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USMLE Step 3 > Cardiology > Flashcards

Flashcards in Cardiology Deck (297):
1

most common cause of death in US

CAD

2

CAD risk factors (8)

1. diabetes mellitus
2. hypertension
3. tobacco use
4. hyperlipidemia
5. peripheral arterial disease (PAD)
6. obesity
7. inactivity
8. family history

3

what is considered "significant" in the family history of CAD?

- females > 65 years of age
- males > 55 years of age

4

chest pain that changes with RESPIRATION

pleuritic pain

5

causes of PLEURITIC chest pain

1. PE
2. pneumonia
3. pleuritis
4. pericarditis
5. pneumothorax

6

cause of chest pain that is tender to palpation

costochondritis

7

causes of POSITIONAL chest pain

pericarditis

8

clues that chest pain is ISCHEMIC in nature

1. dull pain
2. last 15-30 minutes
3. exertional
4. substernal location
5. radiates to jaw or left arm

9

S3 gallop indicates

DILATED left ventricle

10

mechanism of S3 gallop

rapid ventricular filling during diastole

11

mechanism of S4 gallop

atrial systole into a stiff or noncompliant left ventricle

12

S4 gallop indicates

left ventricular HYPERTROPHY

13

best INITIAL step in presentation of chest pain

ASPIRIN

14

which test is best to detect REINFARCTION a few days after initial infarction?

CK-MB

15

which cardiac enzyme rises first?

myoglobin

16

if initial EKG and/or enzymes do NOT establish diagnosis of CAD, next step

stress test

17

when should you order a dipyridamole or adenosine thallium stress test, or dobutamine echocardiogram?

patient can't exercise to target HR of > 85% of maximum

18

situations where patient won't be able to do an exercise stress test

1. COPD
2. amputation
3. deconditioning
4. weakness/previous stroke
5. LE ulcer
6. dementia
7. obesity

19

when should you answer exercise thallium testing, or stress echocardiography?

EKG is unreadable for ischemia

20

situations where EKG may be unreadable for ischemia

1. LBBB
2. digoxin use
3. pacemaker
4. LVH
5. baseline ST segment abnormality

21

next diagnostic test to evaluate an abnormal stress test

angiography

22

mechanism of thallium (nuclear isotope)

decreased uptake = damage

23

- causes acute chest pain
- can occur with exertion or at rest
- ST segment elevation, depression, or normal EKG
- NOT based on enzyme levels, angiography, or stress test results
- BASED ON h/o chest pain with features suggestive of ischemic disease

definition of acute coronary syndrome (ACS)

24

best initial therapy for all cases of ACS

ASPIRIN

25

benefit of using aspirin in ACS

instant effect of inhibiting platelets

26

can be given in ACS, but do NOT lower mortality

nitrates and morphine

27

added to aspirin for patients with ACUTE MI

clopidogrel or ticagrelor

28

only given when angioplasty is done

prasugrel

29

MOA of clopidoGREL, ticaGRELor, and prasuGREL

inhibit ADP activation of platelets

30

what LOWER MORTALITY in STEMI and are TIME DEPENDENT?

thrombolytics and PCI

31

PCI should be done within what timeframe of reaching the ER?

90 MINUTES

32

what if PCI cannot be done within 90 minutes?

thrombolytics

33

indications for thrombolytics

1. cannot perform PCI
2. chest pain for

34

thrombolytics should be done within what timeframe of reaching the ER?

30 MINUTES

35

mechanism of thrombolytics

ACTIVATE plasminoGEN into PLASMIN

(chops up fibrin strands into D-dimers)
(does nothing if already stabilized by factor XIII)

36

lower mortality in ACS, but is NOT time critical

beta blockers

37

should be given to ALL patients with ACS, but only lower mortality if there is LEFT VENTRICULAR DYSFUNCTION, or SYSTOLIC DYSFUNCTION

ACE inhibitors

38

should be given to ALL patients with ACS, regardless of EKG/enzyme levels

statins

39

ALWAYS lower mortality in ACS

1. aspirin
2. thrombolytics
3. angioplasty
4. metoprolol
5. statins
6. clopidoGREL/ticaGRELor/prasuGREL

40

lower mortality in ACS in CERTAIN CONDITIONS

1. ACE/ARBs inhibitors IF EF is LOW

41

do NOT lower mortality in ACS

1. oxygen
2. morphine
3. nitrates
4. calcium channel blockers (actually INCREASE; avoid!)
5. lidocaine
6. amiodarone

42

clopidoGREL or ticaGRELor is used in ACS when

- aspirin allergy
- patient undergoes angioplasty/stenting
- acute MI

43

calcium channel blockers are used in ACS when

- intolerance to beta blockers (e.g. asthma)
- cocaine-induced CP
- coronary vasospasm/Prinzmetal's angina

44

when do you use a pacemaker for AMI?

- 3rd degree AV block
- Mobitz II, second degree AV block
- bifasicular block
- NEW LBBB
- symptomatic bradycardia

45

when is lidocaine or amiodarone used for AMI?

- ONLY in Vtach, or Vfib

46

complications of myocardial infarction

1. cardiogenic shock
2. valve rupture
3. septal rupture
4. myocardial wall rupture
5. sinus bradycardia
6. third degree (complete) heart block
7. right ventricular infarction

47

diagnostic tests for cardiogenic shock

- echo
- Swan-Ganz (right heart) catheter

48

treatment for cardiogenic shock

- ACE inhibitor
- urgent revascularization

49

diagnostic test for valve rupture

echo

50

treatment for valve rupture

- ACE inhibitor
- nitroprusside
- intra-aortic balloon pump as bridge to surgery

51

diagnostic tests for septal rupture

- echo
- right heart cath showing STEP UP IN SATURATION FROM RIGHT ATRIUM TO RIGHT VENTRICLE

52

treatment for septal rupture

- ACE inhibitor
- nitroprusside
- urgent surgery

53

diagnostic test for myocardial wall rupture

echo

54

treatment for myocardial wall rupture

- pericardiocentesis
- urgent cardiac repair

55

diagnostic test for sinus bradycardia

EKG

56

treatment for sinus bradycardia

- atropine
- pacemaker IF there are STILL symptoms

57

diagnostic test for third-degree (complete) heart block

- EKG
- canon "a" waves

58

treatment for third-degree (complete) heart block

- atropine
- pacemaker EVEN IF symptoms resolve

59

diagnostic test for RIGHT ventricular infarction

EKG showing right ventricular leads

60

treatment for RIGHT ventricular infarction

fluid loading

61

ALL post-MI patients should go home on

1. aspirin
2. clopidoGREL, or prasuGREL
3. beta blocker
4. statin
5. ACE inhibitor

62

CAD + LDL > 100

give statins

63

LDL goal in ACS patient with DIABETES

< 70

64

CAD equivalents

1. DM
2. PAD
3. aortic disease
4. carotid disease

65

MC adverse effect of statins

LIVER TOXICITY

66

MC of post-MI erectile dysfunction

anxiety

67

MC of post-MI erectile dysfunction d/t medication

beta blockers

68

contraindicated with sildenafil (PDI's)

nitrates

69

CHF presentation

* SOB, especially on exertion, and...

- edema
- rales
- ascites
- jugular venous distention
- S3 gallop
- orthopnea (SOB when lying flat)
- paroxysmal nocturnal dyspnea (SOB attacks at night)
- fatigue

70

standard of care for pulmonary edema

1. oxygen
2. furosemide (preload reduction)
3. nitrates
4. morphine

71

non-ST segment elevation myocardial infarction treatment

1. no thrombolytics
2. low molecular weight heparin
3. glycoprotein IIb/IIIa inhibitors (lower mortality)

72

MOA of heparin

potentiates effect of antithrombin

73

improve mortality of chronic angina

aspirin and metoprolol

74

which medications should only be used in congestive heart failure, systolic dysfunction, or low ejection fraction?

ACE inhibitors or ARBs

75

AE of ACEI and ARBs

- hyperkalemia with both
- cough with ACEIs

76

when do you add ranolazine?

persistent chest pain

77

indications for CABG

1. THREE coronary vessels > 70% stenosis
2. left main coronary artery > 50-70% stenosis
3. TWO vessels in a DIABETIC
4. 2 or 3 vessels with LOW EF

78

mechanism of rales

increased HYDROSTATIC pressure in pulmonary capillaries --> transudation of liquid into alveoli --> "popping" sound during inhalation

79

MOA of carvedilol

antagonist of B1, B2, and a1 receptors

1. antiarrhythmic
2. anti-ischemic
3. antihypertensive

80

initial diagnostic tests for CHF patient

1. CXR
2. EKG
3. oximeter (maybe an ABG)
4. echo

81

what CXR shows in CHF patient

1. pulmonary vascular congestion
2. cephalization of flow
3. effusion
4. cardiomegaly

82

what EKG shows in CHF patient

1. sinus tachycardia
2. atrial and ventricular arrhythmia

83

what oximeter shows in CHF patient

1. hypoxia
2. respiratory alkalosis (from tachypnea)

84

what echo shows in CHF patient

distinguishes systolic vs diastolic dysfunction

85

possible causes of CHF

1. HTN
2. valvular heart disease
3. MI

86

MOA of imamRINONE and milRINONE

- PDE inhibitors
- increase contractility
- vasodilators= decrease AFTERload

87

MOA of dobutamine

- increase contractility
- vasoconstriction= increases AFTERload

88

clinical diagnosis of acute pulmonary edema

1. SOB
2. rales
3. S3 (splash)
4. orthopnea

89

right heart catheter results in acute pulmonary edema

- CO = decreased
- SVR = increased
- wedge pressure = increased
- RA pressure = increased

(wedge pressure = indirect LA pressure measurement)

90

treatment for SYSTOLIC dysfunction (low EF)

1. ACEI or ARB
2. metoprolol/carvedilol/bisoprolol
3. spironolactone/eplerenone
4. diuretic
5. digoxin

91

treatment for DIASTOLIC dysfunction (normal EF)

1. metoprolol/carvedilol/bisoprolol
2. diuretic

92

decreases mortality in patients with

- EF 120ms

biventricular pacemaker

93

exertional SOB: young female, general population

MVP

94

exertional SOB: healthy young athlete

HCM

95

exertional SOB: immigrant, pregnant

MS

96

exertional SOB: Turner's syndrome, coarctation of aorta

BICUSPID aortic valve

97

exertional SOB: palpitations, atypical chest pain NOT with exertion

MVP

98

possible PE findings in valvular heart disease

- peripheral edema
- carotid pulse findings
- gallops

99

all RIGHT-sided murmurs increase in intensity with

INhalation

100

all LEFT-sided murmurs increase in intensity with

EXhalation

101

ONLY 2 murmurs that become SOFTER with SQUATTING/leg raise

1. MVP
2. HCM

102

ONLY 2 murmurs that LOUDER with STANDING/Valsalva

1. MVP
2. HCM

103

which maneuver increases afterload?

handgrip

104

which murmurs are LOUDER with handgrip maneuver?

1. AR
2. MR
3. VSD

105

which murmurs are SOFTER with handgrip?

1. MVP
2. HCM

106

which medications decrease afterload?

1. amyl nitrate
2. ACEIs

107

which murmurs are LOUDER with amyl nitrate?

1. MVP
2. HCM

108

effect of handgrip on aortic stenosis

SOFTENS murmur

(less blood travels from LV to aorta)

109

effect of amyl nitrate on aortic stenosis

makes it LOUDER

(decreases afterload)

110

AS is best heard where and radiates where?

- 2nd RIGHT intercostal space
- carotid arteries

111

pulmonic valve murmurs are best heard where?

2nd LEFT intercostal space

112

AR, tricuspid murmurs, and VSD are best heard where?

LLSB

113

MR is best heard where and radiates where?

- apex (5th intercostal space)
- axilla

114

best INITIAL test for valvular heart disease

ECHO

115

MOST ACCURATE test for valvular heart disease

left heart catheterization

116

best treatment for REGURGITANT lesions

VASODILATORS

(ACEIs, ARBs, or nifedipine)

117

best treatment for STENOTIC lesions

anatomic repair

118

Valsalva improves murmur

diuretics indicated

119

handgrip makes it worse/amyl nitrate improves murmur

ACEI indicated

120

best treatment for mitral stenosis

balloon valvuloplasty

121

best treatment for severe aortic stenosis

aortic valve replacement

122

- chest pain/syncope
- older
- h/o HTN

AS

123

prognosis of AS

- CAD = 3-5-year average survival
- syncope = 2-3-year average survival
- CHF = 1.5-2-year average survival

124

mechanism of syncope/angina in AS

blocked flow with increased demand = chest pain

125

AS murmur description and location it's best heard

- crescendo-decrescendo
- 2nd RIGHT intercostal space radiating to CAROTIDS

126

mechanism of crescendo-decrescendo murmur of AS

- isovolumetric contraction = no blood moving = no murmur
- mid-systole = peak flow = peak noise

127

best INITIAL test for AS

TTE

128

MORE ACCURATE test for AS

TEE

129

MOST ACCURATE test for AS

left heart catheterization

130

normal aortic valve pressure gradient

ZERO

131

mild AS pressure gradient

< 30mmHg

132

moderate AS pressure gradient

30-70mmHg

133

severe AS pressure gradient

> 70mmHg

134

best INITIAL therapy for AS

diuretics

(don't improve long-term prognosis)
OVERDIURESIS IS DANGEROUS

135

treatment of choice for AS

valve replacement

136

when do you balloon dilate AS?

ONLY when patient can't tolerate surgery

137

how long do bioprosthetic valves last?

about 10 years

138

how long do mechanical valves last?

15-20 years

need to be on warfarin with INR of 2-3

139

causes of AR

- HTN
- rheumatic heart disease
- endocarditis
- cystic medial necrosis

140

MC presentation of AR

1. SOB
2. FATIGUE

141

AR murmur description and location it's best heard

- diastolic decrescendo murmur
- LEFT sternal border

142

Quincke pulse

arterial or capillary pulsations in FINGERNAILS

143

Corrigan's pulse

high bounding pulses

("water-hammer" pulse)

144

Musset's sign

head bobbing with pulse

145

Duroziez's sign

murmur heard over femoral artery

146

Hill's sign

BP gradient much higher in LE's

147

best INITIAL test for AR

TTE

148

MORE ACCURATE test for AR

TEE

149

MOST ACCURATE test for AR

left heart catheterization

150

best INITIAL therapy for AR

- ACEI/ARB, or nifedipine

- and loop diuretic

151

when do you do SURGERY for AR?

(EVEN IF PATIENT IS ASYMPTOMATIC)

- EF 55mm

152

why does high pressure dilate aortic valve?

LaPlace's law

tension = radius x pressure

153

MCC of MS

rheumatic fever

154

special features of MS

1. dysphagia (LA pressing on esophagus)
2. hoarseness (pressure on recurrent laryngeal nerve)
3. a-fib (stroke)

155

mechanism of increased MS symptoms in pregnancy

- 50% increase in plasma volume
- more volume = more pressure, backflow, and symptoms
- ADH levels higher

156

MS murmur description

diastolic RUMBLE after OPENING SNAP

(opening snap moves closer to S2 as mitral stenosis worsens)

157

mechanism of opening snap earlier in worsening MS

worse MS = higher LA pressure = mitral valve opens earlier

(mitral valve opens when LA pressure > LV pressure)

158

best INITIAL test for MS

TTE

159

MORE ACCURATE test for MS

TEE

160

MOST ACCURATE test for MS

left heart catheterization

161

CXR findings for MS (mitral stenosis)

- straightening of left heart border
- elevation of left mainstem bronchus

162

best INITIAL therapy for MS

diuretics

163

most effective therapy for MS

balloon valvuloplasty

164

is pregnancy a contraindication to do balloon valvuloplasty in MS?

NO

165

causes of MR

1. HTN
2. ischemic heart disease
3. any condition leading to dilation of heart

166

S3 gallop can be normal in which patients?

age

167

MC complaint in MR

exertional dyspnea

168

MR murmur description and location it's best heard

- holosystolic murmur that obscures S1 and S2
- apex radiating to axilla

169

best INITIAL test for MR

TTE

170

MORE ACCURATE test for MR

TEE

171

best INITIAL treatment for MR

- ACEI/ARB, or nifedipine

172

when do you do SURGERY for MR?

(EVEN IF PATIENT IS ASYMPTOMATIC)

- LVEF 40mm

173

VSD murmur description

- holosystolic murmur
- LLSB

174

complaint in VSD

SOB

175

diagnostic test for VSD

echo

176

used to determine degree of left-to-right shunting

catheterization

177

VSD treatment

mechanical closure if severe

178

- holosystolic murmur at LLSB
- SOB
- parasternal heave

VSD

179

- FIXED splitting of S2
- SOB
- parasternal heave

ASD

180

mechanism of fixed splitting of S2 in ASD

equal pressure between LA and RA = no change in splitting

181

test for ASD

echo

182

treatment for ASD

percutaneous or catheter repair

183

when is ASD repair most often indicated?

if shunt ratio exceeds 1.5:1

184

WIDE splitting of S2 (P2 delayed) causes

- RBBB
- pulmonic stenosis
- RVH
- pulmonary HTN

185

PARADOXICAL splitting of S2 (P2 delayed) causes

- LBBB
- AS
- LVH
- HTN

186

FIXED splitting of S2

ASD

187

best INITIAL test for DILATED cardiomyopathy

echo

(check EF and wall motion abnormality)

188

MC causes of dilated CMP

- ischemia (MOST COMMON)
- alcohol
- adriamycin
- radiation
- Chagas' disease

189

treatment for DCMP

1. ACEI/ARB
2. BB
3. spironolactone/eplerenone (decrease work of heart)

190

- exertional SOB
- S4 gallop

hypertrophic cardiomyopathy

191

best INITIAL test for HYPERTROPHIC cardiomyopathy

echo

(shows normal EF)

192

treatment for HCMP

1. BB
2. diuretics

193

possible causes of RESTRICTIVE cardiomyopathy

- sarcoidosis
- amyloidosis
- hemochromatosis
- cancer
- myocardial fibrosis
- glycogen storage diseases

194

- exertional SOB
- Kussmaul's sign (increase in jugular venous pressure on inhalation)

restrictive cardiomyopathy

195

- low-voltage EKG
- speckled pattern on echo

amyloidosis

196

what does cardiac catheterization show in RCMP?

rapid x and y descent

197

what does EKG show in RCMP?

low voltage

198

mainstay of diagnosis of RCMP

echo

199

MOST ACCURATE test for RCMP

endomyocardial biopsy

200

treatment for RCMP

1. diuretics
2. correct underlying cause

201

- pleuritic chest pain (changes with respiration)
- positional chest pain (better when sitting up/leaning forward)
-pain is SHARP, and BRIEF

pericarditis

202

only pertinent positive PE finding for pericarditis

FRICTION RUB

203

best INITIAL diagnostic test for pericarditis

EKG

(GLOBAL ST elevation)
(PR segment depression in lead II is pathognomonic)

204

best INITIAL treatment for pericarditis

NSAID

205

treatment for pericarditis if pain persists after NSAID

prednisone

206

- SOB
- hypOtension
- jugular venous distention
- lungs CTA
- PULSUS PARADOXUS (BP decrease > 10mmHg on INhalation)
- ELECTRICAL ALTERNANS (alternating QRS complex heights)

pericardial tamponade

207

mechanism of pulsus paradoxus

inhale = big RV = smaller LV = BP drop > 10mmHg

208

MOST ACCURATE test for pericardial tamponade

echo

209

finding on echo in pericardial tamponade

diastolic collapse of RA and RV

210

right heart catheterization findings of pericardial tamponade

EQUALIZATION of ALL pressures in heart during systole

211

best INITIAL treatment for pericardial tamponade

pericardiocentesis

212

MOST EFFECTIVE treatment for pericardial tamponade

pericardial window placement

213

MOST DANGEROUS thing to give a patient with pericardial tamponade

diuretics

214

- SOB
- signs of chronic right heart failure (edema, JVD, hepatosplenomegaly, ascites)
- Kussmaul's sign (increase in JVD on INhalation)
- PERICARDIAL KNOCK (extra diastolic sound from heart hitting calcified thickened pericardium)

constrictive pericarditis

215

what does CXR show in constrictive pericarditis?

calcification

216

what does EKG show in constrictive pericarditis?

low voltage

217

what does CT and MRI show in constrictive pericarditis?

thickening of pericardium

218

best INITIAL treatment for constrictive pericarditis

diuretic

219

MOST EFFECTIVE treatment for constrictive pericarditis

surgical removal of pericardium

220

- chest pain radiating to back between scapula
- CP is INITIALLY very severe and "ripping"
- difference in BP between RIGHT and LEFT arms

dissection of thoracic aorta

221

best INITIAL test for dissection of thoracic aorta

CXR showing WIDENED MEDIASTINUM

222

MOST ACCURATE for dissection of thoracic aorta

CTA

223

INITIAL treatment for dissection of thoracic aorta

beta blocker, and get EKG/CXR

224

further management of dissection of thoracic aorta

1. order CTA = TEE = MRA
2. start nitroprusside

225

MOST EFFECTIVE treatment for dissection of thoracic aorta

surgery

226

screening US of abdominal aorta should be done in?

MEN OVER 65 who are current or were former SMOKERS

227

when do you repair AAA?

> 5cm

228

- claudication (pain in calves on exertion)
- "smooth, shiny skin" with loss of HAIR and SWEAT GLANDS
- loss of pulses in feet

PAD

229

best INITIAL test for PAD

ankle-brachial index (ABI)

230

what is a NORMAL ankle-brachial index (ABI)?

greater than or equal to 0.9

> 10% difference = OBSTRUCTION

231

MOST ACCURATE test for PAD

angiography

232

best INITIAL treatment for PAD

1. aspirin
2. BP control with ACEI
3. exercise as tolerated
4. cilostazol
5. statin with LDL goal

233

PAIN + PALLOR + PULSELESS =

ARTERIAL OCCLUSION

234

- SUDDEN onset loss of pulse and COLD extremity
- painful
- can have h/o AS or atrial fibrillation

acute arterial embolus

235

are beta blockers contraindicated with PAD?

NO

236

mechanism of why CCB don't work in PAD

CCB dilate muscular layer EXterior to atherosclerotic clot which is INterior

237

perform surgical bypass in PAD when

signs of ischemia:
- gangrene
- pain at REST

238

- palpitations
- IRREGULAR pulse
- h/o HTN, ischemia, or CMP

a-fib

239

initial test for atrial fibrillation

- telemetry monitoring as INpatient
- Holter monitoring as OUTpatient

240

other tests to order once atrial fibrillation is diagnosed

1. echo: looking for clots, valve function, LA size
2. TFT: TSH, T4
3. electrolytes: K+, Mag2+, Ca2+
4. troponin/CK

241

UNSTABLE patient with atrial fibrillation

(unstable = SBP

SYNCHRONIZED electrical cardioversion

242

STABLE patient with atrial fibrillation

slow ventricular HR if > 100-110

243

which medications can be given for atrial fibrillation to control the rate?

- beta blockers (metoprolol/esmolol)
- calcium channel blockers (diltiazem)
- digoxin

should be given IV

244

next best step in patient with a-fib, that's rate controlled

warfarin with goal INR of 2-3

245

other PO AC's for a-fib besides warfarin

- dabigatran (direct THROMBIN inhibitor)
- rivaroxaban (factor Xa inhibitor)
- apixaban (factor Xa inhibitor)

246

CHADS2Vasc

(indicates need for warfarin)

CHF +1
HTN +1
Age
≥ 75 +2
DM +1
Stroke/TIA/Thromboembolism +2
Vascular Disease +1
Age
> 65-74 +1
Female +1

247

- palpitations
- REGULAR rhythm

atrial flutter

248

atrial fibrillation/atrial flutter WITH:

- ischemic heart disease
- migraines
- Graves disease
- pheochromocytoma

beta blockers (metoprolol)

249

atrial fibrillation/atrial flutter WITH:

- asthma
- migrains

calcium channel blockers (diltiazem)

250

atrial fibrillation/atrial flutter WITH:

- borderline hypOtension

digoxin

251

- atrial arrhythmia IN ASSOCIATION WITH COPD/EMPHYSEMA
- tachycardia (HR > 100)

multifocal atrial tachycardia (MAT)

252

MAT EKG finding

POLYMORPHIC P waves

253

treatment for MAT

1. oxygen FIRST
2. THEN diltiazem

254

do NOT use what in MAT?

beta blockers

255

- palpitations and tachycardia
- occasionally syncope
- NOT associated with ischemic heart disease
- REGULAR RHYTHM WITH VENTRICULAR RATE OF 160-180

supraventricular tachycardia (SVT)

256

diagnostic tests for MAT

- EKG first
- if EKG is negative, Holter monitor or telemetry

257

best INITIAL management for UNSTABLE patients

synchronized cardioversion

258

best INITIAL management for STABLE patients

vagal maneuvers

- carotid sinus massage
- ice immersion of the face
- Valsalva

259

NEXT BEST step in management if vagal maneuvers do NOT work

IV adenosine

(most frequently asked SVT question)

260

best long-term management

radiofrequency catheter ablation

261

- SVT that can alternate with ventricular tachycardia
- WORSENING of SVT after use of CCB or digoxin

Wolff-Parkinson-White syndrome (WPW)

262

diagnosis of WPW

DELTA WAVE on EKG

263

MOST ACCURATE test for WPW

electrophysiologic studies

264

best INITIAL treatment for WPW

procainamide

265

best long-term treatment for WPW

radiofrequency catheter ablation

266

mechanism of WPW

neutralized cardiac muscle going around AV node creating aberrant pathway

267

- palpitations
- syncope
- chest pain
- sudden death

ventricular tachycardia (VT)

268

if EKG does not detect VT then

telemetry monitoring

269

MOST ACCURATE diagnostic test for VT

electrophysiologic studies

270

treatment for VT in patient that hemodynamically STABLE

- amiodarone
- lidocaine
- procainamide
- magnesium

271

treatment for VT in patient that hemodynamically UNSTABLE

synchronized cardioversion

272

sudden death

ventricular fibrillation (VF)

273

diagnosis of loss of pulse/VF

EKG

274

treatment for VF

ALWAYS UNsynchronized cardioversion first

275

mechanism for need of synchronization

- T-wave represents refractory period
- electrical shock delivered during the T-wave can set off a WORSE rhythm; VF, and ASYSTOLE

276

BLS for VF

1. continue CPR
2. defibrillate (UNsynchronized cardioversion)
3. IV epinephrine/vasopressin
4. defibrillate (UNsynchronized cardioversion)
5. IV amiodarone/lidocaine
6. defibrillate (UNsynchronized cardioversion)

repeat CPR between each shock

277

management of syncope is based on 3 criteria

1. was the loss of consciousness SUDDEN or GRADUAL?
2. was the regaining of consciousness SUDDEN or GRADUAL?
3. is the cardiac exam NORMAL or ABNORMAL?

278

if syncope onset was GRADUAL, possible causes could be?

- toxic-metabolic
- hypoglycemia
- anemia
- hypoxia

279

if syncope onset was SUDDEN, next question is?

was the regaining of consciousness SUDDEN or GRADUAL?

280

if return to consciousness onset was GRADUAL, possible causes could be?

neurological etiology (seizures)

281

if return to consciousness onset was SUDDEN, next question is?

is the cardiac exam NORMAL or ABNORMAL?

282

if cardiac exam is ABNORMAL, possible causes could be?

structural heart disease:

- aortic or mitral stenosis
- HCM
- mitral valve prolapse (rare)

283

if cardiac exam is NORMAL, possible cause could be?

ventricular arrhythmia

284

diagnostic tests for syncope evaluation

- cardiac/neurological exam
- EKG
- chemistries (looking at glucose, and electrolytes)
- oximeter
- CBC (looking for anemia)
- cardiac enzymes

285

in evaluation of syncope, if murmur is present

order an echo

286

in evaluation of syncope, if the neuro exam is FOCAL, or there's h/o head trauma

order CTH

287

in evaluation of syncope, if headache is described

order CTH

288

in evaluation of syncope, if seizure is described, OR SUSPECTED

order CTH and EEG

289

mechanism of syncope

ONLY BRAINSTEM stroke can cause syncope (controls sleep/wake in brain)

290

further evaluation of syncope if diagnosis is still unclear after INITIAL tests

- Holter monitor as outpatient
- telemetry monitor as inpatient
- repeat cardiac enzymes
- urine/blood toxicology

291

if etiology of syncope is STILL NOT clear

- tilt table test (to diagnose neurocardiogenic (vasovagal) syncope)
- EP testing

292

treatment for syncope

based on etiology

(but most cases lack specific diagnosis)

293

if ventricular dysrhythmia is diagnosed as etiology of syncope, what is indicated?

implantable cardioverter/defibrillator

294

role of colchicine in pericarditis

adds efficacy to NSAIDs and prevents recurrent episodes

295

at what CHADS2Vasc score should a pt be started on warfarin, and should the pt be bridged on heparin?

- 2, or more points

- NO!

296

heart failure is primarily a clinical diagnosis:

name the MAJOR criteria

need either, 2 major criteria, or 1 major and 2 minor

1. paroxysmal nocturnal dyspnea (PND)
2. orthopnea
3. raised jugular venous pressure (JVP)
4. third heart sound
5. increased cardiac silhouette on CXR
6. pulmonary vascular congestion on CXR

297

heart failure is primarily a clinical diagnosis:

name the MINOR criteria

need either, 2 major criteria, or 1 major and 2 minor

1. B/L LE edema
2. nocturnal cough
3. exertional dyspnea
4. tachycardia
5. presence of pleural effusion
6. hepatomegaly