Cardiology Clinical Questions

282 Pages·2011·14.56 MB·English

by  John Higgins

CARDIOLOGY
CLINICAL
QUESTIONS
Notice
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors and the publisher of this work have checked with sources believed
to be reliable in their efforts to provide information that is complete and gener-
ally in accord with the standards accepted at the time of publication. However,
in view of the possibility of human error or changes in medical sciences, neither
the authors nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained
herein is in every respect accurate or complete, and they disclaim all responsibil-
ity for any errors or omissions or for the results obtained from use of the informa-
tion contained in this work. Readers are encouraged to confirm the information
contained herein with other sources. For example and in particular, readers are
advised to check the product information sheet included in the package of each
drug they plan to administer to be certain that the information contained in this
work is accurate and that changes have not been made in the recommended dose
or in the contraindications for administration. This recommendation is of par-
ticular importance in connection with new or infrequently used drugs.
CARDIOLOGY
CLINICAL
QUESTIONS
John P. Higgins, MD, MBA, MPHIL, FACC, FACP, FAHA, FASNC, FSGC
ACSM Certifi ed Clinical Exercise Specialist & Certifi ed Personal Trainer
Associate Professor of Medicine
The University of Texas Health Science Center at Houston (UTHealth)
Director of Exercise Physiology
Memorial Hermann Sports Medicine Institute
Chief of Cardiology, Lyndon B. Johnson General Hospital
Principal Investigator HEARTS
(Houston Early Age Risk Testing & Screening Study)
Houston, Texas
Asif Ali, MD
Clinical Assistant Professor
Division of Cardiovascular Medicine
The University of Texas Health Science Center at Houston (UTHealth)
Memorial Hermann Heart and Vascular Institute
Sub-Clinical Investigator HEARTS
(Houston Early Age Risk Testing & Screening Study)
Houston, Texas
David M. Filsoof, MD
Division of Cardiovasuclar Medicine
Sub-Clinical Investigator of HEARTS
(Houston Early Age Risk Testing & Screening Study)
University of Texas-Houston Health Science Center
Houston, Texas
Mayo School of Graduate Medical Education
Jacksonville, Florida
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2012 by The McGraw-Hill Companies, Inc. All rights reserved. Except as
permitted under the United States Copyright Act of 1976, no part of this publication may be
reproduced or distributed in any form or by any means, or stored in a database or retrieval
system, without the prior written permission of the publisher.
ISBN: 978-0-07-174899-5
MHID: 0-07-174899-7
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-174898-8,
MHID: 0-07-174898-9.
All trademarks are trademarks of their respective owners. Rather than put a trademark
symbol after every occurrence of a trademarked name, we use names in an editorial
fashion only, and to the benefi t of the trademark owner, with no intention of infringement
of the trademark. Where such designations appear in this book, they have been printed
with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and
sales promotions, or for use in corporate training programs. To contact a representative
please e-mail us at [email protected].
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGrawHill”) and
its licensors reserve all rights in and to the work. Use of this work is subject to these terms.
Except as permitted under the Copyright Act of 1976 and the right to store and retrieve
one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce,
modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish
or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may
use the work for your own noncommercial and personal use; any other use of the work is
strictly prohibited. Your right to use the work may be terminated if you fail to comply with
these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE
NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY
OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE
WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH
THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM
ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A
PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that
the functions contained in the work will meet your requirements or that its operation will
be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you
or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or
for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of
any information accessed through the work. Under no circumstances shall McGraw-Hill
and/or its licensors be liable for any indirect, incidental, special, punitive, consequential
or similar damages that result from the use of or inability to use the work, even if any of
them has been advised of the possibility of such damages. This limitation of liability shall
apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort
or otherwise.
CONTENTS
Faculty Advisors .................................................... xiii
Preface ................................................................. xv
Acknowledgments ................................................... xix
Section I. Diagnostic Testing
Does my patient need an
electrophysiological study? .................................... 2
When do I need to order a stress test? ................... 4
What are the indications/criteria for
myocardial perfusion imaging? .............................. 6
Should I refer my patient for
coronary angiography? .......................................... 8
When should I order an echocardiogram on
my patient, and which type should I order? .......... 10
Does my patient need cardiac pacing? ................. 12
Does my patient need an implantable-
cardioverter-defi brillator (ICD)? ......................... 14
Does my patient need further evaluation
with cardiac computed tomography? ................... 16
Section II. ACS
How do I use a TIMI risk score in the patient
with unstable angina/non-ST elevation
myocardial infarction (UA/NSTEMI)? ................ 20
What is my initial management of an unstable
angina (UA)/non-ST-elevation myocardial
infarction (NSTEMI) patient? ............................ 22
What is my initial management for an acute
ST elevation myocardial infarction (STEMI)? ...... 24
v
vi CONTENTS
What initial reperfusion strategy should
I begin in my patient with an acute STEMI? ........ 26
How do you manage a patient post-MI
and treat the complications of MI? ...................... 28
How do I manage variant angina? ....................... 30
Should I refer my patient for PCI or CABG? ....... 32
How do I determine the site of
STEMI infarct/injury on ECG? .......................... 34
How do I manage a patient with
right/inferior myocardial infarction? .................... 36
How to manage a patient with
elevated troponins? ............................................. 38
How do I manage a patient with chronic
stable angina? ..................................................... 40
Should our patient get an intra-aortic
balloon pump placed? ......................................... 42
How do I manage a patient presenting
with cocaine-induced chest pain? ........................ 44
Section III. Valvular Disease
Does my patient with aortic stenosis
need surgery? ..................................................... 48
Does my patient with aortic
regurgitation need surgery? ................................. 50
Does my patient with mitral stenosis
need surgery? ..................................................... 52
Does my patient with mitral regurgitation
need surgery? ..................................................... 54
How do I manage my pregnant patient
with mitral stenosis? ........................................... 56
Does my patient with tricuspid regurgitation
need surgery? ..................................................... 58
Does my patient have endocarditis? ..................... 60
CONTENTS vii
Does my patient need endocarditis
prophylaxis? ....................................................... 62
Should I refer my patient with native
valve endocarditis for surgery? ............................ 64
How do I medically treat prosthetic
valve endocarditis? .............................................. 66
Should I refer my patient with prosthetic
valve endocarditis for surgery? ............................ 68
How do I medically treat endocarditis? ................ 70
How to manage an infected pacemaker? .............. 72
Section IV. Cardiac Diseases
Does my patient have amyloid
cardiomyopathy? ................................................ 76
How do I manage my patient with
atypical angina (cardiac syndrome X)? ................ 78
How do I manage acute pericarditis? ................... 80
How do I manage cardiac tamponade? ................ 82
What should I do if I suspect aortic
dissection? ......................................................... 84
How do I manage a patient with aortic
dissection? ......................................................... 86
How do I manage my patient with a left
ventricular thrombus? ......................................... 88
Does my pregnant patient have peripartum
cardiomyopathy? ................................................ 90
How do I diagnose a patient with deep
venous thrombosis? ............................................ 92
How do I manage a patient with deep
venous thrombosis? ............................................ 94
How do I diagnose pulmonary embolism
in my patient? .................................................... 96
viii CONTENTS
How do I treat my patient with acute
pulmonary embolism? ........................................ 98
Does my patient have pheochromocytoma? ....... 100
How do I manage a patient with
pheochromcytoma? .......................................... 102
How do you manage a patient with
myocarditis? ..................................................... 104
Section V. Examination
What are the abnormal pulses in my
patient and what cardiac conditions
are they associated with? ................................... 108
What is the likely heart murmur I hear? ............. 110
Does my patient need preoperative
cardiac testing for noncardiac surgery? .............. 112
How do I interpret my patients
Swanz–Ganz catheterization? ............................ 114
Does my patient need screening for an
abdominal aortic aneurysm (AAA)? .................. 116
Section VI. Arrhythmias
How do I manage the rate and rhythm in
my patient with atrial fi brillation? ...................... 120
Should I start coumadin in my patient
with atrial fi brillation? ....................................... 122
How do I manage a patient presenting in
acute atrial fl utter? ............................................ 124
How do I manage my patient with
Brugada syndrome? .......................................... 126
How do I manage 3rd degree
atrioventricular block? ...................................... 128
How do I manage my patient with 2nd degree
type I (Wenckebach) atrioventricular block? ....... 130
CONTENTS ix
How do I manage my patient with 2nd degree
type II atrioventricular block? ........................... 132
Is it ok for my patient to consume
an energy beverage? .......................................... 134
Does this ECG show changes of
hyperkalemia? .................................................. 136
Does this ECG show changes
of hypokalemia? ................................................ 138
Does this ECG show changes
of hypercalcemia? ............................................. 140
Does this ECG show changes
of hypocalcemia? .............................................. 142
Does this ECG show right bundle
branch block? ................................................... 144
Does this ECG show left bundle
branch block? ................................................... 146
Does this ECG show left ventricular
hypertrophy? .................................................... 148
Does this ECG show second degree
type I atrioventricular block? ............................. 150
Does this ECG show second degree type II
atrioventricular block (Mobitz II)? .................... 152
Does this ECG show third degree
atrioventricular block? ...................................... 154
What should I do if my patient has
premature ventricular contractions? .................. 156
How do I manage a patient who presents
with WPW? ...................................................... 158
How do I acutely manage a patient with
torsade de pointes (TdP)? ................................. 160
Does this ECG show Wolff–Parkinson–White
syndrome? ....................................................... 162