MKSAP 17 Cardiovascular Medicine | Quizlet

What risk level at which coronary heart disease events prevented exceed GI harms in patients taking daily aspirin for primary prevention?

Men 10 year CHD Risk:

Age 45-59: >4%
Age 60-69: >9%
Age 70-79: >12%

Women 10 year Stroke Risk:

Age 55-59: >3%
Age 60-69: >8%
Age 70-79: >11%

What are the diagnostic criteria for left anterior fascicular block? (3)

1. QRS: 80-120ms
2. Left axis deviation
3. Poor R wave progression

LAF more common than LPF due to fibers being thinner

What are the diagnostic criteria for left posterior fascicular block? (2)

1. QRS: 80-120ms
2. Right axis deviation

What is a bivasicular block? What does this correlate to in the heart?

left anterior or posterior fascicular block PLUS a RBBB

correlates- conduction through only 1 fascicle in the ventricles (may get symptoms of syncope)

What is a trifascicular block? What does this signify?

bifascicular block plus a 1st degree block

signifies poor conduction through the remaining conducting fascicle in the ventricle

What is the prevalence of American adults have some form of CVD?

more than 1 in 3

10% in those aged 20-39

70% in those aged 60-79

2/3 men will develop CVD in their lifetime and 1/3 of women

What is the mortality in heart failure in 5 years?

nearly 50%

What are some risk factor/epidemiology characteristics of cardiovascular disease in women?

women have a higher mortality rate after MI: 26% in women vs 19% in men older than 45 years

incidence of and mortality from stroke is highest among women, with the highest among black women

women have a higher prevalence of risk factors for CVD, including elevated cholesterol levels, diabetes mellitus, HTN, and inactivity (only tobacco use if higher among men)

women have "atypical" symptoms more frequently than men, including nausea, SOB, and unusual fatigue (more than 2/3 of women who die suddenly from CAD either did not recognize the symptoms or had no previous symptoms)

women undergo fewer revascularization procedures than men, with 25% of CABG surgeries and nearly 33% of PCI's occurring in women

What ethnic groups have the highest rate of heart disease?

American Indians and Alaska Natives (12.7%)

followed by whites (11.1%), blacks (10.7%), Hispanics or Latinos (8.6%) and Asians (7.4%)

What % of Americans older than 40 years have peripheral arterial disease?

8.5%; with highest prevalence among older persons, non-Hispanic blacks, and women

What population is most affected by heart failure?

African Americans at a rate of 4.6/1000 person-years, followed by Hispanic, white, and Chinese Americans

What ethnic group has the highest rate of HTN?

Blacks (33.4%; higher in black women); followed by American Indians or Alaska Natives (25.8%), whites (23.3%), Hispanics or Latinos (22.2%) and Asians (18.7%)

Blacks have the highest prevalence of two or more cardiovascular risk factors (48.7%)

the prevalence of risk factors is increased with decreasing levels of education and income

What ethnic groups have the highest level of obesity and lack of physical activity?

Hispanic/Latino adults and non Hispanic blacks

What is considered a family history of premature CAD which significantly increases the risk of CVD?

male <45 years

female <55 years

having a parents with premature CAD doubles risk of MI in men and increases risk in women by 70%

CAD in a sibling increases risk by 50%

What % of the risk for MI has been attributed to modifiable risk factors?

90%

What are the most significant modifiable risk factors for CAD? (3)

1. Elevated cholesterol levels
2. Smoking
3. Psycho-social stressors

What is the attributable risk for MI for each of the 9 risk factors?

1. Elevated cholesterol levels (highest)
2. Smoking
3. Psycho-social stressors
4. Diabetes
5. HTN
6. Abdominal Obesity
7. No alcohol intake
8. Inadequate Exercise
9. Irregular consumption of fruits and vegetables

What % of adults older than 20 years have total cholesterol levels >240?

14%

approximately 6% of adults are estimated to have undiagnosed hypercholesterolemia

What specific cholesterol levels cause increased risk for CAD?

elevated LDL

low HDL

for every 1% decrease in LDL cholesterol level, there is a corresponding 1% decrease in risk for CAD; the risk reduction is even greater with changes in HDL cholesterol, with a risk reduction of 2-3% for every 1% increase in HDL cholesterol level

How much of an increased CVD mortality is there with smoking?

2-3 times

risk of CAD is increased 25% in women who smoke

smoking increases the risk of stroke by 2-4 times (secondhand smoke is also a risk factor for CVD, increasing the risk by 25-30%)

smoking cessation substantially reduces cardiovascular risk within 2 years, and this risk returns to the level of a nonsmoker within 5 years

What % of US adults over 20 years has HTN?

33%

nearly 30% of adults older than 20 years have pre-HTN (systolic BP 120-139; diastolic BP 80-89)

>70% of persons older than 65 years has HTN

What is the prevalence of blood pressure control in the US?

50%

What % of all US adults report no leisure time activity?

33%

less than 30% of high school students engaged in 60 minutes of daily physical activity; this rate was lowest among girls

total energy consumption increased by 22% in women and 10% in men between 1971-2004

What % of the American population older than 20 years are overweight? Obese?

>66% are overweight

>33% are obese

increased caloric intake and less physical activity has led to an increased incidence of obesity

What % of children aged 2-19 years are obese or overweight?

33% are obese or overweight and 17% are obese

What are psychosocial stressors that contribute to cardiovascular risk? (3)

1. Depression (highest)
2. Anger
3. Anxiety

What is the metabolic syndrome?

1. elevated glucose
2. central obesity
3. low HDL
4. elevated triglycerides
5. HTN

more than 34% of adults older than 20 years meet the criteria for metabolic syndrome (3/5 components)

What is the increased risk of CVD in persons with diabetes?

2-4 times; with more than 2/3 of those with diabetes eventually dying of heart disease

risk of stroke is increased 1.8-6 fold in persons with diabetes

What is the prevalence of diabetes in those older than 65 years? In those aged 12-19 years (for prediabetes and diabetes)?

>65 yeas- 27%

12-19 years- has increased from 9-23% from 1999-2007

diabetes is often undiagnosed, and is frequently diagnosed at the time of an acute event such as MI

What are the most recent cholesterol guidelines for patients aged 40-75 years with diabetes?

moderate or high intensity statin

Patients aged 40-75 years with a 10-year atherosclerotic CVD risk greater than or equal to what % should receive high intensity statin therapy because of their increased risk?

7.5%

in patients with diabetes in this age group with a 10-year risk below 7.5%, moderate intensity statin therapy is recommended

What are some associations of chronic kidney disease and cardiovascular disease?

CKD is associated with higher CVD mortality, and more patients with CKD will die of CVD than will go on to have ESKD requiring dialysis

CKD shares many of the same risk factors for CVD such as HTN, DM, and smoking

What systemic inflammatory conditions increase the risk of CVD?

SLE and RA

What are the different risk assessment tools in stratifying patients for CVD risk? (3)

1. Framingham risk score
2. Reynold risk score
3. ACC/AHA cardiovascular risk calculator based on the Pooled Cohort Equations

What are the risk stratifications using the Framingham risk calculator? (http://cvdrisk.nhlbi.nih.gov/calculator.asp)

low risk- 10 year ASCVD of <10%

intermediate risk- 10-20%

high risk- >20%

age is the component that drives most of the risk

underestimates risk in women and minority populations (in an effort to account for the underestimation in women, the Reynold risk score was developed, which is a sex-specific score for both men and women that includes a family history and high-sensitivity CRP; (www.reynoldriskscore.org)

What factors are taken into account in the Pooled Cohort Equations? (9)

1. age
2. sex
3. race
4. total cholesterol
5. HDL cholesterol
6. systolic BP
7. blood pressure lowering medication use
8. diabetes status
9. smoking status

What are the risk stratifications using the Pooled cohort equation?

low risk- <5%

intermediate risk- 5-7.5%

high risk- >7.5%

http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp

When should high-sensitivity CRP evaluation be used?

when intermediate risk patients whom choice of therapy may be affected by reclassification risk

What is the recommendation for using aspirin for primary prevention of CVD in men age 45-79 years?

aspirin recommended when potential benefit of reduction in MI outweighs risk of GI bleeding

What is the recommendation for using aspirin for primary prevention of CVD in women age 55-79 years?

aspirin recommended when potential benefit of reduction in ischemic stroke outweighs risk of GI bleeding

What is the recommendation for using aspirin for primary prevention of CVD in men/women age >80 years?

Insufficient evidence for primary prevention

What is the recommendation for using aspirin for primary prevention of CVD in men age <45 years, women age <55 years?

aspirin not recommended for prevention of MI in men or stroke in women

What are some risk factors for GI bleeding?

history of GI ulcers or use of NSAIDs

Should aspirin be routinely given to patients with diabetes who are at low risk; that is, men younger than 50 years and women younger than 60 years with no major additional cardiovascular risk factors?

NO

What are the 2 main categories of testing used in assessing CAD and evidence of ischemia?

1. functional evidence
2. anatomic evidence

How is ischemia identified with exercise?

on the basis of development of 1mm or greater of horizontal or downsloping ST depression

(coronary territory involved cannot be localized based on the EKG changes alone)

What are some characteristics of the dobutamine echocardiography?

recommended in patients who cannot exercise; recommended when information on an area of myocardium at risk is needed

dobutamine contraindications are severe baseline HTN, unstable angina, and arrhythmias

B-blockers must be withheld before the test

What are some characteristics of the coronary angiography?

provides anatomic diagnosis of the presence and severity of CAD

percutaneous revascularization can be performed following diagnostic study

invasive; risks of vascular access and radiocontrast exposure (kidney dysfunction, allergy, bleeding)

radiation exposure

What are the different CAC scores and how are they categorized?

0 = no disease
1-99 = mild disease
100=399 = moderate disease
400 and above = severe disease

CAC sores >400 are associated with a higher incidence of abnormal perfusion on SPECT imaging

What is the risk of myocardial infarction or death in exercise testing?

1/2,500 tests (considered small risk)

What is the most common manifestation of CAD?

stable angina pectoris

What are the pretest likelihoods of CAD in low-risk and high-risk symptomatic patients with typical angina age 35?

Men: 30-88%

Women: 10-78%

low risk is first number and high risk is second number

What are high risk patients with CAD? (3 factors)

1. Diabetes Mellitus
2. Smoking
3. HLD

low risk patients have none of these factors

both high risk and low risk patients have normal results on resting EKG; if ST-T wave changes or Q waves had been present, the likelihood of CAD would be higher

What are the pretest likelihoods of CAD in low-risk and high-risk symptomatic patients with atypical angina age 45?

Men: 21-70%

Women: 5-43%

What are the pretest likelihoods of CAD in low-risk and high-risk symptomatic patients with atypical angina age 65?

Men: 71-86%

Women: 20-51%

What should be done if a patient has an intermediate pretest probability of CAD?

determine if EKG is normal and patient is able to exercise

What should be done if a patient has an intermediate pretest probability of CAD who has an EKG abnormality and CAN tolerate exercise?

exercise nuclear stress test or exercise echocardiography***

When is dual anti-platelet therapy recommended?

only following PCI or an acute coronary event

What are considered first-line anti-anginal medications?

B-blockers and nitrates

How does ranolazine work? When should it be used?

selective inhibitor of the late inward sodium channel in the myocardium

generally reserved for patients who remain symptomatic with the use of B-blockers, nitrates, and CCB's

Has PCI been shown to be superior to optimal medical therapy in patients with stable angina pectoris for reduction of cardiovascular endpoints such as mortality and myocardial infarction?

NO, however PCI has been associated with improvement in quality of life by reducing the severity and frequency of angina

current guidelines recommend that diagnostic angiography and PCI be reserved for patients with refractory symptoms while on optimal medical therapy, those who are unable to tolerate optimal medical therapy owing to side effects, or those with high-risk features on noninvasive exercise and imaging tests

What should be the next step in management for patients who have undergone successful thrombolytic therapy for STEMI and who have EF <40%?

coronary angiography; otherwise long term medical therapy with aspirin, B-blockers, ACE inhbitors, nitrates, statin, P2Y12 inhibitors

What % of patients with STEMI who undergo thrombolytic therapy do not achieve complete reperfusion?

30-50%

What % of patients will have a left ventricular thrombus after MI?

10-20% of patients after anterior MI despite reperfusion and aggressive treatment

diagnosed by TTE

What are the indications for short-acting nitrates as an antianginal medication?

useful for relief of symptoms, usually prescribed on an as-needed basis

sublingual, spray, or aerosol

How is the diagnosis of coronary vasospasm diagnosed?

by exclusion once angiography confirms the absence of obstructive CAD

What is the difference in outcomes for diabetic patients undergoing PCI vs CABG for revascularization?

CABG is generally associated with fewer repeat revascularization procedures

mortality is similar between the two procedures

a drug eluting stent is recommended to reduce the occurrence of target vessel revascularization because of the more extensive CAD and higher rate of restenosis in patients with diabetes

What are the most common causes of HF with preserved EF? (2)

1. HTN
2. CAD

In general, patients with HFpEF tend to be older, heavier women who have a history of HTN, CAD, and DM

What medications have been shown to decrease mortality and future hospitalizations? (4)

1. ACE inhibitors (or ARBs)
2. B-blockers
3. aldosterone antagonists (NYHA class 2-4)
4. hydralazine-isosorbide dinitrate (specifically for black patients with NYHA class 3-4)

several additional medications have been shown to improve symptoms but have no effect on mortality

What are the 4 different therapies that improve symptoms in heart failure but have no effect on mortality?

1. digoxin
2. diuretics
3. inotropic agents
4. vasodilators

What medications have demonstrated a reduction in mortality in patients with HFpEF?

none

What are some adverse effects of CRT? (3)

1. infection at the site of the device
2. inappropriate firings
3. occasional tricuspid valve regurgitation

What is cardiogenic shock?

persistent, symptomatic hypotension and end-organ dysfunction

patients have acute kidney injury, evidence of liver dysfunction with elevated aminotransferase levels, poor peripheral perfusion with cool extremities, and decreased mental status

What are the reversible causes of cardiogenic shock? (3)

1. acute MI
2. ventricular septal or free wall rupture
3. acute valvular regurgitation (possible from papillary muscle rupture, infection, or ascending aortic arch aneurysm with dissection of the aortic valve)

What IV vasoactive medications can be used for treatment of cardiogenic shock? (8)

1. milrinone (phosphodiesterase inhibitor; vasodilation) (++ inotropy)
2. dobutamine (B1,B2 receptros at low dose gives vasodilation, vasoconstriction at high dose) (++ inotropy)
3. nesiritide
4. sodium nitroprusside (vasodilation)
5. nitroglycerin (vasodilation)
6. vasopressin (negative inotropy)
7. dopamine (D receptor inotropy; B1 at intermediate dose, alpha 1 at high dose); vasoconstriction at high dose); some inotropy
8. norepinephrine (affinity for alpha 1 and 2 receptors greater than for B1 receptors); some inotropy

patients with progressive heart failure are given an inotropic agent such as dobutamine or milrinone

patients with peripheral vasoconstriction (increased SVR) often benefit from the addition of a pure vasodilator (such as sodium nitroprusside)

placement of a right heart catheter can be helpful to assess filling pressures, cardiac output, and SVR

In patients discharged with a diagnosis of heart failure, what is the ideal followup from discharge?

within 7 days, has been associated with a reduction in hospital readmissions

What is the 3 drug immunosuppression regimen early after heart transplantation?

1. calcineurin inhibitor (cyclosporine or tacrolimus)
2. antiproliferative agent (mycophenolate mofetil, sirolimus, or everolimus)
3. prednisone

most centers try to wean patients off of prednisone by 1 year

What is the histologic hallmark of HCM?

myocyte disarray on microscopy

Are cardiac tumors usually primary or metastatic?

metastatic, arising from carcinoma of the lung, breast, kidney, esophagus, or liver, or from blood dyscrasias, such as leukemia or lymphoma

malignant melanoma is commonly associated with cardiac metastases

What part of the heart does papillary fibroelastomas occur in?

left sided cardiac valves or the left ventricular outflow tract; have a central core stalk with fronds and often are mobile, with an appearance resembling a sea anemone

What is the need for surgical resection of cardiac tumors based upon?

size, location, and malignant nature of the cardiac tumor, in addition to symptoms and risk of embolization

What are examples of Class 3 anti-arrhythmic medications? (2)

sotalol, dofetilide

What are examples of Class 4 anti-arrhythmic medications? (2)

1. verapamil
2. diltiazem

What is happening in second degree AV block?

some P waves conduct to the ventricle and some do not

What type of 2nd degree AV block usually represents a block lower in the conduction system and has a higher risk of progression to complete heart block?

2nd degree type 2

What medication can be given to terminate orthodromic AVRT; however, is contraindicated in the preexcited atrial fibrillation and antidromic AVRT?

adenosine or other AV nodal blockers (these medications can promote rapid conduction down the bypass tract and induction of ventricular fibrillation

What is the initial step in evaluating for heart disease?

thorough History and Physical exam; specifically, a careful exploration of changes in functional status, associated symptoms, and the timing and nature of symptoms will help focus the assessment and guide selection of appropriate testing

Which patients is stress testing the most efficacious in?

patients with an intermediate pretest probability of CAD, because it is these patients who, by the results of their stress test, can be reclassified into higher or lower risk categories

What is the ideal stress test for a patient who is able to exercise and has a normal baseline EKG?

exercise stress test

may still be performed in patients with RBB, bifascicular block, or who are on digoxin but ST segments may be more difficult to interpret or may produce false-positive results

patients with severe aortic stenosis, abdominal aortic aneurysm, severe HTN, or uncontrolled arrhythmias should not exercise, rather, these patients should undergo pharmacologic stress testing with imaging

What is the ideal stress test for a patient with an abnormal baseline EKG (ex. LBBB, LVH w/ ST segment abnormalities, or a paced rhythm)?

stress imaging testing

Has routine stress testing in asymptomatic patients with diabetes shown to reduce mortality from cardiovascular disease?

NO

What modalities are considered highly sensitive for picking up the earliest changes with mild stenosis (small degree of impairment of coronary blood flow)?

nuclear or cardiac magnetic resonance (CMR)

with progressive coronary occlusion, diastolic dysfunction followed by systolic dysfunction may be seen by imaging studies such as echocardiography

only when there is significant coronary stenosis will EKG changes be seen and symptoms occur

What are some examples of functional studies used to evaluate for obstructive CAD? (3)

1. EKG changes
2. myocardial perfusion abnormalities
3. wall motion abnormalities

usually under stress conditions

What are some example of anatomic studies used to evaluate for obstructive CAD? (3)

1. single photon emission CT (SPECT)
2. PET/CT scan
3. CMR (cardiac magnetic resonance)

these imaging modalities may also be used to quantify infarction size and assess myocardial viability

more specific signs of ischemia such as reduced regional contractility can be assessed by echocardiography or MRI

A drop of less than what heart rate in the first minute after cessation of exercise has a higher mortality rate?

<12/min

How long should patients exercise for to provide adequate time for development of maximal metabolic demand?

6-12 minutes

What other factors are considered adequate for exercise stress testing?

although achieving 85% of the age-predicted maximal heart rate is considered adequate for diagnosis of ischemia, as heart rate and blood pressure are the major determinants of myocardial oxygen demand, patients should continue to exercise until limited by symptoms

achieving a rate pressure product (heart rate x systolic blood pressure) of at least 25,000 is also considered an adequate workload, as this measure reflects left ventricular myocardial performance

What is the standard Bruce protocol?

increases the speed and grade of the treadmill every 3 minutes, and patients who have poor functional capacity and cannot achieve at least the first stage of the Bruce protocol (5 metabolic equivalents (METs)) have significantly higher all-cause mortality

When should stress tests be terminated?

stress tests should be terminated when the patient has exerted maximal effort and achieved at least 85% of predicted maximal heart rate, the patient requests to stop or experiences significant anginal or other physical symptoms or when other adverse markers develop, such as exertional hypotension, significant hypertension, ST segment elevation or significant ST segment depression , or ventricular or supraventricular arrhythmias

What are 3 examples of exercise stress testing?

1. Exercise EKG
2. Stress echocardiography
3. Nuclear SPECT perfusion