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Internal Medicine Board Review

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Internal Medicine Board Review Cardiology II July 17th, 2014 – PowerPoint PPT presentation

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Title: Internal Medicine Board Review


1
  • Internal Medicine Board Review Cardiology II
  • July 17th, 2014

2
Topics
  • EKGs and arrhythmias/conduction abnormalities
  • Myocardial Disease and Cardiomyopathies
  • Pulmonary artery catheters and hemodynamic data
    interpretation
  • Syncope
  • Valvular heart disease

3
HOLD ON!!!
4
Approach to EKGs
  • Always read the question stem first to know what
    you are looking for
  • Think about the clinical context may not even
    need the tracing
  • Look for patterns that fit the clinical situation
  • Dissect the EKG in your usual systematic way

5
EKG interpretation
  • Use your system, whatever it is
  • ie. Mechanism, Structure, Function
  • If the question includes multiple tracings, it is
    usually looking for a pattern beware that two
    are likely very similar. ie. Mitral stenosis
  • Dont forget you can use paper/pencil as poor
    mans calipers

6
EKG interpretation
  • May include 12 lead, 6 lead, 3 lead or rhythm
    strips
  • Pay attention to which leads you are given (and
    the order/arrangement)
  • Look for standardization if voltage is relevant
    (ie. LVH, tamponade)
  • Count big blocks for heart rate (300, 150, 100,
    75, 60)
  • Remember, each small block is 0.04 seconds

7
Frequently Seen Tracings On Boards
  • Conduction Abnormalities
  • AV block, LBBB, RBBB
  • Bradyarrhythmias
  • Sinus brady, A-fib with junctional escape
  • Atrial Tachyarrhythmias
  • Sinus tach, A-fib, A-flutter, AVNRT, MAT
  • Ventricular Arrhythmias
  • VT, AIVR, torsades
  • Acute Infarction (Identify the vascular
    distribution)
  • Pericarditis
  • Tamponade
  • WPW (ventricular pre-excitation)
  • Long QT syndrome
  • Electrolyte Disturbances
  • Hyperkalemia, hypo/hypercalcemia

8
Normal
9
1st degree AV block
10
2nd degree - Mobitz I (Wenckebach)
11
2nd degree (Mobitz II) AV Block
12
21 AV Block
13
3rd degree AV block
14
Left Bundle Branch Block
15
Right Bundle Branch Block
16
Sinus Bradycardia
17
Sick Sinus Syndrome
18
Atrial Fibrillation with Heart Block and
Junctional Escape
19
Premature Atrial Contractions
20
Premature Ventricular Contractions
21
Sinus Tachycardia
22
Atrial Fibrillation
23
Atrial Flutter (21 conduction)
24
Atrial Flutter (41 conduction)
25
Multifocal Atrial Tachycardia
26
AV Node Reentrant Tachycardia
27
Ventricular Tachycardia
28
Frequent PVCs and Nonsustained Ventricular
Tachycardia
29
Ventricular Tachycardia
30
Torsades de Pointes
31
Torsades de Pointes
32
AIVR (Accelerated Idioventricular Rhythm)
33
AIVR (Accelerated Idioventricular Rhythm)
34
LVH with Repolarization
Abnormalities or Hypertrophic
Cardiomyopathy
35
Tamponade (low voltage with
electrical alternans)
36
Low voltage (amyloid)
37
Anterior Acute Infarction (LAD)
38
Inferior Acute Infarction (RCA)
39
Posterolateral Acute Infarction
(Circumflex)
40
Pericarditis
41
Ventricular Pre-excitation (WPW)
42
Atrial Fibrillation with WPW
43
Long QT syndrome
44
Brugada Syndrome
45
S1Q3T3 (Pulm embolus)
46
Ventricular Pacemaker
47
Pacemaker Failure to Capture
48
Hyperkalemia
49
Hyperkalemia
50
Hypo/hypercalcemia
51
ANY QUESTIONS on EKGs????
52
QUESTION 1
  • A 56 y/o man with ischemic cardiomyopathy
    is being maintained on a medical regimen of
    furosemide 40mg twice daily, spironolactone 25mg
    daily, enalapril 10mg twice daily, digoxin
    0.125mg daily, and carvedilol 6.25mg twice daily.
    In an attempt to titrate up to the target dose of
    25mg BID (the dose shown to have the greatest
    mortality benefit), the carvedilol is increased
    to 12.5mg BID. Five days later, the patient
    returns due to worsening dypsnea on exertion and
    orthopnea. Physical exam is consistent with mild
    volume overload. Which of the following steps in
    this patients management is most appropriate at
    this time?
  • Decrease the dose of enalapril
  • Discontinue the digoxin
  • Discontinue the spironolactone
  • Increase the dose of furosemide to reestablish
    euvolemia
  • Discontinue the carvedilol

53
QUESTION 2
  • You are working in an emergency
    department when a 72 year old woman presents with
    increasing shortness of breath over the past
    12-24 hours. She has a diagnosis of heart failure
    after a myocardial infarction several years ago.
    She has been prescribed an excellent medical
    regimen, but she has been intermittently
    compliant recently. On presentation her vital
    signs reveal a heart rate of 94, blood pressure
    of 196/110, respiratory rate of 24, and oxygen
    saturations of 85 on room air. Physical exam
    reveals no significant peripheral edema, normal
    jugular venous pressure, an S4 gallop, and rales
    in the bilateral lung bases. EKG shows sinus
    mechanism, evidence of an old anterior infarct,
    and nonspecific st-t wave changes which is
    unchanged from her EKG 6 months ago. CXR shows
    moderate pulmonary congestion. Complete blood
    count and basic metabolic panel are unremarkable.
    Which of the following would the most appropriate
    NEXT step in the management of this patient?
  • Emergent endotracheal intubation with mechanical
    ventilation
  • Place an intra-aortic balloon pump
  • Take measures to lower the systemic blood
    pressure, such as administering an ACE-I or
    intravenous nitrates
  • High dose intravenous diuretics
  • Obtain serum cardiac biomarkers to rule out
    myocardial infarction

54
QUESTION 3
  • All of the following statements regarding
    heart failure are true EXCEPT
  • Heart failure is defined as the inability of the
    heart to pump blood to the vital organs at normal
    filling pressures.
  • Heart failure now is the most common hospital
    discharge diagnosis in Medicare patients.
  • The diagnosis of heart failure is excluded by
    demonstrating normal left ventricular systolic
    function on echocardiogram.
  • Heart failure is increasing in prevalence due to
    the aging population and better treatment and
    salvage of patients with acute myocardial
    infarction
  • Heart failure is now responsible for greater than
    1 million hospitalizations in the United States
    each year.

55
Myocardial disease
  • Cardiomyopathies
  • Etiology
  • Reversibility
  • Heart failure treatment

56
Cardiomyopathies - Etiology
  • Ischemic
  • Hypertensive
  • Toxin induced ie. EtOH, anthracyclines
  • Metabolic/Infiltrative ie. thyroid, amyloid
  • Associated with general systemic disease ie.
    MDs, CTDs
  • Peripartum
  • Hypertrophic
  • Valvular ie. AS, AI, MR
  • Inflammatory/Infectious ie. post-viral
    myocarditis, HIV, Chagas
  • Idiopathic
  • Familial

57
Question on Myocardial Dz????
58
QUESTION 4
  • A 22 year old woman is admitted to the ICU
    with profound hypotension. She developed a
    cardiomyopathy 4 months ago after delivery of her
    first child and was found to have an ejection
    fraction of 25. She has done well since that
    time until today, when she was found unresponsive
    by family members. Heart rate is 145 bpm with a
    blood pressure of 86/45 on dopamine. A pulmonary
    artery catheter is placed to help guide
    management with the following hemodynamic
    measurements

59
QUESTION 4 (cont)
Right Atrial Pressure Wedge Pressure Cardiac Output Systemic Vascular Resistance Mixed Venous O2 Saturation
6 mm Hg (normal) 11 mm Hg (normal) 14 L/min (elevated) 450 dynes/sec/cm5 (low) 87 (elevated)
60
QUESTION 4 (cont)
  • Which of the following is the most
    appropriate next step in the management of this
    patient?
  • Place an intra-aortic balloon pump and begin
    workup for heart transplant
  • Begin high dose dobutamine
  • CT chest to evaluate for pulmonary embolus
  • Large boluses of isotonic intravenous fluids
  • Draw blood/urine cultures, broad spectrum IV
    antibiotics, and support with vasopressors

61
PA Catheters (Swan-Ganz)
62
Hemodynamics in hypotension
Cardiac Output PCWP RA Pressure SVR MISC.
Hypovolemia Low Low Low High Tachycardia, Dry MM
Sepsis High Low or normal Low or normal Low Low O2 extr. (High MV O2)
Cardiogenic Low High High or normal High High O2 extr. (Low MV O2)
Neurogenic Normal or high Low or normal Low or normal Low May be bradycardic
Pulmonary Embolus Low Low Normal or high High Very high PVR
63
Questions on PA catheters or hemodynamics????

64
QUESTION 5
  • You are consulted by a psychiatrist to see a
    17 year old woman admitted 4 days ago with newly
    diagnosed psychosis. The patient has had several
    episodes of witnessed syncope in the past 2 days.
    The patient is very stoic and unable to provide
    any history. The HP on the chart states that 2
    first degree relatives have died at early ages in
    their sleep, thought to be due to heart
    attacks. Complete blood count and chemistries
    are within normal limits. An EKG is obtained and
    is shown.

65
QUESTION 5 EKG
66
QUESTION 5 (cont)
  • Which of the following is the most
    appropriate initial recommendation at this time?
  • Obtain an echocardiogram to evaluate for
    hypertrophic cardiomyopathy
  • Perform cardiac MRI to evaluate for
    arrhythmogenic right ventricular dyplasia
  • Transfer patient to a telemetry unit to evaluate
    for supraventricular arrythmias
  • Perform tilt table testing to evaluate for
    vasovagal syncope
  • Discontinue medications that are known to prolong
    the Qtc interval

67
Syncope
  • Sudden transient loss of consciousness and
    postural tone with spontaneous recovery without
    neurologic deficit
  • Differentiate from seizure, SCD
  • Diagnosis on boards (and in practice) should be
    made by history, history, history, physical exam,
    or EKG
  • ECHO only when structural heart disease is likely
  • Additional studies guided by history and the
    clinical suspicion of specific disorders

68
Syncope (hints to specific causes)
  • Young athlete with systolic murmur Hypertrophic
    Cardiomyopathy
  • Older patient with systolic murmur Aortic
    Stenosis
  • Young patient with prodrome, prolonged standing,
    or at church Vasovagal
  • Older patient on multiple HTN meds Orthostasis
  • Head rotation or shaving Carotid Sinus
    Sensitivity
  • Arm exercise Subclavian Steal Syndrome
  • With exertion AS, HCM, MS, Pulm HTN
  • Older patient with paroxysmal A-fib Sick Sinus
  • Swimmer look for long QT

69
Valvular Heart Disease
70
Breaking It Down
  • Valvular heart disease (2-5 questions)
  • Aortic stenosis elderly vs younger
  • Aortic regurgitation Marfans 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

71
Whats the diagnosis?
Question
72
Aortic Stenosis
  • Scenarios middle aged adult with bicuspid
    valve, older adult (gt 70) with tricuspid valve
  • Diagnosis
  • Symptoms are chest pain, syncope, CHF
  • PE shows 3-4 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 when symptoms develop or if EF
    lt50, balloon valvuloplasty is only palliative
    and short-lived

73
Aortic Regurgitation
  • Scenario Marfans 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 /- CXR if dissection
  • Mgt afterload reduction with ACE inhibitor or
    nifedipine, valve replacement for EF lt 50 or
    LVESD gt 55mm (or LVEDD gt 75mm)

74
Aortic Regurgitation
75
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, valve repair
    only for severe regurgitation
  • SBE prophylaxis no longer recommended

76
MVP
77
Whats the diagnosis?
78
Hypertrophic Cardiomyopathy
79
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

80
(No Transcript)
81
HCM EKG
82
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

83
Whats the diagnosis?
84
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, balloon
    valvuloplasty is the first line procedure for
    these pts (as opposed to AS)
  • SBE prophylaxis no longer recommended

85
(No Transcript)
86
Question
  • A 51 year old man verbose description with a
    diastolic murmer. more and more words echo
    confirms tricuspid stenosis (MAN!!??) What is
    the most likely etiology?
  • Senile calcification
  • Carcinoid
  • Ebsteins anomaly
  • Rheumatic fever

87
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 poor prognosis if no reversible cause, O2,
    calcium blockers, Coumadin, prostacyclin analogs
    (epoprostenol), endothelin receptor antagonists
    (bosentan), phosphodiesterase-5 inhibitors
    (sildenafil), lung transplantation

88
QUESTIONS ON ANYTHING????
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