Clinical Pearls in Cardiology

Examination skillsClinical scenarios

Physical examination of a patient's cardiovascular system1.Introduce yourself. position pt.optimal exposure2.cyanosis/clubbingsplinter hemorrhagespallor3.Pulse rate/rhythm, respiratory rate4.BP lying and standing5. JVP: height and waveformcarotid pulse:quality, bruits6. central cyanosisdental cariesconjunctival pallor7.Precordial inspection: shape of chest, abnormal pulsation8.Palpation: site/quality of apex beat, heaves/thrills 

Physical examination continued

9. Listen to apex, axilla, LSE, LLSE10. Sit patient forward- feel for parasternal thrillListen during inspiration and expiration11. Palpate thyroidsacral edema/basal lung dullnessauscultate lungfields for rales12. Lie patient flatPulsatile hepatomegalysplenomegaly; ascitesBruits: renal, femoral13. calf tendernessankle edema, tendon xanthomas, peripheral pulses

Heart FailureHTNCADArrhthymia- A Fib, V fib, SVT Valvular Heart DiseaseInfective endocarditisCardiac clearance/Risk assessmentThe heart in other diseases

Case1

• 51yo man w dilated cardiomyopathy whom you have been treating for the past 3 years has class II NYHA heart failure. Cor angio showed normal coronary arteries. He would like to be more active and asks if anything else can be tried. Takes metop 100mg/d, resting HR 58bpm. Never been able to tolerate ACEI or ARB developing a severe cough in multiple previous trials of these agents. Denies peripheral edema, orthopnea, or PND

Meds and Findings• Metop 100mg/d• Furosemide 20mg/d• Eplerenone 50mg/d• Digoxin 0.125mg/d• ECG- nsr w PR interval 147ms and QRS interval

of 98ms• Echo-LVEF 42%, no sig valve dz, dilated LV w

global hypokinesis• Exam- JVP 8cm, BP 137/76, HR 58, lungs clear,

no peripheral edema• Cardiac exam-+s3,1/6 systolic murmur at LLSB

that decreases w Valsalva, enlarged & sustained point of maximal impulse

Which one of the following is the most reasonable next step in management?

• Prescribe a statin- rosuvastatin 5mg/d• Refer him to a cardiologist for evaluation

for an AICD• Refer him to a cardiologist to be evaluated

for cardiac resynchronization therapy• Initiate treatment w hydralazine and long

acting nitrates• Increase furosemide to 80mg/d

Case 2

• 76 yo man presents w SOB on exertion that began 6mo ago and has gradually worsened. Can no longer perform normal activities wo developing sym and that climbing one flight of stairs causes him to be profoundly SOB. Walking on level ground, he does well, but any hill causes dyspnea. H/O HTN but no h/o HL, T2D, tobacco abuse or F/H/O early CAD. On no meds

Findings• ECG- NSR w normal intervals• CXR -normal cardiac silhouette w clear

lung fields• Echo- LVEF 64% w normal valves, N LV,

RV size and function, no regional wall motion abnormality, normal wall thickness

• Stress test- ability to walk for 4.8 min on Bruce Protocol (78% of predicted functional aerobic capacity), HR incr to 146, BP 200/98, stopped test due to SOB, neg ECG for ischemia

• Exam- lungs clear, JVP 12cm, peripheral edema 1+, BMI 32

Which one of the following actions is the least appropriate to this patient?

• Initiate treatment w ACEI for BP • Initiate treatment w diuretic to resolve

congestion and peripheral edema• Recommend a regular exercise program,

telling him to start slow and increase gradually

• Encourage him to lose weight• Refer him for cor angiography

Case 3

• 66 yo woman w known CAD has had 2 previous MIs, the first 7 years ago & the second 11mos ago. After her last MI, her EF was 28%. Currently has class II NYHA heart failure

• Meds- lisinopril 40mg/d; carvidelol 12.5mg BID; spironolactone 25mg/d; ASA 81mg/d; pravastatin 20mg/d

Findings• Labs- Na 138, K4.4, creat 1.2• Echo- EF 32% w mild MR, markedly enlarged LV

w anterior wall hypokinesis• ECG- HR 60 w SR, PR interval 168 ms, QRS

interval 111 ms, corrected QT interval 402 ms, prior ant MI

• Exam- BP 116/72, HR 60 reg, JVP flat, no peripheral edema, lungs clear w good BS

• Cardiac exam- presence of S3 w enlarged point of maximal impulse that is bifid, no murmur or rub

Which one of the following would be the best therapy for this patient?

• Given that she has NYHA class II HF, continue current therapy

• Add in a diuretic agent such as furosemide 20mg/d

• Add in digoxin 0.125mg every 6hours for 4 times, 0.125 mg /d orally

• Refer for cardiac resynchronization therapy

• Refer for evaluation for an AICD

Case 4• 68 yo man follows up w you after a

hospitalization 2 weeks previously for an episode of acute decompensated HF. During his hospitalization, he underwent diuresis w IV lasix to lose 10lbs of fluid, he has decreased LV function thought to be secy to chronic MR. His MV had been repaired 2 years ago, but his EF of 42% has not improved significantly since then. He has a dilated LV and has sym c/w NYHA class II HF

Meds and Findings• Meds- lasix 20 mg/d; metop 25mg/d;

lisiopril 10mg qhs• Labs- creat 1.4, e GFR 46, K 4.5, clear

lung fields w enlarged cardiac shadow on CXR

• Exam- height 177cm, weight 99kg, BP 118/76, HR 62, both lung bases clear, no leg edema

• Cardiac exam- enlarged bifid; lateral point of maximal impulse, 1/6 holosystolic murmur at apex, pos S3, no S4, JVP 8cm

Which one of the following is the next best step in the treatment of this patient?

• Increase lisinopril to 20mg/d• Add 30 mg of ISMN in am and increase to 60

mg as tolerated• Refer to a dietitian for a low-sodium, fluid

restricted (1500mL) diet• Request that he weigh himself each morning,

provide a schedule for increasing lasix if he gains weight

• Refer him to an electrophysiologist for possible AICD implantation

Case 5• A 73 yo woman w LV systolic dysfunction

whom you have been treating for several years presents to the ED. She is having palpitations and is diagnosed as having A fib HR 130 in the ED. She denies chest pain but is mildly SOB w RVR. She is not sure how long she has had palpitations- thinks they have been intermittent during past few months but have always resolved after a few minutes. This episode lasted more that 2 h, prompting her to seek treatment.

Medical History• HTN well controlled w HCTZ• Hypothyroidism treated medically with normal

TSH• No h/o bleeding problems, strokes or TIAs• No syncope or presyncope• Known CAD w 3-vessel CABG graft performed

11y ago• Meds- HCTZ 25mg/d; lisinopril 20mg/d; metop

12.5mg/d, ASA 81 mg/d• Social history- not physically active, lives in a

high rise retirement complex

Findings• Labs- TSH normal, electrolytes normal,

cbc normal, troponin normal• ECG- A fib, old inferolateral MI, no acute

ST-T changes• Echo- bilateral atrial enlargement w

enlarged LV and decreased function, EF 34%, evidence of inferolateral MI

• Exam- height 167cm, weight 63 kg, lungs clear, rhythm irreg irreg, 1/6 systolic ejection murmur at LLSB, no edema

Which one of the following is the best therapy for this woman w systolic LV dysfunction presenting

w A Fib?• Control HR w beta-blockers and/or dig &

provide anticoagulation w warfarin to INR 2-3

• Administer antiarrhythmic propofenone & perform DC cardioversion

• Administer propofenone, perform TEE to r/o LA thrombus & perform DC cardioversion

• Refer to EP for consideration of AV node ablation w pacemaker implantation & long term anticoagulation

• Refer to EP for pulmonary vein isolation ablation to eradicate the atrial fibrillation

Case 6• A 78 yo woman who you have been treating for the

past 10 y for ch functional NYHA classIII HF, EF 28%, was admitted to the hospital 3 days ago for HF. A year earlier she had an AICD/ CRD implanted. Since being admitted, she has undergone diuresis, lost 8lbs and feels much better. You are ready to dismiss her today, w instructions to continue on her usual home regimen- lasix 20, carvedilol 25mg BID, lisinopril 20mg qhs. She weighs herself daily & takes extra lasix & K when her weight increases. She has been adhering to a low NA diet w 1500ml fluid restriction. Her BNP is 2186. the cause of her HF is CAD, but her last stress test 4mos ago showed a fixed anterior defect but no evidence of ischemia.

Which one of the following would be the best treatment option for this patient at this point in her

care?

• Continuation of current therapy• Addition of an aldosterone inhibitor, such

as spironolactone or eplerenone• Augmentation of current therapy to reduce

her BNP levels to normal and her functional status to NYHA classII or less

• Switch from carvedilol to metoprolol• Follow up stress test