Cardiology - 13% Flashcards

Question

**Left Bundle Branch Block** Conduction Disorders

Answer 1

L ventricle will depolarize from impulses from R ventricle - partially or completely outside conduction system = Widened QRS * Completely LBBB \> 0.12 seconds * Incomplete LBBB \< 0.12 secs but can develop into complete Signifies **Ischemia and structural heart disease**

Answer 2

ectopic focus but still impulse goes through AV and bundle of His so normal QRS complex ## Footnote P wave morphology depends on where ectopic beat is - close to SA node = normal looking P wave, otherwise, it is wider If impulse is close to AV node, atria depolarize opposite direction = **retrograde P wave** Next beat has longer interval Tx - none, BB, CCB

Answer 3

Ectopic beat from ventricular foci - **wide QRS complex** \>0.12s + opposite deflection not a/w P wave Sxs - palpitations Tx - **BBs** and other anti-arrhythmics

Answer 4

Irregular patterns in rate of NSR 1. Respiratory or phasic * normal - decreases w/ age * Inspiration - increase sinus rate (inhibits vagal tone) * Expiration - rate declines 2. Nonrespiratory or nonphasic * not related to respiratory cycle * d/t normal, diseased heart or digitalis intoxication 3. Nonrespiratory, ventriculophasic sinus arrhythmias * 3d AV block * intermittent differences in PP intvls

Answer 5

Dysfunction of Sinus node's automaticity and impulse generation EKG: * sinus rhythm with resting HR of 60bpm * Sinus pause \< 3s * Sinus arrest \> 3 s * tachy-brady alterations MC in elderly Worse with digitalis, CCB, BB, antiarrhythmic Tx - permanent pacemaker

Answer 6

Sudden cardiac arrest a/w palps, dizziness, syncope EKG - polymorphic V Tach either from HypoK or HypoMg rate btwn 150-250 Either cease spontaneously or degenerate into VFib Tx- **IV Magnesium** Cardiovert if unstable

Answer 7

Uncoordinated quivering of ventricle w/ no useful contractions No P waves, QRS Complexes, or T waves, Rate 150-500 bpm pulseless Tx: * Severe hypotension or LOC = Sync Cardioversion * _Pulseless V Tach_ = **Defib and CPR** * 1mg IV bolus epi, q 3-5 mins * Defib 30-50sec * Refract V Fib - **IV Amiodarone** * **Implantable Defib**

Answer 8

a/w CAD, MI, Structural Heart Dz Three or more consecutive Ventricular Premature Beats Regular rhythm - Wide and regular \>120, wide QRS \>0.12 Tx: * Cardioversion if unstable * **Stable → IV amiodarone** * Unstable w/ pulse → sync cardioversion * VT no pulse → Defib * Evential ICD placement * Non-sustained VT * No heart diz or asymp - no tx * Heart dz, recent MI - electrophysiology study

Answer 9

Systolic dysfunction =\> ventricular dilation =\> decreased contractial function =\> reduced CO Eti: * MC in 20-60yo, M, idiopathic 50% * viral myocarditis - Enteroviruses (Coxsackie B), Chagaz dz * Toxic - etoh abse, cocaine, doxorubicin, radiation Sxs: * systolic HF - fatigue, DOE * mitral or tricuspid regurg * lateral displaced PMI * S3 if Dx: * CXR - enlarged heart, pulm edema, pleural effusion * Echo - LV dilation, decr EF, regional or global LV hypokinesis Tx: * HF Tx - ACEI, diuretics, BBS, Digoxin, NA restrictionn * ICD if EF \< 30-35% DDx * Takotsubo CMO - broken heart syndrome, apical L ventricular ballooning d/t catecholamine surge

Answer 10

**_Modified Duke Criteria_** *Major* * bacteremia 2+ blood culture * Echo w/ evidence of vegetation * Newly dx valvular regurgitation *Minor* * RFs - IVDU, indwelling cath, weird valvular morphology * Fever \> 38C or 100.4F * Vasc or embolic phenomena - Janeway lesions * Immunologic phenom - Osler nodes (ouch), Roth spots, acute GMN * Positive blood cultures not meeting major criteria Tx * Acute/Native Valve * **Nafcillin + Gentamicin; Vanco if MRSA**+ * Subacute (HACEK organisms) * **Pencillin or Ampicillin + Gentamicin** * **Vanco if MRSA+** * Prosthetic valve * **Vanco+Gentamicin + Rifampin (For S aureus)** * Fungal * **Ampho B for 6-8 wks**

Answer 11

MC Native Valve infx - **Mitral -** Strep viridans, S aureus, Enterococcus IVDU - S aureus in **tricuspid;** Prosthetic - S. aureus or fungal if w/in 2 mos of implantation Sxs: * Fever, * non spec sx - dyspnea, CP * Murmur * **Janeway lesions -** painless macules on palms and soles * **Roth spots** - retinal hemorrhages w/ pale centers * Petechiae * Splinter hemorrhages

Answer 12

start screening at 18yo Primary HTN resting systolic BP \>= 130 or diastolic BP \>/= 80 on at least two readings, on at least **two separate visits** with no identifiable cause Sxs * Fundoscopy - AV nicking in retinal a., Retinal hemorrhages, papilledema, cotton wool spots * LVH - displaced apical pulse Dx **_ACC/AHA Guidelines_** * Normal - \< 120/80 * Elevated - 120-129 / \< 80 mmHg * Stage 1 - 130-139 or 80-89 mmHg * Stage2 - \>/= 140 mm Hg or \>= 90 mm Hg **_JNC-8 Guidelines_** * Gen pop, age \< 60yo = BP \< 140/90 mmHg * Gen pop, age \> 60yo = BP \< 150/90 mmHg * Pts w/ DM or CKD (regardless of age) = \< 140/90 mmHg

Answer 13

LSM - Weight reduction, DASH diet, Decrease Na intake, no etoh, aerobic exercise _For Gen pop and all DM_ * Non-black - Thiazide diuretic, or ACEI/ARB, or CCB or combo * Black - Initiate Thiazide diuretic or CCB alone or in combo * low renin state\*\*\* _Chronic Kidney dz_ * ACE I or ARB * careful if \>75 with CKD risk of hyperK **_Thiazide Diuretics_** * *‘Chlorthalidone, HCTZ, chlorothiazide’* * Blocks Na and Cl reabs * Good for osteoporosis - incr Ca reabs * **Good for AA pts,** careful with gout or hypercholesteremia * Full anti-HTN effects 12 wks * SE - hypokalemia, sulfa allergies, gout and DM **_CCBs_** * *Dihydropyridine - ‘dipine’* * ***‘Amlodipine**, nifedipine’* * No effect on cardiac contractility & conduction * Effective in elderly * *Non-dihydropyridine - ‘verapamil” & ‘**diltiazem’*** * Vasodilator * Affects contractility and conduction; avoid in HFrEF * Monitor for arrhythmias **_ACE - ‘pril’_** * *‘Lisinopril, catopril, enalapril, ramipril’* * Systolic HF, prior MI, CKD Renal protective - **preferred for DM** * SEs - Bradykinin - cough; incr risk of angioedema, hyperkalemia * C/i preggo **_ARB - ‘sartan’_** * *‘Losartan, irbesartan, valsartan’* * same as above * NO cough * Should not be used with ACE * c/i preggo **_BB_** * Acute MI, angina, migrain pervention, hyperthyroid, migraine, tremor * SE - impotence, postural hypotension, bradycard, depression * wean to stop over 1-2 wks **_Mineralocorticoid Receptor antagonist_** * *"Spironolactone, Eplerenone"* * antagonist aldosterone at distal convoluted renal tubule = incr NaCl and water excretion * for CHF and acute MI w/ low EF * careful with Hyper K - do not start if K \> 5 **_Others_** * Central acting a adrenergic agonist *"clonidine"* * Direct arterial dilators *"hydralazine, minoxidil"* * Pregnancy - acute - *labetalol, hydralazine* * Chronic - *labetalol, nifedipine,* * ***methyldopa*** (check LFT, cause hepatits, hemolytic anemia)

Answer 14

**_Urgency_** **SBP \>180 or \> 120** w/ no evidence of end organ damage No need to emergently lower BP Goal = lower BP by 25% over 24 hrs = outpatient **_Emergency_** **\>220 or \> 130** _Accelerated HTN_ - BP w/ target organ damage - CP, SOB, blurred vision _Malignant HTN_ - elevated BP a/w **papilledema** and other signs of EOD Decr BP \< 25% over 1 hr Tx * ICU admission * **Sodium Nitroprusside for HTN Emergency -** watch for cyanide toxicity * Nicardipine - just BP, not HR * Hydralazine in eclampsia * Nipride for pheo crisis * **Clonidine for HTN urgency**

Answer 15

1. **Primary (familial) HLD or hypercholesterolemia** - overproduction or defective clearance of TG 2. **Secondary Hypercholesterolemia -** 2/2 obesity, DM\*, htn, smoking, sedentary, CKD Sxs * Xanthelasmas - lipid deposits on eyelids * Xanthelomas - tendenous, with familial hypercholesterolemia Dx - Fasting lipid profile * LDL \<100 * HDL \>60 mg/dL * Total Cholesterol \< 200 mg/dL * Triglyceride \< 150 **_Screening - \>7.5% 10 year ACSVD_** * Pts w/ high CVD risk (HTN, DM, tobacco, FH heart dx) * Males start at 25-30 yo * Females at 30-35 yo * Pts w/ lower CV risk * Males start at 35 yo * Females start at 45 yo

Answer 16

**_Hyperlipidemia 2018 guidelines_** 1. any clinical ASVD, stroke, TIA, PAD 2. LDL \> 190 3. Diabetic 40-75, mod intensity; if \> 7.5% then higher intensity 4. 40-75y LDL 70-189 1. Risk 5-20% = mod intensity 2. \>/=20% = high 3. FH ASCVD, ele CRP, smoke, Ca score \> 100 **_HMG-CoA Reductase Inhibitors - "Statins"_** "*Atorvastatin 40-80, Rosuvastatin 20-40"* * decrease LDL, Reduce infl of plaques, lower Trigs, incr HDL * check LFTs and CPK before starting statin * SEs - anorexia, wt loss, aches, myalgias, C/I preggo * **Myopathy** r/o rhabdo - c/i prior muscle symptoms, myalgias (weakness, stiffness) - check CPK, need IV reh2o for renal failure * Avoid w/ fibrates, macrolides (clarith/erythr), amiodarone, verapamil, protease inhibitors, antifungals, grapefruit juice **_PCSK9 Inhibitor_** * **Evolocumab/Repatha, Alirocumab/Praluent** * ****Liver cells to remove LDL * good for patients who cant tolerate statins * once a month, 2x/wk injection * Hypercholesteremia **_Bile acid sequestrants_** * *"cholestyramine, colestipol, coleselevam"* * Binds w/ _bile acid in intestines_, mainly for familial hypercholestremia * Dont use if fasting TG \> 300 * SE - lots of GI issues * C/i - bowel obstruction, hypertriglyceridemia induced pancreatitis * Inhibits abs of warfarin, digoxin, propanolol, thyroid hormones **_Ezetimibe (Zetia)_** * Inhibits _gut absorption_ of cholesterol; reduce LDL \> 20% * add to statin to help decr LDL

Answer 17

Excerbation of uncontrolled DM, obesity, sedentary Sxs * Asymp until TG \> 1000-2000 - incr risk of pancreatitis * Midepigastric pain (chest/back) - TTP * Dyspnea Tx * LSM - low fat/carbs, exercise, limit etoh * Fibrates - **Gemfibrozil, Fenofibrate - decr LDL, incr HDL** * **do not use it with statin** - incr risk myositis and rhabdo

Answer 18

Hereditary - Autosomal Dom, early MI death, young athletes **Hypertrophied Ventricular septum** = Impaired ventricular relaxation/filling Sxs: * Dyspnea, Angina, Syncope - esp during exertion * Sudden cardiac death - due to V fib * **S4**"a-stiff-wall" if outflow obstruction present * Harsh cres-decres murmur at LLSB * **_murmur increases intensity with Valsalva or standing_** - reduced LV volume/preload increases obstruction Dx: * Echo - asymmetrc wall thickeys \> 15mm, small LV chamber size * EKG - LVH, atrial enlargement * CXR - cardiomegaly Tx: * Counseling - avoid dehydration and extreme exertion/exercise * BB - first line, CCB * Avoid Digoxin (incr contractility), Nitrates and diuretics (decr's LV volume) * Surgical - **myectomy - definitive if refrc to medical tx** * ICD For high risk

Answer 19

Eti * Nonhemorrhagic - deh2o, burns, pancreatitis * Hemorrhagic - trauma, ruptured ectopic, GI bleed Sxs * weak pulse, oliguria * hypotension, tachycard, AMS Tx * Nonhemorrhagic - rapid volume repletion - 2L of 0.9% NS or LR * UO for effectiveness - 30mL / hr * watch for hyperchloremic acidosis - HA, confused * Hemorrhagic shock = PRBCs * keep Hgb \>7 g/dl * Vasopressor **only after** volume replaced

Answer 20

Widened mitral valv = Mitral valve prolapse, dilated CMO, ischemic HD backward flow into LA Sxs: * Signs of pulm congestion - pulm effusion, edema * dyspnea, PND, orthopnea * 4th ICS, midclavicular * _**holosystolic apical murmur, blowing, r-\> axilla\*\*\*\***_ Dx: * TTE echocardiogram Tx * Diuretics * antihypertensive * MV replacement

Answer 21

MCC Rheumatic fever (aka GABHS); stiffened mitral valves Sxs: * decrease CO, CHF, Afib common * 4th ICS, midclavicular * **low pitched, DIASTOLIC rumble murmur** * **opening snap** Dx: * Echocardiogram Tx: * MVR * diuretics for mild-mod

Answer 22

Sxs * **Mid to late systolic click** * worse with standing and Valsalva maneuvers * **Panic attacks, palps, young females** Dx * exam + echocardiogram Tx * BB - propanolol * aerobic exercise * Hydration, caffeine * Mitral valve repair

Answer 23

Eti - physical obstruction - PTE, Cardiac tamponade, tension PTX Tx - relieve obstruction, volume

Answer 24

SVT with abrupt onset and offset **Any tachyarrhythmias arising from above Bundle of His** Reentry circuit in or near AV node - electrical impulse travel in circular pattern =\> heart beats fast and regular Sxs: * Palps, SOB, Angina, Syncope, Lightheadedness Dx * EKG rate at **150-250 bpm** * P wave buried in QRS or after * Holter monitor to catch eps Tx: * Cardiovert if hemodynamically unstable * Vagal maneuvers * **Adenosine\*\***

Answer 25

Presence of abn accessory pathway (**Bundle of Kent fibers**) btwn atria and ventricles Type of **orthodromic AVRT** Sxs: * Palps, dyspnea, dizziness, rarely cardiac death Dx: * EKG - shorted PR intvl, widened QRS, **delta waves** Tx: * observed if asymp * Acute tx - **Procainamide\*\*** * **Radio freq ablation is curative**

Answer 26

opening in atrial septum; L =\> R shunt 2nd MC congenital HD Sxs * Asymp until 30yo * \>30yo present w/ dyspnea, and CP * \>50yo present w/ atrial arrhythmias - A fib and RVF Dx * PE - **widely split and fixed S2 into A2** * **systolic ejection murmur at 2nd-3rd LICS** * Echo - definitive\*\* Tx * Small, centrally located ASD - close spontaneously \< 3mm * Mod to large ASD = Transcatheter closure or surgical repair btwn 2-6 yo

Answer 27

Narrowing of aorta; MC below origin of L subclavian Artery Sxs: * **Higher BP in arms than legs (\> 20 mmHg difference)** * Decr pulses in legs, bounding pulses in arms * Bicuspid AV in 50-70% of pts Dx * Radial-femoral pulse delay * EKG w/ LVH * CXR - **notching of ribs, figure 3** * Echo, CT or MRI - definitive Tx * **Balloon angioplasty** w/ stent placement or surgical correction * Prostaglandin E1 - to keep PDA open

Answer 28

Connection btwn aorta and pulm artery after birth (from ductus arteriosus connection that failed to close); **L =\>R shunt** Sxs * FTT, poor feeding, tachycardia, tachypnea Dx * Harsh, **continuous machinery murmur** at 2nd ICS LUSB * **Widened pulse pressure** w/ low DSP * Echo\* Tx * **Indomethacin** for premature babies * Surgical or catheter connection

Answer 29

**Only Cyanotic CHD -** Defect that causes deficient O2 flow out of heart and into body _Four Main Characteristics_ * RV outflow obstruction aka Pulmonary stenosis * R ventricular hypertrophy * Overriding aorta * Ventricular septal defect Sxs * **Tet spells** - hypercyanotic eps during crying or feeding, relieved with squatting Dx * Echo - gold * CXR - **boot shaped heart** Tx * Surgery w/in 1st year of life * Prostaglandin E1 - keep PDA open

Answer 30

MC CHD in childhood; Opening in ventricular septum - shunt btwn ventricles, L→ R shunt Sxs * Child tires easily, can't keep up with children * Loud pitch **harsh, holosystolic** **murmur** Dx * Echo * EKG - mod to severe VSD shows LVH Tx * Surgical closure

Answer 31

2/2 to pericarditis, uremia, cardiac truam Sxs: * painful or painless, depending on rate of effusion * cough * dyspnea * pressure Dx * EKG - **electrical alternans,** non-spec T wave changes, low QRS voltage * Echo - fluid surrounding heart Tx * Observe is small * Pericardiocentesis if + tamponade or large effusion

Answer 32

idiopathic or viral - restrictive pressure on heart echovirus, coxsackie, HIV, TB Sxs: * Dyspnea, fatigue, weakness * Sharp, pleuritic substernal CP =\> relieved by sitting upright or leaning forward * **Friction rub** * **pericardial knock** Dx * ele WBC * EKG * **Diffuse ST seg elevations - concave (smiley)** * **PR depression** * **J point notching** Tx * **NSAIDs** or Aspirin x 7-14d * Colchicine 2nd line * avoid CS - recurrent pericarditis

Answer 33

MCC Atherosclertoic Dz - important risk factor for CV and cerebrovascular M&M Sxs: * intermittent claudication - foot or lower leg pain - relieved by rest * As condition develops, pain at rest develops * Femoral or distal pulses **weak or absent** * Aortic, iliac or femoral bruit may be present * Skin changes - **loss of hair, shiny atrophic skin, pallor w/ dependent rubor** * Severe, chronic = numbness, tingling, ischemic ulceration Dx: * ABI - upper and lower extremities * 0.9-1.2 = normal * \<0.9 = PAD * \<0.4 = severe disease * **Arteriography- gold std** - occlusion Tx: * Stop smoking * Stent - only if short and proximal (femoral and \< 0.3 cm); never stent otherwise * Everything else = **BYPASS** * Meds * ASA * Statin * Cilostazol * Exercise regimen

Answer 34

Congenital ## Footnote Sxs cyanosis at birth, fatigue, dyspnea 2nd LICS JVD, RV hypertrophy heave

Answer 35

Impaired **_diastolic_** relaxation - stiff ventricles decreases filling Eti - infiltrative diseases - **Amyloidosis MCC, Sarcoidosis**, hemachromatosis, scleroderma, chemo, XRT Sxs: * RS HF more common * Chest pain, dyspnea, edema, ascites * Kussmaul's sign - JVP incr with inspiration Dx: * Echo - usual normal systolic contraction * Speckled appearance - infiltrative disorder Tx: * Na restriction, caution diuretics * treat underlying disorders * Poor prog

Answer 36

Eti - bacterial - immune sys reaction = local vasodilation Sxs * confusion, hypoxemia, oliguria * Hypotensive needing pressors (Norepi), tachy Dx - ele plasma lactate (higher = sicker), leukos Tx * **Broad spectrum abx w/in 1st hour = GOAL** * IV fluid hydration - 30mL/kg in first 3 hrs * Vasopressors - Norepi, Vasopressin

Answer 37

**_Reflex Syncope_** * feels it coming on - lighthead, diaphoretic, pallor, N * young adults * Vasovagal or situational **_Orthostatic Syncope_** * elderly, dehydrated, gastroenteritis * ETOH, Nitrates, BB, Antidepressants; Autonomic Dysfunction * Tilt table test - systolic BP drop \>20 w/ standing * tx * Fludrocortisone - mineralocorticoid - hang onto fluid. * Midodrine - vasopressor activity **_Cardiogenic Syncope_** * no premonition - sudden hypotension * arrhythmia or aortic/mitral stenosis, HOCM

Answer 38

Inflammation of superficial vein, usu d/t injury aka need stick Sxs: * pain, erythema at site * vein feels hardened Dx: * Venous duplex US - noncompressible vein Tx: * NSAIDs * elevation * compression stockings

Answer 39

Pulm htn, dilated RV, endocarditis, ebstein anomaly Sxs * JVD, ascites, perip edema * high pitch **pansystolic murmur, accentuated w/ inspiration** * LLSB Tx diuresis, severe TR, then VR

Answer 40

Dilated, tortuous superficial veins 2/2 defective valve structures; weak vein wall = incr intraluminal pressures, rev of venous flow (pooling) Eti: Incr Estrogen = preg, stress of legs, prolonged standing, obesity Sxs: * **Dilated, tortuous superficial veins** * dull ache or pressure w/ prolonged standing, relieved w/ elevation Dx - clinical Tx: * **Conservative** - leg elevation, compression stockings, avoid prolonged standing * Sclerotherapy, radiofreq or laser ablation

Answer 41

RF - smoking, preg, malignancy, OCPs, stationary Sxs * Virchow's triad - stasis of blood flow, hypercoaguable state, vascular damage * unilateral LE pain and swelling Dx * LE venous Doppler * +D-Dimer Tx * Anticoag - Hep or Enoxaparin * DOAC - anticoag for 3-6mos * IVC Filter

Answer 42

Leg pain worse w/ dependency, standing/prolonged sitting Improves w/ walking, elevation of leg; Cyanotic leg w/ dependency Sxs: * **ULCERS** over **medial malleolus\* - ankle or knees** * (arterial ulcers are heels and toes) * uneven ulcer margins * **Stasis dermatitis -** eczematous rash, thickening of skin * **brownish pigmentation** * Pulses and temp usu normal * **Prominent edema common** Tx * below-knee compression * brisk walk * Prognosis for this condition as poor

Answer 43

Secondary - d/t an identifiable cause * HTN in esp in young or old * stage 2 HTN * abrupt onset * Drug resistance * clinical cause **Renal Vascular HTN** - recurrent flash pulm edema, abd bruit * Fibromuscular Dysplasia - young women * tx balloon angioplasty **Pheochromocytoma** - 4Ps - palpitations, htn, perspiration, pain headache **Primary Hyperaldosteronism** * retain water and Na - BP goes up * **hypoKalemia**, order plasma adolesterone:plasma renin activity ratio * tx - aldosterone antagonist - Eplerenone or Aldactone (Spironolactone)

Answer 44

Sxs * Regular \>150 bpm * no P waves * no discernable PR intvl * narrow QRS * palps, dyspnea, CP, syncope Tx * Valsalva * Carotid massage * Adenosine 6mg then 12 mg

Cardiology - 13% Flashcards

(68 cards)