Section 4: Cardiomyopathy, Pericardial Disease, Aortic Disease, and PAD Flashcards Preview

Cardiology USMLE Step 3 > Section 4: Cardiomyopathy, Pericardial Disease, Aortic Disease, and PAD > Flashcards

Flashcards in Section 4: Cardiomyopathy, Pericardial Disease, Aortic Disease, and PAD Deck (27)
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1

Dilated Cardiomyopathy

  • Best initial test
  • Most accurate test

  • Echocardiography is the best initial test to determine the ejection fraction and look for wall motion activity.
  • MUGA or nuclear ventriculography is the most accurate method of determining ejection fraction.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2526-2527).  . Kindle Edition.

2

Causes of dilated cardiomyoathy

  • Ischemia (ischemic heart disease) - most common cause
  • Alcohol
  • Adriamycin
  • Radiation
  • Chagas’ disease

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2529-2530).  . Kindle Edition.

3

Rx of dilated cardiomyopathy

The treatment for all forms of dilated cardiomyopathy, no matter their cause

  • ACE inhibitors or ARBs
  • Beta blockers
  • Spironolactone
  • Digoxin decreases symptoms but does not prolong survival.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2531-2532).  . Kindle Edition.

4

Typical presentation of hypertrophic cardiomyopathy

  • Shortness of breath on exertion
  • An S4 gallop on examination

 

S4 gallop is a sign of left ventricular hypertrophy and decreased compliance or stiffness of the ventricle. S4 gallop does not automatically indicate the need for additional therapy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2534-2537).  . Kindle Edition.

5

Diagnostic testing for hypertrophic cardiomyopathy

Echocardiography shows a normal ejection fraction.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2539-2540).  . Kindle Edition.

6

Rx for hypertrophic cardiomyopathy

  • The mainstay of therapy is with beta blockers and diuretics
  • ACE inhibitors can be used, but their benefit is not as clear
  • Digoxin and spironolactone do not benefit hypertrophic cardiomyopathy.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2541-2543).  . Kindle Edition.

7

Causes of restrictive cardiomyopathy

  • Sarcoidosis
  • Amyloidosis
  • Hemochromatosis
  • Cancer
  • Myocardial fibrosis
  • Glycogen storage diseases.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2545-2546).  . Kindle Edition.

8

Clinical presentations of restrictive cardiomyopathy

Shortness of breath is the main presenting complaint in all forms of cardiomyopathy.

Kussmaul’s sign is present: this is an increase in jugular venous pressure on inhalation.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2547-2548).  . Kindle Edition.

 

9

Diagnostic testings for restrictive cardiomyopathy

  • Cardiac catheterization shows rapid x and y descent
  • The EKG shows low voltage
  • Echocardiography is the mainstay of diagnosis
  • Endomyocardial biopsy is the single most accurate diagnostic test of the etiology.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2549-2552).  . Kindle Edition.

10

Rx for restrictive cardiomyopathy

Diuretics and correcting the underlying cause are the best treatments.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2554).  . Kindle Edition.

11

Clinical presentation of pericarditis

  • Chest pain that is pleuritic (changes with respiration) and positional (relieved by sitting up and leaning forward)
  • The pain will be described as sharp and brief.
  • Friction rub. The rub is only present in 30 percent of patients. There is no pulsus paradoxus, tenderness, edema, or Kussmaul’s sign present. Blood pressure is normal, and there is no jugular venous distention or organomegaly.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2564-2566).  . Kindle Edition.

 

12

Diagnostic tests for pericarditis

  • The best initial test is the EKG. ST segment elevation is present everywhere (all leads).
  • PR segment depression is pathognomonic but is not always present.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2567-2569).  . Kindle Edition.

13

Rx for pericarditis

  • The best initial therapy is an NSAID, such as indomethacin, naproxen, aspirin, or ibuprofen.
  • Advance the clock 1– 2 days and have the patient visit the office.
  • If the pain persists, add prednisone orally to the treatment and advance the clock 1– 2 more days.
  • Colchicine adds efficacy to steroids.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2570-2573).  . Kindle Edition.

14

  • Clinical features of pericardial tamponade

  • Shortness of breath
  • Hypotension
  • Jugular venous distention
  • Pulsus paradoxus: This is a decrease of blood pressure > 10 mm Hg on inhalation.
  • Electrical alternans: This is alterations of the axis of the QRS complex on EKG, manifested as the height of the QRS complex.

     

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2578-2580).  . Kindle Edition.

 

15

Diagnostic testings for cardiac tamponade

  • Echocardiography is the most accurate diagnostic test. The earliest finding of tamponade is diastolic collapse of the right atrium and right ventricle. Remember that it is normal to have 50 mL or less of pericardial fluid, but there should be no collapse of the cardiac structures.
  • EKG will show low voltage and electrical alternans. Electrical alternans is variation of the height of the QRS complex from the heart moving backward and forward in the chest.
  • Right heart catheterization will show “equalization” of all the pressures in the heart during diastole. The wedge pressure will be the same as the right atrial and pulmonary artery diastolic pressure.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2582-2589).  . Kindle Edition.

16

Rx for cardiac tamponade:

  • Best initail therapy
  • Most effective long-term therapy
  • Most dangerous therapy

  • Pericardiocentesis
  • Pericardial window placement
  • Diuretics

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2590-2592).  . Kindle Edition.

17

Clinical presentations of constrictive pericarditis

  • Shortness of breath
  • Edema
  • Jugular venous distention
  • Hepatosplenomegaly
  • Ascites
  • Kussmaul’s sign: Increase in jugular venous pressure on inhalation
  • Pericardial knock: Extra diastolic sound from the heart hitting a calcified, thickened pericardium

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2596-2599).  . Kindle Edition.

18

Diagnostic tests for constrictive pericarditis

  • Chest x-ray: Showing calcification
  • EKG: Low voltage
  • CT and MRI: Showing thickening of the pericardium

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2600-2601).  . Kindle Edition.

19

Rx of constrictive pericarditis

  • Best initial therapy
  • Most effective therapy

  • Diuretic
  • Surgical removal of the pericardium (i.e., pericardial stripping)

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2603-2604).  . Kindle Edition.

 

20

Clinical presentation of dissection of the thoracic aorta

  • Chest pain radiating to the back between the scapula
  • Pain that can be described as very severe and “ripping”
  • Difference in blood pressure between right and left arms

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2607-2609).  . Kindle Edition.

21

Diagnostics tests for dissection of the thoracic aorta

  • Best initial test: Chest x-ray showing a widened mediastinum
  • Most accurate test: CT angiography

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2610-2612).  . Kindle Edition.

22

Rx of dissection of thoracic aorta

  • When the case describes severe chest pain radiating to the back and hypertension, order beta blockers with the first screen in addition to an EKG and chest x-ray
  • No matter what the EKG shows, move the clock forward and order either CT angiography, TEE, or magnetic resonance angiography (MRA): all 3 are equally accurate
  • CT angiography = TEE = Magnetic resonance angiography (MRA) After starting beta blockers, order nitroprusside to control the blood pressure
  • Aortic dissection cases should be placed in the ICU, and a surgical consultation should be ordered. Surgical correction is the most effective therapy.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2624).  . Kindle Edition.

 

23

Criteria to screen for abdominal aortic dissection

  • Screening with an ultrasound should be ordered in over-65 men who were smokers.

Abdominal aortic aneurysm is detected by ultrasound first. AAAs are repaired when they are > 5 cm. Smaller ones are monitored.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2626-2629).  . Kindle Edition.

24

Clinical presentation of peripheral arterial disease (PAD)

  • Claudication (pain in the calves on exertion)
  • “smooth, shiny skin” with loss of hair and sweat glands
  • Decreased or loss of pulses in the feet
  • Spinal stenosis will give pain that is worse with walking downhill and less with walking uphill or while cycling or sitting. Pulses and skin exam will be normal with spinal stenosis
  • Acute arterial embolus will be very sudden in onset with loss of pulse and a cold extremity. It is also quite painful. AS and atrial fibrillation are often in the history for arterial embolus.

     

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2636-2641).  . Kindle Edition.

 

25

Peripheral Artery Disease (PAD):

  • Best initial test
  • Most accurate test

  • Ankle-brachial index (ABI). (A normal ABI should be ≥ 0.9.) Blood pressure in the legs should be equal to or greater than the pressure in the arms. If there is > 10 percent difference, then an obstruction is present.)
  • Angiography

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2644-2645).  . Kindle Edition.

 

26

Rx of peripheral arterial disease:

  1. Best initial therapy
  2. Marginally effective therapy
  3. Ineffective therapy

1. Best initial therapy include:

  • Aspirin
  • Blood pressure control with ACE inhibitors
  • Exercise as tolerated
  • Cilostazol
  • Lipid control with statins to a target LDL < 100

2. Marginally effective therapy: Pentoxifylline

3. Ineffective therapy: Calcium channel blocker

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2646-2657).  . Kindle Edition.

27

Diagnosis:

Pain + Pallor + Pulseless =  ?

Arterial Occlusion

Beta blockers are not contraindicated with PAD. If the patient needs them for ischemic disease, they should be used.

CCS Tip: On CCS, move the clock forward several weeks. PAD is not an emergency! If initial therapies do not work and the pain progresses, or there are signs of ischemia such as gangrene or pain at rest, then perform surgical bypass.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2658-2664).  . Kindle Edition.