4Jugular Venous Pulse Prominent x and y: Constrictive pericarditis Prominent “x” descent:Cardiac tamponadeConstrictive pericarditisAbsent “x” descent:RV infarctionProminent “v” wave:Tricuspid regurgitationProminent “y” descent:Slow “y” descent:TS and RA mixoma.Absent “y” descent:Prominent x and y: Constrictive pericarditisProminent x and absent y: Cardiac tamponadeAbsent x and y: RV infarct.
5QuestionsA 34 year-old patient is on Ma Huang for losing weight. She presents with shortness of breath. EKG shows wide complex tachycardia. HR is 140/min. Cannon “a” waves are present. Cause?a. Sinus tachycardia with WPWb. Sinus tachycardia with aberrant conductionc. Atrial fibrilation with aberrant conduction.d. Ventricular tachycardia.
6Murmurs With inspiration: R side murmurs increase, L side decrease. With standing: HCM and MVP get louder.With squatting or passive leg raising: HCM and MVP become softer and delayed.With valsalva: HCM and MVP get louder and longer.With amyl nitrite inhalation (decreases LV cavity): AR, MR and VSD decrease while those of HCM and AS increase.With exercise (hand grip): HCM and AS decrease.With standing, valsalva, and inhalation of amyl nitrited (all decrease venous return or LV cavity size): Murmurs of HCM and MVP increase in intensity. All others decrease.With isometric exercise and squatting (all increase LV cavity size): Murmur of HCM is decreased.With isometric exercise and valsalva: Murmur of AS is decreased in intensity.
7Questions2. Murmur of which of the following increases with valsalva and decreases with squatting:a. Mitral Regurgitation.b. Hypertrophic cardiomyopathy (HCM)c. Aortic stenosis3. What happens to the murmur of AS with valsalva and hand-grip exercise?a. Increase, decreaseb. Decrease, decreasec. Decrease, increase.
9QuestionsA 44 y/o females has history of increasing SOB with exertion over the last 3 months. PE: Fixed split S2 with a murmur consistent with TR. Rest of HPI is unremarkable. CXR: increased LA, RA, RV and pulmonary circulation. What is the most likely diagnosis?a. Mitral regurgitationb. Aortic stenosisc. Hypertrophic obstructive cardiomyopathyd. Atrial septal defecte. Ventricular septal defect
10Questions A Wide splitting of S2 is representative of: a. Normal sinus rhythm with RBBB.b. Normal sinus rhythm with LBBB.c. Hypertrophic cardiomyopathy.Reversed splitting of S2 occurs in which:a. ASDb. RBBBc. Hypertrophic cardiomyopathy
11Heart sounds2nd sound and opening snap of MS are best heard on the base.LSB: TR, AR, VSD, HCMApex: MR, MS, AS.Below L clavicle: PS, PDA as continuous.Radiation to L axila: MR.Radiation to RSB and carotids: ASRadiation all over the precordium: VSDMS: Loud S1, Split S2, opening snap, rumbling diastolic murmur in apex. Area <2.5 cm, symptoms correlate.PR: Diastolic, decrescendo at LSB (Graham Steel)
12Questions6. A 52 y/o female presents with history of increasing SOB and LE edema. CXR shows pulmonary congestion, straightening of left heart border and Kerle B lines. EKG: sinus tachycardia with LAE, RBBB. PE: Loud S1, opening snap and diastolic murmur at the apex, and SEM in precordium. What is the diagnosis?a. Aortic insufficiencyb. Mitral stenosisc. Aortic stenosisd. Hypertrophic obstructive cardiomyopathy.
13Questions7. A 33 y/o pregnant patient in second trimester has SOB due to MS that is not responding to medical treatment. ECHO shows MV of 0.5cm. What is next step:a. Mitral valvotomy after delivery.b. Offer pregnancy termination.c. Mitral valvotomy now.d. Mitral valve replacement now
15QuestionsA 41 year-old asymptomatic female with MVP and mitral regurgitation is presented. An ECHO shows severe MR with EF of 50%. CAD is ruled out. What is your advice regarding her treatment?a. Refer for valve replacement.b. Follow up closely.c. Begin a diuretic plus ACE-inhibitor.
16Aortic Stenosis Aortic Stenosis HCM Location of murmur Apex and R 2nd intercostal space radiating to carotids.LSB,With thrillNot radiatingSecond soundNo component A2Present A2Carotid PulseSlowly risingBrisk or bifid
17Aortic Stenosis Grades: Mild: Valve area of >1 cm2 or gradient < 40mmHg.Moderate: Valve area of 0.75 to 1 cm2 or gradient mmHg.Severe: Valve area <0.75 cm2 or gradient >70 mmHg.Surgery: If symptoms. Angina, syncope, dyspnea, CHF. If not, risk of death 10-20% per year.If not suitable for valve replacement valvuloplasty is alternative.
18QuestionA 71 year-old females has dizzy spells with near fainting. An echocardiogram shows calcified aortic valve with area of 0.5cm2. The peak systolic valve gradient is 90mmHg. She lives alone and wants everything done for her. What is the next step?a. Coronary arteriographyb. ACE-Inhibitorc. Exercise stress testd. Exercise program with low dose diureticse. Aortic valve replacement
19QuestionA 73 years old patient with R hip fracture, noted to have a SEM. Echo shows AV area of 0.76cm and gradient of 50mmHg, normal LV function. Pt is active and asymptomatic. What is the next step?a. Balloon valvuloplasty prior to surgery.b. Cardiac catheterization.c. Proceed with hip surgery.d. Aortic valve replacement before hip surgery.
20QuestionsA 23 y/o male presents to the ER with witnessed syncope while running to catch a bus. There was no observed postictal state. At PE brisk carotid upstroke. SEM 3/6 at LSB with a systolic thrill. Murmur increase upon standing. What is the most likeky diagnosis?a. Rheumatic mitral regurgitationb. Congenital aortic stenosisc. Hypertrophic obstructive cardiomyopathyd. Ebstein’s anomaly
21DVT/PE prophylaxis Start before or shortly after surgery. Total knee replacement minimum duration is 7 to 10 days with LMWH or warfarin.Total hip replacement minimum duration is days with LMWH or warfarin.IPC only for patients at high risk of bleeding.
22Questions A patient with PE is in shock. Next step? a. Thrombolysisb. Embolectomyc. HeparinA 63 year old construction worker with h/o 3 episodes of DVT on coumadin, INR 2.5 comes again with DVT. What to do?a. Increase dose of coumadinb. Add low molecular weigth heparinc. Greenfield filter
23PAW=RA=RV=PA Cardiac Tamponade Constrictive Pericarditis Right Ventricular InfarctionEqual Diastolic PressuresPresentPresent/AbsentCalcification on X-Ray, CT/MRIAbsentECHOEffusion with diastolic collapseThick/calcified pericardiumLarge RV sizeEKGLow voltage and elect. alternansLow voltageST elevation on Right leadsProminent XProminent YPericardial KnockPulsus ParadoxusAbsent in 2/3 of ptKussmaul signAbsent/Present
24Cardiac TamponadeCauses: Viral, Metastasis, idiopathic, uremic, trauma, cardiac rupture, aortic disection.Features:Depends on the rapidity of fluid accumulation.Limited ventricular filling in diastole, absent YLow cardiac output, hypotension, tachycardia,High jugular venous pressure with prominent x descent.Paradoxical pulse, lungs clear, faint heart soundsEKG: Electrical alternans, low voltageCath: Equalization of pressures (RA, RV, PA, PCWP)Echocardiogram: RV, RA diastolic collapse, IVC dilationTreatment: Pericardiocentesis, IV fluids, surgery.
25Constrictive Pericarditis Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB, cancer, uremia.Features:Filling is reduced abruptly because thickened pericardiumStroke volume is reduced, equalization of pressures.High jugular venous pressure with prominent x and y descents, as M shape.Dip and plateau “square root” sign in L and R ventricular pressuresPericardial knock, kussmaul’s sign, R and L heart failure.EKG: Low voltageECHO: Rapid decrease in filling velocities, abnormal septum motion, pericardial thickness in 80% of cases.Radiology: May have calcificationTreatment: Pericardial resection with mortality 6-20%, diuretics, sinus rhythm, may resolve within months or after antiinflamatory tx.
26Restrictive Cardiomyopathy Causes: Infiltrative, storage and collagen diseases; radiation, anthracyclins.Features:Diastolic dysfunction, pulmonary congestion, may advance to systolic dysfunction.Dyspnea, JVD, Kussmaul’s, R side heart failure.EKG: L or R BBB, L or R VH.ECHO: LVH, homogeneous, dense walls, No calcification.Treatment: Diuretic, stem cell, deferoxamine, pacemaker.
27Acute Right Ventricular Infarction Causes: Inferoposterior infarction extension.Features:High jugular venous pressures, kussmaul sign, hepatomegaly, hypotension.Absent x and y.Cath: Low PAP, low PCWP, High RV EDP.EKG: ST elevation in RV4.Echo: Enlarged hypokinetic RV.
28QuestionA 64 year old male with history of RA, presents with 10 month history of refractory severe lower extremity and scrotal edema, ascitis despite diuretics. CXR with clear lung fields and small bilateral pleural effusions, calcific stipping of the cardiac silhouette. CVP has prominent x and y, with spike and plateau tracing in RV. ECHO showed normal septum thickness. What is the most likely diagnosis?A. Cor PulmonaleB. Cardiac tamponadeC. Constrictive pericarditisD. Amyloid cardiomyopathy
29QuestionA 54 year old male one day post-uncomplicated IWMI. The nurse tells you that patient doesn’t have complains but the BP is 80/45 and the HR is 85. The neck veins are noticeable at the angle of the jaw and the lungs are clear to auscultation. At exam RR, no S3, no edema. What to do next?A. Cardiac catheterizationB. IV dobutamine/lasixC. Atropine and then temporary pacemakerD. IV fluids
30Aortic AneurysmLocalized >50% diameter increase involving all three layers of the wall.Risk factors: Age>60 years, smoking, HTN, dyslipidemia, family history. If younger, think of Marfan, Ehler-Danlos , syphilis, Takayasu’s, trauma, bicuspid valve, aortic coartation.Most common in men, 3:1; infrarenal, mostly asymptomatic, can present with compression symptoms, distal embolism or rupture.Surgery if growth more than 0.5cm/year, abdominal >55 mm in men, >45mm in women, ascending aortic >50mm, and descending >60mm.Patients with >45mm should have f/u 3 months.Percutaneous repair is possible for infrarenal.After surgery, evaluate every 6 months with CT or MRI.
31Aortic dissectionDiagnosis often delayed owing to failure to consider it as a possibility.Risk factors: In younger than 70 years: Turner’s, cocaine, bicuspid valve, collagen disorders-Marfan, Ehlers Danlos-, aortic coartation. In older than 70years: HTN, diabetes, vasculitis and preexisting aortic aneurysm.Blood pass between lumen and media creating a false lumen.Stanford A: Ascending aorta. 2:1. Involves aortic arch in 30%, worse prognosis, surgical emergency. Mortality with surgery 10-30% and without 50%.Stanford B: The rest of aorta. Mortality with medical management 10% per year or better. Surgery if occlusion of major branch, extension of dissection, Marfan. TX: BB, SBP , avoid strenous activity, F/u at 3, 6, 12 months.Presentation: Anterior or posterior CP, AR, MI, pleural or pericardial effusion, mental status changes; splacnic, renal, LE, spine ischemia.TEE, CT, MRI
32QuestionAn elderly patient has chest pain radiating to the back. BP is lower in left arm. Diastolic murmur at LSB. EKG shows ST depression all over, BP 250/130.What is the immediate treatment?a. Thrombolysisb. Aspirin, lovenox. Abciximab.c. Metoprolol and NTG or NTP.d. Nicardipine
33Question What test will you do? A. CT chest w/o contrastB. MRI chest w/o contrastC. TTED. TEEShowed aortic dissection of ascending aorta. Pain has improved. BP is normal. What to do next?Take patient for surgeryContinue medical therapy unless rupture or pain.Wait for few days for patient to stabilize before surgery.
34Carotid Artery Disease Stroke is third leading cause of death.There are about 1 million strokes/year.Carotid duplex for all symptomatic, for asymptomatic with bruits if good candidate for revascularization, or any going for CABG.ASA has RRR 16% for fatal stroke and 28% for non fatal stroke.ASA is as good as CEA for symptomatic with <50% and for asymptomatic with <60%.Extended-release dipyridamole plus ASA superior to ASA alone for secondary prevention.Dual therapy as Clopidogrel plus ASA only for recurrent events despite therapy with ASA. Higher risk of bleed.
35QuestionA patient with recent TIA and ipsilateral 50-69% carotid stenosis, you will recommend:A. Atherosclerotic risk factor modificationB. Antiplatelet therapyC. Carotid endarterectomyD. Carotid Arterial StentingE. A, B and C.
36Bacterial Endocarditis The fourth leading cause of life-threatening disease due to infection.Low incidence but high mortality.2 major Duke criteria or 1 and 3 or 5 minor.CHF occurs on 8-30% of patients.Systemic embolization happens in up to half of cases, of those 65% involve CNS.Perivalvular abscess affect AV in 40%.TTE has sensitivity of 50-80%TEE has sensitivity of 95% for vegetations.Tx: From 2 to 6 weeks.
37DUKE CRITERIA 1. Positive blood culture for Infective Endocarditis Typical microorganism on 2 or more blood cultures: • Viridans streptococci, Streptococcus bovis (gallolyticus), or HABCEK or • Community-acquired Staphylococcus aureus or enterococci.Continuous bacteremia: • 2 positive cultures drawn >12 hours apart, or • all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)Positive blood culture for CB or IgG titer >1:800.2. Evidence of endocardial involvementPositive echocardiogram for IE defined as :Vegetation or abscess ornew partial dehiscence of prosthetic valveNew valvular regurgitation (worsening or changing of preexisting murmur not sufficient)
38Duke criteria Minor criteria : Predisposition: predisposing heart condition or intravenous drug useFever: temperature > 38.0° C (100.4° F)Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesionsImmunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots and rheumatoid factorMicrobiological evidence: positive blood culture but does not meet a major criterion as noted above¹ or serological evidence of active infection with organism consistent with IEEchocardiographic findings: consistent with IE but do not meet a major criterion as noted above¹ Excludes single positive cultures for coagulase-negative staphylococci, diphtheroids, and organisms that do not commonly cause endocarditis.
40AB Prophylaxis for BE Low risk: High risk: Moderate risk: Secundum ASD Innocent murmurCABG surgeryPacemaker/ICDMVP without MRHigh risk:Prosthetic valveCyanotic congenital heart diseasePrevious endocarditisModerate risk:All other congenital heart disease.Bicuspid aortic valveAcquired valve diseaseHCMMVP with MR
41Surgery Indications in Bacterial endocarditis About 20-50% will require surgery.Hemodinamic instability due to valvular regurgitation, destruction.Cardiogenic shockPerivalvular extension, abscessResistant infectionFungal endocarditisVegetation >1cm in diameterRecurrent distal emboli.
42QuestionA 62 years old patient has had aortic valve replaced six months ago. He presents with endocarditis of the valve with findings of moderate CHF due to regurgitation. He is treated for CHF and antibiotics are started. He begins to improve with good response to the treatment. EKG has new prolonged PR interval. What is your next step?A. Continue 2 more weeks with IV AB.B. Surgery consult for AV reconstruction.C. Discharge pt with IV AB by HHC.D. Continue in hospital IV AB until 3 BC are negative.
43Stress testing Criteria for a “ Positive Treadmill Exercise Test”: ST depression of > 0.1 mV (1mm) below the baseline, and lasting longer than 0.08 msec.High Risk Ischemic ResponseIschemia induced by low-level exercise* (less than 4 METs or heart rate < 100 bpm or < 70% of age-predicted heart rate) manifested by 1 or more of the following:Horizontal or downsloping ST depression > 0.1 mVST-segment elevation > 0.1 mV in noninfarct leadFive or more abnormal leadsPersistent ischemic response >3 minutes after exertionTypical anginaExercise-induced decrease in systolic BP by 10 mm Hg
44Stress testing Intermediate: Ischemia induced by moderate-level exercise (4 to 6 METs or HR 100 to 130 bpm (70% to 85% of age-predicted heart rate) with > 1 of the following:Horizontal or downsloping ST depression > 0.1 mVPersistent ischemic response greater than 1 to 3 minutes after exertionThree to 4 abnormal leadsLowNo ischemia or ischemia induced at high-level exercise (> 7 METs or HR > 130 bpm (greater than 85% of age-predicted heart rate)) manifested by:One or 2 abnormal leadsInadequate testInability to reach adequate target workload or heart rate response for age without an ischemic response. For patients undergoing noncardiac surgery, the inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test.
46QuestionA patient with COPD,(having wheezing and ronchi), and PVD, unable to walk even one block needs a cardiac stress test. EKG has RAE. BP is normal. Which one?A. Dobutamine stress testB. Exercise echocardiogramC. Adenosine stress testD. Exercise electrocardiography
48Preoperative Evaluation Risk StratificationProcedure ExamplesVascular (reported cardiacAortic and other major vascular surgeryrisk often > 5%)Peripheral vascular surgeryIntermediate (reportedIntraperitoneal and intrathoracic surgerycardiac risk generally 1%-5%)Carotid endarterectomyHead and neck surgery Orthopedic surgery Prostate surgeryLow† (reported cardiacEndoscopic proceduresrisk generally <1%Superficial procedureCataract surgery Breast surgery Ambulatory surgery
49*Active cardiac conditions ExamplesUnstable coronary syndromesUnstable or severe angina* (CCS class III or IV)†Recent MI‡Decompensated HFNYHA functional class IV;Worsening or new-onset HFSignificant arrhythmiasHigh-grade atrioventricular blockMobitz II atrioventricular blockThird-degree atrioventricular heart blockSymptomatic ventricular arrhythmiasSupraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest)Symptomatic bradycardiaNewly recognized ventricular tachycardiaSevere valvular diseaseSevere aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)
50Can You…1 MetTake care of yourself?4 MetsClimb a flight of stairs or walk up a hill?Eat, dress, or use the toilet?Walk on level ground at 4 mph (6.4 kph)?Walk indoors around the house?Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?Walk a block or 2 on level ground at 2 to 3 mph (3.2 to 4.8 kph)?Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?Do light work around the house like dusting or washing dishes?≥ 10 MetsParticipate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?
51Preoperative Evaluation Revised Cardiac Risk Index or Clinical Risk FactorsIschemic heart diseaseHistory of MIAnginaUse of nitroglycerineQ wavesCongestive heart failureHistory of heart failurePulmonary edemaParoxysmal nocturnal dyspneaPeripheral edema, rales,S3History of Stroke or TIADiabetes on insulin therapyCreatinine>2mg/dl.
53QuestionWhich of the following is most important pre-operative cardiac risk factor for non-cardiac surgical procedures?A. S4 gallopB. S3 gallopC. MI 10 months agoD. Age over 70 years.
54QuestionA 71 year old male with h/o stable angina, now needs vascular surgery in the leg. What is your advice before clearing him for surgery?A. Proceed with surgery.B. Exercise stress test with imaging.C. Adenosine stress testD. Avoid surgeryE. Cardiac catheterization
55Acute Coronary Syndrome Unstable Angina & NSTEMI TIMI risk score:Age 65 years or older3 or more CAD traditional risk factorsDocumented CAD with stenosis of 50%ST segment deviation2 or more anginal episodes in the last 24hrAspirin use within the last 7 daysElevated cardiac enzymesLow risk: 0-2, Conservative approach with non-invasive stress testingIntermediate risk: 3-4 Initiate glycoprotein IIb/IIIa inhibitor and early invasive approach with angiographyHigh risk: 5-7 or persistent pain or elevated troponin, angiography
56QuestionA 51 year old patient comes with typical chest pain, persistent after ASA, nitrates, betablocker, 02, morphine, statin, lovenox, is taken to the cath, showing proximal LAD 70%, Cx 30%, RCA 30%, normal ejection fraction. What to do next?CABGPCIAdd ACEIThrombolysis
57Indications for revascularization For PCIUnstable angina failing medical therapy or TIMI 3 or moreUnstable angina in patient with prior revascularization CABG or PCIST elevation MIFailed thrombolysisUnable to do thrombolysisMI complicated by shock, refractory ventricular arrythmia, CHF or sudden death.For CABGLeft main disease2 vessel disease with proximal LAD w (+) ischemia or low EF, most benefit seen in diabetic patients.3 vessel disease
58ThrombolysisIndications for Tenecteplase: ST elevation >6hr or continuos pain and elevation up to 12hr or new LBBB with typical CP. Follow with CP, ST segment, reperfusion arrythmia, enzymes.Contraindications to thrombolytic therapyAny prior intracranial hemorrageCerebral vascular lesionCNS neoplasmCVA <3 months except within 3 hoursSignificant closed head injury <3 monthsActive bleeding diathesisSuspected aortic dissection
59QuestionA 52-year old diabetic patient is subjected to coronary angiogram because of persistent unstable angina. It shows 2 vessel disease with EF of 35%. What is the treatment?a. PTCAb. CABGc. Medical treatmentd. Thrombolysis
60QuestionA 61 y/o male had an uncomplicated anterior MI over 24 hours ago develop syncope. Telemetry showed V-tach, requiring electrical cardioversion. What to do next?Cardiac catheterizationElectrophysiologic studiesEchocardiographyHolter monitorSignal-average ECG
61QuestionA diabetic patient has chest pain. Because of anterior wall MI with ST elevation, TPA and lovenox are started. Within 30min patient is feeling better ST-T segment came back to baseline but tele shows wide complex, NSVT. What is your next step?Observation onlyIntravenous lidocaineEmergent cardiac catheterizationIntravenous amiodaroneElectrophysiologic study
63QuestionsPatient with IWMI whos BP goes down from 90/60 to 60/20. Next step?, What is the problem?A patient with acute MI, doing well by the second week after admission. Suddenly pt goes into acute CHF, and a new thrill at LLSB if found. What will the hemodynamic monitoring show?
64QuestionA 64 y/o male with history of uncomplicated AWMI 4 days ago has suddenly developed increasing SOB, hypotension, tachycardia, neck veins are distended, new gallop and a SEM. PCWP is 34 with a large V-wave. Diagnosis?Myocardial free-wall ruptureLarge pulmonary embolismVentricular septal ruptureRuptured chordae tendineaeCardiac tamponade
65QuestionA patient with known hypertension, with no past h/o MI is admitted to CCU with a large Q-wave acute anterior MI. On the third day he is suddenly found in shock without any pulse or BP. EKG reveals new ST segment elevation with what appears to be sinus rhythm. What is the diagnosis?A. Free wall ruptureB. Right Ventricle infarctionC. Papillary muscle ruptureD. Ventricular septal rupture