1. Clinical Scenario History A 79-year-old man is referred to you for a recent episode of syncope. While walking on the beach in Florida, he had sudden loss of consciousness and awoke to find his family looking over him. He does not recall the event, but his daughter states that he fell over without warning. He has never had syncope in the past, but does admit to occasional chest pain and exertional dyspnea.

2. Differential Diagnosis of Syncope Vascular Causes Vascular Causes –Orthostatic Drug induced Drug induced Hypovolemia Hypovolemia –Reflex mediated Vasovagal Vasovagal Carotid Sinus Hypersensitivity Carotid Sinus Hypersensitivity Cardiac Cardiac –Anatomic Causes Aortic Dissection Aortic Dissection Aortic Stenosis Aortic Stenosis Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy Cardiac Tamponade Cardiac Tamponade Myocardial Ischemia Myocardial Ischemia Pulmonary Embolism Pulmonary Embolism

3. Differential Diagnosis of Syncope Cardiac (Continued) Cardiac (Continued) –Arrhythmias Bradyarrhythmias Bradyarrhythmias Tachyarrhythmias Tachyarrhythmias

4. A physical examination reveals a blood pressure of 132/76 mmHg and a heart rate of 72 bpm. His lungs are clear. There are delayed and subdued carotid upstrokes with a loud, late- peaking, systolic crescendo-decrescendo murmur over the sternal border near the 2nd intercostal space. The second heart sound is faintly audible. Pulses are 1+ in all four extremities, there is no edema. Clinical Scenario #1 Physical Examination

5. Question The most likely cause of this patient’s syncope is: a.acute myocardial infarction a.acute myocardial infarction b.vasovagal syncope b.vasovagal syncope c.orthostatic hypotension c.orthostatic hypotension d.aortic stenosis d.aortic stenosis e.mitral stenosis e.mitral stenosis

6. The most likely etiology of this patient’s problem is: a) Rheumatic Fever b) Endocarditis c) Connective Tissue Disorder d) Bicuspid Aortic Stenosis e) Senile Degeneration

7. Which pressure tracing would best represent this patient’s condition? A. B.

8. Which pressure tracing would best represent this patient’s condition? C. D.

9. Clinical Scenario #2 A 50-year-old man presents to the urgent care clinic for evaluation of substernal chest pain. Over the past 2 weeks, he has experienced similar chest discomfort that is brought on by light exertion, relieved with rest, and has increased in frequency and duration. He describes having had an episode of chest pain at rest, lasting for 40 minutes, which prompted him to seek medical care. He is currently pain free.

10. The most likely diagnosis of this patient’s problem is: a) Stable Angina b) Pulmonary Embolism c) Myocardial Infarction d) Aortic Dissection e) Unstable Angina

11. Clinical Scenario #2 You send him to the emergency department immediately for further evaluation. A chest radiograph shows mild cardiomegaly. His complete blood count is normal, his creatinine is 0.9 mg/dL, his creatine kinase is 104 mg/dL with an MB index of 1.0, and his cardiac troponin is normal.

12. Which therapy has not been shown to improve mortality in this clinical situation? a) Aspirin b) Nitroglycerin c) Heparin d) Statin therapy e) Beta blocker f) None of the above

13. Following administration of this therapy the patient develops recurrent chest discomfort, you immediately obtain a 12 lead EKG which is shown below.

14. The most likely source of this patient’s problem is the: a) Right Coronary Artery b) Left Anterior Descending Coronary Artery c) Left Circumflex Coronary Artery d) Left Main Coronary Artery

15. His discomfort is unrelieved with additional Nitroglycerine administration. What is your next step in the management of this patient a) He gives no history of active bleeding or recent stroke so you administer thrombolytic therapy. b) The cath lab will be ready to accept the patient in 2 hours, so knowing results are better with PCI you get him ready for the cath lab. c) He already has had relief of his pain once so you administer additional NTG and consider adding additional platelet inhibitor therapy. d) You call the surgeon for emergent coronary bypass surgery.

16. While therapy is being considered the patient develops the following rhythm. What is the rhythm? a) Sinus with premature atrial complexes b) Sinus with first degree heart block c) Sinus with Type I second degree block d) Sinus with Type II second degree block e) Complete heart block

17. The rhythm improves after some time, and his chest discomfort eventually subsides with treatment. His enzymes demonstrate typical progression following reperfusion. A day later the patient suddenly develops dyspnea while laying in bed, he becomes diaphoretic. You are called to see the patient. You enter his room to find him breathing rapidly. His blood pressure is 88/50, his pulse is 120, he has rales on pulmonary exam, his heart is tachycardic but you hear an S3 and a grade 3/6 holosystolic murmur at the apex radiating to the axilla.

18. The most likely cause of this patient’s murmur is: a) Rupture of the papillary muscle leading to mitral regurgitation b) Rupture of the ventricular septum leading to a VSD c) Rupture of the aortic leaflet leading to acute aortic regurgitation d) Pericardial inflammation leading to a pericardial friction rub

19. Which pressure tracing would best represent this patient’s condition? A. B.

20. Which pressure tracing would best represent this patient’s condition? C. D.

21. A 58-year-old postmenopausal woman comes to your office for a routine physical examination. She does not have a history of coronary artery disease or diabetes mellitus. She smokes one pack of cigarettes per day. Family history is negative for premature coronary artery disease. Her physical examination is unremarkable. Blood pressure is 130/85 mmHg. Laboratory data shows: Plasma glucose (fasting)100 mg/dL Plasma total cholesterol238 mg/dL Plasma HDL cholesterol45 mg/dL Plasma LDL cholesterol166 mg/dL Serum triglycerides135 mg/dL Liver function testsNormal

22. Which of the following is most appropriate? a.no specific therapy a.no specific therapy b.smoking cessation and repeat lipid profile in 3 months b.smoking cessation and repeat lipid profile in 3 months c.smoking cessation and therapeutic lifestyle changes (TLC) with goal LDL of <160 mg/dL c.smoking cessation and therapeutic lifestyle changes (TLC) with goal LDL of <160 mg/dL d.smoking cessation, TLC and repeat lipid profile in 3 months, with goal LDL of <130 mg/dL d.smoking cessation, TLC and repeat lipid profile in 3 months, with goal LDL of <130 mg/dL e.initiation of pharmacological therapy with goal LDL of <100 mg/dL e.initiation of pharmacological therapy with goal LDL of <100 mg/dL

23. Risk factors for Coronary Artery Disease Male >45 Male >45 Post menopausal female Post menopausal female Family History of CAD (<55 years old) Family History of CAD (<55 years old) Cigarette smoking Cigarette smoking Hypertension Hypertension Diabetes mellitus (treated or not) Diabetes mellitus (treated or not) Elevated cholesterol Elevated cholesterol

24. Treatment of Elevated Cholesterol Without CAD Without CAD –One risk factors Goal = LDL<160 Goal = LDL<160 –Two or more risk factors Goal = LDL<130 Goal = LDL<130 With CAD With CAD –Goal = LDL<100(70)

25. Pulsus parodoxus is most characteristic of which of the following conditions? a) Aortic stenosis b) Aortic regurgitation c) Cardiac tamponade d) Ventricular septal defect e) Atrial septal defect

26. Pulsus Paradoxus A decrease of >10 mm Hg in systolic blood pressure during inspiration A decrease of >10 mm Hg in systolic blood pressure during inspiration Because of an increase in intrapericardial pressure, left atrial and left ventricular pressures remain fixed so that during inspiration there is a decrease in left ventricular stroke volume Because of an increase in intrapericardial pressure, left atrial and left ventricular pressures remain fixed so that during inspiration there is a decrease in left ventricular stroke volume

27. Which of the following pharmacologic agents have not been shown to improve mortality in the treatment of dilated cardiomyopathy? a. Beta-blockers b. Angiotensin converting enzyme inhibitors c. Digoxin d. Angiotensin receptor blocker e. Spironolactone

28. A 60-year-old male with a history of hypercholesterolemia and smoking reports a 2-year history of substernal chest discomfort precipitated by exertion and relieved by rest. In the past several weeks, the pain has become more frequent and is precipitated by less exertion. a.acute myocardial infarction a.acute myocardial infarction b.unstable angina b.unstable angina c.stable angina c.stable angina d.pulmonary embolism d.pulmonary embolism e.spontaneous pneumothorax e.spontaneous pneumothorax f.pericarditis f.pericarditis g.costochondritis g.costochondritis h.aortic dissection h.aortic dissection I.coronary artery spasm I.coronary artery spasm

29. a.acute myocardial infarction a.acute myocardial infarction b.unstable angina b.unstable angina c.stable angina c.stable angina d.pulmonary embolism d.pulmonary embolism e.spontaneous pneumothorax e.spontaneous pneumothorax f.pericarditis f.pericarditis g.costochondritis g.costochondritis h.aortic dissection h.aortic dissection I.coronary artery spasm I.coronary artery spasm A 36-year-old man presents with intermittent, sharp, mid-sternal chest pain. The pain is somewhat worse with inspiration and is associated with mild dyspnea. Several weeks prior, he and his children had cold symptoms.

30. a.acute myocardial infarction a.acute myocardial infarction b.unstable angina b.unstable angina c.stable angina c.stable angina d.pulmonary embolism d.pulmonary embolism e.spontaneous pneumothorax e.spontaneous pneumothorax f.pericarditis f.pericarditis g.costochondritis g.costochondritis h.aortic dissection h.aortic dissection I.coronary artery spasm I.coronary artery spasm A 45-year-old man presents with sudden, severe, sharp chest pain that radiates to his back. On examination, his weight is 160 pounds; his height is 72 inches. His heart rate if 110 bpm. His blood pressure is 124/70 in the left arm and barely palpable in the right arm.