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WorksheetsBGHMC CV Module 2025 Quiz B
Total questions: 50
Worksheet time: 50mins
A 69-year-old with stable CAD, prior CABG (LIMA–LAD patent, vein grafts occluded) needs urgent hemicolectomy for obstruction. Intraop ST depressions and tachycardia occur with MAP 62 despite phenylephrine. Which intervention most directly improves myocardial supply–demand balance now?
Give nitroprusside to reduce afterload
Titrate esmolol to reduce HR while supporting MAP with norepinephrine
Increase sevoflurane to 1.5 MAC
Large crystalloid bolus
Start dobutamine
A 58-year-old on high-dose long-acting β-blocker for CAD is NPO since midnight for abdominal surgery. On induction he becomes bradycardic (HR 38) and hypotensive (MAP 45). Best initial drug?
Atropine 0.4 mg
Ephedrine 10 mg
Esmolol 30 mg
Nitroglycerin 100 μg
Lidocaine 100 mg
A 76-year-old with low-flow, low-gradient AS (AVA 0.8 cm², mean gradient 32 mmHg, EF 30%) is coming for urgent laparotomy. Dobutamine stress echo shows increased stroke volume and mean gradient rising to 50 mmHg with AVA unchanged. Interpretation most relevant to anesthetic risk:
Pseudo-severe AS; risk is like moderate AS
True severe AS with contractile reserve; treat as severe fixed obstruction
Nonsevere AS with dynamic obstruction
Data inconsistent—cancel surgery
Treat as HOCM
You plan an arterial line for carotid endarterectomy under GA. Shortly after carotid cross-clamp, EEG shows ischemic changes. The surgeon requests a higher pressure. What is the most appropriate immediate target?
Maintain arm MAP 60–65 mmHg
Raise MAP >20% above patient’s baseline
Lower MAP to reduce cerebral edema
Keep MAP unchanged and add mannitol
Switch to nitroprusside infusion
A 63-year-old with moderate MS and pulmonary HTN needs emergent open cholecystectomy. Which ventilator strategy best avoids acute decompensation?
High PEEP to reduce RV afterload
Low–moderate PEEP, avoid hypercarbia, maintain slow–normal rate to allow diastolic filling
Hyperventilate to PaCO₂ 25 mmHg
Increase I:E to 1:1
Maximize tidal volume to reduce dead space
A 72-year-old with EF 20% and CRT-P presents for femur fracture fixation. During reaming, BP falls to 70/40, ETCO2 drops, and TEE (emergent) reveals dilated RV with preserved LV. Which first action best addresses the likely pathophysiology?
Start nitroglycerin infusion
Administer 100% O2, treat hypotension with norepinephrine, and avoid high PEEP
Give esmolol to slow HR
Give furosemide
Increase PEEP to 12 cmH2O
A 61-year-old on prasugrel for a DES placed 9 months ago (stable angina) needs semi-urgent colectomy in 4 days. Best antiplatelet strategy?
Stop aspirin; continue prasugrel
Continue aspirin; stop prasugrel now (7 days preop)
Stop both 5 days preop
Continue both
Bridge with IV heparin
Intraop torsades de pointes occurs in a patient with long-QT after ondansetron. BP is 70/40; still perfusing. Best immediate treatment?
Amiodarone 150 mg
Magnesium sulfate 2 g IV
Lidocaine 100 mg
Adenosine 6 mg
Esmolol infusion
A patient with severe AR under GA becomes hypotensive (MAP 55) and bradycardic (HR 45) after a large remifentanil bolus. Which pressor/inotrope is best now?
Phenylephrine bolus
Ephedrine or low-dose epinephrine to increase HR and forward flow
Vasopressin bolus
Esmolol bolus
Nitroglycerin bolus
A 74-year-old with HFpEF and concentric LVH becomes acutely hypotensive after induction. Stroke-volume variation is 7%. Which action most likely corrects the cause?
1 L fluid bolus
Small phenylephrine bolus to restore afterload, then cautious fluids
Start nitroprusside
Dobutamine infusion
Increase PEEP
A 66-year-old with mechanical mitral valve (bileaflet) on warfarin (goal INR 3.0) needs elective open hysterectomy. She has prior stroke. Best bridging plan?
Stop warfarin 5 days prior; no bridge
Stop warfarin; bridge with therapeutic LMWH/UFH; stop heparin per neuraxial/OR timing
Continue warfarin with FFP available
Stop warfarin 2 days prior only
Switch to DOAC 48 h before
Post-carotid endarterectomy, a normocapnic patient becomes acutely hypertensive (MAP 120) with severe headache and focal seizures. Most likely diagnosis requiring urgent control is:
Carotid thrombosis
Cerebral hyperperfusion syndrome
Hypoglycemia
TIA from hypotension
Intracranial hemorrhage from anticoagulation reversal only
During open AAA, supraceliac cross-clamping is applied. Which change is most expected and must be managed?
Fall in afterload and BP
Acute increase in afterload and LV wall stress
Immediate increase in renal blood flow
Decrease in coronary perfusion pressure due to high diastolic BP
Decrease in LVEDP
Clamp release after AAA repair causes profound hypotension and acidosis. Best pre-emptive strategy to attenuate this response is:
Hyperventilate only
Volume loading, reduce anesthetic depth, vasopressors ready, and gradual declamping
Give furosemide before release
Administer nitroprusside before release
Tighten PEEP
A 68-year-old with CRT-D is paced biventricularly 98% of the time. You plan shoulder arthroplasty with monopolar cautery. What is the most reliable strategy to avoid inhibition of pacing?
Place a magnet over the device during the whole case
Preop reprogram to asynchronous pacing; disable ICD therapies; use cautery precautions
Use bipolar cautery; nothing else
Turn off the device with magnet
Use short-burst cautery and hope for intrinsic rhythm
A 73-year-old with critical AS arrives hypotensive after spinal anesthesia at an outside center. Which two principles guide immediate therapy?
Tachycardia and vasodilation
Restore SVR (α-agonist/vasopressin) and maintain sinus rhythm/preload
High PEEP and nitroglycerin
β-agonist inotropy and low preload
Reduce afterload with clevidipine
A 59-year-old with suspected PE during laparoscopic colectomy has an unexplained rise in PA pressures, hypotension, and sudden ETCO₂ drop. TEE shows RV free-wall akinesis with apical sparing. Best immediate additional therapy?
Epinephrine infusion
Inhaled pulmonary vasodilator (NO or epoprostenol) with norepinephrine to maintain MAP
High PEEP
Esmolol
Nitroglycerin
For a patient with pheochromocytoma optimized with doxazosin, which intraop pressor choice best treats hypotension after tumor vein ligation?
Phenylephrine infusion
Norepinephrine infusion
Esmolol infusion
Nicardipine infusion
Nitroglycerin infusion
A 70-year-old with severe MR and chronic AF (rate-controlled) presents for noncardiac surgery. Which plan best maintains forward flow?
Keep HR <50 to increase filling time
Avoid bradycardia, maintain preload, reduce afterload; avoid sudden ↑SVR
Use pure α-agonists for any hypotension
High PEEP to reduce preload
Deep volatile to suppress HPV
An 82-year-old with constrictive pericarditis is for pericardiectomy. Which waveform/bedside sign is typical before opening the pericardium and helps distinguish it from tamponade?
Pulsus paradoxus
Kussmaul sign with prominent Y descent
Equalization of diastolic pressures with blunted Y
Water-hammer pulse
Alternans
A 55-year-old with EF 25% undergoing colectomy exhibits hypotension after induction. PAOP is 8 mmHg; TEE shows small LV cavity with dynamic mid-cavity gradient. Best pharmacologic step?
Dobutamine
Phenylephrine and small volume bolus; reduce inotropy
Nitroglycerin
Esmolol then nitroprusside
Milrinone
Patient with bileaflet mechanical aortic valve (no risk factors) is scheduled for elective herniorrhaphy. Best anticoagulation approach per risk category?
Continue warfarin
Hold warfarin 5 days; no bridging; resume post-op when hemostasis achieved
Hold 2 days only; check INR morning of
Switch to DOAC 72 h preop
Bridge with full-dose heparin regardless
A 64-year-old with HFrEF on sacubitril/valsartan, carvedilol, and spironolactone comes for major abdominal surgery. Which preop medication plan best reduces hemodynamic instability?
Continue all three the morning of surgery
Continue β-blocker; consider holding ARNI morning-of to reduce vasoplegia; continue MRA
Hold β-blocker to avoid bradycardia
Stop spironolactone to avoid hyperkalemia only
Switch ARNI to ACE-i morning-of
A patient with WPW undergoing GA develops narrow-complex SVT at 190 bpm; BP is 70/40 with poor perfusion. Best immediate step?
A. Adenosine 6 mg
B. Diltiazem 20 mg
C. Synchronized cardioversion
D. Procainamide 10 mg/kg
E. Esmolol infusion
For periop statins in a vascular patient without prior use, the most evidence-based statement is:
Start morning of surgery for benefit
Initiate days–weeks preop if time allows; continue chronically post-op
Stop in chronic users to avoid rhabdomyolysis
Give only if LDL >190 mg/dL
No role perioperatively
A 71-year-old with moderate AR and CKD develops severe hypotension during sepsis. Which vasoactive profile is most favorable?
High-dose phenylephrine
Norepinephrine with low-dose epinephrine if needed
Vasopressin alone
Dopamine
Esmolol
After induction for laparoscopic nephrectomy in a patient with pulmonary HTN, PETCO₂ drops and hypoxemia develops during insufflation. PAP rises from 35 to 65 mmHg. Best ventilatory adjustment to reduce PVR?
Increase PEEP to 15 cmH₂O
Ensure adequate oxygenation, avoid hypercarbia (increase minute ventilation), keep PEEP modest
Switch to N₂O–O₂
Prolong inspiratory time
Use high tidal volumes
A 62-year-old with Brugada syndrome requires GA for bowel resection. Which anesthetic plan best minimizes malignant arrhythmia risk?
Long propofol infusion for maintenance
Sevoflurane at 2 MAC with hyperventilation
Balanced anesthetic; avoid prolonged high-dose propofol infusions; maintain normothermia and electrolytes
Ketamine infusion
High-dose bupivacaine epidural boluses
A 66-year-old with left main disease and poor functional capacity needs urgent colectomy for perforation. Which monitoring choice most improves ability to manage ischemia and hemodynamics intraop?
Pulse ox + NIBP
Arterial line + TEE
Pulmonary artery catheter only
Precordial ST segment leads only
CVP + arterial line, no echo
In a high-risk vascular patient, which noninvasive test best identifies balanced three-vessel ischemia when exercise is impossible?
Dobutamine stress echo
Vasodilator nuclear perfusion imaging (look for transient ischemic dilation, uniform depression)
Coronary calcium score
Resting TTE
6-minute walk test
A patient with severe MR (flail posterior leaflet) and normal coronaries is scheduled for noncardiac surgery. Which induction choice best preserves forward flow?
Large propofol bolus, phenylephrine as needed
Etomidate or small-dose propofol with opioid; prefer vasodilators over pure α-agonists for BP support
High-dose remifentanil then phenylephrine
Ketamine then esmolol
Spinal anesthesia with heavy bupivacaine
A 48-year-old with long-standing HTN shows LV strain pattern on ECG and concentric LVH on echo. Which intraop BP strategy best reduces myocardial events?
MAP 55–60 to reduce bleeding
Maintain BP within ~10–20% of baseline; avoid wide swings
Keep SBP <100 throughout
Use permissive hypotension
Lower diastolic pressure aggressively to improve LV filling
A patient with permanent AF on apixaban presents for urgent hip fixation 36 h after last dose; CrCl 35. You plan neuraxial anesthesia. Most appropriate action?
Proceed with spinal now
Avoid neuraxial; consider GA or delay until adequate DOAC washout
Give PCC then neuraxial
Give vitamin K then neuraxial
Do epidural with test dose only
During thoracotomy, TEE reveals acute severe TR with dilated RV and septal shift. Which step best improves RV output?
Decrease FiO2 to augment HPV
Optimize preload, reduce PEEP, treat hypotension with norepinephrine; consider inhaled pulmonary vasodilator
Esmolol
Nitroprusside
High PEEP to reduce venous return
A 70-year-old with bioprosthetic AVR (3 months ago) on aspirin alone needs noncardiac surgery. Best antiplatelet plan?
Continue aspirin
Stop aspirin 7 days prior
Bridge with heparin
Add clopidogrel temporarily
Stop aspirin 24 h prior
In severe AS, which arrhythmia is most poorly tolerated and should be aggressively prevented/treated?
Sinus tachycardia to 110
New-onset AF with loss of atrial contribution
Sinus bradycardia 55
First-degree AV block
Junctional rhythm at 70
A 60-year-old with HFrEF and severe CAD has persistent hypotension despite adequate volume and norepinephrine. Lactate is rising. TEE shows global depression, no obstruction, full IVC. Best next pharmacologic approach?
Add phenylephrine
Add inodilator (low-dose dobutamine or milrinone) while maintaining MAP with norepinephrine
Give nitroglycerin
High-dose epinephrine alone
Increase volatile depth
A patient with Mobitz II block presents for urgent laparotomy. Which preop step best reduces peri-induction cardiac arrest risk?
Atropine at bedside only
Temporary pacing capability in place (transvenous/transcutaneous) before induction
Esmolol ready
Phenylephrine infusion running
Avoid volatile agents
TEE during unexplained hypotension shows large pericardial effusion with diastolic RV collapse but preserved LV function. ETCO2 is low. Which maneuver is harmful before drainage?
Ketamine induction
Positive-pressure ventilation with high PEEP
Maintain spontaneous ventilation
Small fluid bolus
Phenylephrine
A 68-year-old with resistant hypertension on ACE-i, CCB, thiazide, and spironolactone becomes severely hypertensive on emergence (MAP 125) with no pain. Which titratable IV agent best offers predictable BP control and favorable cerebral/renal perfusion?
Nitroprusside
Nicardipine
Esmolol
Hydralazine
Labetalol in large boluses
A 72-year-old post-op develops myocardial injury after noncardiac surgery (MINS) with troponin rise and no ischemic symptoms. Which action most improves outcomes according to perioperative strategies summarized in Barash/Miller?
Ignore if asymptomatic
Optimize hemodynamics/oxygen balance; initiate/continue guideline-directed therapy (statin, β-blocker if indicated), consider cardiology evaluation
Routine thrombolysis
Immediate cath for all
Switch to NPO and wait
A 65-year-old with severe pulmonary HTN receiving IV epoprostenol via dedicated line presents for surgery. The infusion pump fails intraop. First step?
Clamp the line
Resume epoprostenol immediately (backup pump/hand-bolus per protocol); treat systemic hypotension with norepinephrine
Start vasopressin only
Increase PEEP
Give nitroglycerin
A patient with moderate AS and CAD on chronic β-blocker is scheduled for major abdominal surgery. Best plan regarding β-blocker?
Hold to avoid bradycardia
Continue perioperatively; avoid withdrawal
Convert to short-acting and stop after induction
Give high loading dose morning-of
Replace with calcium channel blocker
A 59-year-old with Takotsubo cardiomyopathy (EF 30%) after recent stress is optimized and needs urgent laparotomy. What intraop pressor/inotrope profile is favored?
High-dose epinephrine
Norepinephrine for MAP support; avoid high β-1 drive; consider vasopressin; cautious inotropes only if needed
Isoproterenol
Dopamine
Dobutamine at 10 μg/kg/min as first-line
A 70-year-old with RBBB and anterior MI 2 years ago develops new bifascicular block during hip arthroplasty with hypotension and bradycardia. Best management?
Atropine alone
Transcutaneous pacing while preparing for transvenous pacing
Continue surgery; observe
Esmolol
Adenosine
For a patient with severe MS undergoing noncardiac surgery, which fluid/vasoactive plan is best?
Aggressive fluids and vasodilators
Maintain preload, avoid tachycardia, treat hypotension with phenylephrine or vasopressin; avoid large fluid shifts
Use ephedrine for any hypotension
Lower SVR with nitroprusside
Use high PEEP to reduce pulmonary edema
A 63-year-old with ischemic MR undergoes laparoscopy. Insufflation raises SVR and worsens hypotension. Which intervention best improves forward flow?
Phenylephrine boluses
Reduce pneumoperitoneum pressure, give vasodilator (nitroglycerin) while supporting MAP with norepinephrine
Esmolol
Add PEEP
Large crystalloid bolus only
A 58-year-old on clopidogrel for prior stroke requires urgent CABG-independent noncardiac surgery today. Platelet function remains inhibited. Of the following, which step most increases hemostatic capacity immediately?
Desmopressin alone
Platelet transfusion (timed near incision) acknowledging variable efficacy
Vitamin K
FFP
Cryoprecipitate
A 76-year-old with severe TR from pulmonary HTN needs noncardiac surgery. Which induction/maintenance strategy best preserves RV output?
Propofol bolus 2.5 mg/kg and high PEEP
Etomidate or small-dose propofol, avoid hypoxia/hypercarbia, maintain modest PEEP, support MAP with norepinephrine
Isoflurane 2 MAC and nitroprusside
Ketamine 2 mg/kg and phenylephrine
Desflurane with rapid changes
A 64-year-old with hypertrophic obstructive cardiomyopathy on metoprolol is stable intraop but develops hypotension during emergence when coughing against the tube. Best immediate action?
Give albuterol and extubate quickly
Deepen anesthesia, give phenylephrine, and ensure adequate volume to minimize dynamic obstruction
Start dobutamine
Give nitroglycerin
Apply high PEEP
