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Flashcards in Cardiovascular Deck (128):
0

Chronic stable angina pectoris:
Underlying cause?

Fixed atherosclerotic stenosis of coronary arteries causes increased myocardial oxygen demand, leading to lactic acidosis

1

Chronic stable angina pectoris:
Precursor lesion of atherosclerosis?

Fatty streak containing foam cells (macrophages)

2

Chronic stable angina pectoris:
Why does the pain radiate together left arm?

Due to shared synapses with C4 and C 5 sensory fibers in the spinal cord (upper 4 intercostal nerves, intercostobrachial nerve)

3

Chronic stable angina pectoris:
What are the major risk factors?
Minor risk factors?

Major: DM, smoking, family history of CAD in first degree relatives or premature CAD (M<50 in females

Minor: age, obesity, estrogen deficiency, homocysteinemia (hypercoaguability)

4

Chronic stable angina pectoris:
What is the best initial test?
Expected findings?

ECG
ST depression, flattening of T waves
(Find ischemia, must rule out ACS)

5

Chronic stable angina pectoris:
Cardiac enzymes?

Should not be elevated

6

Chronic stable angina pectoris:
Next best step if ECG is nondiagnostic in a stable patient?

Exercise stress testing

Angina comes out in stress
ECG before, during, after

7

Chronic stable angina pectoris:
If the patient is unable to walk or exercise, what stress test?

Doubtamine or dypiridamole stress test

8

Chronic stable angina pectoris:
If patient with baseline ECG abnormalities, what stress test to order?

Nuclear stress test (thallium, sestamibi)

9

Chronic stable angina pectoris:
Most appropriate treatment?

Therapeutic lifestyle modifications in diet and exercise
Monitoring of lipid profile
Outpatient treatment with aspirin, nitrates, beta blockers, statins

10

Chronic stable angina pectoris:
Complications?

Acute MI
Aneurysms

11

Chronic stable angina pectoris:
If pain unrelieved by rest or nitrates, what is your assessment now?

Unstable angina---crescendo angina (part ACS)

12

Chronic stable angina pectoris:
If positive stress test, next best step in management?

Angiography
Start anti coagulation, aspirin, clopidogrel, nitrates, and beta blockers

13

Myocardial Infarction:
Pathology?

Ruptured atherosclerotic plaque

14

Myocardial Infarction:
ST elevation in leads V1 to V4 --- blood vessel involved?
Heart wall?

Left anterior descending artery
Anteroseptal wall

15

Myocardial Infarction:
Determine wall affected and blood supply:
V1, V2?
V3, V4?
II, III, avF?
I, avL, V5, V6?

Septal wall, LAD
Anterior wall, LAD
Inferior wall, right coronary
Lateral wall, left circumflex

16

Myocardial Infarction:
Never give nitrates to ___ wall infarction

Inferior

17

Myocardial Infarction:
Two forms? How to differentiate?

STEMI: Q waves, new LBBB, ST elevations in two or more contiguous leads or chest leads

NSTEMI: T wave inversion, ST depression

18

Myocardial Infarction:
Which patient populations will present with this condition in an atypical fashion?

Elderly patients
Diabetics---abdominal pain (umbilicus to jawline), diaphoresis
Women

19

Myocardial Infarction:
Cardiac enzymes to be requested?

Troponins, CK MB

20

Myocardial Infarction:
Troponins rise within ___ hours and are detectable for ___ weeks
Best marker for ___
Artificially increased in ___ (not cleared)

4
2
Recent MI
CKD

21

Myocardial Infarction:
CK-MB rise within ___ hours
Peaks at ___ hours and normalizes in ___ days
Best marker for ___

4
24
2 to 3
Reinfarction

22

Myocardial Infarction:
Most important initial interventions at the ER?

MONA
Morphine
Oxygen
Nitrates
Aspirin---chewed or sublingual

23

Myocardial Infarction:
Gold standard in treatment?

Percutaneous coronary intervention (if within 90 minutes)

24

Myocardial Infarction:
Management of STEMI and NSTEMI

STEMI: PCI or thrombolysis if PCI not available (most effective at 6 hours, effective up to 12 hours), anti coagulation with heparin

NSTEMI: PCI, anti coagulation with heparin
Thrombolysis has NO EFFECT in NSTEMI

25

Myocardial Infarction:
Absolute contraindications in thrombolysis?

Hemorrhagic CVD
Brain tumor
Head trauma
Ischemic CVD within 3 months
Active bleeding (exclude menses)
Aortic dissection

26

Myocardial Infarction:
Medications that have been shown to improve survival?

Aspirin
Beta blockers
ACE inhibitors
ARBs if with LV dysfunction

27

Myocardial Infarction:
Acute complications

Pump failure --- acute CHF
Arrythmias --- V fib --- first 24 hours
Flush pulmonary edema --- back flow of blood in pulmonary vessels --- batwing sign

28

Myocardial Infarction:
Extent of pump failure stratified?

KIllip classification
I: no evidence of heart failure
II: mild to moderate heart failure (s3 gallop, lung rales, jvd)
III: overt pulmonary edema
IV: cardiogenic shock

29

Myocardial Infarction:
CXR revealed pulmonary edema. Why?

Pump failure
LV dysfunction leads to back flow of blood into pulmonary vessels

30

Myocardial Infarction:
Other complications?

Myocardial aneurysm
Papillary muscle rupture
Rupture of interventricular septum
Free wall rupture
Pericarditis (Dressler syndrome)

31

Myocardial Infarction:
Papillary muscle rupture may be manifested by pan systolic murmur radiating to the axilla ___?
Most common cause?

Mitral regurgitation
Inferior wall MI

32

Myocardial Infarction:
Rupture of IV septum manifested by acute right sided HF, harsh ___ murmur in ___, thrill (manifestations similar to VSD)
Most common cause?

Holocystolic
LLSB
Anterior wall MI

33

Myocardial Infarction:
Free wall rupture manifested by sudden chest pain, acute heart failure, hemo___, tamponade, PEA, death in 90%
Most common cause?

Hemopericardium
Lateral wall MI

34

Myocardial Infarction:
Complication that develops weeks to months after. Pleuritic chest pain, pericardial friction rub, fever, treat with NSAIDs
Fibrinous pericarditis, autoimmune

Dressler syndrome

35

Myocardial Infarction:
Complication seen approximately after a month
Persistent ST elevation
Treated with warfarin, surgical repair

Myocardial aneurysm

36

Myocardial Infarction:
Patient develops severe bleeding after heparinization
What will you do?

Stop heparin
Give protamine sulfate

37

Myocardial Infarction:
Patient develops thrombocytopenia after heparinization
Heparin induced thrombocytopenia
What will you do?

Stop heparin
Give lepirudin or argatroban --- direct thrombin inhibitor

38

Congestive Heart Failure:
Most common cause of RHF?

LHF
Note that they can occur together

39

Congestive Heart Failure:
Most important manifestations

Dyspnea
Easy fatigability

40

Congestive Heart Failure:
Underlying cause?

Ventricular dysfunction secondary to CHD or HTN

41

Congestive Heart Failure:
If caused by pulmonary etiology?

Coe pulmonale

42

Congestive Heart Failure:
HP changes?

Concentric LV hypertrophy due to pressure overload
Siderophages (hemosiderin laden macrophages or heart failure cells)

43

Congestive Heart Failure:
Concentric LV hypertrophy --- CHF
While eccentric LV hypertrophy --- ___?

Hyperthyroidism

44

Congestive Heart Failure:
Forms?

Systolic vs diastolic
Low output vs high output
Left vs right

45

Congestive Heart Failure:
Hepatojugular reflux seen in?

Right sided heart failure

46

Congestive Heart Failure:
Systolic vs diastolic --- how?

Systolic HF has low EF less than 40%
Diastolic HF has preserved EF >40 to 50%

47

Congestive Heart Failure:
Low output versus high output --- how?

Low output HF: CO less than 2.5L/min per m2 e.g. MI, HTN, cardiomyopathy

High output HF: CO more than 3.5L/min per m2 e.g. Hyperthyroidism, anemia, beriberi, pregnancy, AV fistula

48

Congestive Heart Failure:
Left vs right?

Left: pulmonary congestion, orthopnea, weakness
Right: peripheral edema, congestive hepatomegaly, systemic venous congestion

49

Congestive Heart Failure:
Functional status assessment?

NYHA Functional Classification
I: no limitation of physical activity
II: slight limitation of physical activity
III: marked limitation of physical activity
IV: complete limitation of physical activity

50

Congestive Heart Failure:
Clinical criteria for diagnosis?

Frammingham Criteria --- see handout page 31

51

Congestive Heart Failure:
Orthopnea?

Redistribution of fluid from the splanchnic circulation and lower extremities into the central circulation during recumbency

52

Congestive Heart Failure:
PND?

Increased pressure in the bronchial arteries leading to airway compression, along with interstitial pulmonary edema

53

Congestive Heart Failure:
Irregular pattern of respiration?

Chyne-Stokes Respiration due to diminished sensitivity of respiratory center to arterial PCO2

54

Congestive Heart Failure:
Why with crackles?

Transudation of fluid from the intravascular space into the alveoli

55

Congestive Heart Failure:
Why abdominal pain?

Chronic passive congestion of the liver leads to distinction of the Glisson's capsule

56

Congestive Heart Failure:
Most important diagnostic test?

2D echocardiography --- assess EF!

57

Congestive Heart Failure:
Use of BNP?

Differentiate cardiogenic from noncardiogenic pulmonary edema during acute SOB
Normal BNP excludes CHF as a cause of SOB

58

Congestive Heart Failure:
Seen on CXR?

Cardiomegaly
Pulmonary congestion
Kerley B lines

59

Congestive Heart Failure:
CXR = pulmonary edema --- most important treatment?

Loop diuretics --- furosemide --- make sure patient has adequate urine output!

60

Congestive Heart Failure:
Drug that decreases hospitalization rate but has no effect on overall mortality?

Digoxin --- inotropic support only

61

Congestive Heart Failure:
Drugs to decrease mortality?

ACE inhibitors / ARBs (EF <35)

AICD---automated int cardiac defibrillation

62

Infective Endocarditis:
What valve?

Tricuspid valve

63

Infective Endocarditis:
Most common MO?

Staphylococcus aureus

64

Infective Endocarditis:
Complications?

Chordate tendinae
Septic embolism

65

Infective Endocarditis:
Virulence factor that conveys:
Penicillin resistance?
Complement inactivation?
Ability to cause chordae rupture?

Penicillin are
Protein A
Hyaluronidase

66

Infective Endocarditis:
Most common cause of:
Acute?
Subacute?
In IV drug abusers?
Native valve?
Prosthetic?
Culture negative?
In the setting of Colin CA?
In the setting of GI surgery?
After open heart surgery?

S. aureus
Viridans strep
S. aureus
Viridans strep
S. epidermidis (coagulase negative staphylococcus)
HÁČEK
S. bovis (marantic endocarditis)
E. faecalis
Fungal

67

Infective Endocarditis:
If occurred in the setting of a patient with SLE, what is your diagnosis?

Libman-Sacks Endocarditis (veg on MV surface and chordae tendinae) or Verrucous Endocarditis (MC for rheumatic -- veg on lines of closure of valve)

68

Infective Endocarditis:
Best initial test?

Transthoracic echocardiography

69

Infective Endocarditis:
Other test besides Transthoracic echocardiography?

Blood cultures from two non contiguous sites

70

Infective Endocarditis:
Criteria used for diagnosis?

Duke's Criteria --- see handout page 32

71

Infective Endocarditis:
Vascular phenomena associated?

Major arterial emboli
Septic pulmonary infarcts
Mycotic aneurysm
Intracranial hemorrhage
Conjunctival hemorrhages
Splinter hemorrhage
Janeway lesions

72

Infective Endocarditis:
Immunologic phenomena associated?

Glomerulonephritis
Osler's nodes
Ruth's spots
Rheumatoid factor

73

Infective Endocarditis:
Most appropriate treatment?

Empiric therapy until cultures are available
Vancomycin plus gentamicin

74

Infective Endocarditis:
High risk patients needing prophylaxis before dental procedures?

Prosthetic valves
Prior IE
Unrepaired cyanotic CHD
Recently repaired CHD
Incompletely repaired CHD
Valvulopathy post transplant

75

Infective Endocarditis:
Drug given for standard prophylaxis before dental procedures?

Amoxicillin --- but if with allergy, give Clindamycin or Clarithromycin

76

Valve defect: apical low pitched diastolic murmur with opening snap?
May be due to previous ___

Mitral stenosis
Rheumatic fever

77

Rheumatic Heart Disease:
HP changes seen in the myocardium?

Aschoff bodies (Anitschkow myocytes)

78

Rheumatic Heart Disease:
Hemodynamic changes?

Increased left atrial diastolic pressure

Eventual atrial fibrillation?

79

Rheumatic Fever:
Criteria for diagnosis?

Jones criteria
See page 32 of your handout

80

What infection usually precedes acute rheumatic fever?

S. pyogenes (GABHS) --- impetigo or pharyngitis

81

Rheumatic Fever:
Pathophysiologic mechanism?

Type II immune reaction, immunologic cross reaction due to streptococcal M proteins --- protein in the heart valves
Molecular mimicry

82

What is Rheumatic Heart Disease?

Long term sequelae of repeated bouts of ARF characterized by permanent valvular damage

83

Most common valvular defects in
Acute rheumatic fever?
Rheumatic heart disease?

Mitral regurgitation
Mitral stenosis

85

Best initial test for ARF or RHD?

2D echocardiography

86

RHD: most appropriate treatment?

surgical repair (valvotomy, commisurotomy --- severe stenosis)
anticoagulation
diuretics

87

What is the most common valvular HD?

MVP (most common)
MS
MR
AS
AR

88

What conditions are associated with MVP?

connective tissue disorders

Ehlers-Danlos Syndrome
Marfan Syndrome
Polycystic Kidney Disease

NOTE: CT d/o -- formation of aneurysms in the Circle of Willis

89

What is the murmur of MVP?

Midsystolic click followed by a midsystolic to late systolic murmur at apex

90

What is the murmur of mitral stenosis?

Opening snap followed by mid diastolic rumble, loud S1 and P2, low pitched rumbling

91

Clinical presentation of MS

Usually asymptomatic until atrial fibrillation pr pregnancy develops

92

What is the murmur of mitral regurgitation?
what are the other signs of MR?

holosystolic murmur at apex radiating to the axilla
MR HOLO

hyperdynamic precordium, brisk carotid upstroke

93

What is the murmur of aortic stenosis?

early systolic ejection murmur at second right ICS, radiating to carotids

94

What are the signs of severe AS?

Gallavardin phenomenon: murmur disappears over sternum, reappears in apex
Pulsus parvus et tardus: small or weak pulse that rises slowly and delayed in occurence

95

murmur disappears over sternum, reappears in apex

Gallavardin phenomenon

96

small or weak pulse that rises slowly and delayed in occurence

Pulsus parvus et tardus

97

what is the murmur of aortic regurgitation?

blowing decrescendo early diastolic murmur in LLSB

98

what are the signs of severe AR?

Austin Flint murmur (mid or late diastolic rumble)
Pulsus bisferiens (double peaking pulse seen when AR occurs with AS)

99

double peaking pulse seen when AR occurs with AS

pulsus bisferiens

100

what are the classic signs of aortic regurgitation?

Corrigan pulse: rapid rise and fall of carotid pulse

Quinke pulse: subungal capillary pulsations

Duroziez sign: diastolic murmur over partially compressed femoral artery

De Musset sign: head bobbing with heart beat

Hill sign: systolic BP >30mmHg in legs than arms

Traube sign: pistol shot femoral pulses

101

Corrigan pulse / Quinke pulse / Duroziez sign / De Musset sign / Hill sign / Traube sign?

rapid rise and fall of carotid pulse

Corrigan pulse

102

Corrigan pulse / Quinke pulse / Duroziez sign / De Musset sign / Hill sign / Traube sign?

subungal capillary pulsations

Quinke pulse

103

Corrigan pulse / Quinke pulse / Duroziez sign / De Musset sign / Hill sign / Traube sign?

diastolic murmur over partially compressed femoral artery

Duroziez sign

104

Corrigan pulse / Quinke pulse / Duroziez sign / De Musset sign / Hill sign / Traube sign?

head bobbing with heart beat

De Musset sign

105

Corrigan pulse / Quinke pulse / Duroziez sign / De Musset sign / Hill sign / Traube sign?

systolic BP >30mmHg in legs than arms

Hill sign

106

Corrigan pulse / Quinke pulse / Duroziez sign / De Musset sign / Hill sign / Traube sign?

pistol shot femoral pulses

Traube sign

107

What is the effect of Valsalva on murmurs?

Increases the intrathoracic pressure
Decreases venous return
Decreases intensity of murmurs

108

What is the effect of squatting on murmurs?

Increases venous return
Increases intensity of murmurs

109

Valsalva maneuver
Standing
Hypovolemia
Vasodilation

Preload increased or decreased?

decreased

110

Squatting
Volume expansion
Bradycardia
Beta blockers

Preload increased or decreased?

increased

111

Squatting
Hypertension
Hand gripping
Volume expansion

Afterload increased or decreased?

increased

112

diffuse ST segment elevations is seen in?

pericarditis

113

pulsus paradoxus is seen in?

tamponade
severe bronchial asthma
pericarditis

114

Pericarditis:
What are the pathophysiologic types of this condition?

Serous pericarditis
Fibrinous pericarditis
Hemorrhagic pericarditis

115

Pericarditis:
most common infectious etiology?

Coxsackie virus type B

116

Pericarditis:
Best initial test for this condition? What are the expected findings?

ECG
Diffuse ST elevations and PR depression

117

Pericarditis:
Most appropriate treatment?

NSAIDs

118

Pericarditis:
If the patient developed pericardial tamponade --- triad observed?

BECK'S TRIAD
Hypotension
JVD
Distant or muffled heart sounds

119

Pericarditis:
If the patient developed pericardial tamponade --- triad observed?
Other findings?

BECK'S TRIAD
Hypotension
JVD
Distant or muffled heart sounds

Pulsus paradoxus (>10mmHg fall in BP with inspiration)
Kussmaul sign (sharp increase in JVP with inspiration --- normally, there should be a decrease)
Ewart sign (dullness, increased fremiti, egophony at left scapula)
Water bottle heart

120

Pericarditis: Pericardial Tamponade
>10mmHg fall in BP with inspiration

pulsus paradoxus

121

Pericarditis: Pericardial Tamponade
sharp increase in JVP with inspiration --- normally, there should be a decrease

Kussmaul sign

122

Pericarditis: Pericardial Tamponade
dullness, increased fremiti, egophony at left scapula

Ewart sign

123

Where can you find a water bottle heart?

Pericarditis --> Pericardial Tamponade

124

ECG findings in cardiac tamponade?

decreased QRS voltage and electrical alternans (wandering baseline)

125

Most appropriate treatment for cardiac tamponade?

Pericardiocentesis

126

Constrictive pericarditis versus acute pericarditis? (3 points of differentiation)

Constrictive pericarditis presents with JVD, signs of R sided HF, and a pericardial knock (due to thickened pericardium)

127

What is the best initial test for constrictive pericarditis? Expected finding?

Transthoracic echocardiography showing increased pericardial thickness with calcification

128

What is the most appropriate treatment for constrictive pericarditis?

Mild cases: diuretics, ACE-inhibitors
Severe cases: pericardiectomy