Transcript UMDNJ~ SOM SECOND YEAR CARDIOLOGY MODULE FALL 2008

UMDNJ~ SOM
SECOND YEAR
CARDIOLOGY
MODULE
FALL SEMESTER
John N. Hamaty, DO, FACC, FACOI
Course Director
COURSE REVIEW
2012
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.
Introduction to
Hemodynamics
John 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
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
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.
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
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
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:
A. Palliative valvuloplasty
B. Afterload reduction with peripheral vasodilators
C. Chronic anti-biotic therapy for chronic rheumatic fever
D. Decrease sodium intake, diuretic therapy, and heart rate control
D
Tell me why…
Pericarditis, Echocardiography
Jerome M. Horwitz, D.O.
 Myocarditis
presents most likely in the following
groups:
 Young Males
 Pregnant Females
 Children (especially neonates)
 Immunocompromised (HIV)
Pericarditis, Echocardiography
Jerome 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
Pericarditis, Echocardiography
Jerome M. Horwitz, D.O.
 Echodoppler
study is safe, reproducible, cost
effective and available at almost any hospital
A patient is suspected of having myocarditis and a myocardial biopsy is
obtained. It revealed no lymphatic infiltrates and no myocytolysis. The
patient has:
A. Active myocarditis
B. Pericarditis
C. The biopsy was negative therefore your initial diagnosis is wrong
D. Non cardiac chest pain and you order a high resolution CT scan.
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
Dyslipidemia and the
Use of Statins
Mario 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
Dyslipidemia and the
Use of Statins
Mario 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
Dyslipidemia and the
Use of Statins
Mario 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 40mg80mg , cheaper; or rosuvastatin 20mg-40mg, generic
not yet available) would be recommended.
Which of the following are true regarding non HDL-C?
A. It is a better surrogate than LDL-C in abnormalities of the
TG/HDL axis?
B. It is usually a better surrogate than LDL-C in patients with
type 2 DM and metabolic syndrome
C. Non HDL-C is the TC minus HDL-C
D. In type 2 DM without known CVD the non HDL-C goal would
be <130mgdL
E. 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?
All of them!
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
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
A. Atrialfibrillation with 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
D
NSR, left ventricular hypertrophy with ST/T wave changes
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
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
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
C. Dobutamine stress echocardiography
D. Treadmill stress echocardiography
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.
Hypertension and the Use of
Antihypertensives
Joshua 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
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.
B.
C.
D.
Calcium channel blocker
Central acting agent such as alpha methyl-dopa
Diuretic therapy in conjunction with salt restriction
Nitroglycerin
C
Diuretic therapy in conjunction with salt restriction
Tell me why…..
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
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.
B.
C.
D.
Hematoma
Pseudoaneurysm
Retroperitoneal bleed
Pruritic rash after cath
C
Retroperitoneal Bleed
Tell me why…..
Acute Myocardial Infarction
Willis Godin,D.O.
 Be
familiar with the medications
indicated for the acute management
of acute MI
 Know medications indicated for longterm 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)
Complications of Myocardial
Infarction
Willis 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
Final bloodwork for 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
All of the above !
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
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 ductus
arteriosis
 Have a complete understanding of the
pathophysiology of left to right
(unidirectional shunts) as well as
bidirectional shunt physiology, particularly
Eisenmenger’s Syndrome
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. Pulsus paradoxus
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.
B
Markedly diminished pulses
in lower extremities
compared to upper extremities.
Syncope / Pacemakers & ICD’s
Yega Raman,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
Syncope / Pacemakers & ICD’s
Yega Raman,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
Syncope / Pacemakers & ICD’s
Yega Raman,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 IIIambulatory Class IV, LBBB with QRS ≥120msec.
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.
B.
C.
D.
Cardiac catheterization
Nuclear stress test
Invasive electrophysiologic study
Head up tilt table test
D
Head’s up! It’s time for tilt table testing
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
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.
B.
C.
D.
E.
Normal saline and sudden cardiac death
Diuretic, vasopressin and sudden cardiac death
Normal saline, aspirin and progressive heart failure
Diuretic, beta-blocker and progressive heart failure
Normal saline, Ace inhibitor and sudden cardiac death
Switching to red wine! (In moderation of course!) And…
D
Diuretic, beta-blocker and progressive heart failure