Cardiovascular Board Review I

1
Cardiovascular Board Review I

• Braden Hexom, MD
• Department of Emergency Medicine
• Mount Sinai School of Medicine

2
Question 1

• A 40 yo M, previous healthy presents with cough,
  low-grade fever, and myalgias for 3-4 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
3
Q1 EKG
4
Q1 Answer

• Appropriate next steps include
• ASA 325 mg, Morphine 2 mg, admit CCU
• ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit
  bolus, activate cath team
• Ketorolac 30 mg IV then ibuprofen 800 mg TID for
  1 week as an outpatient
• Lidocaine 75 mg bolus then 2 mg/min infusion,
  labetalol 20 mg IV, admit to telemetry
• Metoprolol 5 mg IV, NTG IV infusion titrated to
  pain, and cardiology consult

5
Q1 Answer

• Appropriate next steps include
• ASA 325 mg, Morphine 2 mg, admit CCU
• No Need For Monitored Admission
• ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit
  bolus, activate cath team
• No Role for Anticoagulation
• Ketorolac 30 mg IV then ibuprofen 800 mg TID for
  1 week as an outpatient
• 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
• 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

6
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

7
Acute Pericarditis
http//urbanhealth.udmercy.edu/ekg/pdf/acuteperica
rditis.pdf
8
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
9
Q2 Answer

• What combination of therapeutic agents is most
• likely to immediately stabilize this patient?
• Heparin and glycoprotein IIb/IIIa inhibitors
• Angiotensin converting enzyme inhibitor and
  clopidogrel
• Steptokinase and magnesium
• Normal saline bolus and dobutamine

10
Q2 Answer

• What combination of therapeutic agents is most
• likely to immediately stabilize this patient?
• Heparin and glycoprotein IIb/IIIa inhibitors
• Not immediately effective
• Angiotensin converting enzyme inhibitor and
  clopidogrel
• Not immediately effective
• Steptokinase and magnesium
• PCI preferred over thrombolytics
• Normal saline bolus and dobutamine
• RVMI is Preload Dependent

11
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

12
Right Ventricular Infact

• Left Sided EKG
• Right Sided EKG

http//ccn.aacnjournals.org/cgi/reprint/25/2/52.pd
f
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Question 3

• The hypertensive emergency that is most easily
  reversible with pharmaceutical management is

PEER VII Q240
14
Q3 Answer

• Acute coronary syndrome
• Aortic dissection
• Eclampsia / pre-eclampsia
• Encephalopathy
• Intracranial hemorrhage

15
Q3 Answer

• Acute coronary syndrome
• Needs Cath
• Aortic dissection
• Not reversible with meds
• Eclampsia / pre-eclampsia
• Needs Delivery
• Encephalopathy
• Treatment w/in 1st Hour Often Reversible
• Intracranial hemorrhage
• Not reversible with meds

16
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 lt110 mmHg

17
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

18
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
19
Q4 Answer

• Complete Heart Block
• Mobitz second-degree HB, type I Wenckebach
• Mobitz second-degree HB, type II
• QT prolongation with U waves
• Sinus bradycardia

20
Q4 Answer

• Complete Heart Block
• Some P waves conduct
• Mobitz second-degree HB, type I Wenckebach
• PR interval increases
• Mobitz second-degree HB, type II
• PR interval constant
• QT prolongation with U waves
• U waves follow T, seen in Hypokalemia
• Sinus bradycardia
• Not sinus

21
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
22
Q5 Answer

• Atropine 1 mg IV
• External cardiac pacemaker
• Isoproterenol infusion at 2 mcg/min, titrate up
• Normal saline
• Potassium infusion at 10 mEq/hr

23
Q5 Answer

• Atropine 1 mg IV
• Type I (not II) Often due to Vagal tone/IWMI
• External cardiac pacemaker
• Type II Often seen with AWMI -gt Complete HB
• Isoproterenol infusion at 2 mcg/min, titrate up
• An option for refractory sinus bradycardia
• Normal saline
• Not usually PWMI
• Potassium infusion at 10 mEq/hr
• Not a hypokalemia rhythm

24
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

25
AV Nodal Blocks

• Caused by conduction delay in AV node
• First-Degree
• PR interval gt 0.2s (200ms)
• All P waves followed by QRS
• No intervention required

http//urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pd
f
26
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.pd
f
27
AV Nodal Blocks

• Second-Degree Mobitz Type II
• Fixed-length PR interval with one or more
  non-conducted beats
• Signifies major damage to conduction system
• Usually seen in AWMI
• Unstable Requires permanent pacemaker

28
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.pd
f
29
Question 6

• Which of the following statements regarding
  cardiac serum markers is correct?

PEER VII Q342
30
Q6 Answer

• BNP level has little correlation with recurrent
  acute coronary syndromes
• CPK appears within 1-2 hours after an acute MI
  and gone within 24 hours
• Myoglobin appears within 1-2 hours after acute MI
  and peaks at 5-7 hours
• Total CPK is more specific for acute cardiac
  ischemia than CK-MB
• Troponins appear in the first 4 hours after an MI
  and are gone by 24 to 36 hours.

31
Q6 Answer

• 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

32
Cardiac Serum Markers

• Myoglobin is the earliest
• Troponin is the most sensitive and specific

http//www.uptodateonline.com
33
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 valueCirculation
2002 Dec 3106(23)2941-5. 2 http//www.kidney.org
/professionals/KDOQI/guidelines_cvd/troponin.htm 3
http//www.uptodateonline.com
34
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
35
Q7 (continued)
36
Q7 Answer

• Admit the patient to a monitored bed
• Observe the patient, order serial cardiac markers
  and discharge if negative
• Administer thrombolytics
• Cardiovert the patient with 50 joules
• Stress testing once serial cardiac enzymes are
  negative

37
Q7 Answer

• Admit the patient to a monitored bed
• Observe the patient, order serial cardiac markers
  and discharge if negative
• Administer thrombolytics
• Cardiovert the patient with 50 joules
• Stress testing once serial cardiac enzymes are
  negative

38
STEMI / LBBB

• STEMI
• Presence of ST elevations of greater than 1mm in
  two or more anatomically contiguous leads
• LBBB
• QRS gt 0.12 s (120ms)
• Wide, notched R wave in I, aVL, V6
• Small R and deep S in II, III, aVF, V1-V3

39
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
TherapyAnn Emerg Med. 200648358-383.
40
Question 8

• Which of the following statements is true
  concerning infective endocarditis in IV drug
  users?

PEER V Q9
41
Q8 Answer

• Most commonly affects the mitral value
• Rarely associated with septic emboli
• Cardiac murmurs frequently are absent at initial
  presentation
• Steptococcus viridans is the most common
  causative organism
• The majority of patients have previously damaged
  heart valves

42
Q8 Answer

• Most commonly affects the mitral value
• Tricuspid is most common
• Rarely associated with septic emboli
• Is a common cause of septic emboli
• Cardiac murmurs frequently are absent at initial
  presentation
• Murmur develops after extensive valve damage
• Steptococcus viridans is the most common
  causative organism
• Staph, MRSA most common
• The majority of patients have previously damaged
  heart valves

43
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

44
Question 9

• Which of the following drugs can be used to
  treat a patient with known Wolff-Parkinson-White
  syndrome who presents with the rhythm depicted
  below

PEER VII Q126
45
Q9 Answer

• Adenosine
• Digoxin
• Diltiazem
• Metoprolol
• Procainamide

46
Q9 Answer

• Adenosine
• Slows AV conduction -gt V.Fib
• Digoxin
• Slows AV conduction -gt V.Fib
• Diltiazem
• Slows AV conduction -gt V.Fib
• Metoprolol
• Slows AV conduction -gt V.Fib
• Procainamide
• Or Amiodarone (or cardioversion)

47
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
48
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

49
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
50
Q10 Answer

• Administer albuterol and check peak flow
• Discharge home with primary care followup
• Laboratory evaluation, including cardiac markers
• Observation admission for treadmill testing
• Outpatient echo and Holter monitor

51
Q10 Answer

• Administer albuterol and check peak flow
• Not indicated by the history
• Discharge home with primary care followup
• Reasonable for 1st episode with reassuring story
• Laboratory evaluation, including cardiac markers
• No clear evidence for trops in kids
• Observation admission for treadmill testing
• Evals for CAD, very rare in kids
• Outpatient echo and Holter monitor
• May be indicated for recurrent episodes

52
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

53
Concerning EKG Findings(Especially in Young
People)

• 1. Delta Wave/Short PR -gt WPW
• 2. LVH -gt Cardiomyopathy
• 3. RBBB/ST in V1 -gt Brugada
• 4. Long QT -gt Congenital or Aquired

54
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
55
Q11 (continued)
http//sprojects.mmi.mcgill.ca/heart/ecgk1.html
56
Q11 Answer

• Atropine 1 mg IV, amiodarone 300 mg IV slow push
• Calcium chloride 1 amp IV, insulin 10 units IV,
  and dextrose 50 g IV
• Dopamine wide open, and prepare for external
  pacer
• Magnesium sulfate 2 g slow IV push, potassium
  chloride 10 mEq over 20 minutes
• Normal saline 500 mL bolus and pericardiocentesis

57
Q11 Answer

• Atropine 1 mg IV, amiodarone 300 mg IV slow push
• This is not sinus bradycardia, and amio not
  indicated
• Calcium chloride 1 amp IV, insulin 10 units IV,
  and dextrose 50 g IV
• Insulin the most rapidly effective
• Dopamine wide open, and prepare for external
  pacer
• Refractory to pacing. Dopamine wont fix
  underlying issue
• Magnesium sulfate 2 g slow IV push, potassium
  chloride 10 mEq over 20 minutes
• Treatment for Hypokalemia (flat Ts, long QT/QRS,
  big Us)
• Normal saline 500 mL bolus and pericardiocentesis
• Tamponoda usually presents with low voltage

58
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.
59
Hyperkalemia
http//sprojects.mmi.mcgill.ca/heart/ecgk1.html ht
tp//urbanhealth.udmercy.edu/ekg/pdf/hyperkalemia.
pdf
60
Hyperkalemia

• Treatment
• Calcium chloride or gluconate
• Dextrose Insulin
• Bicarbonate
• Lasix
• Albuterol
• Kayexalate

61
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
62
Q12 Answer

• Aortic stenosis
• Pulmonary embolus
• Mitral incompetence
• Pulmonary stenosis
• Tricuspid incompetence

63
Q12 Answer

• Aortic stenosis
• Fits the age group for congenital bicuspid valve
• Pulmonary embolus
• Usually more acute, not exertional
• Mitral incompetence
• SV maintained -gt exertional SOB but not syncope
• Pulmonary stenosis
• Dyspnea and Easy Fatigability
• Tricuspid incompetence
• Causes JVD and peripheral edema (right sided)

64
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

65
Question 13

• Which of the following is the most common ECG
  abnormality associated with mitral valve prolapse?

PEER VII Q222
66
Q13 Answer

• Paroxysmal supraventricular tachycardia
• QT prolongation
• Rapid atrial fibrillation
• ST-segment depression in leads II, III, aVF
• Ventricular tachycardia

67
Q13 Answer

• Paroxysmal supraventricular tachycardia
• Also PVCs, APCs
• QT prolongation
• Reported but rare
• Rapid atrial fibrillation
• Not typical
• ST-segment depression in leads II, III, aVF
• Reported but rare
• Ventricular tachycardia
• Reported but rare

68
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

69
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
70
Q14 Answer

• Mesenteric ischemia
• MI
• Aortic dissection
• Pancreatitis
• Ruptured abdominal aneurysm

71
Q14 Answer

• Mesenteric ischemia
• Always consider in elderly, pain gt exam
• MI
• Usually not tender abdomen
• Aortic dissection
• Must consider but abdomen tender/vitals normal
• Pancreatitis
• No h/o EtOH or other comorbidities
• Ruptured abdominal aneurysm
• No pulsatile mass, normal pulses

72
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!!

73
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

74
Question 15

• Which of the following patients is the most
  appropriate candidate for pacing therapy with a
  transcutaneous cardiac pacemaker?

PEER V Q2
75
Q15 Answer

• 25 yo severely hypothermic M with marked
  bradycardia BP undetectable, P 30
• 43 yo M with bradysystolic cardiac arrest for 40
  minutes, BP undetectable, P 15
• 61 yo F with 1st degree AV block and sinus
  bradycardia unresponsive to 1 mg atropine BP
  90/60, P 48
• 58 yo F with 3rd degree AV block unresponsive to
  3 mg atropine, BP 80/50, P 40
• 78 yo M with Mobitz I second-degree AV block, BP
  90/40, P 70

76
Q15 Answer

• 25 yo severely hypothermic M with marked
  bradycardia BP undetectable, P 30
• 43 yo M with bradysystolic cardiac arrest for 40
  minutes, BP undetectable, P 15
• 61 yo F with 1st degree AV block and sinus
  bradycardia unresponsive to 1 mg atropine BP
  90/60, P 48
• 58 yo F with 3rd degree AV block unresponsive to
  3 mg atropine, BP 80/50, P 40
• 78 yo M with Mobitz I second-degree AV block, BP
  90/40, P 70

77
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