This patient likely has constrictive pericarditis based on the following: 1) Refractory edema despite diuretics suggesting impaired cardiac filling 2) History consistent with an etiology of post-pericarditis from RA 3) Clear lung fields on CXR rule out heart failure as cause of edema

1. PEARLS IN CARDIOLOGY
Sandra Rodriguez
Internal Medicine
2008

2. 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.

3. 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

4. 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.

5. 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.

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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)

12. 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.

13. 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

14. 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

15. 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.

16. 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

17. Aortic Stenosis
 Grades:
 Mild: Valve area of >1 cm2 or gradient < 40mmHg.
 Moderate: Valve area of 0.75 to 1 cm2 or gradient 40-
70 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.

18. 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

19. 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.

20. 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. Ebstein’s anomaly

21. 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.

22. 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

23. PAW=RA=RV=PA
Cardiac
Tamponade
Constrictive
Pericarditis
Right Ventricular
Infarction
Equal Diastolic
Pressures
Present Present Present/Absent
Calcification on X-
Ray, CT/MRI
Absent 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
Pulsus Paradoxus Present Absent in 2/3 of pt Absent
Kussmaul sign Absent Present Absent/Present

24. 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.

25. 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, kussmaul’s 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.

26. Restrictive Cardiomyopathy
 Causes: Infiltrative, storage and collagen
diseases; radiation, anthracyclins.
 Features:
 Diastolic dysfunction, pulmonary congestion, may
advance to systolic dysfunction.
 Dyspnea, JVD, Kussmaul’s, 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.

27. 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.

28. 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

29. Question
 A 54 year old male one day post-uncomplicated
IWMI. The nurse tells you that patient doesn’t
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

30. 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, Takayasu’s, 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.

31. Aortic dissection
 Diagnosis often delayed owing to failure to consider it as a
possibility.
 Risk factors: In younger than 70 years: Turner’s, 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

32. 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

33. 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.

34. 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.

35. Question
 A patient with recent TIA and ipsilateral 50-
69% 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.

36. 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.

37. 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)

38. 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 above¹ 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
 ¹ Excludes single positive cultures for coagulase-negative staphylococci,
diphtheroids, and organisms that do not commonly cause endocarditis.

40. 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 risk:
 All other congenital
heart disease.
 Bicuspid aortic valve
 Acquired valve
disease
 HCM
 MVP with MR

41. 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.

42. 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.

43. 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

44. 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.

45. Un-interpretable Treadmill EKG
 Resting T-wave abnormalities
 WPW
 Paced rhythm
 LVH
 Digoxin
 MVP
 LBBB

46. 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

47. Preoperative Evaluation

48. 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

49. *Active cardiac conditions
Condition Examples
Unstable coronary
syndromes
 Unstable or severe angina* (CCS class III or IV)†
 Recent MI‡
Decompensated HF  NYHA functional class IV;
 Worsening or new-onset HF
Significant
arrhythmias
 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 valvular
disease
 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)

50. Can You… Can You…
1 Met Take care of yourself? 4
Mets
Climb a flight of stairs or
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
Mets
Participate in strenuous
sports like swimming,
singles tennis, football,
basketball, or skiing?

51. Preoperative Evaluation
Revised Cardiac Risk Index or Clinical Risk Factors
 Ischemic heart disease
 History of MIAngina
 Use of nitroglycerine
 Q waves
 Congestive heart failure
 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.

52. Preoperative Evaluation

53. Question
 Which of the following is most important
pre-operative cardiac risk factor for non-
cardiac surgical procedures?
 A. S4 gallop
 B. S3 gallop
 C. MI 10 months ago
 D. Age over 70 years.

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. Complications post-MI
Rupture
Ventricular
Septum
Rupture
Papillary Muscle
Rupture
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
Electro-
mechanical
dissociation
Management Nitro-
hydralazine
IAB
Surgery
Nitro
IAB
Surgery
Usually no
survival

63. 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?

64. 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

65. 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