Cardiology

Question 1

IHD

The single most dangerous factor for cad

Answer 1

The single most dangerous factor for cad is diabetes

Question 2

Physical exam for cp

Answer 2

CV: S3: dilated left ventricle
S4: LVH
Jugulovenous distention**
Holosystolic murmur of mitral regurgitation

Chest rakes
General. Distressed, sob, clutching chest
Ext Edema

Question 3

CAD

the best initial diagnostic test

Answer 3

EKG is Always the best initial diagnostic test but

But if you had to choose btw ekg or meds. You do meds.

Question 4

What is the most accurate test for cp

Answer 4

CK-MB Or troponon

Question 5

WhAt is the best test for reinfarction

Answer 5

Ck mb

Question 6

What is always the wrong answer

Answer 6

LDH level

LDH isoenzymes

Question 7

Which of the following cardiac enzymes rise first

Answer 7

Myoglobin.

Question 8

When is stress test the answer

Answer 8

• when the case is NOT acute

- when the initial ekg and or enzyme do NOT establish the dx

Question 9

When do I Answer dipyramidole stress test or adenosine thallium stress test or dobutamine echo

Answer 9

Ppl who can not exercise > 85% maximin
COPD
amputation 
Deconditioning
Obesity 
Dementia
Lower extremity ulcer 
Weakness of previous stroke 

No caffeine 24 hours before dypiramidole

The adverse s/e of dypiramidole (HA, cp, bronchoconstriction) can be reversed with aminophylline

Question 10

When use Sestamibi nuclear stress. Test

Answer 10

Obesity

Large breasts

Question 11

Reversible ischemia next dx step

Answer 11

Angiography

Question 12

When is coronary bypass the answer

Answer 12

When angiography has been done

Question 13

Most accurate test to evaluate EF

Answer 13

Nuclear ventriculogram

Question 14

Clopidogrl And ticagrelor given when

Answer 14

Added to aspirin for acute mi

Question 15

When give prasugrel

Answer 15

When angioplasty is done

Question 16

prasigrel
Clopidogrel
Ticagrelor
Added when

Answer 16

When people get an angioplasty or stent

Question 17

Which treatments lower mortality in stemi

Answer 17

Thrombolytics
Primary angioplasty

-**they are Very dependent on time

Question 18

Clopidogrel
Ticagrelor
Prawugrel* also a little tidbit
They are used when

Answer 18

Aspirin allergy
Pt undergoes angioplasty and stenting

PrAsugrel has more efficacy than clopidogrel but causes more BLEEDING

Question 19

Prasugrel increases bleeding in

Answer 19

Age > 75

Weight <60 kg

Question 20

When is pacemakers the answer for acute MI

Answer 20

Third degree block
Second degree AV block, Mobitz type II 
Bifascicular block
New LBBB
Sympyomatic bradycardia

Question 21

When is Lidocaine or Amiodarone the answer for acute MI

Answer 21

ONLY when there is v tach or v fib

Do not give them to prevent v arrhythmia

Question 22

Complications of MI

Cardiogenic shock
Valve rupture 
Septal rupture 
Myocardial wall rupture 
Sinus bradycardia 
Third degree complete heart block 
Right ventricular infarction

Answer 22

Complications of MI

Cardiogenic shock( echo; swan ganz catheter. ACE I and urgent revascularization
Valve rupture : Echo. Ace, nitroprisside, intra aortic balloon pump as a bridge to Sx
Septal rupture : Echo, right heart caty. Ace, nitroprusside, urgent Sx
Myocardial wall rupture : Echo. Periocardecentisis and urgent cardiac repairing ir
Sinus bradycardia - EakG. Atropine followed by pacemaker if still symptomatic
Third degree complete heart block - ekg, canon “a” waves… atropine and pacemaker even if still symptomatic
Right ventricular infarction -( e fluid load

Question 23

NSTEMI

Answer 23

No thrombolytic use

LMWH»> unfractionated heparin

GpIib/IIIa inhibitors like abciximab
Tirofiban
Eptifibitide lower mortality especially in those undergoin angioplasty

The single greatest benefit of these meds come with a combination of angioplasty and stents

Question 24

Difference between saphenous vein graft and ima

Answer 24

Svg only good for 5 years

Ima good for 10 yesrs

Question 25

Indications for CABG

Answer 25

Three coronary vessels >70% Left MCA with >50-70% stenosis 2 vessels in diabetics 2-3 vessels with low EF

Question 26

Ranolazine

Answer 26

Anti angina med | Added if other meds do not control pain

Question 27

Give lipids! Strongest indication

Answer 27

CAD + LDL> 100

Question 28

Diabetic LDL goal

Answer 28

< 70

Question 29

Risk Fx for Lipid Tx

Answer 29

``` Cigarette smoke Family Hx ( male<55, women <65) High BP 140/90 Low HDL< 40 Age >55 females , <45 in males ```

Question 30

CAD equivalentS

Answer 30

Diabetes PAD Aortic disease CArotid disease

Question 31

Sex and the heart

Answer 31

Anxiety >> bb as the mcc of ED post infarction Stop nitrates if starting sildenafil

Question 32

CHF sounds

Answer 32

S3; splash | S4: bang

Question 33

Pulmonary edema CCS tip

Answer 33

Tx: Oxygen, furosemide; nitrates and morphine This is the worst manifestation of CHF Ccs; move clock forward only 15-30 and this is a perfect example that all tests and Tx should be ordered at the same time minutes if there is no response to Tx after moving forward the clock, add a Positive inotrope like dobutamine, inamrinone Or milrinone

Question 34

Blue box for pulmonary edema

Answer 34

All cases of pulmonary edema and MI need to be placed in the ICU

Question 35

Important question * What to do when you have v tach assd with pulmonary edema

Answer 35

Synchronized cardioversion—> v tach assd with pulmonary edema Or Afib, flutter or svt Unsyncuronized cardioversion•”—> v fib or v tach with no pulse Anti arrhythmic•> v tach in someone who is hemodynamics stable

Question 36

When nesitiride the answer?

Answer 36

Acute pulmonary edemaa Preload reduction. It’s a synthetic version of anp

Question 37

Pulmonary edema parameters

Answer 37

CO is decreased SVR is increased Wedge pressure is increased RAP music is increased

Question 38

Hypovolemic shock parameters

Answer 38

Decreased CO Increased SVR Decreased wedge pressure Decreased rap

Question 39

Septic shock parameters

Answer 39

Increased co Decreased SVR Decreased wedge pressure Decreased rap

Question 40

Pulmonary hypertension parameters

Answer 40

Decreased co Increased SVR Decreased wedge pressure Increased rAp

Question 41

Spirinolone gives gynecomastia and ED. Anti androgenic | Switch to what?

Answer 41

Epleronone

Question 42

Diastolic dysfunctions Tx?

Answer 42

Bb and diuretics ACe I have not been shown to help do not give spirinolactone or digoxin

Question 43

EF below 35

Answer 43

Implantahle cardioverterz/ defribillayor

Question 44

Systolic dysfunction with low EF

Answer 44

``` Ace I Bb Spirinolactone / epleronone Diuretics Digoxin ```

Question 45

Mcc death in CHF

Answer 45

arrhythmia

Question 46

Single most important fact about CHF inv further mgmt

Answer 46

Mortality decreased by ace, B.B., and spirinolactone | Digoxin decrees Sx but not lower mortality

Question 47

When is biventricular pacemaker the answer

Answer 47

When EF <35 and qrs> 120 msec

Question 48

When is warfarin the answer for CHF

Answer 48

Never | Wrong answer

Question 49

What is an absolute CI to use of bb

Answer 49

Symptomatic bradycardia

Question 50

Systolic murmurs Diastolic murmurs Right sided murmurs Left sided

Answer 50

Systolic murmurs; As, MR, mvp, and HOCM Diastolic murmurs: AR and MS Right sided murmurs : Inc with inhalation Left sided murmurs: inc with exhalation

Question 51

Maneuvers on valvular disorders

Answer 51

Most murmurs get louder with squatting or leg raise. You increase venous return Like … AS, AR, MS, MR and right sided lesions m Only 2 that become softer! Is hocm and mvp Opposite for valsava and standing

Question 52

Effect of handgrip on murmurs

Answer 52

Increases afterload which is what ace does So… AR, MR, murmurs worsen and get louder VSD same thing

Question 53

Table of handgrip vs amyl nitrate

Answer 53

``` They have the opposite effect Handgrip (? Increased aftefload) - AS decreased -AR increased - MS negligible - MR increased m - VSD increased - HOCM and Mvp decreased ``` ``` Amyl nitrate ( decreased afterload) AS increased AR decreased MS negligible MR decreased VSD decreased HOCM and mvp increased ```

Question 54

Valvular lesions Best initial test Most accurate test

Answer 54

Echo... order TTE first on CCS then tee Left heart cath For ccs, order CXR and ekg

Question 55

Regurgitate lesions tx Stenotic lesions tx

Answer 55

Vasodilator therapy like ace, ARBs or nifedipine Stenotic lesions need anatomical repair MS needs balloon valvuloppasty even if pregnant Valsava Improves murmur—> diuretics Amyl nitrate improves murmur —> ACe

Question 56

AS

Answer 56

Presents with cp*, CHF Sx And syncope Old patient with HTN Coronary disease—> 3-5 year survival Syncope: 2-3 year survival CHF: 1.5-2 year survival Increased intensity with leg raises, squatting and amyl nitrate Decreased intensity with vAlsava, handgrip and standing Also case may describe delayed carotid upstroke Dx: best initial is TTE More accurate is tee and left heart cath is most accurate test. Good for aortic pressure gradient

Question 57

Normal aortic valve gradient is…

Answer 57

Zero

Question 58

AR

Answer 58

Causes: HTN, rheumatic heart disease, endocarditis, cystic medial necrosis Mmc presentation: sob and fatigue Diastolic decresxendo murmur beard best at the left sternal border Quinckes pulse: capillaries pulsations in the fingernails Mussets sigh: head bobbing up and down with each pulse Hill sign: bp gradient much higher in Le Corrigans pulse: high bounding pulse . Aka water hammer pulse Duroziez sign: murmur heard over femoral artery ``` Dx: Best initial test TTE More accurate is tee Most accurate app is left heart cath For ccs, choose CXR and ekg ``` Tx: Ace arbs and nifedipine are best initial therapy For ccs, add loops EF>55 Or LVESD <55= surgery

Question 59

MS

Answer 59

MCC is rheumatic fever Pregnant immigrant Sx: dysphagia Hoarseness A fib Diastolic rumble after an opening snap ``` Murmur increases in intensity with leg raising, squatting and expiration DX Best initial TTE More accurate is tee Most accurate left heart cath Ccs, order ekg and cxr (LAH, straights of the left heart border and elevation of the left main stem bronchus Tx:best initial diuretics Most effective is balloon valvuloplasty ```

Question 60

MR

Answer 60

HTN, IHD,And any condition that dilates the heart Mc Sx is DOE Holosystolic murmur that obscures S1 And S2. Best heArd at the apex and radiates to the axilla S3 gallop- when fluid overload states like CHF it MR* Murmur increases in intensity with leg raising, squatting or handgrip ( same as AR) Standing valsava And amyl nitrate decrease intensity Best initial test TTE More accurate tee Treatment is same as A Regurgitation Ace, arbs, and nifedipine Inc ccs, Add loops Sx when EF< 60 or lvesd > 40 mm

Question 61

VSD

Answer 61

Asymptomatic: holosystolic murmur At LLSB Large defects: sob Murmur increases in intensity with leg raising squatting and exhalation ( just like MS) Dx first test echo More accurate cath Tx mild defects don’t need mechanical closure

Question 62

ASD

Answer 62

Small ASDs are asymptomatuc Large ones—> sob and parasternAl heave *** fixed splitting of S2. Most important * step 3 tests this Dx with echo Tx percutaneous or catheter devices Repair — >1.5:1

Question 63

Wide P2 delayed

Answer 63

RBBB PS RVH Pulmonary HTN

Question 64

Paradoxical A2 delayed

Answer 64

LBBB LVH AS HTN

Question 65

Dilated cardiomyopathy

Answer 65

Presents And managed just like CHF so treat with ace, ARBs, B.B. and spirinolactone MCC: ischemia , Alcohol, Adriamycin, radiation and chagas

Question 66

HOCM

Answer 66

Sob and S4 gallop ( LVH and decreased compliance of Ventricle) Echo shows normal EF Tx B.B. and diuretics

Question 67

Restrictive cardiomyopathy

Answer 67

Sob, as with All cardiomyopathy And kussmauls sign Mainstay of diagnosis: - Echo - Most accurate is endomyocardial biopsy - Cath shows rapid x and y descent Amyloid: low voltage on ekg Speckled pattern on echo Tx: diuretics abd treat the underlying cause.

Question 68

Pericarditis Dx Tx

Answer 68

Best initial test EKG - shows diffuse ST elevTion And PR depression Tx is with nsaids+ colchicine Advance the clock 1-2 daysand go to the office and add prednisone orally * advance clock again 1-2 days

Question 69

Pericardial tamponade

Answer 69

On ccs, also examine the lungs Pulsus paraxodus! Electric Alternans on ekg! Dx Best initial : EKG shows low voltage and electric alternans Most accurate echo Right heArt cAth shows equalization of pressures during diastole Tx Best initial therapy pericardiocentesis Most effective therapy is pericardial window placement Most dangerous therapy diuretics

Question 70

Constrictive pericarditis

Answer 70

``` Sob and sign of righ heart failure like… Edema Hepatodplenomegaly Ascites Jvd ``` Pericardial knock! Kussmaul sign! Dx test CXR EKG CT and mri Tx Best initial: diuretic Most effective: surgical removal of the pericardium

Question 71

Aortic dissection

Answer 71

Best initial test CXR Most accurate test ct angio Tx B.B. Order B.B. with ekg and CXR. Move the clock forward then and order… No matter what the ekg shows order… Ct angio = tee= mra Then give Nitroprusside! to control the bp All cases need to go to the icu and a surgical consultation will be needed

Question 72

PAD Dx Tx Ccs tip

Answer 72

Best initial test ABI Most accurate test angio Tx Aspirin ACEi Cilolastazol Exercise as tolerated lipid control with goal <100 Ccs tip: move the clock forward several weeks to see if meds are working and if the pain progresses—> surgical bypass Marginally effective Pentoxifylline Not helpful ca blockers

Question 73

Spinal stenosis

Answer 73

Pain that’s worse walking downhill and better when walking uphill or sitting or cycling Pulses and skin exam are normal

Question 74

Arterial occlusion

Answer 74

Pain + pallor. + pulseless = Arterial occlusion

Question 75

arterial embolus Which 2 condition seen with this

Answer 75

AS and A fib

Question 76

A fib Dx Ccs tip Tx

Answer 76

Dx EKG IP—> telemetry OP—> holter Ccs tip Order: Echo, TSH and T4, electrolÿtes, trop Or ck-mmb Tx: Stable—>rate control with iV B.B., diltoazem or digixin Once rAte is controlled—> anticoagulation with warfarin, dabigatran to INR 2-3 Unstable ( bp less than 90, CHF, or confusion or cp ``` Use chads score C: CHF H: HTN A: Age > 75 D/: diabetes S: stroke/TIA ``` Score 0-1—> Aspirin Score >_ 2•> warfArin, dabihAtran, rivaroxoban, apixAvban ** bridging with heparin is the WRONG answer

Question 77

Multfocal Atrial Tachycardia (MAT)

Answer 77

Polymorphic p waves in association with COPD/emphysema. Tx oxygen first then diltiazem Do not give B.B. **

Question 78

SVT Dx Tx Ccs tip

Answer 78

Dx if ekg doesn’t show svt—> holter monitor or telemetry Best initial Tx unstable patients —> synchronized cardioversion Stable_-> vagal maneuvers If vAgal maneuvers don’t work —> IV adenosine ** Best long term treatment —> radiofrequency catheters ablAtion Ccs—> all causes of dysrhythmia need TTE

Question 79

WPW

Answer 79

Svt that can alternate with v tach * worsening of svt with Ca channel blockers or digoxin Best initial test ekg showing delta waves! Most accurate test electrophysiological studies Best initial therapy procainamide!!! IF the svt or v tach is from wpw - best long term therapy is radio frequency catheter ablation

Question 80

V tach Presentation Dx Tx

Answer 80

Palpitations Syncope Cp Sudden death Best initial test ekg If ekg doesn’t show —> telemetry Most accurate is electrophysiological studies Tx unstable—> synchronized cardioversion Stable _—> amiodarone, lidocaine, procainamide Magnesium

Question 81

V fib Presents Dx Tx

Answer 81

Presents as sudden death Dx ekg Tx unsynchronized cardioversion!!

Question 82

Syncope What to order

Answer 82

- CBC (anemia) - bmp (glucose): hypoglycemic seizure - pulse ox ( hypoxia) - cardiac enzymes (ck mb or troponin - ekg! - echo - head ct - cardiac and neurological exams

Question 83

Syncope Ccs tip

Answer 83

Move the clock forward to get initial test results OP—> holter monitory IP—> telemetry Repeat ck mb or troponin Urine and blood tox screen If etiology is not clear, move the clock forward and order: ``` Holter Telemetry urine tox repeat cardiac enzymes Tilt table Electrophysiological studies ``` ``` Bottom line on ccs, order: EKG Echo Cardiac enzymes Head ct ```

Question 84

PAD Tx

Answer 84

``` Aspirin ACE inhibitor Exercise Cilostazol Statins ``` Marginally effective: pentoxifylline! Ineffective: Ca channel blocker

Question 85

S3 atrial gallop

Answer 85

S3—> fluid overload like … CHF or MR But Normal in patients <30

Question 86

MR Rx

Answer 86

Ace, arbs And nifedipine For ccs add a loop Surgery —>LVEF is < 60 or LVESD > 40 mm

Question 87

AR Tx

Answer 87

Ace, arbs And nifedipine For ccs add a loop Surgery —>LVEF is < 55% or LVESD > 55 mm

Question 88

ASD Tx

Answer 88

Percutaneous or catheter devices | Repair—> if shunt ratio exceeds 1.5 to 1

Question 89

Dilated cardiomyopathy Dx and Tx

Answer 89

Echo is best initial MUGA Or nuclear ventriculogram is most accurate Ace Arbs BB Spirinolactone

Question 90

When Synchronized cardioversion Unsynchronized

Answer 90

Synchronized cardioversion —> anything other than v fib and pulse less v tach Unsynchronized—> v fib, pulseless v tach