LTC Rosh Cardio
A patient with an intermediate risk of coronary artery disease is undergoing an exercise stress test. Which of the following is the most specific finding for myocardial ischemia?
2 mm downsloping ST-segment depression
According to JNC-8, patients older than 60 years with hypertension and no other medical history, should be treated to which of the following blood pressure goals?
< 150/90 mm Hg
Which of the following clinical scenarios can be defined as a hypertensive emergency?
A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours
Which of the following patients should be classified as having unstable angina?
A 55-year-old woman with a history of hypertension but no prior cardiac disease who complains of one episode of chest pressure that began while pushing her grocery cart and lasted 30 minutes
A 28-year-old South Asian immigrant who is in her second trimester of her first pregnancy presents to the emergency department with worsening dyspnea, orthopnea, and lower extremity edema. She has never experienced anything like this before. She has no past medical history, but she reports frequent sore throats and ear infections as a child. Which of the following is most likely to be heard on auscultatory exam?
A diastolic low-pitched decrescendo murmur best heard at the cardiac apex
Which of the following medications has the greatest impact on reducing mortality in patients presenting with acute coronary syndrome?
ASA
Which of the following treatments has a proven mortality benefit in ST-elevation myocardial infarction?
ASA
Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm?
Abdominal mass
A 70-year-old woman with a long history of coronary artery disease is seen in cardiology clinic for routine follow up. She complains of continued angina despite medical therapy. She reports chest pain every time she walks to her mailbox. It does not occur at rest and is relieved by sublingual nitroglycerin. Her medications include carvedilol, amlodipine, daytime transdermal nitroglycerine, sublingual nitroglycerin, aspirin, and simvastatin. On physical exam her BP is 105/72, HR is 51 and RR 16. What is the next step in management?
Add ranolozine
A 65-year-old man presents to the ED for chest pain. You are concerned for acute coronary syndrome and want to administer aspirin, but the patient states that he develops angioedema to aspirin. Which of the following is the most appropriate next step in management?
Administer clopidogrel
A 58-year-old woman presents to your office with complaints of headache, a temperature of 101.1°F, anorexia, and morning stiffness in her hips and shoulders. She indicates that this morning her vision was blurry, whereas yesterday it was normal. Which of the following is the most appropriate next step in management?
Administration of 60 mg of prednisone and referral to ophthalmology
A 66-year-old man with hypertension and type II diabetes mellitus presents to the clinic complaining of chest tightness, dyspnea, and dizziness while mowing his lawn earlier that day. He had similar symptoms two weeks ago. His symptoms resolved within a couple of minutes of sitting to rest. He is currently pain-free. Vital signs are pulse 88 beats per minute, blood pressure 134/88 mm Hg, temperature 98.8°F, oxygen saturation 97%, and 20 respirations per minute. Exam reveals an obese man in no acute distress and is otherwise unremarkable. Electrocardiogram is obtained and shown above. Which of the following is the most likely diagnosis?
Angina pectoris
A 62-year old man presents to the ED complaining of crushing substernal chest pain for the last two hours associated with diaphoresis, nausea, and lightheadedness. His pain improves with sublingual nitroglycerin. Electrocardiogram obtained in triage shows deep Q waves and ST segment elevation in leads V1-V4, with ST depression in leads III and aVF. This pattern on electrocardiogram represents infarction of which area of the myocardium?
Anterior
65-year-old man presents to your office with sudden severe chest pain, asymmetric blood pressures in his arms, and a new evolving aortic regurgitation murmur. The patient describes the chest pain as 10 out of 10 in severity. You decide to call 911 as you suspect what acute emergency?
Aortic dissection
A pregnant female recently diagnosed with gestational hypertension presents to the emergency department with a chief complaint of sudden onset of tearing retrosternal pain. A chest X-ray is obtained which demonstrates a widened mediastinum. What is the most likely diagnosis?
Aortic dissection
Which of the following statements is true regarding giant cell arteritis?
Aortic involvement can lead to valvular disease and dissection
A 65-year-old man presents to his physician for a gradual decline in exertional fortitude and dyspnea on exertion that has been getting worse over the past two months. Physical exam demonstrates a mid-systolic murmur heard best at the second intercostal space near the right sternal border. The murmur decreases with isometric handgrip and Valsalva maneuvers. What is the most likely diagnosis?
Aortic stenosis
A 74-year-old woman with a history of heart failure presents to the ED with shortness of breath. Her vital signs are notable for heart rate 105 beats/minute, blood pressure 180/90 mm Hg, and oxygen saturation of 87 percent on room air. Chest X-ray shows pulmonary edema. You are considering starting nitrates. Which of the following underlying conditions puts the patient at risk of developing nitrate-induced hypotension?
Aortic stenosis
A 45-year-old man with a history of paroxysmal atrial fibrillation presents to the ED with acute onset of severe pain and paresthesias in his right calf. On exam, you note lower extremity pallor and an absent dorsalis pedis pulse. Which of the following is the most likely diagnosis?
Arterial thromboembolism
A woman presents for her annual examination. She has a past medical history of stable angina and her home medications include aspirin and a statin. She continues to have angina 3-4 times a week, but its character, intensity, frequency and duration is unchanged. She has no history of myocardial infarction, diabetes or pulmonary disease. Which of the following interventions is most appropriate at this time?
Atenolol
A 69-year-old man with atherosclerosis presents with calf pain during ambulation. He notices a blanching of the leg skin when the pain is at its worst. If he stops walking, the pain ceases within 5 minutes. He has a 120 pack-year history of tobacco use. Examination of the toes reveals prolonged capillary refill but normal sensation. A recent work-up revealed normal cardiac function. Which of the following abnormalities would most likely be found during examination of this patient's lower extremities?
Atrophic, shiny skin
A 50-year-old woman presents to the Emergency Department following a syncopal episode. On physical exam she is diaphoretic, but alert and orientated. Her blood pressure is 100/50 mm Hg, heart rate 46 beats per minute, and respirations 12 per minute. Her rhythm strip is shown above. What is the most appropriate treatment for this patient's condition?
Atropine
A 65-year-old man presents to the emergency department with chest pain and ST-segment elevation in leads II, III, and aVF. The patient is hypotensive and physical exam reveals jugular venous distention, clear lung fields, and tachycardia. No murmur or S3 is appreciated. What is the next step in management?
Begin IV hydration
Which of the following is most characteristic of Prinzmetal angina?
Chest pain in the early morning
A patient is being discharged from the hospital after having an ST-elevation myocardial infarction. During his stay, he underwent percutaneous coronary intervention with placement of a drug eluting stent. The patient is being sent home on the following medications: aspirin 81 mg, metoprolol 50 mg, nitroglycerin 0.4 mg sublingual, and atorvastatin 40 mg. Which of the following should also be added to his regimen?
Clopidogrel
An elderly man presents with 4 episodes of angina in the past 24 hours. His medical history includes diabetes and advanced COPD. Based on initial testing, you diagnose non-ST-elevation myocardial infarction. You are waiting for the cardiac team to admit him to the critical care unit. In the interim, which of the following is the most appropriate medication to begin?
Clopidogrel
When considering the diagnosis of a patient with leg pain and swelling, you determine that the pretest probability of deep vein thrombosis is high. Which of the following is the most appropriate test in confirming this diagnosis?
Compression ultrasonography
You are managing the blood pressure of a 49-year-old Caucasian woman with enalapril 20 mg twice a day. She does not have diabetes or chronic kidney disease. She has been taking the enalapril for over 1 month. Repeated blood pressure readings in both arms average out to 138/96. Which of the following is the most appropriate treatment at this time?
Continue enalapril and add amlodipine
The emergency department staff began treatment for a woman who presented with chest pain. The pain is described as retrosternal, worse with minimal activity, better with rest, sharp in character and 9/10 in intensity. You are paged to admit her to the intensive care unit under the working diagnosis of unstable angina. Her vitals have remained stable after beginning antiplatelet, antihypertensive and antithrombotic medications. Two hours after admission, a repeat history and physical and review of available test results offers the following information: serial electrocardiograms reveal increasing R wave amplitude; an echocardiogram calculates an ejection fraction of 50%; angina is reported as 9/10 in intensity; atrial natriuretic peptide levels are elevated. Which of the following historical facts would prompt you to immediately consult interventional cardiology for invasive coronary revascularization?
Continued chest pain
A 43-year-old man is currently undergoing palliative radiation therapy for pancreatic cancer. He presents to the emergency department with a 4-day history of gradually worsening left lower extremity pain. Pain is localized to the calf and made worse with ambulation. Exam shows mild edema of the left calf without erythema or warmth. Which of the following is the most likely diagnosis?
DVT
You prescribe ramipril to a 65-year-old man with uncontrolled hypertension and severe renovascular disease. At a follow-up visit four weeks later his creatinine is noted to be 2.3. His creatinine before starting the ramipril was 1.0. By what mechanism did the ACE inhibitor cause this change?
Decreasing glomerular flow
A 68-year-old woman presents to the ED with chest pain. It occurs at rest, and has been getting worse over the past 2 hours. Her past medical history includes COPD, GERD, diabetes, urinary incontinence and Factor V Leiden. Her past surgical history is significant for carpal tunnel release four years ago and total hip arthroplasty 18 months ago. Blood pressure is 168/118 mm Hg, heart rate is 100 BPM and oxygen saturation is 95% on room air. An electrocardiogram reveals ST-elevation. An initial cardiac panel shows a positive troponin level. In this scenario, which of the following in this patient is a relative contraindication to fibrinolytic therapy?
Diastolic BP
A 67-year-old man with diabetes mellitus, chronic lower back pain and previously stable systolic heart failure now has increasing orthopnea and shortness of breath. Physical exam reveals pulmonary crackles, jugular venous distention and lower extremity edema. He is on carvedilol, lisinopril, furosemide, insulin and ibuprofen. Which of the following is appropriate for management of this patient?
Discontinue the ibuprofen
A 58-year-old African-American man with a history of hypertension presents to your office for his annual exam. His BP is 145/95 and HR is 75. He is taking lisinopril as previously prescribed. According to JNC-8 hypertension guidelines, which of the following is the most appropriate next step in his management?
Discontinue the lisinopril and start the patient on hydrochlorothiazide
An elderly woman presents with intermittent leg pain. She states it is a burning heaviness that is not necessarily associated with activity. Inspection reveals several dilated and tortuous veins about the lower legs. The skin is edematous and speckled with dark brown areas of capillary dilation but no specific pallor. Distal motor and sensory examinations are intact. Which of the following is the most appropriate initial tests in the evaluation of these symptoms?
Duplex ultrasonography
A 32-year-old woman presents to the ED complaining of right calf swelling for one week. She is one week postpartum, following an uneventful full-term vaginal delivery. She denies any chest pain, dyspnea, or cough. On examination, her right calf is 16 inches in circumference, and her left calf is 10 inches. Which of the following is the most accurate test to confirm the diagnosis?
Duplex ultrasound
Which one of the following is the most common atypical presenting complaint in an elderly patient diagnosed with acute coronary syndrome?
Dyspnea
A 45-year-old man with a history of obesity and diabetes mellitus presents to the emergency department with abdominal pain that radiates to his back as well as nausea and vomiting. Physical examination reveals tenderness in the epigastrium. Yellow deposits are noted on the extensor surfaces of his forearms. Which of the following will most likely be seen on the patient's lipid panel?
Elevated triglycerides
A woman with chest pain presents to the ED. Her electrocardiogram shows ST elevation in leads V3 and V4. She is started on oxygen, intravenous nitroglycerin, and aspirin. You are preparing her for transfer to the interventional cardiac unit for primary percutaneous cardiac reperfusion. Her heart rate has been consistently < 60, averaging 54 over the past 30 minutes. Which of the following medications is also appropriate treatment at this time?
Eptifibatide
A 28-year-old man presents to establish care at your primary care clinic. He works as an electrical engineer and reports he has a fairly sedentary lifestyle. He states he smokes half a pack of cigarettes a day, and is not interested in quitting. He denies any past medical history and states he does not take any medications. He does mention that his father had a heart attack when he was 43 years old. What is the most appropriate next step for this patient?
Fasting lipid panel
A 65-year-old woman presents to the emergency department in atrial fibrillation with rapid ventricular response for an unknown duration of time. She was started on heparin and no atrial thrombus was seen on transesophageal echocardiogram. She underwent successful direct current cardioversion and is now back in normal sinus rhythm. What is the minimum period of time she must remain on anticoagulation after cardioversion?
Four weeks
A 58-year-old man ran out of his congestive heart failure medications. He presents with significant dyspnea and altered mental status. Examination reveals bibasilar crackles and jugular venous distension. An electrocardiogram shows sinus rhythm with low voltage complexes. Which of the following is most appropriate at this time?
Furosemide
A 74-year-old man presents to the ED with chest pain radiating to the jaw and dyspnea. His past medical history is significant for hypercholesterolemia, hypertension and diabetes. He denies illicit drug use. His blood pressure is 210/122 mm Hg. Physical exam and chest X-ray are normal. His ECG is consistent with left ventricular hypertrophy. Which of the following is the most likely diagnosis?
HTN emergency
A 28-year-old woman with no past medical history presents to the emergency department with acute dyspnea. Physical exam reveals tachycardia, warm extremities, wide-pulse pressure, bounding pulses, a systolic flow murmur, exophthalmos and a neck mass. Which of the following is the most likely diagnosis?
High output HF
What is the earliest change seen on electrocardiogram in an acute ST elevation myocardial infarction?
Hyperacute T waves
A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, had shortness of breath, and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to complain of chest pain. Vitals are unremarkable, and the ECG reveals left ventricular hypertrophy. What management is indicated?
IV fluids and cardio consult
A previously healthy 30-year-old man presents to your clinic with concerns about screening for cholesterol. He has never smoked, is physically active, and is in the normal range for body mass index and blood pressure. He says that his father started taking medication for hyperlipidemia at age 66 and he wants to know when he should start being screened. Which of the following is the most appropriate next step in management according to the United States Preventative Services Task Force?
Initiate lipid screening at 35
Which of the following is the most common cause of sudden cardiac arrest and sudden cardiac death?
Ischemic heart disease
An elderly patient presents to the office complaining of lower extremity skin changes and discomfort that is relieved with elevation. Which of the following would most likely be present on physical exam?
LE edema
A 58-year-old man with chronic hypertension presents to the ED with 10/10 tearing chest pain that radiates to the back. All you can gather from him is that he also has some type of "collagen disorder" and diabetes. A chest radiograph reveals a widened mediastinum. As you prepare for a transesophageal echocardiogram, you would most likely start which of the following medications as a first-line agent?
Labetalol
A 62-year-old man who is a nonsmoker without any significant past medical history presents to your office with questions about his cholesterol. Recent laboratory results include total cholesterol 253 mg/dL, high-density lipoprotein cholesterol 38 mg/dL, low-density lipoprotein cholesterol 165 mg/dL, and triglycerides 250 mg/dL. He has a 10-year ASCVD event risk score of 9%. Which of the following is the most appropriate initial therapy?
Lovastatin
A 45-year-old woman presents with a painful, red, and swollen right leg that has gotten worse over the past couple of days. She denies any trauma, travel or insect bites or any systemic symptoms such as fevers or chills. She has a history of insulin-controlled diabetes mellitus and her average postprandial sugar is 126-136 mmol/L. She also has a history of hyperhomocysteinemia and Factor V Leiden. She had an episode of cellulitis six months ago. On physical exam her vital signs are HR 82, RR 16, BP 142/86, T 99.7°F, and oxygen saturation 98% on room air. On palpation there is a swelling and tenderness of her entire right leg compared to her left. Measurement of her right calf is 3 cm in diameter greater than her left leg. Ultrasound reveals a noncompressible popliteal vein. Which of the following treatment regimens should be initiated in this patient?
Low molecular weight heparin initially and continue anticoagulation therapy for at least twelve months
A 65-year old Caucasian man presents to the emergency room with a crushing substernal chest pain. He states the pain started 30 minutes before and he has never had an episode like this before. He is a smoker and has a history of diabetes. His mother had a myocardial infarction at 60 years of age. He takes insulin for his diabetes but no other medications including over-the-counter medications. He has no known allergies. His initial cardiac troponin was negative and his ECG reveals ST depression that measures 0.8 mm in anterior the leads. According to his TIMI score, which of the following is the most appropriate management?
Measure serial cardiac troponin levels
A 52-year-old woman four days post myocardial infarction presents with a new murmur. On examination, the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspneic at rest and has rales throughout all her lung fields. Her blood pressure is 108/68 mm Hg, and her heart rate is 70 beats per minute. Which of the following would be the definitive clinical intervention?
Mitral valve replacement
A 68-year-old man was admitted to the hospital for an acute exacerbation of his chronic systolic congestive heart failure. What education should be given to this patient upon discharge to help prevent readmission?
Monitor daily weights
A 62-year-old man with a history of hypertension and tobacco abuse presents with acute onset of sharp epigastric abdominal pain with radiation to his back. On arrival, his vitals signs are T 37.3°C, HR 100, BP 180/90 in the right arm and 80/40 in the left arm, RR 27. Which of the following agents is the first line management of this patient's condition?
Negative inotropes
A 67-year-old man with a history of hypertension presents to the emergency department complaining of the acute onset of severe tearing chest and back pain and a syncopal episode. Which of the following physical exam findings would support the most likely diagnosis?
New murmur of aortic regurgitation
A 49-year-old man presents with chest pain. His medical history does not list any cardiac murmur, however, during examination, you hear a mitral regurgitant murmur. Blood pressure is equal in both the left and right arms. Although you have none to compare to, you order an electrocardiogram and there is no ST elevation. A chest radiograph is read as normal. Initial lab testing shows an elevated troponin level. Which of the following is the most correct diagnosis?
Non-STEMI
Which of the following can decrease levels of brain natriuretic peptide?
Obesity
Which of the following should be assessed in the physical exam of a patient with essential hypertension?
Ocular fundus
A 45-year-old woman presents to clinic to discuss her recent diagnoses of diabetes mellitus and hypertriglyceridemia. Which of the following is true regarding her glucose and triglyceride control?
Optimizing glycemic control may improve hypertriglyceridemia
Which of the following is the most predictive risk factor for cardiac ischemia?
PMH of CAD
A 62-year-old man reports to the ED with new-onset, crushing, left-sided chest pain, radiating to the left arm that began suddenly 35 minutes prior to arrival. The patient has a history of hypertension, hypercholesterolemia, diabetes mellitus, and a 60-pack-year smoking history. His EMS ECG demonstrates ST-segment elevation in leads II, III, and aVF. In the ED, his vital signs are BP 135/75, HR 98, and RR 18. What is the most appropriate next step?
Place the patient on a cardiac monitor, administer oxygen if hypoxic, and administer aspirin
A 40-year-old woman presents with recurrent chest pain that occurs shortly after she wakes up in the morning. She has a history of migraine headaches and Raynaud phenomenon. She reports tobacco use and smokes one pack per day. Her chest pain is not reproducible with palpation. An ECG during an episode reveals ST elevation in multiple leads and cardiac biomarkers are normal. Which of the following is the most likely diagnosis?
Prinzmetal angina
A 30-year-old woman with no past medical history presents to the emergency department with substernal chest pain for two hours. It is not worse with exertion and was not relieved by sublingual nitroglycerin. She reports some mild nausea. She does not smoke cigarettes or use any illicit drugs. Her family history includes a grandmother who died of a myocardial infarction at 84 years old. Labs in the emergency department are unremarkable. Point of care troponin is negative, and ECG reveals sinus rhythm. What is your next step in management?
Reassurance
A 52-year-old man states he took his blood pressure and it was elevated to 180/100 mm Hg. He states that he missed his regular dose of antihypertensive medication because he was traveling for business and returned home today. His blood pressure now is 176/102 mm Hg. The patient is otherwise asymptomatic and has a normal physical exam. What is the most appropriate action?
Resume outpatient medication
A 52-year-old man presents to the emergency department via ambulance with substernal chest pain. He received aspirin and nitroglycerin from emergency personnel in route. Vital signs include BP 95/55 mm Hg, HR 60 beats/minute, RR 20 breaths/minute, and T 97.6F. His electrocardiogram is shown above. Which of the following is the most appropriate next diagnostic study?
Right-sided EKG
A woman presents with nausea and vomiting, chest pain at rest and altered mental status. Her past medical history is significant for poorly controlled diabetes mellitus and hypertension, as well as tobacco abuse. Which of the following would you most expect to see on an electrocardiogram?
ST segment elevation
Which of the following is correct regarding cardiac markers in regards to myocardial infarction?
Serum troponin is more sensitive than creatinine phosphokinase (CK-MB)
A 65-year-old man presents to the ED with sudden onset of chest pain that began two hours prior to arrival. He has a history of hypertension treated with hydrochlorothiazide, hyperlipidemia treated with simvastatin, erectile dysfunction treated with sildenafil, and takes a daily aspirin. An ECG demonstrates an anterior wall myocardial infarction. Which of the patient's home medications serves as a contraindication for the use of nitroglycerin to treat his chest pain?
Sildenafil
A 70-year-old woman with a history of hypertension presents to the emergency department with a complaint of abdominal pain. On physical examination, there is a pulsatile mass in the midline of her abdomen. Which of the following is the most common risk factor for the development of this condition?
Smoking
Which of the following is recommended for the treatment of systolic heart failure according to New York Heart Association (NYHA) functional class?
Spironolactone for NYHA class III-IV heart failure and ejection fraction < 35%
A 32-year-old man presents to the emergency department with palpitations and occasional non-exertional chest pain. Physical examination reveals a tall, thin man with pectus excavatum. A late systolic murmur with a midsystolic click is heard on auscultation. Which of the following maneuvers will result in movement of the click later into systole?
Squatting
A 24-year-old woman with no past medical history presents with left wrist pain after a fall. The left extremity is grossly deformed, and the patient complains of severe pain. The patient has a blood pressure of 183/100 mm Hg. What management is indicated for the patient's elevated blood pressure while awaiting X-rays?
Treat the patient's pain and reassess the blood pressure
Which of the following murmurs is associated with an increase in right atrial pressure?
Tricuspid regurgitation
A detailed history and examination does not aid in the evaluation of new-onset hypertension in a 47-year-old man. In an attempt to search for an underlying cause, you order a basic metabolic panel, complete blood count, lipid panel and ECG. Which of the following tests should also be added to this standard diagnostic screen of secondary hypertension?
UA
Which of the following statements is most accurate regarding acute ischemic heart disease?
Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation
A 55-year-old man with no history of atherosclerotic cardiovascular disease or diabetes mellitus presents to your office with questions about his cholesterol. He was previously taking atorvastatin, but stopped because his fasting low-density lipoprotein (LDL) cholesterol level dropped to 90 mg/dL and he was following the lifestyle modifications you previously recommended. Based on the 2018 American College of Cardiology/American Heart Association cholesterol management guidelines, which of the following is the most appropriate next step in his management?
Use a cardiovascular risk calculator to determine the patient's 10-year risk for atherosclerotic cardiovascular disease
A 76-year-old man with a history of hypertension presents after a syncopal event. He also reports decreased exercise tolerance over the last two months. He is currently asymptomatic. His ECG is normal sinus rhythm with no changes. On examination, he has a harsh systolic murmur that radiates to the carotid arteries. Which of the following is true about the most likely cause of his syncope?
Vasodilators and diuretics should be used with caution