Cardiovascular System

Match each acute cardiovascular clinical presentation with its most characteristic pulmonary artery catheterization (hemodynamic) profile.

A 64-year-old man presents to his primary care physician complaining of a two-week history of progressively worsening shortness of breath. Initially, he only felt breathless when walking up an incline, but now he experiences it while walking on level ground. He also reports a new, dry cough that occurs mainly at night, which has prompted him to sleep in a recliner chair for the past three nights. His medical history includes essential hypertension and a 35-pack-year smoking history. His temperature is 37.0°C (98.6°F), blood pressure is 158/92 mm Hg, pulse is 88/min, and respiratory rate is 20/min. Physical examination reveals distention of the jugular veins while the patient is sitting at a 45-degree angle. Auscultation of the lungs demonstrates fine crackles at both lung bases that do not clear with coughing. Cardiac examination reveals a regular rate and rhythm with an extra, low-frequency heart sound occurring shortly after S2. Trace pitting edema is noted in both ankles.

Which of the following is the most likely underlying mechanism for this patient's clinical presentation?

A 74-year-old man presents to the emergency department at 3:00 AM with sudden-onset, severe shortness of breath and wheezing. He has a 45-pack-year smoking history, essential hypertension, and diet-controlled type 2 diabetes mellitus. He reports waking up gasping for air and states that his cough produces frothy sputum. Current medications include amlodipine and metformin. His temperature is 37.0°C (98.6°F), blood pressure is 210/115 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals use of accessory muscles of respiration. Lung auscultation demonstrates diffuse, bilateral end-expiratory wheezes with a prolonged expiratory phase. Cardiac examination reveals a sustained but non-displaced apical impulse and a prominent fourth heart sound (S4). Jugular venous pressure is estimated at 10 cm H2O. There is no lower extremity edema. A chest radiograph reveals peribronchial cuffing, indistinct pulmonary vascular margins, and a normal cardiothoracic ratio. An electrocardiogram demonstrates normal sinus rhythm with voltage criteria for left ventricular hypertrophy. Which of the following pathophysiologic mechanisms is the primary driver of this patient's current respiratory distress?

A 58-year-old man presents to the emergency department with acute-onset, crushing substernal chest pain radiating to his left jaw that began 45 minutes ago. He is diaphoretic and appears distressed. Vital signs show a blood pressure of 145/90 mm Hg and a heart rate of 92/min. Arrange the following steps in the most appropriate chronological order for the initial diagnosis and definitive management of this patient's condition.

A 61-year-old man visits an outpatient clinic due to a three-week history of progressively worsening fatigue, a persistent nighttime cough, and swelling in both ankles. He has not seen a healthcare provider in several years. The patient notes that he recently started sleeping in a recliner chair because lying flat in bed makes him feel as though he is suffocating. His medical history is notable for long-standing, untreated hypertension. Vital signs show a temperature of 37.0°C (98.6°F), pulse of 96/min, respirations of 18/min, and blood pressure of 168/94 mmHg. Examination reveals 2+ pitting edema up to the mid-calves bilaterally. Cardiac auscultation demonstrates a low-frequency extra heart sound occurring shortly after S2. Pulmonary auscultation reveals fine crackles at both lung bases. Which of the following is the most appropriate initial medication to alleviate this patient's acute symptoms?

Match the following classic physical examination findings (heart murmurs and sounds) with their most likely underlying valvular pathology.

During a hospital night shift, a physician assesses a newly admitted patient reporting worsening breathlessness and the inability to sleep lying flat. The patient's medical background includes coronary artery stenting three years ago and a lengthy history of cigarette smoking. Bedside evaluation demonstrates elevated jugular venous pressure, a prominent S3 gallop, and bilateral basilar crackles. Oxygen saturation is 90% on ambient air. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A $24$-year-old male is being evaluated in the cardiology clinic after experiencing an episode of syncope while playing basketball. He has a family history of a sudden, unexplained death in a maternal uncle at age $35$. The evaluation of syncope often hinges on recognizing specific electrocardiographic (ECG) patterns associated with an increased risk of sudden cardiac death. Match each of the following classic ECG findings with its most likely clinical diagnosis.

Match the following antihypertensive medications with their characteristic mechanism of adverse effect or specific clinical contraindication.

A 68-year-old man comes to the clinic due to a three-week history of progressively worsening swelling in his legs and an uncomfortable sensation of abdominal fullness. He also notes increased shortness of breath when walking up a flight of stairs. His medical history is significant for a 45-pack-year smoking habit and chronic bronchitis. His current medications include inhaled tiotropium and as-needed albuterol.

Vital signs show a blood pressure of 128/78 mm Hg, a heart rate of 88/min, a respiratory rate of 18/min, and an oxygen saturation of 87% on room air.

Physical examination reveals an elevated jugular venous pressure of 12 cm H2O. Auscultation of the lungs demonstrates scattered expiratory wheezing but no crackles. Cardiac examination shows a parasternal heave and a loud pulmonic component of the second heart sound. The abdomen is distended with a palpable, tender liver edge. Bilateral pitting edema is present up to the knees.

An echocardiogram demonstrates right ventricular hypertrophy and dilation, with an estimated pulmonary artery systolic pressure of 55 mm Hg. The left ventricular ejection fraction is 60%, and there are no left-sided valvular abnormalities.

Which of the following interventions is most likely to prolong this patient's survival?

A 74-year-old man is evaluated in the outpatient clinic due to a two-month history of progressively worsening exertional dyspnea and a persistent, dry cough. He has a known history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, moderate chronic obstructive pulmonary disease, and recurrent symptomatic ventricular tachycardia. His current daily medications include aspirin, metoprolol succinate, lisinopril, empagliflozin, inhaled tiotropium, and amiodarone, which was initiated eight months ago for arrhythmia control. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, pulse is $64/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry shows an oxygen saturation of $91\%$ on room air. Jugular venous pressure is measured at $6\text{ cm H}_2\text{O}$. Cardiopulmonary examination reveals regular heart sounds with no murmurs, gallops, or rubs. Auscultation of the lungs reveals fine, bilateral inspiratory crackles most prominent at the bases, without any wheezing. There is no lower extremity edema. Laboratory studies show a white blood cell count of $8,500/\mu\text{L}$ and a B-type natriuretic peptide level of $145\text{ pg/mL}$. A high-resolution computed tomography scan of the chest demonstrates diffuse, bilateral ground-glass opacities and thickened interlobular septa. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old male is brought to the emergency department due to acute, severe dyspnea and lightheadedness that began one hour ago. The patient has a history of a "heart murmur" diagnosed in childhood and "asthma." He reports developing a mild upper respiratory tract infection three days ago. Over the past 24 hours, he has been using his albuterol metered-dose inhaler every 1 to 2 hours for perceived wheezing and chest tightness. Despite this, his breathing progressively worsened, culminating in a near-syncopal episode just prior to arrival.

Vital signs include a temperature of 37.2°C (99.0°F), blood pressure of 82/50 mm Hg, heart rate of 138/min, and a respiratory rate of 28/min. Pulse oximetry shows an oxygen saturation of 87% on room air.

Physical examination reveals a diaphoretic, pale patient in severe respiratory distress, utilizing accessory muscles of respiration. The jugular venous pressure is estimated at 9 cm $H_2O$. Palpation of the carotid arteries reveals brisk, bifid upstrokes. Lung auscultation demonstrates diffuse bilateral expiratory wheezes and basilar crackles. Cardiac auscultation reveals a regular tachycardia and a grade 4/6 harsh, crescendo-decrescendo systolic murmur heard best at the left lower sternal border that radiates to the apex but not to the carotids.

An electrocardiogram shows sinus tachycardia, left axis deviation, marked voltage criteria for left ventricular hypertrophy, and deep, narrow Q waves in leads I, aVL, V5, and V6. A portable chest radiograph demonstrates bilateral interstitial infiltrates, prominent pulmonary vasculature, and a normal cardiac silhouette.

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

A 24-year-old man presents to the clinic with acute, sharp chest pain that started yesterday. The pain worsens when he takes a deep breath or lies supine, but significantly improves when he sits up and leans forward. He reports having had a mild upper respiratory tract infection one week ago. His temperature is 37.4°C (99.3°F), blood pressure is 120/78 mmHg, and pulse is 88/min. Cardiac auscultation reveals a scratchy, high-pitched extra sound at the left lower sternal border that is heard during both systole and diastole. An electrocardiogram demonstrates diffuse concave ST-segment elevations and PR-segment depressions in most leads. Which of the following is the most appropriate initial treatment for this patient's condition?

A 64-year-old man arrives at the emergency department reporting the abrupt onset of severe, tearing chest pain that radiates between his shoulder blades. His blood pressure is 210/120 mmHg in the right arm and 180/100 mmHg in the left arm, with a heart rate of 118/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. An acute aortic dissection is highly suspected. Arrange the following steps in the most appropriate clinical sequence for the evaluation and management of this patient.

Match each physical examination finding and dynamic auscultation response with its most likely underlying structural or valvular pathophysiology.

Match the following classic arterial pulse abnormalities with their most likely underlying cardiovascular pathology.

A series of patients present to the cardiac intensive care unit with profound hypotension and cardiogenic shock 3 to 5 days following an acute ST-segment elevation myocardial infarction. Pulmonary artery catheterization (right heart catheterization) is performed for each patient to guide hemodynamic management. Match each post-myocardial infarction complication with its most characteristic hemodynamic profile.

A $60$-year-old male is transported to the emergency department by ambulance following an abrupt onset of severe dyspnea that started $2$ hours ago. He has a known medical history of essential hypertension and mitral valve prolapse. He reports no recent febrile illness, chills, or changes in sputum. His temperature is $37.0^\circ$ C ($98.6^\circ$ F), blood pressure is $165/95$ mmHg, heart rate is $118$/min, respiratory rate is $28$/min, and oxygen saturation is $85\%$ on room air. He is visibly distressed and using accessory muscles of respiration. Jugular venous distention is noted at $8$ cm H $_2$ O. Lung auscultation reveals diffuse bilateral crackles extending up to the apices, accompanied by prominent expiratory wheezing. Cardiac auscultation demonstrates a regular tachycardia with a normal S $1$ and a harsh holosystolic murmur heard best at the apex that radiates to the axilla.

Laboratory results are as follows:
- Leukocyte count: $8,500$/mm $^3$
- Thyroid-stimulating hormone (TSH): $0.1$ $\mu$ U/mL (Normal: $0.4-4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $1.2$ ng/dL (Normal: $0.8-1.8$ ng/dL)
- Arterial blood gas (room air): pH $7.28$, pCO $_2$ $55$ mmHg, pO $_2$ $50$ mmHg, HCO $_3^-$ $25$ mEq/L

Chest radiography reveals bilateral alveolar opacities with a normal-sized cardiac silhouette.

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

An emergency department physician is evaluating a 70-year-old female who complains of worsening shortness of breath over the past three days. The patient states she has been waking up in the middle of the night gasping for air and has had to sleep in a recliner chair. Her medical history includes hypertension, type 2 diabetes mellitus, and coronary artery disease. Vital signs show a blood pressure of 158/92 mm Hg, heart rate of 110/min, and respiratory rate of 24/min. Physical examination reveals elevated jugular venous pressure, an S3 heart sound, and bilateral crackles at the lung bases. Trace pitting edema is noted in the lower extremities. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

An emergency medical response team brings a 65-year-old man to the resuscitation bay due to the sudden onset of severe shortness of breath. The patient has a known history of type 2 diabetes mellitus and a 35-pack-year history of cigarette smoking. He reports that his breathing difficulties awoke him from sleep approximately two hours ago. Upon further questioning, his wife mentions that he complained of deep, aching chest discomfort three days ago, which he attributed to indigestion and for which he refused to seek medical care. Vital signs are temperature 37.1°C (98.8°F), blood pressure 82/54 mmHg, heart rate 128/min and regular, and respiratory rate 32/min. Oxygen saturation is 83% on ambient air. Physical examination reveals an ashen, diaphoretic patient in severe respiratory distress using accessory muscles of respiration. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes throughout all lung fields with scattered dependent crackles. Cardiac auscultation reveals a hyperdynamic precordium and a grade 4/6 harsh holosystolic murmur heard best at the cardiac apex with radiation to the left axilla. Jugular venous pressure is estimated at 6 cm H2O. Electrocardiogram demonstrates normal sinus rhythm with pathologic Q waves and T-wave inversions in leads II, III, and aVF. Chest radiography shows bilateral perihilar alveolar opacities with prominent pulmonary vascular congestion, but a normal cardiac silhouette. Which of the following is the most appropriate next step in the management of this patient?