Cardiovascular System

Emergency medical services bring a 58-year-old male to the emergency department due to the abrupt onset of excruciating, tearing chest pain radiating to his interscapular region. He has a history of poorly controlled hypertension. Vital signs show a blood pressure of $215/115$ mm Hg in his right arm and $180/95$ mm Hg in his left arm. His heart rate is $112$/min. Physical examination reveals a faint early diastolic decrescendo murmur at the right upper sternal border. An initial portable chest radiograph demonstrates a widened mediastinum.

Arrange the following management steps in the optimal chronological sequence to minimize the risk of catastrophic complications and ensure appropriate definitive care.

A 64-year-old man arrives at the emergency department via ambulance with sudden-onset, severe "tearing" chest pain that radiates to his back. His blood pressure is 215/115 mm Hg in the right arm and 175/95 mm Hg in the left arm. His heart rate is 118/min and regular. Physical examination reveals a new early diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. Chest radiography demonstrates a widened mediastinum. The clinical team suspects an acute type A aortic dissection. Arrange the following steps in the correct order for the most appropriate management of this patient.

A 68-year-old man is evaluated in the cardiac intensive care unit on day 4 of an admission for an anterior ST-segment elevation myocardial infarction. He initially presented 14 hours after symptom onset and underwent primary percutaneous coronary intervention of the left anterior descending artery. Over the past hour, he has developed severe dyspnea, agitation, and diaphoresis. His medical history includes hypertension, type 2 diabetes mellitus, and a 45-pack-year smoking history with known chronic obstructive pulmonary disease.

Vital signs:
Temperature: 37.2°C (99.0°F)
Blood pressure: 82/54 mm Hg
Pulse: 124/min
Respirations: 28/min
Oxygen saturation: 87% on room air

Physical examination reveals cool, clammy extremities with 1+ bilateral pitting edema. Jugular venous pressure is estimated at 12 cm $H_2O$. Lung auscultation reveals bilateral basilar crackles and diffuse expiratory wheezing. Cardiac auscultation reveals a regular tachycardia and a new, harsh, grade 4/6 holosystolic murmur with a palpable thrill at the left lower sternal border.

Arterial blood gas analysis on room air:
pH: 7.27
$PaO_2$: 55 mm Hg
$PaCO_2$: 32 mm Hg
$HCO_3^-$: 14 mEq/L

A pulmonary artery catheter is placed, yielding the following oxygen saturation ($S_vO_2$) data:

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

A 59-year-old male is brought to the emergency department by his spouse due to the sudden onset of crushing substernal chest pain that began 1 hour ago. He also reports profound weakness and diaphoresis. His medical history is significant for type 2 diabetes mellitus and hypertension. His current temperature is 37.1°C (98.8°F), blood pressure is 80/50 mmHg, heart rate is 110/min, and respiratory rate is 20/min. Pulse oximetry shows 95% on room air. On physical examination, the patient appears pale and diaphoretic. Jugular venous pulsation is visible 8 cm above the sternal angle. The lungs are clear to auscultation bilaterally with no wheezes or crackles. Cardiac auscultation reveals a regular tachycardia with no murmurs, rubs, or gallops. The extremities are cool and clammy with delayed capillary refill. Laboratory studies show a serum bicarbonate of 18 mEq/L and a lactate level of 4.5 mmol/L. An ECG reveals 3-mm ST-segment elevations in leads II, III, and aVF, as well as reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most appropriate next step in the management of this patient's hemodynamic instability?

During a routine follow-up appointment, a $69$-year-old man is evaluated in the outpatient clinic for a $1$-month history of steadily increasing abdominal girth and swelling in both legs. He has a known history of severe chronic obstructive pulmonary disease (COPD) and is adherent to an inhaled corticosteroid, a long-acting beta-agonist, and a long-acting muscarinic antagonist. He quit smoking $3$ years ago after a $45$-pack-year history. The patient reports worsening exertional fatigue but explicitly denies waking up gasping for air at night or having trouble breathing when lying flat. Vital signs reveal a blood pressure of $126/80$ mm Hg, a heart rate of $92$/min, and a respiratory rate of $18$/min. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination demonstrates distended neck veins. Lung auscultation reveals globally decreased breath sounds and a prolonged expiratory phase, with no crackles appreciated. Cardiac examination shows a prominent parasternal impulse and a holosystolic murmur at the left lower sternal border that augments in intensity during inspiration. Abdominal exam is notable for a tender, palpable liver edge $4$ cm below the right costal margin. Bilateral $3+$ pitting edema is present up to the knees. Which of the following interventions is most likely to slow the progression of this patient's underlying cardiac condition and improve long-term survival?

Match each dynamic auscultation or hemodynamic finding to the most likely underlying cardiovascular pathology.

A 55-year-old standardized patient is being utilized for a bedside physical examination OSCE. Examinees are required to evaluate jugular venous pulse (JVP) waveforms. Match each detailed description of a JVP waveform abnormality with the cardiovascular pathology that best explains its pathogenesis.

Match each structural heart pathology with its most characteristic physical examination findings.

A $74$-year-old woman presents to the emergency department with severe, sudden-onset shortness of breath that began $2$ hours ago. She has a history of type 2 diabetes mellitus, essential hypertension, and a $40$-pack-year smoking history. Current medications include amlodipine, metformin, and atorvastatin. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $185/105\text{ mmHg}$, pulse is $112\text{/min}$, and respirations are $28\text{/min}$. Pulse oximetry shows $88\%$ on room air. The patient appears anxious, diaphoretic, and is sitting upright. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates diffuse expiratory wheezing bilaterally with crackles at the lung bases. Cardiac auscultation reveals a regular tachycardia with a prominent third heart sound ($S_3$). Lower extremities show trace pitting edema. Which of the following is the most appropriate next step in management?

A 72-year-old man is brought to the emergency department due to the sudden onset of severe shortness of breath and a cough productive of pink, frothy sputum that began $1$ hour ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, mild chronic obstructive pulmonary disease (COPD), and poorly controlled hypertension. His current medications include lisinopril, metoprolol succinate, aspirin, and a tiotropium inhaler. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $220/120$ mmHg, pulse is $115$/min, and respirations are $32$/min. Pulse oximetry shows $84\%$ on room air. The patient is alert, oriented, and speaks in short, gasping phrases. Physical examination reveals use of accessory muscles of respiration. Auscultation of the lungs reveals diffuse, high-pitched expiratory wheezes bilaterally with no audible crackles. Cardiovascular examination reveals a regular tachycardia with a prominent $S_4$ gallop. There is no jugular venous distention or lower extremity edema. An arterial blood gas analysis on room air shows:

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

A 74-year-old woman is admitted to the hospital with a 4-week history of progressively worsening exertional dyspnea, increased abdominal girth, and bilateral lower extremity swelling. She has a history of chronic obstructive pulmonary disease (COPD), essential hypertension, and obesity ($BMI$ 36 kg/m $^2$). Her current medications include amlodipine, lisinopril, and a tiotropium inhaler. Blood pressure is 155/92 mm Hg, pulse is 92/min, and respirations are 20/min. Pulse oximetry is 94% on room air. Jugular venous pressure is estimated at 12 cm $H_2O$ and shows a prominent v wave. Lung auscultation reveals distant breath sounds with prolonged expiration and scattered end-expiratory wheezes. Cardiac examination shows a regular rhythm, a right-sided S3 gallop, and a 3/6 holosystolic murmur at the left lower sternal border that increases with inspiration. The abdomen is distended with shifting dullness, and there is 3+ pitting edema of the lower extremities extending to the thighs.

Laboratory testing reveals the following:
Brain natriuretic peptide (BNP): 650 pg/mL
Thyroid-stimulating hormone (TSH): 1.2 $\mu U/mL$ (normal: 0.4-4.0 $\mu U/mL$)
Free thyroxine (T4): 0.7 ng/dL (normal: 0.9-1.7 ng/dL)
Arterial blood gas (room air): pH 7.32, $pCO_2$ 55 mm Hg, $HCO_3^-$ 28 mEq/L

An echocardiogram shows a normal-sized left ventricle with an ejection fraction of 65%. The left atrium is severely enlarged (volume index 48 mL/m $^2$). The right ventricle is dilated and hypokinetic. Estimated pulmonary artery systolic pressure is 70 mm Hg. Tissue Doppler imaging of the mitral annulus shows an $E/e'$ ratio of 18 (normal $< 8$).

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

A $65$-year-old male is evaluated in the cardiac intensive care unit for undifferentiated shock. A pulmonary artery catheter is placed to obtain precise hemodynamic measurements. Match the following cardiac conditions with their most characteristic right heart catheterization hemodynamic profile.

Emergency medical services bring a 68-year-old male to the resuscitation bay due to acute-onset, unremitting respiratory distress. The patient's spouse reports that he was seated on the couch watching television when he suddenly began gasping for air and clutching his chest. Three days prior, he complained of 'terrible heartburn' but refused to seek medical care. His past medical history is significant for diet-controlled type 2 diabetes mellitus. On arrival, he is profoundly diaphoretic, cyanotic, and confused. Vital signs include a blood pressure of $82/56\text{ mmHg}$, heart rate of $128\text{/min}$, and respiratory rate of $30\text{/min}$. Pulse oximetry reads $84\%$ on high-flow oxygen. Physical examination reveals an elevated jugular venous pressure of $11\text{ cm H}_2\text{O}$. Cardiac auscultation is notable for a loud, blowing grade 4/6 holosystolic murmur heard best at the apex with radiation to the left axilla. Pulmonary examination reveals coarse crackles extending up to the apices bilaterally. An emergent 12-lead electrocardiogram demonstrates deep Q waves and T-wave inversions in leads II, III, and aVF. Which of the following is the most appropriate next step in the management of this patient?

Match each classic electrocardiogram (ECG) finding with its most likely associated cardiovascular condition or electrolyte disturbance.

A $70$-year-old man is brought to the emergency department due to sudden-onset severe shortness of breath, generalized weakness, and confusion that developed over the past $4$ hours. His medical history is significant for an inferior ST-elevation myocardial infarction $5$ days ago (for which he presented late and was managed medically), severe chronic obstructive pulmonary disease (COPD), bipolar I disorder, and chronic kidney disease.

On presentation, the patient is lethargic and oriented only to person. Temperature is $35.8^{\circ}\text{C}$ ($96.4^{\circ}\text{F}$), blood pressure is $82/52\text{ mmHg}$, heart rate is $118\text{/min}$, and respiratory rate is $28\text{/min}$. Oxygen saturation is $85\%$ on room air. Physical examination reveals distended neck veins up to the angle of the mandible while sitting at a $45$-degree angle. Chest auscultation demonstrates bilateral crackles extending to the mid-lung fields and diffuse expiratory wheezes. Cardiac auscultation reveals tachycardia with a new, harsh, holosystolic murmur heard best at the apex with radiation to the axilla. His extremities are cool and clammy with $2+$ bilateral pitting edema.

Laboratory studies show:
Leukocyte count: $12,500\text{/mm}^3$
Serum sodium: $131\text{ mEq/L}$
Serum potassium: $4.9\text{ mEq/L}$
Serum chloride: $96\text{ mEq/L}$
Serum bicarbonate: $14\text{ mEq/L}$
Blood urea nitrogen: $55\text{ mg/dL}$
Serum creatinine: $2.6\text{ mg/dL}$ (baseline $1.3\text{ mg/dL}$)
Serum lactate: $6.2\text{ mmol/L}$

Arterial blood gas on room air:
pH: $7.26$
$\text{PaCO}_2$: $29\text{ mmHg}$
$\text{PaO}_2$: $54\text{ mmHg}$

A sputum culture collected three days ago at his primary care clinic for a mild chronic cough has grown *Streptococcus pneumoniae*, which is fully susceptible to amoxicillin. His family mentions he has been profoundly depressed over the past three weeks and urgently requests he be started on fluoxetine.

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

A $69$-year-old man presents to the clinic complaining of a persistent dry cough, progressive shortness of breath on exertion, and worsening fatigue over the last two months. He also notes new-onset anxiety and difficulty sleeping due to his respiratory distress. His past medical history is significant for ischemic cardiomyopathy with a reduced ejection fraction and recurrent symptomatic sustained ventricular tachycardia, for which he takes amiodarone, lisinopril, carvedilol, escitalopram, and rivaroxaban. He has a $10$-pack-year smoking history but quit $15$ years ago. Vital signs include a blood pressure of $112/68\text{ mmHg}$, a heart rate of $64/\text{min}$, a respiratory rate of $22/\text{min}$, and an oxygen saturation of $91\%$ on ambient air. Physical examination reveals fine, late-inspiratory crackles at both lung bases. The jugular venous pressure is $6\text{ cm H}_2\text{O}$. There is no lower extremity edema. Laboratory studies show a leukocyte count of $8,200/\text{mm}^3$, a serum thyroid-stimulating hormone (TSH) level of $8.5\text{ \mu U/mL}$ (normal: $0.4-4.0\text{ \mu U/mL}$), and a free thyroxine (T4) level of $0.6\text{ ng/dL}$ (normal: $0.8-1.8\text{ ng/dL}$). His B-type natriuretic peptide (BNP) level is $145\text{ pg/mL}$ (similar to a baseline of $150\text{ pg/mL}$ three months ago). An electrocardiogram demonstrates normal sinus rhythm with a QTc interval of $475\text{ ms}$. High-resolution computed tomography of the chest reveals peripheral, bilateral ground-glass opacities with associated septal thickening. Which of the following is the most appropriate next step in the management of this patient?

A series of critically ill patients presenting with hypotension and tachycardia undergo pulmonary artery catheterization for hemodynamic monitoring in the intensive care unit. Match each specific hemodynamic profile obtained (Profiles 1 through 4) with the most likely underlying cardiovascular or cardiopulmonary pathology.

(Reference ranges: Right atrial [RA] pressure 2-8 mmHg; Pulmonary artery [PA] pressure 15-30/4-12 mmHg; Pulmonary capillary wedge pressure [PCWP] 6-12 mmHg; Cardiac index [CI] 2.5-4.0 L/min/m²).

A 69-year-old man presents to the emergency department complaining of progressively worsening shortness of breath over the past 2 days. His medical history is significant for chronic obstructive pulmonary disease, essential hypertension, and a myocardial infarction 5 years ago. The patient reports a cough productive of clear sputum and states he has been sleeping in his recliner chair because lying flat makes him feel as though he is suffocating. His temperature is 37.0 C (98.6 F), blood pressure is 168/96 mmHg, pulse is 108/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. On physical examination, the patient is in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation demonstrates bilateral end-expiratory wheezes and prominent crackles in the lower two-thirds of both lung fields. Cardiac auscultation reveals a regular tachycardia with a distinct third heart sound (S3). The jugular venous pressure is 12 cm H2O. Which of the following findings is most likely to be present on this patient's chest radiograph?

A 58-year-old man presents to the emergency department with sudden-onset, severe "tearing" chest pain that radiates to his back. His blood pressure is 210/115 mm Hg in his right arm and 175/90 mm Hg in his left arm. His heart rate is 112/min. Physical examination reveals a diastolic decrescendo murmur at the right sternal border. An electrocardiogram shows sinus tachycardia, and a portable chest x-ray reveals a widened mediastinum. The physician suspects an acute aortic dissection.

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

A $74$-year-old woman is brought to the emergency department from a skilled nursing facility due to progressive confusion, shortness of breath, and decreased urine output over the last $48$ hours. She has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, severe chronic obstructive pulmonary disease (COPD), and stage III chronic kidney disease. Her temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $82/54$ mm Hg, pulse is $118$/min, and respirations are $28$/min. Pulse oximetry shows $85\%$ on room air. Physical examination reveals a lethargic patient in moderate respiratory distress. The jugular venous pressure is estimated at $14$ cm $H_2O$. Chest auscultation reveals bilateral basilar crackles and diffuse expiratory wheezes with a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia and a prominent third heart sound (S3). The extremities are cool and mottled, with 2+ bilateral pitting edema extending to the knees. Laboratory studies show a leukocyte count of $11,200$/mm $^3$, a blood urea nitrogen of $48$ mg/dL, and a serum creatinine of $2.3$ mg/dL (baseline $1.4$ mg/dL). An arterial blood gas on room air reveals a pH of $7.22$, $PaCO_2$ of $60$ mm Hg, $PaO_2$ of $50$ mm Hg, and $HCO_3^-$ of $24$ mEq/L. Which of the following is the most appropriate initial management for this patient?