Cardiology

Question 1

Door to balloon time (PCI=angioplasty=stent)

Answer 1

under 90 minutes

Question 2

Door to needle time (tPA=thrombolytics)

Answer 2

under 30 minutes

Question 3

Absolute C/Is to thrombolytics

Answer 3

1) Bleeding, major (into bowel or brain = melena or h/o hemorrhagic CVA)
2) Surgery, recent (w/in past 2 wks)
3) HTN, severe (>180/110)
4) Stroke, non-hemorrhagic (w/in last 6 mon)

Question 4

ACS tx mnemonic

Answer 4

MONA BASH
Morphine 
O2 
NTG (UNLESS R-sided MI or CHF) 
*ASA (Clopidogrel instead if ASA-allergic, Clopidogrel in addition if h/o stent) 

Bb (CCB instead if asthmatic, cocaine-induced MI, or Prinzmetal angina)
ACEI/ARB
Statin
Heparin (after thrombolytics/PCI to prevent restenosis)

*BEST FOR MORTALITY REDUCTION

Question 5

CP + Chest wall tenderness (give dx and test)

Answer 5

Dx: Costochondritis
Test: PE

Question 6

CP + Radiation to back, unequal BP b/w arms (give dx and test)

Answer 6

Dx: Aortic dissection
Test: contrast CT, TEE

Question 7

CP + Pain worse w/ lying flat, better w/ sitting up, young age (give dx and test)

Answer 7

Dx: Pericarditis
Test: EKG shows ST elevation everywhere, PR depression

Question 8

CP + Epigastric discomfort, pain better when eating (give dx and test)

Answer 8

Dx: Duodenal ulcers
Test: Endoscopy

Question 9

CP + Bad taste, hoarseness, dry cough (give dx and test)

Answer 9

Dx: GERD
Test: none, just give PPIs and see if sx resolve

Question 10

CP + Productive cough, hoarseness, hemoptysis (give dx and test)

Answer 10

Dx: PNA
Test: CXR

Question 11

CP + Sudden-onset SOB, tachycardia, hypoxia (give dx and test)

Answer 11

Dx: PE
Test: spiral CT, V/Q

Question 12

CP + Sharp pleuritic pain, tracheal deviation (give dx and test)

Answer 12

Dx: PTX
Text: CXR

Question 13

Cardiac CP sx; typical vs atypical vs non-cardiac

Answer 13

1) Substernal pressure (crushing, dull, sore)
2) Worse w/ exertion
3) Better w/ rest and NTG

3/3=typical
2/3=atypical
1/3=non-cardiac

Question 14

Statins A/Es

Answer 14

Elevations of LFTs (AST/ALT) in 1%, myositis or CPK elevation in 0.1%

Question 15

Grading murmurs, when to workup, how to workup

Answer 15

I S1S2 > murmur
II S1S2 = murmur
III S1S2

Question 16

Murmurs: Mitral Stenosis (MS) (path, pt, dx, tx)

Answer 16

Path: rheumatic heart dz
Pt: young (usu 30s); LAD –> A-fib, dysphagia (esoph comp), hoarseness (laryngeal n comp); CHF
Dx: MS. Opening Snap, Dia (mitral area)
Tx: balloon valvuloplasty (pt young, wait to surgically replace bc you’ll have to re-replace eventually)

Question 17

Murmurs: Aortic Regurg (AR) (path, pt, dx, tx)

Answer 17

Path: infxn or infarction (endocarditis or MI), HTN, Aortic dissection
Pt: CP; Acute: cardiogenic shock and flash pulm edema, Chronic: CHF
Dx: Dia Decrescendo, Left Lower sternal border (AR in LL)
Tx: Valve replacement (consider CABG); ACEI/ARBs or CCBs delay progression bc vasodilators

Question 18

Murmurs: Aortic Stenosis (AS) (path, pt, dx, tx)

Answer 18

Path: atherosclerosis –> calcification w/ aging; bicuspid aortic valve accelerates process
Pt: old man w/ atherosclerosis, CHF, syncope
Dx: Sys Crescendo-decrescendo (aortic area)
Tx: Valve replacement (consider CABG)

Question 19

Murmurs: Mitral Regurg (MR) (path, pt, dx, tx)

Answer 19

Path: infxn or infarction (endocarditis or MI), HTN, Marfans, Anky spondy, Reiter synd, Syphilis
Pt: CP; Acute: cardiogenic shock and flash pulm edema, Chronic: CHF and A-fib
Dx: HoloSystolic, Headbobbing, Water-hammer pulse, Wide pulse pressure
Tx: Valve replacement

Question 20

Consider CABG w/ which valve replacements?

Answer 20

Aortic, bc ostea of coronary vessels is just superior to aortic valve at root of Ao

Question 21

Anything that dilates the heart (HTN, infxn, infarction) can lead to what kind of murmur?

Answer 21

Regurg (MR and AR)

Question 22

Increase venous return (and therefore preload) how?

Answer 22

Squatting or leg lift

Question 23

Decrease venous return (and therefore preload) how?

Answer 23

Valsalva maneuver (bearing down against closed airway; generates thoracic pressure, impeding venous return of blood to heart –> dec preload; may be used to tx SVT)

Question 24

Define preload

Answer 24

Max vol of blood in LV at end diastole; think more blood coming into heart –> more preload!

Question 25

Define afterload

Answer 25

Max resistance LV must overcome to circulate blood; higher BP = higher afterload

Question 26

Murmurs: Hypertrophic Cardiomyopathy (HCM) (path, pt, dx, tx)

Answer 26

Path: HCM 2/2 longstanding HTN; HOCM 2/2 sarcomere mutations, hypertrophic septum + SAM of mitral valve --> LVOTO (aortic outlet blocked) Pt: young athlete w/ SOB or syncope on exertion (at risk for sudden death; may have FHx) Dx: Sys murmur +/- S4; sounds like AS, EXCEPT more blood makes it BETTER (murmur get softer w/ squatting or leg lift) Tx: Bbs and avoid dehydration

Question 27

Murmurs: Mitral Valve Prolapse (MVP) (path, pt, dx, tx)

Answer 27

Path: congenital; 2-5% of population; valves too big and floppy --> balloons/parachutes out during systole but still touch, better when ventricle widens) Pt: young female Dx: Sys sounds like MR, EXCEPT more blood makes it BETTER (murmur get softer w/ squatting or leg lift) Tx: Bbs and avoid dehydration

Question 28

What does squatting or leg lifts do to preload? How does that affect murmurs?

Answer 28

Squatting or leg lifts INCREASE preload (think of SQUEEZING blood back to heart) MORE blood makes MOST Murmurs LOUDER (MR, AS, AR, MS) Weird ones go away (MVP, HCM)