Dr. Usman's Cardiology Notes

A 63 year old male presented to cardiology clinic for follow up evaluation. He is diabetic, hypertensive and had AWMI 3 years ago with successful revascularization to LAD. He is taking his medications regularly and has active lifestyle. He never smoked but has positive family history of premature CAD. His examination is unremarkable. His lipid profile showed total cholesterol 331, TG 229, LDL 202, HDL 38. His medication include atorvastatin 40 mg at night, Loprin 150 mg daily,   Ramipril 2.5mg OD, metoprolol 25mg BD, and Insulin lantus 20mg HS. He is worried about his lipid profile and have some queries regarding his optimal treatment. a)       How will you manage his elevated LDL in view of recent evidence? b)       What is the route of administration and mechanism of action? c)       Name the trial which have studied this drug d)       What was the result   Answers: a) ...

A 29 years old presented in emergency department with high grade fever with rigor and chills and acute confusional state. Examination was notifiable for a GCS of 13/15. Temperature of 102 o F, heart rate of 130 beats per minute with regular pulse, respiratory rate of 28 per minute, diaphoresis, Grade 2/6 diastolic murmur at left lower sternal border heard on leaning forward and bibasilar crackles. ECG showed sinus tachycardia and chest x-ray showed vascular congestion and right sided alveolar infiltrates. Baseline labs were significant for TLC of 18000 (86% neutrophils), elevated CRP and creatinine of 0.6 mg/dl. Culture result as awaited: a) What is the most probable diagnosis? b) What is Osler’s Triad? c) What empirical antibiotic will you use? d) What is sensitivity and specificity of trans-esophageal echocardiography in this case and what are the possible expected findings? e) When will you consider surgical intervention? Answers: a.       Infectiv...

A 78 year old female, diabetic, overweight and hypertensive presented with severe shortness of breath, orthopnea and paroxysmal nocturnal dyspnea. She has limited mobility at home due to easy fatigue. On examination she was restless , tachycardiac with heart rate of 130 beats per minute, respiratory rate of 26 per minute and Blood Pressure of 110/60 mmHg. Auscultation revealed ejection systolic murmur at upper sternal border radiating to neck, S 3 gallop and a displaced PMI on palpation. There were bilateral crackles in the chest. ECG showed ST depression in anterior precordial leads. Labs revealed a Troponin of 170, Creatinine of 2.0 mg/dl and BNP of 1617. Chest X-Ray revealed pulmonary edema. Echocardiography revealed EF of 35%, global hypokinesia, Aortic Valve Area of 0.8cm 2 and a mean gradient of 28 mmHg. a) What are the treatment options available and which would you recommend for her? b) Name recent trial conducted for such intermediate to high risk patients and its result inter...

A 40 years old female presented with chest pain and light headedness on exertion. Examination showed B.P of 110/90 mmHg, delayed carotid upstroke, double apical impulse, Ejection Systolic Murmur radiating to carotid. ECG is remarkable for Left Ventricular Hypertrophy. Echocardiography revealed critical aortic stenosis with Aortic Valve Area of < 1cm 2 , Mean Gradient of 30 mmHg and Left Ventricular Ejection Fraction of 60 %.   a) How would you differentiate between valvular and sub-valvular aortic stenosis? b) What are the indications for cardiac catheterization and how will you calculate Aortic Valve Area? c) What is paradoxical low flow severe Aortic Stenosis and give two reasons for it? d) What are the class I indications of Aortic Valve Replacement? e) What is the most likely reason for severe Aortic Stenosis in this woman? Answers: a.       Clinical findings of valvular aortic stenosis are presence of ejection click and soft A2. In subvalvular AS ...

Brockenbrough–Braunwald–Morrow sign A 21 Year old male presented with syncope on exertion. Family history positive for Sudden Cardiac Death. Examination revealed Ejection Systolic Murmur at left sternal border and brisk carotid upstroke (not radiating to neck). Murmur accentuated on standing. ECG showing dagger like Q waves in anterolateral leads. a) What is the most likely diagnosis? b) What is brocken brough phenomenon? c) What are the risk factors for Sudden Cardiac Death in this disease? d) Name two treatment options available and which will you consider for this patient and why? Answers: a.       Hypertrophic cardiomyopathy b.       Severe increase in the Left ventricular aortic gradient in the beat after a premature ventricular contraction (PVC) due to increase in contractility and decrease in afterload during the post PVC beat. c.        Risk factors for sudden death Previous Cardiac arrest Sustained ...

A 22 years old female presented with dyspnea on exertion and hoarseness of voice for last six months. Examination revealed loud first heart sound with diatolic murmur and tapping apex beat. ECG revealed p mitrale and sinus rhythm. Echocardiogram revealed MV orifice area of 1 cm 2 . Please answer the following: a) What is Ortner’s Syndrome? b) What is new scoring system for deciding surgical vs percutaneous treatment? c) How will you calculate valve area on cardiac catheterization? d) What are the contraindications to percutaneous transmural balloon valvuloplasty? Answers: a.       Hoarseness occurs when dilated left atrium impinges on the recurrent laryngeal nerve b.       Hung Scoring system c.        By Gorlin Equation d.       The following are contraindications for PMBV (ie, class III recommendations):     Percutaneous mitral balloon valvotomy is not indicate...

A  45 year old male smoker presented with chest pain radiating to neck and left shoulder for last 7 days. Examination was significant for resting tachycardia and pericardial friction rub with clear lung fields. ECG showed sinus tachycardia, diffuse ST elevation in all leads except aVR, V1. Troponins were modestly elevated. CBC, ESR, ANA, TFTs, all were normal. a)       What is the diagnosis (complete diagnosis) b)       What is the cause of troponin elevation c)       Would you consider colchicine? If yes then give reason d)       What are echo Doppler findings of constrictive pericarditis e)       What is Becks traid Answers: a.       Acute MyoPericarditis b.       Myocardial Involvement c.        Yes, it reduces risk of recurrence, COPE Trial d.    ...