Cardiology

Question 1

Criteria for severe aortic stenosis and indications for valve replacement

Answer 1

Aortic jet velocity > 4m/sec or mean transvalvular pressure gradient >40 mm Hg
Replace if meets severe AS criteria and one or more:
-Onset of sxs (angina, syncope)
-LVEF <50%
-Undergoing other cardiac surgery (CABG)

Question 2

Positive stress testing criteria

Answer 2

Clinical variables: 
1. Poor exercise capacity
2. Exercise-induced angina at low workload
3. Fall in systolic BP from baseline
4. Chronotropic incompetence (no HR increase w/ exercise
ECG variables:
1. >1mm ST depression
2. ST depression at low workload
3. ST elevation in leads without Q waves
4. Ventricular arrhythmias

Question 3

Medical tx for CAD

Answer 3

Aspirin
High-intensity statin
Beta-blocker
Optimization of risk factors (smoking cessation, BP control, glucose control)

Question 4

Primary mitral regurgitation

Answer 4

Caused by intrinsic defect of valve (vs secondary which is due to disease process involving left ventricle such as myocardial ischemia or dilated cardiomyopathy)
LVEF <60% considered to be impaired in primary mitral regurgitation
Holosystolic murmur at apex following a click

Question 5

Marfan syndrome

Answer 5

AD, defect in fibrillin-1
Tall stature (height percentile >95%)
Lens subluxation or dislocation (ectopia lentis), tall (usu. >95% percentile)
Aortic root disease, screen with echo on dx and annually thereafter

Question 6

Statin - primary prevention

Answer 6

LDL >190mg/dL: high-intensity statin
Age 40 or more w/ DM and 10-year risk 20% or more: high-intensity statin
Age 40 or more w/ DM and 10-year risk <20%: moderate-intensity statin
10-year risk >7.5-10%: moderate-to-high intensity statin

Question 7

Statin - secondary prevention

Answer 7

Anyone with established ASCVD (ACS, stable angina, arterial revascularization like CABG, stroke, TIA, PAD)
If age 75 or less: high-intensity statin
If age >75: moderate-intensity statin

Question 8

High intensity statins

Answer 8

Atorvastatin 40-80mg

Rosuvastatin 20-40mg

Question 9

Moderate intensity statin

Answer 9

Rosuvastatin 5-10mg
Simvastatin 20-40mg
Pravastatin 40-80mg
Lovastatin 40mg

Question 10

Tx of PAD

Answer 10

1. Risk factor management: Aspirin (1st line) or clopidogrel, statin (PAD qualifies for secondary prevention), smoking cessation, BP and glucose control
2. Supervised exercise program
3. After lifestyle changes, can consider cilostazol (PDE3 inhibitor) 100mg bid
4. Revascularization (stent vs bypass) if persistent symptoms

Question 11

Six Ps of acute limb ischemia and tx

Answer 11

Pain
Pallor
Pulselessness
Poikilothermia
Paresthesia
Paralysis
Tx with IV heparin and emergency surgical revascularization if limb threatened (no arterial doppler)

Question 12

Most important modifiable risk factor for AAA

Answer 12

Smoking

Question 13

AAA screening and management

Answer 13

Screen men age 65-75 who have ever smoked
Tx w/ smoking cessation, aspirin and statin therapy
Elective repair if >5.5cm, rapidly enlarging (0.5cm or more in 6mo) or AAA associated with PAD or aneuryssm
F/u imaging: if 4-5.4cm, U/S q6-12mo, if smaller q2-3 years

Question 14

Asymptomatic left ventricular systolic dysfunction (LVSD) definition and tx

Answer 14

Ejection fraction 40% or less

Tx w/ ACE-i/ARB (start low and increase as tolerated), then add beta blocker

Question 15

Multifocal atrial tachycardia

Answer 15

Caused by exacerbation of lung dz (COPD), electrolyte disturbances or catecholamine surge (sepsis)
P waves of at least 3 different morphologies and atrial rate >100/min
Tx: correct underlying disturbance, AV nodal blockade with nondihydropyridine CCBs (verapamil, diltiazem) or BBs (esmolol) if persistent

Question 16

Management of unstable angina and NSTEMI

Answer 16

• Nitrates prn (caution with hypotension, right ventricular infarct)
• Cardioselective BB such as metoprolol or atenolol. Contraindicated in HF and bradycardia, IV for hypertensive patients
• DAPT: ASA 325mg + P2Y12 receptor blocker
• Anticoagulation: unfractionated heparin, enoxaparin, bivalirudin, or fondaparinux
• High-intensity statin
• Coronary reperfusion within 24h

Question 17

ECG criteria for STEMI

Answer 17

-New ST elevation at the J point in 2 or more anatomically contiguous leads:
>1mm in all leads except V2 and V3
1.5mm or more in women, 2mm or more in men age 40 and more, 2.5mm or more in men <40 in leads V2 and V3
-New LBBB with clinical presentation consistent with ACS

Question 18

Acute Decompensated Heart Failure

Answer 18

IV diuretics
Can add IV vasodilator if inadequate response to diuretics; leads to rapid decrease in cardiac preload, resulting in reduced intracardiac filling pressure and improvement in pulmonary edema

Question 19

Pulmonary hypertension findings and initial eval

Answer 19

Left parasternal lift, right ventricular heave
Loud P2, right-sided P3
Pansystolic murmur of tricsupid regurgitation
JVD, ascites, peripheral edema, hepatomegaly
CXR: prominent pulmonary arteries
Eval: initially with TTE, then right heart cath with mean pulmonary arterial pressure >25mmHg is diagnostic

Question 20

Tx for idiopathic pulmonary hypertension (group 1)

Answer 20

Endothelin receptor antagonists (bosentan, ambrisentan)
PDE5 inhibitors (sildenafil, tadalafil)
Prostacyclin pathway agonists (epoprostenol)
If positive vasoreactive test during right heart cath, CCBs are another option

Question 21

Most effective nonpharmacologic measure to decrease BP in overweight individuals

Answer 21

Weight loss (next is DASH diet)

Question 22

Perioperative risk stratification

Answer 22

Ok to proceed if (in that order):

• No active cardiac conditions (unstable angina, recent MI, decompensated HF, significant arrhythmia or valvular disease)
• Low risk surgery (ambulatory or superficial procedure, endoscopic, cataract, breast)
• Patient has RCRI 1% or less (1 or less of following: high-risk surgery, hx of ischemic heart disease, HF, hx of stroke, DM on insulin, creatinine >2)
• Able to perform 4 METS (climb 2 flights of stairs)

Question 23

Tx of sinus bradycardia from inferior wall MI

Answer 23

IV atropine sulfate if hemodynamically significant (hypotension, cold extremities, pulmonary edema)

Question 24

Down’s syndrome: malformations and later complications

Answer 24

Malformations: endocardial cushion defect (harsh holosystolic murmur), duodenal atresia, Hirschsprung’s disease, atlanto-axial instability and hypothyroidism
Later complications: acute leukemia, Alzheimer-like dementia, autism, ADHD, depressive disorder and seizure disorder

Question 25

Hypertrophic cardiomyopathy

Answer 25

Systolic murmur that increases w/ valsalva, asymmetric septal hypertrophy, systolic anterior motion of mitral leaflets, increased left ventricular outflow tract gradient If sxs of HF and increased LVOT gradient, tx with negative inotropic agents (start w/ BB, add verapamil or disopyramide if persistent symptoms) If sxs refractory to medical therapy, alcohol septal ablation Do NOT use vasodilators (amlodipine, nifedipine), ACE-i/ARBs or nitrates in HCM

Question 26

Indications for ICD placement

Answer 26

Primary prevention: -Prior MI and LVEF 30% or less -NYHA class II or III sxs and LVEF 35% or less Secondary prevention -Prior VF or unstable VT without reversible cause -Prior sustained VT with underlying cardiomyopathy

Question 27

Tx cocaine-related chest pain

Answer 27

Benzo and nitroglycerin Do NOT use BBs (unopposed alpha 1 mediated vasoconstriction) CCBs if persistent chest pain Phentolamine if persistent hypertension Monitor for complications: acute dissection of aorta

Question 28

Criteria for biventricular pacing device

Answer 28

LVEF <35% NYHA class II, III, or IV HF sxs (i.e. any sxs) LBBB with QRS duration >150 msec

Question 29

List the 3 coronary heart disease (CHD) equivalents

Answer 29

1. Noncoronary atherosclerotic disease (eg, carotid, peripheral artery, AAA) 2. Diabetes mellitus 3. Chronic kidney disease

Question 30

Aortic coarctation

Answer 30

``` Claudication Upper extremity hypertension and lower extremity hypotension Brachiofemoral pulse delay May have continuous vs systolic murmur Confirm dx with echocardiogram ```

Question 31

Antiarrhythmic tx in patients with atrial fibrillation

Answer 31

No CAD or structural heart disease: flecainide, propafenone Left ventricular hypertrophy: amiodarone, dronaderone CAD w/o HF: sotalol, dronaderone HF: amiodarone, dofetilide Refractory to meds: radiofrequency ablation

Question 32

CHA2DS2-VASc

Answer 32

``` CHF 1 Hypertension 1 Age 75 or greater 2 Diabetes 1 Stroke/TIA/Thromboembolism 2 Vascular disease 1 Age 65-74 1 Sex 1 if female ```

Question 33

Discontinuing statin therapy

Answer 33

If symptomatic, discontinue | If asymptomatic and CK >10x ULN, discontinue

Question 34

Vasovagal syncope

Answer 34

Pallor, nausea, diaphoresis before (and/or after) syncopal event Regain consciousness rapidly (<1min) Tx with reasurrance and counterpressure techniques (leg crossing with tensing of muscles, tensing of arm muscles with clenches fists)

Question 35

WPW pattern on ECG, criteria for WPW syndrome and tx

Answer 35

Short PR interval with delta wave and widened QRS | Pattern on ECG + symptomatic tachyarrythmia = WPW syndrome, treat w/ catheter ablation

Question 36

Acute aortic dissection management

Answer 36

Pain control IV BBs (esmolol preferred due to short half life) +/- sodium nitroprusside if SBP >120mmHg Emergent surgical repair of ascending

Question 37

Bicuspid aortic valve

Answer 37

Screening echocardiogram for patient and 1st degree relatives F/u echo q1-2 years Evaluate all patient for aortic root or ascending aortic dilation w/ echo, CT or MRI Balloon valvulosplasty in patients with: -Aortic stenosis -No sign AV calcification or aortic regurgitation -Peak gradient >50mmHg

Question 38

Acquired long QT syndrome

Answer 38

Meds: diuretics, zofran, antipsychotics, TCAs, SSRIs, antiarrhythmics, antianginal (ranolazine), anti-infective Metabolic disorders: electrolyte imbalance (low K/Mg/Ca), starvation. hypothyroidism Bradyarrhythmias: sinus node dysfunction, 2md or 3rd degree AV block Others: hypothermia, MI, intracranial disease, HIV

Question 39

Tx per-infarction pericarditis

Answer 39

High-dose aspirin. If still bad, can add colchicine or narcotic analgesics

Question 40

Indications for ICD placement in HCM

Answer 40

Primary prevention -Family history of SCD -Syncope (recurrent and/or associated with exercise) -Nonsustained VT on Holter -Hypotension during exercise -Extreme left ventricular hypertrophy (>3cm septal wall thickness) Secondary prevention -Survivors of cardiac arrest -Sustained spontaneous ventricular arrhythmias

Question 41

Perioperative medications to stop

Answer 41

ACE inhibitors: continue if HF patient, otherwise hold the night before surgery Diuretics: hold on morning of surgery SERMs: hold 4 prior to surgery (risk of thromboembolism)

Question 42

Cardiogenic syncope etiologies

Answer 42

AS/HCM: exertional syncope, systolic murmur on exam VT: no preceding symptoms, cardiomyopathy or previous MI Sick sinus: preceding fatigue or dizziness, sinus pauses on ECG Advanced AV block: bifascicular block or incr. PR interval on ECG, dropped QRS complexes Torsades de pointes: no preceding symptoms, QT prolonging meds, hypo-K/Mg

Question 43

When should INR goal be 2.5-3.5 in valve replacements.

Answer 43

Mitral valve replacement, AVR with risk factors (Afib, severely decreased LVEF <30%, prior thromboembolism, hypercoagulable state) Otherwise goal 2-3 Everyone gets ASA

Question 44

Indications for coronary revascularization

Answer 44

- Patients with refractory angina despite maximal medical therapy - To improve long-term survival: left main coronary stenosis; multivessel CAD (esp. involving proximal LAD) with left ventricular systolic dysfunction

Question 45

Management of unstable angina/NSTEMI

Answer 45

Hemodynamic instability, HF or new MR, recurrent chest pain or ventricular arrhythmia: immediate coronary angiography Otherwise stratify with Thrombolysis in Myocardial Infarction (TIMI) score - 1 pt for each: - Age 65 or greater - 3 or more CAD risk factors (HTN, HLD, diabetes, family hx of CAD or current smoker) - Known CAD (stenosis 50% or greater) - ASA use in past 7 days - Severe angina (2 or more episodes in 24h) - EKG ST changes 0.5mm or greater - Positive cardiac marker (troponin) If score 0-2: stress test If score 3 or more: early coronary angiography (within 24h)

Question 46

Local vascular complications of cardiac cath

Answer 46

Hematoma: no bruit, +/- mass, hemodynamic instability and ipsilateral flank/back pain; get CT A/P Pseudoaneurysm: bulging pulsatile mass, systolic bruit; get U/S of groin AV fistula: no mass, continuous bruit; get lower extremity angiography if initial U/S ambiguous

Question 47

Optimal medical therapy for HF

Answer 47

ACE-i/ARB for everyone If NYHA II (slight limitation with physical activity, ordinary activity causes fatigue, palpitation or dyspnea): -BB w/ EF 40% or less once euvolemic - spironolactone if EF 35% or less with stable renal function and potassium - Diuretic therapy (does not improve mortality) When getting close to NYHA III (marked limitation with physical activity, less than ordinary activity causes fatigue, palpitations, dyspnea): - Isosorbide dinitrate (hydralazine if AA) - Digoxin if symptomatic with spironolactone - Cardiac resynchronization therapy if QRS>150msec

Question 48

Digoxin toxicity toxidrome, medications that cause it

Answer 48

Nausea, anorexia, confusion, vomiting, fatigue, visual disturbances, cardiac abnormalities Caused by verapamil (inhibits renal tubular secretion of digoxin, resulting in 70-100% increase in serum digoxin levels), quinidine, amiodarone, spironolactone

Question 49

Features of compartment syndrome, dx, tx and complications

Answer 49

- Pain out of proportion to injury - Pain increased on passive stretch - Rapidly increasing and tense swelling - Paresthesia (early) Dx w/ tissue pressures: >30mmHg or delta pressure (DBP - compartment pressure <20-30mmHg) Tx w/ fasciotomy (timing of surgical intervention is most important prognostic factor) Complications include rhabdomyolysis, released myoglobin is nephrotoxic leading to acute renal failure

Question 50

Ejection click followed by crescendo-decrescendo systolic murmur

Answer 50

Aortic or pulmonic valve stenosis

Question 51

Nonejection click followed by a continuous systolic murmur

Answer 51

Mitral regurgitation

Question 52

Harsh holosystolic murmur with palpable thrill

Answer 52

VSD

Question 53

Holosystolic murmur that increases with inspiration

Answer 53

Tricuspid regurgitation

Question 54

Opening snap then low-pitched diastolic murmur

Answer 54

Mitral stenosis

Question 55

Movements that increase venous return

Answer 55

Squatting, supine leg raise (increases intensity of most murmurs except MVP and HOCM)

Question 56

Movements that decrease venous return

Answer 56

Standing, valsalva (decrease intensity of most murmurs except MVP and HOCM)

Question 57

Presentation and tx of cyanide toxicity

Answer 57

Presentation: flushing, AMS, metabolic acidosis Often caused by nitroprusside Tx w/ sodium thiosulfate

Question 58

Constrictive pericarditis dx

Answer 58

Hx of viral infection, cardiac surgery or radiation therapy Present with edema, ascites and hepatic congestion Pericardial thickening and calcifications seen on CXR

Question 59

Tx of ADHF

Answer 59

If normal/elevated BP w/ adequate end-organ perfusion: - Supplemental oxygen - IV loop diuretic - Consider IV vasodilator (nitroglycerin) If hypotension or signs of shock: - Supplemental O2 - IV loop diuretic as appropriate - IV vasopressor (norepi)