AAFP: Cardiovascular Flashcards
A 65 yo male with type 2 DM is having increasing symptoms of angina pectoris. His cardiologist has recommended that he undergo heart catheterization and possible intervention if coronary artery disease is found. He comes to your office prior to the procedure and asks for your thoughts regarding treatment options presented by the cardiologist. In addition to optimal medical treatment, if this patient is found to have multivessel coronary disease at the time of heart catheterization, you would recommend which one of the following?
a. Angioplasty without stenting
b. Angioplasty with bare-metal stents
c. Angioplasty with drug-eluting stents
d. Angioplasty of the most significant block artery, followed by CABG
e. CABG
e. CABG
In patients with DM and advanced CAD, CABG is superior to PCI in that it significantly reduces rates of death and MI, although stroke rates are higher in the 30-day perioperative period.
The Future Revascularization Evaluation in Patients with DM: Optimal Mgmt of Multivessel Disease (FREEDOM) trial suggested that these outcomes are similar whether PCI is performed without stents, with bare-metal stents, or with drug-eluting stents.
A 55 yo male with a 4 year hx of type 2 DM was noted to have microalbuminuria 6 mo ago, and returns for a follow-up visit. He has been on an ACEI and his BP is 140/90. The addition of which one of the following medications would INCREASE the likelihood that dialysis would become necessary?
a. HCTZ
b. Amlodipine (Norvasc)
c. Atenolol (Tenormin)
d. Clonidine (Catapres)
e. Losartan (Cozaar)
e. Losartan (Cozaar)
Patients with DM, atherosclerosis, and end-organ damage benefit from ACEI and ARBs equally when they are used to prevent progression of diabetic nephropathy. Combining an ACEI with an ARB is NOT recommended, as it provides no additional benefit and leads to higher creatinine levels, along with an increased likelihood that dialysis will become necessary.
A 39 yo male presents to the ER with a 2-hour hx of chest discomfort, dyspnea, dizziness, and palpitations. He has no hx of CAD. He states that he has had several similar episodes in the last year. On examination, he has a temperature of 98.2 F, a RR of 25/min, a HR of 193 bpm, a BP of 134/82, and an O2 saturation of 96% on room air. The physical exam is otherwise normal. An EKG reveals a regular narrow QRS complex tachycardia with no visible P waves. He converts to normal sinus rhythm with IV adenosine (Adenocard). Which one of the following would be most useful in the long-term mgmt of this patient’s condition?
a. Adenosine
b. Digoxin
c. Vagal maneuvers
d. Pacemaker placement
e. Radiofrequency ablation
e. Radiofrequency ablation
This patient presents with a classic description of SVT. The initial mgmt of SVT centers around stopping the aberrant rhythm. In the hemodynamically stable patient, initial measures should include vagal maneuvers, IV adenosine or verapamil, IV diltiazem or beta-blockade, IV antiarrhythmics, or cardioversion in refractory cases.
Radiofrequency ablation is fast becoming the first-line therapy for all patients with recurrent SVT, not just those refractory to suppressive drug therapies.
Patients with severe (1000-1999 mg/dL) or very severe (>2000 mg/dL) hypertriglyceridemia are at significant risk for __________________.
For patients at risk for this condition, _________ are recommended as the initial treatment.
Pancreatitis; fenofibrate (Tricor)
A 60 yo white female is admitted to the hospital with a submassive pumonary embolism. Which one of the following is most effective for assessing RV dysfunction in this situation?
a. Echocardiography
b. Physical examination
c. 12-Lead electrocardiography
d. Contrast-enhanced CT of the chest
a. Echocardiography
Echocardiography is the best study for detecting RV dysfunction and also allows for estimation of pulmonary artery pressure.
A 62 yo AA male is admitted to the hospital for the third time in 6 mo. with heart failure. He has dyspnea with minimal activity. Echo reveals an EF of 40%. Which one of the following combinations of medications is most appropriate for long-term mgmt of this pt?
a. Enalapril (Vasotec) + digoxin
b. Hydralazine + isosorbide dinitrate
c. Losartan (Cozaar) + amlodipine (Norvasc)
d. Spironolactone (Aldactone) + bisoprolol (Zebeta)
b. Hydralazine + isosorbide dinitrate
The combination of the vasodilators hydralazine and isosorbide dinitrate has been shown to be effective in the treatment of heart failure when standard tx with diuretics, beta-blockers, and ACEI (or ARB) is insufficient to control symptoms or cannot be tolerated. This combination is particularly effective in AA with NYHA class III or IV heart failure, with advantages including reduced mortality rates and improvement in quality-of-life measures.
Amlodipine and other CCBs do not have a direct role in the treatment of heart failure.
A 72 year old previously healthy male presents with a 3-week hx of mild, intermittent chest pressure that occurs when he walks up a steep hill. Which one of the following EKG abnormalities would dictate the use of a pharmacologic stress test as opposed to an exercise stress test?
a. 1st degree AV block
b. LBBB
c. Poor R-wave progression in leads V1 through V3
d. Q-waves in the inferior leads
e. Ventricular trigemin
b. LBBB
LBBB makes the EKG uninterpretable during an exercise stress test, and can also interfere with nuclear imaging performed during the test. It is associated with transient positive defects in the anteroseptal and septal regions in the absence of a lesion within the LAD. This leads to a high rate of false-positive tests and low specificity.
Pharmacologic stress tests using vasodilators such as adenosine have a much higher specificity and PPV for LAD lesions, and the same is true for dobutamine stress echo, which is why these are the preferred methods for evaluating patients with LBBB.
Which one of the following is a preferred first-line agent for managing HTN in patients with stable coronary artery disease?
a. Thiazide diuretic
b. ARB
c. Beta-blocker
d. Long-acting CCB
e. Long-acting nitrate
c. Beta-blocker
AHA guidelines recommend treating HTN in patients with stable heart failure with ACEI and/or beta-blockers.
Other agents, such as thiazide diuretics or CCBs, can be added if needed to achieve BP goals. While thiazide diuretics are often a first choice for uncomplicated HTN, this is not the case for patients with CAD.
Although ARBs have indications similar to those of ACEIs, the AHA recommends using them only in patients who do not tolerate ACEI.
A 75 yo male with a hx of HTN sees you after experiencing an episode of numbness on his R side and loss of strength in his R arm. The numbness and weakness resolved spontaneously within 20 minutes. Carotid Doppler U/S and cerebral angiography both reveal significant carotid stenosis. In addition to starting aspirin, which one of the following would be the most appropriate next step for this patient?
a. Aggressive lowering of BP
b. Clopidogrel (Plavix)
c. Carotid artery stenting
d. Evaluation for occult PDA
e. High-dose statin therapy
e. High-dose statin therapy
Statin drugs are effective for preventing stroke, which should be the key goal in this high-risk patient. They may stabilize the intimal wall.
Rapid lowering of BP could cause brain injury by reducing blood flow in patients with carotid stenosis. Any evidence of hypoperfusion needs to be corrected immediately.
Combination therapy with aspirin and clopidogrel is associated with an increased risk of bleeding and is not recommended for stroke prevention.
Patients over age 70 have worse outcomes with carotid stenting than with endarterectomy.
A 55 yo female has severe sepsis due to pyelonephritis. Her systolic BP remains at 70 mm Hg despite abx and adequate fluid resuscitation. Which one of the following should be considered the vasopressor of first choice for this patient?
a. Dopamine
b. Epinephrine
c. Vasopressin
d. Dobutamine
e. Norepinephrine
e. Norepinephrine
Norepinephrine is considered to be the vasopressor of choice in this situation. It has mainly alpha-adrenergic effects with some beta-adrenergic effects as well. While alpha-adrenergic agents increase MAP, they decrease cardiac output. Norepi’s beta-adrenergic properties counteract the decrease in CO, so there is an increase in BP with little change in PR or CO.
Vasopressin may be useful in patients with cardiac arrest and ventricular fibrillation and may further improve hypotension when used with norepi.
Dobutamine is the inotropic agent of choice but has little effect on BP.
Epinephrine can increase the incidence of arrhythmias when compared with norepi.
Dopamine also increases arrhythmias when compared with norepi and is associated with an increased 28-day death rate.
Which one of the following is most characteristic of the pain associated with acute pericarditis?
a. Improvement when sitting up and leaning forward
b. Improvement when lying supine
c. Worsening with Valsalva maneuver
d. Radiation to the R scapula
a. Improvement when sitting up and leaning forward
The chest pain associated with pericarditis is typically pleuritic, and is worse with inspiration or in positions that put traction on the pleuropericardial tissues, such as lying supine. Patients with acute pericarditis typically get relief or improvement when there is less tension on the pericardium, such as when sitting and leaning forward. This position brings the heart closer to the anterior chest wall, which incidentally is the best position for hearing the pericardial friction rub associated with acute pericarditis.
Blood pressure classification in children is based on:
sex, height, age
A 75 yo otherwise healthy white female 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?
a. Vasovagal syncope
b. TIA
c. Orthostatic hypotension
d. Atrial myxoma
e. Aortic stenosis
e. Aortic stenosis
Syncope with exercise is a manifestation of organic heart disease in which CO is fixed and does not rise (or even fall) with exertion. Syncope, commonly occurring with exertion, is reported in up to 42% of patients with severe aortic stenosis.
Vasovagal syncope is associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, sustained upright posture, heat, hunger, and acute blood loss.
TIAs are not related to exertion.
Orthostatic hypotension is associated with changing from a sitting or lying position to an upright position.
Atrial myxoma is associated with syncope related to changes in position, such as bending, lying down from a seated position, or turning over in bed.
Which one of the following NSAIDs is safest for patients with a previous hx of MI?
a. Ibuprofen
b. Celecoxib (Celebrex)
c. Diclofenac (Zorvolex)
d. Meloxicam (Mobic)
e. Naproxen (Naprosyn)
e. Naproxen (Naprosyn)
All oral NSAIDs increase the risk of MI with the exception of naproxen.
What is the most appropriate initial step in ruling out DVT?
a. D-dimer
b. U/S
c. Venography
d. Impedance plethysmography
a. D-dimer
A negative D-dimer assay has a high negative predictive value for DVT, so the dx can be ruled out in a patient who has a low pretest probability and a negative D-dimer result.
