Cardiology Review

Cardiology Review

June 2, 2008Param Vidwan

22yo women who is 16 weeks pregnant is evaluated for a 2 hour history of severe anterior chest pain radiating to her mid back. She is a tall, thin woman with pectus abnormality of her chest and long, thing fingers. Her pulse is 94/min and regular , and her respiratory rate is 24/min. Her chest wall is diffusely mildly tender to palpation. Her lungs are clear to auscultation. Cardiac auscultation shows a normal S1, a physiologically split S1, and a grade 2/6 diastolic decrescendo murmur at the left sternal border. There is no peripheral edema. Her electrocardiogram shows only nonspecific ST changes. Oxygen saturation by pulse osimetry on room air 99%. Her D-Dimer level is mildly elevated.

Q90: Diagnosis:

Q: Her murmur is due to:Q: Next next step in diagnosis:Q: Management

69yo man is evaluated in the ED for acute onset of substernal chest pain radiating to the left arm. The patient is a former smoker with a history of hypertension.On physical exam, he is diaphoretic, with a blood pressure of 210/95mm Hg in the right arm and 164/56 mm Hg in the left arm, a pulse rate of 90/min and regular, and a respiration rate of 20/min. There is a dullness half way up the right posterior thorax and a 2/6 diastolic murmur at the right upper sternal boarder. ECG shows sinus rhythm with a 2 to 3 mm inferior ST segment elevation.

Q45: What is the next step in management?ASAHeparin gttThrombolytic therapyBeta BlockerACEiIV Hydralazine x 1

49yo male with severe chest pain is seen urgently in the ED. The chest pain, which began abruptly 3 hrs ago, is substernal, sharp in quality, and has been very intense from its onset. He denies prior fever, cough, dyspnea, and hemoptysis. He has a long standing history of hypertension and COPD. His meds include lisinopril and ipratropium inhaler.On physical exam, he is diaphoretic and listless. He complains of chest pain. His temp is 37, HR 126, RR 26. Systelic BP is 88 in right arm and 58 in left arm. Pulses paradox is 16 mmHg. JVD is 12 cm. Lungs are clear. There is no LE edema.Labs show a Hgb of 11, BUN 18, Crt 1.1. CXR shows widened mediastinum and clear lungs.2 liters of normal saline rapid infusion and Dopamine 20 ug/kg/min fail to raise BP.

What is the most likely diagnosis?SepsisBacterial pericarditisAortic DissectionAcute MIPulmonary Embolus

Aortic Dissection

Sanford ClassificationSanford ClassificationType A: Ascending aortaType B: Descending aortaType A are twice as common as Type B and may involve

RCA.

DeBakey ClassificationDeBakey ClassificationI: Ascending AND DescendingII: Ascending aorta aloneIII: Descending aorta alone, just after subclavian artery.

Aortic Dissection

• Ascending aortic dissections are at the greatest risk for complications, so they always require surgery.

• Descending aortic dissection are usually treated medically (persistence of pain means continuing dissection and the need for emergent surgery)

Aortic Dissection

• Risk factors: systemic hypertension, cystic medial necrosis, bicuspid aortic valve, coarctation of the aorta, and 3rd trimester of pregnancy. Aortic dissection is a major cause of death in patients with Marfan Syndrome.

• Diagnosis: CT CT > MRI. Transesophageal echo is accurate for descending thoracic aorta dissection.

A few words about AAA

• Screen all men with history of smoking after the age of 65.

• AAA is CAD risk equivalent• Prophylactic surgery is recommending for: (1)

men with AAA > 5.0cm, (2) women with AAA > 4.5cm, (3) patient with Marfan’s with AAA > 4.5, or (4) rapidly expanding AA (>0.5cm/year) regardless of the size.

• Patient with aneurysm > 45mm should undergo surveillance Q 3 months.

74 year old woman undergoes a routine evaluation. She is a smoker and has hypertension, hypercholesterolemia, and type 2 diabetes. Last year, she had an aysmptomatic 4.4cm infrarenal AAA diagnosed during an ultrasound for suspected gallstones, at which time she was encouraged to stop smoking. She is petite, active, asymptomatic and complaint with her medications which include atenolol, glyburide, metformin, lisinopril, and aspirin.

On physical exam, the blood pressure is 125/78 and the pulse rate is 70/min and regular. The lungs are clear, cardiac examination shows an S4, and abdominal exam shows a nontender abdomen with pulsatile mass. A follow-up ultrasound shows a 5.1 cm aneurysm with thrombus. The patient is again encouraged to stop smoking.

What is the most appropriate next step?Repeat Ultrasound in 6 monthsIncrease dose of atenolol and repeat Ultrasound in 6 monthsElective aneurysm repairStart Warfarin (INR 2-3), repeat ultrasound in 6 months.

66 year old man with history of CAD and HTN is evaluated for abdominal pain, low-grade fever, myalgias, nausea, and generalized weakness. His creatinine level is 6 mg/dl (baseline creatinine is 1.4 mg/dl). Two weeks ago, he was hospitalized for anginal chest pain. Cardiac catherization at that time showed a 30% LAD stenosis and 90% RCA lesion. A right coronary artery stent was placed.On physical exam, temp is 37.8, BP 140/96. On cardiac exam, a right carotid bruit and S4 gallop is present. On pulmonary exam, the lungs are CTAB. There is trace pretibial edema bilaterally, and the distal pulses are not palpable. A netlike violaceous rash is visible over the legs, and the right great toe is cool and cyanotic.Labs: HgB: 8.3, Leukocyte count: 6700 (67% neuts, 22% lymphs, 1% monos, 8% eos, 2% baso). Plt: 434,000.C3: LowC4: NormalUA: 1+ blood, 1+ protein, 3-5 leukocytes, 5-10 erythrocytes.

Diagnosis?Radiocontrast nephropathyPre-renal acute renal failureAcute interstitial nephritisMicroscopid polyangiitisAtheroembolic disease.

Atheroembolic disease: Key points

• Atheroembolic disease can mimic vasculitis• The presence of livedo reticularis (“a netlike

violaceous rash over legs”), Hollenhorts plaque, cyanotic toe, low C3 levels, and peripherial eosinophilia suggests a diagnosis of atheroembolic disease

• This should be suspected in pt with erosive atherosclerosis presenting with acute renal failure

Hollenhorst Plaques

Branch Retinal Artery Occlusion

Neurocardiogenic SyncopeV40: 23-yo female is brought to the emergency department after witnessed

syncope. The patient reports having been at church, where she was standing for approximately 45 min. She noted feeling sweaty and light-headed and “seeing spots.” She was aware of the sensation of her heart beating and then fell to the ground with loss of consciousness. After the fall, according to witnesses, she had a thready pulse and urinary incontinence. She regained consciousness n about 3 minutes. Which of the following aspects of this history is not consistent with neurocardiogenic syncope?

A. Urinary IncontinenceB. Prodrome of seeing spots, diaphoresis, and light-headednessC. PalpitationsD. Thready pulseE. None of the above

Neurocardiogenic syncope• The term includes both vasovagalvasovagal and

vasodepressorvasodepressor syncope. In both cases the patient loses sympathetic tone with subsequent vasodilation. In vasovagal there is resultant bradycardi (due to increased vagal tone)

• In history, look for situational stressorssituational stressors: hot, crowded spaces, stressful environment, long period of standing, hunger, pain.

• ProdromeProdrome: light-headedness, diaphoresis, nausea, weakness, visual changes.

• Incontinence suggests seizure.

Carotid hypersensitivity syncope

• Carotid sinus baroreceptors => bradycardia caused by sinus arrest of AV block, vasodilation, or both.

• Generally, men older than 50• Classically presents with syncope in setting of

shaving, wearing a tight collar, or turning head to one side

• Diagnosis is suggest by carotid sinus massage with prolonged (more than 3 second) asystole.

• V4178yo male presents to the clinic complaining that every time he shaves with a straight razor, he passes out. His symptoms have been occurring for the last 2 months. Occasionally, when he puts on a tight collar, he passes out as well. The LOC is brief, he has no associated prodrome, and he feels well afterwards. His PMHx is notable for hypertension and hypercholesterolemia. His only medication is HCTZ. On physical exam his vital signs are normal, and his cardiac exam I normal with exception of a fourth heart sound. Which of the following is the most appropriate next diagnostic test?

Stress echocardiographyAdenosine thallium scanComputed tomogram of the neckCarotid sinus massageTilt Table Test

Othostatic syncope

• Accounts for 30% of syncope in elderly• #1 cause: dehydration• #2 cause: polypharmacy– Look for AV nodal blockers since they blunt the

normal response of tachycardia when venous returns drops when the patient is transitioning from lying to standing position

– Anticholinergics: diplopia, confusion , disorientation , ataxia, etc.

V-4288yo lady presents to ED with syncope that occurred after she stood up to use the bathroom in the middle of the night. This has happened to her several time over the last month, each time in context of transitioning from a lying to a sitting position. Her PMHx includes HTN, DM Type II, MI, and depression. Her meds include HCTZ, Atenolol, Metformin, ASA, Sertraline, and Simvastatin. On Physical Exam her DBP drops 15 mmHg from supine to standing. Despite adequate volume resuscitation, she remains orthostatic. What should be done next?

Start MineralocorticoidsTilt table testingEchocardiogramDiscontinue metforminDiscontinue Atenolol and sertraline

Know thy murmurs

Valve Defect Murmur Louder with Heart Sounds General Notes

AS SEM at RUSB, diamond shaped

Squatting,Expiration

Absent S2, Parodoxically split S2

Slowed carotid upstroke.Remember 5-3-2 ASH rule

MS Diastolic ruble Same as above S1 enhanced Large a wave, weak y descent

VSD Holosystolic at LLSB

Handgrip Post MI with new murmur

ASD SEM at LSB Fixed split S2.O-Primum: LAD, RBBBO-Secundum: RAD, RBBB

BBB, no prophylaxis Abx for ostium secundum.Look for AV block with primum

V10270 year old male is admitted to the hospital with chest pain for 8 hrs.

Serum studies demonstrate elevation of troponin and CK-MB. ECG demonstrates anterior ST elevation, for which he is given tissue plasminogen activator, heparin, and IV nitroglycerin. His symptoms resolve after treatment. He is started on oral medications and transferred out of the CCU on day #3. On Day #4, he develops severe shortness of breath. BP is 110/70 and pulse is 120. Exam reveals a harsh new Holosystolic murmur at LLSB, which is louder with handgrip. Right heart cath shows step-up in oxygen saturation of blood from RA to RV. The next step in management should be:

1. Emergent cardiac surgery consultation2. IV heparin3. IV heparin and streptokinase4. IV heparin and furosemide5. IV sodium nitroprusside with balloon pump

Post-MI complications

• Papillary muscle rupture. Remember, posteromedial papillary muscle is more commonly involved than anterolateral papillary muscle because of single blood supply from RCA. Classic case: pt is s/p Inferior MI, later becomes hypotensive, has large V waves in pulm capillary wedge tracing, new pansystolic murmur at the apex.

• Pseudoaneurysm and true aneurysms.• Mural thrombi (in anterior and apical STEMI)

Dressler’s Syndrome• Transmural myocardial infarction causes localized

pericardial irritation, and the resultant preicardial friction rub is common.

• Pericaridal effusion is dected in 25% of post MI patients (on echo)

• Most pts do ok, but occationally pain results from inflammatory pericarditis associated with fevers, malaize, leukocytosis, elevated ESR 1 to 2 months after AMI.

• Tx: High-dose ASA. (Corticosteroids and NSAIDs are contraindicated in first month after AMI).