Week 1 Flashcards
1
Q
Nitrate therapy works by which of the following mechanisms?
A
Reducing both preload and afterload
2
Q
propranolol
A
short acting beta blocker; good for controlling hypertension in setting of aortic dissection
3
Q
Woman + prodrome of nausea, sweating, warmth + syncope:
A
vasovagal
4
Q
aortic and pulmonary valve closure
A
S2
5
Q
nicardipine
A
calcium channel blocker
6
Q
Timolol
A
beta-blocker; Glaucoma
7
Q
A patient presents 2 weeks following a myocardial infarction. He complains of chest pain that improves with leaning forward, fever, and malaise. Vital signs are BP 125/70, HR 105, RR 14, and pulse oxygenation 98% on room air. Lab results reveal a leukocytosis and negative troponin. ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?
A
Dressler’s syndrome or postcardiotomy pericarditis is due to an inflammatory reaction to transmural myocardial necrosis.
*May hear a friction rub on exam**
tx: NSAIDs, colchicine, and steroids
8
Q
Which of the following conditions would most likely result in right axis deviation on an ECG?
Aortic valve stenosis
Chronic hypertension
Excess abdominal fat
Pulmonary hypertension
A
Pulmonary hypertension
- In pulmonary hypertension, the right side of the heart must work harder to overcome the increased resistance, or afterload, of the higher pressures in the pulmonary vasculature.
- This results in right ventricular hypertrophy; the direction of depolarization is now in the right axis.
9
Q
A 35-year-old man is evaluated in the emergency department after being the restrained driver in a motor vehicle collision. At presentation, the patient is alert, anxious, and able to verbalize a complaint of chest pain associated with some anterior chest wall bruising. There are no gross deformities on exam. Suddenly, the patient becomes unresponsive. Telemetry shows the rhythm above. No pulse can be palpated. Which of the following is the most appropriate next step in the management of this patient?
rhythm: Pulseless Electrical Activity (PEA)
A
tx: chest compressions
10
Q
Which of the following is the first line treatment for acute pericarditis?
A
NSAID like Ibuprofen or naproxen
11
Q
Which of the following diseases is characterized by the presence of a delta wave on an electrocardiogram?
A
Wolff-Parkinson-White
The bundle of Kent.
tx: radiofrequency ablation
12
Q
Malignancy + sudden onset SOB + syncope:
A
PE (pulmonary embolism)
13
Q
What is the most frequent site of arterial embolism?
A
bifurcation of the common femoral artery.
14
Q
In patients with a myocardial infarction, which three drugs have been shown to decrease mortality?
A
- Aspirin,
- beta-blockers, and
- ACE-inhibitors.
15
Q
A 28-year-old man presents to the emergency department with a one cm laceration to the left forearm. The patient is in good health and has no other complaints. At triage the patient’s blood pressure was noted to be 155/94 mmHg; the remainder of his vital signs are normal. Following repair of the laceration, the patient’s blood pressure is rechecked and is unchanged. What is the best approach to this patient’s elevated blood pressure?
A
Instruct the patient to follow-up with his private physician within two months for recheck; The most common cause of transient hypertension is pain and anxiety.
For diastolic blood pressure greater than or equal to 115 mm Hg, the patient should be evaluated immediately.
16
Q
Which of the following is commonly the first reported symptom of aortic stenosis?
A
Dyspnea
17
Q
A 65-year-old man presents to the ED for chest pain. You are concerned for acute coronary syndrome and want to administer aspirin, but the patient states that he develops angioedema to aspirin. Which of the following is the most appropriate next step in management?
A
Administer clopidogrel in patients with true aspirin allergies, clopidogrel should be substituted for aspirin.
18
Q
A 60-year-old man presents with nighttime dyspnea. His medical history is significant for chronic hypertension. A recent echocardiogram showed an increase in left ventricular chamber volume but normal ventricular wall thickness. Based on this finding alone, which of the following medications is the most appropriate treatment for this patient’s dyspnea?
A
Diagnosis: Dilated cardiomyopathy secondary to chronic hypertension– these indicate likely cardiac failure
Diagnostic test: Echocardiogram
Beta-blockers for heart failure: Bisoprolol Carvedilol Metoprolol
19
Q
verapamil
A
Calcium Channel Blocker; used for hypertension
20
Q
What is the treatment of :
- hemodynamically unstable ventricular tachycardia?
- Stable ventricular tachycardia
A
- Unstable: Electrical cardioversion
- Stable: procainamide, amiodarone (synchronized cardioversion if refractory)
21
Q
mitral and tricuspid valve closure
A
S1
22
Q
Metoprolol
A
Beta-blocker; heart failure
23
Q
When considering the diagnosis of a patient with leg pain and swelling, you determine that the pretest probability of deep vein thrombosis is high. Which of the following is the most appropriate test in confirming this diagnosis?
A
Ultrasound; the diagnostic test for DVT Deep Vein Thrombosis (DVT)
- Patient with a history of smoking, long distance travel, surgery, oral contraceptives use
- Complaining of unilateral leg edema, leg pain, tenderness and warmth PE may show positive Homan’s sign
- Diagnosis is made by first ultrasound, Gold Standard: venography
- Most commonly caused by stasis, hypercoagulable state, trauma (Virchow’s triad)
- Treatment is IV heparin and switch to warfarin
- Comments: Risk stratification by Well’s criteria
24
Q
A patient is being evaluated for palpitations in the emergency department. An ECG reveals a short PR interval, widened QRS and slurred upstroke of the QRS complex. Which of the following is the name of bypass pathway associated with this condition?
A
This is describing a delta wave.
Bundle of Kent (Wolf-Parkinson-White syndrome)
Possible complication: Atrial fibrillation which may lead to ventricular fibrillation
The bundle of Kent is the bypass pathway associated with Wolff-Parkinson-White syndrome, which is the most likely diagnosis in this patient. Wolff-Parkinson-White syndrome is a pattern of pre-excitation on ECG accompanied by a symptomatic tachycardia. It results from an accessory pathway that directly connects the atria and ventricles and bypasses the AV node.
25
(“atrial kick”): Late diastole Blood flowing against noncompliant LV
S4
26
Older male + abdominal/flank pain + syncope
AAA (abdominal aortic aneurysm)
27
A 55-year-old man presents to the emergency department with sub sternal chest pain. He has had three episodes of chest pain with exertion in the past 24 hours. Each has lasted 20–30 min and resolved with rest. His past medical history is significant for hypertension, hyperlipidemia, asthma, and chronic obstructive pulmonary disease. He currently smokes one pack/day of cigarettes. His family history is remarkable for early coronary artery disease in a sibling. Home medications include chlorthalidone, simvastatin, aspirin, albuterol, and home oxygen. In the emergency department, he becomes chest pain–free after receiving three sublingual nitroglycerin tablets. ECG shows 0.8 mm ST-segment depression in V5, V6, lead I and aVL. Cardiac biomarkers are negative. Which aspects of this patient’s history add to the likelihood that he might have death, myocardial infarction (MI), or urgent revascularization in the next 14 days?
Patients with unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) exhibit a wide spectrum of risk of death, MI, or urgent revascularization. Risk stratification tools such as the TIMI risk score are useful for identifying patients who benefit from an early invasive strategy and those who are best suited for a more conservative approach. The TIMI risk score is composed of seven independent risk factors: Age ≥ 65, three or more cardiovascular risk factors, prior stenosis \> 50%, ST-segment deviation ≥ 0.5mm, two or more anginal events in \< 24 h, aspirin usage in the past 7 days, and elevated cardiac markers. **_Aspirin resistance can occur in 5–10% of patients and is more common among those taking lower doses of aspirin. Having unstable angina despite aspirin usage suggests aspirin resistance._**
28
What is the classic auscultatory feature of aortic stenosis?
Crescendo-decrescendo systolic murmur
29
Which of the following can decrease levels of brain natriuretic peptide?
Obesity
30
A patient with palpitations presents to the ED. Her rhythm strip is seen above. Which of the following is the most appropriate initial management?
Rhythm: Torsades de pointes
Magnesium sulfate
* Torsades de pointes is a form of polymorphic ventricular tachycardia. It is characterized by a fluctuating amplitude of the QRS complexes which appear to twist around the isoelectric line.
* Torsades is associated with prolonged QT syndrome, hypokalemia and hypomagnesemia.
* It can deteriorate into ventricular fibrillation.
* Symptoms include palpitations, dizziness, syncope and sudden death.
* Acute management begins with intravenous magnesium.
31
Adolescent athlete + syncope:
HOCM (hypertrophic cardiomyopathy)
32
A 34-year-old man presents to the emergency department with complaints of worsening chest pain, fever, and malaise. The pain is pleuritic, worsens when he lies down and improves when he leans forward. On exam, he appears unwell, but is not in acute distress. Auscultation over the precordium reveals a scratchy, grating sound with a normal S1 and S2. Which of the following is the most likely electrocardiogram finding in this patient?
diagnosis: pericarditis
ekg: ST segment elevation with reciprocal ST depression in leads aVR and V1
33
You are examining an afebrile 78-year-old woman in the emergency department. During cardiac examination, you auscultate a low intensity, low pitch extra heart sound which occurs in early diastole. You do not appreciate any murmurs. Her ECG appears normal. Which of the following is the most likely diagnosis?
* Bacterial endocarditis
* Dilated cardiomyopathy
* Right bundle branch block
* Tricuspid stenosis
Dilated cardiomyopathy
After age 40, the presence of an S3 is usually abnormal, and correlates well with ventricular dysfunction, namely volume overload.
34
Which of the following ECG findings is most characteristic of a premature junctional contraction?
Inverted P’ wave following the QRS
35
A 65-year-old man presents with acute onset of low back pain. His temperature is 98.3°F, blood pressure is 150/90 mm Hg and his heart rate is 110 bpm. Physical examination is notable for equal peripheral pulses in all extremities and a normal neurologic examination. A CT scan is performed which reveals a true and false lumen of the aorta and an intimal flap at the level just below the aortic arch. In addition to pain control, which of the following is the best management strategy?
AGradual return to activity and primary care follow up
BInitiate esmolol drip and obtain vascular surgery consultation
CRecommend outpatient, interval imaging
DStart packed red blood cell transfusion and obtain vascular surgery consultation
BInitiate esmolol drip and obtain vascular surgery consultation
* The patient has a descending aortic dissection.
* The most common symptom in patients presenting with Type B aortic dissection is back pain. Patients are often tachycardic and hypertensive. Unequal pulses in the extremities are actually an uncommon finding.
* The management of aortic dissection rests upon reducing shear stress on the dissection flap in order to reduce the chances of propagation. This is done by reducing heart rate and blood pressure.
* The goal systolic pressure should be 100-120 mm Hg. Agents that can be used are esmolol, labetalol and nitroprusside.
* Vascular surgery should be consulted.
36
A 45-year-old man with a history of paroxysmal atrial fibrillation presents to the ED with acute onset of severe pain and paresthesias in his right calf. On exam, you note lower extremity pallor and an absent dorsalis pedis pulse. Which of the following is the most likely diagnosis?
Arterial thromboembolism
6 P's:
1. Paresthesia
2. Pallor
3. Pulselessness
4. Poikilothermia
5. Paralysis
6. Pain out of proportion to exam
Most arterial thromboemboli originate in the left side of the heart and are frequently associated with a recent myocardial infarction, atrial fibrillation, or valvular abnormalities.
\_\_\_
Arterial Thromboembolism
* Risk factors: recent MI, atrial fibrillation Sudden onset
* 5 Ps: pain, pallor, paresthesias, pulselessness, paralysis, poikilothermia
* Most common source: left heart
* Most common site: femoral artery bifurcation
37
Flecainide
antiarrhythmics
38
What is the preferred treatment of hypotension in the setting of aortic dissection?
What are the preferred agents for control of hypertension in the setting of aortic dissection?
Complaining of sudden "ripping" or "tearing" CP radiating to back CXR will show widened mediastinum PE will show asymmetric pulses/BP
Hypotension: Crystalloids
Hypertension: Negative inotropes; labetalol, esmolol, and propranolol
Diagnosis: CT angiogram
Tx: Type A and complicated type B dissections typically require surgical repair while uncomplicated type B dissections are typically medically managed.
Stanford Type A: Ascending aorta
Standford Type B: Descending aorta
39
A previously healthy 35-year-old woman presents to the emergency department with pleuritic chest pain and malaise. She has been feeling unwell for the past few days with intermittent fever. Her pulse is 87 beats/minute, respiratory rate is 19 breaths/minute, blood pressure is 122/82 mm Hg, and temperature is 37.0°C. On exam, a pericardial friction rub is appreciated. Echocardiography is negative for pericardial effusion. Which of the following is the most appropriate management?
The most appropriate treatment for this patient with acute pericarditis is on an outpatient follow-up and oral naproxen (NSAIDS are first line treatment). Colchicine and corticosteroids are used if refractory.
EKG=thumbprint sign (PR elevation in aVR)
--Viral infections are the most common cause of acute pericarditis in US (worldwide=TB)
\_\_
* Patient will be complaining of pleuritic chest pain radiating to the back that is worse when laying back and improved when leaning forward
* PE will show tachycardia and pericardial friction rub
* ECG will show PR depression, PR elevation (aVR), diffuse ST segment elevation (concave)
* Most commonly caused by Idiopathic then viral (Coxsackie)
40
Muffled heart sounds, hypotension, and jugular venous distention.
Beck’s triad for cardiac tamponade
41
What is the gold standard for diagnosing myocarditis?
Myocardial biopsy.
42
Salmeterol
Long acting beta-2 agonist; Bronchospasm and COPD
43
Enalapril
ACEi; used for high blood pressure
44
A 58-year-old man with chronic hypertension presents to the ED with acute, 10/10 tearing substernal pain that radiates to the back. All you can gather from him is that he also has some type of “collagen disorder” and diabetes. A chest radiograph reveals a widened mediastinum. As you prepare for a transesophageal echocardiogram, you would most likely start which of the following medications as a first-line agent?
Hypertension: Negative inotropes; labetalol, esmolol, and propranolol
Diagnosis: CT angiogram
Tx: Type A and complicated type B dissections typically require surgical repair while uncomplicated type B dissections are typically medically managed.
Stanford Type A: Ascending aorta
Standford Type B: Descending aorta
\_\_\_\_
note: if patient became hypotensive, treat with crystalloids
45
A 65-year-old man presents to the ED with sudden onset of chest pain that began two hours prior to arrival. He has a history of hypertension treated with hydrochlorothiazide, hyperlipidemia treated with simvastatin, erectile dysfunction treated with sildenafil, and takes a daily aspirin. An ECG demonstrates an anterior wall myocardial infarction. Which of the patient’s home medications serves as a contraindication for the use of nitroglycerin to treat this his chest pain?
Sildenafil
46
A 43-year-old man is currently undergoing palliative radiation therapy for pancreatic cancer. He presents to the emergency department with a 4-day history of gradually worsening left lower extremity pain. Pain is localized to the calf and made worse with ambulation. Exam shows mild edema of the left calf without erythema or warmth. Which of the following is the most likely diagnosis?
Deep venous thrombosis
47
A 71-year-old woman presents with 2 days of dizziness and “almost passing out.” Her ECG shows episodes of alternating bradycardia and tachycardia with narrow QRS complexes. Which of the following is the most likely diagnosis?
Sick sinus syndrome
* Sick sinus syndrome occurs as a result of disease of the sinoatrial (SA) node.
* It is associated with tachycardia-bradycardia syndrome in which the sinus rate varies from fast to slow and back again.
* ECG shows an irregular rhythm with pauses in sinus activity.
48
Orthodromic atrioventricular reentrant tachycardia
Wolff-Parkinson-White (WPW) syndrome
49
Losartan
ARB; used for high blood pressure
50
A woman presents with dyspnea on exertion. Cardiac examination reveals an apical late diastolic murmur. You also notice pitting edema in both her legs. She undergoes echocardiographic testing. Which of the following abnormalities would you most expect to see on the echocardiogram?
mitral stenosis; apex with the bell, especially when the patient is placed in the left lateral decubitus position. NO RADIATION.
\_\_\_\_
* Complaining of exertional dyspnea, hemoptysis
* PE will show loud S1, opening snap, low-pitched, rumbling diastolic apical murmur
* Most commonly caused by rheumatic heart disease
\_\_\_\_\_\_
answer: Right ventricular hypertrophy
51
atorvastatin
statin; treats high cholesterol
52
What mediations should be avoided in patients with cocaine related chest pain or hypertension?
BETA-BLOCKERS
53
A 44-year-old man with a history of intravenous opioid use presents to the Emergency Department with fever, cough, and hemoptysis. Vital signs include BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4°F. On auscultation of the chest, you hear a faint systolic ejection murmur. Which of the following would you expect to see on physical examination?
Infectious endocarditis
--Roth spots are retinal hemorrhages with central clearing seen on funduscopic examination.
--Osler nodes are painful nodules on fingers and toes.
--Janeway lesions are painless erythematous plaques on the palms and soles.
--Splinter hemorrhages occur beneath the nails due to septic emboli.
54
Ventricular fibrillation treatment
1. Witnessed
2. Not Witnessed
1. Witnessed: Defribillation
2. Not witnessed: 2 minutes of CPR, followed by defibrillation
55
After return of spontaneous circulation from a ventricular fibrillation arrest, mortality can be determined by calculating a Cardiac Arrest Score, which takes into account which of the following factors?
Witnessed out-of-hospital cardiac arrest patients can be stratified by using the 3-criteria Cardiac Arrest Score developed by Thompson and McCullough.
The criteria are:
(1) Systolic blood pressure in the emergency department;
(2) time from loss of consciousness to return of spontaneous circulation;
(3) neurologic responsiveness.
56
hydrochlorothiazide
thiazide diuretics; treats hypertension
57
A 55-year-old man presents after a syncopal event. He states he just started a new blood pressure medication. His heart rate is 41 beats/minute and his blood pressure is 95/60 mm Hg. Electrocardiogram shows sinus bradycardia. Which of the following medications should be administered?
Diagnosis: Bradycardia
Tx: Atropine
If atropine ineffective: dopamine or epinephrine
Sinus bradycardia can be a result of pathologic factors like hypoxia, hypothermia, cardiac ischemia or infarction, hypothyroidism, or increased intracranial pressure. Many medications also cause sinus bradycardia, including beta-blockers, calcium-channel blockers, digoxin, and opioids. Sinus bradycardia may also be a normal finding in well-conditioned young people, athletes, during sleep, or as a result of vagal stimulation.
58
A 24-year-old woman presents to the Emergency Department with complaints of palpitations and lightheadedness for the past 30 minutes. A rhythm strip is performed and is shown above. She has no significant past medical history and denies any drug or alcohol use. Vital signs show a blood pressure of 132/86 mm Hg and an oxygen saturation of 96 percent on room air. Which of the following medications is the most appropriate for the treatment of this condition? Ekg shows stable narrow-complex supraventricular tachycardia
Adenosine
59
Sudden onset severe HA + syncope:
SAH (subarachnoid hemorrhage)
60
Which class of medications should be given initially for acute pulmonary edema?
Nitrates.
61
A 28-year-old south Asian immigrant who is in her second trimester of her first pregnancy presents to the emergency department complaining of worsening dyspnea, orthopnea and lower extremity edema. She has never experienced anything like this before. She has no past medical history; however, she admits to frequent sore throats and ear infections as a child. Which of the following is most likely to be heard on auscultatory exam?
diastolic low-pitched decrescendo murmur best heard at the cardiac apex
A diastolic low-pitched decrescendo murmur best heard at the cardiac apex would be the most likely auscultatory finding on exam.
This woman likely has mitral stenosis secondary to rheumatic heart disease.
62
A 55-year-old woman presents to the office with progressive dyspnea, paroxysmal dyspnea, orthopnea, and fatigue over the last several months. On auscultation of her heart you hear a low-pitched diastolic rumble best heard in the left lateral decubitus position along with a high-pitched opening snap. Which type of valvular abnormality is associated with these findings?
Mitral stenosis
63
Chest pain with ST elevations in leads II, III, and aVF. What medication is contraindicated?
Diagnosis: STEMI (Inferior myocardial infarction)
Blood vessel: Right coronary artery
***_Contraindicated:_*** nitroglycerin
64
What is the most common cause for syncope in a patient with a non-specific history, normal physical exam and normal EKG?
Unknown
\_\_\_\_\_\_\_\_
San Francisco Syncope Rule (high-risk criteria):
CHESS
* CHF
* Hematocrit \<30%
* ECG abnormal
* SOB
* Systolic BP \<90 mm Hg
65
chlorthalidone
thiazide diuretics; treats hypertension
66
A 62-year-old man reports to the ED with new-onset, crushing, left-sided chest pain, radiating to the left arm that began suddenly 35 minutes prior to arrival. The patient has a history of hypertension, hypercholesterolemia, diabetes mellitus, and a 60-pack-year smoking history. His EMS ECG demonstrates ST-segment elevation in leads II, III, and aVF. In the ED, his vital signs are BP 135/75, HR 98, and RR 18. What is the most appropriate next step?
Diagnosis: Acute MI;
Inferior Blood vessel: Right coronary artery
Management: Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin. The cath lab should be notified immediately after this is performed.
67
Adenosine
Atrioventricular nodal blocker used in treatment of supraventricular tachycardias
68
Which of the following valvular disorders is characterized by any of the following: a low-pitched diastolic murmur heard best over the apex, an early high-pitched, blowing diastolic murmur heard best over the left sternal border, and a wide pulse pressure?
Aortic regurgitation
Physical signs of aortic regurgitation (AR) include
* a rapid, quick arterial pulse (Corrigan’s pulse),
* a wide pulse pressure,
* an early high-pitched, blowing diastolic murmur heard best over the left sternal border,
* an S3 gallop, and
* a low-pitched diastolic murmur at the apex (Austin-Flint murmur).
* The surgical treatment of AR is indicated in symptomatic patients with dyspnea, angina, or CHF. Asymptomatic patients should undergo surgery if left ventricular ejection fraction is 55% or less, or left ventricular end-systolic dimension approaches 5.5 cm.
69
Which of the following would you most expect to find in a patient who presents to the emergency department in cardiogenic shock?
low cardiac index
tx: Treatment mainstay includes prompt inotropic medications such as dopamine, dobutamine and phosphodiesterase inhibitors, and norepinephrine. Other measures include the placement of central and peripheral arterial lines, possible fluid resuscitation, ICU care, electrolyte and acid-base correction, intra-aortic balloon pump, percutaneous coronary intervention or coronary artery bypass grafting. \_\_\_\_\_
Cardiogenic shock is the leading cause of death in acute myocardial infarction. It is characterized by decreased cardiac output and tissue hypoxia in the presence of sufficient intravascular volume. Patients present with hypotension, tachycardia, altered mentation, cool cyanotic extremities, faint peripheral pulses, and oliguria. A low pulse pressure is also typically encountered. Coronary angiography is indicated if myocardial ischemia or infarct is present.
70
An 83-year-old is being evaluated in the emergency department after an episode of syncope. The woman was preparing dinner when she felt her heart start to race. The next thing she remembers is waking up on the floor. She experienced a similar episode about three weeks ago. She has never had anything like this before. Her past medical history is remarkable for hypertension, hyperlipidemia and hypothyroidism. Her medications include lisinopril, atorvastatin and levothyroxine. On physical exam her blood pressure is 142/83, heart rate 76/min, and respiration rate 13/min. Cardiac auscultation reveals no murmur. The remainder of her physical exam is normal. Electrocardiogram reveals normal sinus rhythm with left axis deviation. No cardiac rhythm abnormalities are detected. What is the most likely etiology of this patient’s syncope?
Cardiac dysrhythmia is the most likely cause of this woman’s syncope. Cardiac dysrhythmias are a common cause of syncope in the elderly population. It is characterized by a brief or absent prodrome and palpitations immediately preceding the event. Several episodes over a short period of time in someone with no history of syncope suggest a dysrhythmia.
71
A careful cardiac examination requires close attention to the heart sounds. The second heart sound, S2, is produced by which of the following structures?
S1: Mitral and Tricuspid
S2: Aortic and Pulmonic
The cardiac cycle begins with ventricular contraction, or systole. The pressure generated closes the mitral and tricuspid valves, producing S1, and opens the aortic and pulmonic valves. As the ventricles relax, the previously “pumped-out” blood pushes back on the heart, closing the aortic and pulmonic valves and producing the second heart sound, S2.
\_\_\_
Heart Sounds
* S1: mitral and tricuspid valve closure
* S2: aortic and pulmonary valve closure
* S3: in early diastole
* During rapid ventricular filling phase
* Large amount of blood striking a very compliant left ventricle (LV)
* Normal in children, pregnant women
* S4 (“atrial kick”): Late diastole
* Blood flowing against noncompliant LV
72
A patient is found to have a low pitched rumbling diastolic apical murmur. Which of the following is the most frequent presenting complaint associated with this murmur?
Diagnosis: Mitral stenosis
Complaint: Dyspnea with exertion
Common complication: Atrial fibrillation
73
esmolol
short acting beta blocker; good for controlling hypertension in setting of aortic dissection
74
Which of the following is most commonly seen on chest radiography in a patient with an aortic dissection?
Widened mediastinum
75
A 60-year-old woman with a history of hypertension, dyslipidemia and coronary artery disease was sent to the emergency department from her primary care physician’s office for a heart rate of 40/min. She has no complaints except for mild fatigue. Her medications include metoprolol, atorvastatin, lisinopril and baby aspirin. Her ECG reveals sinus bradycardia and her physical exam is normal. Which of the following is the most appropriate next step in management?
## Footnote
AAdminister atropine
BMake a medication adjustment
CSchedule her for a temporary pacemaker
DWatchful waiting
BMake a medication adjustment
Medication adjustment is the most appropriate in this clinical situation. This patient has sinus bradycardia associated with mild fatigue and is hemodynamically stable. She is currently taking a beta blocker, metoprolol, which can cause or exacerbate sinus bradycardia.
76
Capture beats and fusion beats confirm the diagnosis of which cardiac dysrhythmia?
Ventricular tachycardia
77
Young woman + abdominal pain + syncope
ectopic pregnancy
78
labetalol
short acting beta blocker; good for controlling hypertension in setting of aortic dissection
79
What is the INR range in a patient taking warfarin for atrial fibrillation?
2-3.
80
A 37-year-old woman with a history of Wolff-Parkinson-White presents to the emergency department with shortness of breath and lightheadedness. Her vital signs on arrival are T 36.9°C, HR 160, BP 80/50, RR 27. Her ECG reveals a narrow complex regular tachycardia. Which of the following is the most appropriate next step in the management of this patient?
Cardioversion; hemodynamically unstable patients receive immediate electrical cardioversion
* The first intervention in orthodromic AVRT in a hemodynamically stable patient is a vagal maneuver.
* If this fails, intravenous adenosine can be used,
* followed by AV blocking agents such as beta-blockers or calcium channel blockers.
* Definitive treatment of WPW syndrome is ablation of the accessory pathway.
81
Diltiazem
Calcium channel blocker; Used in treatment of tachydysrhythmias
82
Which of the following is most characteristic of Prinzmetal angina?
Chest pain in the early morning In particular, patients with variant angina report that their episodes are predominantly at rest and that many occur from midnight to early morning. Each episode of chest pain generally lasts 5 to 15 minutes.
tx: Calcium channel blockers or nitrates.
83
A 45-year-old man with a history of obesity and diabetes mellitus presents to the emergency department complaining of abdominal pain that radiates to his back, and nausea and vomiting. Physical examination reveals tenderness in his epigastrium and yellow deposits are noted on the extensor surfaces of his forearms. Which of the following will most likely be seen on his lipid panel?
Markedly elevated triglyceride levels is most consistent with this patient who likely has hypertriglyceridemia pancreatitis.
Hypertriglyceridemia pancreatitis presents similarly to that of acute pancreatitis from other causes and include complaints of abdominal pain, nausea and vomiting. Poorly controlled diabetes, alcoholism, obesity, pregnancy, prior pancreatitis, and a personal or family history of hyperlipidemia should suggest the diagnosis of hypertriglyceridemia pancreatitis. Certain features on the physical examination can help identify hypertriglyceridemia as the cause of acute pancreatitis such as xanthomas over the extensor surfaces of the arms, legs, buttocks, and back or hepatosplenomegaly from fatty infiltration of the liver.
84
What is the greatest risk factor for sudden death from ventricular fibrillation?
Underlying left ventricular dysfunction (LV EF \< 30-35%).
85
A 65-year old Caucasian man presents to the emergency room with a crushing sub sternal chest pain. He states the pain started 30 minutes before and he has never had an episode like this before. He is a smoker and has a history of diabetes. His mother had a myocardial infarction at 60 years of age. He takes insulin for his diabetes but no other medications including over the counter medications. He has no known allergies. His cardiac initial cardiac troponin was negative and his ECG reveals ST depression that measures 0.8 mm in anterior the leads. According to his TIMI score, which of the following is the most appropriate management?
Measure a second cardiac troponin at 12 hours The TIMI risk score is used to estimate mortality in patients with unstable angina and non-ST elevation MI’s.
86
What is the classic auscultatory feature of mitral stenosis?
loud S1 and opening snap in early diastole, accompanied by a low-pitched, rumbling diastolic apical murmur
87
Procainamide
antiarrhythmics
88
A 65-year-old man presents to his physician for a gradual decline in exertional fortitude and dyspnea on exertion that has been getting worse over the past two months. Physical exam demonstrates a mid-systolic murmur heard best at the second intercostal space near the right sternal border. The murmur decreases with isometric handgrip and Valsalva maneuvers. What is the most likely diagnosis?
Aortic stenosis
* The characteristic murmur auscultated is mid systolic and heard best at the second intercostal space near the right sternal border. There is a classic "crescendo-decrescendo" murmur.
* The murmur decreases in intensity with isometric handgrip, standing, and Valsalva maneuvers. Squatting typically does not have an effect on the intensity of the murmur.
\_\_\_
* Aortic Stenosis Patient will be older With a history of diabetes, hypertension
* Complaining of dyspnea, chest pain, syncope
* PE will show crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop
* Most commonly caused by degenerative calcification
* Treatment is aortic valve replacement
* Comments: murmur decreases with valsalva
89
A 20-year-old woman fainted while standing in line at the grocery store. The patient admits to feeling nauseated and diaphoretic before the episode. She denies bowel or bladder incontinence and did not experience a post-ictal state. The woman in line behind her observed jerking motions of her face and fingers. She has no past medical history and does not take any medications. What is the most likely diagnosis?
Vasovagal syncope
Vasovagal, also called neurocardiogenic syncope, is often called the “common faint” and is the most common cause of syncope. Vasovagal syncope is a transient loss of consciousness caused by systemic hypotension and cerebral hypoperfusion. It is a neurally mediated reflex response characterized by bradycardia or peripheral vasodilation. Patients with vasovagal syncope are usually young and healthy. The clinical presentation of “classic” vasovagal refers to syncope triggered by provoking factors such as noxious stimuli, pain, blood draw, intense emotion, fear of bodily injury, prolonged standing, or heat exposure. Prodromal symptoms include feeling warm, sweating, nausea, and pallor.
90
How should you treat LEFT SIDED endocarditis?
Due to: valvular disease, congenital heart disease
Valve: mitral valve
Bacteria: Strep Viridans (likely subacute)
tx: ampicillin and gentamicin
\_\_
* Patient will be complaining of fever, rash, cough and myalgias
* PE will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE)
* Diagnosis is made by echocardiography and Duke's criteria
91
nifedipine
calcium channel blocker
92
Amlodipine
Calcium channel blocker; Treat high blood pressure
93
Which of the following is the most common physical finding in patients with infective endocarditis?
Heart murmur;
fever most common abnormality
94
Bisoprolol
Beta-blocker; heart failure
95
Carvedilol
Beta-blocker; heart failure
96
most common cause of syncope in the general population
Vasovagal
Prodromal symptoms include feeling warm, sweating, nausea, and pallor.
97
A 41-year-old woman presents with fever and retrosternal chest pain of 28 hours duration. A loud friction rub is appreciated over the left sternal border. There is widespread ST-segment elevation seen on her ECG. Which of the following physical findings do you most expect to find in this patient?
Chest pain lessens when she sits forward
diagnosis: acute pericarditis
tx: NSAIDS, like naproxen
ekg: Widespread, concave-up ST-segment elevation with PR depression.
98
drug of first choice for control of mild to moderate hypertension in pregnanc
Methyldopa
99
A 26-year-old ill-appearing man presents to the emergency department with a fever. A grade 3 murmur is detected on examination, and a transthoracic echocardiogram is ordered and reveals a 1.5 cm vegetation on the tricuspid valve. Which one of the following is the most likely causative organism?
Staphylococcus aureus
tx: Vancomycin and ceftriaxone
right-sided infectious endocarditis; most cases occur on the tricuspid valve in persons who use injection drugs.
* Patient will be complaining of fever, rash, cough and myalgias
* PE will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE)
* Diagnosis is made by echocardiography and Duke's criteria
100
A 58-year-old previously healthy woman presents with complaints of dyspnea on exertion and fatigue for the past one month. She denies unexplained weight loss or weight gain, chest pain, or cough. Physical exam reveals a low pitched, diastolic murmur, heard best at the apex. There is an associated opening snap. Which of the following is the most likely diagnosis?
Mitral stenosis is typically associated with a low pitched murmur best at the apex using the bell of the stethoscope. This can also be auscultated more easily when the patient is lying in the left lateral decubitus position or following exertion or exercise. An opening snap can often be auscultated during left ventricular diastole.
101
A 46-year-old woman presents to the Emergency Department with fever, cough, and hemoptysis. She has a history of intravenous opioid use. Vital signs are BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4°F. On auscultation of the chest, you hear a faint systolic ejection murmur. Which of the following is the most appropriate initial therapy?
diagnosis: tricuspid endocarditis/RIGHT sided endocarditis (drug user)
bacteria: staph aureus
tx: Vancomycin and ceftriaxone
\_\_
* Patient will be complaining of fever, rash, cough and myalgias
* PE will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE)
* Diagnosis is made by echocardiography and Duke's criteria
102
in early diastole During rapid ventricular filling phase Large amount of blood striking a very compliant left ventricle (LV) Normal in children, pregnant women
S3
103
A 64-year-old man with a history of hypertension presents to the Emergency Department requesting medication refills. He states that he has not taken his medications for the last 2 weeks. His blood pressure is 190/100. He has no complaints at this time. He has prescription bottles for atenolol and hydrochlorothiazide. What management is indicated?
Give the patient a prescription for his medications and refer to his primary doctor in 48 hours This patient presents with asymptomatic hypertension in the setting of medical non-compliance and should be restarted on his medications and scheduled for follow up with a primary care provider.
104
Which of the following is most closely associated with the development of acute cor pulmonale?
Pulmonary embolism
Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary hypertension is the common link between lung dysfunction and the heart in cor pulmonale. In chronic cor pulmonale, RV hypertrophy (RVH) generally predominates. In acute cor pulmonale, right ventricular dilation mainly occurs.
105
What is used to treat cardiotoxicity from beta-blocker or calcium-channel blocker overdose?
Glucagon
106
An 81-year-old man presents to the Emergency Department in respiratory distress. He is sitting upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood pressure of 190/110 mm Hg, heart rate of 130 beats/minute, respiratory rate of 35 breaths/minute, and oxygen saturation of 85% on room air. Which of the following physical examination findings most strongly suggest heart failure as the cause of his respiratory distress?
Presence of a third heart sound; JVD also seen, but has lower likelihood ratio
\_\_\_\_\_\_\_\_\_\_\_\_\_
* Heart failure is a common cause of respiratory distress. A weakened or diseased left ventricle or one facing high systemic pressures cannot adequately pump blood and as a result, blood pools in the lungs, leading to pulmonary edema and clinical symptoms of congestive heart failure.
* Symptoms include dyspnea on exertion, dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema.
* However, these symptoms are seen in many conditions and cannot be used to distinguish congestive heart failure from other causes of dyspnea.
* Physical exam findings that suggest congestive heart failure include presence of a third heart sound or S3 gallop (likelihood ratio (LR) 11.0), hepatojugular reflux (LR 6.4), and jugular venous distention (LR 5.1). The combination of an S3 gallop and a chest radiograph showing pulmonary venous congestion or interstitial edema is highly suggestive of congestive heart failure.
107
A 52-year-old man states he took his blood pressure and it was elevated to 180/100 mm Hg. He states that he missed his regular dose of antihypertensive medication because he was traveling for business and returned home today. His blood pressure now is 176/102 mm Hg. The patient is otherwise asymptomatic and has a normal physical exam. What is the most appropriate action?
Resume outpatient medication
108
A 65-year-old man presents to the emergency department with chest pain and ST-segment elevation in leads II, III, and aVF. The patient is hypotensive and physical exam reveals jugular venous distention, clear lung fields and tachycardia. No murmur or S3 is appreciated. What is the next step in management?
AAdminister a beta blocker
BAdminister morphine sulfate
CAdminister sublingual nitroglycerin
DBegin intravenous hydration
Begin intravenous hydration
This patient has an ECG concerning for a right ventricular infarct. In this situation, the patient becomes preload dependent (essentially the right ventricle is impaired so there is “passive” flow into the left ventricle). When these patients become hypotensive, the immediate treatment is intravenous hydration to increase preload.
***_Contraindicated: Nitrates_***
109
A woman with chest pain presents to the ED. Her electrocardiogram shows ST elevation in leads V3 and V4. She is started on oxygen, intravenous nitroglycerin, and aspirin. You are preparing her for transfer to the interventional cardiac unit for primary percutaneous cardiac reperfusion. Her heart rate has been consistently \< 60, averaging 54 over the past 30 minutes. Which of the following medications is also appropriate treatment at this time?
ST-elevation myocardial infarction in the anterior heart
vessel: left anterior descending artery
drug: Abciximab; platelet aggregation inhibitor mainly used during and after coronary artery procedures like angioplasty to prevent platelets from sticking together and causing thrombus formation within the coronary artery.
110
This electrocardiogram demonstrates multifocal atrial tachycardia, a form of atrial tachycardia diagnosed on the electrocardiogram by three distinct p-wave morphologies. In approximately 60% of cases, patients have underlying ...
Pulmonary disease, most commonly COPD
111
\_\_\_\_\_\_\_\_\_ is the most specific finding for myocardial ischemia during an exercise stress test.
2 mm downsloping ST-segment depression
112
What is the first-line agent for reduction of triglycerides?
Fibrate, such as gemfibrozil
113
A 34-year-old woman presents with palpitations. Which of the following might you expect to hear on examination if she has mitral valve prolapse?
Mid-systolic click
* The most common symptom of patients with mitral valve prolapse is palpitations.
* Patients may also complain of chest pain, shortness of breath, lightheadedness and fatigue.
* With mitral valve prolapse, on auscultation of the heart a mid-systolic click is heard.
* After the mid-systolic click, a mid- to late-systolic murmur is heard in the mitral region.
114
How do you treat a hypertensive emergency?
IV antihypertensives (labetalol or nicardipine)
Objectives:
* reduce MAP 25% in first hour,
* normalize BP over the next 8 to 24 hours
* Reduction of MAP \> 25% may cause end-organ ischemia
* IV antihypertensives (labetalol or nicardipine)
115
What is the classic auscultatory feature of mitral valve prolapse?
Midsystolic click followed by midsystolic to late systolic murmur over mitral area
116
Which medications are contraindicated in WPW?
ABCD
* Adenosine
* beta-blockers
* calcium channel blockers
* digoxin
117
What cardiac complication is associated with hyperthyroidism?
High-output cardiac failure
