PAEA Emergency Medicine Eor Exam
Questions And Revised Questions And Verified
100% Correct
what is the most effective treatment for symptoms of heart failure? - ANSWER
diuretics
-loop diuretics (-semides) act on inc excretion of Na, Cl, K, H2O (so can go hypo on
these electrolytes), other s/e: hyperglycemia, hyperuricemia
-K-sparing diuretics (spironolactone, eplerenone) aldosterone antagonists; s/e:
hyperkalemia, gynecomastia with spirono
-HCTZ or metolazone (thiazide like diuretic)- s/e: hyponatremia/kalemia,
hyperuricemia, hyperglycemia
what medications are used to treat acute severe heart failure? - ANSWER
*sympathomimetics* (positive inotropes to inc contractility)
-*digoxin*: but has a narrow therapeutic index (can cause arrhythmias, seizures,
dizziness, GI upset, visual disturbances, gynecomastia); toxicity = downsloping ST
segment; antidote: Digoxin Immune Fab
-*dobutamine*: inc contractility (B1 agonist), peripheral vasodilation
-*dopamine*: inc contractility
giving a synthetic BNP, Nesiritide, works by what mechanism to treat heart failure? -
ANSWER -dec RAAS activity
-inc Na+/H2O excretion
why are beta-blockers started after ACE inhibitors/diuretics in heart failure? - ANSWER
want to decrease afterload/preload before slowing down the heart rate
at what EF do heart failure patients need to receive an implantable cardioverter
defibrillator? - ANSWER EF <35% because they tolerate arrhythmias poorly and
there is inc mortality rate
what medication used to treat *systolic* heart failure is a selective sinus node inhibitor
that slows the sinus rate? - ANSWER *ivabradine*: dec mortality rate in pts w/ EF
≤35%, in sinus rhythm, w/ resting pulse ≥70bpm, & already maxed out on BB dose or
unable to take BB
what medication used to treat *systolic* heart failure works by increasing levels of
natriuretic peptides? - ANSWER *sacubitril-valsartan*: decreases mortality rate
in class II-IV HF w/ reduced EF
,what is the treatment for acute pulmonary edema/congestive (aka decompensated)
heart failure? - ANSWER *LMNOP*
-*L*asix: removes fluids- improves sx's
-*M*orphine: reduces preload reducing heart strain
-*N*itrates: vasodilator to reduce pre/afterload
-*O*xygen
-*P*osition: upright to dec venous return
if severe may also need inotropic support
although primary HTN makes up 95% of cases, when should secondary HTN be
considered? what are some causes of secondary HTN? - ANSWER -if refractory
to antihypertensives or severely elevated
-causes: *renal artery stenosis*, fibromuscular dysplasia, atherosclerosis, 1°
hyperaldosteronism, pheochromocytoma, cushing's syndrome, coarctation of the
aorta, sleep apnea, EtOH, OCPs, COX-2 inhibitors
what are the complications of HTN? - ANSWER -CV (CAD, HF, MI, LVH, aortic
dissection, aortic aneurysm, PVD)
-neurologic (TIA, CVA, rutured aneurysms, encephalopathy)
-nephropathy (renal stenosis & sclerosis leading to ESRD)
-optic (retinal hemorrhage, blindness, retinopathy)
thiazide type diuretics (HCTZ, chlorthalidone, metolazone) act on what part of the
nephron to increase water excretion? what are the side effects? - ANSWER -
distal diluting tubule
-s/e: hyponatremia/kalemia/calcemia, hyperuricemia/glycemia (use w/ caution in gout
and DM pts)
*these are 1st line in uncomplicated HTN
loop diuretics (furosemide, bumetanide) are the strongest class of diuretics and can
cause s/e's of volume depletion, hypokalemia/natremia/calcemia,
hyperuricemia/glycemia, hypochloremic metabolic alkalosis, and ototoxicity; what are
they contraindicated in? - ANSWER sulfa allergy
what are the DHP (dihydropyridine) and non-DHP calcium channel blockers? what are
they indicated and contraindicated in? - ANSWER -DHP CCBs: nife*dipine*,
amlo*dipine* (potent vasodilators)
-non-DHP CCBs: verapamil, diltiazem (vasodilators but also act on heart to dec
contractility and conduction/HR) so often used in pts w/ HTN w/ concomitant Afib
,-indications: HTN, angina, raynauds
-contraindications: CHF (esp non-DHPs), 2nd/3rd degree heart block
what are the cardioselective and nonselective beta blockers? - ANSWER -
cardioselection (B1): atenolol, metoprolol, esmolol
-nonselective (B1, B2): propranolol
-a, B1, B2: labetalol, carvedilol
what are contraindications for using beta-blockers? - ANSWER -2nd/3rd degree
heart block, decompensated heart failure
-specifically in nonselective agents: asthma/COPD, may worsen PVD or raynauds,
hypotension, or pulse <50
what is the pathophysiology behind a hypertensive urgency/emergency? - ANSWER
-abrupt rise in BP
-increase in SVR (systemic vascular resistance)
-endothelial cell deterioration
a murmur that is accentuated by sitting up and leaning forward is due to what valve
malfunctioning? murmur accentuated by lying on left side? - ANSWER -sitting
up/leaning forward = aortic murmurs (AS, AR)
-lying on left side = mitral (MS, MR)
what is the MC valvular disease? - ANSWER aortic stenosis (can lead to
obstruction, LVH then LV failure)
what are the causes of aortic stenosis? - ANSWER -degenerative: calcifications
(atherosclerotic/wear & tear in pts >70y
-congenital heart dz: bicuspid valve in pts <70y
-rheumatic heart dz: from strep
what are the clinical manifestations of symptomatic (<1cm^2) aortic stenosis? -
ANSWER -dyspnea
-*angina*
-*syncope* (extertional)
-*CHF*
a systolic "ejection" crescendo-decrescendo murmur at right upper sternal border that
*radiates to carotid/neck*; decreases in intensity with valsalva/standing/handgrip (inc
venous return) and increases with squatting/leg raise/sitting/leaning forward (dec
venous return); *narrowed pulse pressure* - ANSWER aortic stenosis
, for aortic stenosis, what diagnostic studies can be ordered? what can be seen? -
ANSWER -*echo*: small aortic orifice during systole, LVH, thickened/calcified valve
-*EKG*: LVH
-*CXR*: calcifications
-*cardiac cath*: definitive diagnosis; usually used prior to surgery
what are the management options for aortic stenosis? - ANSWER -*valve
replacement* (AVR): mechanical last longer but requires long term anticoagulants,
bioprosthetic does not
-*percutaneous aortic valvuloplasty* (PAV): results in 50% inc in area but 50%
restenosis at 6-12 mos; used as bridge to AVR
-*intraortic balloon pump*: temporary stabilization; bridge to AVR
-*medical therapy* (although not truly effective): avoid things that may decrease
preload- physical exertion, venodilators (nitrates), negative inotropes (CCBs, BBs)
what are the causes of aortic regurgitation/insufficiency? - ANSWER 1. valve
disease- rheumatic heart dz, endocarditis, bicuspid AoV
2. aortic root disease- *HTN*, marfan syndrome, syphilis, RA, SLE, aortic dissection,
ankylosing spondylitis
what kind of CHF can aortic regurgitation cause? - ANSWER LV filling from LA
and aortic regurg -> LV dilated cardiomyopathy -> *systolic HF*
dx? diastolic, decrescendo, blowing murmur maximal at L upper sternal border, inc
intensity with squatting/sitting forward/ handgrip/expiration, dec intensity w/
valsalva/standing/amyl nitrate, austin-flint murmur, *bounding pulses* (d/t inc stroke
vol), *wide pulse pressure*, laterally/inferior displaced PMI, pulsus bisferiens (double
pulse carotid upstroke) - ANSWER aortic regurgitation/insufficiency
*austin-flint murmur is a mid-late diastolic murmur from regurgitant flow competing with
antegrade flow from LA to LV
what are the tx options for aortic regurgitation/insufficiency? - ANSWER - *medical
mgmt*- reduction in *afterload* w/ vasodilators (ACEi, ARBs, nifedipine, hydralazine)
-*surgical* predominately AVR- in severely symptomatic pts or w/ EF ≤50%
what is the MC cause of mitral stenosis? - ANSWER rheumatic heart disease
dx? early-mid diastolic rumble at apex especially in LLD position, opening snap (at
beginning of diastole), prominent S1 , dyspnea, hemoptysis, pulmonary HTN, Afib, R
Questions And Revised Questions And Verified
100% Correct
what is the most effective treatment for symptoms of heart failure? - ANSWER
diuretics
-loop diuretics (-semides) act on inc excretion of Na, Cl, K, H2O (so can go hypo on
these electrolytes), other s/e: hyperglycemia, hyperuricemia
-K-sparing diuretics (spironolactone, eplerenone) aldosterone antagonists; s/e:
hyperkalemia, gynecomastia with spirono
-HCTZ or metolazone (thiazide like diuretic)- s/e: hyponatremia/kalemia,
hyperuricemia, hyperglycemia
what medications are used to treat acute severe heart failure? - ANSWER
*sympathomimetics* (positive inotropes to inc contractility)
-*digoxin*: but has a narrow therapeutic index (can cause arrhythmias, seizures,
dizziness, GI upset, visual disturbances, gynecomastia); toxicity = downsloping ST
segment; antidote: Digoxin Immune Fab
-*dobutamine*: inc contractility (B1 agonist), peripheral vasodilation
-*dopamine*: inc contractility
giving a synthetic BNP, Nesiritide, works by what mechanism to treat heart failure? -
ANSWER -dec RAAS activity
-inc Na+/H2O excretion
why are beta-blockers started after ACE inhibitors/diuretics in heart failure? - ANSWER
want to decrease afterload/preload before slowing down the heart rate
at what EF do heart failure patients need to receive an implantable cardioverter
defibrillator? - ANSWER EF <35% because they tolerate arrhythmias poorly and
there is inc mortality rate
what medication used to treat *systolic* heart failure is a selective sinus node inhibitor
that slows the sinus rate? - ANSWER *ivabradine*: dec mortality rate in pts w/ EF
≤35%, in sinus rhythm, w/ resting pulse ≥70bpm, & already maxed out on BB dose or
unable to take BB
what medication used to treat *systolic* heart failure works by increasing levels of
natriuretic peptides? - ANSWER *sacubitril-valsartan*: decreases mortality rate
in class II-IV HF w/ reduced EF
,what is the treatment for acute pulmonary edema/congestive (aka decompensated)
heart failure? - ANSWER *LMNOP*
-*L*asix: removes fluids- improves sx's
-*M*orphine: reduces preload reducing heart strain
-*N*itrates: vasodilator to reduce pre/afterload
-*O*xygen
-*P*osition: upright to dec venous return
if severe may also need inotropic support
although primary HTN makes up 95% of cases, when should secondary HTN be
considered? what are some causes of secondary HTN? - ANSWER -if refractory
to antihypertensives or severely elevated
-causes: *renal artery stenosis*, fibromuscular dysplasia, atherosclerosis, 1°
hyperaldosteronism, pheochromocytoma, cushing's syndrome, coarctation of the
aorta, sleep apnea, EtOH, OCPs, COX-2 inhibitors
what are the complications of HTN? - ANSWER -CV (CAD, HF, MI, LVH, aortic
dissection, aortic aneurysm, PVD)
-neurologic (TIA, CVA, rutured aneurysms, encephalopathy)
-nephropathy (renal stenosis & sclerosis leading to ESRD)
-optic (retinal hemorrhage, blindness, retinopathy)
thiazide type diuretics (HCTZ, chlorthalidone, metolazone) act on what part of the
nephron to increase water excretion? what are the side effects? - ANSWER -
distal diluting tubule
-s/e: hyponatremia/kalemia/calcemia, hyperuricemia/glycemia (use w/ caution in gout
and DM pts)
*these are 1st line in uncomplicated HTN
loop diuretics (furosemide, bumetanide) are the strongest class of diuretics and can
cause s/e's of volume depletion, hypokalemia/natremia/calcemia,
hyperuricemia/glycemia, hypochloremic metabolic alkalosis, and ototoxicity; what are
they contraindicated in? - ANSWER sulfa allergy
what are the DHP (dihydropyridine) and non-DHP calcium channel blockers? what are
they indicated and contraindicated in? - ANSWER -DHP CCBs: nife*dipine*,
amlo*dipine* (potent vasodilators)
-non-DHP CCBs: verapamil, diltiazem (vasodilators but also act on heart to dec
contractility and conduction/HR) so often used in pts w/ HTN w/ concomitant Afib
,-indications: HTN, angina, raynauds
-contraindications: CHF (esp non-DHPs), 2nd/3rd degree heart block
what are the cardioselective and nonselective beta blockers? - ANSWER -
cardioselection (B1): atenolol, metoprolol, esmolol
-nonselective (B1, B2): propranolol
-a, B1, B2: labetalol, carvedilol
what are contraindications for using beta-blockers? - ANSWER -2nd/3rd degree
heart block, decompensated heart failure
-specifically in nonselective agents: asthma/COPD, may worsen PVD or raynauds,
hypotension, or pulse <50
what is the pathophysiology behind a hypertensive urgency/emergency? - ANSWER
-abrupt rise in BP
-increase in SVR (systemic vascular resistance)
-endothelial cell deterioration
a murmur that is accentuated by sitting up and leaning forward is due to what valve
malfunctioning? murmur accentuated by lying on left side? - ANSWER -sitting
up/leaning forward = aortic murmurs (AS, AR)
-lying on left side = mitral (MS, MR)
what is the MC valvular disease? - ANSWER aortic stenosis (can lead to
obstruction, LVH then LV failure)
what are the causes of aortic stenosis? - ANSWER -degenerative: calcifications
(atherosclerotic/wear & tear in pts >70y
-congenital heart dz: bicuspid valve in pts <70y
-rheumatic heart dz: from strep
what are the clinical manifestations of symptomatic (<1cm^2) aortic stenosis? -
ANSWER -dyspnea
-*angina*
-*syncope* (extertional)
-*CHF*
a systolic "ejection" crescendo-decrescendo murmur at right upper sternal border that
*radiates to carotid/neck*; decreases in intensity with valsalva/standing/handgrip (inc
venous return) and increases with squatting/leg raise/sitting/leaning forward (dec
venous return); *narrowed pulse pressure* - ANSWER aortic stenosis
, for aortic stenosis, what diagnostic studies can be ordered? what can be seen? -
ANSWER -*echo*: small aortic orifice during systole, LVH, thickened/calcified valve
-*EKG*: LVH
-*CXR*: calcifications
-*cardiac cath*: definitive diagnosis; usually used prior to surgery
what are the management options for aortic stenosis? - ANSWER -*valve
replacement* (AVR): mechanical last longer but requires long term anticoagulants,
bioprosthetic does not
-*percutaneous aortic valvuloplasty* (PAV): results in 50% inc in area but 50%
restenosis at 6-12 mos; used as bridge to AVR
-*intraortic balloon pump*: temporary stabilization; bridge to AVR
-*medical therapy* (although not truly effective): avoid things that may decrease
preload- physical exertion, venodilators (nitrates), negative inotropes (CCBs, BBs)
what are the causes of aortic regurgitation/insufficiency? - ANSWER 1. valve
disease- rheumatic heart dz, endocarditis, bicuspid AoV
2. aortic root disease- *HTN*, marfan syndrome, syphilis, RA, SLE, aortic dissection,
ankylosing spondylitis
what kind of CHF can aortic regurgitation cause? - ANSWER LV filling from LA
and aortic regurg -> LV dilated cardiomyopathy -> *systolic HF*
dx? diastolic, decrescendo, blowing murmur maximal at L upper sternal border, inc
intensity with squatting/sitting forward/ handgrip/expiration, dec intensity w/
valsalva/standing/amyl nitrate, austin-flint murmur, *bounding pulses* (d/t inc stroke
vol), *wide pulse pressure*, laterally/inferior displaced PMI, pulsus bisferiens (double
pulse carotid upstroke) - ANSWER aortic regurgitation/insufficiency
*austin-flint murmur is a mid-late diastolic murmur from regurgitant flow competing with
antegrade flow from LA to LV
what are the tx options for aortic regurgitation/insufficiency? - ANSWER - *medical
mgmt*- reduction in *afterload* w/ vasodilators (ACEi, ARBs, nifedipine, hydralazine)
-*surgical* predominately AVR- in severely symptomatic pts or w/ EF ≤50%
what is the MC cause of mitral stenosis? - ANSWER rheumatic heart disease
dx? early-mid diastolic rumble at apex especially in LLD position, opening snap (at
beginning of diastole), prominent S1 , dyspnea, hemoptysis, pulmonary HTN, Afib, R
