Cardiovascular Board Review I

Braden Hexom, MD
Department of Emergency Medicine
Mount Sinai School of Medicine
Question 1
A 40 yo M, previous healthy presents with
cough, low-grade fever, and myalgias for 3-
4 days. Today he has experienced severe,
sharp pleuritic chest pain radiation to the
left shoulder that is worse when he is
supine. He smokes one pack of cigarettes
per day. Vitals signs: BP 160/95, P 110,
RR 18, T 37.2
o
C. A 12-lead EKG is
obtained:
PEER VII Q55
Q1 EKG
Q1 Answer
Appropriate next steps include:
A. ASA 325 mg, Morphine 2 mg, admit CCU

B. ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit bolus,
activate cath team

C. Ketorolac 30 mg IV then ibuprofen 800 mg TID for 1 week
as an outpatient

D. Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20
mg IV, admit to telemetry

E. Metoprolol 5 mg IV, NTG IV infusion titrated to pain, and
cardiology consult

Q1 Answer
Appropriate next steps include:
A. ASA 325 mg, Morphine 2 mg, admit CCU
No Need For Monitored Admission
B. ASA 325 mg, NTG, 0.4 mg SL x 3, heparin 4000 unit bolus,
activate cath team
No Role for Anticoagulation
C. Ketorolac 30 mg IV then ibuprofen 800 mg TID for 1 week
as an outpatient
Acute Pericarditis is Treated with Ibuprofen and Outpatient Followup
D. Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20
mg IV, admit to telemetry
No Idea Why You Would Ever Use This
E. Metoprolol 5 mg IV, NTG IV infusion titrated to pain, and
cardiology consult
Tachycardia and Pain will Resolve with Pain Control
Acute Pericarditis
Inflammation of the pericardium
Sharp or stabbing chest pain with radiation to
back, neck, left shoulder, or arm
Worsened on inspiration or lying supine
EKG:
Acute phase: Diffuse ST elevations (most prominent in
I, V5, V6) with PR depressions (II, aVF, V4-V6)
Isolated pericarditis will not make enzymes or
have dysrhythmias
Dispo for uncomplicated is NSAIDs for 1-3 weeks
and D/C
Acute Pericarditis
http://urbanhealth.udmercy.edu/ekg/pdf/acutepericarditis.pdf
Question 2
A 50 yo M presents with an acute inferior
wall MI. Following the administration of
ASA and NTG, he suddenly becomes
confused and diaphoretic with a BP of
70/30. Physical exam reveals JVD, clear
lungs, and no evidence of a murmur.
Promes 3-9
Q2 Answer
What combination of therapeutic agents is most
likely to immediately stabilize this patient?

A. Heparin and glycoprotein IIb/IIIa inhibitors

B. Angiotensin converting enzyme inhibitor and clopidogrel

C. Steptokinase and magnesium

D. Normal saline bolus and dobutamine

Q2 Answer
What combination of therapeutic agents is most
likely to immediately stabilize this patient?

A. Heparin and glycoprotein IIb/IIIa inhibitors
Not immediately effective
B. Angiotensin converting enzyme inhibitor and clopidogrel
Not immediately effective
C. Steptokinase and magnesium
PCI preferred over thrombolytics
D. Normal saline bolus and dobutamine
RVMI is Preload Dependent
Right Ventricular Infact
Complicates up to 1/3 of inferior wall MIs
EKG
ST Elevations in II, III, aVF
Reciprocal depressions in I, aVL, V5, V6
ST Elevations in V
4R
to V
6R
on right-sided EKG

Prone to hypotension but respond to volume and
pressors / inotropes
PCI preferred over thrombolytics
This is the classic question for RV infact
Right Ventricular Infact
Left Sided EKG




Right Sided EKG
http://ccn.aacnjournals.org/cgi/reprint/25/2/52.pdf
Question 3
The hypertensive emergency that is most
easily reversible with pharmaceutical
management is:

PEER VII Q240
Q3 Answer
A. Acute coronary syndrome

B. Aortic dissection

C. Eclampsia / pre-eclampsia

D. Encephalopathy

E. Intracranial hemorrhage

Q3 Answer
A. Acute coronary syndrome
Needs Cath
B. Aortic dissection
Not reversible with meds
C. Eclampsia / pre-eclampsia
Needs Delivery
D. Encephalopathy
Treatment w/in 1
st
Hour Often Reversible
E. Intracranial hemorrhage
Not reversible with meds
Hypertensive Emergency
Marked elevation of BP with end-organ
dysfunction otherwise HTN urgency
Susceptible end-organs: CV, brain, kidney
Encephalopathy
N/V
Severe Headache
Confusion decreased sensorium coma
Rapid 25% decrease in MAP is the goal
Diastolic <110 mmHg
Hypertensive Emergency
Rare disease, many treatment options
Precipitating causes: drugs, pregnancy
Peds
Pheochromocytoma
Aortic coarctation
Renovascular disease
Only emergencies require immediate
treatment. Urgencies can be discharged
Can use nitroprusside, nitro, labetalol, cardene
Question 4
A 75 yo F presents with decreased level of
consciousness. VS are BP 70/40, P 40, RR
12, and T 36.5
o
C. Blood glucose is 114.
The rhythm strip should be interpreted as:
PEER VII Q92
Q4 Answer
A. Complete Heart Block

B. Mobitz second-degree HB, type I Wenckebach

C. Mobitz second-degree HB, type II

D. QT prolongation with U waves

E. Sinus bradycardia

Q4 Answer
A. Complete Heart Block
Some P waves conduct
B. Mobitz second-degree HB, type I Wenckebach
PR interval increases
C. Mobitz second-degree HB, type II
PR interval constant
D. QT prolongation with U waves
U waves follow T, seen in Hypokalemia
E. Sinus bradycardia
Not sinus
Question 5
The most appropriate initial therapy for a
patient with a pulse of 40, a BP of 70/40,
and the previous EKG is:
PEER VII Q93
Q5 Answer
A. Atropine 1 mg IV

B. External cardiac pacemaker

C. Isoproterenol infusion at 2 mcg/min, titrate up

D. Normal saline

E. Potassium infusion at 10 mEq/hr

Q5 Answer
A. Atropine 1 mg IV
Type I (not II) Often due to Vagal tone/IWMI
B. External cardiac pacemaker
Type II Often seen with AWMI -> Complete HB
C. Isoproterenol infusion at 2 mcg/min, titrate up
An option for refractory sinus bradycardia
D. Normal saline
Not usually PWMI
E. Potassium infusion at 10 mEq/hr
Not a hypokalemia rhythm
Bradycardia
Approach to undifferentiated bradycardia
based on hemodynamic stability
If stable, observe
If unstable
Atropine 0.5 mg IVP, up to 3 mg
Dopamine or Epinephrine drip
External pacing
Transvenous pacing
AV Nodal Blocks
Caused by conduction delay in AV node
First-Degree
PR interval > 0.2s (200ms)
All P waves followed by QRS
No intervention required
http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf
AV Nodal Blocks
Second-Degree Mobitz I (Wenckebach)
Progressive lengthening of PR interval followed
by dropped beat
Seen in IWMI, digoxin toxicity, myocarditis, CAD
Stable rhythm
http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf
AV Nodal Blocks
Second-Degree Mobitz Type II
Fixed-length PR interval with one or more non-
conducted beats
Signifies major damage to conduction system
Usually seen in AWMI
Unstable: Requires permanent pacemaker
AV Nodal Blocks
Third-Degree (Complete) Heart Block
No P waves are conducted through AV node
Junctional or Ventricular escape paces the heart
Unstable: Requires permanent pacemaker

http://urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pdf
Question 6
Which of the following statements
regarding cardiac serum markers is correct?

PEER VII Q342
Q6 Answer
A. BNP level has little correlation with recurrent acute
coronary syndromes

B. CPK appears within 1-2 hours after an acute MI and gone
within 24 hours

C. Myoglobin appears within 1-2 hours after acute MI and
peaks at 5-7 hours

D. Total CPK is more specific for acute cardiac ischemia than
CK-MB

E. Troponins appear in the first 4 hours after an MI and are
gone by 24 to 36 hours.


Q6 Answer
A. BNP level has little correlation with recurrent acute
coronary syndromes
BNP elevated in CHF and ACS
B. CPK appears within 1-2 hours after an acute MI and gone
within 24 hours
Appear 3-8hrs, gone by 2-3 days
C. Myoglobin appears within 1-2 hours after acute MI and
peaks at 5-7 hours
But not cardiac specific
D. Total CPK is more specific for acute cardiac ischemia than
CK-MB
CK-MB more specific, CPK in muscle/kidney/GI/brain
E. Troponins appear in the first 4 hours after an MI and are
gone by 24 to 36 hours.
Troponins appear 3-6 hrs, persist 5-7 fsyd

Cardiac Serum Markers
Myoglobin is the earliest
Troponin is the most sensitive and specific

http://www.uptodateonline.com
Cardiac Serum Markers
Troponins and Renal Failure
Tropnonin clearance is delayed
Troponins are not cleared by dialysis
High false-positive rate
1

Elevated troponins correlate with poor
prognosis
Any non-zero level warrants serial troponins
2,3


1
Apple FS,et al. Predictive valueCirculation 2002 Dec 3;106(23):2941-5.
2
http://www.kidney.org/professionals/KDOQI/guidelines_cvd/troponin.htm
3
http://www.uptodateonline.com
Question 7
An 82 yo woman presents with 1 hour of
substernal chest pressure, dyspnea, and
diaphoresis. Her EKG is shown below. No
old EKG is available for comparison. Her
first set of cardiac enzymes is negative.
Which of the following is the most
appropriate treatment?
Promes Q3-4
Q7 (continued)
Q7 Answer
A. Admit the patient to a monitored bed
B. Observe the patient, order serial cardiac
markers and discharge if negative
C. Administer thrombolytics
D. Cardiovert the patient with 50 joules
E. Stress testing once serial cardiac enzymes
are negative
Q7 Answer
A. Admit the patient to a monitored bed
B. Observe the patient, order serial cardiac
markers and discharge if negative
C. Administer thrombolytics
D. Cardiovert the patient with 50 joules
E. Stress testing once serial cardiac enzymes
are negative
STEMI / LBBB
STEMI
Presence of ST elevations of greater than 1mm
in two or more anatomically contiguous leads

LBBB
QRS > 0.12 s (120ms)
Wide, notched R wave in I, aVL, V
6
Small R and deep S in II, III, aVF, V
1
-V
3
STEMI / LBBB
Indications for Thrombolysis / PCI
MI that meets STEMI criteria
MI symptoms and new LBBB
Acute Posterior MI
Isolated ST-segment depression of at least 1mm in 2
or more leads from V1-V4

ACEP Clinical Policy: Indications for Reperfusion TherapyAnn Emerg Med. 2006;48:358-383.
Question 8
Which of the following statements is true
concerning infective endocarditis in IV drug
users?
PEER V Q9
Q8 Answer
A. Most commonly affects the mitral value

B. Rarely associated with septic emboli

C. Cardiac murmurs frequently are absent at
initial presentation

D. Steptococcus viridans is the most common
causative organism

E. The majority of patients have previously
damaged heart valves
Q8 Answer
A. Most commonly affects the mitral value
Tricuspid is most common
B. Rarely associated with septic emboli
Is a common cause of septic emboli
C. Cardiac murmurs frequently are absent at
initial presentation
Murmur develops after extensive valve damage
D. Steptococcus viridans is the most common
causative organism
Staph, MRSA most common
E. The majority of patients have previously
damaged heart valves
IVDU Endocarditis
Presentation can vary from subacute to acute onset
of fever, dyspnea, weakness, tachycardia,
dysrhythmias
High index of suspicion: IVDU patients with fever
Skin flora is most common: Staph aureus,
including MRSA
Tricuspid is most commonly affected in IVDU
In ED, obtain multiple cultures, treat with Abx
Antibiotics: vancomycin + gent +/- rifampin

Question 9
Which of the following drugs can be used to
treat a patient with known Wolff-Parkinson-
White syndrome who presents with the
rhythm depicted below:
PEER VII Q126
Q9 Answer
A. Adenosine

B. Digoxin

C. Diltiazem

D. Metoprolol

E. Procainamide


Q9 Answer
A. Adenosine
Slows AV conduction -> V.Fib
B. Digoxin
Slows AV conduction -> V.Fib
C. Diltiazem
Slows AV conduction -> V.Fib
D. Metoprolol
Slows AV conduction -> V.Fib
E. Procainamide
Or Amiodarone (or cardioversion)

Wolff-Parkinson-White
Syndrome of pre-excitation due to
accessory pathway from atria to ventricles
EKG
Short PR interval
Delta wave: slurred upstroke of QRS complex

http://medicalfinals.co.uk/QuizJanuary2006Answers.html
Wolff-Parkinson-White
Orthodromic (narrow complex) AVRT
Anterograde conduction in accessory tract
Adenosine 6 mg IV or Verapamil 5 to 10 mg IV

Antidromic (wide complex) AVRT or Afib / Aflut
Retrograde conduction in accessory tract
No AV nodal blockers
If stable: amiodarone or procainamide
If unstable: synchonized cardioversion
Question 10
An 8 yo boy presents with history of chest pain
that gradually worsened while he was watching
television with his mother. The pain lasted 2
hours and then resolved without intervention.
There was no associated dyspnea or syncope. He
has no significant past medical history. Family
history includes a grandmother who died of a heart
attack. Physical exam, ECG, and CXR are
normal. What is the most appropriate next step in
the emergency department?
PEER VII Q338
Q10 Answer
A. Administer albuterol and check peak flow

B. Discharge home with primary care followup

C. Laboratory evaluation, including cardiac
markers

D. Observation admission for treadmill testing

E. Outpatient echo and Holter monitor


Q10 Answer
A. Administer albuterol and check peak flow
Not indicated by the history
B. Discharge home with primary care followup
Reasonable for 1
st
episode with reassuring story
C. Laboratory evaluation, including cardiac
markers
No clear evidence for trops in kids
D. Observation admission for treadmill testing
Evals for CAD, very rare in kids
E. Outpatient echo and Holter monitor
May be indicated for recurrent episodes

Pediatric Chest Pain
Rarely serious unless accompanied by
Syncope
Dyspnea
Fever
Congential Heart Disease
Cyanosis
Congestive Heart Failure
Return to regular activity is the norm
Concerning EKG Findings
(Especially in Young People)
1. Delta Wave/Short PR -> WPW

2. LVH -> Cardiomyopathy

3. RBBB/ST in V1 -> Brugada

4. Long QT -> Congenital or Aquired
Question 11
A 60 yo F with a history of end-stage renal
disease on hemodialysis presents
unresponsive with only a weak carotid
pulse. Cardiac monitoring is started (see
below), and CPR is initiated. Intravenous
access is established, and the patient is
intubated. The next step in management
should be:
PEER VII Q300
Q11 (continued)
http://sprojects.mmi.mcgill.ca/heart/ecgk1.html
Q11 Answer
A. Atropine 1 mg IV, amiodarone 300 mg IV slow push

B. Calcium chloride 1 amp IV, insulin 10 units IV, and
dextrose 50 g IV

C. Dopamine wide open, and prepare for external pacer

D. Magnesium sulfate 2 g slow IV push, potassium
chloride 10 mEq over 20 minutes

E. Normal saline 500 mL bolus and pericardiocentesis

Q11 Answer
A. Atropine 1 mg IV, amiodarone 300 mg IV slow push
This is not sinus bradycardia, and amio not indicated
B. Calcium chloride 1 amp IV, insulin 10 units IV, and
dextrose 50 g IV
Insulin the most rapidly effective
C. Dopamine wide open, and prepare for external pacer
Refractory to pacing. Dopamine wont fix underlying issue
D. Magnesium sulfate 2 g slow IV push, potassium
chloride 10 mEq over 20 minutes
Treatment for Hypokalemia (flat Ts, long QT/QRS, big Us)
E. Normal saline 500 mL bolus and pericardiocentesis
Tamponoda usually presents with low voltage
Hyperkalemia
EKG changes
Peaked T waves
PR prolongation
QRS prolongation, P wave flattening
Loss of P wave, QRS prolongation to sine wave
Webster, et al. Recognising signs of danger. Emerg. Med. J., Jan 2002; 19: 74 77.
Hyperkalemia
http://sprojects.mmi.mcgill.ca/heart/ecgk1.html
http://urbanhealth.udmercy.edu/ekg/pdf/hyperkalemia.pdf
Hyperkalemia
Treatment
Calcium chloride or gluconate
Dextrose + Insulin
Bicarbonate
Lasix
Albuterol
Kayexalate

Question 12
A 49 yo M presents after he fainted while
running on his treadmill at home. He has
been having exertional dyspnea and angina
for the past several months. Which of the
following disease is most likely to cause
these symptoms?
PEER VII Q230
Q12 Answer
A. Aortic stenosis

B. Pulmonary embolus

C. Mitral incompetence

D. Pulmonary stenosis

E. Tricuspid incompetence


Q12 Answer
A. Aortic stenosis
Fits the age group for congenital bicuspid valve
B. Pulmonary embolus
Usually more acute, not exertional
C. Mitral incompetence
SV maintained -> exertional SOB but not syncope
D. Pulmonary stenosis
Dyspnea and Easy Fatigability
E. Tricuspid incompetence
Causes JVD and peripheral edema (right sided)

Aortic Stenosis
Bimodal distribution
Under 65: bicuspid aortic valve
Over 65: calcific degeneration
Outflow tract obstruction with LVH
Crescendo-decrescendo systolic murmur
Classic symptoms
DOE
Syncope
Angina
This is the classic AS question
Question 13
Which of the following is the most common
ECG abnormality associated with mitral
valve prolapse?
PEER VII Q222
Q13 Answer
A. Paroxysmal supraventricular tachycardia

B. QT prolongation

C. Rapid atrial fibrillation

D. ST-segment depression in leads II, III, aVF

E. Ventricular tachycardia

Q13 Answer
A. Paroxysmal supraventricular tachycardia
Also PVCs, APCs
B. QT prolongation
Reported but rare
C. Rapid atrial fibrillation
Not typical
D. ST-segment depression in leads II, III, aVF
Reported but rare
E. Ventricular tachycardia
Reported but rare
Mitral Valve Prolapse
Most common valvular heart disease 2.4%
Usually asymptomatic
When symptomatic
Non-exertional chest pain
Palpitations
Fatigue
Dyspnea unrelated to exertion
Increased incidence of WPW
Palpitations, PVCs, Reentrant SVT
Echo and outpatient cardiology management
Question 14
A 70 yo M complains of severe diffuse abdominal
discomfort that began in his lower epigastric
region 3 hours earlier, shortly after he ate burger
and fries. He denies chest pain, SOB, and flank
pain. He has a history of CHF. Physical exam
reveals an elderly man in severe discomfort. Vital
signs are remarkable for only a mild tachycardia.
The abdomen is soft and nondistended, with
diffuse pain to all areas on palpation. There is no
rebound. Pulses are normal; there are no bruits or
masses. What is the most likely diagnosis?
PEER VII Q19
Q14 Answer
A. Mesenteric ischemia

B. MI

C. Aortic dissection

D. Pancreatitis

E. Ruptured abdominal aneurysm

Q14 Answer
A. Mesenteric ischemia
Always consider in elderly, pain > exam
B. MI
Usually not tender abdomen
C. Aortic dissection
Must consider but abdomen tender/vitals normal
D. Pancreatitis
No h/o EtOH or other comorbidities
E. Ruptured abdominal aneurysm
No pulsatile mass, normal pulses
Mesenteric Ischemia
Elderly patients with severe pain out of
proportion to the physical exam
Pain is poorly localized
Risk factors
Atrial Fibrillation
Vascular disease
CHF
Hypercoagulability
Also consider AAA, Dissection!!
Mesenteric Ischemia
Acute: thromboembolic phenomena
Chronic: usually due to long-standing
atherosclerotic disease (intestinal angina)
High mortality due to risk of bowel necrosis
Workup
CT Angio vs conventional angiography
Serial lactate levels
Early surgical consultation
Question 15
Which of the following patients is the most
appropriate candidate for pacing therapy
with a transcutaneous cardiac pacemaker?
PEER V Q2
Q15 Answer
A. 25 yo severely hypothermic M with marked
bradycardia; BP undetectable, P 30
B. 43 yo M with bradysystolic cardiac arrest for 40
minutes, BP undetectable, P 15
C. 61 yo F with 1
st
degree AV block and sinus
bradycardia unresponsive to 1 mg atropine; BP
90/60, P 48
D. 58 yo F with 3
rd
degree AV block unresponsive
to 3 mg atropine, BP 80/50, P 40
E. 78 yo M with Mobitz I second-degree AV block,
BP 90/40, P 70

Q15 Answer
A. 25 yo severely hypothermic M with marked
bradycardia; BP undetectable, P 30
B. 43 yo M with bradysystolic cardiac arrest for 40
minutes, BP undetectable, P 15
C. 61 yo F with 1
st
degree AV block and sinus
bradycardia unresponsive to 1 mg atropine; BP
90/60, P 48
D. 58 yo F with 3
rd
degree AV block unresponsive
to 3 mg atropine, BP 80/50, P 40
E. 78 yo M with Mobitz I second-degree AV block,
BP 90/40, P 70

Bradycardia
Approach to undifferentiated bradycardia
based on hemodynamic stability
If stable, observe
If unstable
Atropine 0.5 mg IVP, up to 3 mg
Dopamine or Epinephrine drip
External pacing
Transvenous pacing