Pt J, a 35 yo obese woman, presents to the ER complaining of dyspnea. She has left calve pain, left leg edema, tachypnea, tachycardia, takes OCP, and 15 pack year hx of smoking. Dx? Dx Gold Standard?
Pulmonary Angiography, but Spiral CT is the initial method of identification > VP Scan
Which of the following is not a treatment option for a PE?
A) Thrombolysis - Streptokinase, Urokinase, Alteplase
D) O2 Hyperbaric Chamber
E) Vena Cava Filter
D) O2 Hyperbaric Chamber
The Anticoag TOC is Heparin IV followed by LD Heparin or warfarin after the acute phase (3+ months).
LD Heparin is used in pregnancy.
What CXR signs can be seen for PE?
Hampton's Hump - apex central, pleural based, wedge-shaped infiltrates
Westermark's Sign - Unilateral lung oligemia
During an MI time is money. Irreversible cell injury in 20-__ min, Necrosis complete in 3-_ hours.
Location of MI:
(1) Anterior: (V1-V4 leads), _ _ _, 40-50% of cases
(2) Inferior: (__, __, __ leads), _ _ _, 30-40% of cases
(3) Lateral: (_, _, V_, V_ leads), Circumflex, 15-20% of cases
II, III, F
I, L, V5, V6
What is the time frame for which PCI is best?
< 90 min
When should thrombolytics be given if PCI is unavailable?
< 3 hours
CI with NSTEMI.
What does MONA stand for and when is it given?
MONA = Morphine (pain), Oxygen, Nitroglycerin (vasodilator), and Aspirin (antiplatelet).
It is given immediately upon chest pain with suspected MI. BB and clopidogrel (antiplatelet) are also given with ACS.
With what MI is NTG CI?
Right Ventricular = Inferior MI
When is a CCB given during an MI?
If EF > 40% and pt cannot take nitrates or or BB.
* ACE-I is given with reduced LV function to prevent dilation.
What is the leading COD in the U.S. for men and women?
CAD = negative cardiac enzymes
What is the cornerstone of treatment for angina?
What is the first cardiac enzyme to appear?
Myoglobin, but its not specific.
Then CK-MB, more specific
Then Troponins and lastly LD.
What is the most specific cardiac enzyme that lasts the longest?
Troponin I > Troponin T
Pt Y, a 56 yo WM, presents to the office c/o feet pain bilaterally. Bilaterally, the pain is at rest, he has diminished posterior tibialis and dorsalis pedis pulses, there is lack of hair to the LE, and the skin is cold to touch and pale. What dx study can be done in office? What is the dx Gold Standard?
Ankle-brachial index (1.0-1.2 is normal, <0.9 needs tx)
Tx of PVD = Control Risk Factors, bypass/ Fem-Pop, amputation if needed.
Which of the following is not a CCB used for vasodilation of ACS?
B) Amioderone... it's an anti-arrhythmic.
Subacute endocarditis : strep viridins :: Acute endocarditis : ______ _____
Subacute endocarditis : gradual developed sx :: Acute endocarditis : ______ developed sx
Which of the following does not need endocarditis prophylaxis?
A) 65 yo male with a prosthetic heart valve
B) 6 yo female with TOF
C) 17 yo with HCM
D) 22 yo with previous PDA repair
E) 33 yo with MVP with regurgitation
D) 22 yo with previous PTA
Others that DO NOT need prophylaxis = Isolated secundum ASD, Surgical repair of ASD/VSD/PDA, Previous coronary artery bypass graft surgery, Mitral valve prolapse without valvular regurgitation, innocent heart murmurs, Previous Kawasaki without valvular dysfunction, Previous Rheumatic fever without valvular dysfunction, Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
What is 1st line prophylaxis of endocarditis? 2nd line?
1) Amoxicillin po or Ampicillin IV
2) Clindamycin if PCN allergy (or another macrolide)
Describe the Duke Criteria used for dx of endocarditis.
i) Major: 2 (+) blood cultures, Evidence of: vegetations/abscess, dehiscence
ii) Minor: Predisposing condition, Fever >38°C, Immunologic signs (Osler's nodes, Rosh spots, GN, RF), 1 (+) blood culture, Positive echo
What is the TOC for HTN? Second line?
1) Lifestyle Modifications
2) ACE-I/ HCTZ, loop diuretics for acute
* Nitroprusside = TOC for HTN emergency
What is the TOC for CHF?
1) ACE-I + Thiazide/Loop diuretic
2) BB, Digitalis, ARBs, and other diuretics
* CCB are ONLY used with associated angina or HTN
Pt J, 28 yo WF, presents with a murmur. It is midsystolic, medium pitched and heard loudest in the right 2nd ICS with neck radiation. EKG shows LVH and LAA. CXR shows a boot-shaped heart. What murmur is it?
Pt H, 33 yo previous drug abuser, presents to the office with a murmur. Auscultation is heard loudest at the left 2nd ICS with radiation to the apex. It is a diastolic decresendo murmur and leaning forward makes the murmur more prominent. What is the murmur?
Pt L, 42 WF, presents to the clinic for her post rheumatic fever check up. Upon auscultation of the heart, you notice a murmur: middiastolic, at the apex (L 5th ICS), opening snap and S1 accentuation. What murmur is it?
Pt G, 58 yo AA male, presents to the office c/o fatigue. He had an MI 3 months ago. PE reveals a blowing pansystolic murmur heard at the apex. Sitting and leaning forward makes it louder, and S2 is decreased. What is the murmur?
What is the MCC of MVP?
* MVP has a midsystolic click and is late systolic
How does valsalva and standing/squatting affect MVP?
Valsalva/Standing ↑ length of murmur, Squatting/Release of valsalva ↓ length of murmur
Pt V, a 9 yo male, presents to the office with JVD and abdominal pain. CV exam reveals a harsh systolic murmur at the 3rd L ICS that radiates to the neck. There is a wide split of S2 and the murmur increases with inspiration. What is the murmur?
Pt W, a 69 yo male, presents to the office for a f/u of his recent endocarditis. CV exam reveals a pansystolic murmur at the left lower sternal border. There is an S3 heart sound, and positive Carvallo's sign. What is the murmur?
* Carvallo's Sign is when the murmur becomes louder during inspiration... used to distinguish it from mitral regurgitation.
EKG: Sawtooth pattern at a 2:1 or 3:1 ratio at AV node.
What is the MC arrhythmia?
EKG: Irregularly irregular rhythm with no p waves.
Pts with A-fib are assessed using the CHADS score.
A score > _ is treated with warfarin (INR goal of 2-_).
A score of _ is treated with warfain or _______.
0 CHADS score is treated with just _______.
T or F: Both semilunar valve stenoses have a thrill.
AS and PS both have thrills and murmurs that radiate to the neck... remember that the aorta rises to the right sternum before arching, and the pulmonic truck (artery) rises to the left sternum before bifurcating to the lungs.
Which of the following CHADS markers is incorrect?
A) CHF (1 point)
B) Hypertension (1 point)
C) Age over 55 years (1 point)
D) Diabetes Mellitus (1 point)
E) Stroke or TIA hx (2 points)
C) Age over 55 years (1 point)
> 75 yo
A patient presents to the office c/o weakness and dizziness. PE reveals a heart rate of 118 bpm that is irregular upon auscultation. You order an EKG and see absent p waves with an irregularly irregular rhythm. You dx A-fib. How can you treat non-Rx? How can you treat Rx? What will be absent on JVP?
Class 1 = Na+ blockers (A = DQP, B = LTMP, C = MFP)
Class 2 = BB
Class 3 = K+ blockers = amiodarone, ibutilide, sotalol, dofetilide, and dronedarone
Class 4 = CCB = verapamil and diltiazem
Others = Digoxin, Adenosine, and Magnesium sulfate(torsades de pointes)
No "a" wave on JVP
Bypass tracts with _ _ _ _ include the 'bundle of '___' seen in Wolff-Parkinson-White syndrome.
* DELTA wave!!
PVCs with exercise = Bad or Good?
Bad... suppression during exercise = Good
Tx = BB if recurrent or > 10/ hr
What is the definition of VT?
A run of 3 or more PVCs
How do you treat VT: with a pulse? without a pulse? prevention?
Cardioversion/ drugs/ defibrillation for torsades
Beta blockers, Amiodarone, ICDs
What congenital heart defect is common in Down's Syndrome patients?
* RVH, RAE, RAD, ?RBBB, increased pulomonary vasculature
What is the MC congenital heart defect?
* LVH;LAE,+/-RVH, increased pulmonary vasculature
What congenital defect/ valvular defect is seen in Noonan Syndrome?
* Tx = balloon dilation via cardiac catheterization
You are in L&D and a new baby is born. As you are doing your postpartum exam on the newborn you notice diminished femoral pulses and a murmur over the ULSB. BP is also greater on the arm (82/67) than in the leg (62/54). What do you suspect before confirmation by echo?
Echo confirms dx.
CXR will show rib notching and cardiomegally
What is the radiographic sign in children with AS?
Dilated ascending aorta
What is it called when a L-to-R shunt developes increased pulm resistence over time and reverses the shunt to a R-to-L (causing Pulm HTN)? Deoxygenated blood enters systemic circulation, leading to hypoxia.
* Clubbing, cyanosis, polycythemia
Which of the following is an acyanotic lesion?
A) Tetralogy of Fallot
B) Coarction of the Aorta
C) Transposition of the great Arteries
D) Tricuspid Atresia
E) Hypoplastic Left Heart Syndrome
B) Coarction of the Aorta
Cyanotic = 5 T's + H
TOF, TOGA, Tricuspid Atresia, Truncus Arteriosus, and Total Anomalous Pulmonary Venus Connection
Pulmonary Stenosis, RVH, Overriding Aorta, VSD
What heart defect has the blood flow of RA to RV to body through ASD?
VSD is also usually present, so some blood backs up to the lungs and is oxygenated.
Tricuspid Atresia: CXR
Boot-shaped and decreased pulmonary vasculature
What vessels are transposed in TOGA?
Aorta and Pulmonary Artery
What heart defect has the common pulmonary veins insert into other areas other than the LA, most commonly the SVC; so, oxygenated blood mixes with deoxygenated blood in R side of heart?
Total Anomalous Pulmonary Venus Connection
Total Anomalous Pulmonary Venus Connection: CXR
What heart defect has a single arterial trunk arising from normal ventricles (fused aorta and pulmonary artery)? The pulmonary arteries originate from common arterial trunk, and CHF develops due to pulmonary overload.
What 2 valves are hypoplastic in Hypoplastic Left Heart Syndrome?
Mitral Valve and Aortic Valve
* Weak peripheral pulses, CXR = pulmonary vascular congestion
Thrombus : Localized or fixed :: Embolus : ______
Give examples of each:
Anticoagulant: Inhibit blood coagulation
Antithrombotic: Inhibit platelet aggregation
Thrombolytic: Degrades clots that have already formed
Anti-coag: Warfarin and heparin
Anti-thrombo: Clopidegril and ASA
Thrombolytic: Streptokinase, urokinase, reteplase, rtPA
When are thrombolytics indicated?
MI (< 6 hours) and Stroke (< 3 hours)
When are thrombolytics contraindicated?
Recent trauma (esp head)
Warfarin use within
T or F: ST elevation > 1 small box (0.04) in 2 leads is consistent with an MI.
Lateral MI leads = I, L, 5, 6
Anterior MI leads = V1-4
Inferior MI Leads = II, III, avF
T or F: If the QRS is up in avR, then the leads are placed correctly.
The av leads are either reversed, or the heart is on the right side of the body instead of the left (dextrocardia)
T or F: ST Segment elevation in ALL leads except for aVR and V1 indicates Pericarditis.
Pericarditis has ST elevation in 10 leads, _______ T waves late in disease, and ___ voltage.
* PR interval is depressed below baseline
What cardiomyopathy looks like this on EKG: LVH, Left atrial enlargement, Q waves, poor R wave progression, afib?
What cardiomyopathy looks like this on EKG: may have abnormal Q waves in inferior and apical leads, may have evidence of LVH?
What cardiomyopathy looks like this on EKG: conduction disturbances and low-voltage QRS complexes are common with amyloidosis or sarcoidosis, RBBB or LBBB may be present?
When determining axis deviation, Lead I lies along the horizontal axis and positive is ______. avF is the vertical axis, and positive is to the ______. LAD is + F, - I. RAD is - _ +_. Normal is + _ + I. Extreme LAD/ NW territory is - F - I.
Right Atrial Enlargement = ______ p wave.
LAE = __-shaped p wave.
RVH = RAD + _ wave > 7 mm with an ______ going QRS.
LVH = V1 r + V5 or _ s = > 35 mm
On EKG you see the following:
i) Short PR interval (<0.08 secs)
ii) Slurred upstroke (delta wave) to the QRS complex
iii) Also prolonged QRS (>0.12 secs)
What is your interpretation?
What heart block is caused from prolonged conduction delay in the AV node or Bundle of His, and has a regular beat with a consistent prolong PR interval on EKG?
PR > 0.20 (one big block)
* Normal QRS width
What heart block has gradual PR prolongation preceding a dropped p wave with a blocked (absent) QRS complex and then the cycle is picked back up again?
2nd degree type 1 (Wenckebach)
* Normal QRS width
What heart block is caused by an intermittant block in the bundle of his where there is no prolonging PR interval (it is fixed), but p waves with dropped QRS complexes are often?
2nd degree type 2
* Normal QRS width
* May have more than one p wave origin
What heart block has p waves "marching" at their own beat (> 60), and QRS ventricular rhythms at their own rate (slower 30-40)?
What heart block has no p waves, and just ventricular rhythms/ QRS complexes (< 40 bpm)?
Complete Heart Block
ABI index is used for COA and PAD.
> 0.9 (up to 1.3) = Normal
0.4-0.59 = Moderate PAD
< 0.39 =
a) HTN: Retinal exudates, Hemorrhages, Papilledema (Emergency), _-_ nicking
b) DM: Cotton wool spots, Microaneurysms, ______ exudates, Flame hemorrhage, Dot-blot hemorrhages
c) Optic Neuritis: Papillitis, ____ or swollen disc, May be normal
What is the MC type of cardiomyopathy?
* Impaired systolic function, normal wall thickness, enlargement of all cardiac chambers
What cardiomyopathy as the follow sx: fatigue, CHF (left sided or biventricular), ventricular arrythmias, S3 and S4 gallops, MR, +/- TR?
* Decreased LV and RV EF
What cardiomyopathy is common in young athletes and murmurs increased with standing like MVP?
HCM - thickened LV wall
HCM : diastolic dysfunction :: Dilated : _______ dysfunction
What cardiomyopathy has the following sx: asymptomatic, sometimes DOE/fatigue/SOB, S4 gallop, murmurs that increase with valsalva?
* Abnormal Q waves in inferior and apical leads
Which of the following is NOT a cause of restrictive cardiomyopathy?
C) Rheumatic Fever
E) All of the above are causes.
C) Rheumatic Fever
* Restricitive has RHF sx
JONES criteria is for what disease?
2 Major, or 1 major + 1 minor and a + Strep Test
What are the Major Jones Criteria? Minor?
JONES = Joints (polyarthritis), Heart (carditis), Nodules (Janeway and Oslers), Erythema marginatum, Sydenham's Chorea
FEAR 1 P = Fever, Elevated ESR and CRP, Arthralgia, 1st Degree Heart Block, and Prolong PR interval
Yellow vision = what drug overdose?
Nitrite/ Nitrate Overdose treatment =
Lavage, charcoal, ABCs, etc.
Normal BP = 120/__
Pre-HTN = 120-139/ 80-89
HTN Stage 1 = ___-159/ 90-99
Stage 2 = 160-___/100-109
Stage 3 = > ___/ > 110
GOAL: LDL cholesterol goal: <___ mg/dL (soon to be <70 mg/dl)
* Total = < 200
If LDL is > 100 after 3 months, what is your next treatment step?
Rx therapy... Statin unless contraindicated.
If LDL is > 130, what is your treatment option?
Automatic Rx therapy