This patient has class III heart failure with an ejection fraction of 28% and was recently hospitalized for decompensated heart failure. She has been adherent to guideline directed medical therapy including diuretics, beta blockers, ACE inhibitors, and has a cardiac resynchronization device. Given her recent hospitalization and high BNP, adding an aldosterone inhibitor would be a reasonable next step to further optimize her medical management.

1. Clinical Pearls in Cardiology
Examination skills
Clinical scenarios

2. Physical examination of a patient's
cardiovascular system
1.Introduce yourself. position pt.optimal exposure
2.cyanosis/clubbing
splinter hemorrhages
pallor
3.Pulse rate/rhythm, respiratory rate
4.BP lying and standing
5. JVP: height and waveform
carotid pulse:quality, bruits
6. central cyanosis
dental caries
conjunctival pallor
7.Precordial inspection: shape of chest, abnormal pulsation
8.Palpation: site/quality of apex beat, heaves/thrills

3. Physical examination continued
9. Listen to apex, axilla, LSE, LLSE
10. Sit patient forward- feel for parasternal thrill
Listen during inspiration and expiration
11. Palpate thyroid
sacral edema/basal lung dullness
auscultate lungfields for rales
12. Lie patient flat
Pulsatile hepatomegaly
splenomegaly; ascites
Bruits: renal, femoral
13. calf tenderness
ankle edema, tendon xanthomas, peripheral pulses

4. Heart Failure
HTN
CAD
Arrhthymia- A Fib, V fib, SVT
Valvular Heart Disease
Infective endocarditis
Cardiac clearance/Risk
assessment
The heart in other diseases

5. Case1
• 51yo man w dilated cardiomyopathy
whom you have been treating for the past
3 years has class II NYHA heart failure.
Cor angio showed normal coronary
arteries. He would like to be more active
and asks if anything else can be tried.
Takes metop 100mg/d, resting HR
58bpm. Never been able to tolerate ACEI
or ARB developing a severe cough in
multiple previous trials of these agents.
Denies peripheral edema, orthopnea, or

6. Meds and Findings
• Metop 100mg/d
• Furosemide 20mg/d
• Eplerenone 50mg/d
• Digoxin 0.125mg/d
• ECG- nsr w PR interval 147ms and QRS interval
of 98ms
• Echo-LVEF 42%, no sig valve dz, dilated LV w
global hypokinesis
• Exam- JVP 8cm, BP 137/76, HR 58, lungs clear,
no peripheral edema
• Cardiac exam-+s3,1/6 systolic murmur at LLSB
that decreases w Valsalva, enlarged & sustained
point of maximal impulse

7. Which one of the following is the most reasonable
next step in management?
• Prescribe a statin- rosuvastatin 5mg/d
• Refer him to a cardiologist for evaluation
for an AICD
• Refer him to a cardiologist to be evaluated
for cardiac resynchronization therapy
• Initiate treatment w hydralazine and long
acting nitrates
• Increase furosemide to 80mg/d

8. Case 2
• 76 yo man presents w SOB on exertion
that began 6mo ago and has gradually
worsened. Can no longer perform normal
activities wo developing sym and that
climbing one flight of stairs causes him to
be profoundly SOB. Walking on level
ground, he does well, but any hill causes
dyspnea. H/O HTN but no h/o HL, T2D,
tobacco abuse or F/H/O early CAD. On no
meds

9. Findings
• ECG- NSR w normal intervals
• CXR -normal cardiac silhouette w clear
lung fields
• Echo- LVEF 64% w normal valves, N LV,
RV size and function, no regional wall
motion abnormality, normal wall thickness
• Stress test- ability to walk for 4.8 min on
Bruce Protocol (78% of predicted
functional aerobic capacity), HR incr to
146, BP 200/98, stopped test due to SOB,
neg ECG for ischemia
• Exam- lungs clear, JVP 12cm, peripheral
edema 1+, BMI 32

10. Which one of the following actions is
the least appropriate to this patient?
• Initiate treatment w ACEI for BP
• Initiate treatment w diuretic to resolve
congestion and peripheral edema
• Recommend a regular exercise program,
telling him to start slow and increase
gradually
• Encourage him to lose weight
• Refer him for cor angiography

11. Case 3
• 66 yo woman w known CAD has had 2
previous MIs, the first 7 years ago & the
second 11mos ago. After her last MI, her
EF was 28%. Currently has class II NYHA
heart failure
• Meds- lisinopril 40mg/d; carvidelol 12.5mg
BID; spironolactone 25mg/d; ASA 81mg/d;
pravastatin 20mg/d

12. Findings
• Labs- Na 138, K4.4, creat 1.2
• Echo- EF 32% w mild MR, markedly enlarged LV
w anterior wall hypokinesis
• ECG- HR 60 w SR, PR interval 168 ms, QRS
interval 111 ms, corrected QT interval 402 ms,
prior ant MI
• Exam- BP 116/72, HR 60 reg, JVP flat, no
peripheral edema, lungs clear w good BS
• Cardiac exam- presence of S3 w enlarged point
of maximal impulse that is bifid, no murmur or
rub

13. Which one of the following would be the best
therapy for this patient?
• Given that she has NYHA class II HF,
continue current therapy
• Add in a diuretic agent such as
furosemide 20mg/d
• Add in digoxin 0.125mg every 6hours for 4
times, 0.125 mg /d orally
• Refer for cardiac resynchronization
therapy
• Refer for evaluation for an AICD

14. Case 4
• 68 yo man follows up w you after a
hospitalization 2 weeks previously for an
episode of acute decompensated HF.
During his hospitalization, he underwent
diuresis w IV lasix to lose 10lbs of fluid, he
has decreased LV function thought to be
secy to chronic MR. His MV had been
repaired 2 years ago, but his EF of 42%
has not improved significantly since then.
He has a dilated LV and has sym c/w
NYHA class II HF

15. Meds and Findings
• Meds- lasix 20 mg/d; metop 25mg/d;
lisiopril 10mg qhs
• Labs- creat 1.4, e GFR 46, K 4.5, clear
lung fields w enlarged cardiac shadow on
CXR
• Exam- height 177cm, weight 99kg, BP
118/76, HR 62, both lung bases clear, no
leg edema
• Cardiac exam- enlarged bifid; lateral point
of maximal impulse, 1/6 holosystolic
murmur at apex, pos S3, no S4, JVP 8cm

16. Which one of the following is the next best
step in the treatment of this patient?
• Increase lisinopril to 20mg/d
• Add 30 mg of ISMN in am and increase to 60
mg as tolerated
• Refer to a dietitian for a low-sodium, fluid
restricted (1500mL) diet
• Request that he weigh himself each morning,
provide a schedule for increasing lasix if he
gains weight
• Refer him to an electrophysiologist for
possible AICD implantation

17. Case 5
• A 73 yo woman w LV systolic dysfunction
whom you have been treating for several
years presents to the ED. She is having
palpitations and is diagnosed as having A
fib HR 130 in the ED. She denies chest
pain but is mildly SOB w RVR. She is not
sure how long she has had palpitations-
thinks they have been intermittent during
past few months but have always resolved
after a few minutes. This episode lasted
more that 2 h, prompting her to seek
treatment.

18. Medical History
• HTN well controlled w HCTZ
• Hypothyroidism treated medically with normal
TSH
• No h/o bleeding problems, strokes or TIAs
• No syncope or presyncope
• Known CAD w 3-vessel CABG graft performed
11y ago
• Meds- HCTZ 25mg/d; lisinopril 20mg/d; metop
12.5mg/d, ASA 81 mg/d
• Social history- not physically active, lives in a
high rise retirement complex

19. Findings
• Labs- TSH normal, electrolytes normal,
cbc normal, troponin normal
• ECG- A fib, old inferolateral MI, no acute
ST-T changes
• Echo- bilateral atrial enlargement w
enlarged LV and decreased function, EF
34%, evidence of inferolateral MI
• Exam- height 167cm, weight 63 kg, lungs
clear, rhythm irreg irreg, 1/6 systolic
ejection murmur at LLSB, no edema

20. Which one of the following is the best therapy for
this woman w systolic LV dysfunction presenting
w A Fib?
• Control HR w beta-blockers and/or dig &
provide anticoagulation w warfarin to INR
2-3
• Administer antiarrhythmic propofenone &
perform DC cardioversion
• Administer propofenone, perform TEE to
r/o LA thrombus & perform DC
cardioversion
• Refer to EP for consideration of AV node
ablation w pacemaker implantation & long
term anticoagulation
• Refer to EP for pulmonary vein isolation

21. Case 6
• A 78 yo woman who you have been treating for the
past 10 y for ch functional NYHA classIII HF, EF
28%, was admitted to the hospital 3 days ago for
HF. A year earlier she had an AICD/ CRD
implanted. Since being admitted, she has
undergone diuresis, lost 8lbs and feels much
better. You are ready to dismiss her today, w
instructions to continue on her usual home
regimen- lasix 20, carvedilol 25mg BID, lisinopril
20mg qhs. She weighs herself daily & takes extra
lasix & K when her weight increases. She has
been adhering to a low NA diet w 1500ml fluid
restriction. Her BNP is 2186. the cause of her HF
is CAD, but her last stress test 4mos ago showed
a fixed anterior defect but no evidence of ischemia.

22. Which one of the following would be the best
treatment option for this patient at this point in her
care?
• Continuation of current therapy
• Addition of an aldosterone inhibitor, such
as spironolactone or eplerenone
• Augmentation of current therapy to reduce
her BNP levels to normal and her
functional status to NYHA classII or less
• Switch from carvedilol to metoprolol
• Follow up stress test