Diseases of the Myocardium, Acquired

Question 1

What class of medication should you avoid in cocaine toxicity

Answer 1

Beta blockers

Question 2

Cocaine intoxication clinically presents as a

Answer 2

Cocaine intoxication clinically presents as a sympathomimetic toxidrome that includes tachycardia, hypertension, diaphoresis, chest pain, and mydriasis. Patients may also have hyperthermia and cardiac dysrhythmias.

Question 3

Cocaine works by

Answer 3

Cocaine exerts its affects by stimulating and blocking reuptake of multiple neurotransmitters (dopamine, epinephrine, norepinephrine, and serotonin). Although many receptors are activated, the most profound effect is the adrenergic stimulation caused by norepinephrine and epinephrine, resulting in vasoconstriction, increased myocardial contractility, increased myocardial oxygen demand, and increased heart rate.

Question 4

Cocaine-related chest pain ensues as a result of

Answer 4

Cocaine-related chest pain ensues as a result of coronary vasospasm and ischemia due to increased myocardial oxygen demand.

Question 5

Cocaine-related chest pain is most effectively managed through

Answer 5

benzodiazepines, which will decrease the oxygen demand and sympathetic effects

Question 6

Should you give aspirin in cocaine induced chest pain

Answer 6

Aspirin should be administered as well since cocaine induces platelet aggregation

Question 7

Beta-blockers are generally recommended to be avoided in cocaine-related chest pain due to

Answer 7

Beta-blockers are generally recommended to be avoided in cocaine-related chest pain due to the unopposed alpha stimulation that can lead to increased cardiac ischemia. Concern that it can lead to worsening vasoconstriction.

Question 8

Cocaine effects

Answer 8

Question 9

True or false: preexistent cardiovascular disease is a prerequisite for cocaine-related myocardial ischemia.

Answer 9

False

Question 10

Rapid Review: Cocaine Intoxication

Answer 10

Question 11

Myocarditis

Answer 11

Myocarditis occurs when there is inflammation and necrosis of the myocardium. This typically occurs after an infection and can present with fever, chills, and chest pain. The diagnosis is more likely in a young patient. ECG may demonstrate nonspecific ST segment changes, T wave inversions, and QT prolongation. Echocardiography can demonstrate global hypokinesis. Troponins will be elevated given the damage to the cardiac myocytes. Other tests can include an erythrocyte sedimentation rate or C-reactive protein, serum viral titers, and a cardiovascular MRI. An endomyocardial biopsy is the gold standard to confirm the diagnosis, although it is rarely done. The prognosis is variable in myocarditis, and sudden death is possible even in young and previously healthy patients. The treatment of myocarditis is supportive care, with heart failure medications and antidysrhythmics as needed.

Question 12

Myocarditis Chart

Answer 12

Question 13

What is the treatment of pericardial tamponade in a hemodynamically unstable patient?

Answer 13

Pericardiocentesis.

Question 14

Rapid Review: Myocarditis

Answer 14

Question 15

What is the biggest risk factor for the development of a left ventricular aneurysm?

Answer 15

Left anterior descending coronary artery infarction

Question 16

Left ventricular aneurysm

Answer 16

Left ventricular aneurysm formation is a potential complication following a myocardial infarction. Occurring in up to 15% of patients after myocardial infarction, it is characterized by a thinned, focal area of the myocardium and is four times as likely to involve the anterior or apical walls than the inferior or posterior walls. On echocardiogram, the involved segment will appear to paradoxically balloon outward during systole. Electrocardiographic findings include persistent ST segment elevation in the distribution of the recent myocardial infarction. Those at greatest risk for the development of a left ventricular aneurysm include patients with complete occlusion of the left anterior descending artery, delayed or incomplete reperfusion, and absence of collateralization. Treatment of left ventricular aneurysm includes afterload reduction, usually with an angiotensin-converting enzyme inhibitor, and anticoagulation, if there is evidence of significant left ventricular dysfunction or thrombus formation.

Question 17

Left ventricular aneurysm Chart

Answer 17

Question 18

Rapid Review: Left ventricular aneurysm

Answer 18

Question 19

What are the three main complications related to development of a left ventricular aneurysm?

Answer 19

Heart failure, dysrhythmias, and thromboembolic disease.

Question 20

The use of nitrates is contraindicated in patients who also take

Answer 20

sildenafil

Question 21

Sildenafil is an

Answer 21

inhibitor of cyclic guanosine monophosphate specific phosphodiesterase type 5. It leads to an increased release of nitric oxide, resulting in smooth muscle relaxation and vasodilation

Question 22

Sildenafil is commonly used to treat

Answer 22

Erectile dysfunction

Question 23

Which electrolyte is increased with hydrochlorothiazide use?

Answer 23

Calcium (causing hypercalcemia).

Question 24

Erectile Dysfunction

Answer 24

Question 25

Rapid Review: PDE-5 Inhibitors

Answer 25

Question 26

Which medication is the first line treatment for patients with acute decompensate heart failure

Answer 26

This patient presents with symptoms of acute decompensated heart failure and should be started on nitroglycerin therapy immediately. Patients present with shortness of breath, increased work of breathing, tachycardia, hypoxia, crackles on lung examination, and jugular venous distension. These patients experience acute worsening of left ventricular function and output secondary to a number of mechanisms including increased systemic vascular resistance. Therapy focuses on the reduction of preload to decrease the flow of blood into the lungs and afterload reduction to increase the effectiveness of the left ventricle. Both of these goals can be accomplished through the administration of nitroglycerin. At lower doses, nitroglycerin acts as a peripheral vasodilator and increases venous capacitance leading to decreased preload. At higher doses, nitroglycerin causes arterial vasodilation leading to decreased afterload. Because of its rapid onset of action, nitroglycerin is the first-line medication in patients with acute decompensated heart failure.

Question 27

Rapid Review: Acute Decompensated Heart Failure

Answer 27

Question 28

Nitrates chart

Answer 28

Question 29

What life-threatening toxicity is associated with nitroprusside administration?

Answer 29

Cyanide toxicity.

Question 30

Which medication has the greatest impact on reducing mortality in patients presenting with acute coronary syndrome?

Answer 30

Aspirin

Question 31

Aspirin in ACS

Answer 31

Aspirin has been shown to have the greatest effect on reducing mortality in patients with acute coronary syndrome (ACS). Aspirin is an irreversible antiplatelet agent. It inactivates platelets for the life span of the platelet (8–10 days). Studies have demonstrated a 23% reduction in mortality for patients with acute myocardial infarction (AMI) who received aspirin but not thrombolytic therapy. Aspirin also works synergistically with thrombolytics (42% reduction in mortality). Overall, aspirin has a number needed to treat (to prevent death) of 42. Administration of aspirin (chewed and swallowed) is recommended in any patient with suspected ACS.

Question 32

Which cardiac biomarker has the highest sensitivity and specificity?

Answer 32

Cardiac troponin

Question 33

Initial Medical Therapy for ACS

Answer 33

Question 34

Rapid Review: Ischemic Heart Disease

Answer 34

Question 35

Which medication is contraindicated n an inferior STEMI

Answer 35

Nitroglycerin

Question 36

Why is nitroglycerin contraindicated in an inferior MI

Answer 36

Patients with an inferior STEMI may have right ventricular infarct and be preload dependent. In a patient with an inferior STEMI, right ventricular infarct is suggested by the presence of ST elevation in lead III larger than that in lead II. A right ventricular infarct can be discovered by performing a right-sided ECG and looking for ST elevation in lead V4R. In these patients, a preload-reducing medication like nitroglycerin can lead to a precipitous drop in blood pressure.

Question 37

Please interpret this EKG

Answer 37

A right ventricular infarct is suggested by the presence of ST elevation in lead III larger than that in lead II.

Question 38

Right Ventricular Infarction Chart

Answer 38

Question 39

Which coronary artery most commonly supplies the inferior wall with blood?

Answer 39

The right coronary artery.

Question 40

Rapid Review: Inferior ST Elevation Myocardial Infarction

Answer 40

Question 41

The Sgarbossa ST elevation myocardial infarction (STEMI) criteria

Answer 41

ECG predictors of myocardial infarction are used in the presence of a conduction delay like a left bundle branch block (LBBB). ST segment elevation of at least 1 mm that is concordant with the QRS complex in any lead meets one of the criteria for STEMI. Concordant means that the ST segment and QRS complex have the same direction. The two other criteria for STEMI include concordant ST segment depression of at least 1 mm in lead V1, V2, or V3 and ST segment elevation of at least 5 mm that is discordant with the QRS complex. However, this latter criterion is based on the original Sgarbossa criteria and has been replaced in the modified Sgarbossa criteria with excessive discordance, defined by an ST/S ratio > 0.25. The original Sgarbossa criteria assigned weighted scores to determine the likelihood of STEMI. However, in the modified Sgarbossa criteria, meeting any single criterion yields increased sensitivity without significant loss of specificity in the diagnosis of STEMI in the setting of a conduction delay.

Question 42

Sgarbossa Criteria

Answer 42

Question 43

What is the time frame for urgent fibrinolysis in patients with ECG findings of ST elevation myocardial infarction who are not located in a percutaneous coronary intervention (PCI) center and are not able to meet PCI recommended goals?

Answer 43

30 Minutes

Question 44

Rapid Review: Modified Sgarbossa Criteria

Answer 44

Question 45

The most common ECG presentation of a posterior STEMI is to only see

Answer 45

the reciprocal changes in the anterior leads.

Question 46

When horizontal ST depressions are seen in leads V1, V2, and V3 with upright T waves

Answer 46

a posterior ECG should promptly be performed to support the diagnosis

Question 47

What treatment should be avoided in a right-sided myocardial infarction?

Answer 47

Nitroglycerin

Question 48

Interpret the EKG, please

Answer 48

Posterior myocardial infarction

Question 49

Rapid Review: ST Segment Elevation MI

Answer 49

Question 50

Posterior MI Chart

Answer 50

Question 51

Hypertrophic Cardiomyopathy Chart

Answer 51

Question 52

Rapid Review: Hypertrophic Cardiomyopathy

Answer 52

Question 53

Coronary Anatomy

Answer 53

Question 54

Please Interpret this EKG

Answer 54

Anterolateral and inferior STEMI.

Question 55

High Output vs Low Output Heart Failure

Answer 55

Question 56

What physical exam finding is specific to high-output heart failure?

Answer 56

Bounding pulse with a quick upstroke and a wide pulse pressure.

Question 57

Rapid Review: High Output Cardiac Failure

Answer 57

Question 58

What gene mutation is most commonly associated with hypertrophic cardiomyopathy?

Answer 58

Beta-myosin heavy chain.

Question 59

What is the interpretation of this EKG

Answer 59

Posterior STEMI

Question 60

Posterior STEMI EKG

Answer 60

Question 61

Answer 61

Higher Lateral STEMI

Question 62

Higher Lateral STEMI

Answer 62

Question 63

What is the most common complication of acute coronary syndrome?

Answer 63

Cardiac Dysrhythmia

Question 64

What are the classic chest X-ray findings in heart failure?

Answer 64

Kerley B lines and cephalization of flow.

Question 65

Rapid Review: Acute Decompensated Heart Failure

Answer 65

Question 66

General Overview of Acute Decompensated Heart Failure

Answer 66

Question 67

Please Interpret this EKG

Answer 67

Inferior MI

Question 68

Preload Dependence

Answer 68

Question 69

Rapid Review: Inferior STEMI

Answer 69

Question 70

What medication used in the management of acute myocardial infarction activates antithrombin III and inactivates thrombin?

Answer 70

Heparin

Question 72

What percentage of patients with cocaine chest pain are found to have myocardial injury?

Answer 72

Approximately 6

Question 73

Treatment Options for Cocaine Induced Chest Pain

Answer 73

Question 74

Rapid Review: Cocaine Associated Chest Pain

Answer 74

Question 75

What is the next step in hemodynamic management in patients unresponsive to vasopressors?

Answer 75

Intraaortic Balloon Pump

Question 76

Ionotropes and Vasopressors

Answer 76

Question 77

Rapid Review: Cardiogenic Shock

Answer 77

Question 78

The presence of pneumothorax is identified with which sign on ultrasound?

Answer 78

Lung Point Sign

Question 79

B lines Ultrasound

Answer 79

Question 80

B Lines Video Ultrasound

Answer 80

Question 81

Rapid Review: Ultrasound Pulmonary Edema

Answer 81

Question 82

What is the name for small, < 2 cm, horizontal lines representing edematous interlobular septa or lymphatic vessels seen in the lower zone periphery on a chest X-ray in patients with congestive heart failure?

Answer 82

Kerley B lines

Question 83

What is a water hammer pulse?

Answer 83

Bounding pulse with quick upstroke and downstroke.

Question 84

What respiratory intervention can significantly improve symptoms in acute pulmonary edema?

Answer 84

BiPAP

Question 85

This CXR is concerning for

Answer 85

Pulmonary Edema

Question 86

What laboratory test evaluates for a substance released by the ventricles in heart failure?

Answer 86

BNP

Question 87

In an anterior wall ST elevation myocardial infarction, what decreases the rate of aneurysm development?

Answer 87

Time to revascularlization

Question 88

Please Interpret this EKG

Answer 88

Concerning for Ventricular Aneurysm

Question 89

In the setting of ST elevation myocardial infarction, what is the number needed to treat with aspirin to prevent one death

Answer 89

42

Question 90

Types of Acute Coronary Syndromes

Answer 90

Question 91

Rapid Review: Chest Pain

Answer 91

Question 92

What is Brugada syndrome?

Answer 92

Brugada syndrome is a genetic sodium channelopathy that can result in lethal ventricular tachydysrhythmias

Question 93

Please interpret this EKG

Answer 93

Hypertrophic Cardiomyopathy

Question 94

Please interpret this EKG

Answer 94

Considered a STEMI equivalent seen with acute left anterior descending artery occlusion, this shows the de Winter pattern with ST depression and peaked T waves in the precordial leads.

Question 95

Please interpret this EKG

Answer 95

Wellans Syndrome

Question 96

Wellans Syndrome Chart

Answer 96

Question 97

Rapid Review: Wellans Syndrome

Answer 97

Question 98

Besides the history, ECG, age, risk factors, and troponin score, what are two other chest pain scoring tools that are highly sensitive for determining which chest pain patients are appropriate for early discharge from the emergency department?

Answer 98

The North American Chest Pain Rule and the ASPECT Rule.

Question 99

Heart Score Chart

Answer 99

Question 100

Rapid Review: Heart Score

Answer 100

Question 101

Rapid Review: Low Output Heart Failure

Answer 101

Question 102

BNP Chart

Answer 102

Question 103

What marker of kidney function is disproportionately elevated in heart failure?

Answer 103

BUN is elevated greater than creatinine

Question 104

In what leads are the T wave changes of Wellens syndrome most likely to be seen?

Answer 104

V2-V3

Question 105

What is the pharmacologic treatment of choice for hypertrophic cardiomyopathy?

Answer 105

Beta Blocker

Question 106

Which analgesic medication should be avoided in patients diagnosed with acute heart failure?

Answer 106

NSAIDS as they can cause sodium and water retention