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Cardiovascular Step 1 Review UMMSM Board Review Series Monday, February 6 th, 2012 Graham Ingalsbe

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Presentation on theme: "Cardiovascular Step 1 Review UMMSM Board Review Series Monday, February 6 th, 2012 Graham Ingalsbe"— Presentation transcript:

1 Cardiovascular Step 1 Review UMMSM Board Review Series Monday, February 6 th, 2012 Graham Ingalsbe gingalsbe@med.miami.edu

2 Cardiovascular Anatomy & Physiology – Cardiac Output, Starling, Cardiac Cycle, Auscultation, Cell Biology, EKG, Pressures and Fluids Pathology – Congenital Heart Diseases, Hypertension, Hyperlipidemia, Ischemia/Infarction, Cardiomyopathies, CHF, Endocarditis, Tumors, Vaculitides Pharmacology – Antihypertensives, Antianginal, Lipid- lowering agents, Antiarrhythmics

3 Cardiac Cycle Physiology Heart Sounds Overview Cardiac Pearls Sample Questions

4 Cardiac Cycle a wave: atrial contraction. In late diastole, atria propel a final bolus of blood into each ventricle c wave: small rise in atrial pressures as the tricuspid and mitral valves close and bulge into atria v wave: passive filling of the atria from the systemic & pulmonary veins during diastole; blood accumulates in atria

5 S1 & S2 S1: mitral & tricuspid valves close – mitral closes before tricuspid because of higher pressures – nearly always heard as one sound S2: aortic & pulmonic valves close – Inspiration  Decreased intrathoracic pressure  Increased compliance of pulmonary bed (hangout time)  pulmonic valve will close LATER

6 Paradoxical split S2: seen in conditions that prolong LV emptying (aortic stenosis, LBBB). Split “eliminated” on inspiration. Widened split S2: seen in conditions that prolong RV emptying (pulmonic stenosis, RBBB) Fixed split S2: ASD; left to right shunt/flow, excess flow from left heart to pulmonary bed

7 S3 Can be normal in young, healthy (energetic expansion & filling) Occurs in early diastole Blood flowing into a noncompliant chamber (MCC volume overloaded states) Could be left-sided or right-sided depending on ventricle Produces a ventricular gallop Idaho

8 S4 ALWAYS pathologic Coincides w/ atrial contraction in late diastole & a wave of JVP Due to decreased Compliance of LV – Thickened, stiff ventricle (HTN, MI) Left Atrium has to work harder to push blood into the ventricle Could be due to: – 1) Concentric ventricular hypertrophy “atrial gallop” Alaska

9 Murmurs Stenosis – opening problem – Murmurs will be heard when valve is opening – Sten: narrow, Os: opening Regurgitation – closing problem – Murmurs will be heard when valve is attempting to close

10 Stenosis Who is opening in systole? Aortic and pulmonic valves – AS, PS Who is opening in diastole? Mitral and tricuspid vavles – Mitral & tricuspid stenosis

11 Regurgitation Who is closing in systole? Mitral and tricuspid valves – Mitral & tricuspid regurgitation Who is closing in diastole? Aortic and pulmonic vavles – Aortic and pulmonic regurgitation

12 Aortic Stenosis Crescendo-decrescendo systolic ejection murmur Best heard at the 2 nd intercostal space, right sternal border Radiates to the carotids What extra heart sound would appear?

13 Aortic Stenosis Etiology – Calcification of normal or congenital bicuspid valve Pathophysiology – Obstruction of LV outflow in systole – Reduction in aortic valve area  concentric LVH Patients present SAD – Syncope (3 years) – Angina (2 years) – Dyspnea (Heart failure, 5 years) Pulsus parvus et tardus

14 Mitral Stenosis LA is working hard in diastole to push blood into LV Opening snap Blood comes rushing into LV: diastolic rumble LA can hypertrophy  blood stasis  A fib  thrombus

15 Mitral Stenosis Etiology – MCC is recurrent attacks of rheumatic fever Pathophysiology – Narrowing of mitral valve orifice – Dilated & hypertrophied LA over time Patients present with… 1)Dyspnea 2)Dysphagia for solids (big LA on esophagus)

16 Mitral Regurgitation Blood leaking backwards thru incompetent valve LA becomes overloaded Pansystolic, sometimes you can’t hear S1 or S2 Apical murmur, possible S3 & S4

17 Mitral Regurgitation Etiology – Mitral valve prolapse (most common cause) – Functional MV regurg (left sided heart failure) – Infective endocarditis – Rupture of papillary muscle in MI – Acute rheumatic fever, Libman Sacks Endocarditis Pathophys – Retrograde blood flow into LA during systole – Volume overload in LV & LA  LHF Patients present with – Dyspnea, crackles, and cough from LHF

18 Aortic Regurgitation Blood flows back into LV  overloaded  increased EDV Heard after S2 (valve doesn’t close properly) High-pitched diastolic blowing murmur Heard best in 3 rd LIC space Can eventually develop S3 & S4

19 Aortic Regurgitation Etiology – Long-standing essential HTN (most common cause) – Dilated AV root – Infective endocarditis – Chronic rheumatic fever – Aortic dissection – Coarctation – Syphilitic aortitis, Takayasu arteritis Pathophysiology – Retrograde blood flow into LV Patients present with – Widened pulse pressure, bifid pulse – bounding pulses, head nodding with systole

20 Question A 57 y.o woman with a 6 month history of progressive dyspnea on exertion is evaluated in the office. Physical exam reveals an elevated JVP, a grade 2/6 holosytolic murmur at the apex that radiates to the axilla, an enlarged point of maximal impulse, and moderate edema up to both shins. An EKG shows left atrial and ventricular enlargement. CXR shows mild cardiomegaly and pulmonary congestion. Which of the following is the most likely diagnosis? A) Aortic valve regurgitation B) Aortic valve stenosis C) Mitral valve regurgitation D) Mitral valve stenosis E) Tricuspid valve regurgitation

21 Question A 57 y.o woman with a 6 month history of progressive dyspnea on exertion is evaluated in the office. Physical exam reveals an elevated JVP, a grade 2/6 holosytolic murmur at the apex that radiates to the axilla, an enlarged point of maximal impulse, and moderate edema up to both shins. An EKG shows left atrial and ventricular enlargement. CXR shows mild cardiomegaly and pulmonary congestion. Which of the following is the most likely diagnosis? A) Aortic valve regurgitation B) Aortic valve stenosis C) Mitral valve regurgitation D) Mitral valve stenosis E) Tricuspid valve regurgitation

22 Answer C) Mitral valve regurgitation Location: holosystolic, loudest at apex, radiating to axilla Pt has signs of LHF: LA & LV enlargement, pulmonary congestion

23 Question A 79 y.o woman is seen in the office for an annual exam. She walks regularly to and from the bus stop several times per week. It now takes her 25 min to get to the bus stop, whereas it only took her 10 min a year ago. She describes dyspnea midway in her walk, causing her to stop and catch her breath. She does not have angina, syncope or edema. On physical exam, heart rate is 80/min, and blood pressure is 165/86. Lungs are clear. There is a sustained apical impulse. S1 is normal, and there is a single S2 and an S4. A grade 3/6 late-peaking systolic murmur is heard best at the right second intercostal space with radiation into the right carotid artery. Which of the following is the most likely diagnosis? A) Aortic valve stenosis B) Hypertrophic cardiomyopathy C) Mitral valveregurgitation D) Tricuspid valve regurgitation E) Ventricular septal defect

24 Question A 79 y.o woman is seen in the office for an annual exam. She walks regularly to and from the bus stop several times per week. It now takes her 25 min to get to the bus stop, whereas it only took her 10 min a year ago. She describes dyspnea midway in her walk, causing her to stop and catch her breath. She does not have angina, syncope or edema. On physical exam, heart rate is 80/min, and blood pressure is 165/86. Lungs are clear. There is a sustained apical impulse. S1 is normal, and there is a single S2 and an S4. A grade 3/6 late-peaking systolic murmur is heard best at the right second intercostal space with radiation into the right carotid artery. Which of the following is the most likely diagnosis? A) Aortic valve stenosis B) Hypertrophic cardiomyopathy C) Mitral valveregurgitation D) Tricuspid valve regurgitation E) Ventricular septal defect

25 Answer A) Aortic valve stenosis Late peaking systolic murmur, URSB, radiating to carotids Progressive valvulopathy Pt has symptomatic disease with exertional dyspnea & decreased exercise tolerance

26 Mitral Valve Prolapse More common in women Associated with Marfans and Ehlers Danlos syndrome Pathophysiology – Posterior bulging of leaflets into atrium during systole – Redundancy of leaflets and chordae Myxomatous degeneration of mitral valve leaflets due to excess dermatan sulfate Patients present with: – Most: Asymptomatic – Palpitations

27 Mitral Valve Prolapse Murmur: mid systolic click, mid-late systolic crescendo murmur Decreased preload causes the click & murmur to move closer to S1 Standing, Anxiety, Valsalva – Increased preload causes it to move closer to S2 Reclining, Squatting or sustained hand grip

28 Ventricular Septal Defect Defect in interventricular septum Harsh pansystolic murmur at lower left sternal border Associations: tetralogy of Fallot, Fetal alcohol syndrome Spontaneously close in 30 – 50% of cases

29 Atrial Septal Defect Most common adult congenital heart disease Associations: fetal alcohol syndrome, Down syndrome Mid-systolic pulmonary flow murmur Fixed splitting of S2 Excess blood in pulmonary bed causes delay in closure of pulmonary valve

30 Patent Ductus Arteriosus Ductus arteriosus remains open Associations: congenital rubella syndrome, respiratory distress syndrome, complete transposition Machinery like murmur Reversal of the shunt due to increased pulmonary pressures – Unoxygenated blood enters the aorta below the subclavian artery, produces a pink upper body and cyanotic lower body Can close with Indomethacin (PGE2 KEEP)

31 Question A 19 y.o woman is evaluated in the office for palpitations described as “extra beats” that do not occur regularly. She has no history of syncope or presyncope, no cardiovascular risk factors, and no family history of cardiovascular disease. She does not have signs or symptoms of congestive heart failure and takes no medications. On physical exam, vital signs are normal. Lungs are clear. There is no S4 or S3. A grade 2/6 late systolic murmur is present that is heard best at the apex and radiates towards the left axilla. A mid-systolic click is heard. Following a valsalva maneuver and a squat-to-stand maneuver, the midsystolic click moves closer to S1, but the intensity of the murmur does not change. The rest of the exam is unremarkable. Which of the following is the most likely diagnosis accounting for the heart murmur? A) Innocent flow murmur B) Hypertrophic cardiomyopathy C) Mitral valve regurgitation D) Mitral valve prolapse

32 Question A 19 y.o woman is evaluated in the office for palpitations described as “extra beats” that do not occur regularly. She has no history of syncope or presyncope, no cardiovascular risk factors, and no family history of cardiovascular disease. She does not have signs or symptoms of congestive heart failure and takes no medications. On physical exam, vital signs are normal. Lungs are clear. There is no S4 or S3. A grade 2/6 late systolic murmur is present that is heard best at the apex and radiates towards the left axilla. A mid-systolic click is heard. Following a valsalva maneuver and a squat-to-stand maneuver, the midsystolic click moves closer to S1, but the intensity of the murmur does not change. The rest of the exam is unremarkable. Which of the following is the most likely diagnosis accounting for the heart murmur? A) Innocent flow murmur B) Hypertrophic cardiomyopathy C) Mitral valve regurgitation D) Mitral valve prolapse

33 Answer D) Mitral valve prolapse Midsystolic click followed by a late systolic murmur In MVP, the valsalva maneuver and standing from squatting position move the click- murmur complex closer to S1

34 Question A 24 y.o woman who is 23 weeks pregnant is evaluated in the office because of a 2-month history of increasing shortness of breath. On physical exam, blood pressure is 100/80 and HR is 88/min and regular, and RR is 26. On cardiac exam, the apical impulse is faint in the mid left 6 th IC space, and there is a forceful sternal heave. A soft apical systolic murmur, and an opening snap followed by a grade 2/6 mid diastolic murmur. Which of the following is the most likely diagnosis? A) Aortic valve stenosis B) Mitral valve stenosis C) Normal findings of pregnancy D) Patent ductus arteriosus E) Peripartum cardiomyopathy

35 Question A 24 y.o woman who is 23 weeks pregnant is evaluated in the office because of a 2-month history of increasing shortness of breath. On physical exam, blood pressure is 100/80 and HR is 88/min and regular, and RR is 26. On cardiac exam, the apical impulse is faint in the mid left 6 th IC space, and there is a forceful sternal heave. A soft apical systolic murmur, and an opening snap followed by a grade 2/6 mid diastolic murmur. Which of the following is the most likely diagnosis? A) Aortic valve stenosis B) Mitral valve stenosis C) Normal findings of pregnancy D) Patent ductus arteriosus E) Peripartum cardiomyopathy

36 Answer B) Mitral valve stenosis Loud S1, opening snap followed by a rumbling diastolic murmur Previously undiagnosed mitral stenosis often first becomes symptomatic during pregnancy

37 Dilated Cardiomyopathy Causes: alcohol, Beriberi, idiopathic, genetic, Coxsackie B myocarditis, drugs (doxorubicin, daunorubicin), peri/postpartum state, chronic cocaine use, organic solvents, acromegaly Pathophysiology – Decreased contractility  SYSTOLIC dysfunction type of LHF Patients present with… – All chambers dilated (global enlargement) – Regurgitation murmurs – S3 – Balloon appearing on CXR – EF usually less than 40%

38 Hypertrophic Cardiomyopathy Most common cause of sudden cardiac death in young people Pathophys: hypertrophy of myocardium – As blood exits LV, the anterior leaflet of the mitral valve is drawn against the asymmetrically hypertrophied IVS – S4, systolic ejection murmur best at LLSB, slow & late-peaking – DIASTOLIC dysfunction

39 Restrictive Cardiomyopathy Caused by: amyloidosis, radiation, fibrosis after open- heart surgery; Infiltrative diseases: hemochromatosis, sarcoidosis Pathophys: decreased ventricular compliance  DIASTOLIC dysfunction type of LHF Patients present with… – Progressive LHF and RHF Treat underlying cause

40 Manuevers to Differentiate Systolic Murmurs Changing Venous return (preload) Valsalva Squat -> Stand Stand -> Squat Passive leg elevation Changing Systemic Vascular Resistance (afterload) Hand Grip Nitrate

41 Manipulating Venous Return Decreased with valsalva and squatting to standing- HOCM gets louder Increased with standing to squatting and passive leg elevation – HOCM gets softer

42 SVR (Afterload) Hand grip increases afterload – increases regurg murmurs and VSD (decreased in HOCM, MVP) Nitrate decrease afterload

43 Valsalva Antonio Valsalva (1666-1723) was the first to describe and drain the eustachian tube Manuever changes intrathoracic pressure and venous return Bear down -> increases ITP, decreased return and therefore LV volume (HOCM and MVP louder, most others softer)

44 Question A 32 y.o man is evaluated in the office during an annual physical. He is asymptomatic and there is no personal or family hx of cardiac disease. On physical exam, vital signs are normal. S1 and S2 are present, and there is an S4. There is a grade 2/6 cresendo decresendo systolic murmur heard best at the lower left sternal border. The murmur does not radiate to the carotid arteries. The valsalva maneuver increases the intensity of the murmur, and moving from a squatting to standing position decreases the intensity. Which of the following is the most likely diagnosis? A) Aortic valve stenosis B) Atrial septal defect C) Hypertrophic cardiomyopathy D) Mitral valve prolapse E) Ventricular septal defect

45 Question A 32 y.o man is evaluated in the office during an annual physical. He is asymptomatic and there is no personal or family hx of cardiac disease. On physical exam, vital signs are normal. S1 and S2 are present, and there is an S4. There is a grade 2/6 cresendo decresendo systolic murmur heard best at the lower left sternal border. The murmur does not radiate to the carotid arteries. The valsalva maneuver increases the intensity of the murmur, and moving from a squatting to standing position decreases the intensity. Which of the following is the most likely diagnosis? A) Aortic valve stenosis B) Atrial septal defect C) Hypertrophic cardiomyopathy D) Mitral valve prolapse E) Ventricular septal defect

46 Answer C) Hypertrophic cardiomyopathy Murmur increases after a Valsalva maneuver and decreases with standing to squatting Does not radiate to carotids

47 Question A 38 y.o man is hospitalized with palpitations and dyspnea. He has no significant medical hx and does not take any medications. He has a 20 pack year smoking hx and drinks alcohol daily. Does not use illicit drugs. On physical exam, temperature is 98.5, blood pressure 120/80, and HR is 115. Lungs are clear. Cardiac exam shows an irregularly irregular rhythm. There is trace edema at both ankles. Lab studies: Hemoglobin14g/dL Mean corpuscular volume101 fL AST55 U/L ALT45 U/L TSH4.5 microU/mL EKG shows normal voltage, normal axis and atrial fibrillation. Echocardiogram shows dilated ventricles with normal wall thickness and severely decreased systolic fuction (LV EF: 15%). The patient is started on lisinopril, carvedilol, and warfarin. Later in the hospital course, he spontaneously converts to regular rhythm and feels well. EKG shows normal sinus rhythm. Which of the following is the most likely type of cardiomyopathy in this patient? A) Alcoholic B) Amyloid C) Hypertrophic D) Ischemic

48 Question A 38 y.o man is hospitalized with palpitations and dyspnea. He has no significant medical hx and does not take any medications. He has a 20 pack year smoking hx and drinks alcohol daily. Does not use illicit drugs. On physical exam, temperature is 98.5, blood pressure 120/80, and HR is 115. Lungs are clear. Cardiac exam shows an irregularly irregular rhythm. There is trace edema at both ankles. Lab studies: Hemoglobin14g/dL Mean corpuscular volume101 fL AST55 U/L ALT45 U/L TSH4.5 microU/mL EKG shows normal voltage, normal axis and atrial fibrillation. Echocardiogram shows dilated ventricles with normal wall thickness and severely decreased systolic fuction (LV EF: 15%). The patient is started on lisinopril, carvedilol, and warfarin. Later in the hospital course, he spontaneously converts to regular rhythm and feels well. EKG shows normal sinus rhythm. Which of the following is the most likely type of cardiomyopathy in this patient? A) Alcoholic B) Amyloid C) Hypertrophic D) Ischemic

49 Answer A) Alcoholic cardiomyopathy Dilated cariomyopathy Usually occurs after many years but can occur after a short period of heavy consumption Both ventricles are dilated Pt reports drinking daily Labs suggest chronic use (macrocytosis – possible folic acid deficiency), acute episode of heavy use (mild elevation of aminotransferases, new onset A fib)

50 Question A 34 year old male experiences shortness of breath with minimal exertion. Physical examination reveals elevated jugular venous pressure markedly worse with inspiration, a regular rhythm with an S4 heart sound and 2+ lower extremity pitting edema. Laboratory studies are normal. Cardiac biopsy revealed green birefringence with congo red staining. Genetic testing reveals a mutation in the transthyretin gene. Which of the following is the correct diagnosis? A) Restrictive cardiomyopathy B) Dilated cardiomyopathy C) Constrictive pericarditis D) Hypertrophic obstructive cardiomyopathy E) Chagas cardiomyopathy

51 Answer A ) Restrictive cardiomyopathy Amyloidosis of the heart causes a restrictive cardiomyopathy majority of the cases are due to a mutation in the transthyretin gene resulting in the abnormal deposition of this protein in the myocardial tissue The typical stain for amyloid is the congo red stain which displays an “apple green birefringence”. Restrictive cardiomyopathy can also occur from sarcoidosis or hemachromotisis Physical examination reveals an S4 heart sound due to impaired relaxation Dilated cardiomyopathy (B) can occur from viral myocarditis, alcohol, pregnancy, or can be idiopathic. An S3 heart sound would be present. Constrictive pericarditis (C) occurs after prior heart surgery or if many episodes of pericarditis has occurred. A Kussmal’s sign may also be present, but congo red staining would be negative. Hypertrophic obstructive cardiomyopathy or HOCM (D) presents with exertional symptoms such as syncope or sudden death. An S4 heart sound may also be present, but again congo red staining would be negative. Chagas cardiomyopathy (E) is due to infection with Tympanosoma cruzi and is associated with dilated cardiomyopathy, megaesophagus, and megacolon. Parasites may be seen on the biopsy.

52 Question A man recently was started on a new medication by his PCP after he was found to have an LDL of 188mg/dL. Several weeks later he presented to the emergency department with back pain and blood was detected on urine dipstick, but urinalysis showed no red blood cells. What medication was the patient most likely prescribed? A.Niacin B.Cholestyramine C.Ezetimibe D.Atorvastatin E.Gemfibrozil

53 Question A man recently was started on a new medication by his PCP after he was found to have an LDL of 188mg/dL. Several weeks later he presented to the emergency department with back pain and blood was detected on urine dipstick, but urinalysis showed no red blood cells. What medication was the patient most likely prescribed? A.Niacin B.Cholestyramine C.Ezetimibe D.Atorvastatin E.Gemfibrozil

54 Question A 62-year-old gentleman who was recently diagnosed with an ST-segment elevation myocardial infarction acutely develops emesis, cool and clammy skin, dilated neck veins, and syncope. On examination he has distant heart sounds. How long ago was his myocardial infarction? A.2-4 hours B.1-2 days C.3-7 days D.1-2 weeks E.More than 1 month ago

55 Question A 62-year-old gentleman who was recently diagnosed with an ST-segment elevation myocardial infarction acutely develops emesis, cool and clammy skin, dilated neck veins, and syncope. On examination he has distant heart sounds. How long ago was his myocardial infarction? A.2-4 hours B.1-2 days C.3-7 days D.1-2 weeks E.More than 1 month ago

56 Cardiac Pearls/Buzzwords APT M 2245 Young basketball player passes out? HOCM SLE gives LSE – sterile vegetations Antihypertensive drug with terrible rebound hypertension? Clonidine Hypertensive crisis coming from a wine tasting? Taking an MAOI Bipolar woman has child with heart defect? Ebstein’s anomaly “Tearing” chest pain – aortic dissection Several weeks after MI with new-onset friction rub – Dressler’s Lipids CHF Vasculidites

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59 Link to Heart Sounds http://www.e- gcrme.com/gcrme/essential_ausc/#/big12pra ctice http://www.e- gcrme.com/gcrme/essential_ausc/#/big12pra ctice http://depts.washington.edu/physdx/heart/te ch.html http://depts.washington.edu/physdx/heart/te ch.html

60 General Advice Make a schedule, stick to it Keep a routine Resources: Less is more Exercise Trust yourself


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