Board-Review-cardiology.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Congenital Heart Disease,In the Adult,Acyanotic Congenital Heart Disease,(covered in MKSAP),Atrial Septal Defect,Bicuspid Aortic Valve,Most common congenital anomaly,More common in men,Early systolic ejection click and outflow murmur,Diagnosis with echo important because of endocarditis risk,Coarctation and bicuspid aortic valve are associated,Ventricular Septal Defect,Patent Ductus Arteriosus,Valvular pulmonary stenosis,Coarctation of the aorta,Cyanotic Congenital Heart Disease,(covered in MKSAP),Most patients with,unoperated,cyanotic heart disease have developed,Eisenmengers syndrome,.,Tetralogy of Fallot,most have had complete intracardiac repair,occasionally only aortopulmonary shunt.,PI leading to right heart dilation is common,Yearly mortality increases after 25 years due to sudden death,QRS 180ms best predictor,apparent interaction between long QRS and right heart dilation,general agreement to replace pulmonary valve when QRS180.,Transposition of Great Arteries,most have had been repaired with atrial switch(Mustard,Senning)procedure now doing arterial switch,Risk RV failure(survival depends on RV function),sick sinus syndrome,atrial arrhythmias,-,Closure of ASD and VSD indicated if pulmonary to systemic shunt ratio of 1.7:1 or greater with evidence of right or left ventricular volume overload respectively.,ASD second,Most common,Congenital defect,Encountered in adults,(bicuspid AV#1),Majority are secundum,Location of types of Atrial,Septal Defects,More on ASDs,In absence of pulmonary vascular disease shunt is left to right resulting in RV volume overload.,With advancing age diminished LV compliance can lead to increase in shunt fraction with consequent right heart failure,A.fib is common in older adults with ASDs.,Frequency of A.fib and potential for paradoxical embolism lead to high incidence of embolic stroke.,Before repair prophylaxis for endocarditis is not indicated for isolated ASDs.Following closure 6 mos of prophylaxis for endocarditis.,#18 24 y.o.female emigrated from Phillipines eval for murmur.HR 82.O2 sat 97%.JVP normal.Carotid pulses brisk with rapid upstroke.Lungs clear.Sustained apical impulse in 6,th,intercostal space.S1 normal.S2 physiologically split with normal P2.A soft S3 is audible.,Continuous murmur,with crescendo-decresendo quality is heard throughout,loudest 3,rd,left intercostal space.Diagnosis?,Mitral regugitation,Mitral stenosis and insufficiency,Pulmonary stenosis and insufficiency,Patent ducts arteriosus,#18 patent ductus.,Patent ductus arteriosus,In acyanotic adult with patent ductus communication is usually small.Murmur soft and confined to systole.,Most adults with large patent ductus have Eisenmengers physiology and are not surgical candidates.,Closure is indicated if associated with a murmur to prevent the complications of endarteritis.,Closure percutaneously with coil.,PFO,patent foramen ovale,.,Persist in 20%of people.,Can be associated with interatrial septal aneurysm.,Can be diagnosed by contrast echo.,Risk for paradoxical embolism.,The specific indications for closure of a patent foramen ovale after a cerebral embolic event remain unclear,#43 26 y.o.man diagnosed with heart murmur as a baby.Told he would outgrow it.Participates in sports without problem.120/80,64.Lungs clear.Nondisplaced apical impulse.Normal S1,physio split S2.Thrill in 3,rd,left intercostal space and 4/6 holosystolic murmur noted radiating to the right.Echo small perimembranous VSD.Normal chamber size and normal PA pressures.,Refer to surgeon for closure,Treat with amoxicillin 2 gm 1 hour before dental procedures,Refer for percutaneous closure,Initiate lisinopril therapy,#43 Treat w/amoxicillin 2 gm 1 hour before dental procedures,Ventricular Septal Defect,In acyanotic adult VSD usually small,Large VSD present in childhood with CHF or pulmonary hypertension,Most common location in adults is perimembranous near tricuspid valve,Indications for closure in adulthood are large shunt fraction 1.7:1 or greater or left ventricular volume overload(LV overload occurs because shunt is primarily confined to systole and the RV serves as a reservoir for the shunted blood The LV diastolic volume is increased because the stroke volume includes both forward flow and shunted flow),Exam with hemodynamic sig VSD may reveal displaced apical impulse,mitral diastolic rumble,S3.,Endocarditis Risk and Prophylaxis,In Congenital Heart Disease,Risk of endocarditis is substantial,except in,operated,patients with pulmonary stenosis,ASD,VSD,PDA.If residual VSD or PDA leaks present postoperatively,risk persists.,Antibiotic prophylaxis is indicated for almost all patients with,unoperated,congenital heart disease(except isolated ASD),ASDbefore repair no prophylaxis indicated unless other coexisting abnormalities.Prophylaxis for first 6 mos post repair and indefinitely if residual abnormalities.,#5945 y.o.known Eisenmengers b/c of unrepaired VSD.Increased lethargy,frontal headache,and difficulty concentrating.Previous PMD phlebotomized 1 unit every 3 mos.Cyanotic,95/65,95,84%.Clubbing.Clear lungs,nl JVP.Widely physio split S2,loud P2.Holosystolic murmur at left parasternal border.High pitched diastolic murmur at upper left sternal border.Right sided S4.HCT 56%,MCV 72.WBC 5.6.PLT 110.,Symptoms suggest hyperviscosity,they may be caused by iron deficiency.Microcytic erythrocytes are rigid and not easily deformed.Thus viscosity increases paradoxically at lower hematocrit.,Eisenmengers Syndrome and Erythrocytosis,Seconday erythrocytosis is compensatory and usually not associated with symptoms.,Hyperviscosity syndrome can occur when HCT 65.Phlebotomy is indicated only to treat symptoms.,Be sure not iron deficient and not volume depleted.,When phlebotomy is necessary,follow by isovolumic saline repletion(in presence of CHF use 5%dextrose),Pregnancy contraindicated.Maternal mortality excceds 50%with death usually in early postpartum period.,#89,35 y.o.female hypertensive.Told had hypertension at age 20 as well but did not follow up.BP 200/100.S1.S2 physio split.An early systolic ejection sound is noted and early peaking murmur noted in second right intercostal space.Short diastolic murmur along LSB.U/A normal.,Measure TSH,Measure BP lower extremities,Order Echo,Order 24 HR urine test for metanephrine and vanillylmandelic acid,Obtain CXR,#89 Measure BP lower extremities,-,Coarctation of the aorta,Radial femoral delay,Lower blood pressure in the legs,Rib notching(dilated intercostal arteries that provide collateral blood flow),Repair indicated when there is proximal HTN and a gradient exceeding 20 mm Hg,Discrete coarctation is usually amendable to percutaneous repair while longer segments may require surgery,Cardiac Disease And Pregnancy,#11 25 y.o.pregnant female presents with heart murmur noted second trimester.First pregnancy.New murmur.No PMH.Asymptomatic.Mild displaced apical impulse and lower extrem edema.S1 and S2 normal,S3 at apex.2/6 early to mid peaking systolic murmur at left sternal border.Likely cause of murmur?,Bicuspid aortic valve with mild to mod AS,Congenitally abnl pulmonary valve with mod stenosis,Physiologic murmur related to pregnancy,Bicuspid aortic valve with moderate regurgitation,#11 physiologic murmur,-,PHYSICAL FINDINGS AND PREGNANCY,-,-,S3 audible in more than 80%of normal pregnant women,Early peaking ejection systolic murmur audible in 90%-pulmonary outflow murmur,Increased blood volume during pregnancy,(CO increases by 30 to 50%during pregnancy and to about 80%above baseline during labor and delivery),Apical impulse displaces,Lower extremity edema common,Abnormal findings-,-S4,loud 3/6 systolic murmur,diastolic murmur,fixed splitting of S2.,In general,fixed obstructive lesions(MS,AS)poorly tolerated in pregnancyincreased blood volume.,Regurgitant lesions well tolerateddecreased SVR,#20 28 y.o.pregnant female referred for eval of persistent dyspnea secondary to MS.30 weeks pregnant and dyspnea persists after metoprolol,lasix,and digoxin.HR 70.Echo severe MS,mean grad 14,valve area 1 cm2.Trivial MR.RV systolic 50 mmHg.Crackles and edema.What do you recommend?,Surgical mitral valvotomy,Urgent delivery fetus then reassessment of maternal cardiac status,TEE followed by percutaneous mitral balloon valvuloplasty,Diagnostic catheterization,Fetal Echocardiogram,#20 TEE followed by percutaneous mitral balloon valvuloplasty,Percutaneous valvuloplasty treatment of choice in pregnant women with severe MS whose sx cant be controlled with meds.,TEE to eval Mitral valve aparatus and eval for LA thrombus,Abdominal shielding to limit radiation to fetus(Avoid during first trimester),Cardiac surgery can be performed during pregnancy but should be avoided unless absolutely necessary(best time 24-28 weeks)(Maternal mortality 1-5%,fetal 15-38%),#30 28 y.o.female 29 weeks pregnant referred for progressive dyspnea.h/o rheumatic fever and mitral stenosis.4 wk increase dyspnea.No palpitations.Elevated JVP.HR 100.Parasternal impulse present.Opening snap and grade 2 diastolic rumble.EKG sinus tach,LAE,RAD.,What do you recommend?,Digoxin,Metoprolol,Warfarin,Ramipril,amlodipine,#30 metoprolol,to slow HR,increase diastolic filling time.,If sx persist then diuretic,Note:ACE I,ARB contraindicated in pregnancy,#38 35 y.o.female 39 weeks pregnant comes to office increasing dyspnea.No prior PMH.First pregnancy.JVP 13,diffuse apical impulse,apical systolic murmur.S3 and S4.Crackles.EKG tachy.,Diagnosis?,Severe AS,Severe TR,ASD,Peripartum cardiomyopathy,Pulmonary embolism,#38,Peripartum Cardiomyopathy,1:1,300 to 1:15,000 pregancies in US,higher in certain parts of Aftrica,Risk increased in:African Americans,multiple gestations,multiparous,women age 30 years,h/o peripartum cardiomyopathy,Usually occurs during last trimester pregnancy or in first 6 mos post partum(Most commonly diagnosed in first post partum month),50%of women with peripartum cardiomyopathy will have improvement in LV function within 6 mos after delivery.,Delivery is recommended,Unless obstetric reasons for c-sec mode of delivery should be vaginal because of lower hemodynamic burden,Because risk of recurrence of peripartum cardiomyopathy is common repeated pregnancy is“contraindicated”pts with persistent LV dysfunction and pts with h/o serious episode should be counseled to avoid repeat pregnancy,Cardiomyopathy and Pregnancy,Notes on medical therapy,NO ACEI,ARB during pregnancy.(in animals fetal hypotension and death.Also early delivery,low birth weight,oligohydramnios,neonatal anuria and renal failure),Digoxin,and,hydralazine,are considered safe during pregnancy and breast feeding.,Diuretics can be used if sx not controlled by decreased salt and central venous pressue elevated.Most experience with,thiazides,and,lasix,.(diuretics impair uterine blood flow and placental perfusion).,Metoprolol,atenolol,labetalol,have been used safely in pregnancyfetal monitoring recommended for risk of intrauterine growth retardation and fetal bradycardia.,#58,35 y.o.female who has progressive dyspnea days after delivery.EF 20%.Treated ACEI,diuretic,B-blocker.Sx resolve.12 mos after delivery asymptomatic and EF 50%off meds.She comes to you for counseling re:repeat pregnancy.,Advise her that she may proceed,Resume ACE I during pregnancy,Advise her not to become pregnant b/c of risk of recurrent peripartum cardiomyopathy that may be fatal,Evaluate for another cause of cardiomyopathy b/c diagnosis of peripartum cardiomyopathy is now in question,#58 Advise her not to become pregnant b/c of risk of recurrent peripartum cardiomyopathy that may be fatal,Because recurrence of peripartum cardiomyopathy is common,repeated pregnancy is contraindicated.,Regarding cardiomyopathy in general and pregnancy:,Avoid pregnancy is LVEF is less than 40%or NYHA functional class is higher than II.,Bed rest is often required and close cardiac and obstetric monitoring mandatory,Treating CHF is more difficult in pregnant than in nonpregnant women.,#104 28 y.o.female with aortic and mitral mechanical prosthesis.INR therapeutic.Pre-pregnancy consult.,Discontinue warfarin and treat with ASA and dipyridamole during first trimester,Continue warfarin through pregnancy and start heparin 5000 U SQ TID plus ASA,d/c warfarin and treat with enoxaparin 30 mg SQ BID through pregnancy,d/c warfarin and initiate dose adjusted unfractionated heparin SQ during first trimester and resume treatment with warfarin for rest of pregnancy until shortly before delivery,Use clopidogrel and ASA for first trimester and warfarin for rest of pregnancy until shortly before delivery,initiate dose adjusted unfractionated heparin SC during first trimester and then resume treatment with warfarin,-,Anticoagulation and Pregnancy,During pregnancy increased risk of thombosis or embolism,Pregnant women with mechanical heart valve have a 10%risk for development of prosthetic valve thrombosis or another life threatening complication,Data are limited on safety of various anticoagulation regimens and controversy persists,Anticoagulation and Pregnancy,Heparin does not cross the placenta,12-24%incidence of thromboembolic complications including valve thrombosis in high risk pregnant patients treated with SQ unfractionated heparin,Efficacy of dose adjusted SQ heparin not established.Dose should be adjusted so that PTT is at lesat 2-3 times control value 6 hours after adminstered.,Heparin may not provide sufficient anticoagulation for very high risk patients(caged-ball or tilting disk-Bjork Shiley-mechanical prosthesis),Prolonged heparin can lead to thrombocytopenia,osteoporosis,alopecia,Warfarin crosses the placenta,fetal anticoagulationrisk of spontaneous abortion,prematurity,fetal deformity,stillbirth,retroplacental hemorrhage and intracranial hemorrhage.,Historic reports 30%(more recent data 4-10%)risk,warfarin embryopathy,bone and cartilage abnormalities,nasal hypoplasia,optic atrophy,blindness,retartdation,seizures-with use in first trimester.,risk highest if exposure during 6,th,to 12,th,wk.,Low risk if less than 5 mg QD warfarin dose.,Warfarin does not enter breast milk,C-section if labor occurs during warfarin anticoagulation due to risk of fetal intracranial hemorrhage.,Current Recommendations,for anticoagulation,during pregnancy,Anticoagulation and pregnancy Low Molecular Weight Heparin,Currently data insufficient to support use LMWH during pregnancy.,It does not cross placenta and no teratogenic effects reported.,6,th,ACCP conf supports use of LMWH throughout pregnancy except 24 hrs before delivery when recommendation is IV unfractionated heparin.,However FDA changed labeling to state enoxaparin not recommended for prosthetic valves during pregnancy,.,More notes on Anticoagulation and pregnancy,Dipyridamole should not be used during pregnancy(no data on clopidogrel or ticlopidine),Information limited on IIbIIIa inhibitors during pregnancy,81 mg ASA