CV

What are the 3 holosystolic murmurs?

Tricuspid regurgitation Mitral regurgitation Ventral septal defect

Preferred anticoagulant for CKD, CAD, dyspepsia or h/o GI bleeding is ______

Warfarin

Drugs used in hyperkalemia that help drive excess potassium intracellularly.

insulin (with glucose), beta-2 agonists such as albuterol and sodium bicarbonate.

A 23-year-old woman presents with acute onset dizziness and palpitations. Her ECG reveals evidence of AV nodal reentrant tachycardia with a rate of 170. Her blood pressure is 140/70 mm Hg. Which of the following is the most appropriate initial treatment? AAdenosine BCardioversion CValsalva maneuver DVerapamil

C

During a well-child visit, a 9-year-old boy and his father ask about health safety and sports activity. The boy wants to play baseball. His medical history is significant for tetralogy of Fallot, which was surgically corrected when he was 3-years-old. His last echocardiogram shows a right ventricular pressure to be < 50 mm Hg. Which of the following recommendations do you make? AA functional capacity evaluation is needed first BHe may only play leisure sports, like golf or cycling CIt is safe for him to play any sport, including baseball DThe boy should abstain from all sports and physical education class

C Physical activity limitations may be recommended for children with a past history of congenital heart disease. There are no restrictions on any sport activity, including competition and contact sports, in patients who have had surgical correction of tetralogy of Fallot and whose right ventricular pressure is < 50 mm Hg.

A woman presents with dyspnea on exertion. Cardiac examination reveals an apical mid diastolic murmur. You also notice pitting edema in both her legs. She undergoes echocardiographic testing. Which of the following abnormalities would you most expect to see on the echocardiogram? ADecreased trans-mitral mean pressure gradient BIncreased opening of the mitral valve leaflets CRight atrial hypertrophy DRight ventricular hypertrophy

D

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? AContinue enalapril and add amlodipine BContinue enalapril and add losartan CContinue enalapril and add nothing, as she is at goal with just one medication DDouble the dose of enalapril

A

A 70-year-old woman with a medical history of hypertension presents to clinic for her annual visit. She is currently taking lisinopril for her hypertension. During her visit, she reports several months of fatigue and dyspnea on exertion. She denies shortness of breath at rest, orthopnea, and swelling of her lower extremities. On physical exam, the patient is afebrile, with a pulse of 92 bpm, a blood pressure of 125/82 mm Hg, and SpO2 of 97% on room air. She has a regular heart rate and rhythm with normal S1 and S2 heart sounds. The patient has normal breath effort, and lungs are clear to auscultation bilaterally. There is no lower extremity edema. Labs reveal a normal CBC, ferritin, TSH, and BNP. An echocardiogram demonstrates left atrial dilation and a nondilated left ventricle with concentric remodeling and an ejection fraction of 57%. Which of the following is the most effective management? AExercise training BFurosemide CMetoprolol DNo additional interventions ESodium restriction

A This patient presents with heart failure with preserved ejection fraction (HFpEF), or diastolic heart failure. HFpEF is characterized by signs and symptoms of heart failure along with a left ventricular ejection fraction (LVEF) ≥ 50%. Clinical manifestations of HFpEF are similar to those of heart failure with reduced ejection fraction (HFrEF) and include fatigue, weakness, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Patients may present with elevated jugular venous pressure, pulmonary rales, lower extremity edema, and an S4 heart sound (or S4 gallop). Risk factors for HFpEF include advanced age, female sex, obesity, tobacco use, hypertension, diabetes, coronary artery disease, valvular heart disease, and atrial fibrillation. Echocardiogram is the most useful test to diagnose HFpEF and will reveal a normal or slightly increased LVEF and diastolic dysfunction. Concentric remodeling or left ventricular hypertrophy may also be present. Brain natriuretic peptide (BNP) levels may aid in the diagnosis and clinical decision-making of heart failure, but given its limited sensitivity and specificity, normal levels should not be used to exclude the disease. The treatment of HFpEF is largely centered around exercise training to improve performance status, diastolic function, and blood pressure control for patients with associated hypertension. Diuretics should only be used to relieve symptoms of volume overload.

A 75-year-old man with poorly controlled advanced kidney injury presents to the emergency department via EMS from home in cardiac arrest. EMS reports the patient is on dialysis but has not been able to attend his last three appointments due to social complications. Your team continues the advanced cardiac life support algorithm for one more round when there is return of spontaneous circulation. An ECG of the patient's cardiac rhythm is shown above (Afib with peak T waves). Complete blood count, complete metabolic panel, venous blood gas, and cardiac enzymes are obtained. The complete blood cell count and cardiac enzymes are unremarkable. The complete metabolic panel shows the following: sodium 132 mEq/L, potassium 8.0 mEq/L, glucose 110 mg/dL, Cr 4.0 mg/dL, BUN 30 mg/dL. The venous blood gas shows the following: pH of 7.35, bicarbonate 33 mmol/L, anion gap 8 mEq/L, pO₂ 60 mm Hg, and PCO₂ 36 mm Hg. What is the mechanism of action of the first-line drug used to reverse the precipitating condition causing this patient's cardiac arrest? AAntagonizes the membrane actions of potassium BBinds potassium in exchange for other cations CEnhances the sodium-potassium pump of skeletal muscle DIncreases potassium excretion EIncreases systemic pH

A Calcium gluconate antagonizes the membrane actions of potassium and also helps treat or prevent hypocalcemia, which can increase the effects of hyperkalemia on the heart allowing for stabilization of the cardiac membrane. When given intravenously, calcium has a quick onset of a few minutes but lasts only 30-60 minutes. Therefore, other treatments will need to be started once the patient is stabilized

A 75-year-old otherwise healthy woman states that she has passed out three times in the last month during her daily brisk walk. Which one of the following is the most likely cause of her syncope? AAortic stenosis BAtrial myxoma COrthostatic hypotension DVasovagal syncope

A Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does not rise with exertion. Syncope, commonly occurring with exertion, is reported in up to 42% of patients with severe aortic stenosis. The pathology of aortic stenosis includes processes similar to those in atherosclerosis, including lipid accumulation, inflammation, and calcification. The development of significant aortic stenosis tends to occur earlier in those with congenital bicuspid aortic valves. During the asymptomatic latent period, left ventricular hypertrophy and atrial enlargement of preload compensate for the increase in afterload caused by aortic stenosis. As the disease worsens, these compensatory mechanisms fail, leading to symptoms of heart failure, angina, or syncope. Doppler echocardiography is the recommended initial test for patients with classic symptoms of aortic stenosis. It is helpful for estimating aortic valve area, peak and mean transvalvular gradients, and maximum aortic velocity. Aortic valve replacement should be recommended in most patients with any of these symptoms accompanied by evidence of significant aortic stenosis on echocardiography. Vasovagal syncope (D) is associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, sustained upright posture, heat, hunger, and acute blood loss. Orthostatic hypotension (C) is associated with changing from a sitting or lying position to an upright position. Atrial myxoma (B) is associated with syncope related to changes in position, such as bending, lying down from a seated position, or turning over in bed.

A 58-year-old man presents to the clinic for his annual exam. He currently takes no medications and reports no symptoms today. Vital signs are pulse 80 beats per minute, blood pressure 125/80 mm Hg, respirations 16 per minute, and temperature 98.6°F. Physical exam reveals an S3 but is otherwise normal. Electrocardiogram reveals 4 mm Q waves and T wave inversions in leads II, III, and aVF. Which of the following is the best next pharmacologic intervention for this patient? ACarvedilol 3.125 mg bid BCelecoxib 100 mg bid CClopidogrel 75 mg qd DFenofibrate 160 mg qd EPropranolol 20 mg bid

A The patient in the above vignette presents with a missed myocardial infarction. Q waves are negative deflections on ECG that precede the R wave. Q waves can be normal if they are under 2 mm in depth and < 25% of the height of the QRS complex. Q waves, when accompanied by ST segment elevation, are indicative of acute myocardial infarction. If they are present in conjunction with T wave inversions in a patient who is asymptomatic, they are indicative of an old myocardial infarction. A third heart sound (S3) may also be heard in a patient with a previous myocardial infarction due to an overly compliant, dilated left ventricle in the setting of systolic heart failure. Most patients with systolic heart failure will report shortness of breath and decreased exercise tolerance, but some may be asymptomatic in early stages. An S3 can also be a normal finding in athletes, patients who are pregnant, and children. Evaluation of a patient who presents with ECG findings of a missed myocardial infarction should begin with an echocardiogram and stress testing. However, scheduling these tests should not preclude pharmacologic therapy. Patients who have coronary artery disease should begin taking a daily dose of aspirin 81 mg, a daily cardiac-specific beta-blocker, such as carvedilol, and a statin, unless otherwise contraindicated. Beta-blockers decrease the workload on the heart and reduce mortality, aspirin decreases coagulability, and statin drugs decrease cholesterol and improve long-term survival in patients with atherosclerosis. Beta-blocking agents should be avoided or used with caution in patients with symptomatic bradycardia, third-degree heart block, depression, and bronchospastic disease.

A 76-year-old woman presents to her primary care physician due to increasing chest pain and shortness of breath at rest. She has a history of hypertension and states that she was told 3 months ago that she has a murmur but cannot recall any other information about this diagnosis. Which of the following is the most likely diagnosis in this patient? ABicuspid aortic valve BCalcified aortic valve CMitral stenosis DTricuspid regurgitation

B

A patient with dyspnea and angina fails medication management of his symptoms with beta-blockers, ACE-inhibitors and calcium channel blockers. He undergoes complete cardiac evaluation which uncovers the presence of nonobstructive, end-stage hypertrophic cardiomyopathy. Which of the following is the most appropriate treatment at this point in time? AAggressive diuresis BCardiac transplantation CImplantable intracardiac pacing DSurgical myectomy

B

Aortic stenosis can lead to which of the following general patterns of left ventricular remodeling? AAsymmetric left ventricular hypertrophy BConcentric left ventricular hypertrophy CEccentric left ventricular hypertrophy DMixed concentric/eccentric left ventricular hypertrophy

B

In which of the following conditions is hypoxemia caused by a right-to-left shunt? AAsthma BEisenmenger syndrome CPatent foramen ovale DPulmonary embolism

B

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? A50% ejection fraction BContinued chest pain CElevated atrial natriuretic peptide DR wave progression

B

Which of the following patients should be classified as having unstable angina? AA 51-year-old woman who had chest pain three days ago but now is chest pain free and is found to have a positive troponin with Q waves in leads II, III, and aVF, without ST elevations BA 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 CA 65-year-old man with a known history of coronary artery disease who gets chest pain and shortness of breath every time he climbs the steps to his bedroom DA 71-year-old man who underwent a coronary catheterization one month ago for early morning chest pain that showed minimal coronary artery disease with no fixed lesions presents with recurrent early morning chest pain that is relieved by nitroglycerin

B

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? AActivating the arachidonic acid pathway BDecreasing glomerular blood flow CIncreasing angiotensin II activity DIncreasing serum kinin levels

B

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? AAutonomic dysreflexia BHypertensive emergency CHypertensive urgency DSympathetic crisis

B A hypertensive emergency is a severe elevation in blood pressure with evidence of end-organ damage. This requires immediate lowering of blood pressure. There is no specific blood pressure at which hypertensive emergency occurs, however, end-organ damage is less likely if the diastolic BP is < 130 mm Hg. With that being said, the well-accepted criteria for hypertensive crisis are systolic pressure ≥180 mm Hg or diastolic pressure ≥ 110 mm Hg. One must further consider the patient's baseline blood pressure, as a patient with chronic hypertension may not have end-organ damage with pressures around 200/150 mm Hg. Precipitants of hypertensive emergencies include progression of essential hypertension (especially if there is medical noncompliance), progression of renovascular disease, acute cardiac or cerebral ischemic injury and undiagnosed or progressive endocrinopathies. Symptoms of hypertensive emergency include chest pain, dyspnea and neurologic deficits. Associated clinical scenarios include encephalopathy, hemorrhagic or ischemic stroke, aortic dissection, acute myocardial infarction, acute coronary syndrome, acute renal failure, pulmonary edema with respiratory failure, microangiopathic hemolytic anemia and pre-eclampsia/eclampsia/HELLP syndrome.

What is the most common side effect following administration of intravenous amiodarone? ABradycardia BHypotension CNausea DWidening of the QRS interval

B Amiodarone is used in the treatment of both ventricular and supraventricular dysrhythmias. It is classified as a class III antiarrhythmic drug due to is inhibition of outward potassium channels which prolongs the duration of the action potential. It also has properties of class I antiarrhythmics (sodium channel blockage), class II antiarrhythmics (beta adrenergic receptor blockage) and class IV antiarrhythmics (calcium channel blockage). It has superior efficacy compared to many other antiarrhythmic drugs and a low rate of ventricular proarrhythmia. It is not, however, without side effects. The most common side effect of intravenous administration is hypotension, which can occur in up to a quarter of patients and may be attributed to the solvents used in the preparation. Amiodarone Antidysrhythmic Multichannel blocker ACLS protocol Monitor thyroid and liver function Obtain yearly chest X-ray Eye exams Drug interactions

An 83-year-old is being evaluated in the emergency department after an episode of syncope. The woman was preparing dinner when she felt her heart start to race. The next thing she remembers is waking up on the floor. She experienced a similar episode about three weeks ago. She has never had anything like this before. Her past medical history is remarkable for hypertension, hyperlipidemia and hypothyroidism. Her medications include lisinopril, atorvastatin and levothyroxine. On physical exam her blood pressure is 142/83, heart rate 76/min, and respiration rate 13/min. Cardiac auscultation reveals no murmur. The remainder of her physical exam is normal. Electrocardiogram reveals normal sinus rhythm with left axis deviation. No cardiac rhythm abnormalities are detected. What is the most likely etiology of this patient's syncope? AAortic stenosis BCardiac dysrhythmia COrthostatic hypotension DVasovagal

B Cardiac dysrhythmia is the most likely cause of this woman's syncope. Cardiac dysrhythmias are a common cause of syncope in the elderly population. It is characterized by a brief or absent prodrome and palpitations immediately preceding the event. Several episodes over a short period of time in someone with no history of syncope suggest a dysrhythmia. Given this patient's short prodrome, palpitations and history of a previous similar event makes a cardiac dysrhythmia the most likely etiology.

Closure of the ductus arteriosus begins when levels of which of the following substances increases in the immediate post-natal period? AAdrenocorticotrophic hormone BBradykinin CProstaglandin E1 DPulmonary surfactant

B Patent ductus arteriosus (PDA) is one of the acyanotic congenital cardiac defects. Prematurity is a major risk factor. It is also associated with Down's syndrome and maternal rubella infection. Fetal blood flow occurs normally through the ductus arteriosus from the pulmonary artery to the aorta, thus bypassing the pulmonary vasculature. When this passageway remains patent after birth, it can lead to symptoms of persistent respiratory difficulty and work of breathing (dyspnea), recurrent respiratory infections, tachycardia, cardiomegaly, bounding pulses (widened pulse pressure), machine-like murmur and poor weight gain. After the first breath, pulmonary vascular resistance decreases and stimulates bradykinin release from the infant's lungs. This causes smooth muscle contraction about the ductus arteriosus, beginning the narrowing process until this structure scars close to become the ligamentum arteriosum.

A previously healthy 16-year old boy presents to your office after having a syncopal episode at the start of track practice. An ECG reveals a QTc of 520 ms. This is confirmed on a subsequent ECG. This finding is associated with which one of the following rhythm abnormalities? AParoxysmal supraventricular tachycardia BPolymorphic ventricular tachycardia CSinus arrest DThird degree atrioventricular block

B Patients with repeated ECGs showing a QTc interval > 480 ms with a syncopal episode, or > 500 ms in the absence of symptoms, are diagnosed with long QT syndrome if no secondary cause such as medication use is present. Prolonged QT interval is associated with polymorphic ventricular tachycardia, including torsades de pointes, and sudden cardiac death. Most cardiac events are precipitated by vigorous exercise or emotional stress, but they also can occur during sleep. Long QT syndrome is usually diagnosed after a person has a cardiac event such as syncope or cardiac arrest. In some situations, this condition is diagnosed after a family member suddenly dies. It may be treated with beta-blockers and implanted cardioverter defibrillators. Patients with long QT syndrome should avoid participation in competitive sports, strenuous exercise, and stress-related emotions. Epinephrine adrenaline for local anesthesia and asthma medication should be avoided in patients with long QT syndrome. Other medications that should be avoided include certain antibiotics, antifungals, antihistamines, antiarrythmics and psychotropic medications which prolong the QT interval.

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? AAortic regurgitation BHigh output heart failure CLow output heart failure DMethamphetamine intoxication

B This patient most likely has high-output heart failure secondary to thyrotoxicosis. High output heart failure occurs when cardiac output is elevated in patients with reduced systemic vascular resistance.

A 35-year-old woman is being evaluated at her annual well woman exam. She has no complaints and generally feels healthy. She has no past medical history and takes no medications. She walks 30 minutes five days per week with no dyspnea or discomfort. On physical exam her blood pressure is 118/68, pulse 64/min and respiration rate is 13/min. Her body mass index is 22. Cardiac auscultation reveals a 2/6 mid-systolic crescendo-decrescendo murmur heard best at the left lower sternal border without radiation. She has a normal S1 and S2 and normal cardiac impulse. Lungs are clear and peripheral pulses are normal. Electrocardiogram is normal. What is the next appropriate step in management? ACardiac magnetic resonance imaging BNo additional testing CTransesophageal echocardiography DTransthoracic echocardiography

C

A 35-year-old woman with a history of excessive alcohol use presents to clinic with "skipped heart beats." Her examination is normal. An in-office ECG is also normal. Laboratory testing is nonspecific. Which of the following is the next most appropriate test? AEchocardiogram BElectromyography CHolter monitor DSestamibi scan

C

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? ACostochondritis BPanic disorder CPrinzmetal angina DUnstable angina

C

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? AAvoid physical activity BElevate lower extremities CMonitor daily weights DRestrict fluid intake

C

A 75-year-old woman with a medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus presents to the emergency department with dyspnea with exertion for the past day. Her medication list includes aspirin, atorvastatin, lisinopril, metoprolol, and insulin. Vital signs include a heart rate of 115 bpm, blood pressure of 104/62 mm Hg, respiratory rate of 20 breaths per minute, and temperature of 98.6°F. Physical examination reveals the patient to be in mild distress with a regular heart rate and rhythm and clear breath sounds bilaterally. The initial ECG shows ST segment elevation in leads I, II, III, and aVL. The ST elevation in lead II is equal to the elevation in lead III, and there is ST segment depression in leads V1-V3. The patient is taken for emergent cardiac catheterization with coronary angiography. Which of the following coronary arteries would you expect to find occluded? AFirst diagonal branch of the left anterior descending BLeft anterior descending CLeft circumflex DLeft main ERight main

C

Which of the following statements is true regarding prosthetic heart valves? AAnticoagulation is optional with mechanical valves BMechanical valves are associated with less hemolysis and are less thrombogenic than bioprosthetic are CMechanical valves are more prone to paravalvular leaks than bioprosthetic valves are DMechanical valves make opening and closing sounds similar to, but louder than, those of native valves

C

Which one of the following is the most common atypical presenting complaint in an elderly patient diagnosed with acute coronary syndrome? ADiaphoresis BDizziness CDyspnea DWeakness

C

A 50-year-old man with a history of asthma and hypertension presents to the emergency department with shortness of breath, wheezing, and cough. He reports poor compliance with his medications due to lack of access to a primary care provider. He denies chest pain. His vital signs in triage are 36.9°C, HR 87, BP 240/140, RR 22. His physical examination reveals mild wheezing, bibasilar rales, and an S3. His chest X-ray is shown above and his ECG shows normal sinus rhythm. His laboratory workup is significant for a BNP of 360 ng/L and a troponin of 0.3 ng/mL. Which of the following is the most likely cause of the patient's symptoms? AAcute thrombotic myocardial ischemia BAsthma exacerbation CHypertensive emergency DPulmonary embolism

C Hypertensive emergency is an acute elevation of blood pressure associated with end-organ damage, typically to the kidneys, brain, heart, aorta, or eyes. It results from the eventual overwhelming or failure of compensatory mechanisms for end-organ perfusion in the setting of increased mean arterial pressure. This leads to fibrinoid necrosis and end-organ hypoperfusion and ischemia. It is most commonly seen in patients with chronic hypertension who are noncompliant with medications. Blood pressure control is the cornerstone of management for all hypertensive emergencies, but the method of blood pressure control differs based both on the etiology of the hypertensive emergency and the evidence of end-organ damage. Hypertensive pulmonary edema is most commonly due to systolic or diastolic left ventricular dysfunction. Vasodilator and diuretics are the mainstay of therapy in hypertensive pulmonary edema. Nitroglycerin is the preferred antihypertensive agent in the setting of pulmonary edema.

An 84-year-old woman is recovering in the hospital from an acute anterior ST elevation myocardial infarction four days ago without complication. The patient suddenly develops chest pain, tachypnea and dyspnea. Her pulse is 115 beats per minute, respiratory rate is 26 breaths per minute, blood pressure is 85/50 mm Hg in both arms. She has elevated jugular venous pulsations and distant heart sounds. Her lungs are clear to auscultation bilaterally and no new murmur is appreciated. What is the most likely etiology of her acute decompensation? AAcute aortic dissection BAcute mitral regurgitation CLeft ventricular free wall rupture DPost infarction ventricular septal defect

C Left ventricular free wall rupture usually leads to hemopericardium with cardiac tamponade, characterized by the classic triad of jugular venous distention, hypotension and muffled heart sounds. The presence of rupture is first suggested by the development of sudden profound right heart failure and shock, often progressing rapidly to pulseless electrical activity and death. Survival depends primarily upon the rapid recognition and immediate therapy. Patients displaying suggestive symptoms, signs, and ECG changes require a bedside echocardiogram for diagnosis. Treatment is emergent pericardiocentesis and hemodynamic support. Risk factors include first myocardial infarction, anterior location of the infarction, elderly age and female sex. The incidence of myocardial rupture after an MI is about 1% in patients. In about one-half of cases, myocardial rupture occurs within the first five days after a myocardial infarction and in over 90% of cases within two weeks.

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? AAortic ultrasound BEchocardiogram CRenal angiogram DUrinalysis

D

Which of the following is recommended for the treatment of systolic heart failure according to New York Heart Association (NYHA) functional class? AAnticoagulation for NYHA class I-IV heart failure regardless of ejection fraction BCalcium channel blockers for NYHA class III-IV heart failure and ejection fraction < 40% CHydralazine plus nitrates for white patients with NYHA class III-IV heart failure and ejection fraction < 40% DSpironolactone for NYHA class III-IV heart failure and ejection fraction < 35%

D

Which of the following states a correct order of electrical current through the heart during one cycle of normal cardiac depolarization? AAtrioventricular node → sinoatrial node BBundle of His → atrioventricular node CLeft bundle branch → right bundle branch DRight bundle branch → Purkinje fibers

D

A 62-year-old man with a history of hypertension that is controlled well with lisinopril, hyperlipidemia that is managed with simvastatin, and cocaine use presents to the emergency department via ambulance with chest pain that started approximately 20 minutes ago. He describes the chest pain as an intense pressure in his chest that radiates to his left arm. His vital signs are heart rate of 145 bpm, blood pressure of 150/95 mm Hg, respirations of 38/minute, SpO2 of 92%, and temperature of 98.9°F. Upon physical exam, the patient is noted to be diaphoretic. Cardiac exam is notable for tachycardia with a regular rhythm and no murmurs. A troponin level is drawn and is 1.0 ng/mL. An electrocardiogram is performed and is shown above. Which of the following medications should be avoided in the treatment of this patient? AAspirin BDiazepam CDiltiazem DLabetalol ENitroglycerin

D The most common cardiac condition associated with cocaine use is acute coronary syndrome (ACS). Approximately 6% of patients who use cocaine and have chest pain will experience myocardial infarction (MI). This occurs regardless of the route of cocaine ingestion. Cocaine use causes an increase in myocardial oxygen demand via inhibition of norepinephrine uptake. Cocaine also stimulates alpha-adrenergic receptors, which can constrict coronary vessels. Additionally, cocaine use is thought to promote thrombus formation in the coronary arteries. The treatment of cocaine-associated myocardial infarction is similar to the treatment of myocardial infarction from other causes, with early reperfusion an important part of treatment. Coronary angiography and primary percutaneous coronary intervention play a key role in early reperfusion and should be initiated quickly after the initial assessment of the patient. In patients with suspected cocaine use, there is one primary difference in medication management. Beta-blockers, such as labetalol, should not be administered to patients with suspected cocaine ingestion due to unopposed alpha-adrenergic stimulation, which could result in coronary artery vasoconstriction and systemic hypertension.

A 75-year-old woman was hospitalized 2 days ago after experiencing an ST segment elevation myocardial infarction. She had no prior cardiac history. She underwent percutaneous coronary intervention and had antifibrinolytic therapy started in appropriate time frames. A heart echocardiogram showed an ejection fraction of 35% after the infarct. Several medications may be used in the postmyocardial infarction treatment for this patient. What is the survival benefit of angiotensin-converting enzyme inhibitors in patients who have suffered reduced ejection fraction? ADecreases preload BImproves myocardial oxygen supply-demand CInterferes with platelet activation DPrevents postmyocardial infarction cardiac dysrhythmias EPrevents ventricular remodeling

E

A 65-year-old man presents to the clinic for intermittent dizziness that has been present for about 3-4 weeks with gradual onset. He reports that he notices it the most when he wakes up in the morning and gets out of bed, and it does go away after a few minutes. He has occasionally noticed dizziness after watching television. When questioned further, he reports that it primarily occurs when he is going from a lying or sitting to a standing position. He reports no syncope or falls. His medical history is significant for benign prostatic hyperplasia and hypertriglyceridemia. He is taking terazosin 4 mg and a fish oil supplement. His vitals on arrival were blood pressure 120/80 mm Hg and pulse 82 bpm. The nurse immediately performed orthostatic vital signs and ECG. The ECG is shown above (normal). Orthostatic vital signs show a supine blood pressure of 130/86 mm Hg and pulse of 75 bpm. Sitting blood pressure is 125/80 mm Hg and pulse is 80 bpm. Standing blood pressure is 110/74 mm Hg and pulse is 89 bpm. Which of the following is the most likely mechanism that explains this patient's dizziness? AChronic orthostatic intolerance BExtracellular fluid volume depletion CImpaired cardiac output DIncreased systemic vascular resistance EPeripheral vasodilation

E Orthostatic hypotension is the drop in blood pressure with change in body position, such as the change from a supine to sitting or standing position. It can be identified by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of more than 10 mm Hg with the change in position. Typically there is an increase in heart rate as well. The patient's history, orthostatic vital signs showing orthostatic hypotension, the ECG with no concerning findings, and the absence of other concerning symptoms lead to orthostatic hypotension as the most likely cause of his dizziness. The most likely cause is the medication, terazosin, taken by the patient. Peripheral vasodilation can be caused by many medications, including terazosin, which is an alpha-1 adrenergic blocker that is used to treat benign prostatic hyperplasia. This class of medication selectively blocks the vascular postsynaptic alpha-1 adrenergic receptors, which reduces peripheral vascular resistance by inhibiting smooth muscle contraction. The resulting peripheral vasodilation is beneficial for the treatment of benign prostatic hyperplasia and hypertension but can often result in orthostatic hypotension as well.

A 24-year-old woman with no reported prior medical history presents to the emergency department after passing out. She reports that she was donating blood and passed out while sitting down having her blood drawn. She describes feeling cold and sweaty for several seconds immediately before she passed out. She did not fall or hit her head. Vital signs include a heart rate of 75 bpm, blood pressure of 114/72 mm Hg, respiratory rate of 20 breaths per minute, and temperature of 98.6°F. Physical exam reveals a well-appearing woman in no apparent distress. Her heart has a regular rate and rhythm, and her lungs are clear to auscultation. An ECG was performed and is shown above (NORMAL). Which of the following is the most appropriate next step? AAdmit to telemetry for cardiac monitoring and an echocardiogram BCheck orthostatic vital signs CPerform outpatient 48-hour Holter monitor DPerform outpatient loop recorder EProvide reassurance and patient education

E Vasovagal syncope is a type of reflex (neurally-mediated) syncope that is caused by peripheral vasodilation and bradycardia leading to systemic hypotension and cerebral hypoperfusion. It is the most common cause of syncope and is a self-limited and benign process. The common triggers for vasovagal syncope are intensive pain, extreme emotions (often fear), prolonged heat exposure, the sight of blood, and the postexercise cool down period. Patients often experience prodromal symptoms prior to an episode of vasovagal syncope, such as lightheadedness, diaphoresis, hot or cold sensation, palpitations, nausea, and visual blurring. The episode of syncope usually lasts < 1-2 minutes. Patients may feel fatigued after an episode of vasovagal syncope. The diagnosis of vasovagal syncope is made clinically. Vasovagal syncope is a benign process. The treatment of vasovagal syncope is mostly centered on reassurance. Patients should be educated to avoid triggers when possible and to stay hydrated.

Normal QT interval

<440 msec in males <460 msec in females ~2 big boxes

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? AAlteplase BClopidogrel CDigoxin DMetoprolol

B

Which of the following would you most expect to find in a patient who presents to the emergency department in cardiogenic shock? ADehydration BHigh pulse pressure CLow cardiac index DWarm, hyperemic extremities

C

A 60-year-old man presents with nighttime dyspnea. His medical history is significant for chronic hypertension. A recent echocardiogram showed an increase in left ventricular chamber volume but normal ventricular wall thickness. Based on this finding alone, which of the following medications is the most appropriate treatment for this patient's dyspnea? ABisoprolol BPropranolol CSalmeterol DTimolol

A Bisoprolol is a selective beta-1 adrenergic receptor blocker.

___ small squares = 1 large box = ___ seconds = _____ msec

5; 0.20 seconds; 200 msec

Hyperkalemia EKG findings

>5.5 peaked T waves prolonged PR interval loss of P wave widened QRS complex

A 14-year-old boy presents to the clinic for a well child check. He has been growing well and has no medical complaints. On exam, he is found to have a III/VI systolic crescendo-decrescendo murmur heard best over the left sternal border. The murmur increases when moving from a squatting position to a standing position, and increases with Valsalva maneuver. The point of maximal impulse is displaced laterally. Which of the following is the next best step in management? ACease all physical activity until further evaluation can be performed BEncourage hydration during physical activity CPerform genetic testing DPrescribe a beta-blocker

A

A 58-year-old man is undergoing a pre-operative evaluation before an elective surgery scheduled in two weeks. An ECG shows atrial fibrillation with rapid ventricular response. The patient has no symptoms and is completely unaware of his dysrhythmia. He has a past medical history significant for hypertension that is treated with lisinopril. His vital signs are BP 120/80, HR 150, RR 16 and oxygen saturation is 100% on room air. What is the appropriate management with regards to anticoagulation? ADabigatran BDiltiazem CNo therapy DWarfarin and aspirin

A

A 4-year-old boy presents with a 5-day history of fever. On exam he is noted to have non-tender anterior cervical lymphadenopathy, non-exudative conjunctival injection, and swollen hands and feet. Which of the following is the most common complication of this condition? AAplastic anemia BCoronary artery aneurysm CGlomerulonephritis DSevere thrombocytopenia

B

Which of the following describes the correct management of aortic dissection? AAll aortic dissections eventually need surgical or endovascular repair BCrystalloids are the preferred treatment of hypotension in the setting of aortic dissection CStanford type A dissections should be managed chronically with negative inotropes DVasodilators are the preferred treatment of hypertension in the setting of aortic dissection

B Aortic dissection is an uncommon but life-threatening phenomenon that occurs when damage of the intima allows the entry of blood between the intima and media, creating a false lumen. The most important risk factor for aortic dissection is hypertension. Aortic dissection has a bimodal age distribution, with a peak under 40 years of age associated with connective tissue disorders and another peak at greater that 50 years of age associated with chronic hypertension. CT angiogram is the gold standard for diagnosis of dissection. Aortic dissections are defined by their anatomic locations, with Stanford Type A dissections involving the ascending aorta and Stanford Type B dissections involving only the descending aorta. Control of hypertension and heart rate are the cornerstones of acute management of aortic dissection. Negative inotropes are the preferred agents for the control of hypertension in aortic dissection. This is due to their ability to lower blood pressure without increasing heart rate, which would increase shearing force against the intimal flap and lead to propagation of the dissection. Short-acting beta-blockers such as labetalol, esmolol, and propranolol are the first line agents. Calcium channel blockers can be used in the event of contraindication to beta-blockers, though there is more limited literature on their use in this setting. For persistent hypertension, vasodilators such as nitroprusside or nicardipine can be used. Aortic dissection typically presents with hypertension and hypotension, when present, is a poor prognostic indicator and should be managed with crystalloids. Definitive management depends on the anatomic location of the dissection. Type A and complicated type B dissections typically require surgical repair while uncomplicated type B dissections are typically medically managed.

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? AFive days BFour weeks COne year DThree months

B At least four weeks of anticoagulation is recommended post-cardioversion in patients with atrial fibrillation lasting more than 48 hours or for an unknown duration of time. Although electrical atrial activity is normalized following cardioversion, atrial mechanical stunning and a higher risk of stroke may persist for up to four weeks, and warfarin with a goal INR of 2.0-3.0 must be continued during this time. The risk of thromboembolism after cardioversion can be diminished to less than 1% during the four weeks after cardioversion by the use of a month of therapeutic anticoagulation. For patients who have been in atrial fibrillation for less than 48 hours, anticoagulation is not mandatory because clot formation during that time is unlikely. Five days (A) is not enough time to reduce the risk of cardioversion related thromboembolism. Three months (D) and one year (C) of anticoagulation are not recommended. However, lifelong anticoagulation may be recommended depending on the patient's CHADS2 or CHADSVASc score.

Which of the following is a mainstay for the treatment of Kawasaki disease during the acute febrile phase? AAspirin 3-5 mg/kg/day BDexamethasone 0.6 mg/kg CIntravenous immunoglobulin 2 grams/kg DWarfarin 0.2 mg/kg/day

C Kawasaki disease is an acute illness with fever, rash, conjunctivitis, swollen lymph nodes, and widespread inflammation of muscular arteries. Intravenous immunoglobulin (IVIG) and high-dose aspirin form the two components of the treatment of Kawasaki disease during the acute febrile phase of the disease. IVIG involves an infusion of 2 g/kg over 10-12 hours. High-dose aspirin (80-100 mg/kg/day divided into 6-hour dosing regimens) is continued until the child is afebrile for 48-72 hours or longer.

Which of the following laboratory abnormalities would most likely be present in patients receiving mannitol for increased intracranial pressure? AHyperglycemia BHypernatremia CIncreased osmolar gap DNonanion gap acidosis

C Mannitol is an osmotic diuretic that is used in the management of increased intracranial pressure and cerebral edema. Mannitol is a hyperosmotic agent that draws water from the extravascular space and into the central circulation for renal elimination. This mechanism also makes mannitol useful for management of increased intraocular pressure (i.e., glaucoma) and edema. Mannitol is an osmotically active molecule and will cause a patient's serum osmolarity to rise, which increases the osmolar gap. Osmolar gap is calculated by determining an estimated serum osmolality and subtracting that from the patient's measured osmolality. An osmolar gap of greater than 10 indicates that other osmotically active molecules are present in the serum (e.g., ethanol, methanol, ethylene glycol). Complications of the use of mannitol include volume depletion, hyponatremia, and acute kidney injury.

A 7-year-old boy presents to the emergency department with cough and chest pain. The cough has been present for several days, but the chest pain has been present for only one day. His vital signs are notable for a temperature of 38.8°C, heart rate of 150, blood pressure of 78/49, respiratory rate of 50, and oxygen saturation of 94%. He is ill appearing, has coarse breath sounds on lung auscultation, a systolic murmur and a gallop on his cardiac exam, and his liver is palpable 4 centimeters below the right costal margin. His pulses are palpable and capillary refill is 5 seconds. Which of the following is the most likely complication? AAortic valve insufficiency BConstrictive pericarditis CDilated cardiomyopathy DLeft ventricular outflow tract obstruction

C This patient has acute systolic dysfunction in the setting of an upper respiratory infection, which is most likely secondary to myocarditis. Myocarditis can be caused by infections, connective tissues disease, genetic diseases, toxins, and granulomatous diseases. The most common viral etiologies are enterovirus, adenovirus, parvovirus, EBV, and CMV. Myocardial damage may occur from inflammation and direct damage to the myocardium. This results in ventricular enlargement, poor systolic function, and dilated cardiomyopathy. The systolic dysfunction may result in congestive heart failure, arrhythmias, and even death. Patients typically present with chest pain, fever, and fatigue, and in fulminant disease they may have respiratory distress, tachycardia, hypotension, a gallop rhythm, and a murmur. Rash and end-organ involvement (i.e. hepatitis) may be seen. Dilated cardiomyopathy is the most common type of cardiomyopathy, and is characterized by left ventricular systolic dysfunction and left ventricular dilation. In pediatrics, it is usually caused by genetic mutations, myocarditis, or Kawasaki disease.

Persistent fever and bacteremia are found in a 28-year-old woman with new onset murmur. She does not use intravenous drugs, and does not have any prosthetic heart valves or history of congenital heart disease. However, she has significant dental disease and poor dentition. What is the most common organism responsible for bacterial endocarditis in this patient? AClostridium septicum BEscherichia coli CStaphylococcus aureus DStreptococcus viridans

D

A 23-year-old man with a history of intravenous heroin use presents with fever of 101.3°F (38.5°C) and mild cough. His HR is 133 bpm, and BP is 114/72 mm Hg. On examination, he is ill-appearing, and you note a III/VI diastolic murmur. A chest radiograph is unremarkable. The patient states that he was hospitalized two weeks ago for arm cellulitis. Which of the following antibiotic regimens is appropriate for this patient? ACeftriaxone and azithromycin BNafcillin CNafcillin and gentamicin DVancomycin and cefepime

D

A 64-year-old man with a past medical history of hypertension and congestive heart failure is admitted to the intensive care unit. Which of the following intravenous antihypertensive agents cause reductions in both cardiac preload and afterload? AFurosemide BLabetalol CNicardipine DNitroprusside

D

A four-week-old infant presents in cardiac arrest. Cardiopulmonary resuscitation is initiated and the monitor shows pulseless electrical activity. What is the correct concentration and dose of intravenous epinephrine in this setting? A0.01 mL/kg of 1:1,000 concentration B0.01 mL/kg of 1:10,000 concentration C0.1 mL/kg of 1:1,000 concentration D0.1 mL/kg of 1:10,000 concentration

D

A 54-year-old man is found unconscious in a drug store with an empty bottle of minoxidil at his side. He is brought to the emergency room where he is found to be in profound vasodilatory shock with a heart rate of 135 bpm and blood pressure of 57/45 mm Hg. Which of the following vasopressors has the ability to cause a reflex decrease in heart rate and cardiac output? ADopamine BEpinephrine CNorepinephrine DPhenylephrine

D Phenylephrine is a sympathomimetic drug that works by selectively activating alpha-1 adrenergic receptors, causing vasoconstriction. Due to this potent vasoconstriction and increase in systemic vascular resistance (i.e. increase in afterload), there is a compensatory decrease in heart rate and cardiac output. In the setting of an overdose of a direct vasodilator such as minoxidil, phenylephrine has been successfully used to maintain adequate blood pressure to perfuse vital organs without directly stimulating the heart and potentially inducing dysrhythmia. In cases of vasodilatory shock (e.g. sepsis, vasodilator overdose), it is important that vasopressors be initiated only if patients remain hypotensive despite adequate volume resuscitation with isotonic fluids (i.e. 0.9% sodium chloride).

A 23-year-old woman presents to the clinic for her annual physical. On her physical exam, she is well nourished and sitting comfortably. Cardiac and pulmonary exams are unremarkable. Vascular exam reveals 2+ amplitude of dorsalis pedis and posterior tibial pulses bilaterally. Mild swelling of her right foot is noted. She reports no injury or pain. No significant past medical history. She reports returning to California from a trip to Italy last week. Medications include oral contraceptive pills and a multivitamin. Heart rate is 88 beats per minute, BP is 119/81 mm Hg, respirations are 16 breaths per minute, O2 saturation is 100% on room air, and temperature is 97.6°F. D-dimer is 450 ng/mL. Ultrasound shows a 2 cm thrombosis of the right posterior tibial vein. Which of the following treatment options would be most appropriate for this patient? ACompression therapy and leg elevation BIbuprofen therapy and warm compresses CInferior vena cava filter placement DObservation with ultrasound every week for 2-4 weeks ERivaroxaban for 3 months

D This patient has a distal deep vein thrombosis (DVT). A distal DVT is a blood clot in one of the distal veins of the lower extremity. These are generally thought of as veins that are infrapopliteal, or below the knee, and include the anterior and posterior tibial veins as well as the peroneal vein. Diagnosis is made with Doppler ultrasound of the lower extremities. In most cases, DVT in the distal vasculature will resolve spontaneously. Distal DVTs are also less likely to embolize. Observation with ultrasound every week for 2-4 weeks is an acceptable treatment plan for this patient with isolated distal DVT, as she is asymptomatic, has negative D-dimer, and not at high risk for proximal thrombus extension. If proximal thrombus extension is noted on serial ultrasound, anticoagulation with direct oral anticoagulants is preferred. Anticoagulation is also indicated in patients at risk for proximal thrombus extension, those with symptomatic isolated distal DVT, and those with proximal DVT. Risk factors for proximal extension include unprovoked event, D-dimer > 500 ng/mL, extensive thrombosis involving multiple veins, thrombosis close to proximal veins, persistent or irreversible risk factors, personal history of deep vein thrombosis, prolonged immobility, and inpatient status.

which BB has shortest half-life?

Esmolol

preferred anticoagulant for venous thrombosis during pregnancy, liver disease, coagulopathy, and cancer is _______

LMWH (enoxaprin)

Blowing sounds =

regurgitation

Normal PR interval

0.12-0.20 seconds; 120-200msec (3-5 small boxes)

What are the 5 signs of an innocent murmur?

1. Grade <2 intensity 2. Decrease intensity when pt is sitting compared to supine 3. Short systolic duration 4. Minimal radiation 5. Musical or vibratory in quality

A 65-year-old man presents to the emergency department complaining of palpitations for the last week. The palpitations are intermittent, but more severe in the last 3 hours. His heart rate is 140 and blood pressure is 130/80 mm Hg. His ECG is shown above. What is the cardiac rhythm shown on the ECG? AAtrial fibrillation BAtrial flutter CParoxysmal atrial tachycardia DSinus tachycardia

A

A 37-year-old woman with a history of Wolff-Parkinson-White presents to the emergency department with shortness of breath and lightheadedness. Her vital signs on arrival are T 36.9°C, HR 160, BP 80/50, RR 27. Her ECG reveals a narrow complex regular tachycardia. Which of the following is the most appropriate next step in the management of this patient? AAdenosine BCardioversion CFluid bolus DProcainamide

B

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? AAdd ranolazine BIncrease the dose of carvedilol CIncrease the dose of simvastatin DSchedule 24 hour usage of transdermal nitroglycerin

A

A 23-year-old woman delivers her first child. Her family history is positive for three uncles who needed early-in-life surgery for "heart defects." You are asked to assess her 1-day-old infant who does not "appear well" according to the nursing staff. During your examination, which of the following findings most suggests the presence of congenital heart disease? ABasilar crackles and peripheral edema BFever CSymmetric brachial and femoral pulses DSystolic murmur

A Congenital cardiac defects occur in 8 out of 1000 live births. Up to one third of infants born with a congenital cardiac defect develop life-threatening symptoms within the first few days of life, with 80% of infants presenting with congestive heart failure (pulmonary or peripheral edema or both). The mortality rate in this critical period is 90%. The majority of these defects can be screened for in the prenatal period with four-chamber echocardiography. Consider screening in women with diabetes, a family history of congenital heart disease, indomethacin exposure or rubella exposure.

A 12-year-old boy with Wolff-Parkinson-White syndrome presents with palpitations for the past hour. His blood pressure is 110/62 mm Hg and pulse is 166 bpm. The ECG reveals a narrow-complex tachycardia. Vagal maneuvers are ineffective. Which of the following is the next most appropriate management? AAdenosine BCardioversion CProcainamide DRadiofrequency ablation

A Wolff-Parkinson-White syndrome is a congenital cardiac defect in which an abnormal conduction pathway exists between the atria and the ventricles. It is commonly accompanied by congenital cardiomyopathy. Infantile or childhood onset of paroxysmal tachycardia is the typical manifestation. These appear as a narrow complex tachycardia and are referred to as orthodromic. In orthodromic tachycardia, the normal pathway is used for ventricular depolarization, and the accessory pathway (bundle of Kent) is used for the retrograde conduction essential for reentry. Management begins with vagal maneuvers. If unsuccessful and the patient is hemodynamically stable, AV nodal blocking agents, such as adenosine or calcium channel blockers, can be administered.

What valvular disorders require tx similar to HF?

AR, TR

A 76-year-old woman with a history of coronary artery disease presents to the emergency department complaining of recent-onset dyspnea and fatigue. Physical examination reveals peripheral edema and rales on auscultation. Which of the following additional physical exam findings would support the most likely diagnosis? ABradycardia BPulsus alternans CPulsus paradoxus DReduced jugular venous pressure EWidened pulse pressure

B The presence of pulsus alternans supports the diagnosis of heart failure in this patient, as it is most commonly a sign of left ventricular systolic heart failure. Pulsus alternans is the presence of evenly spaced alternating strong and weak peripheral pulses. It is best appreciated by applying light pressure on the peripheral arterial pulse during blood pressure measurement. Heart failure is a clinical syndrome resulting from the heart's inability to meet the body's circulatory demands. The reduction in cardiac output leads to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, resulting in volume retention. It can be caused by any structural or functional cardiac diseases. Risk factors for developing heart failure include coronary heart disease, cigarette smoking, hypertension, obesity, and valvular heart disease. Patients will demonstrate symptoms consistent with decreased cardiac output, such as weakness and fatigue that worsens with exertion, and show signs of excessive fluid accumulation, such as dyspnea, edema, orthopnea, abdominal pain, and ascites. In the setting of acute heart failure, patients may demonstrate sinus tachycardia, diaphoresis, narrow pulse pressure, and cool, pale, or cyanotic extremities. Physical exam will show volume overload with elevated jugular venous pressure, pulmonary congestion, lower extremity edema, scrotal edema, ascites, and enlarged abdomen due to hepatosplenomegaly. Cardiac auscultation reveals an S3 gallop due to elevated left atrial pressure and end-diastolic left ventricular pressure. Due to the enlarged left ventricle, palpation of the precordium demonstrates a laterally displaced apical impulse and a parasternal lift. Pulmonary hypertension may result in secondary to heart failure and will manifest with increased intensity of the P2 heart sound and a palpable pulmonic tap over the left second intercostal space. Lung auscultation may also reveal rales. Diagnosis of heart failure is made using clinical evaluation and diagnostic testing. Echocardiogram is the most useful test used to diagnose heart failure. In a patient with left ventricular systolic heart failure, it will reveal decreased ejection fraction (< 50%), thin ventricular walls, and a dilated left ventricle. Chest X-ray may reveal cardiomegaly, pulmonary edema, and pleural effusions from increased pulmonary pressure from fluid backing up into the lungs. Measurement of brain natriuretic peptide (BNP) may also be helpful in making the diagnosis of heart failure. Patients with dyspnea secondary to heart failure have BNP values above 400 pg/mL, while patients who have dyspnea with a BNP level below 100 pg/mL can effectively be excluded as having heart failure as a cause of their symptoms. Other studies to aid in diagnosis include electrocardiogram, cardiac troponin levels, exercise testing, and right heart catheterization. Diagnosis of heart failure also involves classification of disability. The most common heart failure classification system is the New York Heart Association functional classification. It reflects the progressive nature of the disease, patient symptoms, and objective findings. It is important to note that there is a broad range of symptoms and disease severity that can be seen in patients with heart failure, ranging from mildly symptomatic to severe decompensated heart failure and cardiogenic shock. According to the classification system, class I heart failure includes patients with objective evidence of heart disease but without any limitations of physical activity. Class II heart failure includes patients who have only slight limitation in physical activity without symptoms at rest. Class III heart failure pertains to patients who have marked limitation in physical activity but are symptom-free at rest. Class IV heart failure includes patients who have discomfort with any amount of physical activity and experience symptoms at rest. Management of heart failure is complex and often requires a multidisciplinary team to achieve desired outcomes (increasing functional status, improving quality of life, and decreasing mortality). Treatment is aimed at correcting the underlying cause of the heart failure and associated conditions, lifestyle modifications, pharmacological therapy, device therapy in some cases, cardiac rehabilitation, and preventative care. In general, all patients with left ventricular systolic heart failure should be started on a diuretic, an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, and a beta-blocker. Patients with an ejection fraction less than 35% require an implantable cardioverter-defibrillator.

A 32-year-old previously healthy man presents to the ED with a 4-hour history of palpitations. He denies chest pain, shortness of breath, or history of similar palpitations. He does admit to heavy alcohol use in the past week, drinking 1 pint of vodka and a 24-pack of beer each day. In the ED, his vital signs are BP 135/75, HR 115, RR 14, and oxygen saturation 98% on room air. An irregularly irregular rhythm is heard on auscultation and an ECG shows irregularly irregular QRS complexes without P waves. What is the next step in management? AChemical cardioversion BObservation CRate control DSynchronized cardioversion

B This patient has holiday heart syndrome, which can produce atrial fibrillation, atrial flutter, or atrial tachycardia after excessive alcohol use. Patients generally present with palpitations. The rhythm tends to spontaneously convert back to a sinus rhythm within 24-48 hours; thus, the best step in management at this time is to observe the patient with cardiac monitoring.

Which of the following is a cause of torsades de pointes? ADrugs that shorten the QT interval BHyperkalemia CHypocalcemia DMarijuana use

C

HTN med class for AFlutter/fib

BB, nondihydropyridine CCB

A woman presents to the clinic complaining of pedal edema. Which of the following would be most suggestive of congestive heart failure as the likely etiology? AHistory of bulimia nervosa BHistory of chronic renal insufficiency CHistory of diabetes mellitus DHistory of inflammatory bowel disease

C Patients at increased risk of heart failure are those with a history of myopathy, familial heart disease, rheumatic heart disease, hyperthyroidism, pheochromocytoma, dyslipidemia, diabetes mellitus, hypertension, sleep apnea, peripheral arterial disease, substance abuse, or chemotherapy or radiation to the chest.

Which of the following is most likely to present as a ductal-dependent cardiac lesion? Atrial septal defect Coarctation of the aorta Isolated ventricular septal defect Mitral valve prolapse

Coarctation of the aorta

A 50-year-old man presents to the emergency department with sudden onset of shortness of breath. He has a history of heart failure with an ejection fraction of 25%. Vital signs include temperature 100°F, blood pressure 220/110 mm Hg, heart rate 125 beats/minute, and respiratory rate 30 breaths/minute. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment? AAlbuterol BDobutamine CFurosemide DNitroglycerin

D

A 68-year-old man is being managed on a multi-drug antihypertensive regimen for essential hypertension. His blood pressure is at goal, but he notes persistent constipation and bilateral pedal edema. Which of the following medications is most likely responsible for these side effects? AEnalapril BLosartan CMetoprolol DVerapamil

D

An 18-year-old woman presents to your clinic for a sports physical. She reports no previous health issues or current concerns. Physical exam reveals a thin woman with pectus excavatum, who is in no apparent distress. Her lungs are clear to auscultation, and her heart has a regular rate and rhythm, but auscultation reveals a midsystolic click and late systolic ejection murmur. Her fingers are noted to be elongated. What is the most appropriate intervention for this patient? AComplete 24-hour cardiac monitor BInitiate anticoagulation CInitiate beta-blockers DProvide reassurance ERefer to surgeon

D

Capture beats and fusion beats confirm the diagnosis of which cardiac dysrhythmia? AAtrial fibrillation BSupraventricular tachycardia CVentricular fibrillation DVentricular tachycardia

D

Which of the following is the treatment of choice in antidromic atrioventricular reciprocating tachycardia in a hemodynamically stable patient? AAdenosine BDiltiazem CElectrical cardioversion DProcainamide

D WPW

________ is contraindicated in the setting of coronary artery or structural heart disease because of the increased risk of polymorphic ventricular tachycardia.

Flecainide

Normal QRS complex

Has a duration of 0.06 to 0.12 seconds; 60-120 ms (<3 small boxes)

What valvular disorders require no treatment?

PR, TS, MVP (unless symptomatic, then give BB)

What HTN med classes to not give in hyperkalemia?

Potassium-sparing diuretics, ACE, ARB

Orthodromic AV reciprocating tachycardia = ?

WPW

In normal hearts, which of the following heart valves is composed of two cusps? AAortic BMitral CPulmonic DTricuspid

b

MOA of calcium gluconate

directly antagonizes the effect of potassium on cell membrane excitability, decreasing the cardiotoxic effects of hyperkalemia. While immediate administration of calcium gluconate or calcium chloride does not alter potassium levels, calcium helps prevent potentially fatal cardiac conduction abnormalities or dysrhythmias until the excess extracellular potassium can be driven into cells or out of the body.

What drug can decrease total body potassium levels?

loop or thiazide diuretics (e.g., furosemide)

harsh/rumble sounds =

stenosis

What movements increase venous return?

supine, squat, leg raise

A 33-year-old man with no significant medical history presents to the primary care clinic for decreased exercise tolerance for the past month. While taking his medical history, he notes that his father has a congenital condition affecting his heart. He does not take any medications on a regular basis and is a nonsmoker. His heart rate is 72 beats/minute, blood pressure is 115/74 mm Hg, respiratory rate is 16 breaths/minute, oxygen saturation is 99%, and temperature is 98.6°F. His physical exam reveals a midsystolic murmur that is best heard over the right second intercostal space. His lung exam is without rales. He has no peripheral edema. Based on this information, a nonurgent echocardiogram is ordered. Which of the following is the most likely finding in this patient? ABicuspid aortic valve BCalcific disease of a tricuspid aortic valve CEbstein anomaly DHeart failure ERheumatic aortic valve disease

A

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? ADiastolic blood pressure BFactor V Leiden CGastroesophageal reflux disease DTotal hip arthroplasty

A

A 54-year-old woman presents to the office for her annual physical exam. Her only symptom is a mild headache for 4 or 5 days out of each week for the past 6 months. She reports a family history of high blood pressure and cerebrovascular accidents. She takes no medications and has no previous chronic diagnoses. Vital signs include blood pressure 190/100 mm Hg, pulse 82 beats per minute, temperature 98.6°F, and respirations 15 per minute. Her body mass index is 22 kg/m². Her complete metabolic panel and complete blood count are normal, as is her lipid panel and urinalysis. ECG and CXR are normal. Physical exam, including the fundoscopic exam, is within normal limits. Which of the following combination drug therapies would be the best choice for initial therapy for this patient? AAmlodipine plus diltiazem BAmlodipine plus lisinopril CCaptopril plus losartan DHydrochlorothiazide plus spironolactone ESpironolactone plus captopril

B According to the International Society of Hypertension global hypertension guidelines, treatment of hypertension should begin with a calcium channel blocker, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, or thiazide diuretics. Patients who present with a systolic blood pressure that is 20 mm Hg over goal or a diastolic pressure that is 10 mm Hg over goal may be given combination therapy as initial treatment. The combination therapy should include antihypertensives of two different classes, such as amlodipine (a calcium channel blocker) and lisinopril (an angiotensin-converting enzyme inhibitor). Combination regimens can lead to greater overall blood pressure reduction with fewer side effects than maximum doses of either medication alone. Amlodipine plus diltiazem (A) represents two medications from the calcium channel blocker class. Two medications from the same class, even though they have slightly different mechanisms of action, should be avoided. Captopril plus losartan (C) represents a combination of an angiotensin-converting enzyme inhibitor and an angiotensin II receptor blocker. This combination raises the risk of hyperkalemia and kidney impairment and should be avoided. Hydrochlorothiazide plus spironolactone (D) represents two diuretic drugs. They are technically from different classes of medications, but both work as diuretics, and a combination of medications with differing mechanisms of action is a better choice for initial therapy. Spironolactone plus captopril (E) represents the combination of a potassium-sparing diuretic and an angiotensin-converting enzyme inhibitor. Both of these medications increase the likelihood of hyperkalemia, and their combination should be avoided in patients with normal baseline lab values.

Which of the following can decrease levels of brain natriuretic peptide? AFemale sex BKidney failure CObesity DOlder age

C

A 62-year-old man with a history of hypertension on amlodipine and type 2 diabetes mellitus on metformin presents to the emergency department with dull chest pain that started 8 hours ago. The patient appears mildly diaphoretic. Vital signs include a heart rate of 104 bpm, blood pressure of 135/92 mm Hg, and respiratory rate of 22 breaths per minute. He has a regular rate and rhythm, and his lungs are clear to auscultation bilaterally. An ECG was performed and is shown above. The initial cardiac troponin I is 9.8 ng/mL. You discuss with the cardiologist on call who plans to perform cardiac catheterization with coronary angiography in 24 hours. Which of the following is an appropriate treatment to administer now? AAlteplase BBivalirudin CEnoxaparin DFondaparinux EUnfractionated heparin

E

What class of HTN should you use in a patient w/ osteoporisis?

Thiazide-type diuretics

What movements decrease venous return?

Valsalva, standing

↑venous return (supine, squat, leg raise) = ? w/ murmurs?

↑ in ALL murmurs EXCEPT HOCM & MVP

↓venous return (Valsalva, standing) = ? w/ murmurs?

↓ in ALL murmurs EXCEPT HOCM & MVP

How do you calculate mean arterial pressure? AMAP = [DBP + (2 x SBP)]/3 BMAP = DBP + 1/3(SBP−DBP) CMAP = DBP + 2/3(SBP−DBP) DMAP = SBP + 1/3(SBP−DBP)

B

A 56-year-old man with type 2 diabetes presents today for follow-up for elevated blood pressure after he was seen in the clinic 4 weeks ago for his routine diabetes follow-up. He is not currently on any medications, and his diabetes is controlled with his lifestyle. His blood pressure at his appointment 4 weeks ago was 155/89 mm Hg. The rest of his physical exam and blood work were normal, and he did not report any symptoms. He presents today with an elevated blood pressure reading of 139/88 mm Hg, and he is diagnosed with hypertension. He is placed on chlorthalidone 12.5 mg once daily and is scheduled to follow up again in 4 weeks with a blood pressure check. Which of the following should the patient be counseled on concerning the side effect of chlorthalidone? AHyperglycemia BHyperkalemia CHypernatremia DHypocalcemia EHypouricemia

A

A 70-year-old woman presents to the clinic with reports of fatigue, decreased exercise tolerance, and lightheadedness. She is currently being treated for hypertension, chronic obstructive pulmonary disease, and diabetes with oral medications and inhalers. Her vital signs are blood pressure 130/80 mm Hg, pulse 50 beats per minute, respirations 15 breaths per minute, pulse oxygenation 97%, and temperature 98.6°F. A complete metabolic panel and complete blood count are within normal limits. A telemetry strip is shown above (Wenkebach). Which of the following medications would most likely be responsible for this patient's clinical picture? ADiltiazem BGlipizide CHydrochlorothiazide DMetformin EPropranolol

A

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? ABegin atenolol BBegin lisinopril CBegin nitroglycerin DContinue current medications and follow-up in 1 month

A

Which of the following medications lowers cholesterol by binding bile acids and forming insoluble complexes that are excreted in the feces? AColesevelam BFenofibrate CGemfibrozil DLovastatin

A

A 53-year-old woman with a medical history of chronic kidney disease, type 2 diabetes mellitus, hypertension, and New York Heart Association class 2 congestive heart failure presents to the clinic for follow-up. Over the last 6 months, she has noticed slightly increased ankle swelling. Her medications include lisinopril, metformin, rosuvastatin, and calcium supplement. On cardiac exam, rate and rhythm are regular, and no new murmurs are appreciated. Bilateral 2+ pitting edema is noted. Her vitals are blood pressure 160/90 mm Hg, HR 74 bpm, respirations 16 breaths per minute, and temperature 98.6°F. Labs during her visit today show potassium 5.5 mEq/L (mmol/L). Her creatinine is stable at 2.2 mg/dL. Which of the following medications should be avoided in this patient? AEplerenone BFurosemide CHydrochlorothiazide DMetoprolol succinate EVerapamil

A. Potassium sparin diuretic

What valvular disorders require valve replacement?

AS, PS, MS, MR

What is Brugada syndrome?

Autosomal dominant Cardiac ion channel dysfunction Structurally normal heart Resting ECG: RBBB pattern and STE in V1-V3 Type 1 STE: coved Type 2 or 3 STE: saddleback ECG: J wave elevation Lethal dysrhythmias

A bicuspid aortic valve is often associated with which of the following findings? AAbdominal aortic aneurysm BDilation of the ascending aorta CLeft atrial dilation DPatent foramen ovale

B

A 44-year-old woman presents to the Emergency Department with palpitations following the death of her mother 2 days prior. Her ECG is consistent with normal sinus rhythm with a QTc interval of 520 msec. Her heart rate is 86 bpm and blood pressure is 117/82 mm Hg. Her medications include lisinopril and metformin. She took lorazepam yesterday for anxiety related to the loss of her mother. What is the most appropriate next step? AAdminister adenosine BDiscontinue lorazepam CInitiate propranolol DPerform vasovagal maneuvers

C

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? AAdminister a beta blocker BAdminister morphine sulfate CAdminister sublingual nitroglycerin DBegin intravenous hydration

D

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? AAdd a calcium channel blocker BDecrease the dosage of furosemide CDiscontinue the carvedilol DDiscontinue the ibuprofen

D

Which of the following is an independent cause of secondary hypertension? AAddison's disease BAtrial fibrillation CHypercholesterolemia DPrimary aldosteronism

D

A 50-year-old woman with a history of mitral stenosis secondary to rheumatic fever presents with atrial fibrillation. She does not have a history of heart failure, hypertension, diabetes mellitus or previous stroke or transient ischemic attack. What is the most appropriate management for this patient? AAspirin BDabigatran CNo anticoagulation DWarfarin

D Warfarin is the most appropriate management. This patient has mitral stenosis and requires anticoagulation with warfarin regardless of CHA2DS2 - VASc score. Validated risk factors for thromboembolism in patients with atrial fibrillation include mitral stenosis, previous thromboembolism, heart failure, systolic dysfunction, diabetes, hypertension, presence of a mechanical heart valve and older age. In patients without significant valvular disease, the mostly commonly used method to determine choice of thromboprophylaxis is the CHA2DS2 - VASc score. Those with a score of 0 are at low risk and anticoagulation is a clinical decision. A score of 1 is low to moderate risk and antiplatelet or anticoagulation therapy should be considered. A score of 2 or more is considered moderate to high risk and anticoagulation is recommended. Patients with mitral stenosis who have chronic atrial fibrillation have a stroke risk that may be as high as 7-15 % per year. It is recommended that patients with mitral stenosis and atrial fibrillation be started on warfarin, and it should be continued indefinitely to decrease the risk of systemic thromboembolism. The goal INR is between 2.0 to 3.0.