Dr. Usman's Cardiology Notes

See the figure shown and answer the following questions a)       Describe the aortic pressure tracing b)       Describe normal Atrial pressure tracing c)        Describe atrial pressure tracing in tricuspid regurgitation d)       Effect of Tamponade on atrial pressure tracing Answers: a.       When aortic valve opens, pressure increases as blood flows into the aorta and reaches its maximum. Pressure falls as blood flows out of aorta and aortic valve closes   b.       " a " wave corresponds to right Atrial contraction and its peak demarcates the end of atrial systole. The " c " wave corresponds to right ventricular Contraction causing the tricuspid valve to bulge towards the RA. The " x " descent follows the 'a' wave and corresponds to atrial relaxation and rapid atrial filling due to low pressure. The " v " wave correspon...

A 15 year old boy brought by his father to your clinic with complain of loss of consciousness while playing football. He had two episodes of syncope in past after failing the exam. His physical examination revealed no murmur/ additional heart sound. His ECG and echocardiography both were normal. He underwent ETT which showed NSVT with changing axis a. What is diagnosis? b. How will you treat him initially? c. When ICD is indicated? d. Name the genetic mutation e. Name the treatment option apart from ICD and medical therapy Answers: a.       CPVT b.       Avoidance of competitive sports (football) Beta-blockers class I c.          Aborted cardiac arrest Recurrent Bidirectional or polymorphic VT despite optimal medical therapy Recurrent syncope despite optimal medical therapy d.       Cardiac Ryanodine receptor 2 (RYR2) e.       LCSD (Left cardiac sympath...

  A 16 year old girl accompanying his father in cardiology clinic suddenly collapsed after listening fire alarm in hospital. Senior cardiology fellow successfully resuscitated her. On recovery her physical examination was normal. On inquiry his father informed that she fainted twice at home after doorbell with spontaneous recovery. a) What do you think happened to this young girl? b) Describe two characteristic ECG findings c) How will you manage her? d) Which genetic mutation cause this disease? e) Is flecainide indicated? Answers : a.       Polymorphic VT (Underlying long QT type II) b.       QTc > 480 msec, Low amplitude notched T wave c.        Beta-blockers   (Propanolol, Nidolol) and ICD if recurrent syncope despite on beta blockers or if contraindication to beta blocker and in survivors of cardiac arrest d.       KCNH2 e.       No Referenc...

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 60 year old male diabetic presented with resting limb pain for last 3 days. He has history of intermittent claudication for last 4 years and was compliant to his medications and regular exercise. On examination he has elevation limb pallor with decrease capillary refill on attaining supine position. No skin discoloration and pulses are week but palpable. One year ago his pre and post exercise ABI was 0.6. He is currently on ASA 75mg OD, atorvastatin 10mg HS, cilostazole 100mg BD and Metformin 1G BD. Please provide relevant answers: a) What was the purpose of giving ASA and Cilostazole b) His Digital extraction angiography showed critical disease in superficial femoral artery and popliteal artery. When will you consider him for revascularization and what modality will you choose? c) When will you follow your patient after successful revascularization? d) What non-invasive test will you order apart from history and physical examination in surveillance program? Answers: a)   ...

A 58 year male diabetic, hypertensive and smoker presented for executive checkup in cardiology clinic. He is asymptomatic except for feeling fatigue enough to walk >200 m. His physical examination was normal. You ordered baseline tests including lipid profile. All labs are normal except for elevated cholesterol and LDL. His ECG was normal. Please answer following questions based on guidelines a.       When should we expect PAD? b.       You screened with ABI and it turn out to be 1.29. Will you stop evaluating him or proceed for another test c.        How would you differentiate pseudoclaudication from arterial claudication? d.       How would you classify this patient based on fontaine classification Answers: a.       1)All patients above 70 years of age , 2) Between 50-70years with additional factors like DM, Smoking, 3)Any age with symptom of claudicati...

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 ...