ABFM HEART DISEASE
A 65-year-old female who had an ST-elevation myocardial infarction
(STEMI) treated with fibrinolytic therapy 2 days ago has a sudden
onset of chest pain and shortness of breath. Clinical evaluation reveals
the presence of pulmonary edema with a blood pressure of 86/50 mm
Hg, wet rales, a harsh holosystolic murmur along the left sternal
border radiating toward the base and apex, and an S3 gallop. A
pulmonary artery monitoring catheter is placed and oxygen saturation
is found to be higher in the pulmonary artery than in the right atrium.
Which one of the following complications does the patient most likely
have?
Acute papillary muscle rupture
Ventricular septal rupture
Ventricular free wall rupture
Left ventricular aneurysm
Severe left ventricular failure - ANSWERS-B
In the patient with an ST-elevation myocardial infarction (STEMI),
cardiogenic shock should be considered if pulmonary edema and
hypotension develop. Although extensive left ventricular dysfunction
is responsible for 75% of cases, mechanical complications (e.g.,
acute, severe mitral regurgitation due to papillary muscle rupture,
ventricular septal rupture, or subacute free wall rupture with
tamponade) are another important cause. Conditions that can mimic
cardiogenic shock include aortic dissection and hemorrhagic shock.
,Of the conditions listed, only ventricular septal rupture is associated
with a pulmonary artery oxygenation that is higher than right atrial
oxygenation.
A 65-year-old African-American male presents with a 2-month history
of exertional dyspnea and ankle swelling. His past medical history is
notable for hypertension and angioedema related to a peanut
allergy.On examination his blood pressure is 155/98 mm Hg. His
jugular veins are mildly distended and bibasilar rales are noted. The
cardiac examination reveals a regular rhythm with a soft S3 and no
murmur. Examination of the lower extremities reveals 1+ pitting
ankle edema. Echocardiography shows an estimated left ventricular
ejection fraction of 40%.Which one of the following medications
should be AVOIDED in this patient?
Amlodipine (Norvasc)
Carvedilol (Coreg)
Enalapril (Vasotec)
Furosemide (Lasix)
Hydralazine - ANSWERS-C
Angioedema occurs in less than 1% of patients taking an ACE
inhibitor but is more common in African-Americans. The American
Heart Association recommends that ACE inhibitors not be initiated in
any patient with a history of angioedema (SOR C). Calcium channel
blockers, particularly those with negative inotropic effects such as
verapamil and diltiazem, can cause a worsening of heart failure and
should also be avoided (SOR C).Although angiotensin receptor
blockers (ARBs) would be regarded as safe in this patient and may be
,considered as alternative therapy for patients who develop
angioedema while taking an ACE inhibitor, angioedema can also
occur in patients taking ARBs and extreme caution is advisable when
substituting an ARB in a patient with a history of ACE inhibitor-
associated angioedema (SOR C). There are no contraindications to the
use of a diuretic or a β-blocker in this patient.
A 74-year-old female presents with a 2-month history of increased
dyspnea on exertion. She was a long-time cigarette smoker but quit 20
years ago. She has COPD treated with inhaled ipratropium (Atrovent),
a combination inhaled corticosteroid, and a long-acting β-agonist. She
can walk up one flight of stairs in her home but for the past 2 months
she has had to stop and rest before reaching the top due to increased
dyspnea. She also has severe osteoarthritis of the left hip treated with
acetaminophen, 1000 mg three times daily, and tramadol (Ultram), 50
mg twice daily. A resting EKG in the office is normal.Which one of
the following would be the most appropriate initial study to evaluate
this patient for ischemic heart disease?
A treadmill exercise test
An adenosine technetium 99m test
A dipyridamole thallium test
Treadmill echocardiography
Dobutamine echocardiography - ANSWERS-E
This patient's severe degenerative joint disease would likely limit her
ability to exercise sufficiently to achieve 85% of her expected heart
rate, which is required for an adequate treadmill exercise test, unless
the patient is on β-blocker therapy, which would allow 65% of the
, predicted heart rate to be considered adequate. Dipyridamole and
adenosine are contraindicated for patients with severe asthma, COPD,
hypotension, bradycardia, or heart block. A resting EKG and resting
echocardiography might be appropriate, but would not rule out
ischemic heart disease. Dobutamine provides a pharmacologic means
to stress the heart in patients who cannot exercise. These agents
enhance myocardial contractile performance and wall motion, thus
making poorly functioning areas assessable by echocardiography. In
patients unable to exercise to the target heart rate, pharmacologic
agents are needed to complete stress testing.
A 59-year-old male sees you for a follow-up office visit after having a
drug-eluting stent placed 6 weeks ago following a non-ST-elevation
myocardial infarction. He also has a 2-year history of type 2 diabetes.
He was discharged on the following medications:Aspirin, 81 mg
dailyClopidogrel (Plavix), 75 mg dailyAtorvastatin (Lipitor), 40 mg
dailyMetoprolol tartrate (Lopressor), 25 mg twice dailyRamipril
(Altace), 10 mg dailyMetformin (Glucophage), 500 mg twice
dailyThe patient has been asymptomatic since being discharged from
the hospital. On examination he has a blood pressure of 142/86 mm
Hg and a heart rate of 52 beats/min. The remainder of the examination
is unremarkable. A lipid profile reveals an LDL-cholesterol level of
65 mg/dL, an HDL-cholesterol level of 30 mg/dL, and a serum
triglyceride level of 260 mg/dL. His hemoglobin A1c is 7.2%.Which
one of the following would be most appropriate at this time?
Increas - ANSWERS-B
The long-term management of patients with non-ST-elevation
myocardial infarction involves measures to prevent recurrent cardiac
A 65-year-old female who had an ST-elevation myocardial infarction
(STEMI) treated with fibrinolytic therapy 2 days ago has a sudden
onset of chest pain and shortness of breath. Clinical evaluation reveals
the presence of pulmonary edema with a blood pressure of 86/50 mm
Hg, wet rales, a harsh holosystolic murmur along the left sternal
border radiating toward the base and apex, and an S3 gallop. A
pulmonary artery monitoring catheter is placed and oxygen saturation
is found to be higher in the pulmonary artery than in the right atrium.
Which one of the following complications does the patient most likely
have?
Acute papillary muscle rupture
Ventricular septal rupture
Ventricular free wall rupture
Left ventricular aneurysm
Severe left ventricular failure - ANSWERS-B
In the patient with an ST-elevation myocardial infarction (STEMI),
cardiogenic shock should be considered if pulmonary edema and
hypotension develop. Although extensive left ventricular dysfunction
is responsible for 75% of cases, mechanical complications (e.g.,
acute, severe mitral regurgitation due to papillary muscle rupture,
ventricular septal rupture, or subacute free wall rupture with
tamponade) are another important cause. Conditions that can mimic
cardiogenic shock include aortic dissection and hemorrhagic shock.
,Of the conditions listed, only ventricular septal rupture is associated
with a pulmonary artery oxygenation that is higher than right atrial
oxygenation.
A 65-year-old African-American male presents with a 2-month history
of exertional dyspnea and ankle swelling. His past medical history is
notable for hypertension and angioedema related to a peanut
allergy.On examination his blood pressure is 155/98 mm Hg. His
jugular veins are mildly distended and bibasilar rales are noted. The
cardiac examination reveals a regular rhythm with a soft S3 and no
murmur. Examination of the lower extremities reveals 1+ pitting
ankle edema. Echocardiography shows an estimated left ventricular
ejection fraction of 40%.Which one of the following medications
should be AVOIDED in this patient?
Amlodipine (Norvasc)
Carvedilol (Coreg)
Enalapril (Vasotec)
Furosemide (Lasix)
Hydralazine - ANSWERS-C
Angioedema occurs in less than 1% of patients taking an ACE
inhibitor but is more common in African-Americans. The American
Heart Association recommends that ACE inhibitors not be initiated in
any patient with a history of angioedema (SOR C). Calcium channel
blockers, particularly those with negative inotropic effects such as
verapamil and diltiazem, can cause a worsening of heart failure and
should also be avoided (SOR C).Although angiotensin receptor
blockers (ARBs) would be regarded as safe in this patient and may be
,considered as alternative therapy for patients who develop
angioedema while taking an ACE inhibitor, angioedema can also
occur in patients taking ARBs and extreme caution is advisable when
substituting an ARB in a patient with a history of ACE inhibitor-
associated angioedema (SOR C). There are no contraindications to the
use of a diuretic or a β-blocker in this patient.
A 74-year-old female presents with a 2-month history of increased
dyspnea on exertion. She was a long-time cigarette smoker but quit 20
years ago. She has COPD treated with inhaled ipratropium (Atrovent),
a combination inhaled corticosteroid, and a long-acting β-agonist. She
can walk up one flight of stairs in her home but for the past 2 months
she has had to stop and rest before reaching the top due to increased
dyspnea. She also has severe osteoarthritis of the left hip treated with
acetaminophen, 1000 mg three times daily, and tramadol (Ultram), 50
mg twice daily. A resting EKG in the office is normal.Which one of
the following would be the most appropriate initial study to evaluate
this patient for ischemic heart disease?
A treadmill exercise test
An adenosine technetium 99m test
A dipyridamole thallium test
Treadmill echocardiography
Dobutamine echocardiography - ANSWERS-E
This patient's severe degenerative joint disease would likely limit her
ability to exercise sufficiently to achieve 85% of her expected heart
rate, which is required for an adequate treadmill exercise test, unless
the patient is on β-blocker therapy, which would allow 65% of the
, predicted heart rate to be considered adequate. Dipyridamole and
adenosine are contraindicated for patients with severe asthma, COPD,
hypotension, bradycardia, or heart block. A resting EKG and resting
echocardiography might be appropriate, but would not rule out
ischemic heart disease. Dobutamine provides a pharmacologic means
to stress the heart in patients who cannot exercise. These agents
enhance myocardial contractile performance and wall motion, thus
making poorly functioning areas assessable by echocardiography. In
patients unable to exercise to the target heart rate, pharmacologic
agents are needed to complete stress testing.
A 59-year-old male sees you for a follow-up office visit after having a
drug-eluting stent placed 6 weeks ago following a non-ST-elevation
myocardial infarction. He also has a 2-year history of type 2 diabetes.
He was discharged on the following medications:Aspirin, 81 mg
dailyClopidogrel (Plavix), 75 mg dailyAtorvastatin (Lipitor), 40 mg
dailyMetoprolol tartrate (Lopressor), 25 mg twice dailyRamipril
(Altace), 10 mg dailyMetformin (Glucophage), 500 mg twice
dailyThe patient has been asymptomatic since being discharged from
the hospital. On examination he has a blood pressure of 142/86 mm
Hg and a heart rate of 52 beats/min. The remainder of the examination
is unremarkable. A lipid profile reveals an LDL-cholesterol level of
65 mg/dL, an HDL-cholesterol level of 30 mg/dL, and a serum
triglyceride level of 260 mg/dL. His hemoglobin A1c is 7.2%.Which
one of the following would be most appropriate at this time?
Increas - ANSWERS-B
The long-term management of patients with non-ST-elevation
myocardial infarction involves measures to prevent recurrent cardiac
