Cardiac Board Review Part 1.
A 20-year-old female college student is evaluated at the student health center to establish care. She had no major medical problems prior to college, and there is no family history of cardiovascular disease. BP: 110/60 mm Hg and pulse is 70/min. S1 and S2 are normal and there is an S4 present. There is a harsh grade 2/6 midsystolic murmur heard best at the lower left sternal border. The murmur does not radiate to the carotid arteries. A Valsalva maneuver increases the intensity of the murmur; moving from a standing position to a squatting position, performing a passive leg lift while recumbent, and performing isometric handgrip exercises decrease the intensity. Rapid upstrokes of the carotid pulses are present. Blood pressures in the upper and lower extremities are equal. Which of the following is the most likely diagnosis?
A 76-year-old woman residing in an independent living facility is evaluated during a routine examination. She ambulates well, using a cane because of hip pain, but does not exercise regularly and takes public transportation to complete her daily shopping. She does not have exertional chest discomfort, dizziness, palpitations, dyspnea, or fatigue. She has hypertension. There is no known history of coronary artery disease. She does not smoke. Medications are hydrochlorothiazide and low-dose aspirin. On physical examination, temperature is normal and blood pressure is 150/80 mm Hg. BMI is 22. Cardiac examination reveals a sustained apical impulse; normal S1; and a single, soft S2. An S4 is present. There is a grade 3/6 early-onset systolic, late-peaking murmur that is heard best at the right upper sternal border and radiates to the left carotid artery. Carotid pulses are delayed. There is trace pedal edema. Transthoracic echocardiography demonstrates severe aortic stenosis. No other valvular abnormalities are seen. Biventricular function is normal. There is concentric left ventricular hypertrophy. Pulmonary pressures are at the upper limits of normal. Which of the following is the most appropriate test to perform next?
S2: results from aortic and pulmonic valve closure at end of ventricular systole
Most common causes are dissection and valve destruction from endocarditis.
Results from annular dilation or primary leaflet dysfunction.
A 54-year-old man is evaluated for right-sided chest pain that is described as sharp, begins following large meals, lasts for several minutes, and usually resolves spontaneously. The episodes are not clearly related to activity, nor are they relieved by rest. He has been experiencing the pain for about 4 months. Several of the episodes have resolved with antacids. The most recent episode, which occurred yesterday while walking, lasted 20 minutes and resolved. Medical history includes hypertension and hyperlipidemia. Family history is notable for a brother who had coronary stent placement at the age of 43 years. Current medications are aspirin, atenolol, and atorvastatin. Physical examination is notable for estimated central venous pressure of 6 cm H2O; normal carotid upstroke; and no cardiac murmurs, rubs, or S3. Lung fields are clear. Extremities show no edema, and peripheral pulses are normal bilaterally. Hematocrit, 44%; troponin I at presentation is 0.0 ng/mL; troponin I at 4 hours is 0.0 ng/mL ; creatinekinase, 50 U/L. EKG: shows normal sinus rhythm and no ST- or T-wave changes. CXR: shows a normal cardiac silhouette, no infiltrates, and no pleural effusions. Which of the following is the best diagnostic option?
A 68-year-old woman is evaluated for atypical chest pain of 3 months’ duration. She describes the pain as a left-sided burning that occurs both at rest and when she exercises. It lasts for about 10 minutes, and is relieved by rest and eating. The patient has no history of cardiac disease. She has hypertension, for which she currently takes hydrochlorothiazide. She is a smoker and she has asthma, for which she takes inhaled corticosteroids and frequently uses inhaled bronchodilators. If she pretreats herself with the inhaled bronchodilator, she can walk long distances at a brisk pace. She is afebrile, her blood pressure is 158/84 mm Hg, her pulse is 64/min, and her respiration rate is 18/min. Estimated central venous pressure is 5 cm H2O. On cardiac examination, no murmurs, rubs, or extra heart sounds are noted. The lungs are clear to auscultation. There is trace peripheral edema. Total cholesterol, 200 mg/dL LDL 140; and HDL 50 mg/dL EKG: normalWhich of the following is the most appropriate diagnostic test for this patient?
Exercise Treadmill Testing:
Pharmacologic Stress Testing:
a) Categorize the nature of the chest pain:
If resting EKG ST changes or with any of the following:
Must do echo or nuclear myocardial perfusion as the diagnostic test.
A 65-year-old man is evaluated during a routine follow-up examination for coronary artery disease. He was diagnosed with a myocardial infarction 5 years previously, and was started on medical therapy with aspirin, metoprolol, atorvastatin, lisinopril, and sublingual nitroglycerin. He was asymptomatic until 3 months ago, when he noted progressive exertional angina after walking two blocks. He now uses sublingual nitroglycerin on a daily basis. He has not had any episodes of pain at rest or prolonged chest pain that were not relieved by sublingual nitroglycerin. He has hyperlipidemia and hypertension. PE: a well-developed man who appears comfortable. BP 140/60 mm Hg HR 85/min. Carotid upstrokes are normal with no bruits. Cardiac examination reveals no murmurs. The lungs are clear. Peripheral pulses are equal throughout and there is no peripheral edema. His electrocardiogram is unchanged since the last visit, with no evidence of acute changes.In addition to adding a long-acting nitrate, which of the following is the most appropriate management for this patient?
Contraindications for BB: bradycardia, severe depression, decompensated HF, severe restrictive airway disease
Contraindications for long acting nitrate: severe AS, HCM, PDEi
Contraindications for ranolazine: hepatic impairment, QT prolongation or if pt on dilt, verapamil
PCI does NOT decrease future cardiovascular events or increase survival, it does decrease frequency and severity of anginal symptoms
A 66-year-old man is evaluated in the emergency department for left-sided chest pain that began at rest, lasted for 15 minutes, and has since resolved. A similar episode occurred at rest yesterday, and multiple similar episodes that were associated with exertion have occurred over the past 2 weeks. Pertinent medical history includes hypertension and type 2 diabetes mellitus. Family history is notable for his father undergoing coronary artery bypass graft surgery at age 69 years and his brother undergoing coronary artery bypass graft surgery at age 54 years. Current medications are amlodipine, glyburide, and aspirin. BP 125/65 mm Hg, HR 70/min, RR 12/min. Estimated central venous pressure is 6 cm H2O, carotid upstroke is normal, there are no cardiac murmurs, and the lung fields are clear. Extremities show no edema, and peripheral pulses are normal bilaterally. Troponin I level of 1.2 ng/mL and a creatinine1.4 mg/ dLEKG: 1-mm ST-segment depression in leads aVL, V5, and V6. CXR: normal cardiac silhouette, with no infiltrates and no pleural effusions. The patient is treated with aspirin, intravenous nitroglycerin, unfractionated heparin, metoprolol, and pravastatin.Which of the following should be the next step in this patient’s management?
A 65-year-old woman is evaluated in the hospital 36 hours after presenting in the emergency department with midsternal chest pain. Electrocardiogram on presentation demonstrated no ST-segment shifts, but T-wave inversion was present in leads V3 and V4. She was given nitroglycerin, unfractionated heparin, and a glycoprotein IIb/IIIa inhibitor and was admitted to the hospital. She has a history of hypertension and hyperlipidemia and is a prior smoker. Her medications prior to admission were metoprolol, 25 mg twice daily; atorvastatin, 80 mg/d; and aspirin, 325 mg/d. The patient is afebrile. BP 132/82 mm Hg, HR 68/min and regular, RR 16/min. BMI is 25. There is no jugular venous distention, and no crackles are auscultated. Heart sounds are normal. There is no rub, murmur, or gallop. Her serum cardiac troponin I level rose to a peak of 4.2 ng/mL at 24 hours following the index event. Results of a basic metabolic profile, including blood glucose levels, are normal. Coronary angiography demonstrates diffuse, mild luminal irregularities in all coronary arteries, along with diffuse severe disease in the distal left anterior descending coronary artery not amenable to percutaneous coronary intervention. Left ventriculography demonstrates a left ventricular ejection fraction of 55% with a small focal region of hypokinesis in the apex. The left ventricular end-diastolic pressure is 12 mm Hg. The glycoprotein IIb/IIIa inhibitor is discontinued.Which one of the following agents should be added to this patient’s medication regimen?
A 67-year-old woman is evaluated in the ED for substernal chest pressure that has lasted for just over 3 hours. The pressure has not remitted despite administration of one dose of sublingual nitroglycerin on the way to the hospital. The emergency department is in a community hospital that does not have percutaneous coronary intervention (PCI) capability. The nearest hospital with PCI capability is 45 minutes away. The patient has a history of hypertension and hyperlipidemia. There is no history of recent surgery or bleeding diathesis. Current medications include lisinopril, hydrochlorothiazide, and simvastatin. She has no known drug allergies. Aspirin and sublingual nitroglycerin are administered upon arrival. Temperature is 37.2 °C (99.0 °F), BP 146/92 mm Hg, HR 104/min and regular, RR 18/min. The patient appears uncomfortable. Crackles are heard at the bases of both lung fields. The S1 is normal; the S2 is paradoxically split. No murmur or gallop is present. Results of a complete blood count, basic metabolic profile, and clotting studies are normal. Initial serum troponin I level is 0.5 ng/mL. A stool sample tests negative for occult blood. EKG: normal sinus rhythm with a left bundle branch block. No prior tracing is available for comparison. Intravenous heparin, β-blockers, and morphine are administered. Which of the following is the most appropriate next step in the management of this patient?
A 62-year-old woman is brought to the emergency department by paramedics for chest pain that has been present for 5 hours. Medical history is notable for type 2 diabetes mellitus, hypertension, and a stroke 1 year ago. Medications include glyburide, lisinopril, atorvastatin, and aspirin. On physical examination, she appears comfortable. She is afebrile, blood pressure is 190/90 mm Hg, pulse rate is 88/min and respiration rate is 16/min. Cardiac examination shows no murmurs, extra sounds, or rubs. The lungs are clear and pulses are equal bilaterally. Neurologic examination is normal. The electrocardiogram shows 2-mm ST-segment elevation in leads II, III, and aVF.A coronary catheterization laboratory is not available, and the nearest hospital with percutaneous intervention capability is 1 hour away. Which of the following is the best management option for this patient?
An 85-year-old woman is admitted to the coronary care unit following successful thrombolytic therapy for an acute anterior wall STEMI. Prior to the myocardial infarction she had been active without any medical problems and was taking no medications. BP 120/70 mm Hg and heart rate is 90/ min. There is no jugular venous distention and no cardiac murmurs. The lung fields are clear and there is no peripheral edema. Medications started in the hospital are aspirin, low-molecular-weight heparin, intravenous nitroglycerin, and oral metoprolol. EKG shows Q waves in the anterior leads with upsloping ST segments. On hospital day 3, the patient experiences acute onset of respiratory distress, and her systolic blood pressure falls to 80 mm Hg. Her oxygen saturation remains at 80% despite the administration of 100% oxygen by face mask. She is given dopamine and intravenous furosemide. On physical examination, blood pressure is 96/40 mm Hg, pulse rate is 100/min, and respiration rate is 28/min. Findings include jugular venous distention, crackles throughout both lung fields, and a grade 4/6 systolic murmur associated with a thrill. A pulmonary artery catheter is placed via the right internal jugular vein. The pulmonary capillary wedge pressure tracing shows prominent v wavesWhich of the following is the best immediate treatment option?
A 67-year-old business man is evaluated during a routine health examination. He has a 30 pack-year history of smoking, but quit 5 years ago. He consumes two or more alcoholic beverages on most days. He is asymptomatic, but performs no regular physical exercise. He takes no medications. On physical examination, his blood pressure is 148/92 mm Hg and heart rate is 78/min and regular. His pulses are full, he has no bruits, and results of his lung, heart, abdominal, and rectal examinations are unremarkable. Total serum cholesterol is 240 mg/dL (6.2 mmol/L), HDL cholesterol is 40 mg/dL (1.0 mmol/L), and triglyceride level is 100 mg/dL (1.1 mmol/L). Results of other serum laboratory studies are normal. An abdominal ultrasound for screening purposes demonstrates an infrarenal abdominal aortic aneurysm measuring 4 cm in diameter.In addition to treatment of this patient’s hyperlipidemia and hypertension and discussion about his at-risk drinking, which of the following is the best management option?
A 48-year-old man is evaluated in the emergency department for sudden onset of severe discomfort in the chest and between the shoulder blades. The pain was maximal in intensity at its onset 90 minutes ago and is unaffected by position or breathing. He has a history of hypertension, for which he takes hydrochlorothiazide, 25 mg/d; and lisinopril, 40 mg/d. BP is 200/120 mm Hg, pulse is 100/min, and respiration rate is 20/min. An S4 gallop is present. No cardiac murmur or pericardial rub is present. The lungs are clear to auscultation. Distal pulses are equal and symmetric. Results of a neurologic examination are normal. UDS: positive for cocaine. Serum creatinineis 2.2 mg/dL. His creatinine0.8 mg/dLat the time of his last office evaluation. Serum cardiac troponin and myoglobin levels are normal. An electrocardiogram reveals left ventricular hypertrophy with a secondary repolarization abnormality and sinus tachycardia. Chest radiograph is normal. In addition to emergently lowering the blood pressure and heart rate, which of the following diagnostic tests should be performed next?