Cardiology

Question 1

Risk factors for CAD include…

Answer 1

DM
HTN
tobacco use
HLD
PAD
obesity
inactivity
family hx

Question 2

Typical ischemic chest pain has these characteristics:

Answer 2

substernal location
occurs consistently with a certain level of exertion
relieved by rest or nitro

Question 3

Atypical chest pain usually occurs in…

Answer 3

the elderly, diabetic female

Question 4

Atypical chest pain includes the following characteristics:

Answer 4

dyspnea, palpitations or syncope

Question 5

when one of the following features are present, the patient has something other than CAD:

Answer 5

pleuritic pain (think PE, pneumonia, pleuritis, pericarditis, PNX)
positional pain (pericarditis)
tenderness to palpation (costochondritis)

Question 6

A patient comes to the ED with chest pain. The pain also occurs in the epigastric area and is associated with a sore throat, bad metallic taste in the mouth, and a cough. What do you recommend? (Tx)

Answer 6

PPI

Question 7

An alcoholic patient comes to the ED with chest pain. There is n/v and epigastric tenderness. What do you recommend? (Dx)

Answer 7

check amylase (in real life not useful at all), and lipase

Question 8

A patient comes to the ED with chest pain. There is RUQ tenderness and mild fever. What do you recommend? (Dx)

Answer 8

RUQ U/S to look for gallstones

in reality, patient also gets the full cardiac workup in the ED, including EKG, CBC, BMP, CXR and probably troponin

Question 9

An S3 gallop structurally means…

Answer 9

there is a dilated L ventricle

Question 10

An S4 gallop structurally means…

Answer 10

the atria are contracting against a stiff LV

Question 11

Best initial test for ischemic type chest pain

Answer 11

ALWAYS EKG

Question 12

In single best answer questions, a consultant is necessary when ordering an EKG, checking enzymes, and giving ASA to a patient with ACS (true/false)

Answer 12

false

Question 13

In a clear case of ischemic chest pain if asked to choose between EKG vs combined ASA, second anti-platelet meds, statins, ACEi, BB and nitrates, choose…

Answer 13

treatment first

Question 14

Best test to detect reinfarction a few days after the initial infarction

Answer 14

CK-MB (both CK-MB and troponin rise at 3-6 hrs after the start of chest pain, CK-MB stays elevated for only 1-2 days while troponin stays elevated for 1-2 weeks)

Question 15

first line test for patients with chronic stable angina

Answer 15

stress test (treadmill if preferable, need to be able to achieve 85% maximum HR, or 220 - patient’s age)

Question 16

What should be used if patient cannot do an exercise stress test?

Answer 16

medication stress test with either inotropes (dobutamine) or vasodilators (regadenoson, adenosine or dipyridamole). reduces blood flow through already maximally dilated arteries by dilating the other arteries (coronary steal)

Question 17

contraindications to dobutamine testing include…

Answer 17

uncontrolled HTN (SBP >180), aortic dissection, or recent ACS

Question 18

Next step with abnormal stress test result findings

Answer 18

angiography (definitive treatment)

Question 19

the most accurate test for defining ischemic heart disease is…

Answer 19

CK-MB or troponin (cardiac enzymes)

Question 20

When is exercise thallium test or stress echo the answer?

Answer 20

when the EKG is unreadable for ischemia (LBBB, digoxin use, pacemaker in place, LVH, or any baseline abnormality of ST segment of the EKG)

Question 21

type of stress test used for obese patients

Answer 21

sestamibi nuclear stress (ability to penetrate tissue)

Question 22

What is the best initial treatment for ACS that has been proven to reduce mortality?

Answer 22

ASA (along reduces mortality for MI by 25% and by 50% for unstable angina)

Question 23

What is DAPT?

Answer 23

ASA combined with clopidogrel, ticagrelor, or prasugrel

Question 24

MOA of clopidogrel, prasugrel and ticagrelor

Answer 24

block aggregation of platelets to each other by inhibiting ADP-induced activation of the P2Y12 receptor

Question 25

DO NOT use vasodilator stress testing in patients with the following since it can cause bradycardia and hypotension

Answer 25

sick sinus syndrome or AV block

Question 26

how does nitro relieve ischemic pain?

Answer 26

peripheral vasodilation decreases preload through venous dilation which reduces myocardial wall tension and improves myocardial perfusion

Question 27

ALWAYS ask about this before giving nitrates

Answer 27

if patient takes any PDE-5 inhibitors (sildenafil or tadalafil)

Question 28

with a STEMI, angioplasty must be performed within how many minutes of ED arrival?

Answer 28

90

Question 29

In a patient with a STEMI, what should you do next if angioplasty cannot be performed within 90 minutes?

Answer 29

give thrombolytics

Question 30

Do BB lower mortality in STEMI patients?

Answer 30

yes (and not dependent on timing)

Question 31

do ACEi lower mortality in STEMI patients?

Answer 31

only if there is LV dysfunction (systolic dysfunction)

Question 32

When are statins given to ACS patients?

Answer 32

ALWAYS, does not matter what EKG results or cardiac enzymes show

Question 33

Exact definition of ACS

Answer 33

group of conditions that suddenly stop or severely reduce blood from flowing to the heart muscle (which is why unstable angina, NSTEMI and STEMI all fall under the umbrella of ACS)

Question 34

difference between unstable angina and NSTEMI

Answer 34

both have increased frequency, duration or intensity of chest pain, but NSTEMI will have an increase in cardiac enzymes

Question 35

STEMI definition

Answer 35

>1 mm ST elevation in 2+ contiguous leads or >2 mm ST elevation in V2 and V3 or new LBBB with chest pain

Question 36

Other symptoms of inferior MI other than elevations in leads II, III and aVF

Answer 36

hypotension with elevated JVP and bradycardia (but clear lungs)

Question 37

Beck's triad

Answer 37

hypotension, JVP elevation and muffled heart sounds (found in cardiac tamponade)

Question 38

mg of ASA to chew and swallow for a patient with ACS

Answer 38

325 mg

Question 39

troponins should be rechecked after how many hours if indicated?

Answer 39

4-6 hours

Question 40

dosage of nitro

Answer 40

0.4 mg every 5 minutes up to 3x

Question 41

morphine should NOT be given to patients with MI if...

Answer 41

they are in cardiogenic shock or have right sided MI (decreased RV filling)

Question 42

how do BB reduce mortality in patients with MI?

Answer 42

reduces infarct size if given within the first 24 hours

Question 43

single greatest efficacy in lowering mortality in a STEMI

Answer 43

urgent angioplasty/PCI

Question 44

when would you give verapamil or diltiazem to patients with ACS?

Answer 44

if there is an intolerance for BB such as a severe reactive airway (asthma) or coronary vasospasm/prinzmetal angina

Question 45

when is lidocaine or amio given for acute MI?

Answer 45

with V tach

Question 46

All patients post-MI should go home on...

Answer 46

DAPT BB (decreased O2 demand) ACEi/ARB (decrease remodeling and scarring) high intensity statin (atorvastatin 80 mg)