CARDIO Questions

CARDIOLOGY KAPLAN Qs 183qs TOPIC/Concept Sick Sinus Syndrome = Chronic state of SA node dysfunction or a sluggish or absent SA node pacemaker

Explanation Presentation Tx: Venticular Pacemaker implanted 68yoM checkup after his Acute MI a year ago. Said feeling fine Sx: until 6wks ago started having 1. SOB Palpitations, and feel fatigued 2. Palpitations and SOB. Holter monitor 3. Angina revealed Bradycardia with brief episodes of Atrial Flutter. BP Alternating Bradycardia & 110/75, 50bpm, Resp 15. Supraventricular Tachycardia… Management for this pt? commonly with underlying Atrial Fibrilations or Atrial Flutter = Ventricular Pacemaker Goal: Terminate the BradycardiaTachycardia

Stage 1 HTN: 140/90 to 160/100 Need HTN diagnosis after confirmed elevated BP 3 separate occasions. AGE is big RF

1st: if Stage 1 w/o Comorbidities (CHF, DM, CKD) *Exercise, Diet, + Thiazide (Not Diet, Exercise only…or extra meds) IF Thiazide Max but not reaching BP goal… use 2nd agent: ACE-I or BB can be added

63yoF. BP 147/93…she returns 2 wks later her BP is 148/95, another 2 weeks: 152/98. Which is most appropriate intervention?'

HMG-CoA Reductase Atorvastatin inhibitors (Statins) - DOC to Reduce LDL Statins most POTENT & well tolerated by pts than other lipid lowering meds. Risk: Myositis. Routine LFT ordered (bc SE: Liver Inflammation)

40yoM. Cholesterol panel: Elevated LDL & Low HDL. Diet & excerised done..6mo later HDL normal, but LDL Elevated still. Next Step?

Variant Angina (Prinzmetal) - Transient ST-segment DEPRESSION Coronary vasospasm… in INFERIOR leads angina-like sx. = Classic: Awakens pt from Angina-like sx at rest…due to Sleep coronary vasospasm. Associated w/Vasospatic condition clues: Raynauds Pts w/Prinzmetal: Younger, likely Women. worsens by Cocain, Sumatriptan. (Exercise-Hyperventilation induces MC: RCA…Inferior heart sx…via Alkalosis…vasoconstriction)

30yo Asian F chest pain. Last 2 years has had intermittent nocturnal chest pain lasts up to 10mins. Pain is substernal & heavy pressure radiates to throat. Has Raynaud phenomenon. Social hx occasional use cocaine. EKG unremarkable. Given this pt's likely Diagnosis, which likely finding on Holter monitor during chest pain?

Pericarditis: EGK: *Diffuse ST-segment Elevation, *PR-segment Depression Acute Coronary Sd: Unstable plaque is partially or intermittently obstructs blood flow: Transient ST-Depression 3 separate diagnoses: Unstable Angina, NSTEMI, STEMI

ASPIRIN = ↓Mortality If pt presents with ACS: *New onset chest pain *Worsening pattern *Pain at rest

72yoF chest pain. 2hrs ago was watching tv when she felt a dull pain that radiated to the jaw. Chest tightness and SOB. She had similar pain before, mostly with exertion. PE: clutching her Next step always: ASPIRIN (to chest in pain & sweating ↓platelet thrombus progression) profusely. CVS exam: Distant heart sounds. No STelevation or Oxy, Morphine, Nitrates: Left Bundle branch block. All ACS should be treated with 100% Which steps in Management Oxy, Morphine, Nitrates…but none will give greatest reduction in of these has PROVEN to ↓Mortality MORTALITY?

Diastolic Dysfunction: *↓HR via BB or CCB…to ↑time for Ventricles to fill during Diastole *ensure BP is controlled *prevent further myocardial hypertrophy with ACE-I or ARBs *Prevent remodeling and regress hypertrophy with Spironolactone/Aldosterone antagonist *Avoid BB in COPD or Asthma pt

Verapamil

60yoF h/o HTN, COPD…has SOB. Says has 6mo h/o Hypertrophy dt long HTN…get progressive worsening SOB Diastole dysfunction: Concentric while climbing stairs. Barrelhypertrophy → shaped chest, prolonged 1. SOB on exertion (EDV↓…preload wheezes. Transthoracic echo backs up into lung congested shows Diastolic LV Dysfunction. exertional SOB).... so relax heart Which is Next Best step? during DIASTOLE to improve fill pressures: 1st DOC: BB.... but Pt has COPD (so can't do BB) 2nd line: CCB- Verapamil/Diltiazem = Negative Inotrope...relaxes the LV during diastole 1) Prevents heart relax in diastole can't fill 2) Time in diastole is shortened during Tachycardia

BB: blocks B2-receptors in lungs… lead to bronchoconstriction & ↓lung function Dobutamine only use if pt has Acute Pulmonary Edema, and doesn't respond to IV Loop, Nitrates, Morphine (goal: ↓Preload)

Dobutamine is Positive Inotrope….doesnt relax the LV. *Decreases Afterload….get severe Hypotension

Hypertrophic BB: Metoprolol Cardiomyopathy: *Syncope in Young pts. BB help SLOW Ventricle Rate…. To *Valsalva: ↑Murmur ↑Ventricle Fill time (Any maneuver that decreases LV size → ↑Murmur = obstructive part ↑ as LV cavity shrinks)

21yoF professional dancer… several episodes of near loss of consciousness. No famHx. BP 142/88. PE: brisk carotid upstroke with a double impusle palpable. Loud S4 & harsh systolic murmur -left sternal border. Murmur accentuated during VALSALVA. ECG: LV Hypertrophy. Which drugs most appropriate for this pt?

ACE-I: -pril → ↓Afterload → drop in Pressure gradient across aortic valve….exacerbates/worsens the outlet obstruction (in HCM) Digoxin: ↑Contractility…worsens outflow obstruction of HCM Loop decreases preload: leads to worsening the outlet obstrction

CABG: indications 1) Stenosis of Left main, 3vessels, 2vessels in DM

Coronary artery bypass using INTERNAL MAMMARY Artery

CABG > angioplasty. 2)PCI: percutaneous *3 or more stenotic vessels or coronary intervention…used disease of the Left Main coronary in pts with symptoms artery 3) Internal Mammary artery Internal Mammary artery > is donor best vessel for saphenous vein bc saphenous get coronary artery bypass graft occluded after 5yrs. Internal mammary = good for 10yrs

55yoM has progressive, unstable angina that doesn't respond to meds. H/o DM2 & hypercholesterolemia for past 20yrs. Two of his brothers had MI @50yo. Cardiac catheterization shows 70% occlusion of two coronary arteries, includes Anterior descending EF is 55%. Next best step in management?

Angioplasty & Stents better for ISOLATED vessels rather than multivessel CAD

Mitral Valve Replacement in Percutaneous BALLOON Pregnancy vavuloplasty

25yoF 24wks gestation…has worsening dyspnea & orthopnea over past 10days. *Pregnant w/symptomatic *pt has Life-threatening Pulmonary Treat w/Furosemide but no Mitral Stenosis…failed meds Edema in setting of Mitral Stenosis. improvement. h/o rheumatic → next: Balloon Valvoplasty (Fluid Overload) heart disease & mitral stenosis. is most effective (Save the mom is main concern) PE: JVD, Bilateral Crackles. Best next step management? *Mitral valve replacement is Mitral Steonsis+Pregnant: do risk to Mom & Fetus Percutaneous Balloon Valvuloplasty (Not: urgent C-section)

Pregnant Woman….DO NOT use ACE-I bc can have Renal Defects to Fetus

Digoxin Toxicity: *N/D/Fatigue, Somnolence *Visual alterations (confusing green with yellow halos) *Arrhythmias… (SCOOPED ST-segments or reverse Check sign) Toxicity: get AV node blocked, ↑Automaticity of Ventricles…includes junctional myocardium 1st: Atropine 2nd: Check Digoxin Levels (to see if immune Fab needed)

Digoxin Levels Not: "Digoxin immune Fab" Initial Step in treating Symptomatic Bradycardia: improve the hemodynamics Renal Failure can worsen digoxin toxicity…↓digoxin clearance *Quinidine, Amiodarone, Spironolactone, Verapamil → ↑Digoxin toxicity bc inhibits Renal secretion of Digoxin Atropine ist 1st to tx: Symptomatic Bradycardia with signs of Hypoperfusion

68yoF Nausea, dizziness, SOB, somnolence, fatigue. Began sx 4 days ago. PE: BP 98/46, she appears uncomfortable. Vision confuses green for yellow. Lung prolonged expiratory phase, mild crackles at bases. 1+ pitting edema. CXR: large cardiac silhouette, flattened diaphragms. Atropine given...new BP 115/85. Next Step?

Diastolic LV Dysfunction: dt HTN…Concentric Hypertrophy… heart can't relax during diastole Sx: Dyspnea on exertion Rx: ACE-I Goal: HR 55-60bpm (if push HR down, heart spends more time in Diastole…more time in Diastolic Filling) [Can use CCB: Verpamil or Diltiazem...but don't want HR 10mmHg with Normal Inspiration) Next Best Step: Pericardiocentesis

Pericardiocentesis followed by pericardial window

48yoM chest pain. Suddenly felt dull, crushing chest pain that radiated to jaw and left Cardiac Tamponade: arm. PE: Sweating. Muffled *↓BP, TachyC, Pulsus Paradoxus, heart sounds that are regular Clear breath sounds rate and rhythm. EKG: STEMI… = Real Emergency had PCI. BP drops to 105/55, Need immediate Decompression by Pulse 120/min. Jugulovenous Pericardiocentesis followed by Distension. BP rechecked BP Pericardial Window between 110/55 and 95/55 Management? Cardiac Tamponade… Lt & Rt ventricles get SQUASHED by blood/fluid collection in Pericardial Sac → ↓Capcity of Both Lt & Rt Ventricles. Inspiration → Contracts Diphragm → Returns Blood to Rt Ventricle. So the Already squished Lt ventricle gets more Squashed by Enlarging Rt Ventricle...so can't keep Contraction during Systole → DROP SBP during Systole Vs: Rt Ventricle Infarct...there's NO Pulse Paradoxus. bc heart is Not being Squashed, and any increase in Volume in Rt Ventricle is accommodated by Pericardial Sac.

MI - Inferior Wall: Fluids = Impairs LV filling….get ↓CO Swanz-Ganze shows Elevated Rtsided Pressure and Low filling pressure.

62yoF…has Acute inferior MI. She's oliguric and has BP 80/55. Swan-Ganz catheter is placed… shows diminished Pulmonary Capillary Wedge of 4mmHg. Normal Pulmonary Artery RV Infarct: get ↓Cardiac Output…bc Pressure of 22/4mmHg. Insufficient Lt heart filling Increased mean Rigth arterial pressures…. pressure of 11mmH. Which is RV infarct causes Back up of Venous Next best Step? Blood and Decreased Forward Flow….get ↓LV filling (Low Wedge Pressure) Tx: IV FLuids ..Then Cardiac Catherization (Balloon Angioplasty)

AORTIC STENOSIS *Progress to Angina, Syncope, HF

Decrease intensity of murmur

64yoF comes to ED intermittent chest discomfort. Substernal Hand Grip: compresses forearm pressure occasionally radiates muscles on ATERIOLES → to Left arm and last approx Sx: CP, Dizziness or syncope, Afterload↑. When Afterload 10mins. ..PE: Delayed carotid HF increases, heart can't pump out Upstroke and systolic ejection enough blood…leads to Reduction in murmur 2nd intercostal space SV and ↑ESV. Causes ↑LV Volume right border. Pt does HANDGrip maneuver. Effect likely seen?

CONCENTRIC HYPERTROPHY Hypertension Chronic HTN → Concentric Hypertrophy → Diastolic Dysfunction

Hypertensive Emergency: *Chest discomfort *Papilledema *BP 220/115 best agents: *Labetalol *Nitroprusside

64yoF obese h/o Alcoholism. SOB. Progressive worsening DOC: for Diastolic HF (hypertropy) dyspnea while climbing stairs. BB No CP. BMI 40. Echo shows diastolic LV dysfunction. Likely BB: ↓BP & ↓HR to allow improved cause of her symptoms? Ventricular Filling

Intravenous Labetalol

60yoM Chest pain. Long hx of CAD & HTN and status post Labetalol is combined: Betacoronary bypass procedure 6yrs Adrenergic & Alpha-Adrenergic ago. Pt has chronic stable blocker. angina that's precipitated by activity and relieved by rest. Rapid onset (5mins) - useful for Meds: aspirin, captopril, Hypertensive Emergencies metoprolol. 3wks ago was prescribed sildenafil. BP: Labetalol is safe in pts with Coronary 220/120, Papilledema on disease ocular exam. EKG nonspecific changes. Which is best Avoid Labetalol in Asthma, COPD, HF, treatment indicated at this Bradycardia, Greater than 1st degree time? heart block.

Cold leg & Acute Ischemia Atrial fibrillation → Peripheral arterial Embolization & Cold Leg = Surgerical Emergency.

Emergently transfer to operating room for EMBOLECTOMY.

55yoF long standing h/o Arterial Fibrillation 2/2 Mitral Regurage…comes to ED with *Important in management of cold painful right foot. Past few leg & acute ischemia of lower limb = hours, her foot has become Embolectomy more painful and now is nearly insensate. Pains is Burning. Irreversible damage to tissues occurs Right foot is gray and cool to after 4-6hrs, so need touch, has poor capillary refill. revascularization Dorsalis pedis & posterior tibial 1) Embolectomy pulses are absent on the right. 2) then Anticoagulation - Heparin PT is 14s. (INR 1.4). What's next (but make sure pt NOT allergic to step? Heparin)

Left Heart Failure (paroxysmal nocturnal dyspnea, orthopnea, occasional dyspnea)…has Mitral Regurge. = Pansystolic Murmur best heard at apex, radiates to axilla.

Valve REPAIR AS: Replace MS: Angioplasty MR: Repair EF: 10mmHg with Normal Inspiration)

RV infarct: NO Pulsus Paradoxus

Tx: Pericardiocentesis & Pericardial window (moa: L&R ventricles squashed by collection of blood in pericardial sac)...can't fill

Atropine used in cases of bradycardia (muscarinic-R) Tachycardic in this RCA-MI pt already has overproductive SNS. Atropine blocks M-receptors= ↓Parasym. Tone…. Give atropine to this pt can cause more tachycardia (↑Increased sym. Tone) → induce another MI

Emergency Bypass = for pt in Severe Pt who is decompensating CHF post-MI rapidly (CHF), with right & left HF but no murmur to explain [r/o CHF: lungs CTA) the HF….(=Valve rupture is common Post-MI) = do Emergency Bypass Cardiac Risk factor: *Family h/o Heart disease *Age *Fasting Lipid *DM *CHD RF: smoking, HTN USPSTF: recommends start dyslipidemia screen Men: @20-35yo Women: @20-45yo

Fasting Serum Lipid Studies

55yoM…comes for check up. Everything looks normal, but has Family history: mother with stroke, brother with MI at 50yo, Father died MI 58. BP 142/78. Which is most appropriate screening test for this pt?

If evidence of *TIA: Transient Ischemic Attack *Stroke sx *Bruit heard

Order: Carotid Artery Duplex studies

MI. (+digoxin use)

Echocardiogram

Coronary Artery Bypass Graft & PCI: Percutaneous Coronary Intervention: *Only when MI diagnosis confirmed before mapping out coronary arteries with angiography

Echo: *Diagnose Acute Ischemia: LBBB, LVH, Pacemaker, Non-specific ST-T segment changes on resting EKG, Young females

56yoF h/o Atrial fibrillation, complains of CP. Currently on Digoxin: for Afib controls Pt whom diagnosis of MI is difficult Digoxin. 1 hour ago she's felt ventricular rate. But it due to Nonspecific or Nondiagnostic sudden, dull pain in chest and interrupts EKG interpretation EKG change, next step: Confirm left arm. P 132, BP 105/70. when pt has Acute Coronary diagnosis with: Sweats. PE: Muffled heart Sd....causes NONSPECIFIC *Cardiac Enzymes or ECHO (see wall sounds. Initial EKG elevated JEKG Chnages motion abnormalities indicative of Point, non specific ST changes. *EKG can't be read as having Ischemia) Next Step? ST-seg elevation bc effects of Digoxin obscure these (Next step is NOT EKG). If can't read changes EKG, do echo.

1-2Vessel Dz: Tx: PCI-Balloon & Stent 3-Vessel Dz or Lt Main CAD: Coronary bypass Graft

Unstable Angina dt LEFT MAIN CAD → NSTEMI: Occlude Lt Main coronary artery. = Immediate Coronary Artery Bypass Grafting

Coronary Artery bypass Grafting

68yoM. Compalins of dull, central chest pain and CABG: tightness. Pt feels SOB. PE: *Left Main Coronary Stenosis >50% Sweating profusely. Distant *Lt main equivalent: 70% stenosis of heart sounds, regular rate and PROXIMAL LAD, Lt Cx rhythm. EKG: No ST-elevation. *3 vessel Disease Cath lab, Coronary Angiogram [Case: Unstable Angina due *Symptomatic Acute Coronary Sd shows 60% occlusion Left Main to LEFT MAIN CAD] with ongoing Ischemia…not coronary artery. Next best [Lecture] responsive to Maximal Nonsurgical Step? Therapy

Cocaine-induced cardiac ischemia. Rx: IV Diazepam Acromegaly pt case 1) Order IGF-1 Renal Artery Stenosis → HTN this case.

Renal Artery Stenosis:

68yoF. Difficult to control HTN. She has 3year h/o HTN and HTN in this case: Clues: documented intolerance of Essential HTN is MCCO HTN 1) sensitive to ACE-I ACE-Inhibitors-see by rapid (91%) 2) ↑Creatinine decline in her renal function. 3) her CHF She has had 2 episodes of Acute Pulmonary Edema in [moa: Renal Artery Stenosis depends past. 2 weeks ago her Cr: 1.3mg on Vasoconstriction of Efferent and UA: Microscopic arteriole to maintain GFR. But ACE-I hematuria. BP: 180/100. PE: abolish vasomotor tone in the Prominent Apical impulse. Efferent Arteriole → results in Which most likely cause of this Worsening renal function]...renal pt's HTN? improves by removing ACE-I

Coarctation of Aorta= Pulses Equal & Symmetrical *Pt die YOUNG if defect not corrected in Childhood AAA: Abdominal Aortic Aneurysm

Abdominal U/S: ultrasound

74yoM abdominal pain. Midumbilical region dull, aching, *Cost Effective screening. constant pain. Pain persisted *Definitive test when AAA suspected over past few days with (Sensitivity & Specificity almost increasing intensity, and not 100%) relieved by changes in positioning or eating. Pulsatile (CT scan of abdomen w/IV contrast… mass in abdomen. Diagnostic is 2x expensive as U/S. Exposes pt to test at this time? unnecessary radiation) - CT abdomen usually preop so surgeon can develop plan

MRI: detects abscesses or spinal cord compression DM+HTN…Proteinuria Rx

Start Lisinopril

66yoF recent DM2. Her BP 3 months ago was 140/95, BP must be well controlled to exercise and eat a low-salt diet. prevent Nephropathy progression Gain 4.4lb. BP 144/95. Next ACE-I prevents diabetic nephropathy best step?

Acute Coronary syndrome: STEMI

Aspirin, Heparin, Alteplase combo

74yoM Stable angina & diaphoresis. BP 145/93. PE: STEMI: need urgent revascularization JVD+, basilar crackle, peripheral w/n 90mins need procedure: pulses faint. CXR: Pulmonary Angioplasty & Stent edema. EKG: inferior STsegment elevations. Closes >90mins delay: give Thrombolytics hostpital with angioplasty is (Alteplase) - 25% mortality 2hours away. Which drugs reduction most appropriate? LMWH > unfractionated heparin

Subacute Bacterial Endocarditis: - MR

TEE: Transesophageal enchocardiogram to see if has Valve Vegetation…to estimate degree of Mitral Valve destruction TEE > TTE if other is not possible. TTE=less sensitive/doesn't help tell amount of damage to valve

Intracardiac lesion - dt large Intracardiac Lesion Lt Atrial MYXOMA *Mid-diastolic rumble best heard at Obstruction Sx. apex = Mitral Stenosis or Large Atrial MYXOMA (= MC cardiac Emboli: to CNS, Lower limbs tumor = obstructs Mitral Valve) etc. *Neuro: arm weakness…bc Tumor Emboli…Low fever = a tumor

40yoM 2week h/o fever, anorexia, weight loss, fatigue. PE: appears ill, T: 102, few petechiae in both eyes. CVS: III/VI pan systolic murmur max at apex and radiates to axilla, and pericardial rub. Blood drawn and culture. Which is diagnostic test most likely to confirm diagnosis?

58yoF. Episode of Left upper arm weakness resolved after 6 hrs. Low fever last month. Middiastolic rumbling murmur on fifth intercostal space at midclavicular line. Sent for Echo. What's likely to reveal?

Acute Pulmonary Edema dt CHF Rx: 1) IV Loop-furosemide, Nitrates, Morphine

Intravenous loop diuretic, nitrates, morphine = Reduces PRELOAD (associated with Acute Pulmonary Edema) (Loop - venodilation then diuresis… moves fluid from lungs to circulation, then expelled to urine → ↓VR) Nitroglycerine: venodilates, dilates epicardial coronaries...tx: ischemia Morphine: ↓Anxiety, ↓Sympathetic outflow, Venodilates & ↓Preload...help relieve pulmonary edema

MUGA scan: (multigated acquisition) inject 99mTc - attaches to RBC …outlines cardiac chambers - LV by imaging the isotope in central circulation during systole & diastole. Determines EF in pts with sx of Chronic Heart Failure (Invasive…not for acute setting, or acute pulmonary edema)

Aortic Coarctation *usually asymptomatic *Lesion found on PE.

Aortic Stenosis:

30yoM. BP 160/70. PE: Brachial pulses more prominent than femoral, popliteal, dorsalis Coarctation of Aorta associated with pedis pulses. CT scan of chest IF Symptomatic: several cardiac lesions: w/contrast shows coarctatino *Headaches, Nosebleeds, sx: *VSD of aorta just above ligmentum ↓Lower limb perfusion *Bicuspid Aortic Valve arteriosum. Which conditions *Lt Ventricular Hypoplasia likely associated with pt's condition? Bicuspid Aortic Valves are associated with higher rate of aortic stenosis & insufficiency

PTCA: Percutaneous Transluminal Coronary Angioplasty with stent insertion: 2 vessel disease

PTCA

unless: *Lt Main stenosed (urgent bc if thrombosed....then all 3 major Important Exception is DM coronary a. blocked)or pt…Tx: Coronary Bypass even *3vessel disease if 2 vessel disease present *significant Lt equivalent disease (DM with Non-ST segment (>70% stenosis of Proximal LAD, elevations + 2vessel Proximal LCx) disease….↓Mortality 2-5yrs) = do Coronary Artery Bypass Grafting

BLOCK 7 Femoral Pseudoaneurysm: complication of cardiac catheterization

Femoral pseudoaneurysm *Pulsatile mass *Femoral Bruit *Loss distal pulses/cool mottled lower limb Confirm: Ultrasound of groin

Cholesterol Emboli Syndrome: complication to recognize in postcatheterization patient

Cholesterol emboli presents with Skin findings: *Distal extremities of Livedo Reticularis, Ischemic Ulcerations, Cyanosis, Gangrene, Subcutaneous nodules

Med SE: Started new med (ACE-I), gets Cough… now switch to Losartan (ARBs)

Stop Fosinopril and replace with Losartan ACE-I get dry cough dt ↑Kinin levels

68yoF CP. Dull CP everytime she walks her grandchildren to school. Now she stops and rest for 5 mintues so pain could subside. Denies CP at rest. LDL 140, statin added. Coronary angiography shows patchy disease in distal part of LAD & distal part of Circumflex. Next best step?

68yoF underwent cardiac catheterization via right femoral artery earlier in the morning. She's no complaining of a cool right foot. PE: Pulsatile mass over her right groin with loss of her distal pulses, auscultation bruit over point which right femoral artery entered. Diagnosis?

48yoF persistent dry cough….currenty taking fosinopril….

Aortic Valve Replacement Clear the patient for hip surgery indications in Aortic Stenosis pt: 1) Severe AS+Sx 2) Severe AS in pts undergoing CABG or Valve repair 3) Severe AS with LV EF 100 *Pwaves preceds normal QRS Tx: 1st: VAGAL maneuvers: Carotid massage - usually

Synchronized cardioversion: for Hemodynamic unstable patients (Unconsciousness or shock w/severe HF) = need immediate termination of Tachyarrhythmia

But this Pt has Soft Blowing murmurs on neck auscultation = bilateral Carotid stenosis = so CAN'T Do carotid massage Next best: Valsalva

66yoF palpitations, SOB, lightheadedness. h/o HBP takes water pill. BP: 105/65, P 152, R: 16. PE: distress, ausculation of neck - bilateral bruit, CVS: distant heart sounds, no rubs or gallops. EKG shows…. NEXT BEST STEP?

RV infarct

IV Fluids (to maintain BP)

(Dopamine is useful if IV fluids alone don't help BP… but risk: Cardiac ischemia/pressor)

EKG: ST-elevations (II, III, avF) = RV Infarct

(Metoprolol: can't be used forBradycardia or Hypotension) - No BB for low BP Nitroglycerin: avoid in RV infarcts…bc it's a PRELOAD Reducer…↓RV filling & ↓CO

ST elevation in V4 = is RV infarct specific (now preload dependent….need to keep PRELOAD HIGH)

56yo h/o HTN & Hyperlipidemia. Crushing CP, Diaphoresis, nausea for past 3 hrs. BP 82/60, Pulse 103/min. PE: JVD, no murmurs, clear lungs. EKG shown. Appropriate for this pt?