- A 50 year old white male with a history of hypertension, smoking (60 pack-years), angina, and chronic bronchitis (COPD) presents with 3 hours of substernal chest pain with diaphoresis. He takes diltiazem, isosorbide dinitrate, doxazosin (Cardura®), albuterol and ipatropium (Atrovent®) inhalers, and prednisone 5mg qd for COPD. He appears quite anxious and diaphoretic with moderate nausea. His blood pressure is 90/70 mm, pulse 50 per minute, respirations 24 per minute. His lungs are clear, heart is bradycardic with no murmers, and there is ~10cm of jugular venous distension (estimated jugular venous pressure 15cm). An electrocardiogram (ECG) is most likely to show [1]:
A. Inferior myocardial infarction with evidence of right ventricular involvement
B. Anterior myocardial infarction with lateral extension
C. Anterior myocardial infarction with aneurysm formation
D. Posterior mycoardial infarction with lateral extension
E. Diffuse ST elevation and PR depression - His blood pressure drops to 80/60, pulse 35, and he vomits. The appropriate merttdication to administer at this time is [2]:
A. Prochlorpromazine (Compazine®) rectally
B. Epinephrine 0.5mg repeated in 5 minutes
C. Atropine 0.5-1.0mg repeated up to 2mg total
D. Dopamine 5-10µg/kg/min iv
E. Lidocaine 1mg/kg bolus iv then 2mg/min continuous iv - His heart rate increases to 80 and his blood pressure is 110/70. Which of the following should now be administered, assuming no contraindications [3]:
A. Aspirin, Thrombolytic Therapy and Heparin, beta-blockers, and Intravenous Fluids
B. Aspirin, Thrombolytic Therapy and Heparin, Nitroglycerin intravenously
C. Aspirin, Thrombolytic Therapy and Heparin, beta-blockers, and Intravenous Fluids
D. Aspirin, Thrombolytic Therapy and Heparin, ACE-Inhibitors, and Intravenous Fluids
E. Aspirin, Thrombolytic Therapy and Heparin, and high volumes Intravenous Fluids - Approximately 45 minutes following administration of tissue plasminogen activator, the patient's heart rate drops to 50bpm with wide complexes. Blood pressure is stable at 105/70. The patient has no more chest pain. Which of the following is most likely [4]:
A. Post-myocardial infarction arrhythmia
B. Reperfusion arrhythmia
C. Sinus bradycardia
D. Second Degree Heart Block (Type 1 or 2)
E. Junctional Escape Rhythm due to Sinus Node Damage - Which of the following has not been shown to improve mortality when given routinely after myocardial infarction (MI) [5]:
- Which of the following does not reduce mortality OR reduce myocardial infarction (MI) in patients with an acute coronary syndrome (ACS) [6] ?
- Concerning Coronary Artery Bypass Grafting (CABG), which of the following statement(s) is true [7] ?
- A 28 year white male presents with recurrent light headedness and syncope found to be caused by supraventricular tachycardia (SVT). Analysis of the electrocardiogram during an episode of SVT shows retrograde P waves nearly burried in the qrs. The patient is diaphoretic with a pulse of 160 bpm and a blood pressure of 110/65. He is mentating slowly but coherently. Which of the following is an inappropriate treatment in this setting [8]:
A. Urgent or Emergent Electrical Cardioversion
B. Adenosine 6mg iv push
C. Procainamide 1gm iv loaded at 20mg/minute
D. Metoprolol 2.5mg iv push
E. Diltiazem 20mg iv given over 2 minutes - Electrophysiologic study (EPS) is consistent with the presence of a retrograde bypass tract. The preferred definitive therapy for this condition is [9]:
A. Automatic Implantable Cardioverter-Defibrillator
B. Quinidine Gluconate
C. Flecainide
D. Metoprolol (Toprol®)
E. Catheter Ablation of Bypass Tract - The patient described above is discharged on metoprolol 50mg po twice daily. While out with friends, he loses consciousness without warning. On presentation to the Emergency Room, his pulse is 90bpm, heart rate (rhythm strip) is 180bpm, and his blood pressure is 70/40; he is unconscious. ECG shows an SVT with retrograde P waves at 180bpm. The appropriate therapy is [10]: A. Adenosine 6mg iv push, followed by 12mg iv push if initial dose fails
I. LidocaineII. ß-Adrenergic Blocking AgentsIII. Direct thrombin inhibotrsIV. Thrombolytic Therapy
V. ACE Inhibitors
A. I, II and III have not been shown to improve mortality after MI
B. I and III have not been shown to improve mortality after MI
C. II and IV have not been shown to improve mortality after MI
D. V has not been shown to improve mortality after MI
E. All of the above have improved mortality after MI
I. AspirinII. NitroglycerinIII. Thrombolytic TherapyIV. Direct thrombin inhibitors
V. Early Revascularization with angioplasty ± stenting
A. I, II and III have not been shown to reduce mortality or MI in patients with ACS
B. I and III have not been shown to reduce mortality or MI in patients with ACS
C. II and IV have not been shown to reduce mortality or MI in patients with ACS
D. V has not been shown to reduce mortality or MI in patients with ACS
E. All of the above have been shown to reduce mortality or MI in patients with ACS
I. CABG is generally superior to medical therapy in patients with diabetes mellitusII. CABG is superior to medical therapy in patients with triple vessel coronary artery disease with Ejection Fraction <50%III. Compared with angioplasty alone, CABG results in fewer episodes of revascularizationIV. CABG is the preferred modality of treatment for most patients with distal two vessel coronary artery disease with Normal Ejection Fraction
V. CABG is clearly superior to modern percutaneous coronary interventions with stenting in patients with coronary artery disease
A. I, II, and III are true
B. I and III are true
C. II and IV are true
D. V is true
E. None of the statements is true
B. Metoprolol 2.5mg iv push, followed by 5mg within 5 minutes if initial dose fails
C. Lidocaine 1mg/kg bolus iv, followed by 2-4mg/minute iv
D. Emergent Electrical Cardioversion with 100 Joules
E. Dopamine 10µg/kg/minute titrated to blood pressure
