USMLE Step 2 (Fach) / Cardiology (Lektion)
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Step 2 CK
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- Tachycardia, stable, broad QRS, regular Likely ventricular tachycardia. Amiodarone 300 mg IV over 20-60 minutes.Followed by amiodarone 900 mg IV over 24 hours.
- Tachycardia, stable, broad QRS, irregular Seek expert help Possibilities include:- AF with bundle branch block (→ treat as for narrow complex)- Polymorphic VT (eg, torsades de pointes → give magnesium 2g over 10 min)
- Tachycardia, narrow QRS, regular Usually sinus tachycardia, AV nodal re-entry tachycardia (AVNRT), AV re-entry tachycardia (AVRT), atrial flutter with regular AV conduction. If unstable → synchronised electrical cardioversion Stable:1. ...
- Tachycardia, narrow QRS, irregular Probably atrial fibrillation Unstable → Synchronised electrical cardioversion Stable:- β-blocker or diltiazem- Consider digoxin or amiodarone if evidence of heart failure- Anticoagulate if duration ...
- Widened QRS interval Left bundle branch block: - QRS duration >120 ms- No R wave in V1- Wide, tall R waves in I, V5, V6 Right bundle branch block:- QRS duration >120 ms- RSR' complex ("rabbit ears")- qR or R morphology with ...
- Axis deviations Normal (-30 – +90%):- Lead I: ↑- Lead aVF: ↑ Left axis deviation (≤-30%):- Lead I: ↑- Lead aVF: ↓ Right axis deviation (≥+90%): - Lead I: ↓- Lead aVF: ↑
- ECG - ischemia/infarction Natural progression:- Hyperacute T-waves- ST-segment changes (either depression or elevation)- Q waves > 40 msecs or more than one-third of QRS amplitude→ Q waves signify either acute or prior ischemic ...
- ECG - Ventricular hypertrophy Left ventricular hypertrophy:- S in V1 + R in V6 or V4 is > 35 mm- Alternative criteria: The amplitude of R in aVL + S in V3 is > 28 mm in men or > 20 mm in women. Right ventricular hypertrophy:- Right ...
- Atrial fibrillation Risk factors:- Heart disease: Coronary artery disease, MI, hypertension, mitral valve disease, congestive heart failure- Pericarditis and pericardial trauma- Pulmonary disease, including PE and COPD- ...
- Stable angina pectoris Risk factors:- Diabetes mellitus – worst risk factor- Smoking- Hypertension- Hyperlipidemia- Age- Family history of premature coronary artery disease (men < 55 years, women < 65 years)- Other: Obestiy, ...
- PCI vs. CABG Percutaneous coronary intervention (PCI):- Consists of both coronary angioplasty with a balloon and stenting.- Should be considered in patients with one-, two-, or three-vessel disease. Even with three-vessel disease, ...
- Unstable angina pectoris Clinical features:- Angina at rest - Symptoms are not reproducible/predictable- Usually occurs at rest or with minimal exertion and is usually not relieved by rest or nitroglycerin- Every new-onset angina- ...
- Variant/Vasospastic/Prinzmetal angina Angina caused by transient coronary spasms (usually occurring close to areas of coronary stenosis).Episodes of angina occur at rest and are associated with ventricular dysrhythmias, some of which may ...
- Myocardial infarction Clinical features:- Chest pain→ Often described as crushing and "an elephant standing on my chest"→ Radiation to neck, jaw, arms, or back, commonly to the left side- Painless infarcts or atypical ...
- Complications of acute myocardial infarction Early complications (within 48 h):- Arrhythmia- Acute left heart failure→ Most common cause of in-hospital mortality→ Treat with ACE inhibitor, diuretic- Cardiogenic shock Late complications:- Recurrent ...
- Congestive heart failure Etiology:- Coronary artery disease- Hypertension- Diabetes mellitus- Valvular disease- Cardiomyopathies Risk factors: Smoking, obesity, COPD, hemochromotosis, drug and alcohol abuse Stages: NYHA I-IV ...
- General principals in the treatment of CHF Mild CHF (NYHA Classes I to II)- Mild restriction of sodium intake (< 4 g of sodium) and physical activitiy- Start loop diuretic if volume overload or pulmonary congestion is present- Use an ACE inhibitor ...
- Atrial flutter Supraventricular tachyarrhythmia that is usually caused by a single macroreentrant rhythm within the atria. Etiology:- Heart disease: Heart failure, rheumatic heart disease, CAD- COPD- Atrial septal defect ...
- Paroxysmal supraventricular tachycardia 1. Atrioventricular nodal reentrant tachycardia (AVNRT): tachycardia caused by a dysfunctional AV node that contains two electrical pathways- Two pathways (one fast and the other slow) within the AV node, ...
- Wolff-Parkinson-White syndrome A congenital condition characterized by intermittent tachycardias and signs of ventricular pre-excitation on ECG, which both arise from an accessory pathway known as the “bundle of Kent”. - The bundle ...
- AV block First-degree AV block:- PR interval is prolonged (> 0.2 s)- A QRS complex follows each P wave- Benign condition that does not require treatment Second-degree AV block:1. Mobitz type I (Wenckebach)- Characterized ...
- Cardioversion vs. Defibrillation Cardioversion- Delivery of a shock that is in synchrony with the QRS complex: Purpose is to terminate certain dysrhythmias such as PSVT or VT; an electric shock during T wave can cause Vfib, so the shock ...
- Dilated cardiomyopathy Etiology:- Idiopathic (approx. 50%)- Coronary artery disease, hypertension, peripartum cardiomyopathy, valvular heart disease- Infections: Coxsackie B virus myocarditis, rheumatic heart disease, Chagas ...
- Hypertrophic cardiomyopathy Epidemiology:- Obstructive type/hypertrophic obstructive cardiomyopathy (HOCM): ∼ 70% of cases- Nonobstructive type: ∼ 30% of cases- Alongside myocarditis, hypertrophic cardiomyopathy is one of the ...
- Restrictive cardiomyopathy Etiology:- Idiopathic- Hemochromatosis- Amyloidosis- Sarcoidosis- Scleroderma- Secondary to endomyocardial fibrosis: Eosinophilic endocarditis, postradiation fibrosis, endocardial fibroelastosis Diagnostics:- ...
- Myocarditis Etiology:- Viral: Coxsackie B, parvovirus B19, human herpesvirus 6 (HHV-6), adenovirus, HCV, HIV, EBV, CMV- Bacterial: Streptococcus group A (acute rheumatic fever), Corynebacterium diphtheriae, Borrelia ...
- Acute pericarditis Etiology:- Infectious: Mostly viral (e.g., coxsackie B), tuberculosis, toxoplasmosis- Post-infarction fibrinous pericarditis (1-3 days), Dressler syndrome (weeks to months)- Post-operative (post-pericardiotomy ...
- Constrictive pericarditis Constrictive pericarditis is characterized by compromised cardiac function caused by a thickened, rigid, and fibrous pericardium secondary to acute pericarditis. Etiology:- Infectious: Viral > Bacterial - ...
- Pericardial effusion Pericardial effusion is the acute or chronic accumulation of fluid in the pericardial space (between the parietal and the visceral pericardium). Etiology: - Hemopericardium: Cardiac wall rupture, chest ...
- Cardiac tamponade Defined as accumulation of pericardial fluid. It is the rate of fluid accumulation that is important, not the amount.- Two hundred milliliters of fluid that develops rapidly (i.e., blood secondary to trauma) ...
- Mitral stenosis Etiology- Rheumatic fever (most common)- Autoimmune diseases: systemic lupus erythematosus, rheumatoid arthritis Clinical features:- Initially asymptomatic (onset ∼ 10 years after acute rheumatic carditis) ...
- Aortic stenosis Etiology:- Bicuspid aortic valve: 3:1 male predominance, predisposes the valve to dystrophic calcification, patients present with symptoms of aortic stenosis earlier than in regular aortic valve calcification- ...
- Aortic regurgitation Etiology:- Acute:→ Infective endocarditis→ Aortic dissection (ascending aorta)→ Chest trauma- Chronic:→ Congenital bicuspid valve: most common cause of AR in young adults and in developed countries→ ...
- Mitral regurgitation Etiology:- Degenerative mitral valve disease: mitral valve prolapse, mitral annular calcification, ruptured chordae tendineae- Rheumatic fever- Infective endocarditis- Coronary artery disease, prior myocardial ...
- Tricuspid regurgitation Etiology:- Secondary to RV dilation→ Left ventricular failure is the most common cause→ Right ventricular infarction→ Inferior wall MI→ Cor pulmonale, secondary to pulmonary HTN- Tricuspid ...
- Mitral valve prolapse Etiology:- Mostly idiopathic- Connective tissue disorders: Marfan's syndrome, osteogenesis imperfecta, Ehlers-Danlos syndrome- Myocardial infarction (Infarction of papillary muscles → rupture of chordae ...
- Hypertensive crisis Hypertensive urgency: Severely increased BP (> 220 systolic and/or > 120 diastolic) Hypertensive emergency: Severely increased BP (> 220 systolic and/or > 120 diastolic) with signs of end-organ damage ...
- Aortic dissection Localization:- Ascending aorta: ∼ 65% of cases- Descending aorta, distal to the left subclavian artery: 20% of cases- Aortic arch: 10% of cases- Abdominal aorta: 5% of cases Etiology:- Hypertension- ...
- Abdominal aortic aneurysm Risk factors:- Age- Smoking (most important risk factor)- Atherosclerosis- Hypercholesterolemia and arterial hypertension- Family history- Trauma Location: Most commonly below the renal arteries Clinical ...
- Peripheral vascular disease Risk factors: - Smoking (by far the most important risk factor)- CAD, hyperlipidemia, HTN- Diabetes Sites of occlusion/stenosis- Superficial femoral artery (in Hunter canal) is the most common site - ...
- Acute arterial occlusion Etiology:- Heart (85%)→ Afib→ Post-MI→ Endocarditis→ Myxoma- Aneurysms- Atheromatous plaque Location of the obstruction:- Most common: femoropopliteal artery (∼ 50% of cases)- Brachial artery ...
- Superficial thrombophlebitis - In upper extremities, usually occurs at the site of an IV infusion- In lower extremities, usually associated with varicose veins (in the greater saphenous system)—secondary to static blood flow in ...
- Deep vein thrombosis Risk factors:- History of DVT or PE (30x increased risk) - Immobilization (e.g., surgery, long-distance flights, trauma) (20x increased risk)- Age > 60 years- Malignancy- Hereditary thrombophilia (especially ...
- Chronic venous insufficiency RIsk factors:- Higher age and female sex - Family history of venous disease- Ligamentous laxity- Sedentary lifestyle and prolonged standing- Obesity- Pregnancy- Smoking- Prior thrombosis (postthrombotic ...
- tPA Contraindications Inclusion criteria:- Onset of symptoms ≤ 3 hours (therapeutic window of thrombolytic therapy)- Age ≥ 18 years Exclusion criteria- Previous intracranial hemorrhage- Head trauma or stroke (within the ...
- Congenital lipid disorders Type I – Hyperchylomicronemia: Autosomal recessive condition that is not associated with an increased risk of atherosclerosis. Patients develop eruptive xanthomas, pancreatitis, and hepatosplenomegaly.- Lipoprotein ...
- Endarterectomy Indications:- Carotid endarterectomy (CEA): treatment of choice for patients with significant (> 80%) or symptomatic carotid artery stenosis- Pulmonary endarterectomy: treatment of choice for chronic ...
- Guidelines for statin therapy - LDL cholesterol elevated ≥ 190 mg/dL - Clinical atherosclerotic cardiovascular disease (includes coronary heart disease, stroke, and peripheral arterial disease) - Age 40-75 with diabetes - Age 40-75 ...
- Multifocal atrial tachycardia Etiology:- Exacerbation of pulmonary disease (e.g., COPD)- Electrolyte disturbance (e.g., hypokalemia)- Catecholamine surge (e.g., sepsis) Clinical features:- Typically asymptomatic- Rapid, irregular ...
- Sternal dehiscence Relatively common complication after CABG. Soft tissue dehiscence:- Only the superficial tissues (eg, skin, muscle) separate- No signs of sternal instability or systemic illness- Treatment: Local wound ...