UWORLD

Question 1

mechanism of dipyridamole/adenosine in inducing ischemia during chemical stress test

Answer 1

increase coronary blood flow (coronary steal)

Question 2

MCC of mitral regurgitation in US and mechanism

Answer 2

MVP (myxomatous degeneration of mitral valve leaflets)

Question 3

aortic dissection -> SOB…mechanism?

Answer 3

aortic regurg leading to pulmonary edema

Question 4

substernal chest pain often occuring at night, not associated with activity, transient ST segment elevations on ECG…diagnosis and treatment

Answer 4

variant/Prinzmental angina…usu. occurs without significant cardiac risk factors except smoking (treat with CCBs like dilttiazem and verapamil and nitrates)…prevents coronary vasospasm

Question 5

sinus tachycardia + electric alternans on ECG (variation in QRS amplitude)

Answer 5

pericardial effusion/tamponade, treat with pericardiocentesis

Question 6

COPD + cor pulmonale mechanism

Answer 6

COPD will cause pulmonary hypertension leading to >right ventricluar heart failure -> edema…DIAGNOSE with elevated pulmonary artery systolic pressure

Question 7

aortic stenosis in young patient, no hx of infection

Answer 7

bicuspid aortic valve (may present with S4 and symptoms of heart failure)

in older patients, MCC cause of aortic stenosis is senile calcifications in aortic valve
other common cause is rheumatic heart disease

Question 8

What meds have been shown to reduce all cause mortality in patients with LV systolic heart failure?

Answer 8

ACE inihbitors/ARBs
mineralcorticoid receptor antagonists (spironolactone and eplerenone eplerenone eplerenone epleronone), and (combo nitrates/hydralazine) in african american patients

Question 9

wide pulse pressure, increased awareness of heartbeat when lying on left side, “water hammer” Corrigan pulse

Answer 9

aortic regurgitation

Question 10

physical findings that typically present with aortic stenosis

Answer 10

systolic murmur best heard at right intercostal space (early peaking = early/mild AS, late peaking = severe AS)
diminished carotid pulse
soft S2 (since aortic valve is already narrowed and closing of the valve won't be as loud)

Question 11

3-5 days post MI, acute SOB, hypotension, new soft systolic murmur heard at apex, acute pulmonary edema

Answer 11

papillary muscle rupture causing acute mitral regurgitation

Question 12

3-4 days post MI, acute chest pain, SOB, hypotension, new holosystolic murmur best heard at right sternal border accompanied by thrill

Answer 12

intraventricular septal rupture involving LAD/RCA

Question 13

what to do if HDS patient with aortic dissection + pericardial effusion

Answer 13

CT angiography to confirm diagnosis then surgery

TTE if patient is not HDS

Question 14

wide complex tachycardia with fusion beats, HDS patient vs non HDS (AMS,, hypotension, ischemic chest pain)

Answer 14

sustained monomorphic vtach…
HDS -> amiodarone
non HDS -> urgent synchronized cardioversion

Question 15

STEMI leads 2-3 AVF, develops hypotension after administration of nitrates, with cold extremities, no JVD and clear lungs

Answer 15

right ventricular MI which leads to impaired RV filling…so giving nitrates will abruptly decrase preload in RV leading to profound hypotension (cardiogenic shock)….manage with giving fluids to increase RV preload and improve cardiac output

Question 16

anti ischemic mechanism of nitrates

Answer 16

systemic vasodilation -> decrases left ventricular end diastolic volume -> decreased wall stress and myocardial oxygen demand

Question 17

unexplained CHF symptoms (usu. diastolic), increased ventricular wall thickness with normal ventricular wall cavity (usu. without HTN), proteinuria/nephrotic syndrome, easy bruisability, easy bleeding, peripheral neuropathy,

Answer 17

amyloidosis

Question 18

side effect of Ca channel blockers

Answer 18

peripheral edema

Question 19

Indications for carotid endarterectomy

Answer 19

symptomatic carotid artery stenosis of 70-99%

60-99% without symptoms

Question 20

WPW in afib, how to manage?

Answer 20

HDS - rhythm control with IV ibutilide or PROCAINAMIDE

not HDS - electrical cardioversion

Question 21

progressive peripheral edema, elevated JVP, hepatomegaly, ascites post radiation

Answer 21

constrictive pericarditis

Question 22

Which cardiac medication can cause fatigue, memory loss, dry skin, weight gain, AND HEPATOCELLULAR INURY (thyroid plus liver injury plus pulmonary symptoms)

Answer 22

amiodarone

Question 23

post STEMI and cath, patient develops leg pain (COLD AND NO SWELLING….”mottled” appearance)…what to do

Answer 23

acute limb ischemia! probably from LV thrombus, afib, or aortic athersclerosis
immediate anticoag and TTE to check for LV thrombus!

Question 24

how to lower risk of CCB associated peripheral edema

Answer 24

add on an ACE/ARB!

Question 25

fixed splitting S2 (name defect)

Answer 25

atrial septal defect, can also be associated with midsystolic pulmoary flow murmur

Question 26

pulsus paradoxus

Answer 26

fall in systemic arterial pressure by more than 10 during inspiration, cardiac tamponade

Question 27

pulsus parvus and pulsus tardues

Answer 27

decreased pulse amplitude/delayed pulse upstroke

aortic STENOSIS

Question 28

bounding pulse

Answer 28

aka “water hammer pulse”
AORTIC REGURG
since AR is assoc with increase stroke volume

Question 29

new onset narrow complex tachy, disappearance of P waves…dx and what to do next

Answer 29

probably SVT
now figure out what type of SVT by carotid massage/ vagal maneuvers or IV AMIODARONE to unmask hidden P waves or clarify atrial flutter/atrial tach

IV adenosine increases AV nodal conduction delay and can cause transient block in AVnode…can also terminate paroxysmal vts by interuppting AV reentry circuit

Question 30

patient with PAD + claudication is higher risk for developing what in the next 5 years?

Answer 30

nonfatal myocardial infarction and stroke or death to cardio causes

Question 31

sudden onset tearing chest pain radiating to back, perfusion deficit, decresendo diastolic murmur best heard right sternal border…dx and test?

Answer 31

acute aortic dissection

confirm with TEE or Ct angiography if patient is stable and doesn’t have renal failure/contrast contraindication

Question 32

hypotension, JVD, muffled heart sounds

Answer 32

BECK’S TRIAD

think cardiac tamponade (happens with fluid surrounding heart ->decreased preload, stroke volume, and CO)

Question 33

initial treatment for PAD with intermittent claudication

Answer 33

low dose aspirin, statin, and EXERCISE THERAPY

if exercise therapy fails, consider surgical revascularization

Question 34

long term treatment for post NSTEMI

Answer 34

DUAL ANTIPLATELET with ASA and Py12 blocker
/eplereonenespirinolactone(aldosterone antagonist)
statin
beta blocker

Question 35

squeezing chest pain, holysystolic murmur at apex, ST segment elevations in 2,3 avf, bibasilar crackles….

Answer 35

increased left ventricular filling pressure

happens because MI causes papillary muscle displacement leading to ACUTE MR

chronic MR will increase left atrial size

Question 36

low grade fever, malaise, reddish brown lesions under nail beds, new aortic regurg, recent dental procedure…what to do next?

Answer 36

INFECTIVE ENDOCARDITIS!
obtain serial blood cultures first!!!!
then antibiotics, then echo

Question 37

side effects of amiodarone

Answer 37

cardiac - sympomatic brady, heart block
eye - microdeposits, optic neuropathy (loss of peripheral vision)
hyper/hypothyroidism (ALWAYS ESTABLISH TSH BEFORE STARTING)
INTERSTITIAL PNEUMONITIS, will have SOB and ground glass opacities…GET BASELINE CHEST RADIOGRAPH AND PFT
transaminitis/hepatitis
blue gray skin discoloration

Question 38

recurrent HTN, diffuse athersclerosis, periumbilical bruit, elevated HTN >180 sometimes with maxed out BP meds

Answer 38

renovascular kidney disease causing secondary HTN

Question 39

sudden onset left sided chest pain, anxiety, HTN, dilated pupils, nasal mucosa atrophic, normal cardiac exam, ST segment depression, negative CK/trop…what to do next

Answer 39

cocaine!!!!!!!

give O2 and benzos (diazepam for example)

Question 40

cardiac complication of TB

Answer 40

constrictive pericarditis
fatigue, DOE, pericardial knock, pulsus paradoxus, increased JVP, peripheral edema/ascities, pericardial thickening and calcificaiton

Question 41

management of HDS patient with torsades (recurrent)

Answer 41

iv mag

Question 42

atherosclerotic risk factors, hx of TIA, fluctuating symptoms, stuttering with periods of improvement…

Answer 42

thrombotic stroke

Question 43

hx of cardiac disease (afib, endocard, carotid athero), onset of symptoms abrupt and maximal at start, multiple infarcts within different vascular territories

Answer 43

embolic stroke

Question 44

hx of uncontrolled HTN, drug use, coagulopathy, progressive symptoms over minutes-hours, focal neurologic symptoms then symptoms of increased ICP (vomiting, headache)

Answer 44

intracerbral hemhorrage

Question 45

rupture of AVM, sudden severe headache at onset of neurlgical symptoms, meningeal symptoms/neck stiffness, usually no focal deficits

Answer 45

subarachnoid hemhorrage

Question 46

few weeks after MI, patient presents with chest pain worsened with breathing and better with leaning forward, fever, malaise, elevated ESR, diffuse ST elevations,

Answer 46

Dressler’s syndrome post MI…terat with NSAIDS

Question 47

how to treat HTN and benign essential tremor

Answer 47

beta blocker!

Question 48

what heart findings can you hear in early ACS?

Answer 48

s4 due to decreasing ventricular compliance due to ischemia

Question 49

how to improve worsen mobitz type 1 and 2

Answer 49

mobitz type 1 - improves with exercise/atropine, worsens with carotid massage/vagal maneuvers
mobitz type 2 - worsened by atropine/exercise, improved with carotid (high risk to develop into type II or complete heart block…indication for pacemaker)

Question 50

management of first degree heart block (prolonged PR interval) with normal/prolonged QRS

Answer 50

normal QRS - no further management, benign (due to delayed AV nodalconduction)
rpolonged QRS - likely due to conduction delay below AV and warrants electrophysiology

Question 51

systolic-diastolic abdoinal bruit, unexplained rise in Cr after starting ACE/ARB, asymmetric renal size

Answer 51

renovascular idsease

Question 52

post MI complication that happens past 5 days…shock, JVD

Answer 52

free wall rupture leading to cardiac tamponade

Question 53

which meds to hold 48 hrs before stress testing

Answer 53

beta blockers, CCBs, and nitrates (can continue ACE, ARBS, statins, diuretics)…unless patient has known hx of cardiac disease

Question 54

knife/trauma injury, patient then begins to develop heart failure symptoms (displaced PMI), systolic flow murmur, increased flushing

Answer 54

high output cardiac failure due to arteriovenous fistula from knife wound

Question 55

how to go from HTN urgency to emergency

Answer 55

urgency (>180/120) with or without acute end organ damange
emergency - with malignant HTN (retinal hemhorrages/papilledema, exudates) or HTN encephalopathy (cerebral edema, non localizng neurologic signs like seizures, confusion, restlessness)

Question 56

post MI complications that can occur within hours?

Answer 56

reinfarction
ventricular septal rupture
free wall repture
post infarction angina

Question 57

post MI complications that can occur in days to months

Answer 57

papillary musce rupture (2 days to week)
pericarditis ( Month)
ventricular aneurysm (5-months)

Question 58

cresendo-decesendo murmur hear at left sternal border without carotid radiation, young well built patient

Answer 58

HOCM murmur