CVS IM Flashcards
(105 cards)
1
Q
What does reticulocyte count reflect?
A
Bone marrow production activity
2
Q
Benchmark for adequate BM response to mild/moderate anemia?
A
Above 2.5% correct reticulocyte count
Suggests patient’s anemia is due to blood loss OR hemolytic destruction
3
Q
What does macrocytic or microcytic anemia suggest?
A
Reflect RBC maturation defects
4
Q
What does Normocytic anemia reflect?
A
Decrease in RBC proliferation
5
Q
Does haemoglobin level fall with blood loss immediately?
A
No, only after fluid resuscitation
Fixed amount of RBC is diluted by higher plasma volume
6
Q
Commonest presentation of chronic blood loss?
A
Asymptomatic iron-deficient anemia.
Reticulocytes <2.5% and low MCV
Commonest cause of Fe-deficiency is chronic occult GI bleeding, which depletes iron stores. do endoscopy!!!
6
Q
Etiologies of microcytic anemia?
A
Iron-deficiency
Thalassemia
Chronic disease
Sideroblastic anemia
Sideroblastic anemia is defective incorporation of iron into heme. Due to lead poisoning/drugs/congenital wtv. Rare!!
7
Q
How does FBC present if thalassemia is likely in microcytic anemia?
A
Thalassemia: RBCs are very small with MCV in 60s and uniform (low RDW)
Fe deficiency: MCVs in 70s unless severely deficient, less uniform with higher RDW
8
Q
What does an inflammatory state do to ferritin?
A
Inflammation raises ferritin 3x.
In inflammatory state, up to 100mcg/L can mean Fe deficiency
9
Q
What does transferrin saturation show?
A
Amount of iron binding to Fe-binding proteins.
Below 16% suggests Fe defiency.
Cut-off is higher for pregnancy, renal disease etc etc
10
Q
Confirmatory tests for Thalassemia?
A
Beta = Haemoglobin electrophoresis finds HbF and HbA2
Alpha = Haem electrophoresis shows low HbH
11
Q
What is Red Cell Distribtion Width?
A
Measures heterogeneity of cell size in peripheral blood.
Low in thalassemia, high in Iron deficiency
12
Q
What to exclude for in macrocytic anemia?
A
Reticulocytosis!
Reticulocytes are larger than mature RBCs, and can raise MCV.
13
Q
Etiology of B12/folate deficiency?
A
GI malabsorption (gastrectomy, IBD, ileal resection, pernicious anemia)
Dietary insufficiency in vegans
14
Q
Etiology of macrocytic anemia?
A
Megaloblastic anemia - B12 deficiency
Alcohol and NASH
HypoThyroidism
Drugs
Myelodysplastic syndrome
15
Q
Initial studies for isolated anaemia?
A
Reticulocytes
Serum creatinine
Calcium
Iron studies
16
Q
What does profound anemia with very low reticulocyte suggest?
A
Red Cell aplasia.
Workup usu includes BM aspirate.
17
Q
Consider what etiologies if renal impairment is present in normocytic anemia?
A
CKD
Multiple myeloma
2nd line considerations are: Early Fe deficiency, Anaemia of chronic disease, myelodysplasia, idiopathic
18
Q
How to divide mechanisms of pancytopenia?
A
BM infiltration
Aplasia
Blood cell destruction
19
Q
What is in Iron study panel?
A
Serum iron
Transferrin
Ferritin
Total iron binding capacity
20
Q
What emergencies to consider in pancytopenia?
A
Miroangiopathic hemolytic anaemia
Leukemia
Marrow infiltration
21
Q
Etiology of pancytopenia?
A
Megaloblastic anaemia
Drugs (e.g. cytotoxic drugs)
Cirrhosis with hypersplenism
Autoimmune conditions
Infection e.g. Malaria, HIV, EBV, hepatitis
22
Q
Which drugs can cause pancytopenia?
A
Abx - Linezolid, cotrimoxazole etc
Anti-epileptics
Anti-Thyroid meds
Immunosuppressants
23
Q
Evidence of mechanical hemolysis?
A
Presence of schistocytes
24
Non-MAHA causes of mechanical red cell fragmentation?
Malignant HTN
Hemodynamic turbulence around prosthetic intravascular material e.g. leaky prosthetic valves
March hemoglobinuria
25
Commonest congenital etiologies of hemolytic anemia?
Thalassemia
G6PD
Sickle Cell disease
Hereditary Spherocytosis
26
Hypoxia is a physiological trigger of ____?
Hypoxia can trigger raised erythropoietin and polycythaemia.
27
What is secondary polycythaemia?
Elevated erythryopoietin level drives RBC overproduction
28
What gene is mutated in Primary polycythaemia?
JAK-2 is mutated in 90% of cases
29
Complications of Polycythaemia Vera?
Hyperviscosity symptoms
Thrombosis
Bleedin
Transformation to leukemia or secondary myelofibrosis
30
How to use splenomegaly to differentiate between myeloproliferative disorders?
With splenomegaly = Chronic myeloid leukemia, Primary Myelofibrosis
Without = Polycythemia vera, Myelodysplastic syndromes, Essential Thrombocytosis
31
Can extreme thrombocytosis cause bleeding?
Yes
32
Sinus tachycardia is usually a response to?
Usu a response to non-cardiac disease. E.g. pain, infection, hypovolemia, anemia, hyperT, PE, anxiety.
33
Multifocal atrial tachycardia tends to occur in patients with what comorbids?
Usu in pts with lung disease (e.g. COPD / pneumonia) or heart disease with pulmonary HTN
34
Endocrine disorders that can case sinus Tachy?
HyperT
Hypoglycemia
Phaeochromocytoma
35
What is resistant HTN?
HTN above target with optimal doses of 3 anti-hypertensives from different classes, including a diuretic
36
What is pericardial fat pads?
Normal structures in cardiophrenic angle.
Adipose tissue that surrounds heart.
## Footnote
More prominent in obese patients
37
NYHA classification for Heart Failure?
Stage 1 = No symptoms, no limits to activitty
Stage 2 = mild symptoms, mild limits to ordinary activity
Stage 3 = Limited activity. Only comfortable at rest
Stage 4 = Severely limited activity. Symptoms even at rest
38
What is Electrical Alternans on ECG? What condition does it show?
Alternatingly high and low QRS complexes. 1 high, then 1 low.
This means Pericardial effusion or tamponade
39
What causes Pulsus Paradoxus?
Cardiac tamponade, possibly lesser degree constrictive pericarditis.
| Often due to pericardial disease
40
When diagnosis is uncertain for cardiac chest pain, how often to test ECG and Troponin?
Without certain diagnosis, repeat ECG and Cardiac troponin as often as needed!
Troponin within 2 hrs, ECG as often as every 5 mins if u suspect STEMI
41
If suspected STEMI, do you wait for troponin to do angiogram?
No!! Troponin takes 4 hrs to rise. Do angiogram asap without caring.
| but actl now got super sensitive trops test that detects within 1hr lmao
42
Why are posterior STEMI sometimes missed?
Posterior STEMI due to L circumflex occlusion is often silent on ECG.
Need to rely on other telltale signs or use posterior leads for ECG.
43
Whats the difference between Diastolic and Systolic HF?
Diastolic HF = heart cannot relax normally between beats.
Systolic HF = Heart cant contract effectively with each beat.
| Systolic HF also known as HFrEF
44
Characteristics of diastolic HF?
LV stiffens due to decades of HTN.
Volume overload isnt a mainstay - no pedal edema or high JVP.
Due to stiff LV, pulmonary edema is common + Tachycardia.
45
Red flags for dyspnea that need admission?
O2 sat <92%
Bradycardia <60bpm
Tachycardia >100bpm
Peak Expiratory Flow <33% of best
RR >30/min
46
AFib vs Atrial Flutter?
ECG sign of flutters?
In Atrial flutter, atria beats regularly but faster than the ventricles.
ECG shows saw-tooth pattern
47
3 causes of pansystolic murmur?
Mitral Regurg
Tricuspid Regurg
VSD
48
How to differentiate Mitral regurg vs Tricuspid regurg on PE?
| Heart signs and soft signs
MR has jerky pulse vs TR has normal pulse.
MR loudest over mitral region, TR loudest over tricuspid region.
MR louder on inspiration, TR louder on expiration
MR may have pulsatile hepatomegaly + JVP with giant waveform
48
Which sided murmurs louder on inspiration vs expiration?
**Right murmur louder** on **inspiration**.
**Left murmur** louder on **expiration**.
| Expiration pushes blood into L heart
49
Where do Mitral Regurg or VSD murmurs radiate to?
MR murmurs radiate to axilla.
VSD murmurs radiate to RLSE.
50
What is CHADS-VASC score for AF? Clinical relevance of scoring?
Congestive HF/LV dysfunction?
HTN?
Age?
DM?
Stroke, TIA or Thromboembolism?
Vascular disease?
Gender?
| Scoring system for risk of thromboembolic event (stroke) in AF patients.
## Footnote
Oral anticoagulants recommended for score of 1 in Men, 2 in women
51
Causes of Long Q-T syndrome?
| just some of them
Drugs e.g. antipsychotics, Abx, antidepressants etc
Hypothyroidism
Hypokalemia
Hypomagnesemia
Hypocalcemia
CNS damage e.g. ICH, ischemic stroke
Congenital
| 1st line treatment is beta blockers
52
CVS risk factors for AFib?
Age
HTN
DM
Smoking
Obesity
Sleep apnea
53
What proportion of AMI pts have no non-modifiable RFs for CAD?
10%
54
What to look out for in PE of pts with ACS?
Stigmata of dyslipidemia = xanthelasma, arcus cornealis, xanthomas, thick achilles tendon
Evidence of peripheral vascular disease = absent peripheral pulses, femoral bruit, renal bruit etc.
55
Criteria for premature CAD?
CAD before 55 for males, 45 for females. Estrogen gives protective effect.
| Premature CAD is genetically inherited.
56
Mx of AMI?
| Always divide into general and specific treatment.
General Mx: Rest pt, check ABC, give O2 if hypoxemic. Morphine if in pain. Give GTN
Specific: Anti-platelets, aspirin, anti-coagulants, nitrates, Beta blockers, ACE-inhibitors, ARBs, calcium channel blockers.
1st line of mx for AMI is DAPT (dual antiplatelet therapy)
| If medical therapy fails, do angioplasty
## Footnote
Specific Mx consists of Anti-thrombotic and anti-ischemic drugs (nitrate onwards)
57
6 typical symptoms of HF?
Dyspnea
Reduced effort tolerance
Orthopnea
Paroxysmal Nocturnal dyspnea
Pedal edema
Fatigue
| Elderlies can present with confusion, depression
## Footnote
DROPPF mnemonic
58
4 top causes of HF?
Hypertension
CAD
Valvular Heart disease
Cardiomyopathy
59
4 specific signs of HF?
JVP
Displaced apex beat
S3 heart sound
Hepatojugular reflux`
60
Less specific signs of HF?
Sacral edema, scrotal edema, lung creps, hepatomegaly, ascites, narrow pulse pressure, cheyne-stokes breath, oliguria, cold extremities, pleural effusion, cachexia
61
Troponin vs NT-proBNP? What is the diff
Troponins show myocardial injury.
NT-proBNP shows increased filling pressure of heart. More specific than trops for HF and rises very fast
62
4 pillar classes of drugs for HF?
Entresto
Beta blockers
SGLT2 inhibitors
Spironolactone
## Footnote
Furosemide IV diuretic therapy is standard for HF pts
63
What does aberrant conduction in the heart mean?
Means there are abnormal bypass tracts -> electrical current goes from atrium straight to ventricles.
SVT can be very high
64
Grading of systolic murmurs?
1= barely audible
2 = audible, but soft
3 = Easily audible
4 = Easily audible and a/w thrill
5 = still heard with steth only lightly on chest + 4
6 = Heard with steth off the chest + 5
65
Grading for diastolic murmur?
Grade 1 = Barely audible
2 = Audible, but soft
3 = Easily audible
4 = Loud
66
What does obstructive sleep apnea raise risk of?
Systemic HTN
Hypoxia-induced arrhythmia
Pulm HTN, cor pulmonale
Stroke
AMI
67
How to interpret microcytic hypochromic anemia on FBC?
Once u see on FBC, do iron panel next.
Classic Fe deficient anemia shows up as super low Fe, low ferritin, high transferrin.
If unwell, cuz ferritin is an acute phase reactant, ferritin will be elevated even in Fe deficient states. Ferritin has to be below 50 for it to be considered Fe deficient anemia.
If well, then ferritin should be below 30 to be considered fe deficient anemia.
## Footnote
Fe deficiency in elderlies = alw think of malignancy cuz they may not have bleeding.
68
For Fe deficiency in elderlies, what must be considered?
Alw consider malignacy as bleeding may not be always be present
69
Suspicion of what raises strong need for urgent blood film testing?
Suspicion of leukemia
70
Causes of Normocytic Normochromic anemia (NCNC)?
BM infiltration - Multiple myeloma, leukemia, mets, aplastic anemia
CLD
CKD
MAHA
Acute blood loss
Chronic diseases e.g. RA, SLE, IBD
71
Complications of AMI?
## Footnote
DARTH VADER!
Death
Arrhythmia
Rupture of myocardium, septum, papillary muscles
Tamponade
Heart Failure
Valvular disease
Aneurysm of ventricle
Dressler's syndrome
Embolism/thrombus
mitral Regurg / valvular Regurg
72
Symptoms of severe anemia?
Tachycardia
Hypoxia (cardiac ischemia, conjunctival pallor)
Dizziness
Fatigue
73
Biochemical markers of hemolysis?
High LDH
High unconj BRB
High reticulocyte count
Low haptoglobin
74
Purpose of contrast in CT coronary angiogram?
See vasculature, AND
To visualize calcium deposits to assess extent of calcification of vessel.
75
Why are alpha 1 blockers avoided in super old pts?
Bisoprolol preferred over Metoprolol. Why?
Alpha 1 blockers reduce afterload as well as preload
Bisoprolol more cardioselective.
76
How to respond to hypotensive pts?
## Footnote
Depends on cause!! Cause can be Hypovolemic, Cardiogenic, obstructive, distributive (septic)
If cause is septic, then just do fluid resus.
If IHD, do ECG and trops, which can rise in IHD / liver impairment.
For young patients with TVD, CABG is done instead of PCI (stenting). This is cuz clinically it shows better outcomes. PLUS after stenting, CABG cannot be done after that forever.
## Footnote
But always BCLS principles first!!
77
How to respond to AF patients?
Firstly check what the BP is. If low BP, just give fluids.
Treat underlying cause if possible e.g electrolyte abnormalities, infection etc.
If stable, Immediate treatment = MgSO4 to break arrhythmia chain and Beta blocker = bisprolol, metoprolol
## Footnote
But always BCLS principles first!!
78
How does dissection cause delayed pulse?
Radial pulse deficit can be seen if the subclavian artery is involved on the left or brachiocephalic artery on the right. Frequently, the radial pulse is absent on the left and present on the right.
79
What is patent foramen ovale? How to investigate?
Hole btw atrias.
Bubble study is for stroke pts without stroke RFs, checking for PFO
80
What is Ebstein's anomaly?
Malformed tricuspid valve leaflets that are displaced into RV with subsequent TR and R heart enlargement
81
Are calcium channel blockers contraindicated in Heart Failure?
YES
82
step 1 for STEMI Mx?
MONAT!!!
Morphine
Oxygen
Nitroglycerin
DAPT (Aspirin + Ticagrelor)
83
What happens to ECG when heart is paced from the ventricles?
QRS widens cuz impulse spreads from one ventricle to the other
84
Drugs that cause Torsades De Pointes?
Ciprofloxacin
Macrolides
anti-psychotics
SSRI
85
NOAC of choice for non-valvular AF?
Apixaban 5mg twice daily
86
What does high RDW aka anisocytosis point to?
Iron deficiency anemia
| Hereditary spherocytosis possible too
87
What is hypertensive Urgency vs Emergency?
Both have same parameter of 180/120mmHg.
BUT emergency has end organ damage.
Urgency = can slowly start mx to lower BP
Emergency = BP has to be lowered asap on the day
88
HASBLED score for Afib? 1-year risk of major bleeding in Afib patients currently on anticoagulants
HTN
Abnormal liver or kidney function
Stroke
Bleeding
Labile INRs
Elderly
Drugs/alcohol
0 = low risk
1, 2 = moderate risk
3 = high risk
89
Mx strategies for Afib?
Rate control to lower HR
Rhythm control to restore normal sinus rhythm.
Rate control preferred for long-standing Afib. 1st line are beta blockers or non-DHP Ca channel blockers
Rhythm control preferred for recent onset AFib with CVS disease. Do long-term anti-arrhythmics e.g. Flecainide, Amiodarone
90
Commonest cause of Acute vs Subacute Infective endocarditis?
Acute = Staph aureus, causing rapid destruction of endocardial tissue
Subacute = Viridans Strep, affecting pts with pre-existing damage to heart valves or structural defects
91
2 pathways for Infective endocarditis pathogenesis?
Damaged valvular endothelium -> Sterile vegetation with microthrombus
Valve destruction -> valve regurgitation
92
Risk factors of Infective Endocarditis?
Prosthetic heart valves, acquired valvular disease, chronic hemodialysis
Other cardiac conditions
93
1st line imaging always done for pts with suspected Infective Endocarditis?
| q
TTE
94
What is multiple myeloma?
Malignant plasma cell dyscrasia. Neoplastic proliferation of plasma cells suppress normal BM function. Haematopoiesis is suppressed, causing leukopenia, thrombocytopenia, anaemia
95
Cardinal symptoms of multiple myeloma?
HyperCa
Renal impairment
Anaemia
Bone lytic lesions
Other non-specific symptoms e.g. fever, back pain (commonest)
## Footnote
but often asymptomatic
96
Diagnostics for multiple myeloma?
Serum hyperCa
Serum protein electrophoresis = shows M protein
Serum free light chain assay = High light chains
Urine protein electrophoresis shows immunofixation
Confirm with BM biopsy
| Got more, but this is the core
97
Which cardiac pathology can have URTI symptoms?
Myocarditis
98
What can cause falsely low HbA1c?
Hemolytic anemia
## Footnote
It shortens erythrocyte survival
99
Criteria for Atypical angina vs mild chest pain?
1. Retrosternal chest pain
2. Provoked by exertion
3. Relieved by rest or nitroglycerin
If 1 = mild chest pain
If 2 = atypical angina
100
Causes of radio-radial delay?
Aortic dissection (more of radio-femoral delay)
Coarctation of aorta!!
101
Empirical abx for Infective endocarditis?
Ampicillin, cloxacillin, gentamicin
102
What is INR target for metallic heart valve?
Aortic metal = 2.0 - 3.0
Mitral metal = 2.5 - 3.5
## Footnote
mitral valve INR is higher is because it is a lower pressure system (Atrial + Ventricle) than aortic valve (Ventricle + Aorta)
103
What clotting factor lacking in Haemophilia A? How to test?
What inheritance?
Factor 8. Test intrinsic pathway with aPTT
X-linked recessive inheritance
| Test clotting factor assay as well
## Footnote
Thalassemia also AR inherited.
