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Cardiology Board Review Brenda Shinar, MD February 26, 2013

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Question 1. Answer: C. Exercise electrocardiography www.afp.org/online/en/home/cme/selfstudy/c mebulletin/cardiac-testing/objectives January 2012

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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 Dobutamine Vasodilator Types of Imaging with Stress: No imaging (EKG interpretation only) Nuclear Echocardiogram

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Question 2. Answer: C. Loop event recorder Ambulatory Arrhythmia Monitoring: Choosing the Right Device: Zimetbaum, Peter; Circulation 2010;122:1629-1636

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Understand the Tests Used to Identify Symptomatic Arrhythmias Is there a rhythm disturbance that correlates with the patients 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)

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Question 3. Answer: A. Current smoking

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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 ORAR (%) 3.2549.2 2.8735.7 2.6732.5 2.37 9.9 1.9117.9 1.6220.1 0.91 6.7 0.8612.2 0.7013.7 129.2090.4

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Question 4. Answer: B; Atorvastatin and epifibatide

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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

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

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Question 8. Answer: D; Phenylephrine

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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: Fluids B-blockers Phenylephrine MANEUVERS: Decrease preload: Valsalva Increase preload: Squat Increase afterload: Isometric hand grip

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Question 9. Answer: A; Atrial tachycardia

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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

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Question 10. Answer: C; Cardioversion

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Patients with atrial fibrillation who are hemodynamically unstable should undergo immediate cardioversion

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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

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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

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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

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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)

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Severe aortic stenosis with symptoms requires surgery

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Question 14. Answer: B; IV sodium nitroprusside

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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 Pathophysiology Left ventricle unloads favorably toward path with lowest resisistance: aorta-forward left atrium-backward Management LOWER the systemic blood pressure to favor forward flow: sodium nitroprusside DIURESE TO reduce pulmonary edema SURGERY to REPLACE the VALVE

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Question 15. Answer: C; Follow up ultrasound in 6 to 12 months

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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

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Question 16. Answer: D; Intravenous B-blockade followed by IV sodium nitroprusside

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Anatomy of the Aorta

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

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Aortic Dissection versus Aortic Intramural Hematoma DissectionIntramural 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

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Question 17. Answer: C; IV amiodarone

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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

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Question 18. Answer: D; Haloperidol

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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 age 3.Female sex 4.Multiple QTc prolonging medications 5. Hypokalemia and hypomagnesemia TREATMENT: Stop the offending medication! www.qtdrugs.org

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Question 19. Answer: C; Three sets of blood cultures

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Understand the manifestations of infective endocarditis

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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

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Question 20. Answer: B; Constrictive pericarditis

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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 Kussmals sign Pericardial knock before S3 Cachexia, edema