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Cardiac clinical questions answers more than one-hundred of the clinical cardiology questions most frequently asked of the authors during consultation. The book simulates the consultation process: consult question →data collection→ synthesis of data → solution.
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 generally 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 responsibility for any errors or omissions or for the results obtained from use of the information 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 particular importance in connection with new or infrequently used drugs CARDIOLOGY CLINICAL QUESTIONS John P Higgins, MD, MBA, MPHIL, FACC, FACP, FAHA, FASNC, FSGC ACSM Certified Clinical Exercise Specialist & Certified 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 benefit 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 bulksales@mcgraw-hill.com 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 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? When I need to order a stress test? What are the indications/criteria for myocardial perfusion imaging? Should I refer my patient for coronary angiography? 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 implantablecardioverter-defibrillator (ICD)? 14 Does my patient need further evaluation with cardiac computed tomography? 16 Section II ACS How 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? How you manage a patient post-MI and treat the complications of MI? How I manage variant angina? Should I refer my patient for PCI or CABG? How I determine the site of STEMI infarct/injury on ECG? How I manage a patient with right/inferior myocardial infarction? How to manage a patient with elevated troponins? How I manage a patient with chronic stable angina? Should our patient get an intra-aortic balloon pump placed? How I manage a patient presenting with cocaine-induced chest pain? Section III Valvular Disease Does my patient with aortic stenosis need surgery? Does my patient with aortic regurgitation need surgery? Does my patient with mitral stenosis need surgery? Does my patient with mitral regurgitation need surgery? How I manage my pregnant patient with mitral stenosis? Does my patient with tricuspid regurgitation need surgery? Does my patient have endocarditis? 26 28 30 32 34 36 38 40 42 44 48 50 52 54 56 58 60 C O NT E N T S Does my patient need endocarditis prophylaxis? Should I refer my patient with native valve endocarditis for surgery? How I medically treat prosthetic valve endocarditis? Should I refer my patient with prosthetic valve endocarditis for surgery? How I medically treat endocarditis? How to manage an infected pacemaker? Section IV Cardiac Diseases Does my patient have amyloid cardiomyopathy? How I manage my patient with atypical angina (cardiac syndrome X)? How I manage acute pericarditis? How I manage cardiac tamponade? What should I if I suspect aortic dissection? How I manage a patient with aortic dissection? How I manage my patient with a left ventricular thrombus? Does my pregnant patient have peripartum cardiomyopathy? How I diagnose a patient with deep venous thrombosis? How I manage a patient with deep venous thrombosis? How I diagnose pulmonary embolism in my patient? vii 62 64 66 68 70 72 76 78 80 82 84 86 88 90 92 94 96 viii CONTENTS How I treat my patient with acute pulmonary embolism? 98 Does my patient have pheochromocytoma? 100 How I manage a patient with pheochromcytoma? 102 How 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? What is the likely heart murmur I hear? Does my patient need preoperative cardiac testing for noncardiac surgery? How I interpret my patients Swanz–Ganz catheterization? Does my patient need screening for an abdominal aortic aneurysm (AAA)? Section VI Arrhythmias How I manage the rate and rhythm in my patient with atrial fibrillation? Should I start coumadin in my patient with atrial fibrillation? How I manage a patient presenting in acute atrial flutter? How I manage my patient with Brugada syndrome? How I manage 3rd degree atrioventricular block? How I manage my patient with 2nd degree type I (Wenckebach) atrioventricular block? 108 110 112 114 116 120 122 124 126 128 130 C O N TE N T S How I manage my patient with 2nd degree type II atrioventricular block? Is it ok for my patient to consume an energy beverage? Does this ECG show changes of hyperkalemia? Does this ECG show changes of hypokalemia? Does this ECG show changes of hypercalcemia? Does this ECG show changes of hypocalcemia? Does this ECG show right bundle branch block? Does this ECG show left bundle branch block? Does this ECG show left ventricular hypertrophy? Does this ECG show second degree type I atrioventricular block? Does this ECG show second degree type II atrioventricular block (Mobitz II)? Does this ECG show third degree atrioventricular block? What should I if my patient has premature ventricular contractions? How I manage a patient who presents with WPW? How I acutely manage a patient with torsade de pointes (TdP)? Does this ECG show Wolff–Parkinson–White syndrome? ix 132 134 136 138 140 142 144 146 148 150 152 154 156 158 160 162 ... Does this ECG show Wolff–Parkinson–White syndrome? ix 13 2 13 4 13 6 13 8 14 0 14 2 14 4 14 6 14 8 15 0 15 2 15 4 15 6 15 8 16 0 16 2 x CONTENTS Does this ECG show atrioventricular nodal reentry tachycardia?... manage my patient with 2nd degree type I (Wenckebach) atrioventricular block? 10 8 11 0 11 2 11 4 11 6 12 0 12 2 12 4 12 6 12 8 13 0 C O N TE N T S How I manage my patient with 2nd degree type II atrioventricular... on Clinical Privileges in Cardiology J Am Coll Cardiol 19 90 ;16 :10 61 10 65 4) Updated imaging guidelines for nuclear cardiology procedures, part J Nucl Cardiol 20 01; 8 (1) :G5–G58 8 DIAGNOSTIC TES