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Flashcards in Cardiology Deck (130):
1

Viruses implicated in dilated cardiomyopathy

#1) Coxsackie B. Also parvovirus B19, HHV6, adenovirus and enterovirus.

2

Cardiac problem that results in an S3? S4?

S3 = volume overloaded state, causing eccentric hypertrophy and an extra sound when atrial blood hits blood already in the ventricle.

S4 = pressure overloaded state, causing concentric hypertrophy and an extra sound when atrial blood hits a stiffened ventricle.

3

Sensitivity, specificity and predictive accuracy for diagnosing heart failure in a patient with a BNP > 100

90, 76 and 83%

4

Electrolyte abnormality that is an important predictor of adverse clinical outcomes in patients with CHF?

Hyponatremia, it typically parallels the severity of disease. It occurs due to decreased intravascular volume, ADH release and free water retention

5

Treatment of CHF-related hyponatremia

Free water restriction

6

Drug typically given in the setting of acute MI that is contraindicated if the patient also has pulmonary edema

Beta-blockers, these are contraindicated in patients with acute decompensated heart failure because the increased heart rate is essential to adequate tissue perfusion.

7

Drugs given for initial stabilization of a patient with acute MI. What adjuncts can be given if the patient has persistent pain, hypertension, heart failure, bradycardia or pulmonary edema despite initial treatment?

Beta-blocker (unless hypotensive, bradycardic, heart failure or heart block)

Aspirin + P2Y12 inhibitor (clopidogrel, ticagrelor)

Statin

Heparin

Oxygen

Nitrates (avoid this and diuretics if RV infarct)

Persistent pain, hypertension or heart failure = nitrates +/- morphine for pain.

Bradycardia = atropine

Pulmonary edema = furosemide

8

Cardiac, pulmonary, GI, endocrine, ocular, dermatologic and neurologic side effects of amiodarone.

Cardiac = sinus brady, heart block and long QT

Pulmonary = chronic interstitial pneumonitis

GI = hepatitis and transaminitis

Endocrine = hypothyroidism, hyperthyroidism

Ocular = corneal deposits, optic neuropathy

Derm = blue-grey skin discoloration

Neuro = peripheral neuropathy

9

Arteries most commonly involved in patients with fibromuscular dysplasia

Renal, carotid and vertebral arteries

10

Diagnosis and treatment of fibromuscular dysplasia

Diagnosed with CT angiography, catheter-based digital subtraction arteriography if CT angio is inconclusive.

11

Aldosterone concentration : renin activity in fibromuscular dysplasia? What about with adrenal hyperplasia/adenoma?

~10 in fibromuscular dysplasia. > 15 in primary hyperaldosteronism.

12

ECG characteristics of PAC's

Unusual P-wave morphology because the impulse is coming from somewhere other than the SA node in the atria. Early contractions are also present.

13

Treatment of symptomatic PAC's

Low dose beta-blockers, decrease stress and cessation of tobacco, alcohol and caffeine.

14

Indication for fibrinolysis in patient with MI

Within 12 of hours of onset of symptoms and unable to undergo PCI

15

How long should you continue aspirin and P2y12 receptor blockers after drug-eluting stent placement?

12 months

16

Milrinone mechanism of action

PDE inhibitor that increases myocardial contractility

17

Desired CXR location of central venous catheter

Angle between the trachea & right mainstem bronchus or proximal to the cardiac silhouette

18

Congenital causes of high-output heart failure

PDA, angioma, pulmonary/CNS AVF

19

Acquired causes of high-output heart failure

Trauma, iatrogenic, atherosclerosis (aortocaval fistula) and cancer.

20

Side effects and electrolyte changes seen in patients taking thiazide diuretics

Hyponatremia, hypokalemia, hypercalcemia, hyperglycemia, hyperuricemia and elevated LDL cholesterol.

21

Electrolyte abnormalities that put patients at risk for VT when taking furosemide

Hypokalemia and hypomagnesemia

22

Basic lab analysis for a patient presenting with hypertension

Rule out other causes of hypertension with:
UA, BMP, lipid profile and baseline ECG

23

Signs and symptoms of secondary hypertension

Malignant hypertension, HTN requiring 3+ drugs, sudden rise in BP with previously normal values and onset at

24

Causes of secondary hypertension

Renal parenchymal disease, renovascular disease, primary hyperaldosteronism, pheochromocytoma, Cushing syndrome, hypothyroidism, primary hyperparathyroidism and aortic coarctation.

25

Treatment of beta-blocker or CCB toxicity

IV glucagon

26

Most common cause of aortic regurgitation in developed vs. undeveloped countries.

Developed = bicuspid valve
Undeveloped = rheumatic heart disease

27

Indications for carotid endarterectomy

Men: asymptomatic and > 60% stenosed, symptomatic and > 50% stenosed.

Women: symptomatic or asymptomatic and > 70% stenosed.

28

Management of aortic dissections

IV labetolol. Surgery is only indicated for type A dissections.

29

Why patients with aortic stenosis get angina?

LV hypertrophy results in increased myocardial oxygen demand.

30

Common causes of constrictive pericarditis

Idiopathic or viral, radiation, cardiac surgery, connective tissue disorders and Tb.

31

Management of patients with claudication

Low-dose aspirin and statin therapy + 12 weeks of exercise for 30-45 minutes 3x per week. Add cilostazol if symptoms persist afterwards. Consider vascular consult if ABI

32

Management of cocaine-related STEMI

Same as regular STEMIs except: avoid beta-blockers. Also add IV benzodiazepine, CCB or alpha-blocker to reduce vasospasm.

33

Management of hypertensive emergency

MAP lowered by 10-20% in 1st hour and 5-15% over next 23 hours.

34

Types of heparin-induced thrombocytopenia (HIT)

Type 1 HIT: non-immune direct effect of heparin on platelet activity within first 2 days of exposure. Platelet count normalizes with continued therapy and there are no clinical consequences.

Type 2 HIT: immune-mediated due to anti-platelet factor 4 antibodies complexed with heparin. This causes thrombocytopenia around 30k-60k and thrombosis 5-10 days after starting heparin. This can be life threatening.

35

Hypertensive urgency vs. emergency

Urgency = > 180/120 without symptoms or signs acute end-organ damage

Emergency = MH (retinal hemorrhages, exudates and papilledema) and encephalopathy (cerebral edema and non-localizing neurologic signs and symptoms)

36

Phases of post-MI arrhythmia

1a = immediate arrhythmia within 10 minutes of coronary occlusion due to ischemia-related areas of heterogeneous conduction causing re-entrant arrhythmias.

1b = delayed arrhythmias due to abnormal automaticity 10-60 minutes after MI

37

Lab studies present in a patient with recent atheroembolism from coronary vascularization

Eosinophilia, eosinophiluria and hypocomplementemia with renal dysfunction that can persist beyond 2 weeks.

38

Lab studies present in a patient with contrast-induced nephropathy

Muddy-brown granular and epithelial cell casts 3-5 days after exposure and resolution within 1 week.

39

Mechanisms of niacin-induced peripheral vasodilation

Drug-induced release of histamine and prostaglandins. This is why it can be treated with low-dose aspirin 30-minutes before taking niacin and improvement 2-4 weeks later.

40

CXR sign for pericardial effusion

Water bottle sign with clear lung fields

41

Treatment of stable angina

1st line = beta-blockers. CCB or long-acting nitrates can be used if beta-blockers are contraindicated, poorly tolerated or are ineffective.

42

Osler nodes vs. Janeway lesions

Janeway lesions are non-tender lesions on the palms and soles due to vascular phenomena associated with infective endocarditis.

Osler nodes are painful lesions on the fingertips and toes due to immunologic phenomena associeated with infective endocarditis.

43

Patient has recurrent high fevers, arthritis and a maculopapular, nonpruritic rash affecting the trunk and extremities only during febrile episodes.

Adult Still's disease.

44

Common presentation of uremic pericarditis? Treatment?

BUN > 60 and ECG not consistent with classic pericarditis. Treat with dialysis and avoid heparin (risk of hemorrhage).

45

Indications for urgent dialysis

Acidosis = pH 6.5 refractory to medical therapy

Ingestion = methanol, ethylene glycol, salicylate, Li, sodium valproate, carbamazepine

Overload = fluid retention refractory to diuretics

Uremia = encephalopathy, pericarditis and bleeding.

46

Risks for ascending aortic aneurysms? Descending?

Ascending = cystic medial necrosis (aging) and connective tissue disorders.

Descending = atherosclerosis (HTN, hypercholesterolemia and smoking)

47

Conditions included is atherosclerotic cardiovascular disease (ASCVD)

ACS, MI, angina, hx of arterial revascularization, stroke/TIA or PAD.

48

Recommendation for bystander CPR

Compression-only CPR

49

When to use immersion cooling vs. evaporative cooling for heat stroke.

Exertional heat stroke = immersion. Non-exertional (typically elderly) = evaporative.

50

Drugs to avoid in patients with RV MI.

Those that reduce preload (nitrates, diuretics and opioids) and those that slow heart rate (beta blockers) or decrease contractility (CCBs)

51

AVNRT pathophysiology and ECG findings

2 conducting pathways, one fast and one slow, form within the AV node and cause a rapid, regular rhythm with narrow QRS and buried P waves.

52

Atrial flutter pathophysiology and ECG findings

Caused by a re-entrant circuit around the tricuspid annulus. ECG shows rapid sawtooth flutter waves.

53

2nd line medication to terminate SVT if adenosine fails

Verapamil

54

Management of pulmonary hypertension secondary to severe HFrEF with pulmonary edema? Idiopathic pulmonary hypertension? Pulmonary HTN due to chronic lung disease? Chronic thromboembolism?

Loop diuretics, ACE-I, beta-blockers and aldosterone antagonists (treat the CHF to treat PH).

Oxygen + bronchodilators if due to chronic lung disease.

Endothelin receptor antagonists (bosentan), PDE-5 inhibitors (sildenafil) and/or epoprostenol for idiopathic PH.

Warfarin for chronic thromboembolism

55

When is endovenous ablation indicated for chronic venous stasis?

Persistent symptoms despite conservative treatment and documented reflux.

56

Signs of scleroderma renal crisis

Sudden onset renal failure, MH, mild proteinuria, MAHA/DIC and thrombocytopenia

57

Cause of paradoxical splitting with aortic stenosis

Delayed myocardial relaxation and delayed closure of the aortic valve.

58

Anti-arrhythmic with side effects of diarrhea, tinnitus, QT prolongation, torsades de pointes, hemolytic anemia and thrombocytopenia.

Quinidine

59

CHA2DS2VASc

CHF

HTN

Age > 75

DM

Stroke/TIA/Thromboembolism

Vascular disease (MI, PAD, aortic plaque)

Age 65-74

Sex category

60

Arrhythmia most specific for digitalis toxicity

Atrial tachycardia (150-250) with AV block

61

Meds to withhold prior to stress testing

Hold for 48 hours: beta-blockers, CCB and nitrates.

Hold for 48 hours prior to pharm-stress test: dipyridamole

Hold for 12 hours prior to pharm-stress test: caffeine

Continue ACE-I, ARB, digoxin, statin and diuretics.

62

CYP450 Inhibitors

Acetaminophen (>2g/d), NSAIDs

Antibiotics, antifungals (metronidazole)

Amiodarone

Cimetidine

Cranberry juice, Ginkgo biloba, vitamin E

Omeprazole

Thyroid hormone

SSRIs

63

CYP450 Inducers

Carbamazepine

Ginseng

Green vegetables

Oral contraceptives

Phenobarbital

Rifampin

St. John's wort

64

Treatment for patients with lone atrial fibrillation

None. Their CHADSVAsc score is typically 0, they have no cardiopulmonary or structural heart disease and do not require anticoagulation.

65

Drug options for oral anticoagulation in patients with a-fib

Warfarin, factor Xa inhibitors (rivaroxaban, apixaban) and direct thrombin inhibitors (dabigatran)

66

Beta-blocker mechanism in symptomatic management of hyperthyroidism

Reduce sympathetic stimulation from the increased beta-adrenergic receptors and block peripheral conversion of T4 to T3

67

Chronic vs. acute mitral regurgitation symptoms

Acute mitral regurgitation leads to abrupt and excessive volume overload with increased filling pressures and pulmonary edema. Chronic mitral regurgitation does not cause significant change in left atrial or ventricular size/compliance

68

When is urine sodium not a reliable indicator of hypovolemia?

When patients are taking diuretics

69

Indications for temporary intravenous cardiac pacing?

Sick sinus syndrome or symptomatic second and third degree heart block

70

Calcium channel blockers that commonly cause peripheral edema? Combination of these with what medications can reduce the edema?

Dihydropyridines (amlodipine and nifedipine). Combining them with ACE-I, which have post-capillary venodilatory effect, can resolve the edema.

71

Cardiac condition to watch out for in Hodgkin's survivors even 10-20 years down the road

Constrictive pericarditis can arise late in patients who received XRT and/or anthracycline chemotherapy.

72

Maneuvers that increase the murmur of hypertrophic cardiomyopathy and mitral valve prolapse? What maneuvers decrease it?

Increase: Valsalva, abrupt standing and nitroglycerin (all decrease preload)

Decrease: hand grip (does not increase MVP, increased afterload), passive leg raise (increased preload) and squatting (increased preload and afterload)

73

Treatment of infective endocarditis in patient with penicillin-sensitive S. viridans

IV Penicillin G or IV Ceftriaxone x 4 weeks

74

Murmur of aortic dissection

Diastolic decrescendo murmur at the right sternal border

75

Types of systemic amyloidosis

Primary (AL) or secondary (AA) due to chronic inflammatory conditions.

76

Primary anti-ischemic effects of nitrates

Decreased preload causes decreased left ventricular end diastolic volume and wall stress, reducing myocardial oxygen demand.

77

Studies to order in patients with new-onset a-fib

fT4 and TSH, echo, tox screen, BMP and screen for PE and OSA.

78

When to use immediate synchronized cardioversion

Sustained monomorphic VT unresponsive to antiarrhythmics and unstable a-fib with RVR

79

ECG characteristics of PVCs

QRS > 120msec

Bizarre morphology not representing any conduction abnormality

T-wave in opposite direction of QRS

Compensatory pause

80

First line treatment for patients with frequent and symptomatic PVCs

Escalating doses of beta-blockers or CCBs

81

Anti-arrhythmics with the use dependence phenomenon.

Class IC (flecainide and propafenone) and IV (CCBs) antiarrhythmics have the slowest rate of drug binding and dissociation. Consequently, when patients have increased heart rate, there is less time to dissociate and more sodium channels become blocked resulting in widening of the QRS.

82

Digoxin mechanism of action

Inhibits the Na-K pump, resulting in increased intracellular Na+ levels that simultaneously causes increased intracellular Ca2+ levels and increased contractility.

Additionally it enhances vagal tone and slows AV node conduction.

83

Most common cause of chronic mitral regurgitation in developed countries

Mitral valve prolapse

84

Medications than can reduce the responsiveness of blood pressure to anti-hypertensive medications

NSAIDs, decongestants and glucocorticoids

85

Management of PACs

If infrequent, just reassure that they're benign.

If frequent, get TTE to rule out underlying heart disease and treat with low-dose beta-blocker

86

PAC ECG

Abnormal p-wave morphology due to impulse coming from location other than SA node in atria + irregular rhythm.

87

Drugs to stop in a patient with digoxin toxicity

Loop diuretics. They can cause hypokalemia, which adds to the cardiac effects of digoxin.

88

Treatment of stable a-fib in patients with WPW

IV ibutilide or procainamide. Don't use beta-blockers, CCBs, adenosine or digoxin in these patients because they promote conduction across the accessory pathway and can lead to degeneration to v-fib.

89

Modified Wells criteria for DVT

Bedridden > 3 days
Immobilization
Tender veins
Cancer active
History of DVT
Pitting edema
Unilateral swelling > 3cm
Swollen leg
Superficial non-varicose veins

More likely alternate dx = -2 points

score

90

Next step if modified Wells criteria for DVT is 1?

1 = compression ultrasonography, repeated in 5-7 days if initially negative.

91

Who gets a high-intensity statin?

Clinically significant ASCVD (ACS, MI, angina, TIA, stroke, PAD, hx of revascularization) and age

92

Definition of orthostatic hypotension

Drop > 20mmHg systolic or > 10mmHg diastolic

93

BP difference in arms when you worry about aortic dissection

> 20mmHg SBP difference

94

Definition of pulsus paradoxus

> 10mmHg SBP drop during inspiration

95

1st line drugs for patients with hypertrophic cardiomyopathy

Beta-blockers or CCBs because the promote diastolic relaxation, increased filling and decreased outflow obstruction.

96

Medication recommendations for patients with reversible ischemia seen on stress testing

Aspirin + beta-blocker + lifestyle changes

97

Auscultatory finding very specific for renal artery stenosis

Systolic-diastolic abdominal bruit

98

Anti-platelet and anti-coagulant to give in patients with suspected ACS

Aspirin if low-probability for dissection

Heparin once ECG confirms STEMI

99

Modified Wells criteria for PE

3 points = clinical signs of DVT and no other etiology is more likely than PE

1.5 points = prior PE/DVT, HR > 100, recent surgery/immobilization

1 point = hemoptysis, cancer

> 4 points = PE likely

100

Aortic regurgitation murmur when it is due to root disease vs. valvular disease

Root disease = RLSB
Valvular disease = LLSB

101

Signs of right ventricular heart failure

Elevated JVP

Right ventricular third heart sound

Tricuspid regurgitation

Hepatomegaly with pulsatile liver

LE edema, ascites and/or pleural effusions

Confirmed with pulmonary artery systolic pressures > 25mmHg

102

Hallmark ECG findings in left ventricular aneurysms

Persistent STEMI after MI and deep Q waves in the same leads

103

Cutoff for ST depression

1mm or greater

104

Adverse side effects of PDE-5 inhibitors

Hypotension, blue vision discoloration, ischemic optic neuropathy, priapism, flushing, HA and hearing loss.

105

Medications that can prolong the QT interval

Diuretics (low K, Mg or Ca)

Antiemetics

Antipsychotics

TCAs

SSRIs

Antiarrhythmics (sotalol, amiodarone, flecainide)

Antianginal (ranolazine)

Anti-infectives (macrolides, fluoroquinolones and antifungals)

106

Treatment of patients in torsades de pointes

Stable = IV Mg.
Unstable = immediate defibrillation.
Quinidine/TCA related = sodium bicarbonate

107

Physical exam findings in patients with severe aortic stenosis

Pulsus parvus et tardus
Mid-late systolic murmur (early peak = mild-moderate stenosis)
Soft, single 2nd heart sound due to delayed closure

108

Diagnosis and treatment of autosomal dominant polycystic kidney disease

Dx: u/s
Tx: ACE-I for hypertension, close monitoring of renal function and ultimately dialysis or transplant

109

Pathophysiology of isolated systolic hypertension in the elderly? Treatment?

Pathophys: loss of arterial wall elasticity
Tx: monotherapy with thiazide, ACE-I or CCB

110

ECG characteristics of supraventricular arrhythmias

Narrow QRS + tachycardia

P-waves buried within QRS

Retrograde p-waves (inverted p-waves after QRS or spikes on the QRS)

111

Rhythms included in the domain of supraventricular arrhythmias

Sinus tachycardia

Multifocal atrial tachycardia

Atrial flutter

Atrial fibrillation

AVNRT

AVRT

Junctional tachycardia

112

Rhythms included in the domain of paroxysmal supraventricular tachycardia

AVNRT (most common), AVRT, atrial tachycardia and junctional tachycardia all have abrupt onset and resolution.

113

Murmur heard in patients with atrial septal defects

Significant left to right shunting leads to increased flow across the tricuspid valve, resulting in a mid-diastolic flow murmur at the RLSB.

114

PR interval cutoff for 1st degree heart block

> 200msec

115

Uses of N-acetylcysteine

Mucus dissolution
Protection against contrast-induced renal failure
Acetaminophen overdose

116

2 murmurs that get softer with the handgrip maneuver

Aortic stenosis and hypertrophic cardiomyopathy

117

Murmurs that get louder with squatting and handgrip maneuvers?

These increase afterload and consequently increase the murmurs of AR, MR and VSD.

118

Lifestyle factor associated with the highest risk of AAA expansion and rupture

Smoking

119

Indications for endovascular or operative repair of AAA

Size > 5.5 or rapid expansion (>0.5cm in 6 months or >1cm in 1 year)

120

Differences between Mobitz I and II heart block

Mobitz I: progressive prolongation of PR leading to a dropped beat due to abnormality in AV node. Typically benign, improves with exercise/atropine, worsens with vagal maneuvers and has narrow QRS.

Mobitz II: random dropped beats without PR prolongation due to abnormality below AV node. Exercise/atropine worsen the block, vagal maneuvers improve it and these patients need a pacemaker.

121

Management of patients with renovascular hypertension/renal artery stenosis.

ACE-I/ARB, aspirin and aggressive risk factor reduction.

Renal artery stenting is reserved for those who are non-responsive to medical therapy, have flash pulmonary edema or refractory heart failure due to severe HTN.

122

Treatment of patients with sustained monomorphic VT

Unstable = electrical synchronized cardioversion

Stable = IV amiodarone (may also use procainamide or lidocaine)

123

Medications with mortality benefit for patients with CHF

Beta-blockers

ACE-I/ARBs

Spironolactone

124

ECHO in patients with cardiac amyloidosis

Ventricular wall thickening with normal sized chambers

125

Causes of secondary hypertension

Renal parenchymal disease: proteinuria, RBC casts and elevated serum Cr

Renovascular disease: severe HTN, age > 55, diffuse atherosclerosis, unilateral renal atrophy, resistant heart failure, flash pulmonary edema, abdominal bruit and elevated serum Cr

Primary aldosteronism: adrenal incidentaloma, hypokalemia and mild hypernatremia

Pheo: adrenal incidentaloma, paroxysmal tachycardia, headaches, flushing and diaphoresis

Cushing's: central obesity, plethora, proximal muscle weakness, abdominal striae, ecchymosis, amenorrhea/erectile dysfunction

Hypothyroidism: fatigue, dry skin, cold intolerance, constipation, weight gain and bradycardia

Primary hyperparathyroidism: stones, bones, abdominal moans and psych overtones with elevated Ca

Coarctation: brachial femoral pulse delay

126

Lab findings in patients with Cushing's

Hyperglycemia, hypokalemia, leukocytosis and lymphocytopenia

127

Next step for a young patient with a soft mid-systolic murmur

Reassurance

128

Meds used for cardiac stress testing

Dipyramidole and adenosine are coronary vasodilators that result in coronary steal from ischemic myocardium

129

High risk for thromboembolism threshold in patients with a-fib

A-fib lasting > 48 hours without adequate anticoagulation

130

CK-MB vs. troponin

CK-MB normalizes within 1-2 days, troponin takes 10 days to normalize