Department of medicine

Cardiology Cases

Arrythmia
Congenital Heart Disease
Congestive Heart Failure
Pericardial Disease
Peripheral Vascular & Aortic Diseases
Coronary Artery Disease
Valvular Heart Disease

Objectives & Cases

Cardiology Objectives
Objectives & Cases Index

Arrythmia

Focus will be on EKG rhythm interpretation.

  1. A 75 y F has a syncope episode and presents with a hip fracture. She has been feeling lightheaded in the past. The EMS notes bradycardia with HR ~30/m. The BP is 160/70mmHg.

  2. A 62 y M is admitted with chest pain via EMS. During transit he develops a wide QRS tachycardia and is shocked back to normal rhythm. EKG reveals ST segment elevation in V1-V4.

  3. A 18 y F has palpitations on and off. They are sudden onset, fast palpitations with no precipitating factors. Sometimes the episode goes off by itself  or snaps off with straining. Her EKG is normal, but an Event Monitor shows narrow QRS tachycardia with a delta wave.

  4. A 50 y homeless alcoholic male reports again to the ER with another episode of palpitations. EKG reveals Atrial Fibrillation with Ventricular rate of 150/minute.

  5. A 26 yr pregnant female presents with palpitations and mild dyspnea. EKG is normal. The Holter monitor and Event Monitor only record frequent Premature atrial beats with no sustained arrhythmia.
Congenital Heart Disease
Case 1
Congenital Heart Disease

A 32 year-old white femaile has a heart murmur since childhood and takes regular endocarditis prophylaxis. She is admitted after a motor vehicle accident.

On Examination:
BP=126/76
P=88/m
Bruising over chest wall from steering wheel injury
No cyanosis or clubbing
CVS: JVP not elevated, Apex is displaced down and out
          
S1 soft, narrowly split S2, soft LVS3, no S4
          
5/6 pansystolic murmur over precordium. soft mid-diastolic murmur at
            apex
Chest: Clear
Abdomen: Soft nontender, no organomegaly

Case 2
Congenital Heart Disease

55 y F being evaluated for heart failure and leg edema. No problems till 3-4 years ago. Hypertension for 3 years, presently on ACE Inhibitor and diuretic.

On Examination:
BP 140/90
P=100/m irregular
Leg edema 2+
CVS: JVP elevated, Apex beat left 5th ICS within MCL
           S1 N, S2 wide fixed split, S3+, no S4
           3/6 Ejection systolic murmur over pulmonary area
Chest: Clear
Abdomen:  Hepatomegaly 5 cm, mildly tender – non pulsatile

Case 3
Congenital Heart Disease

A 7-year-old boy from Equador was born prematurely and was a blue baby. Improved somewhat but would develop cyanotic spells when he cried. Mother also describes son taking squatting brakes in the middle of activity. He has never been able to exert much.

On Examination:
Underdeveloped and malnourished
Looks younger than stated age
Has clubbing and central cyanosis
CVS: JVP normal
          Apex beat tapping left 4th ICS 1 cm medial to MCL. RV heave present
          S1 N, S2 single, early systolic click
         
3/6 ejection systolic murmur over pulmonic area
Chest: Clear
Abdomen: No organomegaly

Case 4
Congenital Heart Disease

22 year-old asymptomatic white male comes for pre-employment physical.

On Examination:
BP 130/50, P 72/m - Bounding pulses
CVS: JVP not elevated, PMI displaced 6th ICS 1 cm outside MCL
           S1, S2 Normal. Soft S3
          
Continuous machinery murmur over left infraclavicular fossa
Chest: Clear
Abdomen: No organomegaly

Case 5
Congenital Heart Disease

50 year-old white female being evaluated for difficult to treat hypertension.

On Examination:
Obese female with Short fat neck, BP 160/96 RUE, 130/86 leg
Radiofemoral delay present
CVS: JVP difficult to assess, Apex not localized
          
S1 N, S2 A2>P2, S4+ no murmurs over precordium
          
Pulsations over the back
Chest: Clear
Abdomen: No organomegaly

Case 6
Congenital Heart Disease

An 18-year-old football player sustains sudden cardiac death during practice and is rapidly resuscitated with AED shock. He has a family history of sudden death in the father and one older brother before age 35 years. He occasionally feels light headed but has never passed out.

On Examination:
Powerfully built male
BP 120/80, P=70/m, Bisferiens carotid pulse
CVS: JVP not elevated
           PMI not localized
           S1 N, S2 paradoxical split, S4 present
           3/6 Ejection systolic murmur medial to apex becomes 4/6 with Valsalva or
           standing
Chest: Clear
Abdomen: No organomegaly
CXR: Normal
EKG: LVH with strain

Congestive Heart Failure
  1. A 36-year-old male presents with increasing shortness of breath, edema and weight gain of five to seven days duration. He has been otherwise healthy. On exam he has elevated JVP, leg edema, S3 gallop rhythm and no murmurs. His BP is 150/90 and his HR is 110/minute.

  2. A 85-year-old female has developed leg edema and shortness of breath. She has long standing hypertension which is suboptimally treated. She has been told to have congestive heart failure by her doctor but her Echocardiogram has always shown an Ejection Fraction >60%.

  3. A 50-year-old old heavy smoker with COPD has presented with worsening shortness of breath. He has had multiple such exacerbations in the past. He uses a lot of inhalers and oxygen at home. He has some leg edema which is chronic. He has lost 7 pounds of weight over the past two months.

  4. A 45-year-old male with diabetes, hypertension and hyperlipidemia is being evaluated for heart transplantation. His Ejection fraction is 25-30% and he is NYHA class III to Class IV despite optimal therapy.

  5. A 45-year-old female is admitted for CHF exacerbation. She also has a history of metastatic breast cancer. Her shortness of breath and diffuse crackles in her chest persist despite aggressive diuretic therapy and seven pound weight loss in three days.

  6. A 18-year-old female is being evaluated for leg edema. She denies shortness of breath. Exam reveals elevated JVP and a loud P2 without any murmurs. Echocardiogram reveals a normal LV ejection fraction but the RV is dilated and the RV function appears depressed.
Pericardial Disease
Case 1
Pericardial Disease

A 42-year-old African American Female develops chest pain while driving. Pain is 8/10 in intensity over left breast and makes her hold her breath. There is no radiation of the pain and no other associated features. Her sister has SLE.

On Examination:
No signs of lupus.
BP 120/70 P 78/m
C
VS: JVP not elevated
           PMI not displaced
          
Heart sounds normal
          
Sharp triphasic scratchy sound over the area of Chest pain
Chest: Clear
Abdomen: No organomegaly
CXR: Normal
EKG: Diffuse ST segment elevation.

Case 2
Pericardial Disease

A 70 year-old white male with inoperable lung cancer develops hypotension, weakness and tiredness and leg edema. His dyspnea is only mildly increased from his baseline.

On Examination:
Elderly emaciated male with prominently engorged neck veins and leg edema
BP 100/60, Palpable paradox
Pulses paradox 25mmHg
CVS: JVP elevated, PMI not localized
          
Heart sounds distant
Chest: Absent air entry right base. Dullness at right base.
Abdomen: Hepatomegaly-7cm. Non tender.
CXR: Right pleural effusion. Large cardiac silhouette.
EKG: Low voltage complexes and electrical alternans

Case 3
Pericardial Disease

A 55 year-old white female with chronic liver failure is being evaluated for liver transplantation. She has had a long history of alcohol abuse but has been abstinent for 5 years. She has had multiple episodes of hepatic encephalopathy and GI bleeds.

Her past medical history is significant for Hodgkin’s lymphoma which was treated with chemo and mediastinal radiation therapy 20 years ago.

On Examination:
BP 110/70, P 96/m
Spider nevi and palmar erythema present
CVS: JVP seen till angle of mandible (sitting up).
           Kausmaul’s sign is present
           Leg edema++
           S1, S2, normal. No S3 or S4. no murmurs
Chest: Clear
Abdomen: Distended
                 Ascites present
                 Liver ballottable
ECHO: Large Left and right atria.
             Normal systolic LV and RV function
             No MR or TR. Restrictive physiology on Doppler
             Left and Right heart cardiac catheterization planned

Peripheral Vascular & Aortic Diseases
  1. A 39-year-old female presents with painful hands and feet in the winters. She does not smoke and is otherwise healthy. She describes a blue-white and red response in her extremities and her hands and feet get very painful. She has been wearing mittens with only partial relief.

  2. A 42-year-old male presents with painful hands. He lost both feet (below knee amputations) for peripheral vascular disease. He still continues to smoke.

  3. A 57-year-old white male with known Diabetes Mellitus, CAD, HTN and hyperlipidemia has a non-healing ulcer on the left foot for two months. Recently she has developed pain and bluish-black discoloration of the foot, associated with rest pain.

  4. A 70-year-old African American Male presents with a painful cold right foot. He describes palpitations for two weeks and is noted to be in atrial fibrillation.

  5. A 22-year-old college basketball player (6’6”ft) develops severe chest and back pain while stretching before a game. He gets profusely diaphoretic and passes out. When he comes around he describes a tearing pain between his shoulder blades. In the ER his BP 170/90, P 94/m. Left carotid and Left subclavian pulses are absent. A soft early diastolic murmur is audible.

  6. A 60 year-old white male presents to the ER with severe abdominal pain and near syncope. He is a smoker and has HTN which is treated adequately. He has been having low back pain for the past few months and is taking NSAIDS with incomplete relief. His abdomen is mildly distended and tender. A pulsatile mass is felt in the lower abdomen. A bruit is heard periumbilically. Lower extremity pulses are feeble and there are bruits over both femoral arteries.
Coronary Artery Disease
Case 1-STEMI
Coronary Artery Disease

A 47-year-old old Caucasian man presents with three hours of severe unrelenting retrosternal chest tightness. This is associated with shortness of breath and sweating. The discomfort started when he was chopping wood (usual activity) but would not get relieved with rest, water and Tums. He has never had chest Pain before and has not seen a doctor for over 10 years. He smokes two packs of cigarettes a day and has been doing so for over 30 years. He denies HTN and Diabetes. His brother (age 51) had a 3 vessel CABG 2 years ago and is doing well.

  1. What is the likely diagnosis?
  2. What is the differential diagnosis?
  3. How will the diagnosis be confirmed?
  4. What does the EKG show?
  5. What is the likely pathology of the event?
  6. How should this patient be treated?

Case 2 - Atypical CP with Risk Factors
Coronary Artery Disease

A 55-year-old African-American female with longstanding HTN and Diabetes presents to the ER with Chest Discomfort of 2 days duration. The discomfort feels like a dull ache retrosternally. It is unrelated to exertion and is present at rest. She is also a little short of breath with exertion. There is no radiation of the discomfort and partial relief with Tums and sublingual Nitroglycerine. Patient does not smoke. She is obese and has history of CAD in family members (>60 years).  She is not very compliant with her DM or HTN medications . Her Triglycerides were elevated in the past. She does not remember her LDL- but she is on no medications for lipid lowering.

BP is 170/100mm Hg, HR 76/m
Cardiac exam is suboptimal because of Obesity but no obvious S3, S4, murmurs, clicks or rubs
EKG shows LVH with ST-T abnormalities consistent with strain / ischemia.

  1. What is the likely diagnosis?
  2. What is the differential diagnosis?
  3. How do the Risk Factors affect the decision making process?
  4. How should this patient be evaluated further
  5. How would you manage her initially before the diagnosis is confirmed?
Case 3 - Typical Chest Pain without Risk Factors
Coronary Artery Disease

A 35-year-old Caucasian female presents to the ER with Chest Pain of six hours duration. The pain is a tight and heavy sensation in the retrosternum and neck. She also is mildly short of breath and has to take sighing breaths to help her breathing. She describes some tingling and numbness in both her hands. No radiation of pain to the jaw or back.

Patient is a nurse with two children ages ten and five-years-old. She is very active but does not exercise daily. She has been unrestricted in her activities till now. The pain started while working at the hospital. She has been unwilling to exert herself after that.

She does NOT have Diabetes, Hypertension, Hyperlipidemia, FH of premature CAD and she doesn’t smoke. She is not overweight.  Examination is normal.

  1.  What more information in the H&P would be useful?
  2.  What is the differential diagnosis?
  3.  How would you evaluate this patient further?
Case 4 - Unstable Angina
Coronary Artery Disease

A 55-year-old African-American male presents to the urgent care with chest pain and shortness of breath of 24 hours duration. He is a construction worker and does a lot of manual labor. He has diabetes which is controlled with oral medications. He is on two blood pressure pills for his Hypertension and takes 40 mg Zocor (simvastatin) for hyperlipidemia. He is fairly compliant with his medications. He still smokes 1 ppd.

He had a normal stress test 2 years ago for Chest pain (different quality).

The present episode of chest pain started at work. It got better when he rested but came back soon afterwards. The pain feels like a pressure in the chest – in the retrosternum but more towards the left side. It is not related to breathing or eating. He thought it would go away after overnight rest- but it was present when he got up this morning. He also noticed that he was short of breath and mildly dizzy when he got out of bed.

His BP was 140/90, HR 85/m
Normal S1 and S2 but a soft S4 was audible
No other sounds or murmurs
His initial EKG showed borderline LVH without any ischemic changes

  1. What is the diagnosis?
  2. What would be the early management strategy for this patient?
  3. What tests would you recommend to confirm the diagnosis?
  4. What medications would you use and what are the targets for his RF modification?
Case 5 - NSTEMI
Coronary Artery Disease

A 75-yr old Caucasian male has known CAD and has had a CABG 14 years back. He is taking medications for DM, HTN and hyperlipidemia and visits his doctor regularly. His last stress test was two years back wherein he walked for eight minutes on the treadmill without chest pain.

He has been having chest pain on and off for the past four days. The pain is similar to his CP before the bypass- but is of lesser intensity. He has used sublingual nitroglycerine (expired bottle) without relief. His wife mentions that he looks pale when he has the chest pain episode and that he has not been able to help around the house for the last week or so. Today he had a more severe episode of chest pain and decided to come to the ER.

In the ER the pain was relieved almost completely by the sublingual NTG- and he felt that a weight was lifted off his chest. The EKG showed T wave inversion in the precordial leads and the stat Troponin came back positive at 10.

  1. What is the diagnosis?
  2. What is the course of CAD after medical treatment, angioplasty / stent and after CABG?
  3. What test would you like this patient to have and when?
  4.   What is the pathophysiology of this condition?

Case 6 - Chronic Stable Angina
Coronary Artery Disease

A 60-year-old man has known CAD for many years and has had multiple cardiac catheterizations and two stents. His last cath was six months back after a borderline positive stress test. The cath revealed that his stents were widely patent and that his other proximal coronaries had non-obstructive disease; he has diffuse disease distally- but these were non-revascularisable by intervention or CABG and needed to be medically managed. His Ejection fraction is normal.

He gets angina on moderate to severe exertion but it gets relieved by resting. He uses 2-3 sublingual Nitroglcerine pills per month. The frequency of the Chest pain has not changed for over a year.

He takes Aspirin, Isosorbide mononitrate, Lopressor, Lipitor and Lisinopril daily. His BP is well controlled. His LDL is 75mg/dl. He has no Diabetes and he doesn’t smoke. He is moderately active.

He is being evaluated for hernia surgery and mentions one episode of angina to his nurse during the pre-op anesthesia evaluation. He is given a sublingual NTG which relieves the chest pain completely. (He did not take his AM meds for his blood tests.

  1. What is his diagnosis?
  2. What is the pathophysiology of his condition?
  3. Should he be admitted for his angina (R/o MI protocol)?
  4. Can he undergo his hernia repair surgery?
  5. What peri-operative advice would you give his surgeon / anesthesiologist?

Valvular Heart Disease
Case 1
Valvular Heart Disease

A 35-year-old Hispanic female from Guatemala is admitted with severe dyspnea for the past 3 weeks. She is 30 weeks pregnant. She has orthopnea, and is unable to sleep at night. She developed hemoptysis  and a coughing episode which would not subside. She has h/o Rheumatic fever as a child and has known to have a heart murmur. She was also dyspneic during her last pregnancy 5 years back but improved after delivery.

On Examination:
She is orthopneic
The JVP is elevated and she has leg edema
BP 140/86, P=130/m regular
Her hands and feet are clammy
CVS: There is a tapping apex within the midclavicular line, RV heave is present
           S1 is loud, S2-P2 is loud, Sharp sound is heard after S2. No S4
          
Mid-diastolic rumbling murmur is heard at the apex with pre-systolic
           accentuation
Lung: Bilateral lung crackles, occasional rhonchi
Abdomen: Hepatomegaly-mildly tender and Gravid uterus with normal fetal heart sounds.

Case 2
Valvular Heart Disease

A 44-year-old nurse with a long standing heart murmur describes low-grade fever, fatigue, malaise and weight loss for 1 month. She had dental work done 6 weeks earlier.

On Examination:
She has splinter hemorrhages, early clubbing and painful finger pulps
BP=130/70, P=110/m regular
CVS: Apex beat shifted down and out
           Prominent precordial pulsations
          
S1 normal, S2: P2>A2, soft S3, no S4. Mid systolic click
          
Pansystolic murmur at apex 4/6- conducts to axilla, soft middiastolic murmur
Chest: Occasional basal crackles- disappear with coughing
Abdomen: No organomegaly

Case 3
Valvular Heart Disease

A 60 year-old white male with known heart murmur for years presents with progressive shortness of breath and markedly reduced energy level for two to three months. He has also been having chest pain with exertion for the last two years. Had a negative stress test one year back.

On Examination:
He has leg edema BP=110/80, P=90/m regular
CVS: Apex beat not localized
           JVP elevated
          
S1 soft, S2: paradoxically split, S4
          
Short 4/6 ejection systolic murmur at right 2nd ICS conducted to R carotid
           High pitched short sea-gull murmur at apex
Chest: Basal dullness bilaterally with reduced sounds
Abdomen: No organomegaly

Case 4
Valvular Heart Disease

a 50-year-old African American Male in good physical shape comes in for a regular follow-up of a heart murmur.

On Examination:
Ht 6’4”, 160lbs.
BP 170/30, P 78/m.
Bounding distal pulses
Collapsing radial pulse
CVS: JVP not elevated
           Apex displaced to 7th ICS on midaxillary line- heaving nature
           S1N, S2 N, soft S3, no S4
           3/6 early diastolic murmur at right 3rd, 4th and 5th ICS
           3/6 Ejection systolic murmur at right 2nd ICS
Chest: Clear
Abdomen: No hepatomegaly

Case 5
Valvular Heart Disease

A 19-year-old male is admitted with fever, abdominal pain and leg edema of two weeks duration and hemoptysis x 1 day. He uses IV drugs regularly.

On Examination:
Looks sick and toxic: BP 100/60, P=108/m regular
Leg edema present
CVS: Prominent pulsatile JVP upto angle of jaw
           Rapid vy collapse
           S1N, S2 N, soft RVS3, no S4
           Pansystolic 3/6 murmur at lower right sternal edge and epigastrium, increases
           with inspiration
Chest: Bronchial breath sounds and crackles in right infrascapular region. Normal air entry.
Abdomen: Tender enlarged liver, pulsatile.

Case 6
Valvular Heart Disease

A 15-year-old healthy female goes for an annual check-up before track and field camp. Totally asymptomatic with good exercise tolerance.

On Examination:
BP=100/70, P=50/m
CVS: JVP not elevated, Apex beat normal
           No heave or pulsations
           S1, S2, normal. No S3 or S4
           2/6 soft systolic murmur over left 2nd ICS
Chest: Clear
Abdomen: Normal

 
 
 

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