Cardiac Flashcards
A patient presents with palpitations and reports feeling light-headed. The patient’s blood pressure is 115/75 mmHg. A 12-lead EKG reveals a heart rate of 125 beats per minute along with narrow QRS complexes that are less than 120 milliseconds in duration. Initial treatment includes which of the following?
A.Synchronized cardioversion
B.Vagal maneuver
C.Adenosine
D.Diltiazem
Answer: B. Vagal maneuver
Supraventricular tachycardia is dysrhythmia defined by a narrow complex (QRS <120 milliseconds) at a rate greater than 100 beats per minute. For hemodynamically stable patients with supraventricular tachycardia, vagal maneuvers have been found to be a safe and easily performed diagnostic test as well as an effective first-line treatment intervention according to the 2015 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society Guidelines. If the patient is unstable, consider immediate synchronized cardioversion. If vagal maneuvers are ineffective, consider treatment with adenosine or diltiazem (as a second-line option).
A patient presents complaining of the sudden onset of cold fingers and toes. The patient reports pain and a sharply demarcated color change of the skin (first white, followed by blue) when exposed to cold surfaces or temperatures. The patient has tried nonpharmacologic management with no improvement. Based on this patient’s presentation, which of the following would be indicated for treatment?
A.Captopril
B.Prazosin
C.Methyldopa
D.Amlodipine
Answer: D. Amlodipine
This patient is presenting with symptoms consistent with Raynaud’s phenomenon. Often, nonpharmacologic therapy is the initial approach (e.g., avoiding cold exposure and vasoconstricting drugs, smoking cessation). Pharmacologic therapy can be used in combination for patients to provide control of symptoms. Initial pharmacologic therapy includes dihydropyridine calcium channel blockers (e.g., amlodipine, nifedipine). Alternative options include phosphodiesterase type 5 inhibitors, topical nitrates, losartan, or fluoxetine. Therapies lacking efficacy, such as behavioral therapy, complementary and alternative medicine, angiotensin-converting enzyme (ACE) inhibitors, prazosin, and methyldopa, are not recommended due to lack of sufficient evidence supporting benefit.
After antihypertensive therapy is initiated, a patient’s blood pressure should be rechecked after how many months?
A.1
B.2
C.3
D.4
Answer: A. 1
The 2017 American College of Cardiology/American Heart Association guidelines recommend follow-up in 1 month after initiating (or titrating) an antihypertensive. When blood pressure is under control, a follow-up visit can occur in 3 months.
A patient with hypertension presents with a headache. Blood pressure is 185/115 mmHg. Which finding on fundoscopic exam mandates rapid lowering of blood pressure?
A.Retinal arteriolar narrowing
B.Microaneurysms
C.Arteriovenous nicking (“nipping”)
D.Papilledema
Answer: D. Papilledema
The history and physical examination in patients presenting with severely elevated blood pressure should include a thorough fundoscopic exam to evaluate for signs of target organ damage. The ocular effects from hypertension can be classified as mild, moderate, or severe. “Mild” is characterized by generalized retinal arteriolar narrowing, arteriolar wall thickening, arteriovenous nicking (“nipping”), and opacification of the arteriolar wall (“copper wiring”). “Moderate” is classified by hemorrhages; either flame- or dot-shaped, cotton-wool spots; hard exudates; and microaneurysms. “Severe” involves some or all of the previous symptoms plus optic disc edema (papilledema). This finding requires rapid lowering of blood pressure.
An older adult male patient who is a smoker is newly diagnosed with primary hypertension. He has a history of emphysema and second-degree AV block. His blood pressure from the previous visit is 145/80 mmHg. During the current visit, his blood pressure is 155/80 mmHg. What is the next step?
A.Start patient on atenolol (Tenormin) 50 mg once a day and reassess in 3 months
B.Start patient on felodipine (Cabren) 2.5 mg once a day and reassess in 2 months
C.Start patient on chlorthalidone (Thalitone) 12.5 mg daily and reassess in 1 month
D.Nothing; no action or treatment needed at this time
Answer: C. Start patient on chlorthalidone (Thalitone) 12.5 mg daily and reassess in 1 month
First-line agents for treatment of hypertension include thiazide diuretics, calcium channel blockers (CCBs), and angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. The patient has emphysema, so beta-blockers such as atenolol (Tenormin) cannot be used. He also has a second-degree AV block, which is a contraindication to CCBs such as felodipine (Cabren).
A patient presents complaining of leg pain that occurs while walking but is relieved by rest after a few minutes. Upon physical examination, the patient’s skin appears pale, dry, shiny, and hairless. The patient has an ulceration on the tip of the big toe. Based on this presentation, which of the following initial diagnostic tests is indicated?
A.Lower extremity duplex ultrasound
B. CT scan of the lower extremity
C.Exercise testing
D.Ankle-brachial index
Answer: D. Ankle-brachial index
The patient is presenting with clinical features suggesting lower extremity peripheral artery disease. Intermittent claudication is classically defined as muscle pain that is induced by exercise and relieved with rest. Physical exam findings are often significant for a nonhealing wound or ulcer; skin discoloration or gangrene; and dry, shiny, hairless skin due to diminished blood flow. Diagnosis of arterial stenosis or occlusion (as a result of peripheral artery disease) is confirmed with the ankle-brachial index (a result ≤0.9 has a high degree of sensitivity and specificity for diagnosis). Exercise testing can be obtained if patients with a classic history of claudication have a normal resting ankle-brachial index. Additional vascular imaging (such as a duplex ultrasound or CT) is generally not necessary for establishing a diagnosis of peripheral artery disease but can be useful to identify treatment therapies for intervention.
An African American patient with diabetes mellitus has recently been diagnosed with hypertension. Initial pharmacologic therapy includes which of the following?
A.Metoprolol
B.Ramipril
C.Hydrochlorothiazide
D.Losartan
Answer: C. Hydrochlorothiazide
In African American adults with hypertension without heart failure or chronic kidney disease, including those with diabetes mellitus, initial treatment should include a thiazide-type diuretic or calcium channel blocker.
A patient presents with feelings of palpitations, fatigue, dizziness, and mild dyspnea. A 12-lead EKG is obtained, revealing an irregularly irregular ventricular rhythm with absent P waves. This finding suggests which cardiac arrhythmia?
A.Atrial fibrillation
B.Paroxysmal supraventricular tachycardia
C.Sinus arrhythmia
D.First-degree heart block
Answer: A. Atrial fibrillation
Atrial fibrillation is diagnosed by interpretation of the 12-lead EKG; it is characterized by an irregularly irregular ventricular rhythm with a lack of discrete P waves. QRS complexes are narrow, and the baseline between successive QRS complexes shows irregular coarse fibrillatory waves. Paroxysmal supraventricular tachycardia presents with narrow QRS complexes that are intermittent, start and stop abruptly, and have a regular ventricular response. Sinus arrhythmia is characterized by an irregularity in the rate of normal sinus rhythm. First-degree heart block is a result of delayed or slowed AV conduction presenting as a prolonged PR interval (>200 ms at resting heart rates).
A patient presents complaining of palpitations, fatigue, and mild shortness of breath. A 12-lead EKG reveals rapid, regular atrial activity in a sawtooth pattern at about 300 beats/min and a regular ventricular rate of about 155 beats/min. Which of the following agents can be used for rate control for this arrhythmia?
A.Diltiazem
B.Digoxin
C.Amlodipine
D.Amiodarone
Answer: A. Diltiazem
The patient is experiencing atrial flutter, an abnormal cardiac rhythm characterized by rapid, regular atrial depolarizations (about 300 beats/min) and a regular ventricular rate (about 150 beats/min). Typical P waves are absent, and the atrial activity presents as a sawtooth pattern in leads II, III, and aVF. Rate control in atrial flutter involves administration of a non-dihydropyridine calcium channel blocker (e.g., verapamil, diltiazem) or a beta-blocker. Digoxin is used less frequently due to its side effects and toxicity (it is indicated with concurrent heart failure). Amiodarone, an antiarrhythmic agent, is rarely used as a rate control agent. Reversion to normal sinus rhythm is often accomplished by catheter ablation for definitive treatment (cardioversion is also reasonable). Ibutilide is the drug of choice for pharmacologic reversion as an alternative option.
Which of the following is a diastolic murmur?
A.Mitral regurgitation
B.Aortic stenosis
C.Mitral stenosis
D.Mitral valve prolapse
C. Mitral stenosis
Think
Diastolic is MS ARD
(Mitral stenosis, aortic regurg)
Systolic is MR ASS
(Mitral regurg, aortic stenosis)
A patient with a prosthetic heart valve is about to undergo routine dental cleaning. The patient has no allergies. Which of the following is most preferred for the prevention of infective endocarditis?
A.Nothing; routine dental cleaning is not an indication for antibiotic prophylaxis
B.Clindamycin
C.Amoxicillin
D.Cephalexin
Answer: C. Amoxicillin
Patients with a prosthetic heart valve undergoing invasive dental or oral procedures (including routine dental cleaning) should be prescribed an oral antibiotic regimen for the prevention of endocarditis prior to the procedure. The preferred agent is amoxicillin; cephalexin is an alternative option if the patient is allergic to penicillin. Clindamycin is no longer recommended for antibiotic prophylaxis prior to dental procedures.
A patient with a prosthetic heart valve is about to undergo routine dental cleaning. The patient has no allergies. Which of the following is most preferred for the prevention of infective endocarditis?
A.Nothing; routine dental cleaning is not an indication for antibiotic prophylaxis
B.Clindamycin
C.Amoxicillin
D.Cephalexin
Answer: C. Amoxicillin
Patients with a prosthetic heart valve undergoing invasive dental or oral procedures (including routine dental cleaning) should be prescribed an oral antibiotic regimen for the prevention of endocarditis prior to the procedure. The preferred agent is amoxicillin; cephalexin is an alternative option if the patient is allergic to penicillin. Clindamycin is no longer recommended for antibiotic prophylaxis prior to dental procedures.
A patient presents for a routine check-up complaining of mild symptoms such as fatigue and dyspnea while walking or climbing stairs rapidly. The patient reports a slight limitation of physical activity but feels comfortable at rest. These symptoms suggest which of the following New York Heart Association (NYHA) Functional Classifications of heart failure?
A.I
B.II
C.III
D.IV
Answer: B (II)
