PEARLS IN CARDIOLOGYPEARLS IN CARDIOLOGY

Sandra RodriguezSandra Rodriguez

Internal MedicineInternal Medicine

20082008

Jugular venous PulseJugular venous Pulse

““a” is RA contractiona” is RA contraction ““c” is bulging of TV c” is bulging of TV

during RV systole.during RV systole. ““x” downward x” downward

displacement of TV.displacement of TV. ““v” is atrial filling at v” is atrial filling at

systole, TV closed.systole, TV closed. ““y” is passive atrial y” is passive atrial

emptying.emptying.

Jugular Venous PulseJugular Venous Pulse

Giant “a” wave:Giant “a” wave:Tricuspid stenosisTricuspid stenosisPulmonary stenosisPulmonary stenosisPulmonary hypertensionPulmonary hypertension

Canon “a” wave: (against a closed valve):Canon “a” wave: (against a closed valve):Junctional rhythmJunctional rhythmSlow ventricular tachycardiaSlow ventricular tachycardia2:1 A-V block2:1 A-V blockBigeminyBigeminy

Absent “a” wave:Absent “a” wave:Atrial FibrilationAtrial Fibrilation

Jugular Venous PulseJugular Venous Pulse

Prominent “x” descent:Prominent “x” descent:Cardiac tamponadeCardiac tamponadeConstrictive pericarditisConstrictive pericarditis

Absent “x” descent:Absent “x” descent:RV infarctionRV infarction

Prominent “v” wave:Prominent “v” wave:Tricuspid regurgitationTricuspid regurgitation

Prominent “y” descent:Prominent “y” descent:Constrictive pericarditisConstrictive pericarditis

Slow “y” descent:Slow “y” descent:TS and RA mixoma.TS and RA mixoma.

Absent “y” descent:Absent “y” descent:Cardiac tamponade Cardiac tamponade RV infarctionRV infarction

Prominent x and y: Prominent x and y: Constrictive pericarditisConstrictive pericarditis

Prominent x and absent Prominent x and absent y: Cardiac tamponadey: Cardiac tamponade

Absent x and y: RV Absent x and y: RV infarct.infarct.

QuestionsQuestions

1.1. A 34 year-old patient is on Ma Huang for losing A 34 year-old patient is on Ma Huang for losing weight. She presents with shortness of breath. weight. She presents with shortness of breath. EKG shows wide complex tachycardia. HR is EKG shows wide complex tachycardia. HR is 140/min. Cannon “a” waves are present. 140/min. Cannon “a” waves are present. Cause?Cause?

a. Sinus tachycardia with WPWa. Sinus tachycardia with WPW

b. Sinus tachycardia with aberrant conductionb. Sinus tachycardia with aberrant conduction

c. Atrial fibrilation with aberrant conduction.c. Atrial fibrilation with aberrant conduction.

d. Ventricular tachycardia.d. Ventricular tachycardia.

MurmursMurmurs With inspiration: R side With inspiration: R side

murmurs increase, L side murmurs increase, L side decrease.decrease.

With standing: HCM and MVP With standing: HCM and MVP get louder. get louder.

With squatting or passive leg With squatting or passive leg raising: HCM and MVP raising: HCM and MVP become softer and delayed.become softer and delayed.

With valsalva: HCM and MVP With valsalva: HCM and MVP get louder and longer.get louder and longer.

With amyl nitrite inhalation With amyl nitrite inhalation (decreases LV cavity): AR, MR (decreases LV cavity): AR, MR and VSD decrease while those and VSD decrease while those of HCM and AS increase.of HCM and AS increase.

With exercise (hand grip): With exercise (hand grip): HCM and AS decrease.HCM and AS decrease.

With standing, valsalva, and With standing, valsalva, and inhalation of amyl nitrited (all inhalation of amyl nitrited (all decrease venous return or LV decrease venous return or LV cavity size): Murmurs of HCM cavity size): Murmurs of HCM and MVP increase in intensity. and MVP increase in intensity. All others decrease.All others decrease.

With isometric exercise and With isometric exercise and squatting (all increase LV squatting (all increase LV cavity size): Murmur of HCM cavity size): Murmur of HCM is decreased.is decreased.

With isometric exercise and With isometric exercise and valsalva: Murmur of AS is valsalva: Murmur of AS is decreased in intensity.decreased in intensity.

QuestionsQuestions

2. Murmur of which of the following increases with 2. Murmur of which of the following increases with valsalva and decreases with squatting:valsalva and decreases with squatting:a. Mitral Regurgitation.a. Mitral Regurgitation.b. Hypertrophic cardiomyopathy (HCM)b. Hypertrophic cardiomyopathy (HCM)c. Aortic stenosis c. Aortic stenosis

3. What happens to the murmur of AS with 3. What happens to the murmur of AS with valsalva and hand-grip exercise?valsalva and hand-grip exercise?a. Increase, decreasea. Increase, decreaseb. Decrease, decreaseb. Decrease, decreasec. Decrease, increase.c. Decrease, increase.

Splitting of S2Splitting of S2

INSPIRATIONINSPIRATION EXPIRATIONEXPIRATION

Normal Normal splittingsplitting

s1s1 A2 P2 A2 P2

s1s1 A2 P2A2 P2

Wide splitting Wide splitting (PS,MR,RBB(PS,MR,RBBB, VSD,PDAB, VSD,PDA

s1s1 A2 P2A2 P2 s1s1 A2 P2A2 P2

Paradoxical Paradoxical splitting (AS, splitting (AS, LBBB, HCM, LBBB, HCM, LVH)LVH)

s1s1 P2 A2P2 A2 s1s1 P2 A2P2 A2

Fixed splitting Fixed splitting (ASD)(ASD)

s1s1 A2 P2A2 P2 s1s1 A2 P2A2 P2

QuestionsQuestions A 44 y/o females has history of increasing SOB A 44 y/o females has history of increasing SOB

with exertion over the last 3 months. PE: Fixed with exertion over the last 3 months. PE: Fixed split S2 with a murmur consistent with TR. Rest split S2 with a murmur consistent with TR. Rest of HPI is unremarkable. CXR: increased LA, RA, of HPI is unremarkable. CXR: increased LA, RA, RV and pulmonary circulation. What is the most RV and pulmonary circulation. What is the most likely diagnosis?likely diagnosis?a. Mitral regurgitationa. Mitral regurgitationb. Aortic stenosisb. Aortic stenosisc. Hypertrophic obstructive cardiomyopathyc. Hypertrophic obstructive cardiomyopathyd. Atrial septal defectd. Atrial septal defecte. Ventricular septal defecte. Ventricular septal defect

QuestionsQuestions

A Wide splitting of S2 is representative of:A Wide splitting of S2 is representative of: a. Normal sinus rhythm with RBBB.a. Normal sinus rhythm with RBBB. b. Normal sinus rhythm with LBBB.b. Normal sinus rhythm with LBBB. c. Hypertrophic cardiomyopathy.c. Hypertrophic cardiomyopathy.

Reversed splitting of S2 occurs in which:Reversed splitting of S2 occurs in which:a. ASDa. ASDb. RBBBb. RBBBc. Hypertrophic cardiomyopathyc. Hypertrophic cardiomyopathy

Heart soundsHeart sounds 22ndnd sound and opening snap of MS are best heard on the sound and opening snap of MS are best heard on the

base.base. LSB: TR, AR, VSD, HCMLSB: TR, AR, VSD, HCM Apex: MR, MS, AS.Apex: MR, MS, AS. Below L clavicle: PS, PDA as continuous.Below L clavicle: PS, PDA as continuous. Radiation to L axila: MR.Radiation to L axila: MR. Radiation to RSB and carotids: ASRadiation to RSB and carotids: AS Radiation all over the precordium: VSDRadiation all over the precordium: VSD MS: Loud S1, Split S2, opening snap, rumbling diastolic MS: Loud S1, Split S2, opening snap, rumbling diastolic

murmur in apex. Area <2.5 cm, symptoms correlate.murmur in apex. Area <2.5 cm, symptoms correlate. PR: Diastolic, decrescendo at LSB (Graham Steel)PR: Diastolic, decrescendo at LSB (Graham Steel)

QuestionsQuestions

6. A 52 y/o female presents with history of 6. A 52 y/o female presents with history of increasing SOB and LE edema. CXR shows increasing SOB and LE edema. CXR shows pulmonary congestion, straightening of left heart pulmonary congestion, straightening of left heart border and Kerle B lines. EKG: sinus border and Kerle B lines. EKG: sinus tachycardia with LAE, RBBB. PE: Loud S1, tachycardia with LAE, RBBB. PE: Loud S1, opening snap and diastolic murmur at the apex, opening snap and diastolic murmur at the apex, and SEM in precordium. What is the diagnosis?and SEM in precordium. What is the diagnosis?a. Aortic insufficiencya. Aortic insufficiency

b. Mitral stenosisb. Mitral stenosisc. Aortic stenosisc. Aortic stenosisd. Hypertrophic obstructive cardiomyopathy.d. Hypertrophic obstructive cardiomyopathy.

QuestionsQuestions

7. A 33 y/o pregnant patient in second 7. A 33 y/o pregnant patient in second trimester has SOB due to MS that is not trimester has SOB due to MS that is not responding to medical treatment. ECHO responding to medical treatment. ECHO shows MV of 0.5cm. What is next step:shows MV of 0.5cm. What is next step:

a. Mitral valvotomy after delivery.a. Mitral valvotomy after delivery.

b. Offer pregnancy termination.b. Offer pregnancy termination.

c. Mitral valvotomy now.c. Mitral valvotomy now.

d. Mitral valve replacement nowd. Mitral valve replacement now

Mitral Valve RegurgitationMitral Valve Regurgitation

Etiology:Etiology: Myxomatous degenerationMyxomatous degeneration Rheumatic diseaseRheumatic disease EndocarditisEndocarditis

Grades 1 to 4Grades 1 to 4 Surgical indicationsSurgical indications

If symptomaticIf symptomatic EF<60%EF<60% LVES diameter >4.5cmLVES diameter >4.5cm Pulmonary pressure >55mmg HgPulmonary pressure >55mmg Hg

QuestionsQuestions

A 41 year-old asymptomatic female with A 41 year-old asymptomatic female with MVP and mitral regurgitation is presented. MVP and mitral regurgitation is presented. An ECHO shows severe MR with EF of An ECHO shows severe MR with EF of 50%. CAD is ruled out. What is your 50%. CAD is ruled out. What is your advice regarding her treatment?advice regarding her treatment?

a. Refer for valve replacement.a. Refer for valve replacement.

b. Follow up closely.b. Follow up closely.

c. Begin a diuretic plus ACE-inhibitor.c. Begin a diuretic plus ACE-inhibitor.

Aortic StenosisAortic Stenosis

Aortic StenosisAortic Stenosis HCMHCM

Location of Location of murmurmurmur

Apex and R 2Apex and R 2ndnd intercostal space intercostal space radiating to radiating to carotids.carotids.

LSB,LSB,

With thrillWith thrill

Not radiatingNot radiating

Second Second soundsound

No component A2No component A2 Present A2Present A2

Carotid Carotid PulsePulse

Slowly risingSlowly rising Brisk or bifidBrisk or bifid

Aortic StenosisAortic Stenosis

Grades: Grades: Mild: Valve area of >1 cm2 or gradient < 40mmHg.Mild: Valve area of >1 cm2 or gradient < 40mmHg. Moderate: Valve area of 0.75 to 1 cm2 or gradient 40-Moderate: Valve area of 0.75 to 1 cm2 or gradient 40-

70 mmHg.70 mmHg. Severe: Valve area <0.75 cm2 or gradient >70 Severe: Valve area <0.75 cm2 or gradient >70

mmHg.mmHg. Surgery: If symptoms. Angina, syncope, Surgery: If symptoms. Angina, syncope,

dyspnea, CHF. If not, risk of death 10-20% per dyspnea, CHF. If not, risk of death 10-20% per year.year.

If not suitable for valve replacement If not suitable for valve replacement valvuloplasty is alternative.valvuloplasty is alternative.

QuestionQuestion

A 71 year-old females has dizzy spells with near A 71 year-old females has dizzy spells with near fainting. An echocardiogram shows calcified fainting. An echocardiogram shows calcified aortic valve with area of 0.5cm2. The peak aortic valve with area of 0.5cm2. The peak systolic valve gradient is 90mmHg. She lives systolic valve gradient is 90mmHg. She lives alone and wants everything done for her. What alone and wants everything done for her. What is the next step?is the next step?a. Coronary arteriographya. Coronary arteriographyb. ACE-Inhibitorb. ACE-Inhibitorc. Exercise stress testc. Exercise stress testd. Exercise program with low dose diureticsd. Exercise program with low dose diureticse. Aortic valve replacemente. Aortic valve replacement

QuestionQuestion

A 73 years old patient with R hip fracture, noted A 73 years old patient with R hip fracture, noted to have a SEM. Echo shows AV area of 0.76cm to have a SEM. Echo shows AV area of 0.76cm and gradient of 50mmHg, normal LV function. Pt and gradient of 50mmHg, normal LV function. Pt is active and asymptomatic. What is the next is active and asymptomatic. What is the next step?step?

a. Balloon valvuloplasty prior to surgery.a. Balloon valvuloplasty prior to surgery.

b. Cardiac catheterization.b. Cardiac catheterization.

c. Proceed with hip surgery.c. Proceed with hip surgery.

d. Aortic valve replacement before hip surgery.d. Aortic valve replacement before hip surgery.

QuestionsQuestions

A 23 y/o male presents to the ER with witnessed A 23 y/o male presents to the ER with witnessed syncope while running to catch a bus. There was syncope while running to catch a bus. There was no observed postictal state. At PE brisk carotid no observed postictal state. At PE brisk carotid upstroke. SEM 3/6 at LSB with a systolic thrill. upstroke. SEM 3/6 at LSB with a systolic thrill. Murmur increase upon standing. What is the Murmur increase upon standing. What is the most likeky diagnosis?most likeky diagnosis?a. Rheumatic mitral regurgitationa. Rheumatic mitral regurgitationb. Congenital aortic stenosisb. Congenital aortic stenosisc. Hypertrophic obstructive cardiomyopathyc. Hypertrophic obstructive cardiomyopathyd. Ebstein’s anomalyd. Ebstein’s anomaly

DVT/PE prophylaxisDVT/PE prophylaxis

Start before or shortly after surgery.Start before or shortly after surgery.Total knee replacement minimum duration Total knee replacement minimum duration

is 7 to 10 days with LMWH or warfarin.is 7 to 10 days with LMWH or warfarin.Total hip replacement minimum duration is Total hip replacement minimum duration is

28-42 days with LMWH or warfarin.28-42 days with LMWH or warfarin. IPC only for patients at high risk of IPC only for patients at high risk of

bleeding.bleeding.

QuestionsQuestions

A patient with PE is in shock. Next step?A patient with PE is in shock. Next step? a. Thrombolysisa. Thrombolysis b. Embolectomyb. Embolectomy c. Heparinc. Heparin

A 63 year old construction worker with h/o 3 A 63 year old construction worker with h/o 3 episodes of DVT on coumadin, INR 2.5 comes episodes of DVT on coumadin, INR 2.5 comes again with DVT. What to do?again with DVT. What to do? a. Increase dose of coumadina. Increase dose of coumadin b. Add low molecular weigth heparinb. Add low molecular weigth heparin c. Greenfield filterc. Greenfield filter

PAW=RA=RV=PAPAW=RA=RV=PACardiac Cardiac TamponadeTamponade

Constrictive Constrictive PericarditisPericarditis

Right Ventricular Right Ventricular InfarctionInfarction

Equal Diastolic Equal Diastolic PressuresPressures

PresentPresent PresentPresent Present/AbsentPresent/Absent

Calcification on X-Calcification on X-Ray, CT/MRIRay, CT/MRI

AbsentAbsent PresentPresent AbsentAbsent

ECHOECHO Effusion with Effusion with diastolic collapsediastolic collapse

Thick/calcified Thick/calcified pericardiumpericardium

Large RV sizeLarge RV size

EKGEKG Low voltage and Low voltage and elect. alternanselect. alternans

Low voltageLow voltage ST elevation on ST elevation on Right leadsRight leads

Prominent XProminent X PresentPresent PresentPresent AbsentAbsent

Prominent YProminent Y AbsentAbsent PresentPresent AbsentAbsent

Pericardial KnockPericardial Knock AbsentAbsent PresentPresent AbsentAbsent

Pulsus ParadoxusPulsus Paradoxus PresentPresent Absent in 2/3 of ptAbsent in 2/3 of pt AbsentAbsent

Kussmaul signKussmaul sign AbsentAbsent PresentPresent Absent/PresentAbsent/Present

Cardiac TamponadeCardiac Tamponade Causes: Viral, Metastasis, idiopathic, uremic, trauma, Causes: Viral, Metastasis, idiopathic, uremic, trauma,

cardiac rupture, aortic disection.cardiac rupture, aortic disection. Features: Features:

Depends on the rapidity of fluid accumulation.Depends on the rapidity of fluid accumulation. Limited ventricular filling in diastole, absent Y Limited ventricular filling in diastole, absent Y Low cardiac output, hypotension, tachycardia,Low cardiac output, hypotension, tachycardia, High jugular venous pressure with prominent x descent.High jugular venous pressure with prominent x descent.

Paradoxical pulse, lungs clear, faint heart soundsParadoxical pulse, lungs clear, faint heart sounds EKG: Electrical alternans, low voltageEKG: Electrical alternans, low voltage Cath: Equalization of pressures (RA, RV, PA, PCWP)Cath: Equalization of pressures (RA, RV, PA, PCWP) Echocardiogram: RV, RA diastolic collapse, IVC dilationEchocardiogram: RV, RA diastolic collapse, IVC dilation Treatment: Pericardiocentesis, IV fluids, surgery.Treatment: Pericardiocentesis, IV fluids, surgery.

Constrictive PericarditisConstrictive Pericarditis Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB, Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB,

cancer, uremia.cancer, uremia. Features:Features:

Filling is reduced abruptly because thickened pericardiumFilling is reduced abruptly because thickened pericardium Stroke volume is reduced, equalization of pressures.Stroke volume is reduced, equalization of pressures. High jugular venous pressure with prominent x and y descents, as M High jugular venous pressure with prominent x and y descents, as M

shape.shape. Dip and plateau “square root” sign in L and R ventricular pressuresDip and plateau “square root” sign in L and R ventricular pressures

Pericardial knock, kussmaul’s sign, R and L heart failure.Pericardial knock, kussmaul’s sign, R and L heart failure. EKG: Low voltageEKG: Low voltage ECHO: Rapid decrease in filling velocities, abnormal septum ECHO: Rapid decrease in filling velocities, abnormal septum

motion, pericardial thickness in 80% of cases.motion, pericardial thickness in 80% of cases. Radiology: May have calcificationRadiology: May have calcification Treatment: Pericardial resection with mortality 6-20%, diuretics, Treatment: Pericardial resection with mortality 6-20%, diuretics,

sinus rhythm, may resolve within months or after antiinflamatory tx.sinus rhythm, may resolve within months or after antiinflamatory tx.

Restrictive CardiomyopathyRestrictive Cardiomyopathy Causes: Infiltrative, storage and collagen Causes: Infiltrative, storage and collagen

diseases; radiation, anthracyclins.diseases; radiation, anthracyclins. Features:Features:

Diastolic dysfunction, pulmonary congestion, may Diastolic dysfunction, pulmonary congestion, may advance to systolic dysfunction.advance to systolic dysfunction.

Dyspnea, JVD, Kussmaul’s, R side heart failure.Dyspnea, JVD, Kussmaul’s, R side heart failure. EKG: L or R BBB, L or R VH.EKG: L or R BBB, L or R VH. ECHO: LVH, homogeneous, dense walls, No ECHO: LVH, homogeneous, dense walls, No

calcification.calcification. Treatment: Diuretic, stem cell, deferoxamine, Treatment: Diuretic, stem cell, deferoxamine,

pacemaker.pacemaker.

Acute Right Ventricular InfarctionAcute Right Ventricular Infarction

Causes: Inferoposterior infarction Causes: Inferoposterior infarction extension.extension.

Features:Features:High jugular venous pressures, kussmaul High jugular venous pressures, kussmaul

sign, hepatomegaly, hypotension.sign, hepatomegaly, hypotension.Absent x and y.Absent x and y.Cath: Low PAP, low PCWP, High RV EDP.Cath: Low PAP, low PCWP, High RV EDP.

EKG: ST elevation in RV4.EKG: ST elevation in RV4.Echo: Enlarged hypokinetic RV.Echo: Enlarged hypokinetic RV.

QuestionQuestion A 64 year old male with history of RA, presents with 10 A 64 year old male with history of RA, presents with 10

month history of refractory severe lower extremity and month history of refractory severe lower extremity and scrotal edema, ascitis despite diuretics. CXR with clear scrotal edema, ascitis despite diuretics. CXR with clear lung fields and small bilateral pleural effusions, calcific lung fields and small bilateral pleural effusions, calcific stipping of the cardiac silhouette. CVP has prominent x stipping of the cardiac silhouette. CVP has prominent x and y, with spike and plateau tracing in RV. ECHO and y, with spike and plateau tracing in RV. ECHO showed normal septum thickness. What is the most showed normal septum thickness. What is the most likely diagnosis?likely diagnosis? A. Cor PulmonaleA. Cor Pulmonale B. Cardiac tamponadeB. Cardiac tamponade C. Constrictive pericarditisC. Constrictive pericarditis D. Amyloid cardiomyopathyD. Amyloid cardiomyopathy

QuestionQuestion

A 54 year old male one day post-uncomplicated A 54 year old male one day post-uncomplicated IWMI. The nurse tells you that patient doesn’t IWMI. The nurse tells you that patient doesn’t have complains but the BP is 80/45 and the HR have complains but the BP is 80/45 and the HR is 85. The neck veins are noticeable at the is 85. The neck veins are noticeable at the angle of the jaw and the lungs are clear to angle of the jaw and the lungs are clear to auscultation. At exam RR, no S3, no edema. auscultation. At exam RR, no S3, no edema. What to do next?What to do next? A. Cardiac catheterizationA. Cardiac catheterization B. IV dobutamine/lasixB. IV dobutamine/lasix C. Atropine and then temporary pacemakerC. Atropine and then temporary pacemaker D. IV fluidsD. IV fluids

Aortic AneurysmAortic Aneurysm Localized >50% diameter increase involving all three layers Localized >50% diameter increase involving all three layers

of the wall.of the wall. Risk factors: Age>60 years, smoking, HTN, dyslipidemia, Risk factors: Age>60 years, smoking, HTN, dyslipidemia,

family history. If younger, think of Marfan, Ehler-Danlos , family history. If younger, think of Marfan, Ehler-Danlos , syphilis, Takayasu’s, trauma, bicuspid valve, aortic syphilis, Takayasu’s, trauma, bicuspid valve, aortic coartation.coartation.

Most common in men, 3:1; infrarenal, mostly asymptomatic, Most common in men, 3:1; infrarenal, mostly asymptomatic, can present with compression symptoms, distal embolism can present with compression symptoms, distal embolism or rupture.or rupture.

Surgery if growth more than 0.5cm/year, abdominal >55 Surgery if growth more than 0.5cm/year, abdominal >55 mm in men, >45mm in women, ascending aortic >50mm, mm in men, >45mm in women, ascending aortic >50mm, and descending >60mm.and descending >60mm.

Patients with >45mm should have f/u 3 months.Patients with >45mm should have f/u 3 months. Percutaneous repair is possible for infrarenal.Percutaneous repair is possible for infrarenal. After surgery, evaluate every 6 months with CT or MRI.After surgery, evaluate every 6 months with CT or MRI.

Aortic dissectionAortic dissection Diagnosis often delayed owing to failure to consider it as a Diagnosis often delayed owing to failure to consider it as a

possibility. possibility. Risk factors: In younger than 70 years: Turner’s, cocaine, bicuspid Risk factors: In younger than 70 years: Turner’s, cocaine, bicuspid

valve, collagen disorders-Marfan, Ehlers Danlos-, aortic coartation. valve, collagen disorders-Marfan, Ehlers Danlos-, aortic coartation. In older than 70years: HTN, diabetes, vasculitis and preexisting In older than 70years: HTN, diabetes, vasculitis and preexisting aortic aneurysm.aortic aneurysm.

Blood pass between lumen and media creating a false lumen.Blood pass between lumen and media creating a false lumen. Stanford A: Ascending aorta. 2:1. Involves aortic arch in 30%, Stanford A: Ascending aorta. 2:1. Involves aortic arch in 30%,

worse prognosis, surgical emergency. Mortality with surgery 10-30% worse prognosis, surgical emergency. Mortality with surgery 10-30% and without 50%.and without 50%.

Stanford B: The rest of aorta. Mortality with medical management Stanford B: The rest of aorta. Mortality with medical management 10% per year or better. Surgery if occlusion of major branch, 10% per year or better. Surgery if occlusion of major branch, extension of dissection, Marfan. TX: BB, SBP 100-120, avoid extension of dissection, Marfan. TX: BB, SBP 100-120, avoid strenous activity, F/u at 3, 6, 12 months.strenous activity, F/u at 3, 6, 12 months.

Presentation: Anterior or posterior CP, AR, MI, pleural or pericardial Presentation: Anterior or posterior CP, AR, MI, pleural or pericardial effusion, mental status changes; splacnic, renal, LE, spine ischemia.effusion, mental status changes; splacnic, renal, LE, spine ischemia.

TEE, CT, MRITEE, CT, MRI

QuestionQuestion

An elderly patient has chest pain radiating An elderly patient has chest pain radiating to the back. BP is lower in left arm. to the back. BP is lower in left arm. Diastolic murmur at LSB. EKG shows ST Diastolic murmur at LSB. EKG shows ST depression all over, BP 250/130. depression all over, BP 250/130.

What is the immediate treatment?What is the immediate treatment?a. Thrombolysisa. Thrombolysis

b. Aspirin, lovenox. Abciximab.b. Aspirin, lovenox. Abciximab. c. Metoprolol and NTG or NTP.c. Metoprolol and NTG or NTP. d. Nicardipined. Nicardipine

QuestionQuestion What test will you do?What test will you do?

A. CT chest w/o contrastA. CT chest w/o contrast B. MRI chest w/o contrastB. MRI chest w/o contrast C. TTEC. TTE D. TEED. TEE

Showed aortic dissection of ascending aorta. Showed aortic dissection of ascending aorta. Pain has improved. BP is normal. What to do Pain has improved. BP is normal. What to do next?next? Take patient for surgeryTake patient for surgery Continue medical therapy unless rupture or pain.Continue medical therapy unless rupture or pain. Wait for few days for patient to stabilize before Wait for few days for patient to stabilize before

surgery.surgery.

Carotid Artery DiseaseCarotid Artery Disease Stroke is third leading cause of death.Stroke is third leading cause of death. There are about 1 million strokes/year.There are about 1 million strokes/year. Carotid duplex for all symptomatic, for asymptomatic Carotid duplex for all symptomatic, for asymptomatic

with bruits if good candidate for revascularization, or any with bruits if good candidate for revascularization, or any going for CABG.going for CABG.

ASA has RRR 16% for fatal stroke and 28% for non fatal ASA has RRR 16% for fatal stroke and 28% for non fatal stroke.stroke.

ASA is as good as CEA for symptomatic with <50% and ASA is as good as CEA for symptomatic with <50% and for asymptomatic with <60%.for asymptomatic with <60%.

Extended-release dipyridamole plus ASA superior to Extended-release dipyridamole plus ASA superior to ASA alone for secondary prevention.ASA alone for secondary prevention.

Dual therapy as Clopidogrel plus ASA only for recurrent Dual therapy as Clopidogrel plus ASA only for recurrent events despite therapy with ASA. Higher risk of bleed.events despite therapy with ASA. Higher risk of bleed.

QuestionQuestion

A patient with recent TIA and ipsilateral A patient with recent TIA and ipsilateral 50-69% carotid stenosis, you will 50-69% carotid stenosis, you will recommend:recommend:A. Atherosclerotic risk factor modificationA. Atherosclerotic risk factor modificationB. Antiplatelet therapyB. Antiplatelet therapyC. Carotid endarterectomyC. Carotid endarterectomyD. Carotid Arterial StentingD. Carotid Arterial StentingE. A, B and C.E. A, B and C.

Bacterial EndocarditisBacterial Endocarditis The fourth leading cause of life-threatening disease due The fourth leading cause of life-threatening disease due

to infection.to infection. Low incidence but high mortality.Low incidence but high mortality. 2 major Duke criteria or 1 and 3 or 5 minor.2 major Duke criteria or 1 and 3 or 5 minor. CHF occurs on 8-30% of patients.CHF occurs on 8-30% of patients. Systemic embolization happens in up to half of cases, of Systemic embolization happens in up to half of cases, of

those 65% involve CNS.those 65% involve CNS. Perivalvular abscess affect AV in 40%.Perivalvular abscess affect AV in 40%. TTE has sensitivity of 50-80%TTE has sensitivity of 50-80% TEE has sensitivity of 95% for vegetations.TEE has sensitivity of 95% for vegetations. Tx: From 2 to 6 weeks.Tx: From 2 to 6 weeks.

DUKE CRITERIADUKE CRITERIA1. Positive blood culture for Infective Endocarditis1. Positive blood culture for Infective Endocarditis

Typical microorganism on 2 or more blood cultures: •  Typical microorganism on 2 or more blood cultures: •  Viridans streptococci, Viridans streptococci, Streptococcus bovis (gallolyticus)Streptococcus bovis (gallolyticus), or , or HABCEKHABCEK or •  Community-acquired or •  Community-acquired Staphylococcus aureusStaphylococcus aureus or or enterococci.enterococci.

Continuous bacteremia: •  Continuous bacteremia: •  2 positive cultures drawn >12 hours apart, or •  all of 3 or a 2 positive cultures drawn >12 hours apart, or •  all of 3 or a majority of 4 separate cultures of blood (with first and last majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart) sample drawn 1 hour apart)

Positive blood culture for CB or IgG titer >1:800.Positive blood culture for CB or IgG titer >1:800.2. Evidence of endocardial involvement2. Evidence of endocardial involvement

Positive echocardiogram for IE defined as :Positive echocardiogram for IE defined as : Vegetation or Vegetation or  abscess orabscess or new partial dehiscence of prosthetic valvenew partial dehiscence of prosthetic valve

New valvular regurgitation (worsening or changing of preexisting New valvular regurgitation (worsening or changing of preexisting murmur not sufficient) murmur not sufficient)

Duke criteriaDuke criteria Minor criteria : Minor criteria :

PredispositionPredisposition: predisposing heart condition or intravenous : predisposing heart condition or intravenous drug usedrug use

FeverFever: temperature > 38.0° C (100.4° F): temperature > 38.0° C (100.4° F) Vascular phenomenaVascular phenomena: major arterial emboli, septic pulmonary : major arterial emboli, septic pulmonary

infarcts, mycotic aneurysm, intracranial hemorrhage, infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesionsconjunctival hemorrhages, and Janeway lesions

Immunologic phenomenaImmunologic phenomena: glomerulonephritis, Osler's nodes, : glomerulonephritis, Osler's nodes, Roth spots Roth spots and rheumatoid factorand rheumatoid factor

Microbiological evidenceMicrobiological evidence: positive blood culture but does not : positive blood culture but does not meet a major criterion as noted above¹ or serological evidence meet a major criterion as noted above¹ or serological evidence of active infection with organism consistent with IEof active infection with organism consistent with IE

Echocardiographic findingsEchocardiographic findings: consistent with IE but do not : consistent with IE but do not meet a major criterion as noted above meet a major criterion as noted above

¹ ¹ Excludes single positive cultures for coagulase-negative staphylococci, Excludes single positive cultures for coagulase-negative staphylococci, diphtheroids, and organisms that do not commonly cause endocarditis. diphtheroids, and organisms that do not commonly cause endocarditis.

AB Prophylaxis for BEAB Prophylaxis for BE

Low risk: Low risk: Secundum ASDSecundum ASD Innocent murmurInnocent murmur CABG surgeryCABG surgery Pacemaker/ICDPacemaker/ICD MVP without MRMVP without MR

High risk:High risk: Prosthetic valveProsthetic valve Cyanotic congenital Cyanotic congenital

heart diseaseheart disease Previous endocarditisPrevious endocarditis

Moderate risk:Moderate risk: All other congenital All other congenital

heart disease.heart disease. Bicuspid aortic valveBicuspid aortic valve Acquired valve Acquired valve

diseasedisease HCMHCM MVP with MRMVP with MR

Surgery Indications in Bacterial Surgery Indications in Bacterial endocarditisendocarditis

About 20-50% will require surgery.About 20-50% will require surgery. Hemodinamic instability due to valvular Hemodinamic instability due to valvular

regurgitation, destruction.regurgitation, destruction. Cardiogenic shockCardiogenic shock Perivalvular extension, abscessPerivalvular extension, abscess Resistant infectionResistant infection Fungal endocarditisFungal endocarditis Vegetation >1cm in diameterVegetation >1cm in diameter Recurrent distal emboli.Recurrent distal emboli.

QuestionQuestion A 62 years old patient has had aortic valve A 62 years old patient has had aortic valve

replaced six months ago. He presents with replaced six months ago. He presents with endocarditis of the valve with findings of endocarditis of the valve with findings of moderate CHF due to regurgitation. He is moderate CHF due to regurgitation. He is treated for CHF and antibiotics are started. He treated for CHF and antibiotics are started. He begins to improve with good response to the begins to improve with good response to the treatment. EKG has new prolonged PR interval. treatment. EKG has new prolonged PR interval. What is your next step?What is your next step? A. Continue 2 more weeks with IV AB.A. Continue 2 more weeks with IV AB. B. Surgery consult for AV reconstruction.B. Surgery consult for AV reconstruction. C. Discharge pt with IV AB by HHC.C. Discharge pt with IV AB by HHC. D. Continue in hospital IV AB until 3 BC are negative.D. Continue in hospital IV AB until 3 BC are negative.

Stress testingStress testingCriteria for a “ Positive Treadmill Exercise Test”:Criteria for a “ Positive Treadmill Exercise Test”:

ST depression of > 0.1 mV (1mm) below the baseline, and lasting longer ST depression of > 0.1 mV (1mm) below the baseline, and lasting longer than 0.08 msec.than 0.08 msec.

High Risk Ischemic ResponseHigh Risk Ischemic Response Ischemia induced by low-level exercise* (less than 4 METs or heart rate < 100 Ischemia induced by low-level exercise* (less than 4 METs or heart rate < 100

bpm or < 70% of age-predicted heart rate) manifested by 1 or more of the bpm or < 70% of age-predicted heart rate) manifested by 1 or more of the following:following:

Horizontal or downsloping ST depression > 0.1 mVHorizontal or downsloping ST depression > 0.1 mV ST-segment elevation > 0.1 mV in noninfarct leadST-segment elevation > 0.1 mV in noninfarct lead Five or more abnormal leadsFive or more abnormal leads Persistent ischemic response >3 minutes after exertionPersistent ischemic response >3 minutes after exertion Typical anginaTypical angina Exercise-induced decrease in systolic BP by 10 mm HgExercise-induced decrease in systolic BP by 10 mm Hg

Stress testingStress testingIntermediateIntermediate: :

Ischemia induced by moderate-level exercise (4 to 6 METs or HR 100 to 130 Ischemia induced by moderate-level exercise (4 to 6 METs or HR 100 to 130 bpm (70% to 85% of age-predicted heart rate) with bpm (70% to 85% of age-predicted heart rate) with >> 1 of the following: 1 of the following:

Horizontal or downsloping ST depression > 0.1 mVHorizontal or downsloping ST depression > 0.1 mV Persistent ischemic response greater than 1 to 3 minutes after exertionPersistent ischemic response greater than 1 to 3 minutes after exertion Three to 4 abnormal leadsThree to 4 abnormal leads

Low Low No ischemia or ischemia induced at high-level exercise (> 7 METs or HR > 130 No ischemia or ischemia induced at high-level exercise (> 7 METs or HR > 130 bpm (greater than 85% of age-predicted heart rate)) manifested by:bpm (greater than 85% of age-predicted heart rate)) manifested by:

Horizontal or downsloping ST depression > 0.1 mVHorizontal or downsloping ST depression > 0.1 mV One or 2 abnormal leadsOne or 2 abnormal leads

Inadequate test Inadequate test Inability to reach adequate target workload or heart rate response for age Inability to reach adequate target workload or heart rate response for age without an ischemic response. For patients undergoing noncardiac surgery, the without an ischemic response. For patients undergoing noncardiac surgery, the inability to exercise to at least the intermediate-risk level without ischemia inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test.should be considered an inadequate test.

Un-interpretable Treadmill EKGUn-interpretable Treadmill EKG

Resting T-wave abnormalitiesResting T-wave abnormalitiesWPWWPWPaced rhythmPaced rhythmLVHLVHDigoxinDigoxinMVPMVPLBBBLBBB

QuestionQuestion

A patient with COPD,(having wheezing A patient with COPD,(having wheezing and ronchi), and PVD, unable to walk even and ronchi), and PVD, unable to walk even one block needs a cardiac stress test. one block needs a cardiac stress test. EKG has RAE. BP is normal. Which one?EKG has RAE. BP is normal. Which one?A. Dobutamine stress testA. Dobutamine stress testB. Exercise echocardiogramB. Exercise echocardiogramC. Adenosine stress testC. Adenosine stress testD. Exercise electrocardiographyD. Exercise electrocardiography

Preoperative EvaluationPreoperative Evaluation

Preoperative EvaluationPreoperative Evaluation

Risk Stratification Risk Stratification Procedure Examples Procedure Examples

Vascular (reported cardiac Vascular (reported cardiac Aortic and other major vascular surgery Aortic and other major vascular surgery

risk often > 5%) risk often > 5%) Peripheral vascular surgery Peripheral vascular surgery

Intermediate (reported Intermediate (reported Intraperitoneal and intrathoracic surgery Intraperitoneal and intrathoracic surgery

cardiac risk generally 1%-5%) cardiac risk generally 1%-5%) Carotid endarterectomy Carotid endarterectomy

Head and neck surgery Orthopedic Head and neck surgery Orthopedic

surgery Prostate surgery surgery Prostate surgery

Low† (reported cardiac Low† (reported cardiac Endoscopic procedures Endoscopic procedures

risk generally <1%risk generally <1% Superficial procedure Superficial procedure

Cataract surgery Breast surgery Cataract surgery Breast surgery Ambulatory surgery Ambulatory surgery

*Active cardiac conditions*Active cardiac conditionsConditionCondition ExamplesExamples

Unstable coronary Unstable coronary syndromessyndromes

Unstable or severe angina* (CCS class III or IV)†Unstable or severe angina* (CCS class III or IV)†Recent MI‡Recent MI‡

Decompensated HFDecompensated HF NYHA functional class IV; NYHA functional class IV; Worsening or new-onset HFWorsening or new-onset HF

Significant arrhythmiasSignificant arrhythmias High-grade atrioventricular blockHigh-grade atrioventricular blockMobitz II atrioventricular blockMobitz II atrioventricular blockThird-degree atrioventricular heart blockThird-degree atrioventricular heart blockSymptomatic ventricular arrhythmiasSymptomatic ventricular arrhythmiasSupraventricular arrhythmias (including atrial Supraventricular arrhythmias (including atrial

fibrillation) with uncontrolled ventricular rate (HR > fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest)100 bpm at rest)

Symptomatic bradycardiaSymptomatic bradycardiaNewly recognized ventricular tachycardiaNewly recognized ventricular tachycardia

Severe valvular Severe valvular diseasedisease

Severe aortic stenosis (mean pressure gradient Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)cm2, or symptomatic)

Symptomatic mitral stenosis (progressive Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)dyspnea on exertion, exertional presyncope, or HF)

Can You…Can You… Can You…Can You…

1 Met1 Met Take care of yourself?Take care of yourself? 4 4 MetsMets

Climb a flight of stairs or Climb a flight of stairs or walk up a hill?walk up a hill?

Eat, dress, or use the Eat, dress, or use the toilet?toilet?

Walk on level ground at 4 Walk on level ground at 4 mph (6.4 kph)?mph (6.4 kph)?

Walk indoors around the Walk indoors around the house?house?

Do heavy work around the Do heavy work around the house like scrubbing floors house like scrubbing floors or lifting or moving heavy or lifting or moving heavy furniture?furniture?

Walk a block or 2 on level Walk a block or 2 on level ground at 2 to 3 mph (3.2 ground at 2 to 3 mph (3.2 to 4.8 kph)?to 4.8 kph)?

Participate in moderate Participate in moderate recreational activities like recreational activities like golf, bowling, dancing, golf, bowling, dancing, doubles tennis, or throwing doubles tennis, or throwing a baseball or football?a baseball or football?

4 Mets4 Mets Do light work around the Do light work around the house like dusting or house like dusting or washing dishes?washing dishes?

≥ ≥ 10 10 MetsMets

Participate in strenuous Participate in strenuous sports like swimming, sports like swimming, singles tennis, football, singles tennis, football, basketball, or skiing?basketball, or skiing?

Preoperative EvaluationPreoperative Evaluation

Revised Cardiac Risk Index or Clinical Risk FactorsRevised Cardiac Risk Index or Clinical Risk Factors

Ischemic heart diseaseIschemic heart disease History of MIAnginaHistory of MIAngina Use of nitroglycerine Use of nitroglycerine Q wavesQ waves

Congestive heart failureCongestive heart failure History of heart failureHistory of heart failure Pulmonary edemaPulmonary edema Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea Peripheral edema, rales, Peripheral edema, rales, S3S3

History of Stroke or TIAHistory of Stroke or TIA Diabetes on insulin therapyDiabetes on insulin therapy Creatinine>2mg/dl.Creatinine>2mg/dl.

Preoperative EvaluationPreoperative Evaluation

QuestionQuestion

Which of the following is most important Which of the following is most important pre-operative cardiac risk factor for non-pre-operative cardiac risk factor for non-cardiac surgical procedures?cardiac surgical procedures?A. S4 gallopA. S4 gallopB. S3 gallopB. S3 gallopC. MI 10 months agoC. MI 10 months agoD. Age over 70 years.D. Age over 70 years.

QuestionQuestion

A 71 year old male with h/o stable angina, A 71 year old male with h/o stable angina, now needs vascular surgery in the leg. now needs vascular surgery in the leg. What is your advice before clearing him for What is your advice before clearing him for surgery?surgery?A. Proceed with surgery.A. Proceed with surgery.B. Exercise stress test with imaging.B. Exercise stress test with imaging.C. Adenosine stress testC. Adenosine stress testD. Avoid surgeryD. Avoid surgeryE. Cardiac catheterizationE. Cardiac catheterization

Acute Coronary SyndromeAcute Coronary SyndromeUnstable Angina & NSTEMIUnstable Angina & NSTEMI

TIMI risk score:TIMI risk score: Age 65 years or olderAge 65 years or older 3 or more CAD traditional 3 or more CAD traditional

risk factorsrisk factors Documented CAD with Documented CAD with

stenosis of 50% stenosis of 50% ST segment deviationST segment deviation 2 or more anginal episodes 2 or more anginal episodes

in the last 24hrin the last 24hr Aspirin use within the last 7 Aspirin use within the last 7

daysdays Elevated cardiac enzymesElevated cardiac enzymes

Low risk: 0-2, Low risk: 0-2, Conservative approach Conservative approach with non-invasive stress with non-invasive stress testingtesting

Intermediate risk: 3-4 Intermediate risk: 3-4 Initiate glycoprotein Initiate glycoprotein IIb/IIIa inhibitor and early IIb/IIIa inhibitor and early invasive approach with invasive approach with angiographyangiography

High risk: 5-7 or High risk: 5-7 or persistent pain or persistent pain or elevated troponin, elevated troponin, angiographyangiography

QuestionQuestion

A 51 year old patient comes with typical chest A 51 year old patient comes with typical chest pain, persistent after ASA, nitrates, betablocker, pain, persistent after ASA, nitrates, betablocker, 02, morphine, statin, lovenox, is taken to the 02, morphine, statin, lovenox, is taken to the cath, showing proximal LAD 70%, Cx 30%, RCA cath, showing proximal LAD 70%, Cx 30%, RCA 30%, normal ejection fraction. What to do next?30%, normal ejection fraction. What to do next? CABGCABG PCIPCI Add ACEIAdd ACEI ThrombolysisThrombolysis

Indications for revascularizationIndications for revascularization For PCIFor PCI

Unstable angina failing medical therapy or TIMI 3 or moreUnstable angina failing medical therapy or TIMI 3 or more Unstable angina in patient with prior revascularization CABG or Unstable angina in patient with prior revascularization CABG or

PCIPCI ST elevation MIST elevation MI Failed thrombolysis Failed thrombolysis Unable to do thrombolysisUnable to do thrombolysis MI complicated by shock, refractory ventricular arrythmia, CHF MI complicated by shock, refractory ventricular arrythmia, CHF

or sudden death.or sudden death. For CABGFor CABG

Left main diseaseLeft main disease 2 vessel disease with proximal LAD w (+) ischemia or low EF, 2 vessel disease with proximal LAD w (+) ischemia or low EF,

most benefit seen in diabetic patients.most benefit seen in diabetic patients. 3 vessel disease3 vessel disease

ThrombolysisThrombolysis Indications for Tenecteplase: ST elevation >6hr Indications for Tenecteplase: ST elevation >6hr

or continuos pain and elevation up to 12hr or or continuos pain and elevation up to 12hr or new LBBB with typical CP. Follow with CP, ST new LBBB with typical CP. Follow with CP, ST segment, reperfusion arrythmia, enzymes.segment, reperfusion arrythmia, enzymes.

Contraindications to thrombolytic therapyContraindications to thrombolytic therapy Any prior intracranial hemorrageAny prior intracranial hemorrage Cerebral vascular lesionCerebral vascular lesion CNS neoplasmCNS neoplasm CVA <3 months except within 3 hoursCVA <3 months except within 3 hours Significant closed head injury <3 monthsSignificant closed head injury <3 months Active bleeding diathesisActive bleeding diathesis Suspected aortic dissectionSuspected aortic dissection

QuestionQuestion

A 52-year old diabetic patient is subjected A 52-year old diabetic patient is subjected to coronary angiogram because of to coronary angiogram because of persistent unstable angina. It shows 2 persistent unstable angina. It shows 2 vessel disease with EF of 35%. What is vessel disease with EF of 35%. What is the treatment?the treatment?a. PTCAa. PTCAb. CABGb. CABGc. Medical treatmentc. Medical treatmentd. Thrombolysisd. Thrombolysis

QuestionQuestion

A 61 y/o male had an uncomplicated anterior MI A 61 y/o male had an uncomplicated anterior MI over 24 hours ago develop syncope. Telemetry over 24 hours ago develop syncope. Telemetry showed V-tach, requiring electrical showed V-tach, requiring electrical cardioversion. What to do next?cardioversion. What to do next? Cardiac catheterizationCardiac catheterization Electrophysiologic studiesElectrophysiologic studies EchocardiographyEchocardiography Holter monitorHolter monitor Signal-average ECGSignal-average ECG

QuestionQuestion

A diabetic patient has chest pain. Because of A diabetic patient has chest pain. Because of anterior wall MI with ST elevation, TPA and anterior wall MI with ST elevation, TPA and lovenox are started. Within 30min patient is lovenox are started. Within 30min patient is feeling better ST-T segment came back to feeling better ST-T segment came back to baseline but tele shows wide complex, NSVT. baseline but tele shows wide complex, NSVT. What is your next step?What is your next step? Observation onlyObservation only Intravenous lidocaineIntravenous lidocaine Emergent cardiac catheterizationEmergent cardiac catheterization Intravenous amiodaroneIntravenous amiodarone Electrophysiologic studyElectrophysiologic study

Complications post-MIComplications post-MIRupture Rupture Ventricular Ventricular SeptumSeptum

Rupture Rupture Papillary MusclePapillary Muscle

Rupture Rupture Myocardial WallMyocardial Wall

TimingTiming 2-14 days2-14 days 2-10 days2-10 days 2-7 days2-7 days

Clinical findingsClinical findings Harsh loud Harsh loud systolic thrill systolic thrill LLSBLLSB

Acute Acute Pulmonary Pulmonary edema, MR edema, MR murmurmurmur

Sudden chest Sudden chest pain, shock, pain, shock, JVD, deathJVD, death

New ST elevNew ST elev

Diagnostic Diagnostic parameterparameter

02 step-up in 02 step-up in RV RV

Severe MR, Severe MR, LAELAE

Electro-Electro-mechanical mechanical dissociation dissociation

ManagementManagement Nitro-Nitro-hydralazinehydralazine

IABIAB

SurgerySurgery

NitroNitro

IABIAB

Surgery Surgery

Usually no Usually no survivalsurvival

QuestionsQuestions

Patient with IWMI whos BP goes down Patient with IWMI whos BP goes down from 90/60 to 60/20. Next step?, What is from 90/60 to 60/20. Next step?, What is the problem?the problem?

A patient with acute MI, doing well by the A patient with acute MI, doing well by the second week after admission. Suddenly second week after admission. Suddenly pt goes into acute CHF, and a new thrill at pt goes into acute CHF, and a new thrill at LLSB if found. What will the LLSB if found. What will the hemodynamic monitoring show?hemodynamic monitoring show?

QuestionQuestion

A 64 y/o male with history of uncomplicated A 64 y/o male with history of uncomplicated AWMI 4 days ago has suddenly developed AWMI 4 days ago has suddenly developed increasing SOB, hypotension, tachycardia, neck increasing SOB, hypotension, tachycardia, neck veins are distended, new gallop and a SEM. veins are distended, new gallop and a SEM. PCWP is 34 with a large V-wave. Diagnosis?PCWP is 34 with a large V-wave. Diagnosis? Myocardial free-wall ruptureMyocardial free-wall rupture Large pulmonary embolismLarge pulmonary embolism Ventricular septal ruptureVentricular septal rupture Ruptured chordae tendineaeRuptured chordae tendineae Cardiac tamponadeCardiac tamponade

QuestionQuestion A patient with known hypertension, with no past A patient with known hypertension, with no past

h/o MI is admitted to CCU with a large Q-wave h/o MI is admitted to CCU with a large Q-wave acute anterior MI. On the third day he is acute anterior MI. On the third day he is suddenly found in shock without any pulse or suddenly found in shock without any pulse or BP. EKG reveals new ST segment elevation with BP. EKG reveals new ST segment elevation with what appears to be sinus rhythm. What is the what appears to be sinus rhythm. What is the diagnosis?diagnosis?

A. Free wall ruptureA. Free wall rupture B. Right Ventricle infarctionB. Right Ventricle infarction C. Papillary muscle ruptureC. Papillary muscle rupture D. Ventricular septal ruptureD. Ventricular septal rupture