Week 5

Question 1

Describe stable angina

Answer 1

angina with exertion that is alleviated in 1-3 minutes by rest OR no more than one NTG

Question 2

A stress test should be completed how soon after new onset presentation of stable angina?

Answer 2

within 72 hrs unless contraindicated

Question 3

What 3 groups are most likely to present with atypical symptoms of ACS?

Answer 3

women, elderly, diabetics

Question 4

What differentiates an NSTEMI and Unstable Angina?

Answer 4

NSTEMI = ST depression of > 1mm for > 48 hours

Question 5

Patient presents to the clinic complaining of new onset chest pain that started while he was walking in from the car. The chest pain has been present for 15 minutes and is not alleviated with rest. EKG shows ST depression > 1 mm in contiguous leads. The provider calls 911 for suspicion of unstable angina/evolving NSTEMI. What are 2 things that the provider can do in the office while waiting for EMS? (treatment wise)

Answer 5

Administer ASA chewable tablet and NTG table (if not contraindicated)

Question 6

What EKG finding would you expect in a patient with suspected pericarditis?

Answer 6

Diffuse ST elevation

Question 7

Name three high risk factors for endocarditis?

Answer 7

IVDU, structural cardiac abnormalities, implantable devices, cardiac/vascular prostheses, immunosuppression, and IE history

Question 8

What are the common presenting symptoms in a patient with pericarditis?

Answer 8

Retrosternal chest pain that is worse when supine or leaning forward with inspiration

Question 9

What pathogen most commonly causes endocarditis?

Answer 9

staph aureus

Question 10

What components MUST be present on diagnostic exams in order to diagnose Pericarditis?

Answer 10

At least 2 of the following – sudden onset pleuritic chest pain, diffuse ST segment elevation, pericardial friction rub, and new/worse pericardial effusion on echo

Question 11

What EF is diagnostic of HFrEF?

Answer 11

EF < 40%

Question 12

What are the two classic presenting symptoms of heart failure?

Answer 12

dyspnea and fatigue

Question 13

What ALWAYS needs to be ruled out first in a patient presenting with new onset symptoms of heart failure?

Answer 13

rule out ACE with EKG first

Question 14

Patient with known HF has LV wall thickening on his most recent echo and an EF of 45%. He is asymptomatic. What stage (A,B,C,D) is this patient in?

Answer 14

stage B. structural changes and no symptoms

Question 15

Patient presents to the clinic with new onset cough and +1 LE edema. He has fine bilateral crackles on auscultation. His vital signs are stable and he is in no acute distress. EKG is normal. What should the NP do next? Administer PO Lasix and monitor vs refer to the ER?

Answer 15

ER – hospitalization criteria includes New onset HF congestion symptoms, ACS/MI, Pulmonary edema (pink frothy sputum), New arrhythmia w/ hemodynamic instability, SPO2 <90, Complicating disease state, ? safe home management, Symptoms refractory to PO treatment or home management plan

Question 16

An asymptomatic 63-year-old adult has a low-density lipoprotein level of 135 mg/dL. Which
test is beneficial to assess this patient’s coronary artery disease risk?
a. Coronary artery calcium score (CACS)
b. hsCRP (high-sensitivity CRP)
c. Exercise echocardiography
d. Myocardial perfusion imaging

Answer 16

ANS: B
The hsCRP is useful in asymptomatic men >50 years and women >60 years who have LDL
<160 mg/dL to predict CAD risk. Although the CACS has shown some benefit in patients
with moderate risk, the role for this diagnostic test is unclear. Exercise echocardiography and
myocardial perfusion imaging are not performed initially.

Question 17

Which risk assessment for coronary artery disease is recommended for all female patients?

a. Coronary artery calcium score
b. Electrocardiogram
c. Exercise stress test
d. Framingham risk score

Answer 17

ANS: D
The Framingham risk score is a quick method for identifying potential risk for CAD and can
guide providers in choosing subsequent tests based on risk level. The ECG is performed on
women with risk factors. The exercise stress test is useful in symptomatic women who have a
normal ECG. The CACS may be used if moderate risk is present.

Question 18

During a routine health maintenance examination, the provider auscultates a cervical/carotid
bruit. The patient denies syncope, weakness, or headache. What will the provider do, based on
this finding?
a. Order a carotid duplex ultrasound (US).
b. Order catheter-based angiography.
c. Refer the patient to a neurosurgeon.
d. Schedule a computed tomography angiography (CTA).

Answer 18

ANS: A
Carotid duplex ultrasound is the primary diagnostic tool for carotid stenosis. A cervical bruit
in an asymptomatic patient is an indication for this test. Catheter-based angiography is the
criterion-based standard but has inherent costs and risks. A neurosurgery referral is not
indicated without further testing. CTA is used instead of duplex US if the test is not available,
if US results are inconclusive, or further evaluation is needed based on US results.

Question 19

According to current research, which are associated with a decreased incidence of stroke?
(Select all that apply.)
a. Statin therapy for low density lipoproteins (LDL) of <75 mg
b. B-complex vitamin supplements
c. Glycemic control for patients with diabetes
d. Low-sugar soda
e. Maintain a body mass index (BMI) of <30 kg/m2

Answer 19

ANS: A, C, E
Statin therapy for low density lipoproteins (LDL) of <75 mg, glycemic control for patients
with diabetes, and maintaining a body mass index (BMI) of <30 kg/m2

has shown to lower the
risk of stroke. B-complex vitamins and low-sugar soda have not shown to decreased risk.

Question 20

A patient reports recurrent chest pain that occurs regardless of activity and is not relieved by
rest. The provider administers a nitroglycerin tablet which does not relieve the discomfort.
What is the next action?
a. Administer a second nitroglycerin tablet.
b. Give the patient a beta blocker medication.
c. Prescribe a calcium channel blocker mediation.
d. Start aspirin therapy and refer the patient to a cardiologist.

Answer 20

Patient with these symptoms who do not respond to nitroglycerin is likely to have
microvascular angina. Treatment is effective with beta blockers. These symptoms are not
characteristic of acute MI, so aspirin is not given. A second nitroglycerin tablet is used for
classic angina. Calcium channel blockers are not indicated.

Question 21

A patient is brought to an emergency department with symptoms of acute ST-segment
elevation MI (STEMI). The nearest hospital that can perform percutaneous coronary
intervention (PCI) is 3 hours away. What is the initial treatment for this patient?
a. Administer heparin.
b. Give the patient an oral beta blocker.
c. Initiate fibrinolytic treatment.
d. Transfer to the PCI-capable institution.

Answer 21

ANS: C
Fibrinolytic therapy should be administered to any patient with evolving STEMI within 30
minutes of the time of first medical contact. Patients more than 120 minutes away from a
PCI-capable hospital should be given fibrinolytic therapy since PCI should be performed
within 90 minutes if possible. Giving heparin or beta blockers is not helpful.

Question 22

Which patient meets the criteria for statin therapy to help prevent atherosclerotic
cardiovascular disease? (Select all that apply.)
a. A 55-year old with a history of congestive health failure (CHF)
b. A 70-year old nondiabetic with a 10-year risk score of 7.5% with an LDL-C of 80
mg/dL
c. An otherwise healthy 25-year old with a low-density lipoprotein (LDL-C) level of
196 mg/dL
d. A 45-year old diabetic with an LDL-C of 150 mg/dL
e. A 60-year old with a history of myocardial infarction

Answer 22

B,C, D,E
Adults with a history of known cardiovascular disease, including stroke, caused by
atherosclerosis; those with LDL-C level of greater than 190 mg/dL; adults 40 to 75 years, with
diabetes; adults 40 to 75 years, with LDL-C level of 70 to 189 mg/dL and a 5% to 19.9%
10-year risk of developing cardiovascular disease from atherosclerosis, with risk enhancing
factors; adults 40 to 75 years, with LDL-C level of 70 to 189 mg/dL and a 20% or greater
10-year risk of developing cardiovascular disease from atherosclerosis.

Question 23

A patient experiencing heart failure with reduced ejection fraction will have which symptoms?

a. Dyspnea and fatigue without volume overload
b. Impairment of ventricular filling and relaxation
c. Mild, exertionally related dyspnea
d. Pump failure from left ventricular systolic dysfunction

Answer 23

ANS: D
Heart failure with reduced ejection fraction results in pump failure from ventricular systolic
dysfunction. Heart failure with preserved ejection fraction may have milder symptoms and is
associated with impairment of ventricular filling and relaxation.

Question 24

A patient who has been diagnosed with heart failure for over a year reports being comfortable
while at rest but experiences palpitations and dyspnea when walking to the bathroom. Which
classification of heart failure is appropriate based on these symptoms?
a. Class I
b. Class II
c. Class III
d. Class IV

Answer 24

ANS: B
Patients with Class II heart failure (HF) will have slight limitation of activity and will be
comfortable at rest with symptoms occurring with ordinary physical activity. Patients with
Class I HF do not have limitations and ordinary physical activity does not produce symptoms.
With Class III HF, less than usual activity will produce symptoms. With Class IV HF,
symptoms are present even at rest and all physical activity worsens symptoms.

Question 25

A patient who has Class II heart failure is taking an ACE inhibitor and reports a recurrent
cough that does not interfere with sleep or activity. What will the provider do initially to
manage this patient?
a. Assess serum potassium and sodium immediately
b. Discontinue the ACE inhibitor and prescribe an ARB
c. Provide reassurance that this is a benign side effect
d. Withhold the drug and evaluate renal and pulmonary function

Answer 25

ANS: C
Cough occurs in about 20% of patients who take ACE inhibitors and is not dangerous. The
patient should be reassured that this is the case. If the cough is annoying, alternate therapy
with an ARB may be considered. It is not necessary to evaluate electrolytes, renal function, or
pulmonary function.

Question 26

A patient who is on renal dialysis is diagnosed with infective endocarditis. What causative
organisms are more likely in this patient?
a. Enterococcal organisms
b. Neisseria gonorrhea
c. Pseudomonas aeruginosa
d. Staphylococcus aureus

Answer 26

ANS: D
This patient is more likely to have a health care–associated endocarditis; most of these are
caused by S. aureus. Enterococcal organisms are the second highest cause in this population.

Question 27

A patient has been diagnosed with infective endocarditis and is being treated with empirical
antibiotics after blood cultures are inconclusive. The patient develops a severe headache along
with transient neurologic changes. What is the likely cause of these symptoms?
a. Extra-cardiac abscess formation
b. Haemophilus infection
c. Mycotic aneurysm
d. Rheumatic heart fever

Answer 27

ANS: C
Patients with mycotic aneurysms will present with symptoms of severe unrelenting headache,
neurological changes, and signs of cranial nerve involvement. Extracardiac abscess formation
depends on the organ involved. Haemophilus infections cause larger vegetations in the heart.
Rheumatic heart fever has a classic group of symptoms involving the skin.

Question 28

A patient has native valve endocarditis (NVE). While blood cultures are pending, which
antibiotics will be ordered as empirical treatment?
a. A beta-lactamase-resistant penicillin and an antifungal drug
b. Imipenem-cilastatin and ampicillin
c. Penicillin G and an aminoglycoside antibiotic
d. Vancomycin and quinupristin-dalfopristin

Answer 28

ANS: C
The most common organism in NVE is S. aureus; until resistance is known, treatment with
penicillin G and an aminoglycoside is needed, although most strains causing NVE are not
penicillin-resistant. Antifungal infections are rare and antifungal medications are not part of
empirical therapy. Imipenem-cilastatin plus ampicillin is given for identified Enterococcus
faecalis infection. Vancomycin and quinupristin-dalfopristin is used, with limited evidence for
benefit, for Enterococcus faecium infection.

Question 29

A previously healthy patient presents with sudden onset of dyspnea, fatigue, and orthopnea. A
family history is negative. The provider suspects myocarditis. What is the most likely etiology
for this patient?
a. Autoimmune disorder
b. Bacterial infection
c. Protozoal infection
d. Viral infection

Answer 29

ANS: D
Viral infection is the most common cause of myocarditis. Other infections are less likely.
Although this patient may have an autoimmune disorder, the absence of family history makes
this somewhat less likely.

Question 30

Which test is diagnostic for diagnosing myocarditis?

a. Echocardiogram
b. Electrocardiogram
c. Endomyocardial biopsy
d. Magnetic resonance imaging

Answer 30

ANS: C
Endomyocardial biopsy is the only definitive test to diagnose myocarditis. Other tests are
useful in determining symptoms but are not specific to this diagnosis.

Question 31

A patient who is an avid long-distant runner is diagnosed with viral myocarditis. What will
the provider tell this patient when asked when resuming exercising is permitted?
a. Exercise is contraindicated for life.
b. Exercise may resume when symptoms subside.
c. He may resume exercise in 6 months.
d. He must be symptom-free for 1 year.

Answer 31

ANS: C

Patients with myocarditis should not exercise for 6 months after the onset of symptoms.

Question 32

An elderly adult patient without prior history of cardiovascular disease reports lower leg
soreness and fatigue when shopping or walking in the neighborhood. The primary care
provider notes decreased pedal pulses bilaterally. Which test will the provider order initially
to evaluate for peripheral arterial disease based on these symptoms?
a. Digital subtraction angiography
b. Doppler ankle, arm index
c. Magnetic resonance angiography
d. Segmental limb pressure measurement

Answer 32

ANS: B
The Doppler study may be performed easily to indicate the likelihood of PAD. Other tests are
performed only if indicated.

Question 33

A 75-year-old patient reports pain and a feeling of tiredness in both legs that only relieves
after sitting for 30 minutes or more. What the does provider suspect as the cause for these
symptoms?
a. Buerger’s disease
b. Cauda equina syndrome
c. Diabetic neuropathy
d. Peripheral arterial disease (PAD)

Answer 33

ANS: B
Patients with cauda equina syndrome, which causes spinal stenosis, will often not get relief
until they sit down for a period of time. Buerger’s disease involves both the upper and lower
extremities. Diabetic neuropathy may mask pain. PAD involves these symptoms that stop
with rest.

Question 34

A patient is diagnosed with peripheral arterial disease (PAD) and elects not to have
angioplasty after an angiogram reveals partial obstruction in lower extremity arteries. What
will the provider recommend to help manage this patient’s symptoms?
a. Daily aspirin therapy to prevent clotting
b. Statin therapy with clopidogrel
c. Walking slowly for 15 to 20 minutes twice daily
d. Walking to the point of pain each day

Answer 34

ANS: D
Studies have demonstrated that an exercise program involving walking to the point of pain is
as effective as angioplasty. Medications are useful to prevent progression of plaque formation
and to prevent myocardial infarction (MI).

Question 35

A patient has a cardiac murmur that peaks in mid-systole and is best heard along the left
sternal border. The provider determines that the murmur decreases in intensity when the
patient changes from standing to squatting and increases in intensity with the Valsalva
maneuver. Which will the provider suspect is causing this murmur?
a. Aortic stenosis
b. Hypertrophic cardiomyopathy
c. Mitral valve prolapse
d. Tricuspid regurgitation

Answer 35

ANS: B
These findings occur with hypertrophic cardiomyopathy. With aortic stenosis, the murmur is a
harsh crescendo-decrescendo heard best at the right sternal border that decreases in intensity
with the Valsalva maneuver. With mitral valve prolapse, the murmur is heard in mid- to late
systole, is heard best at the left lower sternal border, and may have a click that moves to later
systole or disappear with the Valsalva maneuver. With tricuspid regurgitation, the murmur
may occur at early, mid, or late systole, is heard at the left lower sternal border, and decreases
with the Valsalva maneuver.

Question 36

A young adult patient is diagnosed with a mitral valve prolapse. During a routine 3-year
health maintenance exam, the provider notes an apical systolic murmur and a mid-systolic
click on auscultation. The patient denies chest pain, syncope, or palpitations. What action will
the provider take?
a. Admit the patient to the hospital for evaluation and treatment.
b. Consult with the cardiologist to determine appropriate diagnostic tests.
c. Continue to monitor the patient every 3 years.
d. Reassure the patient that these findings are expected.

Answer 36

ANS: B
Most patients with mitral valve prolapse are monitored every 3 years unless they have a
systolic murmur. The provider should consult with the cardiologist. Hospital admission is not
necessary since the patient is asymptomatic.

Question 37

Which are factors that can cause a heart murmur? (Select all that apply.)

a. Backward flow through a septal defect
b. Backward flow into a normal vessel
c. Forward flow into a dilated vessel
d. High rates of flow through a normal valve
e. Low rates of flow into a cardiac chamber

Answer 37

A,C,D
High rates of flow into either normal or abnormal vessels can cause murmurs. Backward flow
into septal defects, regurgitant valves, or PDAs can cause murmurs. Forward flow into
constricted or irregular valves or into a dilated vessel can cause murmur. Backward flow into
a normal vessel and low flow rates are not responsible for murmurs.

Question 38

what is the need for immediate cardiology referral?

Answer 38

holosystolic murmur
grade 3 murmur or higher
murmur that increases in intensity when standing
diastolic murmur
has new onset extra heart sound