Cardiovascular

Question 1

What is the most common causative organism of acute bacterial endocarditis in intravenous drug users?

Answer 1

Staphylococcus aureus

Question 2

Which valve is most commonly affected in intravenous drug users with bacterial endocarditis?

Answer 2

Tricuspid valve

Question 3

What is the most common causative organism of subacute bacterial endocarditis in patients with preexisting valve disease?

Answer 3

Streptococcus viridans

Question 4

Which imaging modality is most sensitive for detecting vegetations in infective endocarditis?

Answer 4

Transesophageal echocardiography (TEE)

Question 5

What is the empiric antibiotic treatment for acute bacterial endocarditis?

Answer 5

Vancomycin plus ceftriaxone

Question 6

What cardiac physical exam finding is associated with painless, erythematous lesions on the palms and soles?

Answer 6

Janeway lesions

Question 7

What cardiac condition is suggested by painful, raised nodules on the pads of the fingers or toes in bacterial endocarditis?

Answer 7

Endocarditis, specifically Osler nodes

Question 8

Name a common complication of infective endocarditis that involves the central nervous system

Answer 8

Embolic stroke

Question 9

A 28-year-old male with a history of intravenous drug use presents to the ED with fever, chills, and malaise for 3 days. He reports worsening shortness of breath and pleuritic chest pain. On exam, he is febrile (101.8°F), tachycardic, and has track marks on his arms. A new holosystolic murmur is heard at the lower left sternal border. What is the most likely diagnosis, and what is the next best step?

Answer 9

Acute bacterial endocarditis; order blood cultures and a TEE

Question 10

A 63-year-old woman with a history of mitral valve prolapse presents with fatigue, low-grade fever, and unintentional weight loss over the past month. On exam, she has a low-grade fever, splinter hemorrhages on her nails, and a diastolic murmur at the apex. Blood cultures grow alpha-hemolytic streptococci. What is the likely diagnosis, and what is the standard treatment?

Answer 10

Subacute bacterial endocarditis caused by streptococcus viridans; treat with IV vanco and ceftriaxone for 4-6 weeks

Question 11

A 45-year-old male with a history of a prosthetic aortic valve presents with left-sided weakness and slurred speech. He reports intermittent fevers over the past 2 weeks. Physical exam reveals a right-sided hemiparesis and a systolic murmur at the right upper sternal border. What is the likely diagnosis, and what is the cause of his symptoms?

Answer 11

Infective endocarditis with embolic stroke due to septic emboli from aortic valve vegetation

Question 12

A 50-year-old woman with a history of prosthetic mitral valve is scheduled for a dental extraction. What antibiotic should be given for prophylaxis, and when should it be administered?

A) Cephalexin, 30-60 minutes before the procedure
D) Diclocacillin, 24 hours prior to procedure
C) Amoxicillin, 30-60 minutes before the procedure
D) Penicillin, 24 hours prior to procedure

Answer 12

Amoxicillin 30-60 minutes before the procedure

Question 13

What is the first-line medication for relieving acute anginal symptoms?

Answer 13

Sublingual nitroglycerin

Question 14

What ECG finding is typically associated with stable angina during an episode of chest pain?

Answer 14

Transient ST-segment depression

Question 15

What test is most commonly used to diagnose stable angina?

Answer 15

Exercise stress test

Question 16

What is the most common cause of angina?

Answer 16

Atherosclerotic coronary artery disease

Question 17

What differentiates unstable angina from a myocardial infarction?

Answer 17

Unstable angina does not cause elevated cardiac biomarkers (troponin or CK-MB)

Question 18

Which medication class is indicated for chronic management of stable angina to reduce myocardial oxygen demand?

Answer 18

Beta-blockers

Question 19

What is the preferred antiplatelet therapy for patients with stable angina?

Answer 19

Aspirin

Question 20

What is the first diagnostic test to perform in a patient presenting with acute chest pain in the ED?

Answer 20

12-lead EKG

Question 21

What type of angina is associated with coronary artery spasm?

Answer 21

Prinzmetal (variant) angina

Question 22

What medication is contraindicated in patients with angina and concurrent phosphodiesterase inhibitor (e.g., sildenafil) use?

Answer 22

Nitroglycerin

Question 23

A 67-year-old woman presents to the ED with chest pain that started 2 hours ago while she was resting. The pain has been intermittent, lasting 10–15 minutes each time, and does not fully resolve with nitroglycerin. Her ECG shows no ST-segment elevation but reveals nonspecific T-wave inversions. Initial troponins are negative. What is the most appropriate next step in management?

A. Discharge with outpatient cardiology follow-up
B. Initiate dual antiplatelet therapy and admit for further observation
C. Administer IV thrombolytics
D. Perform emergent coronary angiography

Answer 23

Initiate dual antiplatelet therapy and admit for further observation

This presentation is consistent with unstable angina, requiring admission, dual antiplatelet therapy, and further evaluation for ischemia. Emergent coronary angiography is reserved for STEMI or hemodynamic instability

Question 24

A 75-year-old woman, discharged 1 day ago following admission for an inferior myocardial infarction, presents with acute dyspnea and is noted to have a new holosystolic murmur at the apex that radiates to her axilla. Which of the following complications of her myocardial infarction is most likely?

A) Papillary muscle rupture
B) Pericarditis
C) Right ventricular infarction
D) Ventricular free wall rupture

Answer 24

Papillary muscle rupture

Papillary muscle rupture is seen in approximately 1% of patients with acute MI. It typically occurs 3–5 days after infarction and is most common after inferior MI.

Question 25

What is the name of the tendinous structures that connect the mitral valve leaflets to the papillary muscle?

Answer 25

Chordae tendinae

Question 26

At what point does Dressler Syndrome (post-MI pericarditis) present after a myocardial infarction?

Answer 26

Most commonly 2-10 weeks after an MI

Question 27

What EKG findings are associated with acute pericarditis?

Answer 27

* PR elevation in aVR * PR depression * Diffuse concave ST elevation

Question 28

What are the three components of Beck triad of cardiac tamponade?

Answer 28

* Hypotension * Distended neck veins * Muffled heart sounds

Question 29

A 60-year-old woman presents to the emergency department with chest pain. ECG shows ST-segment elevation in leads V2–V4. Vital signs are BP 80/40 mm Hg and HR 65 bpm. You would like to start IV dobutamine to provide inotropic support. What is the most appropriate additional medication to administer? A) Epinephrine B) Milrinone C) Norepinephrine D) Phenylephrine

Answer 29

Norepinephrine ## Footnote For patients in cardiogenic shock with a systolic blood pressure < 90 mm Hg, the addition of norepinephrine will help to mitigate the vasodilatory effects of dobutamine, thereby preventing further hemodynamic instability.

Question 30

What is the diagnosis in a patient with ECG findings showing ST elevations in leads V3–V6, I, II, III, and aVF?

Answer 30

Anterolateral and inferior STEMI

Question 31

A 65-year-old man presents in respiratory distress. He has a known history of hypertension, heart failure, diabetes mellitus, and hyperlipidemia. He arrives unable to speak in more than two-word phrases secondary to severe distress and tachypnea. Vital signs are remarkable for BP 220/130 mm Hg, HR 105 bpm, RR 40/min, and pulse oximetry 75%. Accessory muscle use, intercostal retractions, and diffuse rales are noted on examination. In addition to placing the patient on BPAP, which of the following should be administered next for blood pressure control? A) Esmolol B) Fenoldopam C) Nicardipine D) Nitroglycerin

Answer 31

Nitroglycerin ## Footnote In patients presenting with an acute hypertensive emergency with acute pulmonary edema, the mainstay of therapy is vasodilators, predominantly nitrates. Nitrates reduce blood pressure, decrease myocardial oxygen consumption, and improve coronary blood flow. A reduction in blood pressure by 25% is recommended in the first hour of treatment.

Question 32

What is the treatment for an episode of acute decompensated heart failure? | What heart sound is heard on exam in a patient in heart failure?

Answer 32

* NIPPV: ↑ oxygenation, ↓ work of breathing, ↓ preload, afterload * Nitroglycerin: ↓ preload, afterload * Furosemide: diuresis * Hypotension without signs of shock: dobutamine (but may worsen hypotension) * Severe hypotension with signs of shock: norepinephrine (↑ systemic vascular resistance, ↑ HR, ↑ BP, ↑ myocardial oxygen demand) | S3 Gallop

Question 33

What will be seen on x-ray in a patient with acute decompensated heart failure?

Answer 33

* Cardiomegaly * Cephalization * Kerley B lines * Effusions

Question 34

A patient presents to the ER with chest pain. An ECG shows diffuse concave ST elevations in almost all of the leads. What is the most likely diagnosis? | What is the treatment?

Answer 34

Pericarditis | NSAIDs, Colchicine, steroids

Question 35

A 53-year-old man presents with sudden chest pain that radiates to the back and abdomen. On examination, his blood pressure is 189/92 mm Hg in the right arm and 150/71 mm Hg in the left arm. Which of the following is the most likely diagnosis? A) Acute pericarditis B) Aortic dissection C) Cardiac tamponade D) Ruptured abdominal aortic aneurysm

Answer 35

Aortic dissection

Question 36

A 30-year-old woman with a history of cocaine use presents to the emergency department after an episode of sudden, severe chest pain radiating to her left arm. On physical examination, the patient is tachycardic and diaphoretic. Which of the following medications should be avoided in this patient? A) Aspirin B) Labatalol C) Lorazepam D) Nitroglycerin

Answer 36

Labetalol ## Footnote Beta-blockers are contraindicated in cocaine-associated chest pain or myocardial ischemia because unopposed alpha-adrenergic stimulation can worsen: Coronary vasospasm, Hypertension, and Myocardial ischemia.