Cardiac Tower

Question 1

Recommend immediate therapy after diagnosis of aortic dissection

Answer 1

In the absence of absolute contraindication for ß-adrenergic blockade, it should be initiated and titrated for a target heart rate of 60 beats/min

Question 2

Manage a patient presenting in hypertensive crisis with aortic dissection

Answer 2

Admit to an intensive care unit and administer intravenous esmolol via continuous infusion

HR should be lowered to less than 60 beats/min and systolic blood pressure should be lowered to 100 to 120 mm Hg within 20 minutes.

Question 3

hypertensive emergencies

Answer 3

blood pressure should be lowered 10% to 20% within the first hour by drip in icu

Question 4

type A aortic dissection

Answer 4

(involving the ascending aorta).Cardiothoracic consultation

Question 5

type B dissection

Answer 5

(ie, isolated to the descending aorta, distal to the left subclavian artery) are treated medically, and the most important treatment in a patient with an aortic dissection is the acute lowering of heart rate and systolic blood pressure within the first 20 minutes after diagnosis, which should be the first step

Question 6

potential complications of hypertensive crisis,

Answer 6

aortic dissection 
acute hypertensive nephrosclerosis
acute coronary syndrome and decompensated heart failure
ischemic or hemorrhagic stroke 
 hypertensive encephalopathy

Question 7

Diagnose acute pericarditis on the basis of clinical and electrocardiographic findings and determine the most appropriate treatment modality

Answer 7

Start aspirin, 650 mg orally 4 times daily; colchicine, 0.5 mg orally twice daily; and pantoprazole, 40 mg orally daily; and admit the patient to the hospital

concave ST-segment elevation with PR-segment depression, except for an aVR lead, acute pericarditis is the most likely diagnosis.

Question 8

Admission criteria for patients with acute pericarditis include

Answer 8

poor prognostic signs such as immunocompromised patients (HIV in this case) or patients treated with anticoagulants (warfarin in this patient).
fever, suspected large pericardial effusion, subacute onset, associated myocarditis, or signs concerning for cardiac tamponade.
Given markedly elevated C-reactive protein, the treatment should be continued until the C-reactive protein returns to normal or when the symptoms resolve completely.

Question 9

Prednisone and other steroids in acute pericarditis

Answer 9

not recommended as first-line treatment of acute pericarditis due to higher recurrence rates after discontinuation. Steroids can be used in refractory cases of acute pericarditis and tapered slowly over several weeks.

Question 10

Diagnose cardiac tamponade complicating ascending aortic dissection and recognize proper management strategies that will most likely improve the patient’s outcome

Answer 10

Beck triad, consisting of distant heart sounds, elevated jugular venous distention with clear lung fields, and decreased arterial blood pressure.

Open pericardiectomy and repair of aorta

Pericardiocentesis should be avoided in the setting of aortic dissection leading to cardiac tamponade. Association of cardiac tamponade with an acute aortic dissection carries an in-hospital mortality of more than 50%; therefore, emergent aortic repair with an open pericardiectomy

Rupture of the ascending wall of the aorta leads to blood accumulation in the pericardial space, signifying a surgical emergency

Question 11

Describe the presentation of acute right ventricular infarction and differentiate it from other common causes of chest pain.

Answer 11

Large/isolated right ventricular infarction typically presents with a clinical triad of hypotension, elevated jugular venous pressure, and clear lungs.

Initial treatment should focus on adequate volume support to maintain right ventricular preload in addition to the usual acute myocardial infarction management. Inotropic support may be needed.
It is important to remember that despite the presence of jugular venous distention, patients with right ventricular infarction require intravenous fluids to optimize right ventricular preload.
Similarly, use of diuretics and nitrates should be avoided.

Question 12

Manage a patient after STEMI with a reduced ejection fraction by applying current guidelines for recommended medications.

Answer 12

ST-elevation myocardial infarction (STEMI) and now has a reduced left ventricular ejection fraction of less than 40%. A regimen that includes an ACE inhibitor, spironolactone, and a β-adrenergic blocker should be initiated.

Question 13

an aldosterone antagonist is indicated with an ejection fraction

Answer 13

less than 40%

Question 14

Recommend appropriate initial management for a patient with acute non–ST-elevation myocardial infarction

Answer 14

Load with clopidogrel, start heparin drip, and call cardiology for nonemergent left heart catheterization

Question 15

Determine the appropriate noninvasive modality of cardiac testing for a patient with chest pain and a left bundle branch block

Answer 15

Exercise radionuclide myocardial perfusion imaging

Question 16

Appropriately manage antiplatelet therapy upon hospital discharge in a patient who has received cardiac stenting.

Answer 16

Aspirin, 81 mg daily, indefinitely; clopidogrel, 75 mg daily for 12 months