UMDNJ~ SOMSECOND YEAR CARDIOLOGY MODULEFALL SEMESTER

COURSE REVIEW2012

John N. Hamaty, DO, FACC, FACOICourse Director

Students, included in this review are basic bullet review points for each lecture in your cardiology module.

Please be aware your exam questions may include,

BUT ARE NOT LIMITED TOthe information in this review.

Review of all material, PowerPoint presentations,and teaching points discussed during the actual

lecture presentation is encouraged

advised, and your individual responsibility.

Introduction to HemodynamicsJohn N. Hamaty, D.O. Understand basic physiology and

hemodynamics of myocardial depolarization and repolarization

Understand the components of S1, S2, S3 and S4

Have a maximal understanding of left ventricular and diastolic pressures and their association to left atrial filling

Understand basics of stethoscope hemodynamics

POP-QUIZ!!

An 82 year old females comes to your office for evaluation. She states she”thinks” she is taking her medications, but isn’t sure which ones they are, or how often she take them. Your blood pressure reading is 200/110mmHg. Which point on this hemodynamic tracing would be effected?

A B C D

And the answer is….C

When someone gets systemic hypertension, the left ventricular pressure must match systolic pressure; and therefore the curve would markedly elevated. The answer would not be B as that is the mitral and tricuspid valve closure which isn’t effected, and the answer would not be D as this point on the curve would not change.

The sound may be accentuated by examination, but the point on the curve would not change.

Auscultation Jay Rubenstone,D.O. Know what the third and fourth heart

sounds represent Know grading of murmur by

auscultation Know what the common systolic and

diastolic murmurs represent

Valvular Heart Disease Jay Rubenstone,D.O. Know common etiologies associated

with valvular stenosis and regurgitation Know how to differentiate degree of

stenosis by valve area Know the common clinical signs and

symptoms as well as common echocardiographic findings associated with decompensation of aortic stenosis, mitral regurgitation and aortic regurgitation

POP-QUIZ!!

A 70 year old female is evaluated here for what is determined to be rheumatic mitral stenosis. Her calculated valve area is 1. 5cm, her rhythm is still sinus rhythm. In light of her not yet being a surgical candidate, appropriate therapy took a turn that she made need surgical intervention would be the following:

A. Palliative valvuloplasty

B. Afterload reduction with peripheral vasodilators

C. Chronic anti-biotic therapy for chronic rheumatic fever

D. Decrease sodium intake, diuretic therapy, and heart rate control

And the answer is….

D

Tell me why…

Pericarditis, EchocardiographyJerome M. Horwitz, D.O.

Myocarditis presents most likely in the following groups:

Young Males Pregnant Females Children (especially neonates) Immunocompromised (HIV)

Pericarditis, EchocardiographyJerome Horwitz,D.O. Pericarditis in the long term hospitalized

patient can be remembered with the TUMOR

T ~ Tumor / trauma U ~ Uremia M ~ Medicines / myocardial infarction O ~ Other infections (TB, bacterial,

fungal) R ~ Rheumatoid / radiation

Pericarditis, EchocardiographyJerome M. Horwitz, D.O.

Echodoppler study is safe, reproducible, cost effective and available at almost any hospital

POP-QUIZ!!

A patient is suspected of having myocarditis and a myocardial biopsy is obtained. It revealed no lymphatic infiltrates and no myocytolysis. The patient has:

A. Active myocarditis

B. Pericarditis

C. The biopsy was negative therefore your initial diagnosis is wrong

D. Non cardiac chest pain and you order a high resolution CT scan.

And the answer is….

BThe answer is B… Pericarditis.

The fact that the biopsy is negative may exclude myocarditis, but would have no effect

on your CLINICAL diagnosis of pericarditis

Dyslipidemia and the Use of StatinsMario Maiese,D.O.

Patients with Framingham risk score >10 (considered moderate risk with metabolic syndrome and all patients with known vascular disease (CAD,PAD,Carotid,AAA or TIA) or vascular disease equivalents (DM or CKD) are candidates for statin therapy to prevent primary or recurrent CV events per the present guidelines

Dyslipidemia and the Use of StatinsMario Maiese,D.O.

Patients with diabetes and/or metabolic syndrome (pre-diabetes) will frequently have triglyceride (TG)/HDL-C axis disorders (high TG and low HDL-C.) In these patients especially and probably all patients, non HDL-C is a better than LDL-C as a surrogate marker of CV risk and is also a better treatment goal. (It is the secondary treatment goal after LDL-C in patients with TG >200 mg/dL per NCEP ATP III.)Non HDL-C, if not already calculated on your lab results, is the total cholesterol (TC) minus the HDL-C. The non HDL-C goal of treatment is 30 mg/dL. The “optional” lower treatment goals for non-HDL-C should be used because of the ever present residual risk and proven benefits of high-dose statins

Statins are the drug of choice for CV risk reduction. Safety and cost should always be considered in choosing a statin. Considering what we know about the lipophilic and metabolic properties of certain statins (lovastatin and simvastatin) associating them with increased risk and drug interactions, pravastatin can easily and safely be substituted for either without compromising efficacy. Pravastatin 80mg is equivalent in potency to 40mg simvastatin (~40% reduction in LDL-C.) If a more potent statin is needed for lipid lowering (simvastatin 80mg is not an option for new patients) then generic atorvastatin 40mg-80mg , cheaper; or rosuvastatin 20mg-40mg, generic not yet available) would be recommended.

Dyslipidemia and the Use of StatinsMario Maiese,D.O.

POP-QUIZ!!

Which of the following are true regarding non HDL-C?

A. It is a better surrogate than LDL-C in abnormalities of the TG/HDL axis?

B. It is usually a better surrogate than LDL-C in patients with type 2 DM and metabolic syndrome

C. Non HDL-C is the TC minus HDL-C

D. In type 2 DM without known CVD the non HDL-C goal would be <130mgdL

E. We should start looking at non-HDL-C probably when TG is >130 mg/dL, even though the guidelines direct us to make that our secondary goal when TG is >200 mg/dL

Well? Which statements are true?

And the answer is….

All of them!

ECG Part I – John N. Hamaty, D.O.Goals and Objectives:

Understand that ECG’s are the gold standard in defining dysrhythmia’s

Understand the basic mechanism of sinus rhythm, along with it’s definition

ECG Part II – John N. Hamaty, D.O. Become familiar with the most common

dysrhythmia’s such as atrial fibrillation, atrial flutter, left and right bundle branch blocks

It is important to understand pattern recognition for acute myocardial infarction in the anterior, inferior and lateral distributions

POP-QUIZ!!

A. Atrialfibrillation with a controlled ventricular response, t wave inversion laterally consider ischemiaB. NSR, t wave inversion laterally, consider ischemiaC. NSR, age indeterminate antero lateral myocardial infarction D. NSR, left ventricular hypertrophy with ST/T wave changes

D

NSR, left ventricular hypertrophy with ST/T wave changes

And the answer is…..

Stress Testing ~ Nuclear and Echo John H. Hamaty, D.O. Understand indications and

contraindications of stress testing Decide on appropriate patient selection

for the appropriate test Understand pharmacology of Adenosine,

Persantine and Dobutamine Understand basic stress testing protocol

Stress Testing ~ Nuclear Cardiology Understand the indications and

contraindications of nuclear stress testing

Understand the pharmacodynamics of thallium and technetium; understand their mechanisms of action and appropriate indications for each agent in determining viability versus myocardiac risk

POP-QUIZ!!

A 62 year old executive comes to your office for evaluation prior to beginning an exercise program. He is a distant smoker and has a history of controlled hypertension. He is not having specific angina symptoms but clearly has been extremely sedentary and wants to change his lifestyle. Your physical examination is generally unremarkable; the ECG reveals a normal sinus rhythm with a left bundle branch block. Which of the following stress testing is most appropriate:A. Pharmacologic stress testingB. Routine treadmill stress testC. Dobutamine stress echocardiographyD. Treadmill stress echocardiography

A

The answer can only be pharmacologic testing for one simple reason….The patient has an underlying LBBB, which immediately obscures the ecg, therefore treadmill of any kind, or any change in heartrate such as dobutamine could not occur.

And the answer is…..

Hypertension and the Use of AntihypertensivesJoshua Crasner, DO FACC, FACOI

Be familiar with Medications utilized to treat hypertension

Recognize genetic patterns associated with hypertension

Be familiar with diagnosis and risk stratification of your patient based on abnormal patterns as well as available treatments

POP-QUIZ!!

You are seeing an African-American 50 year old male in the office as a consult pre-operatively. He has never seen a cardiologist before. His BP is 155/98. He has mild pretibial edema. The rest of his physical exam is normal. What is a reasonable starting drug/drugs for him?

A. Calcium channel blockerB. Central acting agent such as alpha methyl-dopaC. Diuretic therapy in conjunction with salt restriction D. Nitroglycerin

C

Diuretic therapy in conjunction with salt restriction

Tell me why…..

And the answer is…..

Cardiac Catheterization / Radiology Timothy Morris,D.O. Be familiar with pharmacological

agents most routinely used during PTCA Be familiar with the indications and

contraindications for PTCA Be familiar with the indications and

contraindications for Cardiac Catheterization

Be familiar with common complications of PTCA

POP-QUIZ!!

A 79 year old female underwent catheterization for an abnormal stress test. As an interventionalist you are always concerned about complications. Which of the following femoral access cath complications carries the highest mortality:

A. HematomaB. PseudoaneurysmC. Retroperitoneal bleedD. Pruritic rash after cath

C

Retroperitoneal Bleed

Tell me why…..

And the answer is…..

Acute Myocardial Infarction Willis Godin,D.O. Be familiar with the medications indicated

for the acute management of acute MI Know medications indicated for long-term

management post MI Be aware of the indications of reperfusion

and acute MI (determining the use of thrombolytics versus primary PTCA/Angioplasty)

Know the diagnosis involved with the term Acute Coronary Syndrome (ACS)

Complications of Myocardial InfarctionWillis E. Godin, D.O.

Be aware of the various arrhythmias that can present in patients with Acute MI

Be familiar with the common medications used to treat congestive heart failure / left ventricular failure

Know the differences between left ventricular aneurysm versus pseudoaneurysm

POP-QUIZ!!

Final bloodwork for your patient with chest pain in the ED reveals elevation of his cardiac enzymes and he is aggressively treated for a NSTEMI (non-ST elevation myocardial infarction). Which of the following can be a cause of NSTEMI:A. Intense arterial spasmB. Coronary artery dissectionC. Progressive, severe, flow-limiting atherosclerosis due to lipid, calcium, and thrombus depositionD. Conditions that alter myocardial oxygen demand or supply such as intense emotion, tachycardia, or uncontrolled systemic hypertension

All of the above !

And the answer is…..

Congenital Heart Disease John N. Hamaty,D.O. Understand the timing of myocardial

development throughout gestation Understand the major congenital

defects particularly atrial septal defect, it’s multiple forms and timing of abnormality development throughout gestation

Become familiar with the many types of congenital heart disease, particularly in other systemic disease states such as Down’s syndrome

Congenital Heart Disease John N. Hamaty,D.O. Understand the other associated

congenital abnormalities that occur with primary defects

Become familiar with coarctation; tetralogy of fallot and patent ductus arteriosis

Have a complete understanding of the pathophysiology of left to right (unidirectional shunts) as well as bidirectional shunt physiology, particularly Eisenmenger’s Syndrome

POP-QUIZ!!

A 33-year old mentally challenged male was brought to the office by his case worker; they state that when the patient runs, he stops after 30 feet and falls to the ground and grabs his legs in pain. After one to two minutes of rest, he can resume with the same outcome. You are his third doctor. All prior stress echo’s have been normal. You diagnose his problem in less than 1 minute with which of the following findings?A. Pulsus paradoxusB. Markedly diminished pulse in lower extremities compared to upper extremities.C. Blood pressure is greater in left arm compared to right.D. Blood pressure is greater in legs as compared to arms.

BMarkedly diminished pulses

in lower extremities compared to upper extremities.

And the answer is…..

Syncope / Pacemakers & ICD’sYega Raman,D.O.

Indications for temporary and permanent pacing

Choice of pacing modes Indications for ICD/Biventricular devicesEtiology and pathogenesis of syncopeTests to determine the etiology of syncopeManagement of the patient presenting with

syncope

In the absence of structural heart disease, neurocardiogenic syncope is the most common cause of syncope. Diagnosis by history and tilt table is often useful.

Unexplained syncope in the presence of significant structural heart disease carries a poor prognosis; may need invasive electrophysiologic testing to look for brady and tacky arrhythmias

Syncope / Pacemakers & ICD’sYega Raman,D.O.

Pacemaker mode selection is influenced by the underlying atrial rhythm. In patients with permanent atrial fibrillation with symptomatic slow ventricular response and normal LV function, a single chamber ventricular pacemaker is indicated

ICD is indicated for secondary and primary prevention of sudden cardiac death in appropriate patients

Primary prevention of SCD: Cardiomyopathy with LVEF ≤CHF NYHA Class II-III narrows QRS

Bi-ventricular ICD (Cardiac Resynchronization Therapy): Cardiomyopathy with LVEF ≤35%, CHF NYHA Class III- ambulatory Class IV, LBBB with QRS ≥120msec.

Syncope / Pacemakers & ICD’sYega Raman,D.O.

POP-QUIZ!!

A 24 year old female presents with recurrent syncope and near syncope. Some of the episodes are preceded by nausea, sweating and diminished peripheral vision. An ECG and 2D echo are normal. What is the next step to establish the diagnosis?

A. Cardiac catheterization B. Nuclear stress test C. Invasive electrophysiologic study D. Head up tilt table test

DHead’s up! It’s time for tilt table testing

And the answer is…..

Congestive Heart Failure Howard Weingberg,D.O. Know how to calculate cardiac output Be familiar with NY Heart Associations

classifications of Heart Failure Be familiar with ACC/AHC Heart failure

stages Be familiar with Frank-Starling curve

POP-QUIZ!!

Jack Daniels has been a long time alcoholic. He frequent can be found strumming a guitar and drinking a pint of home made bourbon. He usually winds up sleeping on the ground in front of the local tavern. Recently he could not tolerate laying on the ground for more than 15 minutes without having to get up. He is more exhausted and fatigued than ever before, in fact his legs are twice their normal size. When he finally presented to the hospital in congestive heart failure (New York Heart Association Class IV) he needed to be place on a ventilator for a short period of time ( BP: 120/70, heart rate 82bpm). What would you expect his treatment to be and what is he most likely to die from:

A. Normal saline and sudden cardiac deathB. Diuretic, vasopressin and sudden cardiac deathC. Normal saline, aspirin and progressive heart failureD. Diuretic, beta-blocker and progressive heart failureE. Normal saline, Ace inhibitor and sudden cardiac death

Switching to red wine! (In moderation of course!) And…

D

Diuretic, beta-blocker and progressive heart failure

And the last answer Of the day is….