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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