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Cardiology Board Review

Cardiology Board Review. 6.21.10 Lisa Rose-Jones, MD . CAD. MKSAP Q 1. 60 yo M present to ED w/ chest discomfort for 6 hrs. Tx w/ ASA, IV BB, and NTG. Chest pain persists. Initial troponin and CK-MB are elevated.

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Cardiology Board Review

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  1. Cardiology Board Review 6.21.10 Lisa Rose-Jones, MD

  2. CAD

  3. MKSAP Q 1 • 60 yo M present to ED w/ chest discomfort for 6 hrs. Tx w/ ASA, IV BB, and NTG. Chest pain persists. Initial troponin and CK-MB are elevated. Pt taken ergently to Cath lab. Occlusion of prox RCA. PCI is successfully. Following morning doing well on rounds but progessively more hypotensive. JVP elevated. Nml S1, S2. +S3, brief systolic murmur along L sternal border. ECG is unchanged from previous.

  4. What is the most likely cause for this patient’s current findings? • Acute Cardiac tamponade • Aortic dissection • Left Ventricular Free Wall Rupture • Right Ventricular MI • Progressive Coronary Ischemia

  5. *Characteristic RV Infarction: progressive hypotension (always be weary of preload reducers like NTG), elevated JVP, and clear lung fields. +tricuspid regurg ~R precoridal Lead ECG will detect ST elev in V4R ~These pt may require volume challenges

  6. *Other MECHANICAL COMPLICATIONS following MI: ~Ventricular Septal Rupture ~Papillary Muscle Rupture: hear acute mitral regurg murmur ~LV Free Wall Rupture => cardiac tamponade, hypotension and usually death

  7. Q 23 57 yo M comes to ED w/ substernal chest pressure that developed this AM. PMHx of HTN, stable angina, PVD; his meds are HCTZ and ASA. BP 110/80, HR 84. No JVP and lungs clear. Nml S1/2. Abd exam neg, pulses diminished in LE. Continues to have angina at rest. ECG w/ changing ST segs and T waves. Trop 0.8. The patient is given ASA, BB, and enoxaparin, and is transferred to the CCU to await angiography.

  8. What additional therapy should be given in the CCU? • Heparin • Warfarin • Eptifbatide • Bivalirudin • Diltiazem

  9. Early treatment w/ Glycoprotein 2b/3a receptor blockade improves outcomes of PCI. *Indicated only if high risk markers (TIMI Score >3-4, +biomarkers, ST depression, CHF, h/o of recent PCI, or hemodynamic instability. -Abciximab =only if undergoing PCI -Eptifibitide or Tirofiban (if there is no clear inidication that PCI will be performed) *Warfarin offers no protection for Coronary events. SYNERGY trial showed Enoxaparin and Heparin outcomes nearly equivalent (unless switch from LMWH -> UH). Dilitaizem doesn’t affect outcomes in CAD.

  10. Q 37 42 yo M @ rural ED w/ severe L shoulder & chest pain, radiates to jaw. +diaphoresis, dyspnea. No PMHx, no meds. +father has CABG. In the ED, IV Heparin, Atenolol, and an ASA are given. BP 100/79, HR 61. No JVP. Nml S1/2. This hospital does NOT have a Cath lab, closest is 62 miles. Takes 2 hrs to arrange transfer.

  11. What is the BEST management option for this patient? • Glycoprotein receptor blockade • Plavix • Esmolol • Fibrinolytic therapy • NTG

  12. GOAL of all Reperfusion strategies for STEMI is to achieve a patent vessel w/in 90 mins from onset of symptoms. ~4 subgroups in which PCI is preferred: • Contraindications of fibrinolytic therapy • Late arriving STEMI, > 12 hrs after onset of chest pain w/ contd CP and ST elevs • H/O CABG • Cardiogenic Shock

  13. REMEMBER for CAD: • Reperfusion arrhythmias (AIVR) usually do not req antiarrhytmics • Do not need Cardiac Cath after Fibrinolysis if ST seg elevation and CP have resolved • Initial management of ACS related to systemic process, tx the preciptating factor 1st (ie pRBCs if GI bleeding) • ASA allergic: give Plavix

  14. HEART FAILURE

  15. Q 13 55 yo M w/ CAD evaluated w/ 2 wks after having an MI. D/C meds were: ASA, Toprol, ISMN, Lisinopril, and Atorvastatin. Echo revealed inferoposterior akinesis and LVEF of 40%. Exam: HR 60, BP 13-/70. JVP nml, lungs clear. Regular s1/s2. Labs: K-5.7, Cr-1.0, LDL-65. Lisinopril therapy stopped.

  16. Which of the following medications should be started in this patient? • Valsartan • Spironolactone • Amlodipine • Eplerenone • Hydralazine

  17. SHF MEDS: • ACEi (or if intolerant, ARB) ~will usually tolerate a K to 5.5 • B-blocker • Hydralazine/Nitrate combo if can’t tolerate an ACEi or ARB, or adding specifically if african-american • Spironolactone w/ NYHA class 3 or 4 symptoms • Eplerenone (aldo receptor antag) is useful in reduced EF after AMI

  18. REMEMBER for HEART FAILURE: • Digoxin alleviates Sx, reduceds hospitalization 2/2 HF (not mortality) • Diurese HF pt w/ volume overload 1st, then beta block • Put an AICD in a HF pt that comes in w/ unexplained syncope • Put a Biventricular Device in HF pt on optimal therapy w/ continued symptoms and QRS > 120 ms

  19. Arrhythmias

  20. Q 14 23 yo presents w/ palpitations during exercise. Healthy, no meds. Exam and resting ECG nml. Stress test shows sustained monomorphic V tach @ 201 /min. No iscemic changes until arrhythmia developed. The V tach had a Left bundle and infoerior axis morphology. Terminated spontanesouly 7 mins into rest. ECHO nml, MRI nml.

  21. What is the most likely etiology of V tach in this patient? • Coronary spasm • Idiopathic • Arrhythmogenic R ventricular cardiomyopathy • Infiltrative heart disease • Anomalous origin of the coronary arteries

  22. Idiopathic V Tach (no structural heart disease) carries a good prognosis. Tx symptoms, BB first line. ~Expect BP and ST segment elev w/ spasm. Nml MRI/ECHO rule out infiltrative disease, anomolaus coronaries, or arrhythogenic RV cardiomyopathy (would see fatty infiltration).

  23. Q 38 • 68 yo presents for routine eval. No complaints other than lumbago. Active, does yoga 3x/week. Meds include Levothryoxine and HCTZ. Exam: HR 46. On further questioning, she notes palpitations during a yoga class. 24 Ambulatory monitoring reveals HR of 39-82, avg of 45/min and occ pauses up to 2.9 sec. Nml TSH.

  24. What is the BEST management option for this patient? • Pacemaker implantation • Exercise stress test • Repeat 24 hr monitoring • Reassurance and Observation

  25. ONLY when there is definitive correlation b/w sinus bradycardia and symptoms, is pacemaker warranted Class I1. 3rd degree heart block w/ one of following: a. Bradycardia with symptoms b. other medical conditions that require drugs that cause sx brady c. Documented asystole 3.0 seconds or any escape rate <40 bpm in awake, symptom-free patients. d. After catheter ablation of the AV junction e. Postoperative AV block that is not expected to resolve f. Neuromuscular diseases with AV block 2. Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardia Class IIa1. Asymptomatic third-degree AV block w/ average awake ventricular rates of >/= 40 2. Asymptomatic type II second-degree AV block3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally at electrophysiological study for other indications 4. First-degree AV block with symptoms suggestive of pacemaker syndrome and documented alleviation of symptoms with temporary AV pacing

  26. Q 43 68 yo F comes to the ED b/c of racing heart for past 2 hrs. Reports 2 yr history of similar episodes. Been told by PMDs in past to cough/strain, usually works but not today. No chest pain, no other cardiac history. Exam shows BP of 110/60, HR 165, RR 20. Lungs clear. Carotids w/o murmurs, attempt massage w/o effect. ECG is shown.

  27. Which is the drug of choice for terminating this patient’s arrhythmia? • Metoprolol • Verapamil • Adneosine • Digoxin

  28. Q 122 26 yo nurse is evaluated in the ED after episode of syncope. While working stressfull day in the ICU, developed tachycardia and then LOC. +palpitations in past Exam wnl. CXR wnl. ECG initially unremarkable. 10 mins later, developed brief tachycardia. Repeat ECG shown.

  29. What is the most likely diagnosis in this patient? • Atrioventricular nodal reentrant tachycardia • Accelerated Idioventricular tachycardia • Atrioventircular reentrant tachycardia • Multifocal atrial tachycardia

  30. AVNRT: >50% of all SVTs. Circuit involves the AV node, so atria and Ventricle activated simultaneously. So “p” wave usually buried in QRS. AVRT: Circuit involves an accessory pathway. Most orthodromic: travels anterograde down AV node, retrograde up accessory path. Some pts w/ pre-excitation phenomena: during SR, see short PR interval and delta wave (evidence of pre-excitation)= *WPW => ADENOSINE is DRUG of CHOICE, however avoid if any evidence of pre-excitation on ECG

  31. REMEMBER: • In healthy adults, PVCs at rest are common and not cause for concern • Procainamide is drug of choice in a preexcited A fib • DC Cardioversion is 1st line for any unstable tachycardic pt (hypotensive, signs of HF like diaphoresis, pulm edema) • REMEMBER your CHADS2 score, if >2 give warfarin • For A FIB: 1st line is always rate control, only consider antiarrhytmic or ablation if symptomatic from being in controlled A fib • A flutter often result of another acute process, consider referral for ablation earlier as often difficult to rate control

  32. THE AORTA

  33. Q 45 69 yo M presented to ED for acute onset of substernal CP radiating to left arm. +former smoker, h/o HTN On exam: diaphoretic, BP of 210/95 mmHG in R arm and 164/56 in L arm with HR 90. There is dullness ½ way up R posterior troax and 2/6 diasolic murmur at RUSB. ECG shows 2-3 mm inferior ST seg elevation.

  34. Prior to additional diagnostic tests, which of the following is the most appropriate initial medication? • ASA • IV Heparin • Thrombolytic agent • Beta blocker • ACE inhibitor

  35. AORTIC DISSECTION: disparate BPs b/w arms, diastolic murmur of aortic regurg. Do NOT given ASA, heparin, etc if suspect. Initial treatment is w/ Beta Blockers to decrease shear stress. Diagnostic tests should be a TRANSESOPHAGEAL ECHO vs. CHEST CT w/ CONTRAST. `

  36. Valvular Disease

  37. Q 16 82 yo presents for annual exam. PMHx: HTN on chronic BB. Denies all cardiac sx. Takes daily 1 mi walk, no change in exercise tolerance. Exam shows: BP 136/86, HR 80. s1, single s2, grade 3/6 early systolic murmur @ LUSB w/ radiation to carotids. 1+ peripheral edema. LDL is 110. ECHO 2 yrs ago showed moderate calcific aortic stenosis (velocity was 3.6, valve area 1.2, gradient 30) with nml LV fxn. Now ECHO shows jet velocity of 4.2, valve area of 1.0, and gradient of 44).

  38. What is the most appropriate next step? • Reassurance • Begin a cardiac rehab program • HCTZ • Start statin therapy • Refer for Aortic valve replacement

  39. Aortic Stenosis: ~Reassurance remains appropriate if asymptomatic and nml exercise tolerance ~w/ severe stenosis the stiff valve doesn’t snap shut, thus loose aortic component and get only a single S2 (a physiologic split S2 has specificity of 72% of excluding severe AS) ~controling BP important, but use CAUTION w/ any peripheral vasodilators b/c compensation in Stroke Volume across a stenosed valve my be difficult!! ~ Symptoms: Angina (5), Syncope (3), Heart Failure (2)

  40. Q 19 36 yo F in the ED w/ fever & dyspnea. 4 wks of fever to 40C. +heroin use. Exam: 39.6, 100/52, 70, 91% on RA. JVP 12. Bibasilar crackles. HR reg irregulsr. S1, muffled s2. 2/6 diastolic murmur @ R 2nd intercostal space. 1+ pretibial edema. ECG shows a bifascicular block and Mobitz II. ECHO shows 2 veges on aortic valve, w/ leaflet perforation and severe AR. Echoluceny in paravalvular region. Placed on broad spectrum Abx.

  41. What is the most appropriate treatment at this time? • Esmolol IV • Heparin IV • Intraortic ballon pump (IABP) • Permanent pacemaker • Aortic Valve Replacement

  42. Acute Aortic Regurgitation • Whether from endocarditis or Aortic dissection, this is a SURGICAL EMERGENCY! • Esmolol (short acting BB)can slow HR and prolong diastolic filling to aid in forward output in some pts w/ AR (this pt has sig conduction abnml) • IABP is CONTRAINDICATED in AR

  43. Q 44 32 yo M comes in for annual exam. No personal or fmHx of cardiac disease. Exam: s1/s2, +s4, 2/6 crescendo-decrescendo systolic murmur heard best at LLSB w/o radiation to carotids. Increased intensity w/ valsalva. Isometric hand grip, passive leg raising decreases the intensity. Rapid upstrokes of peripheral pulses are present.

  44. What is the most likely diagnosis? • Mitral Valve Prolapse • Hypertrophic cardiomyopathy • Atrial septal defect • Ventricular Septal Defect • Aortic Stenosis

  45. Hypertrophic Cardiomyopathy • If preload is increased (isometric hand grip, stand-> squat) = increased systolic dimension of LV and therefore less obstruction & diminished murmur, Valsalva = decreased preload so increased murmur • Tx even asymptomatic pts w/ BB, avoid strenuous exercise • *different from hypertrophied athlete’s LV in that septum is asymmetrically enlarged

  46. REMEMBER: • ECHO for any Diastolic Murmur, Continuous murmur, or > grade 3/6 • Wide, Fixed split S2 think ASD • Secundum ASD can be prepared percutaneously

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