Module Cardio-MI

A 66-year-old man with chronic kidney disease (CKD) is referred for office evaluation after a recent admission for an acute coronary syndrome. Which of the following statements is TRUE concerning chronic kidney disease (CKD) and cardiovascular disease?

An 80-year-old woman is admitted with acute pulmonary edema on a background of progressive shortness of breath with exertional chest pain for 6 months. She has a history of renal impairment with an eGFR of 40 mL/min. She is initially commenced on IV furosemide with good effect. An echocardiogram reveals LVEF 40% with severe aortic stenosis (AS) with an estimated valve area of 0.7 cm2. What would you do next?

You get a phone call from the heart failure nurse specialist regarding a patient followed up in clinic for titration of medication. He has dilated cardiomyopathy with an EF of 30%. His most recent BP is 110/60 mmHg with heart rate 60 bpm. He is currently on bisoprolol 7.5 mg od and ramipril 5 mg od. His renal function test results have been phoned through to the specialist nurse: Na 136 mmol/L, K 5.5 mmol/L, urea 13 mmol/L, creatinine 270 μmol/L. (Baseline before titration of ACE inhibitor: Na 138 mmol/L, K 4.8 mmol/L, urea 8 mmol/L, creatinine 180 μmol/L.) What would be your advice?

A 57-year-old woman with known heart failure and EF 42% is reviewed in clinic. She is breathless on walking up one flight of stairs or half a mile on the flat. On examination, her BP is 130/90 mmHg and her heart rate is 75 bpm (SR, ECG QRS < 120 ms). Her chest is clear to auscultation. There are no signs of fluid overload. Her current medication is carvedilol 25 mg bd, furosemide 40 mg od, and digoxin 62.5 micrograms od. Her recent renal function tests are Na 141 mmol/L, K 5.1 mmol/L, urea 13.5 mmol/L, and creatinine 236 μmol/L. She has not previously tolerated an ACE inhibitor or spironolactone because of deteriorating renal function and hyperkalemia. What would you do next?

A 65-year-old hypertensive non-diabetic has an eGFR < 40. Screening tests showed microalbuminuria and a normal renal ultrasound. Which class of antihypertensive medication should you start?

A 52 year-old woman has been treated for several years with amlodipine and lisinopril for what has been presumed to be primary hypertension. She is seen by her GP having complained of persistent left loin pain. Her BP is 150/95 mmHg. She is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick testing, there is microscopic haematuria. Which of the following is likely to be the most appropriate investigation at this point?

A 65-year-old diabetic with a creatinine of 1.6 was started on an angiotensin converting enzyme inhibitor for hypertension and presents to the emergency room with weakness. His other medications include a statin for hypercholesterolemia, a beta blocker and spironolactone for congestive heart failure, insulin for diabetes, and aspirin. Laboratory examinations include: K: 7.2 meq/L, Creatinine: 1.8, Glucose: 400 mg/dL, CPK: 400 IU/L. If this patient has a widened QRS on ECG, the first drug given is

An 80-year-old man presents with dyspnea and is found to have CHF caused by systolic dysfunction. He also has mild renal insufficiency, with a creatinine level of 1.4. Which of the following statements is true regarding ACE inhibitor therapy in this patient?

An 82-year-old woman with HTN and chronic renal failure (serum creatinine 3.5 mg/dL) is referred to you for the management of PAF. She has no other risk factors for coronary atherosclerosis and has wellpreserved ventricular function. Her ECG is essentially normal, with a QTcinterval of 400 msec. Which of the following drugs will be suitable for her rhythm management?

A patient with renal failure (creatinine, 3.4 mg/dL) and thrombocytopenia (platelet count, 35,000mm3) presents to you with a pericardial effusion. He is hemodynamically stable. You are concerned about a paracardiac malignancy and would like to characterize the pericardial effusion further. What would be the best method of evaluating this possibility?

An 80-year-old woman is admitted with acute pulmonary edema on a background of progressive shortness of breath with exertional chest pain for 6 months. She has a history of renal impairment with​​ an eGFR of 40 mL/min. She is initially commenced on IVfurosemide with good effect. An echocardiogram reveals LVEF 40% with severe aortic stenosis (AS) with an estimated valve area of 0.7 cm2. What would you do next?

Quelle est la proposition suivant qui est correcte concernant la cardiopathie dilatée post-partum?

Un homme âgé de 26 ans sans antécédent particulier, est suivi par son médecin traitant depuis 6 mois pour spondylarthrite ankylosante débutante. Le motif de la consultation actuelle est une dyspnée d'effort rapidement progressive depuis quelques semaines avec des crises douloureuses rétrosternales constrictives survenant tantôt à l'effort, tantôt au repos la nuit. Auscultation : souffle holodiastolique intense, prédominant le long du bord gauche du sternum. La tension artérielle est à 120/50mmHg. Le pouls radial est très nettement perçu. Quelle est la valvulopathie dont est atteint ce patient?

Une femme de 62 ans, est atteinte d'une polyarthrite rhumatoïde séropositive diagnostiquée il y a huit ans. Quelle est la complication cardiaque la plus fréquente de cette maladie ?

Concernant la vascularite, quelle proposition qui est correcte?

Concernant le syndrome des anti-phospholipides, quelle proposition qui est correcte?

Quelle est la complication cardiaque la plus fréquente de l’ rhumatisme articulaire aigu ?

Femme enceinte de 4 semaines d’aménorrhée présente une embolie pulmonaire nécessitant une anticoagulation. Quelle thérapeutique préconisez-vous?

Femme enceinte de 32 semaines d’aménorrhée présente sa TA : 160/90mmHg avec protéinurie : 2g/24h. Quel est le traitement antihypertenseur qui est le plus approprié dans cette situation ?

Quelle est la proposition suivant qui est correcte concernant l’ rhumatisme articulaire aigu ?

Un homme de 42 ans est hospitalisé pour dyspnée d'effort depuis 3 mois qui s'est rapidement aggravée la semaine passée. Cet homme n'a pas d'antécédents pathologiques notables en dehors d'une cyphoscoliose importante. Il mesure 1 m 81 et pèse 62 kilos (sa mère était également très grande). Auscultation : souffle diastolique en écharpe 4/6, crépitant 1/3 inférieur. Hyperpulsatilité artérielle périphérique, TA = 130/50 mmHg, pouls = 98/mn Absence d’OMI ni de TVJ. Quel diagnostic clinique évoquez-vous ?

Quelle est la proposition suivant qui est correcte concernant la dysfonction érectile?

Quelle est la contre-indication majeure de la grossesse chez la femme ayant une cardiopathie ?

Concernant l’hypertension au cours de la grossesse, quelle proposition qui est correcte?

Concernant l’arythmie au cours de la grossesse, quelle proposition qui est correcte?

Concernant la toxicité cardiaque induite par la chimiothérapie, quelle proposition qui est correcte?

La complication cardiaque causée par l’anthracycline est la plus fréquente :

L’ECG chez le patient ayant une amylose cardiaque montre le plus souvent:

La complication cardiaque la plus souvent rencontrée chez le patient ayant une spondylarthrite ankylosante est :

Concernant l’HIV, quelle proposition qui est correcte?

Concernant le diabète sucré, quelle proposition qui est correcte?

La manifestation clinique de RAA se manifeste par :

Quel est l’examen paraclinique le plus approprié pour rechercher une cardite de RAA ?

Quelle est le traitement de prévention secondaire de RAA ?

Quelle est la complication causée par l’hypertension pulmonaire chez le HIV ?

Which of the following lipid-lowering agents may worsen glycemic control in patients with borderline fasting hyperglycemia?

A 62-year-old tycoon in Kampot presents for physical examination. He is completely asymptomatic and leads a relatively sedentary life style, playing golf twice per week. His past medical history is significant for chronic mild HTN and hyperlipidemia, and he is overweight. He does have a positive family history for early CAD in his father. His current medications include hydroclorothiazide. On physical examination he is found to have a BP of 150/90 mmHg and a HR of 82 bpm. JVP is normal. Carotid upstrokes are normal without bruits. The lungs are clear to auscultation. The heart has a regular rate and rhythm. S1 and S2 are normal. An S4 is present. No murmurs are appreciated. The apical impulse is in normal location and of normal quality. The abdomen is soft with no masses or bruits. The extremities have no clubbing, cyanosis, or edema, and the peripheral pulses are normal. Chest X-ray is unremarkable. The resting ECG is normal. His total cholesterol is 252 mg/dL, LDL cholesterol 142 mg/dL, HDL 38 mg/dL, TG 160 mg/dL. The next best step is:

Lipid-lowering agents:

58-year-old woman is being treated for chronic suppression of a ventricular arrhythmia. After 2 months of pharmacotherapy, she complains about feeling tired all the time. Examination reveals a resting heart rate of 10b/min lower than her previous rate. Her skin is cool and clammy. Laboratory test results indicate low thyroxine and elevated thyroid-stimulating hormone levels. Which of the following agents is most likely to have caused these signs and symptoms?

Guidelines for the use of a statin in hypertension include the following, except:

A 57-year-old woman with a medical history of uncontrolled diabetes, hyperlipidemia, and smoking is being seen at 2-month follow-up after recent hospitalization for anterior STEMI. She reports feeling well and is back to her normal routine without symptoms. Physical exam reveals a blood pressure of 137/75 mmHg and a heart rate of 73 bpm. The remainder of her exam is unremarkable. Blood work shows total cholesterol of 273 mg/dL, LDL 162 mg/dL, HDL 39 mg/dL, and triglycerides of 358 mg/dL. Her HgA1c is 9.8%. Echocardiogram reveals an EF of 35%. Her medications include aspirin 81 mg daily, clopidogrel 75 mg daily, carvedilol 6.25 mg twice daily, lisinopril 20 mg daily, metformin 500 mg twice daily, and pravastatin 40 mg daily. Which of the following interventions would be the most impactful with regard to her long-term cardiovascular morbidity and mortality?

An 83-year-old man with a medical history of coronary artery disease with three-vessel CABG, hypertension, and hyperlipidemia presents to the emergency department with lightheadedness and chest pain radiating down his left arm. The pain began approximately 2 hours ago and has progressively worsened throughout the day. He took one sublingual nitroglycerin at home that did not seem to help. He reports having several episodes of loose, dark stools earlier in the day. He appears to be in moderate distress. Pertinent findings on exam include a blood pressure of 94/52 mmHg, heart rate of 116 bpm, and oxygen saturation of 97%. His neck veins are flat. There is a left carotid bruit present. Lungs are clear to auscultation. Cardiac exam reveals a regular tachycardia with a soft systolic murmur at the right upper sterna border. There is mild epigastric tenderness on abdominal palpation. His extremities are cool to touch; there is no edema. A stat ECG is performed and shows sinus tachycardia with 2-mm ST depressions across the precordium. Currently, the patient reports an urge to defecate. What is the next best step?

A 58-year-old man with a medical history of coronary artery disease treated with PCI to the LAD 2 years ago and hyperlipidemia presents to the emergency room with precordial chest pain radiating down his left arm for the past 2 hours. Physical exam shows blood pressure of 136/77 mmHg, heart rate of 96 bpm, and oxygen saturation of 98%. His JVD is flat and pulmonary exam is unremarkable. Cardiac exam reveals regular rate and rhythm with an S4 gallop. Abdominal exam is benign, and his peripheries are warm. ECG shows 2-mm ST segment depressions in the anterior leads. He is administered aspirin 325 mg, ticagrelor 180 mg, and unfractionated heparin, and is started on a nitroglycerin infusion that has to be titrated to a high dose to achieve resolution of his chest pain. He is scheduled for cardiac catheterization at the end of the day. Just before he is transported out of the emergency department, he begins to experience long runs of ventricular tachycardia associated with lightheadedness. Blood pressure obtained during one of these long runs is 89/54 mmHg. He reports that his chest pain is beginning to return. What is the next best step?

In a patient with PAD, what should be the ideal LDL goal for preventing further disease progression?

A 67-year-old man is diagnosed with peripheral arterial disease. Modification of which of the following risk factors would be advisable for this patient?

A 51-year-old Cambodian man recently relocated to the area and presents to your cabinet as a new patient. He denies having any history of medical problems. He made very infrequent visits to a general practitioner where he previously lived. He is on no medicines and denies having any significant family medical history. He is a current smoker with a 40 pack-year smoking history. His blood pressure is 170/95 mm Hg, and a fourth heart sound is present. His physical examination is otherwise unremarkable. Which of the following statements regarding treatment of this patient’s hypertension is true?

Which of the following is true about smoking and CV disease?

You are asked to see a 41-year-old woman who presents in her 32nd week of pregnancy with sudden onset severe chest discomfort. She has a history of systemic HTN prior to pregnancy controlled on two oral hypotensive agents. Control of HTN has been excellent during pregnancy. She has a past history of smoking but has not used tobacco during the pregnancy. The patient presented to the ED for evaluation. She is markedly diaphoretic. When you see her, she has received 2 SL NTG and has persistent chest pain. She denies cocaine usage. An ECG is obtained and shows 2 mm ST segment elevation in the anterior precordial leads V2, V3, V4. You would recommend which of the following?

You have been referred a 65-year-old man whom the GP has been struggling to manage. For the last year his clinic blood pressure recordings have been persistently around 150/90 mmHg, but he claims to suffer from the ‘white coat’ phenomenon, with home recordings of around 135/90 mmHg which you are satisfied have been undertaken appropriately. He is otherwise healthy, having implemented dietary changes and increased his exercise over the last year, but smokes and intends to continue. What do you recommend?

An overweight (BMI 35) 45-year old man has been referred for investigation of his high blood pressure (160/95 mmHg). He has no significant past medical or family history, but socially he consumes at least 15 pints of beer per week and smokes five cigarettes per day. A 24- hour urinary cortisol is raised and low-dose dexamethasone test is normal. What is the appropriate management?

A 39-year-old man with a medical history of hypertension and smoking presents to the emergency department with worsening chest pain. He reports that he suddenly developed the discomfort after a coughing spell this morning. It has worsened over the past 4 hours so that he now presents to the emergency room. He says it is like a “knife going through my chest to my spine.” There are no exacerbating or alleviating factors that he can identify. Physical exam reveals a blood pressure of 189/92, heart rate of 96 bpm, and oxygen saturation of 96%. He is in moderate discomfort. There is no significant JVD. His lungs are clear, and cardiac exam reveals regular rate and rhythm with a very soft diastolic murmur at the right upper sternal border. He has a trace radial pulse on his left side; the other extremities have 2+ pulses. A basic metabolic profile is remarkable for a creatinine of 1.7. His CK-MB is 22 (units here) and his TnT is 0.8 (units here). An ECG shows nonspecific ST-T changes in leads II, III, and aVF. A chest x-ray is unremarkable. What is the next best step?

A 72-year-old man with a history of mitral valve prolapse, moderate mitral regurgitation, and a remote history of smoking presents with worsening lower extremity edema. Echocardiography shows the aforementioned findings as well as a dilated left atrium and moderate right ventricular dysfunction. His ejection fraction is 60%. What is the cause of his right ventricular dysfunction?

A 70-year-old woman with a history of hypertension, coronary artery disease,and smoking presents with tearing chest pain across the chest that radiates to the back for the past 1 hour. Vitals are HR 100 bpm, BP 190/110 mmHg, RR 18 per minute, and O2 saturation 97% on RA. A chest CT with contrast shows an aortic dissection extending 1 cm distal to the left subclavian artery to 2 cm superior to the renal arteries. What is the most appropriate management strategy?

A 65-year-old man is referred to you for assessment of his complaint of 6 months of progressive exertional dyspnea with activities of daily living. His history is remarkable for hypertension, peptic ulcer disease, and active smoking of one pack per day with >100 packs per year in total. He denies chest pain, orthopnea, PND, or productive cough, but he does report moderate weight loss over the past year. His examination reveals a thin man in no distress who smells of smoke. He is afebrile and normotensive with a room air saturation of 92%. He has diffuse end expiratory wheezing and distant heart sounds without murmurs. His legs are warm and without edema. His ECG is remarkable for sinus rhythm with low QRS voltage and slight right-axis deviation. His labs are all within normal limits, including a B-type natriuretic peptide level. From what you know about this patient right now, in addition to smoking cessation counseling, what would you recommend next?

A 72-year-old woman from Siem Reap comes to see you to establish care, after her previous physician retired. Her medical history is significant for diet-controlled diabetes and a myocardial infarction. She is taking aspirin, simvastatin, and amlodipine. On examination, her blood pressure is 170/95 mm Hg. She has an S4 gallop and 1+ pretibial edema.

A 74-year-old man with diabetic nephropathy is seeing you in clinic on Friday in preparation for his scheduled coronary angiogram on Monday. He currently takes NPH insulin, metformin, lisinopril, furosimide, and aspirin. On physical exam he is euvolemic. Which of these medications should he stop prior to his angiogram?

A 78-year-old man with DM and HTN presents to your office with progressive dyspnea (NYHA functional class III) and lower extremity swelling. In addition to ordering an echocardiogram for assessment of LV systolic function, what is currently the most appropriate next test to assess his diastolic function?

A 66-year-old woman with a history of hyperlipidemia and diabetes presents for the evaluation of dyspnea. Her HR is 66 bpm and her systolic BP is 214/90mmHg. Her LV size on TTE is normal. Her LV EF is 59%. This is her mitral inflow pattern: Which is the finding most consistent with the echocardiogram?

A 52-year old woman with a history of type 2 diabetes mellitus comes to the physician because of facial swelling around her lips and eye. On her last visit 3 weeks ago she was diagnosed with hypertension and appropriate pharmacotherapy was initiated. An image of the woman’s eyes is shown. Which of the following agents could account for the adverse drug reaction in this patient?

A 56-year-old gentleman with type 2 diabetes for 6 years is admitted with severe shortness of breath that developed over 12–24 h. His medications include metformin, pioglitazone, simvastatin, ramipril and aspirin, and he has been on this treatment for more than 2 years. There is no history of chest pain. His blood tests show a normal FBC, U&Es and HbA1c of 7.9%. The most likely cause for this man’s symptoms is:

A 50-year-old man with a history of hypertension, diabetes, and persistent atrial fibrillation, for which he is warfarinized, is admitted with an NSTEMI. He undergoes PCI to his proximal LAD with a drug-eluting stent (DES). What is the best combination of drugs following his intervention?

You are referred a 40-year-old lady with left arm pain. She had a single episode after running for a bus with shopping, which subsided after 5 minutes. She has never previously had exertional chest discomfort. Resting ECG is normal and 8 hours high-sensitivity troponin is negative. She has a BMI of 33 and diet-controlled type 2 diabetes mellitus but is not hypertensive. What do you recommend?

A 45-year-old diabetic male patient has returned to clinic following a recent angiogram. He has stable class 2 angina and is currently on aspirin 75 mg od, atorvastatin 40 mg nocte, and bisoprolol 2.5 mg as antianginal treatment. His symptoms have improved since starting the beta-blocker. The angiogram showed severe plaque in the proximal left anterior descending artery and discrete simple lesions in the mid circumflex and right coronary arteries. The echocardiogram has shown moderate LV impairment. What do you recommend?

On your ward round you review a patient who is 48 hours post anterior STEMI treated successfully with primary angioplasty. He has type 2 diabetes and hypertension. He is gradually improving, having initially suffered with heart failure. He still feels ‘chesty’ and auscultation reveals minimal basal crepitations. Echocardiography has revealed an ejection fraction of 40%. Blood pressure is 110/70 mmHg with heart rate 55 bpm at rest. Ramipril has been titrated to 2.5 mg bd with bisoprolol 2.5mg od. U&Es have remained normal. How would you improve his medical treatment?