Cardiology Board Review

Brenda Shinar, MDFebruary 26, 2013

Question 1.

• Answer: C. Exercise electrocardiography

www.afp.org/online/en/home/cme/selfstudy/cmebulletin/cardiac-testing/objectives January 2012

Understand the Tests Used for Coronary Artery Disease Diagnosis and Prognosis

Indications to Order a Stress Test:

• To diagnose occlusive CAD in a symptomatic patient with intermediate pre-test probability for CAD

• To prognosticate in a patient with known occlusive CAD

• To screen for CAD in an asymptomatic high risk patient prior to high risk surgery

Types of Stress:Exercise

DobutamineVasodilator

Types of Imaging with Stress:No imaging

(EKG interpretation only)Nuclear

Echocardiogram

Question 2.

• Answer: C. Loop event recorder

Ambulatory Arrhythmia Monitoring: Choosing the Right Device: Zimetbaum, Peter; Circulation 2010;122:1629-1636

Understand the Tests Used to Identify Symptomatic Arrhythmias

• Is there a rhythm disturbance that correlates with the patient’s symptoms?

• How frequently do the symptoms occur?

• Is the patient able to push a trigger with the symptom onset?

• Holter 24 hour monitor– Continuous monitoring

• Loop event recorder– Continuous monitoring, but

only saved with patient trigger– Saves preceding several

seconds of rhythm

• Post-symptom event recorder– No preceding rhythm (may

miss the arrhythmia)

Question 3.

• Answer: A. Current smoking

Understand the 9 risk factors for CAD and their degree of importance according to INTERHEART study

RISK FACTOR• Dyslipidemia• Tobacco smoking• Psychosocial Stress• Diabetes mellitus• Hypertension• Abdominal obesity• Moderate alcohol intake• Exercise• Vegetables/fruits daily• All risk factors

OR AR (%)• 3.25 49.2• 2.87 35.7• 2.67 32.5• 2.37 9.9• 1.91 17.9• 1.62 20.1• 0.91 6.7• 0.86 12.2• 0.70 13.7• 129.20 90.4

Question 4.

• Answer: B; Atorvastatin and epifibatide

Initiate medical therapy in a high-risk patient with a non-ST elevation MI

EARLY INVASIVE STRATEGY• Elevated biomarkers• New ST depression• High risk TIMI score (≥3)• Signs of heart failure• Hemodynamic instability• PCI within 6 months• Prior CABG• Continued angina despite

aggressive medical therapy• Reduced LV function (EF <40%)

CONSERVATIVE STRATEGY• Low Risk TIMI score (0-2)• Physician or patient

preference in absence of high risk features

Question 5.

• Answer: C; Start metoprolol succinate

Chronic Heart Failure: Contemporary Diagnosis and Management; Gutam V. Ramani, et al: Mayo Clinic Proceedings; February 2010;85(2):180-195

Know the appropriate treatment for systolic heart failure

Question 6.

• Answer: A; Candesartan

Understand the significance of diastolic heart failure

Definition:• Classic signs and symptoms of

heart failure• Preserved LV EF• Invasive or imaging-based

evidence of abnormal diastolic function

Epidemiology:• 50% to 66% of patients with

heart failure over 70 years of age

Pathophysiology of Remodeling:• Near-normal end diastolic

volumes• Increased wall thickness• Increased ratio of wall

thickness to chamber diameterManagement:

• Treat blood pressure ARB (CHARM trial) decreased hospitalizations but not mortality

• Rate/rhythm control in AF• Diuretics• Revascularize if indicated

Question 7.

• Answer: D; Placement of implantable cardioverter-defibrillator

Know the risk factors for sudden death in patients with HOCM

RISK FACTORS for SCD in HOCM• *Cardiac arrest• *Spontaneous sustained

ventricular tachycardia• *Family history of sudden death

age < 40• Unexplained syncope• LV diastolic wall thickness > or =

30 mm• Blunted increase (< 20 mm Hg) or

decrease in systolic BP with exercise

• Nonsustained VT• Heart failure that has progressed

to dilated cardiomyopathy

* These patients should be given an AICD for prevention of sudden cardiac death

This patient also needs a surgical myotomy procedure…

Question 8.

• Answer: D; Phenylephrine

Diagnose and Manage a Patient with HOCM

Dynamic outlet obstruction WORSENED by (murmur is

louder):

• Decreased preload– Lasix, nitroglycerin

• Increased contractility– Digoxin, dobutamine

• Decreased afterload– Sodium nitroprusside, ACEI,

hydralazine, milrinone

Medications that are helpful in HOCM:

FluidsB-blockers

Phenylephrine

MANEUVERS:• Decrease preload:

– Valsalva• Increase preload:

– Squat• Increase afterload:

– Isometric hand grip

Question 9.

• Answer: A; Atrial tachycardia

Diagnose an acute supraventricular tachycardia

ATRIAL TISSUE ONLY• Multifocal atrial tachycardia

– Variable P-wave morphology and variable PP and PR interval

– COPD• Automatic Ectopic Atrial

Tachycardia– Usually abrupt onset and

termination– May be hard to distinguish from

sinus tachycardia– Dig toxicity and hypokalemia

• Atrial flutter– re-entry within the atrium

• Atrial fibrillation– age, HTN, atrial enlargement,

thyrotoxicosis

AV JUNCTION INVOLVED

• Paroxysmal Supraventricular Tachycardia– Re-entry within the AV node– TERMINATES 95% of the time with

appropriate use of adenosine• Junctional Tachycardia

– Increased automaticity within the lower part of the AV node (N-H region)

– Dig toxicity and severe CHF– May terminate with adenosine

Question 10.

• Answer: C; Cardioversion

Patients with atrial fibrillation who are hemodynamically unstable should undergo immediate

cardioversion

Question 11.

• Answer: E; No bridging agent is needed

Perioperative Management of Warfarin and Antiplatelet Therapy; Amir K. Jaffer; Cleveland Clinic Journal of Medicine; 2009 (76 Supplement 4) S37-44

Question 12.

• Answer: A; Postpone surgery for 6 months

Perioperative Management of Warfarin and Antiplatelet Therapy; Amir K. Jaffer; Cleveland Clinic Journal of Medicine; 2009 (76 Supplement 4) S37-44

ACC/AHA Updated 2007 Guidelines:Perioperative Care for Noncardiac Surgery

• BARE METAL STENT– WAIT 6 weeks (3 months) for non-

urgent, elective surgery– URGENT surgery within first 6

weeks requires dual antiplatelet therapy

• DRUG-ELUTING STENT– WAIT one year for non-urgent,

elective surgery– URGENT surgery within 6 months

requires dual antiplatelet therapy– URGENT surgery after 6 months

must continue aspirin (81 mg/day), restart the clopidogrel after 5 days with 300 mg loading dose

Question 13.

• Answer : C; Surgical valve replacement

Aortic Stenosis: Who should undergo surgery, transcatheter valve replacement? Cleveland Clinic Journal of Medicine Volume 79, No. 7, July 2012 (487-497)

Severe aortic stenosis with symptoms requires surgery

Question 14.

• Answer: B; IV sodium nitroprusside

Acute, severe mitral regurgitation is a surgical problem

Etiologies of acute MR• Acute MI (papillary

dysfunction)• Post-MI (papillary

necrosis)• Ruptured chord (chronic

MVP)• Infectious Endocarditis

PathophysiologyLeft ventricle unloads favorably

toward path with lowest resisistance:

aorta-forwardleft atrium-backward

ManagementLOWER the systemic blood

pressure to favor forward flow: sodium nitroprusside

DIURESE TO reduce pulmonary edema

SURGERY to REPLACE the VALVE

Question 15.

• Answer: C; Follow up ultrasound in 6 to 12 months

Manage asymptomatic abdominal aortic aneurysm found on routine screening

Who gets screened for AAA?• USPSTF:

– Men 65-75 who have ever smoked one time U/S

– No screening in women • ACC/AHA 2005:

– Men 60 or older with family hx of AAA in parent or sibling

– Men 65-75 who have ever smoked• Medicare coverage:

– Men 65-75 who have smoked at least 100 cigarettes in their lifetime

– Males or females with family hx of AAA

What to do with the results?• NO REPEAT SCREEN

– No aneurysm• REPEAT SCREEN IN 6-12

MONTHS– Aneurysm 3-5.5 cm diameter

• REPAIR:– >5.5 cm on presentation– Rapidly expanding with

surveillance imaging (5 mm in 6 months or 10 mm in one year)

– Coexisting PAD or peripheral artery aneurysm

Question 16.

• Answer: D; Intravenous B-blockade followed by IV sodium nitroprusside

Anatomy of the Aorta

Treat a descending aortic intramural hematoma in a lesion of the descending aorta (type B)

Aortic Dissection versus Aortic Intramural Hematoma

Dissection Intramural hematoma

•Entrance tear and exit tear from the intima forming a channel inside the media of the aorta with a flap•More commonly type A (Ascending and Arch)•Better prognosis with surgical treatment

•Rupture of vaso vasorum feeding the aortic media to create a hematoma within the medial layer with an intact intima•More commonly type B (Below LSCA)•Does better with medical treatment•B-blocker + sodium nitroprusside

Question 17.

• Answer: C; IV amiodarone

Manage a patient with a hemodynamically stable wide-complex tachycardia

Differential Diagnosis of Monomorphic Wide

Complex Tachycardia:1. Ventricular Tachycardia

(especially if known CAD or cardiomyopathy)

2. Supraventricular Tachycardia with aberrency

3. Antidromic Atrioventricular Reciprocating Tachycardia(Pre-excitiation)

VT Pearls:• Stable hemodynamics does

NOT rule OUT VT• AV dissociation confirms the

diagnosis of VT – Cannon A Waves– Variable S1 indicate atrium

contracting against a closed tricuspid valve

• Treatment of choice should be amiodarone, procainamide, or sotalol

Question 18.

• Answer: D; Haloperidol

Manage the risk for torsades de pointes in the hospital setting

Risk factors for Torsades de Pointes:

1. QTc interval > 500 msec or increase by 60 msec or more after initiation of a QTc prolonging medication

2. Older age3. Female sex4. Multiple QTc prolonging

medications

5. Hypokalemia and hypomagnesemia

TREATMENT:Stop the offending

medication!www.qtdrugs.org

Question 19.

• Answer: C; Three sets of blood cultures

Understand the manifestations of infective endocarditis

MAJOR CRITERIA FOR IE:BLOOD CULTURES:

• Typical microorganism for IE from 2 separate blood cultures

• Persistently positive blood cultures drawn 12 hours apart, or 3 separate cultures drawn at least 1 hour apart

• Single positive culture for coxiella burnetii, or Ig G titer > 1:800

ENDOCARDIAL INVOLVEMENT:

• Positive echocardiographic evidence of IE

• New valvular regurgitation

Question 20.

• Answer: B; Constrictive pericarditis

Diagnose irradiation-induced constrictive pericarditis

Etiologies:• Idiopathic or viral (42-49%)• Post-cardiac surgery (11-

37%)• Post-radiation therapy (9-

31%) Hodgkins/Breast• Connective Tissue Disease

(3-7%)• Post-Infectious (3-6%) TB or

purulent• Other (1-10%)

Patient symptoms:• Heart failure (67%)• Chest pain (8%)• Abdominal symptoms (7%)• Tamponade (5%)

Physical Exam:• Elevated JVP with rapid x and y

descent• Kussmal’s sign• Pericardial knock before S3• Cachexia, edema