Cardiovascular IV Flashcards
What is the likely diagnosis in a young patient with abrupt onset tachycardia and palpitations?
Paroxysmal supraventricular tachycardia (PSVT)
typically due to an atrioventricular nodal re-entrant tachycardia
What is the likely diagnosis in a young patient with exertional chest pain, a systolic murmur at the first right intercostal space, and a palpable thrill in the suprasternal notch?
Supravalvular aortic stenosis
usually refers to congenital LV outflow tract obstruction; LV hypertrophy develops overtime and increased myocardial O2 demand causing exertional angina
What is the likely diagnosis in a young patient with hypertension and palpable bilateral, non-tender, upper abdominal masses on physical exam?
Autosomal dominant PKD
diagnosis is confirmed with imaging (e.g. ultrasound, CT, MRI)
What is the likely diagnosis in a young patient with hypertension, epistaxis, headaches, and ST-segment depression/T-wave inversion in leads V5-V6 on ECG?
Coarctation of the aorta
ECG findings are indicative of LV hypertrophy; initial evaluation includes assessing for brachial-femoral delay and bilateral upper/lower extremity BP differential
What is the likely diagnosis in a young patient with palpitations, tachycardia, and the ECG below (obtained after administration of medication)?
Wolff-Parkinson-White syndrome
What is the likely diagnosis in a young patient with recent uveitis, complete AV heart block, and bilateral midfield lung opacities on CXR?
Cardiac sarcoidosis
due to non-caseating granulomas infiltrating the myocardium; can result in arrhythmia, cardiomyopathy (restrictive early, dilated late), heart failure, and SCD
What is the likely diagnosis in a young woman with recurrent headaches, significant hypertension, and a subauricular systolic bruit?
Fibromuscular dysplasia
fibromuscular dysplasia most commonly involves the renal and/or internal carotid arteries; treatment involves antihypertensive medication (e.g. ACE inhibitors) and definitive management of renal artery stenosis with surgery or PTA
What is the likely diagnosis in a young woman with significant hypertension, amaurosis fugax, and a carotid bruit?
Fibromuscular dysplasia
non-inflammatory and non-atherosclerotic condition that commonly inv
What is the likely diagnosis in a young, active patient that suddenly collapses while exercising and presents with a temperature of 106 F, confusion, and respiratory distress?
Exertional heat stroke
defined as temperature > 104 F and CNS dysfunction; other signs of organ damage may be present
What is the likely diagnosis in a young, non-smoker that presents with difficulty breathing, pulsus paradoxus, and a normal cardiac exam?
Asthma
other causes of pulsus paradoxus include COPD, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy
What is the likely diagnosis in an elderly patient with fatigue, dizziness, and the ECG findings below?
Sinus bradycardia
What is the likely diagnosis in an elderly patient with syncope, dyspnea, and a slow-rising/delayed pulse?
Aortic stenosis
pulse is known as “pulsus parvus et tardus”; isolated AS is usually caused by age-dependent sclerocalcific changes
What is the likely diagnosis in an immigrant with a history of megacolon that presents with pedal edema, JVD, and cardiomegaly?
Chagas disease
chronic protozoal disease caused by Trypanosoma cruzi, a parasite endemic to Latin America
What is the likely diagnosis in an ischemic cardiomyopathy patient on antiarrhythmics that presents with progressive dyspnea, non-productive cough, and bilateral infiltrates on X-ray without JVD or peripheral edema?
Amiodarone-induced interstitial pneumonitis
usually occurs within months of starting therapy
What is the likely diagnosis in an IV drug abuser with fever, an early diastolic murmur (left sternal border), and 2nd-degree AV block?
Perivalvular abscess (secondary to aortic valve endocarditis)
development of AV block in a patient with IE should raise suspicion for perivalvular abscess extending into adjacent cardiac conduction tissues
What is the likely etiology of NSTEMI in a young patient with chest pain, agitation, and dilated pupils?
Cocaine intoxication
treatment is similar to NSTEMI due to other causes except beta blockers are avoided and IV benzodiazepines are administered (alleviates psychomotor agitation and sympathomimetic effects)
What is the likely physiologic cause of isolated systolic hypertension in an elderly patient?
Increased stiffness of the arterial wall
associated with increased CV morbidity and mortality and should be managed in the same way as primary hypertension
What is the likely underlying cause of a harsh systolic murmur (right second intercostal space) with radiation to the carotid arteries in a young patient in the U.S.?
Bicuspid aortic valve
bicuspid aortic valve is the cause of aortic stenosis in the majority of patinets under 70 years old
What is the likely underlying cause of an early decrescendo diastolic murmur in a young patient in the U.S. with a family history of heart disease?
Congenital bicuspid aortic valve
the murmur is typically best heard while the patient is sitting up, leaning forward, and holding a breath in full expiration
What is the likely underlying cause of hypertension in a young patient with depression, kidney stones, and hypercalcemia?
Primary hyperparathyroidism
however, most patients are asymptomatic; significant hypertension with primary hyperparathyroidism suggests possible MEN2 with pheochromocytoma and requires further evaluation
What is the likely underlying cause of muscle pain in a patient taking metoprolol, lisinopril, aspirin, and simvastatin?
Statin-induced myopathy
possible due to decreased coenzyme Q10 synthesis, which is involved in muscle cell energy production
What is the likely underlying cause of resistant hypertension in a patient with diffuse atherosclerosis and >30% creatinine elevation after starting ACE inhibitors?
Renovascular disease (e.g. renal artery stenosis due to atherosclerosis)
other suggestive findings of renovascular disease include asymmetric kidney size and recurrent flash pulmonary edema
What is the likely underlying cause of syncope in a patient with normal EF, prolonged PR interval, prolonged QRS interval, and a normal QTc interval on ECG?
AV block or bradyarrhythmia
AV block can be intermittent and thus may not be present on ECG at the time of testing
What is the likely underlying cause of syncope in an elderly patient that stood up after a period of bed rest?
Orthostatic hypotension
may be associated with prodromal dizziness and/or blurred vision
What is the likely underlying etiology of atrial fibrillation in a patient with weight loss, lid lag, and a tremor with outstretched hands?
Hyperthyroidism
What is the likely underlying etiology of chest pain for > 1 hour, unrelated to activity in a young patient with normal cardiac and pulmonary exam?
Esophageal disease (e.g. GERD)
features suggestive of esophageal origin include episodes lasting > 1 hour, post-prandial symptoms, associated heartburn, and relief by anti-reflux therapy
What is the mainstay of therapy to improve/normalize heart function in patients with alcoholic cardiomyopathy?
Abstinence from alcohol
alcoholic cardiomyopathy is suggested by CHF in the presence of heavy alcohol consumption, macrocytic anemia, >2:1 AST:ALT ratio, and no evidence of CAD/valvular defects
What is the mechanism by which adenosine reveals obstructive CAD during cardiac stress testing?
Augmentation of flow in non-obstructed vessels
adenosine causes vasodilation of coronary arteries; stenotic vessels are already dilated at baseline and thus vasodilation results in shunting towards non-obstructed vessels (“coronary steal”)
What is the mode of inheritance of hypertrophic obstructive cardiomyopathy?
Autosomal dominant
typically caused by mutations in sarcomere genes (especially the beta-myosin heavy chain and myosin binding protein C genes)
What is the most appropriate initial therapy for a hemodynamically stable patient with chest pain and suspected acute coronary syndrome and low risk for aortic dissection?
Aspirin
reduces the rate of myocardial infarction and overall mortality in patients with ACS
What is the most common cause of constrictive pericarditis in developing countries?
Tuberculosis
especially endemic areas, such as Africa, India, and China
What is the most common cause of constrictive pericarditis in the United States?
Viral or idiopathic (>40%)
other common causes include radiation therapy (30%), cardiac surgery (10%), and connective tissue disorders
What is the most common cause of mitral regurgitation in developed countries?
Mitral valve prolpase
usually causes mild MR with a mid-systolic click and mid-to-late systolic murmur but can develop into severe MR with a holosystolic murmur on examination
What is the most common cause of sudden cardiac arrest in the immediate post-infarction period in patients with acute MI?
Re-entrant ventricular arrhythmias (e.g. ventricular fibrillation)
What is the most common location of ectopic foci that cause atrial fibrillation?
Pulmonary veins
What is the most effective non-pharmacologic measure to decrease blood pressure in a patient with significant tobacco/alcohol use and a BMI of 22 kg/m2?
Dietary Approaches to Stop Hypertension (DASH) diet
in obese individuals, the most effective approach is weight loss
What is the most effective non-pharmacologic measure to decrease blood pressure in an overweight, diabetic patient with significant tobacco/alcohol use?
Weight loss
other effective measures include the DASH diet, low Na+ intake, moderation of alcohol intake, regular exercise, and smoking cessation
What is the most important factor for survival in a patient with an out-of-hospital sudden cardiac arrest?
Elapsed time to effective resuscitation
e.g. adequate bystander CPR, prompt rhythm analysis, and defibrillation in patients found to be in ventricular fibrillation
What is the most important predisposing risk factor associated with aortic dissection?
Hypertension
other risk factors include Marfan syndrome (responsible for ~50% of aortic dissections in patients age < 40) and cocaine use
What is the most useful intervention to improve functional capacity and reduce symptomatic claudication in patients with peripheral artery disease?
Supervised graded exercise program
patients should also be started on low-dose aspirin and a statin; pharmacologic therapy with cilostazol and percutaneous or surgical revascularization may be considered for those with persistent sympotms
What is the next step in management for a patient with extensive alcohol use and hypertension that is not well controlled on two medications?
Counsel for reduction in alcohol intake
while adding a third medication is a reasonable option, counseling to reduce alcohol intake should be attempted first
What is the next step in management for an asymptomatic adult with an early diastolic murmur at the left sternal border that is best heard with expiration?
Transthoracic echocardiogram
diastolic and continuous murmurs are usually due to an underlying pathologic cause and their presence should prompt further evaluation (versus a mid-systolic murmur in a young, asymptomatic adult, which is likely benign and requires no further evaluation)
What is the preferred abortive treatment for episodes of vasospastic angina?
Sublingual nitroglycerin
What is the preferred diagnostic study for hemodynamically stable patients with normal renal function and suspected aortic dissection?
CT angiography
CT angiography (and MR angiography) should be avoided in patients with moderate to severe kidney disease
What is the preferred diagnostic study for patients with renal insufficiency or hemodynamic instability with suspected aortic dissection?
Transesophageal echocardiography
What is the preferred diagnostic test for fibromuscular dysplasia?
Non-invasive imaging (e.g. CT angiography, duplex ultrasound)
catheter-based digital subtraction arteriography may be required in patients with inconclusive results on non-invasive testing
What is the preferred initial management for symptomatic patients with hypertrophic obstructive cardiomyopathy?
Beta blockers
verapamil or disopyramide can be used as additional therapy in patients with persistent symptoms
What is the preferred medication for hypertension associated with autosomal dominant PKD?
ACE inhibitors
What is the preferred preventive treatment for vasospastic angina?
Calcium channel blockers
patients should also be counseled on smoking cessation if applicable; sublingual nitroglycerin is used as an abortive treatment
What is the primary mechanism by which nitrates improve symptoms of angina?
Systemic vasodilation (decreased preload)
results in decreased left ventricular EDV, reducing wall stress and myocardial O2 demand; primarily venodilation but nitrates also cause arterial dilation to a lesser extent
