BOARD REVIEWLida and Justin

9/9/15

HIGH YIELD CARDSMurmursStressRhythmPericarditis tPAPreopRhythmPericarditisHeart FailureValve DiseaseDigoxinSyncope

A 23 year old patient with a history of HOCM who presents to your office for a routine physical. On exam, what characteristics would you expect his murmur to have?

Sitting Standing Valsalva Hand grip

A. B. C. D. E.

X

A.

  Increase Decrease

Inspiration  Right sided murmurs  Left sided murmurs

Expiration  Left sided murmurs   Right sided murmurs

Standing/Valsalva  HOCM, MVP  All other murmurs

Squatting/Sitting  All other murmurs  HOCM, MVP

Hand Grip  All other murmurs  HOCM, AS

Post PVC  HOCM, AS  MVP

Which of the following medications reduces mortality in systolic heart failure?

A. Digoxin B. Hydralazine + Nitrates C. Lasix D. Verapamil E. Imdur

B. Medications that improve mortality in CHF

ACE inhibitors Angiotensin II Blockers Spironolactone for NYHA III or IV Hydralazine + Nitrates Beta blockers

Medications that DON’T improve mortality Digoxin Calcium channel blockers Lasix

A 68-year-old man is admitted to the hospital with a 1-week history of progressive shortness of breath, lower extremity edema, and weight gain of 4.5 kg (10 lb). He has ischemic cardiomyopathy and type 2 diabetes mellitus complicated by nephropathy. Medications are insulin, lisinopril, metoprolol, aspirin, and atorvastatin.

On physical examination, temperature is normal, blood pressure is 130/80 mm Hg, and pulse rate is 80/min. Estimated central venous pressure is 15 cm H2O. Cardiac examination reveals a regular rhythm, an S3, and a grade 2/6 holosystolic murmur radiating to the apex. Lower extremity edema with bilateral pitting to the knees is present.

Hemoglobin 9.5 g/dL, Crt 3.7 mg/dL, Sodium 136 meg/L, Trop <0.1 ng/mL

An echocardiogram shows a left ventricular ejection fraction of 30%, mild to moderate mitral regurgitation, anterior wall akinesis, and left ventricular enlargement.

Which of the following is the most appropriate treatment? A. Erythrocyte transfusion B. Intravenous bumetanide C. Intravenous milrinone D. Low-dose dopamine

B. Intravenous bumetanide Initial therapy for patients with acute

decompensated heart failure and volume overload is diuresis with an intravenous loop diuretic.

You are in rural New Mexico when a 65 year old presents with chest pain. EKG shows ST Elevation in leads V3-V6. There is no Cardiologist in your town and the nearest PCI center is 2 hours away. Which of the following is not a contraindication to thrombolysis?

A. Breast cancer with metastatic lesions to the brain

B. A history of intracranial hemorrhage 10 years ago

C. Blood pressure of 210/100 D. Nephrectomy 3 months ago E. History of atrial fibrillation on coumadin

D.

A 36 year old male with Aortic valve endocarditis transferred to the ICU because of the abrupt onset of hypotension and hypoxemia. BP is 80/30, pulse 120, bilateral crackles are noted on exam and summation gallop is noted. No murmurs are heard. Which of the following is the most appropriate initial therapy?

A. Placement of an intra-aortic balloon pump. B. Esmolol + dobutamine C. Fluid resuscitation D. Broaden antibiotic coverage E. Sodium nitroprusside

E. Sodium nitroprusside

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. He was treated at that time with ibuprofen and had rapid resolution of his symptoms. His only current medications are acetaminophen and codeine.

On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 132/78 mm Hg, pulse rate is 98/min, and respiration rate is 16/min. No jugular venous distention is noted. A two-component pericardial friction rub is heard over the left side of the sternum. Pulsus paradoxus of 6 mm Hg is noted. Lung auscultation reveals normal breath sounds with no wheezing. No pedal edema is present.

Electrocardiogram demonstrates sinus rhythm and no ST-segment shift.

Which of the following is the most appropriate management?

A. Azathioprine B. Chest CT C. Colchicine and aspirin D. Pericardiectomy E. Prednisone

C. Colchicine and aspirin Colchicine plus aspirin is the first-line treatment for

recurrent pericarditis. Lack of ST-segment elevation on electrocardiography does

not exclude pericarditis In patients with recurrent pericarditis who have not

benefited from colchicine plus aspirin and who have not benefited from or cannot tolerate corticosteroid therapy, current guidelines support the use of alternative immunosuppressive therapy with azathioprine or cyclophosphamide. However, these third-line agents are not indicated in this patient who has yet to be treated with colchicine and aspirin.

In patients with acute or recurrent pericarditis, pericardiectomy does not prevent recurrent disease and is only indicated in patients who develop constrictive pericarditis.

A 68-year-old woman is evaluated for palpitations. Her symptoms occur daily during both rest and exertion. She describes the palpitations as intermittent “hard” beats that “take her breath away.” Her symptoms are made worse by caffeine consumption. She reports no dizziness or syncope. Medical history is significant for hypertension and hyperlipidemia. Medications are an ACE inhibitor and a statin.

On physical examination, she is afebrile, blood pressure is 138/80 mm Hg, pulse rate is 83/min, and respiration rate is 18/min. On cardiac examination, the rhythm is regular. There are no murmurs or extra sounds. The lungs are clear. The remainder of the general physical examination is normal.

The electrocardiogram shows normal sinus rhythm with minor ST-segment abnormalities.

Which is the most appropriate testing option to utilize next in this patient?

A. Electrophysiologic study B. 24-Hour continuous ambulatory electrocardiographic

monitor C. Implantable loop recorder D. Postsymptom event recorder

B. 24-Hour continuous ambulatory electrocardiographic monitor

For patients with palpitations that occur on a daily basis, 24- or 48-hour continuous ambulatory electrocardiographic monitoring is appropriate to correlate symptoms with heart rhythm.

A 56-year-old man is evaluated in the hospital for paroxysmal episodes of atrial fibrillation. The patient develops increasing shortness of breath during these episodes. Five days ago, he was admitted for an acute myocardial infarction and cardiogenic shock and received a drug-eluting stent in the left anterior descending coronary artery. Medications are lisinopril, digoxin, furosemide, aspirin, clopidogrel, eplerenone, simvastatin, and unfractionated heparin.

On physical examination, the patient is afebrile, blood pressure is 92/65 mm Hg, and pulse rate is 75/min. Oxygen saturation is 95% with 3 L oxygen by nasal cannula. Cardiac examination reveals estimated central venous pressure of 12 cm H2O. Heart sounds are distant and regular. There is a grade 2/6 holosystolic murmur at the cardiac apex. A summation gallop is present. Crackles are auscultated bilaterally in the lower lung fields.

Transthoracic echocardiogram shows left ventricular ejection fraction of 32%.

Which of the following is the most appropriate treatment for this patient's atrial fibrillation?

A. Amiodarone B. Disopyramide C. Dronedarone D. Flecainide E. Sotalol

Amiodarone is the best option for managing symptomatic atrial fibrillation in the setting of structural heart disease or heart failure.

A 55-year-old man is evaluated before scheduled endoscopic sinus surgery. In addition to symptoms of chronic sinusitis, he has chronic knee pain that limits his activity to below 4 metabolic equivalents (METs). He has no chest pain, dyspnea, or lower extremity edema. He has type 2 diabetes mellitus, coronary artery disease, chronic kidney disease, hypertension, hyperlipidemia, osteoarthritis, and chronic sinusitis. He had a myocardial infarction 5 years ago and was treated with a single bare metal stent. Medications are insulin glargine, metoprolol, aspirin, simvastatin, lisinopril, and acetaminophen.

On physical examination, temperature is normal, blood pressure is 142/84 mm Hg, and pulse rate is 56/min. The electrocardiogram is consistent with a previous lateral myocardial infarction and is unchanged from 1 year ago. Serum creatinine level is 2.1 mg/dL (186 µmol/L).

Which of the following is the most appropriate preoperative management of this patient? A. Discontinue metoprolol B. Obtain dobutamine stress echocardiogram C. Refer for cardiac catheterization D. Proceed to surgery without further testing

In patients without active cardiac conditions undergoing low-risk surgery, preoperative cardiovascular testing is not routinely needed.