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Level 2 Boards > Cardiovascular > Flashcards

Cardiovascular Flashcards

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1
Q

Normal HR

A

60-100 bpm

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2
Q

Right axis deviation causes (4)

A

Right ventricular hypertrophy

Anterolateral MI

Left Posterior Hemiblock

(also consider PE)

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3
Q

Left Axis deviation causes (4)

A

Ventricular tachycardia

Inferior myocardial infarction

Left ventricular hypertrophy

Left anterior hemiblock

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4
Q

Jervell and Lange-Nielsen syndrome

A

Long QT syndrome due to a defect in K channel conduction.

Associated with sensorineural deafness

Treat with Beta blockers and pacemaker

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5
Q

Left bundle branch block

A

WiLLiaM

V1= W QRS pattern
V6= M QRS pattern

Acute MI

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6
Q

Right bundle branch block

A

MaRRoW

V1= M QRS pattern
V6= W QRS pattern

Rabbit ears (M Shaped) in V1

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7
Q

Right atrial abnormality

A

P pulmonale

causes Peaked P waves

> 2.5 mm in lead II

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8
Q

Left atrial abnormality

A

P mitrale

Mitrale causes M shaped P waves

P wave width in Lead II is > 120 sec

Notched P waves

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9
Q

Right sided murmurs do what

A

Increased with inspiration

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10
Q

Left sided murmurs do what

A

Increased with expiration

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11
Q

JVD measurement

A

> 4 cm above sternal angle

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12
Q

Kussmaul sign

A

Increase in jugular venous pressure (JVP) with inspiration

Seen in constrictive pericarditis

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13
Q

An early decrescendo murmur

A

Aortic regurgitation

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14
Q

A mid to late low pitched murmur

A

Mitral stenosis

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15
Q

S3 gallop

A

Rapid ventricular filling due to fluid overload

A sign of fluid overload

Heart failure, mitral valve disease

Normal in young and pregnancy

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16
Q

S4 gallop

A

Stiff noncompliant ventricle

A sign of decreased compliance

Hypertension, aortic stenosis, diastolic dysfunction,

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17
Q

Hear a “plop” while listening to chest

A

Atrial myxoma

Can develop systemic embolization from breakoff of tumor leading to stroke

Tx: Resection

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18
Q

Wolff-Parkinson White

Tx

A

Abnormal fast accessory conduction pathway from atria to ventricle (Bundle of kent)

Delta wave with widened QRS complex and shortened PR interval

Advise against vigorous activity

Procainamide for arrhythmias

Calcium channel blockers are contraindicated

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19
Q

Management for atrial fibrillation (4)

A

ABCD

Anticoagulate
B-blockers to control rate
Cardiovert/calcium channel blockers
Digoxin (in refractory cases)

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20
Q

Collapsing (“waterhammer”) peripheral pulse

A

Aortic incompetence

AV malformation
Patent ductus arteriosus
thyrotoxicosis
Severe anemia

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21
Q

Pulsus paradoxus

A

Decrease in systolic blood pressure >10 Hg with inspiration

Cardiac tamponade
Pericardial constriction
Tension pneumothorax
Foreign body in airway

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22
Q

Pulsus alternans

A

Alternating weak and strong pulses

Cardiomyopathy
Impaired left ventricular systolic function

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23
Q

Jerky peripheral pulses

A

Hypertrophic obstructive cardiomyopathy

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24
Q

Pulsus bisferiens

A

Bifid pulse/ twice beating

Aortic regurgitation
Combined aortic stenosis and aortic regurgitation
Hypertrophic obstructive cardiomyopathy

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25
What can be used to increase heart rate
Atropine
26
Causes of arrthymias
Beta blockers | CCB
27
No P waves Variable and irregular QRS response - Tx
Atrial fibrillation Tx: Beta blockers, CCB or digoxin Anticoagualtion w/ warfarin
28
Causes Atrial fibrillation
PIRATES ``` Pulmonary disease Ischemia Rheumatic heart disease Anemia/ Atrial myxoma Thyrotoxicosis Ethanol Sepsis ```
29
Estimate stroke risk in atrial fibrillation
CHA(2)DS(2)-VASc ``` CHF (1 point) HTN (1 point) Age >= 75 (2points) Diabets (1 point) Stroke or TIA history (2 points) ``` ``` Vascular disease (1 pt) Age 65-74 (1 pt) Sex Category (female) 1 point ```
30
Ventricular tachycardia tx
Amiodarone Lidocaine Procainamide (If stable)
31
Ventricular fibrillation tx
no pulse Electrical defibrillation
32
CXR findings for CHF diagnosis (5)
ABCDE ``` Alveolar edema (Bat's wings) Kerley B lines (interstitial edema) Cardiomegaly Dilated prominent upper lobe vessels Effusion (pleural) ```
33
How to diagnose CHF
Echocardiogram ( tarnsthoracic echocardiogram)
34
Left sided CHF symptoms ( 6)
``` Dyspnea predominates Left sided S3/S4 gallop Bilateral basilar rales Pleural effusions Pulmonary edema Orthopnea, paroxysmal nocturnal dyspnea ```
35
Right sided CHF symptoms (6)
``` Fluid retention predominates Right sided S3/S4 gallop JVD Hepatojugular reflux Peripheral edema Hepatomegaly, ascites ```
36
Acute CHF management (5)
LMNOP ``` Lasix (furosemide) Morphine NItrates Oxygen Position (sit upright) ```
37
CHF management
Loop diuretics ACEI or ARBS w/ loops Beta blockers (avoid when decompensated) but started once euvolemic
38
Loop diuretics (4) SE (6)
Furosemide Ethacrynic acid Bumetanide Torsemide ``` SE: ototoxicity Hypokalemia Hypocalcemia Hyeruricemia Dehydration Gout ```
39
Thiazide diuretics (3) SE (6)
Hydrochlorothiazide Chlorothiazide Chlorthalidone ``` SE: Hypokalemic metabolic alkalosis Hyponatremia HYperGLUC (hyperglycemia, hyperlipidemia, hyperuricemia, hyperCalcemia) ```
40
K sparing agents (4) SE (3) Exception
Spironolactone Eplerenone Triamterene Amiloride SE: Hyperkalemia Gynecomastia Sexual dysfunction Eplerenone does not have antiandrogenic effects that lead to gynecomastia
41
Carbonic anhydrase inhibitors SE (4)
Acetazolamide ``` SE: Hyperchloremic metabolic acidosis Neuropathy NH3 toxicity Sulfa allergy ```
42
Osmotic agents SE (2) CI (2)
Mannitol SE: Pulmonary edema Dehydration CI: Anuria CHF
43
Acute decompensated heart failure tx
Inotropic agents (dobutamine) reduces left ventricular end systolic volume for symptomatic improvement
44
When to place cardiac defibrillator
EF < 35%
45
When to place pacemaker
EF < 35 Dilated cardiomyopathy Widened QRS complex with persistent symptoms
46
Diuretic taht looses alcium
Loops lose calicum Thiazides take in
47
College man passes out playing basketball, ECG shows slurred upstroke of QRS
Wolff-Parkinson white syndrome
48
Dilated Cardiomyopathies Abnormality Left ventricular cavity size (end diastole) Left ventricular cavity size (end diastole) EF Wall thickness
Impaired contractility Large Increased Left ventricular cavity size (end diastole) Large Increased Left ventricular cavity size (end diastole) Decreased EF Wall thickness decreased Balloon like heart
49
Hypertrophic Cardiomyopathies Abnormality Left ventricular cavity size (end diastole) Left ventricular cavity size (end diastole) EF Wall thickness
Impaired relaxation Decreased Left ventricular cavity size (end diastole) Large Decreased Left ventricular cavity size (end diastole) Increased or normal EF Wall thickness largely increased Tx: BB/CCB
50
Restrictive Cardiomyopathies Abnormality Left ventricular cavity size (end diastole) Left ventricular cavity size (end diastole) EF Wall thickness
Impaired elasticity Decreased Left ventricular cavity size (end diastole) Decreased Left ventricular cavity size (end diastole) Normal EF Wall thickness increased Caused by: amyloidosis, sarcoidosis, hemochromatosis)
51
Harsh systolic ejection crescendo-decrescendo murmur in the lower left sternal edge that increases with decrease in preload (valsalva, standing) and decreases in increase in preload ( passive leg raise) Tx
Hypertrophic cardiomyopathy Abnormal mitral leaflet motion= systolic anterior motion of mitral valve Anterior motion of mitral valve leaflets toward the interventricular septum ``` Beta blockers (initial therapy) Non-dihydropyridine CCB ``` CI: Digoxin and spironolactone
52
Prinzmetal angina
Young women Early morning at rest TX: CCB with or without nitrates
53
TIMI Risk score for Unstable Angina/ NSTEMI
Age >= 65 (1pt) Three or more CAD risk factors (1 pt) [ Premature fm hx, DM, smoking, HTN, Increased cholesterol, PAD, abdominal aortic aneurysm] Known CAD; stenosis > 50% (1 pt) ASA use in past 7 days (1 pt) Severe angina (1 pt) [Two or more episodes within 24 hours] ST deviation >= 0.5 mm (1 pt) + cardiac marker (1 pt) >= 3 pts benefit more from enoxaparin (vs unfractionate heparin), glycoprotein IIB/II inhibitors (abciximad, tirofiban, eptifibatide) and early angiography
54
TX MI
MOANing Big from MI (MONA-B) ``` Morphine Oxygen ASA+ Additional second antiplatelet agent (NSTEMI) [Prasugrel or ticagrelor] Nitrates B-blockers ``` IV morphine w/ IV metoclopramide Heart failure: avoid beta blockers (give ACEI)
55
Enoxaparin
Low molecular weight heparin
56
STEMI ECG changes
1) Peaked T waves 2) ST segment elevation 3) Q waves 4) T wave inversion 5) ST segment normalization 6) T wave normalization over several hours to days
57
Cardiac enzymes
Troponin most sensitive 3-12 hrs to rise (troponin and CK-MB) Troponin peaks 24-48 CKMB peaks 24 hrs
58
ST segment elevated leads II, III, aVF
Inferior MI RCA PDA LCX Avoid nitrates and diuretics due to risk for severe hypotension (preload dependent)
59
ST segment elevations V1-V4
Anterior MI LAD Diagonal branches
60
St segment elevations Leads I, AVI, V5-V6
Lateral MI LCA Diagonal
61
ST segment depression in V1-V3 ST elevation in leads I and aVL or ST depression in leads I and aVL
Posterior MI LCX RCA ST elevation in leads I and aVL= LCX ST depression in leads I and aVL= RCA
62
Contraindications to thrombolysis (5)
1. Previous intracranial hemorrhage or major GI bleed 2. Recent major trauma/ surgery/ head injury 3. Ischemic stroke within the last 6 months 4. Severe HTN (>180/110) 5. Known bleeding disorder
63
Timeline of complications post MI
First day: Heart failure 2-4 days: arrhythmia, pericarditis 5-10 days: 1) left ventricular wall rupture (acute pericardial tamponade causing electrical alternans, pulseless electrical activity, JVD) 2) papillary muscle rupture (severe mitral regurgitation, pulmonary edema) 3) Septal rupture (lower left sternal border murmur, increased O2 saturation in the right ventricle) weeks to months: ventricular aneurysm (CHF, arrhythmia, persistent ST segment elevation, mitral regurg, thrombus formation)
64
Post MI 2-4 weeks Fever, pericarditis pleural effusion Leukocytosis Increased ESR
Dressler syndrome
65
Dyslipidemia
LDL > 130 mg/dL or | HDL < 40 mg/dL
66
HMG-COA reductase inhibitors (5) Effects of lipids SE (3)
``` Atorvastin Simvastatin Lovastatin Pravastin Rosuvastatin ``` Decrease LDL Decrease Triglycerides SE: Elevated LFT Myositis Warfarin potentiation
67
Lipoprotein lipase stimulators (fibrates) Effects of lipids SE (5)
Gemfibrozil Decrease triglycerides Increase HDL ``` SE: GI upset Cholelithiasis Myositis (esp in combo w/ statin) Increased LFT Pancreatitis ```
68
Cholesterol absorption inhibitors Effects of lipids SE (3)
Ezetimibe Decrease LDL SE: Diarrhea Abdominal pain Can cause angioedema
69
Niacin Effects of lipids SE (5)
Decrease LDL Increased HDL ``` Skin flushing (can be prevented w/ ASA, due to increase in prostaglandins) Paresthesias Pruritus GI upset Increased LFTs ```
70
Bile acid resins (3) Effects of lipids SE (5)
Cholestyramine Colestipol Colesevelam Decrease LDL ``` SE Constipation GI upset LFT Abnormalities Myalgias Can decrease absorption of other drugs from small intestine ```
71
Proprotein convertase subtilisin/ kexin type 9 (PSCK9) inhibitors (2) Effects of lipids SE (4)
Evolocumab Alirocumab (injectable 2-4 weeks) Decrease Decrease LDL Injection site swelling Rash Muscle/ limb pain Backache
72
HTN non african american tx
ACEI/ ARB Thiazide CCB
73
HTN african american tx
Thiazide | CCB
74
HTN w/ CKD tx
ACEI/ ARB
75
HTN 1) uncomplicated 2) CHF 3) Diabetes 4) Post MI 5) CKD 6) BPH 7) Isolated systolic HTN 8) Pregnancy
1) uncomplicated: Diuretics, CCB, ACEI 2) CHF: Diuretic, Beta blocker, ACEI, ARB, Aldosterone antagonist 3) Diabetes: Diuretics, ACEIs, ARBs, CCBs 4) Post MI: Beta blocker, ACEI, ARB, Aldosterone antagonist 5) CKD: ACEI, ARBs 6) BPH: Diuretics, alpha adrenergic blockers 7) Isolated systolic HTN: Diuretics, ACEIs, CCB (dihydropyridines) 8) Pregnancy: Methyldopa, beta blockers (labetalol), hydralazine
76
BP > 180/120
Hypertensive crises IV medications: labetalol, nitropruside, nicardipine)
77
Pericardial calcifications seen on CXR suggest
Constrictive pericarditis due to chronic fibrosis and calcification of the pericardium
78
Cardiac tamponade tx
Aggressive volume expansion with IV fluids Urgent pericardiocentesis
79
Ascending aortic aneurysm vs descending aortic aneurysm
Ascending - think cystic medial necrosis or connective tissue disease Descending aortic aneurysm - think atherosclerosis
80
Rapid onset of pulmonary congestion, cardiogenic shock and severe dyspnea
Acute aortic regurgitation [ From infective endocarditis, aortic dissection, chest trauma, MI]
81
Uncomfortable heart pounding when laying on left side
Aortic regurgition (chronic)
82
Aortic regurgitation PE (6) Tx
PE: 1) Early blowing diastolic murmur at the left sternal border 2) Mid-diastolic rumble (austin flint murmur) 3) Midsystolic apical murmur Head bob with heart beat Water hammer pulse (corrigan sign) Duroziez sign (femoral bruit) Tx: Vasodilator therapy (dihydropyridine or ACEI)
83
Opening snap and mid diastolic murmur at the apex Pulmonary edema Tx
Mitral valve stenosis Tx: Antiarrhythmics (Beta blockers, digoxin, CCB) and warfarin
84
Aortic dissection due to Aortic aneurysm due to
Dissection: HTN Aneurysm: atherosclerosis
85
Common site of aortic dissection
Above the aortic valve and distal to the left subclavian artery
86
Hypotension | Severe tearing abdominal pain that radiates to the back
Aortic aneurysm Tx: <5 cm monitor >5.5 (abdominal) surgery > 6 cm (thoracic) surgery
87
Sudden tearing/ ripping pain in the anterior chest with or without radiation fo the back Hypertensive Diagnose?
Aortic dissection ``` Anterior chest pain ( ascending) Back pain (descending) ``` If stable: CT angiography Unstable: TEE
88
Screening AAA
men 65-75 who ever smoked
89
Aortic dissection types
Type A: ascending aortia and may progress to involve the arch and thoracoabdominal aorta [More common] Type B: descending thoracic or thoracoabdominal aorta distal to the left subclavian artery without involvement of the ascending aorta [Can be managed medically, IV beta blockers (labetalol) before starting vasodilators (nitroprusside)
90
Imaging for DVT Tx DVT
Doppler Ultrasound TX: LMWH or IV unfractionated heparin followed by PO warfarin for 3-6 months
91
Imaging for PE Tx PE
Spiral CT or V/Q scan TX: LMWH or IV unfractionated heparin followed by PO warfarin for 3-6 months
92
Calf claudication= Buttock claudication= Buttock claudication+ impotence=
Calf claudication= femoral disease Buttock claudication= iliac disease Buttock claudication+ impotence= Leriche syndrome (aortoiliac occlusive disease)
93
Cough Progressive dyspnea Orthopnea Atrial fibrillation with rapid ventricular response Immigrated to US from India Recurrent sore throat as child
Cough, Progressive dyspnea, orthopnea= pulmonary edema with rapid decompensation due to development of new atrial fibrillation Recurrent sore throat= rheumatic heart disease Mitral stenosis is diagnosis [Rheumatic mitral stenosis can become symptomatic w/ pregnancy]
94
Elevated jugular venous pressure Hepatomegaly Ascites Peripheral edema
Constrictive pericarditis
95
Peripartum cardiomyopathy (PPCM)
Rapid onset of systolic heart failure Fatigue Dyspnea Cough Pedal edema at > 36 weeks
96
``` 80 y.o Purulent ulcer Hypotension Tachycardic Tachypnea Lethargy Confusion ```
Septic shock 1) Decreased systemic vascular resistance (reduced afterload) due to peripheral vasodilation 2) Decreased pulmonary capillary wedge pressure (left atrial pressure) due to capillary leakage, which causes decreased preload 3) Elevated mixed venous oxygen saturation due to hyperdynamic circulation with an inability of tissues to adequately extract oxygen
97
Types of shock Central venous pressure (right sided preload) PCWP (left sided preload) Cardiac index (LV output) SVR (afterload) SvO2
Hypovolemic - mass hemorrhage Low CVP, PCWP, CI, SvO2 High SVR Cardiogenic shock - decreased cardiac contractility High CVP, PCWP, SVR Low CI, SvO2 ``` Obstructive shock - increased intrapericardial pressure - pulmonary artery embolism High: CVP, SVR Low: PCWP, CI, SvO2 ``` ``` Distributive - septic shock - neurogenic shock High: CI, SvO2 Low: CVP, PCWP, SVR ``` See screen shot
98
Biphasic stridor in child that improves with extension
Vascular ring
99
Orthostatic hypotension caused by
Decreased baroreceptor responsiveness Insufficient constriction of blood vessels in the lower extremities on standing
100
21 y.o dizziness and palpitations Provoked by fatigue or strong emotions Can stop episode by squatting or taking a deep breath Hypotension Cool extremities Regular narrow complex tachycardia What to do
Supraventricular tachycardia (SVT) Causes hemodynamic instability (hypotension, cool extremities) Tx: Cardioversion
101
Diagnosing aortic dissection
Hemodynamically stable patients= CT angiography If Renal insuffiency= tranesophageal echocardiography (diabetes)
102
Why is K high in CHF
Low distal sodium and water delivery in CHF —> reduced potassium excretion and subsequent hyperkalemia
103
Brain natriuretic peptide (BNP)
hormone released from ventricular myocytes in response to high ventricular filling pressures and wall stress in patients CHF
104
CHF signs (5)
Progressive dyspnea Fatigue Elevated BNP Third heart sound Peripheral edema
105
Exertional dyspnea Orthopnea Nocturnal cough Hemoptysis Emigrated from cambodia 2 years ago Palpitations and irregular heart rate
Rheumatic heart disease Mitral stenosis Risk of development of atrial fibrillation —> left atrial thrombus —> systemic thromboembolic complications (stroke)
106
Syncope while working in garden HTN Tachycardia Widening of mediastinum Small pericardial effusion
Acute aortic dissection Type A (ascending aorta) into pericardial space CT angiography
107
Leg apain Hx Afib Smoker Mottled skin that is cool Pulses not palpable Medication to prevent this
Embolism of a left atrial thrombus Anticoagulation therapy Apixaban: non-vit K antagonist oral anticoagulant (NOAC) directly inhibits factor Xa [Apixaban, dabigatran, rivaroxaban, edoxaban] Aspirin and clopidogrel less effective
108
Harsh crescendo decrescendo systolic ejection murmur over the left upper sternal border
Pulmonary stenosis Tetralogy of fallot
109
Ring of calcification around the heart
Tuberculosis
110
Initial stabilization of acute ST elevated MI
MONA-B ``` Oxygen Aspirin PSY12 inhibitor (clopidogrel) Nitrates Beta blocker Statin Anticoagulation ``` If persistent pain, HTN or heart failure= IV nitroglycerin If persistent severe pain= IV morphine If unstable sinus bradycardia= IV atropine If Pulmonary edema= IV furosemide [If pulmonary edema dont give beta blocker]
111
Right lung biopsy develop= Chest pain Hypotension Severe dyspnea Low cardiac index High PCWP
Cardiogenic shock = Acute MI
112
Maneuvers that increase preload or afterload
Squatting Leg raise Hand grip Supine
113
Maneuvers that decrease preload
Valsalva | Abrupt standing
114
Syncope while peeing
Situational (postmicturition) syncope Form of vasovagal syncope (neurally mediated) Triggers: Micturition, defecation, cough Cardioinhibitory response
115
Patient on digoxin New medication added Anorexia Nausea Generalized weakness now - Also seen features (2)
Drug interaction w/ amiodarone Digoxin toxicity Can lead to color vision changes Atrial tachycardia with AV block
116
From Asia Febrile illness a year ago, with pain and swelling in knees and wrists given NSAIDS Holosystolic murmur at apex radiates to left axilla Mitral regurgitation Tx
Rheumatic heart disease High risk for recurrence Need antibiotic therapy Should receive prophylaxis IM benzathine pencillin G every 4 weeks to prevent recurrence
117
On medication for A fib Treadmill exercise test Heart rate dramatically increases and QRS complex increases What medication
Class I antiarrhythmic drugs that block sodium channels by inhibiting initial depolarization phase Flecainide Propafenone When patient has faster heart rate drug has less time to dissociate from sodium channels—> higher number blocked channels —> progressive decrease in impulse conduction and widening of QRS complex "Use dependence"
118
Amlodipine
Dihydropyridine CCB [no QRS effect]
119
Verapamil | Diltiazem
CCB Prolong refractory period of AV node and increase PR interval
120
Uncontrolled HTN Progessive dyspnea Lower extremity swelling JVD Prominent V waves Holosystolic murmur at left lower sternal border
Decompensated left sided heart failure Tricuspid regurgitation Secondary TR results from right ventricular cavity enlargement from chronic right sided volume/pressure overload (right sided heart failure) Left sided heart failure causes right sided RV enlargement causes tricuspid annular dilation Prominent V waves are highly specific for TR
121
Rumbling diastolic murmur at left lower sternal border no JVP Prominent A wave
Fusion of tricuspid valve commissures [Rheumatic heart disease] Tricuspid stenosis
122
Chest pain given medications aspirin, clopidogrel, LMWH, metoprolol, and lisinopril Hx: Allergic rhinitis Eczema Second day: acute onset dyspnea with wheezing and prolonged expieration
Bronchoconstriction Undiagnosed asthma that was exacerbated by aspirin
123
25 y.o Transient vision loss in right eye Elevated blood pressure Bruit below right mandibular angle High plasma renin Grandmother stroke at 50 - Name - MOA
Fibromuscular dysplasia (FMD) Transient monoocular vision loss is consistent with amaurosis fugax Emboli from severe ipsilateral carotid stenosis cause cause ischemia of optic nerve FMD: noninflammatory and nonatherosclerotic condition caused by abnormal cell developemnt in the arterial wall —> vessel stenosis, aneurysm or dissection Commonly: renal, carotid and vertebral arteries Headache Pulsatile tinnitus Dizziness Transient ischemic attack Stroke Amaurosis fugax Dx: CT angiography of abdomen or duplex U/S FMD decreases perfusion to kidneys which increases both renin and aldosterone levels
124
Preventive medication for anginal episodes How does it work
Beta blockers (first line) Decreased myocardial contractility and decrease in HR
125
Coronary artery vasodilation medication
Dihydropyridine calcium channel blockers Amlodipine Felodipine They increase myocardial oxygen supply by vasodilation and reduce myocardial oxygen demand through systemic arterial vasodilation and reduction of afterload
126
Decreases cardiac afterload
Dihydropyridine calcium channel blockers Amlodipine Felodipine They increase myocardial oxygen supply by vasodilation and reduce myocardial oxygen demand through systemic arterial vasodilation and reduction of afterload
127
Decreases cardiac preload
Nitrates Dilation of venous capacitance vessels and reduction of cardiac preload
128
Tachycardia resolved with cold water immersion
Pasroxysmal supraventricular tachycardia AV nodal reentrant tachycardia ``` Carotid sinus massage Cold water immersion Valsalva Eyeball pressure - Increase parasympathetic tone —> temporary slowing conduction of AV node ```
129
A fib treatment
Diltazem | Beta blockers
130
SOB Abdominal distension Chemotherapy 18 years ago JVD Positive fluid wave Hepatomegaly Pitting edema
Constrictive pericarditis Complication of radiation therapy Pericardial thickening & calcification Inelastic pericardium
131
Portal vein thrombosis/ compression
Decompensated cirrhosis Hypercoagulable states NOT JVP
132
Arteriovenous fistula Afterload Preload Cardiac index
Forms an enlarged vein Fistula allows a portion of blood to bypass the high resistancce of the systemic arterioles , systemic vascular resistance (SVR) is decreased (decreased afterload) Blood through fistula returns to right atrium more quickly—> increased venous return (increased preload) Both increased venous return and decreased SVR contribute to increased cardiac output Risk: high-output heart failure (Increased cardiac preload)
133
Aortic regurg w/ dilated left ventricle why no symptoms
Increased left ventricular compliance
134
AR causes
Increase LV preload Increased SV (due to increased preload) Increase in ventricular contractility Cardiac output sustained Total peripheral resistance (TPR) remains unchanged [TPR increases once decompensation begins]
135
Substernal chest pain HTN Diverticular bleed 2 years ago Cardiac catheterization performed Heparin drip Develops weakness, back pain, SOB, nausea, abdominal discomfort Flat neck veins Hypotension Tachycardia
Retroperitoneal hematoma Non-contrast CT scan
136
Chest pain from cocaine tx
IV diazepam
137
Digeorge findings
Low set ears Micrognathia Cleft palate No thymus Truncus arteriosus Hypocalcemia/ Hypoparathyroidism
138
Horseshoe kidney
Turner syndrome
139
MOA nitroglycerin
Decreased left ventricular wall stress Systemic vasodilation and decreased preload —> decrease in left ventricular end diastolic and end systolic volume —> reduction in left ventricular systolic wall stress 1) Lowers preload 2) Lowers left ventricular end diastolic volume 3) Reduces wall stress
140
Statins MOA
Inhibit HMG-CoA reductase RL enzyme needed to convert HMG-CoA to mevalonate Decrease hepatic cholesterol activates cellular signals that increase the number of LDL receptors [Inhibition of intracellular synthesis pathway]
141
1) Cell surface receptor blockage 2) Extracellular enzyme blockage 3) Inhibition of intracellular synthesis pathway
1) Cell surface receptor blockage= beta blockers 2) Extracellular enzyme blockage= ACEI 3) Inhibition of intracellular synthesis pathways= Statins
142
Mitral valve prolapse change with squatting
Disappears Just like HCM [Other murmurs get louder]
143
Syncopal events triggered by emotion
Vasovagal syncope Tx: Counterpressure maneuver education
144
Progressive dyspnea Lower extremity edema JVD Ascites Concentric Left ventricular hypertrophy Non dilated LV cavity
Restrictive cardiomyopathy
145
Holosystolic murmur at left lower sternal border with diastolic rumble over the cardiac apex Poor feeding
Ventricular septal defect
146
Harsh systolic ejection murmur at left upper sternal border
Tetralogy of Fallot
147
Young Smoking Recurrent chest discomfort at rest or when sleeping Tx
Vasospastic angina CCB - diltiazem - amlodipine, felodipine (preventive) Sublingual nitroglycerin (abortive)
148
80 y.o man putting on shirt and tie and passing out
Carotid hypersensitivity syncope Baroreceptor hypersensitivity
149
Syncope w/ exertion
LV outflow obstruction
150
Leg cramping Peripheral pulses decreased in left leg ABI 0.65 in left and 1.1 in right Next step
Atherosclerotic cardiovascular disease Peripheral artery disease Tx: Supervised graded exercise program Low dose aspirin Statin therapy
151
Hemodynamics in heart failure ``` Contractility Cardiac output Compensatory SVR Afterload ```
Decrease contractility —> decrease cardiac output —> Compensatory neurohormonal activation —> increase systemic vascular resistance —> Increase afterload —> Decrease contractility
152
Calf pain after artery embolectomy Burning sensation in posterior aspect of leg Swollen Tense Exquisitely tender Pain worse w/ dorsiflexion Shiny and cool to touch Patient cant move toes
Compartment syndrome
153
Cold 2 weeks ago Progressive SOB Swelling of feet
Decompensated heart failure from viral myocarditis —> Dilated cardiomyopathy Dilated ventricular chambers and diffuse hypokinesis of the ventricular walls
154
Acute coronary syndrome with low risk for aortic dissection give what medication
Aspirin
155
Light headedness past month Syncopal episode HX HTN Left ventricular hypertrophy Ejection fraction 55%
Cardiogenic syncope Bradyarrhythmia
156
Respiratory variation in systolic blood pressure
Pulsus paradoxus Cardiac tamponade
157
Informed consent
1) Patient diagnosis 2) Risk and benefits of both proposed tx and tx alternatives 3) Risk of refusing treatment
158
QRS that varies in height
Electrical alternans Cardiac tamponade Pericardiocentesis
159
HTN cause to consider
Oral contraceptives
160
Small face and jaw No skin creases on palmar aspect Overlapping fingers Cardiovascular abnormalities?
VSD Trisomy 18 Edwards syndrome
161
27 y.o with bouts of dyspnea on exertion Ejection type Systolic murmur at lower left sternal border that decreases when squatting Inheritence?
Hypertrophic cardiomyopathy Autosomal dominant
162
Dark purple legs Palable pulses
Chronic stasis dermatitis due to venous insufficiency Get Venous doppler U/S
163
Methamphetamine on heart Given IV medication taht acts primarily stimulating beta 1 adrenergic receptors, what is the MOA
Decompensated heart failure Hypotension Cool extremities Low cardiac output state Dobutamine acts on Beta-1 receptors—> increased production of cAMP in cardiac myocytes —> enhanced calcium mediated binding of actin-myosin to troponin C —> Increased myocardial contractility (positive inotropic effect) HR is increased via calcium channel activation (positive chronotropic effect) Increased myocardial contractility —> ejection of higher volume of blood which results in —> decreased left ventricular end systolic volume
164
Adverse effect of pacemaker
Tricuspid regurgitation Result in right sided heart failure Pulsation in neck when lies down Holosystolic murmur at left lower sternal border
165
T wave inversions in V1-V4, Troponin normal Next step
NSTEMI 1) Antiplatelet agents (aspirin, clopidogrel or aspirin and ticagrelor) 2) Anticoagulant therapy (unfractioned heparin, enoxaparin, bivalirudin) 3) Beta blockers (reduce myocardial oxygen demand) 4) Nitrates (reduce oxygen demand and relieve ischemic pain) 5) High intensity statins (stabilize plaques and lower risk of recurrent ACS)
166
Coronary angiogram 5 days ago Now nausea and abdominal pain Painless mottling of skin in feet
Cholesterol emboli
167
Medication used w/ Beta blocker and ACE I to reduce mortality in MI
Eplerenone Spironolactone Mineralocorticoid receptor antagonists (MRA) BLock deleterious effects of aldosterone on the heart
168
Irregular pulse No P waves What will resolve ventricular function
Afib Rate or rhythm control
169
Dyspnea Paroxysmal nocturnal dyspnea Bibasilar crackles Hypoxemia - Name - Due to - Tx
Pulmonary edema Acute decompensated heart failure Tx IV diuresis Oxygen supplementation Noninvasive ventilation
170
Afib originates where
Pulmonary veins is most frequent location for ectopic foci that cause AF
171
Atrial flutter location Tx
Reentrant circuit around the tricuspid annulus Anticoagulation (rivaroxaban, apixaban)
172
18 y.o During expiration that is an extra high pitched sound heard after S1 Systolic crescendo-decrescendo murmur at left upper sternal border S2 split throughout the respiratory cycle and splitting increases with inspiration
Pulmonic stenosis Ejection click= high pitch sound after S1 best heard during expiration
173
Uveitis 6 months ago Bradycardia 2:1 AV block and left bundle branch block Bilateral midfield lung opacities
Sarcoidosis
174
Patient < 55 with unexplained second or third degree heart lbock
Sarcoidosis
175
Fourth heart sound due to
Long standing HTN
176
High amplitude jugular venous pulsations that are seen intermittently at irregular intervals Wide complex tachycardia
Atrioventricular dissociation Ventricular tachycardia Cannon A waves: intermittent prominent waves caused by surge in jugular venous pressure —> atrioventricular dissociation
177
Side effect of Amlodipine
CCB Peripheral edema
178
A fib medication that needs pulmonary fxn testing
Amiodarone Pulmonary function and thyroid tests
179
Muffled heart sounds results in A. Decreased cardiac contractility B. Decreased left ventricular preload C. Increased right ventricular compliance D. Left ventircular outflow obstruction E. Pulmonary HTN
B. Decreased left ventricular preload Increase intrapericardial pressure restricts venous return to the heart and lowers right and left ventricular filling Decrease preload Decrease Stroke volume Decrease cardiac output Decreases right ventricular compliance and shifts interventricular septum toward the left ventircular cavity
180
Patient given niacin 1 week later generalized pruritus and flushing
Prostaglandin related reaction Know SE of niacin Niacin induced peripheral vasodilation
181
9 days of fever Previous 10 day amoxicillin for streptococcus pharyngitis No vaccines Rash on trunk —> extemities Cervical lymph node palpated Erythematous strawberry tongue
Kawasaki disease Next step get echo to check for coronary artery aneurysms
182
Benign murmurs
Early or mid-systolic Grade I or II that decrease with standing and Valsalva maneuver Low pitched Muscial Squaky tone High pitched at LUSB
183
Chest pain, Sharp localized to anterior chest. Exacerbated by deep breathing Six weeks ago have CABG Normal wound 100.4 F 144/78 pulse 99/min Tachycardia nonspecific ST changes Leukocytosis Small pericardial effusion - Name - MOA - TX (3)
Dressler syndrome Immune medicated inflammation NSAIDS + colchicine Self limited disease
184
Trauma Hypotension Tachycardia JVD
Cardiac tamponade
185
Papillary muscle rupture vs interventricular septum rupture vs free wall rupture
Papillary muscle rupture - 3-4 days - RCA - Severe pulmonary edema - New holosystolic murmur (mitral regurgitation) with flail leaflet Interventricular septum rupture - 3-5 days - LAD or RCA - Chest pain - New holosystolic murmur - Biventricular failure - Shock Free wall rupture - 5 days to 2 wks - LAD - Chest pain - Shock - Distant heart sounds
186
Tx Wide complex tachycardia
Sustained monomorphic ventricular tachycardia Amiodarone
187
Hypovolemic shock CO PCWP SVR Blood pressure
Blood pressure decreases Loss volume leads to decrease in preload and pulmonary capillary wedge pressure Consequent decrease in preload—> decrease cardiac output (CO) and BP Stimulates sympathetic NS which increases HR and peripheral vasoconstriction —> Increase in systemic vascular resistance
188
Decrescendo early diastolic murmur at left sternal border Patient leaning forward
Aortic regurgitation Bicuspid aortic valve
189
``` HTN Depression Poor sleep Headaches Muscle weakness ``` Kidney stones Hypercalcemia
Hyperparathyroidism
190
Spontaneous or easily provoked hypokalemia HTN
Primary aldosteronism
191
Recent catheterization Vague abdominal pain Tender in periumbilical area Bluish discoloration of right great toe and all toes of left foot Mottling of leg
Atheroembolism (cholesterol embolism)
192
What should be given to diabetic over age 40
Statin
193
Sudden cardiac arrest
Ventricular fibrillation Reentrant ventricular arrhythmias
194
Kussmaul | JVD
RV failure STEMI with right ventricular myocardial infarction (acute inferior wall MI)
195
Left side Early diastolic heart sound followed by diastolic rumble Hemodynamic findings Pulm A Sys pressure Pulm A dis pressure LV diastolic pressure
Mitral stenosis Rheumatic heart disease Restricted diastolic filling of LV —> increase left atrial pressure —> left atrial dilation—> increase pulm artery pressure (systolic and diastolic)
196
Early diastolic sound followed by mid-diastolic murmur Seen on Echo?
Mitral stenosis Left atrial dilation
197
Pericarditis tx
NSAIDS
198
``` Fatigue Confusion Constipation Weight gain Dry skin ``` Medication that causes this
Hypothyroidism Amiodarone
199
ABI
Peripheral artery disease
200
Afib tx
Warfarin
201
Scratchy sound at left sternal border before S1
Pericarditis Tx: NSAID Colchicine (ibuprofen)
202
Hyperextensible | Easy bruising, poor healing
Ehlers-Danlos MVP
203
High sensitivity for Congestive heart failure
BNP
204
Diastolic dysfunction
Heart failure with preserved ejection fraction Heart cant relax fast enough after each beat ``` Choking sensation Dry cough Palpitations Progressive SOB HTN Bibasilar crackles Afib Pitting edema normal EF ```
205
Medication associated with weight gain and worsening glucose tolerance
Beta adrenergic blockers
206
Regular Narrow complex tachycardia Tx
Superventricular tachycardia IV adenosine
207
Aortic Stenosis what you hear
late peaking crescendo-decrescendo systolic murmur Soft single S2
208
Family Hx sudden death QT interval prolong Congenital sensorineural deafness Tx:
Jervell and Lange-Niesen syndrome AR Risk of torsades de pointes Tx: Beta blocker and pacemaker
209
Cor pulmonale
RV hypertrophy Tricuspid regurgitation w/ right atrial enlargement Elevated pulmonary artery systolic pressure
210
BP 165/75
Isolated systolic hypertension MOA: increased stiffness or decreased elasticity
211
``` Pain in leg Numbness Palpitations in leg Hair is sparse Absent pulses of left, diminished on right Sensation to light touch decreased Weaker dorsiflexion ```
Acute limb ischemia ``` 6 Ps Pain Pallor Paresthesia Pulselessness Poikilothermia (cool extremity) Paralysis (late) ``` Tx: Anticoagulation (heparin) Thrombolysis vs surgery
212
Greatest impact on lowering HTN
Dietary modification to DASH diet
213
pharmacologic stress test
Adenosine Coronary vasodilation and increased myocardial blood flow in non obstructed coronary arteries
214
Infective endocarditis with conduction abnormalities on ECG
Perivalvular abscess
215
INR mechanical valve
2-3
216
TX ventricular fibrillation
Defibrillation
217
MI 2 weeks ago Persistant ST elevations
Ventricular aneurysm
218
Infective endocarditis finding
Tricupsid valve involvement Holosystolic murmur increases with inspiration
219
MVP
Early diastolic murmur (Decrescendo)
220
HTN emergency Given IV furosemide and nitroprusside Next morning, Confused and agitated with tonic clonic seizures
Cyanide toxicity
221
Aortic dissection can progress to
Acute aortic regurgitation [Aortic valve insufficiency] Dont want to lay flat Hypotension pulmonary edema
222
Diastolic collapse with elevated right ventricular pressure
Cardiac tamponade
223
Dilated left ventricle with apical hypokinesis
Cardiogenic shock
224
Engorgement of the inferior vena cava
Cardiogenic shock
225
Right ventricular dilation and hypokinesis
Massive pulmonary embolism
226
Hx of aortic aneurysm what drugs to avoid
Fluroquinolones - levofloxacin - Moxifloxacin - Ciprofloxacin
227
Antihypertensive for diabetic patient with proteinuria
ACE inhibitor | ARB
228
Drugs that slow heart rate
Beta blockers Calcium channel blockers Digoxin Amiodarone
229
Systolic ejection murmur heard along lateral sternal border Increases with Valsalva maneuver
Hypertrophic obstructive cardiomyopathy Increases with decrease in preload
230
Diastolic decrescendo low pitched blowing murmur Best heard sitting up Increases with hand grip maneuver
Aortic insufficiency Increases with increase in afterload
231
Systolic crescendo/decrescendo murmur Increases with squatting
Aortic stenosis Increase with increase in preload (squatting)
232
Holosystolic murmur that increases with hand grip
Mitral regurgitation Increases with increase in after load
233
Diastolic mid to late low pitched murmur preceded by opening snap
Mitral stenosis
234
ECG for pericarditis
Low voltage Diffuse ST segment elevations
235
Metabolic syndrome (6)
``` Abdominal obesity High triglycerides low HDL hypertension insulin resistance prothrombotic or proinflammatory states ```
236
Anterior wall MI Inferior wall MI Posterior wall MI Septum MI
Anterior wall: LAD/ diagonal Inferior wall: PDA Posterior: left circumflex/ oblique, RCA/ Marginal Septum: LAD/ diagonal
237
Reverses effects of heparin
Protamine
238
What parameter is effect by warfarin
Prothrombin time
239
Water bottle shaped heart
Pericardial effusion
240
Gradual prolongation of PR interval till dropped beat
Mobitz type II
241
Third degree or complete AV block
P waves are entirely unrelated to QRS complexes
242
PR intervals > 0.20 second Constatn PR interval
First degree AV block
243
Displace apical impulse Holosystolic murmur Third heart sound
Chronic severe mitral regurgitation Mitral valve prolapse more common in developed countires
244
Rheumatic heart disease causes what heart abnormalities
Mitral stenosis MR Aortic regurgitation
245
Tx asymptomatic bilateral carotid artery stenosis
Antiplatelet agent (aspirin) Statin Careful blood pressure control
246
When to do carotid endarterectomy
Symptomatic patients with high grade carotid stenosis > 70%
247
Worsening fatigue Exertional dyspnea Lower extremity swelling Bruising easily Proteinuria Smoker JVD Small pericardial effusion Concentric thickening of the ventricular walls with diastolic dysfunction
Amyloidosis Fatigue, exertional dyspena, lower extremity swelling in absence of pulmonary edema= right side heart failure Manifestation of restrictive cardiomyopathy (thickened ventricular walls)
248
Bradycardia AV block Hypotension Wheezing
Beta blocker overdose Tx IV atropine IV glucagon
249
Intense holosystolic murmur best heard at cardiac apex
Severe mitral regurgitation S3 gallop Sudden cessation of blood flow into a dilated LV
250
Atherosclerotic CV disease tx
High intensity statin therapy
251
Evaluation of HTN (4)
Chemistry panel (electrolytes and creatinine) Hemoglobin/ hematocrit Urinarlysis (to exclude hematuria and proteinuria) ECG for LV hypertrophy or prior MI
252
Loud midsystolic murmur heard at first right intercostal space Palpable thrill at suprasternal notch Differential blood pressure between upper extremities
Supravalvular aortic stenosis [Congenital left ventricular outflow tract obstruction] Develop LV hypertrophy over time —> Increased myocardial oxygen demand= pain
253
Systolic anterior motion of the mitral valve
Hypertrophic obstructive cardiomyopathy ``` Exertional angina Dyspnea Dizziness Presyncope Syncope ``` Systolic murmur with maximal intensity along the lower left sternal border
254
MI that result in LV systolic dysfunction Resulted in thinned walls and evidence of scaring, dilated left ventricle
Eccentric hypertrophy Due to ischemic heart disease [Deleterious cardiac remodeling —> risk for fatal cardiac arrhythmia (ventricular tachycardia or fibrillation] Cardiac remodeling driven by RAAS pathway Prevented by ACE inhibitor
255
Tx Torsades de pointes
Stable: IV Magnesium sulfate Unstable: defibrillation Polymorphic ventricular tachycardia
256
Adenosine
Tx Paroxysmal supraventricular tachycardia
257
Amiodarone
Artrial and ventricular tachycardia
258
Atropine
Symptomatic sinus bradycardia AV nodal block
259
Tx torsades de points with quinidine use
Sodium bicarbonate
260
Preventing pericarditis after MI
Early coronary reperfusion [Minimizes myocardial necrosis]
261
Passing out while in crown or giving blood due to See on ECG
Vasovagal syncope Bradycardia and sinus arrest
262
32 y.o with HTN Father dies suddenly at 54 BP 175/103 Bilateral nontender uper abdominal masses palpated Hemoglobin elevated
ADPKD Get abdominal US
263
NE used to tx
Severe hypotension and shock
264
HTN Headaches Fourth heart sound Continuous murmur through out the thorax in multiple areas
Coarctation of the aorta Erosions of the inferior costal surfaces
265
"Pounding" heart 150/45 Exertional SOB Heart murmur?
Aortic regurgitation
266
Syncope when waking up to urinate Due to
Peripheral vasodilation
267
37 y.o Weakness and dizziness Two episodes of syncope Vague mid-chest discomfort and left sided neck pain Two ago had sore throat and dry cough He has thready pulses over both radial arteries that disappear with deep inspiration
Cardiac tamponade Due viral pericarditis Pulsus paradoxus is a typical feature of pericardial tamponade, large decrease in systolic blood pressure on inspiration. Loss of palpable radial pulse during inspiration
268
Afib Weakness and slurred speech for 15-20 min How to prevent future episodes ``` A. Amiodarone B. Aspirin C. Clopidogrel D. Long-acting nitrates E. Metoprolol succinate F. Rivaroxaban G. Strict blood glucose control ```
F. Rivaroxaban Give warfarin or NOAC
269
Ventricular tachycardia tx
Amiodarone
270
Young patient URI 2 weeks ago ``` Chest pain Arrhythmias Fatigue SOB Choking sensation when falling asleep ``` PMI displaced
Myocarditis —> Dilated cardiomyopathy
271
Atrial fibrillation Unintentional WL HTN Best initial test?
TSH and free T4 Hyperthyroidism can cause both
272
Tx Atrial fibrillation ``` A. Quinidine B. Clonidine C. Metoprolol D. Hydroclorothiazide E. Amlodipine ```
C. Metoprolol
273
Increased left ventricular end diastolic pressure
Heart failure Hypoxia Hypotension
274
Tx of chest pain in MI
Venous dilation Nitrates [Not coronary artery dilation]
275
Soft murmur starts after the second heart sound and declines in intensity until disappearing suddenly before the first heart sound Murmur heard along with left and right sternal borders Accentuated when patient sits up, leans forward and puts hands in head
Aortic root dilation Aortic regurgitation Decrescendo diastolic murmur
276
59 y.o sudden onset of syncope Twice in two hours while sitting No confusion afterwards Recent placed on Sotalol for sinus rhythm Tx
Torsades de pointes Ventricular Arrhythmia Sotalol —> prolong QT —> torsades de pointes Tx Magnesium sulfate (Hypomagnesemia)
277
CHF put on loop diuretics What other medication for long term outcomes ``` A. Amiodarone B. Amlodipine C. Atenolol D. Chlorthalidone E. Digoxin F. Diltiazem G. Metoprolol succinate H. Propafenone ```
Metoprolol succinate [ACE-I, ARB, beta blockers, aldosterone antagonists] Beta blockers - Metoprolol succinate - Carbedilol - Bisoprolol

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