Internal Medicine Board Review- Cardiology June 16, 2010

Cardiology for the IM Boards Examiners want to assess your ability to make decisions that are pragmatic and not beyond your training level Avoid unnecessary admissions and invasive tests in patients with no or minimal symptoms Make important diagnoses in patients with concerning presentations Provide life-prolonging therapies and recognize contraindications to these therapies

Outline of High Yield Areas Congenital Heart Disease Diagnoses ASD, VSD, Bicuspid AV Rare But Deadly Cardiac Conditions - Brugada Syndrome, HCM, Long QT syndrome, WPW ACS therapies: ASA, BB, ACE-I, Heparin, 2b/3a, Lytics Stable CAD therapies - ACE-I, Statins, ASA, BB Hypertension therapies: DM, stable CAD CHF therapies ACE-I, BB, Hydralazine/Nitrates, ARB, Aldosterone blockade Hyperkalemia from use of multiple agents, etc. ICD and BiV basics Heart Disease in Pregnancy High risk vs. low risk lesions Hemodynamic changes are common Infective Endocarditis Diagnostic criteria, typical organisms Low vs. high risk features Indications for surgery consultation Valvular Heart Disease Aortic stenosis Mitral regurgitation AI with bicsuspid AV MS with history of rheumatic fever

Evaluation of Sinus Tachycardia NEVER admit or perform invasive evaluation on asymptomatic patients Evaluate cheap, easy diagnoses first in asymptomatic patients- anemia, thyroid, infection, drug use, leukemia For patients with symptoms, evaluate life-threatening causes first- PE, sepsis, acute GI bleeding

Acute Coronary Syndromes First line, evidence based therapies: ASA 325 mg x1, heparin/lovenox if no evidence of dissection or bleeding Early notification for primary PCI for STEMI, or TPA if <90 minutes from first medical contact to device activation Plavix and/or 2b3a inhibitors may be too complex for boards, generally indicated in patients with high TIMI risk (> 2 TIMI RF)

TIMI Risk Score Age>65 Known stenosis >50% Chronic ASA use Elevated cardiac enzymes Chest pain>1 episode in last 4 hours >2 RF for CAD ST depression >/= 0.5 mm on ECG 14 day risk of recurrent events from 5 >>>43 %

B-blockers for acute MI Not as important as hemodynamic stability RF for cardiogenic shock- age>70, SBP <120, HR >100 – AVOID BB Beneficial in patients with severe HTN at presentation Oral delivery preferred (lower incidence of severe hypotension, shock and heart block)

RV infarction Suspect in the setting of hypotension with inferior MI R-sided ECG can show STE in V4-V5 Preload dependent condition- CVP must be increase to allow filling of the pulmonary circulation and provide preload to the LV Avoid b-blockers and do not use diuretics unless there is clear pulmonary edema

Pregnant Patient with Cardiac findings Most likely this will be benign in a patient without pulmonary edema or hypoxia Typical changes for pregnancy- decrease in SVR, increase HR, increase in DOE, LE edema, fatigue. Soft systolic murmurs also common Beware of diastolic murmurs- NEVER normal (Mitral stenosis, AI, VSD)

Predictors of poor pregnancy outcome - NYHA III or IV before pregnancy - Saturation <90% on air - Left heart obstruction - Previous cardiac event - Systemic ventricular ejection fraction <40% Cardiac indications for caesarean section: - Aortopathy with root >4 cm - Aortic dissection or aneurysm - Warfarin treatment within two weeks (fetus clears warfarin slowly and may be at risk for cerebral hemorrahage) High risk lesions, advise against pregnancy: - Pulmonary hypertension - Aortopathy with root >4 cm or aneurysm, advise surgery first - Severe aortic stenosis (peak gradient >80 mm Hg or - symptoms), advise surgery first - Systemic ventricular dysfunction NYHA III or IV symptoms

Identify Critical Aortic Stenosis Critical AS should be symptomatic in a functional patients New onset symptoms associated with poor prognosis in all patients Surgery prolongs survival Physical exam for critical AS- absent S2, late peaking SEM, radiation to carotids, pulsus parvus et tardus

Aortic Regurgitation Diastolic murmur over lower sternal borders, usually does not radiate to apex (unless associated with Austin-Flint murmur) Asymptomatic patients – observe, however severe LV enlargement (>70 mm diastole, 50 mm systole) and reduction in EF is an indication for surgery

Treat Symptomatic Mitral Stenosis Balloon valvuloplasty is associated with significant, prolonged reduction in gradient among patients with rheumatic MS High risk BMV features include heavy calcification, leaflet thickening, immobility, and involvement of subvalvular apparatus BMV should only be considered for symptomatic, severe MS (>10 mm mean gradient)

Identify Complications of endocarditis AV block suggests conduction system involvement Indications for urgent surgery- abcess, CHF, fungal infection L sided valves are in continuity with each other- often both are involved in severe cases

Acute MR Complication of endocarditis Treat with IABP placement and surgical consult Understand murmur of acute vs. chronic mitral regurgitation

WPW management Do nothing in asymptomatic patients Symptomatic patients should be referred for ablation WPW with afib- (wide complex) avoid AV nodal blockers- give Procainamide Incidence of sudden death approximately 0.5%/year

VSD Restrictive VSD associated with shunt <1.5:1 and can be managed conservatively Larger VSDs are often symptomatic, and if they present in adult life were likely moderately restrictive in childhood Likely to result in Eisenmenger’s syndrome and severe pulmonary hypertension

Eisenmenger’s syndrome End-stage of congenital heart disease with initial L>R shunt Persistent increase in pulmomary blood flow results in vasculopathy, increased PVR and eventually R to L shunt with hypoxia Treatment is heart-lung transplant, and palliative therapies (O2, vasodilators,etc.) Suspect this in 2nd-3rd decade of life for VSD, 5th-6th decade for ASD

Evaluate Subclinical CAD No evidence that screening for CAD is beneficial Risk stratify patients with symptoms only Always aggressively screen for CAD risk factors, and treat when appropriate Smoking cessation is the most important preventive therapy, followed by statin use, with ASA being least powerful

ASA as preventive therapy Generally, ASA prevents MI in men and stroke in women No good data for universal primary prevention Current USPSTF recommendations are for ASA in men 45-79 with at least 1 RF for CAD, for women age 55-79

CXR findings VSD- cardiomegaly with biventricular enlargement and pulmonary vascular engorgement Aortic coarctation- rib notching Left atrial enlargement in mitral stenosis

Endocarditis Prophylaxis- Class IIa Valve replacement surgery or valve repair with prosthetic material Previous episodes of endocarditis Complex cyanotic congenital heart disease Heart transplant patients with acquired valvular heart disease

DUKE CRITERIA FOR IE DIAGNOSIS A diagnosis can be reached in any of three ways: two major criteria, one major and three minor criteria, or five minor criteria. Major criteria include: Positive blood cultures 2. Evidence of endocardial involvement with positive echocardiogram defined as Minor criteria include: 1. Predisposing factor: known cardiac lesion, recreational drug injection 2. Fever >38°C 3. Evidence of embolism: , Janeway lesions, 4. Immunological problems: glomerulonephritis, Osler's nodes 5. Positive blood culture (that doesn't meet a major criterion) 6. Positive echocardiogram (that doesn't meet a major criterion)

Perform appropriate cardiac testing in a patient with a cardiac pacemaker DO NOT put pacemaker dependent patients on a treadmill Stress test of choice will be adenosine-myocardial perfusion imaging study

Diagnose and Manage Aortic Dissection Acute onset chest pain with radiation to back Underlying HTN or phenotypic evidence of connective tissue disease Brachial SBP difference R>L Treatment with IV B-blocker to decrease DP/DT, urgent surgical consultation for involvement of the ascending aorta CXR with widened mediastinum Avoid anticoagulation until imaging is completed May be associated with pericarditis, neurologic symptoms AI murmur detectable in 1/3 of all cases 2:1 male: female 18% previous cardiac surgery, Bicuspid valve in 10-15%, Marfan syndrome 5-10%,

Number needed to treat Inverse of the absolute reduction in event rates (18/100) / (12/100) = 6/100 100/6 = 16

Treat Asymptomatic LV dysfunction Identify etiology and treat accordingly (i.e. rule out CAD, then search for other causes) Initiate ACE-I and B-blocker therapies at low doses ASA only indicated for patients with CAD Treat all cardiovascular RF and screen with fasting lipids/TSH/HgA1C