FU(9): Critical Illness/Ischemic Heart disease

Question 1

A 55-year-old patient with no history of diabetes presents with stress-induced hyperglycemia in the ICU. Which of the following mechanisms predominantly contributes to this condition?

A.) Direct inhibition of glucose transport into cells by elevated cytokines, causing extracellular glucose accumulation
B.) Increased insulin secretion from the pancreas in response to high cortisol levels, leading to impaired glucose uptake
C.) Insulin resistance in liver and skeletal muscles
D.) Decreased glucagon secretion resulting in impaired glycogen storage, leading to hyperglycemia from elevated blood glucose

Answer 1

C.) Insulin resistance in liver and skeletal muscles

Question 2

In critically ill patients, tight glycemic control targeting a blood glucose level of 80 to 110 mg/dL has been reconsidered because

A.) It leads to an increased requirement for insulin therapy
B.) It has no impact on patient outcomes
C.) It is associated with increased mortality and hypoglycemia
D.) It increases the risk of hyperglycemia

Answer 2

C.) It is associated w/ increased mortality and hypoglycemia

Question 3

Sick euthyroid syndrome in critically ill patients is characterized by

A.) Elevated levels of serum triiodothyronine (T3) and thyroxine (T4)
B.) Predominantly increased thyroid-stimulating hormone (TSH) levels
C.) A significant depression of serum triiodothyronine (T3) levels across all stages
D.) Improvement with thyroid hormone replacement therapy

Answer 3

C.) A significant depression of serum triiodothyronine (T3)

Question 4

A patient in the ICU is diagnosed with relative adrenal insufficiency. Which of the following is the most likely cause?

A.) Impaired cortisol response at the tissue level due to sepsis
B.) Baseline plasma cortisol level above 25 µg/mL
C.) Overproduction of ACTH
D.) Hyperresponsiveness of the adrenal gland to ACTH

Answer 4

A.) Impaired cortisol response at the tissue level due to sepsis

Question 5

Acute renal dysfunction (AKI) in ICU patients is most closely associated with

A.) Hypoalbuminemia, respiratory alkalosis, and decreased dietary protein intake, which reduce kidney function and increase AKI risk.
B.) Hypotension, sepsis, and nephrotoxic agents
C.) Metabolic acidosis, mild hypoxemia, and reduced urine output due to fluid restriction, which lead to progressive kidney damage in ICU patients
D.) Hyperglycemia, electrolyte imbalances, and prolonged fasting, which directly impair renal perfusion and function

Answer 5

B.) Hypotension, sepsis, and nephrotoxic agents

Question 6

A 40-year-old male is admitted to the emergency department following a high-impact fall. He presents with severe hemorrhagic shock and a systolic blood pressure of 70 mm Hg. How could tranexamic acid be used in this scenario?

A.) Administer 2 g IV as a single dose
B.) Administer 1g IV over 10 minutes, then 1 g infusion over 8 hours
C.) Administer only after confirming fibrinolysis on thromboelastography
D.) Tranexamic acid is contraindicated in this scenario

Answer 6

B.) Administer 1g IV over 10 minutes, then 1 g infusion over 8 hours

Question 7

A 45-year-old female patient is undergoing an emergency laparotomy because of a ruptured ectopic pregnancy. During the procedure, she experiences substantial blood loss. What is the most likely complication arising from this scenario, and what is the recommended initial management strategy?

A.) Hemorrhagic coagulopathy; massive transfusion protocol
B.) Heparin-induced thrombocytopenia; administration of direct thrombin inhibitors
C.) Thrombocytopenia; platelet transfusion
D.) Hypercoaguable-state; administration of anticoagulants

Answer 7

A.) Hemorrhagic coagulopathy; massive transfusion protocol

Question 8

Fulminant hepatic failure in a patient can lead to

A.) Improvement in liver function over a short period
B.) Decreased intracranial pressure (ICP) and cerebral edema
C.) Multisystem organ dysfunction culminating in death
D.) Increased hepatic synthetic function and coagulopathy

Answer 8

C.) Multisystem organ dysfunction culminating in death

Question 9

In managing pain in critically ill ICU patients, which of the following is a significant consequence of unrelieved pain?

A.) Enhanced wound healing and decreased infection risk
B.) Improved tissue perfusion and oxygen delivery
C.) Catabolic hypermetabolism causing hyperglycemia and muscle wasting
D.) Decreased levels of catecholamines

Answer 9

C.) Catabolic hypermetabolism causing hyperglycemia and muscle wasting

Question 10

A 60-year-old male, who has a history of chronic kidney disease, has been admitted to the ICU after undergoing major abdominal surgery. Postoperatively, he exhibits oliguria and a notable elevation in serum creatinine levels. What is the most likely diagnosis based on these findings, and what are the key elements of the initial management approach?

A.) Acute kidney injury; optimization of hemodynamics and avoidance of nephrotoxic agents
B.) Urinary tract obstruction; surgical intervention
C.) Prerenal azotemia; fluid resuscitation
D.) Chronic kidney disease exacerbation; immediate initiation of dialysis

Answer 10

A.) Acute kidney injury; optimization of hemodynamics and avoidance of nephrotoxic agents

Question 11

A 65-year-old patient with a history of ischemic heart disease is scheduled for elective surgery. During the preoperative evaluation, which of the following factors would most significantly increase the patient’s risk of perioperative myocardial ischemia?

A.) Mild systemic hypertension
B.) Smoking cessation 6 months prior
C.) History of silent myocardial ischemia
D.) Ability to climb two flights of stairs without symptoms

Answer 11

C.) History of silent myocardial ischemia

Question 12

A patient with a history of coronary artery disease is undergoing elective surgery. To minimize the risk of stent thrombosis, perioperative management should prioritize

A.) Stopping aspirin and clopidogrel five days prior and resume both agents only once surgical healing is complete to prevent stent thrombosis postoperatively
B.) Continuing aspirin if dual antiplatelet therapy (DAPT) is stopped
C.) Switching to a low-dose heparin infusion in place of aspirin to maintain anticoagulation without the bleeding risks of antiplatelet therapy
D.) Discontinuing all antiplatelet therapy one week before surgery to prevent bleeding complications and allow complete recovery of platelet function

Answer 12

B.) Continuing aspirin if dual antiplatelet therapy (DAPT) is stopped

Question 13

Which of the following best describes the pathophysiology of stable angina pectoris in a patient with ischemic heart disease?

A.) Diffuse atherosclerotic disease with less than 50% stenosis, resulting in reduced blood flow at rest and during exertion
B.) Complete occlusion of a major coronary artery segment, leading to constant ischemia and unrelenting chest pain
C.) Temporary coronary artery vasospasm without structural narrowing, causing unpredictable episodes of chest pain
D.) Partial occlusion or significant (>70%) narrowing of a segment of coronary artery

Answer 13

D.) Partial occlusion or significant (>70%) narrowing of a segment of coronary artery

Question 14

A 70-year-old patient with ischemic heart disease presents with an acute myocardial infarction (AMI). Which of the following is the most likely underlying pathophysiological process?

A.) Coronary artery spasm without any atherosclerotic involvement
B.) Ruptured atherosclerotic plaque w/ subsequent thrombus rupture
C.) Gradual occlusion of a coronary artery by stable atherosclerotic plaque
D.) Isolated microvascular dysfunction causing impaired myocardial perfusion

Answer 14

B.) Ruptured atherosclerotic plaque w/ subsequent thrombus rupture

Question 15

During an ischemic episode in a patient with IHD, which of the following ECG changes is most characteristic of subendocardial ischemia?

A.) ST segment elevation in all leads, irrespective of the ischemic area
B.) Prolonged QT interval occurring without any associated chest pain
C.) Diffuse T wave inversion that persists long after symptom resolution
D.) ST segment depression in the area of ischemia that coincides with the timing of chest pain

Answer 15

D.) ST segment depression in the area of ischemia that coincides with the timing of chest pain

Question 16

In a patient with ischemic heart disease undergoing noncardiac surgery, which of the following strategies is recommended to minimize the risk of stent thrombosis?

A.) Avoidance of ß Blockers in the perioperative period
B.) Routine discontinuation of aspirin before surgery
C.) Immediate postoperative resumption of dual anti-platelet therapy
D.) Systematic preoperative coronary revascularization

Answer 16

C.) Immediate postoperative resumption of dual anti-platelet therapy

Question 17

A patient presents with severe chest pain and is diagnosed with STEMI. The most likely underlying cause of this presentation is

A.) Progressive narrowing of the coronary artery over time
B.) Hypertrophic cardiomyopathy leading to obstruction of the left ventricular outflow tract
C.) Rupture of an atherosclerotic plaque with subsequent thrombus formation
D.) Coronary artery spasm

Answer 17

C.) Rupture of an atherosclerotic plaque with subsequent thrombus formation

Question 18

In managing a patient with ischemic heart disease and acute myocardial infarction, the use of which medication is most directly associated with a reduction in mortality?

A.) Calcium channel blockers
B.) ACE inhibitors
C.) Diuretics
D.) Beta blockers

Answer 18

D.) Beta blockers

*ChatGPT answer: Antiplatelet agents (like aspirin) are also critical in the acute setting and have been more directly associated with reducing mortality in acute myocardial infarction

Question 19

A 60-year-old patient with a history of ischemic heart disease is scheduled for a high-risk surgical procedure. In the perioperative period, which of the following factors is the most significant predictor of perioperative myocardial infarction (PMI)?

A.) Presence of ST-segment elevation in preoperative ECG
B.) Prior history of percutaneous coronary intervention with stent placement
C.) Inability to climb more than a flight of stairs without symptoms
D.) Elevated preoperative levels of cardiac-specific troponins

Answer 19

D.) Elevated preoperative levels of cardiac-specific troponins

Question 20

In the management of a patient with unstable angina/NSTEMI, which of the following diagnostic tools is most effective in confirming the diagnosis?

A.) Elevated levels of cardiac-specific troponin’s is key diagnostic criteria in NSTEMI
B.) Increased levels of serum creatinine as an indicator of cardiac stress
C.) Elevated C-reactive protein to confirm myocardial inflammation
D.) Presence of elevated white blood cell count as a marker of ischemia

Answer 20

A.) Elevated levels of cardiac-specific troponin’s is key diagnostic criteria in NSTEMI

Question 21

A patient undergoing surgery develops signs of shock with a low cardiac index and vasoconstriction. Blood lactate levels are elevated. This scenario is most indicative of

A.) Hypodynamic shock
B.) Cardiogenic shock
C.) Hypovolemic shock
D.) Septic shock

Answer 21

A.) Hypodynamic shock

Question 22

In a patient with suspected pericardial tamponade developing shock, the most likely type of shock is

A.) Distributive shock
B.) Hypovolemic shock
C.) Obstructive shock
D.) Cardiogenic shock

Answer 22

C.) Obstructive shock

Question 23

In a patient experiencing massive blood loss during surgery, which of the following is the most appropriate initial management for coagulopathy?

A.) Administration of albumin
B.) Infusion of crystalloid solutions
C.) Use of heparin
D.) Administration of FFP

Answer 23

D.) Administration of FFP

Question 24

For a trauma patient with severe hemorrhagic shock and evidence of fibrinolysis on thromboelastography, the most appropriate intervention is

A.) Immediate use of prothrombin complex concentrates (PCCs)
B.) Administration of recombinant human coagulation factor VIIa (rFVIIa)
C.) High-dose vitamin K administration
D.) Intravenous tranexamic acid

Answer 24

D.) Intravenous tranexamic acid

Question 25

A patient undergoing surgery experiences coagulopathy due to massive blood loss. The primary reason for administering fresh frozen plasma (FFP) in this scenario is to

A.) Increase blood pressure by expanding plasma volume significantly
B.) Replace all clotting factors
C.) Reduce platelet count to counteract excessive clotting
D.) Restore electrolyte levels to maintain cellular function

Answer 25

B.) Replace all clotting factors

Question 26

In a patient with heparin-induced thrombocytopenia (HIT) experiencing bleeding, the administration of platelets is

A.) Avoided d/t the risk of exacerbation of the prothrombotic state
B.) Recommended to rapidly improve platelet count and reduce bleeding risk
C.) Avoided because platelets are ineffective in treating thrombocytopenia in HIT
D.) Administered with heparin to counteract the bleeding more effectively

Answer 26

A.) Avoided d/t the risk of exacerbation of the prothrombotic state

Question 27

A patient reports anginal chest pain during exercise. The ECG demonstrates ST-segment depression and transient symmetric T-wave inversion. These findings are most indicative of

A.) Transmural ischemia
B.) Subendocardial ischemia
C.) Vasospastic angina
D.) Pericarditis

Answer 27

B.) Subendocardial ischemia

Question 28

Why is revascularization by PCI or surgery crucial in managing postinfarction ischemia, especially after ST-elevation myocardial infarction (STEMI)?

A.) To immediately restore impaired coronary blood flow and limit myocardial damage
B.) To alleviate symptoms of pericarditis
C.) To prevent ventricular remodeling and heart failure
D.) To directly correct cardiac dysrhythmias

Answer 28

A.) To immediately restore impaired coronary blood flow and limit myocardial damage

Question 29

What is the primary pathophysiological target of rapid defibrillation in ventricular fibrillation following AMI?

A.) To enhance myocardial oxygenation
B.) To decrease systemic vascular resistance
C.) To alleviate ischemic myocardial pain
D.) To synchronize cardiac electrical activity and restore effective myocardial contraction

Answer 29

D.) To synchronize cardiac electrical activity and restore effective myocardial contraction

Question 30

Why is fluid administration critical in the management of right ventricular infarction?

A.) Reduce RV preload to prevent further myocardial damage
B.) Enhance systemic vascular resistance to support blood pressure
C.) Lower intravascular volume to relieve RV strain and reduce CO
D.) Counteract RV preload and maintain CO

Answer 30

D.) Counteract RV preload and maintain CO

Question 31

What is the primary pathophysiological reason for the high risk of thrombosis following balloon angioplasty without stenting?

A.) Chronic endothelial dysfunction due to atherosclerosis
B.) Immediate allergic reaction to the balloon material
C.) Mechanical vessel injury and delayed reendothelialization
D.) The prolonged systemic inflammatory response

Answer 31

C.) Mechanical vessel injury and delayed reendothelialization

Question 32

Why is there a high risk of major adverse cardiac events (MACE) when surgery is performed within the first 6 weeks after bare-metal stent placement?

A.) High likelihood of vessel rupture from elevated blood pressure alone
B.) Increased plaque formation around the stent due to elevated shear stress
C.) Incomplete reendothelialization of the stented area
D.) Excessive endothelial growth leading to vessel occlusion and ischemia

Answer 32

C.) Incomplete reendothelialization of the stented area

Question 33

What is the primary pathophysiological concern with using neuraxial anesthesia in patients on dual antiplatelet therapy?

A.) Higher likelihood of cerebrospinal fluid infection post-procedure
B.) Spinal hematoma
C.) Higher likelihood of cerebrospinal fluid infection post-procedure
D.) Excessive hypotension from interaction with antiplatelet medications

Answer 33

B.) Spinal hematoma

Question 34

How does the duration of direct laryngoscopy during tracheal intubation impact patients with ischemic heart disease?

A.) It influences the risk of bronchial aspiration
B.) It modulates sympathetic nervous system activation and myocardial oxygen demand
C.) It affects the incidence of airway injuries
D.) It alters the likelihood of reflex laryngospasm

Answer 34

B.) It modulates sympathetic nervous system activation and myocardial oxygen demand

Question 35

What is the primary pathophysiological effect of using volatile anesthetics in patients with ischemic heart disease?
A.) Decrease myocardial oxygen requirements
B.) Increase coronary blood flow to ischemic regions by dilating coronary arteries selectively
C.) Enhance myocardial contractility to improve cardiac output and maintain coronary perfusion
D.) Stimulate sympathetic nervous system activity to increase coronary perfusion pressure

Answer 35

A.) Decrease myocardial oxygen requirements

Question 36

What is the pathophysiological basis for using inotropic drugs to manage hypotension in patients experiencing myocardial ischemia?
A.) To directly dilate coronary arteries and increase oxygen delivery to ischemic regions without increasing heart workload
B.) To reduce myocardial oxygen consumption by decreasing ventricular wall tension and minimizing oxygen demand in ischemic tissue
C.) To restore coronary perfusion pressure
D.) To enhance parasympathetic activity and reduce heart rate, allowing more time for coronary artery filling during diastole

Answer 36

C.) To restore coronary perfusion pressure

Question 37

What is the pathophysiological reasoning for administering β blockers or calcium channel blockers during recovery from anesthesia in patients with ischemic heart disease?

A.) To counteract postoperative respiratory complications
B.) To regulate hemodynamic stress and myocardial oxygen consumption
C.) For effective postoperative analgesia
D.) To mitigate postoperative gastrointestinal disturbances

Answer 37

B.) To regulate hemodynamic stress and myocardial oxygen consumption

Question 38

In heart transplant recipients, why does the transplanted heart exhibit a blunted response to autonomic stimuli such as light anesthesia or intense pain?

A.) The transplanted heart has enhanced vagal tone, which predominates and prevents an increase in heart rate during autonomic stimulation
B.) The transplanted heart has no sympathetic, parasympathetic, or sensory innervation initially
C.) The transplanted heart has increased sensitivity to circulating catecholamines, which counterbalances the effects of autonomic stimuli
D.) The transplanted heart is desensitized to all hormonal signals, including catecholamines, resulting in a stable heart rate regardless of external stimuli

Answer 38

B.) The transplanted heart has no sympathetic, parasympathetic, or sensory innervation initially