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Flashcards in Master the Boards: Cardiology Deck (92):
1

What is Tako-Tsubo cardiomyopathy and the presumed mechanism?

Myocardial infarction occurring in relation to extremely stressful events, common in postmenopausal woman and presumed due to massive catecholamine release. Coronary arteries are normal and patients don't benefit from revascularization. There is evidence of LV hypokinesis.

2

In order for CAD in a parent to be a risk factor for a patient what other information must you know?

The age of onset in that pattern. CAD will only be a risk factor if it occurs early in the parents (males

3

What risk factor lifestyle modification leads to the greatest reduction in CAD risk?

Quitting smoking

4

If the nature of chest pain changes with respiration, bodily position, or upon palpation is it more or less likely ischemia?

Less likely

5

What are EKG findings of pericarditis?

ST elevation throughout
PR depression

6

If the etiology of chest pain is not certain and the EKG is non-diagnostic what should be the next test employed?

Stress test

7

If a patient cannot exercise for a stress test then what other options do yo have for inducing mild ischemia during testing?

Dipyridamole combined with nuclear isotopes (e.g. thallium ,sestamibi)

Dobutamine with echocardiography

8

What is the most accurate method of detecting CAD?

Coronary angiography

9

Surgically correctable levels of coronary stenosis begin at what percentage?

70%

10

What drugs offer the best mortality benefit in chronic angina (3)?

Aspirin
Beta-blocker
Nitrate

11

What is prasugrel?

Thienopyridine (similar to clopidogrel) with best evidence in use for angioplasty and stenting

12

Ticlodipine inhibits platelets and is used in the rare situation when both aspirin and clopidogrel cannot be used.

What are two side effects of ticlodipine?

Neutropenia
TTP

13

What drug has the best mortality benefit in CAD with low ejection fraction(systolic dysfunction)?

ACE inhibitors

14

In CAD, what is the goal of LDL according to national guidelines?

15

What is the most common side effect of statin medications?

Elevated transaminases

(Rhabdomyolysis is not as common as the above)

16

Niacin predominantly has what effect on the lipid profile?

What are three side effects seen?

Increases HDL

Glucose intolerance (hyperglycemia), increased uric acid, itchiness related to histamine release

17

Fibrates have what effect on lipid profile?

When used with statins what are patients at increased risk for?

Lower TGs

Increased risk of myositis

18

Name a bile acid sequestrant medication

Cholestyramine

19

Flatus and abdominal cramping are side effects of what lipid lowering medication?

Cholestyramine

20

Should CCBs be routinely used in CAD, why?

Which two may be used in select situations?

No, they can cause a reflex tachycardia which can increase myocardial oxygen demand in CAD and lead to INCREASED mortality.

Verapamil and diltiazem may be used in those with severe asthma which can't receive beta-blockers, cocaine users, or those with Prinzmetal variant angina

21

Edema, constipation, and heart block may be the side effects of what class of medications?

Calcium channel blockers

Constipation is especially common with verapamil

22

In bypass grafting, which vessel usually lasts longer internal mammary artery or saphenous vein?

Internal mammary artery (10 years)
Saphenous vein (5 years)

23

What is the best intervention for acute coronary syndrome?

Percutaneous coronary intervention (i.e. angioplasty)

24

Increased jugulovenous pressure on inhalation = ?

What is it associated with?

Kussmaul sign

Associated with constrictive pericarditis or restrictive cardiomyopathy

25

A displaced point of maximal impulse is suggestive of what two disease entities?

LVH
Dilated cardiomyopathy

26

ST elevations in V2 - V4 suggest STEMI of what location?

Anterior wall of left ventricle

27

ST elevations in II, III, and aVF suggest STEMI of what location?

Inferior wall

28

Should PVCs be treated?

No, treating them (even in setting of ACS) only worsens outcomes

29

ST depression in leads V1 and V2 suggests of MI of what location?

Posterior wall MI (low mortality)

30

What medication should be given immediately during acute coronary syndrome since it reduces mortality?

Aspirin

(Beta-blocker, nitrate, oxygen, morphine all help but do not lead to reduced mortality as much)

31

How long after an MI does troponin rise and how long does it remain elevated?

4-6 hours post-MI

Remains elevated for 10-14 days so not helpful in determining reinfarction

32

What is better, angioplasty or thrombolytics?

What is the gold standard in terms of time?

Angioplasty (i.e. PCI) should be done within 90 minutes of arriving to ED with chest pain

33

Does warfarin have any utility in CAD?

During PCI, what helps reduce the risk of restenosis?

No, warfarin is really only helpful on the venous circulation

Placement of a drug-eluting stent with PCI reduces the risk of restenosis

34

If a patient is brought to a hospital without a cath lab and they have ACS what should be done, thrombolytics or transfer for PCI?

Thrombolytics, attempt to give within 30 minutes

35

If there is ST depression on EKG of a patient with suspected ACS can thrombolytics be used?

No, they should only be used in cases of ST elevation

36

What type of MI is heparin best used in?

NSTEMI

37

A cannon A wave is an indicator of what pathological cause of bradycardia?

Third degree AV block. They represent atria contracting against a closed tricuspid valve since the atria and ventricles are out of sync.

38

What artery supplies the inferior wall of heart?

Right coronary artery?

39

How should RV infarctions be treated compared to LV infarctions?

They should be fluid resuscitated (Nitrates and other venodilators may worsen cardiac filling in RV infarction)

40

Sudden loss of pulse a few days after an MI is from what complication?

Free wall rupture/tamponade

41

A patient presents a few days after an MI with new onset murmur and pulmonary congestion, what are the two possible causes?

Septal rupture (often present with "step-up" in oxygenation)
Valve rupture (causing mitral regurgitation)

42

What is the utility of an intra-aortic balloon pump?

It is a temporizing measure to help induce blood flow in a heart with poor output due to anatomic causes. It is not a permanent solution and is often done for 24-48 hours prior to valve replacement or transplant.

43

What should be done before discharging a patient from the hospital with myocardial ischemia?

A stress test to determine residual areas in need of revascularization. If the patient remains symptomatic do not do the stress test, likewise if they don't have signs of reversible ischemia.

44

Should patients receive prophylactic antiarrhythmics upon discharge from the hospital after an MI?

NO!

45

Do patients have to wait after an MI to have sex?

Erectile dysfunction post-infarction is most commonly due to?

No, they can go for it.

Anxiety

46

What is the most common cause of CHF?

HTN

47

Name as many causes of cardiomyopathy leading to CHF you can

Alcohol, postviral myocarditis, hemochromatosis, thiamine, radiation, Chagas disease, thyroid disease, peripartum cardiomyopathy, adriamycin/doxorubicin

48

Name the cause of dyspnea

Brown blood, not improving with oxygen supplementation, cyanosis, and clear lungs on auscultation

Methemoglobinemia

49

What are specific H + P findings leading you to consider CHF?

Orthopnea
Paroxysmal Nocturnal Dyspnea
S3

50

Every patient with CHF must undergo what test to evaluate for either systolic or diastolic dysfunction?

Echo

51

What is the best initial test to evaluate EF in CHF?
What is the most accurate test?

Transthoracic Echo
Nuclear ventriculography (TEE is even more accurate)

52

In what situation should you be checking a BNP on a patient?

They present with SOB and CHF is suspected and you don't have immediate access to an echo

53

What disturbance on the lipid profile is the biggest risk factor for CAD?

Elevated LDL

54

What is the benefit of eplerenone over spironolactone?

Doesn't have the antiandrogenic effects of spironolactone

55

Does digoxin (or any positive inotropic agent for that matter) have an effect on mortality in CHF?

What does digoxin have an effect on in CHF?

No effects on mortality

Digoxin does however reduce the frequency of hospitalizations

56

What are the indications for an implantable pacemaker in CHF? (2)

Ischemic cardiomyopathy
Ejection fraction

57

What treatments of systolic-dysfunction CHF have a proven mortality benefit (4 pharmacologic, 1 procedural)?

ACEi/ARB
Beta-blocker
Spironolactone/Eplerenone
Hydralazine/Nitrate
Implantable pacemaker

58

Are diuretics recommended in hypertrophic obstructive cardiomyopathy?

No. They worsen the obstruction

59

What medications have a clear benefit in the treatment of diastolic CHF?

Beta-blockers
Diuretics

60

Amrinone and milrinone function how?
What effects do they have?

PDE inhibitors

Increase contractility, reduce afterload

61

What valvular disease is Rheumatic fever most commonly associated with?

Mitral stenosis

62

What effect does inspiration and expiration have on murmurs on the right and left sides of the heart, respectively? Explain.

Inspiration causes negative intrathoracic pressure which draws increased venous return to the right (increased preload on right) which increases intensity of tricuspid and pulmonic murmurs.

Expiration "pushes" blood out of the lungs and into the left heart, thus accentuating mitral and aortic murmurs.

63

Regurgitant valvular lesions respond best to which type of medical therapy?

ACEi/ARB
Nifedipine
Hydralazine

64

What valvular abnormality may present with dysphagia and hoarseness?

What do squatting and leg raising do to the murmur?

Mitral stenosis; it may compress esophagus and also recurrent laryngeal nerve

Squatting and leg raising increase preload and increase the intensity of the murmur

65

What do Valsalva, standing, and handgrip all do the murmur of aortic stenosis and why?

They all decrease it.

Valsalva and standing both decrease venous return which reduces volume of blood flowing by the valve.
Handgrip increases afterload which also reduces the amount of blood which will pass through the valve.

66

What is a procedural treatment which can be done for mitral stenosis?

Balloon valvoplasty

67

What will handgrip, squatting, leg raising, standing, valsalva, and expiration do to mitral regurgitation murmur?

Handgrip: Increase afterload therefore increase
Squat/Leg raise: Increase preload therefore increase
Standing/Valsalva: Decrease preload therefore decrease
Expiration: Increases left-heart volume and thus increases

68

What are the only two left-sided murmurs which will decrease with expiration?

Hypertrophic cardiomyopathy
Mitral valve prolapse

69

What medical management is recommended for mitral regurgitation?

What is an indication for surgical valve replacement?

ACEi/ARB

Dilation of heart because that can lead to irreversible damage

70

Marfan syndrome may lead to which type of heart murmur?

Aortic regurgitation (via cystic medial necrosis)

71

Which murmur is heard as a diastolic, decrescendo murmur at the lower left sternal border that can also present with head bobbing?

What different maneuvers will change the quality of the murmur?

Aortic regurgitation

Valsalva and standing improve. Handgrip worsens. Squatting and straight leg worsen.

72

What murmur may present with atypical chest pain, palpitations, and a panic attack?

MVP

73

What is the murmur of MVP?

What effects do typical movements have on the murmur?

Midsystolic click murmur that may have a systolic component afterwards from a degree of mitral regurgitation.

Behaves in opposite way of most left-sided murmurs.
Expiration: decreases
Valsalva/standing: increase
Handgrip/Squat/Straight leg raise: decrease

74

Symptomatic MVP is treated with what?

Beta-blocker

Symptoms would include atypical chest pain, palpitations, and panic attack

75

What is the main treatment for cardiomyopathy?

Diruetics

76

What medications lower mortality in dilated cardiomyopathy?

Which help control symptoms?

ACEi/ARB
Beta-blocker
Spironolactone

Symptom control: diuretics and digoxin

77

Anything that decreases left ventricular size or increases heart rate will worsen __________.

Hypertrophic obstructive cardiomyopathy

78

What is the best medication for initial therapy in HOCM?

What medication is contraindicated in HOCM and why?

Beta-blockers is best initial therapy

Diuretics are contraindicated because they will lower ventricular size and worsen obstruction

79

A patient with HOCM presents with a syncopal episode. He is admitted in the hospital. What procedure should he be scheduled for?

Implantable defibrillator placement

80

Are spironolactone and digoxin used in hypertrophic cardiomyopathy?

No

81

What are causes of restrictive cardiomyopathy?

Amyloidosis
Scleroderma
Hematochromatosis
Sarcoid
Endomyocardial fibrosis

82

How do standing and Valsalva maneuvers reduce venous return to the heart?

Standing: opens venous capacitance of legs

Valsalva: Increases intrathoracic pressure and reduces return

83

What effect does handgrip and amyl nitrate have on afterload?

Handgrip: increases afterload so a "fuller" LV

Amyl nitrate: arterial vasodilator which decreases afterload so an "emptier" LV

84

What are medical treatment options for pericarditis of idiopathic origin?

NSAIDs, including indomethacin

Colchicine can reduce recurrences

85

Equalization of pressures in diastole seen in a right heart catheterization may indicate what pathology?

Cardiac tamponade

86

In suspected constrictive pericarditis, what is the best initial test?

Chest X-ray which may show calcification and fibrosis

87

How do the legs appear in severe types of peripheral artery disease?

Smooth and shiny due to loss of hair follicles, sweat glands, and sebaceous glands

88

An ABI less than ____ indicates a degree of PAD

89

What is the single most effective medication in peripheral artery disease and how does it work?

Cilostazol: PDE3 inhibitor which leads to arterial vasodilation

90

What medications are used to control BP in patients presenting with aortic dissection?

Beta-blockers first

Others include nitroprusside (but beta-blocker must be used before because it guards against a reflex tachycardia associated with nitroprusside)

91

What is the pathophysiologic mechanism of peripartum cardiomyopathy?

What drugs can be used for this?

Antibodies made against the myocardium (usually develops AFTER giving birth)

ACEi/ARB, beta-blocker, diuretic, spironolactone, digoxin

92

What is Eisenmenger syndrome?

A person with VSD eventually develops pulmonary hypertension severe enough to switch the shunt through the VSD so that it is right to left