Fixed split 2nd heart sound.
ASD
Pt with fever, weight loss, and fatigue for several months. Diastolic sound with a soft rumble or pulp at the apex
Atrial myxoma
Murmurs that increase with inspiration
tricuspid stenosis
A murmur of aortic stenosis is best heard on
expiration
HOCM vs. AS. which increases with Valsalva
HOCM
16yo boy comes for a routine check-up. Murmur radiating throughout the precordium. No change with Valsalva and EKG shows mild LVH
VSD
most common murmur in adult hood on the left sternal border
VSD
pt wants to know how to decrease his risk of CAD. he’s a smoker and LDL is 80
Same pt but LDL is much higher
Stop smoking
statin
60yo women with CP on exsertion who can exercise and has no EKG changes
get Exercise EKG
Male 40 yo or over with CP. w.t.d
Stress test
Women 60 yo or over with CP
Stress test
Male < 39 yo with CP on exertion or relieving factors
stress test
Female >50 with CP on exertion or relieving factors
Stress test
Pt needs a stress test. Can exercise and ekg shows ST-T changes or LVH. what test
Exercise echo
Pt needs a stress test. Can exercise and EKG shows LBBB or V-pacing. what test
Vasodilator MPI or SPECT/PET
Pt needs a stress test. Cant exercise, and a wheeze is heard on the exam
Dobutamine
Pt needs a stress test. Cant exercise and a wheeze is NOT heard on the exam
Dobutamine or any vasodilator (adenosine)
Pt needs a stress test. Cant exercise, and a wheeze is NOT heard on the exam and EKG shows LBBB or V-pacing
MPI
50 yo Male. can exercise and has LVH on his EKG
stress Echo
60 yo male. cant exercise and has normal ekg. hx of COPD and wheeze is heard on the exam
Dobutamine stress test
65 yo woman with exertional dyspnea and occasional chest pain. EKG showed LBBB. what test
Adenosine or Dobutamine PET
btw RBBB, LBBB, and pacemaker. WHich one can undergo exercise EKG
RBBB
Where is the lesion?
ST depressions in I, aVL, V4-V6
Left circumflex artery stenosis
Where is the lesion?
ST depression in II, III, aVF
RCA
When NOT to do a stress test
Unstable angina or/and aortic stenosis with symptoms
An obese female who undergoes an exercise stress test but only can achieve a 50% increase in HR before having to stop. w.t.d
Repeat test but use pharmacological stress test
A pt with chronic angina now comes in with increased frequency. already on ASA and nitrate.
pt still has chest pain. HR 80
pt still has chest pain but HR is now 55
Add beta blocker
Increase the dose of beta-blocker
Angiogram with possible PCI
pt has increased angina but is refractory to beta-blockers, CCB and PCI shows nothing that can be stented w.t.d
Ranolazine.
Keep in mind this doesn’t improve mortality
45yo male presents with CP while shoveling snow. trops negative, EKG negative. PMHx is clean. w.t.d
Admit to hospital and get a stress test
65 yo male wakes up with severe retrosternal chest pain lasting 40mins that was accompanied by sweating and diaphoresis. in the ED–>EKG shows ST depression and T wave inversion.
Pt is started on ASA, IV nitrates, and LMWH and loaded with Plavix.
Pain gets better, but the ST depression persists.
What is this called, and how to diagnose it
Silent ischemia
Coronary angiogram
42 yo woman with retrosternal chest pain for 2 hours. no PMHx. runs 2 miles x 3 days/ week. EKG shows non-specific T wave changes and trops are elevated. w.t.d
Coronary angiogram
65 yo female has exertional SOB during exercise and relieved at rest.
MR during exercise which goes away post exercise
S4 +
The echo shows mild hypokinesia, and EF is 60%.
what’s the etiology of the chest pain
Ischemia
What is Wellens syndrome on EKG
Only deep T-wave inversions in leads V1-V4
pt comes to you without chest pain but states they had CP earlier.
EKG shows deep T wave inversions in leads V1 through V4.
w.t.d
Angiogram right away.
don’t need to wait for the stress test
pt presents with CP and EKG is negative.
A nuclear scan shows reversible ischemia.
an angiogram is negative.
What is going on and how do you treat it
Microvascular angina or syndrome X
Treat with CCB or Beta-blocker with nitrates
pt with CP at night 5-15min at rest.
EKG shows ST-T wave changes. w.t.d
Angiogram
pt with CP at night 5-15min at rest.
EKG shows ST-T wave changes and the angiogram is negative. w.t.d
Ambulatory EKG
pt with CP at night 5-15min at rest.
EKG shows ST-T wave changes and the angiogram is negative.
you do an Ambulatory EKG that is positive.
what is the diagnosis
Vasoplastic angina
pt with CP at night 5-15min at rest.
EKG and stress test is negative. w.t.d
Ambulatory EKG
pt with CP at night 5-15min at rest.
EKG and stress test is negative.
You do an amb EKG that is positive. w.t.d
angiogram
pt with CP at night 5-15min at rest.
EKG and stress test is negative.
You do an amb EKG that is positive but the angiogram is negative.
what is the diagnosis
Vasoplastic angina
An elderly man with hx of syncope. EKG is normal. He started he starts to feel dizzy after dinner. At that time his EKG shows ST depression in II, III, and aVF. 15 min later, the EKG is normal.
What’s the diagnosis and what’s the treatment
Postprandial ischemia
Cardiac cath and have him eat small frequent meals
24 yo with cocaine-induced chest pain who is found to have ST elevations.
how to treat
PCI
Benzo, nitrates, and ASA. In that order
Use CCB to prevent CP in the future
pt is treated with tPA for elevation in trops and ST- revelations.
afterwards, CP and ST elevation were resolved. Trop tripled.
w.t.d
Nothing
What is the cardiac enzyme that normalizes the earliest
Myoglobin
65 y male. Admitted to MICU for pneumonia. EKG is normal and trop is elevated. w.t.d
Echo.
Trops could be from other things in a critically ill patient.
pt presents with chest pain and low BP. what’s the next best step
Right-sided EKG. V3R and V4R
What are the indications to push thrombolysis
- CP typical for infarction >30 min with LBBB
- ST elevation 1mm in two contiguous leads
- < 12 hours post-MI
- Pt is > 2 hours away from PCI center and NOT in shock
Absolute contraindications for thrombolytic therapy
- Previous hemorrhagic stroke
- Other CVA events < 1 year
- Intracranial neoplasm
- Active internal bleed
Relative contraindications for thrombolytic therapy
- CVA >1 year
- Recent internal bleed or major trauma <2-4 weeks
- BP >180/110
- Pregnant
- Active peptic ulcer disease
Indications for PCI
- Acute ST elevation MI
- ST elevation with CP for more than 12 hours
- MI with shock and pt is less than 2 hours from PCI center and <75yo
- STEMI post-CABG
- if tPA is contraindicated
- unstable angina
Pt is allergic to ASA. w.t.d
use ticagrelor or prasugrel
Pt going for CABG, ticagrelor or prasugrel should not be used. T/F
True
When is CABG used over PCI
- Left main disease
- Three vessel disease with decreased EF
- Two vessel disease with proximal LAD and decreased LVEF
- DM with CAD. They have diffuse lesions
pt with CAD s/p stent. what meds on discharge
DAPT. with ASA and ticagrelor
Active GI bleeding pt who underwent PCI with stent. EKG shows ST depression. GI needs to scope. Hb is very low and currently getting transfused w.t.d
Do the colonoscopy and stabilize pt first.
Pt with a stent placed 3 months ago on ASA and ticagrelor presents with GI bleed. w.t.d
stop ticagrelor and continue ASA.
restart ticagrelor back on ASAP
A pt with sent place 12 months ago on ASA and ticagrelor presents with GI bleeding. w.t.d
D/C ticagrelor and continue ASA at 81 mg QD
A pt with stents placed 9 months ago on ASA and ticagrelor going for knee replacement surgery. w.t.d
Delay surgery by 3 months
A pt with Afib has MI and PCI. w.t.d
Continue DOAC and add clopidogrel for one year. After 1 year, just DOAC alone for life.
pt now with Afib. had MI s/p PCI one year ago and is taking ASA
D/C ASA and start DOAC for life
pt with retrosternal CP for >1 hour and is diaphoretic.
EKG shows LBBB and ST-elevation in the anterior leads.
Trops are pending and no prior EKG
take this person straight to cath lab
Pt with CP and ST elevation get tPA and 2 hours later BP drops and the pt is SOB.
w.t.d
PCI NOT IABP
Elderly pt with IWMI and gets PCI with stents in proximal RCA. pt BP drops
What is the best first step
Give a fluid bolus and then Dobutamine
pt with CP for 3 hours presents to the ED with ST elevations in V II, III, avF. trops are negative
w.t.d
PCI and if PCI isn’t available —> tPA
pt gets tPA for STEMI what needs to be done next
PCI AFTER 2 hours
BUT if the patient starts to become unstable—> PCI NOW and don’t wait the 2 hours
pt is admitted with MI; 3 days later, presents with chest pain relieved with NTG. w.t.d
Cath
A pt has a cardiac cath 6 hours ago. Now appears diaphoretic and clammy skin. BP drops, and HR increases. exam shows no erythema or swelling at the puncture site. IVF bolus is given. Hb earlier was 14 and now it’s 8.
w.t.d
CT scan of the abdomen looking for retroperitoneal hemorrhage.
pt has a cardiac cath 2 days ago. no presents with pain in the groin area. exam reveals an erythematous area with mild swelling. w.t.d
Ultrasound looking for an expanding pseudoaneurysm
pt with MI, 9 days later with persistent chest pain, worse on deep breath. pericardial friction rub heard. on beta blocker, as, statin and ACE. CxR with effusion
EKG show ST elevations and PR depressions
Post-myocardial infarction syndrome
How to treat Post-myocardial infarction syndrome
high dose ASA (6-8gms/day) for 3-4 weeks with colchicine
Factors that have been shown to improve survival in MI
- PCI
- Thrombolylic therapy after Q wave MI
- Beta-blockers
- ASA
- After load reduction (ACE or ARNI)
- Stop smoking
- Statin
- ICD 40 days after MI
- ICD 90 days after PCI
- Cardiac rehab
PCI, CABG, or statin. Which one improves LONG-TERM survival
Statin
What is the sequence of events for the management of ACS.
- ASA
- NTG
- Beta-blockers
- Atorvastatin
- UFH
- Ticagrelor
- PCI
pt with unstable angina with CKD. has already received ASA, BB, and statin.
Unfractionated heparin
NOT LMWH
pt with MI has acute MR
Papillary muscle rupture
pt with MI has acute VSD
Septal wall rupture
Pt with MI has signs of tamponade
Free wall rupture
Pt presents with CP. EKG reveals an MI and is treated with tPA, heparin, nitrates, BB, and ACE. Within 24 hours, pt develops NSVT. w.t.d
Just observe.
What the mechanism of reperfusion arrhythmias
accumulated calcium causing a change in cardiac frequency
Pt presents with CP. EKG reveals an MI and is treated with tPA, heparin, nitrates, BB, and ACE. Within 24 hours, pt develops sustained VT and is unstable. w.t.d
Cardiovert QRS is distinct or just defib if QRS or T is not seen.
Pt presents with CP. EKG reveals an MI and is treated with tPA, heparin, nitrates, BB, and ACE. Within 24 hours, pt develops sustained VT and is stable. w.t.d
give amio or lidocaine
If post-MI arrhythmias are less than 48 hours, what is the cause
ischemia
If post-MI arrhythmias are greater than 48 hours, what is the cause?
Scare tissue. pt will need ICD
Pt with ICD post-MI has 2 discharges in 2 months
add amio
Pt with ICD and amio post-MI is still having discharges
Radiofrep cath ablation
What patients need CRT with ICD
LBBB or QRS prolongation
What pts need CRT and ICD placed at the same time
LBBB or QRS prolongation AND EF less than or equal to 35%
What would you see on EKG 2-3 weeks after post-MI pericarditis
Deep T waves inversions
pt has CABG or AVR 4 years ago. now has SOB for the last 3-4 months. JVD, hepatomegaly, and pedal edema. EKG and CxR look normal. whats the Dx
Pericarditis
Pt presents with SOB on exertion with BMI of 40 and JVD of 14. BNP is only 160
IV Lasix
falsely low with obesity
This is called a type 2 error.
You start CHF patients on ACE or ARNI. Now has Scr that jumped from 1.1–>2, and K jumped from 4–>5.6. w.t.d
D/C ACE or ARNI and start hydralazine and nitrates
Pt on oral Lasix now has severe pitting edema and JVD of 12. w.t.d
Switch to IV Lasix and maximize the ACE. There is likely a lack of gut absorption.
Pt is D/C from the hospital for CHF exacerbation. What’s the next best step in management?
Setting up follow-up visit within one week.
Pt on spironolactone for six months and now has a left breast enlargement. w.t.d
Biopsy
Pt on spironolactone for six months and now has a bilateral breast enlargement. w.t.d
D/C spironolactone and start eplerenone
CHF patient on Lasix 60mg daily. All other HF meds are maxed out. The echo shows EF of 35% and EKG shows QRS 0.15 secs and LBBB
Start metolazone 30min before Lasix. This is part of GDMT. Don’t start ICD with CRT just yet
CHF patient on Lasix 60mg daily. All other HF meds are maxed out. The echo shows EF of 35%, and EKG shows QRS 0.15 secs and LBBB.
You start metolazone 30min before Lasix. 3 months later nothing has changed
Start ICD and CRT
EF less than 35% –> start ICD
EF less than 35% and LBBB or ORS great than 15 sec –> ICD and CRT at the same time
what drugs DONT improve survival in heart failure
Digoxin
CCB
Lasix
How do you switch from ACE to ARNI
D/C ACE and wait 36 hours for a wash-out period, and then start ARNI.
The only exception to this rule would be if the patient is on candesartan. You can switch to ANRI after 24 hours
You start ACE and pt has syncope. w.t.d
Continue ACE.
first dose syncope
You start ACE and pt develops angioedema
Switch to ARB
What sort of kidney issues are associated with ACE
Decreased constriction on efferent arterioles. This can cause renal failure in marginal patients
Can ACE cause neutropenia
Yes
What drugs should you not use in heart failure
NSAIDS Glitazone CCB cilostazol Metformin in advanced disease
ACE and ARB combo has shown what
Less proteinuria and poorer renal outcomes
Pt is a 65 yo woman who now presents with SOB on exertion that is relieved by rest. Loud S4 and soft S2. JVD of 12. EKF shows LBBB and Echo is 24%. Lasix is started, and symptoms improve. Pt had no history of heart failure before this admission. w.t.d
Coronary angiogram
Post-menopausal women with S4. Ischemia S4 and CHF S3.
