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Select the ONE answer that is BEST in each case.
A 58-year-old man is undergoing cardiac catheterization for evaluation of chest pain symptoms. He is worried about the risks, and as part of obtaining informed consent, you advise him about the risks and benefits of the procedure. Which of the following aspects of angiography is true?
Contrast media used in cardiac catheterization may result in renal impairment. The group at highest risk includes diabetics with renal disease and those with preexisting renal failure. Good hydration is essential. Other manifestations of contrast media include nausea and vomiting (common), and anaphylactoid reactions characterized by low-grade fever, hives, itching, angioedema, bronchospasm, and even shock. Side effects are reduced with the use of new low osmolality contrast media.
A 23-year-old man develops sharp left-sided chest pain, fever, and a friction rub heard at the lower left sternal border, unaffected by respiration. The pain is also aggevated by lying down and relieved by sitting up. He is otherwise well with no other symptoms and the remaining physical examination is normal. Which of the following is the most likely cause for his symptoms?
Pericarditis in clinical practice is commonly idiopathic and frequently assumed to be of possible viral origin. Coxsackieviruses are a common cause, but herpesviruses are not. Although TB, rheumatic fever, and MI can cause pericarditis, they are unlikely in this case.
A 72-year-old woman with angina undergoes cardiac catheterization. The pulmonary capillary “wedge” pressure is an approximation of the pressure in which of the following structures?
Left-heart catheterization is a more accurate measurement, but involves a slightly increased risk. End-expiratory PA diastolic pressure is very close (2–4 mm) to wedge pressure as well. A discordance between wedge pressure and PA diastolic pressure suggests the presence of pulmonary hypertension.
A 58-year-old man with hypertension is brought to the emergency room after suddenonset chest pain that radiates to his back and arms. He is in moderate distress with a blood pressure of 160/90 mm Hg in the left arm and 120/70 mm Hg in the right arm. Cardiac examination reveals a soft second heart sound and a murmur of aortic insufficiency. His ECG shows sinus tachycardia but no acute ischemic changes, and the chest x-ray (CXR) is shown in Fig. Which of the following is the most appropriate next step in confirming the diagnosis?
Aortic dissection is a medical emergency requiring prompt attention. Other cardiac and pulmonary causes of chest pain can be quickly ruled out with ECG and CXR. CT scan of the chest is sensitive (93–100%) in ruling out dissection. Transesophageal echocardiography is equally as sensitive but not a transthoracic echo.
A 17-year-old girl develops exertional dyspnea, but has no cough, sputum, or wheezing symptoms. On examination, she has a fixed splitting of her second heart sound and a 3/6 systolic ejection murmur heard best over the left sternal border. An echocardiogram confirms the condition. Which of the following is the best physiologic explanation for her condition?
This is characteristic of an atrial septal defect. Pulmonary blood flow is greater because of increased blood flow from the right atrium, which receives blood from the vena cava and left atrium.
A 19-year-old man develops typical angina pectoris. There is no family history of premature CAD. Which of the following is the most likely diagnosis?
Angina or infarction in young patients should prompt the physician to consider congenital coronary artery anomaly or congenital coronary artery aneurysm. Acquired coronary artery aneurysm can be caused by atherosclerosis, trauma, angioplasty, atherectomy, vasculitis, mycotic emboli, Kawasaki syndrome, or arterial dissection
A 32-year-old asymptomatic woman has a rapidly rising, forceful pulse that collapses quickly. Which of the following is the most likely diagnosis?
This pulse is seen in aortic regurgitation. The pressure in diastole is usually 50 mm Hg or lower. This is known as a water hammer or Corrigan’s pulse. Abisferiens pulse (in the bisferiens wave form there are two pressure peaks) may be present as well. Systolic blood pressure is elevated
A 63-year-old woman on digitalis for chronic atrial fibrillation experiences fatigue, nausea, and anorexia. Her pulse is regular at 50 beats/min, and the heart sounds, chest, and abdominal examinations are normal. On the ECG, no P waves are visible and the QRS complexes are narrow and regular. Which of the following is the most appropriate management step?
Digoxin toxicity may cause any dysrhythmia. Classically, dysrhythmias that are associated with increased automaticity and decreased AV conduction occur (i.e., paroxysmal atrial tachycardia with 2:1 block, accelerated junctional rhythm, or bidirectional ventricular tachycardia [torsade de pointes]). Sinus bradycardia and other bradyarrhythmias are very common. Slow atrial fibrillation with very little variation in the ventricular rate (regularization of the RR interval) may occur. This arrhythmia is likely slow atrial fibrillation. Symptoms of digitalis toxicity include anorexia, nausea, fatigue, dizziness, and visual disturbances. The presence of hypokalemia increases the likelihood of digitalis toxicity.
A 47-year-old man is found to have edema, ascites, and hepatosplenomegaly. The examination of his neck veins reveals elevated venous pressure with a deep y descent. Heart size on x-ray is normal. Which of the following etiologies is not a possible explanation for this syndrome?
Commonly, no cause is found for constrictive pericarditis. Some patients do give a history of previous acute pericarditis. TB is now an uncommon cause. Cancer can cause constriction but is uncommon. Rheumatic fever does not cause pericarditis.
A 65-year-old man develops palpitations and dizziness. His blood pressure is 80/50 mm Hg and his pulse is regular at 150/min. His ECG shows a “saw-toothed” pattern of P waves. Which of the following procedures is most appropriate in converting him back to sinus rhythm?
The maneuvers listed increase the block and are useful for diagnosis, but not for converting the atrial flutter to a sinus rhythm. Electrical cardioversion is the method of choice in patients who are hemodynamically unstable. Often very low amounts of energy during cardioversion will convert atrial flutter.
A 63-year-old woman presents with symptoms of palpitations and atrial flutter on the ECG. Which of the following is the most likely mechanism of this arrhythmia?
Atrial flutter is characterized by regular atrial activation with an atrial rate of >240 beats/ min. The ventricular response depends on the conduction of the AV node, usually there is 2:1 or 3:1 conduction. It is now known that the predominant mechanism for atrial flutter is right atrial macroreentry with circular activation. Atrial flutter typically originates from the right atrium and most often involves a large circuit that travels around the area of the tricuspid valve. This type of atrial flutter is referred to as typical atrial flutter. Less commonly, atrial flutter can result from circuits in other areas of the right or left atrium.
A 62-year-old man has progressive symptoms of dyspnea, and more recently noticed difficulty lying supine. Examination shows an elevated JVP at 8 cm, with a third heart sound, pedal edema, and bibasilar crackles on auscultation. Which one of the following may be implicated in fluid retention for this condition?
Retention of fluid is complex and not due to any one factor, however, hormones may contribute. Growth hormone does not have fluidretaining properties. The exact mechanisms that initiate renal conservation of salt and water are not precisely understood, but may include arterial volume receptors sensing a decrease in the effective arterial blood volume. Aldosterone, renin, and vasopressin are generally increased in heart failure.
Three months after an anterior MI, a 73-yearold man has a follow-up ECG. He is clinically feeling well with no further angina symptoms. His ECG shows Q waves in the anterior leads with persistant ST-segment elevation. The current ECG is most compatible with which of the following diagnosis?
ST elevation persisting 2 weeks after an infarct, an abnormal pericardial impulse, and a bulge on the left ventricular border on x-ray are characteristic of an aneurysm. Ventricular aneurysms are most often a result of a large anterior infarct. The poor prognosis associated with these aneurysms is due to the associated left ventricular dysfunction, rather than to the aneurysm itself.
A 79-year-old man presents with syncope. On physical examination, he has a slow upstroke in his carotid pulse and a diamond-shaped systolic murmur at the base. His chest is clear. Which of the following findings is his CXR most likely to reveal?
In aortic stenosis, there is normal overall cardiac size, but dilatation of the proximal ascending aorta and blunt rounding of the lower left cardiac contour. Calcification of the valve is often difficult to determine on plain films. Although left atrial enlargement can occur, its presence on the CXR should raise other diagnostic possibilities, such as mitral valve disease
A 49-year-old man has his serum lipids measured. Which pattern suggests the lowest risk for CAD?
This combination, although the total cholesterol is borderline, has high HDL cholesterol, which is protective. Nevertheless, a level this high would likely require treatment.
A 16-year-old boy is found to have hypertension on routine evaluation. On examination, the blood pressure in his arms is higher than in his legs by more than 10 mm Hg. Which of the following is the most likely diagnosis?
Besides coarctation of the aorta, aortic occlusive disease, dissection of the aorta, and abdominal aneurysm may lead to differential blood pressure in arms and legs. Coarctation is the third most common form of congenital cardiac disease. One-third of the patients will be hypertensive. The femoral pulses are weak, delayed, and even absent.
A 79-year-old man with a 40-year history of hypertension and cardiomegaly on CXR is likely to show which of the following on his ECG?
He likely has LVH. Signs include left axis deviation, highvoltage QRS complexes in V5 and V6, deep S in V1 and V2, and prolonged QRS in the left precordial leads. Age, orientation of the heart in the chest, and noncardiac factors make the ECG an imperfect tool for diagnosing or excluding LVH. The ECG is more accurate and better for following progression or regression of LVH.
A 59-year-old woman presents for the first time with untreated congestive heart failure (CHF). Urinalysis and urine biochemistrty is most likely to show which of the following?
High urinary specific gravity, nocturia, and daytime oliguria occur in addition to low urinary sodium content in untreated CHF. These changes are the result of the activation of the renin-angiotensin-aldosterone system.
A 60-year-old woman presents with symptoms of weight loss, anxiety, and palpitations. On examination, she has a thyoid goiter. Which of the following is the most likely cardiac finding?
Thyroid disease may affect the heart muscle directly or there may be excessive sympathetic stimulation. Common symptoms of thyrotoxic heart disease include palpitations, exertional dyspnea, and worsening angina. Atrial fibrillation is particularly common in older individuals.
A 70-year-old woman is found to have an irregular pulse rate on a routine visit. She is experiencing no new symptoms at rest or on exertion. On the ECG, there are no P waves and an irregular RR interval at a rate of 70/min. On her previous ECG from 4 years ago she was in sinus rhythm. Which of the following is the most appropriate next step in management?
Since the duration of atrial fibrillation is not known, it is presumed to be chronic. There is an increased risk of cardioembolic events if restoration of sinus rhythm is attempted before anticoagulating the patient for 3–4 weeks. Aspirin is only modestly effective in reducing cardioembolic events and not the first choice. Beta-blockers are not indicated since the rate is controlled.