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Cardiovascular Board Review I

Cardiovascular Board Review I. Braden Hexom, MD Department of Emergency Medicine Mount Sinai School of Medicine. Question 1.

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Cardiovascular Board Review I

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  1. Cardiovascular Board Review I Braden Hexom, MD Department of Emergency Medicine Mount Sinai School of Medicine

  2. Question 1 A 40 yo M, previous healthy presents with cough, low-grade fever, and myalgias for 3-4 days. Today he has experienced severe, sharp pleuritic chest pain radiation to the left shoulder that is worse when he is supine. He smokes one pack of cigarettes per day. Vitals signs: BP 160/95, P 110, RR 18, T 37.2 oC. A 12-lead EKG is obtained: PEER VII Q55

  3. Q1 EKG

  4. Q1 Answer Appropriate next steps include: • ASA 325 mg, Morphine 2 mg, admit CCU • ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit bolus, activate cath team • Ketorolac 30 mg IV then ibuprofen 800 mg TID for 1 week as an outpatient • Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20 mg IV, admit to telemetry • Metoprolol 5 mg IV, NTG IV infusion titrated to pain, and cardiology consult

  5. Q1 Answer Appropriate next steps include: • ASA 325 mg, Morphine 2 mg, admit CCU • No Need For Monitored Admission • ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit bolus, activate cath team • No Role for Anticoagulation • Ketorolac 30 mg IV then ibuprofen 800 mg TID for 1 week as an outpatient • Acute Pericarditis is Treated with Ibuprofen and Outpatient Followup • Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20 mg IV, admit to telemetry • No Idea Why You Would Ever Use This • Metoprolol 5 mg IV, NTG IV infusion titrated to pain, and cardiology consult • Tachycardia and Pain will Resolve with Pain Control

  6. Acute Pericarditis • Inflammation of the pericardium • Sharp or stabbing chest pain with radiation to back, neck, left shoulder, or arm • Worsened on inspiration or lying supine • EKG: • Acute phase: Diffuse ST elevations (most prominent in I, V5, V6) with PR depressions (II, aVF, V4-V6) • Isolated pericarditis will not make enzymes or have dysrhythmias • Dispo for uncomplicated is NSAIDs for 1-3 weeks and D/C

  7. Acute Pericarditis http://urbanhealth.udmercy.edu/ekg/pdf/acutepericarditis.pdf

  8. Question 2 A 50 yo M presents with an acute inferior wall MI. Following the administration of ASA and NTG, he suddenly becomes confused and diaphoretic with a BP of 70/30. Physical exam reveals JVD, clear lungs, and no evidence of a murmur. Promes 3-9

  9. Q2 Answer What combination of therapeutic agents is most likely to immediately stabilize this patient? • Heparin and glycoprotein IIb/IIIa inhibitors • Angiotensin converting enzyme inhibitor and clopidogrel • Steptokinase and magnesium • Normal saline bolus and dobutamine

  10. Q2 Answer What combination of therapeutic agents is most likely to immediately stabilize this patient? • Heparin and glycoprotein IIb/IIIa inhibitors • Not immediately effective • Angiotensin converting enzyme inhibitor and clopidogrel • Not immediately effective • Steptokinase and magnesium • PCI preferred over thrombolytics • Normal saline bolus and dobutamine • RVMI is Preload Dependent

  11. Right Ventricular Infact • Complicates up to 1/3 of inferior wall MIs • EKG • ST Elevations in II, III, aVF • Reciprocal depressions in I, aVL, V5, V6 • ST Elevations in V4R to V6R on right-sided EKG • Prone to hypotension but respond to volume and pressors / inotropes • PCI preferred over thrombolytics • This is the classic question for RV infact

  12. Right Ventricular Infact Left Sided EKG Right Sided EKG http://ccn.aacnjournals.org/cgi/reprint/25/2/52.pdf

  13. Question 3 The hypertensive emergency that is most easily reversible with pharmaceutical management is: PEER VII Q240

  14. Q3 Answer • Acute coronary syndrome • Aortic dissection • Eclampsia / pre-eclampsia • Encephalopathy • Intracranial hemorrhage

  15. Q3 Answer • Acute coronary syndrome • Needs Cath • Aortic dissection • Not reversible with meds • Eclampsia / pre-eclampsia • Needs Delivery • Encephalopathy • Treatment w/in 1st Hour Often Reversible • Intracranial hemorrhage • Not reversible with meds

  16. Hypertensive Emergency • Marked elevation of BP with end-organ dysfunction otherwise HTN urgency • Susceptible end-organs: CV, brain, kidney • Encephalopathy • N/V • Severe Headache • Confusion  decreased sensorium  coma • Rapid 25% decrease in MAP is the goal • Diastolic <110 mmHg

  17. Hypertensive Emergency • Rare disease, many treatment options • Precipitating causes: drugs, pregnancy • Peds • Pheochromocytoma • Aortic coarctation • Renovascular disease • Only emergencies require immediate treatment. Urgencies can be discharged • Can use nitroprusside, nitro, labetalol, cardene

  18. Question 4 A 75 yo F presents with decreased level of consciousness. VS are BP 70/40, P 40, RR 12, and T 36.5 oC. Blood glucose is 114. The rhythm strip should be interpreted as: PEER VII Q92

  19. Q4 Answer • Complete Heart Block • Mobitz second-degree HB, type I Wenckebach • Mobitz second-degree HB, type II • QT prolongation with U waves • Sinus bradycardia

  20. Q4 Answer • Complete Heart Block • Some P waves conduct • Mobitz second-degree HB, type I Wenckebach • PR interval increases • Mobitz second-degree HB, type II • PR interval constant • QT prolongation with U waves • U waves follow T, seen in Hypokalemia • Sinus bradycardia • Not sinus

  21. Question 5 The most appropriate initial therapy for a patient with a pulse of 40, a BP of 70/40, and the previous EKG is: PEER VII Q93

  22. Q5 Answer • Atropine 1 mg IV • External cardiac pacemaker • Isoproterenol infusion at 2 mcg/min, titrate up • Normal saline • Potassium infusion at 10 mEq/hr

  23. Q5 Answer • Atropine 1 mg IV • Type I (not II) Often due to Vagal tone/IWMI • External cardiac pacemaker • Type II Often seen with AWMI -> Complete HB • Isoproterenol infusion at 2 mcg/min, titrate up • An option for refractory sinus bradycardia • Normal saline • Not usually PWMI • Potassium infusion at 10 mEq/hr • Not a hypokalemia rhythm

  24. Bradycardia • Approach to undifferentiated bradycardia based on hemodynamic stability • If stable, observe • If unstable • Atropine 0.5 mg IVP, up to 3 mg • Dopamine or Epinephrine drip • External pacing • Transvenous pacing

  25. AV Nodal Blocks • Caused by conduction delay in AV node • First-Degree • PR interval > 0.2s (200ms) • All P waves followed by QRS • No intervention required http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf

  26. AV Nodal Blocks • Second-Degree Mobitz I (Wenckebach) • Progressive lengthening of PR interval followed by dropped beat • Seen in IWMI, digoxin toxicity, myocarditis, CAD • Stable rhythm http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf

  27. AV Nodal Blocks • Second-Degree Mobitz Type II • Fixed-length PR interval with one or more non-conducted beats • Signifies major damage to conduction system • Usually seen in AWMI • Unstable: Requires permanent pacemaker

  28. AV Nodal Blocks • Third-Degree (Complete) Heart Block • No P waves are conducted through AV node • Junctional or Ventricular escape paces the heart • Unstable: Requires permanent pacemaker http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf

  29. Question 6 Which of the following statements regarding cardiac serum markers is correct? PEER VII Q342

  30. Q6 Answer • BNP level has little correlation with recurrent acute coronary syndromes • CPK appears within 1-2 hours after an acute MI and gone within 24 hours • Myoglobin appears within 1-2 hours after acute MI and peaks at 5-7 hours • Total CPK is more specific for acute cardiac ischemia than CK-MB • Troponins appear in the first 4 hours after an MI and are gone by 24 to 36 hours.

  31. Q6 Answer • BNP level has little correlation with recurrent acute coronary syndromes • BNP elevated in CHF and ACS • CPK appears within 1-2 hours after an acute MI and gone within 24 hours • Appear 3-8hrs, gone by 2-3 days • Myoglobin appears within 1-2 hours after acute MI and peaks at 5-7 hours • But not cardiac specific • Total CPK is more specific for acute cardiac ischemia than CK-MB • CK-MB more specific, CPK in muscle/kidney/GI/brain • Troponins appear in the first 4 hours after an MI and are gone by 24 to 36 hours. • Troponins appear 3-6 hrs, persist 5-7 fsyd

  32. Cardiac Serum Markers • Myoglobin is the earliest • Troponin is the most sensitive and specific http://www.uptodateonline.com

  33. Cardiac Serum Markers • Troponins and Renal Failure • Tropnonin clearance is delayed • Troponins are not cleared by dialysis • High false-positive rate1 • Elevated troponins correlate with poor prognosis • Any non-zero level warrants serial troponins2,3 1 Apple FS,et al. Predictive value…Circulation 2002 Dec 3;106(23):2941-5. 2 http://www.kidney.org/professionals/KDOQI/guidelines_cvd/troponin.htm 3 http://www.uptodateonline.com

  34. Question 7 An 82 yo woman presents with 1 hour of substernal chest pressure, dyspnea, and diaphoresis. Her EKG is shown below. No old EKG is available for comparison. Her first set of cardiac enzymes is negative. Which of the following is the most appropriate treatment? Promes Q3-4

  35. Q7 (continued)

  36. Q7 Answer • Admit the patient to a monitored bed • Observe the patient, order serial cardiac markers and discharge if negative • Administer thrombolytics • Cardiovert the patient with 50 joules • Stress testing once serial cardiac enzymes are negative

  37. Q7 Answer • Admit the patient to a monitored bed • Observe the patient, order serial cardiac markers and discharge if negative • Administer thrombolytics • Cardiovert the patient with 50 joules • Stress testing once serial cardiac enzymes are negative

  38. STEMI / LBBB • STEMI • Presence of ST elevations of greater than 1mm in two or more anatomically contiguous leads • LBBB • QRS > 0.12 s (120ms) • Wide, notched R wave in I, aVL, V6 • Small R and deep S in II, III, aVF, V1-V3

  39. STEMI / LBBB • Indications for Thrombolysis / PCI • MI that meets STEMI criteria • MI symptoms and new LBBB • Acute Posterior MI • Isolated ST-segment depression of at least 1mm in 2 or more leads from V1-V4 ACEP Clinical Policy: Indications for Reperfusion Therapy…Ann Emerg Med. 2006;48:358-383.

  40. Question 8 Which of the following statements is true concerning infective endocarditis in IV drug users? PEER V Q9

  41. Q8 Answer • Most commonly affects the mitral value • Rarely associated with septic emboli • Cardiac murmurs frequently are absent at initial presentation • Steptococcus viridans is the most common causative organism • The majority of patients have previously damaged heart valves

  42. Q8 Answer • Most commonly affects the mitral value • Tricuspid is most common • Rarely associated with septic emboli • Is a common cause of septic emboli • Cardiac murmurs frequently are absent at initial presentation • Murmur develops after extensive valve damage • Steptococcus viridans is the most common causative organism • Staph, MRSA most common • The majority of patients have previously damaged heart valves

  43. IVDU Endocarditis • Presentation can vary from subacute to acute onset of fever, dyspnea, weakness, tachycardia, dysrhythmias • High index of suspicion: IVDU patients with fever • Skin flora is most common: Staph aureus, including MRSA • Tricuspid is most commonly affected in IVDU • In ED, obtain multiple cultures, treat with Abx • Antibiotics: vancomycin + gent +/- rifampin

  44. Question 9 Which of the following drugs can be used to treat a patient with known Wolff-Parkinson-White syndrome who presents with the rhythm depicted below: PEER VII Q126

  45. Q9 Answer • Adenosine • Digoxin • Diltiazem • Metoprolol • Procainamide

  46. Q9 Answer • Adenosine • Slows AV conduction -> V.Fib • Digoxin • Slows AV conduction -> V.Fib • Diltiazem • Slows AV conduction -> V.Fib • Metoprolol • Slows AV conduction -> V.Fib • Procainamide • Or Amiodarone (or cardioversion)

  47. Wolff-Parkinson-White • Syndrome of pre-excitation due to accessory pathway from atria to ventricles • EKG • Short PR interval • Delta wave: slurred upstroke of QRS complex http://medicalfinals.co.uk/QuizJanuary2006Answers.html

  48. Wolff-Parkinson-White • Orthodromic (narrow complex) AVRT • Anterograde conduction in accessory tract • Adenosine 6 mg IV or Verapamil 5 to 10 mg IV • Antidromic (wide complex) AVRT or Afib / Aflut • Retrograde conduction in accessory tract • No AV nodal blockers • If stable: amiodarone or procainamide • If unstable: synchonized cardioversion

  49. Question 10 An 8 yo boy presents with history of chest pain that gradually worsened while he was watching television with his mother. The pain lasted 2 hours and then resolved without intervention. There was no associated dyspnea or syncope. He has no significant past medical history. Family history includes a grandmother who died of a heart attack. Physical exam, ECG, and CXR are normal. What is the most appropriate next step in the emergency department? PEER VII Q338

  50. Q10 Answer • Administer albuterol and check peak flow • Discharge home with primary care followup • Laboratory evaluation, including cardiac markers • Observation admission for treadmill testing • Outpatient echo and Holter monitor

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