Cardiology

Cardiology

Part 1:
ACS
Heart Failure
Pericardial Disease
 ACS
• PE: new MR, S3 or S4 sings of ischemia

• STEMI equivalents:
• new LBB
• or posterior MI (tall R and ST dep in V1-V3)

• Angina equivalents (diabetic W)

• DOE
• Fatigue
• N/V
TIMI scoreà 7 points
TIMI 0-2?

5
 TIMI 0-2?

EKG Stress Test

6
TIMI of 3 or greater

7
TIMI of 3 or greater

Early Angiography
8
TIMI 0-2 stress first, otherwise cath
 Don’t Be Tricked
• What are non-STEMI causes of STE?
– Give me 5…
 Don’t Be Tricked
• Non-STEMI causes of STE
– Acute pericarditis
– LV aneurysm
– Takotsubo’s CM
– Coronary vasospasm
– Normal variant
When do You Choose Thrombolytics?

12
 Thrombolytics
• If PCI not available within X minutes
 Thrombolytics
• If PCI not available within 90 minutes

• Bunch of contraindications, but remember:

• ICH
• recent ischemic stroke (3mo)
• head trauma
• active PUD
• BP 180/110
15
When do you send for CABG in the presence of a
STEMI?

• Give me 4…
When do you send for CABG in the presence
of a STEMI?

• Failure of PCI or fibrinolysis

• Cardiogenic shock
• Lt main or Lt main equivalent dz
• 2-3 ves dz involving LAD AND reduced EF
 Don’t be Tricked
• If can transfer and have PCI done in <90min, choose transfer to
PCI rather than thrombolytic for STEMI

• No thrombolytics in NSTEMI or asx w onset of pain >24hr ago

• Reperfusion arrhythmias after thrombolytics are common and

do NOT require antiarrhythmic therapy

• No spironolactone in acute MI
– Effectiveness not known
– (eplerenon can be used for sev LV dysfunction after MI)
 Signs of a Right Sided/Posterior MI

• Elevated CVP with clear lungs

• Hypotension
• Tachycardia

• Tx: IVFs
• Why get a right-sided EKG?
 RV Infarct: EKG
• The most useful lead is V4R
• place V4 electrode in the 5th right
intercostal space in the midclavicular line

• STE in V4R has a sensitivity of 88%, specificity

of 78% and diagnostic accuracy of 83% in the
diagnosis of RV MI.
 When do you choose an intra-aortic balloon
pump?

• Give me 4…
When to place an intra-aortic balloon pump?

• Cardiogenic shock
• Acute MR or VSD
• Intractable V tach
• Refractory angina

• Severe AR…AVOID IABP.

 Post-MI complications: 2-7 days out
• What will you see with these?

• VSD & Papillary muscle rupture

• LV free wall rupture
 Post-MI complications: 2-7 days out
• VSD & Papillary muscle rupture
– Both cause:
– flash pulm edema
– hypotension
– loud holosystolic mumur and thrill

• LV free wall rupture

– Sudden hypotension or cardiac death assoc w PEA

• Dx: emergency echo

 Who are ICDs indicated in?

• Give me 3…
 Who are ICDs indicated in?
• EF< 30% & at least:

• >40days since MI
• >3months since PCI or CABG
What is associated w increased hospitalizations &
death in post MI patients that we should screen
everyone for?
What is assoc w increased hospitalizations & death
in post MI pts that we should screen for?
 Other causes of CP
• Vasospasm (W w migraines)à tx CCB

• Cocaine (CP after a party)à tx CCB

• Tall thin, AI murmurà dissectionà CT or TEE

• PE

• Tall, thin smokerà PTXà CXR

 Test Yourself
• 56 W, 3hr CP, BP 80/60, HR 120, RR 30
• On exam: +JVD, crackles, S3
• EKG: STE in V2-V6

• What do you want to do next?

 Answer

• STEMI w cardiogenic shock

• Choose cardiac cath & PCI

 Test Yourself
• 58M CP, BP 80/50, HR 54
• On exam: +JVD, but clear lungs, no murmur or
S3
• EKG: STE II, III, aVF
 Answer
• RV MI
• Choose IVFs
• Obtain right-sided EKG for V4R tracing
 Chronic Stable Angina: RF Goals
• HDL?
• A1c?
• BP?
 Chronic Stable Angina: RF Goals
• HDL: <100
• A1c: <7
• BP: <140/90
 Don’t Be Tricked

• No HRT, Vit E, folate or B12 as tx for CAD

• Mod to high risk for CAD?

• Rx ASA
• if h/o GIB, take ASA w PPI
 Choose proper test for those w intermediate
probability of CAD
• Can exercise & norm EKG?

• Abn EKG but can exercise?

• LBBB?

• Unable to exercise?

• V paced?
 Choose proper test for those w intermediate
probability of CAD
• Can exercise & norm EKG? exercise EKG

• Abn EKG but can exercise?

• LBBB?

• Unable to exercise?

• V paced?
 Choose proper test for those w intermediate
probability of CAD
• Can exercise & norm EKG? exercise EKG

• Abn EKG but can exercise? exercise echo or exercise

EKG w myocardial perfusion imaging

• LBBB?

• Unable to exercise?

• V paced?
 Choose proper test for those w intermediate
probability of CAD
• Can exercise & norm EKG? exercise EKG

• Abn EKG but can exercise? exercise echo or exercise

EKG w myocardial perfusion imaging

• LBBB? vasodilator myocardial perfusion imaging

• Unable to exercise?

• V paced?
 Choose proper test for those w intermediate
probability of CAD
• Can exercise & norm EKG? exercise EKG

• Abn EKG but can exercise? exercise echo or exercise

EKG w myocardial perfusion imaging

• LBBB? vasodilator myocardial perfusion imaging

• Unable to exercise? pharm stress myocardial

perfusion or dobutamine echo

• V paced?
 Choose proper test for those w intermediate
probability of CAD
• Can exercise & norm EKG? exercise EKG

• Abn EKG but can exercise? exercise echo or exercise

EKG w myocardial perfusion imaging

• LBBB? vasodilator myocardial perfusion imaging

• Unable to exercise? pharm stress myocardial

perfusion or dobutamine echo

• V paced? pharm stress myocardial perfusion

High pretest probability of CAD coming in with
stable angina?
• Just cath them :)
High pretest probability of CAD coming in with
stable angina?
 Tx stable angina
• Lifestyle modification for all
• Asa, statin, BB
– Goal HR 55-60 so uptitrate BB

• If no response to anti-anginals?
 Tx stable angina
• Lifestyle modification for all
• Asa, statin, BB
– Goal HR 55-60 so uptitrate BB

• Ranolazine if no response to antianginals

– X and X increase levels of ranolazine by 50%, must
reduce ranolazine dose if on these drugs
– All thru p450
 Tx stable angina
• Lifestyle modification for all
• Asa, statin, BB
– Goal HR 55-60 so uptitrate BB

• Ranolazine if no response to antianginals

– Diltiazem and verapamil increase levels of
ranolazine by 50%, must reduce ranolazine dose if
on these drugs
– All thru p450
 When to add an ACEi?

• Give me 4…
 When to add ACEi
• EF <35%
• h/o CAD, stroke, PVD
• DM
• 1 additional CAD RF
 When is PCI or CABG helpful
in chronic
• Give me another 4 baby… stable
angina?
 When is PCI or CABG helpful in chronic stable
angina?

• Angina refractory to med therapy

• High risk criteria on stress
• High risk coronary anatomy
• like Lt main or 3ves dz
• Sig CAD w red EF
 What about CABG in pts w DM?
1. ?
2. ?
3. ?
 What about CABG in pts w DM?
1. Sev Left main dz
2. 3 vessel dz
3. 2 ves dz if one is the LAD & there is red EF
 Don’t Be Tricked
• Don’t select PCI or CABG for stable angina in
absence of high risk features
 Test Yourself
• 69M exertional CP, normal PE & EKG. Father
died of AMI at 61

• What meds do you start?

• Andy further testing?
 Answer
• Rx ASA, SL nitro, BB
• Follow up w exercise stress test
– Intermediate pretest probability bc of gender &
age
– no fam hx of premature CAD, no HTN, DM,
smoking
Done with ACS/Angina!

On To Heart Failure

59
 Heart Failure
• BNP>500 = HF

• BNP<100 excludes HF as cause of acute

dyspnea
 Don’t Be Tricked

• BNP can NOT differentiate systolic from diastolic HF

• What things increase BNP?

• Decrease?
 Don’t Be Tricked

• BNP can NOT differentiate systolic from diastolic HF

• What things increase BNP?

– kidney failure, older age, female sex

• Decrease?
• obesity
 PM & ICDs in HF..when to place
• BiV pacing for:
– NYHA class X, EF<X & QRS >X
– NYHA class X, EF<X & QRS >X

• ICD for:
– Ischemic and nonischemic CM w EF<X%
 PM & ICDs in HF
• BiV pacing for:
– NYHA class III-IV, EF<35%, & QRS >120msec
– NYHA class II, EF<30%, & QRS >150msec

• ICD for:
– Ischemic and nonischemic CM w EF<35%
 Don’t Be Tricked
• Don’t start BB in decompensated CHF

• Generally, continue BB during decompensation if were

previously stable using BB

• Use metoprolol in COPD or asthma

• No NSAIDs or TZDs: worsen HF

• No role of CCB in systolic CHF

• Avoid digoxin in CKD pts or in changing kidney function

 Test Yourself
• 66W w stable HF, now with orthopnea
• on ACEi & furosemide
• BP 140/68, HR 102
• overloaded on exam

• What should you do with her meds?

 Test Yourself
• 66W w stable HF, now with orthopnea
• on ACEi & furosemide
• BP 140/68, HR 102
• overloaded on exam

• What should you do with her meds?

• increase lasix and lisinopril dosages
• add BB when pt is stable
 HF w preserved EF=diastolic
• X medicine
– Reduces hospitalizations in diastolic HF but no
change in mortality

• Tx underlying causes:
– HTN
– tachycardia
 HF w preserved EF=diastolic
• Candesartan
– Reduces hospitalizations in diastolic HF but no
change in mortality

• Tx underlying causes:
– HTN
– tachycardia
 Dilated CM

• Dilation & reduced function of 1 or both

ventricles
• Get HF, arrhythmias, sudden death
• 50% idiopathic

• Tx: Reverse underlying cause then standard HF

med
 Causes of dilated CM
• Give me 4…or more..
 Causes of dilated CM
• Myocarditisàhigh trop
– Multinucleated giant cells on bx = giant cell myocarditis
• Alcohol
• Drug-inducedàcocaine, amphetamines
– Labetolol preferred BB
• Tachycardia-induced
• Arrhythmogenic RV dysplasia
• Takotsubo’s
 Test Yourself
• 35M drinker, heart failure on exam

• Dx: alcoholic cardiomyopahty

• Choose echo & alcohol cessation
 Peripartum CM
• Dx 1mo before or 5mo after delivery
• Avoid ACEi/ARB if still pregnant, deliver early

• Should they have more babies?

 Peripartum CM
• Dx 1mo before or 5mo after delivery
• Avoid ACEi/ARB if still pregnant, deliver early

• Discourage subsequent pregnancies even if EF

recovers
 Hypertrophic CM
• 50% inherited AD

• Tx: avoid strenuous exercise

• BB 1st line
• ACEi only if reduced EF

• All need genetic counseling

• When do you choose surgery or septal ablation?

 Hypertrophic CM
• 50% inherited AD

• Tx: avoid strenuous exercise

• BB 1st line
• ACEi only if reduced EF

• All need genetic counseling

• When do you choose surgery or septal ablation?

• Outflow gradient >50mmHg and symptoms despite max medical
therapy
 EKG in HOCM
• LVH
• LAE
• Deeply inverted symmetric Ts in V3-V6
– Can mimic ischemia
 Don’t Be Tricked
• EP studies NOT useful in predicting risk of
sudden death in HOCM
• ie not the right test answer

• Do NOT Rx digoxin, vasodilators or diuretics

– All increase outflow obstruction
 Test Yourself
• 18yo basketball player collapsed at practice

• Answer: HOCM
– Young person collapses at athletic event
 Restrictive CM
• Abnormally rigid ventricular walls causes DIASTOLIC
DYSFUNCTION without systolic dys
• Most have normal systolic function

• Right sided HF & pulm HTN from pulm venous congestion

• Kussmaul signà engorged jugular veins w inspiration

• Cathàelevated RV & LV diastolic Ps & characteristic “early

ventricular diastolic dip & plateau”
 Causes of Restrictive CM
• Infiltrative dz
– Amyloid, sarcoid, hemochromatosis
• Glycogen storage dz
• Endomyocardial process
– Fibrosis, hypereosinophilic synd, carcinoid,
radiation, anthracycline
• Noninfiltrating dz
– scleroderma
Clues in the history in pt with diastolic dysfunction

• What might you see?

• Amyloidà

• Sarcoidà

• Hemochromatosisà
 Clues in the history in pt with diastolic dysfunction

• Amyloidà neuropathy, proteinuria, HM, periorbital

ecchymosis
– low voltage EKG
– Dx: abd fat pad aspiration

• Sarcoidà hilar LAN, skin, joint, eye lesions

– Usual heart block
– Dx: cardiac MRI with gadolinium

• Hemochromatosisà abn LFTs, OA, DM, ED, HF

– Dx: high ferritin and transferrin saturation
OA in hemachromatosis
2nd & 3rd MCP JOINTS!!!!

87
Amyloid purura (NEJM 2007)
 Don’t Be Tricked

• No endomyocardial biopsy unless hemachromatosis,

sarcoidosis, or amyloidosis is suspected
– Can do cardiac MRI for sarcoid
BB in Restictive CM: Good or Bad?
 BB in Restictive CM
• Watch out!
• Most have conduction abnormalities and need
high HR to maintain CO
 Test Yourself
• 63M DOE/fatigue
• PE: +JVD, prominent jugular a wave, S4, 2/6
holosys murmur at LSB, clear lungs
• enlarged tender liver
• petechiae over face & periorbital ecchymosis
 Answer
Dx: amyloid CM
Notice the noncardiac sx

94
 Done with Heart Failure!
Moving on to pericardial disease &
restrictive CM

95
 Pericardial Tamponade & Constriction
• Dyspnea, fatigue, edema, HM, ascites WITH clear lungs

• PE: JVD, pulsus paradoxus, tachycardia, reduced HSs,

hypotension

• Which patients?
– Cancer
– Recent cardiac sx
– Dissecting aneurysm
– Pericarditis
– Collagen vascular dz
Kussmaul Sign?
 Kussmaul Sign
• paradoxical rise in JVP on inspiration
• or increase in CVP with inspiration
 Tamponade

• No effusion = No tamponade
 Constrictive pericarditis
• Thick fibrotic pericardium that does not allow
ventricular expansion during diastole so get
impaired filling
– Usually result of pericarditis

• Xray: calcified pericardium

• Loud S3 (pericardiac knock) & friction rub

 Chronic constrictive pericarditis
• CO depends on high preload so careful with
diuretics (usually avoid all together)

• Pericardiectomy is most effective treatment

BUT is unnecesary is pts w early dz (NYHA I)
and unwarranted in advanced dz (NYHA IV)
 Don’t Be tricked
• In constrictive pericarditis, echo will show
shifting of ventricular septum to-&-fro during
diastole
– Manifestation of Rt and Lt Ventricles competing
for confined space during filling

– These findings are NOT seen in restrictive CM

 Restrictive CM vs. Constrictive pericarditis
Must be able to differentiate

• Restrictive CM
– S3
– Really high BNP
– EKG: BBB
– Echo: LVH and atrial enlargement on echo

• Constrictive pericarditis
– Pericardial knock
– CXR: calcified pericardium
– Echo: Accentuated drop in peak LV filling during inspiration (pulsus
paradoxus in tamponade)
– Rt heart cath: equalized Lt & Rt diastolic ventricular pressures
(within 5mmHg)
 Test Yourself
• 44W ovarian cancer p/w fatigue, dyspnea,
edema. BP 90/50, HR 130, +20mmHg pulsus
paradoxis
• PE: +JVD that increase w inspiration, reduced HSs

• Dx: acute pericardial tamponade likely from

metastatic dz
• Order echo, give fluids & vasopressors
 Acute Pericarditis
• Acute sharp stabbing pain worse with inspiration &
lying down

• Med history:
– Cancer
– Trauma
– Arthralgia (suggest collagen vasc dz)
– MI
– Thoracic sx
– Hydralazine & minoxidil…WHY?
 Classic PE finding
• 2 or 3 component pericardial friction rub

• EKG: diffuse STE (no reciprocal depressions)

– PR dep in limb leads
– PR elevation in aVR

• If effusion?
• If pulsus paradoxus >10mmHg?
 Classic PE finding
• 2 or 3 component pericardial friction rub

• EKG: diffuse STE (no reciprocal depressions)

– PR dep in limb leads
– PR elevation in aVR

• If effusion? Electrical alterans

• If pulsus paradoxus >10mmHg? Tamponade
 Don’t be tricked
• CEs may be slightly elevated in isolated
pericarditis
 Tx pericarditis
• 1st line: ASA (after MI), NSAIDs, colchicine

• Recurrent pericarditis?
– Choose colchicine + aspirin

• Pericarditis that does not respond to ASA or NSAIDs?

– Choose 2-3d of steroids
• Increases risk of recurrence though 9

• Tamponade or unstable? Emergent pericardiocentesis

– So any question that has pulsus paradoxus >10mmHg, the
answer is emergen pericardiocentesis
 Test Yourself
• 57M 2d CP worse w lying flat. 3 component
friction rub

• Anser: pericarditis
– Look for diffuse STE and PR depr
– IGNORE elevated trop tempting you to answer
“acute MI”
Cardiology

Part 2:
Vavular Dz
Murmurs
 Rheumatic Fever
• Give penicillin to pts with group A strep infections
– Or erythromycin if penicillin allergy

• h/o of RF: longterm ppx penicillin

– Bc recurrent infections are dangerous

• Rheumatic valvular dz:

– Ppx for at least 10yrs after last epi of RF
– Or until age 40
• Whichever is LONGER
 Rheumatic Fever
• Mitral valve: MS & MR
• AV 2nd most common affected valve
 Tx Rheumatic Fever
• Abx required even if throat cx negative for GAS

• ASA drug of choice

– Nonresponse to salicylates makes RF unlikely
 Heart Murmurs General Tips
• Which increase in intensity w inspiration?

• Which increase in intensity w Valsalva or

standing from squatting?

• Which has a click that may move closer to S1

and lengthen w Valsalva?
 Heart Murmurs
• Which increase in intensity w inspiration?
– Right sided
• Which increase in intensity w Valsalva or
standing from squatting?

• Which has a click that may move closer to S1

and lengthen w Valsalva?
 Heart Murmurs
• Which increase in intensity w inspiration?
– Right sided
• Which increase in intensity w Valsalva or
standing from squatting?
– HOCM
• Which has a click that may move closer to S1
and lengthen w Valsalva?
 Heart Murmurs
• Which increase in intensity w inspiration?
– Right sided
• Which increase in intensity w Valsalva or
standing from squatting?
– HOCM
• Which has a click that may move closer to S1
and lengthen w Valsalva?
– MVP
 S2

• Normal: should only hear split S2 w inspiration

• Abn splitting of S2 helps differentiate murmurs

Abn splitting of S2 helps differentiate murmurs

Splitting during inspiration & expiration?

– Things that delay RV ejection:
• PS
• VSD w left to right shunt
• ASD w left to right shunt
• RBBB
Abn splitting of S2 helps differentiate murmurs

Reversed or splitting only w expiration?

– Things that prolong LV ejection:
• AS
• HOCM
• ACS w LV dysfunction
• LBBB
 Innocent Murmurs
• Midsystolic
• Base of heart
• 1-2/6 without radiation
• Associated w normal splitting of S2
 Signs of SERIOUS disease
• S4
• Grade 3/6 or greater
• Any diastolic murmur
• Fixed splitting of S2

• If any of these are in the question or pt has

symptoms or a continuous murmurà answer is
Echo
– Any diastolic murmur gets an echo
 Don’t Be tricked
• An increased P2, S3, early peaking systolic
murmur over LUSB are NORMAL in pregnancy

• Innocent heart murmurs do not require Echos

 Test Yourself
• 19 F, asx, murmur on sports exam.
Nonradiating, 2/6 midsystolic over RUSB,
normal split S2, soft S3

• Dx: innocent murmur, no further work up

 Cheat Sheet for the Non-Cardiologist

• Mr Ass
• Ms Aid

• MR & AS è Systolic murmurs

• MS & AI è Diastolic murmurs

 Aortic Stenosis
• Calcifications or AV sclerosis most common
cause

• Pts w bicuspid valves should be evaluated for

dilation of aortic arch

• SSX: HF, angina, syncope

 Findings of AS
• Midsystolic
• RUSB
• Radiates to carotids
• Pulsus parvus et tardus
– Delayed low amplitude carotid pulse

• CXR: boot shaped heart

• Echo: LAE, LVH, calcified AV

• Severe AS:
– AVA <1cm2
– Mean transvalvular gradient >50mmHG
 Heyde syndrome
• What’s That?
 Heyde syndrome
• Aortic Stenosis + GI Bleed
– Acquired von willebrand dz due to disruption of
VWF through diseased AV
 Don’t be tricked
• Echo significantly underestimated the
transvalvular gradient in pt with AS & low EF

• If the calculated valve area increases with

dobutamine stress, then diagnose
pseudostenosis

• Do NOT select exercise stress test for pts w

symptomatic AS!
 Pseudostenosisà
not on test but will see with your patients

• If you have low EF & mild AS, the echo can give you a
falsely small AVA making the AS appear severe

• This phenomenon is called “pseudostenosis”

– Low force of weak LV is not strong enough to open
even a weakly stenotic valve

• If you give dobuatmineàincrease COàAVA will be

more accurate
 Work up of AS
• Equivocal symptoms: exercise stress test
– If hypotensive during exerciseà immediate
replacement

• Cath for all pts >35 who are going for AVR
– Need to make sure no CAD requiring CABG while
the surgeons are in there
 Serial Echos for AS?***
• Mild AS?

• Moderate AS?

• Asymptomatic w severe AS?

 Take Note
• They love follow-up imaging questions in cards
& pulm (because there are guidelines that no
one knows, so easy to test & hard to get right)
 Serial Echos for AS?
• Mild AS? Every 5 years

• Moderate AS? Every 2 years

• Asymptomatic w severe AS? Every 1 year

 When to send for AVR
• Any age if have symptoms
• Undergoing CABG for CAD
• LV dysfunction
• Hypotension during exercise stress

• Young pts with congenital AS & no AV

calcificationsà can go for percutaneous
valvuloplasty
 Test Yourself
• 71, HF sx, murmur of AS, EF 30%, calcified AV
w mean gradient of 26

• Dx: Severe AS w CM despite low gradient

– Bc of severe LV dysfunction

• Choose cardiac cath and probable valve

replacement
 Aortic Regurgitation
• Classified as Chronic & Acute
 Chronic AR
• Seen w bicuspid AV, marfans, aortic aneurysms

• Sx: angina, orthopnea, DOE

 PE of AR
• Soft S1, soft or absent A1, loud S3

• Diastolic murmur LUSB or RUSB

• Louder when leaning forward or exhaling

 PE of AR
• Wide pulse pressure
• De Musset sign
– bobbing head w heart beat
• Duroziez sign
– systolic M w compression of prox fem A
• Traube sign
– Pistol shot sounds over peripheral arteries
• Corrigan pulse
– Water hammer pulse w abrupt distention & collapse
• Quincke pulse
– Systolic plethora & diastolic blanching in nail beds w nail compressions
 Chronic AR
• EKG: LAD & LVH
• CXR: CM, aortic root dilatation, calcification

• Test for syphilis & get echo

– “Never marry the man with the bobbing
head”…unless he’s super rich…J
 Serial Echos in Chronic AR***
• Echo 2-3mo after initial diagnosis to exclude
rapid progression

• Asx w LV dilatation? Every 6-12mo

• Asx with normal LV? Every 2-3yrs

 When to go for AVR in chronic AR
• Symptomatic (even if EF normal)
• Plan for CABG or other valvular sx
• Progressive LV dilatation
• EF<50%
• Declining exercise performance
 Acute AR
• Aortic dissection, endocarditis, traumatic
rupture (rare)

• Short, soft sometimes inaudible diastolic

murmur
• Normal heart size
• Normal pulse pressure
 Tx Acute AR
• Schedule immediate AVR for acute AR

• Bridge w nitroprusside and diuretics

 Don’t be tricked
• Do NOT select BB or IABP for acute ARà both
may worsen AR
 Test Yourself
• 36, AV endocarditis transferred to ICU w abrupt
onset hypotension & hypoxemia.
• BP 80/30, HR 120, crackles and gallop.
• No murmur

• Dx: acute AR
• Choose echo, IV sodium nitroprusside & dobutamine
as bridge to urgent surgery
 Mitral Stenosis
• Most common sx: orthopnea & PND

• PE:
– Prominent a wave
– Tapping apical impulse
– Right sided HF
– Opening snap & attenuated P2
– Low-pitched rumbling diastolic mumur
 Give Away on Test

Mitral Stenosis= Snap

 Unlike AS, percutanous valvuotomy (repair) is
preferred over replacement for MS

• MV repair indicated if:

– No LA appendage thrombus on echo
– Pt is symptomatic with MVA <1cm2 or <1.5cm2 w exercise
limitations

• If had MS + mild MR, can do repair, but if the MR is mod or

sevà have to replace the valve L
– Has been on every test I have taken in residency
 Test Yourself
• 28W 29wks pregnant p/w DOE.
• Tachycardia, JVP, parasternal impulse
• Opening snap, 2/6 rumbling diastolic murmur w presystolic
accentuation

• Dx: MS
– Classic presentation in pregnancy bc of increased
intravascular volume
• Choose metoprolol to allow for greater LV diastolic filling time
& to relieve pulm HTN
 Don’t be tricked
• All pts with MS and Afib get warfarin, doesn’t
matter the CHADS2 score
– CHADS2 only calculated for nonvalvular Afib
 Mitral Regurgitation

• Like AR, can be chronic or acute

 Chronic MR
Causes:
• MVP
• IE
• HCM
• Ischemia
• Marfans
• Ventricular dilation

• Sx: orthopnea, PND, edema

 Murmur of Chronic MR
• Holosystolic
• Radiates to left axilla
• Displaced hyperdynamic apical impulse
• Decreased intensity of S2
• Widely split S2
• S3
• Increased P2
 Tx chronic MR
• Diuretics, BB, ACEi, +/- digoxin or
spironolactone

• Associated Afib requires anticoagulation!

 When to repair MV?
• Symptomatic
– Even if EF & LV size are normal
• Notice this is a theme in all valvular disease

• EF <55% or LV dilated to >45mm

– even if no sx

• Repair preferred to replacement (avoid AC)

• If from ischemiaà MR should improve after

revascularization
 Acute MR
• Causesà papillary muscle rupture (post MI),
– chordae tendineae rupture (myxomatous valve dz)
– endocarditis

• Sx: Abrupt onset dyspnea, flash pulm edema, cardiogenic

shock

• PE: right sided HF

– Holosystolic murmur at apex that radiates to axilla
• There may be NO murmur w acute MR bc wide open
 Tx Acute MR
• Sodium nitroprusside
– Like in AR
– but can give nitroglycerine for MR which we avoid in AR

• Another differenceà IABP should be used if

unstable acute MR
– Worsens AR

• Surgery for acute severe MR

 Don’t be tricked
• Do not select mitral valve surgery if EF <30%
 Test Yourself
• 63M asx found to have MR
• EF 52%, LV size 51mm

• Choose mitral valve replacement or repair

 Mitral Valve Prolapse
• Most common cause of MR (though most do not have MR)
• Usually asx
• Can cause CP, palpitations, syncope, dyspnea, emboli
– If sx, tx w BB

• High-pitched midystolic click followed by late systolic

murmur loudest at apex
 Mitral Valve Prolapse
• MVP = Click

• Standing from sitting & valsalva cause the click

and murmur to come earlier

• Squatting does the oppositeà click and

murmur are delayed and softer
 Test Yourself
• 28W w palpitations. Isolated click on exam, echo w
mild MR, 24hr ECG w 728 isolated PVCs

• What to do next?
 Test Yourself
• 28W w palpitations. Isolated click on exam, echo w
mild MR, 24hr ECG w 728 isolated PVCs

• Provide reassurance & counsel on lifestyle

modification
– Avoid caffeine & other stimulants
 Tricuspid Regurgitation
• Causes: marfans, ebstein’s, AV canal malformations, IE, carcinoid,
pulm HTN, RF

• PE: prominent v wave, increased JVP w inspiration, hepatic

pulsations

• Holosystolic murmur LLSB, increases w inspiration

– Know it is either TR or PR if increases w inspiration (right
sided) and must be TR if systolic as PR would be diastolic
 Don’t Be Tricked
• Mild or less severe TR is common, easy to
identify on echo, is physiologically normal, and
does NOT require treatment
 Prosthetic Valves
• Valve dysfunction: new cardiac sx, emboli,
hemolytic anemia (schistocytes)

• If valve dysfunction is suspected, TEE is

procedure of choice
– Do not select TTE in prosthetic valves
 Don’t Be tricked
• Begin long term AC for pts with mechanical
heart valves
– Prosthetic require short but not long term AC but
are not as durable and more likely to get infected
 Goal INR in mechanical valves
• AVà 2-3

• AV + risk factorà 2.5-3.5

– RFs= Afib, prior emboli, hypercoagulable, low EF

• MVà 2.5-3.5

• All should be on ASA

 Keep in mind when asked about anticoagulation

• No need to hold AC before cataract sx

• For AVs, stop warfarin 4-5d before sx, let INR<1.5 and restart as soon as
safe post op
– Higher flow across AV so less likely to clot than mitral so bridging in low
risk pts not necessary

• If high risk for thrombosis (mitral valve, Afib), bridge with IV heparin once
INR<2

• Do NOT use Vit K to reverse, if needed urgently, use FFP

– Takes several days for factors to become deplete again for AC
 Atrial Septal Defect
• Fixed split S2
• Pulmonic midsystolic murmur
• Tricuspid diastolic flow murmur

• Ostium secundum most common

• EKG: RAD, RBBB

• Ostium primum associated w mitral disease

 When to close an ASD?
• Right atrial or ventricular enlargement
• Large left to right shunt
• Symptoms
– Dyspnea, paradoxical emboli

• Select percutaneous device closure for secundum

– vs. surgical closure for primum & associated MV
defects
 Don’t be tricked

• Closure of ASD is contraindicated if shunt

reversal is present
 Test Yourself
• 26 W, no sx, 30wks preg, fixed split S2, 2/6
early SEM in LUSB

• Dx: ASD
– Like MS, often first discovered in preg bc of
increased intravascular volume
 Ventricular Septal Defect
• Loud systolic murmur that obliterates the S2

• What suggests a hemodynamically important

VSD?
– Displaced apical impulse
– Mitral diastolic flow rumble
 When to close a VSD?
• Progressive AR or TR
• Progressive LV volume overload
• Recurrent endocarditis

• Large VSDs can cause pulm HTN and right to

left shunt (Eisenmenger)
– At this stage, closure is contraindicated
• Similar to our ASD don’t be trickedà if shunt reversal,
no surgery
 Cardiology

Part 3:
Arrhythmias
Aortic Dz
PAD
Preop risk assessment
 Palpitations/Arrhythmia work up
• Resting EKG in all

• Ambulatory 24hr ECGà only if daily symptoms

• Exercise ECGà only if exercise-related
• Event monitorà for long arrythmias >1-2min where pt’s have enough time to
activate the device
• Loop recorderà for infrequent sx, saves the prior 30sec-2min after pt activates
the recorder
– Usually the test answer
• Implanted recorderà invasive, for long term monitoring mo-yr
• EP studyà for treatment not diagnosis
– Rarely the test answer
Narrow Complex Tachycardias
 Atrial Fibrillation
• No Ps
• Narrow complex
– Wide complex if there is underlying conduction
delay like RBBB or accessory pathway
• Irregularly irregular

• The presence of deformed Ts or STs “hiding” P

waves rule out Afib
 Tx Afib
• Almost all require AC as the stroke risk in
nonvalvular Afib with one other risk factor
exceeds risk of bleed

• CHADS2
 AC in Afib
• Because the daily risk of stroke in nonvalvular
Afib is low, most do not require bridging when
warfarin is interrupted for procedures
 Tx Afib
• No benefit to rhythm control in elderly
– May be appropriate in young w persistent Afib

• Amio- 1st line in ischemic HD & LV dysfunction

• For older asx pts, clinical outcomes are not

improved with HR <80 compared to more
lenient target of <100
 Don’t be Tricked
• No Digoxin as single agent for rate control

• No catheter ablation of AVN before medication

trial for rate control

• No CCBs, BBs, or digoxin in pts with Afib & WPW

– Then they just go down conduction pathway which
has no inhibition
 Test Yourself
• 55W CP & SOB x12hr
• BP 70/40, HR 160
• EKG: wide complex tachycardia shown
 Test Yourself

• Cardioversion
– always the answer in Afib w hemodynamic
instability
 Atrial Flutter
• EKG: saw tooth in inferior leads, positive deflection in V1
• Ventricular response in regular
• Most 150 beats per min (2:1 block)

• Tx: radiofrequency catheter ablation superior to medical

therapy
– Bc reentrant tachycardia
– AC like you would for Afib
Other Supraventricular Tachycardias

AVNRT much more common than AVRT (85% of the time)

AVNRT should be your guess & there should be no visible Ps
AVNRT much more common than AVRT (85% of the time)
This is AVRT , notice the Ps are buried in the ST segments
MAT: correct underlying cardiac or pulm dz, low K/Mg.
Tx: metoprolol (verapamil if bronchospasm)
 Don’t be tricked

• Do NOT treat irregular, wide complex

tachycardia or polymorphic tachycardia with
adenosine
 Test Yourself
• 32W, 4hr palpitations
• BP 80/50, HR very rapid (they do not give a #).
• EKG regular, narrow compex tachy of 180 bpm,
norm QRS morphology, no Ps are seen

• Dx: AVNRT
• Choose valsalva, carotid sinus massage, verapamil
(can cause hypotension) or IV adenosine
 Wolff-Parkinson-White Syndrome
• Accessory AV conduction pathway

• EKG: short PR, delta wave, norm or long QRS

• Afib associated w WPW is a risk factor for

sudden death caused by degeneration into VF
 Don’t be tricked
• Asymptomatic WPW without arrhythmia does
NOT require investigation or treatment

• Do NOT select CCB, BB or digoxin for pts with

Afib & WPW because can convert Afib to VT or
Vfib
 Tx WPW
• ?
 Tx WPW
• Procainamide

• Cardioversion is preferred for any unstable

WPW pt

• Board Question: pre-op intervention in asx

WPW pt?
 Test Yourself
• 28W, 4hr palpitations
• BP 130/80, irregularly irregular HR of 140
• EKG shows Afib w ventricular rate of 180-270.
QRS is broad and bizarre

• Dx: WPW
• Begin IV procainamide
 Heart Blocks
• Choose IV atropin +/- transcutaneous or
transvenous pacing for symptoms of
hemodynamic compromise
May precede to 3rd deg block
 When to put in a permanent PM?
• Persistent, advanced mobitz type 2
• Transient 2nd degree block w BBB
• 3rd deg block
• Symptomatic block at any level
 Ventricular Tachycardia
QRS >120msec & AV dissocation
Nonsustained <30sec

1. Vtach
Monomorphic (no variation in QRS complexes)
Polymorphic

2. Torsades de pointesà specific form of polymorphic

VT associated w long QT

3. Vfib
 VT vs. SVT w aberrancy
• Which is more common?
 VT vs SVT w aberrancy
• VT much more common, so any wide complex
tachycardia should be considered VT til proven
otherwise (so no adenosine)
– If prior MI or structural heart dz, chance of it
being VT even higher
 Don’t Be tricked
• In pts w structural heart disease, therapy to
suppress PVCs does NOT affect outcomes
 Tx PVCs
• BB only for:
– Disabling symptoms
– Nonsustained VT with symptoms

• Acute sustained VT
– Hemodynamically stable w impaired EFà IV lidocaine or amio
– Unstableà immediate electrical cardioversion

• ICDs reduce sudden cardiac death in VF or sustained VT

associated w hemodynamic compromise
 Test Yourself
• 65W chronic stable angina, prior MI, p/w
lightheadedness & palpitations.
• Vitals stable.
• EKG w wide complex tachycardia & RBBB.
• No prior EKGs for comparison

• Dx: likely sustained VT

• Acute tx: IV lidocaine or amio
 Sudden Cardiac Death
• Risk greatest when QTc >500

• Select echo for survivors of sudden cardiac

death

• Brugada syndrome?
 Brugada syndrome

• Inherited, structurally normal heart but

abnormal conduction system associated w
sudden death
– Incomplete RBBB w STE in V1-V2
 Who gets an ICD?
• Survivors of cardiac arrest 2/2 VF or VT not explained by
reversible cause
• After sustained VT in presence of structural HD
• EF <35%
• Brugada syndrome
• Inherited long QT synd not responding to BB
• After MI w EF <30% 3mo later
• High risk HOCM pts
– Familial sudden death, multiple repetitive nonsustainedVT,
extreme LVH, exercise hypotension
 Test Yourself
• 55M 4mo after large MI, asx, Ef 28%

• Answer: pt at high risk for sudden cardiac

death and should be considered for ICD
 Aortic Atheroemboli***
• Clinical findings: livido reticularis, gangrene of digits,
transient vision loss

• A golden or brightly refractile cholesterol body within a

retinal A (Hollenhorst plaque) is pathognomonic

• Common presentation: stroke or AKI after cardiac or aortic

sx or cath

• Dx by biopsy of muscle, skin, kidney or other organs

• Tx: control CV risk factors

 Test Yourself
• 67 M w AKI 10d after cath
• BP 170/100
• bruits over abd and femoral A
• legs are lacy & purple

• Look for cholesterol emboli to skin and kidneys

• Choose skin biopsy & control all CV risk factors
 Coarctation of the Aorta
• HTN
• Diminished femoral pulses
• Radial-to-femoral delay
• Murmur of AS w continuous murmur audible
over the back

• CXR: classic “figure 3”

• MRA confirms the diagnosis
• Tx: balloon dilatation
 Test Yourself
• 35 immigrant female w cold feet and leg cramping w
walking.
• BP 160/90.
• Systolic murmur at RUSB

• Dx: coarctation w bicuspid AV

• Be alert for congenital HD in questions about
“immigrant” patients
Thoracic Aortic Aneurysm & Dissection

• Yearly echo until root 4.5cm, then every 6mo

• Repair when 5-5.5cm

• Counsel against pregnancy if root >4cm

 Symptoms & Signs
• Compressionà
– hoarseness, dysphagia, recurrent PNA, SVC syndrome
• Chest, flank, abd, back pain

• New AR murmur
• HF
• BP differential between arms

• CXR: wide mediastinum

• Dx: TEE, CT w contrast, MRA
 Type A=Surgery
• Type A dissections involve the ascending aorta,
all other class B

• Emergent surgery is required for Type A

dissections. Uncomplicated type B dissections
can by treated w medical therapy alone
– BB
 When to do prophylactic surgery
• Sxs of hoarseness, dysphagia, back pain
• Ascending aorta diameter of >50-60mm
• Descending aorta diameter of >60-70mm
• Rapid growth of >10mm/year
 Don’t be tricked
• Which anti-HTN do you not use for acute
aortic dissection bc it increases shear stress?
 Don’t be tricked
• Do NOT use hydralazine for acute aortic
dissection bc it increases shear stress

• Schedule surgery for type B dissection if major

vessel like a renal artery is involved
 Test Yourself
• 73M, 1hr severe tearing CP
• BP 90/60 on right and 130/70 on left
• CXR w widened mediastinum

• Dx: dissection of the aortic arch

• Choose BB, sodium nitroprusside and
emergent imaging
 Abdominal Aortic Aneurysm
• Screening: one time U/S indicated for asx AAA
in any male who has EVERY smoked between
65-75yo

• Pulsatile abd mass

• Tx: CV risk factors, BB preferred

 Don’t be tricked
• U/S is NOT accurate for diagnosing ruptured
AAA
– New abd, flank or back pain with shock/syncope
– CT or MRA
 When to repair an asx AAA?
• >5.5cm in diameter
• Growth of >0.5cm/yr
• Symptomatic

• Follow up for unrepaired AAA

– If >4cm every 6mo
– If <4cm every 2-3yrs
 Peripheral Arterial Disease
• RF: age, smoking, DM, HLD

• Intermittent claudication is the classic sign

• Ddx spinal stenosis (pain when standing that

resolves with sitting, lying or leaning forward)
 5 Ps
• Pain
• Paresthesias
• Pallor
• Paralysis
• Pulselessness
 ABI
• Highest systolic arm BP compared to highest
systolic ankle BP (ankle/arm)
• <0.9 =PAD
• <0.4 ischemic rest pain
• False normal in diabetics w calcified
noncompressible arteries (ABI >1.4)
 Don’t be tricked
• ABI >1.4, then a toe-brachial index will be a
better assessment
 Tx PAD
• PAD= CAD risk equivalent
– Same BP & lipid goals

• All with symptomatic PAD should begin a

supervised exercise training program

• Meds: ASA, statin (LDL<100)

– cilostazol for sx PAD
– ramipril (reduces MI, stoke or vascular death in PAD)
 Acute arterial ischemia
• Antiplat, heparin and urgent surgery

• If chronic but rest pain or poorly healing

ulcersà schedule angioplasty or surgery
– All others get medical therapy
 Don’t be tricked
• Do not use cilostazol in pts with low EF or h/o
HF

• BB are NOT contraindicated in pts w PAD

 Test Yourself
• 60M, 6mo claudication thighs & calves.
• ABI 0.66 & 0.55
• Symptomatic despite lifestyle management
program

• Choose to begin cilostazol

 Preop Cardiac Risk Assessment
• Should delay elective surgery for the following
active cardiac conditions:
– ACS (MI<30d ago, unstable or severe angina)
– Decompensated HF
– Sig arrhythmia
– Severe valvular dz
 Who can go for elective surgery without
further cardiac w/u?

• Low risk sx
– endoscopy, breast, cataract, outpt sx

• >=4METs
– can climb a flight of stairs, walk up a hill, walk at
4mi/hr without sx
 RCRI used to risk stratify the other ppl

*0= no further tests

*3 or more RFs if undergoing a vascular sx & further workup will
change their management? may get additional cardiac work up;
consider BB
 Who does not need preop
assessment?
Patients at low risk who:
• Having minor surgery under local anesthesia (cataracts) w no
comorbidities
• <55yo, no murmurs, no illnesses
• Recent normal cath (past 6m-1y) & no new sx
• Require emergent surgery

• Isolated BP <180/100 does not increase risk of complications

 On every test I’ve taken
• Postpone elective surgery in someone who
has received a bare metal stent for at least 4-
6wks & 1yr if received drug-eluting stent
 Post Surgical MIs
• Most within 24-48hrs after surgery
• 50% have CP, the other 50% may have new
onset HF, hypotension or SVT

• Asx pts at high cardiac risk should be

monitored w EKGs and CEs for up to 1wk
postop
 Test Yourself
• 82M evaluated for preop eval for AAA
• HTN on ACEi, no h/o MI, stroke, angina,
arrhythmia, kid dz, DM. BP 130/80, exam
normal, Cr 1.2, EKG w LVH
– (RCRI 0)

• Choose proceed to surgery without additional

preop testing
BREAK TIME