Internal Medicine Essentials Questions: Cardiovascular Medicine

Question 1

A patient presents with persistent chest pain that is worse when lying down and has diffuse ST-elevations on electrocardiogram. What should you recommend and tell the patient?

Answer 1

These findings are suggestive of pericarditis, often seen after a recent URI. The pain will likely go away on its own, and NSAIDs can be used in the meantime.

Question 2

Why is asking about pain radiation important in taking a history in chest pain?

Answer 2

Cardiac pain often radiates to the arm or shoulder, while costochondritis doesn’t –it remains in the anterior chest wall.

Question 3

How is the onset of chest pain different in costochondritis?

Answer 3

Costochondritis usually has an insidious onset, whereas angina is usually sudden.

Question 4

Describe the ways to distinguish between pericarditis and costochondritis.

Answer 4

•Pericarditis:

• presents with a friction rub
• causes pleuritic pain
• often follows a URI or MI or is found in someone with a connective tissue disease

•Costochondritis:

• worse with lateral bending
• reproducible with palpation

Question 5

Discuss the presentation of a patient with spontaneous pneumothorax.

Answer 5

• History: pleuritic chest pain of sudden onset; SOB
• Physical exam: decreased chest expansion on affected side; midline trachea (because it is not a tension pneumothorax); decreased breath sounds on affected side; distant heart sounds; hyperresonance

Question 6

If a patient has nonanginal chest pain and a cardiac workup is negative, _____________ is a reasonable diagnostic/therapeutic option.

Answer 6

PPI trial

Question 7

A man has chronic stable angina (verified by stress ECG) that has not responded to his initial dose of metoprolol. What should you do?

Answer 7

Increase the metoprolol until no longer tolerate (HR 60).

Question 8

If a patient has chronic stable angina –meaning they have already had a stress test and have not had a change in symptoms – that is refractory to medical therapy, then you should refer them to ________________.

Answer 8

coronary angiography; doing this can both diagnose and treat perfusion defects

Note: percutaneous intervention should only be done in cases of angina that are refractory to medicine.

Question 9

What history questions can you ask to help decide if chest pain is reflux-related?

Answer 9

• “Is it worse with lying down?”

* “Is it worse after eating?”

Question 10

The medical treatment for MI comprises what six drugs?

Answer 10

• Aspirin
• Clopidogrel
• Thrombolytics (tPA)
• Heparin
• IV nitroglycerin
• Beta-blocker

Question 11

Review the contraindications to beta-blockers?

Answer 11

• Heart block
• SBP less than 90 mm Hg
• HR less than 50 BPM

Question 12

Percutaneous intervention has been shown to benefit MI patients up to ___________ hours after the onset of symptoms.

Answer 12

12

If a patient cannot get the door-to-balloon time of 90 minutes, start them on thrombolytics and do PCI if possible within 12 hours of symptom onset.

Question 13

A patient has an MI and develops hematologic instability with a new-onset holosystolic murmur at the lower-left sternal border. What happened?

Answer 13

VSD due to infarction

Question 14

Why are the dihydropyridine CCBs contraindicated in acute coronary syndrome?

Answer 14

Reflex tachycardia

Question 15

__________ presents with bradycardia and sinus pauses.

Answer 15

Sick sinus syndrome

Question 16

Differentiate type I and II second-degree heart block.

Answer 16

• I: progressive lengthening of PR interval until a beat is lost
• II: sudden loss of beat without changes in PR interval

(“oNE is leNgthEning. 2 you get in2rupted with a lost beat.”)

Question 17

Review the ECG findings of LBBB.

Answer 17

• Absent Q in I, aVL, and V6

* Wide, positive R wave in I, aVL, and V6

Question 18

True or false: the heart block caused by Lyme disease is reversible.

Answer 18

True!

Intravenous ceftriaxone for 21 days can reverse it.

Question 19

A score of _____ or more on the CHA2DS2VAS indicates anticoagulation.

Answer 19

2

Question 20

WPW can cause _______________.

Answer 20

ventricular preexcitation syndrome

Question 21

Atrial flutter classically has the atrial rate of _________.

Answer 21

300 beats/min

A fib beats at 600 beats/min.

Question 22

Multifocal atrial tachycardia most often presents in ______________.

Answer 22

patients with chronic lung disease (because the vasoconstriction of lung disease leads to right atrial enlargement)

Question 23

Review the treatment of asymptomatic HCM.

Answer 23

• Advise that the patient avoids strenuous physical activity
• Beta-blockers
• Implantable cardioverters

Question 24

Which factors can make a BNP falsely low?

Answer 24

• Obesity (the most influential factor)
• Female sex
• Old age

Question 25

In a patient with a high pretest probability of CAD –such as multiple risk factors and an echo demonstrating hypokinesis –then the correct diagnostic should be _____________.

Answer 25

coronary angiography

A stress test is so likely to be positive in a patient with hypokinesis on echo that you should proceed to coronary angiography.

Question 26

How do you treat peripartum cardiomyopathy?

Answer 26

The same as non-pregnant cardiomyopathy: beta-blockers, diuretics, and (after delivery) ACE-inhibitors

Question 27

What murmur suggests that a prosthetic aortic valve is dysfunctional?

Answer 27

An early diastolic murmur

Prosthetic valves are designed to move during systole, so a systolic click or systolic ejection murmur is normal. A diastolic murmur, on the other hand, indicates that the valve is allowing backflow –not normal.

Question 28

List the characteristics that indicate that murmur is benign and does not require further workup.

Answer 28

• Patient is asymptomatic
• Normal physical exam with exception of murmur (i.e., no edema, thrills, heaves, lung crackles, etc.)
• Murmur is 1/6 or 2/6 in intensity
• Murmur does not radiate
• ECG (if done for another reason) is normal

Question 29

Explain the role of balloon valvuloplasty.

Answer 29

In patients with aortic stenosis causing heart failure, the definitive treatment is valve replacement. Balloon valvuloplasty can be done as a bridge treatment in hemodynamically unstable patients.

Question 30

How should you manage a patient with bicuspid aortic valve who has no symptoms and evidence of mild aortic regurgitation?

Answer 30

Follow-up in 1 year

Bicuspid aortic valve does confer an increased risk of endocarditis and aortic stenosis, but if the patient is asymptomatic and lacks signs of progressive disease then follow-up is all that is needed.

Question 31

The proper treatment for hypertension secondary to fibromuscular dysplasia is ________________.

Answer 31

angioplasty of the renal vasculature

Question 32

To bridge to warfarin, you need to give LMWH for _____ days and reach an INR of _____.

Answer 32

5; 2

Question 33

Which of the heparins is not renally cleared?

Answer 33

Unfractionated

It is cleared by the reticuloendothelial system.

Do not give fondaparinux to those with GFRs less than 30.