Cardiovascular Disorders

For patients who are on a high-intensity statin but intolerant, what should you do for them and why?

Consider switching to a lower-intensity statin or non-statin therapy, as high-intensity statins may cause side effects that lead to intolerance. This approach helps manage cholesterol levels while minimizing adverse reactions.

Vasospastic angina results from what process?

A temporary spasm of the coronary arteries that reduces blood flow to the heart.

How is vasospastic angina diagnosed?

It is diagnosed through patient history, physical examination, and tests like electrocardiograms (ECG) that may show ischemic changes during episodes.

What are the clinical features for vasospastic angina?

Chest pain that typically occurs at rest, often during the night or early morning, and may be associated with transient ST-segment elevation on an ECG during episodes.

What is the best treatment for vasospastic angina and why?

The best treatment includes calcium channel blockers and nitrates, as they help relax the coronary arteries and prevent spasms.

When aortic stenosis is suspected, what is the best imaging test and why?

The best imaging test is a transthoracic echocardiogram, as it provides detailed information about the heart's structure and function, allowing for assessment of the severity of the aortic stenosis.

What will you hear on cardiac auscultation with pulmonic stenosis?

An ejection click, followed by a crescendo-decrescendo systolic murmur over the left second intercostal space and widened splitting of S2.

A patient with history of coronary artery disease requests clearance for dental surgery. They have no difficulty performing activities of exertion. Will this patient require further evaluation?

No further evaluation is needed, as the patient is asymptomatic during exertion and has stable coronary artery disease.

What is the most effective intervention for reducing the risk of hypertension and why?

The most effective intervention for reducing the risk of hypertension is lifestyle modification, including regular physical activity, a healthy diet, and weight management, as these changes can significantly lower blood pressure and improve overall cardiovascular health.

What features are seen with stasis dermatitis?

Swelling, redness, itching, and scaling of the skin, typically occurring in the lower extremities due to impaired venous circulation.

If venous insufficiency remains untreated, what is a potential complication?

Venous ulcers or chronic skin changes.

Of venous and arterial ulcers, which one is more painful?

Arterial ulcers are generally more painful than venous ulcers due to reduced blood flow and oxygen to the affected area.

A patient has persistent elevated blood pressure despite antihypertensive treatment and asymmetric kidney size. What is the cause of the persistent hypertension and why?

This condition is likely due to renal artery stenosis, which leads to reduced blood flow to one kidney, activating the renin-angiotensin-aldosterone system and causing persistent hypertension.

A patient presents with symptoms of angina. What is the first test to get and why?

The first test to perform is an exercise electrocardiogram (ECG), as it helps to assess the heart's electrical activity and identify any abnormalities associated with angina.

What are the top 4 classes of medications used for heart failure with reduced ejection fraction?

ACE inhibitors, beta-blockers, SGLT-2 inhibitors, and aldosterone antagonists. These medications help improve heart function, reduce symptoms, and decrease hospitalizations.

What is a main difference between chest pain from angina as opposed to chest pain from acid reflux?

Chest pain from angina is typically associated with exertion and relieved by rest or nitroglycerin, while chest pain from acid reflux is often related to meals, the pain is prolonged, and may improve with antacids. Angina is related to cardiac ischemia, whereas acid reflux is due to gastrointestinal issues.

What are the features of pericarditis?

Sharp, pleuritic chest pain that worsens with inspiration or coughing, a pericardial friction rub on auscultation, and may be associated with fever and signs of inflammation. It often results from viral infections, autoimmune diseases, or post-myocardial infarction.

What is the prominent feature on X-ray with coarctation of the aorta? Why will you see that?

The prominent feature on X-ray is a "figure 3 sign," which occurs due to indirect signs of the coarctation, including indentation of the aorta and collateral circulation formation.

Why do patients with coarctation of aorta have nosebleeds and headaches?

Due to hypertension that results from increased blood pressure in the upper body, as the narrowed segment of the aorta restricts blood flow to the lower body.

If a patient with acute coronary syndrome is at risk for having a heart attack and the ECG is normal, what should you do next?

You should perform serial cardiac enzyme tests and ECGs to assess for myocardial injury, as normal ECG does not rule out the possibility of an acute coronary event.

How does hyperthyroidism cause heart failure?

By increasing heart rate and cardiac output, causing the heart to work harder. This can result in cardiomyopathy and eventual heart failure due to chronic stress on the heart muscle.

How does heavy alcohol use affect triglyceride levels?

Heavy alcohol use can lead to elevated triglyceride levels by promoting fatty acid synthesis in the liver and impairing lipid metabolism, resulting in increased fat storage.

Why is a medication like fenofibrate not taken with atorvastatin?

Both medications can increase the risk of muscle-related side effects, such as rhabdomyolysis, especially when used together, necessitating careful monitoring.

What is the main cause of pulmonary hypertension?

An increase in blood pressure in the pulmonary arteries, often due to left heart disease, chronic lung diseases, or conditions affecting blood vessels.

What is the best treatment for pulmonary hypertension due to heart failure?

Managing the underlying heart condition, which may include medications like diuretics, ACE inhibitors, and beta-blockers, along with pulmonary vasodilators in some cases.

If a patient were to have a blood pressure that is 20/10 above target level but no other abnormalities, what should be done next?

The next step would be to assess the patient's overall health, review their medication adherence, and consider adjusting their antihypertensive treatment to bring blood pressure back to target levels.

A patient with a STEMI is being treated but still has pulmonary edema. What is the best treatment?

The best treatment for a patient with a STEMI and pulmonary edema includes administering diuretics to reduce fluid overload, along with optimizing heart failure management and considering interventions to restore coronary perfusion.

How do nitrates lower demands of heart?

Nitrates lower the heart's demand for oxygen by dilating veins, which reduces the workload on the heart and decreases myocardial oxygen consumption.

What are some of the features of cholesterol microemboli migration?

Cholesterol microemboli migration features include skin and mucosal ischemia, livedo reticularis (blue toe syndrome), and acute kidney injury. These emboli can originate from atherosclerotic plaques and may cause organ damage as they travel through the bloodstream.

What is a complication of MI that can occur within 3-5 days following the event?

Ventricular free wall rupture, which can lead to cardiac tamponade and is often fatal.

What is post-cardiac injury syndrome?

A condition that occurs after heart surgery or injury, characterized by fever, pericarditis, and pleuritis, as a result of an autoimmune response.

What is the best treatment for preventing angina and why?

The best treatment for preventing angina is the use of beta-blockers, as they decrease heart rate and myocardial oxygen demand, effectively reducing the frequency and severity of angina attacks.

Why do patients with prosthetic heart valves have increased risk of developing emboli?

Prosthetic mitral (and tricuspid) valves are particularly susceptible to thrombus, at least in part due to lower blood flow rates through the valve.

If a patient has a ruptured abdominal aortic aneurysm but history isn’t clear, what should be done next?

A focused bedside ultrasound should be performed.

What causes tricuspid regurgitation?

Comes from right ventricular cavity enlargement, leading to dilation of the tricuspid valve annulus 

In a patient with atrial fibrillation, what are the risk factors for developing thromboembolism?

CHF, HTN, 65+, diabetes, stroke, valvular disease, and female sex; if they have 1 or more of these things, get them on an anticoagulant

In patients with severe aortic stenosis, when would surgery be needed?

In all symptomatic patients and those with left ventricular ejection fraction <50%

Why is PAD associated with myocardial infarction?

It indicates systemic atherosclerosis, which increases the risk of coronary artery disease and heart attacks.

Nonsustained ventricular tachycardia is defined as 

≥3 consecutive ventricular beats at a rate >100/min with a duration <30 seconds

If non-sustained ventricular tachycardia is detected, what should be done next?

Evaluate reversible causes such as electrolyte imbalance

What are some features that should have you suspecting unstable angina?

Symptoms such as chest pain at rest, increasing frequency or duration of pain, or pain that is more severe than previous episodes.

What’s a good way to differentiate between arterial embolus versus arterial thrombus?

An arterial embolus typically originates from a distant site and travels through the bloodstream, while an arterial thrombus forms directly at the site of vascular injury or obstruction.

Patients with prior myocardial infarction complicated by left ventricular systolic dysfunction with ejection fraction ≤30%, what are they at increased risk for developing and why?

They are at increased risk for developing heart failure and arrhythmias due to impaired cardiac function and reduced ability to pump blood effectively.

What is another non-cardiac condition vasospastic angina is similar to?

It is similar to esophageal spasm, where both conditions involve episodes of chest pain due to spasms of smooth muscle. It is also related to Raynaud’s phenomenon, which involves vasospasm of peripheral blood vessels.

What would happen if following placement of stent in coronary artery, the patient does not take the prescribed anti-platelet therapy?

The patient may experience stent thrombosis, which is the formation of a blood clot within the stent, leading to potential acute coronary syndrome or myocardial infarction.

When there is ST-elevation in leads II, III, and aVF, what ventricle will fail?

The right ventricle will fail, indicating an inferior ST-elevation myocardial infarction (STEMI) often associated with right coronary artery occlusion.

In patients with hyperthyroidism and atrial fibrillation, what is the best treatment and why?

The best treatment is beta-blockers, as they help control the heart rate and manage symptoms associated with hyperthyroidism and atrial fibrillation.

If someone has severe mitral regurgitation, what should be done?

Surgical intervention, such as mitral valve repair or replacement, may be necessary to prevent heart failure and other complications.

For patients with STEMI, what should be the goal to improve long-term prognosis?

The goal should be to restore coronary blood flow as quickly as possible, typically through reperfusion therapy such as percutaneous coronary intervention (PCI) or thrombolytics.

Why does mitral regurgitation occur in dilated cardiomyopathy?

In DCM, the left ventricular dysfunction often leads to a displacement or dysfunction of the papillary muscles

A patient presents with chest pain lasting several months that is unrelated to exercise. She has no family history and the EKG is normal. Should she undergo any further testing for coronary artery disease?

Further testing may not be necessary, as her symptoms are atypical for coronary artery disease. However, if symptoms persist or worsen, consider non-invasive testing such as a stress test or coronary angiography to rule out other potential causes.

What is the most sensitive marker for heart failure?

B-type natriuretic peptide (BNP), which is released in response to ventricular volume expansion and pressure overload.

If someone is agitated, sweating, has dilated pupils and ST-segment depression on EKG, what did they take?

Stimulant drugs, such as cocaine or amphetamines.

What is the treatment for cocaine intoxication?

The primary treatment for cocaine intoxication includes supportive care, benzodiazepines for agitation or seizures, and in severe cases, antipsychotics. Use of beta-blockers is generally avoided due to the risk of exacerbating hypertension and tachycardia.

For patients who are older than 40 and have diabetes, should they be prescribed statins?

Yes, statins are recommended for primary prevention of cardiovascular disease in these patients.

Who is considered high risk for developing ASCVD?

Individuals with conditions such as diabetes, hypertension, high cholesterol, or a history of smoking. Other factors include older age, family history of heart disease, and metabolic syndrome.

Why is colchicine also given to treat pericarditis?

Reduce inflammation and prevent recurrence of pericarditis. It helps to alleviate symptoms and improve recovery time.

If a patient with bilateral crackles were to have resolution of symptoms following diuretic administration, what was the cause of the symptoms?

Fluid overload from congestive heart failure

What features differentiate aortic stenosis from hypertrophic cardiomyopathy?

Aortic stenosis has ejection click with the murmur that typically increases with squatting and decreases with standing, while hypertrophic cardiomyopathy is characterized by a systolic murmur that increases with Valsalva maneuver; the carotid pulses are soft and delayed with aortic stenosis and are brisk in hypertrophic cardiomyopathy.

How does chronic lung disease cause cor pulmonale?

Chronic lung disease leads to increased pulmonary artery pressure due to hypoxia and vascular resistance, ultimately resulting in right heart failure known as cor pulmonale.

What are the EKG patterns for hyperkalemia?

Peaked T waves, widening QRS complexes, and loss of P waves. These changes can progress to ventricular fibrillation or asystole.

What differentiates syncope due to carotid sinus hypersensitivity as opposed to autonomic nerve dysfunction?

Carotid sinus hypersensitivity causes syncope due to excessive vagal response triggered by carotid stimulation, while autonomic nerve dysfunction results from impaired autonomic regulation leading to inadequate blood flow and blood pressure drops.

What do QRS complexes look like in Mobitz type I as opposed to type II?

QRS in type I are narrow; in type II, they are wider

What heart issues can be seen with sarcoidosis?

Sarcoidosis can lead to conduction abnormalities, heart block, and granulomatous infiltration of the myocardium, potentially resulting in cardiomyopathy.

What will be seen with severe aortic stenosis?

Severe aortic stenosis can lead to left ventricular hypertrophy, decreased cardiac output, and symptoms such as exertional dyspnea, angina, and syncope due to reduced blood flow.

With severe aortic stenosis, why will you see a soft and single S2 during inspiration?

This occurs due to reduced mobility of the aortic valve and the close timing of the aortic and pulmonic valve closure, leading to a diminished second heart sound.

How much does arterial blood pressure drop during inspiration?

Arterial blood pressure typically drops by <10 mmHg during inspiration

What is pulsus paradoxus and what causes it?

Pulsus paradoxus is an exaggerated drop in blood pressure during inspiration, typically more than 10 mmHg. It is commonly caused by conditions such as cardiac tamponade, severe asthma, or obstructive sleep apnea.

In digoxin toxicity, what is seen with EKG?

Atrial tachycardia with atrioventricular (AV) block

What will be seen with aortic dissection?

A sudden onset of severe chest or back pain, often described as tearing or ripping, and may be associated with unequal blood pressures in the arms.

What is the greatest risk factor for developing aortic dissection?

Hypertension, particularly chronic high blood pressure.

What kind of heart disease can radiation cause?

Constrictive pericarditis

Constrictive pericarditis occurs as a result of 

radiation therapy to the chest, leading to thickening and fibrous scarring of the pericardium, which restricts heart function.

When a patient can’t take beta-blockers for HOCM, what’s the best alternative?

Calcium channel blockers such as verapamil or diltiazem.

What kind of murmur is heard with tricuspid regurgitation?

A holosystolic murmur best heard at the left lower sternal border that increases with inspiration

What would the size of the aortic valve have to be to constitute severe aortic stenosis?

An aortic valve area of less than 1.0 cm².

When aortic stenosis isn’t the cause of angina, what is?

Coronary artery disease (CAD)

How is hyponatremia associated with poor heart failure prognosis?

It reflects a state of volume overload and poor cardiac output.

What are the signs of anaphylactic shock?

Signs include difficulty breathing (high RR), swelling of the throat, generalized itching, rapid heartbeat, low blood pressure, flushed skin, rash, vomiting and diarrhea, and confusion or loss of consciousness.

What are some metabolic side effects of beta blockers?

Metabolic side effects of beta blockers may include weight gain, altered lipid metabolism, and insulin resistance. These effects can impact overall cardiovascular health.

What is done when first-degree heart block is diagnosed?

First-degree heart block typically requires observation, as it often does not necessitate treatment unless associated with symptoms or other heart conditions.

What does a ventricular beat look like on EKG?

A ventricular beat on an EKG is characterized by a wide QRS complex, typically greater than 0.12 seconds, and may occur without a preceding P wave. It indicates that the impulse is originating from the ventricles rather than the atria.

How would you treat ventricular tachycardia?

Treatment of ventricular tachycardia may include medications such as antiarrhythmics like amiodarone if stable.

If unstable, electrical cardioversion, or catheter ablation

What are features of AVNRT?

A rapid heart rate, often between 150-250 beats per minute, with narrow QRS complexes on EKG. It typically presents with palpitations, dizziness, and sometimes syncope.

What helps relieve AVNRT?

Vagal maneuvers, such as the Valsalva maneuver and cold-water immersion, can help terminate AVNRT by slowing down the heart rate and interrupting the reentrant circuit.

In hypovolemic shock, what happens to cardiac output?

Cardiac output decreases due to reduced blood volume, leading to inadequate perfusion of organs and tissues.

When conditions cause an S4?

Hypertension, aortic stenosis, or ischemic heart disease like acute coronary syndrome. It indicates decreased ventricular compliance and is typically associated with left ventricular hypertrophy.

What is the problem with the preload in cardiac tamponade?

Preload is decreased due to the accumulation of fluid in the pericardial space, which restricts the heart's ability to fill properly during diastole, leading to reduced stroke volume.

When can interventricular septum rupture develop?

Interventricular septum rupture can develop after a myocardial infarction, particularly within the first 3-5 days following an acute heart attack, due to necrosis of the septal tissue.

When the IV septum ruptures from MI, what signs are present?

Signs include sudden onset of chest pain, hypotension, and a new, loud heart murmur due to left-to-right shunting. Patients may also exhibit signs of heart failure and shock.

What is electrical alternans?

A phenomenon where the amplitude of the QRS complexes varies on consecutive beats, often associated with pericardial effusion or cardiac tamponade.

What cardiac issue does viral myocarditis cause?

Viral myocarditis can lead to heart failure and arrhythmias due to inflammation of the heart muscle, impacting its ability to pump effectively.

What precedes viral myocarditis?

Viral infections, such as influenza or enteroviruses.

What is the cause of viral myocarditis?

Viral myocarditis is primarily caused by viral infections, particularly by viruses like Coxsackievirus, adenovirus, and influenza, which lead to inflammation of the heart muscle.

What causes atrial fibrillation?

Atrial fibrillation is often caused by conditions that affect the heart's electrical system, such as hypertension, heart valve disease, or coronary artery disease.

What causes the palpitations in atrial fibrillation?

Palpitations in atrial fibrillation are caused by the rapid and irregular electrical signals in the atria, leading to an uncoordinated heartbeat.

For a patient with mild and stable angina, if they are given the proper medications, is there any other testing that needs to be done?

For a patient with mild and stable angina, if they are given the proper medications, further testing may not be necessary unless symptoms worsen or new risk factors develop. Regular follow-up and monitoring of the patient's condition are essential.

What can ischemic cardiomyopathy lead to?

Ischemic cardiomyopathy can lead to heart failure, arrhythmias, and an increased risk of heart attacks due to reduced blood flow to the heart muscle.

What are signs in high-output heart failure?

Signs of high-output heart failure include increased heart rate, fatigue, shortness of breath, and swelling in the legs and abdomen due to excess fluid retention.

What causes high-output heart failure?

Conditions that increase the body's demand for blood flow, such as anemia, hyperthyroidism, or arteriovenous fistulas, leading to the heart being unable to meet these demands.