Internal Medicine Board Review

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• Internal Medicine Board Review Cardiology II
• July 17th, 2014

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Topics

• EKGs and arrhythmias/conduction abnormalities
• Myocardial Disease and Cardiomyopathies
• Pulmonary artery catheters and hemodynamic data
  interpretation
• Syncope
• Valvular heart disease

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HOLD ON!!!
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Approach to EKGs

• 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

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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
• Dont forget you can use paper/pencil as poor
  mans calipers

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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

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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

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Normal
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1st degree AV block
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2nd degree - Mobitz I (Wenckebach)
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2nd degree (Mobitz II) AV Block
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21 AV Block
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3rd degree AV block
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Left Bundle Branch Block
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Right Bundle Branch Block
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Sinus Bradycardia
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Sick Sinus Syndrome
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Atrial Fibrillation with Heart Block and
Junctional Escape
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Premature Atrial Contractions
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Premature Ventricular Contractions
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Sinus Tachycardia
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Atrial Fibrillation
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Atrial Flutter (21 conduction)
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Atrial Flutter (41 conduction)
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Multifocal Atrial Tachycardia
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AV Node Reentrant Tachycardia
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Ventricular Tachycardia
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Frequent PVCs and Nonsustained Ventricular
Tachycardia
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Ventricular Tachycardia
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Torsades de Pointes
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Torsades de Pointes
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AIVR (Accelerated Idioventricular Rhythm)
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AIVR (Accelerated Idioventricular Rhythm)
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LVH with Repolarization
Abnormalities or Hypertrophic
Cardiomyopathy
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Tamponade (low voltage with
electrical alternans)
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Low voltage (amyloid)
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Anterior Acute Infarction (LAD)
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Inferior Acute Infarction (RCA)
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Posterolateral Acute Infarction
(Circumflex)
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Pericarditis
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Ventricular Pre-excitation (WPW)
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Atrial Fibrillation with WPW
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Long QT syndrome
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Brugada Syndrome
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S1Q3T3 (Pulm embolus)
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Ventricular Pacemaker
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Pacemaker Failure to Capture
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Hyperkalemia
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Hyperkalemia
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Hypo/hypercalcemia
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ANY QUESTIONS on EKGs????
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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 patients management is most appropriate at
  this time?
• Decrease the dose of enalapril
• Discontinue the digoxin
• Discontinue the spironolactone
• Increase the dose of furosemide to reestablish
  euvolemia
• Discontinue the carvedilol

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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?
• Emergent endotracheal intubation with mechanical
  ventilation
• Place an intra-aortic balloon pump
• Take measures to lower the systemic blood
  pressure, such as administering an ACE-I or
  intravenous nitrates
• High dose intravenous diuretics
• Obtain serum cardiac biomarkers to rule out
  myocardial infarction

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QUESTION 3

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

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Myocardial disease

• Cardiomyopathies
• Etiology
• Reversibility
• Heart failure treatment

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Cardiomyopathies - Etiology

• Ischemic
• Hypertensive
• Toxin induced ie. EtOH, anthracyclines
• Metabolic/Infiltrative ie. thyroid, amyloid
• Associated with general systemic disease ie.
  MDs, CTDs
• Peripartum
• Hypertrophic
• Valvular ie. AS, AI, MR
• Inflammatory/Infectious ie. post-viral
  myocarditis, HIV, Chagas
• Idiopathic
• Familial

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Question on Myocardial Dz????
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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

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QUESTION 4 (cont)
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/cm5 (low) 87 (elevated)
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QUESTION 4 (cont)

• Which of the following is the most
  appropriate next step in the management of this
  patient?
• Place an intra-aortic balloon pump and begin
  workup for heart transplant
• Begin high dose dobutamine
• CT chest to evaluate for pulmonary embolus
• Large boluses of isotonic intravenous fluids
• Draw blood/urine cultures, broad spectrum IV
  antibiotics, and support with vasopressors

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PA Catheters (Swan-Ganz)
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Hemodynamics in hypotension
Cardiac Output PCWP RA Pressure SVR MISC.
Hypovolemia Low Low Low High Tachycardia, Dry MM
Sepsis High Low or normal Low or normal Low Low O2 extr. (High MV O2)
Cardiogenic Low High High or normal High High O2 extr. (Low MV O2)
Neurogenic Normal or high Low or normal Low or normal Low May be bradycardic
Pulmonary Embolus Low Low Normal or high High Very high PVR
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Questions on PA catheters or hemodynamics????

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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 HP 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.

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QUESTION 5 EKG
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QUESTION 5 (cont)

• Which of the following is the most
  appropriate initial recommendation at this time?
• Obtain an echocardiogram to evaluate for
  hypertrophic cardiomyopathy
• Perform cardiac MRI to evaluate for
  arrhythmogenic right ventricular dyplasia
• Transfer patient to a telemetry unit to evaluate
  for supraventricular arrythmias
• Perform tilt table testing to evaluate for
  vasovagal syncope
• Discontinue medications that are known to prolong
  the Qtc interval

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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

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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

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Valvular Heart Disease
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Breaking It Down

• Valvular heart disease (2-5 questions)
• Aortic stenosis elderly vs younger
• Aortic regurgitation Marfans 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

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Whats the diagnosis?
Question
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Aortic Stenosis

• Scenarios middle aged adult with bicuspid
  valve, older adult (gt 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
  lt50, balloon valvuloplasty is only palliative
  and short-lived

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Aortic Regurgitation

• Scenario Marfans 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 lt 50 or
  LVESD gt 55mm (or LVEDD gt 75mm)

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Aortic Regurgitation
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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

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MVP
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Whats the diagnosis?
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Hypertrophic Cardiomyopathy
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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

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(No Transcript)
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HCM EKG
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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

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Whats the diagnosis?
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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

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(No Transcript)
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Question

• 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?
• Senile calcification
• Carcinoid
• Ebsteins anomaly
• Rheumatic fever

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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

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QUESTIONS ON ANYTHING????