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Cardiology Board Review

Cardiology Board Review. Brenda Shinar, MD February 26, 2013. Question 1. Answer: C. Exercise electrocardiography. www.afp.org/online/en/home/cme/selfstudy/cmebulletin/cardiac-testing/objectives January 2012. Understand the Tests Used for Coronary Artery Disease Diagnosis and Prognosis.

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Cardiology Board Review

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  1. Cardiology Board Review Brenda Shinar, MD February 26, 2013

  2. Question 1. • Answer: C. Exercise electrocardiography www.afp.org/online/en/home/cme/selfstudy/cmebulletin/cardiac-testing/objectives January 2012

  3. Understand the Tests Used for Coronary Artery Disease Diagnosis and Prognosis Indications to Order a Stress Test: Types of Stress: Exercise Dobutamine Vasodilator Types of Imaging with Stress: No imaging (EKG interpretation only) Nuclear Echocardiogram • To diagnose occlusive CAD in a symptomatic patient with intermediate pre-test probability for CAD • To prognosticate in a patient with known occlusive CAD • To screen for CAD in an asymptomatic high risk patient prior to high risk surgery

  4. Question 2. • Answer: C. Loop event recorder Ambulatory Arrhythmia Monitoring: Choosing the Right Device: Zimetbaum, Peter; Circulation 2010;122:1629-1636

  5. Understand the Tests Used to Identify Symptomatic Arrhythmias • Is there a rhythm disturbance that correlates with the patient’s symptoms? • How frequently do the symptoms occur? • Is the patient able to push a trigger with the symptom onset? • Holter 24 hour monitor • Continuous monitoring • Loop event recorder • Continuous monitoring, but only saved with patient trigger • Saves preceding several seconds of rhythm • Post-symptom event recorder • No preceding rhythm (may miss the arrhythmia)

  6. Question 3. • Answer: A. Current smoking

  7. Understand the 9 risk factors for CAD and their degree of importance according to INTERHEART study RISK FACTOR • Dyslipidemia • Tobacco smoking • Psychosocial Stress • Diabetes mellitus • Hypertension • Abdominal obesity • Moderate alcohol intake • Exercise • Vegetables/fruits daily • All risk factors ORAR (%) • 3.25 49.2 • 2.87 35.7 • 2.67 32.5 • 2.37 9.9 • 1.91 17.9 • 1.62 20.1 • 0.91 6.7 • 0.86 12.2 • 0.70 13.7 • 129.20 90.4

  8. Question 4. • Answer: B; Atorvastatin and epifibatide

  9. Initiate medical therapy in a high-risk patient with a non-ST elevation MI EARLY INVASIVE STRATEGY CONSERVATIVE STRATEGY Low Risk TIMI score (0-2) Physician or patient preference in absence of high risk features • Elevated biomarkers • New ST depression • High risk TIMI score (≥3) • Signs of heart failure • Hemodynamic instability • PCI within 6 months • Prior CABG • Continued angina despite aggressive medical therapy • Reduced LV function (EF <40%)

  10. Question 5. • Answer: C; Start metoprololsuccinate Chronic Heart Failure: Contemporary Diagnosis and Management; Gutam V. Ramani, et al: Mayo Clinic Proceedings; February 2010;85(2):180-195

  11. Know the appropriate treatment for systolic heart failure

  12. Question 6. • Answer: A; Candesartan

  13. Understand the significance of diastolic heart failure Definition: • Classic signs and symptoms of heart failure • Preserved LV EF • Invasive or imaging-based evidence of abnormal diastolic function Epidemiology: • 50% to 66% of patients with heart failure over 70 years of age Pathophysiology of Remodeling: • Near-normal end diastolic volumes • Increased wall thickness • Increased ratio of wall thickness to chamber diameter Management: • Treat blood pressure ARB (CHARM trial) decreased hospitalizations but not mortality • Rate/rhythm control in AF • Diuretics • Revascularize if indicated

  14. Question 7. • Answer: D; Placement of implantable cardioverter-defibrillator

  15. Know the risk factors for sudden death in patients with HOCM RISK FACTORS for SCD in HOCM • *Cardiac arrest • *Spontaneous sustained ventricular tachycardia • *Family history of sudden death age < 40 • Unexplained syncope • LV diastolic wall thickness > or = 30 mm • Blunted increase (< 20 mm Hg) or decrease in systolic BP with exercise • Nonsustained VT • Heart failure that has progressed to dilated cardiomyopathy * These patients should be given an AICD for prevention of sudden cardiac death This patient also needs a surgical myotomy procedure…

  16. Question 8. • Answer: D; Phenylephrine

  17. Diagnose and Manage a Patient with HOCM Dynamic outlet obstruction WORSENED by (murmur is louder): • Decreased preload • Lasix, nitroglycerin • Increased contractility • Digoxin, dobutamine • Decreased afterload • Sodium nitroprusside, ACEI, hydralazine, milrinone Medications that are helpful in HOCM: Fluids B-blockers Phenylephrine MANEUVERS: • Decrease preload: • Valsalva • Increase preload: • Squat • Increaseafterload: • Isometric hand grip

  18. Question 9. • Answer: A; Atrial tachycardia

  19. Diagnose an acute supraventricular tachycardia ATRIAL TISSUE ONLY • Multifocal atrial tachycardia • Variable P-wave morphology and variable PP and PR interval • COPD • Automatic Ectopic Atrial Tachycardia • Usually abrupt onset and termination • May be hard to distinguish from sinus tachycardia • Dig toxicity and hypokalemia • Atrial flutter • re-entry within the atrium • Atrial fibrillation • age, HTN, atrial enlargement, thyrotoxicosis AV JUNCTION INVOLVED • Paroxysmal Supraventricular Tachycardia • Re-entry within the AV node • TERMINATES 95% of the time with appropriate use of adenosine • Junctional Tachycardia • Increased automaticity within the lower part of the AV node (N-H region) • Dig toxicity and severe CHF • May terminate with adenosine

  20. Question 10. • Answer: C; Cardioversion

  21. Patients with atrial fibrillation who are hemodynamically unstable should undergo immediate cardioversion

  22. Question 11. • Answer: E; No bridging agent is needed Perioperative Management of Warfarin and Antiplatelet Therapy; Amir K. Jaffer; Cleveland Clinic Journal of Medicine; 2009 (76 Supplement 4) S37-44

  23. Question 12. • Answer: A; Postpone surgery for 6 months Perioperative Management of Warfarin and Antiplatelet Therapy; Amir K. Jaffer; Cleveland Clinic Journal of Medicine; 2009 (76 Supplement 4) S37-44

  24. ACC/AHA Updated 2007 Guidelines:Perioperative Care for Noncardiac Surgery • BARE METAL STENT • WAIT 6 weeks (3 months) for non-urgent, elective surgery • URGENT surgery within first 6 weeks requires dual antiplatelet therapy • DRUG-ELUTING STENT • WAIT one year for non-urgent, elective surgery • URGENT surgery within 6 months requires dual antiplatelet therapy • URGENT surgery after 6 months must continue aspirin (81 mg/day), restart the clopidogrel after 5 days with 300 mg loading dose

  25. Question 13. • Answer : C; Surgical valve replacement Aortic Stenosis: Who should undergo surgery, transcatheter valve replacement? Cleveland Clinic Journal of Medicine Volume 79, No. 7, July 2012 (487-497)

  26. Severe aortic stenosis with symptoms requires surgery

  27. Question 14. • Answer: B; IV sodium nitroprusside

  28. Acute, severe mitral regurgitation is a surgical problem Etiologies of acute MR • Acute MI (papillary dysfunction) • Post-MI (papillary necrosis) • Ruptured chord (chronic MVP) • Infectious Endocarditis Pathophysiology Left ventricle unloads favorably toward path with lowest resisistance: aorta-forward left atrium-backward Management LOWER the systemic blood pressure to favor forward flow: sodium nitroprusside DIURESE TO reduce pulmonary edema SURGERY to REPLACE the VALVE

  29. Question 15. • Answer: C; Follow up ultrasound in 6 to 12 months

  30. Manage asymptomatic abdominal aortic aneurysm found on routine screening Who gets screened for AAA? What to do with the results? NO REPEAT SCREEN No aneurysm REPEAT SCREEN IN 6-12 MONTHS Aneurysm 3-5.5 cm diameter REPAIR: >5.5 cm on presentation Rapidly expanding with surveillance imaging (5 mm in 6 months or 10 mm in one year) Coexisting PAD or peripheral artery aneurysm • USPSTF: • Men 65-75 who have ever smoked one time U/S • No screening in women  • ACC/AHA 2005: • Men 60 or older with family hx of AAA in parent or sibling • Men 65-75 who have ever smoked • Medicare coverage: • Men 65-75 who have smoked at least 100 cigarettes in their lifetime • Males or females with family hx of AAA

  31. Question 16. • Answer: D; Intravenous B-blockade followed by IV sodium nitroprusside

  32. Anatomy of the Aorta

  33. Treat a descending aortic intramural hematoma in a lesion of the descending aorta (type B)

  34. Aortic Dissection versus Aortic Intramural Hematoma Dissection Intramural hematoma • Entrance tear and exit tear from the intima forming a channel inside the media of the aorta with a flap • More commonly type A (Ascending and Arch) • Better prognosis with surgical treatment • Rupture of vasovasorum feeding the aortic media to create a hematoma within the medial layer with an intact intima • More commonly type B (Below LSCA) • Does better with medical treatment • B-blocker + sodium nitroprusside

  35. Question 17. • Answer: C; IV amiodarone

  36. Manage a patient with a hemodynamically stable wide-complex tachycardia Differential Diagnosis of Monomorphic Wide Complex Tachycardia: • Ventricular Tachycardia (especially if known CAD or cardiomyopathy) • Supraventricular Tachycardia with aberrency • AntidromicAtrioventricular Reciprocating Tachycardia(Pre-excitiation) VT Pearls: • Stable hemodynamics does NOT rule OUT VT • AV dissociation confirms the diagnosis of VT • Cannon A Waves • Variable S1 indicate atrium contracting against a closed tricuspid valve • Treatment of choice should be amiodarone, procainamide, or sotalol

  37. Question 18. • Answer: D; Haloperidol

  38. Manage the risk for torsades de pointes in the hospital setting Risk factors for Torsades de Pointes: • QTc interval > 500 msec or increase by 60 msec or more after initiation of a QTc prolonging medication • Older age • Female sex • Multiple QTc prolonging medications 5. Hypokalemia and hypomagnesemia TREATMENT: Stop the offending medication! www.qtdrugs.org

  39. Question 19. • Answer: C; Three sets of blood cultures

  40. Understand the manifestations of infective endocarditis

  41. MAJOR CRITERIA FOR IE: BLOOD CULTURES: • Typical microorganism for IE from 2 separate blood cultures • Persistently positive blood cultures drawn 12 hours apart, or 3 separate cultures drawn at least 1 hour apart • Single positive culture for coxiellaburnetii, or Ig G titer > 1:800 ENDOCARDIAL INVOLVEMENT: • Positive echocardiographic evidence of IE • New valvular regurgitation

  42. Question 20. • Answer: B; Constrictive pericarditis

  43. Diagnose irradiation-induced constrictive pericarditis Etiologies: • Idiopathic or viral (42-49%) • Post-cardiac surgery (11-37%) • Post-radiation therapy (9-31%) Hodgkins/Breast • Connective Tissue Disease (3-7%) • Post-Infectious (3-6%) TB or purulent • Other (1-10%) Patient symptoms: • Heart failure (67%) • Chest pain (8%) • Abdominal symptoms (7%) • Tamponade (5%) Physical Exam: • Elevated JVP with rapid x and y descent • Kussmal’s sign • Pericardial knock before S3 • Cachexia, edema

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