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Internal Medicine Board
Review – Cardiology II
th
July 17 , 2014
Topics
 EKG’s and arrhythmias/conduction
abnormalities
 Myocardial Disease and
Cardiomyopathies
 Pulmonary artery catheters and
hemodynamic data interpretation
 Syncope
 Valvular heart disease
HOLD ON!!!
Approach to EKG’s
 Always read the question stem first to
know what you are looking for
 Think about the clinical context; may not
even need the tracing
 Look for patterns that fit the clinical
situation
 Dissect the EKG in your usual
systematic way
EKG interpretation
 Use your system, whatever it is
 ie. Mechanism, Structure, Function
 If the question includes multiple
tracings, it is usually looking for a
pattern; beware that two are likely very
similar. ie. Mitral stenosis
 Don’t forget you can use paper/pencil
as “poor man’s calipers”
EKG interpretation
 May include 12 lead, 6 lead, 3 lead or rhythm
strips
 Pay attention to which leads you are given
(and the order/arrangement)
 Look for standardization if voltage is relevant
(ie. LVH, tamponade)
 Count big blocks for heart rate (300, 150,
100, 75, 60…)
 Remember, each small block is 0.04 seconds
Frequently Seen Tracings On Boards
 Conduction Abnormalities
 AV block, LBBB, RBBB
 Bradyarrhythmias
 Sinus brady, A-fib with junctional escape
 Atrial Tachyarrhythmias
 Sinus tach, A-fib, A-flutter, AVNRT, MAT
 Ventricular Arrhythmias
 VT, AIVR, torsades
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Acute Infarction (Identify the vascular distribution)
Pericarditis
Tamponade
WPW (ventricular pre-excitation)
Long QT syndrome
Electrolyte Disturbances
 Hyperkalemia, hypo/hypercalcemia
Normal
1st degree AV block
2nd degree - Mobitz I (Wenckebach)
2nd degree (Mobitz II) AV Block
2:1 AV Block
3rd degree AV block
Left Bundle Branch Block
Right Bundle Branch Block
Sinus Bradycardia
Sick Sinus Syndrome
Atrial Fibrillation with Heart Block and
Junctional Escape
Premature Atrial Contractions
Premature Ventricular Contractions
Sinus Tachycardia
Atrial Fibrillation
Atrial Flutter (2:1 conduction)
Atrial Flutter (4:1 conduction)
Multifocal Atrial Tachycardia
AV Node Reentrant Tachycardia
Ventricular Tachycardia
Frequent PVC’s and Nonsustained
Ventricular Tachycardia
Ventricular Tachycardia
Torsades de Pointes
Torsades de Pointes
AIVR (Accelerated Idioventricular Rhythm)
AIVR (Accelerated Idioventricular Rhythm)
LVH with Repolarization
Abnormalities or Hypertrophic
Cardiomyopathy
Tamponade (low voltage with
electrical alternans)
Low voltage (amyloid)
Anterior Acute Infarction (LAD)
Inferior Acute Infarction (RCA)
Posterolateral Acute Infarction
(Circumflex)
Pericarditis
Ventricular Pre-excitation (WPW)
Atrial Fibrillation with WPW
Long QT syndrome
Brugada Syndrome
S1Q3T3 (Pulm embolus)
Ventricular Pacemaker
Pacemaker Failure to Capture
Hyperkalemia
Hyperkalemia
Hypo/hypercalcemia
ANY QUESTIONS on EKG’s????
QUESTION #1
A 56 y/o man with ischemic cardiomyopathy is being
maintained on a medical regimen of furosemide 40mg
twice daily, spironolactone 25mg daily, enalapril 10mg
twice daily, digoxin 0.125mg daily, and carvedilol 6.25mg
twice daily. In an attempt to titrate up to the target dose of
25mg BID (the dose shown to have the greatest mortality
benefit), the carvedilol is increased to 12.5mg BID. Five
days later, the patient returns due to worsening dypsnea
on exertion and orthopnea. Physical exam is consistent
with mild volume overload. Which of the following steps in
this patient’s management is most appropriate at this time?
A.
B.
C.
D.
E.
Decrease the dose of enalapril
Discontinue the digoxin
Discontinue the spironolactone
Increase the dose of furosemide to reestablish euvolemia
Discontinue the carvedilol
QUESTION #2
You are working in an emergency department when a 72 year old woman presents
with increasing shortness of breath over the past 12-24 hours. She has a
diagnosis of heart failure after a myocardial infarction several years ago. She has
been prescribed an excellent medical regimen, but she has been intermittently
compliant recently. On presentation her vital signs reveal a heart rate of 94, blood
pressure of 196/110, respiratory rate of 24, and oxygen saturations of 85% on
room air. Physical exam reveals no significant peripheral edema, normal jugular
venous pressure, an S4 gallop, and rales in the bilateral lung bases. EKG shows
sinus mechanism, evidence of an old anterior infarct, and nonspecific st-t wave
changes which is unchanged from her EKG 6 months ago. CXR shows moderate
pulmonary congestion. Complete blood count and basic metabolic panel are
unremarkable. Which of the following would the most appropriate NEXT step in
the management of this patient?
A.
B.
C.
D.
E.
Emergent endotracheal intubation with mechanical ventilation
Place an intra-aortic balloon pump
Take measures to lower the systemic blood pressure, such as administering an ACE-I or
intravenous nitrates
High dose intravenous diuretics
Obtain serum cardiac biomarkers to rule out myocardial infarction
QUESTION #3
All of the following statements regarding heart
failure are true EXCEPT:
A.
B.
C.
D.
E.
Heart failure is defined as the inability of the heart to pump
blood to the vital organs at normal filling pressures.
Heart failure now is the most common hospital discharge
diagnosis in Medicare patients.
The diagnosis of heart failure is excluded by
demonstrating normal left ventricular systolic function on
echocardiogram.
Heart failure is increasing in prevalence due to the aging
population and better treatment and salvage of patients
with acute myocardial infarction
Heart failure is now responsible for greater than 1 million
hospitalizations in the United States each year.
Myocardial disease
 Cardiomyopathies
 Etiology
 Reversibility
 Heart failure treatment
Cardiomyopathies - Etiology
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Ischemic
Hypertensive
Toxin induced ie. EtOH, anthracyclines
Metabolic/Infiltrative ie. thyroid, amyloid
Associated with general systemic disease ie. MD’s,
CTD’s
Peripartum
Hypertrophic
Valvular ie. AS, AI, MR
Inflammatory/Infectious ie. post-viral myocarditis,
HIV, Chaga’s
Idiopathic
Familial
Question on Myocardial Dz????
QUESTION #4
A 22 year old woman is admitted to the ICU
with profound hypotension. She developed a
cardiomyopathy 4 months ago after delivery
of her first child and was found to have an
ejection fraction of 25%. She has done well
since that time until today, when she was
found unresponsive by family members.
Heart rate is 145 bpm with a blood pressure
of 86/45 on dopamine. A pulmonary artery
catheter is placed to help guide management
with the following hemodynamic
measurements:
QUESTION #4 (con’t)
Right Atrial
Pressure
Wedge
Pressure
Cardiac
Output
Systemic
Mixed
Vascular
Venous O2
Resistance Saturation
6 mm Hg
(normal)
11 mm Hg
(normal)
14 L/min
(elevated)
450
87%
dynes/sec/cm5 (elevated)
(low)
QUESTION #4 (con’t)
Which of the following is the most
appropriate next step in the management
of this patient?
A. Place an intra-aortic balloon pump and begin
workup for heart transplant
B. Begin high dose dobutamine
C. CT chest to evaluate for pulmonary embolus
D. Large boluses of isotonic intravenous fluids
E. Draw blood/urine cultures, broad spectrum IV
antibiotics, and support with vasopressors
PA Catheters (Swan-Ganz)
Hemodynamics in hypotension
Cardiac
Output
PCWP
RA
SVR
MISC.
Pressure
Hypovolemia Low
Low
Low
High
Tachycardia,
Dry MM
Sepsis
High
Low or
normal
Low or
normal
Low
Low O2 extr.
(High MV O2)
Cardiogenic
Low
High
High or
normal
High
High O2 extr.
(Low MV O2)
Neurogenic
Normal or Low or
high
normal
Low or
normal
Low
May be
bradycardic
Pulmonary
Embolus
Low
Normal or High
high
Low
Very high PVR
Questions on PA catheters or
hemodynamics????
QUESTION #5
You are consulted by a psychiatrist to see a
17 year old woman admitted 4 days ago with
newly diagnosed psychosis. The patient has
had several episodes of witnessed syncope
in the past 2 days. The patient is very stoic
and unable to provide any history. The H&P
on the chart states that 2 first degree relatives
have died at early ages in their sleep, thought
to be due to “heart attacks.” Complete blood
count and chemistries are within normal
limits. An EKG is obtained and is shown.
QUESTION #5 EKG
QUESTION #5 (con’t)
Which of the following is the most
appropriate initial recommendation at this
time?
A. Obtain an echocardiogram to evaluate for
hypertrophic cardiomyopathy
B. Perform cardiac MRI to evaluate for
arrhythmogenic right ventricular dyplasia
C. Transfer patient to a telemetry unit to evaluate for
supraventricular arrythmias
D. Perform tilt table testing to evaluate for
vasovagal syncope
E. Discontinue medications that are known to
prolong the Qtc interval
Syncope
 Sudden transient loss of consciousness and
postural tone with spontaneous recovery
without neurologic deficit
 Differentiate from seizure, SCD
 Diagnosis on boards (and in practice) should
be made by history, history, history, physical
exam, or EKG
 ECHO only when structural heart disease is
likely
 Additional studies guided by history and the
clinical suspicion of specific disorders
Syncope (hints to specific causes)
 Young athlete with systolic murmur – Hypertrophic
Cardiomyopathy
 Older patient with systolic murmur – Aortic Stenosis
 Young patient with prodrome, prolonged standing, or
at church – Vasovagal
 Older patient on multiple HTN meds – Orthostasis
 Head rotation or shaving – Carotid Sinus Sensitivity
 Arm exercise – Subclavian Steal Syndrome
 With exertion – AS, HCM, MS, Pulm HTN
 Older patient with paroxysmal A-fib – Sick Sinus
 Swimmer – look for long QT
Valvular Heart Disease
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Breaking It Down
 Valvular heart disease (2-5 questions)
 Aortic stenosis – elderly vs younger
 Aortic regurgitation – Marfan’s or
endocarditis
 MVP – maneuvers, SBE prophylaxis
 HCM – sudden death in an athlete,
maneuvers
 Mitral stenosis – rheumatic heart disease
 Tricuspid stenosis with carcinoid patient
 Tricuspid regurgitation in a patient with
right heart failure
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Question
What’s the
diagnosis?
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Aortic Stenosis
 Scenarios – middle aged adult with bicuspid
valve, older adult (> 70) with tricuspid valve
 Diagnosis
 Symptoms are chest pain, syncope, CHF
 PE shows 3-4 SEM at RUSB radiating to carotids,
pulsus parvus et tardus (weak and delayed
upstrokes)
 Tests – echo, cath only as pre-op for CAD
 Mgt – surgery when symptoms develop or if
EF <50%, balloon valvuloplasty is only
palliative and short-lived
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Aortic Regurgitation
 Scenario – Marfan’s syndrome, endocarditis
 Diagnosis – shortness of breath, early highpitched decrescendo diastolic murmur at left
or right upper sternal border, wide pulse
pressure, brisk pulses
 Test – echo +/- CXR if dissection
 Mgt – afterload reduction with ACE inhibitor
or nifedipine, valve replacement for EF < 50%
or LVESD > 55mm (or LVEDD > 75mm)
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Aortic Regurgitation
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MVP
 Favorite board question
 Scenario – young woman with palpitations,
chest pain
 Diagnosis – mid-systolic click with late
systolic murmur, increases with Valsalva
 Test – echo
 Mgt – beta blocker for symptoms, valve repair
only for severe regurgitation
 SBE prophylaxis no longer recommended**
75
MVP
What’s the diagnosis?
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Hypertrophic Cardiomyopathy
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Hypertrophic Cardiomyopathy
 Favorite board question
 Scenario – young athlete with syncope or aborted
sudden death, SOB, diastolic heart failure
 Diagnosis – SEM at RUSB which increases with
Valsalva, brisk carotid upstrokes, S4, pulsus
bisferiens
 Test – EKG with LVH and T wave inversion, echo
 Mgt – beta blockers and calcium channel blockers,
surgical or percutaneous myectomy, ICD placement if
high risk for sudden death, no competitive athletics
except golf and bowling, screening of first- and
second-degree relatives
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80
HCM EKG
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Differentiating Aortic Stenosis from
Hypertrophic Cardiomyopathy
 Same
 Both may present with syncope
 Both have a harsh SEM radiating to the
carotids
 Different
 HCM usually younger than AS
 Carotid upstrokes are brisk with HCM,
diminished with AS
 Murmur gets louder with Valsalva with
HCM, softer with Valsalva with AS
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What’s the diagnosis?
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Mitral Stenosis
 Yet another favorite board question
 Scenario – woman with history of rheumatic heart
disease
 Diagnosis – DOE, palpitations, PND, diastolic
rumble with loud S1 and opening snap just after
S2, small PMI, palpable P2, rales
 Tests – echo, TEE to grade valve
 Mgt – slow heart rate to improve diastolic filling
time – beta blockers, balloon valvuloplasty is the
first line procedure for these pts (as opposed to
AS)
 SBE prophylaxis no longer recommended**
84
85
Question
 A 51 year old man… verbose description… with a
diastolic murmer…. more and more words… echo
confirms tricuspid stenosis (MAN!!??) What is the most
likely etiology?
1.
2.
3.
4.
Senile calcification
Carcinoid
Ebstein’s anomaly
Rheumatic fever
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Tricuspid Regurgitation
 Not a likely test question, but may see a case of pulm
HTN with TR and also PR
 Scenario – young woman with severe SOB, hypoxia,
and right heart failure – edema, ascites, elevated
JVP, large v wave, pulsatile liver
 Diagnosis – echo, right heart cath, CTA – must rule
out other etiologies – CTD, congenital heart disease,
recurrent PE
 Mgt – poor prognosis if no reversible cause, O2,
calcium blockers, Coumadin, prostacyclin analogs
(epoprostenol), endothelin receptor antagonists
(bosentan), phosphodiesterase-5 inhibitors
(sildenafil), lung transplantation
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QUESTIONS ON ANYTHING????