1-100 Flashcards
what is the most appropriate management for a patient with infective endocarditis and acute HF?
urgent cardiac surgery +diuretica +AB
The next step in management for a patient who is not responsive to escalating
doses of oral diuretics is to
administer intravenous diuretics.
Current guidelines recommend thrombolytic therapy for patients with STsegment elevation myocardial infarction (STEMI) who present within
12 hours after symptom onset when primary percutaneous coronary intervention (PCI)
cannot be performed within 2 hours after first medical contact.
Criteria for
successful thrombolysis include
improvement or relief of pain, >50% resolution in the magnitude of ST-segment elevation, and reperfusion arrhythmias (e.g., accelerated idioventricular rhythm).
Patients with new-onset heart failure and a high likelihood of coronary artery disease who are candidates for coronary revascularization should undergo
HC
The most appropriate class of medications for a patient who is hospitalized with acute decompensated heart failure, severely depressed left
cardiac output, and evidence of poor renal perfusion and who is not responding to intravenous loop diuretics is
an inotropic agent (Dobu)
The most likely diagnosis in a patient with dyspnea on exertion and deep,
symmetric T-wave inversions in leads V2 and V3 accompanied by a flat ST
segment is
unstable angina.
In a person with symptoms consistent with myocardial ischemia,
electrocardiographic (ECG) evidence of deep, symmetric T-wave inversions in
leads V2 and V3, accompanied by a flat ST segment, is suggestive of
a critical stenosis of the proximal left anterior descending coronary artery. (This ECG
pattern and associated coronary stenosis is often called Wellens syndrome.)
Most patients with
aortic dissection present with
h chest pain, and some have syncope.
The most likely diagnosis in a patient with pleuritic chest pain, fever, new scratchy
systolic and diastolic auscultatory findings, and new ST-segment elevations
within a few days after an acute myocardial infarction is
pericarditis
In-stent restenosis does not occur within days after stent placement. TRUE or FALSE?
true
When a patient with a history of stroke requires dual antiplatelet therapy, the most
appropriate medications are aspirin plus either
clopidogrel or ticagrelor. NOT prasugrel (increased bleeding risk)
Patients with pericarditis may have ST-segment elevation, but
the changes are not localized to a single coronary artery distribution.
The most likely cause of acute ST-segment elevation in a patient who recently had a stent inserted is
stent thrombosis
The most appropriate anticoagulant treatment for a patient with a non–ST-segment elevation acute coronary syndrome who is being managed noninvasively is
subcutaneous
low-molecular-weight heparin (Subcutaneous enoxaparin)
……… has technical advantages for patients undergoing early invasive management, but once a noninvasive management strategy is chosen, ………..provides a
more practical option and is associated with lower rates of recurrent myocardial infarction.
Intravenous UFH …..LMWH
……………… is usually restricted to patients undergoing early intervention and is given in the catheterization laboratory
Intravenous LMWH or fondaparinux
In addition to clopidogrel and aspirin, the recommended treatment for a patient with advanced kidney disease and evidence of a non–ST-segment elevation myocardial
infarction who does not presently have chest pain is
intravenous unfractionated heparin.
Management of new-onset atrial fibrillation that is characterized by a rapid
ventricular response despite multiple rate-control medications and a depressed
left ventricular ejection fraction should include
a trial of electrical cardioversion, if
no intracardiac thrombus is present on transesophageal echocardiography
Cardioversion in AF is indicated when
rate control is not achieved promptly with pharmacologic measures or when the
patient experiences ongoing hypotension, angina, or heart failure.
Transesophageal echocardiography to exclude intracardiac thrombus (especially
left atrial appendage thrombus) and anticoagulation are recommended when?
before cardioversion in a patient with atrial fibrillation of unknown or more than 48 hours’
duration. Anticoagulation is recommended for one month after cardioversion.
Although flecainide can be used to terminate atrial fibrillation, it should be avoided
in patients with
coronary artery disease, significant structural heart disease, or
left ventricular dysfunction.
Postcardiac injury syndrome (Dressler syndrome) should be treated with
high-dose aspirin, analgesics, and colchicine
Use of simvastatin has been associated with an increased risk for myopathy, and
several common medications increase plasma levels of this drug. Medications
that are contraindicated in simvastatin users include
ketoconazole, erythromycin,
protease inhibitors, gemfibrozil, cyclosporine, and danazol. Verapamil, diltiazem,
amiodarone, and dronedarone can be used safely only when a patient’s
simvastatin dose is kept at or below 10 mg daily. Amlodipine can be added when
the simvastatin dose is no more than 20 mg. Ramipril can be added to a
medication regimen that includes daily simvastatin at 40 mg
The most appropriate long-term treatment for a patient with chest pain and a
diagnosis of Prinzmetal variant angina is
a calcium-channel blocker.
As-needed sublingual nitroglycerin would not prevent recurrent episodes of
variant angina. TRUE OR FALSE?
true
Beta-blockers are recommended for patients with angina and conventional
obstructive coronary disease but not for patients with vasospasm and otherwise
normal coronary arteries. Propranolol (a nonselective beta-blocker) has been
shown to exacerbate
vasospasm
The medication that is most appropriate for a patient with refractory, low-level,
chronic stable angina whose heart rate and blood pressure are low-normal while
taking appropriate doses of a beta-blocker and a nitrate is
ranolazine. Ranolazine, an inhibitor of myocyte sodium channels, prevents cellular calcium
overload, reduces diastolic wall tension, and improves oxygen supply–demand
mismatch — thereby improving angina. Ranolazine has minimal effects on blood
pressure and heart rate. In a patient with chronic stable angina who is receiving
maximal doses of routine antianginal medications or whose low blood pressure
and heart rate prevent the safe uptitration of other antianginal agents, ranolazine
is the therapy of choice
……….is an absolute contraindication to
thrombolytic therapy because of concern for hemorrhagic conversion and
intracranial hemorrhage in this setting. Hence, this patient should not receive
reteplase, tenecteplase, or alteplase.
An ischemic stroke within the past 3 months
Other absolute contraindications to
thrombolytic therapy include previous intracranial hemorrhage, cerebrovascular
lesion or intracranial neoplasm, suspected aortic dissection, active bleeding or
diatheses, closed-head or facial trauma within the past 3 months, intracranial or
intraspinal surgery within the past 2 months, and severe uncontrolled
hypertension that is unresponsive to emergency treatment.
The goal is to perform primary PCI within ………. after the first
medical contact.
90 minutes
The lipid-lowering therapy that is most appropriate for a patient with an acute coronary syndrome is
high-dose statin therapy, such as atorvastatin 80 mg daily
Patients ……………..who are experiencing a myocardial infarction are
more likely than other patients to present without chest pain. Health care
providers should be alert for atypical symptoms such as jaw, neck, ear, arm, or
epigastric discomfort, which can be “anginal equivalents.” New-onset exertional
dyspnea is the most common anginal equivalent.
with diabetes mellitus
Cardiogenic shock, which occurs in about ………….f patients with acute
myocardial infarction (AMI), is associated with high rates of morbidity and
mortality.
5% to 8% o
Mechanical causes of post-AMI cardiogenic shock are
pump failure,
acute mitral regurgitation (MR) caused by papillary muscle rupture, ventricular
septal rupture, and free wall rupture. A papillary muscle rupture is the mechanical
complication most likely to cause cardiogenic shock in a patient who has had an
inferior myocardial infarction and has no evidence of intracardiac shunting.
A 72-year-old woman presents with an 8-month history of chest pressure and left-arm pain that occur only during substantial physical activity. Nuclear imaging during an
exercise test identifies a reversible area of hypoperfusion in the distribution of the right coronary artery. Other than optimizing medical therapy, what is the most appropriate
management approach?
Patients with low-risk stable angina are best managed with optimal medical therapy and do not require further investigation.
Dobutamine echocardiography, a form of pharmacologic stress testing with echocardiographic imaging during rest and stress, is indicated in a patient
who cannot exercise.
Echocardiography is preferred over nuclear imaging when
dyspnea prompts the stress testing, because the patient’s diastolic left ventricular function, valvular abnormalities, and right ventricular function and pressures can be assessed.
Coronary CT angiography is reasonable for symptomatic patients who
are at intermediate risk for CAD, including patients with equivocal stress-test results and those with
known or suspected coronary anomalies.
Cardiac catheterization with coronary angiography is recommended for stable CAD if
symptoms interfere with lifestyle despite optimal medical therapy or if a stress test
identifies high-risk findings (e.g., low exercise tolerance, electrocardiographic or imaging findings suggesting left-main or 3-vessel CAD).
Coronary calcium scoring is generally performed to estimate the risk for CAD in
asymptomatic person. It adds no useful information in a symptomatic patient with imaging abnormalities on stress testing.
The recommended duration of dual antiplatelet therapy after implantation of a
drug-eluting stent depends on
the original indication for the stent but should not
exceed one year.
Pseudoaneurysm,
the most common peripheral vascular complication after cardiac catheterization, occurs when the wall of an artery is disrupted by the puncture and does
not adequately seal after the procedure. Pseudoaneurysms are rare after diagnostic cardiac catheterization, but the incidence increases to 2% to 6% after coronary intervention
because of the intensity of required anticoagulation. Pseudoaneurysms manifest as a pulsatile mass at the catheter insertion site and have a systolic bruit. Ultrasound can
confirm the diagnosis of pseudoaneurysm
Femoral artery dissection should not result in
a pulsatile mass or a systolic bruit
The most appropriate management approach for a patient with type 2 diabetes who has severe three-vessel coronary disease and left ventricular systolic dysfunction is
coronary artery bypass grafting
Thrombolytic therapy can reduce the mortality risk associated with an STsegment-elevation myocardial infarction. It should be administered to patients
who present
within 12 hours after symptom onset when primary percutaneous
coronary intervention (PCI) cannot be performed within 2 hours.
Clinical markers of successful reperfusion include
.
resolution of chest pain, >70%
ST-segment resolution on electrocardiogram (ECG), and reperfusion arrhythmias,
such as accelerated idioventricular rhythm.
Urgent transfer to a PCI-capable hospital is recommended for patients who are in
cardiogenic shock, have severe heart failure, or have failed reperfusion.
Early
cardiac catheterization with coronary angiography — within 24 hours (but not
within the first 2 to 3 hours after thrombolysis) — is recommended for
patients
with ST-segment-elevation myocardial infarction who have received thrombolytic
therapy, even when they are hemodynamically stable and have clinical evidence of
successful reperfusion.
The most appropriate management for a patient with a non–ST-segment elevation myocardial infarction who is determined to be at risk for recurrent ischemia or death is an
invasive strategy, with cardiac catheterization with coronary angiography performed within
12 to 24 hours after presentation
guidelines mbt NSTEMI?
TIMI Risk Score for UA/NSTEMI
GRACE
complications after HC?
all correct, but occlusion and fistula are rare, dissection no mass, hematoma not plusatile
For a STEMI patient who presents to a facility that is unable to perform PCI, the
goal is to transfer him or her to a PCI-capable facility and perform the procedure
within
120 minutes after the first medical contact (although <90 minutes is
optimal). If primary PCI cannot be performed within 120 minutes, thrombolytic
therapy (e.g., tenecteplase) should be administered, barring any contraindications.
After successful thrombolysis, expeditious transfer to a PCI-capable facility
should be part of a pharmacoinvasive strategy because of the potential for
coronary reocclusion. Transfer is also warranted for rescue PCI when reperfusion
is not successful
An implantable cardioverter–defibrillator is appropriate as primary prevention for
patients with heart failure whose left ventricular ejection fraction is
≤35%. Few
data support placement of an implantable cardioverter–defibrillator in
asymptomatic patients with sustained (≥30 sec) VT and a left ventricular ejection
fraction >35%.
…………………………………..are more likely than
other patients to lack typical, ischemic chest pain when they experience a
myocardial infarction (MI). Providers should remain vigilant for atypical
symptoms of MI, such as diaphoresis, unexplained fatigue, nausea, vomiting,
upper abdominal discomfort, and exertional symptoms. An MI should be
excluded as a matter of urgency in this older woman with unexplained, worsening
abdominal discomfort.
Women, older adults, and patients with diabetes mellitus
If the presentation represents unstable angina, an
electrocardiogram may show abnormalities only during
an episode of pain.
calculate senstivity, specificity, PPV, NPV
describe the hemodynamiks in patient with inferior MI and right ventricular MI?
In a patient with RV infarction, the central venous pressure (a measure of right
atrial pressure) is elevated, whereas the systolic pressures in the more central
chambers (i.e., right ventricle and pulmonary artery) are normal.
The pulmonary capillary wedge pressure (a measure of left atrial pressure) is low
or normal.
Cardiac output is normal or reduced, not increased, in the setting of MI. Despite
the elevation in central venous pressure, patients with RV infarction are quite
preload-dependent; thus, in the setting of hypotension, they often require
substantial expansion of intravascular volume (with intravenous fluid
administration).
when does the right ventricular infarction occur? what are the consequences? how to detect it?
The electrocardiogram shows an inferior myocardial infarction (MI), which is
most often the result of right coronary artery occlusion. If the occlusion occurs in
the proximal portion of the vessel, right ventricular (RV) MI may occur. In a patient
with an inferior MI, one indicator of concomitant RV involvement is hypotension
that is precipitated or exacerbated by administration of nitroglycerin. A right-sided
electrocardiogram can help in reaching this diagnosis; ST-segment elevation in
lead V4R is the single most powerful predictor of right ventricular involvement.
what do you expect in early acute pericarditis in the ECG?
In the absence of treatment, the ECG changes may progress through four stages:
● Stage 1: diffuse ST-segment elevation and PR-segment depression
● Stage 2: normalization of the ST and PR segments, often with T-wave flattening
● Stage 3: widespread T-wave inversions
● Stage 4: normalization of T waves
Stage 1 typically occurs in the first hours to days, stage 2 within several days, and
stages 3 and 4 within days to weeks. This patient has had chest pain for 7 days,
and his ECG changes are in stage 3.
how to define acute pericarditis?
Acute pericarditis is defined by the presence of two of the following three
features: pleuritic anterior chest pain, a pericardial friction rub (which is often
scratchy in character), and characteristic electrocardiographic (ECG) changes
consisting of widespread ST-segment elevation and PR-segment depression. On
physical examination, patients will often have improvement or relief of their pain
when leaning forward.
PE findings in short?
Although pulmonary embolism can cause pleuritic chest pain, the patient has no
tachycardia or hypoxemia. Furthermore, the pleural friction rub associated with
pulmonary embolism is audible only during active breathing (i.e., it is absent as
the breath is held), in contrast with a pericardial friction rub, which is audible
throughout the respiratory cycl
when should you consider ICD in patients with MI? and WHEN?
Left ventricular (LV) dysfunction after a myocardial infarction (MI) predisposes the
patient to ventricular arrhythmias and increased risk for sudden cardiac death. An
implantable cardioverter–defibrillator (ICD) should be considered if the patient
meets one of these two criteria:
● Persistent LV dysfunction (LV ejection fraction <35%) despite optimal medical
therapy (a beta-blocker, an angiotensin-converting–enzyme inhibitor, and a
statin, with or without spironolactone)
● A malignant ventricular arrhythmia (ventricular tachycardia or fibrillation) more
than 24 hours after the MI
Current guidelines recommend echocardiographic evaluation of LV systolic
function for an ICD a minimum of 40 days (about 6 weeks) after an MI or 3
months after primary percutaneous coronary intervention or coronary artery
bypass surgery. By then, stunned myocardium may have recovered its function
and/or ventricular remodeling may have occurred, resulting in an improvement in
LV function and obviating the need for an ICD.
The most appropriate treatment for Helicobacter pylori infection is
standard
quadruple therapy (a proton pump inhibitor, bismuth subsalicylate, metronidazole,
and tetracycline).
The most appropriate initial treatment for a patient whose stomach biopsy
findings show Helicobacter pylori infection and dense infiltrates of B-cells of the
mucosal lymphoid tissue
(representing MALT lymphoma) includes antibiotics for
the Helicobacter pylori infection. This treatment results in a remission in 50% to
80% of patients with H. pylori–associated gastric mucosal–associated lymphoid
tissue lymphoma
Schatzki rings are
benign, mucosal structures at the gastroesophageal junction
that classically cause intermittent solid food dysphagia, most commonly with
meat and bread. Schatzki rings appear as a narrowing in the distal esophagus on
upper gastrointestinal series; additional imaging with a barium-covered tablet can
help identify the site of the functional obstruction.
First-line therapy for Schatzki rings is
balloon or Savary dilation, which is
associated with prompt symptom resolution and a low rate of recurrence. After
dilation, acid suppression is recommended, particularly in patients with recurrent
strictures and symptomatic gastroesophageal reflux disease.
Esophageal stenting is used to treat
malignant obstructions and refractory peptic
strictures, which usually cause progressive solid food dysphagia.
Botulinum toxin injection into the lower esophageal sphincter can be used to treat
achalasia, particularly in patients who are not candidates for surgery. Achalasia
typically causes dysphagia to both solid foods and liquids, as well as regurgitation
of undigested food. A barium esophagram classically demonstrates a dilated
esophagus with a narrowed esophgogastric junction; this results in a bird-beak
appearance caused by the loss of peristalsis in the distal esophagus and a
persistently contracted lower esophageal sphincter.
An upper esophageal sphincter myotomy is the treatment for
Zenker diverticulum,
which typically occurs in older patients and causes regurgitation and aspiration.
Swallowed budesonide is used to treat
eosinophilic esophagitis, which tends to
occur in younger patients and causes dysphagia (predominantly to solids) and
food impaction.
eosinophilic esophagitis treatment? what is it?
Swallowed budesonide is used to treat eosinophilic esophagitis, which tends to
occur in younger patients and causes dysphagia (predominantly to solids) and
food impaction.
Zenker diverticulum treatment
An upper esophageal sphincter myotomy is the treatment for
which typically occurs in older patients and causes regurgitation and aspiration.
Before diagnosing or initiating therapy in a patient with suspected achalasia, ………….and other structural diseases must be ruled out with …………….
pseudoachalasia …………upper endoscopy
The differential diagnosis possibilities for salivary swellings are as follows, in order of frequency:
● Benign neoplasms
● Malignancy
● Salivary stones and stenosis
● Salivary swelling (adenosis) secondary to a systemic illness such as Sjögren syndrome or HIV infection
The most appropriate evaluation for an older adult with a new 1.5-cm submandibular mass that is not erythematous is
CT of the head and neck.
Pseudoachalasia refers to diseasesthat can cause esophageal motor
abnormalities similar to primary achalasiaa such as
(e.g., malignancy,
eosinophilic gastroenteritis, Chagas disease)
When primary achalasia is the likely diagnosis, it should be confirmed with highresolution esophageal manometry; therapy options include
nifedipine, injection of
botulinum toxin into the LES, pneumatic dilation of the LES, or Heller myotomy.
Patients of any age with chronic obstructive pulmonary disease should receive
pneumococcal vaccination and an annual influenza vacci
Annual influenza immunization is recommended for all individuals over 6 months
of age. Multiple formulations of the influenza vaccine are available:
● Trivalent inactivated influenza vaccine injections (high-dose or made with
adjuvant) are licensed only for individuals aged 65 or older.
● Standard-dose quadrivalent inactivated influenza vaccine injections are used in
children and adults up to 64 years of age.
● The quadrivalent nasal spray influenza vaccine containing live attenuated virus
can be used in individuals 2 to 49 years of age who are not pregnant and who
do not have immunosuppression or other high-risk medical conditions.
A patient with a presumed chronic obstructive pulmonary disease exacerbation that is unresponsive to conventional treatment should be evaluated for
pulmonary embolism.
Up to ………….. of patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD) may have an underlying …………..
25%
PE pulmonary embolism.
The most appropriate initial management for a patient who has chronic obstructive pulmonary disease with acute on chronic hypercapnic respiratory failure and who can
adequately protect his or her airway is
bilevel noninvasive positive-airway pressure.
The most appropriate intervention for a patient with chronic obstructive pulmonary disease who develops acute on chronic hypercapnic respiratory failure is a trial of bilevel
noninvasive positive-pressure ventilation (NPPV). Compared with endotracheal intubation, NPPV has been shown to reduce mortality risk and shorten the duration of
hospitalization. NPPV should not be used in patients with severely impaired consciousness because they might not be able to protect their airway. However, in the presence of
very mild impairments in mentation, such as patients who have slight somnolence but can be aroused and will interact with the examiner, NPPV can still be tried with close
monitoring before proceeding to endotracheal intubation
Increasing oxygen supplementation in a patient whose partial pressure of oxygen is close to normal i
increases the chance of carbon dioxide retention and can contribute to
clinical deterioration (by decreasing hypoxia-induced respiratory drive) and to worsening ventilation-perfusion matching (by releasing hypoxic vasocontriction).
what does this guy have?
a recently hospitalized 64-year-old man with morbid obesity, obstructive sleep apnea, and chronic obstructive pulmonary disease
(COPD) who develops acute on chronic respiratory acidosis secondary to a COPD exacerbation, who has mild somnolence but can be easily aroused and answer simple
questions, and who has been started on bronchodilator, glucocorticoid, and antibiotic therapy as well as supplemental oxygen at 4 liters per minute via nasal cannula with
resulting arterial blood gas values of pH 7.28 (reference range, 7.38–7.44), partial pressure of carbon dioxide 78 mm Hg (35–45), and partial pressure of oxygen 78
(80–100)?
acute on chronic hypercapnic respiratory failure
Nitrofurantoin, which is often used to treat urinary tract infections, causes a wide
range of
pulmonary toxicities, including acute, subacute, and chronic forms of
interstitial lung disease
Sarcoidosis can manifest as
hilar adenopathy (on a chest radiograph) and skin
lesions, such as erythema nodosum. Erythema nodosum is the characteristic
lesion of acute sarcoidosis; its tenderness can be mitigated by treatment with a
nonsteroidal antiinflammatory drug, such as ibuprofen.
Pulmonary sarcoidosis has four stages:
● Stage 1 (as in this case): bilateral hilar adenopathy
● Stage 2: bilateral hilar adenopathy and parenchymal infiltrates
● Stage 3: parenchymal infiltrates without adenopathy
● Stage 4: signs of fibrosis
Vocal-cord dysfunction should be suspected in a patient who
experiences
shortness of breath, coughing, and tightness of the chest for brief periods despite
adequate treatment for asthma. During these episodes, the patient typically has
normal oxygen saturation and appears acutely dyspneic. Auscultation of the
chest may reveal more prominent wheezing over the proximal airways and
sometimes stridor. Normally, vocal cords are open during inhalation. Vocal-cord
dysfunction or paradoxical vocal-fold motion can be diagnosed when the vocal
cords are observed to close abnormally during inhalation. Laboratory tests are
usually unrevealing between episodes, and the patient’s symptoms may be
erroneously attributed to anxiety.
The best therapeutic strategy for treating idiopathic pulmonary fibrosis is
supportive therapy, including pulmonary rehabilitation and adequate oxygen supplementation.
the differential for ground-glass opacities
includes
acute exacerbation of idiopathic pulmonary fibrosis (IPF), infectious pneumonia, pulmonary edema, and pulmonary hemorrhage.
Worsening hypoxemia in a patient with idiopathic pulmonary fibrosis may represent an acute exacerbation of the IPF, but
other diagnoses must be ruled out
This patient has severe, symptomatic hypokalemia with electrocardiographic changes (QT prolongation) and requires
urgent potassium replacement to avoid further
complications, such as arrhythmias and rhabdomyolysis.
Refractory hypokalemia in a patient who recently received chemotherapy with
cisplatin is likely related to
a deficiency in magnesium.
Magnesium depletion that is unrecognized, untreated, or both can lead to
refractory hypokalemia. Magnesium deficiency can stem from
gastrointestinal
causes or renal causes. Gastrointestinal losses can occur in the setting of
diarrhea or from the use of proton pump inhibitors. Renal magnesium wasting
can be induced by any number of medications, including chemotherapeutic
agents (e.g., cisplatin, carboplatin, vinblastine, bleomycin, pegylated liposomal
doxorubicin, cetuximab, panitumumab), antibiotics (e.g., amphotericin B and
aminoglycoside), and loop or thiazide diuretics. The majority of renal magnesium
reabsorption occurs in the thick ascending loop of Henle; the remainder is
absorbed in the proximal tubule and distal convoluted tubule.
To control blood pressure and improve long-term outcomes in a patient with
scleroderma renal crisis, the initial choice of antihypertensive drug class is
an
angiotensin-converting–enzyme inhibitor.
