Step 3 · 9–11%

Cardiovascular System

Chest pain, heart failure, rhythm, pressure and vessels: the next step and the long-term plan.

Chest pain & acute coronary syndromes

Read the ECG within minutes, let ST elevation (not troponin) trigger reperfusion, and know which drugs help, which harm, and what breaks after an infarct.

Rules to know

Chest pain in the ED → 12-lead ECG within 10 minutes of arrival; repeat every 15–30 minutes if nondiagnostic and pain continues
ST elevation in two contiguous leads, symptoms under 12 hours → primary PCI within 90 minutes of first contact, 120 if transfer is needed
STEMI where PCI cannot happen within 120 minutes → fibrinolytic within 30 minutes of arrival, then transfer for angiography within 2–24 hours
Ongoing pain or under 50% ST resolution 60–90 minutes after lytics → failed reperfusion; immediate rescue PCI
Fibrinolysis absolute bars → any prior brain bleed, ischemic stroke within 3 months, brain tumor, active bleeding, possible aortic dissection, recent head injury
ST depression in V1–V3 with tall R waves → posterior STEMI; confirm with leads V7–V9 and reperfuse
Inferior STEMI with hypotension and clear lungs → record V4R; right ventricular infarct needs IV fluid, no nitrates, morphine or diuretics
Rising troponin, no ST elevation → NSTEMI: aspirin, P2Y12 inhibitor, parenteral anticoagulant, high-intensity statin, oral beta-blocker if no heart failure
NSTE-ACS with refractory angina, shock, VT/VF or acute heart failure → immediate angiography, within 2 hours
Stable NSTEMI with rising troponin or dynamic ST changes → angiography within 24 hours
ACS going to PCI → ticagrelor or prasugrel preferred over clopidogrel; prasugrel is contraindicated after stroke or TIA
Suspected ACS on arrival → chew 162–325 mg non-enteric aspirin unless truly allergic
Nitroglycerin for ischemic pain → withhold if SBP under 90, RV infarct, or PDE-5 inhibitor within 24–48 hours
Oxygen in ACS → only when saturation is below 90%; routine oxygen adds nothing
High-sensitivity troponin pathway → samples at 0 and 1–3 hours; very low, flat values rule out MI
Serial troponins negative, normal ECG, low-risk score → discharge without stress testing; intermediate risk → coronary CTA or stress test
Cocaine or methamphetamine chest pain → benzodiazepines, aspirin, nitrates; no beta-blocker during acute intoxication
STEMI with multivessel disease, hemodynamically stable → culprit PCI, then complete revascularization of other significant lesions; in shock treat culprit only
Cardiogenic shock from MI → emergent revascularization, norepinephrine, consider mechanical circulatory support at a shock center
New holosystolic apical murmur and flash pulmonary edema days after MI → papillary muscle rupture; emergency surgery
Harsh new murmur and shock after MI → ventricular septal rupture; oxygen saturation jumps from right atrium to right ventricle; surgery
Sudden tamponade and PEA within 2 weeks of MI → free wall rupture; pericardiocentesis as bridge to surgery
Persistent ST elevation weeks after anterior MI → LV aneurysm; echo for mural thrombus, anticoagulate about 3 months if present
Pleuritic pain, rub and fever weeks after MI → post-infarction (Dressler) pericarditis; aspirin plus colchicine, avoid other NSAIDs and steroids
VF within 48 hours of MI → defibrillate and revascularize; that early event alone does not call for an ICD
Young woman, often peripartum, with MI and no atherosclerosis → spontaneous coronary artery dissection; conservative care unless ischemia continues
Troponin rise from sepsis, anemia or tachyarrhythmia → type 2 MI; treat the cause, not with an ACS protocol
Apical ballooning after emotional or physical stress, open coronaries → takotsubo; supportive HF care, repeat echo, usually recovers in weeks

Traps that cost points

Waiting for a troponin result before activating the cath lab in STEMI→ ST elevation with symptoms is the trigger. Troponin lags by hours, and every delay costs myocardium.
Treating hypotension in inferior MI with nitroglycerin or furosemide→ Check V4R. A right ventricular infarct depends on preload, so give fluids and hold nitrates, morphine and diuretics.
Giving fibrinolytics for ST depression or NSTEMI→ Lytics help only ST elevation or posterior MI; in NSTE-ACS they add bleeding without benefit. Anticoagulate and plan angiography.
Starting metoprolol in cocaine-associated chest pain→ During acute intoxication a beta-blocker can leave alpha stimulation unopposed. Use benzodiazepines, nitrates and calcium channel blockers first.
Putting every chest-pain patient on high-flow oxygen→ Oxygen helps only hypoxemia; in patients with normal saturation it does not shrink infarcts or save lives.
Choosing prasugrel for a patient with a past TIA→ Prior stroke or TIA raises intracranial bleeding on prasugrel; use ticagrelor or clopidogrel.
IV beta-blocker for STEMI with rales or borderline pressure→ Early IV beta-blockade can tip pump failure into shock. Start an oral beta-blocker within 24 hours once there are no signs of heart failure or low output.
Running a full ACS protocol for a troponin bump in septic shock→ Supply-demand injury needs its cause treated; heparin and dual antiplatelet drugs add bleeding without benefit.
Ordering an ICD for VF that occurred on day 1 of an MI→ Early VF reflects acute ischemia; reassess EF at 40 days (90 after revascularization) before deciding on a primary-prevention ICD.

Hypertension

In the Brain

Confirm with out-of-office readings, pick the first drug by comorbidity, look for secondary causes in the right patients, and save rapid IV lowering for true organ damage.

Rules to know

High office reading without a diagnosis → confirm with home or ambulatory monitoring before labeling hypertension
Accurate office measurement → seated 5 minutes, back supported, arm at heart level, correct cuff, average readings over 2 or more visits
High in clinic, normal at home → white-coat hypertension; no drugs, keep checking out-of-office pressure
Normal in clinic, high at home or on ambulatory monitor → masked hypertension; treat like sustained hypertension
Elevated BP (systolic 120–129, diastolic under 80) → lifestyle changes, recheck in 3–6 months
Stage 1 (130–139/80–89) with CVD, diabetes or CKD → medication plus lifestyle
Stage 1 at low estimated risk → lifestyle for 3–6 months, then medication if still ≥130/80
Stage 2 (≥140/90) → lifestyle plus two first-line drugs from different classes, ideally one combination pill
Treatment target for most adults, including healthy older adults → below 130/80
First-line classes → thiazide-type diuretic (chlorthalidone or indapamide), ACE inhibitor or ARB, dihydropyridine calcium channel blocker
Diabetes or CKD with albuminuria → ACE inhibitor or ARB as part of the regimen
Black adult without CKD or heart failure → thiazide or calcium channel blocker to start
Hypertension plus HFrEF, prior MI or angina → use the drugs those conditions need (beta-blocker, ACEi/ARB/ARNI, MRA)
ACE inhibitor with ARB or aliskiren → never combine; more hyperkalemia and kidney injury, no gain
Starting ACEi, ARB or diuretic → creatinine and potassium in 1–2 weeks; creatinine rise up to 30% is acceptable
Above goal on 3 drugs including a diuretic → resistant hypertension; check adherence, technique, NSAIDs, alcohol, sleep apnea, then add spironolactone
Resistant hypertension, low potassium or adrenal nodule → aldosterone-renin ratio for primary aldosteronism
Secondary cause clues → onset before 30, abrupt worsening, resistant pressure, hypokalemia, abdominal bruit, episodic spells
Young woman with severe hypertension and abdominal bruit → fibromuscular dysplasia; CT or MR angiography, angioplasty
Flash pulmonary edema or creatinine jump on ACE inhibitor, older vascular patient → renal artery stenosis; medical therapy first, stent rarely
BP ≥180/120 without organ damage → severe hypertension, not an emergency; restart or adjust oral drugs, recheck within days
BP ≥180/120 with encephalopathy, pulmonary edema, ACS, AKI or retinal hemorrhage → emergency; ICU, IV nicardipine, clevidipine or labetalol
Hypertensive emergency without dissection, stroke or preeclampsia → lower by no more than 25% in hour 1, toward 160/100 over 2–6 hours
Woman who could become pregnant → avoid ACE inhibitors and ARBs without reliable contraception; labetalol or nifedipine if pregnancy planned
Dry cough on ACE inhibitor → switch to an ARB; after angioedema, never use ACE inhibitors again
Ankle edema on amlodipine → dose-related vasodilation; lower dose or add ACEi/ARB, diuretics do little
Thiazide side effects → low sodium and potassium, high calcium, uric acid and glucose; can trigger gout
Minoxidil → fluid retention, pericardial effusion and hair growth; pair with loop diuretic and beta-blocker
Doxazosin or other alpha-blocker → not first-line for pressure; orthostatic hypotension, keep for BPH symptoms or add-on

Traps that cost points

Starting medication after one high office reading→ Confirm with home or ambulatory readings; white-coat effect is common and a label has costs.
IV labetalol in the ED for an asymptomatic BP of 190/115→ Without organ damage, rapid IV lowering risks stroke and kidney injury. Resume or adjust oral drugs and arrange close follow-up.
Bringing a hypertensive emergency to normal within the first hour→ Autoregulation is reset; drop pressure by 25% at most in hour 1. Aortic dissection is the exception, needing SBP below 120 within minutes.
Adding furosemide for amlodipine ankle swelling→ The edema is capillary, not volume; reduce the dose or add an ACE inhibitor or ARB, which offsets it.
Combining lisinopril and losartan to cut proteinuria further→ Dual RAAS blockade raises hyperkalemia and AKI without better outcomes; maximize one agent and add an SGLT2 inhibitor in CKD.
Stopping an ACE inhibitor when creatinine rises 15% after starting→ Rises under 30% reflect expected hemodynamic change; continue and recheck. Larger rises suggest volume depletion or renal artery stenosis.
Calling hypertension resistant before checking adherence and cuff technique→ Pseudo-resistance is common: confirm adherence, measure out-of-office, stop NSAIDs and decongestants, then add spironolactone.
Choosing atenolol first for uncomplicated hypertension→ Beta-blockers protect less against stroke; use them only when another indication exists.
Imaging the renal arteries in every older hypertensive→ Stenting rarely beats medical therapy; image only when the result would change care, such as flash pulmonary edema or truly refractory pressure.

Heart failure & cardiomyopathies

In the Brain

Classify by ejection fraction, start all four drug classes in HFrEF, diurese to dry weight, and find the trigger behind every admission.

Rules to know

Dyspnea and edema, possible HF → BNP or NT-proBNP and transthoracic echo; a normal BNP makes HF unlikely
EF ≤40% → four drug classes: ARNI (or ACEi/ARB), evidence-based beta-blocker, MRA, SGLT2 inhibitor; start low, add quickly
Choosing the RAAS drug in HFrEF → sacubitril-valsartan preferred; allow 36 hours after the last ACE inhibitor dose
Beta-blocker for HFrEF → carvedilol, metoprolol succinate or bisoprolol only; begin when euvolemic, titrate every 2 weeks
Adding spironolactone or eplerenone → only if potassium under 5.0 and eGFR over 30; recheck both within a week
SGLT2 inhibitor in HF → dapagliflozin or empagliflozin at any EF, diabetes or not; a small early creatinine rise is expected
Black patient with HFrEF still symptomatic on full therapy, or RAAS-intolerant → add hydralazine plus isosorbide dinitrate
EF ≥50% (HFpEF) → diuretic for congestion, SGLT2 inhibitor, control BP and AF, treat obesity; MRA or ARNI may help
EF recovered on treatment → continue every drug; stopping them often brings relapse
Congested decompensated HF → IV loop diuretic at least equal to the total home oral dose; add a thiazide if response is poor
Acute pulmonary edema with high BP → sit upright, noninvasive ventilation, IV nitroglycerin, IV loop diuretic
Cold, wet, hypotensive HF → low output; ICU, dobutamine or milrinone or a vasopressor, consider mechanical support
Admission for HF → hunt the trigger: missed drugs or salt, ischemia, new AF, infection, uncontrolled BP, NSAIDs, thyroid disease
Already on a beta-blocker, admitted with mild decompensation → continue it; hold only for shock or marked low output
Stable HF self-care → weigh daily; call for a gain of 2–3 lb in a day or 5 lb in a week
EF ≤35% and NYHA II–III despite 3 months of full therapy → primary-prevention ICD if expected survival exceeds 1 year
EF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, still symptomatic → cardiac resynchronization therapy
Iron deficiency in HFrEF → IV iron if ferritin under 100, or 100–299 with transferrin saturation under 20%
Drugs that worsen HFrEF → NSAIDs, diltiazem and verapamil, thiazolidinediones, most antiarrhythmics except amiodarone and dofetilide
Young athlete, exertional syncope, murmur louder with Valsalva or standing → hypertrophic cardiomyopathy; echo, no competitive sport until evaluated
Symptomatic obstructive HCM → beta-blocker or verapamil, avoid dehydration and vasodilators; cardiac myosin inhibitor or septal reduction if refractory
HCM high-risk features → ICD for family sudden death, unexplained syncope, wall ≥30 mm or EF under 50%
HCM diagnosed → screen first-degree relatives with ECG, echo and genetic testing
Heavy drinker with dilated cardiomyopathy → abstinence plus full HF therapy; function often recovers
Before anthracycline or trastuzumab → baseline echo and serial EF checks; doxorubicin damage is dose-related and lasting
Thick walls, low-voltage ECG, HFpEF in an older patient → amyloidosis; light chains and immunofixation, then technetium pyrophosphate scan
Viral illness then chest pain, HF and troponin with open coronaries → myocarditis; cardiac MRI, HF care, no sports 3–6 months
New HF from the last month of pregnancy to 5 months postpartum → peripartum cardiomyopathy; counsel on recurrence before another pregnancy
Persistent tachycardia with new low EF → tachycardia-induced cardiomyopathy; rate or rhythm control usually restores function
Warm extremities, wide pulse pressure and HF → high-output state: thyrotoxicosis, severe anemia, AV fistula, thiamine deficiency, Paget disease

Traps that cost points

Stopping guideline drugs once the EF has normalized→ Withdrawal leads to relapse in many patients; continue all classes indefinitely.
Switching lisinopril to sacubitril-valsartan the same day→ Neprilysin inhibition on top of an ACE inhibitor causes angioedema; wait 36 hours after the last ACE inhibitor dose.
Diltiazem for AF rate control in HFrEF→ Nondihydropyridine calcium channel blockers depress contractility when EF ≤40%; use a beta-blocker, digoxin or amiodarone.
Holding diuretics for a small creatinine rise in a still-congested patient→ Residual congestion predicts worse outcomes; modest creatinine rises during effective decongestion are acceptable.
Prescribing atenolol or metoprolol tartrate as HF therapy→ Only carvedilol, metoprolol succinate and bisoprolol lower mortality in HFrEF.
Giving nitrates or brisk diuresis in obstructive HCM→ Less preload worsens outflow obstruction; use beta-blockers or verapamil and keep the patient well hydrated.
Stopping the SGLT2 inhibitor after creatinine rises 10–20%→ That early eGFR dip is hemodynamic and kidney-protective over time; continue the drug.
Adding pioglitazone for diabetes in a patient with HF→ Thiazolidinediones cause fluid retention and HF admissions; choose an SGLT2 inhibitor or GLP-1 RA.
Starting or increasing a beta-blocker during an acute congested admission→ Start or uptitrate after decongestion; while unstable, the negative inotropy can drop output further.

Arrhythmias & conduction disease

In the Brain

Unstable means electricity now; stable means name the rhythm first. In AF, decide stroke prevention separately from rate and rhythm.

Rules to know

Tachycardia with hypotension, ischemic pain, acute HF or confusion → synchronized cardioversion immediately
Pulseless VT or VF → CPR and unsynchronized shock; epinephrine every 3–5 minutes, amiodarone after the third shock
PEA or asystole → CPR and early epinephrine, search for reversible causes (hypoxia, hyperkalemia, tamponade, tension pneumothorax, PE); never shock
Stable new AF with rapid rate → beta-blocker or diltiazem if EF over 40%; resting rate below 110 is acceptable at first
AF stroke risk → CHA2DS2-VASc; anticoagulate at ≥2 in men or ≥3 in women, consider at 1 or 2
AF needing anticoagulation → DOAC (apixaban, rivaroxaban, edoxaban, dabigatran) over warfarin
AF with a mechanical valve or moderate-severe mitral stenosis → warfarin; DOACs are contraindicated
AF ≥48 hours or of unknown duration, cardioversion planned → 3 weeks of anticoagulation or a clear TEE first, then ≥4 weeks after
Aspirin alone for AF stroke prevention → not recommended; it is neither effective nor much safer
AF with a firm contraindication to long-term anticoagulation → left atrial appendage occlusion
AF rhythm control → favored early, with ongoing symptoms, in younger patients or HFrEF; catheter ablation is often first-line
Antiarrhythmic for AF → no structural disease: flecainide or propafenone; CAD: sotalol, dofetilide or dronedarone; HFrEF: amiodarone or dofetilide
Long-term amiodarone → TSH and liver tests every 6 months, baseline chest x-ray and PFTs, eye exam for visual change
Sawtooth flutter waves, ventricular rate near 150 → atrial flutter; same anticoagulation rules as AF, ablation usually cures
Irregular narrow tachycardia with ≥3 P-wave shapes in a COPD patient → multifocal atrial tachycardia; treat the lung disease, replace K and Mg
Regular narrow-complex tachycardia, stable → vagal maneuver, then adenosine 6 mg rapid push, then 12 mg; ablation if recurrent
Irregular, very fast, wide QRS of changing shape → pre-excited AF in WPW; procainamide or cardioversion, never AV-nodal blockers
Stable regular wide-complex tachycardia → assume VT; IV amiodarone or procainamide, cardiovert if it persists
Torsades de pointes → IV magnesium 2 g; defibrillate if pulseless; pacing or isoproterenol for recurrence
QTc over 500 ms, or up 60 ms on a drug → stop QT-prolonging drugs, correct potassium and magnesium
Common QT-prolonging drugs → macrolides, fluoroquinolones, ondansetron, haloperidol, methadone, citalopram, sotalol, dofetilide
Symptomatic bradycardia → atropine 1 mg, then transcutaneous pacing or dopamine or epinephrine infusion
Slow rhythm → first exclude beta-blocker, calcium channel blocker or digoxin, hyperkalemia, hypothyroidism, Lyme carditis, inferior MI
Mobitz II or complete heart block → permanent pacemaker even without symptoms; temporary pacing if unstable
First-degree block or Mobitz I without symptoms → no treatment; review AV-nodal drugs
Older patient alternating slow and fast rhythms → sick sinus syndrome; pacemaker, then rate-control drugs can be used safely
Nausea, yellow vision, bidirectional VT or atrial tachycardia with block on digoxin → toxicity; digoxin immune Fab, check potassium
Isolated PVCs, structurally normal heart → reassure, cut stimulants; echo if frequent, beta-blocker if bothersome
Survived VT or VF without a reversible cause → ICD
Paced patient with dizziness and pacing spikes not followed by complexes → failure to capture; device interrogation

Traps that cost points

Adenosine or diltiazem for an irregular wide-complex tachycardia→ This may be pre-excited AF; blocking the AV node can speed conduction down the pathway into VF. Use procainamide or cardioversion.
Choosing aspirin over a DOAC for an 80-year-old with AF→ Aspirin barely lowers stroke risk and bleeds nearly as much; age is a reason to anticoagulate, not to avoid it.
Starting apixaban for AF in a patient with a mechanical mitral valve→ DOACs caused more valve thrombosis and stroke in these patients; warfarin is required.
Cardioverting AF of unknown duration without anticoagulation or TEE→ Left atrial thrombus can embolize when rhythm returns; anticoagulate 3 weeks or exclude thrombus by TEE.
Stopping anticoagulation after AF ablation or successful cardioversion→ Stroke risk follows the risk score, not the current rhythm; continue anticoagulation according to the score.
Treating a stable wide-complex tachycardia as SVT with aberrancy→ Most wide regular tachycardias in adults with heart disease are VT; verapamil can cause collapse.
Relying on atropine for Mobitz II or complete heart block→ Block below the AV node rarely responds; move to transcutaneous, then transvenous pacing.
Giving amiodarone for torsades→ It prolongs QT further; magnesium, potassium repletion, stopping culprit drugs and raising the heart rate end torsades.
Choosing flecainide for AF in a patient with prior MI→ Class IC drugs raise mortality in ischemic or structural heart disease; use sotalol, dofetilide, dronedarone or amiodarone.

Stable angina & secondary prevention

In the Brain

After ACS, send patients home on the right drug set and into rehab; for stable chest pain, pick the test by the ECG and exercise ability, and treat medically before stenting.

Rules to know

Discharge after ACS → aspirin, P2Y12 inhibitor, high-intensity statin, beta-blocker, sublingual nitroglycerin; ACE inhibitor if EF ≤40%, diabetes, hypertension or CKD
Dual antiplatelet therapy after ACS → 12 months by default; drop to one agent after 1–3 months if bleeding risk is high
Elective PCI for stable disease → DAPT for 6 months, then a single antiplatelet
After MI, EF ≤40% with HF symptoms or diabetes → add eplerenone or spironolactone
EF ≤35% on full therapy, ≥40 days after MI → ICD (wait 90 days after revascularization)
After ACS, PCI, CABG or with stable angina → refer to cardiac rehabilitation; it lowers death and readmission
LDL still ≥70 mg/dL on maximal statin after ACS → add ezetimibe, then a PCSK9 inhibitor
Sexual activity after uncomplicated MI → usually safe after about 1 week if mild exertion causes no symptoms
Any nitrate in use → no PDE-5 inhibitor; the combination causes profound hypotension
Return to driving and work after uncomplicated PCI → often within 1–2 weeks if symptom-free; about 4 weeks after CABG
Stable exertional chest pain, able to exercise, interpretable ECG → exercise ECG test or coronary CT angiography by risk
Unable to exercise → pharmacologic stress imaging: vasodilator nuclear scan or dobutamine echo
LBBB, paced rhythm, LVH with strain, digoxin or WPW on resting ECG → imaging stress test, not exercise ECG alone
LBBB or paced rhythm needing stress imaging → vasodilator perfusion scan; exercise produces false septal defects
Active wheezing needing pharmacologic stress → dobutamine echo; adenosine and regadenoson can trigger bronchospasm
Younger patient at intermediate risk, no known CAD → coronary CT angiography is a strong first test
Stable angina → sublingual nitroglycerin, beta-blocker for symptoms, aspirin, high-intensity statin, BP control
Angina despite a beta-blocker → add a long-acting nitrate or dihydropyridine calcium channel blocker; ranolazine next
Stable CAD with ischemia on testing but controlled symptoms → optimal medical therapy; routine stenting does not reduce death or MI
Revascularize stable CAD for → refractory angina, significant left main stenosis, or multivessel disease with EF ≤35%
Multivessel CAD in a diabetic → CABG preferred over PCI
Rest angina at night, transient ST elevation, clean coronaries → vasospasm; calcium channel blocker plus nitrate, avoid smoking, cocaine and triptans
Smoker after MI → quitting is the strongest modifiable step; varenicline is safe in cardiac patients
Depression after MI → screen; sertraline and psychotherapy are safe and help adherence
Pain relief after MI → acetaminophen first; NSAIDs raise reinfarction, HF and death
Coronary disease → yearly inactivated influenza vaccine; it lowers cardiovascular events
Hormone therapy or antioxidant vitamins for heart protection → no benefit; do not prescribe

Traps that cost points

Sending stable CAD with moderate ischemia straight to PCI→ In stable disease, stents relieve angina but do not lower death or MI; start optimal medical therapy and revascularize for refractory symptoms or high-risk anatomy.
Exercise ECG in a patient with baseline LBBB→ ST changes cannot be read; order vasodilator myocardial perfusion imaging.
Adenosine stress test in an actively wheezing patient→ Vasodilators can provoke bronchospasm; dobutamine echo is the safer choice.
Prescribing sildenafil to a patient who uses isosorbide mononitrate→ Both raise cGMP and together cause severe hypotension; avoid the pairing and discuss alternatives.
Implanting an ICD one week after MI for EF 30%→ EF often improves; recheck at 40 days (90 after revascularization) on therapy, with a wearable defibrillator meanwhile if risk is high.
Ibuprofen for musculoskeletal pain after MI→ NSAIDs increase reinfarction, HF and death; use acetaminophen or topical agents.
Choosing PCI for multivessel disease in a diabetic→ CABG reduces death and MI compared with PCI in diabetics with multivessel disease.
Stopping P2Y12 therapy early for an elective dental cleaning→ Minor procedures proceed on antiplatelets; premature interruption after a stent risks stent thrombosis.
Skipping cardiac rehab referral for an older patient→ Rehab benefits every age group and is underused; refer at discharge.

Lipids & statin therapy

In the Brain

Choose statin intensity by risk group rather than LDL alone, check adherence before adding drugs, and treat very high triglycerides to prevent pancreatitis.

Rules to know

Clinical ASCVD (MI, stroke, PAD, revascularization) → high-intensity statin: atorvastatin 40–80 or rosuvastatin 20–40 mg
LDL ≥190 mg/dL in an adult → high-intensity statin without a risk calculation
Tendon xanthomas or early family heart disease with very high LDL → familial hypercholesterolemia; cascade testing of relatives, including children
Diabetes, age 40–75 → at least moderate-intensity statin; high intensity with added risk factors or target-organ damage
Age 40–75, no ASCVD, ≥1 risk factor, 10-year risk ≥10% → moderate-intensity statin
Intermediate risk, statin decision unclear → risk enhancers (family history, CKD, inflammatory disease, high Lp(a), South Asian ancestry) or coronary calcium
Coronary calcium score 0 in a nonsmoker → reasonable to defer statin and rescan in 5–10 years; score ≥100 → start statin
ASCVD with LDL ≥70 on maximal tolerated statin → add ezetimibe; PCSK9 inhibitor if still above goal
Statin started or changed → lipid panel in 4–12 weeks for response and adherence, then every 3–12 months
Before a statin → lipid panel and ALT; no routine CK or repeat liver tests without symptoms
Muscle aches on a statin → check CK; stop if CK over 10 times normal or symptoms severe; rechallenge after resolution
Statin intolerance → another statin, lower dose or alternate days; then ezetimibe, bempedoic acid or PCSK9 inhibitor
Mild ALT rise under 3 times normal on a statin → continue and recheck; serious liver injury is rare
Raised myopathy risk on statins → gemfibrozil, macrolides, azole antifungals, protease inhibitors, cyclosporine, untreated hypothyroidism
Triglycerides ≥500, especially ≥1000 mg/dL → fibrate, stop alcohol, control glucose to prevent pancreatitis
Triglycerides 150–499 on a statin, ASCVD or high-risk diabetes → icosapent ethyl lowers events
New dyslipidemia → check TSH, glucose, creatinine, urine protein and liver tests for secondary causes
High triglycerides → think alcohol, uncontrolled diabetes, oral estrogen, nephrotic syndrome, retinoids, atypical antipsychotics, some HIV drugs
Lipoprotein(a) → measure once in adulthood; a high level justifies stronger LDL lowering
Age over 75 already taking a statin → continue if tolerated; starting one is a shared decision
CKD not on dialysis, age ≥50 → statin, with or without ezetimibe
Dialysis patient not already on a statin → do not start one routinely
Pregnancy planned or confirmed → stop the statin for most women; resume after breastfeeding
Niacin or fibrate added to a statin for event reduction → no benefit; only side effects
Child with eruptive xanthomas, lipemia retinalis, recurrent pancreatitis → familial chylomicronemia (lipoprotein lipase deficiency); strict fat restriction
Statin and new diabetes → small rise in glucose; cardiovascular benefit far outweighs it

Traps that cost points

Moderate-intensity statin after an MI→ Clinical ASCVD calls for high intensity; lower LDL means fewer recurrent events.
Jumping to a PCSK9 inhibitor when LDL stays high on a statin→ First confirm adherence and maximize the statin, then add ezetimibe; PCSK9 inhibitors come after.
Ordering CK and liver tests every few months on a statin→ Check only for symptoms; routine monitoring finds noise and leads to needless stops.
Stopping the statin for an ALT twice normal→ Mild asymptomatic rises are common and often transient; continue and recheck.
Adding gemfibrozil to a statin for high triglycerides→ Gemfibrozil sharply raises myopathy risk; fenofibrate is the safer fibrate when one is needed.
Treating triglycerides of 1,200 with a statin alone→ Pancreatitis is the immediate danger; start a fibrate, stop alcohol and control glucose first.
Starting lipid drugs without checking TSH→ Hypothyroidism raises LDL and statin myopathy risk; treat it first.
Adding niacin to raise a low HDL→ Drug-raised HDL has not reduced events, and niacin adds flushing, hyperglycemia and liver toxicity.

Valve disease, endocarditis & pericardium

In the Brain

Echo any murmur that is diastolic, loud or symptomatic, operate on severe valve disease once symptoms or ventricular dysfunction appear, culture before treating endocarditis, and drain tamponade.

Rules to know

Soft midsystolic murmur, normal S2, asymptomatic young person → innocent; no echo
Diastolic, continuous, holosystolic, loud or symptomatic murmur → transthoracic echo
Exertional syncope, angina or dyspnea, late-peaking murmur to carotids → aortic stenosis; echo
Severe aortic stenosis with symptoms → valve replacement; medicines do not change survival
Asymptomatic severe AS with EF under 50% or other cardiac surgery → replace the valve
Severe asymptomatic AS with normal EF → echo every 6–12 months and report symptoms at once; moderate AS every 1–2 years
TAVR or surgical valve → TAVR favored around 80 and older or at high surgical risk; surgery usually under 65; shared choice between
Severe chronic aortic regurgitation → replace for symptoms, EF ≤55%, or LV end-systolic diameter over 50 mm
Acute severe aortic regurgitation from dissection or endocarditis → emergency surgery; no balloon pump
Severe primary mitral regurgitation → surgery, repair preferred, for symptoms, EF ≤60%, or end-systolic diameter ≥40 mm
Midsystolic click with late murmur → mitral valve prolapse; reassure, echo if murmur or symptoms
Opening snap and diastolic rumble, dyspnea in pregnancy or new AF → rheumatic mitral stenosis, often in immigrants
Severe symptomatic mitral stenosis with suitable anatomy → percutaneous balloon commissurotomy
Rheumatic heart disease → benzathine penicillin every 3–4 weeks for at least 10 years, often to age 40
Mechanical valve → lifelong warfarin; INR goal 2.5 for aortic, 3.0 for mitral or aortic with risk factors
Bioprosthetic valve with AF beyond the first 3 months → DOAC is acceptable
Bicuspid aortic valve → image the ascending aorta; echo screening of first-degree relatives
Suspected endocarditis → 3 blood culture sets from separate sites before antibiotics, then TTE; TEE if prosthetic valve or TTE negative with high suspicion
Native-valve endocarditis needing empiric therapy → vancomycin plus ceftriaxone after cultures; narrow by organism
Fever, injection drug use, tricuspid vegetation, septic lung emboli → right-sided S. aureus endocarditis
Endocarditis → early surgery for valve-related HF, abscess or heart block, fungal or resistant organism, bacteremia beyond 5–7 days of therapy, recurrent emboli
Streptococcus gallolyticus (bovis) bacteremia or endocarditis → colonoscopy
Dental prophylaxis needed → prosthetic valve or repair material, prior endocarditis, unrepaired cyanotic disease, transplant valvulopathy; amoxicillin 2 g beforehand
Penicillin-allergic patient needing endocarditis prophylaxis → azithromycin or doxycycline; clindamycin no longer advised
Pleuritic pain better leaning forward, diffuse ST elevation, PR depression → rub confirms pericarditis; NSAID or aspirin plus colchicine 3 months
Pericarditis with high-risk features → admit for fever over 38°C, large effusion, tamponade, troponin rise or no response in 1 week
Recurrent pericarditis → NSAID plus colchicine for 6 months; IL-1 blocker if refractory; avoid early steroids
Hypotension, distended neck veins, quiet heart, pulsus paradoxus over 10 mmHg → tamponade; echo and urgent pericardiocentesis
Edema, Kussmaul sign and pericardial knock after radiation, surgery or TB → constrictive pericarditis; pericardiectomy
Positional dyspnea or syncope, emboli, diastolic plop → left atrial myxoma; surgical removal

Traps that cost points

Starting antibiotics in a stable suspected endocarditis patient before cultures→ Even one dose can sterilize cultures and leave the organism unknown through weeks of therapy; draw three sets first.
Endocarditis prophylaxis for mitral valve prolapse or a bicuspid valve→ Only the highest-risk cardiac conditions qualify; good dental hygiene matters more.
Furosemide or nitrates for a patient in tamponade→ Tamponade is preload-dependent; give fluids and drain the pericardium.
Prednisone first-line for idiopathic pericarditis→ Early steroids increase recurrence; use NSAID or aspirin with colchicine, keeping steroids for contraindications or specific causes.
Waiting for symptoms in severe AS with an EF of 45%→ LV dysfunction is itself an indication; replace the valve now.
Assuming a normal TTE excludes prosthetic valve endocarditis→ TTE misses many prosthetic and small vegetations; obtain a TEE.
Stopping warfarin before a tooth extraction in a mechanical valve patient→ Minor dental work proceeds at therapeutic INR with local hemostasis; interruption risks valve thrombosis.
Skipping colonoscopy after S. gallolyticus endocarditis→ This organism is linked to colorectal neoplasia; colonoscopy is part of the workup.

Aorta & peripheral vascular disease

In the Brain

Tearing pain means image the aorta before anticoagulating; screen the right men for AAA; treat claudication with walking and risk-factor control before procedures.

Rules to know

Tearing chest or back pain, unequal arm pressures, wide mediastinum → aortic dissection; CTA chest, TEE if unstable
Confirmed dissection → IV esmolol or labetalol first to HR under 60 and SBP under 120, then a vasodilator if needed; opioids for pain
Ascending (type A) dissection → emergency surgery
Descending (type B) dissection without complications → medical control; endovascular repair for malperfusion, rupture, expansion or refractory pain
Men 65–75 who ever smoked → one-time abdominal ultrasound for AAA
AAA 3.0–3.9 cm → ultrasound every 3 years; 4.0–4.9 cm yearly; 5.0–5.4 cm every 6 months
AAA repair thresholds → ≥5.5 cm in men, ≥5.0 cm in women, growth ≥0.5 cm a year, or symptoms
Known AAA with back or abdominal pain and hypotension → rupture; straight to the operating room, permissive hypotension
After endovascular aneurysm repair → lifelong imaging for endoleak
Thoracic aortic aneurysm ≥5.5 cm → repair; lower thresholds in Marfan, Loeys-Dietz or bicuspid valve
Calf pain on walking relieved by rest → claudication; ankle-brachial index ≤0.90 confirms PAD
ABI over 1.40 from stiff vessels in diabetes or CKD → toe-brachial index
Classic claudication but normal resting ABI → exercise ABI
PAD → antiplatelet, high-intensity statin, smoking cessation, BP and glucose control; low-dose rivaroxaban plus aspirin if bleeding risk low
Claudication → supervised exercise therapy first; add cilostazol if still limiting, never in heart failure
Rest pain, nonhealing wound or gangrene → chronic limb-threatening ischemia; urgent vascular referral for revascularization
Sudden cold, pale, pulseless, painful limb → acute limb ischemia; IV heparin bolus now, emergent vascular surgery
Acute limb ischemia in a patient with AF → embolus; embolectomy or thrombolysis, then long-term anticoagulation
Blue toes, livedo, AKI and eosinophilia after catheterization → cholesterol emboli; supportive care and statin, avoid anticoagulation
Young heavy smoker with digital ischemia and migratory phlebitis → thromboangiitis obliterans; complete tobacco abstinence
Asymptomatic adults → no carotid screening; duplex only if the result would change care
Asymptomatic carotid stenosis ≥70% → intensive medical therapy; revascularization only for selected low-risk patients after specialist review
Cold-triggered white, then blue, then red fingers → Raynaud phenomenon; keep warm, stop smoking, nifedipine or amlodipine if needed
Raynaud starting after 30, asymmetric, with digital ulcers or abnormal nailfold capillaries → secondary; ANA and rheumatology
Tender cord along a superficial vein → superficial thrombophlebitis; ultrasound, anticoagulate if ≥5 cm long or near the saphenofemoral junction
Leg edema, brown pigment, medial ankle ulcer → chronic venous insufficiency; compression, elevation, walking
Pulsatile groin mass with bruit after femoral access → pseudoaneurysm; duplex, ultrasound-guided thrombin injection
High-speed deceleration injury, wide mediastinum → traumatic aortic injury; CTA, BP control, endovascular repair

Traps that cost points

Giving heparin or lytics for chest pain before excluding dissection→ Anticoagulation can be fatal in dissection; check pulses, mediastinum and imaging when pain is tearing or goes to the back.
Starting nitroprusside before a beta-blocker in dissection→ Vasodilation alone triggers reflex tachycardia and more shear stress; control the heart rate first.
Ordering AAA screening for a 70-year-old woman who never smoked→ Benefit is proven in men who ever smoked; screening never-smoking women is not recommended.
Sending an unstable patient with a known AAA to CT→ Hypotension plus pain means rupture; go to the operating room.
Referring new claudication straight for stenting→ Exercise, statin, antiplatelet and smoking cessation come first; revascularize for limiting symptoms despite them or a threatened limb.
Prescribing cilostazol to a patient with HFrEF→ Cilostazol is a PDE-3 inhibitor and is contraindicated in heart failure of any severity.
Anticoagulating for cholesterol emboli→ Anticoagulation may worsen plaque disruption and showering; give supportive care and statins.
Waiting for angiography before heparin in acute limb ischemia→ Heparin stops clot propagation; give the bolus as soon as the diagnosis is made clinically.
Avoiding beta-blockers in PAD→ Cardioselective beta-blockers do not worsen claudication and should be used when the heart needs them.

Syncope & perioperative cardiac care

In the Brain

History, orthostatic vitals and ECG sort syncope into benign and cardiac; before surgery, ask whether the patient can do 4 METs and whether any test would change the plan.

Rules to know

Any syncope → history, orthostatic vital signs and ECG; together they find most causes
Warmth and nausea before fainting after standing, pain or blood → vasovagal; reassure, counterpressure maneuvers, fluids
Syncope on exertion, while lying down, with palpitations or without warning → presume cardiac; admit, telemetry, echo
Syncope high-risk markers → structural heart disease, HF, abnormal ECG, family sudden death under 50, older age, serious injury
Systolic drop ≥20 or diastolic drop ≥10 within 3 minutes of standing → orthostatic hypotension
Orthostatic hypotension in an older adult → stop alpha-blockers, diuretics, vasodilators and TCAs; fluids, salt, compression, slow rising
Orthostatic symptoms despite nondrug steps → midodrine, fludrocortisone or droxidopa
Syncope with head turning, shaving or a tight collar → carotid sinus hypersensitivity; monitored carotid massage, pacemaker if asystole
Faint during urination, coughing or defecation → situational syncope; reassure, avoid triggers
Recurrent unexplained syncope, possible arrhythmia → monitor by frequency: Holter if daily, patch for weeks, implantable loop recorder if rare
Standing heart rate rise ≥30 without hypotension in a young woman → POTS; fluids, salt, graded exercise
Tongue biting, long confusion afterward, head turning during the event → seizure rather than syncope
Low-risk syncope in a healthy young adult → no routine head CT, broad labs or echo
Emergency surgery → operate; do not delay for cardiac testing
Active cardiac condition before elective surgery → postpone and treat ACS, decompensated HF, serious arrhythmia or severe symptomatic valve disease
Elevated-risk surgery, patient climbs two flights or does ≥4 METs → proceed without stress testing
Elevated risk with poor or unknown capacity → BNP or stress testing only if results would change management
Low-risk procedure such as cataract, skin surgery or endoscopy → no preoperative ECG, echo or routine labs
Chronic beta-blocker → continue through surgery; never start one on the morning of surgery
Statin users → continue; consider starting before vascular surgery
ACE inhibitor or ARB for hypertension → reasonable to hold 24 hours before surgery; restart when stable
Elective surgery after a drug-eluting stent → delay ≥6 months (12 if placed for ACS); keep aspirin through surgery
Stopping a P2Y12 inhibitor before surgery → clopidogrel 5 days, ticagrelor 3–5 days, prasugrel 7 days
Warfarin before high-bleeding-risk surgery → stop 5 days ahead; bridge only for mechanical mitral valve or stroke or VTE within 3 months
DOAC before surgery → hold 1–2 days by bleeding risk, longer for dabigatran with low CrCl; no heparin bridge
Severe symptomatic aortic stenosis needing elective surgery → treat the valve first
Stable CAD awaiting noncardiac surgery → no revascularization just to get through the operation
Revised cardiac risk index items → high-risk surgery, ischemic heart disease, HF, cerebrovascular disease, insulin therapy, creatinine over 2

Traps that cost points

Stress testing a patient who climbs stairs without symptoms→ Good functional capacity predicts low risk; testing adds delay and downstream procedures without benefit.
Starting high-dose metoprolol on the morning of surgery→ Beta-blockade started right before surgery increased stroke and death; continue only existing therapy.
Bridging warfarin with heparin for every AF patient→ Bridging doubles major bleeding without reducing stroke in most AF patients; reserve it for the highest thrombotic risk.
Stopping aspirin before surgery in a patient with a recent stent→ Continue aspirin; stent thrombosis is often fatal. Delay elective surgery if the P2Y12 inhibitor cannot yet be stopped safely.
Head CT for every syncope→ Imaging rarely helps without focal deficits or head trauma; history, orthostatic vitals and ECG decide.
Discharging exertional syncope with a systolic murmur→ Think aortic stenosis or HCM; admit, monitor and obtain an echo.
Coronary stenting before vascular surgery to lower operative risk→ Prophylactic revascularization does not cut perioperative MI or death and adds antiplatelet bleeding.
Delaying an emergency laparotomy for cardiology clearance→ Emergency surgery proceeds; manage risk with monitoring and continued cardiac drugs.

Congenital & pediatric heart disease

In the Brain

Cyanosis or shock in a newborn that oxygen does not fix calls for prostaglandin; most small shunts close or stay benign; Kawasaki needs IVIG and echo follow-up.

Rules to know

Newborn cyanosis not improving with 100% oxygen → cyanotic heart lesion; prostaglandin E1 to keep the ductus open, echo
Newborn oximetry screen after 24 hours → fail if under 90% anywhere; repeat if 90–94% or hand-foot gap over 3%
Neonate in shock with weak femoral pulses in the first 2 weeks → ductal-dependent left obstruction; prostaglandin E1 now
Cyanosis at birth, single S2, egg-shaped heart → transposition; prostaglandin, balloon atrial septostomy, arterial switch
Toddler squats after play, boot-shaped heart, harsh systolic murmur → tetralogy of Fallot
Hypercyanotic spell → knee-to-chest, calm the child, oxygen, morphine, IV fluid; phenylephrine or beta-blocker if refractory
Harsh holosystolic murmur, lower left sternal edge → VSD; small ones often close, large ones cause HF at 4–8 weeks
Infant sweats with feeds, breathes fast, gains weight poorly → large left-to-right shunt or HF; echo
Fixed split S2 with ejection murmur at upper left sternal border → atrial septal defect; close if the right heart is enlarged
Continuous machine-like murmur, bounding pulses → PDA; indomethacin, ibuprofen or acetaminophen in preterm infants, catheter closure later
Down syndrome → echo in the newborn period for atrioventricular canal defect
Turner syndrome → echo for coarctation and bicuspid valve at diagnosis
Arm hypertension, weak delayed femoral pulses → coarctation; four-limb pressures and echo, then repair
Two-month-old irritable during feeds with anterolateral infarct pattern → anomalous left coronary from pulmonary artery; surgery
Soft vibratory systolic murmur louder supine, normal S2, well child → innocent Still murmur; reassure
Continuous neck hum that vanishes lying down or with jugular pressure → venous hum; benign
Unrepaired large shunt, later cyanosis and clubbing → Eisenmenger syndrome; closure no longer possible, pregnancy dangerous
Fever ≥5 days with conjunctivitis, red lips, rash, hand changes, neck node → Kawasaki disease; IVIG and aspirin, ideally by day 10
Fever ≥5 days with only 2–3 Kawasaki signs → CRP, ESR and echo for incomplete Kawasaki
Kawasaki follow-up → echo at diagnosis, 1–2 weeks and 4–6 weeks; giant aneurysms need anticoagulation
After IVIG → delay measles and varicella vaccines 11 months; yearly inactivated flu vaccine while on aspirin
Migratory arthritis, carditis or chorea weeks after untreated strep throat → acute rheumatic fever; echo, ASO titer, penicillin
Adult under 60 with embolic stroke, no other cause, and PFO → percutaneous PFO closure
Repaired tetralogy, Fontan or other complex lesion → lifelong adult congenital cardiology follow-up for arrhythmia and HF
Teen with exertional chest pain, syncope or family sudden death → ECG and echo before sports
22q11 deletion with hypocalcemia and thymic hypoplasia → conotruncal defects: truncus arteriosus, interrupted arch, tetralogy

Traps that cost points

Relying on oxygen alone for a cyanotic or shocked neonate→ If the ductus is closing, only prostaglandin E1 restores flow; start it before echo confirms the lesion.
Ordering an echo for every soft murmur in a thriving child→ Innocent murmurs are common; echo for diastolic, harsh or holosystolic murmurs or symptoms.
Delaying IVIG until all classic Kawasaki criteria appear→ Incomplete Kawasaki also causes aneurysms; treat when labs or echo support it.
Giving MMR two months after IVIG→ Passive antibody blocks the live vaccine; wait 11 months.
Giving dobutamine or a diuretic during a tet spell→ Inotropes and volume loss worsen outflow spasm; raise systemic resistance and preload instead.
Using ibuprofen for fever in a child on aspirin after Kawasaki→ Ibuprofen blocks the antiplatelet effect of aspirin; choose acetaminophen.
Discharging a newborn whose leg saturation is lower than the hand→ A hand-foot difference suggests a ductal-dependent lesion; follow the oximetry algorithm and get an echo.
Closing a large VSD in an adult with Eisenmenger physiology→ With fixed pulmonary vascular disease, closure worsens right heart failure; manage medically and refer.