Cardiology Blueprint: Questions and Answers for Medical Students, Exams of Medicine

Download Cardiology Blueprint: Questions and Answers for Medical Students and more Exams Medicine in PDF only on Docsity!

Family Medicine EOR - Cardiology Blueprint

questions with correct answers

What are 95% of HTN cases? CORRECT ANSWER essential HTN What are secondary causes of HTN? CORRECT ANSWER - renal disease

• renal stenosis
• aortic coarctation
• hyperaldosteronism from tumor or hyperplasia
• Cushing's
• pheochromocytoma
• OSA What are the JNC-7 classifications and initial treatment of HTN? CORRECT ANSWER pre-HTN: 120/80-139/89 --> lifestyle changes HTN Stage I: 140/90-159/99 --> thiazide (or loop if renal patient) HTN Stage II: >160/100 --> thiazide + 2nd agent What is the 2nd MCC of ESRD? CORRECT ANSWER HTN What signifies an advanced stage of malignant HTN? CORRECT ANSWER papilledema What is hypertensive urgency CORRECT ANSWER - stable or no end organ damage
• no raised ICP

What are symptoms and signs of hypertensive urgency CORRECT ANSWER - SOB

• HA
• BP >220/ How is hypertensive urgency managed? CORRECT ANSWER - lower BP slowly over 24-48h with labetaolol, clonidine, captopril, furosemide, or nicardipine
• reduce to/below 160/
• MAP should not be lowered by >25% in first several hours What happens in a hypertensive emergency? CORRECT ANSWER - rapidly progressing end organ damage
• 180/120+
• papilledema if malignant What are signs and symptoms of a hypertensive emergency CORRECT ANSWER
• chest pain
• AMS
• weakness
• MI
• acute CHF
• renal failure
• ICH
• eclampsia
• aortic dissection
• retinal damage

How is a hypertensive emergency managed? CORRECT ANSWER decrease MAP by no more than 25% in 1st hour and then another 5-15% over next 23h with IV agents unless:

• acute phase of ischemic stroke (don't lower BP unless patient with 185/110+ who can have thrombolytics or patient with 220/120+ who cannot have thrombolytics)
• acute aortic dissection (BP reduced to SBP 100-120 in 20min) How is HTN monitored in primary care CORRECT ANSWER - annual urine microalbumin
• annual BMP
• annual lipids
• baseline EKG (look for LVH) How much does a single pharmacologic agent lower BP in HTN? CORRECT ANSWER by 10-20 mmHg (may need 2nd agent) What thiazides are used to treat HTN? CORRECT ANSWER - HCTZ
• chlorthalidone When is a thiazide preferred for treating HTN? CORRECT ANSWER good for osteoporosis because it is calcium sparing When can't a thiazide be used? CORRECT ANSWER CrCl< What loop diuretic is used to treat HTN? CORRECT ANSWER furosemide What are some K-sparing agents for HTN? CORRECT ANSWER - spironolactone

• eplerenone What is the problem with K-sparing agents? CORRECT ANSWER not very potent What ACEIs are used to treat HTN? CORRECT ANSWER - benazepril
• enalapril
• lisinopril What is a common side effect of ACEIs? CORRECT ANSWER cough What precautions should be taken with ACEIs? CORRECT ANSWER - can cause renal failure
• stop if serum Cr increases by 30%
• pregnancy D What ARBs are used to treat HTN? CORRECT ANSWER - irbesartan
• losartan
• olmesartan
• valsartan What is a common side effect of ARBs? CORRECT ANSWER cough What precautions should be taken with ARBs? CORRECT ANSWER - can cause renal failure
• stop if serum Cr increases by 30%
• pregnancy D

What CCBs are used to treat HTN? CORRECT ANSWER - nifedipine (dihydropyridine)

• amlodipine (dihydropyridine)
• verapamil (non-dihydropyridine)
• diltiazem (non-dihydropyridine) What warning was issued by the FDA regarding CCBs? CORRECT ANSWER caution with using simvastatin with amlodipine, verapamil, and diltiazem What is a contraindication to CCBs? CORRECT ANSWER heart failure When can clonidine be used to treat HTN? CORRECT ANSWER refractory HTN (due to risk of falls) What is a contraindication to B-blockers? CORRECT ANSWER - heart block
• decompensated heart failure What can B-blockers mask? CORRECT ANSWER signs of hypoglycemia What are the preferred HTN drug class if a patient also has a history of diabetes? CORRECT ANSWER - thiazide
• B-blocker
• ACEI/ARB
• CCB

What are the preferred HTN drug class if a patient also has a history of MI? CORRECT ANSWER - B-blocker

• ACEI
• AA What are the preferred HTN drug class if a patient also has a history of CAD? CORRECT ANSWER - thiazide
• B-blocker
• ACEI
• CCB What are the preferred HTN drug class if a patient also has a history of CHF? CORRECT ANSWER - thiazide
• B_blocker
• ACEI/ARB
• AA What are the preferred HTN drug class if a patient also is pregnant? CORRECT ANSWER - clonidine
• methyldopa What are the preferred HTN drug class for older patients? CORRECT ANSWER CCB What are the preferred HTN drug class if a patient also has a history of CKD? CORRECT ANSWER ACEI/ARB

What are the preferred HTN drug class if a patient also has a history of stroke? CORRECT ANSWER - thiazide

• ACEI What are the risk factors for coronary artery disease? CORRECT ANSWER - age
• males
• FHx
• sedentary lifestyle
• tobacco
• HTN
• DM
• increased lipids What is the underlying pathology of acute MIs? CORRECT ANSWER burst plaque --> activation of clotting system --> infarction How long does it typically take for stable angina to resolve? CORRECT ANSWER 2-30min How many classes are there for coronary artery disease? CORRECT ANSWER 4 For coronary artery disease, what does Class 1 look like? CORRECT ANSWER no limitations or symptoms with normal activity For coronary artery disease, what does Class 2 look like? CORRECT ANSWER slight limitations and normal activity result in symptoms

For coronary artery disease, what does Class 3 look like? CORRECT ANSWER marked limitation and minimal activity results in symptoms For coronary artery disease, what does Class 4 look like? CORRECT ANSWER symptoms persist with minimal activity and rest What is the differential for cardiac chest pain? CORRECT ANSWER - atherosclerosis

• vasospasm (from cocaine or stimulants
• Prinzmetal's angina (women <50yo)
• coronary artery or aortic dissection
• congenital abnormality
• aortic stenosis
• HCM
• coronary thrombus or embolus What is the differential for non-cardiac chest pain? CORRECT ANSWER - costochondritis: reproducible on palpation
• intercostal shingles
• cervical or thoracic spine disease: reproducible with certain movements of head/neck, causes paresthesias
• PUD
• GERD
• cholecystitis
• PE
• pneumonia
• pneumothorax: dyspnea

What are physical exam findings of coronary artery disease? CORRECT ANSWER - S

• arterial bruits
• abnormal funduscopic exam
• corneal arcus
• xanthelasma
• tendinous xanthoma
• CHF
• murmurs What should be done if a patient has a low probability of coronary artery disease? CORRECT ANSWER stress test What should be done if a patient has a intermediate probability of coronary artery disease? CORRECT ANSWER stress test What should be done if a patient has a high probability of coronary artery disease? CORRECT ANSWER cardiac catheterization How is new or worsening coronary artery disease managed? CORRECT ANSWER - refer to cardiology
• ED if EKG shows new ischemic changes (ST depression/elevation, inverted T waves, hemodynamic instability) What is the LDL goal for management of stable coronary artery disease? CORRECT ANSWER <100 or <

What medication classes are used to manage stable coronary artery disease? CORRECT ANSWER - B-blocker (proven mortality benefit)

• CCB
• statin
• clopidogrel
• nitrates PRN How often should someone with stable coronary artery disease be checked? CORRECT ANSWER - PCP every 6mo
• annual CBC (check for anemia)
• annual lipids FBG
• cardiologist every 1-2y What leads to congestive heart failure? CORRECT ANSWER ischemic heart disease (systolic HF) also:
• bad valves
• HTN (diastolic HF)
• myocarditis
• pericarditis
• alcoholism (R HF)
• substance abuse
• COPD (R HF) What is found on physical exam for right heart failure? CORRECT ANSWER - mostly clear lungs with dullness at bases

• increased JVD with hepatojugular reflux
• tricuspid regurg
• peripheral edema What is found on physical exam for left heart failure? CORRECT ANSWER - crackles
• wheezes
• dullness at bases
• frothy or pink sputum
• displaced PMI
• mitrl What sound is heard in congestive heart failure? CORRECT ANSWER S3 gallop What is the workup for congestive heart failure? CORRECT ANSWER - referral for echo
• EKG for LVH
• CXR for pulmonary edema
• BNP What lifestyle changes can be made to manage congestive heart failure? CORRECT ANSWER - salt restriction
• daily weights
• avoid NSAIDs
• avoid CCBs

What classification system is used for congestive heart failure? CORRECT ANSWER New York Heart classification What is Class 1 of the New York Heart classification? CORRECT ANSWER - no limitation of physical activity

• physical activity does not cause fatigue, palpitation, or SOB What is Class 2 of the New York Heart classification? CORRECT ANSWER - slight limitation of physical activity
• comfortable at rest, but physical activity results in fatigue, palpitations, or SOB What is Class 3A of the New York Heart classification? CORRECT ANSWER - limitation of physical activity
• comfortable at rest, but ordinary activity causes fatigue, palpitations, or SOB What is Class 3B of the New York Heart classification? CORRECT ANSWER - significant limitation of physical activity
• comfortable at rest, but minimal activity causes fatigue, palpitation, or SOB What is Class 4 of the New York Heart classification? CORRECT ANSWER - unable to carry on any physical activity without discomfort
• symptoms of heart failure at rest How is peripheral vascular disease defined? CORRECT ANSWER systemic atherosclerosis distal to the aortic arch What leads to peripheral vascular disease? CORRECT ANSWER atherosclerosis in the descending aorta, external iliac arteries, LE arteries

Who is at risk for peripheral vascular disease? CORRECT ANSWER - smoking

• diabetes
• HTN
• hyperlipidemia
• obesity What are factors in the presentation of peripheral vascular disease? CORRECT ANSWER - degree of occlusion
• location of plaques How does peripheral vascular disease present? CORRECT ANSWER - diminished periphera; pulses
• femoral bruits
• cool skin or abnormal skin color
• poor hair growth (shiny hairless toes!)
• intermittent pain and claudication as a result of muscle tissue ischemia that is reproducible
• ulcers and gangrene (diabetes) Where does the intermittent pain and claudication of peripheral vascular disease occur? CORRECT ANSWER area BELOW the level of disease What is the character of the pain associated with peripheral vascular disease? CORRECT ANSWER - worsens with activity
• goes away with rest

• can have resting pain (especially at night) when baseline demand ofr oxygen is greater than inflow What is the differential for peripheral vascular disease? CORRECT ANSWER ... What is the most common complaint of HTN? CORRECT ANSWER Non-specific HA What is the BP goal for patients of any age with diabetes? CORRECT ANSWER <130/ What is the anti-HTN medication of choice in a pregnant patient? CORRECT ANSWER Labetolol, Methyldopa, Nifedipine Treatment for thrombophlebitis/DVT? CORRECT ANSWER Superficial thrombophlebitis is treated with bed rest, local heat, elevation of extremity, NSAIDs Antibiotics Surgical intervention if serious What is an Aortic aneurysm? CORRECT ANSWER Weakness and subsequent dilation of the vessel wall Where do AA occur? Which is more common? CORRECT ANSWER Abdominal (90%) Thoracic (10%)

Causes of AA? Which is most common? CORRECT ANSWER Atherosclerosis <---MC cause Genetic Giant cell arteritis Vasculitis Trauma Marfan syndrome Ehlers-Danlos syndrome What is the classic patient to have an AA? CORRECT ANSWER Elderly male smoker with CAD, emphysema, and renal impairment What are clinical features of an abdominal AA (AAA)? CORRECT ANSWER Asymptomatic Pulsating abdominal mass Abdominal or back pain What are clinical features of a thoracic AA? CORRECT ANSWER Asymptomatic Substernal, back, neck pain Dyspnea Stridor Cough Dysphagia Hoarseness Symptoms of SVC syndrome

Diagnostic studies for AAA? CORRECT ANSWER Abdominal US is study of choice! Diagnostic studies for thoracic AA? CORRECT ANSWER Aortography CT/MRI are preferred over US What are the current recommendations for screening for AAA? CORRECT ANSWER Single abdominal US in men >65 who have ever smoked followed by contrast CT Tx for AAA? CORRECT ANSWER Replace with graft, either endovascular (EVAR) or open surgical repair (5 year survival is >60%) What is aortic dissection?What is the MC cause of aortic dissection? CORRECT ANSWER Separation of the walls of the aorta from an intimal tear and disease of the tunica media. A false lumen is created and a "reentry" tear may occur, resulting in a double barrel aorta What is the MC cause of aortic dissection? CORRECT ANSWER HTN What are clinical features of a aortic dissection? CORRECT ANSWER "Ripping or "tearing" chest pain radiating to the back Severe back, abdominal, flank pain Hypotension/shock What are the two classes of aortic dissection? CORRECT ANSWER Debakey Stanford

What is Debakey I, II, III? CORRECT ANSWER I - involves ascending and descending aorta II - involves ascending aorta only III - Involves descending aorta only What is Stanford A and B? CORRECT ANSWER A - Involves ascending aorta B - involves descending aorta Which type of dissection requires surgery? CORRECT ANSWER Stanford A (DeBakey I and II) Diagnostic tests for aortic dissection? CORRECT ANSWER CXR - widened mediastinum, pleural effusion TEE CTA Aortography - gold standard (but not often done) Tx for type A aortic dissection? B? CORRECT ANSWER A is treated with excision of tear and a portion of the ascending aorta, replacement with aortic graft, and repair or replacement of the aortic valve B is treated medically with tight BP control with BB and afterload reducers (Nitroprusside). May need surgery. What medications are recommended for BP control in aortic dissection? CORRECT ANSWER Nitroprusside and a B-blocker What would you find on a CXR with CHF? CORRECT ANSWER Kerley B lines

Pulmonary edema Cardiomegaly Pulmonary effusions Venous dilations What would you find on an EKG with CHF? CORRECT ANSWER LA hypertrophy Arrhythmias (can be any rhythm) LV Hypertrophy What would you find in an Echo with CHF? CORRECT ANSWER Low EF (if systolic dysfunction) Hypertrophy Valve abnormality Wall motion abnormalities What is cardiomyopathy? CORRECT ANSWER Type of heart disease where heart is abnormally enlarged, thickened, or stiffened thus reducing its ability to pump. More common in men, especially AA. What are the three types of primary cardiomyopathy? Which is the most common type? CORRECT ANSWER Dilated (DCM) <---most common (95%) Hypertrophic (HCM) Restrictive (RCM) What is dialated cardiomyopathy? CORRECT ANSWER The left ventricle (or both ventricles) have lost their pumping strength which results in dilation of the ventricle to compensate.

What are causes of dilated cardiomyopathy? CORRECT ANSWER Genetic (25%) Excessive alcohol intake Postpartum state Chemo toxicity Endocrinopathies Myocarditis Idiopathic What is the criteria for diagnosis of DCM? CORRECT ANSWER Requires evidence of dilation and LVEF <40% Dyspnea S3 gallop Pulmonary crackles Increased JVP Diagnostic studies for DCM? CORRECT ANSWER EKG - will show nonspecific ST and T wave changes, conduction abnormalities, and ventricular ectopy CXR - will show cardiomegaly and pulmonary congestion Echo - will show LV dysfunction and dilation with high diastolic pressures and low cardiac output (EF) Nuclear studies/cardiac cath Treatment for DCM? CORRECT ANSWER Abstinence from alcohol Treat underlying disease Pharm tx

CHF treatments Implantable defibrillators Definitive tx is cardiac transplant What are 5 pharm treatments you can initiate with DCM? (5) Which is first line? CORRECT ANSWER ACEI and diuretics (1st line) Digoxin Carvedilol Hydralyzine/nitrate Anticoagulation prn What is Hypertrophic cardiomyopathy? CORRECT ANSWER Genetic disease characterized by hypertrophy of the septum, a small LV, systolic anterior mitral motion (SAM), diastolic dysfunction. Microscopic myocardial abnormalities promote development of arrhythmias How does HCM clinically present? CORRECT ANSWER SSAAAD: Syncope SCD Angina Arrhythmias Asymptomatic Dyspnea PE findings with HCM? CORRECT ANSWER Sustained PMI or triple apical impulse Loud S4 gallop

Bisferiens carotid pulse JVP pulsations with prominent "a" wave A harsh systolic murmur at LSB which gets worse with Valsalva and lessens with squatting Diagnostic studies and findings for HCM? CORRECT ANSWER CXR - unremarkable EKG - nonspecific ST and T wave changes, exaggerated septal Q waves, LVH Echo - key to diagnosis! LVH, assymmetric septal hypertrophy, small LV, diastolic dysfunction Can also do myocardial perfusion, cardiac MRI, cardiac cath Tx for HCM? CORRECT ANSWER Beta blockers <---first line CCBs Disopyramide Anti-arrhythmics Pacemakers/ICD Mitral valve replacement Myoectomy Septal ablation Transplant (for severe cases) What is restrictive cardiomyopathy (RCM)? CORRECT ANSWER Fibrosis or infiltration of the ventricular wall because of collagen-defect diseases. Most commonly amyloidosis, radiation, postoperative changes, diabetes, and endomyocardial fibrosis. LV is small-normal sized with mildly reduced function.

What is the hallmark of RCM? CORRECT ANSWER Abnormal diastolic dysfunction What are clinical manifestations of RCM? CORRECT ANSWER Dyspnea on exertion Advanced disease you will see right sided HF and Pulmonary HTN Diagnostic studies and findings with RCM? CORRECT ANSWER CXR - mildly enlarged cardiac silhouette Echo - key to diagnosis! EKG Cardiac MRI Cardiac cath Endomyocardial biopsy - will differentiate restrictive disease from other forms of cardiomyopathies or pericarditis Tx for RCM? CORRECT ANSWER No good treatment - you can use diuretics for extremely high filling pressures Transplant is indicated for severe disease What is "broken heart syndrome"? CORRECT ANSWER AKA Takotsubo cardiomyopathy. It is a stressed induced CM. Due to large volume of catecholamines which results in hypocontractility of the left ventricular apex. Clinical presentation can be indistinguishable from MI. What diagnostic study can distinguish Takotsubo cardiomyopathy from MI? CORRECT ANSWER Cardiac cath - will show hypocontractility of LV apex and patent coronary arteries

Who usually gets "broken heart syndrome"? How is it treated? CORRECT ANSWER Postmenopausal women. Supportive care; resolves on its own in <2 months. What valve is affected with Rheumatic heart disease? CORRECT ANSWER Mitral valve - causes stenosis What is an Austin Flint murmur? Quincke sign? "Water hammer" pulse? CORRECT ANSWER Austin flint murmur - Reverberation of regurgitant flow Quincke sign - capillary pulsations of the nail bed "Water hammer" pulse - increased pulse pressure palpated over peripheral arteries Musset sign - head bobbing with each heart beat What is Pericarditis? CORRECT ANSWER Inflammation of the pericardium which is usually idiopathic or viral (90%). Other causes include bacterial, autoimmune, connective tissue disease, neoplasm, radiation, chemo, drug toxicity, cardiac surgery, or myxedema. MC in men and <50 yo. Clinical features of pericarditis? What are the three classic features of pericarditis? CORRECT ANSWER 3 classic features: Pleuritic, sharp chest pain (relieved by sitting upright/leaning forward), Diffuse ST elevation, Friction rub Constrictive pericarditis causes dyspnea, fatigue, weakness, edema, hepatomegaly, ascites Diagnostic studies for pericarditis? CORRECT ANSWER CBC - WBC elevated EKG - diffuse ST elevation Echo, dopper, CT, MRI may be helpful Tx for pericarditis? CORRECT ANSWER Steroids

NSAIDs Antibiotics if bacterial Pericardiectomy if constrictive pericarditis What is Pericardial effusion? CORRECT ANSWER Build up of fluid between the pericardium and heart. Produces a restrictive pressure on the heart. Similar pathophysiology to pleural effusion of the lungs. What causes a pericardial effusion? CORRECT ANSWER Caused by pericarditis, lung cancer, uremia, trauma Clinical features of pericardial effusion? CORRECT ANSWER May be painful or painless. Cough and dyspnea are common. How is pericardial effusion different from cardiac tamponade? CORRECT ANSWER Cardiac tamponade is where there is a pericardial effusion that causes a significant degree of compression of the heart resulting in decreased blood being pumped around the body. Clinical features of cardiac tamponade? CORRECT ANSWER Beck's triad (Hypotension, JVD, Muffled heart sounds)!! Tachycardia Tachypnea Narrow pulse pressure Pulsus paradoxus (breathing in causes drop in BP) Diagnostic studies and findings with cardiac tamponade CORRECT ANSWER Echo

CXR - water bottle heart shape EKG - electrical alternans Tx of cardiac tamponade? CORRECT ANSWER If there is hemodynamic compromise, a pericardiocentesis is necessary to relieve fluid accumulation. NSAIDs - if due to pericarditis Abx - if infectious How are recurrent pericardial effusions treated? CORRECT ANSWER Pericardial window What is Myocarditis? CORRECT ANSWER Inflammation of the heart muscle due to.... Why is it difficult to diagnose myocarditis? CORRECT ANSWER The clinical presentation of myocarditis is highly variable and can mimic other noninflammatory cardiac disorders. Therefore, a high level of clinical suspicion is needed Who should you suspect myocarditis in? CORRECT ANSWER Patients with or without cardiac signs and symptoms who have a rise in cardiac biomarkers (eg, troponin), EKG changes suggestive of acute myocardial injury, arrhythmia, or abnormalities of cardiac function (typically on echo or cardiac magnetic resonance [CMR]), particularly if the clinical findings are new and unexplained Clinical features of myocarditis? CORRECT ANSWER Chest pain DOE, Fatigue Increase in troponin S3, S4 gallop