Cardiology Flashcards
(219 cards)
1
Q
What does meant by low Pretest probability of CAD?
A
Low (<10%)
Asymptomatic people of all ages
Atypical chest pain in women age <50
2
Q
What does meant by Intermediate Pretest probability of CAD?
A
Intermediate
(20%-80%)
Atypical angina in men of all ages
Atypical Angina in women age >50
Typical angina in women age 30-50
3
Q
What does meant by high Pretest probability of CAD?
A
High
(>90%)
Typical angina in men age >40
Typical angina in women age >60
4
Q
Important point of Aspirin
A
Aspirin is given before heparin in ACA as it reduces the rate of MI, stroke and overall mortality in ACS
5
Q
How to approach chest Pain In Emergency dept?
A
Take history & do Examination
Check stability—> if unstable then stabilise hemodynamics and find the cause
If stable then do ECG/CXR
If ECG consistent with ACS then give anticoagulants if NSTEMI /// if STEMI then t/m with ER CATH & thrombolysis
If ECG normal—> do CXR—> if diagnostic then t/m the cause Or if non-dx then check underlying other cause of chest pain / check cardiac markers
6
Q
What medication to hold prior to cardiac stress testing?
A
BB / CCB / Nitrates = hold for 48 hours
Dipyridamole = Hold for 48 hours prior to vasodilator stress test
Caffeine containing food Or Drinks = hold for 12 hours prior to vasodilator stress test
7
Q
What medication can be continued before doing cardiac stress testing?
A
AIDS
A = ARBs/ACEI ID = Digoxin / diuretics S = statins
8
Q
How chest wall/ musculoskeletal chest pain presents?
A
Persistent and prolong pain with palpation
Worse with movement Or change in position
Often follows repetitive activity
9
Q
How pulmonary/pleuritic (pleurisy, pneumonia, pericarditis, PE) chest pain present?
A
Sharp/stabbing pain
Worse with inspiration
Pericarditis:: Worse when lying flat
PE / Pneuomthorax:: Respiratory distress / hypoxia
10
Q
How GIT/Esophageal chest pain present?
A
Non exertional prolong chest pain lasting>1 hour
Nocturnal pain
Postprandial symptoms
11
Q
What is the first line agent for stable chronic angina?
A
Beta blocker
But CCB can be combine with BB of angina persist Or as alternate therapy
12
Q
When to used short acting form and long acting form of nitrates in stable chronic angina?
A
Short acting form is used in the acute setting
Long acting form is an add on therapy for persistent angina
13
Q
How variant angina different from ACS on the basis of ECG?
A
In variant angina, Transient ST elevation and then return to baseline
Whereas ST depression in unstable angina and longer duration of ST elevation in MI.
14
Q
Which vessels and what are the ECG findings of Right ventricle MI?
A
RCA
ST elevation in leads V4-V6R
***Right ventricle MI occurs in 50% of inferior MI
15
Q
Important point of Inferior wall MI
A
Transient bradycardia Or AC block occurs due to enhanced cabal time so give IV fluid unless pulmonary congestion
16
Q
Important point of RVMI
A
RV MI (Heat failure) leads to decrease preload and resultant hypotension
So avoid all those medications which decreases preload viz nitroglycerin / Diuretics / Opioids)
Also be cautious when using BB and CCB
17
Q
Which artery and what are the findings of Posterior MI?
A
LCX or RCA
ST depression in leads V1-V3
ST elevation in leads I & aVL (LCX)
ST depression in leads I & aVL (RCA)
18
Q
Which artery and what are the ECG findings of lateral wall MI?
A
LCX diagonal
ST elevation in leads I, aVL, V5 & V6
ST depression in leads II, III & aVF
19
Q
Important point
A
Occlusion of LAD can cause 2nd degrees AV block as it perfumed anterior 2/3rd of septum
20
Q
What is the MC arrhythmia will be seen in setting of acute MI?
A
Ventricular fibrillation
21
Q
What is the mechanism of arrhythmias within 10 mins of coronary occlusion?
A
Arrhythmia occurring within 10 mins of coronary occlusion—immediate or phase 1a ventricular arrhythmia
MOA:: reentrant arrhythmia
22
Q
What is the mechanism of arrhythmias within 10-60 mins after acute infarction?
A
Arrhythmia occurring within 10-60 min after acute infarction—delayed or phase 1b arrhythmia—
MOA: abnormal automaticity
23
Q
How ventricular aneurysm different from MI on ECG?
A
Ventricular aneurysm has persistent ST elevation after recent MI and deep Q waves in same leads
Whereas ST elevation resolve within a few weeks of an MI
24
Q
What are CXR and Echo findings of ventricular aneurysm?
A
CXR = Prominence Or Bulge among left heart border
ECHO = showing dyskinetic wall motion of a portion of left ventricle
25
How to t/m dressler syndrome?
NSAIDs is mainstay of therapy
Steroids can be used in refractory cases Or when NSAIDs are contraindicated
Avoid to use anticoagulant to prevent development of hemorrhagic pericardial effusion
26
How to avoid coronary stent thrombosis?
Give long term dual anti-platelet therapy with aspirin and platelet P2Y12 receptor blocker
27
What is the most important intervention to improve long term prognosis of MI esp STEMI?
PCI
| or Fibrinolytic therapy
28
Name the discharge medication of MI
* Dual anti-platelet therapy
* BB
* ACEI or ARB
* STATINS
* Aldosterone antagonist if EF <40% with HF symptoms Or DM
29
Important point
ACEi should be started in all pts with MI within 24 hours to prevent remodeling of heart
i.e. dilation of left ventricle with thinning of ventricular wall which takes wks to months
30
What are the causes of heart failure with preserved left ventricular function?
* Diastolic heart failure (HOCM / Restrictive cardiomyopathy / HTN / Occult CAD)
* Valvular Heart disease (AR AS / MR MS)
* Pericardial disease (Constrictive pericarditis / Cardiac tamponade)
* High Output cardiac conditions ( Thyrotoxicosis / Severe anaemia / Wet beri / Paget’s disease/ AV Fistula)
31
How to t/m acute decompensated HF with normal Or Elevated BP with adequate end organ damage?
Supplemental O2
IV loop diuretics
Consider IV vasodilator Viz nitroglycerin
32
How to t/m acute decompensated HF with hypotension Or signs of shock?
Supplemental O2
IV loop diuretics
IV vasodilator Viz nitroglycerin
33
What are the laboratory findings suggest poor prognostic factors in systolic HF?
Low Serum Sodium
Elevated Pro-BNP level
Renal insufficiency
34
What are the clinical findings suggest poor prognostic factors in systolic HF?
Resting tachycardia with higher NYHA functional class
Elevated JVP with presence of S3 gallop
Low BP and maximal O2 consumption
Moderate to severe MR
35
What are the ECG and ECHO finding suggests poor prognostic factors in systolic HF?
ECG:::
LBBB and QRS>120msec
ECHO:::
Severe LV dysfunction
Concomitant diastolic dysfunction
Reduced Right ventricular function
Pulmonary HTN
36
What is the initial therapy in hyponatremia in CHF patient?
Restrict water intake
ACEi
and loop diuretics
37
What are the features of Cocaine Induced STEMI?
Chest pain due to coronary vasoconstriction
Increase Sympathetic activity Viz pupil dilation /HTN / tachycardia
Blood crusted nose
38
What are medication not to used in Cocaine Induced STEMI?
Beta blockers
Fibrinolytics due to increased risk of intracranial hemorrhage
39
Where the sound of murmur localized if Aortic regurgitation occurs due to valvular disease?
murmur heard along left sternal border (3rd and 4th Intercostal space)
40
Where the sound of murmur localized if Aortic regurgitation occurs due to aortic root dilation?
murmur best heard at right sternal border
41
Important point
If new AV block is present in case of IV drug user alongwith AR murmur, suspect perivalvular abscess extending into adjacent cardiac conduction pathway (conduction defects not common in tricuspid endocarditis)
42
What are the causes of Dilated Cardiomyopathy?
ABCDe
```
A= alcohol abuse
B= beri beri (wet) / Coxsackie B virus
C= cocaine / Chagas
D= Doxorubicin toxicity
E= elsewhere (hemochromatosis / sarcoidosis /peripartum cardiomyopathy
```
43
What are the laboratory findings of Dilated Cardiomyopathy?
ECHO:::
Dilated heart / systolic regurgitant murmur
CXR:::
Balloon appearance of heart
Miscellaneous:::
Eccentric hypertrophy
44
How takotsubo cardiomyopathy occurs?
Ventricular apical ballooning likely due to increased sympathetic stimulation
45
What is the histological finding of HOCM?
Marked ventricular concentric hypertrophy
(Sarcomere added in parallel)
Myofibrillar disarray and fibrosis
46
Name the protein get mutated in HOCM?
Genes encoding sarcomere protein such as myosin binding protein C and B-myosin heavy chain
47
Name the condition which cause isolated Right HF
Cor pulmonale
48
What will be detected in physical finding in HOCM?
carotid pulse with dual upstroke due to mid-systolic obstruction during cardiac contraction
49
What are the major causes of sudden cardiac death?
CAD
HOCM
Arrhythmia Viz long QT Syndrome
Congenital heart disease
50
What is Cornell Criteria?
It is criteria for HOCM
Tall "R" wave in aVL plus deep "S" wave in V3
51
What is the difference b/w HOCM and restrictive cardiomyopathy?
HOCM:::
Wall is asymmetrical thick
Restrictive cardiomyopathy:::
Wall is symmetrical thick
52
What is the ECHO findings of amyloidosis?
Increased ventricular wall thickness with normal ventricular cavity dimensions (esp in ots without HTN)
53
What will be ECHO finding of Dilated Cardiomyopathy?
echo shows dilated ventricles with diffuse hypokinesia resulting in a low ejection fraction (i.e. systolic dysfunction)
54
What will be laboratory findings of Cardiac tamponade?
CXR:::
Enlarged globular cardiac silhouette (water bottle heart shape)
ECG:::
Electrical alternans with sinus tachycardia is highly specific for large pericardial effusion
55
When to consider S3 sound normal?
Children
Young adult
Pregnancy
56
Important point of S4
S4 is heard in acute MI because of ischemia induced myocardial dysfunction
57
What is the key distinguished feature of benign and pathological murmur?
benign Vs pathological murmur is change in instensity with change in position. Position that dec. venous return to heart, dec intensity of innocent murmur.
58
In which condition Hepatojuglar reflux seen?
Common in constrictive pericarditis, right ventricular infarction and restrictive cardiomyopathy
59
What is Kussmaul’s sign?
lack of ↓ or an ↑ in JVP on inspiration
60
What are the causes of Constrictive pericarditis?
Viral pericarditis
Cardiac surgery
Tb
Radiation therapy
61
Which is the ECHO and CXR finding of Constrictive pericarditis?
ECHO:::
Increase pericardial thickness
Abnormal Septal motion
Bi atrial enlargement
CXR:::
Pericardial calcification
62
What is the JVP finding of Constrictive pericarditis?
Prominent X and Y descent
63
Difference between Pericardial knock and S3
Pericardial knock::
Occurs earlier than S3 gallop
Louder and higher pitched than the S3
Heard with the diaphragm over a larger area
S3:::
Best heard with a lightly
64
How to t/m Constrictive pericarditis?
Temporary:::
Diuretics
Definitive:::
Pericardiectomy (also in refractory cases)
65
Important point of Uremic pericarditis
Does not present with classic ECG findings of pericarditis as inflammatory cells do not penetrate the myocardium and lack of involvement of epicardium
66
What is the effective t/m of Uremic pericarditis?
Dialysis is the most effective treatment for UP and can resolve symptoms and decrease the size of any pericardial effusion
67
How to t/m first degree heart block with normal QRS?
No further evaluation needed
68
What to do if patient has first degree heart block with wide QRS?
It should have electrophysiologic testing to determine the site of conduction delay
69
Difference between first degree heart block with Normal and wide QRS complex?
Normal QRS::
due to conduction delay in AV node
Wide QRS::
conduction delay below AV node, mostly bundle branches
70
What is pacemaker syndrome?
uncomfortable sensation of awareness of heart beat due to atrial contraction against close mitral valve during ventricular systole.
71
At what level there is block in 2nd degree heart block?
Type 1::
Usually AV node
Type 2::
Below the level of AV node
72
How exercise(Or atropine) and vagal maneuvers?
Atropine (Or Exercise)::
Improves type 1 block whereas worsen type 2 block
Vagal Maneuvers::
Improves type 2 block whereas worsen type 1 block
73
What will be the ECG findings type 1 block?
Constant P-P interval
Increasing PR interval
Decreasing R-R interval
74
Difference between first degree and other heart block
First degree always have conducted P waves with Qrs , unlike other AV blocks
75
What are the ECG findings of type 2B block?
Normal PR interval
Constant RR interval
Non conducting P waves
Area of drop QRS complex
76
What are the ECG findings of third degree third block?
PP and RR interval constant
Escape rhythm
77
Important point of third degree heart block
Unless an escape rhythm is initiated, ventricle a-systole will occur
78
Name the drugs contraindicated in third degree heart block
Beta blocker and Digoxin
79
What is the most frequent location of ectopic foci that cause AF?
Pulmonary vein
80
What are the causes of tachycardia mediated cardiomyopathy?
AF / atrial flutter
ventricular tachycardia / incessant atrial/junctional tachycardia
and
atrioventricular nodal reentrant tachycardia.
81
How tachyarrhythmias induced cardiomyopathy occurs?
tachyarrhythmias with prolonged periods of rapid ventricular rates can lead to this cardiomyopathy
82
How to t/m tachyarrhythmias induced cardiomyopathy?
AV nodal block agents
Anti arrhythmics agent
Catheter ablation of arrhythmias
83
Name the pulmonary origin condition associated with A fib
Obstructive sleep apnea
Pulmonary embolism
COPD
Acute hypoxia
84
Name the cardiac origin condition associated with A FIB
Hypertensive heart disease
CAD
MR/MS
CHF / HOCM
ASD
Post cardiac surgery
85
How to control the rate in A fib?
| .
Rate control is achieved by beta blockers (metoprolol), calcium channel blockers (diltiazem) or digoxin to control ventricular rates.
86
What are the indications of rhythm control in A fib?
Hemodynamic unstable patient with rapid A fib
Not responding to rate controlling drugs
recurrent symptomatic episodes (eg, palpitations, lightheadedness, dyspnea, angina) or
heart failure symptoms in setting of underlying left ventricular systolic dysfunction
87
Important point of A FIB
Attempting cardioversion for an unknown duration or >48 hours without adequate anticoagulation inc. risk of systemic thromboembolism
88
How to valvular Afib or mechanical/prosthetic valve?
Warfarin
89
What will be t/m if CHADVASc score is more than 2?
Oral anticoagulants
90
What will be t/m if CHADVASc score is 1?
Aspirin Or Oral anticoagulants
91
What will be t/m if CHADVASc score is zero?
None
92
What is lone AF?
presence of paroxysmal, persistent or permanent atrial fibrillation with no evidence of cardiopulmonary or structural heart disease.
Required no treatment
93
How Atrial premature beats occur?
depolarization of the atria originating in a focus outside SA node
Check the ECG
94
Difference between HTN urgency and HTN emergency?
HTN urgency:::
BP more than >180/120 with no Sx or acute end organ damage
HTN E/R:::
Severe HTN with acute, life threatening end organ damage
95
Important point of atrial premature beats?
P wave has a d/f shape from one originating from SA node
96
What is malignant HTN?
Severe HTN with retinal hemorrhages, exudates or papilledema
| there can also be malignant nephrosclerosis but non-dx and not always present
97
What is HTN Encephalopathy?
Severe HTN with cerebral edema, non-neurological signs and symptoms
98
Important point of t/m in HTN Emergency
BP should be lowered 10-20% in 1st hour and 5-15% in next 23 hours - Excessive drop in BP results cerebral ischemia with altered mental status and/or generalized seizures
99
Name the initial HTN medication for black ethnicities
Thiazide Or CCB
| but not ACEI and ARBs
100
Name the initial HTN medication for non black ethnicities
ACEI / ARBs
| Thiazide / CCB
101
How to isolated systolic HTN?
monotherapy with low dose thiazide diuretic, ACEi or a long acting calcium channel blocker
102
What is the most effective method to control HTN?
Life style modification
Obese ppl:: Reducing weight
Non obese:: DASH diet
103
Name the anti HTN contraindicated in pregnancy
ACEi
ARBs
Aldosterone antagonist
Direct renin inhibitors
Furosemide
Nitropursside
104
What are first and 2nd line anti HTN medication in pregnancy?
First line:::
Methyldopa > Labetolol > hydralazine > CCB (nifedipine)
2nd Line:::
Thiazides
Clonidine
105
How cyanide toxicity occurs?
If it is given in high amount or prolong.
SxS ::: alter mental status / lactate acidosis / fits and coma
106
How to counter the Edema due to CCB?
By giving ACEi Or ARBs
107
How to t/m BB toxicity?
Secure airway
Give isotonic fluids bolus and IV atropine for low BP and bradycardia
If refractory Or severe hypotension then give IV glucagon
108
Important point of HTN
All pts with resistant HTN, severe or malignant HTN, sudden BP rise in a pt with previously controlled BP, age of onset <30 years without family h/o HTN should be screened for 2* causes of HTN
109
How to d/f bruit of AAA and Renal artery stenosis?
AAA:::
Bruit only heard in systolic
Renal Artery Stenosis:::
Bruit heard in systolic and diastolic
110
Triad of Renal artery stenosis
Severe HTN with atherosclerosis and abdominal bruit
Increase serum creatinine after starting ACEi Or ARBs
asymmetric kidney size or a small atrophic U/L kidney
111
How to d/f difference in BP of upper limb causes?
Difference in BP in arms more in left than right—-> subclavian atherosclerosis
Difference in BP in arms more in right than left—-> coarctation proximal to left Subclavian artery origin
112
Name the condition which has both abdominal and carotid bruits
Fibromuscular dysplasia
113
Triad of Renal Artery stenosis
Young Female with Secondary HTN
Flank pain
Neurological features viz TIA / stroke / Recurrent Headache / Pulsatile tinnitus
114
Name the imaging used for diagnosing Fibromuscular dysplasia
Preferred Imaging:::
Duplex US
CTA
MRA
Others::: catheter based arteriography
115
How to t/m fibromuscular dysplasia?
Anti HTN:::
ACEi / ARBs first line
2nd Line:::
PTA
Do surgery if PTA unsuccessful
116
At what area murmur of coarctation of aorta is heard?
Systolic ejection murmur at left interscapular area
117
What are the Chest X Ray findings of co arctation of aorta?
3 sign from aortic indentation
Notching of 3rd to 8th ribs from enlarged intercostal arteries
118
How to t/m aortic co arctation?
Balloon angioplasty with or without stent
119
Important point of digoxin toxicity
Atrial tachycardia with AV block is arrythmia specific for digitalis toxicity
- Multifocal atrial tachy is rarely associated with digitalis toxicity. It is more commonly a consequence of pulmonary
dis.
120
Name the medication which can cause digoxin toxicity
Amiodarone
verapamil
quinidine
and propafenone increases the serum levels of digoxin and can lead to toxicity
121
What skin changes occur due to digoxin toxicity?
Blue gray skin discolouration
122
What are the examination findings of cor pulmonale?
Peripheral Edema with pulsatile liver from congestion
Right sided heave with TR murmur
Loud S2
Increase JVP with Prominent “a” wave
123
What is the gold standard test for Cor pulmonale?
Right HEART CATH:::
elevated pulmonary artery systolic pressure (<25 mmHg).
Right ventricular dysfunction
Pulmonary HTN
No left heart disease
124
What are ECG findings of cor pulmonale?
Right BBB
Right axis deviation
Right ventricular hypertrophy
Right atrial enlargement
125
What is the normal right atrial pressure?
Mean of 4 mmHg
126
What is the normal PCWP?
Mean of 9 mmHg
127
What is the normal cardiac index?
2.8--4.2 L/min/m2
128
What changes occur in hyperdynamic phase of Septic shock?
Hyperdynamic phase
dec in SVR
dec. BP,
inc. HR
and CO (warm shock)
129
What changes occur in hypodynamic phase of Septic shock?
inc. SVR,
| dec. in CO grave deterioration (cold shock)
130
Triad of Exerational heat stroke
Body temperature >104 'F
Alter metal status
Multi organ failure
131
What are the risk factors for Exerational heat stroke?
Physical activity in hot and humid weather
Dehydration and obesity
Lack of physical fitness with poor acclimatization
Medication viz anticholinergic / anti histamine / tricyclic / phenothiazine
132
How non Exerational heat stroke occur ?
More freqeuntly affect elderly pt with significant underlying comorbidities that limit their ability to escape or cope with excessive heat
133
How to t/m non Exerational heat stroke?
evaporative cooling (eg spraying lukewarm water while fans blod air on pt) is more imp than ice immersion which is associated with inc mortality in this case
134
What amount of lipid lowering agents given in patient whose age is ≤75 with atherosclerotic diseases?
High intensity statin
135
What amount of lipid lowering agents given in patient whose age is ≥75 with atherosclerotic diseases?
Moderate intensity statin
136
What amount statin given patient whose LDL is ≥190?
High intensity statin
137
What amount of lipid lowering agents given in patient whose age is 40-75 with diabetes?
If 10 years ASCVD risk <7.5%::
Moderate intensity statin
If 10 years ASCVD risk >7.5%::
High intensity statin
138
How to t/m the patient whose TAG level is 150-500mg/dl?
Lifestyle modification
If CVS risk then give statin
139
How to t/m the patient whose TAG level is ≥1000mg/dl?
Initially to prevent pancreatitis by giving fibrates and fish oil / abstinence from alcohol
Once TAG reach ≤500mg/dl then do lifestyle modification and add statin if CVS risk
140
What are the risk factors for cholesterol crystal embolism?
Invasive procedures like cardiac cath Or Vascular procedure
Comorbidities like HTN / DM / High cholesterol)
141
What are important or different features of Cholesterol crystal embolism?
Blue toe syndrome:
cyanotic toes with intact pulses.
Livedo reticularis:
blanches with pressure application
Hollenhost spots:
bright, yellow, refractile plaques in retinal artery
142
What are laboratory findings of cholesterol crystal embolism?
Increase eosinophils in cbc as well in urine D/R
High creatinine with low complement levels
Renal Or skin Biopsy::
Biconvex, needle shaped clefts within occluded vessels
Perivascular inflammation with eosinophils
143
How acute lower limb ischemia?
pain
pallor
poikilothermia (cool extremity)
paresthesia
pulselessness
and paralysis
144
How to t/m acute limb ischemia?
Give heparin before proceeding for surgery as this drug will stop propagating the thrombus
145
What are the indications for carotid endarterectomy in female?
Do it in female whether asymptomatic or symptomatic with stenosis 70-99%
146
What are the indications for carotid endarterectomy in Male ?
Asymptomatic with stenosis 60-69%
Symptomatic::
50-69% stenosis
70-99% stenosis
147
What does it mean to be symptomatic if patient has carotid stenosis?
Symptomatic means:
| occurence within past 6 months of sudden onset focal neurological symptoms corresponding to a carotid artery lesion
148
Triad of Vagovagal syncope
There is always trigger
Prodrome Sx before unconscious viz pallor, nausea, dizziness and diaphoresis
Short duration of syncope which improve with supine position
149
What is orthostatic Hypotension?
Drop in systolic BP >20mmHg and diastolic >10mmHg on standing from sitting position within 2-5min of standing from supine position
150
What are main causes of orthostatic Hypotension?
decreased baroreceptor sensitivity
Hypovolemia
151
What is PULSUS PARVUS ET TARDUS?
Arterial pulse with decreased amplitude and delayed peak.
Common in severe aortic stenosis
152
What is PULSUS BISFERIENS (OR BIPHASIC PULSE)?
Two strong systolic peaks or aortc pulse from left ventricular ejection separated by a midsystolic dip.
Can be palpated in pts with significant aortic regurgitation with or without stenosis, HOCM, and occasionally large PDA
153
What are the immunologic phenomena seen in infective endocarditis?
Osler nodes:: Painful, nodules violaceous seen on the finger and toes
Roth spots:: edematous and haemorrhagic lesion of the retina
154
How to t/m Infective endocarditis?
Empirically with vancomycin after taking blood culture
T/m::
Penicillin susceptible strains should be treated with IV aqueous penicillin G (every 4-6 hours or 24 hours continuous infusion) or IV ceftriaxone (once daily) for 4 weeks.
155
What is the MCC of death in infective endocarditis?
Valvular insufficiency
156
What is the preferred prophylactic medication for Rheumatic fever?
IM Benzathine penicillin G for every 4 weeks
157
Important point of aortic dissection
50% cases in ppl <40 years are due to Marfan syndrome but HTN is most common risk factor seen in 75% patients
158
Name imaging test to dx aortic dissection
TEE>TTE
CT and MRI are alternatives if emergency TEE is not available
159
How HOLT-ORAM SYNDROME (HEART HAND SYNDROME) presents?
Both upper limb defects (e.g. deformities of radius and carpal bone)
and atrial septal defect
160
What are the causes of A-systole/PEA?
5Hs
And
5Ts
5Hs::
Hypovolemia
Hypoxia
```
Hydrogen ion (acidosis)
Hypo/hyper kalemia
```
Hypothermia
5Ts::
Tension pneumothorax
Tamponade cardiac
Toxins
Thrombosis
Trauma
161
What is synchronised cardio version and when to use it?
Synchronized cardioversion delivers energy synchronized to QRS complex—
used in symptomatic or sustained monomorphic VT(unresponsive to antiarrhythmics) AND hemodynamically unstable atrial fibrillation with rapid ventricular response.
162
What is un-Synchronized cardio version and when to use it?
Defibrillation delivers energy randomly during cardiac cycle without synchronization to QRS complex.
Needed for pulseless ventricular tachycardia and ventricular fibrillation
163
How to avoid cardiac complication when doing Central venous catheter?
To avoid myocardial perforation, catheter tip should be located proximal to either cardiac silhouette or the angle between the trachea and the right mainstem bronchus.
Ideally catheter tip should lie in superior vena cava. Tip placement in smaller vessels can cause perforation
164
WHO classification of Pulmonary HTN
Group 1::
Due to unknown PAH
Group 2::
Due to left heart disease
Group 3
Due to chronic lung disease
Group 4::
Due to thromboembolic occlusion of the pulmonary vasculature
Group 5::
Due to haematological /metabolic / systemic disorder
165
What are the chest X-ray findings of thoracic Aorta aneurysm?
CXR in TAA:
widened mediastinal silhoutte
↑ aortic knob
and tracheal deviation
166
How to d/f thoracic aortic aneurysms from tortuous aorta?
CXR cannot distinguish TAA from tortuous aorta
confirm with CT with contrast
167
What are the causes of thoracic aortic aneurysms?
Ascending aorta aneurysms:::
cystic medial degeneration (cox of aging) or connective tissue disease ( eg Marfan and Ehler Danlos)
Descending aorta aneurysms:::
due to atherosclerosis; risk factor: HTN, hypercholestrolemia and smoking
168
What is basic difference b/w thoracic and abdominal aorta aneurysms?
unlike thoracic aortic aneurysm, it does not form false lumen and an intimal flap and is composed of all 3 layers
169
Important point of AAA
AAA >3cm
Imaging modality of choice:
abdominal ultrasound
Screen the men who smoke with age of 65-75years
risk of AAA formation and expansion is lower in diabetics than non-diabetics
170
What are the risk of AAA which increases the chances of rupture?
large aneurysm diameter (>/=5.5cm)
aortic expansion rate >0.5cm/6mo and >1cm/year
female gender, current ongoing smoking and HTN
(HTN has weak association with AAA formation and expansion and rupture)
171
What are the indications for surgical repair Or Endovascular repair of AAA?
size >5.5cm,
rapid rate of expansion >0.5cm/6months and >1cm/year
and presence of symptoms (abdominal, back or flank pain; limb ischemia) regardless of size
172
Triad of Leriche syndrome
Erectile dysfunction
Buttock and hip pain
Absent femoral pulse on examination
173
What to do if ankle brachial index test comes positive?
Arterial duplex US
174
How to t/m peripheral arterial disease?
Start with::
Anti platelets agents with lipid lowering agents and exercise
If not settle out with above therapy do::
Cilostazol
Percutaneous or surgical revascularization
175
How to approach DVT?
Through WELLS criteria if high chance of DVT then do compression U/S—> if positive—>give anticoagulant
If negative—> repeat the test after a week
——
If low chance of DVT—>check D dimer—>if increase—>follow the above pattern
If decreases—>unlikely DVT
176
Which anticoagulant to give for DVT?
Proved DVT:
begin anticoagulation with Heparin followed by warfarin, rivaroxaban or apixaban
177
Important findings of CXR in PE
,Westermark’s sign
(peripheral hyperlucency due to oligemia)
Hampton’s hump
(peripheral wedge of lung opacity due to pulmonary infarction)
and
Fleishner’s sign
(enlarged pulmonary artery)
178
How to t/m Torsades de pointes?
IV MgSO4 doesn’t matter if magnesium is normal
If cause of torsades de pointe is quinidine then use Sodium bicarbonate
179
How to managed Wide complex tachycardia if there is no AV dissociation or fusion/capture beats?
Consider it SVT with aberrancy
If vitally stable--->vagal maneuver, rate/rythm control
If vitally unstable---> Direct cardioversion
180
How to managed Wide complex tachycardia if there is AV dissociation or fusion/capture beats?
DX of VT
If vitally stable---> amidarone
If vitally unstable---> DC cardioversion
181
Important point of Acute MR
Short time so no compensatory changes made result left atrial and ventricular size remain normal with normal or increase EF
182
Important point of Chronic MR
Enough time so compensatory changes made result left atrial and ventricular size increases with normal or increase EF initial but wall stress would eventually leads to decrease in EF
183
Important point of Preload / After load and CO
1) Sepsis:: Both Preload Afterload decrease and CO initially increase and then Decrease
2) Adrenergic agonist like epi activate both alpha and Beta result increase Afterload, Preload and CO
3) Increase Afterload and Preload with Decrease CO seen in Decompensated HF
184
What are the cardio origin syncope causes?
LV outflow obstruction
VT
Conduction impairment like sick sinus syndrome or AV block
185
What are the orthostatic origin syncope causes?
1) vasodilator Medication like alpha blocker/ anti HTN
Inotropic / chronotropic blocker like BB
2) hypovolemia
3) Autonomic dysfunction more seen in DM/ parkinson
186
What are the Reflex syncope causes?
Vasovagal
Situational
Carotid hypersensitivity
187
Why sedation and Intubation avoided in HYPOVOLEMIC SHOCK?
Intubation or Positive pressure ventilation increases Intra thoracic pressure result Decrease venous return
Sedation dilated the vein result pooling of blood
188
How much alcohol intake would cause hypertension?
More than 2 drinks per day
Or
More than 5 drinks in single sitting
189
How to Approach STEMI?
| B-SOMAN
LIFE saving treatment is PCI or tPA
But initially
BB, Statin, O2, Morphine, aspirin plus , Nitrates
190
Name the medicine avoided/given in STEMI in specific situation
1) Give BB but avoid if low BB and pulse, sxs of HF or heart block
2) Lasix if pul-edema but avoid if patient has low BP Or dehydrated
3) Unstable sinus bradycardia----> IV atropine
4) Avoid Nitrates if low BP, R-heart infarction or severe aortic stenosis
191
Triad of Vasospastic angina
Chest pain occur at Rest or sleep (not on exertion)
Seen in young age with positive hx of cocaine and smoking
Transient ST elevation with no blockage of coronary artery on angiography
192
How to manage Vasospastic angina?
CCB as preventive
| Nitroglycerin as abortive
193
Important point of Vasospastic angina and raynaud phenomenon;; Claudication and angina
Both have same pathophysiology that is hyperactivity of muscle of arteries
Both Claudication and angina have same pathophysiology somehow
194
What are the surgical indications of Infective Endocarditis?
If patient developed sxs like HF
Bacteremia even on ABx
Large vegetation or persistent septic emboli
Fungus Or MDR pathogen result d/f to eradicate organism
Extension of infection viz abscess, fistula or heart block
195
Name the medicine given for Chronic stable angina
1) First line---> BB
Cardiac selective CCB alternative to BB if BB CI
2) Add non cardiac selective CCB (with BB) which dilates coronary and systematic artery result reduced Afterload
3) Nitrates if still persistent or Ranolazine if refractory angina which decrease calcium influx in myocardiocytes
196
What is the typical finding of Pericarditis?
Pericarial frictional rub which is triphasic that is heard in atrial systole, ventricular systole and early ventricular diastole
197
What are the PRIMARY PREVENTION indications for statin therapy in prevention of ASCVD?
1) Age more or at least 40 with DM regardless of LDL level
Or
2) LDL more than 190mg/dl
Or
3) Estimated 10 year risk of ASCVD >7.5%-10%
198
What are the SECONDARY PREVENTION indications for statin therapy in prevention of ASCVD?
Already established ASCVD like
Acute coronary syndrome
Stable angina
Stoke TIA PAD
Arterial Revascularization like CABG
199
What are the CNS and CVS complications of aortic dissection?
CNS
Stoke due to carotid artery
Horner syndrome due to carotid sympathetic plexus
Lower extremity paraplegia (spinal arteries)
CVS::
Acute AR due to aortic root / valve
MI due to coronary artery Ostia
Pericardial effusion or tamponade (pericardium)
200
What are the complications of pulmo, Abdominal and Renal complications of Aortic Dissection?
Pulmo::
Hemothorax due to pleural cavity
```
GIT:
Abdominal pain (mesenteric arteries)
```
Renal:
Renal injury due to renal arteries
201
What Factors leads to S.aureus and S.epidermis induced Infective Endocarditis?
Prosthetic device
Intravascular catheter
Implanted devices (Pacemaker / defibrillator)
202
What Factors leads to Viridian streptococci induced Infective Endocarditis?
Gingival manipulation
Respiratory tract incision or biopsy
203
What Factors leads to Enterococci induced Infective Endocarditis?
Nosocomial UTI
204
What Factors leads to fungi induced Infective Endocarditis?
Prolonged Abx therapy
Intravascular catheter
Immuno incompetent
205
Name the parameters of CHA2 DS2 VASc for non Valvular A.fib
| Patient is assigned in one of the “age” group
C CHF
H HTN
A2 >75
D DM
S2 stroke Or TIA
V vascular disease like prior MI
A 65-74
Sc sex category like female
206
Name the anti diabetic meds given for CVS patient
Metformin
GLP-1 Agnoist like Liraglutide
SGLT2 Inhibitor like Empagliflozin
207
How Post cardiac surgery syndrome occur and what are the causes of it?
Form of acute pericarditis due to “”immune mediated inflammation (deposition of Immune complex)”” in the pericardium occur to exposure of antigen
Causes are PCI , Cardiax surgery or trauma and MI (dressler syndrome)
208
How to treat post cardiac surgery syndrome?
| If not manage properly—> leads to constrictive pericarditis
Tx
NASID and colchicine
Steroid if refractory cases
209
If JVP pulse shows (1)Prominent V wave and absent X descent what condition is it?
1a) if shows Prominent A wave and flattened Y wave descent what condition is it?
And if (2)shows flattened Y wave what condition is it?
1) Tricuspid Regurgitation
Absent X wave descent due to elevated R-atrial pressure throughout ventricular systole
1a) Tricuspid stenosis
2) Pericardial effusion
External right ventricular compression with restricted diastolic filling
210
What is Cannon A waves?
Prominent A waves cause by surge in JVP due to R-atrium contraction against a closed tricuspid valve
Seen in AV dissociation (v-tach Or complete AV block)
211
Name the d/f types of Stress Test
1) If able to reach HR—> exercise ECG test
2) if Patient has LBBB, pacemaker placed Or unable to reach HR—-> pharma stress test with adenosine or dipyridamole
3) If patient has reactive airway disease Or unable to reach HR—> dobutamine Stress echo
212
What are different types of stress test contraindications?
| tHR (Targeted HR)
1) Don’t do Exercise ECG test if patient has LBBB, Pacemaker placed or Unable to reach tHR
2) Don’t do pharma stress test of patient has reactive airway diseases or patient taking theophylline/dipyridamole
3) Don’t do Dobutamine stress Echo—> if patient has tacchyarrhythmia
213
Name the Antiarrhymatic increase the PR, QRS and QT interval
Start with QT then QRS and then PR
1) Amidarone increases the duration of all three
2) Class 1a, Class 3 and Sotalol increases QT interval
3) Class 1c also increases QRS besides amidarone
4) Class 2, 4 , Sotalol and amidarone increase PR interval
214
Name the Antiarrhymatic increase the PR, QRS and QT interval
Start with QT then QRS and then PR
1) Amidarone increases the duration of all three
2) Class 1a, Class 3 and Sotalol increases QT interval
3) Class 1c also increases QRS besides amidarone
4) Class 2, 4 , Sotalol and amidarone increase PR interval
215
What are the causes of Multifocal Atrial tachycardia and how to manage it?
Surge of Catecholamines like in sepsis
Imbalance lytes like low potassium
Exacerbation of Pulmonary disease like COPD
Rx
t/m underlying cause
If condition persist even after t/m underlying cause then give AV nodal blocking agent
216
What are the causes of Stress induced (Takotsubo cardiomyopathy) and how to manage it?
Post menopausal female
Recent physical or emotional stress
Rx is supportive care as it will resolve on its own
217
What are d/f test to dx Stress induced (Takotsubo cardiomyopathy)?
ECG--->shows Ischemic changes in chest leads
Cath---> no blockage in coronary arteries
ECHO shows hypokinesis in apical LV whereas hyperkinesis in Basilar
218
How BB toxicity present physically and on ECG?
AMS with breathing d/f ( bronchospasm)
Low BP, HR and Glucose
Fits
EKG show Increase PR interval and bradycardia
219
How to manage BB toxicity?
First secure airway Along with IV fluid infusion
Not response---->.IV atropine
Not response--------> IV glucagon.
