UMDNJ~ SOM SECOND YEAR CARDIOLOGY MODULE FALL SEMESTER

1. UMDNJ~ SOMSECOND YEAR CARDIOLOGY MODULEFALL SEMESTER COURSE REVIEW 2012 John N. Hamaty, DO, FACC, FACOI Course Director

2. Students, included in this review are basic bullet review points for each lecture in your cardiology module. Please be aware your exam questions may include, BUT ARE NOT LIMITED TO the information in this review. Review of all material, PowerPoint presentations, and teaching points discussed during the actual lecture presentation is encouraged advised, and your individual responsibility.

3. Introduction to HemodynamicsJohn N. Hamaty, D.O. • Understand basic physiology and hemodynamics of myocardial depolarization and repolarization • Understand the components of S1, S2, S3 and S4 • Have a maximal understanding of left ventricular and diastolic pressures and their association to left atrial filling • Understand basics of stethoscope hemodynamics

4. POP-QUIZ!! An 82 year old females comes to your office for evaluation. She states she”thinks” she is taking her medications, but isn’t sure which ones they are, or how often she take them. Your blood pressure reading is 200/110mmHg. Which point on this hemodynamic tracing would be effected? A B C D

5. And the answer is…. C When someone gets systemic hypertension, the left ventricular pressure must match systolic pressure; and therefore the curve would markedly elevated. The answer would not be B as that is the mitral and tricuspid valve closure which isn’t effected, and the answer would not be D as this point on the curve would not change. The sound may be accentuated by examination, but the point on the curve would not change.

6. Auscultation Jay Rubenstone,D.O. • Know what the third and fourth heart sounds represent • Know grading of murmur by auscultation • Know what the common systolic and diastolic murmurs represent

7. Valvular Heart Disease Jay Rubenstone,D.O. • Know common etiologies associated with valvular stenosis and regurgitation • Know how to differentiate degree of stenosis by valve area • Know the common clinical signs and symptoms as well as common echocardiographic findings associated with decompensation of aortic stenosis, mitral regurgitation and aortic regurgitation

8. POP-QUIZ!! A 70 year old female is evaluated here for what is determined to be rheumatic mitral stenosis. Her calculated valve area is 1. 5cm, her rhythm is still sinus rhythm. In light of her not yet being a surgical candidate, appropriate therapy took a turn that she made need surgical intervention would be the following: Palliative valvuloplasty Afterload reduction with peripheral vasodilators Chronic anti-biotic therapy for chronic rheumatic fever D. Decrease sodium intake, diuretic therapy, and heart rate control

9. And the answer is…. D Tell me why…

10. Pericarditis, EchocardiographyJerome M. Horwitz, D.O. • Myocarditis presents most likely in the following groups: • Young Males • Pregnant Females • Children (especially neonates) • Immunocompromised (HIV)

11. Pericarditis, EchocardiographyJerome Horwitz,D.O. • Pericarditis in the long term hospitalized patient can be remembered with the TUMOR • T ~ Tumor / trauma • U ~ Uremia • M ~ Medicines / myocardial infarction • O ~ Other infections (TB, bacterial, fungal) • R ~ Rheumatoid / radiation

12. Pericarditis, EchocardiographyJerome M. Horwitz, D.O. • Echodoppler study is safe, reproducible, cost effective and available at almost any hospital

13. POP-QUIZ!! A patient is suspected of having myocarditis and a myocardial biopsy is obtained. It revealed no lymphatic infiltrates and no myocytolysis. The patient has: Active myocarditis Pericarditis The biopsy was negative therefore your initial diagnosis is wrong Non cardiac chest pain and you order a high resolution CT scan.

14. And the answer is…. B The answer is B… Pericarditis. The fact that the biopsy is negative may exclude myocarditis, but would have no effect on your CLINICAL diagnosis of pericarditis

15. Dyslipidemia and the Use of StatinsMario Maiese,D.O. • Patients with Framingham risk score >10 (considered moderate risk with metabolic syndrome and all patients with known vascular disease (CAD,PAD,Carotid,AAA or TIA) or vascular disease equivalents (DM or CKD) are candidates for statin therapy to prevent primary or recurrent CV events per the present guidelines

16. Dyslipidemia and the Use of StatinsMario Maiese,D.O. • Patients with diabetes and/or metabolic syndrome (pre-diabetes) will frequently have triglyceride (TG)/HDL-C axis disorders (high TG and low HDL-C.) In these patients especially and probably all patients, non HDL-C is a better than LDL-C as a surrogate marker of CV risk and is also a better treatment goal. (It is the secondary treatment goal after LDL-C in patients with TG >200 mg/dL per NCEP ATP III.)Non HDL-C, if not already calculated on your lab results, is the total cholesterol (TC) minus the HDL-C. The non HDL-C goal of treatment is 30 mg/dL. The “optional” lower treatment goals for non-HDL-C should be used because of the ever present residual risk and proven benefits of high-dose statins

17. Dyslipidemia and the Use of StatinsMario Maiese,D.O. • Statins are the drug of choice for CV risk reduction. Safety and cost should always be considered in choosing a statin. Considering what we know about the lipophilic and metabolic properties of certain statins (lovastatin and simvastatin) associating them with increased risk and drug interactions, pravastatin can easily and safely be substituted for either without compromising efficacy. Pravastatin 80mg is equivalent in potency to 40mg simvastatin (~40% reduction in LDL-C.) If a more potent statin is needed for lipid lowering (simvastatin 80mg is not an option for new patients) then generic atorvastatin 40mg-80mg , cheaper; or rosuvastatin 20mg-40mg, generic not yet available) would be recommended.

18. POP-QUIZ!!

19. Which of the following are true regarding non HDL-C? It is a better surrogate than LDL-C in abnormalities of the TG/HDL axis? It is usually a better surrogate than LDL-C in patients with type 2 DM and metabolic syndrome Non HDL-C is the TC minus HDL-C In type 2 DM without known CVD the non HDL-C goal would be <130mgdL We should start looking at non-HDL-C probably when TG is >130 mg/dL, even though the guidelines direct us to make that our secondary goal when TG is >200 mg/dL Well? Which statements are true?

20. And the answer is…. All of them!

21. ECG Part I – John N. Hamaty, D.O. Goals and Objectives: • Understand that ECG’s are the gold standard in defining dysrhythmia’s • Understand the basic mechanism of sinus rhythm, along with it’s definition

22. ECG Part II – John N. Hamaty, D.O. • Become familiar with the most common dysrhythmia’s such as atrial fibrillation, atrial flutter, left and right bundle branch blocks • It is important to understand pattern recognition for acute myocardial infarction in the anterior, inferior and lateral distributions

23. POP-QUIZ!! A. Atrialfibrillationwith a controlled ventricular response, t wave inversion laterally consider ischemia B. NSR, t wave inversion laterally, consider ischemia C. NSR, age indeterminate antero lateral myocardial infarction D. NSR, left ventricular hypertrophy with ST/T wave changes

24. And the answer is…. • . D NSR, left ventricular hypertrophy with ST/T wave changes

25. Stress Testing ~ Nuclear and Echo John H. Hamaty, D.O. • Understand indications and contraindications of stress testing • Decide on appropriate patient selection for the appropriate test • Understand pharmacology of Adenosine, Persantine and Dobutamine • Understand basic stress testing protocol

26. Stress Testing ~ Nuclear Cardiology • Understand the indications and contraindications of nuclear stress testing • Understand the pharmacodynamics of thallium and technetium; understand their mechanisms of action and appropriate indications for each agent in determining viability versus myocardiac risk

27. POP-QUIZ!! • A 62 year old executive comes to your office for evaluation prior to beginning an exercise program. He is a distant smoker and has a history of controlled hypertension. He is not having specific angina symptoms but clearly has been extremely sedentary and wants to change his lifestyle. Your physical examination is generally unremarkable; the ECG reveals a normal sinus rhythm with a left bundle branch block. • Which of the following stress testing is most appropriate: • A. Pharmacologic stress testing • B. Routine treadmill stress test • Dobutamine stress echocardiography • Treadmill stress echocardiography

28. And the answer is…. • . A The answer can only be pharmacologic testing for one simple reason…. The patient has an underlying LBBB, which immediately obscures the ecg, therefore treadmill of any kind, or any change in heartrate such as dobutamine could not occur.

29. Hypertension and the Use of AntihypertensivesJoshua Crasner, DO FACC, FACOI • Be familiar with Medications utilized to treat hypertension • Recognize genetic patterns associated with hypertension • Be familiar with diagnosis and risk stratification of your patient based on abnormal patterns as well as available treatments

30. POP-QUIZ!! You are seeing an African-American 50 year old male in the office as a consult pre-operatively. He has never seen a cardiologist before. His BP is 155/98. He has mild pretibial edema. The rest of his physical exam is normal. What is a reasonable starting drug/drugs for him? A. Calcium channel blocker B. Central acting agent such as alpha methyl-dopa C. Diuretic therapy in conjunction with salt restriction D. Nitroglycerin

31. And the answer is…. • . C Diuretic therapy in conjunction with salt restriction Tell me why…..

32. Cardiac Catheterization / Radiology Timothy Morris,D.O. • Be familiar with pharmacological agents most routinely used during PTCA • Be familiar with the indications and contraindications for PTCA • Be familiar with the indications and contraindications for Cardiac Catheterization • Be familiar with common complications of PTCA

33. POP-QUIZ!! A 79 year old female underwent catheterization for an abnormal stress test. As an interventionalist you are always concerned about complications. Which of the following femoral access cath complications carries the highest mortality: A. Hematoma B. Pseudoaneurysm C. Retroperitoneal bleed Pruritic rash after cath

34. And the answer is…. • . C Retroperitoneal Bleed Tell me why…..

35. Acute Myocardial Infarction Willis Godin,D.O. • Be familiar with the medications indicated for the acute management of acute MI • Know medications indicated for long-term management post MI • Be aware of the indications of reperfusion and acute MI (determining the use of thrombolytics versus primary PTCA/Angioplasty) • Know the diagnosis involved with the term Acute Coronary Syndrome (ACS)

36. Complications of Myocardial InfarctionWillis E. Godin, D.O. • Be aware of the various arrhythmias that can present in patients with Acute MI • Be familiar with the common medications used to treat congestive heart failure / left ventricular failure • Know the differences between left ventricular aneurysm versus pseudoaneurysm

37. POP-QUIZ!! Final bloodworkfor your patient with chest pain in the ED reveals elevation of his cardiac enzymes and he is aggressively treated for a NSTEMI (non-ST elevation myocardial infarction). Which of the following can be a cause of NSTEMI: A. Intense arterial spasm B. Coronary artery dissection C. Progressive, severe, flow-limiting atherosclerosis due to lipid, calcium, and thrombus deposition D. Conditions that alter myocardial oxygen demand or supply such as intense emotion, tachycardia, or uncontrolled systemic hypertension

38. And the answer is…. • . All of the above !

39. Congenital Heart Disease John N. Hamaty,D.O. • Understand the timing of myocardial development throughout gestation • Understand the major congenital defects particularly atrial septal defect, it’s multiple forms and timing of abnormality development throughout gestation • Become familiar with the many types of congenital heart disease, particularly in other systemic disease states such as Down’s syndrome

40. Congenital Heart Disease John N. Hamaty,D.O. • Understand the other associated congenital abnormalities that occur with primary defects • Become familiar with coarctation; tetralogy of fallot and patent ductusarteriosis • Have a complete understanding of the pathophysiology of left to right (unidirectional shunts) as well as bidirectional shunt physiology, particularly Eisenmenger’s Syndrome

41. POP-QUIZ!! A 33-year old mentally challenged male was brought to the office by his case worker; they state that when the patient runs, he stops after 30 feet and falls to the ground and grabs his legs in pain. After one to two minutes of rest, he can resume with the same outcome. You are his third doctor. All prior stress echo’s have been normal. You diagnose his problem in less than 1 minute with which of the following findings? A. Pulsusparadoxus B. Markedly diminished pulse in lower extremities compared to upper extremities. C. Blood pressure is greater in left arm compared to right. D. Blood pressure is greater in legs as compared to arms.

42. And the answer is…. • . B Markedly diminished pulses in lower extremities compared to upper extremities.

43. Syncope / Pacemakers & ICD’sYegaRaman,D.O. • Indications for temporary and permanent pacing • Choice of pacing modes • Indications for ICD/Biventricular devices • Etiology and pathogenesis of syncope • Tests to determine the etiology of syncope • Management of the patient presenting with syncope

44. Syncope / Pacemakers & ICD’sYegaRaman,D.O. • In the absence of structural heart disease, neurocardiogenic syncope is the most common cause of syncope. Diagnosis by history and tilt table is often useful. • Unexplained syncope in the presence of significant structural heart disease carries a poor prognosis; may need invasive electrophysiologic testing to look for brady and tacky arrhythmias

45. Syncope / Pacemakers & ICD’sYegaRaman,D.O. • Pacemaker mode selection is influenced by the underlying atrial rhythm. In patients with permanent atrial fibrillation with symptomatic slow ventricular response and normal LV function, a single chamber ventricular pacemaker is indicated • ICD is indicated for secondary and primary prevention of sudden cardiac death in appropriate patients • Primary prevention of SCD: Cardiomyopathy with LVEF ≤CHF NYHA Class II-III narrows QRS • Bi-ventricular ICD (Cardiac Resynchronization Therapy): Cardiomyopathy with LVEF ≤35%, CHF NYHA Class III- ambulatory Class IV, LBBB with QRS ≥120msec.

46. POP-QUIZ!! A 24 year old female presents with recurrent syncope and near syncope. Some of the episodes are preceded by nausea, sweating and diminished peripheral vision. An ECG and 2D echo are normal. What is the next step to establish the diagnosis? A. Cardiac catheterization B. Nuclear stress test C. Invasive electrophysiologic study D. Head up tilt table test

47. And the answer is…. • . D Head’s up! It’s time for tilt table testing

48. Congestive Heart Failure Howard Weingberg,D.O. • Know how to calculate cardiac output • Be familiar with NY Heart Associations classifications of Heart Failure • Be familiar with ACC/AHC Heart failure stages • Be familiar with Frank-Starling curve

49. POP-QUIZ!! Jack Daniels has been a long time alcoholic. He frequent can be found strumming a guitar and drinking a pint of home made bourbon. He usually winds up sleeping on the ground in front of the local tavern. Recently he could not tolerate laying on the ground for more than 15 minutes without having to get up. He is more exhausted and fatigued than ever before, in fact his legs are twice their normal size. When he finally presented to the hospital in congestive heart failure (New York Heart Association Class IV) he needed to be place on a ventilator for a short period of time ( BP: 120/70, heart rate 82bpm). What would you expect his treatment to be and what is he most likely to die from: A. Normal saline and sudden cardiac death B. Diuretic, vasopressin and sudden cardiac death C. Normal saline, aspirin and progressive heart failure D. Diuretic, beta-blocker and progressive heart failure E. Normal saline, Ace inhibitor and sudden cardiac death

50. And the last answer • Of the day is…. Switching to red wine! (In moderation of course!) And… D Diuretic, beta-blocker and progressive heart failure