R Cardio Review Part 2
One Step Further Question: What formula is used to calculate the minimum systolic blood pressure for a child age 1-10 years?
Answer: Minimum SBP = 70 + (2 x age in years).
One Step Further Question: What is the most common cause of ventricular tachycardia?
Answer: Myocardial ischemia or infarct.
One Step Further Question: What is the most common etiology of ventricular fibrillation?
Answer: Myocardial ischemia.
One Step Further Question: Name some medications which are prescribed for venous insufficiency?
Answer: No oral medications have been shown to be beneficial in the treatment of this condition.
One Step Further Question: Mitral valve prolapse is often associated with what conditions?
Answer: Marfan's syndrome and Ehlers-Danlos syndrome.
One Step Further Question: Approximately one-third of patients with Wolff-Parkinson-White develop what tachydysrhythmia?
Answer: Atrial fibrillation, and if atrial fibrillation conducts rapidly down the bypass pathway, it can degenerate into ventricular fibrillation.
One Step Further Question: What is an example of a drug that reduces cardiac contractility?
Answer: Beta blockers.
One Step Further Question: What is the most common X-ray finding in acute aortic dissection?
Answer: Mediastinal widening is seen in the majority of aortic dissection cases.
One Step Further Question: What is the role of beta-adrenergic blocking agents in acute myocardial infarction?
Answer: Beta-adrenergic blockers given within 24 hours of presentation reduce the risk of developing ventricular dysrhythmias.
One Step Further Question: What medication is contraindicated in the treatment of Prinzmetal's angina?
Answer: Beta-blockers.
One Step Further Question: Premature ventricular complexes are often caused by or made worse by what common agents?
Answer: Caffeine, alcohol and nicotine.
Rapid Review Acute Coronary Syndrome: Management
Acute Coronary Syndrome: Management Aspirin: ↓ mortality, ↓ infarct size, ↓ reinfarction rate Clopridogrel: patients with aspirin allergy Heparin: ↓ DVT, ↓ reinfarction, ↓ stroke, ↓ LV thrombus, ↓ reocclusion Nitroglycerin: Coronary artery dilation/vascular smooth muscle relaxation → ↓preload/afterload → ↓ myocardial O2 demand Contraindications: sildenafil use within 24 hrs, RV infarction ß-blockers: ↓ Myocardial O2 demand, ↓ ventricular fibrillation IV indications: tachydysrhythmias, intractable HTN Morphine: ↓ Preload/afterload, ↓ sympathetic activity No mortality benefit Glycoprotein IIb/IIIa inhibitors: benefit in patients undergoing PCI PCI: Preferred over thrombolytics in all STEMI patients PCI center: <90 minutes contact to device time Non-PCI center: transfer to PCI center if contact to device time can be <120 minutes Non-PCI center: thrombolytics if contact to device time to be >120 minutes Thrombolytics: begin within 30 minutes of ED arrival if selected
One Step Further Question: What is the most common cause of acute coronary syndrome?
Answer: Atherosclerosis.
One Step Further Question: What dysrhythmia is most commonly associated with tricuspid regurgitation?
Answer: Atrial fibrillation (80% of patients with tricuspid regurgitation).
Rapid Review Anaphylactic Reaction
Anaphylactic Reaction IgE-mast cell mediated Airway management Antihistamines, dexamethasone, IM epinephrine, IVF Glucagon for refractory hypotension in patient with known HTN
One Step Further Question: Why do H2 blockers help with cutaneous symptoms in allergic reactions?
Answer: 10% of histamine receptors in the skin are of the H2 variety.
One Step Further Question: What is the normal range for the PR interval?
Answer: 120-200 milliseconds.
One Step Further Question: How long should an individual undergo treatment for an isolated pulmonary embolism with no other risk factors?
Answer: 3 months.
One Step Further Question: What ankle-brachial index measurement is frequently seen with resting pain?
Answer: < 0.4.
One Step Further Question: What is the classic physical sign associated with tricuspid regurgitation?
Answer: A large, bounding v wave is seen during jugular vein inspection. Also, a pulsatile liver may be palpable.
One Step Further Question: Electrocautery during surgery can inhibit pacemaker function. How can the pacemaker be changed into an asynchronous mode during the procedure?
Answer: A magnet can safely be placed over the pacemaker during surgery.
One Step Further Question: What are Osler's nodes?
Answer: A sign of subacute bacterial endocarditis, these are the result of immune complex deposition, leading to tender nodules in the digit pads.
One Step Further Question: What is an Austin-Flint murmur?
Answer: A variant of aortic regurgitation, the Austin-Flint murmur is best heard with the bell at the apex, is more low-pitched and rumbling, and can be presystolic or mid-diastolic.
One Step Further Question: What is the mechanism of action of adenosine?
Answer: AV nodal conduction blockade.
One Step Further Question: What ethnic group in the US has the highest incidence of Kawasaki disease?
Answer: Americans of Asian and Pacific island descent.
One Step Further Question: What antibiotic is recommended as prophylaxis for high-risk patients undergoing a dental extraction?
Answer: Amoxicillin (2 grams by mouth).
One Step Further Question: What is the most common cause of restrictive cardiomyopathy?
Answer: Amyloidosis.
One Step Further Question: What is a DeBakey type 2 dissection?
Answer: An aortic dissection that only involves the ascending aorta.
One Step Further Question: What is malignant hypertension?
Answer: An outdated term which has been replaced by hypertensive emergency.
One Step Further Question: In patients with aortic dissection, what is the recommended blood pressure goal?
Answer: Antihypertensives should be titrated to a systolic blood pressure of 110 mm Hg.
One Step Further Question: List some medications whose side effects can cause symptoms of orthostasis?
Answer: Antiparkinsonian drugs, antiadrenergics, anticholinergics, antidepressants, antiarrhythmics, antipsychotics, diuretics, narcotics and sedatives.
One Step Further Question: Antithrombotics include which medications?
Answer: Antiplatelets (aspirin, glycoprotein IIb/IIIa, adenosine diphosphate, cyclooxygenase, phosphodiesterase, and thromboxane inhibitors), anticoagulants (vitamin K, factor Xa and thrombin inhibitors) and thrombo-fibrinolytics (plasminogen activators).
One Step Further Question: Other than cardiac ischemia or infarct, what are some other cardiac causes of chest pain?
Answer: Aortic dissection, pericarditis and myopericarditis.
One Step Further Question: What is Heyde's syndrome?
Answer: Aortic stenosis and gastrointestinal bleeding from gastrointestinal angiodysplasia.
One Step Further Question: Patients with bicuspid aortic valve more frequently develop what aortic valvular abnormality?
Answer: Aortic stenosis occurs much more frequently than aortic regurgitation
One Step Further Question: In patients with a myocardial infarction, which three drugs have been shown to decrease mortality?
Answer: Aspirin, beta-blockers, and ACE-inhibitors. Beyond The Boards The Air Versus Oxygen in ST-elevation Myocardial Infarction (AVOID) trial compared supplemental oxygen vs no oxygen unless oxygen fell below 94%. The AVOID study found in patients with ST-elevation myocardial infarction who were not hypoxic, administration of oxygen may increase myocardial injury, recurrent myocardial infarction, and major cardiac arrhythmia and may be associated with greater infarct size at 6 months.
One Step Further Question: What are the main actions of diltiazem?
Answer: Calcium channel blockade into myocardial cells resulting in decreased contraction, AV nodal conduction, and, to a lesser degree, vasodilation.
One Step Further Question: What does hypotension in the setting of aortic dissection usually indicate?
Answer: Cardiac tamponade or aortic rupture.
One Step Further Question: What is the most common presenting symptom in patients with acute ischemic heart disease?
Answer: Central-chest discomfort.
One Step Further Question: In a patient traveling from Central America, what is a leading cause of myocarditis?
Answer: Chagas' disease caused by Trypanosoma cruzi.
One Step Further Question: What is proBNP?
Answer: Cleavage of the prohormone proBNP produces biologically active 32 amino acid BNP (brain natriuretic peptide) as well as the biologically inert 76 amino acid N-terminal proBNP (NT-proBNP).
One Step Further Question: What is the mechanism of action of clopidogrel?
Answer: Clopidogrel binds to the platelet adenosine diphosphate (ADP) receptor to irreversibly inhibit activation and aggregation for the life of the platelet.
One Step Further Question: What antipsychotic drug has a black-box warning for the development of pericarditis and myocarditis?
Answer: Clozapine
One Step Further Question: What medication may prevent recurrent episodes and is also used in the treatment of refractory pericarditis?
Answer: Colchicine.
One Step Further Question: What therapy, when used in the acute phase, may be effective in preventing recurrent symptoms of pericarditis?
Answer: Colchicine.
One Step Further Question: What is the name of the rapid quick arterial pulse seen in aortic regurgitation?
Answer: Corrigan's pulse.
One Step Further Question: How long after an acute myocardial infarction does a left ventricular aneurysm occur?
Answer: Days to weeks.
One Step Further Question: What are some triggers that can precipitate cardiac arrest in long QT syndrome?
Answer: Depending on the specific channel affected, various triggers can precipitate cardiac arrest including exercise, sudden loud noises or sleep.
One Step Further Question: Which value has greater influence on the mean arterial pressure, the diastolic or systolic blood pressure?
Answer: Diastolic blood pressure.
One Step Further Question: Which medications are associated with periodic sinus arrest?
Answer: Digitalis, procainamide and quinidine.
One Step Further Question: What is the most common symptom of cardiac ischemia in patients older than 85 years?
Answer: Dyspnea.
One Step Further Question: How would you differentiate pericarditis from myocarditis?
Answer: Echocardiogram.
One Step Further Question: What is the name of the ECG finding classically associated with large pericardial effusions?
Answer: Electrical alternans.
One Step Further Question: How do you definitively diagnose myocarditis?
Answer: Endomyocardial biopsy.
One Step Further Question: Which gram-negative organisms which are difficult to culture can cause endocarditis?
Answer: HACEK group (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella).
One Step Further Question: Which electrolyte abnormality can cause increased blood pressure?
Answer: Hypercalcemia.
One Step Further Question: Besides IV isoproterenol (overdrive pacing), what other IV agent can be used to treat torsades de pointes?
Answer: IV magnesium sulfate.
One Step Further Question: What is the most common cause of pericarditis?
Answer: Idiopathic.
One Step Further Question: What is the treatment of atrial fibrillation with rapid ventricular response?
Answer: If stable, rate control via calcium channel blocker (e.g.) diltiazem or beta-blocker (e.g. metoprolol).
One Step Further Question: What is the next step in management for secondary prevention of sudden cardiac arrest?
Answer: Implantable cardioverter-defibrillator (ICD).
One Step Further Question: Other than magnesium sulfate and cardioversion/defibrillation, what is another treatment for torsades de pointes?
Answer: Increase the heart rate to shorten ventricular repolarization, also known as overdrive pacing.
One Step Further Question: Adults with unrepaired coarctation of the aorta are at increased risk for what other vascular disorder?
Answer: Intracranial aneurysms.
One Step Further Question: Which antihypertensive agent is preferable for a hypertensive emergency caused by a pheochromocytoma?
Answer: Intravenous phentolamine is an alpha-blocker which can be used to block the catecholamine effects of a pheochromocytoma.
One Step Further Question: Does the volume of a pericardial friction rub increase or decrease with inspiration?
Answer: It increases during inspiration.
One Step Further Question: Large pericardial effusions (>250 ml) have what classic appearance on chest radiograph?
Answer: Large "water-bottle" cardiac silhouette with epicardial halo.
One Step Further Question: 0.2 seconds on an ECG is one small or one large block?
Answer: Large. Each small block is 0.04 seconds. Therefore, 5 small blocks to every 1 large block (5 x 0.04 = 0.2)
One Step Further Question: Which two components of the cardiac cycle are impaired in heart failure with preserved ejection fraction?
Answer: Left ventricular filling and relaxation.
One Step Further Question: What electrolyte deficiency is associated with Prinzmetal angina?
Answer: Magnesium deficiency.
One Step Further Question: Is rhythm control superior to rate control in atrial fibrillation?
Answer: No, rate- and rhythm-control strategies improve symptoms, but neither has been conclusively shown to improve survival compared to the other.
One Step Further Question: Can a S4 be heard in normal individuals?
Answer: No.
One Step Further Question: Is antibiotic prophylaxis indicated in patients with isolated aortic stenosis?
Answer: No.
One Step Further Question: Do all pericardial effusions cause tamponade?
Answer: No. Chronic effusions are less likely to cause tamponade than acute effusions.
One Step Further Question: What is the role of antibiotics in the prevention of post-streptococcal glomerulonephritis (PSGN)?
Answer: None. Antibiotics do not prevent PSGN.
One Step Further Question: What is the name of the tender nodules found on the fingertips of patients with infective endocarditis?
Answer: Osler nodes.
One Step Further Question: The ankle-brachial index is used to evaluate which disease?
Answer: Peripheral arterial disease (normal is 0.9-1.4; < 0.9 = PAD; >1.4 = calcified PAD).
One Step Further Question: What vascular emergency of the leg results from a large DVT?
Answer: Phlegmasia cerulea dolens.
One Step Further Question: Name three genetic disorders, and their respective protein abnormalities, that are associated with aortic dissection?
Answer: Polycystic kidney disease (polycystin), Marfan's syndrome (fibrillin) and Ehlers-Danlos IV (type 3 procollagen).
One Step Further Question: What other disease do up to 50% of patients with temporal arteritis also have?
Answer: Polymyalgia rheumatica, which manifests as proximal muscle pain and stiffness, often involving the upper > lower extremities.
One Step Further Question: What are contraindications to lower extremity ablation therapy?
Answer: Pregnancy, thromboembolism, moderate to severe peripheral artery disease, joint disease that affects mobility, and congenital venous abnormality.
One Step Further Question: What side effect is responsible for the greatest number of deaths associated with amiodarone use?
Answer: Pulmonary toxicity, the most common of which is chronic interstitial pneumonitis.
One Step Further Question: How many joules are recommended for defibrillation of pulseless electrical activity?
Answer: Pulseless electrical activity (PEA) is not a shockable rhythm; defibrillation is not indicated.
One Step Further Question: What are the two side effects associated with long term use of flecainide?
Answer: QRS widening and PR prolongation. Antiarrhythmics: Class IC Class I: fast Na+ channel blockers "Can I have fries, please.": flecainide, propafenone ↑ AV node refractory period ↑ PR/QRS
One Step Further Question: Name two congenital QT-prolongation syndromes?
Answer: Romano-Ward syndrome and Jervell-Lange-Nielsen syndrome.
One Step Further Question: What is the Sokolow-Lyon electrocardiographic definition of left ventricular hypertrophy?
Answer: S wave in V1 + R wave in V5 or V6 ≥ 35 mm.
One Step Further Question: What is the most common significant dysrhythmia in pediatrics?
Answer: SVT.
One Step Further Question: What medication, if used within the last 24 hours, is a contraindication to administration of nitroglycerin?
Answer: Sildenafil.
One Step Further Question: What is the most common etiology of healthcare-associated infective endocarditis?
Answer: Staphylococcus aureus.
One Step Further Question: What is the equation for the target heart rate used for an exercise stress test?
Answer: Target heat rate = 85 % (220 - age (in years)).
One Step Further Question: What is the most common cardiac cause for cyanosis of children (of any age)?
Answer: Tetralogy of Fallot
One Step Further Question: What is the INR range in a patient taking warfarin for atrial fibrillation?
Answer: The INR range is 2-3.
One Step Further Question: While AV block is first examined by determining the length of the PR interval, bundle branch blocks are first examined by determining the length of which electrocardiographic entity?
Answer: The QRS complex.
One Step Further Question: What is the most common site of aortic dissection?
Answer: The ascending aorta.
One Step Further Question: What is the name of the accessory bundle in WPW syndrome?
Answer: The bundle of Kent.
One Step Further Question: Which arteries must be evaluated for aneurysm in any patient with a diagnosed AAA?
Answer: The femoral (85% association) and popliteal (62% association) arteries.
One Step Further Question: Which coronary artery most commonly supplies the inferior wall with blood?
Answer: The right coronary artery.
One Step Further Question: What part of the duodenum is most commonly involved in aortoenteric fistulas?
Answer: The third and fourth portions.
One Step Further Question: Which pericarditis cases are most prone to develop tamponade?
Answer: Those which are idiopathic or due to malignancy or uremia.
One Step Further Question: What dysrhythmia are patients with prolonged QT interval at risk for?
Answer: Torsades de pointes.
One Step Further Question: Prior to electrical cardioversion in a hemodynamically stable patient with atrial fibrillation that has been present for > 48 hrs, what test needs to be done to assess for atrial clot formation?
Answer: Transesophageal echocardiogram.
One Step Further Question: Which class of migraine abortive medications should be avoided in patients with Prinzmetal's angina?
Answer: Triptan medications, which can exacerbate coronary vasospasms, should be avoided in patients with Prinzmetal's angina.
One Step Further Question: The risk of death in unstable angina is four-fold increased if which three biomarkers are elevated?
Answer: Troponin I or T, high-sensitivity C-reactive protein and B-type natriuretic peptide.
One Step Further Question: True or false: All patients aged 40 years and older with diabetes mellitus should receive statin therapy?
Answer: True.
One Step Further Question: How many grams of sodium can one eat per day on a low sodium diet?
Answer: Under 2 grams.
One Step Further Question: What is the definitive treatment for aortic stenosis?
Answer: Valve replacement.
One Step Further Question: What effect does nitroglycerin have?
Answer: Veno- and arterialdilation, decreasing preload and afterload of the heart.
One Step Further Question: What is the most common etiology of myocarditis in children?
Answer: Viral infections.
One Step Further Question: What formula is used to calculate the average weight in a child?
Answer: Weight (kg) = (2 x age in years) + 8.
One Step Further Question: What is antidromic conduction?
Answer: When the impulse is conducted anterograde through the accessory pathway and retrograde through the AV node. The QRS complex is wide.
One Step Further Question: Ventricular tachycardia is most difficult to distinguish from which other dysrhythmia?
Answer: Wide-complex supraventricular tachycardia (SVT with aberrancy such as a bundle-branch block).
Rapid Review Aortic Regurgitation
Aortic Regurgitation Acute MCC: endocarditis Chronic MCC: rheumatic heart disease Blowing diastolic murmur at left sternal border Pulse pressure: normal (acute), widened (chronic) de Musset sign: head bobbing with systole Quincke's pulse: prominent nail pulsations Duroziez murmur: "singsong" murmur over femoral artery Austin-Flint murmur: mid-diastolic murmur in severe AR Rx objective: ↓ afterload
Rapid Review Aortic Stenosis
Aortic Stenosis Patient will be older With a history of diabetes, hypertension Complaining of dyspnea, chest pain, syncope PE will show crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop Most commonly caused by degenerative calcification Treatment is aortic valve replacement Comments: murmur decreases with Valsalva
Rapid Review Atrial Fibrillation
Atrial Fibrillation Alcohol Irregularly irregular No P waves Narrow QRS unless conduction block or accessory pathway Unstable: cardioversion Stable: Rate control with CCBs, ßBs < 48 hours duration: cardiovert to sinus rhthym > 48 hours duration: anticoagulate, echo to r/o thrombus, then cardioversion
Rapid Review Atrial Fibrillation
Atrial Fibrillation Alcohol Irregularly irregular No P waves Narrow QRS unless conduction block or accessory pathway Unstable: cardioversion Stable: Rate control with CCBs, ßBs <48 hours duration: cardiovert to sinus rhthym >48 hours duration: anticoagulate, echo to r/o thrombus, then cardioversion
Rapid Review Brain Natriuretic Peptide (BNP)
Brain Natriuretic Peptide (BNP) ↑ Ventricular myocyte stretch → release ↓ In obese BNP < 100 pg/mL: heart failure unlikely Level does not correlate with heart failure severity
Rapid Review Cardiac Biomarkers
Cardiac Biomarkers Troponin Highest sensitivity and specificity Time detectable from onset: 3-12 hours Peak: 24-48 hours Return to baseline: 5-14 days CK-MB Time detectable from onset: 3-12 hours Peak: 24 hours Return to baseline: 48-72 hrs Useful for dx of reinfarction Myoglobin First to appear, first to peak, first to decline Lacks specificity
Rapid Review Cardiac Electrical Conduction System
Cardiac Electrical Conduction System SA node → AV node → bundle of his → bundle branches → purkinje fibers
Rapid Review Coarctation of the Aorta
Coarctation of the Aorta PE will show higher blood pressure in the arms than in the legs EKG will show LVH CXR will show notching of ribs Diagnosis is made by echo Treatment is balloon angioplasty with stent placement, or surgical correction Comments: Associated with Turner's syndrome
18 months ago, an elderly patient received a mitral valve replacement. Unfortunately, for the past year, he has been fighting subacute bacterial endocarditis. He has been admitted to the hospital 3 times in the past 6 months. Of all things, he is most concerned with unsightly changes of his palms. During inspection, you appreciate that both palms have several nontender macules of red to brown to black coloration. His daughter is getting married in 3 weeks, and he doesn't want people to see these "weird rashes" on his hands. Which of the following correctly names these findings? Janeway lesions Raynaud's phenomenon Roth spots Splinter hemorrhages
Correct Answer ( A ) Explanation: Septic emboli can also present with cutaneous findings, namely Janeway lesions, however, these are usually present in subacute rather than acute endocarditis. They are described as multicolored hemorrhagic macules which appear on the palms and soles. Treatment of prosthetic valve endocarditis of >1 year's duration is vancomycin plus gentamicin plus ceftriaxone, adjusted, of course, to culture results
Which of the following is a risk factor for the condition shown above? Bicuspid aortic valve Chronic heroin use Fibromuscular dysplasia Tobacco use
Correct Answer ( A ) Explanation: 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. Other risk factors include chronic cocaine use, bicuspid aortic valve, collagen disorders, pre-existing aortic aneurysm, aortic surgery or instrumentation, vasculitis involving the aorta, pregnancy and delivery, and aortic coarctation. 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. The presentation of aortic dissection depends on the anatomic location of the dissection, with the most common presentation being sharp or tearing chest pain. More distal aortic dissections may present with abdominal or flank pain. A history of diabetes, prior aortic surgery, or pre-existing aortic aneurysm may cause a painless presentation. Other presentations include syncope, stroke from carotid involvement, and spinal cord syndromes. CT angiogram is the gold standard for diagnosis of dissection.
A patient with an intermediate risk of coronary artery disease is undergoing an exercise stress test. Which of the following is the most specific finding for myocardial ischemia? 2 mm downsloping ST-segment depression 2 mm upsloping ST-segment depression Increase of systolic blood pressure Sporadic premature ventricular complexes
Correct Answer ( A ) Explanation: 2 mm downsloping ST-segment depression is the most specific finding for myocardial ischemia during an exercise stress test. Subendocardial ischemia during exercise produces ST-segment depression or elevation or both. ST-segment depression that occurs during exercise testing is one of the most identifiable ECG signs of myocardial ischemia. The ECG portion of the exercise test is generally considered abnormal, or positive for ischemia, when there is ≥ 1 mm horizontal or downsloping ST-segment depression in one or more leads. Horizontal or downsloping ST-segment depression is generally more specific for ischemia than upsloping ST-segment depression.
A 35-year-old woman is seen in the clinic with a chief complaint of frequent palpitations associated with symptoms of pre-syncope. She experiences these episodes two to three times per day. Her resting ECG in the office is normal sinus rhythm with heart rate 65/min. Her physical exam is unremarkable. Which of the following is the most appropriate next step in management? 24-48 hour continuous ambulatory ECG monitor Electrophysiologic testing Implantable loop recorder Post-symptom event recorder
Correct Answer ( A ) Explanation: 24-48 hour continuous ambulatory ECG monitor, also known as a Holter-monitor, is the most appropriate next step in management. It is one of the most frequently used and cost-effective noninvasive tests used to evaluate cardiac rhythm abnormalities. The clinical utility of the ambulatory ECG recording lies in its ability to continuously examine the patient's cardiac rhythm over an extended period of time during normal routine activity, including any physical and psychological changes. Various rhythm recorders can be used to capture a dysrhythmia. Selection depends on the frequency and duration of symptoms. A Holter monitor is worn for 24-48 hours and is used for evaluation of more frequent symptoms. This patients symptoms occur daily, so a 24-48 hour monitor is likely to capture a possible dysrhythmia during an episode of palpitations or pre-syncope.
Which of the following features can differentiate myocardial infarction from pericarditis? Chest pain ECG with reciprocal changes ECG with ST-segment elevations T wave flattening
Correct Answer ( B ) Explanation: Reciprocal ST-segment depressions should never be seen in patients with pericarditis and an ECG with this finding should always be assumed to be from myocardial ischemia or infarction. There is no single best test for pericarditis but clinicians rely on the ECG as the best tool. Early in the disease, the ECG findings of acute pericarditis can mimic those of acute myocardial infarction (MI). The differentiation is critical as timely treatment of MI improves outcomes. Additionally, thrombolytic therapy should not be given to patients with pericarditis as it may precipitate hemorrhage into the pericardial space.
A 65-year-old man presents to the ED for chest pain. You are concerned for acute coronary syndrome and want to administer aspirin, but the patient states that he develops angioedema to aspirin. Which of the following is the most appropriate next step in management? Administer clopidogrel Administer dipyridamole Administer the lower dose, 81 mg of aspirin and observe closely for angioedema Pretreat with corticosteroids and antihistamines and administer full-dose aspirin
Correct Answer ( A ) Explanation: A 162-325 mg dose of aspirin taken early in the course of myocardial infarction (MI) has been shown to produce a 23% reduction in 30-day mortality. Patients with an aspirin allergy are at risk for losing this benefit. The use of clopidogrel was shown in the CAPRIE trial to be a sufficient antiplatelet inhibitor when compared to aspirin. Therefore, in patients with true aspirin allergies, clopidogrel should be substituted for aspirin. Dipyridamole (B) is used to inhibit thrombus formation but has not been shown to reduce mortality in acute coronary syndrome. It is commonly used in combination with aspirin for the secondary prevention of stroke and TIA. With a true aspirin allergy, all doses of aspirin (C & D) are contraindicated.
Which of the following vital signs is considered abnormal in a 1-year-old patient? Heart rate of 160 beats per minute Oxygen saturation of 98% on room air Respiratory rate of 26 breaths per minute Systolic blood pressure of 85 mm Hg
Correct Answer ( A ) Explanation: A heart rate of 160 beats per minute would be considered tachycardia in a 1-year-old patient. The average heart rate for a 1-year-old is 120 beats per minute.
In which of the following clinical scenarios is an implantable cardioverter-defibrillator indicated for the prevention of ventricular dysrhythmias and sudden cardiac death? A patient with a left ventricular ejection fraction < 35% and heart failure NYHA Functional Class II or III A patient with a normal left ventricular ejection fraction and asymptomatic structural heart disease A patient with sustained ventricular tachycardia in the setting of an acute myocardial infarction A patient with sustained ventricular tachycardia in the setting of hyperkalemia
Correct Answer ( A ) Explanation: A patient with a left ventricular ejection fraction ≤ 35% and heart failure NYHA Functional Class II or III is a clinical scenario in which an implantable cardioverter-defibrillator is indicated. An implantable cardioverter-defibrillator is a small device combining a cardioverter and defibrillator into one implantable unit that is surgically placed in the chest or abdomen. It is battery powered and programmed to detect dysrhythmias, mainly sustained ventricular tachycardia and ventricular fibrillation, which can lead to sudden cardiac death. It has a very high success rate in rapidly terminating ventricular dysrhythmias and evidence shows that it improves survival. Implantable cardioverter-defibrillator implantation is generally considered the first-line treatment for the secondary prevention of sudden cardiac death in patients who have survived an event and for primary prevention in certain high risk populations. Published guidelines exclude cases that are considered "reversible causes." Some of the major indications are as follows.
Which of the following is the most common location of aortoenteric fistula formation? Duodenum Esophagus Jejunum Sigmoid colon
Correct Answer ( A ) Explanation: An aortoenteric fistula is an abnormal communication between the aorta and the gastrointestinal tract. Primary aortoenteric fistulas are caused by compression of gastrointestinal structures by an aortic aneurysm. Secondary aortoenteric fistulas result from erosion of an aortic prosthetic graft into an adjacent gastrointestinal structure. As such, abdominal aortic aneurysm and a history of aortic surgery are the most common risk factors for aortoenteric fistula formation. Other causes include reflux esophagitis, peptic ulcer disease, non-aneurysmal aortitis, and penetrating aortic ulcers. The duodenum is the most common site of fistula formation. The classic triad of gastrointestinal bleeding, abdominal pain, and a palpable mass is rarely present and a known history of aortic aneurysm is often lacking. Gastrointestinal bleeding, including hematemesis, hematochezia, and melena, is often the presenting symptom. Although massive hemorrhage is common, many patients will have a small "herald bleed," a seemingly self-limited episode of gastrointestinal bleeding, prior to a larger bleed. Complications include hemorrhage and sepsis from seeding of the blood with gastrointestinal flora. While uncommon, aortoenteric fistula should be on the differential diagnosis for gastrointestinal bleeds, especially in patients with a history of aneurysm or aortic surgery, as the condition is life-threatening. Management of aortoenteric fistulas is surgical repair.
A 74-year-old man is having a preoperative ECG performed. What is your interpretation of his ECG? Atrial fibrillation Atrial flutter Normal sinus rhythm Sinus tachycardia
Correct Answer ( A ) Explanation: Atrial fibrillation is an irregularly irregular rhythm due to uncoordinated atrial activation and random occurrence of ventricular depolarization. The atria are not contracting, but they do discharge electrical impulses to the ventricles. However, no single impulse depolarizes the atria completely, so only an occasional impulse gets through the AV node. It is the most common sustained dysrhythmia in clinical practice.
Which of the following conditions is a result of a rapid increase in pericardial pressure and a clinical picture of acute restrictive cardiomyopathy? Cardiac tamponade Constrictive pericarditis Pericardial effusion Pneumopericardium
Correct Answer ( A ) Explanation: Cardiac tamponade results from acute compression of the myocardium by rapid fluid (or gas) accumulation in the pericardial sac. Tamponade develops when fluid filling the pericardial sac accumulates faster than the rate of stretch in the parietal pericardium. The resulting extrinsic pressure on the myocardium exceeds right atrial pressure leading to a reduction in right ventricular filling. With a continued rise in pericardial pressure, cardiac compliance decreases. Flow of blood into the right side of the heart ceases, leading to a precipitous decline in cardiac output. Key to remember: the rate of fluid accumulation, not the absolute volume, is the important factor in the development of tamponade.
A patient is being discharged from the hospital after having a ST-elevation myocardial infarction. During his stay, he underwent percutaneous coronary intervention with placement of a drug eluting stent. The patient is being sent home on the following medications: aspirin 81 mg, metoprolol 50 mg, nitroglycerin 0.4 mg sublingual, and atorvastatin 40 mg. Which of the following should also be added to his regimen? AClopidogrel BFish oil CRanolazine DReteplase
Correct Answer ( A ) Explanation: Clopidogrel (Plavix®) is a platelet P2Y12 receptor blocker. Similar agents include ticagrelor (Brillenta®) and prasugrel (Effient®). Dual antiplatelet therapy with aspirin and a platelet P2Y12 receptor blocker (such as clopidogrel) decreases the risk of coronary artery stent thrombosis and its consequences of myocardial infarction or death more than the use of aspirin alone. The duration of therapy of dual antiplatelet therapy differs for each type of stent. The current recommendation is treatment with a platelet P2Y12 receptor blocker for at least one year after placement of a drug eluting stent and one month after bare metal stent. Aspirin should be continued indefinitely for all stented patients. Fish oil (B) is sometimes recommended for primary and secondary prevention of coronary artery disease but is not essential for post percutaneous coronary intervention therapy. Ranolazine (C) is an anti-anginal medication that is added only after calcium channel blockers, beta-blockers, and nitrates have failed to control angina. Reteplase (D) is a fibrinolytic agent used to treat ST-elevation myocardial infarctions when a catheterization lab is not readily available. None of these agents play a role in preventing stent thrombosis.
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
Correct Answer ( A ) Explanation: Dilated cardiomyopathy (DCM) is a complication of chronic hypertension and coronary artery disease. Patients with cardiomyopathy typically suffer from symptoms of cardiac failure, especially dyspnea and edema. If cardiac failure is suspected, the initial evaluation for underlying cardiomyopathy includes an echocardiogram. In DCM, the echocardiogram usually demonstrates an enlarged ventricular chamber with normal or decreased wall thickness. Ejection fraction, a marker of systolic function, will also typically be normal or decreased. Treatment of DCM follows the American College of Cardiology and the American Heart Association's guidelines for the treatment of heart failure. In addition to lifestyle modifications, pharmacotherapy includes ACE-inhibitors or ARBs, loop diuretics and beta-blockers. Bisoprolol is a selective beta-1 adrenergic receptor blocker. Bisoprolol, carvedilol, and metoprolol, but not propranolol (B), are the only beta-blockers with proven benefit in heart failure management. Salmeterol (C) is a long-acting beta-2-agonist used in treating bronchospasm and COPD, not heart failure.
Which of the following drugs is most likely to be associated with the development of atrial tachydysrhythmias? Ethanol Gamma hydroxybutyrate (GHB) Lorazepam Phenobarbital
Correct Answer ( A ) Explanation: Ethanol abuse is associated with the development of atrial dysrhythmias, specifically, atrial fibrillation. Alcohol ingestion (acute or chronic) has multiple effects on the cardiovascular system. It can exacerbate coronary artery disease, lead to cardiomyopathy and produce dysrhythmias. Left ventricular dysfunction is common in patients with moderate alcohol consumption. Additionally, these patients may have diastolic dysfunction. Supraventricular and ventricular dysrhythmias are common. The so called "holiday heart" that occurs with heavy drinking can present as atrial fibrillation or, in unusual cases, ventricular tachycardia. Additionally, electrolyte deficiencies (hypokalemia and hypomagnesemia) predispose to dysrhythmias.
Which of the following is the most common physical finding in patients with infective endocarditis? Heart murmur Janeway lesion Osler nodes Splinter hemorrhages
Correct Answer ( A ) Explanation: Infective endocarditis occurs when pathogens introduced to the systemic circulation invade the endocardial surface of the heart, including the heart valves. Staphylococcal and Streptococcal bacteria are the most common culprits. The clinical signs and symptoms of endocarditis are varied. Symptoms include fever, chills, dyspnea, weakness, nausea, vomiting, cough, and chest pain. Regarding physical findings, fever is the most common abnormality, seen in 90%. The majority of patients with endocarditis will have a heart murmur (85%). Approximately half of patients with endocarditis develop embolic phenomena, where septic microemboli break off and lodge in downstream tissues. Characteristic skin findings are somewhat less common. Osler nodes, tender lesions on the pads of the fingers, are seen in 10-23% of patients with endocarditis. Janeway lesions, nontender erythematous lesions on the extremities, are seen in 10%, and splinter hemorrhages, linear lines in under the nails, are seen in 15% of patients. The treatment of infective endocarditis involves antibiotic therapy targeted to the suspected pathogen, and stabilization of any hemodynamic instability.
Which of the following treatments has a proven mortality benefit in ST-elevation myocardial infarction? Aspirin Morphine Nitroglycerin Oxygen
Correct Answer ( A ) Explanation: ST elevation myocardial infarction (STEMI) occurs when there is thrombus formation causing a blockage of a coronary vessel. Common symptoms include gradual onset of chest tightness or pressure that radiates to the arms or neck. The classic teaching is to give morphine, nitroglycerin, oxygen, and aspirin for acute coronary syndrome. However, only aspirin has shown a mortality benefit. In recent prospective studies morphine (B) has been associated with a higher mortality rate but no causative relationship has been established. Although nitroglycerin (C) can help reduce ischemic pain through coronary vasodilation it does not reverse the underlying cause. It is not associated with a mortality benefit. Supplemental oxygen (D) is not associated with a mortality benefit and may even cause harm in non-hypoxic patients.
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? Aortic stenosis Atrial myxoma Orthostatic hypotension Vasovagal syncope
Correct Answer ( A ) Explanation: 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. 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.
Which of the following statements is true regarding giant cell arteritis? Aortic involvement can lead to valvular disease and dissection Corticosteroid therapy should be initiated only when biopsy confirms the disease Histologic findings of inflammation are irreversible It is associated with sudden, painful binocular vision loss
Correct Answer ( A ) Explanation: Temporal arteritis is a chronic segmental vasculitis of medium and large vessels. Although it most commonly affects one or more branches of the carotid artery (temporal artery, ophthalmic artery, and posterior ciliary artery), the aorta can also be involved. Aortic involvement can lead to valvular insufficiency, aortic arch syndrome, and dissection. The carotid and vertebrobasilar arteries can also be affected, which can lead to neurologic complications. The condition is associated with a markedly elevated erythrocyte sedimentation rate (50-100 mm/hr).
30-year-old man with ankylosing spondylitis presents for a routine physical. This is the first encounter that you appreciate a murmur during cardiac auscultation. You appreciate a diastolic, high pitched, blowing murmur while listening with the diaphragm in the left sternal border. There is no palpable thrill. Which of the following is the most likely diagnosis? Aortic regurgitation Aortic stenosis Mitral regurgitation Tricuspid stenosis
Correct Answer ( A ) Explanation: The murmur of aortic regurgitation is best heard with the diaphragm in the left sternal border. It can be accentuated when a patient sits and leans forward. This is a diastolic murmur, as compared to the systolic stenotic murmur of the same valve. It is often high pitched, blowing and decrescendo in nature. A widened pulse pressure is seen due to incompetence of this valve as it allows previously "pumped-out" blood to return back into the left ventricle. Common causes include rheumatic heart disease, trauma and endocarditis, and it can also be associated with Marfan's syndrome, syphilis and ankylosing spondylitis. Mitral regurgitation (C) is a pansystolic murmur best heard at the apex. Tricuspid stenosis (D) is a diastolic rumble heard over the left sternal border at the level of the fourth intercostal space. A right ventricular thrill is commonly palpated.
A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, shortness of breath and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to complain of chest pain. Vitals are unremarkable and the ECG reveals left ventricular hypertrophy. What management is indicated? Intravenous fluids and cardiology consultation Morphine sulfate and admit to telemetry Sublingual nitroglycerin and activation of the cardiac catheterization lab Sublingual nitroglycerin and admit to telemetry
Correct Answer ( A ) Explanation: The patient presents with syncope and a systolic murmur radiating to the neck, which suggests the presence of critical aortic stenosis. Management should focus on restoring preload and cardiology consultation. Aortic stenosis is the most common cardiac-valve lesion in the U.S. A normal aortic valve has an area of 3 cm squared. Reduction by 50% causes significant obstruction and critical aortic stenosis occurs with a valve area <0.8 cm squared. As the disease progresses, left ventricular hypertrophy develops to maintain cardiac output. Patients often are asymptomatic until aortic stenosis has progressed to severe or critical levels. At this point, they often develop angina (due to increased demand and decreased supply), exertional syncope (fixed cardiac output), and congestive heart failure (diastolic and systolic dysfunction). The classic physical examination finding is a crescendo-decrescendo, systolic ejection murmur that radiates to the bilateral carotid arteries. Additionally, carotid pulses may be both diminished and delayed. Once patients develop symptoms, survival is markedly reduced unless the valve is replaced. 50% of patients with angina die within 5 years, 50% with syncope die within 3 years and 50% with dyspnea die within 2 years. Immediate medical management should focus on restoring preload with fluids or blood transfusion if significant anemia is present. The only definitive treatment is valve replacement.
A 62-year-old man with a history of ongoing tobacco abuse, hypertension, dyslipidemia and erectile dysfunction complains of progressive aching pain in his right buttock and hip. The pain is worse with walking and is relieved with rest. Physical exam of the lower extremities reveals slightly diminished femoral, popliteal, and dorsalis pedis pulses. Which of the following is the most likely site of this patient's peripheral arterial disease? Aortoiliac artery Common femoral artery Popliteal artery Superficial femoral artery
Correct Answer ( A ) Explanation: This patient most likely has peripheral arterial disease in the right aortoiliac artery. Peripheral arterial disease is physiologically significant atherosclerosis of the aortic bifurcations or arteries of the lower limbs. It is strongly associated with smoking, diabetes mellitus, and aging and shares all the risk factors common to atherosclerosis. This patient presents with right hip and buttock claudication, diminished femoral pulses and erectile dysfunction. This presentation commonly represents atherosclerotic disease within the aortoiliac system and is sometimes referred to as Leriche syndrome. Classic claudication is characterized by leg pain that is consistently reproduced with exercise and relieved with rest. The degree of symptoms of claudication depends upon the severity of stenosis, the collateral circulation, and the vigor of exercise. Patients with claudication can present with buttock, hip, thigh, calf, or foot pain, alone or in combination. The usual relationships are between pain location and corresponding anatomic site of arterial occlusive disease. Peripheral arterial disease in the common femoral artery (B) may cause thigh pain with effort but would not result in erectile dysfunction. Peripheral arterial disease in the popliteal artery (C) would produce pain in the lower one-third of the calf. Peripheral arterial disease within the superficial femoral artery (D) usually produces an effort-related discomfort in the upper two-thirds of the calf.
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? Atrial fibrillation Atrial flutter Paroxysmal atrial tachycardia Sinus tachycardia
Correct Answer ( A ) Explanation: To analyze the heart rhythm on this ECG, a systematic approach is recommended.. First, look at the rate. This rate is fast (tachycardia), greater than 100 beats per minute. Then, look at the width of the QRS complex for a clue to where the impulse originates. The QRS complexes here are narrow so this is a supraventricular tachycardia. Next, evaluate the regularity of the rhythm. Is it regular or irregular? If the rhythm is irregular, is there still a pattern to the beats? If there is no pattern to the beats, it is irregularly irregular. If a rhythm is irregularly irregular, ask, "Is this atrial fibrillation?". This rhythm is irregularly irregular. Last, look for P waves and their relationship to the QRS. In this case there are no consistent P waves, confirming the diagnosis of atrial fibrillation.
A previously healthy 38-year-old woman presents to your office with complaints of dilated veins and itching in both lower legs that has been worsening since the birth of her last child. The symptoms are improved with elevation of her legs. Which of the following is the most effective management? Compression stockings Laser therapy Sclerotherapy Venous reconstruction
Correct Answer ( A ) Explanation: Varicose veins are a type of chronic venous disease or venous insufficiency. The spectrum of disease in venous insufficiency ranges from mild to severe, with milder forms being uncomfortable and cosmetically unappealing and more severe forms causing serious systemic manifestations. Venous insufficiency may or may not be symptomatic. When symptoms are present, they can range from venous dilation to skin changes to ulceration. The dilation of the veins occurs due to increased venous pressure, resulting in varicose veins or telangiectasias, which are smaller, spider veins seen on the surface of the skin. Varicose veins are more frequently seen in women and are a very common finding, occurring in approximately a quarter of all adults in the United States. Risk factors for the development of venous insufficiency include advanced age, pregnancy, prolonged standing, obesity, smoking, prior venous thrombosis, sedentary lifestyle and lower extremity trauma. Patients generally present with complaints of heaviness or pain in the legs, pruritus, burning sensations, restless legs or night cramps, edema and skin changes. Diagnosis is initially clinical and then confirmed with duplex ultrasound. Conservative management with leg elevation, compression stockings and exercise is the initial treatment in the majority of cases of varicose veins.
A 58-year-old man with chronic hypertension presents to the ED with acute, 10/10 tearing substernal pain that radiates to the back. All you can gather from him is that he also has some type of "collagen disorder" and diabetes. A chest radiograph reveals a widened mediastinum. As you prepare for a transesophageal echocardiogram, you would most likely start which of the following medications as a first-line agent? Clonidine Labetalol Lisinopril Nitroprusside
Correct Answer ( B ) Explanation: A classic aortic dissection involves an intimal tear and hemorrhagic extravasation into the intima-media space. Aortic dissections can be defined as proximal, affecting the ascending aorta, or distal, involving the descending aorta distal to the subclavian take-off. Several risk factors of this potentially fatal condition exist, and include hypertension, congenital aortic valve disorder (coarctation, root-dilatation or bicuspid valve), trauma, cardiac surgery, aortitis and connective tissue disorder. Both types are characterized by severe, "ripping or tearing" pain that is maximal at onset (as compared to the crescendo pain of an acute coronary syndrome) and located in the chest, back or abdomen. A new aortic insufficiency murmur is more common in proximal dissection, while a history of hypertension is more common in the distal type. Evaluation includes chest radiograph, chest CT and transesophageal echocardiogram. First-line therapy is intravenous beta-blockers, such as labetalol or esmolol, followed by vasodilators like nitroprusside. Emergency surgery is very likely, especially for proximal dissections.
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? Autonomic dysreflexia Hypertensive emergency Hypertensive urgency Sympathetic crisis
Correct Answer ( B ) Explanation: 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.
Which of the following murmurs is associated with an increase in right atrial pressure? Aortic regurgitation Mitral regurgitation Mitral stenosis Tricuspid regurgitation
Correct Answer ( D ) Explanation: Valve disorders are often characterized in terms of stenosis (incomplete opening of the valve, thereby increasing the resistance in blood flow) or regurgitation (an incomplete closure of a valve, resulting in a backflow of blood). The tricuspid valve is 1 of 2 atrioventricular (AV) valves and lies between the right atrium and right ventricle. In tricuspid regurgitation, there is incomplete forward flow from the right atrium into the right ventricle and blood flows from the right ventricle into the right atrium during systole. This backflow of blood results in increased right atrial pressure. Tricuspid regurgitation is caused by right ventricular dilation secondary to pulmonary hypertension, rheumatic heart disease, and infective endocarditis. Patients may complain of fatigue and dyspnea on exertion. On exam, there may be a holosystolic murmur best heard at the xiphoid area adjacent to the left sternal border. The aortic valve is one of 2 semilunar valves (the other being the pulmonary valve) and is positioned between the left ventricle and aortic trunk
Elective surgical repair should be offered to which of the following patients with asymptomatic abdominal aortic aneurysm? 22-year-old man with Ehlers-Danlos syndrome; aneurysm size 3.5 cm 42-year-old man with hypertension; aneurysm size 3.9 cm with 0.9 cm expansion in 6 months 52-year-old man with positive family history; aneurysm size 4.5 cm 62-year-old man with tobacco use; aneurysm size 4.5 cm with aneurysm growth 0.2 cm in two years
Correct Answer ( B ) Explanation: Abdominal aortic aneurysm (AAA) is defined as any infrarenal aortic diameter ≥ 3 cm. It occurs in men 5-10x more than women. Risk factors include family history (12-19% of first-degree relatives are affected), male sex, age, atherosclerosis, tobacco use and hypertension. The underlying pathology involves oxidative stress, aortic wall inflammation and proteolytic degradation of elastin and collagen. Abdominal ultrasound screening is recommended in any male aged 65-75 years who has ever smoked. Most AAAs are asymptomatic and found incidentally during other diagnostic testing. However, if found, AAAs must be monitored, as size, and not comorbidity, usually dictates management. Elective surgical correction of an asymptomatic AAA is offered to patients when an AAA grows ≥ 5.5 cm, or grows more than 0.6 to 0.8 cm over 6 months. Therefore, the 42-year-old man with hypertension aneurysm size 3.9 cm with 0.9 cm expansion in 6 months should undergo elective repair. Those with AAAs < 5.5 cm, or growth ≤ 0.6 cm per year (A, C and D) are followed with serial ultrasound monitoring, no matter what the age or underlying comorbidity.
What is the most common side effect following administration of intravenous amiodarone? Bradycardia Hypotension Nausea Widening of the QRS interval
Correct Answer ( B ) Explanation: 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
A 35-year-old woman is being managed for multiple episodes of chest pain that have been awakening her from sleep on several early mornings for the past 2 months. An electrocardiogram after one episode showed ST elevation. Coronary angiography did not reveal any stenotic lesions. She has no cardiac risk factors and is otherwise healthy. Which of the following daily medications is most likely to provide relief from her condition? Adenosine Amlodipine Aspirin Propranolol
Correct Answer ( B ) Explanation: Amlodipine is the most appropriate selection to use as daily prophylaxis against the anginal pain caused by Prinzmetal (variant) angina. Amlodipine, as well as other long-acting calcium channel blockers and nitrates, is effective at preventing the coronary vasospasm responsible for the chest pain seen in Prinzmetal's angina. This syndrome most commonly occurs in women under 50 years of age, with a classic presentation being angina in the early morning that awakens a patient from sleep. Of note, Prinzmetal's angina is not brought on by typical factors responsible for aggravating the angina of atherosclerosis, and patients may have no coronary risk factors. The work-up of any chest pain of suspected cardiac origin would include an electrocardiogram which, in this case, would show ST-segment elevation in the distribution of the vasoconstricted coronary artery. Coronary angiography will also be helpful to rule out a stenotic lesion in need of intervention. If Prinzmetal angina without a complicated stenotic lesion is diagnosed, patients should be counseled to avoid substances that contribute to vasoconstriction. Two important contributors are cigarette smoking and the use of cocaine. Treatment should consist of daily calcium channel blockers or nitrates to prevent vasoconstriction, and break-through nitrates as needed for acute episodes.
Which of the following describes the correct management of aortic dissection? All aortic dissections eventually need surgical or endovascular repair Crystalloids are the preferred treatment of hypotension in the setting of aortic dissection Stanford type A dissections should be managed chronically with negative inotropes Vasodilators are the preferred treatment of hypertension in the setting of aortic dissection
Correct Answer ( B ) Explanation: 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 managed
Which of the following is commonly the first reported symptom of aortic stenosis? Chest pain Dyspnea Syncope Vomiting
Correct Answer ( B ) Explanation: In aortic stenosis, structural damage to the aortic valve obstructs ventricular outflow. The most common cause of aortic stenosis in the United States is degenerative calcification, also known as calcific aortic stenosis. Incidence is associated with traditional cardiovascular risks factors of age, hypertension, hyperlipidemia, diabetes, and tobacco use. Bicuspid aortic valves, in which the normal trileaflet aortic valve has only two leaflets, is another cause of aortic stenosis, particularly in younger individuals. Worldwide, rheumatic heart disease is a major cause of aortic stenosis. When aortic stenosis develops, there is typically a long asymptomatic period, during which the left ventricular hypertrophies to compensate for the outflow obstruction, and cardiac output is preserved. However, when ventricular wall is so thickened as to impede diastolic filling, cardiac output is decreased and symptoms appear. The classic triad of aortic stenosis is known by the acronym SAD: syncope, angina, and dyspnea. Dyspnea is often the first symptom to appear, followed by chest pain, and then syncope (classically with exertion) and clinical signs and symptoms of heart failure. The characteristic murmur of aortic stenosis is a harsh systolic ejection murmur heard best at the right second intercostal space radiating to the carotids. A narrowed pulse pressure may also be present.
62-year-old man with a history of hypertension and tobacco abuse presents with acute onset of sharp epigastric abdominal pain with radiation to his back. On arrival, his vitals signs are T 37.3°C, HR 100, BP 180/90 in the right arm and 80/40 in the left arm, RR 27. Which of the following agents is the first line management of this patient's condition? Diuretics Negative inotropes Vasodilators Vasopressors
Correct Answer ( B ) Explanation: Aortic dissection occurs when damage of the intima allows the entry of blood between the intima and media, creating a false lumen. The presentation of aortic dissection depends on the anatomic location of the dissection, with the most common presentation being sharp or tearing chest pain. Hypertension is typically present and hypotension is a poor prognostic indicator. A difference in blood pressures between opposite arms and a pulse deficit may also occur. 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. 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 or esmolol, are the first line agents. For persistent hypertension despite maximal therapy with negative inotropes, vasodilators can be used.
Which of the following is an indication for permanent pacemaker placement? Asymptomatic Mobitz type I second-degree AV block Asymptomatic Mobitz type II second degree heart block Asymptomatic sinus bradycardia with heart rate of 40/min Asymptomatic three second sinus pauses
Correct Answer ( B ) Explanation: Asymptomatic Mobitz type II second-degree AV block is an indication for pacemaker placement. This block has a high risk of progressing to complete heart block and should be treated with pacemaker placement, regardless of symptoms. In general, the long term treatment for symptomatic sinus bradycardia or heart block without reversible cause is a permanent pacemaker. These devices are usually placed in the left pectoral area with leads inserted through a vein into the heart. Two general factors guide the decision to place a permanent pacemaker: the association of symptoms with a brady-dysrhythmia and the potential for progression of the rhythm disturbance. Progression is largely dependent on the anatomical location of the conduction abnormality. The location of an AV conduction abnormality, within the AV node or below the AV node in the His-Purkinje system is an important determinant of both the probability and progression rate of conduction system disease. Disease below the AV node, in the His-Purkinje system, is generally considered to be less stable. The most common indications for pacemaker implantation are sinus node dysfunction followed by AV block. Sinus bradycardia in which symptoms such as dizziness, lightheadedness, syncope, fatigue, or poor exercise tolerance are present should be treated. Acquired AV block is the second most common indication for permanent pacemaker placement. Complete, or third-degree AV block, advanced second-degree AV block, symptomatic Mobitz I or Mobitz II second-degree AV block are all indications for pacemaker placement. Asymptomatic sinus bradycardia with heart rate of 40/min (C), asymptomatic Mobitz type I second-degree AV block (A) and asymptomatic three second sinus pauses (D) are not indications for a pacemaker in the absence of symptoms.
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 she remain on anticoagulation after cardioversion? Five days Four weeks One year Three months
Correct Answer ( B ) Explanation: 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.
Which of the following patients with atrial fibrillation has the greatest risk for complications from anticoagulation therapy? A 64-year-old woman with hypertension and history of colon cancer A 66-year-old man with a history of hypertension, diabetes, and ethanol abuse A 79-year-old man with a history of congestive heart failure A 90-year-old otherwise healthy woman
Correct Answer ( B ) Explanation: Atrial fibrillation is associated with arterial thromboembolism and ischemic stroke; therefore, anticoagulation is recommended in most cases. The HAS-BLED risk score is based upon seven risk factors for bleeding, including age > 65 years, and has been recommended within the European Society of Cardiology and Canadian guidelines for assessing the risk of bleeding in atrial fibrillation management. The 66-year-old man with a history of hypertension, diabetes, and ethanol abuse has a HAS-BLED score of 3 which corresponds to a high risk for bleeding
Which of the following best describes the finding seen in the ECG above? Left bundle branch block Right bundle branch block Third-degree AV block Type I second-second degree AV block
Correct Answer ( B ) Explanation: Bundle branch blocks are abnormal conduction abnormalities (not rhythm disturbances) in which the ventricles depolarize in sequence, rather than simultaneously, thus producing a wide QRS complex (> 120 msec) and a ST segment with a slope opposite that of the terminal half of the QRS complex. A right bundle branch block (RBBB) is a unifascicular block in which ventricular activation is by way of the left bundle branch. The impulse travels down the left bundle, thus activating the septum from the left side (as it normally does in the absence of RBBB). This is followed by activation of the free wall of the left ventricle and finally the free wall of the right ventricle. Because of the two changes in direction, there is a tendency toward triphasic complexes in a RBBB (RSR'). The ECG in a RBBB will show a wide S wave in lead I and a RSR' pattern in lead V1.
How do you calculate mean arterial pressure (MAP)? [DBP = diastolic blood pressure, SBP = systolic blood pressure] MAP = [DBP + (2 x SBP)]/3 MAP = DBP + 1/3(SBP-DBP) MAP = DBP + 2/3(SBP-DBP) MAP = SBP + 1/3(SBP-DBP)
Correct Answer ( B ) Explanation: Calculation of the mean arterial pressure (MAP) provides a weighted average of the systolic blood pressure (SBP) and the diastolic blood pressure (DBP). It is a determination of tissue perfusion and is normally 70-100 mm Hg in adults. A MAP of approximately 60 is necessary to perfuse the coronary arteries, brain, and kidneys.
Which of the following is a mainstay for the treatment of Kawasaki disease during the acute febrile phase? Aspirin - low dose Intravenous immunoglobulin (IVIG) Steroids Warfarin
Correct Answer ( B ) Explanation: Intravenous immunoglobulin (IVIG), as well as 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 to 12 hours. High dose aspirin (80-100mg/kg/day divided into 6 hour dosing regimens) is continued until the child is afebrile for 48 to 72 hours or longer.
A 58-year-old woman presents with progressive orthopnea and peripheral edema. She also gets "winded" when she climbs a full flight of stairs. Which of the following laboratory tests helps define a cardiac versus a pulmonary cause of dyspnea? Beta-2 microglobulin Beta-type natriuretic peptide Erythrocyte sedimentation rate Homovanillic acid
Correct Answer ( B ) Explanation: Cardiomyopathy is defined as a group of diseases which involve the muscle or electrical system of the heart. There are several causes, most of which are genetic in nature. Other etiologies are related to infectious, autoimmune, inflammatory, infiltrative, toxic, electrolytic, endocrine, nutritional and radiation etiologies. There are four main types: dilated, hypertrophic, restrictive and arrhythmogenic-right-ventricular (fibro fatty infiltration of the right ventricle). Dilated cardiomyopathy (DCM) is the most common subtype. It is the third most common cause of cardiac failure, behind coronary artery disease and hypertension. Adult DCM is most commonly caused by hypertension and coronary artery disease, but also is caused by genetic and infectious etiologies. Patients usually present with symptoms of heart failure, such as peripheral and pulmonary edema, cough, orthopnea and dyspnea at rest, with exertion or of the paroxysmal-nocturnal type. Initial evaluation of a patient with these symptoms includes electrocardiography, echocardiography, chest radiography and baseline chemistries, namely Beta-type (Brain) natriuretic peptide (BNP). BNP is secreted by the cardiac myocytes in response to increased volume and filling pressures. Beta-2 microglobulin (A) is used to evaluate hematologic disorders like multiple myeloma, lymphoma and leukemia. It is also associated with multiple sclerosis and other CNS disorders, as well as renal tubular disorders. Erythrocyte sedimentation rate (C) is a marker of inflammation. It is not a reliable test in differentiating cardiac from pulmonary dysfunction. Homovanillic acid (D) is a biomarker of metabolic stress in the central nervous system, not the cardiac or pulmonary systems.
What is the most commonly seen symptom or sign in patients with acute aortic dissection? Aortic insufficiency murmur Chest pain Pulse deficit Syncope
Correct Answer ( B ) Explanation: Chest pain is the most common symptom seen in patients with acute aortic dissection. Aortic dissection is an uncommon presentation but it represents a difficult and life-threatening diagnosis. Difficulty in diagnosing the disease stems from the myriad of presentations and manifestations the disease can assume. Approximately 73% of patients with acute aortic dissection will present complaining of chest pain. This symptom is more common in those patients with ascending dissections whereas back pain is more common in those with descending thoracic dissections. Some complaint of pain is seen in up to 96% of patients. The pain is classically described as ripping or tearing but only about 50% of patients will describe it in this way.
A bicuspid aortic valve is often associated with which of the following findings? Abdominal aortic aneurysm Dilation of the ascending aorta Left atrial dilation Patent foramen ovale
Correct Answer ( B ) Explanation: Dilation of the ascending aorta is frequently associated with a bicuspid aortic valve. Bicuspid aortic valve disease is one of the most common congenital heart lesions, occurring in approximately 1% of the population. Bicuspid aortic valve has an increased prevalence associated with congenital lesions such as coarctation of the aorta or Turner syndrome. More than 70% of patients with a bicuspid valve will require surgical intervention for a stenotic or regurgitant valve or aortic pathology over the course of a lifetime. Dilation of the ascending aorta in the setting of a bicuspid valve was previously considered a secondary event due to abnormal aortic valve function; however, it is now recognized to be caused by intrinsically abnormal connective tissue. As a result, serial evaluation of ascending aortic diameter should be performed by transthoracic echocardiography.
Which of the following is a minor Jones criteria for the diagnosis of acute rheumatic fever? Carditis Fever Polyarthritis Sydenham chorea
Correct Answer ( B ) Explanation: Fever is one of 6 minor Jones criteria for the diagnosis of acute rheumatic fever (ARF). ARF results from molecular cross-reactivity between streptococcus and host cell proteins resulting in antibody formation. This is a type II hypersensitivity inflammatory reaction. Diagnosis is based on the Jones criteria, which contains major and minor criteria. A patient is determined to have ARF if they have evidence of a prior group A streptococcus infection along with either 2 major criteria or 1 major and 2 minor criteria. Aside from fever, the other minor criteria are previous history of ARF, arthralgia, elevated ESR/CRP, prolonged PR interval and rising antistrep antibody titers. Patients should be investigated for rheumatic heart disease. Treatment usually starts with treating residual group A streptococcal infection and treatment of pain and inflammation with non-steroidal anti-inflammatory agents, salicylates and steroids.
Which of the following is a class IC anti-arrhythmic? Amiodarone Flecainide Lidocaine Procainamide
Correct Answer ( B ) Explanation: Flecainide is a class IC anti-arrhythmic drug. All class I anti-arrhythmics exert their action at the fast sodium channels. The subsets of class I relate to how the drugs affect depolarization, repolarization and conduction. The class IC drugs slow depolarization and conduction. Flecainide is most commonly used in the treatment of supraventricular tachycardias as well as ventricular tachycardia not related to acute ischemia.
A 67-year-old woman with New York Heart Association class III congestive heart failure presents to clinic for a routine examination. Her chief complaint is worsening peripheral edema. Which of the following abnormalities would you most expect to find during a physical examination? Finger-nail clubbing Jugular venous distension Pancreatic duct congestion Pulsus paradoxus
Correct Answer ( B ) Explanation: Heart failure takes on many forms, however, the overall pathology is a failure to pump blood forward at a sufficient rate. Etiologies include ischemic heart disease (coronary atherosclerotic disease) and cardiomyopathy. Cardiac failure can be backward, or "congestive", versus forward, or "impaired perfusion". Impaired perfusion symptoms include fatigue, weakness, poor appetite, mental status changes and exercise intolerance. Left-sided congestive failure results in dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, crackles and pulmonary basilar dullness to percussion. Right-sided failure causes peripheral edema, RUQ discomfort, bloating, ascites, hepatosplenomegaly, hepatojugular reflux, jugular venous distension and increased jugular venous pulsation. Congestive failure is also associated with an S3 heart sound. Pulsus paradoxus (D) is a systolic blood pressure drop of ≥ 10 mm Hg during inspiration. It is commonly seen in pericardial tamponade, but not congestive heart failure.
A 49-year-old man presents with chest pain. His medical history does not list any cardiac murmur, however, during examination, you hear a mitral regurgitant murmur. Blood pressure is equal in both the left and right arms. Although you have none to compare to, you order an electrocardiogram and notice ST segment depression in three different leads and T-wave inversion in two different leads. No other abnormalities are appreciated. A chest radiograph is read as normal. Initial lab testing shows an elevated troponin level. Which of the following is the most correct diagnosis? Aortic dissection Non ST-segment elevation myocardial infarction ST-segment elevation myocardial infarction Unstable angina
Correct Answer ( B ) Explanation: Myocardial infarction encompasses both non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). It is defined as myocardial cell death and necrosis as diagnosed by a rise and fall in cardiac enzymes (in association with appropriate clinical presentation) or by pathologic findings of prior myocardial infarction (e.g. new Q waves on ECG). NSTEMI represents subtotal coronary thrombosis and myocardial ischemia infarct. Common symptoms include angina less than 30 minutes duration, dyspnea, diaphoresis and palpitations. Myocardial insult is also associated with a new-onset mitral regurgitation murmur, newly-auscultated S4 and a paradoxical S2. New infarcts can be identified with a positive troponin on laboratory testing.
Nitrate therapy works by which of the following mechanisms? Reducing afterload Reducing both preload and afterload Reducing cardiac contractility Reducing preload
Correct Answer ( B ) Explanation: Nitrates work by reducing both preload and afterload. Nitroglycerine was the first treatment for angina pectoris and dates back to the 1800s. It still remains first-line drug therapy for many patients. Nitrates dilate veins and coronary arteries and to a lesser extent systemic arteries by relaxing vascular smooth muscle. Thus, nitrates reduce preload by increasing venous capacitance and improve coronary blood flow by coronary vasodilatation. Decreased preload lowers left ventricular end-diastolic pressure, thereby decreasing wall stress, resulting in a decrease in myocardial oxygen demand. At higher doses the afterload effects cause a drop in systemic blood pressure further decreasing wall stress and oxygen demand. Nitrates do not have a direct effect on cardiac chronotropy or inotropy. The primary adverse effects induced by nitrate therapy include hypotension, headache, and tachycardia. Nitrates should be avoided in patients with one or more of the following: systolic blood pressure less than 90 mm Hg, heart rate less than 50/min, or heart rate greater than 100/min. It should also be avoided in known or suspected right ventricular infarction, in patients who have taken a phosphodiesterase inhibitor for erectile dysfunction within the last 24 hours, in patients with hypertrophic cardiomyopathy or severe aortic stenosis.
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? Atelplase Clopidogrel Digoxin Metoprolol
Correct Answer ( B ) Explanation: Non-ST-elevation myocardial infarction (NSTEMI) treatment begins with a basic anti-ischemic regimen consisting of oxygen, morphine, nitrates, and possibly beta-blockers and ACE-inhibitors. Antiplatelet medications are then considered. Choices include aspirin, clopidogrel, and prasugrel. NSTEMI treatment is rounded out with anticoagulants such as enoxaparin, bivalirudin, and fondaparinux. Based on risk stratification, definitive treatment may include medications-alone, angiography, percutaneous cardiac intervention or coronary artery bypass surgery. Clo
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? 50% ejection fraction Continued chest pain Elevated atrial natriuretic peptide R wave progression
Correct Answer ( B ) Explanation: Patients with unstable angina are mostly admitted to a critical care unit after initial presentation. There, an anti-ischemic regimen, if not already begun, is initiated. This typically includes oxygen, nitrates, analgesics and beta-blockers. Serial monitoring for new dysrhythmias, recurrent ischemia, dynamic electrocardiography, changing laboratory results and worsening angina is necessary to maximize patient outcomes. Further management includes risk stratification to determine if early invasive treatment is appropriate. High-risk indicators that favor early invasive treatment strategies include hemodynamic instability, elevated troponin I or T levels, a history of CABG, a history of percutaneous coronary intervention (PCI) within the past 6 months, recurrent angina despite anti-ischemic therapy, symptoms of congestive heart failure (S3, pulmonary edema, crackles, mitral regurgitation) or an ejection fraction < 40%. An ejection fraction < 40%, not 50% (A), favors early invasive treatment of unstable angina. Whereas elevated B-type natriuretic peptide is associated with poor outcomes in patients with unstable angina, atrial natriuretic peptide (C) is not. It is however responsible for water, sodium and potassium homeostasis. Its action is opposite of aldosterone. R wave progression (D) is not indicative of invasive management of unstable angina. New or presumably new ST depression is, however.
A young woman with Raynaud's phenomenon presents with a 3 month history of cyclical short episodes of chest pain. Her social history is positive for intermittent cocaine use. The pain occurs most commonly after she wakes in the morning, lasts for 20 minutes, then resolves. This pain occurs at rest and is not worse with exercise or increased activity. Which of the following would you most expect to find during an evaluation of these symptoms? ACoronary artery stenosis BNormal exercise stress test CPain relief during ergonivine administration DST-segment depression
Correct Answer ( B ) Explanation: Prinzmetal's angina, also known as variant angina, is due to endothelium dysfunction and coronary vasospasm. It can occur in normal or diseased arteries. It commonly occurs in younger women who do not have the typical cardiac risk factors, except for tobacco use, however, it can be associated with atherosclerosis as well. It is associated with other vasospastic conditions such as migraine headache and Raynaud's phenomenon. Predisposing factors in developing coronary vasospasm include cocaine and tobacco use, cold weather and psychological stress. Symptoms include cyclical angina that occurs at rest, most commonly in the early morning and late evening hours, and is not made worse with exercise or other cardiac loading. Dysrhythmias are common and can be fatal. It is diagnosed by observing angina with transient ST-segment elevation, especially with increasing doses of intravenous ergonovine or acetylcholine. Exercise treadmill testing is normal in patients with Prinzmetal's angina as this condition is not due to increasing cardiac demand. Successful treatment can be accomplished with medications. Prognosis is favorable when there is no concordant coronary atherosclerosis or stenosis.
A previously healthy 27-year-old woman presents to your clinic with concerns about screening for cholesterol. She has never smoked, is physically active, and is in the normal range for body mass index and blood pressure. She says that her father started taking medication for hyperlipidemia at age 66 and she wants to know when she should start being screened. Which of the following is the most appropriate next step in management? Initiate lipid screening at age 35 Initiate lipid screening at age 45 Initiate preventative therapy with aspirin Initiate preventative therapy with lovastatin
Correct Answer ( B ) Explanation: Screening for lipid abnormalities is a part of determining overall cardiovascular risk. Lipid-lowering therapy is one way to improve cardiovascular outcomes and patients at risk should be screened to evaluate the need for treatment with aspirin or statins. The need for and timing of screening is determined by assessing patient risk factors including age, sex, and other risk factors for cardiovascular disease such as smoking, hypertension and family history of premature coronary heart disease. Patients are at higher risk if they have more than one risk factor or a single risk factor that is severe. Examples of severe single risk factors include a heavy smoking history or multiple first-degree family members with coronary heart disease at a young age. Women determined to be at low risk should start screening for lipid abnormalities at age 45. Men at low risk should start screening at age 35.
A 55-year-old man presents after a syncopal event. He states he just started a new blood pressure medication. His heart rate is 41 beats/minute and his blood pressure is 95/60 mm Hg. Electrocardiogram shows sinus bradycardia. Which of the following medications should be administered? Adenosine Atropine Diltiazem Procainamide
Correct Answer ( B ) Explanation: Sinus bradycardia refers to a discharge rate from the sinoatrial node of < 60 beats/minute. Sinus bradycardia can be a result of pathologic factors like hypoxia, hypothermia, cardiac ischemia or infarction, hypothyroidism, or increased intracranial pressure. Many medications also cause sinus bradycardia, including beta-blockers, calcium-channel blockers, digoxin, and opioids. Sinus bradycardia may also be a normal finding in well-conditioned young people, athletes, during sleep, or as a result of vagal stimulation. On electrocardiogram, sinus bradycardia is indistinguishable from sinus rhythm other than having a slower rate. Patients with sinus bradycardia may be asymptomatic or may complain of dizziness or lightheadedness. An especially slow rate may result in signs of hypoperfusion (e.g. hypotension, altered mental status, or ischemic chest pain). The treatment of sinus bradycardia depends on the underlying cause and the clinical effects. Underlying causes should be corrected. Unstable patients should be treated with atropine while transcutaneous pacing is initiated and arrangements for transvenous pacing are made. Infusions of dopamine or epinephrine are also indicated to increase the heart rate if atropine is ineffective. Glucagon is used to treat cardiotoxicity from beta-blocker or calcium channel blocker overdose.
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? Aggressive diuresis Cardiac transplantation Implantable intracardiac pacing Surgical myectomy
Correct Answer ( B ) Explanation: The management of hypertrophic cardiomyopathy should follow heart failure treatment guidelines. This includes a careful use of diuretics, as many patients with HCM require higher filling pressures to maintain cardiac function. This is especially true if edema is not a main finding. Negative inotropes and negative chronotropes are also recommended, and include beta-blockers and calcium channel blockers. If pharmacotherapy is unsuccessful, further treatment is dictated by whether the hypertrophic cardiomyopathy is obstructive or nonobstructive. If obstructive physiology is detected, surgical options may be required, and include cardiac pacing, surgical myectomy or septal ablation. If nonobstructive physiology is found, cardiac transplant is usually the only viable solution.
A 58-year old man is brought to the ED for chest pain that started 30 minutes prior to arrival while he was jogging in the park. Initially, the patient's cardiac monitor shows sinus tachycardia with a rate of 120 beats per minute. However, while you are interviewing the patient in the resuscitation bay, he suddenly becomes pale, pulseless, and the above rhythm is seen on the cardiac monitor. Which of the following is the definitive next step to manage this rhythm? Chest compressions Defibrillation Epinephrine Synchronized cardioversion
Correct Answer ( B ) Explanation: The treatment of ventricular fibrillation depends upon whether the onset was witnessed or unwitnessed. If the cardiac arrest is witnessed (as in this case) and of short duration with an initial rhythm of ventricular fibrillation or tachycardia, the patient should receive immediate defibrillation with 200 joules biphasic (or 360 joules monophasic). Newer biphasic defibrillators are preferred. They have a better first-shock success rate than the older monophasic models have while delivering less electrical current and causing less myocardial cell damage.
Which of the following patients should receive prophylactic antibiotics to prevent endocarditis? 18-year-old pregnant woman with a history of a repaired congenital heart defect, with an impending vaginal delivery 19-year-old woman with a history of endocarditis who is undergoing a dental extraction 20-year-old man with a prosthetic heart valve who requires a Foley catheter due to urinary obstruction 21-year-old man with a history of a heart transplant and valvulopathy who is undergoing suture repair of a facial laceration
Correct Answer ( B ) Explanation: This patient meets high-risk criteria (history of endocarditis) and requires antibiotic prophylaxis. The American Heart Association has published guidelines regarding prophylaxis for infective endocarditis in high-risk patients undergoing dental or invasive respiratory procedures.
A 35-year-old woman on oral contraceptives presents for evaluation of thigh pain and swelling. She was seen 6 days ago for the same complaint and had a negative ultrasound. Which of the following is the most appropriate plan? CT venogram Diuretic therapy Reassurance Repeat Doppler ultrasound
Correct Answer ( D ) Explanation: Venous doppler ultrasound performed by a qualified sonographer has a sensitivity and specificity of approximately 95% in the detection of deep vein thrombosis (DVT) of the proximal leg. The evaluation typically includes three different points: common femoral vein, superficial femoral vein and the popliteal vein. In patients with a high pre-test probability (as in this case of a woman on oral contraceptive medication), a repeat doppler ultrasound is indicated in patients with persistent symptoms. An alternative approach on the initial visit is to also perform a d-dimer which if negative in combination with the three-point ultrasound excludes the diagnosis of DVT.
A 34-year-old woman presents to the ED with chest pain that is worse with inspiration and better upon leaning forward. She has had a runny nose and cough for the last week. In the ED, her vital signs are BP 134/78, HR 86, RR 14, oxygen saturation 99% on room air, and T101°F. On exam, a friction rub is heard. An ECG displays global ST segment elevation with PR segment depression. What is the most likely diagnosis, and what would be the next step in management? Acute myocardial infarction; give aspirin, nitroglycerin, consult cardiology, and activate the cath lab Acute pericarditis; give nonsteroidal anti-inflammatory drugs Cardiac tamponade; perform immediate pericardiocentesis Pulmonary embolism; order CT angiography of the chest
Correct Answer ( B ) Explanation: This patient most likely has acute pericarditis, which is inflammation of the pericardial sac. Patients present with pleuritic chest pain that is typically worse when lying supine, deep inspiration, or swallowing. The pain is usually relieved by leaning forward. On auscultation, a pericardial friction rub may be heard. Pulsus paradoxus may also be observed, which is a fall in systolic blood pressure of greater than 10 mmHg with inspiration. Pericarditis can have many etiologies including infection, systemic connective tissue diseases, uremia, post-radiation, or post-myocardial infarction (Dressler's syndrome). Although there is no definitive diagnostic test, an ECG can demonstrate diffuse ST segment elevation, diffuse PR segment depression, and PR elevation in aVR (thumbprint sign). Treatment of pericarditis is mainly supportive. NSAIDs will reduce inflammation and pain. Steroids or colchicine may be given for refractory cases.
A 64-year-old man with a history of hypertension presents to the Emergency Department requesting medication refills. He states that he has not taken his medications for the last 2 weeks. His blood pressure is 190/100. He has no complaints at this time. He has prescription bottles for atenolol and hydrochlorothiazide. What management is indicated? Change his medications to a calcium-channel blocker Give the patient a prescription for his medications and refer to his primary doctor in 48 hours Start intravenous labetalol and admit to the floor Start intravenous labetalol and admit to the intensive care unit
Correct Answer ( B ) Explanation: This patient presents with asymptomatic hypertension in the setting of medical non-compliance and should be restarted on his medications and scheduled for follow up with a primary care provider. Accelerated hypertension is defined as markedly elevated blood pressure in the absence of symptoms. This is in contrast with hypertensive emergency where the patient has symptoms or evidence of end organ system dysfunction or both as a result of elevated blood pressure. Accelerated hypertension has a poor long-term prognosis if not controlled but does not pose an immediate threat. As such, it should not be aggressively treated with parenteral medications. Rapid lowering of blood pressure in patients with chronic elevated blood pressure can cause organ hypoperfusion, particularly brain hypoperfusion, and lead to serious sequelae. These patients should be restarted on their medications (if appropriate) and sent for follow up with a primary care physician to monitor and treat the elevated blood pressure.
A 27-year-old woman presents to the emergency department with complaints of fever, rash, and myalgias. She also admits to night sweats and nausea. On exam, there are multiple scars in her left antecubital fossa, scattered petechiae, and tender nodules on the tips of her digits. Cardiac auscultation reveals a murmur. Which of the following is the most likely diagnosis? Acute pericarditis Bacterial endocarditis Community-acquired pneumonia Hypertrophic cardiomyopathy
Correct Answer ( B ) Explanation: This woman most likely has bacterial endocarditis caused by intravenous drug use. Infective endocarditis is an infection of the endocardial or valvular surfaces of the heart. Underlying valvular disease is present in about half of cases. Colonization of the valve by bacteria or fungi can occur during dental, upper respiratory, urologic, or surgical procedures. Intravenous drug use (IVDU) is also a source of bacteremia. Most cases of native valve endocarditis are caused by Streptococcus species, including S viridans. Staphylococcus aureus accounts for over 60% of endocarditis associated with IVDU. The tricuspid valve is most commonly affected in IVDU associated endocarditis. Almost all patients have fever. Other nonspecific symptoms include chills, anorexia, weight loss, myalgias, and malaise. Dyspnea and cough are common complaints when the tricuspid valve is affected due to embolic showering of the pulmonary vasculature. Roth spots (retinal hemorrhages), Osler nodes (distal digital subcutaneous nodules), and Janeway lesions (nontender maculae on palms and soles) are caused by peripheral emboli. Petechiae are the most common skin finding. Blood cultures are key in the diagnosis of infective endocarditis. Three sets of blood cultures should be obtained prior to initiating antibiotics. Transthoracic echocardiography can be used initially, but cannot be used to rule out endocarditis due low sensitivity. Transesophageal echocardiography has a sensitivity of 90-100% for valvular lesions. Electrocardiography is usually nonspecific. The Modified Duke criteria can aid in the diagnosis. Treatment depends on underlying history and suspected etiology, but empiric IV antibiotic regimens should be initiated prior to obtaining culture results.
A 44-year-old woman presents with a three day history of pleuritic chest pain radiating to the back. It is worsened by lying supine. On examination, a friction rub is appreciated when she leans forward. Which of the following would you expect to see on her ECG? APeaked T waves in V1-V6 BPR depression in aVR CPR depression in II, aVF, and V4-V6 DST segment elevation in the anterior leads with reciprocal changes inferiorly
Correct Answer ( C ) Explanation: While PR depression is seen in most leads, the PR segment is elevated in aVR (B). Diffuse ST elevations and PR depressions in V2-V6, I, II, III, aVL and aVF are seen in the first hours to days of illness with reciprocal ST depression and PR elevation in aVR. In contrast to changes seen in acute myocardial infarction, the ST segments are concave, diffuse and not associated with T wave inversions initially. Over the course of one to three weeks, the ST segments will normalize and the T waves flattened. The flattened T waves can later become inverted followed by a return to a normal appearing ECG after many weeks.
Which of the following patients is considered hypotensive? A 1-year-old boy with a systolic blood pressure of 75 mm Hg A 2-year-old girl with a systolic blood pressure of 80 mm Hg A 3-year-old girl with a systolic blood pressure of 70 mm Hg A 6-year-old boy with a systolic blood pressure of 85 mm Hg
Correct Answer ( C ) Explanation: A 3-year-old girl with a systolic blood pressure of 70 mm Hg is considered to be hypotensive. The minimum systolic blood pressure in a child (1-10 years) is calculated by the formula: Minimum SBP = 70 + (2 x age in years). Therefore, the minimum systolic blood pressure for a 3-year-old is 76 mm Hg. The minimum systolic blood pressure for a neonate (0-28 days) is 60 mm Hg and an infant (1-12 months) is 70 mm Hg.
Which of the following statements is most accurate regarding acute ischemic heart disease? Elderly patients more often present with typical chest pain than atypical chest pain Reproducible chest wall tenderness excludes ischemia as a cause of chest pain Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation Women rarely present with atypical features of acute coronary syndrome
Correct Answer ( C ) Explanation: A typical feature of acute coronary syndrome is crushing retrosternal chest pain or pressure. Often this is lacking, and patients present with atypical features of the pain or the presence of angina equivalent symptoms (e.g., dyspnea, nausea, vomiting, dizziness). Many patients with a diagnosis of ACS have pain that is pleuritic, positional, or reproduced by palpation. One large study showed that up to 33% of patients diagnosed with acute myocardial infarction did not have chest pain on presentation. Atypical complaints include dyspnea; nausea; diaphoresis; syncope; and pain in the arms, epigastrium, shoulder, or neck. Atypical features of ACS are present with increasing frequency in older populations. In patients older than 85 years (A), atypical symptoms are more common than typical chest pain, with dyspnea being the most common. Isolated physical exam findings are rarely diagnostic of the origin of chest pain. Palpation of the chest wall (B) may reveal localized tenderness, but 5%-10% of patients with ACS have chest pain and associated palpable chest wall tenderness. Being female (D) is a risk factor for an atypical presentation of ACS.
Which of the following is a late complication of acute myocardial infarction? Cardiogenic shock Complete heart block Dressler syndrome Pulmonary edema
Correct Answer ( C ) Explanation: Dressler syndrome is an autoimmune mediated acute febrile illness associated with a pericarditis that occurs two weeks to several months after an acute myocardial infarction. It may also occur after surgery or traumatic myocardial injury. Symptoms include fever, cough, palpitations and chest pain, which may be similar to chest pain experienced during a myocardial infarction (MI). The postulation is that after a myocardial infarction, antigens to myocardial cells are released into the pericardial fluid which trigger the autoimmune process. Dressler syndrome is seen in approximately 5% of patients post-MI. Large pericardial effusions may occur leading to cardiac tamponade. Cardiogenic shock (A) occurs within hours of an AMI. This is characterized by hypotension and signs of heart failure. These patients may require inotropic support and or an intra-aortic balloon pump.
A man with dyspnea-on-exertion presents for cardiac evaluation. Physical exam is significant for a left sternal border systolic murmur which is louder during a Valsalva maneuver. An S4 is also appreciated. The ECG shows large QRS complexes. An echocardiogram reveals a decrease in left ventricular chamber volume and normal left atrial measurements. Which of the following is the most likely diagnosis? Aortic stenosis Dilated cardiomyopathy Hypertrophic cardiomyopathy Mitral stenosis
Correct Answer ( C ) Explanation: Hypertrophic cardiomyopathy (HCM) results from left or right ventricular hypertrophy or both. This condition can be primarily caused by autosomal dominant genetic mutations of the cardiac sarcomere genes and myocardial fiber hypertrophy. Secondary causes include aortic stenosis, mitral valve abnormalities, coronary heart disease and chronic systemic hypertension. Most patients are asymptomatic upon presentation, however, the common clinical manifestations are dyspnea, angina and dysrhythmia. Decreased chamber volume and increased ventricular wall thickness are the key echocardiographic findings in HCM. Furthermore, the ECG typically shows left ventricular hypertrophy, T-wave inversion and large QRS complexes. A harsh, left sternal border, systolic, crescendo-decrescendo murmur which is worse with Valsalva maneuver is quite typical of HCM. Aortic stenosis (A) is associated with a right, not left, sternal border pansystolic murmur that is decreased, not increased, during a Valsalva maneuver. S3, normal or thin ventricular wall and enlarged ventricular chamber volume are more common with dilated cardiomyopathy (B). S4, thick ventricular wall and decreased ventricular chamber volume are more common with hypertrophic cardiomyopathy. Mitral stenosis (D) produces a diastolic, not systolic, murmur, and is associated with increased left atrial size and pressure.
A 32-year-old man with a history of intravenous drug use presents to the emergency department with complaints of chest pain, shortness of breath, cough and fever. Physical exam reveals a temperature of 102°F, new heart murmur, diffuse petechial rash and subungual hemorrhages. Which of the following is the most appropriate next step in management? Begin anticoagulation therapy Begin empiric antibiotic therapy Obtain three sets of blood cultures Order cardiovascular surgical consult
Correct Answer ( C ) Explanation: Infective endocarditis (IE) affects the endocardial surface of the heart including the valves and mural endocardium. Different types of endocarditis have different pathogens and etiologies. Intravenous drug use is a risk factor for bacterial endocarditis. Diagnosis may be challenging and requires a high level of suspicion, as patients generally have no previous cardiac disease or heart murmurs. Patients often present with nonspecific complaints of fever, chills, night sweats, myalgias, joint pain, anorexia, and weight loss. Clinical manifestations include fever and heart murmurs. Classic signs of IE include petechiae, subungual hemorrhages, tender nodules on the fingertips, and nontender macules on the palms and soles. In the emergent setting, initial goals include stabilizing the patient and making the correct diagnosis. Three sets of blood cultures should be obtained over the first 60-90 minutes and then empiric antibiotic therapy may be administered based on the patient's history and risk factors.
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? Avoid physical activity Elevate lower extremities Monitor daily weights Restrict fluid intake
Correct Answer ( C ) Explanation: Instructing patients to monitor daily weights can help prevent heart failure readmission. Heart failure is one of the most common causes of hospitalization, hospital readmission and death. Due to the complexity and long-term nature of heart failure regimens, the need for careful diet and weight management, and the importance of intervention in the early phases of decompensation, patient self-management is crucial in avoiding hospitalizations. Patients should be specifically instructed to take all medications as directed, monitor daily weights, monitor for signs and symptoms, adhere to a low-sodium diet, limit alcohol consumption and stop smoking. Elevation of the lower extremities (B) can help reduce edema but it will not help prevent readmission to the hospital with a congestive heart failure exacerbation. Heart failure patients should not be advised to avoid physical activity (A). In stable patients, increasing physical activity or regular exercise can help diminish symptoms. Lastly, restricting fluid intake (D) has not been shown to prevent heart failure readmissions.
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? Acute aortic dissection Acute mitral regurgitation Left ventricular free wall rupture Post infarction ventricular septal defect
Correct Answer ( C ) Explanation: 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 33-year-old woman with no medical problems presents with chest pain and shortness of breath. The symptoms worsened over the previous two days and increase with exertion. The patient denies cough, but last week reports fevers, chills, coughing and myalgias. Her ECG demonstrates sinus tachycardia without ST segment changes. Vital signs are T 100.7°F, HR 120, BP 108/60, RR 16, 100% saturation on room air. Which of the following is the most likely diagnosis? Acute coronary syndrome Mediastinitis Myocarditis Pulmonary embolism
Correct Answer ( C ) Explanation: Myocarditis can be due to an infectious or non-infectious process, with most infectious etiologies caused by a viral infection, most commonly parvovirus B19, adenovirus, coxsackie B virus, and Echovirus. Trypanasoma cruzi (Chagas disease) is the most common etiology worldwide. Myocardial necrosis occurs likely as a result of direct invasion of the offending organism as well cytotoxic effects of the host's immune system. Individuals develop flulike symptoms and in adults chest pain and shortness of breath. One of the hallmark signs of myocarditis is tachycardia out of proportion to fever. Depending on the time of presentation, patients may have symptoms of heart failure as the left ventricular ejection fraction is impaired as a result of the myocarditis. Troponin is often elevated as the disease progresses. The gold standard for diagnosis is endomyocardial biopsy. Management is supportive. ACE inhibitors help reduce myocardial inflammation.
An elderly man complains of dizziness upon standing. He denies being dizzy once he has stood for 5 minutes, and also denies being dizzy when supine or seated. He denies associated chest pain, palpitations, or dyspnea. Which of the following tests should first be performed during the evaluation of this positional dizziness? Chest radiograph Head-up tilt-table testing Orthostatic vital signs Transesophageal echocardiography
Correct Answer ( C ) Explanation: Orthostatic hypotension is due to an inadequate physiologic response to postural changes. This condition mostly exists in the elderly population. It is estimated that nearly 25% of syncopal admissions to the ED are due to orthostatic hypotension. Symptoms of orthostatic hypotension include dizziness, weakness, fatigue, light-headedness, headache or syncope which occur after standing. Primary causes include frailty, dehydration, poor cardiac output or autonomic instability. However, there are a multitude of underlying conditions that can cause secondary orthostasis. These include anemia, hemorrhage, cardiac dysfunction, venous insufficiency, endocrine dysfunction (hypothyroidism, hypoaldosteronism, adrenal insufficiency, diabetes insipidus, hypokalemia) and neurologic dysfunction (autonomic neuropathy, vitamin B12 deficiency). If suspected, orthostatic vital signs must be obtained as follows: BP and heart rate must be measured in the supine position, then repeated after 3 minutes of standing. If normal, but orthostasis is still suspected, then the patient should be sent for head-up tilt-table testing.
A 5-year-old girl with Turner syndrome is found to have systolic hypertension. Further examination reveals diminished femoral pulses. Which of the following is the best initial test for establishing the most likely diagnosis? Cardiac catheterization Chest X-ray Echocardiogram Electrocardiogram
Correct Answer ( C ) Explanation: Patients with Turner syndrome are at increased risk for coarctation of the aorta and should have an echocardiogram to establish the diagnosis and determine the severity of the stenosis. Coarctation of the aorta is defined as a narrowing of the aorta. Most cases of coarctation of the aorta are congenital and associated with other congenital cardiac defects. Acquired cases are usually due to an inflammatory disease, such as Takayasu arteritis. Approximately 30% of patients with Turner syndrome have a coarctation. In order to maintain normal systolic function, several compensatory mechanisms arise to overcome the left ventricular outflow tract obstruction. These mechanisms include left ventricular hypertrophy and the development of collateral blood flow to circumvent the lesion. Systolic hypertension and diminished or delayed femoral pulses are classic physical exam findings. Older children and adults may complain of chest pain, cold extremities, and claudication. If collateral flow has had time to develop, a continuous murmur may be heard over the left anterior chest or left midline back. Initial diagnostic studies include electrocardiography, chest radiography, and echocardiography. Chest radiography may reveal notching of the ribs. In most patients, echocardiography with Doppler can establish the diagnosis, determine the severity, and evaluate for additional defects without the need for further imaging studies. Computed tomography and magnetic resonance imaging may be required in adults for complete evaluation of the thoracic aorta. Patients with coarctation of the aorta should be referred to a cardiovascular surgeon for evaluation. Accelerated coronary artery disease, aortic dissection, stroke, and heart failure are common complications in patients who do not undergo surgical repair for the lesion.
An 81-year-old man with 10 years of coronary artery disease presents with chest pain and altered mental status. His ECG shows consecutive, large and wide QRS complexes. P waves cannot be appreciated. His pulse is 188 bpm. Which of the following is the most likely diagnosis? Atrial fibrillation Atrial flutter Ventricular fibrillation Ventricular tachycardia
Correct Answer ( D ) Explanation: Ventricular tachycardia is described electrocardiographically as "continuous PVCs", or more specifically, consecutive, fast, large and wide QRS complexes. A wide QRS complex clues one in that the underlying electrical problem is in the ventricles. Ventricular tachycardia can be further defined as monomorphic (QRSs are the same form) versus polymorphic (differing appearance of the QRSs), or sustained (>30 seconds) versus non-sustained (<30 seconds, self-terminates). In this tachydysrhythmia, the ventricles depolarize and contract so fast that cardiac output decreases, especially in the elderly or those with diseased myocardium or coronaries. This perpetuates ventricular ischemia leading to a precipitous decline if the dysrhythmia is not treated.
A 40-year-old woman complains of recurrent chest pain that occurs shortly after she wakes up in the morning. She has a history of migraine headaches and Raynaud's phenomenon. She admits to tobacco abuse and smokes 1 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? Costochondritis Panic disorder Prinzmetal angina Unstable angina
Correct Answer ( C ) Explanation: Prinzmetal angina, or variant angina, is the most likely diagnosis in this patient. Prinzmetal angina is characterized by spontaneous episodes of angina in association with ST-segment elevation on ECG. The cause is a transient, abrupt, and marked reduction in the luminal diameter of an epicardial coronary artery due to spasm which leads to transient myocardial ischemia. Unlike most other causes of chest pain and ST-segment elevation, the ST-segment returns to baseline rapidly upon resolution of symptoms. This is a diagnosis of exclusion. Patients with variant angina are often younger and exhibit fewer classic cardiovascular risk factors, with the exception of cigarette smoking. Variant angina may be associated with other vasospastic disorders such as Raynaud's phenomenon and migraine headache or its treatment, such as sumitriptan. A history of drug abuse, such as cocaine, may also be present.
Which of the following is a medical treatment for congenital long QT syndrome? Flecainide Propafenone Propranolol Quinidine
Correct Answer ( C ) Explanation: Propranolol is the appropriate treatment for congenital long QT syndrome as beta blockers are the mainstay of treatment for this condition. Long QT syndrome is the most common channelopathy and is thought to affect 1 in 5000 persons. It is a disorder of myocardial repolarization characterized by a prolonged QT interval on ECG and an increased risk of sudden cardiac death: QTc is usually > 460 ms. This syndrome is associated with an increased risk of a characteristic life threatening polymorphic ventricular tachycardia known as torsades de pointes or "twisting of the points." The primary symptoms in patients with long QT syndrome include palpitations, syncope, seizures, and cardiac arrest, and patients usually have syncope related to polymorphic ventricular tachycardia. Factors conferring the highest risk for sudden cardiac death include a history of sudden cardiac arrest, recent syncope, and QTc interval greater than 500ms. Beta blockers, such as propranolol, have shown to reduce both syncope and sudden cardiac death. The goal of beta blocker therapy is to blunt the maximal heart rate achieved during exertion and are thought to interrupt the "trigger" for torsades de pointe and shorten the QT interval
A 62-year-old man with a history of sarcoidosis presents to his cardiologist with dyspnea, fatigue, and signs of right-sided heart failure. Physical exam shows elevated jugular venous pressure and hepatomegaly. Echocardiogram shows reduced diastolic filling. Magnetic resonance imaging shows gadolinium hyperenhancement. Which of the following is the most likely diagnosis? Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Takotsubo cardiomyopathy
Correct Answer ( C ) Explanation: Restrictive cardiomyopathy occurs due to fibrosis or infiltration of the ventricular wall because of collagen-defect diseases. It can occur due to amyloidosis, endomyocardial fibrosis, hemochromatosis or sarcoidosis. Patients often present with decreased tolerance of exercise. Pulmonary hypertension is common. In advanced cases, patients develop right-sided congestive heart failure. Physical exam shows elevated jugular venous pressure (JVP) and Kussmaul's sign (a paradoxical rise in JVP on inspiration). Chest radiography shows mild to moderate cardiomegaly. Echocardiography is key to diagnosis, showing rapid, early diastolic filling and a small-normal sized, thickened left ventricle. MRI shows gadolinium hyperenhancement. Diuretics may be useful symptomatic treatment. Prognosis is poor if due to amyloidosis. Cardiac transplantation can be used if there is no systemic involvement Takotsubo myopathy (D) occurs after a large discharge of catecholamines due to a major stressor. It is more common in postmenopausal women. Symptoms include angina and dyspnea.
Which of the following is correct regarding cardiac markers in regards to myocardial infarction? Creatinine phosphokinase (CK) is specific to cardiac tissue Myocardial infarction can be ruled out with a single serum myoglobin Serum troponin is more sensitive than creatinine phosphokinase (CK-MB) Troponin levels return to normal in 2-3 days
Correct Answer ( C ) Explanation: Serum troponin is a more sensitive marker of myocardial infarction than creatinine phosphokinase (CK-MB). Biochemical markers (troponin, CK-MB, myoglobin) are essential in the diagnosis and risk stratification of myocardial infarction. Troponin I and T are myocardium specific proteins that are released from myocardial cells after cell damage occurs. Both have been found to be highly specific and sensitive for the early detection of myocardial injury and have supplanted the use of other biomarkers. The presence of serially negative troponins also predicts a low risk for an event. Troponin levels may not be detectable for up to 12 hours after symptoms onset in some patients with acute myocardial infarction. However, with highly sensitive troponin assays, detection may be possible as early as 3 hours.
A 71-year-old woman presents with 2 days of dizziness and "almost passing out." Her ECG shows episodes of alternating bradycardia and tachycardia with narrow QRS complexes. Which of the following is the most likely diagnosis? Atrial flutter Digitalis toxicity Sick sinus syndrome Ventricular tachycardia
Correct Answer ( C ) Explanation: Sick sinus syndrome occurs as a result of disease of the sinoatrial (SA) node. It is associated with tachycardia-bradycardia syndrome in which the sinus rate varies from fast to slow and back again. ECG shows an irregular rhythm with pauses in sinus activity. Management depends on the presentation. For rhythms that are too slow, the patient may require a pacemaker. Whereas rhythms that are too fast may be treated with calcium channel blockers or beta-blockers
Which of the following is the most common cause of sudden cardiac arrest and sudden cardiac death? Anomalous coronary artery Cardiomyopathy Ischemic heart disease Left ventricular hypertrophy
Correct Answer ( C ) Explanation: Sudden cardiac arrest and sudden cardiac death usually occurs in people with some form of underlying structural heart disease, most notably ischemic heart disease. Sudden cardiac arrest and sudden cardiac death refer to the sudden cessation of cardiac activity with hemodynamic collapse. Events that are successfully treated leading to patient survival are referred to as sudden cardiac arrest, while those that lead to death are referred to as sudden cardiac death. As much as 70% of sudden cardiac arrest have been attributed to coronary or ischemic heart disease. Among patients with coronary heart disease, sudden cardiac arrest or death can occur both during an acute coronary syndrome and in the setting of chronic, otherwise stable coronary heart disease. Often such patients have had prior myocardial damage and scar that serves as a substrate for sudden cardiac arrest.
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? Atropine Cardioversion Valsalva maneuver Verapamil
Correct Answer ( C ) Explanation: Supraventricular tachycardias (SVT) include paroxysmal, reentry or preexcitation tachycardias. Reentry SVTs include AV nodal reentry (AVNRT), atrioventricular reentry, or atrial reentry. Reentry circuits require the presence of at least two different conduction pathways with differential refractory times. It is characterized by an abrupt onset and termination of tachycardia, that distinguishes it from sinus tachycardia, which has gradual changes in rate. It is precipitated by a premature atrial or ventricular contraction or hyperadrenergic state. The ECG shows a regular, fast rhythm with absent P waves and narrow QRS complex. Unstable patients require immediate synchronized cardioversion. Stable patients, such as the patient above, should first undergo vagal maneuvers. Some common vagal maneuvers include holding your breath and bearing down (Valsalva maneuver), coughing, gagging, and immersing your face in ice-cold water. If vagal maneuvers are unsuccessful, adenosine is used both diagnostically and therapeutically. Adenosine transiently blocks the AV-node and allows the circuit to "reset."
A 65-year-old man presents to the ED with a known history of heart failure. He complains of progressive shortness of breath over the preceding month to the point that he now has to rest even when he walks from his bed to the bathroom. These symptoms resolve at rest. What is this patient's New York Heart Association classification? I II III IV
Correct Answer ( C ) Explanation: The New York Heart Association functional classification scheme is used to assess the severity of functional limitations in patients with chronic heart failure and correlates fairly well with prognosis. Patients in Class III have moderate limitations and have symptoms of heart failure with minimal activity such as walking across a room.
A patient is being evaluated for palpitations in the emergency department. An ECG reveals a short PR interval, widened QRS and slurred upstroke of the QRS complex. Which of the following is the name of bypass pathway associated with this condition? Bachmann's bundle Bundle of His Bundle of Kent Left bundle branch
Correct Answer ( C ) Explanation: The bundle of Kent is the bypass pathway associated with Wolff-Parkinson-White syndrome, which is the most likely diagnosis in this patient. Wolff-Parkinson-White syndrome is a pattern of pre-excitation on ECG accompanied by a symptomatic tachycardia. It results from an accessory pathway that directly connects the atria and ventricles and bypasses the AV node. The bypass pathways are accessory connections called Kent bundles between the atrium and ventricle. If a bypass pathway conducts antegrade, a pre-excitation pattern may be seen on the ECG. This includes a short PR interval because the bypass pathway conducts rapidly and faster than the AV node; a delta wave, which is a slurred initial segment of the QRS complex resulting from slow conduction through ventricular tissue instead of the His-Purkinje system; and a widened QRS that consists of fusion between early ventricular activation from pre-excitation with the later ventricular activation resulting from transmission through the AV node.
What is the classic auscultatory feature of mitral valve prolapse? Crescendo-decrescendo systolic murmur Loud S1 and an opening snap in diastole Midsytolic click Soft diastolic murmur
Correct Answer ( C ) Explanation: The classic auscultatory features of mitral valve prolapse are a midsystolic "click" followed by a midsystolic to late systolic murmur over the mitral area. This click results from snapping of the chordae tendineae during the prolapse of the valve. Mitral valve prolapse (MVP) is defined pathophysiologically as an abnormal movement of one or both of the mitral valve leaflets across the plane of the valve during systole. The typical auscultatory findings should suggest MVP and can be confirmed by echocardiography. Symptoms attributed to MVP, however, are often not explained by the degree of prolapse or mitral regurgitation. Although generally a benign condition, it is infrequently associated with more serious cardiac pathology such as mitral regurgitation, endocarditis, and arrhythmias. Echocardiographic studies report a true prevalence of less than 1% in both men and women versus the previously reported 5% with a female predominance.
A four-year-old girl is brought to the ED by her parents due to lethargy. A week prior, the girl had a cough and cold. Later, symptoms progressed to include fever and malaise. She has been less active with decreased appetite. A few hours prior to arrival in the ER, she was having difficulty breathing. On exam, temperature is 38.3°C, respiratory rate is 35, heart rate is 126, blood pressure is 90/60, with clear breath sounds, hepatomegaly, and poor pulses. Which of the following is the most likely diagnosis? Bronchiolitis Dysrhythmia Myocarditis Pneumonia
Correct Answer ( C ) Explanation: The girl demonstrates signs and symptoms that are suspicious for myocarditis, which is a condition that results from inflammation of the heart muscle. The majority of children present with acute or fulminant disease. Myocarditis can be caused by infectious, toxic, or autoimmune conditions. Common causes of viral myocarditis include enterovirus (coxsackie group B), adenovirus, parvovirus B19, Epstein-Barr virus, cytomegalovirus, and human herpes 6 (HHV-6). The presentation of the disease is variable, and patients can present with broad symptoms that range from subclinical disease to cardiogenic shock, arrhythmias, and sudden death. There is usually a history of a recent respiratory or gastrointestinal illness within the previous weeks. There is a prodrome of fever, myalgia, and malaise several days prior to the onset of symptoms of heart dysfunction. Then, patients present with heart failure symptoms that include dyspnea at rest, exercise intolerance, syncope, tachypnea, tachycardia, and hepatomegaly. Testing is focused on determining the severity of cardiac dysfunction and these include electrocardiography (ECG), cardiac biomarkers, chest radiography, and echocardiography. Confirmation of myocarditis is generally made by cardiac magnetic resonance imaging or endomyocardial biopsy.
An eight-year-old girl was brought to the clinic due to chest pain. One week ago, she had rhinorrhea, abdominal pain, and fever. Later, she complained of stabbing chest pain that is worse with inspiration and relieved by sitting upright. On physical exam, heart rate is 120, respiratory rate is 20, blood pressure is100/80, with clear breath sounds and distant heart sounds. Which of the following is the most likely diagnosis? ACostochondritisY BGastroesophageal reflux CPericarditis DPulmonary embolism
Correct Answer ( C ) Explanation: The girl has signs and symptoms that are suspicious for pericarditis. There are several viral agents that can cause pericarditis like enteroviruses, influenza, adenovirus, respiratory syncytial virus, and parvovirus. The most common symptom of pericarditis is chest pain that is characterized as sharp or stabbing, positional, radiating, worse with inspiration and relieved by sitting upright or prone. Other nonspecific symptoms include cough, fever, dyspnea, abdominal pain, and vomiting. Clues to the diagnosis are physical exam findings of muffled or distant heart sounds, tachycardia, narrow pulse pressure, jugular venous distension, and a pericardial friction rub provide clues to the diagnosis of acute pericarditis. Pericarditis can be complicated by cardiac tamponade that is recognized by the excessive fall of systolic blood pressure (>10 mm Hg) with inspiration. Abnormal findings on ECG include low voltage QRS amplitude, tachycardia, and abnormalities of the ST segments, PR segments, and T waves. Chest X-ray findings may be normal if effusion is not present. On the other hand, there may be cardiac enlargement in the presence of an effusion. The most sensitive test to identify the size and location of a pericardial effusion is by echocardiography.
A previously healthy 35-year-old woman presents to the emergency department with pleuritic chest pain and malaise. She has been feeling unwell for the past few days with intermittent fever. Her pulse is 87 beats/minute, respiratory rate is 19 breaths/minute, blood pressure is 122/82 mm Hg, and temperature is 37.0°C. On exam, a pericardial friction rub is appreciated. Echocardiography is negative for pericardial effusion. Which of the following is the most appropriate management? Admission and intravenous acyclovir Admission and intravenous gentamicin Outpatient follow-up and oral naproxen Outpatient follow-up and oral prednisone
Correct Answer ( C ) Explanation: The most appropriate treatment for this patient with acute pericarditis is on an outpatient follow-up and oral naproxen. Acute pericarditis is an inflammation of the pericardium. Acute pericarditis is most commonly seen in men under the age of 50 years. Viral infections are the most common cause of acute pericarditis in the United States. Worldwide, tuberculosis is the most common cause. Other causes of pericarditis include bacteria, uremia, neoplasms, myocardial infarctions (Dressler syndrome), radiation, and rheumatoid conditions. In most cases of acute pericarditis, the pericardium becomes inflamed and infiltrated with leukocytes. Pericardial effusions can develop during pericarditis. Effusions that accumulate rapidly may cause cardiac tamponade. Regardless of etiology, most cases of pericarditis present with pleuritic, postural chest pain. The pain may radiate to the neck, shoulders, back, or epigastric region. A pericardial friction rub is pathognomonic and is very specific, but lacks sensitivity. The friction rub is often transient and serial exams may be necessary for detection. Other physical findings may depend on the etiology. Viral pericarditis is usually accompanied by flu-like symptoms, low-grade fever, malaise, dyspnea, and tachypnea. Fever may be absent in uremic pericarditis. Patients with bacterial pericarditis often appear systemically toxic. Lab findings and diagnostics should be used to rule out other serious causes of chest pain, such as myocardial infarction, pulmonary embolism, or aortic dissection. Echocardiography should be used to evaluate for effusion. Electrocardiography may show generalized ST segment elevation and PR segment depression. Chest radiographs are usually normal unless a significant pericardial effusion is present. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line treatment unless contraindicated. Colchicine and corticosteroids can be used in severe or refractory cases. Corticosteroids increase the risk of recurrence. Uremic pericarditis should be treated with urgent dialysis. Indications for admission include presence of effusion, fever, immunosuppression, trauma, oral anticoagulation therapy, myopericarditis, or failure of oral NSAIDs therapy.
Which of the following is the most predictive risk factor for cardiac ischemia? Diabetes mellitus Family history of coronary artery disease Past medical history of coronary artery disease Tobacco use
Correct Answer ( C ) Explanation: The most predictive risk factor for cardiac ischemia is a past medical history of coronary artery disease. The classical coronary risk factors have been repeatedly shown to increase the risk of ischemic heart disease in patients followed over many years. But in the acute setting, a history of coronary artery disease is most predictive
You receive the laboratory report of a pericardial effusion sample sent yesterday from an inpatient with metastatic lung cancer. Which of the following results would you most expect? Exudate with Gram-positive bacilli Exudate with low-protein and high glucose levels Exudate with positive cytology Transudate with elevated carcinoembryonic antigen levels
Correct Answer ( C ) Explanation: There are several different reasons why the pericardial sac fills with fluid. Pericardial effusion often poses several diagnostic questions. In order to work through a differential, a sample of pericardial fluid can be sent to the lab for analysis testing. As is common with other fluid analyses, the first step in evaluating pericardial fluid is to differentiate transudate from exudate. Transudate represents an imbalance between vessel hydrostatic and oncotic pressure. Transudates are usually associated with some cardiac disease, such as congestive heart failure, or hepatic disease, such as cirrhosis. Other causes of transudative effusion include nephrotic syndrome, hypothyroidism and amyloidosis. On the other hand, exudates herald the presence of some traumatic injury or inflammation. Exudate can be infectious in nature, as in viral, bacterial or fungal pericarditis, or even myocarditis and endocarditis. Exudates are also commonly associated with autoimmune rheumatic conditions, such as rheumatoid arthritis or systemic lupus erythematosus. Cancer, either primary or metastatic, can also produce a pericardial exudate. In addition, exudates can be bloody, as in bleeding disorders or direct trauma. Once the pericardial effusion is deemed exudative, other tests are employed. Total cell counts, WBC differentials, fluid glucose, total protein and lactate dehydrogenase levels, microscopic examination, Gram stain, culture and susceptibility testing, AFB smear and culture, cytology and parasitic testing round out the typical battery of tests used to determine the source of a pericardial exudative effusion. Light's criteria are used to help differentiate transudative from exudative effusions - most commonly in pleural effusions but the table below can also be applied to pericardial effusions.
A 54-year-old man with a history of schizophrenia presents to the ED after a syncopal episode. During your evaluation, he becomes diaphoretic and complains of dizziness. You are able to feel a radial pulse, and he is alert and talking with you. His rhythm strip is seen above. Which of the following represents the first-line treatment of this disorder? Amiodarone Labetalol Magnesium sulfate Synchronized cardioversion
Correct Answer ( C ) Explanation: This ECG shows a rapid, irregular, wide-complex rhythm with multiple QRS morphologies or polymorphic ventricular tachycardia. This most commonly appears as a cyclical progressive change in cardiac axis—otherwise known as torsades de pointes. Torsades often occurs in the setting of a prolonged QT interval during sinus rhythm and is due to abnormal ventricular repolarization. The patient above has a history of schizophrenia. This condition is managed with antipsychotics (risperidone, olanzapine), which are associated with prolonging the QT interval. A QT interval of 500 msec (congenital or acquired) is a risk factor for development of torsades. In adults, however, most causes of QT prolongation are acquired and multifactorial involving drug interactions, myocardial ischemia, and electrolyte disturbances. The immediate management for a patient with torsades is IV magnesium sulfate given as a bolus. If this patient decompensates and loses his pulse, then he'll require defibrillation.
A 17-year-old man with no past medical history presents complaining of constant chest pain for 5 days. He states that he had a cold 2 weeks ago and feels like he never got better. His vitals are T 36.8°C, HR 91, BP 122/75, RR 18, and oxygen saturation 99%. A 12-lead ECG is performed as seen above. What is the appropriate immediate management for this patient? Aspirin 325 mg and activation of the cardiac catheterization lab Azithromycin 500 mg by mouth, followed by 250 mg once a day for 4 days Ibuprofen and prompt follow-up with his primary care doctor Serum d-Dimer test
Correct Answer ( C ) Explanation: This patient presents with acute pericarditis. His ECG shows sinus tachycardia at 102 beats per minute with diffuse small ST elevations (II, aVF, V2-V6); PR depression (II, III, aVF, V2-V6); and no reciprocal ST depressions. The treatment of pericarditis consists of high-dose nonsteroidal anti-inflammatory medications (e.g., ibuprofen 400-800 mg 3 times per day for 7-14 days). Other treatment options include aspirin 2-4 grams per day and indomethacin 75-150 mg per day.
A 21-year-old woman presents with shortness of breath, rash and nausea after an insect bite. Her vitals are T 97.7°F, HR 128, BP 85/56, RR 28, oxygen saturation 93%. Exam reveals diffuse hives and posterior pharyngeal swelling. Which of the following should be immediately administered? Epinephrine 1:10,000, 0.3 mL IM Epinephrine 1:10,000, 10 mL IV Epinephrine 1:1000, 0.3 mL IM Epinephrine 1:1000, 0.3 mL IV
Correct Answer ( C ) Explanation: This patient presents with anaphylactic shock from an insect bite and requires immediate administration of epinephrine. Epinephrine is potentially life-saving in severe anaphylactic reactions. During an anaphylactic reaction, mast cells degranulate leading to release of histamines and other immune mediators. These mediators lead to the hallmark symptoms of allergic reactions including hives, nausea and vomiting, airway edema, bronchoconstriction and hypotension. Epinephrine acts immediately on adrenergic receptors to reverse these symptoms. Inhaled beta agonists can also be given to rapidly reverse bronchoconstriction. Many of the other treatments in anaphylaxis have a delayed onset of action. Diphenhydramine (H1 receptor blocker) acts by blocking the effect of histamine on H1 receptors mainly in the skin. Ranitidine, famotidine and other H2 blockers can mitigate some of the gastrointestinal symptoms caused by histamine as well as some of the cutaneous manifestations. Steroids mainly act by stabilizing mast cells from further degranulation but this effect is usually delayed 4-6 hours after administration. Steroids also increase the expression of beta-receptors in the lung increasing the efficacy of inhaled beta-agonists. Epinephrine should be given as 300 - 500 mcg IM in the anterolateral thigh. This dose equates to 0.3 - 0.5 mL of the 1:1000 preparation.
A patient with palpitations presents to the ED. Her rhythm strip is seen above. Which of the following is the most appropriate initial management? Amiodarone Cardioversion Magnesium sulfate Transvenous pacing at 60-80 bpm
Correct Answer ( C ) Explanation: Torsades de pointes is a form of polymorphic ventricular tachycardia. It is characterized by a fluctuating amplitude of the QRS complexes which appear to twist around the isoelectric line. Torsades is associated with prolonged QT syndrome, hypokalemia and hypomagnesemia. It can deteriorate into ventricular fibrillation. Symptoms include palpitations, dizziness, syncope and sudden death. Acute management begins with intravenous magnesium.
Which of the following is a cause of torsades de pointes? Drugs that shorten the QT interval Hyperkalemia Hypocalcemia Marijuana use
Correct Answer ( C ) Explanation: Torsades de pointes may be caused by electrolyte disturbances (hypokalemia, hypomagnesemia, hypocalcemia), antiarrhythmic drugs that prolong the QT interval (procainamide, quinidine, disopyramide), N-acetylprocainamide, droperidol, amiodarone, phenothiazines, haloperidol, tricyclic antidepressants, terfenadine, astemizole, ketoconazole, erythromycin, TMP-SMZ, high-dose methadone, or cocaine. Torsades de pointes is also associated with hereditary long QT interval syndromes. It is a form of ventricular tachycardia manifested by episodes of alternating electrical polarity, with the amplitude of the QRS complex twisting around an isoelectric baseline resembling a spindle. The rhythm usually starts with a PVC and is preceded by widening of the QT interval. Treatment involves intravenous infusion of magnesium sulfate and cardioversion.
You discover a blowing, holosystolic murmur in a newborn boy, heard loudest at the left sternal border. A pediatric cardiologist diagnoses Ebstein's anomaly. In addition to a malformed right atrium and ventricle, which of the following abnormalities would you most expect to see on this patient's echocardiogram? Left ventricular hypertrophy Overriding aorta Tricuspid insufficiency Tricuspid stenosis
Correct Answer ( C ) Explanation: Tricuspid regurgitation (or incompetence, or insufficiency) manifests as a blowing, pansystolic murmur. It is commonly associated with a thrill. It is most intense in the left, fourth intercostal space, however, it can radiate to the apex, making it difficult to differentiate from a mitral regurgitation murmur. Like tricuspid stenosis, it is quite rare, affecting only 1% of the US population. Causes include rheumatic heart disease, right ventricular dilation, myxomatous degeneration and varied connective tissue disorders. It is part of Ebstein's anomaly, a congenital heart defect in which the tricuspid leaflets attach to the right ventricular wall, leading to a larger than normal right atrium and smaller than normal right ventricle. Ebstein's anomaly is also commonly associated with an atrial septal defect, patent foramen ovale and the pre-excitation, re-entrant conduction defect of Wolff-Parkinson-White syndrome. Diuretics are the mainstay of treatment, and valvuloplasty or valve repair, if necessary, is far more common than valve replacement.
An elderly woman presents with intermittent leg pain. She states it is a burning heaviness that is not necessarily associated with activity. Inspection reveals several dilated and tortuous veins about the lower legs. The skin is edematous and speckled with dark brown areas of capillary dilation but no specific pallor. Distal motor and sensory examinations are intact. Which of the following is the most appropriate initial tests in the evaluation of these symptoms? Angiography Coagulation panel Duplex ultrasonography Electrodiagnostics
Correct Answer ( C ) Explanation: Venous insufficiency, mainly due to incompetent or absent venous valves, can lead to retrograde blood flow in the superficial or deep venous systems. Ultimately, this leads to the syndrome of chronic venous insufficiency, which is marked by poor cosmesis, pain, lipodermatosclerosis, ulceration and life-threatening infections. The pain is usually described as burning, cramping or heaviness that occurs constantly in almost 20%, and episodically in almost 50% of sufferers. Chronic venous stasis or hypertension causes the characteristic skin changes of capillary proliferation, red or brown coloring, fat necrosis and fibrosis. These may be associated with edema, cellulitis, ulceration and cutaneous infarction. Although typical, these physical findings are only suggestive of the condition. Any suspicion is best evaluated initially with duplex ultrasonography.
A woman with known coronary artery disease presents to the ED with chest pain and ventricular tachycardia. Five minutes after admission she becomes unresponsive. Her rhythm strip is seen above. Which of the following is the most appropriate intervention? Beta-blockade Cardioversion Defibrillation Vasopressin
Correct Answer ( C ) Explanation: Ventricular fibrillation is the most common dysrhythmia in cardiac arrest patients. Instead of coordinated ventricular depolarization and contraction, ventricular fibrillation (VF) is characterized by rapid disorganized excitation potentials that amount to ineffective contraction. VF occurs with acute infarct or ischemia as well as old infarct or ischemia. Common triggers include electrocution, myocardial ischemia, and hypoxia. Electrocardiographically, VF appears as a chaotic, disorganized waveform that has no discernible typical morphology. Ventricular fibrillation is incompatible with life. Treatment is with immediate defibrillation.
Which of the following states a correct order of electrical current through the heart during one cycle of normal cardiac depolarization? Atrioventricular node -> sinoatrial node Bundle of His -> atrioventricular node Left bundle branch -> right bundle branch Right bundle branch -> purkinje fibers
Correct Answer ( D ) Explanation: A normal cycle of cardiac depolarization begins in the right atrium's sinoatrial node and passes through the right atrium's internodal tracts to activate the atrioventricular node. The AV node then sends the electrical impulse to the Bundle of His, which then passes current through the left and right bundle branches to the ventricular Purkinje fibers. Atrioventricular (AV) block is characterized as a delay in processing the electrical impulse within the atrioventricular node. This ultimately results in a delay in ventricular depolarization and contraction. There are three main types: first, second and third degree AV block. First-degree AV block is characterized as a prolonged PR interval > 0.2 sec, beginning at the start of the P wave and ending at the start of the QRS complex. Common causes of this type of block include electrolyte abnormalities, enhanced vagal tone (as in athletes), myocarditis or infarction and medications. Common medications which slow cardiac conduction through the AV node and produce a prolonged PR interval include beta and calcium-channel blockers, anticholinesterases and digitalis.
A 55-year-old man is being evaluated for sudden onset of chest pain. He describes the pain as sharp that is improved by sitting up and leaning forward. The chest pain is made worse by inspiration or coughing. An ECG shows new widespread ST segment elevation. Auscultation over the left sternal border is heard in the above audio clip. Which of the following is the most likely diagnosis? Aortic stenosis Mitral stenosis Patent ductus arteriosus Pericarditis
Correct Answer ( D ) Explanation: A pericardial friction rub is most commonly associated with pericarditis. It resembles the sound of squeaky leather and is often described as grating, scratching, or rasping. The pericardium is a double-walled sac around the heart. The inner (visceral) and outer (parietal) layers are normally lubricated by a small amount of pericardial fluid, but when inflammation of pericardium is present, the 2 walls move against each other with audible friction (the rub). In children, rheumatic fever is often the cause of pericardial friction rub. The friction rub is usually best heard between the apex and sternum but may be audible across the precordium.
A 46-year-old woman with a past history of a DVT was recently diagnosed with Burkitt's lymphoma. Recent blood work revealed a creatinine of 2.3. She is currently hospitalized to receive chemotherapy when she suddenly develops tachycardia to a rate of 130 and oxygen saturation of 91%. Which of the following is the most appropriate test to confirm the diagnosis of pulmonary embolism? Chest X-ray CT angiogram of the chest with intravenous contrast D-dimer V/Q scan
Correct Answer ( D ) Explanation: According to the modified Wells Criteria this patient has a high clinical probability for a pulmonary embolism (PE). This patient has multiple risk factors for a PE including cancer, previous DVT, and immobilization secondary to hospitalization. She also has a heart rate greater than 100 and a decreased oxygen saturation, which are associated with PE. The elevated creatinine is a contraindication to receiving intravenous contrast and therefore a she cannot undergo CT angiography, which is the usual test of choice. Therefore, the most appropriate test for this patient is a V/Q scan.
A 76-year-old man with a history of hypertension presents after a syncopal event. He also reports decreased exercise tolerance over the last two months. He is currently asymptomatic. His ECG is normal sinus rhythm with no changes. On examination, he has a harsh systolic murmur that radiates to the carotid arteries. Which of the following is true about the most likely cause of his syncope? Critical disease is defined by heart valve area less than 2 cm2 It typically results from rupture of the chordae tendinae The murmur increases with valsalva Vasodilators and diuretics should be used with caution
Correct Answer ( D ) Explanation: Aortic stenosis is an abnormality of the heart valve that prevents left ventricular outflow. This results in left ventricular hypertrophy which eventually impairs diastolic filling and results in increased myocardial oxygen demand. The most common cause is degenerative calcification associated with diabetes, hypertension, and advanced age. Exam findings include a harsh systolic murmur that radiates to the carotids as well as an S4 gallop. Carotid pulses may be delayed and diminished and a narrowed pulse pressure is typically present. Classic symptoms start with dyspnea and chest pain and progress to syncope and congestive heart failure. Although patients may be asymptomatic for a long period of time, once symptoms develop mortality increases significantly. Because patients with critical aortic stenosis are preload dependent, vasodilators and diuretics should be avoided as they can cause significant hypotension. Definitive treatment is aortic valve replacement. A normal aortic valve area is greater than 3 cm2. Critical aortic stenosis (A) is defined by a heart valve area of less than 0.8 cm2. Mitral regurgitation is most commonly caused by post-myocardial infarction rupture of the chordae tendinae (B) or papillary muscle dysfunction and presents with acute onset of pulmonary edema and midsystolic apical murmur. The murmur of aortic stenosis decreases with valsalva (C).
Which of the following treatments is contraindicated in the treatment of a 5-month-old with supraventricular tachycardia? Adenosine Ice bag to face Propranolol Verapamil
Correct Answer ( D ) Explanation: Due to poor calcium reserves in the sarcoplasmic reticulum in infants, verapamil (calcium channel blocker) use in infants can cause profound hypotension and cardiovascular collapse. Therefore, it should be avoided in patients younger than 12-months-old.
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? Clostridium septicum Escherichia coli Staphylococcus aureus Streptococcus viridans
Correct Answer ( D ) Explanation: Endocarditis is infection of the cardiac endothelium or valves or both. Acute cases are associated with normal valves and virulent bacteria, while subacute cases represent smoldering infections of abnormal valves with less virulent bacteria. Risk factors include valve prosthesis, history of rheumatic heart disease or prior endocarditis, mitral valve prolapse or regurgitation, congenital cyanotic heart disease, intravenous drug use, indwelling venous catheter, diabetes, poor dentition, hemodialysis and intracardiac devices. Symptoms include persistent bacteremia or fever and other constitutional symptoms (night sweats, weight loss, fatigue, anorexia). Complications include valve defects, septic emboli leading to stroke, pulmonary embolus or myocardial infarction and immune complex deposition disease such as glomerulonephritis and arthritis. The most common cause of native valve endocarditis in a non-user of intravenous drugs is Streptococcus viridans, especially in those with dental disease, as this organism is normally present in the oral cavity.
Which of the following diseases is characterized by the presence of a delta wave on an electrocardiogram? Charcot-Marie-Tooth disease Parkinsonism Parkinson's disease Wolff-Parkinson-White syndrome
Correct Answer ( D ) Explanation: Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac condition in which there is an abnormal conduction pathway (accessory bundle) between the atria and ventricles other than the atrioventricular node. This pathway provides the basis for a reentrant circuit which bypasses the typical delay thru the AV node, typically resulting in premature ventricular depolarization and supraventricular tachyarrhythmia. The premature depolarization of some of the ventricle produces a "slurring" of the normal depolarization wave thru the AV node. This is seen as a gradual upsloping of the QR segment, called a delta wave, which creates an illusion of PR interval shortening and QRS lengthening. Charcot-Marie-Tooth disease (A) is a hereditary sensorimotor neuropathy which commonly leads to peroneal muscular atrophy.
You see a one-year-old girl in your office. The girl was brought by her parents to the clinic for a well child examination. The girl has been doing well and has gained weight appropriately. The parents deny respiratory difficulties or diaphoresis. On physical exam, you note a murmur. Which of the following features is usually associated with an innocent murmur? Blowing quality Grade 3 intensity Increased intensity with upright position Short systolic duration
Correct Answer ( D ) Explanation: Heart murmurs are common in infants and children. While the prevalence of congenital heart disease is approximately 1 percent, a majority of children have innocent murmurs at some time. Being able to distinguish a murmur associated with heart disease from a benign etiology is important for diagnosis and management. When evaluating an infant or child with a cardiac murmur, it is important to assess whether there are any symptoms concerning for heart disease. Concerning symptoms at any age include respiratory difficulties, diaphoresis (especially with exertion), and poor growth. In infants, symptoms may include poor feeding or excessive irritability. In older children, chest pain and syncope are important symptoms. The physical examination should include careful review of the vital signs, assessment of heart rate and rhythm, assessment of pulses, and a detailed cardiovascular exam. Features associated with innocent murmurs include the following: grade ≤ 2 intensity (flow murmurs and innocent Still's murmur are usually grade I or grade II in intensity), softer intensity when the patient is sitting compared with when the patient is supine, short systolic duration, minimal radiation, musical or vibratory quality.
You are seeing an African-American 42-year-old man for an initial primary care visit. His medical history is significant for diabetes, seasonal allergies, obesity, and rotator cuff repair. His medications include insulin and desloratadine. Proper blood pressure readings are taken: 154/98 and 148/94. Which of the following medications is most appropriate when initiating antihypertensive management in this patient? Candesartan Captopril Carvedilol Chlorthalidone
Correct Answer ( D ) Explanation: JNC-8 has published recommendations for hypertensive management in early 2014. The goal for all patients < 60 years of age is < 140/90 mm Hg. JNC-8's Initial antihypertensive choice for African-Americans is a thiazide-type diuretic or a calcium channel blocker. In comparison, the initial antihypertensive choice in the non-African-American population is a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). In both sub-populations, these recommendations hold true even if the patient also has diabetes mellitus. calcium channel blocker choices include amlodipine, nitrendipine and diltiazem ER. thiazide-type diuretic choices include indapamide, hydrochlorothiazide, chlorthalidone and bendroflumethazide.
A woman complains of her heart racing, facial flushing and headache after taking an unknown pill in her purse. Which of the following is the most likely medication? Amitriptyline Metformin Metoprolol Nitroglycerin
Correct Answer ( D ) Explanation: Nitroglycerin can cause reflex tachycardia, flushing and headache. It produces a vasodilator effect on the peripheral veins and arteries with more prominent effects on the veins. Nitroglycerine primarily reduces cardiac oxygen demand by decreasing preload as well as some reduction in afterload. It dilates coronary arteries and improves collateral flow to ischemic regions. Nitroglycerine vasodilates blood vessels by releasing nitric oxide in smooth muscle. This vasodilation can cause hypotension. The elevated heart rate is reflexive in nature; the heart attempts to compensate for the drop in blood pressure.
Which of the following can decrease levels of brain natriuretic peptide? Elderly age Female sex Kidney failure Obesity
Correct Answer ( D ) Explanation: Obesity can falsely decrease levels of brain natriuretic peptide. Brain natriuretic peptide is a natriuretic hormone that was initially identified in the brain but is also released from the heart, particularly the ventricles. It is released in response to volume expansion and increased wall stress in the cardiac ventricles. Increased plasma concentrations are found in heart failure in response to increased ventricular filling pressures from volume overload. An elevated serum brain natriuretic peptide is a nonspecific finding that does not establish the diagnosis of heart failure. However, levels > 500 pg/mL is consistent with heart failure, and a level < 100 pg/mL effectively eliminates heart failure as an acute cause of dyspnea. It is most useful in differentiating dyspnea due to heart failure verses that due to pulmonary disease. Brain natriuretic peptide is less helpful in the setting of increased body mass index as obese patients tend to have lower plasma levels of brain natriuretic peptide concentrations than nonobese patients. The etiology of this phenomena is not entirely understood.
Which of the following is an independent cause of secondary hypertension? Addison's disease Atrial fibrillation Hypercholesterolemia Primary aldosteronism
Correct Answer ( D ) Explanation: Primary aldosteronism is a potential cause of secondary hypertension. Hypertension can be divided into essential or secondary hypertension. Approximately 95% of patients with elevated blood pressure have essential hypertension. Secondary cause of elevated blood pressure should be suspected in patients with severe or resistant hypertension, in patients younger than 30 years without risk factors for hypertension, in patients with malignant hypertension, or hypertension onset before the age of puberty. Potential causes of secondary hypertension include renovascular disease, primary kidney disease, primary aldosteronism, obstructive sleep apnea, long-term corticosteroid use, coarctation of the aorta, thyroid disease, drugs, or pheochromocytoma. Renovascular disease is the most common potentially correctable cause of secondary hypertension. Signs, symptoms, and laboratory findings are dependent upon the etiology. Patients with secondary hypertension due to renovascular disease may present with an abdominal bruit or decreased kidney function after initiating antihypertensive therapy. Primary aldosteronism typically causes hypokalemia, mild hypernatremia, or drug-resistant hypertension. Patients with sleep apnea are usually obese and may complain of daytime somnolence, fatigue, headache, or depression. Drug-induced hypertension can be caused by oral contraceptives, decongestants, nonsteroidal anti-inflammatory drugs (NSAIDs), or cocaine. The treatment of secondary hypertension is based upon the underlying etiology. Complications of untreated hypertension include heart failure, cerebrovascular disease, renal insufficiency, and aortic dissection.
A 19-year-old college student presents dead-on-arrival to the ED. A post mortem autopsy reveals significant calcification of the aortic valve cusps. Upon review of his medical history, you would most likely find documentation of a murmur heard in which of the following locations? Apex Left, fourth intercostal space Right, fourth intercostal space Right, second intercostal space
Correct Answer ( D ) Explanation: Proper cardiac auscultation begins with an understanding of which chest wall location is associated with which valve-sound. The aortic valve is best appreciated in the right, second intercostal space just lateral to the sternum. The pulmonic valve is best heard in the left, second intercostal space just lateral to the sternum. The tricuspid valve can be appreciated in the left, fourth intercostal space over the left sternal border. The mitral valve is best appreciated in the left, fifth intercostal space about the midclavicular line, also known as the apex. The murmur of aortic stenosis occurs during systole between S1 and S2. As such, it is also called an ejection murmur. It is best heard in the right, second intercostal space. Other characteristics include medium pitch, crescendo-decrescendo tonality and possible associated thrill. Aortic stenosis is due to calcification of the valve cusps. It is a common cause of sudden death, especially in children and adolescents. It can also be associated with rheumatic heart disease, atherosclerosis and congenital bicuspid valve malformation.
A 65-year-old woman presented to the emergency department with sub-sternal chest pain and dyspnea. Her cardiac biomarkers were mildly elevated and there was ST-segment elevation in the anterior leads. Apical ballooning was seen on echocardiography and coronary angiography revealed normal coronary arteries. She has no past medical history and takes no medications. Recently the patient lost her husband of 40 years. What is the most likely diagnosis? Non-ST-elevation myocardial infarction Pericarditis ST-elevation myocardial infarction Stress-induced cardiomyopathy
Correct Answer ( D ) Explanation: Stress-induced cardiomyopathy, also called Takotsubo cardiomyopathy and "broken heart" syndrome, is an increasingly reported syndrome characterized by transient cardiac dysfunction with ventricular apical ballooning, usually triggered by intense emotional or physical stress. This syndrome mimics acute myocardial infarction, but in the absence of obstructive coronary artery disease. It is approximated that stress cardiomyopathy accounts for approximately 2% of suspected acute coronary syndromes. Stress cardiomyopathy was historically called Takotsubo cardiomyopathy. Takotsubo is a Japanese word for octopus trap which resembles the characteristic apical ballooning seen on ventriculogram or echocardiography. It has also been referred to as apical ballooning syndrome or broken heart syndrome. The pathophysiology remains unknown, but catecholamine-mediated myocardial stunning is thought to be the most likely mechanism. This disorder is more common in women, specifically postmenopausal women. Patients typically present following physical stress or a stressful emotional event such as a loss of a loved one, natural disaster, or devastating financial losses; however, a triggering event is not always present. Common presenting features include electrocardiographic changes (often anterior ST-segment elevations), mildly elevated cardiac biomarkers, sub-sternal chest pain, and dyspnea. Accepted criteria for the diagnosis are (1) ST segment elevation, (2) transient regional wall motion abnormalities of apex and mid ventricle, (3) the absence of coronary artery disease, and (4) absence of other causes of left ventricular dysfunction such as pheochromocytoma or myocarditis. In-hospital mortality is approximately 2% and patients who survive the acute episode typically recover in several weeks. Treatment is largely supportive care with hydration and efforts to alleviate physical or emotional stressor.
A 37-year-old man presents to the emergency department with chest pain and shortness of breath. His medical history is significant for uncontrolled type I diabetes and end-stage renal disease on hemodialysis. His last dialysis was four days ago and he missed his appointment this morning. His labs are notable for a fingerstick blood glucose 300 mg/dL, potassium 7.0 mmol/L, magnesium 2.0 mEq/L, and phosphorus 4.0 mmol/L. Which of the following findings is most likely to be seen on this patient's ECG? Osborn waves QT interval prolongation U waves Widened QRS complex
Correct Answer ( D ) Explanation: Symptomatic hyperkalemia is a life-threatening electrolyte abnormality typically seen in patients with underlying acute or chronic kidney disease. It can also be seen in conditions that cause increased tissue breakdown such as tumor lysis syndrome, rhabdomyolysis, and crush injuries. Muscle weakness and paralysis, cardiac conduction abnormalities and cardiac dysrhythmias are the most serious manifestations of hyperkalemia. Symmetrical peaked T waves with a shortened QT interval and ST-T segment depression are the earliest ECG changes seen in patients with hyperkalemia. Worsening hyperkalemia results in progressive lengthening of the PR interval and QRS duration, disappearance of the P wave, and ultimately widening of the QRS complex into a sinusoidal pattern. Treatment of hyperkalemia includes antagonizing the membrane effects of potassium, driving extracellular potassium into cells, and removing potassium from the body. Osborn waves (A), also known as J-waves, are positive deflections in the junction of the QRS complex and the ST segment. They are most commonly seen in patients with hypothermia. QT interval prolongation (B) is seen in hypokalemia, hypomagnesemia, and hypocalcemia. QT interval shortening is seen in hyperkalemia. U waves (C) are small deflections that follow the T wave and are typically seen in hypokalemia, rather than hyperkalemia.
A 62-year-old previously healthy, nonsmoking man presents to your office with questions about his cholesterol. His recent lab results include total cholesterol 245 mg/dL, high- density lipoprotein 38 mg/dL, low-density lipoprotein 165 mg/dL and triglycerides 250 mg/dL. He has an ASCVD score of 9%. Which of the following is the most appropriate initial therapy? Fenofibrate Fish oil Gemfibrozil Lovastatin
Correct Answer ( D ) Explanation: The American College of Cardiology and the American Heart Association (ACC/AHA) released a new set of guidelines in November 2013 for treatment of hyperlipidemia with the focus being to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) in adults. Cardiovascular risk is estimated based on age, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, gender, smoking status, systolic blood pressure and the presence or absence of diabetes. Several online calculators are available to determine risk. Four groups have been identified as benefiting from statin therapy: patients with ASCVD, patients with LDL levels greater than or equal to 190 mg/dL, patients aged 40-75 years with diabetes and an LDL level of 70-189 mg/dL, and patients with an LDL level of 70-189 mg/dL and a 10-year ASCVD risk of greater than or equal to 7.5%. The starting point to reduce the risk of ASCVD is lifestyle modifications such as regular physical exercise, heart-healthy diet, smoking cessation and maintaining a healthy weight. First-line treatment for patients meeting criteria for treatment of hypercholesterolemia is statin therapy, including lovastatin. This patient meets criteria for treatment based on his ASCVD score of > 7.5%.
A 14-day old boy is brought to clinic for a well-child check. The boy was born full-term via normal spontaneous vaginal delivery to a G2, P2 mother who had limited prenatal care. There were no complications at delivery. The boy has not yet regained birth weight and has been breastfeeding poorly. On physical examination, you note bluish discoloration of the lips and oral mucosa, clear breath sounds and a harsh left upper sternal border murmur. Which of the following chest X-ray findings is consistent with Tetralogy of Fallot? Egg-shaped heart Heart shaped like a snowman Increased pulmonary blood flow Lack of vascular congestion
Correct Answer ( D ) Explanation: The boy has central cyanosis with a harsh murmur characteristic of pulmonary stenosis. These findings are suspicious for tetralogy of Fallot (TOF). TOF is composed of four anatomic defects consisting of an overriding aorta, right ventricular hypertrophy, pulmonary stenosis, and ventricular septal defect (VSD). The clinical presentation depends upon the degree of pulmonary stenosis. The more severe the stenosis, the greater is the reduction of pulmonary blood flow and increased cyanosis. On examination, the patients are usually comfortable and in no distress. During hypercyanotic (tet) spells, patients usually become hyperpneic or agitated. The murmur of TOF is usually due to pulmonary stenosis and not the VSD. The murmur is due to the degree of obstruction and to the amount of flow across the obstruction. The diagnosis of TOF is generally made by echocardiography. Other tests that are often performed during the evaluation of TOF include chest radiography and electrocardiogram. The classic chest X-ray in TOF demonstrates a "boot-shaped" heart with an upturned apex and a concave main pulmonary artery segment. The heart size is often normal, and pulmonary flow will appear normal or decreased. Treatment of TOF involves surgical closure of the VSD as well as repair of the pulmonary stenosis. The timing of this procedure depends upon the degree of obstruction to pulmonary blood flow. The following are possible chest radiography findings in cyanotic heart diseases: egg-shaped heart (A) is found in transposition of the great arteries, heart shaped like a snowman (B) is described in total anomalous pulmonary venous return, and increased pulmonary blood flow (C) can be found in truncus arteriosus, transposition of the great arteries, and total anomalous pulmonary venous return.
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? Aortic ultrasound Echocardiogram Renal angiogram Urinalysis
Correct Answer ( D ) Explanation: The evaluation of hypertension involves specific history questions, exam findings and laboratory testing. A standard history should include questions about the presence of comorbidities (coronary artery disease, atherosclerosis, congestive heart failure, previous myocardial infarction, peripheral arterial disease, hypercholesterolemia, transient ischemic attacks and strokes, diabetes, renal insufficiency, endocrinopathies, retinal disease, connective tissue disease and obstructive sleep apnea), medications (oral contraceptives, corticosteroids, NSAIDs and cyclosporine), social history (salt intake, tobacco use, alcohol use, cocaine and methamphetamine use, dietary intake, and exercise trends) and family history of hypertension. The physical examination must include serial bilateral arm BP measurements, cardiac exam (murmurs, evidence of left ventricular hypertrophy), peripheral vascular and skin exam (edema, bruits, capillary refill, striae, moon fascies), thyroid exam, abdominal exam (masses, bruits), fundoscopic exam and neurologic exam. Baseline laboratory-diagnostic testing should include a basic metabolic panel, complete blood count, urinalysis, lipid panel and ECG.
A 55-year-old woman presents to the office with progressive dyspnea, paroxysmal dyspnea, orthopnea, and fatigue over the last several months. On auscultation of her heart you hear a low-pitched diastolic rumble best heard in the left lateral decubitus position along with a high-pitched opening snap. Which type of valvular abnormality is associated with these findings? Aortic regurgitaion Aortic stenosis Mitral regurgitation Mitral stenosis
Correct Answer ( D ) Explanation: The main symptoms of mitral stenosis (MS) are slowly progressive dyspnea and fatigue. Most auscultatory signs of MS are missed if not performed in the left lateral decubitus position. Typically, the first heart sound (S1) is accentuated. A low-pitched diastolic rumble, heard with the bell of the stethoscope over the apex is also present. The high-pitched opening snap (OS) is caused by the abrupt stopping of the domed mitral valve into the left ventricle (also appreciated in most patients midway between the left sternal border and apex). A shorter A2-OS distance indicates a more severe MS. Signs of pulmonary hypertension such as a loud P2 and right ventricular hypertrophy can also be present as MS becomes more severe. Mitral stenosis is defined as the reduced ability of the blood to move from the left atrium to the left ventricle in diastole. It is mostly caused by dysfunction in the mitral valve, which lacks the ability to open its leaflets in diastole. Mitral valve stenosis (MS) is predominantly caused by rheumatic carditis and is more prevalent in female patients.
A 55-year-old man presents to the emergency department complaining of palpitations, nausea, and dizziness for 30 minutes. He is afebrile, his pulse is 140 beats per minute, and his blood pressure is 78/50 mm Hg. As the nurse attaches him to the cardiac monitor, you see the rhythm strip seen above. What is the most appropriate treatment? Adenosine 6 mg IV push Defibrillation at 360 joules Procainamide 18 mg/kg infused over 30 minutes Synchronized cardioversion at 200 joules
Correct Answer ( D ) Explanation: The monitor shows a wide complex tachycardia. Clinically, he is hypotensive and unstable, which necessitates the use of electrical rather than pharmacologic treatment. Synchronized cardioversion is indicated for the treatment of unstable tachydysrhythmias, including certain supraventricular dysrhythmias as well as monomorphic ventricular tachycardia. For treatment of ventricular fibrillation or polymorphic ventricular tachycardia, defibrillation (not synchronized cardioversion) is indicated. Defibrillating a patient who has a pulse (B) is dangerous and can result in the R-on-T phenomenon. This occurs when a depolarizing impulse (endogenous or exogenous) is delivered during ventricular repolarization (T wave). This can result in polymorphic ventricular tachycardia or ventricular fibrillation. To avoid this complication, synchronized cardioversion coordinates delivery of an electrical impulse so that it occurs with initiation of ventricular contraction (i.e., at the beginning of the QRS complex), thereby avoiding a shock during the relative refractory period of the cardiac cycle. Procainamide (C) is an option for patients with stable ventricular tachycardia, but it is not appropriate treatment of a hypotensive patient with an undifferentiated wide complex tachycardia. Procainamide may also worsen hypotension.
52-year-old man presents to the Emergency Department via ambulance with substernal chest pain. He received aspirin and nitroglycerin from emergency personnel in route. Vital signs include BP 95/55 mm Hg, HR 60 beats/minute, RR 20 breaths/minute, and T 97.6°F. His electrocardiogram is shown above. Which of the following is the most appropriate next diagnostic study? Chest radiograph Computed tomographic angiogram of the chest Posterior electrocardiogram Right-sided electrocardiogram
Correct Answer ( D ) Explanation: This patient has an ECG consistent with an inferior ST segment elevation myocardial infarction. Inferior wall myocardial infarction may be accompanied by bradycardia due to involvement of the AV node or hypotension due to total right ventricular involvement. The inferior wall and right ventricle are supplied by the right coronary artery. ST segment elevation in leads II, III, and aVF is suggestive of an inferior wall infarct. This patient is suffering from hypotension and bradycardia as well, which suggest a potential right ventricular infarct. ECG findings suggestive of this include ST segment elevation in leads II, III, and aVF with the elevation in lead III greater than that of lead II or associated elevation in lead V1. Any ST segment elevation in the inferior leads should prompt a right-sided electrocardiogram. ST segment elevation in leads V4R and V5R is diagnostic of a right ventricular infarct. Cardiac enzymes should also be drawn and troponin I would characteristically be elevated in ST segment elevation myocardial infarction 2-6 hours after symptom onset. Lack of positive troponin should not delay treatment. ST segment elevation in two contiguous anatomic leads should prompt immediate initiation of therapy. Aspirin 324 mg PO chewable should be administered immediately to prevent further platelet aggregation. Clopidogrel and heparin are also indicated. Nitroglycerin may be given to improve myocardial oxygen supply by dilating the coronary arteries; however, it is contraindicated in right ventricular infarct due to risk for profound hypotension. Definitive treatment for ST segment elevation myocardial infarction is cardiac catheterization and revascularization. If the patient is going to be greater than 90 minutes from medical contact to balloon time from the nearest cardiac catheterization center, thrombolytics are recommended.
A 62-year-old man reports to the ED with new-onset, crushing, left-sided chest pain, radiating to the left arm that began suddenly 35 minutes prior to arrival. The patient has a history of hypertension, hypercholesterolemia, diabetes mellitus, and a 60-pack-year smoking history. His EMS ECG demonstrates ST-segment elevation in leads II, III, and aVF. In the ED, his vital signs are BP 135/75, HR 98, and RR 18. What is the most appropriate next step? Arrange for the patient to have an emergent stress test Call the cath lab emergently and prepare the patient for transport Give the patient nitroglycerin and draw labs, including troponins Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin
Correct Answer ( D ) Explanation: This patient has an acute myocardial infarction (MI). An acute MI is clinically characterized by left-sided, substernal, chest pain (often described as an "elephant on my chest," tightness, or pressure rather than pain itself) that radiates down the left arm or left jaw, diaphoresis, nausea/vomiting, and shortness of breath. These symptoms are a result of myocardial death due to coronary vessel occlusion or vasospasm, often as a result of rupture of an atherosclerotic plaque. The definition of an acute MI, as described by the European Society for Cardiology and American College of Cardiology (ACC) is a rise and fall of a cardiac biomarker (troponin) in addition to clinical symptoms, ECG changes, or coronary artery changes as noted on an interventional level. Risk factors for an acute MI include hypertension, hypercholesterolemia, diabetes, tobacco, male, increased age, and family history. This patient has ST-segment changes in leads II, III, and aVF, correlating to an inferior wall MI. In a patient with an acute MI, the first step in management is to place the patient on a cardiac monitor to recognize any dysrhythmias, establish a peripheral IV, give oxygen if hypoxic, and administer aspirin.
A 52-year-old man states he took his blood pressure and it was elevated to 180/100 mm Hg. He states that he missed his regular dose of antihypertensive medication because he was traveling for business and returned home today. His blood pressure now is 176/102 mm Hg. The patient is otherwise asymptomatic and has a normal physical exam. What is the most appropriate action? Admission for blood pressure monitoring Obtain an ECG Reduce mean arterial pressure by 25% with an intravenous antihypertensive Resume outpatient medication
Correct Answer ( D ) Explanation: This patient has asymptomatic hypertension. Without any symptoms or signs of end organ damage, there is no acute intervention necessary. Patients with elevated blood pressure may have vague symptoms (headache, weakness, fatigue). There is no evidence to support the acute reduction of blood pressure in these patients. The physician may elect to administer a dose of the patient's usual medication or discharge with a plan for resumption of these medications at home. Since the patient in the above clinical scenario has a known diagnosis of hypertension and did not recently take his medications, it is appropriate to have him resume the same medication at the same dose. Patients who have an elevated blood pressure despite taking their antihypertensives will need to be assessed by their primary care physician for alteration of their regimen.
A patient presents with chest pain and the ECG seen above. Which of the following medications is contraindicated in this patient's management? Aspirin Clopidogrel Heparin Nitroglycerin
Correct Answer ( D ) Explanation: This patient presents with an inferior ST elevation myocardial infarction (STEMI) and the use of nitroglycerin is relatively contraindicated in management. In patients with myocardial ischemia or infarction, nitrates are used to decreased myocardial oxygen demand. They increase venous capacitance leading to decreased preload and are direct coronary artery vasodilators. Coronary artery vasodilation leads to increased blood flow to ischemic myocardium. The beneficial effects of nitrates are profound leading to their recommendation for most patients with a systolic blood pressure > 90 mm Hg. An inferior STEMI is one of these contraindications. Patients with an inferior STEMI may also have right ventricular infarct and be preload dependent. In a patient with an inferior STEMI, right ventricular infarct is suggested by the presence of ST elevation in lead III larger than that in lead II. A right ventricular infarct can be discovered by performing a right-sided ECG and looking for ST elevation in lead "RV4." In these patients, a preload reducing medication like nitroglycerin can lead to a precipitous drop in blood pressure.
76-year-old man with colorectal cancer presents to the ED with dyspnea and fatigue. He is hypotensive, tachycardic, tachypneic and afebrile. The jugular venous pulse rides high on lateral neck inspection. Cardiac sounds, but not breath sounds, are distant. There is no discernable friction rub or murmur, however, his blood pressure decreases during inspiration. An ECG reveals normal rhythm, increased rate and decreased voltages. Which of the following treatments is most appropriate in this patient's plan of care? Cardioversion Endarterectomy Hemodialysis Pericardiocentesis
Correct Answer ( D ) Explanation: This scenario most likely represents cardiac tamponade. Pericardial tamponade refers to the dampening effect of rapidly accumulating pericardial effusion. An increase in intrapericaridal pressure compresses the heart chambers, decreases venous return and ultimately decreases cardiac output. As this occurs, it becomes ever more difficult for blood to flow from chamber to chamber. Causes include pericarditis, traumatic aortic dissection and myocardial rupture. Patients usually present with severe dyspnea, fatigue and hypotension. Typical exam findings include Beck's triad of hypotension, distant heart sounds and increased jugular venous pressure. Tachycardia and clear-sounding tachypnea are common. Pulsus paradoxus, a decrease in systolic blood pressure more than 10 mm Hg during inspiration, is also commonly present. However, pulsus paradoxus also accompanies constrictive pericarditis, congestive heart failure, pulmonary embolism, and end-stage obstructive pulmonary disease. Distant heart sounds and friction rubs may be present. Chest radiographs show large cardiac silhouettes, and ECGs may reveal a widespread decrease in voltage with an effusion and electrical alternans in tamponade. Classic echocardiographic findings are effusion, interventricular septal shift during inspiration, diastolic collapse of the right atrium and respiration-timed alterations in transvalvular flow. This medical emergency is treated with cardiopulmonary stabilization, pericardiocentesis (percutaneous drainage of pericardial fluid), cautious volume replacement and inotropic medications such as dobutamine.
Which of the following is associated with a shortened PR interval? Brugada Syndrome Mobitz 2° AV Block Wellens Syndrome Wolff-Parkinson-White syndrome
Correct Answer ( D ) Explanation: Wolff-Parkinson-White syndrome (WPW) is a congenital condition in which there is an abnormal accessory conduction pathway called the bundle of Kent. This accessory conduction pathway causes a premature depolarization of the ventricles by bypassing the AV node. The AV node typically acts to delay depolarization (the PR interval) to the ventricles to allow them to fill before contracting (QRS complex). The accessory pathway causes early depolarization of the ventricles resulting in an early QRS complex, thereby shortening the PR interval. On an ECG, this is represented by an upslope of the QRS complex (delta wave) that causes a widened QRS complex (>120 msec). The primary significance of WPW syndrome is that it predisposes patients to the development of tachydysrhythmias, particularly atrial fibrillation. Brugada Syndrome (A) is a hereditary condition characterized by a right bundle branch block-like pattern with ST elevation in Leads V1 to V3. Wellens Syndrome (C) is described by a large inverted T wave in Leads V2 and V3 and is associated with critical stenosis of the proximal left anterior descending coronary artery. Both Brugada and Wellens syndromes have normal PR intervals.
A 72-year-old woman presents to the ED with an acute onset of dyspnea and palpitations that began four hours prior to arrival. Vital signs include a heart rate of 144 beats per minute, blood pressure of 80/50 mm Hg, respiratory rate of 28 breaths per minute, temperature of 37.0°C, and a pulse oximetry of 88% on room air. The above 12-lead ECG is obtained. What is the most appropriate next step in the management of this patient? AAnticoagulation with enoxaparin followed by warfarin BChemical cardioversion using procainamide CRate control using diltiazem DRate control using esmolol ESynchronized cardioversion
Correct Answer ( E ) Explanation: This patient has atrial fibrillation with a rapid ventricular rate and is hemodynamically unstable (BP 80/50 mm Hg and pulse ox 88%). This dysrhythmia needs to be emergently corrected in order to stabilize the patient; failure to do so could result in sudden cardiac death. In such circumstances, emergent synchronized cardioversion is required. If the patient is hemodynamically stable, the approach to management (rate vs. rhythm control) depends on the time of dysrhythmia onset. If the onset is unknown or greater than 48 hours, then cardioversion should be delayed until the patient can be adequately anticoagulated with enoxaparin (A) followed by warfarin. In the interim, rate control would be accomplished with either esmolol (D), a short acting ß-blocker, or diltiazem (C), a calcium channel blocker. For patients with stable paroxysmal atrial fibrillation and duration of onset < 48 hours, chemical cardioversion using procainamide (B) can be attempted. In unstable patients, regardless of the rhythm duration, synchronized electrical cardioversion is recommended. Alternatives to procainamide include amiodarone, ibutilide, and, to a lesser degree, flecainide.
Rapid Review Dilated Cardiomyopathy
Dilated Cardiomyopathy Causes: idiopathic > viral myocarditis, Chagas disease Echo: 4 dilated chambers (ventricles > atria) Systolic pump failure → heart failure S3, S4 Peripheral embolization of mural thrombi Most common dysrhythmia: atrial fibrillation ßBs, ACEIs, diuretics, digoxin, anticoagulation, AICD
Rapid Review Heart Failure Staging/Classification
Heart Failure Staging/Classification American Heart Association/American College of Cardiology staging: Stage A: high risk without symptoms/disease Stage B: structural disease without sx Stage C: structural disease + sx Stage D: refractory heart failure New York Heart Association Classification: I: asymptomatic II: sx with ordinary activity III: asymptomatic only at rest IV: sx at rest
Rapid Review Hypertensive Emergency
Hypertensive Emergency Hypertension with acute end-organ system injury Encephalopathy, cardiac ischemia, renal ischemia Objectives: reduce MAP 25% in first hour, normalize BP over the next 8 to 24 hours Reduction of MAP > 25% may cause end-organ ischemia IV antihypertensives (labetalol or nicardipine)
Rapid Review Hypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathy Asymmetric LV septal wall hypertrophy → outflow obstruction Autosomal dominant (familial form) Young patient Exertional syncope Sudden cardiac death S4 gallop Midsystolic murmur (↑ as preload ↓) Rx: ßBs or CCBs
Rapid Review Inferior ST-Elevation Myocardial Infarction
Inferior ST-Elevation Myocardial Infarction RCA occlusion ST elevations: II,III, aVF RV infarction ST elevations: V4R and V5R JVD, hypotension Rx: IVF NTG contraindicated
Rapid Review Lower Limits of Pediatric Systolic Blood Pressure
Lower Limits of Pediatric Systolic Blood Pressure 0-28 days: 60 mm Hg 1-12 months: 70 mm Hg 1-10 years: 70 mm Hg + (2 x age in years) >10 years: 90 mm Hg
Rapid Review Kawasaki Disease
Kawasaki Disease Patient will be a child < 4 years old With a history of high fever for 5 days Complaining of conjunctivitis, rash, adenopathy, strawberry tongue, hand/feet edema, fever Treatment is IVIG + aspirin Comments: #1 cause of pediatric acquired heart disease, risk for coronary artery aneurysm Mnemonic: CRASH and burn: Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet edema, Fever
Rapid Review Light's Criteria
Light's Criteria Fluid is exudate if one of the following Light's criteria is present: Fluid protein/serum protein ≥ 0.5 Fluid lactate dehydrogenase (LDH)/serum LDH ≥ 0.6 Fluid LDH level > 2/3 the upper limit of normal of serum LDH
Rapid Review Myocarditis
Myocarditis Leads to dilated cardiomyopathy, CHF Sudden death in young adults Idiopathic (viral etiology is suspected but unproven) > viral (parvovirus B19, adenovirus, coxsackie B, echovirus) Viral prodrome Positive troponin ST-segment elevation ECHO shows global hypokinesis Supportive management, possible transplant
Rapid Review Normal Pediatric Heart Rates
Normal Pediatric Heart Rates <1: 100-160 bpm 1-2: 90-150 bpm 2-5: 80-140 bpm 6-12: 70-120 bpm >12: 60-100 bpm
Rapid Review Pericardial Tamponade
Pericardial Tamponade Patient will be complaining of dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck's triad), pulsus paradoxus ECG will show low voltage QRS, electrical alterans Echocardiography will show diastolic collapse of RV Treatment is pericardiocentesis
Rapid Review Prinzmetal Angina (Variant Angina
Prinzmetal Angina (Variant Angina) Patient with a history of HTN, smoking, DM, obesity, or cocaine use Complaining of squeezing, pressure-like chest discomfort at rest ECG will show transient ST-segment elevations and cardiac enzymes will be normal Diagnosis is made by cardiac stress test Most commonly caused by coronary artery spasm Treatment is calcium channel blockers and nitrates
Rapid Review Pulmonary Embolism
Pulmonary Embolism 95% arise from deep leg veins Sudden onset of symptoms in 50% SOB, CP, tachypnea ECG: sinus tachycardia, nonspecific ST-T changes, right heart strain, S1Q3T3 (classic finding) CXR: nonspecific abnormalities, Hampton's hump (pleural-based wedge infarct), Westermark's sign (vascular cut-off sign) V/Q scan: usually nondiagnostic Low clinical suspicion: negative D-dimer excludes PE Dx of choice: CTPA Treatment: Anticoagulation Thrombolytics (if massive and HD unstable or submassive with shock, respiratory failure or evidence of moderate to severe RV strain) Embolectomy (last resort)
Rapid Review Rheumatic Fever
Rheumatic Fever Patient with a history of GAS infection Complaining of fever, red skin lesions on the trunk and proximal extremities, and small, non-tender lumps located over the joints PE will show JONES criteria: Joints, Oh, no carditis!, Nodules, Erythema marginatum, Sydenham's chorea Labs will show anti-streptolysin O, anti-DNase B, positive throat culture, or positive rapid antigen test Treatment is antibiotics, NSAIDs Comments: Modified Jones Criteria for a first episode of acute rheumatic fever: need 2 major or 1 major and 2 minor
Rapid Review Right Bundle Branch Block (RBBB)
Right Bundle Branch Block (RBBB) QRS > 120 ms RSR' pattern in V1-V3 Wide, slurred S wave in lateral leads
Rapid Review Sick Sinus Syndrome (SSS)
Sick Sinus Syndrome (SSS) SA node dysfunction Tachycardia-bradycardia syndrome: sinus rate varies from fast to slow and back again Syncope, palpitations Definitive rx: pacemaker placement + rate control medication Untreated SSS → sinus block or sinus arrest
Rapid Review Supraventricular Tachycardia
Supraventricular Tachycardia All tachydysrhythmias that arise above the bifurcation of the bundle of His Characteristics: Atrial rate 120-200 Rhythm: regular Narrow QRS Causes Pre-excitation syndromes (WPW) Mitral disease Digitalis toxicity Drugs and toxins Hyperthyroidism Treatment: Vagal maneuvers (Valsalva) Adenosine (first-line medication), ßBs, CCBs Unstable: synchronized cardioversion
Rapid Review Supraventricular Tachycardia amended 6/20/16
Supraventricular Tachycardia amended 6/20/16 All tachydysrhythmias that arise above the bifurcation of the bundle of His Characteristics: Atrial rate 120-200 Rhythm: regular Narrow QRS Causes Pre-excitation syndromes (WPW) Mitral disease Digitalis toxicity Drugs and toxins Hyperthyroidism Treatment: Vagal maneuvers (Valsalva) Adenosine (first-line medication), ßBs, CCBs Unstable: synchronized cardioversion
Rapid Review Tetralogy of Fallot
Tetralogy of Fallot Patient with a history of episodes of cyanosis (tet spells) and squatting for relief PE will show pulmonic stenosis, right ventricular hypertrophy, overriding aorta, VSD CXR will show "boot-shaped" heart Comments: Most common cyanotic congenital heart disease Mnemonic: PROVe:: Pulmonic stenosis, Right ventricular hypertrophy, Overriding aorta, VSD
S3 vs S4 murmurs
The S3 heart sound, also referred to as a protodiastolic gallop or ventricular gallop, is generally associated with acute heart failure. The sound is associated with early diastolic filling and is heard in such pathologic states as volume overload and left ventricular systolic dysfunction. It occurs at the beginning of diastole and produces a rhythm classically compared to the cadence of the word Kentucky (S1 = Ken; S2 = tuck; S3 = y). The S3 may be normal in people under 40 years of age, may sometimes be heard in pregnancy, and in some athletes but should disappear before middle age. S3 is a dull, low-pitched sound best heard with the bell placed over the cardiac apex with the patient lying in the left lateral decubitus position.
Rapid Review Torsades de Pointes (TdP)
Torsades de Pointes (TdP) ECG will show rhythm > 100 beats per minute and frequent variation in the QRS axis and morphology Most commonly caused by acquired or congenital long QT interval syndrome Treatment is Unstable: defibrillation Stable: intravenous magnesium sulfate and stopping the offending drug
Rapid Review Tricuspid Regurgitation
Tricuspid Regurgitation Causes: tricuspid ring stretching > pulmonary HTN, endocarditis, rheumatic heart disease Pansystolic murmur at left sternal border JVP: giant c-v wave Atrial fibrillation
Rapid Review Vasculitis
Vasculitis Temporal arteritis: PMR, carotid artery branches affected, vision loss, Rx: immediate steroids Takayasu's arteritis: Asian, decreased pulses PAN: generalized without lung involvement, HBV Buerger's disease: smokers, claudication of hands/feet Granulomatosis with polyangiitis (GPA): Upper and lower respiratory sx + renal sx, c-anca Microscopic polyangitis: similar to GPA but without nasopharyngeal involvement, p-ANCA Churg-Strauss syndrome: vasculitis + eosinophilia + asthma Cryoglobulinemia: HCV, malaise, skin lesions, joint pain Behçet's disease: oral and genital ulcers, hyperreactivity to needle sticks
Rapid Review Ventricular Fibrillation
Ventricular Fibrillation Most common cause: ischemic heart disease ECG: irregular chaotic pattern without P waves or QRS complexes Immediate defibrillation
Rapid Review Ventricular Tachycardia
Ventricular Tachycardia > 3 consecutive ectopic ventricular beats Monomorphic, polymorphic Bidirectional: digoxin toxicity Wide complexes Pulseless: immediate defibrillation Unstable: synchronized cardioversion Stable: procainamide, amiodarone, synchronized cardioversion (refractory) If unsure, manage all wide complex tachycardias as ventricular tachycardia
Rapid Review Dysrhythmias
Ventricular Tachycardia AV dissociation, wide-complex Rate typically 150-200 >3 consecutive ectopic ventricular beats Monomorphic, polymorphic Bidirectional: digoxin toxicity Pulseless: immediate defibrillation Unstable: synchronized cardioversion Stable: procainamide, amiodarone, synchronized cardioversion (refractory) If unsure, manage all wide complex tachycardias as ventricular tachycardia Ventricular Fibrillation Wide-complex, disorganized No cardiac output or pulse Incompatible with life Defibrillation, ACLS Atrial Flutter Sawtooth pattern Atrial rate: 250-300/minute Ventricular rate: 150- +/-30 AV node conducts every 2 or 3 atrial impulses Atrial Fibrillation Irregularly irregular No P waves Narrow QRS unless conduction block or accessory pathway Variable ventricular response rate
Rapid Review Wolff-Parkinson-White (WPW) Syndrome
Wolff-Parkinson-White (WPW) Syndrome ECG will show short PR interval, delta wave, wide QRS Most commonly caused by an accessory pathway (bundle of Kent) connects atria to ventricles, bypassing AV node Definitive treatment is radiofrequency ablation
