Summary cardiology

round
2016 Dr. Avishag LaishFarkash
Cardiology department
Barzilai MC, Ashkelon

Case #1
60 yo male
2 weeks post hospitalization for AMI
c/o malaise, fever, chest pain
(atypical, pericardial)
Lab: leukocytosis, ESR
Echo: pericardial effusion
* Dg? Tx?

Answer: Dressler syndrome

(Postmyocardial infarction syndrome)
Incidence: 3-4% of all MI (1957)
incidence
dramatically since then
Suspected
immunopathological
process
Localized fibrinous
pericarditis
containing PMNs at

 Tx: ASA 500-650 mg up to X4-6/d

Avoid GC and NSAIDS within 4 weeks
of AMI
- risk of impaired infarct healing
- cause of ventricular rupture
- Causes of coronary vascular
resistance

Case #2

60 yo male
10 d post inferior MI
Weakness, dizziness
ECG:

* Dg? Tx?

Answer: Persistent symptomatic

third-degree AV block post MI

GL summary for pacemaker implantation in AV

conduction block in acute MI
Class I
1. Persistent 2DAVB in HPS with bilateral BBB or 3DAVB
within/below His after AMI
2. Transient advanced infra-nodal AVB and associated BBB (if
site of block uncertain- EPS)
3. Persistent and symptomatic 2DAVB or 3DAVB
Class III
4. Transient AVB in the absence of IVCD
5. Transient AVB with isolated LAHB
6. Acquired LAHB without AVB
7. Persistent 1DAVB with BBB that is old or age-indetermined

Case #3

65 yo male
HTN
Treated with cardiloc 5mgX1 (BB)
Due to uncontrolled HTN Ikacor 80 mgX3
(CCB) was added to the Tx.
He was presented to ER with syncope.
ECG:
* Dg? Tx?

Answer: Acquired (drug-induced)

3DAVB
GL summary for PM implantation in acquired AVB
Class I
1. 3DAVB/high DAVB associated with:
- Symptomatic bradycardia
- Essential drug Tx that produces symptomatic bradycardia
- Periods of asystole >3s or any escape rate <40bpm while awake, or
escape from below AVN
- Postoperative AVB not expected to resolve
- Catheter ablation of AVN
- Neuromuscular disease, regardless of symptoms
2. 2DAVB with symptomatic bradycardia
3. 2DAVB type II with wide QRS complex
4. Exercise-induced 2DAVB or 3DAVB in the absence of ischemia
5. AF with bradycardia and pauses>5sec

Cont.
GL summary for PM implantation in acquired AVB
Class IIa
1. Asymptomatic 3DAVB
2. Asymptomatic 2DAVB type II with narrow QRS
3. Asymptomatic 2DAVB type II with block within or below His in EPS
4. 1DAVB or 2DAVB with symptoms similar to PM syndrome
Class IIb
2. AVB in the setting of drug use/toxicity, when the block is expected to
recur even with drug discontinuation
3. NMD with any AVB
Class III
4. Asymptomatic 1DAVB
5. Asymptomatic 2DAVB type I (AVN level)
6. AVB that is expected to resolve or is unlikely to recur (Lyme disease,
drug toxicity)

Case #4
65 yo male
Asymptomatic
ECG #1:

 ECG #2:

* Dg? Tx?

Answer: Alternating BBB

GL summary for PM implantation in chronic BFB and TFB:
Class I
1. Intermittent 3DAVB
2. Type II 2DAVB
3. Alternating BBB
Class IIa
4. Syncope not demonstrated to be d/t AVB and other causes (e.g. VT)
have been excluded
5. Incidental finding at EPS of markedly prolonged HV (>100 ms) in
asymptomatic patients
6. Incidental finding at EPS of pacing-induced infra-His block that is not
physiologic
Class IIb
7. NMD with any FB regardless of symptoms (d/t unpredictable progression
to AV conduction disease)
Class III
8. FB without AVB or symptoms
9. FB with 1DAVB without symptoms

Case #5

1) Timing of re-vascularization in acute ST elevation MI? Which revascularization?

Case #6

1) Antithrombotic and anti-coagulation Tx in STE MI?

Case #7
56 yo female
Heavy smoker
Diabetes Mellitus II
Hypertension
Presented with ST elevation MI within 2h of chest pain
After successful primary PCI to mid-LAD
LVEF 30% NYHA FC II

1) What is the long term medical therapy that you

should recommend to improve prognosis?
2) What are your recommendations for lifestyle changes
and cardiac rehabilitation programs?

Case #8

56 yo female
Heavy smoker
Diabetes Mellitus Insulin Tx
Hypertension
Presented with ST elevation MI within 2h of chest
pain

After successful primary PCI to mid-LAD

LVEF 30% NYHA FC II
* How will you follow-up on her after discharge?

Case #9

56 yo female
Heavy smoker
Diabetes Mellitus Insulin Tx
Hypertension
Chronic renal failure

Presented with chest pain, fever and atrial fibrillation

Normal ECG
Normal echo
Elevated troponin level

* What is the differential diagnosis?

Case #10

56 yo female
Heavy smoker
Diabetes Mellitus Insulin Tx
Hypertension

Presented with NSTE-ACS (Troponin +)

* What are your recommendations for
platelet-inhibition in this patient?

Case #11

56 yo female
Heavy smoker
Diabetes Mellitus
Hypertension
Prior PCI

Presented with NSTE-ACS (Troponin -)

* What should be the timing for
revescularization?

Case # 12

56 yo female
Heavy smoker
Diabetes Mellitus
Hypertension

Presented with NSTE-ACS

* What are your recommendations for
long-term management at discharge?

Case #13

76 yr old lady, HTN

For the first time- 2 days of anginal CP
Persistent STE
Echo: large transmural ant. wall infarction
PCI: LAD no reperfusion
On day 4 CP then shock and EMD

* Dg? Tx?

Free wall rupture

Incidence: ~1-6% (0.8-6.2%)

(up to 10% of pts dying in

hospital from STEMI). Can be a form of SCD in pts with undetected/silent
MI

Fibrinolytic Tx >PPCI
old hypertensive women
first and large transmural infarct ( no
collaterls,
late arrival, persistent STE/no reperfusion or
rec.
STE)
LV>RV>atria
anterior or lateral wall (terminal distribution of LAD)

 Time course: Bimodal peak: within 24h and

3-5 days; range 1-14 days (days 1-4 in the
borders of infarct; second week- center)
Clinical manifestation: catastrophic vs.
subacute vs. pericardial type.
Sudden profound shock, often PEA (d/t
tamponade)
CP (anginal/ pleuritic/ pericardial), syncope,
hypotension, arrhythmia, nausea,
restlessness, SCD
Physical findings: JVP (29% of pts), pulsus
paradoxus (47%), EMD, cardiogenic shock

 Echocardiographic findings: >5mm

pericardial effusion (some pts); layered, highacoustic echoes w/I pericardium (blood clot);
direct visualization of tear; signs of
tamponade.
Right heart catheterization: ventriculography
insensitive; classic signs of tamponade not
always present (equalization of diastolic
pressures among cardiac chambers)
Tx: hemodynamic stabilization of pt
( immediate pericardiocentesis, inotropic
agents, IABP ) and prompt surgical repair.
Cardiac cath only if favorable condition, for
delineating coronary anatomy.

Case #14
60 yr old male
ECG: antero-lateral wall STEMI, cardiogenic
shock
Echo: Hypokinesis anterior wall, septum,
lateral wall, apex
Cath: Prox LAD thrombus. PPCI.
5 days later symptoms compatible with TIA
* Dg? Tx?

LV Thrombus
Pathogenesis: Endocardial
inflammation during acute phase of MI
probably provides a thrombogenic
surface for clots to form in LV
Incidence: -Has dropped 20% to 5%
(AC)
-Early mural
thrombus(w/I 48-72h) =
extremely poor early
prognosis

 Echo features prone to embolize:

mobility
Protrusion into ventricular chamber
Visualization in multiple views
Contiguous zones of akinesis and
hyperkinesis

 Tx: IV heparin (X1.5-2 PTT) then

ASA+ warfarin for 3-6 months in the
following events:
Demonstrable mural thrombi
Embolic event has already occurred
Large anterior MI (common practice)
MI in non anterior distribution if a
thrombus or large WMA is detected

Case #15

35 yo female with palpitations

Dg? DD? Tx?

Case #16
-

65 yo male
HTN, DM, Good LV function
Prior episodes of palpitations, weakness
Presented to ER with a similar episode for the past 12 h

Dg? Tx?