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CCSET1 Flashcards

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1
Q

What is the deal with low cholesterol levels in heart failure patients?

A

Low cholesterol is linked to worse outcomes in cardiac pts as it is probably a surrogate for cardiac cachexia (poor nutritional status)

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2
Q

What is the deal with patients who have a recently diagnosed CMO and concern for need for AICD?

A

You should medically optimize them first then consider AICD later if nonresponsive in EF

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3
Q

What is the preferred intervention for those with severe SYMPTOMATIC AS with low-intermediate surgical risk?

A

Surgical Aortic Valve Replacement (SAVR) as opposed to TAVR

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4
Q

What is the next step to take if aspirated fluid from a pericardiocentesis is sanginous?

A

Transduce the catheter; sanginous fluid may be due to hemopericardium or due to LV puncture; by transducing the catheter you will see a wave form consistent with LV fxn if you?ve pierced the LV; placing a pericardial drain is contraindicated without knowing where the tip is

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5
Q

What are the most common complications of cardiac catheterizations?

A

Complications related to vascular access: pseudoaneurysm, retroperitoneal hemorrhage, femoral AV fistula, need for surgical repair etc.

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6
Q

What is the first line drug for coronary vasospasm?

A

Diltiazem; do NOT give beta blockers as the theoretical risk is for unopposed alpha, like cocaine induced CP

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7
Q

Prolonged QT can trigger prolonged ______ which then lead to polymorphic VT (PMVT)

A

Afterdepolarizations

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8
Q

What is the drug of choice for terminating PMVT related to QT prolongation? Mechanism of action?

A

Magnesium Sulfate can give 1-2 grams over 30-60 sec and repeat q5-15 min; it increases the influx of calcium to shorten length of depolarization (i.e. a long QT is essentially long ventricular depolarization)

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9
Q

A gradient of ______ across a coarctation is considered to be significant and need repair? What may a continuous murmur suggest?

A

>20 mmhg; continuous murmur indicates presence of collaterals

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10
Q

Explain why isopropyl ingestion does not have an anion gap acidosis but ethylene glycol and methanol do

A

Isopropyl is degraded to acetone so it is typified by osmolar gap and ketosis but the others create glycolic acid and formic acid, respectively so have increased OG and AG

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11
Q

What pacing mode provides AV synchrony in patients with AV block?

A

DDD mode

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12
Q

Mutations in dystrophin will lead to what type of cardiomyopathy?

A

Dilated cardiomyopathy– associated with Duchenne Muscular Dystrophy

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13
Q

When is IV TPA plus mechanical thrombectomy with stentreiver preferred mgmt of acute ischemic stroke?

A

In patients with proximal MCA (probs other ones too) with a LARGE ischemic penumbra (as evidenced by the perfusion image of MRI) and a SMALL core infarct area (evidenced by the ASPECTS score)

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14
Q

What is an Austin Flint murmur?

A

When you have an aortic regurgitation murmur (i.e. a diastolic murmur) that also has a late diastolic rumble and it is thought to be due to early closure of the MV resulting in a functional mitral stenosis

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15
Q

What provocative test can be done to induce coronary vasospasm?

A

Intracoronary acetylcholine

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16
Q

What are considerations for a patient who is to undergo cardiac gated CT?

A

Cannot be in Afib as the extensive R-R variability leads to motion artifact; need HR in 60s and NSR, consider renal fxn as well as there is contrast

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17
Q

What is the preferred initial management for mitral stenosis? What if this isnt working and the pt is pregnant?

A

Beta blockers to allow more diastolic filling time; if pt has symptomatic severe MS refractory to beta blockade and is pregnant then need for balloon valvuloplasty

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18
Q

The presence of a dilated coronary sinus on an echo is highly associated with what?

A

Persistent L superior vena cava though it is a benign finding

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19
Q

When should you place an AICD in peripartum CMO

A

Would optimize medical Tx first and wait 6 months then re-evaluate EF; otherwise if arrhythmia then place it

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20
Q

What mechanical complications of acute myocardial infarction can result in shock?

A

Papillary muscle rupture, ventricular septal rupture, free wall rupture, and RV infarction

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21
Q

What are the most common cardiac masses?

A

Malignant metastases are more common that primary heart tumors

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22
Q

The Echo Score for indication of mitral valve replacement includes what 4 things?

A

Valvular mobility, Valvular thickening, Amount of calcification, and amount of submitral apparatus scar and retention; Each on grade 1-4

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23
Q

How does concern for PAH often start, clinically?

A

Often times incidentally on TTE when you see high PASP w/ or w/o R heart enlargement then worry about OSA, possibly CTEPH (get a VQ scan) but R heart catheterization is required for dx

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24
Q

What does someones temperature have to be to pronounce them as brain dead?

A

36 C at least as cerebral hypothermia can mimic brain death

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25
How is starvation ketosis different from alcoholic ketoacidosis or isopropyl ingestion?
Starvation ketosis will not have an osmolar gap and isopropyl will
26
Can you tell the difference between WNV meningitis based on CSF vs. other meningitis d/t arboviridae?
No often there is a lymphocytic pleocytosis with some increased protein but you need to isolate the antigen or find virus-specific IgM titers
27
If a patient has mixed valvular disease (i.e. BOTH AS and AR) how should you manage?
Follow the guidelines for the dominant lesion; i.e. if pt has moderate AR and severe AS then treat as AS
28
What is the probable pathophysiology of atrial fibrillation in a highly conditioned individual with ventricular rates less than 100?
Generally this is parasympathetically mediated; vagal tone activates muscarinic receptors attached to the IKACH channel which does a bunch of things including decreasing duration of action potential in atria
29
A New Mexico screening test identifed 5 parameters on a blood smear for Hantavirus Pulmonary syndrome, what are they?
Thrombocytopenia, Hemoconcentration, Granulocytic left shift, Lack of toxic changes in myeloid series, and \>10% immunoblasts present (this is in the context of a pulm-renal type syndrome)
30
True or False: if you give lytics to someone for a STEMI you need to then do emergent angiography
False: you "risk stratify" them; so resolution of sx, improvement of ST elevations by 50% or more, and evidence of reperfusion arrhythmias like accelerated idioventricular rhythm are all signs of epicardial patency; if clinical uncertainty though, then do angio emergently; most will undergo angio within 24 hours to DEFINE THE ANATOMY
31
How is STEMI defined in men and women?
New ST elevation at the J point in @ least 2 contiguous leads greater than 2 mm in men and 1.5 mm in women
32
A key to figuring out isopropyl alcohol ingestion is to calculate what
Osmolar gap (2x Na + Glu/18 + BUN/2.8) then check acetone/ketones as isopropyl broken down by EtOH dehydrogenase to acetone
33
What types of sleep disordered breathing may CHF patients have?
OSA (tx w/ CPAP or BiPAP) or CSA (Tx with adaptive servoventilation)
34
What is Weil disease?
The second phase of Leptospirosis which is immune-mediated (icterohemorrhagic fever) there is a biphasic infxn
35
The basis of the apnea test is rooted in what acid-base principle?
That CO2 drives respirations; so person should be disconnected from the vent for long enough for the PCO2 to get to \>60 so that there is a strong chemoreceptor drive to breath
36
What is the most appropriate mgmt of a pt who goes to the cath lab for stable ischemic heart disease and L main dz and/or complex multivessel dz is found?
Evaluation by a Multidisciplinary Heart Team; PCI may be reasonable but ad hoc PCI after defining multivessel CAD is discouraged as they may need CABG
37
What does it mean to say that the RSBI has continuous predictive ability?
That generally it is used as a threshold so \<105 assoc with lower chance of reintubation but by continuous (not binary) lower scores assoc with lower chances i.e. 30 is better than 90
38
New onset atrial fibrillation is a common problem in sepsis, what effect does this have on mortality?
There is a higher risk of mortality (about 7%) in patients with new onset Atrial fibrillation in sepsis than in septic pts without Afib
39
What are some signs of "advanced heart failure" that means maybe pt needs a VAD or transplant?
Intolerance to beta blockers or ACE-I (i.e. cannot tolerate guideline-directed tx), ICD shocks multiple times, cachexia and temporal wasting (cardiac cachexia)
40
What sort of clinical presentation should make you think about something like giant cell myocarditis?
A new onset acute systolic heart failure with dilated LV and high degree AV blocks; should get endomyocardial bx
41
What may be considered for a patient who has inadequate rate control after thorough trials of medical tx and are not candidates for rhythm control?
AV node ablation with permanent pacemaker pacemaker placement
42
Peripartum CMO is the development of dilated CMO when
AT 36 weeks gestation to up to 6 months post-partum-- Dx of exclusion need to r/o other stuff; no one knows why it happens possibly related to abnromal prolactin handling
43
What kind of virus is West Nile Virus and when did it first rear its head in the US?
Flavivirus; first in 1999 NYC outbreak
44
Giant cell myocarditis often requires what form of therapy ultimately?
Transplantation; transplant free survival very low; some evidence for immunosuppression though
45
What is propofol infusion syndrome?
Refractory bradycardia associated with metabolic acidosis, rhabdo, HLD and fatty liver
46
5 ECGs on the EP study are arranged how?
Surface EKG, High Right Atrial Recording, His bundle recording, Coronary sinus recording, and right ventricular recording
47
Why is leptospirosis becoming more recognized as associated with floods and triathletes?
Because of rodent-infected water
48
What gene is arrhythmogenic right ventricular cardiomyopathy associated with?
Plakoglobin
49
What may be the best bet for central access in a cardiac arrest situation?
Intraosseous route as the medullary cavity is noncollapsable and peripheral and central veins may be very collapsed
50
Leptospirosis and Hantavirus Pulmonary Syndrome should be considered together as possible infectious disease mimics of what clinical presentation?
Pulmonary Renal Syndrome
51
What does the term pulmonary-renal syndrome usually refer to?
Diffuse Alveolar Hemorrhage with presence of Glomerulonephritis usually due to ANCA, Anti-GBM or some other immune complex disorder leading to thrombotic microangiopathy but some infections can mimic- pneumonic plague, Hantavirus pulmonary syndrome, Leptospirosis, and inhalational anthrax
52
What kinds of symptoms may a person with West Nile Virus show?
Meningitis, encephalitis, flaccid paralysis (possibly requiring intubation) or a mixed picture
53
What is the benefit of Heliox in asthma pts?
Use of helium over nitrogen provides laminar flow
54
When someone says a "Nerve Agent" has been used what class of drugs does that refer to? What is the Tx?
Organophosphates; Pyridostigmine
55
A trial demonstrated that what combination of platelets:FFP:pRBC is optimal in massive transfusion protocols (related to trauma)?
1:1:1 as you are essentially, by design, getting more stuff aimed at coagulation than pRBC which was associated with less exsanguination; used to be that plt and FFP given based on coags but now done in anticipatory fashion
56
If pt has prolonged QT what would be the magnesium goals?
You can give a bunch of mag to get them to the upper limit of normal or a bit above is the word on the street
57
What test is good for identifying hibernating myocardium?
A Viability study; i.e. redistribution thallium study which can show that an area of heart is still viable and amenable to revascularization
58
How would you diagnose coronary-subclavian steal syndrome in a patient with prior LIMA-LAD w/ concern for subclavian stenosis who is having angina?
Vertebral Artery Doppler; will show reversal of flow in ipsilateral vertebral artery
59
Mutations in Tafazzin are associated with what heart conditions?
Dilated CMO and LV noncompaction
60
A QTc greater than _____ is assoc with increased risk for PMVT? What are some important causes?
500 ms; Hypokalemia, Hypomagnesemia, Hypocalcemia, hypothermia, ischemia, increased ICP and drugs
61
What is the concern for negative p waves in lead II with symptomatic palpitations?
Probably an ectopic atrial rhythm (i.e. NOT sinus); if pt is symptomatic with this then can try beta blockers to slow the conduction via AV node but may need to refer for EP mapping and ablation
62
A patient who recently had a pacemaker placed who now has evidence of right heart failure should be concerning for what? Tests?
Lead implantation into the RV and this can lead to a primary TR; need to check TTE but even if normal may need TEE if suspicion high enough
63
A Low ventriculoatrial time on EP study excludes the possibility of what?
A bypass tract
64
What is the epidemiology of Hantavirus Pulmonary Syndrome and Leptospirosis
It is evolving and is including recent heavy rains and flooding as there is increase in pollen and rodent population in closer proximity to humans
65
What is the classical examination of coarctation of the aorta?
Systemic HTN, brachial-femoral pulse delay, decreased pulsatility with blunting of the abdominal aortic doppler pattern
66
When do most cases of West Nile Virus occur?
Between July and September
67
Mutations in plakoglobin are associated with what syndrome?
Arrhythmogenic Right Ventricular Cardiomyopathy/Hypertrophy
68
How would you manage a ostium secundum ASD vs a sinus venosus ASD?
Percutaneous closure is the standard of care for secundum ASDs but surgical closure required for sinus venosus ASDs as they are often linked to anomalous pulmonary venous return to he SVC
69
If a patient is not at a PCI-capable location and has STEMI while on chronic anticoagulation for afib what is the next step?
Cannot give lytics because on AC; transfer to PCI capable location and give DAPT (ASA and clopidogrel)
70
Explain the Biphasic nature of Leptospira infxn
Biphasic icterohemorrhagic condition with acute liver failure, renal failure and neuro dysfxn; Initial phase = spirochete; 2nd phase = Weil Disease and is immunologically mediated
71
What features are programmable on a pacemaker?
Sensing/Pacing, Timing cycles, rate responsiveness, detection of arrhythmias, and mode switching
72
What does it mean if an ICD interrogation states that there are elevated ventricular rates that are irregular?
Atrial Fibrillation with RVR; of note, OSA is a big risk factor for AF w/ RVR should consider sleep study in those pts
73
What are some treatment options for Budd-Chiari
Thrombolysis, anticoagulation, angioplasty, TIPS, etc. generally AC or lytics
74
What is the utility of statins in patients with NICMO?
Not useful unless pt has other indication i.e. stroke or HLD
75
A differential for right heart failure should include what things?
Constrictive pericarditis, a structurally abnormal tricuspid valve (Ebstein's, prolapse) or secondary TR due to OSA, pulmonary HTN; also lead implantation in the RV can lead to primary TR
76
Per the FREEDOM trial what is the preferred mgmt of triple vessel dz in diabetics?
CABG
77
In cases when you think a person has HFpEF and is euvolemic on exam, what test could you do that may help confirm the Dx?
R heart catheterization that could show normal filling pressures but with exaggerated increase in filling pressure s with exercise and an associated blunting in cardiac output
78
What is the most important risk factor for unplanned extubation
Increased level of consciousness though you should still do intermittent sedation (i.e. with holidays)
79
What sorts of things cause Budd-Chiari?
MPNs, HCC (or other liver cancers like mets), liver infxn (abscess, cyst), OCP use, pregnancy, and hypercoagulable states including PNH
80
How should you triage symptomatic carotid artery dz?
Seriously, as it can present a high short term risk of stroke and should be evaluated/treated urgently; i.e. Amaurosis fugax should get carotid duplex and CEA/Stenting
81
What is a good next step if you are having difficulty maintaining euvolemia in a CHF pt on furosemide (i.e. multiple readmits etc)?
Switch to torsemide given better bioavailability; esp. if the pt gets admitted and is diuresed with IV lasix and it goes well this may indicated they don?t get good PO absorption; do this over adding metolazone as it has higher assoc. with electrolyte abnormalities
82
What combination of meds for NSTEMI has lowest risk of bleeding? What can you say about bleeding and mortality?
UFH (heparin gtt), clopidogrel, and aspirin; bleeding is associated with worse clinical outcomes
83
How are myxomas usually obtained? Name a familial syndrome
Often sporadic, Carney Syndrome/Carney Complex
84
What endocrine disorder is associated with myxoma formation?
Cushing disease; PPNAD syndrome is Primary Pigmented Nodular Adrenocortical Disease and can lead to cushing dz which is associated with myxomas
85
If a patient has an inferior MI with pulmonary edema what should you be concerned for?
Papillary muscle rupture (may not have a murmur in early setting); inferior MI often has more R sided CHF findings and hypotension but if w/ pulm edema possible flail mitral valve
86
What should you do for a pt diagnosed with NICMO 6 months ago who has been on guideline directed tx who still has EF of 30%?
Place AICD for primary prevention of sudden cardiac death
87
What are some typical TTE findings of HFpEF (5)? What are the BNP values?
Concentric LV remodeling, LA dilation, Diastolic dysfunction, pulmonary HTN, and abnormal E/e' ratios; BNP is often normal
88
What should you think about in a patient presenting with new onset acute heart failure with reduced ejectio fraction and high degree AV block? What should you do?
Myocarditis due to giant cell myocarditis or some infiltrative process such as sarcoidosis; Endomyocardial biopsy has class I indication for new-onset heart failure within 2 w - 3 m duration with dilated LV and high degree AV block
89
The presence of immunoblasts on a peripheral smear (defined as enlarged lymphocyte \>2-3x diameter of small lymphocyte) in the setting of a pulmonary renal syndrome should make you consider what infectious disease?
Hantavirus Pulmonary Syndrome
90
What confirms the dx of Budd-Chiari?
Doppler US showing void or turbulent flow in hepatic vein; often w/ hepatomegaly and caudate lobe enlargement; otherwise venography but rarely needed
91
What is the MOA of dexmedetomidine? What are the main adverse effects?
Selective Alpha-2 agonist; hypotension and bradycardia but associated with better cognitive outcomes
92
What is the classic triad of Budd Chiari?
Abdominal pain, ascites, and hepatomegaly
93
Why should you use pressure bags or rapid infusion pumps for intraosseous access?
The mean intramedullary pressure is around 30 mmHg as opposed to venous which may be around 0. So you need pressure to get stuff in; that?s why they are so hard to flush!
94
For newly diagnosed mitral stenosis, the preferred initial mgmt is \_\_\_\_\_\_
Beta blockers to allow more diastolic filling time; if pt has symptomatic severe MS refractory to beta blockade and is pregnant then need for balloon valvuloplasty
95
High amounts of propofol are associated with what
Apneic episodes and hypertriglyceridemia
96
Name 4 infectious diseases that can mimic immune-mediated pulmonary renal syndromes
Pneumonic Plague (Y. pestis), Hantavirus Pulmonary Syndrome, Leptospirosis, and Inhalational Anthrax
97
True or False: if someone has had Out of Hospital Cardiac Arrest and was coded and got ROSC they should not go to the cath lab if they are not responsive neurologically
False: you always take to cath lab for possible intervention; neurologic prognostication is not done until 72 hours later after hypothermia protocol
98
You can draw blood samples from an IO catheter but should expect discrepencies in what values?
WBC and bicarbonate

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