Internal Medicine Board Review
Cardiology
Mike McMullan, M.D., FACC
July 17, 2014
Internal Medicine Examination
• Cardiology is the largest section of the review
• Why is this?
– Cardiology is the largest section of the boards
 40% more than the next closest topic
 14% of exam, pulmonary is next at 10%
– Cardiovascular disease affects more people than any
other disease process
 Almost half of your family, friends, neighbors, and patients
will eventually die from heart disease
Cardiology Topic Breakdown
Cardiology Topic Breakdown
My Assignment
• To cover these areas
–
–
–
–
–
• In order to answer
Physical examination
Valvular disease
Congenital heart disease
Pericardial disease
Endocarditis/SBE prophylaxis
– 0 questions
– 2-5 questions
– 0-1 questions
– 1-4 questions
– 0-1 questions
_____________
3-11 questions
But “the truth of the matter” is that physical
examination will encompass all 32 questions!
Breaking It Down – My Method
• Focused board oriented pearls of frequently-tested
disease processes (This is NOT a comprehensive
discussion of each topic!)
– Broken down by general topics
– Highlight common scenarios within each topic




Symptoms
Physical findings
Diagnostic tests
Management
• Common word associations
Breaking It Down
• Physical examination
– Knowing the basics will help you figure out questions
– Will often ask for the diagnostic test (echo) rather than
the diagnosis (aortic stenosis)
– Be aware of normal findings that require no further w/u
– e.g. innocent flow murmurs, venous hum
– Recognize cardiac clues to systemic diseases – e.g.
rapid atrial fibrillation with a scratchy murmur
hyperthyroidism
Means–Lerman scratch
The Basics
Where does S1 occur?
A.
B.
C.
D.
E.
F.
a
b
c
d
e
f
S1
Where does S2 occur?
S2
A.
B.
C.
D.
E.
F.
a
b
c
d
e
f
Where does S4 occur?
A.
B.
C.
D.
E.
F.
a
b
c
d
e
f
S4
The Basics
• 4 heart sounds
– S1 – closure of mitral/tricuspid valves
– S2 – closure of aortic/pulmonic valves
– S3 – rapid ventricular filling with rapid flow
deceleration
 May be normal in pts < 40 y/o
 Often seen in CMP and ventricular failure
– S4 – atrial contraction against a stiff ventricle
 HTN
 HCM
 Aortic stenosis
Which of these sounds is lost in a
patient with atrial fibrillation?
A. S1
B. S2
C. S3
D. S4
The Basics
• 3 additional heart sounds
– Click (occur with valve closure)
 Usually MVP
 Rarely tricuspid click in Ebstein’s anomaly
– Opening snap (occur with valve opening)
 Usually right after S2 - mitral stenosis
 Can occur at beginning of systole – congenital aortic stenosis –
and is more often called ejection sound
– Rub (occur with cardiac motion)
 Up to 3 components
– Atrial systole
– Ventricular systole
– Ventricular diastole
 2 of 3 components are in diastole
The Basics
• 3 types of mumurs
– Systolic
 Systolic ejection=mid-systolic=crescendo-decrescendo
 Pansystolic=holosystolic
 Late systolic – associated with click = MVP!
– Diastolic
 Early high-pitched decrescendo
– Aortic or pulmonic regurgitation
 Low pitched rumble throughout diastole
– Mitral or tricuspid stenosis
– Continuous
 Patent ductus arteriosus
 AP window
 Shunt or fistula
Basic Murmurs
S1
S2
ES
S4S1
OS
S3
S1
S2
Venous Waveforms in a Nutshell
Venous Waveforms in a Nutshell
Ventricular
systole
Ventricular
systole
Large “v” Waves
What’s the diagnosis?
A.
B.
C.
D.
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Tricuspid regurgitation
What’s the diagnosis?
A.
B.
C.
D.
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Tricuspid regurgitation
What’s the diagnosis?
A.
B.
C.
D.
Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis
40
30
mmHg
LV
20
x
10
0
y LA
What’s the diagnosis?
A.
B.
C.
D.
Brockenbrough sign
Aortic stenosis
HCM with obstruction
MVP
Aortic regurgitation
Pulsus bisferiens
Normal Findings
• Innocent murmurs
– Grade 1-2 (mid)systolic ejection murmurs
– NEVER





Grade 3 or more
Pansystolic
Diastolic
Continuous
Other abnormal sounds – e.g. fixed split S2
• Venous hums
– High flow states – e.g. anemia
– Goes away when lays down
Breaking It Down
• Pericardial disease (1-4 questions)
– Cardiac tamponade
– Constrictive pericarditis
– Acute pericarditis
Cardiac Tamponade
• Scenarios – trauma and breast cancer are the two
biggies on boards, also lupus and renal failure,
occasionally viral pericarditis (rarely aortic dissection)
• Diagnosis – Beck’s triad (hypotension and elevated
neck veins with quiet precordium), pulsus paradoxus,
electrical alternans
• Tests - Swan hemodynamics with equalization of all
diastolic pressures and slow y descent, echo
• Mgt – pericardiocentesis
RA Pressure in Tamponade
Constrictive Pericarditis
• Scenarios – post-radiation for lymphoma, CTD,
TB
• Diagnosis – dyspnea, elevated JVP, Kussmaul’s
sign, edema, pericardial knock
• Tests – echo, CT or MRI, cath with prominent x
and y descents, equalization of diastolic pressures
with square root sign
• Mgt – pericardial stripping
Constrictive Pericarditis
Kussmaul’s sign
125
Constrictive Pericarditis
LV
100
75
Y>X
RVEDP > 1/3 RVSP
Square-root
50
sign
Equalization of Diastolic Pressures
RV
2
5
X
0
Y
RA
LA
Acute Pericarditis
• Scenarios – usually post-viral syndrome
• Diagnosis – pleuritic chest pain, feels better sitting up and
leaning forward, pericardial friction rub
• Tests – EKG with diffuse ST elevation, elevated ESR,
CRP and/or biomarkers
• Mgt – NSAIDs
– Ibuprofen 600-800 mg TID or
– ASA 650-1000 mg TID or
– Indomethacin 50 mg TID for 7-10 days
• Colchicine 0.5 – 0.6 mg BID
• Refractory – prednisone plus colchicine
Breaking It Down
• Congenital heart disease (0-1 questions)
–
–
–
–
–
–
ASD – recognize the EKG
VSD – almost always no treatment necessary in adults
PDA – continuous murmur
Coarctation of aorta – secondary HTN, differential BP’s
If cyanotic pt (unlikely), probably Tetralogy of Fallot
Pregnancy – tolerated in all patients except pulmonary
HTN and cardiomyopathies
Atrial Septal Defect
•
•
•
•
4 types but only need to know ostium secundum for boards
Scenario – young adult with murmur or palpitations
Diagnosis – fixed split S2, 2/6 SEM at LUSB
Tests – EKG with incomplete RBBB and RAD, echo, cath with
shunt run
• Mgt – closure (percutaneously or surgically) for shunt > 1.5:1
• No SBE prophylaxis recommended – low risk
Atrial Septal Defect
ASD EKG
ASD TEE
ASD Occluder
VSD
• Scenario – asymptomatic young adult referred for
murmur
• Diagnosis – loud grade 5/6 pansystolic murmur at
LSB
• Test – echo
• Mgt – closure not typically needed for adults, no
longer need SBE prophylaxis by guidelines
Ventricular Septal Defect
Ventricular Septal Defect
Ventricular Septal Defect
PDA
• Scenario – teen or young adult referred for
murmur
• Diagnosis – usually asymptomatic, continuous
murmur LSB
• Tests – echo
• Mgt – closure if murmur noted or left ventricular
enlargement or pulmonary HTN, small ones
without murmur do not need to be closed, no
longer need SBE prophylaxis
Patent Ductus Arteriosus
Patent Ductus Arteriosus
Coarctation of Aorta
• Great IM board question since it is a secondary
cause of HTN
• Scenario – young adult with HTN, association
with Turner’s syndrome
• Diagnosis – BP in arms vs legs, radiofemoral
pulse delay, 2/6 SEM LSB, may have aortic
ejection click with bicuspid aortic valve
• Tests – CXR with figure 3 sign and rib notching,
echo, CT angio or MRA
• Mgt – surgical repair, less commonly stent
Coarctation of Aorta
Coarctation CXR
Cyanotic Lesions
• Not likely for an IM board
• Tetralogy most common – young person with
cyanosis and squatting
• Eisenmenger’s (secondary pulm HTN with
conversion to right-to-left shunt) most commonly
occurs with VSD
• Ebstein’s may present as cyanosis in adult, usually
with palpitations due to right-sided accessory
pathway, marked RAE on EKG and echo
Tetralogy of Fallot
Pregnancy and Heart Disease
• Lots of pregnant women on the boards – not many with
heart disease
• Cardiac lesions affecting pregnancy
–
–
–
–
Pulmonary HTN
Cyanotic lesions (uncorrected)
Stenotic valve lesions
CMP
• Recommend vaginal delivery with facilitated second stage
• Peripartum CMP may occur last 3 months of pregnancy or
first 6 months after delivery
• Marfan’s and coarctation are at higher risk for aortic
rupture during surgery
Pregnancy and Heart Disease
• High risk
–
–
–
–
–
–
Eisenmenger’s syndrome
Severe pulmonary HTN
Severe aortic stenosis/LVOT obstruction
Coarctation of the aorta with obstruction
Marfan’s syndrome with aortic root > 43 mm
Symptomatic systemic ventricular dysfunction with EF < 40%
• Need referral to high risk OB center with cardiology collaboration
• Lower risk lesions can typically have normal pregnancy and delivery
• CARPREG score
–
–
–
–
Poor functional status (NYHA >2) or cyanosis
Systemic ventricular dysfunction
Left heart obstruction
History of heart failure, stroke, or arrhythmia
Risk of CHD in Offspring of Parents with CHD
• Typically 3-12%
• Can be up to 50% (Marfan’s syndrome)
• Fetal ultrasonography recommended @18 weeks
Breaking It Down
• Valvular heart disease (2-5 questions)
–
–
–
–
–
–
–
Aortic stenosis – elderly vs younger
Aortic regurgitation – Marfan’s or endocarditis
MVP – maneuvers, SBE prophylaxis
HCM – sudden death in an athlete, maneuvers
Mitral stenosis – rheumatic heart disease
Tricuspid stenosis with carcinoid patient
Tricuspid regurgitation in a patient with right heart
failure
Aortic Stenosis
• Scenarios – young to middle aged adult with bicuspid valve,
older adult (> 70 y/o) with tricuspid valve
• Diagnosis
– Symptoms are chest pain, syncope, CHF
– PE shows 3-4/6 SEM at RUSB radiating to carotids, pulsus parvus et
tardus (weak and delayed upstrokes)
• Tests – echo, cath only as pre-op for CAD
• Mgt – surgery, balloon valvuloplasty is only palliative and
short-lived, TAVR new option – only for inoperable or extreme
high risk at present – probably too early for boards right now
Aortic Regurgitation
• Scenario – Marfan’s syndrome, endocarditis
• Diagnosis – shortness of breath, early high-pitched
decrescendo diastolic murmur at left or right upper
sternal border, wide pulse pressure, brisk pulses
• Test – echo
• Mgt – afterload reduction with ACE inhibitor or
nifedipine, valve replacement for EF < 55% or
LVESD > 55mm
MVP
• Favorite board question
• Scenario – young woman with palpitations, chest pain
• Diagnosis – mid-systolic click with late systolic
murmur, increases with Valsalva
• Test – echo
• Mgt – beta blocker for symptoms, SBE prophylaxis
no longer recommended!, valve repair only for severe
regurgitation +/- atrial fibrillation or pulmonary HTN
MVP
Hypertrophic Cardiomyopathy
• Favorite board question
• Scenario – young athlete with syncope or aborted sudden
death, SOB, diastolic heart failure
• Diagnosis – SEM at RUSB which increases with Valsalva,
brisk carotid upstrokes, S4, pulsus bisferiens
• Test – EKG with LVH and T wave inversion, echo
• Mgt – beta blockers and calcium channel blockers, surgical
or percutaneous myectomy, ICD placement if high risk for
sudden death, no competitive athletics except golf and
bowling, screening of first- and second-degree relatives
HCM
HCM EKG
Differentiating Aortic Stenosis from
Hypertrophic Cardiomyopathy
• Same
– Both may present with syncope
– Both have a harsh SEM radiating to the carotids
• Different
– HCM usually younger than AS
– Carotid upstrokes are brisk with HCM, diminished with AS
– Murmur gets louder with Valsalva with HCM, softer with
Valsalva with AS
Mitral Stenosis
• Yet another favorite board question
• Scenario – woman with history of rheumatic heart disease
• Diagnosis – DOE, palpitations, PND, diastolic rumble with loud
S1 and opening snap just after S2, small PMI, palpable P2, rales
• Tests – echo, TEE to grade valve
• Mgt – slow heart rate to improve diastolic filling time – beta
blockers, SBE prophylaxis no longer required, balloon
valvuloplasty is the first line procedure for these pts (as opposed
to AS)
Tricuspid Stenosis
• Not a likely question
• Same murmur as mitral stenosis but at left sternal
border rather than apex
• Present with right heart failure rather than DOE
and rales
• Seen in association with carcinoid and with prior
use of Fen-Phen
Tricuspid Regurgitation
• Not a likely test question, but may see a case of pulm HTN
with TR and also PR
• Scenario – young woman with severe SOB, hypoxia, and right
heart failure – edema, ascites, elevated JVP, large v wave,
pulsatile liver
• Diagnosis – echo, right heart cath, CTA – must rule out other
etiologies – CTD, congenital heart disease, recurrent PE
• Mgt – pulm HTN has poor prognosis if no reversible cause,
O2, calcium blockers, Coumadin, prostacyclin analogs
(epoprostenol), endothelin receptor antagonists (bosentan),
phosphodiesterase-5 inhibitors (sildenafil), lung transplantation
Endocarditis Guidelines – Updated 2008
• No Class I indications for endocarditis prophylaxis
• Class IIA recommendations
– Antibiotic prophylaxis is reasonable for dental procedures
for patients with –
 Prosthetic cardiac valve or material used in valve repair
 Previous endocarditis
 Congenital heart disease
– Unrepaired cyanotic disease, including palliative shunts/conduits
– Completely repaired CHD for the first six months after correction
– Repaired CHD with residual defects at site of prosthesis
 Cardiac transplant with valvular heart disease
– No prophylaxis for GI or GU procedures
SBE Prophylaxis
• Know prophylaxis regimen
– Amoxicillin 2.0 g orally 1 hour before procedure
• Know what to use in a PCN allergic patient!
– Clindamycin 600 mg orally 1 hour before procedure
– Keflex 2.0 g orally 1 hour before procedure
– Zithromax 500 mg orally 1 hour before procedure
Endocarditis
• Scenario – think about it in a pt with multisystem involvement, fever,
chills, skin lesions, recent dental work or surgery, murmur – also with
an IV drug user with multiple lung lesions
• Diagnosis – clinical picture, fever, regurgitant murmur, splenomegaly,
Janeway lesions, Osler’s nodes, Roth’s spots, anemia, leukocytosis,
elevated ESR and CRP, glomerulonephritis
• Tests – blood cultures are mainstay of diagnosis, echo/TEE
• Mgt – IV antibiotics
–
–
–
–
Empiric therapy – Vancomycin after 2-3 sets of blood cultures drawn
Guide further therapy based on organism/sensitivities
PCN G or Rocephin for 4 weeks
PCN G + Gentamicin for 2 weeks
• Common organism – Viridans group streptococci
• Unusual organism associations
– Strep gallolyticus (formerly Strep bovis)
 Associated with colon cancer
 Needs colonscopy
The Bottom Line
• Recognize word associations
–
–
–
–
–
–
–
–
–
–
–
–
Irregularly irregular
Mid-systolic click
Pulsus paradoxus
Pulsus alternans
Electrical alternans
Pulsus parvus et tardus
Kussmaul’s sign
Large v waves
Prominent x and y descents
Fixed splitting of S2
Paradoxical splitting of S2
Wide physiologic splitting of S2
The Bottom Line
• Recognize word associations
–
–
–
–
–
–
–
–
–
Pericardial knock
Pericardial rub
Continuous murmur
Pansystolic murmur
Early high pitched diastolic murmur
Low pitched diastolic rumble
Elevated neck veins with clear lung fields
Elevated neck veins with hypotension and quiet precordium
Murmur increases with Valsalva
80 year old woman presents with syncope, on exam has weak
carotid upstrokes, a normal S1 with a diminished S2, and a
grade III/VI systolic ejection murmur at the RUSB radiating
to the carotids.
A. Bicuspid aortic valve stenosis
B. Tricuspid aortic valve stenosis
C. Hypertrophic cardiomyopathy
D. VSD
40 year old man with Marfan’s syndrome, a blood pressure of
150/50, brisk pulses throughout, and an early high-pitched
diastolic murmur heard best at the RUSB
A. Hypertrophic
cardiomyopathy
B. Mitral stenosis
C. Aortic regurgitation
D. Pulmonic regurgitation
30 year old woman who presents with palpitations, on exam
has a normal S1 and S2, a midsystolic click, and a late
systolic murmur that occurs earlier (becomes longer and/or
louder) with Valsalva maneuver
A. VSD
B. Hypertrophic
cardiomyopathy
C. Mitral regurgitation
D. Mitral valve prolapse
20 year old basketball player referred for episode of syncope,
noted to have brisk carotid upstrokes, a normal S1 and S2
with an S4 gallop, and a grade II/VI systolic ejection murmur
at the LSB which becomes louder with Valsalva maneuver
A.Bicuspid aortic stenosis
B.Tricuspid aortic stenosis
C.Hypertrophic
cardiomyopathy
D.Mitral valve prolapse
Maneuvers
• Valsalva and standing decrease ALL murmurs
except –
– Hypertrophic cardiomyopathy
– Mitral valve prolapse
• Therefore – Valsalva and standing increase the
murmur of HCM and MVP
• Squatting reduces the murmur of HCM and MVP
35 year old woman with increasing dyspnea and fatigue, a
history of rheumatic heart disease, a loud S1, a prominent S2
followed by an opening snap, and a diastolic rumble which
becomes louder at the end of diastole
A.Mitral stenosis
B.Aortic regurgitation
C.VSD
D.PDA
35 year old woman referred for palpitations and murmur,
normal S1 with wide fixed splitting of S2, and a grade II/VI
systolic ejection murmur at the LUSB
A.Pulmonary stenosis
B.VSD
C.ASD
D.Aortic stenosis
65 year old man who is asymptomatic, noted to have a normal
S1, a second heart sound of normal intensity which splits with
expiration and becomes single with inspiration (paradoxical
splitting), and no murmur
A.Left bundle branch block
B.Right bundle branch block
C.Aortic stenosis
D.HTN
This was on the 1994 IM board exam!
Best of luck!
•
•
•
•
•
Get a good night’s sleep!
Trust your initial reaction.
Use clinical judgment.
Look for the point of the question.
If no clue, guess and move on. Can always come
back if time allows.
And remember…
Bonus questions!
• E-mail me with your answers. Or if you have
questions or suggestions.
• mmcmullan@umc.edu
25 year old man who presents to the ER following a
stab wound to the left chest, found to have a BP of
80/50, HR 130, a pulsus paradoxus of 20 mm Hg,
distended neck veins, and distant heart sounds
A. Constrictive pericarditis
B. Cardiac tamponade
C. Restrictive cardiomyopathy
D. Tension pneumothorax
28 year old woman with primary pulmonary
hypertension, elevated neck veins with a prominent v
wave, a II/VI pansystolic murmur at the LLSB that
increases with inspiration, and a pulsatile liver
A.Mitral regurgitation
B.Tricuspid regurgitation
C.VSD
D.ASD
45 year old veteran who presents with palpitations
and SOB after a week-end of binge drinking, on
exam has a radial pulse of 120, an apical pulse of
180, and an irregularly irregular heart rhythm
A.PAC’s
B.Bigeminy
C.Atrial flutter
D.Atrial fibrillation
25 year old woman with a history of recent onset
hypertension, diminished femoral pulses, and a grade
II/VI systolic ejection murmur at the LSB and back
A. Subclavian stenosis
B. Peripheral vascular disease
C. Coarctation of the aorta
D. Renal artery stenosis
70 year old man from a nursing home with elevated
neck veins that increase with inspiration and
prominent x and y descents, normal S1 and S2 with a
loud S3 knock, and no murmur
A.Constrictive pericarditis
B.Restrictive cardiomyopathy
C.Cardiac tamponade
D.Tricuspid regurgitation
35 year old woman referred for murmur, has a
continuous murmur at the 2nd left intercostal space
A.Tetralogy of Fallot
B.Pulmonary stenosis
C.Patent ductus arteriosus
D.Coarctation of the aorta
35 year old woman with a history of a
murmur since birth, has a grade IV/VI
pansystolic murmur at the left sternal border
A.Tetralogy of Fallot
B.ASD
C.VSD
D.Transposition of the great
arteries
5 year old boy with a history of cyanosis and digital
clubbing, noted to stop and “squat” during play, has
an RV lift, a single S2, and a grade III/VI systolic
ejection murmur at the LUSB
A. Tetralogy of Fallot
B. VSD
C. Pulmonic stenosis
D. ASD
E. Transposition of the great arteries
You are performing routine physical exams for
your local high school athletes. You notice a
continuous murmur over the neck in a healthyappearing 18 y/o girl while she is sitting on the
stretcher. What is the most likely diagnosis
and how do you confirm it?
Venous hum! Lay her back
down and it will go away.
The next patient has a 2/6 midsystolic murmur
at the LUSB with physiologic splitting of S2.
What is the most likely diagnosis?
Innocent murmur
- always < 2/6 murmur
- never diastolic
- never pansystolic
- normal S2
A 30 y/o man presents with chest pain which is less severe
when he sits up and leans forward. On exam, he has a
scratchy sound in systole and diastole heard throughout his
precordium. This is his EKG. Most likely diagnosis is -
A.
B.
C.
D.
Myocardial infarction
Pulmonary embolus
Pericarditis
Pneumothorax
Bonus questions - answers
• B, B, D, C, A, C, C, A
• Venous hum, innocent murmur
• C
• Remember, e-mail me for questions!