Cardiovascular Emergencies practice questions

Answer: D) Low potassium

• AIncorrect. It should decrease.
• BIncorrect. Loop diuretics lower potassium.
• CIncorrect. Potassium is the key concern.
• DCorrect. Diuretics cause potassium loss.

Answer: A) Severe aortic stenosis

• ACorrect. Avoid drugs that drop preload sharply.
• BIncorrect. The triad suggests aortic stenosis.
• CIncorrect. The triad suggests aortic stenosis.
• DIncorrect. It's a serious finding.

Answer: A) Immediate vascular surgery consultation and preparation for the OR, with blood products titrated to a systolic BP of about 80–100 mm Hg

Back or flank pain, a pulsatile abdominal mass and hypotension suggest a ruptured AAA. An unstable patient needs immediate vascular surgery and the OR without waiting for CT, with blood products and permissive hypotension.

• ACorrect. The classic triad (back pain, pulsatile mass, hypotension) in an unstable patient points to a ruptured AAA. The patient goes to the OR on clinical grounds or after a bedside ultrasound, with immediate vascular surgery consultation, large-bore access and blood products. Permissive hypotension (SBP about 80–100 mm Hg) is commonly used.
• BIncorrect. CT with contrast is preferred only for hemodynamically stable patients. In an unstable patient, delaying surgery for imaging increases mortality.
• CIncorrect. Aggressive crystalloid resuscitation to a normal BP can worsen bleeding and dilute clotting factors. Permissive hypotension with blood products is favored.
• DIncorrect. Renal colic can cause flank pain, but it does not cause a pulsatile mass or hemorrhagic shock. Treating this patient as having renal colic would dangerously delay definitive care.

Answer: B) Evidence of acute target-organ injury

What separates hypertensive emergency from urgency is acute target-organ damage, not the BP reading or nonspecific symptoms such as headache.

• AIncorrect. Both urgency and emergency usually involve systolic BP above 180 or diastolic above 120 mm Hg, and these cutoffs are arbitrary. The BP number alone does not tell the two apart.
• BCorrect. Hypertensive emergency means severe BP elevation with acute hypertension-mediated organ damage, such as encephalopathy, stroke, MI, pulmonary edema, aortic dissection, or acute kidney injury. Urgency has no acute organ injury.
• CIncorrect. Patients with urgency may have nonspecific symptoms such as headache. Headache by itself does not show acute organ damage.
• DIncorrect. A history of poorly controlled hypertension is common in both conditions. The classification depends on acute organ injury, not on the patient's history.

Answer: D) Amiodarone or procainamide, per protocol

• AIncorrect. Treat while stable.
• BIncorrect. It can be dangerous if the rhythm is VT.
• CIncorrect. It speeds the heart.
• DCorrect. Prepare for cardioversion if unstable.

Answer: A) Diltiazem IV bolus to control the ventricular rate

In WPW with atrial fibrillation, AV nodal blockers such as diltiazem, verapamil, adenosine and beta-blockers are avoided because they promote conduction down the accessory pathway and can cause VF. Procainamide, ibutilide or cardioversion are used instead.

• ACorrect. Diltiazem is a calcium channel blocker that blocks the AV node. In pre-excited AF, blocking the AV node lets impulses conduct preferentially down the accessory pathway, which can lead to ventricular fibrillation. StatPearls specifically lists diltiazem, verapamil, adenosine and beta-blockers as drugs to avoid.
• BIncorrect. StatPearls names procainamide as an agent of choice for AF with pre-excitation in a stable patient.
• CIncorrect. StatPearls names ibutilide, along with procainamide, as an agent of choice for AF with pre-excitation.
• DIncorrect. Electrical cardioversion is an accepted treatment for WPW-related tachycardia, and sedation before an elective synchronized shock is appropriate.

Answer: C) Hypertrophic cardiomyopathy

• AIncorrect. Exertional syncope needs a cardiac workup.
• BIncorrect. Exertional syncope is a red flag.
• CCorrect. It can cause sudden cardiac death.
• DIncorrect. The murmur suggests a heart problem.

Answer: B) 162 to 325 mg non-enteric-coated aspirin, chewed

For suspected ACS, give a loading dose of 162 to 325 mg aspirin as soon as possible, chewed (not enteric-coated) for rapid absorption, followed by a lower daily maintenance dose.

• AIncorrect. A single 81 mg tablet is below the recommended ACS loading dose of 162 to 325 mg. 81 mg is closer to a daily maintenance dose.
• BCorrect. StatPearls recommends a loading dose of 162 to 325 mg for suspected ACS as soon as possible, preferably chewed for faster absorption and platelet inhibition.
• CIncorrect. The dose is in range, but enteric-coated tablets are built to dissolve later, which delays the antiplatelet effect. Chewing is preferred for rapid absorption.
• DIncorrect. This is an analgesic/antipyretic dose and is higher than the recommended 162 to 325 mg ACS loading dose.

Answer: D) 90 minutes or less

• AIncorrect. The goal is 90 minutes.
• BIncorrect. That's far too long.
• CIncorrect. That's far too long.
• DCorrect. Faster reperfusion saves heart muscle.

Answer: A) 12-lead electrocardiogram

In an older adult with syncope, especially while seated and without warning symptoms, cardiac causes must be ruled out first. A 12-lead ECG is the priority initial test, and neuroimaging is reserved for suspected cerebrovascular causes.

• ACorrect. Cardiac causes of syncope are more common in older adults, and syncope while seated without a prodrome raises concern for an arrhythmia. The ECG is the most effective first diagnostic study and is a minimum requirement for older adults with syncope.
• BIncorrect. Head CT is indicated when a cerebrovascular cause or head injury is suspected. This patient has no focal deficits and no head trauma.
• CIncorrect. An EEG may help if a seizure is suspected. It is not a first-line test for brief syncope without seizure features.
• DIncorrect. Carotid imaging is for a suspected cerebrovascular cause. It does not assess the more likely and dangerous cardiac causes in this patient.