CARDIAC MISCELLANY FOR INTERNAL MEDICINE Jarrod D. Frizzell, MD, MS Sep 17, 2015

Cardiology on the medicine boards 2015 Cardiology14% Hypertension5% Pericardial disease<2% Ischemic heart disease<2% Dysrhythmias/conduction defects<2% Congenital heart disease<2% Valvular heart disease<2% Myocardial disease<2% Cardiac tumors<2% Endocarditis<2% Vascular disease<2% Syncope<2% Preoperative evaluation<2% Lipid disorders<2% Antithrombotic therapy<2% Other cardiovascular disease<2%

Few notes Be familiar with ECG BBB, AF, AFL CXR CAD/ACS Normal PAC (numbers/waves) Sounds added 2013 Systolic vs diastolic murmur Fixed splitting Know HTN cold Not trying to trick you Generally conservative (less testing, cheaper, etc.)

Question 1 59yoM with no known medical history presents with chest pressure and shortness of breath. 6 days ago, he had chest pressure with shortness of breath with exertion that lasted for an hour or two then went away. 3 days ago, he had intense severe chest pressure; later, he had shortness of breath. Over the course of the next few days until presentation, the chest pressure eventually lessened, and the shortness of breath grew worse “all of a sudden” today.

Question 1 Exam: T 38.8 HR 105 BP 89/55 RR 24 O2 sat 88% NRB Tachycardic, 1/6 holosystolic murmur at apex, Mild JVD with no LE edema Inspiratory crackles, R>L Labs: WBC 15, Hgb 8.8, Plt 170 Tn 1.05 ECG and CXR are available for review

Question 1

Which is the best next step in management? A) Intravenous antibiotics B) Intravenous diuretic C) Intravenous inotropic support D) Urgent cardiac catheterization E) Consult cardiology

Question 1b Which vessel do you expect to be the culprit? A) Left main B) LAD C) LCX D) RCA

Question 1c Which mechanical complication is this patient most at risk for? A) Papillary muscle rupture B) Ventricular septal defect C) Left ventricular free wall rupture

Word association Mechanical complications of MI Pump failure—LAD (supplies ~60% of myo) VSD—LAD Rupture—LCX (esp 1 st MI, women, no other disease) MR/pap rupture—RCA Avoid DOB RV infarct—RCA Avoid NTG, give fluids Takes time for muscle to rot (typically 2-3d)

Question 2 60yoF with breast cancer undergoes pulmonary artery catheterization to evaluate shortness of breath. Her pressures and oxygen saturation are below: LocationPressure% O2 RA2074 RV36/2073 PA36/2073 PCWP2090

Question 2 20

Question 2 What is the next best step in management? A) Emergent pericardiocentesis B) Initiation of PDE C) Inhaled bronchodilators D) Emergent cardiac surgery

Question 2b 60yoF with diabetes undergoes pulmonary artery catheterization to evaluate shortness of breath of acute onset lasting for the past 3 days. Her pressures are oxygen saturation are below: LocationPressure% O2 RA2074 RV52/2084 PA52/3084 PCWP1595

Question 2b What is the next best step in management? A) Emergent pericardiocentesis B) Initiation of PDE C) Inhaled bronchodilators D) Emergent cardiac surgery

PAC “Rule of 6s” for normal pressures RA ≤6 RV 36/6 PA 36/12 PCWP 12 Venous waveforms A—atrial kick C—valve closure (pressure wave reflects back into atrium) V—passive filling of atrium Watch for “step-ups” in O2 sat (indicates L  R shunt)

PAC

Other pericardial things Tamponade  cancer Lung, breast, lymphoma Restrictive (JVD+clear lungs) Usually radiation (pericardial disease) Think also of amyloid, HHC, infiltrative disease Constrictive heart disease Post-CT surgery Inflammatory disease TB Kussmaul’s sign Pericarditis Know ECG Colchicine+NSAIDS (not steroids)

Question 3 35yoM presents for evaluation of shortness of breath. He has been taking inhaled bronchodilators per advice of previous PCP without effect. Exam T 36.3 HR 98 BP 112/65 RR 16 94% RA RRR, no g/r/m, fixed splitting of second heart sound CTAB

Question 3 Which of the following is the most likely diagnosis? A) ASD B) VSD C) PFO D) Pulmonary hypertension

Question 4 63yoF with a history of alcoholism is found down. On EMS arrival, she became unstable and received ACLS protocol. Upon resuscitation, her ECG is as shown.

Question 4

What is the most likely diagnosis? A) Alcoholic cardiomyopathy B) Acute coronary syndrome C) Hypokalemia D) Hypocalcemia E) Hyponatremia

Question 4b What rhythm is most likely the cause of her cardiac arrest? A) Asystole B) PEA C) VT D) VF

Question 5 25yoM with a history of severe asthma requiring intubation presents with palpitations. A) ST-elevation MI B) SVT C) VT D) AF E) AFL

Question 5

Question 5b What is the next best step in management? A) Adenosine B) Verapamil C) DCCV D) Reassurance

Question 5

AVNRTBaseline

Question 6 72yoF presents with palpitations. A) ST-elevation MI B) SVT C) VT D) AF E) AFL

Question 6

Ashman’s Phenomenon

Question 7 75yoM h/o CAD and HF presents with palpitations. A) ST-elevation MI B) SVT C) VT D) AF E) AFL

Question 8—Systolic Murmurs 1) Increase w/ resp 2) Increase w/ HG 3) Decrease w/ HG 4) Late-peaking A) HOCM B) MR C) AS (severe) D) TR

Question 9—Diastolic Murmurs 1) Rheumatic 2) Continuous/machine 3) Endocarditis A) AR B) MS C) PDA