Cardio Disease

Question 1

What are the indications for PCI?

Answer 1

1. STEMI,
2. High risk acute coronary syndrome,
3. Refractory angina

Question 2

What are the indications for a CABG?

Answer 2

1. Advanced 3 vessel disease
2. Left main disease
3. Multivessel + diabetes

Question 3

What are the four causes of an anterior mediastinal mass?

Answer 3

Thymoma
Teratoma
Terrible lymphoma

Question 4

Peripheral Artery Disease

Answer 4

Definition: Atherosclerosis, thromboembolism or vasculitis, causing limited flow to the limbs

Risk Factors: Dyslipidemia, hypertension, diabetes, smoking etc. Often goes along with CAD

Symptoms: 
Claudiacation: discomfort in legs during exercise, relieved with rest
Signs:
Peripheral bruits (renal)
Loss of distal pulses
Ulcers/gangrene, shiny skin, hair loss
Postive Buerger's test

Diagnosis:
Ankle blood pressure vs brachial (ABI)= 1)
Arterial doppler ultrasound
CT angiography (see stenosis)

Management:
Medical: risk factor management
Anti-platelet therapy

Question 5

Critical limb ischemia

Answer 5

1. Chronic ischemic pain occurs at rest= BAD
2. 50% amputation rate
3. More aggressive and invasive interventions

Question 6

Acute limb ischemia

Answer 6

Definition: Sudden decrease in limb perfusion that threatens limb viability
Etiology: Emboli (atrial or ventricular fib)
Symptoms:
Acute onset, motor weakness, sensory loss
6P’s (pulseless, pallor, PAIN…)

Question 7

Abdominal aortic aneurysm

Answer 7

Definition: Prominent dilatation of the aorta
Often due to high blood pressure, and weak arterial walls due to atherosclerosis.
May rupture… DEATH!

Signs:
Physical exam- feel laterally pulsating abdominal pulses.

Question 8

What is the CCS angina classification?

Answer 8

1. Chest pain only with strenuous, rapid, prolonged exertion
2. Slight limitation of ordinary activity, chest pain with walking or climbing stairs rapidly
3. Chest pain with low levels of exertion (1-2 blocks walking or

Question 9

How do we predict probability that chest pain is due to CAD?

Answer 9

Low (90%): Men over 40 with angina, women with typical angina over 60

Question 10

How does the pretest probability of CAD impact the utility of stress testing?

Answer 10

Small gain in low and high ends: if low probability, very unlikely that they tested positived. If high, very likely that they did test positive. In between, big gain from testing.

At upper end, testing may be more useful prognostically than diagnostically

Question 11

What tests can be used to evaluate coronary artery disease?

Answer 11

Framingham risk score
Exercise stress test (are sx reproducible)
Stress test plus nuclear imaging (good for heart blocks, increases sensitivity)
Pharmacologic stress testing
Coronary angiography

Question 12

What is Prinzmetal angina?

Answer 12

A coronary artery spasm in the ABSENCE of overt atherosclerotic lesions.

Intense vasospasm reduces coronary oxygen supply

Potentially due to increased sympathetic input

Question 13

What are the signs of right heart failure?

Answer 13

1. Elevated JVP
2. Hepatomegaly
3. Peripheral edema

Question 14

What is an aoritic dissection and what are the types?

Answer 14

Dissection= tear of intima (inner layer) of aorta, propagates between layers down the length of the aorta.

1. Type A: ascending aorta (aging, connective tissue disorders)
2. Type 2: descending & abdominal (atherosclerosis)

Question 15

What are the symptoms of aortic dissections? What tests are done to diagnose?

Answer 15

1. Sudden, severe, midline, sharp, ripping pain
2. Syncope, decreased LOC, coma
3. Hemodynamic insufficiency, cardiogenic shock
4. DEATH

Tests:
CT with contrast- best chance
MRI- for type B or chronic (too slow for A!)

Question 16

How are aortic dissections treated?

Answer 16

1. Type A: ALWAYS SURGICAL (repair flap) (mortality still 26%)
2. Type B: Medically: beta blockers, vasodilators,

Question 17

Where is the peripheral arterial disease if pain is felt in the:

1. Buttocks, hips, thighs,
2. Calves
3. Arms

Answer 17

1. Distal aorta or iliac arteries
2. Femoral or popliteal
3. Subclavian or axillary

Question 18

What ECG changes are seen in infarct and ischemia?

Answer 18

1. Peaked or inverted T waves
2. ST depression in ischemia
3. ST elevation in infarction
4. Deep Q waves in late or old infarct
5. Poor R wave progression

Question 19

What causes ECG left axis deviation?

Answer 19

1. Inferior wall MI

2. Left anterior fascicular block

Question 20

What causes ECG right axis deviation?

Answer 20

1. Right ventricular hypertrophy
2. Acute right heart strain
3. Left posterior fasiscular block

Question 21

How should stable angina be treated?

Answer 21

1. Aspirin and anti-anginals ( nitro)
2. Beta blockers
3. Cholesterol (lower with statin) and cigarettes (smoking cessation)
4. Diet and diabetes (good diet, prevent diabetes or manage)
5. Education and exercise

Question 22

What is treatment for acute coronary sydromes?

Answer 22

1. Anti-ischemic therapy- beta blockers, nitrates, CCB
2. 5 Aspirin-immediately on presentation
3. Clopidogrel (inhibit more pathways of platelet activation)
4. anti coagulate ( LMWH, NOAC)
5. Thrombolytics for stemis, possible cardiac catheterization
6. Ace inhibitors and statins ( limit adverse remodelling, mortality)

Question 23

When do cardiac enzymes become positive in ACS?

Answer 23

1. Troponins: rise 3-4h after, peak 18-36h, present for about 10 days
2. Creatine kinase: rises 3-8 hours, peaks 24, normal around 72

Question 24

In what other conditions may cardiac enzymes be elevated?

Answer 24

1. Heart failure
2. Myocarditis
3. Pulmonary embolism causing RV strain

Question 25

When is an S3 a normal finding?

Answer 25

1. In children and young adults

Question 26

What is protocol for atrial fib that has been present for more than 48 hours?

Answer 26

1. More than 48 h may predispose to thrombus | 2. So anticoagulation and slow HR for at least 3 weeks before chemical/electrical cardioversion to sinus rhythm

Question 27

What kind of embolism does a fib cause?

Answer 27

1. Systemic (goes to brain and body)

Question 28

Which medication is the most effective at maintaining sinus rhythm?

Answer 28

Amiodarone (class 3 antiarrhythmic)

Question 29

Syncope definition

Answer 29

Transient loss of consciousness due to global cerebral hypo perfusion

Question 30

What are the causes of syncope?

Answer 30

1. Obstructive: emboli, aortic stenosis 2. Arrhythmic: Bradycardia/ 3rd degree heart block, tachycardia 3. Reflex: **vasovagal, carotid sinus, acute inferior MI 4. Orthostatic: hypovolemia, hypotensive drugs (*beta blockers)

Question 31

What typically causes myocarditis?

Answer 31

1. Viral: coxsackievirus 2. Parasites 3. Inflammatory 4. Thyroid

Question 32

Plus us parvus et tardus

Answer 32

Aortic stenosis

Question 33

Wide pulse pressure

Answer 33

Aortic regurg

Question 34

Double impulse pulse

Answer 34

AI or HOCM

Question 35

Fixed split S2

Answer 35

ASD

Question 36

Opening snap

Answer 36

Mitral stenosis

Question 37

Ejection click

Answer 37

Bicuspid aortic valve

Question 38

Mid systolic click

Answer 38

Mitral valve prolapse

Question 39

CV wave

Answer 39

Tricuspid regurgitation