1. Internal Medicine Board Review Cardiology
Mike McMullan, M.D., FACC
July 17, 2014

2. Internal Medicine Examination
Cardiology is the largest section of the review
Why is this?
Cardiology is the largest section of the boards
40% more than the next closest topic
14% of exam, pulmonary is next at 10%
Cardiovascular disease affects more people than any other disease process
Almost half of your family, friends, neighbors, and patients will eventually die from heart disease

3. Cardiology Topic Breakdown

4. Cardiology Topic Breakdown

5. My Assignment To cover these areas In order to answer
Physical examination
Valvular disease
Congenital heart disease
Pericardial disease
Endocarditis/SBE prophylaxis
In order to answer
0 questions
2-5 questions
0-1 questions
1-4 questions
_____________
3-11 questions
But “the truth of the matter” is that physical examination will encompass all 32 questions!

6. Breaking 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 topics
Highlight common scenarios within each topic
Symptoms
Physical findings
Diagnostic tests
Management
Common word associations

7. Breaking It Down Physical examination
Knowing the basics will help you figure out questions
Will 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 hum
Recognize cardiac clues to systemic diseases – e.g. rapid atrial fibrillation with a scratchy murmur
hyperthyroidism
Means–Lerman scratch

8. The Basics

9. Where does S1 occur? a b c d e f S1

10. Where does S2 occur? S2 a b c d e f

11. Where does S4 occur? a b c d e f S4

12. The Basics 4 heart sounds S1 – closure of mitral/tricuspid valves
S2 – closure of aortic/pulmonic valves
S3 – rapid ventricular filling with rapid flow deceleration
May be normal in pts < 40 y/o
Often seen in CMP and ventricular failure
S4 – atrial contraction against a stiff ventricle
HTN
HCM
Aortic stenosis

13. Which of these sounds is lost in a patient with atrial fibrillation?

14. The Basics 3 additional heart sounds Click (occur with valve closure)
Usually MVP
Rarely tricuspid click in Ebstein’s anomaly
Opening snap (occur with valve opening)
Usually right after S2 - mitral stenosis
Can occur at beginning of systole – congenital aortic stenosis – and is more often called ejection sound
Rub (occur with cardiac motion)
Up to 3 components
Atrial systole
Ventricular systole
Ventricular diastole
2 of 3 components are in diastole

15. The Basics 3 types of mumurs Systolic Diastolic Continuous
Systolic ejection=mid-systolic=crescendo-decrescendo
Pansystolic=holosystolic
Late systolic – associated with click = MVP!
Diastolic
Early high-pitched decrescendo
Aortic or pulmonic regurgitation
Low pitched rumble throughout diastole
Mitral or tricuspid stenosis
Continuous
Patent ductus arteriosus
AP window
Shunt or fistula

16. Basic Murmurs S1 S2 S1 S2 ES OS S4 S1 S3

17. Venous Waveforms in a Nutshell

18. Venous Waveforms in a Nutshell
Ventricular
systole
Ventricular
systole

19. Large “v” Waves

20. What’s the diagnosis? Aortic stenosis Aortic regurgitation
Mitral regurgitation
Tricuspid regurgitation

21. What’s the diagnosis? Aortic stenosis Aortic regurgitation
Mitral regurgitation
Tricuspid regurgitation

22. What’s the diagnosis? Mitral regurgitation Mitral stenosis
Aortic regurgitation
Aortic stenosis 40 30
mmHg LV 20 x y LA 10

23. What’s the diagnosis? Aortic stenosis HCM with obstruction MVP
Brockenbrough sign
Aortic stenosis
HCM with obstruction
MVP
Aortic regurgitation
Pulsus bisferiens

25. Normal Findings Innocent murmurs Venous hums
Grade 1-2 (mid)systolic ejection murmurs
NEVER
Grade 3 or more
Pansystolic
Diastolic
Continuous
Other abnormal sounds – e.g. fixed split S2
Venous hums
High flow states – e.g. anemia
Goes away when lays down

26. Breaking It Down Pericardial disease (1-4 questions) Cardiac tamponade
Constrictive pericarditis
Acute pericarditis

27. Cardiac Tamponade
Scenarios – 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 alternans
Tests - Swan hemodynamics with equalization of all diastolic pressures and slow y descent, echo
Mgt – pericardiocentesis

29. RA Pressure in Tamponade

31. Constrictive Pericarditis
Scenarios – post-radiation for lymphoma, CTD, TB
Diagnosis – dyspnea, elevated JVP, Kussmaul’s sign, edema, pericardial knock
Tests – echo, CT or MRI, cath with prominent x and y descents, equalization of diastolic pressures with square root sign
Mgt – pericardial stripping

32. Constrictive Pericarditis
Kussmaul’s sign

34. 125 LA
Equalization of Diastolic Pressures 25 50 75
100 RA RV LV
Constrictive Pericarditis X Y
Y>X
Square-root sign
RVEDP > 1/3 RVSP

35. Acute Pericarditis Scenarios – usually post-viral syndrome
Diagnosis – pleuritic chest pain, feels better sitting up and leaning forward, pericardial friction rub
Tests – EKG with diffuse ST elevation, elevated ESR, CRP and/or biomarkers
Mgt – NSAIDs
Ibuprofen mg TID or
ASA mg TID or
Indomethacin 50 mg TID for 7-10 days
Colchicine 0.5 – 0.6 mg BID
Refractory – prednisone plus colchicine

38. Breaking It Down Congenital heart disease (0-1 questions)
ASD – recognize the EKG
VSD – almost always no treatment necessary in adults
PDA – continuous murmur
Coarctation of aorta – secondary HTN, differential BP’s
If cyanotic pt (unlikely), probably Tetralogy of Fallot
Pregnancy – tolerated in all patients except pulmonary HTN and cardiomyopathies

39. Atrial Septal Defect
4 types but only need to know ostium secundum for boards
Scenario – young adult with murmur or palpitations
Diagnosis – fixed split S2, 2/6 SEM at LUSB
Tests – EKG with incomplete RBBB and RAD, echo, cath with shunt run
Mgt – closure (percutaneously or surgically) for shunt > 1.5:1
No SBE prophylaxis recommended – low risk

40. Atrial Septal Defect

41. ASD EKG

42. ASD TEE

43. ASD Occluder

44. VSD Scenario – asymptomatic young adult referred for murmur
Diagnosis – loud grade 5/6 pansystolic murmur at LSB
Test – echo
Mgt – closure not typically needed for adults, no longer need SBE prophylaxis by guidelines

45. Ventricular Septal Defect

46. Ventricular Septal Defect

47. Ventricular Septal Defect

48. PDA Scenario – teen or young adult referred for murmur
Diagnosis – usually asymptomatic, continuous murmur LSB
Tests – echo
Mgt – 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

49. Patent Ductus Arteriosus

50. Patent Ductus Arteriosus

51. Coarctation of Aorta
Great IM board question since it is a secondary cause of HTN
Scenario – young adult with HTN, association with Turner’s syndrome
Diagnosis – BP in arms vs legs, radiofemoral pulse delay, 2/6 SEM LSB, may have aortic ejection click with bicuspid aortic valve
Tests – CXR with figure 3 sign and rib notching, echo, CT angio or MRA
Mgt – surgical repair, less commonly stent

52. Coarctation of Aorta

53. Coarctation CXR

55. Cyanotic Lesions Not likely for an IM board
Tetralogy most common – young person with cyanosis and squatting
Eisenmenger’s (secondary pulm HTN with conversion to right-to-left shunt) most commonly occurs with VSD
Ebstein’s may present as cyanosis in adult, usually with palpitations due to right-sided accessory pathway, marked RAE on EKG and echo

56. Tetralogy of Fallot

57. Pregnancy and Heart Disease
Lots of pregnant women on the boards – not many with heart disease
Cardiac lesions affecting pregnancy
Pulmonary HTN
Cyanotic lesions (uncorrected)
Stenotic valve lesions
CMP
Recommend vaginal delivery with facilitated second stage
Peripartum CMP may occur last 3 months of pregnancy or first 6 months after delivery
Marfan’s and coarctation are at higher risk for aortic rupture during surgery

58. Pregnancy and Heart Disease
High risk
Eisenmenger’s syndrome
Severe pulmonary HTN
Severe aortic stenosis/LVOT obstruction
Coarctation of the aorta with obstruction
Marfan’s syndrome with aortic root > 43 mm
Symptomatic systemic ventricular dysfunction with EF < 40%
Need referral to high risk OB center with cardiology collaboration
Lower risk lesions can typically have normal pregnancy and delivery
CARPREG score
Poor functional status (NYHA >2) or cyanosis
Systemic ventricular dysfunction
Left heart obstruction
History of heart failure, stroke, or arrhythmia

59. Risk of CHD in Offspring of Parents with CHD
Typically 3-12%
Can be up to 50% (Marfan’s syndrome)
Fetal ultrasonography weeks

60. Breaking It Down Valvular heart disease (2-5 questions)
Aortic stenosis – elderly vs younger
Aortic regurgitation – Marfan’s or endocarditis
MVP – maneuvers, SBE prophylaxis
HCM – sudden death in an athlete, maneuvers
Mitral stenosis – rheumatic heart disease
Tricuspid stenosis with carcinoid patient
Tricuspid regurgitation in a patient with right heart failure

61. Aortic Stenosis
Scenarios – young to middle aged adult with bicuspid valve, older adult (> 70 y/o) with tricuspid valve
Diagnosis
Symptoms are chest pain, syncope, CHF
PE 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 CAD
Mgt – 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

62. Aortic 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 pulses
Test – echo
Mgt – afterload reduction with ACE inhibitor or nifedipine, valve replacement for EF < 55% or LVESD > 55mm

63. MVP Favorite board question
Scenario – young woman with palpitations, chest pain
Diagnosis – mid-systolic click with late systolic murmur, increases with Valsalva
Test – echo
Mgt – beta blocker for symptoms, SBE prophylaxis no longer recommended!, valve repair only for severe regurgitation +/- atrial fibrillation or pulmonary HTN

64. MVP

65. Hypertrophic Cardiomyopathy
Favorite board question
Scenario – young athlete with syncope or aborted sudden death, SOB, diastolic heart failure
Diagnosis – SEM at RUSB which increases with Valsalva, brisk carotid upstrokes, S4, pulsus bisferiens
Test – EKG with LVH and T wave inversion, echo
Mgt – beta blockers and calcium channel blockers, surgical or percutaneous myectomy, ICD placement if high risk for sudden death, no competitive athletics except golf and bowling, screening of first- and second-degree relatives

66. HCM

68. HCM EKG

69. Differentiating Aortic Stenosis from Hypertrophic Cardiomyopathy
Same
Both may present with syncope
Both have a harsh SEM radiating to the carotids
Different
HCM usually younger than AS
Carotid upstrokes are brisk with HCM, diminished with AS
Murmur gets louder with Valsalva with HCM, softer with Valsalva with AS

70. Mitral Stenosis Yet another favorite board question
Scenario – woman with history of rheumatic heart disease
Diagnosis – DOE, palpitations, PND, diastolic rumble with loud S1 and opening snap just after S2, small PMI, palpable P2, rales
Tests – echo, TEE to grade valve
Mgt – slow heart rate to improve diastolic filling time – beta blockers, SBE prophylaxis no longer required, balloon valvuloplasty is the first line procedure for these pts (as opposed to AS)

71. Tricuspid Stenosis Not a likely question
Same murmur as mitral stenosis but at left sternal border rather than apex
Present with right heart failure rather than DOE and rales
Seen in association with carcinoid and with prior use of Fen-Phen

72. Tricuspid Regurgitation
Not a likely test question, but may see a case of pulm HTN with TR and also PR
Scenario – young woman with severe SOB, hypoxia, and right heart failure – edema, ascites, elevated JVP, large v wave, pulsatile liver
Diagnosis – echo, right heart cath, CTA – must rule out other etiologies – CTD, congenital heart disease, recurrent PE
Mgt – 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

73. Endocarditis Guidelines – Updated 2008
No Class I indications for endocarditis prophylaxis
Class IIA recommendations
Antibiotic prophylaxis is reasonable for dental procedures for patients with –
Prosthetic cardiac valve or material used in valve repair
Previous endocarditis
Congenital heart disease
Unrepaired cyanotic disease, including palliative shunts/conduits
Completely repaired CHD for the first six months after correction
Repaired CHD with residual defects at site of prosthesis
Cardiac transplant with valvular heart disease
No prophylaxis for GI or GU procedures

74. SBE Prophylaxis Know prophylaxis regimen
Amoxicillin 2.0 g orally 1 hour before procedure
Know what to use in a PCN allergic patient!
Clindamycin 600 mg orally 1 hour before procedure
Keflex 2.0 g orally 1 hour before procedure
Zithromax 500 mg orally 1 hour before procedure

75. Endocarditis
Scenario – 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 lesions
Diagnosis – clinical picture, fever, regurgitant murmur, splenomegaly, Janeway lesions, Osler’s nodes, Roth’s spots, anemia, leukocytosis, elevated ESR and CRP, glomerulonephritis
Tests – blood cultures are mainstay of diagnosis, echo/TEE
Mgt – IV antibiotics
Empiric therapy – Vancomycin after 2-3 sets of blood cultures drawn
Guide further therapy based on organism/sensitivities
PCN G or Rocephin for 4 weeks
PCN G + Gentamicin for 2 weeks
Common organism – Viridans group streptococci
Unusual organism associations
Strep gallolyticus (formerly Strep bovis)
Associated with colon cancer
Needs colonscopy

80. The Bottom Line Recognize word associations Irregularly irregular
Mid-systolic click
Pulsus paradoxus
Pulsus alternans
Electrical alternans
Pulsus parvus et tardus
Kussmaul’s sign
Large v waves
Prominent x and y descents
Fixed splitting of S2
Paradoxical splitting of S2
Wide physiologic splitting of S2

81. The Bottom Line Recognize word associations Pericardial knock
Pericardial rub
Continuous murmur
Pansystolic murmur
Early high pitched diastolic murmur
Low pitched diastolic rumble
Elevated neck veins with clear lung fields
Elevated neck veins with hypotension and quiet precordium
Murmur increases with Valsalva

82. 80 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 stenosis
Tricuspid aortic valve stenosis
Hypertrophic cardiomyopathy
VSD

83. 40 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 RUSB
Hypertrophic cardiomyopathy
Mitral stenosis
Aortic regurgitation
Pulmonic regurgitation

84. 30 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 maneuver
VSD
Hypertrophic cardiomyopathy
Mitral regurgitation
Mitral valve prolapse

85. Bicuspid 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 maneuver
Bicuspid aortic stenosis
Tricuspid aortic stenosis
Hypertrophic cardiomyopathy
Mitral valve prolapse

86. Maneuvers Valsalva and standing decrease ALL murmurs except –
Hypertrophic cardiomyopathy
Mitral valve prolapse
Therefore – Valsalva and standing increase the murmur of HCM and MVP
Squatting reduces the murmur of HCM and MVP

87. Mitral 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 diastole
Mitral stenosis
Aortic regurgitation
VSD
PDA

88. Pulmonary 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 LUSB
Pulmonary stenosis
VSD
ASD
Aortic stenosis

89. Left 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 murmur
Left bundle branch block
Right bundle branch block
Aortic stenosis
HTN
This was on the 1994 IM board exam!

90. Best 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.

91. And remember…

92. Bonus questions!
me with your answers. Or if you have questions or suggestions.

93. 25 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 sounds
Constrictive pericarditis
Cardiac tamponade
Restrictive cardiomyopathy
Tension pneumothorax

94. 28 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 liver
Mitral regurgitation
Tricuspid regurgitation
VSD
ASD

95. 45 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 rhythm
PAC’s
Bigeminy
Atrial flutter
Atrial fibrillation

96. 25 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 back
Subclavian stenosis
Peripheral vascular disease
Coarctation of the aorta
Renal artery stenosis

97. 70 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 murmur
Constrictive pericarditis
Restrictive cardiomyopathy
Cardiac tamponade
Tricuspid regurgitation

98. 35 year old woman referred for murmur, has a continuous murmur at the 2nd left intercostal space
Tetralogy of Fallot
Pulmonary stenosis
Patent ductus arteriosus
Coarctation of the aorta

99. 35 year old woman with a history of a murmur since birth, has a grade IV/VI pansystolic murmur at the left sternal border
Tetralogy of Fallot
ASD
VSD
Transposition of the great arteries

100. 5 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 LUSB
Tetralogy of Fallot
VSD
Pulmonic stenosis
ASD
Transposition of the great arteries

101. Venous 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.

102. The 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

103. Myocardial 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 infarction
Pulmonary embolus
Pericarditis
Pneumothorax

104. Bonus questions - answers
B, B, D, C, A, C, C, A
Venous hum, innocent murmur C
Remember, me for questions!