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Flashcards in Cardiology Deck (122):
0

What are the main five risk factors for coronary artery disease?

Gender/age: male greater than 45, female greater than 55.
Family history of first myocardial infarction in the mail at less than 45 or a female at less than 55
HDL less than 40
Hypertension
Smoking

1

What are the risk equivalents for coronary artery disease?

Diabetes,
history of significant carotid disease/endarterectomy,
history of peripheral arterial disease, history of abdominal aortic aneurysm.

2

What are the LDL goals with coronary artery disease risk factors and coronary artery disease equivalents?

If there are 0 to 1 risk factors the LDL should be less than 160.
If there are greater than or equal to two risk factors the LDL should be less than 130.
For risk equivalents, the goal should be less than 100 – optimally less than 70.
If the patient has already had a cardiovascular event, the goal is less than 70 or the previous LDL decreased by 50%.

3

Cardiac findings in graves disease

Tachycardia and wide pulse pressure

4

What effects does alcohol have on the cardiovascular system?

Increased blood pressure, increased heart rate, increased cardiac output at rest, increased myocardial oxygen consumption, and increased risk for myocardial infarction. Dyslipidemia can be precipitated or aggravated. Muscle weakness and sudden-death, possibly due to hypoglycemia, are also associated.

5

What cardiac abnormality in the baby is associated with use of lithium in pregnancy?

Most commonly, Ebstein's anomaly of the Tricuspid valve

6

What is Dressler's syndrome?

Pericarditis that occurs 1 to 2 weeks after myocardial infarction.

7

How common is primary hyperaldosteronism?
What are its symptoms?
How is it diagnosed?

It is present in as many as 20% of patients referred to specialists for poorly controlled hypertension. It is more common in women. It's it is often asymptomatic. Many patients will not be hypokalemic. Screening can be done with a morning plasma aldosterone/Reanon ratio. If the ratio is 20 or more and the aldosterone level is greater than 15 ng/dL, then primary hyperaldosteronism is likely and referral for confirmatory testing should be considered.

8

What murmur increases in intensity with Valsalva?

The Valsalva maneuver decreases venous return to the heart, thereby decreasing cardiac output. this causes most murmurs to decrease in length and intensity. The murmur of hypertrophic obstructive cardiomyopathy however increases in loudness. the murmur of mitral valve prolapse becomes longer and may also become louder.

9

What drugs should be avoided in tachycardia due to Wolff-Parkinson-White syndrome? What drugs should be used?

Adenosine, digoxin and calcium channel antagonists should be avoided, as they may make the tachycardia rate increase and cause ventriclar fibrillation. Procainamide is usually the treatment of choice, though amiodarone may also be used.

10

Who should get low-dose ASA for MI or CVA prevention?

Men 45-79 for MI prevention

Women 55-79 for ischemic CVA prevention

11

What is the drug of choice for mitral valve prolapse?

Propranolol or another beta blocker, but only if the patient is symptomatic.

12

What effect does diabetes have on the risk for abdominal aortic aneurysm?

It is protective, and decreases the risk by one half.

13

What drug or drugs should be used to manage hypertension in a patient-who has previously had a stroke?

A combination of a diuretic and an ACE inhibitor. This combination has been clinically shown to reduce the risk of recurrent stroke

14

What drug used for hypertension has been showed to decrease serum uric acid levels?

Losartan

16

What cardiac arrhythmia has been reported with high-dose methadone use?

QT prolongation and torsades de pointes

17

What is a normal ejection fraction?

55 to 75%

18

What clinical differences are seen in infants with ventricular septal defect versus hypoplastic left heart syndrome versus TGA versus tetralogy of Fallot versus PDA?

VSD causes overload of both ventricles. The murmur is harsh and holosystolic usually heard best at the left lower sternal border. As the volume of shunting increases cardiac enlargement and increased pulmonary pulmonary vascular markings can be seen on x-ray. The infant is not cyanotic.

Hypoplastic left heart syndrome is manifested by near obliteration of the left ventricle on the EKG and chest radiograph. The infant is cyanotic.

Transposition of the great vessels would cause AV conduction defects and single-sided hypertrophy on the EKG. chest x-ray would show a straight shoulder on the left heart border where the aorta was directed to the right. The infant is not cyanotic.

Tetrology of Fallot causes cyanosis and right ventricular enlargement.

The murmur of PDA is continuous and best heard below the left clavicle the EKG shows left atrial and ventricular enlargement. The infant is not cyanotic.

19

Amiodarone should not be combined with which drugs?

Lidocaine or digoxin

20

What are the toxicities of amiodarone?

It can cause fatal interstitial lung disease. It causes increased sinus bradycardia and AV block. It can cause corneal depositions and keratopathy. There is a 1 to 2% incidence of anterior ischemic optic neuropathy. It can cause gynecomastia and epididymitis. It may cause hypo more than hyperthyroidism. It can cause abnormal LFTs.

21

How long should it take for an ACE related cough to resolve after the drug is stopped?

It usually stops within four weeks, but it may take up to three months.

22

Describe ACE related cough

It occurs in 5 to 35% of patients. It is a dry cough. It occurs independent of the duration of the prescription. There is an increased incidence in women, non-smokers, and people of Chinese ancestry.

23

What drugs are combination Alpha and beta blockers?

Labetolol and carvedolol

24

What are the classifications and treatments for acute decompensated heart failure?

Note: wet equals pulmonary wedge pressure of over 18 and warm equals cardiac index over 2.2.

Warm and dry: treatment is diuretics and vasodilators

25

What is the goal for rate control of atrial fibrillation?

A resting heart rate of less than 110

26

What are the recommended treatments for a low, intermediate and high CHADS2 score?

High, or greater than or equal to two: warfarin

Intermediate, or one: warfarin or aspirin 75 to 325 mg per day

Low, or zero: aspirin 75 to 325 mg per day

27

What drugs should be avoided in congestive heart failure?

Nonselective calcium channel blockers, class I antiarrhythmics, and NSAIDs. Vasoselective calcium channel blockers may be okay.

28

What murmurs change with a change in position from squat to stand?

Mitral valve prolapse: the click moves toward S2 with squat and toward S1 with stand.

Hypertrophic cardiomyopathy: the murmur is softer with squat and louder withstand.

29

Describe the murmur of mitral regurgitation.

It is a mid to late systolic murmur best heard over the apex and radiating to the left axilla. it is a blowing murmur, medium to high pitched.

30

Who gets mitral valve stenosis?

There is a 3/1 ratio of female to male. Usually occurs age 40s to 50s. It is almost always rheumatic.

31

Which murmurs are right sided? Where are they best heard? What happens to them with respiration?

Tricuspid regurgitation and pulmonic stenosis are systolic murmurs. Tricuspid murmurs are heard best at the left lower sternal border and pulmonic murmurs are heard best at the left upper sternal border. All of these members very with inspiration and expiration.

32

What are the symptoms of VSD? Describe its murmur. What are the ECG findings?

Patients have fatigue and symptoms of heart failure. There is a holosystolic murmur and thrill, a laterally displaced PMI and a loud P2. If the defect is small the ECG is normal. If not LDH, LAE, RAD, RVH and RAE findings may be present on ECG.

33

What is the best method for evaluating stroke risk in a patient with atrial fibrillation?

The CHADS2 score.

34

What are the typical findings of mitral valve prolapse?

Atypical chest pain, dyspnea, fatigue, psychiatric symptoms including panic. There is a mid systolic click and a late systolic murmur. ECG is often normal. There may however, be nonspecific ST T-wave changes, T-wave inversion's, prominent Qs, and prolonged QT intervals.

35

What are the typical findings with atrial septal defect?

Exercise intolerance. Wide fixed split of S2, and a loud P2. ECG findings include inverted P waves in the inferior leads, first-degree AV block, right axis deviation, right ventricular hypertrophy, and incomplete right bundle branch block.

36

What is the likely infarction site if the ECG shows ST elevation in II, III and F?

Inferior wall, right coronary artery

37

What is the likely site of infarction if the ECG shows ST elevation in V1, V2 and V3?

The anteroseptal wall and the left anterior descending artery

38

What is the likely site of infarct if the ECG shows ST depression in leads V1 through V2?

Posterior wall, right coronary artery

39

What is the likely infarct site if there is ST elevation in leads I, L and V4-6?

Lateral wall, left circumflex artery.

40

What is the likely infarct site if there is ST elevation in all precordial leads?

The entire anterior wall, left anterior descending artery.

41

What drugs should be avoided in patients with CHF who also have diabetes, COPD, and depression?

For diabetes: TZDs such as pioglitazone and rosiglitazone should be avoided.

For COPD: nonselective beta blockers should be avoided and also beta agonist metered dose inhalers.

For depression: venlafaxine or Effexor should be avoided due to its increased blood pressure risk.

42

What are the ECG findings for right ventricular hypertrophy?

R greater than S in V1

43

What are the EKG signs of atrial enlargement?

A P-wave larger than 1×1 box in lead V1, or a P greater than 2.5×2.5 boxes in lead II.

44

What is the algorithm for ventricular fibrillation or pulseless ventricular tachycardia?

Defibrillation times one, five cycles CPR, defibrillation times one if there is a shockable rhythm, give vasopressors (epinephrine or vasopressin), defibrillation times one if shockable rhythm, give amiodarone or lidocaine

45

Describe the murmur of mitral stenosis.

It is a mid diastolic rumble. It is best heard at the apex with the patient in the left lateral position. It is best heard in exhalation. It is low pitched and increases with mild exercise.

46

List the possible causes of acquired long QT interval.

Drugs, electrolyte disturbances, chronic medical conditions such as anorexia nervosa, and nutritional deficiencies such as vitamin D deficiency.

47

What would the resulting diagnosis be for an acute coronary syndrome which has ST segment depression, T-wave inversion, and a normal troponin level?

Unstable angina

48

What's with the resulting diagnosis be for an acute coronary syndrome which has ST segment depression and T-wave inversion, and elevated troponin levels?

NSTEMI

49

What would the resultant diagnosis be for an acute coronary syndrome with ST segment elevation and elevated troponin level?

STEMI

50

What would the resultant diagnosis be for an acute coronary syndrome with ST segment elevation, and a normal troponin level?

Spasm angina

51

When do troponin levels typically increase in myocardial infarction? How long does the elevation last?

They typically do not increase until approximately six hours after the onset of chest pain. Once they are elevated they may remain elevated for up to 10 days.

52

What are the three most common nonischemic causes for troponin level elevation?

Heart failure, pulmonary embolus, and myocarditis or pericarditis.

53

What are the noncardiac causes of non-ischemic troponin level elevation?

Renal insufficiency, acute stroke or subarachnoid hemorrhage, severe pulmonary hypertension, extreme exertion, chemotherapy, critical illness or sepsis, burns.

54

Which patients should not use nitroglycerin for chest pain?

Those who have taken phosphodiesterase inhibitors such as sildenafil and tadalafil within the previous 24 hours.

Nitroglycerin should be used with caution in patients with right ventricular infarction or diastolic dysfunction to prevent systemic hypotension.

55

Should a patient with an acute coronary syndrome continue to take his or her NSAID?

No – there are increased risks of mortality, reinfarction, hypertension and heart failure.

56

What antiplatelet therapy should be used for a patient who has a bare metal stent placed?

Aspirin for one month at 162 to 325 mg per day, then long-term at 75 to 162 mg per day. 600 mg loading dose of clopidogrel before the procedure, followed by 75 mg per day for one year.

57

What should be the antiplatelet therapy for a patient who has a drug eluting stent placed?

Aspirin 162 to 325 mg per day for six months, then long-term at 75 to 162 mg per day. Clopidogrel 600 mg loading dose before procedure followed by 75 mg per day for one year.

58

What antiplatelet therapy should be administered for a patient who receives fibrinolysis?

Aspirin initial dose of 160 to 325 mg/day, then long-term at 75 to 162 mg per day. Clopidogrel 300 mg loading dose before procedure, followed by 75 mg/day for at least one month, up to one year. If the patient is older than 75 years, administer 75 mg per day for one month; no initial bolus given.

59

What antiplatelet therapy is given for patient who has had coronary artery bypass surgery?

Aspirin: an initial dose of 162 to 325 mg/day, then long-term at 75 to 162 mg per day. If Clopidogrel therapy was already started, it should be discontinued for 5 to 7 days before surgery; consider continuation after surgery for 9 to 12 months.

60

What three drugs should be started in the hospital for anyone who has an acute coronary syndrome?

Oral beta blockers which should be started within the first 24 hours. ACEs, which should be administered at a low dose within the first 24 hours of hospitalization but can be started anytime before discharge. Statins: if the patient is already taking a Staten it should be continued, otherwise it should be started in all patients with ACS during hospital admission, regardless of the baseline level of LDL.

61

Patients with inferior MIs should be monitored for what possible complications?

The right ventricle is often involved. Patients with right ventricular infarctions are volume sensitive and care should be taken to prevent hypovolemia induced hypotension. In addition the patient should be monitored for evidence of sinus node dysfunction; ventricular tachycardia at a slow rate; and manifestations of AV block, including first-degree AV block, second-degree Mobitz type I AV block and third degree or complete AV block.

62

Patients with anterior MIs should be monitored for what complications?

Bundle branch block, rapid ventricular rate, and heart failure, which is more likely that in patients with posterior MIs.

63

What are the drugs of choice for pain in patients with acute coronary syndrome who are cocaine users?

Beta blockers should be avoided to prevent the vasoconstriction that can occur when beta blockers leave alpha stimulation unopposed. Nitroglycerin and benzodiazepines are the drugs of choice for pain management, calcium channel blocker should be used only to manage refractory pain.

64

How are ventricular arrhythmias managed in a patient who is a cocaine user?

Early onset arrhythmias which are suspected to be caused by cocaine can be managed with sodium bicarbonate. Late onset arrhythmias probably related to ischemia can be managed with IV lidocaine.

65

In what classes of patient is a drug eluting stent preferred over a bare metal stent?

Patients with diabetes, and patients with high-risk coronary lesions, or those that have more narrow obstructions or are long.

66

When is CABG the preferred treatment for patients with acute coronary syndrome?

In patients with multivessel disease who have diabetes or are over age 65.

It is the preferred therapy for left main coronary disease or left main equivalent disease (i.e. high-grade proximal stenosis of the left anterior descending and circumflex arteries) and for diffuse three vessel disease.

67

What G.I. protective drugs should not be administered with clopidogrel?

PPIs should not be administered because they decrease the levels of clopidogrel's active metabolite by 47%. Cimetidine should not be administered because it is metabolized by the same cytochome system as PPI's.

68

What is it Tokotsubo cardiomyopathy?

It is also called broken heart syndrome. Patients present with chest pain associated with focal systolic dysfunction and normal coronary arteries. The proposed etiology of this condition is an epinephrine surge associated with marked stress.

69

How is supraventricular tachycardia with aberrant conduction diagnosed by the Brugada criteria?

there is an RS complex in precordial leads

the longest precordial RS interval in one or more precordial leads is shorter than 100 ms.

There is no AV dissociation.

The morphologic criteria for ventricular tachycardia are absent in leads VI, V2 and V-6.

70

Which calcium channel blockers maybe added to beta blocker therapy for angina?

Long acting dihydropyridine calcium channel blockers, which include amlodipine and extended release nifedipine

71

Which beta blockers have been shown to reduce the rates of death and hospitalization in heart failure patients?

Bisoprolol, carvedilol, and metoprolol

72

When stratifying patient risk to determine whether an implantable cardioverter – defibrillator is indicated for primary prevention of sudden cardiac death, what sort of patient is at greatest risk?

Patients with heart failure and an injection fraction of less than or equal to 35%.

73

Name as many cardio-selective beta blockers as you can.

Metoprolol, atenolol

74

What is one of the likely causes of secondary hypertension in young women from ages 19 to 39? How would you evaluate for it?

Fibromuscular dysplasia. It is more common in females, and has a predilection for causing stenosis of the renal arteries. The diagnosis can be made using MRI with gadolinium contrast media, or with CT angiography.

75

What are the common causes of secondary hypertension in young versus middle-aged adults?

Young adults age 19 to 39 are more likely to have coarctation of the aorta, thyroid dysfunction, renal parenchymal disease, and fibromuscular dysplasia.

Middle-aged adults are more likely to have primary aldosteronism, sleep apnea, pheochromocytoma, and Cushing's syndrome.

76

Which statins are the most powerful for lowering LDL-C?

Rosuvastatin and atorvastatin

77

What location of myocardial infarction is frequently associated with hypotension during the acute event?

Right ventricular infarction

78

At what size should an abdominal aortic aneurysm be referred for surgical intervention?

At over 5 cm.

79

What are the signs and symptoms of abdominal aortic aneurysm rupture?

Pain in the abdomen, flank, legs, buttocks and testicular or groin area. Syncope, vomiting, possibly hypotension, plus or minus pulsatile mass. Femoral pulses are normal. Hematuria is present in up to 10 to 30% of cases.

80

What is the acute management of aortic dissection?

Use IV nitroprusside to lower blood blood pressure to systolic of 90 to 110, and lower velocity of LV injection with IV esmolol. The beta blocker should be started first.

81

What is Leriche syndrome?

Claudication with thigh, hip and buttock pain, with impotence; seen in aortoiliac atherosclerotic occlusion.

82

What ankle brachial pressure indices indicate mild moderate or severe arterial occlusive disease?

Normal is 0.9 to 1.3, mild is 0.7 to 0.89, my moderate is 0.4 to 0.69, and severe is less than 0.4.

83

What is blue toe syndrome?

It occurs when cholesterol or atherothrombosis emboli occlude a small vessels resulting in painful bluish toes. Pulses remain present and it is often confused with bruising. It can involve multiple organs, especially the kidneys. The diagnosis can be confirmed with skin or muscle biopsy or cholesterol crystals on funduscopic exam. Treatment is watchful waiting with amputation of necrotic areas.

84

What is the relationship between increase in systolic or diastolic blood pressure and the risk of heart disease and stroke?

For every 20 point increase in systolic blood pressure or 10 point increase in diastolic blood pressure, there is a doubling of mortality from both ischemic heart disease and stroke.

85

What are the indications for use of calcium channel blockers in hypertensive patients?

Long acting calcium channel blockers should be used in patients with hypertension, including elderly patients with isolated systolic hypertension, with the following coexisting conditions: angina pectoris, Raynaud phenomenon, asthma or COPD, and failure to respond to or tolerate other medications.

Generally the choice should be a long acting dihydropyridine CCB, but long acting non-dihydropyridine's such as verapamil and diltiazem are more likely to be useful in diabetes because they decrease albumin excretion.

86

What is the most appropriate choice of antihypertensive agent in a patient with hypertension and erectile dysfunction who is being treated with a PDE-5 inhibitor?

An ACE, ARB or CCB. These have a neutral affect on erectile dysfunction. Centrally acting alpha-1 agonists, beta blockers and diuretics have a negative effect on erectilel dysfunction.

87

What antihypertensives increased erectile dysfunction?

Centrally acting alpha-1 agonist, beta blockers, and diuretics.

88

What diuretics should be used in a patient with a GSR of under 30 or 40?

Thiazides are typically considered ineffective except for metolazone. Metolazone is is usually used in combination with furosemide or torsemide.

89

Is high diastolic blood pressure or systolic blood pressure a more important cardiovascular risk factor?

Up to age 50 diastolic hypertension is a more important cardiovascular risk factor. Over 50 systolic hypertension is a more important risk factor.

90

Recurrent stroke prevention is a compelling indication for what classes of antihypertensives?

Diuretics and ACE's

91

When may aldosterone antagonists be indicated for hypertension?

In patients who are post MI or patients who have heart failure.

92

What are the common causes of renal arteries stenosis? What is its presentation? How is it diagnosed?

In people under 30 the most common causes fibromuscular disease. In people over 30 most common causes atherosclerotic disease. It may present with accelerated or resistant hypertension, renal dysfunction, or flash pulmonary edema. The diagnosis is made with duplex ultrasound, MRI, or CT angiogram. Elevated renin level alone is not diagnostic.

93

What is the USPSTF recommendation for screening for lipid disorders in adults?

All men at or over 35 should be screened. Men 25 to 35 and woman at or over 45 at increased risk for CHD should be screened. CHD risk factors include diabetes, CHD or non-coronary atherosclerosis, family history of cardiovascular disease at age less than 50 in males and less than 60 in females, tobacco use, hypertension, or BMI greater than or equal to 30.

94

What are the causes of secondary dyslipidemia?

Diabetes, hypothyroidism, obstructive liver disease, chronic renal failure, and medications including thiazide diuretics and antipsychotics.

95

The NCEP guidelines for metabolic syndrome do not include what criterion?

LDL cholesterol

96

The LDL-C goal is decreased in patients with which risk factors?

Age over 45 in men and 55 in women, cigarette smoking, hypertension with BP greater than 140/90 or on antihypertensive medication, low HDL cholesterol less than 40 mg/dL, family history of premature CHD in a first-degree male relative at less than 55 or any first-degree female relative at less than 60

97

In a patient with hyperlipidemia and triglycerides over 500, what should be the initial treatment?

A fibrate to decrease the risk of pancreatitis.

98

Which fibrates have the most or least risk of myopathy when combined with statins? Which fibrate is most appropriate if renal dysfunction is present?

Fenofibrate has a lower risk of myopathy; gemfibrazole has a higher risk but is more appropriate in renal dysfunction.

99

What medications and substances increase the risk of statin- associated myopathy?

Fibric acid derivatives, especially gemfibrazole; niacin, cyclosporine, azole antifungals, macrolide antibiotics, HIV protease inhibitors, verapamil and diltiazem, amiodarone, and more than 1 quart per day of grapefruit juice.

100

What is the most common cause of Mobitz type one second degree AV block?

What is it treatment?

It almost always represents disease of the AV node. It may be seen in athletically fit individuals, especially during sleep. In the acute setting interior wall ischemia is most likely.

The rhythm itself does not generally require treatment. The underlying cause may require treatment.

101

What calcium channel blockers do not usually cause significant AV slowing?

The dihydropyridine CCB's. All of these end in pine: for example nifedipine.

102

Describe Mobitz type II second degree AV block

There are intermittently non-conducted P waves not preceded by PR prolongation and not followed by PR shortening.

103

What does Mobitz type II second degree AV block represent? How is it treated?

It almost always represents disease of the distal conduction system below the AV node: the His-Purkinje system. It may progress to third degree heart block with no emerging escape rhythm. The treatment is a permanent pacemaker.

104

What patients may recover from third degree AV block? What is the treatment if they do not recover?

If the AV block is the result of an inferior MI, the AV node may recover. If it is the result of an anterior MI the distal conduction system is typically permanently damaged. In this case the treatment would be a permanent pacemaker.

105

How do you distinguish third-degree AV block that results from an inferior MI as opposed to an anterior MI?

In inferior MI situations, the escape rhythm typically originates in the AV junction and is narrow-complex. With an anterior MI, the escape rhythm originates in the ventricles is and is wide- complex.

106

What is considered to be a controlled rate for atrial fibrillation?

Less than 120.

107

What should be the therapy for low, moderate and high-risk CHADS2 scores?

Low risk or score of zero: aspirin therapy

Moderate risk or a score of one: aspirin or warfarin

High or greater than or equal to two: warfarin

108

Obstruction of what coronary artery is likely to cause sinus node disease?

What are other causes of sinus node disease?

The right or circumflex coronary artery.

Other causes include intrinsic aging, superimposed drug effect, and hypothyroidism.

109

What is the definition of sustained versus nonsustained ventricular tachycardia?

Duration of less than 30 seconds with self termination is nonsustained. Duration of greater than 30 seconds is sustained even if it ultimately self terminates.

110

What conditions are associated with torsade de pointes?

Hypomagnesemia, hypokalemia, and medications or conditions that prolonged QT interval.

111

What is the definition of systolic heart failure?

An ejection fraction of less than 40%.

112

What is eplerenone?

It is an aldosterone – antagonist antihypertensive that has less hormonal side effects than spironolactone.

113

If digoxin is used for heart heart failure, what is the target level?

Less than or equal to one. Most people are toxic at two, even though this level is considered high normal.

114

How is diastolic heart failure defined? How is it treated?

Heart failure with an ejection fraction of over 40%. Patients tend to be volume sensitive and can develop hypotension with excessive diuresis. If rapid atrial fibrillation is present digoxin is indicated for rate control. Careful preload reduction is appropriate. Careful decrease in heart rate, using a beta blocker or a non-dihydropyridine CCB is appropriate.

115

How are BNP levels used to exclude or rule in CHF?

A BNP level of less than 100 excludes CHF as a cause of dyspnea. A BNP of over 400 confers a 95% likelihood of CHF. BNP levels of 100 to 400 requires further investigation and may mean a pulmonary disorder such as lung cancer, cor pulmonale or pulmonary embolus; or another disorder such as cirrhosis, primary hyperaldosteronism, or Cushing disease.

116

What is the natural history of IHSS?

It usually stays the same or worsens with age. The mortality rate is believed to be about one percent, with some series estimating 5%. Thus in most cases lifespan is normal.

117

What are the indications for aortic valve replacement?

Aortic valve gradient over 50 mg of Mercury with an aortic valve area less than 1 cm². In addition the patient should be symptomatic. In this situation patients have a dismal prognosis without treatment and prompt correction of the mechanical obstruction with aortic valve replacement is indicated.

118

What are the recommendations for changing a patient from dabigatran to warfarin?

Start warfarin now and stop dabigatran in three days. An INR should not be checked until two days after stopping dabigatran.

119

What cardiac rhythm abnormality is most commonly seen in patients with anorexia nervosa?

Sinus bradycardia

120

What are the conditions that cause cyanotic congenital heart disease?

Transposition of the great vessels, total anomalous pulmonary venous return, tetralogy of Fallot, truncus arteriosus, hypoplastic left heart syndrome, tricuspid atresia and pulmonary atresia

121

Talk about statins: which are most powerful, which are least powerful, which cause less muscle toxicity, which are most effective in raising HDL, and which are best in renal impairment?

At maximum doses, rosuvastatin is the most powerful statin followed by atorvastatin. Both of these agents are significantly more potent than the other statins with fluvastatin being the least potent.

Sivvastatin has more muscle toxicity than the others, and should not be used over 40 mg per day. Pravastatin and fluvastatin have the least intrinsic muscle toxicity.

Rosuvastatin raises HDL by up to 10% and is followed by simvastatin in terms of increasing HDL.

Atovastatin and fluvastatin do not require adjustment in renal insufficiency and are the statins of choice in patients with severe renal impairment.

122

Which statins are extensively metabolized by the CYP3A4, and should be changed to a different statin if the patient is on one of these drugs?

Lovastatin, simvastatin, and to a lesser extent atorvastatin are extensively metabolized by CYP3A4. these drugs should be changed to another statin if the patient is taking a a trong inhibitor of CYP3A4 including antiviral drugs, clarithromycin, itraconazole, ketoconazole, and nicardipine.