Presentation on theme: "Internal Medicine Board Review Cardiology"— Presentation transcript:
1Internal Medicine Board Review Cardiology Mike McMullan, M.D., FACCJuly 17, 2014
2Internal Medicine Examination Cardiology is the largest section of the reviewWhy is this?Cardiology is the largest section of the boards40% more than the next closest topic14% of exam, pulmonary is next at 10%Cardiovascular disease affects more people than any other disease processAlmost half of your family, friends, neighbors, and patients will eventually die from heart disease
5My Assignment To cover these areas In order to answer Physical examinationValvular diseaseCongenital heart diseasePericardial diseaseEndocarditis/SBE prophylaxisIn order to answer0 questions2-5 questions0-1 questions1-4 questions_____________3-11 questionsBut “the truth of the matter” is that physical examination will encompass all 32 questions!
6Breaking It Down – My Method Focused board oriented pearls of frequently-tested disease processes (This is NOT a comprehensive discussion of each topic!)Broken down by general topicsHighlight common scenarios within each topicSymptomsPhysical findingsDiagnostic testsManagementCommon word associations
7Breaking It Down Physical examination Knowing the basics will help you figure out questionsWill often ask for the diagnostic test (echo) rather than the diagnosis (aortic stenosis)Be aware of normal findings that require no further w/u – e.g. innocent flow murmurs, venous humRecognize cardiac clues to systemic diseases – e.g. rapid atrial fibrillation with a scratchy murmurhyperthyroidismMeans–Lerman scratch
12The Basics 4 heart sounds S1 – closure of mitral/tricuspid valves S2 – closure of aortic/pulmonic valvesS3 – rapid ventricular filling with rapid flow decelerationMay be normal in pts < 40 y/oOften seen in CMP and ventricular failureS4 – atrial contraction against a stiff ventricleHTNHCMAortic stenosis
13Which of these sounds is lost in a patient with atrial fibrillation?
14The Basics 3 additional heart sounds Click (occur with valve closure) Usually MVPRarely tricuspid click in Ebstein’s anomalyOpening snap (occur with valve opening)Usually right after S2 - mitral stenosisCan occur at beginning of systole – congenital aortic stenosis – and is more often called ejection soundRub (occur with cardiac motion)Up to 3 componentsAtrial systoleVentricular systoleVentricular diastole2 of 3 components are in diastole
15The Basics 3 types of mumurs Systolic Diastolic Continuous Systolic ejection=mid-systolic=crescendo-decrescendoPansystolic=holosystolicLate systolic – associated with click = MVP!DiastolicEarly high-pitched decrescendoAortic or pulmonic regurgitationLow pitched rumble throughout diastoleMitral or tricuspid stenosisContinuousPatent ductus arteriosusAP windowShunt or fistula
25Normal Findings Innocent murmurs Venous hums Grade 1-2 (mid)systolic ejection murmursNEVERGrade 3 or morePansystolicDiastolicContinuousOther abnormal sounds – e.g. fixed split S2Venous humsHigh flow states – e.g. anemiaGoes away when lays down
26Breaking It Down Pericardial disease (1-4 questions) Cardiac tamponade Constrictive pericarditisAcute pericarditis
27Cardiac TamponadeScenarios – trauma and breast cancer are the two biggies on boards, also lupus and renal failure, occasionally viral pericarditis (rarely aortic dissection)Diagnosis – Beck’s triad (hypotension and elevated neck veins with quiet precordium), pulsus paradoxus, electrical alternansTests - Swan hemodynamics with equalization of all diastolic pressures and slow y descent, echoMgt – pericardiocentesis
38Breaking It Down Congenital heart disease (0-1 questions) ASD – recognize the EKGVSD – almost always no treatment necessary in adultsPDA – continuous murmurCoarctation of aorta – secondary HTN, differential BP’sIf cyanotic pt (unlikely), probably Tetralogy of FallotPregnancy – tolerated in all patients except pulmonary HTN and cardiomyopathies
39Atrial Septal Defect4 types but only need to know ostium secundum for boardsScenario – young adult with murmur or palpitationsDiagnosis – fixed split S2, 2/6 SEM at LUSBTests – EKG with incomplete RBBB and RAD, echo, cath with shunt runMgt – closure (percutaneously or surgically) for shunt > 1.5:1No SBE prophylaxis recommended – low risk
44VSD Scenario – asymptomatic young adult referred for murmur Diagnosis – loud grade 5/6 pansystolic murmur at LSBTest – echoMgt – closure not typically needed for adults, no longer need SBE prophylaxis by guidelines
48PDA Scenario – teen or young adult referred for murmur Diagnosis – usually asymptomatic, continuous murmur LSBTests – echoMgt – closure if murmur noted or left ventricular enlargement or pulmonary HTN, small ones without murmur do not need to be closed, no longer need SBE prophylaxis
51Coarctation of AortaGreat IM board question since it is a secondary cause of HTNScenario – young adult with HTN, association with Turner’s syndromeDiagnosis – BP in arms vs legs, radiofemoral pulse delay, 2/6 SEM LSB, may have aortic ejection click with bicuspid aortic valveTests – CXR with figure 3 sign and rib notching, echo, CT angio or MRAMgt – surgical repair, less commonly stent
55Cyanotic Lesions Not likely for an IM board Tetralogy most common – young person with cyanosis and squattingEisenmenger’s (secondary pulm HTN with conversion to right-to-left shunt) most commonly occurs with VSDEbstein’s may present as cyanosis in adult, usually with palpitations due to right-sided accessory pathway, marked RAE on EKG and echo
57Pregnancy and Heart Disease Lots of pregnant women on the boards – not many with heart diseaseCardiac lesions affecting pregnancyPulmonary HTNCyanotic lesions (uncorrected)Stenotic valve lesionsCMPRecommend vaginal delivery with facilitated second stagePeripartum CMP may occur last 3 months of pregnancy or first 6 months after deliveryMarfan’s and coarctation are at higher risk for aortic rupture during surgery
58Pregnancy and Heart Disease High riskEisenmenger’s syndromeSevere pulmonary HTNSevere aortic stenosis/LVOT obstructionCoarctation of the aorta with obstructionMarfan’s syndrome with aortic root > 43 mmSymptomatic systemic ventricular dysfunction with EF < 40%Need referral to high risk OB center with cardiology collaborationLower risk lesions can typically have normal pregnancy and deliveryCARPREG scorePoor functional status (NYHA >2) or cyanosisSystemic ventricular dysfunctionLeft heart obstructionHistory of heart failure, stroke, or arrhythmia
59Risk of CHD in Offspring of Parents with CHD Typically 3-12%Can be up to 50% (Marfan’s syndrome)Fetal ultrasonography weeks
60Breaking It Down Valvular heart disease (2-5 questions) Aortic stenosis – elderly vs youngerAortic regurgitation – Marfan’s or endocarditisMVP – maneuvers, SBE prophylaxisHCM – sudden death in an athlete, maneuversMitral stenosis – rheumatic heart diseaseTricuspid stenosis with carcinoid patientTricuspid regurgitation in a patient with right heart failure
61Aortic StenosisScenarios – young to middle aged adult with bicuspid valve, older adult (> 70 y/o) with tricuspid valveDiagnosisSymptoms are chest pain, syncope, CHFPE shows 3-4/6 SEM at RUSB radiating to carotids, pulsus parvus et tardus (weak and delayed upstrokes)Tests – echo, cath only as pre-op for CADMgt – surgery, balloon valvuloplasty is only palliative and short-lived, TAVR new option – only for inoperable or extreme high risk at present – probably too early for boards right now
62Aortic Regurgitation Scenario – Marfan’s syndrome, endocarditis Diagnosis – shortness of breath, early high-pitched decrescendo diastolic murmur at left or right upper sternal border, wide pulse pressure, brisk pulsesTest – echoMgt – afterload reduction with ACE inhibitor or nifedipine, valve replacement for EF < 55% or LVESD > 55mm
63MVP Favorite board question Scenario – young woman with palpitations, chest painDiagnosis – mid-systolic click with late systolic murmur, increases with ValsalvaTest – echoMgt – beta blocker for symptoms, SBE prophylaxis no longer recommended!, valve repair only for severe regurgitation +/- atrial fibrillation or pulmonary HTN
65Hypertrophic Cardiomyopathy Favorite board questionScenario – young athlete with syncope or aborted sudden death, SOB, diastolic heart failureDiagnosis – SEM at RUSB which increases with Valsalva, brisk carotid upstrokes, S4, pulsus bisferiensTest – EKG with LVH and T wave inversion, echoMgt – 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
69Differentiating Aortic Stenosis from Hypertrophic Cardiomyopathy SameBoth may present with syncopeBoth have a harsh SEM radiating to the carotidsDifferentHCM usually younger than ASCarotid upstrokes are brisk with HCM, diminished with ASMurmur gets louder with Valsalva with HCM, softer with Valsalva with AS
70Mitral Stenosis Yet another favorite board question Scenario – woman with history of rheumatic heart diseaseDiagnosis – DOE, palpitations, PND, diastolic rumble with loud S1 and opening snap just after S2, small PMI, palpable P2, ralesTests – echo, TEE to grade valveMgt – slow heart rate to improve diastolic filling time – beta blockers, SBE prophylaxis no longer required, balloon valvuloplasty is the first line procedure for these pts (as opposed to AS)
71Tricuspid Stenosis Not a likely question Same murmur as mitral stenosis but at left sternal border rather than apexPresent with right heart failure rather than DOE and ralesSeen in association with carcinoid and with prior use of Fen-Phen
72Tricuspid Regurgitation Not a likely test question, but may see a case of pulm HTN with TR and also PRScenario – young woman with severe SOB, hypoxia, and right heart failure – edema, ascites, elevated JVP, large v wave, pulsatile liverDiagnosis – echo, right heart cath, CTA – must rule out other etiologies – CTD, congenital heart disease, recurrent PEMgt – pulm HTN has poor prognosis if no reversible cause, O2, calcium blockers, Coumadin, prostacyclin analogs (epoprostenol), endothelin receptor antagonists (bosentan), phosphodiesterase-5 inhibitors (sildenafil), lung transplantation
73Endocarditis Guidelines – Updated 2008 No Class I indications for endocarditis prophylaxisClass IIA recommendationsAntibiotic prophylaxis is reasonable for dental procedures for patients with –Prosthetic cardiac valve or material used in valve repairPrevious endocarditisCongenital heart diseaseUnrepaired cyanotic disease, including palliative shunts/conduitsCompletely repaired CHD for the first six months after correctionRepaired CHD with residual defects at site of prosthesisCardiac transplant with valvular heart diseaseNo prophylaxis for GI or GU procedures
74SBE Prophylaxis Know prophylaxis regimen Amoxicillin 2.0 g orally 1 hour before procedureKnow what to use in a PCN allergic patient!Clindamycin 600 mg orally 1 hour before procedureKeflex 2.0 g orally 1 hour before procedureZithromax 500 mg orally 1 hour before procedure
75EndocarditisScenario – think about it in a pt with multisystem involvement, fever, chills, skin lesions, recent dental work or surgery, murmur – also with an IV drug user with multiple lung lesionsDiagnosis – clinical picture, fever, regurgitant murmur, splenomegaly, Janeway lesions, Osler’s nodes, Roth’s spots, anemia, leukocytosis, elevated ESR and CRP, glomerulonephritisTests – blood cultures are mainstay of diagnosis, echo/TEEMgt – IV antibioticsEmpiric therapy – Vancomycin after 2-3 sets of blood cultures drawnGuide further therapy based on organism/sensitivitiesPCN G or Rocephin for 4 weeksPCN G + Gentamicin for 2 weeksCommon organism – Viridans group streptococciUnusual organism associationsStrep gallolyticus (formerly Strep bovis)Associated with colon cancerNeeds colonscopy
80The Bottom Line Recognize word associations Irregularly irregular Mid-systolic clickPulsus paradoxusPulsus alternansElectrical alternansPulsus parvus et tardusKussmaul’s signLarge v wavesProminent x and y descentsFixed splitting of S2Paradoxical splitting of S2Wide physiologic splitting of S2
81The Bottom Line Recognize word associations Pericardial knock Pericardial rubContinuous murmurPansystolic murmurEarly high pitched diastolic murmurLow pitched diastolic rumbleElevated neck veins with clear lung fieldsElevated neck veins with hypotension and quiet precordiumMurmur increases with Valsalva
8280 year old woman presents with syncope, on exam has weak carotid upstrokes, a normal S1 with a diminished S2, and a grade III/VI systolic ejection murmur at the RUSB radiating to the carotids.Bicuspid aortic valve stenosisTricuspid aortic valve stenosisHypertrophic cardiomyopathyVSD
8340 year old man with Marfan’s syndrome, a blood pressure of 150/50, brisk pulses throughout, and an early high-pitched diastolic murmur heard best at the RUSBHypertrophic cardiomyopathyMitral stenosisAortic regurgitationPulmonic regurgitation
8430 year old woman who presents with palpitations, on exam has a normal S1 and S2, a midsystolic click, and a late systolic murmur that occurs earlier (becomes longer and/or louder) with Valsalva maneuverVSDHypertrophic cardiomyopathyMitral regurgitationMitral valve prolapse
85Bicuspid aortic stenosis Tricuspid aortic stenosis 20 year old basketball player referred for episode of syncope, noted to have brisk carotid upstrokes, a normal S1 and S2 with an S4 gallop, and a grade II/VI systolic ejection murmur at the LSB which becomes louder with Valsalva maneuverBicuspid aortic stenosisTricuspid aortic stenosisHypertrophic cardiomyopathyMitral valve prolapse
86Maneuvers Valsalva and standing decrease ALL murmurs except – Hypertrophic cardiomyopathyMitral valve prolapseTherefore – Valsalva and standing increase the murmur of HCM and MVPSquatting reduces the murmur of HCM and MVP
87Mitral stenosis Aortic regurgitation VSD PDA 35 year old woman with increasing dyspnea and fatigue, a history of rheumatic heart disease, a loud S1, a prominent S2 followed by an opening snap, and a diastolic rumble which becomes louder at the end of diastoleMitral stenosisAortic regurgitationVSDPDA
88Pulmonary stenosis VSD ASD Aortic stenosis 35 year old woman referred for palpitations and murmur, normal S1 with wide fixed splitting of S2, and a grade II/VI systolic ejection murmur at the LUSBPulmonary stenosisVSDASDAortic stenosis
89Left bundle branch block Right bundle branch block Aortic stenosis HTN 65 year old man who is asymptomatic, noted to have a normal S1, a second heart sound of normal intensity which splits with expiration and becomes single with inspiration (paradoxical splitting), and no murmurLeft bundle branch blockRight bundle branch blockAortic stenosisHTNThis was on the 1994 IM board exam!
90Best of luck! Get a good night’s sleep! Trust your initial reaction. Use clinical judgment.Look for the point of the question.If no clue, guess and move on. Can always come back if time allows.
92Bonus questions!me with your answers. Or if you have questions or suggestions.
9325 year old man who presents to the ER following a stab wound to the left chest, found to have a BP of 80/50, HR 130, a pulsus paradoxus of 20 mm Hg, distended neck veins, and distant heart soundsConstrictive pericarditisCardiac tamponadeRestrictive cardiomyopathyTension pneumothorax
9428 year old woman with primary pulmonary hypertension, elevated neck veins with a prominent v wave, a II/VI pansystolic murmur at the LLSB that increases with inspiration, and a pulsatile liverMitral regurgitationTricuspid regurgitationVSDASD
9545 year old veteran who presents with palpitations and SOB after a week-end of binge drinking, on exam has a radial pulse of 120, an apical pulse of 180, and an irregularly irregular heart rhythmPAC’sBigeminyAtrial flutterAtrial fibrillation
9625 year old woman with a history of recent onset hypertension, diminished femoral pulses, and a grade II/VI systolic ejection murmur at the LSB and backSubclavian stenosisPeripheral vascular diseaseCoarctation of the aortaRenal artery stenosis
9770 year old man from a nursing home with elevated neck veins that increase with inspiration and prominent x and y descents, normal S1 and S2 with a loud S3 knock, and no murmurConstrictive pericarditisRestrictive cardiomyopathyCardiac tamponadeTricuspid regurgitation
9835 year old woman referred for murmur, has a continuous murmur at the 2nd left intercostal space Tetralogy of FallotPulmonary stenosisPatent ductus arteriosusCoarctation of the aorta
9935 year old woman with a history of a murmur since birth, has a grade IV/VI pansystolic murmur at the left sternal borderTetralogy of FallotASDVSDTransposition of the great arteries
1005 year old boy with a history of cyanosis and digital clubbing, noted to stop and “squat” during play, has an RV lift, a single S2, and a grade III/VI systolic ejection murmur at the LUSBTetralogy of FallotVSDPulmonic stenosisASDTransposition of the great arteries
101Venous hum! Lay her back down and it will go away. You are performing routine physical exams for your local high school athletes. You notice a continuous murmur over the neck in a healthy-appearing 18 y/o girl while she is sitting on the stretcher. What is the most likely diagnosis and how do you confirm it?Venous hum! Lay her back down and it will go away.
102The next patient has a 2/6 midsystolic murmur at the LUSB with physiologic splitting of S2. What is the most likely diagnosis?Innocent murmur- always < 2/6 murmur- never diastolic- never pansystolic- normal S2
103Myocardial infarction Pulmonary embolus Pericarditis Pneumothorax A 30 y/o man presents with chest pain which is less severe when he sits up and leans forward. On exam, he has a scratchy sound in systole and diastole heard throughout his precordium. This is his EKG. Most likely diagnosis is -Myocardial infarctionPulmonary embolusPericarditisPneumothorax
104Bonus questions - answers B, B, D, C, A, C, C, AVenous hum, innocent murmurCRemember, me for questions!