Internal Medicine Board Review Cardiology

1. Internal Medicine Board ReviewCardiology Mike McMullan, M.D., FACC July 17, 2014

2. Internal Medicine Examination • Cardiology is the largest section of the review • Why is this? • Cardiology is the largest section of the boards • 40% more than the next closest topic • 14% of exam, pulmonary is next at 10% • Cardiovascular disease affects more people than any other disease process • Almost half of your family, friends, neighbors, and patients will eventually die from heart disease

3. Cardiology Topic Breakdown

4. Cardiology Topic Breakdown

5. To cover these areas Physical examination Valvular disease Congenital heart disease Pericardial disease Endocarditis/SBE prophylaxis In order to answer 0 questions 2-5 questions 0-1 questions 1-4 questions 0-1 questions _____________ 3-11 questions My Assignment But “the truth of the matter” is that physical examination will encompass all 32 questions!

6. Breaking It Down – My Method • Focused board oriented pearls of frequently-tested disease processes (This is NOT a comprehensive discussion of each topic!) • Broken down by general topics • Highlight common scenarios within each topic • Symptoms • Physical findings • Diagnostic tests • Management • Common word associations

7. Breaking It Down • Physical examination • Knowing the basics will help you figure out questions • Will often ask for the diagnostic test (echo) rather than the diagnosis (aortic stenosis) • Be aware of normal findings that require no further w/u – e.g. innocent flow murmurs, venous hum • Recognize cardiac clues to systemic diseases – e.g. rapid atrial fibrillation with a scratchy murmur hyperthyroidism Means–Lerman scratch

8. The Basics

9. Where does S1 occur? • a • b • c • d • e • f S1

10. Where does S2 occur? S2 • a • b • c • d • e • f

11. Where does S4 occur? • a • b • c • d • e • f S4

12. The Basics • 4 heart sounds • S1 – closure of mitral/tricuspid valves • S2 – closure of aortic/pulmonic valves • S3 – rapid ventricular filling with rapid flow deceleration • May be normal in pts < 40 y/o • Often seen in CMP and ventricular failure • S4 – atrial contraction against a stiff ventricle • HTN • HCM • Aortic stenosis

13. Which of these sounds is lost in a patient with atrial fibrillation? • S1 • S2 • S3 • S4

14. The Basics • 3 additional heart sounds • Click (occur with valve closure) • Usually MVP • Rarely tricuspid click in Ebstein’s anomaly • Opening snap (occur with valve opening) • Usually right after S2 - mitral stenosis • Can occur at beginning of systole – congenital aortic stenosis – and is more often called ejection sound • Rub (occur with cardiac motion) • Up to 3 components • Atrial systole • Ventricular systole • Ventricular diastole • 2 of 3 components are in diastole

15. The Basics • 3 types of mumurs • Systolic • Systolic ejection=mid-systolic=crescendo-decrescendo • Pansystolic=holosystolic • Late systolic – associated with click = MVP! • Diastolic • Early high-pitched decrescendo • Aortic or pulmonic regurgitation • Low pitched rumble throughout diastole • Mitral or tricuspid stenosis • Continuous • Patent ductus arteriosus • AP window • Shunt or fistula

16. Basic Murmurs S1 S2 S1 S2 ES OS S4 S1 S3

17. Venous Waveforms in a Nutshell

18. Venous Waveforms in a Nutshell Ventricular systole Ventricular systole

19. Large “v” Waves

20. What’s the diagnosis? • Aortic stenosis • Aortic regurgitation • Mitral regurgitation • Tricuspid regurgitation

21. What’s the diagnosis? • Aortic stenosis • Aortic regurgitation • Mitral regurgitation • Tricuspid regurgitation

22. What’s the diagnosis? • Mitral regurgitation • Mitral stenosis • Aortic regurgitation • Aortic stenosis 40 30 mmHg LV 20 x y LA 10 0

23. What’s the diagnosis? Brockenbrough sign • Aortic stenosis • HCM with obstruction • MVP • Aortic regurgitation Pulsus bisferiens

25. Normal Findings • Innocent murmurs • Grade 1-2 (mid)systolic ejection murmurs • NEVER • Grade 3 or more • Pansystolic • Diastolic • Continuous • Other abnormal sounds – e.g. fixed split S2 • Venous hums • High flow states – e.g. anemia • Goes away when lays down

26. Breaking It Down • Pericardial disease (1-4 questions) • Cardiac tamponade • Constrictive pericarditis • Acute pericarditis

27. Cardiac Tamponade • Scenarios – trauma and breast cancer are the two biggies on boards, also lupus and renal failure, occasionally viral pericarditis (rarely aortic dissection) • Diagnosis – Beck’s triad (hypotension and elevated neck veins with quiet precordium), pulsus paradoxus, electrical alternans • Tests - Swan hemodynamics with equalization of all diastolic pressures and slow y descent, echo • Mgt – pericardiocentesis

29. RA Pressure in Tamponade

31. Constrictive Pericarditis • Scenarios – post-radiation for lymphoma, CTD, TB • Diagnosis – dyspnea, elevated JVP, Kussmaul’s sign, edema, pericardial knock • Tests – echo, CT or MRI, cath with prominent x and y descents, equalization of diastolic pressures with square root sign • Mgt – pericardial stripping

32. Constrictive Pericarditis Kussmaul’s sign

34. 125 Constrictive Pericarditis LV 100 75 Y>X RVEDP > 1/3 RVSP Square-root sign 50 Equalization of Diastolic Pressures RV Y 25 X RA LA 0

35. Acute Pericarditis • Scenarios – usually post-viral syndrome • Diagnosis – pleuritic chest pain, feels better sitting up and leaning forward, pericardial friction rub • Tests – EKG with diffuse ST elevation, elevated ESR, CRP and/or biomarkers • Mgt – NSAIDs • Ibuprofen 600-800 mg TID or • ASA 650-1000 mg TID or • Indomethacin 50 mg TID for 7-10 days • Colchicine 0.5 – 0.6 mg BID • Refractory – prednisone plus colchicine

38. Breaking It Down • Congenital heart disease (0-1 questions) • ASD – recognize the EKG • VSD – almost always no treatment necessary in adults • PDA – continuous murmur • Coarctation of aorta – secondary HTN, differential BP’s • If cyanotic pt (unlikely), probably Tetralogy of Fallot • Pregnancy – tolerated in all patients except pulmonary HTN and cardiomyopathies

39. Atrial Septal Defect • 4 types but only need to know ostium secundum for boards • Scenario – young adult with murmur or palpitations • Diagnosis – fixed split S2, 2/6 SEM at LUSB • Tests – EKG with incomplete RBBB and RAD, echo, cath with shunt run • Mgt – closure (percutaneously or surgically) for shunt > 1.5:1 • No SBE prophylaxis recommended – low risk

40. Atrial Septal Defect

41. ASD EKG

42. ASD TEE

43. ASD Occluder

44. VSD • Scenario – asymptomatic young adult referred for murmur • Diagnosis – loud grade 5/6 pansystolic murmur at LSB • Test – echo • Mgt – closure not typically needed for adults, no longer need SBE prophylaxis by guidelines

45. Ventricular Septal Defect

46. Ventricular Septal Defect

47. Ventricular Septal Defect

48. PDA • Scenario – teen or young adult referred for murmur • Diagnosis – usually asymptomatic, continuousmurmur LSB • Tests – echo • Mgt – closure if murmur noted or left ventricular enlargement or pulmonary HTN, small ones without murmur do not need to be closed, no longer need SBE prophylaxis

49. Patent Ductus Arteriosus

50. Patent Ductus Arteriosus