CARDIOVASCULAR SYSTEM

1. VSD typically have a harsh holosystolic murmur with maximal

intensity over the left 3rd and 4th intercostal spaces accompanied
by a thrill.
2. Palpable thrill - VSD & PDA.
3. TS - Along left sternal border.
4. ASD - wide and fixed splitting of the second heart sound.
Has mid-systolic ejection murmur across the pulmonic valve,
and a mid-diastolic rumble across the tricuspid valve.
5. The systolic murmur of MVP starts earlier (and is longer and
softer) with standing, Valsalva, and inhalation of amyl nitrate.
Conversely, it is delayed in onset (and shorter in duration) with
squatting, leg elevation, and handgrip.
6. Risk factors for peripartum CM include maternal age >30,
multiple gestation, and preeclampsia. Risk of recurrence
with patients with LVEF <20% at diagnosis. The risk is stratified
based on LV function at diagnosis and current LV function as
assessed by transthoracic echocardiogram.
7. Stable angina - we do Exercise ECG, and if patient cannot
exercise, then we do pharmacologic stress testing (eg,
adenosine myocardial perfusion imaging, dobutamine
echocardiography). If stress testing comes positive, then we do
Coronary angiography.
8. Cocaine intoxication - seen with aortic dissection. Treat with
BZDs and nitroglycerin.
9. Beta blockers should be avoided in acute cocaine ingestion due
to the risk of excessive alpha-1 receptor-mediated vasoconstriction.

10. The chest pain in combination with new neurologic findings

of right-sided weakness is highly suspicious for acute dissection
of the ascending aorta. Rapid diagnosis is essential and can be
made by CT angiography of the chest.
11. In dissections involving the ascending aorta (type A), patients
typically have sharp anterior chest pain (back pain is more
common in type B dissections).
12. Anticoagulation (eg, low-molecular-weight heparin) is indicated
for the treatment of acute coronary syndrome. Anticoagulation is
contraindicated in the setting of acute aortic dissection.
13. Patients with coronary artery disease (CAD) and prior MI
should be started on appropriate therapy including beta blocker,
high intensity statin, anti-platelet therapy, and ACE inhibitor or
angiotensin-receptor blocker.
14. Fibrate therapy (gemfibrozil or fenofibrate) is indicated to
reduce triglyceride levels in patients with severe
hypertriglyceridemia (>880 mg/dL).
15. The classic Wolff-Parkinson-White pattern on ECG consists of
short PR interval, delta wave, and wide QRS complex. Some
patients can become symptomatic with tachyarrhythmias, and
syncope can result. Catheter ablation is the recommended
therapy in patients with WPW syndrome.
16. Risk factors associated with abdominal aneurysm rupture
include large diameter (20% risk in aneurysms >6 cm), rate of
expansion (>0.5 cm in 6 months), and current cigarette smoking.
17. Marfans syndrome - Aortic root disease; tall stature, myopia,
and increased arm span to height ratio.
18. c/o acute-onset pain, diminished pulses, and paleness and
coolness of the left foot, apical diastolic murmur which are
consistent with acute arterial occlusion.
19. ACE inhibitor stopped one night before surgery; Diuretic - skip
the morning dose before surgery.
20. SERMs (both raloxifene and tamoxifen) are associated with an
increased risk of venous thromboembolism. It is recommended
that these agents be discontinued 4 weeks prior to any surgical
procedure associated with a moderate to high risk of venous
thromboembolism (eg, knee replacement).
21. Trastuzumab-related cardiotoxicity is unrelated to cumulative
dosage and is often reversible in most patients after
discontinuation of trastuzumab therapy.
22. Direct oral anticoagulants (DOACs) (eg, rivaroxaban) should
be discontinued 1-3 days before surgery and do not require
bridging anticoagulation because of their rapid onset when
reinitiated.
23. First-line antihypertensive drug classes include ACE inhibitors,
angiotensin II receptor blockers (ARBs), calcium channel blockers,
and thiazide diuretics.
24. ACE inhibitors should not be used with ARBs because of the
risk for hyperkalemia and nephrotoxicity.
25. C/o suspected ACS, collection of at least 2 troponin levels 3
hours apart is recommended.
26. Patients with an immediately-threatened extremity (severe
pain, delayed capillary refill, absent arterial Doppler signals, and
sensory or motor deficits) are at risk for irreversible myonecrosis
within 4–6 hours and should have anticoagulation and emergency
surgical revascularization.
27. Patients with underlying connective tissue disease are at risk
for acute mitral valve regurgitation (MR) due to chordae tendineae
rupture.
28. Papillary muscle rupture with acute, severe MR can occur as a
life-threatening mechanical complication of acute MI, typically 3-5
days after the infarct.
29. c/o velvety skin with scar formation and previous bilateral
hernias are suggestive of underlying connective tissue disease
(Ehler Danlos Syndrome).
30. In men age >40, ST-elevation myocardial infarction (STEMI) is
diagnosed by ECG showing >1 mm (0.1 mV) ST elevation (>2 mm
in leads V2 and V3) in ≥2 anatomically contiguous leads. Primary
percutaneous coronary intervention is recommended within 90
minutes of the first medical contact in patients with STEMI.
31. Nonsteroidal anti-inflammatory agents (eg, aspirin, ibuprofen)
and colchicine are indicated in patients with acute viral or
idiopathic pericarditis.
32. An arterial pseudoaneurysm usually presents as a tender,
pulsatile mass with a systolic bruit, and the diagnosis is
confirmed by ultrasonography. Small pseudoaneurysms can be
treated with ultrasound-guided compression or thrombin injection
into the pseudoaneurysm cavity.
33. Femoral arteriovenous fistula evaluated by lower extremity
angiography.
34. Noncontrast CT scan of the abdomen and pelvis is indicated for
suspected retroperitoneal hematoma.
35. Pseudoaneurysm is a potential complication of arterial access
for cardiac catheterization.
36. Intravenous amiodarone - For atrial fibrillation.
37. Multifocal atrial tachycardia (MAT) most commonly occurs in
elderly patients who are hospitalized with an exacerbation of
underlying pulmonary disease (eg, chronic obstructive pulmonary
disease). The diagnosis is made by ECG demonstrating P waves of
at least 3 different morphologies and an atrial rate >100/min.
38. Electrolyte disturbances (eg, hypokalemia, hypomagnesemia)
are a common cause of MAT.
39. Intravenous diuretics (eg, furosemide) lower intracardiac filling
pressures and improve pulmonary edema.
40. The addition of an intravenous vasodilator (Nitroglycerin) is
recommended in patients with acute decompensated heart
failure (ADHF) who have an inadequate response to initial diuretic
therapy.
41. Milrinone is a selective phosphodiesterase-3 inhibitor
- reserved for severe ADHF that is refractory to other management.

42. Anticholinergic therapy with intravenous atropine is the

initial treatment of choice for patients with hemodynamically
significant bradycardia due to inferior wall MI. Temporary cardiac
pacing is the treatment of choice in patients with MI and sinus
bradycardia that does not respond to atropine.
43. Long-term amiodarone use is associated with thyroid
dysfunction, hepatotoxicity, cardiac bradyarrhythmias, chronic
interstitial pneumonitis, neurologic symptoms (eg, ataxia,
peripheral neuropathy), blue-gray skin discoloration, and visual
disturbances.
44. c/o echocardiogram showing increased ventricular wall
thickness with normal left ventricular cavity dimensions - Cardiac
amyloidosis.
45. Pericarditis is a common complication of coronary artery
bypass graft surgery, and some degree of postoperative pericardial
effusion develops in almost 85% of patients.
46. Constrictive pericarditis is an important cause of right heart
failure. It may occur following viral pericarditis or cardiac
surgery. Characteristic features include peripheral edema, ascites,
elevated jugular venous pressure, hepatojugular reflux, Kussmaul's
sign, pericardial knock, and pericardial calcifications on chest
radiograph.
47. Athletes participating in intense training can develop
nonpathologic cardiovascular changes, including resting sinus
bradycardia with or without first-degree atrioventricular block and
left ventricular hypertrophy detected on ECG (Athlete's heart).
48. A commonly used risk stratification tool is the Thrombolysis in
Myocardial Infarction (TIMI) risk score, which counts 1 point
each for age >65, >3 risk factors for coronary artery disease
(CAD), known CAD with >50% stenosis, recent use of aspirin,
multiple episodes of angina in the last 24 hours, elevated troponin
I, and ST-segment deviation >0.5 mm on ECG.
49. Retrograde extension of the dissection from the descending
aorta to the aortic arch and carotid arteries - unilateral weakness,
ipsilateral Horner syndrome).
50. Nitroprusside is metabolized to cyanide, which can cause
toxicity in patients receiving prolonged infusions, especially if renal
insufficiency is present. Toxicity should be suspected in any
patient with a nitroprusside infusion who develops metabolic
acidosis, respiratory depression and acute neurologic changes (eg,
confusion, seizures).
51. Patients with deep venous thrombosis or pulmonary embolism
are typically treated with ≥3 months anticoagulation with an oral
factor Xa inhibitor such as rivaroxaban.
52. SSRIs/SNRIs can also control hot flashes in menopausal
symptoms.
53. Ebstein anomaly is characterized by atrialization of the right
ventricle due to a malformed tricuspid valve.
54. Congenital pulmonary valve stenosis - Noonan syndrome.
55. IDM - transient hypertrophic cardiomyopathy with a thickened
interventricular septum due to excess glycogen deposition in the
fetal myocardium.
56. Upright tilt table testing is typically reserved for patients with
an unclear cause of syncope (eg, to differentiate vasovagal syncope
from orthostatic syncope).
57. Diabetes mellitus is a significant predictor of adverse
cardiovascular outcomes, especially in women. It is considered to
be a coronary heart disease risk equivalent.
58. C/o bicuspid aortic valve - Balloon valvuloplasty is indicated in
symptomatic and asymptomatic (if they plan to become pregnant or
participate in competitive sports) young adults when the following
criteria are met:

 Aortic stenosis
 No significant AV calcification or aortic regurgitation
 Peak gradient >50 mm Hg

59. Bicuspid aortic valve is an autosomal dominant trait with

incomplete penetrance, although it can also occur sporadically.
Current guidelines recommend echocardiography screening of
first-degree relatives.
60. The murmur of mitral stenosis is a soft, low-pitched rumble
best heard with the bell of the stethoscope at the cardiac apex,
which is located in the fifth intercostal space (between the 5th and
6th ribs) at the left mid-clavicular line.
61. 2nd ICS - left sternal border - Pul valve; Right sternal border -
Aortic valve.
62. 5th ICS left sternal border - TV.
63. Metoprolol and verapamil are used to treat HCM.
Metoprolol is largely selective for beta 1 receptors, it can block
beta 2 receptors as well, causing acute asthma exacerbation.
64. c/o crescendo-decrescendo systolic murmur @ left lower sternal
border, that decreases in intensity with maneuvers that increase
left ventricular (LV) blood volume (eg, passive leg raise) + S4,
likely has hypertrophic cardiomyopathy (HCM).
65. Standing & Valsalva - Increase murmur of HCM.
66. Squatting, Handgrip and leg raise - Decrease intensity of murmur of
HCM.
67. Syncope due to VT usually has no warning symptoms; high risk of
sudden cardiac death.
68. Transthoracic echocardiography allows an estimate of pulmonary
arterial pressure and is the initial diagnostic evaluation in patients with
suspected pulmonary hypertension.
69. Normal left ventricular function on echocardiography and
normal pulmonary capillary wedge pressure (<18 mm Hg) rule out
PH due to left-sided heart failure (group 2). Treatment of PH
associated with heart failure and reduced ejection fraction includes
a renin-angiotensin inhibitor and cardioselective beta blocker
70. Group 3 PH - inhaled muscarinic antagonist. Group 4 PH - Pul
thromboendarterectomy.
71. All syptomatc PH - Rx phosphodiesterase type 5 inhibitor (eg,
tadalafil), endothelin receptor antagonist (eg, bosentan).
72. Patients undergoing noncardiac surgery should be assessed for
perioperative cardiac risk based on procedural- and patient-specific
risk factors. Low-risk (≤1%) patients as well as those at increased
risk (>1%) with adequate functional capacity (≥4 metabolic
equivalents) can typically undergo surgery without further testing.
73. Emergency cardiac catheterization and revascularization within
90 minutes from the first medical contact is the goal of treatment
in patients with ST-elevation myocardial infarction.
74. Dual antiplatelet therapy with aspirin and platelet P2Y12
receptor blockers (clopidogrel, prasugrel, or ticagrelor), nitrates,
beta blockers, statins, and anticoagulant therapy is to treat
NSTEMI.
75. c/o Bradycardia - Give atropine - If refractory, we do temporary
cardiac pacing > Do PCI for STEMI.
76. c/o warm skin, elevated pulse pressure, and hyperdynamic left
ventricular ejection fraction (LVEF) are consistent with high-
output heart failure (Hyperthyroidism).
[Link] sodium bicarbonate is given for QRS interval
widening or ventricular arrhythmia in TCA overdose. Patients who
are refractory to sodium bicarbonate may respond to adjuvant
magnesium or lidocaine.
78. Sodium bicarbonate can alkalinize the urine, which is its main
action for treating salicylate toxicity.
79. Sodium bicarbonate is also used for treatment of
hyperkalemia.
80. Niacin - Increases HDL levels.
81. Beta blockers, calcium channel blockers, and nitrates can cause
false negative results on exercise and pharmacologic stress testing
and should be held for 48 hours prior to testing.
82. Patients with high-risk ECG features (eg, >1 mm ST
depression, ST elevation without Q waves) during stress testing
likely have clinically significant CAD and a high short-term risk of
cardiovascular events (eg, unstable angina, myocardial infarction).
83. Electrolyte imbalances (↓ potassium, ↓ magnesium,
↓ calcium), sinus bradycardia associated with TdP. Structural heart
disease, heart failure, and left ventricular hypertrophy are
associated with an increased risk of developing drug-induced TdP.
84. c/o blunt thoracic trauma - FAST / USG > AP CXR. PA and
lateral view require patient to stand.
85. c/o nausa, vomitting and confusion - Digoxin
toxicity. Verapamil inhibits the renal tubular secretion of digoxin,
resulting in almost 70-100% increase in serum digoxin levels. The
other medications, which can cause digoxin toxicity, are quinidine,
amiodarone, and spironolactone.
86. Myocardial reperfusion commonly precipitates an accelerated
idioventricular rhythm.
87. Early defibrillation is indicated in patients with ventricular
fibrillation (VF) and/or pulseless ventricular tachycardia (VT).
88. Lightning injury can cause cardiac arrest with asystole or
ventricular fibrillation. It should be treated with prompt
uninterrupted cardiopulmonary resuscitation and use of
vasopressors (eg, epinephrine).
89. Left ventricular dysfunction is characteristically segmental,
with mid and apical hypokinesis and basilar hyperkinesis -
Takutsubo CMP.
90. Right ventricular dilation and hypokinesis are seen with acute
pulmonary embolism.
91. Beta blockers are contraindicated in ADHF as they decrease
contractility and heart rate and may worsen pulmonary edema due
to ADHF.
92. Nitroglycerin is contraindicated in RVMI.
93. Acute coronary syndrome due to non-ST elevation myocardial
infarction or unstable angina is treated with dual antiplatelet
therapy, anticoagulation, a beta blocker, and a high-intensity
statin.
94. Echo shows right atrial and ventricular collapse in Cardiac
tamponade specifically.
95. Patients with cardiac tamponade have an elevated JVP with an
absent or a blunted y descent.
96. External laser treatment is used to treat particular veins and/or
telangiectasias.
97. Lidocaine - Wide complex tachycardia - Class IB AA.
98. Beta blockers (eg, metoprolol) can lead to unopposed alpha-1
receptor-mediated vasoconstriction in patients with acute cocaine
ingestion and are contraindicated.
99. The initial management of myocardial ischemia due to acute
cocaine intoxication includes intravenous benzodiazepines and
nitroglycerin to improve the mismatch of myocardial oxygen supply
and demand. Patients with persistent ST elevation despite medical
therapy should undergo coronary revascularization without delay.
100. Glyburide can cause dermatologic side effects including
photosensitivity reactions, maculopapular eruptions, purpura, or
urticaria.
101. Peripheral edema is a common side effect of dihydropyridine
CCBs (eg, amlodipine, nifedipine).
102. Patients with hypertrophic cardiomyopathy are at increased
risk for atrial fibrillation and ventricular tachycardia. Evidence of
atrial fibrillation on ECG monitoring warrants the initiation of
chronic anticoagulation, and evidence of ventricular tachycardia
(eg, bursts of nonsustained ventricular tachycardia) may warrant
placement of an implantable cardioverter defibrillator.
103. c/o heart failure - Reduce preload by initiating diuretics. Add
venodilator nitroglycerin if needed, or a balanced vasodilator (eg,
nitroprusside) may be given to patients needing afterload
reduction.
104. Improving myocardial contractility with intravenous inotropic
agents is recommended only in patients with cardiogenic shock (ie,
low cardiac output), which would present with severe hypotension
and/or poor organ perfusion.
[Link] initiation of chronic hemodialysis for CKD is typically
delayed until the estimated glomerular filtration rate reaches 7.5-
15 mL/min/1.73 m2 (sometimes lower) or complications of CKD (eg,
uremic symptoms, volume overload) become unmanageable with
medications alone.
106. Chronic obstructive pulmonary disease can present similarly
to decompensated heart failure, which can be excluded in patients
without evidence of intravascular volume overload (eg, jugular
venous distension). Because brain natriuretic peptide is degraded
by neprilysin, it is an unreliable marker of volume status in patients
being treated with an angiotensin receptor-neprilysin inhibitor (eg,
sacubitril-valsartan).
107. c/o sudden cardiac arrest with pulseless electrical
activity (PEA) and should receive immediate cardiopulmonary
resuscitation (CPR) with chest compressions.
108. PEA refers to an organized cardiac rhythm (eg, sinus
bradycardia, atrial fibrillation) that is unable to generate sufficient
cardiac output to create a measurable blood pressure or palpable
pulse and defibrillation is ineffective.
109. Severe AS is defined as aortic jet velocity >4.0 m/sec or
mean transvalvular gradient >40 mm Hg on echocardiogram,
either of which typically occurs when aortic valve area decreases to
<1 cm2.
110. Noonan syndrome is an autosomal dominant disorder
characterized by short stature, facial dysmorphism, and a spectrum
of congenital heart defects - pulmonic stenosis, atrial septal
defects, and hypertrophic cardiomyopathy.
111. Loud S1 and mid-diastolic apical rumbling murmur seen with
Mitral stenosis.
112. Mitral stenosis - ECG shows P mitrale (broad and notched P
waves), atrial tachyarrhythmias and RVH (tall R waves in V1 & V2).
CXR shows pulmonary blood flow redistribution to upper lobes,
dialated pulmonary vessels, left atrial enlargement, flattened left
heart border. MS seen with RHD.
113. The following ECG findings are diagnostic of STEMI:

 New ST elevation at the J point in >2 anatomically contiguous leads with the following
threshold:

o >1 mm (0.1 mV) in all leads except V2 and V3

o >1.5 mm in women, >2 mm in men age >40, and >2.5 mm in men age <40 in
leads V2 and V3
 New left bundle branch block with clinical presentation consistent with acute coronary
syndrome

114. An R prime wave (second R wave) in V1 accompanied by a

widened S wave in V6 describes a right bundle branch block.
115. Patients with PAD should be initiated on antiplatelet and high-
intensity statin therapy for secondary prevention of cardiovascular
events.
116. Exercise ECG stress testing is preferred for patients able to
achieve adequate exertion levels on a treadmill. For those with limited
exertional walking capacity (eg, osteoarthritis), pharmacologic stress
testing is most appropriate. It can be performed with (eg, dobutamine
stress echocardiography) or without echocardiography (eg, adenosine
myocardial perfusion imaging).
117. Aldosterone antagonists improve mortality and reduce heart failure–
related hospitalization, and are therefore indicated in the following
patient populations:

-NYHA class II, III, or IV heart failure (essentially any symptoms) and LVEF
≤35%
-ST elevation myocardial infarction complicated by LVEF ≤40% and either heart
failure symptoms or comorbid diabetes mellitus.
118. In addition, spironolactone, but not eplerenone, is associated with endocrine side
effects (eg, gynecomastia, decreased libido) that are sometimes use-limiting.
119. When pharmacologic therapy is needed, high-dose aspirin is the treatment of
choice for symptomatic management of peri-infarction pericarditis. Other anti-
inflammatory agents (eg, other nonsteroidal anti-inflammatory drugs, glucocorticoids)
should be avoided as they may impair myocardial healing and increase the risk of
ventricular septal or free wall rupture.
120. Beta blockers are considered first-line treatment for hypertension in patients with
HCM.
121. Alcohol septal ablation is usually reserved for HCM patients with persistent
symptoms refractory to medical therapy.
122. Implantable cardioverter-defibrillator placement is indicated for preventing sudden
cardiac death (SCD) in patients who have hypertrophic cardiomyopathy and an increased risk
for SCD due to:

 Prior history of cardiac arrest or sustained, spontaneous ventricular tachycardia (VT)

 Family history of sudden death
 Recurrent or exertional syncope
 Nonsustained VT
 Hypotension with exercise
 Extreme left ventricular hypertrophy

123. Implantable cardioverter-defibrillator (ICD) placement is

indicated for prevention of SCD in patients with a history of cardiac
arrest or sustained, spontaneous ventricular tachycardia (VT).
124. c/o cardiogenic shock in the setting of acute inferior ST-
elevation myocardial infarction (STEMI) after administration of
nitroglycerine and morphine - due to right ventricular MI. RVMI
is seen in 30%-50% of patients with acute inferior MI. Patients
typically present with hypotension or shock, jugular vein
distension, and clear lung fields.
125. Patients with hypotension and normal or low jugular venous
pressure should be treated with a bolus of intravenous fluids
(isotonic saline). This generally improves right ventricular preload
and facilitates left ventricular filling.
126. Inotropic agent dopamine are used in patients with RVMI and
persistent hypotension despite aggressive fluid resuscitation.
127. An S3 is typically pathologic in patients age >40, indicative of
an enlarged ventricular chamber such as occurs with heart
failure with reduced ejection fraction.
128. Scarring from previous myocardial infarction (evidenced by Q
waves on ECG and wall motion abnormality on echocardiogram)
increases the risk of ventricular arrhythmia.
129. Orthostatic hypotension - usually occurs with a change in
position from supine or sitting to standing. Syncope that occurs
after going from standing to sitting position is not consistent with
orthostatic syncope.
130. CoA - UE HTN + LE claudication.
131. CYP2C9 inhibition - Increased warfarin effect - Amiodarone
and azoles.
132. CYP2C9 induction - Decreased warfarin effect - Rifampin,
phenytoin, SJW.
133. It is recommended that the warfarin dose be reduced by 25%-
50% to compensate for the increase in serum concentration of
warfarin after initiating amiodarone therapy.
134. Hypertrophic cardiomyopathy - ECG: left axis deviation,
abnormalities of depolarization (eg, Q waves) or repolarization (eg,
inverted T waves).

135. The major risk factors for SCD in patients with HCM include the following:

 Family history of SCD in a close relative age <50

 Personal history of sustained ventricular arrhythmia
 Personal history of syncope deemed likely due to ventricular arrhythmia
 Massive LV hypertrophy with wall thickness >30 mm
 LV ejection fraction <50%

136. Patients with PSVT typically have intermittent, abrupt-onset

palpitations accompanied by a sensation of a rapid heartbeat, and
ECG demonstrates a narrow-complex tachycardia with regular R-R
intervals; inverted P waves are often buried within the QRS
complex but are sometimes visible.
137. PSVT - In hemodynamically stable patients - vagal maneuvers
(eg, Valsalva) or adenosine; however, hemodynamically unstable -
urgent synchronized cardioversion. Cardiac ablation of the
secondary conduction pathway is the definitive treatment of choice.
138. WPW Syndrome - The classic ECG findings are short PR
interval, slurred upstroke of the QRS complex (delta wave), and
widening of the QRS complex.
139. A holosystolic murmur at the lower sternum that increases
with inspiration - TR.
140. A harsh holosystolic murmur with maximal intensity over the
left third and fourth intercostal space with a palpable thrill - VSD.
141. Low pitched mid diastolic murmur @ cardiac apex + opening
snap after S2 - Mitral stenosis.
142. Two types of AAOCA commonly associated with SCD are the
left main coronary artery originating from the right aortic
sinus and the right coronary artery originating from the left
aortic sinus.
143. ECG findings for Brugada syndrome (right bundle branch
block and ST-segment elevation in leads V1-V3). ECG findings of
long QT syndrome (QTc >450 msec in men or >470 msec in
women).
144. Anomalous aortic origin of a coronary artery is a common
cause of sudden cardiac death in young athletes with normal ECG.
HCM would be the cause if presenting with systolic murmur
increasing in intensity with standing.
145. Stable anginal pain usually resolves within a few minutes of
rest or sublingual nitroglycerin administration; anginal pain lasting
longer than 20 minutes is suggestive of acute coronary syndrome
(ACS).
146. The left main coronary artery arises from the left coronary
ostium and branches off into the left anterior descending
(LAD) artery and left circumflex artery.
147. The left circumflex coronary artery runs in the left
atrioventricular groove to supply the lateral wall of the left
ventricle.
148. The LAD artery runs along the anterior interventricular
groove and supplies the anterior wall of the left ventricle.
149. The right coronary artery runs in the right atrioventricular
groove to supply the right ventricle and inferoposterior walls of
the left ventricle.
150. Patients with severe, chronic primary MR and left ventricular
(LV) ejection fraction <60% are considered to have impaired LV
systolic function, and mitral valve surgery is typically indicated.
[Link] with warfarin or other anticoagulants (eg,
dabigatran, rivaroxaban, apixaban) is recommended for men with a
CHA2DS2-VASc score of ≥2 and women with a score ≥3.
152. ASD - wide and fixed splitting S2, a mid-systolic ejection
murmur over the left upper sternal border, a mid-diastolic
rumble resulting from increased flow across the tricuspid
valve.
153. HCM and LV outflow tract obstruction reveals a harsh
crescendo-decrescendo systolic murmur heard best at the apex and
lower left sternal border.
154. Cardiac resynchronization therapy with a biventricular pacing
device is recommended in patients in sinus rhythm with the
combination of symptomatic heart failure, left ventricular ejection
fraction <35%, and left bundle branch block with QRS duration
>150 msec.
155. The following examination findings are consistent with severe AS:

 A soft, single second heart sound (S2)

 A delayed and diminished carotid pulse ("parvus et tardus")
 Loud and late-peaking systolic murmur

156. Wide pulse pressures are often seen in patients with aortic
regurgitation.
157. Aortic coarctation is a congenital narrowing of the aorta.
Patients with mild narrowing may have claudication due to
decreased blood flow distal to the aorta. Key findings include
upper extremity hypertension, lower extremity hypotension, and
weak/delayed distal pulses (brachifemoral delay).
158. Parasternal heave occurs with right ventricular hypertrophy.
159. Pulsus paradoxus is a large decline in blood pressure (>10
mm Hg) during inspiration that occurs with cardiac tamponade.
160. Chronic systemic hypertension and obesity, as seen in this
patient, are usually the most prominent contributors to HFpEF.
They cause concentric left ventricular (LV) hypertrophy and
myocardial interstitial fibrosis that lead to diastolic dysfunction
and eventual decompensated volume overload.
161. Heart failure with preserved ejection fraction is a common
cause of heart failure. Chronic heart failure often manifests with
mild interstitial edema (ie, Kerley B lines on chest x-ray) without
alveolar edema (ie, no crackles on examination).
162. Anticoagulation therapy with a vitamin K antagonist (ie,
warfarin) is recommended for all patients with a mechanical
prosthetic valve to reduce the rates of valve thrombosis and
thromboembolism. Low-dose aspirin is added to warfarin only in
patients with a mechanical prosthetic valve and a separate, strong
indication (eg, severe coronary artery disease).
163. Amiodarone or dofetilide are the preferred antiarrhythmic
agents in patients with AF and left ventricular (LV) systolic
dysfunction with ejection fraction <35%.
164. An anticipated complication of chemotherapy is tumor lysis
syndrome, which results in significant elevations in serum
potassium, uric acid, and phosphate (with decreased serum
calcium). Severe hyperkalemia can lead to a widened QRS complex
(eg, sine wave pattern), which can progress to ventricular asystole
and cardiac arrest.
165. In patients age >40, an S3 gallop (which occurs just after S2)
is the most specific finding for decompensated heart failure.
166. Severe mitral stenosis, defined as a mitral valve area ≤1.5
cm2 (normal: 4-6).
167. Hemodynamic parameters from pulmonary artery
catheterization in cardiogenic shock show low cardiac index (CI)
due to impaired cardiac contractility, elevated pulmonary
capillary wedge pressure (PCWP) due to volume overload, with
a compensatory elevation in systemic vascular resistance
(SVR).
168. Patients with pulmonary embolus have elevated right atrial,
right ventricular, and pulmonary artery pressures.
169. ASD - step-up in oxygen saturation from the superior/inferior
vena cava to the right atrium.
170. PDA - step-up in oxygen saturation from the right ventricle to
the pulmonary artery.
171. VSD - step-up in oxygen saturation from RA to RV.
172. Per guidelines, all patients with asymptomatic LVSD (ie,
ejection fraction ≤40%) should be initiated on an angiotensin
system inhibitor (eg, ACE inhibitor), as these drugs have been
shown to delay the onset of symptomatic heart failure and
improve long-term cardiac morbidity and mortality.
173. The most reliable and possibly the only finding of DVT is
increased circumference of the affected leg due to localized
edema, resulting from increased venous hydrostatic pressure distal
to the thrombus and inflammatory disruption of vascular membrane
integrity.