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M.T.B > Internal Med- Cardiology > Flashcards

Internal Med- Cardiology Flashcards

1
Q

Which age group of women are likely to suffer from a CAD/IHD?

A

> 55 years (non-menstruating women)

Menstruating women virtually never have MI’s because of the protective effects of estrogen.

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2
Q

Which of the following is the most dangerous in a Pt’s lipid profile?

> Ttiglycerides
> Total Cholesterol
< HDL
> LDL
Obesity
A

> LDL

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3
Q

Describe Tako-Tsubo cardiomyopathy

How would you Tx it?

A

It is an acute myocardial damage most often occurring in postmenopausal women following an overwhelming, emotional stressful event which causes a massive catecholamine discharge and results in apical left ventriculular ballooning and ventricular dyskinesia.

Tx: B-Blockers & ACE-i

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4
Q

Correcting which of the following risk factors foe CAD will result in the most immediate benefit for the Pt?

a Diabetes Mellitus
b Tobacco smoking 
c HTN
d Hyperlipidemia
e Weight loss
A

Smoking cessation.

Within 1 year, risk decreases by 50% and within 2 years, 90%

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5
Q

Which 3 features of chest pain will rule out Ischemic pain or CAD?

A 
1 Pleuritic (Changes with respiration)
2 Positional (Changes with position)
3 Tender (Changes with touch of the chest wall)
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6
Q

What is the average duration of pain in:

  • Stable
  • ACS
A

Stable: >2 , <10min
ACS: >10- 30min

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7
Q

What is pathognomonic for Costochondritis?

What is the most accurate test?

A

Chest wall tendreness

Physical Exam

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8
Q

What is pathognomonic for Pericarditis?

What is the most accurate test?

A

Pain worse with lying flat, better when sitting up, young (<40)

ECG with global ST elevation, PR depression

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9
Q

What is pathognomonic for Duodenal ulcer?

What is the most accurate test?

A

Epigastric discomfort, pain better when eating

Endoscopy

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10
Q

What is pathognomonic for GERD?

What is the most accurate test?

A

Bad taste, cough, hoarseness

Response to PPIs, Aluminium hydroxide & Magnesiumhydroxide

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11
Q

What is pathognomonic for Pneumonia?

What is the most accurate test?

A

Cough, Sputum, Hemoptysis

CXR

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12
Q

What is pathognomonic for PE?

What is the most accurate test?

A

Sudden-onset shortness of breath, tachycardia, hypoxia

Spiral CT or V/Q scan

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13
Q

What is pathognomonic for Pneumothorax?

What is the most accurate test?

A

Sharp, pleuritic pain, tracheal deviation

CXR

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14
Q

What is the best initial test for all forms of chest pain?

A

ECG/EKG

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15
Q

In which of the following situations involving chest pain would you order for Enzymes (CK-MB/ Troponin):

1) Office (ambulatory clinic ) chest pain for days to weeks
2) Emergency department chest pain for minutes to hours

A

1) Office (ambulatory clinic ) chest pain for days to weeks=> No enzymes, Transfer Pt to Emergency department
2) Emergency department chest pain for minutes to hours=> Yes enzymes but after ECG is obtained.

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16
Q

What are the types of Cardiac Stress Tests?

What can be used to evaluate it?

A

Provocation:
•exercise stress test
•pharmacologic stress test

An ECG, echocardiography, and/or myocardial perfusion imaging.
Clinical features, blood pressure, and heart rate are evaluated/recorded simultaneously.

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17
Q

Describe the Cardiac exercise stress test

A
  • The patient exercises until the target heart rate is achieved (e.g., on a treadmill).
  • Maximum heart rate = 220 – age (in years)
  • Target heart rate = 85% of the maximum heart rate
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18
Q

What are the 2 limitations of the standard Cardiac (Exercise Tolerance) stress test?

How can the limitations be Mgx?

A

1) Pt may not be able to exercise
2) ECG cannot be read because of a baseline abnormality (LBBB, Pacemaker use, digoxin)

Mgx

1) Do pharmacologic stress test
2) Use of myocardial perfusion imaging or EchoCG for detection of wall motion abnormalities

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19
Q

Describe the pharmacologic stress test

A

IV administration of positive inotropic/chronotropic substances (e.g., dobutamine) or vasodilators (e.g., *dipyridamole [may provoke bronchospasm, avoid in asthmatics] or adenosine) to simulate the effect of exercise on the myocardium

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20
Q

Describe Radionuclide myocardial perfusion imaging

A

The test uses radioactive material called tracers (thallium or sestamibi). Tracers mix with blood and are taken up by the heart muscle as the blood flows through the hearts arteries.
A special “gamma” camera takes pictures of the heart to show how well the heart muscle is perfused. If the heart muscle is alive the isotope will be picked up by the muscle and shows it as a hotspot but if its not picked up it shows as a cold spot

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21
Q

What is the main indication for a stress test?

A

*Detection of ischemia or

Unclear etiology of symptoms of heart disease and ECG is not diagnostic (Stable, NSTEMI, Unstable)

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22
Q

A man with atypical chest pain is found to have normal nuclear isotope uptake in his myocardium at rest. On exercise, there is decreased uptake in the inferior wall. 2hrs after the exercise, the uptake of nuclear isotope returns to normal.

What is the right thing to do?

a. Coronary angiography
b. Bypass surgery
c. PCI (e.g. angioplasty)
d. Dobutamine echocardiography
e. Nothing; its an artifact

A

a. Coronary angiography

Catheterization (Coronary angiography) helps us determine the anatomic location, number of the artery disease and the degree of narrowing (stenosis).
It helps us determine which patients get Bypass or angioplasty or medication only

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23
Q

What is the indication for Stenting or CABG on Angiography?

A
  • If stenosis <50% => insignificant
  • If stenosis >70% => surgical intervention

1 or 2 vessel disease=> Stent

2 vessel disease in a diabetic or any 3 vessel disease or left main disease=> CABG

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24
Q

What is the Holter monitor used for? what are its limitations?

A

It is used to detect rhythm disorders

not accurate for ischemia or ST segment evaluation.

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25
Q

Describe the devisions in IHD

A

IHD divides into:
1) Stable

2) ACS:
I. Unstable (a. New onset[Denovo] b. Progressive [Cresendo] c. Vasospastic)
II. STEMI
III. NSTEMI

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26
Q

What 2 drugs should be given immediately upon arrival to the emergency room in all Pt’s with ACS?

A

2 Antiplatelets:
Aspirin + Clopidogrel/Ticagrelor

They all inhibit the P2Y12 receptor on the platelets

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27
Q

When is the use of anti platelets not suitable with regards to coronary artery disease (CAD)?

A

in Chronic or Stable CAD

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28
Q

How would you manage ACS?

A

Initial management:

  • IV access
  • Evaluate 12-lead ECG

Symptomatic Tx

  • Morphine
  • Oxygen
  • Nitroglycerine
  • Diazepam

Blood thinners (2 anti platelets + 1 anticoagulant):

  • Aspirin + Clopidogrel/Ticagrelor
  • LMWH (e.g. Enoxiparin)

B-Blocker (IV or PO)
-Metprolol

*M.O.N.A.- B.B.
A=> Antiepileptic (Diazepam)
B=> (Blood-thiner, B-blocker)

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29
Q

Which drugs are used for post MI Prevention?

A

Give ABS-Ace=> B-blocker, ACE inhibitor, Aspirin, Statin

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30
Q

What is the most common adverse effect of ACE inhibitors?

A

Cough (occurs in 7% of Pt)

Also, Hyperkalemia due its effects in inhibiting aldosterone (same with ARB)

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31
Q

When should Statins be used?

A

in CAD, PAD, Stroke and DM: with LDL>100

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32
Q

Explain S1, S2, S3 and S4 auscultation sounds

A

S1=> Closure of Atrioventricular valves (Mitral and Tricuspid)
S2=> Closure of Semilunar valves (Aortic and Pulmonary)
S3=> Blood striking a compliment LV (it is consistent with Systolic HF but can be present in pregnancy and athletes)
S4=> Contraction of atria forcing blood into the LV. If the LV is noncompliant/stiff (eg LVH, Diastolic HF) the S4 is produced by blood striking the LV

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33
Q

What is Palsus Paradoxus? When is it present?

A

It is a decrease in Pulse strength and Systolic BP >10mmHg during inspiration. It is commonly seen in Pt’s with hyperinflation and air trapping (Asthma or COPD exacerbations, Croup [coz of increased negative pressure] ). It may be seen in those with cardiac tamponade, constrictive pericarditis.
The variable reduction in BP can also cause some peripheral pulses to be lost, accounting for the irregularity in pulse.

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34
Q

In situations that it’s supposed to be present, what situations would make Palsus Paradoxus not present?

A

Aortic regurgitation, Atrial septal defect and Severe hypotension

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35
Q

What kind of sound is heard in a patient with a Patent ductus arteriousus?

A

a continuous machinery murmur

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36
Q

On auscultation, what causes a displaced point of maximal impulse? (Shift in the apex beat)

A

LVH or Dilated Cardiomyopathy

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37
Q

Infarction of which part of the myocardium is associated with the greatest mortality rates?

A

Anterior

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38
Q

What is the Mgx of Premature Ventricular Complexes (PVCs) and Premature Atrial Complexes?

A

They are associated with the later development of more severe arrhythmias, but no additional therapy is needed if Magnisium and Potassium levels are normal

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39
Q

If a Pt has a PVC thats associated with an acute infarction, how would you Mgx the Pt?

A

Tx infarction only. Tx of PVCs worsens the outcome.

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40
Q

A 70 year old woman comes to the emergency department with crushing substernal chest pain for the last hour. An ECG shows ST segment elevation in V2 to V4. What is the most appropriate next step in the management of this patient?

a. CK-MB level
b. Oxygen
c. Nitroglycerine sublingual
d. Aspirin
e. Thrombolytics
f. Metoprolol
g. Atrovostatin
h. Angioplasty
i. Consult cardiology
j. Transfer the patient to the intensive care unit
k. Troponin level
i. Morphine
m. Angiography
n. Clopidogrel

A

d. Aspirin- it lowers mortality with all ACS’s and is critical to administer as rapidly as possible.
CK-MB and Troponin will not be elevated within 1hr.
Morphine, Oxygen and Nitroglycerine should be administered but they do not lower mortality.
Clopidogrel is indicated when the Pt is intolerant to aspirin or has undergone angioplasty with stenting.
Aspirin is followed by another form of acute revascularisation (Thrombolytics or Angioplasty)

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41
Q

Which cardiac biomarker is used to Dx a reinfarction?

A

CK-MB

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42
Q

Which is more superior Angioplasty (PCI) or Thrombolytics? What is the time frame in which they should be performed?

A

Angioplasty (PCI) is superior to Thrombolytics because of survival and mortality benefits and should be permed within 90 min of Pt arriving to the emergency department.

*if Angioplasty (PCI) is not available give Thrombolytics (can be given within the 1st 12hrs of onset of chest pain, risk reduction is as high as 50% within the 1st 2hrs, so the earlier the better)

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43
Q

When are Thrombolytics indicated in ACS?

A

When there is ST elevation but they are not as good as PCI

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44
Q

When is Heparin indicated in ACS?

A

In NSTEMI because we want to prevent the clot from growing further. Can also be used in STEMI but only after Thrombolytics

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45
Q

When are GPIIb/IIIa inhibitors indicated in ACS?

A

In unstable angina and NSTEMI

They are only beneficial in STEMI if is to undergo angioplasty and stenting.

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46
Q

Which is more superior LMWH or UF-Heparin?

A

LMWH is superior in terms of mortality benefit.

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47
Q

What is the empiric therapy for Bradycardias?

A

Atropine then a Pacemaker if atropine is ineffective

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48
Q

Which vessels supply the right side of the heart?

What are the complications of its occlusion?

A

R. Coronary artery=> R. Marginal=> Posterior descending artery

Inferior wall infarction
Right Ventricular Infarction=> right sided insufficiency will result in a reflex tachycardia
SA or AV node insufficiency/block

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49
Q

What is pathognomonic for a Cardiac tamponade/ Free wall rupture?

A
  • Sudden loss of pulse

- A decrease in Systolic BP >10mmHg on inspiration=> Palsus Paradoxus

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50
Q

How can you Dx Cardiac tamponade/ Free wall rupture?

What is the next best step after Dx Cardiac tamponade/ Free wall rupture?

A

Emergency Echocardiography or detection of Palsus Paradoxus

Emergency Pericardiocentesis is done on the way to the operating room.

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51
Q

How can you tell the difference between V. Tach and V. Fib?

How would u Mgx them?

A

Use ECG:
V. Tach=> >/= 3 consecutive premature ventricular beats which can be either Monomorphic (single QRS morphology) or Polymorphic (multiple QRS morphologies)

V. Fib=> Usually > 300 bpm. Erratic undulations with unclear QRS complexes.

Both are treated with Emergency Electrical Shock (Cardioversion/Defibrillation)

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52
Q

What is pathognomonic for a Valve or Septal Rupture as a complication of an MI?

A

A new onset murmur and pulmonary congestion or rales

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53
Q

What is pathognomonic for a Septal Rupture as a complication of an MI?

A

A new onset murmur and pulmonary congestion or rales

A step-up in oxygen saturation as it goes from the RA to the RV coz the SaO2 from the left (>95%) is shared with/ shunted to the SvO2 of the right side (≈75%).

e. g. RA 72%, RV 85%
* In a normal situation blood in RA & RV should have the same value

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54
Q

What is the most accurate Dx test for a Valve and Septal?

A

Echocardiography

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55
Q

What are the Key features of a Third-degree AV block?

A

Bradycardia and cannon A waves/ cannon atrial waves coz of complete disassociation between atria and ventricles. (A “cannon A wave” occurs when the right atrium contracts against a closed tricuspid valve)

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56
Q

What is the Key feature of Sinus bradycardia?

A

No cannon A waves

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57
Q

What are the Key features of V. Fib?

A

Loss of pulse and Erratic undulations with unclear QRS complexes.

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58
Q

What are the Postinfarction routine Medications?

A

ABS-Ace

Aspirin
B-Blockers (Metoprolol)
Statins
ACE-inhibitors

Clopidogrel or Ticagrelor in those intolerant to aspirin

ARB’s in those with cough on ACE-i

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59
Q

What is the prerequisite upon discharging all patients with ACS?

A

Everyone gets a stress test. It determines if angiography is needed. If signs of irreversible myocardial schema are present, there is no need to do angiography because we cant revascularise dead tissue.
The stress test should not be performed if the patient is symptomatic

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60
Q

Which prophylactic anti arrhythmic medications can be used in V. Tach or V. Fib?

A

Amiodarone or any anti arrhythmic medications SHOULD NOT be used, rophylactic anti arrhythmic medicationsi increase Mortality

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61
Q

Which drug should the Pt not use when on Nitrates?

A

Slidenafil => will result in hypotension coz both are vasodilators

62
Q

What can cause erectile dysfunction post MI?

A

Anxiety and the use of B-blockers

63
Q

When can an MI Pt reengage in sexual activity?

A

if no symptoms, immediately

64
Q

What are the 2 main mechanisms of Congestive Heart Failure (CHF)?

A

1) Systolic Dysfunction- low ejection fraction due to dilation
2) Diastolic Dysfunction- inability of heart to relax and receive blood. Ejection fraction is normal or high

65
Q

What is the clinical presentation of CHF?

A

Exertional dyspnea
Pulmonary edema (rales/crackles on auscultation)
Peripheral edema
Positional Orthopnea (worse when lying flat, relieved when sitting up or standing)
Jagularvenous distention (JVD)
Paroxysmal nocturnal dyspnea (PND- sudden worsening at night, during sleep)
S3 gallop rhythm

66
Q

What are the other key features including Dyspnea that will result in a PE as the most likely diagnosis?

A

Sudden onset, clear lungs

67
Q

What are the other key features including Dyspnea that will result in Asthma as the most likely diagnosis?

A

Sudden onset, wheezing, increased expiratory phase

68
Q

What are the other key features including Dyspnea that will result in Pneumonia as the most likely diagnosis?

A

Slow onset, fever, sputum, unilateral rales/rhonchi/cracles

69
Q

What are the other key features including Dyspnea that will result in a Pneumothorax as the most likely diagnosis?

A

Decreased breath sounds unilaterally, tracheal deviation

70
Q

What are the other key features including Dyspnea that will result in a Panic Attack as the most likely diagnosis?

A

Circumoral numbness, caffeine use, Hx of anxiety

71
Q

What are the other key features including Dyspnea that will result in Anemia as the most likely diagnosis?

A

Pallor, gradual over days to weeks

72
Q

What are the other key features including Dyspnea that will result in a Tamponade as the most likely diagnosis?

A

Pulsus paradoxes, decreased heart sounds, JVD

73
Q

What are the other key features including Dyspnea that will result in an Arrhythmia of almost any kind as the most likely diagnosis?

A

Palpitations, syncope

74
Q

What are the other key features including Dyspnea that will result in a Pleural Effusion as the most likely diagnosis?

A

Dullness to percussion at bases

75
Q

What are the other key features including Dyspnea that will result in COPD as the most likely diagnosis?

A

Long Hx of smoking, barrel chest

76
Q

What are the other key features including Dyspnea that will result in Carbon monoxide poisoning as the most likely diagnosis?

A

Burning building/car, wood burning in winter, suicide attempt

77
Q

What is the most important diagnostic test for CHF? Why?

A

Echocardiography, because it allows us to distinguish between systolic and diastolic dysfunction and also evaluate the ejection fraction.

78
Q

What is the best initial test in CHF?

What is the most accurate test in CHF?

A

Transthoracic echo. *Transesophageal echo is the most accurate when evaluating valves

Multiple-gated acquisition scan (MUGA scan) or Nuclear Ventriculography is the most accurate for CHF

79
Q

When is a BNP-level the next best step?

A

in a Pt with shortness of breath, etiology of dyspnea is unclear and you cannot wait for an echo to be done. A normal BNP-level excludes CHF as a cause of shortness of breath

80
Q

What 2 things need to be considered when managing a Pt with CHF?

A

1) Setting- emergency department versus office or clinic.

2) Presence of acute symptoms of dyspnea at the time of presentation.

81
Q

Which medications are used in systolic dysfunction CHF?

A

AB-block SpiDiDi

ACE-i / ARBs
B-Blockers (but not in an acute setting)
Spironolactone
Diuretics (loop- Furosemide)
Digoxin
82
Q

Which B-Blockers are beneficial in CHF?

A

MBC
Metoprolol- Beta1 specific
Bisoprolol- Beta1 specific
Carvedilol- Nonspecific B-blocker with Alpha1 receptor blocking activity

83
Q

What are the effects of B-Blockers in CHF

A

Anti-ischemic effect
Decrease HR=> decreased oxygen demand
Antiarrhythmic effect

**Should not be given in acute CHF

84
Q

What could cause a Pt with CHF to develop gynecomastia? How is it Mgx?

A

The use of spiranolatone can result in antiandrogenic effect leading to gynecomastia. Eplerenone can inhibit aldosterone without causing antiandrogenic effects.

85
Q

Do Diuretics lower mortality in CHF

A

No, they control symptoms. ACEi/ARBs and B-Blockers, Spironolactone, Hydralazine/Nitrates lower mortality

86
Q

Which pacemakers can be used in CHF and when?

A

1) Implantable defibrillator - in ischemic cardiomyopathy and injection fraction <35%
2) Biventricular pacemaker- in dilated cardiomyopathy and injection fraction <35%

87
Q

What is the Mgx of Diastolic Dysfunction CHF?

Can Hypertrophic Obstructive Cardiomyopathy (HOCM) be Mgx similarly?

A

B-blockers and Diuretics are beneficial. Digoxin and Spironolactone should not be given. The reset are unclear.

B-blockers should not be used on HOCM

88
Q

What will be the C-XR findings in a Pt with Pulmonary Edema due to CHF?

A
  • “Bat Wing” appearance
  • Vascular congestion with cephalisation of flow
  • Kerley’s B lines- short lines perpendicular to the pleural surface at the lung base. They represent deem of the interlobular septa.
  • If chronic => enlargement of heart and pleural effusion
89
Q

What do we expect to find on Arterial Blood Gas (ABG) in CHF?

A

Respiratory Alkalosis due to hyperventilation

90
Q

Why is the ECG the most important test to do acutely in CHF?

A

It can lead to change in immediate therapy.
If A.fib, A.flut or V.tach is the cause of Pulmonary edema=> the 1st thing to do is perform rapid synchronised cardioversion

91
Q 
A 74 year old woman comes to the emergency department with an acute onset of shortness of breath, respiratory rate of 38 per minute, rales to her apices, S3 gallop and jagularvenous distension.
What is the best initial step in the Mgx of this Pt?
a. Oximeter
b. Echo
c. IV Furosemide
d. Ramipril
e. Metoprolol
f. Nesiritide
A

c. IV Furosemide
The best initial step in a Pt with acute pulmonary edema is to remove the fluid with a loop diuretic.

Echo should be done but it is not urgent

92
Q

What is the best initial therapy in acute pulmonary edema?

A 
Preload reduction:
Morphine
Oxygen
Nitrates
Loop Diuretics

MON-Loop

93
Q

Which Positive Inotropic agent can be used in CHF Pulmonary Edema and when is it indicated?

How does it differ from the others?

A

Dobutamine- when Pt does not respond to preload reduction therapy.

Dobutamine is used in an acute setting but Digoxin cannot be used in an acute setting because its will start after several weeks from its initial use

94
Q

Which valvular disease(s) is(are) associated with Rheumatic fever?

A

Any form of valvular disease, but Mitral Stenosis is the most common

95
Q

Which valvular disease is associated with Ageing?

A

Aortic Stenosis

96
Q

Which conditions are associated with Regurgitant disease?

A

HTN and IHD

97
Q

What is pathognomonic for Right Sided Valvular disease (Tricuspid and Pulmonary valve)?

A

They increase intensity/loudness with inhalation

98
Q

What is pathognomonic for Left Sided Vascular disease (Mitral and Aortic valve)?

A

They all increase intensity/loudness with exhalation except for mitral valve prolapse and hypertrophic obstructive cardiomyopathy

99
Q

What is the best initial test for all valvular diseases?

A

Transesophageal Echo

100
Q

What is the most accurate test for all valvular diseases?

A

Catheterisation

101
Q

Which clinical feature is associated with all forms of valvular disease?

How would you mange it?

A

Fluid overload in the lungs (Pulmonary Edema)

Mgx=> Diuretics

102
Q

What are some of the Physical features and clinical findings in Mitral Stenosis?

A
  • Diastolic Murmur - Squatting and leg raising increase the intensity
  • LAH=> compression of esophagus=> Dysphagia
  • LAH=> Hoarseness of voice- coz of pressing on laryngeal nerve
  • A.Fib=> stroke
  • Hemoptysis
103
Q

What ECG changes can you expect to see in Mitral Stenosis?

A

A.Fib and LAH (Biphasic P wave)

104
Q

What C-XR changes can you expect to see in Mitral Stenosis?

A
  • Straightening of left heart border

- Elevation of the left main-stem bronchus

105
Q

What is the Mgx of Mitral Stenosis?

A
  1. If fluid overload is present=> Diuretics and Sodium restriction
  2. Ballon Valvuloplasty (BV)
  3. If BV fails=> Valve Replacement
  4. If A.Fib present=> Warfarin to an INR of 2-3 + Rate Control=> B-blockers/ digoxin/ diltiazem/verapamil
106
Q

What are some of the Physical features and clinical findings in Aortic Stenosis?

A
  • Systolic, crescendo-decrescendo murmur
  • The most common presentation is Angina
  • Syncope
107
Q

What ECG changes can you expect to see in Aortic Stenosis?

A

Sokolow-Lyon index:

S in V1 + R in V5 or V6 (whichever is larger) ≥ 35 mm (≥ 7 large squares)
OR,
R in aVL ≥ 11 mm

108
Q

What C-XR changes can you expect to see in Aortic Stenosis?

A

Cardiac enlargement (LVH) defined by a diameter greater than 50% of the total trans thoracic diameter

109
Q

What is the Mgx of Aortic Stenosis?

A

The most effective is valve replacement

Balloon valvuloplasty is not effective coz the main mechanism for developing Aortic Stenosis is calcification

110
Q

What are some of the Physical features and clinical findings in Mitral Regurgitation?

A
  • Same signs as CHF + a pansystolic (holosystolic) murmur.
  • Murmur radiates to the axilla
  • Squatting and leg raising increase the intensity of the murmur
111
Q

What is the Mgx of Mitral Regurgitation?

A

ACEi / ARB decrease the rate of progression of a regurgitant lesion

Valve replacement is indicated when the left ventricular end systolic diameter is >40mm or ejection fraction is <60%

112
Q

What are some of the Physical features and clinical findings in Aortic Regurgitation?

A

-Same signs as CHF + diastolic, decrescendo murmur.
-Wide pulse pressure (Systolic BP - Diastolic BP)=> Hyperdynamic circulation, leading to;
-Water-harmer pulse
-Quincke’s sign (pulsations in the nail bed)
-Hill sign (BP in legs as much as 40mmHg above arm BP)
-Head bobbing (de Musset sign)
Over time=> eccentric LVH

113
Q

What is the Mgx of Aortic Regurgitation?

A

ACEi / ARB or CCB will increase forward flow of blood and delay progression

Valve replacement is indicated when the left ventricular end systolic diameter is >55mm or ejection fraction is <55%

114
Q

What are some of the Physical features and clinical findings in Mitral Valve Prolapse?

A
  • Often asymptomatic
  • Mid systolic click with murmur just after the click
  • Sx of CHF are usually absent
  • Atypical chest pain
  • Palpitations
  • Panic attack
115
Q

What is the Mgx of Mitral Valve Prolapse?

A

B-blockers are used in symptomatic Pts

A few stitches into the valve to tighten the leaflets

116
Q

What are the types of Cardiomyopathy?

A

1) Dilated- systolic dysfunction or low EF CM
2) Hypertrophic- diastolic dysfunction or Cardiac failure with preserved EF
3) Restrictive

117
Q

What is the general clinical presentation of Cardiomyopathies?

A

Edema, Rales, and JVD

118
Q

What is the best initial test or most accurate test for Cardiomyopathies?

A

Echocardiography

119
Q

Which group of drugs is used in all Cardiomyopathies?

A

B-blockers

120
Q

What is the difference between HCM and HOCM?

A

HCM- is a reaction to a stressor on the heart like >BP

HOCM- is a genetic disorder with an abnormal shape to the septum of the heart, which will anatomically obstruct outflow from the LV. It is responsible for sudden death, particularly in healthy athletes. Sx worsened by anything increasing HR (Exercise, Diuretics)

121
Q

What pathognomonic feature on echocardiography is specific for HOCM?

A

Systolic anterior motion of the mitral valve

122
Q

What is the Mgx of HCM and HOCM?

A
  • B-blockers for both HCM and HOCM
  • Negative inotrops like Verapamil
  • Diuretics in HCM but contraindicated in HOCM
123
Q

What is the etiology of Dilated Cardiomyopathy?

A 
Alcohol
Postviral Myocarditis
Radiation
Toxins (Chemo)=> Doxorubicin (Adriamycin)
Chagas Diseae
124
Q

What is the etiology of Restrictive Cardiomyopathy?

A

Sarcoidosis
Amyloidosis
Hemochromatosis
Scleroderma

125
Q

What is Restrictive Cardiomyopathy?

A

It is a CM that combines aspects of both DCM and HCM. The heart neither contracts nor relaxes.

126
Q

What effect does the Valsalva manuver or suddenly standing from a squatting position have on Stenotic and Regurgitant murmurs have?

A

The effect is similar to that of diuretic use.

Diuretics are used to Tx Stenotic and Regurgitant murmurs, therefore the Valsalva manuver or suddenly standing will improve (reduce) the murmurs

127
Q

What is characteristic of the pain in Pericarditis?

A

Sharp pain that changes intensity with respiration as well as the position of the body.
Pain is worse on lying down and improved by sitting up.

128
Q

What are the characteristic ECG changes in Pericarditis?

A

Global ST elevation.

PR Depression is more specific

129
Q

How would you Mgx Pericarditis?

A

Treat the underlying cause.
If no clear cause, presume a viral etiology with Coxsackie B virus and Tx with NSAIDs and Colchicine (decreases recurrences)

130
Q

How much fluid is required to cause cardiac temponade and which side does compression begin?

A

50ml can cause a tamponade but the pericardium can accommodate as much as 2 litres.
Compression will begin on the right side because the walls are thinner.

131
Q

What are some of the diagnostic tests that can be done in Cardiac tamponade?

A

1) ECG- Electrical Alternans (different heights of QRS complexes between beats)
2) C-XR- Globular heart
3) Echocardiogram- RA and RV diastolic collapse (Because compression will begin on the right side because the walls are thinner.)
4) Right heart catheterisation- equalisation of pressures in diastole

**Pulsus Paradoxus

132
Q

How would you Mgx Cardiac tamponade?

A

1) Pericardiocentesis
2) IV fluids
3) A hole/window into pericardium for recurrent cases (A hole from the pericardial space into the pleural cavity to prevent a cardiac tamponade)

133
Q

What is your opinion on using Diuretics for Cardiac tamponade?

A

Diuretics will decrease intracardiac filling and will worsen the collapse of the right side of the heart.

134
Q

What combination of clinical features would make constrictive Pericarditis the most likely diagnosis?

A

Signs of RHF + Calcification on C-XR

RHF;

  • edema
  • ascites
  • hepatosplenomegaly
  • JVD
  • Kussmaul Sign: Increased JVD on inhalation (normally neck veins should go down on inhalation)
  • Pericardial Knock- an extra heart sound in diastole from ventricular filling as blood hits a stiff, rigid pericardium.
135
Q

What is the best initial test in Dx constrictive Pericarditis?

A

C-XR- shows calcifications

but CT and MRI are more accurate

136
Q

How would you Mgx Pericarditis?

A

1) Diuretics - to relieve Sx of edema

2) Surgical removal of pericardium (pericardial stripping)

137
Q

What clinical feature would make Peripheral Artery Disease (PAD) the most likely diagnosis?

A

Leg (limb) pain in the calves on exertion, relieved by rest

Most commonly in lower limbs

138
Q

Severe Peripheral Artery Disease (PAD) is associated what kind of skin changes?

A

Critical limb Ischemia- Ulcer / Gangrene

Loss of:

  • hair follicles
  • sweat glands
  • sebaceous glands

Shiny and smooth skin

139
Q

What is the best initial test for Dx Peripheral Artery Disease (PAD)?

What is the most accurate test for Peripheral Artery Disease (PAD)?

A

Best initial test=> Anckle-Brachial Index (ABI)

Most accurate test=> Angiogram/Angiography
[Digital subtraction angiography (DSA): gold standard]

140
Q

Explain the Anckle-Brachial Index (ABI)

A

Its the ratio of the Systolic BP in the ankles to the Systolic BP in the brachial artery, which is normally equal between them or slightly greater in the ankles because of gravity.
Normal ABI is 0.9–1.4
Values below 0.9 indicate PAD
Values above 1.4 indicate a noncompressible calcified vessel

Or if the difference between them is >10% => PAD

141
Q

What forms of PAD are associated with Intermittent claudication?

A

1 Femoropopliteal disease (most common) → calf claudication
2 Aortoiliac disease (Leriche’s syndrome)
• Level of the aortic bifurcation or bilateral occlusion of the iliac arteries

142
Q

What is the best initial therapy for PAD?

A
  • Cessation of smoking
  • For all patients=> long-term antiplatelet therapy with aspirin, clopidogrel, or **ticagrelor (reduces mortality and morbidity)
  • ***Cilostazol (Vasodilator and Anti-platelet)
  • Lipid-lowering agent if LDL>100 (usually statins)
  • Antihypertensive treatment

**Calcium CB do not help in PAD

143
Q

a 67-year-old man comes to the emergency department with sudden onset of chest pain. He also has pain between his scapulae. He has a history of hypertension and tobacco smoking. His BP is 169/108.

What is the best initial test?

a. C-XR
b. C-CT
c. MRA
d. Transesophageal echocardiogram
e. Transthoracic echocardiogram
f. CT angiogram
g. Angiography

A

a. C-XR
Although not as sensitive as the rest of the tests, the C-XR might show widening of the mediastinum, which is an excellent clue as to the presence of aortic dissection

144
Q

What clinical features would make Aortic Dissection the most likely diagnosis?

A
  • Severe and sudden chest pain
  • Pain between the scapulae
  • Difference in BP between the arms
145
Q

Which of the following is the most accurate for diagnosing Aortic Dissection?

a. MRA
b. Transesophageal echocardiogram
c. Transthoracic echocardiogram
d. CT angiogram
e. Angiography

A

e. Angiography

there is no difference in the accuracy of MRA, CT-angiography or TEE

*MRA=CTA=TEE

146
Q

What is the Tx of Aortic Dissection and what is the order in which the Tx is given?

A
  1. B-blockers
  2. Nitroprusside
  3. Surgical correction

B-blockers will decrease the “shearing forces” that will worsen the dissection.
B-blockers must be started before Nitroprusside to protect against reflex tachycardia (due to vasodilatory effect of nitroprusside)

147
Q

What are the indications of screening for an Aortic Aneurysm and how would you screen?

A

Men who have a history of smoking and are >65years old.

With Ultrasound

148
Q

What is Peripartum Cardiomyopathy?

A

It is a Dilated Cardiomyopathy resulting LV dysfunction due to an unclear mechanism of antibodies made against the myocardium. In most cases it happens after delivery but can also happen before or during delivery.
A repeat pregnancy will provoke enormous antibody production

149
Q

What is the Tx for Peripartum Cardiomyopathy?

A 
Same drugs for Dilated Cardiomyopathy:
A.B-block Spi Di Di
-ACEi/ARB (acceptable coz most cases are after pregnancy)
-B-blockers
-Spiranolactone
-Diurestics
-Digoxin
150
Q

Which of the following is the most dangerous in pregnant women?

a. Mitral stenosis
b. Peripartum cardiomyopathy
c. Eisenmenger phenomenon
d. Mitral valve prolapse
e. Atrial septal defect

A

b. Peripartum cardiomyopathy

Peripartum cardiomyopathy is the worst in pregnancy, followed by Eisenmenger phenomenon

M.T.B (9 decks)

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