Cardiovascular Disease
Core concepts
Candidates must be fluent in acute coronary syndrome (ACS), heart failure phenotypes, atrial fibrillation, valvular disease, pericardial disease, aortic dissection, and hypertensive emergencies. For ACS, know the distinction between STEMI and NSTEMI, the role of aspirin, P2Y12 inhibitors, anticoagulation, and reperfusion timing. In heart failure, separate HFrEF from HFpEF and recognize that congestion (orthopnea, JVD, S3, pulmonary edema) drives acute presentation more often than low output. Atrial fibrillation requires rate control, rhythm consideration, and stroke-risk stratification with CHA2DS2-VASc; the HAS-BLED score informs bleeding risk but rarely justifies withholding anticoagulation.
Traps
- Giving a nonselective beta-blocker in cocaine-associated chest pain.
- Administering thrombolytics before excluding aortic dissection.
- Starting beta-blockade during acute decompensated heart failure with hypotension.
- Assuming all AF can receive a DOAC; moderate-to-severe mitral stenosis and mechanical valves require warfarin.
- Missing pericarditis (positional, pleuritic, diffuse ST elevation, PR depression) and calling it STEMI.
- Overlooking ACE-inhibitor cough or angioedema, and bilateral renal artery stenosis as a contraindication.
Worked example
A 58-year-old with 2 hours of substernal pressure, diaphoresis, and inferior ST elevations has a heart rate of 48 and hypotension. The rhythm is sinus bradycardia with third-degree AV block. The right answer combines aspirin, anticoagulation, and urgent reperfusion, plus a fluid bolus with atropine and pacing readiness for inferior MI with bradycardia and hypotension. Rule of thumb: treat the patient, not the monitor; inferior infarcts often involve the right ventricle, which is preload dependent.