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PEARLS IN CARDIOLOGY Sandra Rodriguez Internal Medicine 2008.

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1 PEARLS IN CARDIOLOGY Sandra Rodriguez Internal Medicine 2008

2 Jugular venous Pulse “a” is RA contraction “a” is RA contraction “c” is bulging of TV during RV systole. “c” is bulging of TV during RV systole. “x” downward displacement of TV. “x” downward displacement of TV. “v” is atrial filling at systole, TV closed. “v” is atrial filling at systole, TV closed. “y” is passive atrial emptying. “y” is passive atrial emptying.

3 Jugular Venous Pulse Giant “a” wave: Tricuspid stenosis Pulmonary stenosis Pulmonary hypertension Canon “a” wave: (against a closed valve): Junctional rhythm Slow ventricular tachycardia 2:1 A-V block Bigeminy Absent “a” wave: Atrial Fibrilation

4 Jugular Venous Pulse Prominent “x” descent: Cardiac tamponade Constrictive pericarditis Absent “x” descent: RV infarction Prominent “v” wave: Tricuspid regurgitation Prominent “y” descent: Constrictive pericarditis Slow “y” descent: TS and RA mixoma. Absent “y” descent: Cardiac tamponade RV infarction Prominent x and y: Constrictive pericarditis Prominent x and y: Constrictive pericarditis Prominent x and absent y: Cardiac tamponade Prominent x and absent y: Cardiac tamponade Absent x and y: RV infarct. Absent x and y: RV infarct.

5 Questions 1. A 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 WPW b. Sinus tachycardia with aberrant conduction c. Atrial fibrilation with aberrant conduction. d. Ventricular tachycardia.

6 Murmurs With inspiration: R side murmurs increase, L side decrease. With inspiration: R side murmurs increase, L side decrease. With standing: HCM and MVP get louder. With standing: HCM and MVP get louder. With squatting or passive leg raising: HCM and MVP become softer and delayed. With squatting or passive leg raising: HCM and MVP become softer and delayed. With valsalva: HCM and MVP get louder and longer. 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 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 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 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 squatting (all increase LV cavity size): Murmur of HCM is decreased. With isometric exercise and valsalva: Murmur of AS is decreased in intensity. With isometric exercise and valsalva: Murmur of AS is decreased in intensity.

7 Questions 2. Murmur of which of the following increases with valsalva and decreases with squatting: a. Mitral Regurgitation. b. Hypertrophic cardiomyopathy (HCM) c. Aortic stenosis 3. What happens to the murmur of AS with valsalva and hand-grip exercise? a. Increase, decrease b. Decrease, decrease c. Decrease, increase.

8 Splitting of S2 INSPIRATIONEXPIRATION Normal splitting s1 A2 P2 s1 Wide splitting (PS,MR,RBB B, VSD,PDA s1 A2 P2 s1 Paradoxical splitting (AS, LBBB, HCM, LVH) s1 P2 A2 s1 Fixed splitting (ASD) s1 A2 P2 s1

9 Questions A 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 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 regurgitation b. Aortic stenosis c. Hypertrophic obstructive cardiomyopathy d. Atrial septal defect e. Ventricular septal defect

10 Questions A Wide splitting of S2 is representative of: A Wide splitting of S2 is representative of: a. Normal sinus rhythm with RBBB. a. Normal sinus rhythm with RBBB. b. Normal sinus rhythm with LBBB. b. Normal sinus rhythm with LBBB. c. Hypertrophic cardiomyopathy. c. Hypertrophic cardiomyopathy. Reversed splitting of S2 occurs in which: Reversed splitting of S2 occurs in which: a. ASD b. RBBB c. Hypertrophic cardiomyopathy

11 Heart sounds 2 nd sound and opening snap of MS are best heard on the base. 2 nd sound and opening snap of MS are best heard on the base. LSB: TR, AR, VSD, HCM LSB: TR, AR, VSD, HCM Apex: MR, MS, AS. Apex: MR, MS, AS. Below L clavicle: PS, PDA as continuous. Below L clavicle: PS, PDA as continuous. Radiation to L axila: MR. Radiation to L axila: MR. Radiation to RSB and carotids: AS Radiation to RSB and carotids: AS Radiation all over the precordium: VSD Radiation all over the precordium: VSD MS: Loud S1, Split S2, opening snap, rumbling diastolic murmur in apex. Area <2.5 cm, symptoms correlate. MS: Loud S1, Split S2, opening snap, rumbling diastolic murmur in apex. Area <2.5 cm, symptoms correlate. PR: Diastolic, decrescendo at LSB (Graham Steel) PR: Diastolic, decrescendo at LSB (Graham Steel)

12 Questions 6. 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 insufficiency b. Mitral stenosis b. Mitral stenosis c. Aortic stenosis d. Hypertrophic obstructive cardiomyopathy.

13 Questions 7. 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

14 Mitral Valve Regurgitation Etiology: Etiology: Myxomatous degeneration Myxomatous degeneration Rheumatic disease Rheumatic disease Endocarditis Endocarditis Grades 1 to 4 Grades 1 to 4 Surgical indications Surgical indications If symptomatic If symptomatic EF<60% EF<60% LVES diameter >4.5cm LVES diameter >4.5cm Pulmonary pressure >55mmg Hg Pulmonary pressure >55mmg Hg

15 Questions A 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 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. b. Follow up closely. c. Begin a diuretic plus ACE-inhibitor. c. Begin a diuretic plus ACE-inhibitor.

16 Aortic Stenosis HCM Location of murmur Apex and R 2 nd intercostal space radiating to carotids. LSB, With thrill Not radiating Second sound No component A2 Present A2 Carotid Pulse Slowly rising Brisk or bifid

17 Aortic Stenosis Grades: Grades: Mild: Valve area of >1 cm2 or gradient 1 cm2 or gradient < 40mmHg. Moderate: Valve area of 0.75 to 1 cm2 or gradient 40- 70 mmHg. Moderate: Valve area of 0.75 to 1 cm2 or gradient 40- 70 mmHg. Severe: Valve area 70 mmHg. Severe: Valve area 70 mmHg. Surgery: If symptoms. Angina, syncope, dyspnea, CHF. If not, risk of death 10-20% per year. 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. If not suitable for valve replacement valvuloplasty is alternative.

18 Question A 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 arteriography b. ACE-Inhibitor c. Exercise stress test d. Exercise program with low dose diuretics e. Aortic valve replacement

19 Question A 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 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.

20 Questions A 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 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 regurgitation b. Congenital aortic stenosis c. Hypertrophic obstructive cardiomyopathy d. Ebstein’s anomaly

21 DVT/PE prophylaxis Start before or shortly after surgery. Start before or shortly after surgery. Total knee replacement minimum duration is 7 to 10 days with LMWH or warfarin. Total knee replacement minimum duration is 7 to 10 days with LMWH or warfarin. Total hip replacement minimum duration is 28-42 days with LMWH or warfarin. Total hip replacement minimum duration is 28-42 days with LMWH or warfarin. IPC only for patients at high risk of bleeding. IPC only for patients at high risk of bleeding.

22 Questions A patient with PE is in shock. Next step? A patient with PE is in shock. Next step? a. Thrombolysis a. Thrombolysis b. Embolectomy b. Embolectomy c. Heparin c. Heparin A 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 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 coumadin a. Increase dose of coumadin b. Add low molecular weigth heparin b. Add low molecular weigth heparin c. Greenfield filter c. Greenfield filter

23 PAW=RA=RV=PA Cardiac Tamponade Constrictive Pericarditis Right Ventricular Infarction Equal Diastolic Pressures PresentPresentPresent/Absent Calcification on X- Ray, CT/MRI AbsentPresentAbsent ECHO Effusion with diastolic collapse Thick/calcified pericardium Large RV size EKG Low voltage and elect. alternans Low voltage ST elevation on Right leads Prominent X PresentPresentAbsent Prominent Y AbsentPresentAbsent Pericardial Knock AbsentPresentAbsent Pulsus Paradoxus Present Absent in 2/3 of pt Absent Kussmaul sign AbsentPresentAbsent/Present

24 Cardiac Tamponade Causes: Viral, Metastasis, idiopathic, uremic, trauma, cardiac rupture, aortic disection. Causes: Viral, Metastasis, idiopathic, uremic, trauma, cardiac rupture, aortic disection. Features: Features: Depends on the rapidity of fluid accumulation. Depends on the rapidity of fluid accumulation. Limited ventricular filling in diastole, absent Y Limited ventricular filling in diastole, absent Y Low cardiac output, hypotension, tachycardia, Low cardiac output, hypotension, tachycardia, High jugular venous pressure with prominent x descent. High jugular venous pressure with prominent x descent. Paradoxical pulse, lungs clear, faint heart sounds Paradoxical pulse, lungs clear, faint heart sounds EKG: Electrical alternans, low voltage EKG: Electrical alternans, low voltage Cath: Equalization of pressures (RA, RV, PA, PCWP) Cath: Equalization of pressures (RA, RV, PA, PCWP) Echocardiogram: RV, RA diastolic collapse, IVC dilation Echocardiogram: RV, RA diastolic collapse, IVC dilation Treatment: Pericardiocentesis, IV fluids, surgery. Treatment: Pericardiocentesis, IV fluids, surgery.

25 Constrictive Pericarditis Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB, cancer, uremia. Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB, cancer, uremia. Features: Features: Filling is reduced abruptly because thickened pericardium Filling is reduced abruptly because thickened pericardium Stroke volume is reduced, equalization of pressures. Stroke volume is reduced, equalization of pressures. High jugular venous pressure with prominent x and y descents, as M shape. High jugular venous pressure with prominent x and y descents, as M shape. Dip and plateau “square root” sign in L and R ventricular pressures Dip and plateau “square root” sign in L and R ventricular pressures Pericardial knock, kussmaul’s sign, R and L heart failure. Pericardial knock, kussmaul’s sign, R and L heart failure. EKG: Low voltage EKG: Low voltage ECHO: Rapid decrease in filling velocities, abnormal septum motion, pericardial thickness in 80% of cases. ECHO: Rapid decrease in filling velocities, abnormal septum motion, pericardial thickness in 80% of cases. Radiology: May have calcification Radiology: May have calcification Treatment: Pericardial resection with mortality 6-20%, diuretics, sinus rhythm, may resolve within months or after antiinflamatory tx. Treatment: Pericardial resection with mortality 6-20%, diuretics, sinus rhythm, may resolve within months or after antiinflamatory tx.

26 Restrictive Cardiomyopathy Causes: Infiltrative, storage and collagen diseases; radiation, anthracyclins. Causes: Infiltrative, storage and collagen diseases; radiation, anthracyclins. Features: Features: Diastolic dysfunction, pulmonary congestion, may advance to systolic dysfunction. Diastolic dysfunction, pulmonary congestion, may advance to systolic dysfunction. Dyspnea, JVD, Kussmaul’s, R side heart failure. Dyspnea, JVD, Kussmaul’s, R side heart failure. EKG: L or R BBB, L or R VH. EKG: L or R BBB, L or R VH. ECHO: LVH, homogeneous, dense walls, No calcification. ECHO: LVH, homogeneous, dense walls, No calcification. Treatment: Diuretic, stem cell, deferoxamine, pacemaker. Treatment: Diuretic, stem cell, deferoxamine, pacemaker.

27 Acute Right Ventricular Infarction Causes: Inferoposterior infarction extension. Causes: Inferoposterior infarction extension. Features: Features: High jugular venous pressures, kussmaul sign, hepatomegaly, hypotension. High jugular venous pressures, kussmaul sign, hepatomegaly, hypotension. Absent x and y. Absent x and y. Cath: Low PAP, low PCWP, High RV EDP. Cath: Low PAP, low PCWP, High RV EDP. EKG: ST elevation in RV4. EKG: ST elevation in RV4. Echo: Enlarged hypokinetic RV. Echo: Enlarged hypokinetic RV.

28 Question A 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 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 Pulmonale A. Cor Pulmonale B. Cardiac tamponade B. Cardiac tamponade C. Constrictive pericarditis C. Constrictive pericarditis D. Amyloid cardiomyopathy D. Amyloid cardiomyopathy

29 Question A 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 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 catheterization A. Cardiac catheterization B. IV dobutamine/lasix B. IV dobutamine/lasix C. Atropine and then temporary pacemaker C. Atropine and then temporary pacemaker D. IV fluids D. IV fluids

30 Aortic Aneurysm Localized >50% diameter increase involving all three layers of the wall. Localized >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. 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. 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. 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. Patients with >45mm should have f/u 3 months. Percutaneous repair is possible for infrarenal. Percutaneous repair is possible for infrarenal. After surgery, evaluate every 6 months with CT or MRI. After surgery, evaluate every 6 months with CT or MRI.

31 Aortic dissection Diagnosis often delayed owing to failure to consider it as a possibility. Diagnosis 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. 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. 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 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 100-120, avoid strenous activity, F/u at 3, 6, 12 months. 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 100-120, 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. Presentation: Anterior or posterior CP, AR, MI, pleural or pericardial effusion, mental status changes; splacnic, renal, LE, spine ischemia. TEE, CT, MRI TEE, CT, MRI

32 Question An 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. An 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? What is the immediate treatment? a. Thrombolysis b. Aspirin, lovenox. Abciximab. b. Aspirin, lovenox. Abciximab. c. Metoprolol and NTG or NTP. c. Metoprolol and NTG or NTP. d. Nicardipine d. Nicardipine

33 Question What test will you do? What test will you do? A. CT chest w/o contrast A. CT chest w/o contrast B. MRI chest w/o contrast B. MRI chest w/o contrast C. TTE C. TTE D. TEE D. TEE Showed aortic dissection of ascending aorta. Pain has improved. BP is normal. What to do next? Showed aortic dissection of ascending aorta. Pain has improved. BP is normal. What to do next? Take patient for surgery Take patient for surgery Continue medical therapy unless rupture or pain. Continue medical therapy unless rupture or pain. Wait for few days for patient to stabilize before surgery. Wait for few days for patient to stabilize before surgery.

34 Carotid Artery Disease Stroke is third leading cause of death. Stroke is third leading cause of death. There are about 1 million strokes/year. 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. 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 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%. 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. 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. Dual therapy as Clopidogrel plus ASA only for recurrent events despite therapy with ASA. Higher risk of bleed.

35 Question A patient with recent TIA and ipsilateral 50-69% carotid stenosis, you will recommend: A patient with recent TIA and ipsilateral 50-69% carotid stenosis, you will recommend: A. Atherosclerotic risk factor modification A. Atherosclerotic risk factor modification B. Antiplatelet therapy B. Antiplatelet therapy C. Carotid endarterectomy C. Carotid endarterectomy D. Carotid Arterial Stenting D. Carotid Arterial Stenting E. A, B and C. E. A, B and C.

36 Bacterial Endocarditis The fourth leading cause of life-threatening disease due to infection. The fourth leading cause of life-threatening disease due to infection. Low incidence but high mortality. Low incidence but high mortality. 2 major Duke criteria or 1 and 3 or 5 minor. 2 major Duke criteria or 1 and 3 or 5 minor. CHF occurs on 8-30% of patients. CHF occurs on 8-30% of patients. Systemic embolization happens in up to half of cases, of those 65% involve CNS. Systemic embolization happens in up to half of cases, of those 65% involve CNS. Perivalvular abscess affect AV in 40%. Perivalvular abscess affect AV in 40%. TTE has sensitivity of 50-80% TTE has sensitivity of 50-80% TEE has sensitivity of 95% for vegetations. TEE has sensitivity of 95% for vegetations. Tx: From 2 to 6 weeks. Tx: From 2 to 6 weeks.

37 DUKE 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. Typical microorganism on 2 or more blood cultures: Viridans streptococci, Streptococcus bovis (gallolyticus), or HABCEK or Community-acquired Staphylococcus aureus or enterococci. HABCEK 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) 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. Positive blood culture for CB or IgG titer >1:800. 2. Evidence of endocardial involvement Positive echocardiogram for IE defined as : Positive echocardiogram for IE defined as : Vegetation or Vegetation or abscess or abscess or new partial dehiscence of prosthetic valve new partial dehiscence of prosthetic valve New valvular regurgitation (worsening or changing of preexisting murmur not sufficient) New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

38 Duke criteria Minor criteria : Minor criteria : Predisposition: predisposing heart condition or intravenous drug use Predisposition: predisposing heart condition or intravenous drug use Fever: temperature > 38.0° C (100.4° F) Fever: temperature > 38.0° C (100.4° F) Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots and rheumatoid factor Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots and rheumatoid factor Roth spots Roth spots Microbiological evidence: positive blood culture but does not meet a major criterion as noted above¹ or serological evidence of active infection with organism consistent with IE Microbiological evidence: positive blood culture but does not meet a major criterion as noted above¹ or serological evidence of active infection with organism consistent with IE Echocardiographic findings: consistent with IE but do not meet a major criterion as noted above Echocardiographic findings: consistent with IE but do not meet a major criterion as noted above ¹ Excludes single positive cultures for coagulase-negative staphylococci, diphtheroids, and organisms that do not commonly cause endocarditis. ¹ Excludes single positive cultures for coagulase-negative staphylococci, diphtheroids, and organisms that do not commonly cause endocarditis.

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40 AB Prophylaxis for BE Low risk: Low risk: Secundum ASD Secundum ASD Innocent murmur Innocent murmur CABG surgery CABG surgery Pacemaker/ICD Pacemaker/ICD MVP without MR MVP without MR High risk: High risk: Prosthetic valve Prosthetic valve Cyanotic congenital heart disease Cyanotic congenital heart disease Previous endocarditis Previous endocarditis Moderate risk: Moderate risk: All other congenital heart disease. Bicuspid aortic valve Acquired valve disease HCM MVP with MR

41 Surgery Indications in Bacterial endocarditis About 20-50% will require surgery. About 20-50% will require surgery. Hemodinamic instability due to valvular regurgitation, destruction. Hemodinamic instability due to valvular regurgitation, destruction. Cardiogenic shock Cardiogenic shock Perivalvular extension, abscess Perivalvular extension, abscess Resistant infection Resistant infection Fungal endocarditis Fungal endocarditis Vegetation >1cm in diameter Vegetation >1cm in diameter Recurrent distal emboli. Recurrent distal emboli.

42 Question A 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 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. A. Continue 2 more weeks with IV AB. B. Surgery consult for AV reconstruction. B. Surgery consult for AV reconstruction. C. Discharge pt with IV AB by HHC. C. Discharge pt with IV AB by HHC. D. Continue in hospital IV AB until 3 BC are negative. D. Continue in hospital IV AB until 3 BC are negative.

43 Stress 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 Response Ischemia 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 mV Horizontal or downsloping ST depression > 0.1 mV ST-segment elevation > 0.1 mV in noninfarct lead ST-segment elevation > 0.1 mV in noninfarct lead Five or more abnormal leads Five or more abnormal leads Persistent ischemic response >3 minutes after exertion Persistent ischemic response >3 minutes after exertion Typical angina Typical angina Exercise-induced decrease in systolic BP by 10 mm Hg Exercise-induced decrease in systolic BP by 10 mm Hg

44 Stress 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 mV Horizontal or downsloping ST depression > 0.1 mV Persistent ischemic response greater than 1 to 3 minutes after exertion Persistent ischemic response greater than 1 to 3 minutes after exertion Three to 4 abnormal leads Three to 4 abnormal leadsLow No ischemia or ischemia induced at high-level exercise (> 7 METs or HR > 130 bpm (greater than 85% of age-predicted heart rate)) manifested by: Horizontal or downsloping ST depression > 0.1 mV Horizontal or downsloping ST depression > 0.1 mV One or 2 abnormal leads One or 2 abnormal leads Inadequate test Inability 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.

45 Un-interpretable Treadmill EKG Resting T-wave abnormalities Resting T-wave abnormalities WPW WPW Paced rhythm Paced rhythm LVH LVH Digoxin Digoxin MVP MVP LBBB LBBB

46 Question A 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 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 test A. Dobutamine stress test B. Exercise echocardiogram B. Exercise echocardiogram C. Adenosine stress test C. Adenosine stress test D. Exercise electrocardiography D. Exercise electrocardiography

47 Preoperative Evaluation

48 Risk Stratification Procedure Examples Vascular (reported cardiac Aortic and other major vascular surgery risk often > 5%) Peripheral vascular surgery Intermediate (reported Intraperitoneal and intrathoracic surgery cardiac risk generally 1%-5%) Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Low† (reported cardiac Endoscopic procedures risk generally <1% Superficial procedure Cataract surgery Breast surgery Ambulatory surgery

49 *Active cardiac conditions ConditionExamples Unstable coronary syndromes Unstable or severe angina* (CCS class III or IV)† Unstable or severe angina* (CCS class III or IV)† Recent MI‡ Recent MI‡ Decompensated HF NYHA functional class IV; NYHA functional class IV; Worsening or new-onset HF Worsening or new-onset HF Significant arrhythmias High-grade atrioventricular block High-grade atrioventricular block Mobitz II atrioventricular block Mobitz II atrioventricular block Third-degree atrioventricular heart block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest) Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest) Symptomatic bradycardia Symptomatic bradycardia Newly recognized ventricular tachycardia Newly recognized ventricular tachycardia Severe valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic) Severe 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) Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)

50 Can You… 1 Met Take care of yourself? 4 Mets Climb 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? 4 Mets Do light work around the house like dusting or washing dishes? ≥ 10 Mets Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

51 Preoperative Evaluation Revised Cardiac Risk Index or Clinical Risk Factors Ischemic heart disease Ischemic heart disease History of MIAngina History of MIAngina Use of nitroglycerine Use of nitroglycerine Q waves Q waves Congestive heart failure Congestive heart failure History of heart failure History of heart failure Pulmonary edema Pulmonary edema Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea Peripheral edema, rales, Peripheral edema, rales, S3 S3 History of Stroke or TIA History of Stroke or TIA Diabetes on insulin therapy Diabetes on insulin therapy Creatinine>2mg/dl. Creatinine>2mg/dl.

52 Preoperative Evaluation

53 Question Which of the following is most important pre-operative cardiac risk factor for non- cardiac surgical procedures? Which of the following is most important pre-operative cardiac risk factor for non- cardiac surgical procedures? A. S4 gallop A. S4 gallop B. S3 gallop B. S3 gallop C. MI 10 months ago C. MI 10 months ago D. Age over 70 years. D. Age over 70 years.

54 Question A 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 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. A. Proceed with surgery. B. Exercise stress test with imaging. B. Exercise stress test with imaging. C. Adenosine stress test C. Adenosine stress test D. Avoid surgery D. Avoid surgery E. Cardiac catheterization E. Cardiac catheterization

55 Acute Coronary Syndrome Unstable Angina & NSTEMI TIMI risk score: TIMI risk score: Age 65 years or older Age 65 years or older 3 or more CAD traditional risk factors 3 or more CAD traditional risk factors Documented CAD with stenosis of 50% Documented CAD with stenosis of 50% ST segment deviation ST segment deviation 2 or more anginal episodes in the last 24hr 2 or more anginal episodes in the last 24hr Aspirin use within the last 7 days Aspirin use within the last 7 days Elevated cardiac enzymes Elevated cardiac enzymes Low risk: 0-2, Conservative approach with non-invasive stress testing Low risk: 0-2, Conservative approach with non-invasive stress testing Intermediate risk: 3-4 Initiate glycoprotein IIb/IIIa inhibitor and early invasive approach with angiography Intermediate risk: 3-4 Initiate glycoprotein IIb/IIIa inhibitor and early invasive approach with angiography High risk: 5-7 or persistent pain or elevated troponin, angiography High risk: 5-7 or persistent pain or elevated troponin, angiography

56 Question A 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? A 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? CABG CABG PCI PCI Add ACEI Add ACEI Thrombolysis Thrombolysis

57 Indications for revascularization For PCI For PCI Unstable angina failing medical therapy or TIMI 3 or more Unstable angina failing medical therapy or TIMI 3 or more Unstable angina in patient with prior revascularization CABG or PCI Unstable angina in patient with prior revascularization CABG or PCI ST elevation MI ST elevation MI Failed thrombolysis Failed thrombolysis Unable to do thrombolysis Unable to do thrombolysis MI complicated by shock, refractory ventricular arrythmia, CHF or sudden death. MI complicated by shock, refractory ventricular arrythmia, CHF or sudden death. For CABG For CABG Left main disease Left main disease 2 vessel disease with proximal LAD w (+) ischemia or low EF, most benefit seen in diabetic patients. 2 vessel disease with proximal LAD w (+) ischemia or low EF, most benefit seen in diabetic patients. 3 vessel disease 3 vessel disease

58 Thrombolysis Indications 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. Indications 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 therapy Contraindications to thrombolytic therapy Any prior intracranial hemorrage Any prior intracranial hemorrage Cerebral vascular lesion Cerebral vascular lesion CNS neoplasm CNS neoplasm CVA <3 months except within 3 hours CVA <3 months except within 3 hours Significant closed head injury <3 months Significant closed head injury <3 months Active bleeding diathesis Active bleeding diathesis Suspected aortic dissection Suspected aortic dissection

59 Question A 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 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. PTCA a. PTCA b. CABG b. CABG c. Medical treatment c. Medical treatment d. Thrombolysis d. Thrombolysis

60 Question A 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? A 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 catheterization Cardiac catheterization Electrophysiologic studies Electrophysiologic studies Echocardiography Echocardiography Holter monitor Holter monitor Signal-average ECG Signal-average ECG

61 Question A 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? A 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 only Observation only Intravenous lidocaine Intravenous lidocaine Emergent cardiac catheterization Emergent cardiac catheterization Intravenous amiodarone Intravenous amiodarone Electrophysiologic study Electrophysiologic study

62 Complications post-MI Rupture Ventricular Septum Rupture Papillary Muscle Rupture Myocardial Wall Timing 2-14 days 2-10 days 2-7 days Clinical findings Harsh loud systolic thrill LLSB Acute Pulmonary edema, MR murmur Sudden chest pain, shock, JVD, death New ST elev Diagnostic parameter 02 step-up in RV Severe MR, LAE Electro- mechanical dissociation Management Nitro- hydralazine IABSurgeryNitroIABSurgery Usually no survival

63 Questions Patient with IWMI whos BP goes down from 90/60 to 60/20. Next step?, What is the problem? Patient 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? 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?

64 Question A 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? A 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 rupture Myocardial free-wall rupture Large pulmonary embolism Large pulmonary embolism Ventricular septal rupture Ventricular septal rupture Ruptured chordae tendineae Ruptured chordae tendineae Cardiac tamponade Cardiac tamponade

65 Question A 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 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 rupture A. Free wall rupture B. Right Ventricle infarction B. Right Ventricle infarction C. Papillary muscle rupture C. Papillary muscle rupture D. Ventricular septal rupture D. Ventricular septal rupture


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