Internal Medicine Board Review- Cardiology

June 16, 2010

Cardiology for the IM Boards

• Examiners want to assess your ability to make decisions that are pragmatic and not beyond your training level

• Avoid unnecessary admissions and invasive tests in patients with no or minimal symptoms

• Make important diagnoses in patients with concerning presentations

• Provide life-prolonging therapies and recognize contraindications to these therapies

Outline of High Yield AreasACS therapies:- ASA, BB, ACE-I, Heparin, 2b/3a,

Lytics

Stable CAD therapies- ACE-I, Statins, ASA, BB

Congenital Heart Disease Diagnoses- ASD, VSD, Bicuspid AV

Rare But Deadly Cardiac Conditions- Brugada Syndrome, HCM, Long QT

syndrome, WPW

Hypertension therapies:- DM, stable CAD

CHF therapies- ACE-I, BB, Hydralazine/Nitrates, ARB,

Aldosterone blockade- Hyperkalemia from use of multiple agents, etc. - ICD and BiV basics

Heart Disease in Pregnancy- High risk vs. low risk lesions- Hemodynamic changes are common

Infective Endocarditis- Diagnostic criteria, typical organisms- Low vs. high risk features- Indications for surgery consultation

Valvular Heart Disease- Aortic stenosis- Mitral regurgitation- AI with bicsuspid AV- MS with history of rheumatic fever

Evaluation of Sinus Tachycardia

• NEVER admit or perform invasive evaluation on asymptomatic patients

• Evaluate cheap, easy diagnoses first in asymptomatic patients- anemia, thyroid, infection, drug use, leukemia

• For patients with symptoms, evaluate life-threatening causes first- PE, sepsis, acute GI bleeding

Acute Coronary Syndromes

• First line, evidence based therapies: ASA 325 mg x1, heparin/lovenox if no evidence of dissection or bleeding

• Early notification for primary PCI for STEMI, or TPA if <90 minutes from first medical contact to device activation

• Plavix and/or 2b3a inhibitors may be too complex for boards, generally indicated in patients with high TIMI risk (> 2 TIMI RF)

TIMI Risk Score

• Age>65 • Known stenosis >50%• Chronic ASA use• Elevated cardiac enzymes• Chest pain>1 episode in last 4

hours• >2 RF for CAD• ST depression >/= 0.5 mm on

ECG

14 day risk of recurrent events from 5 >>>43 %

B-blockers for acute MI

• Not as important as hemodynamic stability

• RF for cardiogenic shock- age>70, SBP <120, HR >100 – AVOID BB

• Beneficial in patients with severe HTN at presentation

• Oral delivery preferred (lower incidence of severe hypotension, shock and heart block)

RV infarction

• Suspect in the setting of hypotension with inferior MI

• R-sided ECG can show STE in V4-V5• Preload dependent condition- CVP must

be increase to allow filling of the pulmonary circulation and provide preload to the LV

• Avoid b-blockers and do not use diuretics unless there is clear pulmonary edema

Pregnant Patient with Cardiac findings

• Most likely this will be benign in a patient without pulmonary edema or hypoxia

• Typical changes for pregnancy- decrease in SVR, increase HR, increase in DOE, LE edema, fatigue. Soft systolic murmurs also common

• Beware of diastolic murmurs- NEVER normal (Mitral stenosis, AI, VSD)

Predictors of poor pregnancy outcome- NYHA III or IV before pregnancy- Saturation <90% on air- Left heart obstruction- Previous cardiac event- Systemic ventricular ejection fraction <40%

Cardiac indications for caesarean section:- Aortopathy with root >4 cm- Aortic dissection or aneurysm- Warfarin treatment within two weeks (fetus clears warfarin slowly and may be at risk for cerebral hemorrahage)

High risk lesions, advise against pregnancy:- Pulmonary hypertension- Aortopathy with root >4 cm or aneurysm, advise surgery first- Severe aortic stenosis (peak gradient >80 mm Hg or - symptoms), advise surgery first- Systemic ventricular dysfunction NYHA III or IV symptoms

Identify Critical Aortic Stenosis

• Critical AS should be symptomatic in a functional patients

• New onset symptoms associated with poor prognosis in all patients

• Surgery prolongs survival

• Physical exam for critical AS- absent S2, late peaking SEM, radiation to carotids, pulsus parvus et tardus

Aortic Regurgitation

• Diastolic murmur over lower sternal borders, usually does not radiate to apex (unless associated with Austin-Flint murmur)

• Asymptomatic patients – observe, however severe LV enlargement (>70 mm diastole, 50 mm systole) and reduction in EF is an indication for surgery

Treat Symptomatic Mitral Stenosis

• Balloon valvuloplasty is associated with significant, prolonged reduction in gradient among patients with rheumatic MS

• High risk BMV features include heavy calcification, leaflet thickening, immobility, and involvement of subvalvular apparatus

• BMV should only be considered for symptomatic, severe MS (>10 mm mean gradient)

Identify Complications of endocarditis

• AV block suggests conduction system involvement

• Indications for urgent surgery- abcess, CHF, fungal infection

• L sided valves are in continuity with each other- often both are involved in severe cases

Acute MR

• Complication of endocarditis

• Treat with IABP placement and surgical consult

• Understand murmur of acute vs. chronic mitral regurgitation

WPW management

• Do nothing in asymptomatic patients

• Symptomatic patients should be referred for ablation

• WPW with afib- (wide complex) avoid AV nodal blockers- give Procainamide

• Incidence of sudden death approximately 0.5%/year

VSD

• Restrictive VSD associated with shunt <1.5:1 and can be managed conservatively

• Larger VSDs are often symptomatic, and if they present in adult life were likely moderately restrictive in childhood

• Likely to result in Eisenmenger’s syndrome and severe pulmonary hypertension

Eisenmenger’s syndrome

• End-stage of congenital heart disease with initial L>R shunt

• Persistent increase in pulmomary blood flow results in vasculopathy, increased PVR and eventually R to L shunt with hypoxia

• Treatment is heart-lung transplant, and palliative therapies (O2, vasodilators,etc.)

• Suspect this in 2nd-3rd decade of life for VSD, 5th-6th decade for ASD

Evaluate Subclinical CAD

• No evidence that screening for CAD is beneficial

• Risk stratify patients with symptoms only

• Always aggressively screen for CAD risk factors, and treat when appropriate

• Smoking cessation is the most important preventive therapy, followed by statin use, with ASA being least powerful

ASA as preventive therapy

• Generally, ASA prevents MI in men and stroke in women

• No good data for universal primary prevention

• Current USPSTF recommendations are for ASA in men 45-79 with at least 1 RF for CAD, for women age 55-79

CXR findings

• VSD- cardiomegaly with biventricular enlargement and pulmonary vascular engorgement

• Aortic coarctation- rib notching

• Left atrial enlargement in mitral stenosis

Endocarditis Prophylaxis- Class IIa

• Valve replacement surgery or valve repair with prosthetic material

• Previous episodes of endocarditis

• Complex cyanotic congenital heart disease

• Heart transplant patients with acquired valvular heart disease

A diagnosis can be reached in any of three ways: two major criteria, one major and three minor criteria, or five minor criteria.

Major criteria include:1. Positive blood cultures2. Evidence of endocardial involvement with positive echocardiogram defined as

Minor criteria include:1. Predisposing factor: known cardiac lesion, recreational drug injection 2. Fever >38°C 3. Evidence of embolism: , Janeway lesions, 4. Immunological problems: glomerulonephritis, Osler's nodes 5. Positive blood culture (that doesn't meet a major criterion) 6. Positive echocardiogram (that doesn't meet a major criterion)

DUKE CRITERIA FOR IE DIAGNOSIS

Perform appropriate cardiac testing in a patient with a cardiac pacemaker

• DO NOT put pacemaker dependent patients on a treadmill

• Stress test of choice will be adenosine-myocardial perfusion imaging study

Diagnose and Manage Aortic Dissection

• Acute onset chest pain with radiation to back• Underlying HTN or phenotypic evidence of connective

tissue disease • Brachial SBP difference R>L• Treatment with IV B-blocker to decrease DP/DT, urgent

surgical consultation for involvement of the ascending aorta

• CXR with widened mediastinum• Avoid anticoagulation until imaging is completed• May be associated with pericarditis, neurologic

symptoms• AI murmur detectable in 1/3 of all cases• 2:1 male: female• 18% previous cardiac surgery, Bicuspid valve in 10-15%,

Marfan syndrome 5-10%,

Number needed to treat

• Inverse of the absolute reduction in event rates

• (18/100) / (12/100) = 6/100

• 100/6 = 16

Treat Asymptomatic LV dysfunction

• Identify etiology and treat accordingly (i.e. rule out CAD, then search for other causes)

• Initiate ACE-I and B-blocker therapies at low doses

• ASA only indicated for patients with CAD

• Treat all cardiovascular RF and screen with fasting lipids/TSH/HgA1C