Cardiovascular Critical Care I
Answer: C
A diagnosis of cardiogenic shock is most likely, given
the patient’s history, presentation, ongoing vasopres-
sor requirement, elevated BNP, and lack of infectious
symptoms (Answer A is incorrect). Furthermore, this
patient has positive troponins and ST-segment elevation
in leads II, III, and aVF (inferior leads), making STEMI
the primary diagnosis and reason for cardiogenic shock
(Answer C is correct; Answer D is incorrect). The pres-
ence of hypotension and bradycardia are more likely
consistent with complications of an inferior MI with
possible RV involvement, as opposed to an acute exac-
erbation of HF. The patient also has a preserved LVEF
and not systolic HF (Answer B is incorrect).
ST-segment elevation in leads II, III, and aVF (infe-
rior) are most consistent with the right coronary artery
(Answer D is correct). Answers A (left main coronary
artery), B (left anterior descending artery), and C (left
circumflex coronary artery) are incorrect.
Answer: B
According to the SOAP II investigation, dopamine is
associated with increased rates of adverse events in
patients with cardiogenic shock compared with norepi-
nephrine (Answer B is correct; Answer A is incorrect).
Milrinone (Answer C), although helpful in some patients
with HF, would not be favored, given the patient’s cur-
rent hypotension and acute renal failure. Normal saline
administration (Answer D) would likely be detrimen-
tal because of the patient’s signs of fluid overload,
including BNP elevation, hyponatremia, and rales on
examination.
Answer: A
Lidocaine would be most favorable in patients with isch-
emia-mediated ventricular arrhythmias, and although
the patient is not currently in VT, he is having persistent
premature ventricular contractions (bigeminy), further
increasing concern for ongoing ischemia and myocardial
irritability (Answer A is correct). Metoprolol (Answer
C) and diltiazem (Answer D) would be contraindicated
because of ongoing cardiogenic shock and vasopressor
requirements. Amiodarone 300 mg intravenous push
(Answer B) is no longer appropriate because the patient
has a pulse and blood pressure and is currently not in
VT. Furthermore, rapid administration of amiodarone
may lead to worsening hypotension.
Answer: A
The patient’s heart catheterization was performed
through the femoral artery, a vessel that is much more
difficult to compress to facilitate hemostasis. Hematomas
can occur at the access site; however, the most serious
bleeding complication associated with this access site is
a retroperitoneal bleed (Answer A is correct). Answer B
(dissection/rupture), Answer C (stent thrombosis), and
Answer D (papillary muscle rupture) are incorrect.
Answer: C
Vasopressin would be favored because, when admin-
istered at normal physiologic doses, it mediates
predominant increases in SVR while minimally affect-
ing the PVR (Answer C is correct). Phenylephrine
(Answer B), however, will increase both PVR and SVR
by the α1-receptors. Given the patient’s ongoing hypo-
tension, low cardiac index, and rising CVP, inaction
(Answer A) would be inappropriate, and additional vol-
ume administration (Answer D) would be detrimental in
the setting of volume overload and RV failure.
Answer: B
Amiodarone boluses would be safest if administered
slowly for 10 minutes to avoid additional hypotension,
followed by a continuous infusion (Answer B is cor-
rect; Answer A is incorrect). Metoprolol (Answer C)
and diltiazem (Answer D) would be contraindicated
because of ongoing cardiogenic shock and vasopressor
requirements.
Answer: D
Because of the diagnosis of acute MI, current quality
measures would require initiation of or documenta-
tion to contraindications for each item except for ACE
inhibitors/ARBs (Answer D) because the patient still
has an LVEF greater than 40%. Answer A (aspirin con-
traindication), Answer B (statin contraindication), and C
(β-blocker contraindication) are incorrect.