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USMLE2 Medicine 08
Cardiology 2
Question | Answer |
---|---|
S3 (sounds, reason for sound, where to listen best) | SLOSH(S1) ing(S2) in(S3), large volume filling ventricle, use bell at apex |
S4 (sounds, reason for sound, where to listen best) | a(S4) STIFF(S1) wall(S2), atrial contraction against a stiff/hypertrophied ventricle, use bell at apex. |
heart failure | inability of ventricle to efficiently pump blood throughout circulation |
systolic dysfunction means what? | reduced ejection fraction. loss of contractile strength --> ventricular dilation --> decrease in ventricular emptying --> reduced EF |
diastolic dysfunction means what? | impaired ventricular filling (nl EF). |
examples of systolic heart failure | ischemic cardiomyopathy, dilated cardiomyopathy |
examples of diastolic heart failure | infiltrative cardiomyopathies (amyloidosis) |
congestive HF | SOB, fatigue, inc LV diastolic P --> inc pulmonary venous P --> transudate from pulm capillaries into interstitium --> circulatory congestion (pulmonary edema, peripheral edema, elevated JVP) |
Sx's of heart failure | SOB, Orthopnea, Parosyxmal nocturnal dyspnea, Fatigue/weakness |
Sx's and PE of heart failure | SF POW, RJ HEAP, has heart failure. Sx - SOB, Fatigue, Parosyxmal nocturnal dyspnea, Orthopnea (SOB when lying flat, requires pillows), Weakness; PE – Rales, JVD elevated, Hepatomegaly, Edema, Ascites, PMI displaced → enlarged heart (systolic HF). |
Class I heart failure | no limitation of activities, no sx's with ordinary activities |
Class II heart failure | slight, mild limitation of activity; comfortable at rest and with mild exertion |
Class III heart failure | market limitation of activity; comfortable ONLY at rest |
Class IV heart failure | confined to bed/chair; any physical activity brings on discomfort, sx's at rest |
What can you determine on cardiac echo? | EF, valvular heart disease, dilation, thickening, systolic vs diastolic dysfunction |
BNP | brain natriuretic peptide. secreted by cardiac myocytes when stretched. 97% sensitivity in HF pts |
Non-pharmacologic tx for HF | decreased salt in diet |
Benefits of ACEi for HF pts | Improve survival, reduce ventricular hypertrophy and sx’s. (vasodilation → dec preload and afterload → dec RA and Pulm P) |
which is the best ACEi for HF? | they are all equal |
Meds for HF - no renal disease | Heart Failure: Shit - FML. 1. Spironolactone (if HF class 3-4), 2. Furosemide, 3. Metop or carvedilol (dec mortality), 4. Lisinopril |
Meds for HF - have renal disease | Heart Failure with renal probs even worse! F*** HIM! 1. Furosemide, 2. Hydralazine, 3. Isosorbide, 4. Metop or carvedilol |
What must you monitor when pt on Spironolactone? | K levels |
Hyperkalemia increases or decreases digitalis activity? | K and digitalis compete for the same binding site, so hyperK decreases digitalis activity, while hyPOK increases toxicity. |
Effect of digitalis on heart | increases force and velocity of myocardial contraction, promotes increased EF (more complete emptying) |
What do you use dig for? (3) | CHF, afib, paroxysmal tachycardia |
Conditions that predispose to dig toxicity | REACT By Dig. 1. Renal insufficiency, 2. Electrolytes (hypoK, hypoMg, hyperCa), 3. Age (elderly), 4. COPD (hypoxia), 5. hypoThyroid, 6. Block (SA and AV heart block), 7. Drugs (Increases dig toxicity: QRST Quinidine veRapamil Spirono Thiazides (furosem) |
How do you reverse Dig toxicity? | 1. stop drug, 2. give K, 3. Lidocaine and phenytoin, 4. if acute OD use Digibind |
How to treat acute severe HF? What must you monitor? | Dopamine and amrinone (PDEi) --> both increase inotropy. Monitor BP and have pt on telemetry. |
If meds fail to manage HF, then what? | biventricular pacing, defibrillator, heart transplant |
cough productive of pink frothy sputum | Pulmonary Edema |
Kerley B lines | pulmonary edema --> suggest CHF |
How to tx pulmonary edema? | FUNMODA! 1. Furosemide, 2. Upright, 3. NTG, 4. O2, 5. Dig (if afib), 6. ACEi |
Rheumatic fever causes what valve pathology? | mitral stenosis |
double density R heart border | mitral stenosis |
Rheumatic fever - what valve pathology most common in men, what most common in women? | men - mitral insufficiency, women - mitral stenosis |
How to tx mitral stenosis? | 1. diuretics and salt restriction for the pulmonary edema, 2. if pt had afib, then Digitalis and anticoagulants |
when to surgically tx mitral stenosis | when sx's despite medical management AND functional HF class III |
click murmur syndrome | mitral insufficiency |
barlow syndrome | symptomatic mitral valve prolapse |
barlow syndrome | symptomatic mitral valve prolapse |
holosystolic apical murmur radiating to axilla | mitral insuff |
how to tx mitral insufficiency | relieve sx's by increasing forward CO and reducing pulm HTN: digitalis, diuretics, ACEi, anticogulants (warfarin). WADD |
mid to late systolic click, late systolic murmur at apex | MVP |
Murmur that improves with squatting and worsens with Valsalva | team's MVP feels better when squatting in front of goal and worse when he strains to poop in front of the goal (Valsalva). |
Tx for MVP | only when sx's: endocarditis prophy, Bblocker for CP, antiarrhythmics for arrhythmias |
pulsus tardus et parvus | Aortic stenosis |
harsh SEM that radiates to carotids | Aortic stenosis |
When to surgically manage aortic stenosis? | valva area reduced to below 0.8cm area or when pt becomes sx-matic |
what is surgical tx for aortic stenosis? | valve replacement. if too ill for surgery --> balloon valvuloplasty |
brisk bifid carotid upstrokes | HOCM |
SEM that does not radiate to carotids | HOCM |
large septal Q waves on EKG V1-3, pseudo infarct pattern, LVH | HOCM |
SEM that is louder with Valsalva and softer with squatting (2 conditions) | HOCM and MVP |
SEM that gets softer with leg raise | HOCM |
duroziez sign | heart trill or murmur heard over the femoral arteries --> aortic insufficiency |
deep Q waves in L precordial leads | LVH --> can be aortic stenosis |
is endocarditis prophylaxis recommended in aortic insufficiency? in MVP? | no in AI, in MVP only in severe cases |
stroke volume increases - what kind of cardiomyopathy? | hypertrophic |
EF increases - what kind of cardiomyopathy? | hypertrophic |
is HOCM genetic? if so, what inheritance pattern? what chromosome? | yes, autosomal dominant, chromosome 14 |
what is hallmark of HOCM? | unexplained myocardial hypertrophy with thickening of the interventricular septum |
what is most common cause for heart transplants? | dilated/congestive cardiomyopathy |
In HOCM, do these things make the murmur better or worse: increased contractility, increased preload, increased afterload | increased contractility - worse. increased preload - better. increased afterload (squatting, handgrip) - better. |
murmur that improves with handgripping | HOCM |
what drugs should you NOT give to HOCM pts? | increase in contractility (digitalis, isoproterenol) |
are B blockers recommended for HOCM pts? | yes because slows HR and increases preload |
large jugular A wave, S4, adn bifid carotid pulse | HOCM |
Tx for HOCM | B-blockers, CCB, surgery |
square root sign on cardiac cath (2) | restrictive cardiomyopathy, constrictive pericarditis |
M-shaped atrial waveform on cardiac cath | restrictive cardiomyopathy |
tx for restrictive cardiomyopathy | no tx; consider heart transplantation |
what is the heart condition that is best heard with pt sitting leaning forward at forced end expiration | pericarditis |
diffuse ST segment elevation on EKG | acute pericarditis |
serosanguinous pericardial fluid (2) | classic of TB or neoplastic diseases |
water bottle config on CXR | pericarditis |
electrical alternans on EKG | pericardial effusion |
pulsus paradoxus and equal P in LA and RA | cardiac tamponade |
Tx for cardiac tamponade | pericardiocentesis or subxiphoid surgical drainage |
Kussmaul sign | JVD that increases with inspiration - abnormal RH filling |
pericardial knock | constrictive pericarditis |
on cardiac cath: markes Y descent in RA P tracing | constrictive pericarditis |
on cardiac cath: equalization of end-diastolic P in all 4 heart chambers and pulm artery | constrictive pericarditis |
diagnostic procedure of choice for constrictive pericarditis | CT (not echo) |
Tx of constrictive pericarditis | Na restriction and diuretics, pericardiectomy |
valsalva causes what? | sinus bradycardia and decreased venous return |
Tx of sinus brady | Atropine, then pacemaker if refractory |
Difference in response to atropine in Mobitz type I and II | Mobitz Type I (Wenckebach) - PR interval shortens and AV conduction increased. Type II - no effect from atropine |
Most common cause of 3rd degree AV block | complete AV dissociation, Lenegre disease - simple fibrous degenerative changes in conduction system that is a result of aging |
Adams Stokes attacks | asystole/heart block/vfib --> dec blood to brain --> sudden syncope +/- sz's |
DOC to tx superventricular tachycardias | IV verapamil or adenosine |
carotid massage to tx what? | AV node massage --> inc vagal tone --> break AV node re-entry tachycardia |
who is most likely to get multifocal atrial tachycardia | chronic lung disease or elderly |
Tx for aflutter | if hemodynamically unstable, cardiversion. Then digitalis, CCB (verapamil/diltiazem), and Bblockers. BCD |
Drugs to phamacologically convert afib | amiodarone, flecainide, ibutilide |
Drugs to maintain sinus rhythm in pts with afib | amiodarone, flecainide |
what is one of the first steps in tx afib? what drugs? | rate control <100bpm. BCD again. Bblocker (metop/atenolol), CCB (ver/diltia), Dig (if systolic HF) |
contraindications to the use of warfarin | TCP, surgery or trauma, EtOH |
Drug to tx WPW if pt is hemodynamically stable | procainamide |
What drugs to avoid in pt with WPW | anything that will block or slow the AV node, which will shift conduction to accessory pathway: dig, betablockers, CCB |
what is definitive tx for WPW? | ablation |
intermittent cannon waves in JVP | simultaneous contraction of atria and ventricles in Vtach |
Wide complex tachycardias with regular rhythms (3) | VW's: VT, SVT (with aberration), WPW |
Narrow complex tachycardias with regular rhythm (3) | SAP: Sinus Tach, PSVT, Aflutter |
Narrow complex tachycardias with irregular rhythm (2) | MA: Afib, MAT |
What is the progression of meds to give to a stable pt in v-tach? What to do if pt is unstable? | O2, IV, Amiodarone, Lidocaine, Procainamide. Cardiovert if unstable. |
what electrolytes prolong QT? | hypo K and hypo Mg |
Anti-arrhythmic drugs that can prolong QT | quinidine, procainamide, or disopyramide. Also, TCA's and Li |
If tosades caused by an anti-arrhythmic drug, | switch to lidocaine or phenytoin, neither of which prolongs ventricular repol |
Three drugs used in ACLS VFib algorithm | epi, amiodarone, lidocaine |
Three drugs used in ACLS PEA algorithm | Epi, vasopressin, atropine if epi and vasopressin don't work |
antiarrhythmic drug that causes blue gray "smurf" skin | Amiodarone |
antiarrhythmic drug that causes corneal deposits | Amiodarone if taken for 6 months |
anacrotic pulse | pulsus tardus et parvus, aortic insufficiency |
water hammer pulse | aortic insuff, AV fistula, and PDA |
pulsus paradoxus | COPD, asthma, pericardial constriction |
pulsus alternans | pericardial effusion, severe LV failure |
majority of thrombi in afib arises from where? | L atrial appendage |
widened pulse pressure and thyroid issues | hyperthyroidism |
drug to get rid of torsades | give MgSO4 |
Tx of Vtach | amiodarone or lidocaine |
best test to dx arrhythmogenic RV dysplasia | MRI will show infiltration, wall thinning, and abnl contraction pattern |
most likely finding on echo of pt with long h/o EtOH abuse | dilated cardiomyopathy |
most common etiology of narrow complex tachycardia referred for EP studies in adults | AVNRT |
most common etiology of narrow complex tachycardia referred for EP studies in children | AVRT |
what heart problems in Lyme disease? | conduction problems and myocarditis |
OSA causes.... | hypoxia and hypercapnea --> pulm HTN, widened A-a gradient |
most common cardiovascular complication of rheumatoid arthritis | pericarditis |
T or F: for tx of stable angina, PTCA and medical management have same effectiveness for death and infarction outcome | TRUE |
what tx is contraindicated in aortic dissection? | intra-aortic balloon pump, which will inflate in diastole |
pre-operative management of aortic dissection | inotropic agents and vasodilators until surg can be done |
most common cause of unexpected death in Asian Americans | Brugada syndrome |
RBBB, STE in V1-V2 | Brudgada |
how to elicit Brugada EKG characteristics? | flecainide or procainamide |
how to tx Brugada | AICD |
what do people with Brugada die of? | polymorphic vtach |
Jervell and Lange-Nielsen syndrome | long QT syndrome, autosomal recessive, associated with hearing loss |
Romano-Ward syndrome | long QT syndrome, autosomal dominant, most common form of inherited long QT syndrome |
definitive tx for Romano Ward Syndrome | surgical ganglionectomy |
Lown-Ganong-Levine syndrome (LGL) | type of AVRT, pts w accessory pathway that connects the atria directly to the bundle of His |
short PR, nl QRS, no delta wave | Lown-Ganong-Levine syndrome (LGL) |
Class I anti-arrhythmics | Na channel blockers. |
Class Ia anti-arrhythmics, mechanism and examples | fastNa channel blockers (AP leangthened, leans rt). Quinidine, Procainamide |
Class Ib anti-arrhythmics, mechanism and examples | Na channel blockers – shortens AP (shorter plateau). Lidocaine, Phenytoin |
Class Ic anti-arrythmics, mechanism and examples | Na channel blockers – leans R, also shorter plateau, AP overall same. Flecainide and Propafenone |
Class II anti-arrhythmics, mechanism and examples | Bblockers. Metop, Atenolol |
Class III anti-arrhythmics, mechanism and examples | K-blockers→prolong repolarization. Amiodarone, ibutilide |
Class IV anti-arrhythmics, mechanism, and examples | CCB – decrease AV nodal conduction. Verapamil and diltiazem |
Tx of tosades after MgSO4 | Bblocker |
what classes of drugs to avoid in torsades | Ic, and III because all prolong the QT (flecainide, amiodarone and ibutilide) |
Quincke pulse | alternate blanching and flushing of the nail bed due to pulsation of subpapillary arteriolar and venous plexuses; seen in aortic insufficiency and other conditions and occasionally in normal persons. |
Osborne wave on EKG | camel-hump sign, late delta wave, hathook jxn, hypothermic wave, prominent J wave. people suffering from HYPOTHERMIA with a temperature of less than 32 C, hypercalcemia, brain injury, vasospastic angina, or ventricular fibrillation |
peripartum cardiomyopathy | dilated cardiomyopathy |
what meds to use in flash pulm edema? what meds are contraindicated | Nitroprusside, labetalol/esmolol, No nifedipine because unpredictable rapid drop in BP --> strokes. Also and clonidine. |
two cardiovascular conditions associated with hoarseness | mitral stenosis, aortic aneurysm |
trepopnea | positional dyspnea in latera decub position; can be caused by atrial myxoma, intracardiac thrombus |
bisferiens pulse | two peaks per cardiac cycle - HOCM, aortic insuff, PDA, fever, exercise |
tx for papillary muscle rupture | afterload reduction: first with nitroprusside, then with intra-aortic balloon pump |
tx for RV infarction | (inferior MI) give IV fluids and do what you can to increase preload, including stopping all vasodilators and starting vasopressor or inotropic support, intra-aortic balloon pump would be helpful |
EKG ST depression in V1-V3 | posterior STEMI - should go to cath lab! |
calculate MAP | [(SBP+2DBP)/3] |
EKG findings in acute PE due to | (S1Q3T3) due to RV strain |
what is intra-aortic balloon pump used for? | augment therapy after CT surg, bridge to transplant, pain control in unstable angina, tx refractory arrhythmias |
vsd murmur, asd murmur | vsd systolic murmur, asd no murmur |
in pts with mod/severe mitral regurg, what is most likely cardiac rhythm disturbance? | afib |
in pts with mild mitral regurg, what is most likely cardiac rhythm disturbance? | premature atrial contractions |