Internal Medicine EOR: Cardiovascular (Smarty PANCE)

What is stable angina?

Predictable chest pain with exertion relieved by rest or nitroglycerin within 5 minutes - due to fixed coronary stenosis (>70%)

What are the classic characteristics of cardiac chest pain?

Substernal pressure/heaviness, radiation to jaw/left arm, provoked by exertion/cold/emotion, relieved by rest/nitroglycerin

What is the difference between stable and unstable angina?

Stable: predictable, exertional, relieved by rest; Unstable: new-onset, crescendo pattern, at rest (part of ACS)

What is Prinzmetal's (variant) angina?

Coronary vasospasm causing angina at rest, typically at night, with transient ST elevation - responds to calcium channel blockers

What is first-line treatment for stable angina?

Antiplatelet therapy (aspirin), beta-blocker, sublingual nitroglycerin PRN, statin, risk factor modification

What is the mechanism of action of nitroglycerin in angina?

Venodilation reduces preload, coronary vasodilation improves myocardial oxygen supply, decreases oxygen demand

When should coronary angiography be performed for stable angina?

High-risk features on stress test, refractory symptoms despite medical therapy, or Canadian Class III-IV angina

What diagnostic test is preferred for diagnosing stable angina in patients who can exercise?

Exercise stress ECG (first-line for intermediate pretest probability), or stress echo/nuclear if baseline ECG abnormal

CARDIAC ARRHYTHMIAS/CONDUCTION DISORDERS

CARDIAC ARRHYTHMIAS/CONDUCTION DISORDERS

What is atrial fibrillation and its most dangerous complication?

Irregularly irregular rhythm with absent P waves - most dangerous complication is thromboembolic stroke

What is the CHA2DS2-VASc score used for?

Risk stratification for stroke in atrial fibrillation to determine need for anticoagulation (score ≥2 males, ≥3 females warrants anticoagulation)

What medications are used for rate control in atrial fibrillation?

Beta-blockers (metoprolol), non-dihydropyridine calcium channel blockers (diltiazem, verapamil), digoxin

What is the most common type of supraventricular tachycardia (SVT)?

Atrioventricular nodal reentrant tachycardia (AVNRT) - narrow complex regular tachycardia

What is the acute treatment for stable SVT?

Vagal maneuvers first, then adenosine 6mg rapid IV push (12mg if no response), followed by calcium channel blockers or beta-blockers

What ECG finding defines first-degree AV block?

PR interval >200 ms (>5 small boxes) - benign, requires no treatment

What is the treatment for symptomatic third-degree (complete) heart block?

Permanent pacemaker placement - medical emergency if hemodynamically unstable

What is the definition of bradycardia and when does it require treatment?

Heart rate <60 bpm - only treat if symptomatic (hypotension, altered mental status, syncope, chest pain)

What is the characteristic ECG finding in atrial flutter?

Sawtooth flutter waves (F waves) at rate 250-350 bpm, usually with 2:1 AV conduction (ventricular rate ~150 bpm)

What defines wide-complex tachycardia and most common cause?

QRS >120ms - assume ventricular tachycardia until proven otherwise (treat as VT)

CARDIOMYOPATHY

CARDIOMYOPATHY

What are the three main types of cardiomyopathy?

Dilated (most common), Hypertrophic (most common genetic), Restrictive (least common)

What is dilated cardiomyopathy and its most common causes?

Enlarged ventricles with systolic dysfunction (EF <40%) - causes: idiopathic, alcohol, viral myocarditis, chemotherapy

What is hypertrophic cardiomyopathy (HCM)?

Asymmetric septal hypertrophy with LV outflow obstruction - most common cause of sudden cardiac death in young athletes

What physical exam finding is characteristic of HCM?

Harsh systolic crescendo-decrescendo murmur at LLSB that increases with Valsalva and decreases with squatting

What is the treatment for hypertrophic cardiomyopathy?

Beta-blockers or non-dihydropyridine CCBs, avoid dehydration/vasodilators, ICD for high-risk patients

What is restrictive cardiomyopathy?

Impaired ventricular filling due to rigid ventricles - causes: amyloidosis, sarcoidosis, hemochromatosis, radiation

What ECG finding is classic for hypertrophic cardiomyopathy?

Left ventricular hypertrophy with deep Q waves in lateral leads (I, aVL, V5-V6)

CONGESTIVE HEART FAILURE

CONGESTIVE HEART FAILURE

What is heart failure with reduced ejection fraction (HFrEF)?

EF ≤40% with systolic dysfunction - treated with guideline-directed medical therapy (GDMT)

What are the four pillars of GDMT for HFrEF?

ACE inhibitor/ARB/ARNI, Beta-blocker, Mineralocorticoid receptor antagonist (MRA), SGLT2 inhibitor

What are the classic symptoms of left-sided heart failure? Use mnemonic POPE

Pulmonary congestion, Orthopnea, Paroxysmal nocturnal dyspnea, Exertional dyspnea

What are the classic symptoms of right-sided heart failure?

Peripheral edema, jugular venous distension, hepatomegaly, ascites, weight gain

What is the most useful diagnostic test for heart failure?

BNP (>100 pg/mL) or NT-proBNP (>300 pg/mL) - elevated levels support HF diagnosis

What is the New York Heart Association (NYHA) functional classification?

Class I: no limitation; Class II: slight limitation; Class III: marked limitation; Class IV: symptoms at rest

What diuretic is first-line for volume overload in heart failure?

Loop diuretics (furosemide) - acts on loop of Henle to promote sodium and water excretion

What medications should be avoided in systolic heart failure?

NSAIDs, non-dihydropyridine CCBs (diltiazem, verapamil), most antiarrhythmics (except amiodarone)

What is acute decompensated heart failure treatment?

IV diuretics (furosemide), oxygen, uptitrate GDMT, treat precipitating factors (infection, arrhythmia, nonadherence)

CORONARY VASCULAR DISEASE

CORONARY VASCULAR DISEASE

What percentage of coronary stenosis is hemodynamically significant?

≥70% stenosis in major epicardial vessel or ≥50% left main stenosis causes flow-limiting ischemia

What are the major modifiable risk factors for CAD? Use mnemonic HDSML

Hypertension, Diabetes, Smoking, Metabolic syndrome/obesity, Lipid disorders

What are the non-modifiable risk factors for CAD?

Age (men >45, women >55), male sex, family history of premature CAD, genetics

What is the gold standard test for diagnosing coronary artery disease?

Coronary angiography (cardiac catheterization) - invasive, allows for intervention (PCI)

What non-invasive test has highest sensitivity for detecting CAD?

Coronary CT angiography (CCTA) - excellent negative predictive value, best for low-intermediate risk

What secondary prevention medications are indicated after CAD diagnosis?

Aspirin, high-intensity statin, beta-blocker (if prior MI), ACE inhibitor (if reduced EF or diabetes)

ENDOCARDITIS

ENDOCARDITIS

What are the classic clinical features of infective endocarditis? Use mnemonic FROM JANE

Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nail bed hemorrhages, Emboli

What are the most common organisms causing native valve endocarditis?

Staphylococcus aureus (most common overall), Streptococcus viridans (subacute), Enterococcus

What is the most common organism in IVDU-associated endocarditis?

Staphylococcus aureus - typically affects tricuspid valve (right-sided)

What are the modified Duke criteria for diagnosing endocarditis?

2 major criteria OR 1 major + 3 minor OR 5 minor criteria - includes blood cultures and echocardiography

What imaging is first-line for suspected endocarditis?

Transthoracic echocardiogram (TTE) first, transesophageal (TEE) if TTE negative but high suspicion

What is the empiric antibiotic treatment for native valve endocarditis?

Vancomycin PLUS ceftriaxone (or gentamicin) - adjust based on culture results

What is the duration of antibiotic therapy for endocarditis?

4-6 weeks IV antibiotics depending on organism and valve involved (longer for prosthetic valves)

When is surgical intervention indicated in endocarditis?

Heart failure, valve dysfunction, large vegetations (>10mm), recurrent emboli, prosthetic valve infection, abscess formation

HEART MURMURS

HEART MURMURS

What is the classic murmur of aortic stenosis?

Harsh systolic crescendo-decrescendo murmur at RUSB radiating to carotids, decreases with Valsalva

What is the classic murmur of aortic regurgitation?

High-pitched, blowing diastolic decrescendo murmur at LLSB, heard best sitting forward in expiration

What is the classic murmur of mitral stenosis?

Low-pitched, rumbling diastolic murmur at apex with opening snap, heard best in left lateral position

What is the classic murmur of mitral regurgitation?

Holosystolic (pansystolic) murmur at apex radiating to axilla, does not change with Valsalva

What maneuver increases the intensity of most murmurs?

Squatting or leg raise increases preload/afterload - increases most murmurs EXCEPT HCM and MVP

What maneuver increases murmurs of HCM and MVP?

Valsalva or standing decreases preload - increases HCM and MVP murmurs, decreases all others

What is the difference between systolic and diastolic murmurs?

Systolic: between S1 and S2; Diastolic: between S2 and S1 - all diastolic murmurs are pathologic

HYPERLIPIDEMIA

HYPERLIPIDEMIA

What are the target LDL cholesterol levels for primary prevention?

LDL <100 mg/dL for most patients, <70 mg/dL for diabetics or those with very high risk

What is the first-line medication for hyperlipidemia?

Statins (HMG-CoA reductase inhibitors) - reduce LDL, decrease cardiovascular events and mortality

What are high-intensity statins?

Atorvastatin 40-80mg, Rosuvastatin 20-40mg - lower LDL by ≥50%

What are the indications for statin therapy per ACC/AHA?

LDL ≥190, diabetes age 40-75, 10-year ASCVD risk ≥7.5%, clinical ASCVD

What are the major side effects of statins?

Myalgias/myopathy, elevated liver enzymes, increased diabetes risk, rarely rhabdomyolysis

What medication is used for hypertriglyceridemia?

Fibrates (fenofibrate) for triglycerides >500 mg/dL to prevent pancreatitis

What is the mechanism of action of ezetimibe?

Inhibits cholesterol absorption in small intestine - added to statin if LDL goal not met

What lipid abnormality pattern is seen in metabolic syndrome?

High triglycerides (>150), low HDL (<40 men, <50 women), normal or slightly elevated LDL

HYPERTENSION

HYPERTENSION

What blood pressure defines hypertension per 2017 ACC/AHA guidelines?

Systolic ≥130 mmHg or Diastolic ≥90 mmHg (Stage 1); ≥140/90 (Stage 2)

What is the target blood pressure for most patients?

<130/80 mmHg for most adults, <130/80 for those with diabetes or CKD

What are first-line antihypertensive medications for most patients?

Thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers (CCBs)

What is the preferred antihypertensive in African American patients?

Thiazide diuretic or calcium channel blocker (ACE/ARB less effective as monotherapy)

What is the preferred antihypertensive for patients with diabetes or CKD?

ACE inhibitor or ARB - provides renal protection and slows progression of nephropathy

What defines hypertensive urgency vs emergency?

Urgency: BP >180/120 without end-organ damage; Emergency: BP >180/120 WITH end-organ damage

What is the treatment for hypertensive urgency?

Oral antihypertensive (restart home meds or add new agent), lower BP gradually over 24-48 hours

What is white coat hypertension?

Elevated BP in office (≥130/80) but normal at home (<130/80) - confirm with ambulatory BP monitoring

What lifestyle modifications help lower blood pressure?

DASH diet, sodium restriction (<2g/day), weight loss, exercise, limit alcohol, smoking cessation

MYOCARDIAL INFARCTION

MYOCARDIAL INFARCTION

What defines STEMI vs NSTEMI?

STEMI: ST elevation ≥1mm in 2 contiguous leads or new LBBB; NSTEMI: elevated troponin without ST elevation

What is the time goal for reperfusion therapy in STEMI?

Door-to-balloon (PCI) <90 minutes OR door-to-needle (fibrinolysis) <30 minutes

What are absolute contraindications to fibrinolytic therapy?

Prior intracranial hemorrhage, known intracranial malignancy, ischemic stroke within 3 months, active bleeding, suspected aortic dissection

What are the immediate treatments for acute MI? Use mnemonic MONA

Morphine (if pain not relieved), Oxygen (if hypoxic), Nitroglycerin, Aspirin 162-325mg chewed

What medications should be given to all MI patients (no contraindications)?

Dual antiplatelet therapy (aspirin + P2Y12 inhibitor), high-intensity statin, beta-blocker, ACE inhibitor (especially if EF <40%)

What ECG leads correspond to anterior MI?

V1-V4 (LAD territory) - highest risk for complications including cardiogenic shock

What ECG leads correspond to inferior MI?

II, III, aVF (RCA territory) - check right-sided leads (V4R) to assess for RV infarction

What is the most common complication within first 24 hours of MI?

Ventricular arrhythmias (VT/VF) - peak incidence in first 4 hours

What mechanical complications occur days to weeks post-MI?

Free wall rupture (1-5 days), VSD (3-5 days), papillary muscle rupture (3-5 days), ventricular aneurysm (weeks-months)

MYOCARDITIS

MYOCARDITIS

What is myocarditis?

Inflammatory disease of myocardium causing cardiac dysfunction - most commonly viral (coxsackievirus B, parvovirus B19)

What are the classic presenting symptoms of myocarditis?

Chest pain (often pleuritic), dyspnea, fatigue, palpitations, symptoms following viral URI (1-2 weeks prior)

What laboratory findings suggest myocarditis?

Elevated troponin, elevated BNP, elevated ESR/CRP, leukocytosis

What is the gold standard for diagnosing myocarditis?

Endomyocardial biopsy - shows inflammatory infiltrate, but rarely performed due to low sensitivity

What ECG findings are seen in myocarditis?

ST elevation (mimics STEMI), diffuse ST changes, PR depression, new arrhythmias, conduction abnormalities

What is the treatment for acute myocarditis?

Supportive care, treat heart failure (diuretics, ACE inhibitors, beta-blockers), avoid NSAIDs, rest from exercise

What is giant cell myocarditis?

Rapidly progressive, fulminant myocarditis with very high mortality - requires aggressive immunosuppression or transplant

PERICARDITIS

PERICARDITIS

What are the classic symptoms of acute pericarditis? Use mnemonic FEAR

Friction rub, ECG changes, Anterior chest pain (sharp, pleuritic), Relief with sitting forward