Cardiology Board Review – Part II
March 21, 2013
A 65-year-old man is evaluated for 2 months of central chest pain with exertion and relief with
rest, exertional dyspnea, orthopnea, and lower-extremity edema. He has a 25-year history of
hypertension and a 44-year history of smoking. His only medication is hydrochlorothiazide.
On physical examination, he is afebrile. Blood pressure is 118/80 mm Hg, pulse is 95/min, and
respiration rate is 16/min. There is mild jugular venous distention. Cardiac examination reveals a
regular rate and rhythm, normal S1 and S2, and no murmurs or S3. Crackles are heard at both lung
bases. There is mild bilateral edema at the ankles. Laboratory studies show a serum troponin T
level of less than 0.01 ng/mL (0.01 µg/L). Electrocardiogram is normal. Echocardiogram shows an
20%
20%hypertrophy
20%
20%
20%
ejection fraction of 40%, global hypokinesis, and mild left
ventricular
Which of the following is the most appropriate diagnostic test?
1.
2.
3.
4.
5.
Cardiac catheterization
Cardiac MRI
Radionuclide ventriculography
Nuclear medicine stress test
Standard exercise stress test
1
2
3
4
5
CHF Etiologies
CHF
Ischemic
Nonischemic
Valvular
Other:
• R-sided failure
• HOCM
• Diastolic
High Output
Dilated
Restrictive
Hyperthyroid
Idiopathic
Amyloidosis
Anemia
Toxins (EtOH,
cocaine)
Hemochromatosis
Tachycardiainduced
Drugs (Chemo,
HAART)
Sarcoidosis
Peripartum
Infections (Viral,
Lyme, Rickettsial)
A 70-year-old woman is evaluated for a 1-month history of dyspnea on exertion and fatigue. She
can still perform activities of daily living, including vacuuming, grocery shopping, and ascending
two flights of stairs carrying laundry. She has a history of hypertension, mild COPD, and smoking.
Her medications are lisinopril, hydrochlorothiazide, and albuterol as needed.
On exam, she is afebrile. BP 110/80 mm Hg and HR 70/min. Jugular veins are not distended.
There is a grade 2/6 holosystolic murmur at the left sternal border that radiates to the axilla,
which was not noted during an examination 1 year ago. Rate and rhythm are regular, S1 and S2
are normal, and there is no S3. The lung sounds are distant but clear without wheezing, and there
is no edema. Laboratory studies show normal hemoglobin and TSH levels. Electrocardiogram
shows low voltage and left axis deviation. Echocardiogram shows an ejection fraction of 35%,
20%
20%
20%
20%
20%
global hypokinesis, and mild mitral regurgitation. Chest radiograph shows flattening of the
diaphragms but is otherwise normal
Which of the following is the most appropriate treatment?
1.
2.
3.
4.
5.
Amlodipine
Carvedilol
Digoxin
Losartan
Spironolactone
1
2
3
4
5
A 60-year-old white woman is evaluated for dyspnea with mild activity (ascending less than one
flight of stairs, walking less than one block on level ground) that has been stable for the past year.
She has a history of nonischemic cardiomyopathy (last ejection fraction 20%). Her current
medications are lisinopril, carvedilol, digoxin, and furosemide. She had an implantable ICD placed
1 year ago.
On physical examination, she is afebrile. Blood pressure is 95/75 mm Hg, and pulse rate is
70/min. Jugular veins are not distended, and the lungs are clear. Cardiac examination discloses a
regular rate and rhythm, no murmurs, normal S1 and S2, and no S3. There is no edema. Laboratory
studies show a serum potassium level of 4.7 meq/L and a creatinine level of 1.8 mg/dL, which has
been stable for the past year.
25%
Which of the following is the most appropriate addition to her 25%
treatment
1.
2.
3.
4.
25%
25%
Angiotensin receptor blocker
Hydralazine
Metolazone
Spironolactone
1
2
3
4
A 65-year-old black man is evaluated during a routine annual visit. Over the past year he has had
a progressive decline in functional status. Last year he could exercise by walking several blocks at
a time, and now he gets tired after one block at most; sometimes he gets short of breath with
dressing and showering. He reports no symptoms of orthopnea or paroxysmal nocturnal dyspnea
and has had no change in medications since last year. He has a 25-year history of hypertension, a
5-year history of ischemic cardiomyopathy, and received an implantable ICD 1 year ago. An
echocardiogram done 6 months ago showed an ejection fraction of 20%. He takes aspirin,
enalapril, metoprolol, spironolactone, furosemide, digoxin, pravastatin, and isosorbide dinitrate.
On physical examination, he is afebrile. Blood pressure is 100/70 mm Hg and pulse is 70/min.
There is no jugular venous distention and the lungs are clear. Cardiac examination discloses a
regular rate and rhythm with no S3 or murmurs. There is no edema.
and Creat
his
25% Hgb
25%
25%are at 25%
baseline. TFTs wnl, EKG shows NSR.
Which of the following is the most appropriate adjustment to this patient’s treatment?
1.
2.
3.
4.
Add hydralazine
Increase digoxin
Increase furosemide
Stop metoprolol
1
2
3
4
NYHA CHF Staging
***know this***
NYHA Stage
Symptoms
1-year mortality
I
asymptomatic
5-10%
II
Slight limitation of activity
15-30%
III
Marked limitation of activity
15-30%
IV
Symptoms at rest
50-60%
CHF Chronic Med Therapy
Med
MOA
Which stage?
Mortality
benefit?
Misc
ACEI
Afterload reduction
All
Decreased by 20%
Bblocker
Prevents remodeling
& prevents
arrhythmias
All
Decreased by 30%
*don’t start if acutely
decompensated
Loop diuretic
diuresis
PRN
None
Can augment with
thiazide
(metolazone)
Digoxin
? Improved
contractility
? III/IV
None
(but does decrease
hospitalizations &
improves symptoms)
Spironolactone
Suppresses Aldo thus
decreases Na
retention
III/IV
Decreased by 30%
Hydralazine &
Isosorbide Dinitrate
Afterload reduction
III/IV (esp African
American)
Decreased in AfricanAmericans
*if cannot tolerate
2/2 gynecomastia,
can substitute
Eplerenone
A 72-year-old man is evaluated for fatigue and dyspnea. Over the last several months to a year,
he has had increasing fatigue, exercise intolerance, and dyspnea on even mild exertion. He
becomes short of breath walking across a room, although he is asymptomatic at rest. He has a
history of coronary artery disease, with a myocardial infarction and four-vessel coronary artery
bypass graft surgery 4 years ago. He also has hyperlipidemia. Medications are aspirin, low-dose
carvedilol, lisinopril, digoxin, spironolactone, furosemide, pravastatin.
On exam, his BP is 92/57 mm Hg, HR 57/min, and RR 12/min. PMI is displaced laterally. Rhythm is
regular and bradycardic. S1 and S2 are normal, with a grade 2/6 to 3/6 holosystolic murmur at the
apex. An S3 is present. Estimated CVP is 8 cm H2O; there is no hepatojugular reflux. The lungs are
clear. There is no ascites. The liver edge is palpable 1 cm below the right costal margin. The lower
extremities are warm with decreased distal pulses bilaterally. There is no ankle edema.
25% QRS25%
ECG demonstrates sinus rhythm with a rate of 55/min. PR interval25%
is 180 msec,
width is 25%
180
msec, and QT interval is 380 msec. Left bundle branch block is seen. A dobutamine stress
echocardiogram reveals a left ventricular ejection fraction of 33% with a large anteroapical area
of akinesis and no ischemia.
Which of the following is the most appropriate management option for this patient?
1.
2.
3.
4.
Add amiodarone
Biventricular pacemaker-defibrillator
Dual-chamber pacemaker
Implantable defibrillator
1
2
3
4
Device Therapy
• ICD
– For prevention of primary sudden cardiac death if:
Class II or III on optimal meds
+
Expected survival > 1 yr
+
EF <35%
– For secondary prevention if:
hx of significant vent arrhythmia or cardiac arrest
• BiV Pacemaker (Cardiac Resynchronization Therapy)
– In CHF, interventricular conduction delay is common -> poor coordination of
ventricular contraction -> poor hemodynamics
– BiV device: one lead pacing RV, one lead in RA to sense intrinsic rhythm, one
lead in coronary sinus to pace LV
– Criteria:
• Class III or IV + EF <35% + Ventricular dyssynchrony (QRS >120ms, LBBB)
– Benefit: increased QOL, increased exercise capacity, decreased symptoms,
decreased mortality 22%
A 45-year-old man with NICM presents to the ED with progressive shortness of breath over one
month and edema but no chest pain. Previously, he was symptomatic with moderate activity
(New York Heart Association class II heart failure). He has a dual-chamber implantable ICD.
Current medications are lisinopril, furosemide, and carvedilol; however, he ran out of carvedilol 6
weeks ago. His most recent echocardiogram 3 months ago showed an EF of 20%.
On exam, he is afebrile, BP 80/50 mm Hg, HR 115/min, and RR 16/min. He has jugular venous
distention. Heart rhythm is regular, and an S3 is heard. Lung examination reveals crackles. Edema
is present. The extremities are cool, and mentation is intact.
Pertinent laboratory results include serum sodium, 130 meq/L, creatinine, 2.6 mg/dL (was normal
1 month ago), troponin <0.01 ng/mL. ECG shows no acute ischemic
changes;25%
QRS duration
25%
25% is 10025%
msec.
Which of the following is the most appropriate treatment at this time?
1.
2.
3.
4.
Intravenous dobutamine
Intravenous furosemide
Intravenous nesiritide
Oral carvedilol
1
2
3
4
Cardiogenic Shock
•
Causes:
– Extensive MI (75%), myocarditis, end stage CM, prolonged bypass, etc
•
Criteria:
– Sustained hypotension + decreased CI (<2.2 L/min/m2) + increased PCWP
•
If evidence of inadequate perfusion, need INOTROPIC support
– Dobutamine – inotrope with some vasodilation
– Dopamine (low-med dose)
•
•
•
1-5µg/kg/min = increased renal blood flow and urine output (dopaminergic agonist properties)
5-15µg/kg/min = increased renal blood flow, increased HR, increased cardiac contractility/cardiac
output (beta-agonist)
>15µg/kg/min = vasoconstriction (alpha-agonist)
– Milrinone – Phosphodiesterase inhibitor in cardiac and vascular tissue – vasodilation and
inotropic effects
•
•
watch for worsened hypotension; don’t use in renal failure
If refractory to meds, consider Intraaortic Balloon Pump
– Inflates during diastole to help with coronary perfusion
– Deflates during systole to help decrease afterload
•
If still refractory, consider LVAD or transplant
A 40-year-old man is admitted to the hospital after an episode of syncope at work. He has had a
1-week history of progressive shortness of breath, orthopnea, and fatigue. On admission he is
found to be hypotensive and is started on intravenous dopamine. Echocardiogram shows dilated
left and right ventricles with a left ventricular ejection fraction of 10% and no regional wall
motion abnormalities. Telemetry shows frequent and prolonged runs of nonsustained ventricular
tachycardia. He has no other medical problems and takes no medications.
On physical examination, he is afebrile. Blood pressure is 70 mm Hg systolic, pulse is 110/min,
and respiration rate is 20/min. The jugular veins are distended. Heart rate is regular, and a
summation gallop is noted. There is no rash or skin lesions. Extremities are cool with no edema.
Labs show a serum troponin level of 5 ng/mL. Chest radiograph shows mild cardiomegaly and
pulmonary edema and no other abnormalities. Electrocardiogram shows sinus tachycardia,
25%Cardiac
25%
25%
25%
normal QRS duration, and frequent premature ventricular complexes.
catheterization
after admission shows normal coronary arteries.
Which of the following is the most appropriate management step?
Biventricular pacemaker placement
Cardiac MRI
Endomyocardial biopsy
Implantable defibrillator placement
1
2
3
4
Who did President Obama pick to win
the NCAA Tournament?
14%
14%
14%
14%
14%
14%
14%
1.
2.
3.
4.
5.
6.
7.
Louisville
Kansas
Duke
Indiana
North Carolina
Gonzaga
Creighton
A 77-year-old woman is admitted to the hospital for intermittent dizziness over the past few days.
She does not have chest discomfort, dyspnea, palpitations, syncope, orthopnea, or edema. She
underwent coronary artery bypass graft surgery 6 years ago after a myocardial infarction. She has
hypertension, hyperlipidemia, and paroxysmal atrial fibrillation with a history of rapid ventricular
response. She notes that over the past several years, she feels she has slowed down and has had
problems with memory, which she attributes to aging. Medications are metoprolol, HCTZ,
pravastatin, lisinopril, aspirin, and warfarin.
On physical examination, her blood pressure is 137/88 mm Hg and her pulse is 52/min. Estimated
central venous pressure is 7 cm H2O. The point of maximal impulse is felt in the fifth intercostal
space and at the midcostal line. Cardiac auscultation reveals bradycardia with regular S1 and S2, as
well as an S4. A grade 2/6 early systolic murmur is heard at the left upper sternal border. The
25%
25%
25%
25%
lungs are clear to auscultation. Edema is not present.
On telemetry, she has sinus bradycardia with rates between 40/min and 50/min, with two
symptomatic sinus pauses of 3 to 5 seconds each.
Which of the following is the most appropriate management for this patient?
1.
2.
3.
4.
Add amiodarone
Discontinue metoprolol
Echocardiography
Pacemaker implantation
1
2
3
4
Bradycardia
•
Don’t forget about Reversible Causes!
–
•
Lyme, hypothyroidism, hyperK, meds, ischemia
Sick Sinus Syndrome/Sinus Node dysfunction
–
–
–
Typically seen in elderly
Associated with paroxysmal Afib/flutter in 50%
Tachy-brady syndrome = common subtype
•
•
Tx: pacemaker + aggressive rate control
AV Block
–
–
1st degree = prolonged PR due to delay within AV node
2nd degree
•
•
Mobitz I (Wenckebach) = progressive delay of conduction within AV node, therefore progressive elongation of PR
resulting in dropped beat
Mobitz II = constant PR with intermittent failure of conduction
–
–
3rd
Needs pacemaker if advanced or symptomatic
degree
•
Escape rate:
–
–
•
•
Junctional (40-60 beats/min) – narrow QRS
Ventricular (slower) – wide QRS
If reversible (Meds, Lyme, ischemia) – can monitor
If nonreversible, need PACEMAKER
A 54-year-old man is evaluated for recurrent arrhythmia. He was diagnosed with atrial flutter
with a rapid ventricular response 6 weeks ago. Rate control was initially difficult to achieve; he
underwent cardioversion and was started on metoprolol. He has had general fatigue since
initiation of metoprolol. Two days ago, he had a recurrence of his arrhythmia; his fatigue
worsened, and he began experiencing dyspnea on exertion. He denies chest pain,
lightheadedness, and heart racing. He has no other medical problems, and his only other
medication is daily aspirin.
On physical examination, his blood pressure is 123/65 mm Hg and his pulse is 50/min. BMI is 24.
Cardiac examination reveals bradycardia with an irregular rhythm, normal S1 and S2, and no
murmurs or gallops. Lungs are clear to auscultation. The electrocardiogram shows atrial flutter
25%
25%
25%
25%
with a 6:1 block and a ventricular rate of 50/min.
Which of the following is the most appropriate management for this patient?
1.
2.
3.
4.
Add amiodarone
Add digoxin
Discontinue metoprolol; initiate flecainide
Radiofrequency ablation
1
2
3
4
Tachycardia
• AVNRT (60% of SVT) –
•
reentry circuit within AV
node
AVRT (30% of SVT) –
accessory pathway
• WPW
Tachycardia
Narrow
Wide
Regular
Sinus
Tach
•
•
•
Atrial
tach
AVRT
Irregular
AVNRT
Flutter
Afib
Preexcitation
(6%)
MAT
If any of the above are unstable - need synchronized cardioversion
If stable: vagal maneuver or adenosine (if AV node part of reentry circuit)
• ***Do NOT use AV nodal blockers if AVRT!!!
After arrhythmia terminated, then check:
EKG: looking for prior MI, LVH, long QT
Echo: looking for underlying structural disease
Labs: electrolytes, TFTs (K, Ca, Mg – disturbances may
precipitate arrhythmias)
SVT with
aberrant
conduction
(20%)
Vtach
(80%)
An 18-year-old woman is evaluated for recurrent syncope. She has experienced four syncopal
episodes in her lifetime, all of which occurred during activity. The most recent was last week,
when she dove into a pool and had a brief loss of consciousness. Episodes have no prodrome,
and she has had no dizziness. She is healthy and active, without cardiopulmonary complaints, and
takes no medications. Her maternal cousin drowned at age 10 years, and her mother has been
diagnosed with a seizure disorder.
On physical examination, her blood pressure is 112/65 mm Hg and her pulse is 67/min and
regular. The cardiopulmonary and general physical examinations
are normal.
25%
25%
25%
25%
Which of the following is the most likely diagnosis?
1. Brugada syndrome
2. Long QT syndrome
3. Short QT syndrome
4. Wolff-Parkinson-White syndrome
1
2
3
4
A 67-year-old man presented to the emergency department 2 days ago with an acute STelevation myocardial infarction. During the initial evaluation, he became unresponsive due to
ventricular fibrillation. He was successfully resuscitated and taken to the cardiac catheterization
lab, where a 100% occlusion of his proximal left anterior descending artery was stented. His
postinfarction course was notable for mild heart failure, which has now resolved. He is now
stable on his current medical regimen. Current medications include aspirin, metoprolol,
atorvastatin, clopidogrel, and lisinopril.
On physical examination, his blood pressure is 115/72 mm Hg, his pulse is 65/min, and his
respiration rate is 12/min. There is no jugular venous distention, crackles, murmur, or S3.
Transthoracic echocardiogram reveals mild hypokinesis of the anterior wall and a left ventricular
25%
25%
25%
25%
ejection fraction of 42%.
Which of the following is the best management option at this time?
1.
2.
3.
4.
Add amiodarone
Continue medical management
Implantable cardioverter-defibrillator placement
Order electrophysiology study
1
2
3
4
Tachycardia Pearls…
•
Afib cardioversion for long-term control:
– Without anticoagulation if Afib <48h
– If >48h, need at least 3 weeks of therapeutic INR OR negative TEE while on heparin gtt
*need 4 weeks anticoagulation after cardioversion
•
WPW = AVRT
*If Afib, use PROCAINAMIDE
– No AV nodal blocking agents if Afib -> will go into Vfib!!!
•
•
PVCs – treat only if symptomatic (AVN blockers)
NSVT – (total duration <30s)
–
–
–
If symptomatic – use AVN blockers
Treat reversible ischemia if present
ICD if EF <35% (to protect from SVT)
•
•
SVT (>30s)
–
–
–
•
EP study if EF 35-55% -> if can induce SVT, then ICD needed
Commonly seen with prior MI
Amio or Lidocaine in acute setting (unless unstable – then cardioversion)
ICD if EF 35%; EP study if >35% for decision on ICD
Sudden Cardiac Death
–
Vfib = most common cause
•
•
Triggers: electrolyte disturbances, druge (cocaine, QT prolonging agents, etc), acute stress
Genetics: familial dilated CM, HOCM, long QT syndrome, Brugada Syndrome
Which team has won the most NCAA
Tournament Championships?
14%
14%
14%
14%
14%
14%
14%
1.
2.
3.
4.
5.
6.
7.
Kentucky
Duke
UNC
Indiana
UCLA
Michigan State
Kansas
A 45-year-old man is evaluated in the emergency department for a 2-day history of substernal
sharp intermittent chest pain that is aggravated by deep breaths. He began experiencing severe
chest pain 4 hours prior to his emergency department visit. He has a 3-day history of
nonproductive cough, sore throat, myalgias, and malaise. He has had hypertension for 12 years.
His medications are hydrochlorothiazide and amlodipine.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 168/100 mm Hg,
pulse is 110/min, and respiration rate is 26/min. Oxygen saturation on ambient air is 96%. The
patient’s face and chest appear diaphoretic. The oropharynx is erythematous. There is no jugular
venous distention and no hepatojugular reflux. Cardiac examination discloses a two-component
rub that is loudest at the apex, distant heart sounds, and no murmurs. Pulmonary examination
discloses normal breath sounds and no crackles. Initial serum troponin T level is 0.6 ng/mL. ECG
20%
20%
20%
shows sinus tachycardia and concave upward ST-segment elevation20%
in leads
V1 through
V20%
6. Chest
radiograph shows no infiltrates and a normal cardiac silhouette.
Which of the following is the most likely diagnosis?
1. Acute myocardial infarction
2. Acute viral pericarditis
3. Costochondritis
4. Pleuritis
5. Pulmonary embolism
1
2
3
4
5
A 34-year-old woman is evaluated for sharp intermittent pleuritic chest pain that has persisted
for 1 week. The pain is worse when she lies down in the supine position. She has had no fever,
chills, cough, or weight loss. She had acute viral pericarditis 6 months ago that was treated
initially with ibuprofen, but when she failed to respond after 3 days, a 10-day tapering dosage of
prednisone was instituted, leading to resolution of clinical symptoms.
Cardiac examination discloses a pericardial friction rub at the lower left sternal border but no
gallops. ECG consistent with acute pericarditis.
Which of the following is the most appropriate treatment?
1.
2.
3.
4.
25%
25%
25%
2
3
25%
Colchicine
High-dose ASA
High-dose Ibuprofen
Prednisone
1
4
Acute Pericarditis
• Acute Therapy
Causes
– 1st line: Anti-inflammatories
(taper over 4-6 weeks)
• High dose ASA 650mg q4-6h
– Preferred if pt post-MI
Idiopathic
Viral
Bacterial
Uremia
Neoplasm
Other
• Ibuprofen 800mg q8h
– Not if renal failure
– 2nd line: Colchicine (add to 1st
line if persistent symptoms)
• Not if renal failure
– 3rd line: Prednisone 60mg/d
– Avoid anticoagulation
• 10-30% will recur
– Colchicine for recurrent
disease
A 45-year-old man is evaluated in the emergency department for a 3-day history of progressively
worsening dyspnea on exertion to the point that he is unable to walk more than one block
without resting. He has had sharp intermittent pleuritic chest pain and a nonproductive cough
with myalgias and malaise for 7 days and has had orthostatic dizziness for 2 days. He is taking no
medications.
On exam, temperature is 37.7 °C (99.9 °F), blood pressure is 88/44 mm Hg, pulse is 125/min, and
respiration rate is 29/min. O2 Sat is 95%. Pulsus paradoxus is 15 mm Hg. Estimated CVP is 10 cm
H2O. He has muffled heart sounds with no rubs. Lung auscultation reveals normal breath sounds
and no crackles. There is 2+ pedal edema. Blood pressure and heart rate are unchanged after a
500-mL intravenous normal saline challenge.
25%
25%
25%
ECG shows sinus tachycardia, diffuse low voltage, and no ST-segment25%
shifts. Echocardiogram
shows a large circumferential pericardial effusion, right ventricular and atrial free wall diastolic
collapse, normal left ventricular systolic function, and an ejection fraction of 70%.
Which of the following is the most appropriate treatment?
1.
2.
3.
4.
Dobutamine
Levofloxacin & Tobramycin
Pericardiocentesis
Surgical Pericardiectomy
1
2
3
4
Tamponade
• Clinical:
– Dyspnea, tachycardia, +JVD,
hypotension
• Echo clues:
– Diastolic collapse of R sided
chambers
– Increased respiratory variation of
mitral & tricuspid inflow velocities
– IVD dilation
• Treatment:
– Volume & pressors &
– Avoid mechanical ventilation!!
(decreases venous return)
– If due to dissection,
pericardiocentesis can exacerbate
instability, so need surgery
A 45-year-old man is evaluated for a 6-month history of progressive dyspnea on exertion and
lower-extremity edema. He can now walk only one block before needing to rest. He reports
orthostatic dizziness in the last 2 weeks. He denies chest pain, palpitations, or syncope. He was
diagnosed 15 years ago with non-Hodgkin lymphoma, which was treated with chest irradiation
and chemotherapy and is now in remission. He also has type 2 diabetes mellitus. He takes
furosemide (80 mg, 3 times daily), glyburide, and low-dose aspirin.
On physical examination, he is afebrile. Blood pressure is 125/60 mm Hg supine and 100/50 mm
Hg standing; pulse is 90/min supine and 110/min standing. Respiration rate is 23/min. BMI is 28.
There is jugular venous distention and jugular venous engorgement with inspiration. Estimated
central venous pressure is 15 cm H2O. Cardiac examination discloses diminished heart sounds and
a prominent early diastolic sound but no gallops or murmurs. Pulmonary auscultation discloses
normal breath sounds and no crackles. Abdominal examination shows
25% shifting
25% dullness,
25%and lower
25%
extremities show 3+ pitting edema to the level of the knees. The remainder of the physical
examination is normal.
Creat 2, BUN 40, total cholesterol 300, Albumin 3.0, ALT 130, AST 112, UA negative for protein
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Restrictive Cardiomyopathy
Constrictive Pericarditis
Nephrotic Syndrome
Systolic Heart Failure
1
2
3
4
Constrictive Pericarditis vs Restrictive Cardiomyopathy
Both result in severe diastolic dysfunction and restricted ventricular filling
Both present thus with R-sided heart failure signs/symptoms
Constrictive Pericarditis
Restrictive
Cardiomyopathy
Etiology
Same as Pericarditis
Infiltrative Diseases
(amyloid, sarcoid, etc)
BNP
normal
Typically elevated
CXR: pericardial calcifications
+/-
-
EKG: Presence of BBB
Not supportive
Supports dx
Echo: LVH and atrial enlargement
-
+
Echo: diastolic motion of septum
+
-
Echo:
decreased LV filling during
inspiration
+ (Kussmaul’s sign)
-
MRI: increased pericardial thickness
+
-
RHC: Equalized diastolic LV and RV
+
-
pressures
How many times have all 4 #1 seeds
made it to the Final Four?
20%
20%
20%
20%
20%
1.
2.
3.
4.
5.
1
2
3
4
5
A 35-year-old black woman is evaluated for progressive dyspnea 3 weeks after delivery of her
first child. Other than hypertension during pregnancy, the pregnancy and delivery were
uncomplicated. She has no history of cardiovascular disease.
On physical examination, the blood pressure is 110/70 mm Hg in both upper extremities, the
heart rate is 105/min and regular, and the respiratory rate is 28/min. The estimated central
venous pressure is 10 cm H2O and there are no carotid bruits. The apical impulse is displaced and
diffuse. There is a grade 2/6 holosystolic murmur noted at the apex. Third and fourth heart
sounds are also noted at the apex. There is dullness to percussion at the posterior lung bases
bilaterally, and there are crackles extending up half of the lung fields. Lower extremity pulses are
normal and without delay, but pedal edema is present.
25%
25% or25%
The electrocardiogram demonstrates sinus tachycardia. There are
no ST-segment
T-wave 25%
changes. The chest radiograph demonstrates bilateral pleural effusions and interstitial infiltrates.
The aortic contour is unremarkable.
Which of the following is the most likely cause of the patient’s current symptoms?
1.
2.
3.
4.
Acute Myocardial Infarction
Aortic Dissection
Coarctation of the Aorta
Peripartum Cardiomyopathy
1
2
3
4
CV Disease & Pregnancy
• Meds to Avoid in Pregnancy:
– Warfarin, ACEI/ARB, Nitroprusside, Amio
• Peripartum Cardiomyopathy (*Major cause of
pregnancy-related deaths in North America)
– occurs during the last trimester of pregnancy or up to 6
months postpartum in the absence of an identifiable cause
– RF: multifetal pregnancies, multiparous women; >30 yo,
black women, gestational hypertension, preeclampsia
– Tx: delivery & typical heart failure management (avoiding
ACEI/ARB)
• Anticoag if EF <35% (LMWH)
• Consider IVIG or Pentoxifylline
How many times has the
Championship game went into
overtime?
20%
20%
20%
20%
20%
1.
2.
3.
4.
5.
5
6
7
8
9
A 32-year-old woman presents for evaluation of a murmur recently heard on physical
examination. She has noted mild reduction in exercise capacity over the past 6 to 12 months. She
has no known history of cardiovascular disease, although a murmur was reported early in life.
On physical examination, the blood pressure is 100/70 mm Hg and the pulse is 68/min and
regular. The estimated central venous pressure is mildly elevated; the jugular venous pulse
contour demonstrates equal a and v waves. The apical impulse is not displaced. There is an
impulse noted along the left sternal border. The S1 is normal. The S2 is split throughout the
respiratory cycle. A grade 2/6 midsystolic murmur is noted at the second left intercostal space.
There is a grade 2/6 diastolic rumble noted at the lower left sternal border. Both of these
murmurs increase with inspiration. The remaining findings on physical examination are
unremarkable. An electrocardiogram demonstrates normal sinus rhythm with normal axis and
20%
20%
20%
20%
20%
intervals.
Which of the following is the most likely diagnosis in this patient?
1.
2.
3.
4.
5.
Atrial septal defect
Hypertrophic cardiomyopathy
Left atrial myxoma
Pulmonary arterial hypertension
Rheumatic mitral stenosis
1
2
3
4
5
An asymptomatic 25-year-old man is evaluated for hypertension diagnosed during a recent preemployment physical examination. He does not remember being told about hypertension in the
past, and he has no family history of hypertension. He is not taking any medications.
On physical examination, his blood pressure is 170/60 mm Hg in both upper extremities. The
heart rate is 65/min and regular. Carotid examination is normal; estimated central venous
pressure is not elevated. The apical impulse is displaced and sustained. An ejection click is noted
at the apex and left sternal border. There is a grade 2/6 early systolic murmur noted at the
second right intercostal space. No diastolic murmur is noted over the anterior precordium.
Systolic and diastolic murmurs are noted over the patient’s back. There is no bruit noted over the
abdomen. The lower extremity pulses are reduced and delayed.
25%
25%
25%
2
3
25%
Which of the following is the most likely diagnosis in this patient?
1.
2.
3.
4.
Coarctation of the aorta
Essential hypertension
Pheochromocytoma
Renal artery stenosis
1
4
Adult Congenital Heart Disease - Pearls
• ASD
*Fixed Split S2, midsystolic flow murmur & tricuspid diastole rumble
*a wave = v wave
• VSD
– Holosystolic murmur at LLSB (often obliterates S2)
– If large, can cause Eisenmenger’s syndrome (irreversible pulm vascular disease due
to longstanding shunt with reversal of flow)
– Down’s syndrome
• PFO
– Often found in adults when they present with stroke (paradoxical embolus)
– Some association with migraine headaches
• Coarctation
– Associated with Turner’s and bicuspid Aortic valve
– Increased BP in arms compared to legs, radial-to-femoral artery delay, systolic
murmur often with +S4, “rib notching” and “figure 3 sign” on CXR
• PDA
– Persistence associated with maternal rubella and premies
– “Machine-like” murmur at L infraclavicular area, wide pulse pressure
14%
14%
14%
14%
14%
14%
14%
Where is this year’s Final Four being
played??
1.
2.
3.
4.
5.
6.
7.
Charleston
Chicago
New York
San Antonio
Atlanta
Miami
San Francisco
A 57-year old man is evaluated for cramping discomfort in the right thigh, which occurs when
walking two blocks and is relieved quickly with rest. The patient is a house painter who goes up
and down ladders frequently in the course of his work. He is a current smoker with a 40-packyear history. His brother has coronary artery disease, and his mother died at age 65 of a heart
attack. He is taking no medications.
On physical examination, his temperature is normal, pulse is 72/min and regular, and his
respiration rate is 16/min. The blood pressure in his right and left arms is 140/84 mm Hg and
140/82 mm Hg. His highest right ankle/foot systolic pressure is 138 mm Hg, and his highest left
ankle/foot systolic pressure is 142 mm Hg. Examination of his lower extremities reveals scant hair
present below mid-shin level. There is no abdominal or femoral bruit. Distal pulses are present
but diminished. Capillary refill in the toes is intact, and there is no
pedal edema,
skin
25%
25% varicosities,
25%
25%
breakdown, or ulceration. Results of a neurologic examination are normal.
Which of the following is the most appropriate management option for this patient?
1.
2.
3.
4.
MRI of the lumbosacral spine
Measurement of ankle-brachial index with exercise
Treatment with ibuprofen
Venous duplex ultrasonography of the lower extremities
1
2
3
4
Peripheral Arterial Disease
• Symptoms (Claudication):
– Mild-Mod: leg fatigue,
difficulty walking, atypical
leg pain
– Severe: pain at rest,
ulceration, gangrene
• DDx:
– OA, sensory neuropathy,
Msk pain, Venous disease,
Lumbar radiculopathy,
Spinal Stenosis
(pseudoclaudication)
• Claudication sites:
PAD - Diagnosis
• ABIs (ankle pressure/brachial pressure)
–
–
–
–
–
1.0-1.30 – normal
0.91-0.99 – borderline
0.41-0.90 – mild-moderate PAD
0.00-0.40 – severe PAD
If >1.30 = noncompressible artery -> needs to try toe-brachial index
• Exercise ABIs
– If normal ABIs but high suspicion for PAD
– If ABI decrease by 20% post-exercise, then patient has significant PAD
• Segmental Limb Pressure recordings
– To locate affected region
• MRA vs CTA
– To locate affected region
A 68-year-old man is evaluated for left calf pain that occurs after walking 2 to 3 blocks and is
relieved with rest; he has had the pain for about 6 months. He has a history of coronary artery
disease with depressed left ventricular systolic function (left ventricular ejection fraction, 30%)
treated with coronary artery bypass grafting 2 years ago and subsequent implanted cardiac
defibrillator placement for primary prevention purposes. He has hypertension and
hyperlipidemia, and is a prior cigarette smoker. His medications include atorvastatin, aspirin,
metoprolol, and lisinopril.
On physical examination, blood pressure is 110/70 mm Hg, pulse is 68/min and regular, and
respiration rate is 16/min. Peripheral pulses are diminished. There is no skin breakdown or
ulceration and no abdominal or femoral bruits. Ankle-brachial index is 0.7 on the left and 1.0 on
the right. Segmental plethysmography demonstrates a pressure drop of 20 mm Hg below the left
25%
25%
25%
25%
knee.
Which of the following is the most appropriate treatment for this patient?
1.
2.
3.
4.
Femoral-popliteal bypass
Medical treatment with cilostazol
Percutaneous intervention
Supervised exercise program
1
2
3
4
PAD - Treatment
• If no lifestyle limiting symptoms:
–
–
–
–
RF modification (LDL <100, statin, stop smoking)
ASA, Bblocker
Exercise
Consider cilostasol if claudication (but not in CAD)
• If lifestyle limiting symptoms:
– Angioplasty (best for short segments of large calibur
vessels)
– Bypass (best for distal, mutivessel occlusive disease)
When was the last time a team
entered the NCAA tournament with an
undefeated record?
17%
17%
17%
17%
17%
17%
1.
2.
3.
4.
5.
6.
2001
1991
2005
1995
1985
1984
A 72-year-old man is evaluated in the emergency department for acute severe pain during rest in
the lower left leg that began 3 days ago. The patient has repeatedly used
oxycodone/acetaminophen that he had at home for relief of pain. His pain is now much better,
but he finds that he is having difficulty walking. He has had progressive exertional pain in the
lower left leg over the past year. Five years ago, he had a left femoral popliteal bypass for
occlusive peripheral arterial disease with distal ulceration. He has hypertension and
hyperlipidemia. He has a 50 pack-year smoking history. Current daily medications include aspirin,
lisinopril, hydrochlorothiazide, and simvastatin.
On physical examination, the patient’s temperature is 37.8 °C (100.1 °F), blood pressure is 106/60
mm Hg, pulse is 100/min, and respiration rate is 20/min. The left lower extremity is pale and cool
from the toes to the mid shin, and there is a small ulceration on the ball of the left foot. The left
posterior tibialis and dorsalis pedis pulses are not palpable and cannot
identified25%
by Doppler
25% be 25%
25%
ultrasonography. Venous Doppler signals are audible. The left foot and calf feel stiff, and the
patient can only weakly flex the foot. Toe movement on the left side is minimal, and sensation to
light touch is absent.
Which of the following is the most appropriate treatment for this patient?
1.
2.
3.
4.
Emergent surgical revascularization
Intravenous heparin
Intra-arterial thrombolytic therapy
Prompt amputation
1
2
3
4
Acute Limb Ischemia!!
• Remember the 6 P’s!
• Due to embolus or thrombosis = ACUTE SX
• Management:
– Class I: mod-severe claudication but NO rest pain
• ASA, heparin, surgery consult
– Class II: PAIN AT REST
• URGENT intervention; consider lytics
– Class III: irreversible disease (absent dopplers,
profound anesthesia, paralysis)
• Need amputation