A 62-year-old male patient presents with complaints of dyspnea on exertion, presyncope, and mild exertional chest pain. Exam reveals a harsh 3/6 late peaking systolic murmur loudest at the right sternal border that radiates to the carotids. Which disorder is suspected?
- Mitral valve prolapse
- Hypertrophic cardiomyopathy
- Aortic stenosis
- Mitral regurgitation
3. Aortic stenosis
The hallmark symptoms of aortic stenosis are exertional chest pain, dyspnea, and syncope. The typical murmur is a systolic murmur loudest at the aortic area radiating to the carotid. The severity of AS is related to how late it peaks and whether it obliterates the second heart sound. Loudness does not correlate with severity.
A patient with a history of Type 2 Diabetes and coronary disease has the following lipid panel: LDL 128, HDL 30, and Trig 208. What should the first-line treatment be?
- Lifestyle modification with diet and exercise
- Atorvastatin 20 mg daily
- Atorvastatin 80 mg daily
3. Atorvastatin 80 mg daily
A patient with known coronary disease and DM is at high risk for a cardiac event. Per the ACC/AHA cholesterol management guidelines, the patient will need high-dose statin therapy such as Atorvastatin 80 as first-line treatment. Atorvastatin will also lower the triglycerides and raise the HDL somewhat in this patient.
The FNP is performing a routine physical exam on a 60-year-old male who is a new patient and has been lost to medical follow-up for 20 years. The patient denies any past medical history and has a family history of hypertension and CAD. BP today is 158/92. What would be the appropriate next step?
- Start Lisinopril 10 mg daily
- Have the patient return in 2 weeks
- Start HCTZ 12.5 mg daily
- Teach the patient lifestyle modification and have him return in 1 year for a follow-up.
2. Have the patient return in 2 weeks
In order to diagnose HTN, 2 measurements must be made on different occasions. Per JNC 8 guidelines, the BP is considered elevated and will need medication if it is elevated when he returns. Either Lisinopril or HCTZ will be appropriate as first-line treatment.
A patient with a history of systolic heart failure presents for routine follow-up. His medication list consists of an ACE inhibitor, aspirin, and a statin. Which medication should be added for decreased mortality?
Patients with systolic heart failure should be on certain beta-blockers for their mortality benefits. Carvedilol and sustained-release Metoprolol are indicated for this. Other BB (beta blockers) do not have the mortality data and should not be used in heart failure. Lasix and digoxin are effective in symptom management in HF, but do not have mortality benefits. ARBs do have mortality data, but are not indicated if a patient is already on an ACE inhibitor. ARBs are used as an alternative to ACE inhibitors in HF.
A 45-year-old male presents with chest tightness with exertion that resolves with rest. He has a past medical history of HTN and high cholesterol. Which diagnostic test would be first line in identifying the likely etiology of these symptoms?
- Exercise stress test
- Cardiac catheterization
- Troponin levels
2. Exercise stress test
The patient is likely experiencing stable angina, which is characterized by exertional chest pain resolved with rest. The patient has risk factors such as gender, HTN, and high cholesterol. An exercise stress test is the first-line test for diagnosing coronary artery disease; a cardiac catheterization is an invasive test that would be ordered as confirmatory if the stress test were positive. An EKG or troponins will only be helpful in the setting of current chest pain, a previous MI, or a current MI.
A patient with a history of a mitral valve prolapse and an allergy to PCN asks about dental care. What does the patient need to know?
- No prophylaxis is needed in MVP.
- Take clindamycin 600 mg BID for 3 days before the treatment.
- Take amoxicillin 2 gms one hour prior to treatment.
- You should not have dental care if you have MVP.
1. No prophylaxis is needed in MVP.
The most current guidelines for bacterial endocarditis prophylaxis do not include MVP as a condition that warrants prophylaxis. Based on the old guidelines, MVP was treated with prophylaxis and patients may be used to this. The NP should educate the patient on new guidelines. The correct dosage of prophylaxis in an eligible patient with a PCN allergy would be clindamycin 600 mg 30 to 60 min prior to dental care.
A patient presents for a routine physical exam and the nurse practitioner identifies that the patient has a 2/4 diastolic murmur located at the midaxillary line. What would be the next step in the treatment plan?
- Assure the patient that it is likely a physiologic murmur.
- Order an echocardiogram.
- Order a stress test.
- Educate the patient on identification of symptoms of aortic stenosis.
2. Order an echocardiogram.
A diastolic murmur is never physiologic and should be evaluated by echo to determine the cause. A stress test will not give information on the etiology of the murmur.
During the routine physical exam of a new 30-year-old male patient, he states his father died of sudden cardiac death at the age of 40. What diagnostic test would be an essential part of the treatment plan?
- Lipid panel
- Genetic testing
- Chest X-ray
Patients with a family history of early sudden cardiac death should be evaluated for hypertrophic cardiomyopathy. An echocardiogram is the most accurate means to identify this condition.
A 38-year-old woman presents to the office with complaints of chest pain that started this morning. The pain is described as sharp and worsening on inspiration. The patient’s HR is 108 and BP 100/70. What question is important to ask in order to support the most likely diagnosis in this patient?
- Does the patient have a family history of coronary disease?
- What is her normal blood pressure?
- What medications is the patient on?
- Is she a diabetic?
3. What medications is the patient on?
The patient presents with typical signs and symptoms of a pulmonary embolism. In a young patient, the most likely culprit would be the use of oral contraceptives which could be ascertained with a medication history.
On a routine visit, a 78-year-old gentleman is found to be in atrial fibrillation on an EKG. The patient has a history of CAD and CHF and is asymptomatic. What is the most important thing to include in the patient’s treatment plan?
- Immediate cardioversion
- Beta-blocker therapy
- Stress test
A patient with AFib of unknown duration is not a candidate for immediate cardioversion without identifying if there is a clot present in the LA. A CHADS score should be calculated to determine the patient’s risk of stroke and the need for anticoagulation. This patient’s score is a 3 (age over 75, history of CHF, and history of HTN). A CHADS score greater than 2 indicates a high risk of CVA and that the patient needs to be anticoagulated. A stress test would not be indicated until the patient’s rates were identified as controlled (via Holter) and beta-blockers are only indicated if a patient has a fast ventricular rate, which is not indicated in this scenario.
While doing a cardiovascular exam on a patient, the FNP identifies that the PMI is 11 cm lateral to the midsternal border. What is the appropriate next step?
- Document the findings as this is normal.
- Get an EKG.
- Refer patient directly to a cardiologist.
- Start the patient on an ACE inhibitor.
2. Get an EKG.
A PMI greater than 11 cm from the midsternal border is considered displaced and abnormal. It likely represents LVH, which can be seen by EKG. The patient will likely need an echo and then an ACE inhibitor, but the EKG would be the first thing that needs to be done. A cardiology referral is not immediately necessary.
In an adult, the finding of an S3 on cardiac auscultation may indicate what?
- Normal heart function
- Heart failure
2. Heart failure
A third heart sound is pathologic in adults. The most likely causes are heart failure, diminished contractility of the ventricle, mitral regurgitation, or tricuspid regurgitation (Bickley, 2013).
What should be included as part of the plan in a patient with heart failure who is taking an ACE inhibitor, a beta-blocker, and aldactone?
- Monitor potassium and renal function.
- Echocardiograms every 3 months.
- Encourage a diet high in bananas, orange juice, and salmon.
- Discontinuation of all other diuretics.
1. Monitor potassium and renal function.
Patients with renal dysfunction are at risk for hyperkalemia on aldactone. Ace inhibitors also increase potassium levels. Therefore, renal function and potassium should be closely monitored, and consideration made for discontinuation of aldactone in patients with renal insufficiency. Patients should follow a low-potassium diet. Echocardiograms are not warranted every 3 months, and aldactone dosage in heart failure is aimed at neurohormonal effects and is not sufficient enough to cause diuresis. Loop diuretics are still warranted for fluid management.
A 45-year-old obese female with a history of type 2 diabetes asks if she could start an aerobic exercise plan. How should the nurse practitioner respond?
- "Absolutely, you may begin immediately."
- "You should have a stress test before you begin intense exercise."
- "Aerobic exercise is not safe in a patient with diabetes."
- "Once your blood sugar is under control, you can start exercising."
2. "You should have a stress test before you begin intense exercise."
Patients with type 2 DM have the same risk of an MI as a patient with a previous MI. In addition, neuropathy from diabetes can mask the typical angina symptoms. A patient with DM should have a screening stress test before beginning an intense exercise program.
A 65-year-old male patient with a history of DM is diagnosed with HTN. Which medication should the patient be started on first line?
- Ace inhibitor
- Calcium channel blocker
1. Ace inhibitor
Diabetic patients with HTN should be treated with an ACE inhibitor or ARBs for renal protection, as well as for blood pressure control.
Therapeutic lifestyle changes are recommended for a patient with elevated cholesterol levels. Patient education should include:
- Weight training three times a week
- Low-sodium diet
- High-fiber diet
- Very-low-fat diet
3. High-fiber diet
Therapeutic lifestyle changes for high cholesterol include changing to a low-saturated-fat and high-fiber diet. Maintaining a healthy weight is important, but very-low-fat diets can be counterproductive in cholesterol management. A low-sodium diet is helpful for HTN and heart failure but not for high cholesterol. Exercise should consist of aerobic exercise, not necessarily weight training.
What is the term used to determine a valve that is not able to open completely to allow the flow of blood through or out of the heart?
A valve that cannot open fully is stenotic. The most common valve to develop stenosis is the aortic valve. A valve that does not close completely is termed regurgitant or incompetent.
What heart sound is characteristic of mitral valve prolapse?
- A diastolic murmur
- A midsystolic click
- S4 heart sound
- No findings are often the case.
2. A midsystolic click
The most common finding in MVP is a midsystolic click. If the patient has developed MR, a systolic murmur will also be noted. A diastolic murmur is usually found in aortic regurgitation or mitral stenosis.
Which condition requires prophylaxis prior to dental work to prevent bacterial endocarditis?
- Mitral valve prolapse
- Previous episode of endocarditis
- Mitral valve repair
- Presence of a pacemaker
2. Previous episode of endocarditis
According to the updated guidelines, prophylaxis is only warranted in high-risk conditions. Previous endocarditis is considered high risk for developing IE (infectious endocarditis) again. Mitral valve prolapse is no longer an indication. Valve replacement would be an indication, but not repair of a valve. A pacemaker or ICD does not necessitate SBE prophylaxis.
What is the main goal for treatment of HTN?
- Maintain cerebral perfusion
- Prevent target organ damage
- Lower lipids
- Prevent obesity
2. Prevent target organ damage
The goal of treating HTN is to prevent target organ damage. Avoiding hypotension will maintain perfusion. Lipid levels and obesity are not affected by HTN, but both are comorbidities that can contribute to cardiovascular complications.
A patient presents to the office with JVD, hepatomegaly, and bilateral 2+ pitting edema. The patient denies shortness of breath and lungs are clear to auscultation (CTA). What underlying problem is suspected in this patient?
- Recent LV MI
The patient is exhibiting signs of right-sided heart failure (cor pulmonale) without left-sided involvement. The most common underlying cause of right-sided heart failure is increased pulmonary artery pressure from chronic lung disease. A recent MI would cause left-sided failure, and anemia would cause high-output failure. Manifestations of a DVT would include unilateral edema and not hepatomegaly and JVD.
A patient presents with complaints of a "fast heartbeat." An EKG reveals sinus tachycardia 110 bpm. What would be the next appropriate step?
- Start a beta-blocker to lower the heart rate.
- Determine the underlying cause of the tachycardia.
- Discuss anxiety treatments.
- Explain to the patient that this is a normal variant.
2. Determine the underlying cause of the tachycardia.
Sinus tach is a sign of an underlying cause, and treatment is focused on finding and treating the cause. Beta-blockers would suppress and mask the underlying cause.
A patient presents for follow-up of systolic heart failure with an ejection fraction of 30%. His meds consist of a beta-blocker, an ACE-inhibitor, and baby aspirin. He is NYHA class I. What should be included in the plan of care?
- Add aldactone 12.5 mg daily.
- Refer to a cardiologist for an implantable defibrillator.
- Discontinue aspirin.
- Limit activity.
2. Refer to a cardiologist for an implantable defibrillator.
Patients with ejection fractions of less than 35% are at risk for sudden cardiac death from ventricular arrhythmias. Prophylactic placement of ICDs is indicated in this population. Aldactone is only indicated in class II and IV HF.
A patient presents with a DVT and has no evident risk factors for the disorder. What would the FNP do next?
- Continue anticoagulation indefinitely since there is no known cause.
- Evaluate the presence of familial clotting disorders.
- Plan for insertion of an IVC filter.
- Since the patient does not have risk factors, there is no need for anticoagulation.
2. Evaluate the presence of familial clotting disorders.
Without obvious risk factors or cause for the DVT, the provider should evaluate the patient for the presence of familial clotting disorders. Once the presence or absence of these disorders are identified, the time frame for anticoagulation can be determined.
A 55-year-old patient with DM presents to the office with complaints of chest tightness intermittently over the past 2 months. The discomfort occurs with exertion or stress and is relieved with rest. The EKG is unchanged from previous. What should the FNP do next?
- Order an NSAID for musculoskeletal chest pain.
- Order an exercise stress test for the presence of coronary artery disease.
- Send the patient to the ER immediately.
- Repeat the EKG in 2 weeks to see if there are any further changes.
2. Order an exercise stress test for the presence of coronary artery disease.
Chest discomfort in a patient with risk factors that is exertional is likely ischemic in nature. A stress test will determine the presence of coronary artery disease. With stable angina, the EKG will be normal at rest and does not indicate that the pain is not cardiac in nature. Since the patient is exhibiting stable angina, a trip to the ER is not necessary at this time.
A patient with known PAD presents to the office with complaints of increasing leg pain at rest. What does the NP think may be occurring?
- Progression of the arterial disease
- Development of a DVT
- Normal PAD symptoms
- A clotting disorder
1. Progression of the arterial disease
Patients with PAD experience intermittent claudication. Progression to rest pain means that the disease is worsening. A DVT often does not cause significant pain.
A 42-year-old female presents to the office with bulging and painful superficial leg veins. What would predispose this patient to the disorder that is suspected?
- A desk job
- High cholesterol
The symptoms described likely indicate varicose veins. Predisposing factors include standing for long periods of time, obesity, pregnancy, and family history.
What antihypertensive has been shown to be most effective in African Americans, as well as in decreasing stroke risk?
- ACE inhibitors
- Calcium channel blockers
3. Calcium channel blockers
African Americans have been shown to have a decreased risk of stroke with the use of calcium channel blockers compared to other antihypertensives. CCB are also effective in lowering BP in this population. ACE inhibitors should not be used first line unless other compelling evidence requires their use.
In evaluating a patient with chest pain, it is noted that the pain is resolved with sublingual nitroglycerin. What does this information indicate?
- The pain is ischemic in nature.
- The patient’s blood pressure is too high.
- The pain may be ischemic or esophageal in nature.
- No further workup is necessary.
3. The pain may be ischemic or esophageal in nature.
The fact that pain is relieved with nitroglycerin does not necessarily point to an ischemic cause for the pain. Nitroglycerin can also be effective at relieving the pain or esophageal spasm. Further assessment and workup is essential to determining the actual cause of this pain.
A 75-year-old patient with a history of HTN presents with dyspnea on exertion and palpations over the past 2 weeks. An EKG shows atrial fibrillation with a heart rate of 115 bpm. What would the treatment plan include?
- Anticoagulation and rate control
- Initiation of an antiarrhythmic drug
- Immediate hospitalization
- Immediate stress test
1. Anticoagulation and rate control
The patient has likely had AFib with rapid response for the past two weeks. The patient needs to be started on anticoagulation, and rate controlled to decrease his symptoms. The patient does not need to be sent to the hospital unless he is unstable. An antiarrhythmic drug would not be first line. A stress test would be indicated once the rate was controlled, but if done without rate control, it would likely cause worsening symptoms.