CARDIOLOGY KAPLAN Qs
183qs
TOPIC/Concept
Sick Sinus Syndrome
= Chronic state of SA node
dysfunction or a sluggish or
absent SA node pacemaker
Stage 1 HTN: 140/90 to
160/100
Need HTN diagnosis after
confirmed elevated BP 3
separate occasions.
AGE is big RF
Explanation
Tx: Venticular Pacemaker implanted 68yoM checkup after his Acute
Sx:
1. SOB
2. Palpitations
3. Angina
Alternating Bradycardia &
Supraventricular Tachycardia
commonly with underlying Atrial
Fibrilations or Atrial Flutter
Goal: Terminate the Bradycardia-
Tachycardia
1st: if Stage 1 w/o Comorbidities
(CHF, DM, CKD)
*Exercise, Diet, + Thiazide
(Not Diet, Exercise onlyor extra
meds)
IF Thiazide Max but not reaching BP
goal use 2nd agent:
ACE-I or BB can be added
Presentation
MI a year ago. Said feeling fine
until 6wks ago started having
Palpitations, and feel fatigued
and SOB. Holter monitor
revealed Bradycardia with brief
episodes of Atrial Flutter. BP
110/75, 50bpm, Resp 15.
Management for this pt?
= Ventricular Pacemaker
63yoF. BP 147/93she returns
2 wks later her BP is 148/95,
another 2 weeks: 152/98.
Which is most appropriate
intervention?'
HMG-CoA Reductase
inhibitors (Statins) - DOC to
Reduce LDL
Atorvastatin 40yoM. Cholesterol panel:
Elevated LDL & Low HDL. Diet &
Statins most POTENT & well excerised done..6mo later HDL
tolerated by pts than other lipid normal, but LDL Elevated still.
lowering meds. Next Step?
Risk: Myositis.
Routine LFT ordered (bc SE: Liver
Inflammation)

Variant Angina (Prinzmetal) - Transient ST-segment DEPRESSION 30yo Asian F chest pain. Last 2
Coronary vasospasm in INFERIOR leads years has had intermittent
angina-like sx. nocturnal chest pain lasts up to
= Classic: Awakens pt from Angina-like sx at restdue to 10mins. Pain is substernal &
Sleep coronary vasospasm. heavy pressure radiates to
Associated w/Vasospatic throat. Has Raynaud
condition clues: Raynauds Pts w/Prinzmetal: Younger, likely phenomenon. Social hx
Women. occasional use cocaine. EKG
worsens by Cocain, unremarkable. Given this pt's
Sumatriptan. (Exercise-Hyperventilation induces likely Diagnosis, which likely
MC: RCAInferior heart sxvia Alkalosisvasoconstriction) finding on Holter monitor
during chest pain?

Pericarditis:
EGK:
*Diffuse ST-segment
Elevation,
*PR-segment Depression

Acute Coronary Sd: Unstable
plaque is partially or
intermittently obstructs
blood flow:
Transient ST-Depression
3 separate diagnoses:
Unstable Angina, NSTEMI,
STEMI
ASPIRIN = Mortality 72yoF chest pain. 2hrs ago was
If pt presents with ACS: watching tv when she felt a dull
*New onset chest pain pain that radiated to the jaw.
*Worsening pattern Chest tightness and SOB. She
*Pain at rest had similar pain before, mostly
with exertion. PE: clutching her
Next step always: ASPIRIN (to chest in pain & sweating
platelet thrombus progression) profusely. CVS exam: Distant
heart sounds. No STelevation or
Oxy, Morphine, Nitrates: Left Bundle branch block.
All ACS should be treated with 100% Which steps in Management
Oxy, Morphine, Nitratesbut none will give greatest reduction in
of these has PROVEN to Mortality MORTALITY?
Diastolic Dysfunction:
*HR via BB or CCBto
time for Ventricles to fill
during Diastole
*ensure BP is controlled
*prevent further myocardial
hypertrophy with ACE-I or
ARBs
*Prevent remodeling and
regress hypertrophy with
Spironolactone/Aldosterone
antagonist
*Avoid BB in COPD or
Asthma pt
Dobutamine -
only use if pt has Acute
Pulmonary Edema, and
doesn't respond to IV Loop,
Nitrates, Morphine (goal:
Preload)
Hypertrophic BB: Metoprolol
Cardiomyopathy:
*Syncope in Young pts. BB help SLOW Ventricle Rate. To
*Valsalva: Murmur Ventricle Fill time
(Any maneuver that
decreases LV size
Murmur = obstructive part
as LV cavity shrinks)
Verapamil 60yoF h/o HTN, COPDhas
SOB. Says has 6mo h/o
Hypertrophy dt long HTNget progressive worsening SOB
Diastole dysfunction: Concentric while climbing stairs. Barrel-
hypertrophy shaped chest, prolonged
1. SOB on exertion (EDVpreload wheezes. Transthoracic echo
backs up into lung congested - shows Diastolic LV Dysfunction.
exertional SOB).... so relax heart Which is Next Best step?
during DIASTOLE to improve fill
pressures:
1st DOC: BB.... but Pt has COPD (so
can't do BB)
2nd line: CCB- Verapamil/Diltiazem
= Negative Inotrope...relaxes the LV
during diastole
1) Prevents heart relax in diastole -
can't fill
2) Time in diastole is shortened
during Tachycardia
BB: blocks B2-receptors in lungs
lead to bronchoconstriction & lung
function
Dobutamine is Positive
Inotrope.doesnt relax the LV.
*Decreases Afterload.get severe
Hypotension
21yoF professional dancer
several episodes of near loss of
consciousness. No famHx. BP
142/88. PE: brisk carotid
upstroke with a double impusle
palpable. Loud S4 & harsh
systolic murmur -left sternal
border. Murmur accentuated
during VALSALVA. ECG: LV
Hypertrophy. Which drugs most
appropriate for this pt?
 ACE-I: -pril Afterload drop in
Pressure gradient across aortic
valve.exacerbates/worsens the
outlet obstruction (in HCM)

Digoxin: Contractilityworsens
outflow obstruction of HCM

Loop decreases preload: leads to

worsening the outlet obstrction

CABG: indications Coronary artery bypass using 55yoM has progressive,

1) Stenosis of Left main, INTERNAL MAMMARY Artery unstable angina that doesn't
3vessels, 2vessels in DM respond to meds. H/o DM2 &
CABG > angioplasty. hypercholesterolemia for past
2)PCI: percutaneous *3 or more stenotic vessels or 20yrs. Two of his brothers had
coronary interventionused disease of the Left Main coronary MI @50yo. Cardiac
in pts with symptoms artery catheterization shows 70%
occlusion of two coronary
3) Internal Mammary artery Internal Mammary artery > arteries, includes Anterior
is donor best vessel for saphenous vein bc saphenous get descending EF is 55%. Next
coronary artery bypass graft occluded after 5yrs. best step in management?
Internal mammary = good for 10yrs

Angioplasty & Stents better for

ISOLATED vessels rather than multi-
vessel CAD

Mitral Valve Replacement in Percutaneous BALLOON 25yoF 24wks gestationhas

Pregnancy vavuloplasty worsening dyspnea &
orthopnea over past 10days.
*Pregnant w/symptomatic *pt has Life-threatening Pulmonary Treat w/Furosemide but no
Mitral Stenosisfailed meds Edema in setting of Mitral Stenosis. improvement. h/o rheumatic
next: Balloon Valvoplasty (Fluid Overload) heart disease & mitral stenosis.
is most effective (Save the mom is main concern) PE: JVD, Bilateral Crackles. Best
next step management?
*Mitral valve replacement is Mitral Steonsis+Pregnant: do
risk to Mom & Fetus Percutaneous Balloon Valvuloplasty

(Not: urgent C-section)

Pregnant Woman.DO NOT use

ACE-I bc can have Renal Defects to
Fetus
Digoxin Toxicity:
*N/D/Fatigue, Somnolence
*Visual alterations
(confusing green with yellow
halos)
*Arrhythmias
(SCOOPED ST-segments or
reverse Check sign)
Toxicity: get AV node
blocked, Automaticity of
Ventriclesincludes
junctional myocardium
1st: Atropine
2nd: Check Digoxin Levels
(to see if immune Fab
needed)
Digoxin Levels
Not: "Digoxin immune Fab"
Initial Step in treating Symptomatic
Bradycardia: improve the
hemodynamics
Renal Failure can worsen digoxin
toxicitydigoxin clearance
*Quinidine, Amiodarone,
Spironolactone, Verapamil
Digoxin toxicity bc inhibits Renal
secretion of Digoxin
Atropine ist 1st to tx: Symptomatic
Bradycardia with signs of
Hypoperfusion
68yoF Nausea, dizziness, SOB,
somnolence, fatigue. Began sx
4 days ago. PE: BP 98/46, she
appears uncomfortable. Vision
confuses green for yellow.
Lung prolonged expiratory
phase, mild crackles at bases.
1+ pitting edema. CXR: large
cardiac silhouette, flattened
diaphragms. Atropine
given...new BP 115/85. Next
Step?
Diastolic LV Dysfunction: dt
HTNConcentric
Hypertrophy heart can't
relax during diastole
Sx: Dyspnea on exertion
Rx: ACE-I
Goal: HR 55-60bpm
(if push HR down, heart
spends more time in
Diastolemore time in
Diastolic Filling)
[Can use CCB: Verpamil or
Diltiazem...but don't want
HR <55]
Diastolic LV Dysfunction
Rx goal: HR
*BB
*CCB
CAD
Lisinopril 58yoM h/o HTN comes in bc of
(HR...reducing AFTERLOAD w/ACE- SOB. Has Progressive worsening
I or ARBs)...-pril improves exercisedyspnea while climbing stairs.
tolerance, but no mortality in pts No CP and SOB at rest. On
with Concentric HTN Aspirin & metoprolol. PE:
Regular HR & Rhythm with
LV can't fill properly bc: absence of murmurs or rubs,
1) Concentric Hypertrophyprevents has S4. BP 150/80. PE: Rales
heart from Relaxing during Diastole @bases. LE edema. Echo shows
LV filling pressures w/Normal
2) Time spent in Diastole is EF. Next Best Step?
SHORTENED during Tachycardia
EDV is reduced & EDP bc LV STIFF
& non-compliant Pulmonary
Congestionbc excess PRELOAD
backs up into Lungs Exertional
Dyspnea
Rx: Negative Inotropic to relax the
heart during Diastole
Decrease HR Amount of Time
for Ventricles to Fill
Other Meds used to Treat Heart
Failure:
*ACE-I or ARBs (prevents remodeling
and act to regress hypertrophy)
*Aldosterone Antagonists (prevents
& regresses hypertrophy and
fibrosis)
Metoprolol 56yoM CP & SOB with
exertion. Exercise stress test
BB = MORTALITY in Acute reveals coronary artery
Coronary Sd pt - unstable angina diseaseBP readings given.
etc.) & POST-MI pt. 146/96, 150/90, 140/96. Drug
BB: BP, HR-to lessen strain on appropriate?
heart, Perfusion to heart tissue.
BB: Arrhythmias
 ACE-I 2nd line BP med.

ACE-I: 1st line BP in DMbc slows

progression of Diabetic
Nephropathy. Also Improves
SURVIVAL in pts w. CHF: bc
AFTERLOAD

ACE-I: Post-MI pt with LV damage,

beneficial effect on SURVIVAL
secondary to Remodeling effect on
Ventricle

AORTIC STENOSIS Bicuspid Valve 28yoF Chest pain with

exertion. Started 4mo ago
Angina symptoms bc 1. <70yo w/dyspnea, lightheaded and
demand by hypertrophied 2. Crescendo-decrescendo systolic felt faint while exercising. BP
LV (Subendocardium murmur, Right 2nd intercostal space 154/92. PE: Delayed carotid
ischemia) radiates to carotids. LV hypertrophy upstrokes that are diminished
in amplitude. Forceful apical
MC: Congenital Bicuspid Aortic Valve impusle & soft S2. Harsh
Less likely sequelae of Rheumatic crescendo-decrescendo systolic
Valvular Disease murmur best heard at right 2nd
Rheumatic Valve disease in pt from ICSpace radiates to carotids.
Developing country. ECG shoes LVH. Likely cause of
pt's condition?

PAC: Premature Atrial Order a 72 hour holter monitor 59yoM CC Palpitations. Says
Contractions feels like his heart "skips a beat
do: 72 hour holter monitor Holter Monitor records all of pt's sometimes". EKG shows normal
Heart beats sinus rhythm. What's Next Step
in diagnosing this pt?
[Echo doesn't help diagnose PACs are extra impulses that can
PACs] originate from anywhere in Right or
Left Atria. ..makes pt feel like hearts
skipping a beat

Don't give THROMBOLYTIC

therapy if patient has >10
mins of CPR (Prolonged CPR)
why: After 10mins of CPR,
likelihood of trauma to
Anterior Chest Wall is high
(Fractures)..= risk Bleeding
CARDIAC TAMPONADE Pericardiocentesis followed by 48yoM chest pain. Suddenly
Post MI complications: pericardial window felt dull, crushing chest pain
1. Hypotension that radiated to jaw and left
2. Tachycardia Cardiac Tamponade: arm. PE: Sweating. Muffled
3. Clear lungs auscultation *BP, TachyC, Pulsus Paradoxus, heart sounds that are regular
4. Pulsus Paradoxus Clear breath sounds rate and rhythm. EKG: STEMI
Cx signs: Same as RV = Real Emergency had PCI. BP drops to 105/55,
infarct. But difference is Need immediate Decompression by Pulse 120/min. Jugulovenous
Pulsus Paradoxus (SBP Pericardiocentesis followed by Distension. BP rechecked BP
>10mmHg with Normal Pericardial Window between 110/55 and 95/55
Inspiration) Management?
Cardiac Tamponade Lt & Rt
Next Best Step: ventricles get SQUASHED by
Pericardiocentesis blood/fluid collection in Pericardial
Sac Capcity of Both Lt & Rt
Ventricles.

Inspiration Contracts Diphragm

Returns Blood to Rt Ventricle. So the
Already squished Lt ventricle gets
more Squashed by Enlarging Rt
Ventricle...so can't keep Contraction
during Systole DROP SBP during
Systole

Vs: Rt Ventricle Infarct...there's NO

Pulse Paradoxus. bc heart is Not
being Squashed, and any increase in
Volume in Rt Ventricle is
accommodated by Pericardial Sac.

MI - Inferior Wall: Fluids 62yoFhas Acute inferior MI.

= Impairs LV filling.get CO She's oliguric and has BP 80/55.
Swanz-Ganze shows Elevated Rt- Swan-Ganz catheter is placed
sided Pressure and Low filling shows diminished Pulmonary
pressure. Capillary Wedge of 4mmHg.
Normal Pulmonary Artery
RV Infarct: get Cardiac Outputbc Pressure of 22/4mmHg.
Insufficient Lt heart filling Increased mean Rigth arterial
pressures. pressure of 11mmH. Which is
RV infarct causes Back up of Venous Next best Step?
Blood and Decreased Forward
Flow.get LV filling (Low Wedge
Pressure)
Tx: IV FLuids
..Then Cardiac Catherization (Balloon
Angioplasty)
AORTIC STENOSIS Decrease intensity of murmur 64yoF comes to ED intermittent
*Progress to Angina, chest discomfort. Substernal
Syncope, HF Hand Grip: compresses forearm pressure occasionally radiates
muscles on ATERIOLES to Left arm and last approx
Sx: CP, Dizziness or syncope, Afterload. When Afterload 10mins. ..PE: Delayed carotid
HF increases, heart can't pump out Upstroke and systolic ejection
enough bloodleads to Reduction in murmur 2nd intercostal space
SV and ESV. Causes LV Volume right border. Pt does HAND-
Grip maneuver. Effect likely
seen?

CONCENTRIC HYPERTROPHY Hypertension 64yoF obese h/o Alcoholism.

SOB. Progressive worsening
Chronic HTN Concentric DOC: for Diastolic HF (hypertropy) dyspnea while climbing stairs.
Hypertrophy Diastolic BB No CP. BMI 40. Echo shows
Dysfunction diastolic LV dysfunction. Likely
BB: BP & HR to allow improved cause of her symptoms?
Ventricular Filling

Hypertensive Emergency: Intravenous Labetalol 60yoM Chest pain. Long hx of

*Chest discomfort CAD & HTN and status post
*Papilledema Labetalol is combined: Beta- coronary bypass procedure 6yrs
*BP 220/115 Adrenergic & Alpha-Adrenergic ago. Pt has chronic stable
blocker. angina that's precipitated by
best agents: activity and relieved by rest.
*Labetalol Rapid onset (5mins) - useful for Meds: aspirin, captopril,
*Nitroprusside Hypertensive Emergencies metoprolol. 3wks ago was
prescribed sildenafil. BP:
Labetalol is safe in pts with Coronary 220/120, Papilledema on
disease ocular exam. EKG nonspecific
changes. Which is best
Avoid Labetalol in Asthma, COPD, HF, treatment indicated at this
Bradycardia, Greater than 1st degree time?
heart block.
Cold leg & Acute Ischemia Emergently transfer to operating 55yoF long standing h/o
Atrial fibrillation room for EMBOLECTOMY. Arterial Fibrillation 2/2 Mitral
Peripheral arterial Reguragecomes to ED with
Embolization & Cold Leg *Important in management of cold painful right foot. Past few
= Surgerical Emergency. leg & acute ischemia of lower limb = hours, her foot has become
Embolectomy more painful and now is nearly
insensate. Pains is Burning.
Irreversible damage to tissues occurs Right foot is gray and cool to
after 4-6hrs, so need touch, has poor capillary refill.
revascularization Dorsalis pedis & posterior tibial
1) Embolectomy pulses are absent on the right.
2) then Anticoagulation - Heparin PT is 14s. (INR 1.4). What's next
(but make sure pt NOT allergic to step?
Heparin)

Left Heart Failure Valve REPAIR 66yoM h/o bacterial

(paroxysmal nocturnal
dyspnea, orthopnea, AS: Replace
occasional dyspnea)has MS: Angioplasty
Mitral Regurge. MR: Repair
= Pansystolic Murmur best
heard at apex, radiates to EF: <60%...candidate for Valve
axilla. Replacement
MR can decompensate into
Fulminant HF very fast.
EF cut-off is <55%
Surgery is Best when EF is 55-65%
endocarditis comes bc SOB.
Past 2 montsh been waking up
in middle of night gasping for
breath. Using 4 pillows to fall
asleep and occasionally
dispneic on climbing stairs. PE:
absence of JVD and pedal
edema. Pansystolic murmur
heard best at apex & radiates
to Axilla is audible. EKG: EF
55%. Which of following is next
best step?

Cholesterol: CAD Initiate Drug Therapy for Control of 48yo previously healthy man.
his Hyperlipidemia Fasting total serum cholesterol
299mg/dL. BP 135/85. Labs
This Pt's Risk Factors: 2weeks ago. Total Cholesterol:
Family Hx 299mg
Age HDL: 65mg/dL
Tobacco LDL: 170mg/dL
HDL >60 = -1RF Best Next Step?
= has 2 total RF = Moderate risk for
Coronary Disease.
HYPOTENSION & Administer ATROPINE IV 50yoM has acute MI. 8hrs after
Bradycardia this event, BP 70/50mmHg.
= a Vagal response RCA SA node Inferior Wall Pulse 45/min. EKG reveals sinus
Sinus BradyCardia rhythm. Which is most
(Give Atropine: appropriate intervention?
Anticholinergic)

BPH+HTN Terazosin 58yoM Difficulty voiding. Delay

when he "attempts to go",
Co-Treatment 2 things at same time: often wets underwear. BP
Terazosin is Alpha 1-receptor 160/92. Which
Antagonist useful for treatment of antihypertensive for this pt?
HTN & BPH

Right Ventricle Infarct - Fluids 72yoF abdominal pain. Waking

Postinfarct complication
*STEMI in inferior leads (II,
III, avF)
*Hypotension
*CTA
don't give meds that
decrease preload (nitrates,
diuretics)
DOC: FLUIDS to increase
PRELOAD (More in, more
out)
up in morning with a dull,
Hypotension epigastric pain, nauseous and
Tachycardia sweaty. CVS PE: Muffled heart
CTA sounds. EKG: ST-elevation in
Absent pulsus paradoxus. leads II, III, avF. She undergoes
coronary angiography and
ST-elevation in Leads II, III, avF percutaneous coronary
[=RCAsupplies Right Ventricle] intervention. 24hhrs later BP
falls to 105/67 with no
variation on inspiration. P: 128,
Chest CTA. Next best step in
management?
Cardiac Tamponade: RV infarct:
Signs are exact same as RV NO Pulsus Paradoxus
infarct.one Clinical sign
that is Different: Pulsus
Paradoxus
(SBP >10mmHg with
Normal Inspiration)

Tx: Pericardiocentesis &

Pericardial window

(moa: L&R ventricles

squashed by collection of
blood in pericardial
sac)...can't fill

Atropine used in cases of

bradycardia (muscarinic-R)

Tachycardic in this RCA-MI pt already

has overproductive SNS. Atropine
blocks M-receptors= Parasym.
Tone. Give atropine to this pt can
cause more tachycardia (Increased
sym. Tone) induce another MI

Emergency Bypass = for pt in Severe Pt who is decompensating

CHF post-MI rapidly (CHF), with right & left
HF but no murmur to explain
[r/o CHF: lungs CTA) the HF.(=Valve rupture is
common Post-MI) = do
Emergency Bypass

Cardiac Risk factor: Fasting Serum Lipid Studies 55yoMcomes for check up.
*Family h/o Heart disease Everything looks normal, but
*Age has Family history: mother
*Fasting Lipid with stroke, brother with MI at
*DM 50yo, Father died MI 58. BP
*CHD RF: smoking, HTN 142/78. Which is most
appropriate screening test for
USPSTF: recommends start this pt?
dyslipidemia screen
Men: @20-35yo
Women: @20-45yo
If evidence of Order: Carotid Artery Duplex studies
*TIA: Transient Ischemic
Attack
*Stroke sx
*Bruit heard

MI. (+digoxin use) Echocardiogram 56yoF h/o Atrial fibrillation,

complains of CP. Currently on
Digoxin: for Afib controls Pt whom diagnosis of MI is difficult Digoxin. 1 hour ago she's felt
ventricular rate. But it due to Nonspecific or Nondiagnostic sudden, dull pain in chest and
interrupts EKG interpretation EKG change, next step: Confirm left arm. P 132, BP 105/70.
when pt has Acute Coronary diagnosis with: Sweats. PE: Muffled heart
Sd....causes NONSPECIFIC *Cardiac Enzymes or ECHO (see wall sounds. Initial EKG elevated J-
EKG Chnages motion abnormalities indicative of Point, non specific ST changes.
*EKG can't be read as having Ischemia) Next Step?
ST-seg elevation bc effects of
Digoxin obscure these (Next step is NOT EKG). If can't read
changes EKG, do echo.

Coronary Artery Bypass Echo:

Graft & PCI: Percutaneous
Coronary Intervention:
*Only when MI diagnosis
confirmed before mapping
out coronary arteries with
angiography
*Diagnose Acute Ischemia: LBBB,
LVH, Pacemaker, Non-specific ST-T
segment changes on resting EKG,
Young females

1-2Vessel Dz: Tx: PCI-Balloon

& Stent
3-Vessel Dz or Lt Main CAD:
Coronary bypass Graft

Unstable Angina dt LEFT Coronary Artery bypass Grafting 68yoM. Compalins of dull,
MAIN CAD NSTEMI: central chest pain and
Occlude Lt Main coronary CABG: tightness. Pt feels SOB. PE:
artery. *Left Main Coronary Stenosis >50% Sweating profusely. Distant
= Immediate Coronary *Lt main equivalent: 70% stenosis of heart sounds, regular rate and
Artery Bypass Grafting PROXIMAL LAD, Lt Cx rhythm. EKG: No ST-elevation.
*3 vessel Disease Cath lab, Coronary Angiogram
[Case: Unstable Angina due *Symptomatic Acute Coronary Sd shows 60% occlusion Left Main
to LEFT MAIN CAD] with ongoing Ischemianot coronary artery. Next best
[Lecture] responsive to Maximal Nonsurgical Step?
Therapy
Cocaine-induced cardiac
ischemia.
Rx: IV Diazepam
Acromegaly pt case -
1) Order IGF-1
Renal Artery Stenosis Renal Artery Stenosis: 68yoF. Difficult to control HTN.
HTN this case. She has 3year h/o HTN and
HTN in this case: Clues: documented intolerance of
Essential HTN is MCCO HTN 1) sensitive to ACE-I ACE-Inhibitors-see by rapid
(91%) 2) Creatinine decline in her renal function.
3) her CHF She has had 2 episodes of
Acute Pulmonary Edema in
[moa: Renal Artery Stenosis depends past. 2 weeks ago her Cr: 1.3mg
on Vasoconstriction of Efferent and UA: Microscopic
arteriole to maintain GFR. But ACE-I hematuria. BP: 180/100. PE:
abolish vasomotor tone in the Prominent Apical impulse.
Efferent Arteriole results in Which most likely cause of this
Worsening renal function]...renal pt's HTN?
improves by removing ACE-I

Coarctation of Aorta= Pulses Equal &

Symmetrical
*Pt die YOUNG if defect not
corrected in Childhood

AAA: Abdominal Aortic Abdominal U/S: ultrasound 74yoM abdominal pain. Mid-
Aneurysm umbilical region dull, aching,
*Cost Effective screening. constant pain. Pain persisted
*Definitive test when AAA suspected over past few days with
(Sensitivity & Specificity almost increasing intensity, and not
100%) relieved by changes in
positioning or eating. Pulsatile
(CT scan of abdomen w/IV contrast mass in abdomen. Diagnostic
is 2x expensive as U/S. Exposes pt to test at this time?
unnecessary radiation) - CT
abdomen usually preop so surgeon
can develop plan

MRI: detects abscesses or spinal

cord compression
DM+HTNProteinuria Start Lisinopril 66yoF recent DM2. Her BP 3
Rx months ago was 140/95,
BP must be well controlled to exercise and eat a low-salt diet.
prevent Nephropathy progression Gain 4.4lb. BP 144/95. Next
ACE-I prevents diabetic nephropathy best step?
Acute Coronary syndrome: Aspirin, Heparin, Alteplase combo
STEMI
STEMI: need urgent revascularization JVD+, basilar crackle, peripheral
w/n 90mins need procedure:
Angioplasty & Stent
>90mins delay: give Thrombolytics hostpital with angioplasty is
(Alteplase) - 25% mortality
reduction
LMWH > unfractionated heparin
Subacute Bacterial TEE: Transesophageal
Endocarditis: enchocardiogram
- MR
to see if has Valve Vegetationto
estimate degree of Mitral Valve
destruction
TEE > TTE if other is not possible.
TTE=less sensitive/doesn't help tell
amount of damage to valve
Intracardiac lesion - dt large Intracardiac Lesion
Lt Atrial MYXOMA
*Mid-diastolic rumble best heard at
Obstruction Sx. apex = Mitral Stenosis or Large
Atrial MYXOMA (= MC cardiac
Emboli: to CNS, Lower limbs tumor = obstructs Mitral Valve)
etc. *Neuro: arm weaknessbc Tumor
EmboliLow fever = a tumor
74yoM Stable angina &
diaphoresis. BP 145/93. PE:
pulses faint. CXR: Pulmonary
edema. EKG: inferior ST-
segment elevations. Closes
2hours away. Which drugs
most appropriate?
40yoM 2week h/o fever,
anorexia, weight loss, fatigue.
PE: appears ill, T: 102, few
petechiae in both eyes. CVS:
III/VI pan systolic murmur max
at apex and radiates to axilla,
and pericardial rub. Blood
drawn and culture. Which is
diagnostic test most likely to
confirm diagnosis?
58yoF. Episode of Left upper
arm weakness resolved after 6
hrs. Low fever last month. Mid-
diastolic rumbling murmur on
fifth intercostal space at
midclavicular line. Sent for
Echo. What's likely to reveal?
Acute Pulmonary Edema dt Intravenous loop diuretic, nitrates,
CHF morphine
Rx:
1) IV Loop-furosemide, = Reduces PRELOAD (associated with
Nitrates, Morphine Acute Pulmonary Edema)
(Loop - venodilation then diuresis
moves fluid from lungs to
circulation, then expelled to urine
VR)

Nitroglycerine: venodilates, dilates

epicardial coronaries...tx: ischemia

Morphine: Anxiety, Sympathetic

outflow, Venodilates &
Preload...help relieve pulmonary
edema

MUGA scan:
(multigated acquisition) inject 99mTc
- attaches to RBC outlines cardiac
chambers - LV by imaging the
isotope in central circulation during
systole & diastole.
Determines EF in pts with sx of
Chronic Heart Failure
(Invasivenot for acute setting, or
acute pulmonary edema)

Aortic Coarctation Aortic Stenosis: 30yoM. BP 160/70. PE: Brachial

*usually asymptomatic pulses more prominent than
*Lesion found on PE. femoral, popliteal, dorsalis
Coarctation of Aorta associated with pedis pulses. CT scan of chest
IF Symptomatic: several cardiac lesions: w/contrast shows coarctatino
*Headaches, Nosebleeds, sx: *VSD of aorta just above ligmentum
Lower limb perfusion *Bicuspid Aortic Valve arteriosum. Which conditions
*Lt Ventricular Hypoplasia likely associated with pt's
condition?
Bicuspid Aortic Valves are associated
with higher rate of aortic stenosis &
insufficiency
PTCA: Percutaneous PTCA 68yoF CP. Dull CP everytime she
Transluminal Coronary walks her grandchildren to
Angioplasty with stent unless: school. Now she stops and rest
insertion: 2 vessel disease *Lt Main stenosed (urgent bc if for 5 mintues so pain could
thrombosed....then all 3 major subside. Denies CP at rest. LDL
Important Exception is DM coronary a. blocked)or 140, statin added. Coronary
ptTx: Coronary Bypass even *3vessel disease angiography shows patchy
if 2 vessel disease present *significant Lt equivalent disease disease in distal part of LAD &
(DM with Non-ST segment (>70% stenosis of Proximal LAD, distal part of Circumflex. Next
elevations + 2vessel Proximal LCx) best step?
disease.Mortality 2-5yrs) = do Coronary Artery Bypass
Grafting

BLOCK 7
Femoral Pseudoaneurysm:
complication of cardiac
catheterization
Femoral pseudoaneurysm 68yoF underwent cardiac
catheterization via right
*Pulsatile mass femoral artery earlier in the
*Femoral Bruit morning. She's no complaining
*Loss distal pulses/cool mottled of a cool right foot. PE:
lower limb Pulsatile mass over her right
groin with loss of her distal
Confirm: Ultrasound of groin pulses, auscultation bruit over
point which right femoral artery
entered. Diagnosis?

Cholesterol Emboli Cholesterol emboli presents with

Syndrome: complication to
recognize in post-
catheterization patient
Skin findings:
*Distal extremities of Livedo
Reticularis, Ischemic Ulcerations,
Cyanosis, Gangrene, Subcutaneous
nodules

Med SE: Stop Fosinopril and replace with 48yoF persistent dry
Started new med (ACE-I), Losartan cough.currenty taking
gets Cough now switch to fosinopril.
Losartan (ARBs) ACE-I get dry cough dt Kinin levels
Aortic Valve Replacement Clear the patient for hip surgery
indications in Aortic Stenosis
pt:
1) Severe AS+Sx
2) Severe AS in pts
undergoing CABG or Valve
repair
3) Severe AS with LV EF <50%
Balloon valvulotomy is
reserved for adults who are
poor surgical candidates bc
procedure has high rate of
Re-stenosis
Quit smoking Morbidity
& Mortality
Aortic Dissection: = an
emergency
1) Hemodynamic stable?
2) No: Give Labetalol
3) Yes:
*TEE: (pt is intubated) acute
CP or when cx unstable
*MRI: chronic
CP+hemodynamically stable
*Spiral CT w contrast: initial
screen in pts with suspected
aortic dissection
Asthma or COPD:
avoid Propranolol or Non-
selective BB
B1 selective: Metoprolol is
ok
68yoF. No major illnesses.
Systolic ejection murmur heard.
Normal S1 and physiologically
split S2. TTE: aortic valve
diameter 1.4cm with moderate
aortic stenosis, with EF 55%.
Appropriate treatment for this
patient?
Labetalol 62yoF CP/N/SOB/sudden
dysphagia. Pain radiates to left
Aortic Dissection: jaw and back; not increased or
*Vitals: hemodynamic state? relieved by changing body
*HTN Aortic Dissection/Aortic position. Diagnosed 7yr ago
Rupture. with HTN treated with HCTZ.
BP: 160/92, P115, R26. PE:
1st) Control BP: Labetalol (a & b Apical Impulse with regular
blocker) Pulse (<60/min ideal), rhythm, and asymmetric pulses
vasodilation on upper extremities. Breath
sounds diminished on left. EKG:
*Keep SBP 100-120 LV hypertrophy but no ST-
segment alterations. CXR: hazy
(Not: Nitroprusside, TEE, TTE) aortic knob+mediastinum
wide. Next best step?
Propranolol 38yoM new onset Wheezing.
h/o HTN, been on propranolol,
NS BB can cause: Bronchospasm enalapril, HCTZ. BP 134/88. PE:
(blocks b-receptors in bronchial tree) soft expiratory wheezes. Med
b+ bronchodilation most likely contributes to pt's
b- bronchoconstricts wheezing?
Acute Pulmonary Edema Dopamine 56yoF h/o DM2, panic, stable
angina. Has SOB. Suddenly
Rx: If pt doesn't respond to: IV difficulty breathing. No CP.BP
1) IV furosemide, nitrates furosemide, nitrates, morphine (all 152/94. Lung: Rales, JVD
2) if no response to these reduced PRELOAD)give: present. Treated with IV
meds, give: Dobutamine to Dobutamine (pos. Inotrope & furosemide, glyceryl trinitrate,
Afterload and Cardiac Decreases AFTERLOAD Cardiac and morphine, but do not
Output (Pos. Inotrope) Output) relieve her symptoms. IV
Risk: HYPOTENSION BP bc dobutamine begun and 10mins
Dobutamine SE: afterload reduction later BP 75/60. Next best step?
Hypotension (Afterload) If Hypotension give DOPAMINE
Rx: Dopamine (Afterload) (pressor effect:
AFTERLOAD...reverses severe
Hypotension effect of Dobutamine)

Pulmonary Regurgitation Pulmonary Regurgitation 36yoM h/o cardiac surgery in

dt: idiopathic, traumatic, or
iatrogeniccould've occur
from Surgical Repair of
Tetralogy of Fallot.
*can be long-term complication of
ToF surgical repair.
*diastole murmur in 2nd Lt
intercostal space
*Long-standing pulmonary regurge
RV failurepresents with
Tricuspid Regurgitation and an S3
gallop
childhood. PE: Systolic thrill at
left sternal border, soft diastole
murmur at heart base that
increases with inspiration and
decreases with Valsalva
maneuver. Extra sound heard
after diastole and wide split
second heart sound. Diagnosis?

Post-MI complication of CHF: Congestive Heart Failure 82yoM CP. 8hrs earlier he
began experiencing dull,
(All listed: Cardiac "crushing" CP that radiated to
tamponade, Free wall his Lt arm. Dyspnea. N/S a lot.
rupture, Papillary m. rupture, Finally decided something
RV infarct) must be done...called 911. BP
*pt doesn't present with 168/82. PE: moribund,
tamponade findings: Clear facemask. 12hrs after admit, BP
lungs, Pulse paradox (SBP 103/62 drop. JVD. Auscultation:
>10 w/inspiration) Scattered Rales & Wheezes.
Diagnosis?
*Free wall rupture:
hemodynamic collapse...as
result of Tamponade (2
answers same/vaguely same
= both wrong answer)
*RV infarct...lungs clear
w/no Rales
Stable Angina- angiography Perform Coronary Angiography

Max therapy: Stable Angina sx or on Maximal med

*ASA therapy for Stable anginashould do
*Statin (Goal LDL <100, coronary angiography to determine
70mg optimal) if next step should be ANGIOPLASTY
*Metoprolol HR: <60 w or w/o STENTING or CABG
If HR>60, Dose metoprolol
before Angiogram is done. Angioplasty improves SYMPTOMS
(not mortality)
Angioplasty indications:
*Stable Angina
*Survives Cardiac Arrest or Vtachy,
Vfib
*CHF

Essential Hypertension CCB 58yoF. HTN. Wt loss & diet

restriction for 6mo.Has
Essential HTN, eventually can't Migraines, Raynaud, BP 155/85.
control BP purely with Diet & Drugs most appropriate for this
Exercise pt?
CCB for SBP
CCB for Raynaud phenomenon, and
prophylaxis to migraines

Hypertension WITHOUT Raynaud sd: CCB

other comorbidities: DM: ACE-I, Thiazide, BB, CCB
Thiazide (inexpensive) COPD/Asthma: Avoid BB
Post-MI: BB, ACE-I, Spironolactone
CKD: ACE-I, ARB

DM+HTN Add LISINOPRIL to his regimen 58yoM, exercises 3x a week.

h/o DM2, HTN. Currently on
Goal BP: 140/90 ACE-I reduces Progression of hydrochlorothiazide and
Microalbuminuria & kidney disease metformin. BP 147/85 P
in DM. 75/min. Next Step?
Give: ACE-I (-pril) to DM pt. - DOC bc
Renoprotective

Also give ACE-I with normal BP &

microalbuminuria in DM
Hypertensive Emergency:
*SBP & DBP + end organ
damage
= Must Immediate IV Sodium
NITROPRUSSIDE (BP by
25%), or IV Nitroglycerin, IV:
Labetalol, Hydralazine,
Esmolol, Enalapril
to reduce risk for cerebral,
cardiac and renal infarcts
Hypertensive URGENCY:
BP alone, without
symptoms or end-organ
damage
=Oral Hypertensives
Tamponade
*Pulsus Paradoxus
*Hypotension
*Electrical Alternans in pts
w/Breast CA, Pericardial
Effusion, RV Collapse
Pulmonary Edema: dt HF
Mitral Regurge mumur :
with Hand-grip
Maneuvers: will Murmur
Amyl Nitrate: Afterload
Valsalva: VR/AFTERLOAD AFTERLOAD MR murmur
Give pt IV medication to reduce BP 70yoM, blurry vision, blood-
tinged urine. Hx of HTN &
*BP & ICP and Renal failure currently on BB, ACE-I, CCB.
Triage pt as Hypertensive Emergency Forgot to refill his meds BP
200/110, Flame hemorrhages,
papilledema. Abdominal bruit.
UA: 3+ RBC, RBC casts. Next
best step?
Pericardiocentesis 72yoF h/o HTN, DM, Breast
CAworsening SOB. PE: 90/60,
w/Pericardial window SBP drops 60 on deep
inspiration. JVD+. CXR:
Cardiomegly. ST elevations in
leads II and III. Echo: Pericardial
Effusion w Rt atrial collapse,
RV collapse. Next step?
100% oxygen 56yo DM SOB. For past 6 hrs
has dypsnea at rest, and cough
for HF acute Pulmonary Edema sputum. BP 156/94. JVD+ &
Pedal edmea. Sputum is
1) 100% oxygen 1st! (immediate bloodstained. Auscultation:
relieves hypoxia) Fine crepitations throughout
2) then: IV Loop, Nitrates, Morphine chest. Next best Step?
(takes time)
3) Dobutamine if others don't work.
(AFTERLOAD)
4) Hydralazine (AFTERLOAD) but
SE: SLE like
If Hypotension after Dobutamine;
Rx: Dopamine
Cardiogenic Shock Inotropic Drugs 62yo M, ICU, had acute MI whil
undergoing coronary
Myocardial Ischemia Cardiogenic angioplastyXR: Pulmonary
shock. congestionpulmonary edema.
Rx: Inotropes Wedge pressure 29, High
Myocardial Contractility pulmonary and systemic
improves Cardiac Output peripheral resistence.
Dobutamine, Milrinone (NOT EPI or Appropriate treatment at this
NE) time?

Hypertension: Weight Reduction 52yoM. PMI: elevated SBP. BP

154/92. BMI 30. Wants
BMI: 30 (N: 18.5-24.9) PreHTN: SPB 120-139 or DBP 80- lifestyle modifications.
Weight BP by 5- 89. 1st try Weight Loss Recommendations to lower BP?
20mmHg.

Lifestyle modification:
Smoking, Weight loss,
Alcohol, Na diet, Aerobic
exercise

ASD: Atrial Septal Defect
Atrial Septal Defect
*Relatively young female h/o fixed
split of S2, Pulmonary Ejection
murmur, RBBB. = ASD
Inspiratory Split of S2 occurs dt
inflow into RV and delays closure
of Pulmonic Valve.
42yoF SOB 4months. S1
normal, but there's fix split S2.
Midsystolic ejection murmur
over left sternal border. CXR:
Prominent pulmonary artery,
increased pulmonary
congestion, cardiomegaly. EKG:
RBBB. Likely diagnosis?

ASD:
*Large LtoR shunts and
*Normal Pulmonary Artery Pressure
Wide,
*Fixed Split S2 = pathognomonic

Emergent HTN+coexisting IV Nitroglycerin 62yoF CP, Pain began during

signs of IHD
=IV Nitroglycerin (DOC)
(BP to prevent ischemic
infarct of brain, heart,
kidneys)
morning walk. Dull Pressure
Normally Emergent HTN: IV over breastbone radiated to left
Nitroprusside (IF no comorbid sx) arm. Not relieved by rest. BP
190/100. Agent to lower BP?
Here Pt has Comorbid Signs of
Ischemic heart disease (CP)
IV Nitroglycerin
Aortic Stenosis:
Pericardial TAMPONADE -
complication of Transmural
MI.
= Emergency
*Hypotension BP
*Equilibration of pressures in
all chambers of heart
*Narrow Pulse Pressure
*Low volt on EKG
Mitral Stenosis:
MS decreases LV filling and
elevates Lt atrial pressures Mitral Stenosis
Pulmonary Congestion.
Sx:
*Lt HF - SOB, Dyspnea on
exertion
*Hemoptysis occurs as result ensuded: P2 heart sound
of Rupture of Small
Pulmonary Blood vessel
*later: Pulm. HTN bc RV
works against P s/s chronic
pulm congestion
Transesophageal Echocardiogram 60yoM CP w exertion. BP:
160/94. PE: regular S1, S2, S4
heard. Systolic crescendo-
decrescendo murmur at Rt 2nd
ICS radiates to Carotid Arteries.
EKG: LV Hypertrophy. Which is
most appropriate to confirm
likely diagnosis?
Pulmonary Artery Capillary Wedge
Pressure: measures LV End diastolic
filling pressures and cardiac output.
Thallium stress test: checks
"Hypoperfused areas" during
exercise
arrange for Pericardiocentesis 70yoM EKG acute MI. Vitals are
normal 6 days after
= to relieve pressure on heart hospitalization, pt becomes
confused, drowsy, complains of
(free wall rupture MC around day 7 mild dyspnea. BP is now 65/50,
post MI) P: 120, R25. Pulse ox 80%RA.
EKG: Sinus tachy, Pulmonary
artery cath placed: RAP: 18 (N:
2-10), RVP 30/18 (N: 15-30/0-5)
PCWP: 17 (N: 5-11)
Next step?
Increased S1 intensity 56yoF h/o rheumatic fever.
Slowly progressive DOE and
orthopnea 6mo. Pulse 93 and
*Diastolic murmur irrgular, Mid-diastolic murmur
*S1 intensity near apex. Loud opening snap
*Opening Snap heard after S2. Rhythm
irregular. Likely to be found on
Late findings of MS after Pulm. HTN PE?
Sx: DOE, SOB, occasional Hemoptysis
Constrictive Pericarditis:
can cause sx: CHF
*JVD w/Inspiration
*S3
*Pericardial calcifications on
CXR
*PA catheter by all 4
chambers have equal
Diastolic Pressures
STEMI
Constrictive Pericarditis
RA pressure 20, RV pressure 32/20, 62yoM progressive SOB,
PA pressure 34/20, PCWP 21 fatigue, hypotension for
7months. JVD increases during
Constrictive Pericarditis: inspiration and a weak pulse.
Sx: SOB dt developing HF.
*Tachycardia
*Hypotensive
*Tachypneic
*Weak Pulse, Low C.O.
*JVD w/Inspiration (Kussmaul
sign) (Neg. Pressure to venous
inflow). peripheral edema, but
clear LUNG
*Early diastolic sound (pericardial
knock)
Ischemic Stroke 70yoM Substernal CP. Crushing
8/10 intesnity without
*Thrombolytics to revascularize the radiation. . EKG: ST-elevation
coronary arteries: tPA (tissue Leads V1-Ve with LV
plasminogen activator) hypertrophy. Aspirin 325 given.
Contraindications: Which is absolute
1) h/o Cerebral hemorrhage at any contraindication to initiating
time thrombolytic in this pt?
2) Structural cerebral vascular lesion
3) Malignant intracranial tumor
4) Ischemic Stroke w/n 3months
5) suspected aortic dissection
6) Active bleeding or bleeding
diathesis (not menses)
7) Closed-head trauma or facial
trauma in 3 months
Pericardial Knock 42yoF 3mo h/o DOE. No CP. h/o
of rheumatoid arthritis, no
Constrictive Pericarditis from famHx of CAD. Lateral CXR
Chronic Scarring Loss elasticity of shows Calcification of Heart
pericardial sac Border. Diagnosis of
Pericardial Knock (sound just before Constrictive Pericarditis made.
S3) results from Sudden Cessation of PE: Likely to be seen?
Ventricular Filling as Ventricle is
prevented from expanding further
by Rigid Pericardium
Pheochromocytoma
*Catecholamines Metanephrines
*Paroxysmal or Persistent
Hypertension
*Tachycardia
*Sweating
*Feeling of Impending Doom
= sx bc high Catecholamines
Chronic Atrial Fibrillation
Plasma Fractionated Free
heartbeat followed by
Decrease the Warfarin Dose
Why:
*Amiodarone drug interaction risk
w/Digoxin and Warfarin
Polyarteritis Nodosa
50yoM having transient Rapid
Sweating, Flushing, sense of
Impending doom. BP 195/140,
P: 160 during the episode. Goes
to ER, but all that is gone by
time he's seen. Which is most
sensitive test for diagnosing
the condition?
48yoF treated with Atenolol
and Warfarin for last 4 months
for Atrial Fibrillation in clinic bc
Claudication for last 6wks. PE:
bilateral 1+ ankle edema &
diminished pulses. ABI: 0.8.
Stopped Atenolol bc no
structure abnormalities. She's
started on Amiodarone. Next
Step?
SVT: Supraventricular
Tachycardia
ORDER:
1st) Carotid Massage
2) Valsalva (if can't do carotid
massage/carotid bruit-
stenosis)
3) Adenosine > Verpamil =
DOC (if got both choice, pick
adenosine)
Synchronized cardioversion:
for Hemodynamic unstable
patients (Unconsciousness or
shock w/severe HF) = need
immediate termination of
Tachyarrhythmia
Forcefully exhaling against closed
mouth and nose
SVT: EKG TachyC >100
*Pwaves preceds normal QRS
Tx:
1st: VAGAL maneuvers: Carotid
massage - usually
But this Pt has Soft Blowing
murmurs on neck auscultation =
bilateral Carotid stenosis = so CAN'T
Do carotid massage
Next best: Valsalva
66yoF palpitations, SOB,
lightheadedness. h/o HBP
takes water pill. BP:
105/65, P 152, R: 16. PE:
distress, ausculation of
neck - bilateral bruit, CVS:
distant heart sounds, no
rubs or gallops. EKG
shows. NEXT BEST STEP?
RV infarct
(Dopamine is useful if IV
fluids alone don't help BP
but risk: Cardiac
ischemia/pressor)
(Metoprolol: can't be used
forBradycardia or
Hypotension) - No BB for low
BP
Nitroglycerin: avoid in RV
infarctsbc it's a PRELOAD
ReducerRV filling & CO
IV Fluids (to maintain BP)
EKG: ST-elevations (II, III, avF) = RV
Infarct
ST elevation in V4 = is RV infarct
specific (now preload
dependent.need to keep
PRELOAD HIGH)
56yo h/o HTN &
Hyperlipidemia. Crushing
CP, Diaphoresis, nausea for
past 3 hrs. BP 82/60, Pulse
103/min. PE: JVD, no
murmurs, clear lungs. EKG
shown. Appropriate for this
pt?