Step 3 Cardiology I

  1. Risk Factors for Coronary Artery Disease
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  2. DM as Risk Factor for CAD
    • Strict glycemic control significantly lowers microvascular complications (eg, retinopathy, nephropathy, neuropathy) but does not consistently reduce macrovascular complications (eg, CHD, stroke).
    • Patients with diabetes have a significant risk of atherosclerotic vascular disease and future cardiovascular events, with all-cause mortality equal to patients with established coronary heart disease (CHD) and prior myocardial infarction.
  3. Secondary Hypertension
    • A secondary cause of hypertension should be suspected in a very young or very old patient presenting with new-onset severe hypertension.
    • Renal parenchymal disease is the most common cause of secondary hypertension in young patients.
    • After renal parenchymal disease and endocrine etiologies, renovascular disease is the third leading cause of secondary hypertension.
  4. Abdominal Aortic aneurysm
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  5. Smoking and Expansion of AAA
    • Current cigarette smoking is the most important modifiable risk factor and has been associated with the highest rate of aneurysm expansion and rupture.
    • The pathophysiology is likely due to increased inflammation and degeneration of connective tissue in the aortic wall.
    • Therefore, smoking cessation is essential and has the greatest impact on decreasing the likelihood of aneurysm expansion.
  6. Antithrombotic Therapy in patients with Mechanical Heart Valve
    • Patients with mechanical mitral valves have twice the risk compared to those with aortic valve prostheses. Therefore, long-term treatment with aspirin and warfarin is recommended for all patients with mechanical aortic or mitral valve replacement to reduce the rates of systemic thromboembolism.
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  7. Targeted INR for Mechanical Heart Valve
    • Target International Normalized Ratio (INR) for aortic valves without risk factors is 2.0-3.0.
    • Target INR for mechanical aortic valves with high risk features (eg, atrial fibrillation, left ventricular dysfunction [ejection fraction less than 30%], prior thromboembolism, presence of hypercoagulable state) and mechanical mitral valves is 2.5-3.5.
  8. Acute Mitral Regurgitation
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  9. Acute Mitral Regurgitation
    • Patients with acute MR typically have a dramatic presentation (due to lack of time for left heart adaptation) compared to those with chronic MR.
    • They often present with sudden onset of hypotension which can rapidly progress to cardiogenic shock, with poor tissue perfusion and peripheral vasoconstriction.
    • Cardiac examination shows a hyperdynamic precordium and a midsystolic or holosystolic murmur.
    • Patients with acute, severe MR have early equalization of left atrial and left ventricular pressures, and up to 50% of patients (especially with ischemic MR) may have no audible murmur (silent MR).
    • Diagnosis is typically confirmed by transthoracic or transesophageal echocardiography.
  10. Ehler Danlos Versus Marfan's
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  11. Ehlers-Danlos Syndromes
    • It is a connective tissue disorder that is characterized by joint hypermobility, recurrent joint dislocations, "velvety" hyperextensible skin with easy bruisability, and delayed healing with atrophic scars.
    • Patients may have associated skeletal abnormalities, including thoracolumbar scoliosis and pes planus.
    • Other features include hernias, cervical insufficiency, and uterine prolapse.
    • Mitral valve prolapse with myxomatous degeneration of the valvular apparatus is a complication of EDS and can lead to rupture of chordae tendineae and acute mitral regurgitation (MR).
  12. Multifocal or multiform atrial tachycardia (MAT)
    • It is characterized by the presence of 3 or more P waves of different morphologies.
    • The QRS complexes are narrow, while the PR segments and the R-R intervals are variable.
    • The heart rate can reach up to 200 beats per minute.
  13. Causes of Multifocal atrial Tachycardia
    • MAT is usually secondary to the following conditions:
    • 1) hypoxia
    • 2) chronic obstructive pulmonary disease (COPD)
    • 3) hypokalemia
    • 4) hypomagnesemia
    • 5) coronary/ hypertensive/ valvular disease
    • 6) medications (i.e., theophylline, aminophylline, isoproterenol)
    • Therapy is aimed at correcting the underlying cause.
  14. Treatment of Multifocal Atrial tachycardia
    • Treatment of multifocal atrial tachycardia (MAT) is directed towards the correction of the underlying etiology (e.g., hypoxia, hypokalemia, hypomagnesemia).
    • If therapy is not effective and there are no contraindications, beta-blockers can be used successfully.
    • In patients with asthma or COPD, verapamil is the drug of choice.
  15. Long QT Syndrome
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  16. Torsades de pointes (TdP)
    It refers to the form of polymorphic VT that occurs in the setting of acquired or congenital QT prolongation and is characterized by cyclic alteration of QRS axis and/or morphology.
  17. Acquired Long QT Syndrome
    • The presence of bradyarrhythmias (sinus bradycardia or pauses) is associated with an increased risk of developing torsades de pointes in patients with drug induced acquired long QT syndrome (LQTS).
    • Common medications implicated in LQTS include antipsychotics, antidepressants, macrolides, fluoroquinolones, and antifungals.
  18. Management of Long QT Syndrome
    • Intravenous magnesium sulfate is indicated as first line therapy for the treatment and prevention of recurrent episodes of torsade de pointes, regardless of the patient's baseline serum magnesium levels.
    • Temporary transvenous pacing should be used in patients who do not respond to intravenous magnesium sulfate.
  19. Metformin and its Contraindications
    • Metformin is contraindicated for patients with renal insufficiency, hepatic dysfunction, alcohol abuse, sepsis, or congestive heart failure (especially with creatinine more than 1.5 mg/dl).
    • It can increase the risk for lactic acidosis when combined with large-dose intravenous iodine contrast (eg, during coronary angiography).
    • Metformin is usually held on the day contrast is given and restarted at least 48 hours later after documenting stable renal function.
  20. Death of Patient in SLE
    • SLE is associated with accelerated atherosclerosis due to a combination of traditional (eg, hypertension, hyperlipidemia) and disease-related risk factors (eg, chronic inflammation, glucocorticoid use).
    • Compared to other women age 35-44, patients with SLE have an almost 50-fold increase in CAD risk.
    • CAD is a significant contributor to premature death in SLE patients.
  21. Rate Control in AF
    • Beta blockers or non-dihydropyridine calcium channel blockers are the preferred first-line agents for ventricular rate control in patients with rapid atrial fibrillation.
    • Beta blockers are contraindicated or should be used with caution in patients with worsening congestive heart failure, hypotension, bronchospasm, and bradyarrhythmias.
  22. Participating Prisoners in Medical research
    Prisoners must be given equal rights to non-prisoners regarding participation in medical research, and should not be taken advantage of because of their legal status.
  23. Revascularization in patient with Stable Angina
    • Coronary revascularization is indicated primarily for 2 groups of patients with stable angina:
    • • Patients with refractory angina despite maximal medical therapy
    • • Patients in whom revascularization will improve long-term survival. This includes those with left main coronary stenosis and those with multivessel CAD (especially involving the proximal LAD) along with left ventricular systolic dysfunction.
  24. DM and Multivessel CAD
    In patients with diabetes and multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery is preferred over percutaneous coronary intervention due to a lower rate of all-cause mortality and myocardial infarction with CABG.
  25. PCI Vs CABG in CAD
    • PCI with bare metal or drug-eluting stents is an excellent revascularization option for patients with refractory angina due to severe single- or two-vessel CAD not involving the proximal LAD.
    • However, CABG is superior to PCI in patients with multivessel CAD (especially involving the proximal LAD) and left ventricular dysfunction, with lower rates of repeat revascularization and improved clinical outcomes.
  26. Measuring EF using Radionucleide Ventriculography
    • Radionuclide ventriculography has high accuracy and reproducibility for measuring ejection fractions.
    • Its most common use is in the initial evaluation and subsequent follow-up of patients receiving cardiotoxic chemotherapy agents such as doxorubicin.
  27. Initiating Doxycycline in Cardiac Compromised Patients
    • A radionuclide ventriculogram is generally performed at baseline before chemotherapy is initiated, and before each subsequent dose of chemotherapy.
    • The therapeutic regimen is dependent on the baseline cardiac function, with anthracycline chemotherapy contraindicated in patients with baseline ejection fractions less than 30%, and modified dosing required for patients with baseline ejection fractions of less than 50%.
    • A decrease in the ejection fraction by ten or more percentage points may warrant discontinuation of therapy.
  28. Bradyarrhythmias in the setting of Inferior wall MI
    • In the setting of acute inferior Ml, these bradyarrhythmias are typically transient and respond to intravenous atropine which is the initial intervention of choice.
    • In contrast to patients with inferior wall Ml, bradyarrhythmias associated with anterior wall Ml are commonly due to damage to the conduction system below the AV node.
  29. Treatment of Bradyarrhythmias in Anterior Wall MI
    • AV block in the setting of anterior Ml portends a bad prognosis.
    • Temporary transvenous cardiac pacing is indicated in patients with persistent and symptomatic bradyarrhythmias (eg, hypotension, dizziness, heart failure, syncope) that are not responsive to atropine.
  30. Initiation of Sexual Activity Post MI
    • Low-risk patients can perform light-intensity exercise without symptoms and should be able to initiate or resume sexual activity.
    • Examples include those with few CVD risk factors, controlled hypertension, asymptomatic left ventricular dysfunction, or successful revascularization of clinically significant lesions (more than 50%-60%).
  31. Initiation of sexual activity in Intermediate and High Risk Patients
    • High-risk patients should be referred for a detailed assessment prior to advising on activity.
    • Examples of high risk include those with refractory angina, New York Heart Association class IV heart failure, significant arrhythmias, or severe valvular disease.
    • • For indeterminate/intermediate-risk patients, stress testing is recommended to reclassify them as low- or high-risk and to help guide decisions.
  32. Interaction with Warfarin
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  33. Dosing Warfarin in patient taking amiodarone
    It is recommended that the warfarin dose be reduced by 25%-50% to compensate for the increase in serum concentration of warfarin after initiating amiodarone therapy.
  34. Atrial Fibrillation in Thyroid Disease
    • AF is the most common supraventricular arrhythmia, occurring in about 10%- 20% of patients with hyperthyroidism.
    • Thyroid hormones cause an increase in sympathetic activity, due to an increase in beta-adrenergic gene expression, which is responsible for many of the symptoms of hyperthyroidism (eg, palpitations, tachycardia, anxiety, tremors).
    • Beta blockers (eg, propranolol) are recommended initially to ameliorate hyperadrenergic symptoms and control heart rate until the patients become euthyroid with thionamides and/or radioiodine.
  35. CVS Effects of Hyperthyroidism
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  36. Management of Graves Disease
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  37. ADR of Thiozolidinediones
    • PPAR-y receptors are present in the collecting tubule of the nephron, and stimulation by pioglitazone results in increased sodium reabsorption. This is the same channel via which aldosterone mediates its effects on sodium retention.
    • Fluid retention can occur in 4- 6% of patients on thiazolidinediones, but most of these patients likely have underlying heart failure.
  38. Angioedema caused by ACE Inhibitors
    • Angioedema is a possible side effect of angiotensin converting-enzyme inhibitors that occurs in less than 1% of patients.
    • Those with this reaction should discontinue the drug or switch to an angiotensin-receptor blocker (ARB) if needed.
    • The risk of angioedema with ARBs is low, and ARBs have benefits similar to those of ACE inhibitors.
  39. Guidelines of PCI
    • Current guidelines recommend the use of primary percutaneous coronary intervention (PCI) for any patient with acute STEMI as follows:
    • • Within 12 hours of symptom onset AND
    • • Within 90 minutes of first medical contact to device time at a PCI-capable facility (door to balloon time)
    • OR
    • • Within 120 minutes of first medical contact to device time at a non-PCI-capable facility (to allow time for transport to a PCI-capable facility).
  40. Management of AV Block
    • The initial management approach is to identify and correct any reversible causes of depressed AV conduction (eg, myocardial ischemia, medications, enhanced vagal tone).
    • Patients with Mobitz type II AV block have a high likelihood of progressing to third-degree or complete AV block.
    • In the absence of reversible causes, all patients with symptomatic Mobitz type I and Mobitz type II AV block (symptomatic or asymptomatic) should be managed with implantation of a permanent pacemaker.
    • Patients with severe symptoms and/or hemodynamic instability with severe bradycardia or hypotension should be managed initially with a temporary transvenous or transcutaneous external pacemaker prior to a permanent pacemaker.
  41. Type II AV Block
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  42. Pericardial Temponade
    • The typical physical signs and symptoms arise from the limited filling of the ventricle.
    • The classic Beck's triad is hypotension, muffled or distant heart sounds, and elevated jugular venous pressure.
    • Cardiac tamponade is a surgical emergency, and an ECHO should be obtained urgently.ECHO will reveal the large pericardial effusion, with prominent collapse of the right atrium and ventricle during diastole.
    • Cardiac catheterization can confirm the diagnosis by showing equalization of diastolic pressures in all chambers.
    • Rapid pericardiocentesis is life-saving.
  43. Acute aortic dissection
    • It refers to a tear in the aortic intima with separation of the intima from the media, thereby creating a false lumen within the aortic wall.
    • The dissection may propagate either distal or proximal to the intimal tear, causing the associated clinical manifestations.
  44. Risk Factors of Acute aortic Dissection
    It is usually seen in elderly males with a longstanding history of hypertension and atherosclerosis; however, some conditions associated with or predisposing to aortic dissection in younger patients include a history of connective tissue disorder (Marfan's syndrome, Ehler-Danlos syndrome), inflammatory vasculitis (Takayasu's arteritis, giant cell arteritis, syphilis aortitis), bicuspid aortic valve, coarctation of aorta, use of crack cocaine and trauma.
  45. Clinical Features of Aortic Dissection
    • Most of the patients present with a sudden onset of sharp tearing chest or back pain.
    • Patients with ascending aortic dissection may also develop acute aortic insufficiency, thereby causing acute heart failure (with early diastolic decrescendo murmur), acute myocardial infarction due to the dissection extending into coronary vessels, cardiac tamponade or hemothorax or neurological deficits due to the direct extension of dissection into the carotid arteries.
  46. Investigating a patient of Aortic Dissection
    • Physical examination may reveal a significant difference in the blood pressure between the two arms due to the involvement of the subclavian vessels.
    • The diagnosis is usually suspected based on the history and physical examination, along with mediastinal widening on chest radiograph and the absence of typical electrocardiographic findings of myocardial ischemia or infarction.
    • Transesophageal echocardiography is the modality of choice for rapid confirmation of the diagnosis.
  47. Treatment of Aortic Dissection
    • Acute aortic dissection involving the ascending aorta is a life-threatening emergency, and all such patients should have emergent surgical intervention.
    • The goal of early medical treatment is to rapidly reduce the shearing stress on the aortic wall and prevent the further propagation of dissection.
    • This is achieved by rapidly lowering the systolic blood pressure and left ventricular contractility with the use of intravenous beta-blockers.
  48. Management Of BP in Aortic Dissection
    • Intravenous beta-blockers are the initial drugs of choice in the management of patients with aortic dissection.
    • The goal is to reduce the systolic blood pressure to 100 to 120mmHg, and to reduce the heart rate to less than 60 per min.
    • An intravenous loading dose of propanolol or labetalol followed by an IV infusion can be used to achieve the desired heart rate and blood pressure in most patients.
    • If the blood pressure continues to remain high (systolic blood pressure greater than 100 mmHg), direct vasodilator sodium nitroprusside should be added to the beta-blockers to achieve the desired blood pressure goal.
  49. Cocaine Related Chest Pain
    • Cocaine-related chest pain patients should be treated early with benzodiazepines.
    • Benzodiazepines (e.g. lorazepam) can decrease anxiety and agitation associated with cocaine use.
    • Because the cardiovascular manifestations of cocaine use are intimately associated with its neuropsychiatric effects, benzodiazepines may indirectly decrease myocardial ischemia by resolving associated hypertension and tachycardia.
    • Avoid beta blockers to prevent coronary vasospasm caused by unopposed alpha stimulation.
  50. Treating HTN in patient with Cocaine related chest pain
    • In patients with cocaine-related chest pain, more aggressive management of hypertension is indicated when blood pressure does not improve with benzodiazepines.
    • Phentolamine is particularly effective and additionally decreases coronary artery vasospasm, although nitroprusside and nitroglycerine are also reasonable options.
    • Beta-blockers should be avoided.
Author
Ashik863
ID
336015
Card Set
Step 3 Cardiology I
Description
MI, Coronary
Updated