Cardiology Board Cardiology Board ReviewReview

6.21.106.21.10Lisa Rose-Jones, MDLisa Rose-Jones, MD

CADCAD

MKSAP Q 1MKSAP Q 1 60 yo M present to ED w/ chest discomfort for 60 yo M present to ED w/ chest discomfort for

6 hrs. Tx w/ ASA, IV BB, and NTG. Chest pain 6 hrs. Tx w/ ASA, IV BB, and NTG. Chest pain persists. Initial troponin and CK-MB are persists. Initial troponin and CK-MB are elevated.elevated.

Pt taken ergently to Cath lab. Occlusion of Pt taken ergently to Cath lab. Occlusion of prox RCA. PCI is successfully. Following prox RCA. PCI is successfully. Following morning doing well on rounds but progessively morning doing well on rounds but progessively more hypotensive. JVP elevated. Nml S1, S2. more hypotensive. JVP elevated. Nml S1, S2. +S3, brief systolic murmur along L sternal +S3, brief systolic murmur along L sternal border. ECG is unchanged from previous.border. ECG is unchanged from previous.

What is the most likely cause for this What is the most likely cause for this patient’s current findings?patient’s current findings?

1.1. Acute Cardiac tamponadeAcute Cardiac tamponade2.2. Aortic dissectionAortic dissection3.3. Left Ventricular Free Wall RuptureLeft Ventricular Free Wall Rupture4.4. Right Ventricular MIRight Ventricular MI5.5. Progressive Coronary IschemiaProgressive Coronary Ischemia

**Characteristic RV InfarctionCharacteristic RV Infarction: : progressive hypotension (always be progressive hypotension (always be weary of preload reducers like NTG), weary of preload reducers like NTG), elevated JVP, and clear lung fields. elevated JVP, and clear lung fields. +tricuspid regurg+tricuspid regurg

~R precoridal Lead ECG will detect ST ~R precoridal Lead ECG will detect ST elev in V4Relev in V4R

~These pt may require volume ~These pt may require volume challengeschallenges

*Other MECHANICAL COMPLICATIONS *Other MECHANICAL COMPLICATIONS following MI:following MI:

~Ventricular Septal Rupture~Ventricular Septal Rupture

~Papillary Muscle Rupture: hear acute ~Papillary Muscle Rupture: hear acute mitral regurg murmurmitral regurg murmur

~LV Free Wall Rupture => cardiac ~LV Free Wall Rupture => cardiac tamponade, hypotension and usually tamponade, hypotension and usually deathdeath

Q 23Q 2357 yo M comes to ED w/ substernal chest 57 yo M comes to ED w/ substernal chest

pressure that developed this AM. PMHx of pressure that developed this AM. PMHx of HTN, stable angina, PVD; his meds are HCTZ HTN, stable angina, PVD; his meds are HCTZ and ASA.and ASA.

BP 110/80, HR 84. No JVP and lungs clear. BP 110/80, HR 84. No JVP and lungs clear. Nml S1/2. Abd exam neg, pulses diminished Nml S1/2. Abd exam neg, pulses diminished in LE. Continues to have angina at rest. ECG in LE. Continues to have angina at rest. ECG w/ changing ST segs and T waves. Trop 0.8. w/ changing ST segs and T waves. Trop 0.8. The patient is given ASA, BB, and The patient is given ASA, BB, and enoxaparin, and is transferred to the CCU to enoxaparin, and is transferred to the CCU to await angiography.await angiography.

What additional therapy should be What additional therapy should be given in the CCU?given in the CCU?

1.1. HeparinHeparin2.2. WarfarinWarfarin3.3. EptifbatideEptifbatide4.4. BivalirudinBivalirudin5.5. DiltiazemDiltiazem

Early treatment w/ Glycoprotein 2b/3a Early treatment w/ Glycoprotein 2b/3a receptor blockade improves outcomes of receptor blockade improves outcomes of PCI. *Indicated only if high risk markers PCI. *Indicated only if high risk markers (TIMI Score >3-4, +biomarkers, ST (TIMI Score >3-4, +biomarkers, ST depression, CHF, h/o of recent PCI, or depression, CHF, h/o of recent PCI, or hemodynamic instability. hemodynamic instability.

-Abciximab =only if undergoing PCI-Abciximab =only if undergoing PCI-Eptifibitide or Tirofiban (if there is no clear -Eptifibitide or Tirofiban (if there is no clear

inidication that PCI will be performed)inidication that PCI will be performed)*Warfarin offers no protection for Coronary events. SYNERGY trial *Warfarin offers no protection for Coronary events. SYNERGY trial

showed Enoxaparin and Heparin outcomes nearly equivalent showed Enoxaparin and Heparin outcomes nearly equivalent (unless switch from LMWH -> UH). Dilitaizem doesn’t affect (unless switch from LMWH -> UH). Dilitaizem doesn’t affect outcomes in CAD.outcomes in CAD.

Q 37Q 3742 yo M @ rural ED w/ severe L 42 yo M @ rural ED w/ severe L

shoulder & chest pain, radiates to shoulder & chest pain, radiates to jaw. +diaphoresis, dyspnea. No jaw. +diaphoresis, dyspnea. No PMHx, no meds. +father has CABG.PMHx, no meds. +father has CABG.

In the ED, IV Heparin, Atenolol, and an In the ED, IV Heparin, Atenolol, and an ASA are given. BP 100/79, HR 61. ASA are given. BP 100/79, HR 61. No JVP. Nml S1/2. This hospital does No JVP. Nml S1/2. This hospital does NOT have a Cath lab, closest is 62 NOT have a Cath lab, closest is 62 miles. Takes 2 hrs to arrange miles. Takes 2 hrs to arrange transfer.transfer.

What is the BEST management option What is the BEST management option for this patient?for this patient?

1.1. Glycoprotein receptor blockadeGlycoprotein receptor blockade2.2. PlavixPlavix3.3. EsmololEsmolol4.4. Fibrinolytic therapyFibrinolytic therapy5.5. NTGNTG

GOAL of all Reperfusion strategies for GOAL of all Reperfusion strategies for STEMI is to achieve a patent vessel STEMI is to achieve a patent vessel w/in 90 mins from onset of symptoms.w/in 90 mins from onset of symptoms.

~4 subgroups in which PCI is preferred:~4 subgroups in which PCI is preferred:A.A. Contraindications of fibrinolytic therapyContraindications of fibrinolytic therapyB.B. Late arriving STEMI, > 12 hrs after Late arriving STEMI, > 12 hrs after

onset of chest pain w/ contd CP and ST onset of chest pain w/ contd CP and ST elevselevs

C.C. H/O CABGH/O CABGD.D. Cardiogenic ShockCardiogenic Shock

REMEMBER for CAD:REMEMBER for CAD: Reperfusion arrhythmias (AIVR) usually Reperfusion arrhythmias (AIVR) usually

do not req antiarrhytmicsdo not req antiarrhytmics Do not need Cardiac Cath after Do not need Cardiac Cath after

Fibrinolysis if ST seg elevation and CP Fibrinolysis if ST seg elevation and CP have resolvedhave resolved

Initial management of ACS related to Initial management of ACS related to systemic process, tx the preciptating systemic process, tx the preciptating factor 1factor 1stst (ie pRBCs if GI bleeding) (ie pRBCs if GI bleeding)

ASA allergic: give PlavixASA allergic: give Plavix

HEART FAILUREHEART FAILURE

Q 13Q 1355 yo M w/ CAD evaluated w/ 2 wks 55 yo M w/ CAD evaluated w/ 2 wks

after having an MI. D/C meds were: after having an MI. D/C meds were: ASA, Toprol, ISMN, Lisinopril, and ASA, Toprol, ISMN, Lisinopril, and Atorvastatin. Echo revealed Atorvastatin. Echo revealed inferoposterior akinesis and LVEF of inferoposterior akinesis and LVEF of 40%.40%.

Exam: HR 60, BP 13-/70. JVP nml, lungs Exam: HR 60, BP 13-/70. JVP nml, lungs clear. Regular s1/s2. Labs: K-5.7, Cr-clear. Regular s1/s2. Labs: K-5.7, Cr-1.0, LDL-65. Lisinopril therapy 1.0, LDL-65. Lisinopril therapy stopped.stopped.

Which of the following medications Which of the following medications should be started in this patient?should be started in this patient?

1.1. ValsartanValsartan2.2. SpironolactoneSpironolactone3.3. AmlodipineAmlodipine4.4. EplerenoneEplerenone5.5. HydralazineHydralazine

SHF MEDS:SHF MEDS: ACEi (or if intolerant, ARB)ACEi (or if intolerant, ARB) ~will usually tolerate a K to 5.5~will usually tolerate a K to 5.5 B-blockerB-blocker Hydralazine/Nitrate combo if can’t tolerate an Hydralazine/Nitrate combo if can’t tolerate an

ACEi or ARB, or adding specifically if african-ACEi or ARB, or adding specifically if african-americanamerican

Spironolactone w/ NYHA class 3 or 4 Spironolactone w/ NYHA class 3 or 4 symptomssymptoms

Eplerenone (aldo receptor antag) is useful in Eplerenone (aldo receptor antag) is useful in reduced EF after AMIreduced EF after AMI

REMEMBER for HEART REMEMBER for HEART FAILURE:FAILURE:

Digoxin alleviates Sx, reduceds Digoxin alleviates Sx, reduceds hospitalization 2/2 HF (not mortality)hospitalization 2/2 HF (not mortality)

Diurese HF pt w/ volume overload 1Diurese HF pt w/ volume overload 1stst, , then beta blockthen beta block

Put an AICD in a HF pt that comes in Put an AICD in a HF pt that comes in w/ unexplained syncopew/ unexplained syncope

Put a Biventricular Device in HF pt on Put a Biventricular Device in HF pt on optimal therapy w/ continued optimal therapy w/ continued symptoms and QRS > 120 mssymptoms and QRS > 120 ms

ArrhythmiasArrhythmias

Q 14Q 1423 yo presents w/ palpitations during 23 yo presents w/ palpitations during

exercise. Healthy, no meds. Exam exercise. Healthy, no meds. Exam and resting ECG nml. Stress test and resting ECG nml. Stress test shows sustained monomorphic V shows sustained monomorphic V tach @ 201 /min. No iscemic tach @ 201 /min. No iscemic changes until arrhythmia developed. changes until arrhythmia developed. The V tach had a Left bundle and The V tach had a Left bundle and infoerior axis morphology. infoerior axis morphology. Terminated spontanesouly 7 mins Terminated spontanesouly 7 mins into rest. ECHO nml, MRI nml.into rest. ECHO nml, MRI nml.

What is the most likely etiology of V What is the most likely etiology of V tach in this patient?tach in this patient?

1.1. Coronary spasmCoronary spasm2.2. IdiopathicIdiopathic3.3. Arrhythmogenic R ventricular Arrhythmogenic R ventricular

cardiomyopathycardiomyopathy4.4. Infiltrative heart diseaseInfiltrative heart disease5.5. Anomalous origin of the coronary Anomalous origin of the coronary

arteriesarteries

Idiopathic V Tach (no structural heart Idiopathic V Tach (no structural heart disease) carries a good prognosis. Tx disease) carries a good prognosis. Tx symptoms, BB first line.symptoms, BB first line.

~Expect BP and ST segment elev w/ ~Expect BP and ST segment elev w/ spasm. Nml MRI/ECHO rule out spasm. Nml MRI/ECHO rule out infiltrative disease, anomolaus infiltrative disease, anomolaus coronaries, or arrhythogenic RV coronaries, or arrhythogenic RV cardiomyopathy (would see fatty cardiomyopathy (would see fatty infiltration).infiltration).

Q 38Q 38 68 yo presents for routine eval. No 68 yo presents for routine eval. No

complaints other than lumbago. complaints other than lumbago. Active, does yoga 3x/week. Meds Active, does yoga 3x/week. Meds include Levothryoxine and HCTZ. include Levothryoxine and HCTZ. Exam: HR 46. On further questioning, Exam: HR 46. On further questioning, she notes palpitations during a yoga she notes palpitations during a yoga class. 24 Ambulatory monitoring class. 24 Ambulatory monitoring reveals HR of 39-82, avg of 45/min reveals HR of 39-82, avg of 45/min and occ pauses up to 2.9 sec. Nml and occ pauses up to 2.9 sec. Nml TSH.TSH.

What is the BEST management option What is the BEST management option for this patient?for this patient?

1.1. Pacemaker implantationPacemaker implantation2.2. Exercise stress testExercise stress test3.3. Repeat 24 hr monitoringRepeat 24 hr monitoring4.4. Reassurance and ObservationReassurance and Observation

ONLY when there is definitive ONLY when there is definitive correlation b/w sinus bradycardia correlation b/w sinus bradycardia and and symptomssymptoms, is pacemaker , is pacemaker warrantedwarranted

Class IClass I1.1. 3 3rdrd degree heart block w/ one of following: degree heart block w/ one of following:a. Bradycardia with symptoms a. Bradycardia with symptoms b. other medical conditions that require drugs that cause sx bradyb. other medical conditions that require drugs that cause sx bradyc. Documented asystole 3.0 seconds or any escape rate <40 bpm in c. Documented asystole 3.0 seconds or any escape rate <40 bpm in awake, symptom-awake, symptom-free patients. free patients. d. After catheter ablation of the AV junctiond. After catheter ablation of the AV junctione. Postoperative AV block that is not expected to resolvee. Postoperative AV block that is not expected to resolvef. Neuromuscular diseases with AV blockf. Neuromuscular diseases with AV block

2. 2. Second-degree AV block regardless of type or site of block, with associated symptomatic Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardiabradycardia

Class IIaClass IIa1. Asymptomatic third-degree AV block w/ average awake ventricular rates of >/= 40 1. Asymptomatic third-degree AV block w/ average awake ventricular rates of >/= 40 2. Asymptomatic type II second-degree AV block2. Asymptomatic type II second-degree AV block3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found 3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally at electrophysiological study for other indicationsincidentally at electrophysiological study for other indications4. First-degree AV block with symptoms suggestive of pacemaker syndrome and 4. First-degree AV block with symptoms suggestive of pacemaker syndrome and documented alleviation of symptoms with temporary AV pacingdocumented alleviation of symptoms with temporary AV pacing

Q 43Q 4368 yo F comes to the ED b/c of racing 68 yo F comes to the ED b/c of racing

heart for past 2 hrs. Reports 2 yr heart for past 2 hrs. Reports 2 yr history of similar episodes. Been told history of similar episodes. Been told by PMDs in past to cough/strain, by PMDs in past to cough/strain, usually works but not today. No chest usually works but not today. No chest pain, no other cardiac history.pain, no other cardiac history.

Exam shows BP of 110/60, HR 165, Exam shows BP of 110/60, HR 165, RR 20. Lungs clear. Carotids w/o RR 20. Lungs clear. Carotids w/o murmurs, attempt massage w/o murmurs, attempt massage w/o effect. ECG is shown.effect. ECG is shown.

Which is the drug of choice for Which is the drug of choice for terminating this patient’s terminating this patient’s arrhythmia?arrhythmia?

1.1. MetoprololMetoprolol2.2. VerapamilVerapamil3.3. AdneosineAdneosine4.4. DigoxinDigoxin

Q 122Q 12226 yo nurse is evaluated in the ED 26 yo nurse is evaluated in the ED

after episode of syncope. While after episode of syncope. While working stressfull day in the ICU, working stressfull day in the ICU, developed tachycardia and then LOC. developed tachycardia and then LOC. +palpitations in past+palpitations in past

Exam wnl. CXR wnl. ECG initially Exam wnl. CXR wnl. ECG initially unremarkable. 10 mins later, unremarkable. 10 mins later, developed brief tachycardia. Repeat developed brief tachycardia. Repeat ECG shown.ECG shown.

What is the most likely diagnosis in What is the most likely diagnosis in this patient?this patient?

1.1. Atrioventricular nodal reentrant Atrioventricular nodal reentrant tachycardiatachycardia

2.2. Accelerated Idioventricular Accelerated Idioventricular tachycardiatachycardia

3.3. Atrioventircular reentrant Atrioventircular reentrant tachycardiatachycardia

4.4. Multifocal atrial tachycardiaMultifocal atrial tachycardia

AVNRT: AVNRT: >50% of all SVTs. Circuit involves the >50% of all SVTs. Circuit involves the AV node, so atria and Ventricle activated AV node, so atria and Ventricle activated simultaneously. So “p” wave usually buried in simultaneously. So “p” wave usually buried in QRS.QRS.

AVRT: AVRT: Circuit involves an accessory Circuit involves an accessory pathway. Most orthodromic: travels pathway. Most orthodromic: travels anterograde down AV node, retrograde up anterograde down AV node, retrograde up accessory path. Some pts w/ pre-excitation accessory path. Some pts w/ pre-excitation phenomena: during SR, see short PR interval phenomena: during SR, see short PR interval and delta wave (evidence of pre-excitation)= and delta wave (evidence of pre-excitation)= **WPWWPW

=> ADENOSINE is DRUG of CHOICE, => ADENOSINE is DRUG of CHOICE, however avoid if any evidence of pre-however avoid if any evidence of pre-excitation on ECGexcitation on ECG

REMEMBER:REMEMBER: In healthy adults, PVCs at rest are common and not In healthy adults, PVCs at rest are common and not

cause for concerncause for concern Procainamide is drug of choice in a preexcited A fibProcainamide is drug of choice in a preexcited A fib DC Cardioversion is 1DC Cardioversion is 1stst line for any unstable line for any unstable

tachycardic pt (hypotensive, signs of HF like tachycardic pt (hypotensive, signs of HF like diaphoresis, pulm edema)diaphoresis, pulm edema)

REMEMBER your CHADS2 score, if >2 give warfarinREMEMBER your CHADS2 score, if >2 give warfarin For A FIB: 1For A FIB: 1stst line is always rate control, only line is always rate control, only

consider antiarrhytmic or ablation if symptomatic consider antiarrhytmic or ablation if symptomatic from being in controlled A fibfrom being in controlled A fib

A flutter often result of another acute process, A flutter often result of another acute process, consider referral for ablation earlier as often difficult consider referral for ablation earlier as often difficult to rate controlto rate control

THE AORTATHE AORTA

Q 45Q 4569 yo M presented to ED for acute 69 yo M presented to ED for acute

onset of substernal CP radiating to onset of substernal CP radiating to left arm. +former smoker, h/o HTNleft arm. +former smoker, h/o HTN

On exam: diaphoretic, BP of 210/95 On exam: diaphoretic, BP of 210/95 mmHG in R arm and 164/56 in L arm mmHG in R arm and 164/56 in L arm with HR 90. There is dullness ½ way with HR 90. There is dullness ½ way up R posterior troax and 2/6 diasolic up R posterior troax and 2/6 diasolic murmur at RUSB. ECG shows 2-3 mm murmur at RUSB. ECG shows 2-3 mm inferior ST seg elevation.inferior ST seg elevation.

Prior to additional diagnostic tests, Prior to additional diagnostic tests, which of the following is the most which of the following is the most appropriate initial medication?appropriate initial medication?

1.1. ASAASA2.2. IV HeparinIV Heparin3.3. Thrombolytic agentThrombolytic agent4.4. Beta blockerBeta blocker5.5. ACE inhibitorACE inhibitor

AORTIC DISSECTIONAORTIC DISSECTION: disparate BPs : disparate BPs b/w arms, diastolic murmur of aortic b/w arms, diastolic murmur of aortic regurg. Do NOT given ASA, heparin, regurg. Do NOT given ASA, heparin, etc if suspect. Initial treatment is w/ etc if suspect. Initial treatment is w/ Beta Blockers to decrease shear Beta Blockers to decrease shear stress. Diagnostic tests should be a stress. Diagnostic tests should be a TRANSESOPHAGEAL ECHO vs. CHEST TRANSESOPHAGEAL ECHO vs. CHEST CT w/ CONTRAST.CT w/ CONTRAST.

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Valvular DiseaseValvular Disease

Q 16Q 1682 yo presents for annual exam. PMHx: HTN on 82 yo presents for annual exam. PMHx: HTN on

chronic BB. Denies all cardiac sx. Takes daily chronic BB. Denies all cardiac sx. Takes daily 1 mi walk, no change in exercise tolerance.1 mi walk, no change in exercise tolerance.

Exam shows: BP 136/86, HR 80. s1, single s2, Exam shows: BP 136/86, HR 80. s1, single s2, grade 3/6 early systolic murmur @ LUSB w/ grade 3/6 early systolic murmur @ LUSB w/ radiation to carotids. 1+ peripheral edema. radiation to carotids. 1+ peripheral edema. LDL is 110. ECHO 2 yrs ago showed LDL is 110. ECHO 2 yrs ago showed moderate calcific aortic stenosis (velocity was moderate calcific aortic stenosis (velocity was 3.6, valve area 1.2, gradient 30) with nml LV 3.6, valve area 1.2, gradient 30) with nml LV fxn. Now ECHO shows jet velocity of 4.2, fxn. Now ECHO shows jet velocity of 4.2, valve area of 1.0, and gradient of 44).valve area of 1.0, and gradient of 44).

What is the most appropriate next What is the most appropriate next step?step?

1.1. ReassuranceReassurance2.2. Begin a cardiac rehab programBegin a cardiac rehab program3.3. HCTZHCTZ4.4. Start statin therapyStart statin therapy5.5. Refer for Aortic valve replacementRefer for Aortic valve replacement

Aortic Stenosis:Aortic Stenosis:~Reassurance remains appropriate if ~Reassurance remains appropriate if

asymptomatic and nml exercise toleranceasymptomatic and nml exercise tolerance~w/ severe stenosis the stiff valve doesn’t ~w/ severe stenosis the stiff valve doesn’t

snap shut, thus loose aortic component and snap shut, thus loose aortic component and get only a single S2 (a physiologic split S2 get only a single S2 (a physiologic split S2 has specificity of 72% of excluding severe has specificity of 72% of excluding severe AS)AS)

~controling BP important, but use CAUTION ~controling BP important, but use CAUTION w/ any peripheral vasodilators b/c w/ any peripheral vasodilators b/c compensation in Stroke Volume across a compensation in Stroke Volume across a stenosed valve my be difficult!! stenosed valve my be difficult!!

~ Symptoms: Angina (5), Syncope (3), Heart ~ Symptoms: Angina (5), Syncope (3), Heart Failure (2)Failure (2)

Q 19Q 1936 yo F in the ED w/ fever & dyspnea. 4 36 yo F in the ED w/ fever & dyspnea. 4

wks of fever to 40C. +heroin use.wks of fever to 40C. +heroin use.Exam: 39.6, 100/52, 70, 91% on RA. JVP Exam: 39.6, 100/52, 70, 91% on RA. JVP

12. Bibasilar crackles. HR reg irregulsr. 12. Bibasilar crackles. HR reg irregulsr. S1, muffled s2. 2/6 diastolic murmur @ S1, muffled s2. 2/6 diastolic murmur @ R 2R 2ndnd intercostal space. 1+ pretibial intercostal space. 1+ pretibial edema. ECG shows a bifascicular block edema. ECG shows a bifascicular block and Mobitz II. ECHO shows 2 veges on and Mobitz II. ECHO shows 2 veges on aortic valve, w/ leaflet perforation and aortic valve, w/ leaflet perforation and severe AR. Echoluceny in paravalvular severe AR. Echoluceny in paravalvular region. Placed on broad spectrum Abx.region. Placed on broad spectrum Abx.

What is the most appropriate What is the most appropriate treatment at this time?treatment at this time?

1.1. Esmolol IVEsmolol IV2.2. Heparin IVHeparin IV3.3. Intraortic ballon pump (IABP)Intraortic ballon pump (IABP)4.4. Permanent pacemakerPermanent pacemaker5.5. Aortic Valve ReplacementAortic Valve Replacement

Acute Aortic RegurgitationAcute Aortic Regurgitation Whether from endocarditis or Aortic Whether from endocarditis or Aortic

dissection, this is a SURGICAL dissection, this is a SURGICAL EMERGENCY!EMERGENCY!

Esmolol (short acting BB)can slow HR Esmolol (short acting BB)can slow HR and prolong diastolic filling to aid in and prolong diastolic filling to aid in forward output in some pts w/ AR forward output in some pts w/ AR (this pt has sig conduction abnml)(this pt has sig conduction abnml)

IABP is CONTRAINDICATED in AR IABP is CONTRAINDICATED in AR

Q 44Q 4432 yo M comes in for annual exam. No 32 yo M comes in for annual exam. No

personal or fmHx of cardiac disease. personal or fmHx of cardiac disease. Exam: s1/s2, +s4, 2/6 crescendo-Exam: s1/s2, +s4, 2/6 crescendo-decrescendo systolic murmur heard decrescendo systolic murmur heard best at LLSB w/o radiation to best at LLSB w/o radiation to carotids. Increased intensity w/ carotids. Increased intensity w/ valsalva. Isometric hand grip, passive valsalva. Isometric hand grip, passive leg raising decreases the intensity. leg raising decreases the intensity. Rapid upstrokes of peripheral pulses Rapid upstrokes of peripheral pulses are present.are present.

What is the most likely diagnosis?What is the most likely diagnosis?1.1. Mitral Valve ProlapseMitral Valve Prolapse2.2. Hypertrophic cardiomyopathyHypertrophic cardiomyopathy3.3. Atrial septal defectAtrial septal defect4.4. Ventricular Septal DefectVentricular Septal Defect5.5. Aortic StenosisAortic Stenosis

Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy

If preload is increased (isometric hand grip, If preload is increased (isometric hand grip, stand-> squat) = increased systolic stand-> squat) = increased systolic dimension of LV and therefore less dimension of LV and therefore less obstruction & diminished murmur, Valsalva obstruction & diminished murmur, Valsalva = decreased preload so increased murmur= decreased preload so increased murmur

Tx even asymptomatic pts w/ BB, avoid Tx even asymptomatic pts w/ BB, avoid strenuous exercisestrenuous exercise

*different from hypertrophied athlete’s LV *different from hypertrophied athlete’s LV in that septum is asymmetrically enlargedin that septum is asymmetrically enlarged

REMEMBER:REMEMBER: ECHO for any Diastolic Murmur, ECHO for any Diastolic Murmur,

Continuous murmur, or > grade 3/6Continuous murmur, or > grade 3/6 Wide, Fixed split S2 think ASDWide, Fixed split S2 think ASD Secundum ASD can be prepared Secundum ASD can be prepared

percutaneouslypercutaneously