A 68-year-old man comes to the emergency department because of a 1-week history of difficulty breathing. He has had recurrent palpitations over the past 2 years. During this time, he has also had several episodes of anxiety despite no change in his daily life. He has occasional sharp chest pain localized to the left upper sternal border. He has no abdominal pain or leg swelling. Two years ago, he had streptococcal pharyngitis, which was promptly treated with a 10-day course of penicillin. He has never traveled outside of the country. His temperature is 36.5°C (97.7°F), pulse is 82/min, and blood pressure is 140/85 mm Hg. Physical examination shows a 3/6 holosystolic murmur that is loudest at the apex and radiates to the axilla with a mid-systolic click. Bilateral fine crackles are heard on lung auscultation. Which of the following is the most likely cause of this patient's symptoms?

Inflammatory valve degeneration

Ectopic production of serotonin

Overproduction of catecholamines

A 38-year-old woman comes to the physician because of a 10-month history of nonbloody diarrhea and recurrent episodes of flushing and wheezing. She does not take any medications. Physical examination shows a hyperpigmented rash around the base of her neck. Cardiac examination shows a grade 4/6, holosystolic murmur in the 5th intercostal space at the left midclavicular line. Echocardiography shows left-sided endocardial and valvular fibrosis with moderate mitral regurgitation; there are no septal defects or right-sided valvular defects. Urinalysis shows increased 5-hydroxyindoleacetic acid concentration. Further evaluation of this patient is most likely to show which of the following findings?

Tumor in the lung without metastasis

Tumor in the descending colon with hepatic metastasis

Tumor in the left atrium with hepatic metastasis

Tumor in the pancreas without metastasis

Tumor in the appendix without metastasis

A previously healthy 20-year-old man is brought to the emergency department 15 minutes after collapsing while playing basketball. He has no history of serious illness. On arrival, there is no palpable pulse or respiratory effort observed. He is declared dead. The family agrees to an autopsy. Cardiac workup prior to this patient's death would most likely have shown which of the following findings?

Systolic anterior motion of the mitral valve

Narrowing of the left main coronary artery

A 52-year-old woman comes to the physician because of a 1-month history of mild fever, fatigue, and shortness of breath. She has no history of serious medical illness and takes no medications. Cardiopulmonary examination shows a mid-diastolic plopping sound heard best at the apex and bilateral rales at the base of the lungs. Echocardiography shows a pedunculated, heterogeneous mass in the left atrium. A biopsy of the mass shows clusters of mesenchymal cells surrounded by gelatinous material. Further evaluation of this patient is most likely to show which of the following?

Increased IL-6 serum concentration

Increased S100 protein serum concentration

A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?

Radionuclide myocardial perfusion imaging

24-hour ambulatory ECG monitoring

A 38-year-old woman is referred to a cardiologist for evaluation of syncope. Over the past year she has experienced 2 syncopal events. The first event occurred while she was standing, and the second when she laid down on her side. She denies bowel or bladder incontinence during the episodes or palpitations. However, she reports the presence of a low-grade fever over the past 3 months and a recent visit to the emergency department for a transient ischemic attack. She has a history of intravenous drug use but reports not having used in over 5 years. Temperature is 100.0°F (37.8°C), blood pressure is 115/72 mmHg, pulse is 90/min, and respirations are 20/min and regular. A detailed neurologic examination reveals no focal deficits. Cardiac auscultation demonstrates a diastolic "plop" at the cardiac apex. Which of the following findings will most likely be demonstrated on transthoracic echocardiography?

Decreased left ventricular ejection fraction

A 65-year-old man with hypertension comes to the physician for a routine health maintenance examination. Current medications include atenolol, lisinopril, and atorvastatin. His pulse is 86/min, respirations are 18/min, and blood pressure is 145/95 mm Hg. Cardiac examination is shown. Which of the following is the most likely cause of this physical examination finding?

Decreased compliance of the left ventricle

Myxomatous degeneration of the mitral valve

Inflammation of the pericardium

Thickening of the mitral valve leaflets

Cardiac tumors for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Classification - The Tumor Lineup

Secondary (Metastatic) > Primary
- Metastases are 20-40x more common.
- Sources: Melanoma, lung, breast, lymphoma.
Primary Tumors (Benign > Malignant)
- Benign (~75%):
  - Myxoma: Most common in adults (left atrium).
  - Rhabdomyoma: Most common in children (tuberous sclerosis).
  - Fibroma, Lipoma.
- Malignant (~25%):
  - Angiosarcoma: Most common primary malignant.

Cardiac Tumors: Location and Gross Appearance

⭐ Atrial myxomas can cause constitutional symptoms (fever, weight loss) via IL-6 production and a characteristic "tumor plop" on auscultation.

Atrial Myxoma - Jelly Ball Menace

Atrial Myxoma Histology (H&E)

Epidemiology: Most common primary cardiac tumor in adults. Benign, but clinically malignant due to effects.
Location: ~75% arise in the left atrium, often attached to the interatrial septum at the fossa ovalis.
Pathology: Gelatinous, friable mass ("jelly ball") composed of myxoma cells in a myxoid stroma.
Clinical Triad:
- Constitutional: Fever, weight loss, malaise (due to IL-6 production).
- Obstructive: Mimics mitral stenosis (dyspnea, syncope). Positional symptoms are common. Auscultation may reveal a diastolic "tumor plop."
- Embolic: Fragments can break off, causing systemic emboli (e.g., stroke) or pulmonary emboli if right-sided.

⭐ Association: Multiple myxomas, often in younger patients, are associated with Carney Complex (autosomal dominant syndrome: myxomas, spotty pigmentation, endocrine tumors).

Other Primary Tumors - Rogues' Gallery

Rhabdomyoma
- Most common primary cardiac tumor in children; often multiple.
- Associated with Tuberous Sclerosis (TSC).
- Typically found in the ventricles.
- Histology: Large, vacuolated "spider cells" containing glycogen.
- High rate of spontaneous regression.
Angiosarcoma
- Most common primary malignant cardiac tumor in adults.
- Arises from vascular endothelium.
- Usually originates in the right atrium.
- Presents with right-sided heart failure, hemorrhagic pericardial effusion.
- Poor prognosis due to early metastasis.

⭐ High-Yield: Over 50% of children with cardiac rhabdomyomas have Tuberous Sclerosis. Conversely, up to 80% of neonates with TSC will have a rhabdomyoma.

Metastatic Tumors - The Real Invaders

20-40x more common than primary cardiac tumors. The heart is rarely the first site of metastasis.
Common Primaries: Lung & breast (direct extension), melanoma (hematogenous), lymphoma & leukemia (lymphatic/hematogenous).
- 📌 Mnemonic: My Lungs Bleed Leukemia (Melanoma, Lung, Breast, Leukemia/Lymphoma).
Clinical Picture: Often asymptomatic. If symptomatic, usually due to pericardial involvement.
- Presents as pericardial effusion, tamponade, or constrictive pericarditis.
- Arrhythmias or heart block if myocardium is invaded.

⭐ Melanoma has the highest propensity for cardiac metastasis; up to 50% of patients with metastatic melanoma have cardiac involvement found at autopsy.

Echocardiogram: Pericardial effusion & cardiac mass

Diagnosis & Management - Find and Fix

Diagnosis:
- Echocardiography (TTE/TEE) is the initial and primary diagnostic tool.
- Cardiac MRI/CT for superior tissue characterization and surgical planning.
- Biopsy is high-risk (embolization) and usually avoided pre-operatively.
Management:
- Surgical resection is the definitive treatment for most primary tumors.
- Benign tumors (e.g., myxoma) are often curative post-resection.
- Malignant tumors may require adjuvant chemotherapy/radiation.

Echocardiogram: Left Atrial Myxoma Prolapsing Mitral Valve

⭐ Myxomas can present with constitutional symptoms (fever, weight loss) and elevated inflammatory markers (↑ESR, ↑CRP), mimicking endocarditis or vasculitis.

High‑Yield Points - ⚡ Biggest Takeaways

Metastatic tumors are far more common than primary ones, typically from lung, breast, or melanoma.

Most common primary tumor in adults: atrial myxoma, usually in the left atrium.

Myxomas present with constitutional symptoms, embolic events, or "ball-valve" obstruction.

Most common in children: rhabdomyoma, strongly associated with tuberous sclerosis.

Rhabdomyomas often regress spontaneously in children.

The most common malignant primary tumor is angiosarcoma.

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Cardiac tumors