1. Internal Medicine Board Review- Cardiology
June 16, 2010

2. 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

3. 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

4. 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

5. 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)

6. 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 %

7. 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)

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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)

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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 with at least 1 RF for CAD, for women age 55-79

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

22. 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

23. 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)

24. 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

25. 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%,

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

27. 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