CARDIOLOGY STEP 3 REVIEWBy James K. Rustad, M.D.
Copyright © 2009 All Rights Reserved.
Outline
Arrythmias and Chest Pain Pericarditis Endocarditis Rheumatic Fever Hypertension Valvular Heart Disease Congential Heart Diseases
Arrhythmias
Wolf Parkinson White Syndrome Accessory
pathway between atria and ventricle
Short PR interval (no AV nodal delay) and delta wave at onset of wide slurred QRS complex
WPW (continued)
If symptomatic – best initial therapy Procainamide (for VT or SVT from WPW)
Long term treatment: Radiofrequency ablation
Avoid digitalis, beta blocker and calcium channel blocker (may precipate arrhythmia)
Atrial fibrillation
Irregularly irregular heart beat
EKG – no P wave, irregular RR interval
Rule out Thyrotoxicosis Often patient has
history of HTN, ischemia, or cardiomyopathy.
If patient is unstable > Synchronized Cardioversion
Rate control and anticoagulation Rate control medications including beta
blockers (metoprolol, esmolol), calcium channel blockers (diltiazem), or digoxin.
Once rate is controlled, anticoagulation with warfarin for INR 2-3 for all patients with atrial arrhythmia lasting beyond 48 hours.
Clinical Scenario
23 year old woman comes for evaluation of “rapid heart beat.” Pulse is 130 but otherwise VSS. EKG shows Paroxysmal Supraventricular Tachycardia. The next most appropriate step in management is:
A) IV heparin B) Load digoxin C) Carotid Massage D) Immediate Cardioversion
Management of SVT
1) Valsalva 2) Carotid massage 3) Adenosine (if 6 mg ineffective give 6
mg more) 4) Verapamil, Diltiazem 5) If hemodynamically unstable:
Synchronized Cardioversion
Clinical Case: Syncope
62 yo woman comes to clinic complaining of fainting spells. Investigation with Holter Monitor shows two episodes of arrhythmia, one of sinus brady 40/min and one SVT with 200/min.
The most appropriate step in management is: A) Start atenolol B) Start verapamil C) Echocardiogram D) Recommend Dual chamber pacemaker E) Refer for cardiac catheterization
Tachy-Brady Syndrome (Sick Sinus)
Treatment: Dual Chamber Pacemaker
Initially try to D/C digitalis, calcium channel blocker, beta blocker –
If still symptomatic - PACEMAKER
Chest Pain
Risk factors for CAD
Men >45, Women >55
Male gender Diabetes, HTN,
Lipid abnormality (increased LDL)
Smoking Physical inactivity Increased
Homocysteine
Differential Diagnosis Nonpleuritic CP
Cardiac: MI/infarction, myocarditis Esophageal: spasm, esophagitis,
ulceration, neoplasm, achalasia, diverticula, foreign body
Referred pain from subdiaphragmatic GI structures
Gallbladder and biliary: cholecystitis, cholelithiasis, impacted stone, neoplasm
Gastric and duodenal: hiatal hernia, neoplasm, PUD
Differential (continued)
Chest pain associated with MVP Pulmonary: neoplasm, pneumonia,
PE/infarction Mediastinal tumors: lymphoma,
thymoma Pain originating from skin, breasts and
musculoskeletal structures: herpes zoster, mastitis, cervical spondylosis
Dissecting aortic aneurysm Pancreatic: pancreatitis, neoplasm
Angina
Exertional chest pain relieved by rest.
Tightness, squeezing, pressure like.
Short duration 3-20 minutes.
EKG during chest pain: T wave inversion and ST depression.
Stable angina: Aspirin and Metoprolol have benefit on mortality; nitrates helpful for pain.
Unstable angina
1. History of chronic angina but recent increase in frequency, intensity.
2. New onset (less than 2 months) severe and 3 or more episodes a day.
Angina at rest.
Unstable Angina Management S/L NTG for chest pain (IV next option),
Aspirin, Bed Rest, O2 Clopidrogrel, Heparin for 48 hours,
platelet glycoprotein IIb/IIIa receptor antagonist
Beta Blocker (or Ca channel blocker) Enzymes X 3 and admit to CCU
Clinical Scenario
55 year old man with diabetes comes to clinic for follow-up after ED visit for L sided chest pressure 2 weeks lasting 10-20 min in duration with no radiation. Escalation of symptoms 2 days prior to ED visit, SOB on exertion, and diaphoresis on onset of pressure.
Transient 1.5 mm ST elevation anterior leads, no Q waves, and negative enzymes. BP 150/80.
Total cholesterol of 290 with HDL 33 and LDL 222 Most appropriate next step in management?
Unstable Angina
A) Continue Aspirin 325 mg daily and close follow up
B) Stop Aspirin and start Clopidrogrel C) Schedule him for coronary
angiography D) Start therapy with Lovastatin E) Initiate therapy with Nifedipine
Unstable angina (continued) The answer is D: Long term goals include
LDL <100. patient should be managed conservatively by managing risk factors optimally.
Coronary angiography is accepted for those who continue to report symptoms despite aggressive management, escalation of symptoms/severity, or hemodynamic instability.
Stress test Poor Prognosis ST depression
over 2 mm at < 6 min on BRUCE protocol
ST dep. persists > 5 min post exercise
ST elevation Hypotension HR < 70%
predicted max
Indications of CABG
Left main disease Triple vessel
disease with low EF
Diabetes with 2 or more vessels involved
MI
Chest pain greater than 30 min. Diaphoresis, SOB, weakness, pain.
Cardiac Enzymes: CK-MB, Troponin I, Troponin T
ST elevation MI
Q wave, transmural
ST elevation greater or = to 1 mm in two consecutive leads.
O2, S/L NTG, Morphine, Aspirin or Clopidrogrel, B-blocker, IV heparin.
PTCA OR Thrombolytic (less than 12 hours post MI, ST elevation, New LBBB)
Non ST elevation MI
Sub-endocardial, ST depression or T-wave inversion
No Q wave but cardiac enzymes up
Manage similar to unstable angina.
With continued Chest Pain – Cardiac Cath
Clinical Scenario
61 year old male with CAD and history of 2 MI’s comes to ER because of chest pain and SOB.
EKG shows sinus rhythm with ST-segment elevation in leads II, III and aVF
Next appropriate diagnostic step to order?
A) cardiac stress test B) chest X-ray C) EKG with R-sided
leads D) green dye cardiac
output measurement E) Ventilation-
perfusion scan
Right Ventricular Infarct
Check Right sided lead V4 for ST elevation!
Hypotension but elevated JVD (increased right atrial pressure)
Positive Kussmaul’s, clear lung field
Treat with IV fluids and manage like MI
Knowledge test
A 58 year old man comes to the office several days after going to the ER with an episode of chest pain. He had a normal EKG and normal CK-MB and was discharged. What is most appropriate for further management?
Stress testing
When the case is not acute and initial EKG/enzymes do not establish diagnosis: the stress test is a way of increasing the sensitivity of detection of CAD.
What if the stress test is abnormal?
If the stress test shows an area of “reversible ischemia,” angiography is the next diagnostic test.
“Fixed defects” – unchanged between exercise and rest – is a scar from a previous infarction.
Clinical Scenario
52 year old man comes to ED unresponsive with no pulse. After assessing ABC’s, the next appropriate step is which of the following?
Amiodarone load, defibrillate, intubate, push adenosine or push epinephrine?
ACLS Protocol
CPR until defibrillator ready.
3 shocks: 200, 300 then 360 J then intubation.
1 mg of epinephrine Shock again w/ 360 J If no stable rhythm:
Amiodarone loading
Aortic Dissection
Type A: intimal tear at ascending aorta just distal to aortic valve. Look for new aortic regurgitation murmur. SURGICAL EMERGENCY!!!!
Type B: just distal to L subclavian artery. Mostly managed medically but still call SURGERY!
Symptom: sudden onset of chest pain radiates to back.
Signs: Widening of mediastinum in CXR
Asymmetrical pulse, BP (R 180/100 and L 130/70)
Aortic dissection investigation and treatment
Stable vitals: CT chest with contrast
Vitals unstable: TEE Keep pulse around 60+,
decrease reflex tachy and tear propagation with IV Propranolol or Labetalol
Keep systolic BP around 100 with IV Nitroprusside or Verapamil
Special topic: Diastolic Dysfunction
Diastolic dysfunction refers to an abnormality in the heart's (LV) filling during diastole (phase of the cardiac cycle when the heart (ventricle) is not contracting but is actually relaxed and filling with blood that is being returned to it, either from the body (into RV) or from the lungs (into LV).
DD
Ventricle = balloon made thick rubber. Fills with high pressure, volume can’t expand.
HTN = LV muscle hypertrophies to deal with the high pressure, and LV becomes stiff
Aortic Stenosis =ventricular muscle has hypertrophied and becomes stiff, due to the increased pressure load placed on it by the stenosis.
Special topic: Jugular Venous Pressure
A: Atrial contraction
C: Closure of Tricuspid
X: Atrial RelaXation
V: Venous filling Y: opening of
Tricuspid
JVP is Right Atrial Pressure
Large right sided “a” wave is Tricuspid stenosis
Large left sided “a” wave is Mitral Stensosis
Rapid x and y descent is Constrictive Pericarditis (rapid x only = cardiac tamponade)
Canon “a” wave = complete heart block (atria and ventricle have own rhythm, no coordination)
Pericarditis
Acute Pericarditis
Mid sternal chest pain, non radiating.
Relieved by sitting up and leaning forward.
Worst with supine and inspiration.
Associated hx: viral fever, breast cancer, s/p radiation therapy, renal failure, MI
EKG: Diffuse ST elevation and PR depression.
Confirm with Echo Treatment:
Aspirin, NSAIDS.
Clinical scenario
58 year old woman with metastatic lung cancer and HTN admitted for CP, SOB.
s/p radiation Transthoracic echo
shows constrictive pericarditis, but no pericardial effusion present.
On physical, what would you expect?
A) increase in JVP with inspiration.
B) inspiratory stridor C) jugular venous
flattening D) muffled cardiac
sounds E) tracheal deviation
to right
Kussmaul’s sign
Increase in jugular pressure with inspiration.
Increased R-sided pressure exerted by noncompliant pericardium as heart moved inferiorly by descending diaphragm during inspiration.
Endocarditis
Endocarditis
Most present with a fever for a few days.
Other possible s/sx: splinter hemorrhage of finger nail (sub-ungal hemorrhage), palate/conjunctival petechia
Osler Node (painful,violaceous raised lesions of fingers/toes/feet)
Roth’s spot: exudative lesions in the retina
Fever + New or Changed murmur Blood cultures
first! If positive, do an
ECHO to look for vegetations.
Common organisms/treatment Common: Strep
viridens Virulent: Staph
aureus S/P cardiac
surgery: Staph epidermis (for this or prosthetic valve give vanco + rifampin + genta)
Strep: Penicillin with Gentamicin or Ceftriaxone
Staph: Nafcillin + Genta
Best empiric therapy (or for MRSA or Penicillin allergy): Vanco + Gent
Give Ceftriaxone if c/s shows: Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella
IV Drug Abuse
Endocarditis typically involves R side of heart (injecting in veins) – usually staph aureus, MRSA
Fever, pleuritic chest pain, cough, hemoptysis
CXR: nodular density in both lung fields, cavitary lesion
Endocarditis Prophylaxis
Previous endocarditis. Prosthetic cardiac
valve. Congenital Cyanotic
cardiac disease. First 6 mos after repair with prosthetic material (or with residual effects after repair).
Cardiac Valvulopathy in transplanted heart.
Procedures which need prophylaxis:
Dental procedures that cause bleeding (amoxicillin - or clindamycin if patient allergic to penicillin)
Respiratory tract surgery or surgery of infected skin.
Valve replacement surgery Anatomic defects –
difficult to correct with only ABX!
Valve rupture/prosthetic valve
Abscess Fungal endocarditis Embolic events
after starting ABX.
Rheumatic Fever
Acute RF usually develops after 2-4 weeks of pharyngeal infection with Group A streptococcus.
Can erysipelas lead to rheumatic fever?
No --- skin goes to kidneys only. Throat goes to kidneys and heart.
Earliest Symptomatic manifestation
Arthritis --- migratory and involves large joints mainly lower extremity. Subjective pain greater than objective inflammation.
Erythema marginatum
Non-pruritic Erythematous
lesion with pale center, mostly on trunk, rounded margin.
Early manifestation
Evanescent (appear, disappear)
Syndenham chorea
Commonly on one side and ceases during sleep.
Abrupt, purposeless, non rhythmic involuntary movement.
Rheumatic Fever (continued)
Early: Mitral Regurgitation
Late: Mitral stenosis, secondary to scarring and calcification of damaged valve.
Nodule: mostly over bony surface.
Firm, painless, usually disappears within a month.
Carditis Subcutaneous Nodule
Diagnosis: Jones Criteria
Carditis Polyarthritis Chorea Subcutaneous
Nodule Erythema
Marginatum
Fever Arthralgia Previous RF or
Rheumatic Heart disease
Major Minor
Rheumatic Fever treatment
Aspirin Oral Penicillin V for
10 days or Benzathine Penicillin G IM X 1 dose
Penicillin allergic: Erythromycin X 10 days
Oral Penicillin V or oral sulfadiazine daily or Pen. G IM q4 weeks
Until patient is approx. 20 years old (approx. 10 years from attack)
Acute Treatment Prophylaxis
Hypertension
Management of Blood PressureBlood Pressure
Systolic Diastolic Management
Recheck
Stage I 140-159 90-99 Thiazide unless other indication
Within 2 months
Stage II Greater than or equal to 160
> Or = to 100
2 Drug Combo
If greater than 180/110 treat right away, otherwise recheck within one month
Thiazide diuretics
They work by inhibiting reabsorption of Na+ and Cl− ions from the distal convoluted tubules by blocking the thiazide-sensitive Na+-Cl− symporter. Thiazides also cause loss of potassium and an increase in serum uric acid.
Hypokalemia, Hyponatremia and Hyperuricemia
Recommended starting dose: Hydrochlorothiazide 25 mg once daily
K+ sparing diuretics (think SAT) Spironolactone inhibits
the effect of aldosterone by competing for intracellular Ald. receptor in the distal tubule cells (it actually works on Ald. receptors in the collecting duct). This increases the secretion of water and sodium, while decreasing the excretion of potassium.
Amiloride works by directly blocking the epithelial sodium channel (ENaC) thereby inhibiting sodium reabsorption in the distal convoluted tubules and collecting ducts in the kidneys.
Triamterene with similar Mechanism to Amiloride.
Loop Diuretics
Loop diuretics act on the Na+- K+ - 2Cl- cotransporter in the thick ascending limb of the loop of Henle - inhibit sodium and chloride reabsorption.
Loop (of Henle) diuretics
Loop diuretics prevent the urine from becoming concentrated and disrupt generation of hypertonic renal medulla. Water has less of an osmotic driving force to leave the collecting duct system, ultimately resulting in increased urine production.
Furosemide, Bumetanide, Ethacrynic acid, Torsemide
Beta Blockers
Cardioselective (Beta 1)
Atenolol 50-100 mg/day
Metoprolol 25-100 mg/day
Non-selective: Propranolol 40-80 mg PO BID
Alpha and Beta blocker: Labetolol (The recommended initial dosage is 100 mg twice daily - usual maintenance dosage of labetalol HCl is between 200 and 400 mg twice daily).
ACE inhibitors
Lisinopril: recommended initial dose is 10 mg qdaily. Usual dosage range is 20 to 40 mg per day administered in a single daily dose.
Side effects: Dry cough, hyperkalemia, angioedema.
ACE inhibitors (continued)
Angiotensin II receptor blockers Losartan Irbesartan Valsartan Candesartan
Calcium Channel Blockers Non-
Dihydropyridine (bradycardia)
Diltiazem Verapamil
(constipation)
Dihydropyridine (cause Tachycardia)
Amlodipine 5-10 mg/day
Felodipine Nifedipine 30-60
mg/day
Calcium channel blockers: Ankle Edema
Valvular Heart Disease
Presents with Shortness of breath ---“worse with exertion or exercise.”
Physical findings: Murmur, Rales on lung exam. Possibly peripheral edema, carotid pulse findings, gallops.
Heart Sounds
S1: Closing of the mitral valve. S2: Aortic valve closes first, followed by
pulmonic. Right sided murmurs increase on
inspiration because the lung expands and intrathoracic pressure goes down > blood to the heart increases.
Wide splitting of S2
Aortic valve closes earlier Pulmonic valve closes later MR, VSD, Pulmonary Stenosis, Pulmonary
Artery Hypertension, RBBB
MR
Holosystolic murmur best heard at apex radiates to the axilla.
Blood travels from Left Ventricle to Left atrium.
There is less blood for LV to pump out and the Aortic Valve closes earlier.
MR
Test of choice: Transthoracic Echocardiogram
Acute MR caused by rupture of chordae tendinae during MI or Endocarditis. Tx: Emergency Surgery.
Chronic MR should be referred for surgery when symptomatic or asymptomatic with EF < 55% or LV end systolic dimension greater than 45 mm.
Ventricular Septal Defect
Holosystolic murmur, Lower left sternal border
Most common acyanotic congenital cardiac anomaly.
Blood goes from Left Ventricle to Right Ventricle. Less blood in LV available to pump out and aortic valve closes earlier.
Echo for diagnosis, but catheterization can determine degree of L > R shunting most accurately.
Pulmonary Stenosis
Pulmonic valve closes later (Stenotic valves take longer to close).
Pulmonary Hypertension
The pressure is high in the vessel and it is hard to pump blood. The Right Ventricle has to pump blood into pulmonary artery against high pressure. Pulmonary valve closes later.
Right bundle branch block Right ventricle
contracts slowly and pulmonic valve closes later.
Narrow splitting (paradoxical) Aortic valve closes later Pulmonic valve earlier. Sometimes paradoxical splitting where
pulmonic valve closes before aortic valve.
Aortic stenosis, HOCM, LBBB
Aortic Stenosis
Stenotic valves close later.
Midsystolic, upper right sternal border.
Aortic Stenosis
“Crescendo-decrescendo” murmur
Upper right sternal border and radiates to carotids.
Aortic Stenosis
Syncope Angina Dyspnea
Aortic Stenosis
LVH on EKG Treatment of
choice is valve replacement.
Clinical scenario
52 year old woman comes to ED complaining of SOB. History notable for heart murmur and HTN.
Loud ejection murmur at cardiac apex and rales bilaterally in both lung fields. ECG shows LVH.
Most appropriate next diagnostic step? A) cardiac stress test B) Chest CT C) Transesophageal Echocardiogram D) Transthoracic Echocardiogram E) Ventilation-perfusion scan
HOCM
Outflow tract obstruction --- Aortic valve closes later.
Left Bundle Branch Block
Left ventricle closes slowly and Aortic valve closes later.
Blood return
Increases Blood Return (increase venous return to heart).
Decreased Blood Return. All murmurs decrease with standing and valsalva except for…..
Squatting and Leg Raise Standing/Valsalva
HOCM and MVP
Hypertrophic Obstructive Cardiomyopathy
Mitral Valve Prolapse (mid systolic click followed by late systolic murmur)
Hand grip
Increases afterload. Improves or lessens the murmurs of MVP and HOCM as the left ventricular chamber is more full.
Mitral Valve Prolapse
Young thin female with occasional palpitation and mild chest pain.
Treatment: Beta Blocker
Mitral Stenosis
Middiastolic at apex best heard with bell. Diastolic rumble after opening snap.
Rheumatic fever most common cause. Pregnant patient (large increase in plasma volume).
Mitral Stenosis Symptoms Dyspnea (due to
pulmonary edema) Hemoptysis (due to
increased pressure in pulmonary vessels)
Hoarseness due to compression of recurrent laryngeal nerve from enlarged LA – “Ortner’s syndrome”
Treatment of Mitral Stenosis Diuretics are best
initial therapy, but do not alter progression.
MS without MR: Percutaneous Mitral Balloon valvuloplasty.
Aortic regurgitation
Causes: Rheumatic fever, aortic root diseases (Marfan’s, anklosing spondylitis, Reiter’s), congenital bicuspid valve, HTN
Murmur: Diastolic decresendo murmur best heard at L sternal border.
AR: “rapid rise and fall” of pulse Elevated systolic
and low diastolic pressure
Wide arterial pulse pressure
Aortic regurgitation factoids Hill sign: blood
pressure gradient higher in lower extremities.
Corrigan’s pulse: High bounding pulses (“water-hammer”)
Quinke pulse: Arterial or capillary pulsations in fingernails.
Musset’s sign: Head bobbing up and down with each pulse.
Duroziez’s sign: murmur heard over femoral artery
Chronic AR treatment
Medical: reduce afterload with ACE inhibitor, Nifedipine, Hydralazine.
Beta Blocker Surgical indication:
symptoms or LVEF less than 55% or LV end systolic dimension > 50 mm
More Congential Heart Diseases
Patent Ductus Arteriosus
Connects descending aorta and pulmonary artery.
Maternal Rubella infection in early pregnancy.
In premature infant: close with Indomethacin.
More common in girls.
Upper left sternal border continuous machinery murmur.
Tetralogy of Fallot
Most common congential cyanotic cardiac anomaly.
Child while playing may develop SOB, cyanosis.
Coarctation of Aorta
98% occur at origin of left subclavian artery
BP higher in arms than legs
Give PGE1 to maintain patent ductus
Surgical repair after stabilization
Turner’s syndrome