Cardiovascular System

Paramedics rush a 55-year-old male to the resuscitation bay following the acute onset of crushing substernal chest discomfort that began while he was doing yard work. En route, emergency medical personnel administered chewable aspirin and one dose of sublingual nitroglycerin. Upon arrival, the patient appears ashen and confused. Vital signs reveal a blood pressure of 78/48 mmHg, heart rate of 112/min, and respiratory rate of 18/min. Physical examination demonstrates pronounced jugular venous distention. Pulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes. Cardiac auscultation shows a regular, rapid rhythm with no murmurs, rubs, or gallops. A 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF. Which of the following is the most appropriate next step in the management of this patient's current hemodynamic state?

During a cardiovascular clinical skills workshop, a group of medical students is reviewing the hemodynamic effects of various physical examination maneuvers on structural heart lesions. Match each described pathophysiological hemodynamic change (left) with the appropriate clinical scenario consisting of a bedside maneuver and its corresponding underlying cardiac pathology (right).

A 58-year-old man is brought to the emergency department for sudden, excruciating chest pain radiating to his interscapular region. He appears diaphoretic and in severe distress. Blood pressure is 210/110 mm Hg in the right arm and 170/95 mm Hg in the left arm. Heart rate is 118/min. A new early diastolic decrescendo murmur is heard at the right upper sternal border. Neurologic examination reveals no focal deficits. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy without acute ischemic changes. Chest radiograph demonstrates a widened mediastinum. Arrange the following next steps in the management of this patient in the most appropriate chronological order.

A 76-year-old male presents to the emergency department reporting five days of progressively worsening shortness of breath, increased volume of yellow sputum, and new swelling in both of his legs. His medical history includes severe chronic obstructive pulmonary disease and a myocardial infarction six years ago.

Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 135/85 mmHg, pulse of 112/min, and respirations of 26/min. Oxygen saturation is 88% on room air. Physical examination reveals a barrel-shaped chest and use of accessory muscles. The jugular venous pressure is visibly elevated to 11 cm $H_2O$. Cardiac auscultation shows distant heart sounds and a regular tachycardia without murmurs or gallops. Lung auscultation reveals prolonged expiration with diffuse expiratory wheezes, but no crackles are present. Bilateral 2+ pitting edema is noted up to the knees.

A chest radiograph demonstrates hyperinflated lungs, flattened diaphragms, and prominent central pulmonary arteries without alveolar infiltrates or pleural effusions. An electrocardiogram shows sinus tachycardia, right axis deviation, and right ventricular hypertrophy.

Assuming a diagnosis of acute decompensated heart failure due to his cardiac history and volume overload status, the treating physician administers a dose of intravenous furosemide. Sixty minutes later, the patient becomes acutely confused. Repeat vital signs show a blood pressure of 72/45 mmHg and a pulse of 128/min.

Which of the following is the most likely primary mechanism for this patient's acute clinical deterioration?

Match each distinct arterial pulse or blood pressure finding with its most characteristic underlying cardiovascular pathology.

Paramedics transport an $82$-year-old male resident of an assisted living facility to the acute care bay after he was found severely short of breath and lethargic. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, severe chronic obstructive pulmonary disease (COPD), and stage $3$ chronic kidney disease. Vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $84/52\text{ mm Hg}$, pulse of $110/\text{min}$ and irregularly irregular, and respiratory rate of $32/\text{min}$. Pulse oximetry is $80\%$ on room air. Physical examination reveals a somnolent patient using accessory muscles of respiration. Jugular venous distention is prominent up to the angle of the mandible. Auscultation of the lungs reveals diffuse bilateral expiratory wheezing with no focal consolidation. Cardiac examination demonstrates a prominent $S_3$ gallop and a $2/6$ holosystolic murmur at the apex. Point-of-care arterial blood gas analysis on room air reveals:

$\text{pH}$: $7.16$
$\text{pCO}_2$: $74\text{ mm Hg}$
$\text{pO}_2$: $48\text{ mm Hg}$
$\text{HCO}_3^-$: $25\text{ mEq/L}$

Which of the following is the most appropriate next step in management?

A $74$-year-old woman is brought to the emergency department via ambulance with acute, severe respiratory distress that awoke her from sleep $30$ minutes ago. She is profoundly diaphoretic, anxious, and sitting bolt upright on the stretcher. Her blood pressure is $240/130$ mm Hg, heart rate is $128$/min, and respiratory rate is $38$/min. Oxygen saturation is $82\%$ on room air. Physical examination reveals a hyperdynamic precordium and diffuse, coarse crackles auscultated throughout all lung fields bilaterally. There is no significant lower extremity edema. Arrange the following therapeutic interventions in the most appropriate chronological sequence for the optimal acute management of this patient's condition.

An emergency department physician evaluates a 67-year-old man due to four days of escalating dyspnea and nocturnal coughing. The patient reports having to sleep upright in a recliner to avoid respiratory distress. His medical background includes type 2 diabetes, essential hypertension, and osteoarthritis. He recently began taking over-the-counter ibuprofen around the clock for severe knee pain. He smoked one pack of cigarettes daily for 35 years but ceased a decade ago. Temperature is 37.0°C (98.6°F), blood pressure is 158/92 mm Hg, pulse is 112/min, and respirations are 22/min. Pulse oximetry is 92% on room air. Physical examination reveals an anxious patient utilizing accessory respiratory muscles. Jugular venous pressure is elevated at 11 cm H2O. Chest auscultation demonstrates bibasilar dullness to percussion and widespread expiratory wheezes. Cardiac evaluation shows a regular rhythm with a normal S1 and S2, accompanied by a low-frequency sound occurring shortly after S2. Moderate pitting edema is present up to the mid-shins bilaterally. Which of the following is the most appropriate initial pharmacotherapy for this patient?

An emergency response team evaluates a $65$-year-old female in the resuscitation bay for sudden-onset respiratory distress. The patient's husband states she has been experiencing progressive exertional fatigue over the past week and abruptly awoke gasping for air early this morning. Her medical history includes diet-controlled type 2 diabetes, essential hypertension, and a long-standing history of tobacco use ($45$ pack-years). Her home medications are metformin and lisinopril, though she admits to frequent nonadherence.

Upon initial assessment, her temperature is $36.8^{\circ}\text{C}$ ($98.2^{\circ}\text{F}$), blood pressure is $192/110\text{ mm Hg}$, pulse is $118/\text{min}$, and respiratory rate is $30/\text{min}$. Pulse oximetry displays an oxygen saturation of $86\%$ on ambient air. The patient is diaphoretic and speaks in one-word sentences. Pulmonary auscultation reveals widespread, high-pitched expiratory wheezing; no rales are present. Heart rhythm is rapid and regular. Examination of the neck shows prominent sternocleidomastoid retractions, making venous assessment difficult.

An arterial blood gas analysis reveals a pH of $7.47$, a $\text{PaCO}_2$ of $31\text{ mm Hg}$, and a $\text{PaO}_2$ of $54\text{ mm Hg}$. A portable anteroposterior chest radiograph demonstrates thickening of the bronchial walls (peribronchial cuffing), prominent interlobular septa, and loss of distinct margins of the hilar vessels. Both hemidiaphragms possess a normal, domed contour.

Which of the following is the most appropriate initial intervention for this patient's acute respiratory failure?

A 62-year-old woman is brought to the emergency department due to sudden onset of severe shortness of breath and lightheadedness. She underwent a right total hip arthroplasty 10 days ago. Her temperature is 37.1°C (98.8°F), blood pressure is 76/48 mm Hg, pulse is 128/min, and respirations are 28/min. Pulse oximetry shows 87% on room air. Physical examination reveals a patient in severe respiratory distress. The jugular venous pressure is estimated at 13 cm H2O. Auscultation of the lungs reveals clear breath sounds bilaterally. Cardiac auscultation reveals a regular tachycardia and a prominent P2, but no murmurs or gallops. The right lower extremity is mildly swollen and tender to palpation compared to the left. Which of the following is the most appropriate next step in the management of this patient?

Carefully read the clinical vignettes describing various cardiac presentations. Match each clinical presentation with its most likely corresponding jugular venous pressure (JVP) waveform abnormality.

An emergency response team evaluates a $68$-year-old female who awoke abruptly with severe respiratory distress. Her medical history is notable for long-standing essential hypertension, obesity, diet-controlled type 2 diabetes mellitus, and a $35$-pack-year smoking habit.

Upon arrival at the emergency department, she appears highly anxious, diaphoretic, and is utilizing accessory muscles of respiration. Vital signs exhibit a blood pressure of $165/85 \text{ mmHg}$, a heart rate of $96 \text{ bpm}$, a respiratory rate of $28 \text{ breaths/min}$, and an oxygen saturation of $86\%$ on ambient air.

Auscultation of the lungs reveals a prolonged expiratory phase accompanied by high-pitched, diffuse bilateral wheezes. A faint $2/6$ systolic murmur is auscultated at the left lower sternal border.

The evaluating physician suspects an acute exacerbation of chronic obstructive pulmonary disease and immediately orders continuous nebulized albuterol along with intravenous methylprednisolone.

Twenty minutes after initiating therapy, the patient's condition deteriorates precipitously. She reports new-onset severe dizziness and retrosternal chest pressure.
Repeat vital signs indicate a blood pressure of $78/42 \text{ mmHg}$ and a heart rate of $128 \text{ bpm}$.
Repeat cardiac auscultation demonstrates that the previously faint murmur is now a prominent $4/6$ harsh, crescendo-decrescendo systolic murmur at the left lower sternal border.

A $12$-lead electrocardiogram demonstrates sinus tachycardia, voltage criteria for left ventricular hypertrophy, and deep, narrow Q waves in leads I, aVL, $V_5$, and $V_6$, with no ST-segment elevations.

Which of the following is the most appropriate next step in managing this patient's acute hemodynamic collapse?

Match each distinctive cardiac auscultation finding and its response to dynamic bedside maneuvers with the most likely underlying structural valvular pathology.

A 58-year-old man is evaluated in the emergency department for sudden-onset, severe "tearing" chest pain that radiates to his interscapular region. He is markedly anxious and diaphoretic. His blood pressure is $218/115\text{ mmHg}$ in the right arm and $182/95\text{ mmHg}$ in the left arm. His heart rate is $114\text{/min}$. Physical examination reveals a new prominent early diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram reveals sinus tachycardia and voltage criteria for left ventricular hypertrophy. Bedside chest radiography demonstrates a widened mediastinum. Arrange the following interventions in the most appropriate sequential order for the acute management of this patient.

A physician is evaluating a 62-year-old man on the medical ward due to acute-onset severe shortness of breath. The patient was admitted 24 hours ago for community-acquired pneumonia and was started on targeted antimicrobial therapy with ceftriaxone and azithromycin. In the emergency department, his initial blood pressure was 88/58 mm Hg, for which he received a total of 4 liters of normal saline. His blood pressure subsequently normalized. His past medical history includes chronic obstructive pulmonary disease (COPD), hypertension, and hypothyroidism. Currently, he reports worsening dyspnea and difficulty breathing while lying flat. His temperature is 37.1 C (98.8 F), blood pressure is 158/92 mm Hg, pulse is 112/min, and respirations are 26/min. Pulse oximetry is 86% on room air. Physical examination shows distended neck veins up to 10 cm above the sternal angle. Cardiac auscultation reveals a regular tachycardia with a prominent third heart sound (S3). Lung examination demonstrates bilateral crackles extending to the mid-lung fields, alongside the previously noted right lower lobe bronchial breath sounds. There is mild bilateral lower extremity pitting edema. Arterial blood gas analysis on room air shows $pH = 7.32$, $pCO_2 = 52\text{ mm Hg}$, and $pO_2 = 56\text{ mm Hg}$. Which of the following is the most appropriate next step in management for this patient's acute respiratory decline?

Match the following clinical scenarios of patients presenting with acute circulatory collapse to their most likely corresponding invasive hemodynamic profile (pulmonary capillary wedge pressure [PCWP], cardiac output [CO], systemic vascular resistance [SVR], and right atrial pressure [RAP]).

A 27-year-old primigravida at 28 weeks gestation is brought to the emergency department with sudden-onset severe dyspnea and a cough producing frothy sputum. Over the past month, she experienced progressive fatigue and exertional dyspnea, which she assumed were normal changes of pregnancy. She recently emigrated from Southeast Asia and has had limited medical care. She is terrified and tearfully states, 'Please don't do any surgery, I refuse a C-section no matter what happens.'

Temperature is 36.8°C (98.2°F), blood pressure is 108/64 mm Hg, and pulse is 138/min and irregularly irregular. Respirations are 32/min. Pulse oximetry is 86% on room air. Physical examination reveals bibasilar crackles extending to the mid-lung fields and widespread expiratory wheezing. Cardiac auscultation in the left lateral decubitus position reveals a loud first heart sound, a high-pitched early diastolic sound, and a low-pitched diastolic rumble at the apex. An electrocardiogram demonstrates narrow QRS complexes with absent P waves and varying R-R intervals. Arterial blood gas on room air shows a pH of 7.28, $\text{PaCO}_2$ of 55 mm Hg, and $\text{PaO}_2$ of 58 mm Hg. Continuous fetal heart rate monitoring demonstrates a baseline of 160/min with minimal variability and recurrent late decelerations.

Which of the following is the most appropriate next step in management?

A $65$-year-old man is brought to the emergency department by ambulance due to severe, heavy chest pressure, diaphoresis, and worsening shortness of breath that began $90$ minutes ago. His medical history is significant for chronic obstructive pulmonary disease (COPD), hyperlipidemia, and hypothyroidism. His home medications include a statin, an inhaled fluticasone-salmeterol diskus, and oral levothyroxine.

Upon arrival, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry is $92\%$ on room air.

Physical examination reveals prominent jugular venous distention while the patient is sitting at a $45^\circ$ angle. Lung auscultation shows prolonged expiration with mild, scattered wheezes bilaterally, but the lungs are clear of crackles. Cardiac examination reveals tachycardia with a regular rhythm; no murmurs or gallops are appreciated. The liver edge is palpable $4\text{ cm}$ below the right costal margin.

Laboratory testing shows:
- Troponin I: $2.4\text{ ng/mL}$ (Normal $<0.04\text{ ng/mL}$)
- TSH: $5.5\text{ \mu U/mL}$ (Normal $0.4 - 4.0\text{ \mu U/mL}$)
- Free T4: $1.1\text{ ng/dL}$ (Normal $0.8 - 1.8\text{ ng/dL}$)

Arterial blood gas on room air reveals a pH of $7.36$, $\text{pCO}_2$ of $48\text{ mm Hg}$, and $\text{pO}_2$ of $65\text{ mm Hg}$.

A $12$-lead electrocardiogram demonstrates $3\text{-mm}$ ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL.

The patient is given chewable aspirin and an intravenous fluid bolus. Which of the following interventions is most strongly contraindicated in the immediate management of this patient's condition?

Match each of the following clinical presentations of cardiovascular disease with its most characteristic combination of jugular venous pulse (JVP) and arterial pulse contour findings.

Paramedics transport a 74-year-old female to the emergency department because she awoke suddenly with a sensation of suffocating. Her medical history is notable for hypertension, diet-controlled type 2 diabetes mellitus, and a 40-pack-year smoking history. Current medications include daily amlodipine and metoprolol succinate. Upon arrival, she appears in acute distress, sitting upright and using accessory muscles of respiration. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $182/105\text{ mm Hg}$, pulse $114/\text{min}$, and respirations $28/\text{min}$. Pulse oximetry is $88\%$ on room air.

Physical examination reveals marked jugular venous distention to $11\text{ cm H}_2\text{O}$. Lung auscultation demonstrates diffuse expiratory wheezing and coarse crackles extending halfway up both posterior lung fields. Cardiac auscultation is limited by breath sounds but reveals a regular tachycardia and a low-frequency diastolic sound heard best at the cardiac apex.

Arterial blood gas analysis on room air reveals the following:

Chest radiography displays an enlarged cardiac silhouette, prominent interstitial markings, and bilateral pleural effusions.

What is the most appropriate initial pharmacologic therapy for this patient?