Presentation is loading. Please wait.

Presentation is loading. Please wait.

Internal Medicine Board Review – Cardiology II July 17 th, 2014 Internal Medicine Board Review – Cardiology II July 17 th, 2014.

Similar presentations


Presentation on theme: "Internal Medicine Board Review – Cardiology II July 17 th, 2014 Internal Medicine Board Review – Cardiology II July 17 th, 2014."— Presentation transcript:

1 Internal Medicine Board Review – Cardiology II July 17 th, 2014 Internal Medicine Board Review – Cardiology II July 17 th, 2014

2 Topics  EKG’s and arrhythmias/conduction abnormalities  Myocardial Disease and Cardiomyopathies  Pulmonary artery catheters and hemodynamic data interpretation  Syncope  Valvular heart disease  EKG’s and arrhythmias/conduction abnormalities  Myocardial Disease and Cardiomyopathies  Pulmonary artery catheters and hemodynamic data interpretation  Syncope  Valvular heart disease

3 HOLD ON!!!

4 Approach to EKG’s  Always read the question stem first to know what you are looking for  Think about the clinical context; may not even need the tracing  Look for patterns that fit the clinical situation  Dissect the EKG in your usual systematic way  Always read the question stem first to know what you are looking for  Think about the clinical context; may not even need the tracing  Look for patterns that fit the clinical situation  Dissect the EKG in your usual systematic way

5 EKG interpretation  Use your system, whatever it is  ie. Mechanism, Structure, Function  If the question includes multiple tracings, it is usually looking for a pattern; beware that two are likely very similar. ie. Mitral stenosis  Don’t forget you can use paper/pencil as “poor man’s calipers”  Use your system, whatever it is  ie. Mechanism, Structure, Function  If the question includes multiple tracings, it is usually looking for a pattern; beware that two are likely very similar. ie. Mitral stenosis  Don’t forget you can use paper/pencil as “poor man’s calipers”

6 EKG interpretation  May include 12 lead, 6 lead, 3 lead or rhythm strips  Pay attention to which leads you are given (and the order/arrangement)  Look for standardization if voltage is relevant (ie. LVH, tamponade)  Count big blocks for heart rate (300, 150, 100, 75, 60…)  Remember, each small block is 0.04 seconds  May include 12 lead, 6 lead, 3 lead or rhythm strips  Pay attention to which leads you are given (and the order/arrangement)  Look for standardization if voltage is relevant (ie. LVH, tamponade)  Count big blocks for heart rate (300, 150, 100, 75, 60…)  Remember, each small block is 0.04 seconds

7 Frequently Seen Tracings On Boards  Conduction Abnormalities  AV block, LBBB, RBBB  Bradyarrhythmias  Sinus brady, A-fib with junctional escape  Atrial Tachyarrhythmias  Sinus tach, A-fib, A-flutter, AVNRT, MAT  Ventricular Arrhythmias  VT, AIVR, torsades  Acute Infarction (Identify the vascular distribution)  Pericarditis  Tamponade  WPW (ventricular pre-excitation)  Long QT syndrome  Electrolyte Disturbances  Hyperkalemia, hypo/hypercalcemia  Conduction Abnormalities  AV block, LBBB, RBBB  Bradyarrhythmias  Sinus brady, A-fib with junctional escape  Atrial Tachyarrhythmias  Sinus tach, A-fib, A-flutter, AVNRT, MAT  Ventricular Arrhythmias  VT, AIVR, torsades  Acute Infarction (Identify the vascular distribution)  Pericarditis  Tamponade  WPW (ventricular pre-excitation)  Long QT syndrome  Electrolyte Disturbances  Hyperkalemia, hypo/hypercalcemia

8 Normal

9 1 st degree AV block

10 2 nd degree - Mobitz I (Wenckebach)

11 2 nd degree (Mobitz II) AV Block

12 2:1 AV Block

13 3 rd degree AV block

14 Left Bundle Branch Block

15 Right Bundle Branch Block

16 Sinus Bradycardia

17 Sick Sinus Syndrome

18 Atrial Fibrillation with Heart Block and Junctional Escape

19 Premature Atrial Contractions

20 Premature Ventricular Contractions

21 Sinus Tachycardia

22 Atrial Fibrillation

23 Atrial Flutter (2:1 conduction)

24 Atrial Flutter (4:1 conduction)

25 Multifocal Atrial Tachycardia

26 AV Node Reentrant Tachycardia

27 Ventricular Tachycardia

28 Frequent PVC’s and Nonsustained Ventricular Tachycardia

29 Ventricular Tachycardia

30 Torsades de Pointes

31

32 AIVR (Accelerated Idioventricular Rhythm)

33

34 LVH with Repolarization Abnormalities or Hypertrophic Cardiomyopathy

35 Tamponade (low voltage with electrical alternans)

36 Low voltage (amyloid)

37 Anterior Acute Infarction (LAD)

38 Inferior Acute Infarction (RCA)

39 Posterolateral Acute Infarction (Circumflex)

40 Pericarditis

41 Ventricular Pre-excitation (WPW)

42 Atrial Fibrillation with WPW

43 Long QT syndrome

44 Brugada Syndrome

45 S1Q3T3 (Pulm embolus)

46 Ventricular Pacemaker

47 Pacemaker Failure to Capture

48 Hyperkalemia

49

50 Hypo/hypercalcemia

51 ANY QUESTIONS on EKG’s????

52 QUESTION #1 A 56 y/o man with ischemic cardiomyopathy is being maintained on a medical regimen of furosemide 40mg twice daily, spironolactone 25mg daily, enalapril 10mg twice daily, digoxin 0.125mg daily, and carvedilol 6.25mg twice daily. In an attempt to titrate up to the target dose of 25mg BID (the dose shown to have the greatest mortality benefit), the carvedilol is increased to 12.5mg BID. Five days later, the patient returns due to worsening dypsnea on exertion and orthopnea. Physical exam is consistent with mild volume overload. Which of the following steps in this patient’s management is most appropriate at this time? A.Decrease the dose of enalapril B.Discontinue the digoxin C.Discontinue the spironolactone D.Increase the dose of furosemide to reestablish euvolemia E.Discontinue the carvedilol A 56 y/o man with ischemic cardiomyopathy is being maintained on a medical regimen of furosemide 40mg twice daily, spironolactone 25mg daily, enalapril 10mg twice daily, digoxin 0.125mg daily, and carvedilol 6.25mg twice daily. In an attempt to titrate up to the target dose of 25mg BID (the dose shown to have the greatest mortality benefit), the carvedilol is increased to 12.5mg BID. Five days later, the patient returns due to worsening dypsnea on exertion and orthopnea. Physical exam is consistent with mild volume overload. Which of the following steps in this patient’s management is most appropriate at this time? A.Decrease the dose of enalapril B.Discontinue the digoxin C.Discontinue the spironolactone D.Increase the dose of furosemide to reestablish euvolemia E.Discontinue the carvedilol

53 QUESTION #2 You are working in an emergency department when a 72 year old woman presents with increasing shortness of breath over the past 12-24 hours. She has a diagnosis of heart failure after a myocardial infarction several years ago. She has been prescribed an excellent medical regimen, but she has been intermittently compliant recently. On presentation her vital signs reveal a heart rate of 94, blood pressure of 196/110, respiratory rate of 24, and oxygen saturations of 85% on room air. Physical exam reveals no significant peripheral edema, normal jugular venous pressure, an S4 gallop, and rales in the bilateral lung bases. EKG shows sinus mechanism, evidence of an old anterior infarct, and nonspecific st-t wave changes which is unchanged from her EKG 6 months ago. CXR shows moderate pulmonary congestion. Complete blood count and basic metabolic panel are unremarkable. Which of the following would the most appropriate NEXT step in the management of this patient? A.Emergent endotracheal intubation with mechanical ventilation B.Place an intra-aortic balloon pump C.Take measures to lower the systemic blood pressure, such as administering an ACE-I or intravenous nitrates D.High dose intravenous diuretics E.Obtain serum cardiac biomarkers to rule out myocardial infarction You are working in an emergency department when a 72 year old woman presents with increasing shortness of breath over the past 12-24 hours. She has a diagnosis of heart failure after a myocardial infarction several years ago. She has been prescribed an excellent medical regimen, but she has been intermittently compliant recently. On presentation her vital signs reveal a heart rate of 94, blood pressure of 196/110, respiratory rate of 24, and oxygen saturations of 85% on room air. Physical exam reveals no significant peripheral edema, normal jugular venous pressure, an S4 gallop, and rales in the bilateral lung bases. EKG shows sinus mechanism, evidence of an old anterior infarct, and nonspecific st-t wave changes which is unchanged from her EKG 6 months ago. CXR shows moderate pulmonary congestion. Complete blood count and basic metabolic panel are unremarkable. Which of the following would the most appropriate NEXT step in the management of this patient? A.Emergent endotracheal intubation with mechanical ventilation B.Place an intra-aortic balloon pump C.Take measures to lower the systemic blood pressure, such as administering an ACE-I or intravenous nitrates D.High dose intravenous diuretics E.Obtain serum cardiac biomarkers to rule out myocardial infarction

54 QUESTION #3 All of the following statements regarding heart failure are true EXCEPT: A.Heart failure is defined as the inability of the heart to pump blood to the vital organs at normal filling pressures. B.Heart failure now is the most common hospital discharge diagnosis in Medicare patients. C.The diagnosis of heart failure is excluded by demonstrating normal left ventricular systolic function on echocardiogram. D.Heart failure is increasing in prevalence due to the aging population and better treatment and salvage of patients with acute myocardial infarction E.Heart failure is now responsible for greater than 1 million hospitalizations in the United States each year. All of the following statements regarding heart failure are true EXCEPT: A.Heart failure is defined as the inability of the heart to pump blood to the vital organs at normal filling pressures. B.Heart failure now is the most common hospital discharge diagnosis in Medicare patients. C.The diagnosis of heart failure is excluded by demonstrating normal left ventricular systolic function on echocardiogram. D.Heart failure is increasing in prevalence due to the aging population and better treatment and salvage of patients with acute myocardial infarction E.Heart failure is now responsible for greater than 1 million hospitalizations in the United States each year.

55 Myocardial disease  Cardiomyopathies  Etiology  Reversibility  Heart failure treatment  Cardiomyopathies  Etiology  Reversibility  Heart failure treatment

56 Cardiomyopathies - Etiology  Ischemic  Hypertensive  Toxin induced ie. EtOH, anthracyclines  Metabolic/Infiltrative ie. thyroid, amyloid  Associated with general systemic disease ie. MD’s, CTD’s  Peripartum  Hypertrophic  Valvular ie. AS, AI, MR  Inflammatory/Infectious ie. post-viral myocarditis, HIV, Chaga’s  Idiopathic  Familial  Ischemic  Hypertensive  Toxin induced ie. EtOH, anthracyclines  Metabolic/Infiltrative ie. thyroid, amyloid  Associated with general systemic disease ie. MD’s, CTD’s  Peripartum  Hypertrophic  Valvular ie. AS, AI, MR  Inflammatory/Infectious ie. post-viral myocarditis, HIV, Chaga’s  Idiopathic  Familial

57 Question on Myocardial Dz????

58 QUESTION #4 A 22 year old woman is admitted to the ICU with profound hypotension. She developed a cardiomyopathy 4 months ago after delivery of her first child and was found to have an ejection fraction of 25%. She has done well since that time until today, when she was found unresponsive by family members. Heart rate is 145 bpm with a blood pressure of 86/45 on dopamine. A pulmonary artery catheter is placed to help guide management with the following hemodynamic measurements:

59 QUESTION #4 (con’t) Right Atrial Pressure Wedge Pressure Cardiac Output Systemic Vascular Resistance Mixed Venous O2 Saturation 6 mm Hg (normal) 11 mm Hg (normal) 14 L/min (elevated) 450 dynes/sec/cm 5 (low) 87% (elevated)

60 QUESTION #4 (con’t) Which of the following is the most appropriate next step in the management of this patient? A.Place an intra-aortic balloon pump and begin workup for heart transplant B.Begin high dose dobutamine C.CT chest to evaluate for pulmonary embolus D.Large boluses of isotonic intravenous fluids E.Draw blood/urine cultures, broad spectrum IV antibiotics, and support with vasopressors Which of the following is the most appropriate next step in the management of this patient? A.Place an intra-aortic balloon pump and begin workup for heart transplant B.Begin high dose dobutamine C.CT chest to evaluate for pulmonary embolus D.Large boluses of isotonic intravenous fluids E.Draw blood/urine cultures, broad spectrum IV antibiotics, and support with vasopressors

61 PA Catheters (Swan-Ganz)

62 Hemodynamics in hypotension Cardiac Output PCWPRA Pressure SVRMISC. HypovolemiaLow HighTachycardia, Dry MM SepsisHighLow or normal LowLow O2 extr. (High MV O2) CardiogenicLowHighHigh or normal HighHigh O2 extr. (Low MV O2) NeurogenicNormal or high Low or normal LowMay be bradycardic Pulmonary Embolus Low Normal or high HighVery high PVR

63 Questions on PA catheters or hemodynamics????

64 QUESTION #5 You are consulted by a psychiatrist to see a 17 year old woman admitted 4 days ago with newly diagnosed psychosis. The patient has had several episodes of witnessed syncope in the past 2 days. The patient is very stoic and unable to provide any history. The H&P on the chart states that 2 first degree relatives have died at early ages in their sleep, thought to be due to “heart attacks.” Complete blood count and chemistries are within normal limits. An EKG is obtained and is shown.

65 QUESTION #5 EKG

66 QUESTION #5 (con’t) Which of the following is the most appropriate initial recommendation at this time? A.Obtain an echocardiogram to evaluate for hypertrophic cardiomyopathy B.Perform cardiac MRI to evaluate for arrhythmogenic right ventricular dyplasia C.Transfer patient to a telemetry unit to evaluate for supraventricular arrythmias D.Perform tilt table testing to evaluate for vasovagal syncope E.Discontinue medications that are known to prolong the Qtc interval Which of the following is the most appropriate initial recommendation at this time? A.Obtain an echocardiogram to evaluate for hypertrophic cardiomyopathy B.Perform cardiac MRI to evaluate for arrhythmogenic right ventricular dyplasia C.Transfer patient to a telemetry unit to evaluate for supraventricular arrythmias D.Perform tilt table testing to evaluate for vasovagal syncope E.Discontinue medications that are known to prolong the Qtc interval

67 Syncope  Sudden transient loss of consciousness and postural tone with spontaneous recovery without neurologic deficit  Differentiate from seizure, SCD  Diagnosis on boards (and in practice) should be made by history, history, history, physical exam, or EKG  ECHO only when structural heart disease is likely  Additional studies guided by history and the clinical suspicion of specific disorders  Sudden transient loss of consciousness and postural tone with spontaneous recovery without neurologic deficit  Differentiate from seizure, SCD  Diagnosis on boards (and in practice) should be made by history, history, history, physical exam, or EKG  ECHO only when structural heart disease is likely  Additional studies guided by history and the clinical suspicion of specific disorders

68 Syncope (hints to specific causes)  Young athlete with systolic murmur – Hypertrophic Cardiomyopathy  Older patient with systolic murmur – Aortic Stenosis  Young patient with prodrome, prolonged standing, or at church – Vasovagal  Older patient on multiple HTN meds – Orthostasis  Head rotation or shaving – Carotid Sinus Sensitivity  Arm exercise – Subclavian Steal Syndrome  With exertion – AS, HCM, MS, Pulm HTN  Older patient with paroxysmal A-fib – Sick Sinus  Swimmer – look for long QT  Young athlete with systolic murmur – Hypertrophic Cardiomyopathy  Older patient with systolic murmur – Aortic Stenosis  Young patient with prodrome, prolonged standing, or at church – Vasovagal  Older patient on multiple HTN meds – Orthostasis  Head rotation or shaving – Carotid Sinus Sensitivity  Arm exercise – Subclavian Steal Syndrome  With exertion – AS, HCM, MS, Pulm HTN  Older patient with paroxysmal A-fib – Sick Sinus  Swimmer – look for long QT

69 69 Valvular Heart Disease

70  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  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 70 Breaking It Down

71 What’s the diagnosis? 71 Question

72 Aortic Stenosis  Scenarios – middle aged adult with bicuspid valve, older adult (> 70) with tricuspid valve  Diagnosis  Symptoms are chest pain, syncope, CHF  PE shows 3-4 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 when symptoms develop or if EF <50%, balloon valvuloplasty is only palliative and short-lived  Scenarios – middle aged adult with bicuspid valve, older adult (> 70) with tricuspid valve  Diagnosis  Symptoms are chest pain, syncope, CHF  PE shows 3-4 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 when symptoms develop or if EF <50%, balloon valvuloplasty is only palliative and short-lived 72

73 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 +/- CXR if dissection  Mgt – afterload reduction with ACE inhibitor or nifedipine, valve replacement for EF 55mm (or LVEDD > 75mm)  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 +/- CXR if dissection  Mgt – afterload reduction with ACE inhibitor or nifedipine, valve replacement for EF 55mm (or LVEDD > 75mm) 73

74 74 Aortic Regurgitation

75 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, valve repair only for severe regurgitation  SBE prophylaxis no longer recommended**  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, valve repair only for severe regurgitation  SBE prophylaxis no longer recommended** 75

76 MVP

77 What’s the diagnosis? 77

78 Hypertrophic Cardiomyopathy 78

79 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  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 79

80 80

81 HCM EKG 81

82 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  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 82

83 What’s the diagnosis? 83

84 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, balloon valvuloplasty is the first line procedure for these pts (as opposed to AS)  SBE prophylaxis no longer recommended**  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, balloon valvuloplasty is the first line procedure for these pts (as opposed to AS)  SBE prophylaxis no longer recommended** 84

85 85

86  A 51 year old man… verbose description… with a diastolic murmer…. more and more words… echo confirms tricuspid stenosis (MAN!!??) What is the most likely etiology? 1.Senile calcification 2.Carcinoid 3.Ebstein’s anomaly 4.Rheumatic fever  A 51 year old man… verbose description… with a diastolic murmer…. more and more words… echo confirms tricuspid stenosis (MAN!!??) What is the most likely etiology? 1.Senile calcification 2.Carcinoid 3.Ebstein’s anomaly 4.Rheumatic fever 86 Question

87 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 – poor prognosis if no reversible cause, O2, calcium blockers, Coumadin, prostacyclin analogs (epoprostenol), endothelin receptor antagonists (bosentan), phosphodiesterase-5 inhibitors (sildenafil), lung transplantation  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 – poor prognosis if no reversible cause, O2, calcium blockers, Coumadin, prostacyclin analogs (epoprostenol), endothelin receptor antagonists (bosentan), phosphodiesterase-5 inhibitors (sildenafil), lung transplantation 87

88 QUESTIONS ON ANYTHING????


Download ppt "Internal Medicine Board Review – Cardiology II July 17 th, 2014 Internal Medicine Board Review – Cardiology II July 17 th, 2014."

Similar presentations


Ads by Google