Cardiology Board Review Brenda Shinar, MD February 26,
2013
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Question 1. Answer: C. Exercise electrocardiography
www.afp.org/online/en/home/cme/selfstudy/c
mebulletin/cardiac-testing/objectives January 2012
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Understand the Tests Used for Coronary Artery Disease Diagnosis
and Prognosis Indications to Order a Stress Test: To diagnose
occlusive CAD in a symptomatic patient with intermediate pre-test
probability for CAD To prognosticate in a patient with known
occlusive CAD To screen for CAD in an asymptomatic high risk
patient prior to high risk surgery Types of Stress: Exercise
Dobutamine Vasodilator Types of Imaging with Stress: No imaging
(EKG interpretation only) Nuclear Echocardiogram
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Question 2. Answer: C. Loop event recorder Ambulatory
Arrhythmia Monitoring: Choosing the Right Device: Zimetbaum, Peter;
Circulation 2010;122:1629-1636
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Understand the Tests Used to Identify Symptomatic Arrhythmias
Is there a rhythm disturbance that correlates with the patients
symptoms? How frequently do the symptoms occur? Is the patient able
to push a trigger with the symptom onset? Holter 24 hour monitor
Continuous monitoring Loop event recorder Continuous monitoring,
but only saved with patient trigger Saves preceding several seconds
of rhythm Post-symptom event recorder No preceding rhythm (may miss
the arrhythmia)
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Question 3. Answer: A. Current smoking
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Understand the 9 risk factors for CAD and their degree of
importance according to INTERHEART study RISK FACTOR Dyslipidemia
Tobacco smoking Psychosocial Stress Diabetes mellitus Hypertension
Abdominal obesity Moderate alcohol intake Exercise
Vegetables/fruits daily All risk factors ORAR (%) 3.2549.2 2.8735.7
2.6732.5 2.37 9.9 1.9117.9 1.6220.1 0.91 6.7 0.8612.2 0.7013.7
129.2090.4
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Question 4. Answer: B; Atorvastatin and epifibatide
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Initiate medical therapy in a high-risk patient with a non-ST
elevation MI EARLY INVASIVE STRATEGY Elevated biomarkers New ST
depression High risk TIMI score (3) Signs of heart failure
Hemodynamic instability PCI within 6 months Prior CABG Continued
angina despite aggressive medical therapy Reduced LV function
(EF
Know the risk factors for sudden death in patients with HOCM
RISK FACTORS for SCD in HOCM *Cardiac arrest *Spontaneous sustained
ventricular tachycardia *Family history of sudden death age < 40
Unexplained syncope LV diastolic wall thickness > or = 30 mm
Blunted increase (< 20 mm Hg) or decrease in systolic BP with
exercise Nonsustained VT Heart failure that has progressed to
dilated cardiomyopathy * These patients should be given an AICD for
prevention of sudden cardiac death This patient also needs a
surgical myotomy procedure
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Question 8. Answer: D; Phenylephrine
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Diagnose and Manage a Patient with HOCM Dynamic outlet
obstruction WORSENED by (murmur is louder): Decreased preload
Lasix, nitroglycerin Increased contractility Digoxin, dobutamine
Decreased afterload Sodium nitroprusside, ACEI, hydralazine,
milrinone Medications that are helpful in HOCM: Fluids B-blockers
Phenylephrine MANEUVERS: Decrease preload: Valsalva Increase
preload: Squat Increase afterload: Isometric hand grip
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Question 9. Answer: A; Atrial tachycardia
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Diagnose an acute supraventricular tachycardia ATRIAL TISSUE
ONLY Multifocal atrial tachycardia Variable P-wave morphology and
variable PP and PR interval COPD Automatic Ectopic Atrial
Tachycardia Usually abrupt onset and termination May be hard to
distinguish from sinus tachycardia Dig toxicity and hypokalemia
Atrial flutter re-entry within the atrium Atrial fibrillation age,
HTN, atrial enlargement, thyrotoxicosis AV JUNCTION INVOLVED
Paroxysmal Supraventricular Tachycardia Re-entry within the AV node
TERMINATES 95% of the time with appropriate use of adenosine
Junctional Tachycardia Increased automaticity within the lower part
of the AV node (N-H region) Dig toxicity and severe CHF May
terminate with adenosine
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Question 10. Answer: C; Cardioversion
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Patients with atrial fibrillation who are hemodynamically
unstable should undergo immediate cardioversion
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Question 11. Answer: E; No bridging agent is needed
Perioperative Management of Warfarin and Antiplatelet Therapy; Amir
K. Jaffer; Cleveland Clinic Journal of Medicine; 2009 (76
Supplement 4) S37-44
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Question 12. Answer: A; Postpone surgery for 6 months
Perioperative Management of Warfarin and Antiplatelet Therapy; Amir
K. Jaffer; Cleveland Clinic Journal of Medicine; 2009 (76
Supplement 4) S37-44
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ACC/AHA Updated 2007 Guidelines: Perioperative Care for
Noncardiac Surgery BARE METAL STENT WAIT 6 weeks (3 months) for
non-urgent, elective surgery URGENT surgery within first 6 weeks
requires dual antiplatelet therapy DRUG-ELUTING STENT WAIT one year
for non-urgent, elective surgery URGENT surgery within 6 months
requires dual antiplatelet therapy URGENT surgery after 6 months
must continue aspirin (81 mg/day), restart the clopidogrel after 5
days with 300 mg loading dose
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Question 13. Answer : C; Surgical valve replacement Aortic
Stenosis: Who should undergo surgery, transcatheter valve
replacement? Cleveland Clinic Journal of Medicine Volume 79, No. 7,
July 2012 (487- 497)
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Severe aortic stenosis with symptoms requires surgery
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Question 14. Answer: B; IV sodium nitroprusside
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Acute, severe mitral regurgitation is a surgical problem
Etiologies of acute MR Acute MI (papillary dysfunction) Post-MI
(papillary necrosis) Ruptured chord (chronic MVP) Infectious
Endocarditis Pathophysiology Left ventricle unloads favorably
toward path with lowest resisistance: aorta-forward left
atrium-backward Management LOWER the systemic blood pressure to
favor forward flow: sodium nitroprusside DIURESE TO reduce
pulmonary edema SURGERY to REPLACE the VALVE
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Question 15. Answer: C; Follow up ultrasound in 6 to 12
months
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Manage asymptomatic abdominal aortic aneurysm found on routine
screening Who gets screened for AAA? USPSTF: Men 65-75 who have
ever smoked one time U/S No screening in women ACC/AHA 2005: Men 60
or older with family hx of AAA in parent or sibling Men 65-75 who
have ever smoked Medicare coverage: Men 65-75 who have smoked at
least 100 cigarettes in their lifetime Males or females with family
hx of AAA What to do with the results? NO REPEAT SCREEN No aneurysm
REPEAT SCREEN IN 6-12 MONTHS Aneurysm 3-5.5 cm diameter REPAIR:
>5.5 cm on presentation Rapidly expanding with surveillance
imaging (5 mm in 6 months or 10 mm in one year) Coexisting PAD or
peripheral artery aneurysm
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Question 16. Answer: D; Intravenous B-blockade followed by IV
sodium nitroprusside
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Anatomy of the Aorta
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Treat a descending aortic intramural hematoma in a lesion of
the descending aorta (type B)
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Aortic Dissection versus Aortic Intramural Hematoma
DissectionIntramural hematoma Entrance tear and exit tear from the
intima forming a channel inside the media of the aorta with a flap
More commonly type A (Ascending and Arch) Better prognosis with
surgical treatment Rupture of vaso vasorum feeding the aortic media
to create a hematoma within the medial layer with an intact intima
More commonly type B (Below LSCA) Does better with medical
treatment B-blocker + sodium nitroprusside
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Question 17. Answer: C; IV amiodarone
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Manage a patient with a hemodynamically stable wide-complex
tachycardia Differential Diagnosis of Monomorphic Wide Complex
Tachycardia: 1.Ventricular Tachycardia (especially if known CAD or
cardiomyopathy) 2.Supraventricular Tachycardia with aberrency
3.Antidromic Atrioventricular Reciprocating
Tachycardia(Pre-excitiation) VT Pearls: Stable hemodynamics does
NOT rule OUT VT AV dissociation confirms the diagnosis of VT Cannon
A Waves Variable S1 indicate atrium contracting against a closed
tricuspid valve Treatment of choice should be amiodarone,
procainamide, or sotalol
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Question 18. Answer: D; Haloperidol
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Manage the risk for torsades de pointes in the hospital setting
Risk factors for Torsades de Pointes: 1.QTc interval > 500 msec
or increase by 60 msec or more after initiation of a QTc prolonging
medication 2.Older age 3.Female sex 4.Multiple QTc prolonging
medications 5. Hypokalemia and hypomagnesemia TREATMENT: Stop the
offending medication! www.qtdrugs.org
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Question 19. Answer: C; Three sets of blood cultures
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Understand the manifestations of infective endocarditis
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MAJOR CRITERIA FOR IE: BLOOD CULTURES: Typical microorganism
for IE from 2 separate blood cultures Persistently positive blood
cultures drawn 12 hours apart, or 3 separate cultures drawn at
least 1 hour apart Single positive culture for coxiella burnetii,
or Ig G titer > 1:800 ENDOCARDIAL INVOLVEMENT: Positive
echocardiographic evidence of IE New valvular regurgitation
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Question 20. Answer: B; Constrictive pericarditis
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Diagnose irradiation-induced constrictive pericarditis
Etiologies: Idiopathic or viral (42-49%) Post-cardiac surgery (11-
37%) Post-radiation therapy (9- 31%) Hodgkins/Breast Connective
Tissue Disease (3-7%) Post-Infectious (3-6%) TB or purulent Other
(1-10%) Patient symptoms: Heart failure (67%) Chest pain (8%)
Abdominal symptoms (7%) Tamponade (5%) Physical Exam: Elevated JVP
with rapid x and y descent Kussmals sign Pericardial knock before
S3 Cachexia, edema