Shared Flashcard Set

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part 10 - cardiovascoular
yanivfenig
519
Medical
Graduate
09/27/2012

Additional Medical Flashcards

 


 

Cards

Term
what are the current global trends of cardiovascular disease morbidity and mortality
Definition
decreasing in the high income countries and increasing significantly in the low-medium ones
Term
in the New York Heart Association Functional Classification, what is the difference btwn NYHA class 3 and 4?
Definition
symptoms at rest
Term
what are the 2 parameters in the New York Heart Association Functional Classification
Definition
limitations and symptoms
Term
4 situations where a heart murmur would call for echo follow up
Definition
1. all diastolic or continuous murmurs
of the systolic murmur:
2. grade 3 and up especially holo or late systolic
3. abnormal ECG or CXR
4. abnormal physical findings indicating cardiac disease
Term
what % of patients with SA node dysfunction develop supraventricular tachycardia (usually atrial fib and flutter)
Definition
33%-50%
Term
6 condition which predispose to persistent atrial fibrillation in SA node
Definition
advanced age, hypertension, diabetes mellitus, left ventricular dilation, valvular heart disease, and ventricular pacing
Term
when should patients with tachycardia-bradycardia variant of SSS (SA node dysfunction) be anticoagulated
Definition
age>65, history of stroke, valvular heart disease, left ventricular dysfunction, or atrial enlargement
Term
what are the mortality rates with SA node dysfunction
Definition
not increased in comparison to the general population
Term
SA node dysfunction occurs MC with which type of MI?
Definition
inferior MI (RCA)
Term
what disorders of potassium and magnesium may cause AV block?
Definition
hyperkalemia and hypermagnesemia
Term
6 drugs that can cause AV block
Definition
Beta blockers
Adenosine
Calcium channel blockers Antiarrhythmics (class I and III)
Digitalis
Lithium
Term
6 drugs that cause both AV block and SA node dysfunction
Definition
Pentamidine (Abx pcp/trypanosoma) Narcotics Phenothiazines (antihistamines and neuroleptics) Amitiriptyline Cimetidine clonidine
Term
how do you perform temporary pacing for less than a few minutes? and for several days?
Definition
transcutaneous pacing
transvenous temporary pacing - jugular or subclavian
Term
what is the indication of temporary pacing in patients with AV block
Definition
elimination of drugs as possible cause and institution of other drugs to solve problem - take some time to go into effect - meantime use temporary pacing
Term
according to the American heart association what are class 1 indications?
Definition
consensus of opinions that therapy is useful and effective
Term
according to the American heart association what are class 2a indications?
Definition
conflict - favoring treatment
Term
according to the American heart association what are class 2b indications?
Definition
conflict - undecided
Term
according to the American heart association what are class 3 indications?
Definition
conflict - discouraging treatment
Term
2 class I indications for pacemaking in SA node dysfunction
Definition
symptoms - tempral correlation btwn symptoms and dysfunction
sinus pause > 5 sec
Term
2 class IIa indications for pacemaking in SA node dysfunction
Definition
1. patient experiences syncope and later is found to have SA node dysfunction during which he has no symptoms
2. with heart rates <40 beats/min without a clear and consistent relationship between bradycardia and symptoms
Term
Class IIb indication for pacing in SA node dysfunction
Definition
Mildly symptomatic patients with waking chronic heart rates <40 beats/min
Term
what is the preferred method of pacing in SA node dysfunction
Definition
dual chamber (except in carotid sinus hypersensitivity) and AV synchronous pacing d/t reduced rates of atrial fib and increased quality of life. no affect on mortality
Term
what is the preferred method of pacing in carotid sinus hypersensitivity associated SA node dysfunction
Definition
single chamber
Term
5 CLASS I indications for permanent pacemaker placement in type 2 2nd and 3rd degree AV block
Definition
1. in ECG - Periods of asystole >3 s or any escape rate <40 beats/min while awake or wide QRS
2. Postoperative AV block not expected to resolve
3. Catheter ablation of the AV junction
4. neuromuscular disease
5. Atrial fibrillation with bradycardia and pauses >5s
Term
2 CLASS I indications for permanent pacemaker placement in any 2nd and 3rd degree AV block
Definition
symptomatic bradycardia
exercised induced
Term
4 CLASS IIa indications for permanent pacemaker placement?
Definition
First- or second-degree AV block with symptoms similar to pacemaker syndrome
Term
2 CLASS IIb indications for permanent pacemaker placement?
Definition
1. Marked first-degree AV block (PR interval >300 ms) in patients with LV dysfunction in whom shortening the AV delay would improve hemodynamics
2. Neuromuscular diseases with any degree of AV block
Term
3. contraindications (Class 3 indications) to pacemaker placement d/t AV block
Definition
1. Asymptomatic first-degree AV block
2. Asymptomatic type I second-degree AV block at the AV node level
3. AV block that is expected to resolve or is unlikely to recur (Lyme disease, drug toxicity)
Term
when should you not/contraindications/Class III indications for permanent pacemaker placement in SA node dysfunction
Definition
1. asymptomatic patients, even those with heart rates <40 beats/min
2. SA node dysfunction in which symptoms are not associated with bradycardia
3. SA node dysfunction with symptomatic bradycardia due to nonessential drug therapy
Term
4 Class I indications for Pacemaker Implantation in AV Conduction Block after the acute phase of Myocardial Infarction
Definition
1. 2nd and 3rd degree permanent AV block and symptomatic
2. type 2 second degree permanent AV block within the his-purkinje with alternating Bundle Branch Block
3. type 3 permanent AV block within or below the his-purkinje
4. type 2 second and third degree temporary infarnodal AV block with bundle branch block
Term
Class IIb indication for Pacemaker Implantation in AV Conduction Block after the acute phase of Myocardial Infarction
Definition
1. Persistent second- or third-degree AV block at the AV node level
Term
3 Class I indications for permanent pacemaker implantation in bifascicular and trifascicular block
Definition
1. Intermittent third-degree AV block
2. Type II second-degree AV block
3. Alternating bundle branch block
Term
3 Class IIa indications for permanent pacemaker implantation in bifascicular and trifascicular block
Definition
1. Syncope not demonstrated to be due to AV block when other likely causes (e.g., ventricular tachycardia) have been excluded
2. Incidental finding at electrophysiologic study of a markedly prolonged HV interval (>100 ms) in asymptomatic patients
3. Incidental finding at electrophysiologic study of pacing-induced infra-His block that is not physiologic
Term
Class IIb indication for permanent pacemaker implantation in bifascicular and trifascicular block
Definition
Neuromuscular diseases with any degree of fascicular block regardless of the presence of symptoms, because there may be unpredictable progression of AV conduction disease
Term
what is the MC arrhythmia?
Definition
atrial premature complex
Term
what is the indication for immediately terminating the AF? preffered method? success rates?
Definition
patient who is hemodynamically unstable. electrical cardioversion. >90% success rates
Term
in a patient presenting with AF and who is hemodynamically stable, 2 issues that need to be addressed
Definition
1. acute rate control
2. anticoagulation
Term
2 parameters in the decision to provide anticoagulation in a patient presenting with AF and needing acute rate control
Definition
1. time - has the AF persisted for more than 12 hrs
2. are there risk factors for stroke (8)
Term
8 risk factors for stroke in determining need for anticoagulation in AF
Definition
History of stroke or transient ischemic attack

Mitral stenosis

Hypertension

Diabetes mellitus

Age >65 years

Congestive heart failure

Left ventricular dysfunction

Marked left atrial enlargement (>5.0 cm)
Term
3 things that must be given attention initially in a patient presenting with atrial fibrillation
Definition
Reversible causes of atrial fibrillation must be ruled out
• The true time of onset of the atrial fibrillation and the frequency of the episodes should be ascertained, if possible
• A careful estimation of the patient’s symptom burden should be made.
Term
4 possible reversible causes of atrial fibrillation
Definition
1. alcohol
2. hyperthyroidism
3. valvular dysfunction
4. obstructive sleep apnea
Term
in the acute setting of performing rate control to a patient with atrial fibrillation, what are the considerations for either a CCB or a beta-blocker/
Definition
CCBs are relatively contraindicated in patients with heart failure, while beta-blockers can exacerbatere active airway disease
Term
when can cardioversion be preformed without prior anticoagulation in newly diagnosed atrial fibrillation
Definition
within 48 hours of the onset of atrial fibrillation, if the time of onset is clear
Term
If the time of onset of AF is unclear or if more than 48 hours have passed, there are two general strategies for proceeding to electrical cardioversion
Definition
1. TEE + start anticoagulation at the same time. if no thrombus in left atrium - proceed to electrical cardioversion
2. start anticoagulation and maintain INR of 2-3 for 3 wks, after which cardioversion can be performed
Term
no matter the strategy chosen to perform cardioversion in the patient presenting acutely with atrial fibrillation, what should be the management afterwards
Definition
1 months of anticoagulation
Term
considerations for choosing rhythm or rate control in the newly diagnosed patient with AF
Definition
rate control - patients whose history
suggests a single episode, or episodes that previously self-terminated
rhythm control - frequent episodes or history suggesting ongoing AF for a long period
Term
2 first line drugs in the rhythm control of a patient with newly diagnosed AF. 2 contraindications for their use
Definition
Propafenone (Rythmol) and flecainide
(Tambocor)
CIs: CAD and significant structural heart disease
Term
2 drug options in the rhythm control of a patient with newly diagnosed AF and CHD. CI and precautions
Definition
Sotalol (Betapace) and dofetilide (Tikosyn). sotalol is CIed in patients with CHF, and dofetilide carries a long list of drug interactions. Both must be used with extreme caution in patients with renal insufficiency, and hospital admission is required for initiation or upward titration of the dose
Term
which patients should avoid amiodarone for rhythm control of a patient with newly diagnosed AF?
Definition
younger patients because toxicity of amiodarone increases with the cumulative dose
Term
what is the pill-in-the-pocket strategy of performing rhythm control to newly diagnosed AF patients
Definition
patients are instructed to take their medication only when they have a bout of AF
Term
on which circumstances is it reasonable to recommend the pill in the pocket strategy of rhythm control of newly diagnosed AF?
Definition
patients with infrequent symptomatic recurrences of paroxysmal AF
Term
2 agents used for the pill in the pocket approach to rhythm control. considerations?
Definition
Flecainide and propafenone are the agents of choice for this approach because of their safety profile and efficacy in chemical cardioversion
Term
which patients may start the pill in the pocket approach to rhythm control in the outpatient clinic and which should be admitted for observation during initiation of therapy? and why
Definition
outpatient - lone paroxysmal episode
admission - structural heart disease or conduction abnormalities.
to observe for excessive PR prolongation or arrhythmias
Term
what about anticoagulation in the setting of the pill in the pocket approach to rhythm control?
Definition
no need. patients supposed to return to sinus rhythm in a few hrs and are expected to report to the ER if they don't to perform cardioversion within 48 hours
Term
what is a new option for rhythm control? how does it work? CIs
Definition
Dronedarone (Multaq). works like amiodarone only w/o the side effects because it lacks iodine
CIed in patients with severe or newly decompensated CHF. may cause hepatic toxicity
Term
considerations for choosing rate (1) or rhythm control (2) in the long term
Definition
rate control - asymptomatic patient
rhythm control - rate control cannot be achieved or symptomatic despite adequate control of the heart rate
Term
what % of patients go back to fibrillation after successful rhythm control management
Definition
over 50%
Term
under which circumstances are patients with AF recommended for chronic long term anticoagulation
Definition
persistent or frequent and long-lived paroxysmal AF and risk factors determined by the CHADS score
Term
how is the scoring determined in CHADS score for the risk of stroke in AF
Definition
1 point each for CHF, HTN, age 75
or older, and DM; 2 points for prior stroke or TIA
Term
what is the recommendation for patients with AF and a CHADS score of 0
Definition
daily low dose aspirin
Term
what is the recommendation for patients with AF and a CHADS score of 1
Definition
physician's judgement of whether to treat with aspirin or coumadin
Term
what is the recommendation for patients with AF and a CHADS score of 2
Definition
coumadin INR 2-3
Term
what is a reasonable strategy in select patients with a CHADS2 score of 2 or greater in whom warfarin cannot be used for reasons such as personal aversion to the medication, side effects, or nonbleeding complications or in patients whose INR is exceedingly difficult to keep within the therapeutic range
Definition
aspirin + plavix
Term
what is a drug more efficient at perventing stroke as an anticoagulant in comparison to coumadin. how is it inferior to coumadin
Definition
Dabigatran (PRADAXA)
more GI bleedings
Term
the standard dosage of dabigatran (pradaxa) is limited by what?
Definition
creatinine clearance > 30
Term
what is the incidence of AF after open heart surgery? what are the initial mgmt steps
Definition
25-50%, attempts at cardioversion
Term
what is a concern in the patient that had just undergone open heart surgery and develops new onset AF?
Definition
he cannot be anticoagulated so rate, rhythm and close monitoring of bouts of AF should be instituted
Term
what is a good choice of antiarhythmic drug in the acutely post open heart surgery patient who had developed new onset AF
Definition
amiodarone - very effective. should be stopped after a few months
Term
what is the problem with onset of AF in the setting of an acute severe illness such as sepsis and shock? what can be done?
Definition
patients are often treated for shock with vasopressors. you cannot add beta blocker or CCB for rate control because of their vasodilitatory effect. amiodarone or digoxine are options, cardioversion less so
Term
what is a potential adverse effect of antiarhythmics for the treatment of atrial flutter
Definition
they slow down the atrial beat rate to a level that might be low enough for the AV node to transfer to the ventricules in a 1:1 ratio causing ventricular tachycardia
Term
what is the treatment in high anaesthetic risk patients with atrial flutter? 3 drugs
Definition
pharmacologic cardioversion
procainamide, amiodarone, or ibutilide
Term
what are the recurrence rates with successful pharmacologic cardioversion in atrial flutter
Definition
80% in one year
Term
in what type of conditions does multifocal atrial tachycardia usually occur
Definition
pulmonary diseases
Term
definition of multifocal atrial tachycardia? ventricular rate?
Definition
3 distinct P-wave morphologies and often at least 3 different PR intervals, and the associated atrial and ventricular rates are typically between 100 and 150 beats per minute
Term
what distinguishes multifocal atrial tachycardia from atrial fibrillation
Definition
The presence of an isoelectric baseline
Term
what distinguishes multifocal atrial tachycardia from sinus tachycardia with APCs?
Definition
The absence of any intervening sinus rhythm
Term
2 ways to distinguish focal sinus tachycardia from focal reentrent atrial tachycardia
Definition
1. adenosine - persistence of the AT in the presence of AV block
2. in focal reentrent the first p wave changes shape
Term
what is the treatment of focal atrial tachycardia?
Definition
pharmacologically same as AF and AFL, except less indications for anticoagulation: severe atrial dilatation, >5 cm left atrial diameter with a high risk of AF, and/or a history of coincident paroxysmal AF
Term
in the ECG of AVNRT what can be said of the APC that elicits the tachycardia
Definition
it has a prolonged PR expressing the conductance in the slow pathway
Term
4 treatment options for AVNRT
Definition
the logic is to slow the AV node
1. vagal stimulation: valsalva or carotid massage
2. adenosine
3. bb or CCB
4. cardioversion
Term
4 of the MC anatomical sites for accessory pathways in descending order
Definition
left atrium to the left ventricle, followed by posterior septal, right free wall, and anterior septal APs
Term
what is the delta wave at the beginning of the QRS in AVRT?
Definition
muscle to muscle conduction that starts the QRS is slow and so the more gradual rise of the QRS
Term
what is a dangerous complication of WPW (accessory pathway)
Definition
development of AF, which will have rapid conduction to the ventricules
Term
what is a dangerous complication of WPW (accessory pathway)
Definition
development of AF, which will have rapid conduction to the ventricules
Term
what is bigeminy
Definition
every sinus beat is followed by a VPC
Term
what is trigeminty
Definition
every 2 sinus beats are followed by a VPC
Term
what is the meaning of the term "fully compensatory pause" in regards to VPCs?
Definition
the duration between the last QRS before the PVC and the next QRS complex is equal to twice the sinus rate
Term
what is a noncompensatory pause in regards to VPCs
Definition
very early VPC is able to enter the atria and resent the SA node so the next sinus beat comes earlier and the length btwn the beat before and after the VPC is shorter than 2 standard sinus beats
Term
what is a reversible complication of VPCs
Definition
cardiomyopathy
Term
what is the treatment of VPCs in the setting of cardiac structural abnormalities?
Definition
antiarythmic drugs have not proven to reduce mortality from SCD
Term
how to distinguish btwn accelerated idioventricular tachycardia and slow VT? and why is it important
Definition
gradual onset and offset and more variability in cycle length
AIVR is benign
Term
5 conditions that may lead to AIVT?
Definition
MI, cocaine intoxication, myocarditis, digoxin intoxication, and postoperative cardiac surgery
Term
which conditions typically cause VT and not AIVT?
Definition
chronic infarction or cardiomyopathy
Term
what is the duration of a non-sustained VT
Definition
over 30 secs
Term
2 conditions that cause wide complex tachycardia
Definition
VT or SVT with aberrant ventricular conduction due to right or left bundle branch block
Term
5 ways to distinguish VT from SVT with BBB on ECG?
Definition
1. presence of a pre-excited QRS pattern indicates atrial arrhythmia
2. (1) the presence of a QRS duration >140 ms in the absence of drug therapy, (2) a superior and rightward QRS frontal plane axis, (3) a bizarre QRS complex that does not mimic the characteristic QRS pattern associated with left or right bundle branch block, and (4) slurring of the initial portion of the QRS
Term
The IV administration of verapamil and/or adenosine is not recommended as a diagnostic test
Definition
Term
why is defibrillation given in an asynchronous method
Definition
if it would try to synchronize to the QRS it might never give out an electrical shock
Term
what are the initial doses of defibrillation given in a state of non-sustained polymorphic VT, Ventricular flutter and VF
Definition
100 biphasic or 200 monophasic
Term
which 2 medications should be given IV concurrently to attempts of defibrillation (w/o interrupting the Defibrillation)
Definition
lidocaine and amiodarone
Term
what is the treatment of any monomorphic wide complex rhythm that results in hemodynamic compromise
Definition
synchronous electrical shock
Term
what is the preventive treatment of VT in patients with structural heart disease
Definition
ICD
Term
what 2 options in addition to ICD in patients with a structural heart disease and a prior event of VT/VF
Definition
1. sotalol or amiodarone (as long as they don't have long QT syndrome)
2. Catheter ablative therapy
Term
what is the definition of VT storm?
Definition
more than 2 events requiring ICD or defibrillation in 24 hrs
Term
a VT storm with inability to return for prolonged periods of time to sinus rhythm, is usually caused by which 2 conditions
Definition
acute MI or fulminant myocarditis
Term
2 indications for ICD implantation in patients with non-ischemic cardiomyopathy
Definition
LV ejection fraction < 35% or a history of unexplained syncope with significant LV dysfunction
Term
what is The signature VT associated with digoxin toxicity
Definition
bidirectional VT
Term
what is the trigger for VT in the setting of long QT syndrome
Definition
early afterdepolarizations potentiated by intracellular calcium accumulation from a prolonged action potential plateau
Term
what is the MC genetic abnormality in long QT syndrome? what is the trigger? when is the first cardiac event?
Definition
LQT1, exercise or emotional stress, 80% experience a cardiac event by the time they are 20
Term
what is Jervell and Lange-Nielsen syndrome?
Definition
two allele LQT1 syndrome - more arrhythmias, deafness
Term
what is the definition of short QT syndrome
Definition
QT interval <320 ms
Term
what are the complications of short QT syndrome? 2 treatments
Definition
AF and VF. ICD and Quinidine to lengthen the QT interval
Term
what is the diagnostic test used to elicit the typical ECG pattern of Brugada syndrome
Definition
Flecainide
Term
what is the drug treatment of brugada
Definition
isoproterenol or quinidine
Term
what are the indications for ICD in patients with Brugada
Definition
prior syncope or arrhythmia or positive ECG provocation test
Term
what is the pathophysiology of Catecholaminergic Polymorphic VT? what is the ECG pattern
Definition
ryonidine mutation causes leak of calcium from the SR to the cell. bidirectional complexes
Term
3 conditions associated with life threatening arrhythmias in the young athlete
Definition
hypertrophic cardiomyopathy, arrhythmogenic cardimyopathy, and acute myocarditis
Term
what is the workup of a young athlete presenting with syncope
Definition
ECG and TTE
Term
what do you look for in the ECG of a young athlete presenting with syncope
Definition
preexcitation, QT prolongation, a Brugada-type ECG pattern or epsilon waves, and T-wave inversions consistent with a nonischemic RV or LV cardiomyopathy or myocarditis
Term
2 ECG findings in Arrhythmogenic Rv Cardiomyopathy/Dysplasia (Arvcm/D)
Definition
t wave inversions, and epsilon wave(a terminal notch in the QRS complex) in leads V1-3
Term
4 arrhythmogenic conditions that allow the young athlete to participate in all competitive sports?
Definition
Gene carriers for arrhythmia syndromes without phenotype VT

Asymptomatic Wolff-Parkinson-White syndrome

Premature ventricular complexes when no increase in PVCs or symptoms occur with exercise

Nonsustained ventricular tachycardia with no structural heart disease
Term
3 arrhythmogenic conditions should restrict young athlete to low intensity competitive sports only
Definition
brugada, long QT syndrome and non-sustained polyphasic VT with associated structural abnormalities
Term
which arrhythmogenic condition should entail a restriction to preform any sports?
Definition
Catecholaminergic polymorphic VT
Term
what is the overall annual mortality rates in patients with HF? with HF and NYHA I? NYHA IV?
Definition
30%, 5%, 30-70%
Term
what is a typical (40%) respiratory phenomenon in advanced HF?
Definition
Cheyne-stokes, periods of apnea raise PCO2, which elicit bouts of hyperventilation
Term
which biomarker may help distinguish btwn cardiac and pulmonary causes of dyspnea
Definition
BNP
Term
5 groups of drugs that may percipitate acute decompensation in chronic HF
Definition
Calcium antagonists (verapamil, diltiazem)
Beta blockers
Nonsteroidal anti-inflammatory drugs
Antiarrhythmic agents [all class I agents, sotalol (class III)]
Anti-TNF antibodies
Term
what intervention is recommended in patients with NYHA I-III, but notin patients with NYHA IV HF?
Definition
modest exercise
Term
what are the salt restrictions in CHF
Definition
mild - 2-3 grams, moderate-severe <2 gram
Term
what are the restrictions on drinking?
Definition
if patient is hyponatremic at Na<130, restriction should be <2 L of water daily
Term
in the treatment of new onset HF, when do you start ACEi?
Definition
after you have optimized the dose of diuretics, because they attenuate the effect of ACEi
Term
how do you start ACEi in HF
Definition
initiated in low doses, followed by gradual increments if the lower doses have been well tolerated
Term
2 indications for beta blockers in HF
Definition
symptomatic or asymptomatic HF and a depressed EF <40%
Term
how do you administer beta blockers for the treatment of HF?
Definition
gradually, dose increase is done in no less than 2 week intervals, otherwise fluid retention would ensue
Term
when do you expect to find fluid retention as a result of initiating beta blockers in a patient with HF? what is the 1st mgmt of this?
Definition
3-5 days after initiation, add diuretics
Term
what is the indication to start Aldactone therapy in patients with HF?
Definition
NYHA class IV or class III (previously class IV) HF who have a depressed EF (<35%) and are receiving standard therapy, including diuretics, ACE inhibitors, and beta blockers
Term
2 conditions where aldosterone is not recommended as treatment for HF
Definition
creatinine is >2.5 mg/dL (or creatinine clearance is <30 mL/min) or when the serum potassium is >5 mmol
Term
what 2 drugs are recommended as part of standard HF therapy in addition to beta blockers and ACE inhibitors for African Americans with NYHA class II–IV HF
Definition
hydralazine and nitrates
Term
which 5 Agents may be considered as part of additional therapy of symptomatic HF unresponsive to ACEi+BB
Definition
ARB, spironolactone, the combination of hydralazine and isosorbide dinitrate, and digitalis
Term
what is an indication for digitalis in HF
Definition
symptomatic LV systolic dysfunction who have concomitant atrial fibrillation
Term
what is the place of aspirin in HF?
Definition
although it may exacerbate HF, in patients with concomitant IHD low dose aspirin is indicated
Term
apart from the obvious indications for anticoagulation (venous, stroke, a-fib prevention), what is another situation where it is indicated to administer warfarin in HF?
Definition
patients with ischemic cardiomyopathy and recent anterior MI or documented LV thrombus for 3 months
Term
what % of patients with HF experience atrial fibrillation
Definition
15-30%
Term
which are the only 2 anti arrhytmic drugs that do not have negative inotropic effects
Definition
amiodarone and dofetilide
Term
what is the preferred drug for restoring and maintaining sinus rhythm in patients with HF and concomitant A fib
Definition
amiodarone
Term
when administering amiodarone to a patient with heart failure what are 2 possible drug interactions
Definition
warfarin and digoxin - reduce dose of both
Term
2 indications for cardiac resynchronization therapy (aka Biventricular pacing) in patients with HF
Definition
patients in sinus rhythm with an EF <35% and a QRS >120 ms and those who remain symptomatic (NYHA III–IV) despite optimal medical therapy
Term
indications for prophylactic ICD in patients with HF
Definition
patients in NYHA class II–III HF with a depressed EF of <35% who are already on optimal background therapy, including an ACE inhibitor (or ARB), a beta blocker, and an aldosterone antagonist
Term
1st step is classifying the patient with acute decompensation of HF to one of 4 classes
Definition
normal LV filling pressure with normal perfusion (Profile A), elevated LV filling pressure with normal perfusion (Profile B), elevated LV filling pressures with decreased perfusion (Profile C), and normal or low LV filling pressure with decreased tissue perfusion (Profile L)
Term
how do you treat a patient presenting with acute HF decompensation, being profile C, "cold and wet"
Definition
Intravenous inotropic agents with vasodilating action [dobutamine, low-dose dopamine, milrinone]
Term
what is the treatment of a patient presenting with acute decompensation of HF, being of profile L, "cold and dry"
Definition
right-heart catheterization for the presence of an occult elevation of LV filling pressures. If LV filling pressures are low [pulmonary capillary wedge pressure (PCWP) <12 mmHg], a cautious trial of fluid repletion may be considered
Term
what is the effect of vasodilators used in HF? nitroglycerin, nitroprusside, and nesiritide
Definition
dilating effects on arterial resistance and venous capacitance vessels, which results in a lowering of LV filling pressure, a reduction in mitral regurgitation, and improved forward cardiac output without increasing heart rate or causing arrhythmias
Term
The most common side effect of IV or oral nitrates
Definition
headache
Term
what is Nesiritide? (for the treatment of HF)
Definition
recombinant form of brain-type natriuretic peptide which lowers LV filling pressures
Term
what is the effect of inotropic agents? milrinone and dobutamine
Definition
stimulating cardiac contractility as well as producing peripheral vasodilation
Term
what are the indications to use inotropic agents
Definition
settings in which vasodilators and diuretics are not helpful, such as in patients with poor systemic perfusion and/or cardiogenic shock, patients requiring short-term hemodynamic support after an MI or surgery, and patients awaiting cardiac transplantation, or as palliative care in patients with advanced HF
Term
the effects of dopamine are dose related. explain
Definition
Low doses of dopamine (2
Term
Vasopressin Antagonists - Tolvaptan (oral) and conivaptan (IV) are not approved for the treatment of HF
Definition
Term
which 2 groups of patients get the top priority for heart transplantation
Definition
requiring hospitalization at the transplant center for IV inotropic support with a pulmonary artery catheter in place for hemodynamic monitoring or to patients requiring mechanical circulatory support [i.e., intra-aortic balloon pump (IABP), right or left ventricular assist device (RVAD, LVAD), extracorporeal membrane oxygenation (ECMO), or mechanical ventilation]
Term
which patients get second highest priority for heart transplantation
Definition
patients requiring ongoing inotropic support, but without a pulmonary artery catheter in place
Term
after the 1st and 2nd top criteria for heart transplantation, how is the rest of the list prioritized
Definition
according to time on the list, taking into account ABO blood type and body-size compatibility
Term
what are the general indications for heart transplantation in HF
Definition
younger and without significant comorbidities
Term
what are the survival rates of patients undergoing heart transplantation for HF
Definition
83% and 76% survival 1 and 3 years posttransplant
Term
what is the immunosuppression three-drug regimen used by most centers after heart transplantation?
Definition
calcineurin inhibitor (cyclosporine or tacrolimus), an inhibitor of T cell proliferation or differentiation (azathioprine, mycophenolate mofetil, or sirolimus), and at least a short initial course of glucocorticoids
Term
the strategy of immunosuppression for heart transplantation consists of an initial induction with antibodies against T cells and continues with the three drug regimen
Definition
Term
how and on what grounds is the Diagnosis of cardiac allograft rejection made after heart transplantation
Definition
endomyocardial biopsy, either done on a surveillance basis or in response to clinical deterioration
Term
3 immunosuppressive drugs used post heart transplantation that are associated with less coronary heart disease, at least in the short term
Definition
mycophenolate mofetil and the mammalian target of rapamycin (mTOR) inhibitors sirolimus and everolimus
Term
statins are also used post heart transplant b/c they also reduce the risk of CHD
Definition
Term
what is the major cause of death in the 1st post heart transplantation year
Definition
infections
Term
2 major indications for long-term ventricular assistance
Definition
1. are at risk of imminent death from cardiogenic shock.
2. LVEF < 25%, peak VO2 < 14 mL/kg/min or are dependent on inotropic therapy or support with intra-aortic balloon counterpulsation
Term
how many patients with a left ventricular assist device actually reach transplantation
Definition
75% of younger patients receiving a transplant by 1 year
Term
what are the survival rates of patients treated with left ventricular assist device which changed indications during the wait for transplant from "bridging" to "destination"?
Definition
survival rates of only 65% at 6 months and 34% at 1 year
Term
what is the difference btwn patent formen ovale and ostium secondum ASD
Definition
the latter presents functional and anatomic patency
Term
what are 2 manifestations of ASD before the 4th decade of life
Definition
physical underdevelopment and an increased tendency for respiratory infections
Term
what type of ASD occurs in down's syndrome
Definition
primius ostium ASD
Term
4 manifestations of ASD starting the 4th decade of life
Definition
atrial arrhythmias, pulmonary arterial hypertension, bidirectional and then right-to-left shunting of blood, and right heart failure
Term
what are the findings on auscultation of ASD
Definition
wide permanent split of S2, and loud P1, pulmonary midsystolic outflow murmur
Term
what is an additional finding on auscultation in patients with primum ostium ASD (down's) and not in the rest of the types of ASDs
Definition
an apical holosystolic murmur indicates associated mitral or tricuspid regurgitation or a ventricular septal defect (VSD)
Term
what other structures are commonly involved in primum ostium ASD
Definition
the mitral valves
Term
3 surgical options for the repair of secondum ostium ASD
Definition
patch of pericardium or of prosthetic material or percutaneous transcatheter device closure
Term
what is the indication for simple secondum ostium ASD repair
Definition
all patients with uncomplicated secundum ASD with significant left-to-right shunting, i.e., pulmonary-to-systemic flow ratios 2:1
Term
surgical repair is not recommended for patients with VSD and...
Definition
pulmonary-to-systemic flow ratios of <1.5 to 2:1
Term
2 surgical treatment options in patients who have developed eisenmenger's syndrome
Definition
single-lung transplantation with intracardiac defect repair and total heart-lung transplantation
Term
what is the pharmacological treatment of bicuspid aortic valve
Definition
digoxin and diuretics, and if aortic valve is dilated - beta blockers
Term
what is the indication of aortic valve replacement in bicuspid aortic valve
Definition
adults with critical obstruction, (aortic valve area <0.45 cm2/m2), with symptoms secondary to LV dysfunction or myocardial ischemia, or with hemodynamic evidence of LV dysfunction
Term
what is the surgical treatment of asymptomatic children or adolescents or young adults with critical aortic stenosis without valvular calcification
Definition
aortic balloon valvuloplasty
Term
in which syndrome do you see supravalvular aortic stenosis
Definition
williams syndrome trisomy 18
Term
where is the most common site of coarctation of the aorta
Definition
distal to the origin of the left subclavian artery
Term
what is a CNS complication of coarctation of the aorta
Definition
Circle of lewis aneurysms - 10% of patients
Term
what is a physical finding on palpation in coarctation of the aorta
Definition
Enlarged and pulsatile collateral vessels may be palpated in the intercostal spaces
Term
2 options for auscultation in coarctation of the aorta
Definition
A midsystolic murmur over the left interscapular space may become continuous if the lumen is narrowed sufficiently to result in a high- velocity jet across the lesion throughout the cardiac cycle
Term
among the obvious findings (dilated subclavian, aorta), what else can be found on CXR in a patient with coarctation of the aorta
Definition
Notching of the third to ninth ribs
Term
level of severity in aortic stenosis according to the peak systolic pressure gradient
Definition
PSPG of 30-50 is considered moderate
Term
pulmonary stenosis causes syncope (like aortic stenosis)
Definition
Term
treatment of pulmonary stenosis
Definition
balloon valvuloplasty
Term
severity of mitral stenosis
Definition
moderate - mitral valve orifice 1 cm2–1.5 cm2
Term
what is the effect of moderate MS on CO? severe MS?
Definition
moderate - the CO is normal or almost so at rest, but rises subnormally during exertion

severe - CO is subnormal at rest and may fail to rise or may even decline during activity
Term
how long does it take to develop symptoms in MS d/t rheumatic heart disease
Definition
20 yrs
Term
incidence of systemic embolization in MS
Definition
20%
Term
how does The time interval between A2 and OS (opening snap) with the severity of MS?
Definition
inversely
Term
2 right side (more pronounced with inspiration) murmurs associated with mitral stenosis (that already shows pulmonary hypertension)
Definition
Carvallo's sign - TR
Graham Steell murmur - PR
Term
4 earliest CXR findings in MS
Definition
straightening of the upper left border of the cardiac silhouette, prominence of the main pulmonary arteries, dilation of the upper lobe pulmonary veins, and posterior displacement of the esophagus by an enlarged LA
Term
when can you see kerley B lines (intralobular septa) on CXR in a patient with MS
Definition
when resting mean LA pressure exceeds approximately 20 mmHg
Term
Like MS, significant MR may also be associated with a prominent diastolic murmur at the apex due to increased antegrade transmitral flow, how do you tell them apart
Definition
in MR it commences later and there is often clear-cut LV enlargement
Term
the apical mid-diastolic murmur associated with severe AR (Austin Flint murmur) may be mistaken for MS, how can you tell them apart
Definition
AR is not intensified in presystole and becomes softer with administration of amyl nitrite
Term
what is the indication for catheterization in mitral stenosis
Definition
patients who have undergone PMBV or previous mitral valve surgery, and who have redeveloped limiting symptoms, especially if questions regarding the severity of the valve lesion(s) remain after echocardiography
Term
what are the indications of anticoagulation for patients with MS
Definition
no exclusive indications - AF or a history of thromboembolism
Term
what is the indication for mitral valvotomy in patients with MS + 2 exceptions
Definition
symptomatic [New York Heart Association (NYHA) Functional Class II–IV] patients with isolated MS, whose effective orifice (valve area) is <1.5 cm2

in the patient who is entirely asymptomatic and/or who has mild stenosis (mitral valve area >1.5 cm2) there are 2 indications for mitral valvotomy - recurrent systemic embolization or severe pulmonary hypertension (PA systolic pressures >50 mmHg at rest or >60 mmHg with exercise)
Term
4 considerations in opting for PMBV instead of surgical valvotomy
Definition
1. relatively pliable leaflets
2. little or no commissural calcium
3. subvalvular structures should not be significantly scarred or thickened
4. no left atrial thrombus
Term
on deciding on the right approach, PMBV or open surgery, in mitral valvotomy, which test is preformed beforehand
Definition
1. TTE to decide on the approach
Term
which test should be done prior to, and on the same day, of performing PMBV for mitral stenosis
Definition
1. TEE to make sure there is no thrombus in the left atrium
Term
2 elements that determine successful mitral valvotomy
Definition
50% reduction in the mean mitral valve gradient and a doubling of the mitral valve area
Term
3 indications for Mitral valve replacement (MVR) in patients with MS
Definition
significant associated MR, those in whom the valve has been severely distorted by previous transcatheter or operative manipulation, or those in whom the surgeon does not find it possible to improve valve function significantly with valvotomy
Term
what defines severe mitral regurgitation
Definition
regurgitant volume 60 mL/beat, regurgitant fraction (RF) 50%, and effective regurgitant orifice area 0.40 cm2
Term
what is the basic classification of the indications for mitral valve repair/replacement in the case of MR?
Definition
is the etiology ischemic or not
Term
5 indications for mitral valve repair in non ischemic severe mitral regurgitation
Definition
1. symptomatic

asymptomatic:
2. LV dysfunction: LVEF<60 and/or LVESD> 4.0 cm
3. pulmonary hypertension
4. new onset atrial fibrillation
5. non of the previous ones but highly experienced center with more than 90% success rates
Term
what complication is seen in 4% of patients with severe mitral regurgitation with an ROA>0.4 cm?
Definition
SCD
Term
what is the surgical treatment (does not show survival benefit) of ischemic MR
Definition
mitral valve repair with undersized anuloplasty and concurrent coronary bypass surgery
Term
3 syndromes that may cause mitral valve prolapse
Definition
Marfan's syndrome, osteogenesis imperfecta, and Ehlers-Danlos syndrome
Term
what cardiac anomaly is associated in 20% of patients with ostium secundum atrial septal defect
Definition
mitral valve prolapse
Term
what is the MCC of isolated severe MR requiring surgery?
Definition
mitral valve prolapse
Term
what is the MC clinical manifestation of mitral valve prolapse
Definition
asymptomatic
Term
what is The prevalence of bicuspid aortic valve disease among first-degree relatives of an affected individual
Definition
10%
Term
what complication is often associated with bicuspid aortic valve?
Definition
aortic aneurysm
Term
important sign of aortic stenosis on physical examination
Definition
The peripheral arterial pulse rises slowly to a delayed peak (pulsus parvus et tardus). A thrill or anacrotic "shudder" may be palpable over the carotid arteries, more commonly the left
Term
severity of aortic stenosis
Definition
moderate AS is defined by a valve area of 1–1.5 cm2
Term
3 indications for aortic valve replacement
Definition
patients with severe AS (valve area <1 cm2 or 0.6 cm2/m2 body surface area) who are symptomatic, those who exhibit LV dysfunction (EF <50%), as well as those with BAV disease and an aneurysmal or expanding aortic root (maximal dimension >4.5 cm or annual increase in size >0.5 cm/year)
Term
4 relative indications for aortic valve replacement in aortic stenosis
Definition
abnormal response to treadmill exercise;
rapid progression of AS, especially when urgent access to medical care might be compromised;
very severe AS defined by a valve area <0.6 cm2;
severe LV hypertrophy suggested by a wall thickness of >15 mm
Term
what is the right timing to perform aortic valve replacement in aortic stenosis/
Definition
within 3-4 months of symptoms onset
Term
what is the 10 yr survival of patients who undero aortic valve replacement for aortic stenosis
Definition
60%
Term
what % of patients with a bioprosthetic valve for aortic stenosis develop primary valve failure after 10 yrs
Definition
30%
Term
3 definitions of severe aortic stenosis
Definition
AVA<1cm2, mean systolic gradient>40, Vmax>4m/s
Term
what is the role of Percutaneous Balloon Aortic Valvuloplasty in aortic stenosis?
Definition
congenital, noncalcific AS
Term
what is the indication for Transcatheter aortic valve implantation (TAVI) in aortic stenosis?
Definition
patients who have an indication for aortic valve replacement, but are too high risk to undergo surgery
Term
4 signs in the arterial pulse of patients with AR
Definition
"water-hammer" pulse, which collapses suddenly as arterial pressure falls rapidly during late systole and diastole (Corrigan's pulse), and

capillary pulsations, an alternate flushing and paling of the skin at the root of the nail while pressure is applied to the tip of the nail (Quincke's pulse), are characteristic of chronic severe AR.

A booming "pistol-shot" sound can be heard over the femoral arteries (Traube's sign),

and a to-and-fro murmur (Duroziez's sign) is audible if the femoral artery is lightly compressed with a stethoscope
Term
3 murmurs in AR
Definition
1. classic decrescendo mid diastolic high pitched
2. mid systolic
3. end diastolic austin flint - the AR jet hitting the mitral valve
Term
what is the definition of severe AR
Definition
the central jet width assessed by color flow Doppler imaging exceeds 65% of the left ventricular outflow tract, the regurgitant volume is 60 mL/beat, the regurgitant fraction is 50%, and there is diastolic flow reversal in the proximal descending thoracic aorta
Term
2 treatment that are CIed in acute severe AR
Definition
beta blockers (ok to use in chronic AR) and Intraaortic balloon counterpulsation
Term
what is the timing for surgery in acute severe AR
Definition
within 24 hrs of the diagnosis
Term
what is the consensus on pharmacological treatment in chronic severe AR?
Definition
vasodilators to keep systolic BP < 140
Term
what is the pharmacological treatment to delay the aortic root enlargement in marfan syndrome and aortic root dilation
Definition
ARBs and BBs
Term
what is the correct timing for surgery in chronic severe AR? how do you monitor it?
Definition
after the onset of LV dysfunction but prior to the development of severe symptoms - echo every 6 months
Operation can be deferred as long as the patient both remains asymptomatic and retains normal LV function without severe chamber dilation (end-diastolic dimension >75 mm)
Term
5 indications for performing aortic valve replacement in aortic regurgitation
Definition
1. symptomatic
LV dysfunction:
2. LVEF <50%
3. LV end-systolic dimension >55 mm
4. end-systolic volume >55 mL/m2
5. LV diastolic dimension >75 mm
Term
in which side, right or left, do congestive symptoms develop first in dilated cardiomyopathy? restrictive?
Definition
left
right
Term
in which type of cardiomyopathy is it uncommon to find ventricular arrhythmias
Definition
restrictive
Term
3 bacterial causes of infective myocarditis to cause dilated cardiomyopathy
Definition
Q fever, Lyme disease, C.diphtheria
Term
2 viral causes of infective myocarditis to cause dilated cardiomyopathy
Definition
Coxsackie, adenovirus, HIV, hepatitis C
Term
which 3 chemotherapeutic agents cause dilated cardiomyopathy
Definition
anthracyclines, trastuzumab, interferon
Term
3 nutritional deficiencies that cause dilated cardiomyopathy
Definition
thiamine, selenium, carnitine
Term
3 electrolyte deficiencies that cause dilated cardiomyopathies
Definition
calcium, phosphate, magnesium
Term
2 metabolic disorders that cause dilated cardiomyopathy
Definition
hemochromatosis, obesity
Term
3 endocrinopathies that cause dilated cardiomyopathy
Definition
Thyroid disease
Pheochromocytoma
Diabetes
Term
what is the definitive diagnosis of myocarditis
Definition
Bx showing infiltrative lymphocytes and myocyte necrosis, but this is seen in 10-20%
Term
when does the function of the LV return to normal in over 50% of patients with viral myocarditis
Definition
6-12 months
Term
what is the treatment of viral myocarditis with a rapid downward progression of hemodynamics
Definition
IV glucocorticoids
Term
what % of HIV infected patients experience myocarditis
Definition
10-40%
Term
which 4 factors can cause myocarditis in HIV
Definition
HIV itself, other viruses, antiviral treatment through toxic and hypersensitivity effects
Term
what is The most commonly diagnosed noninfectious cause of myocarditis granulomatous myocarditis, including both sarcoidosis and giant cell myocarditis
Definition
granulomatous myocarditis, including both sarcoidosis and giant cell myocarditis
Term
what is the presentation of Takotsubu acute cardiomyopathy
Definition
pulmonary edema, hypotension, and chest pain with ECG changes mimicking an acute infarction
Term
what is the prevalence of hypertrophic cardiomyopathy
Definition
1:500 adults
Term
what is the MC presenting symptom in hypertrophic cardiomyopathy
Definition
Dyspnea on exertion
Term
The gradient and the murmur in hypertrophic cardiomyopathy may be enhanced by which 2 maneuvers
Definition
maneuvers that decrease ventricular volume, such as the Valsalva maneuver, or standing after squatting
Term
The gradient and the murmur in hypertrophic cardiomyopathy may be decreased by which 2 maneuvers
Definition
by increasing ventricular volume or vascular resistance, such as with squatting or handgrip
Term
what % of patients with hypertrophic cardiomyopathy experience sudden cardiac death
Definition
1%
Term
4 ECG stages of acute pericarditis
Definition
In stage 1, there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2 to V6, with reciprocal depressions only in aVR and sometimes V1, as well as depression of the PR segment below the TP segment reflecting atrial involvement. Usually there are no significant changes in QRS complexes. In stage 2, after several days, the ST segments return to normal, and only then, or even later, do the T waves become inverted (stage 3). Ultimately, weeks or months after the onset of acute pericarditis, the ECG returns to normal in stage 4
Term
what are the 3 MC causes of tamponade
Definition
neoplastic disease, idiopathic pericarditis, and renal failure
Term
what is Beck's triad in tamponade
Definition
hypotension, soft or absent heart sounds, and jugular venous distention with a prominent x descent but an absent y descent
Term
what ECG finding should raise the suspicion of cardiac tamponade
Definition
electrical alternans of the P, QRS, or T waves - alternation of QRS complex amplitude or axis between beats and a possible wandering base-line
Term
what finding on atrial pressure graph is usually present in constrictive pericarditis but not in tamponade
Definition
Prominent y descent
Term
what finding on Echo is usually present in tamponade but absent in constrictive pericarditis
Definition
Right atrial collapse and RVDC
Term
which sign on PE is absent on tamponade but present on constrictive pericarditis and restrictive cardiomyopathy
Definition
Kussmaul's sign - The cervical veins are distended and may remain so even after intensive diuretic treatment, and venous pressure may fail to decline during inspiration
Term
which sign on PE is absent on both tamponade and restrictive cardiomyopathy but present on constrictive pericarditis
Definition
pericardial knock - an early third heart sound
Term
2 finding in echo that are present in constrictive pericarditis but not in cardiac tamponade
Definition
pericardial thickening and calcification
Term
which sign on PE is usually present in tamponade but in only 33% of constrictive pericarditive
Definition
pulsus paradoxus
Term
what is the explanation for pulsus paradoxus
Definition
both ventricles share a tight incompressible covering, i.e., the pericardial sac, the inspiratory enlargement of the right ventricle in cardiac tamponade compresses and reduces left ventricular volume; leftward bulging of the interventricular septum further reduces the left ventricular cavity as the right ventricle enlarges during inspiration
Term
what is the finding on doppler-echo in tamponade associated with the tricuspid valve in comparison with mitral valve
Definition
Doppler ultrasound shows that tricuspid and pulmonic valve flow velocities increase markedly during inspiration, whereas pulmonic vein, mitral, and aortic flow velocities diminish
Term
what is the MC site for pericardiocentesis in tamponade
Definition
subxiphoid approach
Term
Pericardial effusion is a common cardiac manifestation of HIV; it is usually secondary to
Definition
infection (often mycobacterial) or neoplasm, most frequently lymphoma
Term
what is the explanation for the presence of the prominent y descent in constrictive pericarditis and its absence in tamponade
Definition
In constrictive pericarditis, ventricular filling is unimpeded during early diastole but is reduced abruptly when the elastic limit of the pericardium is reached, whereas in cardiac tamponade, ventricular filling is impeded throughout diastole
Term
what signs and symptoms affect the abdomen in chronic constrictive pericarditis
Definition
weight gain, increased abdominal girth, abdominal discomfort, a protuberant abdomen
Term
what is the most common type of primary cardiac tumor in all age groups
Definition
myxoma
Term
3 findings in Carney syndrome
Definition
(1) myxomas (cardiac, skin, and/or breast), (2) lentigines and/or pigmented nevi, and (3) endocrine overactivity (primary nodular adrenal cortical disease with or without Cushing's syndrome, testicular tumors, and/or pituitary adenomas with gigantism or acromegaly
Term
The most common clinical presentation of cardiac myxoma
Definition
mitral stenosis or regurgitation
Term
the most common tumors of the cardiac valves
Definition
Papillary fibroelastomas
Term
tumors metastatic to the heart are much more common than primary tumors
Definition
Term
at what age should screening for lipid disorders begin
Definition
20
Term
guidelines match the intensity of treatment of lipid disorders to an individual's risk - what are the risk classes
Definition
Very high ACS, or CHD w/DM, or multiple CRFs, goal 70, drug 70

High - 10-year CHD risk of >20%, any evidence of established atherosclerosis, or diabetes, goal 100, drug 100

Moderately high - 2+ risk factors (10-year risk, 10–20%), goal 100, drug 130

Moderate - 2+ risk factors (risk <10%): goal 130, drug 160

low - 0–1 risk factor - goal 160, drug 190
Term
what are the 5 elements that presence of 3 of them determine metabolic syndrome
Definition
abdominal circumferance, TG, HDL, BP 130/85, fasting glucose
Term
what is considered a positive exercise stress test
Definition
flat or downsloping depression of the ST segment >0.1 mV below baseline (i.e., the PR segment) and lasting longer than 0.08 s
Term
cardiac work=?
Definition
heart rate X blood pressure
Term
7 CIs to cardiac stress testing
Definition
rest angina within 48 h, unstable rhythm, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, severe pulmonary hypertension, and active infective endocarditis
Term
signs that indicate the presence of a high risk for coronary heart disease in non-invasive tests
Definition
inability to exercise for 6 min, i.e., stage II (Bruce protocol) of the exercise test; a strongly positive exercise test showing onset of myocardial ischemia at low workloads (0.1 mV ST-segment depression before completion of stage II, 0.2 mV ST depression at any stage, ST depression for >5 min after the cessation of exercise, a decline in systolic pressure >10 mmHg during exercise, the development of ventricular tachyarrhythmias during exercise); the development of large or multiple perfusion defects or increased lung uptake during stress radioisotope perfusion imaging; and a decrease in left ventricular ejection fraction during exercise on radionuclide ventriculography or during stress echocardiography
Term
what are the effects of nitrates on ischemich heart disease
Definition
improve exercise tolerance in patients with chronic angina and relieve ischemia in patients with unstable angina as well as patients with Prinzmetal's variant angina
Term
what is the effect of beta blockers in ischemic heart disease
Definition
reduce myocardial oxygen demand by inhibiting the increases in heart rate, arterial pressure, and myocardial contractility caused by adrenergic activation
Term
when are CCBs indicated in ischemic heart disease
Definition
when beta blockers are contraindicated, no tolerated or ineffective
Term
which CCBs can be given simultaneously with BBs?
Definition
amlodipine, nifedipine etc. - synergistic

Diltiazem - only in patients with normal ventricular function and no conduction disturbances

Verapamil - shouldn't be given at all with BBs
Term
what is the strategy of antiplatelet treatment in patient with chronic stable IHD?
Definition
studies have not shown any benefit from the routine addition of clopidogrel to aspirin in patients with chronic stable IHD, Although combined treatment with clopidogrel and aspirin for at least a year is recommended in patients with an acute coronary syndrome treated with implantation of a drug-eluting stent,
Term
what is the role of ACEi in IHD?
Definition
survivors of myocardial infarction

hypertension, LDL goals not reached with initial therapy with other drugs

high risk of vascular diseases such as diabetes or LV dysfunction
Term
when should ACEi not be used in IHD?
Definition
normal LV function and have achieved blood pressure and LDL goals on other therapies
Term
what is an approved treatment for patients who continue to experience angina in IHD on standard therapy: BB, CCB, and nitrates
Definition
Ranolazine - affects the sodium-dependent calcium channels during myocardial ischemia to prevent calcium overload
Term
3 CIs of Ranolazine in IHD
Definition
hepatic impairment
QTc prolongation
with use of drugs that inhibit the CYP3A metabolic system (diltiazem, verapamil)
Term
NSAIDs increase the risk of IHD
Definition
Term
3 indications for percutaneous coronary intervention? when not to use
Definition
1. MC - symptom-limiting angina pectoris, despite medical therapy, accompanied by evidence of ischemia during a stress test

2. unstable angina

3. MI

not to use in stable exertional angina, 3 vessel disease or left main
Term
2 elements that render PCI successful
Definition
adequate dilation (an increase in luminal diameter >20% to a residual diameter obstruction <50%)

relief of angina
Term
how are aspirin and a thienopyridine administered after PCI with placement of a bare metal stent? a drug-eluting stent?
Definition
bare metal stent - 3 months of both post procedure

drug eluting stent - one year of thienopyridine and a lifetime of aspirin
Term
which 3 vessels are used in coronary artery bypass grafting
Definition
internal mammary artery or a radial artery, saphenous vein
Term
for which vessels is Long-term patency rates in CABG higher and for which lower?
Definition
internal mammary and radial artery have higher patency rates than saphenous vein
Term
in which procedure is the redevelopment of angina greater, PCI or CABG?
Definition
PCI
Term
in which procedure are stroke rates lower, PCI or CABG?
Definition
PCI
Term
definition of unstable angina
Definition
angina pectoris with at least one of three features: (1) it occurs at rest (or with minimal exertion), usually lasting >10 minutes; (2) it is severe and of new onset (i.e., within the prior 4–6 weeks); and/or (3) it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously)
Term
NSTEMI=?
Definition
UA + positive cardiac biomarkers
Term
what are the recommendations for a patient presenting to the ED with chest pain and over a 12 hour monitoring is found not to suffer from STEMI or NSTEMI/UA?
Definition
recommended an elective stress test of CT angiography
Term
The TIMI Risk Score for UA/NSTEMI - clinical risk stratification score to identify increasing risk of death, myocardial infarction, or urgent revascularization - 7 factors
Definition
3 and over CAD risk factors
aspirin in the last week
2 anginal events within the last 24 hrs
prior obstruction >50%
age >65
elevated biomarkers
ST depression
Term
what effect do the cumulative factors in the TIMI risk score have on the risk associated with UA/NSTEMI? how can it be useful beyond just as a prognostic tool?
Definition
0/1 factors - 5%
2 - 8%
3- 13%
4 - 20%
5 - 26%
6/7 - 41%
it is useful both in predicting the risk of recurrent cardiac events and in identifying those patients who would derive the greatest benefit from antithrombotic therapies more potent than unfractionated heparin, such as low molecular–weight heparin (LMWH) and glycoprotein IIb/IIIa inhibitors, and from an early invasive strategy
Term
when is a patient with UA allowed ambulation?
Definition
if the patient shows no recurrence of ischemia (discomfort or ECG changes) and does not develop a biomarker of necrosis for 12–24 h
Term
2 CIs for the use of nitrates in UA/NSTEMI
Definition
hypotension or the use of sildenafil or other drugs in that class within the previous 24–48 h
Term
what is the ambulant pharmacological treatment of UA/NSTEMI (should be started at admission)
Definition
Nitrates, BBs, statins
CCBs - if still symptomatic or BB CIed

[aspirin + clopidogrel] or [aspirin + prasugrel]

UFH/Clexane/Bivalirudin/Fondaparinux
Term
what is the definition of early invasive approach in the treament of UA/NSTEMI
Definition
PCI within 48 hours of presentation
Term
5 group of drugs are recommended for the long term management of patients with ACS
Definition
BBs
statins
ACEi/ARBs
aspirin + [clopidogrel or prasugrel]
Term
what is the treatment of an acute episode of prinzmetal's angina and prevention of recurrence
Definition
nitrates and CCBs
Term
which are the preferable cardiac biomarkers for diagnosing acute MI
Definition
troponin T and I
Term
troponin T and I remain elevated for how long?
Definition
7-10 days
Term
when do CK-MB levels rise in the blood and when do they decrease in the setting of acute MI?
Definition
4-8 hrs and decrease in 48-72 hrs
Term
why is troponin superior to CK-MB in the diagnosis of acute MI?
Definition
it is much more specific
Term
which measurement of the cardiac biomarkers correlate with infarct size and which does not?
Definition
total amount of biomarkers released correlates where as peak levels don't
Term
in what situations is PCI preferred over fibrinolysis for the treatment STEMI
Definition
diagnosis is in doubt

cardiogenic shock

bleeding risk is increased

symptoms have been present for at least 2–3 h when the clot is more mature and less easily lysed by fibrinolytic drugs
Term
when should fibrinolytics be ideally given to the patient with STEMI
Definition
within 30 mins of presentation - "door to needle"
Term
3 fibrinolytic agents approved by the U.S. Food and Drug Administration for intravenous use in patients with STEMI
Definition
tissue plasminogen activator (tPA), streptokinase, tenecteplase (TNK), and reteplase (rPA)
Term
flow in the culprit coronary artery is classified for patency by the TIMI score
Definition
grade 0 - complete occlusion of the infarct-related artery;

grade 1 - some penetration of the contrast material beyond the point of obstruction but without perfusion of the distal coronary bed;

grade 2 - perfusion of the entire infarct vessel into the distal bed, but with flow that is delayed compared with that of a normal artery

grade 3 - full perfusion of the infarct vessel with normal flow.
Term
in what situations is fibrinolysis preferable to PCI in the setting of NSTEMI
Definition
patients presenting in the first hour of symptoms, if there are logistical concerns about transportation of the patient to a suitable PCI center (experienced operator and team with a track record for a "door-to-balloon" time of <2 h), or there is an anticipated delay of at least 1 h between the time that fibrinolysis could be started versus implementation of PCI
Term
5 absolute CIs to fibrinolytic therapy
Definition
history of cerebrovascular hemorrhage at any time, a nonhemorrhagic stroke or other cerebrovascular event within the past year, marked hypertension (a reliably determined systolic arterial pressure >180 mmHg and/or a diastolic pressure >110 mmHg) at any time during the acute presentation, suspicion of aortic dissection, and active internal bleeding (excluding menses).
Term
what % patients undergoing fibrinolysis with streptokinase experience an allergic reaction, mild hypotension?
Definition
2%
4-10%
Term
in what circumstances should Cardiac catheterization and coronary angiography be carried out after fibrinolytic therapy
Definition
(1) failure of reperfusion (persistent chest pain and ST-segment elevation >90 min), in which case a rescue PCI should be considered; or (2) coronary artery reocclusion (re-elevation of ST segments and/or recurrent chest pain) or the development of recurrent ischemia (such as recurrent angina in the early hospital course or a positive exercise stress test before discharge), in which case an urgent PCI should be considered
Term
killip classification for heart failure in the post MI hospital setting to determine risk of in-hospital death
Definition
class I, no signs of pulmonary or venous congestion;

class II, moderate heart failure as evidenced by rales at the lung bases, S3 gallop, tachypnea, or signs of failure of the right side of the heart, including venous and hepatic congestion;

class III, severe heart failure, pulmonary edema; and

class IV, shock with systolic pressure <90 mmHg and evidence of peripheral vasoconstriction, peripheral cyanosis, mental confusion, and oliguria
Term
who should be prophylactically treated with ICD post MI
Definition
patients who have had VT or VF more than 48 hours after initial presentation -
1. NYHA class II/III with LVEF 30-40%
2. NYHA class I with LVEF 30-35%
Term
what is the treatment of supraventricular arrhythmia in the post MI hospital setting
Definition
digoxin if concurrent heart failure
CCB/BB - otherwise
electric shock - abnormal rhythm persists for >2 h with a ventricular rate >120 bpm, or if tachycardia induces heart failure, shock, or ischemia
Term
what is the treatment of bradycardia in post MI hospital settings
Definition
atropine (not isoproterenol)
Term
what treatment should be carried out in the post MI hospital patient with bradycardia d/t AV block and in what conditions
Definition
Temporary electrical pacing if it improves hemodynamics and its not an inferoposterior infarction with complete heart block associated with heart failure, hypotension, marked bradycardia, or significant ventricular ectopic activity
Term
how many days of hospitalization for uncomplicated STEMI
Definition
5 days
Term
long term treatment post MI
Definition
BBs for at least 2 years and
statins, ACEi, aspirin, coumadin indefinitely
Term
medications that cause hypertension
Definition
High-dose estrogens, adrenal steroids, decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, monamine oxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatory agents, cocaine
Term
6 causes of wide pulse pressure d/t increased cardiac output
Definition
a. Aortic regurgitation
b. Thyrotoxicosis.
c. Hyperkinetic heart syndrome.
d. Fever.
e. Arteriovenous fistula
f. Patent ductus arteriosus
Term
reasons to suspect renovascular disease as the cause of hypertension
Definition
severe or refractory hypertension, recent loss of hypertension control or recent onset of moderately severe hypertension, and unexplained deterioration of renal function or deterioration of renal function associated with an ACE inhibitor
Term
what is a screening test for renal artery stenosis
Definition
OIH - renal blood flow

DTPA [99mTc]-diethylenetriamine pentaacetic acid (DTPA) scan - glomerular filtration rate before and after captopril
Term
what is a positive test on DPTA/OIH for renovascular hypertension
Definition
(1) decreased relative uptake by the involved kidney, which contributes <40% of total renal function, (2) delayed uptake on the affected side, and (3) delayed washout on the affected side
Term
what is the "gold standard" for evaluation and identification of renal artery lesions
Definition
contrast angiography
Term
what % of the renal artery lumen need to be occluded in order to get hypertension
Definition
70%
Term
what is the measure used to determine if a renal artery lesion causing hypertension would respond to vascular repair
Definition
A lateralizing renal vein renin ratio (ratio >1.5 of affected side/contralateral side) has a 90% predictive value
Term
what is the reason that Patients with fibromuscular disease have more favorable outcomes than do patients with atherosclerotic lesions
Definition
younger age, shorter duration of hypertension, and less systemic disease
Term
what is the method of choice for surgical repair of renal artery atherosclerosis?
if this is not successful?
Definition
PTRA

surgical revascularization or if or concomitant aortic surgery is required, e.g., to repair an aneurysm
Term
what is a good screening test for hyperaldosteronism as a cause of hypertension?
Definition
The ratio of plasma aldosterone to plasma renin activity (PA/PRA)
Term
which 3 drugs may affect the PA/PRA test for hyperaldosteronism
Definition
aldosterone antagonists, ARBs, and ACEi
Term
3 confirmatory test for diagnosing hyperaldosteronism after PA/PRA
Definition
failure to suppress aldosterone in response to an oral/IV NaCl load, fludrocortisone, or captopril
Term
4 possible lesions that may cause primary hyperaldosteronism
Definition
adrenal adenoma

bilateral adrenocortical hyperplasia (idiopathic hyperaldosteronism)

adrenal carcinoma

ectopic malignancy, e.g., ovarian arrhenoblastoma
Term
what is the next step in the workup of a patient who's been diagnosed with primary hyperaldosteronism?
Definition
CT of the adrenals and if nothing is found adrenal scintography
Term
what is the first line therapy of hypertension (over 140/90)
Definition
a thiazide + [ACEi/ARB/BB]
Term
4 conditions for which the BP goal is 130/80
Definition
diabetes, coronary heart disease, chronic kidney disease, or additional cardiovascular disease risk factors
Term
which patients may benefit from reducing the systolic BP up to 120
Definition
those with proteinuria 1g/d
Term
The term resistant hypertension refers to ....
Definition
patients with blood pressures persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic, in a reasonable combination and at full doses.
Term
what is the BP goal for hypertensive encephalopathy treatment
Definition
The initial goal of therapy is to reduce mean arterial blood pressure by no more than 25% within minutes to 2 h or to a blood pressure in the range of 160/100–110 mmHg
Term
3 drug options for the treatment of hypertensive encephalopathy
Definition
nitroprusside, labetalol, nicardipine
Term
in comparison to malignant hypertension with encephalopathy, what should be the treatment approach to malignant hypertesion w/o encephalopathy?
Definition
less aggressive using one of the following: captopril, clonidine, and labetalol.
Term
when should you start hypertensive treatment for patients with ischemic stroke that are not candidates for thrombolytic therapy? and for those who are?
Definition
SBP>220 or DBP>130
undergoing thrombolysis: SBP>185 or DBP>110
Term
when should you start antihypertensive therapy for patients with hemorrhagic stroke?
Definition
SBP>180 or DBP>130
Term
whats the common site of TB aortic aneurysm
Definition
thoracic
Term
whats the common site of syphilitic aortic aneurysm
Definition
ascending or arch of aorta
Term
which to vasculitides may cause aortic aneurysm and where?
Definition
takayasu and giant cell arthritides
aortic arch and thoracic aorta
Term
the spondyloarthropathies may cause aortic aneurysms at what site
Definition
ascending aorta
Term
which is the most common pathology associated with aortic arch and descending aortic aneurysms? what about ascending aorta
Definition
atherosclerosis
cystic medial necrosis
Term
what are the indications for placement of a prosthetic graft in thoracic aortic aneurysm
Definition
symptomatic thoracic aortic aneurysms, those in whom the ascending aortic diameter is >5.5–6 cm or the descending thoracic aortic diameter is >6.5-7 cm, and those with an aneurysm that has increased by >1 cm per year

in Marfan syndrome or bicuspid aortic valve, ascending thoracic aortic aneurysms >5 cm
Term
what is the recommended pharmacological treatment of thoracic aortic aneurysm
Definition
BB
Term
over which size of abdominal aortic aneurysm does the risk of rupture increase incrementally
Definition
5 cm
Term
is screening done for abdominal aortic aneurysm?
Definition
yes in men that have a history of smoking btwn the ages of 65-74
Term
what should you do with the siblings and offsprings of patients who have been diagnosed with AAA or TAA or peripheral arterial aneurysms?
Definition
screen for AAA also in them
Term
3 indications for surgical repair of AAA?
Definition
expanding rapidly, symptomatic or over 5.5 cm
Term
what is the ECG in aortic dissection?
Definition
normal, and this is a way to rule out acute coronary syndrome
Term
what is the goal of treatment for aortic dissection
Definition
reducing cardiac contractility and systemic arterial pressure, and thus shear stress.
Term
what is the medical treatment of aortic dissection
Definition
IV BB to reduce heart rate to 60 and IV nitroprusside to reduce SBP to 120
Term
what are the indications for surgical repair of aortic dissection
Definition
acute ascending aortic dissections and intramural hematomas (type A) and for complicated type B dissections, including those characterized by propagation, compromise of major aortic branches, impending rupture, or continued pain
Term
what are the 3 parts of the surgical repair of aortic dissection
Definition
excision of the intimal flap, obliteration of the false lumen, and placement of an interposition graft
Term
what are the symptoms of Chronic Atherosclerotic Occlusive Disease
Definition
Claudication characteristically involves the buttocks, thighs, and calves and may be associated with impotence in males (Leriche syndrome)
Term
what is a non invasive test for peripherial artery disease
Definition
ankle:brachial index of blood pressure. in healthy over 1, in PAD less than 1
Term
which drug may increase the distance of walking before onset of claudication
Definition
Cilostazol - phosphodiesterase inhibitor
Term
what test must be done in the definitive diagonosis of pulmonary hypertension
Definition
cardiac catheterization
Term
which part of the cardiac catheterization helps determine if the patient with pulmonary hypertension is eligible for treatment with CCBs
Definition
drug testing with a short-acting pulmonary vasodilator to determine the extent of pulmonary vasodilator reactivity
Term
when administering a new drug for pulmonary hypertension, how should assessment of its efficacy be done?
Definition
Repeat assessments should be performed within 8 weeks of initiating a new drug, as patients who do not respond initially are not likely to respond with longer exposure
Term
which is the only combination therapy for pulmonary hypertension that has been proven to beneficial?
Definition
adding sildenafil to epoprostenol
Term
what is the name of the mechanism of restenosis which appears on bare metal stents more so than on drug eluting stents?
Definition
neointimal hyperplasia
Term
is there an indication for PCI in stable angina?
Definition
no, only when symptoms worsen or evidence of severe ischemia on noninvasive testing occurs
Term
comparison of CABG vs. PCI with DES for three-vessel coronary disease or left main disease
Definition
CABG - associated with higher rates of stroke
PCI+DES - associated with higher rates of revascularization procedures

mortality same
Term
what is the name of the mechanism of restenosis which appears on bare metal stents more so than on drug eluting stents?
Definition
neointimal hyperplasia
Term
is there an indication for PCI in stable angina?
Definition
no, only when symptoms worsen or evidence of severe ischemia on noninvasive testing occurs
Term
is there an indication for PCI in stable angina?
Definition
no, only when symptoms worsen or evidence of severe ischemia on noninvasive testing occurs
Term
comparison of CABG vs. PCI with DES for three-vessel coronary disease or left main disease
Definition
CABG - associated with higher rates of stroke
PCI+DES - associated with higher rates of revascularization procedures

mortality same
Term
what is The most common reason to decide not to do angioplasty, but to opt for CABG,
Definition
the presence of a chronic total occlusion (>3 months in duration).
Term
coronary lesion considered to be adequate for PCI and stent
Definition
proximal noncalcified subtotal lesion - "type A"
Term
patients with ACS at a high risk benefit from PCI - who is considered high risk in ACS
Definition
refractory ischemia, recurrent angina, positive cardiac-specific enzymes, new ST-segment depression, low ejection fraction, severe arrhythmias, or a recent PCI or CABG
Term
in which patients would you prefer bare metal stent over drug eluting stent/
Definition
low risk for restenosis: large vessels, non diabetic, focal lesion

CIs to drug eluting stents: medical non-compliance (dual anticoagulation for over 6 months), ACS-STEMI, chronic anticoagulation, anticipated surgery, high risk for bleeding
Term
how is mitral stenosis in pregnancy treated?
Definition
BB and digoxin
Term
what is a typical finding on auscultation of mitral stenosis
Definition
opening snap and accentuated S1
Term
what is the treatment of VT after MI in a hemodynamically stable patient
Definition
amiodarone
Term
what is the diagnostic test for AAA?
Definition
CT with contrast or MRI (not US, which is used for screening)
Term
in the evaluation of CAD, when is the modality of choice either nuclear imaging or echocardiography?
Definition
resting electrocardiographic abnormalities, or if the patient has had prior coronary revascularization
Term
in the evaluation of CAD, what is the imaging modality of choice in a patient with LBBB, pacemaker or previous MI?
Definition
nuclear imaging
Term
when would you consider PET, in the evaluation of CAD?
Definition
morbidly obese or female with large/dense breasts
Term
absolute CI for stopping amiodarone
Definition
hyperthyroidism
Term
which treatment reduces the ocurence of VF post MI
Definition
BB
Term
what is the treatment of pulmonary artery hypertension that is responsive to adenosine on catheterization
Definition
CCBs
Term
3 ways to distinguish AS from HOCM
Definition
1. valsalva or rapidly standing - increased murmur in HOCM and decreased in AS
2. beat after PVC - pulse pressure increases in AS and decreases in HOCM
3. carotid pulse - HOCM: bisferiens, jerky
Term
what sign on ECG with LBBB and RBBB suggests underlying ischemia?
Definition
concordance of the T wave to the last part of the QRS
Term
what would you find on auscultation of RBBB
Definition
wide splitting of S1 and S2
Term
what is type A and type B aortic dissection?
Definition
A - ascending aorta (BP higher in right arm and normal in left arm)
B- arch and descending aorta (BP normal in right arm and higher in left arm)
Term
what is the diagnosis method of choice for type A and type B aortic dissection?
Definition
stable patient - type A: TTE, type B: MRI/CT/TEE

unstable patient: TEE
Term
Tx of aortic dissection w/o hypotension
Definition
IV BB and nitroprusside
Term
which drug is CIed in aortic dissection
Definition
hydralazine
Term
when is emergent/urgent surgical correction indicated in aortic dissection
Definition
1. type A
2. type B with compromise of major aortic branches, impending rupture, or continued pain
Term
what is the long term treatment of patients with aortic dissection and intramural hematomas (w or w/o surgery)
Definition
BB and either ACEi or CCB
Term
what is the follow up regimen of aortic dissection
Definition
contrast CT/MRI every 6-12 months
Term
which treatment is most beneficial for decreasing complications following CABG
Definition
aspirin
Term
claudication - a patient with leg pain while walking that goes away when resting. how is the diagnosis made?
Definition
ankle-brachial index test
Term
Bisferiens pulse
Definition
aortic regurgitation
HCM
Term
pulsus alterans
Definition
left ventricular systolic dysfunction
Term
pulsus parvus et tardus - pulse is weak/small (parvus), and late (tardus)
Definition
aortic stenosis
Term
dicrotic pulse
Definition
high systemic resistance or low cardiac output
Term
CIs to elective cardiac catheterization
Definition
decompensated CHF; ARF; severe chronic renal insufficiency, unless dialysis is planned; bacteremia; acute stroke; active gastrointestinal bleeding; severe, uncorrected electrolyte abnormalities; a history of an anaphylactic/anaphylactoid reaction to iodinated contrast agents; and a history of allergy/bronchospasm to aspirin
Term
which drug for HTN can cause constrictive pericarditis
Definition
hydralazine
Term
drugs that can cause pericarditis and pericardial effusion
Definition
procainamide, hydralazine, isoniazid, minoxidyl, anticoagulants, phenytoin
Term
T wave inversion in all precordial leads in a young athletes - what do you do?
Definition
echo to r/o hypertrophic cardiomyopathy
Term
what effect does amiodarone have on P450
Definition
inhibition
Term
which drug decreases Intestinal cholesterol absorption by LDL receptors
Definition
Ezetimibe
Term
which drug for lowering cholesterol increases LDL receptors in liver
Definition
statins and bile acid sequestrants
Term
which drugs decrease VLDL production
Definition
statins, niacin, fibrate
Term
what is the mechanism of fibrates for lowering VLDL
Definition
increased LPL
Term
what is the follow up needed for patients on ezetimibe
Definition
transaminases
Term
Tx of WPW + AF in a hemodynamically stable patient
Definition
procainamide or ibutilide
Term
Tx of WPW + AF in a hemodynamically unstable patient
Definition
electric cardioversion
Term
treatment of QT prolonging drug leading to pause-dependent polymorphic VT
Definition
stop drug. correct Mg + K. emergency pacing to prevent pauses
Term
infective endocarditis within 2 months of prosthetic valve replacement
Definition
S. aureus, CoNS, facultative gram-negative bacilli, diphtheroids, and fungi
Term
Transvenous pacemaker– or implanted defibrillator–associated endocarditis
Definition
S. aureus or CoNS
Term
treatment of pulmonary edema
Definition
positive pressure ventilation, diuretics, nitrates, morphine, ACEi
if underlying cardiogenic cause can add: IV BNP (nesiritide), positive ionotropes (dopamine, dobutamine), intra aortic balloon pump
Term
when is intra aortic balloon pump indicated in pulmonary edema
Definition
caused by severe mitral regurgitation or ventricular septal rupture
Term
what distinguishes the murmur in HOCM from AS
Definition
when afterload increases HOCM decreases (such as with squatting or hand gripping)
Term
which treatment may help in hypertrophic cardiomyopathy if beta blockers, verapamil and diuretics do not control the symptoms
Definition
disopyramide
Term
which treatment can help reduce the risk of sudden death in hypertrophic cardiomyopathy
Definition
besides ICD, amiodarone
Term
the murmur in MVP behaves like...
Definition
HOCM
Term
what is a treatment for pain and palpitations in MVP
Definition
beta blockers
Term
2 CIs for intra aortic balloon pump
Definition
aortic regurgitation, aortic dissection
Term
3 valvular abnormalities that cause syncope
Definition
mitral valve prolapse, bicuspid aortic valve, aortic stenosis
Term
how is the diagnosis of acromegaly made
Definition
first serum IGF1, to confirm- GH suppression by glucose
Term
echo findings in HOCM
Definition
תנועה סיסטולית קדמית של עלה המסתם המיטרלי SAM + היפרטרופיה משמעותית של הספטום + חסימת מוצא חדר שמאל בסיסטולה
Term
treatment of patient post-MI with sustained VT that has past?
Definition
do not treat
Term
conditions that predispose to AIVR
Definition
acute myocardial infarction (MI), cocaine intoxication, acute myocarditis, digoxin intoxication, and postoperative cardiac surgery
Term
what is the treatment of sustained AIVR associated with bradycardia (usually in the setting of RV infarction associated with proximal right coronary artery occlusion)
Definition
atropine or pacing
Term
what is the MC pathogen involved in prosthetic valve infective endocarditis within a year after the replacement
Definition
staph coag neg
Term
what is the MC pathogen involved in prosthetic valve infective endocarditis a year after replacement and there after
Definition
staph aureus
Term
what is the MC arrhythmia in digoxin intoxication
Definition
SVT with alternating AV blockטכיקרדיה עלייתית עם חסם AV משתנה
Term
mitral stenosis can cause recurrent PE - emboli to be lodged in the pulmonary system
Definition
Term
how do you diagnose brugada syndrome in a patient with an unequivocal ECG - saddleback ST elevations
Definition
procainamide challenge to elicit the classic pattern
Term
what is the management of recurrent VT in brugada syndrome
Definition
isoproterenol or quinidine administration
Term
what are the indications for ICD implantation in brugada
Definition
documented arrhythmia episodes and patients with syncope and positive spontaneous or provoked coved-type ECG ST-segment changes in V1–V3
Term
effect of lithium on ECG
Definition
shorter QT
Term
malignant hypertension - 4 clinical manifestations
Definition
encephalopathy, retinopathy, deteriorating renal function with proteinuria, microangiopathic hemolytic anemia
Term
what happens to A2 in severe aortic stenosis?
Definition
it disappears
Term
murmur at beginning of diastole
Definition
aortic regurgitation
Term
ecg of tamponade
Definition
electrical alternans
Term
relative contraindications of beta blockers in ischemic heart disease
Definition
asthma, AV block, severe bradycardia, Raynaud's phenomenon, mental depression
Term
when are BB contraindicated in CHF
Definition
acute decompensation of CHF
Term
when does MR complicate MI
Definition
within 1 day post
Term
which electrolyte disturbance causes long QT syndrome
Definition
hypokalemia, hypomagnesemia, hypocalcemia
Term
which drugs cause long QT
Definition
anti-arrhythmics: quinidine, amiodarone, sotolol, procainamide
antihistamines, macrolide-erythromycin, fluoroquinolones, TCA, domperidone, antipsychotic - halidol, methadone
Term
digoxin does not cause long QT
Definition
Term
risk factors for torsadess de pointes
Definition
subarachnoid hemorrhage, hypothermia, female sex, bradycardia, LVH, HF, acidosis, hypoxia, hypokalemia, hypocalcemia, hypomagnesemia, erythromycin, TCA, methadone, haloperidol, anti arrhythmic class 3 and 1A, diuretics (hypokalemia)
Term
post MI and EF<40
Definition
perform EPS - if VT implant ICD
Term
what is the initial treatment for CHF
Definition
ACEi or diuretics (depending if there's fluid retention
Term
what is the indication for CRT in CHF
Definition
NYHA 3-4 + QRS>120 ms
Term
non bacterial causes of pericarditis
Definition
NSAIDs, colchicine, steroids
Term
secondary prevention of pericarditis
Definition
colchicine
Term
when does DCM become symptomatic
Definition
age 20-30
Term
hypothyroidism doesn't cause increase activity of coumadin
Definition
fever, malignancy, CHF, and advanced age do
Term
aortic stenosis heart sounds
Definition
A2 low or absent
duration of murmur correlates with severity of stenosis
midsystolic murmur
Term
suspected aortic dissection and chronic coumadin therapy within the therapeutic range are both CIs to fibrinolysis
Definition
Term
acute VSD is an indication for intra aortic balloon pump
Definition
Term
diet for essential hypertension
Definition
low sodium
high potassium and calcium
Term
the first marker to increase in MI
Definition
myoglobin
Term
MCC of mortality in CHF
Definition
worsening HF or ventricular arrhythmia
Term
most sensitive test for aortic dissection
Definition
CT
Term
MC sign in endocarditis
Definition
anemia
Term
test for severity and duration of BP
Definition
fundus
Term
in which prosthetic heart valve is bridging therapy with clexane ineffective
Definition
mitral valve
Term
DES - more rethrombosis, BMS - more restenosis
Definition
Term
CIs to use of dobutamine in stress test
Definition
אסטמה, COPD, ל"ד נמוך (90/60), שימוש בקפאין / תיאופילין לפני הבדיקה, 2nd / 3rd degree AV block או sick sinus syndrome.
Term
signs of pulmonary hypertension
Definition
קוצ"נ במאמץ, עייפות, אנגינה פקטוריס, סינקופה ובצקת פריפרית
Term
when do you see permanent canon a waves and when - temporary ones?
Definition
permanent - junctional rhythm
temporary - complete AV block, A-V dissociation with VT
Term
S4 during acute MR
Definition
Term
wide split of S1
Definition
RBBB
Term
what finding indicates severe AS
Definition
הפיק של האיוושה מאוחר יותר
Term
role of BB in HCM
Definition
חסמי בטא יכולים להוריד תדירות סינקופה ואנגינה פקטוריס בעת ל50 אחוז, אך לא מוריד SCD
Term
role of amiodarone in HCM
Definition
אמיודרן כנראה אפקטיבי בהורדת תדירות SVT והפרעות קצב חדריות וייתכן השפעה כל SCD
Term
role of CCB in HCM
Definition
CCB מסוג נונדיהידרו-דילטם וורפמיל –מוריד נוקשות של החדר-מעלה סבילות למאמץ
Term
drugs to avoid in HCM
Definition
מדיגוקסין, משתנים, ניטריטים, CCB מסוג דיהידרו, וואזודילטורים, בטא אגוניסט
Term
in the treatment of MI d/t cocaine use, which routine drug is omitted from treatment
Definition
BB
Term
conditions of cannon a wave - atrium contracts against resistance
Definition
o TS
o יל"ד ריאתי
o PS
o הפרעות קצב בהם העליה הימנית מתכווצת בעוד המסתם הטריקוספידאילי סגור. כמו VT , AV BLOCK שלם, AV DISSOCIATION
Term
אין גלי A בחולים עם AF
Definition
Term
prinzmetal angina
Definition
• לרוב החולים יש פלאק לא חסימתי כ1 ס"מ לפני הספאזם
יכול להיות טרופונין
צעירים ומעשנים
• טיפול –ניטרטים ו-CCBבעיקר דה-הידרו. אספירין יכול להחמיר
שכיח יותר בright coronary
Term
apart from being a class 3 antiarrhythmic, amiodarone is also....
Definition
an alpha blocker
Term
apart from being a class 1 antiarrhythmic, quinidine is also a...
Definition
alpha blocker
Term
indications for intraaortic balloon pump
Definition
• שוק קרדיוגני
• סיבוכי MI כמו קרע של ספטום או MR
• UA
• ועוד
Term
aortic stenosis
Definition
הרוב זכרים
• בעולם המערבי הסיבה השכיחה ביותר היא הסתיידות תלויית גיל.
• הרבה פעמים, גם בחולים הקשים, הCO במנוחה הוא בגבולות הנורמלים הרי שהוא לא מצליח לעלות באופן נורמלי בזמן מאמץ.
o דיספנאה במאמץ-מוות תוך שנתיים
o אנגינה-בדכ מתפתח מאוחר יותר-מוות תוך 3 שנים
o סינקופה במאמץ –מוות תוך 3 שנים
o אין סימני CO נמוך כמו חולשה, כחלון וכחקציה עד שלב מתקדם כי CO נשמר לרוב במנוחה
סימני אי ספיקה שמאלית וימנית נראה בשלבים מתקדמים-מוות תוך שנה וחצי
THRILL סיסטולי בבסיס הלב, בסופרסטרנל נוטצ' ולאורך הקרוטידים
o הסתיידות מפחיתה את הקול של סגירת מסתם אאורטלי
o קול S4 באפקס-משקף את ההיפרטרופיה
o קול S3 בדרך כלל מופיע בשלב מאוחר כאשר הLV עובר התרחבות משמעותית
האוושה נשמעת הכי טוב בבסיס הלב במרווח בינצילעי שני מימין
להמנע מפעילות גופנית בחולים עם מחלה קשה גם בשלב אסימפטומטי
אלו עם הרחבה או אנוריזמה בשורש האאורטה עם קוטר מקסימלי מעל 4.5 או עליה שנתית בקצב של מעל ל0.5 ס"מ לשנה, גם אם אסימפטומטים
Term
CIs for elective cardiac catheterization
Definition
• היפוקלמיה לא נשלטת
• איריטבליות חדרית לא נשלטת
• יל"ד לא מאוזן
• מחלת חום חריפה
• אי ספיקת לב לא מאוזנת
• PTT מעל 18
• רגישות לחומר ניגוד
• אי ספיקת כליות חמורה ,אלא אם כן מתוכנן דיאליזה
Term
CIs for BB in acute STEMI
Definition
o ברדיקרדיה מתחת ל60
o לחץ סיסטולי מתחת ל100
o PR מעל 0.24 שניות
o חירחורים בריאות שיותר מ10 ס"מ מעל לסרעפת (אי ספיקה קשה או הפרעה קשה בתפקוד LV)
o גם תת לחץ דם אורטוסטטי
o מחלת ריאות קשה
Term
מי צריך קומדין לאחר STEMI
Definition
• אוטם קדמי
• הפרעה קשה בפעילות חדר שמאל
• אי ספיקת לב
• היסטוריה של תסחיפים
• עדות באקו לטרומבוס מוראלי
• AF
• כל אלו יקבלו טיפול תרפואטי מלא בקלקסן או הפרין בזמן אשפוז ולאחר מכן לפחות 3 חודשי קומדין
• טרומואמבוליזם מסבך 10 אחוז מהSTEMI
Term
• מבחן מאמץ לא מייצג טוב את עורק הCX
Definition
Term
CIs for stress test
Definition
o אנגינה במנוחה ב48 שעות אחרונות
o קצב לב לא יציב
o AS קשה
o מיוקרדיטיס
o אי ספיקת לב לא מאוזנת
o יל"ד ריאתי קשה
o אנדוקרדיטיס פעיל
Term
למי מבחן מאמץ סטנדרטי לא יעיל ועדיף מיפוי עם טליום/טכניציום במהלך מבחן מאמץ או מבחן פרמקולוגי
Definition
o Preexcitation syndrome
o LBBB
o Paced ventricular rhythm -קוצב
o מעל 1 מ"מ של ירידה בst במנוחה
o WPW
Term
relative CIs for fibrinolysis
Definition
שימוש בנוגדי קרישה, פרוצדורה ניתוחית/חודרנית בשבועיים האחרונים,צורך בהחייאה קרדיופולמונרית ממושכת מעל 10 דקות בשבועיים האחרונים,נטייה ידועה לדמם, הריון, דימום עיני, מחלה פפטית פעילה, היסטוריה של ל"ד שכעת מאוזן
Term
milrinone
Definition
מעכב פוספודיאסטראז 3 . יש לה אפקט סינרגיסטי עם אגוניסטים לרצפטורי בטא וכנראה עדיפה בחולים המטופלים בחסמי בטא. יותר אפקטיבית מדובוטומין ומאפשרת הורדה רבה יותר בלחצי מילוי של חדר שמאלי-יותר סיכוי ללחץ דם
Term
different doses of dopamine
Definition
• מינון נמוך של דופמין-מגרה רצפטור דופמנירגי וגורם לואזודילטציה של כלי דם כלייתים וספנכניקים. במינון בינוני מגרה בטא 2 וגורמים לעליה בCO עם שינוי מזערי בקצב לב או SVR. מינון גבוה-בעיקר דרך אלפא 1 וגורם לואזוקונסטריקציה שגורמת לעליה בSVR , עליה בלחצי מילוי של חדר שמאל ועליה בקצב לב
Term
what is the pharmacological treatment of arrhythmogenic right ventricular dysplasia
Definition
Sotalol, a beta blocker and a class III antiarrhythmic agent, is the most effective antiarrhythmic agent in ARVD
Term
Stress testing is recommended for low risk patients (table 2) with suspected ACS without recurrent ischemic discomfort after at least six to eight hours of observation if follow-up 12 lead ECG is normal or unchanged from previous tracings and two troponin levels at least six hours apart are normal - stress testing with imaging (either rMPI or echocardiography) is recommended for the following Patients who have an uninterpretable ECG for ischemia
Definition
LBBB, ventricular paced rhythm, LVH with strain pattern, or digoxin therapy
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