Who am I - Cardio (week 2)

Important medications in treating heart failure because they decrease mortality

- ACE inhibitors - angiotensin II receptor blockers -spironolactone -and (usually) ß-blockers

What will increase murmur intensity associated with hypertrophic cardiomyopathy?

-Conditions that cause reduced ventricular volumes such as the valsalva, sudden standing, & tachycardia

Absolute contraindications for fibrinolytic use in STEMI

-Prior intracranial hemorrhage (ICH) -Known structural cerebral vascular lesion. -Known malignant intracranial neoplasm.Ischemic stroke within 3 months. -Suspected aortic dissection.Active bleeding or bleeding diathesis (excluding menses)

Signs of systolic cardiac dysfunction

-Reduced ejection fraction -increased end-diastolic volume -decreased contractility

Jugular venous distention is best seen in the neck when the bed is angled at?

45°

59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A. Anticoagulation B. Embolectomy C. Thrombolysis D. Inferior vena cava filter

A. Anticoagulation Anticoagulation is the treatment of choice in patients with pulmonary embolism with normal ventricular function and no absolute contraindications.

Which of the following studies is not usually required in the routine diagnosis and management of heart failure? A. Cardiac CT scanning B. ECG C. Chest radiography D. Echocardiography

A. Cardiac CT scanning However, cardiac CT scanning is usually not required in the routine diagnosis and management of heart failure, and echocardiography and MRI may provide similar information without exposing the patient to ionizing radiation.

A 48 year-old male presents to the ED with complaints of chest pressure, dyspnea on exertion, and diaphoresis that has been present for the last one hour. Electrocardiogram reveals normal sinus rhythm at 92/minute along with ST segment elevation in leads V3-V5. Initial cardiac enzymes are normal. What is the next most appropriate step in the management of this patient? A. Coronary artery revascularization B. Admission for medical management C. Administer lidocaine D. Administer nitrates

A. Coronary artery revascularization - STEMI = quick revascularization

Which of the following tests is generally the next step after clinical prediction rule results indicate that a patient has a low or moderate pretest probability of pulmonary embolism? A. D-dimer measurement B. Troponin level measurement C. Brain natriuretic peptide (BNP) measurement D. Activated partial thromboplastin time (aPTT) measurement

A. D-dimer measurement

A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A. Daily weights B. Daily spirometry C. Daily blood glucose D. Daily fat intake

A. Daily weights More weight = more water = worse HF = sad PAs Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure.

A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis? A. Heart failure B. Subacute bacterial endocarditis C. Pulmonary embolus D. Pneumonia

A. Heart failure Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure.

Which of the following is accurate regarding the workup of ACS? A. High-sensitivity cardiac troponin is more sensitive than creatine kinase isoenzyme (CK-MB) in detecting myocardial infarctions B. Echocardiography is routinely indicated as a first-line test for diagnosis of ACS C. Myoglobin levels alone may be used to detect ACS D. Normal ECG findings or ECG results that remain unchanged from the baseline exclude the possibility that chest pain is ischemic in origin

A. High-sensitivity cardiac troponin is more sensitive than creatine kinase isoenzyme (CK-MB) in detecting myocardial infarctions

A 23-year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Aortic stenosis C. Mitral regurgitation D. Pulmonic stenosis

A. Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining.

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? A. Leg swelling and pain with palpation of deep veins B. Heart rate > 100 C. Hemoptysis D. Past history of cancer

A. Leg swelling and pain with palpation of deep veins Leg swelling and pain with palpation of the deep veins are consistent with a DVT and increase the likelihood of a PE.

A 16-year-old male presents with complaint of syncope after basketball practice today. Physical examination reveals a systolic murmur along the left sternal border that increases with Valsalva maneuver. An electrocardiogram reveals left ventricular hypertrophy. Echocardiogram shows asymmetric left ventricular hypertrophy with a hypercontractile left ventricle. Which of the following is the initial medication of choice in this patient? A. Metoprolol (Lopressor) B. Cozaar C. Lisinopril (Zestril) D. Hydrochlorothiazide (Diuril)

A. Metoprolol (Lopressor) Beta-blockers are the initial drug of choice in a symptomatic patient with hypertrophic cardiomyopathy. Avoid nitrates and other drugs that decrease preload (eg, diuretics, ACE inhibitors, angiotensin II receptor blockers) because these decrease LV size and worsen LV function.

Which of the following is accurate about the etiology of ACS? A. Most cases of ACS occur from disruption of a previously nonsevere lesion B. Decreased blood glucose levels are risk factors for a major adverse cardiac event (MACE) in patients with suspected ACS C. ACS without elevation in demand typically excludes thrombosis or plaque hemorrhage D. Takotsubo syndrome only occurs in the presence of clinical coronary artery disease (CAD)

A. Most cases of ACS occur from disruption of a previously nonsevere lesion -Most cases of ACS occur from disruption of a previously nonsevere lesion (an atherosclerotic lesion that was previously hemodynamically insignificant yet vulnerable to rupture).

A 49-year-old female presents complaining of several episodes of chest pain recently. Initial ECG in the emergency department shows no acute changes. Two hours later, while the patient was having pain, repeat electrocardiogram revealed ST segment elevation in leads II, III, and AVF. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice in this patient? A. Nifedipine (Procardia) B. Metoprolol (Lopressor) C. Lisinopril (Zestril) D. Carvedilol (Coreg)

A. Nifedipine This patient is most likely having coronary artery spasm. This can be treated prophylactically with calcium channel blockers such as nifedipine.

n which of the following categories of patients do AHA/ACC guidelines indicate ICDs? A. Patients with symptomatic documented hemodynamically unstable ventricular tachycardia with an LVEF < 40% B. Patients who have no history of prior rhythm problems with an LVEF of 40% C. Patients who are asymptomatic (NYHA class I) with an LVEF of 35% D. Patients who are newly diagnosed with an LVEF of 35% 10 days post-MI

A. Patients with symptomatic documented hemodynamically unstable ventricular tachycardia with an LVEF < 40%

A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test's mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis? A. Right ventricular failure B. Pericarditis C. Exacerbation of COPD D. Cirrhosis

A. Right ventricular failure Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites.

Contraindications to beta blockade following an acute myocardial infarction include which of the following? A. Third degree A-V block B. Sinus tachycardia C. Hypertension D. Rapid ventricular response to Atrial fibrillation/flutter

A. Third degree A-V block Bad juju (BB CI in 2nd & 3rd block)

Eliciting a history from a patient presenting with dyspnea due to early heart failure the severity of the dyspnea should be quantified by A. amount of activity that precipitates it. B. how many pillows they sleep on at night. C. how long it takes the dyspnea to resolve. D. any associated comorbidities.

A. amount of activity that precipitates it.

What chambers are affected in dilated cardiomyopathy? A. enlargement and dilation of all four chambers B. enlargement and dilation of the left ventricle C. enlargement and dilation of the right ventricle D. enlargement and dilation of the right atrium

A. enlargement and dilation of all four chambers

What is the diagnostic study of choice for pulmonary hypertension? A. right heart catheterization B. spirometry C. chest X-ray D. echocardiography

A. right heart catheterization Gold !!!!

A patient who cannot tolerate angiotensin-converting enzyme inhibitors should be prescribed what class of medication?

Angiotensin receptor blockers (ARB)

Q waves and ST elevation in leads *I, AVL, and V2 to V6*

Anterior wall infarction

Anginal chest pain is most commonly described as which of the following? A. Pain changing with position or respiration B. A sensation of discomfort C. Tearing pain radiating to the back D. Pain lasting for several hours

B. A sensation of discomfort Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes, described as dull, aching or pressure.

A 72-year-old female is being discharged from the hospital following an acute anterolateral wall myocardial infarction. While in the hospital the patient has not had any dysrhythmias or hemodynamic compromise. Which of the following medications should be a part of her discharge medications? A. Warfarin (Coumadin) B. Captopril (Capoten) C. Digoxin (Lanoxin) D. Furosemide (Lasix)

B. Captopril (Capoten) -ACE inhibitors have been shown to decrease left ventricular hypertrophy and remodeling to allow for a greater ejection fraction.

Which of the following medications should be avoided in patients with hypertrophic obstructive cardiomyopathy? A. Aspirin B. Digoxin C. Disopyramide D. Acetaminophen E. Atenolol

B. Digoxin

A 50-year-old male with history of alcohol abuse presents with complaint of worsening dyspnea. Physical examination reveals bibasilar rales, elevated jugular venous pressure, an S3 and lower extremity edema. Chest x-ray reveals pulmonary congestion and cardiomegaly. Electrocardiogram shows frequent ventricular ectopy. Echocardiogram shows left ventricular dilatation and an ejection fraction of 30%. Which of the following is the most likely diagnosis in this patient? A. Hypertrophic cardiomyopathy B. Dilated cardiomyopathy C. Restrictive cardiomyopathy D. Takotsubo cardiomyopathy

B. Dilated cardiomyopathy Dilated cardiomyopathy is often caused by chronic alcohol use. It is characterized by signs and symptoms of left-sided heart failure, a dilated left ventricle and decreased ejection fraction.

During an inferior wall myocardial infarction the signs and symptoms of nausea and vomiting, weakness and sinus bradycardia are a result of what mechanism? A. Increased sympathetic tone B. Increased vagal tone C. Activation of the renin-angiotensin system D. Activation of the inflammatory and complement cascade system

B. Increased vagal tone - increased vagal tone is common in inferior wall MI, if SA node is involved bradycardia may develop

A 59-year-old male with history of hypertension and dyslipidemia presents with complaint of substernal chest pain for two hours. The pain woke him from sleep, does not radiate, and is associated with nausea and diaphoresis. Electrocardiogram reveals ST segment elevation in leads II, III, and AVF. Which of the following walls of the ventricle is most likely at risk? A. Anterior B. Inferior C. Lateral D. Posterior

B. Inferior

A 63 year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis? A. Aortic dissection B. Inferior wall myocardial infarction C. Acute pericarditis D. Pulmonary embolus

B. Inferior wall myocardial infarction - presents with chest pressure and associated N/V. ST segment elevation in leads II, III, and aVF are classic findings in inferior wall MI

Which of the following statements is accurate about physical examination findings in patients with pulmonary emboli? A. Temperature in excess of 103° F is common in patients with pulmonary emboli B. Tachypnea is among the most common physical signs of pulmonary emboli C. Chest wall tenderness as the sole physical finding indicates a cause other than pulmonary embolism D. Patients with massive pulmonary embolism display signs of systemic hypertension

B. Tachypnea is among the most common physical signs of pulmonary emboli

A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation? A. Ventilation perfusion (V/Q) scan B. Ultrasound of the legs C. Echocardiography D. D-dimer

B. Ultrasound of the legs In a patient with a high likelihood of pulmonary embolism or an inpatient, as in this case, ultrasound of the legs would be the next diagnostic step after a nondiagnostic CT.

Which of the following is accurate about the treatment of pulmonary embolism? A. Thrombolytics are the treatment of choice in most children with pulmonary emboli B. When possible, thrombolytic therapy should be used in patients with acute pulmonary embolism associated with hypotension C. Most patients with acute pulmonary embolism should receive IV unfractionated heparin (UFH) instead of low-molecular-weight heparin (LMWH) D. Subcutaneous (SC) UFH is preferred to fondaparinux in patients with acute pulmonary embolism

B. When possible, thrombolytic therapy should be used in patients with acute pulmonary embolism associated with hypotension

What is the most common cause of non-ischemic DCM in the US? A. HTN B. chronic alcoholism C. viral myocarditis D. genetic predisposition

B. chronic alcoholism Chronic alcoholism is the most common cause of non-ischemic cardiomyopathies in the US. Ischemic cardiomyopathy is the #1 cause of dilated cardiomyopathy and more than 60% of patients with heart failure have this.

A 60 year-old male with history of hypertension and hyperlipidemia presents with intermittent chest heaviness for one month. The patient states he has had occasional heaviness in his chest while walking on his treadmill at home or shoveling snow. He also admits to mild dyspnea on exertion. His symptoms are relieved with 2-3 minutes of rest. He denies lightheadedness, syncope, orthopnea or lower extremity edema. Vitals reveal a BP of 130/90, HR 70, regular, RR 14. Cardiac examination revealed a normal S1 and S2, without murmur or rub. Lungs were clear to auscultation. Extremities are without edema. EKG reveals no acute change and cardiac enzymes are negative. Which of the following is the most appropriate next diagnostic study? A. cardiac catheterization B. nuclear exercise stress test C. helical (spiral) CT D. transthoracic Echocardiogram

B. nuclear exercise stress test This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient.

n congestive heart failure the mechanism responsible for the production of an S3 gallop is A. contraction of atria in late diastole against a stiffened ventricle. B. rapid ventricular filling during early diastole. C. vibration of a partially closed mitral valve during mid to late diastole. D. secondary to closure of the mitral valve leaflets during systole.

B. rapid ventricular filling during early diastole. Rapid ventricular filling during early diastole is the mechanism responsible for the S3.

Recommended in all stages of chronic heart failure.

Beta-blockers

What hormone secreted by the ventricles can be used as a screening test for heart failure?

Brain natriuretic peptide (BNP)

A 68 year-old female comes to the office for an annual physical examination. Her past medical history is significant for a 40-pack year cigarette smoking history. She takes no medications and has not been hospitalized for any surgery. Family medical history reveals that her mother is living, age 87, in good health without medical problems. Her father is deceased at age 45 from a motor vehicle crash. She has two siblings that are alive and well. From this information, how many identifiable risk factors for cardiovascular heart disease exist in this patient? A. 0 B. 1 C. 2 D. 3

C. 2 - Age and smoking

A 48 year-old male with a history of coronary artery disease and two myocardial infarctions complains of shortness of breath at rest and 2-pillow orthopnea. His oxygen saturation is 85% on room air. The patient denies any prior history of symptoms. The patient denies smoking. Results of a beta-natriuretic peptide (BNP) are elevated. What should be your next course of action for this patient? A. Send him home on 20 mg furosemide (Lasix) p.o. every day and recheck in one week B. Send him home on clarithromycin (Biaxin) 500 mg p.o. BID and recheck in 1 week C. Admit to the hospital for workup of left ventricular dysfunction D. Admit to the hospital for workup of pneumonia

C. Admit to the hospital for workup of left ventricular dysfunction - dont send home with O2 sat at 885... thats silly... An elevated BNP is seen in a situation where there is increased pressure in the ventricle during diastole. This is representative of the left ventricle being stretched excessively when a patient has CHF. Sending a patient home would be inappropriate in this case.

Which of the following medication classes is contraindicated in a patient with variant or Prinzmetal's angina? A. Calcium channel blockers B. ACE inhibitors C. Beta blockers D. Angiotensin II receptor blockers

C. Beta blockers Use of a beta-blocker such as propranolol is contraindicated in Prinzmetal's angina. Beta blockers have been noted to exacerbate coronary vasospasm potentially leading to worsening ischemia.

Of the following, which is considered the more significant risk factor for pulmonary embolism? A. Hypercystinuria B. Mild bradycardia C. Hemolytic anemia D. Hypolipidemia

C. Hemolytic anemia

Which of the following is accurate regarding screening for coronary heart disease (CHD), according to American College of Physicians (ACP) guidelines? A. Cardiac screening improves patient outcomes, even in asymptomatic, low-risk adults B. The screening of asymptomatic, low-risk adults for cardiac disease should include resting or stress electrocardiography or echocardiography C. Low-risk adults should not be screened using stress myocardial perfusion imaging D. Individual risk factor measurements alone are sufficient to determine overall estimate of risk

C. Low-risk adults should not be screened using stress myocardial perfusion imaging

A 63 year-old male with history of hypertension and tobacco abuse presents complaining of dyspnea on exertion for two weeks. The patient admits to one episode of chest discomfort while shoveling snow which was relieved after five minutes of rest. Vital signs are BP 130/70, HR 68, RR 14. Heart exam reveals regular rate and rhythm, normal S1 and S2, no murmur, gallop, or rub. Lungs are clear to auscultation bilaterally. There is no edema noted. Which of the following is the most appropriate initial diagnostic study for this patient? A. Helical CT scan B. Chest x-ray C. Nuclear stress test D. Cardiac catheterization

C. Nuclear stress test In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease.

A 52-year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient? A. Coronary artery bypass grafting (CABG) B. Streptokinase C. Percutaneous coronary intervention (PCI) D. Warfarin (Coumadin)

C. Percutaneous coronary intervention (PCI) Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis.

Which of the following American College of Cardiology (ACC) and American Heart Association (AHA) stages do the majority of patients with heart failure fall under? A. Stage A B. Stage B C. Stage C D. Stage D

C. Stage C

Which of the following is the most likely presentation of an acute pulmonary embolism (PE) in a patient without preexisting cardiac or pulmonary disease? A. Anginal chest pain B. Cough C. Tachypnea D. Palpitations

C. Tachypnea Tachypnea is the most common symptom in acute PE.

What happens to the myocardium in restrictive cardiomyopathy? A. myocytes are injured and necrosis occurs with myocardial fibrosis when muscle cells fail they dilate B. hypertrophy of myocardial fibers and interstitial fibrosis C. The myocardium is infiltrated with abnormal tissue leading to impaired ventricular wall motion and abnormal contraction and relaxation

C. The myocardium is infiltrated with abnormal tissue leading to impaired ventricular wall motion and abnormal contraction and relaxation In restrictive cardiomyopathy the myocardium is infiltrated with abnormal tissue leading to impaired ventricular wall motion and abnormal contraction and relaxation

What population is most susceptible to RCM? A. women of northern African descent B. men of Asian descent C. men of northern European descent

C. men of northern European descent Although cardiomyopathy is a relatively common condition, restrictive cardiomyopathy, in which relaxation of the heart muscle is impaired, is the least common type. In the United States and in Europe, restrictive cardiomyopathy accounts for less than five percent of all cardiomyopathies. Men of northern European descent are the most susceptible to RCM.

Which of the following is an absolute contraindication to thrombolytic therapy in a patient with an acute ST segment elevation myocardial infarction? A. history of severe hypertension presently controlled B. current use of anticoagulation therapy C. previous hemorrhagic stroke D. active peptic ulcer disease

C. previous hemorrhagic stroke Dont kill the peoples... Absolute contraindications to thrombolytic therapy include a previous hemorrhagic stroke, a stroke within one year, a known intracranial neoplasm, active internal bleeding, and a suspected aortic dissection.

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis? A. atelectasis B. pneumothorax C. pulmonary embolism D. myocardial infarction

C. pulmonary embolism Risk factors for pulmonary embolism include advanced age, surgery and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.

Appears at 4-6 hours, peaks at 12-24 hours and *lasts for 3-4 days*

CK/CK-MB

Right-sided heart failure due to chronic lung disease

Cor pulmonale

Patient will present as → 65 y/o with 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate COPD. His PMH is relevant for a 40 pack-year smoking history, type II DM, hyperlipidemia, and coronary artery stenting 2 years ago. PE shows barrel-shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), the pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%.

Cor pulmonale Buz -progressive dyspnea, heptajugular reflux, pulsus paradoxus, HR, RR, O2 sat

An O2 saturation of 90% corresponds to what PO2 value? A. 90 mmHg B. 80 mmHg C. 70 mmHg D. 60 mmHg

D. 60 mmHg O2 sat values above 90% correspond with a PO2 >70 mmHg and values less than 94% represent hypoxemia. Less than 90% O2 sat warrants measurement of arterial blood gasses.

Which of the following should be avoided in patients with heart failure? A. Diuretics B. Digoxin C. Anticoagulants D. Calcium channel blockers

D. Calcium channel blockers The ACC/AHA guidelines advise that nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers, and most antiarrhythmic agents may exacerbate heart failure and should be avoided in most patients. NSAIDs can cause sodium retention and peripheral vasoconstriction and can attenuate the efficacy and enhance the toxicity of diuretics and ACE inhibitors.

A patient with which of the following is at highest risk for coronary artery disease? A. Congenital heart disease B. Polycystic ovary syndrome C. Acute renal failure D. Diabetes mellitus

D. Diabetes mellitus DM = CAD (hopefully this is type 2...)

Which of the following is accurate regarding treatment of ACS? A. In patients with complete vessel occlusion without collateralization of the infarct-related vessel, pushing nitrates is indicated B. Dual antiplatelet therapy with clopidogrel and aspirin is often used in patients with prior ischemic stroke C. Eptifibatide should typically be administered 12 hours or more before angiography D. Diagnostic angiography with intent to perform revascularization is indicated in patients with unstable angina/NSTEMI who have refractory angina or hemodynamic or electrical instability

D. Diagnostic angiography with intent to perform revascularization is indicated in patients with unstable angina/NSTEMI who have refractory angina or hemodynamic or electrical instability

Which of the following is accurate about the etiology of pulmonary emboli? A. Most pulmonary emboli originate in the pelvic, renal, or upper extremity veins B. Small thrombi typically travel less distally and are less likely to produce pleuritic chest pain C. Most pulmonary emboli are single D. The lower lobes of the lung are more commonly involved with emboli than the upper lobes

D. The lower lobes of the lung are more commonly involved with emboli than the upper lobes Pulmonary emboli usually arise from thrombi originating in the deep venous system of the lower extremities;After traveling to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise. Smaller thrombi typically travel more distally, occluding smaller vessels in the lung periphery. These are more likely to produce pleuritic chest pain by initiating an inflammatory response adjacent to the parietal pleura. most are multiple

A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains inactive the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis? A. Acute myocardial infarction B. Prinzmetal variant angina C. Stable angina D. Unstable angina

D. Unstable angina Pain in unstable angina is precipitated by less effort than before or occurs at rest.

Which of the following is accurate about the presentation of ACS? A. Exertional dyspnea due to ACS rarely resolves with pain and rarely improves with rest B. Hypertension typically indicates ventricular dysfunction due to myocardial ischemia C. Rales on pulmonary examination may suggest right ventricular dysfunction or aortic valve regurgitation D. Women may have coronary events more often without typical symptoms

D. Women may have coronary events more often without typical symptoms

Which of the following is not a cause of restrictive cardiomyopathy? A. hemochromatosis B. amyloidosis C. sarcoidosis D. asbestosis

D. asbestosis Amyloidosis, hemochromatosis and sarcoidosis are all causes of restrictive cardiomyopathy. Asbestosis is not a cause of restrictive cardiomyopathy.

A 58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is A. daily aspirin to prevent MI. B. nitrate therapy for the angina. C. aggressive risk factor reduction. D. referral for coronary artery revascularization.

D. referral for coronary artery revascularization. Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.

Which of the following is a cause of high output heart failure? A. myocardial ischemia B. complete heart block C. aortic stenosis D. thyrotoxicosis

D. thyrotoxicosis High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget's disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.

Pulmonary hypertension is defined as a mean pulmonary arterial pressure of A. ≥ 5 mm Hg B. ≥ 10 mm Hg C. ≥ 15 mm Hg D. ≥ 25 mm Hg

D. ≥ 25 mm Hg Blood pressure in the lungs is usually very low < 15 mm HG. In pulmonary hypertension the pressure increases > 25 mmHG at rest!

Restrictive cardiomyopathy occurs by what mechanism?

Depositing into or between the myocardial cells

Type of heart failure with a preserved ejection fraction

Diastolic heart failure

Heart failure resulting from the ventricles being unable to adequately fill with blood.

Diastolic heart failure.

An antiarrhythmic used to treat atrial flutter and atrial fibrillation in patients with heart failure.

Digoxin

Patient will present as → a 28-year-old Caucasian female complaining of a one-week history of fatigue, progressively worsening shortness of breath, and swelling of her feet and ankles. She denies any chest pain. Her past medical history is unremarkable except for a recent cold two weeks prior to this presentation. She denies any past surgical history. She takes oral contraceptive pills as her only medication. She denies any recreational drug use. On physical exam, her temperature is 37 C (98.6 F), blood pressure is 120/70 mmHg, pulse is 84/min, and respiratory rate is 20/min. Her physical exam is also notable for bibasilar crackles, jugular venous distension, an S3 gallop, and 2+ pitting edema up to the ankles bilaterally. Her electrolytes and complete blood count are within normal limits. CXR reveals cardiomegaly with pulmonary congestion, EKG shows nonspecific ST and T wave changes, and echocardiography demonstrates left ventricular dilation and dysfunction and low cardiac output.

Dilated Cardiomyopathy BUZZZ BUZZZZ - Fatigue, progressively worsening SOB, pedal edema 2+, recent cold, bibasilar crackles, jugular venous distension, S3 heard, cardiomegaly w/ congestion, left ventricular dilation & dysfunction, low cardiac outpt

The diagnosis of diastolic heart failure is best made with what study?

Doppler echocardiography

What is the best test for diagnosing CHF?

Echocardiogram

Once a patient is diagnosed with hypertrophic cardiomyopathy what family counseling must be done?

Entire family must be screened for hypertrophic cardiomyopathy

The most effective diuretic in the treatment of heart failure

Furosemide

Cardiac syndrome of cardiac pump dysfunction that involves dyspnea, orthopnea, and fatigue.

Heart failure

Angina syncope and heart failure in a child likely represents what???

Hypertrophic Cardiomyopathy

Patient will present as → a 25-year-old woman presents the ER after a syncopal episode. She had a loss of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and an III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage.

Hypertrophic Cardiomyopathy BUZZ LADIES - Syncopal episode, LOC x3 over past x12 months, systolic ejection murmur, decreases with squatting

Name the three inferior leads

II, III, and aVF

All drugs that have been shown to decrease mortality in heart failure have been shown to do so by?

Increased sympathetic stimulation and increased (hormone) aldosterone production

Q waves and ST elevation in leads *II, III, and AVF*

Inferior wall infarction

ST elevations in leads *I, AVL, and V5 to V6*

Lateral wall infarction

A blockage of which artery causes an anterior wall MI?

Left anterior descending

A blockage of which artery causes lateral wall MI?

Left circumflex artery

Patient present as → a 60-year old caucasian male with shortness of breath and fatigue on exertion. On physical exam, you note an S3 heart sound, crackles on pulmonary auscultation, and a displaced left apical impulse. He undergoes an echocardiogram and is found to have a dilated left ventricle and an ejection fraction of 35%.

Left ventricular heart failure Buzz buzz -SOB, fatigue on exertion, S3 , crackles, displaced left apical impulse, dilated left ventricle, EF <35

What is the most common cause of right-sided congestive heart failure

Left-sided congestive heart failure

An S3 heart sound on *expiration* most likely indicates what type of heart failure?

Left-sided heart failure

Associated with paroxysmal nocturnal dyspnea

Left-sided heart failure

Systolic heart failure is defined as having an ejection fraction of?

Less than 40%

Both decrease preload on the heart, but are not associated with improved survival in patients with congestive heart failure

Loop and thiazide diuretics

patient will present as → a 64-year-old man comes to the emergency department because of chest discomfort for the past 5 hours. When the patient is asked where the pain is located, he places a clenched fist to indicate a squeezing over his substernal region. The pain radiates to the neck, left shoulder, and left arm. His temperature is 36.8°C (98°F), pulse is 55/min, respirations are 17/min, and blood pressure is 117/78 mm Hg. The examination shows a diaphoretic male. ECG shows inverted U-waves in leads V5 and V6. The cardiac biomarker test shows an elevated concentration of troponin.

NSTEMI BUZZ BUZZZ - Chest discomfort for the past 5 hours, clenched fists to indicate squeezing over his substernal region, radiates to neck, left shoulder, left arm. EKG inverted U waves in V5-6. Elevated troponin

Patient will present as → a 58-year old obese male who is brought to the emergency department with severe substernal chest pain of one hour's duration. The patient was taking a morning walk when the onset of pain led him to seek care. His past medical history includes coronary artery disease, hyperlipidemia, and hypertension. Medications include aspirin, losartan, and atorvastatin. An electrocardiogram reveals T-wave inversions in leads II, III, and aVF and ST depressions in V5 and V6. The basic metabolic panel and complete blood count were within normal limits. A point-of-care troponin I level was elevated at 1.8 ng/mL (normal ≤ 0.06 ng/mL).

NSTEMI BUZZZZDY BUZZZ - severe substernal chest pain, PMH of coronary artery disease, hyperlipidemia, and hypertension, T-wave inversions in leads II, III, and aVF and ST depressions in V5 and V6. troponin I level was elevated at 1.8 ng/mL (normal ≤ 0.06 ng/mL).

Patient with acute crushing chest pain with evidence of myocardial necrosis (cardiac markers in blood; troponin I or troponin T and elevated CK) without acute ST-segment elevation or Q waves

Non-ST-Segment Elevation MI (NSTEMI)

List two types of surgical procedures to correct HOCM.

Open heart and excision - Alcohol ablation done through cardiac cath

GOLD STANDARD treatment best if within 3 hours (90 minutes) of sx onset of STEMI

PCI (Percutaneous Coronary Intervention)

Virchow's triad: hypercoagulable state, venous stasis, vascular injury. Tachycardia (most common)T changes, S1Q3T3 (Indicates cor pulmonale). Chest radiograph: Westermark's sign and Hampton's Hump - triangular infiltrate secondary to intraparenchymal hemorrhage

PE

Constrictive cardiomyopathy occurs by what mechanism?

Pericardial sac constricts

ST depressions and then elevations in *V1 to V3*

Posterior wall infarction

Coronary artery vasospasms causing transient ST segment elevations, not associated with clot

Prinzmetal variant angina

Which angina am I... Coronary artery vasospasms causing transient ST-segment elevations, not associated with clot

Prinzmetal variant angina

Patient will present as → a 65-year old man who presents to the ED at 1 am with 90 minutes of central chest pressure that awoke him from sleep. He says he thinks he has 'indigestion.' The pain is non-radiating, with mild shortness of breath but no nausea, vomiting or diaphoresis. He is an ex-smoker with a 20 pack-year history. There is no previous history of CAD, diabetes, hypertension or high cholesterol. On arrival, he looks well, with normal heart rate (54 bpm), blood pressure (127/86) and oxygen saturation (98% on room air). His pain has improved slightly with sublingual nitrates in the ambulance, although he still has some ongoing chest discomfort. His ECG is shown below. Troponins are positive. He is admitted to hospital and undergoes emergent cardiac catheterization, where he is without obstructive coronary disease, but his symptoms can be provoked with the administration of intravenous ergonovine.

Prinzmetal variant angina BUZZZZZ 90 min of central chest pressure that awake him, exsmoker, troponins are positive, sx provoked with IV meds

Patient will present as → 43 y/o F with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings (seen here) demonstrate peripheral "pruning" of the large pulmonary arteries.

Pulmonary HTN BUZZZZZZZZZ - Hx COPD, worsening dyspnea, widened splitting S2, prunung of large pulmonary arteries

Patient will present as → a 68-year-old woman who underwent hip replacement surgery two weeks ago. The postoperative period was complicated by pneumonia, and the patient has been bed-ridden ever since. A nurse calls you to the patient's room due to vital sign abnormalities and complaints of chest pain. The patient's HR is 105 bpm, BP is 90/60 mmHg, RR is 35 rpm, and T is 100.2F. You note jugular venous distension and profound dyspnea. Upon auscultation you notice tachypnea and crackles heard

Pulmonary embolism Buzz - bed-ridden, CP, 105BPM, RR 53

Patient will present as → a 58-year-old man complaining of several months of worsening shortness of breath and ankle swelling. He denies palpitations, lightheadedness, syncope, or chest pain. He has a past medical history significant for hereditary hemochromatosis. On physical exam, his temperature is 37 C (98.6 F), pulse is 78, blood pressure is 130/72 mm Hg, and respiratory rate is 16. He has elevated jugular venous pressure, diminished breath sounds at the lung bases, tender hepatomegaly, and bilateral pitting ankle edema. There are no murmurs, rubs, or gallops. EKG shows low-voltage QRS complexes without any signs of ischemia. His chest x-ray shows a normal-sized heart and bilateral pleural effusions. Echocardiography shows symmetrical thickening of the left ventricle, normal left ventricular volume, and mildly reduced systolic function.

Restrictive Cardiomyopathy - Worsening SOB, ankle swelling, PMH hemochromatosis, elevated jugular venous pressure, diminished breath sounds, tender hepatomegaly, bilateral pitting ankle edema, low voltage QRS complexes, bilateral pleural effusion, symmetrical thickening of left ventricle, normal LV volume, mildly reduced systolic function

Patient present as → a 64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes with increasing shortness of breath and ankle swelling over the past month. On physical examination, you note jugular venous distention, increased hepatojugular reflex, and hepatomegaly. His lungs are clear to auscultation.

Right ventricular heart failure Buzz - SOB, ankle swelling, JVD, hepatojugular reflex. hepatomegaly, clear to auscultation

What type of heart failure is associated with dependent, pitting edema and jugular venous distention are classic signs

Right-sided congestive heart failure

Heart failure is associated with hepatomegaly

Right-sided heart

An S3 heart sound on *inspiration* most likely indicates what type of heart failure?

Right-sided heart failure

Dilated cardiomyopathy is associated with what heart sound?

S3 Heart Sound

What heart sound will likely be present with hypertrophic cardiomyopathy?

S4

Substernal chest pain radiating to the neck and arm with ST segment elevations > 1mm in > 2 contiguous leads on ECG and evidence of myocardial necrosis (cardiac markers in blood; troponin I or troponin T and elevated CK)

ST-Segment Elevation Myocardial Infarction (STEMI)

Patient will present as → a 70-year-old male complaining of left-sided crushing substernal chest pain that began suddenly while he was walking his dog. He denies any past medical history, has not seen a physician recently and has smoked one pack per day for the past 50 years. Vital signs are BP 85/50 mmHg, HR 50 bpm, RR 22, T 99.1 deg F. Physical exam shows an obese, nervous man with jugular venous distension and clear lung fields. An electrocardiogram (seen here) shows ST elevations in II, III, and aVF. The echocardiogram showed marked motion abnormalities in the inferior posterior, lateral wall. An initial troponin I was 238 ng/ml (normal range 0-2.5 ng/ml). The patient was taken for emergent cardiac catheterization. This demonstrated an occluded right coronary artery that was opened with primary angioplasty and stent placement.

STEMI BUZZZ - left-sided crushing substernal CP, smoking, ST elevations in II, II, aVF, troponin high, occluded right coronary artery

patient will present as → a 60-year-old man is brought to the emergency department because of crushing substernal chest pain for the past 45 minutes. He received 325 mg of aspirin en route. Nitroglycerin does not relieve his pain. He has a history of diabetes and hypertension. Medications include carvedilol and sildenafil. His temperature is 36.8°C (98°F), pulse is 99/min, respirations are 18/min, and blood pressure is 192/88 mm Hg. He appears diaphoretic. ECG shows ST-segment elevation in leads V1, V2, and V3.

STEMI BUZZZZ -crushing substernal chest pain, blood pressure is 192/88, diaphoretic. ECG shows ST-segment elevation in leads V1, V2, and V3.

A drug that affects the renin-angiotensin-aldosterone system. It limits cardiac remodelling in heart failure and is additive to the positive effect of ACE inhibitors.

Spironolactone

Chest pain or discomfort that most often occurs with activity or emotional stress *relieved by rest*

Stable angina

Which angina am I... Predictable, relieved by rest and/or nitroglycerine

Stable angina

Patient will present as → a 50-year-old woman with a history of hyperlipidemia and diabetes type 2 complaining of "chest pain attacks." She says that these attacks tend to occur while walking up five flights of stairs to get to her apartment, they last for 15-20 minutes and are relieved by rest. She describes the pain as sharp and substernal. A baseline EKG is unremarkable. Suspecting the diagnosis, you perform an exercise stress EKG and observe transient ST depressions in the anterolateral leads after significant exertion.

Stable angina BUzz buzz - hx of HDL & DM2, chest pain attacks, walking up stairs, rest relieves, transient ST depression

A type of congestive heart failure that is commonly secondary to ischemic heart disease or dilated cardiomyopathy

Systolic dysfunction

Appears at 2-4 hours, peaks 12-24 hours and *lasts for 7-10 days*

Troponin

Chest pain or discomfort that most often occurs with activity or emotional stress. Previously stable and predictable symptoms of angina that are more frequent, increasing or *present at rest*

Unstable angina

Which angina am I... Previously stable and predictable symptoms of angina that are more frequent, increasing or present at rest

Unstable angina

Patient will present as → a 58-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia who presents to an emergency department for evaluation of chest pain. He reports somewhat suddenly experiencing dull left-sided chest discomfort while at rest at home that was not relieved with taking nitroglycerin. His vital signs are T 37.1, HR 94 beats per minute, BP 133/87, and O2 saturation 97% on room air. His ECG shows no ST-segment changes; serum troponin is not elevated. His chest pain subsequently resolves and he is admitted to the cardiac service for further management.

Unstable angina Buuzzzzz - Hx of CAD, HTN, HDL, chest discomfort while at rest, not better with nitro, no ST segment changes, troponin normal

Which EKG leads are used to diagnose an anterolateral MI?

V5 and V6

What maneuver makes the hypertrophic cardiomyopathy murmur louder?

Valsalva or standing

What causes the sudden cardiac death in a Hypertrophic Cardiomyopathy?

Ventricular tachycardia that degenerates into ventricular fibrillation

What is the definition of cardiomyopathy?`

heart disease resulting from a primary abnormality in the myocardium

Patient presents to ED in acute CHF. What drug class will likely be first choice?

loop duiretics