Board Review
Cardiovascular
Medicine
Lida and Justin
9/17/15
1. A 55-year-old man is evaluated for a 2-month history of dyspnea on exertion without
chest pain. Medical history is significant for type 2 diabetes mellitus, hypertension, and
hyperlipidemia. Medications are metformin, lisinopril, pravastatin, and aspirin.
On physical examination, blood pressure is 110/75 mm Hg and pulse rate is 60/min. BMI
is 35. Jugular venous distention is noted, and trace lower extremity edema is present.
The point of maximal impulse is normal in size and location. Cardiac examination
reveals a regular rate and rhythm, and the chest is clear to auscultation.
Laboratory studies show a serum B-type natriuretic peptide level of 110 pg/mL.
Electrocardiogram is shown :. Echocardiogram shows inferior wall hypokinesis and
ejection fraction of 35%.
Which of the following is the most appropriate diagnostic test to perform next?
• A. Adenosine thallium stress test
• B. Cardiac magnetic resonance (CMR) imaging
• C. Cardiopulmonary exercise test
• D. Coronary angiography
1. A 55-year-old man is evaluated for a 2-month history of dyspnea on exertion without
chest pain. Medical history is significant for type 2 diabetes mellitus, hypertension, and
hyperlipidemia. Medications are metformin, lisinopril, pravastatin, and aspirin.
On physical examination, blood pressure is 110/75 mm Hg and pulse rate is 60/min. BMI
is 35. Jugular venous distention is noted, and trace lower extremity edema is present.
The point of maximal impulse is normal in size and location. Cardiac examination reveals
a regular rate and rhythm, and the chest is clear to auscultation.
Laboratory studies show a serum B-type natriuretic peptide level of 110 pg/mL.
Electrocardiogram is shown :.
Echocardiogram shows inferior wall hypokinesis and ejection fraction of 35%.
Which of the following is the most appropriate diagnostic test to perform next?
• A. Adenosine thallium stress test
• B. Cardiac magnetic resonance (CMR) imaging
• C. Cardiopulmonary exercise test
• D. Coronary angiography
Answer is D
• Coronary angiography is indicated in the
evaluation of new-onset heart failure in
patients with angina or new-onset left
ventricular dysfunction in the setting of a
condition that may predispose to silent
ischemia.
2. A 54-year-old woman is evaluated by a PCP. She has no symptoms at the time of
the exam.
On physical examination, blood pressure is 158/68 mm Hg, pulse rate is 92/min, and
respiration rate is 20/min. Jugular venous distention is visible 2 cm above the clavicle
in the upright position. There is a regular rhythm with normal S1 and S2. There is a
grade 2/6 early-peaking systolic murmur at the right upper sternal border and a
grade 3/6 diastolic decrescendo murmur at the left lower sternal border. Lungs are
clear to auscultation.
Transthoracic echocardiogram is ordered and shows a dilated and mildly
hypertrophied left ventricle (end-diastolic diameter 80 mm, end-systolic diameter 45
mm) with estimated left ventricular ejection fraction of 50%. There is a bicuspid
aortic valve with moderate calcification of the leaflets. The peak aortic valve
gradient is 35 mm Hg, and the calculated aortic valve area is 1.3 cm2. There is severe
aortic regurgitation. The ascending aortic maximum diameter is 40 mm.
Which of the following is the most appropriate treatment?
A. Aortic valve replacement
B. Aortic valve replacement and ascending aortic graft placement
C. Begin carvedilol and reassess in 3 months
D. Repeat Echocardiogram in 3 months
When to repair
AI
- Symptomatic patient
- If EF < 50 %
- If End Diastolic dimension
is > 75 mm (or end
systolic dimension
> 55 mm
To graft or not to graft
• A bicuspid aortic valve is frequently associated
with dilation of the ascending aorta, which is now
recognized to be caused by abnormal connective
tissue or an aortopathy in patients with a bicuspid
aortic valve
• So if ascending aortic diameter greater than 45
mm at the time of planned aortic valve surgery,
repair of the ascending aorta, performed by
placement of a graft
3. A 75-year-old woman is evaluated in the emergency department for a 7-day history
of nausea, poor oral intake, and confusion. Medical history is significant for persistent
atrial fibrillation and hypertension. Medications are metoprolol, digoxin, and warfarin.
On physical examination, temperature is normal, blood pressure is 105/74 mm Hg, and
pulse rate is 49/min. She is oriented to name, but does not know the date or that she
is in the emergency department. The remainder of the examination is normal.
Laboratory studies reveal a serum creatinine level of 3.2 mg/dL (283 µmol/L),
potassium level of 4.8 meq/L (4.8 mmol/L), and INR of 2.3.
Which of the following is the most appropriate management?
• A. Direct-current cardioversion
• B. Insert a temporary pacemaker
• C. Measure the digoxin level
• D. Start dobutamine
3. A 75-year-old woman is evaluated in the emergency department for
a 7-day history of nausea, poor oral intake, and confusion. Medical
history is significant for persistent atrial fibrillation and hypertension.
Medications are metoprolol, digoxin, and warfarin.
On physical examination, temperature is normal, blood pressure is
105/74 mm Hg, and pulse rate is 49/min. She is oriented to name, but
does not know the date or that she is in the emergency department.
The remainder of the examination is normal.
Laboratory studies reveal a serum creatinine level of 3.2 mg/dL (283
µmol/L), potassium level of 4.8 meq/L (4.8 mmol/L), and INR of 2.3.
Which of the following is the most appropriate management?
• A. Direct-current cardioversion
• B. Insert a temporary pacemaker
• C. Measure the digoxin level
• D. Start dobutamine
Answer is C
• A regularized ventricular rate in the setting of
atrial fibrillation is concerning for complete
atrioventricular block with a junctional or
ventricular escape and the possibility of digoxin
toxicity.
• Associated with hyperK
• Use Dig-specific fab antibody fragments to reverse
toxicity within 4 hours. Watch out for low K after
admin due to restoration of the Na-K pump.
4. A 72-year-old woman is evaluated during a routine follow-up appointment
for aortic stenosis. She does not have any symptoms, including chest pain or
dyspnea. She feels that she is in good health “for her age.”
On physical examination, vital signs are normal. Estimated central venous
pressure is normal. Carotid upstrokes are diminished and delayed. The apical
impulse is sustained but not displaced. S1 is normal, but S2 is decreased in
intensity. There is a grade 3/6 late-peaking, systolic, crescendo-decrescendo
murmur at the right upper sternal border which radiates to the right carotid.
Lungs are clear to auscultation.
Transthoracic echocardiogram shows normal left ventricular ejection fraction
(62%) with moderate concentric hypertrophy (septal and posterior wall
thickness 1.4 cm). The aortic valve leaflets are calcified with poor mobility.
There is severe aortic stenosis with a peak aortic valve gradient of 65 mm Hg,
mean gradient of 42 mm Hg, and calculated aortic valve area of 0.8 cm2.
Which of the following is the most appropriate management of this patient?
A. Aortic valve replacement surgery
B. Balloon aortic valvuloplasty
C. Dobutamine stress echocardiography
D. Repeat echocardiography in 12 months
4. A 72-year-old woman is evaluated during a routine follow-up appointment
for aortic stenosis. She does not have any symptoms, including chest pain or
dyspnea. She feels that she is in good health “for her age.”
On physical examination, vital signs are normal. Estimated central venous
pressure is normal. Carotid upstrokes are diminished and delayed. The apical
impulse is sustained but not displaced. S1 is normal, but S2 is decreased in
intensity. There is a grade 3/6 late-peaking, systolic, crescendo-decrescendo
murmur at the right upper sternal border which radiates to the right carotid.
Lungs are clear to auscultation.
Transthoracic echocardiogram shows normal left ventricular ejection fraction
(62%) with moderate concentric hypertrophy (septal and posterior wall
thickness 1.4 cm). The aortic valve leaflets are calcified with poor mobility.
There is severe aortic stenosis with a peak aortic valve gradient of 65 mm Hg,
mean gradient of 42 mm Hg, and calculated aortic valve area of 0.8 cm2.
Which of the following is the most appropriate management of this patient?
A. Aortic valve replacement surgery
B. Balloon aortic valvuloplasty
C. Dobutamine stress echocardiography
D. Repeat echocardiography in 12 months
Answer is D
• In patients with severe aortic stenosis without
symptoms, aortic valve replacement is
indicated if left ventricular ejection fraction is
below 50%, exercise results in hypotension or
symptoms, or rapid progression of stenosis or
very severe stenosis (mean gradient >60 mm
Hg) has occurred.
5. A 42-year-old woman is evaluated in the emergency department for progressive shortness
of breath for 3 weeks. Medical history is noncontributory. She takes no medications.
On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 112/64 mm Hg,
pulse rate is 62/min, and respiration rate is 20/min. Estimated central venous pressure and
carotid upstrokes are normal. Cardiac auscultation discloses an opening snap, loud P2, a grade
2/6 diastolic low-pitched murmur at the apex, and a grade 2/6 holosystolic murmur at the
apex radiating to the axilla.
Electrocardiogram demonstrates sinus tachycardia, left atrial enlargement, and right axis
deviation. Transthoracic echocardiogram demonstrates normal biventricular size and
function; a dilated left atrium; reduced posterior mitral leaflet excursion without leaflet
calcification or significant thickening; severe mitral stenosis with mean gradient 15 mm Hg;
moderate mitral regurgitation; and mild tricuspid regurgitation. Estimated pulmonary artery
systolic pressure is 58 mm Hg.
Which of the following is the most appropriate treatment?
A. Balloon mitral valvuloplasty
B. Metoprolol
C. Mitral valve replacement
D. Open surgical commissurotomy
E. Repeat TTE in 3 months
C. MV Repair vs
replacement
• Mitral valve is the Best valve – Easy to repair
with valvuloplasty (anatomically )
• So prefer repair unless
MS with Moderate to severe MR
Concomitant other valve disease needing
surgery - like AR needing replacement
Indication for
intervention
AORTIC STENOSIS AORTIC
REGURGITATION
MITRAL STENOSIS MITRAL
REGURGITAION
SYMPTOMS
SYMPTOMS
SYMPTOMS
LVEF<50%
LVEF<50%
LVEF <60%
LV dilation - >75
mm end diastolic
dimension (or ESD
>55mm)
Atrial Fibrillation
Pulmonary
hypertension
(Very severe MS
with favorable
morphology in the
absence of
symptoms)
SYMPTOMS
Pulmonary
hypertension
6. A 38-year-old man is evaluated for progressive dyspnea and edema. He has a history
of injection drug use, which he discontinued 7 years ago. For the past several months,
he has noted worsening dyspnea with his daily activities. During the same period, he
has had worsening lower extremity edema and abdominal fullness.
On physical examination, temperature is normal, blood pressure is 124/84 mm Hg,
pulse rate is 75/min, and respiration rate is 16/min. There is jugular venous distention to
the jaw with a prominent v wave. Heart rhythm is regular. The apical impulse and heart
sounds are normal. There is a grade 2/6 low-pitched, holosystolic murmur along the left
sternal border that increases during inspiration. Lung examination is normal. The liver
span is increased. There are ascites and edema to the thigh level.
Electrocardiogram shows atrial flutter with 4:1 conduction with a right bundle branch
block. Transthoracic echocardiogram shows normal left ventricular dimensions and
systolic function. The right ventricle is dilated with reduced systolic contraction. There
is poor coaptation of the tricuspid valve leaflets with mobile, thickened leaflets and
severe tricuspid regurgitation. The right atrium is also dilated. The estimated right
ventricular systolic pressure is 25 mm Hg by Doppler velocity. Blood cultures are
negative.
Which of the following is the most appropriate treatment?
A. Cardioversion of atrial flutter
B. Digoxin
C. Nafcillin intravenously for 4 weeks
D. Tricuspid valve replacement surgery
6. A 38-year-old man is evaluated for progressive dyspnea and edema. He has a history of
injection drug use, which he discontinued 7 years ago. For the past several months, he has noted
worsening dyspnea with his daily activities. During the same period, he has had worsening lower
extremity edema and abdominal fullness.
On physical examination, temperature is normal, blood pressure is 124/84 mm Hg, pulse rate is
75/min, and respiration rate is 16/min. There is jugular venous distention to the jaw with a
prominent v wave. Heart rhythm is regular. The apical impulse and heart sounds are normal.
There is a grade 2/6 low-pitched, holosystolic murmur along the left sternal border that increases
during inspiration. Lung examination is normal. The liver span is increased. There are ascites and
edema to the thigh level.
Electrocardiogram shows atrial flutter with 4:1 conduction with a right bundle branch block.
Transthoracic echocardiogram shows normal left ventricular dimensions and systolic function.
The right ventricle is dilated with reduced systolic contraction. There is poor coaptation of the
tricuspid valve leaflets with mobile, thickened leaflets and severe tricuspid regurgitation. The
right atrium is also dilated. The estimated right ventricular systolic pressure is 25 mm Hg by
Doppler velocity. Blood cultures are negative.
Which of the following is the most appropriate treatment?
A. Cardioversion of atrial flutter
B. Digoxin
C. Nafcillin intravenously for 4 weeks
D. Tricuspid valve replacement surgery
Answer is D
• Tricuspid valve surgery should be considered in
patients with severe tricuspid regurgitation
and either symptoms or evidence of
progressive right ventricular enlargement or
dysfunction.
7. A 42 year old woman with a history of diabetes presents to the ED
after a syncopal episode that occurred while standing in line to
purchase concert tickets. She reports that she felt “woozy” and
became pale and sweaty before fainting. Friends observed jerking
motions of her face and fingers. ECG obtained in the ED showed normal
sinus rhythm. What is the best next step in workup?
A. EEG
B. Reassurance
C. Tilt-table testing
D. Dobutamine echocardiography
E. Carotid ultrasound
Syncope Workup
Evaluation
When should it be performed
ECG
All cases
Echocardiography
If structural heart disease is suspected
Unclear etiology or arrythmia
suspected
Ambulatory ECG monitoring
Stress testing
Carotid sinus massage
Exercise associated syncope
Carotid sinus syncope or unexplained
syncope in elderly
Tilt table testing
Presumed neurocardiogenic sycnope
if recurrent or hish risk for injury
EP testing
Almost never
Cardiac enzymes
NEVER!
EEG
NEVER!
Head CT/MRI
NEVER!
Carotid doppler
NEVER!
8. A 38-year-old man is evaluated during a routine health examination. He exercises 2 or
3 days each week by jogging for 30 minutes without shortness of breath or chest
discomfort. During stressful emotional situations, he occasionally feels “skipped heart
beats” but has not had prolonged palpitations, presyncope, or syncope. He generally
feels in good health. He has no history of medical problems and takes no medications.
He has not had fever or chills.
Physical examination shows normal temperature, blood pressure is 124/68 mm Hg,
pulse rate is 64/min and regular, and respiration rate is 14/min. BMI is 23. Cardiac
examination demonstrates a grade 2/6 early systolic crescendo-decrescendo murmur
heard best at the lower left sternal border without radiation. Lungs are clear. Peripheral
pulses are normal.
Electrocardiogram is normal.
Which of the following is the most appropriate next test?
A. Ambulatory electrocardiography
B. Transesophageal echocardiography
C. Transthoracic echocardiography
D. No additional testing
8. A 38-year-old man is evaluated during a routine health examination. He
exercises 2 or 3 days each week by jogging for 30 minutes without shortness
of breath or chest discomfort. During stressful emotional situations, he
occasionally feels “skipped heart beats” but has not had prolonged
palpitations, presyncope, or syncope. He generally feels in good health. He
has no history of medical problems and takes no medications. He has not had
fever or chills.
Physical examination shows normal temperature, blood pressure is 124/68
mm Hg, pulse rate is 64/min and regular, and respiration rate is 14/min. BMI is
23. Cardiac examination demonstrates a grade 2/6 early systolic crescendodecrescendo murmur heard best at the lower left sternal border without
radiation. Lungs are clear. Peripheral pulses are normal.
Electrocardiogram is normal.
Which of the following is the most appropriate next test?
A. Ambulatory electrocardiography
B. Transesophageal echocardiography
C. Transthoracic echocardiography
D. No additional testing
Answer is D
• Echocardiography is NOT indicated for patients with
brief, early systolic, low-intensity murmurs detected by
physical examination without symptoms or associated
findings of valvular or cardiac dysfunction.
• Transthoracic echocardiography is recommended for
diagnosis of:
•
•
•
•
•
•
•
systolic murmurs grade 3/6 or greater in intensity,
diastolic murmurs,
continuous murmurs,
holosystolic murmurs,
late systolic murmurs,
murmurs associated with ejection clicks,
or murmurs that radiate to the neck or back