Transcript AOA Cardiology Review 2009

AOA Cardiology
Review
High Yield USMLE FACTS
2009
Patrick Brine
&
Brian Katz
Case #1 HTN
 A 34 year-old man undergoing a routine physical
examination is found to have a blood pressure of 165/105
mm Hg. The physician asks the patient to return the next
week and the week following, and each time repeats the
evaluation yielding the following results: 170/102, 168/107,
175/108, 167/102 mm Hg.
 Patient’s BP should be classified as which?
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A.
B.
C.
D.
E.
F.
Optimal
Normal
High-Normal
Stage 1 HTN
Stage 2 HTN
Stage 3 HTN
Case # 1
 ANSWER: E
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Pre-HTN: 120-139/80-89
Stage I: 140-159/90-99
Stage II: >160/>100
Dx with 2 or more BP or 2 subsequent visits
 What % of these patients have essential HTN?
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A.
B.
C.
D.
E.
Less than 5%
10-15%
40-50%
70-80%
90-95%
Case # 1
 ANSWER: E
– RF for Essential HTN
 Cardiovascular Dz
 High Cholesterol
 Diabetes
 Family Hx
 Smoking
 High Salt Diet
 Alcohol Use
 Race and Sex: African Americans and Males
Case # 1
 HTN Complications: High Yield USMLE
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Kidney: Hyaline Arteriosclerosis
Cardiac: Left Ventricular Hypertrophy
Eye: Cotton wool spots from Retinal Ischemia
Large and Small Vessel Damage
 Aneursyms, Strokes, Atherosclerosis
 Treatment
– Lifestyle modifications: decrease Na, exercise, diet, decrease
smoking and alcohol intake
– Thiazides
– ACEI in DM and Post MI
– B Blocker in Post MI
Case # 2 HTN

A 35 year-old man has hypertension, which has been difficult to control with
medication. Periodically, he experiences periods when he develops intense
symptoms including racing heart, lightheadedness, flushing, diaphoresis, clammy
skin, headache, and a sense of impending doom. He has gone to the emergency
department of a local hospital several times during these episodes, but by the time
he is seen several hours later, symptoms have long passed, and nothing can be
found on physical examination or serum chemistry studies.
 The patient’s physician orders a 24 hour urine to be collected,
which is found to contain significantly elevated levels of VMA.
This compound is a degradation product of which of the
following?
– A: Acetylcholine
– B: Cholesterol
– C: Epinephrine
– D: Serotonin
– E: Testosterone
Case # 2
 ANSWER: C
– VMA: degradation product of Epinephrine and
Norepinephrine
– Serotonin: produced by carcinoid tumors:
measured directly or by 5HIAA
– Testosterone: measured directly in serum or
precursors: DHEA, DHT, androstiendione
Case # 2
 Q2: What is the most likely Diagnosis?
– A: Leiomyosarcoma
– B: Lymphoma
– C: Neuroblastoma
– D: Pheochromocytoma
– E: Small Cell Carcinoma
Case # 2
 ANSWER: D
– PHEO is commonly tested on USMLE
 Rare cause of 2nd HTN
 RULE OF TENs:
– 10% bilat,
– 10% outside of the Adrenal medulla
– 10% malignant
Case # 2
 Q3: The patient’s lesion has been
associated with which of the following
thyroid lesions?
– A: Follicular Carcinoma
– B: Graves Disease
– C: Hashimoto’s Disease
– D: Medullary Carcinoma
– E: Papillary Carcinoma
Case # 2
 Answer: D
– MEN Syndromes:
 MEN I: 3 P’s: Pituitary, Parathyroid, Pancreas
– Parathyroid hyperplasia, Zollinger-Ellison Syndrome
 MEN IIa: Thyroid, Pheochromocytoma, Parathyroid
 MEN IIb: Thyroid, Pheochromocytoma, Mucosal
Neuronal Tumors
Case # 2
 Final Q: The patient is scheduled for
surgical removal of the tumor. Which of the
following agents should be administered?
– A: Iodide
– B: Lorazepam
– C: Phenoxybenzamine
– D: Propylthiuricil
– E: Spirinolactone
CASE # 2
 ANSWER: C
– alpha blockers used: prevents constriction of peripheral blood
vessels
 EPINEPHRINE REVERSAL: Blocking alpha receptors forces
epinephrine to bind to beta receptors and decrease blood pressure
 Other causes of 2nd HTN:
– Renal Artery Stenosis: ABD BRUIT, fibromuscular dysplasia
– Hyperaldosteronism: Conn Syn: R/A ratio, decreased K, increased
Na, metabolic alkalosis- ADRENAL ADENOMA
– Cushing’s: Elevated Cortisol level
– Thyroid: Hyperthyroidism: elevated T4, suppressed TSH
– Coarctation of the Aorta: unequal ext. blood pressures
Case # 3 Ht Failure
 A 45 year-old woman presents to her primary care physician
complaining of fatigue, weight gain, and shortness of breath. She has
always been an active athlete, but in the past 2 weeks, has found it
impossible to jog for more than a few minutes, after which she feels
tired and winded. She feels her appetite is normal or has even
declined, but she noticed she has gained 15 lbs and her pants and
shoes no longer fit. She appears fatigued, but in NAD. Expiratory
wheezes at both bases. Normal S1, S2 with a II/IV soft holosystolic
murmur heard best at the apex. Distended abdomen. CXR reveals
cardiomegaly and increased vascular markings.
 Which of the following is the most likely diagnosis?
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A.
B.
C.
D.
E.
Acute Leukemia
Cardiomyopathy
Fibromyalgia
Hypothyroidism
Major Depressive Disorder
 Answer: B
Case # 3
– Heart Failure
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
Poor Cardiac Output
SX: SOB
Fatigue
poor appetite
Edema
Ascites
cardiomegaly
– Which of the following is the most likely cause of the patient’s
murmur?
 A. Aortic Insufficiency
 B. Aortic Stenosis
 C. High-Output flow murmur
 D. Mitral Regurgitation
 E. Mitral Stenosis
 F. Pulmonic Insufficiency
 G. Pulmonic Stenosis
 H. Tricuspid Regurgitation
Case # 3
 Answer: D
– Mitral Regurg- holosystolic heard best at apex
– Aortic Stenosis- crescendo/decrescendo systolic murmur 2nd Rt
intercostal and radiation to carotids
– Aortic Regurg- diastolic murmur flow
– Mitral Stenosis- soft diastolic at apex
 Blood in the pulmonary vein is at the same pressure as
blood in which of the following?
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A: Aorta
B. Lt Atrium
C. Lt Ventricle
D. Rt. Atrium
E. Rt. Ventricle
Case # 3
 Answer: B High Yield Cardio Physiology
– Closed vs. Open circulation
Case # 3
 What impt. Physiologic effect will starting this patient on an
ACEI achieve?
– A. Decrease in arteriolar resistance, resulting in less resistance to
forward cardiac outpt.
– B. Decrease in cardiac filling pressures, resulting in less pulm.
Congestion
– C. Increase in arteriolar resistance, resulting in improved blood
pressure
– D. Increase in Lt. Ventricular End-Diastolic Volume, improving in
stroke volume via starling Forces
– E. Increase in Myocardial Contractility, resulting in improved stroke
volume
– F. Stabilization of myocardial membranes, resulting in reduced risk
of arrythmia
Case # 3
 Answer: A High Yield R-A-A
system
– Heart failure promotes an
elevated SVR due to poor
cardiac outpt
– ACEI decrease the resistance
against the heart pumping to
increase volume in the poor
outpt state. AFTERLOAD
REDUCTION
– Decrease Preload
 Aldosterone and ADH
elevate LV End Diastolic
Volume
 Leads to Vascular
Congestion
 NITRATES AND
DIURETICS REDUCE
PRELOAD
– Increase Contractility
 Inotropic Drugs
Case # 3
Case # 3
Case # 4 Heart Failure
 A 40 year-old man presents to the emergency department complaining
of severe SOB. The SOB has been worsening over the past few years,
and the patient reports growing tachypneic with mild exertion, and
sometimes even at night. On exam, he has generalized edema, JVD,
and hepatic distention. Cardiac exam shows Rt. Ventricular Heave, a
rt. Sided S3, and S4 with a pulm. Ejection click. A CXR shows
Cardiomegaly and a widening of the hilar vessels, including pulm.
Arteries. EKG shows tall Peaked P waves in II, III, and aVF, rt axis
deviation, and RVH.
 Which of the following is the most likely Diagnosis?
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A.
B.
C.
D.
E.
Cor Pulmonale
Hypertrophic Cardiomyopathy
Lt Ventricular Ht Failure
MI
PE (acute)
Case # 4

ANSWER: A High yield Ht Failure
– Enlargement of Rt. Ventricle 2nd to diseases of LUNGS, THORAX, or PULM.
CIRCULATION.
– Rt. Atrial Enlargement- EKG: Tall, peaked P waves in leads II, III, aVF
– MOST COMMON Cause of Rt. Ht Failure
 LT SIDED HT FAILURE

Pulm. HTN is suspected in the pt. and a Swan Ganz Catheter is placed.
Which of the following denotes the correct anatomic sequence of vessels
that would be traversed by the catheter if it was introduced into the Lt.
Subclavian vein?
– A. Lt. Subclavian vein, Lt. Brachiocephalic vein, SVC, Rt. Atrium, RV, Pulm
Artery
– B. Lt. Subclavian vein, Lt Common Carotid, SVC, Rt. Atrium, RV, Pulm Artery.
– C. Lt. Subclavian Vein, Lt. Jugular Vein, Lt. Atrium, Lt. Ventricle, Aorta
– D. Lt. Subclavian Vein, Lt. Jugular Vein, SVC, Rt. Atrium, Rt. Ventricle, Pulm
Artery
– E. Lt. Subclavian Vein, SVC, Rt. Atrium, Rt. Ventricle, Pulm. Artery
Case # 4
 Answer: A HIGH YIELD Cardio Anatomy
Case # 4
 Which of the following physiologic stimuli will
result in decreased Pulmonary Vascular
Resistance?
– A. Decreased Cardiac Output
– B. Increased Cardiac Output
– C. Low O2 Tension
– D. Lung Volumes near Residual Volume (RV)
– E. Lung Volumes near Total Lung Capacity
(TLC)
Case # 4
 Answer: B
– Pulmonary Circulation maintains itself as a low-pressure system.
PVR is decreased in the setting of Increased Cardiac Output.
Increase RV output forces distention of capillaries decreasing PVR
– Lung Volumes also affect PVR.
Case # 4
 Some of the exam findings include HEPATIC
congestion. Which of the following terms is
commonly used to identify the macroscopic
pattern of red, depressed hepatic nodules with
pale periphery that accompanies the chronic
hepatic congestion seen in this condition?
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A.
B.
C.
D.
E.
Centrilobular Hemorrhage
Cirrhosis
Fatty Change
Nutmeg Liver
Piecemeal necrosis
Case # 4
 Answer: D
– Nutmeg Liver is due to CHRONIC passive
congestion in centrilobular region with hypoxia
and fatty changes- NUTMEG
Case # 4
 RT. Sided Ht Failure
Case # 5 Chest Pain
 45 year-old man presents to ER with chest pain began 20 minutes prior
while pumping gas. He describes the pain as substernal, intense, dull,
and squeezing. It does not change with respiration. He also complains
that he is nauseated. He has never experienced anything like this
before. His temp is 99.5, BP 124/76, P 80, RR 22, O2 Sat of 95% on
RA. On exam, he is diaphoretic, CTA, RRR. JVP is elevated to level
of jaw. His abd is nontender with normal bowel sounds. An EKG
shows normal sinus rhythm, normal intervals, and ST elevation in leads
II, III, and aVF. CXR reveals no cardiac and pulmonary abnormalities.
 Which of the following is the most likely diagnosis?
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A.
B.
C.
D.
E.
Acute MI
Aortic Dissection
Gastroesophageal reflux
Pericarditis
PE
Case # 5
 Answer: A High Yield Diff Dx of Chest Pain
– CARDIAC VS NONCARDIAC CAUSES
 RULE OUT WITH SX, EKG, CXR, Cardiac Enzymes
– EKG Findings in Acute ST Elevation MI
 II, III, avF- inferior wall
 V1-V2- Posterior Wall
 V2-V4- Anterior Wall
 V5-V6- Lateral Wall
Case # 5
Case # 5
 What is the pathophysiologic process most likely
to be responsible for this patient’s presentation?
– A. Atherosclerotic plaque rupture resulting in thrombus
formation
– B. Buildup of atherosclerotic stenosis to produce highgrade obstruction of the artery
– C. Dissection of the vessel
– D. Embolization of the clot, air, or foreign material
– E. Myocardial Hypertrophy resulting in vessel narrowing
Case # 5
 Answer: A
– ACS: rupture of plaque often of one that is not
producing high grade stenosis
– HIGH GRADE STENOSIS CAUSES ANGINA
 Which of the following is most likely to be diseased
in this patient?
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A. Coronary Sinus
B. Lt Anterior Descending artery
C. Lt. Circumflex coronary artery
D. Lt. Main Coronary artery
E. Rt. Coronary artery
Case # 5

Answer: E
– Rt coronary artery
 Gives off branches to the RV, the SA nodal Artery, AV nodal artery, and 85% of people the
Posterior Descending Artery
– Posterior supplies inferior wall of the RV and LV and 1/3 of the interventricular septum (II, III, aVF)
– Lt main coronary artery (I, aVL, V2-V6)
 Divides into the Lt anterior Descending and the Circumflex
 Ant Descending supplies the anterior and anteroseptal portions of the LV- (V2 to V6)
 Circumflex supplies Lateral Wall of LV (I, aVL, V5, V6)

Aspirin is given in ER. Decreased Production of which mediator is
responsible for the beneficial effects of aspirin?
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A.
B.
C.
D.
E.
cAMP
Platelet glycoprotein IIb/IIIa
Prostacyclin
Thromboxane A2
Ubiquinone (coenzyme Q)
Case # 5
 Answer: D
– Inhibits cyclooxygenase which produces prostaglandins from
arachadonic acid
– Cyclooxygenase produces Thromboxane A2 which is a platelet
aggregator and potent vasoconstrictor
– IIb/IIIa: promotes aggregation (clodipidogrel)
 Elevation of which of the following enzymes is the most
specific for this patient’s condition?
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A.
B.
C.
D.
E.
Alanine aminotransferase
Creatinine Phosphokinase
Lactate Dehydrogenase
Transferrin
Troponin
Case # 5
 Answer: E
– Troponins : most sensitive elevate in 3-12 hrs and peak
at 24 hours. Last 5-14 days
– CPK: most sensitive is CKMB elevated in 8-24 hours
and last 48-72 hours
 3 days after admission, patient becomes SOB and hypotensive.
HR is 100 and normal EKG. BP 75/50, RR 38, O2 sat is 60% on 2 L
NC. CXR reveals bilateral fluffy infiltrates. Which of the following
complications has occurred?
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A. Dilation of the Lt Ventricle
B. Dressler Syn.
C. Rupture of the Lt. Ventricular Free Wall
D. Rupture of papillary muscle
E. VTACH
Case # 5
 Answer: D High Yield MI complications
– Cardiogenic Shock with Severe Pulm Edema
– THINK: Arrhythmia, Cardiac Tamponade, or LV valvular
dysfnx
 INFERIOR MI like papillary dysfnx
 Dilation of LV- ST elevation in Ant Leads and MR
 Dressler Syn- Autoimmune Pericarditis 6-8 weeks after MIPleuritc Pain, SOB, Friction Rub
 LV free wall rupture would cause Cardiac Tamponade- 3-5 days
after MI think more extensive MI
 Arrhythmias in the first 24 hours of MI
–D
Case # 5
 Other Causes of Chest Pain
– Aortic Dissection: tearing pain
 Know ascending vs. descending and tx difference
 Promptly lower BP to prevent further dissection
 Marfan Syn asstd- other causes such as Syphilis that cause an aortic
root dilatation
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PE
Pericarditis
Pneumothorax
Pneumo
Musculoskeletal
GI
Psychogenic
Case # 6
 19 year-old referred to physician for abn. Heart sound on
Physical Exam. Denies SOB, chest pain but does have
Palpitations. He is adopted. 79 inches tall and 160 lb with
long arms and legs. On exam, has a mid-systolic click,
heard best at the apex. The click is heard better with
standing or valsalva.
 Which of the following cardiac abnormalities does this
patient most likely have?
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A. Aortic Regurgitation
B. Aortic Stenosis
C. Mitral Stenosis
D. Mitral valve prolapse
E. Tricuspid Regurgitation
Case # 6
 Answer: D
– MVP can cause Palpitations, SOB, Chest Pain
 Classic Midsystolic Click that is sometimes followed by murmur – at apex,
increase with valsalva and standing
– AR blowing diastolic murmur Lt 2nd intercostal border
– AS crescendo-decrescendo systolic murmur Rt 2nd intercostal space that
radiates to carotids
– MS low-pitched diastolic murmur at apex
 Preceded by opening snap
– TR blowing systolic murmur at Lt. Lower sternal border
 An echocardiogram is performed. Which of the following would
likely be observed during the study?
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A.
B.
C.
D.
E.
Ballooning of the aortic valve into the ventricle during diastole
Ballooning of the mitral valve into the atrium during diastole
Rupture of the aortic valve
Rupture of the tricuspid valve
Stenotic mitral valve
Case # 6
 Answer: B USMLE HIGH YIELD
– Marfan Syndrome and MVP commonly related to same
question
 Over the next year, patient develops Chest Pain, SOB, and
progressive fatigue. On auscultation, he has a midsystolic
click which is now followed by high pitched blowing systolic
murmur. Which of the following is the most likely cause of
this new development?
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A. Aortic Aneurysm
B. Aortic Stenosis
C. Mitral Regurgitation
D. Mitral Stenosis
E. MI
Case # 6
 Answer: C
– Severe cases MVP develops into MR
– Mitral Stenosis 2nd to Rheumatic Fever
– Aortic Aneurysm is asstd with Marfan Syndome
Diastolic Murmurs
Systolic Murmurs
Case # 7
 A pediatrician sees a 4 month old boy for the first time. He
had been delivered at home by his grandmother, who had
been a midwife in SE Asia. Baby had been born on time
and weighed 7 lbs at birth. Exam shows continuous
murmur heard best at the Lt. upper Sternal Border. A thrill,
analagous to kitten’s purring, can be felt over the left side
of the baby’s chest.
 The infant’s murmur is suggestive of which of the
following diagnoses?
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A. Coarctation of the Aorta
B. Hypoplastic Left Ventricle
C. Mitral Valve Stenosis
D. PDA
E. Tricuspid Valve Stenosis
Case # 7
 Answer: D High Yield USMLE
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–
–
–
PDA- machine-like murmur
Treated with Indomethacin
To keep open- add Prostaglandins
Coarctation of the Aorta soft Bruit
 Patients with syncope cannot maintain sufficient
cardiac output to meet peripheral perfusion demands.
Which of the following best describes cardiac output?
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A. CO= End Diastolic Volume- End Systolic Volume
B. CO= HR x MAP
C. CO= HR x SV
D. CO= SV x MAP
E. CO= SVR x MAP
Case # 7
 Answer: C
– Stroke Volume = End Diastolic – End Systolic
 In a patient with Aortic Stenosis, which of the following sets
of changes depict the MAP, Pulm Wedge Pressure, Lt Atrial
Pressure, and Lt Ventricular Peak Systolic Pressure
compared to a healthy individual?
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MAP
A. normal
B. normal
C. normal
D. decreased
LVPSP
increased
increased
increased
normal
PWP
increased
normal
normal
increased
LAP
increased
increased
normal
increased
Case # 7
 Answer: A
– In AS:
 Blood is ejected through smaller than normal opening
 Increases Resistance to flow which increases LVPSP
 LVPSP increase causes increase in LAP as well as Pulmonary Wedge
Pressure( which clinically measures LAP)
 With a patient with MR, which of the following sets of changes
depict LAP at the end of ventricular systole and at the end of
ventricular diastole of this patient compared to a healthy
individual






A.
B.
C.
D.
E.
End Systolic LAP
normal
increased
increased
decreased
decreased
End Diastolic LAP
Increased
normal
increased
decreased
normal
Case # 7
 Answer: B
– MR has elevated LAP toward the end of systole
Endocarditis:
High Yield Subacute vs. Acute
Case # 8
 54 year old man presents to ER with palpitations and SOB.
Temp of 98.6, BP 102/68, P 130, R 26. Elevated JVP,
cardiac exam reveals irregular rate and rhythm, with a low
pitched diastolic murmur preceded by an opening snap
over the apex. Lung exam revealed bibasilar crackles. 2+
bilateral pitting edema. EKG shows an irregular undulation
of the baseline, absence of P waves, and a narrow QRS
complex that are irregularly irregular?
 What is the following preliminary diagnosis?
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–
–
–
–
A. Atrial Arrythmia
B. 1st degree AV block
C. Normal sinus rhythm
D. 3rd degree AV block
E. Ventricular arrhythmia
Case # 8
 Answer: A High Yield Arrhythmias
– Narrow Complex QRS means it is Supraventricular
source- atrial
– Ventricular arrythmias wide QRS complex
– AV block- conduction delay
 PR interval delay
 Which of the following best describes the
patient’s cardiac rhythm?
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–
–
–
–
A. Atrial Fibrillation
B. Atrial Flutter
C. Multifocal Atrial Tachycardia
D. Sinus Bradycardia
E. Sinus Tachycardia
Case # 8
 Answer: A
 What is the underlying cause of the
arrhythmia?
– A. Aortic Stenosis
– B. Hyperthyroidism
– C. Hypothyroidism
– D. Mitral Stenosis
Case # 8
 Answer: D
– Murmur diastolic and causing lt atrial dilatation
which promotes arrhythmias
– Think of mitral stenois and rheumatic fever
Arrhythmias
Heart Failure
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