Cardiovascular System

A 64-year-old man presents to the outpatient clinic reporting a 2-month history of retrosternal chest tightness. The discomfort occurs predictably after walking two blocks and resolves completely with 5 minutes of rest. He has a history of type 2 diabetes mellitus, hyperlipidemia, and hypertension. Current medications include lisinopril and metformin. Vital signs are within normal limits. Physical examination is unremarkable. A resting 12-lead electrocardiogram shows normal sinus rhythm without ST-segment or T-wave abnormalities.

Arrange the following steps in the most appropriate sequential order for the optimal long-term evaluation and management of this patient's condition, assuming each successive step reveals findings that appropriately warrant further escalation of care.

A $74$-year-old woman is brought to the emergency department by ambulance due to severe shortness of breath that awoke her from sleep $2$ hours ago. She has a history of chronic obstructive pulmonary disease (COPD), essential hypertension, and osteoarthritis. Her home medications include a daily tiotropium inhaler and amlodipine. She reports a dry cough but denies fever, chills, or changes in sputum production. She appears in severe respiratory distress, sitting upright and using accessory muscles of respiration. Vital signs are temperature $37.0^{\circ}C$ ($98.6^{\circ}F$), blood pressure $182/105$ mm Hg, pulse $112$/min, and respirations $28$/min. Pulse oximetry is $88\%$ on room air. Jugular venous pressure is $10$ cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezes and a prolonged expiratory phase; no crackles are appreciated. Cardiac examination reveals a regular tachycardia with a faint, high-frequency presystolic sound at the apex. There is no peripheral edema. Arterial blood gas analysis on room air reveals a pH of $7.28$, $PaCO_2$ of $60$ mm Hg, $PaO_2$ of $55$ mm Hg, and $HCO_3^-$ of $27$ mEq/L. A bedside chest radiograph shows hyperinflated lungs, prominent upper lobe vessels, and peribronchial cuffing, without distinct alveolar infiltrates. Electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. Which of the following is the most appropriate next step in management?

A $68$-year-old man with a history of prior myocardial infarction and ischemic cardiomyopathy is brought to the emergency department after a witnessed episode of near-syncope at home. Upon arrival, he appears pale and lethargic but withdraws to painful stimuli. His vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), a heart rate of $188\text{ /min}$, a blood pressure of $78/50\text{ mmHg}$, and a respiratory rate of $22\text{ /min}$. Continuous cardiac monitoring reveals a regular, wide-complex tachycardia. His oxygen saturation is $94\%$ on room air.

Based on the Advanced Cardiovascular Life Support (ACLS) guidelines, arrange the following acute management steps in the correct sequential order for this patient.

A 64-year-old man is brought to the emergency department due to sudden-onset, excruciating chest pain that radiates to his back. His blood pressure is 210/120 mm Hg in the right arm and 185/105 mm Hg in the left arm. Heart rate is 118/min. Physical examination reveals a bounding pulse and a new early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy. The physician strongly suspects an acute aortic dissection and prepares to manage the patient. Arrange the following diagnostic and therapeutic interventions in the most appropriate sequential order for this patient.

An emergency medical team brings a female in her early thirties to the resuscitation bay following a brief loss of consciousness at her workplace. Upon arrival, the patient is lethargic and complains of profound weakness, lightheadedness, and difficulty breathing. She reports recovering from a severe viral upper respiratory tract infection two weeks ago but otherwise has no chronic medical conditions.

Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $128$/min, respirations are $26$/min, and blood pressure is $78/48$ mmHg. When assessed during normal inhalation, her systolic blood pressure drops to $62$ mmHg.

Physical evaluation reveals marked distension of the external jugular veins while she is positioned at a $45$-degree angle. Auscultation of the chest demonstrates clear lung fields bilaterally without rhonchi or crepitations. Cardiac auscultation reveals a regular, rapid rhythm with significantly distant and muffled heart sounds. An electrocardiogram shows sinus tachycardia with low-voltage QRS complexes and beat-to-beat variation in QRS amplitude.

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

Match each structural or valvular heart pathology with its most characteristic physical examination or auscultatory finding.

Match the following physical examination findings of cardiac murmurs with their most likely underlying pathophysiology or structural etiology.

Match each classic electrocardiographic (ECG) description to its corresponding cardiac condition.

An emergency medical services team brings a 58-year-old man to the hospital due to severe, continuous substernal chest pain, shortness of breath, and profound diaphoresis that began 45 minutes ago. His medical history is significant for hyperlipidemia and a 35-pack-year smoking habit. Initial vital signs demonstrate a blood pressure of $85/50\text{ mmHg}$, a heart rate of $55/\text{min}$, and a respiratory rate of $20/\text{min}$. Physical examination reveals significantly elevated jugular venous pressure, but the lung fields are completely clear to auscultation bilaterally. A 12-lead electrocardiogram demonstrates $3\text{ mm}$ 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 hypotension?

During a routine follow-up appointment, a $65$-year-old female patient complains of increasing difficulty breathing over the last $5$ days. She notes that she can no longer sleep in her bed and has spent the last two nights in a reclining chair. Her medical history includes long-standing hypertension, stable angina, and type 2 diabetes mellitus. She denies any fever, productive sputum, or recent sick contacts. Vital signs reveal a blood pressure of $162/88\text{ mm Hg}$, a heart rate of $95\text{/min}$, and a respiratory rate of $22\text{/min}$. Oxygen saturation is $93\%$ on ambient air. Cardiovascular examination demonstrates elevated jugular venous pressure and an audible S3 gallop. Pulmonary auscultation reveals crackles at the bases of both lungs. Examination of the lower extremities shows significant $2+$ bilateral pitting edema. Laboratory testing is notable for a B-type natriuretic peptide (BNP) level of $920\text{ pg/mL}$, a normal leukocyte count, and normal thyroid-stimulating hormone (TSH) and free T4 levels. An arterial blood gas shows a pH of $7.43$, $\text{pCO}_2$ of $34\text{ mm Hg}$, and $\text{pO}_2$ of $72\text{ mm Hg}$. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A physician evaluates a 71-year-old retired mechanic who reports worsening shortness of breath over the past week. He states that he frequently wakes up in the middle of the night feeling as though he is suffocating and has resorted to sleeping in a reclining chair. His medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. Current medications include lisinopril and atorvastatin. His blood pressure is 158/92 mmHg, pulse is 98/min, and respiratory rate is 22/min. Physical examination demonstrates distended neck veins when positioned at 45 degrees. Lung auscultation reveals bilateral crackles at the bases and scattered expiratory wheezes. Cardiac auscultation reveals a regular rhythm with a low-frequency diastolic sound heard just after S2 at the apex. Bilateral 2+ pitting edema is present in the lower extremities. Which of the following is the most likely primary pathophysiologic mechanism responsible for this patient's current symptoms?

Match each cardiovascular medication to its most characteristic adverse effect.

A 28-year-old woman, gravida 1, para 0, at 28 weeks gestation is brought to the emergency department due to the sudden onset of severe shortness of breath, orthopnea, and a cough productive of pink, frothy sputum. She recently immigrated to the United States and has had limited prenatal care. Over the past month, she noticed progressive fatigue and palpitations, which she attributed to normal pregnancy. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, heart rate is $142\text{/min}$ and irregularly irregular, and respiratory rate is $32\text{/min}$. Pulse oximetry is $86\%$ on room air. Jugular venous distension is prominent. Lung auscultation reveals diffuse bilateral crackles and prolonged expiratory wheezes. Cardiac auscultation demonstrates a loud S1, an early diastolic sound, and a low-pitched, mid-diastolic rumble best heard at the cardiac apex. Arterial blood gas analysis on room air reveals:

$\text{pH}$: $7.30$
$\text{pCO}_2$: $55\text{ mm Hg}$
$\text{pO}_2$: $55\text{ mm Hg}$
$\text{HCO}_3^-$: $26\text{ mEq/L}$

In addition to noninvasive positive pressure ventilation, which of the following is the most appropriate next step in pharmacologic management for this patient?

A 65-year-old man suddenly collapses while walking in the hospital hallway. A physician is the first to arrive and finds the patient unresponsive, with no normal breathing and no palpable carotid pulse. The physician immediately calls for help and requests a resuscitation cart. Arrange the following subsequent steps in the most appropriate chronological sequence for managing this patient's cardiac arrest, assuming the underlying rhythm is ventricular fibrillation.

Match each valvular heart disease with its most characteristic auscultatory physical exam finding.

A 32-year-old woman comes to the emergency department complaining of sudden-onset palpitations and mild shortness of breath that started 30 minutes ago. She has no significant past medical history. Her temperature is 37.0°C (98.6°F), blood pressure is 118/76 mmHg, pulse is 185/min, and respiratory rate is 18/min. Pulse oximetry is 99% on room air. An electrocardiogram reveals a regular, narrow-complex tachycardia with no discernible P waves. Assuming each subsequent intervention fails to terminate the arrhythmia and the patient remains hemodynamically stable until the final step, arrange the following management options in the correct sequential order from first to last according to standard treatment algorithms.

Match each clinical presentation of shock with its most characteristic invasive hemodynamic profile (Central Venous Pressure [CVP], Pulmonary Capillary Wedge Pressure [PCWP], Cardiac Index [CI], and Systemic Vascular Resistance [SVR]).

A 55-year-old male presents to the triage desk of the local hospital reporting progressive difficulty breathing that began two days ago. He states that he has been unable to sleep in his bed due to a feeling of suffocation and has been resting in a recliner chair. He also notes a new cough that occasionally produces pink, frothy sputum. Medical history is significant for essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Current medications include lisinopril, amlodipine, and metformin. Vital signs demonstrate a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $178/102$ mmHg, pulse of 112/min, and respiratory rate of 26/min. Pulse oximetry reveals an oxygen saturation of 89% on room air. On physical examination, the patient appears distressed and is using accessory muscles to breathe. Evaluation of the neck shows jugular venous distention up to the angle of the mandible while seated upright. Cardiac auscultation is notable for a regular, rapid rhythm and a low-frequency diastolic sound heard best at the cardiac apex. Lung auscultation reveals bilateral expiratory wheezes and fine crackles extending from the bases to the mid-lung zones. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

A 64-year-old woman presents to the emergency department with a 3-day history of progressively worsening shortness of breath and a dry cough. She has a 35-pack-year smoking history and a history of an anterior myocardial infarction 4 years ago. On physical examination, her blood pressure is 155/90 mmHg, heart rate is 102/min, and respiratory rate is 22/min. Oxygen saturation is 89% on room air. Lung auscultation reveals diffuse expiratory wheezes bilaterally and prolonged expiration. Cardiac auscultation reveals a regular rhythm with an audible S3 gallop. She has 2+ pitting edema in both lower extremities. Which of the following laboratory findings is most useful to differentiate the primary cause of this patient's respiratory symptoms from a chronic obstructive pulmonary disease (COPD) exacerbation?

A 62-year-old man presents with severe substernal chest pain. He is diagnosed with an acute ST-segment elevation myocardial infarction (STEMI). In the absence of immediate reperfusion therapy, electrocardiographic (ECG) changes in the affected leads typically evolve in a predictable chronological sequence. Arrange the following classic ECG findings in the chronological order of their appearance, from earliest to latest.