1. Cardiology Board Review – Part II
March 21, 2013

2. Cardiac catheterization Cardiac MRI Radionuclide ventriculography
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 ejection fraction of 40%, global hypokinesis, and mild left ventricular hypertrophy Which of the following is the most appropriate diagnostic test?
Cardiac catheterization
Cardiac MRI
Radionuclide ventriculography
Nuclear medicine stress test
Standard exercise stress test
In a patient with new-onset CHF, need to evaluate for ischemic causes and possible revascularization

3. Infections (Viral, Lyme, Rickettsial)
CHF Etiologies
CHF
Ischemic
Nonischemic
Valvular
High Output
Hyperthyroid
Anemia
Tachycardia-induced
Peripartum
Dilated
Idiopathic
Toxins (EtOH, cocaine)
Drugs (Chemo, HAART)
Infections (Viral, Lyme, Rickettsial)
Restrictive
Amyloidosis
Hemochromatosis
Sarcoidosis
Other:
R-sided failure
HOCM
Diastolic

4. Amlodipine Carvedilol Digoxin Losartan Spironolactone
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%, 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?
Amlodipine
Carvedilol
Digoxin
Losartan
Spironolactone
NYHA Class II CHF

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. Which of the following is the most appropriate addition to her treatment
Angiotensin receptor blocker
Hydralazine
Metolazone
Spironolactone

6. A 65-year-old black man is evaluated during a routine annual visit
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. Hgb and Creat are at his baseline. TFTs wnl, EKG shows NSR. Which of the following is the most appropriate adjustment to this patient’s treatment?
Add hydralazine
Increase digoxin
Increase furosemide
Stop metoprolol
Stage 3 CHF in an African-American

7. 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 IV
Symptoms at rest
50-60%

8. CHF Chronic Med Therapy
MOA
Which stage?
Mortality benefit?
Misc
ACEI
Afterload reduction
All
Decreased by 20%
Bblocker
Prevents remodeling & prevents arrhythmias
Decreased by 30%
*don’t start if acutely decompensated
Loop diuretic
diuresis
PRN
None
Can augment with thiazide (metolazone)
Digoxin
? Improved contractility
? III/IV
(but does decrease hospitalizations & improves symptoms)
Spironolactone
Suppresses Aldo thus decreases Na retention
III/IV
*if cannot tolerate 2/2 gynecomastia, can substitute Eplerenone
Hydralazine & Isosorbide Dinitrate
III/IV (esp African American)
Decreased in African-Americans

9. A 72-year-old man is evaluated for fatigue and dyspnea
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. ECG demonstrates sinus rhythm with a rate of 55/min. PR interval is 180 msec, QRS width is 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?
Add amiodarone
Biventricular pacemaker-defibrillator
Dual-chamber pacemaker
Implantable defibrillator

10. Device Therapy ICD BiV Pacemaker (Cardiac Resynchronization Therapy)
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%

11. Intravenous dobutamine Intravenous furosemide Intravenous nesiritide
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; QRS duration is 100 msec. Which of the following is the most appropriate treatment at this time?
Intravenous dobutamine
Intravenous furosemide
Intravenous nesiritide
Oral carvedilol

12. Cardiogenic Shock Causes: Criteria:
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

13. 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, normal QRS duration, and frequent premature ventricular complexes. Cardiac 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
Endomyocardial biopsy is recommended in patients with new-onset heart failure (<2 weeks) with hemodynamic compromise and in those with new-onset heart failure of 2 weeks’ to 3 months’ duration associated with a dilated left ventricle and new ventricular arrhythmias
Giant cell myocarditis is a rare, idiopathic cause of fulminant or subacute-onset heart failure – urgent transplant indicated

14. Who did President Obama pick to win the NCAA Tournament?
Louisville
Kansas
Duke
Indiana
North Carolina
Gonzaga
Creighton

15. Discontinue metoprolol Echocardiography Pacemaker implantation
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 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?
Sick Sinus Syndrome with episodes of RVR and also CAD with need for bblocker
Add amiodarone
Discontinue metoprolol
Echocardiography
Pacemaker implantation

16. 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
Needs pacemaker if advanced or symptomatic
3rd 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
“Advanced 2nd degree type 2 – 2 or more consecutive nonconducted P waves

17. Discontinue metoprolol; initiate flecainide Radiofrequency ablation
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 with a 6:1 block and a ventricular rate of 50/min. Which of the following is the most appropriate management for this patient?
Add amiodarone
Add digoxin
Discontinue metoprolol; initiate flecainide
Radiofrequency ablation
This patient has recurrent atrial flutter (AFL) that is symptomatic despite reasonable rate control at rest. Digoxin will further decrease HR at rest. Amiodarone has lots of side effects. Flecainide has poor efficacy and needs to be used with AV nodal blocker. Radiofrequency ablation of typical AFL has a long-term success rate of greater than 90% and a risk of complications of 1% to 2%, and is the most appropriate treatment for this patient

18. Tachycardia AVNRT (60% of SVT) – reentry circuit within AV node
AVRT (30% of SVT) – accessory pathway
WPW
Tachycardia
Narrow
Regular
Sinus Tach
Atrial tach
AVRT
AVNRT
Irregular
Flutter
Afib
MAT
Wide
Pre-excitation (6%)
SVT with aberrant conduction (20%)
Vtach (80%)
Treat as VT unless certain of other diagnosis
SVT with aberrant conduction (i.e. BBB)
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)

19. An 18-year-old woman is evaluated for recurrent syncope
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. Which of the following is the most likely diagnosis?
Brugada syndrome
Long QT syndrome
Short QT syndrome
Wolff-Parkinson-White syndrome

20. Continue medical management
A 67-year-old man presented to the emergency department 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 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 ejection fraction of 42%. Which of the following is the best management option at this time?
Add amiodarone
Continue medical management
Implantable cardioverter-defibrillator placement
Order electrophysiology study
Unlike sudden cardiac death occurring in other settings, cardiac arrest occurring within the first 48 hours of an acute, transmural myocardial infarction does not require secondary prevention therapy other than standard post–myocardial infarction care

21. 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)
EP study if EF 35-55% -> if can induce SVT, then ICD needed
SVT (>30s)
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
Brugada: J point elevation V1-V3 + RBBB

22. Which team has won the most NCAA Tournament Championships?
Kentucky
Duke
UNC
Indiana
UCLA
Michigan State
Kansas
With 11 national titles, UCLA has the record for the most NCAA Men's Division I Basketball Championships; John Wooden coached UCLA to 10 of its 11 titles. The University of Kentucky is second, with 8 national titles, while Indiana University and the University of North Carolina are tied for third with 5 national titles. Duke University ranks fifth with 4 national titles

23. 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 shows sinus tachycardia and concave upward ST-segment elevation in leads V1 through V6. Chest radiograph shows no infiltrates and a normal cardiac silhouette. Which of the following is the most likely diagnosis?
Acute myocardial infarction
Acute viral pericarditis
Costochondritis
Pleuritis
Pulmonary embolism

24. 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?
Colchicine
High-dose ASA
High-dose Ibuprofen
Prednisone

25. Acute Pericarditis Acute Therapy 10-30% will recur
1st line: Anti-inflammatories (taper over 4-6 weeks)
High dose ASA 650mg q4-6h
Preferred if pt post-MI
Ibuprofen 800mg q8h
Not if renal failure
2nd line: Colchicine (add to 1st line if persistent symptoms)
3rd line: Prednisone 60mg/d
Avoid anticoagulation
10-30% will recur
Colchicine for recurrent disease
Other: post-MI (acute vs Desslers), autoimmune, meds, chest XRT, Trauma

26. Levofloxacin & Tobramycin Pericardiocentesis Surgical Pericardiectomy
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. ECG shows sinus tachycardia, diffuse low voltage, and no ST-segment 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?
Dobutamine
Levofloxacin & Tobramycin
Pericardiocentesis
Surgical Pericardiectomy
Pulsus paradoxus – fall in SBP >10mmHg with inspiration
Cause: likely due to acute viral pericarditis

27. Tamponade Clinical: Echo clues: Treatment:
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

28. Restrictive Cardiomyopathy Constrictive Pericarditis
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 shifting dullness, and lower 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?
Kussmaul’s sign
Restrictive Cardiomyopathy
Constrictive Pericarditis
Nephrotic Syndrome
Systolic Heart Failure

29. 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
CP: intraventricular dependence – all pressures equal; septum can move; rigid pericardium protects from effects of inspiration and negative intrathroacic pressure

30. How many times have all 4 #1 seeds made it to the Final Four?2 3 4 5
Has happened only once, in 2008, when Kansas, North Carolina, UCLA, and Memphis all won their regionals

31. 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. The electrocardiogram demonstrates sinus tachycardia. There are no ST-segment or T-wave 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?
Acute Myocardial Infarction
Aortic Dissection
Coarctation of the Aorta
Peripartum Cardiomyopathy

32. 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

33. How many times has the Championship game went into overtime?5 6 7 8 9

34. Hypertrophic cardiomyopathy Left atrial myxoma
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 intervals. Which of the following is the most likely diagnosis in this patient?
Atrial septal defect
Hypertrophic cardiomyopathy
Left atrial myxoma
Pulmonary arterial hypertension
Rheumatic mitral stenosis
The characteristic physical examination findings in atrial septal defect are a right ventricular impulse, fixed splitting of the S2, a pulmonary mid-systolic murmur and a tricuspid diastolic flow rumble

35. An asymptomatic 25-year-old man is evaluated for hypertension diagnosed during a recent pre-employment 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. Which of the following is the most likely diagnosis in this patient?
Coarctation of the aorta
Essential hypertension
Pheochromocytoma
Renal artery stenosis

36. 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

37. Where is this year’s Final Four being played??
Charleston
Chicago
New York
San Antonio
Atlanta
Miami
San Francisco

38. 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-pack-year 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, varicosities, skin breakdown, or ulceration. Results of a neurologic examination are normal. Which of the following is the most appropriate management option for this patient?
MRI of the lumbosacral spine
Measurement of ankle-brachial index with exercise
Treatment with ibuprofen
Venous duplex ultrasonography of the lower extremities

39. 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:
pseudoclaudication: improvement with leaning forward

40. PAD - Diagnosis ABIs (ankle pressure/brachial pressure) Exercise ABIs
– normal
– borderline
– mild-moderate PAD
– 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

41. 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 knee. Which of the following is the most appropriate treatment for this patient?
Femoral-popliteal bypass
Medical treatment with cilostazol
Percutaneous intervention
Supervised exercise program

42. 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)

43. When was the last time a team entered the NCAA tournament with an undefeated record?
2001
1991
2005
1995
1985
1984
UNLV in 1991

44. Emergent surgical revascularization Intravenous heparin
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 be identified by Doppler 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?
Emergent surgical revascularization
Intravenous heparin
Intra-arterial thrombolytic therapy
Prompt amputation
Class II ischemia – IIa has evidence of intact vascular flow and no sensorimotor; Iib some sensorimotor defects and intact venous flow signals

45. 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