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Cardiology Flashcards

1
Q

BB CIs

A

1- Asthma
2- HR <50 without pacemaker
3- Recent <4w or acute CHF exacerbation PLUS Cardiogenic shock or flash Pulmonary edema

  • Use with caution (not preferred) in patients with BP <90/60 or HR 50-59
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2
Q

Peripartum Cardiomyopathy Treatment

A

1- Ferusmide till euvolemic
2- BB once euvolemia established

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3
Q

Pulse pressure definition

A

Systolic - Diastolic

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4
Q

Pulse pressure in advanced HF

A

Narrow

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5
Q

Pulse pressure range

A

40-60 mmHg

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6
Q

Weight in advanced HF

A

Weight loss ( catabolic state )

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7
Q

HFpEF >40%, best medication for mortality

A

MRA (spironolactone), with careful attention to serum K+

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8
Q

Carvedilol maximum therapeutic dosage

A

25mg BID

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9
Q

BNP

A

NT-proBNP and BNP ranges differes across age groups

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10
Q

Five drug classes may worsen CHF and therefore should be avoided?

A

1- CCB (except amlodipine)
2- NSAIDs
3- TZD (pioglitazone)
4- inhaled anesthetics
5- Some antidepressants (SSRI may be used judiciously )

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11
Q

Whats the most common type of Paroxysmal SVT?

A

AVNRT [Atrioventricular Nodal Reentrant Tachycardia]

  • common among women and young adults
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12
Q

Second most common type of Paroxysmal SVT?

A
  • AVRT ( Atrioventricular Reciprocating Tachycardia )

Most common type in childrens

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13
Q

Acute pericarditis most common cause

A

More than 90%: idiopathic or viral

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14
Q

First line treatment for acute pericarditis

A
  • NSAIDS
  • Indomethacin may reduce myocardial perfusion, therefore not preferred in patients with CCS OR ACS
  • 2nd line: Colchicine, alone or in combination with NSAIDs

Steriod: shown to increase risk of recurrent pericarditis
Therefore, not preferred, unless indicated

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15
Q

JNC 8, when to start Anti-htn according to age

A

Older than 60: 150/90
Younger, DM, or CKD: 140/90

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16
Q

When to decide to add on or increase dose of anti HTN?

A
  • if target BP not reached within 1 month
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17
Q

First line antihypertensive in CKD and DM nephropathy

A

ACEI

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18
Q

Anti htn for COPD patients

A

Selective BB is the agent of choice. Reduce mortality and COPD exacerbation

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19
Q

Mention two selective B1 BB?

A
  • Bisoprolol
  • Metoprolol
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20
Q

BB B1 Selective safer in whom?

A
  • Diabetic with PAD
  • Asthma and COPD
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21
Q

Anti HTN in pregnancy

A
  • labetalol 1st line
  • Nifedipine, methyldopa
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22
Q

Anti HTN for recurrent stroke prevention

A

ACEI and thiazide diuretic

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23
Q

When to stop ACEI in CKD?

A

Raise in creatinine >30% > should prompt investigations to renal artery stenosis

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24
Q

Strongest clinical evidence among Thiazide diuretics?

A
  • Chlorthalidone
  • All thiazide most effective when combined with ACEI
    Monitor for Hypokalemia
    Loop diuretic may be needed if eGFR <40
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25
Q

Preferred ARBS in gout and hyperuricemia

A
  • Losartan
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26
Q

Preferred ARBS in migraine patients

A

Candesartan

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27
Q

BB for DM SE

A

Mask hypoglycemia awareness
Adversly affect glucose

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28
Q

CCB classes

A

Di-hydro-pyridine: Amlodipine, nifedipine,
Non- Di-hydro-pyridine: diltiazem, verapamil

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29
Q

Can di-hydro-pyridine combined with BB?

A

YES
But Non dhp ccb is CI, due to redueced HR and heart block SE

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30
Q

Vasodilators in HTN

A

Hydralazine and Minoxidil: may cause reflex tachycardia (needs BB), and fluid retention (needs diuretic)

Alpha blockers as doxazosin, terazosin: orthostatic hypotension

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31
Q

Centrally acting agent for HTN

A

Clonidine (available as weekly patch). Methyldopa, guanfacine

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32
Q

What features suggest secondary HTN

A

1- <40 yo with grade 2.
2- Childhood with any grade
3- Resisitant
4- Extensive HMOD

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33
Q

BB in pheochromocytoma?

A

Will increase BP

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34
Q

When to initiate high intensity statin?

A

1- LDL 190
2- ASCVD 10year risk 20%

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35
Q

When to initiate moderate intensity statin?

A
  • 40-75 and Diabetic
  • 40-75 and LDL 70-189 and ASCVD risk is 7.5-<20% “intermediate risk” + risk enhancers favoring statin
  • 40-75 and LDL 70-189 and ASCVD risk is 5-<7.5% “borderline risk” + risk enhancers favoring statin then DISCUSS “class 2b (mainly lifestyle and risk factors management)

Low risk (<5%) is always for lifestyle risk factors decreasing

USPTF: 40-75 + ASCVDA RISK >10%

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36
Q

What is risk decision is uncertain?

A

Consider measuring CAC in selected patients

CAC: 100 initiate statin
CAC: 1-99 Favoring statin specially after age 55
CAC: zero no statin (unless family history of premature CHD or smoker)

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37
Q

What are high intensity statins?

A

Atorva 40
Rosuva 20

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38
Q

What are moderate intensity statin

A
  • Lova 40
  • Atorva 20
  • Simva 20
  • Rosuva 10
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39
Q

Mention the ASCVD Risk enhancers?

A
  • Family history of premature ASCVD (55 MALE, 65 FEMALE)
  • CKD
  • Metabolic syndrome
  • Premature menopause
  • Preeclampsia
  • inflammatory disease ( specially HIV, RA, PSORIASIS)
  • Ethnicity

Lab:
- Persistently elevated TG 175. Or LDL 160

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40
Q

Age 0-19 with dyslipidemia

A
  • lifestyle
  • statin if familial
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41
Q

Age 20-39 with dyslipidemia

A
  • lifestyle
  • Consider statin if FH of premature CVD PLUS LDL 160
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42
Q

Mechanism of action of statin?

A

Inhibit HMG-CoA Reductase > this leads to increase activity of LDL receptors on liver

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43
Q

Mechanism of action of Fibrates?

A
  • Increase Lipprotein lipase activity
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44
Q

PE in dyslipidemia

A

1- Orange large tonsils, intermittent neuropathy, hepatosplenomegaly, very low HDL and TC, yellow mucosa, conreal opacitiy: Tangier disease

2- Eruptive xanthoma: chylomicronemia syndrome “TG from 1500 to 2000”

3- Tendinous xanthoma, arcus juvelinis: Familial hypercholesteremia

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45
Q

JNC-8 BP targets

A

60 years old: 150/90
<60 even if CKD or DM: 140/90

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46
Q

When to refer HTN?

A

uncontrolled on more than THREE drugs

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47
Q

Orthostatic hypotension definition

A

Fall in systolic 20mmHG
Fall in diastolic 10mmHG

5 minutes set or supine
Then 2-3 minutes upright

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48
Q

Orthostatic hypotension causing medications?

A

Antihypertensive and diuretics

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49
Q

Hypertension emergency goals?

A
  • MAP 10-20% in the first hour
  • MAP 5-15% over 23 hours

MAP REDUCTION >25% may cause end organ ischemia

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50
Q

Exception for gradual reduction of BP over a course of one day in hypertension emergency

A

1- Ischemic stroke
2- ICH
3- Aortic dissection

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51
Q

What IV antihypertensive increase renal perfusion?

A

FENOLDOPAM ( Dopamine-1 reception agonist)

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52
Q

USPSTF HTN screening

A

18 years old, every 3-5 years

At least yearly IF: Age >40, risk factors (obesity) or prehypertensive (120-129 systolic) twice a year

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53
Q

Elbow Xanthoma versus Eruptive Xanthoma

A

Elbow Xanthoma: LDL >300
Eruptive Xanthoma: LDL >1000

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54
Q

First line agent to prevent Pancreatitis In HyperTriglycermia of 500mg/dL or more

A

FIBRATE (Gemfibrozil)

Mild to moderate elevation (>150 but >500): lifestyle and consider statin based on ASCVD risk assessment

Severe elevation (>500): FIBRATE
If still uncontrolled FIBRATE + OMEGA3 FATTY ACID

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55
Q

What age group more responsive to ACEI and ARBS?

A

<50 YEARS OLD

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56
Q

Clonidine mechanism of action

A

Centerally acting presynaptic Alpha-2 adrenergic agonist
Decrease sympathitic response

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57
Q

Calcium channel blockers

A

NON-DiHydroPyridine is Dilitizam and veraprimil
NON = NON BEAT = HEART BLOCK

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58
Q

Most frequent electrolyte abnormality with thiazides diuretic?

A

Hypokalemia

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59
Q

First line antihypertensive in CKD?

A

ACEI or ARBS

REGARDLESS OF AGE (EVEN IF BLACK)

The only exception is those who aged 75 or older with reduced renal function ( fear of Hyperkalemia and increased creatinine )

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60
Q

Cardiogenic shock

A

Narrow pulse pressure
LOW cardiac index

HIGH pulmonary capillary wedge

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61
Q

The only shock with HIGH Mixed venous oxygen (SvO2) IS?

A

SEPTIC SHOCK

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62
Q

Most common cause of cardiogenic shock

A

ACUTE MI

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63
Q

Best antihypertensive for GOUT?

A
  • Losartan

Diuretics (thiazide and ferusmide) increase urate reabsorption

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64
Q

Most common cause of drug-resistant hypertension?

A

Primary hyperaldosteronism

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65
Q

Treatment of Conn?

A

Adenoma: surgery
Hyperplasia: sprinolactone

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66
Q

Septic shock treatment

A

Measure and follow lactate level

1- fluid (30cc/kg)
2- Norepenphrine if MAP still <65
3- vasopressin

Septic: Norepenphrine, Dopamine
Cardiogenic: Dubtamine

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67
Q

SIRS?

A

Temp: >38, <36
HR: >90
RR: >20
WBC: >12000 or less than 4000

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68
Q

First line for orthostatic hypotension

A

Lifestyle: water intake, smaller meal with less carbs, avoid alcohol, isometric and lower extremities exercise, stand up slowly, avoid overheating

Fludrocortisone, Midodrine (alpha-1 agonist), Pyridostigmine

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69
Q

CCB with greater effect on AV node?

A

Verapamil

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70
Q

Polycystic kidney disease

A
  • AD
  • ACEI or ARBS
  • Family history
  • PKD1 gene
  • U/S
  • flank pain or hematuria
  • Most common inherited cause of CKD
  • Tolvaptan (large kidney volume or decline in GFR)
  • Increased risk of liver involvement, berry aneurysm, and inctracerebral haemorrhage
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71
Q

Postural tachycardia syndrome

A

Raise in HR >30bpm with standing
Absence of orthostatic hypotension

Treatment: fluid and salt intake and structured exercise therapy, usually resolved within 6 weeks

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72
Q

When to start combined antihypertensive?

A

Systolic >20mmHg or diastolic >10mmHG above target

Meaning:
18-59: >160/100
60: >170/100

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73
Q

RAS management ( renal artery stenosis )

A
  • ACEI or ARBS are first line
  • Percutanous angioplasty
  • Surgical revasculization
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74
Q

Compelling indications?

A

Stable angina: BB, CCB
Atrial flutter/fibrillation rate control: BB, NON-CCB

Systolic HF, POST MI, CKD: ACEI

BPH: ALPHA BLOCKERS

ESSENTRIAL TERMOR: NON SELECTIVE BB

HYPERTHYRODISM: BB

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75
Q

Antihypertensive CI

A

Angioedema: ACEI
Asthma: BB
Depression: Reserpine
Liver disease: Methyldopa
Pregnancy: ACEI, ARBS
Second or third degree Heart block: BB, NON-CCB

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76
Q

Antihypertensive adverse effect on comorbid conditions

A

Depression: BB, and colondine
Gout: diuretics
Hyperkalemia: ACEI and ARBS
Hypokalemia and Hyponatermia: Thiazide
Renovascular disease: ACEI and ARBS

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77
Q

Hypertensive emergency special drug indication

A
  • Vasodilators:

Nitruprusside: combine with BB to avoid reflex tachycardia

Nicradipine: caution with CAD and CHF

FENOLDOPAM: Caution with glaucoma

Nitroglycerin: PREFERRED IN CORONARY ISCHEMIA

Hydralazine: ECLAMPSIA

Enalaprilat: preferred in Acute HF. Avoid in Acute MU

  • Adrenergic inhibitors:

Labetalol: Caution in AHF

Esmolol: AORTIC DISSECTION

Phentolamine: PHEOCHROMOCYTOMA

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78
Q

Goal of BP in Ischemic stroke?

A
  • <220/120 if not candidate for tPA
  • <185/110 if candidate for tPA
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79
Q

What BB doesn’t carry risk of Predm and dm?

A

Carvedilol and Nebivolol

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80
Q

What condition necessitates the most RAPID correction of blood pressure?

A

AORTIC DISSECTION

WITH A GOAL OF 100-120 SYSTOLIC WITHIN 20 MINTUES

BB first to reduce HR <60.

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81
Q

HF classification

A

HFrEF: EF of 40% or lower
HFpEF: EF of 50% or more
(HF with borderline preserved ejection fraction is 41 to to 49, it is a definition, but treatment and outcome is the same HFpEF)

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82
Q

Most common cause of HF?

A

IHD

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83
Q

Most common cause of right HF

A

Left HF

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84
Q

Rule of BNP

A

Distinguish cardiac from pulmonary etiology of dyspnea

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85
Q

Gold standard test for HF?

A

TTE

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86
Q

Most common cause of HFpEF?

A

Hypertension

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87
Q

Advanced HF laboratory marker?

A

Hyponatermia

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88
Q

NT Pro-BNP

A

Also elevated in CKD

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89
Q

Albumin in advanced HF

A

LOW (<3.4mg/dl)

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90
Q

NYHA classes

A

Class 1: No limitation - Asymptomatic

Class 2: Slight limitation - Mild symptoms with ordinary activities

Class 3: Moderate limitation: Symptoms with minimal activity

Class 4: Severe limitation - Symptoms at rest

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91
Q

HFrEF classes guided treatment

A

ACEI:
Class 1 or more

BB:
Class 2 or more

Spirnolactone:
Class 3 or more if EF<35%

Hydralazine plus nitrate:
- Class 2 or more
- Black or cannot tolerate ACEI and ARBS

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92
Q

Does SGLT-2 have mortality benefit in HFrEF?

A

Reduced hospitalization

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93
Q

Initially diagnosed HFrEF and volume overload

A
  • Ferusmide is mandatory
  • Initiate ACEI during or after optimization of Ferusmide
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94
Q

HFrEF and CCB?

A

Amlodipine, and felodipine are particularly safe if given for HF but with other indication (HTN, Angina)

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95
Q

BB that carry mortality benefit in HFrEF?

A
  • Metoprolol Succinate ER
  • Bisoprolol
  • Carvedilol
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96
Q

Ferusmide mechanism of action?

A
  • Inhibit reabsoprtion of Na+, K+, and Cl-
  • Common electrolytes abnormalities with Loop Diueretics: Hypo N+, k+, Mg+
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97
Q

BNP for HF, High positive or negative predictive value?

A

High Negative predictive value
So a low BNP helps to r/o heart failure
Sensitive, but not specific

Strong predictor of mortality in 2-3 months, but monitoring in OPD is useless

All cardiac disease can elevate BNP and NT-proBNP

Non cardiac causes:
- advanced age
- anemia
- renal failure
- pulmonary; OSA, severe pneumonia, embolism, P.HTN
- Sepsis or critical illness
- severe burn

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98
Q

S3 versus S4 in heart failure?

A

S3 early diastole: Systolic HF (HFrEF) - may be normal
S4 late diastole: Diastolic HF (HFpEF) - always abnormal

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99
Q

Medications used for HFpEF?

A
  • SGLT-2: Mortality benefit, and reduce hospitalization
  • MRA (spirnolactone): reduce hospitalization, with less clear mortality benefit

Others are usually not indicated since there’s no benefit including (ACEI, BB, Nitrate and hydralazine)

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100
Q

Recommendations for SGLT-2i in HFrEF??

A

Reduce hospitalization in patients with HFrEF + DM + established or high risk ASCVDs

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101
Q

Diastolic HF versus Systolic HF?

A

Diastolic: Reduce active ventricular relaxation and Reduce passive ventricular compliance

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102
Q

Three most common causes of HFpEF?

A

IHD
HTN
VHD

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103
Q

Pericardial effusion versus Cardiac temponade

A
  • Can occurs from right sided HF
  • ECG:
    Start with effusion > sinus tachycardia with low voltage QRS complex > effusion progress > Cardiac tamponade > Electrical alternans ( alternating high and low QRS complex amplitudes between beats )
  • Echo in cardiac tempondae:
    Diastolic collapse of right ventricles ( HIGHLY SENSITIVE AND SPECIFIC )

Early systolic collapse of Right atrium (less sensitive but very specific)

Plethoric IVC

  • Management:
    Saline bolts (cuz patient is preload dependant)
    Pericardiocentesis
    Pericardial window
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104
Q

Two non-pharmacological treatments help to reduce mortality in HFrEF?

A

Disease management and Telemonitoring

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105
Q

AHA/ACC HF classification

A

Stage A: High risk - No symptoms or structural disease
Stage B: Structural disease - No symptoms
Stage C: Structural disease + Symptoms
Stage D: Refractory HF

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106
Q

How to estimate left atrial pressure?

A

Swan Ganz Catheter ( Pulmonary Artery Catheter )

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107
Q

Leading cause of 2ndry healthcare-associated bacteremia?

A

UTI associated with Urinary Catheter

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108
Q

CCB and HF?

A

Non-hydropyridine is not permitted “negative iontropic effects”

Hydropyridine, such as amlodipine, has no rule in HF, but can be used if additional management of HTN is needed. Not indicated if EF is 30% or less

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109
Q

Hydrochlorothiazide and HF?

A

If patients has insuffienct response to loop “inhibit sodium reabsorption at loop of henle”

Thiazide combined to loop have increased efficacy “inhibit remaining sodium reabsoprtion at distal tobules”

*Monitor for Hypokalemia if combined

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110
Q

Which Antiobiotics should be avoided or carefully monitored in patients with HF?

A
  • TRI-Sulphate (BACTRUM)

Risk of HYPERKALEMIA

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111
Q

Prinzmetal angina

A

Occur without precipitating factor and associated with ST ELEVATION

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112
Q

Premature CVD

A

Men <55
Women <65

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113
Q

ACEI in ACS?

A

STEMI: Yes
Non-STEMI: Controversial

114
Q

When nitrate is CI in ACS?

A

Inferior MI

115
Q

ST elevation arteries

A

Inferior MI:
- aVF, II, III
- RIGHT CORONARY ARTERY

Anterior MI:
- V1-V4
- Left anterior descending artery

Lateral MI:
- aVL, V5-V6

Posterior MI:
- ST DEPRESSION V1-V3
- ST ELEVATION V8-V9

116
Q

Criteria for ST elevation

A

> 1mm in more than two contiguous leads
Anterior leads (V2-3): 1.5mm in females, 2mm in male >40, 2.5mm in male <40

117
Q

Most common atypical feature of MI?

A
  • DYSPNEA
118
Q

Medical therapy for Acute Coronary Syndrome

A

MONA BAAS

M ( Morphine ):
- Relieve pain and reduce work of breathing in setting of Pulmonary edema
- Only used if Nitro failed to relieve pain

O (Oxygen):
- given if O2 <90, dyspnea, or HF

N (Nitroglycerin):
- Relieve ongoing chest pain, reduce BP

A (Antiplateles):
- Reduce recurrent thrombosis, and stent thrombosis
- PCI? So DUAL NEEDED
- Aspirin before PCI and continued indefinitely
- PGY12I continue for 1 year if stent placed
- GPIIB/IIIA antagonist for PCI “abciximab, eptifibatide” IN HIGH RISK ONLY

B(BB):
- Prevent recurrent ischemia and arrhythmia

A (ANTICOAGULANT):
- If LV thrombus OR Afib OR receiving thrombolytics OR undergoing PCI
- Unfractioned heparin
- Direct thrombin inhibitor (BIVALIRUDIN)

A (ACEI):
- in STEMI

S (Statin)
- High intensity

119
Q

Reperfusion management for ACS?

A
  • PCI:
    PCI Center with door to ballon time <90m
    Non-PCI Center with door to ballon time <120m
  • Thrombolysis:
    Can be given up to 12 hours from symptoms onset
    CI: ICH, IC malignancy, ischemic stroke within 3 months, Aortic dissection
120
Q

Percentage present with atypical MI symptoms?

A

33%

121
Q

First line in stable angina?

A
  • BB
  • Nitro usually In more acute settings
122
Q

Which class of Angina does BB is CI?

A

Primenzal angina

123
Q

Most sensitive and specific cardiac bio marker?

A
  • Troponin T&I
    Detected at 3 hours, return to normal in 2 weeks
    Rise more rapidly than CK-MB
    Highest sensitivy and specific
  • CK-MB
    Detected at 3 hours, return to normal in 2-3 days
    Useful for Dx of reinfarction
  • Myoglobin
    Detected at 1 hour, return to normal in 1-2 days
    First to appear, first to peak, first to decline
    Not specific
124
Q

First aid in ACS

A

Chewable aspirin, non enteric coated, 162-325 mg

125
Q

Erliest change in ECG in STEMI?

A

Hyperacute T wave

126
Q

Risk stratification for unstable Angina / NSETMI patients

A

TIMI SCORE:
Age 65 OR Older
3 CAD risk factors
Known coronary artery stenosis 50%
Aspirin use in last 7 days
Severe angina (2episodes in 24 hours)
ECG ST elevation 0.5mm
Positive troponin

PCI if:

  • hemodynamicly unstable
  • continued angina despite anti-ischemic therapy
  • CHF symptoms ( s3, pulmonary edema, crackles, mitral regurgitation, elevated BNP “not ANP””, new ST depression)
  • EF <40%
  • History of CABG
  • History of PCI within the past 6 months
  • Elevated troponin
127
Q

Initial intervention for ACS

A
  • ABC
  • IV line and cardiopulmonary monitor
  • Aspirin 325 orally, or rectally
  • History and PE and LABS ( cbc, cardiac enzymes, electrolytes, coagulation profile)
  • Pain control with NTG (0..4mg, sublingual three tablets)
  • Start dual antiplateles
  • Start Anticoagulant
  • Give BB
  • persistant pain give Morphine
  • Statin as early as possible, before PCI in patients not on statin
128
Q

In addition to BB, what antihypertensive medications has also mortality benefit in ACS, but is BEST for patients with HF, EF40% OR LESS, STEMI (SPECIALLY ANTERIOR)

A

ACEI

129
Q

Cocaine induces ischemic symptoms, what medication to avoid?

A

BB

130
Q

Cardiomyopathy types

A

1- Dilated CM
2- Hypertrophic CM
3- Restrictive CM

131
Q

What is the most common cardiomyopathy?

A

Dilated cardiomyopathy

132
Q

What is the most common cause of dilated cardiomyopathy

A

Idiopathic

ECG findings of: LVH, Low limb lead voltage

133
Q

Idiopathic dilated cardiomyopathy and family screening

A

A lot of familial dilated cardiomyopathy was initially diagnosed as idiopathic.
So, history taking of family is imp (3-4 generations)
Screening for first degree relatives is imp
Consider genetic testing (AD)

How to screen?
- HX
- PE
- ECG
- ECHO
- CK and MM isoenzyme

134
Q

ACLS protocol for cardiac arrest

A

Start CPR:

1- Shockable rhythm?
Shock > continue CRP 2m > Shock > CPR 2m > Epinephrine every 3-5m > amiodarone
Initiate targeted temperature management after ICU admission (maintain normothermia, and avoid hyperthermia)

2- Asystole/PEA?
CPR 2m and Epinephrine every 3-5m

CPR QUALITY
Push hard (5cm) and fast (100-120/m)
Allow full chest recoil (1/3 AP chest diameter in child)
If no advanced airway 30:2 compression to ventilation ratio
If there’s advanced airway (endotracheal intubation or supraglottic advanced airway), give 1 breath every 6 seconds = 10 breath/m

135
Q

What is the most metabolic cause of cardiac arrest?

A

Hyperkalemia

136
Q

Most common cause of restrictive cardiomyopathy?

A

Amylodosis

137
Q

Restrictive cardiomyopathy VERSUS Constructive pericarditis?

A
  • Constructive pericarditis present similarly in term of symptoms
  • pericardial calcification, knob, no palpable impulse, absence of S3 gallop, and lower BNP <400. Are all suggestive of constructive pericarditis rather than restrictive cardiomyopathy
138
Q

Most common primary cardiomyopathy?

A

Hypertrophic cardiomyopathy

139
Q

Hypertrophic cardiomyopathy meds?

A
  • BB
  • Verapamil for patients without left ventricular outflow obstruction (Non-DHP)

Used only for symptomatic patients, or with HTN

140
Q

Primary treatment of hypertrophic cardiomyopathy at risk of sudden death?

A

ICD
Implantable cardioverter-defibrillator
First line if:
1- documented ventricular arrhythmia
2- High risk for SCD

Risk factors for SCD?
1- Age <30 with evidence of nonsustained ventricular tachycardia
2- Thickness of ventricular wall or septum In echo is 3cm or above
3- family history of SCD
4- recent unexplained syncope
5- hypotension during stress testing

If had history of syncope due to heart block?
Evaluate for implantation of dual chamber permenant pacemaker with ICD

Septal myoectomy?
Doesn’t prevent SCD, it usually used if the patient develop heart failure that is referactory to medical management

141
Q

Takotsubo (stress) cardiomyopathy

A

Broken heart syndrome
More common in women, specially postmeopause
Mimics STEMI

Diagnostic criteria:
1- ECG abnormalities or modest cardiac enzymes elevation
2- left ventricular systolic dysfunction on echo ( apical ballooning of the left ventricure)
3- absence of atherosclerosis on angiography
4- absence of pheochromoctyoma or myocarditis (by cardiac MRI)

142
Q

Acute MI, when can he do stress test?

A

Two days

143
Q

Familial dilated cardiomyopathy treatment?

A
  • ACEI and diuretics
  • Cardiac transplant
  • LVAD (LEFT VENTRICULAR ASSIST DEVICE) if not candidate for transplant

Implantable cardioverter defibrillator should be considered in patients with +ve family history of sudden cardiac death. Even if EF >35% ( the usual cutoff for prophylactic placement)

144
Q

Restrictive cardiomyopathy

A

MOST COMMON CAUSE IS AMYLODOSIS

ECG: low voltage
Echo: impaired diastolic filling, and preserved systolic function

TREATMENT OF CARDIAC AMYLODOSIS: LOOPS +- SPIRONOLACTONE

145
Q

DVT, most appropitate and gold standard?

A

Duplex U/S

Gold: Venography (CT or MR)
MR VENOGRAPHY HAVE 100% SENSITIVITY

146
Q

Aortic dissection Stanford classification

A

A: involve ascending aorta and most common. Most common. Require emergency surgical intervention

B: No involvement of ascending aorta (distal to left subclavian artery = descending)

147
Q

Aortic dissection Medical management

A

1- Decrease HR to <60 with IV BB (Esomolol)
2- Maintain SBP 100-120mmHg with IV Nitroprusside (vasodilator) only after HR is controlled

148
Q

Aortic aneurysm definition of smoker in recommendations

A

Lifetime 100 ciggrates

149
Q

AAA diagnostic cut-off and monitoring

A

AAA diagnostic cutoff: 3cm dilatation

Monitoring:

3 - 3.9: US every 2-3 years

4 - 4.9: US annualy

5 - 5.4: US every 6 months (MRI,CT can be used)

5.5cm: surgery

Rapidly expanding (>0.5cm over 6m): surgery

Symptomatic: surgery

Repair if going for another cardiac surgery if: >4.5cm

Women: higher risk of rupture so >5cm is a safe approach to consider surgery

150
Q

Most common complication of Bicuspid aortic valve?

A

Aortic stenosis

151
Q

PAD testing

A

ABI:
High: >1.4 ( suggest calcified artery )
Normal (1.01-1.4)
Borderline-low: 0.91-1
Low: 0.90 or less
Mild 0.9-0.75
Moderate PAD 0.75-0.4
Severe PAD <0.4

ABI interpretation and next step:
If high: toe-brachial index (normal if >0.65)
If normal or borderline- low with highly suspicious history > Exercise ABI testing
If low: PAD is the most likely diagnosis, further testing as necessary

0.9 or less: indicated 50% stenosis
0.4 or less: indicated ischemia

Conventional arteriography:
The gold standard

If the limb is threatening (rest pain, ischemic ulcer, gangrene):
Contrast angiography

For lesion localization and planning for intervention:
Contrast angiography

152
Q

Most common symptom in Aortic dissection

A

Chest pain

Back pain: more common in those with descending aortic dissection

153
Q

Imaging for Aortic dissection

A

Initial: CXR
Best imagining: CTA

Hemodynamic unstable: CTA (gold standard), or TEE

154
Q

AAA is more common in men, but risk of. Rupture and negative surgical outcome is more common in?

A

Females

155
Q

Aortic dissection physical findings?

A
  • Wide pulse pressure
  • 20mmHG difference in SBP between left and right arm
  • Can cause aortic regurgitation > diastolic decrescendo murmur
156
Q

CVI > Varicose veins > superficial phlebitis, superficial thrombophlebitis, superficial vein thrombosis

A

For superficial phlebitis:
- NSAIDS, warm moist compressor
——————————
For superficial thrombophlebitis, or superficial vein thrombosis, same
If at increased risk of DVT:
- 5cm thrombosis
- thrombosis with proximity to the deep venous system (5cm from saphenofemoral or saphenopopliteal junction)

USE LMWH or fondaparinux for 45 days

157
Q

Modified wells score (Pretest probability of DVT):

A

if alternative diagnosis is As likely or More likely than that of DVT > -2 points

Each point for:

History:
- Active cancer ( on treatment or palliative, or within 6 months of treatment )
- Paralysis or plaster immobilization
- Bedridden >3days, or major surgery <3m )
- previous documented DVT

PE:
- Entire leg swelling
- Calf swelling more than 3cm when compared to the other leg “measured 10 cm below tibial tubersity”
- pitting edema
- Localized tenderness along the distribution of deep venous system
- collateral superficial veins (no varicose)

SCORE:
High probability
1-2: Moderate probability
Low probability
—————————————

Low- Moderate probability > D-dimmer > if positive > U/S > if negative U/S> repeat in 1 week
(Some experts recommend initial U/S if moderate probability)

High probability > U/S

158
Q

Aortic dissection and BP

A

Type A: Hypotensive
Type B: Hypertensive

159
Q

Tender nodule in lower extremities?

A

1- Polyarteritis nodule
2- Erythema nodusm

160
Q

Pathognomonic feature of Polyarteritis nodusa?

A

Startburst livedo

161
Q

Upper extremity venous thrombosis criteria

A

One point of each:
- subclavian or jugular vein catheter or device
- unilateral pitting edema
- localized pain in that extremity
- minus one point if other diagnosis is suspectible

2 scores = high probability for upper extremity DVT

162
Q

DVT haemodynamically stable management

A

Isolated distal calf vein:
Anticoagulant only if symptomatic, or high risk for proximal extension.
F/u after two weeks to monitor extention, if extended, anticoagulant is indicatied

  • deep veins involvement ( popliteal, femoral, iliac ):
    Oral anticoagulant unless contraindicated (plt <70.000, severe liver or renal diseases)
  • DOAC is the threatment of choice
    Factor XA INHIBITORS ( apixiban, rivaroxaban, edoxaban)
    Direct thrombin inhibitor (Dabigatran)

Rivaroxaban, 15mg BID with food for 3 weeks, then 20mg OD

If warfarin would be used, should be bridged with IV heparin for 5 days

Duration:
First episode; 3 months

163
Q

PAD most common artery involved?

A
  • Common iliac artery > External iliac artery > common femoral artery > superficial femoral artery > popliteal > anterior tibial
  • Internal iliac artery: buttock
  • Common femoral artery: Thigh pain
  • Superficial femoral artery
    (Calf pain) IS THE MOST COMMON ( upper 2/3 of the calf )
  • Popliteal artery: Lower 1/3 of the calf
  • anterior tibial artery: foot pain
164
Q

Aortic stenosis, When to refer to a cardiologist?

A

1- Symptomatic (SAD)
2- Severe stenosis: defines as mean pressure gradient is more or equal to 40mmhg, Or, Maximum transaortic volecity more or equal to 4m/s, Or aortic valve area less than or equal to 1 cm
3- Reduced ejection fraction (<50%)
4- going to other cardiac surgery

Surgical valve replacement is preferred. However, if the patient is high surgical risk, trans catheter aortic valve replacement may be considered

  • Hints for severe aortic stenosis: soft, inaudible aortic component of S2
165
Q

Preferred anti HTN for aortic stenosis

A
  • ACEI
  • Diuretics

Try to avoid ( BB, CCB, alpha blockers )

166
Q

Most common cause of Aortic stenosis

A

Degenerative calcification

167
Q

Sublingual nitroglycerin mechanism of action?

A
  • convert to Nitric oxide
  • dilate all blood vessels and decrease preload to the heart > decrease myocardial oxygen demand
168
Q

Antianginal medications?

A
  • BB: first line
  • Nitroglycerin
  • CCB
169
Q

Algorithm for vascular testing in symptomatic PAD

A

If Critical limb ischemia (ANY OF THE FOLLOWING), refer to vascular specialist for contrast angiography and management:
- Rest pain and dependant rubor
- Tissue loss
- Non healing ulceration (>2w)
- Gangrene

If Claudication/ atypical leg symptoms, measure ABI:

> 1.3: calcification
0.91 to 1.3: Normal
0.90 or less: Abnormal

  • Calcified > refer
  • Normal-borderline > exercise ABI if typical claudication
  • Abnormal: treat risk factor for mild >0.8, refer for revasculrization for moderate to severe
170
Q

Ankle and Arterial insuffiency versus venous insuffiency?

A
  • skin change or ulcer to the lateral aspect of ankle (lateral malleolus) > arterial
  • skin change or ulcer to the medial aspect of ankle (medial malleolus) > venous
171
Q

Marfan and aortic aneurysm/dissection

A

Thoracic aortic aneurysm once become sympatomic surgery is indicated!
5cm is the cut off for surgery in Marfan
Mostly ascending

Marfan:
- AD
- Mutation of fibrillin-1 gene
- Pectus deformities
- Wrist sign: thumb overlap terminal phalanx of the fifth digit
- Thumb sign: thumbnail projects beyond the border of the hand
- Ectopia lentils: dislocation of ocular lens
- Scoliosis/ kyphosis
- Aortic root dilation > aortic dissection

Annual echo is required: Aortic root dilation, aortic regurgitation, mitral proplase with or without regurgitation

Patient with Marian + dilated aortic root: should be restricted from competitive sport, contact sport, isometric exercise.. but light regular activity is advised

Marfan female should be counseled by cardiologist about: risk of aortic dissection at pregnancy, and risk of uterine rupture at delivery

Stimulants ( as for ADHD ) should not be used in marfan with cardiac involvement

172
Q

Pulmonary venous stenosis

A
  • Complication of catheter ablation for atrial fibrillation
  • dyspnea, cough, hemoptysis, recurrent chest infection
  • usually 2-5 months after the procedure
  • treated with angioplasty
173
Q

Highest RF for PAD

A
  • Smoking and Diabetes
174
Q

Medical management of PAD:

A
  • Smoking casseation
  • structured exercise program
  • statin
  • Antiplatelet

Cilostazol can be given if no heart failure.

175
Q

Definition of ABI borderline PAD

A

0.91 to 0.99

176
Q

Spider veins/ reticular vein/ varicose vein

A

Spider: <1mm
Reticular: 1-3mm
Varicose: >3mm, bulge above the skin

177
Q

Sinus node dysfunction

A
  • Formerly known as sick sinus syndrome
  • Most commonly caused by SA node dysfunction
  • Medications causing sick sinus dysfunction (BB, CCB, digitalis, LITHIUM, anti arrhythmic drugs), Hyperthyrodism
  • ECG: Tachycardia (Afib most commonly, SVT, atrial flutter) followed by bradycardia. May required Holter monitor to detect ( Tachy,Brady syndrome )
  • Treatment:
    If on offending medications: D/C to check if it was medication-induces sick sinus dysfunction
    If not meds induces: PACEMAKER FOR BRADY who developed symptoms, FOLLOWED BY MEDICATIONS FOR TACHYCARDIA (BB, CCB,ANTIDYSRHYTHAMIC)

Surgery? Radiofrequency ablation around AV NODE

178
Q

Carotid sinus hypersenstivity

A
  • Carotid sinus massage: sinus pause more than 3 seconds, or symptomatic drop in blood pressure upon massage
179
Q

Heart block

A

ECG:

First degree
- Prolonged PR interval (>200m/s) (more than 5 small square)

2nd degree Mobtiz I
- Progressive prolongation of PR interval, then QRS drop

2nd degree Mobtiz II
- No prolonged PR, QRS dropped

3rd degree (complete heart block)
- No relation between P and QRS

Management
IV atropine OR IV dopamine OR temporary pacing to Any unstable defined as:
- Hypotensive
- Unstable bradycardia: altered mental status, ischemic chest pain, acute heart failure

Ongoing management:
- can investigate as outpatient if stable for 1st degree, or 2nd degree Mobtiz I
- Plan for permenant pacemaker in Mobtiz II AND 3rd degree heart block without reversible causes.
- Plan for permenant pacemaker in low risk ( 1st degree and Mobtiz I ) If symptomatic, neurmuscular disease, infranodal block

180
Q

Afib

A

Types:

Paroxysmal:
Terminate within a week, with or without intervention

Persistant:
Fails to terminate within a week, often require pharmacological or electrical cardio version

Long standing:
More than a year

Permanent:
Joint decision to no longer pursue a rhythm control strategy

Treatment:

  • unstable: cardioversion
  • Stable: rate control ( BB, or Non-CCB as diltiazem ) versus rhythm control. Around 110bpm is acceptable
  • > 48hours, anticoagulate 3 weeks prior to cardioversion (DOAC), cause warfarin may take up to 6 weeks for patients to be effectively coagulated
  • CHADS,VASC score (used to determine risk of embolization “specifically stroke”in non vulvular Afib patients)
  • HAS-BLED score to asses risk of bleeding

CHF or LV dysfunction (EF40or less): +1
Hypertension: 1
Age 75: +1
DM: +1
Stroke, TIA, or thromboembolism: +2
Vascular disease (MI, PAD, aortic plaque): +1
Age 65-74: +1
Female: +1

2 male, or 3 women: initiate DOAC

Indications for warfarin:
- Vulvular Afib (moderate to severe mitral stenosis “is defined as valve area <1.5cm”, mechanical heart valve, Hypertrophic cardiomyopathy)
- APL

Reversal agents for bleeding:
- Direct thrombin inhibitor ( Dabigatran ): Idarucizumab
- Factor Xa inhibitor ( Apixiban, rivaroxaban ): andexanet Alfa

  • Since most of thrombus formed within left atrium appendage, chronic anticoagulation is considered according to chadvascs score

Contraindication to anticoagulant:
Unacceptable high risk of bleeding, thus include
- Thrombocytopenia
- Prior severe bleeding (ICH)
- recurrent bleeding
- High risk of fall, or previous fall resulting in injury
- poor medication complainance

Those, referral for a placement of percutanoues left atrial appendage occlusion device should be considered

Radiofrequency catheter ablation: beneficial for symptoms improvement, but doesn’t reduced risk of embolism stroke

Therapeutic INR in non Vulvular Afib: 2-3

181
Q

Supraventricular Tachycardia (SVT)

A

Unstable: Cardioversion

Stable: Vagal maneuver (to increase parasympathetic tone) first, if cannot performed or failed, Adenosine.

Iv metoprolol, or verapamil if vagal and adenosine ineffective

IV Digoxin if all above failed

182
Q

DOAC and antiepleptics?

A

-Phentyoin
-phenobarbital
-carbamazepine

Contraindicated with:

  • Dabagrtan
  • Abixiban
  • Rivarxiban
183
Q

Prolonged QT syndrome

A

Causes:
Most common: medications
Familial
Hypokalemia
Hypocalcemia
Hypomaganesmia

Offending medications:
- antiarrhythmic
Class IA: procainamide, quinidine
Class IC: Propafenone, flecaindine

  • older generations antipsychotic (haloperidol, droperidol), phenothiazine
  • Cyclic antidepressant
  • certain antiobiotics
    Fluoroquinolone
    Macrolide
    Antifungal/ antiviral
  • Nonsedating antihistamine
  • Gastric motility agents
  • methadone
  • ECG:
    Men QT interval >440 msec
    Women QT interval > 460 msec
  • treatment:
    Symptomatic: Propranolol or Nadolol
    ICD for high risk of sudden death

Congenital: BB even if asymptomatic (propranolol). Cardiology consultation, consider genetic testing and counseling

Acquired: Stop offending medication, correct electrolytes imbalance

Torsades de pointes: IV Magnesium sulphate or pacing

ICD indications:
1- syncope”specially if recurrent”
2- aborted cardiac arrest
3- ventricular tachycardia (eg. torsade de pointes ) on BB

184
Q

Torsades de pointes

A

Most common caused by: acquired or congenital prolonged QT syndrome

ECG: wide complex tachycardia with QRS polymorphism

Management:
Unstable: Defibrillation
Stable: IV Mg and stop offending drug

185
Q

Right bundle branch block

A

Wide QRS complex
((((Triphasic QRS complex in lead V1))))
Wide S wave in leads I, v5, or V6

186
Q

Valsalva maneuver

A

Vagal stimulation by:

  • cold stimulants to the face
  • Valsalva maneuver: blow through a closed mouth or into straw/ syringe
  • stimulate gag reflex

Thus will increase pressure in IVC > decrease preload > increase periphral vascular resistance > sudden termination the Manuver > sudden increase in the preload while the periphral vascular resistance is still high > rise in MAP > parasympathetic response that decrease the heart rate

** Carotid massage is CI in childrens

187
Q

Verapamil contraindications

A

WW

  • WIDE QRS
  • SUSPECTED WPW SYNDROME
188
Q

Premature ventricular contractions (PVCs)

A

Occur in general population
Specially lying on left side

Frequent ventricular premature beats: identify cardiac etiology; echo, holster, ecg, stress ecg

Risk factors:
- HTN WITH LVH
- MI
- HF
- HCM
- CHD
- idiopathic ventricular tachycardia

ECG:
- Earlier than the next expected normal QRS
- Wider than normal QRS, morphology is bizarre
- No preceding P wave
- followed by Pause

Asymptomatic: none
Symptomatic: BB- ccb

189
Q

Basic ECG

A

P: depolarization of atria

PR: conduction through AV node

QRS: depolarization of ventricles

ST: between de, and re, POLRIZATION

T wave: ventricular repolarization

Normal HR: 60-100
PR: 120-200
QRS: 60-100

190
Q

Normal P wave in ECG in normal sinus rhythm

A

Upright in leads I, II, aVF, V1 to V6

Inverted in avR

191
Q

Ventricular Tachycardia

A
  • Most common cause: previous MI
  • Pulsless: immediate defibrillator
  • Unstable: Cardioversion
  • Stable: Amiodarone
192
Q

Amiodarone Monitoring and Recommendations

A
  • Chronic interstitial pneumonitis is the Most common complication
  • Pulmonary toxicity is the most common cause of death among long term amiodarone users

Others:
- Pulmonary ( fibrosis )
- Nephrotoxic
- Hepatotoxic
- Metabolic (thyroid disorders, dyslipidemia )
- neurogenic ( tremor, neuropathy, ataxia )
- skin ( photosensitivity, bluish skin discoloration )
- Eyes: corneal micro deposits, optic neuropathy
- Cardiac: QT prolongation and Torsades de pointes, symptomatic SA or conduction system impairment

Baseline investigations:
- ECG
- TFT
- LFT
- CXR and PFT
- PE (neurological, eye examination, skin examination)

Follow up:
- TFT, LFT : every 6 months
- CXR and ECG: annually
- Derma, neuro, eye exam, PFT: PRN

When to discontinue amiodarone?
- Hyperthyrodism
- Optic neuropathy
- Any pulmonary disease

When to continue amiodarone?
- hypothyroidism: continue and treat
- corneal micro deposit
- Photosenstivity: avoid sunlight, use sunblock

When to reduce dose or discontinue?
- CNS complications (ataxia, dizziness, fatigue )
- Skin blue gray discoloration
- ECG changes
- Hepatotoxicity

193
Q

Aortic valve replacement complications

A
  • AV block ( heart block ) > Pacemaker
194
Q

Wolff Parkinson White Syndrome

A

Most commonly caused by accessory pathway (BUNDLE OF KENT)

ECG:

1- Delta wave: slurred upstroke of QRS complex
2- Wide QRS
3- Short PR

Associated with; atrioventricular nodal reentrant

Acute treatment?
Orthodromic (down): vagal manuver > adenosine > bb > ccb
Antidromic (up): procainamide
Unstable: cardioversion
Definitive: Radiofrequency ablation

Concommunit Afib : Ibutilide ( BB- CC is contraindicated )

195
Q

The most frequent mechanism of sudden cardiac death in acute MI is?

A

Ventricular fibrillation

Immediate treatment:
Non-Synchorized Cardioversion (defibrillation)
using Biphasic Waveform defibrillator

Defibrillation = Ventricular tachycardia or V fib

196
Q

Anticoagulants

A

We are preferring to treat thromboembolism generally with DOAC (Direct Oral AntiCoagulant) previously known as NOAC (New Oral AntiCoagulant)

EXCEPT in those situations you should treat with WARFARIN!
1- Antiphospholipid syndrome
2- Left atrium thrombus
3- Moderate to severe mitral stenosis (including valvular A fib which is A fib with moderate to severe MS)
4- Cardiac prosthesis
5- Creatinine clearance less than 30 (except for Apixaban can be used till Crcl 15)
6- Cerebral venous thrombosis
7- Hypertrophic cardiomyopathy

197
Q

Non vulvular afib, doesn’t want anticoagulant for reasons other than bleeding

A

Aspirin + clopdigrel

198
Q

Multifocal atrial tachycardia (MAT)

A

Associated with COPD

ECG:
- HR >100
- P wave: variable morphology “at least three”

Treatment:
- Treat underlying cause + CCB

199
Q

Approach to narrow QRS tachycardia

A

Q1- is it regular or irregular?

Regular: P wave visibility
Not visible: AV nodal reentry tachycardia (AVNRT)
Visible: atrial flutter, sinus tachycardia (same p wave) , focal atrial tachycardia (different p wave than baseline, RP prolonged)

Irregular: Afib, atrial flutter with variable AV block, Multifocal atrial tachycardia, Sinus tachycardia with premature atrial complex

200
Q

Focal atrial tachycardia

A

Rhythm control if not hypotensive

BORDERLINE HYPOTENSIVE: IV AMIODARONE
NORMOTENSTIVE: IV BB OR NON-CCB

Types of heart block can appear with focal atrial tachycardia?
- 2nd degree heartblock

201
Q

Sinus bradycardia

A

Causes:
- Medications ( BB, CCB, Digoxin)
- IHD
- Hyperkalemia
- Hypoglycemia
- Hypothyorism
- Hypothermia
- OSA
- Sick sinus syndrome
- Increased vagal tone (athletes)

Treatment:
Symptomatic: Atropine > epinephrine, dopamine > transcutaneous pacing
Asymptomatic: observation

202
Q

Paroxysmal SVT

A
  • most common type?
    AV- Nodal Reentrant Tachycardia
  • Hormone?
    Progesterone

-ECG?
No P wave, Narrow qrs and regular

  • Treatment?
    Vagal > adenosine > cardioversion if unstable
203
Q

Troponin non cardiac causes?

A
  • Renal failure
  • Sepsis
  • Drug toxicity
  • Stroke
  • SAH
204
Q

Sinus bradycardia, what to exclude?

A

Sinus node dysfunction (Sick sinus syndrome)
With Hother monitor

205
Q

Definitive treatment for SVT?

A

Ablation

206
Q

A fib caused by acute or alcohol use?

A

Holiday heart

207
Q

Left bundle branch block

A
  • LAD artery
  • Widenend QRS
  • lead I: Large wide R wave
  • Lead V1: negative wave

Indications for cardiac resynchronization therapy (biventricular pacemaker) to pass the ventricular conduction system entirely:
Left bundle branch block + HF NYHA class 2-3

208
Q

Ethanol toxicity and cardiac

A
  • associated with development of atrial arrhythmia, specially Afib
  • Ataxia, gait instability, slurred speech
  • severe intoxication 4H ( hypothermia, hypotension, hypoglycemia, hypoventilation )
  • Supportive, In severe cases; glucose and thiamine
209
Q

Afib initial labs and imaging

A
  • CBC
  • Kidney function
  • Renal function
  • TSH
  • CXR and ECHO

Drugs: only if suspected (ventolin, lithium, alcohol, diet pills)
Sleep study: if OSA is suspected as the cause

210
Q

V tachy

A

Shock
Sock
Before the third shock: consider amiodarone

211
Q

VULVULAR HEART DISEASES

A

REFER TO PDF EXPERT

212
Q

Acute Rheumatic Fever

A

Type two hypersenstivity reaction, where is the Antibodies against GAS crossely reacting with host cell protein.

History: recent GAS infection

Diagnosis: Revised Jones Criteria
Labs: antistreptolysin O, anti-DNase B, Throat culture, rapid antigen test.

Treatment is AB and NSAID
Antibiotic for GAS doesn’t prevent against PSGN

The goal is to prevent GAS and recurrent rheumatic fever, which may worsen already existing rheumatic heart disease, or induce it

  • drugs:
    Penicillin G (IM) is the first line. Every 21d or 28d (21d is preferred in high risk situation such as acute recurrence of Rheumatic fever despite adherence to 28d injections)

Penicillin V (oral) is the second line, usually due adherence issue

Penicillin allergy?
1- desensitization
2- Azithromycin
3- Erythromycin ( more side effects and more daily doses)
4- clarithromycin

Duration (whichever longer):

Without carditis: 5 years, or till 21
With carditis: 10 years, or till 21
With carditis + residual heart disease (VHD): 10 years or till 40 years, sometimes lifelong prophylaxis is indicated ( higher risk to exposed to GAS; teacher, crowdy, healthcare worker )

213
Q

Mitral stenosis and anticoagulants?

A
  • Afib
  • Left atrial thrombus
  • Prior embolic event
214
Q

Congenital Heart Diseases

A

1- VSD:
- Most common pathological murmur in childhood
- Types:
Infundibular
Memberanous “MOST COMMON”
Inlet
Muscular
Rare type: Gerbode defect, defiency of AV septum separating left ventricle from right atrium, needs periodic screening for sinus node dysfunction And tricuspid regurgitation
- Small: often asymptomatic aside from murmur
- Moderate: FTT, diaphoresis with feeding, tachypnea,..
- Large: risk of Eisenmenger syndrome
- Loud harsh PANSYSTOLIC murmur, lower left sternal border
- diagnosis: Echo. Moderate-to-large VSD can be detected in utero “16-18w”
- Treatment:
small: monitoring without intervention
Moderate, large: monitoring, diuretics for symptoms
Moderate, large unresponsive to medical therapy: surgery
Surgery should be avoided in severe pulmonary HTN
Down: A-V septal defect is the most common, followed by VSD

2- Coarocation of aorta:
- Narrowing of descending aorta
- Associated with Turner, intracranial aneurysm, bicuspid aortic valve”
- Bicuspic AV, and VSD are the most common cardiac defected associated with coarocation of aorta
- Systolic BP in upper limbs, and femoral delay
- ECG: LVH
- CXR: Ribs notching
- Diagnosis: Echo
- treatment: ballon angioplasty with stent, or surgical correction

3- ASD:
- Wide fixed split S2
- Most commonly caused by persistant Ostium SECUNDOM “septum primum, septum SECUDUM, AV septum””
- Osteum Secondum caused by growth arrest or osteum secondum, or excessive absorption of the septum primum
- small: usually asymptomatic
- large: FFT, diaphoresis,… and recurrent pulmonary infection
- CXR with large ASD: Cardiac enlargement AND increase pulmonary vascularity
- ECG: incomplete right bundle branch block
- treament:
Often close spountanously during childhood
If persistant: Percutanous closure or surgery

4-: Teratology of Fallot
- Most common CYANOTIC CHD
- Associated with trisomy 21 “down”
- Cresencendo decrescendo harsh systolic ur ur
- Echo PROV: Pulmonary valve stenosis, RVH, Overrding aorta, VSD
- Cyanosis with exertion called hyper cyanotic spells or tet spells “with feeding, crying..” and squatting for relieve
CXR: Boot shaped heart

5- Brugada syndrome
- AD conduction disorder
- ECG: V1-V2 coved or saddleback ST segment
- Schizophrenia can be associated with brugada pattern ECG
- Nocturnal agonal breathing with gasping breaths during sleep, represent aborted cardiac dysrhythmia, common presentation to Brugada
- Amiodarone, most effective medication to prevent tachyarrhythmia in those patient
- BEST management: ICD “for symptomatic (preceding syncope or V dysrhthmia”or family history of sudden cardiac death

6- PDA
- RF: birth at high amplitiude, prematurity, rubella, female, genetics
- hemodynamic close 10-15h soon after birth. And histological obliteration by the third week
- bounding pulse, wide pulse pressure
- continuous machinery like flow murmur radiated to the back, best heart left upper sternal border 2nd ics below the clavicle
- indeomethacin or ibuprofen in premature infants, surgery
- can leads to Eismenger

7- Ttransoprtation of great vessels
- Aorta raised from RV
- pulmonary artery arise form LV
- typically, no murmur heart unless concumient VSD

8- Pantology of Fallot:
- Teratolgy of Fallot + ASD

215
Q

Infective Endocarditis

A
  • Risk factors:
    VHD (mitral valve prolapse or regurgitation)
    History of RHD or IE
    Congenital cyanotic heart disease
    Intracradiac or intravascular device

Indwelling venous catheter
IV drug use
DM
HIV
Age greater than 60
Male
Poor dentition
Hemodialysis

  • most common symptoms: fever > malaise
  • PE: FROM JANE ( Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, anemia, nail bed haemorrhage, embolism
  • Diagnosis: Echo and Duke criteria
  • Most common caused by (REFER TO UTD)
    Most common worldwide: staph aureus
    Most common in US and developed conurry: Staph aureus

Staph aureus 1/3 of cases and more important in hospital acquired. Strept in more important in community

IV drug abusers: Staph aureus, typically tricuspid valve
Native valve: Staph aureus, typically mitral
Previously diseased native valve (CHD, degeneration, calcified, RHD): Strep viridans, typically mitral
GI malignancy: strep Bovis

Murmur: most often not presented on initial presentation
IV drug Endocarditis carries a lower mortality rate than prosthetics valve endocarditis
Tranthoracic echo carries a sensitivity only 60% for endocarditis. If the transthoracic is negative, and clinical suspection is high > TRANSESOPHAGEAL ECHO

Treatment:
Microbiological response to treatment assessed every 1-2 days with blood culture until bacterimia cleared
Duration is 6 weeks
Empiric antiobiotic should cover MRSA, so it’s always VANCOMYCIN
AB can be ulcer once we have the culture results

Indications for valve replacement surgery:
1- New onset Heart failure
2- perivalvular abcess
3- persistent positive culture despite 7 days of Antibiotic
4- Persistent embolic event despite treatment with Antibiotic

Criteria for prophylaxis AB:
Both of the following
1- high risk patient for IE
2- high risk procedure

High risk patents:
1- Prosthetic heart valve, prosthetic material used in valve repair
2- Prior IE
3- Unrepaired cyanotic congenital heart disease, including palliative shunts or conduits
4- Repaird CHD with prosthesis during the first 6 months after procedure. OR. Repaired CHD with residual defect at or adjacent to the site of prosthesis device or patch
5- Heart transplant with valvulopathy

High risk procedures:
1- Dental: include routine dental cleaning
2- Respiratory: Incision or biopsy of respiratory mucosa
3- Skin or soft tissue: infected tissue surgical management
4- Cardiac surgery with prosthesis
Other procedure (trans esophageal echo, GI AND GU) doesn’t require AB, except if active infection is present at the site of the procedure

Choose of Antibiotics:
Amoxicillin, 2g, 30-60m prior to procedure
If pencillin allergic > azithromycin, clarithromycin, doxycycline,, cephalexin

216
Q

MODIFIED DUKE CRITERIA

A

Modified Duke criteria:

Pathological
- from tissue culture or histology ( from vegetation including embolism, or intracardiac abcess )

Major
- Positive blood culture ( 2, 12 hours apart, typical organisms as staph, strept, HÁČEK, Ecoli, or single culture of coxiella burnetii )
- Echo ( evidence of endocardial vegetation - new valve regulation - abcess - prosthetic valve dehiscence )

  • Minor “TIMER”

T: Temp >38
I: Immunological phenomena (Osler nodes, Roth spot, positive RF, Glumeronephritis)
M: Microbiological not meeting major,
E: Embolic phenomenal ärterial or septic emboli, conjunctival haemorrhage, mycotic aneurysm, Janeway lesion),
R: Risk factor

DEFINITIVE:
2 Major
1 Major + 3 Minor
5 Minor
1 pathological

POSSIBLE:
1 Major + 1 Minor
3 Minor

REJECTED DIAGNOSIS:
Not definitive or possible
Firm alternative diagnosis present
Absence of surgical or autopsy evidence of IE in the period of first three days of AB
Resolution of clinical characteristics of IE in 4 days or less of AB

217
Q

Acute pericarditis / Pericardial effusion

A

MCC:
- Idiopathic or viral
- Uremic: BUN >60mg/dL, no st elevation

  • Pleurtic chest pain ( worse on supine, inspiration, or coughin - improve on sitting or leaning forward )
  • Pericardial friction rub, best heard on leaning forward and inspire
  • ECG:
    PR depression
    PR elevation in lead aVR
    widespread ST elevation
    In ongoing non treated condition: PR and ST may normalize, and T wave flattening or inversion may develop
  • CXR: cardiomegaly “200ml required for cardiomegaly to appears”
  • ECHO: should be performed after cardiac surgery, or haemodynamcally unstable patients r/o pericardial effusion or temponade. OTHERWISE: ECG IS THE BEST BUT SHOULD BE FOLLOWED BY ECHO. Echo usually normal in patients with pericarditis, so ECG is best, and then evaluate for effusion by echo

Treatment:
- NSAIDs “Aspirin for Dressler, and Ibuprofen for others pericarditis”
- Colchicine “prevent recurrence, so add it to NSAIDs”
- Steroid have the higher recurrence rate ( refractory / cannot use primary medications / certain rheumatological disorders )

NSAIDS
- Indomethacin may reduce myocardial perfusion, therefore not preferred in patients with CCS OR ACS
- 2nd line: Colchicine, alone or in combination with NSAIDs

Steriod: shown to increase risk of recurrent pericarditis
Therefore, not preferred, unless indicated

Criteria to admission:
1- fever
2- subacute presentation
3- high troponin
4- immunocompromised
5- anticoagulant use
- presence of pericardial effusion or temponade
- trauma
- failure to outpatient tx

—————-
Pericardial effusion:

  • Most commonly after episode of Acute pericarditis
  • Usually asymptomatic, but if cocomminet with acute pericarditis, presented typically with fever, fatigue, sob, elevated JVP, edema
  • highly suggestive physical sign of pericardial effusion is dullness to percussion at the point of maximal impulse

Ecg: Sinus tachycardia with low QRS voltage

Treatment:
Acute affecting hemodynamic stability: Pericardiocentesis

Chronic/ stable:
Treat underlying etiology
Pericardiocentesis: if there’s symptomatic pericardial effusion, or greater than 20mm effusion

218
Q

Most common primary cardiac tumor?

A

Atrial Myxoma
Most commonly involve left atrium

Echo is initial
MRI is gold standard

Most serious complication: emboli

219
Q

Myocarditis

A

Etiology: most commonly viral

Most common cause worldwide is: Chagas’ disease “protocol; trypanosoma Cruzi”

PE: Tachycardia disapproptane to degree of fever or discomfort, s3 or s4 gallop

Echo and MRI
Gold standard is Endomyocardial Biopsy

Treatment is supportative
Chronic myocarditis: immunosuppressant
Giant, esionophilic myocarditis: IVIG

220
Q

Modified Jones criteria for Acute Rheumatic fever

A

Evidence of GAS infection, PLUS:

First episode: 2 major, or, 1 major + 2 minors
Recurrent: 2 major, or 1 major + 2 minors, OR, 3 minors

Evidence of GAS infection, (any of the following):
1- increased Antistreptolysin O or anti DNase
2- Positive throat culture of GAS
3- positive rapid antigen test
4- Recent scarlet fever

Major ( JONES)

J (JOINT): migrating Polyarteritis, or mono in mod-high risk groups “knee/ankle/wrist/elbow”
O (Ouch, my heart, Carditis): Echo valvulitis, or new or changing murmur (mitral regurgitation), both clinical and subclinical
N(Nodule): subcutaneous, painless, firm, usually over bone or tendon
E (Erythema marginatum): Nonpruritic rash over the trunk and extremities, sparing the face

Minor:
Fever
Poly/monoarthrlagia
High ESR or CRP
Prolonged PR interval on ECG

221
Q

Some causes of sudden cardiac arrest?

A
  • Congenital long QT syndrome
  • Short QT syndrome
  • Commito cord is
  • Idiopathy ventricular tachycardia
  • idiopathic ventricular fibrillation
222
Q

Innocent heart murmur

A

7S:
Short duration (not holosystolic)
Single (no clicks or gallops)
Small (not radiated)
Soft (low amplitude)
Sweet sounding (not harsh)
Sensitive (change with positing and respiration) > murmur that are loudest in supine, disappear in standing or valsalva are usually innocent
SYSTOLIC

223
Q

Pulsus paradoxus definition and DDx

A

Drop in SBP with inspiration more than 10 mmHG

O/E: feel the pulse while auscultation > listen to the beat without feeling the pulse

Differential diagnosis:
- Constructive pericarditis
- Cardiac temponade
- Croup
- Obstructive lung disease
- Pulmonary embolism
- Vena cava thrombus

224
Q

Electrical alternans

A

Beat to beat difference in QRS axis or amplitude
Seen in temponade, or effusion

The cause is the heart swing in the pericardial fluid, usually with large effusion

225
Q

Heart valves

A

Prosthetic heart valve:

Biological: Last 10 years, No anticoagulant, No click
Mechanical: Last >20 years, Anticoagulant, Click

Mechanical valve require anticoagulant because they are MORE thrombogenic and hemolysis than Biological valve.

In auscultation: Mechanical ( loud metallic closure sound, softer opening click ). Biological ( same sounds at native, but louder )

Paravalvular leaks: more common with mechanical valve than biological

Recommended INR?
Mitral: 3
Aortic: 2.5-3

2-3 in general. If the patient have additional risk factors for thromboembolism such as; Afib, LV dysfunction, previous embolism> THE TARGET WOULD BE 2.5-3.5

226
Q

Mechanical complications of acute MI?

A

Mechanical complication of acute MI

1- LV free wall rupture

2- VSD

3- Papillary muscle rupture (acute mitral regurgatioin)

VSD: Holosystolic murmur, thrill

Mitral regurgitation: Holosystolic murmur, No thrill, radiated to axilla

227
Q

Safest ACEI in patient taking simvastatin?

A

Ramipril, can take 40mg daily

228
Q

Stable angina medications

A

BB is the first line

If not relieving
Long acting nitrate “isosorbide mononitrate” NOT dinitrate (short acting)

If not releving
CCB
Amlodopine or EXTENDED release nifedipine if the patient taking BB

Non-DHT if the patient not taking BB

229
Q

Minimum amount of dual antiplateles after stenting

A

Drug eluting stent [DES]:
- 6 months for stable angina
- 1 year for ACS

Bare metal stent:
- 1 month

STOPDAPT trial and SMARTCHOICE trial

230
Q

Dual antiplatelets and surgery

A

Aspirin: can be continued safely, except if very high risk bleeding procedure [ neurosurgery, posterior eye surgery]

231
Q

Atrial arrhythmias

A

Atrial flutters “saw tooth pattern”: regular
SVT: regular

Afib: irregular
MAT: irregular

232
Q

Rate versus rhythm control in Afib

A
  • it is patient specific, no significant difference of all causes of mortality between the two approaches
  • patients who tend to benefit more from rhythm control are: YOUNGER, HIGHLY SYMPTOMATIC, LESS RESPONSIVE TO RATE CONTROL, RISK FOR TACHYCARDIA MEDIATED CARDIOMYOPATHY
233
Q

Sinus bradycardia causes?

A

1- Medications ( BB, Non-DHP CCB, antiarrhythmic, cholinestrase inhibitors )
2- OSA
3- hypothyroidism
4- acute mi
5- electrolytes abnormalities

If all the above causes are ruled out, you’re left with Sinus Node Dysfunction (cause of bradycardia in elderly) > pacemaker if symptomatic

234
Q

Hypertensive emergency ( Heart failure )

A

First line: IV Nitroglycerin

IV nicradipine > may cause reflux tachycardia > harmful for CAD

IV Labetalol > CONTRAINDICATED IN ACUTE HEART FAILURE

235
Q

Pediatrics HTN

A
  • other arm and one leg measurement of BP > to evaluate coarocation of aorta
  • from the age of 13 years old, don’t use precentile, use table ( grade 1 is 130/80 - grade 2 140/90 ) according to American Academy of pediatrics
  • cuff blade ( 80-100% length, and 40% width ) of arm circumference
  • age of BP measurement: 3 years
236
Q

VHD and EF!!

A
  • Aortic stenosis: <35%
  • Mitral regurgitation: <60%!!!!!!!!!!!!!! (Associated with rapidly declining 10 years survival)

Don’t forget symptomatic; surgery

237
Q

Varicose veins

A

Conservative management

Interventional treatment ( sclerotherapy, endovenous laser ablation, surgical vein ligation ) if;
- Severe symptoms or skin changes, or failure of conservative
- saphenous vein reflux in Doppler “as this is the primary target in most procedures ”

238
Q

Preoperative management for Cardiac Conditions

A

1- Afib
Target ventricular rate is: <110
For elective surgery, if >110, postpone the surgery until adequate rate control

2- Aortic sclerosis
Right sternal systolic murmur with otherwise no symptoms or signs

3- stable CAD, no symptoms, and good functional capacity (exercise capacity is 4 or more metabolic equivalent”
No cardiac investigations needed for low risk surgeries [ including cataract, endoscopic, superficial procedures, breast surgery, ambulatory surgeries ] AND medium risk non-cardiac surgeries [ including colonectomy, rotator cuff tear ]

4- Active cardiac conditions
This include [ unstable angina, decompensated heart failure, concerning arrhythmia, severe VHD ]
Cardiac evaluation is required

5- Post PCI elective surgeries:
Metal stent: 1m
DES: 6m
DAPT: continue aspirin if possible, and restart pgy12 Inhibitors ASAP after surgery
If delaying surgery is inadviseable > cardiology consultation

6- Urgent and Emergent: Proceede

7- Unstable CAD and not on BB:
Never start before surgery to avoid significant bradycardia and hypotension. Start low dose and titrate up slowly weeks before the surgery

8- Mechanical heart valve on warfarin
Stop warfarin 5 days before surgery, and, initiate IV heparin “THERAPUTIC DOSAGE” or LMWH infusion when INR is less than 2.5 (2-2.5)
IV: for end stage CKD
LMWH: for normal-borderline CKD

239
Q

Pleural friction rub versus pericardial friction rub

A

Pericardial friction rub: Acute pericarditis, best listened when the patient end of expiration and leaning forward, PERSIST when the patient hold his breath

Pleural friction rub: PE, absent when the patient hold his breath

240
Q

Adultscent with ST elevation and history of Kawasaki

A

Long term squeal of Kawasaki is: Coronary Artery Aneurysm > can lead to thrombosis OR stenosis > Acute MI

241
Q

Spironlactone indications and contraindications

A

Indications
EF <35% AND NYHA class3-4
EF <30 AND NYHA class2

CI:
Advanced renal disease ( baseline creatinine 2 for female and 2.5 for male, or eGFR <30 )

242
Q

Indications for ICD and biventricular pacing for cardiac resynchorization for prevent sudden cardiac death?

A

ICD:
Non-ischemic cardiomyopathy and LVEF <35% and NYHA 2-3

If left bundle branch block and QRS >150msec add biventricular pacing CRT

243
Q

Kawasaki disease

A

Criteria [ CRASH BURN ]

Fever met the criteria + at least 4/5:

Burn: fever for 5 days

C: conjunctivitis ( non exudative, spare the limbus )
R: Rash (erythema or polymorphous exanthem )
A: Adenopathy ( Anterior cervical, >1.5cm )
S: Strawberry tongue ( erythema of lib and oral cavity )
H: Hand and feet swelling

Treat to prevent cardiac complications: Coronary artery aneurysm > stenosis or thrombosis > SCD, IHD

IVIGg + IV high dose Aspirin
Treatment should started within 7 days, or 10 days maximammily
After 10th day, treatment reserved for those with ongoing unexplained fever or signs of ongoing inflammation

Glucocorticoids? > can be used along with IVIG for patients with high risk of CAA, but not alone

ALL children should undergone BASELINE ECHO, but this should not delay treatment > to look for coronary artery morphology, left ventricular and valvular function, and evidence of pericardial effusion

ECG? Not required unless arrhythmia symptoms

Incomplete Kawasaki disease? As patients with a major and 3 or 2 minor; other etiology should be suspected as EBV ( respiratory virus panel, serology for viruses )

244
Q

HF and ivabardine and Carvidalol and Dapagliflozin

A

BEAUTIFUL TRIAL
Showed increase cardiovascular event if resting HR >70
So used if the patient on maximum tolerated BB + HR >70

Carvidalol
25mg BID for <85kg
50mg BID for >85kg

Data showed a lower moratily than Empa in HF

Hydralazine and isosobide-denitrate
If ACEI or ARBS is not tolerated
Or; add on if persistant symptoms despite full guideline directed medical therapy (ACEI-ARNI-ARBS, BB, Spironalctone, SGLT-2)

245
Q

Myocarditis most common cause

A

Viral
Specifically enteroviral ( coxacki virus )

246
Q

Aortic stenosis

A

Soft or absent aortic sound of 2nd heart sound

247
Q

Lyme cardiac disease

A

History of Camping in US
Organism: Borrelia burgdoferi
Characteristic circular rash (erythema migrants)
Heart: Conduction disorders
Early non disseminated disease: oral “doxy, amoxi”
late disseminated: IV Ceftriaxone

248
Q

ACS and dual antiplatelets timing

A

STEMI: immediate
NSTEMI AND UA: often P2Y12i added after angiography

249
Q

Acute management of ACS contraindications

A

BB: CI in bradycardia and CARDIOGENIC SHOCK

Nitrate: CI in inferior MI

250
Q

OSA-mediated bradycardia

A

CPAP is the treatment
Permenant pacemaker is not indicated

251
Q

Post operative Afib

A

Frequently seen
Self limiting
80% resolve within the first 24 hours

252
Q

Approach to pediatrics HTN

A

Definition: systolic or diastolic 95th percentile or above for age,sex,height On 3 separate visits

Echo should be included as an initial workup

253
Q

Carotid hypersensitivity syndrome

A

Test is recommended in patients age >40 with syncope of uncertain etiology

Diagnostic criteria after carotid sinus message:
1- syncope + asystole >3seconds
2- fall in SBP >50mmHg

Contraindications to carotid sinus massage:
1- ipsilateral carotid artery stenosis or bruits
2- History of TIA or stroke within the past 3 months

Treatment:
Permanent pacing

254
Q

Lidocaine and arrhythmia?

A

For wide complex QRS and not first line

255
Q

Primary goals in HFpEF

A

1- Maintain euvolemia
2- Maintain targeted BP
3- Check for CAD by stress testing
4- revasculrize documented ischemia

256
Q

Atypical MI symptoms

A

Typical are sub sternal heavy/squeezy sensation

Atypical (elderly, DM, women):
Burning sensation, vague discomfort, fullness in the chest

257
Q

BNP interpretation in dyspnea patients

A

Normal (<100): no cardiac dyspnea / obesity

Intermediate (100-400): Possible CHF, AKI/CKD or others; pulmonary HTn, advanced age, stroke or ICH

Elevated (>400): likely CHD(95% liekhood), could be sepsis or hematologyical malignancy

NT prop BNP:
<300 unlikely
more: likely

258
Q

Vasovagal syncope

A

Often preceded by nausea, diaphoresis, bradycardia, pallor

Management: reassurance, avoid trigged, assuming supine position at onset of symptoms. Physical counterpressure manutvers can abort or delay the episode of syncope

259
Q

Streptococcus gallolyticus ( S bovis ) and colon

A

Colonscopy for underlying malignancy

260
Q

Acute decompnesated HF management

A

1- IV diuretics 40mg ferusmide
2- supplemental oxygen
3- vasodilators ( nitroprusside, nitroglycerin): if severe HTN not responding to diuretica
4- iontropes: short term treatment with hypotension and signs of hypoperfusion: dubtamine, milrinone

261
Q

Carotid artery stenosis management

A

Medical as secondary prevention in patients with TIA or stroke should include; Antiplatets, statin, and control BP

Endarterectomy:
>50% if symptomatic
>70% if asymptomatic

Complete occlusion (100%): no benefit of surgery

No need for warfarin/DOACs here

262
Q

Statins and hypothyroidism

A

Hypothyroidism can precipitate statin myopathy
Statin can aggravate hypothyroid myopathy

Any statin myopathy? Screen for TSH

263
Q

Peri infarction pericarditis

A

High dose aspirin

Use of anticoagulants/steriod/NSAIDs should be avoided in that sitting

264
Q

Thrombolysis contraindications

A

1- History of ICH
2- History of ischemic stroke within 3 months
3- History of recent intracranial, intraxial surgery
4- History of intraaxial neoplasm

5- BP >185/110
6- Platelets <100,000
7- Glucose <60
8- INR >1.7, PT >15sec, high PTT

265
Q

Dyslipidemia screening

A

Men 35 years old
Women 45 years old

Younger with additional CVD risk factors

266
Q

Hyperkalemia ECG changes

A

1-Prolonged PR interval and tall t wave

2- ST depression, loss of P wave

3- Wide QRS

4- Asystole

267
Q

High risk procedure?

A

Aortic and other major vascular surgeries

268
Q

Pericardial effusion and hypothyroidism

A

Incidence: 25%

269
Q

ABC or CAB for cardiac arrest?

A

CAB

270
Q

Aortic stenosis and monitoring

A

Mild (Every 3-5 years):
Mean gradient <20

Moderate (Every 1-2 years)
Mean gradient 20-39

Severe (Every 6 months if asymptomatic, surgery if symptomatic)
Mean gradient >40
Aortic area<1cm

Surgery Recommended for asymptomatic if severe + LVEF <50%

271
Q

Post prandial hypotension التخمة

A

Dropped SBP >20mmHg

Treatment:
Increase fluid intake
Decrease meal size and carbs
Standing up slowly
Compression stocking

272
Q

Is Ejection fraction reduce with aging?

A

NO

Aging
Atrial: increase in size and volume
Ventricular: increase mass and wall thickness

Resting LVEF doesn’t change in healthy older individuals

273
Q

Syncope etiologies

A

1- Vasovagal syncope (cardioneurogenic syncope):
- triggers: prolonged standing, emotional distress, painful stimuli
- prodromal symptoms: nausea, warmth, diaphoresis

2- situational syncope:
- triggers: cough, micturation, defecation

3- Orthostatic syncope:
Postural changes in HR/BP upon standing suddenly

4-: Aortic stenosis/ HOCM/ anomalous coronary arteries:
Syncope with exertion or exercise

5- Ventricular arrhythmias:
Prior history of CAD, cardiomyopathies, or HF

6- Sick sinus syndrome/ AV block/ Bradyarrhthmia:
Increased QRS and PR durations

7- Torsades de pointes (congenital/acquired long QT syndromes):
Hypokalemia, hypomagensemia, medications, family Hx of SCD, syncope with triggers “ëxercise, sleeping)

274
Q

PAD

A

Smoking
Antiplatet
Statin
Dm and HTn
Structured exercise program

Failed?

Cilostazol

Revascularization ( per cutaneous or surgical )
Usually for ABI <0.5 or limb threatening ischemia

275
Q

Risk factors for resistant HTN

A
  • Black
  • Elderly
  • Male
  • Obese
  • LVH
  • DM / CKD-albumiuria / high CVD risk
  • OSA
  • Insomnia
  • genetics
  • hyperuricemia
  • hyperaldosternism
  • vascular disease
  • genetica
276
Q

Modified framingham ciriteria of HF

A

2 major / or 1 major and 2 minors

Majors:
- PND
- orthopnea
- JVP elevated
- pulmonary rales
- 3rd heart sound
- Caridomegaly on CXR
- Pulmonary edema on CXR
- weight loss 4.5kg in 5 days in response to treatment of presumed HF

Minor:
- bilateral leg edema
- nocturnal cough
- dyspnea on ordinary exertion
- hepatomegaly
- pleural effusion
- tachycardia, HR 120
- wight loss 4.5kg in 5 days

277
Q

CXR in HF

A

ABCDE:

A: alveolar edema “bat wings”
B: karely B lines “intersitial edema”
C: Cardiomegaly
D: dilated prominent upper lobe vessels
E: effusion “pleural effusion”

278
Q

TEE in HF?

A
  • pregancy and severe obesity
  • patients on mechanical ventilation
279
Q

ARNI versus ACEI and ARBS

A

ARNI = ARBS + neprilysin = Valsartan+secubitril

Symptomatic HFrEF class 2/3 recommended to change to ARNI for further reduce morbidity and mortality

Allor 36hr between stopping ACEI and switch to ARNI “concerns of angiodedma

280
Q

Empa or dapa?

A

Dapa better a little bit in studies

eGFR: 30 for dapa, and 20 for empa

281
Q

Medications to avoid in HF patients

A

1- non selective NSAIDS + selective COX-2 inhibitors
2- CCB: nifedipine, verapamil, dilitizam
3- most antiaarhthmic ( except class 3 )
4- Thiazolidibediones
5- Saxagliptin, Alogliptib
6- alpha1 blockers; doxazosin

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