Cardiology UWorld/Pastest. Questions with accurate answers. Graded A+

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Cardiology UWorld/Pastest. Questions with accurate answers. Graded A+ The use of 5PDE inhibitors is contraindicated in patients using _________________ for the treatment of angina, as the combi... nation of these two drugs may cause life-threatening hypotension. - ✔✔Nitrates (ex. nitroglycerin) IV drug users usually manifest with _______________ valve abnormalities - ✔✔Tricuspid valvue. > When the organism enters the venous circulation, on its way to the heart, the first value it encounters is the tricuspid valve. The FROM JANE mnemonic describes the symptoms of? - ✔✔Bacterial endocarditis FROM JANE F - Fever R - Roth's spots O - Osler nodes M- Murmur J - Laneway lesions A - Anemia N - Nail bed hemorrhages E - Emboli. The most common infectious organism is IV drug supers is S. aureus. FYI - Crackles upon lung auscultation will be seen when there is black flow of blood into the lungs due to LEFT heart or MITRAL valve abnormalities. SO not this due because this most commonly affect the tricuspid valve. Tetralogy of Fallot presents with pulmonary stenosis, VSD, overriding aorta and right ventricular hypertrophy. Abnormal migration of the __________________, is responsible for malalignment (anterosuperior displacement) of the infundibular septum - ✔✔Neural crest cells A man presents with fever, recent upper respiratory infection, pleuritic test pain, and diffuse ST-segment elevation with PR-segment depression on ECG consistent with a diagnosis of _________________________ - ✔✔Acute pericarditis. > Pleuritic chest pain is aggravated by deep inspiration and movements that increase pericardial stretch. > Acute pericarditis is most often due to a viral infection An apical diastolic rumble with opening snap is heard in __________________ - ✔✔mitral stenosis A high-pitched apical pan systolic murmur radiating to the axilla is characteristic of ____________________ - ✔✔mitral regurgitation A continuous systolic and diastolic murmur obscuring the S2 sound and radiating to the back is heard in ______________________ - ✔✔coarctation of the aorta A patient has both diabetes and hypertension. These type of patients require a specific combination of t antihypertensive medication that not only lowers the blood pressure but also is protective of the kidneys. Diabetes mellitus can have detrimental effects on the kidney; therefore it is important to maintain appropriate rental function. ___________ and __________ are medications that not only help lower blood pressure but are also protective against diabetic nephropathy. - ✔✔ARBs (angiotensin II receptor blockers) And ACEi In ____________________, patients typically present it hypertension in the upper extremities and relative hypertension in the lower extremities with occasional leg claudication symptoms. - ✔✔Aortic coarctation - characterized by narrowing of the aortic lumen typically in a post ducal location. > This is because blood shunts preferentially through the arch vessels flow is reduced through the descending aorta. What are the symptoms of renal artery stenosis? - ✔✔Renal artery stenosis - narrowing of the renal artery - Secondary hypertension > This causes decreased blood flow to the kidneys, which can be in turn cause fluid retention and hypertension. However, a BRUIT is typically heard on auscultation of the abdomen and CREATININE would be elevated due to decreased renal perfusion. In ________________. a constant, machine-like murmur may be detected on cardiac auscultation - ✔✔Patent ductus arteriosus . > Patients with a patent ductus have a sleet-to-right shunt that can result in left ventricular dilatation and failure if untreated. In _______________ there is left-to-right shunt and can be detected by a fixed, widely split S2 on cardiac auscultation - ✔✔Atrial septal defect In the presence of secondary hypertension, you should always first rule out _____________ and ________________ - ✔✔Nicotine AND oral contraceptives. What is most likely the diagnosis? A 4 y/o boy from China with restlessness, chest pain, and abdominal pain. Approximately 8 months ago, he had a suspected viral illness with fever, cervical lymphadenopathy, erythematous oropharynx, and a desquamating rash on his feet that resolved without treatment. An EKG shows ST segment elevations in leads II, III, and aVF - ✔✔Kawasaki disease Patients with Kawasaki disease may develop coronary artery thrombosis, which can lead to myocardial infarction The symptoms of Kawasaki disease may be remembered with the mnemonic "CRASH and burn": - C: Conjunctivitis - R: Rash (polymorphous -> desquamating) - A: Adenopathy (cervical lymph nodes) - S: Strawberry tongue (oral mucositis) - H: Hand-foot erythema and edema - & - Burn: Fever - mnemonic: CRASH and burn Mucocutaneous lumps node syndrome (Kawasaki ideas) may present similar to a self-resolving illness, but has serious implications if left untreated. Left untreated, this insidious vasculitis can cause coronary artery aneurysm and myocardial infarction, which are particularly devastating in children. > This patient's EKG is diagnostic for an inferior wall infarction. > Treatment with aspirin during the symptomatic phase of this child's illness could have prevented this presentation. Since the _____________ nerve runs along the carotid artery it may be damaged during carotid endarterectomy, leading to difficult to control severe hypertension. Hoarseness and dysphagia are also supportive of vagus nerve injury, in particular, the recurrent laryngeal branch. - ✔✔vagus nerve ____________________ usually follows infection with enterohemorrhagic E. coli. In addition the presence of renal failure and a microangiopathichaemolytic anemia. - ✔✔Hemolytic uremic syndrome Idiopathic thrombocytopenia purpura is not associated with a ______________ platelet count and the purpic rash is not ____________________ - ✔✔Normal; palpable _____________________ is a small-vessel vasculitis characterized by palpable purpura - usually located on the buttock area and lower extremities. Additional clinical manifestations include arthralgia, diarrhea, abdominal pain and glomerulonephritis. - ✔✔Hence-Schonlein purpura Usually seen in children ages of 4 to 7 years old. The following symptoms of characterized by which disorder? Diffuse chest pain that alleviated upon leaning forward. Temperature of 37.9 degrees C, blood pressure of 140/84 mmHg, pulse of 76/min. Cardiac auscultation reveals a faction rub. Electrocardiogram (ECG) shows ST segment elevations in nearly every lead. The 64 y/o women comes to the ED because of worsening chest pain over the past 2 days. She had a sore throat a week ago. She has a history of hypertension and hyperlipidemia. - ✔✔Pericarditis - inflammation of the pericardium Most likely due to, Post-viral complication > The patient reported symptoms of a recent viral infection (sluggishness and sore throat), and then developed pericardial symptoms acutely. A friction rub is often heard on cardiac auscultation and diffuse ST segment elevations are seen on ECG, which can be confused with myocardial infarction. _________________ syndrome refers to post-myocardial infarction pericarditis. There are ST elevation but it is NOT diffuse (diffuse represents transmural infarction) - ✔✔Dressler Dressler syndrome - pericarditis that arises 6-8 weeks after infarction due to an autoimmune phenomenon where you began to produce antibodies against your own pericardium Pericarditis can be cased by ____________, but we would expect other symptoms such as rash, myalgaia, or joint pain. A positive antinuclear antibodies test is also likely. - ✔✔Lupus (SLE) _____________________ such as simvastatin, lovastatin, and atorvastatin are used in patients with high low-density lipoprotein (LDL) levels. Inhibition of HMG CoA reductase decrease cholesterol formation via the cholesterol pathway. Common adverse effects include myopathy and liver toxicity. - ✔✔HMG CoA reductase inhibitors > The creatinine phophokinase (CPK) level should be checked in patients with statin-induced myopathy and if it is more than 10 times the normal level the statin should be stopped. > Liver function tests should also be checked in patients on statin therapy, and if the enzyme levels are increased to 3 times the normal limit the statin should be stopped. ______________________ is a bile acid resin. It binds with bile salt and prevents reabsorption of cholesterol from the GI that. Common adverse effects include GI upset such as constiptation, diarrhea and bloating, but not muscle ache. It also decreases reabsorption of warfarin and fat-soblue vitamins. - ✔✔Cholestryamine ____________________ prevents cholesterol absorption from the GI tract. It is not used as a single therapy, rather in conjunction with a statin. - ✔✔Ezetimbie. _________________ decrease VLDL, LDL, and triglyceride and slightly increase HDL levels. They are most commonly used in patients with very high triglyceride levels. Adverse effects include gall stone formation, rash, myositis. They usually cause muscle damage when used in combination with statin and it is NOT the drug of choice for a patient with high LDL. - ✔✔Vibrates. __________________ is used in patients with hyperlipidemia. It inhibits very low-density lipoprotein (VLDL), decreases LDL and triglyceride, and increases high-density lipoprotein (HDL) levels. Common adverse effects include flushing and itching, but not muscle ache. Aspirin should be given prior to administration to prevent its side effects - ✔✔Nicotinic acid A 4-mouth old infant is brought to the physician for a routine examination. Physical examination shows epicanthic folds and a palmar simian crease. Cytogenetic texting shows an autosomal trisomy. Which cardiac anomalies is most common associated with this condition? - ✔✔Complete atrioventricular septal defect > The description with the presence of epicanthic folds and a simian crease should alert to the diagnosis of Down's syndrome or trisomy 21. Complete atrioventricular septal defect is the most common cardiac abnormality associated with this condition, with an estimated prevalence of about 35% in this population > Other cardiac abnormalities that CAN appear but are not the MOST common are: atrial septal defect, mitral stenosis, patent ductus arteriousus, Tetralogy of Fallot Case: A 75 yo man is brought to the ED because of a 2-hour history of crushing, substernal pain that radiates to the left jaw. He is administered morphine, oxygen, sublingual nitroglycerin, and metoprolol. One hour later, he has ventricular fibrillation, is unable to be resuscitated, and dies.. Which of the following microbic changes is most likely to be found on autospy of the patient? - ✔✔No change This clinical vignette is consistent with acute myocardial infarction (MI). Medical treatment for MI includes oxygen, beta-blocker, nitroglycerin, aspirin, and morphine for pain. If percutaneous coronary intervention (PCI) is available, gold standard treatment for acute MI is a door-toballon time of under 90 minutes. When PCI is not available, thrombolytic therapy is indicated in the absence of any contraindications. > Between *0 and 4 hours*, NO CHANGE is obsessed, either grossly or microscopically. > Between *4 and 12 hours* coagulative necrosis and wavy fibers are evident as surrounding viable myocardium continues to contract. > Neutrophilic infiltrate is generally present between 1 and 4 days post-MI. Fibrinous pericarditis with chest pain may mimic symptoms of reinfarction. In this case CKMB is useful to rule out reinfarciton. > Granulation tissue with capillary proliferation and macrophage infiltration is most apparent beginning *one week* after infarction > Acellular fibrosis and scar do not become evident until approximately one month after infarction. Case: A 64 y/o is brought to he ED after complaining of crushing best pain and shortness of breath. ECG reveals ST-segment elevations in leads I, aVL, and V5, V6. CK-MB levels are also elevated. She is treated according to protocol for her condition. However, ten hours latter, despite aggressive resuscitative measures, she dies. What is most likely the reason for her death? - ✔✔Ventricular fibrillation This patient pretend to the ED experiencing a MI. In patients with MI, the MOST COMMON cause of sudden death is arrhythmia, particularly ventricular fibrillation. Complications > 0-24 hrs: Arrhythmia, cariogenic shock, heart failure > 1-3 days: Fibrinous pericarditis > 3-7 days: Myocardial rupture (free wall or septum depending on the location of MI), papillary muscle rupture. LV pseudoaneursym (high chance of rupture). > 2 months: Dressler's Syndrome, Ventricular aneurysm (which can cause mural thrombus), heart failure Case: A 42 y/o man comes to the physician because of High blood pressure. Physical examination shows yellow flat plaques of the lower eyelids. He says it has been present for many years. His father died of a MI at 50 years old. He feels well and exercises regularly without difficulty. His body mass index is 24 kg/m2. Which of the following physical signs would most likely be present in the examination? - ✔✔Tendon xanthomata > The appearance is of yellow flat plaques over the lower eyelids. They represent areas of lipid-containing macrophages. The diagnosis is xanthelasma. > It is possible given the premature death of his father that he has familial hypercholesterolemia. In that case he may well have tendon xanthomata*. These are hard, non-tender nodular enlargement of tendons. The y are most commonly found on the knuckles and the Achilles tendon. What kinds of diseases do you see an enlarged liver? - ✔✔An enlarged liver or hepatomegaly is present in conditions like 1) Hepatitis (infectious, drug-induce, alcoholic, or nonalcoholic) 2) Storage disorders (glycogen storage diseases or hemochromatosis) 3) Impaired hepatic venous outflow (Budd-chairir or right heart filature), 4) Biliary tract idosderes 5) Infiltrative diseases What condition would you see *speckled iris* (Brushfield spots) - ✔✔A speckeld iris (brush field spots) is due to small white or greyish/brown spots on the periphery of the iris due to aggregation of connective tissue These are normal in children, but are also a feature of Down syndrome. Case: A 64 yo man is brought to the ED because of pleuritic chest pain over the past 3 hours. The pain began while lying in bed. He has a history of diabetes mellitus and a MI 4 weeks prior, for which he underwent coronary artery bypass surgery. The surgery was uncomplicated and the patient recovered uneventfully.He smokes 1.5 packs of cigarettes per day and does not drink alcohol. The patient appears colorable and has a regular pulse, a pericardial rub, and no cardiac murmurs. Serum inflammatory market are elated. ECG and serial cardiac troponin levels are normal. What is most likely the diagnosis? - ✔✔Dressler syndrome > Dressler syndrome is a complication of transmural myocardial infarction thought to arise from formation of autoantibodies against cardiac antigens released from necrotic myocytes. > Symptoms include mild fever and pleuritic chest pain often several weeks after an MI. It is usually similar to pericardial type pain: often received by leaning forward and exacerbated in the supine position. Case: A 16 y/o boy with beta thalassemia requiring regular blood transfusions is diagnosed with heart filature and new onset diabetes mellitus. He is placed on the waiting list for a heat transplant. What is the most likely cause of heart failure in this patient? - ✔✔Iron overload cardiomyopathy > Frequent blood transfusion result in the *accumulation and deposition of iron* in various organs including the liver, heart, and pancreas. Iron overload cardiomyopathy is a term coined to a secondary cause of cardiomyopathy resulting from the accumulation of iron in the heart, usually from genetic disorders of iron metabolism or repeated blood transfusion. > It is deterrable by cardiac MRI and suggestive lab studies, including a ferritin level > 300 ng/ml and a transferrin saturation >55%. An _______________________ is due to mismatch between major histocompatibility antigen on blood cells, such as the ABO system. It causes severe intravascular hemolysis, disseminated intravascular coagulation, renal filature and shock and has a high mortality if not recognized quickly. - ✔✔Acute hemolytic transfusion reaction Case: A 3 y/o boy is brought to the ED because of high fever, cervical lymph node enlargement, conjunctival congestion, redness of lips and palms, and desquamation of fingertips. Physical examination shows erythema of the oral cavity. Lab show hemoglobin 11 mg/dl; platelet count 1,000,000 mm3. Symptoms resolved after 2 weeks. During the third week the child dies unexpectedly. Autospy shows vasculitis of coronary arteries and aneurysm formation. What is the most likely diagnosis? - ✔✔Kawasaki diseases (mucocutaneous lymph node syndrome) Kawasaki diseases, also known as mucocutaneous lymph node syndrome, is an acute, fertile, multistyem disease of children. Most cases occur prior to the age of 5. A coronary arteritis is an important hallmark feature of this diseases and is often found on autopsy. There is associated intimal proliferation and infiltration of the vessel wall with mononuclear cells. Along the artery, beadlike aneurysms and thromboses may be discerned. Other manifestation include cardiomegaly, myocardial ischemia and infarction, myocarditis, and pericarditis > High-dose IV (intravenous) globulin and aspirin have been shown to be effective in reducing the incidence of coronary artery abnormalities when administered early in the course of the disease. Platelet counts are abnormally elevated in Kawasaki's disease A prolonged PR interval (defined as >200 ms) with 1:1 conduction ratio of P waves to QRS complies is characteristic of _______________________ - ✔✔1st degree heart block. > First Degree Block - A conduction block that occurs at the AV node (or the bundle of His, which is immediately distal) > Every atrial impulse does eventually get conducted > The only thing that you need to diagnose a First Degree Block is a PR internal longer than 200 msec > Better known as a "delay" rather than a true block > It is of little clinical consequence, but is seen more frequently in aging hearts where the conduction system is starting to slip. 2nd degree heart block, _________________________ is characterized by progressive lengthening of the PR interval until a QRS complex is dropped. It is usually symptomatic, of no clinical significance and therefore does not require treatment. - ✔✔Mobritz type 1 or Wenkebach phenomenon 2nd degree heart block, _______________________ is characterized by consistent unchanging PR intervals (usually normal in duration but can be prolonged) followed by the block of one or more P waves that fail to conduct to the ventricles. - ✔✔Moritz type 2 > Moritz type 2 is a high degree AV block with the potential for progressing to complete heart block ___________________________ is identified by P waves and QRS complexes that are independent of each other - ✔✔Complete heart block (or 3rd degree heart block) A normal PR interval is _____________ ms - ✔✔< 200 Case: A 1-day-old term new born of a diabetic mother is evaluated for blue discoloration of the skin, clubbing of the fingers, poor feeding, and severe shortness of breath. Physical examination shows lethargy and cyanosis. He is started on supplemental oxygen without improvement in oxygenation. Chest X-ray shows normal cardiac silhouette, lung marking and costophrenic angles. Echocardiogram shows an anterior aorta arising from the right ventricle with the pulmonary artery taking off from the left ventricle and he mistreated with intravenous prostaglandin. - ✔✔Failure of migration of neural crest and endocardial cells > The differential diagnosis of neonatal cyanosis and respiratory distress is broad, including aspiration of meconium or amniotic fluid, congenital heart disease, diaphragmatic herina, bronchopulmonary dysplasia, pneumonia, pulmonary immaturity, and transient tachypnea of the newborn. In this case, this newborn is suffering from transposition of great vessels, evidenced by the severe cyanosis immediately after birth without improvement with supplemental oxygen (due to cardiac shunting) and echocardiogram showing the aorta taking off from the right ventricle and pulmonary artery from the left ventricle. > Treatment of transposition of the great vessels requires prostaglandin in order to keep the ductus arteriosus open until surgery can correct the vessel origins. > Transposition of great vessels results from *failure of migration of neural crest and endocardial cells which results in failure of the pulmonary artery and aorta to correctly twist and attach to the right and left ventricles respectively. > Infants of diabetic mothers are at a greater risk of developing transition of the great vessels. Atrial septal defects (ASD) are associated with a _____________ heart sound on physical exam. - ✔✔Fixed-split S2 > Similar to a VSD, ASD is typically not associated with cyanosis, unless left untreated for a significant period of time, which may lead to Eisenmenger's syndrome that results in cyanosis. However, ASD would not present with cyanosis on the first day of life Failure of complete formation of the membranous inter ventricular septum results in a ventricular septal defect (VSD), which is typically associated with a _________________heart murmur. - ✔✔holosystolic > VSD is typically not associated with cyanosis, especially in the first days of life. Large VSDs, if left untreated may result in Eisenmenger's sydrnome, which results in a right to left intracardiac shunt and, ultimately, cyanosis. Case: A 42 yo man with allergic rhinitis and asthma is treated with inhaled bronchodilators, cromolyn sodium, and anti-inflammatory agent montelukast. He develops mild fever, malaise, weight loss, night sweats, multiple joint pain, tingling sensation in both hands and feet, and occasional abdominal pain with diarrhea. Additionally, he has a stuffy nose, cough, and external shortness of breath. Laboratory studies show peripheral blood eosinophils of 24%. His serum p-ANCA is positive. Blood urea nitrogen and creatinine are within normal range. Urinalysis is unrevealing. What is most likely the diagnosis? - ✔✔Churg-Strauss syndrome >This patient is suffering from eosinophilic granulomatosis with polyangiitis Churg-Strauss syndrome, which is characterized by a triad of: 1) Late-onset asthma/allergic rhinitis 2) Systemic vasculitis (presenting with constitutional symptoms (fever, malaise, weight loss and night sweats), rash, mono neuritis multiplex, arthropathies, gastrointestinal disturbances, etc.) 3) Peripheral eosinophilia - an elevated pANCA is also suggestive of this diagnosis. Peripheral eosinophilia is a component of ___________________________ syndrome - ✔✔Churg-Strauss The clinical presentation of classic polyarteritis nods is similar to that of Churg-Strauss syndrome, except that it is not associated with _______________ or ________________. It typically does NOT involve the lung. Glomerulonephritis and gastrointestinal vasculitis occur in the majority of patients with polyarteritis nodosa. - ✔✔Asthma; esoinophilia Granulomatosis with polyangiitis (GPA) is a form of non-caveating granulomatous, necrotizing vasculitis. The classic triad of organ involvement consist of: 1) ______________ 2) ______________ 3) ______________ - ✔✔1) Upper respiratory tract and sinuses (leading to chronic sinusitis, rhinitis, nosebleed, septal perforation and saddle nose deformity) 2) Lungs (leading to hemoptysis and pulmonary cavitary lesions) 3) Kidneys (leading to necrotizing glomerulonephritis or rapidly progressive glomerulonephritis). Like other systemic vasculitic syndromes, it may also affect skin, nervous system, GI tract and joint. c-ANCA is found in majority of patients, but significant eosinophilia is rarely seen. ______________________ is a small-vessel vasculitis. It is similar to GPA, except that it is not granulomatous in nature and does not involve upper respiratory tract. p-ANCA is positive this as well. - ✔✔Microscopic polyangiitis Case: A newborn, with Apgar scores of 8 and 9 at 1 and 5 minutes respectively, is examined for suspected congenital anomaly. Physical examination shows prominent epicentral folds, microcephaly, a harsh systolic murmur heard best in the left fifth intercostal space, and a high -pitched cry. What is most likely responsible for this newborn's underlying condition? - ✔✔A micro deletion in the short arm of chromosome 5. > This newborn has Cri-du-chat syndrome, which is caused by a *microdeletion in the short arm of chromosome 5.* > Individuals with this condition usually have moderate to severe intellectual disability and a severe delay in motor development. Physical examination of the newborn will commonly real microcephaly, prominent epicentral folds, excessive drooling, and cardiac defects (most commonly a VSD). These newborns may also have difficult feeding and gaining weight, due to the struggle in swallowing and sucking. The characteristic feature of this condition is a high-pitched, "meowing" cry. Meiotic nondijucntion of chromosome 18 would result in ________________________, which is characterized by micrognathia, rocker-bottom feet, and clenched hands. - ✔✔Edwards syndrome Deletion of long arm of chromosome 22 will cause _______________________, which commonly results in recurrent viral and fungal infection (secondary to thrice alpaca), cardiac defects, abnormal facies with cleft palate, and hypocalcemia (secondary to parathyroid aplasia. - ✔✔DiGeroge syndrome A microdeletion in the long arm of chromosome 7 results in ___________________, which is characterized by an "elfin" facies, excessive sociability with well-dveloepd verbal skills, cardiovascular deficits, and hypercalcemia. - ✔✔Williams syndrome Imprinting of the long arm of chromosome 15 will result in either _________________ or __________________, depending on if the maternal or paternal chromosome was imprinted. - ✔✔Angelman syndrome; Prader-Willi syndrome Case: A 45 yo man with diabetes mellitus and uncontrolled hypertension comes to the ED because of tearing chest pain radiating to the mid scapular region. He smokes 1 pack of cigarettes daily. His blood pressure is 210/120 mmHg, pulse is 60/min, respirations are 24/min and oxygen saturation is 96% on room air. Chest radiography shows widening of the mediastinum. What is the most important predisposing factor for this patient's condition? - ✔✔Hypertension > This patient has an acute thoracic dissection (Sudden-onset, chest pain radiating to the back with mediastinal widening on chest radiography). Extension of aortic dissection to the root of the aorta may involve the ostia of the coronary arteries, resulting in occlusion and myocardial infarction. The right coronary artery is most often involved and may lead to an inferior wall myocardial infarction. A marked elevation of blood pressure in a patient with aortic dissection implies a hypertensive crisis or emergency and requires immediate lowering of the blood pressure. Chronic hypertensions results in cystic medial degeneration of the aorta and weakening of the aortic wall. With a superimposed marked elevation in blood pressure, aortic dissection may occur. The most important predisposing factor for thoracic aortic dissection is *hypertension* __________________ is a catastrophic separation between the layers of the aorta. It is a intimal tear. Once breached, the blood enters the media layer & creates a new lumen. - ✔✔> The media will continue to peel apart longitudinally Thus the aortic dissection can prorate into all the major vessels (carotids, renal arteries, iliac arteries, coronary arteries, pericardium) Location > The most common location is the first few centimeters of ascending aorta just after it leaves the heart > Second most common location is "Distal to the left subclavian artery Causes: > Congenial weakening of the media layer (Ex. Marfan Syndrome, Ehlers-Danlos) > Aortic aneurysm > Forceful weightlifting, Cocaine use, Severe Hypertension Classification scheme: > Standford Classification system is the most common - Dissection of Ascending Aorta is Type A. ("A is for Ascending") - Dissection beyond the Arch is Type B. ("B is for Beyond" > DeBakey Classification system - Type 1: Ascending and Desending Aorta - Type 2: Only Ascending Aorta - Type 3: Only Desending Aorta Presentation: > Severe midline pain radiating to the back (Ex. Older male with poorly controlled hypertension. Pain is sharp or tearing; Will not improve with Nitroglycerin) In Subclavian is involved there may be a difference in BP. 20 mmHg is significant. > Chest X-ray: Widened mediastinum (only present in 60% of patients) Treatment: > Reduce BP and HR to minimize shear forces in the aorta Ex. Esomolol for Easy titratable and Heart Rate reduction Type A: Emergency cardiothocric surgery Type B: Treated with beta-blockers (unless organ ischemia occurs) Case: A 31 yo man comes to the physician because of shortness of breath. he has a history of intravenous drug use in the past. Chest radiograph shows enlarged heart with a dilated right atrium. Examination shows jugular venous distention and pulsatile hepatomegaly. What is most likely the diagnosis? - ✔✔Tricuspid regurgitation > Intravenous drug users are at risk of infective endocarditis, most commonly caused by Staphylococcus aureus in this population. These microbes enter the right side of the heart via return from the right side of the heart via return from the vena cava, causing vegetation on right-sided heart valves and valvular heart disease. > Classically, the tricuspid valve is affected, resulting in *tricuspid regurgitation* which will cause a pulsatile liver. > In addition, the jugular venous pressure is often raised in tricuspid regurgitation with "CV" waves (prominent v waves and a rapid y descent), and significant jugular venous distention. Patients with _____________________ will have a wide pulse pressure and possibly have water hammer pulses and head bobbing on exam along with a descending decrescendo mumur - ✔✔Aortic regurgitation _______________________ most commonly occurs to rheumatic heart disease rather than IV drug use. Additionally, patients with mitral stenosis are unlikely to have JVD and a pulsatile liver (unless there is also right sided heart failure) - ✔✔Mitral stenosis Case: A 16 yo boy, recently migrated from India, comes to the physician because of increased fatigue, dyspnea and a blue tinge to the skin after exertion for the past 5 months. He reports having difficulty when playing sports with his friends. he often gets tired, and stops trying to catch his breath. Also, he recalled 5 fainting episodes that occurred in the last two months while playing basketball. His mother reports that he was diagnosed with a hole in his heart when he was born but never had surgery because the parents believed that the hole would close by itself. Physical examination reveals a thin, cyanotic male with clubbing of the fingers. Echocardiography shows an opening between the right and left ventricles. What is the most likely cause of the patient's current presentation? - ✔✔Pulmonary hypertension > The patient's cyanosis along with other symptoms of hypoxia, present later in life rather than early on. The congenital malformation that was present at birth is a VSD since echocardiography reveals a hole between ventricles. In a VSD, blood flows from the LV (high pressure0 to the RV (low pressure) resulting in *an increased blood flow in the pulmonary circulation*. However, over time, the overload of in the pulmonary artery will cause increased pulmonary vascular resistance and subsequent right ventricular hypertrophy as a compensatory mechanism. > When the pulmonary vascular resistance increases and surpasses the systemic vascular resistance, the shunt will reverse, shunting blood from RV to LV. This is called *Eisenmenger syndrome* The patient will have cyanosis and signs/symptoms of hypoxia especially after exertion since the blood is not getting appropriately oxygenated. Clubbing of the fingers and polycythemia may also be present. __________________ is characterized by a downward displacement of the tricuspid valve leaflets into the right ventricle. It can cause *tricuspid regurgitation* and is commonly associated with lithium exposed to the fetus in utero. - ✔✔Einstein's anomaly _______________ is a condition of the pulmonary artery and aorta that can persist after birth. It is associated with a continuous machine-lied murmur heard at the left 2nd intercostal space during inspiration and expiration. - ✔✔Patent ductus arteriousus (PDA) > Uncorrected PDA can lead to Eisenmeger syndrome Case: A 22 yo woman comes to the physician because of an upward ocular lens displacement. She has a history of 2 episodes of pneumothorax over the past 12 months. Physical examination shows inwardly grown ribs and sternum, producing a sunken appearance to the anterior chest wall. She appears tall and thin, has flat feet and a high arched palate. The entire distal phalanx of the thumb projects beyond the ulnar border of the palm when thumbs are opposed maximally. Upon wrapping the thumb and little finger around the other wrist, the distal phalanges of thug and little finger overlap each other. What is the most likely finding on a transthroaic echocardiography? - ✔✔Dilated aortic root >The patient presents with tall and thin stature, lens dislocation, arachnodactyly (positive thumb and wrist signs), high arched palate, precuts excavated, and history of pneumothorax, all suggesting *Marfan syndrome* as the underlying condition. > Marfan syndrome is a connective tissue disorder resulting from a mutation in the fibrillar gene (FBN1 gene located on chromosome 15, encoding the connective protein fibrillar 1). The pattern of transmission is autosomal dominant with complete penetrance. >Marfan syndrome is associated with a variety of clinical manifestation mainly in the musculoskeletal, cardiac, and ocular system. Coarctation of the aorta is associated with _______________________ and present with hypertension in the upper extremities and hypotension in the lower extremities. "Rib nothing" may be apparent on the chest x-ray. - ✔✔Turner syndrome ____________________ has a early manifestation that usually occurs about 2-5 days after an MI - ✔✔Acute fibrinous pericarditis ____________________ often presents with fever, malaise, and a new murmur. Blood cultures may be positive. There are no significant ECG changes with it unless the conduction system is also involved, perhaps from an abscess. - ✔✔Infective endocarditis (IE) ___________________ is an important cause of persistent ST segment elevation after an MI. It is characterized by a paradoxical systolic budge palpable over the pericardial area. Ventricular aneursym can predispose to statin and thrombus formation. - ✔✔Ventricular aneursym Case: A previously healthy 39 yo woman comes to the physician because of a 2-month history of headaches, fevers, weight loss, and abdominal cramping worsened after meals. Her blood pressure is 188/110 mmHg. Physical examination shows diffuse purpuric lesson on the lower extrmieis. Laboratory studies show elevated inflammatory marker. What hepatitis seropositivity would most likely be seen in this patient? - ✔✔Hepatitis B seropositivity > Polyarteritis nodosa is an acute systemic vasculitis characterized by immune-complex-mediated necrotizing inflammation of the small and medium-sized vessels. > Patients are usually young adults and symptoms develop over weeks to months. Renal and visceral muscular arteries are most commonly involved, causing systems of hypertension/renal failure and GI pain, respectively. > The pulmonary arteries are characteristically SPARED. > All patients should be tested for *hepatitis B as approximately one third of those with polyarteritis nodosa are seropositive.* Case: A 55 yo man with history of hypertension, hypercholesterolemia, and diabetes comes to the ED because of shortness of breath, diaphoresis, and severe, left-sided, retrosternal, chest pain over the past hour. The pain radiates to the jaw and left arm. Vital signs show blood pressure of 190/100 mmHg and pulse of 120/min. ECG shows ST elevations in leads V2-V5. He returns 3 weeks later with chest pain and palpitations. ECG shows and R and R' in V1 and V2 and auscultation reveals wide splitting. Which best describes the location of the lesion in this patient? - ✔✔It is located between the bundle of His and Purkinje fibers > The patient is presenting with Right Bundle Branch Block (RBBB) post myocardial infarction. *RBBB is manifested by a wide splitting sound on auscultation* due to delayed right ventricular contraction and a bifid R wave, also known as "rabbit ears," in leads V1 and V2. The cardiac conduction signal reaches the *bundle of His* and then travels through the right and left bundle beaches to the *Purkinje fibers*. Damage to the ______________ results in delayed action potential conduction such as 1st, 2nd, or 3rd degree ____ block. - ✔✔AV node; AV It would NOT cause rabbit ears in V1 and V2 and wide splitting. The is characteristic of Right Bundle Branch Block (RBBB). Damage to the ____________ may result in conduction abnormalities such as anterior or posterior fascicular block. - ✔✔Purkinje fiber > The Purkinje fibers conduct the cardiac action potentials through he inter ventricular septum to the ventricles. Damage to the _________ would result in a slow heart rate. - ✔✔Atria > The atria conduct the cardiac action between between the SA anode and the AV node. Case: A 25 yo woman at 14 weeks' gestation comes to the physician because of progressive shortness of breath over the past 2 weeks. A 3/6 ejection murmur is auscultated at the second left intercostal space near the sternum. The jugular vein is distended. There is hepatojugularreflex when pressure is applied on the right upper abdominal quadrant. Electrocardiography shows an incomplete right bundle branch block with right axis deviation. What is the additional finding not eh physical examination? - ✔✔Fixed S2 splitting > The pregnant woman has symptoms and sings of *heart failure*, including progressive shortness of breath, jugular vein distention, and hepatojugular reflex. >During pregnancy, blood volume increases any pre-existing, but previously asymptomatic, congenial heart diseases may become symptomatic. > One of the most common congenital heart defects in adults is atrial septal defect (ASD). This woman most likely has an ASD, leading to cardiac decompensation during pregnancy (not all women with ASD become decompensated during pregnancy). The second clue to the diagnosis of ASD is the present elf an *incomplete right bundle branch block* and *right axis deviation*, which is characteristic ECG findings in ASD. > Typical auscultatory findings of ASD are *Fixed S2 splitting,* a flow systolic murmur across the pulmonic valve, and loud P2 (Due to secondary pulmonary hypertension). There is a right ventricular hypertrophy with parasternal heave. An _________________ is heard in patients with prolonged hypertension (it is not associated with ASD) - ✔✔Accentuated A2 sound A *continous machinery murmur* at the left upper sternal border or second intercostal space beneath the clavicle with radiation to the back is characteristic of ___________________ - ✔✔Patent ductus arteriosus (PDA) Pulsus paradoxus is seen in _______________ - ✔✔cardiac tamponade Case: A 48 yo man comes to the physician for antihyperlipidemic therapy. He has an allergy to penicillin and sulfonamides. A fasting lipid panel shows: total cholesterol, 262 mg/dL; low-density lipoprotein (LDL), 188 mg/dL; high-density lipoprotein (HDL), 42 mg/dL; triglycerides, 502 mg/dL. A family member takes colestipol. Which factor is most likely to be responsible for the contraindication of bile acid sequestrates in this case? - ✔✔Triglyceride level > Bil acid sequestrates have a minimal or even negative effect on triglyceride levels; in other words, in some cases they can raise *triglyceride levels*, modestly. This property makes them unique among antihyperlipidemic therapies. This patient has very high triglycerides (>150 mg/dL), thus bile acid resins would be inappropriate for his care. A ________________ can effetely lower a patient's high LDL levels by binding to negatively charged bile acids and salts in the small intestine, thus facilitating their excretion in the feces. This prompts the liver to divert cholesterol to form more bile acids, ultimately decreasing intracellular cholesterol, simulating LDL receptor synthesis, and lowering circulating levels of LDL. - ✔✔Bile acid sequestrate Case: A 65 yo man comes to the physician because of a 6 month history of facial discoloration and photosensitivity. He has a history of atrial fibrillation, hypertension, and diabetes. (Bluish-grey discoloration) What medication is most likely responsible for the appearance of his facial rash? . - ✔✔Amiodarone > Amiodarone is used for atrial fibrillation. Long-term use and at doses greater than 400 mg/d increases risk. The pigmentation may be preceded by a photo allergic eruption. Pigmentation may slowly resolve months to years after withdrawal of the drug, although it can be permanent. What 2 side effects of Rosuvastatin? - ✔✔Hepatotoxicity and myopathy > Rosuvastatin is an HMG CoA reductase inhibitor used for the treatment of hypercholesterolemia. What is 2 side effects of Ramipril? - ✔✔Dry cough; angioedema > Ramipril is an ACE inhibitor used for the treatment of hypertension. What are side effect amlodipine? - ✔✔Extremity edema, constipation, and flossing > Amlodipine is a calcium channel blocker used in the treatment of hypertension What is a side effect of Procainamide? - ✔✔Drug induced lupus > Procainamide is a class 1A anti arrhythmic medication Case: A 50 yo woman comes to the physician because of lower extremity cellulitis. Physical examination reveals a first heart sound, and a second heart sound which changes in quality on deep inspiration at the left upper sternal border. What is the most likely physiologic mechanisms underlying this phenomenon? - ✔✔Increased return to the right hear during inspiration, which prolongs closure of the pulmonic valve. > Closure of the mitral and tricuspid value mark the beginning of ventricular systole and produces the first heart sound or S1. > The second heart sound, or S2, is produced by closure of the aortic and pulmonic valves, and marks the end of ventricular systole. > Physiologic splitting of the second heart sound (S2) during inspiration into its A2 and P2 components is a normal phenomenon. > S2 splitting results from the aortic valve closing slightly before the pulmonary valve, and this is more prominent with inspiration due to *increased RV stroke volume*. > The pulmonary vascular resistance is less than the systemic vascular resistance and with inspiration, pulmonary arterial resistance further declines, leading to further delay in pulmonary valve closure and a more produced split. More produced splitting can be pathologic and delayed closure of pulmonary valve can result from conduction or hemodynamic abnormalities. A _______________ defect classically produced *fixed splitting of S2, which does not disappear with expiration. - ✔✔Atrial septal (defect) Patients with poor contractility of the left ventricle may present with a 3rd heart sound, which is highly specific for __________________. A 3rd heart sound occurs due to the filling of a ventricle that has not completely emptied due to poor contractility. - ✔✔Heart Failure > A 3rd heart sound would NOT be expected to change with inspiration and expiration. Case: A 4-month-old infant is brought to the ED because of lethargy, poor feeding and clammy skin. She had a natural birth at home without any complications. However, she has not yet been evaluated by a pediatrician. Physical examination reveals a cyanosis, with rapid, labored breathing, and cool extremities. Her blood pressure is 110/72 mmHg, pulse is 163/min, respirations are 54/min, temperature is 37.2 C (98.9 F), and oxygen saturation is 84% in room air. Upon heart auscultation there is a systolic ejection murmur at the left upper sternal border and a fixed split S2. Chest x-ray reveals a heart with a "figure 8" configuration. What is the most likely etiology of this infant's presentation? - ✔✔Total anomalous pulmonary venous return > Total anomalous pulmonary venous return (TAPVR) is a congenital heart defect leading to cyanosis (blue babies) early in life. In TAPVR, the pulmonary vein drains in SVC instead of the left atrium. A pathognomic radiological sign is a "figure 8 configuration" or "snowman" on an X-ray. > A patent ductus arteriosus and/or atrial steal defect are present in order to maintain cardiac output or else the condition can be fatal since no oxygenated blood will enter the systemic circulation. it is important to note that in infants, the heart rate ranges from 80-140/min, and respiratory rate from 20-30/min. Case: A 43 yo woman comes to the physician because of acute-onset of high fevers, lethargy and dyspnoea. Cardiac biomarkers are mildly elevated. An ECG shows normal sinus rhythm. A clinical diagnosis of viral myocarditis is made. What is the most likely causative pathogen? - ✔✔Coxsackie B virus > Coxsackie B virus is the most common cause of viral myocarditis _______________ is the most common cause of the common cold - ✔✔Coronavirus ____________________ virus causes croup in young children - ✔✔Parainfluenza Echovirus causes ___________________ - ✔✔aseptic meningitis Case: A 63 yo woman comes to the physician because of shortness of breath and an episode of near syncope. She is a chronic smoker and was recently diagnosed with an inoperable breast cancer. She has had an 18 kg (40 lb) weight loss over the past year. Her pulse is 140 ppm and blood pressure is 90/50 mmHg. Her blood pressure significantly drops during inspiration. The jugular veins are distended and heart sounds are muffled. ECG shows low voltage QRS complexes. Chest x-rays (CXR) shows globular cardiac shadow. What is the most likely diagnosis? - ✔✔Cardiac tamponade > This patient has tachycardia, hypotension, *pulsus paradoxes (significant drop in blood pressure during inspiration), distended neck veins, muffled heart sounds, low voltage QRS complexes and globular cardiac show; these features suggest cardiac tamponade (a hypertensive pericardial effusion). The episode of near syncope is due to circulatory compromise, leading to cerebral hypo perfusion. Dyspnea results from impairment of venous return and reduced cardiac output. The patient has a history of inoperable breast cancer. Pericardial extension or metastasis of breast cancer can result in pericardial effusion and bleeding; with increasing accusation of pericardial fluid, *cardiac tamponade* ultimately ensues, leading to hemodynamic compromise. > Cardiac tamponade is a potentially life-threatening condition characterized by accumulation of the pericardial fluid under high pressure. From a pathophysiological point of view, it is a hypertensive pericardial effusion. The manifestation include the classic *Beck triad* (hypotension, distended neck veins and distant heart sounds), and pulses paradoxus (reduction is systolic pressure of more than 10 mmHg during inspiration. If pericardial effusion is large, chest X-ray will demonstrate a large, globular heart show. Treatment involves urgent pericardiocentesis. ________________________ is characterized by thickens, fibrotic and calcification pericardium as a result of chronic inflammation or scarring. As a result, cardiac expansion is impaired and a diastolic dysfunction ensues, more significantly affecting the right side of heart then the left side (Because the main function of the right ventricle is expansion and reception of venous blood.) - ✔✔constrictive pericarditis > Tuberculosis is the most common cause of constrictive pericarditis worldwide, while most cases in the US are idiopathic, or secondary to scarring from previous open-heart surgery or period chest irradiation, or pericardial metastases. > Although pulsus paradoxus is rarely seen in constrictive pericarditis, the manifestations leading to diagnosis include symptoms of right-sided heart failure (hepatomegaly, abdominal distention and lower limb edema) *Kussmaul sign* (paradoxical rise in jugular venous pressure and neck vein distention on inspiration) and pericardial calcification on chest x-ray. . Case: A 72 yo man with history of hyperlipidemia and HTN presents to the ED with cough and shortness of breath the that bene worsening over the past 24 hours. On examination, he is afebrile, has blood pressure of 10/60 mmHg, heart rate of 110 BPM and O2 Sat of 95 on room air. On chest auscultation, the patient has fine crackles in bilateral lung bases. He also has a new audible systolic murmur at the apex. What is most likely causing the patient's pulmonary symptoms? - ✔✔Pulmonary edema > This patient is most likely suffering from flash pulmonary edema. he has multiple cardiac risk factors including advanced age, hypertension, and hyperlipidemia. He has a new systolic murmur that is loudest at the apex, most likely representing mitral valve regurgitation, it is possible that he is suffering from an acutely ruptured papillary muscle, causing mitral valve dysfunction. > Mitral valve disease can lead to the backup of blood into the left atrium and ultimately into the pulmonary vasculature, which can lead to transudation of the fluid into the bilateral pulmonary alveolar space known as *pulmonary edema.* Pericardial effusion is milky to manifest with Beck's raid of ________, ________, and ________ - ✔✔Distant heart sounds, hypotension, and distended neck veins. Dual antiplatelet therapy is used for ________________________ in patients who had a stroke while on a single antiplatelet agent. However dual anti platelet therapy is not indicated for primary stroke prevention in atrial fibrillation or atrial flutter. - ✔✔Secondary stroke prevention Ex. Clopidogrel and aspirin Ex. Dipyridamole and aspirin A EKG shows F-waves (saw tooth appearance) and is diagnostic for __________________ - ✔✔Atrial flutter > Future stroke risk in patients with atrial flutter is high. The CHA2D2-VASc score is used to predict future stroke risk and whether long-term management should be with antiplatelet therapy or anticoagulation. > Patients with a CHA2DS2-VASc of >2 should be treated with long term anticoagulation with vitamin K antagonist (Warfarin), direct thrombin inhibitors or factor Xa inhibitors. > A patient with a score of 0-1 could have antiplatelet agent such as aspirin alone. ________________________ is highly associated with an increased risk of developing Alzheimer's dementia. - ✔✔Down Syndrome > The extra copy of chromosome 21 confers an increased risk of accumulating the amyloid precursor protein responsible for cereal plaque development in Alzheimer's dementia. The most common congenital cardiac defect is Down sydrnome is ___________ - ✔✔Endocardial cushion (atrioventricular septal defect). > Gestational testing for this syndrome includes testing for decreased serum PAPP-A increased free beta-hCG. > Ultrasound testing in the first trimester will show increased nuchal translucency, and second-semester quad screen testing will show decades alpha fetoprotein, estriol, and increased inhibin A and beta-hCG. Case: A 32 yo man comes to the ED because of extreme pain in his fingers that started two weeks ago. The pain is constant, even at rest, and nothing alleviates it. His past medical history is unremarkable his vital sings are within normal limits. Additional history reveals a healthy diet, excerise an occasion, no alcohol consumption and smoking of two packs/day for the past fourteen years. Physical examination shows cold finger bilaterally with discoloration and ulceration on the palmar surface of the index and middle finger on the right and and middle and ring finger on the left hand. There is delayed capillary refill. What is most likely cause of the patient's presentation? - ✔✔Thromboangiitis obliterans > This is a typical presentation of aprons with a history of heavy smoking that has Buerger diseases, also known as thromboangiitis obliterans.. This disease is characterized by acute and chronic inflammation of small and medium sized arteries. Cigaretes smoking cause toxicity and can lead to acute an chronic dame, thrombosis, and necrosis of the material endothelium. > Raynaud's phenomena may also be present. > Smoking cessation is the treatment of Buerger's disease Microscopic polyanittis is a cnecrotizing vasculitis commonly involved in the lung, kidneys, and skin. It can present with palpable pupura and is a_________________ positive. - ✔✔Myeloperoxidase. What disorder? Patient can present with unilateral headache, visual abnormalities, facial pain especially at the temporal area where the temporal artery courses? - ✔✔ [Show More]

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