
Recent Immobilization or surgery
Tachycardia >100

+3
Signs or symptoms of DVT
No alternative diagnosis as or more likely than PE

If total points 0-4 then PE is unlikely

Question 16

Investigations based on Well’s score

Answer 16

Unlikely 
--> D dimer 
If negative = no PE 
If positive 
--> CTPA 
If negative = no PE 
If positive = PE 

Likely
–> CTPA
If negative = no PE
If positive = PE

Question 17

PE management

Answer 17

LMWH short term while starting warfarin or DOAC long term

Question 18

CXR in PE

Answer 18

band atelectasis

decreased lung volume on affected side

pulmonary infarct/hemorrhage

edema

Question 19

ECG in PE

Answer 19

Tachycardia

A fib

RV strain (inverted T wave, ST depression in V1-V3)

S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign. A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain

Question 20

ABG in PE

Answer 20

Hypoxemia

Hypocapnia

High Aa gradient

Respiratory alkalosis

Question 21

Pneumonia management

Answer 21

Outpatient
Previously well and no abx use in last 3 months -
Macrolide OR doxycyline

Comorbidities or abx use in last 3 months -
Respiratory fluoroquinolone OR beta lactam + macrolide

Inpatient
Ward - resp fluoroquinolone

ICU - beta lactam + (macrolide OR resp fluoroquinolone)

Resp fluoroquinolone - (moxi, femi, levofloxacin)
beta lactam - (cefotaxime, ceftriaxone)
Macrolide - (azithro, clarithro, erythro)

Question 22

Pneumothorax risk factors

Answer 22

asthma, COPD, lung procedures

Question 23

Panic attack clinical presentation

Answer 23

panic attack is an abrupt surge of intense fear of intense discomfort that
1. peaks within minutes and
2. is time limited with
3. 4+ of the following symptoms
palpitation / heart pounding
sweating
trembling / shaking
sensation of shortness of breath or smothering
feeling of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, lightheaded or faint
chills or heat sensation
paresthesia (numbness or tingling sensation)
derealization (feeling of unreality) or depersonalization (being detached from one self)
fear of losing control or going crazy
fear of dying

Question 24

Panic attack management

Answer 24

Benzo PRN

Question 25

Causes of secondary hypertension

Answer 25

renovascular hypertension: renal artery stenosis, fibromuscular dysplasia renal hypertension: chronic kidney disease including polycystic kidney disease and diabetic nephropathy, kidney transplant endocrine: hypothyroidism, hyperthyroidism, hyperaldosteronism, Cushing’s syndrome, pheochromocytoma, hyperparathyroidism

Question 26

Guidelines for diagnosis of HTN

Answer 26

1. Elevated BP reading at office, home or pharmacy 2. Hypertension visit 1 BP 180/110 + = hypertension AOBP 135/85 + OBPM 140/90 + NO = no hypertension, annual BP measurement recommended YES = out of office assessment (ABPM preferred or HBPM diagnostic series or OBPM alternate method) 3. Hypertension visit 2 (within 1 month) ``` Daytime ABPM or HBPM 135/85+ 24h ABPM 130/80+ NO = white coat hypertension (complete HBPM or ABPM to confirm and if still below then no hypertension and annual BP measurement recommended) YES = hypertension ``` 3. OBPM Hypertension visit 2 140+ or 90+ then go to step 4 4. Hypertension visit 3 160+ or 100+ YES = hypertension NO = go to step 5 5. Hypertension visit 4-5 140+ or 90+ YES = hypertension NO = no hypertension (annual BP measurement recommended)

Question 27

Hypertensive urgency

Answer 27

asymptomatic and BP >180/110

Question 28

Hypertensive emergency

Answer 28

BP > 180/110 with end organ damage

Question 29

How often should follow up occur for patients with hypertension

Answer 29

hypertensive patients with lifestyle modification alone should be followed up at 3-6 months interval patients on antihypertensive medication treatment should be followed up every 1-2 months until readings on 2 consecutive visits are below target, then follow up at 3-6 months interval

Question 30

Physical exam components for a patient with hypertension

Answer 30

weight, waist circumference, height vitals: blood pressure, heart rate neurological: cognitive assessment for dementia look for signs of stroke including gait, cranial nerves, speech, motor, sensory, reflexes eye: fundoscopy for signs of hypertensive retinopathy including papilledema, hemorrhage, AV nicking cardiovascular: signs of heart failure or left ventricular dysfunction including elevated JVP, displaced apex, peripheral edema, auscultate for S3, S4, loud A2, heart murmur peripheral vascular: palpate peripheral pulses for peripheral vascular disease, auscultate for bruit at renal arteries

Question 31

Indications for investigation for hypertension due to renovascular disease

Answer 31

patients with >2 of the following should be investigated for renovascular hypertension: sudden onset or worsening of hypertension at age <30 years or >55 years presence of abdominal bruit hypertension resistant to >3 antihypertensive medications increase in serum creatinine >30% with use of ACE inhibitor (ACEI) or ARB atherosclerotic vascular disease (coronary artery disease, peripheral vascular disease), particularly in patients who smoke or have dyslipidemia recurrent pulmonary edema associated with hypertensive surges

Question 32

Indications for investigation for hypertension due to hyperaldosteronism

Answer 32

patients with any of the following should be investigated for hyperaldosteronism hypertensive patients with spontaneous hypokalemia (K < 3.5 mmol/L) hypertensive patients with marked diuretic induced hypokalemia (K < 3 mmol/L) patients with hypertension refractory to >3 antihypertensive medication hypertensive patients with incidental adrenal adenoma

Question 33

Indications for investigation for hypertension due to pheochromocytoma

Answer 33

patients with any of the following should be investigated for pheochromocytoma paroxysmal or severe (blood pressure >180/110) sustained hypertension refractory to usually anti-hypertensive therapy patients with hypertension and multiple symptoms suggestive of catecholamine excess (headaches, palpitations, sweating, panic attacks, pallor) hypertension triggered by beta-blockers, MAO inhibitors, micturition or changes in abdominal pressure patients with incidentally discovered adrenal mass or multiple endocrine neoplasia (MEN2A, MEN2B, von Recklinghausen’s neurofibromatosis, von Hippel-Lindau disease)

Question 34

Investigations for pheochromocytoma

Answer 34

screening for pheochromocytoma include 24 urinary total metanephrine and urinary metanephrine-to-creatinine ratio high 24 urinary total metanephrine and urinary metanephrine-to-creatinine ratio should be followed up with MRI to visualize adrenal tumors

Question 35

Investigations for renal vascular hypertension

Answer 35

captopril-enhanced radioisotope renal scan - contraindicated in patients with chronic kidney disease GFR<60 Doppler sonography MR angiography CT angiography - contraindicated in patients in renal failure (i.e. abnormally high creatinine)

Question 36

Investigations for hyperaldosteronism

Answer 36

screening for hyperaldosteronism include plasma aldosterone and plasma renin activity high plasma aldosterone and plasma renin activity followed up with maneuvers for autonomous hyper-secretion of aldosterone (saline loading test, fludrocortisone suppression test, plasma aldosterone to plasma renin activity ratio or captopril suppression test)

Question 37

Indications for antihypertensive use

Answer 37

1) average diastolic blood pressure >100mmHg or systolic blood pressure >160mmHg even if without any target organ damage or other cardiovascular risk factors 2) average diastolic blood pressure >90mmHg with macro vascular target organ damage or cardiovascular risk factors (other than hypertension) 3) average systolic blood pressure >140mmHg with macro vascular target organ damage

Question 38

Antihypertensives medication guidelines

Answer 38

1st line anti-hypertensives - thiazide and thiazide-like diuretics, which have the most evidence - beta blocker (in patients age <60 years) - ACEI) (in non-black patients)/ARB - long acting calcium channel blocker (CCB) 1) initial mono therapy with any of 1st line if systolic blood pressure is 20mmHg above target or diastolic blood pressure is 10mmHg above target, consider start combination therapy 2) if not achieve target blood pressure with mono therapy, add on medications from another class of 1st line anti-hypertensives recommended combinations = (thiazide / thiazide-like diuretics or CCB) + (ACEI or ARB or beta blocker) combinations NOT recommended = (non-dihydropyridine CCB + beta blocker) (ACEI + ARB) 3) if hypertension still not at target with >2 anti-hypertensives from 1st line classes, may add other anti-hypertensive drugs not from 1st line classes e.g. alpha blockers - Doxazosin, Prazosin, Terazosin centrally acting agents - clonidine, guanfacine, methyldopa non-dihydropyridine CCB - verapamil, diltiazem

Question 39

HTN management for hypertensive patients with coronary artery disease

Answer 39

ACEI, ARB and beta blocker preferred over other 1st line therapies preferred combination = ACEI + dihydropyridine CCB

Question 40

HTN management for hypertensive patients with recent myocardial infarction (MI)

Answer 40

initial therapy = (ACEI or ARB) + (beta blocker or dihydropyridine CCB)

Question 41

HTN management for hypertensive patients with heart failure

Answer 41

initial therapy = (ACEI or ARB) + beta blocker aldosterone antagonist (e.g. Spironolactone) may be added

Question 42

HTN management for hypertensive patients with stroke

Answer 42

blood pressure control usually not indicated in setting of acute stroke unless very high post stroke preferred combination = ACEI + thiazide / thiazide-like diuretics

Question 43

Management for hypertensive patients with non-diabetic chronic kidney disease

Answer 43

ACEI and ARB preferred over other 1st line therapies thiazide / thiazide-like diuretics preferred as additive anti-hypertensive therapy

Question 44

Management for hypertensive patients with renovascular disease

Answer 44

ACEI or ARB used with caution due to risk of acute renal failure or unilateral kidney disease consider intervention (angioplasty & stunting or surgery) if hypertension despite >3 anti-hypertensive combination therapy, deteriorating kidney function, bilateral renal artery lesion or recurrent episode of flash pulmonary edema

Question 45

Management for hypertensive patients with diabetes

Answer 45

ACEI and ARB preferred for patients with cardiovascular or kidney disease preferred combination = ACEI + dihydropyridine CCB

Question 46

non-dihydropyridine CCB contraindication

Answer 46

heart failure

Question 47

blood pressure equation

Answer 47

blood pressure = cardiac output (stroke volume x heart rate) / peripheral vascular resistance (inversely proportional to vascular diameter)

Question 48

Thiazide diuretic MOA

Answer 48

thiazide diuretics block Na-Cl symporter, decreasing Na reabsorption in distal convoluted tubule, which result in increased Na & H2O renal excretion to decrease stroke volume

Question 49

ACEi MOA

Answer 49

ACEI inhibits ACE to decrease renin-angiotensin-aldosterone (RAA) system and increased bradykinin decreased RAA increase Na and H2O renal excretion, resulting in decreased stroke volume and vasodilation increased bradykinin cause vasodilation, decreasing peripheral vascular resistance

Question 50

ACEi side effects

Answer 50

electrolyte abnormalities: hyperkalemia acute renal failure with decreased GFR angioedema interaction with K sparing diuretics, ARB and NSAID cough

Question 51

ARB MOA

Answer 51

ARB block angiotensin AT1 receptors, which cause vasodilation decreased aldosterone to increase Na and H2O renal excretion, resulting in decreased stroke volume decreased sympathetic activity

Question 52

BB MOA

Answer 52

block beta 1, beta 2 and / or alpha adrenergic receptors beta 1 selective blocker most commonly prescribed beta 1 blockade “1 heart” = decrease heart rate, decrease heart contractility and decrease RAA, thereby decreasing cardiac output and causing vasodilatation beta 2 blockade “2 lungs” = bronchoconstriction and increased vascular resistance

Question 53

CCB types and examples of each

Answer 53

dihydropyridine (DHP) CCB end with “-dipine” including Amlodipine, Nifedipine non-dihydropyridine (NDHP) CCB including Verapamil, Diltiazem

Question 54

Indication for DHP CCB

Answer 54

DHP CCB may be indicated in patients with comorbidities that could also be treated with DHP CCB including Raynaud’s and migraine

Question 55

CCB MOAs

Answer 55

DHP CCB decrease Ca influx in vascular smooth muscle, causing vasodilatation to decrease peripheral vascular resistance NDHP CCB decrease Ca influx in cardiomyocyte, decreasing heart contraction to decrease cardiac output

Question 56

K sparing diuretic indication in hypertension

Answer 56

2nd line antihypertensive diuretic Amiloride and Triamterene usually used in mild to moderate hypertension with normal renal function Spironolactone usually used in hypertensive patients with severe heart failure

Question 57

K sparing diuretic MOAs

Answer 57

Amiloride & Triamterene: inhibit ENaC sodium channel in collecting duct, leading to Na & H2O renal excretion to decrease stroke volume Spironolactone: block aldosterone receptor in collecting duct, leading to Na & H2O renal excretion to decrease stroke volume

Question 58

Loop diuretics indication in hypertension (Lasix)

Answer 58

2nd line antihypertensive diuretic usually indicated in hypertensive patients with volume overload (from renal failure, heart failure or cirrhosis)

Question 59

Loop diuretic contraindication

Answer 59

sulfa allergy

Question 60

Thiazide diuretic contraindication

Answer 60

sulfa allergy

Question 61

Loop diuretic MOA

Answer 61

inhibit Na-K-2Cl symporter on thick ascending limb, decreasing Na reabsorption leading to increased Na & H2O renal excretion to decrease stroke volume

Question 62

What is malignant hypertension

Answer 62

hypertensive emergency

Question 63

What is hypertensive crisis

Answer 63

hypertensive urgency

Question 64

Malignant hypertension management

Answer 64

1. Admit to ICU 2. Stabilize 3. Treat underlying cause 4. usually reduce blood pressure slowly to prevent ischemic damage usually reduce mean arterial pressure 10-20% in first hour and then reduce by 25% gradually over next 23 hours compared to baseline target blood pressure <170/110 mmHg 1st line = IV Labetalol (beta blocker) or IV Nitroprusside (vasodilator) 5) Address target organ damage and symptoms 6) after 24 hours of blood pressure control, then discharge from ICU and start on oral anti-hypertensive medication

Question 65

Acute target organ damage in hypertensive emergency can include what?

Answer 65

hypertensive encephalopathy including papilledema acute ischemic stroke intracranial hemorrhage acute left ventricular failure acute coronary syndrome acute aortic dissection acute kidney injury eclampsia of pregnancy

Question 66

5 big risk factors for ischemic heart disease

Answer 66

1) dyslipidemia (high total cholesterol, high LDL, low HDL) 2) smoking 3) diabetes 4) hypertension 5) family history of premature cardiovascular disease (1st degree relative with CVD at <55 years for men or <65 years for women) -- this doubles your Framingham risk score

Question 67

What is the definition of metabolic syndrome

Answer 67

central obesity based on waist circumference (>101cm for men; >88cm for women) plus 2+ of following: hypertriglyceridemia (>1.7) low HDL cholesterol (<1 for men, <1.3 for women) hypertension (>130/85 or treatment for hypertension) high fasting glucose (>5.6 mmol/L) or diabetes

Question 68

What is the Framingham risk score

Answer 68

Framingham risk score used to calculate 10 year future risk of cardiovascular disease for patients with NO history of cardiovascular disease

Question 69

How often should screening for dyslipidemia occur

Answer 69

every 3-5 years if Framingham risk score <5% every year if Framingham risk score >5%

Question 70

Statin indications

Answer 70

``` High risk (FRS >20%) start statin in all patients ``` ``` Intermediate risk (FRS 10-19%) start statin if LDL cholesterol is high (>3.5) or apoprotein B >1.2 or non-HDL cholesterol >4.3 if do not satisfy treatment threshold but higher risk based on secondary testing, then start statin ``` ``` Low risk (FRS <10%) start statin if LDL cholesterol >5 or familial hypercholesterolemia if do not satisfy treatment threshold and FRS 5-9% but higher risk based on secondary testing, then start statin ```

Question 71

LDL target

Answer 71

LDL cholesterol <2 or >50% decrease in LDL cholesterol

Question 72

What does non invasive cardiac testing include

Answer 72

1) non-invasive stress testing | 2) rest echocardiogram for left ventricular ejection fraction

Question 73

Indications for non invasive cardiac testing

Answer 73

patients satisfying any of the criteria below should undergo both non-invasive stress testing and rest echocardiogram: adults age >30 with >2 angina criteria male age >40 and female age >60 with 1 angina criteria male age <40 and female <60 with 1 angina criteria and other cardiovascular risk factors

Question 74

Requirements to be able to complete exercise stress test

Answer 74

ECG normal Ability to exercise to 85% heart rate

Question 75

What is the strongest prognostic factor in ischemic heart disease

Answer 75

left ventricular ejection fraction

Question 76

Indications for invasive angiography

Answer 76

high pre-test likelihood of ischemic heart disease (male >50 with 3 angina criteria) high risk features on non-invasive stress test or left ventricular ejection fraction on echocardiogram history of sudden cardiac arrest life-threatening arrhythmia on ECG

Question 77

Long term angina relief

Answer 77

1st line = beta blockers beta blocker recommended for patients with MI or reduced ejection fraction or heart failure dose of beta blocker usually titrated to target resting heart rate of 55-60 BPM 2nd line = dihydropyridine calcium channel blocker 3rd line = long acting nitrate

Question 78

vessels used for cabg

Answer 78

saphenous vein or internal mammary artery

Question 79

what is secondary prevention of ischemic heart disease

Answer 79

intervention for patients with history of ischemic heart disease to slow worsening of coronary artery disease or prevent cardiovascular event (myocardial infarction, stroke)

Question 80

What does secondary prevention of ischemic heart disease include

Answer 80

1. surveillance 2. all of the primary prevention interventions (see above) 3. anti-platelet agents ASA 81 mg or Clopidogrel 75 mg Post ACS or PCI with stent placement, P2Y12 receptor antagonist should be added to Aspirin for at least 12 months P2Y12 receptor antagonist can be any of the following Clopidogrel, Prasugrel, Ticagrelor Post CABG aspirin 100-325mg daily started within 6 hours after surgery for 1 year 4. Renin-Angiotensin-Aldosterone system blockers ACEI indicated in all patients with ischemic heart disease, especially if left ventricular ejection fraction <40%, hypertensive, diabetic or chronic kidney disease for patients intolerant to ACEI, ARB can be used as a substitute aldosterone blocker (Spironolactone) indicated in post-MI patients with all of the following: on therapeutic dose of ACEI and beta blocker left ejection fraction 0-40% have diabetes or heart failure 5. beta blockers beta blockers indicated in all patients with ischemic heart disease, especially if patient has any of the following left ventricular ejection fraction 0-40% history of MI or ACS heart failure 6. cardiac rehabilitation 7. Statin statin for all patients with ischemic heart disease (even if normal lipid profile)