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1

systolic murmur that is heard in apex, radiates to axilla and increases with grip maneuver and decreases with valsalva

mitral regurgitation

2

sounds heard with acute mitral regurg

soft decrescendo systolic murmur
decreased S1
presence of S4

3

four MCC of acute heart failure

papillary muscle rupture
infective endocarditis
rupture of chordae tendinae
chest wall trauma with compromise of valvular apparatus

4

CF in Ehlers Danlos

pes planus
scoliosis
thin, velvety, fragile skin (cigarette paper)
easy bruisability
past hx of hernias and MVP

5

cocaine related chest pain - tx.

tx early with BDZs
-avoid beta blockers (to avoid causing coronary vasospasm)

6

Tx. persistent HTN after cocaine use

phentolamine
- also decreases coronary vasospasm
(alt. nitroglycerin, nitroprusside)

7

valve dz in an immigrant or a pregnant person

mitral stenosis

8

valve dz in Turner's syndrome pt with coarctation of the aorta

bicuspid aortic valve

9

valve dz in pt presenting with palpitations, atypical chest pain not with exertion

MVP

10

systolic murmurs

AS
MVP
MR
HOCM

11

diastolic murmurs

AR
MS

12

all right sided murmurs increase in intensity with...

inhalation

13

all left sided murmurs increase in intensity with...

exhalation

14

effect of squatting and lifting legs in the air on heart

return blood to heart therefore, increase venous return to the heart

15

effect of Valsalve maneuver and standing up on the heart....

decrease venous return to the heart

16

which murmurs get louder with squatting and leg raise

all right sided murmurs
AS, AR, MS, MR

17

which murmurs get softer with squatting and leg raise

MVP
HOCM
- these murmurs INCREASE with valsalva

18

which murmurs increase in loudness with valsalva/standing

HOCM
MVP

19

Effect of handgrip on heart and which murmurs does it make louder?

1. increases afterload
2. Worsens VSD, AR and MR murmur
3. Improves/softens MVP and HOCM

20

effect of amyl nitrate on heart and murmurs

1. decreases afterload
2. softens, AR and MR
3. worsens MVP and HOCM (increases the obstruction and degree of prolapse)

21

effect of amylnitrate and handgrip on murmur of AS

handgrip actually makes AS murmur softer --> creates less of a gradient between LV and aorta. Amyl nitrate increases the gradient and thus, increases murmur of AS

22

any murmur that improves with amyl nitrate will improve with tx with what med?

ACEI
murmurs: AR, MR, VSD

23

best initial test for valve lesions (1)
most accurate test for valve lesions (2)

1. echo (TTE --> TEE)
2. left heart catheterization
- also order EKG and CXR on ccs

24

best treatment for regurgitant lesions

vasodilator therapy - ACEI or ARBs, nifedipine

25

in which murmurs is diuretic therapy indicated

if murmur improves with valsalva (decreased venous return) --> AS, AR, MS, MR, VSD

26

crescendo-descrescendo systolic murmur, heard best at 2nd intercostal space, radiates to carotid arteries, delayed carotid upstroke

AS

27

how do you assess severity of AS?

measure pressure gradient across valve
Normal < 30
Moderate 30-70
Severe > 70 mmHg

28

best initial therapy for AS (1)
treatment of choice for AS (2)

1. diuretics
2. valve replacement

29

diastolic descrescendo murmur heard best at left sternal border

AR

30

clinical findings unique to AR

Quinke's pulse - pulsations in fingernails
Corrigan's pulse - bounding pulses
Musset's sign: head bobbing up and down with each pulse
Duroziez's sign - murmur heard over femoral artery
Hill sign - BP gradient high in lower extremities

31

Tx. aortic regurg

1. ACE, ARBs and nifedipine - best initial
2. add furosemide
3. surgery if EF < 55%

32

diastolic rumble murmur with opening snap, best heard at cardiac apex, S1 louder than S2

mitral stenosis

33

unique clinical findings in MS

dysphagia and hoarseness due to pressure of LA pressing on esophagus and recurrent laryngeal nerve (Ortner's syndrome)
atrial fibrillation
mitral facies - pinkish-purple patches on cheeks

34

XR findings in MS

LA enlargement with flattened left heart border
dilated pulm vessels

35

EKG findings in MS

broad, notched P waves
RVH: tall R in V1 and V2

36

Tx. mitral stenosis

diuretics
most effective = balloon valvuloplasty
if pregnant - do not hesitate to perform valvuloplasty

37

holosystolic murmus that obscures both S1 and S2, heard best at apex that radiates to axilla, S3 gallop often present

mitral regurg

38

S3 gallop

assoc. with fluid overload states, such as CHF or MR

39

Tx. mitral regurg

1. ACE, ARBs and nifedipine - best initial
2. add furosemide
3. surgery if if LVEF < 60% or LVED > 40 mm

40

holosystolic murmur at the LLSB that worsens with exhalation, squatting and leg raise

VSD

41

murmur assoc with ASD

fixed splitting of S2

42

Tx. ASD

percutaneous or catheter devices
- repair indicated when the shunt ratio exceeds 1.5:1

43

causes of wide splitting of S2 with delayed P2

RBBB
PS
RVH
pulm HTN

44

causes of paradoxical splitting of S2 with A2 delayed

LBBB
AS
LVH
HTN

45

best initial test for cardiomyopathy

ECHO

46

most accurate method for determining EF

MUGA
nuclear ventriculography

47

Tx. dilated cardiomyopathy

ACEi/ARBs
BB
spironolactone

48

S4 gallop

sign of LVH and decreased compliance or stiffness of the ventricle

49

Tx. HCM

beta blockers
diuretics

50

Dx. findings in restrictive evaluation

cardiac cath --> rapid x and y descent
EKG --> low voltage
echo = mainstay of diagnosis
single most accurate dx test: endomyocardial biopsy

51

best initial test for pericarditis

EKG --> diffuse ST elevation, PR depression

52

best initial therapy for pericarditis

NSAID
if the pain persists for > 2 days, add prenisone orally

53

CF in pericardial tamponade

SOB
hypotension
JVD
pulsus paradoxus
EKG: electrical alternans

54

most accurate diagnostic test for tamponade

echo --> diastolic collapse of RA and RV

55

results of right heart cath in tamponade

equalization of all pressures in the heart during diastole

56

best initial therapy for tamponade

pericardiocentesis

57

unique features of constrictive pericarditis

sx of chronic RHF -> JVD, hepatomeg, ascites, edema
Kussmaul's sign: JVD with inspiration
pericardial knock

58

best initial therapy for constrictive pericarditis

diuretics

59

most effective therapy for constrictive pericarditis

pericardial stripping

60

pt presents with severe chest pain that radiates to the back. on exam,he is hypertensive with BP are greater in the right arm vs left arm - dx? best initial test? most accurate test?

Dx. thoracic dissection
initial test: CXR shows widening mediastinum
best test: CT angio = TEE = MRA

61

first steps in management if you suspect pt with thoracic dissection

1) start BB
get EKG, CXR --> CT angio or TEE or MRA
2) nitroprusside to control BP
3) place in ICU
4) get surgery consult

62

best initial test for PAD

ankle brachial index
normal should be > 0.9

63

best initial therapy for PAD

1. aspirin or clopidogrel (most effective)
2. ACEI
3. supervised exercise program
4. cilastazol - only if severe symptoms
5. lipid control with statins

64

pentoxyfylline

marginally effective therapy for PAD, used only if cilostazol is ineffective

65

for CCS, tests to order once A-fib is found

1. ECHO
2. TFTs
3. electrolytes: K+, Mg, Ca
4. troponin or CK MB

66

Tx. unstable pt with A-fib

synchronized cardioversion
- without any TEE or anticoagulation

67

Tx. stable pt with A-fib

1. slow HR with BB (metoprolol or esmolol) or CCB (diltiazem)
2. anticoagulation with warfarin (INR 2-3) or dabigatran

68

CHADS

CHF
HTN
Age > 75
Diabetes
Stroke/TIA (2)
- score > 2 warrants warfarin
if score < 2, can tx with aspirin

69

causes of multifocal atrial tachycardia

secondary to hypoxia (COPD), hypokalemia, hypomag, coronary/valvular dz, meds (theophylline, aminophylline, isoproterenol)

70

Tx. MAT

correct underlying cause
if that does not work --> CCBs (verapamil)

71

best initial therapy for unstable pts with SVT

synchronized cardioversion

72

best initial therapy for stable pts with SVT

Vagal maneuvers
- if vagal maneuvers do not work --> IV adenosine

73

best long term management of SVT

radiofrequency catheter ablation

74

pt with history of SVT is treated with a CCB which worsens his/her symptoms - dx?

WPW

75

best initial therapy if pt is described as being in SVT or VT from WPW

procainamide

76

therapy options for pt who is hemodynamically stable in VT

amiodarone
lidocaine
procainamide
Mg

77

acquired QT prolongation

hypomagnesemia
hypokalemia
meds - macrolides, antihistamines, psychotropic drugs