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

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

Cardiology Topic Breakdown

Cardiology Topic Breakdown

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

Breaking It Down – My Method Focused board oriented pearls of frequently-tested disease processes (This is NOT a comprehensive discussion of each topic!) Broken down by general topics Highlight common scenarios within each topic Symptoms Physical findings Diagnostic tests Management Common word associations

Breaking It Down Physical examination Knowing the basics will help you figure out questions Will often ask for the diagnostic test (echo) rather than the diagnosis (aortic stenosis) Be aware of normal findings that require no further w/u – e.g. innocent flow murmurs, venous hum Recognize cardiac clues to systemic diseases – e.g. rapid atrial fibrillation with a scratchy murmur hyperthyroidism Means–Lerman scratch

The Basics

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

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

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

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

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

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

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

Basic Murmurs S1 S2 S1 S2 ES OS S4 S1 S3

Venous Waveforms in a Nutshell

Venous Waveforms in a Nutshell Ventricular systole Ventricular systole

Large “v” Waves

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

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

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

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

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

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

Cardiac Tamponade Scenarios – trauma and breast cancer are the two biggies on boards, also lupus and renal failure, occasionally viral pericarditis (rarely aortic dissection) Diagnosis – Beck’s triad (hypotension and elevated neck veins with quiet precordium), pulsus paradoxus, electrical alternans Tests - Swan hemodynamics with equalization of all diastolic pressures and slow y descent, echo Mgt – pericardiocentesis

RA Pressure in Tamponade

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

Constrictive Pericarditis Kussmaul’s sign

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

Acute Pericarditis Scenarios – usually post-viral syndrome Diagnosis – pleuritic chest pain, feels better sitting up and leaning forward, pericardial friction rub Tests – EKG with diffuse ST elevation, elevated ESR, CRP and/or biomarkers Mgt – NSAIDs Ibuprofen 600-800 mg TID or ASA 650-1000 mg TID or Indomethacin 50 mg TID for 7-10 days Colchicine 0.5 – 0.6 mg BID Refractory – prednisone plus colchicine

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

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

Atrial Septal Defect

ASD EKG

ASD TEE

ASD Occluder

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

Ventricular Septal Defect

Ventricular Septal Defect

Ventricular Septal Defect

PDA Scenario – teen or young adult referred for murmur Diagnosis – usually asymptomatic, continuous murmur LSB Tests – echo Mgt – closure if murmur noted or left ventricular enlargement or pulmonary HTN, small ones without murmur do not need to be closed, no longer need SBE prophylaxis

Patent Ductus Arteriosus

Patent Ductus Arteriosus

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

Coarctation of Aorta

Coarctation CXR

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

Tetralogy of Fallot

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

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

Risk of CHD in Offspring of Parents with CHD Typically 3-12% Can be up to 50% (Marfan’s syndrome) Fetal ultrasonography recommended @18 weeks

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

Aortic Stenosis Scenarios – young to middle aged adult with bicuspid valve, older adult (> 70 y/o) with tricuspid valve Diagnosis Symptoms are chest pain, syncope, CHF PE shows 3-4/6 SEM at RUSB radiating to carotids, pulsus parvus et tardus (weak and delayed upstrokes) Tests – echo, cath only as pre-op for CAD Mgt – surgery, balloon valvuloplasty is only palliative and short-lived, TAVR new option – only for inoperable or extreme high risk at present – probably too early for boards right now

Aortic Regurgitation Scenario – Marfan’s syndrome, endocarditis Diagnosis – shortness of breath, early high-pitched decrescendo diastolic murmur at left or right upper sternal border, wide pulse pressure, brisk pulses Test – echo Mgt – afterload reduction with ACE inhibitor or nifedipine, valve replacement for EF < 55% or LVESD > 55mm

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

MVP

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

HCM

HCM EKG

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

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

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

Tricuspid Regurgitation Not a likely test question, but may see a case of pulm HTN with TR and also PR Scenario – young woman with severe SOB, hypoxia, and right heart failure – edema, ascites, elevated JVP, large v wave, pulsatile liver Diagnosis – echo, right heart cath, CTA – must rule out other etiologies – CTD, congenital heart disease, recurrent PE Mgt – pulm HTN has poor prognosis if no reversible cause, O2, calcium blockers, Coumadin, prostacyclin analogs (epoprostenol), endothelin receptor antagonists (bosentan), phosphodiesterase-5 inhibitors (sildenafil), lung transplantation

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

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

Endocarditis Scenario – think about it in a pt with multisystem involvement, fever, chills, skin lesions, recent dental work or surgery, murmur – also with an IV drug user with multiple lung lesions Diagnosis – clinical picture, fever, regurgitant murmur, splenomegaly, Janeway lesions, Osler’s nodes, Roth’s spots, anemia, leukocytosis, elevated ESR and CRP, glomerulonephritis Tests – blood cultures are mainstay of diagnosis, echo/TEE Mgt – IV antibiotics Empiric therapy – Vancomycin after 2-3 sets of blood cultures drawn Guide further therapy based on organism/sensitivities PCN G or Rocephin for 4 weeks PCN G + Gentamicin for 2 weeks Common organism – Viridans group streptococci Unusual organism associations Strep gallolyticus (formerly Strep bovis) Associated with colon cancer Needs colonscopy

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

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

80 year old woman presents with syncope, on exam has weak carotid upstrokes, a normal S1 with a diminished S2, and a grade III/VI systolic ejection murmur at the RUSB radiating to the carotids. Bicuspid aortic valve stenosis Tricuspid aortic valve stenosis Hypertrophic cardiomyopathy VSD

40 year old man with Marfan’s syndrome, a blood pressure of 150/50, brisk pulses throughout, and an early high-pitched diastolic murmur heard best at the RUSB Hypertrophic cardiomyopathy Mitral stenosis Aortic regurgitation Pulmonic regurgitation

30 year old woman who presents with palpitations, on exam has a normal S1 and S2, a midsystolic click, and a late systolic murmur that occurs earlier (becomes longer and/or louder) with Valsalva maneuver VSD Hypertrophic cardiomyopathy Mitral regurgitation Mitral valve prolapse

Bicuspid aortic stenosis Tricuspid aortic stenosis 20 year old basketball player referred for episode of syncope, noted to have brisk carotid upstrokes, a normal S1 and S2 with an S4 gallop, and a grade II/VI systolic ejection murmur at the LSB which becomes louder with Valsalva maneuver Bicuspid aortic stenosis Tricuspid aortic stenosis Hypertrophic cardiomyopathy Mitral valve prolapse

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

Mitral stenosis Aortic regurgitation VSD PDA 35 year old woman with increasing dyspnea and fatigue, a history of rheumatic heart disease, a loud S1, a prominent S2 followed by an opening snap, and a diastolic rumble which becomes louder at the end of diastole Mitral stenosis Aortic regurgitation VSD PDA

Pulmonary stenosis VSD ASD Aortic stenosis 35 year old woman referred for palpitations and murmur, normal S1 with wide fixed splitting of S2, and a grade II/VI systolic ejection murmur at the LUSB Pulmonary stenosis VSD ASD Aortic stenosis

Left bundle branch block Right bundle branch block Aortic stenosis HTN 65 year old man who is asymptomatic, noted to have a normal S1, a second heart sound of normal intensity which splits with expiration and becomes single with inspiration (paradoxical splitting), and no murmur Left bundle branch block Right bundle branch block Aortic stenosis HTN This was on the 1994 IM board exam!

Best of luck! Get a good night’s sleep! Trust your initial reaction. Use clinical judgment. Look for the point of the question. If no clue, guess and move on. Can always come back if time allows.

And remember…

Bonus questions! E-mail me with your answers. Or if you have questions or suggestions. mmcmullan@umc.edu

25 year old man who presents to the ER following a stab wound to the left chest, found to have a BP of 80/50, HR 130, a pulsus paradoxus of 20 mm Hg, distended neck veins, and distant heart sounds Constrictive pericarditis Cardiac tamponade Restrictive cardiomyopathy Tension pneumothorax

28 year old woman with primary pulmonary hypertension, elevated neck veins with a prominent v wave, a II/VI pansystolic murmur at the LLSB that increases with inspiration, and a pulsatile liver Mitral regurgitation Tricuspid regurgitation VSD ASD

45 year old veteran who presents with palpitations and SOB after a week-end of binge drinking, on exam has a radial pulse of 120, an apical pulse of 180, and an irregularly irregular heart rhythm PAC’s Bigeminy Atrial flutter Atrial fibrillation

25 year old woman with a history of recent onset hypertension, diminished femoral pulses, and a grade II/VI systolic ejection murmur at the LSB and back Subclavian stenosis Peripheral vascular disease Coarctation of the aorta Renal artery stenosis

70 year old man from a nursing home with elevated neck veins that increase with inspiration and prominent x and y descents, normal S1 and S2 with a loud S3 knock, and no murmur Constrictive pericarditis Restrictive cardiomyopathy Cardiac tamponade Tricuspid regurgitation

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

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

5 year old boy with a history of cyanosis and digital clubbing, noted to stop and “squat” during play, has an RV lift, a single S2, and a grade III/VI systolic ejection murmur at the LUSB Tetralogy of Fallot VSD Pulmonic stenosis ASD Transposition of the great arteries

Venous hum! Lay her back down and it will go away. You are performing routine physical exams for your local high school athletes. You notice a continuous murmur over the neck in a healthy-appearing 18 y/o girl while she is sitting on the stretcher. What is the most likely diagnosis and how do you confirm it? Venous hum! Lay her back down and it will go away.

The next patient has a 2/6 midsystolic murmur at the LUSB with physiologic splitting of S2. What is the most likely diagnosis? Innocent murmur - always < 2/6 murmur - never diastolic - never pansystolic - normal S2

Myocardial infarction Pulmonary embolus Pericarditis Pneumothorax A 30 y/o man presents with chest pain which is less severe when he sits up and leans forward. On exam, he has a scratchy sound in systole and diastole heard throughout his precordium. This is his EKG. Most likely diagnosis is - Myocardial infarction Pulmonary embolus Pericarditis Pneumothorax

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