A 50-year-old man with a history of stage 4 kidney disease was admitted to the hospital for an elective hemicolectomy. His past medical history is significant for severe diverticulitis. After the procedure he becomes septic and was placed on broad spectrum antibiotics. On morning rounds, he appear weak and complains of fatigue and nausea. His words are soft and he has difficulty answering questions. His temperature is 38.9°C (102.1°F), heart rate is 110/min, respiratory rate is 15/min, blood pressure 90/65 mm Hg, and saturation is 89% on room air. On physical exam, his mental status appears altered. He has a bruise on his left arm that spontaneously appeared overnight. His cardiac exam is positive for a weak friction rub. Blood specimens are collected and sent for evaluation. An ECG is performed (see image). What therapy will this patient most likely receive next?

Send the patient for hemodialysis

Perform a STAT pericardiocentesis

Prepare the patient for renal transplant

Treat the patient with cyclophosphamide and prednisone

A 72-year-old man is taken to the emergency room after losing consciousness. According to his wife, he suddenly complained of fluttering in his chest, lightheadedness, and profuse sweating while walking to the grocery store. He then turned gray, lost consciousness, and collapsed onto the ground. His medical history is significant for a prior anterior wall myocardial infarction 2 years ago that was complicated by severe left ventricular systolic dysfunction. His blood pressure is 80/50 mm Hg, the temperature is 36.7°C (98.0°F), and the carotid pulse is not palpable. An ECG was obtained and the results are shown in the picture. Cardiopulmonary resuscitation is initiated and the patient is cardioverted to sinus rhythm with an external defibrillator. The patient regains consciousness and states there was no antecedent chest discomfort. Cardiac enzymes are negative and serum electrolytes are normal. Which of the following is the best next step for this patient?

Implantable cardioverter-defibrillator

Temporary or permanent cardiac pacing

A 43-year-old woman presents to the emergency department complaining of palpitations, dry cough, and shortness of breath for 1 week. She immigrated to the United States from Korea at the age of 20. She says that her heart is racing and she has never felt these symptoms before. Her cough is dry and is associated with shortness of breath that occurs with minimal exertion. Her past medical history is otherwise unremarkable. She has no allergies and is not currently taking any medications. She is a nonsmoker and an occasional drinker. She denies illicit drug use. Her blood pressure is 100/65 mm Hg, pulse is 76/min, respiratory rate is 23/min, and temperature is 36.8°C (98.2°F). Her physical examination is significant for bibasilar lung crackles and a non-radiating, low-pitched, mid-diastolic rumbling murmur best heard at the apical region. In addition, she has jugular vein distention and bilateral pitting edema in her lower extremities. Which of the following best describes the infectious agent that led to this patient’s condition?

A bacterium that induces complete lysis of the red cells of a blood agar plate with an oxygen-sensitive cytotoxin

A bacterium that induces partial lysis of red cells with hydrogen peroxide

A bacterium that requires an anaerobic environment to grow properly

A bacterium that does not lyse red cells

A bacterium that induces heme degradation of the red cells of a blood agar plate

A 72-year-old woman is brought to the emergency department by ambulance after an unexpected fall at home 1 hour ago. She was resuscitated at the scene by paramedics before being transferred to the hospital. She has a history of ischemic heart disease and type 2 diabetes mellitus. She has not taken any sedative medications. Her GCS is 6. She is connected to a mechanical ventilator. Her medical records show that she signed a living will 5 years ago, which indicates her refusal to receive any type of cardiopulmonary resuscitation, intubation, or maintenance of life support on mechanical ventilation. Her son, who has a durable power-of-attorney for her healthcare decisions, objects to the discontinuation of mechanical ventilation and wishes that his mother be kept alive without suffering in the chance that she might recover. Which of the following is the most appropriate response to her son regarding his wishes for his mother?

“Based on her wishes, mechanical ventilation must be discontinued.”

“We will take every measure necessary to prolong her life.”

“She may be eligible for hospice care.”

“The opinion of her primary care physician must be obtained regarding further steps in management.”

“Further management decisions will be referred to the hospital’s ethics committee.”

A 71-year-old woman with a past medical history of type 2 diabetes, hypercholesterolemia, and hypertension was admitted to the hospital 8 hours ago with substernal chest pain for management of acute non-ST-elevated myocardial infarction (NSTEMI). The ECG findings noted by ST-depressions and T-wave inversions on anterolateral leads, which is also accompanied by elevated cardiac enzymes. Upon diagnosis, management with inhaled oxygen therapy, beta-blockers and aspirin, and low-molecular-weight heparin therapy were initiated, and she was placed on bed rest with continuous electrocardiographic monitoring. Since admission, she required 2 doses of sublingual nitroglycerin for recurrent angina, and the repeat troponin levels continued to rise. Given her risk factors, plans were made for early coronary angiography. The telemetry nurse calls the on-call physician because of her concern with the patient's mild confusion and increasing need for supplemental oxygen. At bedside evaluation, The vital signs include: heart rate 122/min, blood pressure 89/40 mm Hg, and the pulse oximetry is 91% on 6L of oxygen by nasal cannula. The telemetry and a repeat ECG show sinus tachycardia. She is breathing rapidly, appears confused, and complains of shortness of breath. On physical exam, the skin is cool and clammy and appears pale and dull. She has diffuse bilateral pulmonary crackles, and an S3 gallop is noted on chest auscultation with no new murmurs. She has jugular venous distention to the jaw-line, rapid and faint radial pulses, and 1+ dependent edema. She is immediately transferred to the intensive care unit for respiratory support and precautions for airway security. The bedside sonography shows abnormal hypodynamic anterior wall movement and an ejection fraction of 20%, but no evidence of mitral regurgitation or ventricular shunt. The chest X-ray demonstrates cephalization of pulmonary veins and pulmonary edema. What is the most appropriate next step in the stabilization of this patient?

Initiate dopamine therapy and diuresis

Obtain blood cultures and start preliminary broad-spectrum antibiotics

Start intravenous fluids and epinephrine therapy

Intubate the patient and perform an emergency cardiocentesis

Insert two large-bore intravenous catheters and start rapid fluid resuscitation

A 72-year-old woman comes to the emergency department because of a 2-week history of worsening shortness of breath, lower extremity swelling, and a 3-kg (6.6-lb) weight gain. Crackles are heard on auscultation of the chest. Cardiac examination shows a dull, low-pitched early diastolic sound at the 5th left intercostal space that becomes louder in the left lateral decubitus position at end-expiration. Which of the following is the most likely cause of these auscultation findings?

Decreased left myocardial compliance

Increased ventricular contractility

Increased capacity of the pulmonary circulation

Decreased left-ventricular filling pressure

Increased left ventricular end-systolic volume

Advanced heart failure and transplantation for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Advanced HF Staging - The Downward Spiral

Describes patients with refractory Stage D heart failure, often considered for Mechanical Circulatory Support (MCS) or transplant. The INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles categorize patients based on clinical severity, guiding therapy timing.

⭐ Patients in INTERMACS profiles 1-3 have the highest urgency and mortality risk, often necessitating immediate intervention with temporary or durable MCS as a bridge to transplant or as destination therapy.

Bridge to Transplant - Mechanical Life Support

Mechanical Circulatory Support (MCS) is used for refractory heart failure, stabilizing patients awaiting transplant.

Intra-Aortic Balloon Pump (IABP):
- Mechanism: Counter-pulsation. Inflates in diastole (↑ coronary perfusion), deflates in systole (↓ afterload).
- Use: Short-term, acute cardiogenic shock.
Ventricular Assist Devices (VADs):
- Types: LVAD, RVAD, BiVAD.
- Function: Unloads the ventricle, improving end-organ perfusion.
- Indications: Bridge-to-transplant, destination therapy.
- Complications: Thromboembolism, bleeding (GI), infection.
ECMO (Extracorporeal Membrane Oxygenation):
- VA-ECMO: Provides both cardiac and respiratory support.
- Use: Most severe cases, cardiac arrest.

⭐ Patients with continuous-flow LVADs often have a non-palpable pulse and require lifelong anticoagulation (e.g., Warfarin + Aspirin) to prevent pump thrombosis.

Mechanical Circulatory Support Devices Placement

Heart Transplantation - The Ultimate Upgrade

Indications: End-stage HF with refractory cardiogenic shock, NYHA Class III-IV symptoms despite optimal therapy, intractable angina, or malignant arrhythmias.
Contraindications (Absolute): Active malignancy, irreversible end-organ damage (e.g., severe pulmonary HTN with PVR >5 Wood units), active infection, significant psychosocial instability.

Immunosuppression: Triple therapy is standard.
- Calcineurin Inhibitor (e.g., Tacrolimus)
- Antimetabolite (e.g., Mycophenolate Mofetil)
- Corticosteroids (tapered)

⭐ Post-transplant Complications: In the first year, the leading cause of mortality is infection. After the first year, cardiac allograft vasculopathy (CAV) and malignancy are the primary causes.

Post-Transplant Hurdles - New Heart, New Problems

Rejection: A primary threat to the allograft, categorized by timing and mechanism.
- Hyperacute: Occurs within minutes; mediated by pre-formed anti-donor antibodies.
- Acute Cellular: Peaks in the first 1-3 months; T-cell mediated. Diagnosed via endomyocardial biopsy showing lymphocytic infiltrates. Treated with high-dose corticosteroids.
- Chronic: Cardiac Allograft Vasculopathy (CAV) is the leading cause of late graft failure.
Infection: High risk from immunosuppression. Prophylaxis is key against CMV, Pneumocystis jirovecii, and Aspergillus.
Malignancy: Increased long-term risk, especially skin cancers and Post-Transplant Lymphoproliferative Disorder (PTLD).

Heart Transplant Rejection: Surveillance and Evaluation

⭐ Cardiac Allograft Vasculopathy (CAV) is a diffuse, accelerated form of coronary artery disease in the transplanted heart. It's a leading cause of late graft failure and often clinically silent until advanced due to denervation of the donor heart.

High‑Yield Points - ⚡ Biggest Takeaways

Advanced heart failure is defined by persistent, severe symptoms (NYHA Class III-IV) despite maximal medical and device therapy.

Intravenous inotropes (e.g., milrinone) serve as a bridge to decision or for palliation but may increase long-term mortality.

LVADs are used as a bridge to transplantation or as destination therapy; key risks include thrombosis, bleeding, and infection.

Heart transplantation is the definitive therapy for eligible patients with refractory end-stage HF.

Post-transplant issues include acute/chronic rejection, opportunistic infections, and cardiac allograft vasculopathy (CAV).

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