Transcript Cardiovascular Board Review II

Cardiovascular Board Review II
Sohan Parekh, MD
Department of Emergency Medicine
Mount Sinai School of Medicine
Question 1
Regarding treatment of heart failure in patients
with diastolic rather than systolic dysfunction:
A.
B.
C.
D.
E.
Aggressive therapy with diuretics is more effective
b-Blocking agents might improve cardiac output
Both are associated with impaired cardiac contractility
Most patients with CHF have diastolic dysfunction
Ventricular filling pressures are higher in systolic
dysfunction than in diastolic dysfunction
PEER VII 268
Q1 Answer
Regarding treatment of heart failure in patients
with diastolic rather than systolic dysfunction:
A.
B.
C.
D.
E.
Aggressive therapy with diuretics is more effective
b-Blocking agents might improve cardiac output
Both are associated with impaired cardiac contractility
Most patients with CHF have diastolic dysfunction
Ventricular filling pressures are higher in systolic
dysfunction than in diastolic dysfunction
Heart Failure Syndromes
• Systolic dysfunction
– EF < 40%
– Decreased contractility due to ischemic heart disease
– Intolerant to high afterload
• Diastolic dysfunction
– Preserved contractility, EF normal or increased
– Impaired relaxation and diastolic filling
– Due to long-standing hypertension
– Intolerant to tachycardia which reduces filling time
Heart Failure Syndromes
• Left Heart Failure
– DOE, orthopnea, PND
– Cough with pink, frothy sputum
– Rales on lung exam
– CXR: pulmonary edema, cephalization, Kerley B lines
• Right Heart Failure
– Less common than left heart failure
– Cause include left heart failure, pHTN, PE
– Anasarca, Hepatomegaly, Ascites
Question 2
A 30 yo M with a history of prior episode of
tachycardia presents with palpitations. His
pulse is 170, and blood pressure is 100/50.
The EKG reveals the rhythm depicted in
EKG below.
PEER VII 142
Q2 (continued)
Q2 (continued)
Which of the following treatments would
terminate the tachycardia most rapidly?
A.
B.
C.
D.
E.
Adenosine 6 mg IV rapid bolus
Amiodarone 150 mg IV over 10 minutes
Diltiazem 15 mg IV slow push
Lidocaine 75 mg IV slow push
Procainaminde 1000 mg over 20 minutes
Q2 Answer
Which of the following treatments would
terminate the tachycardia most rapidly?
A.
B.
C.
D.
E.
Adenosine 6 mg IV rapid bolus
Amiodarone 150 mg IV over 10 minutes
Diltiazem 15 mg IV slow push
Lidocaine 75 mg IV slow push
Procainaminde 1000 mg over 20 minutes
Post adenosine
Supraventricular Tachycardia
• Regular rhythm
• Originates above bifurcation of His bundle
• Palpitations, chest pain, syncope, APE
• Treatment approach based on hemodynamic
stability & QRS morphology
– If wide-complex: treat as VT
– If unstable: synchronized cardioversion
Supraventricular Tachycardia
• Stable SVT
– Vagal Manuevers: carotid massage, diving
reflex, Valsalva manuever
– Adenosine 6  12  12 ( 18?)
– Diltiazem, Esmolol, Digoxin
– Amiodarone
• If known SVT with normal lytes and return to
baseline, can be discharged
Question 3
Which of the following statements
comparing dilated cardiomyopathy and
hypertrophic cardiomyopathy is correct?
PEER VII 335
Q3 (continued)
A. Both are improved by digitalis and nitrate
therapy
B. Both involve four-chamber heart enlargement
C. Dilated cardiomyopathy is a more common cause
of sudden death in young patients
D. Dilated cardiomyopathy is associated with
diastolic dysfunction
E. Most cases of hypertrophic cardiomyopathy are
hereditary
Q3 Answer
A. Both are improved by digitalis and nitrate
therapy
B. Both involve four-chamber heart enlargement
C. Dilated cardiomyopathy is a more common cause
of sudden death in young patients
D. Dilated cardiomyopathy is associated with
diastolic dysfunction
E. Most cases of hypertrophic cardiomyopathy are
hereditary
The Cardiomyopathies
• Dilated cardiomyopathy
– 80% idiopathic
– Dilation and hypertrophy of myocardium resulting in
decreased cardiac output
– Pump failure results in CHF, syncope, DOE
– Stagnant blood flow in LV can results in mural thrombi
with resultant embolic complications
– ECG shows LVH; CXR shows cardiomegaly and CHF
– Treatment with diuretics and nitrates acutely
– Long term ACE-I and b-blockers decrease mortality
The Cardiomyopathies
• Hypertropic (aka HCM, HOCM, IHSS)
– 50% of cases are hereditary
– Hypertrophy of the intraventricular septum without
ventricular dilation
– CO is normal, diastolic filling is impaired
– Symptoms: DOE, palpitations, chest pain
– SEM which increases with Valsalva
– ECG shows LVH only 30%; CXR negative
– Outflow obstruction worse with exertion, nitrates, dig
The Cardiomyopathies
• Restrictive
– Decreased diastolic volume of both ventricles
– Uncommon, often idiopathic
– Infiltrative disease
– Symptoms: CHF. Chest pain uncommon
– CXR: CHF without cardiomegaly
– ED treatment is symptomatic for CHF and/or
underlying disease
The Cardiomyopathies
Dilated
Hypertrophic
Restrictive
Cause
80% idiopathic
50% hereditary
Idiopathic and
infiltrative disease
Pathology
4-chamber dilation
Septal hypertrophy
Restricted myocyte
compliance
Symptoms
CHF, chest pain
Syncope,
palpitations, CHF
CHF
Failure
Systolic
Diastolic and
outflow obstruction
Diasolic
Findings
Cardiomegaly
SEM
Non-specific
ED Treatment
Diuretics
No Nitrates or
Digoxin
Diuretics
Question 4
A 51 yo M with a history of HTN and ERSD
presents with chest heaviness and SOB. Vital
signs are blood pressure 95/80, HR 135, RR 18,
and temperature 36.7oC. Exam reveals JVD,
bibasilar inspiratory crackles, distant heart sounds,
and pitting peripheral edema. CXR demonstrates
cardiomegaly with mild bilateral pulmonary
vascular congestion. The rhythm strip is shown
below.
PEER VII 38
Q4 (continued)
Which of the following is the most appropriate therapy?
Q4 (continued)
A. Blood cultures x 2, broad-spectrum antibiotics, and
dopamine infusion at 10 units/kg/min
B. Calcium gluconate IV, insulin 10 units IV, detrose
50 g IV, and arrange for emergent dialysis
C. Diltiazem 20 mg IV bolus, followed by drip at 5
mg/hr
D. Heparin 5000 units IV bolus, followed by
synchronous cardioversion at 75J
E. Normal saline 500 mL IV bolus, and emergent
pericardiocentesis
Q4 Answer
A. Blood cultures x 2, broad-spectrum antibiotics, and
dopamine infusion at 10 units/kg/min
B. Calcium gluconate IV, insulin 10 units IV, detrose
50 g IV, and arrange for emergent dialysis
C. Diltiazem 20 mg IV bolus, followed by drip at 5
mg/hr
D. Heparin 5000 units IV bolus, followed by
synchronous cardioversion at 75J
E. Normal saline 500 mL IV bolus, and emergent
pericardiocentesis
Cardiac Tamponade
• Pericardial effusion compressing RV causing
impaired filling and decreased cardiac output
• Effusion can be medical or traumatic
– Medical: usually chronic and large volume
– Traumatic: small volume (< 100 cc)
• Causes: uremia, cancer, infectious, SLE
Cardiac Tamponade
• Findings
– Beck’s triad
• Hypotension
• Distended neck veins
• Muffled heart tones
– Narrow pulse pressure
– Pulsus Parodoxus
• EKG: low voltage, electrical alternans (20 %)
Cardiac Tamponade
• CXR: +/- enlarged cardiac silhouette
(“water-bottle”)
• Treatment
– IVF trial
– Pericardiocentesis
Question 5
Which of the following statements regarding
cocaine-associated chest pain is correct?
A.
B.
C.
D.
E.
Cardiac markers are often unreliable in patient with cocaineassociated MI
Aspirin and b-blockers are indicated
A minority of patients with cocaine-associated MI have evidence
of underlying coronary artery disease
Palpitations and tachycardia are the most commonly associated
symptoms
The average time from cocaine use to the presentation of the
patient in the ED is 2 hours
PEER VII 381
Q5 Answer
Which of the following statements regarding
cocaine-associated chest pain is correct?
A.
B.
C.
D.
E.
Cardiac markers are often unreliable in patient with cocaineassociated MI
Aspirin and b-blockers are indicated
A minority of patients with cocaine-associated MI have evidence
of underlying coronary artery disease
Palpitations and tachycardia are the most commonly associated
symptoms
The average time from cocaine use to the presentation of the
patient in the ED is 2 hours
Cocaine Chest Pain
• Causes arterial vasoconstriction, sympathetic
surge, and increased platelet aggregation
• Greatest risk from cocaine use is in the first hour
• Patients present with chest pain, tachycardia, HTN
• Workup: EKG, serial cardiac enzymes
Cocaine Chest Pain
• Treatment
–
–
–
–
Benzodiazepines are the mainstay of treatment
ASA can be given
Chest pain should be controlled with NTG
Blood pressure control can be achieved with
direct a-blockade or Ca-channel blocker
– b-blockers absolutely contraindicated
Cocaine Chest Pain
• Dispo
– If they make enzymes, admit
– If older with other risk factors, consider
stress
– If young, discharge with Rx for cocaine
and metoprolol
Question 6
In the treatment of hyperkalemia-induced cardiac
arrest, which of the following treatment
modalitites provides the most rapid reduction in
serum potassium levels?
A.
B.
C.
D.
E.
Calcium gluconate
Insulin
Magnesium sulfate
Sodium bicarbonate
Sodium polystyrene sulfonate
PEER VII 143
Q6 Answer
In the treatment of hyperkalemia-induced cardiac
arrest, which of the following treatment
modalitites provides the most rapid reduction in
serum potassium levels?
A.
B.
C.
D.
E.
Calcium gluconate
Insulin
Magnesium sulfate
Sodium bicarbonate
Sodium polystyrene sulfonate
Hyperkalemia
• EKG changes
–
–
–
–
Peaked T waves
PR prolongation
QRS prolongation, P wave flattening
Loss of P wave, QRS prolongation to sine wave
Webster, et al. Recognising signs of danger. Emerg. Med. J., Jan 2002; 19: 74 – 77.
Hyperkalemia
http://sprojects.mmi.mcgill.ca/heart/ecgk1.html
http://urbanhealth.udmercy.edu/ekg/pdf/hyperkalemia.pdf
Hyperkalemia
• Treatment
–
–
–
–
–
–
Calcium chloride or gluconate
Dextrose + Insulin (onset: 20 min, duration: 1 hr)
Bicarbonate (onset: 10 min, duration: 2 hr)
Lasix
Albuterol
Kayexalate (onset: 2 hr)
Question 7
Which of the following is true concerning
the rhythm in the EKG below?
PEER V
Q7 (continued)
A. Is a benign rhythm with low mortality
B. Overdrive pacing is an effective treatment
C. Occurs in patients with shortened QT
interval
D. Responds to IV calcium
E. Procainamide is first-line therapy
Q7 Answer
A. Is a benign rhythm with low mortality
B. Overdrive pacing is an effective treatment
C. Occurs in patients with shortened QT
interval
D. Responds to IV calcium
E. Procainamide is first-line therapy
Torsades de Pointes
• Polymorphic V-tach
• Can degenerate into Vfib
• Underlying long-QT (QTc > 460 ms)
– Drug-induced (Haldol, TCAs, procainamide)
– Congenital prolonged QT syndrome
• Treatment
– Magnesium IV
– Overdrive pacing
– Cardioversion if unstable
Question 8
Which of the following statements regarding
posterior wall infarction is correct?
A.
B.
C.
D.
E.
Associated with ST-segment depression in V1
ECG shows an inverted T wave in V1
ECG shows large S waves in V1
Occurs in 5% of all acute MIs
Results from occlusion of the LAD
PEER VII 249
Q8 Answer
Which of the following statements regarding
posterior wall infarction is correct?
A.
B.
C.
D.
E.
Associated with ST-segment depression in V1
ECG shows an inverted T wave in V1
ECG shows large S waves in V1
Occurs in 5% of all acute MIs
Results from occlusion of the LAD
STEMI
• Complete occlusion of coronary artery
• ECG with characteristic ST elevations
• ASA +/- b-blocker
• PCI vs Thrombolytics
STEMI
• Posterior Wall MI
– ST depression, R:S ratio > 1 in V1 to V2
http://emj.bmj.com/cgi/content/abstract/19/2/129?ck=nck
STEMI
• Anterior Wall MI
– ST elevations in V2-V4
– Reciprocal ST depressions in II, III, aVF
http://urbanhealth.udmercy.edu/ekg/pdf/acuteAnterWallMI.pdf
STEMI
• Inferior Wall MI
– ST elevations in II, III, aVF
– Must obtain Right-sided EKG
http://www.lf2.cuni.cz/Projekty/interna/heart_sounds/ekg4/ekg12.jpg
STEMI
• Lateral Wall MI
– ST elevations in I, aVL, V5, V6
http://sprojects.mmi.mcgill.ca/heart/ecg9805316.html
Question 9
Which of the following is most commonly seen in
infants with congestive heart failure?
A.
B.
C.
D.
E.
Bilateral pedal edema
Bounding femoral pulses
Excessive weight gain
Jugular venous distention
Sweating with eating
PEER VII 376
Q9 Answer
Which of the following is most commonly seen in
infants with congestive heart failure?
A.
B.
C.
D.
E.
Bilateral pedal edema
Bounding femoral pulses
Excessive weight gain
Jugular venous distention
Sweating with eating
Infant CHF
• CHF results from left-to-right shunting
– VSD
– PDA
– Coarctation of the Aorta
• Symptoms
– Poor feeding with sweating during feeds
– Poor growth and weight gain
– Weak cry; Coughing and wheezing
Infant CHF
• Findings
– Weak peripheral pulses
– Rales
• EKG: possible SVT, otherwise non-specific
• CXR
– Cloudy lung files
– Cardiomegaly
Question 10
A 45 yo F s/p heart transplant five years ago,
presents to the ED with a 2d of SOB, and nonproductive cough. She is on immunosuppressant
therapy. VS include BP 98/60, HR 130, RR 22, T
37.9 0C, and SaO2 95%. The physical exam is
unremarkable except for scattered basilar rales.
CXR shows cephalization, interstitial infiltrates, a
slightly enlarged heart, and no effusions. EKG
shows sinus tachycardia.
Q10 (continued)
Which study is indicated next, as part of an
appropriate ED evaluation of this patient?
A.
B.
C.
D.
E.
Blood cultures, then start empiric antibiotics
V/Q Scan
Serum cardiac markers
Cardiac MRI
TEE
Q10 Answer
Which study is indicated next, as part of an
appropriate ED evaluation of this patient?
A.
B.
C.
D.
E.
Blood cultures, then start empiric antibiotics
V/Q Scan
Serum cardiac markers
Cardiac MRI
TEE
Heart Transplant
• Post-transplant physiology
– Heart is denervated
– Both recipient and donor sinus nodes are functional
thus 2 sets of P waves
Circulation. 2007 Jan 23;115(3):e41-2
Heart Transplant
• Ischemia of graft difficult to detect
– Patients with CHF, SOB must have serial CE
• Rejection
– Mostly asymptomatic but can have dysrhythmia
– Dose with steroids
• Dysrhythmias
– Bradycardia: isoproterenol (atropine doesn’t work)
– Trachycardia: Standard resuscitation measures
Question 11
What is the most effective medication to lower
blood pressure in a patient with an acute aortic
dissection?
A. Fentanyl
B. Labetalol
C. Metoprolol
D. Nitroglycerin
E. Sodium Nitroprusside
PEER VII Q331
Q11 Answer
What is the most effective medication to lower
blood pressure in a patient with an acute aortic
dissection?
A. Fentanyl
B. Labetalol
C. Metoprolol
D. Nitroglycerin
E. Sodium Nitroprusside
Aortic Dissection
• Violation of intima of aorta resulting in false lumen
• Bimodal distribution
– Young patients with connective tissue disease
– Older patients with hypertension
• Clinical presentation
– Abrupt onset of tearing chest pain or back pain
– Neurologic symptoms are common
Aortic Dissection
• Diagnosis
– CXR: Abnomal in 90% of cases
• Wide mediastinum
• Abnormal aortic contour
• Pleural effusion
– CT-A with IV contrast or aortogram if stable for
transport
– Bedside TEE
Aortic Dissection
• Disposition depends on type
– Type A (ascending): surgery
– Type B (descending): medical mangement
• Treatment
– Must control the shear force on the intimal flap
– b-blocker to decrease pulse
– Anti-hypertensive to decrease BP
• Sodium nitroprusside, fenoldopam, nicardipine
Question 12
A 74 yo F presents by ambulance after she passed
our at church. She is awake and alert but says she
feels dizzy. VS include BP 80/50, HR 41, and
temperature 36.8oC, O2 sat 99% on 3L. Cardiac
monitoring reveals the rhythm depicted below.
PEER VII Q331
Q12 (continued)
Administration of atropine 1 mg IV has no effect
on her blood pressure or heart rate. The next step
should be:
A.
B.
C.
D.
E.
Dopamine infusion at 20 mcg/kg/min
Epinephrine 1 mg IV slow push
Stat cardiology consultation
Transcutaneous cardiac pacing
Transvenous cardiac pacing
Q12 Answer
Administration of atropine 1 mg IV has no effect
on her blood pressure or heart rate. The next step
should be:
A.
B.
C.
D.
E.
Dopamine infusion at 20 mcg/kg/min
Epinephrine 1 mg IV slow push
Stat cardiology consultation
Transcutaneous cardiac pacing
Transvenous cardiac pacing
AV Nodal Blocks
• Caused by conduction delay in AV node
• First-Degree
– PR interval > 0.2s (200ms)
– All P waves followed by QRS
– No intervention required
http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf
AV Nodal Blocks
• Second-Degree Mobitz I (Wenckebach)
– Progressive lengthening of PR interval
followed by dropped beat
– Seen in MI, digoxin toxicity, myocarditis, CAD
– Stable rhythm
http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf
AV Nodal Blocks
• Second-Degree Mobitz Type II
– Fixed-length PR interval with one or more nonconducted beats
– Signifies major damage to conduction system
– Unstable: Requires permanent pacemaker
AV Nodal Blocks
• Third-Degree (Complete) Heart Block
– No P waves are conducted through AV node
– Junctional or Ventricular escape paces the heart
– Unstable: Requires permanent pacemaker
http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf
Question 13
A 28 yo M presents with a laceration to the
left forearm. The patient is in good health
and has no other complaints. At triage the
patient's blood pressure was noted to be
155/94 mmHg; the remainder of his vital
signs are normal. Following repair of the
laceration, the patient's blood pressure is
rechecked and is unchanged.
Q13 (continued)
What is the best approach to this patient's
elevated blood pressure?
A. Administer labetalol or nifedipine with observation
until SBP is < 140
B. Evaluate for end-organ damage with CXR, ECG,
electrolytes, BUN/Cr and UA
C. Instruct the patient to follow-up with his private
physician within two months for recheck
D. No further management required
E. Admit for blood pressure control and workup
Q13 Answer
What is the best approach to this patient's
elevated blood pressure?
A. Administer labetalol or nifedipine with observation
until SBP is < 140
B. Evaluate for end-organ damage with CXR, ECG,
electrolytes, BUN/Cr and UA
C. Instruct the patient to follow-up with his private
physician within two months for recheck
D. No further management required
E. Admit for blood pressure control and workup
Hypertension
• Classifications
– Emergency: Elevated blood pressure with
associated end-organ dysfunction
– Urgency: Elevated blood pressure with risk of
imminent target organ dysfunction
– Essential hypertension: SPB > 140 or DBP >90
Hypertension
• Only HTN emergencies require immediate treatment
– Labetalol
– Nitroprusside
– Fenoldopam
– Nicardipine
• For HTN urgencies, goal is reduction of blood pressure in
the next 24-48 hours
• For non-urgent blood pressure elevation, refer for timely
follow up
Question 14
A 7 wk old full-term M is brought in 45
minutes after having a 60-second episode of
unresponsiveness and cyanosis. He
remained pale and limp for 20 minutes and
refused to feed. Cardiac exam reveals a
pulse of 160, a harsh pansystolic ejection
murmur and the LSB, and a single second
heart sound. O2 sat is 84%.
PEER VI
Q14 (continued)
What is the most likely diagnosis?
A.
B.
C.
D.
E.
Coarctation of the Aorta
Hypoplastic left heart syndrome
Patent ductus arteriosus
Tetrology of Fallot
Transposition of the great vessels
Q14 (continued)
What is the most likely diagnosis?
A.
B.
C.
D.
E.
Coarctation of the Aorta
Hypoplastic left heart syndrome
Patent ductus arteriosus
Tetrology of Fallot
Transposition of the great vessels
Cyanotic Congenital Disease
• Due to anatomic shunt with mixing of oxygenated
and deoxygenated blood
• The 5 Ts
– Tetrology of Fallot
– Truncus Ateriosus
– Transposition of the Great Arerties
– Tricuspid Atresia
– Total Anomalous Venous Return
Cyanotic Congenital Disease
• Tetrology of Fallot
– VSD, overriding aorta, RV obstruction, RVH
– Tet spells: episodic SOB triggered by crying, eating, or
playing
– Tachypnea  cyanosis  seizures shock
– O2, Position in knee-chest position
• For severe shock within the first 2 weeks of life, possible
closure of PDA
– Prostaglandin E1
Question 15
Concerning the treatment of acute
decompensated heart failure with nesiritide,
which of the new following statements is
most accurate?
PEER VII Q379
Q15 (continued)
A. In controlled trials, nesiritide administration resulted in
better hemodynamic improvements than placebo
B. Nesiritide does not affect renal function in patients with
acutely decompensated heart failure
C. Nesiritide has demonstrated clear superiority to
conventional vasodilator and diuretic based therapy
D. The hemodynamic effects of nesiritide include
vasoconstriction of the veins and arteries, including the
coronary arteries
E. The use of nesiritide is clearly associated with an
increased death rate at 30 days
Q15 (continued)
A. In controlled trials, nesiritide administration resulted in
better hemodynamic improvements than placebo
B. Nesiritide does not affect renal function in patients with
acutely decompensated heart failure
C. Nesiritide has demonstrated clear superiority to
conventional vasodilator and diuretic based therapy
D. The hemodynamic effects of nesiritide include
vasoconstriction of the veins and arteries, including the
coronary arteries
E. The use of nesiritide is clearly associated with an
increased death rate at 30 days
CHF and Cardiogenic Shock
• Acute pulmonary edema
– Oxygen
– Nitro (SL and IV)
– Non-invasive ventilation
• CHF
– Diuretics
– Afterload reduction (blood pressure control)
CHF and Cardiogenic Shock
• Nesiritide
– Endogenous BNP counteracting renin system
– Dilation of arterial and venous systems with
increase in SV and CO versus placebo
– Increased mortality and worsening renal failure
– Don’t use this in the ED
CHF and Cardiogenic Shock
• Cardiogenic shock
– Pump failure resulting in inadequate tissue
perfusion
– Most often secondary of massive acute MI
– Also consider acute valvular disease or severe
decompensated heart failure
– Evidence of volume overload with poor
perfusion (hypotension, cool, mottled skin)
– Treatment focused on correcting poor perfusion
CHF and Cardiogenic Shock
• Cardiogenic shock treatment
–
–
–
–
–
Fluid challenge if no pulmonary edema
Vasopressors: Dopamine or norepinephrine
Inotropy: Dobutamine
Phosphdiesterase inhibitors: Milrinone
Find / steal / create a CCU bed immediately