Valves
A 37-year-old woman presents with progressive shortness of breath and blood-tinged sputum. Examination reveals an increased S1 and a high-pitched extra sound heard after S2 (an opening snap). A low-pitched diastolic murmur is heard at the apex. What is the most likely diagnosis?
A) Aortic stenosis
B) Atrial septal defect
C) Mitral insufficiency
D) Mitral stenosis
E) Pulmonic stenosis
D
A 74-year-old woman post-myocardial infarction develops hypotension (BP 80/62 mm Hg), confusion, and cool, clammy skin. Which of the following would an arterial blood gas (ABG) most likely show?
A) Hypoxemia with normal pH
B) Primary metabolic acidosis
C) Primary metabolic alkalosis
D) Primary respiratory acidosis
E) Primary respiratory alkalosis
B
A patient with AF develops sudden unilateral leg pain, pallor, pulselessness, and paresthesias.
Most likely diagnosis?
A. DVT
B. Cellulitis
C. Acute arterial embolism
D. Compartment syndrome
E. Vasculitis
C
AF = embolic phenomena until proven otherwise.
A patient has:
Which medication class has been shown to reduce mortality?
A. Loop diuretics
B. Digoxin
C. Beta blockers
D. Nitrates alone
C
A patient with mitral regurgitation squeezes a handgrip during examination.
What happens to the murmur?
A. Decreases
B. Increases
C. Disappears
D. Splits
B
Handgrip ↑ afterload → ↑ MR, AR, VSD.
A 63-year-old man with HFrEF (EF 25%) presents with worsening dyspnea. BP 88/56 mmHg, cool extremities, lactate 5.1 mmol/L, Cr 2.3 mg/dL.
Which medication should be held immediately?
A. Furosemide
B. Empagliflozin
C. Carvedilol
D. Spironolactone
E. Aspirin
C. Carvedilol
Cardiogenic shock = hold beta-blockers.
A 73-year-old man with a history of hypertension presents with moderate chest pain and difficulty breathing. He is diaphoretic, his pulse is 185/min and thready, and his blood pressure is 85/45 mm Hg. A rhythm strip reveals a wide-complex tachycardia. Which of the following is the most appropriate initial step in management?
A) Administration of esmolol
B) Administration of intravenous nitroglycerin
C) Intravenous administration of morphine
D) Endotracheal intubation
E) Synchronized cardioversion
E. Patients with unstable wide-complex tachycardia (hypotension, diaphoresis, altered mental status) require immediate synchronized cardioversion to restore cardiac output
A 55-year-old woman presents with the sudden onset of "ripping" substernal chest pain. Her blood pressure is 220/128 mm Hg. An X-ray of the chest shows a widened aortic root and dilated ascending aorta. Which of the following is the most likely pathophysiological cause?
A) Aortic dissection due to Takayasu arteritis
B) Degeneration of the aortic wall from Marfan syndrome
C) Medial degeneration of the aorta
D) Rupture of a sinus of Valsalva aneurysm
E) Traumatic disruption of the aorta from a fall
C. In older patients with chronic hypertension, the breakdown of mural collagen and elastin in the tunica media (cystic medial necrosis or medial degeneration) weakens the wall, leading to aortic dissection
A 75-year-old man develops syncope while walking. Echo:
What is the definitive treatment?
A. Metoprolol
B. Furosemide
C. Balloon valvuloplasty
D. TAVR/SAVR
E. ACE inhibitor
D
Symptomatic severe AS → valve replacement.
Which patient qualifies for ICD placement for primary prevention of sudden cardiac death?
A. EF 40%
B. EF 35% after MI despite optimal GDMT
C. New diagnosis of HFrEF yesterday
D. HFpEF with syncope
B
A 68-year-old man with ischemic cardiomyopathy (EF 25%) presents with sustained monomorphic VT. BP is 118/72 mmHg and he is alert. ECG confirms VT at 170 bpm.
What is the most appropriate initial management?
A. Synchronized cardioversion
B. Procainamide infusion
C. Adenosine
D. Metoprolol IV
E. Immediate ICD placement
B. Procainamide
Stable monomorphic VT → antiarrhythmic first. Unstable VT → synchronized cardioversion.
A patient with severe PAH develops hypotension and worsening RV failure.
Which intervention may worsen hemodynamics?
A. Norepinephrine
B. Dobutamine
C. Aggressive IV fluids
D. Inhaled nitric oxide
E. Vasopressin
C
RV failure is preload dependent, but excessive fluids worsen septal shift and cardiac output.