Cardio internal finals 6th Flashcards
(159 cards)
1
Q
מהם הטריגרים ל-
AF
6
A
- היפרתירואידיזם
- הרעלת אלכוהול
- MI
- PE
- פריקרדיטיס
- ניתוח לב
2
Q
מה ההגדרה של כל אחד מהמצבים הבאים:
Paroxysmal AF
Persistant AF
long standing persistant
A
- Paroxysmal AF- spontaneous AF lasting < 7 days
- Persistant AF- 7 days < AF < 1 year
- long standing persistant- > 1 year
3
Q
Tx for acute Unstable AF
בצקת ריאות, אי יציבות המודינאמית, אנגינה ממשמעותית
A
Cardioversion- Synchronized
4
Q
Tx for Acute stable AF
AF < 48 hours
AF > 48 hours
A
AF < 48 hours
Cardioversion- by medications (like sotalol/ amiodarone) or synchronized
AF > 48 hours / unknown age
Cardioversion only if one of the following option is present:
1. pt on anticoagulation > 3 weeks
2. complete TEE without thrombus in the left atrial “ear”
5
Q
What is the Following Tx excepted after cardioversion?
AF
A
Anti-coagulations for 4 weeks after cardioversion
if CHA2DS2 VASc- then for life
6
Q
What is the Tx in acute AF immidietly before cardioversion?
A
- Slow the rate- BB or CCB
- start Anti-coagulation (does not metter if CHASDS persist)
בשלב האקוטי סביב היפוך ניתן א”ק ללא קשר ל-CHADS VAS
7
Q
How do we perform Rate control in AF
in acutic setting vs Chronic setting
A
Rate control for acute setting
BB / CCB (non-dhydro- Verpamil or dilitezam)
Rate control for chronic setting
BB and CBB (alone or in combination)
*HR target- < 80 in rest, < 100 while excersing.
8
Q
When is the best time to perform rythm control in order to reduce the incident of CV in AF pt?
A
in early stages = less then a year since Dx
9
Q
Which pt will most benefit early Ablation in AF?
A
Pt with Paroxysmal AF
גם בחולים שנראה שמצליחים להישאר בסינוס נמשיך לתת א”ק כל עוד
CHADS VAS מצדיק
10
Q
AF
Which classes of Anti-arytmhic drugs are a Tx for Rythem control
A
Class I- Na channel blocker
Class III K channel blocker
11
Q
Rythem control
Which AA Class III medication is a/w increase risk for death in pt with CHF or persistant long standing AF
A
Droendarone
12
Q
Which AA Class IIII is consider to be a second option for pt with CHF or coronary Heart disease, with more the 40% experince sort kind of toxocitiy while taking this drug?
A
Amiodarone
נהוג לשמור לחולים שלךא יכולים לקבל תרופות אחרות . שלא עזרו = לא קו 1
13
Q
Which AA Class III medications are a/w prolong QT
A
Dofetillide + Sotalol
שמורה לחולים שלא יכולים לקבל תרופותצ מסוג
Class I AA
14
Q
Which conditions are C/I for using Class I AA drugs?
A
Pt without any structual heart changes
C/I in pt with coronary heart disease or CHF
15
Q
באיזה מטופלים עם פרפור פרוזדורים היעילות של אבלציה עולה על היעילות של תרופות אנטי-אריתמיות?
A
- Pt with paroxysmal AF who have not treated before (as 1st line)
- paroxysmal AF who have failed on AA drugs (the most), (as 2nd line)
- HFrEF
היעילות של אבלציה עולה על היעילות של תרופות אנטי-אריתמיות
16
Q
באיזה מטופלים אבלציה פחות יעילה מתרופות אנטי-אריתמיות
בפרפור פרוזדורים
A
Persistant AF
17
Q
AF
What is the sucess rate after 1st ablation and the 2nd ablation
A
1st ablation -70%
2nd ablation- 90%
in contrast to atrial flatter- 90% on 1st ablation
אבלציה מגבירה את התגובתיות לטיפול אנט אריתמי
18
Q
Which complication from Ablation in AF can present weeks to month after the procedure with dyspnea and hemoptisys?
A
Pulmonic vein stenosis
19
Q
In which situations pt with AFib will also need Anti-coagulation (even if CA2HDS2 VAS
and which Ag treatment?
A
**MS **
becuase of RHD, HOCM, Hx of stroke
Tx
Comadin (vit K antagonist)- AF + severe RHD or mehanical valve. target INR > 2
DOACS- direct inhibitor of thrombin or Xa, C/I in Cr CL < 15
20
Q
איפה נבצע אבלציה ומה היעילות שלה ברפרוף פרוזדורים
Atrial flutter
A
Cavotricuspid sinus, 90% success rate
21
Q
What are Stage I and Stage II HTN
A
Stage I- 130-139/80-89
Stage II- >140 / >90
Elevated 120-129/ < 80
22
Q
Which physical test can help us indentified psuedohypertension
A
feels radial pulse altough theres a block with the magenta
מצב נדיר במבוגרים בשל עורקים מסוידים מאוד, דורש מדידה תוך עורקית
23
Q
Which 2 types of pt can develop Renal artery stenosis
A
- older pt with atherosclerosis
- women with fibromuscular dysplasia
24
Q
How to Dx Renal artery stenosis?
A
Doppler of renal arteries»_space; CTA/ MRA
Gold standart- Arthriography with contrast
סימנים לחסימה משמעותית- היצרות > 70%, קולטרליים, יחס <1.5 בהפרשת רנין בין שני הורידים הכלייתים
25
What the surgical and the pharmacological treatments for **Renal artery stenosis?**
1. **Pharmacological-** ACEi / ARBs 1st line in unilateral atherosclerosis RAS (c/i in bi-lateral), also- statins, aspirin, smoking cessation.
2. **Surgical-** no advantage over pharmecology, failed on pharmacological treatmet / severe disease **mainly for Fibromuscular dyslasia**
26
What are the main ceuases for secondary HTN
OSA
Renal artery stenosis
ADPKD
Fibromuscular dysplasia - womens 40-50 (carotid, renal- pearls of strings)
pheochromocytoma
medications- high dose estrogens (COP's), steroids, MAOi, TCA, Psuedoheprine (nasal cogestio), Cyclosporine & Tarcolimus, NSIADS
EPO
Cocanine
Primary Aldo
Liddle syndrome- Aldo will be low
Cushing
coarctation of the aorta
27
מה הראה מחקר
Accomplish?
ACEi + CBB > ACEi + diuretic
in lowering the risk for CV and death in high risk pt
28
In which Subgroups ACEi showed superiority on lowering BP over other drugs?
DM 2
aphro-americans with hypertensive nephropathy
also reduce mortality of MI
29
Which lowering BP group showed a better protection rates against strokes?
CCB
30
What is the main effects of B1 anatagonist?
* lowering Contractility
* lowering renin realse from the kidney
31
all the following medication are:
Bisoprolol
Atenolol
Metoprolol
(BAM)
Beta1 cario selective antagonist
beta-blockers
| Side effect- Hyperkalemia (b1)
32
Which 2 beta-blockers are non selevtive (b2 + b1)
Timolol
propranolol
| Timolol = team= בקבוצה של כל הביתא
## Footnote
not recommend in Asthma and contrictive pulmonary disease
33
Which medications are alpha-1 + beta1+2 blockers?
Carvedilol
Labetalol (also a bit beta agonist "la beta LOL"= שיגועים
34
Side affects of Thiazides
* Hypokalemia
* insulin resistance
* high cholesterol
* could worsen hyperurecemia and gout (like loop diuretics)
* impotence
35
how to treat Hypokalemia with thiazides?
Amiloride or Triametrene (eNac)
weak anti HTN , can prevent hypokalemia with combination with thiazide
36
Side effects of Spironolactone (Aldactone)
Gnycomastia
impotency
ammenorhea/ irrgular periods
| can give Elperenone- without those side effects
37
Hypertensive urgency vs emergency
defintions
Urgency- BP >180/ >120
Emergency- Same BP + **evidance of organ demege**
38
all of the following are menefistation of --------
Retinopathy- hemmorage, papiledemma, glomerular damage or FSGN, MicroAngiopathyic Hemolytic Anemia (MAHA), Ancephalopathy
**Makignant HTN**
Rapid change in BP >> organ damage
39
What is the BP target when theres Encephalopathy?
and what is the Tx?
| HTN crisis
lowering BP in 25% or till 160/110-100 in minutes to 2 hours
**Tx:**
Nitroprusside
Labetalol
Nicardipine
| if HTN crisis + Scleroderma (renal crisis)= use of ACEi
40
What is the BP target for the following situations:
1. ischemic stroke who is candidate to tPA or Brain cathether?
2. ischemic stoke which no candidate?
3. Hemorhagic stroke?
**1. ischemic stroke who is candidate to tPA or Brain cathether- ** BP goal 185/ 110>
**2. ischemic stoke which no candidate-** Only when over 220/120 low in 15% in first 24 hours.
**3. Hemorhagic stroke-** only when systolic > 220, low in IV drip to 140-179 (Same medications as Malignant HTN)
| Malignant HTN medications:
Nitroprusside
Labetalol
Nicardipine
41
Immidiate Tx for aortic dissection?
IV BB + IV Nitroprusside
BP target sys < 120 (by the hand that shows the higher BP)
42
What is the Treatment for Adrenergic Crisus?
Phentolamine (alpha blocker) or Nitroprusside
43
Most common cause of HF?
Ischemic heart disease
44
Tx for **Acute decompensate HF?**
1. Loop diuretics until eovulemia
2. Vasodilators- Nitroglycerin or nitropruside
3. Ionotropes- Dubotemine / Dopamine (low dose = vasodiltor, high= constrictor), Milrinone (PDE-5 inhibitor, may cause low BP)
45
Which medications are used in HFpEF
* Spironolactone- less hospital admissions
* Candesartan- less hospital admissions
* Sacubitril/ Valsartan- improvment of function and symptoms
46
Tx for HFrEF
| first line, if symptoms persist (stage I + II)
1. ACEi/ ARBS + Beta-blockers + SGLT2i
**if pt symptomatic adds:**
MRA (spironolactone/ elprenone) and ARNI (sacubitril/valsartan) instead of ACEi / ARBs
**if symptoms persists**
wide QRS + LBBB - CRT (Cardiac Resynchronization Therapy)
ICD- if indicate
47
Which medicaitons are advices for HFrEF as reduce mortality
* **ACEi/ ARBS-** without correlation with severity of symtoms
* **BB-** same
* **SGLT2i-** same
* ** MRA (mineraloreceptor antagonist)-** add on over ACEi/ARBS + BB who are still symptomatic
* **ARNI (Valsartan + scubitril)-** Tx who suffer under ACEi/ ARBS
48
Which medications are the chosen to treat Supra-ventricular arrytmhias in the setting of CHF?
Amiodarone
Dofentilide
49
Which pt will be the optimal pt to treat with Cardiac resynchronzation therapy?
HFrEF, with **Sinus rythem, wide QRS** > 149 (but less also good), with** LBBB**
## Footnote
חולים שפחות מתאימים- dominant .AF, lateral wall scar RBBB, Decompensenated CHF
50
What are the indication fo ICD?
1. after event of SCD w/o reversible reason
2. NYHA II-III + EF < 35%
3. > 40 days post MI + EF < 30%
| one of the above
51
What is the 2 Treatment options for Secondary Mitral Regurgitation
1. condiser CRT if candidate
2. Replacment / repair- only in pt that either way going to CABG
3. Mitral clip- non surgery candidate. **prefferd approch**
| include also improving the CHF therapy given
52
Which factors elevate BNP and which decrease?
**Elevate**
1. elderly
2. womens
3. CKD
4. under ARNI treatment (niprylsin inhibitor)
**Decrease**
1. obesity
2. balanced CHF
53
Defenition of Cardiomypopathy
Heart muscle disease without stractural reasons or HTN.
54
How to Dx Infectious Myocarditis?
* Clinical presentation + Echocardiogram
* Infectious panel- adenovirus, influenza ,covid
* biopsy- 80-90% negetive
in MRI- edema and enhence after gadolinum mainly in mid-wall
55
Non infetious myocarditis DDx
Sarcoidosis
Giant cell myocarditis
Polymyositis, Dermatomyositis, SLE- Eosinophilic myocarditis
Transplent rejection
Checkpoint inhibitors treatemnt
56
Heart Sarcoidosis
1. which approch will be the best for Dx?
2. Whats the Tx?
1. **Biopsy-** mainly from mediastinal LN
2. **Tx-** High dose steroids follow by MTX
57
What is Takotubo Cardiomyopathy (DCM)?
Acute stress induce CM- mainly women after physical / mental stress
involve intensive symphathetic activetu
| Takotsubo- name of japanse octepus that the LV reasemble in this CM
58
Takotsubo CM
Dx
Treatment
**Dx-** Clinical signs (pulmonary edema, chest pain..) , Echo- global dilation of LV with decrease contraction of the apical base of the heart =** Apical ballooning apperance**
**Tx-** non selective alpha and beta blockers. if Prolong QT- magnesium
| חולף תוך ימים עד שבועות. פרוגנוזה טובה
59
Which Chemothrapic agents are Highly a/w Toxic Cardiomyopathy?
Antheracyclins (**Doxirubicin**)
**Trastuzumab**- Hercptin , anti HER2
if given together highly cardiotoxicity
| Dilated CM
60
What are the metabolic reasons for DCM
* Thiamine def. (Beri-beri)- firstly Hyperdynamic HF >> low output HF
* Def. in selenium, calcium, magnesium, phosphate
61
Which cardiomyopathy will be mainly with reduce diastolic function
and what will be the clinical presenation
**Restrictive CM**
Both atrials will be enlrage
**clinical presentation**
mainly of right HF- peripheral edema, asictes, with both ventricles with high pressure, positive kussumel sign
| DDx: constrictive pericarditis
62
DDx for restrictive CM
**דברים שמסנינים את רקמת הלב**
**Amyolidosis**- most common
Hemochromatosis
Fabry
Glycogen storage disease II,III
Radiation
Scleroderma
63
Which type of amyloydosis can filtrate the heart, what is a unique cherateristic of each one
**AL/primary amyloid-** MM >> also Nephrotic syndrome may present
**ATTRm-** mutent ATTR, young people, afro-americans
**ATTRwd-** old mans > 90 (mainly), can manifest with spinal stenosis
*both can present with peripharal neuropatrhy and Carpal tunnel synd
64
When amyloidosis is suspected?
ECG + Echo
מיוקראד מעובה + וולטאז נמוך באק"ג
65
How to Dx all types of heart amyloydosis?
| Restrictive CM
Biopsy 100%
DPD- only for ATTR types
66
Tx for Restrictive CM by Amyloydosis?
1. **AL-** Bortezomib (proteosome inhibitors)
2. **ATTR-** Tafamidis for neuropathy
C/I for digoxin
BB + ACEi / ARBs- can worsen the symptoms
for the HF- mainly diuretics and symptomatic
67
Common Tx for HCM
| Target- low HR + contractility, remain per-load
1. **BB + CCB **(non dhydro like vermapil)- also if Afib
if symptoms persist:
**Disopyramide-** AA with negetive ionotropic effect
if edema present- carefully diuretics
68
What are the risk factors in HOCM for considering ICD?
1. Hx of Heart arrest or sustained VT- most strong
2. Syncope w/o other explaination
3. spontanyous NSVT
4. LV thickness > 30 mm
5. family Hx of HCM
6. abnormal reaction for exresice-BP drop or not elevate during exerisce
## Footnote
when theres 2 of the risk - ICD implantaion **as long as survive > 1 year**
69
What are the etiologies for blood in the pericard?
1. malignancy
2. CKD
3. after heart surgery
4. TB
70
A pt present with Friction rub and diffuse ST elevations + PR depression
Pericarditis
71
Tx for pericarditis
1st line
2nd line
3rd line
1st line- NSAIDS / Aspirin+ PPI + Colchicine
2nd line- Steroids (increase risk for reccurence)
3rd line- Azathioporine or anakirna- for high reccurence > 2y and refoctroy for 1-2 line treatment
72
Which Reumatological diseases are most common for pericarditis
**SLE and Drug induce SLE**
**Drug induce SHIPP:**
S- sulfa drugs (like SMX)
H- hidralyzine (BP mainly pregnancy)
I- Isoniazide (TB Tx)
P- procaniamide
P- phyntoin
73
Tx for uremic pericarditis?
dialysis
| **w/o chest pain**
74
Chronic Constractive pericarditis has a similar clinical picture as right / left sided diastolyc/ systolic HF
Right sided diastolic HF
75
What is positve kussmaul's sign?
When JVP is not flattend during inspiration - means there somthing blocking the heart from getting all the blood from the RA.
| in Temponade we will see positive kussmel sign
76
Chronic Constractive pericarditis
how we Dx?
whats the Tx?
Dx- MRI/ CT
Tx- Pericardial resection
| if pt > 50 yrs . Diagnostic cardiac catheterization before procedure
77
What is beck's triad
when we will see it?
**Temponade**
1. Distant heart sound
2. hypotension
3. Jugular veins congestion
| significant X decent w/o Y decent
78
all of the following are clues for ?
CXR- increase size of heart
ECG- Electrical alternans + low QRS amplitude
Pulsus paradoxsus
**Temponade**
79
Temponade
Dx?
Tx?
DX- Echo
Tx- Pericardiocentesis
80
Sever Aortic steosis defintion
narrow of Aortic valve < 1 cm
gradient > 40 mmHg
velocity > 4
81
What is low flow low gradient AS
not meet the floe and gradient of typical Aortic stenosis
1. low EF < 50%
2. normal EF
82
Which valve pathogly is with paradoxial split of S2 + Pulsus parvus et tardus?
AS
83
What are the 3 main indications (Class I) to replace Aortic valve?
1. **Symptomatic AS**
2. **Asymotpmatics AS +**
EF< 50%
Going trough cardiac procedure anyway
84
When we will replave Valve to mechanic and when to biology?
Biology- better > 65 yrs (30% malfunction in 10 years)
Mechanical- require comadin for life
85
TAVI (גישה מלעורית להחלפת מסתם)
Prons and cons
Prons:
less compilcations then SAVR (surgical)
Cons:
more will need ICD (AV-block)
86
When we will prefferd using TAVI instead of SAVR
* Older pt.
* Fragile
* significant co-morbidites
* porcelain aorta
| Pt < 65 yrs we will preder SAVR ,
## Footnote
SAVR- Bicuspid valve, reumatic disease of valve, annulus too large / small for tavi, pereferd mechanical valve, Afib, absecnt of vascular approch to TAVI (Femoral)
87
When Aortic Regurgitation will be Treated surgically?
1. Severe AR + symptomatic
2. Severe AR + Asymptomatic
Class I:
1. Severe AR + symptomatic
2. Severe AR + Asymptomatic with:
EF < 55%
either way doing a cardiac surgery
class IIa:
Severe AR + Asymptomatic with LVESD > 50 mmHg
Moderate AR + either way going to a cardiac surgery
| התערבות לרוב בהחלפת מסתם
88
Most common cause of primary MR ?
MVP
| mostly by the process of myxomatous degeneration
89
DDx of primary MR
4 main reasons
1. MVP- most common
2. RHD
3. congenital
4. IE or radiations
90
DDx for secondary MR?
3 main
Dilated CM, ishecmin CM
HOCM
Afib
91
What is the most common reason for acute MR?
MI
rupture of the papillary muscle- most common the posterio-lateral (blood by Post. decending artery- think about it when Inf. MI )
92
What will be the Tx for **Primary and secondary MR**?
severe symptomatic
severe- asymptomatic
**Primary**
2. 1. severe symptomatic- always surgery
2. severe- asymptomatic- must also have EF < 60% or LVESD > 40 mmHg
3. Miral clip- for high risk pt (for surgery)
93
When we will preform Mitral clip **in primary and secondary MR**
**Primary-** very high risk pt. (for surgery)
**Secondary-** Severe MR + EF < 50%, remain symptomatic despite pharmacologic Tx
94
In aortic dissection
which layer is ruptrue and where the blood builds up
Intima rupture >> blood builds up in the intima - media layers >> false lumen
95
What is the most common risk factor for aortic dissection?
HTN
96
Which drug can cause aortic dissection in a free risk pt?
Cocaine
97
Which murmur will be found in 50% of pt with aortic disecction?
Diastolic murmuer - AR
98
How we Dx Aortic Dissection?
**Echo**- stable/ non stable pt
**CTA/ MRI**- test of choice in stable pt
99
What is the immidiate Tx of aortic disecction?
Systolic < 120 by:
1. **BB- **labetalol or Esmolol
1. **Nitropruside IV **- given in ICU setting
100
What is the criteria for repairing aortic anyresums?
| 6 inidcations
1. symptoms or complication (aka aortic dissection)
2. aysomptomatic :
3. קוטר > 5.5 ס"מ
4. קצב גדילה של > 0.5 ס"מ בשנה
5. marfan + dissection - 4-5 cm
6. bicuspid valve who are supposed to go surgey when aorta > 4.5 cm
101
AV block + inferior MI
which dagree
whats the prognosis and Tx?
mostly 2nd degree
mostly reversible. does not require any pacemakers
102
AV block + anterior MI
which dagree
whats the prognosis and Tx?
2 to 3rd dagree- not stable. RBBB
temorary pacmaker needed
103
When we will consider MRI in the present of AV block?
AVB < 60 yrs
or high clincal suspect for stractural disease
## Footnote
diseases: amyloidosis, myocarditis, sarcoidosis...
104
PET - CT can help us diagnose which 2 conditions in the present of AVB?
Amyloidosis- TTR (familial)
Sarcoidosis
105
Which substance will increase the AV node conduction and which will decrease?
**increase conduction-** Atrophine, Isoproterenol (beta-agonist), exresice = increase sympathetic activity
**Decrease conduction-** vagal manuvers, carotid massage = increase para-sym activity
## Footnote
תמונה הפוכה במידה ויש חסם הולכה אינפרא-נודולרי (כנראה הכוונה ל-RBBB או LBBB
106
When we will do a **EPS test** in pt with syncope and AV block?
high suspiction of higher dagree AV block and non invasive methods did not helped
בודקים מהירויות הולכה:
1. AV - His > 130
2. His - ventricles > 55 always pathological, indication for Pacemaker
107
Which AV block dagree will be treated with Atropine or Isoproterenol?
AVB II (morbitz I)
only if symptomatic
108
What are the indication for persistant CDI
1. **non reversible Morbiz II and up**
2. **non reversible Weknbach-Morbitz I only if**-
* symptomatic
* present of progressive disease that can worsen the AVB
109
What is Pacemaker syndrome?
**disynchronization of the AV node**
distendent Jugulars, syncope, myalgia, dizziness- **Clinical picture of CHF**
| mainly when using VVI- one electrode in each room
110
Which pacemaker recommend in order to prevent pacemaker syndrome
when its C/I?
DDD- 1 electrode in the atria, second in the ventricle
**recommend for Pt with sinus and AV block**
C/I- Afib
111
Which pacemkaer recommend for AVB + EF < 50%
CRT- synchronization between the ventricles
## Footnote
3 total pacemkaers- VVI- one electrode in each room >> pacmaker syn.
DDD- atria + ventricle. C/I Afib
112
קווי הטיפול ב-
PSVT with nerrow complex
Vagal manuvers >> Adenosine IV (C/I heart transplent) >> BB + CBB
113
Tx in pre-excited tachycardia with Afib/ Flutter
Tx- Cardioversion or butilide or procinamide
| מצב מסכן חיים, wideQRS irregular with bizarre changed complexes
114
Cannon A waves in JVP wave?
VT
115
Which electrolyte disturbance can cause prolong QT?
all the hypo- hypomagnesemia, hypocalcemia, hypocalemia
116
Drug induce prolong QT
AA class IA + III, Macrolide, Flueroqionolone, resperim, clindamycin, halidol
117
Pharmecological Tx for Torsa de pointes?
Magnesium sulfate 1-2 gram IV
| if not enough >> consider adding **isoproterenol (b agonist)**
118
Brugada syndrome definition
icecream scoop ST + inverted T waves in more then 1 lead (V1-V3)
+
events of syncope or cardiac arrest (due to pleomorphic VT)
| **ICD-** unexplain syncome / cardiac arrest
**Ablation-** reccurent VT
119
Epsilon wave + inverted T waves + wide QR in V1-V3
| which syndrome?
Arrythmogenic RV cardiomyopathy
| הגדלת חדר ימין, אזור צלקת בהדמייה- החלפת המיוקרד ברקמה פיברו-שומנית
## Footnote
**ICD is the Tx** VT under stress- BB
120
Well's score
what does this score checking
what the meaning of above and below 4
**the clinical likehood of PE**
WS > 4 - high clinical suspect >> proceed directly to imaging
WS < 4- low >> proceed to Di-dimer
121
Which test is the test of choine in PE and DVT with high clinical suspect
**PE- ** chest CTA >> lung mismatch test >> Venous US
**DVT-** Venous US
## Footnote
**each time we move fowerd in test is when the test is non-diagnostic, unavalible or unsafe**
122
What is Mconnell's sign
hypokinesis of the free wall of RV + hyperkinesis of apex RV
**סימן עקיף לאמבוליזם בריאה**
123
What is the primary Tx in PR with :
1. normotensive + normal RV
2. Normotensive + hypokinesis RV
3. Hypotension
P**1. normotensive + normal RV**- Anticoagulation alone +- IVC filter
**2. Normotensive + hypokinesis RV**- Anti-coagulation. consider also tPA
**3. Hypotension**- Anti-coagulation + tPA / Embolectomy (cathter or surgical)
124
Which medication are 1st line Tx in massive PE
hypotension present - 500 ml Normal seline
first line pressors- NE + dubotamine
## Footnote
other lines- VA ECMO- as bridge for definitve Tx with thrombolysis or embolectomy
125
C/I for tPA in Tx of PE?
| and what is the risk for major and intra-cranial bleeding
1. intra-cranial disease
2. surgery in the last 2 weeks
3. trauma
risk for major bleeding 10%
risk for intra-cranial bleeding 2-3%
## Footnote
**When given tPA, at first always combine with heparin**
126
Indications for IVC filter
1. Active bleeding = prevent use of Anti-coagulation
2. Reccurent VTE despite optimal therapy
127
Dx of APLA
**Rq 1 clinical criteria and 1 lab**
Clinical:
1. at least one thrombotic event (venous/ arterial)
2. abortion (1 abortion/ early delivery < 34 weeks, or 3 abortion < 10 wks)
Lab:
high lab results in 2 seperate test (>12 hrs apart) Lupuse Anti-coagulant, Anti-cardiolipin, Beta-2 glycoprotein
LAC- not tested when using comadin
128
# Right atria wave pressure
what symbole the A wave ?
| When we will see Cannon waves and when A will be abscent
**A**trial Contraction
**Cannon A wave-** contraction infornt of closed TV (Complete AV block, SSS, VT)
**Abscent-** afib (atria is not contracting)
| End diastole
129
# Right atria wave pressure
what symbole the X descent ?
| when will be up and when will be down
Atrial Rela**x**ation
high X descent- constrictive pericarditis
low X descent- TR
| mid systole
130
# Right atria wave pressure
what symbole the c wave ?
TV **C**usps bulging into RA
| Early systole
131
# Right atria wave pressure
what symbole the v wave ?
| when this V wave will be increase
rapid Atrial Filling
**increse in TR**
| late systole
132
# Right atria wave pressure
what symbole the y descent ?
| when it will elevate and when decrease
earl**y** ventricular filling
**elevation of y desecnt**- Constrictive pericarditise, RV failure
**decrease-** Temponade
| late systole
133
Which situation we will see pulsus paradoxus
* Temponade
* massive PE, Tension PTX
* hemmoragic shock
* severe obstractvie lung disease- asthema, COPD exc.
| decrease in more then 10 mmHg in insperium
134
Paradoxial splitting of S2?
LBBB
Right sided ICD
AS
HOCM
acute ischemic myocardium
135
S3
early diastole sound = rapid filling
dilated room
136
S4 meaning
end diastole
Stiff ventricle (reduce comliance)
137
# ECG findings
diffuse inverted T waves , prolong QT, deep T waves
| which extra-cardiac situation is ?
SAH
138
Which pt consider to be High risk in positve stress test
angina during the test or ST depression > 2mm in number of leads
| need for catheraztion
139
Which condition is increase the likelhood for
FP and FN results in exresice test?
**FP-** low pre-test probability for IHD
**FN-** condition involves only the LCX (does not show well on the ECG)
140
which medication is used in Echo heart test?
dobutamine (b1 agonist)
141
באיזה חומרים משתמשים במיפוי לב
ומה עלולים לעשות כתופעת לוואי
**Adenosine and dipidremole**
vasodilation of the coronary.
Side affect- excarsarvation of asthma
## Footnote
if theres ischemia there will be a "coronary steal"- which mean that more blood will go to non-ischemic area from the ischemic areas.
142
What is the Calcium score
probability for CAD
high > 400
depends also on pt presentation
143
What is the specifity and sensetivity of CT coronary and which type of pt is best for
Sensetivity -99%
specifity- 90%
**very good for rule out CAD**
good for pt with weak-mild probability for CAD
144
# מהי בדיקת ההדמיה המתאימה במצבים הבאים
Pain chest in a pt w/o any know coronary disease + normal ECG
if can do stress test >> **Stress test**
if can't >> echo stress or heart imaging )מיפוי לב(
145
# מהי בדיקת ההדמיה המתאימה במצבים הבאים
Pain chest in a pt w/o any know coronary disease + pathological ECG (LBBB/ LVH)
echo stress or heart imaging )מיפוי לב( or CTA
146
# CAD imaging
Which imgaging to choose for the following pt
Atypical pain + low pre-test probability
Medium to High pre-test probaility
**Atypical pain + low pre-test probability**- coronary CTA
**Medium to High pre-test probaility**- Imaging under stress (מיפוי או אקו מאמץ)
147
When CABG is preffered over Catheterization
1. left main involvment
2. 3 arteris
3. 2 arteris (one is proximal LAD) + EF < 50% or DM
4. lesions that not fit PCI
148
Which type of troponing is specific for MI?
Troponin I + T
149
Which Anti-PLT is the best choice for candiate for PCI (in the setting of ACS)
| and what is the C/I
**Prasugrel**
| לא לטיפול שמרני
## Footnote
**C/I**- previous CVA, High risk for bleeding
150
Which Anti-coagulation from the NOAC has similar afficacy as clexane but less chande of bleeding
**Foundaparinux**
| דורש החלפה להפרין בזמן צנתור כדי למנוע טרומבוס משני לפרוצדורה
151
What include the long term Tx for ACS- NSTE
ACEi ARBS
BB
Statins- if not < 55, add PCSK9i or Ezetimibe
GLP1 or SGLT2 - in selected pt with DM2
Anti-PLT- 3 month after event / 12 month / high risk for 3 years
* adding **Ribaroxoban** to DAPT show improve prognosis (depsite increase probaility for bleeding)
152
which medications we will give in Acute STEMI
1. Bolus ASpirin
1. P2Y12 inhibitors (plavix, bralinta, effient)
1. GPIIb/IIIa inhibitors- for prevention of thrombotic complications
1. Anti-coagulation- Clecxane > heparin
1. Symptomatic Tx- Nitroglycerina / morphine
2. BB- relieve symptoms, decrease MI size
3. ACEi/ ARBs- in stable pt after STEMI
## Footnote
C/I CCB
153
How medically we can provoke prinzmetal varient angina
injeciton of Ach to coronary- due to endothelial disfunction will lead oto vasospasm
| Tx- nitrates, CBB
154
PHTN (pulmonary)
Definition
mean pulmonary atrieal pressure > 20 mmHg
155
Which test is the most importent screening test to evaluate PHTN?
**Bubble study - Echo**- when est. pressure in the pulmonary artery > 35 mmhg = caculate by the velocity in TV
**also can use Echo-** Large RV/ RVH - suggest PTHN
156
What is the Gold standart for Dx of PHTN?
wedge pressure
PVR (pulmonary vascular resistance)
157
Which medication are given in PAH (type I)
1. CBB- when positive vaso-reactive test ( MPAP > 10 mmhg, and less then 40)
2. if vaso reactive negetive- Prostenoids, Endothelin receptor antagonist, PDE-5 inhibitors (sildenafil)
3. lung transplant- in severe refactory pt.
158
Which arrytmia can develop after succsesful thrombolysis therapy for MI
**AIVR**
absecnt of P waves
wide QRS
159
