Internal Medicine Board Review

1. Internal Medicine Board Review Heart Failure Arrhythmia March 1, 2010 Gene Kim

4. Functional Class • NYHA Functional Class • I: Asymptomatic • II: Slight limitation of physical activity • III: Marked limitation of physical activity • IV: Unable to perform activity without symptioms.

5. Functional Class • ACC/AHA Stages • A: No structural disease or symptoms. • B: Structural disease, no symptoms. • C: Structural disease, symptoms – past or present. • D: Refractory symptoms to medical therapy.

6. Question • A 70 year old woman is evaluated for a 1-month history of DOE and fatigue. She can still perform ADLs, including vacuuming, grocery shopping, and ascending two flights of stairs carrying laundry. She has a history of HTN, mild COPD, and smoking. Her medications are lisinopril, HCTZ, and albuterol as needed. • On PE, she is afebrile. BP is 110/80 mmHg, pulse 70/min. Jugular veins are not distended. There is a grade 2/6 holosystolic murmur at the left sternal border that radiates to the axilla, which was not noted during an examination 1 year ago. Rate and rhythm are regular, S1 and S2 are normal, and there is no S3. The lung sounds are distant but clear without wheezing and there is no edema. Laboratory studies show normal Hgb and TSH levels. ECG shows low voltage and LAD. Echocardiogram shows an EF of 35%, global hypokinesis, and mild MR. CXR show flattening of the diaphrams but is otherwise normal.

7. Which of the following is the most appropriate treatment? • Amlodipine • Carvedilol • Digoxin • Losartan • Spironolactone

8. Which of the following is the most appropriate treatment? • Amlodipine • Carvedilol • Digoxin • Losartan • Spironolactone

9. Medical Therapy • Angiotensin Converting Enzyme Inhibitors • Indicated for any functional class • Mortality reduction approx. 20%. • β-Blockers • Indicated for any functional class • Mortality reduction approx. 30%. • Not to be started in the acute decompensated state.

10. Question • A 60 yr old white woman is evaluated for dyspnea with mild activity (ascending less than one flight of stairs, walking less than one block on level ground) that has been stable for the past year. She has a history of non-ischemic cardiomyopathy (last EF: 20%). Her current medications are lisinopril, carvedilol, digoxin, and furosemide. She had an ICD placed one year ago. • On PE, she is afebrile. BP is 95/75, P: 70/min. Jugular veins are nondistended, and lungs are clear. Cardiac exam reveals normal S1 and S2, no S3. There is no edema. Laboratory studies show a serum potassium of 4.7 meq/L, creatinine of 1.8mg/dL, which has been stable for the past year.

11. Which of the following is the most appropriate addition to her treatment? • Angiotensin receptor blocker • Hydralazine • Metolazone • Spironolactone

12. Which of the following is the most appropriate addition to her treatment? • Angiotensin receptor blocker • Hydralazine • Metolazone • Spironolactone

13. Medical Therapy • Diuretics • Used for volume control • No data on use • Spironolactone • Indicated in class III-IV heart failure. • Caution in renal insufficiency - hyperkalemia

14. Medical Therapy • Digoxin • Indicated in class II-IV heart failure. • Symptom control – no mortality benefit. • Hydralazine and Nitrates • Indicated in class III-IV heart failure. • In addition to ACEi and β-blockers. • 40% mortality reduction in AAHeFT.

15. Question • A 37 year old woman with a history of peripartum cardiomyopathy several years ago is evaluated 12 weeks into her second pregnancy. She became pregnant despite the use of a combination OCP and plans to proceed with the pregnancy. She is currently asymptomatic but leads a sedentary lifestyle. She is taking no medications. • On PE, BP is 110/70 mmHg, pulse 80/min and regular. Estimated CVP is 3cm H20 and there is no edema. • The ECG shows sinus rhythm but is otherwise unremarkable. An echocardiogram is performed and demonstrates mild left ventricular enlargement with a calculated EF of 40%. The valves and pulmonary pressures are normal.

16. Which of the following medications should be initiated at this time? • Digoxin • Furosemide • Hydralazine • Lisinopril • Metoprolol

17. Which of the following medications should be initiated at this time? • Digoxin • Furosemide • Hydralazine • Lisinopril • Metoprolol

18. Question • A 40 year old man is hospitalized for a 3-day history of progressive fatigue, dyspnea, nausea, and early satiety. He has a history of viral cardiomyopathy that was diagnosed 3 years ago. His last EF was 20% by echo done 3 months ago. An ICD was placed 2 years ago for primary prophylaxis. Medications are metoprolol and enalapril. • On PE, he is afebrile and slightly lethargic. BP is 80/60 mmHg, pulse 110/min, respiration 20/min. Estimated CVP is 5 mmH20, Heart sounds are soft ad regular. Lungs are clear. There is mild RUQ abdominal tenderness without guarding or rebound. No edema is noted.

19. Question - continued • Laboratory findings are as follows: Hgb 10g/dL (down from 12 g/dL one month ago); leukocyte count, 9000/uL; creatinine, 2.9 mg/dL (up from 1.3 mg/dL one month ago); ALT, 500 U/L, AST, 860 U/L (both normal one month ago). • ECG shows sinus tachycardia. He is admitted to the ICU and a pulmonary artery catheter is placed to manage hypotension and for assessment of volume status.

20. Question - continued • Pulmonary artery catheterization measurements: • CVP: 5 mmHg • PA: 25/14 mmHg • PCWP: 14 mmHg • Cardiac output: 2.54 L/min • Cardiac index: 1.48 L/min/m2

21. In addition to stopping the metoprolol, which of the following is the most appropriate treatment? • Intravenous furosemide • Intravenous milrinone • Intravenous nesiritide • Intravenous saline • Packed RBC transfusion

22. In addition to stopping the metoprolol, which of the following is the most appropriate treatment? • Intravenous furosemide • Intravenous milrinone • Intravenous nesiritide • Intravenous saline • Packed RBC transfusion

23. Management of Acute Decompensated Heart Failure • Cardiogenic Shock • Sustained hypotension • CI < 2.2 L/min/m2 • Elevated PCWP >15mmHg • Evaluate for evidence of end organ malperfusion. • Treat underlying cause: • MI • Tamponade • Volume overload

24. Management of Acute Decompensated Heart Failure • Ionotropic support if evidence for end organ malperfusion. • PA catheter placement if volume status uncertain, ongoing hemodynamic instability. • Inadequate perfusion despite inotropic support, proceed to IABP.

25. Device Therapy • ICD • NYHA class II – III. • Survival > 1 year. • EF <35%. • SCD-HeFT: 23% mortality ↓ • CRT • NYHA class III –IV. • EF <35% • QRS >120 ms, LBBB.

26. Device Therapy • Chronic ionotropic support confers high long-term mortality (40-90%) despite presence of ICD. • Ventricular assist device indicated if symptomatic heart failure persists. • Can serve as bridge to transplantation or as destination therapy.

27. Arrhythmia

28. Question • A 77 year old woman is admitted for intermittent dizziness over the past few days. She does not have chest discomfort, dyspnea, palpitations, syncope, orthopnea, or edema. She underwent CABG surgery 6 years ago after an MI. She has HTN, hyperlipidemia, and paroxysmal atrial fibrillation with a history of RVR. She notes that over the past several years, she feels she has slowed down and has had problems with memory, which she attributes to aging. Medications are metoprolol, HCTZ, pravastatin, lisinopril, ASA, and warfarin.

29. Question - Continued • On PE, BP 137/88 mmHg, pulse 52/min. Estimated CVP is 7 cmH20. The PMI is felt in the left intercostal space and at the midcostal line. Cardiac auscultation reveals bradycardia with a regular S1 and S2, as well as an S4. A grade 2/6 early systolic murmur is heard at the left upper sternal border. The lungs are clear. Edema is not present. • On telemetry, she has sinus bradycardia with rates between 40/min and 50/min, with two symptomatic sinus pauses of 3 to 5 seconds each.

30. Which of the following is the most appropriate management for this patient? • Add amiodarone • Discontinue metoprolol • Echocardiography • Pacemaker implantation

31. Which of the following is the most appropriate management for this patient? • Add amiodarone • Discontinue metoprolol • Echocardiography • Pacemaker implantation

32. Bradyarrhythmias • Sick Sinus Syndrome • Sinus arrest • Exit Block • Reduced automaticity of SA node • Tachy-brady syndrome subtype of SSS • RVR during episodes of atrial fibrillation • Resting bradycardia between episodes • Prolonged sinus pauses upon conversion of Afib

33. Bradyarrhythmias • AV Block • First degree: stable PR prolongation • Second degree: • Mobitz I: progressive PR prolongation • Mobitz II: constant PR interval, intermittent non-conducted P waves. • Third degree: complete heart block. • Atrial rate > ventricular rate. • Ventricular rate > atrial rate is AV dissociation.

34. Question • A 26 year old woman who is 25 weeks pregnant is evaluated in the ED for palpitations and episodic lightheadedness. She has no history of cardiovascular disease or tachycardia. • On PE, her BP is 100/70 mmHg, pulse is 175/min. The estimated CVP is normal and there are no carotid bruits. The apical impulse is not displaced. The examination is otherwise unremarkable. • A valsalva maneuver is performed by the patient and carotid sinus massage is performed by the attending physician, but the tachycardia continues.

35. ECG

36. Which of the following medications should be initiated at this time? • Adenosine • Amiodarone • Digoxin • Diltiazem • Metoprolol

37. Which of the following medications should be initiated at this time? • Adenosine • Amiodarone • Digoxin • Diltiazem • Metoprolol

38. Tachyarrhythmias • Narrow-complex vs Wide Complex? • Regular or Irregular? • Wide-Complex Tachycardias • VT • AV dissociation • Capture, fusion complexes • Concordance • SVT with Aberrant conduction

40. Question • A 42 year old man is evaluated for recurrent, highly symptomatic paroxysmal atrial fibrillation. He was initially diagnosed 6 months ago. His evaluation revealed no underlying cause and his resting ECG and echo were normal. Despite treatment with metoprolol, episodes occur 3-4 times daily and last from a few minutes to several hours. During events, he feels drained and unable to concentrate, with a sensation of irregular heart-beat. He experiences DOE and lightheadedness, but denies CP and syncope. Episodes are triggered by activity, caffeine, and alcohol. He takes no medications other than the metoprolol. • On PE, BP 130/60, pulse 70/min and regular. S1 and S2 are normal and there is no murmur or extra heart sounds. Estimated CVP is 5 cm H2O and the lungs are clear. The remainder of the PE is normal.

41. Which of the following is the most appropriate management for this patient? • Add amiodarone • Add digoxin • 24-hour ambulatory monitoring • Implanted loop recorder

42. Which of the following is the most appropriate management for this patient? • Add amiodarone • Add digoxin • 24-hour ambulatory monitoring • Implanted loop recorder

43. Atrial Fibrillation • Rate control vs rhythm control • Asymptomatic • Rate control an option • Symptomatic • Anti-arrhythmic vs non-pharmacologic • Anticoagulation based on stroke risk • CHADS2 score • ASA vs warfarin

44. Anti-arrhythmics • Class I: sodium channel blockade • IA) procainamide • IB) lidocaine • IC) Flecanide, propafenone • Class II: β-blockers • Class III: potassium channel blockade • Amiodarone, Sotalol, dofetilide • Class IV: Calcium channel blockade

45. Atrial Fibrillation • Non-pharmacologic therapies • Ablation (pulmonary vein isolation) • Patients who cannot tolerate rate control strategy. • Failed at least one anti-arrhythmic. • AV nodal ablation and Pacemaker implantation • Renders patient PM dependent. • Generally for elderly patients unable to tolerate other strategies.

46. Question • A 54 year old man is evaluated for recurrent arrhythmia. He was diagnosed with atrial flutter with RVR 6 weeks ago. Rate control was initially difficult to achieve; he underwent cardioversion and was started on metoprolol. Two days ago, he had a recurrence of his arrhythmia; his fatigue worsened, and he began to experience DOE. He denies chest pain, lightheadedness, and heart racing. He has no other medical problems, and his only other medication is daily aspirin. • On PE, BP is 123/65 mmHg, pulse 50/min. BMI is 24. Cardiac exam reveals bradycardia with an irregular rhythm, normal S1 and S2, and no murmurs or gallops. Lungs are clear to auscultation. • The electrocardiogram shows atrial flutter with a 6:1 block and a ventricular rate of 50/min.

47. Which of the following is the most appropriate managament for this patient? • Add amiodarone • Add digoxin • Discontinue metoprolol, initiate flecanide • Radiofrequency ablation

48. Which of the following is the most appropriate managament for this patient? • Add amiodarone • Add digoxin • Discontinue metoprolol, initiate flecanide • Radiofrequency ablation

49. Atrial Flutter • Most cases are “typical” flutter • Counterclockwise cavotricuspid isthmus dependent circuit. • 240-340 cycles/min. • Characteristic sawtooth pattern in inferior leads on ECG. • Cardioversion effective. • Ablation is first-line therapy for recurrent flutter. • 90% success rate, low complication rate. • Anticoagulation guidelines same as Afib.

50. Supraventricular Tachycardias • AV nodal reentrant tachycardia (60%) • AV reentrant tachycardia (30%) • Atrial Tachycardia (10%)