CARDIOLOGY Flashcards

Question 1

Q

What sort of waves should you expect with SVT (supraventricular tachycardia)

Answer

A

-narrow complex tachycardia
-retrograde p waves that often appear w/in t wave or ST segment

Question 2

Q

What 2 grps do NOT get exercise ekg stress test

Answer

A

(1) Pt unable to exercise
(2) Pts with baseline ekg abnormalities

Question 3

Q

What 4 ekg abnormalities require a pt NOT get tested using exercise ekg stress test

Answer

A

(1)WPW
(2) ST depressions
(3) LBBB or ventricular pacing/pacemakers–both cause false-positive LV anteroseptal defects
(4) digoxin use
These pts require stress testing with pharmacologic agent instead

Question 4

Q

STEMI Management:

a) What 4 things should you immediately give pt with STEMI
b) What 1 question do you need to ask

Answer

A

4 THINGS:
(1) ASA loading dose (162-324 mg)
(2) P2Y12 inhibitory (clopidogrel, ticagrelor)
(3) IV anticoagulation: UFH, enoxaparin, bivalirudin
(4) oxygen prn, BB prn

1 QUESTION TO ASK:
Is pt at PCI-capable facility. IF yes, goal 1st medical contact-to-balloon time 90 mins (or can be transferred to this facility w/in 120 mins.).
IF NO, thrombolytics.

Question 5

Q

NSTEMI Management
What is management –2 main options– for NSTEMI

Answer

A

1) Invasive managment–>Coronary angio. Note can be immediate (w/in hrs), early (2-24hrs), or delayed (24-72hrs)

NSTEMI part of ACUTE coronary syndrome (ACS). ACS (STEMI, UA, NSTEMI) is umbrella term for presentation of ACUTE CHEST PAIN +/- ekg findings of ischemia

Ok, you’ve done ekg and no ST changes. Drawn labs and troponin is negative (meaning UA or NSTEMI). Now have 2 options

#2) Medical management (ischemia-guided therapy)

Question 6

Q

What are 4 indications for IMMEDIATE invasive therapy (coronary angio w/in 2hrs)

Answer

A

(1) signs/sx of HF (JVP, LE)
-(2) hemodynamic instability
-(3) recurrent/refractory angina not responding to medical therapy
-(4) life-threatening arrhythmias (vtach, vfib)

Question 7

Q

What are indications for EARLY invasive therapy (coronary angio w/in 2-24hrs)

Answer

A

new ST depression
positive trop
GRACE score >140

Question 8

Q

Do STEMI and NSTEMI-ACS pts selected for PCI get parenteral anticoagulation and DAPT

Answer

A

Yes. But remember, NSTEMI-ACS do NOT get fibrinolytics

Question 9

Q

What is therapy for ischemia-guided NSTEMI-ACS management?

Answer

A

Basically same as those getting invasive management except that fondaparinux ok if NO invasive tx planned

(1) ASA loading dose (162-324 mg)
(2) P2Y12 inhibitory (clopidogrel, ticagrelor)
(3) IV anticoagulation: UFH, enoxaparin, bivalirudin OR Fondaparinux

**NEXT do stress test or eval LV function **(w/echo. IF EF <40%, early angio needed)

** In the PLATO trial, ticagrelor was found to be superior to clopidogrel in reducing the incidence of cardiovascular death, myocardial infarction, and stroke after ACS, and the American College of Cardiology/American Heart Association guideline confirms that it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy. Clopidogrel or ticagrelor therapy may be used regardless of the ACS treatment strategy; however, prasugrel is indicated only in patients treated with percutaneous coronary intervention.

Question 10

Q

Aortic Stenosis. Answer 5 Questions
(1) What are RFs
(2) Describe murmur
(3) What makes louder
(4) How do you assess severity? What is dx? (5) What is tx

Answer

A

AORTIC STENOSIS:
(1) RFs: age-related clarification, congenital bicuspid aortic valves btwn 40-70yrs
(2) Murmur: systolic cresendo-descrendo along right upper sternal border
(3) Louder w/squatting, expiration
(4) Dx w/doppler echo. Severity assessed by:
-mean gradient ≥ 40mm Hg
-peak velocity ≥ 4m/sec
-VALVE AREA < 1cm2
(5) Treatment always SURGICAL.
Indications for tx:
–Symptomatic SEVERE OR
–asymptomatic SEVERE w/EF <50% OR
–asymptomatic SEVERE undergoing cardiac surgery

**SAVR (surgical AV replacement)&raquo_space; TAVR (transcatheter AV replacement).
**TAVR is less invasive (becs catheter) but less durable and so preferred in pts >80yrs.

Question 11

Q

Mitral Stenosis. Answer 5 Questions
(1) What are RFs
(2) Describe murmur
(3) What makes louder
(4) How do you assess severity? What is dx? (5) What is tx

Answer

A

MITRAL STENOSIS
(1) Usually 2/2 rheumatic fever. Other causes include SLE and severe valve calcification. Afib common and also can cause pulmonary HTN and R-sided HF.
(2) diastolic murmur w/opening snap, low-pitched rumbling; best heard at left 5th interspace at midclavicular line
(3) Squatting, expiration
(4) cardiac echo, TTE 1st. Severe MS is defined as VALVE AREA ≤ 1.5cm2
(5) Medical management (diuresis/BB/CCB) or surgical (mitral balloon valvotomy) IF severe and symptomatic.

Surgical mitral valve repair/replacement LESS desirable

IF pregnant with MS: BB –>surgical repair

Question 12

Q

What is medical management for MS

Answer

A

*Medical management: diuresis + heart rate control (BB, CCB)

*IF non-pregnant with MS AND afib/thrombus/prior embolic event: warfarin.

*IF pregnant with MS and Afib/thrombus/prior embolic event: heparin instead (becs of the teratogenic effects of warfarin).

**DOACs NOT indicated in afib+MS

Question 13

Q

Mitral REGURGE. Answer 5 Questions
(1) What are RFs
(2) Describe murmur
(3) What makes louder
(4) How do you assess severity? What is dx? (5) What is tx

Answer

A

MITRAL REGURGE
(1) Any issue w/mitral valve–>rheumatic heart dx, endocarditis, MVP, ischemia involving papillary muscle (from CAD or MI -see this w/acute MR)
(2) Chronic MR different from acute MR. ———Chronic MR: constant holosystolic murmur
-Acute MR: descrescendo early systolic murmur at APEX (AR is descrendo diasytolic murmur @ left sternal border) + wet lungs
(3) Louder with:
-Chronic MR: increased afterload (handgrip, expiration), no change in valsalva
-Acute MR: Squatting, expiration
(4) Cardiac Echo, TTE. Chronic worse than acute
(5) Chronic: diuretics, afterload reducing agents (ACE-I/ARB)
-Secondary needed for acute AR

**IF surgery, reconstruction preferred UNLESS have Rheumatic fever–then replacement

Question 14

Q

What is treatment for prinzmetal angina? What agent should be avoided?

Answer

A

**With Prinzmetal agina pt p/w CP at rest, transient ST elevations, neg trop, and normal coronary arteries.
-Tx: CCB
-AVOID BB as this can increase risk of spasms.

Question 15

Q

Describe 3 general tx for afib

Answer

A

1) urgent/emergent cardioconvert –>hemodynamically unstable tachycardia
2) Rate control –> common for asx or minimally sx pts
3) Rhythm control –>preferred for symptomatic or younger pts

Question 16

Q

Discuss cardioconversion strategy for afib

Answer

A

1) DC cardioversion preferred to pharmacologic cardioversion

2) When doing cardioversion, IF afib >48hrs or duration unknown then:
-anticoagulation recommended for 3wks prior and 4wks after cardioversion (regardless of CHADS2Vasc score) OR
-Use TEE to r/o thrombus and then cardioconvert (TEE-guided cardioconversion is fast and effective)

Note if afib <48hrs, most pts can be cardioconverted safely w/out any preceding anticoagulation

Question 17

Q

Describe in detail rhythm control-pharmacologic cardioversion options for a fib

Answer

A

**if >48hrs, 1st TEE to r/o thrombus then pharmacologic cardio. remember electric cardioconversion is PREFERRED over pharmacological, both get TEE 1st

IF Afib >7days
-1st option: dofitilide
-2nd line: amiodarone or ibutilide

IF Afib < 7 days
-1st option: dofetilide, flecainide, ibutilide, or propefanone
-2nd line: amiodarine

Question 18

Q

Describe anticoagulation strategy for Afib

Answer

A

Anticoagulation to prevent thrombosis in afib pts (regardless of rhtymn or rate control strategy) recomended.

1) CHA2 DS2 VASc used for risk stratification of non-valvular afib pts.
2) Warfarin (regardless of CHAA2 DS2 VAsc) for–HCM AND prosthetic vavles

Question 19

Q

What is CHA2 DS2 VASc

Answer

A

This is risk stratification for pts WITH NON-VALVULAR afib (no prosthetic valves, rheumatic MS) – used to determine whether pt with afib should be on an anticoagulant.
C: CHF or EF <35% (1 pt)
H: HTN (1 pt)
A : Age ≥ 75 (2pts)
D: DM (1 pt)
S: Stroke/TIA/thrombolic event (2 pts)
V: vascular dx (prior MI, PAD, aortic plaque) (1pt)
A: AGe 65-74 (1pt)
Sc: Sex Category (1pt)

IF 2+ then get warfarin or DOAC.

Question 20

Q

What is DAPT? How is duration determined?

Answer

A

DAPT: Aspirin and P2Y12 inhibitor (clopidogrel, ticagrelor) indicated for ACS, CAD , and also PAD.

DURATION: DAPT determined by indication.
*IF DAPT for ACS– > then ≥ 12 mos regardless of whether BMS, DES, or no stent
*IF DAPT for stable CAD –> then depends on type of stent.
-DES: at least 6 months of DAPT
-BMS: at least 1 month of DAPT
*IF bleeding risk:
-cont 1 drug (ASA or clopidogrel) after 4 months
*IF afib:
-warfarin/DOAC. d/c aspirin. NO triple tx
*IF mechaical value
-warfarain + clopidogrel.

Question 21

Q

What are 2 types of temporary pacemakers? What are indications for temporary pacemaker?

Answer

A

TYPES of temporary pacemaker:
-transvenous or trancutaneous

INDICATIONS:
-asystole
-symptomatic bradycardia (includes sinus brady w/hypotension)
-bilateral bundle branch block (BBB)
-overiding pacing for torsade de pointes

Question 22

Q

What are indications for PERMANENT pacemaker?

Answer

A

-symptomatic bradycardia
-asymptomatic high-grade AV block (3rd degree block OR 2nd-degree AV block, mobitz type 2)
-alternating bundle branch
-afib + tachycardia (tachy-brady symptom)

*Note, 2nd degree AV block, Mobitz type 1 (aka Wenckeback block) only requires tx if pt sx –>then becomes “symptomatic bradycardia”

Question 23

Q

What is duration of DAPT based on stent if CAD

Answer

A

For bare metal stent: at least 1 month
For drug-eluting stent: at least 6 months

Question 24

Q

What is regimen for pts following STEMI

Answer

A

BB w/in 24hrs
ACE-I w/in 24hrs
Keep bsg <180
Statin
sprionolactone if EF <40%
DAPT (ASA, clopidogrel) for at least 1yr

Question 25

Q

What is dx for LBBB

Answer

A

1) left axis deviation (I, avf)
2) wide QRS (>3 boxes)
3) V1: neg QRS, with pos ST
4) V6: pos QRS, with neg ST

Question 26

Q

What is dx for LVH

Answer

A

1) avl: R >12mm
2) V1 Swave + R wave in V5/V6 > 35mm
3) avL R wave + V3 s wave >28mm M/20 mm F

Question 27

Q

Desc HCM. What EKG findings?

Answer

A

HCM
-autosomal dominant
-thickened left ventricle
-murmur (like AS): crescendo descrendo systolic murmur along LEFT sternal border
-Louder w/standing or Valsalva
-Decr with sustained handgrip
-Tx: BB, CCB
-ICD: arrhythmia, SCD in two 1st family members, myocardium thickness >30mm (>3cm) anywhere in left ventricle, unexplained syncopal episode

EKG findings:
-LVH, left atrial enlargement
-deeply inverted T waves (V3-V6) mimics ischemia

Question 28

Q

Describe type B aortic dissection

Answer

A

Description: tear in DESCENDING aorta only (distal to the subclavian artery)
Dx: CTA
Tx: IV BB (1st line) –>CCB (if BB contraindicated 2/2 reactive airway dx)

Question 29

Q

Describe type A aortic dissection

Answer

A

-tear in ascending aorta, arch
-Dx: CTA 1st (or TEE)
Tx: emergent surgery;

Question 30

Q

What is goal BP for HTN tx

Answer

A

Goal <130/80. There are TWO exceptions:
(1) low risk pt w/ASCVD <10% and stage 1 HTN, goal can be <140/90 (also w/pre-eclampsia, pheo)
(2) CKD pts, SBP goal <120 (also w/aortic dissection)

Question 31

Q

What is hypertensive URGENCY

Answer

A

Severe incr in BP BUT pt is otherwise stable.
-Tx: incr meds w/close outpt followup

Question 32

Q

What is hypertensive emergency

Answer

A

THIS requires hospitalization. See sx/symptoms of end-org damage
-blood pressire: >180/120

Question 33

Q

Describe 4 scenarios for statin treatment. Which 2 are high-intensity. What is high-intesntiy statin

Answer

A

(1) LDL ≥ 190 : high-intensity statin
(2) LDL 70-189 AND 40-75yrs and ASCVD ≥ 20%: high-intensity
(3) LDL 70-189 AND 40-75yrs and DM : mod/high
(4) Clinical ASCVD*: high

*Clinical ASCVD: ACS, stable or unstable angina, coronary artery revascularization, stroke/TIA, or PAD

HIGH intensity statin:
40-80mg atorvastatin, 20-40mg rosuvastatin

**The 10-year risk for ASCVD can be categorized as low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%).

Question 34

Q

What is medium intensity statin

Answer

A

10-20mg atorvastain, 20-40mg simvastatin

Question 35

Q

Desc renal artery HTN

Answer

A

Secondary HTN
-seen in young female, fibromuscular dysplasia
-Tx: ACE-I/ARB
-Dx: renal u/s; definitive angio

Question 36

Q

What is tx for HFrEF

Answer

A

(1) ACE-I/ARB
(2) BB
(3) Diuretics
(4) SLG-2 inhibitor
(5) Spironolactone
**Blk pts: hydralazine+ isosorbide dinitrate

Question 37

Q

What is tx for HFpEF

Answer

A

**BP control + diuresis
(1) ACE-I/ARB
(2) Diuretics
(3) SLG-2 inhibitor

Question 38

Q

Is BB a good 2nd line tx for HTN

Answer

A

No, unless pt has h/o MI or angina.

Question 39

Q

S4 gallop is common in which type of pts

Question 40

Q

What are causes of secondary HTN

Answer

A

1) renovascular: elevated renin, abd bruit, renal u/s for dx, ACE-I/ARB for tx
2) hyperaldostronism: low k, metab alk, low renin

Question 41

Q

What are 1st line tx for HTN

Answer

A

-thiazide diuretics (chlorthalidone), ACE-I/ARB, CCB (amlodipine)

Question 42

Q

What ppx is given to pt with infective endocariditis who is allergic to PCN.

Answer

A

1st line tx is amoxicillin (2g po 15mins prior to dental procedure)
IF PCN allergy, then:
-clindamycin
-cephalexin
-azithromycin or clarithyromycin

Question 43

Q

What is a Still murmur

Answer

A

Innocent murmur
-Brief, vibratory, grade 1-3 midsystolic low-pitched murmur
-heard at LL sternal border, sometimes radiates to cardiac apex
-Louseds in supine and diministhes in intenstity w/sitting or standing up
-Seen in young adult (often before they participate in comeptitice sports, get hx )

Question 44

Q

What class of cardiac drugs cause symptomatic orthostatic HTN

Answer

A

nonselective alpha-blockers–relax smooth muscle in bladder and prostate, often rx for BPH –BUT orthostatic hypotension esp common with 2 agents–> doxazosin, terazosin
*Other alpha blockers (tamsulosin, silodosin) are mor selective for prostate tissue
**NOTE: BB may case bradycardia or exacerbate hypotension BUT does not generally cause profound orthostatic HTN

Question 45

Q

What is the most common cause of syncope

Answer

A

Vasovagal: syncope caused by reflex-mediated reduction in vascular tone, heart rate, or both.

Question 46

Q

Do you need to order cardiac testing pre-operatively for elective surgery in pt w/stable CAD and/or no cardiac sx

Answer

A

No. Guidelines recommend no perioperative testing in pts who’s functional capacity is >4 METS (metabolic equivalents). Pts who can climb 1 flight of steps are considered to be at this level. Of note, do exclude active cardiac issues ( unstable coronary dx, HF with volume overload BUT if surgery emergency, can bypass)

Question 47

Q

Descr AS

Answer

A

-Sx: angina, HF, syncope (w/exercise)
-Murmur: mid-to late peaking (diamond shaped) ejection murmur +/- ejection click; decr absent S2 (2/2 decr mobility of aortic valve leaflets), paradoxical S2 split (becs stenotic valve closes AFTER pulmonary valve)
-PE: carotid pulse (parvus et tardus–weak amplitude and delayed), S4 gallop,
**murmur transmits to carotids–think AS. IF normal, consider aortic sclerosis
-Prognosis: pt’s w/symptomatic severe AS have 10% risk of suddent death.
-Dx: echo (as w/all valvular heart dx)
Tx: SAVR&raquo_space; RAVR. Medical tx NOT effective

Question 48

Q

What valvular conditions can be treated with afterload reduction

Answer

A

-chronic AR, MR
-Use ACEI/ARBs for afterload reduction. You can use diuretics to tx sx od volume overload

NOTE Surgery indicated for:
(1) AR: Aortic valve REPLACEMENT (AVR) if (1) symptomatic severe AR (2) asx severe defined as LVEF <55% or LV enlargement with LV end-systolic diameter ≥ 50 mm
(2) MR: valve REPAIR surgery if (1) symptomatic severe MR (2) Asx severe defined as LVEF <60% or LV enlargement with LV end-systolic diameter ≥ 40mm

Question 49

Q

What is syncope? What are main causes

Answer

A

Syncope
-Definition: sudden transient loss of consciousness w/loss of postural tone followed by SPONTANEOUS recovery. Different from other types of loss of consciousness such as seizures or narcolepsy.

CAUSES
(1) neurocardiogenic
(2) Cardiac
(3) Orthostatic hypotension
(4) Meds **a-blockers for BPH –>terazosin, prazosin

Question 50

Q

What are sxs of neruocardiogenic syncope? What are subtypes of neruocardiogenic syncope?

Answer

A

Neurocardiogenic syncope:
(1) SX: dizziness/ prodromal featuers (n/w etc_ +/- myoclonic jerks mimicking seizure

SUBTYPES:
(1) Vasovagal. most common. Triggered by intense emotion, standing, ETOH, heat. Typically have prodrome (ie nausea/vomitting)
(2) Situational. brought by SPECIFIC scenarios-cough, micturition, straining
(3) Caroid sinus hypersensitivity. Dx with pause of >3sec during carotic sinus massage

Question 51

Q

When do you use tilt-table to dx syncope

Answer

A

Tilt=table used to diagnose neurocardiogenic syncope

Question 52

Q

Type A dissection usu causes what type of regurge? what type of MI?

Answer

A

Type A dissection (acending aorta) can cause
=new AR
=hemopericardium with TAMPONADE
=inferior MI (due to invovlement of right coronary artery).
-Dissection typically presents w/severe anterior chest pain +/- severe interscapulary back pain

Don’t be fooled –treat AS (CTA for dx, emergent surgery ) FIRST. NOT AR or MI….

Question 53

Q

What are 8 absolute contraindications to fibrinolytic tx

Answer

A

1) Stroke
-hemorrhagic ever/any
-ischemic (past 3mos)
2) intracranial neoplasm
3) suspect aortic dissection
4) active bleeding
5) severe face/head trauma
6) neurosurgery/spine surgery (past 2 mos)
7) persistent severe HNT unresponsive to medical tx
8) active bleeding

Question 54

Q

What are 3 main causes of ST segment elevation. What are 4 causes you also nee to remember

Answer

A

(1) Acute STEMI
(2) Coronary vasopastic (Prinzmetal) angina
(3) Pericarditis (will also see PR DEPRESSIONS)

**Don’t forget about
(1) early repolarization variant (<40yrs, J wave)
(2) stress-induced (takotsubo) cardiomyopathy
(3) LBBB
(4) hypothermia (J wave aka Osborn wave)

Question 55

Q

Describe prizmetal angina vs microvacular angina

Answer

A

Prinzmetal angina (aka coronary spasms_
-Def: coronary spasms cause vasospastic angina
-Transient ST elevations
-Tx: CCB, nitrates

Microvascular angina
-Def: Angina w/ischemic changes on cardiac stress test BUT visually normal coronary arteries on angiogram. Type of ischemia with No Obstructive Coronary Artery Disease (INOCA)
-Dx: adenosine or acetylcholine provocation via intracoronary injection. Cardiac MRI perfusion imaging and cardiac PET can also be helpful

REVIEW
1) DIFFUSE ST changes –>think pericarditis. LOOK for PR depressions
2) TRANSIENT ST changes– > think prinzmetal. LOOK for coronary distribution BUT transient
3) ST elevations that are CONCAVE up (happy face)
-IF diffuse (with PR depressions) –> pericarditis
-IF young (<40yrs) and no reciprocal ST depressions + notching (V4/V5) think : EARLY repolarization
4) ST elevations CONCAVE dwn -
-> STEMI
–>IF visually normal angio –>microvascular angina

Question 56

Q

What is target INR for mechanical valves

Answer

A

Use warfarin only
Aortic: av INR 2.5
Mitral: INR 3.0

Question 57

Q

You are performing chest compressions on pt who goes into asystole. What should you do?

Answer

A

ACLS–for non shockable rhythm–give epinephrine ASAP. Remember to used CLOSED LOOP communication

https://img.grepmed.com/uploads/10756/acls-management-adult-lifesupport-aha2020-original.jpeg

Question 58

Q

What is the most common cardiac tumor

Answer

A

Atrial myxoma. Often composed of gelatinous material w/irregular borders
Sx:stroke, TIA, syncope, arrithyma
Definitive tx: surgical excision

Question 59

Q

Desc aortic regurge and mitral regurge murmurs

Answer

A

AORTIC REGURGE
(1) Chronic AR
-2/2 valve deformity, Marfan
-decsrendso diastolic, high-pitched
-1st: afterload reduc: ACE-I/ARB
-surgery(AV replacement): LVEF <55%
(2) Acute AR
-2/2 endocarditis, dissection
-short diastolic murmur (NO bounding pulse); CO/BP LOW
-1st: Urgent Surgery

MITRAL REGURGE
(1) Chronic MR
-holosystolic murmur, heard @ apex, radiates to axilla
-1st: afterload reduc: ACE-I/ARB
-surgery(AV replacement): LVEF <60%
(2) Acute MR
-descrescrendo, systolic murmur @ apex
-Urgent surgery

**Note AS: murmur @ RUSB and radiates to carotids and also apex. MR heart @ apex and radiates to axilla

Question 60

Q

what is a long term sequale of kawasaki dx. What 5 symptoms should make you think Kawasaki

Answer

A

coronary thrombus
**The most dangerous complication of Kawasaki is coronary aneurysm which over time can cause myocardial infarction 2/2 thrombosis. Rare complication men&raquo_space;women

KAWASAKI
-rash (childhood) involves MOUTH
-febrile illness, affects medium-sized vessels, manifests with: (1) fever (2) lymphadenopathy (3) conjunctivitis (4) RASH (palms & soles ) (5) erythematous mucosa (strawberry tongue)

Question 61

Q

What is the connection btwn prolonged Qtc and torsades

Answer

A

With prolonged Qtc there is a tendency to develop polymorphic Vtach. If prolonged Qtx is from bradycardia, the polymorphic Vtach called Torsades.

Question 62

Q

What are some causes of prolonged QTc.

Answer

A

Prolonged QTC: >450 ms

1) HYPOcalcemia
2) HYPOmagenesium
3) HYPOkalemia
4) TCA overdose
5) Several meds
-antipsychotics
-abx
-antihistamies
-opiods

Question 63

Q

After return of spontaneous circulation, a comatose pt recovering from cardiac arrest should be treated with what?

Answer

A

Targeted temperature management

Question 64

Q

What is treatment for ventricular tachycardia?

Answer

A

IF STABLE: amiodarone

IF UNSTABLE –>cardioversion!!
-hypotension
-change in mental status
-angina
-PULMONARY EDEMA

Answer 64

A

Leads V1, V6

https://i.pinimg.com/originals/20/f4/b7/20f4b7c478c3a77bb083d0edc69bf843.jpg

Answer 65

A

WPW:
- symptomatic AVRT with evidence of preexcitation on resting ECG (delta wave)
-delta wave becs of “early conduction” via accessory path.
-the accessory/bypass track conducts faster than AV node
-AF occurs in 1/3 of pts

TX
-1st line therapy: ablation
-Asymptomatic WPW conduction without arrhythmia (WPW pattern) does not require investigation or treatment.
-AVOID SVT meds –BB/CCB/adenosine

Answer 66

A

V tach–most common
Tx: IF unstable–cardioconvert. If stable–>amiodarone
SVT w/aberracncy. Expect to see LBBB or RBBB.
Tx: AV nodal blocking meds: BB/CBB/adenosine
A fib with WPW. Rhythm is IRregular (becs of afib.) QRS wide becs of delta wave. NEVER give AV-nodal blocking meds (BB/CCB) becs can cause vfib.Tx: procainamide, synchronize cardioversion.

Answer 67

A

LBBB
-conduction block of left bundle branch–>takes longer for left ventricle to contract
-QRS> 120 ms (3 sm squares), widened

EKG FINDINGS:
-V1: NEGative QRS + ST elevation
-V6: reverse of V1

Answer 68

A

EKG FINDINGS:
-V1: Rabbit Ears ‘RsR

Answer 69

A

(1) MITRAL VALVE PROLAPSE
-mid-systolic CLICK +/- MR
(2) MITRAL STENOSIS
- diastolic rumble

**MITRAL REGURGE
-chronic: holo SYSTOLIC, constant murmur
-acute: pan SYSTOLIC, decrescendo murmur @ apex

Answer 70

A

Assess LEVF after 40 days (~6wks) . AFter 40 days, if LEVF continues to be low (LEVF <=30%, then ICD may be useful)

Answer 71

A

Surgical repair indicated for:
-aneurysm ≥ 5.5 cm OR
- growing ≥ 5cm/year

Answer 72

A

(1) Lifestyle modifcations
-low wt, exercise–>for all afib pts
-Tx of OSA, DM, HTN, HLD for all pts
(2) Anticoagulation
-Use CHA2 DS2 VASc to risk stratify
-(A) 65-74 is 1 pt; A2>=75 is 2 pts
-Men >=2, Women >= start, usu DOACs (unless bare metal stent)
(3) Rhythm vs Rate control

Answer 73

A

1) Exercise stress testing preferred
-no if LBBB, pacemaker,can’t excercise
2) Pharmacological stress testing
-Dobutamine–>no if pacemaker
-adenosine –>MPI only. no if brochospams

Answer 74

A

AV: 2.5
MV: 3.0

Answer 75

A

1) hemodynamically unstable–>cardioversion (electrical/pharmocologic)
*IF duration unknown or
afib >48hrs–>r/o thrombus by (1) TEE&raquo_space; (2) anticoagulate 3wksprior

2) stable afib: rate vs rhythm control +/- anticoagulation (risk stratification using CHA2 DS2 VASc)
*valvular always use warfarin

3) Afib +PCI: dual therapy ONLY
-clopidogrel +DOAC (NO aspirin)

Answer 76

A

1) hypokalemia
2) digitalis intoxication

Answer 77

A

-numerous studies have demonstrated superior symptom treatment with rate PLUS rhythm control compared with rate control alone.
-because the long-term effects of rate-only control are unknown, rhythm control is often pursued in younger patients (aged <50 years)
- A strategy of early rhythm control (within 1 year of diagnosis) among patients at high risk for adverse cardiovascular events was tested in the randomized EAST-AFNET 4 trial.
-High risk was defined as age older than 75 years or a previous transient ischemic attack or stroke, or meeting two of the following criteria: age older than 65 years, female sex, heart failure, hypertension, diabetes, severe CAD, chronic kidney disease, and LV hypertrophy. -Early rhythm control (drugs or ablation) +RATE control superior in this population

Answer 78

A

1) Afib + PCI
-DOAC +clopidogrel (NO aspirin)
2) Afib + CAD
-rivoxaban (NO aspirin)
3) Afib in HF pts
-rhythm control

Answer 79

A

-NARROW complex tachycardia. Can be grouped into:
(1) REGULAR rhythm
-sinus tachy: p b4 every QRS
-AVNRT: p after/buried in QRS
*sinus tachy usu 2/2 stress/fever/exercise etc
-1st line tx: IV adenosine. IF recurrent CCB/BB

(2) IRREGULAR rhythma
-afib: irregular irregular
-aflutter: see in VI, II, III, avF
-MAT: diff p waves

TX:
-BB/CCB, adenosine, vagal
*if STOPS w/adenosine–usu AVNRT/AVRT

Answer 80

A

TETRALOGY OF FALLOT (TOF)
-most common congenital cause of cyanosis
-4 defects: (1) large VSD (2) overriding aorta (3) RVH (4) pulmonary valve stenosis
- pulmonary stenosis: RV hypertrophy, prominent jugular a wave, palpable right ventricular lift
-Increased risk of endocarditis

EISENMENGER
-Severe PH with cardiac shunt reversal (right-to-left shunting) caused by long-standing, unrepaired VSD, PDA, or ASD.
-Pregnancy absolute contraindication
-Tx: heart-lung transplant

Answer 81

A

COARCTATION
-Associated with bicuspid aortic valve (AS)
-hear a systolic murmur in left infraclavicular region or over back
-SX: diminished femoral pulses
-DX: continuous murmur over back, “3 sign” CXR, LVH on ekg

Answer 82

A

1) HYPERkalemia
2) MI
3) intercerebral hemorrage

**INVERTED T waves seen w/HCM.

Answer 83

A

1) digoxin
2) amiodarone
3) HYPOkalemia
4) bradycardia

Best seen in leads V1, V2 and after T wave

Answer 84

A

1) No p waves
2) Inverted p waves
-after QRS
-before QRS

Answer 85

A

1) REGULAR wide complex
-Vtach (tx amiodarone)

2) IRREGULAR wide complex
-afib (WPW, w/aberrancy), aflutter

3) METABOLIC
-TCA overdose (tx: IV bicarbonate)
-hyperkalemia
-severe acidosis

**https://rushemergencymedicine.org/2019/08/09/wide-complex-tachycardia/

Answer 86

A

CARDIAC TAMPONADE (obstructive shock)
*fluid in the pericardial sac, compresses heart
-JVP: rapid x, blunted y descent
-Sx: hypotension, elevated JVP, muffled heart sounds, CLEAR Lungs
-Pulsux paradoxus: inspiratory fall in SBP

CONSTRICTIVE PERICARDITIS (obstructive shock)
*result of scarring and consequent loss of the normal elasticity of the pericardial sac
-JVP: rapid x, y descent
-Kussmaul sign: elevated JVP w/inspiration

REMEMBER:
1) diastolic pressure equal in all 4 chambers for Tamponade and constrictive pericarditis
2) How do you tell the 2 apart–look at inspiration (JVP up/Kussmal/Constrictive vs SBP exaggerated dec/Pulsus paradoxus/tamponade); look at JVP waves (x descent only-tamponade; x and y descent- constrictive)

Answer 87

A

1) constricted pupils
2) neck pain
3) unilateral head pain
*hypertensive patient, lk for cholesterol emboli on fundoscopic exam

Answer 88

A

ASD
-fixed splitting of S2
-EKG: RBBB, r axis deviation
-CXR: r heart enlargement

Answer 89

A

3rd pregnangy can be predisposing factor for aortic dissection
-Dx: cTA
-Tx: surgery, IV BB (labetalol)

Answer 90

A

-labetalol
-CCB
-meythldopa

Answer 91

A

AMYLOIDOSIS
-restrictive sx (dyspnea, fatigue, HF–elevated JVD, edema,wet lungs)
-increased wall thickness (low amplitude on ekg)
-Dx: CMR imaging

Answer 92

A

Takotsubo CARDIOMYOPATHY
-SPECIFIC CARDIOMYOPATHY: clinical syndrome associated with reduced LVEF, elevated cardiac enzyme levels, and signs of ischemia on ECG. typically occurs in older women and is usually precipitated by a stressful physical or emotional event
-aka APICAL balloon syndrome w/preservation of basal wall
-Cardiac imaging shows wall motion abnormalities that do not follow a coronary artery territory (typically, apical dyskinesis or ballooning)

-Tx: symptomatic. Resolves in days to weeks with supportive care.

PHEOCHROMOCYTOMA
-also p/w apical wall ballooning w/preserved function of the base

Answer 93

A

ACUTE LIMB ISCHEMIA
-akin to ACS
-6 Ps
-Tx: surgery

PERIPHERAL ARTERY DX (PAD)
-akin to CAD
-Sx: claudication w/exercise
-Dx: ABI (abn; =<0.9). >1.4 requires toe brachial index
-Tx: ASA, statin + cilostazol (to improve EXCERCISE tolerance) + low-dose rivaroxaban (improve CARDIAC outcomes)

Answer 94

A

ICD CRITERIA FOR POST-MI PATIENTS:
1) >40 days since MI
2) or >3 months since PCI or CABG

Answer 95

A

1) RIGHT ventricular infarction
-hypotension + CLEAR lungs + elevated JVP
-dx: ekg (elevated ST in leav V4)
-tx: IVFs

2) MECHANICAL complications
-VSD, papillary wall, LV free wall rupture
–>VSD/papillary wall: hypotension + PULMONARY edema +loud holosytolic murmur/thrill
–>LV free wall rupture: SUDDEN hypotension + PEA
-dx:echo (emergency)
-tx: inatra-arotic balloon pump + afterload reductin (sodium nitroprusside) + diuretics –>emergency surgery

3)CArdiogenic shock
-Tx: intra aortic ballon

4)

Answer 96

A

Urgent invasive treatment (within 2 hours) -indicated for:
1) hemodynamic instability
2) refractory chest pain
3) HEART FAILURE
4) ventricular arrhythmias.

Answer 97

A

TRUE. Fevers in pt w/ bioprosthetic valve–>be suspicious for ENDOCARDITIS
-Order TEE to eval further.

*Why ppx abx used for high-risk individuals

Answer 98

A

MAJOR
-Positive blood clx
- new valvular murmur
- positive echo findings

MINOR
-heart condition/drug use
-fever
-embolic vascular phenomena
-immunologic phenomena
-positive blood clx not meeting major criteria

DIAGNOSIS:
-2 major
-1 major, 3 minor
- 5 minor

Answer 99

A

1) ATRIAL Myxomas
~ 50 yrs
-usu in LEFT atrium
-systemic sx (fever wt loss) +vascular occlusive sx
-Tx: surgery

2) Papillary fibrolelastoma
~80 yrs
-usu on surface of aortic or mitral valve
-globular appearance on echo

3) ANGIOSARCOMA
-MOST common
-usu in RIGHT atrium +pericardial effusion
-sx: dyspnea, SOB, poor survival

Answer 100

A

SCAD
-MOST common cause of pregnancy-associated MI
-Usu during 1st mo postpartum
-Sx: chest pain + ekg findings
-Echo: Regional wall motion abnormalities

Answer 101

A

eft ventricular systolic dysfunction recognized toward the end of pregnancy or in the months following delivery

MEDS
-Women with peripartum cardiomyopathy should be promptly treated with medical therapy that may include β-blockers, digoxin, hydralazine, nitrates, and diuretics.
-ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists are teratogenic and should be avoided until after delivery

Answer 102

A

TRUE
*In pregnant patients with a mechanical valve prosthesis, warfarin anticoagulation is preferred during the first trimester if the daily dose is 5 mg or less; intravenous unfractionated heparin or dose-adjusted low-molecular-weight heparin is preferred if the warfarin dose is more than 5 mg daily.

CARDIAC MEDS CAN USE:
BB, CCB, hydralazine, digoxin, adenosine, diuretics

CONTRAINDICATED
-ACE-I/ARBS, spironolactone

Answer 103

A

Permanent Pacemaker:
-symptomatic bradycardia
-high grade block (3rd degree, 2nd degree Type 2)

ICD:
(1)PRIMARY prevention: Post MI/ non-ischemic HF (≥40 days after MI)
- EF ≤ 30% +optimal tx + HF sx (NHA II/III)
- EF ≤ 35% +optimal tx + regardless of HF sx
(2) SECONDARY prevention:
-Sustained ventricular arrhythmias (>30 seconds) –VT/VF
cardiac arrest (without a reversible cause)
(3) Specific medical conditions:
-Brugada syndrome w/syncope
-inherited long QT syndrome not responding to β-blockers
-Hypertrophic cardiomyopathy (IF Previous sudden cardiac death or sustained VT should receive an ICD

CRT:
*pacing both left/right ventricles
-EF ≤ 35% + LBBB w/prolonged QT AND HF sx

Answer 104

A

The key difference between ICD and pacemaker:

ICD
- implantable device that sends out a shock when the heart beats way too FAST rate

PACEMAKER
- implantable device that sends out electrical pulses when the heart beats way too SLOW.

Answer 105

A

-Long QT syndrome may be inherited, but most are acquired. Patients may experience syncope or SCD as the result of ventricular arrhythmia.
-Look for HYPOkalemia, HYPOmagnesemia, structural heart disease, medications, and drug interactions.

-LOOK specifically for:
(1) macrolide and fluoroquinolone antibiotics (especially moxifloxacin)
(2) terfenadine and astemizole antihistamines
(3) antipsychotic and antidepressants
(4) methadone
(5) antifungal medications
(6) class Ia and class III antiarrhythmics

Answer 106

A

(1) HCM
-Syncope, VF during exercise
-EKG: LVH, inverted T waves (V3-V6)
-Tx: BB/CCB, ICD, surgical myectomy

(2) Brugada
-Syncope during sleep
-EKG: coved ST-elevation (V1-V3)
Tx: ICD, catheter ablation

(3) Long QT syndrome
-Syncope during sleep, auditory triggers, and/or during exercise (depending on subtype)
-EKG: QTc usually >460 ms; torsades de pointes
-Tx: BB, avoidance of QT-prolonging drugs, ICD in selected patients

(4) arrhythmogenic right ventricular cardiomyopathy/dysplasia
-Syncope, palpitations
-EKG: inverted T-waves (V1-V3), monomorphic VT, frequent PVCs
-Echo: abnl RV size and function
-Tx: BB, antiarrhythmic medications, catheter ablation, exercise abstinence (uniform)

Answer 107

A

1) hypotension
2) bradycardia
3) hyperglycemia
4) metabolic acidosis (2/2 inc lactate from tissue hypoperfusion)

*lisinopril overdose:hypotension but NO bradycardia

Answer 108

A

-fatigue, n/v, headache
-hyponatremia
-tremor
-xerstomia

Answer 109

A

DIAGNOSIS
- ankle branchial index (<0.9 diagnostic for PAD)
-IF ABI >1.4, toe brachial index
-IF ABI nl but sx, exercise ABI

TREATMENT
-ASA
-cilostazol: improve exercise tolerance
-low-dose rivaroxaban: improve cardiac outcomes

Answer 110

A

-Any wide QRS tachycardia should be considered to be VT until proven otherwise.

-In the presence of known structural heart disease, especially a previous MI, the diagnosis of VT is almost certain.

Answer 111

A

-Torsades de pointes is a specific form of polymorphic VT associated with long QT interval.
-Torsades de pointes episodes are typically short-lived and terminate spontaneously, but multiple successive episodes may result in syncope or VF.

Answer 112

A

1) Idiopathic VT (NO identifiable structural heart disease):
-1st line: BB, CCB

2) Structural heart disease (MOST common)
-angiography and revascularization
-catheter ablation if reccurrent
-ICD if sustained or to prevent SCD

3) Acute treatment of sustained VT:
-IF unstable: electrical cardioversion
-IF Pulseless VT: electrical cardioversion
-IF stable: IV amiodarone (also procainamide sotalol).

Answer 113

A

SCAD
- MOST common cause of pregnancy-associated MI
-Usus occurs in 1st month postpartum

Coronary vasospasm
-DIFFUSE and TRANSIENT ST elevations
-CP at rest
-Trop usu normal
-can be assoc w/hemodynamic instability
-Tx: CCB

Microvascular angina
-Angina w/ischemic changes on cardiac stress test BUT visually normal coronary arteries on angiogram.
-Type of ischemia with No Obstructive Coronary Artery Disease (INOCA)
-Dx: adenosine or acetylcholine provocation via intracoronary injection. CMR or cardiac PET also helpful to visualize MICRO lesions

Answer 114

A

Heart Transplant!
- acceptable candidates for cardiac transplantation are generally younger than 65 to 70 years with no medical contraindications and have good social support and adherence
-ICD placement is currently indicated in patients with ejection fraction less than 25% and poor exercise tolerance despite maximally tolerated therapy, with either a high predicted 1- or 2-year mortality or inotrope dependency, who still want aggressive restorative care.

Answer 115

A

CONTRAINDICATED
-ACE-I/ARBS, spironolactone
-for peripartum cardiomyopathy have to use HF drugs but NOT the ones above!
-Management includes early delivery

Answer 116

A

Cardiac stress testing is best used in patients with an intermediate pretest probability of coronary artery disease.

1) Exercise ECG is a reasonable diagnostic test in patients who can exercise and have normal findings on a baseline ECG
*ekg abnormalities (LBBB, ST depression >1mm, LVH, WPW)
2) IF patient can exercise and no major ekg abnormalities (LBBB, pacemaker) –> stress induced ETT + imaging (CMR, echo, MPI)
3) IF pt has major ekg abnormalities (LBBB, pacemaker) and/or can’t exercise –> pharmacological + imaging
-adenosine: esp if LBBB on ekg. NO for respiratory airway dx
-dobutamine: NO for Aortic stenosis or pacemaker

Answer 117

A

for BOTH atrial fib and PAF–use CHA2 DS2 VASc.
-DOAC preferred if criteria met (>=2 men, >=3 female)
- WARFARIN preferred if pt has mod/severe Mitral Stenosis OR mechanical valve
-IF pt also has ACS indication for antiplatelet tx, use DOAC/wafarin + clopidogrel.

Answer 118

A

PDE-5 inhibitors (sildenafil, meds often used for erectile dysfunction) contraindicated with Nitrates (isorbide dinitrate) 2/2 significant hypotension

Answer 119

A

Pulmonary regurge

Answer 120

A

(1) Pericarditis
-inflammation of pericardial sac (can result in effusion). diffuse ST depressions
-Tx: NSAIDS + colchine
(2) Pericardial effusion –>tamponade
-elevated JVP/muffled heart sounds/pulsus paradoxus, exaggerated SBP dec w/inspiration, x descent/blunted y descent
-tx: urgent drainage of pericardial fluid with either pericardiocentesis or surgery.
(3) constrictive pericarditis
-resolution of effusion, leaves pericardial thickening, fibrosis
-elevated CVP, prominent x & y descent, Kussmaul (elevated JVP w/inspiration)
-tx: IF transient, same as acute pericarditis. IF chronic, surgical pericardiectomy.

Answer 121

A

one-time screening with DUPLEX U/S in all men aged 65 to 75 years who have smoked at least 100 cigarettes in their lifetime

Answer 122

A

aortic aneurysm is defined as an increase in the aortic diameter. Surgery indicated for:

(1) Aortic diameter >5.5 cm (general pop)
(2) Aortic diameter >4.5 cm (Marfan (4-5), Pregnancy, requires surgery for CAD or valve repair–LOWER threshold)
(3) Rapid growth >0.5 cm (5 mm) per year

Medical therapy for asymptomatic aortic aneurysm includes lowering BP to <130/80 mm Hg; β-blockers are the preferred antihypertensive agent. In patients with Marfan syndrome, β-blockers and losartan reduce the rate of aneurysm growth

Answer 123

A

(1) SMALLER than 4.0 cm
-duplex u/s q 2-3 yrs

(2) 4.0 to 5.5 cm
- CT angiography or duplex u/s q6 to 12 mos

Answer 124

A

(1) CT angiography to identify the location of AAA (suprarenal, juxtarenal, or infrarenal)
(2) The choice between open surgical repair and endovascular repair (EVAR) is driven by LOCATION
-Open surgical repair: suprarenal and juxtarenal aneurysms
-Endovascular repair: infrarenal aneurysms often can be treated with EVAR. .

Answer 125

A

CTA&raquo_space; TEE

Answer 126

A

Conditioms
-pregnancy, uncontrolled HTN, MArfan’s

Murmur: AR

Answer 127

A

Flecainide is a class IC antiarrhythmic agent and, along with propafenone, is absolutely contraindicated in patients with ischemic heart disease,

Answer 128

A

1) bradycardia
2) hypotension
3) hyPerglcymeia
4) metabolic acidosis

Answer 129

A

ASAP
-ASA high dose
-antiplatelet (clopidogrel/ ticagrelor)
-heparin (UFH only for PCI, any for thrombolytic)
-nitro/morphine prn

24HRS
-BB (not hypotensive)
-high dose statin
-ACE-I (if intolerant ARB)

Eplerenone: 3 to 14 days after MI if LVEF ≤40% and clinical HF or diabetes

Answer 130

A

ASD
- defect in the atrial septum resulting in a left-to-right shunt w/eventual right-sided cardiac chamber dilatation
-Adults p/w dyspnea, atrial arrhythmias, and/or right heart enlargement
-elevated central venous pressure, a right ventricular lift, and fixed splitting of the S2
-Large left-to-right shunt causes a pulmonary midsystolic flow murmur and a tricuspid diastolic flow rumble owing to increased flow. -EKG: right axis deviation, incomplete right bundle branch block, and right ventricular hypertrophy

Answer 131

A

Ostium SECUNDUM ASD
-RBB, RVH, right atrial enlargement

Ostium primum ASD
-LAD, first-degree AV block

Answer 132

A

-BB [ONLY bisoprolol, carvedilol, metoprolol succinate)
-ARNI valsartan-sacubitril (instead of ACE-I); contraindicated in pt with angioedema!
-SLG2 inhibitor
-EF <30%: Aldosterone antagonists-NO CKD! (spironolactone, eplerenone–more selective an assoc w/fewer gynecomastia)
-Blk pts: isosorbide dinitrate–hydralazine
-diuretics

*Reduce hospitalizations
-digoxin
-Ivabradine: EF <30%, HR >70, max BB use

Answer 133

A

(1) ACUTE DISSECTION
-SBP to <120 mm Hg in first hour
-IV β-blocker therapy ± nitroprusside
-pain control with opioids

(2) EMERGENT SURGERY
-cardiogenic shock
-type A dissection/ intramural hematoma

(3) Uncomplicated type B dissection is treated with continued medical therapy alone, except in patients with complications, including end-organ ischemia.

Answer 134

A

Most thoracic aortic aneurysms are asymptomatic. Surveillance and treatment depend on aneurysm size and subsequent rupture risk. Surveillance intervals for asymptomatic thoracic aortic aneurysm of the aortic root and ascending aorta are:

1) Annual imaging: 3.5 to 4.4 cm
2) q 6mos: 4.5 to 5.4 cm (4.5 - 5.0 if Marfan)

Answer 135

A

(1) ICD
- EF =< 35% + symptomatic on meds

(2) Cardiac resynchronization therapy
- EF =< 35% + symptomatic on meds+ LBBB + QRS >150 ms

Answer 136

A

Indications for surgery include:

(1) valvular dysfunction and acute HF
(2) left-sided IE caused by Staphylococcus aureus, fungal infection, or highly resistant organisms
(3) complete heart block
(4) perivalvular abscess or fistula formation
(5) positive blood clx despite >5days IV abx
(6) prosthetic valve endocarditis

Answer 137

A

(1) control of hypertension
(2) Diuretics –relief of volume overload
(3) AND SLG2-inhibitor

Answer 138

A

Mobitz TYPE 2
-dizziness and syncope

Complete HB
-fatigue, dyspnea, chest pain, presyncope or syncope, and cardiac arrest.

Answer 139

A

Junctional rhythms are regular supraventricular rhythms in which the P wave in lead II is negative (preceding or following the QRS complex) or absent (arrows).

Answer 140

A

(1) cardiac arrest 2/2 VF or VT
(2) sustained VF or VT
(3) HF with EF ≤35% + symptomatic on meds
(4) Brugada syndrome with syncope
(5) Inherited long QT syndrome not responding to β-blockers
(6) ≥40 days after MI with an EF ≤30%

Answer 141

A

HYPERTENSIVE URGENCY:
-BP>180/120 w/NO evidence of organ damage
-SBP should be lowered no more than 25% within 1st hr, then to <160/100 mm Hg w/in 2-6 hrs, then cautiously to target w/in 24-48 hrs
-IF on meds: and not adherent–slowly resume
-IF on med: and adherent–slowly add 1 med
-IF newly diagnosed: captopril, clonidine, furosemide–want 20-30bp drop to be slow

HYPERTENSIVE EMERGENCY:
-BP 180/120 AND e/o organ damage( acute HF, myocardial damage–elevated trop)
-Tx: IV nitroglycerin (IV BB if NO HF)

Answer 142

A

True-severe LF-LG aortic stenosis is amenable to valve replacement, whereas pseudo-severe aortic stenosis requires management of the underlying cardiomyopathy.

Answer 143

A

HCM
-AD
-echo, ekg, genetic counseling (if sacromere mutation identified) for all first-degree relatives of patients with HCM

Answer 144

A

Athlete’s Heart
-wall thickness <13mm

HCM
- ≥15 mm in any LV region or > 13 mm in person w/ 1st degree relative

Answer 145

A

1) BB or CCB
2) ICD indication
- cardiac arrest, sustained VT
-.risk factors for sudden cardiac death: (1) death in 2 1st degree relatives (2) LVH > 30 mm (3) syncope (4) EF < 50%
3) Surgical myomectomy
-severe obstructive sx
+ a resting or provoked LVOT gradient of 50 mm Hg or greater

Answer 146

A

TRUE; for HCM pts
Also genetic testing if genetic variant found in 1st degree relatve (AD!)

Answer 147

A

AS
-EF <50%

AR
-EF ≤55%

MR
-EF ≤60%
-LV end-systolic diam ≥40mm

AS/MS: a discrepancy between resting echocardiographic findings and clinical symptoms, exercise echocardiograph

Answer 148

A

respiratory—COPD

Answer 149

A

-mechanical valves: warfarin
-HCM: warfarin

Answer 150

A

TREATMENT
1) BB or CCB
2) avoid competitive sports
3) IF afib: warfarin
4) IF outflow gradient> 50mm HG: Surgery or septal
5) IF h/o sustaintained VT, 2 st degree relatives w/SCD: ICD

SCREENING
-TEE + EKG q1-2 yrs to eval for MR and LVH
-genetic counseling (if sarcomeric mutation is identified in index case).

Answer 151

A

Hypertensive emergency
-target organ damage (ex: ischemia, HF)

TREATMENT
-acute Aortic dissection: IV Esmolol, labetalol
-acute HF/pulmonary edema: IV nitroglycerin, nitroprusside. NO BB
-ACS: IV Esmolol, nitroglycerin
-acute kidney injury: CCB –Nicardipine
-Eclampsia or preeclampsia: IV Hydralazine, labetalol, nicardipine. NO
ACE inhibitors, ARBs, renin inhibitors, nitroprusside contraindicated

Answer 152

A

1) metop succinate
2) carvedilol
3) bisoprolol

Answer 153

A

IF EF < 40% +/- DM (regardless of volume overload)

CAVEATS:
1) Aldosterone antagonists should NOT used for diuretic therapy, and patients with volume overload should be treated with a loop or thiazide diuretic.
2) do NOT use with kidney failure (GFR of at least 30 mL/min/1.73 m2.)
3) Of the two agents, eplerenone is a more selective aldosterone antagonist and is associated with lower incidence of gynecomastia and breast tenderness.

Answer 154

A

When he shaded area separating the LAP from the LVP during diastole represents the elevated pressure gradient that is characteristic of mitral stenosis

https://www.cvphysiology.com/Heart%20Disease/HD004

Answer 155

A

RHEUMATIC FEVER
-Multisystem dx (joints, carditis, nodes, erythema marginatum, chorea)
-caused by untreated pharyngitis 2/2 grp A strep
-Dx: Jones criteria
(1) Major criteria include carditis, arthritis, chorea, erythema marginatum, and subcutaneous nodules
(2) minor criteria include prolonged PR interval, arthralgia, fever, and elevated inflammatory markers.
- recent history of group A streptococcal infection + 2 major criteria OR 1 major and two minor criteria.
-Tx: PCN

ENDOCARDITIS
-inflammatory dx that affects abnl valves (congenital, prosthetic, mostly 2/2 staph&raquo_space; or strep)
-Dx: Duke’s criteria
(1) 2 major (bld clx, echo, new murmur)
(2) 1 major + 3 minor (embolic, fever, immunologic)
(3) 5 minor criteria
-Tx: IV abx +/- surgery.
-Dental ppx

Answer 156

A

NORMAL: I (+) aVF (+)
Right axis deviation: I (-) aVF (+)
Left axis deviation: I (+) aVF (-)

Answer 157

A

CVP=measure of right atrial pressure.
-Elevated with RV infarct

**RV infarct: Look for JVD with clear lungs, hypotension, and tachycardia

**Remeber: PCWP is measure of LEFT atrial pressure

Answer 158

A

1st: Cardioselective β-blockers (NO if reactive airways disease/wheezing)

2nd: CCB (amlodipine)
-Avoid short-acting CCB

3rd: Nitrates (isosorbide mononitrate) are as effective as β-blockers and calcium channel blockers in reducing angina.
-IF using nitrates THEN NO sildenafil, vardenafil, tadalafil
-

Ranolazine:
FINAL: after BB-CCB-nitrate
-Ranolazine should be considered in patients who remain symptomatic despite optimal doses of β-blockers, calcium channel blockers, and nitrates.

Answer 159

A

ADENOSINE
-NO for respiratory airway dx

DOBUTAMINE
-NO for Aortic stenosis or pacemaker

Answer 160

A

Ezetimbe–>PCSK9 monoclonal antibodies (alirocumab and evolocumab)

**Lipophilic statins (atorvastatin, simvastatin, and lovastatin) have a higher propensity to cause statin myopathy compared with hydrophilic statins (fluvastatin, pravastatin, and rosuvastatin).

Answer 161

A

STATIN–>ezetimibe–>evolocumab

Answer 162

A

(1) initiate intravenous anticoagulation with unfractionated heparin, (2) perform angiography, and (3) establish a plan for reperfusion of the l

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