04-17-2008, 11:56 AM
Triplehelix's MKSAP notes till yet put together...thanks a ton, triple... keep up the great work..all the best for everything ahead
MKSAP 14 neurology notes:
1. A spinal cord disorder should be considered in any patient with bilateral motor and sensory dysfunction in the extremities in the absence of signs or symptoms of brain or brainstem dysfunction.
2. Spinal cord compression due to epidural metastasis is a neurologic emergency for which urgent MRI of the entire spine is appropriate.
3. Vertebral artery dissection typically presents with neck or head pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperature sensation, dysmetria, ataxia, and vertigo.
4. Magnetic resonance angiography is a sensitive diagnostic test for vertebral artery dissection as a cause of stroke.
5. Juvenile myoclonic epilepsy is a primary, genetic, generalized epilepsy that typically manifests with myoclonic jerks followed by a generalized tonic“clonic seizure
6. Guillain“Barré syndrome is characterized by proximal and distal weakness, autonomic symptoms, cranial nerve involvement, and respiratory failure.
7. Treatment of Guillain“Barré syndrome with either intravenous immunoglobulin or plasmapheresis is indicated in patients who cannot walk independently or who have impaired respiratory function or rapidly progressive weakness.
8. Small, stable, asymptomatic meningiomas can be followed with serial neuroimaging.
9. In large, symptomatic, or progressive meningiomas, surgical resection offers an 80% chance of cure.
10. Personality change, lost initiative, and slowing of thought, with relative preservation of recent memory, suggest frontotemporal dementia.
11. Frontotemporal dementia is usually associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding that is usually clearly demonstrated on MRI.
12. Elevation of the cerebrospinal fluid 14-3-3 protein in a patient with rapidly progressive dementia and normal structural imaging suggests Creutzfeldt“Jakob disease.
13. Treatment with interferon-beta decreases the incidence of additional attacks in patients with monosymptomatic demyelination, including optic neuritis and myelopathy.
14. Propranolol and primidone are first-line drugs in the treatment of essential tremor (postural and action tremor).
15. The diagnosis of Parkinson's disease requires the presence of at least two of the following: tremor at rest, bradykinesia, rigidity, and postural reflex abnormality.
16. The characteristics of migraine headache without aura include worsening of the headache with movement, limitation of activities, and photo- and phonophobia
17. Transverse myelitis is an acute or subacute demyelinative or inflammatory disorder of the spinal cord that causes motor, sensory, and autonomic dysfunction below a spinal cord level.
18. High-dose intravenous corticosteroids are indicated for initial treatment of acute transverse myelitis.
19. Secondary prevention of cardioembolic stroke consists of warfarin with a target INR of 2.0 to 3.0.
20. Heparin has no established role in the acute treatment of stroke.
21. The manifestations of partial seizures depend on their neuroanatomic location.
22. Frontal seizures are brief and are usually not associated with aura or postictal confusion.
23. Hereditary sensorimotor neuropathy is an autosomal dominant disorder that usually presents with clumsiness or difficulty running in the first decade of life.
24. Hereditary sensorimotor neuropathy is characterized by distal muscle atrophy, weakness, and sensory loss associated with high arches (pes cavus) and hammertoes
25. Cell type and tumor grade are the most important determinants of survival in glioma.
26. Higher-grade gliomas are more aggressive than lower grade.
27. Alzheimer's disease is characterized by primary dementia with prominent amnesia.
28. Dementia with Lewy bodies, characterized by fluctuating cognition, parkinsonism, and/or visual hallucinations, often coexists with Alzheimer's disease.
29. All patients with relapsing multiple sclerosis should be considered for immunomodulatory therapy with either a form of interferon-beta or glatiramer acetate.
30. Adult-onset idiopathic dystonia is usually focal or segmental and does not generalize to other parts of the body.
31. Botulinum toxin injections can correct the abnormal posture and alleviate the pain associated with cervical dystonia.
32. Approximately 20% of patients with migraine have headache with aura, that is, neurologic problems such as visual hallucinations or numbness or tingling before or during headache.
33. Lhermitte's sign, an œelectric shock“like sensation down the neck, back, or extremities occurring with neck flexion, is a helpful historical clue to a cervical spinal cord disorder.
34. Cervical spondylosis is a chronic disorder of degenerative and hypertrophic changes of the vertebrae, ligaments, and disks that may narrow the spinal canal and cause cervical spinal cord compression.
35. In patients with stroke not eligible for thrombolytic therapy, aspirin modestly reduces both the short-term risk of recurrent stroke and the long-term risk of stroke-related death and disability.
36. In patients with acute stroke, thrombolytic therapy must be started within 3 hours of the onset of symptoms or of the time the patient was last known to be well.
37. Elderly patients may be particularly sensitive to the cognitive, motor, and coordination side effects of phenytoin, even if the serum phenytoin level is in the therapeutic range.
38. Gabapentin, lamotrigine, and carbamazepine are equally effective at controlling partial onset seizures in the elderly, but gabapentin and lamotrigine are better tolerated.
39. Peripheral nervous system vasculitis usually presents with asymmetric weakness and sensory loss in specific nerve distributions.
40. In an elderly patient with recurrent glioblastoma and poor performance status, referral for hospice care is preferable to additional antitumor treatment.
41. The three specific criteria for dementia with Lewy bodies are fluctuating encephalopathy, parkinsonism, and visual hallucinations.
42. A centrally acting anticholinesterase agent may alleviate the inattention, hallucinations, and fluctuating encephalopathy of dementia with Lewy bodies.
43. Women taking immunomodulatory treatment for multiple sclerosis should use effective contraception, or if they want to become pregnant, stop therapy several months before attempting to conceive.
44. Involuntary brief, irregular, unpredictable movements fleeting from one body part to another are hallmarks of chorea.
45. Chorea can occur as a hereditary and degenerative disease or secondary to drugs, metabolic disorders, infections, immune-mediated diseases, and vascular lesions.
46. Tension-type headache is distinguished from migraine by the fact that patients with tension headache are not disabled and can carry out activities of daily living in a normal, expedient manner.
47. Vitamin B12 deficiency can cause dysfunction of the posterior columns and corticospinal tracts of the spinal cord, causing paresthesias, loss of vibration and position sense, sensory ataxia, weakness, and upper motor neuron signs.
48. Neurologic signs of vitamin B12 deficiency may manifest in the absence of hematologic signs of vitamin B12 deficiency.
49. In a patient with a transient ischemic attack, carotid artery ultrasonography showing a >50% stenosis of the internal carotid artery may be an indication for carotid endarterectomy.
50. A single antiepileptic drug should be used in pregnant women with epilepsy; multiple drug therapy increases the risk for birth defects.
51. Chronic inflammatory demyelinating polyneuropathy, the chronic form of Guillain“Barré syndrome, is characterized by proximal and distal weakness, areflexia, and distal sensory loss.
52. Chronic inflammatory demyelinating polyneuropathy progresses in a stepwise or relapsing course for at least 8 weeks and can occur early in the course of HIV infection.
53. In a young patient with totally resected low-grade glioma, postsurgical management consists of observation with serial neuroimaging.
54. Vascular dementia is suggested by a history of vascular risk factors, abrupt onset with subsequent improvement, periventricular white matter ischemia on imaging, and focal neurologic findings.
55. Intravenous methylprednisolone therapy followed by an oral prednisone taper speeds recovery of visual acuity in optic neuritis
56. The restless legs syndrome consists of abnormal sensations in the legs and restlessness relieved by movement.
57. Patients are at risk for developing analgesic overuse headache if they use prescription or over-the-counter medication for headache more than 2 days a week.
58. Pseudotumor cerebri is characterized by papilledema, postural change with headache, visual changes, recent report of rapid weight gain, or introduction of oral contraceptives or tetracycline.
59. Infarction of the spinal cord typically presents as sudden spinal cord dysfunction.
60. Spinal cord infarction usually affects the territory of the anterior spinal artery, causing weakness and pinprick loss of sensation with sparing of vibration and position sense.
61. CT scan may miss subarachnoid hemorrhage, especially when there is a delay in presentation after the initial hemorrhage.
62. Focal neurologic symptoms 3 to 7 days after a subarachnoid hemorrhage may be due to vasospasm with cerebral ischemia.
63. Patients with epilepsy who are most likely to remain seizure free after medication withdrawal are those with no structural brain lesion, no epileptiform or focal abnormalities on electroencephalogram, a sustained seizure-free period, and no abnormalities on neurologic examination.
64. Patients with epilepsy who discontinue antiepileptic medication should stop driving for at least 3 months and preferably 6 months from the start of the taper.
65. Critical illness polyneuropathy is a common cause of failure to wean from a ventilator in a patient with associated multiorgan failure and sepsis.
66. Critical illness polyneuropathy is characterized by generalized or distal flaccid paralysis, depressed or absent reflexes, and distal sensory loss with sparing of cranial nerve function.
67. Patients with primary central nervous system lymphoma should be evaluated for vitreal or uveal involvement before therapy is begun.
68. Aggressive resection is not recommended in primary central nervous system lymphoma; methotrexate chemotherapy is primary therapy.
69. Donepezil, an acetylcholinesterase inhibitor, may cause mild peripheral cholinergic side effects, including increased vagal tone, with bradycardia, and occasionally atrioventricular block.
70. In at least 50% of patients with relapsing“remitting multiple sclerosis, disease will evolve to a secondary progressive course.
71. In at least 50% of patients with relapsing“remitting multiple sclerosis, disease will evolve to a secondary progressive course.
72. Metoclopramide, which blocks dopamine receptors both in the periphery and inside the central nervous system, can induce parkinsonism.
73. Prednisone is the most appropriate treatment for episodic cluster headache.
74. Acute cervical spinal cord compression due to hyperextension injury is common in elderly patients.
75. Emergent MRI of the cervical spinal cord is indicated in any patient with quadriparesis after a fall.
76. The classic symptoms of cerebellar stroke are headache, vertigo, and ataxia.
77. Patients with epilepsy who fail to respond to three trials of antiepileptic drugs are unlikely to ever become seizure free with drug therapy.
78. Treatment-resistant patients with epilepsy should be evaluated for a surgically remediable epilepsy syndrome.
79. Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, which results in impaired neuromuscular transmission.
80. Myasthenia gravis is characterized by fatigable weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles.
81. Leptomeningeal spread of systemic carcinoma manifests as a cranial neuropathy or spinal polyradiculopathy, or as encephalopathy, diffuse brain infiltration, or communicating hydrocephalus.
82. Creutzfeldt“Jakob disease is suggested by subacute progression of dementia with myoclonus and other motor signs and a normal brain MRI.
83. In the setting of subacutely progressive dementia, the presence of 14-3-3 protein in cerebrospinal fluid, or electroencephalography showing periodic sharp waves, can be diagnostic of Creutzfeldt“Jakob disease.
84. Mitoxantrone therapy is of modest benefit in slowing progression of secondary progressive or severe relapsing“remitting multiple sclerosis.
85. The primary concern about mitoxantrone therapy is the risk for cardiotoxicity.
86. Progressive supranuclear palsy is characterized by parkinsonism with early gait and balance involvement, vertical gaze palsy, severe dysarthria, and dysphagia.
87. Normal pressure hydrocephalus is characterized by the classic triad of gait impairment, cognitive decline, and urinary incontinence.
88. Patients with idiopathic intracranial hypertension present with signs and symptoms of increased intracranial pressure without a mass lesion on brain imaging.
89. In patients with possible idiopathic intracranial hypertension, a diagnostic and potentially therapeutic lumbar puncture is indicated after brain imaging excludes a mass lesion.
90. Severe cerebral anoxia from cardiac arrest can cause severe diffuse cerebral hemispheric cortical injury with relative preservation of brainstem function, leading to the development of a vegetative state.
91. A vegetative state is a condition of complete unawareness of self or the environment, accompanied by sleep“wake cycles and preservation of brainstem and hypothalamic functions.
92. Intracerebral hemorrhage with extensive subarachnoid hemorrhage is the hallmark of a ruptured arteriovenous malformation.
93. Conventional angiography is the definitive diagnostic procedure for detecting arteriovenous malformations and berry aneurysms.
94. In a patient with status epilepticus, after the airway is stabilized and plasma glucose determined to be normal, parenteral antiepileptic medications should be started.
95. Lorazepam is the preferred benzodiazepine for initial therapy for a patient in status epilepticus.
96. Myasthenia gravis crisis is characterized by dysphagia requiring nasogastric feeding and/or severe respiratory muscle weakness necessitating ventilation.
97. Myasthenia gravis crisis is treated with either plasmapheresis or intravenous immunoglobulin.
98. Radiation-induced leukoencephalopathy is a subcortical process affecting white matter and characterized by the triad of gait apraxia, dementia, and urinary incontinence.
99. Radiation-induced leukoencephalopathy may occur months to years after radiation and is more common after whole-brain compared with focal brain irradiation.
100. Mild cognitive impairment consists of isolated mild amnesia with no impairment of interpersonal, occupational, or daily living activities.
101. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year.
102. Amantadine is the first-line pharmacologic agent for treatment of multiple sclerosis-related fatigue.
103. Multiple system atrophy is characterized by orthostatic hypotension, neurogenic bladder, constipation, and impotence, with gait-predominant parkinsonism and corticospinal tract signs.
104. Carbamazepine is the appropriate treatment for trigeminal neuralgia.
105. Patients with the locked-in syndrome are quadriplegic, have paralysis of horizontal eye movements and bulbar muscles, and can communicate only by moving their eyes vertically or blinking.
106. The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion.
107. Antiplatelet therapy, statins, and ACE inhibitors each reduce the risk of recurrent stroke even in the absence of chronic hypertension or a lipid disorder.
108. Headache may be a limiting factor in the use of the combination of aspirin and extended-release dipyridamole for secondary stroke prevention.
109. Nonepileptic seizures of psychogenic origin can be differentiated from epilepsy by their longer duration, normal electroencephalogram findings, and maintenance of consciousness.
110. Nonepileptic psychogenic seizures are often associated with moaning, crying, and arrhythmic shaking of the body.
111. Absence seizures are characterized by a brief loss of awareness with no movement or very subtle movements of the lips and fingers.
112. Juvenile myoclonic epilepsy is characterized by myoclonic seizures and often accompanied by absence and generalized tonic“clonic seizures.
113. Amyotrophic lateral sclerosis is characterized by pathologic hyperreflexia, spasticity, extensor plantar responses, along with atrophy, fasciculations, and weakness.
114. Muscle weakness in amyotrophic lateral sclerosis usually begins distally and asymmetrically in the upper or lower extremities or may be limited initially to the bulbar muscles, resulting in dysarthria and dysphagia.
115. Surgical resection is indicated for an accessible solitary brain metastasis in patients with limited or no systemic tumor.
116. Cholinesterase inhibitors have modest efficacy on cognitive and global function in mild to moderate Alzheimer's disease.
117. Vitamin E and selegiline may delay the progression of Alzheimer's disease, but do not alleviate cognitive or psychiatric symptoms.
118. In patients with possible multiple sclerosis, new MRI white-matter lesions or new gadolinium-enhancing lesions on serial brain or spinal cord MRI at least 3 months after an initial scan, indicate dissemination of demyelination, even without a new clinically evident attack.
119. Carbidopa-levodopa is the first-line treatment for patients older than 70 years with new-onset Parkinson's disease.
120. Complications associated with the use of dopamine agonists, such as somnolence, drug-induced psychosis, and dizziness, are more common in patients older than 70 years.
121. The risk of rupture of a small intracranial aneurysm is less than the risk of complications with clipping or endovascular coiling of the aneurysm.
122. Incidentally discovered small aneurysms should be re-evaluated periodically for enlargement.
123. Oxcarbazepine is effective monotherapy for partial onset seizures.
124. Risk factors for recurrent seizures include multiple previous seizures, a history of significant head trauma, focal electroencephalogram abnormalities, and structural abnormality on MRI.
125. Amyotrophic lateral sclerosis causes progressive respiratory muscle weakness that may present with supine dyspnea, frequent arousals, daytime fatigue, or morning headache.
126. Noninvasive positive-pressure ventilation should be started in patients with amyotrophic lateral sclerosis whose forced vital capacity is less than 50% or who has symptoms of nocturnal hypoventilation.
127. Neurologic symptoms in conjunction with normal brain imaging and the detection of a systemic cancer are most likely due to an immune-mediated paraneoplastic neurologic syndrome.
128. Memantine may alleviate cognitive symptoms and improve global function in moderate to severe Alzheimer's disease when added to cholinesterase inhibitor therapy.
129. Estrogen replacement in post-menopausal women with Alzheimer's dementia has not been shown to alleviate cognitive symptoms or delay disease progression.
130. Drug-induced psychosis in Parkinson's disease consists primarily of visual hallucinations, evolving at times into paranoid-type delusions.
131. Infection with fever can temporarily exacerbate a chronic neurologic defect in a patient with a previous stroke.
132. Partial complex epilepsy consists of stereotyped nonconvulsive seizures with loss of awareness and amnesia for events.
133. Myotonic dystrophy is an autosomal dominant disorder that presents with distal weakness and muscle stiffness and is characterized by cataracts, frontal balding, temporal muscle atrophy, and cognitive dysfunction.
134. Cardiac disease resulting in arrhythmias and respiratory failure due to diaphragmatic weakness are common features of myotonic dystrophy.
135. Lambert-Eaton myasthenic syndrome is characterized by symmetrical proximal muscle weakness and autonomic dysfunction.
136. Lambert-Eaton myasthenic syndrome is diagnosed by motor nerve conduction studies with repetitive stimulation.
137. Cognitive impairment accompanied by fluctuating lethargy and inattention, hallucinations, and asterixis is likely the result of a toxic encephalopathy.
138. Drugs that block dopamine receptors can induce acute dystonic reactions.
139. In acute ischemic stroke, tissue plasminogen activator is indicated if therapy is started within 3 hours of onset of symptoms, there is no hemorrhage on CT scan, and all other eligibility criteria are met.
140. All states require that an episode of loss of awareness be reported to government authorities, either to the Department of Health or to the Department of Motor Vehicles.
141. Hypothyroid myopathy is characterized by muscle pain, cramps, stiffness, fatigue, and paresthesias.
142. In hypothyroid myopathy, creatine kinase levels may be 10 to 100 times normal, but thyroid function tests should be performed before electromyography or muscle biopsy.
143. Paraneoplastic limbic encephalitis is most commonly associated with small-cell lung cancer.
144. Paraneoplastic limbic encephalitis is characterized by rapidly progressive decline in short-term memory and seizures.
145. The most common heritable form of Alzheimer's disease results from a mutation in presenilin-1.
146. Testing for presenilin-1 may be useful when a heritable form of Alzheimer's disease is suspected.
147. CT scan of the brain is indicated to diagnose suspected intracerebral hemorrhage.
148. Head trauma increases the relative risk for epilepsy by 10 only if there is penetration of the dura or loss of consciousness for more than 30 minutes.
149. Critical illness myopathy is common in ventilator-dependent patients who have been treated with corticosteroids and neuromuscular blocking agents.
150. Critical illness myopathy is characterized by ventilator dependence, generalized or proximal flaccid paralysis, muscle atrophy, and high creatine kinase levels.
151. Primary impairment of concentration and attention, as opposed to memory, is likely the result of depression rather than a neurodegenerative condition.
152. Carotid endarterectomy is the appropriate intervention in patients with symptomatic carotid artery stenosis, especially within the first few weeks after initial symptoms.
153. Depression is a possible side effect of many antiepileptic drugs, including phenobarbital, phenytoin, valproate, levetiracetam, and topiramate.
154. Selective serotonin reuptake inhibitors, moclobemide, venlafaxine, and nefazodone do not increase the seizure threshold in patients with epilepsy and therefore are the preferred pharmacologic agents in depression.
155. Polymyositis is characterized by proximal muscle weakness, elevated creatine kinase levels, and needle electromyography showing diffuse fibrillations and myopathic motor unit potentials.
156. Results of creatine kinase measurement and needle electromyography are invariably normal in steroid myopathy but abnormal in inflammatory myopathy.
157. Antiplatelet therapy is the mainstay of secondary stroke prevention in patients with cryptogenic stroke.
158. Clopidogrel is the preferred antiplatelet therapy for aspirin-allergic patients with a history of stroke
Cardiology Notes:
160. Right ventricular infarction should be suspected in patients with inferior myocardial infarction who present with hypotension, clear lung fields, and elevated jugular venous pressure.
161. An echocardiogram establishes the diagnosis of right ventricular infarction by demonstrating right ventricular enlargement and hypokinesis.
162. Implantable cardioverter-defibrillator therapy reduces risk of sudden death in survivors of cardiac arrest due to ventricular tachycardia or ventricular fibrillation without a reversible cause.
163. Spontaneous coronary dissection may occur during pregnancy.
164. In patients with ST-elevation myocardial infarction, successful fibrinolysis is suggested by resolution of chest pain and ST-segment elevation and/or transient ventricular arrhythmias early after reperfusion.
165. In patients with ST-elevation myocardial infarction, reperfusion arrhythmias, typically manifested as a transient accelerated idioventricular arrhythmia, usually do not require additional antiarrhythmic therapy.
166. Thrombosis of mechanical valves may present with valve dysfunction rather than embolic events.
167. Intravenous heparin should be started immediately while diagnostic evaluation is in progress.
168. Chest CT scan with contrast is indicated to detect acute aortic dissection.
169. In patients at risk for radiocontrast nephropathy and contraindication to MRI, transesophageal echocardiography is the test of choice for possible aortic dissection.
170. Breast and lung carcinoma are the most common causes of malignant pericardial disease.
171. The epicardium is the most common location of metastatic cardiac neoplasm.
172. An ACE inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients.
173. Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.
174. Fixed splitting of the S2 is the auscultatory hallmark of atrial septal defect.
175. A divergence between electrocardiography showing low-voltage and echocardiography demonstrating a substantial increase in left ventricular wall thickness is a useful diagnostic clue for cardiac amyloidosis.
176. Abdominal fat aspiration biopsy is a safe and reasonably sensitive test for the diagnosis of amyloidosis.
177. Physical examination is helpful is identifying the presence, but not the severity, of valve disease.
178. The most sensitive sign on physical examination to exclude the diagnosis of severe aortic stenosis is a physiologically split S2.
179. Most patients with peripheral vascular disease have an ABI grade 3/6 in intensity, continuous murmurs, or any diastolic murmur.
192. Surgery for native valve endocarditis is indicated if there is significant hemodynamic instability or evidence of paravalvular extension.
193. Factors favoring earlier timing of surgery include significant congestive heart failure, resistant infections, and large mobile vegetations.
194. Even if active bacteremia is still present or if the antibiotic treatment course is ongoing, surgery for endocarditis should not be delayed if surgical criteria are met.
195. Medical therapy for acute, recent myocardial infarction includes β-blockers, aspirin, angiotensin-converting enzyme inhibitors, and statins.
196. Smoking cessation is the single most effective intervention for patients with peripheral vascular disease.
197. β blockade does not promote clinical claudication.
198. Cilostazol is relatively contraindicated in patients with congestive heart failure.
199. Patients with heart failure who have severe symptoms and evidence for ventricular dyssynchrony benefit from implantation of a biventricular pacemaker.
200. Biventricular pacing improves cardiac performance and quality of life and may also improve survival.
201. Glycoprotein receptor blockade is indicated for patients with acute coronary syndrome who will undergo coronary angiography and intervention.
202. Patients with ST-elevation myocardial infarction treated with stents require aspirin and clopidogrel at discharge.
203. Patients with ST-elevation myocardial infarction treated without stents may be managed with aspirin alone or with warfarin if indicated for atrial fibrillation or anterior akinesis or aneurysm.
204. In low-risk patients with lone atrial fibrillation, warfarin anticoagulation is not required. Aspirin or no therapy is recommended.
205. A systolic murmur, an S3 gallop, and mild peripheral edema are normal findings during pregnancy.
206. In the absence of significant mitral regurgitation, primary mitral valve prolapse has a benign prognosis.
207. Antibiotic prophylaxis for endocarditis is indicated in mitral valve prolapse if there is more than mild mitral regurgitation, if a murmur is heard on auscultation, or if the patient has high-risk echocardiographic features.
208. Initial management of acute coronary syndrome related to a systemic process, such as anemia, is treatment of the precipitating factor.
209. Medical therapy for NSTEMI in patients with TIMI low-risk status has acceptable outcomes.
210. Patients with atrial fibrillation and risk factors for stroke require anticoagulation with warfarin.
211. Risk factors for stroke in nonrheumatic atrial fibrillation include prior embolic event or stroke, hypertension, advanced age, congestive heart failure, coronary artery disease, and diabetes mellitus.
212. β-blockers should not be initiated in heart failure patients who are acutely decompensated or volume overloaded.
213. Patients with atrial fibrillation and minimal symptoms can usually be managed with rate control alone (without rhythm control).
214. Echocardiography is indicated when a new murmur, a systolic murmur ≥grade 3/6, or any diastolic murmur is heard.
215. Physiologic valvular regurgitation does not pose a risk of endocarditis and does not require antibiotic prophylaxis.
216. Antibiotic prophylaxis for endocarditis is tailored to the risk of the procedure and the risk of the patient.
217. Although pericardiectomy is the most effective treatment for constrictive pericarditis, it is unnecessary in patients with early disease.
218. Atrial flutter is characterized by saw-tooth pattern flutter waves most noticeable in the inferior leads.
219. The preferred treatment for recurrent atrial flutter is radiofrequency catheter ablation.
220. Aspirin-allergic patients with ST-elevation myocardial infarction can be treated with clopidogrel as part of postinfarction medical therapy.
221. Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.
222. Patients with STEMI should undergo coronary reperfusion in the most expeditious manner.
223. STEMI patients who cannot be reperfused by direct coronary intervention within 90 to 120 minutes should receive fibrinolytic therapy if there are no contraindications.
224. The decision to implant a pacemaker for sinus node dysfunction depends on the presence of symptoms rather than heart rate alone.
225. Subacute cardiac tamponade may be caused by acute viral pericarditis.
226. Echocardiography is a useful diagnostic modality for the delineation of pericardial hemodynamics.
227. ¢ Papillary muscle dysfunction or rupture should be suspected in patients with clinical signs of acute mitral regurgitation in the setting of a myocardial infarction.
228. ¢ An echocardiogram should be performed if papillary muscle dysfunction is suspected.
229. ¢ Mitral regurgitation due to papillary muscle dysfunction often improves following coronary revascularization
230. Syncope in a patient with cardiomyopathy may be due to potentially fatal ventricular arrhythmia.
231. An ICD is indicated for patients with left ventricular dysfunction and hemodynamically significant ventricular arrhythmias.
232. Coronary artery bypass grafting improves survival in patients with obstructive left main and/or multivessel coronary artery disease.
233. Coronary artery bypass grafting improves survival in comparison to percutaneous intervention in diabetic patients with multivessel coronary artery disease.
234. Atrioventricular nodal re-entrant tachycardia is characterized by a narrow QRS complex and lack of visible P waves.
235. The first treatment of choice for atrioventricular tachycardia is carotid sinus massage.
236. If carotid sinus massage is unsuccessful, adenosine is the drug of choice for the termination of narrow-complex supraventricular tachycardias.
237. The murmur of hypertrophic cardiomyopathy increases after a Valsalva maneuver and decreases after a sit-to-squat maneuver, performing passive recumbent leg lifts, or performing handgripping exercises.
238. Ascending aortic dissection may involve the coronary arteries, most commonly the right coronary artery.
239. Ascending aortic dissection may lead to disruption of the aortic valve, leading to aortic regurgitation.
240. Noonan syndrome is characterized by short stature, intellectual impairment, unique facial features, neck webbing, and congenital heart defects.
241. Noonan syndrome should always be considered in a patient with pulmonary valve stenosis.
242. The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory medication, such as indomethacin.
243. Anticoagulation therapy is contraindicated in pericarditis because of the risk of hemopericardium.
244. Perioperative β blockade decreases cardiovascular risk in patients undergoing noncardiac surgery.
245. Hypertension (blood pressure >180/110 mm Hg) is a relative contraindication to fibrinolysis in patients with STEMI.
246. Revascularization should proceed expeditiously with concomitant medical therapy for hypertension complicating STEMI.
247. Restrictive cardiomyopathy is a late complication of radiation therapy.
248. A normal left ventricular wall thickness in radiation-induced restrictive cardiomyopathy helps to differentiate this entity from other cardiomyopathies characterized by ventricular hypertrophy.
249. In asymptomatic patients with chronic aortic regurgitation, surgery should be considered when left ventricular ejection fraction drops below 60% or the left ventricular systolic dimension reaches 55 mm.
250. In asymptomatic patients with aortic regurgitation, nifedipine may delay the timing of surgical intervention.
251. Aortic coarctation is associated with a continuous murmur (often posterior thorax) and elevated but equal blood pressure in both upper extremities.
252. A bicuspid aortic valve is often seen in association with aortic coarctation, presenting with aortic regurgitation or aortic stenosis.
253. Physical findings of mitral regurgitation include holosystolic murmur at the apex radiating to the axilla, without respiratory variation.
254. In healthy adults, premature ventricular contractions are common and are not a cause for concern.
255. Suppression of premature ventricular contractions is indicated only in patients with severe and disabling symptoms.
256. Smoking, hypertension, advanced age, and male sex are risk factors for abdominal aortic aneurysm.
257. Most abdominal aortic aneurysms are asymptomatic, but abdominal pain is the most common symptom.
258. Patients at high risk for a subsequent coronary event after a myocardial infarction include those with multivessel coronary artery disease, anterior myocardial infarction, or a left ventricular ejection fraction 0.5 cm/year) increase in aneurysm size.
307. Severe hemolytic anemia in a patient with a mechanical valve suggests paravalvular leakage due to partial dehiscence of the valve or infection.
308. Prosthetic valve dehiscence or dysfunction should be suspected in patients that develop symptoms of congestive heart failure, particularly if these symptoms occur in the first 6 months following surgery.
309. Right ventricular infarction is a cause of hypotension following inferior infarction and typically requires appropriate volume infusion.
310. Right ventricular infarction should be suspected as a cause of hypotension when findings of right heart failure coincide with an absence of evidence of pulmonary congestion.
311. Implantation of a cardioverter-defibrillator is an important prophylactic treatment in patients with hypertrophic cardiomyopathy and high risk for sudden death.
312. Clinical features that predict high risk for sudden death in patients with hypertrophic cardiomyopathy include family history of sudden death, syncope, marked left ventricular septal hypertrophy, nonsustained ventricular tachycardia, and exertional hypotension.
313. Papillary muscle rupture and ventricular septal defect are recognized mechanical complications that occur early after myocardial infarction.
314. Both papillary muscle rupture and ventricular septal defect present with hypotension and acute dyspnea.
315. Annual echocardiography is appropriate in a patient with asymptomatic severe mitral regurgitation.
316. The timing of surgery for severe mitral regurgitation is based on symptoms and measures of left ventricular size and systolic function.
317. Classic features of Marfan's syndrome includes tall stature, high arched palate, joint hypermobility, scoliosis, and positive œwrist sign.
318. Patients with Marfan's syndrome are at increased risk for asymptomatic thoracic aortic aneurysm and associated aortic valve incompetence.
319. Intravenous amiodarone is the drug of choice for shock-resistant ventricular fibrillation.
320. The risk of coronary artery disease in diabetic patients is 2 to 4 times higher than in nondiabetic patients.
321. The pretest likelihood of disease should be calculated using available algorithms in patients with coronary risk factors.
322. In patients with chest pain and intermediate risk of coronary artery disease, non-invasive testing is indicated.
323. Patients with chest pain and low coronary artery disease risk with a normal electrocardiogram and a normal exercise electrocardiogram can be discharged without coronary angiography.
324. Although uncommon, left atrial myxoma should be considered in young patients with embolic stroke.
325. Echocardiography is an important imaging modality for diagnosis of an intracardiac tumor.
326. Women with Marfan syndrome are at increased risk of aortic dissection during pregnancy.
327. Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy.
328. The tachycardia rate in atrioventricular nodal reentrant tachycardia is typically 160“180/min with the P wave buried in the QRS complex.
329. ¢ If atrioventricular nodal reentrant tachycardia does not respond to vagal maneuvers, adenosine is the treatment of choice
330. Continuous effective anticoagulation is needed throughout pregnancy in women with mechanical heart valves.
331. Radiofrequency catheter ablation is the most effective treatment for atrioventricular nodal reentrant tachycardia.
332. Calcium-channel blockers may be used for prophylaxis of recurrent atrioventricular nodal reentrant tachycardia but are less effective than radiofrequency catheter ablation.
333. The cardiac output is low in primary cardiogenic shock, and inotropic agents may be needed to augment myocardial contractility and thus cardiac output.
334. Exercise (or pharmacologic) stress testing is the most sensitive noninvasive method to establish the diagnosis of coronary artery disease.
335. Exercise (or pharmacologic) stress cardiac imaging can be used to evaluate for coronary artery disease if the resting electrocardiogram is abnormal.
336. The role of electron-beam CT coronary calcium scores is not yet established in the assessment of coronary artery disease.
337. Prolonged immobility followed by a stroke or transient ischemic attack should raise the suspicion of a paradoxical embolism.
338. Transesophageal echocardiography is the test of choice to confirm the diagnosis of a suspected patent foramen ovale or cardiac source of embolus.
339. ¢ Systemic lupus erythematosus is a cause of premature atherosclerotic coronary disease.
340. ¢ Other causes of acute myocardial infarction in young persons include coronary spasm, embolic coronary occlusion, and Kawasaki's disease.
341. High risk patients that require a heparin anticoagulation bridge after stopping warfarin prior to surgery include those with a mitral mechanical valve, atrial fibrillation, or previous embolism.
342. Low risk patients do not require a heparin bridge after stopping warfarin prior to surgery and include patients with a bileaflet aortic valve and no other high risk features.
343. Aspirin alone is not a sufficient replacement for warfarin, and is used only as a chronic adjunct in patients who manifest systemic emboli despite therapeutic warfarin therapy.
344. Radial-femoral delay is a characteristic physical finding in aortic coarctation.
345. Bicuspid aortic valves are common in patients with aortic coarctation and are associated with a systolic ejection click and systolic murmur noted over the aortic area.
346. Elevated B-type natriuretic peptide levels occur with renal failure, acute coronary syndrome or myocardial infarction, and acute volume or pressure overload.
347. Adenosine is the treatment of choice for narrow-complex tachycardia.
348. Neither adenosine nor other atrioventricular nodal blocking agents should be given to patients with preexcited tachycardias.
349. Procainamide is the drug of choice for wide-complex tachycardia of unclear etiology.
350. Coronary angiography is indicated in patients with a history of unstable angina or non-ST-elevation myocardial infarction.
351. In patients with a high pretest probability of coronary artery disease, a negative stress test result is most likely to be false.
352. Spinal stenosis is characterized by pain with standing or walking that is relieved by sitting or bending forward and is further supported by a normal ABI.
353. Leg ischemia is characterized by pain with exertion and with a decrease in ABI of at least 20 % with exercise.
354. The use of angiotensin-converting enzyme inhibitors should be avoided during pregnancy.
355. Hydralazine and nitrates are the vasodilators of choice to treat heart failure during pregnancy.
356. Induction of mild hypothermia improves outcomes in comatose survivors of out-of-hospital cardiac arrest.
357. Aortic valve replacement is recommended once symptom onset occurs, regardless of patient age.
358. Symptom onset in aortic stenosis is often insidious and may include exertional dyspnea.
359. Alcoholic cardiomyopathy is a dilated cardiomyopathy.
360. Therapy for alcoholic cardiomyopathy must include total abstinence from alcohol.
361. In chronic angina, coronary artery bypass graft surgery is indicated for patients refractory to medical therapy; a large area of ischemic myocardium; high-risk coronary anatomy; and reduced left ventricular systolic function.
362. Atrial tachycardia with variable block is a classic electrocardiographic finding in digitalis toxicity.
363. The first-line treatment for life-threatening digitalis toxicity is administration of digoxin-specific antibody fragments.
364. Iron deficiency is a common cause for dyspnea and fatigue in patients with cyanotic heart disease.
365. The most common cause of iron deficiency in patients with cyanotic heart disease is recurrent phlebotomy.
366. Mitral valve surgery is indicated for symptomatic patients with chronic, severe mitral regurgitation.
367. In asymptomatic patients with chronic, severe mitral regurgitation, criteria for mitral valve surgery include an end-systolic dimension >45 mm, an end-diastolic dimension >60 mm, and an ejection fraction
MKSAP 14 neurology notes:
1. A spinal cord disorder should be considered in any patient with bilateral motor and sensory dysfunction in the extremities in the absence of signs or symptoms of brain or brainstem dysfunction.
2. Spinal cord compression due to epidural metastasis is a neurologic emergency for which urgent MRI of the entire spine is appropriate.
3. Vertebral artery dissection typically presents with neck or head pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperature sensation, dysmetria, ataxia, and vertigo.
4. Magnetic resonance angiography is a sensitive diagnostic test for vertebral artery dissection as a cause of stroke.
5. Juvenile myoclonic epilepsy is a primary, genetic, generalized epilepsy that typically manifests with myoclonic jerks followed by a generalized tonic“clonic seizure
6. Guillain“Barré syndrome is characterized by proximal and distal weakness, autonomic symptoms, cranial nerve involvement, and respiratory failure.
7. Treatment of Guillain“Barré syndrome with either intravenous immunoglobulin or plasmapheresis is indicated in patients who cannot walk independently or who have impaired respiratory function or rapidly progressive weakness.
8. Small, stable, asymptomatic meningiomas can be followed with serial neuroimaging.
9. In large, symptomatic, or progressive meningiomas, surgical resection offers an 80% chance of cure.
10. Personality change, lost initiative, and slowing of thought, with relative preservation of recent memory, suggest frontotemporal dementia.
11. Frontotemporal dementia is usually associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding that is usually clearly demonstrated on MRI.
12. Elevation of the cerebrospinal fluid 14-3-3 protein in a patient with rapidly progressive dementia and normal structural imaging suggests Creutzfeldt“Jakob disease.
13. Treatment with interferon-beta decreases the incidence of additional attacks in patients with monosymptomatic demyelination, including optic neuritis and myelopathy.
14. Propranolol and primidone are first-line drugs in the treatment of essential tremor (postural and action tremor).
15. The diagnosis of Parkinson's disease requires the presence of at least two of the following: tremor at rest, bradykinesia, rigidity, and postural reflex abnormality.
16. The characteristics of migraine headache without aura include worsening of the headache with movement, limitation of activities, and photo- and phonophobia
17. Transverse myelitis is an acute or subacute demyelinative or inflammatory disorder of the spinal cord that causes motor, sensory, and autonomic dysfunction below a spinal cord level.
18. High-dose intravenous corticosteroids are indicated for initial treatment of acute transverse myelitis.
19. Secondary prevention of cardioembolic stroke consists of warfarin with a target INR of 2.0 to 3.0.
20. Heparin has no established role in the acute treatment of stroke.
21. The manifestations of partial seizures depend on their neuroanatomic location.
22. Frontal seizures are brief and are usually not associated with aura or postictal confusion.
23. Hereditary sensorimotor neuropathy is an autosomal dominant disorder that usually presents with clumsiness or difficulty running in the first decade of life.
24. Hereditary sensorimotor neuropathy is characterized by distal muscle atrophy, weakness, and sensory loss associated with high arches (pes cavus) and hammertoes
25. Cell type and tumor grade are the most important determinants of survival in glioma.
26. Higher-grade gliomas are more aggressive than lower grade.
27. Alzheimer's disease is characterized by primary dementia with prominent amnesia.
28. Dementia with Lewy bodies, characterized by fluctuating cognition, parkinsonism, and/or visual hallucinations, often coexists with Alzheimer's disease.
29. All patients with relapsing multiple sclerosis should be considered for immunomodulatory therapy with either a form of interferon-beta or glatiramer acetate.
30. Adult-onset idiopathic dystonia is usually focal or segmental and does not generalize to other parts of the body.
31. Botulinum toxin injections can correct the abnormal posture and alleviate the pain associated with cervical dystonia.
32. Approximately 20% of patients with migraine have headache with aura, that is, neurologic problems such as visual hallucinations or numbness or tingling before or during headache.
33. Lhermitte's sign, an œelectric shock“like sensation down the neck, back, or extremities occurring with neck flexion, is a helpful historical clue to a cervical spinal cord disorder.
34. Cervical spondylosis is a chronic disorder of degenerative and hypertrophic changes of the vertebrae, ligaments, and disks that may narrow the spinal canal and cause cervical spinal cord compression.
35. In patients with stroke not eligible for thrombolytic therapy, aspirin modestly reduces both the short-term risk of recurrent stroke and the long-term risk of stroke-related death and disability.
36. In patients with acute stroke, thrombolytic therapy must be started within 3 hours of the onset of symptoms or of the time the patient was last known to be well.
37. Elderly patients may be particularly sensitive to the cognitive, motor, and coordination side effects of phenytoin, even if the serum phenytoin level is in the therapeutic range.
38. Gabapentin, lamotrigine, and carbamazepine are equally effective at controlling partial onset seizures in the elderly, but gabapentin and lamotrigine are better tolerated.
39. Peripheral nervous system vasculitis usually presents with asymmetric weakness and sensory loss in specific nerve distributions.
40. In an elderly patient with recurrent glioblastoma and poor performance status, referral for hospice care is preferable to additional antitumor treatment.
41. The three specific criteria for dementia with Lewy bodies are fluctuating encephalopathy, parkinsonism, and visual hallucinations.
42. A centrally acting anticholinesterase agent may alleviate the inattention, hallucinations, and fluctuating encephalopathy of dementia with Lewy bodies.
43. Women taking immunomodulatory treatment for multiple sclerosis should use effective contraception, or if they want to become pregnant, stop therapy several months before attempting to conceive.
44. Involuntary brief, irregular, unpredictable movements fleeting from one body part to another are hallmarks of chorea.
45. Chorea can occur as a hereditary and degenerative disease or secondary to drugs, metabolic disorders, infections, immune-mediated diseases, and vascular lesions.
46. Tension-type headache is distinguished from migraine by the fact that patients with tension headache are not disabled and can carry out activities of daily living in a normal, expedient manner.
47. Vitamin B12 deficiency can cause dysfunction of the posterior columns and corticospinal tracts of the spinal cord, causing paresthesias, loss of vibration and position sense, sensory ataxia, weakness, and upper motor neuron signs.
48. Neurologic signs of vitamin B12 deficiency may manifest in the absence of hematologic signs of vitamin B12 deficiency.
49. In a patient with a transient ischemic attack, carotid artery ultrasonography showing a >50% stenosis of the internal carotid artery may be an indication for carotid endarterectomy.
50. A single antiepileptic drug should be used in pregnant women with epilepsy; multiple drug therapy increases the risk for birth defects.
51. Chronic inflammatory demyelinating polyneuropathy, the chronic form of Guillain“Barré syndrome, is characterized by proximal and distal weakness, areflexia, and distal sensory loss.
52. Chronic inflammatory demyelinating polyneuropathy progresses in a stepwise or relapsing course for at least 8 weeks and can occur early in the course of HIV infection.
53. In a young patient with totally resected low-grade glioma, postsurgical management consists of observation with serial neuroimaging.
54. Vascular dementia is suggested by a history of vascular risk factors, abrupt onset with subsequent improvement, periventricular white matter ischemia on imaging, and focal neurologic findings.
55. Intravenous methylprednisolone therapy followed by an oral prednisone taper speeds recovery of visual acuity in optic neuritis
56. The restless legs syndrome consists of abnormal sensations in the legs and restlessness relieved by movement.
57. Patients are at risk for developing analgesic overuse headache if they use prescription or over-the-counter medication for headache more than 2 days a week.
58. Pseudotumor cerebri is characterized by papilledema, postural change with headache, visual changes, recent report of rapid weight gain, or introduction of oral contraceptives or tetracycline.
59. Infarction of the spinal cord typically presents as sudden spinal cord dysfunction.
60. Spinal cord infarction usually affects the territory of the anterior spinal artery, causing weakness and pinprick loss of sensation with sparing of vibration and position sense.
61. CT scan may miss subarachnoid hemorrhage, especially when there is a delay in presentation after the initial hemorrhage.
62. Focal neurologic symptoms 3 to 7 days after a subarachnoid hemorrhage may be due to vasospasm with cerebral ischemia.
63. Patients with epilepsy who are most likely to remain seizure free after medication withdrawal are those with no structural brain lesion, no epileptiform or focal abnormalities on electroencephalogram, a sustained seizure-free period, and no abnormalities on neurologic examination.
64. Patients with epilepsy who discontinue antiepileptic medication should stop driving for at least 3 months and preferably 6 months from the start of the taper.
65. Critical illness polyneuropathy is a common cause of failure to wean from a ventilator in a patient with associated multiorgan failure and sepsis.
66. Critical illness polyneuropathy is characterized by generalized or distal flaccid paralysis, depressed or absent reflexes, and distal sensory loss with sparing of cranial nerve function.
67. Patients with primary central nervous system lymphoma should be evaluated for vitreal or uveal involvement before therapy is begun.
68. Aggressive resection is not recommended in primary central nervous system lymphoma; methotrexate chemotherapy is primary therapy.
69. Donepezil, an acetylcholinesterase inhibitor, may cause mild peripheral cholinergic side effects, including increased vagal tone, with bradycardia, and occasionally atrioventricular block.
70. In at least 50% of patients with relapsing“remitting multiple sclerosis, disease will evolve to a secondary progressive course.
71. In at least 50% of patients with relapsing“remitting multiple sclerosis, disease will evolve to a secondary progressive course.
72. Metoclopramide, which blocks dopamine receptors both in the periphery and inside the central nervous system, can induce parkinsonism.
73. Prednisone is the most appropriate treatment for episodic cluster headache.
74. Acute cervical spinal cord compression due to hyperextension injury is common in elderly patients.
75. Emergent MRI of the cervical spinal cord is indicated in any patient with quadriparesis after a fall.
76. The classic symptoms of cerebellar stroke are headache, vertigo, and ataxia.
77. Patients with epilepsy who fail to respond to three trials of antiepileptic drugs are unlikely to ever become seizure free with drug therapy.
78. Treatment-resistant patients with epilepsy should be evaluated for a surgically remediable epilepsy syndrome.
79. Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, which results in impaired neuromuscular transmission.
80. Myasthenia gravis is characterized by fatigable weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles.
81. Leptomeningeal spread of systemic carcinoma manifests as a cranial neuropathy or spinal polyradiculopathy, or as encephalopathy, diffuse brain infiltration, or communicating hydrocephalus.
82. Creutzfeldt“Jakob disease is suggested by subacute progression of dementia with myoclonus and other motor signs and a normal brain MRI.
83. In the setting of subacutely progressive dementia, the presence of 14-3-3 protein in cerebrospinal fluid, or electroencephalography showing periodic sharp waves, can be diagnostic of Creutzfeldt“Jakob disease.
84. Mitoxantrone therapy is of modest benefit in slowing progression of secondary progressive or severe relapsing“remitting multiple sclerosis.
85. The primary concern about mitoxantrone therapy is the risk for cardiotoxicity.
86. Progressive supranuclear palsy is characterized by parkinsonism with early gait and balance involvement, vertical gaze palsy, severe dysarthria, and dysphagia.
87. Normal pressure hydrocephalus is characterized by the classic triad of gait impairment, cognitive decline, and urinary incontinence.
88. Patients with idiopathic intracranial hypertension present with signs and symptoms of increased intracranial pressure without a mass lesion on brain imaging.
89. In patients with possible idiopathic intracranial hypertension, a diagnostic and potentially therapeutic lumbar puncture is indicated after brain imaging excludes a mass lesion.
90. Severe cerebral anoxia from cardiac arrest can cause severe diffuse cerebral hemispheric cortical injury with relative preservation of brainstem function, leading to the development of a vegetative state.
91. A vegetative state is a condition of complete unawareness of self or the environment, accompanied by sleep“wake cycles and preservation of brainstem and hypothalamic functions.
92. Intracerebral hemorrhage with extensive subarachnoid hemorrhage is the hallmark of a ruptured arteriovenous malformation.
93. Conventional angiography is the definitive diagnostic procedure for detecting arteriovenous malformations and berry aneurysms.
94. In a patient with status epilepticus, after the airway is stabilized and plasma glucose determined to be normal, parenteral antiepileptic medications should be started.
95. Lorazepam is the preferred benzodiazepine for initial therapy for a patient in status epilepticus.
96. Myasthenia gravis crisis is characterized by dysphagia requiring nasogastric feeding and/or severe respiratory muscle weakness necessitating ventilation.
97. Myasthenia gravis crisis is treated with either plasmapheresis or intravenous immunoglobulin.
98. Radiation-induced leukoencephalopathy is a subcortical process affecting white matter and characterized by the triad of gait apraxia, dementia, and urinary incontinence.
99. Radiation-induced leukoencephalopathy may occur months to years after radiation and is more common after whole-brain compared with focal brain irradiation.
100. Mild cognitive impairment consists of isolated mild amnesia with no impairment of interpersonal, occupational, or daily living activities.
101. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year.
102. Amantadine is the first-line pharmacologic agent for treatment of multiple sclerosis-related fatigue.
103. Multiple system atrophy is characterized by orthostatic hypotension, neurogenic bladder, constipation, and impotence, with gait-predominant parkinsonism and corticospinal tract signs.
104. Carbamazepine is the appropriate treatment for trigeminal neuralgia.
105. Patients with the locked-in syndrome are quadriplegic, have paralysis of horizontal eye movements and bulbar muscles, and can communicate only by moving their eyes vertically or blinking.
106. The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion.
107. Antiplatelet therapy, statins, and ACE inhibitors each reduce the risk of recurrent stroke even in the absence of chronic hypertension or a lipid disorder.
108. Headache may be a limiting factor in the use of the combination of aspirin and extended-release dipyridamole for secondary stroke prevention.
109. Nonepileptic seizures of psychogenic origin can be differentiated from epilepsy by their longer duration, normal electroencephalogram findings, and maintenance of consciousness.
110. Nonepileptic psychogenic seizures are often associated with moaning, crying, and arrhythmic shaking of the body.
111. Absence seizures are characterized by a brief loss of awareness with no movement or very subtle movements of the lips and fingers.
112. Juvenile myoclonic epilepsy is characterized by myoclonic seizures and often accompanied by absence and generalized tonic“clonic seizures.
113. Amyotrophic lateral sclerosis is characterized by pathologic hyperreflexia, spasticity, extensor plantar responses, along with atrophy, fasciculations, and weakness.
114. Muscle weakness in amyotrophic lateral sclerosis usually begins distally and asymmetrically in the upper or lower extremities or may be limited initially to the bulbar muscles, resulting in dysarthria and dysphagia.
115. Surgical resection is indicated for an accessible solitary brain metastasis in patients with limited or no systemic tumor.
116. Cholinesterase inhibitors have modest efficacy on cognitive and global function in mild to moderate Alzheimer's disease.
117. Vitamin E and selegiline may delay the progression of Alzheimer's disease, but do not alleviate cognitive or psychiatric symptoms.
118. In patients with possible multiple sclerosis, new MRI white-matter lesions or new gadolinium-enhancing lesions on serial brain or spinal cord MRI at least 3 months after an initial scan, indicate dissemination of demyelination, even without a new clinically evident attack.
119. Carbidopa-levodopa is the first-line treatment for patients older than 70 years with new-onset Parkinson's disease.
120. Complications associated with the use of dopamine agonists, such as somnolence, drug-induced psychosis, and dizziness, are more common in patients older than 70 years.
121. The risk of rupture of a small intracranial aneurysm is less than the risk of complications with clipping or endovascular coiling of the aneurysm.
122. Incidentally discovered small aneurysms should be re-evaluated periodically for enlargement.
123. Oxcarbazepine is effective monotherapy for partial onset seizures.
124. Risk factors for recurrent seizures include multiple previous seizures, a history of significant head trauma, focal electroencephalogram abnormalities, and structural abnormality on MRI.
125. Amyotrophic lateral sclerosis causes progressive respiratory muscle weakness that may present with supine dyspnea, frequent arousals, daytime fatigue, or morning headache.
126. Noninvasive positive-pressure ventilation should be started in patients with amyotrophic lateral sclerosis whose forced vital capacity is less than 50% or who has symptoms of nocturnal hypoventilation.
127. Neurologic symptoms in conjunction with normal brain imaging and the detection of a systemic cancer are most likely due to an immune-mediated paraneoplastic neurologic syndrome.
128. Memantine may alleviate cognitive symptoms and improve global function in moderate to severe Alzheimer's disease when added to cholinesterase inhibitor therapy.
129. Estrogen replacement in post-menopausal women with Alzheimer's dementia has not been shown to alleviate cognitive symptoms or delay disease progression.
130. Drug-induced psychosis in Parkinson's disease consists primarily of visual hallucinations, evolving at times into paranoid-type delusions.
131. Infection with fever can temporarily exacerbate a chronic neurologic defect in a patient with a previous stroke.
132. Partial complex epilepsy consists of stereotyped nonconvulsive seizures with loss of awareness and amnesia for events.
133. Myotonic dystrophy is an autosomal dominant disorder that presents with distal weakness and muscle stiffness and is characterized by cataracts, frontal balding, temporal muscle atrophy, and cognitive dysfunction.
134. Cardiac disease resulting in arrhythmias and respiratory failure due to diaphragmatic weakness are common features of myotonic dystrophy.
135. Lambert-Eaton myasthenic syndrome is characterized by symmetrical proximal muscle weakness and autonomic dysfunction.
136. Lambert-Eaton myasthenic syndrome is diagnosed by motor nerve conduction studies with repetitive stimulation.
137. Cognitive impairment accompanied by fluctuating lethargy and inattention, hallucinations, and asterixis is likely the result of a toxic encephalopathy.
138. Drugs that block dopamine receptors can induce acute dystonic reactions.
139. In acute ischemic stroke, tissue plasminogen activator is indicated if therapy is started within 3 hours of onset of symptoms, there is no hemorrhage on CT scan, and all other eligibility criteria are met.
140. All states require that an episode of loss of awareness be reported to government authorities, either to the Department of Health or to the Department of Motor Vehicles.
141. Hypothyroid myopathy is characterized by muscle pain, cramps, stiffness, fatigue, and paresthesias.
142. In hypothyroid myopathy, creatine kinase levels may be 10 to 100 times normal, but thyroid function tests should be performed before electromyography or muscle biopsy.
143. Paraneoplastic limbic encephalitis is most commonly associated with small-cell lung cancer.
144. Paraneoplastic limbic encephalitis is characterized by rapidly progressive decline in short-term memory and seizures.
145. The most common heritable form of Alzheimer's disease results from a mutation in presenilin-1.
146. Testing for presenilin-1 may be useful when a heritable form of Alzheimer's disease is suspected.
147. CT scan of the brain is indicated to diagnose suspected intracerebral hemorrhage.
148. Head trauma increases the relative risk for epilepsy by 10 only if there is penetration of the dura or loss of consciousness for more than 30 minutes.
149. Critical illness myopathy is common in ventilator-dependent patients who have been treated with corticosteroids and neuromuscular blocking agents.
150. Critical illness myopathy is characterized by ventilator dependence, generalized or proximal flaccid paralysis, muscle atrophy, and high creatine kinase levels.
151. Primary impairment of concentration and attention, as opposed to memory, is likely the result of depression rather than a neurodegenerative condition.
152. Carotid endarterectomy is the appropriate intervention in patients with symptomatic carotid artery stenosis, especially within the first few weeks after initial symptoms.
153. Depression is a possible side effect of many antiepileptic drugs, including phenobarbital, phenytoin, valproate, levetiracetam, and topiramate.
154. Selective serotonin reuptake inhibitors, moclobemide, venlafaxine, and nefazodone do not increase the seizure threshold in patients with epilepsy and therefore are the preferred pharmacologic agents in depression.
155. Polymyositis is characterized by proximal muscle weakness, elevated creatine kinase levels, and needle electromyography showing diffuse fibrillations and myopathic motor unit potentials.
156. Results of creatine kinase measurement and needle electromyography are invariably normal in steroid myopathy but abnormal in inflammatory myopathy.
157. Antiplatelet therapy is the mainstay of secondary stroke prevention in patients with cryptogenic stroke.
158. Clopidogrel is the preferred antiplatelet therapy for aspirin-allergic patients with a history of stroke
Cardiology Notes:
160. Right ventricular infarction should be suspected in patients with inferior myocardial infarction who present with hypotension, clear lung fields, and elevated jugular venous pressure.
161. An echocardiogram establishes the diagnosis of right ventricular infarction by demonstrating right ventricular enlargement and hypokinesis.
162. Implantable cardioverter-defibrillator therapy reduces risk of sudden death in survivors of cardiac arrest due to ventricular tachycardia or ventricular fibrillation without a reversible cause.
163. Spontaneous coronary dissection may occur during pregnancy.
164. In patients with ST-elevation myocardial infarction, successful fibrinolysis is suggested by resolution of chest pain and ST-segment elevation and/or transient ventricular arrhythmias early after reperfusion.
165. In patients with ST-elevation myocardial infarction, reperfusion arrhythmias, typically manifested as a transient accelerated idioventricular arrhythmia, usually do not require additional antiarrhythmic therapy.
166. Thrombosis of mechanical valves may present with valve dysfunction rather than embolic events.
167. Intravenous heparin should be started immediately while diagnostic evaluation is in progress.
168. Chest CT scan with contrast is indicated to detect acute aortic dissection.
169. In patients at risk for radiocontrast nephropathy and contraindication to MRI, transesophageal echocardiography is the test of choice for possible aortic dissection.
170. Breast and lung carcinoma are the most common causes of malignant pericardial disease.
171. The epicardium is the most common location of metastatic cardiac neoplasm.
172. An ACE inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients.
173. Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.
174. Fixed splitting of the S2 is the auscultatory hallmark of atrial septal defect.
175. A divergence between electrocardiography showing low-voltage and echocardiography demonstrating a substantial increase in left ventricular wall thickness is a useful diagnostic clue for cardiac amyloidosis.
176. Abdominal fat aspiration biopsy is a safe and reasonably sensitive test for the diagnosis of amyloidosis.
177. Physical examination is helpful is identifying the presence, but not the severity, of valve disease.
178. The most sensitive sign on physical examination to exclude the diagnosis of severe aortic stenosis is a physiologically split S2.
179. Most patients with peripheral vascular disease have an ABI grade 3/6 in intensity, continuous murmurs, or any diastolic murmur.
192. Surgery for native valve endocarditis is indicated if there is significant hemodynamic instability or evidence of paravalvular extension.
193. Factors favoring earlier timing of surgery include significant congestive heart failure, resistant infections, and large mobile vegetations.
194. Even if active bacteremia is still present or if the antibiotic treatment course is ongoing, surgery for endocarditis should not be delayed if surgical criteria are met.
195. Medical therapy for acute, recent myocardial infarction includes β-blockers, aspirin, angiotensin-converting enzyme inhibitors, and statins.
196. Smoking cessation is the single most effective intervention for patients with peripheral vascular disease.
197. β blockade does not promote clinical claudication.
198. Cilostazol is relatively contraindicated in patients with congestive heart failure.
199. Patients with heart failure who have severe symptoms and evidence for ventricular dyssynchrony benefit from implantation of a biventricular pacemaker.
200. Biventricular pacing improves cardiac performance and quality of life and may also improve survival.
201. Glycoprotein receptor blockade is indicated for patients with acute coronary syndrome who will undergo coronary angiography and intervention.
202. Patients with ST-elevation myocardial infarction treated with stents require aspirin and clopidogrel at discharge.
203. Patients with ST-elevation myocardial infarction treated without stents may be managed with aspirin alone or with warfarin if indicated for atrial fibrillation or anterior akinesis or aneurysm.
204. In low-risk patients with lone atrial fibrillation, warfarin anticoagulation is not required. Aspirin or no therapy is recommended.
205. A systolic murmur, an S3 gallop, and mild peripheral edema are normal findings during pregnancy.
206. In the absence of significant mitral regurgitation, primary mitral valve prolapse has a benign prognosis.
207. Antibiotic prophylaxis for endocarditis is indicated in mitral valve prolapse if there is more than mild mitral regurgitation, if a murmur is heard on auscultation, or if the patient has high-risk echocardiographic features.
208. Initial management of acute coronary syndrome related to a systemic process, such as anemia, is treatment of the precipitating factor.
209. Medical therapy for NSTEMI in patients with TIMI low-risk status has acceptable outcomes.
210. Patients with atrial fibrillation and risk factors for stroke require anticoagulation with warfarin.
211. Risk factors for stroke in nonrheumatic atrial fibrillation include prior embolic event or stroke, hypertension, advanced age, congestive heart failure, coronary artery disease, and diabetes mellitus.
212. β-blockers should not be initiated in heart failure patients who are acutely decompensated or volume overloaded.
213. Patients with atrial fibrillation and minimal symptoms can usually be managed with rate control alone (without rhythm control).
214. Echocardiography is indicated when a new murmur, a systolic murmur ≥grade 3/6, or any diastolic murmur is heard.
215. Physiologic valvular regurgitation does not pose a risk of endocarditis and does not require antibiotic prophylaxis.
216. Antibiotic prophylaxis for endocarditis is tailored to the risk of the procedure and the risk of the patient.
217. Although pericardiectomy is the most effective treatment for constrictive pericarditis, it is unnecessary in patients with early disease.
218. Atrial flutter is characterized by saw-tooth pattern flutter waves most noticeable in the inferior leads.
219. The preferred treatment for recurrent atrial flutter is radiofrequency catheter ablation.
220. Aspirin-allergic patients with ST-elevation myocardial infarction can be treated with clopidogrel as part of postinfarction medical therapy.
221. Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.
222. Patients with STEMI should undergo coronary reperfusion in the most expeditious manner.
223. STEMI patients who cannot be reperfused by direct coronary intervention within 90 to 120 minutes should receive fibrinolytic therapy if there are no contraindications.
224. The decision to implant a pacemaker for sinus node dysfunction depends on the presence of symptoms rather than heart rate alone.
225. Subacute cardiac tamponade may be caused by acute viral pericarditis.
226. Echocardiography is a useful diagnostic modality for the delineation of pericardial hemodynamics.
227. ¢ Papillary muscle dysfunction or rupture should be suspected in patients with clinical signs of acute mitral regurgitation in the setting of a myocardial infarction.
228. ¢ An echocardiogram should be performed if papillary muscle dysfunction is suspected.
229. ¢ Mitral regurgitation due to papillary muscle dysfunction often improves following coronary revascularization
230. Syncope in a patient with cardiomyopathy may be due to potentially fatal ventricular arrhythmia.
231. An ICD is indicated for patients with left ventricular dysfunction and hemodynamically significant ventricular arrhythmias.
232. Coronary artery bypass grafting improves survival in patients with obstructive left main and/or multivessel coronary artery disease.
233. Coronary artery bypass grafting improves survival in comparison to percutaneous intervention in diabetic patients with multivessel coronary artery disease.
234. Atrioventricular nodal re-entrant tachycardia is characterized by a narrow QRS complex and lack of visible P waves.
235. The first treatment of choice for atrioventricular tachycardia is carotid sinus massage.
236. If carotid sinus massage is unsuccessful, adenosine is the drug of choice for the termination of narrow-complex supraventricular tachycardias.
237. The murmur of hypertrophic cardiomyopathy increases after a Valsalva maneuver and decreases after a sit-to-squat maneuver, performing passive recumbent leg lifts, or performing handgripping exercises.
238. Ascending aortic dissection may involve the coronary arteries, most commonly the right coronary artery.
239. Ascending aortic dissection may lead to disruption of the aortic valve, leading to aortic regurgitation.
240. Noonan syndrome is characterized by short stature, intellectual impairment, unique facial features, neck webbing, and congenital heart defects.
241. Noonan syndrome should always be considered in a patient with pulmonary valve stenosis.
242. The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory medication, such as indomethacin.
243. Anticoagulation therapy is contraindicated in pericarditis because of the risk of hemopericardium.
244. Perioperative β blockade decreases cardiovascular risk in patients undergoing noncardiac surgery.
245. Hypertension (blood pressure >180/110 mm Hg) is a relative contraindication to fibrinolysis in patients with STEMI.
246. Revascularization should proceed expeditiously with concomitant medical therapy for hypertension complicating STEMI.
247. Restrictive cardiomyopathy is a late complication of radiation therapy.
248. A normal left ventricular wall thickness in radiation-induced restrictive cardiomyopathy helps to differentiate this entity from other cardiomyopathies characterized by ventricular hypertrophy.
249. In asymptomatic patients with chronic aortic regurgitation, surgery should be considered when left ventricular ejection fraction drops below 60% or the left ventricular systolic dimension reaches 55 mm.
250. In asymptomatic patients with aortic regurgitation, nifedipine may delay the timing of surgical intervention.
251. Aortic coarctation is associated with a continuous murmur (often posterior thorax) and elevated but equal blood pressure in both upper extremities.
252. A bicuspid aortic valve is often seen in association with aortic coarctation, presenting with aortic regurgitation or aortic stenosis.
253. Physical findings of mitral regurgitation include holosystolic murmur at the apex radiating to the axilla, without respiratory variation.
254. In healthy adults, premature ventricular contractions are common and are not a cause for concern.
255. Suppression of premature ventricular contractions is indicated only in patients with severe and disabling symptoms.
256. Smoking, hypertension, advanced age, and male sex are risk factors for abdominal aortic aneurysm.
257. Most abdominal aortic aneurysms are asymptomatic, but abdominal pain is the most common symptom.
258. Patients at high risk for a subsequent coronary event after a myocardial infarction include those with multivessel coronary artery disease, anterior myocardial infarction, or a left ventricular ejection fraction 0.5 cm/year) increase in aneurysm size.
307. Severe hemolytic anemia in a patient with a mechanical valve suggests paravalvular leakage due to partial dehiscence of the valve or infection.
308. Prosthetic valve dehiscence or dysfunction should be suspected in patients that develop symptoms of congestive heart failure, particularly if these symptoms occur in the first 6 months following surgery.
309. Right ventricular infarction is a cause of hypotension following inferior infarction and typically requires appropriate volume infusion.
310. Right ventricular infarction should be suspected as a cause of hypotension when findings of right heart failure coincide with an absence of evidence of pulmonary congestion.
311. Implantation of a cardioverter-defibrillator is an important prophylactic treatment in patients with hypertrophic cardiomyopathy and high risk for sudden death.
312. Clinical features that predict high risk for sudden death in patients with hypertrophic cardiomyopathy include family history of sudden death, syncope, marked left ventricular septal hypertrophy, nonsustained ventricular tachycardia, and exertional hypotension.
313. Papillary muscle rupture and ventricular septal defect are recognized mechanical complications that occur early after myocardial infarction.
314. Both papillary muscle rupture and ventricular septal defect present with hypotension and acute dyspnea.
315. Annual echocardiography is appropriate in a patient with asymptomatic severe mitral regurgitation.
316. The timing of surgery for severe mitral regurgitation is based on symptoms and measures of left ventricular size and systolic function.
317. Classic features of Marfan's syndrome includes tall stature, high arched palate, joint hypermobility, scoliosis, and positive œwrist sign.
318. Patients with Marfan's syndrome are at increased risk for asymptomatic thoracic aortic aneurysm and associated aortic valve incompetence.
319. Intravenous amiodarone is the drug of choice for shock-resistant ventricular fibrillation.
320. The risk of coronary artery disease in diabetic patients is 2 to 4 times higher than in nondiabetic patients.
321. The pretest likelihood of disease should be calculated using available algorithms in patients with coronary risk factors.
322. In patients with chest pain and intermediate risk of coronary artery disease, non-invasive testing is indicated.
323. Patients with chest pain and low coronary artery disease risk with a normal electrocardiogram and a normal exercise electrocardiogram can be discharged without coronary angiography.
324. Although uncommon, left atrial myxoma should be considered in young patients with embolic stroke.
325. Echocardiography is an important imaging modality for diagnosis of an intracardiac tumor.
326. Women with Marfan syndrome are at increased risk of aortic dissection during pregnancy.
327. Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy.
328. The tachycardia rate in atrioventricular nodal reentrant tachycardia is typically 160“180/min with the P wave buried in the QRS complex.
329. ¢ If atrioventricular nodal reentrant tachycardia does not respond to vagal maneuvers, adenosine is the treatment of choice
330. Continuous effective anticoagulation is needed throughout pregnancy in women with mechanical heart valves.
331. Radiofrequency catheter ablation is the most effective treatment for atrioventricular nodal reentrant tachycardia.
332. Calcium-channel blockers may be used for prophylaxis of recurrent atrioventricular nodal reentrant tachycardia but are less effective than radiofrequency catheter ablation.
333. The cardiac output is low in primary cardiogenic shock, and inotropic agents may be needed to augment myocardial contractility and thus cardiac output.
334. Exercise (or pharmacologic) stress testing is the most sensitive noninvasive method to establish the diagnosis of coronary artery disease.
335. Exercise (or pharmacologic) stress cardiac imaging can be used to evaluate for coronary artery disease if the resting electrocardiogram is abnormal.
336. The role of electron-beam CT coronary calcium scores is not yet established in the assessment of coronary artery disease.
337. Prolonged immobility followed by a stroke or transient ischemic attack should raise the suspicion of a paradoxical embolism.
338. Transesophageal echocardiography is the test of choice to confirm the diagnosis of a suspected patent foramen ovale or cardiac source of embolus.
339. ¢ Systemic lupus erythematosus is a cause of premature atherosclerotic coronary disease.
340. ¢ Other causes of acute myocardial infarction in young persons include coronary spasm, embolic coronary occlusion, and Kawasaki's disease.
341. High risk patients that require a heparin anticoagulation bridge after stopping warfarin prior to surgery include those with a mitral mechanical valve, atrial fibrillation, or previous embolism.
342. Low risk patients do not require a heparin bridge after stopping warfarin prior to surgery and include patients with a bileaflet aortic valve and no other high risk features.
343. Aspirin alone is not a sufficient replacement for warfarin, and is used only as a chronic adjunct in patients who manifest systemic emboli despite therapeutic warfarin therapy.
344. Radial-femoral delay is a characteristic physical finding in aortic coarctation.
345. Bicuspid aortic valves are common in patients with aortic coarctation and are associated with a systolic ejection click and systolic murmur noted over the aortic area.
346. Elevated B-type natriuretic peptide levels occur with renal failure, acute coronary syndrome or myocardial infarction, and acute volume or pressure overload.
347. Adenosine is the treatment of choice for narrow-complex tachycardia.
348. Neither adenosine nor other atrioventricular nodal blocking agents should be given to patients with preexcited tachycardias.
349. Procainamide is the drug of choice for wide-complex tachycardia of unclear etiology.
350. Coronary angiography is indicated in patients with a history of unstable angina or non-ST-elevation myocardial infarction.
351. In patients with a high pretest probability of coronary artery disease, a negative stress test result is most likely to be false.
352. Spinal stenosis is characterized by pain with standing or walking that is relieved by sitting or bending forward and is further supported by a normal ABI.
353. Leg ischemia is characterized by pain with exertion and with a decrease in ABI of at least 20 % with exercise.
354. The use of angiotensin-converting enzyme inhibitors should be avoided during pregnancy.
355. Hydralazine and nitrates are the vasodilators of choice to treat heart failure during pregnancy.
356. Induction of mild hypothermia improves outcomes in comatose survivors of out-of-hospital cardiac arrest.
357. Aortic valve replacement is recommended once symptom onset occurs, regardless of patient age.
358. Symptom onset in aortic stenosis is often insidious and may include exertional dyspnea.
359. Alcoholic cardiomyopathy is a dilated cardiomyopathy.
360. Therapy for alcoholic cardiomyopathy must include total abstinence from alcohol.
361. In chronic angina, coronary artery bypass graft surgery is indicated for patients refractory to medical therapy; a large area of ischemic myocardium; high-risk coronary anatomy; and reduced left ventricular systolic function.
362. Atrial tachycardia with variable block is a classic electrocardiographic finding in digitalis toxicity.
363. The first-line treatment for life-threatening digitalis toxicity is administration of digoxin-specific antibody fragments.
364. Iron deficiency is a common cause for dyspnea and fatigue in patients with cyanotic heart disease.
365. The most common cause of iron deficiency in patients with cyanotic heart disease is recurrent phlebotomy.
366. Mitral valve surgery is indicated for symptomatic patients with chronic, severe mitral regurgitation.
367. In asymptomatic patients with chronic, severe mitral regurgitation, criteria for mitral valve surgery include an end-systolic dimension >45 mm, an end-diastolic dimension >60 mm, and an ejection fraction