Cardiovascular Flashcards
20% of EORE Content
1
Q
Which of the following conditions is the most common cause of secondary hypertension in adults?
A. Graves disease
B. Pheochromocytoma
C. Primary aldosteronism
D. Renal artery stenosis
A
Renal Artery Stenosis
In children it is renal parenchymal disease
2
Q
A 61-year-old woman presents to the office with worsening flu-like symptoms for five weeks. She reports low-grade fever most days, general malaise, and night sweats. On physical exam, you notice painless erythematous macules on the palms and soles, as well as tender nodules on the pads of the fingers. Laboratory results reveal leukocytosis and anemia, blood cultures show gram-positive cocci, and the blood agar shows a green discoloration. What is the most common pathogen responsible for this patient’s symptoms?
A
Streptococcus viridans (the most common cause of subacute endocarditis)
The presentation described is infective endocarditis, specifically subacute bacterial endocarditis. The symptoms, including low-grade fever, malaise, and night sweats over an extended period, along with the presence of Janeway lesions (painless erythematous macules on the palms and soles) and Osler nodes (tender nodules on the pads of the fingers), are classic signs of this condition.
The laboratory findings of leukocytosis (elevated white blood cell count) and anemia further support the diagnosis. The blood culture results showing gram-positive cocci and the blood agar revealing green discoloration indicate the presence of alpha-hemolytic bacteria. This green discoloration on blood agar is characteristic of Streptococcus viridans, a group of bacteria commonly found in the oral cavity and a leading cause of subacute bacterial endocarditis.
3
Q
Which arrhythmia is characterized by a “sawtooth” pattern on the ECG?
A
Atrial Flutter
4
Q
What is the first-line treatment for symptomatic bradycardia?
A
Atropine
5
Q
Which medication is commonly used for rate control in atrial fibrillation?
A
Beta-Blockers (motoprolol)
6
Q
What is the definitive treatment for patients with recurrent ventricular tachycardia or ventricular fibrillation?
A
Implantable cardioverter-defibrillator (ICD)
7
Q
What is the most appropriate first step in the management of a stable patient with paroxysmal supraventricular tachycardia (PSVT)?
A
Vagal Meneuvers
8
Q
A 68-year-old male presents to the emergency department with palpitations, shortness of breath, and fatigue that started earlier in the day. His ECG shows an irregularly irregular rhythm with no distinct P waves and a ventricular rate of 120 beats per minute. What is the most likely diagnosis?
A
Atrial Fibrillation
9
Q
A 72-year-old woman presents with sudden onset palpitations and lightheadedness. Her ECG shows a narrow complex tachycardia with a regular rhythm at a rate of 180 beats per minute. She is hemodynamically stable. Which of the following is the best initial management?
A) Immediate synchronized cardioversion
B) Intravenous adenosine
C) Intravenous amiodarone
D) Vagal maneuvers
A
Vagal maneuvers
10
Q
A 55-year-old male presents with chest pain and shortness of breath. His ECG shows ST-segment elevation in leads II, III, and aVF with a heart rate of 40 beats per minute. His blood pressure is 80/60 mmHg. What is the most appropriate immediate treatment?
A) Atropine
B) Beta-blocker
C) Amiodarone
D) Immediate coronary angiography
A
Atropine
The patient in this vignette is a 55-year-old male presenting with chest pain and shortness of breath. His ECG shows ST-segment elevation in leads II, III, and aVF, which indicates an inferior myocardial infarction (MI). Additionally, the patient has a heart rate of 40 beats per minute (bradycardia) and hypotension (blood pressure 80/60 mmHg), which are concerning signs that suggest the patient is in cardiogenic shock due to the MI.
11
Q
What heart arrhythmia is associated with EKG patterns that bradycardia alternates with tachycardia?
A
Sick Sinus Syndrome
12
Q
What is the most common cause of dilated cardiomyopathy in the United States?
A) Alcohol abuse
B) Viral myocarditis
C) Coronary artery disease
D) Genetic mutations
A
Coronary artery disease (CAD)
13
Q
Which of the following is a hallmark finding on echocardiography for a patient with dilated cardiomyopathy?
A) Concentric left ventricular hypertrophy
B) Left ventricular dilation with reduced ejection fraction
C) Right ventricular hypertrophy
D) Increased left ventricular wall thickness
A
Left ventricular dilation with reduced ejection fraction
14
Q
Which class of medication is typically first-line in the management of symptomatic dilated cardiomyopathy?
A
ACE Inhibitors
15
Q
Which electrolyte abnormality is commonly associated with the use of loop diuretics in patients with dilated cardiomyopathy?
A) Hyperkalemia
B) Hypokalemia
C) Hypercalcemia
D) Hypermagnesemia
A
Hypokalemia
16
Q
A 55-year-old male with a history of hypertension and chronic alcohol abuse presents with progressive dyspnea, orthopnea, and lower extremity swelling over the past three months. Physical examination reveals an S3 gallop, jugular venous distension, and bilateral pitting edema. An echocardiogram shows a dilated left ventricle with an ejection fraction of 25%.
Which of the following is the most appropriate initial management for this patient?
A) Start intravenous diuretics and ACE inhibitors
B) Schedule for immediate coronary angiography
C) Initiate beta-blocker therapy
D) Recommend alcohol cessation only
A
Start intravenous diuretics and ACE inhibitors
17
Q
What is Dressler’s Syndrome?
What is the treatment?
What should be avoided to prevent pericardial wall thinning?
A
Pericarditis following a myocaridal infarction
ASA or Colchacine
NSAIDs and corticosteroids
18
Q
What are the two most common symptoms associated with a pulmonary embolism?
What is the best initial test when working up a PE?
A
Dyspnea (m/c) and pleuritic chest pain
Spiral CT
19
Q
The treatment for a pulmonary embolism is low molecular weight heparin plus warfarin. What are the low molecular weight agents?
A
- Enoxaparin
- Daltaparin
- Tinzaparin
20
Q
What are common signs and symptoms of congestive heart failure?
A
- Exertional dyspnea (SOB), then with rest
- Chronic nonproductive cough, worse in a recumbent position
- Fatigue
- Orthopnea (late), night cough, relieved by sitting up or sleeping with additional pillows
- Paroxysmal nocturnal dyspnea
- Nocturia
21
Q
What are the pharmacological agents used to treat heart failure?
Hint: LMNOP
A
- Loop Diuretics (don’t use in diastolic HF)
- Morphine (reduces pre-load)
- Nitrates (reduces pre-load)
- Oxygen
- Position
CCB for diastolic HF
22
Q
What adventatous breath sound is associated with congestive heart failure?
What will be seen on CXR?
A
Rales
Kerley B Lines
23
Q
What is the BEST test for working up congestive heart failure?
A
Echocardiogram
24
Q
What is stable angina?
A
- predictable; presents with a consistent amount of exertion
- the patient can achieve relief with rest or nitroglycerin
- indicative of a stable, flow-limiting plaque
25
What is the first line treatment for african american patients with essential hypertension?
CCB or Thiazide
26
A 71-year-old woman presents to the clinic due to a headache. Her vital signs are heart rate of 90 beats/minute, respirations of 18 per minute, temperature of 97.8°F, and blood pressure of 200/100 mm Hg in both arms. Findings on physical exam are within normal limits except for bilateral papilledema. At the previous three office visits, the patient’s blood pressure averaged 150/90 mm Hg. Her only medications are amlodipine 10 mg daily and simvastatin 40 mg daily, both of which she takes regularly.
What the most likely diagnosis?
Hypertensive Emergency where there are signs of end-organ damage (papilledema, headache)
27
What tick-borne disease is most likely to be associated with an atrioventricular heart block?
Lyme Disease
28
What psychiatric disorder has a high association with Burgada Syndrome?
Schizophrenia
29
Who should routinely get Aspirin for primary prevention of CVD?
USPSTF recommendations
* Adults aged 40 to 59 years with a ≥10% 10-year CVD risk (grade C)
* Adults 60 years or older – The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older
30
What are some common manifestations of endocarditis?
* Osler Nodes: painful raised red lesions on the hands and feet
* Janeway Lesions: non-tender, flat, small lesions on hands/feet
* Petechiae: palate or conjunctiva
* Clubbing
* Roth Spots: retinal hemorrhages with pale centers
31
What is the USPSTF recommendation for high cholesterol screening?
USPSTF recommends screening for patients with NO evidence of CVD and NO other risk factors should begin at 35 years of age
32
What patient groups are most likely to benefit from statin therapy?
1. Patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
2. Patients with primary LDL-C levels of 190 mg per dL or greater
3. Patients WITH diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
4. Patients WITHOUT diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
33
What is the targeted LDL in a patient with diabetes?
LDL < 70; anything above 70 should be treated with statin therapy
34
What are some side effects of ACE inhibitors?
Ace inhibitors are associated with cough, angioedema, and can cause hyperkalemia.
They are contraindicated in pregnancy
35
In what patients are beta-blockers contraindicated as antihypertensive therapy?
Asthmatics
36
What are the rate controlling calcium channel blockers?
Verapamil and Diltiazam
37
What medication class should be used to treat high triglycerides?
Fibrates (Fenofibrate and Gemfibrizil)
38
What are the diagnostic tests for leg claudication?
* An ankle-brachial index (ABI), which uses Doppler measurements to compare the BP in the upper and lower extremities, is a highly sensitive and specific test
* An ABI of ≤ 0.9 indicates significant disease
**Angiography remains the gold standard study**
39
You are examining a patient who has been following up for several months. You notice that his head is bobbing; in addition, his carotid pulses have a rapid upstroke with a rapid fall. His BP is 120/60 mm Hg (right arm) and 145/60 mm Hg (right leg). What is the most likely diagnosis?
| What is the definitive treatment?
## Footnote
What can be used prior to definitive treatment?
Aortic Regurgitation
| Surgical therapy
## Footnote
Medical therapy to reduce afterload (ACE inhibitors, ARBs, Nifedipine)
40
Which of the following medical conditions is most likely to increase the risk of multifocal atrial tachycardia?
A. Acute pancreatitis
B. Chronic obstructive pulmonary disease
C. Hyperlipidemia
D. Hypothyroidism
COPD or Other Pulmonary Diseases
Common examples of pulmonary diseases provoking multifocal atrial tachycardia are COPD and pneumonia. These pulmonary conditions can cause hypoxia, hypercapnia, and acidosis, which are all triggers of ectopic atrial activity.
41
What is the goal LDL for patients with diabetes and coronary artery disease?
LDL < 100 mg/dL
42
What is the number one independent risk factor for an acute MI?
Diabetes
43
What is the first line therapy for hypertriglyceridemia?
Fibrates (Fenofibrate) are the most potent medications to decrease trigylcerides - can reduce TG level as much as 50% or greater
44
What is the MOA of nitroglycerin?
| What are some associated side effects?
Increased myocardial blood supply - increases coronary artery blood flow and collateral circulation as wellas reduces coronary artery vasospasm.
Vasodilation occurs due to stimulation of guanylate cyclase, which increases cGMP
| HA, flushing, tolerance (tachyphylaxis), hypotension, peripheral edema
45
What manuvers can be done to increase venous return?
| Does increase venous return increase most murmur intenstities?
* Supine Position
* Squatting
* Leg elevation
| Yes, except hypertrophic cardiomyopathy and the click of mitral prolapse
46
What is the most common valvular disease and what are the two etiologies?
Aortic Stenosis
Degenerative: calcifications, wear and tear, especially in patients > 70 years
Congenital and Bicuspid Valve: common in patients < 70 years
47
Describe the murmur associated with aortic stenosis?
| What is the first symptom of aortic stenosis?
Harsh, low-pitched, mid-late peaking, systolic, crescendo-decrescendo murmur best heard a the right upper sternal border
Will increase with increased venous return (squatting, supine, and leg raise)
| Exertional dyspnea
48
What is the most commonly occluded artery in acute coronary syndromes?
Left Anterior Descending Artery
49
What drug class are "Statins" and what is their MOA?
| What are some adverse effects?
HMG-CoA Reductase Inhibitors
* Lovastatin, Pravastain, Simvastatin, Rosuvastatin, Atorvastatin, Fluvastatin, Pitavastatin
MOA: prevent synthesis of mevalonate, a cholesterol precursor, by inhibiting HMG-CoA reductase, the first and rate limiting step in helpatic cholesterol synthesis
| Myopathy, hepatic dysfunction, hyperglycemia
## Footnote
High intensity Statins (Rosuvastatin and Simvastatin) can cause proteinuria and hematuria
50
A 64-year-old man with a medical history of hypertension on hydrochlorothiazide 25 mg daily presents to the urgent care with chest pain since this morning. He describes the pain as sharp, constant, and worse with inspiration. He reports the chest pain happens at rest and does not worsen with exertion. He reports the pain radiates to his left shoulder. Vital signs today include HR of 100 bpm, BP of 132/81 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, and T of 98.4°F. On physical exam, a pericardial friction rub is heard at the end of expiration. The chest wall is symmetric, without deformity, and atraumatic in appearance. No tenderness to palpation of the chest wall is noted. What should be ordered to determine if this is pericarditis vs. and pericardial effusion due to friction rub on exam?
Echocardiogram
51
What are the EKG changes associated with pericarditis?
* PR elevation in aVR
* PR depression
* Diffuse concave ST elevation
52
In which ECG leads can a myocardial infarction in the anteroseptal portion of the heart be seen?
Leads V1-V3
53
The ACC has an atherosclerotic cardiovascular disease (ASCVD) risk calculator that determines a patient’s 10-year risk of a cardiovascular disease event. At what percentage risk level is prescription of a moderate-intensity statin recommended?
> 7.5%
Clinically, most use > 10% risk with a grey zone between 5-10%
54
In patients with heart failure with reduced ejection fraction (HFrEF) what medication classes can improve mortality?
* angiotensin-converting enzyme (ACE) inhibitors
* angiotensin II receptor blockers (ARBs)
* beta-blockers
* mineralocorticoid receptor antagonists
* sodium-glucose cotransporter 2 (SGLT2) inhibitors
ACE inhibitors are usually introduced first
55
Describe the murmur associated with hypertrophic cardiomyopathy?
Harsh systolic cresendo-decresendo murmur heard best at left sternal border, may have a loud S4
Murmur will increase in intensity with decreased venous return (Valsalva, standing) – this is different than aortic stenosis that will decrease in intensity
56
What ankle-brachial index (ABI) ratio suggests a degree of arterial obstruction often associated with claudication?
| What is a normal ABI?
ABI of 0.4-0.9
| 0.9 - 1.4
57
What is a helpful physical exam finding that can differentiate peripheral artery disease from chronic venous insufficiency?
Leg swelling/edema; PAD does not have leg swelling
58
What is Pancoast Syndrome and what type of lung cancer is it associated with?
Pancoast syndrome involves a lung malignancy in the superior sulcus. These tumors can cause nerve impingement that leads to arm or shoulder pain and hand muscle atrophy. They can also disrupt the sympathetic nerve chain, which innervates the eye, leading to ptosis, miosis, and anhidrosis of the ipsilateral side (Horner syndrome).
Non-Small Cell Lung Cancer
59
What type of birth control should be avoided in women with a history of deep vein thrombosis?
Contraceptives containing estrogen
60
A 58-year-old male presents to the emergency department with chest pain that began while he was mowing the lawn. The pain is described as a pressure-like sensation located in the substernal area, radiating to the left arm. The patient reports that the pain was relieved after he rested and took a sublingual nitroglycerin tablet, which he borrowed from a neighbor. He has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. On examination, his blood pressure is 150/90 mmHg, heart rate is 88 bpm, and no murmurs are heard on auscultation. What is the most likely diagnosis?
Stable angina as it resolved with rest and nitroglycerin
61
A 67-year-old woman with a history of coronary artery disease presents with chest pain at rest for the past two hours. She describes the pain as severe, located in the middle of her chest, and radiating to her jaw. She denies any relief with rest or her usual dose of nitroglycerin. Her ECG shows ST-segment depressions in leads V2 to V4. What is the most appropriate next step in management?
A) Discharge home with aspirin and follow-up in the clinic
B) Admit for observation with serial cardiac enzymes and continuous ECG monitoring
C) Schedule for outpatient stress testing
D) Start thrombolytic therapy immediately
**Admit for observation with serial cardiac enzymes and continuous ECG monitoring**
Unstable angina is characterized by a worsening pattern of chest pain that can occur at rest, is more severe, and may not be relieved by nitroglycerin, indicating that the patient's condition could be evolving towards a myocardial infarction (MI).
It allows for close monitoring and early detection of progression to myocardial infarction, while also managing any ongoing ischemia.
62
A 72-year-old male with a past medical history of hypertension and chronic obstructive pulmonary disease (COPD) presents with exertional chest pain. He reports that the pain is more frequent and occurs with less physical activity than it used to. The pain is described as squeezing and is associated with shortness of breath. His current medications include an inhaled bronchodilator, a beta-blocker, and a statin. Which of the following changes in his symptoms is most concerning for unstable angina?
A) Pain is now occurring at rest
B) Pain occurs only after meals
C) Pain is relieved with increased doses of nitroglycerin
D) Pain is associated with light-headedness
Pain is now occuring at rest
63
A 55-year-old woman with no significant past medical history comes to the clinic complaining of intermittent chest pain. She describes the pain as a tightness in her chest that occurs when she walks up a flight of stairs and resolves with rest. She denies any history of similar symptoms. Her physical examination is unremarkable. Which of the following tests would be most appropriate to confirm the diagnosis of stable angina?
A) Coronary angiography
B) Echocardiogram
C) Exercise stress test
D) Cardiac MRI
Exercise Stress Test
64
Which heart valve is most commonly affected by infective endocarditis in intravenous drug users?
Tricuspid Valve
65
What is the most common organism responsible for acute bacterial endocarditis?
| What is the most common organism responsible for subacute endocarditis?
S. aureus
| Strep Viridans
66
Which imaging modality is the gold standard for diagnosing endocarditis?
Transesophageal echocardiogram (TEE)
67
Name one major criterion from the Duke criteria used for the diagnosis of endocarditis
* Blood cultures: S. aureus, S. viridans, S. bovis or other typical species x 2, 12 hours apart
* Echocardiogram: vegetations are seen (tricuspid-IV drug users, mitral-non drug users)
* New regurgitant murmur
68
Which skin manifestations are commonly associated with endocarditis?
* Janeway Lesions (painless bumps on hands and soles)
* Osler Nodes (painfull bumps on toes and fingers)
* Splinter hemorrhages (under fingernails)
69
What is the initial empiric antibiotic therapy for native valve endocarditis?
Vancomycin and ceftriaxone
70
A 45-year-old African American male with a history of obesity presents for a routine check-up. His blood pressure readings over the past few months have consistently been around 150/95 mmHg. He denies any chest pain, shortness of breath, or headaches. His current medications include only a multivitamin. On examination, his BMI is 32 kg/m², and his physical exam is otherwise unremarkable. What is the most appropriate first-line treatment for this patient?
Hydrochlorothizide
## Footnote
Clinical guidelines recommend that African American patients with hypertension, particularly those without chronic kidney disease (CKD), may respond better to thiazide diuretics or calcium channel blockers as first-line therapy compared to other classes of antihypertensives, such as ACE inhibitors or beta-blockers.
71
A 62-year-old woman with a history of type 2 diabetes mellitus presents with elevated blood pressure readings over the past few months, averaging 160/100 mmHg. She has been managing her diabetes with metformin and lifestyle changes. On examination, she has no signs of end-organ damage. Which class of antihypertensive medication is most appropriate as the initial treatment in this patient?
A) Beta-blocker
B) Calcium channel blocker
C) ACE inhibitor
D) Thiazide diuretic
| What is the number one cause of mortality in diabetes patients?
ACE inhibitor
| Heart Disease (MI)
## Footnote
Patients with diabetes are at increased risk of cardiovascular events, and controlling blood pressure is crucial to reducing this risk.
ACE inhibitors, such as lisinopril, are first-line in patients with diabetes who have hypertension. This is due to ACE inhibitors' ability to control blood pressure but also provide renal protection, which is particularly important in diabetic patients to prevent the progression of diabetic nephropathy.
72
A 38-year-old female presents with persistent hypertension despite being on three antihypertensive medications, including a thiazide diuretic, ACE inhibitor, and calcium channel blocker. Her blood pressure today is 165/100 mmHg. She denies any headaches, chest pain, or visual changes. Laboratory workup reveals normal kidney function and electrolytes. What is the most likely underlying cause of her resistant hypertension?
A) Primary aldosteronism
B) Pheochromocytoma
C) Renal artery stenosis
D) Obstructive sleep apnea
Renal Artery Stenosis
73
What is Dressler's Syndrome?
| What is the treatment?
## Footnote
What should be avoided to prevent pericardial wall thinning?
Pericarditis following a myocaridal infarction
| ASA or Colchacine
## Footnote
NSAIDs and corticosteroids
74
What are the two most common symptoms associated with a pulmonary embolism?
| What is the best initial test when working up a PE?
Dyspnea (m/c) and pleuritic chest pain
| Spiral CT
75
Which of the following medical conditions is most likely to increase the risk of multifocal atrial tachycardia?
A. Acute pancreatitis
B. Chronic obstructive pulmonary disease
C. Hyperlipidemia
D. Hypothyroidism
COPD or Other Pulmonary Diseases
Common examples of pulmonary diseases provoking multifocal atrial tachycardia are COPD and pneumonia. These pulmonary conditions can cause hypoxia, hypercapnia, and acidosis, which are all triggers of ectopic atrial activity.
76
At what anatomical sites does the abdominal aorta begin and end?
The abdominal aorta begins at the level of the diaphragm and ends at the level of the umbilicus, where it bifurcates into the left and right iliac arteries.
77
A 68-year-old patient with diabetes, hypertension, hyperlipidemia, and overweight and a history of smoking undergoes a screening ultrasound for an abdominal aortic aneurysm. He is nonsymptomatic. Screening reveals an abdominal aortic aneurysm with a diameter of 3 cm. Which recommendation would result in the greatest immediate reduction of risk for this patient?
A. Adding an angiotensin-converting enzyme inhibitor
B. Initiating a diet and exercise routine
C. Initiating statin therapy
D. Smoking cessation
Smoking cessation would have the greatest immediate reduction of risk but all are important treatments
78
Which of the following patients is at risk for having an atypical presentation of an acute myocardial infarction?
A. 21-year-old man with a history of asthma
B. 37-year-old man with a history of obesity
C. 72-year-old woman with a history of diabetes and hypertension
D. 75-year-old man with a family history of coronary artery diseas
72-year old woman with a history of diabetes and hypertension
79
What is the Levine sign?
Clenched fist placed over the heart in the setting of chest pain
80
What are other causes of elevated troponin in addition to acute myocardial infarction?
* Myocarditis
* Pericarditis
* Rapid atrial fibrillation
* Heart failure
* Pulmonary embolism
* Aortic dissection
* Sepsis
81
What are the first-line antihypertensive agents in patients with acute aortic dissection?
Esmolol or labetalol
82
A 35-year-old woman presents with palpitations, dyspnea, and mild chest pain that started at rest. On physical exam, she is noted to be diaphoretic and tachycardic. Her blood pressure is 130/80 mm Hg, heart rate is 170 beats per minute, and respiratory rate is 22 breaths per minute. Her rhythm strip is shown above. The rhythm persists despite the initiation of the Valsalva maneuver. Which of the following is the most appropriate pharmacologic treatment to give next for this patient’s condition?
A) Adenosine
B) Diltiazem
C) Esmolol
D) Procainamide
Adenosine
83
What medication class should be initiated imediately in patients with an NSTEMI?
High-dose statins (atorvastatin) are recommended in all patients with NSTEMI as they improve outcomes and delay death or major cardiovascular events by up to three months
84
A 65-year-old woman with a history of COPD presents to your clinic with multiple presyncopal events over the past three months. You obtain ECG and initiate treatment with metoprolol. The pathophysiology of the disease that is causing the symptoms in your patient is a single excitable electrical focus in the left or right atrium. What is the diagnosis?
| What pattern is seen on EKG?
**Atrial flutter** is a tachydysrhythmia caused by a single excitable electrical focus in the left or right atrium but most commonly in the right atrium.
| Sawtooth Pattern
85
What is the most common risk factor for the development of abdominal aortic aneurysm?
| What is the USPSTF's recommendation for screening of AAA?
Smoking
| One time screening via ultrasound for men 65-75 who have smoked
86
At what diameter is an abdominal aortic aneurysm considered surgical?
Generally, surgical repair is considered when the aneurysm is ≥ 5.5 cm or if it is rapidly expanding. Some sources say > 5.0 cm for women.
87
What imaging modality is most commonly used for initial screening of an abdominal aortic aneurysm?
Abdominal Ultrasound
88
A 68-year-old man presents to the clinic for his annual physical exam. He has a 45-pack-year smoking history and no significant complaints. On physical exam, a pulsatile mass is palpated in the abdomen. He denies pain or tenderness. What is the next best step in managing this patient?
A) Computed tomography (CT) scan of the abdomen
B) Abdominal ultrasound
C) Magnetic resonance imaging (MRI)
D) Abdominal X-ray
Abdominal ultrasound
## Footnote
Abdominal ultrasound is the preferred initial diagnostic test for screening and evaluating an asymptomatic abdominal aortic aneurysm. It is non-invasive and highly sensitive for detecting AAA
89
A 72-year-old man with a history of hypertension and smoking presents with sudden, severe abdominal and back pain. On arrival, he is hypotensive with a blood pressure of 90/60 mmHg. He appears pale and diaphoretic. Physical exam reveals a pulsatile abdominal mass. Which of the following is the most appropriate next step in management?
A) Order an abdominal ultrasound
B) Immediate surgical consultation
C) Start intravenous nitroglycerin
D) Administer oral beta-blockers
Immediate surgical consultation
## Footnote
A ruptured AAA is a surgical emergency. Immediate surgical intervention is required. Imaging can confirm the diagnosis, but the priority is to stabilize the patient and get them to surgery as soon as possible
90
A 65-year-old male with a history of coronary artery disease and a 40-pack-year smoking history undergoes screening for abdominal aortic aneurysm. An abdominal ultrasound reveals an infrarenal aortic aneurysm measuring 4.2 cm. What is the recommended follow-up for this patient?
A) Annual abdominal ultrasound
B) Immediate surgical repair
C) Abdominal ultrasound every 6 months
D) No further follow-up is needed
Annual abdominal ultrasound
## Footnote
For an aneurysm between 4.0 and 4.9 cm, annual ultrasound monitoring is recommended to assess for aneurysm growth. Surgical repair is typically considered when the aneurysm reaches ≥ 5.5 cm or if it grows rapidly
91
A 70-year-old male presents with a history of hypertension, hyperlipidemia, and a 50-pack-year smoking history. He underwent an ultrasound screening that revealed an abdominal aortic aneurysm measuring 5.6 cm. He is asymptomatic and denies any abdominal pain or back pain. What is the most appropriate management?
A) Continue with conservative management and monitor with regular ultrasounds
B) Prescribe statins and antihypertensive therapy
C) Refer for elective surgical repair
D) Begin anticoagulation therapy
Refer for elective surgical repair
## Footnote
An aneurysm ≥ 5.5 cm in diameter in men is an indication for elective surgical repair, even if the patient is asymptomatic, due to the high risk of rupture.
92
What is the primary pathological change leading to the formation of an abdominal aortic aneurysm?
| Which layer of the aortic wall is most commonly affected?
Degeneration and weakening of the aortic wall, primarily due to loss of elastin and collagen in the tunica media
| Tunica media
93
What genetic disorder is associated with an increased risk of aortic aneurysm due to connective tissue defects?
Marfan Syndrome, which affects fibrillin, leading to a weakened aortic wall
94
A 70-year-old man with a history of hypertension and a 50-pack-year smoking history is diagnosed with an abdominal aortic aneurysm. Which of the following best explains the underlying pathophysiology of aneurysm formation in this patient?
A) Progressive deposition of calcium in the arterial wall
B) Increased synthesis of collagen and elastin in the aortic wall
C) Degradation of elastin and collagen in the tunica media due to chronic inflammation
D) Weakening of the endothelial layer due to atherosclerotic plaque rupture
Degradation of elastin and collagen in the tunica media due to chronic inflammation
95
A 58-year-old man with a history of hypertension and smoking is diagnosed with a 4.5 cm abdominal aortic aneurysm. The degradation of the extracellular matrix and structural components of the aortic wall is central to the development of his aneurysm. Which cells are primarily involved in mediating this degradation?
A) Neutrophils
B) Macrophages
C) Endothelial cells
D) Platelets
Macrophages
## Footnote
Macrophages infiltrate the aortic wall in AAA and secrete matrix metalloproteinases (MMPs), which degrade elastin and collagen, leading to weakening of the aortic wall and aneurysm formation
96
A 72-year-old man with a history of tobacco use disorder presents with fatigue and unintentional weight loss over the last month. He is also reporting a feeling of fullness in his head that is made worse with bending forward. A chest radiograph is obtained and shows a large hilar mass with bulky mediastinal adenopathy. Which of the following physical exam findings would be most consistent with his diagnosis?
A) Alteration in gait
B) Distention of the chest wall veins
C) Dry mouth with reduced salivation
D) Ptosis
Distention of the chest wall veins
## Footnote
This patient has superior vena cava syndrome caused by small cell lung cancer (the m/c cause)
97
A 65-year-old man with a history of hypertension, hypercholesterolemia, and a 40 pack-year smoking history presents to his primary care provider 1 week after stent placement during a percutaneous transluminal coronary angioplasty. He states he has been feeling well since the procedure. He also reports he lost his postvisit summary and is unsure of any medication changes he should be aware of. What medication should be initiated in this patient?
A) Dabigatran
B) Dipyridamole
C) Heparin
D) Ticagrelor
Ticagrelor
## Footnote
All patients with CAD should be prescribed a daily aspirin unless contraindicated. Patients who recently had a stent placed should be prescribed dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., ticagrelor or clopidogrel)
98
What is the most common cause of rheumatic fever?
| What diagnostic criteria is used to diagnose acute rheumatic fever?
Group A Strep (GAS) infection, specifically from streptococcal pharyngitis
| Jones Criteria
99
What heart valve is most commonly affected in rheumatic heart disease?
The mitral valve (mitral stenosis is the most common consequence)
100
What is the first-line treatment for an acute episode of rheumatic fever?
Penicillin (or other antibiotics to eradicate streptococcal infection) and anti-inflammatory therapy (aspirin or NSAIDs)
101
What is the long-term prevention strategy for patients with rheumatic heart disease?
Long-term antibiotic prophylaxis, usually with penicillin, to prevent recurrent Group A streptococcal infections
102
A 12-year-old boy presents with fever, migratory joint pain, and a rash. He had a sore throat 3 weeks ago that was not treated. On physical exam, you note a new heart murmur and erythema marginatum. Which of the following diagnostic tools would most likely confirm his suspected diagnosis?
A) Blood cultures
B) Antistreptolysin O (ASO) titer
C) Chest X-ray
D) Electrocardiogram
Antistreptolysin O (ASO) titer
## Footnote
Elevated ASO titer is indicative of a recent streptococcal infection, which is a common precursor to acute rheumatic fever. The presence of migratory arthritis, a new murmur, and erythema marginatum suggests rheumatic fever, which is confirmed with evidence of a recent Group A Streptococcal infection
103
A 25-year-old woman presents with dyspnea on exertion and a history of rheumatic fever during childhood. Physical examination reveals a diastolic murmur best heard at the apex and an opening snap. Which heart valve is most likely affected?
Rheumatic heart disease most commonly affects the mitral valve, leading to mitral stenosis, which is characterized by a diastolic murmur and an opening snap.
104
A 10-year-old girl presents with migratory joint pain, fever, and a recent history of streptococcal pharyngitis. Physical exam reveals a systolic murmur and subcutaneous nodules over her joints. According to the Jones criteria, how many major criteria are required, along with evidence of a recent streptococcal infection, to diagnose acute rheumatic fever?
To diagnose acute rheumatic fever, 2 major criteria (or 1 major and 2 minor criteria) from the Jones criteria, along with evidence of recent streptococcal infection, are required.
Major criteria include
* carditis
* polyarthritis
* chorea
* erythema marginatum
* subcutaneous nodules.
105
A 13-year-old boy presents with fever, migratory joint pain, and a rash. He had an untreated sore throat 4 weeks ago. Examination reveals a new heart murmur and erythema marginatum. Which of the following best describes the pathophysiology of rheumatic fever?
A) Direct bacterial invasion of the heart valves
B) Autoimmune reaction triggered by Group A Streptococcus
C) Formation of a granulomatous response to infection
D) Viral-mediated damage to the cardiac tissue
Autoimmune reaction triggered by Group A Strep
## Footnote
Rheumatic fever results from an autoimmune response to Group A Streptococcus infection, where antibodies cross-react with heart tissue, joints, skin, and the central nervous system
106
What medication classes are contraindicated in patients with right ventricular infarction?
Nitrates and Diuretics
107
What is the heparin antidote (reversal agent)?
Protamine Sulfate
108
What anti-hypertensive drug class can lower melatonin therefore causing fatigue and sleep disturbances?
Beta-Blockers
109
What artery is occluded in an anterior wall STEMI and what leads will the infarct be?
| Why is this called the "widow maker"
Anterior wall infarction is caused by an occlusion of the LAD.
Infarct will appear in leads V3 and V4.
| It involves a large area of the left ventricle and has a bad prognosis
