Cardiology Board Review - uscmedicine.blog · Cardiology Board Review Lin 2020. Cardiovascular Disease. Cardiovascular Disease CAD heart failure & cardiomyopathy valvular disease

Cardiology Board ReviewLin 2020

Cardiovascular Disease

Cardiovascular Disease

CAD

heart failure & cardiomyopathy

valvular disease

stroke

congenital heart disease

arrhythmias

sudden cardiac arrest

PAD

Risk Factors

Lifestyle

EthnicityGenetics

Lipids**TobaccoBlood pressureGlucoseDietEnergy intakePhysical activity

Specific Risk Groups

HTN

Women

Obesity & metabolic syndrome

Diabetes

Inflammatory conditions

CKD

HIVPremature CADCVD in siblings

Hawaiian/PIAmerican IndiansNHWBlacksHispanics/LatinosAsians

Diagnostic Studies

Functional Anatomical

Exercise EKGSPECTPETTTECardiac MRI

Invasive angiographyCoronary CT angioCoronary artery calcium scoreFractional-flow CT

Evaluating Coronary Anatomy

Stress Test Indications

ExerciseNormal EKG Complete RBBB

WPW> 1 mm ST depressionPrior CABG or PCILBBB (exercise echo)

Unable to exercisePaced rhythmLBBB*

Stress Test

Evaluating Arrhythmias

24-hour Holter monitor

Event recorder

Implantable loop recorder

EP study

Question 1

A 68-yo man is evaluated for a 2-mo. history of exertional dyspnea. He has DM, HTN, and DLD and takes lisinopril, HCTZ, metformin, and atorvastatin.

Vital signs are normal. O2 is 99% on RA. He has a regular rhythm and a paradoxically split S2. There is no peripheral edema.

An electrocardiogram is shown.Which of the following is the most appropriate diagnostic test to perform next?A. Adenosine single-photon emission CTB. Coronary artery calcium scoringC. Exercise single-photon emission CTD. Exercise EKG

Question 1

A 68-yo man is evaluated for a 2-mo. history of exertional dyspnea. He has DM, HTN, and DLD and takes lisinopril, HCTZ, metformin, and atorvastatin.

Vital signs are normal. O2 is 99% on RA. He has a regular rhythm and a paradoxically split S2. There is no peripheral edema.

An electrocardiogram is shown.Which of the following is the most appropriate diagnostic test to perform next?A. Adenosine single-photon emission CTB. Coronary artery calcium scoringC. Exercise single-photon emission CTD. Exercise EKG

Question 2

A 60-yo man is evaluated in the hospital for a 2-day history of intermittent chest pain and dyspnea on exertion. He has T2DM, HTN, DLD, COPD, and peripheral neuropathy. His ability to exercise is limited by his COPD. He takes metformin, simvastatin, low-dose aspirin, lisinopril, amlodipine, and an albuterol-ipratropium inhaler.

Temp is normal, BP 128/78, HR 80/min, RR 16/min. O2 is 94% on RA. Pulmonary examination reveals expiratory wheezing bilaterally. Heart sounds are distant. No edema is present.

Serial serum troponin I measurements are negative. An electrocardiogram demonstrates left ventricular hypertrophy with repolarization abnormalities.

Which of the following is the most appropriate diagnostic test to perform next?

A. Adenosine single-photon emission CT

B. Coronary angiogram

C. Coronary CT angiogram

D. Exercise EKG

Question 2

A 60-yo man is evaluated in the hospital for a 2-day history of intermittent chest pain and dyspnea on exertion. He has T2DM, HTN, DLD, COPD, and peripheral neuropathy. His ability to exercise is limited by his COPD. He takes metformin, simvastatin, low-dose aspirin, lisinopril, amlodipine, and an albuterol-ipratropium inhaler.

Temp is normal, BP 128/78, HR 80/min, RR 16/min. O2 is 94% on RA. Pulmonary examination reveals expiratory wheezing bilaterally. Heart sounds are distant. No edema is present.

Serial serum troponin I measurements are negative. An electrocardiogram demonstrates left ventricular hypertrophy with repolarization abnormalities.


A. Adenosine single-photon emission CT

B. Coronary angiogram

C. Coronary CT angiogram

D. Exercise EKG

Question 3

A 56-year-old man is evaluated for cardiovascular risk assessment. At a recent employee health screening, he was informed that he has elevated cholesterol levels. He feels well and exercises three to four times per week without any symptoms. He does not use tobacco. Medical history is unremarkable. Family history is notable for a myocardial infarction in his father at age 54 years. He takes no medications.

On physical examination, the patient is afebrile, blood pressure is 124/82 mm Hg, and pulse rate is 76/min. BMI is 28. Cardiovascular examination is normal.

His 10-year risk for atherosclerotic cardiovascular disease using the Pooled Cohort Equations is 7%.

Which of the following is the most reasonable next step in management?

A. Adenosine CMR

B. Coronary artery calcium scoring

C. Exercise stress echo

D. Lipoprotein(a) measurement

E. Pharmacologic nuclear stress test

Total chol 149 mg/dL

HDL 38 mg/dL

LDL 122 mg/dL

Triglycerides 170 mg/dL

Question 3

A 56-year-old man is evaluated for cardiovascular risk assessment. At a recent employee health screening, he was informed that he has elevated cholesterol levels. He feels well and exercises three to four times per week without any symptoms. He does not use tobacco. Medical history is unremarkable. Family history is notable for a myocardial infarction in his father at age 54 years. He takes no medications.

On physical examination, the patient is afebrile, blood pressure is 124/82 mm Hg, and pulse rate is 76/min. BMI is 28. Cardiovascular examination is normal.

His 10-year risk for atherosclerotic cardiovascular disease using the Pooled Cohort Equations is 7%.

Which of the following is the most reasonable next step in management?

A. Adenosine CMR

B. Coronary artery calcium scoring

C. Exercise stress echo

D. Lipoprotein(a) measurement

E. Pharmacologic nuclear stress test

Total chol 149 mg/dL

HDL 38 mg/dL

LDL 122 mg/dL

Triglycerides 170 mg/dL

Ischemic Heart Disease

Stable Angina

Reproducible anginal symptoms (chest pain or pressure) ≥ 2 months precipitated by exertion or emotional stress

Finn JACC 2012

Stable AnginaManagement - Medication

ExerciseTobacco cessation

Diet & lifestyleBP < 130/80

AspirinStatin

ACEi / ARB

β-blockersCCB

NitratesRanolazine

Risk Factor Modifications

Cardioprotective Medications

Anti-anginal Medications

Stable AnginaManagement - RevascularizationRefractory to medical therapy or markedly abnormal stress test

PCI CABG

Medically refractory anginaUnable to tolerate optimate medical therapy

High-risk features on non-invasive tests

L main*3 vessel disease

DM + multivessel disease

Continue GDMT post PCI or CABG

Acute Coronary Syndromes

STEMI

Non-STE ACS

NSTEMI

Unstable Angina

PCI

thrombolytics

TIMI or GRACE

angiography

medical management

Amsterdam Circulation 2014

Acute Coronary SyndromesSTEMI

1• Door to balloon 90 minutes

• Thrombolytics if w/in 12 hours and no PPCI within 120 minutes

2

• Loading aspirin 325 mg

• Anticoagulant (heparin, lovenox, fondaparinux)

• P2Y12 inhibitor (clopidogrel, prasugrel, ticragelor)

3

• β-blocker

• ACEi

• high intensity statin

Acute Coronary SyndromesSTEMI Complications

Electrical Mechanical

Cardiogenic shock

LV free wall ruptureRV infarction

VSDAcute MR

Atrial fibrillationVTVF

AV block

Acute Coronary SyndromesNSTE – ACS Risk Stratification

Antman JAMA 2000

TIMI SCORE

Historical Points

Age ≥ 65 1

≥ 3 CAD risk factors(FHx, HTN, DLD, DM, smoker)

1

Known CAD (≥ 50% stenosis) 1

ASA use in the past 7 days 1

Presentation Points

Recent (≤ 24h) severe angina 1

↑ cardiac markers 1

ST deviation ≥ 0.5 mm 1

Acute Coronary SyndromesNSTE-ACE Management

Intermediate risk(TIMI 3-4)

Low risk(TIMI 0-2)

High risk(TIMI 5-7)

DAPTAnticoagulant

Stress test

DAPTAnticoagulant

Angiography

Acute Coronary SyndromesNSTE-ACE Management - Medical

Statinβ-blockers

ACEi

NitratesCCB

Cardioprotective Anti-anginal

AspirinP2Y12 inhibitorAnticoagulant*

Antiplatelet

Question 4

A 65-yo man was hospitalized 24 hours ago with findings of a large anterior MI. He underwent primary PCI with stent placement in the proximal LAD. He is currently asymptomatic. He has DLD and HTN and takes atorvastatin, aspirin, prasugrel, captopril, and metoprolol.

Temp normal, BP 110/65, HR 65/min, RR 18/min. O2 is 98% on RA. The remainder of the exam is unremarkable.

An EKG obtained in the CCU is shown.Which of the following is the most appropriate treatment?A. AtropineB. Discontinue metoprolol an observeC. Emergent coronary angiographyD. Emergent pacing

Question 4

A 65-yo man was hospitalized 24 hours ago with findings of a large anterior MI. He underwent primary PCI with stent placement in the proximal LAD. He is currently asymptomatic. He has DLD and HTN and takes atorvastatin, aspirin, prasugrel, captopril, and metoprolol.

Temp normal, BP 110/65, HR 65/min, RR 18/min. O2 is 98% on RA. The remainder of the exam is unremarkable.

An EKG obtained in the CCU is shown.Which of the following is the most appropriate treatment?A. AtropineB. Discontinue metoprolol an observeC. Emergent coronary angiographyD. Emergent pacing

Question 5

A 76-yo woman is evaluated before discharge. She was diagnosed with a non–ST-elevation myocardial infarction 3 days ago. She declined angiography, and nuclear stress testing revealed a small lateral perfusion defect and normal LVEF. She has had no further discomfort since admission. Medical history is significant for hyperlipidemia, hypertension, and transient ischemic attack. Medications are low-dose aspirin, ramipril, metoprolol, and atorvastatin.

On physical examination, vital signs and the remainder of the examination are unremarkable.

In addition to low-dose aspirin, which of the following is the optimal antithrombotic regimen for this patient?

A. Prasugrel

B. Ticagrelor

C. Warfarin

D. No additional antithrombotic therapy

Question 5

A 76-yo woman is evaluated before discharge. She was diagnosed with a non–ST-elevation myocardial infarction 3 days ago. She declined angiography, and nuclear stress testing revealed a small lateral perfusion defect and normal LVEF. She has had no further discomfort since admission. Medical history is significant for hyperlipidemia, hypertension, and transient ischemic attack. Medications are low-dose aspirin, ramipril, metoprolol, and atorvastatin.

On physical examination, vital signs and the remainder of the examination are unremarkable.

In addition to low-dose aspirin, which of the following is the optimal antithrombotic regimen for this patient?

A. Prasugrel

B. Ticagrelor

C. Warfarin

D. No additional antithrombotic therapy

Question 6

A 48-yo woman is evaluated for exertional substernal chest pain of several weeks' duration. The chest pain consistently subsides with rest. Medical history is significant for episodic migraine. She has no history of hypertension, hyperlipidemia, or other medical problems. She is a nonsmoker. She takes no medications other than naproxen as needed.

Vital signs are normal. O2 is 98% on RA. The remainder of the exam is unremarkable.

An EKG demonstrates baseline 1.5-mm lateral ST-segment depressions. Nuclear stress testing reveals a mild anterior wall perfusion defect, and a subsequent coronary angiogram demonstrates normal coronary arteries.

Which of the following is the most likely diagnosis?

A. Acute coronary syndrome with spontaneous recanalization

B. Cardiac syndrome X

C. Somatic symptom disorder

D. Takotsubo cardiomyopathy

Question 6

A 48-yo woman is evaluated for exertional substernal chest pain of several weeks' duration. The chest pain consistently subsides with rest. Medical history is significant for episodic migraine. She has no history of hypertension, hyperlipidemia, or other medical problems. She is a nonsmoker. She takes no medications other than naproxen as needed.

Vital signs are normal. O2 is 98% on RA. The remainder of the exam is unremarkable.

An EKG demonstrates baseline 1.5-mm lateral ST-segment depressions. Nuclear stress testing reveals a mild anterior wall perfusion defect, and a subsequent coronary angiogram demonstrates normal coronary arteries.


A. Acute coronary syndrome with spontaneous recanalization

B. Cardiac syndrome X

C. Somatic symptom disorder

D. Takotsubo cardiomyopathy

Question 7

A 55-yo woman is evaluated in the hospital for a single 10-minute episode of chest pain at rest, which occurred 1 hour before presentation. She has HTN and DLD and takes hydrochlorothiazide, ramipril, and pravastatin.

Vital signs are normal. The remainder of the exam is unremarkable.

Labs are notable for normal serum troponin levels.

An EKG demonstrates 1-mm ST-segment depressions in leads V4 through V6.

Aspirin and metoprolol are initiated.

Which of the following is the most appropriate management?

A. Amlodipine

B. Enoxaparin and eptifibatide

C. Exercise stress testing

D. Urgent angiography

Question 7

A 55-yo woman is evaluated in the hospital for a single 10-minute episode of chest pain at rest, which occurred 1 hour before presentation. She has HTN and DLD and takes hydrochlorothiazide, ramipril, and pravastatin.

Vital signs are normal. The remainder of the exam is unremarkable.

Labs are notable for normal serum troponin levels.

An EKG demonstrates 1-mm ST-segment depressions in leads V4 through V6.

Aspirin and metoprolol are initiated.


A. Amlodipine

B. Enoxaparin and eptifibatide

C. Exercise stress testing

D. Urgent angiography

Heart Failure

Etiologies

HFrEF HFpEF

CADHypertensionMyocarditis

Valvular heart diseaseInfiltrative process

HypertensionAging

ObesityDMCAD

Infiltrative process

Diagnosis & Evaluation

• Volume overload• S3

• EKG• CXR• BNP• TSH• TTE

NYHA Class Description

I Structural disease, no symptoms

II Symptomatic, slight limitation

III Symptomatic, marked limitation

IV Inability to perform any activity without symptoms

Detour - BNP

Elevated when ↑R or L filling pressures & systolic/diastolic HF

BNP < 100 effectively excludes HF as cause of acute dyspnea

Renal failureOld ageFemale

Obesity

HFrEF Management

CCBIvabradine

DiureticsSpironolactone

ISDN/hydralazine

ACEi or ARBARNI

β-blockers

Goal BP < 130/80ICD

1. LVEF ≤ 35% 2. NYHA II or III

MI > 40d & LVEF < 30%

CRT (BiV pacing)1. LVEF ≤ 35%2. NYHA II – IV 3. Sinus rhythm 4. LBBB QRS > 150 ms

Question 8

A 72-yo man is evaluated in the hospital for heart failure. In the past month, he has developed progressive dyspnea, such that he cannot walk 50 meters without stopping to catch his breath. He has HTN and ischemic cardiomyopathy. During the hospitalization, a perfusion imaging study demonstrated no ischemia, and a TTE revealed a LVEF 20%. Medications are aspirin, ramipril, isosorbide mononitrate, and furosemide.

Patient is afebrile, BP 120/68, HR 73/min, RR 22/min. The estimated CVP is 9 cm H2O. A paradoxical split S2 and an S3 are present. Lungs are clear to auscultation.

A 12-lead electrocardiogram is shown.

In addition to diuresis, which of the following is the most appropriate treatment before discharge?A. Add carvedilolB. Add ivabradineC. Cardiac resynchronization therapyD. Implantable cardioverter-defibrillator placement

Question 8

A 72-yo man is evaluated in the hospital for heart failure. In the past month, he has developed progressive dyspnea, such that he cannot walk 50 meters without stopping to catch his breath. He has HTN and ischemic cardiomyopathy. During the hospitalization, a perfusion imaging study demonstrated no ischemia, and a TTE revealed a LVEF 20%. Medications are aspirin, ramipril, isosorbide mononitrate, and furosemide.

Patient is afebrile, BP 120/68, HR 73/min, RR 22/min. The estimated CVP is 9 cm H2O. A paradoxical split S2 and an S3 are present. Lungs are clear to auscultation.

A 12-lead electrocardiogram is shown.

In addition to diuresis, which of the following is the most appropriate treatment before discharge?A. Add carvedilolB. Add ivabradineC. Cardiac resynchronization therapyD. Implantable cardioverter-defibrillator placement

Question 9

A 72-yo woman is evaluated during a follow-up visit. She has a 3-year history of HF with a LVEF of 25% and NYHA class III symptoms. She has an ICD. She reports manageable lightheadedness with standing. Medications are lisinopril, carvedilol, and spironolactone at maximally tolerated doses.

The patient is afebrile, BP 98/64, and HR 68/min. The estimated CVP is 6 cm H2O. An S3 is present. The lungs are clear to auscultation. There is no lower extremity edema.


A. Add ivabradine

B. Add valsartan-sacubitril

C. Discontinue carvedilol and start ivabradine

D. Discontinue lisinopril and start valsartan-sacubitril

E. Continue current medications

Question 9

A 72-yo woman is evaluated during a follow-up visit. She has a 3-year history of HF with a LVEF of 25% and NYHA class III symptoms. She has an ICD. She reports manageable lightheadedness with standing. Medications are lisinopril, carvedilol, and spironolactone at maximally tolerated doses.

The patient is afebrile, BP 98/64, and HR 68/min. The estimated CVP is 6 cm H2O. An S3 is present. The lungs are clear to auscultation. There is no lower extremity edema.


A. Add ivabradine

B. Add valsartan-sacubitril

C. Discontinue carvedilol and start ivabradine

D. Discontinue lisinopril and start valsartan-sacubitril

E. Continue current medications

Question 10

A 67-yo man is evaluated during a follow-up visit. He has a 7-year history of heart failure with placement of an ICD 6 years ago. He has NYHA class II symptoms and is currently stable. Since his last visit 6 months ago, he has had no changes in medications, symptoms, or other medical issues. Medications are valsartan-sacubitril, carvedilol, furosemide, and spironolactone.

The patient is afebrile, BP 108/74, HR 64/min. He has no JVD or S3. No edema is noted.

TTE obtained 1 year ago demonstrated a LVEF of 25% and LVEDD of 6.7 cm; these findings are unchanged from 2 years ago.

Heart failure education and the need for diet and medication adherence are reinforced.

Which of the following is the most appropriate testing to perform at this visit?

A. TTE

B. 24-hour ambulatory EKG monitor

C. Serum BNP

D. Serum electrolyte measurement and kidney function studies

Question 10

A 67-yo man is evaluated during a follow-up visit. He has a 7-year history of heart failure with placement of an ICD 6 years ago. He has NYHA class II symptoms and is currently stable. Since his last visit 6 months ago, he has had no changes in medications, symptoms, or other medical issues. Medications are valsartan-sacubitril, carvedilol, furosemide, and spironolactone.

The patient is afebrile, BP 108/74, HR 64/min. He has no JVD or S3. No edema is noted.

TTE obtained 1 year ago demonstrated a LVEF of 25% and LVEDD of 6.7 cm; these findings are unchanged from 2 years ago.

Heart failure education and the need for diet and medication adherence are reinforced.

Which of the following is the most appropriate testing to perform at this visit?

A. TTE

B. 24-hour ambulatory EKG monitor

C. Serum BNP

D. Serum electrolyte measurement and kidney function studies

Question 11

A 72-yo woman is evaluated during a routine office visit. She has a 3-year history of HFpEFand a long history of HTN. She has exertional dyspnea with walking around the house, almost nightly PND, and peripheral edema. Cardiac catheterization performed 2 years ago revealed normal coronary arteries. Medications are hydrochlorothiazide and diltiazem.

The patient is afebrile, BP 136/82, HR 48/min, and RR 18/min. There is JVD. An S4 is present. Pulmonary examination reveals no wheezes or crackles. Peripheral edema is noted.

Labs are significant for a serum Cr of 1.2 mg/dL and a serum Na level of 139 mEq/L.


A. Add ivabradine

B. Add valsartan

C. Discontinue HCTZ and diltiazem, start furosemide

D. Refer for pacemaker placement

Question 11

A 72-yo woman is evaluated during a routine office visit. She has a 3-year history of HFpEFand a long history of HTN. She has exertional dyspnea with walking around the house, almost nightly PND, and peripheral edema. Cardiac catheterization performed 2 years ago revealed normal coronary arteries. Medications are hydrochlorothiazide and diltiazem.

The patient is afebrile, BP 136/82, HR 48/min, and RR 18/min. There is JVD. An S4 is present. Pulmonary examination reveals no wheezes or crackles. Peripheral edema is noted.

Labs are significant for a serum Cr of 1.2 mg/dL and a serum Na level of 139 mEq/L.


A. Add ivabradine

B. Add valsartan

C. Discontinue HCTZ and diltiazem, start furosemide

D. Refer for pacemaker placement

Question 12

A 45-yo man is evaluated during a second follow-up visit after hospitalization for new-onset HFrEF. His LVEF at the time of diagnosis 2 months ago was 42%. He reports feeling better, with improving exercise tolerance and no exertional dyspnea. Medications are lisinopril, low-dose carvedilol, and furosemide. He is black.

The patient is afebrile, BP 120/76, HR 84/min, and RR 16/min. The estimated CVP is normal. There is no S3. Lungs are clear, and there is no peripheral edema.

Which of the following is the most appropriate treatment?

A. Add digoxin

B. Add hydralazine and isosorbide dinitrate

C. Increase carvedilol

D. Increase furosemide

Question 12

A 45-yo man is evaluated during a second follow-up visit after hospitalization for new-onset HFrEF. His LVEF at the time of diagnosis 2 months ago was 42%. He reports feeling better, with improving exercise tolerance and no exertional dyspnea. Medications are lisinopril, low-dose carvedilol, and furosemide. He is black.

The patient is afebrile, BP 120/76, HR 84/min, and RR 16/min. The estimated CVP is normal. There is no S3. Lungs are clear, and there is no peripheral edema.


A. Add digoxin

B. Add hydralazine and isosorbide dinitrate

C. Increase carvedilol

D. Increase furosemide

Dysrhythmias

DysrhythmiasBradycardia

p wave?

yesfollowed by

QRS?

yes

sinus bradycardia

1st degree AV block

2nd degree AV block

nocomplete

heart block

no

slow afib

aflutter

junctional rhythm

Approach to Bradycardia

< 60 bpm

Management

Indications for permanent pacing

• Symptomatic bradycardia w/o reversible cause• Permanent afib and symptomatic bradycardia• Alternating bundle branch block• Complete heart block• Mobitz type 2 2nd degree AV block• High degree AV block (> 1 successive non-

conducted p wave, with several consecutive P waves without QRS)

Symptomatic & unstable

AtropineDopamine/epinephrineTranscutaneous pacing

DysrhythmiasTachycardia

Approach to Tachycardia

narrow complex tachycardia

regular p waves

regularsinus

tachycardia

sawtooth atrial flutter

abnormalAVNRT

AVRT

irregular

atrial fibrillation

MAT

wide complex tachycardia

regular

monomorphic VT

SVT with aberrancy

irregular

polymorphic VT

VF

> 100 bpm

Sinus Tachycardia

Most common tachycardia

• Inappropriate sinus tachycardia (IST) – 2nd to 4th decade in women• r/o hyperthyroidism, anemia, pheo, structural heart disease

• Rx: remove aggravating factors and exercise therapy• B-blockers, CCB

• Postural orthostatic tachycardia syndrome (POTS) – dysautonomia characterized by orthostatic + excessive tachycardia when standing• Confirm with tilt-table test

Atrial Fibrillation

• Valvular Afib = mod-severe MS or mechanical valve replacement

• > 55 yo + cryptogenic stroke or TIA → 30-day EKG monitoring

Risk Factors

DM

Obesity

HTN

CAD

OSA

Atrial FibrillationManagement - Acute

Stable

UnstableSynchronized cardioversion

Evaluate underlying etiology

AnticoagulationSynchronized cardioversion

Rate vs rhythm control

Atrial FibrillationManagement – Chronic

Anticoagulation

Rate vs Rhythm

Ablation

• CHADS2VASc: men > 2, women > 3• NOACs > warfarin if non-valvular• Warfarin if valvular

• Rate: < 80 bpm• Rhythm: favored in younger patients

• Best if no LA enlargement, comorbid conditions• 70-90% success rate

Atrial Flutter

• Rhythm control is favored

• Catheter ablation has high success rate

• Anticoagulate like Afib

SVT

• AVNRT• Short RP interval

• AVRT – WPW syndrome• Reentrant circuit with a bypass pathway and AV node

• Short PR interval + delta wave

• MAT• Irregular SVT with 3+ p wave morphologies

SVTManagement• Vagal maneuvers (Valsalva), Carotid sinus massage, Facial immersion

• Adenosine • If terminates, typically AV node dependent (AVNRT, AVRT)

• If no termination, aflutter, attach

• CCV and β-blockers to prevent recurrent AVNRT

Question 13

An 81-yo man is evaluated before elective hip arthroplasty. He has HTN and OA. He reports no CP, palpitations, exertional dyspnea, or other symptoms of CV disease. He takes lisinopril and celecoxib.

Vital signs are normal. The cardiopulmonary examination is normal. ROM of the R hip is limited by pain without overlying erythema or warmth.

Labs reveal normal kidney function and electrolyte levels.

A 12-lead EKG is shown. Findings are unchanged from 7 years ago.

Which of the following is the most appropriate treatment?A. Dobutamine TTEB. TTEC. Temporary pacemaker placement D. No further testing or intervention

Question 13

An 81-yo man is evaluated before elective hip arthroplasty. He has HTN and OA. He reports no CP, palpitations, exertional dyspnea, or other symptoms of CV disease. He takes lisinopril and celecoxib.

Vital signs are normal. The cardiopulmonary examination is normal. ROM of the R hip is limited by pain without overlying erythema or warmth.

Labs reveal normal kidney function and electrolyte levels.

A 12-lead EKG is shown. Findings are unchanged from 7 years ago.

Which of the following is the most appropriate treatment?A. Dobutamine TTEB. TTEC. Temporary pacemaker placement D. No further testing or intervention

Question 14

A 25-yo woman is evaluated for intermittent palpitations associated with occasional episodes of SOB and lightheadedness. These episodes last from 30 to 90 minutes. She had a similar episode of symptoms during college that required an ED visit; SVT was diagnosed. She takes no medications.

Vital signs are normal. Cardiac examination is normal. The remainder of the examination is unremarkable.

A 12-lead EKG is shown. A resting TTE demonstrates normal LVEF and a structurally normal heart.

Which of the following is the most appropriate next step in management?A. AtenololB. EP studyC. FlecainideD. Verapamil

Question 14

A 25-yo woman is evaluated for intermittent palpitations associated with occasional episodes of SOB and lightheadedness. These episodes last from 30 to 90 minutes. She had a similar episode of symptoms during college that required an ED visit; SVT was diagnosed. She takes no medications.

Vital signs are normal. Cardiac examination is normal. The remainder of the examination is unremarkable.

A 12-lead EKG is shown. A resting TTE demonstrates normal LVEF and a structurally normal heart.

Which of the following is the most appropriate next step in management?A. AtenololB. EP studyC. FlecainideD. Verapamil

Question 15

A 75-yo woman is evaluated during a routine visit. She has HTN and CAD with placement of a stent in the mid RCA 5 years ago. She is symptom free. She takes metoprolol succinate, lisinopril, aspirin, and atorvastatin.

Temp is normal, BP 130/80, HR 72/min, and RR 16/min. BMI is 23. The precordial cadence is irregularly irregular. The remainder of the examination is unremarkable.

An EKG shows atrial fibrillation.


A. Add clopidogrel

B. Add oral anticoagulant

C. Discontinue ASA, begin clopidogrel and oral anticoagulant

D. Discontinue ASA, begin oral anticoagulant

E. No change in therapy

Question 15

A 75-yo woman is evaluated during a routine visit. She has HTN and CAD with placement of a stent in the mid RCA 5 years ago. She is symptom free. She takes metoprolol succinate, lisinopril, aspirin, and atorvastatin.

Temp is normal, BP 130/80, HR 72/min, and RR 16/min. BMI is 23. The precordial cadence is irregularly irregular. The remainder of the examination is unremarkable.

An EKG shows atrial fibrillation.


A. Add clopidogrel

B. Add oral anticoagulant

C. Discontinue ASA, begin clopidogrel and oral anticoagulant

D. Discontinue ASA, begin oral anticoagulant

E. No change in therapy

Valvular Heart Disease

Aortic StenosisEvaluation

• Exertional dyspnea• Angina• Syncope• Heart failure• Sudden cardiac

death

• Late-peaking systolic murmur, radiation to carotids

• Diminished/absent aortic component of S2

• Pulsus parvus et tardus

Etiologies

Age-related degeneration

Bicuspid aortic valve

Rheumatic disease

Chest radiation

Thickened AV → ↑ afterload → LVH, stiffness, ↑ LVEDP → LA enlargement → arrhythmias

Aortic StenosisSeverity & Monitoring

SeverityTransaortic velocity

(m/sec)Mean pressure

gradient (mmHg)Aortic valve area (cm2)

Frequency of TTE evaluation

Mild 2.0 – 2.9 10 – 19 1.5 – 2.9 q3-5 years

Moderate 3.0 – 3.9 20 – 39 1.0 - 1.4 q1-2 years

Severe ≥ 4.0 ≥ 40 < 1.0 q6-12 months

** low AVA & low gradient or velocity:1. Pseudostenosis (severe LV dysfunction + low CO)2. Paradoxical aortic stenosis

Aortic StenosisManagement

Ross Circulation 1968

1. Symptoms

2. LVEF < 50%

3. Cardiac surgery for another indication

Surgical vs transcatheter (TAVR if trileaflet, intermediate or high surgical risk, without severe AR)

Mitral StenosisEvaluation

• Fatigue• Dyspnea with

exertion• Atrial fibrillation• Stroke• Lower extremity

edema

• Low-pitched diastolic rumble at apex

• Opening snap

Etiologies

Rheumatic disease

Parachute mitral valve

Chest radiation

Mitral annular calcification

Obstructive flow from LA into LV → elevated LA pressures → pulmonary congestion, pHTN

Mitral StenosisSeverity & Monitoring

SeverityMean gradient

(mmHg)Systolic PAP (mmHg)

Mitral valve area (cm2)

Frequency of TTE evaluation

Mild < 5 < 30 > 1.5 q3-5 years

Moderate 5 – 10 30 – 50 1.0 – 1.5 q1-2 years

Severe ≥ 10 ≥ 50 < 1.0 annually

Mitral StenosisManagement

1. Symptomatic

2. Pulmonary hypertension

3. Planned pregnancy with severe MS

Percutaneous balloon mitral commissurotomy

Atrial fibrillation

- Mild MS + Afib = NOACs

- Moderate – severe MS + Afib = warfarin

Aortic RegurgitationEvaluation

• SOB• Fatigue• Angina• Acute heart failure

• Bounding peripheral pulses

• Diastolic decrescendo murmur

Etiologies

Ascending aortic dilation

Valvular abnormalities

Endocarditis

Aortic dissection

Volume overload → progressive LV dilation, eccentric hypertrophy

Aortic RegurgitationManagement

1. Symptomatic

2. LVESD > 50 mm

3. LVEF < 50%

4. Cardiac surgery for other reason

Surgical AV repair

Medical therapy: CCB, ACEi or ARB

Acute severe AR- Surgical repair

Mitral RegurgitationEvaluation

• Fatigue• Dyspnea• Pulmonary edema

• Blowing holosytolicmurmur @ apex

• +/- systolic click (if MVP)

Etiologies

Myxomatous valve disease

Mitral valve prolapse

Rheumatic heart disease

Ischemic cardiomyopathy

Endocarditis

LV dilatation + LA hypertension → pulmonary hypertension → RV failure

Mitral RegurgitationManagement

1. Symptomatic

2. LVESD > 40 mm

3. LVEF < 60%

4. Pulmonary hypertension

5. New onset Afib

6. Cardiac surgery for other reason

Surgical MV repair

Mitraclip otherwise (FDA 2013)

Acute severe MR- Vaodilator therapy (nitroprusside)

- Decrease aortic impedence- Improves cardiac output

- IABP- Surgical repair

Bicuspid Aortic Valves

Most common congenital heart abnormality

Associated with:

• Aortic coarctation

• PDA

• Aortic aneurysm and dissection

Rx: AV replacement when stenotic

• Repair aortic root or replace ascending aorta indicated in patients with bicuspid AV when aortic root diameter is > 5 cm.

Tricuspid Regurgitation

Management: loop diuretics & aldosterone antagonists to improve symptoms of R sided congestion

Etiologies

Cor pulmonale with RV failure

Pacemaker/defibrillator lead placement

Congenital abnormalities

Endocarditis

• Fatigue • Elevated JVP• Hepatic congestion• Peripheral edema

Tricuspid Stenosis

Management: surgery for this when treat rheumatic mitral disease

Etiologies

Rheumatic disease

Radiation

Carcinoid syndrome

• Fatigue• Cold skin

• Elevated JVP• Hepatic congestion• Peripheral edema• Diastolic rumble

Indications for Intervention

Valvular Lesion Indications for Intervention Type of Intervention

Aortic stenosis 1. Symptomatic 2. LVEF < 50%3. Moderate stenosis at time of other cardiac surgery4. Rapidly progressive

Valve replacement

Aortic regurgitation 1. Symptomatic2. LVEF < 50%3. LVESD > 50 mm

Valve replacement

Mitral stenosis 1. Symptomatic2. Pulmonary hypertension

Balloon valvuloplasty

Mitral regurgitation 1. Symptomatic2. LVEF < 60%3. LVESD > 40 mm4. Pulmonary hypertension5. New onset atrial fibrillation

1. Surgical valve repair2. MitraClip

Prosthetic Valves

Mechanical Valve Bioprosthetic valve

Age < 50 yo > 70 yo

Anticoagulation Lifelong anticoagulation• AV: INR 2.5• AV + RF for thrombolisim

or older model: INR 3.0• MV: INR 3.0

Aspirin

Temporary anticoagulation (3 mo)

• INR 2.5Aspirin

Monitoring BaselineRepeat with symptoms

Annual TTE after 10 years

Question 16

An 80-yo woman is evaluated for a 6-mo history of worsening exertional dyspnea. Two nights ago, she awoke with sudden-onset dyspnea that was relieved with ambulation. She has not had chest pain. Medical history is significant for MI 8 years ago. She also has a history of LV dysfunction but has been previously well compensated. She takes lisinopril, aspirin, metoprolol, and rosuvastatin.

Temp is normal, BP 95/60, HR 56/min, and RR 18/min. The lungs are clear. The carotid upstroke is low in volume. The apical impulse is laterally displaced and enlarged. S1 is soft; the aortic component of S2 is diminished. There is no S3 or S4. A grade 2/6 mid-peaking systolic murmur is heard throughout the precordium. The remainder of the examination is normal.

TTE demonstrates a LVEF of 32%. The AV is slightly calcified. The stroke volume is markedly decreased (23 mL/m2). The mean aortic gradient is 20 mm Hg (consistent with mild to moderate stenosis), and the AVA is calculated to be 0.7 cm2 (consistent with severe stenosis).

Which of the following is the most appropriate next step in management?

A. Aortic valve replacement

B. Coronary angiography

C. Dobutamine echocardiography

D. Switch lisinopril to valsartan-sacubitril

Question 16

An 80-yo woman is evaluated for a 6-mo history of worsening exertional dyspnea. Two nights ago, she awoke with sudden-onset dyspnea that was relieved with ambulation. She has not had chest pain. Medical history is significant for MI 8 years ago. She also has a history of LV dysfunction but has been previously well compensated. She takes lisinopril, aspirin, metoprolol, and rosuvastatin.

Temp is normal, BP 95/60, HR 56/min, and RR 18/min. The lungs are clear. The carotid upstroke is low in volume. The apical impulse is laterally displaced and enlarged. S1 is soft; the aortic component of S2 is diminished. There is no S3 or S4. A grade 2/6 mid-peaking systolic murmur is heard throughout the precordium. The remainder of the examination is normal.

TTE demonstrates a LVEF of 32%. The AV is slightly calcified. The stroke volume is markedly decreased (23 mL/m2). The mean aortic gradient is 20 mm Hg (consistent with mild to moderate stenosis), and the AVA is calculated to be 0.7 cm2 (consistent with severe stenosis).


A. Aortic valve replacement

B. Coronary angiography

C. Dobutamine echocardiography

D. Switch lisinopril to valsartan-sacubitril

Question 17

A 78-yo man is evaluated for exertional dyspnea. He was previously asymptomatic, but 4 months ago he began having SOB during moderate levels of activity. The dyspnea dissipates with rest. He is otherwise healthy and takes no medications.

Temp is normal, supine BP 132/80, HR 80/min, and RR 22/min. The lungs are clear to auscultation. The carotid upstroke is delayed. There is a grade 3/6 late-peaking systolic murmur best heard at the base of the heart with radiation to both carotid arteries. S1 is normal; the aortic component of S2 is diminished. The remainder of the examination is unremarkable.

TTE demonstrates a LVEF 65%. There is moderate aortic stenosis, with a mean gradient of 28 mm Hg and an aortic valve area of 1.5 cm2.


A. Cardiac catheterization

B. Surgical AV replacement

C. Transcatheter AV replacement

D. Continued clinical observation

Question 17

A 78-yo man is evaluated for exertional dyspnea. He was previously asymptomatic, but 4 months ago he began having SOB during moderate levels of activity. The dyspnea dissipates with rest. He is otherwise healthy and takes no medications.

Temp is normal, supine BP 132/80, HR 80/min, and RR 22/min. The lungs are clear to auscultation. The carotid upstroke is delayed. There is a grade 3/6 late-peaking systolic murmur best heard at the base of the heart with radiation to both carotid arteries. S1 is normal; the aortic component of S2 is diminished. The remainder of the examination is unremarkable.

TTE demonstrates a LVEF 65%. There is moderate aortic stenosis, with a mean gradient of 28 mm Hg and an aortic valve area of 1.5 cm2.


A. Cardiac catheterization

B. Surgical AV replacement

C. Transcatheter AV replacement

D. Continued clinical observation

Question 18

A 45-yo man is evaluated for HTN. He is otherwise healthy and has not had any symptoms. His father died of an acute MI at age 49 years. He takes no medications.

Temp is normal, BP 172/80, HR 80/min, and RR is normal. The lungs are clear. JVP is normal. S1 and S2 are normal. There is a soft ejection click that precedes a grade 2/6 diastolic decrescendo murmur, which is best heard at the right lower sternal border.

A TTE shows a bicuspid AV with mild AR. The LVEF 50%. The ascending aorta is enlarged, with a dimension of 42 mm in the mid-portion.


A. Annual TTE

B. CT angiography of aorta

C. Infective endocarditis prophylaxis

D. Surgical aortic valve replacement

Question 18

A 45-yo man is evaluated for HTN. He is otherwise healthy and has not had any symptoms. His father died of an acute MI at age 49 years. He takes no medications.

Temp is normal, BP 172/80, HR 80/min, and RR is normal. The lungs are clear. JVP is normal. S1 and S2 are normal. There is a soft ejection click that precedes a grade 2/6 diastolic decrescendo murmur, which is best heard at the right lower sternal border.

A TTE shows a bicuspid AV with mild AR. The LVEF 50%. The ascending aorta is enlarged, with a dimension of 42 mm in the mid-portion.


A. Annual TTE

B. CT angiography of aorta

C. Infective endocarditis prophylaxis

D. Surgical aortic valve replacement

Question 19

A 65-yo woman is evaluated during a routine examination. She was diagnosed with a cardiac murmur in early adulthood. She is active, healthy, and without symptoms. She takes no medications.

Vital signs are normal. A grade 3/6 holosystolic murmur preceded by multiple clicks is present at the apex. Physical findings are otherwise unremarkable.

TTE demonstrates a LVEF 50%. The left ventricle is moderately dilated with an LVESD of 42 mm. Myxomatous degeneration of the MV is present with severe regurgitation due to posterior leaflet prolapse.


A. Serial clinical and echocardiographic evaluations

B. Surgical mitral valve repair

C. Surgical mitral valve replacement

D. Transcatheter mitral valve repair

Question 19

A 65-yo woman is evaluated during a routine examination. She was diagnosed with a cardiac murmur in early adulthood. She is active, healthy, and without symptoms. She takes no medications.

Vital signs are normal. A grade 3/6 holosystolic murmur preceded by multiple clicks is present at the apex. Physical findings are otherwise unremarkable.

TTE demonstrates a LVEF 50%. The left ventricle is moderately dilated with an LVESD of 42 mm. Myxomatous degeneration of the MV is present with severe regurgitation due to posterior leaflet prolapse.


A. Serial clinical and echocardiographic evaluations

B. Surgical mitral valve repair

C. Surgical mitral valve replacement

D. Transcatheter mitral valve repair

Question 20

A 66-yo man has just received an AV replacement with a mechanical prosthesis. He is otherwise healthy and takes no medications.

On physical examination, vital signs are normal. There is a regular rhythm with a normal S1, a mechanical S2, and no murmurs. The remainder of the physical examination is normal.

Which of the following is the most appropriate antithrombotic therapy?

A. Apixaban

B. Dabigatran

C. Warfarin

D. Warfarin and aspirin

E. No anticoagulation needed

Question 20

A 66-yo man has just received an AV replacement with a mechanical prosthesis. He is otherwise healthy and takes no medications.

On physical examination, vital signs are normal. There is a regular rhythm with a normal S1, a mechanical S2, and no murmurs. The remainder of the physical examination is normal.

Which of the following is the most appropriate antithrombotic therapy?

A. Apixaban

B. Dabigatran

C. Warfarin

D. Warfarin and aspirin

E. No anticoagulation needed

Infective Endocarditis

Diagnosis

Major criteria

2 separate blood cultures positive for organisms typical of IE

Echocardiographic evidence of endocardial involvement

Minor criteria

Predisposition (predisposing heart condition or IVDU)

Temp > 38°C

Vascular phenomena

Immunologic phenomena

Microbiologic evidence

Risk Factors• Advanced age• DM• Immunosuppressed• IVDU• CHD• Implanted cardiovascular

device

Organisms

Blood culture + 90% of IE cases

Native valve

S. aureusViridans strep

Strep bovisHACEK

BartonellaEnterococci

Prosthetic valve

Early< 2 months

Intermediate2-12 months

Late> 1 year

Hospital acquired

(S. aureus)

Coag-negative

staph

Similar to native valve

Management

• Symptomatic heart failure & valvular dysfunction

• L sided IE 2/2 fungal infections or highly-resistant organisms

• Complications – annular or aortic abscess, destructive penetrating lesion, heart block

• Persistent bacteremia or fevers > 5-7 days despite appropriate anti-microbial

• IV antibiotics for 4-6 weeks for L sided IE

Antibiotic Prophylaxis

• Manipulate gingival tissue or periapical region

• Perforation of oral mucosa

• History of IE• Cardiac transplant• Prosthetic valve/material• Congenital heart disease*

Amoxicillin 2 gm

Question 21

A 46-yo man is evaluated in the hospital for a 6-week history of fatigue and worsening dyspnea. He has a bicuspid aortic valve. He takes no medications.

Temp 38.1 °C (100.6 °F), BP 118/58, HR 92/min, RR 18/min, satting 98% on 2 L of O2. He has a grade 2/6 diastolic murmur heard best at the LLSB. There are crackles at the lung bases bilaterally. Conjunctival hemorrhage is present in the L eye.

WBC of 15,000/µL (15 × 109/L). Three sets of blood cultures are positive for gram-positive cocci.

An EKG shows sinus rhythm, a PR interval of 220 ms, and QRS duration of 100 ms.


A. Cardiac MRI

B. Coronary CT angiography

C. TTE

D. TEE

Question 21

A 46-yo man is evaluated in the hospital for a 6-week history of fatigue and worsening dyspnea. He has a bicuspid aortic valve. He takes no medications.

Temp 38.1 °C (100.6 °F), BP 118/58, HR 92/min, RR 18/min, satting 98% on 2 L of O2. He has a grade 2/6 diastolic murmur heard best at the LLSB. There are crackles at the lung bases bilaterally. Conjunctival hemorrhage is present in the L eye.

WBC of 15,000/µL (15 × 109/L). Three sets of blood cultures are positive for gram-positive cocci.

An EKG shows sinus rhythm, a PR interval of 220 ms, and QRS duration of 100 ms.


A. Cardiac MRI

B. Coronary CT angiography

C. TTE

D. TEE

Myocardial Disease

Cardiomyopathy

Hypertrophic Cardiomyopathy

Restrictive Cardiomyopathy

Dilated Cardiomyopathy

Hypertrophic Cardiomyopathy

Diffuse or focal myocardial hypertrophy → LVOT obstruction

Autosomal dominant

Hypertrophic CardiomyopathySigns, Symptoms, Evaluation

• Exercise intolerance

• Left-sided HF symptoms (late)

• Arrhythmias• Syncope

• Systolic murmur, increased with Valsalva

• TTE – EF > 60%• EKG• CMR• 24 hr ambulatory

EKG monitoring

Hypertrophic CardiomyopathyRisk Stratification

Risk Factors

Sudden death in first degree relative

LV wall thickness ≥ 30 mm

Recent, unexplained syncope

NSVT

Abnormal BP response to exercise

Sustained VT or resuscitated sudden death event

> 1 risk factor → ICD placement

Hypertrophic CardiomyopathyManagement & Surveillance

Avoid high-intensity competitive sports

• Non-vasodilating β-blockers• Verapamil or diltiazem• Diuretics (cautiously)

Septal myectomy if LVOT gradient ≥ 50 mm or recurrent syncope

Avoid vasodilation and decreased preloadAfib – rate control & anticoagulation

SurveillanceAnnual EKG

TTE q1-2 years

Repeat TTE if change in clinical status or cardiac event

Restrictive Cardiomyopathy

Stiff, non-compliant ventricular walls

Interstitial fibrosis → stiffening of ventricles → increased pressure during normal diastolic filling

• Fibrosis 2/2 radiation• Infiltrative diseases• Hemochromatosis• Lysosomal storage disease

Restrictive CardiomyopathySigns, Symptoms, Evaluation

• Exercise intolerance• Peripheral edema• Hepatomegaly• Ascites

• Elevated JVP• Kussmaul sign• S3 gallop• Regurgitant murmur

• TTE – biatrialenlargement, severe diastolic dysfunction, normal ventricular size

• CMR• BNP

Restrictive CardiomyopathyManagementTreat underlying cause if possible & diseases that might affect diastolic function (HTN, DM, CAD, amyloidosis)

• Congestion - loop diuretics

• Afib – anticoagulation and rate control

Dilated Cardiomyopathy

Dilation and reduced function of one or both ventricles

• Idiopathic• Infection • Toxic exposure • Inflammatory • Metabolic

Dilated CardiomyopathySigns, Symptoms, Evaluation

• Exercise intolerance• L-sided HF symptoms

• Elevated JVP • TTE – EF < 30%, thin LV walls

• CMR• BNP

Dilated CardiomyopathyManagement

• Reverse underlying cause if possible

• Standard medical therapy for HF

Question 22

An 18-yo man is evaluated as part of a preparticipation sports examination. He is attending college on a basketball scholarship. He reports no symptoms. He denies any medical history or meds.

Vital signs are normal. Cardiac exam reveals a brisk carotid upstroke. A grade 3/6 systolic crescendo-decrescendo murmur is heard best along the left sternal border; it decreases with squatting and is more pronounced in the upright position. Lungs are clear to auscultation.

An electrocardiogram shows voltage criteria for LVH with abnormal repolarization. A TTE demonstrates asymmetric septal hypertrophy with septal thickness of 18 mm. Systolic anterior motion of the MV is present, and the peak instantaneous LVOT gradient at rest is 30 mm Hg.

Which of the following is the most appropriate management regarding this patient’s participation on the basketball team?

A. Advise the patient he should not play basketball

B. Begin B-blocker therapy

C. Refer for alcohol septal ablation

D. Refer for ICD placement

Question 22

An 18-yo man is evaluated as part of a preparticipation sports examination. He is attending college on a basketball scholarship. He reports no symptoms. He denies any medical history or meds.

Vital signs are normal. Cardiac exam reveals a brisk carotid upstroke. A grade 3/6 systolic crescendo-decrescendo murmur is heard best along the left sternal border; it decreases with squatting and is more pronounced in the upright position. Lungs are clear to auscultation.

An electrocardiogram shows voltage criteria for LVH with abnormal repolarization. A TTE demonstrates asymmetric septal hypertrophy with septal thickness of 18 mm. Systolic anterior motion of the MV is present, and the peak instantaneous LVOT gradient at rest is 30 mm Hg.

Which of the following is the most appropriate management regarding this patient’s participation on the basketball team?

A. Advise the patient he should not play basketball

B. Begin B-blocker therapy

C. Refer for alcohol septal ablation

D. Refer for ICD placement

Question 23

A 36-yo man is evaluated for a 3-day history of progressive exertional dyspnea and palpitations. He has HOCM and mild MR. His only medication is metoprolol succinate.

On examination, pulse rate is 116/min and irregularly irregular. Oxygen saturation is 98% on RA. There is JVD. A grade 3/6 systolic crescendo-decrescendo murmur is heard along the left sternal border. The remainder of the examination is normal.

An EKG demonstrates atrial fibrillation with RVR. TEE shows asymmetric septal hypertrophy and dynamic LVOT obstruction, with a gradient of 36 mm Hg. There is no evidence of LA appendage thrombus.

His CHA2DS2-VASc score is 0 points.

In addition to acute anticoagulation with heparin, which of the following is most appropriate for thromboembolic risk reduction in this patient?

A. Dabigatran

B. Dose-adjusted warfarin

C. High-dose aspirin

D. No further therapy

Question 23

A 36-yo man is evaluated for a 3-day history of progressive exertional dyspnea and palpitations. He has HOCM and mild MR. His only medication is metoprolol succinate.

On examination, pulse rate is 116/min and irregularly irregular. Oxygen saturation is 98% on RA. There is JVD. A grade 3/6 systolic crescendo-decrescendo murmur is heard along the left sternal border. The remainder of the examination is normal.

An EKG demonstrates atrial fibrillation with RVR. TEE shows asymmetric septal hypertrophy and dynamic LVOT obstruction, with a gradient of 36 mm Hg. There is no evidence of LA appendage thrombus.

His CHA2DS2-VASc score is 0 points.

In addition to acute anticoagulation with heparin, which of the following is most appropriate for thromboembolic risk reduction in this patient?

A. Dabigatran

B. Dose-adjusted warfarin

C. High-dose aspirin

D. No further therapy

Question 24

A 64-yo woman is hospitalized for progressive fatigue, dyspnea, orthopnea, and peripheral edema that have been present for the last 18 months. During this time, she has been hospitalized several times for heart failure with preserved EF. She has HTN and takes spironolactone, furosemide, and amlodipine.

BP 136/84, HR 90/min. JVD is present. Crackles are noted at the bases of both lungs. A loud S3 is heard at the apex. A grade 2/6 holosystolic murmur is heard at the LLSB and increases in intensity during inspiration. Abdominal ascites and bilateral pitting edema to the knees are present.

Serum ferritin of 180 ng/mL and a BNP of 560 pg/mL (560 ng/L). Unremarkable SPEP/UPEP.

RHC demonstrates diastolic equalization of pressures at 18 mm Hg. Simultaneous R and L ventricular hemodynamics demonstrate concordant rise and fall of systolic pressures with respiration. CMR with gadolinium shows a pericardial thickness of 2 mm without enhancement and marked late gadolinium enhancement of the papillary muscle. TTE shows symmetric LV wall thickness of 11 mm, normal LV cavity size, a LVEF 55%, and severe biatrial dilatation. RV size and function are normal. TR is noted, and the RVSP is estimated at 72 mm Hg. There is no pericardial effusion.


A. Constrictive pericarditis

B. Fabry disease

C. Hemochromatosis

D. Primary restrictive cardiomyopathy

Question 24

A 64-yo woman is hospitalized for progressive fatigue, dyspnea, orthopnea, and peripheral edema that have been present for the last 18 months. During this time, she has been hospitalized several times for heart failure with preserved EF. She has HTN and takes spironolactone, furosemide, and amlodipine.

BP 136/84, HR 90/min. JVD is present. Crackles are noted at the bases of both lungs. A loud S3 is heard at the apex. A grade 2/6 holosystolic murmur is heard at the LLSB and increases in intensity during inspiration. Abdominal ascites and bilateral pitting edema to the knees are present.

Serum ferritin of 180 ng/mL and a BNP of 560 pg/mL (560 ng/L). Unremarkable SPEP/UPEP.

RHC demonstrates diastolic equalization of pressures at 18 mm Hg. Simultaneous R and L ventricular hemodynamics demonstrate concordant rise and fall of systolic pressures with respiration. CMR with gadolinium shows a pericardial thickness of 2 mm without enhancement and marked late gadolinium enhancement of the papillary muscle. TTE shows symmetric LV wall thickness of 11 mm, normal LV cavity size, a LVEF 55%, and severe biatrial dilatation. RV size and function are normal. TR is noted, and the RVSP is estimated at 72 mm Hg. There is no pericardial effusion.


A. Constrictive pericarditis

B. Fabry disease

C. Hemochromatosis

D. Primary restrictive cardiomyopathy

Cardiac Tumors

Primary Metastatic

MyxomaSarcoma

Lymphoma

MelanomaThymomaGerm Cell

LungStomach

Colon

Myxomas

• Constitutional symptoms• Diastolic murmur• Tumor “plop”

Carney complex – LAMB syndrome

Surgical resection

Documents

Cardiology Board Review - uscmedicine.blog · Cardiology Board Review Lin 2020. Cardiovascular Disease. Cardiovascular Disease CAD heart failure & cardiomyopathy valvular disease