Transcript Cardiology Board Review I

Cardiovascular Board Review I
Braden Hexom, MD
Department of Emergency Medicine
Mount Sinai School of Medicine
Question 1
A 40 yo M, previous healthy presents with
cough, low-grade fever, and myalgias for 34 days. Today he has experienced severe,
sharp pleuritic chest pain radiation to the
left shoulder that is worse when he is
supine. He smokes one pack of cigarettes
per day. Vitals signs: BP 160/95, P 110,
RR 18, T 37.2 oC. A 12-lead EKG is
obtained:
PEER VII Q55
Q1 EKG
Q1 Answer
Appropriate next steps include:
A.
ASA 325 mg, Morphine 2 mg, admit CCU
B.
ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit bolus,
activate cath team
C.
Ketorolac 30 mg IV then ibuprofen 800 mg TID for 1 week
as an outpatient
D.
Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20
mg IV, admit to telemetry
E.
Metoprolol 5 mg IV, NTG IV infusion titrated to pain, and
cardiology consult
Q1 Answer
Appropriate next steps include:
A.
ASA 325 mg, Morphine 2 mg, admit CCU
–
B.
No Need For Monitored Admission
ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit bolus,
activate cath team
–
C.
No Role for Anticoagulation
Ketorolac 30 mg IV then ibuprofen 800 mg TID for 1 week
as an outpatient
–
D.
Acute Pericarditis is Treated with Ibuprofen and Outpatient Followup
Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20
mg IV, admit to telemetry
–
E.
No Idea Why You Would Ever Use This
Metoprolol 5 mg IV, NTG IV infusion titrated to pain, and
cardiology consult
–
Tachycardia and Pain will Resolve with Pain Control
Acute Pericarditis
• Inflammation of the pericardium
• Sharp or stabbing chest pain with radiation to
back, neck, left shoulder, or arm
• Worsened on inspiration or lying supine
• EKG:
– Acute phase: Diffuse ST elevations (most prominent in
I, V5, V6) with PR depressions (II, aVF, V4-V6)
• Isolated pericarditis will not make enzymes or
have dysrhythmias
• Dispo for uncomplicated is NSAIDs for 1-3 weeks
and D/C
Acute Pericarditis
http://urbanhealth.udmercy.edu/ekg/pdf/acutepericarditis.pdf
Question 2
A 50 yo M presents with an acute inferior
wall MI. Following the administration of
ASA and NTG, he suddenly becomes
confused and diaphoretic with a BP of
70/30. Physical exam reveals JVD, clear
lungs, and no evidence of a murmur.
Promes 3-9
Q2 Answer
What combination of therapeutic agents is most
likely to immediately stabilize this patient?
A. Heparin and glycoprotein IIb/IIIa inhibitors
B. Angiotensin converting enzyme inhibitor and clopidogrel
C. Steptokinase and magnesium
D. Normal saline bolus and dobutamine
Q2 Answer
What combination of therapeutic agents is most
likely to immediately stabilize this patient?
A. Heparin and glycoprotein IIb/IIIa inhibitors
–
Not immediately effective
B. Angiotensin converting enzyme inhibitor and clopidogrel
–
Not immediately effective
C. Steptokinase and magnesium
–
PCI preferred over thrombolytics
D. Normal saline bolus and dobutamine
–
RVMI is Preload Dependent
Right Ventricular Infact
• Complicates up to 1/3 of inferior wall MIs
• EKG
– ST Elevations in II, III, aVF
– Reciprocal depressions in I, aVL, V5, V6
– ST Elevations in V4R to V6R on right-sided EKG
• Prone to hypotension but respond to volume and
pressors / inotropes
• PCI preferred over thrombolytics
• This is the classic question for RV infact
Right Ventricular Infact
Left Sided EKG
Right Sided EKG
http://ccn.aacnjournals.org/cgi/reprint/25/2/52.pdf
Question 3
The hypertensive emergency that is most
easily reversible with pharmaceutical
management is:
PEER VII Q240
Q3 Answer
A. Acute coronary syndrome
B. Aortic dissection
C. Eclampsia / pre-eclampsia
D. Encephalopathy
E. Intracranial hemorrhage
Q3 Answer
A. Acute coronary syndrome
–
Needs Cath
B. Aortic dissection
–
Not reversible with meds
C. Eclampsia / pre-eclampsia
–
Needs Delivery
D. Encephalopathy
–
Treatment w/in 1st Hour Often Reversible
E. Intracranial hemorrhage
–
Not reversible with meds
Hypertensive Emergency
• Marked elevation of BP with end-organ
dysfunction  otherwise HTN urgency
• Susceptible end-organs: CV, brain, kidney
• Encephalopathy
– N/V
– Severe Headache
– Confusion  decreased sensorium  coma
• Rapid 25% decrease in MAP is the goal
– Diastolic <110 mmHg
Hypertensive Emergency
• Rare disease, many treatment options
• Precipitating causes: drugs, pregnancy
• Peds
– Pheochromocytoma
– Aortic coarctation
– Renovascular disease
• Only emergencies require immediate
treatment. Urgencies can be discharged
• Can use nitroprusside, nitro, labetalol, cardene
Question 4
A 75 yo F presents with decreased level of
consciousness. VS are BP 70/40, P 40, RR
12, and T 36.5 oC. Blood glucose is 114.
The rhythm strip should be interpreted as:
PEER VII Q92
Q4 Answer
A. Complete Heart Block
B. Mobitz second-degree HB, type I Wenckebach
C. Mobitz second-degree HB, type II
D. QT prolongation with U waves
E. Sinus bradycardia
Q4 Answer
A. Complete Heart Block
–
Some P waves conduct
B. Mobitz second-degree HB, type I Wenckebach
–
PR interval increases
C. Mobitz second-degree HB, type II
–
PR interval constant
D. QT prolongation with U waves
–
U waves follow T, seen in Hypokalemia
E. Sinus bradycardia
–
Not sinus
Question 5
The most appropriate initial therapy for a
patient with a pulse of 40, a BP of 70/40,
and the previous EKG is:
PEER VII Q93
Q5 Answer
A. Atropine 1 mg IV
B. External cardiac pacemaker
C. Isoproterenol infusion at 2 mcg/min, titrate up
D. Normal saline
E. Potassium infusion at 10 mEq/hr
Q5 Answer
A. Atropine 1 mg IV
–
Type I (not II) Often due to Vagal tone/IWMI
B. External cardiac pacemaker
–
Type II Often seen with AWMI -> Complete HB
C. Isoproterenol infusion at 2 mcg/min, titrate up
–
An option for refractory sinus bradycardia
D. Normal saline
–
Not usually PWMI
E. Potassium infusion at 10 mEq/hr
–
Not a hypokalemia rhythm
Bradycardia
• Approach to undifferentiated bradycardia
based on hemodynamic stability
• If stable, observe
• If unstable
–
–
–
–
Atropine 0.5 mg IVP, up to 3 mg
Dopamine or Epinephrine drip
External pacing
Transvenous 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 IWMI, 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
– Usually seen in AWMI
– 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 6
Which of the following statements
regarding cardiac serum markers is correct?
PEER VII Q342
Q6 Answer
A.
BNP level has little correlation with recurrent acute
coronary syndromes
B.
CPK appears within 1-2 hours after an acute MI and gone
within 24 hours
C.
Myoglobin appears within 1-2 hours after acute MI and
peaks at 5-7 hours
D.
Total CPK is more specific for acute cardiac ischemia than
CK-MB
E.
Troponins appear in the first 4 hours after an MI and are
gone by 24 to 36 hours.
Q6 Answer
A.
B.
C.
D.
E.
BNP level has little correlation with recurrent acute
coronary syndromes
– BNP elevated in CHF and ACS
CPK appears within 1-2 hours after an acute MI and gone
within 24 hours
– Appear 3-8hrs, gone by 2-3 days
Myoglobin appears within 1-2 hours after acute MI and
peaks at 5-7 hours
– But not cardiac specific
Total CPK is more specific for acute cardiac ischemia than
CK-MB
– CK-MB more specific, CPK in muscle/kidney/GI/brain
Troponins appear in the first 4 hours after an MI and are
gone by 24 to 36 hours.
– Troponins appear 3-6 hrs, persist 5-7 fsyd
Cardiac Serum Markers
• Myoglobin is the earliest
• Troponin is the most sensitive and specific
http://www.uptodateonline.com
Cardiac Serum Markers
• Troponins and Renal Failure
–
–
–
–
Tropnonin clearance is delayed
Troponins are not cleared by dialysis
High false-positive rate1
Elevated troponins correlate with poor
prognosis
– Any non-zero level warrants serial troponins2,3
1 Apple
FS,et al. Predictive value…Circulation 2002 Dec 3;106(23):2941-5.
2 http://www.kidney.org/professionals/KDOQI/guidelines_cvd/troponin.htm
3 http://www.uptodateonline.com
Question 7
An 82 yo woman presents with 1 hour of
substernal chest pressure, dyspnea, and
diaphoresis. Her EKG is shown below. No
old EKG is available for comparison. Her
first set of cardiac enzymes is negative.
Which of the following is the most
appropriate treatment?
Promes Q3-4
Q7 (continued)
Q7 Answer
A. Admit the patient to a monitored bed
B. Observe the patient, order serial cardiac
markers and discharge if negative
C. Administer thrombolytics
D. Cardiovert the patient with 50 joules
E. Stress testing once serial cardiac enzymes
are negative
Q7 Answer
A. Admit the patient to a monitored bed
B. Observe the patient, order serial cardiac
markers and discharge if negative
C. Administer thrombolytics
D. Cardiovert the patient with 50 joules
E. Stress testing once serial cardiac enzymes
are negative
STEMI / LBBB
• STEMI
– Presence of ST elevations of greater than 1mm
in two or more anatomically contiguous leads
• LBBB
– QRS > 0.12 s (120ms)
– Wide, notched R wave in I, aVL, V6
– Small R and deep S in II, III, aVF, V1-V3
STEMI / LBBB
• Indications for Thrombolysis / PCI
– MI that meets STEMI criteria
– MI symptoms and new LBBB
– Acute Posterior MI
• Isolated ST-segment depression of at least 1mm in 2
or more leads from V1-V4
ACEP Clinical Policy: Indications for Reperfusion Therapy…Ann Emerg Med. 2006;48:358-383.
Question 8
Which of the following statements is true
concerning infective endocarditis in IV drug
users?
PEER V Q9
Q8 Answer
A. Most commonly affects the mitral value
B. Rarely associated with septic emboli
C. Cardiac murmurs frequently are absent at
initial presentation
D. Steptococcus viridans is the most common
causative organism
E. The majority of patients have previously
damaged heart valves
Q8 Answer
A. Most commonly affects the mitral value
–
Tricuspid is most common
B. Rarely associated with septic emboli
–
Is a common cause of septic emboli
C. Cardiac murmurs frequently are absent at
initial presentation
–
Murmur develops after extensive valve damage
D. Steptococcus viridans is the most common
causative organism
–
Staph, MRSA most common
E. The majority of patients have previously
damaged heart valves
IVDU Endocarditis
• Presentation can vary from subacute to acute onset
of fever, dyspnea, weakness, tachycardia,
dysrhythmias
• High index of suspicion: IVDU patients with fever
• Skin flora is most common: Staph aureus,
including MRSA
• Tricuspid is most commonly affected in IVDU
• In ED, obtain multiple cultures, treat with Abx
• Antibiotics: vancomycin + gent +/- rifampin
Question 9
Which of the following drugs can be used to
treat a patient with known Wolff-ParkinsonWhite syndrome who presents with the
rhythm depicted below:
PEER VII Q126
Q9 Answer
A. Adenosine
B. Digoxin
C. Diltiazem
D. Metoprolol
E. Procainamide
Q9 Answer
A. Adenosine
–
Slows AV conduction -> V.Fib
B. Digoxin
–
Slows AV conduction -> V.Fib
C. Diltiazem
–
Slows AV conduction -> V.Fib
D. Metoprolol
–
Slows AV conduction -> V.Fib
E. Procainamide
–
Or Amiodarone (or cardioversion)
Wolff-Parkinson-White
• Syndrome of pre-excitation due to
accessory pathway from atria to ventricles
• EKG
– Short PR interval
– Delta wave: slurred upstroke of QRS complex
http://medicalfinals.co.uk/QuizJanuary2006Answers.html
Wolff-Parkinson-White
• Orthodromic (narrow complex) AVRT
– Anterograde conduction in accessory tract
– Adenosine 6 mg IV or Verapamil 5 to 10 mg IV
• Antidromic (wide complex) AVRT or Afib / Aflut
–
–
–
–
Retrograde conduction in accessory tract
No AV nodal blockers
If stable: amiodarone or procainamide
If unstable: synchonized cardioversion
Question 10
An 8 yo boy presents with history of chest pain
that gradually worsened while he was watching
television with his mother. The pain lasted 2
hours and then resolved without intervention.
There was no associated dyspnea or syncope. He
has no significant past medical history. Family
history includes a grandmother who died of a heart
attack. Physical exam, ECG, and CXR are
normal. What is the most appropriate next step in
the emergency department?
PEER VII Q338
Q10 Answer
A. Administer albuterol and check peak flow
B. Discharge home with primary care followup
C. Laboratory evaluation, including cardiac
markers
D. Observation admission for treadmill testing
E. Outpatient echo and Holter monitor
Q10 Answer
A. Administer albuterol and check peak flow
–
Not indicated by the history
B. Discharge home with primary care followup
–
Reasonable for 1st episode with reassuring story
C. Laboratory evaluation, including cardiac
markers
–
No clear evidence for trops in kids
D. Observation admission for treadmill testing
–
Evals for CAD, very rare in kids
E. Outpatient echo and Holter monitor
–
May be indicated for recurrent episodes
Pediatric Chest Pain
• Rarely serious unless accompanied by
–
–
–
–
Syncope
Dyspnea
Fever
Congential Heart Disease
• Cyanosis
• Congestive Heart Failure
• Return to regular activity is the norm
Concerning EKG Findings
(Especially in Young People)
• 1. Delta Wave/Short PR -> WPW
• 2. LVH -> Cardiomyopathy
• 3. RBBB/ST in V1 -> Brugada
• 4. Long QT
-> Congenital or Aquired
Question 11
A 60 yo F with a history of end-stage renal
disease on hemodialysis presents
unresponsive with only a weak carotid
pulse. Cardiac monitoring is started (see
below), and CPR is initiated. Intravenous
access is established, and the patient is
intubated. The next step in management
should be:
PEER VII Q300
Q11 (continued)
http://sprojects.mmi.mcgill.ca/heart/ecgk1.html
Q11 Answer
A. Atropine 1 mg IV, amiodarone 300 mg IV slow push
B. Calcium chloride 1 amp IV, insulin 10 units IV, and
dextrose 50 g IV
C. Dopamine wide open, and prepare for external pacer
D. Magnesium sulfate 2 g slow IV push, potassium
chloride 10 mEq over 20 minutes
E. Normal saline 500 mL bolus and pericardiocentesis
Q11 Answer
A. Atropine 1 mg IV, amiodarone 300 mg IV slow push
–
This is not sinus bradycardia, and amio not indicated
B. Calcium chloride 1 amp IV, insulin 10 units IV, and
dextrose 50 g IV
–
Insulin the most rapidly effective
C. Dopamine wide open, and prepare for external pacer
–
Refractory to pacing. Dopamine won’t fix underlying issue
D. Magnesium sulfate 2 g slow IV push, potassium
chloride 10 mEq over 20 minutes
–
Treatment for Hypokalemia (flat Ts, long QT/QRS, big Us)
E. Normal saline 500 mL bolus and pericardiocentesis
–
Tamponoda usually presents with low voltage
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
Bicarbonate
Lasix
Albuterol
Kayexalate
Question 12
A 49 yo M presents after he fainted while
running on his treadmill at home. He has
been having exertional dyspnea and angina
for the past several months. Which of the
following disease is most likely to cause
these symptoms?
PEER VII Q230
Q12 Answer
A. Aortic stenosis
B. Pulmonary embolus
C. Mitral incompetence
D. Pulmonary stenosis
E. Tricuspid incompetence
Q12 Answer
A. Aortic stenosis
–
Fits the age group for congenital bicuspid valve
B. Pulmonary embolus
–
Usually more acute, not exertional
C. Mitral incompetence
–
SV maintained -> exertional SOB but not syncope
D. Pulmonary stenosis
–
Dyspnea and Easy Fatigability
E. Tricuspid incompetence
–
Causes JVD and peripheral edema (right sided)
Aortic Stenosis
• Bimodal distribution
– Under 65: bicuspid aortic valve
– Over 65: calcific degeneration
• Outflow tract obstruction with LVH
• Crescendo-decrescendo systolic murmur
• Classic symptoms
– DOE
– Syncope
– Angina
• This is the classic AS question
Question 13
Which of the following is the most common
ECG abnormality associated with mitral
valve prolapse?
PEER VII Q222
Q13 Answer
A. Paroxysmal supraventricular tachycardia
B. QT prolongation
C. Rapid atrial fibrillation
D. ST-segment depression in leads II, III, aVF
E. Ventricular tachycardia
Q13 Answer
A. Paroxysmal supraventricular tachycardia
–
Also PVCs, APCs
B. QT prolongation
–
Reported but rare
C. Rapid atrial fibrillation
–
Not typical
D. ST-segment depression in leads II, III, aVF
–
Reported but rare
E. Ventricular tachycardia
–
Reported but rare
Mitral Valve Prolapse
• Most common valvular heart disease – 2.4%
• Usually asymptomatic
• When symptomatic
–
–
–
–
–
–
Non-exertional chest pain
Palpitations
Fatigue
Dyspnea unrelated to exertion
Increased incidence of WPW
Palpitations, PVCs, Reentrant SVT
• Echo and outpatient cardiology management
Question 14
A 70 yo M complains of severe diffuse abdominal
discomfort that began in his lower epigastric
region 3 hours earlier, shortly after he ate burger
and fries. He denies chest pain, SOB, and flank
pain. He has a history of CHF. Physical exam
reveals an elderly man in severe discomfort. Vital
signs are remarkable for only a mild tachycardia.
The abdomen is soft and nondistended, with
diffuse pain to all areas on palpation. There is no
rebound. Pulses are normal; there are no bruits or
masses. What is the most likely diagnosis?
PEER VII Q19
Q14 Answer
A. Mesenteric ischemia
B. MI
C. Aortic dissection
D. Pancreatitis
E. Ruptured abdominal aneurysm
Q14 Answer
A. Mesenteric ischemia
–
Always consider in elderly, pain > exam
B. MI
–
Usually not tender abdomen
C. Aortic dissection
–
Must consider but abdomen tender/vitals normal
D. Pancreatitis
–
No h/o EtOH or other comorbidities
E. Ruptured abdominal aneurysm
–
No pulsatile mass, normal pulses
Mesenteric Ischemia
• Elderly patients with severe pain out of
proportion to the physical exam
• Pain is poorly localized
• Risk factors
–
–
–
–
Atrial Fibrillation
Vascular disease
CHF
Hypercoagulability
• Also consider AAA, Dissection!!
Mesenteric Ischemia
• Acute: thromboembolic phenomena
• Chronic: usually due to long-standing
atherosclerotic disease (intestinal angina)
• High mortality due to risk of bowel necrosis
• Workup
– CT Angio vs conventional angiography
– Serial lactate levels
– Early surgical consultation
Question 15
Which of the following patients is the most
appropriate candidate for pacing therapy
with a transcutaneous cardiac pacemaker?
PEER V Q2
Q15 Answer
A. 25 yo severely hypothermic M with marked
bradycardia; BP undetectable, P 30
B. 43 yo M with bradysystolic cardiac arrest for 40
minutes, BP undetectable, P 15
C. 61 yo F with 1st degree AV block and sinus
bradycardia unresponsive to 1 mg atropine; BP
90/60, P 48
D. 58 yo F with 3rd degree AV block unresponsive
to 3 mg atropine, BP 80/50, P 40
E. 78 yo M with Mobitz I second-degree AV block,
BP 90/40, P 70
Q15 Answer
A. 25 yo severely hypothermic M with marked
bradycardia; BP undetectable, P 30
B. 43 yo M with bradysystolic cardiac arrest for 40
minutes, BP undetectable, P 15
C. 61 yo F with 1st degree AV block and sinus
bradycardia unresponsive to 1 mg atropine; BP
90/60, P 48
D. 58 yo F with 3rd degree AV block unresponsive
to 3 mg atropine, BP 80/50, P 40
E. 78 yo M with Mobitz I second-degree AV block,
BP 90/40, P 70
Bradycardia
• Approach to undifferentiated bradycardia
based on hemodynamic stability
• If stable, observe
• If unstable
–
–
–
–
Atropine 0.5 mg IVP, up to 3 mg
Dopamine or Epinephrine drip
External pacing
Transvenous pacing