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54 Cards in this Set
- Front
- Back
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A 79 y/o man presents to clinic with a 5-month history of progressive dyspnea on exertion. He denies angina, syncope, or palpitations, but occasionally feels light- headed.
His vitals signs are normal. His cardiac exam is notable for a II/VI systolic ejection murmur heard best at the RUSB with radiation into the carotids. The aortic component of his second heart sound is diminished. He has bibasilar rales, pitting edema, and an elevated JVP. 12-lead ECG shows evidence of LVH. Transthoracic echocardiogram shows a severely calcified aortic valve with an estimated valve area of 0.8 cm2, and LVEF 40% What is the most appropriate next step in mgt? |
Aortic Valve Replacement
Late peaking, harsh (mid-) systolic murmur heard best at the R base of the heart, radiates to heard Sustained apical impulse S2 diminshes with progressive or severe AS Elderly patients do well with surgery |
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ACC/AHA guidelines for AVR with AoV Stenosis - Class I indications
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-Severe AS with symptoms (HF, syncope, angina)
-Severe AS undergoing cardiac surgery/CABG -Severe AS with LV systolic dysfunction (EF <50%) |
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A 28 y/o mildly obese woman presents to clinic complaining of worsening dyspnea on exertion for 6 months. She denies any other symptoms. She has no significant past medical or surgical history.
Her cardiac exam is remarkable for a normal S1 and a fixed split S2 with a I/VI mid-systolic murmur at the upper left sternal border. The rest of her examination is unremarkable. An echocardiogram shows normal left ventricular function and a mildly dilated right ventricle. An ECG is obtained: shows RBBB Which of the following would confirm the dx? |
Contrast Echocardiogram
Dx = ASD, secundum |
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Fixed split second heart sound
RBBB, RA/RV enlargement d/t increased pressure load due to L-->R shunting |
ASD
Secundum ASD most common, often occur in isolation, F>>M Primum ASD often occurs with other abnormalities (e.g., VSD, cleft mitral valve) Most common presentation: asymptomatic or progressive exercise intolerance typically in the second decade of life Often discovered incidentally with detection of a murmur |
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Indication for ASD closure
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Presence of right-sided chamber enlargement is indication for closure
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Paradoxical Splitting
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LBBB
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Which of the following patients with mitral regurgitation is a poor candidate for mitral valve repair/replacement?
a) 69 y/o asymptomatic woman with an ejection fraction of 45% b) 55 y/o man with CHF and an LVEF of 25% c) 45y/omanwithfatigue,dyspneaonexertion,and ejection fraction of 55% d) 70 y/o man with symptomatic mitral stenosis e) 58 y/o asymptomatic woman with an end systolic cavity dimension of 55 mm |
Answer B
Surgically-treated patients with mild symptoms and minimal LV dysfunction fare better than patients with severe symptoms and severe LV dysfunction • Pts with LVEF<30%do poorly with MVR (especially if chordal continuity cannot be preserved)—surgery contraindicated • In patients with MR and concomitant MS, replacement indicated |
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Class I indications for Surgery for Severe MR
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-Acute
-Symptomatic with LVEF >30% and end systolic dimension </=55 mm -Asymptomatic with LVEF </=60% and/or end systolic dimension >/=40 |
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A 22 y/o man presents for a health maintenance exam. He is asymptomatic and has no complaints. He denies any history of syncope. Physical exam notable for a II/VI systolic ejection murmur heard best at the lower left sternal border that increases with Valsalva maneuver.
His murmur is most likely due to: |
Hypertrophic Cardiomyopathy
-Young pts with presenting palpitations or syncope with athletic activity -Aut Dom, may have SCD -Systolic murmur increased with Valsalva - AVOID Volume depletion -Tx with beta-blockers (nadalol) |
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A 25 y/o man is seen for a physical exam. He has no complaints and is asymptomatic. A II/VI systolic ejection murmur is heard at the apex, which decreases with Valsalva maneuver, and accentuates with handgrip.
His murmur is likely due to which of the following? |
Mitral Regurgitation
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Inspiration intensifies which murmurs
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Murmurs that originate in R-heart:
"INSPIRING TRIPS" - Tricuspid Regurg, Pulmonic Stenosis |
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Valsalva and squatting to standing intensifies what murmurs
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Increases HCM (decreased AS b/c decreasing flow)
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Standing to squatting and passive leg elevation
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Decreases HCM, Increases AS
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Isometric Hand grip or transient arterial occlusion (increasing afterload, LV volume)
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Blood leaving LV flows prefers "alternative path)
Increases MR, VSD murmurs (decreases HCM, AS murmurs) |
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A 40 y/o man presents for follow-up. He reports having increasing palpitations and some dyspnea on exertion. He is on no medications. He has no family history of heart disease. Physical exam is remarkable for a II/IV diastolic murmur that is heard best at the lower right sternal border, increasing when leaning forward.
His murmur is most likely due to: |
Aortic Regurgitation
The patient most likely has a bicuspid aortic valve |
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Associated conditiosn with bicuspid AoV
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-Coarctation (esp with HTN)
-Aortopathy (aneurysm, dissection) -Aortic regurgitation/aortic stenosis |
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Indication for AVR in chronic severe aortic regurgitation?
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NYHA Class III Symptoms
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ACC/AHA guidelines for AVR with Aortic Regurgitation
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CLASS I (indicated)
- Symptomatic with severe AR regardless of systolic function - Asymptomatic with severe AR and EF <50% - Severe AR undergoing cardiac surgery Class IIa *strong supportive evidence* - Asymptomatic with severe AR, normal EF with LVEDd >75 or LVESd >55 |
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Endocarditis prophylaxis guidelines
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-Prosthetic valve or material used in repair
-Prior IE -Congenital heart diseases -- unrepaired cyanotic CHD, including palliative shunts and conduits -- completely repaired defect with prosthetic material during first 6 months after procedure -- Repaired CHD with residual defects at/near site of prosthetic patch or devise (b/c of inhibition of endothelialization) -Cardiac transplant patients who develop valvulopathy |
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ou have taken care of a 56 y/o dairy farmer with rheumatic valvular heart disease for many years. Two years ago he had elective replacement of his mitral valve with a mechanical prosthetic valve and a tricuspid annuloplasty.
His dentist calls you for advice regarding endocarditis prophylaxis prior to dental extraction. The patient has never had IE. One year ago he developed a marked urticarial rash associated with bronchospasm following ampicillin administration prior to dental cleaning. What do you recommend? |
Clindamycin 600 mg orally 1 hour b/f the procedure
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A 38 y/o Cambodian woman is admitted to the hospital with cough, dyspnea, and hemoptysis. She denies fever, chills, night sweats, or weight loss. Her chest xray shows mitral valve calcification, left atrial enlargement and pulmonary venous congestion.
What will the heart exam likely reveal |
Apical rumbling diastolic murmur that intensifies just before S1
• Loud S1 • Opening snap • Rumbling diastolic murmur, heard best at LV apex • Chest x-ray: watch for left atrial enlargement, pulmonary congestion, calcified mitral valve • ECG findings of LAE & RVH nearly pathognomonic • Treatment centers upon relief of symptoms, beta- blockers, percutaneous balloon valvuloplasty, or surgical repair |
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Most common cause of infective endocarditis in IVDA
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Staph aureus
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Anticoagulation tx with mechanical valve prostehsis in pts undergoing noncardiac surgery; i.e. Who requires bridging with heparin
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RFs for increased risk for thrombosis while off warfarin (REQUIRES HEPARIN/LMWH):
- Prior embolic event - Older generation valves - Known AFib - LV Systolic dysfunction - Hypercoagulability |
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57 yo woman with nonischemic cardiomyopathy diagnosed several months ago, class III HF, DOE with one flight of stairs, on BB, ACEI, digoxin, furosemide, spironolactone. On exam, BP 137/82, HR 87, JVP 9 cm, lungs clear. Echo: EF 33%. ECG: LBBB with QRS 160 ms.
What is the next best management step? A. Increase BB and ACEI B. Refer for single chamber ICD C. Refer for dual chamber ICD D. Refer for biventricular pacemaker ICD |
Answer A -- optimize medications before referring for ICD placement or biV; increase beta-blocker and ACEI
3 months later, if EF still <35%, then Biventricular Pacemaker ICD (women benefit more than men) |
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28 yo woman with episodes of heart racing. Started at age 15, increasing in frequency, now weekly, triggered by caffeine, bending over, self terminates with deep breathing, can last up to five minutes. Otherwise healthy. Normal exam.
What is the next best management step? A. Calcium channel blocker B. Betablocker C. Holter D. “Card-type” recording monitor E. “Looping-type” event recorder |
E - Loop Event Recorder
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R' in V1 during SVT; disappears after adenosine
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A retrograde atrial pulse
Pathognomic for AVNRT |
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Young patient with irregular wide SVT and palpitations -- tx?
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Procainamide -- suspect WPW; see delta waves
IV diltiazem will place patient in VFIB |
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65 year old man presents with chest tightness over the last two months.
He only experiences his symptoms when climbing hills quickly, and the tightness is quickly relieved by rest. Prior history of hypertension and hyperlipidemia, managed with diet and exercise. He smoked until 30 years ago. His father had an MI at age 58. What is the most appropriate next step? A-Nuclear stress test B-Dobutamine stress echocardiogram C-Admission for unstable angina D-Treat with aspirin and beta blocker E-Cardiac catheterization |
Typical Angina in an elderly M -- high risk
Next step -- Tx with ASA and Beta Blocker, then stress test |
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Indications for risk stratification stress testing
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Stable angina
Following myocardial infarction Pre-operative evaluation in high risk vascular patients |
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Heart conditions that contraindicate pregnancy
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“Contraindicated” in patients with Marfan syndrome and aorta > 4.0 cm or Eisenmenger’s syndrome
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In patients with an ascending aortic diameter greater than 45 mm at the time of planned aortic valve surgery, what additional tx is needed?
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Repair of the ascending aorta, performed by placement of a graft conduit or homograft, is indicated and performed concomitantly
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All patients with an acute coronary syndrome should receive...
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All patients with an acute coronary syndrome should receive nitrates, a β-blocker, aspirin, clopidogrel (unless an increased risk of bleeding exists), and a statin. In addition, patients with a high TIMI risk score (5-7) should receive anticoagulation therapy (unfractionated heparin, low-molecular-weight heparin [LMWH], or bivalirudin) and a glycoprotein IIb/IIIa inhibitor, such as eptifibatide. Although the benefit of intensive lipid lowering in the early phases of an acute coronary syndrome (before discharge) is still being established, current consensus recommends early intensive lipid-lowering therapy with a statin for NSTEMI and unstable angina regardless of risk score.
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The first-line treatment for recurrent pericarditis
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ASA + Colchicine
Initial tx for first time -- NSAIDs |
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The best option for managing symptomatic atrial fibrillation in the setting of structural heart disease or heart failure
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Amiodarone is the best option for managing symptomatic atrial fibrillation in the setting of structural heart disease or heart failure
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Perioperative anticoagulation recommendations for patients with AoV
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For patients with a mechanical valve in the aortic position and without additional risk factors, the current recommendation for periprocedural anticoagulation is to stop warfarin 48 to 72 hours before the procedure and restart it within 24 hours after the procedure; bridging with heparin is usually not necessary unless they are high risk for other reasons (h/o TIA/stroke).
For MV replacements -- must; reason: this is a low flow valve where as the aortic valve is a high flow valve. |
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Pulmonary Valve Stenosis - tx?
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For patients with pulmonary valve stenosis requiring intervention, pulmonary balloon valvuloplasty is the preferred treatment unless the pulmonary annulus is hypoplastic or there is subvalvular or supravalvular pulmonary stenosis, severe pulmonary valve regurgitation, or associated cardiovascular disease that mandates operative intervention
Symptomatic patients with pulmonary valve stenosis should have pulmonary balloon valvuloplasty for a peak instantaneous gradient of greater than 50 mm Hg (mean gradient >30 mm Hg) with less than moderate pulmonary valve regurgitation. For patients with severe pulmonary valve stenosis without symptoms, pulmonary balloon valvuloplasty is the treatment of choice if the pulmonary valve is pliable and the peak instantaneous pressure is greater than 60 mm Hg (mean gradient >40 mm Hg) in the absence of greater than moderate pulmonary valve regurgitation. |
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Indications for MV Repair
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LVEF <60%
LV end-systolic diameter >40 mm Pulmonary hypertension (PA systolic pressure ≥50 mm Hg at rest or ≥60 mm Hg during exercise) New-onset atrial fibrillation Mitral valve repair if anatomy favorable (presence of annular dilation, mitral leaflet prolapse, or myxomatous changes without calcification or stenosis) |
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Indications of Aortic valve replacement with ascending aorta graft replacement if enlarged
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Symptoms
LVEF <50% LV dilatation (end -systolic dimension >55 or End Diasatolic dimension >75) If Aorta >45 mm |
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Indications for valve repair in AS
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Symptoms
LVEF <50% Abnormal BP response (decrease in systolic pressure) during exercise Rapidly progressive stenosis |
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Patients with unstable angina or a non-ST-elevation myocardial infarction treated medically who do not receive a stent should be treated with clopidogrel at least for how long?
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Patients with unstable angina or a non-ST-elevation myocardial infarction treated medically who do not receive a stent should take clopidogrel for at least 1 month and ideally for up to 1 year.
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What to do with an ICD prior to surgery
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ICD shock function must be turned off. If a magnet is placed over an ICD, it turns off shock therapy but does not affect the pacing capabilities.
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Next step in patients with repaired Aortic Coarctation.
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In patients with repaired aortic coarctation, CT or MRI can be used to assess for recurrent coarctation or aneurysm, both of which are common late complications after repair.
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A prominent a wave in the jugular venous pulsations, a right ventricular lift, a systolic thrill, and an ejection click that diminishes in intensity during inspiration.
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Pulmonic Stenosis
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New Heart Failure, next step?
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Coronary angiography to evaluate for ischemia
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The most common cause of late ventricular dysfunction in cardiac transplant patients and should be considered in transplant patients with new-onset heart failure.
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Cardiac allograft vasculopathy
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How to monitor patients who are not yet candidates for AS surgery?
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In patients with severe aortic stenosis without symptoms, aortic valve replacement is indicated if left ventricular ejection fraction is below 50%, exercise results in hypotension or symptoms, or rapid progression of stenosis or very severe stenosis (mean gradient >60 mm Hg) has occurred.
Monitor yearly with TTE if severe |
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Cilostazol contraindications
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Cilostazol is an oral phosphodiesterase III inhibitor that has demonstrated increases in pain-free walking and overall walking distance in persons with claudication in randomized clinical trials. However, cilostazol is contraindicated in patients with heart failure or a left ventricular ejection fraction below 40%. This contraindication stems from cilostazol's similar pharmacologic action to the inotropic drugs milrinone and inamrinone, which demonstrated increased mortality in heart failure patients with long-term use.
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Indications for closing ASD
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Closure of an atrial septal defect is indicated in patients with right-sided cardiac chamber enlargement and no evidence of pulmonary hypertension.
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A rapid, irregular, wide-complex tachycardia with slight variations in the QRS morphology and presence of delta waves
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A rapid, irregular, wide-complex tachycardia with slight variations in the QRS morphology and presence of delta waves is consistent with preexcited atrial fibrillation.
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Balloom Mitral Valvuloplasty
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Balloon mitral valvuloplasty is the treatment of choice for patients with amenable anatomy and severe symptomatic mitral stenosis
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Treatment for hemodynamic collapse in patients with HCM
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Phenylepherine
In patients with left ventricular outflow tract obstruction associated with hypertrophic cardiomyopathy, inotropic agents may precipitate hemodynamic collapse and are contraindicated. |
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Platypnea-orthodeoxia in the presence of a documented patent foramen ovale
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Indications for PFO closure
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Initial evaluation for patients' with cyanotic congenital heart disease
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Short-course iron therapy is indicated for patients with cyanotic congenital heart disease and relative iron deficiency (normal hemoglobin level, 18-20 g/dL [180-200 g/L]; normal hematocrit, 60%-65%).
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If Ankle-Brachial index >1.4, next step?
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In a patient with suspected peripheral arterial disease, an ankle-brachial index above 1.40 is noninterpretable; measurement of the great toe systolic pressure can establish the diagnosis.
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