Cardiovascular System

Flashcards covering major topics from AAA, ACS, endocarditis, heart failure, murmurs, arrhythmias, hypertension, lipids, PAD, DVT/PE, MVP, obesity, and related cardiovascular concepts as presented in the notes.

What is the classic triad suggesting a ruptured abdominal aortic aneurysm (AAA)?

Acute abdominal pain, abdominal distention, and hemodynamic instability.

Who is at highest risk for an abdominal aortic aneurysm (AAA)?

Older white male who is a current or former smoker with hypertension.

What is the initial imaging test of choice for suspected AAA?

Abdominal ultrasound.

What conditions are included under Acute Coronary Syndrome (ACS)

ST-elevation myocardial infarction (STEMI), non–ST-elevation myocardial infarction (NSTEMI), and unstable angina.

Describe the classic presentation of ACS.

Middle-aged to older man with onset of constant chest or substernal discomfort lasting >15 minutes, described as squeezing, tight, crushing, a knot, heavy pressure, or band-like, possibly radiating to arms, neck, jaw, back; provoked by exertion, emotion, or large meals; may be diaphoretic with palpitations, dyspnea, nausea, or vomiting; atypical in some women, older adults, or diabetics.

What is the best initial diagnostic test for ACS?

12-lead electrocardiogram (EKG).

What is the recommended aspirin dose for suspected ACS?

Chewable aspirin 162–325 mg, unless contraindicated.

What is another name for infective endocarditis?

Bacterial endocarditis.

List common risk factors for infective endocarditis.

Valvular abnormalities, IV drug use, indwelling cardiac devices, immunosuppression, recent dental or surgical procedures.

Which organisms most commonly cause infective endocarditis?

Staphylococcus aureus, streptococci, and enterococci.

What are classic peripheral signs of endocarditis that may appear on the skin or nails?

Splinter hemorrhages, Janeway lesions, Osler nodes, Roth spots.

What is the first diagnostic test typically used when suspected endocarditis is present?

Transthoracic echocardiogram (TTE).

What are typical signs and symptoms of heart failure?

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, edema, fatigue, and orthostatic intolerance.

How is heart failure with reduced ejection fraction (HFrEF) defined in terms of LV EF?

LV ejection fraction (EF) ≤ 40%.

What EF range defines mid-range EF heart failure?

EF 41% to 49%.

What EF defines heart failure with preserved ejection fraction (HFpEF)?

EF ≥ 50%.

Which heart sound is commonly associated with heart failure?

S3 gallop (ventricular “gallop”).

Which heart sound is commonly abnormal when heard after age 40 and often indicates LVH?

S3 is typically abnormal after 40; S4 is associated with LVH and diastolic dysfunction.

Where is the Point of Maximal Impulse (PMI) located?

At the apex, typically the fifth intercostal space (ICS) at the left midclavicular line.

What causes PMI displacement in severe LVH or pregnancy?

LVH (lateral displacement, larger than normal) or pregnancy (upward and leftward shift due to diaphragmatic elevation).

Trace the deoxygenated blood flow from the body to the lungs.

Superior/inferior vena cava → right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → lungs.

Trace the oxygenated blood flow from the lungs to the body.

Lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation.

What mnemonic helps recall the heart sounds S1 and S2 and their valve origins?

Motivated apples: M = mitral, T = tricuspid (AV valves) for S1; A = aortic, P = pulmonic (semilunar valves) for S2.

What does S1 represent and which valves close during S1?

S1 represents systole; closure of the mitral and tricuspid (AV) valves.

What does S2 represent and which valves close during S2?

S2 represents diastole; closure of the aortic and pulmonic (semilunar) valves.

What is the S3 heart sound and what is it usually indicative of

An early diastolic ventricular gallop, usually associated with heart failure or volume overload.

What is the S4 heart sound and what does it suggest?

A late diastolic atrial gallop suggesting LVH or stiff ventricle; usually abnormal when palpable.

What are the two stethoscope components used for different sounds?

Bell for low-pitched sounds (S3/S4/Murmurs like MS); Diaphragm for mid- to high-pitched sounds (MR, AS, lung sounds).

Where is a physiologic S2 split best heard?

Pulmonic area (left upper sternal border) with inspiration.

What is a key guideline tip for evaluating heart murmurs?

Identify timing (systolic vs diastolic) and location (aortic, Erb’s point, mitral/apex).

What does MR. PASS stand for in murmur mnemonics?

MR = Mitral Regurgitation; P = Physiologic (flow murmur); AS = Aortic Stenosis (systolic murmurs).

What does MS. ARD stand for in murmur mnemonics?

MS = Mitral Stenosis; AR = Aortic Regurgitation (diastolic murmurs).

Where is the mitral (apical) murmur best heard and to what can it radiate?

Best heard at the apex (5th left ICS, MCL); radiates to the axilla.

Where is the aortic murmur best heard and can it radiate?

Best heard at the 2nd right ICS (aortic area); can radiate to the neck.

What is the characteristic murmur of aortic stenosis?

Mid-systolic (ejection) murmur, harsh quality, can radiate to the neck; best at the 2nd right ICS.

How is aortic regurgitation typically heard and where?

High-pitched diastolic murmur heard best at the left sternal border or Erb’s point; louder when patient leans forward with expiration.

What is the grading scale for murmurs up to Grade VI?

Grade I to VI, with Grade IV the first time a thrill is palpable; Grade VI heard without stethoscope on chest.

What is the endocarditis prophylaxis oral regimen for a patient with a high-risk condition?

Amoxicillin 2 g PO 1 hour before the procedure.

What IV regimens can be used for endocarditis prophylaxis in penicillin-allergic patients or with IV access issues?

Ampicillin 2 g IV/IM or cefazolin/ceftriaxone 1 g IV/IM.

What are classic signs of infective endocarditis on the nails and skin?

Splinter hemorrhages, Osler nodes, Janeway lesions.

What is the first diagnostic test for suspected endocarditis?

Transthoracic echocardiography (TTE).

What are the common organisms causing endocarditis and the category of endocarditis?

Staphylococci, streptococci, enterococci; native valve endocarditis vs prosthetic valve endocarditis.

What is the most common arrhythmia in the United States and a major cause of stroke?

Atrial fibrillation (AF).

What is a key sign of AF with rapid ventricular response (RVR) to watch for on exam?

Irregularly irregular pulse with no discrete P waves on EKG.

What tool is used to decide whether to anticoagulate a patient with AF?

CHA2DS2-VASc score.

What CHA2DS2-VASc score indicates indication for anticoagulation?

Score of 2 or more generally; some clinicians treat at 1 depending on risk factors.

What is the recommended target INR range for warfarin in AF?

INR 2.0 to 3.0.

What is the initial approach to anticoagulation in AF regarding onset and monitoring?

Initial anticoagulation may take up to 3 days for full effect; monitor INR every 2–3 days until therapeutic.

Name four direct-acting anticoagulants (DOACs).

Dabigatran, rivaroxaban, edoxaban, apixaban.

Which reversal agents correspond to DOACs: dabigatran and factor Xa inhibitors?

Idarucizumab (Praxbind) for dabigatran; andexanet alfa (Andexxa) for rivaroxaban/apixaban.

What is the preferred anticoagulant in nonvalvular AF according to guidelines?

Direct-acting oral anticoagulants (DOACs) are preferred over warfarin in many nonvalvular AF cases.

What is the role of warfarin and its monitoring in AF?

Warfarin used for AF with certain conditions (e.g., mechanical valves, MS); monitor INR regularly (goal 2–3).

What initial management options exist for new-onset AF with stability?

Rate control (beta-blockers, non-dihydropyridine CCBs, or digoxin) or rhythm control (amiodarone) and possible cardioversion within 48 hours.

What is a key instruction for vagal maneuvers used to treat PSVT?

Vagal maneuvers (e.g., Valsalva, carotid sinus massage) can terminate PSVT; carotid massage requires monitoring and is contraindicated in TIA/stroke within 3 months, carotid bruits.

What is a hallmark EKG feature of WPW syndrome?

Short PR interval with a widened QRS complex; risk of rapid tachyarrhythmias; ablation considered.

What is a classic EKG feature of STEMI?

ST-segment elevation in contiguous leads and hyperacute T waves; tombstone QRS may appear in V2–V4.

What EKG changes are typical of NSTEMI?

T-wave flattening or inversion; ST-segment depression; Q waves not necessarily present.

What is the definition of hypertensive emergency vs urgency?

Urgency: SBP >180 or DBP >120 without target organ damage; Emergency: BP >180/120 with target organ damage.

What is the recommended initial BP management approach for isolated systolic hypertension in older adults?

Low-dose thiazide diuretic or long-acting dihydropyridine CCB; start slowly and monitor.

What is a common consequence of secondary hypertension due to CKD regarding initial therapy?

ACE inhibitors or ARBs are first-line to reduce proteinuria and control BP.

What is the DASH diet and its purpose?

Dietary Approach to Stop Hypertension; emphasizes fruits, vegetables, low-fat dairy, lean proteins; lowers BP.

What is the normal ABI range that excludes significant PAD?

ABI 0.91 to 1.3 excludes significant disease; ≤0.9 suggests PAD.

What pharmacologic therapy can help improving walking distance in PAD?

Cilostazol (Pletal) as a vasodilator; can be used with aspirin or clopidogrel.

What is Raynaud’s phenomenon and its typical color changes?

Reversible vasospasm with color changes white (pallor) → blue (cyanosis) → red (reperfusion).

What is pulsus paradoxus and with what condition is it commonly associated?

A fall in systolic BP >10 mmHg during inspiration, commonly seen in cardiac tamponade.

What are the two major categories of DVT risk factors per Virchow’s triad?

Stasis (blood flow abnormalities) and hypercoagulability; endothelial injury.

What is the diagnostic test of choice for suspected DVT?

Compression ultrasonography with Doppler.

What are common initial treatments for uncomplicated superficial thrombophlebitis?

NSAIDs (e.g., ibuprofen), warm compresses, limb elevation; ultrasound if DVT suspected.

What is the standard initial treatment approach for acute DVT or PE when stable?

Anticoagulation with low-molecular-weight heparin or heparin followed by warfarin or DOACs.

What is the primary goal in managing heart failure therapy (HFpEF vs HFrEF)?

HFpEF: diuretics for symptoms; consider SGLT2 inhibitors and MRA; avoidCS; HF with reduced EF (HFrEF): GDMT including diuretic, ACEI/ARB/ARNI, beta-blocker.

What is the recommended first-line statin intensity for ASCVD prevention per ACC/AHA 2018 guidelines?

High-intensity statin therapy (e.g., atorvastatin 40–80 mg or rosuvastatin 20–40 mg).

What are common high-intensity statin options listed?

Atorvastatin 40–80 mg; Rosuvastatin 20–40 mg; Simvastatin 20–40 mg (and others listed in guidelines).

What non-statin therapies are considered if LDL remains above goal despite maximally tolerated statin?

Ezetimibe; PCSK9 inhibitors (e.g., evolocumab, alirocumab); possibly CAC-guided decisions; consider ezetimibe first, then PCSK9 inhibitors if needed.

When is a CAC score used in ASCVD risk assessment and statin decision-making according to 2018 ACC/AHA guidelines?

To refine risk in borderline cases (e.g., 10-year ASCVD risk 5–20% or 7.5–20% with risk enhancers); CAC score >0 may favor statin initiation.

Which agents are listed as PCSK9 inhibitors?

Evolocumab (Repatha) and Alirocumab (Praluent).

What is the typical mechanism and side effects of thiazide diuretics?

Inhibit Na+/Cl− reabsorption in distal tubules; can cause hyperglycemia, hyperuricemia, hyponatremia, hypokalemia, photosensitivity; sulfa allergy caution.

Name two commonly used loop diuretics.

Furosemide (Lasix) and Bumetanide (Bumex).

What is the main concern with ACE inhibitors and ARBs in pregnancy?

Contraindicated in pregnancy due to fetal kidney malformations and other risks.

What is the hallmark physical sign associated with MVP (mitral valve prolapse)?

Mid-systolic click with a late systolic murmur; MVP syndrome may include fatigue and palpitations.

What is the primary diagnostic test for suspected MVP?

Echocardiography (often transthoracic).

What nonpharmacologic lifestyle measures are recommended for hypertension management?

Weight loss, reduced sodium intake (<1.5 g/day), adequate potassium intake, physical activity, limit alcohol, smoking cessation.

What is the typical BMI classification for obesity?

Obesity: BMI ≥ 30 kg/m2.

What is the recommended walking program for cardiovascular health?

Regular aerobic activity 3–4 days per week, 40 minutes per session, with resistance training 2–3 days.

What is the key test to evaluate for secondary hypertension due to renal disease?

Renal function tests (creatinine, eGFR), urinalysis, and urine albumin-to-creatinine ratio.

What is the typical renal outcome when ACE inhibitors or ARBs are used in CKD with proteinuria?

BP control and reduction in proteinuria; ACEI/ARB are first-line in CKD with proteinuria.

What is Raynaud’s phenomenon and how is it managed initially?

Reversible vasospasm with color changes (white-blue-red) in extremities; avoid cold, caffeine; start with calcium channel blockers like nifedipine or amlodipine.

What is the ankle-brachial index (ABI) used for?

Assess PAD severity; ABI ≤0.9 indicates PAD; 0.91–1.3 generally excludes PAD.

What is cilostazol used for in PAD and what cautions exist?

Pletal (cilostazol) improves walking distance; avoid with grapefruit juice and certain drug interactions.

What is the classic presentation of a superficial thrombophlebitis?

Indurated, warm, tender vein with erythema; may have a palpable cord; usually afebrile.

What is pulsus paradoxus and which condition is it a sign of?

Drop in SBP >10 mmHg during inspiration; sign of cardiac tamponade among other conditions.

What is the difference between primary and secondary Raynaud’s phenomenon?

Primary: idiopathic, more common in women; Secondary: associated with autoimmune disease (e.g., scleroderma, lupus).

What is the recommended approach to diagnosing hypertension (out-of-office considerations)?

Ambulatory BP monitoring is the gold standard; confirm with home BP measurements (SMBP) and multiple office readings.

What is the role of echocardiography in endocarditis management?

Evaluates valve structure and function to identify vegetations, regurgitation, or abscess; essential for diagnosis and monitoring.

When should endocarditis prophylaxis be given before dental procedures for high-risk patients?

Oral amoxicillin 2 g one hour before the procedure or alternatives for those with allergies; tailored to high-risk conditions.

What is a key feature that differentiates carotid sinus massage contraindications from safe practice?

Contraindications include recent TIA/stroke (<3 months), carotid bruits, or vascular disease; continuous ECG monitoring is advised during procedure.

What is a common ECG feature of AF with rapid ventricular rate (RVR) in exams?

Irregularly irregular rhythm with absent discrete P waves.

What therapy is preferred for reducing thromboembolic risk in AF patients with high risk factors?

Oral anticoagulation (DOACs preferred in nonvalvular AF; warfarin when indicated).

How is STEMI characterized on EKG?

ST-segment elevation in contiguous leads with tall, peaked T waves and possibly Q waves developing later.

What is a key management step for suspected ACS beyond aspirin?

Call emergency services (911) and initiate rapid assessment and reperfusion planning.

What is the typical clinical finding in isolated systolic hypertension of older adults?

Elevated systolic BP with normal or low diastolic BP; increased pulse pressure due to arterial stiffness.