Cardiovascular System

A 68-year-old woman is brought to the emergency department by her family due to sudden-onset, severe shortness of breath that awoke her from sleep 2 hours ago. She reports feeling as though she is "drowning" and has a prominent cough producing frothy sputum. Her medical history is significant for long-standing bronchial asthma, poorly controlled essential hypertension, and osteoarthritis. Current medications include inhaled budesonide-formoterol, amlodipine, and diclofenac. Upon arrival, her blood pressure is 225/120 mm Hg, heart rate is 118/min, respiratory rate is 32/min, and oxygen saturation is 84% on room air. The patient is diaphoretic, sitting bolt upright, and using accessory muscles of respiration. Lung auscultation reveals diffuse, loud expiratory wheezing bilaterally with faint crackles at the lung bases. Cardiac examination is notable for regular tachycardia and an S4 gallop; an S3 gallop is not appreciated due to the loud breath sounds. A bedside point-of-care ultrasound reveals bilateral B-lines in all lung zones. Electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. Which of the following is the most appropriate initial pharmacological therapy for this patient?

Match the following classic electrocardiographic (ECG) findings with their most likely underlying structural or electrophysiologic pathology.

An emergency medical services team brings a $73$-year-old man to the acute care bay with severe respiratory distress that began abruptly two hours ago. The patient is visibly agitated, diaphoretic, and cannot speak in full sentences. His wife reports that he has a history of essential hypertension, osteoarthritis, a $40$-pack-year smoking habit, and treatment-resistant depression for which a new medication (phenelzine) was initiated three weeks ago.

Vital signs:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Blood pressure: $192/108\text{ mm Hg}$
Heart rate: $118\text{/min}$
Respiratory rate: $28\text{/min}$
Oxygen saturation: $86\%$ on room air

Physical examination reveals prominent jugular venous distention. Lung auscultation yields diffuse, high-pitched expiratory wheezing bilaterally with prolonged expiratory phases. Cardiac examination reveals a regular tachycardia with a prominent extra heart sound heard just after $\text{S}_2$ at the cardiac apex. The abdomen is distended with a palpable liver edge $4\text{ cm}$ below the right costal margin.

Arterial blood gas analysis on room air shows:
$\text{pH}$: $7.49$
$\text{pCO}_2$: $29\text{ mm Hg}$
$\text{pO}_2$: $54\text{ mm Hg}$
$\text{HCO}_3^-$: $22\text{ mEq/L}$

Chest radiography reveals bilateral perihilar opacities and blunting of the costophrenic angles.

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

An $82$-year-old man arrives at the emergency department accompanied by his daughter due to a $3$-day history of progressively worsening difficulty breathing. He states he cannot sleep lying flat and requires three pillows at night. Medical history is significant for coronary artery disease with a previous myocardial infarction, type 2 diabetes mellitus, and severe chronic obstructive pulmonary disease (COPD). His current medications include lisinopril, metoprolol succinate, and a daily tiotropium inhaler.

Vital signs are:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Blood pressure: $158/92\text{ mm Hg}$
Pulse: $115/\text{min}$
Respirations: $28/\text{min}$
Oxygen saturation: $85\%$ on room air

Physical examination shows a patient in acute respiratory distress using accessory muscles. The jugular venous pressure is distended to $12\text{ cm H}_2\text{O}$. Auscultation of the chest reveals diminished breath sounds with prolonged expiration, diffuse expiratory wheezes, and dullness to percussion at the lung bases. Cardiac examination reveals a regular tachycardia, a normal $S_1$ and $S_2$, and an extra low-frequency heart sound occurring just after $S_2$.

Laboratory and arterial blood gas (room air) results are as follows:

A portable chest radiograph displays an enlarged cardiac silhouette, perihilar alveolar opacities, and bilateral blunting of the costophrenic angles. The patient is placed on noninvasive positive-pressure ventilation.

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

A 58-year-old man is evaluated in the emergency department for sudden-onset, severe, "tearing" chest pain that radiates to his back. The pain began one hour ago while he was lifting heavy boxes. He has a history of poorly controlled hypertension. His temperature is 37.2°C (99.0°F), pulse is 112/min, and respirations are 22/min. Blood pressure is 215/115 mm Hg in the right arm and 175/95 mm Hg in the left arm. Physical examination reveals a new early diastolic decrescendo murmur heard best at the right upper sternal border. An electrocardiogram shows sinus tachycardia and left ventricular hypertrophy without acute ischemic changes. Chest radiography reveals a widened mediastinum.

Arrange the following patient management steps in the most appropriate chronological order.

A $58$-year-old man is brought to the emergency department complaining of sudden-onset, severe, "tearing" chest pain that radiates to his back. He appears diaphoretic and is in acute distress. Vital signs show a blood pressure of $210/115$ mmHg in the right arm and $175/95$ mmHg in the left arm, a heart rate of $112$/min, and a respiratory rate of $20$/min. An electrocardiogram shows sinus tachycardia with no ST-segment or T-wave abnormalities. A portable chest x-ray reveals a widened mediastinum. Arrange the following steps in the most appropriate chronological order for the acute management of this patient.

A $64$-year-old woman is brought to the triage desk by her family due to extreme lightheadedness and a progressive inability to catch her breath over the past three days. She has a medical history significant for severe rheumatoid arthritis and chronic obstructive pulmonary disease. Two weeks ago, she experienced a self-limiting febrile viral illness. On examination, the patient appears visibly distressed and diaphoretic. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $118\text{/min}$, respiratory rate of $24\text{/min}$, and blood pressure of $86/60\text{ mmHg}$. During normal inspiration, her systolic blood pressure decreases by $18\text{ mmHg}$. Jugular venous distention is prominent up to the angle of the mandible while she sits upright. Pulmonary auscultation reveals globally distant breath sounds but no crackles or active wheezing. Cardiac auscultation is limited by an increased anterior-posterior chest diameter, and no murmurs are appreciated. An electrocardiogram demonstrates a regular tachycardia with low-voltage QRS complexes in the limb leads and shifting electrical axes. Which of the following is the most appropriate next step in management?

Match the following structural heart diseases with their characteristic dynamic auscultation findings elicited during physical maneuvers.

Emergency medical services transport a $62$-year-old male patient to the acute care unit due to two hours of unrelenting, oppressive chest discomfort that radiates to his jaw. He also reports profound diaphoresis and severe lightheadedness. His medical background includes type 2 diabetes mellitus, hyperlipidemia, and a $40$-pack-year smoking history. Upon arrival, his temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), his blood pressure is remarkably low at $82/52\text{ mm Hg}$, pulse is $52\text{ beats/min}$, and respirations are $18\text{ breaths/min}$. Pulse oximetry reveals an oxygen saturation of $96\%$ on room air. Physical evaluation shows prominent jugular venous pulsations at $10\text{ cm}$ above the sternal angle while seated at $45$ degrees. Pulmonary auscultation indicates completely clear breath sounds bilaterally without any wheezes or crackles. The cardiac exam reveals a regular bradycardic rhythm with a right-sided S3 gallop, but no significant murmurs. An electrocardiogram is rapidly acquired and demonstrates $3\text{ mm}$ ST-segment elevations in leads II, III, and aVF, along with 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?

A $32$-year-old man comes to the emergency department because of a $5$-day history of high fever, profound fatigue, and severe joint pains. His past medical history is significant for severe opioid use disorder, and he reports injecting heroin daily. His temperature is $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), blood pressure is $114/68 \text{ mm Hg}$, pulse is $118/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination shows multiple needle track marks in both antecubital fossae. Cardiovascular auscultation reveals a regular tachycardia and a grade $3/6$ holosystolic murmur at the left lower sternal border; the murmur's intensity increases with inspiration. The lungs are clear to auscultation bilaterally. Small, linear, dark-red hemorrhages are noted beneath the nail beds of his right hand. Three sets of blood cultures are obtained. Which of the following is the most appropriate next step in management?

A $54$-year-old male visitor suddenly collapses in the main hospital concourse. He is unresponsive, apneic, and pulseless. The rapid response team arrives within two minutes, initiates high-quality cardiopulmonary resuscitation (CPR), and attaches a manual defibrillator. The monitor reveals coarse ventricular fibrillation. No vascular access is currently in place. Place the following resuscitative actions in the correct chronological order of execution as dictated by the Advanced Cardiac Life Support (ACLS) pulseless arrest algorithm. Assume the patient remains in refractory ventricular fibrillation throughout the entire resuscitation effort.

A 68-year-old woman is evaluated in the surgical telemetry unit on postoperative day 3 following an uncomplicated partial colectomy for early-stage colon cancer. Over the last 4 hours, she has developed severe shortness of breath and a cough productive of pink, frothy sputum. During her surgery and the immediate postoperative period, she received a total of 6 liters of intravenous crystalloids. Her medical history includes hypertension, osteoarthritis, and a 40-pack-year smoking history.

Her temperature is 37.7°C (99.9°F), blood pressure is 180/100 mmHg, pulse is 115/min, and respirations are 28/min. Pulse oximetry is 86% on room air.

Physical examination reveals a patient in moderate respiratory distress, using accessory muscles of respiration. Jugular venous distention is present to the angle of the mandible while the patient is sitting at a 45-degree angle. Lung auscultation reveals diffuse bilateral expiratory wheezes and crackles extending halfway up both lung fields. Cardiac auscultation reveals a regular tachycardia with a prominent third heart sound ($S_3$).

Arterial blood gas analysis on room air shows:
pH: 7.28
$PaCO_2$: 56 mmHg
$PaO_2$: 54 mmHg
$HCO_3^-$: 25 mEq/L

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

A 75-year-old man is brought to the emergency department after a syncopal episode at home. On arrival, he is lethargic and complains of lightheadedness and mild chest heaviness. His blood pressure is 82/50 mm Hg, and his pulse is 32/min. An electrocardiogram reveals sinus bradycardia with no evidence of acute ischemia. The patient is immediately placed on a continuous cardiac monitor and receives supplemental oxygen. Arrange the following interventions in the correct sequential order for the stepwise management of this hemodynamically unstable patient, from immediate acute stabilization to definitive long-term therapy.

Transported via emergency medical services with severe, acute-onset respiratory distress, a 71-year-old individual is evaluated in the resuscitation bay. The patient has a history of a remote myocardial infarction and a 35-pack-year smoking history. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 172/98 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Oxygen saturation is 85% on room air.

Physical examination reveals a patient sitting upright and using accessory muscles of respiration. The jugular venous pressure is elevated to 11 cm $H_2O$. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. Lung auscultation demonstrates diffuse, bilateral end-expiratory wheezing without focal crackles. Bilateral trace pitting edema is present in the lower extremities.

Arterial blood gas analysis on room air shows:
$pH$: 7.26
$PaCO_2$: 58 mm Hg
$PaO_2$: 52 mm Hg
$HCO_3^-$: 25 mEq/L

Laboratory evaluation reveals a leukocyte count of 8,200/mm³ and a thyroid-stimulating hormone (TSH) level of 5.8 mU/L (normal: 0.4-4.0 mU/L).

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

A 73-year-old man presents to the primary care clinic reporting progressively worsening swelling in his legs and an uncomfortable sensation of fullness in his abdomen over the last six weeks. He also notes that he now becomes breathless after walking just one block, which represents a significant decline from his previous baseline. His medical history is significant for chronic bronchitis and a 50-pack-year smoking history. His only current medication is an albuterol inhaler used as needed. His pulse is 95/min, respiratory rate is 20/min, and blood pressure is 120/78 mmHg. Pulse oximetry shows an oxygen saturation of 87% on room air. Physical examination reveals marked jugular venous distention with prominent 'v' waves. Cardiac auscultation demonstrates a prominent right ventricular heave and a grade 3/6 holosystolic murmur at the lower left sternal border that intensifies with deep inspiration. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse rhonchi, but no crackles are heard. The liver is palpated 4 cm below the right costal margin and is tender. There is 3+ pitting edema of the lower extremities extending up to the knees. Which of the following interventions is most likely to prolong this patient's survival?

A 65-year-old hospitalized patient is evaluated for acute-onset hypotension and signs of poor organ perfusion. The intensive care team places a pulmonary artery (Swan-Ganz) catheter to determine the specific etiology of the shock state. Match each set of central hemodynamic parameters obtained from the catheterization to the most likely underlying clinical condition.

An emergency department physician evaluates a 61-year-old female for rapidly worsening respiratory distress. The patient was awakened from sleep two hours ago with a severe sensation of smothering. Her past medical history is significant for a 45-pack-year smoking habit, hyperlipidemia, and poorly controlled hypertension. Current vital signs include a temperature of $37.1^\circ$ C ($98.8^\circ$ F), blood pressure of $192/110$ mmHg, pulse of $118$/min, and respiratory rate of $30$/min. Pulse oximetry shows an oxygen saturation of $85\%$ on room air.

Physical examination reveals a diaphoretic patient speaking in one-word sentences and using accessory muscles of respiration. Jugular venous pulsation is visible at $10$ cm above the sternal angle. Auscultation of the lungs demonstrates diffuse, bilateral expiratory wheezing with a prolonged expiratory phase, alongside rare basilar crackles. Cardiac auscultation reveals a regular, rapid rhythm with an audible S4 gallop, but no murmurs are appreciated. The lower extremities exhibit trace bilateral pretibial edema.

Bedside arterial blood gas analysis on room air reveals:

A portable chest radiograph displays cephalization of the pulmonary vessels, peribronchial cuffing, and indistinct vascular margins, without lobar consolidation or pleural effusions.

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

Emergency medical services bring a somnolent $74$-year-old female to the resuscitation bay following the abrupt onset of severe respiratory distress and palpitations at her nursing home two hours ago. The patient has a documented medical history of severe chronic obstructive pulmonary disease, hypertension, and osteoarthritis. Upon arrival, her blood pressure is $78/52 \text{ mmHg}$, pulse is $152/\text{min}$ and irregularly irregular, and respiratory rate is $30/\text{min}$. Oxygen saturation is $85\%$ on room air.

Physical examination reveals a diaphoretic, lethargic patient with pale, cool extremities. Jugular venous pressure is markedly elevated up to the angle of the mandible. Auscultation of the lungs demonstrates diffuse expiratory wheezing and coarse bilateral inspiratory crackles up to the mid-lung fields. Cardiac auscultation reveals a rapid, irregular rhythm with no distinct murmurs.

An arterial blood gas on room air shows:
$pH$: $7.21$
$PaCO_2$: $64 \text{ mmHg}$
$PaO_2$: $52 \text{ mmHg}$
$HCO_3^-$: $25 \text{ mEq/L}$

A 12-lead electrocardiogram demonstrates a narrow-complex tachycardia with an irregularly irregular R-R interval and absent P waves.

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

An unaccompanied 72-year-old woman is triaged in the acute care unit after experiencing 48 hours of constant chest "fluttering" and progressive exertional breathlessness. She has a known medical history of severe chronic obstructive pulmonary disease (COPD), for which she uses a daily umeclidinium-vilanterol inhaler, and essential hypertension. Upon evaluation, her vital signs are:

- Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
- Blood pressure: $124/82\text{ mm Hg}$
- Heart rate: $148/\text{min}$ and irregularly irregular
- Respiratory rate: $22/\text{min}$
- Oxygen saturation: $95\%$ on room air

Physical examination reveals a completely irregular cardiac rhythm with absent murmurs, rubs, or gallops. Pulmonary auscultation reveals a prolonged expiratory phase globally, but no focal crackles, rhonchi, or active wheezing are appreciated. There is no jugular venous distension or peripheral edema.

Initial laboratory testing yields the following results:
- Leukocyte count: $7,200/\text{mm}^3$
- Thyroid-stimulating hormone (TSH): $2.8\text{ }\mu\text{U/mL}$ (Normal: $0.4-4.0\text{ }\mu\text{U/mL}$)
- Free T4: $1.1\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)

Arterial blood gas (room air):
- pH: $7.48$
- PaCO $_2$: $31\text{ mm Hg}$
- PaO $_2$: $76\text{ mm Hg}$

A 12-lead electrocardiogram demonstrates an irregularly irregular rhythm with narrow QRS complexes and an absence of discernible P waves.

Which of the following is the most appropriate initial pharmacologic intervention for this patient's current condition?

A $67$-year-old woman is evaluated in the cardiac intensive care unit after a sudden episode of unresponsiveness. She was admitted $4$ days ago for an acute anterior ST-segment elevation myocardial infarction and underwent successful percutaneous coronary intervention of the left anterior descending artery. Her medical history is notable for hypertension, type 2 diabetes mellitus, and a $40$-pack-year smoking history. Following the episode of unresponsiveness, she quickly regains consciousness but reports feeling extremely weak and lightheaded. Her temperature is $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure is $72/40$ mm Hg, pulse is $126$/min and regular, and respirations are $26$/min. Pulse oximetry is $93\%$ on room air. Physical examination reveals cold, clammy extremities and significant jugular venous distention. The apical impulse is not palpable. Lung fields are clear to auscultation bilaterally. Heart sounds are distant, and no murmurs, rubs, or gallops are appreciated. An electrocardiogram shows sinus tachycardia and persistent ST-segment elevations in the anterior leads, unchanged from the post-intervention electrocardiogram. Arterial blood gas analysis on room air reveals a pH of $7.24$, pCO $_2$ of $32$ mm Hg, and pO $_2$ of $68$ mm Hg. Which of the following is the most appropriate next step in the management of this patient?