Week 1 Flashcards
Nitrate therapy works by which of the following mechanisms?
Reducing both preload and afterload
propranolol
short acting beta blocker; good for controlling hypertension in setting of aortic dissection
Woman + prodrome of nausea, sweating, warmth + syncope:
vasovagal
aortic and pulmonary valve closure
S2
nicardipine
calcium channel blocker
Timolol
beta-blocker; Glaucoma
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?
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
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
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.
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)
tx: chest compressions
Which of the following is the first line treatment for acute pericarditis?
NSAID like Ibuprofen or naproxen
Which of the following diseases is characterized by the presence of a delta wave on an electrocardiogram?
Wolff-Parkinson-White
The bundle of Kent.
tx: radiofrequency ablation
Malignancy + sudden onset SOB + syncope:
PE (pulmonary embolism)
What is the most frequent site of arterial embolism?
bifurcation of the common femoral artery.
In patients with a myocardial infarction, which three drugs have been shown to decrease mortality?
- Aspirin,
- beta-blockers, and
- ACE-inhibitors.
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?
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.
Which of the following is commonly the first reported symptom of aortic stenosis?
Dyspnea
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?
Administer clopidogrel in patients with true aspirin allergies, clopidogrel should be substituted for aspirin.
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?
Diagnosis: Dilated cardiomyopathy secondary to chronic hypertension– these indicate likely cardiac failure
Diagnostic test: Echocardiogram
Beta-blockers for heart failure: Bisoprolol Carvedilol Metoprolol
verapamil
Calcium Channel Blocker; used for hypertension
What is the treatment of :
- hemodynamically unstable ventricular tachycardia?
- Stable ventricular tachycardia
- Unstable: Electrical cardioversion
- Stable: procainamide, amiodarone (synchronized cardioversion if refractory)
mitral and tricuspid valve closure
S1
Metoprolol
Beta-blocker; heart failure
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?
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
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?
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.
(“atrial kick”): Late diastole Blood flowing against noncompliant LV
S4
Older male + abdominal/flank pain + syncope
AAA (abdominal aortic aneurysm)
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.
What is the classic auscultatory feature of aortic stenosis?
Crescendo-decrescendo systolic murmur
Which of the following can decrease levels of brain natriuretic peptide?
Obesity
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.
Adolescent athlete + syncope:
HOCM (hypertrophic cardiomyopathy)
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
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.
Which of the following ECG findings is most characteristic of a premature junctional contraction?
Inverted P’ wave following the QRS
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.
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:
- Paresthesia
- Pallor
- Pulselessness
- Poikilothermia
- Paralysis
- 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
Flecainide
antiarrhythmics
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
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)
Muffled heart sounds, hypotension, and jugular venous distention.
Beck’s triad for cardiac tamponade
What is the gold standard for diagnosing myocarditis?
Myocardial biopsy.
Salmeterol
Long acting beta-2 agonist; Bronchospasm and COPD
Enalapril
ACEi; used for high blood pressure
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
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
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
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.
