cardiac Flashcards
Which patient should have pulmonary function testing as part of the presurgical exam?
a. A patient older than 60 years of age
b. A patient undergoing major intrathoracic surgery
c. A patient with a history of pneumonia in the last 2 years
d. A patient with diabetes and morbid obesity
ANS: B Any patient undergoing major thoracic surgery should have pulmonary function testing. Age over 60 years, a history of pneumonia, and diabetes and obesity do not require pulmonary function testing unless there is comorbid COPD.
A patient prescribed a beta blocker medication is in the emergency department with reports of
syncope, shortness of breath, and hypotension. A cardiac monitor reveals a heart rate of 35
beats per minute. Which medication may be used to stabilize this patient?
a. Adenosine
b. Amiodarone
c. Atropine
d. Epinephrine
ANS: D
Epinephrine is indicated if unstable bradycardia is caused by beta blockers. This patient is
symptomatic and unstable and should be treated. Adenosine and amiodarone are used to treat
tachycardia. Atropine is used for some types of bradycardia, but not when induced by beta
blockers.
A patient reports heart palpitation but no other symptoms and has no prior history of
cardiovascular disease. The clinic provider performs an electrocardiogram and notes atrial
fibrillation and a heart rate of 120 beats per minute. Which is the initial course of action in
treating this patient?
a. Administer atenolol intravenously.
b. Admit to the hospital for urgent cardioversion.
c. Refer the patient to a cardiologist.
d. Initiate steps to begin anticoagulant therapy.
ANS: C
This patient has no history of serious heart disease and does not have symptoms of chest
pressure, acute MI, or congestive heart failure and may be referred to a cardiologist for
evaluation and treatment but anticoagulant therapy to minimize the risk of clot formation
should be started initially. The 2014 AHA Guidelines for Atrial Fibrillation recommend
shared decision-making in regard to anticoagulation based on relative risk of the patient for
thromboembolic event. Atenolol is given IV for patients who are unstable; the advanced life
support treatment guidelines do not recommend treatment of tachycardia if the patient is
stable. Urgent cardioversion is rarely needed if the heart rate is less than 150 beats per minute
unless there are underlying heart conditions.
Which cardiac arrhythmia in an unstable patient requires unsynchronized shocks, or defibrillation? a. Atrial fibrillation b. Atrial flutter c. Monomorphic ventricular tachycardia d. Polymorphic ventricular tachycardia
ANS: D
Polymorphic ventricular tachycardia should be treated as ventricular fibrillation with
unsynchronized shocks. The other arrhythmias are treated with synchronized cardioversion
An asymptomatic 63-year-old adult has a low-density lipoprotein level of 135 mg/dL. Which test is beneficial to assess this patient’s coronary artery disease risk?
a. Coronary artery calcium score (CACS)
b. hsCRP (high-sensitivity CRP)
c. Exercise echocardiography
d. Myocardial perfusion imaging
ANS: B
The hsCRP is useful in asymptomatic men >50 years and women >60 years who have LDL
<160 mg/dL to predict CAD risk. Although the CACS has shown some benefit in patients with moderate risk, the role for this diagnostic test is unclear. Exercise echocardiography and
myocardial perfusion imaging are not performed initially.
Which risk assessment for coronary artery disease is recommended for all female patients?
a. Coronary artery calcium score
b. Electrocardiogram
c. Exercise stress test
d. Framingham risk score
ANS: D
The Framingham risk score is a quick method for identifying potential risk for CAD and can guide providers in choosing subsequent tests based on risk level. The ECG is performed on
women with risk factors. The exercise stress test is useful in symptomatic women who have a normal ECG. The CACS may be used if moderate risk is present.
A patient reports abdominal and back pain with anorexia and nausea. During an exam, the provider notes a pulsatile abdominal mass. What is the initial action?
a. Immediate referral to a thoracic surgeon
b. Ordering computerized tomography (CT) angiography
c. Scheduling a magnetic resonance imaging (MRI) to evaluate for aortic disease
d. Ultrasound of the mass to determine size (US)
ANS: D
This patient has symptoms consistent with an aortic aneurysm. The initial step is to determine
the size of the aneurysm; this can be done by US. Immediate referral is not necessary. MRI
and CT diagnostic tests are ordered before surgery to evaluate the characteristics of the aneurysm.
A 70-year-old patient presents with an aortic aneurysm measuring 5.0 cm. The patient has poorly controlled hypertension, and decompensated heart failure. What is the recommendation
for treatment for this patient?
a. Endovascular stent grafting of the aneurysm
b. Immediate open surgical repair of the aneurysm
c. No intervention is necessary for this patient
d. Serial ultrasonographic surveillance (US) of the aneurysm
ANS: D
This patient’s aneurysm is less than 5.5 cm and repair is not necessary at this time. Serial US surveillance is necessary to continue to evaluate size. Repair is risky in patients with
hypertension and heart failure, so avoiding procedures if possible is recommended
A patient reports sustained, irregular heart palpitations. What is the most likely cause of these symptoms?
a. Anemia
b. Atrial fibrillation
c. Extrasystole
d. Paroxysmal attacks
ANS: B
Atrial fibrillation causes palpitations that are irregular and tend to be sustained. Anemia will
cause rapid palpitations that are regular. Extrasystole causes palpitations or an awareness of
isolated extra beats with a pause. Paroxysmal attacks start and terminate abruptly and are
usually rapid and regular.
An adult patient reports frequent episodes of syncope and lightheadedness. The provider notes a heart rate of 70 beats per minute. What action will the provider take next?
a. Evaluation of the patient’s orthostatic vital signs
b. Monitoring the patient’s heart rate while the patient is bearing down
c. Prescribing an electrocardiogram (ECG) and exercise stress test (ETT)
d. Reassuring the patient that the symptoms are non-cardiac in origin
ANS: A
Orthostatic vital signs are helpful to exclude orthostatic hypotension as a cause of syncope and are easily performed in the clinic. Assessment for vagal bradycardia may be performed next. ECG and ETT are not recommended as an initial evaluation in a healthy patient unless other causes are not determined. Without an assessment of the cause of the syncope, cardiac
causes cannot be excluded.
A child with a history of asthma is brought to the clinic with a rapid heart rate. A cardiac monitor shows a heart rate of 225 beats per minute. The provider notifies transport to take the child to the emergency department. What initial intervention may be attempted in the
clinic?
a. Intravenous adenosine
b. Administration of a beta blocker
c. A loading dose of digoxin
d. A carotid massage
ANS: D
This child has paroxysmal supraventricular tachycardia (PSVT). Vagal maneuvers or carotid
massage may be attempted to slow the ventricular rate. Adenosine is contraindicated in patients with asthma. Medications such as beta blockers and digoxin are not used in emergency treatment of PSVT.
During a routine health maintenance examination, the provider auscultates a cervical/carotid
bruit. The patient denies syncope, weakness, or headache. What will the provider do, based on
this finding?
a. Order a carotid duplex ultrasound (US).
b. Order catheter-based angiography.
c. Refer the patient to a neurosurgeon.
d. Schedule a computed tomography angiography (CTA).
ANS: A
Carotid duplex ultrasound is the primary diagnostic tool for carotid stenosis. A cervical bruit
in an asymptomatic patient is an indication for this test. Catheter-based angiography is the
criterion-based standard but has inherent costs and risks. A neurosurgery referral is not
indicated without further testing. CTA is used instead of duplex US if the test is not available,
if US results are inconclusive, or further evaluation is needed based on US results.
A patient experiencing heart failure with reduced ejection fraction will have which symptoms?
a. Dyspnea and fatigue without volume overload
b. Impairment of ventricular filling and relaxation
c. Mild, exertionally related dyspnea
d. Pump failure from left ventricular systolic dysfunction
ANS: D
Heart failure with reduced ejection fraction results in pump failure from ventricular systolic
dysfunction. Heart failure with preserved ejection fraction may have milder symptoms and is associated with impairment of ventricular filling and relaxation.
A patient who has been diagnosed with heart failure for over a year reports being comfortable
while at rest but experiences palpitations and dyspnea when walking to the bathroom. Which
classification of heart failure is appropriate based on these symptoms?
a. Class I
b. Class II
c. Class III
d. Class IV
ANS: B
Patients with Class II heart failure (HF) will have slight limitation of activity and will be
comfortable at rest with symptoms occurring with ordinary physical activity. Patients with
Class I HF do not have limitations and ordinary physical activity does not produce symptoms.
With Class III HF, less than usual activity will produce symptoms. With Class IV HF,
symptoms are present even at rest and all physical activity worsens symptoms
A patient who has Class II heart failure is taking an ACE inhibitor and reports a recurrent cough that does not interfere with sleep or activity. What will the provider do initially to manage this patient?
a. Assess serum potassium and sodium immediately
b. Discontinue the ACE inhibitor and prescribe an ARB
c. Provide reassurance that this is a benign side effect
d. Withhold the drug and evaluate renal and pulmonary function
ANS: C
Cough occurs in about 20% of patients who take ACE inhibitors and is not dangerous. The
patient should be reassured that this is the case. If the cough is annoying, alternate therapy with an ARB may be considered. It is not necessary to evaluate electrolytes, renal function, or pulmonary function.
A patient who is on renal dialysis is diagnosed with infective endocarditis. What causative organisms are more likely in this patient?
a. Enterococcal organisms
b. Neisseria gonorrhea
c. Pseudomonas aeruginosa
d. Staphylococcus aureus
ANS: D
This patient is more likely to have a health care–associated endocarditis; most of these are caused by S. aureus. Enterococcal organisms are the second highest cause in this population.
A patient has native valve endocarditis (NVE). While blood cultures are pending, which antibiotics will be ordered as empirical treatment?
a. A beta-lactamase-resistant penicillin and an antifungal drug
b. Imipenem-cilastatin and ampicillin
c. Penicillin G and an aminoglycoside antibiotic
d. Vancomycin and quinupristin-dalfopristin
ANS: C
The most common organism in NVE is S. aureus; until resistance is known, treatment with penicillin G and an aminoglycoside is needed, although most strains causing NVE are not penicillin-resistant. Antifungal infections are rare and antifungal medications are not part of
empirical therapy. Imipenem-cilastatin plus ampicillin is given for identified Enterococcus
faecalis infection. Vancomycin and quinupristin-dalfopristin is used, with limited evidence for
benefit, for Enterococcus faecium infection.
A previously healthy patient presents with sudden onset of dyspnea, fatigue, and orthopnea. A
family history is negative. The provider suspects myocarditis. What is the most likely etiology
for this patient?
a. Autoimmune disorder
b. Bacterial infection
c. Protozoal infection
d. Viral infection
ANS: D
Viral infection is the most common cause of myocarditis. Other infections are less likely.
Although this patient may have an autoimmune disorder, the absence of family history makes this somewhat less likely
