Chemo & Consequences
Grown-Up Heart Kids
Aorta Anxiety
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100
What is the classic cardiotoxicity of anthracyclines and its mechanism?
Dilated cardiomyopathy; free radical-mediated oxidative damage to cardiomyocytes — dose-dependent and largely irreversible
100
What shunt direction occurs in an uncorrected VSD and what murmur does it produce?
Left-to-right shunt; harsh holosystolic murmur at left lower sternal border
100
Type A vs Type B aortic dissection — define and first-line management of each?
Type A: involves ascending aorta → emergent surgery. Type B: descending only → medical management (beta-blocker, BP control) unless complicated
100
What ECG finding in an athlete is normal and does not require further workup?
Sinus bradycardia, first-degree AV block, early repolarization, incomplete RBBB, voltage criteria for LVH — all training-related normal variants
100
Digoxin toxicity classic ECG finding?
Scooped ST depression ("Salvador Dali" sign) — also bradyarrhythmias, heart block, bidirectional VT in severe toxicity
200
Trastuzumab cardiotoxicity differs from anthracyclines in what two key ways?
largely reversible with drug discontinuation
not dose-dependent — mechanism is HER2 receptor blockade impairing cardiomyocyte repair rather than direct toxic injury
200
Eisenmenger syndrome — define it and name two absolute contraindications once established?
Reversal of left-to-right to right-to-left shunt due to pulmonary hypertension; contraindications: defect closure (fatal) and pregnancy (maternal mortality up to 50%)
200
What genetic syndrome has hypertelorism, bifid uvula/cleft palate, arterial tortuosity — TGFBR1/2 mutation?
Loeys-Dietz syndrome
200
Athlete's heart vs HCM — what wall thickness is the gray zone where differentiation is difficult?
13–15mm — below this is almost always athlete's heart; above 16mm is almost always pathologic
200
QT prolonging drugs — name the four drug classes most commonly responsible for drug-induced torsades?
antiarrhythmics (sotalol, dofetilide, amiodarone),
antipsychotics (haloperidol, quetiapine)
antibiotics (azithromycin, fluoroquinolones),
antiemetics (ondansetron, metoclopramide)
200
What is the 2024 self-employment tax rate and what income does it apply to?
15.3% on first $168,600 (Social Security 12.4% + Medicare 2.9%); additional 0.9% Medicare surtax on earnings above $200,000 single/$250,000 MFJ
300
Fluorouracil cardiotoxicity — mechanism and which patients are highest risk?
Coronary vasospasm causing demand ischemia
highest risk in patients with pre-existing CAD or prior chest radiation — occurs in up to 10% of patients
300
In repaired TOF, what is the most common cause of late sudden death and its substrate?
Ventricular tachycardia via scar-mediated reentry at RVOT surgical scar (ventriculotomy or transannular patch); QRS duration >180ms is the strongest non-invasive risk marker — distinct from overall late mortality which is dominated by RV failure from chronic pulmonary regurgitation
300
Tricyclic antidepressant overdose — mechanism of cardiotoxicity and ECG finding?
Sodium channel blockade → wide QRS; also alpha blockade (hypotension) and anticholinergic effects (tachycardia); terminal R wave in aVR >3mm predicts arrhythmia risk
300
What is the difference between a revocable and irrevocable trust and why would a high-earning physician choose the latter?
Revocable: you control it, can change it, assets still in your estate for tax purposes.
Irrevocable: you give up control, assets removed from your taxable estate — used for asset protection from malpractice, Medicaid planning, and reducing estate tax exposure above the $13.6M federal exemption (2024)
400
Per ACC cardio-oncology guidelines, when should cardioprotective therapy be started during anthracycline treatment?
ACE inhibitor/ARB + beta-blocker initiated when EF drops ≥10% or GLS declines >15% — some centers start prophylactically in high-risk patients (prior cardiac disease, high cumulative dose.
400
Scimitar syndrome — describe the anatomy and its hemodynamic consequence?
Partial anomalous pulmonary venous return of right lung to IVC — left-to-right shunt; scimitar sign on CXR (curved vessel shadow); associated with right lung hypoplasia and dextroposition of heart
400
Clozapine cardiac toxicity — what life-threatening complication occurs and when in treatment course?
Myocarditis — occurs in first 4–8 weeks of treatment; also cardiomyopathy with chronic use; monitor troponin and CRP weekly for first month; discontinue immediately if myocarditis suspected
500
Clonal hematopoiesis of indeterminate potential (CHIP) — why is it relevant to cardio-oncology?
CHIP mutations (TET2, DNMT3A) independently increase cardiovascular risk — accelerate atherosclerosis and heart failure; also increases risk of chemotherapy cardiotoxicity; emerging screening target in cardio-oncology
500
Name four specific long-term complications of Fontan circulation and their mechanisms?
Protein-losing enteropathy (elevated venous pressure → gut lymphatic leak)
Fontan-associated liver disease (hepatic venous congestion → fibrosis → HCC)
plastic bronchitis (lymphatic casts in airways)
atrial arrhythmias (massively dilated atria from chronic high pressure)
500
Chloroquine/hydroxychloroquine overdose — ECG findings and how do you treat it?
Wide QRS, QT prolongation, ventricular arrhythmias — sodium channel blockade similar to TCA; sodium bicarbonate alkalinizes serum, reduces drug-channel binding, narrows QRS; also treat hypokalemia aggressively
500
Explain how S-corp election reduces self-employment tax, the IRS reasonable salary requirement, and the risk of underpaying salary.
S-corp splits income into W2 salary (subject to FICA 15.3%) and distributions (not subject to FICA); IRS requires "reasonable compensation" for services — typically 40–60% of net profit; underpaying salary triggers IRS audit, back FICA taxes, penalties; savings of $10,000-$30,000/year at high income levels if structured correctly