6.21.10 rose-jones board review

7/29/2019 6.21.10 Rose-Jones Board Review

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Cardiology Board Review

6.21.10

Lisa Rose-Jones, MD


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CAD


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MKSAP Q 1

60 yo M present to ED w/ chest discomfort for 6hrs. Tx w/ ASA, IV BB, and NTG. Chest painpersists. Initial troponin and CK-MB are

elevated.Pt taken ergently to Cath lab. Occlusion of proxRCA. PCI is successfully. Following morningdoing well on rounds but progessively more

hypotensive. JVP elevated. Nml S1, S2. +S3,brief systolic murmur along L sternal border.ECG is unchanged from previous.


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What is the most likely cause for thispatients current findings?

1. Acute Cardiac tamponade

2. Aortic dissection

3. Left Ventricular Free Wall Rupture

4. Right Ventricular MI

5.Progressive Coronary Ischemia


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*Characteristic RV Infarction:

progressive hypotension (always be weary

of preload reducers like NTG), elevatedJVP, and clear lung fields. +tricuspidregurg

~R precoridal Lead ECG will detect ST elevin V4R

~These pt may require volume challenges


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*Other MECHANICAL COMPLICATIONSfollowing MI:

~Ventricular Septal Rupture

~Papillary Muscle Rupture: hear acute mitral

regurg murmur

~LV Free Wall Rupture => cardiac

tamponade, hypotension and usually death


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Q 2357 yo M comes to ED w/ substernal chest pressure

that developed this AM. PMHx of HTN, stableangina, PVD; his meds are HCTZ and ASA.

BP 110/80, HR 84. No JVP and lungs clear. Nml

S1/2. Abd exam neg, pulses diminished in LE.Continues to have angina at rest. ECG w/changing ST segs and T waves. Trop 0.8. Thepatient is given ASA, BB, and enoxaparin, and is

transferred to the CCU to await angiography.


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What additional therapy should be given inthe CCU?

1. Heparin

2. Warfarin

3. Eptifbatide4. Bivalirudin

5. Diltiazem


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Early treatment w/ Glycoprotein 2b/3areceptor blockade improves outcomes ofPCI. *Indicated only if high risk markers(TIMI Score >3-4, +biomarkers, STdepression, CHF, h/o of recent PCI, orhemodynamic instability.

-Abciximab =only if undergoing PCI-Eptifibitide or Tirofiban (if there is no clear

inidication that PCI will be performed)

*Warfarin offers no protection for Coronary events. SYNERGY trialshowed Enoxaparin and Heparin outcomes nearly equivalent (unlessswitch from LMWH -> UH). Dilitaizem doesnt affect outcomes inCAD.


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Q 3742 yo M @ rural ED w/ severe L shoulder &

chest pain, radiates to jaw. +diaphoresis,dyspnea. No PMHx, no meds. +father hasCABG.

In the ED, IV Heparin, Atenolol, and an ASAare given. BP 100/79, HR 61. No JVP.Nml S1/2. This hospital does NOT have a

Cath lab, closest is 62 miles. Takes 2 hrsto arrange transfer.


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What is the BEST management option forthis patient?

1. Glycoprotein receptor blockade2. Plavix

3. Esmolol

4. Fibrinolytic therapy

5. NTG


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GOAL of all Reperfusion strategies for STEMIis to achieve a patent vessel w/in 90

mins from onset of symptoms.

~4 subgroups in which PCI is preferred:

A. Contraindications of fibrinolytic therapyB. Late arriving STEMI, > 12 hrs after onset

of chest pain w/ contd CP and ST elevs

C. H/O CABGD. Cardiogenic Shock


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REMEMBER for CAD:

Reperfusion arrhythmias (AIVR) usually donot req antiarrhytmics

Do not need Cardiac Cath after Fibrinolysisif ST seg elevation and CP have resolved

Initial management of ACS related tosystemic process, tx the preciptatingfactor 1st (ie pRBCs if GI bleeding)

ASA allergic: give Plavix


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Q 1355 yo M w/ CAD evaluated w/ 2 wks after

having an MI. D/C meds were: ASA,Toprol, ISMN, Lisinopril, and Atorvastatin.Echo revealed inferoposterior akinesis and

LVEF of 40%.Exam: HR 60, BP 13-/70. JVP nml, lungs

clear. Regular s1/s2. Labs: K-5.7, Cr-1.0,

LDL-65. Lisinopril therapy stopped.


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Which of the following medications should bestarted in this patient?

1. Valsartan

2. Spironolactone

3. Amlodipine4. Eplerenone

5. Hydralazine


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SHF MEDS:

ACEi (or if intolerant, ARB)

~will usually tolerate a K to 5.5

B-blocker

Hydralazine/Nitrate combo if cant tolerate anACEi or ARB, or adding specifically if african-american

Spironolactone w/ NYHA class 3 or 4 symptoms Eplerenone (aldo receptor antag) is useful in

reduced EF after AMI


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REMEMBER for HEART FAILURE:

Digoxin alleviates Sx, reducedshospitalization 2/2 HF (not mortality)

Diurese HF pt w/ volume overload 1st,

then beta block Put an AICD in a HF pt that comes in w/

unexplained syncope

Put a Biventricular Device in HF pt onoptimal therapy w/ continued symptomsand QRS > 120 ms


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Arrhythmias


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Q 1423 yo presents w/ palpitations during

exercise. Healthy, no meds. Exam andresting ECG nml. Stress test showssustained monomorphic V tach @ 201

/min. No iscemic changes until arrhythmiadeveloped. The V tach had a Left bundleand infoerior axis morphology.

Terminated spontanesouly 7 mins intorest. ECHO nml, MRI nml.


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What is the most likely etiology of V tach inthis patient?

1. Coronary spasm2. Idiopathic

3. Arrhythmogenic R ventricular

cardiomyopathy4. Infiltrative heart disease

5. Anomalous origin of the coronary arteries


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Idiopathic V Tach (no structural heartdisease) carries a good prognosis. Tx

symptoms, BB first line.

~Expect BP and ST segment elev w/ spasm.

Nml MRI/ECHO rule out infiltrative disease,anomolaus coronaries, or arrhythogenic RVcardiomyopathy (would see fattyinfiltration).


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Q 38 68 yo presents for routine eval. No

complaints other than lumbago. Active,does yoga 3x/week. Meds includeLevothryoxine and HCTZ. Exam: HR 46.

On further questioning, she notespalpitations during a yoga class. 24

Ambulatory monitoring reveals HR of 39-82, avg of 45/min and occ pauses up to 2.9sec. Nml TSH.

Wh t i th BEST t ti f


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What is the BEST management option forthis patient?

1. Pacemaker implantation

2. Exercise stress test

3. Repeat 24 hr monitoring

4. Reassurance and Observation

O h h i d fi i i


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ONLY when there is definitivecorrelation b/w sinus bradycardia andsymptoms, is pacemaker warranted

Class I1. 3rd degree heart block w/ one of following:

a. Bradycardia with symptomsb. other medical conditions that require drugs that cause sx bradyc. Documented asystole 3.0 seconds or any escape rate /= 402. Asymptomatic type II second-degree AV block3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally atelectrophysiological study for other indications4. First-degree AV block with symptoms suggestive of pacemaker syndrome and documentedalleviation of symptoms with temporary AV pacing


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Q 4368 yo F comes to the ED b/c of racing heart

for past 2 hrs. Reports 2 yr history ofsimilar episodes. Been told by PMDs inpast to cough/strain, usually works but not

today. No chest pain, no other cardiachistory.

Exam shows BP of 110/60, HR 165, RR 20.

Lungs clear. Carotids w/o murmurs,attempt massage w/o effect. ECG isshown.


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Which is the drug of choice for terminatingthis patients arrhythmia?

1. Metoprolol2. Verapamil

3. Adneosine

4. Digoxin


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Q 12226 yo nurse is evaluated in the ED after

episode of syncope. While workingstressfull day in the ICU, developedtachycardia and then LOC. +palpitations in

pastExam wnl. CXR wnl. ECG initially

unremarkable. 10 mins later, developed

brief tachycardia. Repeat ECG shown.


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What is the most likely diagnosis in thispatient?

1. Atrioventricular nodal reentranttachycardia

2. Accelerated Idioventricular tachycardia

3. Atrioventircular reentrant tachycardia4. Multifocal atrial tachycardia

AVNRT


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AVNRT: >50% of all SVTs. Circuit involves theAV node, so atria and Ventricle activatedsimultaneously. So p wave usually buried in

QRS.AVRT: Circuit involves an accessory pathway.

Most orthodromic: travels anterograde down AVnode, retrograde up accessory path. Some pts

w/ pre-excitation phenomena: during SR, seeshort PR interval and delta wave (evidence ofpre-excitation)= *WPW

=> ADENOSINE is DRUG of CHOICE,however avoid if any evidence of pre-excitation on ECG


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REMEMBER:

In healthy adults, PVCs at rest are common and notcause for concern

Procainamide is drug of choice in a preexcited A fib DC Cardioversion is 1st line for any unstable tachycardic

pt (hypotensive, signs of HF like diaphoresis, pulmedema)

REMEMBER your CHADS2 score, if >2 give warfarin For A FIB: 1st line is always rate control, only consider

antiarrhytmic or ablation if symptomatic from being incontrolled A fib

A flutter often result of another acute process, considerreferral for ablation earlier as often difficult to ratecontrol


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THE AORTA


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Q 4569 yo M presented to ED for acute onset of

substernal CP radiating to left arm.+former smoker, h/o HTN

On exam: diaphoretic, BP of 210/95 mmHG

in R arm and 164/56 in L arm with HR 90.There is dullness way up R posteriortroax and 2/6 diasolic murmur at RUSB.ECG shows 2-3 mm inferior ST segelevation.

P i ddi i l di i hi h f


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Prior to additional diagnostic tests, which ofthe following is the most appropriateinitial medication?

1. ASA

2. IV Heparin

3. Thrombolytic agent4. Beta blocker

5. ACE inhibitor


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AORTIC DISSECTION: disparate BPs b/warms, diastolic murmur of aortic regurg. DoNOT given ASA, heparin, etc if suspect.

Initial treatment is w/ Beta Blockers todecrease shear stress. Diagnostic testsshould be a TRANSESOPHAGEAL ECHO vs.CHEST CT w/ CONTRAST.

`


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Valvular Disease


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Q 1682 yo presents for annual exam. PMHx: HTN on

chronic BB. Denies all cardiac sx. Takes daily 1mi walk, no change in exercise tolerance.

Exam shows: BP 136/86, HR 80. s1, single s2,grade 3/6 early systolic murmur @ LUSB w/

radiation to carotids. 1+ peripheral edema. LDLis 110. ECHO 2 yrs ago showed moderatecalcific aortic stenosis (velocity was 3.6, valvearea 1.2, gradient 30) with nml LV fxn. NowECHO shows jet velocity of 4.2, valve area of1.0, and gradient of 44).

Wh t i th t i t t t ?


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What is the most appropriate next step?

1. Reassurance2. Begin a cardiac rehab program

3. HCTZ

4. Start statin therapy5. Refer for Aortic valve replacement

Aortic Stenosis:


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Aortic Stenosis:

~Reassurance remains appropriate if asymptomaticand nml exercise tolerance

~w/ severe stenosis the stiff valve doesnt snapshut, thus loose aortic component and get only asingle S2 (a physiologic split S2 has specificity of72% of excluding severe AS)

~controling BP important, but use CAUTION w/ anyperipheral vasodilators b/c compensation inStroke Volume across a stenosed valve my bedifficult!!

~ Symptoms: Angina (5), Syncope (3), HeartFailure (2)


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Q 1936 yo F in the ED w/ fever & dyspnea. 4 wks

of fever to 40C. +heroin use.Exam: 39.6, 100/52, 70, 91% on RA. JVP

12. Bibasilar crackles. HR reg irregulsr. S1,muffled s2. 2/6 diastolic murmur @ R 2ndintercostal space. 1+ pretibial edema.ECG shows a bifascicular block and MobitzII. ECHO shows 2 veges on aortic valve,

w/ leaflet perforation and severe AR.Echoluceny in paravalvular region. Placedon broad spectrum Abx.

Wh t i th t i t t t t t


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What is the most appropriate treatment atthis time?

1. Esmolol IV2. Heparin IV

3. Intraortic ballon pump (IABP)

4. Permanent pacemaker5. Aortic Valve Replacement


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Acute Aortic Regurgitation

Whether from endocarditis or Aorticdissection, this is a SURGICALEMERGENCY!

Esmolol (short acting BB)can slow HR andprolong diastolic filling to aid in forwardoutput in some pts w/ AR (this pt has sig

conduction abnml) IABP is CONTRAINDICATED in AR

Q


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Q 4432 yo M comes in for annual exam. No

personal or fmHx of cardiac disease.Exam: s1/s2, +s4, 2/6 crescendo-decrescendo systolic murmur heard best

at LLSB w/o radiation to carotids.Increased intensity w/ valsalva. Isometrichand grip, passive leg raising decreasesthe intensity. Rapid upstrokes ofperipheral pulses are present.

What is the most likely diagnosis?


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What is the most likely diagnosis?

1. Mitral Valve Prolapse

2. Hypertrophic cardiomyopathy3. Atrial septal defect

4. Ventricular Septal Defect

5. Aortic Stenosis


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Hypertrophic Cardiomyopathy

If preload is increased (isometric hand grip,stand-> squat) = increased systolic dimension ofLV and therefore less obstruction & diminished

murmur, Valsalva = decreased preload soincreased murmur

Tx even asymptomatic pts w/ BB, avoidstrenuous exercise

*different from hypertrophied athletes LV inthat septum is asymmetrically enlarged


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REMEMBER:

ECHO for any Diastolic Murmur,Continuous murmur, or > grade 3/6

Wide, Fixed split S2 think ASD

Secundum ASD can be preparedpercutaneously

6.21.10 rose-jones board review

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