Snapshot A 70-year-old man presents to the emergency room with chest pain for the past hour. He has a medical history of coronary artery disease, hyperlipidemia, and type 2 diabetes mellitus. He has a 30-pack-year smoking history and drinks alcohol regularly. His electrocardiogram reveals ST-segment elevations in leads V3 and V4. Aspirin is given and he is rushed for an angioplasty. (Myocardial infarction with left main coronary artery involvement) Anatomy Coronary arteries include right coronary artery (RCA) arises from right aortic sinus supplies right ventricle and His bundle branches sinoatrial nodal artery supplies the sino-atrial (SA) node right marginal artery supplies the right ventricle posterior descending artery (PDA) supplies AV node (supplied by atrioventricular nodal artery) posterior portion of interventricular septum and ventricles posteromedial papillary muscle left main coronary artery (LCA) arises from left aortic sinus branches left circumflex coronary artery (LCX) supplies lateral and posterior wall of left ventricle anterolateral papillary muscle supplies some blood flow to SA node and AV node left anterior descending artery (LAD) supplies anterior portion of the interventricular septum anterolateral papillary muscle anterior surface of the left ventricle most common artery to be involved in myocardial infarction Coronary arterial system dominance defined by which artery supplies the PDA right dominance 85% of cases RCA gives rise to PDA left dominance 8% of cases LCX gives rise to PDA codominance 7% of cases both LCX and RCA give rise to PDA Coronary sinus the endpoint of coronary flow and is continuous with the right atrium in chronic pulmonary hypertension, coronary sinus becomes dilated blood in the coronary sinus has the lowest oxygen content in the body oxygen saturation levels 30% Left atrium most posterior part of the heart enlargement can compress the esophagus, causing dysphagia the left recurrent laryngeal nerve, causing hoarseness Localization of Myocardial Infarctions (MI) Leads with ST-Segment Elevation Location of MI Vessel(s) Affected V1-V2 Septal LAD V3-V4 Anterior LAD V5-V6 Apical LAD, LCX, or RCA I and aVL Lateral LCX V7-V9 Posterior RCA and LCX II, III, and aVF Inferior RCA and LCX Pathology Coronary steal phenomenon myocardial ischemia results from narrowing of coronary arteries after vasodilator use classically, dipyramidole is associated with this dilation of microvessels to non-ischemic tissues can “steal” blood flow away from the heart
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.CV.4723) A 55-year-old man with a past medical history of hypertension, hyperlipidemia, and insulin dependent diabetes mellitus presents to the ED with a sudden onset of substernal chest pain and pressure that radiated into his neck and down his left arm. The pain started a few hours ago while he was watching television. It was not relieved by rest. He was given aspirin by EMS en route to the hospital. His current medications are glargine insulin, hydrochlorothiazide, and atorvastatin. He has not had any similar episodes previously. His family history is significant for an uncle who had a heart attack at age 45. He drinks one drink every other day and has a 25-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 63/minute, respirations are 22/minute, and point-of-care glucose level is 110 mg/dl. Troponin level is elevated. EKG is shown in Figure A. What is the most likely etiology of this patient’s presentation? Review Topic QID: 108549 FIGURES: A 1 Left main coronary artery occlusion 12% (26/224) 2 Right main coronary artery occlusion 31% (70/224) 3 Left circumflex artery occlusion 14% (31/224) 4 Left anterior descending artery occlusion 38% (86/224) 5 Coronary vasospasm 1% (3/224) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.CV.150) A 24-year-old man presents to the emergency room with a stab wound to the left chest at the 4th intercostal space. The patient is hemodynamically unstable, and the trauma attending is concerned that there is penetrating trauma to the heart. Which cardiovascular structure is most likely to be affected by such a wound? Review Topic QID: 100666 1 Left atrium 6% (4/65) 2 Left ventricle 22% (14/65) 3 Right atrium 5% (3/65) 4 Right ventricle 65% (42/65) 5 Aorta 2% (1/65) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (M1.CV.24) A 49-year-old male presents to the emergency room with dyspnea and pulmonary edema. He reports that he has been smoking 2 packs a day for the past 25 years and has difficulty breathing during any sustained physical activity. His blood pressure is normal, and he reports a history of COPD. An echocardiogram was ordered as part of a cardiac workup. Which of the following would be the most likely finding? Review Topic QID: 100540 1 Aoritc stenosis 8% (5/59) 2 Mitral valve insufficiency 25% (15/59) 3 Left ventricular hypertrophy 39% (23/59) 4 Coronary sinus dilation 17% (10/59) 5 Tricuspid valve stenosis 5% (3/59) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (M1.CV.48) A healthy 23-year-old male is undergoing an exercise stress test as part of his physiology class. If blood were to be sampled at different locations before and after the stress test, which area of the body would contain the lowest oxygen content at both time points? Review Topic QID: 100564 1 Superior vena cava 3% (14/439) 2 Inferior vena cava 11% (47/439) 3 Coronary sinus 33% (146/439) 4 Pulmonary artery 44% (192/439) 5 Pulmonary vein 7% (30/439) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.CV.204) In the coronary steal phenomenon, vessel dilation is paradoxically harmful because blood is diverted from ischemic areas of the myocardium. Which of the following is responsible for the coronary steal phenomenon? Review Topic QID: 100720 1 Venodilation 2% (1/59) 2 Microvessel dilation 54% (32/59) 3 Dilation of the large coronary arteries 29% (17/59) 4 Arterial dilation 15% (9/59) 5 Volume loss of fluid in the periphery 0% (0/59) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.CV.1) A 62-year-old Caucasian male presents to the emergency room with severe substernal chest pain, diaphoresis, and nausea. Imaging reveals transmural myocardial infarction in the posterior 1/3 of the ventricular septum. Which of this patient's coronary arteries is most likely occluded? Review Topic QID: 100803 1 Left circumflex 17% (14/84) 2 Left anterior descending 5% (4/84) 3 Diagonal perforators 2% (2/84) 4 Septal perforators 5% (4/84) 5 Right main 71% (60/84) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 5
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