Cardiovascular System

A 68-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the emergency department with palpitations, fatigue, and mild shortness of breath that began 3 days ago. His blood pressure is 125/80 mm Hg, heart rate is 142/min and irregularly irregular, and respiratory rate is 18/min. An electrocardiogram confirms atrial fibrillation with rapid ventricular response. The physician decides to pursue an early rhythm control strategy to alleviate his persistent symptoms.

Arrange the following management steps in the most appropriate chronological sequence for this patient:

An emergency medical services team brings a $76$-year-old female resident of a skilled nursing facility to the hospital because of severe respiratory distress that awakened her from sleep. The patient is unable to speak in full sentences and is actively coughing up pink, frothy sputum. Her past medical history is notable for systemic hypertension, osteoarthritis, and a $30$-pack-year history of smoking (quit $15$ years ago). Two weeks ago, she was prescribed daily naproxen for worsening knee pain.

Upon arrival, her temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure is $192/108\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $30/\text{min}$. Oxygen saturation is $84\%$ on room air.

Physical examination displays prominent use of accessory respiratory muscles. The internal jugular vein is visibly distended while the patient is sitting upright. Chest auscultation reveals diffuse expiratory wheezes and coarse crackles extending halfway up both lung fields. Cardiac examination is significant for a rapid, regular rhythm with a distinct low-frequency sound heard just after $S_2$.

An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes.

Which of the following is the most appropriate initial pharmacological therapy for this patient?

Match the following structural heart pathologies with their characteristic auscultatory findings and their specific responses to physiological maneuvers.

A 28-year-old pregnant woman (G1P0 at 26 weeks gestation) is evaluated in the acute care clinic for a 2-hour history of severe breathlessness, palpitations, and an inability to lie flat. She recently immigrated from Southeast Asia and reports experiencing recurrent, untreated sore throats during her childhood.

Current vital signs reveal a temperature of 37.1°C (98.8°F), blood pressure of 112/68 mmHg, and a respiratory rate of 26/min. Her pulse is 135/min and irregularly irregular. Pulse oximetry demonstrates an oxygen saturation of 91% on ambient air.

Physical examination highlights prominent jugular venous distention. Cardiac auscultation is notable for a loud first heart sound ($S_1$), a sharp high-pitched sound immediately following the second heart sound ($S_2$), and a low-pitched, rumbling diastolic murmur heard optimally at the cardiac apex. Pulmonary auscultation reveals bilateral crackles extending up to the mid-lung fields.

A 12-lead electrocardiogram confirms an irregularly irregular rhythm characterized by narrow QRS complexes and an absence of distinct P waves.

Which of the following is the most appropriate initial pharmacological step to alleviate this patient's acute respiratory distress?

A $66$-year-old man is evaluated in the emergency department for sudden, severe difficulty breathing that awoke him from sleep. The patient states he felt as though he were suffocating and developed a cough producing frothy sputum. His past medical history is notable for a $45$-pack-year smoking habit and an anterior ST-segment elevation myocardial infarction three years prior, for which he underwent percutaneous coronary intervention. His daily medications include low-dose aspirin, carvedilol, and rosuvastatin, but he admits to running out of these medications two weeks ago.

Vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $172/96\text{ mmHg}$, heart rate of $112/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry shows an oxygen saturation of $87\%$ on room air.

On physical examination, the patient is in severe respiratory distress and utilizing accessory muscles. Jugular venous distention is prominent up to the angle of the mandible while the patient is sitting upright. Pulmonary auscultation demonstrates prolonged expiratory phases with loud, diffuse wheezing in all lung fields, alongside bilateral crackles at the lung bases. Cardiac auscultation reveals a regular, rapid rhythm with a distinct low-frequency diastolic sound heard just after S2. There is $2+$ pitting edema extending to the mid-calves bilaterally.

An arterial blood gas analysis on room air shows:
pH: $7.28$
PaCO $_2$: $56\text{ mmHg}$
PaO $_2$: $58\text{ mmHg}$
HCO $_3^-$: $25\text{ mEq/L}$

Which of the following is the most appropriate initial pharmacologic step in managing this patient's condition?

A 32-year-old woman presents to the emergency department complaining of sudden-onset, rapid heart palpitations and mild chest fullness that began 30 minutes ago while sitting at her desk. She denies syncope, severe shortness of breath, or chest pain. Her blood pressure is 115/75 mm Hg, pulse is 185/min, and respiratory rate is 16/min. Physical examination reveals regular, rapid heart sounds with no murmurs. An electrocardiogram demonstrates a regular, narrow-complex tachycardia with no discernible P waves.

Arrange the following interventions in the most appropriate sequential order for managing this patient's arrhythmia, assuming each preceding step fails to restore sinus rhythm.

A 54-year-old woman with a history of metastatic breast cancer is brought to the emergency department due to progressive, severe dyspnea and lightheadedness over the last 48 hours. She is diaphoretic and tachypneic. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 82/52 mm Hg (which decreases to 68/46 mm Hg during inspiration), heart rate of 122/min, and respiratory rate of 26/min. Physical examination reveals jugular venous distention to the angle of the mandible while sitting at a 45-degree angle. Heart sounds are distant. Lungs are clear to auscultation bilaterally. Electrocardiography demonstrates sinus tachycardia with low QRS voltage and beat-to-beat variation in the QRS complex amplitude. Arrange the following management steps in the most appropriate chronological sequence for this patient's acute presentation.

Match each classic cardiac auscultation finding with the valvular pathology it most accurately describes.

An $82$-year-old man is evaluated on postoperative day $2$ following an elective right total hip arthroplasty due to the sudden onset of shortness of breath and mild agitation. His medical history is significant for a $35$-pack-year smoking history with known chronic obstructive pulmonary disease (COPD), major depressive disorder managed with citalopram, and diet-controlled type 2 diabetes mellitus. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $168/94\text{ mmHg}$, heart rate is $114/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $87\%$ on room air. Physical examination reveals an elevated jugular venous pressure of $11\text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. Lung auscultation demonstrates diffuse, bilateral expiratory wheezes. The surgical incision is clean and intact. The lower extremities exhibit 2+ bilateral pitting edema. Initial laboratory studies show a normal complete blood count and a basic metabolic panel within normal limits. Thyroid studies reveal a thyroid-stimulating hormone (TSH) level of $1.4\text{ }\mu\text{U/mL}$ (normal: $0.4-4.0\text{ }\mu\text{U/mL}$) and a free T4 level of $0.6\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$). Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of a hypotensive patient with their most likely corresponding hemodynamic profile obtained via pulmonary artery catheterization. The parameters include central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), and systemic vascular resistance (SVR).

A 58-year-old man presents to the clinic with progressive abdominal swelling, lower extremity edema, and exertional fatigue over the past 4 months. He has a history of Hodgkin lymphoma, for which he received mantle field radiation therapy 20 years ago. He has no history of tobacco or alcohol use. Vital signs are within normal limits. Physical examination shows marked jugular venous distension; the jugular venous pressure paradoxically increases during inspiration. Lung fields are clear to auscultation bilaterally. Cardiac auscultation reveals a regular rhythm and a high-pitched, early diastolic sound at the left sternal border. The abdomen is distended with a positive fluid wave, and the liver edge is palpable 4 cm below the right costal margin. Bilateral lower extremities demonstrate 2+ pitting edema up to the knees. An electrocardiogram reveals low-voltage QRS complexes in the limb leads. Which of the following is the most likely primary mechanism underlying this patient's presentation?

A $65$-year-old man is brought to the emergency department due to the sudden onset of severe, tearing chest pain that radiates to his back. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $210/120\text{ mmHg}$ in the right arm and $170/95\text{ mmHg}$ in the left arm, pulse is $112/\text{min}$, and respirations are $20/\text{min}$. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. A portable chest radiograph shows a widened mediastinum. Acute ascending aortic dissection is strongly suspected. Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 65-year-old man is evaluated in the hospital on day 4 of admission for infective endocarditis. He initially presented with a 2-week history of fatigue, low-grade fever, and a new holosystolic murmur at the cardiac apex. A transthoracic echocardiogram obtained on admission demonstrated a $1.2$-cm vegetation on the posterior leaflet of the mitral valve with moderate mitral regurgitation. Empiric therapy with intravenous vancomycin and ceftriaxone was initiated. Today, final blood culture results from admission show growth of *Streptococcus gallolyticus* (formerly *Streptococcus bovis*) in all four bottles. Susceptibility testing confirms the organism is highly susceptible to penicillin (minimum inhibitory concentration $\leq 0.12$ $\mu$ g/mL) and ceftriaxone. The patient is currently afebrile and hemodynamically stable. His renal function is normal, and he has no known drug allergies.

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

A 68-year-old man is brought to the emergency department due to the sudden onset of crushing substernal chest pain, severe diaphoresis, and profound dizziness that began an hour ago. His past medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. His current blood pressure is 78/50 mm Hg, and his heart rate is 55/min. Respirations are 22/min, and oxygen saturation is 96% on room air. Physical examination reveals clear lungs bilaterally with no crackles or wheezes. The jugular veins are markedly distended. A standard 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF, along with reciprocal changes in leads I and aVL.

Arrange the following management steps in the most appropriate chronological sequence for the diagnostic evaluation, hemodynamic stabilization, and definitive treatment of this patient's condition.

Match each valvular heart disease with its most characteristic constellation of physical examination findings.

An 82-year-old woman arrives at the emergency department via ambulance due to the sudden onset of severe respiratory distress that began 3 hours ago. Her medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of 40%, diet-controlled type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD) for which she uses an as-needed bronchodilator. Yesterday, she was diagnosed with an uncomplicated urinary tract infection; urine culture results returned today showing *Escherichia coli* that is susceptible to all tested antibiotics, including the oral nitrofurantoin she is currently taking.

On arrival, her temperature is 37.2°C (99.0°F), blood pressure is 188/102 mm Hg, pulse is 114/min, and respirations are 28/min. Pulse oximetry shows 86% on room air. Physical examination reveals a patient in moderate distress, speaking in short sentences. The jugular venous pressure is estimated at 11 cm H2O. Chest auscultation reveals scattered expiratory wheezes and bilateral basilar crackles. Cardiac examination shows tachycardia with a regular rhythm and a distinct S3 gallop.

Laboratory results are as follows:
Leukocytes: 11,500/mm³
B-type natriuretic peptide: 1,350 pg/mL
Thyroid-stimulating hormone (TSH): 0.2 mU/L (normal: 0.5–5.0 mU/L)
Free thyroxine (T4): 0.6 ng/dL (normal: 0.9–1.7 ng/dL)

Arterial blood gas (on room air):
pH: 7.28
PaCO₂: 25 mm Hg
PaO₂: 55 mm Hg
HCO₃⁻: 11 mEq/L
Lactate: 4.2 mmol/L (normal: 0.5–1.0 mmol/L)

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

A 68-year-old man is evaluated in the outpatient clinic for worsening shortness of breath over the past week. He reports progressive difficulty walking short distances and a persistent, non-productive cough that is most prominent when he lies down to sleep. Medical history includes long-standing essential hypertension, obesity, and a 40-pack-year smoking history. Current medications are lisinopril and amlodipine. Vital signs are temperature $37.0^\circ C$, blood pressure $168/95 \text{ mm Hg}$, pulse $92\text{/min}$, and respirations $22\text{/min}$. Oxygen saturation is $92\%$ on room air. Physical examination reveals an obese man with mild respiratory effort. Jugular venous pressure is estimated at $9 \text{ cm H}_2\text{O}$ above the sternal angle. Pulmonary auscultation demonstrates bilateral end-expiratory wheezes and scattered bibasilar crackles. Cardiac examination reveals a regular rhythm with a distinct fourth heart sound (S4). Trace bilateral lower extremity edema is noted. Bedside spirometry indicates an $FEV_1/FVC$ ratio of $78\%$. Which of the following pathophysiologic mechanisms best explains this patient's current symptoms?

Paramedics bring a 59-year-old woman to the emergency department after she reported severe dizziness and near-syncope at home. For the past two weeks, she has experienced worsening fatigue and an inability to lie flat without profound breathlessness. She has a history of left-sided breast cancer treated with lumpectomy and radiation therapy eight years ago, as well as a 30-pack-year smoking history. Current vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $86/52\text{ mm Hg}$ (which decreases to $72/45\text{ mm Hg}$ upon inspiration), heart rate of $122\text{/min}$, and respiratory rate of $26\text{/min}$. Arterial blood gas analysis on room air shows a pH of $7.50$, PaCO $_2$ of $28\text{ mm Hg}$, and PaO $_2$ of $88\text{ mm Hg}$. Physical examination reveals distended neck veins while sitting upright. Pulmonary auscultation shows clear breath sounds bilaterally. Cardiac auscultation reveals muffled heart sounds and no discernible murmurs. Extremities are cool to the touch without pitting edema. A 12-lead electrocardiogram demonstrates sinus tachycardia with beat-to-beat variation in the QRS complex amplitude. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old female teacher presents to the urgent care clinic complaining of a suddenly 'racing heart' that began 30 minutes ago while she was grading papers. She denies chest pain, shortness of breath, or lightheadedness. Her blood pressure is 122/78 mm Hg, pulse is 175/min, and respiratory rate is 16/min. Oxygen saturation is 99% on room air. A 12-lead electrocardiogram demonstrates a regular, narrow-complex tachycardia with no discernible P waves. Assuming each subsequent step fails to terminate the arrhythmia, arrange the following therapeutic interventions in the correct stepwise order of administration for this patient.

A 29-year-old woman, G1P0 at $26$ weeks gestation, presents to the emergency department with progressively worsening shortness of breath, orthopnea, and intermittent blood-tinged sputum over the past two weeks. She recently emigrated from Southeast Asia and has had limited prenatal care. She is highly anxious but clearly states, "I want to do everything possible to keep my baby, no matter what happens to me. I refuse any procedure that will deliver my baby early." Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $105/65$ mmHg, heart rate of $122$/min, respiratory rate of $26$/min, and oxygen saturation of $92\%$ on room air. Physical examination reveals an elevated jugular venous pressure. Lung auscultation demonstrates diffuse bilateral expiratory wheezes and bibasilar crackles. Cardiac auscultation at the left lateral decubitus position reveals a loud S1, an early diastolic extra sound, and a low-pitched mid-diastolic rumble. Which of the following is the most appropriate management plan for this patient?