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Internal Medicine Board
Review- Cardiology
June 16, 2010
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 Areas
ACS therapies:
- ASA, BB, ACE-I, Heparin, 2b/3a,
Lytics
Stable CAD therapies
- ACE-I, Statins, ASA, BB
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
Congenital Heart Disease Diagnoses
- ASD, VSD, Bicuspid AV
Rare But Deadly Cardiac Conditions
- Brugada Syndrome, HCM, Long QT
syndrome, WPW
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 lifethreatening 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
DUKE CRITERIA FOR IE DIAGNOSIS
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 cultures
2. 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)
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 adenosinemyocardial 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
Treat Asymptomatic LV dysfunction
• Identify etiology and treat accordingly (i.e.
rule out CAD, then search for other
causes)
• Initiate ACE-I and B-blocker therapies at
low doses
• ASA only indicated for patients with CAD
• Treat all cardiovascular RF and screen
with fasting lipids/TSH/HgA1C