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. • [email protected] 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!