Cardiovascular System Sample 10 PDF

**Question Bank** **QID** 01 **Discipline/** **Competency** **System/** **Content Area** Cardiovascular system **Topic to be tested** Acute inflammatory disease -- Endocarditis **Include as distractors** Myocarditis, pulmonary embolism, rheumatic heart disease, pericarditis **Include in...

**Question Bank** **QID** 01 **Discipline/** **Competency** **System/** **Content Area** Cardiovascular system **Topic to be tested** Acute inflammatory disease -- Endocarditis **Include as distractors** Myocarditis, pulmonary embolism, rheumatic heart disease, pericarditis **Include in explanation** Modified Duke\'s criteria **Author Last Name** HAQ **Author First Name** MAHEEN **Stem/Data** A 17-year-old boy comes to the hospital complaining of low-grade intermittent fever, chills, cough, and shortness of breath with exertion for the last 2 months that is not responding to the conventional medication. He has a history of fever with pain in joints and was diagnosed with mitral valve prolapse three years ago. On physical examination, he has pallor with generalized erythematous macular skin rash, mostly on his palms and needle tracks on his left arm. There is a systolic murmur at the apex of the heart and an early diastolic murmur at the pulmonic area on auscultation. His body mass index (BMI) is 32.4 kg/m^2^, his temperature is 102.1°F (38.9°C), his blood pressure is 90/51 mmHg, his heart rate is 113 beats per minute, his respiratory rate is 20 breaths per minute, and oxygen saturation is 96% on room air. Laboratory investigation revealed a hemoglobin (Hb) level of 11.4 g/dL, total leukocyte count (TLC) of 16,440/mm^3^, CRP of 201.8 mg/dL, Procalcitonin of 17.58 ng/mL, and blood cultures are positive for the growth of Staphylococcus aureus. **Lead-In** Which of the following is the most probably diagnosis? **Image in stem** **Source of image** **Correct Answer** Infective endocarditis **Explanation for Correct Answer** In this case, the patient\'s clinical presentation with low-grade fever, history of joint pain, mitral valve prolapse, and needle marks on the arm are suggestive of infective endocarditis. Infective endocarditis (IE) is the inflammation of the endocardium, clinically present with fever, chills, malaise, and fatigue often associated with headache, anorexia, and generalized weakness. The classic signs include: - Petechiae - Osler nodes -- Subcutaneous tender nodules located on the pads of digits. - Splinter hemorrhages -- Dark red lesions in the nailbeds - Janeway lesions -- Non-tender hemorrhagic maculae on the palms and soles - Roth spots -- small clear-centered retinal hemorrhages Initially, 12-lead electrocardiography (ECG) helps in evaluating the underlying cause. Laboratory investigations, especially blood cultures, point out the infective process. However, a transthoracic echocardiogram (TTE) is a common diagnostic tool, but if it is negative, then transesophageal echocardiogram (TEE) is considered more sensitive and specific by the American Heart Association (AHA). IE diagnosis is more specifically based on Modified Duke\'s Criteria, which uses clinical signs and symptoms, laboratory investigations, and results of imaging studies. After the initial stabilization, long-term antibacterial therapy is done for treatment, followed by cardiothoracic surgical intervention if needed. **The image/table in the Explanation** +-----------------------------------+-----------------------------------+ | MODIFIED DUKE\'S CRITERIA -- | | | INFECTIVE ENDOCARDITIS DIAGNOSTIC | | | CRITERIA | | +===================================+===================================+ | MAJOR CRITERIA | - 2 +ive blood cultures for | | | typical microorganisms | | | causing endocarditis | | | | | | - Echocardiographic proof of | | | endocardial involvement | | | (valvular vegetation) | +-----------------------------------+-----------------------------------+ | MINOR CRITERIA | 1. Predisposing cardiac disorder | | | or intravenous drug use | | | | | | 2. Fever [\>] | | | 100.4°F ( [\>] | | | 38°C) | | | | | | 3. Vascular or embolic | | | phenomena: | | | | | | - Arterial embolism | | | | | | - Septic pulmonary embolism | | | | | | - Intracranial hemorrhage | | | | | | - Conjunctival petechiae | | | | | | - Janeway lesions | | | | | | 4. Immunologic phenomena: | | | | | | - Glomerulonephritis | | | | | | - Osler nodes | | | | | | - Roth spots | | | | | | - Rheumatoid factor | | | | | | 5. +ive blood culture | | | conformable with but not | | | meeting the major criteria | +-----------------------------------+-----------------------------------+ | DEFINITE INFECTIVE ENDOCARDITIS | Two major criteria | | | | | | Or | | | | | | 1 major Plus 3 minor criteria | +-----------------------------------+-----------------------------------+ | POSSIBLE INFECTIVE ENDOCARDITIS | One major Plus one minor criteria | | | | | | Or | | | | | | Three minor criteria | +-----------------------------------+-----------------------------------+ **Image Source** **Distractor 1** Myocarditis **Answer for Distractor 1** Myocarditis is inflammation of the myocardium mostly due to a viral infection. Typical clinical presentations include increase jugular vein pressure, peripheral edema, heart failure and S3 gallop. Identifying the exact cause often requires a tissue biopsy. The main focus of treatment is bed rest and cardiac support. **Distractor 2** Pulmonary embolism **Answer for Distractor 2** Pulmonary embolism (PE) is disturbance of the blood flow by a thrombus in the pulmonary artery and its branches. Common symptoms are pleuritic chest pain, cough, shortness of breath, syncope with signs of pedal edema, reduced breath sounds, elevated neck veins, and loud P2 part of S2. For the diagnosis of PE, three systems are there: 1. 2. 3. **Distractor 3** Rheumatic heart disease **Answer for Distractor 3** Damage of the cardiac valves as a systemic immune process due to rheumatic fever. Signs and symptoms include fever, chest pain, migratory joint pain, subcutaneous nodules, and motor dysfunction. There are no specific diagnostic criteria, but laboratory investigations, imaging studies, and ECG findings help diagnose. **Distractor 4** Pericarditis **Answer for Distractor 4** Pericarditis is the inflammation of the pericardium, which leads to an effusion. It is frequently asymptomatic, but classical clinical features include central chest pain, a notable pericardial friction rub on auscultation, widespread saddle-shaped ST elevation, and PR depression on ECG. **Distractor 5 (Optional but please consider adding if appropriate)** **Answer for Distractor 5** **(Optional) Distractor 6** **Answer for Distractor 6** **Vital Concept** Infective endocarditis is inflammation of the endocardium, usually involving cardiac valves. Usually occurs due to bacterial infections and clinically present with fever, chest pain, specific signs of petechiae, and splinter hemorrhages. Osler nodes and Janeway lesions. It is diagnosed mostly by Modified Duke\'s Criteria and treated with extensive antibacterial therapy. References 1. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison\'s Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical; 2018 2. Infectious endocarditis - StatPearls - NCBI bookshelf. (2022, April 28). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK557641/ 3. Infective endocarditis: Practice essentials, background, pathophysiology. (2022, July 1). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/216650-overview +-----------------+-----------------+-----------------+-----------------+ | **Question | | **QID** | 02 | | Bank** | | | | +=================+=================+=================+=================+ | **Discipline/** | | **System/** | Cardiovascular | | | | | system | | **Competency** | | **Content | | | | | Area** | | +-----------------+-----------------+-----------------+-----------------+ | **Topic to be | Coronary artery | | | | tested** | disease -- | | | | | Acute coronary | | | | | syndrome (ACS) | | | +-----------------+-----------------+-----------------+-----------------+ | **Include as | - Initial | | | | distractors** | management | | | | | of ACS | | | | | | | | | | - Further | | | | | management | | | | | of ACS with | | | | | PCI and | | | | | thrombolysi | | | | | s | | | | | | | | | | - Possible | | | | | options of | | | | | misdiagnosi | | | | | s | | | | | with | | | | | anxiety and | | | | | esophagitis | | | +-----------------+-----------------+-----------------+-----------------+ | **Include in | | | | | explanation** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Author Last | HAQ | **Author First | MAHEEN | | Name** | | Name** | | +-----------------+-----------------+-----------------+-----------------+ | **Stem/Data** | A 55-year-old | | | | | male truck | | | | | driver comes to | | | | | the hospital's | | | | | emergency | | | | | department with | | | | | severe chest | | | | | pain and | | | | | diaphoresis for | | | | | the last 30 | | | | | minutes. His | | | | | chest pain is | | | | | central, | | | | | crushing in | | | | | nature, and | | | | | radiating to | | | | | the left arm. | | | | | He has been | | | | | hypertensive | | | | | for eight years | | | | | and is a chain | | | | | smoker | | | | | consuming 20 | | | | | cigarettes | | | | | daily (37 pack | | | | | years). | | | | | | | | | | On physical | | | | | examination, he | | | | | is a little | | | | | restless and | | | | | can verbally | | | | | communicate. On | | | | | auscultation, | | | | | there are no | | | | | heart murmurs. | | | | | His blood | | | | | pressure is | | | | | 182/104 mmHg, | | | | | his heart rate | | | | | is 92 beats per | | | | | minute, and his | | | | | oxygen | | | | | saturation is | | | | | 97% on room | | | | | air. The | | | | | initial 12-lead | | | | | electrocardiogr | | | | | aphy | | | | | shows a heart | | | | | rate of 100 | | | | | beats per | | | | | minute, sinus | | | | | rhythm and | | | | | ST-segment | | | | | elevation at | | | | | V1, V2, and V3 | | | | | leads. | | | | | | | | | | Laboratory | | | | | investigations | | | | | revealed that | | | | | the complete | | | | | blood count | | | | | (CBC) is | | | | | normal. | | | | | Glucose, 109 | | | | | mg/dL, Blood | | | | | Urea Nitrogen | | | | | (BUN) is | | | | | 11mg/dL, and | | | | | Creatinine was | | | | | 0.8mg/dL. | | | | | Normal | | | | | urinalysis and | | | | | normal chest | | | | | X-ray. His | | | | | Troponin T | | | | | level is 0.8 | | | | | ng/mL and | | | | | Troponin I | | | | | level is 1.2 | | | | | ng/mL. His pain | | | | | has relieved | | | | | promptly after | | | | | the oral | | | | | administration | | | | | of aspirin 300 | | | | | mg. | | | +-----------------+-----------------+-----------------+-----------------+ | **Lead-In** | **What should | | | | | be the next | | | | | step in | | | | | management that | | | | | is most | | | | | appropriate?** | | | +-----------------+-----------------+-----------------+-----------------+ | **Image in | | | | | stem** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Source of | | | | | image** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Correct | Give sublingual | | | | Answer** | Glyceryl | | | | | Trinitrate | | | | | (GTN), 300 to | | | | | 600 mg | | | | | clopidogrel as | | | | | a loading dose | | | +-----------------+-----------------+-----------------+-----------------+ | **Explanation | CAD mostly | | | | for Correct | demonstrate | | | | Answer** | acute coronary | | | | | syndrome, | | | | | including | | | | | ST-elevated | | | | | myocardial | | | | | infarction-STEM | | | | | I, | | | | | Non-ST elevated | | | | | myocardial | | | | | infarction-NSTE | | | | | MI, | | | | | and unstable | | | | | angina. The | | | | | most common | | | | | risk factors | | | | | are smoking, | | | | | hypertension, | | | | | diabetes, and | | | | | hyperlipidemia. | | | | | | | | | | The sudden | | | | | onset of | | | | | substernal | | | | | crushing chest | | | | | pain is a | | | | | typical symptom | | | | | that radiates | | | | | to the left arm | | | | | and is most | | | | | commonly | | | | | relieved with | | | | | aspirin and | | | | | GTN. The | | | | | patient may | | | | | also complain | | | | | of nausea, | | | | | epigastric | | | | | pain, | | | | | diaphoresis, | | | | | and shortness | | | | | of breath. | | | | | | | | | | First-line | | | | | management | | | | | would start | | | | | with the | | | | | administration | | | | | of morphine for | | | | | pain control, | | | | | oxygen therapy | | | | | if saturation | | | | | is less than | | | | | 95%, oral | | | | | aspirin | | | | | (162-325 mg ), | | | | | Sublingual or | | | | | intravenous | | | | | (IV) GTN, and | | | | | clopidogrel | | | | | (300-600 mg). | | | | | | | | | | Further | | | | | management of | | | | | ACS is based on | | | | | whether it is | | | | | STEMI, NSTEMI | | | | | or unstable | | | | | angina. For | | | | | STEMI, an early | | | | | catheterization | | | | | and | | | | | percutaneous | | | | | intervention | | | | | (PCI) is | | | | | recommended by | | | | | American Heart | | | | | Association | | | | | (AHA) within 90 | | | | | to 120 minutes | | | | | of symptom | | | | | onset. In the | | | | | case of the | | | | | unavailability | | | | | of PCI, | | | | | thrombolysis is | | | | | an alternative. | | | | | | | | | | Patients with | | | | | NSTEMI should | | | | | receive | | | | | aggressive | | | | | treatment with | | | | | the addition of | | | | | low--molecular- | | | | | weight | | | | | heparin (LMWH), | | | | | a beta-blocker | | | | | and IV platelet | | | | | glycoprotein | | | | | 2b/3a complex | | | | | blockers and | | | | | urgent | | | | | revascularizati | | | | | on. | | | | | | | | | | Moreover, early | | | | | initiation of | | | | | treatment with | | | | | Beta-blockers, | | | | | statin, and ACE | | | | | inhibitors in | | | | | ACS is always | | | | | beneficial. | | | +-----------------+-----------------+-----------------+-----------------+ | **The image in | | | | | the | | | | | Explanation** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Image | | | | | Source** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Advice dietary | | | | 1** | control and | | | | | give | | | | | Histamine-2 | | | | | receptor | | | | | antagonists | | | | | with Proton | | | | | pump inhibitors | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | In cases of | | | | Distractor 1** | esophagitis, | | | | | the patient | | | | | usually | | | | | presents with | | | | | central chest | | | | | or epigastric | | | | | pain with a | | | | | heaviness that | | | | | is mostly | | | | | similar to the | | | | | chest pain in | | | | | coronary artery | | | | | disease. Proton | | | | | Pump Inhibitors | | | | | are potential | | | | | inhibitors of | | | | | the proton-H+ | | | | | pump in the | | | | | apical | | | | | secretory | | | | | membrane of the | | | | | gastric acid | | | | | secretory | | | | | cells. H2 | | | | | receptor | | | | | antagonists are | | | | | the first-line | | | | | agents for | | | | | grade I-II | | | | | esophagitis. | | | | | | | | | | As per ECG and | | | | | other | | | | | investigations, | | | | | it is evident | | | | | that it is not | | | | | esophagitis; | | | | | therefore, this | | | | | advice is not | | | | | useful in this | | | | | case. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Administer | | | | 2** | intravenous | | | | | (IV) morphine | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | Morphine is an | | | | Distractor 2** | opioid | | | | | analgesic used | | | | | to relieve | | | | | severe pain, | | | | | usually in the | | | | | emergency | | | | | department, for | | | | | example, in | | | | | cases of acute | | | | | coronary | | | | | syndrome. It | | | | | can be used in | | | | | parallel as it | | | | | relieves pain | | | | | rapidly but has | | | | | no prognostic | | | | | benefits in | | | | | treating | | | | | coronary artery | | | | | diseases. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Thrombolysis | | | | 3** | directly with | | | | | tissue | | | | | plasminogen | | | | | activator (TPA) | | | | | -- Alteplase | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | Acute coronary | | | | Distractor 3** | syndrome is | | | | | managed | | | | | initially in | | | | | the emergency | | | | | department with | | | | | defined doses | | | | | of morphine, | | | | | oxygen therapy | | | | | (if required), | | | | | nitroglycerin | | | | | and aspirin. | | | | | | | | | | Afterwards, | | | | | patients should | | | | | undergo | | | | | coronary | | | | | angiography and | | | | | percutaneous | | | | | coronary | | | | | intervention | | | | | (PCI) within 90 | | | | | to 120 minutes | | | | | of the onset of | | | | | the symptoms | | | | | and | | | | | presentation at | | | | | a PCI-capable | | | | | hospital. | | | | | | | | | | Thrombolysis | | | | | would be an | | | | | acceptable | | | | | alternative if | | | | | coronary | | | | | angiography and | | | | | potentially | | | | | percutaneous | | | | | intervention | | | | | cannot be done | | | | | within two | | | | | hours. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Keep the | | | | 4** | patient under | | | | | observation | | | | | only for 24 | | | | | hours | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | In the case of | | | | Distractor 4** | the acute | | | | | coronary | | | | | syndrome, | | | | | immediate | | | | | management is | | | | | required under | | | | | the standard | | | | | protocols. | | | | | Patients must | | | | | be treated with | | | | | the appropriate | | | | | dosage of | | | | | morphine, | | | | | nitroglycerine, | | | | | and aspirin, | | | | | followed by PCI | | | | | or | | | | | thrombolysis. | | | | | Patients with | | | | | prominent | | | | | features of ACS | | | | | via physical | | | | | examination, | | | | | laboratory | | | | | investigations | | | | | and imaging | | | | | cannot be kept | | | | | under | | | | | observation | | | | | only. It will | | | | | worsen the | | | | | disease | | | | | process, which | | | | | will be | | | | | difficult to | | | | | manage. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor 5 | Advice | | | | (Optional but | cognitive | | | | please consider | behavioural | | | | adding if | therapy (CBT) | | | | appropriate)** | and give | | | | | escitalopram 10 | | | | | mg per day | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | Angina pain and | | | | Distractor 5** | symptoms of | | | | | angina usually | | | | | coincide with | | | | | the symptoms of | | | | | a panic attack | | | | | or anxiety | | | | | disorder. | | | | | Cognitive | | | | | behavioural | | | | | therapy is one | | | | | of the best | | | | | treatments in | | | | | such cases, and | | | | | escitalopram | | | | | (selective | | | | | serotonin | | | | | reuptake | | | | | inhibitor -- | | | | | SSRI) is a good | | | | | choice for mood | | | | | betterment and | | | | | long-term | | | | | management of | | | | | anxiety | | | | | disorders. | | | | | However, the | | | | | examinations | | | | | and | | | | | investigations | | | | | prove it is an | | | | | acute coronary | | | | | syndrome in | | | | | this case. | | | | | Therefore it is | | | | | not a suitable | | | | | treatment | | | | | option. | | | +-----------------+-----------------+-----------------+-----------------+ | **(Optional) | | | | | Distractor 6** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | | | | | Distractor 6** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Vital | Coronary heart | | | | Concept** | disease and | | | | | acute coronary | | | | | syndrome are | | | | | among the major | | | | | causes of death | | | | | at an early age | | | | | worldwide. | | | | | Healthcare | | | | | providers must | | | | | maintain a high | | | | | degree of | | | | | surveillance to | | | | | assess ACS. An | | | | | integral | | | | | feature of | | | | | prompt | | | | | management of | | | | | STEMI and ACS | | | | | is the | | | | | availability of | | | | | good emergency | | | | | medical | | | | | services. ACS | | | | | can be | | | | | prevented with | | | | | adaptation to a | | | | | healthy | | | | | lifestyle. | | | +-----------------+-----------------+-----------------+-----------------+ | References | 1. Acute | | | | | coronary | | | | | syndrome - | | | | | StatPearls | | | | | - | | | | | NCBI | | | | | bookshelf. | | | | | (2021, July | | | | | 19). | | | | | National | | | | | Center for | | | | | Biotechnolo | | | | | gy | | | | | Information | | | | |. | | | | | https://www | | | | |.ncbi.nlm.nih.g | | | | | ov/books/NBK459 | | | | | 157/ | | | | | | | | | | 2. Acute | | | | | coronary | | | | | syndrome | | | | | treatment & | | | | | management: | | | | | Approach | | | | | considerati | | | | | ons, | | | | | pharmacolog | | | | | ic | | | | | anti-ischem | | | | | ic | | | | | therapy, | | | | | pharmacolog | | | | | ic | | | | | Antithrombo | | | | | tic | | | | | therapy. | | | | | (2021, | | | | | October | | | | | 17). | | | | | Diseases & | | | | | Conditions | | | | | - | | | | | Medscape | | | | | Reference. | | | | | https://eme | | | | | dicine.medscape | | | | |.com/article/19 | | | | | 10735-treatment | | | | | | | | | | 3. Papadakis | | | | | M.A., & | | | | | McPhee | | | | | S.J., & | | | | | Rabow M.W., | | | | | & McQuaid | | | | | K.R.(Eds.), | | | | | (2022). | | | | | Current | | | | | Medical | | | | | Diagnosis & | | | | | Treatment 2 | | | | | 022. | | | | | McGraw | | | | | Hill. | | | +-----------------+-----------------+-----------------+-----------------+ +-----------------+-----------------+-----------------+-----------------+ | **Question | | **QID** | 03 | | Bank** | | | | +=================+=================+=================+=================+ | **Discipline/** | | **System/** | Cardiovascular | | | | | system | | **Competency** | | **Content | | | | | Area** | | +-----------------+-----------------+-----------------+-----------------+ | **Topic to be | Non-surgical | | | | tested** | cardiac | | | | | intervention -- | | | | | Percutaneous | | | | | coronary | | | | | intervention | | | | | (PCI) | | | +-----------------+-----------------+-----------------+-----------------+ | **Include as | Treatment | | | | distractors** | options for | | | | | acute coronary | | | | | syndrome with | | | | | thrombolysis, | | | | | glyceryl | | | | | nitrate only, | | | | | Intravenous | | | | | morphine and | | | | | keeping the | | | | | patient under | | | | | observation | | | +-----------------+-----------------+-----------------+-----------------+ | **Include in | | | | | explanation** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Author Last | HAQ | **Author First | MAHEEN | | Name** | | Name** | | +-----------------+-----------------+-----------------+-----------------+ | **Stem/Data** | A 63-year-old | | | | | man is admitted | | | | | to the | | | | | hospital\'s | | | | | emergency | | | | | department (ED) | | | | | with sudden | | | | | shortness of | | | | | breath, severe | | | | | chest pain and | | | | | profuse | | | | | sweating for | | | | | the last 30 | | | | | minutes. His | | | | | chest pain is | | | | | centralized and | | | | | radiates to the | | | | | left jaw and | | | | | arm. He has | | | | | been | | | | | hypertensive | | | | | for the last 25 | | | | | years with poor | | | | | drug | | | | | compliance. | | | | | | | | | | On physical | | | | | examination, he | | | | | looks pale, | | | | | anxious and | | | | | diaphoretic. | | | | | His blood | | | | | pressure is | | | | | 175/110 mmHg, | | | | | equal on both | | | | | arms, his heart | | | | | rate is 120 | | | | | beats per | | | | | minute, and his | | | | | oxygen | | | | | saturation is | | | | | 93% on room | | | | | air. | | | | | | | | | | Serial | | | | | electrography | | | | | (ECGs) revealed | | | | | sinus | | | | | tachycardia and | | | | | left | | | | | ventricular | | | | | hypertrophy | | | | | with | | | | | ST-elevation in | | | | | II, III and avF | | | | | lead. | | | | | | | | | | Laboratory data | | | | | shows that | | | | | haemoglobin | | | | | (Hb) is | | | | | 14.5 g/dL, Urea | | | | | 17 mg/dL, | | | | | Creatinine 1.0 | | | | | mg/dL, Troponin | | | | | I 1.2 ng/mL. He | | | | | has been given | | | | | a loading dose | | | | | of aspirin 300 | | | | | mg, sublingual | | | | | glyceryl | | | | | trinitrate | | | | | (GTN) 500 mcg | | | | | and clopidogrel | | | | | 600 mg. | | | +-----------------+-----------------+-----------------+-----------------+ | **Lead-In** | **What would be | | | | | the next | | | | | appropriate | | | | | step for | | | | | management?** | | | +-----------------+-----------------+-----------------+-----------------+ | **Image in | | | | | stem** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Source of | | | | | image** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Correct | Percutaneous | | | | Answer** | coronary | | | | | intervention | | | | | (PCI) | | | +-----------------+-----------------+-----------------+-----------------+ | **Explanation | Diagnostic | | | | for Correct | angiography for | | | | Answer** | performing | | | | | revascularizati | | | | | on | | | | | is an initial | | | | | plan for | | | | | serious | | | | | coronary artery | | | | | disease | | | | | patients, | | | | | followed by | | | | | PCI. The major | | | | | clinical | | | | | indications of | | | | | PCI are as | | | | | follows: | | | | | | | | | | 1. Acute | | | | | ST-elevatio | | | | | n | | | | | myocardial | | | | | infarction | | | | | | | | | | - The | | | | | preferred | | | | | reperfusion | | | | | technique | | | | | is primary | | | | | PCI, which | | | | | is | | | | | restricted | | | | | to time. | | | | | | | | | | - The onset | | | | | of symptoms | | | | | for almost | | | | | 12 hours. | | | | | | | | | | - Contraindic | | | | | ations | | | | | to | | | | | fibrinolyti | | | | | c | | | | | therapy. | | | | | | | | | | 2. Non--ST-ele | | | | | vation | | | | | myocardial | | | | | infarction | | | | | | | | | | - Initial | | | | | invasive | | | | | therapy | | | | | within 120 | | | | | minutes of | | | | | the onset | | | | | of symptoms | | | | | of | | | | | refractory | | | | | or | | | | | recurrent | | | | | angina, | | | | | heart | | | | | failure, | | | | | hemodynamic | | | | | instability | | | | | , | | | | | mitral | | | | | regurgitati | | | | | on, | | | | | or | | | | | prolonged | | | | | ventricular | | | | | fibrillatio | | | | | n. | | | | | | | | | | - Increasing | | | | | troponin | | | | | levels | | | | | within 24 | | | | | hours. | | | | | | | | | | 3. Unstable or | | | | | stable | | | | | angina | | | | | | | | | | If initially | | | | | stabilized, | | | | | coronary | | | | | angiography | | | | | should be done | | | | | in patients | | | | | with acute MI, | | | | | followed by | | | | | percutaneous | | | | | coronary | | | | | intervention | | | | | (PCI) within 90 | | | | | to 120 minutes | | | | | of the onset of | | | | | the symptoms | | | | | and | | | | | presentation at | | | | | a PCI-capable | | | | | hospital. | | | +-----------------+-----------------+-----------------+-----------------+ | **The image in | | | | | the | | | | | explanation** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Image | | | | | Source** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Increase the | | | | 1** | dose of GTN | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | GTN causes | | | | Distractor 1** | vasodilation of | | | | | arteries and | | | | | veins, | | | | | increasing the | | | | | blood supply to | | | | | the heart. So | | | | | in angina, it | | | | | helps the heart | | | | | muscles to get | | | | | enough oxygen | | | | | and decreases | | | | | chest pain. | | | | | | | | | | It can be used | | | | | parallel to PCI | | | | | to relieve the | | | | | patient\'s | | | | | symptoms but | | | | | increasing its | | | | | dose will not | | | | | be beneficial. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Thrombolyse | | | | 2** | with alteplase | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | Thrombolysis | | | | Distractor 2** | with tissue | | | | | plasminogen | | | | | activator (TPA) | | | | | or alteplase | | | | | has beneficial | | | | | prognostics in | | | | | acute coronary | | | | | syndrome | | | | | patients. | | | | | | | | | | However, | | | | | thrombolysis is | | | | | only acceptable | | | | | when coronary | | | | | angiography and | | | | | PCI cannot be | | | | | done within 2 | | | | | hours of the | | | | | onset of | | | | | symptoms. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Intravenous | | | | 3** | (IV) | | | | | diamorphine 3 | | | | | mg | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | Morphine -- | | | | Distractor 3** | being an opioid | | | | | analgesic, is | | | | | used to relieve | | | | | severe pain. It | | | | | can be used | | | | | with PCI to | | | | | relieve chest | | | | | pain rapidly | | | | | but has no | | | | | prognostic | | | | | benefits in | | | | | treating | | | | | coronary artery | | | | | diseases alone. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor | Monitor and | | | | 4** | observe the | | | | | patient | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | Patients with | | | | Distractor 4** | sudden onset of | | | | | angina pain | | | | | always need | | | | | immediate | | | | | management with | | | | | predefined | | | | | protocols. | | | | | Patients should | | | | | get treatment | | | | | with the | | | | | appropriate | | | | | dosage of | | | | | morphine, | | | | | nitroglycerine, | | | | | and aspirin, | | | | | followed by PCI | | | | | or | | | | | thrombolysis. | | | | | Such patients | | | | | with prominent | | | | | signs and | | | | | symptoms cannot | | | | | be kept under | | | | | observation | | | | | only as it will | | | | | endanger the | | | | | patient\'s life | | | | | by worsening | | | | | the disease | | | | | process. | | | +-----------------+-----------------+-----------------+-----------------+ | **Distractor 5 | | | | | (Optional but | | | | | please consider | | | | | adding if | | | | | appropriate)** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | | | | | Distractor 5** | | | | +-----------------+-----------------+-----------------+-----------------+ | **(Optional) | | | | | Distractor 6** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Answer for | | | | | Distractor 6** | | | | +-----------------+-----------------+-----------------+-----------------+ | **Vital | If the patient | | | | Concept** | with angina has | | | | | arrived in the | | | | | PCI-capable | | | | | hospital within | | | | | 90 minutes and | | | | | has evident MI | | | | | on ECG should | | | | | be initially | | | | | stabilized with | | | | | ACS protocol | | | | | followed by | | | | | PCI. | | | +-----------------+-----------------+-----------------+-----------------+ | References | 1. Papadakis | | | | | M.A., & | | | | | McPhee | | | | | S.J., & | | | | | Rabow M.W., | | | | | & McQuaid | | | | | K.R.(Eds.), | | | | | (2022). | | | | | Current | | | | | Medical | | | | | Diagnosis & | | | | | Treatment 2 | | | | | 022. | | | | | McGraw | | | | | Hill. | | | | | | | | | | 2. Acute | | | | | coronary | | | | | syndrome | | | | | treatment & | | | | | management: | | | | | Approach | | | | | considerati | | | | | ons, | | | | | pharmacolog | | | | | ic | | | | | anti-ischem | | | | | ic | | | | | therapy, | | | | | pharmacolog | | | | | ic | | | | | Antithrombo | | | | | tic | | | | | therapy. | | | | | (2021, | | | | | October | | | | | 17). | | | | | Diseases & | | | | | Conditions | | | | | - | | | | | Medscape | | | | | Reference. | | | | | https://eme | | | | | dicine.medscape | | | | |.com/article/19 | | | | | 10735-treatment | | | | | \#d14 | | | | | | | | | | 3. Percutaneou | | | | | s | | | | | coronary | | | | | interventio | | | | | n - | | | | | StatPearls | | | | | - | | | | | NCBI | | | | | bookshelf. | | | | | (2022, June | | | | | 11). | | | | | National | | | | | Center for | | | | | Biotechnolo | | | | | gy | | | | | Information | | | | |. | | | | | https://www | | | | |.ncbi.nlm.nih.g | | | | | ov/books/NBK556 | | | | | 123/ | | | +-----------------+-----------------+-----------------+-----------------+ +-----------------+-----------------+-----------------+-----------------+ | **Question | | **QID** | 04 | | Bank** | | | | +=================+=================+=================+=================+ | **Discipline/** | | **System/** | Cardiovascular | | | | | system | | **Competency** | | **Content | | | | | Area** | | +-----------------+-----------------+-----------------+-----------------+ | **Topic to be | Arterial | | | | tested** | Hypertension | | | +-----------------+-----------------+-----------------+-----------------+ | **Include as | Possible causes | | | | distractors** | of acute | | | | | exacerbation of | | | | | congestive | | | | | heart failure | | | | | (CHF) | | | +-----------------+-----------------+-----------------+-----------------+ | **Include in | Arterial | | | | explanation** | hypertension is | | | | | the major cause | | | | | of CHF | | | | | worsening | | | +-----------------+-----------------+-----------------+-----------------+ | **Author Last | HAQ | **Author First | MAHEEN | | Name** | | Name** | | +-----------------+-----------------+-----------------+-----------------+ | **Stem/Data** | A 59-year-old | | | | | man comes to | | | | | the hospital\'s | | | | | emergency | | | | | department | | | | | complaining of | | | | | shortness of | | | | | breath for last | | | | | 10 days. It | | | | | exaggerates | | | | | when he lies on | | | | | the bed and | | | | | climbs the | | | | | stairs to his | | | | | apartment on | | | | | the 2^nd^ | | | | | floor. His | | | | | mother had a | | | | | myocardial | | | | | infarction (MI) | | | | | at age 55. He | | | | | drinks two | | | | | glasses of wine | | | | | daily after | | | | | dinner. He has | | | | | been | | | | | hypertensive | | | | | for 15 years | | | | | and used beta | | | | | blockers but | | | | | stopped 2 years | | | | | ago. He has | | | | | been taking | | | | | ibuprofen for | | | | | osteoarthritis | | | | | and | | | | | atorvastatin | | | | | for | | | | | hyperlipidemia | | | | | for the last 2 | | | | | weeks. | | | | | | | | | | On physical | | | | | examination, he | | | | | has dilated | | | | | jugular vein | | | | | and pitting | | | | | oedema. His | | | | | temperature is | | | | | 37.0°C | | | | | (98.6°F), his | | | | | heart rate is | | | | | 112 beats per | | | | | minute, his | | | | | blood pressure | | | | | (BP) is 145/92 | | | | | mmHg, his | | | | | weight is 82 | | | | | kg, and his | | | | | body mass index | | | | | (BMI) is 26.2 | | | | | kg/m^2^. There | | | | | is a | | | | | late-diastolic | | | | | murmur on the | | | | | auscultation of | | | | | the heart, and | | | | | lung | | | | | auscultation | | | | | revealed | | | | | bilateral basal | | | | | crackles. | | | | | | | | | | His laboratory | | | | | investigation | | | | | shows a normal | | | | | range of serum | | | | | electrolytes. | | | | | His creatinine | | | | | is 1.1 mg/dL | | | | | (normal, | | | | | 0.84-1.21 | | | | | mg/dL), and his | | | | | low density | | | | | lipoprotein | | | | | cholesterol | | | | | (LDL-C) is 151 | | | | | mg/dL | | | | | (desirable | | | | | \