Cardiovascular II

Question 1

The CHA2DS2-VASc score is useful for assessing thromboembolic risk in patients with […]:

C: Congestive heart failure

H: Hypertension

A2: Age > 75* (2 points)

D: Diabetes mellitus

S2: Stroke/TIA/thromboembolism* (2 points)

V: Vascular disease (prior MI, PAD, or aortic plaque)

A: Age 65-74

Sc: Sex category (female)

Answer 1

The CHA2DS2-VASc score is useful for assessing thromboembolic risk in patients with non-valvular atrial fibrillation:

C: Congestive heart failure

H: Hypertension

A2: Age > 75* (2 points)

D: Diabetes mellitus

S2: Stroke/TIA/thromboembolism* (2 points)

V: Vascular disease (prior MI, PAD, or aortic plaque)

A: Age 65-74

Sc: Sex category (female)

Question 2

The combination of atrial tachycardia with AV block is fairly specific for […] toxicity.

Answer 2

The combination of atrial tachycardia with AV block is fairly specific for digitalis toxicity.

digitalis causes both an increased ectopy in the atria or ventricles (atrial tachycardia) and an increased vagal tone (AV block)

Question 3

The current indications for operative/endovascular repair of an AAA include rapid rate of expansion, presence of symptoms, and aneurysm size > […] cm.

Answer 3

The current indications for operative/endovascular repair of an AAA include rapid rate of expansion, presence of symptoms, and aneurysm size > 5.5 cm.

rapid rate of expansion is considered > 0.5 cm in 6 months or > 1 cm per year

Question 4

The murmur of pulmonic stenosis is characterized by an ejection click followed by a crescendo-decrescendo systolic murmur over the […] space.

Answer 4

The murmur of pulmonic stenosis is characterized by an ejection click followed by a crescendo-decrescendo systolic murmur over the left second intercostal space.

versus aortic stenosis, which is typically heard over the right second intercostal space

Question 5

The presence of a continuous abdominal bruit has a high specificity for the presence of […] hypertension.

Answer 5

The presence of a continuous abdominal bruit has a high specificity for the presence of renovascular hypertension.

Question 6

The strongest predictors of abdominal aortic aneurysm rupture are large aneurysm diameter, rapid rate of expansion, and […].

Answer 6

The strongest predictors of abdominal aortic aneurysm rupture are large aneurysm diameter, rapid rate of expansion, and current cigarette smoking.

Question 7

True ventricular aneurysm is a complication that may occur months after an MI and increases risk for mural […].

Answer 7

True ventricular aneurysm is a complication that may occur months after an MI and increases risk for mural thrombus.

echocardiogram typically reveals a thinned and dyskinetic myocardial wall

Question 8

What abnormal heart sound is associated with a stiff left ventricle (e.g. LV hypertrophy due to prolonged hypertension)?

Answer 8

S4

often referred to as “ten-nes-see” a sound, which corresponds to S4-S1-S2

Question 9

What abnormal heart sound is associated with volume overload (e.g. CHF with LV dysfunction)?

Answer 9

S3

often referred to as “ken-tuc-ky” a sound, which corresponds to S1-S2-S3

Question 10

What abnormal heart sound is often heard during the acute phase of myocardial infarction?

Answer 10

S4 (atrial gallop)

due to left ventricular stiffening and dysfunction

Question 11

What abnormal RBC may be seen in patients with scleroderma renal crisis?

Answer 11

Schistocytes

due to microangiopathic hemolytic anemia

Question 12

What adrenergic receptor is the primary target of dobutamine?

Answer 12

Beta-1 receptors (agonist)

also has a weak affinity for beta-2 and alpha-1 receptors

Question 13

What age range of diabetic patients should be started on statin therapy?

Answer 13

40 - 75 years old

high-intensity if 10-year ASCVD risk > 7.5%; moderate intensity if < 7.5%

Question 14

What analgesics are associated with decreased metabolism of warfarin (i.e. increased bleeding risk)?

Answer 14

acetaminophen and NSAIDs

other notable CYP450 inhibitors include amiodarone and some antibiotics/antifungals (e.g. metronidazole)

Question 15

What anti-hypertensive medication is commonly associated with peripheral edema as an adverse effect?

Answer 15

Dihydropyridine Ca2+-channel blockers

due to preferential dilation of precapillary vessels (arteriolar dilation), which increases capillary hydrostatic pressure

Question 16

What area of the myocardium is likely involved in an MI with ST elevations in leads I and aVL?

Answer 16

Lateral (typically LCX obstruction)

Question 17

What area of the myocardium is likely involved in an MI with ST elevations in leads II, III, and aVF?

Answer 17

Inferior (typically RCA obstruction, or less commonly LCX)

Question 18

What area of the myocardium is likely involved in an MI with ST elevations in leads V1 - V4?

Answer 18

Anterior (typically LAD obstruction)

Question 19

What arrhythmia commonly develops in patients with mitral stenosis?

Answer 19

Atrial fibrillation

due to significant left atrial dilatation

Question 20

What artery is likely obstructed given the ECG below?

Answer 20

Right coronary artery

Question 21

What class of drugs should be administered within 24 hours of an MI to limit ventricular remodeling?

Answer 21

ACE inhibitors

except in patients with a contraindication; ventricular remodeling often results in dilatation of the ventricle

Question 22

What classes of medications (3) should be held for 48 hours prior to cardiac stress testing?

Answer 22

beta blockers, calcium channel blockers, and nitrates

exception: continue these medications in patients with known CAD undergoing stress testing to assess the efficacy of anti-anginal medication

Question 23

What CXR finding is often found in patients with coarctation of the aorta?

Answer 23

Notching of the ribs

also may have a “3” sign due to indentation of the aorta with pre- and post-stenotic dilation

Question 24

What drug classes (2) are used as first-line therapy for chronic stable angina?

Answer 24

beta-blockers (preferred) and non-dihydropyridine CCBs

these drugs decrease myocardial O2 demand by reducing myocardial contractility and heart rate

Question 25

What drug classes are useful for reducing Ca2+ channel blocker-induced peripheral edema?

Answer 25

ACE inhibitors and ARBs dihydropridine Ca2+ channel blockers cause edema due to pre-capillary vasodilation; ACE inhibitors relieve edema via post-capillary venodilation

Question 26

What ECG finding is fairly specific for pericardial effusion?

Answer 26

Electrical alterans diagnosis of pericardial effusion can be more definitely made using echocardiogram

Question 27

What electrolyte abnormality may potentiate the effects of digoxin?

Answer 27

Hypokalemia

Question 28

What electrolyte abnormality parallels the severity of heart failure and is an independent predictor of adverse clinical outcomes?

Answer 28

Hyponatremia caused by increased levels of renin, norepinephrine, and ADH; treatment involves fluid restriction, ACE inhibitors, and loop diuretics

Question 29

What hypertensive complication is defined as severe hypertension (\> 180/120 mmHg) with no symptoms or acute end-organ damage?

Answer 29

Hypertensive urgency

Question 30

What hypertensive complication presents as severe hypertension (\> 180/120 mmHg) with cerebral edema and non-localized neurologic signs/symptoms (e.g. confusion)?

Answer 30

Hypertensive encephalopathy (hypertensive emergency)

Question 31

What hypertensive complication presents as severe hypertension (\> 180/120 mmHg) with retinal hemorrhages, exudates, or papilledema?

Answer 31

Malignant hypertension (hypertensive emergency)

Question 32

What imaging study is used for the definitive diagnosis of cardiac tamponade?

Answer 32

Echocardiography management includes immediate percutaneous or surgical drainage of pericardial fluid

Question 33

What imaging study should be considered in a patient with acute limb ischemia after an MI?

Answer 33

Transthoracic echocardiogram to screen for LV thrombus and evaluate LV function; patients also require immediate anticoagulation and vascular surgery consult

Question 34

What intervention is most likely to improve cardiovascular and overall long-term mortality in patients with acute STEMI?

Answer 34

Restoration of coronary blood flow (e.g. PCI, fibrinolysis)

Question 35

What is preferred treatment to prevent coronary artery disease in a patient with inducible ischemia?

Answer 35

Anti-platelet therapy (e.g. aspirin) a decreased tracer uptake with stress but normal at rest indicates inducible ischemia

Question 36

What is the best initial management for a hemodynamically stable patient with palpitations and the ECG findings below?

Answer 36

IV amiodarone

Question 37

What is the first-line therapy for conscious and stable patients with torsades de pointes?

Answer 37

IV magnesium if patient is hemodynamically unstable, immediate defibrillation is indicated

Question 38

What is the imaging modality of choice for diagnosis and follow-up of abdominal aortic aneurysms?

Answer 38

Abdominal ultrasound cheap and does not require contrast (vs. CT and MRI)

Question 39

What is the initial management for a patient with pulmonary hypertension that presents with JVD, peripheral edema, bibasilar crackles, and an ejection fraction of 30%?

Answer 39

Loop diuretics and ACE inhibitors (or ARBs) the pulmonary hypertension is due to LV systolic dysfunction and thus treatment involves addressing the underlying cause; beta-blockers and occasionally aldosterone antagonists may be used for long-term management as well (note: endothelin-1 receptor antagonists and PDE-5 inhibitors are used for idiopathic pulmonary hypertension)

Question 40

What is the initial management for a patient with suspected acute arterial occlusion leading to an immediately-threatened limb (e.g. sensory loss, weakness)?

Answer 40

Anticoagulation (e.g. IV heparin) should be done prior to further evaluation with non-invasive or invasive imaging

Question 41

What is the initial management for a patient with suspected acute limb ischemia?

Answer 41

Anticoagulation (e.g. IV heparin) should be initiated empirically, prior to further evaluation with other imaging studies

Question 42

What is the initial management for hypotension in a patient with a right ventricular MI that has low-normal JVP?

Answer 42

IV saline bolus (nitrates should be avoided) RVMI often creates high sensitivity to intravascular volume depletion; hypotension with low JVP suggests inadequate RV preload

Question 43

What is the initial management of choice (besides pain control) for patients with type B aortic dissection?

Answer 43

IV beta blockers (e.g. labetalol, esmolol, propanolol) results in decreased HR, BP, and LV contractility (less aortic wall stress)

Question 44

What is the initial therapy for patients with atrial fibrillation due to hyperthyroidism?

Answer 44

Beta blockers helps control heart rate and hyperadrenergic symptoms; should be continued until the patient becomes euthyroid with thionamides, radioiodine, and/or surgery

Question 45

What is the initial treatment for a hemodynamically stable patient with atrial fibrillation with rapid ventricular response?

Answer 45

Rate control (e.g. beta blockers or CCBs) rhythm control should be considered in patients unable to achieve adequate HR control or in those with recurrent symptomatic episodes

Question 46

What is the initial treatment for chronic venous insufficiency?

Answer 46

Conservation measures (e.g. leg elevation, exercise, compression therapy) patients who do not respond to conservative measures should have diagnosis of CVI confirmed by identification of venous reflux in the deep venous system on duplex ultrasound

Question 47

What is the initial treatment for symptomatic sinus bradycardia?

Answer 47

IV atropine in patients with inadequate response, further treatment options include IV epinephrine or dopamine, or transcutaneous pacing

Question 48

What is the initial treatment for tachycardia-mediated cardiomyopathy?

Answer 48

Rate or rhythm control presents with progressive dyspnea, decreased exercise tolerance, and LV systolic dysfunction secondary to chronic tachycardia (e.g. chronic A-fib)

Question 49

What is the initial treatment of choice for a patient with atrial fibrillation that develops asystole or pulseless electrical activity (no palpable pulse but electrical activity on ECG)?

Answer 49

CPR with vasopressor therapy (e.g. epinephrine) potentially reversible causes of PEA should also be investigated (see below)

Question 50

What is the initial treatment of choice for a patient with persistent tachyarrhythmia with associated hemodynamic instability?

Answer 50

Immediate synchronized cardioversion energy delivered is synchronized to the QRS complex to minimize the likelihood of the shock occuring during repolarization, which can precipitate ventricular fibrillation; hemodynamically stable patients may be managed with rate control (e.g. beta-blockers, non-dihydropyridine CCBs)