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Internal Medicine Board Review- Cardiology. June 16, 2010. Cardiology for the IM Boards. Examiners want to assess your ability to make decisions that are pragmatic and not beyond your training level Avoid unnecessary admissions and invasive tests in patients with no or minimal symptoms

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cardiology for the im boards
Cardiology for the IM Boards
  • Examiners want to assess your ability to make decisions that are pragmatic and not beyond your training level
  • Avoid unnecessary admissions and invasive tests in patients with no or minimal symptoms
  • Make important diagnoses in patients with concerning presentations
  • Provide life-prolonging therapies and recognize contraindications to these therapies
outline of high yield areas
ACS therapies:

ASA, BB, ACE-I, Heparin, 2b/3a, Lytics

Stable CAD therapies

- ACE-I, Statins, ASA, BB

Congenital Heart Disease Diagnoses

ASD, VSD, Bicuspid AV

Rare But Deadly Cardiac Conditions

- Brugada Syndrome, HCM, Long QT syndrome, WPW

Outline of High Yield Areas

Hypertension therapies:

  • DM, stable CAD

CHF therapies

  • ACE-I, BB, Hydralazine/Nitrates, ARB, Aldosterone blockade
  • Hyperkalemia from use of multiple agents, etc.
  • ICD and BiV basics

Heart Disease in Pregnancy

  • High risk vs. low risk lesions
  • Hemodynamic changes are common

Infective Endocarditis

  • Diagnostic criteria, typical organisms
  • Low vs. high risk features
  • Indications for surgery consultation

Valvular Heart Disease

  • Aortic stenosis
  • Mitral regurgitation
  • AI with bicsuspid AV
  • MS with history of rheumatic fever
evaluation of sinus tachycardia
Evaluation of Sinus Tachycardia
  • NEVER admit or perform invasive evaluation on asymptomatic patients
  • Evaluate cheap, easy diagnoses first in asymptomatic patients- anemia, thyroid, infection, drug use, leukemia
  • For patients with symptoms, evaluate life-threatening causes first- PE, sepsis, acute GI bleeding
acute coronary syndromes
Acute Coronary Syndromes
  • First line, evidence based therapies: ASA 325 mg x1, heparin/lovenox if no evidence of dissection or bleeding
  • Early notification for primary PCI for STEMI, or TPA if <90 minutes from first medical contact to device activation
  • Plavix and/or 2b3a inhibitors may be too complex for boards, generally indicated in patients with high TIMI risk (> 2 TIMI RF)
timi risk score
TIMI Risk Score
  • Age>65
  • Known stenosis >50%
  • Chronic ASA use
  • Elevated cardiac enzymes
  • Chest pain>1 episode in last 4 hours
  • >2 RF for CAD
  • ST depression >/= 0.5 mm on ECG

14 day risk of recurrent events from 5 >>>43 %

b blockers for acute mi
B-blockers for acute MI
  • Not as important as hemodynamic stability
  • RF for cardiogenic shock- age>70, SBP <120, HR >100 – AVOID BB
  • Beneficial in patients with severe HTN at presentation
  • Oral delivery preferred (lower incidence of severe hypotension, shock and heart block)
rv infarction
RV infarction
  • Suspect in the setting of hypotension with inferior MI
  • R-sided ECG can show STE in V4-V5
  • Preload dependent condition- CVP must be increase to allow filling of the pulmonary circulation and provide preload to the LV
  • Avoid b-blockers and do not use diuretics unless there is clear pulmonary edema
pregnant patient with cardiac findings
Pregnant Patient with Cardiac findings
  • Most likely this will be benign in a patient without pulmonary edema or hypoxia
  • Typical changes for pregnancy- decrease in SVR, increase HR, increase in DOE, LE edema, fatigue. Soft systolic murmurs also common
  • Beware of diastolic murmurs- NEVER normal (Mitral stenosis, AI, VSD)

Predictors of poor pregnancy outcome

- NYHA III or IV before pregnancy

- Saturation <90% on air

- Left heart obstruction

- Previous cardiac event

- Systemic ventricular ejection fraction <40%

Cardiac indications for caesarean section:

- Aortopathy with root >4 cm

- Aortic dissection or aneurysm

- Warfarin treatment within two weeks (fetus clears warfarin slowly and may be at risk for cerebral hemorrahage)

High risk lesions, advise against pregnancy:

- Pulmonary hypertension

- Aortopathy with root >4 cm or aneurysm, advise surgery first

- Severe aortic stenosis (peak gradient >80 mm Hg or - symptoms), advise surgery first

- Systemic ventricular dysfunction NYHA III or IV symptoms

identify critical aortic stenosis
Identify Critical Aortic Stenosis
  • Critical AS should be symptomatic in a functional patients
  • New onset symptoms associated with poor prognosis in all patients
  • Surgery prolongs survival
  • Physical exam for critical AS- absent S2, late peaking SEM, radiation to carotids, pulsus parvus et tardus
aortic regurgitation
Aortic Regurgitation
  • Diastolic murmur over lower sternal borders, usually does not radiate to apex (unless associated with Austin-Flint murmur)
  • Asymptomatic patients – observe, however severe LV enlargement (>70 mm diastole, 50 mm systole) and reduction in EF is an indication for surgery
treat symptomatic mitral stenosis
Treat Symptomatic Mitral Stenosis
  • Balloon valvuloplasty is associated with significant, prolonged reduction in gradient among patients with rheumatic MS
  • High risk BMV features include heavy calcification, leaflet thickening, immobility, and involvement of subvalvular apparatus
  • BMV should only be considered for symptomatic, severe MS (>10 mm mean gradient)
identify complications of endocarditis
Identify Complications of endocarditis
  • AV block suggests conduction system involvement
  • Indications for urgent surgery- abcess, CHF, fungal infection
  • L sided valves are in continuity with each other- often both are involved in severe cases
acute mr
Acute MR
  • Complication of endocarditis
  • Treat with IABP placement and surgical consult
  • Understand murmur of acute vs. chronic mitral regurgitation
wpw management
WPW management
  • Do nothing in asymptomatic patients
  • Symptomatic patients should be referred for ablation
  • WPW with afib- (wide complex) avoid AV nodal blockers- give Procainamide
  • Incidence of sudden death approximately 0.5%/year
  • Restrictive VSD associated with shunt <1.5:1 and can be managed conservatively
  • Larger VSDs are often symptomatic, and if they present in adult life were likely moderately restrictive in childhood
  • Likely to result in Eisenmenger’s syndrome and severe pulmonary hypertension
eisenmenger s syndrome
Eisenmenger’s syndrome
  • End-stage of congenital heart disease with initial L>R shunt
  • Persistent increase in pulmomary blood flow results in vasculopathy, increased PVR and eventually R to L shunt with hypoxia
  • Treatment is heart-lung transplant, and palliative therapies (O2, vasodilators,etc.)
  • Suspect this in 2nd-3rd decade of life for VSD, 5th-6th decade for ASD
evaluate subclinical cad
Evaluate Subclinical CAD
  • No evidence that screening for CAD is beneficial
  • Risk stratify patients with symptoms only
  • Always aggressively screen for CAD risk factors, and treat when appropriate
  • Smoking cessation is the most important preventive therapy, followed by statin use, with ASA being least powerful
asa as preventive therapy
ASA as preventive therapy
  • Generally, ASA prevents MI in men and stroke in women
  • No good data for universal primary prevention
  • Current USPSTF recommendations are for ASA in men 45-79 with at least 1 RF for CAD, for women age 55-79
cxr findings
CXR findings
  • VSD- cardiomegaly with biventricular enlargement and pulmonary vascular engorgement
  • Aortic coarctation- rib notching
  • Left atrial enlargement in mitral stenosis
endocarditis prophylaxis class iia
Endocarditis Prophylaxis- Class IIa
  • Valve replacement surgery or valve repair with prosthetic material
  • Previous episodes of endocarditis
  • Complex cyanotic congenital heart disease
  • Heart transplant patients with acquired valvular heart disease


  • A diagnosis can be reached in any of three ways: two major criteria, one major and three minor criteria, or five minor criteria.
  • Major criteria include:
  • Positive blood cultures
  • 2. Evidence of endocardial involvement with positive echocardiogram defined as
  • Minor criteria include:
  • 1. Predisposing factor: known cardiac lesion, recreational drug injection
  • 2. Fever >38°C
  • 3. Evidence of embolism: , Janeway lesions,
  • 4. Immunological problems: glomerulonephritis, Osler's nodes
  • 5. Positive blood culture (that doesn't meet a major criterion)
  • 6. Positive echocardiogram (that doesn't meet a major criterion)
perform appropriate cardiac testing in a patient with a cardiac pacemaker
Perform appropriate cardiac testing in a patient with a cardiac pacemaker
  • DO NOT put pacemaker dependent patients on a treadmill
  • Stress test of choice will be adenosine-myocardial perfusion imaging study
diagnose and manage aortic dissection
Diagnose and Manage Aortic Dissection
  • Acute onset chest pain with radiation to back
  • Underlying HTN or phenotypic evidence of connective tissue disease
  • Brachial SBP difference R>L
  • Treatment with IV B-blocker to decrease DP/DT, urgent surgical consultation for involvement of the ascending aorta
  • CXR with widened mediastinum
  • Avoid anticoagulation until imaging is completed
  • May be associated with pericarditis, neurologic symptoms
  • AI murmur detectable in 1/3 of all cases
  • 2:1 male: female
  • 18% previous cardiac surgery, Bicuspid valve in 10-15%, Marfan syndrome 5-10%,
number needed to treat
Number needed to treat
  • Inverse of the absolute reduction in event rates
  • (18/100) / (12/100) = 6/100
  • 100/6 = 16
treat asymptomatic lv dysfunction
Treat Asymptomatic LV dysfunction
  • Identify etiology and treat accordingly (i.e. rule out CAD, then search for other causes)
  • Initiate ACE-I and B-blocker therapies at low doses
  • ASA only indicated for patients with CAD
  • Treat all cardiovascular RF and screen with fasting lipids/TSH/HgA1C