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Internal Medicine Board Review

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Title: Internal Medicine Board Review


1
Internal Medicine Board Review
  • Heart Failure
  • Arrhythmia

March 1, 2010 Gene Kim
2
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4
Functional Class
  • NYHA Functional Class
  • I Asymptomatic
  • II Slight limitation of physical activity
  • III Marked limitation of physical activity
  • IV Unable to perform activity without symptioms.

5
Functional Class
  • ACC/AHA Stages
  • A No structural disease or symptoms.
  • B Structural disease, no symptoms.
  • C Structural disease, symptoms past or
    present.
  • D Refractory symptoms to medical therapy.

6
Question
  • A 70 year old woman is evaluated for a 1-month
    history of DOE and fatigue. She can still perform
    ADLs, including vacuuming, grocery shopping, and
    ascending two flights of stairs carrying laundry.
    She has a history of HTN, mild COPD, and
    smoking. Her medications are lisinopril, HCTZ,
    and albuterol as needed.
  • On PE, she is afebrile. BP is 110/80 mmHg, pulse
    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 Hgb and
    TSH levels. ECG shows low voltage and LAD.
    Echocardiogram shows an EF of 35, global
    hypokinesis, and mild MR. CXR show flattening of
    the diaphrams but is otherwise normal.

7
Which of the following is the most appropriate
treatment?
  1. Amlodipine
  2. Carvedilol
  3. Digoxin
  4. Losartan
  5. Spironolactone

8
Which of the following is the most appropriate
treatment?
  1. Amlodipine
  2. Carvedilol
  3. Digoxin
  4. Losartan
  5. Spironolactone

9
Medical Therapy
  • Angiotensin Converting Enzyme Inhibitors
  • Indicated for any functional class
  • Mortality reduction approx. 20.
  • ß-Blockers
  • Indicated for any functional class
  • Mortality reduction approx. 30.
  • Not to be started in the acute decompensated
    state.

10
Question
  • A 60 yr 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 non-ischemic
    cardiomyopathy (last EF 20). Her current
    medications are lisinopril, carvedilol, digoxin,
    and furosemide. She had an ICD placed one year
    ago.
  • On PE, she is afebrile. BP is 95/75, P 70/min.
    Jugular veins are nondistended, and lungs are
    clear. Cardiac exam reveals normal S1 and S2, no
    S3. There is no edema. Laboratory studies show a
    serum potassium of 4.7 meq/L, creatinine of
    1.8mg/dL, which has been stable for the past year.

11
Which of the following is the most appropriate
addition to her treatment?
  1. Angiotensin receptor blocker
  2. Hydralazine
  3. Metolazone
  4. Spironolactone

12
Which of the following is the most appropriate
addition to her treatment?
  1. Angiotensin receptor blocker
  2. Hydralazine
  3. Metolazone
  4. Spironolactone

13
Medical Therapy
  • Diuretics
  • Used for volume control
  • No data on use
  • Spironolactone
  • Indicated in class III-IV heart failure.
  • Caution in renal insufficiency - hyperkalemia

14
Medical Therapy
  • Digoxin
  • Indicated in class II-IV heart failure.
  • Symptom control no mortality benefit.
  • Hydralazine and Nitrates
  • Indicated in class III-IV heart failure.
  • In addition to ACEi and ß-blockers.
  • 40 mortality reduction in AAHeFT.

15
Question
  • A 37 year old woman with a history of peripartum
    cardiomyopathy several years ago is evaluated 12
    weeks into her second pregnancy. She became
    pregnant despite the use of a combination OCP and
    plans to proceed with the pregnancy. She is
    currently asymptomatic but leads a sedentary
    lifestyle. She is taking no medications.
  • On PE, BP is 110/70 mmHg, pulse 80/min and
    regular. Estimated CVP is 3cm H20 and there is
    no edema.
  • The ECG shows sinus rhythm but is otherwise
    unremarkable. An echocardiogram is performed and
    demonstrates mild left ventricular enlargement
    with a calculated EF of 40. The valves and
    pulmonary pressures are normal.

16
Which of the following medications should be
initiated at this time?
  1. Digoxin
  2. Furosemide
  3. Hydralazine
  4. Lisinopril
  5. Metoprolol

17
Which of the following medications should be
initiated at this time?
  1. Digoxin
  2. Furosemide
  3. Hydralazine
  4. Lisinopril
  5. Metoprolol

18
Question
  • A 40 year old man is hospitalized for a 3-day
    history of progressive fatigue, dyspnea, nausea,
    and early satiety. He has a history of viral
    cardiomyopathy that was diagnosed 3 years ago.
    His last EF was 20 by echo done 3 months ago. An
    ICD was placed 2 years ago for primary
    prophylaxis. Medications are metoprolol and
    enalapril.
  • On PE, he is afebrile and slightly lethargic. BP
    is 80/60 mmHg, pulse 110/min, respiration 20/min.
    Estimated CVP is 5 mmH20, Heart sounds are soft
    ad regular. Lungs are clear. There is mild RUQ
    abdominal tenderness without guarding or rebound.
    No edema is noted.

19
Question - continued
  • Laboratory findings are as follows Hgb 10g/dL
    (down from 12 g/dL one month ago) leukocyte
    count, 9000/uL creatinine, 2.9 mg/dL (up from
    1.3 mg/dL one month ago) ALT, 500 U/L, AST, 860
    U/L (both normal one month ago).
  • ECG shows sinus tachycardia. He is admitted to
    the ICU and a pulmonary artery catheter is placed
    to manage hypotension and for assessment of
    volume status.

20
Question - continued
  • Pulmonary artery catheterization measurements
  • CVP 5 mmHg
  • PA 25/14 mmHg
  • PCWP 14 mmHg
  • Cardiac output 2.54 L/min
  • Cardiac index 1.48 L/min/m2

21
In addition to stopping the metoprolol, which of
the following is the most appropriate treatment?
  1. Intravenous furosemide
  2. Intravenous milrinone
  3. Intravenous nesiritide
  4. Intravenous saline
  5. Packed RBC transfusion

22
In addition to stopping the metoprolol, which of
the following is the most appropriate treatment?
  1. Intravenous furosemide
  2. Intravenous milrinone
  3. Intravenous nesiritide
  4. Intravenous saline
  5. Packed RBC transfusion

23
Management of Acute Decompensated Heart Failure
  • Cardiogenic Shock
  • Sustained hypotension
  • CI lt 2.2 L/min/m2
  • Elevated PCWP gt15mmHg
  • Evaluate for evidence of end organ malperfusion.
  • Treat underlying cause
  • MI
  • Tamponade
  • Volume overload

24
Management of Acute Decompensated Heart Failure
  • Ionotropic support if evidence for end organ
    malperfusion.
  • PA catheter placement if volume status uncertain,
    ongoing hemodynamic instability.
  • Inadequate perfusion despite inotropic support,
    proceed to IABP.

25
Device Therapy
  • ICD
  • NYHA class II III.
  • Survival gt 1 year.
  • EF lt35.
  • SCD-HeFT 23 mortality ?
  • CRT
  • NYHA class III IV.
  • EF lt35
  • QRS gt120 ms, LBBB.

26
Device Therapy
  • Chronic ionotropic support confers high long-term
    mortality (40-90) despite presence of ICD.
  • Ventricular assist device indicated if
    symptomatic heart failure persists.
  • Can serve as bridge to transplantation or as
    destination therapy.

27
Arrhythmia
28
Question
  • A 77 year old woman is admitted for intermittent
    dizziness over the past few days. She does not
    have chest discomfort, dyspnea, palpitations,
    syncope, orthopnea, or edema. She underwent CABG
    surgery 6 years ago after an MI. She has HTN,
    hyperlipidemia, and paroxysmal atrial
    fibrillation with a history of RVR. 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, ASA,
    and warfarin.

29
Question - Continued
  • On PE, BP 137/88 mmHg, pulse 52/min. Estimated
    CVP is 7 cmH20. The PMI is felt in the left
    intercostal space and at the midcostal line.
    Cardiac auscultation reveals bradycardia with a
    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 lungs are clear. 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.

30
Which of the following is the most appropriate
management for this patient?
  1. Add amiodarone
  2. Discontinue metoprolol
  3. Echocardiography
  4. Pacemaker implantation

31
Which of the following is the most appropriate
management for this patient?
  1. Add amiodarone
  2. Discontinue metoprolol
  3. Echocardiography
  4. Pacemaker implantation

32
Bradyarrhythmias
  • Sick Sinus Syndrome
  • Sinus arrest
  • Exit Block
  • Reduced automaticity of SA node
  • Tachy-brady syndrome subtype of SSS
  • RVR during episodes of atrial fibrillation
  • Resting bradycardia between episodes
  • Prolonged sinus pauses upon conversion of Afib

33
Bradyarrhythmias
  • AV Block
  • First degree stable PR prolongation
  • Second degree
  • Mobitz I progressive PR prolongation
  • Mobitz II constant PR interval, intermittent
    non-conducted P waves.
  • Third degree complete heart block.
  • Atrial rate gt ventricular rate.
  • Ventricular rate gt atrial rate is AV dissociation.

34
Question
  • A 26 year old woman who is 25 weeks pregnant is
    evaluated in the ED for palpitations and episodic
    lightheadedness. She has no history of
    cardiovascular disease or tachycardia.
  • On PE, her BP is 100/70 mmHg, pulse is 175/min.
    The estimated CVP is normal and there are no
    carotid bruits. The apical impulse is not
    displaced. The examination is otherwise
    unremarkable.
  • A valsalva maneuver is performed by the patient
    and carotid sinus massage is performed by the
    attending physician, but the tachycardia
    continues.

35
ECG
36
Which of the following medications should be
initiated at this time?
  1. Adenosine
  2. Amiodarone
  3. Digoxin
  4. Diltiazem
  5. Metoprolol

37
Which of the following medications should be
initiated at this time?
  1. Adenosine
  2. Amiodarone
  3. Digoxin
  4. Diltiazem
  5. Metoprolol

38
Tachyarrhythmias
  • Narrow-complex vs Wide Complex?
  • Regular or Irregular?
  • Wide-Complex Tachycardias
  • VT
  • AV dissociation
  • Capture, fusion complexes
  • Concordance
  • SVT with Aberrant conduction

39
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40
Question
  • A 42 year old man is evaluated for recurrent,
    highly symptomatic paroxysmal atrial
    fibrillation. He was initially diagnosed 6 months
    ago. His evaluation revealed no underlying cause
    and his resting ECG and echo were normal. Despite
    treatment with metoprolol, episodes occur 3-4
    times daily and last from a few minutes to
    several hours. During events, he feels drained
    and unable to concentrate, with a sensation of
    irregular heart-beat. He experiences DOE and
    lightheadedness, but denies CP and syncope.
    Episodes are triggered by activity, caffeine, and
    alcohol. He takes no medications other than the
    metoprolol.
  • On PE, BP 130/60, pulse 70/min and regular. S1
    and S2 are normal and there is no murmur or extra
    heart sounds. Estimated CVP is 5 cm H2O and the
    lungs are clear. The remainder of the PE is
    normal.

41
Which of the following is the most appropriate
management for this patient?
  1. Add amiodarone
  2. Add digoxin
  3. 24-hour ambulatory monitoring
  4. Implanted loop recorder

42
Which of the following is the most appropriate
management for this patient?
  1. Add amiodarone
  2. Add digoxin
  3. 24-hour ambulatory monitoring
  4. Implanted loop recorder

43
Atrial Fibrillation
  • Rate control vs rhythm control
  • Asymptomatic
  • Rate control an option
  • Symptomatic
  • Anti-arrhythmic vs non-pharmacologic
  • Anticoagulation based on stroke risk
  • CHADS2 score
  • ASA vs warfarin

44
Anti-arrhythmics
  • Class I sodium channel blockade
  • IA) procainamide
  • IB) lidocaine
  • IC) Flecanide, propafenone
  • Class II ß-blockers
  • Class III potassium channel blockade
  • Amiodarone, Sotalol, dofetilide
  • Class IV Calcium channel blockade

45
Atrial Fibrillation
  • Non-pharmacologic therapies
  • Ablation (pulmonary vein isolation)
  • Patients who cannot tolerate rate control
    strategy.
  • Failed at least one anti-arrhythmic.
  • AV nodal ablation and Pacemaker implantation
  • Renders patient PM dependent.
  • Generally for elderly patients unable to tolerate
    other strategies.

46
Question
  • A 54 year old man is evaluated for recurrent
    arrhythmia. He was diagnosed with atrial flutter
    with RVR 6 weeks ago. Rate control was initially
    difficult to achieve he underwent cardioversion
    and was started on metoprolol. Two days ago, he
    had a recurrence of his arrhythmia his fatigue
    worsened, and he began to experience DOE. He
    denies chest pain, lightheadedness, and heart
    racing. He has no other medical problems, and
    his only other medication is daily aspirin.
  • On PE, BP is 123/65 mmHg, pulse 50/min. BMI is
    24. Cardiac exam 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 with a
    61 block and a ventricular rate of 50/min.

47
Which of the following is the most appropriate
managament for this patient?
  1. Add amiodarone
  2. Add digoxin
  3. Discontinue metoprolol, initiate flecanide
  4. Radiofrequency ablation

48
Which of the following is the most appropriate
managament for this patient?
  1. Add amiodarone
  2. Add digoxin
  3. Discontinue metoprolol, initiate flecanide
  4. Radiofrequency ablation

49
Atrial Flutter
  • Most cases are typical flutter
  • Counterclockwise cavotricuspid isthmus dependent
    circuit.
  • 240-340 cycles/min.
  • Characteristic sawtooth pattern in inferior leads
    on ECG.
  • Cardioversion effective.
  • Ablation is first-line therapy for recurrent
    flutter.
  • 90 success rate, low complication rate.
  • Anticoagulation guidelines same as Afib.

50
Supraventricular Tachycardias
  • AV nodal reentrant tachycardia (60)
  • AV reentrant tachycardia (30)
  • Atrial Tachycardia (10)

51
Wolf-Parkinson-White Syndrome
  • Characterized by ventricular pre-excitation.
  • Symptomatic tachycardia
  • Caution in patients with pre-excited tachycardia.
  • Example rapid atrial fibrillation.
  • AV nodal blocking agents contraindicated.
  • Ablation is now first-line therapy.

52
Question
  • A 67 year old man presented to the ED 2 days ago
    with an acute ST-elevation myocardial infarction.
    During the initial evaluation, he became
    unresponsive due to ventricular fibrillation. He
    was successfully resuscitated and taken to the
    catheterization lab, where a 100 occlusion of
    his proximal LAD was stented. His postinfarction
    course was notable for mild heart failure, which
    has now resolved. His is now stable on his
    current medical regimen. Current medications
    include ASA, metoprolol, lisinopril,
    atorvastatin, and clopidogrel.
  • On PE, BP is 115/72 mmHg, pulse 65/min,
    respirations 12/min. There is no jugular venous
    distension, crackles, murmur, or S3.
    Transthoracic echo reveals mild hypokinesis of
    the anterior wall and a LVEF of 42.

53
Which of the following is the best management
option at this time?
  1. Add amiodarone
  2. Continue medical management
  3. Implantable cardioverter-defibrillator placement
  4. Order electrophysiology study

54
Which of the following is the best management
option at this time?
  1. Add amiodarone
  2. Continue medical management
  3. Implantable cardioverter-defibrillator placement
  4. Order electrophysiology study

55
Ventricular Tachycardia
56
Ventricular Tachycardia
  • Most common mechanism is reentry.
  • Usually monomorphic.
  • Polymorphic VT usually due to genetic disorder
    (long QT, Brugada).
  • Management usually with ICD over medical therapy.

57
Good Luck
  • Please do not panic
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