Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Cardiology (Review) Year 5 – Internal Medicine Presented by: Dr. Taysir Prepared by: Ali JassimAlhashli

2. Extended Matching • Match each presentation with its disease (they are MATCHED below):

3. ECG Cases • Patient had retrosternal chest pain on rest for 1 hour duration that is associated with profuse sweating. ECG shows the following: This is STEMI with ST-segment elevation in chest leads V1, V2, V3 and V4 representing antero-septal infarction. In this case, LAD artery would be ocluded. Thrombolytics can be given unless contraindicated and management of this patient will be with: morphine, oxygen, nitroglycerin, aspirin, clopidogrel and heparin.

4. ECG Cases • Middle-aged male with history of diabetes and hypertension presented with chest pain on rest for 25 minutes. Pain is conducted to the lower jaw. This is STEMI with ST-segment elevation in the following leads: II, III and avF suggesting an infarction of the inferior wall. Pay attention, that pain with inferior infarction is usually referred to epigastric area and patient might be misdiagnosed as having GERD and treated with PPIs or H2-blockers with no improvement or even death!

5. ECG Cases • An 80 years old male presented with syncope and dizziness. Blood pressure was 150/90 mmHg. You can notice that there is no relation between P-waves and QRS-complexes… This is complete heart block. This patient would be initially managed with atropine and dopamine (although they usually do not work). Pacing of the heart is necessary

6. ECG Cases • A 40 years old female presented to emergency with palpitation for 2 hours duration with no chest pain. QRS complexes are narrow; there is a regular rhythm; P-waves are not present and there is tachycardia… This is supraventricular tachycardia. IV adenosine is effective in < 90% of cases

7. ECG Cases • A 50 years old male with multiple episodes of syncope. He had an ECG abnormality on the attached rhythm strip: This is Ventricular Tachycardia (VT) which is defined as ≥ 3 consecutive beats of ventricular origin at a rate of < 120 beats/minute. QRS complexes are wide and often bizarre.

8. ECG Cases • This patient has MI 6 weeks ago. He is not having any angina pectoris at present. V1, V2 and V3 showing inverted T-waves and Q-waves. Recommended discharge medications after MI are: aspirin, clopidogrel, B-blocker and statins. ACE and diuretics are added for patients with heart failure

9. Questions • This image is an angiogram of the aortic arch showing (coarctation of aorta) after the left subclavian artery. • Patients present with hypertension and radio-femoral delay. • Other causes of hypertension in young population: • Renal artery stenosis. • Polycystic kidney disease. • Congenital hydronephrosis due to anatomical abnormalities. • Glomerulonephritis (commonly due to post-streptococcal infection). • This condition is corrected with surgery (which has a 20% mortality rate!)

10. Questions • Case: patient presented with a sharp, tearing chest pain for 2 hours duration which radiates to the back. • Image shows a CT-scan of the chest which reveals the presence of a true and false lumen in ascending aorta (both connected via neck between them). • This is aortic dissection that is corrected by surgery.

11. Questions • Case: patient has raised JVP reaching his ear lobe with muffling of heart sounds. • Image shows a chest x-ray of cardiac temponadewith loss of aortic knuckle and aorto-pulmonary window (flask-shape appearance). • Management: pericardial aspiration which can be done by two methods: • 30 degrees 1 cm below xyphoid process inserting the needle towards the left nipple until reaching pericardial cavity under guidance of ECHO. • Inserting the needle in 5th ICS of MCL. A maximum of 1.5 L of fluid is aspirated at a time → not all of fluid is aspirated at a time → because this can result in hemodynamic instability and pulmonary edema.

12. Questions • Image shows a 10 years old girl with central cyanosis, loud S2, increased JVP and parasternal heave and a blood pressure of 80/60 mmHg. • This girl has primary pulmonary hypertension which results in right ventricular hypertrophy (RVH). This condition cannot be reversed and prognosis is very poor. • Complications: • Severe hemoptysis. • Right-sided heart failure.

13. Questions • Rhythm strip below shows (hyperacute T-waves) in which T-waves are tall and tented. This commonly occurs in 2 conditions: • Hyperkalemia in patients with Chronic renal failure (ESRD). • Myocardial Infarction (MI). How would you differentiate between the two conditions mentioned above? → in MI, ST-segment is also affected but not in hyperkalemia.

14. Questions • Image is of a patient with gross ascites. What is your differential diagnosis? • Chronic liver disease such as liver cirrhosis which results in portal hypertesnion. • Intra-abdominal malignancy. • Nephrotic syndrome. • Right-sided heart failure. • Hypoproteinemia. • Constrictive pericarditis: in which pericardium is calcified when viewed by CT-scan of the chest. This condition is managed by pericardiectomy which has a hight mortality rate reaching up to 50%!! → why? → because it is difficult for the patient to differentiate between pericardium and myocardium due to adherence and calcifications.

15. Questions • Image showing vegetations of infective endocarditis. • Infective endocarditis is colonization of heart valves with microbial organisms (S.aureus when acute; S.viridans when subacute) resulting in fever, vegetations and valve injury (aortic and mitral valves are most commonly affected). • Condition is diagnosed by a combination of positive blood cultures and abnormal transesophageal ECHO and other minor criteria. • Vancomycin and gentamicin are the standard empirinc treatment of infective endocarditis. You must alter therapy as soon as a specific microbiologic agent is known.

16. Questions • Fundoscopy showing the following: • Dark red spots: representing deep hemorrhages. • Light flame-shaped spots: representing superficial hemorrhages. • Silver-wiring: representing hypertensive/arteriosclerotic retinopathy. • Retinal exudates (yellow). • Papilledema: Swelling of the optic disc due to increased intra-cranial pressure. You will notice the loss of optic disc borders and the loss of optic cup.

17. Questions Brain abscess in endocarditis. MRI of S.aureusendocarditis-associated brain abscess in a 75 years old patient. (A): the FLAIR-sequence shows perifocal edema (arrow). (B): contrast enhancement indicates the capsule of the abscess (arrow). (C): the diffusion-weighted imaging shows increased signal intensity within the abscess cavity.

18. Questions • Pulmonary edema is considered a medical emergency and requires hospitalization. It leads to impaired gas exchange and may cause respiratory failure. Cardiogenic pulmonary edema is caused by an acute increase in left ventricular pressure due to ventricular dysfunction which leads to fluid accumulation in the pulmonary interstitium. • CXR in the image shows pulmonary edema with pulmonary effusion on both sides. • Management of patient: oxygen, diuretics (furosemide), morphine sulfate, sitting the patient upright, nitrogylcerin to reduce preload and IV ACE inhibitors.

19. Questions • CXR (1): • A 19 years old male who presented to emergency with pleuritic chest pain, dyspnea and hypoxia. • CXR shows tension pneumothoraxleading to the collapse of right lung and pushing heart and mediastinum to the left side. • Percussion: hyper-resonance of the right side of the chest. • CXR (2): • Consolidation of right lower zone of the lung (bacterial pneumonia). • Tactile phremitus is increased, percussion is dull and there is reduced air entry to the affected side with bronchial breathing and egophony.

20. Questions • Image (1): • Janeway lesions occurring in 10-15% of patients with infective endocarditis. Description: macular, red/ hemorrhagic, painless patches on palms or soles. • Image (2): • Clubbing of fingers. What are your differentials: • Lung cancer. • Bronchiectasis. • Cystic Fibrosis (CF). • COPD. • Liver cirrhosis. • IBD.

21. Questions Massive pulmonary embolism detected by CT-angio. Patient has hypoxia and hypocapnia (hypocarbia)

22. Good Luck!Wish You All The Best