Which factor is associated with the development of infective endocarditis Quizlet

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Correct Answer ( C )
Explanation:
Infective endocarditis (IE) affects the endocardial surface of the heart including the valves and mural endocardium. Different types of endocarditis have different pathogens and etiologies. Intravenous drug use is a risk factor for bacterial endocarditis. Diagnosis may be challenging and requires a high level of suspicion, as patients generally have no previous cardiac disease or heart murmurs. Patients often present with nonspecific complaints of fever, chills, night sweats, myalgias, joint pain, anorexia, and weight loss. Clinical manifestations include fever and heart murmurs. Classic signs of IE include petechiae, subungual hemorrhages, tender nodules on the fingertips, and nontender macules on the palms and soles. In the emergent setting, initial goals include stabilizing the patient and making the correct diagnosis. Three sets of blood cultures should be obtained over the first 60-90 minutes and then empiric antibiotic therapy may be administered based on the patient's history and risk factors.

A 62-year-old man reports to the ED with new-onset, crushing, left-sided chest pain, radiating to the left arm that began suddenly 35 minutes prior to arrival. The patient has a history of hypertension, hypercholesterolemia, diabetes mellitus, and a 60-pack-year smoking history. His EMS ECG demonstrates ST-segment elevation in leads II, III, and aVF. In the ED, his vital signs are BP 135/75, HR 98, and RR 18. What is the most appropriate next step?

Arrange for the patient to have an emergent stress test
Call the cath lab emergently and prepare the patient for transport
Give the patient nitroglycerin and draw labs, including troponins
Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin

Correct Answer ( D )
Explanation:
This patient has an acute myocardial infarction (MI). An acute MI is clinically characterized by left-sided, substernal, chest pain (often described as an "elephant on my chest," tightness, or pressure rather than pain itself) that radiates down the left arm or left jaw, diaphoresis, nausea/vomiting, and shortness of breath. These symptoms are a result of myocardial death due to coronary vessel occlusion or vasospasm, often as a result of rupture of an atherosclerotic plaque. The definition of an acute MI, as described by the European Society for Cardiology and American College of Cardiology (ACC) is a rise and fall of a cardiac biomarker (troponin) in addition to clinical symptoms, ECG changes, or coronary artery changes as noted on an interventional level. Risk factors for an acute MI include hypertension, hypercholesterolemia, diabetes, tobacco, male, increased age, and family history. This patient has ST-segment changes in leads II, III, and aVF, correlating to an inferior wall MI. In a patient with an acute MI, the first step in management is to place the patient on a cardiac monitor to recognize any dysrhythmias, establish a peripheral IV, give oxygen if hypoxic, and administer aspirin.

Correct Answer ( A )
Explanation:
Infective endocarditis occurs when pathogens introduced to the systemic circulation invade the endocardial surface of the heart, including the heart valves. Staphylococcal and Streptococcal bacteria are the most common culprits. The clinical signs and symptoms of endocarditis are varied. Symptoms include fever, chills, dyspnea, weakness, nausea, vomiting, cough, and chest pain. Regarding physical findings, fever is the most common abnormality, seen in 90%. The majority of patients with endocarditis will have a heart murmur (85%). Approximately half of patients with endocarditis develop embolic phenomena, where septic microemboli break off and lodge in downstream tissues. Characteristic skin findings are somewhat less common. Osler nodes, tender lesions on the pads of the fingers, are seen in 10-23% of patients with endocarditis. Janeway lesions, nontender erythematous lesions on the extremities, are seen in 10%, and splinter hemorrhages, linear lines in under the nails, are seen in 15% of patients. The treatment of infective endocarditis involves antibiotic therapy targeted to the suspected pathogen, and stabilization of any hemodynamic instability.

Correct Answer ( D )
Explanation:
The evaluation of hypertension involves specific history questions, exam findings and laboratory testing. A standard history should include questions about the presence of comorbidities (coronary artery disease, atherosclerosis, congestive heart failure, previous myocardial infarction, peripheral arterial disease, hypercholesterolemia, transient ischemic attacks and strokes, diabetes, renal insufficiency, endocrinopathies, retinal disease, connective tissue disease and obstructive sleep apnea), medications (oral contraceptives, corticosteroids, NSAIDs and cyclosporine), social history (salt intake, tobacco use, alcohol use, cocaine and methamphetamine use, dietary intake, and exercise trends) and family history of hypertension. The physical examination must include serial bilateral arm BP measurements, cardiac exam (murmurs, evidence of left ventricular hypertrophy), peripheral vascular and skin exam (edema, bruits, capillary refill, striae, moon fascies), thyroid exam, abdominal exam (masses, bruits), fundoscopic exam and neurologic exam. Baseline laboratory-diagnostic testing should include a basic metabolic panel, complete blood count, urinalysis, lipid panel and ECG.

Correct Answer ( A )
Explanation:
Dilated cardiomyopathy (DCM) is a complication of chronic hypertension and coronary artery disease. Patients with cardiomyopathy typically suffer from symptoms of cardiac failure, especially dyspnea and edema. If cardiac failure is suspected, the initial evaluation for underlying cardiomyopathy includes an echocardiogram. In DCM, the echocardiogram usually demonstrates an enlarged ventricular chamber with normal or decreased wall thickness. Ejection fraction, a marker of systolic function, will also typically be normal or decreased. Treatment of DCM follows the American College of Cardiology and the American Heart Association's guidelines for the treatment of heart failure. In addition to lifestyle modifications, pharmacotherapy includes ACE-inhibitors or ARBs, loop diuretics and beta-blockers. Bisoprolol is a selective beta-1 adrenergic receptor blocker.

Bisoprolol, carvedilol, and metoprolol, but not propranolol (B), are the only beta-blockers with proven benefit in heart failure management. Salmeterol (C) is a long-acting beta-2-agonist used in treating bronchospasm and COPD, not heart failure.

Correct Answer ( A )
Explanation:
This patient most likely has peripheral arterial disease in the right aortoiliac artery. Peripheral arterial disease is physiologically significant atherosclerosis of the aortic bifurcations or arteries of the lower limbs. It is strongly associated with smoking, diabetes mellitus, and aging and shares all the risk factors common to atherosclerosis. This patient presents with right hip and buttock claudication, diminished femoral pulses and erectile dysfunction. This presentation commonly represents atherosclerotic disease within the aortoiliac system and is sometimes referred to as Leriche syndrome. Classic claudication is characterized by leg pain that is consistently reproduced with exercise and relieved with rest. The degree of symptoms of claudication depends upon the severity of stenosis, the collateral circulation, and the vigor of exercise. Patients with claudication can present with buttock, hip, thigh, calf, or foot pain, alone or in combination. The usual relationships are between pain location and corresponding anatomic site of arterial occlusive disease.

Peripheral arterial disease in the common femoral artery (B) may cause thigh pain with effort but would not result in erectile dysfunction. Peripheral arterial disease in the popliteal artery (C) would produce pain in the lower one-third of the calf. Peripheral arterial disease within the superficial femoral artery (D) usually produces an effort-related discomfort in the upper two-thirds of the calf.

Correct Answer ( D )
Explanation:
Stress-induced cardiomyopathy, also called Takotsubo cardiomyopathy and "broken heart" syndrome, is an increasingly reported syndrome characterized by transient cardiac dysfunction with ventricular apical ballooning, usually triggered by intense emotional or physical stress. This syndrome mimics acute myocardial infarction, but in the absence of obstructive coronary artery disease. It is approximated that stress cardiomyopathy accounts for approximately 2% of suspected acute coronary syndromes. Stress cardiomyopathy was historically called Takotsubo cardiomyopathy. Takotsubo is a Japanese word for octopus trap which resembles the characteristic apical ballooning seen on ventriculogram or echocardiography. It has also been referred to as apical ballooning syndrome or broken heart syndrome. The pathophysiology remains unknown, but catecholamine-mediated myocardial stunning is thought to be the most likely mechanism. This disorder is more common in women, specifically postmenopausal women. Patients typically present following physical stress or a stressful emotional event such as a loss of a loved one, natural disaster, or devastating financial losses; however, a triggering event is not always present. Common presenting features include electrocardiographic changes (often anterior ST-segment elevations), mildly elevated cardiac biomarkers, sub-sternal chest pain, and dyspnea. Accepted criteria for the diagnosis are (1) ST segment elevation, (2) transient regional wall motion abnormalities of apex and mid ventricle, (3) the absence of coronary artery disease, and (4) absence of other causes of left ventricular dysfunction such as pheochromocytoma or myocarditis. In-hospital mortality is approximately 2% and patients who survive the acute episode typically recover in several weeks. Treatment is largely supportive care with hydration and efforts to alleviate physical or emotional stressor.

Correct Answer ( D )
Explanation:
Endocarditis is infection of the cardiac endothelium or valves or both. Acute cases are associated with normal valves and virulent bacteria, while subacute cases represent smoldering infections of abnormal valves with less virulent bacteria. Risk factors include valve prosthesis, history of rheumatic heart disease or prior endocarditis, mitral valve prolapse or regurgitation, congenital cyanotic heart disease, intravenous drug use, indwelling venous catheter, diabetes, poor dentition, hemodialysis and intracardiac devices. Symptoms include persistent bacteremia or fever and other constitutional symptoms (night sweats, weight loss, fatigue, anorexia). Complications include valve defects, septic emboli leading to stroke, pulmonary embolus or myocardial infarction and immune complex deposition disease such as glomerulonephritis and arthritis. The most common cause of native valve endocarditis in a non-user of intravenous drugs is Streptococcus viridans, especially in those with dental disease, as this organism is normally present in the oral cavity.

Correct Answer ( B )
Explanation:
Asymptomatic Mobitz type II second-degree AV block is an indication for pacemaker placement. This block has a high risk of progressing to complete heart block and should be treated with pacemaker placement, regardless of symptoms. In general, the long term treatment for symptomatic sinus bradycardia or heart block without reversible cause is a permanent pacemaker. These devices are usually placed in the left pectoral area with leads inserted through a vein into the heart. Two general factors guide the decision to place a permanent pacemaker: the association of symptoms with a brady-dysrhythmia and the potential for progression of the rhythm disturbance. Progression is largely dependent on the anatomical location of the conduction abnormality. The location of an AV conduction abnormality, within the AV node or below the AV node in the His-Purkinje system is an important determinant of both the probability and progression rate of conduction system disease. Disease below the AV node, in the His-Purkinje system, is generally considered to be less stable. The most common indications for pacemaker implantation are sinus node dysfunction followed by AV block. Sinus bradycardia in which symptoms such as dizziness, lightheadedness, syncope, fatigue, or poor exercise tolerance are present should be treated. Acquired AV block is the second most common indication for permanent pacemaker placement. Complete, or third-degree AV block, advanced second-degree AV block, symptomatic Mobitz I or Mobitz II second-degree AV block are all indications for pacemaker placement.

Asymptomatic sinus bradycardia with heart rate of 40/min (C), asymptomatic Mobitz type I second-degree AV block (A) and asymptomatic three second sinus pauses (D) are not indications for a pacemaker in the absence of symptoms.

Correct Answer ( C )
Explanation:
Supraventricular tachycardias (SVT) include paroxysmal, reentry or preexcitation tachycardias. Reentry SVTs include AV nodal reentry (AVNRT), atrioventricular reentry, or atrial reentry. Reentry circuits require the presence of at least two different conduction pathways with differential refractory times. It is characterized by an abrupt onset and termination of tachycardia, that distinguishes it from sinus tachycardia, which has gradual changes in rate. It is precipitated by a premature atrial or ventricular contraction or hyperadrenergic state. The ECG shows a regular, fast rhythm with absent P waves and narrow QRS complex. Unstable patients require immediate synchronized cardioversion. Stable patients, such as the patient above, should first undergo vagal maneuvers. Some common vagal maneuvers include holding your breath and bearing down (Valsalva maneuver), coughing, gagging, and immersing your face in ice-cold water. If vagal maneuvers are unsuccessful, adenosine is used both diagnostically and therapeutically. Adenosine transiently blocks the AV-node and allows the circuit to "reset."

Correct Answer ( D )
Explanation:
The boy has central cyanosis with a harsh murmur characteristic of pulmonary stenosis. These findings are suspicious for tetralogy of Fallot (TOF). TOF is composed of four anatomic defects consisting of an overriding aorta, right ventricular hypertrophy, pulmonary stenosis, and ventricular septal defect (VSD). The clinical presentation depends upon the degree of pulmonary stenosis. The more severe the stenosis, the greater is the reduction of pulmonary blood flow and increased cyanosis. On examination, the patients are usually comfortable and in no distress. During hypercyanotic (tet) spells, patients usually become hyperpneic or agitated. The murmur of TOF is usually due to pulmonary stenosis and not the VSD. The murmur is due to the degree of obstruction and to the amount of flow across the obstruction. The diagnosis of TOF is generally made by echocardiography. Other tests that are often performed during the evaluation of TOF include chest radiography and electrocardiogram. The classic chest X-ray in TOF demonstrates a "boot-shaped" heart with an upturned apex and a concave main pulmonary artery segment. The heart size is often normal, and pulmonary flow will appear normal or decreased. Treatment of TOF involves surgical closure of the VSD as well as repair of the pulmonary stenosis. The timing of this procedure depends upon the degree of obstruction to pulmonary blood flow.

The following are possible chest radiography findings in cyanotic heart diseases: egg-shaped heart (A) is found in transposition of the great arteries, heart shaped like a snowman (B) is described in total anomalous pulmonary venous return, and increased pulmonary blood flow (C) can be found in truncus arteriosus, transposition of the great arteries, and total anomalous pulmonary venous return.

Correct Answer ( C )
Explanation:
There are several different reasons why the pericardial sac fills with fluid. Pericardial effusion often poses several diagnostic questions. In order to work through a differential, a sample of pericardial fluid can be sent to the lab for analysis testing. As is common with other fluid analyses, the first step in evaluating pericardial fluid is to differentiate transudate from exudate. Transudate represents an imbalance between vessel hydrostatic and oncotic pressure. Transudates are usually associated with some cardiac disease, such as congestive heart failure, or hepatic disease, such as cirrhosis. Other causes of transudative effusion include nephrotic syndrome, hypothyroidism and amyloidosis. On the other hand, exudates herald the presence of some traumatic injury or inflammation. Exudate can be infectious in nature, as in viral, bacterial or fungal pericarditis, or even myocarditis and endocarditis. Exudates are also commonly associated with autoimmune rheumatic conditions, such as rheumatoid arthritis or systemic lupus erythematosus. Cancer, either primary or metastatic, can also produce a pericardial exudate. In addition, exudates can be bloody, as in bleeding disorders or direct trauma. Once the pericardial effusion is deemed exudative, other tests are employed. Total cell counts, WBC differentials, fluid glucose, total protein and lactate dehydrogenase levels, microscopic examination, Gram stain, culture and susceptibility testing, AFB smear and culture, cytology and parasitic testing round out the typical battery of tests used to determine the source of a pericardial exudative effusion. Light's criteria are used to help differentiate transudative from exudative effusions - most commonly in pleural effusions but the table below can also be applied to pericardial effusions.

Vasculitis

Temporal arteritis: PMR, carotid artery branches affected, vision loss, Rx: immediate steroids
Takayasu's arteritis: Asian, decreased pulses
PAN: generalized without lung involvement, HBV
Buerger's disease: smokers, claudication of hands/feet
Granulomatosis with polyangiitis (GPA): Upper and lower respiratory sx + renal sx, c-anca
Microscopic polyangitis: similar to GPA but without nasopharyngeal involvement, p-ANCA
Churg-Strauss syndrome: vasculitis + eosinophilia + asthma
Cryoglobulinemia: HCV, malaise, skin lesions, joint pain
Behçet's disease: oral and genital ulcers, hyperreactivity to needle sticks

Correct Answer ( B )
Explanation:
Non-ST-elevation myocardial infarction (NSTEMI) treatment begins with a basic anti-ischemic regimen consisting of oxygen, morphine, nitrates, and possibly beta-blockers and ACE-inhibitors. Antiplatelet medications are then considered. Choices include aspirin, clopidogrel, and prasugrel. NSTEMI treatment is rounded out with anticoagulants such as enoxaparin, bivalirudin, and fondaparinux. Based on risk stratification, definitive treatment may include medications-alone, angiography, percutaneous cardiac intervention or coronary artery bypass surgery. Clo

A 34-year-old woman presents to the ED with chest pain that is worse with inspiration and better upon leaning forward. She has had a runny nose and cough for the last week. In the ED, her vital signs are BP 134/78, HR 86, RR 14, oxygen saturation 99% on room air, and T101°F. On exam, a friction rub is heard. An ECG displays global ST segment elevation with PR segment depression. What is the most likely diagnosis, and what would be the next step in management?

Acute myocardial infarction; give aspirin, nitroglycerin, consult cardiology, and activate the cath lab
Acute pericarditis; give nonsteroidal anti-inflammatory drugs
Cardiac tamponade; perform immediate pericardiocentesis
Pulmonary embolism; order CT angiography of the chest

Correct Answer ( B )
Explanation:
This patient most likely has acute pericarditis, which is inflammation of the pericardial sac. Patients present with pleuritic chest pain that is typically worse when lying supine, deep inspiration, or swallowing. The pain is usually relieved by leaning forward. On auscultation, a pericardial friction rub may be heard. Pulsus paradoxus may also be observed, which is a fall in systolic blood pressure of greater than 10 mmHg with inspiration. Pericarditis can have many etiologies including infection, systemic connective tissue diseases, uremia, post-radiation, or post-myocardial infarction (Dressler's syndrome). Although there is no definitive diagnostic test, an ECG can demonstrate diffuse ST segment elevation, diffuse PR segment depression, and PR elevation in aVR (thumbprint sign). Treatment of pericarditis is mainly supportive. NSAIDs will reduce inflammation and pain. Steroids or colchicine may be given for refractory cases.

Correct Answer ( A )
Explanation:
Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does not rise with exertion. Syncope, commonly occurring with exertion, is reported in up to 42% of patients with severe aortic stenosis. The pathology of aortic stenosis includes processes similar to those in atherosclerosis, including lipid accumulation, inflammation, and calcification. The development of significant aortic stenosis tends to occur earlier in those with congenital bicuspid aortic valves. During the asymptomatic latent period, left ventricular hypertrophy and atrial enlargement of preload compensate for the increase in afterload caused by aortic stenosis. As the disease worsens, these compensatory mechanisms fail, leading to symptoms of heart failure, angina, or syncope. Doppler echocardiography is the recommended initial test for patients with classic symptoms of aortic stenosis. It is helpful for estimating aortic valve area, peak and mean transvalvular gradients, and maximum aortic velocity. Aortic valve replacement should be recommended in most patients with any of these symptoms accompanied by evidence of significant aortic stenosis on echocardiography.

Atrial myxoma (B) is associated with syncope related to changes in position, such as bending, lying down from a seated position, or turning over in bed.

Correct Answer ( A )
Explanation:
To analyze the heart rhythm on this ECG, a systematic approach is recommended.. First, look at the rate. This rate is fast (tachycardia), greater than 100 beats per minute. Then, look at the width of the QRS complex for a clue to where the impulse originates. The QRS complexes here are narrow so this is a supraventricular tachycardia. Next, evaluate the regularity of the rhythm. Is it regular or irregular? If the rhythm is irregular, is there still a pattern to the beats? If there is no pattern to the beats, it is irregularly irregular. If a rhythm is irregularly irregular, ask, "Is this atrial fibrillation?". This rhythm is irregularly irregular. Last, look for P waves and their relationship to the QRS. In this case there are no consistent P waves, confirming the diagnosis of atrial fibrillation.

A 21-year-old woman presents with shortness of breath, rash and nausea after an insect bite. Her vitals are T 97.7°F, HR 128, BP 85/56, RR 28, oxygen saturation 93%. Exam reveals diffuse hives and posterior pharyngeal swelling. Which of the following should be immediately administered?

Epinephrine 1:10,000, 0.3 mL IM
Epinephrine 1:10,000, 10 mL IV
Epinephrine 1:1000, 0.3 mL IM
Epinephrine 1:1000, 0.3 mL IV

Correct Answer ( B )
Explanation:
Cardiomyopathy is defined as a group of diseases which involve the muscle or electrical system of the heart. There are several causes, most of which are genetic in nature. Other etiologies are related to infectious, autoimmune, inflammatory, infiltrative, toxic, electrolytic, endocrine, nutritional and radiation etiologies. There are four main types: dilated, hypertrophic, restrictive and arrhythmogenic-right-ventricular (fibro fatty infiltration of the right ventricle). Dilated cardiomyopathy (DCM) is the most common subtype. It is the third most common cause of cardiac failure, behind coronary artery disease and hypertension. Adult DCM is most commonly caused by hypertension and coronary artery disease, but also is caused by genetic and infectious etiologies. Patients usually present with symptoms of heart failure, such as peripheral and pulmonary edema, cough, orthopnea and dyspnea at rest, with exertion or of the paroxysmal-nocturnal type. Initial evaluation of a patient with these symptoms includes electrocardiography, echocardiography, chest radiography and baseline chemistries, namely Beta-type (Brain) natriuretic peptide (BNP). BNP is secreted by the cardiac myocytes in response to increased volume and filling pressures.

Beta-2 microglobulin (A) is used to evaluate hematologic disorders like multiple myeloma, lymphoma and leukemia. It is also associated with multiple sclerosis and other CNS disorders, as well as renal tubular disorders. Erythrocyte sedimentation rate (C) is a marker of inflammation. It is not a reliable test in differentiating cardiac from pulmonary dysfunction. Homovanillic acid (D) is a biomarker of metabolic stress in the central nervous system, not the cardiac or pulmonary systems.

Correct Answer ( E )
Explanation:
This patient has atrial fibrillation with a rapid ventricular rate and is hemodynamically unstable (BP 80/50 mm Hg and pulse ox 88%). This dysrhythmia needs to be emergently corrected in order to stabilize the patient; failure to do so could result in sudden cardiac death. In such circumstances, emergent synchronized cardioversion is required.

If the patient is hemodynamically stable, the approach to management (rate vs. rhythm control) depends on the time of dysrhythmia onset. If the onset is unknown or greater than 48 hours, then cardioversion should be delayed until the patient can be adequately anticoagulated with enoxaparin (A) followed by warfarin. In the interim, rate control would be accomplished with either esmolol (D), a short acting ß-blocker, or diltiazem (C), a calcium channel blocker. For patients with stable paroxysmal atrial fibrillation and duration of onset < 48 hours, chemical cardioversion using procainamide (B) can be attempted. In unstable patients, regardless of the rhythm duration, synchronized electrical cardioversion is recommended. Alternatives to procainamide include amiodarone, ibutilide, and, to a lesser degree, flecainide.

Correct Answer ( B )
Explanation:
Patients with unstable angina are mostly admitted to a critical care unit after initial presentation. There, an anti-ischemic regimen, if not already begun, is initiated. This typically includes oxygen, nitrates, analgesics and beta-blockers. Serial monitoring for new dysrhythmias, recurrent ischemia, dynamic electrocardiography, changing laboratory results and worsening angina is necessary to maximize patient outcomes. Further management includes risk stratification to determine if early invasive treatment is appropriate. High-risk indicators that favor early invasive treatment strategies include hemodynamic instability, elevated troponin I or T levels, a history of CABG, a history of percutaneous coronary intervention (PCI) within the past 6 months, recurrent angina despite anti-ischemic therapy, symptoms of congestive heart failure (S3, pulmonary edema, crackles, mitral regurgitation) or an ejection fraction < 40%.

An ejection fraction < 40%, not 50% (A), favors early invasive treatment of unstable angina. Whereas elevated B-type natriuretic peptide is associated with poor outcomes in patients with unstable angina, atrial natriuretic peptide (C) is not. It is however responsible for water, sodium and potassium homeostasis. Its action is opposite of aldosterone. R wave progression (D) is not indicative of invasive management of unstable angina. New or presumably new ST depression is, however.

Correct Answer ( D )
Explanation:
Primary aldosteronism is a potential cause of secondary hypertension. Hypertension can be divided into essential or secondary hypertension. Approximately 95% of patients with elevated blood pressure have essential hypertension. Secondary cause of elevated blood pressure should be suspected in patients with severe or resistant hypertension, in patients younger than 30 years without risk factors for hypertension, in patients with malignant hypertension, or hypertension onset before the age of puberty. Potential causes of secondary hypertension include renovascular disease, primary kidney disease, primary aldosteronism, obstructive sleep apnea, long-term corticosteroid use, coarctation of the aorta, thyroid disease, drugs, or pheochromocytoma. Renovascular disease is the most common potentially correctable cause of secondary hypertension. Signs, symptoms, and laboratory findings are dependent upon the etiology. Patients with secondary hypertension due to renovascular disease may present with an abdominal bruit or decreased kidney function after initiating antihypertensive therapy. Primary aldosteronism typically causes hypokalemia, mild hypernatremia, or drug-resistant hypertension. Patients with sleep apnea are usually obese and may complain of daytime somnolence, fatigue, headache, or depression. Drug-induced hypertension can be caused by oral contraceptives, decongestants, nonsteroidal anti-inflammatory drugs (NSAIDs), or cocaine. The treatment of secondary hypertension is based upon the underlying etiology. Complications of untreated hypertension include heart failure, cerebrovascular disease, renal insufficiency, and aortic dissection.

Correct Answer ( C )
Explanation:
A typical feature of acute coronary syndrome is crushing retrosternal chest pain or pressure. Often this is lacking, and patients present with atypical features of the pain or the presence of angina equivalent symptoms (e.g., dyspnea, nausea, vomiting, dizziness). Many patients with a diagnosis of ACS have pain that is pleuritic, positional, or reproduced by palpation. One large study showed that up to 33% of patients diagnosed with acute myocardial infarction did not have chest pain on presentation. Atypical complaints include dyspnea; nausea; diaphoresis; syncope; and pain in the arms, epigastrium, shoulder, or neck.

Atypical features of ACS are present with increasing frequency in older populations. In patients older than 85 years (A), atypical symptoms are more common than typical chest pain, with dyspnea being the most common. Isolated physical exam findings are rarely diagnostic of the origin of chest pain. Palpation of the chest wall (B) may reveal localized tenderness, but 5%-10% of patients with ACS have chest pain and associated palpable chest wall tenderness. Being female (D) is a risk factor for an atypical presentation of ACS.

Correct Answer ( C )
Explanation:
Patients with Turner syndrome are at increased risk for coarctation of the aorta and should have an echocardiogram to establish the diagnosis and determine the severity of the stenosis. Coarctation of the aorta is defined as a narrowing of the aorta. Most cases of coarctation of the aorta are congenital and associated with other congenital cardiac defects. Acquired cases are usually due to an inflammatory disease, such as Takayasu arteritis. Approximately 30% of patients with Turner syndrome have a coarctation. In order to maintain normal systolic function, several compensatory mechanisms arise to overcome the left ventricular outflow tract obstruction. These mechanisms include left ventricular hypertrophy and the development of collateral blood flow to circumvent the lesion. Systolic hypertension and diminished or delayed femoral pulses are classic physical exam findings. Older children and adults may complain of chest pain, cold extremities, and claudication. If collateral flow has had time to develop, a continuous murmur may be heard over the left anterior chest or left midline back. Initial diagnostic studies include electrocardiography, chest radiography, and echocardiography. Chest radiography may reveal notching of the ribs. In most patients, echocardiography with Doppler can establish the diagnosis, determine the severity, and evaluate for additional defects without the need for further imaging studies. Computed tomography and magnetic resonance imaging may be required in adults for complete evaluation of the thoracic aorta. Patients with coarctation of the aorta should be referred to a cardiovascular surgeon for evaluation. Accelerated coronary artery disease, aortic dissection, stroke, and heart failure are common complications in patients who do not undergo surgical repair for the lesion.

Correct Answer ( A )
Explanation:

Aortic dissection is an uncommon but life-threatening phenomenon that occurs when damage of the intima allows the entry of blood between the intima and media, creating a false lumen. The most important risk factor for aortic dissection is hypertension. Other risk factors include chronic cocaine use, bicuspid aortic valve, collagen disorders, pre-existing aortic aneurysm, aortic surgery or instrumentation, vasculitis involving the aorta, pregnancy and delivery, and aortic coarctation. Aortic dissection has a bimodal age distribution, with a peak under 40 years of age associated with connective tissue disorders and another peak at greater that 50 years of age associated with chronic hypertension. The presentation of aortic dissection depends on the anatomic location of the dissection, with the most common presentation being sharp or tearing chest pain. More distal aortic dissections may present with abdominal or flank pain. A history of diabetes, prior aortic surgery, or pre-existing aortic aneurysm may cause a painless presentation. Other presentations include syncope, stroke from carotid involvement, and spinal cord syndromes. CT angiogram is the gold standard for diagnosis of dissection.

Correct Answer ( C )
Explanation:
Orthostatic hypotension is due to an inadequate physiologic response to postural changes. This condition mostly exists in the elderly population. It is estimated that nearly 25% of syncopal admissions to the ED are due to orthostatic hypotension. Symptoms of orthostatic hypotension include dizziness, weakness, fatigue, light-headedness, headache or syncope which occur after standing. Primary causes include frailty, dehydration, poor cardiac output or autonomic instability. However, there are a multitude of underlying conditions that can cause secondary orthostasis. These include anemia, hemorrhage, cardiac dysfunction, venous insufficiency, endocrine dysfunction (hypothyroidism, hypoaldosteronism, adrenal insufficiency, diabetes insipidus, hypokalemia) and neurologic dysfunction (autonomic neuropathy, vitamin B12 deficiency). If suspected, orthostatic vital signs must be obtained as follows: BP and heart rate must be measured in the supine position, then repeated after 3 minutes of standing. If normal, but orthostasis is still suspected, then the patient should be sent for head-up tilt-table testing.

Correct Answer ( D )
Explanation:
Symptomatic hyperkalemia is a life-threatening electrolyte abnormality typically seen in patients with underlying acute or chronic kidney disease. It can also be seen in conditions that cause increased tissue breakdown such as tumor lysis syndrome, rhabdomyolysis, and crush injuries. Muscle weakness and paralysis, cardiac conduction abnormalities and cardiac dysrhythmias are the most serious manifestations of hyperkalemia. Symmetrical peaked T waves with a shortened QT interval and ST-T segment depression are the earliest ECG changes seen in patients with hyperkalemia. Worsening hyperkalemia results in progressive lengthening of the PR interval and QRS duration, disappearance of the P wave, and ultimately widening of the QRS complex into a sinusoidal pattern. Treatment of hyperkalemia includes antagonizing the membrane effects of potassium, driving extracellular potassium into cells, and removing potassium from the body.

Osborn waves (A), also known as J-waves, are positive deflections in the junction of the QRS complex and the ST segment. They are most commonly seen in patients with hypothermia. QT interval prolongation (B) is seen in hypokalemia, hypomagnesemia, and hypocalcemia. QT interval shortening is seen in hyperkalemia. U waves (C) are small deflections that follow the T wave and are typically seen in hypokalemia, rather than hyperkalemia.

Correct Answer ( C )
Explanation:
Instructing patients to monitor daily weights can help prevent heart failure readmission. Heart failure is one of the most common causes of hospitalization, hospital readmission and death. Due to the complexity and long-term nature of heart failure regimens, the need for careful diet and weight management, and the importance of intervention in the early phases of decompensation, patient self-management is crucial in avoiding hospitalizations. Patients should be specifically instructed to take all medications as directed, monitor daily weights, monitor for signs and symptoms, adhere to a low-sodium diet, limit alcohol consumption and stop smoking.

Elevation of the lower extremities (B) can help reduce edema but it will not help prevent readmission to the hospital with a congestive heart failure exacerbation. Heart failure patients should not be advised to avoid physical activity (A). In stable patients, increasing physical activity or regular exercise can help diminish symptoms. Lastly, restricting fluid intake (D) has not been shown to prevent heart failure readmissions.

Rheumatic Fever

Patient with a history of GAS infection
Complaining of fever, red skin lesions on the trunk and proximal extremities, and small, non-tender lumps located over the joints
PE will show JONES criteria: Joints, Oh, no carditis!, Nodules, Erythema marginatum, Sydenham's chorea
Labs will show anti-streptolysin O, anti-DNase B, positive throat culture, or positive rapid antigen test
Treatment is antibiotics, NSAIDs
Comments: Modified Jones Criteria for a first episode of acute rheumatic fever: need 2 major or 1 major and 2 minor

Correct Answer ( B )
Explanation:
This woman most likely has bacterial endocarditis caused by intravenous drug use. Infective endocarditis is an infection of the endocardial or valvular surfaces of the heart. Underlying valvular disease is present in about half of cases. Colonization of the valve by bacteria or fungi can occur during dental, upper respiratory, urologic, or surgical procedures. Intravenous drug use (IVDU) is also a source of bacteremia. Most cases of native valve endocarditis are caused by Streptococcus species, including S viridans. Staphylococcus aureus accounts for over 60% of endocarditis associated with IVDU. The tricuspid valve is most commonly affected in IVDU associated endocarditis. Almost all patients have fever. Other nonspecific symptoms include chills, anorexia, weight loss, myalgias, and malaise. Dyspnea and cough are common complaints when the tricuspid valve is affected due to embolic showering of the pulmonary vasculature. Roth spots (retinal hemorrhages), Osler nodes (distal digital subcutaneous nodules), and Janeway lesions (nontender maculae on palms and soles) are caused by peripheral emboli. Petechiae are the most common skin finding. Blood cultures are key in the diagnosis of infective endocarditis. Three sets of blood cultures should be obtained prior to initiating antibiotics. Transthoracic echocardiography can be used initially, but cannot be used to rule out endocarditis due low sensitivity. Transesophageal echocardiography has a sensitivity of 90-100% for valvular lesions. Electrocardiography is usually nonspecific. The Modified Duke criteria can aid in the diagnosis. Treatment depends on underlying history and suspected etiology, but empiric IV antibiotic regimens should be initiated prior to obtaining culture results.

A four-year-old girl is brought to the ED by her parents due to lethargy. A week prior, the girl had a cough and cold. Later, symptoms progressed to include fever and malaise. She has been less active with decreased appetite. A few hours prior to arrival in the ER, she was having difficulty breathing. On exam, temperature is 38.3°C, respiratory rate is 35, heart rate is 126, blood pressure is 90/60, with clear breath sounds, hepatomegaly, and poor pulses. Which of the following is the most likely diagnosis?

Bronchiolitis
Dysrhythmia
Myocarditis
Pneumonia

Correct Answer ( C )
Explanation:
The girl demonstrates signs and symptoms that are suspicious for myocarditis, which is a condition that results from inflammation of the heart muscle. The majority of children present with acute or fulminant disease. Myocarditis can be caused by infectious, toxic, or autoimmune conditions. Common causes of viral myocarditis include enterovirus (coxsackie group B), adenovirus, parvovirus B19, Epstein-Barr virus, cytomegalovirus, and human herpes 6 (HHV-6). The presentation of the disease is variable, and patients can present with broad symptoms that range from subclinical disease to cardiogenic shock, arrhythmias, and sudden death. There is usually a history of a recent respiratory or gastrointestinal illness within the previous weeks. There is a prodrome of fever, myalgia, and malaise several days prior to the onset of symptoms of heart dysfunction. Then, patients present with heart failure symptoms that include dyspnea at rest, exercise intolerance, syncope, tachypnea, tachycardia, and hepatomegaly. Testing is focused on determining the severity of cardiac dysfunction and these include electrocardiography (ECG), cardiac biomarkers, chest radiography, and echocardiography. Confirmation of myocarditis is generally made by cardiac magnetic resonance imaging or endomyocardial biopsy.

Correct Answer ( D )
Explanation:
Heart murmurs are common in infants and children. While the prevalence of congenital heart disease is approximately 1 percent, a majority of children have innocent murmurs at some time. Being able to distinguish a murmur associated with heart disease from a benign etiology is important for diagnosis and management. When evaluating an infant or child with a cardiac murmur, it is important to assess whether there are any symptoms concerning for heart disease. Concerning symptoms at any age include respiratory difficulties, diaphoresis (especially with exertion), and poor growth. In infants, symptoms may include poor feeding or excessive irritability. In older children, chest pain and syncope are important symptoms. The physical examination should include careful review of the vital signs, assessment of heart rate and rhythm, assessment of pulses, and a detailed cardiovascular exam. Features associated with innocent murmurs include the following: grade ≤ 2 intensity (flow murmurs and innocent Still's murmur are usually grade I or grade II in intensity), softer intensity when the patient is sitting compared with when the patient is supine, short systolic duration, minimal radiation, musical or vibratory quality.

Correct Answer ( C )
Explanation:
The most appropriate treatment for this patient with acute pericarditis is on an outpatient follow-up and oral naproxen. Acute pericarditis is an inflammation of the pericardium. Acute pericarditis is most commonly seen in men under the age of 50 years. Viral infections are the most common cause of acute pericarditis in the United States. Worldwide, tuberculosis is the most common cause. Other causes of pericarditis include bacteria, uremia, neoplasms, myocardial infarctions (Dressler syndrome), radiation, and rheumatoid conditions. In most cases of acute pericarditis, the pericardium becomes inflamed and infiltrated with leukocytes. Pericardial effusions can develop during pericarditis. Effusions that accumulate rapidly may cause cardiac tamponade. Regardless of etiology, most cases of pericarditis present with pleuritic, postural chest pain. The pain may radiate to the neck, shoulders, back, or epigastric region. A pericardial friction rub is pathognomonic and is very specific, but lacks sensitivity. The friction rub is often transient and serial exams may be necessary for detection. Other physical findings may depend on the etiology. Viral pericarditis is usually accompanied by flu-like symptoms, low-grade fever, malaise, dyspnea, and tachypnea. Fever may be absent in uremic pericarditis. Patients with bacterial pericarditis often appear systemically toxic. Lab findings and diagnostics should be used to rule out other serious causes of chest pain, such as myocardial infarction, pulmonary embolism, or aortic dissection. Echocardiography should be used to evaluate for effusion. Electrocardiography may show generalized ST segment elevation and PR segment depression. Chest radiographs are usually normal unless a significant pericardial effusion is present. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line treatment unless contraindicated. Colchicine and corticosteroids can be used in severe or refractory cases. Corticosteroids increase the risk of recurrence. Uremic pericarditis should be treated with urgent dialysis. Indications for admission include presence of effusion, fever, immunosuppression, trauma, oral anticoagulation therapy, myopericarditis, or failure of oral NSAIDs therapy.

Correct Answer ( A )
Explanation:
Varicose veins are a type of chronic venous disease or venous insufficiency. The spectrum of disease in venous insufficiency ranges from mild to severe, with milder forms being uncomfortable and cosmetically unappealing and more severe forms causing serious systemic manifestations. Venous insufficiency may or may not be symptomatic. When symptoms are present, they can range from venous dilation to skin changes to ulceration. The dilation of the veins occurs due to increased venous pressure, resulting in varicose veins or telangiectasias, which are smaller, spider veins seen on the surface of the skin. Varicose veins are more frequently seen in women and are a very common finding, occurring in approximately a quarter of all adults in the United States. Risk factors for the development of venous insufficiency include advanced age, pregnancy, prolonged standing, obesity, smoking, prior venous thrombosis, sedentary lifestyle and lower extremity trauma. Patients generally present with complaints of heaviness or pain in the legs, pruritus, burning sensations, restless legs or night cramps, edema and skin changes. Diagnosis is initially clinical and then confirmed with duplex ultrasound. Conservative management with leg elevation, compression stockings and exercise is the initial treatment in the majority of cases of varicose veins.

Correct Answer ( B )
Explanation:
Heart failure takes on many forms, however, the overall pathology is a failure to pump blood forward at a sufficient rate. Etiologies include ischemic heart disease (coronary atherosclerotic disease) and cardiomyopathy. Cardiac failure can be backward, or "congestive", versus forward, or "impaired perfusion". Impaired perfusion symptoms include fatigue, weakness, poor appetite, mental status changes and exercise intolerance. Left-sided congestive failure results in dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, crackles and pulmonary basilar dullness to percussion. Right-sided failure causes peripheral edema, RUQ discomfort, bloating, ascites, hepatosplenomegaly, hepatojugular reflux, jugular venous distension and increased jugular venous pulsation. Congestive failure is also associated with an S3 heart sound.

Pulsus paradoxus (D) is a systolic blood pressure drop of ≥ 10 mm Hg during inspiration. It is commonly seen in pericardial tamponade, but not congestive heart failure.

Acute Coronary Syndrome: Management

Aspirin: ↓ mortality, ↓ infarct size, ↓ reinfarction rate
Clopridogrel: patients with aspirin allergy
Heparin: ↓ DVT, ↓ reinfarction, ↓ stroke, ↓ LV thrombus, ↓ reocclusion
Nitroglycerin:
Coronary artery dilation/vascular smooth muscle relaxation → ↓preload/afterload → ↓ myocardial O2 demand
Contraindications: sildenafil use within 24 hrs, RV infarction
ß-blockers:
↓ Myocardial O2 demand, ↓ ventricular fibrillation
IV indications: tachydysrhythmias, intractable HTN
Morphine:
↓ Preload/afterload, ↓ sympathetic activity
No mortality benefit
Glycoprotein IIb/IIIa inhibitors: benefit in patients undergoing PCI
PCI:
Preferred over thrombolytics in all STEMI patients
PCI center: <90 minutes contact to device time
Non-PCI center: transfer to PCI center if contact to device time can be <120 minutes
Non-PCI center: thrombolytics if contact to device time to be >120 minutes
Thrombolytics: begin within 30 minutes of ED arrival if selected

Correct Answer ( B )
Explanation:
In aortic stenosis, structural damage to the aortic valve obstructs ventricular outflow. The most common cause of aortic stenosis in the United States is degenerative calcification, also known as calcific aortic stenosis. Incidence is associated with traditional cardiovascular risks factors of age, hypertension, hyperlipidemia, diabetes, and tobacco use. Bicuspid aortic valves, in which the normal trileaflet aortic valve has only two leaflets, is another cause of aortic stenosis, particularly in younger individuals. Worldwide, rheumatic heart disease is a major cause of aortic stenosis. When aortic stenosis develops, there is typically a long asymptomatic period, during which the left ventricular hypertrophies to compensate for the outflow obstruction, and cardiac output is preserved. However, when ventricular wall is so thickened as to impede diastolic filling, cardiac output is decreased and symptoms appear. The classic triad of aortic stenosis is known by the acronym SAD: syncope, angina, and dyspnea. Dyspnea is often the first symptom to appear, followed by chest pain, and then syncope (classically with exertion) and clinical signs and symptoms of heart failure. The characteristic murmur of aortic stenosis is a harsh systolic ejection murmur heard best at the right second intercostal space radiating to the carotids. A narrowed pulse pressure may also be present.

Correct Answer ( B )
Explanation:
Sinus bradycardia refers to a discharge rate from the sinoatrial node of < 60 beats/minute. Sinus bradycardia can be a result of pathologic factors like hypoxia, hypothermia, cardiac ischemia or infarction, hypothyroidism, or increased intracranial pressure. Many medications also cause sinus bradycardia, including beta-blockers, calcium-channel blockers, digoxin, and opioids. Sinus bradycardia may also be a normal finding in well-conditioned young people, athletes, during sleep, or as a result of vagal stimulation. On electrocardiogram, sinus bradycardia is indistinguishable from sinus rhythm other than having a slower rate. Patients with sinus bradycardia may be asymptomatic or may complain of dizziness or lightheadedness. An especially slow rate may result in signs of hypoperfusion (e.g. hypotension, altered mental status, or ischemic chest pain). The treatment of sinus bradycardia depends on the underlying cause and the clinical effects. Underlying causes should be corrected. Unstable patients should be treated with atropine while transcutaneous pacing is initiated and arrangements for transvenous pacing are made. Infusions of dopamine or epinephrine are also indicated to increase the heart rate if atropine is ineffective. Glucagon is used to treat cardiotoxicity from beta-blocker or calcium channel blocker overdose.

Correct Answer ( A )
Explanation:
An aortoenteric fistula is an abnormal communication between the aorta and the gastrointestinal tract. Primary aortoenteric fistulas are caused by compression of gastrointestinal structures by an aortic aneurysm. Secondary aortoenteric fistulas result from erosion of an aortic prosthetic graft into an adjacent gastrointestinal structure. As such, abdominal aortic aneurysm and a history of aortic surgery are the most common risk factors for aortoenteric fistula formation. Other causes include reflux esophagitis, peptic ulcer disease, non-aneurysmal aortitis, and penetrating aortic ulcers. The duodenum is the most common site of fistula formation. The classic triad of gastrointestinal bleeding, abdominal pain, and a palpable mass is rarely present and a known history of aortic aneurysm is often lacking. Gastrointestinal bleeding, including hematemesis, hematochezia, and melena, is often the presenting symptom. Although massive hemorrhage is common, many patients will have a small "herald bleed," a seemingly self-limited episode of gastrointestinal bleeding, prior to a larger bleed. Complications include hemorrhage and sepsis from seeding of the blood with gastrointestinal flora. While uncommon, aortoenteric fistula should be on the differential diagnosis for gastrointestinal bleeds, especially in patients with a history of aneurysm or aortic surgery, as the condition is life-threatening. Management of aortoenteric fistulas is surgical repair.

Correct Answer ( C )
Explanation:
Torsades de pointes may be caused by electrolyte disturbances (hypokalemia, hypomagnesemia, hypocalcemia), antiarrhythmic drugs that prolong the QT interval (procainamide, quinidine, disopyramide), N-acetylprocainamide, droperidol, amiodarone, phenothiazines, haloperidol, tricyclic antidepressants, terfenadine, astemizole, ketoconazole, erythromycin, TMP-SMZ, high-dose methadone, or cocaine. Torsades de pointes is also associated with hereditary long QT interval syndromes. It is a form of ventricular tachycardia manifested by episodes of alternating electrical polarity, with the amplitude of the QRS complex twisting around an isoelectric baseline resembling a spindle. The rhythm usually starts with a PVC and is preceded by widening of the QT interval. Treatment involves intravenous infusion of magnesium sulfate and cardioversion.

Correct Answer ( B )
Explanation:
Aortic dissection is an uncommon but life-threatening phenomenon that occurs when damage of the intima allows the entry of blood between the intima and media, creating a false lumen. The most important risk factor for aortic dissection is hypertension. Aortic dissection has a bimodal age distribution, with a peak under 40 years of age associated with connective tissue disorders and another peak at greater that 50 years of age associated with chronic hypertension. CT angiogram is the gold standard for diagnosis of dissection. Aortic dissections are defined by their anatomic locations, with Stanford Type A dissections involving the ascending aorta and Stanford Type B dissections involving only the descending aorta. Control of hypertension and heart rate are the cornerstones of acute management of aortic dissection. Negative inotropes are the preferred agents for the control of hypertension in aortic dissection. This is due to their ability to lower blood pressure without increasing heart rate, which would increase shearing force against the intimal flap and lead to propagation of the dissection. Short-acting beta-blockers such as labetalol, esmolol, and propranolol are the first line agents. Calcium channel blockers can be used in the event of contraindication to beta-blockers, though there is more limited literature on their use in this setting. For persistent hypertension, vasodilators such as nitroprusside or nicardipine can be used. Aortic dissection typically presents with hypertension and hypotension, when present, is a poor prognostic indicator and should be managed with crystalloids. Definitive management depends on the anatomic location of the dissection. Type A and complicated type B dissections typically require surgical repair while uncomplicated type B dissections are typically managed

Correct Answer ( C )
Explanation:
Hypertrophic cardiomyopathy (HCM) results from left or right ventricular hypertrophy or both. This condition can be primarily caused by autosomal dominant genetic mutations of the cardiac sarcomere genes and myocardial fiber hypertrophy. Secondary causes include aortic stenosis, mitral valve abnormalities, coronary heart disease and chronic systemic hypertension. Most patients are asymptomatic upon presentation, however, the common clinical manifestations are dyspnea, angina and dysrhythmia. Decreased chamber volume and increased ventricular wall thickness are the key echocardiographic findings in HCM. Furthermore, the ECG typically shows left ventricular hypertrophy, T-wave inversion and large QRS complexes. A harsh, left sternal border, systolic, crescendo-decrescendo murmur which is worse with Valsalva maneuver is quite typical of HCM.

Aortic stenosis (A) is associated with a right, not left, sternal border pansystolic murmur that is decreased, not increased, during a Valsalva maneuver. S3, normal or thin ventricular wall and enlarged ventricular chamber volume are more common with dilated cardiomyopathy (B). S4, thick ventricular wall and decreased ventricular chamber volume are more common with hypertrophic cardiomyopathy. Mitral stenosis (D) produces a diastolic, not systolic, murmur, and is associated with increased left atrial size and pressure.

Kawasaki Disease

Patient will be a child < 4 years old
With a history of high fever for 5 days
Complaining of conjunctivitis, rash, adenopathy, strawberry tongue, hand/feet edema, fever
Treatment is IVIG + aspirin
Comments: #1 cause of pediatric acquired heart disease, risk for coronary artery aneurysm
Mnemonic: CRASH and burn: Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet edema, Fever

Correct Answer ( B )
Explanation:
Abdominal aortic aneurysm (AAA) is defined as any infrarenal aortic diameter ≥ 3 cm. It occurs in men 5-10x more than women. Risk factors include family history (12-19% of first-degree relatives are affected), male sex, age, atherosclerosis, tobacco use and hypertension. The underlying pathology involves oxidative stress, aortic wall inflammation and proteolytic degradation of elastin and collagen. Abdominal ultrasound screening is recommended in any male aged 65-75 years who has ever smoked. Most AAAs are asymptomatic and found incidentally during other diagnostic testing. However, if found, AAAs must be monitored, as size, and not comorbidity, usually dictates management. Elective surgical correction of an asymptomatic AAA is offered to patients when an AAA grows ≥ 5.5 cm, or grows more than 0.6 to 0.8 cm over 6 months. Therefore, the 42-year-old man with hypertension aneurysm size 3.9 cm with 0.9 cm expansion in 6 months should undergo elective repair.

Those with AAAs < 5.5 cm, or growth ≤ 0.6 cm per year (A, C and D) are followed with serial ultrasound monitoring, no matter what the age or underlying comorbidity.

Correct Answer ( D )
Explanation:
The American College of Cardiology and the American Heart Association (ACC/AHA) released a new set of guidelines in November 2013 for treatment of hyperlipidemia with the focus being to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) in adults. Cardiovascular risk is estimated based on age, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, gender, smoking status, systolic blood pressure and the presence or absence of diabetes. Several online calculators are available to determine risk. Four groups have been identified as benefiting from statin therapy: patients with ASCVD, patients with LDL levels greater than or equal to 190 mg/dL, patients aged 40-75 years with diabetes and an LDL level of 70-189 mg/dL, and patients with an LDL level of 70-189 mg/dL and a 10-year ASCVD risk of greater than or equal to 7.5%. The starting point to reduce the risk of ASCVD is lifestyle modifications such as regular physical exercise, heart-healthy diet, smoking cessation and maintaining a healthy weight. First-line treatment for patients meeting criteria for treatment of hypercholesterolemia is statin therapy, including lovastatin. This patient meets criteria for treatment based on his ASCVD score of > 7.5%.

Correct Answer ( B )
Explanation:
A hypertensive emergency is a severe elevation in blood pressure with evidence of end-organ damage. This requires immediate lowering of blood pressure. There is no specific blood pressure at which hypertensive emergency occurs, however, end-organ damage is less likely if the diastolic BP is < 130 mm Hg. With that being said, the well-accepted criteria for hypertensive crisis are systolic pressure ≥180 mm Hg or diastolic pressure ≥ 110 mm Hg. One must further consider the patient's baseline blood pressure, as a patient with chronic hypertension may not have end-organ damage with pressures around 200/150 mm Hg. Precipitants of hypertensive emergencies include progression of essential hypertension (especially if there is medical noncompliance), progression of renovascular disease, acute cardiac or cerebral ischemic injury and undiagnosed or progressive endocrinopathies. Symptoms of hypertensive emergency include chest pain, dyspnea and neurologic deficits. Associated clinical scenarios include encephalopathy, hemorrhagic or ischemic stroke, aortic dissection, acute myocardial infarction, acute coronary syndrome, acute renal failure, pulmonary edema with respiratory failure, microangiopathic hemolytic anemia and pre-eclampsia/eclampsia/HELLP syndrome.

Correct Answer ( C )
Explanation:
Tricuspid regurgitation (or incompetence, or insufficiency) manifests as a blowing, pansystolic murmur. It is commonly associated with a thrill. It is most intense in the left, fourth intercostal space, however, it can radiate to the apex, making it difficult to differentiate from a mitral regurgitation murmur. Like tricuspid stenosis, it is quite rare, affecting only 1% of the US population. Causes include rheumatic heart disease, right ventricular dilation, myxomatous degeneration and varied connective tissue disorders. It is part of Ebstein's anomaly, a congenital heart defect in which the tricuspid leaflets attach to the right ventricular wall, leading to a larger than normal right atrium and smaller than normal right ventricle. Ebstein's anomaly is also commonly associated with an atrial septal defect, patent foramen ovale and the pre-excitation, re-entrant conduction defect of Wolff-Parkinson-White syndrome. Diuretics are the mainstay of treatment, and valvuloplasty or valve repair, if necessary, is far more common than valve replacement.

Correct Answer ( D )
Explanation:
Proper cardiac auscultation begins with an understanding of which chest wall location is associated with which valve-sound. The aortic valve is best appreciated in the right, second intercostal space just lateral to the sternum. The pulmonic valve is best heard in the left, second intercostal space just lateral to the sternum. The tricuspid valve can be appreciated in the left, fourth intercostal space over the left sternal border. The mitral valve is best appreciated in the left, fifth intercostal space about the midclavicular line, also known as the apex. The murmur of aortic stenosis occurs during systole between S1 and S2. As such, it is also called an ejection murmur. It is best heard in the right, second intercostal space. Other characteristics include medium pitch, crescendo-decrescendo tonality and possible associated thrill. Aortic stenosis is due to calcification of the valve cusps. It is a common cause of sudden death, especially in children and adolescents. It can also be associated with rheumatic heart disease, atherosclerosis and congenital bicuspid valve malformation.

Correct Answer ( C )
Explanation:
Venous insufficiency, mainly due to incompetent or absent venous valves, can lead to retrograde blood flow in the superficial or deep venous systems. Ultimately, this leads to the syndrome of chronic venous insufficiency, which is marked by poor cosmesis, pain, lipodermatosclerosis, ulceration and life-threatening infections. The pain is usually described as burning, cramping or heaviness that occurs constantly in almost 20%, and episodically in almost 50% of sufferers. Chronic venous stasis or hypertension causes the characteristic skin changes of capillary proliferation, red or brown coloring, fat necrosis and fibrosis. These may be associated with edema, cellulitis, ulceration and cutaneous infarction. Although typical, these physical findings are only suggestive of the condition. Any suspicion is best evaluated initially with duplex ultrasonography.

Correct Answer ( B )
Explanation:
A classic aortic dissection involves an intimal tear and hemorrhagic extravasation into the intima-media space. Aortic dissections can be defined as proximal, affecting the ascending aorta, or distal, involving the descending aorta distal to the subclavian take-off. Several risk factors of this potentially fatal condition exist, and include hypertension, congenital aortic valve disorder (coarctation, root-dilatation or bicuspid valve), trauma, cardiac surgery, aortitis and connective tissue disorder. Both types are characterized by severe, "ripping or tearing" pain that is maximal at onset (as compared to the crescendo pain of an acute coronary syndrome) and located in the chest, back or abdomen. A new aortic insufficiency murmur is more common in proximal dissection, while a history of hypertension is more common in the distal type. Evaluation includes chest radiograph, chest CT and transesophageal echocardiogram. First-line therapy is intravenous beta-blockers, such as labetalol or esmolol, followed by vasodilators like nitroprusside. Emergency surgery is very likely, especially for proximal dissections.

Correct Answer ( C )
Explanation:
The girl has signs and symptoms that are suspicious for pericarditis. There are several viral agents that can cause pericarditis like enteroviruses, influenza, adenovirus, respiratory syncytial virus, and parvovirus. The most common symptom of pericarditis is chest pain that is characterized as sharp or stabbing, positional, radiating, worse with inspiration and relieved by sitting upright or prone. Other nonspecific symptoms include cough, fever, dyspnea, abdominal pain, and vomiting. Clues to the diagnosis are physical exam findings of muffled or distant heart sounds, tachycardia, narrow pulse pressure, jugular venous distension, and a pericardial friction rub provide clues to the diagnosis of acute pericarditis. Pericarditis can be complicated by cardiac tamponade that is recognized by the excessive fall of systolic blood pressure (>10 mm Hg) with inspiration. Abnormal findings on ECG include low voltage QRS amplitude, tachycardia, and abnormalities of the ST segments, PR segments, and T waves. Chest X-ray findings may be normal if effusion is not present. On the other hand, there may be cardiac enlargement in the presence of an effusion. The most sensitive test to identify the size and location of a pericardial effusion is by echocardiography.

Correct Answer ( D )
Explanation:
This scenario most likely represents cardiac tamponade. Pericardial tamponade refers to the dampening effect of rapidly accumulating pericardial effusion. An increase in intrapericaridal pressure compresses the heart chambers, decreases venous return and ultimately decreases cardiac output. As this occurs, it becomes ever more difficult for blood to flow from chamber to chamber. Causes include pericarditis, traumatic aortic dissection and myocardial rupture. Patients usually present with severe dyspnea, fatigue and hypotension. Typical exam findings include Beck's triad of hypotension, distant heart sounds and increased jugular venous pressure. Tachycardia and clear-sounding tachypnea are common. Pulsus paradoxus, a decrease in systolic blood pressure more than 10 mm Hg during inspiration, is also commonly present. However, pulsus paradoxus also accompanies constrictive pericarditis, congestive heart failure, pulmonary embolism, and end-stage obstructive pulmonary disease. Distant heart sounds and friction rubs may be present. Chest radiographs show large cardiac silhouettes, and ECGs may reveal a widespread decrease in voltage with an effusion and electrical alternans in tamponade. Classic echocardiographic findings are effusion, interventricular septal shift during inspiration, diastolic collapse of the right atrium and respiration-timed alterations in transvalvular flow. This medical emergency is treated with cardiopulmonary stabilization, pericardiocentesis (percutaneous drainage of pericardial fluid), cautious volume replacement and inotropic medications such as dobutamine.

Which factor is associated with the development of infective endocarditis?

What is the most common cause of the infective endocarditis?

What is the most common complication associated with infective endocarditis?

Which of the following is a risk factor in endocarditis infecciosa IEC?