Cardiology Board

Review

CAD

MKSAP Q 1

60 yo M present to ED w/ chest discomfort for

6 hrs. Tx w/ ASA, IV BB, and NTG. Chest pain
persists. Initial troponin and CK-MB are
elevated.
Pt taken ergently to Cath lab. Occlusion of
prox RCA. PCI is successfully. Following
morning doing well on rounds but progessively
more hypotensive. JVP elevated. Nml S1, S2.
+S3, brief systolic murmur along L sternal
border. ECG is unchanged from previous.

What is the most likely cause for this

patients current findings?
1.
2.
3.
4.
5.

Acute Cardiac tamponade

Aortic dissection
Left Ventricular Free Wall Rupture
Right Ventricular MI
Progressive Coronary Ischemia

*Characteristic RV Infarction:
progressive hypotension (always be
weary of preload reducers like NTG),
elevated JVP, and clear lung fields.
+tricuspid regurg
~R precoridal Lead ECG will detect ST
elev in V4R
~These pt may require volume
challenges

*Other MECHANICAL COMPLICATIONS

following MI:
~Ventricular Septal Rupture
~Papillary Muscle Rupture: hear acute
mitral regurg murmur
~LV Free Wall Rupture => cardiac
tamponade, hypotension and usually
death

Q 23
57 yo M comes to ED w/ substernal chest
pressure that developed this AM. PMHx of
HTN, stable angina, PVD; his meds are
HCTZ and ASA.
BP 110/80, HR 84. No JVP and lungs clear.
Nml S1/2. Abd exam neg, pulses
diminished in LE. Continues to have angina
at rest. ECG w/ changing ST segs and T
waves. Trop 0.8. The patient is given ASA,
BB, and enoxaparin, and is transferred to
the CCU to await angiography.

What additional therapy should be

given in the CCU?
1.
2.
3.
4.
5.

Heparin
Warfarin
Eptifbatide
Bivalirudin
Diltiazem

Early treatment w/ Glycoprotein 2b/3a

receptor blockade improves outcomes of
PCI. *Indicated only if high risk markers
(TIMI Score >3-4, +biomarkers, ST
depression, CHF, h/o of recent PCI, or
hemodynamic instability.
-Abciximab =only if undergoing PCI
-Eptifibitide or Tirofiban (if there is no clear
inidication that PCI will be performed)
*Warfarin offers no protection for Coronary events. SYNERGY trial
showed Enoxaparin and Heparin outcomes nearly equivalent
(unless switch from LMWH -> UH). Dilitaizem doesnt affect
outcomes in CAD.

Q 37
42 yo M @ rural ED w/ severe L
shoulder & chest pain, radiates to
jaw. +diaphoresis, dyspnea. No
PMHx, no meds. +father has CABG.
In the ED, IV Heparin, Atenolol, and an
ASA are given. BP 100/79, HR 61.
No JVP. Nml S1/2. This hospital does
NOT have a Cath lab, closest is 62
miles. Takes 2 hrs to arrange
transfer.

What is the BEST management option

for this patient?
1. Glycoprotein receptor blockade
2. Plavix
3. Esmolol
4. Fibrinolytic therapy
5. NTG

GOAL of all Reperfusion strategies for

STEMI is to achieve a patent vessel w/in
90 mins from onset of symptoms.
~4 subgroups in which PCI is preferred:
A. Contraindications of fibrinolytic therapy
B. Late arriving STEMI, > 12 hrs after onset
of chest pain w/ contd CP and ST elevs
C. H/O CABG
D. Cardiogenic Shock

REMEMBER for CAD:

Reperfusion

arrhythmias (AIVR) usually

do not req antiarrhytmics
Do not need Cardiac Cath after
Fibrinolysis if ST seg elevation and CP
have resolved
Initial management of ACS related to
systemic process, tx the preciptating
factor 1st (ie pRBCs if GI bleeding)
ASA allergic: give Plavix

HEART FAILURE

Q 13
55 yo M w/ CAD evaluated w/ 2 wks
after having an MI. D/C meds were:
ASA, Toprol, ISMN, Lisinopril, and
Atorvastatin. Echo revealed
inferoposterior akinesis and LVEF of
40%.
Exam: HR 60, BP 13-/70. JVP nml, lungs
clear. Regular s1/s2. Labs: K-5.7, Cr1.0, LDL-65. Lisinopril therapy
stopped.

Which of the following medications

should be started in this patient?
1.
2.
3.
4.
5.

Valsartan
Spironolactone
Amlodipine
Eplerenone
Hydralazine

SHF MEDS:

ACEi (or if intolerant, ARB)

~will usually tolerate a K to 5.5

B-blocker
Hydralazine/Nitrate combo if cant tolerate an
ACEi or ARB, or adding specifically if africanamerican
Spironolactone w/ NYHA class 3 or 4
symptoms
Eplerenone (aldo receptor antag) is useful in
reduced EF after AMI

REMEMBER for HEART FAILURE:

Digoxin

alleviates Sx, reduceds

hospitalization 2/2 HF (not mortality)
Diurese HF pt w/ volume overload 1 st,
then beta block
Put an AICD in a HF pt that comes in
w/ unexplained syncope
Put a Biventricular Device in HF pt on
optimal therapy w/ continued
symptoms and QRS > 120 ms

Arrhythmias

Q 14
23 yo presents w/ palpitations during
exercise. Healthy, no meds. Exam
and resting ECG nml. Stress test
shows sustained monomorphic V
tach @ 201 /min. No iscemic
changes until arrhythmia developed.
The V tach had a Left bundle and
infoerior axis morphology.
Terminated spontanesouly 7 mins
into rest. ECHO nml, MRI nml.

What is the most likely etiology of V

tach in this patient?
1. Coronary spasm
2. Idiopathic
3. Arrhythmogenic R ventricular
cardiomyopathy
4. Infiltrative heart disease
5. Anomalous origin of the coronary
arteries

Idiopathic V Tach (no structural heart

disease) carries a good prognosis. Tx
symptoms, BB first line.
~Expect BP and ST segment elev w/
spasm. Nml MRI/ECHO rule out
infiltrative disease, anomolaus
coronaries, or arrhythogenic RV
cardiomyopathy (would see fatty
infiltration).

Q 38
68

yo presents for routine eval. No

complaints other than lumbago.
Active, does yoga 3x/week. Meds
include Levothryoxine and HCTZ.
Exam: HR 46. On further questioning,
she notes palpitations during a yoga
class. 24 Ambulatory monitoring
reveals HR of 39-82, avg of 45/min
and occ pauses up to 2.9 sec. Nml
TSH.

What is the BEST management option

for this patient?
1. Pacemaker implantation
2. Exercise stress test
3. Repeat 24 hr monitoring
4. Reassurance and Observation

ONLY when there is definitive

correlation b/w sinus bradycardia
and symptoms, is pacemaker
warranted
Class I
1. 3rd degree heart block w/ one of following:
a. Bradycardia with symptoms
b. other medical conditions that require drugs that cause sx brady
c. Documented asystole 3.0 seconds or any escape rate <40 bpm in
free patients.
d. After catheter ablation of the AV junction
e. Postoperative AV block that is not expected to resolve
f. Neuromuscular diseases with AV block

awake, symptom-

2. Second-degree AV block regardless of type or site of block, with associated symptomatic

bradycardia
Class IIa
1. Asymptomatic third-degree AV block w/ average awake ventricular rates of >/= 40
2. Asymptomatic type II second-degree AV block
3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally
at electrophysiological study for other indications
4. First-degree AV block with symptoms suggestive of pacemaker syndrome and documented
alleviation of symptoms with temporary AV pacing

Q 43
68 yo F comes to the ED b/c of racing
heart for past 2 hrs. Reports 2 yr
history of similar episodes. Been told
by PMDs in past to cough/strain,
usually works but not today. No chest
pain, no other cardiac history.
Exam shows BP of 110/60, HR 165,
RR 20. Lungs clear. Carotids w/o
murmurs, attempt massage w/o
effect. ECG is shown.

Which is the drug of choice for

terminating this patients
arrhythmia?
1. Metoprolol
2. Verapamil
3. Adneosine
4. Digoxin

Q 122
26 yo nurse is evaluated in the ED
after episode of syncope. While
working stressfull day in the ICU,
developed tachycardia and then LOC.
+palpitations in past
Exam wnl. CXR wnl. ECG initially
unremarkable. 10 mins later,
developed brief tachycardia. Repeat
ECG shown.

What is the most likely diagnosis in

this patient?
1. Atrioventricular nodal reentrant
tachycardia
2. Accelerated Idioventricular
tachycardia
3. Atrioventircular reentrant
tachycardia
4. Multifocal atrial tachycardia

AVNRT: >50% of all SVTs. Circuit involves the

AV node, so atria and Ventricle activated

simultaneously. So p wave usually buried in
QRS.
AVRT: Circuit involves an accessory pathway.
Most orthodromic: travels anterograde down
AV node, retrograde up accessory path. Some
pts w/ pre-excitation phenomena: during SR,
see short PR interval and delta wave
(evidence of pre-excitation)= *WPW
=> ADENOSINE is DRUG of CHOICE,
however avoid if any evidence of preexcitation on ECG

REMEMBER:

In healthy adults, PVCs at rest are common and not

cause for concern
Procainamide is drug of choice in a preexcited A fib
DC Cardioversion is 1st line for any unstable
tachycardic pt (hypotensive, signs of HF like
diaphoresis, pulm edema)
REMEMBER your CHADS2 score, if >2 give warfarin
For A FIB: 1st line is always rate control, only
consider antiarrhytmic or ablation if symptomatic
from being in controlled A fib
A flutter often result of another acute process,
consider referral for ablation earlier as often difficult
to rate control

THE AORTA

Q 45
69 yo M presented to ED for acute
onset of substernal CP radiating to
left arm. +former smoker, h/o HTN
On exam: diaphoretic, BP of 210/95
mmHG in R arm and 164/56 in L arm
with HR 90. There is dullness way
up R posterior troax and 2/6 diasolic
murmur at RUSB. ECG shows 2-3 mm
inferior ST seg elevation.

Prior to additional diagnostic tests,

which of the following is the most
appropriate initial medication?
1. ASA
2. IV Heparin
3. Thrombolytic agent
4. Beta blocker
5. ACE inhibitor

AORTIC DISSECTION: disparate BPs

b/w arms, diastolic murmur of aortic
regurg. Do NOT given ASA, heparin,
etc if suspect. Initial treatment is w/
Beta Blockers to decrease shear
stress. Diagnostic tests should be a
TRANSESOPHAGEAL ECHO vs. CHEST
CT w/ CONTRAST.
`

Valvular Disease

Q 16
82 yo presents for annual exam. PMHx: HTN on
chronic BB. Denies all cardiac sx. Takes daily
1 mi walk, no change in exercise tolerance.
Exam shows: BP 136/86, HR 80. s1, single s2,
grade 3/6 early systolic murmur @ LUSB w/
radiation to carotids. 1+ peripheral edema.
LDL is 110. ECHO 2 yrs ago showed
moderate calcific aortic stenosis (velocity
was 3.6, valve area 1.2, gradient 30) with
nml LV fxn. Now ECHO shows jet velocity of
4.2, valve area of 1.0, and gradient of 44).

What is the most appropriate next

step?
1.
2.
3.
4.
5.

Reassurance
Begin a cardiac rehab program
HCTZ
Start statin therapy
Refer for Aortic valve replacement

Aortic Stenosis:
~Reassurance remains appropriate if
asymptomatic and nml exercise tolerance
~w/ severe stenosis the stiff valve doesnt
snap shut, thus loose aortic component and
get only a single S2 (a physiologic split S2
has specificity of 72% of excluding severe
AS)
~controling BP important, but use CAUTION
w/ any peripheral vasodilators b/c
compensation in Stroke Volume across a
stenosed valve my be difficult!!
~ Symptoms: Angina (5), Syncope (3), Heart
Failure (2)

Q 19
36 yo F in the ED w/ fever & dyspnea. 4
wks of fever to 40C. +heroin use.
Exam: 39.6, 100/52, 70, 91% on RA. JVP
12. Bibasilar crackles. HR reg irregulsr.
S1, muffled s2. 2/6 diastolic murmur @
R 2nd intercostal space. 1+ pretibial
edema. ECG shows a bifascicular block
and Mobitz II. ECHO shows 2 veges on
aortic valve, w/ leaflet perforation and
severe AR. Echoluceny in paravalvular
region. Placed on broad spectrum Abx.

What is the most appropriate

treatment at this time?
1. Esmolol IV
2. Heparin IV
3. Intraortic ballon pump (IABP)
4. Permanent pacemaker
5. Aortic Valve Replacement

Acute Aortic Regurgitation

Whether

from endocarditis or Aortic

dissection, this is a SURGICAL
EMERGENCY!
Esmolol (short acting BB)can slow HR
and prolong diastolic filling to aid in
forward output in some pts w/ AR
(this pt has sig conduction abnml)
IABP is CONTRAINDICATED in AR

Q 44
32 yo M comes in for annual exam. No
personal or fmHx of cardiac disease.
Exam: s1/s2, +s4, 2/6 crescendodecrescendo systolic murmur heard
best at LLSB w/o radiation to
carotids. Increased intensity w/
valsalva. Isometric hand grip, passive
leg raising decreases the intensity.
Rapid upstrokes of peripheral pulses
are present.

What is the most likely diagnosis?

1. Mitral Valve Prolapse
2. Hypertrophic cardiomyopathy
3. Atrial septal defect
4. Ventricular Septal Defect
5. Aortic Stenosis

Hypertrophic
Cardiomyopathy

If preload is increased (isometric hand

grip, stand-> squat) = increased systolic
dimension of LV and therefore less
obstruction & diminished murmur, Valsalva
= decreased preload so increased murmur
Tx even asymptomatic pts w/ BB, avoid
strenuous exercise
*different from hypertrophied athletes LV
in that septum is asymmetrically enlarged

REMEMBER:
ECHO

for any Diastolic Murmur,

Continuous murmur, or > grade 3/6
Wide, Fixed split S2 think ASD
Secundum ASD can be prepared
percutaneously