Cardiology

Question 1

Benefit of digoxin in CHF

Answer 1

• decreases hospitalization

Question 2

Fibromuscular dysplasia

Answer 2

• Renal artery stenosis in a young adult

Symptoms: headache, elevated BP, and renal bruit

Treatment: percutaneous angioplasty w/ stent placement

Question 3

Orthostatic hypotension

Answer 3

• Drop in systolic BP >20 mmHg from lying down to standing.

- Prolonged recumbence increases the risk.

Question 4

Treatment for PSVT

Answer 4

• Valsalva maneuver, carotid massage, cold water immersion —–>increase vagal tone ——> decreased conduction through AV node
• Adenosine is another AV nodal blocker that can be used.

Question 5

Hepatojugular reflux

Answer 5

• Useful in differentiating between liver pathology and heart pathology; specific for heart path
• Reflects a failing right ventricle.

Due to: constrictive pericarditis, right ventricular infarction, and restrictive cardiomyopathy

Question 6

Constrictive pericarditis

Answer 6

Signs: Kussmaul’s sign - lack of decrease or an increase in JVD during inspiration, pericardial knock, and pericardial calcifications on CXR

Question 7

Side effect of amlodipine

Answer 7

Lower extremity edema

• Due to preferential dilation of the precapillary arterioles.
• Seen more with dihydropyridine CCB more so than with non-DHP CCBs
• Addition of and ACE inhibitor or ARB can reduce this side-effect.

Question 8

Amiodarone toxicity

Answer 8

• contraindicated in lung disease due to pulmonary toxicity.

Question 9

Beta-blockers in lung disease

Answer 9

Contraindicated in obstructive lung disease (COPD and asthma), but not in restrictive lung disease

Question 10

Aortic regurgitation

Answer 10

Common causes: aortic root dilation, post-inflammatory, and congenital bicuspid aortic valve

Clinical features: diastolic decrescendo murmur, widened pulse pressure (collapsing/water hammer pulse), uncomfortable awareness of heart beat while in left lateral decubitus position

Question 11

Nitroglycerin

Answer 11

Used to treat angina
Acts by converting to nitric oxide and causing vasodilation of the blood vessels
Secondary effects: increased contractility and reflex tachycardia caused by baroreceptor firing in response to decreased blood pressure

Question 12

Pathologic Q waves

Answer 12

Possibly indicates previous MI

• > 40 ms (1mm) wide
• > 2mm deep
• > 25% depth of QRS
• seen in leads V1-3

Question 13

ST depression

Answer 13

> or= .5 mm depression in 2 or more contiguous leads

Question 14

Dobutamine

Answer 14

sympathomimetic drug which acts on the beta-1 adrenoreceptors on the heart, increasing contractility, heart rate, and CO
- Can cause vasodilation, leading to hypotension

Question 15

Dipyradimole -thallium

Answer 15

Phosphodiesterase inhibitor that increases cAMP and cGMP

- Cuases vasodilation of the blood vessels

Question 16

Conditions that may confound results of perfusion imaging

Answer 16

Left bundle branch block and ventricular pacer

Question 17

Adenosine (stress test)

Answer 17

causes vasodilation of the coronary vasculature

Question 18

Aliskiren

Answer 18

direct renin inhibitor

Question 19

grade I or II midsystolic ejection murmur

Answer 19

innocent flow murmur of childhood - no workup necessary

Question 20

Potential side effects of statins

Answer 20

muscle damage, hepatotoxicity

Question 21

Possible side effects of ARBs

Answer 21

hyperkalemia, hypotension, and renal failure

Question 22

Aortic stenosis

Answer 22

Crescendo-decrescendo systolic ejection murmur, loudest at the right sternal border, radiating to the carotids

1. Diminished and delayed carotid pulse (pulsus parvus and tardus) due to blood flow obstruction
2. Mid to late (if severe enough to cause symptoms) peaking systolic murmur from turbulence due to stenosis
   - Early peaking is seen in milder, asymptomatic disease.
3. Presence of soft and single second heart sound

Question 23

Mitral stenosis

Answer 23

Mid-to-late (if mild) diastolic murmur following an opening snap, heard best at the apex

• If severe, the diastolic murmur will start closer to the opening snap
• Typically have a loud S1

Question 24

S3

Answer 24

Heard in people with chronic severe mitral or aortic regurgitation, heart failure and sometimes in high output states such as pregnancy or thyrotoxicosis

• Heard after S2, in early diastole during the rapid ventricular filling phase.
• Due to increased filling pressures and dilated ventricles

Question 25

Symptomatic AVF

Answer 25

Congenital - patent ductus arteriosos, angiomas, pulmonary AVF, CNS AVF Acquired - trauma, iatrogenic, atherosclerosis, cancer - Decreases systemic vascular resistence because the blood bypasses the capillaries (resistence vessels) Symptoms: widened pulse pressure

Question 26

Causes of high-output heart failure

Answer 26

AVF, thyrotoxicosis, Paget's disease, anemia, and thiamine deficiency

Question 27

Right ventricular MI

Answer 27

In addition to normal MI treatment, fluids may be needed to increase preload - Avoid nitrates and diuretics

Question 28

ECG changes in PE

Answer 28

tachycardia, nonspecific ST segment and T wave abnormalities, new onset RBBB, S1Q3T3 pattern - large S wave in lead I, a Q wave in lead III, and a inverted T wave in lead III

Question 29

RBBB

Answer 29

``` wide QRS (>120 ms) V1(M), V6 (W) ```

Question 30

Beta-blocker overdose

Answer 30

Symptoms: bradycardia, AV block, hypotension, diffuse wheezing, hypoglycemia, seizures - Beta 2 receptors also cause increased insulin release which in overdoses can cause hypoglycemia - Calcium channel bloackers, digoxin, and cholinergic agents can cause similar findings, but the wheezing is specific for beta blockers Treatment: secure an airway, give fluids, IV atropine - in patients with profound hypotension, IV glucagon is then given ----> increases intracellular cAMP (helpful in CCB overdose too) Additional therapies: IV calcium, vasopressors, high dose insulin and glucose, and IV lipid emulsion therapy

Question 31

Aminophylline

Answer 31

``` methylxanthine in the same class as theophylline inhibits phosphodiesterase leading to increased cAMP ---> bronchodilation, positive inotropic and chronotropic effects ```

Question 32

Digoxin overdose

Answer 32

Symptoms: fatigue, anorexia, nausea, blurred vision, disturbed color perception, and cardiac arrhythmias

Question 33

Normal JVP

Question 34

Common signs of end organ damage seen in preeclampsia

Answer 34

proteinuria, thrombocytopenia, transaminitis, elevated creatinine, pulmonary edema, headache, visual changes

Question 35

Effects of progesterone on vasculature

Answer 35

rising progesterone during early pregnancy causes vasodilation ---> 5-10 mmHg decrease in BP - typically returns to normal during the third trimester

Question 36

Pregnancy-related risks with HTN

Answer 36

superimposed preeclampsia, postpartum hemorrhage, preterm delivery, gestational diabetes, abruptio placentae, C-section, oligohydramnios, fetal growth restriction, mortality to newborn

Question 37

Placenta accreta risk factors

Answer 37

previous C-section, uterine curettage

Question 38

How does aortic rupture cause hypertension

Answer 38

visceral afferent reflexes cause a hypertension or a pseudocoarctation response

Question 39

Treatment for reversible exercise-induced ischemia

Answer 39

Aspirin, beta-blockers and lifestyle modification

Question 40

Albuterol

Answer 40

B2>B1 | - B1 activity can cause tachycardia, hypertension and arrythmias in pts w/ CAD

Question 41

Erythropoeitin

Answer 41

contraindicated in pts with CAD due to possible thromboembolic events and stroke

Question 42

Metformin

Answer 42

Can cause lactic acidosis in pts predisposed to hypoxia (CAD, CKD)

Question 43

Lesser known characteristics of Turner syndrome

Answer 43

narrow, high-arched palate, cubitis valgus, aortic root dilation putting the patient at risk for aortic dissection

Question 44

Patent ductus arteriosis

Answer 44

can present asymptomatically or with symptoms of extertional dyspnea or CHF - seen in congenital rubella syndrome and Char syndrome

Question 45

Char syndrome

Answer 45

facial anomolies, patent ductus arteriosis, and limb abnormalities

Question 46

Restrictive cardiomyopathy

Answer 46

right-sided heart failure is more prominent

Question 47

Clopidogrel, prasugrel, ticagrelor, ticlopidine

Answer 47

ADP receptor inhibitors (ADP binding to P2y12 receptor induces GpIIb/IIIa expression on the platelet surface ---> fibrinogen binds here --->platelet aggregate)

Question 48

Drug-eluting stents

Answer 48

DAPT recommended in all pts for at least 12 months following placement

Question 49

Direct factor Xa inhibitor

Answer 49

apixiban | - Used for nonvalvular a fib, DVT and PE

Question 50

Postinfarction pericarditis

Answer 50

NSAIDs and sometimes cholchicine inhibitors

Question 51

Milrinone

Answer 51

selective phosphodiesterase inhibitor that increases cardiac contractility (increased cAMP) - Increases mortality in CHF pts

Question 52

CYP450 inhibitors

Answer 52

SICKFACES.COM Sodium valproate, Isoniazid, Cimetidine, Ketaconazole, Fluconazole, Alcohol, Chloramphenicol, Erythromycin, Sulfonamides, Ciprofloxacin, Omeprazole, Metronidazole, Grapefruit juice - also NSAIDs and acetaminophen, amiodarone, cranberry juice, Ginko balboa, vitamin E, thyroid hormone, SSRIs

Question 53

CYP450 inducers

Answer 53

CRAP GPS induce me to madness Carbamazipines, rifampicin, chronic alcohol, phenytoin, griseofulvin, phenobarbitol, sulfonylureas - Also ginseng, greens, oral contraceptives, St. John's wort

Question 54

Tetrology of Fallot

Answer 54

Infundibular spasm can be induced by exertion or agitation, causing blood to flow from right to left across VSD - Oxygen can be given to cause vasodilation of the pulmonary vasculature and and vasoconstriction of the systemic vasculature - ductal dependent pulmonary blood flow

Question 55

Transposition of the great vessels

Answer 55

- Most common form of cyanotic CHD presenting in the first 24 hrs of life - Pulmonary and systemic circuits are in parallel rather than series. - PFO is necessary for survival Three variants: 1) TGA with intact ventricular septum 2) TGA with VSD 3) TGA with VSD and pulmonic stenosis Clinical manifestations: - Cyanosis present from birth - Loud single S2 - Mild cardiomegaly, increased pulmonary vascular markings. - Egg-shaped cardiac silhouette (narrow mediastinum) ECG - right ventricular hypertrophy and right axis deviation Treatment: PGE1 to increase aorta to pulmonary artery shunting via the ductus arteriosus - ductal independent mixing lesions

Question 56

Tricuspid atresia

Answer 56

- Severe hypoplasia or absence of the right ventricle Two types: 1) with normally related great arteries 2) with TGA - Usually have PFO and VSD and pulmonary stenosis or atresia - Degree of pulmonary stenosis dictates the severity of cyanosis - patency of the ductus arteriosus becomes important here - If pulmonary atresia is present, severe cyanosis can occur with closure of the ductus arteriosis ECG: left axis deviation, right atrial enlargement and left ventricular hypertrophy - Minimal pulmonary blood flow, single S2 -ductal dependent pulmonary blood flow

Question 57

Truncus arteriosis

Answer 57

VSD is always present - Associated with DiGoeorge syndrome - CHF develops due to increased pulmonary blood flow that develops due to decreased pulmonary vascular resistence, and decreased systemic blood flow. - Single S2, nonspecific systolic ejection murmur - Widended pulse pressure and bounding arterial pulses - Cardiomegaly, increased pulmonary vasculature

Question 58

Total anomolous pulmonary venous connection

Answer 58

4 variants: 1) Supracardiac - blood drains via a vertical vein into the innominate vein or directly into the SVC 2) cardiac - blood drains into the coronary sinus or directly into the R atrium 3) infradiaphragmatic - blood drains via a vertical vein into the portal or hepatic veins 4) Mixed - combination of above - Presence of pulmonary venous obstruction dicatates cyanosis - ASD or PFO must be present - leads to CHF - Typically severe cyanosis and respiratory distress Chest XR - pulmonary edema and "snowman sign" (enlarged supracardiac veins and SVC)