1. Ischemic Heart Disease Case 1 A 44 year old woman comes to the office complaining of intermittent substernal chest pain for the last several weeks. The pain sometimes happens with exertion, sometimes at rest and there is no fixed pattern. She also complains of nausea. She has no past medical history. A 44 year old woman comes to the office complaining of intermittent substernal chest pain for the last several weeks. The pain sometimes happens with exertion, sometimes at rest and there is no fixed pattern. She also complains of nausea. She has no past medical history. 1. What is the most common risk for coronary artery disease? 2. What three features of chest pain on history or physical on the boards tell you for sure the pain is not ischemic in nature? 3. Her initial EKG is normal. What is the next best step in management? 4. What in the question will make you answer a thallium stress test? 4. What in the question will make you answer a thallium stress test? 5. When is the answer a dipyridamole, adenosine or dobutamine stress test?

2. A 44 year old woman comes to the office complaining of intermittent substernal chest pain for the last several weeks. The pain sometimes happens with exertion, sometimes at rest and there is no fixed pattern. She also complains of nausea. Her stress test is Abnormal. A 44 year old woman comes to the office complaining of intermittent substernal chest pain for the last several weeks. The pain sometimes happens with exertion, sometimes at rest and there is no fixed pattern. She also complains of nausea. Her stress test is Abnormal. 1. What is the next step in management? 2. What is the GOAL of therapy for her LDL? 2. What is the GOAL of therapy for her LDL? 3. What are the coronary artery disease equivalents? 4. What is the most common adverse effect of statins?

3. Case 3 A 68 year old man comes to the emergency department of a small rural hospital in Wyoming with one hour of crushing substernal chest pain after shoveling snow. The pain radiates to his arm and jaw. He is sweating, nauseated and has Levine’s sign when describing the pain. He has a history of hypertension and smokes one pack a day of cigarettes. His initial EKG shows 2 mm of ST elevation in V2-V4. 1. What is the best initial step? 2. When are calcium blockers the answer? 3. When is lidocaine or amiodarone the answer? 4. What is the most accurate diagnostic step at this time?

4. Question Case 3 A 65 year old man comes to the emergency department with 30 minutes of substernal chest pain and ST segment elevation in II, III, aVF. He has received aspirin, metoprolol and undergone angioplasty. Which of the following is most likely to lower his mortality? a. Oxygen b. Nitrates c. ACE inhibitors d. Statins e. Morphine f. Lidocaine f. Lidocaine

5. Question A 64 year old man comes to the emergency department 1 hour after he had 40 minutes of substernal chest pain. He had a non- hemorhagic stroke six weeks ago and currently has a blood pressure of 182/108. The EKG shows ST elevation in V2-V4. He has received aspirin and oxygen. Which of the following is most appropriate in his management? a. Thrombolytics now b. Transfer for Angioplasty c. Nitrates d. Coronary bypass surgery e. Add metoprolol and ACE inhibitors only f. Add metoprolol and ACE inhibitors then give thrombolytics

6. Case 6 A 68 year old man comes to the Emergency Department with one hour of crushing substernal chest pain radiating to his arm and jaw. He has never had chest pain before. The initial EKG has 1 mm of ST depression (or normal) in V2-V4. 1. What is the next best step in management? 2. His pain persists despite this. What will you do next? 3. When are calcium blockers the answer? 3. When are calcium blockers the answer? When you cannot give beta blockers. 4. What should be done in all patients on the following day? 4. What should be done in all patients on the following day?

7. Question A 24 year old man comes to the emergency department with 30 minutes of chest pain that developed after injecting cocaine. His EKG is normal. What would you order first for him? a. Diltiazem b. Metoprolol c. Thrombolytics d. Angioplasty e. Angiography

8. Case 8 A 68 year old man who was transferred from the CCU five days ago after having a myocardial infarction becomes part of your service. He has had no further chest pain or discomfort for the last several days and he feels quite well. He is now ready for discharge. 1. What will you do prior to discharge? -Stress testing 2. Is angiography necessary? 2. Is angiography necessary? Only if the stress test shows significant ischemia 3. When will you answer coronary artery bypass grafting (CABG)? 3. When will you answer coronary artery bypass grafting (CABG)? 4. What will you discharge him on? 5. What advice will you give him? 6. His wife asks you if the patient will have sex with her. What do you tell her?

9. a. Aspirin, beta blockers, ACE inhibitors, Statins b. Beta blockers, ACE inhibitors, warfarin c. Aspirin alone d. Aspirin, beta blockers, warfarin Question Case 8 A patient is being discharged after a myocardial infarction. What will you discharge him on?

10. Congestive Heart Failure Case 1 A 64 year old woman with a history of a myocardial infarction comes to the emergency room with the acute onset of shortness of breath over the last several hours. She can’t remember what medications she is supposed to be using. She has a bag of potato chips in one hand and a pepperoni pizza in the other. On physical examination she has rales to her apices, an S3 gallop, pedal edema which extends to her areola, ascites and jugulovenous distension. 1. What will you do first for her? 2. What is the MOST accurate means of assessing her ejection fraction? 3. What will you do differently if the labs in the case state his baseline creatinine is 2.3? 4. When are angiotensin II receptor blockers the answer?

11. Case 2 Two days later the same patient has completely improved. She is ten pounds lighter and she has no dyspnea. What will you discharge her on?

12. Valvular Heart Disease A 27 year old woman comes to the office for evaluation of mild dyspnea. She emigrated from South America several years ago. On physical examination she has a respiratory rate of 22, jugulovenous distention and bilateral basilar rales. Cardiac exam reveals a loud S1 and a high pitched sound in diastole immediately followed by a diastolic murmur. 1. What is the most likely diagnosis? 1. What is the most likely diagnosis? 2. What is the ‘best initial’ and ‘most accurate’ diagnostic tests? Echo is always first. Cardiac angiography is more accurate and can give direct pressure measurements. Echo is always first. Cardiac angiography is more accurate and can give direct pressure measurements. 3. What is the best initial therapy? Diuretics and sodium restriction Diuretics and sodium restriction Several months later she returns because of worsening dyspnea despite therapy. She is now six months pregnant. 4. What is the best therapy for her now?

13. Atrial Arrhythmias Case 1 Supraventricular tachycardia A 29 year old senior medical resident comes to the emergency room with palpitations. He has been studying for the boards and has had 5 cups of coffee, 4 beers, 3 cheeseburgers, 2 ‘power drinks’ and 1 viagra. An EKG shows supraventricular tachycardia at a rate of 160. His blood pressure is 124/80. 1. What would you do first? 2. What is next if this is unsuccessful? 3. What other medications are acceptable to control the rate? 4. If the SVT continues to be recurrent what is the best long term therapy? 4. If the SVT continues to be recurrent what is the best long term therapy? 5. If the case were changed to atrial flutter how would the above answers differ?

14. Case 3 A 64 year old woman with a history of hypertension comes to the office for a routine visit. She is maintained on a diuretic with good control of her blood pressure. You note that her heart rate is 118 and is irregularly irregular. She firmly denies symptoms and had no idea that her rate was elevated or that her rhythm was irregular or for how long. A EKG shows atrial fibrillation at a rate of 118. 1. What is the best initial step in management? 2. After this is accomplished what would you do next? 3. What is the best method of converting her to sinus rhythm?

15. A 41 year old gastroenterologist has been having palpitations. His EKG shows atrial fibrillation with a rate of 80. He has no past medical history, no diabetes and no hypertension. His echo is normal. When you discuss cardioversion by electricity or medications he refuses and instructs you to do something to yourself that is anatomically impossible. What is the best therapy for this patient?

16. A 47 year old man comes to see you for advice about smoking cessation. He has no current complaints and no past medical history. He is on no medications and has no allergies. He is not black, white, Asian or Hispanic. On physical examination he has a blood pressure of 155/92. He comes back the following week to have his blood pressure checked again because his managed care plan will not pay for ambulatory home blood pressure monitoring. His blood pressure is now 152/94. The following week it is the same. 1. What is the next best step in the management of this patient? 1. What is the next best step in the management of this patient? 2. Which of these will be the most effective? 3. Which of them has the weakest data to suggest efficacy?

17. After four months of attempts he comes back and says he would rather just be fat and lazy, keep smoking and take some pills. What is the best initial medical therapy? What is the best initial medical therapy? What will you do in the 30% of patients who are not adequately controlled with this regimen?

18. When you see THIS in the history Use THIS as the ‘best initial therapy’ Diabetes Myocardial infarction CHF Isolated systolic hypertension Migraine headaches BPH Asthma Depression Peripheral arterial disease Osteoporosis Pregnancy

19. Case 2 A man has hypertension, a history of myocardial infarction and hyperlipidemia. Case 2 A man has hypertension, a history of myocardial infarction and hyperlipidemia. What will you answer as the first drug to use to control his blood pressure?

20. Case 3 A woman has hypertension, a history of myocardial infarction and diabetes. 1. What will you answer as the first drug to use to control his blood pressure? 2. What is the blood pressure goal of therapy?

21. Case 4 A man has a history of a mild myocardial infarction, hypertension and asthma. What will you answer as the first drug to use to control his blood pressure?

22. Case 5 A 54 year old man comes to the emergency department with several hours of headache, blurry vision, mild confusion, and dyspnea. His blood pressure is 210/130. What is the best therapy for this patient? When is sublingual nifedipine the correct answer?

23. Case 7 A 24 year old woman comes to see you because of headaches. On physical examination you find a blood pressure of 160/105. On physical examination you find a bruit on one side. A renal ultrasound shows both kidneys are small but one of the kidneys is slightly smaller than the other. What is the next best diagnostic step? What is the most accurate diagnostic test? What is the best initial therapy?