Cardiology Board Review I 3n2c2l

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, it 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, it 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, it CCU –

B.

No Need For Monitored ission

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, it 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 istration 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.

K 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 K 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 K 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 K is more specific for acute cardiac ischemia than CK-MB – CK-MB more specific, K 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. it the patient to a monitored bed B. Observe the patient, order serial cardiac markers and discharge if negative C. ister thrombolytics D. Cardiovert the patient with 50 joules E. Stress testing once serial cardiac enzymes are negative

Q7 Answer A. it the patient to a monitored bed B. Observe the patient, order serial cardiac markers and discharge if negative C. ister 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 s?

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. ister albuterol and check peak flow

B. Discharge home with primary care followup C. Laboratory evaluation, including cardiac markers D. Observation ission for treill testing E. Outpatient echo and Holter monitor

Q10 Answer A. ister 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 ission for treill 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 R 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 treill 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