Flashcards in Cardiology Deck (113):
Treatment for symptomatic mitral regurgitation from ischemic cardiomyopathy?
Decrease Preload (loop diuretics)
Decrease Afterload (ACEi &/or B-blockers)
Evalute w/ catheritization
Best initial test for CHF?
Most accurate test for CHF?
Best initial = Echo
Most accurate = MUGA
MUGA: IV injected 99mTc attaches to patient's RBCs and retained in vascular space --> it outlines the cardiac chambers, especially LV --> image the isotope in systole and diastole to determine EF accurately w/ visualization of any LV wall abnormality
8 hours after having an acute MI, 50 yo man has a BP of 70/50 and pulse 45. EKG shows normal sinus rhythm. What is most appropriate intervention?
Hypotension + bradycardia = vagal response (give anti-ACh)
Finding on EKG in hypothermia?
Common cause of hypothermia?
Osborn wave = upward deflection following R wave (lead II)
Check for HYPOGLYCEMIA
What causes diastolic LV dysfunction?
Long-standing HTN --> cause concentric hypertrophy of LV and leads to a heart that can NOT relax during diastole (filling of the heart chamber) --> this stiff ventricle from hypertrophy causes S4
- LV volume is reduced (from hypertrophy)
- End diastole pressure is increased (less chamber space)
*See pulmonary congestion from EXCESS PRELOAD
1) decrease HR (B-blocker or CCB) --> increases amt of time for ventricles to fill during diastole
2) ACEi/ARB --> reduce AFTERLOAD
What anti-HTN also treats Raynaud phenomenon and prophylaxis against migraines?
Anti-HTN in diabetic patients and CHF?
Anti-HTN in people with coronary artery disease? What condition should they be avoided in?
Avoid in ASTHMA
Can be used as migraine prophylaxis, but WORSENS Raynauds!
Hallmark symptom of vertebrobasilar insufficiency causing a TIA?
Other S/S: diplopia, dysphagia, dyarthria, facial numbness/paresthesia, syncope
These TIAs much shorter than internal carotid TIAs
What condition is seen with shortened PR segment?
What drugs are you NEVER to give?
Med of choice for tx?
WPW syndrome (pre-excitation syndrome) --> short PR segment w/ delta wave (slurred QRS)
- Accessory connections b/w atrium and ventricle that allows electrical conduction to bypass AV node
**CCB, B-blockers, digoxin --> block conduction at AV node pathway, increasing conduction in the aberrant pathway causing SVT or VT
What body changes are seen in hypokalemia?
What EKG changes are seen with hypokalemia?
Weakness --> starts in LE, progresses to trunk & UE
depressed ST segment
decreased T wave amplitude
After cardiac catheterization, how can you differentiate b/w cholesterol embolism and contrast nephropathy?
Cholesterol embolism = look for secondary signs of embolism
*Acute Kidney Failure (high Cr)
Post-MI complication resulting in hypotension and bradycardia?
What artery is affected?
Complete (3rd degree) heart block
*Both SA & AV nodes are infarcted = can't maintain synchronized rhythm --> this is due to R CORONARY artery blockage
*Atria and ventricles contract at different rates --> occasionally the atria contract against closed valves --> this back-pressure of venous blood to SVC and jugular veins causes the "canon A waves" on jugulovenous pulse
Anti-HTN with benign essential tremor (worse with movement)?
B-blocker (propranolol) - can help control the tremor
Best initial tx for HTN?
Thiazide diuretic (HCTZ)
Best initial test for ANY valvular heart lesion?
Most accurate test of ANY valvular heart lesion?
Best initial = transthoracic ECHO
Most accurate = cardiac catheterization and angiography ONLY if ECHO results are inconclusive or surgery in the works
S/S of R ventricle MI?
If suspected, what needs to be done to confirm? What are confirmatory findings?
What is treatment?
Bradycardia, hypotension, STEMI in leads II, III, avF
**Confirm with R sided EKG --> will see ST elevations in V4, V5
Tx: IV fluids (decreased RV compliance, reduced filling, and reduced R-sided stroke volume --> preload dependent) --> only give fluids if NO signs of fluid overload
What are the 3 different forms of amiodarone toxicity?
What are other side effects of amiodarone?
What is amiodarone used for?
*1) Organizing pneumonia
*2) Chronic intersitital pneumonitis (patchy, alveolar infiltrate w/ NON-productive cough)
*Other s/e: hypo/hyperthyroidism, liver toxicity
Amiodarone used for AFib and VT
Indication for CABG over angioplasty and stenting?
What is best vessel to use for CABG?
1) Significant stenosis of L main coronary
2) 3-vessel disease
3) 2-vessel disease in diabetic patients
Internal mammary artery
Patients with newly diagnosed HTN should have what further testing? Why?
To assess secondary causes for HTN
Treatment of SVT that is:
- hemodynamically stable?
- hemodynamically unstable?
Stable = 1) vagal maneuvers, 2) adenosine/CCB
Unstable = sedation w/ DC cardioversion
Most common type of cardiomyopathy?
Most common cause?
AAA size 3-4mm - what is criteria for f/u?
Greater than what size = surgery?
Major risk factor for AAA?
US screening every year
EKG findings: persistent ST elevations in leads V1-V3 with RBBB appearance ("M" sign) with or without terminal S waves in lateral leads.
Also most common cause of sudden cardiac death in men from Thailand/Laos?
Common cause of HTN in young females?
55 yo man with dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Has a blowing diastolic murmur at the L sternal border with a mid-diastolic rumble. What is the murmur and its special name?
Aortic regurgitation --> Austin Flint murmur (blood flows backwards through aortic valve and hits the anterior leaflet of the mitral valve)
*If Austin-Flint is present = valve replacement
What is Druoziez's sign?
Femoral bruit associated w/ aortic regurgitation
Explain why people with prior MIs have increased LVEDV and increased stroke volume?
Ischemic cardiomyopathy --> decreased cardiac output due to impaired myocardial contractility --> as a result:
1) SVR increases to maintain overall BP
2) Increased blood volume from activation of RAAS --> increased blood volume and preload = increased LVEDV
Aortic stenosis is associated with what GI pathology?
What is this syndrome called?
Angiodysplasia of the colon (R sided usually & bleeds)
IV drug users at risk for what infection?
What murmur will they have?
What intensifies the murmur?
What is seen on imaging (cxr)?
Tricuspid regurge (holo systolic)
Louder with inspiration
CXR: scattered masses at lung periphery from emboli
Most common cause of secondary HTN in children?
What is the physical exam finding?
Finding on angiography?
Hum/Bruit in the costovertebral angle due to well-developed collaterals
"String-of-beads" pattern of renal artery
Person with infective endocarditis suddenly develops AV block. What is most common cause of this?
Perivalvular abscess extending into the adjacent cardiac conduction tissues
What should be suggested in CHF and ECHO findings of increased ventricular wall thickness with normal LV cavity dimensions in absence of HTN?
What medications have shown to increase survival in CHF? What medication has NOT shown to increase survival but commonly given?
ACEi, ARBs, B-blocker, Spironolactone
Digoxin does NOT increase survival
What is a simple way to assess functional vs pathologic murmur in a child?
Positional body changes
*With decreasing the venous return (Valsalva or standing), this will REDUCE intensity of INNOCENT murmurs
All young patients with systemic HTN should be evaluated for what?
What is seen on ECG? CXR?
Coarctation of the aorta
EKG changes: LVH, T-wave changes in precordial leads
CXR: notching of 3-8th ribs from erosion of intercostal arteries ("3" sign)
What heart sound is commonly heard during MI?
Atrial gallop (S4)
*LV stiffening and dysfunction induced by myocardial ischemia
What are complications you must consider with large ANTERIOR lead STEMIs?
What treatments and tests are needed?
1) LV thrombus formation
2) Anteroapical aneurysm formation
Are CCB (dihydroperodine) used in treatment of coronary artery disease?
What are 2 common side effects?
NO --> can cause reflex tachycardia on the heart
In a STEMI, after giving aspirin, what is next best treatment?
Angioplasty (greatest mortality benefit)
Most common cause of death first several days after STEMI?
What is the genetic characteristic of hypertrophic cardiomyopathy?
Autosomal dominant --> mutation in genes coding myocardial contractile proteins of cardiac sarcomeres
*Beta-myosin heavy chain gene
Patient has anterior wall MI. 2 yrs later, he is found dead and his heart shows dilated LV with thinning and a scar on the anterior LV. What med could have prevented this?
*Prevent myocardial remodeling after an MI
What must you look for in association with aortic dissection? How to confirm?
Mediastinal widening on CXR
*Pericardial effusion --> confirm with TEE
What is a big risk factor for developing constrictive pericarditis?
What are the s/s?
Radiation therapy (esp for Hodgkin lymphoma)
R heart failure = peripheral edema, elevated JVD, enlarged liver, ascites
What 3 medication classes should be held 48 hours before cardiac stress test? Why?
*All are anti-anginal and reduce extent and severity of ischemia --> you WANT to assess ischemia in stress test!
Most common cause of mitral regurgitation in US?
What can it lead to?
Mitral valve prolapse --> myxomatous degeneration of mitral valve leaflets and chordae
- Early finding = mid-systolic click
- As it progresses --> murmur becomes holosystolic and click may disappear
*It can cause LV dilation --> AFib
*Also can cause CHF
Treatment for premature atrial beats?
NONE --> just observation
What is the treatment for WPW syndrome?
If unstable = cardioversion
What side effects must you monitor for with statins?
*Myopathy --> elevated CPK (can progress to renal compromise/failure)
*Hepatitis --> elevated LFT's
56 yo male complaining of progressively worsening fatigue, difficulty concentrating, and increasingly forgetful. He also has vague RUQ pain and constipation. He has gained 6 lbs unintentionally. His skin appears dry. He has HTN, cardiomyopathy, and persistent AFib. What medication should you conducer as the culprit?
What other side effects are associated with it?
**Hypothyroidism --> fatigue, memory loss, constipation, wt gain, dry skin
*Liver toxicity --> monitor LFTs
*Pneumonitis --> get CXR
A child has cyanosis and no improvement in SpO2 after being given 100% O2. He has a continuous machine-like murmur. What is the next best step?
Prostaglandin E1 --> prevents closure of PDA (helps mix oxygenated blood with deoxygenated blood )
What are signs of digoxin toxicity?
How can you get acute episodes of toxicity?
GI: Nausea, vomiting, diarrhea
Visual: scotoma, blurry vision, halos
*RENAL clearance --> if you use any diuretics can cause LOW potassium which will increase the effects and toxicity OR you can have acute kidney damage and will INCREASE digoxin blood levels!
Most common EKG finding in cardiac tamponade?
Electrical alterans --> beat-to-beat variation of QRS axis and amplitude (from swinging of heart in pericardial cavity)
Sinus tachycardia also
Tx in people with unstable AFib?
What is a common cause of HTN in women?
Most important non-pharmacological means of lowering BP?
Weight loss --> DASH diet, exercise
What heart condition is associated with carotid pulses with dual upstrokes and systolic ejection murmur along L sternal border with strong apical impulse?
**LV outflow obstruction is the cause
What maneuvers will INCREASE the murmur in hypertrophic cardiomyopathy?
Things that DECREASE chamber size/preload = increase the outflow obstruction
**Valsalva (strain phase), abrupt standing, amyl nitrite
What heart problems result from digoxin toxicity?
Atrial tachycardia w/ AV block
*Increased ectopy (atrial tachy) and increased vagal tone (hence the AV block)
DOC for hypertrophic cardiomyopathy? Why?
What maneuvers worsen this condition?
B-blocker (CCB also) --> slow the heart and prolong diastolic filling = less outflow obstruction
In someone with acute inferior MI with new holosystolic murmur heard at the apex, what physiologic parameter will be increased?
Acute MR --> excessive volume leaking back into the L atrium --> during diastole, there is rapid passive filling of LV augmented by LA contraction at end diastole --> acute MR leads to excessive diastolic volume overload, which causes elevated LVEDP
What anti-HTN has side effect of peripheral edema?
What other anti-HTN can help reduce this s/e?
CCB ("-dipine") --> dilate PRE-capillary vessels (arterioles)
ACEi/ARB --> help dilate POST-capillary venules
What is treatment of hemodynamically STABLE VT?
What is treatment of hemodynamically UNSTABLE VT?
Cardioversion (if pulseless, severely symptomatic, or hemodynam unstable)
What condition leads to bounding pulses?
3 most common causes of this heart abnormality (1 acquired, 2 congenital)?
Back flow into LV = increased LVEDV
1) Rheumatic heart disease (Acquired)
2) Aortic root dilation
3) Bicuspid aortic valve
Which drug has NEVER been proven to lower mortality in CHF?
What drugs lower mortality in CHF?
Best mgmt for regurgitate heart valves?
Vasodilators --> reduce afterload
(ACEi/ARB, nifedipine, hydralazine)
What 2 conditions point you towards mitral stenosis?
Pregnancy (increased blood volume)
Immigrant (rheumatic fever)
Mitral stenosis can result in what 2 GI side effects?
Dysphagia (LA presses on esophagus)
Hoarseness (LA presses on laryngeal nerve)
LA hypertrophy on EKG?
Biphasic P wave in V1
Best initial tx for either AR or AS?
Vasodilators (ACEi/ARB, nifedipine)
Effect of standing or Valsalva?
Effect of handgrip?
Squatting and leg raising?
Decrease venous return to the heart
Increases venous return to the heart
What 2 murmurs do NOT increase with expiration?
What 4 subsets now are recommended to start statin therapy?
1) Significant atherosclerotic dx (ACS, MI, angina, revascularization, stroke, TIA, PAD)
2) LDL > 190
3) Age 40-75 with diabetes
4) 10yr ASCVD risk > 7.5
How does aging affect arteries and blood pressure?
*Normally, the elastic properties of arteries allow them to absorb energy from systole --> they then recoil and this is what maintains diastole when the heart relaxes
As you age, the elastic properties decrease (lower compliance) and arteries can't absorb the energy from systole --> have a higher systolic pressure (become like rigid pipes) and can't maintain the diastolic pressures
Have wider pulse pressure
Most sensitive cardiac marker for MI?
Most useful for assessing re-occlusion after a recent MI?
Troponin T (takes 10 days to return to normal)
CK-MB (1-2 days to return to normal)
What other cardiac drug will cause digoxin toxicity if given together?
What are the acute s/s of digoxin toxicity?
GI: anorexia, nausea, vomiting, abd pain + weakness/confusion
**If given together --> need to decrease digoxin dose by 25-50% because the amiodarone will increase digoxin levels
In hemodynamically stable patient with SVT, what are the 2 treatments?
What EKG finding in neonates is NEVER normal?
What is it an indication of?
What other signs are associated with this disease?
L axis deviation (the RV should be larger b/c of ductus arteriosis in utero)
Tricuspid valve atresia
*L axis deviation on EKG
*Decreased pulmonary markings on CXR (hypoplasia of RV and pulm outflow tract)
What is the most likely anatomic site for the origin of atrial fibrillation?
Absent P waves & irregularly irregular R-R intervals
Best treatment for torsades?
Person with knife-injury can develop what abnormality?
How does this affect heart physiology?
- Blood bypasses capillaries
Decreases systemic vascular resistance
Increases cardiac preload
Increases cardiac output
*Causes high output cardiac failure
What is the mechanism of nitroglycerin in reducing anginal pain?
*Nitroglycerin --> dilation of veins (capacitance vessels)
Increased venous capacitance --> venous pooling --> big DECREASE IN PRELOAD + decrease in heart size --> O2 requirement of heart greatly decreases
Family hx of sudden death, congenital sensorineural deafness, and QT prolongation (> 600ms) - what is this?
Jervell and Lange-Nielsen syndrome (congenital long QT syndrome)
Tx: maintain normal levels of Ca, K, Mg
Common drug-induced causes of prolonged QT interval?
Opioids (methadone, oxycodone)
Antiarrhythmics (qunidine, procainamide, amiodarone, sotalol)
Person with hx of MI has deep Q waves in leads I, aVL, and V2-V5 with a 4-mm ST-segment elevation, which is unchanged from readings at discharge 2 months ago. what is the following cause of this?
*Persistent ST-segment elevation after a recent MI + deep Q waves in same leads
Usually see LV enlargement with heart failure
Current guidelines for AAA screening?
Men 65-75yo with (+) smoking hx
Most common mechanism of PSVT?
How do vagal maneuvers help break PSVT?
Re-entry into AV node
*Increase vagal tone --> decreases conduction through the AV node
What signs are seen in acute limb ischemia?
5 P's: pain, pulseless, paresthesia, poikilothermia, pallor
TX: IV heparin + embolectomy
Why is a single S2 heard in transposition of the great vessels?
The aorta is now anterior to the pulmonary artery
*Aorta is out of RV and pulm artery is out of LV
Most important risk factor for strokes?
Previously healthy 32 yo woman recently returned from a trip to Texas. She has been having progressive dyspnea on exertion and now has dyspnea at night. She has B/L pitting ankle edema and her liver is enlarged. She has decreased breath sounds B/L at the bases with an enlarged cardiac silhouette and B/L pleural effusions on CXR. What is the cause?
CHF --> likely from viral myocarditis (Coxsackie B)
Patient comes to ER with episode of syncope. He recently got over an URI 1 week ago. Vitals are stable. Neck veins are distended and heart sounds are distant. LCAB. CXR shows b/l pleural effusions and enlarged cardiac silhouette. What EKG finding is specific for this condition?
**Electrical alterans --> beat-to-beat variations in QRS complexes (heart's swinging back and forth within increased quantity of pericardial fluid)
*Prior URI is clue --> pericardial effusions are often secondary to viral pericarditis
Treatment of choice for acute aortic dissection (Type A or B)?
*Lower HR + BP = minimize stress on aortic wall
24 yo with sudden onset syncope has crescendo-drescendo murmur @ L sternal border with NO radiation to carotids. What is the cause?
What is uremic pericarditis?
What is tx?
Form of pericarditis seen in people with renal failure and BUN > 60.
Person has enlarged liver, prominent abdominal fluid, and dilation of jugular vein with manual compression of abdomen. There is B/L LE edema. He has barrel-shaped chest w/ B/L end-expiratory wheezes. What is the cause of his edema?
*Pulmonary HTN (elevated pulm systolic pressure >25)
Only type of restrictive cardiomyopathy that is reversible?
Hemochromatosis --> phlebotomy
Differentiation b/w restrictive and hypertrophic cardiomyopathy?
SYMMETRIC thickening of LV = restrictive
INTERVENTRICULAR septum thickest = hypertrophic
What can trigger vasovagal syncope?
How to test?
Prodrome of dizziness, nausea, pallor, diaphoresis
*Upright tilt table test
Person with IV drug history - what is most common bug and valve affected by endocarditis?
*Pulmonary septic emboli --> causing pulmonary infiltrates, abscesses (multiple) --> located in lung periphery
What is the mechanism behind muscle weakness of statin drugs?
Decrease coenzyme Q10 synthesis --> involved in muscle cell energy production and possibly contributes to statin-induced myopathy
Features of constrictive pericarditis?
*R heart failure (progressive peripheral edema, JVD, ascites, hepatomegaly)
*Pericardial thickening + calcification
*Prior cardiac surgery
Cardiac complication of Marfan?
Acute aortic dissection --> can progress to aortic root regurgitation (early decrescendo diastolic murmur)
What is potential complication of Lidocaine administration in person with acute coronary syndrome?
Common findings in elderly women with diabetes who are having acute MI?
Treatment for Viridans group strep (Strep mutans)?
IV penicillin G OR IV ceftriaxone for 4 weeks
What is pulsus paradoxus?
What 3 conditions is it commonly seen in?
When systemic arterial pressure drops MORE than 10mmHg during INSPIRATION
1) Cardiac tamponade (during inspiration, the increased preload to R heart causes IV septum to shift into the LV, reducing its LVEDV = decreased stroke volume and reduced systolic BP)
2) Severe asthma
3) COPD (more negative intrathoracic pressure causes pooling of blood in pulmonary vasculature = less return to the heart)
Most common heart defect in Down children?
Complete atrioventricular septal defects
Common cause of pericardial effusion?
Recent viral URI
Diminished heart sounds
*Difficult to palpate maximal apical impulse
Clear lung sounds
This physical exam finding is indicative of R-heart failure?
*Failing RV can't accommodate an increase in venous return --> JV distends