Cardiology Review
June 2, 2008
Param Vidwan
22yo women who is 16 weeks pregnant is evaluated for a 2 hour history of
severe anterior chest pain radiating to her mid back. She is a tall, thin woman
with pectus abnormality of her chest and long, thing fingers. Her pulse is
94/min and regular , and her respiratory rate is 24/min. Her chest wall is
diffusely mildly tender to palpation. Her lungs are clear to auscultation.
Cardiac auscultation shows a normal S1, a physiologically split S1, and a grade
2/6 diastolic decrescendo murmur at the left sternal border. There is no
peripheral edema. Her electrocardiogram shows only nonspecific ST changes.
Oxygen saturation by pulse osimetry on room air 99%. Her D-Dimer level is
mildly elevated.
Q90: Diagnosis:
Q: Her murmur is due to:
Q: Next next step in diagnosis:
Q: Management
69yo man is evaluated in the ED for acute onset of substernal chest
pain radiating to the left arm. The patient is a former smoker with a
history of hypertension.
On physical exam, he is diaphoretic, with a blood pressure of
210/95mm Hg in the right arm and 164/56 mm Hg in the left arm, a
pulse rate of 90/min and regular, and a respiration rate of 20/min.
There is a dullness half way up the right posterior thorax and a 2/6
diastolic murmur at the right upper sternal boarder. ECG shows sinus
rhythm with a 2 to 3 mm inferior ST segment elevation.
Q45: What is the next step in management?
ASA
Heparin gtt
Thrombolytic therapy
Beta Blocker
ACEi
IV Hydralazine x 1
49yo male with severe chest pain is seen urgently in the ED. The chest
pain, which began abruptly 3 hrs ago, is substernal, sharp in quality, and
has been very intense from its onset. He denies prior fever, cough,
dyspnea, and hemoptysis. He has a long standing history of hypertension
and COPD. His meds include lisinopril and ipratropium inhaler.
On physical exam, he is diaphoretic and listless. He complains of chest
pain. His temp is 37, HR 126, RR 26. Systelic BP is 88 in right arm and 58 in
left arm. Pulses paradox is 16 mmHg. JVD is 12 cm. Lungs are clear. There
is no LE edema.
Labs show a Hgb of 11, BUN 18, Crt 1.1. CXR shows widened mediastinum
and clear lungs.
2 liters of normal saline rapid infusion and Dopamine 20 ug/kg/min fail to
raise BP.
What is the most likely diagnosis?
Sepsis
Bacterial pericarditis
Aortic Dissection
Acute MI
Pulmonary Embolus
Aortic Dissection
Sanford Classification
Type A: Ascending aorta
Type B: Descending aorta
Type A are twice as common as Type B and may involve
RCA.
DeBakey Classification
I: Ascending AND Descending
II: Ascending aorta alone
III: Descending aorta alone, just after subclavian artery.
Aortic Dissection
• Ascending aortic dissections are at the
greatest risk for complications, so they always
require surgery.
• Descending aortic dissection are usually
treated medically (persistence of pain means
continuing dissection and the need for
emergent surgery)
Aortic Dissection
• Risk factors: systemic hypertension, cystic
medial necrosis, bicuspid aortic valve,
coarctation of the aorta, and 3rd trimester of
pregnancy. Aortic dissection is a major cause
of death in patients with Marfan Syndrome.
• Diagnosis: CT > MRI. Transesophageal echo is
accurate for descending thoracic aorta
dissection.
Suspicion of aortic dissection
Imaging test: CT, MRI, TEE
Beta Blocker
Nitroprusside (not nitroglycerin)
Sanford Type A: Emergent
Surgical treatment
Sanford Type B: Medical
Management
A few words about AAA
• Screen all men with history of smoking after the
age of 65.
• AAA is CAD risk equivalent
• Prophylactic surgery is recommending for: (1)
men with AAA > 5.0cm, (2) women with AAA >
4.5cm, (3) patient with Marfan’s with AAA > 4.5,
or (4) rapidly expanding AA (>0.5cm/year)
regardless of the size.
• Patient with aneurysm > 45mm should undergo
surveillance Q 3 months.
74 year old woman undergoes a routine evaluation. She is a smoker and has
hypertension, hypercholesterolemia, and type 2 diabetes. Last year, she
had an aysmptomatic 4.4cm infrarenal AAA diagnosed during an
ultrasound for suspected gallstones, at which time she was encouraged to
stop smoking. She is petite, active, asymptomatic and complaint with her
medications which include atenolol, glyburide, metformin, lisinopril, and
aspirin.
On physical exam, the blood pressure is 125/78 and the pulse rate is 70/min
and regular. The lungs are clear, cardiac examination shows an S4, and
abdominal exam shows a nontender abdomen with pulsatile mass. A
follow-up ultrasound shows a 5.1 cm aneurysm with thrombus. The
patient is again encouraged to stop smoking.
What is the most appropriate next step?
Repeat Ultrasound in 6 months
Increase dose of atenolol and repeat Ultrasound in 6 months
Elective aneurysm repair
Start Warfarin (INR 2-3), repeat ultrasound in 6 months.
66 year old man with history of CAD and HTN is evaluated for abdominal pain, lowgrade fever, myalgias, nausea, and generalized weakness. His creatinine level is 6
mg/dl (baseline creatinine is 1.4 mg/dl). Two weeks ago, he was hospitalized for
anginal chest pain. Cardiac catherization at that time showed a 30% LAD stenosis
and 90% RCA lesion. A right coronary artery stent was placed.
On physical exam, temp is 37.8, BP 140/96. On cardiac exam, a right carotid bruit
and S4 gallop is present. On pulmonary exam, the lungs are CTAB. There is trace
pretibial edema bilaterally, and the distal pulses are not palpable. A netlike
violaceous rash is visible over the legs, and the right great toe is cool and cyanotic.
Labs:
HgB: 8.3, Leukocyte count: 6700 (67% neuts, 22% lymphs, 1% monos, 8% eos, 2%
baso). Plt: 434,000.
C3: Low
C4: Normal
UA: 1+ blood, 1+ protein, 3-5 leukocytes, 5-10 erythrocytes.
Diagnosis?
Radiocontrast nephropathy
Pre-renal acute renal failure
Acute interstitial nephritis
Microscopid polyangiitis
Atheroembolic disease.
Atheroembolic disease: Key points
• Atheroembolic disease can mimic vasculitis
• The presence of livedo reticularis (“a netlike
violaceous rash over legs”), Hollenhorts
plaque, cyanotic toe, low C3 levels, and
peripherial eosinophilia suggests a diagnosis
of atheroembolic disease
• This should be suspected in pt with erosive
atherosclerosis presenting with acute renal
failure
Hollenhorst Plaques
Branch Retinal Artery Occlusion
Neurocardiogenic Syncope
V40:
23-yo female is brought to the emergency department after witnessed
syncope. The patient reports having been at church, where she was
standing for approximately 45 min. She noted feeling sweaty and
light-headed and “seeing spots.” She was aware of the sensation of
her heart beating and then fell to the ground with loss of
consciousness. After the fall, according to witnesses, she had a
thready pulse and urinary incontinence. She regained
consciousness n about 3 minutes. Which of the following aspects of
this history is not consistent with neurocardiogenic syncope?
A. Urinary Incontinence
B. Prodrome of seeing spots, diaphoresis, and light-headedness
C. Palpitations
D. Thready pulse
E. None of the above
Neurocardiogenic syncope
• The term includes both vasovagal and
vasodepressor syncope. In both cases the patient
loses sympathetic tone with subsequent
vasodilation. In vasovagal there is resultant
bradycardi (due to increased vagal tone)
• In history, look for situational stressors: hot,
crowded spaces, stressful environment, long
period of standing, hunger, pain.
• Prodrome: light-headedness, diaphoresis,
nausea, weakness, visual changes.
• Incontinence suggests seizure.
Carotid hypersensitivity syncope
• Carotid sinus baroreceptors => bradycardia
caused by sinus arrest of AV block,
vasodilation, or both.
• Generally, men older than 50
• Classically presents with syncope in setting of
shaving, wearing a tight collar, or turning head
to one side
• Diagnosis is suggest by carotid sinus massage
with prolonged (more than 3 second) asystole.
• V41
78yo male presents to the clinic complaining that every time he
shaves with a straight razor, he passes out. His symptoms have
been occurring for the last 2 months. Occasionally, when he puts
on a tight collar, he passes out as well. The LOC is brief, he has no
associated prodrome, and he feels well afterwards. His PMHx is
notable for hypertension and hypercholesterolemia. His only
medication is HCTZ. On physical exam his vital signs are normal, and
his cardiac exam I normal with exception of a fourth heart sound.
Which of the following is the most appropriate next diagnostic test?
Stress echocardiography
Adenosine thallium scan
Computed tomogram of the neck
Carotid sinus massage
Tilt Table Test
Othostatic syncope
• Accounts for 30% of syncope in elderly
• #1 cause: dehydration
• #2 cause: polypharmacy
– Look for AV nodal blockers since they blunt the
normal response of tachycardia when venous
returns drops when the patient is transitioning
from lying to standing position
– Anticholinergics: diplopia, confusion ,
disorientation , ataxia, etc.
V-42
88yo lady presents to ED with syncope that occurred after she
stood up to use the bathroom in the middle of the night. This has
happened to her several time over the last month, each time in
context of transitioning from a lying to a sitting position. Her PMHx
includes HTN, DM Type II, MI, and depression. Her meds include
HCTZ, Atenolol, Metformin, ASA, Sertraline, and Simvastatin. On
Physical Exam her DBP drops 15 mmHg from supine to standing.
Despite adequate volume resuscitation, she remains orthostatic.
What should be done next?
Start Mineralocorticoids
Tilt table testing
Echocardiogram
Discontinue metformin
Discontinue Atenolol and sertraline
Know thy murmurs
Valve Defect
Murmur
Louder with
Heart Sounds
General Notes
AS
SEM at RUSB,
diamond
shaped
Squatting,
Expiration
Absent S2,
Parodoxically
split S2
Slowed carotid
upstroke.
Remember 5-32 ASH rule
MS
Diastolic ruble
Same as above
S1 enhanced
Large a wave,
weak y descent
VSD
Holosystolic at
LLSB
Handgrip
ASD
SEM at LSB
Post MI with
new murmur
Fixed split S2.
O-Primum:
LAD, RBBB
O-Secundum:
RAD, RBBB
BBB, no
prophylaxis Abx
for ostium
secundum.
Look for AV
block with
primum
V102
70 year old male is admitted to the hospital with chest pain for 8 hrs.
Serum studies demonstrate elevation of troponin and CK-MB. ECG
demonstrates anterior ST elevation, for which he is given tissue
plasminogen activator, heparin, and IV nitroglycerin. His symptoms
resolve after treatment. He is started on oral medications and
transferred out of the CCU on day #3. On Day #4, he develops
severe shortness of breath. BP is 110/70 and pulse is 120. Exam
reveals a harsh new Holosystolic murmur at LLSB, which is louder
with handgrip. Right heart cath shows step-up in oxygen saturation
of blood from RA to RV. The next step in management should be:
1. Emergent cardiac surgery consultation
2. IV heparin
3. IV heparin and streptokinase
4. IV heparin and furosemide
5. IV sodium nitroprusside with balloon pump
Post-MI complications
• Papillary muscle rupture. Remember,
posteromedial papillary muscle is more
commonly involved than anterolateral papillary
muscle because of single blood supply from RCA.
Classic case: pt is s/p Inferior MI, later becomes
hypotensive, has large V waves in pulm capillary
wedge tracing, new pansystolic murmur at the
apex.
• Pseudoaneurysm and true aneurysms.
• Mural thrombi (in anterior and apical STEMI)
Dressler’s Syndrome
• Transmural myocardial infarction causes localized
pericardial irritation, and the resultant preicardial
friction rub is common.
• Pericaridal effusion is dected in 25% of post MI
patients (on echo)
• Most pts do ok, but occationally pain results from
inflammatory pericarditis associated with fevers,
malaize, leukocytosis, elevated ESR 1 to 2 months
after AMI.
• Tx: High-dose ASA. (Corticosteroids and NSAIDs
are contraindicated in first month after AMI).