Internal Medicine Board Review- Cardiology

1. Internal Medicine Board Review- Cardiology June 16, 2010

2. Cardiology for the IM Boards • Examiners want to assess your ability to make decisions that are pragmatic and not beyond your training level • Avoid unnecessary admissions and invasive tests in patients with no or minimal symptoms • Make important diagnoses in patients with concerning presentations • Provide life-prolonging therapies and recognize contraindications to these therapies

3. ACS therapies: ASA, BB, ACE-I, Heparin, 2b/3a, Lytics Stable CAD therapies - ACE-I, Statins, ASA, BB Congenital Heart Disease Diagnoses ASD, VSD, Bicuspid AV Rare But Deadly Cardiac Conditions - Brugada Syndrome, HCM, Long QT syndrome, WPW Outline of High Yield Areas Hypertension therapies: • DM, stable CAD CHF therapies • ACE-I, BB, Hydralazine/Nitrates, ARB, Aldosterone blockade • Hyperkalemia from use of multiple agents, etc. • ICD and BiV basics Heart Disease in Pregnancy • High risk vs. low risk lesions • Hemodynamic changes are common Infective Endocarditis • Diagnostic criteria, typical organisms • Low vs. high risk features • Indications for surgery consultation Valvular Heart Disease • Aortic stenosis • Mitral regurgitation • AI with bicsuspid AV • MS with history of rheumatic fever

4. Evaluation of Sinus Tachycardia • NEVER admit or perform invasive evaluation on asymptomatic patients • Evaluate cheap, easy diagnoses first in asymptomatic patients- anemia, thyroid, infection, drug use, leukemia • For patients with symptoms, evaluate life-threatening causes first- PE, sepsis, acute GI bleeding

5. Acute Coronary Syndromes • First line, evidence based therapies: ASA 325 mg x1, heparin/lovenox if no evidence of dissection or bleeding • Early notification for primary PCI for STEMI, or TPA if <90 minutes from first medical contact to device activation • Plavix and/or 2b3a inhibitors may be too complex for boards, generally indicated in patients with high TIMI risk (> 2 TIMI RF)

6. TIMI Risk Score • Age>65 • Known stenosis >50% • Chronic ASA use • Elevated cardiac enzymes • Chest pain>1 episode in last 4 hours • >2 RF for CAD • ST depression >/= 0.5 mm on ECG 14 day risk of recurrent events from 5 >>>43 %

7. B-blockers for acute MI • Not as important as hemodynamic stability • RF for cardiogenic shock- age>70, SBP <120, HR >100 – AVOID BB • Beneficial in patients with severe HTN at presentation • Oral delivery preferred (lower incidence of severe hypotension, shock and heart block)

8. RV infarction • Suspect in the setting of hypotension with inferior MI • R-sided ECG can show STE in V4-V5 • Preload dependent condition- CVP must be increase to allow filling of the pulmonary circulation and provide preload to the LV • Avoid b-blockers and do not use diuretics unless there is clear pulmonary edema

9. Pregnant Patient with Cardiac findings • Most likely this will be benign in a patient without pulmonary edema or hypoxia • Typical changes for pregnancy- decrease in SVR, increase HR, increase in DOE, LE edema, fatigue. Soft systolic murmurs also common • Beware of diastolic murmurs- NEVER normal (Mitral stenosis, AI, VSD)

10. Predictors of poor pregnancy outcome - NYHA III or IV before pregnancy - Saturation <90% on air - Left heart obstruction - Previous cardiac event - Systemic ventricular ejection fraction <40% Cardiac indications for caesarean section: - Aortopathy with root >4 cm - Aortic dissection or aneurysm - Warfarin treatment within two weeks (fetus clears warfarin slowly and may be at risk for cerebral hemorrahage) High risk lesions, advise against pregnancy: - Pulmonary hypertension - Aortopathy with root >4 cm or aneurysm, advise surgery first - Severe aortic stenosis (peak gradient >80 mm Hg or - symptoms), advise surgery first - Systemic ventricular dysfunction NYHA III or IV symptoms

11. Identify Critical Aortic Stenosis • Critical AS should be symptomatic in a functional patients • New onset symptoms associated with poor prognosis in all patients • Surgery prolongs survival • Physical exam for critical AS- absent S2, late peaking SEM, radiation to carotids, pulsus parvus et tardus

12. Aortic Regurgitation • Diastolic murmur over lower sternal borders, usually does not radiate to apex (unless associated with Austin-Flint murmur) • Asymptomatic patients – observe, however severe LV enlargement (>70 mm diastole, 50 mm systole) and reduction in EF is an indication for surgery

13. Treat Symptomatic Mitral Stenosis • Balloon valvuloplasty is associated with significant, prolonged reduction in gradient among patients with rheumatic MS • High risk BMV features include heavy calcification, leaflet thickening, immobility, and involvement of subvalvular apparatus • BMV should only be considered for symptomatic, severe MS (>10 mm mean gradient)

14. Identify Complications of endocarditis • AV block suggests conduction system involvement • Indications for urgent surgery- abcess, CHF, fungal infection • L sided valves are in continuity with each other- often both are involved in severe cases

15. Acute MR • Complication of endocarditis • Treat with IABP placement and surgical consult • Understand murmur of acute vs. chronic mitral regurgitation

16. WPW management • Do nothing in asymptomatic patients • Symptomatic patients should be referred for ablation • WPW with afib- (wide complex) avoid AV nodal blockers- give Procainamide • Incidence of sudden death approximately 0.5%/year

17. VSD • Restrictive VSD associated with shunt <1.5:1 and can be managed conservatively • Larger VSDs are often symptomatic, and if they present in adult life were likely moderately restrictive in childhood • Likely to result in Eisenmenger’s syndrome and severe pulmonary hypertension

18. Eisenmenger’s syndrome • End-stage of congenital heart disease with initial L>R shunt • Persistent increase in pulmomary blood flow results in vasculopathy, increased PVR and eventually R to L shunt with hypoxia • Treatment is heart-lung transplant, and palliative therapies (O2, vasodilators,etc.) • Suspect this in 2nd-3rd decade of life for VSD, 5th-6th decade for ASD

19. Evaluate Subclinical CAD • No evidence that screening for CAD is beneficial • Risk stratify patients with symptoms only • Always aggressively screen for CAD risk factors, and treat when appropriate • Smoking cessation is the most important preventive therapy, followed by statin use, with ASA being least powerful

20. ASA as preventive therapy • Generally, ASA prevents MI in men and stroke in women • No good data for universal primary prevention • Current USPSTF recommendations are for ASA in men 45-79 with at least 1 RF for CAD, for women age 55-79

21. CXR findings • VSD- cardiomegaly with biventricular enlargement and pulmonary vascular engorgement • Aortic coarctation- rib notching • Left atrial enlargement in mitral stenosis

22. Endocarditis Prophylaxis- Class IIa • Valve replacement surgery or valve repair with prosthetic material • Previous episodes of endocarditis • Complex cyanotic congenital heart disease • Heart transplant patients with acquired valvular heart disease

23. DUKE CRITERIA FOR IE DIAGNOSIS • A diagnosis can be reached in any of three ways: two major criteria, one major and three minor criteria, or five minor criteria. • Major criteria include: • Positive blood cultures • 2. Evidence of endocardial involvement with positive echocardiogram defined as • Minor criteria include: • 1. Predisposing factor: known cardiac lesion, recreational drug injection • 2. Fever >38°C • 3. Evidence of embolism: , Janeway lesions, • 4. Immunological problems: glomerulonephritis, Osler's nodes • 5. Positive blood culture (that doesn't meet a major criterion) • 6. Positive echocardiogram (that doesn't meet a major criterion)

24. Perform appropriate cardiac testing in a patient with a cardiac pacemaker • DO NOT put pacemaker dependent patients on a treadmill • Stress test of choice will be adenosine-myocardial perfusion imaging study

25. Diagnose and Manage Aortic Dissection • Acute onset chest pain with radiation to back • Underlying HTN or phenotypic evidence of connective tissue disease • Brachial SBP difference R>L • Treatment with IV B-blocker to decrease DP/DT, urgent surgical consultation for involvement of the ascending aorta • CXR with widened mediastinum • Avoid anticoagulation until imaging is completed • May be associated with pericarditis, neurologic symptoms • AI murmur detectable in 1/3 of all cases • 2:1 male: female • 18% previous cardiac surgery, Bicuspid valve in 10-15%, Marfan syndrome 5-10%,

26. Number needed to treat • Inverse of the absolute reduction in event rates • (18/100) / (12/100) = 6/100 • 100/6 = 16

27. Treat Asymptomatic LV dysfunction • Identify etiology and treat accordingly (i.e. rule out CAD, then search for other causes) • Initiate ACE-I and B-blocker therapies at low doses • ASA only indicated for patients with CAD • Treat all cardiovascular RF and screen with fasting lipids/TSH/HgA1C