Cardiovascular 1

A 72-year-old man presents for a routine visit. He was incidentally found to have an irregularly irregular pulse, and ECG confirms atrial fibrillation with a ventricular rate of 88 beats/min. He is asymptomatic. His history includes hypertension treated with ramipril, and type 2 diabetes managed with metformin. He has no history of stroke, heart failure, or vascular disease, and is not currently on any antithrombotic therapy.

A patient with a history of heart failure and hypertension presents to the emergency department with confusion, visual disturbances, and palpitations. On examination, blood pressure is 100/60 mmHg, heart rate is 110 beats per minute, respiratory rate is 15 breaths per minute, and temperature is 98 degrees Fahrenheit (36.7 degrees Celsius). The patient is diaphoretic and appears unwell. Current medications include thyroxine, digoxin (digitalis), furosemide, and aspirin 81 mg daily.

A 69-year-old man presents for follow-up. He had a myocardial infarction three weeks ago. He feels well and denies any symptoms other than generalized weakness. Vitals and physical exam are normal.

A 57-year-old male presents to the emergency department with sudden-onset chest pain, palpitations, and shortness of breath that began 30 minutes ago while he was at rest. He is alert and oriented, with blood pressure 118/76 mmHg, heart rate 182 beats per minute, respiratory rate 20 breaths per minute, and oxygen saturation 98% on room air. The cardiac monitor and ECG show a regular, narrow-complex tachycardia at a rate of approximately 180 beats per minute with a QRS duration of 80 milliseconds and no discernible P waves preceding the QRS complexes, a pattern consistent with paroxysmal supraventricular tachycardia (most likely atrioventricular nodal reentrant tachycardia).

A 40-year-old male presents to the emergency department with left-sided chest pain and difficulty breathing for the past 6 hours. On entering the room, you notice he is sitting up in bed and leaning forward. He states the pain worsens when he lies flat and improves when he leans forward. Vital signs: blood pressure 140/85, heart rate 99, temperature 100 degrees Fahrenheit. On auscultation of the chest, you hear a pericardial friction rub. Based on this presentation and supporting ECG findings, he is diagnosed with acute pericarditis.

A 6-year-old male patient with a dysrhythmia is started on amiodarone by his cardiologist. He is advised to follow up regularly with his family physician for ongoing monitoring while on this medication.

A 39-year-old female patient hospitalized for treatment of a deep vein thrombosis (DVT) following surgery needs to be started on long-term anticoagulation therapy. She is otherwise healthy, and her only regular medication is an oral contraceptive.

A 56-year-old man presents to your clinic with left-sided chest pain. The pain began while he was clearing snow off his driveway and resolved after a few minutes of rest. He reports several similar episodes over the past month, always brought on by exertion and relieved by rest. He denies pain at rest, and his vital signs are stable.

A 66-year-old male presents with pain in his lower legs. He usually walks 5 kilometers every day, but for the past three months he has been unable to complete his usual walks because of cramping calf pain that begins after about one kilometer and resolves within a few minutes of resting. He has a history of dyslipidemia and is a current smoker with a 30 pack-year history. On examination, both feet are cool to the touch, the skin over the lower legs is shiny with reduced hair growth, and the dorsalis pedis and posterior tibial pulses are diminished bilaterally. Ankle-brachial index is measured at 0.65, confirming peripheral artery disease (PAD) with intermittent claudication.

A 42-year-old man who smokes about half a pack of cigarettes daily presents to your clinic with a two-week history of headaches, irritability, and neck pain. He is otherwise healthy. On examination, blood pressure is 168/104 mmHg, heart rate is 90 beats per minute, respiratory rate is 12 breaths per minute, and temperature is 98°F (36.7°C). He returns one week later for a confirmatory blood pressure check, which remains elevated at 162/100 mmHg, meeting criteria for a diagnosis of hypertension.

A 72-year-old man with hypertension, type 2 diabetes, coronary artery disease, and chronic kidney disease (eGFR 42 mL/min) presents with 3 days of worsening shortness of breath, orthopnea, and difficulty lying flat. He has gained 3 kg in the past week. He denies chest pain. Vitals: BP 162/94 mmHg, HR 112/min, RR 28/min, O2 saturation 91% on room air, temperature 36.8°C Examination: crackles at both lung bases, elevated jugular venous pressure, bilateral pitting edema, S3 gallop ECG: sinus tachycardia Chest X-ray: pulmonary edema Labs: BNP significantly elevated, creatinine 2.1 mg/dL (baseline 1.7)

A 68-year-old man collapses in the waiting room of a family medicine clinic. Staff find him unresponsive, not breathing, and without a palpable carotid pulse, and they start chest compressions. An automated external defibrillator is applied, it identifies ventricular fibrillation, and a single biphasic shock is delivered. The patient has a history of hypertension and a previous myocardial infarction, and takes ramipril and metoprolol.

A 74-year-old man is brought to the emergency department with 1 day of fatigue, shortness of breath and lightheadedness, and a near-faint episode this morning. He has hypertension and dyslipidemia treated with ramipril and atorvastatin. He takes no beta-blocker, calcium channel blocker or digoxin and has no known drug allergies. On examination he is diaphoretic, confused and has cool extremities, with clear lungs. IV access is in place. The ECG shows regular P waves at about 90/min with no relationship to the regular, wide QRS complexes at about 38/min, and no ST-segment elevation. Potassium 4.2 mmol/L (3.5-5.0), creatinine 92 µmol/L (60-110), high-sensitivity troponin T 8 ng/L (less than 14), glucose 6.1 mmol/L (4.0-7.8).

A 34-year-old woman presents to the emergency department with 45 minutes of sudden-onset palpitations, chest discomfort and lightheadedness. She has had similar but shorter episodes in the past that stopped on their own. She has epilepsy and takes carbamazepine, and she has no known drug allergies. On examination she is alert and well perfused, with no signs of heart failure. An ECG shows a regular, narrow-complex tachycardia at 190/min with no discernible P waves.

A 68-year-old man is seen in the emergency department after two brief episodes of syncope in the past week. Each episode occurred without warning while he was walking, and he recovered fully within a minute. He has hypertension treated with ramipril and amlodipine, and takes no other medications. He has no chest pain or history of coronary artery disease. On examination, the pulse is regular and slow, and the cardiovascular and neurological examinations are otherwise normal. ECG shows a regular atrial rate with intermittent non-conducted P waves. The PR interval on conducted beats is constant and normal, with no preceding prolongation, and the QRS is wide with a right bundle branch block pattern. Sodium, potassium, calcium, magnesium, creatinine, TSH, and high-sensitivity troponin are normal.

A 64-year-old man is seen in cardiology clinic for recurrent episodes of palpitations and dyspnea lasting several hours about once a month; paroxysmal atrial fibrillation was documented on Holter monitoring. His symptoms persist despite adequate rate control. He has a history of myocardial infarction 5 years ago with chronic heart failure (NYHA class II, LVEF 35% on echocardiography). His medications are warfarin (INR stable at 2.5), metoprolol 100 mg BID, ramipril, and atorvastatin. Today he is in sinus rhythm with a PR interval of 180 ms and QTc of 430 ms. Creatinine 98 µmol/L (60-110), ALT 28 U/L (10-40), TSH 2.1 mIU/L (0.4-4.0), potassium 4.3 mmol/L (3.5-5.0). A rhythm control strategy is planned.