Cardiology CME - Hrudoy 2019

The sudden onset of breathlessness and presyncope in a patient with a recent history of hip fracture suggests a possible pulmonary thromboembolism. Pulmonary thromboembolism occurs when a blood clot, usually from the lower extremities, travels to the lungs, causing a blockage in the pulmonary arteries. This can lead to symptoms such as shortness of breath, chest pain, and a rapid heart rate (sinus tachycardia). Given the patient's clinical presentation and ECG findings, pulmonary thromboembolism is the most likely diagnosis.

According to ACLS protocol, one cycle of adult CPR consists of 30 chest compressions followed by 2 rescue breaths. This ratio allows for effective chest compressions to maintain circulation while also providing necessary oxygenation through rescue breaths. This protocol is based on the most current evidence and guidelines for performing CPR on adults.

Aspirin (Disprin) is the first choice of drug to be given in acute myocardial infarction. This is because aspirin is an antiplatelet medication that helps to prevent blood clots from forming in the arteries, which is crucial in the management of a heart attack. By inhibiting platelet aggregation, aspirin reduces the risk of further clot formation and helps to restore blood flow to the heart muscle. It is a widely used and effective medication in the acute treatment of myocardial infarction.

The correct answer is "All of the above." This means that all of the statements mentioned in the question are true regarding secondary prophylaxis for rheumatic fever. Secondary prophylaxis is recommended lifelong after valve surgery and for more severe valvular disease. Additionally, regular penicillin injections every 2 weeks are beneficial in preventing recurrent episodes of rheumatic fever.

ACEI/ARB (Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers) are the first-line antihypertensive medications recommended for patients under 50 years of age with primary hypertension. These drugs work by blocking the effects of angiotensin, a hormone that constricts blood vessels, thereby reducing blood pressure. They are effective in treating hypertension and have shown additional benefits in preventing cardiovascular diseases. Beta blockers, diuretics, and calcium channel blockers are also commonly used antihypertensive medications, but ACEI/ARB are generally preferred as the initial treatment option for this specific patient population.

Typical angina is characterized by substernal chest discomfort that is initiated by exertion or stress and relieved with rest. Perspirations, or excessive sweating, is not typically associated with angina. Therefore, perspirations do not satisfy the criteria for typical angina.

For patients with hypertension and asthma (P), it is preferable to use Methyldopa or Labetalol and avoid Enalapril. For patients with hypertension and heart failure with a left ventricular ejection fraction (LV EF) of 0.40 (Q), it is preferable to use Enalapril and Metoprolol Succinate and avoid Nifedipine Retard. For patients with hypertension, old inferior MI, post PTCA, EF 70%, and acute viral hepatitis (R), it is preferable to use Nifedipine Retard and avoid Metoprolol. For patients with hypertension and pregnancy (S), it is preferable to use Metoprolol and avoid Methyldopa. Therefore, the correct answer is PQRS = YXZW.

Non-cardiac chest pain refers to chest pain that is not caused by a heart condition. The features of non-cardiac chest pain include sharp chest pain lasting less than 15 seconds, positional and localized pain, inframammary pain, and pain that is reproducible with palpation. However, discomfort that radiates to both arms and shoulder is not a feature of non-cardiac chest pain. This type of radiation is commonly associated with cardiac chest pain, such as in the case of a heart attack.

The patient is a young individual with severe mitral stenosis, left atrial enlargement, and a low risk of left atrial clots (Wilkinson's score-6). Balloon mitral valvotomy is the treatment of choice in this case. It is a minimally invasive procedure that involves inflating a balloon in the narrowed mitral valve to widen it and improve blood flow. This procedure is preferred over open mitral valvotomy or mitral valve replacement because it is less invasive and has a lower risk of complications.

Combining ACE inhibitors (ACEI) and angiotensin receptor blockers (ARB) should be avoided because both medications work on the same pathway to lower blood pressure. ACE inhibitors block the enzyme that converts angiotensin I to angiotensin II, while ARBs block the receptor for angiotensin II. Using both medications together can lead to an excessive decrease in blood pressure, potentially causing dizziness, fainting, or other adverse effects. Therefore, it is recommended to avoid the combination of ACE inhibitors and ARBs.

The answer suggests that beta blockers should not be initiated on the day of surgery. This is because patients who are already receiving beta blockers should continue taking them, rather than starting them on the day of surgery. The other options mentioned in the question are not relevant to the use of beta blockers on the day of surgery.

Antibiotic prophylaxis is the administration of antibiotics to prevent infection in certain high-risk procedures. Tooth extraction, tonsillectomy, and skin or soft tissue surgery are all invasive procedures that can introduce bacteria into the bloodstream. Antibiotic prophylaxis is recommended in these cases to prevent the development of infections. However, vaginal or caesarean delivery is a natural process that does not involve the same level of invasiveness as the other procedures listed. Therefore, antibiotic prophylaxis is not indicated in vaginal or caesarean delivery.

In the management of cardiogenic shock, all the options listed are true except for the treatment with fluids in AWMI. Fluids are typically not recommended in the treatment of acute wall myocardial infarction (AWMI) as it can worsen the condition by increasing the workload on the heart and potentially leading to pulmonary edema. Instead, other interventions such as emergency revascularization with PCI or CABG, inotropic support, and the use of IABP are commonly used to manage cardiogenic shock.

The correct answer is "Non STEMI" because thrombolysis is not indicated in non-ST segment elevation myocardial infarction (non-STEMI) cases. Thrombolysis is primarily used in ST segment elevation myocardial infarction (STEMI) cases where there is evidence of complete occlusion of a coronary artery. Non-STEMI cases involve partial occlusion or blockage of the coronary artery, and other treatment options such as medications or invasive procedures may be more appropriate.

Cardiac syncope refers to fainting episodes caused by a problem with the heart. Elderly individuals and those with structural heart disease are more likely to experience cardiac syncope due to age-related changes in the cardiovascular system and underlying heart conditions. Syncope in the supine position is also suggestive of cardiac syncope as it may be caused by a decrease in blood flow to the brain. However, frequent recurrence and prolonged history are not typically associated with cardiac syncope. Instead, these symptoms may indicate other causes such as vasovagal syncope or neurological conditions.

In hypotensive patients, determining blood pressure solely based on Korotkoff sounds may not be accurate. Hypotensive patients have low blood pressure, and in some cases, the Korotkoff sounds may not be audible or may be very faint. In such situations, alternative methods such as invasive blood pressure monitoring or Doppler ultrasound may be necessary to accurately measure blood pressure.

Calcium channel blockers are contraindicated in ischemic ventricular tachycardia (VT) because they can further depress myocardial contractility and worsen ischemia. These drugs work by blocking the entry of calcium into the myocardial cells, which reduces the contractility of the heart muscle. In ischemic VT, there is already a reduced blood supply to the heart, and the heart muscle is not receiving enough oxygen. Calcium channel blockers can exacerbate this condition by further reducing the contractility of the heart, leading to potentially life-threatening consequences. Therefore, they should be avoided in the treatment of ischemic VT.

Aspirin is not typically prescribed as a routine medication for diabetics who are non-hypertensive and non-smokers. It is commonly used for its blood-thinning properties to prevent cardiovascular events in individuals at high risk, such as those with a history of heart disease or stroke. However, in this case, the patient does not have any indications for aspirin therapy based on the information provided. Therefore, it may be considered an unnecessary medicine in his prescription.

In Pre-excited AF, the treatment of choice is not any of the options provided. Pre-excited AF refers to atrial fibrillation that occurs in individuals with a pre-existing accessory pathway, such as Wolff-Parkinson-White syndrome. In these cases, the use of medications like beta blockers, calcium blockers, adenosine, or amiodarone may actually worsen the condition or lead to more rapid ventricular response. The treatment approach for pre-excited AF typically involves electrical cardioversion or catheter ablation to eliminate the accessory pathway and restore normal heart rhythm.

Torsemide is a loop diuretic that is commonly used to treat fluid retention and high blood pressure. However, in the context of accelerated hypertension complicating acute myocardial infarction (AMI), it is contraindicated. This is because Torsemide can cause excessive fluid loss and decrease blood volume, which can worsen the already compromised cardiac function in AMI. Therefore, it is important to avoid Torsemide in this specific scenario to prevent further complications.

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Amiodarone is not useful for primary prevention of sudden cardiac death (SCD) in high-risk patients. Amiodarone is primarily used for the treatment of arrhythmias, including ventricular arrhythmias, but it is not recommended as a first-line therapy for primary prevention of SCD. Other interventions such as implantable cardioverter-defibrillators (ICDs) are more effective in reducing the risk of SCD in high-risk patients. Therefore, the statement that Amiodarone is useful for primary prevention of SCD in high-risk patients is not true.

The ACC guidelines for the treatment of acute decompensated normotensive heart failure recommend serial monitoring of renal function and serum electrolytes, chest radiograph, and routine repeat measurement of LV function assessment. Therefore, the correct answer is C & D, which states that the use of invasive hemodynamic monitoring is not recommended.

Prophylaxis for prevention of endocarditis is suggested in patients with certain conditions that increase the risk of developing infective endocarditis. These conditions include prosthetic heart valves, repaired congenital heart defects (CHD) with residual shunts or valvular regurgitation at the site adjacent to a prosthetic patch, and repaired CHD with an occlusion device during the first six months after the procedure. Valvular regurgitation due to a structurally abnormal valve is not specifically mentioned as a condition requiring prophylaxis for endocarditis. Therefore, the correct answer is "Valvular regurgitation due to structurally abnormal valve."

The appropriate treatment for heart failure in the given case includes aspirin, digoxin, frusemide + spironolactone combination, daily atenolol, and enalapril. These medications target different aspects of heart failure management such as reducing blood pressure, improving heart function, and preventing blood clots. However, the other options listed in the question, such as Lasix, deriphyllin, digoxin, oral KCl and Lasix, nifedipine retard, clonidine, aspirin, atorvastatin, insulin, are not appropriate for the treatment of heart failure in this specific case.

In this question, the correct answer is PQR=Z Y X. This means that for the first case (P), the best advice would be to do an echo for LV function assessment, followed by a stress test like dobutamine stress test or a stress thallium scan if the echo is normal. Aspirin, atorvastatin, and a nitrate should also be started. For the second case (Q), the best advice would be to start aspirin, atorvastatin, and metoprolol due to a high probability of CAD. If angina does not get relieved with drugs, a coronary angiogram can be done. For the third case (R), there is a very low likelihood of myocardial ischemia, so the patient can be reassured and sent home with symptomatic treatment. Echo is optional but not essential.

The correct answer states that aspirin significantly reduced MI in the Physician's health study. This means that in this particular study, the use of aspirin resulted in a significant decrease in the occurrence of myocardial infarction (heart attack). This suggests that aspirin can be effective in preventing heart attacks in individuals included in the Physician's health study.

All of the above options are considered as the treatment of choice for the management of supraventricular tachycardia (SVT) in pregnancy. Each medication has its own benefits and considerations, and the choice depends on the individual patient's condition and preferences. Metoprolol, digoxin, flecainide, sotalol, and verapamil are commonly used to control heart rate and rhythm in pregnant women with SVT. It is important to consult with a healthcare professional to determine the most appropriate treatment option based on the specific circumstances of the patient.

According to the latest ESC guidelines, hypertension is defined as clinic measurement >= 140/90 mm Hg, daytime ambulatory BP monitoring >= 135/85 mm Hg, nighttime ambulatory BP monitoring >= 120/70 mm Hg, and 24 hr ambulatory blood pressure monitoring >= 130/80 mm Hg. Therefore, the correct answer is "Daytime ambulatory BP monitoring >= 135/90 mm Hg" because it is not a valid definition of hypertension according to the guidelines.