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ROSH: Cardio A

Terms in this set (19)

A 63-year-old man presents to the clinic complaining of severe pain in his left leg. He states the pain began suddenly three hours ago. He reports smoking one pack of cigarettes per day for the past 20 years. He does not take any medications because he has not been to the doctor in over a decade. On exam, his left leg is cool to the touch and pale, with no palpable pedal or popliteal pulses. He is unable to actively bend his knee, although there is no obvious swelling or deformity of the knee joint. Which of the following additional findings would be most likely in this patient?

Bradycardia
Decreased sensation to light touch of left leg
Pedal edema of left leg
Shiny, hairless skin of left leg
Decreased sensation to light touch of left leg

The patient in the above vignette is most likely suffering an acute arterial occlusion of his left lower extremity. Signs and symptoms of acute arterial embolism are characterized by the six Ps: pain, poikilothermia, paresthesias, pulselessness, paralysis, and pallor. Shiny, hairless skin of the left leg (D) would indicate chronic arterial insufficiency, not acute arterial occlusion. The patient may have acute on chronic arterial occlusion, in which case the leg may have atrophic and hairless skin, but this is an indicator of chronic arterial disease not acute occlusion.
A 42-year-old man presents to the emergency department with pleuritic chest pain that worsens when taking deep breaths and lying on his back but is better with sitting up and leaning forward. He had similar symptoms about one year ago that resolved. Physical exam reveals a pericardial friction rub, and an electrocardiogram reveals widespread ST elevation in multiple leads. He is given ibuprofen. Which of the following drugs is used as adjunct therapy to prevent recurrent episodes of this condition in this patient?

Aspirin
Colchicine
Indomethacin
Prednisone
Colchicine

Acute pericarditis occurs when there is inflammation of the pericardium. The pain is pleuritic in quality but can also be described as sharp, dull, aching, burning, or pressing. Pain is worse during inspiration, when lying flat, during swallowing, and with certain motions. It is relieved with sitting and leaning forward. Colchicine can also be used as first-line therapy in combination with aspirin or an NSAID, especially in cases of recurrent pericarditis or in patients whose symptoms continue beyond 14 days. Aspirin (A) is a first-line treatment along with other NSAIDs but should not be used in combination with ibuprofen in the patient described in the vignette above. Indomethacin (C) can be used to treat pericarditis but should not be used in combination with ibuprofen since it is also an NSAID. Prednisone (D) should only be used in refractory cases where NSAIDs are not effective or contraindicated or if there is an underlying disease that requires it.
A 58-year-old man is brought to the emergency department by ambulance for substernal chest pain that started 45 minutes ago. He endorses dyspnea and radiation of his pain to his left shoulder and arm. His past medical history includes hypertension, dyslipidemia, and diabetes mellitus type II. Cardiac enzymes are drawn and evaluated upon arrival to the emergency department. Twelve-lead ECG shows ST segment elevation in leads II, III, and aVF. The patient undergoes successful cardiac intervention and is released from the hospital after stabilization five days later. Which of the following medications has the largest long-term impact on this patient's recovery?

Aspirin
Metoprolol
Nitroglycerin
Simvastatin
Metoprolol

Acute coronary syndrome is a group of conditions that can be classified based on clinical and diagnostic findings. The three conditions comprising the group of conditions (unstable angina, non-ST elevation myocardial infarction,and ST elevation myocardial infarction) present with similar signs and symptoms of chest pain, dyspnea, and diaphoresis, among others. . Medical management also includes nitrates, beta-blockers, such as metoprolol, angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, oxygen, morphine, anticoagulant therapy (heparin), antiplatelet therapy (aspirin), and HMG-CoA reductase inhibitors (atorvastatin). Supplemental oxygen should be given to maintain arterial oxygen saturation above 90%. It is not indicated in normoxic patients as it can cause vasoconstriction of the coronary arteries. Morphine has been associated with high risk of death and should be administered only for severe, persistent chest pain that is not relieved by other treatment strategies. Beta-blockers and ACE inhibitors have been shown to have the most significant impact on long-term recovery as they prevent permanent remodeling of the cardiac tissue following infarct. Aspirin (A), although part of the treatment protocol for acute coronary syndrome, serves as antiplatelet therapy during acute ischemia and does not have as significant long-term benefits compared to beta-blocker therapy. Similarly, nitroglycerin (C) is used in treating acute coronary syndrome to relieve pain associated with ischemia but does not have long-term effects. Nitrates should be used with caution in patients with right ventricular infarction or severe aortic stenosis as it can cause hypotension and hemodynamic decompensation. All patients should be started on high-intensity statin therapy (atorvastatin or rosuvastatin) within 24 hours of acute myocardial infarction to decrease further coronary artery disease events. Simvastatin (D) is a moderate intensity statin and is therefore not a first-line lipid-lowering agent following myocardial infarction. Atorvastatin is a high-intensity statin that should be prescribed to all patients after acute coronary syndrome.
Which of the following distinguishes venous insufficiency from venous thromboembolism?

Aching calf pain
Lipodermatosclerosis
Lower extremity edema
Radiating pain from hip to foot
Lipodermatosclerosis

The physical exam findings associated with chronic venous insufficiency are largely dependent on severity of disease. In mild cases, telangiectasia and reticular veins may be present. In moderate to severe cases, varicose veins, edema, hemosiderin staining, ulcerations, and lipodermatosclerosis may develop. Lipodermatosclerosis is a fibrosing panniculitis of the subcutaneous tissue characterized by a firm area of induration. The condition is initially located at the medial ankles and can spread circumferentially to the midleg
A cachectic 70-year-old man presents to the urgent care complaining of dyspnea. He states he has been feeling poorly for the past year, with inadvertent weight loss and decreased appetite. He smokes two packs of cigarettes per day and takes no daily medications. In the past two days, he has felt increasingly breathless. Physical exam reveals elevated jugular venous pulsations, decreased heart sounds, and cool extremities. Blood pressure is 90/50 mm Hg. Which of the following additional physical exam findings would be most consistent with the most likely diagnosis?

Bradycardia
Decreased breath sounds
Fourth heart sound
Pulsus paradoxus
Pulsus paradoxus

Cardiac tamponade describes fluid in the pericardial sac that compresses the myocardium and limits the ability of the ventricles to completely fill during diastole. Signs and symptoms of cardiac tamponade include the classic Beck triad:increased jugular venous pulsations, muffled or distant heart sounds, and systemic hypotension. Other signs include pulsus paradoxus, where the blood pressure falls on inspiration, and electrical alternans, in which the QRS complex on electrocardiogram appears to alternate between high and low voltage.
What heart murmur is described as a holosystolic murmur best heard over the lower-left second and third interspaces and along the left mid sternal border?

Austin Flint murmur
Carey Coombs murmur
Tricuspid regurgitation murmur
Ventricular septal defect murmur
Tricuspid regurgitation murmur

A tricuspid regurgitation murmur is a holosystolic murmur best heard over the lower-left second and third interspaces and along the left mid sternal border or at the subxiphoid area. The murmur is created by the backflow of blood into the right atrium. The development of tricuspid regurgitation is most often secondary to another condition (typically pulmonary hypertension).
A 59-year-old man presents to the clinic with no specific complaints. He has a past medical history of refractory atrial fibrillation for which he underwent catheter ablation two months ago. A routine ECG is performed with the results shown above (image shows 3 regular beats, then a dropped QRS). Which of the following therapies is indicated?

Atropine
Dopamine
No therapy is required
Permanent pacemaker placement
Permanent pacemaker placement

Atrioventricular block is a cardiac dysrhythmia defined as a delay or interruption in the electrical impulses from the atria to the ventricles. Also termed heart block, this delay is categorized as first-degree when the PR interval exceeds 200 milliseconds with all atrial impulses conducted to the ventricles. Second-degree heart block presents with intermittently blocked beats while third-degree heart block (complete heart block) results in no atrial impulses being transmitted to the ventricles. Second-degree heart block can be divided into Mobitz type I (Wenckebach), in which the PR interval progressively lengthens prior to a blocked beat, and Mobitz type II, which presents with intermittently nonconducted atrial beats not preceded by a lengthening PR interval. Mobitz type II atrioventricular block has pathologic and iatrogenic etiologies including myocardial ischemia, cardiomyopathy, myocarditis, hyperkalemia, postcardiac surgery, and postcatheter ablation, among others.
A 74-year-old man presents to the emergency department complaining of dyspnea and decreased exercise tolerance that has worsened in the past few months. Which of the following physical exam findings would suggest a diagnosis of restrictive cardiomyopathy rather than constrictive pericarditis?

Kussmaul sign
Pericardial knock
Peripheral edema
Third heart sound
Third heart sound

Restrictive cardiomyopathy is a condition defined by diastolic dysfunction due to stiffness of the ventricles. Constrictive pericarditis presents similarly but causes inadequate filling of the chambers secondary to constriction of the fibrous pericardial sac that surrounds the heart. These conditions initially present with signs and symptoms of heart failure, such as dyspnea, exercise intolerance, and fatigue, and both lead to diastolic heart failure. Cardiac auscultation can provide some diagnostic value with 50% of patients with constrictive pericarditis demonstrating a pericardial knock, whereas restrictive cardiomyopathy presents with an audible third heart sound (S3). This accessory heart sound is present due to the abrupt cessation of rapid ventricular filling as blood strikes the stiff myocardial walls.
How is mitral stenosis differentiated from atrial septal defect on auscultation?

A midsystolic click
A wide and fixed splitting of S2
An Austin Flint murmur
An opening snap
An opening snap

Mitral stenosis is a valvular heart condition resulting from mitral commissural adhesions; thickened, immobile mitral valve leaflets; and fibrosis and calcification of the chordae tendineae.
Which of the following medications is known to prolong the QT interval and increase the risk of torsades de pointes?

Diphenhydramine
Moxifloxacin
Promethazine
Sildenafil
Moxifloxacin

Torsades de pointes means "twisting of the points" in French and describes a tachydysrhythmia associated with prolongation of the QT interval. Many drugs carry a moderate risk of prolongation of the QT interval and torsades de pointes, including fluoroquinolone antibiotics (such as moxifloxacin), macrolide antibiotics, tricyclic antidepressants, antifungals (fluconazole), and certain antiemetics (ondansetron).
A 17-year-old male athlete presents to his primary care provider for a physical examination and medical clearance to participate in a basketball program. On examination, a crescendo-decrescendo systolic murmur is heard. Which of the following characteristics is concerning for hypertrophic cardiomyopathy?

A decrease in intensity of the murmur following administration of nitroglycerin
A decrease in intensity of the murmur upon the assumption of an upright posture from a supine position
An increase in intensity of the murmur during Valsalva maneuver
An increase in intensity of the murmur heard after going from a standing to a squatting position
An increase in intensity of the murmur during Valsalva maneuver

An increase in intensity of the murmur can be appreciated when the patient assumes an upright posture from a squatting, sitting, or supine position; when performing the Valsalva maneuver; and following the administration of nitroglycerin. A decrease in the intensity of the murmur can be appreciated when the patient assumes a sitting or a squatting position from the standing position.
A 45-year-old woman with diabetes presents to the clinic for a refill of her metformin 500 mg, which she takes twice daily with meals. Her glycosylated hemoglobin is 6.5%, and her vitals are pulse 80 bpm, respirations 18/minute, and blood pressure 140/90 mm Hg. Her blood pressure readings on her last two visits were 142/88 mm Hg and 138/90 mm Hg. She is currently on a low-sodium and low-carbohydrate diet, and she exercises 30 minutes per day, 5 days per week. Which of the following is the best treatment option for this patient?

Add lisinopril 10 mg daily
Add lisinopril-hydrochlorothiazide 10 mg/12.5 mg daily
Increase metformin to 1,000 mg twice daily
Maintain current medication and increase exercise to 40 minutes daily, 6 days per week
Add lisinopril 10 mg daily

First-line pharmacotherapy for hypertension treatment in patients with diabetes, such as the patient in the vignette, is angiotensin-converting enzyme inhibitors (such as lisinopril) or angiotensin II receptor blockers. These agents help control blood pressure and slow the progression of diabetic nephropathy. A common side effect of this class of medication is dry cough.
A 19-year-old man presents for a routine physical. He has no past medical history and takes no medications. While he denies any symptoms at this time, he reports prior episodes of palpitations and mild chest pain that resolved spontaneously. His ECG findings are shown above (shows WPW). Which of the following is the best initial clinical course?

Catheter ablation
Direct current cardioversion
Flecainide administration
Verapamil administration
Catheter ablation

Wolff-Parkinson-White syndrome is a pre-excitation syndrome that results from accessory pathways between the atria and the ventricles. When antegrade electrical conductions follow these conduits and bypass the atrioventricular node, the ventricles undergo early depolarization. If the diagnosis is uncertain, synchronized cardioversion is the clinical intervention of choice. Adenosine, verapamil, diltiazem, beta-blockers (metoprolol, propranolol), and digoxin are contraindicated in patients with an uncertain diagnosis and underlying Wolff-Parkinson-White syndrome. Additionally, amiodarone is contraindicated in the treatment of atrial fibrillation with rapid ventricular rate in the setting of pre-excitation. These patients should be treated with intravenous ibutilide or procainamide with synchronized cardioversion if the dysrhythmia is refractory. Chronic prevention of secondary arrhythmias in patients with Wolff-Parkinson-White syndrome is accomplished via catheter ablation of the accessory pathway. Those unable or unwilling to undergo this intervention can be treated with oral flecainide or propafenone unless contraindicated.
A 72-year-old man presents to the clinic after cardiac stent placement. He has a new diagnosis of congestive heart failure with an ejection fraction of 25%. He is dyspneic on minimal exertion but asymptomatic at rest. A thorough review of his new medications is performed, and he demonstrates understanding. His most recent complete metabolic panel revealed sodium and potassium within normal limits. Which of the following represents appropriate health education for this patient?

Abstain from alcohol consumption
Monitor weight on home scale weekly
Reduce fluid intake to 1.5 L per day
Reduce sodium intake to 1.5 g per day
Abstain from alcohol consumption

Heart failure describes ventricular dysfunction resulting from diastolic filling deficits, poor systolic contractility, or both. Common causes of heart failure include hypertension, obesity, smoking, excessive alcohol consumption, congenital or valvular heart disease,ischemic heart disease, rheumatic heart disease, pregnancy, and chest radiation. Monitor weight on home scale weekly (B) is not often enough. Minor changes in weight can signify decompensated heart failure, which calls for hospitalization or medication change. Therefore, patients with any class of heart failure should be encouraged to measure their weight on a home scale daily and report any increase of 2 lbs or more to their health care provider. Reduce fluid intake to 1.5 L per day (C) is not recommended. In fact, fluid restriction of any type in heart failure patients is not advised, unless the patient has symptomatic hyponatremia or refractory class IV heart failure. The patient in the above vignette had a normal serum sodium (as evidenced by the normal complete metabolic panel) and would fall in the class III heart failure category. Reduce sodium intake to 1.5 g per day (D) is too stringent and not necessary. Sodium reduction to 3 g or less per day is much more manageable for the patient and is recommended by the American College of Cardiologists and American Heart Association, according to their 2017 heart failure guidelines.
A 71-year-old woman presents to the clinic due to a headache. Her vital signs are heart rate of 90 beats/minute, respirations of 18 per minute, temperature of 97.8°F, and blood pressure of 200/100 mm Hg in both arms. Findings on physical exam are within normal limits except for bilateral papilledema. At the previous three office visits, the patient's blood pressure averaged 150/90 mm Hg. Her only medications are amlodipine 10 mg daily and simvastatin 40 mg daily, both of which she takes regularly. Which of the following represents the most likely diagnosis?

Acute cerebrovascular accident
Hypertensive emergency
Hypertensive urgency
Stable, poorly controlled hypertension
Hypertensive emergency

A hypertensive emergency is defined as a significantly elevated blood pressure with signs of ongoing end-organ damage. Image shows examples. Hypertensive urgency (C) describes a patient with significantly elevated blood pressure who is asymptomatic. The patient in this vignette has a headache and signs of end-organ damage (papilledema), so her case should be considered an emergency.
A 42-year-old man presents to the clinic complaining of chest discomfort. He does not have the discomfort currently, but he feels a tightening under his sternum whenever he works out or rides his bike. The pain does not radiate and is not reproducible on physical exam. Vital signs, laboratory data, and electrocardiogram are within normal limits. Which of the following is the most likely diagnosis?

Cardiac tamponade
Costochondritis
Stable angina pectoris
Unstable angina pectoris
Stable angina pectoris

Stable angina pectoris refers to chest discomfort that is the result of cardiac ischemia, is brought on by physical exertion, and is relieved by rest.
A 32-year-old man presents to the free medical clinic to discuss recent lab results. He is generally healthy. He reports a family history of elevated triglycerides. Laboratory studies show a triglyceride level of 980 mg/dL. Which of the following would be the best pharmacotherapy at this time?

Cholestyramine
Fenofibrate
Pravastatin
Pravastatin and fenofibrate concurrent administration
Fenofibrate

Hypertriglyceridemia is defined as a fasting blood triglyceride level of > 150 mg/dL.
Mild = 150 -499
Moderate = 500 - 886
Severe = >886 mg/dL

Treatment of hypertriglyceridemia consists of removing an identified cause, lifestyle modifications such as avoiding alcohol and refined sugars, lowering caloric intake, exercise, and treatment of underlying medical conditions that are implicated. Fibrates such as gemfibrozil and fenofibrate are ideal, but muscle toxicity is an important side effect that the patient should be educated on. Also, warfarin dosage needs to be adjusted if fibrates are used. Cholestyramine (A) is not indicated at this time, as it is primarily used for hypercholesterolemia without significant reduction in triglycerides. Pravastatin (C) can lower triglycerides but is not as effective as fibrates. The incidence of muscular side effects could potentially significantly increase with pravastatin and fenofibrate concurrent administration (D).
A 65-year-old man with a past medical history of hypertension and systemic lupus erythematosus presents to the emergency department complaining of a sudden onset of dyspnea and fatigue. An electrocardiogram (ECG) is performed and demonstrates low voltage QRS complexes with sinus tachycardia. Physical exam findings include pulsus paradoxus. Which of the following is the most likely diagnosis?

Congestive heart failure
Myocardial infarction
Myopericarditis
Pericardial effusion
Pericardial effusion

A pericardial effusion occurs when there is a buildup of fluid in the pericardium, the fibrous sac that surrounds the heart. ymptoms of cardiac tamponade include sinus tachycardia, pulsus paradoxus, and elevated jugular venous pressure. Clinical presentation of pericardial effusions can vary widely, depend on how large the effusion is, and whether the effusion occurred acutely or is chronic. Patients may complain of fatigue, dyspnea on exertion, or edema. An electrocardiogram may show low-voltage QRS complexes or electrical alternans.
A 70-year-old obese woman presents to the emergency department complaining of palpitations. Her blood pressure is 110/80 mm Hg in bilateral arms. Her pulse is 150 beats per minute. Respirations, temperature, and oxygenation are within normal limits. An electrocardiogram is performed and is shown above (shows rapid, regular atrial rate and a regular ventricular response rate). The patient takes no daily medications and states her only chronic medical problem is sleep apnea, for which she was prescribed a CPAP machine that she does not use. Which of the following represents the best definitive treatment choice for this patient?

Amiodarone
Cardioversion
Procainamide
Radiofrequency ablation
Radiofrequency ablation

Diagnosis of atrial flutter is with electrocardiogram, where a regular, rapid atrial rate will appear as a sawtooth pattern and QRS complexes will be equally spaced and rapid. Treatment of atrial flutter must address the rapid rate, work to return the patient to normal sinus rhythm, prevent systemic emboli, and prevent recurrence of the dysrhythmia. Beta-blockers or calcium channel blockers are often given for rate control, and heparin is initiated for prevention of embolization. Return to normal sinus rhythm can be accomplished with antidysrhythmic agents, cardioversion, or radiofrequency ablation of accessory pathways. The latter is the preferred method because it provides definitive treatment and lower likelihood of recurrence. Patients who are hemodynamically unstable should undergo urgent cardioversion. Amiodarone (A) is an antidysrhythmic agent that can slow the atrial flutter rate and conduction through the atrioventricular node. However, amiodarone carries the risk of leading to a 1:1 atrioventricular conduction rate, which can increase the heart rate in a patient with atrial flutter. This is because the atrioventricular conduction rate is normally 2:1 in atrial flutter. Patients who are hemodynamically stable may be candidates for oral antidysrhythmic agents and anticoagulants while they wait for spontaneous return of normal sinus rhythm, although this is not guaranteed to occur.
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