Cardiovascular Step 1 Review

UMMSM Board Review SeriesMonday, February 6th Graham Ingalsbegingalsbe@med.miami.edu

Cardiovascular

• Anatomy & Physiology – Cardiac Output, Starling, Cardiac Cycle, Auscultation, Cell Biology, EKG, Pressures and Fluids

• Pathology – Congenital Heart Diseases, Hypertension, Hyperlipidemia, Ischemia/Infarction, Cardiomyopathies, CHF, Endocarditis, Tumors, Vaculitides

• Pharmacology – Antihypertensives, Antianginal, Lipid-lowering agents, Antiarrhythmics

• Cardiac Cycle Physiology• Heart Sounds Overview• Cardiac Pearls• Sample Questions

Cardiac Cyclea wave: atrial contraction. In late diastole, atria propel a final bolus of blood into each ventricle

c wave: small rise in atrial pressures as the tricuspid and mitral valves close and bulge into atria

v wave: passive filling of the atria from the systemic & pulmonary veins during diastole; blood accumulates in atria

S1 & S2• S1: mitral & tricuspid valves close– mitral closes before tricuspid

because of higher pressures – nearly always heard as one sound

• S2: aortic & pulmonic valves close– Inspiration Decreased intrathoracic

pressure more blood is sucked into right side of the heart pulmonic valve will close LATER because it has extra blood to accommodate

• Paradoxical split S2: seen in conditions that prolong LV emptying (aortic stenosis, LBBB). Split “eliminated” on inspiration.

• Widened split S2: seen in conditions that prolong RV emptying (pulmonic stenosis, RBBB)

• Fixed split S2: ASD; left to right shunt, increased flow thru pulmonic valve

S3• Normal in young, healthy (energetic

expansion & filling)• Pathologic after age 40• Occurs in early diastole• Blood rushing into a chamber that is

volume overloaded produces turbulence• Could be left-sided or right-sided

depending on ventricle• Occurs with regurgitant type of

murmurs• Produces a ventricular gallop• Idaho

S4

• ALWAYS pathologic• Coincides w/ atrial contraction in late

diastole & a wave of JVP• Due to decreased Compliance of LV

– Thickened, stiff ventricle (HTN, MI)• Left Atrium has to work harder to push

blood into the ventricle• Could be due to:

– 1) Concentric ventricular hypertrophy• “atrial gallop”• Alaska

Murmurs

• Stenosis – opening problem– Murmurs will be heard when

valve is opening– Sten: narrow, Os: opening

• Regurgitation – closing problem– Murmurs will be heard when

valve is attempting to close

Stenosis

• Who is opening in systole?• Aortic and pulmonic valves– AS, PS

• Who is opening in diastole?• Mitral and tricuspid vavles– Mitral & tricuspid stenosis

Regurgitation

• Who is closing in systole?• Mitral and tricuspid valves– Mitral & tricuspid regurgitation

• Who is closing in diastole?• Aortic and pulmonic vavles– Aortic and pulmonic regurgitation

Aortic Stenosis• Crescendo-descrescendo systolic ejection murmur• Best heard at the 2nd intercostal space, right sternal

border• Radiates to the carotids• Intensity increases on expiration• Might hear an S4

Aortic Stenosis• Etiology– Calcification of normal or bicuspid valve

• Pathophysiology– Obstruction of LV outflow in systole– Reduction in aortic valve area concentric LVH

• Patients present SAD– Syncope– Angina– Dyspnea

• Pulsus parvus et tardus

Mitral Stenosis• LA is working hard in diastole to push blood into

LV• Opening snap• Blood comes rushing into LV: diastolic rumble• LA can hypertrophy blood stasis A fib

thrombus• Increases in intensity on expiration

Mitral Stenosis• Etiology– Recurrent attacks of rheumatic fever

• Pathophysiology– Narrowing of mitral valve orifice– Dilated & hypertrophied LA over time

• Patients present with…1) Dyspnea2) Atrial fibrillation3) Pulmonary venous HTN4) Dysphagia for solids

Mitral Regurgitation• Blood leaking backwards thru incompetent valve• LA becomes overloaded• Pansystolic, sometimes you can’t hear S1 or S2• Apical murmur, possible S3 & S4• Increases in intensity on expiration

Mitral Regurgitation• Etiology– Mitral valve prolapse (most common cause)– Functional MV regurg (left sided heart failure)– Infective endocarditis– Rupture of papillary muscle in MI– Acute rheumatic fever, Libman Sacks Endocarditis

• Pathophys– Retrograde blood flow into LA during systole– Volume overload in LV & LA LHF

• Patients present with– Dyspnea, crackles, and cough from LHF

Aortic Regurgitation• Blood trickles back into LV overloaded

increased EDV• Heard after S2 (valve doesn’t close properly)• High-pitched diastolic blowing murmur• Heard best in 2nd IC space• Increases in intensity on expiration• S3 & S4

Aortic Regurgitation• Etiology– Isolated AV root dilation (most common cause)– Infective endocarditis– Long-standing essential HTN– Chronic rheumatic fever– Aortic dissection– Coarctation– Syphilitic aortitis, Takayasu arteritis

• Pathophysiology– Retrograde blood flow into LV

• Patients present with– Widened pulse pressure, bifid pulse– bounding pulses, head nodding with systole

Question• A 57 y.o woman with a 6 month history of progressive dyspnea on

exertion is evaluated in the office. Physical exam reveals an elevated JVP, a grade 2/6 holosytolic murmur at the apex that radiates to the axilla, an enlarged point of maximal impulse, and moderate edema up to both shins. An EKG shows left atrial and ventricular enlargement. CXR shows mild cardiomegaly and pulmonary congestion. Which of the following is the most likely diagnosis?

• A) Aortic valve regurgitation • B) Aortic valve stenosis• C) Mitral valve regurgitation• D) Mitral valve stenosis• E) Tricuspid valve regurgitation

Question• A 79 y.o woman is seen in the office for an annual exam. She walks regularly to

and from the bus stop several times per week. It now takes her 25 min to get to the bus stop, whereas it only took her 10 min a year ago. She describes dyspnea midway in her walk, causing her to stop and catch her breath. She does not have angina, syncope or edema.

• On physical exam, heart rate is 80/min, and blood pressure is 165/86. Lungs are clear. There is a sustained apical impulse. S1 is normal, and there is a single S2 and an S4. A grade 3/6 late-peaking systolic murmur is heard best at the right second intercostal space with radiation into the right carotid artery.

• Which of the following is the most likely diagnosis?• A) Aortic valve stenosis• B) Hypertrophic cardiomyopathy• C) Mitral valveregurgitation• D) Tricuspid valve regurgitation• E) Ventricular septal defect

Mitral Valve Prolapse

• AD inheritance in some cases• More common in women• Associated with Marfans and Ehlers Danlos syndrome• Pathophys

– Posterior bulging of leaflets into atrium during systole– Redundancy of tissue

• Myxomatous degeneration of mitral valve leaflets due to excess dermatan sulfate

• Patients present with…– Most: Asymptomatic!– Palpitations

Mitral Valve Prolapse• Murmur: mid systolic click, mid-late systolic

regurgitation murmur• Decreased preload causes the click & murmur to

move closer to S1 • Standing, Anxiety, Valsalva

– Increased preload causes it to move closer to S2• Reclining, Squatting or sustained hand grip

Ventricular Septal Defect

• Most common congenital heart disease• Defect in membranous interventricular septum• Harsh pansystolic murmur at lower left sternal

border• Associations: tetralogy of Fallot, Fetal alcohol

syndrome• Spontaneously close in 30 – 50% of cases

Atrial Septal Defect• Patent foramen ovale• Most common adult congenital heart disease• Associations: fetal alcohol syndrome, Down syndrome• Mid-systolic murmur • Fixed splitting of S2 • Excess blood in right atrium causes delay in closure of

pulmonary valve

Patent Ductus Arteriosus• Ductus arteriosus remains open• Associations: congenital rubella syndrome, respiratory

distress syndrome, complete transposition• Machinery like murmur• Reversal of the shunt due to pulmonary HTN

– Unoxygenated blood enters the aorta below the subclavian artery, produces a pink upper body and cyanotic lower body

• Close with Indomethacin

Question• A 19 y.o woman is evaluated in the office for palpitations described as “extra beats”

that do not occur regularly. She has no history of syncope or presyncope, no cardiovascular risk factors, and no family history of cardiovascular disease. She does not have signs or symptoms of congestive heart failure and takes no medications.

• On physical exam, vital signs are normal. Lungs are clear. There is no S4 or S3. A grade 2/6 late systolic murmur is present that is heard best at the apex and radiates towards the left axilla. A mid-systolic click is heard. Following a valsalva maneuver and a squat-to-stand maneuver, the midsystolic click moves closer to S1, but the intensity of the murmur does not change. The rest of the exam is unremarkable.

• Which of the following is the most likely diagnosis accounting for the heart murmur?• A) Innocent flow murmur• B) Hypertrophic cardiomyopathy• C) Mitral valve regurgitation• D) Mitral valve prolapse

Question• A 24 y.o woman who is 23 weeks pregnant is evaluated in the office

because of a 2-month history of increasing shortness of breath. On physical exam, blood pressure is 100/80 and HR is 88/min and regular, and RR is 26. On cardiac exam, the apical impulse is faint in the mid left 6th IC space, and there is a forceful sternal heave. A soft apical systolic murmur, and an opening snap followed by a grade 2/6 mid diastolic murmur. Which of the following is the most likely diagnosis?

• A) Aortic valve stenosis• B) Mitral valve stenosis• C) Normal findings of pregnancy• D) Patent ductus arteriosus• E) Peripartum cardiomyopathy

Dilated Cardiomyopathy• Most common• Causes: alcohol, Beriberi, idiopathic, genetic, Coxsackie B

myocarditis, drugs (doxorubicin, daunorubicin), peri/postpartum state, chronic cocaine use, organic solvents, acromegaly

• Pathophys– Decreased contractility SYSTOLIC dysfunction type of LHF

• Patients present with…– All chambers dilated (global enlargement)– Regurgitation murmurs– S3 – Balloon appearing on CXR– EF usually less than 40%

Hypertrophic Cardiomyopathy• Most common cause of sudden death in young people• Pathophys: hypertrophy of myocardium

– As blood exits LV, the anterior leaflet of the mitral valve is drawn against the asymmetrically hypertrophied IVS

– S4, systolic murmur– DIASTOLIC dysfunction

• Preload changes on murmur intensity OPPOSITE to that of AV stenosis

Restricted Cardiomyopathy• Least common cardiomyopathy• Caused by: amyloidosis, radiation,

fibrosis after open-heart surgery; Infiltrative diseases: hemochromatosis, sarcoidosis

• Pathophys: decreased ventricular compliance DIASTOLIC dysfunction type of LHF

• Patients present with…– Progressive LHF and RHF

• Treat underlying cause

Question• In a hospital cardiac care unit, there are three patients with

different cardiac conditions: a 52-year-old man with dilated cardiomyopathy, an 18-year-old girl with mitral valve prolapse, and a 30-year-old man with infective endocarditis of the mitral valve. Which of the following features do all these patients most likely share?

(A) Decreased compliance(B) Depressed myocardial contractility(C) Infectious etiology(D) Mitral valve stenosis(E) Risk of systemic thromboembolism

Question• A 32 y.o man is evaluated in the office during an annual physical. He is

asymptomatic and there is no personal or family hx of cardiac disease. On physical exam, vital signs are normal. S1 and S2 are present, and there is an S4. There is a grade 2/6 cresendo decresendo systolic murmur heard best at the lower left sternal border. The murmur does not radiate to the carotid arteries. The valsalva maneuver increases the intensity of the murmur, and moving from a squatting to standing position decreases the intensity. Which of the following is the most likely diagnosis?

• A) Aortic valve stenosis• B) Atrial septal defect• C) Hypertrophic cardiomyopathy• D) Mitral valve prolapse• E) Ventricular septal defect

Question• A 38 y.o man is hospitalized with palpitations and dyspnea. He has no significant medical hx and does

not take any medications. He has a 20 pack year smoking hx and drinks alcohol daily. Does not use illicit drugs.

• On physical exam, temperature is 98.5, blood pressure 120/80, and HR is 115. Lungs are clear. Cardiac exam shows an irregularly irregular rhythm. There is trace edema at both ankles.

• Lab studies:• Hemoglobin 14g/dL• Mean corpuscular volume 101 fL• AST 55 U/L• ALT 45 U/L• TSH 4.5 microU/mL• EKG shows normal voltage, normal axis and atrial fibrillation. Echocardiogram shows dilated ventricles

with normal wall thickness and severely decreased systolic fuction (LV EF: 15%). The patient is started on lisinopril, carvedilol, and warfarin. Later in the hospital course, he spontaneously converts to regular rhythm and feels well. EKG shows normal sinus rhythm.

• Which of the following is the most likely type of cardiomyopathy in this patient?• A) Alcoholic• B) Amyloid• C) Hypertrophic• D) Ischemic

Question• A 34 year old male experiences shortness of breath with minimal

exertion. Physical examination reveals elevated jugular venous pressure markedly worse with inspiration, a regular rhythm with an S4 heart sound and 2+ lower extremity pitting edema. Laboratory studies are normal. Cardiac biopsy revealed green birefringence with congo red staining. Genetic testing reveals a mutation in the transthyretin gene. Which of the following is the correct diagnosis?

• A) Restrictive cardiomyopathy • B) Dilated cardiomyopathy• C) Constrictive pericarditis• D) Hypertrophic obstructive cardiomyopathy• E) Chagas cardiomyopathy

Question

A man recently was started on a new medication by his PCP after he was found to have an LDL of 188mg/dL. Several weeks later he presented to the emergency department with back pain and blood was detected on urine dipstick, but urinalysis showed no red blood cells. What medication was the patient most likely prescribed?

A. NiacinB. CholestyramineC. EzetimibeD. AtorvastatinE. Gemfibrozil

Question

A 62-year-old gentleman who was recently diagnosed with an ST-segment elevation myocardial infarction acutely develops emesis, cool and clammy skin, dilated neck veins, and syncope. On examination he has distant heart sounds. How long ago was his myocardial infarction?

A. 2-4 hoursB. 1-2 daysC. 3-7 daysD. 1-2 weeksE. More than 1 month ago

Cardiac Pearls/Buzzwords

• APT M 2245• Young basketball player passes out? HOCM• SLE gives LSE – sterile vegetations• Antihypertensive drug with terrible rebound hypertension?

Clonidine• Hypertensive crisis coming from a wine tasting? Taking an

MAOI• Bipolar woman has child with heart defect? Ebstein’s anomaly• “Tearing” chest pain – aortic dissection• Several weeks after MI with new-onset friction rub – Dressler’s

Link to Heart Sounds

• http://www.e-gcrme.com/gcrme/essential_ausc/#/big12practice