PEARLS IN CARDIOLOGY

Sandra Rodriguez
Internal Medicine
2008

Jugular venous Pulse

a

is RA contraction
c is bulging of TV
during RV systole.
x downward
displacement of TV.
v is atrial filling at
systole, TV closed.
y is passive atrial
emptying.

Jugular Venous Pulse

Giant a wave:
Tricuspid stenosis
Pulmonary stenosis
Pulmonary hypertension
Canon a wave: (against a closed valve):
Junctional rhythm
Slow ventricular tachycardia
2:1 A-V block
Bigeminy
Absent a wave:
Atrial Fibrilation

Jugular Venous Pulse

Prominent x descent:
Cardiac tamponade
Constrictive pericarditis
Absent x descent:
RV infarction
Prominent v wave:
Tricuspid regurgitation
Prominent y descent:
Constrictive pericarditis
Slow y descent:
TS and RA mixoma.
Absent y descent:
Cardiac tamponade
RV infarction

Prominent x and y:
Constrictive pericarditis
Prominent x and absent
y: Cardiac tamponade
Absent x and y: RV
infarct.

Questions
1.

A 34 year-old patient is on Ma Huang for losing

weight. She presents with shortness of breath.
EKG shows wide complex tachycardia. HR is
140/min. Cannon a waves are present.
Cause?
a. Sinus tachycardia with WPW
b. Sinus tachycardia with aberrant conduction
c. Atrial fibrilation with aberrant conduction.
d. Ventricular tachycardia.

Murmurs

With inspiration: R side

murmurs increase, L side
decrease.
With standing: HCM and MVP
get louder.
With squatting or passive leg
raising: HCM and MVP
become softer and delayed.
With valsalva: HCM and MVP
get louder and longer.
With amyl nitrite inhalation
(decreases LV cavity): AR, MR
and VSD decrease while those
of HCM and AS increase.
With exercise (hand grip):
HCM and AS decrease.

With standing, valsalva, and

inhalation of amyl nitrited (all
decrease venous return or LV
cavity size): Murmurs of HCM
and MVP increase in intensity.
All others decrease.
With isometric exercise and
squatting (all increase LV
cavity size): Murmur of HCM
is decreased.
With isometric exercise and
valsalva: Murmur of AS is
decreased in intensity.

Questions
2. Murmur of which of the following increases with
valsalva and decreases with squatting:
a. Mitral Regurgitation.
b. Hypertrophic cardiomyopathy (HCM)
c. Aortic stenosis
3. What happens to the murmur of AS with
valsalva and hand-grip exercise?
a. Increase, decrease
b. Decrease, decrease
c. Decrease, increase.

Splitting of S2
INSPIRATION

EXPIRATION

Normal
splitting

s1

A2

P2 s1

A2

P2

Wide splitting
(PS,MR,RBB
B, VSD,PDA

s1

A2

P2 s1

A2

P2

Paradoxical
splitting (AS,
LBBB, HCM,
LVH)

s1

P2

A2 s1

P2

A2

Fixed splitting
(ASD)

s1

A2

P2 s1

A2

P2

Questions
A 44

y/o females has history of increasing SOB

with exertion over the last 3 months. PE: Fixed
split S2 with a murmur consistent with TR. Rest
of HPI is unremarkable. CXR: increased LA, RA,
RV and pulmonary circulation. What is the most
likely diagnosis?
a. Mitral regurgitation
b. Aortic stenosis
c. Hypertrophic obstructive cardiomyopathy
d. Atrial septal defect
e. Ventricular septal defect

Questions
A Wide splitting of S2 is representative of:
a. Normal sinus rhythm with RBBB.
b. Normal sinus rhythm with LBBB.
c. Hypertrophic cardiomyopathy.
Reversed splitting of S2 occurs in which:
a. ASD
b. RBBB
c. Hypertrophic cardiomyopathy

Heart sounds

2nd sound and opening snap of MS are best heard on the

base.
LSB: TR, AR, VSD, HCM
Apex: MR, MS, AS.
Below L clavicle: PS, PDA as continuous.
Radiation to L axila: MR.
Radiation to RSB and carotids: AS
Radiation all over the precordium: VSD
MS: Loud S1, Split S2, opening snap, rumbling diastolic
murmur in apex. Area <2.5 cm, symptoms correlate.
PR: Diastolic, decrescendo at LSB (Graham Steel)

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

Questions
7. A 33 y/o pregnant patient in second
trimester has SOB due to MS that is not
responding to medical treatment. ECHO
shows MV of 0.5cm. What is next step:
a. Mitral valvotomy after delivery.
b. Offer pregnancy termination.
c. Mitral valvotomy now.
d. Mitral valve replacement now

Mitral Valve Regurgitation

Etiology:
Myxomatous

degeneration
Rheumatic disease
Endocarditis
Grades

1 to 4
Surgical indications
If

symptomatic
EF<60%
LVES diameter >4.5cm
Pulmonary pressure >55mmg Hg

Questions
A 41

year-old asymptomatic female with

MVP and mitral regurgitation is presented.
An ECHO shows severe MR with EF of
50%. CAD is ruled out. What is your
advice regarding her treatment?
a. Refer for valve replacement.
b. Follow up closely.
c. Begin a diuretic plus ACE-inhibitor.

Aortic Stenosis
Aortic Stenosis

HCM

Location of
murmur

Apex and R 2nd

intercostal space
radiating to
carotids.

LSB,
With thrill
Not radiating

Second
sound

No component A2

Present A2

Carotid
Pulse

Slowly rising

Brisk or bifid

Aortic Stenosis
Grades:
Mild:

Valve area of >1 cm2 or gradient < 40mmHg.

Moderate: Valve area of 0.75 to 1 cm2 or gradient 4070 mmHg.
Severe: Valve area <0.75 cm2 or gradient >70 mmHg.
Surgery:

If symptoms. Angina, syncope,

dyspnea, CHF. If not, risk of death 10-20% per
year.
If not suitable for valve replacement
valvuloplasty is alternative.

Question
A 71 year-old females has dizzy spells with near
fainting. An echocardiogram shows calcified
aortic valve with area of 0.5cm2. The peak
systolic valve gradient is 90mmHg. She lives
alone and wants everything done for her. What
is the next step?
a. Coronary arteriography
b. ACE-Inhibitor
c. Exercise stress test
d. Exercise program with low dose diuretics
e. Aortic valve replacement

Question
A 73

years old patient with R hip fracture, noted

to have a SEM. Echo shows AV area of 0.76cm
and gradient of 50mmHg, normal LV function. Pt
is active and asymptomatic. What is the next
step?
a. Balloon valvuloplasty prior to surgery.
b. Cardiac catheterization.
c. Proceed with hip surgery.
d. Aortic valve replacement before hip surgery.

Questions
A 23

y/o male presents to the ER with witnessed

syncope while running to catch a bus. There was
no observed postictal state. At PE brisk carotid
upstroke. SEM 3/6 at LSB with a systolic thrill.
Murmur increase upon standing. What is the
most likeky diagnosis?
a. Rheumatic mitral regurgitation
b. Congenital aortic stenosis
c. Hypertrophic obstructive cardiomyopathy
d. Ebsteins anomaly

DVT/PE prophylaxis
Start

before or shortly after surgery.

Total knee replacement minimum duration
is 7 to 10 days with LMWH or warfarin.
Total hip replacement minimum duration is
28-42 days with LMWH or warfarin.
IPC only for patients at high risk of
bleeding.

Questions
A patient

with PE is in shock. Next step?

a. Thrombolysis
b.

Embolectomy
c. Heparin
A 63

year old construction worker with h/o 3

episodes of DVT on coumadin, INR 2.5 comes
again with DVT. What to do?
a.

Increase dose of coumadin

b. Add low molecular weigth heparin
c. Greenfield filter

PAW=RA=RV=PA
Cardiac
Tamponade

Constrictive
Pericarditis

Right Ventricular
Infarction

Present

Present

Present/Absent

Calcification on X- Absent
Ray, CT/MRI

Present

Absent

ECHO

Effusion with
diastolic collapse

Thick/calcified
pericardium

Large RV size

EKG

Low voltage and

elect. alternans

Low voltage

ST elevation on
Right leads

Prominent X

Present

Present

Absent

Prominent Y

Absent

Present

Absent

Pericardial Knock

Absent

Present

Absent

Equal Diastolic
Pressures

Pulsus Paradoxus Present

Absent in 2/3 of pt Absent

Kussmaul sign

Present

Absent

Absent/Present

Cardiac Tamponade

Causes: Viral, Metastasis, idiopathic, uremic, trauma,

cardiac rupture, aortic disection.
Features:

Depends on the rapidity of fluid accumulation.

Limited ventricular filling in diastole, absent Y
Low cardiac output, hypotension, tachycardia,
High jugular venous pressure with prominent x descent.

Paradoxical pulse, lungs clear, faint heart sounds

EKG: Electrical alternans, low voltage
Cath: Equalization of pressures (RA, RV, PA, PCWP)
Echocardiogram: RV, RA diastolic collapse, IVC dilation
Treatment: Pericardiocentesis, IV fluids, surgery.

Constrictive Pericarditis

Causes: Post acute pericarditis, surgery, trauma, RA, radiation, TB,

cancer, uremia.
Features:

Filling is reduced abruptly because thickened pericardium

Stroke volume is reduced, equalization of pressures.
High jugular venous pressure with prominent x and y descents, as M
shape.
Dip and plateau square root sign in L and R ventricular pressures

Pericardial knock, kussmauls sign, R and L heart failure.

EKG: Low voltage
ECHO: Rapid decrease in filling velocities, abnormal septum
motion, pericardial thickness in 80% of cases.
Radiology: May have calcification
Treatment: Pericardial resection with mortality 6-20%, diuretics,
sinus rhythm, may resolve within months or after antiinflamatory tx.

Restrictive Cardiomyopathy
Causes:

Infiltrative, storage and collagen

diseases; radiation, anthracyclins.
Features:
Diastolic

dysfunction, pulmonary congestion, may

advance to systolic dysfunction.
Dyspnea, JVD, Kussmauls, R side heart failure.
EKG:

L or R BBB, L or R VH.
ECHO: LVH, homogeneous, dense walls, No
calcification.
Treatment: Diuretic, stem cell, deferoxamine,
pacemaker.

Acute Right Ventricular Infarction

Causes:

Inferoposterior infarction
extension.
Features:
High

jugular venous pressures, kussmaul

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

ST elevation in RV4.
Echo: Enlarged hypokinetic RV.

Question

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

month history of refractory severe lower extremity and
scrotal edema, ascitis despite diuretics. CXR with clear
lung fields and small bilateral pleural effusions, calcific
stipping of the cardiac silhouette. CVP has prominent x
and y, with spike and plateau tracing in RV. ECHO
showed normal septum thickness. What is the most
likely diagnosis?

A. Cor Pulmonale
B. Cardiac tamponade
C. Constrictive pericarditis
D. Amyloid cardiomyopathy

Question
A 54

year old male one day post-uncomplicated

IWMI. The nurse tells you that patient doesnt
have complains but the BP is 80/45 and the HR
is 85. The neck veins are noticeable at the
angle of the jaw and the lungs are clear to
auscultation. At exam RR, no S3, no edema.
What to do next?
A.

Cardiac catheterization
B. IV dobutamine/lasix
C. Atropine and then temporary pacemaker
D. IV fluids

Aortic Aneurysm

Localized >50% diameter increase involving all three layers of

the wall.
Risk factors: Age>60 years, smoking, HTN, dyslipidemia,
family history. If younger, think of Marfan, Ehler-Danlos ,
syphilis, Takayasus, trauma, bicuspid valve, aortic coartation.
Most common in men, 3:1; infrarenal, mostly asymptomatic,
can present with compression symptoms, distal embolism or
rupture.
Surgery if growth more than 0.5cm/year, abdominal >55 mm in
men, >45mm in women, ascending aortic >50mm, and
descending >60mm.
Patients with >45mm should have f/u 3 months.
Percutaneous repair is possible for infrarenal.
After surgery, evaluate every 6 months with CT or MRI.

Aortic dissection

Diagnosis often delayed owing to failure to consider it as a possibility.

Risk factors: In younger than 70 years: Turners, cocaine, bicuspid
valve, collagen disorders-Marfan, Ehlers Danlos-, aortic coartation. In
older than 70years: HTN, diabetes, vasculitis and preexisting aortic
aneurysm.
Blood pass between lumen and media creating a false lumen.
Stanford A: Ascending aorta. 2:1. Involves aortic arch in 30%, worse
prognosis, surgical emergency. Mortality with surgery 10-30% and
without 50%.
Stanford B: The rest of aorta. Mortality with medical management
10% per year or better. Surgery if occlusion of major branch,
extension of dissection, Marfan. TX: BB, SBP 100-120, avoid
strenous activity, F/u at 3, 6, 12 months.
Presentation: Anterior or posterior CP, AR, MI, pleural or pericardial
effusion, mental status changes; splacnic, renal, LE, spine ischemia.
TEE, CT, MRI

Question
An

elderly patient has chest pain radiating

to the back. BP is lower in left arm.
Diastolic murmur at LSB. EKG shows ST
depression all over, BP 250/130.
What is the immediate treatment?
a. Thrombolysis
b. Aspirin, lovenox. Abciximab.
c. Metoprolol and NTG or NTP.
d. Nicardipine

Question
What

test will you do?

A.

CT chest w/o contrast

B. MRI chest w/o contrast
C. TTE
D. TEE
Showed

aortic dissection of ascending aorta.

Pain has improved. BP is normal. What to do
next?
Take

patient for surgery

Continue medical therapy unless rupture or pain.
Wait for few days for patient to stabilize before
surgery.

Carotid Artery Disease

Stroke is third leading cause of death.

There are about 1 million strokes/year.
Carotid duplex for all symptomatic, for asymptomatic
with bruits if good candidate for revascularization, or any
going for CABG.
ASA has RRR 16% for fatal stroke and 28% for non fatal
stroke.
ASA is as good as CEA for symptomatic with <50% and
for asymptomatic with <60%.
Extended-release dipyridamole plus ASA superior to ASA
alone for secondary prevention.
Dual therapy as Clopidogrel plus ASA only for recurrent
events despite therapy with ASA. Higher risk of bleed.

Question
A patient

with recent TIA and ipsilateral 5069% carotid stenosis, you will recommend:
A. Atherosclerotic

risk factor modification

B. Antiplatelet therapy
C. Carotid endarterectomy
D. Carotid Arterial Stenting
E. A, B and C.

Bacterial Endocarditis

The fourth leading cause of life-threatening disease due

to infection.
Low incidence but high mortality.
2 major Duke criteria or 1 and 3 or 5 minor.
CHF occurs on 8-30% of patients.
Systemic embolization happens in up to half of cases, of
those 65% involve CNS.
Perivalvular abscess affect AV in 40%.
TTE has sensitivity of 50-80%
TEE has sensitivity of 95% for vegetations.
Tx: From 2 to 6 weeks.

DUKE CRITERIA
1. Positive blood culture for Infective Endocarditis
Typical microorganism on 2 or more blood cultures:

Viridans streptococci, Streptococcus bovis (gallolyticus), or

HABCEK or Community-acquired Staphylococcus aureus or
enterococci.
Continuous bacteremia:

2 positive cultures drawn >12 hours apart, or all of 3 or a

majority of 4 separate cultures of blood (with first and last
sample drawn 1 hour apart)
Positive blood culture for CB or IgG titer >1:800.
2. Evidence of endocardial involvement
Positive echocardiogram for IE defined as :
Vegetation or
abscess or
new partial dehiscence of prosthetic valve

New valvular regurgitation (worsening or changing of preexisting

murmur not sufficient)

Duke criteria

Minor criteria :
Predisposition: predisposing heart condition or intravenous
drug use
Fever: temperature > 38.0 C (100.4 F)
Vascular phenomena: major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage,
conjunctival hemorrhages, and Janeway lesions
Immunologic phenomena : glomerulonephritis, Osler's nodes,
Roth spots and rheumatoid factor
Microbiological evidence: positive blood culture but does not
meet a major criterion as noted above or serological evidence
of active infection with organism consistent with IE
Echocardiographic findings: consistent with IE but do not
meet a major criterion as noted above

Excludes single positive cultures for coagulase-negative staphylococci,

diphtheroids, and organisms that do not commonly cause endocarditis.

AB Prophylaxis for BE
Low

risk:

Secundum ASD
Innocent

murmur
CABG surgery
Pacemaker/ICD
MVP without MR
High

risk:

Prosthetic

valve
Cyanotic congenital
heart disease
Previous endocarditis

Moderate
All

risk:

other congenital
heart disease.
Bicuspid aortic valve
Acquired valve
disease
HCM
MVP with MR

Surgery Indications in Bacterial

endocarditis
About

20-50% will require surgery.

Hemodinamic instability due to valvular
regurgitation, destruction.
Cardiogenic shock
Perivalvular extension, abscess
Resistant infection
Fungal endocarditis
Vegetation >1cm in diameter
Recurrent distal emboli.

Question
A 62

years old patient has had aortic valve

replaced six months ago. He presents with
endocarditis of the valve with findings of
moderate CHF due to regurgitation. He is
treated for CHF and antibiotics are started. He
begins to improve with good response to the
treatment. EKG has new prolonged PR interval.
What is your next step?
A.

Continue 2 more weeks with IV AB.

B. Surgery consult for AV reconstruction.
C. Discharge pt with IV AB by HHC.
D. Continue in hospital IV AB until 3 BC are negative.

Stress testing
Criteria for a Positive Treadmill Exercise Test:
ST depression of > 0.1 mV (1mm) below the baseline, and lasting longer
than 0.08 msec.
High Risk Ischemic Response
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
following:

Horizontal or downsloping ST depression > 0.1 mV

ST-segment elevation > 0.1 mV in noninfarct lead
Five or more abnormal leads
Persistent ischemic response >3 minutes after exertion
Typical angina
Exercise-induced decrease in systolic BP by 10 mm Hg

Stress testing
Intermediate:
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 > 1 of the following:

Horizontal or downsloping ST depression > 0.1 mV

Persistent ischemic response greater than 1 to 3 minutes after exertion
Three to 4 abnormal leads

Low
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:

Horizontal or downsloping ST depression > 0.1 mV

One or 2 abnormal leads

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

Un-interpretable Treadmill EKG

Resting T-wave
WPW
Paced

rhythm

LVH
Digoxin
MVP
LBBB

abnormalities

Question
A patient

with COPD,(having wheezing

and ronchi), and PVD, unable to walk even
one block needs a cardiac stress test.
EKG has RAE. BP is normal. Which one?
A.

Dobutamine stress test

B. Exercise echocardiogram
C. Adenosine stress test
D. Exercise electrocardiography

Preoperative Evaluation

Preoperative Evaluation
Risk Stratification

Procedure Examples

Vascular (reported cardiac

Aortic and other major vascular surgery

risk often > 5%)

Peripheral vascular surgery

Intermediate (reported

Intraperitoneal and intrathoracic surgery

cardiac risk generally 1%-5%)

Carotid endarterectomy
Head and neck surgery Orthopedic
surgery Prostate surgery

Low (reported cardiac

Endoscopic procedures

risk generally <1%

Superficial procedure
Cataract surgery Breast surgery
Ambulatory surgery

*Active cardiac conditions

Condition

Examples

Unstable coronary
syndromes
Decompensated HF

Unstable

or severe angina* (CCS class III or IV)

Recent MI

Significant arrhythmias

Severe valvular
disease

NYHA functional class IV;

Worsening or new-onset HF
High-grade

atrioventricular block
Mobitz II atrioventricular block
Third-degree atrioventricular heart block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (including atrial
fibrillation) with uncontrolled ventricular rate (HR >
100 bpm at rest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
Severe

aortic stenosis (mean pressure gradient

greater than 40 mm Hg, aortic valve area less than 1.0
cm2, or symptomatic)
Symptomatic mitral stenosis (progressive
dyspnea on exertion, exertional presyncope, or HF)

Can You
1 Met Take care of yourself?

Can You
4
Climb a flight of stairs or
Mets walk up a hill?

Eat, dress, or use the

toilet?

Walk on level ground at 4

mph (6.4 kph)?

Walk indoors around the

house?

Do heavy work around the

house like scrubbing floors
or lifting or moving heavy
furniture?

Walk a block or 2 on level

ground at 2 to 3 mph (3.2
to 4.8 kph)?

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

4 Mets Do light work around the

house like dusting or
washing dishes?

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

Preoperative Evaluation
Revised Cardiac Risk Index or Clinical Risk Factors

Ischemic heart disease

Congestive heart failure

History of MIAngina
Use of nitroglycerine
Q waves
History of heart failure
Pulmonary edema
Paroxysmal nocturnal dyspnea
Peripheral edema, rales,
S3

History of Stroke or TIA

Diabetes on insulin therapy
Creatinine>2mg/dl.

Preoperative Evaluation

Question
Which

of the following is most important

pre-operative cardiac risk factor for noncardiac surgical procedures?
A.

S4 gallop
B. S3 gallop
C. MI 10 months ago
D. Age over 70 years.

Question
A 71

year old male with h/o stable angina,

now needs vascular surgery in the leg.
What is your advice before clearing him
for surgery?
A.

Proceed with surgery.

B. Exercise stress test with imaging.
C. Adenosine stress test
D. Avoid surgery
E. Cardiac catheterization

Acute Coronary Syndrome

Unstable Angina & NSTEMI

TIMI risk score:

Age 65 years or older

3 or more CAD traditional
risk factors
Documented CAD with
stenosis of 50%
ST segment deviation
2 or more anginal episodes
in the last 24hr
Aspirin use within the last 7
days
Elevated cardiac enzymes

Low risk: 0-2,

Conservative approach
with non-invasive stress
testing
Intermediate risk: 3-4
Initiate glycoprotein IIb/IIIa
inhibitor and early
invasive approach with
angiography
High risk: 5-7 or
persistent pain or
elevated troponin,
angiography

Question
A 51

year old patient comes with typical chest

pain, persistent after ASA, nitrates, betablocker,
02, morphine, statin, lovenox, is taken to the
cath, showing proximal LAD 70%, Cx 30%, RCA
30%, normal ejection fraction. What to do next?
CABG
PCI
Add ACEI
Thrombolysis

Indications for revascularization

For PCI

Unstable angina failing medical therapy or TIMI 3 or more

Unstable angina in patient with prior revascularization CABG or
PCI
ST elevation MI
Failed thrombolysis
Unable to do thrombolysis
MI complicated by shock, refractory ventricular arrythmia, CHF
or sudden death.

For CABG

Left main disease

2 vessel disease with proximal LAD w (+) ischemia or low EF,
most benefit seen in diabetic patients.
3 vessel disease

Thrombolysis
Indications

for Tenecteplase: ST elevation >6hr

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

prior intracranial hemorrage

Cerebral vascular lesion
CNS neoplasm
CVA <3 months except within 3 hours
Significant closed head injury <3 months
Active bleeding diathesis
Suspected aortic dissection

Question
A 52-year

old diabetic patient is subjected

to coronary angiogram because of
persistent unstable angina. It shows 2
vessel disease with EF of 35%. What is
the treatment?
a.

PTCA
b. CABG
c. Medical treatment
d. Thrombolysis

Question
A 61

y/o male had an uncomplicated anterior MI

over 24 hours ago develop syncope. Telemetry
showed V-tach, requiring electrical
cardioversion. What to do next?
Cardiac

catheterization
Electrophysiologic studies
Echocardiography
Holter monitor
Signal-average ECG

Question
A diabetic

patient has chest pain. Because of

anterior wall MI with ST elevation, TPA and
lovenox are started. Within 30min patient is
feeling better ST-T segment came back to
baseline but tele shows wide complex, NSVT.
What is your next step?
Observation

only
Intravenous lidocaine
Emergent cardiac catheterization
Intravenous amiodarone
Electrophysiologic study

Complications post-MI
Rupture
Ventricular
Septum

Rupture
Rupture
Papillary Muscle Myocardial Wall

Timing

2-14 days

2-10 days

2-7 days

Clinical findings

Harsh loud
systolic thrill
LLSB

Acute
Pulmonary
edema, MR
murmur

Sudden chest
pain, shock,
JVD, death
New ST elev

Diagnostic
parameter

02 step-up in
RV

Severe MR,
LAE

Electromechanical
dissociation

Management

Nitrohydralazine
IAB
Surgery

Nitro
IAB
Surgery

Usually no
survival

Questions
Patient

with IWMI whos BP goes down

from 90/60 to 60/20. Next step?, What is
the problem?
A patient with acute MI, doing well by the
second week after admission. Suddenly
pt goes into acute CHF, and a new thrill at
LLSB if found. What will the
hemodynamic monitoring show?

Question
A 64

y/o male with history of uncomplicated

AWMI 4 days ago has suddenly developed
increasing SOB, hypotension, tachycardia, neck
veins are distended, new gallop and a SEM.
PCWP is 34 with a large V-wave. Diagnosis?
Myocardial

free-wall rupture
Large pulmonary embolism
Ventricular septal rupture
Ruptured chordae tendineae
Cardiac tamponade

Question
A patient

with known hypertension, with no past

h/o MI is admitted to CCU with a large Q-wave
acute anterior MI. On the third day he is
suddenly found in shock without any pulse or
BP. EKG reveals new ST segment elevation with
what appears to be sinus rhythm. What is the
diagnosis?
A. Free wall rupture
B. Right Ventricle infarction
C. Papillary muscle rupture
D. Ventricular septal rupture