High Yield

Question 1

A young patient presents with CHEST PAIN following a pary where COCAINE was used. What is the TEST/THERAPY?

Answer 1

ECHO/CALCIUM CHANNEL BLOCKER (DO NOT use ß-blocker)

Question 2

TREATMENT for acute PE?

Answer 2

UFH or LMWH

Question 3

How do you TREAT TAKOTSUBO CARDIOMYOPATHY (stress-induced)?

Answer 3

ß-BLOCKER, ACE-I

Question 4

YOUNG man, SUBSTERNAL CHEST PAIN, deep T-WAVE INVERSIONS V₂-V₄ and a HARSH SYSTOLIC MURMUR that INCREASES with the VALSALVA MANEUVER?

Answer 4

Hypertrophic Cardiomyopathy (HCM) - DIAGNOSE with ECHO and TREAT with ß-BLOCKER

Question 5

Nonspecific ECG CHANGES, ST-DEPRESSION, T-WAVE INVERION with NORMAL CARDIAC BIOMARKERS?

Answer 5

ACS - UNSTABLE ANGIA (when there are POSITIVE BIOMARKERS - ACS - NSTEMI)

Question 6

POSITIVE CARDIAC BIOMARKERS, TALL R-WAVES and ST-DEPRESSION in V₁-V₃?

Answer 6

POSTERIOR WALL MI

Question 7

ST-ELEVATION in leads II, III, aVF?

Answer 7

INFERIOR WALL MI

Question 8

ST-ELEVATION in leads V₁-V₃?

Answer 8

ANTEROSEPTAL MI

Question 9

ST-ELEVATION in leads V₄-V₆, possibly leads I and aVL?

Answer 9

LATERAL and APICAL MI

Question 10

ST-ELEVATION V₄R-V₆R, TALL R-WAVES in V₁-V₃?

Answer 10

RIGHT VENTRICLE MI

Question 11

A patient with UNSTABLE ANGINA or NSTEMI presents with HEMODYNAMIC INSTABILITY, HF, RECURRENT ANGINA while at REST in spite of MEDICAL THERAPY, NEW or WORSENING MR MURMUR, SUSTAINED VT. What is the NEXT STEP?

Answer 11

IMMEDIATE ANGIOGRAPHY (otherwise, if these are not present, risk stratify according to TIMI 0-2 vs 3-7)

TIMI 0-2 (low): ASA, ß-BLOCKER, NITRATES, HEPARIN, STATIN, CLOPIDOGREL, STRESS TESTING before discharge

TIMI 3-7 (intermediate to high): ASA, ß-BLOCKER, NITRATES, HEPARIN, STATIN, CLOPIDOGREL, ANGIOGRAPHY

Question 12

In a patient with a POST-MI STRESS TEST results demonstrating EXERCISE-INDUCED ST-DEPRESSION or ELEVATION, inability to achieve 5 METs during testing, inability to increase SBP by 10-30 mm Hg or inability to exercise due to ARTHRITIS, what should be done NEXT?

Answer 12

CARDIAC CATHETERIZATION

Question 13

A patient presents with STEMI, what should be deone NEXT?

Answer 13

CARDIAC ANGIOGRAPHY

Question 14

ASPIRIN, CLOPIDOGREL, ß-BLOCKER, ACE-I, ANTICOAGULANT (UFH, LMWH, bivalirudin) and HIGH-INTENSITY STATIN should ALL be given to WHOM?

Answer 14

ALL patients with ACS (STEMI, NSTEMI, UNSTABLE ANGINA)

Question 15

These drugs should be given to ALL patients 3-14 DAYS POST-MI if LVEF ≤40% and have clinical HF or DM?

Answer 15

SPIRONOLACTONE or EPLERENONE

Question 16

A patient with a STEMI either FAILS PCI therapy or experiences MECHANICAL COMPLICATIONS (PAPILLARY muscle rupture, VSD or FREE WALL RUPTURE), what should be done NEXT?

Answer 16

CABG

Question 17

A patient presents with ST-ELEVATION V₄R-V₆R, TALL R-WAVES in V₁-V₃ and has JVD with CLEAR LUNGS, HYPOTENSION and TACHYCARDIA, what is this and HOW do you TREAT?

Answer 17

RIGHT VENTRICULAR INFARCTION - TREAT with IV FLUIDS (will worsen hypotension with nitroglycerin or morphine)

Question 18

A patient presents with CARDIOGENIC SHOCK, ACUTE MITRAL REGURGITATION or VSD, INTRACTABLE VT or REFRACTORY ANGINA. Wat can be done BEFORE SURGERY for ACUTE TREATMENT?

Answer 18

INTRA-AORTIC BALLOON PUMP or LVAD

Question 19

Is RANOLAZINE used in the TREATMENT of ACS?

Answer 19

NO!!

Question 20

A patient s/p ACUTE MI develops SYMPTOMATIC BRADYCARDIA or COMPLETE HEART BLOCK, what can be done for treatment?

Answer 20

TEMPORARY PACING

Question 21

A patient s/p ACUTE MI 2-7 DAYS AGO presents with ABRUPT PULMONARY EDEMA or HYPOTENSION with a LOUD HOLOSYSTOLIC MURMUR and THRILL, what is suspected and how is this DIAGNOSED?

Answer 21

VSD or PAPILLARY MUSCLE RUPTURE - DIAGNOSE with ECHO - TREAT with STABILIZATION (IABP, sodium NITROPRUSSIDE and DIURETICS) then CABG

Question 22

A POST-MI patient presents >40 DAYS since the MI and >3 MONTHS since PCI or CABG with LVEF ≤35% and NYHA CLASS II or III or LVEF ≤30% and NYHA CLASS I symptoms, what is the TREATMENT?

Answer 22

AICD

Question 23

58 yo man presents with ACUTE CHEST PAIN, ST-ELEVATION in leads II, III and aVF, BP is 82/52 mm Hg and a pulse rate of 54/min. Physical exam shows JVD with CLEAR LUNGS and NO MURMUR OR S3. WHAT is the DIAGNOSIS and how do you TREAT?

Answer 23

DIAGNOSIS: RV MI

TREATMENT: IVF, CARDIAC CATHETERIZATION

Question 24

In a patient with SYMPTOMS of STABLE ANGINA (chest pain on exertion and relieved by rest) with an INTERMEDIATE pretest probability of CAD (10%-90%) who CAN EXERCISE but has an ABNORMAL ECG (pre-excitation WPW, >1 mm ST-DEPRESSION, LV HYPERTROPHY) or has had PREVIOUS PCI or CABG or is using DIGOXIN, what should be done NEXT?

Answer 24

EXERCISE ECG STRESS TEST with MYOCARDIAL PERFUSION IMAGING or EXERCISE ECHO

Question 25

In a patient with **SYMPTOMS** of **STABLE ANGINA** (chest pain on exertion and relieved by rest) with an **INTERMEDIATE** pretest probability of **CAD** (**10%**-**90%**) who **CANNOT EXERCISE** and has a **PACED RHYTHM** or **LBBB**, what should be done **NEXT**?

Answer 25

**PHARMACOLOGIC STRESS MYOCARDIAL PERFUSION IMAGING** or **DOBUTAMINE ECHO**

Question 26

In a patient with **STABLE ANGINA** but **HIGH PRETEST PROBABILITY** of **CAD** (**\>90%**) **OR** with **LV DYSFUNCTION**, **HIGHLY**-**POSITIVE** **STRESS TEST** or **LEFT MAIN** or **3 VESSEL CAD** (DUKE ≤-11), what should be sone **NEXT**?

Answer 26

**CORONARY ANGIOGRAPHY**

Question 27

In a patient with **STABLE ANGINA** found to have **LBBB** on **ECG**, who requires a **STRESS TEST** because their **PRETEST PROBABILITY** for **CAD** was between **10%**-**90%** and who **CAN EXERCISE**, what **STRESS TEST** is **APPROPRIATE**?

Answer 27

**STRESS ECHO** or **VASODIALATOR STRESS PERFUSION IMAGING** (adenosine, dipyridamole, regadenoson) - **DO NOT** use **EXERCISE** in these patients

Question 28

What are the **FOUR** (**4**) **MAJOR** medication classes for **STABLE ANGINA**?

Answer 28

1. **ß**-**BLOCKERS**, 2. **NITRATES**, 3. **CALCIUM CHANNEL BLOCKERS** (only after the first two are maximized and pt is still symptomatic or they are intolerant of ß-blockers) and 4. **RANOLAZINE** (inhibits late sodium current and is only added after the first three fail to control symptoms)

Question 29

A patient with **SYMPTOMS** of **PAROXYSMAL** **NOCTURNAL** **DYSPNEA**, an **S3**, **DYSPNEA** on **EXERTION** and **CRACKLES** on **PULMONARY AUSCULTATION** most likely has what **DIAGNOSIS**?

Answer 29

**HEART FAILURE** (HF)

Question 30

A **BNP** level **ABOVE WHAT**, is compatible with **HF** and **BELOW WHAT** is **NOT HF**?

Answer 30

**BNP \>400** pg/mL is compatible with **HF** **BNP \<100** pg/mL is **NOT HF**

Question 31

In **ALL** patients with **SYMPTOMATIC NYHA** class **II**-**IV** **HF_REF** (NOT HF_PEF) with **EXCESSIVE DAYTIME SLEEPINESS**, what **TEST** should be performed?

Answer 31

**SLEEP STUDY**

Question 32

**HOW** do **KIDNEY FAILURE**, **FEMALE SEX**, **OLDER AGE** and **OBESITY** affect **BNP**?

Answer 32

**Kidney failure, Female Sex** and **Older Age**: **INCREASE BNP** **Obesity**: **DECREASES BNP**

Question 33

**IN** **ADDITION** to **STANDARD** **THERAPY** for **NYHA CLASS II**-**IV** **HF** and **EF \<40%**, what **OTHER MEDS** are benefitial for **BLACK PATIENTS** and those with **LOW OUTPUT** or **HYPOTENSION** or who **CANNOT TOLERATE** **ACE**-**I**/**ARBs** to **REDUCE MORTALITY**?

Answer 33

**HYDRALAZINE** **+** **NITRATES**

Question 34

Patients with **HF_REF** (**EF \<35%**), in **SINUS RHYTHM** with **HR ≥70**/**min** should get what **AGENT**?

Answer 34

**IVABRADINE**

Question 35

In patients with **HF_REF** who **ARE** or **HAVE BEEN** on an **ACE**-**I** or **ARB** and are **NYHA CLASS II**-**III**, should get their **ACE**-**I** or **ARB SUBSTITUTED** with what **AGENT**?

Answer 35

**VALSARTAN**-**SACUBITRIL**

Question 36

What should be **DONE** with **NSAIDs** and **THIAZOLIDINEDIONES** (**GLITAZONES**) in patients with **HF**?

Answer 36

**DISCONTINUED** (these worsen HF)

Question 37

Which **CALCIUM CHANNEL BLOCKERS** are **HARMFUL** in patients with **HF**?

Answer 37

**NONDIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS** (**VERAPAMIL**, **DILTIAEM**)

Question 38

When a patient presents with **SYMPTOMS** of **HF** and **ECHO** reveals an **EF \>50%** without significant valvular abnormalities, what is the diagnosis?

Answer 38

**HF_PEF**

Question 39

What are the **TREATMENT** **GOALS** in **HF_PEF**?

Answer 39

Treat any underlying **HTN**, **A**-**FIB** and optimize diastolic filling by treating tachycardia and volume overload with **DIURETICS**

Question 40

In **DRUG**-**INDUCED** (**COCAINE**, **AMPHETAMINES**) **CARDIOMYOPATHY**, what is the **PREFERRED** **ß**-**BLOCKER** for treatment?

Answer 40

**LABETALOL** (because it has **alpha**-**blocker** **activity** as well)

Question 41

In **GIANT**-**CELL** **MYOCARDITIS** (biventricular enlargement, refractory ventricular arrhythmias, cardiogenic shock, multinucleated giant cells on myocardial biopsy), what is the **TREATMENT**?

Answer 41

**IMMUNOSUPPRESSANT** **TREATMENT** and **LVAD**/**CARDIAC TRANSPLANT**

Question 42

In **PREGNANT WOMEN** with **LVEF** **\<45%** due to **PERIPARTUM CARDIOMYOPATHY** (**1 MONTH BEFORE** delivery up to **5 MONTHS AFTER** delivery) what **THERAPY** should be started if **EF ≤35%** and what should they be **ADVISED** if the **LV DYSFUNCTION** is **PERSISTENT** (**\>6 MONTHS POSTPARTUM**)?

Answer 42

**START WARFARIN if EF ≤35%** **ADVISE AGAINST SUBSEQUENT PREGNANCY** if **PERSISTENT LV DYSFUNCTION**

Question 43

Besides treating the **UNDERLYING CAUSE**, **WHAT** is the **STANDARD** **TREATMENT** for **ACUTE** **MYOCARDITIS** (bacterial, viral, autoimmune), **ALCOHOLIC CARDIOMYOPATHY**, **DRUG**-**INDUCED** **CARDIOMYOPATHY** and **HEMOCHROMATOSIS** **CARDIOMYOPATHY**?

Answer 43

**STANDARD HF TREATMENT**