UW Buzzwords - Step 2 CK
Which type of AMI is associated with an increased risk of arterial embolism?
Anterior wall MI
EKG finding of digitalis toxicity
Atrial tachycardia with AV block
Young black, dyspnea on exertion, harsh diamond shaped systolic murmur best heard at the left lower sternal border, left ventricular hypertrophy, asymmetrical septal hypertrophy. What is the inheritance of this disease?
Autosomal dominant (hypertrophic cardiomyopathy).
Premature atrial beats
Benign, neither require any follow up nor treatment.
First week after MI, advanced age, large Q wave infarct, hypotensive, pulse is not palpable, EKG shows tachycardia, blood pressure drops with inspiration, heart sounds are inaudible.
Cardiac tamponade due to free left ventricular wall rupture.
Fibrillatory waves and absence of regular QRS (ventricular fibrillation). The next step in management is?
Defibrillation, 200-360 joules.
Middle age or older male, loses his consciousness after urination/coughing.
Situational syncope
What would the administration of lidocaine to a patient with ventricular premature beats (VPBs) most likely result in?
Increase in the risk of asystole.
Fever, chills, weakness, and/or a new onset murmur of a patient who has undergone genitoruinary instrumentation, has a history of IV drug abuse, or a history of prosthetic valves.
Infective endocarditis
A patient who is hypotensive receives fluid and pressor support. Later, he is found to have all digits blue. Most likely cause?
Norepinephrine
The earliest EKG finding in acute MI
Peaked (hyperacute) T waves, followed by ST segment elevation, followed by the inversion of T waves, followed by the appearance of Q waves.
Decreased right atrial pressure/pulmonary capillary wedge pressure (PCWP, 6-12 mmHg), normal mixed venous oxygen concentration (MVo2, 15.5 vol%), elevated cardiac output
Septic shock
Which abnormality is most likely to be present in cases of restrictive cardiomyopathy?
Severe diastolic dysfunction
Which antihypertensive medication is best for patients with osteoporosis?
Thiazide diuretics (decrease in the urinary calcium excretion).
Diastolic and continuous murmurs or loud systolic murmurs. What is the next best step in the management?
Transthoracic Doppler echocardiograhy
Saw tooth EKG > 48 hours -> Chronic stable atrial flutter
Treat with rate control, calcium channel blockers (verapamil or diltiazem) or beta-blockers.
A patient of chronic aortic regurgitation (high-pitched diastolic decrescendo murmur heard best in the left third intercostal space, bounding pulse) develops symptoms of LV dysfunction (pulmonary edema). Most appropriate next step management?
Use of diurectics, digoxin, and vasodilators (ACE inhibitors).
The most effective way to screen a low risk population for the presence of underlying cardiac disease.
A detailed medical history and physical examination.
A pulsatile non-tender mass above umbilicus, history of MI and hypertension. Which step is the most appropriate in the management?
Abdominal ultrasound (abdominal aortic aneurysum).
Heart failure, thrombocytopenia, macrocytosis, and elevated transaminases -> alcoholic dilated cardiomyopathy. What measure is the most likely to reverse the heart failure?
Abstinence from alcohol.
Intensive retrosternal pain that radiates to the back of the chest, normal EKG, hypertension, early diastolic murmur (aortic regurgitation). What is the best step in the management?
Aortic dissection, transesophageal echocardiography is diagnositic.
Recurrent chest pain after acute MI, worsened by breathing and improved by leaning forward, presence of a pericardial friction rub and diffuse ST segment elevation that is concave upwards.
Acute pericarditis
Tachypnea, breathless, bilateral diffuse alveolar infiltrates with prominent air bronchograms and normal heart size and sounds, alcoholic, acute pancreatitis. What is the most likely diagnosis?
Acute respiratory distress syndrome due to acute pancreatitis.
Antibiotic prophylaxis for infective endocarditis (IE) is recommended for high-risk conditions:
All prosthetic heart valves. Any history of previous bacterial endocarditis. Complex cyanotic congenital heart disease and surgically constructed systemic pulomonary shunts.
Indications for aortic valve replacement
All symptomatic patients with AS; Patients with severe AS undergoing CABG or other valvular surgery; Asymptomatic patients with severe AS and either poor LV systolic function, LV hypertrophy > 15 mm, valve area < 0.6 cm2 or abnormal response to exercise.
Which medications should be withheld before exercise EKG testing?
Anti-ischemic drugs, digoxin, medications that slow the heart rate (e.g., beta blockers).
Tearing or ripping chest pain radiating to the back, a difference in the pulse rate or blood pressure between the two arms.
Aortic dissection, transesophageal echocardiogram (TEE) or thoracic CT with IV contrast are diagnostic.
Chest pain on exertion, loud systolic ejection murmur heard along the left sternal border, soft S2, point of maximal impulse is displaced downwards and laterally. What step would you take next?
Aortic stenosis angina, Order an echocardiogram to differentiate from ischemic angina.
Increased intensity of apical impulse, narrow pulse pressure, systolic murmur at the base of the heart, elderly
Aortic stenosis due to age-related sclerocalcific changes
Middle age adult, ejection systolic murmur radiating to the neck, best heard at the right second intercostal space. What is most likely the cause of this patient's abnormal findings?
Aortic stenosis due to bicuspid aortic valves.
Orthopnea (breathlessness worse while lying flat), S3, bibasilar crackles, elevated JVP, low extremity edema, hepatomegaly, history of COPD. Which marker is most likely elevated?
B-type Natriuretic Peptide (BNP), which can help distinguish between CHF and other causes of dyspnea (e.g., COPD).
Elderly, orthostatic syncope upon getting up in the morning, mucosal dryness, diarrhea, decreased appetite, diuretic therapy. Which lab value is the most sensitive indicator of the patient's underlying condition?
BUN/creatinine ratio (Dehydration).
Palpitations, lightheadedness, insomnia, fatigability, weight loss, ECG shows atrial fibrillation. What is the next best step in the management?
Beta blocker (hyperthyroidism-related tachysystolic atrial fibrillation)
Dyspnea, S4, normal cardiac size, normal ejection fraction, and normal left ventricular end diastolic volume -> isolated left ventricular diastolic dysfunction due to hypertrophic cardiomyopathy.
Beta blockers
Mid systolic click with late systolic crescendo-decrescendo murmur. Click and murmur occurs earlier with Valsalva maneuver and it disappears with squatting. Normal EKG. What is the best therapy?
Beta blockers (mitral valve prolapse).
Stable angina, hypertension. What is the best medication?
Beta blockers, increasing the threshold for the development of an anginal episode and control the hypertension.
Which antihypertensive medicine reduces the risk of perioperative mortality in patients at risk for coronary heart disease?
Beta-blockers
Massive upper GI bleed, chest pain radiating to left arm, cardiac enzymes are normal. What is the most appropriate next step in the management?
Blood transfusion (unstable angina due to anemia).
MRI shows an aortic aneurysm distal to the left subclavian artery in a young male. What is the most likely cause?
Blunt trauma from motor vehicle accident.
Which biomarker of cardiac injury can establish the diagnosis of re-infarction?
CK-MB
Rib notching, a "3" sign on the chest x-ray.
Coarctation of aorta
Young male, venous track marks, EKG changes of myocardial ischemia
Cocaine intoxication, treat with benzodiazepines along with aspirin and nitrates.
Difficulty walking, pain is relieved with rest. Which medication is the best choice to control this patient's hypertension?
Calcium channel blockers (e.g., amlodipine) are preferred as antihypertensive drugs in patients with peripheral vascular disease.
Severe chest pain radiating to left shoulder, not relieved by nitroglycerine. Which drug does not improve survival in this patient?
Calcium channel blockers (e.g., nifedipine) do not improve survival in patients with acute MI.
Which medication should patients with unstable angina/non-ST elevation MI (UA/NSTEMI) or post PCI (percutaneous coronary intervention) be taking after discharge?
Clopidogrel
What effect of dipyridamole helps in making the diagnosis of angina pectoris?
Coronary steal, the redistribution of the coronary blood flow to 'non-diseased' segments.
Chest pain alleviated by leaning forward and worsened by coughing and deep breathing, history of URI, pericardial friction rub. What is the most likely cause of these symptoms?
Coxsackie virus (acute pericarditis).
Antepartum hemorrhage, placenta previa (hypovolemic or hemorrhagic shock)
Decreased cardiac output (CO), decreased central venous pressure (or PCWP) -> increased systemic vascular resistance (SVR), increased HR, decreased BP (fail to return to baseline).
Antibiotic prophylaxis for infective endocarditis (IE) is recommended both in high-risk and moderate-risk patients for these procedures:
Dental procedure with bleeding. Respiratory procedures like rigid bronchoscopy and operations involving mucosa. Genitoruinary tract procedures like prostatic surgery, cystoscopy and urethral dilatation.
A patient congestive heart failure and AF. What is the most appropriate next step treatment
Digoxin, slowing down AV conduction and positive inotropic effect, or anticoagulate, reducing the morbidity and mortality associated with AF.
Fatigue, shortness of breath, swelling of feet, bilateral basal crackles, elevated jugular venous pressure, recent cold in an otherwise healthy patient. Transthoracic echocardiogram of heart will most likely show?
Dilated ventricles with diffuse hypokinesia (dialted cardiomyopathy due to acute viral myocarditis).
What is the most important mechanism responsible for pain relief in patients with anginal pain treated with nitroglycerin?
Dilation of veins (capacitance vessels) and decrease in ventricular preload.
Uncontrolled hypertension, oral contraceptive use. What is the most appropriate next step?
Discontinuation of the oral contraceptive.
Acute heart failure resulting in pulmonary edema in acute infero-lateral MI. Most beneficial next step.
Diuretics (furosemide), rapid relieving the pulmonary edema
Young patient with chest pain/myocardial infarction or stroke, agitation, dilated pupils, decreased appetite, sweating.
Drug induced vasospasm (cocaine intoxication)
A patient with an MI who develops a cold leg. What should be considered besides vascular surgery consult?
ECHO to rule out a thrombus in the left ventricle.
Chest pain, dyspnea, syncope, high-pitched mid-systolic murmur heard at the second intercostal space and radiates to the neck. What is the most appropriate modality to confirm the diagnosis?
Echocardiography
ST elevation MI, most appropriate next step management
Emergency PTCA within one hour.
Exertional substernal chest pain radiating to the left arm. Pain relieved with rest or nitroglycerine. Which investigation is the most appropriate next step?
Exercise stress testing/Stress EKG or an exercise echocardiogram (stable angina).
An apical pansystolic murmur (PSM) radiating to the axilla, shortness of breath, bibasilar rales after acute anterior wall MI. What is the most likely explanation for this patient's deterioration?
Mitral regurgitation due to papillary muscle dysfunction or rupture.
A tapping apex beat, a loud first heart sound, a mid-diastolic rumble at the apex, rheumatic fever history.
Mitral stenosis.
What is the most likely cause of mitral regurgitation?
Mitral valve prolapse
A mid or late systolic click that occurs earlier with maneuvers that decrease left ventricular volume such as Valsalva and standing.
Mitral valve prolapse (MVP)
Narrow QRS, progressive increase in PR interval until a ventricular beat is dropped.
Mobitz type I heart block
Which arrythmia requires treatment?
Mobitz type II AV block. Can progress to complete heart block, atropine must be available until a permanent pacemaker is inserted.
Antibiotic prophylaxis for infective endocarditis (IE) is recommended in high-risk patients for these procedures:
Gastrointestinal procedures like sclerotherapy of varices, gastrointestinal surgery involving mucosa, biliary tract surgery, esophageal stricture dilatation and ERCP in the presence of obstruction.
Metabolic side effects of thiazide diuretics
Hyperglycemia, increased LDL cholesterol and plasma triglycerides, hyponatremia, hypokalemia, and hypercalcemia.
Most common cause of sudden cardiac death in young athletes
Hypertrophic cardiomyopathy
Young adult, repeated chest pain on exertion, III/IV systolic murmur along the left sternal border, left ventricular hypertrophy. What is the most appropriate pharmacological treatment?
Hypertrophic cardiomyopathy, beta-blockers are the first line of medication.
Ventricular tachycardia (regular, wide complex tachycardia), stable blood pressure. What is the next best step?
IV amiodarone or lidocaine.
Biventricular failure (ankle swelling, difficulty breathing, S3), arrhythmia, excessive fatigue, history of a flu-like illness.
Idiopathic dilated cardiomyopathy due to Coxsackie's B virus infection.
Acute ST segment elevation MI, history of hemorrhagic stroke. Which step is the most appropriate in the management?
Immediate coronary angiography and PTCA
High-pitched, harsh ejection systolic murmur heard at the second right intercostal space and radiates to the neck. What is the most appropriate next step?
Infective endocarditis prophylaxis and regular follow ups (aortic stenosis even if asymptomatic).
High-pitched pansystolic murmur at the apex that radiates to the axilla. What is the most likely cause of this valvular dysfunction?
Isolated mitral regurgitation due to mitral valve prolapse.
Which statement about the BP control in a patient with diabetes and chronic renal failure?
Keep systolic pressure < 130 mmHg to slow end-organ damage.
What is the most useful diagnostic finding for ventricular septal rupture in the setting of acute MI?
Left to right shunt.
Hypertension and hypokalemia. What is the most appropriate next step?
Measure plasma renin activity and serum aldosterone concentration (primary hyperaldosteronism)
Recurrent ventricular tachycardia in a patient with CHF, taking digoxin and furosemide. The patient has received amiodarone and now is stable. What is the most important next step in the management?
Measure serum electrolytes (electrolyte imbalance due to diuretics and digoxin toxicity).
Sudden retrosternal pain after PE treated with warfarin, mediastinum widening, ultrasound is negative for pericardial fluid.
Mediastinal hemorrhage
ST depression, T wave inversion, angina of recent onset, angina at rest, accelerated angina, post-infarct angina, post-revascularization angina, failure to resolve with increasing doses of nitroglycerin -> unstable angina.
Should be hospitalized and treated with aspirin, IV heparin, and IV nitroglycerin.
Lower extremity edema, hypertension treated with amlodipine, normal physical exam and normal lab. What is the most likely cause of the edema?
Side effect of amlodipine (dihydropyridine calcium channel blockers).
III AV block. The next step in management?
Permanent pacemaker, atropine should always be available at the bedside.
Cutaneous flushing and intensive generalized pruritis after taking niacin. What is the most probable cause of the complaint?
Prostaglandin-induced peripheral vasodilatation, can be reduced by low-dose aspirin.
Normal pressure range
RAP <5, RVP < 25/5, pulmonary atery pressure (PAP) < 25/10, PCWP <12, LAP <12, LVP <130/10, AAP < 130/90.
What is the most common cause of death in patients with acute myocardial infarction?
Reentrant ventricular arrhythmia (ventricular fibrillation), reentry is the pathophysiologic mechanism.
Dyspnea, ankle edema, bibasilar crakles, symmetrical thickening of left ventricular walls, normal pericardial thickness.
Restrictive cardiomyopathy. With constrictive pericarditis, chest x-ray may show pericardial calcifications and the CT scan usually shows increased thickness of pericardium.
Acute inferior wall MI, hypotension (right ventricular infarction), bradycardia. What is the most likely mechanism?
Right coronary artery occlusion
IV drug abuser, high fever/chills, heart murmur, painful erythematous nodules on the pulp of fingers. What is the most likely organism responsible for this illness?
Staphylococcus aureus (Infective endocarditis).
Low-grade fever, malaise, pleuritic chest pain, neck pain, fatigue two-to-four weeks after an MI. ECG reveals non-specific ST elevations. What is the next step?
Start NSAIDs (Dressler syndrome).
HR > 140/min, regular, loss of 'P' waves and narrow QRS complex
Supraventricular tachycardia. If the patient is stable, vagal maneuvers then IV adenosine push. If unstable, electrical cardioversion.
Most common cause of aortic dissection
Systemic hypertension
What is the most likely mechanism of mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy?
Systolic anterior motion of mitral leaflet
Severe chest pain, dyspnea, lower extremity edema, point of maximal apical impulse displaced to the left, holosystolic apical murmur, history of MI, non-compliance with the treatment regimen.
Systolic heart failure, depressed cardiac index (CI), increased total peripheral resistance (TPR), and increased left ventricular end-diastolic volume (LVEDV).
Tearing pain with radiation to the back and a difference in BP of greater than 30 mmHg between two arms (acute aortic dissection). Most appropriate diagnostic step?
Transesophageal echocardiography or chest CT
Rapid ventricular tachycardia, varing QRS morphology with prolonged QT. What is the most likely cause of this arrythmia?
Torsades de pointes (polymorphic ventricular tachycardia), caused by Quinidine. Magnesium replacement is the treatment.
Immigrant, fatigue, dyspnea, elevation of jugular venous pressure, reduced heart sound, pedal edema. What is the most likely cause for this patient's symptoms?
Tuberculosis (constrictive pericarditis)
Ischemic chest paint only partially relieved by nitroglycerin, T wave inversion in the anteroseptal leads and negative cardiac enzymes.
Unstable angina, treat with IV heparin, aspirin, beta-blocker, and nitroglycerin.
Chest pain, SOB, hypoxia, new onset right bundle branch block (RBBB). What is the next step?
V/Q scan (pulmonary embolism). Anticoagulant therapy takes precedence over any diagnostic test.
Recurrent syncopal episodes, prodrome (lightheadedness, weakness, and blurred vision), provocation by an emotional situation, rapid recovery of consciousness.
Vasovagal syncope (common faint), neurally mediated or neurocardiogenic syncope, upright tilt table testing to confirm the diagnosis.
For urethral catheterization, uterine D&C, therapeutic abortion, sterilization or insertion or removal of IUD,
prophylaxis is recommended only when an infection is present.
