Shared Flashcard Set

Details

Cardiology Module
Things to remember
183
Anatomy
Graduate
10/10/2011

Additional Anatomy Flashcards

 


 

Cards

Term

What 3 positions must be checked in a patient when assessing their blood pressure?

 

What can be seen morphologically with severe heart disease (no stethiscope or tools required).

Definition

Standing, sitting, and lying down.

 

A "heave" in the chest.

Term
Where should the physician stand when listening for heart sounds?
Definition
On the right side of the patient.
Term
Where is the PMI?
Definition
4th to 5th left intercostal space at the mid-clavicular line
Term

In a supine position, what angle should the patient's head be to aid in veinous return?

 

What is the clinical advantage of this?

 

What can be seen in a patient who has heart failure (or kidney or lung disease)?

Definition

30 degrees.

 

Helps with ascultation/palpation of the jugular veinous pulse

 

When viewed from lateral, the filling level of the jugular will be greater than 3cm of vertical height above the sternal angle.

Term
When listening for S1, what should be palpated for regarding sound timing?
Definition
Time the hearing of S1 while palpating for the carrotid pulse (occurs after S1).
Term

What sounds are best heard with the diaphragm?

 

Which are best heard with the bell?

Definition

High frequency sounds such as S1, S2, Systolic clicks and high pitched murmors)

 

Low frequency sounds (3rd and 4th heart sounds)

Term

Where is it best to hear S1 on a patient's chest?

 

WHEN is S1 possible to be heard?

Definition

lower left sternal boarder for tricuspid, PMI for mitral

 

Before the carrotid upstroke

Term

What occurs during S1?

 

During each of these events, where should the sound of S1 be MAXIMAL?

 

What part of the heart cycle does S1 signify?

Definition

Mitral valve closure-best heard at the apex of the heart (PMI).

 

Tricuspid valve closure-best heard at the 4th LEFT intercostal space.

 

Aortic and pulmonic valve opening-not usually heard.

 

Systole

 

Term

On ascultation, you discern that a patient has a "wooshing" noise during S1.  What is this MOST LIKELY to be?

 

What part of the stethiscope is best used to hear this sound?

Definition

A systolic murmor indicating mitral regurgitation.

 

Diaphragm

Term
A heavy smoker with known lung disease presents with a "wooshing" sound during S1 on ascultation with your stethiscope is at his left 4th intercostal space.  This is most likely:  
Definition
Tricuspid valve regurgitation due to pulmonary issues.
Term

What is occurring during S2?

 

What is best heard during S2?

Definition

Start of diastolie, Aortic and pulmonic valve closure.

 

Aortic valve closure is mainly heard, and thus problems heard are typically aortic in nature.

Term
What part of the chest is the best place to hear for aortic problems?
Definition
Between 2nd and 3rd Intercostals of the right sternal boarder.
Term
A patient presents with an S2 that is just as loud as S1 towards the PMI.  This could indicate:
Definition
Aortic valve "slamming" potentially due to high peripheral resistance as in atherosclerosis.
Term

 

A patient presents with an S1 that is just as loud as S2 towards the second left intercostal space.  This could indicate:

 

Definition
Mitral valve "slamming" due to increased pressure in the heart as in heart failure.
Term

During deep inspiration, a new heart sound can be heard.  What causes this sound?

 

When might this sound NOT be heard?

Definition

S2 splitting due to the late closure of the pulmonic valve as a result of the increased time of ventricular ejection from the extended filling during diastole (due to the decreased intrathoracic pressure during inspiration).

 

In a patient with lung problems, the increased lung pressures and right ventricle pressures make it harder to fill the ventricles during diastole.  Because of this, less blood fills the ventricle than would normally, and the pulmonic and aortic valves will close at about the same time.

Term

Which location on the chest is best to hear the:

 

Mitral valve

Aortic valve

pulmonary valve

tricuspid valve

Definition

PMI (left 4-5 intercostals on midclavicular line)

Right between second and 3rd intercostals on sternal boarder

Left between second and 3rd intercostals on sternal boarder

between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternalborder
Term
Describe the hemodynamic curve chronologically in regards to puressures seen in the ventricles and in the aorta.
Definition

1. Ventricles are empty and have just started expanding; very low pressure (less than 5mmHg).

2. A "blip" of pressure can be seen during atrial ejection.

3. Ventricles are beginning to slow expansion, causing a rise in pressure with continued filling. This is isovolemic contraction.

4. Pressure passes 80mmHg and the aortic valve is opened, starting the ejection phase.  A peak pressure of 120 is reached about midway through ejection, and it continues until pressure drops to about 80 again.

5. ventricles relax and expand as pressure is lowered and the next filling cycle begins.

Term
During what phases in the hemodynamic cycle can each of the heart sounds be heard?
Definition

S1: start of systole just at the point of isovolemic contraction (tricuspid and mitral "slam" shut here)

 

S2: Start of diastolie just at the end of the ejection phase (aortic and pulmonary valves "slam" shut).

 

S3: "active relaxation" sound heard in individuals with heart failure due to the heart's attempt to expand its volume actively.  Hypertrophy may decrease ventricular volume, and this is one consequence.

 

S4: Occurs just after atrial contraction, usually just prior to S1.  Again, a thin structure such as an atria is being asked to contract forcefully against a non-compliant ventricle.

Term

What should the diastolic ventricular pressure be around in a healthy individual?

 

What about in the aorta?

 

What does this indicate if higher than normal?

Definition

Around 10mmHg

 

Around 80mmHg

 

Can indicate heart failure in that the ventricles are not adequately emptying.

Term

When an EKG is lined up to a ventricular pressure curve, when do the Q, R, S and T waves occur in respect to the volume curve?

 

What does each signal?

Definition

P wave occurs just prior to atrial contraction. signals atrial contraction

 

QRS complex occurs with the start of isovolemic contraction. Signals ventricular contraction.

 

T wave occurs mid rapid ejection, signals ventricular repolarization.

Term
When is S4 normal?
Definition
In children.
Term

Where is the best place to hear S3?

 

S4?

Definition

Using the bell, best to hear along sternal boarder.

 

S4 can be heard everywhere.

Term
What is the "A1C of Blood Pressure Control"?
Definition
An uncharacteristically loud S2
Term
If you know the left atrial systolie pressure in a patient, what else do you know?
Definition
Left ventricular end diastolie pressure.
Term
When would it be impossible to hear S4 in a patient with cardiac abnormalities?
Definition
If they are in Afib!
Term

What drug class is very helpful in the treatment of patients with heart failure? Why?

 

Which drug is contraindicated? Why?

Definition

Beta Blockers; avoid catacholamine surges which may cause a heart attack by overworking the heart.

 

Calcium channel blockers (dihydropyradines) because they decrease contractility (negative ionotrope) which is the only thing keeping the heart nourshed enough to work at all!

Term

What is the normal cross sectional area of the mitral valve?

 

At what diameter is a diagnosis of mitral stenosis appropriate?

 

During what heart sound would mitral valve stenosis be audible? How would it sound?

Definition

4-6cm2

 

2cm2

 

S1, sounds like a "whoosh" as blood escapes through the mitral valve during systole. http://www.youtube.com/watch?v=L5DEqvgS_xs

Term
Worldwide, what is the most common cause of mitral valve weakness and thus prolapse?
Definition
Rheumatic fever
Term

In mitral valve stenosis, what is the most common area to be stenosed?

 

What about second most common?

Definition

The commissure of the valve (30%)

Cuspal region (15%)

Term

What is the pathophysioloy of pulmonary hypertension?

 

How do these patients present?

Definition

1. Passive backward transmission of increased left atrial pressure.

2. Pulmonary arteriolar constriction due to decreased oxygenation.

3. Organic obliterative changes in the pulmonary vascular bed.

4. Increased overall pressure builds over time, eventually leading to right ventricular failure.

 

ExertionalDyspnea
Cough/Wheezing
Orthopnea/PND/CHF
Hemoptysis-Rupture of Pulm Vein-Brochial Vein Shunts
Term
What is the most serious consequence of mitral stenosis regarding mortality?
Definition
Atrial fibrillation
Term
What is a facial manifestiation of mitral stenosis that is not very prevalant, but is indictive if present?
Definition
Mitral faces-associated with prominent livid colour of the cheeks and acral cyanosis in the face
Term
What can be seen on physical exam in a patient with mitral stenosis?
Definition
Mitral Facies-pink, purple facial patches due to decrease CO and systemic vasoconstriction
Hepatomegally
Edema
Ascites
Hydrothorax With Right Heart Failure
Term
When it comes to valvular disease, what is the imaging study that is the "cornerstone of diagnosis?"
Definition
Echocardiogram
Term
In mitral stenosis, what is a VITAL pharmacologic intervention?
Definition
Beta Blockers- prevents shortened filling times brought about by epinephrie.
Term

What would the effect of mitral valve regurgitation be on the physiology of the heart?

 

What is the mesurement and the value of this mesurement which prompts surgical intervention?

 

What is the logic behind this?

Definition

Contractility increases due to a decrease in effective afterload pressure, eventually leading to left ventricular hypertrophy.  Ejection fraction starts to decline with these changes.

 

An ejection fraction around 60%

 

Surgery mortality is low, and preserving ventricular function by acting sooner will benifit the patient more.

Term

What are the clinical signs seen in a patient with mitral regurgitation?

 

What usually occurs just BEFORE the onset of these symptoms?

 

What is an important therapy to institute in these patients? How does this work?

Definition
Shortness of Breath
ExertionalDyspnea
Congestive Heart Failure
RHF
Significant symptoms in chronic MR usually do not develop until LV decompensation occurs.
Diuretic therapy decreases these symptoms. lowers preload and volume that needs to be pumped so that lung symptoms subside.
 
 
 
 
 
 
Term
What is the most common etiology of mitral valve prolapse?
Definition
Primary valvular problems such as rheumatic fever
Term

An asymoptomatic patient with Marfan's syndrome is ascultated for cardiac problems.  You hear a mid systolic click (http://www.youtube.com/watch?v=PsmGx2XMxF8).  This is most likely what?

 

What is the etiology of this condition?

 

What would be a good therapy (if any) to put this patient on?

Definition

Mitral valve prolapse

 

Myxomatous proliferation and degeneration of valve leaflets brought on because of his genetic condition.

 

Low dose asprin.

Term
What is the normal cross sectional area of the aortic valve?
Definition
3-4cm2
Term

What is the most common cause of aortic stenosis in a patient that is less than 65 years old?

 

What about in patients older than 65?

Definition

A bicuspid (congential) aortic valve (congenital aortic stenosis)

 

Degenerative (senile) acquired aortic stenosis

Term
What percentage of individuals older than 65 years old have aortic sclerosis?
Definition
30%
Term

What is the critical valve cross sectional area regarding the aortic valve?

 

At what diameter should these patients undergo surgery to have the BEST prognosis?

Definition

0.7-0.8cm2

 

Best done when the valve area is at 1cm2

Term

A 54 year old male presents in the ER with angina and a blood pressure reading of 165/85.  He was brought in after he fainted when getting out of bed.  You note that he is sitting straight upright and has a quickened respiration rate.  This is most likely:

 

What therapy should NOT be used?

Definition

Aortic stenosis

 

(Angina, Syncopy and/or CHF)

 

Should NOT use beta-blockers; the heart NEEDS to work!

Term
What is the 3 year survival rate in an untreated person experiencing angina, syncopy or CHF?
Definition
50%
Term
What is "valve mismatch"?
Definition
Effective valve replacement area is just as small as the origional valve cross sectional area, hence no improvement was made with the surgery.
Term
What is the most common cause of aortic regurgitation?
Definition
Degenerative (atherosclerosis)
Term
In aortic regurgitation, what causes the rheumatic-fibrotic retraction of the valve leaflets?
Definition
Ankylosing spondylitis, Behchets, Psoratic arthritis, giant cell arteritis
Term
When taking a patient's blood pressure, you note heart sounds at around 40mmHg.  This is very strange, especially considering that the systolic pressure was noted at around 170.  What is this called, and what does it indicate?
Definition

Korotkoff sounds

 

Aortic Stenosis

Term
An African American male patient has a blood pressure of 155/98.  What would be a good therapy to lower this high blood pressure?
Definition
Diuretics with salt restriction
Term
A patient presents with congestive heart failure and an ejection fraction of 30%.  This patient is on multiple blood pressure mediciations, but what would be a BAD option to put this patient on?
Definition
Alpha blockers
Term

A patient presents with hypertensive heart disease (167/90) and has an S4 gallop.  There is a normal EKG.  What would be the next things to order?

 

What kind of heart dysfunction is this primarily?

Definition

Echo

Lipid panel

electrolytes

seconary causes of hypertension screening

 

Diastolic dysfunction

Term
A 55 year old patient presents with type 2 diabetes.  He presents in the ER after an acute MI. What drug should be used on this patient both short term and long  term?
Definition
Ace inhibitors and beta blockers
Term
A patient with a recent MI has an LDL of 90. Is this a good value to have as a patient with a history of MI?
Definition
No, intervene with statins
Term
A 40 year old patient's dad has an MI at the age of 39, and now presents with a high LDL (130).  Is this a good value?
Definition
No
Term
A middle aged patient has carrotid bruits, hypertension and is a type 2 diabetic.  What should the LDL of this patient be to minimize her risks?
Definition
Less than 70
Term
In a hypertensive diabetic (type 2) male, what is an important pharmacological intervention?
Definition
Statins
Term
What is a very worrisome cause of syncopy that MUST be investigated when a person has a fainting episode?
Definition
Structural heart disease.
Term
What is the MOST COMMON cause of syncope?
Definition
Cerebrovascular/neurological causes
Term
What happens to heart rate and blood pressure during syncope?
Definition
Both decrease
Term
A patient describes a feeling of lightheadedness after taking his blood pressure medication.  He also noticed a "narrowing" of his vision for a few seconds.  What is the cause of these symptoms?
Definition
hypotension causing the peripheral vision vessels of the retina to collapse.
Term
What cause of syncope has the HIGHEST rate of mortality?
Definition
cardiac problems causing syncope
Term
65 year old male with h/o inferior wall myocardial infarction 1 year ago presents with rapid palpitation and syncope. An ECG shows SR and old inferior wall myocardial infarction. A 2D echo shows LVEF 40% with  inferoapical dyskinesis. Coronary angiography reveals totally occluded right coronary artery with collaterals. What is the next step?
Definition
Answer: Electrophysiologic study (to look for inducible sustained VT)
Term

 

 72 year old male with chronic atrial fibrillation of greater than 10 years’ duration is admitted following a syncopal episode. A 2D echo shows markedly dilated left atrium and LVEF 60%. Telemetry  reveals atrial fibrillation with slow ventricular response and pauses of 4 to 8 seconds associated with near syncope.

          How would you proceed?

 

Definition
Answer: Implant single chamber rate responsive pacemaker  
Term

A patient presents with a head injury after an episode of syncope.  After her recovery, she is asked about the episode and it is found that she has no history of syncope.

 

What would be an appropriate next step to find out what is wrong?

 

Depending on this result, what should be done next?

Definition

Test for structural heart disease via an echo or other methods.

 

If no structural heart disease is found, perform a tilt table test.

 

If found, do an electrophysiologic study of the heart.

Term
A patient presents with ventricular tachicardia.  What kind of pacemaker should be used?
Definition
Temporary pacemaker
Term
A patient presents with chronic A-fib, and it is determined that he is a good candidate for a pacemaker.  What kind of pacemaker would be appropriate?
Definition
A ventricular retrosponsive pacemaker
Term

A patient with a single chamber pacemaker has severe hypotension. A blood test shows an increase in ANP levels. What is this patient most likely suffering from?

 

What should be done?

Definition

pacemaker syndrome

 

Institute a dual chamber pacemaker to allow opening of the mitral and tricuspid valves.

Term
When would it be appropriate to give a patient an Implantable Cardioverter Defibrillator (ICD)?
Definition

Secondary prevention: Prevention of SCD in patients with prior VF or sustained VT.

 

Primary prevention: Prevention of SCD in individuals without a h/o VF or sustained VT.

 

VF/sustained unstable VT not in the setting of a completely reversible cause.

LVEF ≤ 35%, CHF NYHA class II, III.

Ischemic dilated cardiomyopathy, LVEF ≤ 40%, NSVT and inducible sustained VT.

Syncope, LV dysfunction, inducible sustained VT.

High risk patients with: hypertrophic cardiomyopathy, LQT syndrome, RV dysplasia, Brugada syndrome

Term
What are the ACC guidelines for giving a patient Cardiac Resyncronization Therapy (RCT)?
Definition

LVEF ≤ 35%

QRS ≥ 120 msec

NYHA functional Class III or ambulatory Class IV

Optimal medical therapy

Term

58 year old male, CAD, prior MI 1 year ago, LVEF 28%, CHF  NYHA class II, treated with a betablocker, ACE inhibitor and statin; ECG: Sinus rhythm, old anteroseptal MI, QRS 98 msec

Question :  For prevention of sudden cardiac death, you would suggest:

Definition
Implantation of an ICD
Term
In the decision to give a patient an ICD, you notice that they have a wide QRS complex.  What kind of ICD should you use?
Definition

A bi-ventricular ICD

if it was narrow, use a normal ICD

Term
What are the grades of ascultation intensity?
Definition

Grade 1Very Faint

Grade 2Quiet, but Heard Immediately

Grade 3Moderately Loud, Not Associated witha Thrill

Grade 4Loud, May Be Associated with aThrill

Grade 5Very Loud

Grade 6May be Heard w/stethoscopeoff chest

Term
On ascultation, you notice a wide splitting of S1 irrespective of inspiration.  What could this be indictive of?
Definition

RBBB

PVC from Left Ventricle

Term
On ascultation, you notice only one heart sound for S2 even when the patient inhales and exhales deeply.  What could this be caused by?
Definition

Normal

LBBB

PVC from Right Ventricle

Paced Beats

Term

On ascultation, you notice a very pronounced and loud S1.  What could this be indictive of?

 

What if the sound was decreased?

Definition

Short PR

Rapid HR

Atrial Fibrillation

Mitral Stenosis

 

Mitral Stenosis (Immobile Leaflets)

Opposite of Causes of Increased Intensity

Term
What is one reason that a patient would have a fixed S2 split?
Definition
Atrial septal defect
Term
On ascultation, you notice that your patient has persistent S2 splitting.  What might cause this?
Definition

RBBB

Pure MR

Healthy Adolescents when in Supine Position

Term

What are the reasons for hearing paradoxial splitting of S2?

 

What about for S2 increased intensity?

Definition

Paradoxical Splitting- P2 before A2

LBBB

Paced Beats

Increased Intensity

A2Systemic HTN

Dilated Aortic Root

P2Pulmonary HTN

Dilated Pulmonary Trunk

Term
On ascultation, you notice a normal S1 followed by a "rough" noise when listening with your diaphragm.  This noise comes almost directly after the sound of S1.  What could this be?
Definition

Ejection Sound- Usually High Frequency

 

Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve

Pulmonary Valve-Pulmonic Stenosis Vary with Respirations

Prosthetic Valves- Mechanical, Not Bioprosthetic

Term
During ascultation, you notice a "click" occurring during mid-systole (halfway between S1 and S2).  What is this very indictive of?
Definition
Mitral valve prolapse
Term
During ascultation, you notice a "snapping" noise almost immediately after hearing S2.  What most likely caused this?
Definition

Opening Snap of Mitral Stenosis (MS)

High Frequency-Left Lateral Decubitus Position, Apex

Occurs after S2, before S3

MS More Severe with Short A2-OS Interval

Precordial Knock

Chronic Constrictive Pericarditis

Mitral Regurgitation

Atrial Myxoma

Older Model Prosthetic Mitral Valve

Term

What sound can be heard that is almost pathognomonic for CHF?

 

Is the bell or diaphragm better to use for this?

Definition

S3 (mid diastolic sound)

Bell (low frequency)

Term
What are the common causes of S4?
Definition

During Atrial Phase of LV Filling

Consequence of Ventricular Stiffness

Absent in Atrial Fibrillation or Ventricular Pacing

Low Frequency Sound Best Heart 

At the Apex

Pt in Left Lateral Decubitus Position

HTN, Aortic Stenosis, Ischemic Heart Disease

Term
What is the sound difference between aortic stenosis and mitral valve prolapse?
Definition

aortic stenosis-creshendo-decreshendo.

 

Mitral valve prolapse=creshendo only

Term

What are the characteristic sounds of mitral stenosis?

 

What is the best way to hear these sounds?

Definition

Follows Opening Snap

Low Pitch Rumble

 

Best Heard 

Apex over LV 

Using Bell of Stethoscope

Pt in Left Lateral Decubitus Position

Term
What are 4 complications of aortic stenosis?
Definition

Arrhythmias

 

Endocarditis

 

Left-sided heart failure

 

Left ventricular hypertrophy (enlargement) caused by the extra work of pushing blood through the narrowed valve

Term
What are the important non-surgical therapies to institute when treating mitral stenosis? 
Definition
Endocarditis Prophylaxis
Activity Limitation
Diruetics- Decrease Na Intake
Heart Rate Control for A-fib or Sinus Rhythm
Anticoagulation
Term

In mitral regurgitation, what percentage of ejection fraction is a SERIOUS risk?

 

What is the relationship between EF and post operative mortality?

Definition

35% or less.

 

As EF decreases, post surgery mortality increases.

Term
What sound changes occur with progressing aortic stenosis?
Definition

Systolic Murmur

Diamond-Shaped, harsh, left sternal boarder to right intercostal spaces, neck and apex

Late peak, obliteration of S2, consistent with bedside Dx of Critical AS

Pulses Parvus

Delayed and Prolonged Carotid Impulse

Term
in aortic stenosis what are 3 things that can happen to patients that can increase mortality?
Definition
Angina, syncopy or CHF
Term

How are patients with aortic insufficiency followed?

 

What are the criteria for surgery?

Definition

Follow by Echo Yearly

Endocarditis Prophalaxis for all AR

May not require medical treatment

 

Symptomatic Patients -valve area 0.7-0.8cm2 or less

Asymptomatic Patients-progressive LV disfunction (EF <35%) or hypotensive response to mild exercise

Delaying surgery in asymptomatic patients with good exercise tolerance is contraversial

Term
What REALLY is the murmor in ASD?
Definition
a pulmonic outflow tract murmor best heard at the left 2nd intercostal space.  NEVER hear a murmor FROM the ASD!
Term

What clinical symptoms/diseases are collected under the term Acute Coronary Syndrome (ACS)?

 

What do they have in common?

Definition

Unstable angina

Non-ST-segment-elevation MI

ST-segment-elevation MI

 

Each condition shares common pathophysiologic origins related to the instability and rupture of artherosclerotic vulnerable plaques

Term
What distinguished unstable angina and NSTEMI?
Definition
Whether the ischemia is prolonged enough to lead to structural myocardial damage and to the release of detectable markers of myocardial injury
Term
What are the common causes of an NSTEMI?
Definition

Intense arterial spasm

 

Progressive, severe, flow-limiting atherosclerosis due to intimal hyperplasia or to lipid, calcium, and thrombus deposition, or to fibrointimal hyperplasia after PCI

 

Coronary artery dissection

 

Conditions that alter myocardial oxygen demand or supply, such as intense emotion, tachycardia, or uncontrolled systemic hypertension (secondary MI)

Term
When do plaque ruptures often occur?
Definition
Often occurs in arteries where the atherosclerotic lesions previously had caused only mild-to-moderate obstruction
Term
How is the diagnosis of UA or an MI Made?
Definition

If ischemia is neither severe nor prolonged (usually <20min) and oftern occurs at rest, patients are given a diagnosis of UA

 

If ischemia lasts longer than 30 minutes and is associated with elevated cardiac markers, the diagnosis of MI is made

 

Further classification as STEMI or NSTEMI is made on the basis of electrocardiographic findings.

Term
What is the test of first choice when screening for ACS? What type of ACS is it most specific for?
Definition

EKG

 

Most sensitive for STEMI

Term
What are the 7 components of the TIMI risk score?
Definition

Age ≥ 65 years?Yes +1

≥ 3 Risk Factors for CAD?Yes +1

Known CAD (stenosis ≥ 50%)?Yes +1

Asprin use in Past 7d?Yes +1

Severe angina (≥ 2 episodes w/in 24 hrs)?Yes +1

ST changes ≥ 0.5mm?Yes +1

+ Cardiac Marker?Yes +1

Term
What 5 tests aid in risk stratification for people with ACS?
Definition

Clinical history

Physical examination

12 lead ECG

Biochemical marker measurement

Noninvasive risk stratification

Term
What drug class should be used in patients with refractive pain due to ischemia?
Definition
Nitrates
Term
What are the contraindications to using nitrates?
Definition

Patients who have taken sildenafil, tadalafil, or vardenafil in the previous 24 hours

Systemic hypotension

Marked tachycardia

Severe aortic stenosis

Right ventricular infarct

Term
What are the contraindications to using beta blockers?
Definition

Bradycardia

Heart block

Asthema

Diabetes patients prone to hypoglycemia

Term
A non-diabetic patient with a heart rate of 89bpm experiences an episode of UA.  He has no history of asthema.  What treatment should be started for this patient?
Definition
Beta blockers (ideally within 24 hours of starting medical treatment)
Term
An asthmatic patient presents with high blood pressure (despite nitrate usage) and NSTEMI.  What drug would be best to institute?
Definition

Calcium channel blockers

 

Dihydropyridines

Nifedipine, amlodipine

 

Nondihydropyridines

Verapamil, diltiazem

Term
In a patient with ACS, what therapy would be best to reduce their risk of thrombosis the most?
Definition
Low dose asprin and Clopidogrel (2nd generation thienopyridine)
Term

Describe the early invasive strategy and the early conservative strategies for patients with ACS?

 

When is each best to use?

Definition

In the early-invasive strategy, all patients without contraindications undergo coronary angiography with the intent to perform revascularization within 4 to 24 hours of hospital admission.

 

The early-conservative strategy consists of aggressive medical therapy for patients

 

An early-invasive treatment strategy is of most benefit to high-risk patients

An early-conservative strategy is recommended for low-risk patients

Term
What are the main factors attributed to the pathogenesis in patients with ACS?
Definition
Plaque composition and inflammation are more important in the pathogenesis of ACS than is the actual degree of stenosis
Term
What is the most accurate predictor of mortality after an acute myocardial infarction?
Definition
Left ventricular health (observe cardiac output and other aspect of LV health)
Term
What is the best way to manage a patient with left ventricular failure?
Definition
Managed most effectively first by reduction of ventricular preload and then, if possible, by lowering afterload
Term

What are the characteristics of cardiogenic shock?

 

when does this usually occur?

 

What is often found on autopsy with this syndrome?

 

What treatments are possible for this syndrome?

Definition

Low output state characterized by elevated ventricular filling pressures, low cardiac output, systemic hypotension, and evidence of vital organ hypoperfusion

 

Occurs usually after an AMI

 

At autopsy, more than 2/3 of patients with cardiogenic shock demonstrate stenosis of 75 percent or more of the luminal diameter of all 3 major coronary vessels and loss of about 40 percent of LV mass

 

Same as tx for LV failure

Intraaortic balloon counterpulsation

Revascularization

Term

What other compilcations can be found in people who develop an intraventricular septal rupture after an acute MI?

 

What are the characteristic physical findings in patients who have such a rupture?

 

How can it be treated?

Definition

Associated with complete heart block, right bundle branch block, and atrial fibrillation in 20-30 percent of cases

 

Characterized by the appearance of a new harsh, loud holosystolic murmur

Best heard at the lower left sternal border

Usually accompanied by a thrill

Can be recognized by 2-D echocardiography

 

Catheter placement of an umbrella-shaped device within the ruptured septum

Term

What are the features that characterize a free wall rupture?

 

When do these occur?

Definition

Elderly

HTN

More frequently occurs in left ventricle

Seldom occurs in atria

Usually involves the anterior or lateral walls

Usually associated with a relatively large transmural infarction involving atleast 20% of the left ventricle

 

It occurs between 1 day and 3 weeks, but most commonly 1 to 4 days after infarction

Most often occurs in patients without previous infarction

Term

A diabetic, obese woman dies in her living room in a matter of seconds.  Her husband states that she clutched her chest, fell over, and ceased moving and breathing almost immediately.  What did she die of?  What is the pathology of this?

 

What are the factors that affect the survival in a patient that has this condition?

Definition

A free wall rupture-Usually leads to hemopericardium and death from cardiac tamponade

 

Occasionally, rupture of the free wall of the ventricle occurs as the first clinical manifestation in patients with undetected or silent MI, and then it may be considered a form of “sudden cardiac death”

 

Survival depends on the recognition of this complication, on hemodynamic stabilization of the patient, and most importantly, on prompt surgical repair

Term
What are the differences between a typical ventricular aneurysm and a ventricular psuedoaneurysm?
Definition

True aneurysm: wide base, walls composed of myocardium and low risk of rupture.

 

Psuedoaneurysm: narrow base, wall composed of thrombus and pericardium, and high risk of rupture.

Term
What are the characteristics and causes of acute mitral valve regurgitation?
Definition

Due to partial or total rupture of a papillary muscle

 

Rare but often fatal complication of transmural MI

 

Complete transection of a left ventricular papillary muscle is incompatible with life because the sudden massive mitral regurgitation that develops cannot be tolerated

 

Rupture of a portion of a papillary muscle resulting in severe mitral regurgitation is much more frequent and is not immediately fatal

Term
What are the characteristics of a right ventricular infarction?
Definition

Frequently accompanies inferior LV infarction or rarely occurs in isolated form

 

Right-sided filling pressures are elevated, whereas left ventricular filling pressure is normal or only slighty raised

 

Cardiac output is often markedly depressed

 

Common among patients with inferior LV infarction

Unexplained systemic arterial hypotension or diminished cardiac output or marked hypotension in response to small doses of nitroglycerine in patients with inferior infarction should lead to the prompt consideration of this diagnosis

 

Common among patients with inferior LV infarction

 

Unexplained systemic arterial hypotension or diminished cardiac output or marked hypotension in response to small doses of nitroglycerine in patients with inferior infarction should lead to the prompt consideration of this diagnosis

Term

What are two ways to detect a right ventricular infarction?

 

Why is this important?

 

What treatment should be instituted?

Definition

Most patients with RV infarction have ST segment elevation in lead V4R (right precordial lead in V4 position)

 

2-D echocardiography : abnormal wall motion of the right ventricle as well as right ventricular dilitation and depressed RV ejection fraction

 

In patients with an inferior MI, it is important to know this when thinking about treatment with nitrates which is a large contraindication with a right ventricular MI (decreases preload).

 

Volume expansion.

Term
What is the proper treatment of a ventricular arrhythmia?
Definition
Usually pursue a conservative approach and do not routinely prescribe antiarrhythmic drugs but instead determine whether recurrent ischemia or electrolyte/metabolic disturbances are present
Term
What treatments can be used to treat ventricular tach.?  What about ventricular fibrillation (post recovery)?
Definition
lidocaine and amiodarone
Term
What blood level is a HIGH risk factor for ventricular fibrillation if too high or low?
Definition
Potassium levels (low is an even larger risk than high)
Term
What are the characteristics of bradyarrythmias, specifically sinus bradycardia?
Definition

Common arrhythmia occuring during the early phases of AMI

Particularly frequent in patients with inferior and posterior infarction

Isolated sinus bradycardia, unaccompanied by hypotension or ventricular ectopy, should be observed rather than treated initially

Atropine should be utilized if hypotension accompanies any degree of sinus bradycardia

Term
What treatment should be instituted for patients with a Atrioventricular block or a Intraventricular Block?
Definition
Digitalis, B-blockers, Calcium antagonists
Term

What are the characteristics of a 2nd degree heart block? (Mobitz type II)

 

How is this treated?

Definition

 

Rare conduction defect after AMI

Often progresses suddenly to complete AV block (3rd degree heart block.  This is unlike a 1st degree heart block which doesn't usually progress.)

 

Treated with a temporary external or transvenous demand pacemaker

Term

What is a common situation to see a pericardial effusion?

 

Does this cause any sort of hemodynamic compromise such as cardiac tamponade?

Definition

More common in patients with anterior MI and with larger infarcts and when congestive heart failure is present

 

Majority do not cause hemodynamic compromise; when tamponade occurs, it is usually due to ventricular rupture or hemorrhagic pericarditis

Term
How is pericarditis often treated?
Definition
Treatment of pericardial discomfort consists of aspirin at does as high as 650mg every 4-6 hours. (corticosteroids should be avoided because they may interfere with myocardial scar formation)
Term

What are the characteristics of Dressler syndrome?

 

When does it usually occur?

 

What is an effective treatment of this condition?

Definition

Post-myocardial infarction syndrome

Usually occurs 1 to 8 weeks after infarction

Patients present with malaise, fever, pericardial discomfort, leukocytosis, elevated ESR,and a pericardial effusion

Cause of this syndrome not clearly established (? Immunopathological process)

Treatment : ASA 650mg Q4hrs

Term
What criteria must be met for a normal sinus rhythm?
Definition
  1. A heart rate between 60-100 beats per minute.
  2.  The SA node pacing the heart.
  3.  Regularity- Regular
  4.  A "P" wave must be present for every "QRS" complex in a ratio of 1:1.
  5.  PR interval is between .12 second and .20 second.
  6.  QRS complex width should be less than .12 second.
Term
What areas of the heart are supplied by the LAD, the LCX, and the RCA?
Definition
    The left anterior descending coronary artery (LAD) and it's branches usually supply the anterior and anterolateral walls of the left ventricle and the anterior two-thirds of the septum.

The left circumflex coronary artery (LCX) and its branches usually supply the posterolateral wall of the left ventricle.


The right coronary artery (RCA) supplies the right ventricle, the inferior (diaphragmatic) and true posterior walls of the left ventricle, and the posterior third of the septum.


The RCA also gives off the AV nodal coronary artery in 85-90% of individuals; in the remaining 10-15%, this artery is a branch of the LCX.

Term
What are the characteristics of an inferior MI?
Definition
Pathologic Q waves and evolving ST-T changes in leads II, III, aVF 

Q waves usually largest in lead III, next largest in lead aVF, and smallest in lead II 
Term
What are the characteristics of a true posterior MI?
Definition

[image] ECG changes are seen in anterior precordial leads V1-3, but are the mirror image of an anteroseptal MI:

[image] Increased R wave amplitude and duration (i.e., a "pathologic R wave" is a mirror image of a pathologic Q) 

[image] R/S ratio in V1 or V2 >1 (i.e., prominent anterior forces)

[image] Hyperacute ST-T wave changes: i.e., ST depression and large, inverted T waves in V1-3

[image] Late normalization of ST-T with symmetrical upright T waves in V1-3



[image] Often seen with inferior MI (i.e., "inferoposterior MI") 

Term
how does an anteroseptal MI appear on EKG?
Definition
[image] Q, QS, or qrS complexes in leads V1-V3 (V4)

[image] Evolving ST-T changes
Term
What is the difference seen on EKG between an anterior MI and an anterolateral MI?
Definition

 Q, QS, or qrS complexes in leads V1-V3 (V4)

 Evolving ST-T changes

    but usually V1 is spared; if V4-6 involved call it "anterolateral"
Term

What are the findings on EKG that are characteristic of left ventricular hypertrophy?

 

When a patient has these characteristics, what other findings on EKG are important regarding other pathology?

Definition

R wave in lead 1 greater than 11cm

 

On any 2 chest leads, combine an R and S wave (one on each) and have a sum of >35mm

 

None, left ventricular hypertrophy obscures and skews other findings

Term

What usually sets off an episode of AVNRT? (AV Nodal Re-entry tachycardia)?

 

What is a very useful long term treatment for such patients?

 

How does this present on EKG?

Definition

A PAC (premature atrial contraction)

 

Beta blockers, Calcium channel blockers.  Slow down heart rate enough for the retrograde signals to be halted.

 

normal but narrow QRS complex without P waves.

Term
What leads should be used to best visualize atrial problems?
Definition
Leads II, III and aVF
Term
What is a key finding in diagnosing a left bundle branch block?
Definition

QRS complex longer than 120ms

Prominant R waves in Leads I, aVL, V5 and V6

Hallmark=HUGE negative deflecting S waves

Term

What leads should be used to detect a right bundle branch block?  

 

What would be seen?

 

How can this be differentiated from a left bundle branch block

Definition

V1 V2 and V3

 

Positive deflections

 

V1 is positive in RBBB, not in LBBB

Inferior limb leads (II, III, aVF) should be normal in LBBB

 

 

Term

What can be seen in cardiac ischemia that is DIFFERENT from the appearance of an acute MI?

 

Using leads, how can you tell where the ischemia is?

Definition

ST depression

V4,5, and 6=Lateral

II, III, and aVF=inferior

 

Term
A patient presents on EKG with largely depressed Q waves in leads V1, 2 and 3. They are otherwise largely asymptomatic.  What does this indicate?
Definition
A past anterio-septal MI
Term
What is a very common problem associated with a primum sinus defect that is often overlooked?
Definition

An anomalous pulmonary vein can develop, delivering unoxygenated blood to pulmonary return. (sinus venosus)

 

Mitral valve defect, particularly mitral regurg. "endocardial cushion" today known as an AV valve (cleft mitral valve).

Term
What is the most common type of ASD?
Definition
secundum
Term
What is the hallmark(s) of an ASD (particularly a secundum)?
Definition

Dilated right atrium, ventricle and pulmonary artery.

 

A constant split of S2.

Term
What population typically presents with a ASD primum with mitral regurg?
Definition
Down's syndrome patients.
Term

How can you distinguish an ASD from a VSD?

 

What can happen with a sizable VSD?

 

How can one distinguish from a patient foramen ovale?

Definition

No dilation of right atrium in VSD, but dilation of right ventricle and pulmonary artery.

 

Kids with VSD typically go into heart failure. "Size is everything".  Also, age of occurance determines how worrisome this complication is.

 

No dilation of the right heart, only in pulmonary vasculature.

Term
Which is easier to hear on ascultation, ASD or VSD?
Definition
VSD (Holosystolic murmur which is harsh and loud, similar to mitral regurg. but much more severe.)  Can feel a heave!  Typical in children.
Term

What is Eisenmenger's complex?

 

What causes the main complication in this disease, and what often kills these patients?

Definition

Change from left to right shunt, to a right to left shunt.  Occurs after a long ASD or VSD. Cyanotic lesion.

 

Pulmonary hypertension

Term
What is a major hallmark of pulmonary hypertension on ascultation?
Definition
Very intesnse S2, especially in areas such as the PMI.
Term
What is the hallmark sound of a PDA?
Definition
A "machine like" murmur that drowns our the regular heart sounds.
Term

In which gender is a coarctation more common?

 

What can be seen on X-ray?

 

What is this associated with?

 

What is one typical clinical presentation especially seen in kids?

Definition

MORE COMMON IN MALES

 

RIB NOTCHING OCCURS DUE TO PHYSICAL ERROSION OF THE UNDERSURFACE OF THE RIBS AS A RESULT OF INTERCOSTAL COLLATERAL CIRCULATION

 

ASSOCIATED WITH  BICUSPID AORTIC VALVE

 

Systolic ejection murmur (aortic stenosis) as well as pain in the legs after running.

Term

What are the 4 clinical findings of Tetrology of Fallot?

 

What do children tend to do with this disorder?

Definition

1)  INFUNDIBULAR STENOSIS

2) VENTRICULAR SEPTAL DEFECT

3) RIGHT VENTRICULAR HYPERTROPHY

4) OVERRIDING OF THE AORTA 

High incidence of ASD as well.

 

Children tend to "squat" as they get short of breath to aid in veinous return.

Term
What is a powerful treatment for long term pericarditis?
Definition
Colchicine
Term
What is the most common cause of pericarditis?
Definition
Cocsakie viruses type A and B
Term
What are the causes of pericarditis?
Definition

TUMOR

Trauma

Uremia

MI

Other infections

Rheumatic disease

Term
What is Dressler's syndrome and how can it be treated?
Definition

A syndrome consisting of fever, pericarditis and pleuritis often occurring after an MI or cardiac surgery.

 

Treat with high dose asprin

Term

What is the standard for diagnosing a pericardial effusion?

 

What can be seen on EKG and on physical exam that is not diagnostic, but is highly suggestive?

 

What is a test that is NOT helpful in this diagnosis?

Definition

Echo

 

Can see electrical alternans on EKG (heart "swinging in a liquid sack") Diminished heart sounds, including a decreased friction rub if present.

 

X-ray (cannot distinguish a large heart from a pleural effusion via x-ray)

Term
What is Beck's triad?  What does this indicate?
Definition

Decreased arterial pressure

decreased heart sounds

distended neck veins

 

Indictive of a cardiac tamponade

Term
Who is most at risk for myocarditis?
Definition
young males, pregnant women, children and the immunosuppressed
Term
What are the Dallas criteria for the diagnosis of myocarditis?
Definition

Introduced in 1986 for dx of pericardits

Based on endomyocardial biopsy specimens

1. Active Myocarditis: if light microscopy revealed 

       infiltrating lymphocytes and myocytolysis

 

2. Borderline or on going Myocardits if lymphocyte

      infiltration and NO myocytolysis

 

3. Negative for Myocarditis if no lymphocytic infiltrate

      and no myocytolysis

Term
What is a MAJOR limitation when imaging with a portable X-ray machine?
Definition
Cannot diagnose cardiomegaly (it is an AP x-ray)
Term
What does a "bat wing deformity" indicate?
Definition
Acute pulmonary edema
Term
What do Kerley B lines indicate?
Definition
interstital edema often caused by heart failure
Term
Which type of x-ray is best for estimating right ventricular size?
Definition
An AP x-ray or left lateral
Term
What cardiac structure is obscured if a patient has a right middle lobe pneumonia?
Definition
The right atrium
Term

In a de-acceleration injury, what usually ruptures in the ABDOMEN?

 

What about in the CHEST?

Definition

Duodenum

 

Aorta (due to the ligamentum arteriosum)

Term
A patient presents with an S2 murmur and appears to have a calcified aortic valve on imaging.  What must be ruled out following this finding?
Definition
Aortic stenosis
Term

A teenager presents with severe hypertension, but normal blood pressures in their lower limbs.  On x-ray, what is one very probable finding?

 

What is this most likely to be?

 

Definition

Rib knotching

 

coarctation of the aorta

Term
What does a "calcium stripe sign" with a double aortic lumen indicate on x-ray?
Definition
Aortic dissection
Term
What is the mechanism of action of an angioseal (balloon)?
Definition
Opens an occluded/stenosed vessel with a controlled dissection
Term
What are the absolute contraindications for cardiac catheterization?
Definition

 

 

LESION LESS THEN 50% blockage, NEGATIVE flow across the lesion.

 

NO SURGICAL BACKUP (not really a problem anymore today)

 

SEVERE SYSTEMIC DISEASE WITH A LIMITED LIFESPAN

 

Term
What are the indications for cardiac cath. in asymptomatic patients?
Definition

POSITIVE STRESS TEST

SUDDEN CARDIAC DEATH

INDIVIDUALS IN HIGH RISK PROFFESIONS

PRIOR TO SURGERY WITH BORDERLINE POSITIVE NONINVASIVE STRESS TESTS AND RISK FACTORS 

Term
Which population has the highest risk for heart disease, and should be stress tested?
Definition
Diabetics
Term
What are the indications for using pharmacologic stress testing?
Definition

Patients unable to exercise

Preoperative risk stratification

Early postinfarct risk stratification

Left bundle branch block-EKG is abnormal anyway! Don't want to stress test.

Fixed-rate pacemakers

Term
An asthmatic patient is severely obese and cannot walk.  He is also a type 2 diabetic.  What kind of stress test should be used?
Definition
Dobutamine stress test
Term

When would a dobutamine stress test be preferred over a persantine/adenosine stress test?

 

What is a major drawback to this type of stress test?

Definition

In a patient with asthema

 

Takes a very long time!

Term
A 26 year old pregnant female needs to undergo a stress test.  What would be her best option?
Definition
A treadmill stress/echo
Term

What can be deduced from a thallium-201 nuclear scan that cannot be gained from a technetium-99 scan?

 

What is the advantage of a technetium scan?

Definition

Myocardial viability (parts of the heart can be inactive due to "cardiac shock", and can only be picked up with this type of scan)

 

Allows for more accurate imaging, allowing better pictures to be taken and even ejection fraction to be calculated.

Term
What are the NYHA classes of heart failure, and which are most treatable?
Definition

 

Class I:No symptoms with ordinary activity

 

Class II:Slight limitation of physical activity.

Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina

 

Class III:Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain

 

Class IV:Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest

 

Classes II and III are most treatable (usually don't see class I in the doctor's office)

 

Term
What are the stages of heart failure according to the ACC and AHA?
Definition

Stage A:  Patient at high risk for developing HF with no structural disorder of the heart

Stage B:  Patient with structural disorder without symptoms of HF

Stage C:  Patient with past or current symptoms of HF associated with underlying structural heart disease

Stage D:  Patient with end-stage disease who requires specialized treatment strategies

Term
What are the compensation mechanisms of heart failure?
Definition

Frank-Starling Mechanism

 

 Neurohormonal Activation (Sympathetic nervous system (SNS), Renin-angiotensin-aldosterone system (RAAS), and Vasopressin (a.k.a. antidiuretic hormone, ADH)).

 

 Ventricular Remodeling

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