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Self-Assessment Questions

Cardiology

Cardiogenic Shock: Review Questions

Arti J. Choure, MD, and Deepak L. Bhatt, MD

Dr. Choure is an internal medicine resident, and Dr. Bhatt is an associate professor and staff physician in cardiac, peripheral, and carotid intervention; both are at the Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, OH.



Choose the single best answer for each question.

1. A 60-year-old man with a past medical history of hypercholesterolemia presents to the emergency department with 2 hours of crushing substernal chest pain radiating to his left arm, nausea, and diaphoresis. On examination, his blood pressure is 82/48 mm Hg, heart rate is 110 bpm, and oxygen saturation is 95% on 4 L of oxygen. He is in severe respiratory distress and has cold clammy extremities, an S3 gallop, and bilateral crackles on auscultation. Electrocardiogram reveals ST elevation in the anterolateral leads and ST depression in the inferior leads. The patient is given aspirin, nitroglycerin, heparin, and intravenous fluids. Vasopressors are started to maintain blood pressure, but he remains hypotensive despite receiving 2 pressors. Which of the following is the most appropriate next step in management until the patient reaches the catheterization laboratory?
  1. Add a phosphodiesterase inhibitor
  2. Initiate cardiac glycosides
  3. Insert an intra-aortic balloon counterpulsation
  4. More aggressive fluid resuscitation
  5. Sodium nitroprusside infusion
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2. Which of the following steps has been shown to have a mortality benefit in patients with cardiogenic shock caused by to myocardial infarction (MI)?

  1. Addition of glycoprotein IIb/IIIa inhibitors
  2. ß-Adrenergic agonists
  3. Early cardiac catheterization followed by revascularization by percutaneous coronary intervention (PCI) or surgical revascularization
  4. Initial medical stabilization with blood pressure control prior to catheterization
  5. Thrombolytic infusion
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3. A 65-year-old man with a history of type 2 diabetes presents to the emergency department with 4 hours of chest pain. Physical examination reveals a heart rate of 120 bpm and a systolic blood pressure of 62 mm Hg with a palpable pulse. Electrocardiogram reveals ST elevation in leads V1 to V4. The patient undergoes emergent cardiac catheterization followed by PCI. A pulmonary artery catheter is inserted for hemodynamic monitoring. Which of the following hemodynamic subsets satisfies the criteria for true cardiogenic shock in this patient?
  1. Pulmonary capillary wedge pressure (PCWP) < 18 mm Hg; cardiac index > 2.2
  2. PCWP > 18 mm Hg; cardiac index > 2.2
  3. PCWP < 18 mm Hg; cardiac index < 2.2
  4. PCWP > 18 mm Hg; cardiac index < 2.2
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4. A 75-year-old woman with a past medical history of hypertension is admitted with acute anterior wall MI and is Killip class III on admission. She receives intravenous thrombolytic therapy, and her chest pain resolves. Seventy-two hours later, her chest pain suddenly recurs and she develops respiratory distress and becomes hypotensive. Physical examination reveals a new pansystolic murmur best heard at the left sternal border with thrill and S3 gallop. Pulmonary capillary wedge tracings reveal some V wave prominence and oximetry reveals the following oxygen saturations: superior vena cava, 66%; inferior vena cava, 70%; right atrial, 70%; right ventricular, 80%; and pulmonary arterial, 82%. Which of the following is the most likely diagnosis based on these findings?

  1. Cardiac rupture
  2. Mitral regurgitation due to papillary muscle rupture
  3. Ventricular aneurysm
  4. Ventricular pseudoaneurysm
  5. Ventricular septal rupture (VSR)
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