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Internal Medicine Board Review – Cardiology II
July 17th, 2014
Internal Medicine Board Review – Cardiology II
July 17th, 2014
Topics Topics
EKG’s and arrhythmias/conduction abnormalities
Myocardial Disease and Cardiomyopathies
Pulmonary artery catheters and hemodynamic data interpretation
Syncope Valvular heart disease
EKG’s and arrhythmias/conduction abnormalities
Myocardial Disease and Cardiomyopathies
Pulmonary artery catheters and hemodynamic data interpretation
Syncope Valvular heart disease
HOLD ON!!!HOLD ON!!!
Approach to EKG’s Approach to EKG’s
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
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
EKG interpretation 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
Don’t forget you can use paper/pencil as “poor man’s calipers”
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
Don’t forget you can use paper/pencil as “poor man’s calipers”
EKG interpretation 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
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
Frequently Seen Tracings On Boards 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
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
2nd degree - Mobitz I (Wenckebach) 2nd degree - Mobitz I (Wenckebach)
2nd degree (Mobitz II) AV Block 2nd degree (Mobitz II) AV Block
Left Bundle Branch Block Left Bundle Branch Block
Right Bundle Branch Block Right Bundle Branch Block
Atrial Fibrillation with Heart Block and Junctional
Escape
Atrial Fibrillation with Heart Block and Junctional
Escape
Premature Atrial Contractions Premature Atrial Contractions
Premature Ventricular Contractions Premature Ventricular Contractions
Atrial Flutter (2:1 conduction) Atrial Flutter (2:1 conduction)
Atrial Flutter (4:1 conduction) Atrial Flutter (4:1 conduction)
Multifocal Atrial Tachycardia Multifocal Atrial Tachycardia
AV Node Reentrant Tachycardia AV Node Reentrant Tachycardia
Frequent PVC’s and Nonsustained Ventricular Tachycardia
Frequent PVC’s and Nonsustained Ventricular Tachycardia
AIVR (Accelerated Idioventricular Rhythm) AIVR (Accelerated Idioventricular Rhythm)
AIVR (Accelerated Idioventricular Rhythm) AIVR (Accelerated Idioventricular Rhythm)
LVH with Repolarization Abnormalities or Hypertrophic Cardiomyopathy
LVH with Repolarization Abnormalities or Hypertrophic Cardiomyopathy
Tamponade (low voltage with electrical alternans) Tamponade (low voltage with electrical alternans)
Anterior Acute Infarction (LAD) Anterior Acute Infarction (LAD)
Inferior Acute Infarction (RCA) Inferior Acute Infarction (RCA)
Posterolateral Acute Infarction (Circumflex) Posterolateral Acute Infarction (Circumflex)
Ventricular Pre-excitation (WPW) Ventricular Pre-excitation (WPW)
Atrial Fibrillation with WPW Atrial Fibrillation with WPW
Pacemaker Failure to Capture Pacemaker Failure to Capture
ANY QUESTIONS on EKG’s???? ANY QUESTIONS on EKG’s????
QUESTION #1 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 patient’s management is most appropriate at this time?
A. Decrease the dose of enalaprilB. Discontinue the digoxinC. Discontinue the spironolactoneD. Increase the dose of furosemide to reestablish euvolemiaE. Discontinue the carvedilol
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 patient’s management is most appropriate at this time?
A. Decrease the dose of enalaprilB. Discontinue the digoxinC. Discontinue the spironolactoneD. Increase the dose of furosemide to reestablish euvolemiaE. Discontinue the carvedilol
QUESTION #2 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?
A. Emergent endotracheal intubation with mechanical ventilationB. Place an intra-aortic balloon pumpC. Take measures to lower the systemic blood pressure, such as administering an ACE-I or
intravenous nitratesD. High dose intravenous diureticsE. Obtain serum cardiac biomarkers to rule out myocardial infarction
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?
A. Emergent endotracheal intubation with mechanical ventilationB. Place an intra-aortic balloon pumpC. Take measures to lower the systemic blood pressure, such as administering an ACE-I or
intravenous nitratesD. High dose intravenous diureticsE. Obtain serum cardiac biomarkers to rule out myocardial infarction
QUESTION #3 QUESTION #3
All of the following statements regarding heart failure are true EXCEPT:
A. Heart failure is defined as the inability of the heart to pump blood to the vital organs at normal filling pressures.
B. Heart failure now is the most common hospital discharge diagnosis in Medicare patients.
C. The diagnosis of heart failure is excluded by demonstrating normal left ventricular systolic function on echocardiogram.
D. Heart failure is increasing in prevalence due to the aging population and better treatment and salvage of patients with acute myocardial infarction
E. Heart failure is now responsible for greater than 1 million hospitalizations in the United States each year.
All of the following statements regarding heart failure are true EXCEPT:
A. Heart failure is defined as the inability of the heart to pump blood to the vital organs at normal filling pressures.
B. Heart failure now is the most common hospital discharge diagnosis in Medicare patients.
C. The diagnosis of heart failure is excluded by demonstrating normal left ventricular systolic function on echocardiogram.
D. Heart failure is increasing in prevalence due to the aging population and better treatment and salvage of patients with acute myocardial infarction
E. Heart failure is now responsible for greater than 1 million hospitalizations in the United States each year.
Myocardial disease Myocardial disease
Cardiomyopathies Etiology Reversibility
Heart failure treatment
Cardiomyopathies Etiology Reversibility
Heart failure treatment
Cardiomyopathies - Etiology Cardiomyopathies - Etiology
Ischemic Hypertensive Toxin induced ie. EtOH, anthracyclines Metabolic/Infiltrative ie. thyroid, amyloid Associated with general systemic disease ie. MD’s,
CTD’s Peripartum Hypertrophic Valvular ie. AS, AI, MR Inflammatory/Infectious ie. post-viral myocarditis,
HIV, Chaga’s Idiopathic Familial
Ischemic Hypertensive Toxin induced ie. EtOH, anthracyclines Metabolic/Infiltrative ie. thyroid, amyloid Associated with general systemic disease ie. MD’s,
CTD’s Peripartum Hypertrophic Valvular ie. AS, AI, MR Inflammatory/Infectious ie. post-viral myocarditis,
HIV, Chaga’s Idiopathic Familial
Question on Myocardial Dz????
Question on Myocardial Dz????
QUESTION #4 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:
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:
QUESTION #4 (con’t) QUESTION #4 (con’t)
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)
QUESTION #4 (con’t) QUESTION #4 (con’t)
Which of the following is the most appropriate next step in the management of this patient?
A. Place an intra-aortic balloon pump and begin workup for heart transplant
B. Begin high dose dobutamineC. CT chest to evaluate for pulmonary embolusD. Large boluses of isotonic intravenous fluidsE. Draw blood/urine cultures, broad spectrum IV
antibiotics, and support with vasopressors
Which of the following is the most appropriate next step in the management of this patient?
A. Place an intra-aortic balloon pump and begin workup for heart transplant
B. Begin high dose dobutamineC. CT chest to evaluate for pulmonary embolusD. Large boluses of isotonic intravenous fluidsE. Draw blood/urine cultures, broad spectrum IV
antibiotics, and support with vasopressors
PA Catheters (Swan-Ganz) PA Catheters (Swan-Ganz)
Hemodynamics in hypotension 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
Questions on PA catheters or hemodynamics????
Questions on PA catheters or hemodynamics????
QUESTION #5 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 H&P 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.
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 H&P 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.
QUESTION #5 EKG QUESTION #5 EKG
QUESTION #5 (con’t) QUESTION #5 (con’t)
Which of the following is the most appropriate initial recommendation at this time?A. Obtain an echocardiogram to evaluate for
hypertrophic cardiomyopathyB. Perform cardiac MRI to evaluate for
arrhythmogenic right ventricular dyplasiaC. Transfer patient to a telemetry unit to evaluate for
supraventricular arrythmiasD. Perform tilt table testing to evaluate for
vasovagal syncopeE. Discontinue medications that are known to
prolong the Qtc interval
Which of the following is the most appropriate initial recommendation at this time?A. Obtain an echocardiogram to evaluate for
hypertrophic cardiomyopathyB. Perform cardiac MRI to evaluate for
arrhythmogenic right ventricular dyplasiaC. Transfer patient to a telemetry unit to evaluate for
supraventricular arrythmiasD. Perform tilt table testing to evaluate for
vasovagal syncopeE. Discontinue medications that are known to
prolong the Qtc interval
Syncope 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
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
Syncope (hints to specific causes) 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
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 DiseaseValvular Heart Disease
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
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
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Breaking It DownBreaking It Down
What’s the diagnosis?
What’s the diagnosis?
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QuestionQuestion
Aortic StenosisAortic Stenosis
Scenarios – middle aged adult with bicuspid valve, older adult (> 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
<50%, balloon valvuloplasty is only palliative and short-lived
Scenarios – middle aged adult with bicuspid valve, older adult (> 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
<50%, balloon valvuloplasty is only palliative and short-lived
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Aortic RegurgitationAortic 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 +/- CXR if dissection Mgt – afterload reduction with ACE inhibitor
or nifedipine, valve replacement for EF < 50% or LVESD > 55mm (or LVEDD > 75mm)
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 +/- CXR if dissection Mgt – afterload reduction with ACE inhibitor
or nifedipine, valve replacement for EF < 50% or LVESD > 55mm (or LVEDD > 75mm)
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Aortic Regurgitation
MVPMVP
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**
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
What’s the diagnosis?What’s the diagnosis?
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Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
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Hypertrophic CardiomyopathyHypertrophic 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
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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HCM EKGHCM EKG
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Differentiating Aortic Stenosis from Hypertrophic Cardiomyopathy
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
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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What’s the diagnosis?What’s the diagnosis?
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Mitral StenosisMitral 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**
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**84
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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?
1. Senile calcification2. Carcinoid3. Ebstein’s anomaly4. Rheumatic fever
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?
1. Senile calcification2. Carcinoid3. Ebstein’s anomaly4. Rheumatic fever
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QuestionQuestion
Tricuspid RegurgitationTricuspid 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
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????QUESTIONS ON ANYTHING????
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