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Cardiology

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What is the indication for low-dose aspirin for primary prevention?

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What EKG findings do you expect to see in STEMI?

 

What is Wellen’s Pattern or Syndrome?

  • Deep T-wave inversions in multiple precordial leads eg V1-V4 in a patient presenting with ischemic chest pain can suggest high-grade LAD stenosis

  • Sample EKG: https://www.jetem.org/wellens/

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How might RV infarction present? What is a unique aspect of treatment of RV infarction?

 

ICDs are indicated post-MI if which criteria are met?

  • >40 days since MI or >3 months since PCI/CABG 

                                  And

 

How long do you need dual anti-platelet therapy (DAPT) for a BMS vs DES?

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What signs/symptoms have the highest likelihood ratio for HF? 

  • PND and S3

 

What are the NYHA functional classes?

  • Class 1. No limitation in physical activity

  • Class 2. Slight limitation of physical activity

  • Class 3. Marked limitation of physical activity

  • Class 4. Unable to carry on any physical activity without symptoms

 

What are the AHA stages of heart failure?

  • Stage A: at risk for HF but without structural heart changes

  • Stage B: structural heart disease but without heart failure symptoms

  • Stage C: structural heart disease with current or prior heart failure symptoms

  • Stage D: refractory heart failure requiring advanced intervention 

 

What degree of BNP level elevation is very suggestive of HF? Less than what level is suggestive against HF? 

  • Generally, >400 very suggestive; <100 suggestive against

  • Falsely low BNP in obesity

  • Unreliable BNP in ESRD and patients on entresto

 

Indication and benefit for typical HFrEF medications?

  • ACE/ARB: all stages; reduces mortality

  • Entresto: class II-IV, EF <40%; reduces mortality more so than ACEI/ARBs alone

  • Hydralazine+nitrates: class III-IV in addition to standard therapy and in those who cannot tolerate ACEi/ARBs; reduces mortality in African-American patients with HFrEF

  • Beta blockers (specifically Metoprolol succinate, carvedilol, and bisoprolol): all classes, reduces mortality

  • Aldosterone antagonists: class III-IV or class II PLUS EF < 35%; reduces mortality

  • Digoxin: may improve refractory symptoms; decreases hospitalizations, no mortality benefit

  • Diuretics: volume overload; decreases symptoms and hospitalizations

  • SGLT-2 inhibitors: reduces mortality in HFrEF and reduces hospitalizations in HFpEF (EMPEROR preserved trial)

  • Ivabradine: EF <35% with HR >70 despite max BB

  • ICD: class II-III with EF <35%, class I with EF <30; improves survival (note that class IV is provided no mortality benefit)

  • https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063

  • https://twitter.com/Drroxmehran/status/1431253161856184325

 

Indication and benefit for typical HFpEF medications?

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How might a patient in cardiogenic shock present?

 

How would you manage a patient with cardiogenic shock?

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What are the classes of pulmonary HTN?

 

For new pHTN, what tests should you order?

  • Liver chemistries, HIV, thyroid function, ANA, anticentromere antibody

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What are possible causes of pericarditis?

  • Viral infections (Coxsackie), uremia, autoimmune, bacterial, trauma, post-MI (Dressler’s syndrome)

 

What is the treatment of pericarditis?

 

What are typical EKG findings in pericarditis?

  • Diffuse concave ST elevation

  • PR depression

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What are the exam findings with effusions?

  • Tachycardia, muffled heart sounds, elevated JVP, pulsus paradoxus

  • Pulsus paradoxus - an exaggerated drop in systemic blood pressure of greater than 10 mmHg during inspiration

 

What is the unique EKG finding with effusions?

  • Electrical alternans

 

Management of pericardial effusions?

  • Pericardiocentesis or pericardial window

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What is the most common EKG finding in PE?

 

What are the EKG changes that may be seen with hyperkalemia?

  • Peaked T waves, PR prolongation, widening QRS, p wave flattening

 

What does a J-wave or Osborne wave indicate?

  • Hypothermia or hypocalcemia

 

What medications commonly prolong the QT interval?

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What are the types of heart block that require a pacemaker? 

  • Mobitz type 2 second degree and third-degree/complete

 

Which types of heart block is atropine best indicated for?

  • 1st degree and 2nd degree mobitz type 1

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What are some causes of sinus bradycardia (HR <50)? 

  • Hypoxia, ischemic event, infection, meds (AV-nodal blockers/opioids/sedatives/acetylcholinesterase inhibitors), hypothermia, hypothyroidism (myxedema coma), OSA, hyperkalemia, post cardiac surgery, athletes, age-related myocardial fibrosis

 

When do you treat sinus bradycardia? 

  • Only if a patient is symptomatic (lightheaded/dizzy, fatigue, syncope, dyspnea, chest pain, confusion) or hemodynamically unstable

 

Why can bradycardia be dangerous? 

  • Decreased heart rate will lead to decreased cardiac output if stroke volume cannot appropriately compensate (CO = HR x SV) → cardiogenic shock

 

What are the first-line medications? 

  • Atropine 0.5mg q3-5 minutes, maximum 3 mg → if unstable or not working, dopamine gtt or epi → Transcutaneous/venous pacing (transfer to CCU). Also, consider giving calcium as many bradycardias are calcium-responsive

  • https://emcrit.org/ibcc/bradycardia/#calcium

 

What are the absolute indications for a pacemaker for bradycardia? 

  • Class I = Documented symptomatic sinus bradycardia including frequent sinus pauses;

  • Class II = Sinus bradycardia with heart rate less than 40, but no clear association between the symptoms and bradycardia or Minimally symptomatic patients with chronic heart rate less than 40 while awake

  • https://www.ncbi.nlm.nih.gov/books/NBK507823/

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What are long standing risk factors for afib? 

  • Age, HTN, CAD, T2DM, smoking, obesity, OSA, moderate to heavy alcohol consumption 

 

What testing should patients undergo? 

  • Check TSH 

  • Echo to look for valvular or structural disease and assess extent of LA dysfunction 

  • Sleep study if patient is at increased risk of OSA

 

Afib RVR management:

https://twitter.com/thame/status/1064576827245645825/photo/1

  • Stable → IV Metoprolol vs IV Diltiazem

  • Unstable → Cardiovert

  • Borderline

    • IVF trial

    • Metoprolol or Esmolol

    • Digoxin

    • Amiodarone

  • EF <40%, avoid diltiazem 

  • Contraindications for B blockers - severe COPD, acute asthma exacerbation, hypotension, decompensated CHF (cardiogenic shock)

 

Is rate control vs rhythm control preferred in patients with Afib:

 

When is anticoagulation indicated?

  • If the duration of afib <48 hours, low risk for thrombus formation and stroke. Can cardiovert without anticoagulation. 

  • If the duration of afib is unknown or >48 hours, anticoagulation is needed 3 weeks before cardioversion OR TEE can be performed to rule out thrombus followed by cardioversion

  • Regardless of the duration of afib, all patients should receive 4 weeks of anticoagulation following cardioversion due to increased risk of thombro-embolic events after sinus rhythm is restored

 

What are the indications for anticoagulation in afib?

 

What are indications (ABCD) for decreased dosing of apixaban in afib? 

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Which leads typically best demonstrate flutter waves? 

  • Inferior leads 

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What is SVT?

  • Abnormally rapid HR, typically narrow complex (not always)

 

How do you manage SVT?

  • Trial vagal maneuvers (blow into a straw)

  • Push adenosine → 6 mg, then 12 mg

  • Tell patient they will have impending sensation of doom, have pads on, have continuous EKG on

  • Consider cardioversion if refractory

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Easily addressed etiology of VTach in hospital?

  • Electrolyte abnormalities

 

Etiologies of PEA?

  • Hs and Ts

    • Hypovolemia

    • Hypoxia

    • Hydrogen ion (acidosis)

    • Hypo/hyperkalemia

    • Hypothermia

    • Tension pneumothorax

    • Trauma

    • Tamponade

    • Thrombosis, pulmonary

    • Thrombosis, coronary

​​https://www.ncbi.nlm.nih.gov/books/NBK513349/

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What are the three main indications for AVR? 

  • Symptoms, EF <50% in asymptomatic patients, undergoing concomitant cardiac surgery

 

What are the indications for open surgery > TAVR?

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What is first line therapy for symptomatic mitral stenosis?

  • Percutaneous balloon mitral commissurotomy

 

Presentation of acute mitral regurgitation?

  • Dyspnea, pulmonary edema, even cardiogenic shock

 

Treatment of acute mitral regurgitation?

  • Nitroprusside, balloon pump, surgical correction 

 

Indications for surgical repair in chronic mitral regurgitation?

  • Symptomatic

  • Asymptomatic with EF <60% and/or LV ESD >40 mm

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What is the medical management of dissections?

  • Tight blood pressure control to 100-120 systolic, can use nitroprusside or beta blockers

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