1. Sandra Rodriguez Internal Medicine 2008
PEARLS IN CARDIOLOGY
Sandra Rodriguez
Internal Medicine
2008

2. Jugular venous Pulse “a” is RA contraction
“c” is bulging of TV during RV systole.
“x” downward displacement of TV.
“v” is atrial filling at systole, TV closed.
“y” is passive atrial emptying.

3. Jugular Venous Pulse Giant “a” wave: Tricuspid stenosis
Pulmonary stenosis
Pulmonary hypertension
Canon “a” wave: (against a closed valve):
Junctional rhythm
Slow ventricular tachycardia
2:1 A-V block
Bigeminy
Absent “a” wave:
Atrial Fibrilation

4. Jugular Venous Pulse Prominent x and y: Constrictive pericarditis
Prominent “x” descent:
Cardiac tamponade
Constrictive pericarditis
Absent “x” descent:
RV infarction
Prominent “v” wave:
Tricuspid regurgitation
Prominent “y” descent:
Slow “y” descent:
TS and RA mixoma.
Absent “y” descent:
Prominent x and y: Constrictive pericarditis
Prominent x and absent y: Cardiac tamponade
Absent x and y: RV infarct.

5. Questions
A 34 year-old patient is on Ma Huang for losing weight. She presents with shortness of breath. EKG shows wide complex tachycardia. HR is 140/min. Cannon “a” waves are present. Cause?
a. Sinus tachycardia with WPW
b. Sinus tachycardia with aberrant conduction
c. Atrial fibrilation with aberrant conduction.
d. Ventricular tachycardia.

6. Murmurs With inspiration: R side murmurs increase, L side decrease.
With standing: HCM and MVP get louder.
With squatting or passive leg raising: HCM and MVP become softer and delayed.
With valsalva: HCM and MVP get louder and longer.
With amyl nitrite inhalation (decreases LV cavity): AR, MR and VSD decrease while those of HCM and AS increase.
With exercise (hand grip): HCM and AS decrease.
With standing, valsalva, and inhalation of amyl nitrited (all decrease venous return or LV cavity size): Murmurs of HCM and MVP increase in intensity. All others decrease.
With isometric exercise and squatting (all increase LV cavity size): Murmur of HCM is decreased.
With isometric exercise and valsalva: Murmur of AS is decreased in intensity.

7. Questions
2. Murmur of which of the following increases with valsalva and decreases with squatting:
a. Mitral Regurgitation.
b. Hypertrophic cardiomyopathy (HCM)
c. Aortic stenosis
3. What happens to the murmur of AS with valsalva and hand-grip exercise?
a. Increase, decrease
b. Decrease, decrease
c. Decrease, increase.

8. Splitting of S2 INSPIRATION EXPIRATION Normal splitting s1 A2 P2 P2 A2
Wide splitting (PS,MR,RBBB, VSD,PDA
Paradoxical splitting (AS, LBBB, HCM, LVH)
P A2
Fixed splitting (ASD)

9. Questions
A 44 y/o females has history of increasing SOB with exertion over the last 3 months. PE: Fixed split S2 with a murmur consistent with TR. Rest of HPI is unremarkable. CXR: increased LA, RA, RV and pulmonary circulation. What is the most likely diagnosis?
a. Mitral regurgitation
b. Aortic stenosis
c. Hypertrophic obstructive cardiomyopathy
d. Atrial septal defect
e. Ventricular septal defect

10. Questions A Wide splitting of S2 is representative of:
a. Normal sinus rhythm with RBBB.
b. Normal sinus rhythm with LBBB.
c. Hypertrophic cardiomyopathy.
Reversed splitting of S2 occurs in which:
a. ASD
b. RBBB
c. Hypertrophic cardiomyopathy

11. Heart sounds
2nd sound and opening snap of MS are best heard on the base.
LSB: TR, AR, VSD, HCM
Apex: MR, MS, AS.
Below L clavicle: PS, PDA as continuous.
Radiation to L axila: MR.
Radiation to RSB and carotids: AS
Radiation all over the precordium: VSD
MS: Loud S1, Split S2, opening snap, rumbling diastolic murmur in apex. Area <2.5 cm, symptoms correlate.
PR: Diastolic, decrescendo at LSB (Graham Steel)

12. Questions
6. A 52 y/o female presents with history of increasing SOB and LE edema. CXR shows pulmonary congestion, straightening of left heart border and Kerle B lines. EKG: sinus tachycardia with LAE, RBBB. PE: Loud S1, opening snap and diastolic murmur at the apex, and SEM in precordium. What is the diagnosis?
a. Aortic insufficiency
b. Mitral stenosis
c. Aortic stenosis
d. Hypertrophic obstructive cardiomyopathy.

13. Questions
7. A 33 y/o pregnant patient in second trimester has SOB due to MS that is not responding to medical treatment. ECHO shows MV of 0.5cm. What is next step:
a. Mitral valvotomy after delivery.
b. Offer pregnancy termination.
c. Mitral valvotomy now.
d. Mitral valve replacement now

14. Mitral Valve Regurgitation
Etiology:
Myxomatous degeneration
Rheumatic disease
Endocarditis
Grades 1 to 4
Surgical indications
If symptomatic
EF<60%
LVES diameter >4.5cm
Pulmonary pressure >55mmg Hg

15. Questions
A 41 year-old asymptomatic female with MVP and mitral regurgitation is presented. An ECHO shows severe MR with EF of 50%. CAD is ruled out. What is your advice regarding her treatment?
a. Refer for valve replacement.
b. Follow up closely.
c. Begin a diuretic plus ACE-inhibitor.

16. Aortic Stenosis Aortic Stenosis HCM Location of murmur
Apex and R 2nd intercostal space radiating to carotids.
LSB,
With thrill
Not radiating
Second sound
No component A2
Present A2
Carotid Pulse
Slowly rising
Brisk or bifid

17. Aortic Stenosis Grades:
Mild: Valve area of >1 cm2 or gradient < 40mmHg.
Moderate: Valve area of 0.75 to 1 cm2 or gradient mmHg.
Severe: Valve area <0.75 cm2 or gradient >70 mmHg.
Surgery: If symptoms. Angina, syncope, dyspnea, CHF. If not, risk of death 10-20% per year.
If not suitable for valve replacement valvuloplasty is alternative.

18. Question
A 71 year-old females has dizzy spells with near fainting. An echocardiogram shows calcified aortic valve with area of 0.5cm2. The peak systolic valve gradient is 90mmHg. She lives alone and wants everything done for her. What is the next step?
a. Coronary arteriography
b. ACE-Inhibitor
c. Exercise stress test
d. Exercise program with low dose diuretics
e. Aortic valve replacement

19. Question
A 73 years old patient with R hip fracture, noted to have a SEM. Echo shows AV area of 0.76cm and gradient of 50mmHg, normal LV function. Pt is active and asymptomatic. What is the next step?
a. Balloon valvuloplasty prior to surgery.
b. Cardiac catheterization.
c. Proceed with hip surgery.
d. Aortic valve replacement before hip surgery.

20. Questions
A 23 y/o male presents to the ER with witnessed syncope while running to catch a bus. There was no observed postictal state. At PE brisk carotid upstroke. SEM 3/6 at LSB with a systolic thrill. Murmur increase upon standing. What is the most likeky diagnosis?
a. Rheumatic mitral regurgitation
b. Congenital aortic stenosis
c. Hypertrophic obstructive cardiomyopathy
d. Ebstein’s anomaly

21. DVT/PE prophylaxis Start before or shortly after surgery.
Total knee replacement minimum duration is 7 to 10 days with LMWH or warfarin.
Total hip replacement minimum duration is days with LMWH or warfarin.
IPC only for patients at high risk of bleeding.

22. Questions A patient with PE is in shock. Next step?
a. Thrombolysis
b. Embolectomy
c. Heparin
A 63 year old construction worker with h/o 3 episodes of DVT on coumadin, INR 2.5 comes again with DVT. What to do?
a. Increase dose of coumadin
b. Add low molecular weigth heparin
c. Greenfield filter

23. PAW=RA=RV=PA Cardiac Tamponade Constrictive Pericarditis
Right Ventricular Infarction
Equal Diastolic Pressures
Present
Present/Absent
Calcification on X-Ray, CT/MRI
Absent
ECHO
Effusion with diastolic collapse
Thick/calcified pericardium
Large RV size
EKG
Low voltage and elect. alternans
Low voltage
ST elevation on Right leads
Prominent X
Prominent Y
Pericardial Knock
Pulsus Paradoxus
Absent in 2/3 of pt
Kussmaul sign
Absent/Present

24. Cardiac Tamponade
Causes: Viral, Metastasis, idiopathic, uremic, trauma, cardiac rupture, aortic disection.
Features:
Depends on the rapidity of fluid accumulation.
Limited ventricular filling in diastole, absent Y
Low cardiac output, hypotension, tachycardia,
High jugular venous pressure with prominent x descent.
Paradoxical pulse, lungs clear, faint heart sounds
EKG: Electrical alternans, low voltage
Cath: Equalization of pressures (RA, RV, PA, PCWP)
Echocardiogram: RV, RA diastolic collapse, IVC dilation
Treatment: Pericardiocentesis, IV fluids, surgery.

25. Constrictive Pericarditis
Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB, cancer, uremia.
Features:
Filling is reduced abruptly because thickened pericardium
Stroke volume is reduced, equalization of pressures.
High jugular venous pressure with prominent x and y descents, as M shape.
Dip and plateau “square root” sign in L and R ventricular pressures
Pericardial knock, kussmaul’s sign, R and L heart failure.
EKG: Low voltage
ECHO: Rapid decrease in filling velocities, abnormal septum motion, pericardial thickness in 80% of cases.
Radiology: May have calcification
Treatment: Pericardial resection with mortality 6-20%, diuretics, sinus rhythm, may resolve within months or after antiinflamatory tx.

26. Restrictive Cardiomyopathy
Causes: Infiltrative, storage and collagen diseases; radiation, anthracyclins.
Features:
Diastolic dysfunction, pulmonary congestion, may advance to systolic dysfunction.
Dyspnea, JVD, Kussmaul’s, R side heart failure.
EKG: L or R BBB, L or R VH.
ECHO: LVH, homogeneous, dense walls, No calcification.
Treatment: Diuretic, stem cell, deferoxamine, pacemaker.

27. Acute Right Ventricular Infarction
Causes: Inferoposterior infarction extension.
Features:
High jugular venous pressures, kussmaul sign, hepatomegaly, hypotension.
Absent x and y.
Cath: Low PAP, low PCWP, High RV EDP.
EKG: ST elevation in RV4.
Echo: Enlarged hypokinetic RV.

28. Question
A 64 year old male with history of RA, presents with 10 month history of refractory severe lower extremity and scrotal edema, ascitis despite diuretics. CXR with clear lung fields and small bilateral pleural effusions, calcific stipping of the cardiac silhouette. CVP has prominent x and y, with spike and plateau tracing in RV. ECHO showed normal septum thickness. What is the most likely diagnosis?
A. Cor Pulmonale
B. Cardiac tamponade
C. Constrictive pericarditis
D. Amyloid cardiomyopathy

29. Question
A 54 year old male one day post-uncomplicated IWMI. The nurse tells you that patient doesn’t have complains but the BP is 80/45 and the HR is 85. The neck veins are noticeable at the angle of the jaw and the lungs are clear to auscultation. At exam RR, no S3, no edema. What to do next?
A. Cardiac catheterization
B. IV dobutamine/lasix
C. Atropine and then temporary pacemaker
D. IV fluids

30. Aortic Aneurysm
Localized >50% diameter increase involving all three layers of the wall.
Risk factors: Age>60 years, smoking, HTN, dyslipidemia, family history. If younger, think of Marfan, Ehler-Danlos , syphilis, Takayasu’s, trauma, bicuspid valve, aortic coartation.
Most common in men, 3:1; infrarenal, mostly asymptomatic, can present with compression symptoms, distal embolism or rupture.
Surgery if growth more than 0.5cm/year, abdominal >55 mm in men, >45mm in women, ascending aortic >50mm, and descending >60mm.
Patients with >45mm should have f/u 3 months.
Percutaneous repair is possible for infrarenal.
After surgery, evaluate every 6 months with CT or MRI.

31. Aortic dissection
Diagnosis often delayed owing to failure to consider it as a possibility.
Risk factors: In younger than 70 years: Turner’s, cocaine, bicuspid valve, collagen disorders-Marfan, Ehlers Danlos-, aortic coartation. In older than 70years: HTN, diabetes, vasculitis and preexisting aortic aneurysm.
Blood pass between lumen and media creating a false lumen.
Stanford A: Ascending aorta. 2:1. Involves aortic arch in 30%, worse prognosis, surgical emergency. Mortality with surgery 10-30% and without 50%.
Stanford B: The rest of aorta. Mortality with medical management 10% per year or better. Surgery if occlusion of major branch, extension of dissection, Marfan. TX: BB, SBP , avoid strenous activity, F/u at 3, 6, 12 months.
Presentation: Anterior or posterior CP, AR, MI, pleural or pericardial effusion, mental status changes; splacnic, renal, LE, spine ischemia.
TEE, CT, MRI

32. Question
An elderly patient has chest pain radiating to the back. BP is lower in left arm. Diastolic murmur at LSB. EKG shows ST depression all over, BP 250/130.
What is the immediate treatment?
a. Thrombolysis
b. Aspirin, lovenox. Abciximab.
c. Metoprolol and NTG or NTP.
d. Nicardipine

33. Question What test will you do?
A. CT chest w/o contrast
B. MRI chest w/o contrast
C. TTE
D. TEE
Showed aortic dissection of ascending aorta. Pain has improved. BP is normal. What to do next?
Take patient for surgery
Continue medical therapy unless rupture or pain.
Wait for few days for patient to stabilize before surgery.

34. Carotid Artery Disease
Stroke is third leading cause of death.
There are about 1 million strokes/year.
Carotid duplex for all symptomatic, for asymptomatic with bruits if good candidate for revascularization, or any going for CABG.
ASA has RRR 16% for fatal stroke and 28% for non fatal stroke.
ASA is as good as CEA for symptomatic with <50% and for asymptomatic with <60%.
Extended-release dipyridamole plus ASA superior to ASA alone for secondary prevention.
Dual therapy as Clopidogrel plus ASA only for recurrent events despite therapy with ASA. Higher risk of bleed.

35. Question
A patient with recent TIA and ipsilateral 50-69% carotid stenosis, you will recommend:
A. Atherosclerotic risk factor modification
B. Antiplatelet therapy
C. Carotid endarterectomy
D. Carotid Arterial Stenting
E. A, B and C.

36. Bacterial Endocarditis
The fourth leading cause of life-threatening disease due to infection.
Low incidence but high mortality.
2 major Duke criteria or 1 and 3 or 5 minor.
CHF occurs on 8-30% of patients.
Systemic embolization happens in up to half of cases, of those 65% involve CNS.
Perivalvular abscess affect AV in 40%.
TTE has sensitivity of 50-80%
TEE has sensitivity of 95% for vegetations.
Tx: From 2 to 6 weeks.

37. DUKE CRITERIA 1. Positive blood culture for Infective Endocarditis
Typical microorganism on 2 or more blood cultures: •  Viridans streptococci, Streptococcus bovis (gallolyticus), or HABCEK or •  Community-acquired Staphylococcus aureus or enterococci.
Continuous bacteremia: •  2 positive cultures drawn >12 hours apart, or •  all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
Positive blood culture for CB or IgG titer >1:800.
2. Evidence of endocardial involvement
Positive echocardiogram for IE defined as :
Vegetation or 
abscess or
new partial dehiscence of prosthetic valve
New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

38. Duke criteria Minor criteria :
Predisposition: predisposing heart condition or intravenous drug use
Fever: temperature > 38.0° C (100.4° F)
Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots and rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major criterion as noted above¹ or serological evidence of active infection with organism consistent with IE
Echocardiographic findings: consistent with IE but do not meet a major criterion as noted above
¹ Excludes single positive cultures for coagulase-negative staphylococci, diphtheroids, and organisms that do not commonly cause endocarditis.

40. AB Prophylaxis for BE Low risk: High risk: Moderate risk: Secundum ASD
Innocent murmur
CABG surgery
Pacemaker/ICD
MVP without MR
High risk:
Prosthetic valve
Cyanotic congenital heart disease
Previous endocarditis
Moderate risk:
All other congenital heart disease.
Bicuspid aortic valve
Acquired valve disease
HCM
MVP with MR

41. Surgery Indications in Bacterial endocarditis
About 20-50% will require surgery.
Hemodinamic instability due to valvular regurgitation, destruction.
Cardiogenic shock
Perivalvular extension, abscess
Resistant infection
Fungal endocarditis
Vegetation >1cm in diameter
Recurrent distal emboli.

42. Question
A 62 years old patient has had aortic valve replaced six months ago. He presents with endocarditis of the valve with findings of moderate CHF due to regurgitation. He is treated for CHF and antibiotics are started. He begins to improve with good response to the treatment. EKG has new prolonged PR interval. What is your next step?
A. Continue 2 more weeks with IV AB.
B. Surgery consult for AV reconstruction.
C. Discharge pt with IV AB by HHC.
D. Continue in hospital IV AB until 3 BC are negative.

43. Stress testing Criteria for a “ Positive Treadmill Exercise Test”:
ST depression of > 0.1 mV (1mm) below the baseline, and lasting longer than 0.08 msec.
High Risk Ischemic Response
Ischemia induced by low-level exercise* (less than 4 METs or heart rate < 100 bpm or < 70% of age-predicted heart rate) manifested by 1 or more of the following:
Horizontal or downsloping ST depression > 0.1 mV
ST-segment elevation > 0.1 mV in noninfarct lead
Five or more abnormal leads
Persistent ischemic response >3 minutes after exertion
Typical angina
Exercise-induced decrease in systolic BP by 10 mm Hg

44. Stress testing Intermediate:
Ischemia induced by moderate-level exercise (4 to 6 METs or HR 100 to 130 bpm (70% to 85% of age-predicted heart rate) with > 1 of the following:
Horizontal or downsloping ST depression > 0.1 mV
Persistent ischemic response greater than 1 to 3 minutes after exertion
Three to 4 abnormal leads
Low
No ischemia or ischemia induced at high-level exercise (> 7 METs or HR > 130 bpm (greater than 85% of age-predicted heart rate)) manifested by:
One or 2 abnormal leads
Inadequate test
Inability to reach adequate target workload or heart rate response for age without an ischemic response. For patients undergoing noncardiac surgery, the inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test.

45. Un-interpretable Treadmill EKG
Resting T-wave abnormalities
WPW
Paced rhythm
LVH
Digoxin
MVP
LBBB

46. Question
A patient with COPD,(having wheezing and ronchi), and PVD, unable to walk even one block needs a cardiac stress test. EKG has RAE. BP is normal. Which one?
A. Dobutamine stress test
B. Exercise echocardiogram
C. Adenosine stress test
D. Exercise electrocardiography

47. Preoperative Evaluation

48. Preoperative Evaluation
Risk Stratification
Procedure Examples
Vascular (reported cardiac
Aortic and other major vascular surgery
risk often > 5%)
Peripheral vascular surgery
Intermediate (reported
Intraperitoneal and intrathoracic surgery
cardiac risk generally 1%-5%)
Carotid endarterectomy
Head and neck surgery Orthopedic surgery Prostate surgery
Low† (reported cardiac
Endoscopic procedures
risk generally <1%
Superficial procedure
Cataract surgery Breast surgery Ambulatory surgery

49. *Active cardiac conditions
Examples
Unstable coronary syndromes
Unstable or severe angina* (CCS class III or IV)†
Recent MI‡
Decompensated HF
NYHA functional class IV;
Worsening or new-onset HF
Significant arrhythmias
High-grade atrioventricular block
Mobitz II atrioventricular block
Third-degree atrioventricular heart block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
Severe valvular disease
Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)
Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)

50. Can You…
1 Met
Take care of yourself?
4 Mets
Climb a flight of stairs or walk up a hill?
Eat, dress, or use the toilet?
Walk on level ground at 4 mph (6.4 kph)?
Walk indoors around the house?
Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?
Walk a block or 2 on level ground at 2 to 3 mph (3.2 to 4.8 kph)?
Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
Do light work around the house like dusting or washing dishes?
≥ 10 Mets
Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

51. Preoperative Evaluation
Revised Cardiac Risk Index or Clinical Risk Factors
Ischemic heart disease
History of MIAngina
Use of nitroglycerine
Q waves
Congestive heart failure
History of heart failure
Pulmonary edema
Paroxysmal nocturnal dyspnea
Peripheral edema, rales, S3
History of Stroke or TIA
Diabetes on insulin therapy
Creatinine>2mg/dl.

52. Preoperative Evaluation

53. Question
Which of the following is most important pre-operative cardiac risk factor for non-cardiac surgical procedures?
A. S4 gallop
B. S3 gallop
C. MI 10 months ago
D. Age over 70 years.

54. Question
A 71 year old male with h/o stable angina, now needs vascular surgery in the leg. What is your advice before clearing him for surgery?
A. Proceed with surgery.
B. Exercise stress test with imaging.
C. Adenosine stress test
D. Avoid surgery
E. Cardiac catheterization

55. Acute Coronary Syndrome Unstable Angina & NSTEMI
TIMI risk score:
Age 65 years or older
3 or more CAD traditional risk factors
Documented CAD with stenosis of 50%
ST segment deviation
2 or more anginal episodes in the last 24hr
Aspirin use within the last 7 days
Elevated cardiac enzymes
Low risk: 0-2, Conservative approach with non-invasive stress testing
Intermediate risk: 3-4 Initiate glycoprotein IIb/IIIa inhibitor and early invasive approach with angiography
High risk: 5-7 or persistent pain or elevated troponin, angiography

56. Question
A 51 year old patient comes with typical chest pain, persistent after ASA, nitrates, betablocker, 02, morphine, statin, lovenox, is taken to the cath, showing proximal LAD 70%, Cx 30%, RCA 30%, normal ejection fraction. What to do next?
CABG
PCI
Add ACEI
Thrombolysis

57. Indications for revascularization
For PCI
Unstable angina failing medical therapy or TIMI 3 or more
Unstable angina in patient with prior revascularization CABG or PCI
ST elevation MI
Failed thrombolysis
Unable to do thrombolysis
MI complicated by shock, refractory ventricular arrythmia, CHF or sudden death.
For CABG
Left main disease
2 vessel disease with proximal LAD w (+) ischemia or low EF, most benefit seen in diabetic patients.
3 vessel disease

58. Thrombolysis
Indications for Tenecteplase: ST elevation >6hr or continuos pain and elevation up to 12hr or new LBBB with typical CP. Follow with CP, ST segment, reperfusion arrythmia, enzymes.
Contraindications to thrombolytic therapy
Any prior intracranial hemorrage
Cerebral vascular lesion
CNS neoplasm
CVA <3 months except within 3 hours
Significant closed head injury <3 months
Active bleeding diathesis
Suspected aortic dissection

59. Question
A 52-year old diabetic patient is subjected to coronary angiogram because of persistent unstable angina. It shows 2 vessel disease with EF of 35%. What is the treatment?
a. PTCA
b. CABG
c. Medical treatment
d. Thrombolysis

60. Question
A 61 y/o male had an uncomplicated anterior MI over 24 hours ago develop syncope. Telemetry showed V-tach, requiring electrical cardioversion. What to do next?
Cardiac catheterization
Electrophysiologic studies
Echocardiography
Holter monitor
Signal-average ECG

61. Question
A diabetic patient has chest pain. Because of anterior wall MI with ST elevation, TPA and lovenox are started. Within 30min patient is feeling better ST-T segment came back to baseline but tele shows wide complex, NSVT. What is your next step?
Observation only
Intravenous lidocaine
Emergent cardiac catheterization
Intravenous amiodarone
Electrophysiologic study

62. Complications post-MI
Rupture Ventricular Septum
Rupture Papillary Muscle
Rupture Myocardial Wall
Timing
2-14 days
2-10 days
2-7 days
Clinical findings
Harsh loud systolic thrill LLSB
Acute Pulmonary edema, MR murmur
Sudden chest pain, shock, JVD, death
New ST elev
Diagnostic parameter
02 step-up in RV
Severe MR, LAE
Electro-mechanical dissociation
Management
Nitro-hydralazine
IAB
Surgery
Nitro
Usually no survival

63. Questions
Patient with IWMI whos BP goes down from 90/60 to 60/20. Next step?, What is the problem?
A patient with acute MI, doing well by the second week after admission. Suddenly pt goes into acute CHF, and a new thrill at LLSB if found. What will the hemodynamic monitoring show?

64. Question
A 64 y/o male with history of uncomplicated AWMI 4 days ago has suddenly developed increasing SOB, hypotension, tachycardia, neck veins are distended, new gallop and a SEM. PCWP is 34 with a large V-wave. Diagnosis?
Myocardial free-wall rupture
Large pulmonary embolism
Ventricular septal rupture
Ruptured chordae tendineae
Cardiac tamponade

65. Question
A patient with known hypertension, with no past h/o MI is admitted to CCU with a large Q-wave acute anterior MI. On the third day he is suddenly found in shock without any pulse or BP. EKG reveals new ST segment elevation with what appears to be sinus rhythm. What is the diagnosis?
A. Free wall rupture
B. Right Ventricle infarction
C. Papillary muscle rupture
D. Ventricular septal rupture