24 year old male presenting for an annual check up. He reports playing intermural basketball on the weekends. Patient presents with this EKG:
Hypertrophic Cardiomyopathy
Autosomal dominant, usually this is a mutation in genes that code for sarcomeric proteins
______ is a rare acquired disorder characterized by cyanosis and dyspnea in the upright position as a result of right-to-left shunting across a PFO or, less commonly, through an atrial septal defect. A transient increase in right atrial pressure or change in right atrial anatomy resulting from myocardial infarction, pulmonary embolism, tricuspid regurgitation, or acute right-sided heart failure may precipitate this syndrome.
Platypnea-orthodeoxia syndrome
Thoracic aortic aneurysm (TAA) is defined as an increase in the thoracic aortic diameter of greater than 50% relative to the expected or normal aortic dimension. TAAs may occur at the level of the aortic root, ascending aorta, aortic arch, or descending aorta. They most commonly involve the aortic root and ascending aorta, often forming at the site of aortic atherosclerosis. In a patient with an ascending aortic aneurysm, what diameter should they be referred for elective aortic repair? What if they had a history of Marfan's or Ehler Danlos syndrome?
In patients with an ascending aortic diameter exceeding 5.5 cm, elective aortic repair is warranted to prevent the morbidity and mortality associated with aneurysm rupture; patients with Marfan or Ehlers-Danlos syndrome should undergo aortic repair at 4.5 to 5.0 cm.
61 year old male presents with dyspnea on exertion and palpitations. Name this rhythm.
Atrial fibrillation
In Guardians of the Galaxy Volume 1, what were the three items Rocket Raccon claimed he needed in order to escape the prison?
A security guard's arm band, a battery, and a prosthetic leg
**** DAILY TRIPLE ****
HOCM is typically seen in younger adults. Most patients that have this condition remain asymptomatic and have a normal life. However, HOCM is usually caught when a murmur is found. Describe the HOCM murmur to me. Tell me what happens to the murmur with a) Valsalva b) handgrip and c) squatting. Lastly, how does this murmur differ from valvular aortic stenosis?
Ejection quality murmur that is best heard at the left lower sternal border.
Valsalva (decreases preload) will increase the murmur
Handgrip (increases afterload) will decrease the murmur
Squatting (increases afterload and preload) will decrease the murmur
Valvular AS usually has radiation into the carotids, where HOCM does not. Carotid impulse is brisk in HOCM vs AS having a delayed or diminished carotid upstroke (parvus et tardus). AS murmurs typically don't change in response to Valsalva or positions.
The foramen ovale is a passage in the superior portion of the fossa ovalis that allows oxygenated placental blood to transfer to the fetal circulation. It normally closes within the first weeks of life; however, in 25% to 30% of the population, it remains patent. Most patients are asymptomatic and need no intervention. When is PFO closure recommended?
In patients younger than 60 years with a patent foramen ovale (PFO) and embolic stroke of unknown source
What are some indications for when thoracic endovascular aortic repair is recommended in patients with a descending aortic aneurysm? (2 of 3)
When the diameter is greater than 6.0 cm, has exhibited rapid growth (>0.5 cm/year), or has caused end-organ damage.
What is the rhythm?
Multifocal atrial tachycardia
In the show Friends, what is Chandler M Bing's job title?
Statistical Analysis and Data Reconfiguration
In patients with obstructive symptoms, such as dyspnea or syncope/near-syncope, lifestyle modification and medical therapy form the basis of management. Patients should be advised to avoid dehydration, excessive alcohol intake, and situational exposures that may result in vasodilation and decreased preload (for example, saunas, hot tubs) because these may provoke greater LVOT obstruction. What is first-line medical therapy for HOCM patients who present with LVOT symptoms?
Nonvasodilating beta blockers (Carvedilol, labetalol and nebivolol should be avoided)
For those who can't tolerate beta blockers, verapamil or diltiazem can be used.
An atrial septal defect (ASD) is a flaw or hole in the atrial septum resulting in a left-to-right shunt with eventual right-sided cardiac chamber dilatation in most patients. ASDs may be suspected in patients with unexplained right heart enlargement or atrial arrhythmias. What are the main indications for ASD closure?
The main indications for atrial septal defect (ASD) closure include right-sided cardiac chamber enlargement, symptoms of dyspnea, or atrial arrhythmias; asymptomatic, small ASDs without right heart enlargement can simply be monitored with clinical and echocardiographic surveillance.
AAA is most commonly diagnosed incidentally by CTA or abdominal ultrasonography. U.S. Preventive Services Task Force recommends one-time screening with duplex ultrasonography in all men aged 65 to 75 years who have smoked at least 100 cigarettes in their lifetime. Once an AAA is discovered, how often should surveillance be done in someone who has an AAA with a diameter of 3.6 cm? What if it was 4.2 cm?
In patients with an AAA diameter of 4.0 cm or less, surveillance with duplex ultrasonography every 2 to 3 years is warranted. In patients with an AAA diameter of 4.1 to 5.4 cm, surveillance with CTA or duplex ultrasonography should be performed every 6 to 12 months.
What is the rhythm? What is the management?
Complete (third degree) heart block
Pacemaker
Which American rapper originally went by the name Lesane Parish Crooks?
Tupac
Restrictive cardiomyopathy (RCM) is a rare disorder characterized by abnormally stiff, noncompliant ventricles. With increasing interstitial fibrosis, the ventricles stiffen, resulting in increased pressure during normal diastolic filling. Patients may present at any age, usually with symptoms of dyspnea, peripheral edema, and exercise intolerance. Hepatomegaly and ascites may also be present late in the disease course. What echocardiography findings in RCM?
Restrictive cardiomyopathy should be suspected in patients when echocardiography demonstrates biatrial enlargement and severe diastolic dysfunction in the setting of normal ventricular size, wall thickness, and systolic function.
A 52-year-old woman is evaluated in the emergency department for progressive dyspnea. Medical history is notable for aortic stenosis and long-standing hypertension. Family history is unremarkable. Medications are metoprolol and chlorthalidone.
On physical examination, temperature is normal, blood pressure is 190/90 mm Hg in both upper extremities, pulse rate is 80/min and regular, and respiration rate is 22/min. The jugular venous pressure is normal. The apical impulse is displaced and sustained. The S1 is normal, and the S2 is soft; an S4 is noted at the apex. An ejection click is heard at the apex and left sternal border. A systolic ejection murmur is noted along the right sternal border, and a separate systolic murmur is noted under the left clavicle and over the left posterior chest. The femoral pulses are diminished, and the radial artery–to–femoral artery pulse is delayed. No bruits are appreciated in the epigastrium or over the femoral vessels.
A chest radiograph is shown.
What is the most likely diagnosis and what are the indications for further intervention?
Aortic coarctation
Indications for intervention in patients with coarctation include a systolic peak (peak-to-peak) pressure gradient of 20 mm Hg or greater or radiologic evidence of severe coarctation with collateral flow. Percutaneous or surgical intervention options are available; selection depends on the length, location, and severity of coarctation and the presence of associated cardiovascular lesions.
Acute aortic dissection involves tearing of the aortic intima, leading to passage of blood from the true lumen of the aorta into a false lumen. Propagation of the dissection can result in cardiac tamponade; acute aortic regurgitation; compromise of arterial side branches (carotid, mesenteric, renal, or iliac arteries); and underperfusion of organs such as the brain, intestines, or kidneys. Aortic dissections are categorized according to their location of origin by use of the Stanford classification, which describes type A dissections as originating within the ascending aorta or arch and type B dissections as originating distal to the left subclavian artery. For management, how are Type A managed and how is Type B managed? (include first line medications and current guideline goals within the first hour)
Type A - emergent surgery
Type B without cardiogenic shock - Current guidelines recommend reducing systolic blood pressure to 120 mm Hg or less in the first hour in patients with aortic dissection. Intravenous β-blockers are first-line treatment; for hypertension that does not completely respond to β-blockers, intravenous vasodilators (nitroprusside, nicardipine) should be administered.
24 year old Korean male presents for lightheadedness and shortness of breath. Family history pertinent for an uncle that passed away at at the age of 41 unexpectedly. Name this rhythm.
Brugada syndrome
Neil Armstrong, Buzz Aldrin and…? Who was the third astronaut involved in the Apollo 11 mission that landed on the moon?
Command Module Pilot Michael Collins
Primary cardiac tumors, which are exceedingly rare, are benign in two thirds of patients. Of the benign tumors, nearly 50% are atrial myxomas. Myxomas may occur in either atria but are most commonly attached to the fossa ovalis within the left atrium. Myxomas are usually solitary and discovered at a mean age of 50 years, often after a systemic embolic event. When tumors are multiple, recurrent, or discovered at a young age, they may indicate the Carney complex. What makes up the Carney complex and which gene mutation is associated with this?
Carney complex is an inherited condition characterized by spotty skin pigmentation, cardiac (heart) myxomas (tumors composed of mucous connective tissue), skin myxomas, endocrine tumors or over-activity, and schwannomas.
The Carney complex is associated with mutations of the PRKAR1A gene, which may function as a tumor suppressor gene.
What are the 4 components of Tetralogy of Fallot?
Also, post ToF repair, which murmurs are expected to be present?
Four components include: large subaortic VSD, infundibular or valvular PS, aortic override, and right ventricular hypertrophy.
Severe pulmonic regurgitation or stenosis and tricuspid regurgitationWhen should aortic repair be pursued in patients with an abdominal aortic aneurysm?
Aortic repair should be performed in patients with an abdominal aortic aneurysm (AAA) diameter of 5.5 cm or larger, in those with rapid expansion in AAA size, and in patients presenting with symptoms resulting from AAA (abdominal or back pain/tenderness).
Typical AVNRT
Who liberalized Venezuela, Peru, Colombia, Bolivia and Ecuador from Spanish rule?
Simon Bolivar