Pt with MS, on auscultation; opening snap indicate NON-calcified mitral valve

Most common finding on cardiac examination in patient with miral valve

disease….atrial fibrillation

AS … ejection systolic murmur radiate to carotid

ASD… wide fixed splitting of S2

VSD… pan-systolic murmur radiating to whole myocardium

PDA… continuous machinery murmur

Pt with well developed UL& underdeveloped LL. Exam shows delayed femoral
pulsation… Coarctation of Aorta (COA)

COA murmur… at whole precordium radiating to back

MCC of cyanotic congenital heart disease… TOF

Cyanotic spells in pt with TOF occur at childhood (not directly after birth)

1st step in management of cyanotic spells in TOF… Squatting position

Cyanosis since birth (at 1st day of life)… TGVs

1st step in management… PG infusion (to maintain patency of PDA)

Heart failure symptoms few days after birth… hypo-plastic left heart $

Most imp drug for AR…….ACEI

Fixed splitted S2……ASD

More common association with ASD…..RBBB

Most common cyanotic heart disease….TOF

Most common complication of TOF….cyanotic spells

3 day child with symptoms of HF and shock... hypoplastic ventricle

Systolic murmur over aortic area with syncope…AS

Cyanosis since birth……TOG

Cyanosis relieved by squatting….TOF

Systolic murmur radiating to the back....coarctation of aorta

Continuous machinery murmur…..PDA

Mid-diastolic rumbling murmur……………. MS

Decrescendo early diastolic murmur…….. AR

Systolic murmur over apex radiate to axilla…MR

Systolic murmur over apex radiate to carotid…AS

Most common drug addiction causing CHD…..cocaine

Most common material causing CHD….alcohol

Most common CHD with down…..endocardial cushion

Most common CHD with DM…….VSD

Marked difference bet upper body pressure and lower body pressure (delayed
femoral pulse)… Coarctation of aorta (COA)

Most common complication with MS…..AF

1st step in TOGV… prostaglandin infusion

Pt with chest pain improve with setting &leaning forward… preicarditis

MCC………………… Viral infection (coxackie virus)

TTT…………………. NSAIDs

TTT of uremic pericarditis….. Dialysis

Best inv of constrictive pericarditis… CT (calcified pericardium)

TTT…………………….. peri-cardiectomy

Pt with distant heart sounds, ++ JVP, hypotension… Pericardial effusion and

tamponade…….next step is chest x-ray

Main TTT of pericardial effusion… Pericardiocentesis

Immigrant from Iraq/ Aboriginal with erythema marginatum. Lab shows ++ ASO
titer. ECG shows prolonged PR interval… Rheumatic fever

Aboriginal with rash, migatory arthritis and H/O URTI…….RHEUMATIC

FEVER…..next step…..oral penicillin

Most imp ECG findings in rheumatic fever… prolonged PR interval

Organisms causing Infective Endocrditis:

Most common over all…………….…strep viridians

After dental procedure ……….. strep. viridians

Drug addict…….staph

After cardiac cath……. staph

After GIT or geniotourinary procedure….. strep fecalis

Colon cancer ……..……………… strep bovis… vvvvvvvvvvv imp

Pt with IE, Blood culture grows step bovis… Next step: colonoscopy

MC affected valve in drug addict with IE… Tricuspid valve

MC valve lesion in drug addict with IE… Tricuspid regurge

1st most imp inv of IE…. Trans-esophageal Echo (detect vegetation)

2nd most imp inv of IE… Blood culture (identify organism)

Prophylaxis against IE… 2 conditions MUST be met;

- Significant cardiac defect (prosthetic valve, previous IE)

 - Dental procedure

Prophylaxis against IE… Amoxicillin 1h before & ½ an hour after procedure

1st MCC of dilated CM…… Alcohol

2nd MCC of dilated CM…… Viral (MC virus: coxackie virus)

Young pt with Syncope/ Arrhythmias or Sudden death during exercise with F/H of
sudden death during exercise at young age………..…………… HOCM

Genetics of HOCM……………… AD

Symptoms of HOMC are more severe with exercise, dehydration, valsalva or

standing

MCC of death in HOCM………….. Obstruction

2nd MCC of death………………… Arrhythmias

MC type of arrhythmias…….. V.tach and V.fib

Inv of choice of HOCM…………………………………………………….. Echo

TTT of choice of HOCM………………….. 1st line: BB & 2nd line: CCB

TTT of arrhythmias in HOCM………….. Implantable defibrillator

1st MC RF of IHD……………………………….…….. HTN

2nd MC RF of IHD…………………………………….. Smoking

Highest risk of MI in pt with IHD………………. Angina (not HTN)

Young smoker with recurrent attacks of typical chest pain… Variant angina

TTT of variant angina… stop smoking, nitrates during attack

Pt with H/O typical chest pain, ECG is normal… Next step: Exercise ECG

Nitrates… Relieve chest pain in IHD

Pt with DM, HTN, hyperlipidemia lose consciousness, lab shows serum glucose of
<40… which medication is responsible… BB

BB mask the signs of hypoglycemia BUT it doesn’t cause it

Imp findings in ECG in MI… ST segment elevation

ST elevation at II, III& aVF… inferior wall infarction

The earliest cardiac enzyme to appear…………… Myoglobin

The most accurate enzyme……………………………. Troponin

The best enzyme to detect Re-infarction……… CK-MB

Definitive TTT of MI………………………………………... Angioplasty

Best TTT in case of late presentation…………...… Heparin

Late presentation with significant chest pain… Nitrates

Medication decrease mortality… BB, ACE-Is& statin

Best inv/TTT of myocardial aneurysm… Echo/ Surgery

After MI … No operation for 6 months

Emergent surgery (e.g. fracture femur) with H/O angioplasty & stent in the last 6
months … Don’t stop clopidogrel (high risk of thrombosis)

Elective endoscpoy with H/O angioplasty & stent in the last 6 months … Don’t
stop clopidogrel (high risk of thrombosis)

Female on OCP develops HTN… 1st: stop OCP and 2nd: re-evaluate

Pt with BP > 140/90 for the 1st time… Ask pt to come back in 1-2 Ws

Best inv for HTN……..ampulatory monitoring

Best inv for paroxysmal arrythmia………holter

Imp inv of arrythmia……….TFT, CBC and electrolytes

1st life style modification in TTT of HTN…… Wt loss

2nd life style modification in TTT of HTN…… low Na diet

Best initial drug for HTN……Thiazides

First drug for DM with HTN……ACEI

First line for DM + Protenuria…….ACEI

HTN + unilateral renal artery stenosis…….ACEI

HTN + bilateral renal artery stenosis… Angioplasty& stent

HTN + OSTEOPOROSIS…….THIAZIDES

HTN + Hyperthyroidism…….BB

HTN + BPH……..Alpha blockers

HTN + HF……………ACEI

HTN and pregnancy……alpha methly dopa and labetalol

Hypertensive emergency… Hospitalization& 1st line: Labetolol/ 2nd line: Na

nitroprusside

MC RF of digitalis toxicity… hypokalemia

Presentation… Vomiting, abd pain, colored vision& arrhythmia in ECG

Most imp ECG finding… down sloping ST segment with sagging appearance

TTT……………. Digitalis antibodies

Patient on digoxin develop arrythmia…….stop digoxin and give potassium

MCC of Lt sided HF (LHF)…………………………………………. MI

MCC of Rt sided HF (RHF)…………………………………………. Left sided HF

Most imp sign of LHF………. Bilateral basal lung crepitation

Most imp sign of RHF……… Systemic congestion

Inv of choice of HF…………… Echo

Hepato- jugular reflux… +ve in hepatomegally DT congestive HF

Hepato- jugular reflux… -ve in hepatomegally DT liver pathology

Medications MUST be given in HF… ACE-Is, BB and aldosteron antagonist

Most dangerous type of lipids…..LDL

Most imp in exam to say familial….tendon xanthoma (NOT xanselesma)

DOC for hyperlipidemia… Statin

Mechanism of action…… HMG-COA reductase inhibitor

Pt on statin, BB, ACE-I, aspirin develop myopathy… Cause: Statin

Inv of choice in suspected statin- induced myopathy… CK

Imp SE of statin… myopathy (check CK)& Hepatitis (check AST, ALT)

Imp forbidden combinations

Statin and gemfibrizol………….. Severe rhabdomyolysis

Nitrates and sildenafil………… Severe hypotension

Allopurinol and azathioprine…….severe toxicity

Pt with severe chest pain radiating to the back… Aortic dissection

MC RF of aortic dissection…………………………………….. HTN

X-ray of aortic dissection… Wide mediastinum

Aortic dissection and stable patient… CT angio

Aortic dissection and unstable patient… Trans-esophageal echo

1st step in TTT of aortic dissection… Lower BP (BB is the best to start with)

MC medication causing orthstatic hypotension… Diuretics

1st line of TTT…………… IV fluid

2nd line……………………. Stop the offending drug

Inv of choice…… Upright tilt table test

Pt with BPH loses conscious while micturating… Situational syncope

vasovagal arrythmia
onset Gradual sudden
recovery delayed Quick
Triggering factors Prolonged Exercise
standing -
emotional stress -
painful stimuli.

quick recovery
HOCM vs AS??.....VVVVVVV IMP

Both of them…….young age

Both of them…..sudden syncope

Both of them…..risky with exercise

Both of them….sudden death

HOCM…….positive family history

HOCM…..systolic murmur over sternal border

HOCM murmur….noooo radiation

AS….systolic murmur over aortic area radiate to carotid

Chest pain…..more with Aortic stenosis

MI and surgery:

No operation before 6 months

Stent and urgent operation:

Do not stop clopidogrel…..risk of thrombosis

Target lipid profile????

Total Cholesterol………less than 4 mmol/l

LDL…………….less than 2 mmol/l

HDL…………..more than 1 mmol/l

TG…………….less than 2 mmol/l

Drug of choice…….statin to maximum tolerated dose

Sudden tearing chest pain referred to the back and HTN………aortic dissection

Next step………CXR……..wide mediastinum

47 ys male patient HTN, DM and smoker next best step………..CVS risk assessment

Best assessment for obesity causing CVS disease……..waist hip ratio

DM type 2 with any CVS risk facto …add statin regardless lipid profile