Ziad Aro, MD

Internal medicine
Cardiology

Physical
examination
 Heart murmurs
 Aortic stenosis: narrow pulse pressure, ejection click, mid systolic, crescendo
decrescendo murmur. Paradoxical splitting of S2. absent A2 in severe AS.
positive S3, S4.
2nd RSB >> CAROTID.
Aortic Stenosis
 Heart murmurs
 Aortic regurgitation: Wide Pulse pressure, absent A2, S4, decrescendo
murmur, 3rd LSB. No radiation.
Aortic regurgitation
 Heart murmurs
 Mitral stenosis: accentuated S1, opening snap, diastolic murmur(apex). No
radiation.
Mitral stenosis
 Heart murmurs
 Mitral regurgitation: absent S1, S3, S4, holosystolic murmur, APEX>>AXILLA.
Mitral regurgitation
Heart murmurs
 Jugular venous wave

 A wave – Atrial contraction.

- absent in Atrial fibrillation.
- Raised in AS or TS.
 C wave – Tricuspid valve bulge upwards into the right atrium. Severe TR
 X wave – fall in atrial pressure after the a wave.
 V wave – Atrial filling.
- Increased in severe TR.
 Y wave – Tricuspid valve opens and blood rapidly empties into the right
ventricle.
- Rapid Y descent: MR, TR, Constrictive pericarditis, Restrictive
cardiomyopathy, Right MI.
- No Y descent: Tamponade.
Kussmaul’s Sign – Rise or lack of fall of the JVP
with inspiration.
 Constrictive pericarditis.
 Restrictive cardiomyopathy.
 Right MI.
 Massive PE.
 Severe TR.
Pulsos Paradoxus – fall in systolic pressure > 10mmhg
with inspiration.
 Tamponade
 Massive PE
 Severe obstructive lung disease
 Tension pneumothorax
 Hemorrhagic shock
 Cardiology

Heart failure
NYHA CLASS
 Heart failure with
reduced ejection fraction – EF<40%.

 Heart failure with

preserved ejection fraction – EF > 40%.
HF management:
Cardiology
Pericarditis
 Pericarditis - Criteria
 Chest pain: severe, retrosternal, pleuritic, radiates to left arm, neck, and left
shoulder. Intensified while lying supine, relieved by sitting up and leaning
forward.
 Pericardial friction rub: 85% of patients.
 Diffuse ST ELEVATIONS and PR segment depression.
 Pericarditis - Criteria
 Chest pain: severe, retrosternal, pleuritic, radiates to left arm, neck, and left
shoulder. Intensified while lying supine, relieved by sitting up and leaning
forward.
 Pericardial friction rub: 85% of patients.
 Diffuse ST ELEVATIONS and PR segment depression.
 Pericardial effusion.
 Pericarditis - Treatment
 NSAID’S / ASPIRIN … 1-2 weeks.
 Colchicine … 3 months.
 Steroids ? Patients who have failed therapy or do not tolerate NSAIDS and
colchicine. REMEMBER! Steroids increase the risk of subsequent
recurrence, use carefully for short period of time.
 Remember! Anticoagulants should be avoided in pericarditis because they
increase the risk of tamponade.
 2nd and 3rd lines: azathioprine or anakinra(IL-1 receptor antagonist).
 Tamponade
 Becks triad – increased JVP, hypotension, absent heart sounds.
 PULSUS PARADOXUS !!
 Causes: idiopathic pericarditis, trauma, TB,
Neoplastic disease, aortic dissection, post surgery.
 Treatment: Pericardiocentesis.
ACS
 ACS

 Stable angina: angina with exertion, relieved by rest / nitroglycerin.

 Unstable angina: New onset, crescendo, at rest.
 Unstable angina + Troponin = Non ST Elevation MI.
 ACS
ST Elevation MI
WHAT SHOULD YOU DO ??
Cath Lab!!
Examples
Massive anterior wall STEMI
Massive antero-lateral wall STEMI
Massive antero-lateral wall STEMI
High lateral STEMI
Infero-latral STEMI
Inferior STEMI
 Pulmonary Embolism

 D-Dimer – excellent to rule out DVT/PE

- Remember!! Rule out and not Rule in!
- Ddimer is not specific and is also elevated in MI, pneumonia,
Sepsis, cancer,post-operative, 2nd and 3rd trimester in pregnancy.
 To rule in PE >> use CTA.
 To rule in DVT >> use US.
 How do you decide what imaging to use?....
Calculate wells Score for your patient:

>0 >4
 Pulmonary Embolism
 ECG:
- most sensistive – sinus tachycardia, T wave inversion in V1-V4.
- most specific but not sensitive – S1Q3T3
 Pulmonary Embolism
Treatment
 Massive PE = PE and hemodynamic instability >> thrombolysis / Embolectomy.
 Non massive PE / DVT >> Anti-coagulation (LMWH, Coumadin, NOAC’s).
Electrophysiology
Heart AXIS
Look at lead 2:
-negative >> left axis
-positive >> normal axis.
LVH
RVH
Left bundle branch block - LBBB
Left bundle branch block - LBBB
Right bundle branch block - RBBB
Right bundle branch block - RBBB
Left anterior fasicular block
Left anterior fasicular block
Left anterior fasicular block
Left posterior fasicular block
Left posterior fasicular block
Left posterior fasicular block
AV BLOCKS
1st degree AVB / Prolonged PR
2ND degree AVB – MOBITZ 1 - Wenckebach
2ND degree AVB – MOBITZ 2
3rd degree AVB - CAVB
Pericarditis
Tachy - Arrhythmias
 to help you remember…
ECG Regular rythem Irregular rythem
Narrow complex SVT, sinus tachycardia Atrial fibrillation
Wide complex Ventricular tachycardia Ventricular fibrillation

 Remember: UNSTABLE PATIENT = chest pain/dyspnea/shock/confusion.

 Remember: Unstable patient + any Tachy-arrhythmia = CARDIOVERSION!
Atrial fibrillation
Wolf Parkinson white
Wolf Parkinson white
Atrial flutter
Atrial flutter
SVT – Supraventricular tachycardia
SVT
Ventricular Tachycardia
Polymorphic VT
Torsades de pointes – Polymorphic VT + long QT
VF – Ventricular fibrillation
VF
VF
Questions
1. 88 years old is admitted due to intermittent chest pain in the last 24 hours, he
is unconscious and blood pressure cannot be measured, ecg:
The most appropriate management:

 1. Unsynchronized cardioversion
 2. IV metaprolol 5 mg
 3. Synchronized cardioversion
 4. IV ikacor 5 mg
Tachy-arrhythmia:

 Regular ?

 QRS comlex ?
Regular
Irregular
QRS complex:
Tachy-arrhythmia:

regular irregular

Narrow QRS SVT Atrial Fib / Flutter

Wide QRS VT VF
SVT treatment
Harrison’s 20 1742-1743
Treatment
 Unstable tachy-arrhythmia = chest pain, dyspnea, confusion, shock.
 UNSTABLE?? >> Cardioversion !!
Remember !! Always synchronized CV accept in polymorphic VT and VF >>
Unsynchronized CV !!

 Stable??
Afib/flutter >> BB, CCB, Digoxin.
SVT >> Vagal maneuvers, ADENOSINE !!
VT >> Procor(amiodarone).

 SVT treatment – Harrison’s 20 1742-1743

88 years old is admitted due to intermittent chest pain in the last 24 hours, he is
unconscious and blood pressure cannot be measured, ecg:
The most appropriate management:

 1. Unsynchronized cardioversion
 2. IV metaprolol 5 mg
 3. Synchronized cardioversion
 4. IV ikacor 5 mg
2. An 80-year-old woman brought to emergency due to deteriorated
consciousness, her systolic blood pressure is 45 mmhg, she is pale, her skin is
cold and diaphoretic. Which is the most appropriate first step in managing the
patient?

 1. synchronized cardioversion
 2. unsynchronized cardioversion
 3. intravenous beta blocker (i.e metoprolol)
 4. intravenous loading of antiarrhythmic agent (i.e amiodarone)
 regular irregular

Narrow QRS SVT Atrial Fib / Flutter

Wide QRS VT VF
An 80-year-old woman brought to emergency due to deteriorated consciousness,
her systolic blood pressure is 45 mmhg, she is pale, her skin is cold and
diaphoretic. Which is the most appropriate first step in managing the patient?

 1. synchronized cardioversion
 2. unsynchronized cardioversion
 3. intravenous beta blocker (i.e metoprolol)
 4. intravenous loading of antiarrhythmic agent (i.e amiodarone)
3. 70 years old male is admitted due to COPD exacerbation, during addmition
(MAT) is noted, what is the most appropriate management:

 1. Improve breathing and control COPD exacerbation

 2. Beta blockers
 3. Calcium channel blocker
 4. Amiodarone
Multi-Focal atrial tachycardia - MAT
MAT – 3 different P waves
 Multi-Focal atrial tachycardia – MAT
Treatment

 MAT is usually encountered in patients with chronic lung disease or acute

illness.

 Treatment – directed at treating the underlying disease and correct any

metabolic abnormalities.
 For example – patient with COPD and desaturation + MAT >> give O2 and
correct hypoxemia.

Harrison’s 20 – page 1745.

70 years old male is admitted due to COPD exacerbation, during addmition (MAT)
is noted, what is the most appropriate management:

 1. Improve breathing and control COPD exacerbation

 2. Beta blockers
 3. Calcium channel blocker
 4. Amiodarone
4. The treatment of patient with stable coronary heart disease that does not
undergo coronary stent placement:

 1. Aspirin alone
 2. Aspirin + clopidogrel
 3. Aspirin + ticagrelor
 4. Aspirin + prasugrel
Stable coronary artery disease
 No stenting : Single anti-platelet Agent – Aspirin.
 After coronary stenting:

Treatment of Stable coronary artery disease – Harrison’s 20 page 1858

Important !!
The treatment of patient with stable coronary heart disease that does not
undergo coronary stent placement:

 1. Aspirin alone
 2. Aspirin + clopidogrel
 3. Aspirin + ticagrelor
 4. Aspirin + prasugrel
5. 52 years old acute myocardial infarction 2 years ago treated for systolic heart
failure, recently complains breast enlargement and sensitivity, which drug may
cause this phenomenon?

 1. Aspirin
 2. Eplerenone
 3. Spironolactone
 4. Hydrochlorothiazide
Gynecomastia
Gynecomastia & Spirinolactone
 Spirinolactone :
- Non selective aldosterone anagonist.
- In HF with EF<35% and NYHA2-4 >> reduces mortality.
- Used also in treatment of hypertension.
- Side effects: Gynecomastia, impotence, menstrual abnormalities.
- Eplerenone – newer agent, selective aldosterone antagonist, and doesn’t
cause gynecomastia.

 Gynecomastia – Also in … Cirrhosis !

 Harrison’s 20 Page 1903

52 years old acute myocardial infarction 2 years ago treated for systolic heart
failure, recently complains breast enlargement and sensitivity, which drugs may
cause this phenomenon?

 1. Aspirin
 2. Eplerenone
 3. Spironolactone
 4. Hydrochlorothiazide
6. A 55 years old male brought unconscious to the ER there is no previous medical
history ( ECG attached) what is the diagnosis?

 1. ST elevation MI
 2. Non ST elevation MI
 3. Complete AV block
 4. Pacemaker rhythm
 A 55 years old male brought unconscious to the ER there is no previous
medical history ( ECG attached) what is the diagnosis?

 1. ST elevation MI
 2. Non ST elevation MI
 3. Complete AV block
 4. Pacemaker rhythm
Pacemaker
Pacemaker Rythem – look for the spike!!
Pacemaker Rythem – look for the spike!!

Harrison’s 20 - Page 1725

Pacemaker indications – AV block
Pacemaker indications – SA node dysfunction
7. A 59-year-
old male present with severe chest pain and shortness of breath, attached is his
ECG:Which of the following states describes this diagnosis:

 1. Anterior wall ST elevation myocardial infarct

 2. non ST elevation myocardial infarction
 3. Ventricular fibrillation
 4. Atrial fibrillation
 5. Inferior wall ST elevation myocardial infarction.
ECG LEADS…
LAD Occlusion - STEMI
After PCI and LAD stenting…
7. A 59-year-
old male present with severe chest pain and shortness of breath, attached is his
ECG:Which of the following states describes this diagnosis:

 1. Anterior wall ST elevation myocardial infarct

 2. non ST elevation myocardial infarction
 3. Ventricular fibrillation
 4. Atrial fibrillation
 5. Inferior wall ST elevation myocardial infarction.

 STEMI – Harrison’s 20 1872

8. 70 tear old male is admitted to the E.R with abdominal pain and a new atrial
fibrillation on the E.C.G. the pain is constant at 10/10, the abdomen is soft with
no peritonitis. What is the next step?

 CT angiography
 Plain abdominal X-ray
 Chest X-ray
 Serum amylase and lipase
 70 tear old male is admitted to the E.R with abdominal pain and a new atrial
fibrillation on the E.C.G. the pain is constant at 10/10, the abdomen is soft
with no peritonitis. What is the next step?

 CT angiography
 Plain abdominal X-ray
 Chest X-ray
 Serum amylase and lipase
Mesenteric Event/Ischemia
 Remember the anatomy…
Mesenteric Event/Ischemia
 Cause – arterial emboli / thrombosis.
 Remember – atrial fibrillation patients with no anti-coagulation are prone
to mesenteric events !!
 Abdominal pain – out of proportion to the physical findings.
 Diagnosis – CT ANGIOGRAM.
 Gold standard – angiography.
 Treatment – laparotomy and embolectomy via arteriotomy.
 Mortality > 50%

 Harrison’s 20 page 2292

10. A 51-year-old male is admitted with symptomatic atrial fibrillation. He is
started on sotalol. What needs to be followed during his admission?

 1. Renal function
 2. Lung function
 3. QT segment on ECG
 4. Left ventricle ejection fraction (LVEF)
4 classes of anti-arrhythmic drugs
 Class 1 – agents that block block inward sodium current
 Class 2 – anti-sympathetic agents.
 Class 3 – agents that prolong action potential duration.
 Class 4 – Calcium channel blockers
Drug Class

1
3
3
1
3
1
1
1
1
1
3

Harrison’s 20 1738
A 51-year-old male is admitted with symptomatic atrial fibrillation. He is started
on sotalol. What needs to be followed during his admission?

 1. Renal function
 2. Lung function
 3. QT segment on ECG
 4. Left ventricle ejection fraction (LVEF)
11. A 50-year-old man was admitted due to acute shortness of breath and chest
pain. Auscultation reveals bilateral rales over the lower half of lungs, without
dullness in percussion, systolic blood pressure 210 mmhg, oxygenation saturation
with face mask is only 82%. Which of the following is best treatment?

 1. sublingual mononit and wait 10 minutes for the blood pressure reduced
 2. intravenous fluid
 3. intravenous antibiotics (1 gr ceftriaxone)
 4. intratracheal intubation before any medical treatment
 A 50-year-old man was admitted due to acute shortness of breath and chest
pain. Auscultation reveals bilateral rales over the lower half of lungs, without
dullness in percussion, systolic blood pressure 210 mmhg, oxygenation
saturation with face mask is only 82%. Which of the following is best
treatment?

 1. sublingual mononit and wait 10 minutes for the blood pressure reduced
 2. intravenous fluid
 3. intravenous antibiotics (1 gr ceftriaxone)
 4. intratracheal intubation before any medical treatment
Pulmonary Edema – treatment
- Oxygen therapy.
- non invasive ventilation (BIPAP).
- invasive ventilation.
Pulmonary Edema – treatment
- Oxygen therapy.
- Non invasive ventilation (BIPAP).
- Invasive ventilation.
- In ESKD – Dialysis.
- FUSID !! Venodilator + Diuretic.
>> dose: 0.5mg/kg, higher dose 1mg/kg if CKD or chronic diuretic use,
hypervolemia, or failure of a lower dose.
- Nitrate – venodilators + coronary vasodilators.
- Morphine – venodilator, relieving dyspnea and anxiety.

Harrison’s 20 page 2057

12. A 96-year-old man, 2 days post-coronary therapeutic catheterization with
stent placement, presents with a temperature of 38°c, malaise and cyanosis of
the toe. Blood work reveals leukocytosis and eosinophilia:

 1. sepsis, bacteremia
 2. endocarditis, infection of the stent
 3. cholesterol emboli
 4. deep vein thrombosis (dvt)
 A 96-year-old man, 2 days post-coronary therapeutic catheterization with
stent placement, presents with a temperature of 38°c, malaise and cyanosis
of the toe. Blood work reveals leukocytosis and eosinophilia:

 1. sepsis, bacteremia
 2. endocarditis, infection of the stent
 3. cholesterol emboli
 4. deep vein thrombosis (dvt)
Cholesterol emboli
 Cholesterol emboli
 Cholesterol shower into the circulation.
 Following endovascular procedures, use of anti-coagulation, or less
commonly – spontaneously.
 Fever, Hollenhorst plaques in the retina, TIA, CVA, liVedo reticularis, Blue toe,
AKI and FSGS may lead to ESKD over few years.
 Eosinophilia, eosinophiluria, low C3 C4.
 Management – supportive.
 After endovascular procedures, DD:
- Contrast nephropathy.
- cholesterol emboli.

After 24 hours

 Harrison’s 20 page 2148

13. Which of the following therapeutic agents used in the treatment of patients
with heart failure does not prolong the life expectancy?

 1. Enalapril
 2. Carvedilol
 3. Digoxin
 4. Eplerenon
 Which of the following therapeutic agents used in the treatment of patients
with heart failure does not prolong the life expectancy?

 1. Enalapril
 2. Carvedilol
 3. Digoxin
 4. Eplerenon
 Heart failure
 Heart failure with preserved Ejection fraction (EF>40%)
>> no treatment that reduces mortality.
 Heart failure with reduced EF (EF<40%)
>> drugs and devices that reduce mortality:
- BB in EF<40%.
- ACEI/ARB in EF<40%.
- MRA – Spironolactone – EF<35% and NYHA2-4.
- ARNI – Entresto in EF<35% and persistent symptoms despite BB ACEI and an MRA.
- ICD – NYHA2-3 and ef<35% or EF<30%.
- CRTD – NYHA3-4 and EF<35% and QRS>150ms with LBBB configuration.
 Any other treatment – symptomatic treatment with no reduction in mortality.

 Harrison’s 20 page 1772

HF management:
14. An 80-year-old man admitted due to shortness of breath and chest pain.
Echocardiography reveals aortic stenosis with a gradient of 72 mmHg and 0.4 cm
maximal valve diameter. Which of the following is true regarding the valvular
disease described in this question?

 1. Mild aortic stenosis

 2. Mild to moderate aortic stenosis
 3. Moderate aortic stenosis
 4. Severe aortic stenosis
 An 80-year-old man admitted due to shortness of breath and chest pain.
Echocardiography reveals aortic stenosis with a gradient of 72 mmHg and 0.4
cm maximal valve diameter. Which of the following is true regarding the
valvular disease described in this question?

 1. Mild aortic stenosis

 2. Mild to moderate aortic stenosis
 3. Moderate aortic stenosis
 4. Severe aortic stenosis
 AS
 Aortic stenosis: ejection, mid systolic, crescendo decrescendo murmur.
Paradoxical splitting of S2. absent A2 in severe AS. positive S3, S4.
2nd RSB >> CAROTID.
 Aortic Stenosis

 Harrison’s 20 page 1806

15. A 60-year
old man presents to the emergency room with shortness of breath. Auscultation reveals a diastolic
murmur. Blood pressure is high with a wide pulse pressure. Which of the following is the most likely
diagnosis?

 1. VSD
 2. Aortic stenosis
 3. Aortic insufficiency
 4. Mitral stenosis
 5. Mitral insufficiency
 A 60-year-
old man presents to the emergency room with shortness of breath. Auscultati
on reveals a diastolic
murmur. Blood pressure is high with a wide pulse pressure. Which of the follo
wing is the most likely diagnosis?

 1. VSD Holo-systolic murmur.

 2. Aortic stenosis
 3. Aortic insufficiency
 4. Mitral stenosis
 5. Mitral insufficiency
 AR
 Aortic regurgitation: Wide Pulse pressure, absent A2, S4, decrescendo
murmur, 3rd LSB. No radiation.
Aortic regurgitation – page 1812
16. A 55-year-
old man with shortness of breath with effort. He has a systolic murmur which inc
rease with Valsalva maneuver. Which of the following is the most likely diagnosis?

 1. Aortic stenosis
 2. Subaortic stenosis
 3. Unstable angina pectoris
 4. Pericardial tamponade
 5. A and/or B
 A 55-year-
old man with shortness of breath with effort. He has a systolic murmur which
increase with
Valsalva maneuver. Which of the following is the most likely diagnosis?

 1. Aortic stenosis
 2. Sub-aortic stenosis – HOCM.
 3. Unstable angina pectoris
 4. Pericardial tamponade
 5. A and/or B
Heart murmurs

page 1674
Heart murmurs – remember:
- Valsalva + standing: increase intensity of HOCM and MVP murmur.
- squatting : decrease intensity of HOCM and MVP murmur.
- Hand grip exercise: decrease intensity of HOCM murmur.
- Right side murmurs increase with inspiration.
- left side murmurs increase with expiration.
17. Which of the following cause prolonged QT on ECG :

 1. Hypocalcemia
 2. Hyperphosphatemia
 3. Hyponatremia
 4. Hypermagnesemia
 5. A and/or D
QT interval
LONG QT – more than 440ms in men or 460ms in women

page 1760-1761
Long QT - Hypocalcemia
Short QT = QT<360ms.

 Hypercalcemia
 Short QT syndrome
 Digoxin
 Which of the following cause prolonged QT on ECG :

 1. Hypocalcemia
 2. Hyperphosphatemia
 3. Hyponatremia
 4. Hypermagnesemia
 5. A and/or D
18.Which of the following drugs does not prolong the life expectancy of patients
with systolic heart failure :

 1. Sacubitril/valsartan
 2. pironolactone
 3. Furosemide
 4. Ramipril
 5. Carvedilol
 Which of the following drugs does not prolong the life expectancy of patients
with systolic heart failure :

 1. Sacubitril/valsartan >> ARNI(ENTRESTO) – Angotensin receptor neprilysin

inhibitor.
 2. pironolactone
 3. Furosemide
 4. Ramipril
 5. Carvedilol
19. A 70-year-
old female with hypertension complains of chest pain, her blood pressure differs
between arms and
she is diaphoretic and tachycardic. Aortic dissection is suspected. Which of the fo
llowing findings on her chest X-ray will support the diagnosis:

 1. Serpentine aorta
 2. Right pleural effusion
 3. Elevated left diaphragm
 4. Widening of the mediastinum
 5. An air bubble in the stomach
 A 70-year-
old female with hypertension complains of chest pain, her blood pressure diff
ers between arms and
she is diaphoretic and tachycardic. Aortic dissection is suspected. Which of th
e following findings on her chest X-ray will support the diagnosis:

 1. Serpentine aorta
 2. Right pleural effusion
 3. Elevated left diaphragm
 4. Widening of the mediastinum
 5. An air bubble in the stomach
Aortic dissection
 Stanford A – dissection involves
the ascending aorta.
 Stanford B – dissection does not involve
the ascending aorta.

 DeBakey 1 / 2 / 3:
Aortic dissection –clinical manefistations
 Men>women
 Sixth/seventh decade of life
 Sudden onset of chest/inter-scapular pain.
 Loss of pulse, Aortic regurgitation with acute heart failure and pulmonary
edema, MI, bowel ischemia, renal failure.
 Horner syndrome, svc syndrome, cardiac tamponade.
Aortic dissection –clinical manefistations
 Wide mediastinum:
Aortic dissection – Diagnosis
 CT-ANGIOGRAM:
Treatment – Aortic dissection
 IV BB to reduce pulse to 60beats/min.
 IV nitroprissideto reduce systolic blood pressure below 120mmhg.

 Stanford Type A involving ascending aorta – SURGERY !!

 Stanford Type B:
- complicated – endovascular treatment.
- Uncomplicated – Medical therapy without surgery. BB+ACEI.

 Page 1920-1921
Aortic aneurysms
 Thoracic vs. abdominal
Aortic aneurysms - treatment
 Ascending Thoracic aortic aneurysm –
- beta blockers.
- Surgery with graft if: symptoms, ascending aorta>5.5cm, growth
rate>0.5cm/year. In Marfan-ascending aorta > 4-5cm.

 Descending thoracic aortic aneurysm:

- beta blockers.
- surgery if Descending thoracic aortic aneurysm > 6cm.
- endovascular repair if Descending thoracic aortic aneurysm > 5.5cm.

 Abdominal aortic aneurysm:

- beta blockers have not proven effective!!
- operative repair/endovascular repair if > 5.5cm.
 A 61-year-
old woman complains of malaise. ECG pic . Which of the following is the most
likely diagnosis?

 1. Ventricular flutter
 2. Atrial fibrillation
 3. Supraventricular tachycardia
 4. Pacemaker rhythm
 A 61-year-old woman complains of malaise. ECG pic .
Which of the following is the most likely diagnosis?

 1. Ventricular flutter
 2. Atrial fibrillation
 3. Supraventricular tachycardia
 4. Pacemaker rhythm
Pacemaker implantation
CRTD – HF, EF<35%, NYHA3-4, LBBB, QRS>150ms
20. 76 years old female is brought to the ER due to generalized malaise and
palpitations. These symptoms occur episodically over the last week. B.P 125/85
mmHg. Treatment?
1. electrocardioversion.
2. Cardioversion with amiodarone
3. Decrease heart rate with beta blockers
4. Decrease heart rate with digoxin
5. Cardioversion with adenosine
 regular irregular

Narrow QRS SVT Atrial Fib / Flutter

Wide QRS VT VF
 Management of atrial fibrillation
Unstable stable

Electrical cardioversion Duration < 48H Duration > 48H

Cardioversion Slow with BB, CCB, Digoxin

Anti-coagulation
TEE
for 3 weeks
Use in rapid atrial fibrillation
and heart failure

Cardioversion

Page 1746
 CHADSVASc

pradaxa

xarelto

eliquis
ESC GUIDLINES
20. 76 years old female is brought to the ER due to generalized malaise and
palpitations. These symptoms occur episodically over the last week. B.P 125/85
mmHg. Treatment?
1. electrocardioversion.
2. Cardioversion with amiodarone
3. Decrease heart rate with beta blockers
4. Decrease heart rate with digoxin
5. Cardioversion with adenosine
21. 88 years old female with dyspnea. Evaluated chest x-ray diagnosis pulmonary
edema. Heart echo identified that her aortic valve area is 0.59 cm2 with a
gradient of 30mmHg. The LVEF is 20%. What is the most probable diagnosis?

1. Normal aortic valve, pulmonary edema by left ventricle failure alone.

2. Mild aortic stenosis caused by Left ventricle failure.
3. Moderate aortic stenosis causing heart failure.
4. Severe aortic stenosis causing heart failure.
5. Normal echo, proceed with non-cardiac evaluation.
21. 88 years old female with dyspnea. Evaluated chest x-ray diagnosis pulmonary
edema. Heart echo identified that her aortic valve area is 0.59 cm2 with a
gradient of 30mmHg. The LVEF is 20%. What is the most probable diagnosis?

1. Normal aortic valve, pulmonary edema by left ventricle failure alone.

2. Mild aortic stenosis caused by Left ventricle failure.
3. Moderate aortic stenosis causing heart failure.
4. Severe aortic stenosis causing heart failure.
5. Normal echo, proceed with non-cardiac evaluation.
Aortic stenosis

 Severe : Aortic valve Area < 1, max/mean gradient > 53/40.

 Management: Surgical Aortic valve replacement, if intermediate-high risk for
surgery >> TAVI – Trans-catheter aortic valve replacement.
 TAVI – 10% risk for AV block and early Stroke.
22. 27 years old complains of chest pain that worsens when bending forward.
During the past week she has elevated body temperature, general malaise and
dyspnea. Below is the ECG at the E.R
what is the most appropriate next step?

1. Cardio scan to rule out MI

2. Chest CT scan with I.V contrast to
rule out aortic dissection.
3. Thin slice chest CT scan to
evaluate lung parenchyma.
4. Heart echo to evaluate for
pericardial effusion.
5. MRI (CMR) to rule out
constrictive pericarditis
22. 27 years old complains of chest pain that worsens when bending forward.
During the past week she has elevated body temperature, general malaise and
dyspnea. Below is the ECG at the E.R
what is the most appropriate next step?

1. Cardio scan to rule out MI

2. Chest CT scan with I.V contrast to
rule out aortic dissection.
3. Thin slice chest CT scan to
evaluate lung parenchyma.
4. Heart echo to evaluate for
pericardial effusion.
5. MRI (CMR) to rule out
constrictive pericarditis
 Pericarditis - Criteria
 Chest pain: severe, retrosternal, pleuritic, radiates to left arm, neck, and lrft
shoulder. Intensified while lying supine, relieved by sitting up and leaning
forward.
 Pericardial friction rub: 85% of patients.
 Diffuse ST ELEVATIONS and PR segment depression.
 Pericardial effusion.
 Pericarditis - Treatment
 NSAID’S / ASPIRIN … 1-2 weeks.
 Colchicine … 3 months.
 Steroids ? Patients who have failed therapy or do not tolerate NSAIDS and
colchicine. REMEMBER! Steroids increase the risk of subsequent
recurrence, use carefully for short period of time.
 Remember! Anticoagulants should be avoided in pericarditis because they
increase the risk of tamponade.
 2nd and 3rd lines: azathioprine or anakinra(IL-1 receptor antagonist).
23. 67 years old male is discharged from the hospital following MI. Atorvastatin
80 mg once a day is prescribed. Upon discharge what needs to be explained to
the patient regarding the use of this medication?

1. Musculoskeltal pain is expected but it always resolves within 2 weeks.

2. Elevated blood cpk is expected but it always resolves within 2 weeks.
3. The aim of treatment is to decrease HDL cholesterol.
4. The aim of the treatment is to elevate the life expectancy following MI.
5. The aim of the treatment is to decrease the chest pain that is expected
following MI.
23. 67 years old male is discharged from the hospital following MI. Atorvastatin
80 mg once a day is prescribed. Upon discharge what needs to be explained to
the patient regarding the use of this medication?

1. Musculoskeltal pain is expected but it always resolves within 2 weeks.

2. Elevated blood cpk is expected but it always resolves within 2 weeks.
3. The aim of treatment is to decrease HDL cholesterol.
4. The aim of the treatment is to elevate the life expectancy following MI.
5. The aim of the treatment is to decrease the chest pain that is expected
following MI.
LDL - Cholesterol
 LDL – “bad” cholesterol
 The lower LDL >> the Better !
 HDL – “good” cholesterol
 Following MI/CVA >> target LDL < 70
 Diabetes + end organ damage >> target LDL < 70
 Diabetes with no end organ damage / Smokers >> target LDL < 100
Statins
 HMG COA reductase inhibitors.
 Reduce LDL and TG
 Modest HDL raising effect
 Side effects
- dyspepsia, myalgia, arthralgia
- rhabdomyolysis – Rare, increase with co administration of erythromycin,
anti-fungal agents, and fibrates.
- if there is muscle symptoms >> check creatine kinase – CPK. But serum CPK
should not be monitored on a routine basis.
- if AST / ALT greater than three times the upper normal limit(RARE!!) >> stop
therapy.

 Page 2901-2902
PCSK9 inhibitors
 50% reduction of LDL
 Second line if LDL is not reduced to acceptable levels with statins+ezetrol.
 Page 2902
24. Patient with known arterial hypertension. Has now orthostatic hypotension.
History reveals ischemic heart disease and diabetes. Which medication should
not be given anymore?

1. Ramipril (ACE Inhibitor)

2. Bisoprolol (beta Blocker)
3. Doxazocin (alpha Blocker)
4. Empagliflozin (SGLT 2 inhibitor)
5. Insulinglargine
24. Patient with known arterial hypertension. Has now orthostatic hypotension.
History reveals ischemic heart disease and diabetes. Which medication should
not be given anymore?

1. Ramipril (ACE Inhibitor)

2. Bisoprolol (beta Blocker)
3. Doxazocin (alpha Blocker)
4. Empagliflozin (SGLT 2 inhibitor)
5. Insulinglargine
24. Patient with known arterial hypertension. Has now orthostatic hypotension.
History reveals ischemic heart disease and diabetes. Which medication should
not be given anymore?

1. Ramipril (ACE Inhibitor) – Reduce remodeling after MI, Reduce mortality in

EF<40%.
2. Bisoprolol (beta Blocker) - Reduce remodeling after MI, Reduce mortality in
EF<40%.
3. Doxazocin (alpha Blocker) – Can cause orthostatic hypotension.
4. Empagliflozin (SGLT 2 inhibitor) – Reduce MI, death, deterioration in CKD, and
hospitalizations in patients with CARDIOVASCULAR disease.
5. Insulinglargine
Orthostatic hypotension

page 126
 Orthostatic hypotension

- Alpha blockers to treat

prostatic hypertrophy and
hypertension
25. 55 year old woman admitted for evaluation of 2 episodes of syncope during
morning walks. No medical history, no medication. EKG is attached.
Management?
1. Pacemaker implantation as early as possible
2. Coronary catheterization to rule out arterial
occlusion as early as possible
3. Holter monitor 24 hours
4. Heart rate monitoring with implanted
monitor 30 days
5. Tilt Test
COMPLETE AVB >> Pacemaker
25. 55 year old woman admitted for evaluation of 2 episodes of syncope during
morning walks. No medical history, no medication. EKG is attached.
Management?
1. Pacemaker implantation as early as possible
2. Coronary catheterization to rule out arterial
occlusion as early as possible
3. Holter monitor 24 hours
4. Heart rate monitoring with implanted
monitor 30 days
5. Tilt Test
26. 80 year old female with permanent atrial fibrillation is treated with b-
blocker and oral anti coagulation (DOAC). She is in the ER for sudden right
hemiparesis and dysarthria. Most probable diagnosis and first step in the ER?

1. Suspected cerebral infarct as a complication of atrial fibrillation,

transesophageal echo as soon as possible.
2. Suspected thromboembolic cerebral infarct, i.v. heparin single dose.
3. Suspected cerebral bleeding, immediate brain CT without i.v. contrast.
4. Suspected cerebral bleeding, 4 units FFP before any work up.
5. Suspected thromboembolic.
26. 80 year old female with permanent atrial fibrillation is treated with b-blocker and oral anti
coagulation (DOAC). She is in the ER for sudden right hemiparesis and dysarthria. Most probable
diagnosis and first step in the ER?

1. Suspected cerebral infarct as a complication of atrial fibrillation, transesophageal echo as soon

as possible.
2. Suspected thromboembolic cerebral infarct, i.v. heparin single dose.
3. Suspected cerebral bleeding, immediate brain CT without i.v. contrast.
4. Suspected cerebral bleeding, 4 units FFP before any work up.
5. Suspected thromboembolic.

** patients anti-coagulated + neurological symptoms >> SUSPECT HEMORRHAGIC CVA >> CT

pradaxa

xarelto

eliquis
27. 55 years old male undergoes coronary categorization for NSTEMI During the
procedure drug eluding stent (DES) is placed . Which of the following medication
regimen is most appropriate assuming he has no other past medical history.

1. Aspirin+ warfarin
2. Clopedogrel + LMWH
3. Prasugrel + dabigatran
4. Prasugrel + warfarin
5. Ticagrelor + aspirin
27. 55 years old male undergoes coronary categorization for NSTEMI During the
procedure drug eluding stent (DES) is placed . Which of the following medication
regimen is most appropriate assuming he has no other past medical history.

1. Aspirin+ warfarin
2. Clopedogrel + LMWH
3. Prasugrel + dabigatran
4. Prasugrel + warfarin
5. Ticagrelor + aspirin
Dual antiplatelet therapy after PCI…

A – Aspirin
C – Clopedogrel
P – Prasugrel
T – Ticagrelor

ESC GUIDLINES
PCI in patient under anti-coagulation
use only aspirin/Clopidogrel!!!!

ESC GUIDLINES
28. A 80-year-
old COPD patient complains of shortness of breath and pleural pain. Examinations reveals
tachycardia and hypoxemia. Which of the following tests will diagnose pulmonary embolism m
ost accurately in this patient:

1. Perfusion lung scan

2. Perfusion/ventilation lung scan
3. Chest CT angiography
4. Serum D-dimer
5. Pulmonary function test with effusion
28. A 80-year-
old COPD patient complains of shortness of breath and pleural pain. Examinations reveals
tachycardia and hypoxemia. Which of the following tests will diagnose pulmonary embolism m
ost accurately in this patient:

1. Perfusion lung scan

2. Perfusion/ventilation lung scan
3. Chest CT angiography
4. Serum D-dimer
5. Pulmonary function test with effusion
 Pulmonary Embolism

 D-Dimer – excellent to rule out DVT/PE

- Remember!! Rule out and not Rule in!
- Ddimer is not specific and is also elevated in MI, pneumonia,
Sepsis, cancer,post-operative, 2nd and 3rd trimester in pregnancy.
 To rule in PE >> use CTA.
 To rule in DVT >> use US.
 How do you decide what imaging to use?....

 Page 1912
Calculate wells Score for your patient:

>0 >4

US CTA
29. A 23-year-old medical student complains of anxiety before his anatomy exam.
Based on the attached ECG, which of the following is the most likely diagnosis?

1. Sinus arrhythmia, a benign condition in young adults

2. AV block grade 1
3. AV block grade 2, Mobitz 1
4. AV block grade 2, Mobitz 2
5. Premature ventricular beats (VPB’s)
29. A 23-year-old medical student complains of anxiety before his anatomy exam.
Based on the attached ECG, which of the following is the most likely diagnosis?

1. Sinus arrhythmia, a benign condition in young adults

2. AV block grade 1
3. AV block grade 2, Mobitz 1
4. AV block grade 2, Mobitz 2
5. Premature ventricular beats (VPB’s)
30. Which of the following disease typically causes both stenosis and insufficiency
of the mitral valve?

1. Chordae rupture as a complication of acute myocardial infarct

2. Acute bacterial endocarditis
3. Dilated cardiomyopathy
4. Rheumatic heart disease
5. Blunt trauma to the chest
30. Which of the following disease typically causes both stenosis and insufficiency
of the mitral valve?

1. Chordae rupture as a complication of acute myocardial infarct

2. Acute bacterial endocarditis
3. Dilated cardiomyopathy
4. Rheumatic heart disease
5. Blunt trauma to the chest
Page 1814 and 1818
 RHD of mitral valve –
hockey stick sign

Endocarditis

Chordae rupture
- MI
- Endocarditis
31. A 62-year-old man presents to the emergency room with malaise and
palpitations. His history is positive for paroxysmal atrial fibrillation. Attached is
the ECG script performed immediately.
1. VT
2. VF
3. Atrial flutter
4. Atrial fibrillation
31. A 62-year-old man presents to the emergency room with malaise and
palpitations. His history is positive for paroxysmal atrial fibrillation. Attached is
the ECG script performed immediately.
1. VT
2. VF
3. Atrial flutter
4. Atrial fibrillation with LBBB.
 Atrial fibrillation – Irregular irregularity.

 LBBB:

QRS>120ms
 Atrial fibrillation + WPW >> also wide complex because of accessory pathway
and delta wave:
32. 52-year-old man with advance heart failure (due to several myocardial
infarcts) complains that he is experiencing enlargement and tenderness of the
breast tissue which bothers him over the last months. Which of the following
drugs is responsible for these symptoms?

1. Carvedilol
2. Amiodarone
3. Warfarin
4. Furosemide
5. Spironolactone
32. 52-year-old man with advance heart failure (due to several myocardial
infarcts) complains that he is experiencing enlargement and tenderness of the
breast tissue which bothers him over the last months. Which of the following
drugs is responsible for these symptoms?

1. Carvedilol
2. Amiodarone
3. Warfarin
4. Furosemide
5. Spironolactone

Use eplerenone – doesn’t cause gynecomastia

BB that reduce mortality if Heart failure
with EF < 40% :
 Carvedilol
 Bisoprolol
 Metoprolol
33. A 50-year-old man is admitted for pyelonephritis. During his hospital stay his
pulse goes up to 124 beats/min, ECG shows sinus tachycardia, and rectal
temperature is 39.4°C. Which of the following describes the next therapeutic
step?

1. Treatment with a short term beta blocker such as propranolol

2. Treatment with a short term calcium channel blocker such as ikacor
3. Treatment with an anti pyretic drug such as optalgin
4. Loading dose of an antiarrhythmic agent such as amiodarone
5. Intravenous steroids such as hydrocortisone
33. A 50-year-old man is admitted for pyelonephritis. During his hospital stay his
pulse goes up to 124 beats/min, ECG shows sinus tachycardia, and rectal
temperature is 39.4°C. Which of the following describes the next therapeutic
step?

1. Treatment with a short term beta blocker such as propranolol

2. Treatment with a short term calcium channel blocker such as ikacor
3. Treatment with an anti pyretic drug such as optalgin
4. Loading dose of an antiarrhythmic agent such as amiodarone
5. Intravenous steroids such as hydrocortisone
Sinus Tachycardia

Treat the underlying CAUSE >> Tachycardia will resolve!!

Page 1735
34. A 50-year-old man with a mid-systolic crescendo-de-crescendo murmur.
Which of the following heart defects cause this kind of murmur?

1. MR
2. MS
3. AR
4. AS
5. VSD
34. A 50-year-old man with a mid-systolic crescendo-de-crescendo murmur.
Which of the following heart defects cause this kind of murmur?

1. MR
2. MS
3. AR
4. AS
5. VSD
35. An examination of 24 year old male reveals continuous murmur heard over
both systolic and diastolic.
Which of the following action regarding this murmur is the most appropriate?

1. follow up as an out patient

2. 1-2/6 murmur does not warrant further work up
3. 3/6 or more murmur warrant a referral for echocardiograph
4. the patient should be referred for echocardiogram
35. An examination of 24 year old male reveals continuous murmur heard over
both systolic and diastolic.
Which of the following action regarding this murmur is the most appropriate?

1. follow up as an out patient

2. 1-2/6 murmur does not warrant further work up
3. 3/6 or more murmur warrant a referral for echocardiograph
4. the patient should be referred for echocardiogram
Heart murmurs
Page 242:
36. A 69 year old woman complains of dizziness and fatigue, while lying down her
blood pressure is 145/70, pulse 82. 3 minutes after standing up, her blood
pressure is 140/68, pulse 91. Can the diagnosis of orthostatic hypotension be
established?

1. a test wasn't performed right , there should be at least 5 minute wait between
posture.
2. the increase in the pulse rate while rising from lying down to standing up rules
out the diagnosis.
3. the results rule out the diagnosis.
4. orthostatic hypotension can be diagnosed based on the decrease in diastolic
blood pressure.
5. orthostatic hypotension can be diagnosed based on the decrease in systolic
blood pressure.
36. A 69 year old woman complains of dizziness and fatigue, while lying down her
blood pressure is 145/70, pulse 82. 3 minutes after standing up, her blood
pressure is 140/68, pulse 91. Can the diagnosis of orthostatic hypotension be
established?

1. a test wasn't performed right , there should be at least 5 minute wait between
posture.
2. the increase in the pulse rate while rising from lying down to standing up rules
out the diagnosis.
3. the results rule out the diagnosis.
4. orthostatic hypotension can be diagnosed based on the decrease in diastolic
blood pressure.
5. orthostatic hypotension can be diagnosed based on the decrease in systolic
blood pressure.
Page 126
37. A 44 year old male is admitted due to chest pain, ECG was done during the
stay:

1. QT interval is 0.36 second

2. axis is -30 degrees
3. there is evidence of ischemia in inferior lead
4. there is evidence of ischemia in lateral lead
5. lack of normal R wave progressing in the V1-V6 leads
37. A 44 year old male is admitted due to chest pain, ECG was done during the
stay:

1. QT interval is 0.36 second

2. axis is -30 degrees
3. there is evidence of ischemia in inferior lead
4. there is evidence of ischemia in lateral lead
5. lack of normal R wave progressing in the V1-V6 leads
QTC calculation

Lets go back to our question >>>>

QT = 360-380Ms
38. A 52 year old male is admitted due to chest pain, few hours later he
complains of general weakness, his blood pressure is 90/52 an ECG reveals
monomorphic ventrical tachycardia. Which of the following is the most
appropriate treatment?

1. intravenous adenosine
2. intravenous metoprolol
3. intravenous ikacor
4. synchronized defibrillation
5. non-synchronized defibrillation
38. A 52 year old male is admitted due to chest pain, few hours later he
complains of general weakness, his blood pressure is 90/52 an ECG reveals
monomorphic ventrical tachycardia. Which of the following is the most
appropriate treatment?

1. intravenous adenosine
2. intravenous metoprolol
3. intravenous ikacor
4. synchronized defibrillation
5. non-synchronized defibrillation
 Remember !!
Tachycardia + Unstable patient >> CARDIOVERSION.
 Always synchronized Except in polymorphic VT or VF >> UN-synchronized.
39. Which of the following patients diagnosed with heart failure have an absolute
indication for implantable cardioverter defibrillator (ICD)?

1. post myocardial infarction with ejection fraction 55% and sudden loss of
consciousness
2. post myocardial infarction with ejection fraction 28%, no symptoms of heart
failure
3. idiopathic heart failure with ejection fraction 30%, NYHA class 1
4. post myocardial infarction with ejection fraction 25% , NYHA class 4 despite
medical treatment
5. B and/or D
39. Which of the following patients diagnosed with heart failure have an absolute
indication for implantable cardioverter defibrillator (ICD)?

1. post myocardial infarction with ejection fraction 55% and sudden loss of
consciousness
2. post myocardial infarction with ejection fraction 28%, no symptoms of heart
failure
3. idiopathic heart failure with ejection fraction 30%, NYHA class 1
4. post myocardial infarction with ejection fraction 25% , NYHA class 4 despite
medical treatment
5. B and/or D
ICD- Implantable cardioverter defibrillator
 Indications:
- NYHA 2/3 + EF<35% - irrespective of heart failure etiology.
- EF< 31% (even if asymptomatic) – only in IHD patients.

 Not recommended if:

- within 40 days of myocardial infarction.
- Terminal illness with life span < 6 months.
- NYHA class 4 who are not candidates for heart transplant.
- If NYHA class 4 + candidates for CRT >> implant CRTD!!
40. Which of the following sentences, according aortic valve replacement
comparing cardiac catheterization to other therapeutic options, is correct?

1. It’s an experimental, not routinely therapeutic option.

2. In high risk patients, one or two survival rates following valve replacement by
cardiac catheterization is comparable to survival after surgical valve
replacement.
3. In high risk patients there are better results with medical treatment
compared to valve replacement by cardiac catheterization.
4. AV block do not occur following replacement by cardiac catheterization, as
opposing to post surgical valve replacement.
5. In valve replacement by cardiac catheterization a mechanical valve is
implanted and therefore anticoagulation is warranted for life.
40. Which of the following sentences, according aortic valve replacement
comparing cardiac catheterization to other therapeutic options, is correct?

1. It’s an experimental, not routinely therapeutic option.

2. In high risk patients, one or two survival rates following valve replacement by
cardiac catheterization is comparable to survival after surgical valve
replacement.
3. In high risk patients there are better results with medical treatment
compared to valve replacement by cardiac catheterization.
4. AV block do not occur following replacement by cardiac catheterization, as
opposing to post surgical valve replacement.
5. In valve replacement by cardiac catheterization a mechanical valve is
implanted and therefore anticoagulation is warranted for life.
Surgical AVR <<>> TAVI
Trans-catheter aortic valve implantation
 In Severe symptomatic Aortic stenosis >> We need to Replace the aortic valve.
 Surgical AVR – mechanical / biologic Valve
- mechanical – Coumadin for life
- biological – no need for anti-coagulation
 TAVI – biological, no need for anti-coagulation.

IMPORTANT!!
Page 1807
41. A 31 year old male present with pressing chest pain over the past 3 days, he
also complains of an elevated body temperature, throat pain, chills. The
following ECG has P wave on his admission to the hospital.
Which of the following most likely diagnosis?
41. A 31 year old male present with pressing chest pain over the past 3 days, he
also complains of an elevated body temperature, throat pain, chills. The
following ECG has P wave on his admission to the hospital.
Which of the following most likely diagnosis?

1. pneumonia with symptomatic tachycardia

2. infective endocarditis
3. acute anterior wall myocardial infarction
4. acute inferior wall myocardial infarction
5. pericarditis
41. A 31 year old male present with pressing chest pain over the past 3 days, he
also complains of an elevated body temperature, throat pain, chills. The
following ECG has P wave on his admission to the hospital.
Which of the following most likely diagnosis?

1. pneumonia with symptomatic tachycardia

2. infective endocarditis
3. acute anterior wall myocardial infarction
4. acute inferior wall myocardial infarction
5. pericarditis
42. A 62 years old woman, who has been diagnosed 4 months ago with non small
cell lung carcinoma, presents to the ER with a shortness of breath. Physical
examination reveals dilated veins on the upper chest and significantly congested
jugular veins. Auscultation is normal with good bilateral breathing sounds. BP is
105/67 mm Hg. Which of the following is the most likely diagnosis?

1. Pneumothorax
2. Tension pneumothorax
3. Cardiac tamponade
4. SVC syndrome
5. Malignant obstruction of the main bronchi and lung atelectasis
42. A 62 years old woman, who has been diagnosed 4 months ago with non small
cell lung carcinoma, presents to the ER with a shortness of breath. Physical
examination reveals dilated veins on the upper chest and significantly congested
jugular veins. Auscultation is normal with good bilateral breathing sounds. BP is
105/67 mm Hg. Which of the following is the most likely diagnosis?

1. Pneumothorax
2. Tension pneumothorax
3. Cardiac tamponade
4. SVC syndrome
5. Malignant obstruction of the main bronchi and lung atelectasis
SVC syndrome
SVC Syndrome
treatment
 Non small cell carcinoma – radiation
 Small cell carcinoma/lymphoma – chemotherapy
 Intravascular stent

 Page 511
43. A 64 year old man has been admitted due to impaired consciousness and low
blood pressure. When trying to figure out which type of shock the patient is in,
which of the following points to cardiogenic shock?

1. A
2. B
3. C
4. D
5. E
43. A 64 year old man has been admitted due to impaired consciousness and low
blood pressure. When trying to figure out which type of shock the patient is in,
which of the following points to cardiogenic shock?

1. A
2. B
3. C
4. D
5. E
Shock…
44. A 50 year old male with history of diabetes, hypertension and dyslipidemia
presents with chest pain. ECG shows average inversion of ant wall T wave,
troponin is normal on 3 consecutive tests over 12 hours vital signs are stable.
How would you define this patient condition?

1. cardiogenic shock
2. ST elevation MI(STEMI)
3. non ST elevation MI (non STEMI)
4. unstable angina
5. non cardiogenic chest pain
44. A 50 year old male with history of diabetes, hypertension and dyslipidemia
presents with chest pain. ECG shows average inversion of ant wall T wave,
troponin is normal on 3 consecutive tests over 12 hours vital signs are stable.
How would you define this patient condition?

1. cardiogenic shock
2. ST elevation MI(STEMI)
3. non ST elevation MI (non STEMI)
4. unstable angina
5. non cardiogenic chest pain
 ACS

 Stable angina: angina with exertion, relieved by rest / nitroglycerin.

 Unstable angina: New onset, crescendo, at rest.
 Unstable angina + Troponin = Non ST Elevation MI.

Could have ST – T wave changes but not ST elevation!!

45. An 84 year old woman present with shortness of breath on excretion Echo
reveals an aortic value of 0.6cm with gradient of 60 mmHg on the value what is
the best course of treatment?

1. Treatment of high dose fluid orally

2. Aortic valve replacement surgery
3. Aortic balloon valvuplasty
4. Digoxin
5. Follow up without intubation at this stage
45. An 84 year old woman present with shortness of breath on excretion Echo
reveals an aortic value of 0.6cm with gradient of 60 mmHg on the value what is
the best course of treatment?

1. Treatment of high dose fluid orally

2. Aortic valve replacement surgery
3. Aortic balloon valvuplasty
4. Digoxin
5. Follow up without intubation at this stage
 Aortic Stenosis
AVA<1
or max/median gradient > 53/40
46. A patient with atrial fibrillation is admitted with weakness of his right arm
and dysarthria. During his hospital stay he is diagnosed with an ischemic stroke.
Which of the following long term treatments is most likely to prevent recurrent
strokes?

1. Aspirin
2. Clopidogel ( PLAVIX)
3. Aspirin and Clopidogel (PLAVIX)
4. Anticoagulation
5. Dipyridamol
46. A patient with atrial fibrillation is admitted with weakness of his right arm
and dysarthria. During his hospital stay he is diagnosed with an ischemic stroke.
Which of the following long term treatments is most likely to prevent recurrent
strokes?

1. Aspirin
2. Clopidogel ( PLAVIX)
3. Aspirin and Clopidogel (PLAVIX)
4. Anticoagulation
5. Dipyridamol

Why do we calculate CHADSVASc ?????

To prevent cardio-emboli and CVA!!
ESC GUIDLINES
The END