Cardiovascular Board Review I

1
Cardiovascular Board Review I

• Sohan Parekh, 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 (continued)

• 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
• 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

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 (continued)

• 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
• Angiotensin converting enzyme inhibitor and
  clopidogrel
• Steptokinase and magnesium
• Normal saline bolus and dobutamine

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
13
Question 3

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

PEER VII Q240
14
Q3 (continued)

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

15
Q3 Answer

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

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 BP is the goal

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

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 (continued)

• 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
• Mobitz second-degree HB, type I (Wenckebach)
• Mobitz second-degree HB, type II
• QT prolongation with U waves
• Sinus bradycardia

21
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
22
AV Nodal Blocks

• Second-Degree Mobitz I (Wenckebach)
• Progressive lengthening of PR interval followed
  by dropped beat
• Seen in MI, digoxin toxicity, myocarditis, CAD
• Stable rhythm

http//urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pd
f
23
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
• Unstable Requires permanent pacemaker

24
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
25
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
26
Q5 (continued)

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

27
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

28
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

29
Interlude Wencke Back
30
(No Transcript)
31
Question 6

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

PEER VII Q342
32
Q6 (continued)

• 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.

33
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.

34
Cardiac Serum Markers

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

http//www.uptodateonline.com
35
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
36
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
37
Q7 (continued)
38
Q7 (continued)

• 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

39
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

40
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

41
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.
42
Question 8

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

PEER V Q9
43
Q8 (continued)

• 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

44
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

45
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

46
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
47
Q9 (continued)

• Adenosine
• Digoxin
• Diltiazem
• Metoprolol
• Procainamide

PEER VII Q126
48
Q9 Answer

• Adenosine
• Digoxin
• Diltiazem
• Metoprolol
• Procainamide

49
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
50
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

51
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
52
Q10 (continued)

• 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

53
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

54
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

55
InterludeFat Kids
56
(No Transcript)
57
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
58
Q11 (continued)
http//sprojects.mmi.mcgill.ca/heart/ecgk1.html
59
Q11 (continued)

• 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
  pacemaking
• Magnesium sulfate 2 g slow IV push, potassium
  chloride 10 mEq over 20 minutes
• Normal saline 500 mL bolus and pericardiocentesis

60
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
  pacemaking
• Magnesium sulfate 2 g slow IV push, potassium
  chloride 10 mEq over 20 minutes
• Normal saline 500 mL bolus and pericardiocentesis

61
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.
62
Hyperkalemia
http//sprojects.mmi.mcgill.ca/heart/ecgk1.html ht
tp//urbanhealth.udmercy.edu/ekg/pdf/hyperkalemia.
pdf
63
Hyperkalemia

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

64
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
65
Q12 (continued)

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

66
Q12 Answer

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

67
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

68
Question 13

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

PEER VII Q222
69
Q13 (continued)

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

70
Q13 Answer

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

71
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
• Echo and outpatient cardiology management

72
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
73
Q14 (continued)

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

74
Q14 Answer

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

75
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

76
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

77
Question 15

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

PEER V Q2
78
Q15 (continued)

• 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

79
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

80
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