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Question 1

Diagnosis/Cardiology An 8 year-old boy is brought to a health care provider complaining of dyspnea and fatigue. On physical examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is A. ventricular septal defect. B. atrial septal defect. C. congenital aortic stenosis. D. patent ductus arteriosus.

Answer 1

Explanations (u) A. Ventricular septal defect causes a holosystolic murmur rather than a continuous machinery-like murmur. (u) B. Atrial septal defect causes a fixed split S2 rather than a continuous systolic heart murmur. (u) C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in the second intercostal space. (c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium.

Question 2

Diagnostic Studies/Cardiology A 63 year-old male with history of hypertension and tobacco abuse presents complaining of dyspnea on exertion for two weeks. The patient admits to one episode of chest discomfort while shoveling snow which was relieved after five minutes of rest. Vital signs are BP 130/70, HR 68, RR 14. Heart exam reveals regular rate and rhythm, normal S1 and S2, no murmur, gallop, or rub. Lungs are clear to auscultation bilaterally. There is no edema noted. Which of the following is the most appropriate initial diagnostic study for this patient? A. Helical CT scan B. Chest x-ray C. Nuclear stress test D. Cardiac catheterization

Answer 2

Explanations (u) A. Helical CT scan aids in the diagnosis of pulmonary embolism, not in the evaluation of angina. (u) B. Chest x-ray is not used as a diagnostic study to evaluate symptoms of angina or coronary heart disease. (c) C. In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease. (u) D. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings

Question 3

Clinical Intervention/Cardiology A 52 year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient? A. Coronary artery bypass grafting (CABG) B. Streptokinase C. Percutaneous coronary intervention (PCI) D. Warfarin (Coumadin)

Answer 3

Explanations (u) A. Percutaneous coronary intervention is a better, less invasive alternative to CABG for single vessel coronary artery disease. (h) B. Streptokinase is not commonly used for treatment of acute myocardial infarction because it is ineffective at opening the occluded artery and reducing mortality. Streptokinase would be harmful because it would increase the risk of bleeding. (c) C. Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis. (u) D. Warfarin is used to prevent thrombosis and not for acute treatment

Question 4

Clinical Intervention/Cardiology A patient presents with an acutely painful and cold left leg. Distal pulses are absent. Leg is cyanotic. There are no signs of gangrene or other open lesions. Symptoms occurred one hour ago. Which of the following treatments is most appropriate? A. Vena cava filter B. Embolectomy C. Amputation D. Aspirin

Answer 4

Explanations (u) A. Vena cava filters are used in the management of venous thromboembolic disease when anticoagulation cannot be done. (c) B. Embolectomy within 4 to 6 hours is the treatment of choice. (h) C. Amputation is done only when no viable tissue is present. Cutting off a viable limb is never a good idea. (u) D. Aspirin is used in the prevention and treatment of coronary disease and has no role in the treatment of peripheral arterial embolism.

Question 5

Clinical Therapeutics/Cardiology Which of the following medications used in the treatment of supraventricular tachycardia is able to cause sinus arrest and asystole for a few seconds while it breaks the paroxysmal supraventricular tachycardia? A. Digoxin (Lanoxin) B. Adenosine (Adenocard) C. Verapamil (Calan) D. Quinidine (Quinaglute)

Answer 5

Explanations (u) A. Digoxin is not used for the acute termination of supraventricular tachycardia. (c) B. Adenosine is an endogenous nucleoside that results in profound (although transient) slowing of the AV conduction and sinus node discharge rate. This agent has a very short half-life of 6 seconds. (u) C. Although verapamil may be used for the termination of acute supraventricular tachycardia, it does not lead to sinus arrest in therapeutic doses. (u) D. Quinidine is rarely used today and is not indicated for the termination of supraventricular tachycardia

Question 6

Diagnosis/Cardiology An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse

Answer 6

Explanations (c) A. The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area. (u) B. Patients with aortic regurgitation are likely to complain of an uncomfortable awareness of their heart, especially when lying down. These patients develop sinus tachycardia with exertion and complain of palpitations and head pounding with activity. (u) C. The symptoms related to mitral stenosis are related to increased pulmonary pressure after the left atrium can no longer overcome the outflow obstruction. (u) D. Patients with mitral valve prolapse are typically asymptomatic throughout their lives, although a wide range of symptoms is possible. When symptoms do occur, palpitations from arrhythmias are most common along with lightheadedness. Syncope is not part of this disease process

Question 7

History & Physical/Cardiology Which of the following would you expect on physical examination in a patient with mitral valve stenosis? A. Systolic blowing murmur B. Opening snap C. Mid-systolic click D. Paradoxically split S2

Answer 7

Explanations (u) A. Mitral stenosis is a diastolic, not a systolic murmur. (c) B. Mitral stenosis is characterized by a mid-diastolic opening snap. (u) C. Mid-systolic clicks are noted in mitral valve prolapse, not mitral stenosis. (u) D. Paradoxical splitting of S2 occurs in aortic stenosis not mitral stenosis.

Question 8

Scientific Concepts/Cardiology Which of the following is the most common cause for acute myocardial infarction? A. Occlusion caused by coronary microemboli B. Thrombus development at a site of vascular injury C. Congenital abnormalities D. Severe coronary artery spasm

Answer 8

Explanations (u) A. Coronary microemboli occlusion is a rare cause of acute myocardial infarction. (c) B. Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion. (u) C. Congenital abnormalities are rare causes of acute MI. (u) D. Severe coronary artery spasm is more likely to result in Prinzmetal’s angina rather than true infarction.

Question 9

Health Maintenance/Cardiology A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A. Daily weights B. Daily spirometry C. Daily blood glucose D. Daily fat intake

Answer 9

Explanations (c) A. Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure. (u) B. Spirometry monitoring is important in a patient with asthma, not heart failure. (u) C. Daily blood glucose monitoring is important in a patient with diabetes, not heart failure. (u) D. Daily fat intake is important, but will not improve his heart failure management.

Question 10

Scientific Concepts/Cardiology Which of the following is the most common cause of arterial embolization? A. Rheumatic heart disease B. Myxoma C. Atrial fibrillation D. Venous thrombosis

Answer 10

Explanations (u) A. Rheumatic heart disease is a rare cause of embolization (u) B. Myxoma is a rare cause of embolization. (c) C. Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus. (u) D. Venous thrombosis may be a cause of embolization paradoxically, but is uncommon.

Question 11

Scientific Concepts/Cardiology The most common arrhythmia encountered in patients with mitral stenosis is A. atrial flutter. B. atrial fibrillation. C. paroxysmal atrial tachycardia. D. atrio-ventricular dissociation.

Answer 11

Explanations (u) A. See B for explanation. (c) B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the development of atrial fibrillation. (u) C. See B for explanation. (u) D. See B for explanation.

Question 12

Clinical Therapeutics/Cardiology Long term use of which of the following drugs may cause a drug-induced lupus-type eruption? A. prednisone B. tetracycline C. procainamide D. oral contraceptives

Answer 12

Explanations (u) A. Prednisone is not implicated in drug-induced skin reactions. (u) B. Tetracycline and sulfonamides are known to cause a photosensitive rash on sun exposed areas of the skin. (c) C. Procainamide and hydralazine are the most common drugs that may cause a lupus-like eruption. (u) D. Oral contraceptives may induce erythema nodosum.

Question 13

. Scientific Concepts/Cardiology Which of the following is a cause of high output heart failure? A. myocardial ischemia B. complete heart block C. aortic stenosis D. thyrotoxicosis

Answer 13

Explanations (u) A. Low output heart failure occurs secondary to ischemic heart disease, hypertension, dilated cardiomyopathy, valvular and pericardial disease, and arrhythmia. (u) B. See A for explanation. (u) C. See A for explanation. (c) D. High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget’s disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.

Question 14

Diagnosis/Cardiology A 46 year-old male with no past medical history presents complaining of chest pain for four hours. The patient admits to feeling very poorly over the past two weeks with fever and upper respiratory symptoms. The patient denies shortness of breath or diaphoresis. On examination the patient appears fatigued. Vital signs reveal a BP of 130/80, HR 90 and regular, RR 14. The patient is afebrile. Labs reveal a Troponin I of 10.33 ug/L (0-0.4ug/L). Cardiac catheterization shows normal coronary arteries and an ejection fraction of 40% with global hypokinesis. Which of the following is the most likely diagnosis? A. myocarditis B. pericarditis C. hypertrophic cardiomyopathy D. coronary artery disease

Answer 14

Explanations (c) A. Myocarditis often occurs secondary to acute viral illness and causes cardiac dysfunction. Patients will commonly have a history of a recent febrile illness. Chest pain may mimic that of a myocardial infarction and Troponin I levels maybe elevated in one-third of patients. Contractile dysfunction is seen on catheterization and/or echocardiogram. (u) B. Pericarditis does not typically cause ventricular dysfunction and cardiac enzymes are usually normal. (u) C. Hypertrophic cardiomyopathy is associated with ventricular hypercontractility. (u) D. This patient had normal coronary arteries on cardiac catheterization, no signs of coronary artery disease.

Question 15

Clinical Therapeutics/Cardiology Which of the following antihypertensive agents is considered to have both alpha- and beta-blocker activities? A. carvedilol (Coreg) B. hydralazine (Apresoline) C. minoxidil (Loniten) D. spironolactone (Aldactone)

Answer 15

Explanations (c) A. Carvedilol has both alpha- and beta-blocker activities. (u) B. Hydralazine and minoxidil are considered vasodilators. (u) C. See B for explanation. (u) D. Spironolactone is a potassium-sparing diuretic.

Question 16

. Diagnosis/Cardiology A 12 year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis? A. abdominal aortic aneurysm B. pheochromocytoma C. coarctation of the aorta D. thoracic outlet syndrome

Answer 16

Explanations (u) A. Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child. (u) B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine release from the adrenal medulla, but does not cause variations in blood pressure in the upper and lower extremities. (c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the “3” is due to the coarctation site with proximal and distal dilations. (u) D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old.

Question 17

Clinical Therapeutics/Cardiology According to the recent JNC VII guidelines, a 34 year-old male who has type 1 diabetes mellitus and hypertension should be started on which type of antihypertensive agent? A. beta-blocker B. loop diuretic C. ACE inhibitor D. thiazide diuretic

Answer 17

Explanations (u) A. Beta blockers could potentially be harmful in a patient with diabetes mellitus. Use a cardioselective beta- blocker to reduce the incidence of hypoglycemia. (u) B. See C for explanation. (c) C. ACE inhibitors are effective in young patients. They are capable of providing protection to the kidney especially in diabetes mellitus. (u) D. See C for explanation.

Question 18

Scientific Concepts/Cardiology A patient presents with moderate mitral stenosis. Which of the following complications is associated with an increased risk of systemic embolization in this patient? A. atrial fibrillation B. pulmonary hypertension C. increased left atrial pressure D. left ventricular dilatation

Answer 18

Explanations (c) A. 50-80% of patients with mitral stenosis will develop paroxysmal or chronic atrial fibrillation; 20-30% of patients with atrial fibrillation will have systemic embolization. (u) B. Pulmonary hypertension can occur in patients with severe mitral stenosis with symptoms of low cardiac output and right sided heart failure. Pulmonary hypertension does not cause systemic embolization. (u) C. Patients with mitral stenosis can have increased left atrial pressures relative to the left ventricular diastolic pressures; this does not usually cause systemic embolization. (u) D. Left ventricular dilatation is more common in aortic valve disease than mitral valve disease.

Question 19

Diagnostic Studies/Cardiology A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient’s physical features? A. right atrial enlargement B. aortic root dilation C. pulmonic stenosis D. ventricular septal defect

Answer 19

Explanations (u) A. Patients with Marfan’s syndrome commonly have mitral valve prolapse and possibly aortic regurgitation. Right atrial enlargement, pulmonic stenosis and ventricular septal defect are not commonly seen. (c) B. This patient has the signs and symptoms consistent with Marfan’s syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease. (u) C. See A for explanation. (u) D. See A for explanation.

Question 20

Diagnosis/Cardiology A patient presents with chest pain. ECG done in the emergency department reveals ST segment elevation in leads II, III, and AVF. This is most consistent with a myocardial infarction in which of the following areas? A. anterior wall B. inferior wall C. posterior wall D. lateral wal

Answer 20

Explanations (u) A. Anterior wall myocardial infarction is characterized by ST segment elevation in 1 or more of the precordial (V1- V6) leads. (c) B. Inferior wall myocardial infarction is characterized by ST segment elevation in leads II, III, and AVF. (u) C. Posterior wall myocardial infarction is characterized by ST segment depression in leads V1-V3 and a large R wave in leads V1-V3. (u) D. Lateral wall myocardial infarction is characterized by ST segment elevation in leads I and AVL.

Question 21

Clinical Therapeutics/Cardiology Which of the following is an absolute contraindication to thrombolytic therapy in a patient with an acute ST segment elevation myocardial infarction? A. history of severe hypertension presently controlled B. current use of anticoagulation therapy C. previous hemorrhagic stroke D. active peptic ulcer disease

Answer 21

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Absolute contraindications to thrombolytic therapy include a previous hemorrhagic stroke, a stroke within one year, a known intracranial neoplasm, active internal bleeding, and a suspected aortic dissection. Severe, but controlled hypertension, use of anticoagulation, and active peptic ulcer disease are relative contraindications in which the risk/benefit ratio must be weighed in each patient. (u) D. See C for explanation

Question 22

Health Maintenance/Cardiology A postmenopausal woman is at greatest risk of death from which of the following? A. stroke B. heart disease C. ovarian cancer D. breast cancer

Answer 22

Explanations (u) A. See B for explanation. (c) B. Although women tend to be concerned about dying from breast cancer, heart disease is the number one killer of postmenopausal women. (u) C. See B for explanation. (u) D. See B for explanation

Question 23

Diagnosis/Cardiology A 46 year-old female is being evaluated for a new-onset hypertension that was discovered on screening at her workplace. The patient had several readings revealing systolic and diastolic hypertension. Patient is currently on no medications. Physical examination is unremarkable. A complete laboratory evaluation revealed hypokalemia as the only abnormality. Which of the following is the most likely diagnosis for this patient? A. pheochromocytoma B. renal artery stenosis C. coarctation of the aorta D. primary aldosteronism

Answer 23

Explanations (u) A. Pheochromocytoma will result in an increase in the production and release of catecholamines, which results in an increase in urinary metanephrines on testing. (u) B. Renal artery stenosis is identified by an abnormal radionuclide uptake on the affected kidney. (u) C. Coarctation of the aorta is identified by delayed and weakened femoral pulses along with a blood pressure in the lower extremities significantly lower than in the upper extremities. (c) D. Primary aldosteronism has an increased aldosterone secretion, which causes the retention of sodium and the loss of potassium. This should be the primary consideration for this patient.

Question 24

Clinical Intervention/Cardiology A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be A. vasodilator therapy. B. bypass surgery. C. exercise program. D. embolectomy.

Answer 24

Explanations (u) A. Vasodilator therapy is not indicated. (c) B. Bypass surgery is indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients. (u) C. While an exercise program is appropriate with claudication, rest pain is a surgical indication. (u) D. Embolectomy is used for acute arterial occlusion

Question 25

Clinical Therapeutics/Cardiology Which electrolyte abnormality is associated with an increase in the risk for digoxin toxicity?] A. hypercalcemia B. hypokalemia C. hypermagnesemia D. hyponatremia

Answer 25

Explanations (u) A. See B for explanation. (c) B. Decreased concentration of potassium results in the increased activity of cardiac glycosides by increasing tissue binding and decreasing renal excretion of digoxin. Potassium loss is the only significant electrolyte abnormality that significantly affects digoxin metabolism. (u) C. See B for explanation. (u) D. See B for explanation.

Question 26

Health Maintenance/Cardiology A 56 year-old male, status post myocardial infarction, is noted to have left ventricular hypertrophy and an ejection fraction of 38%. Which of the following medications should be prescribed to prevent the development of heart failure symptoms? A. amlodipine (Norvasc) B. furosemide (Lasix) C. hydrochlorothiazide (HCTZ) D. lisinopril (Zestril

Answer 26

xplanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. ACE inhibitors have been shown to markedly improve survival and are also recommended for prevention of symptoms in patients at risk for heart failure

Question 27

Health Maintenance/Cardiology A 74 year-old patient presents with signs and symptoms of heart failure. EKG shows the patient to be in atrial fibrillation at a rate of 80 bpm. Blood pressure is 120/76. The patient denies complaint of palpitations, chest pain, or syncope. Which of the following is the most important long term therapy in this patient? A. verapamil (Calan) B. amiodarone (Cordarone) C. furosemide (Lasix) D. warfarin (Coumadin)

Answer 27

Explanations (u) A. Calcium channel blockers are utilized in rate control of atrial fibrillation. This patient’s rate is controlled at 80bpm presently. (u) B. Antiarrhythmic therapy may be considered in patients with atrial fibrillation; however anticoagulation therapy must occur first. (u) C. Diuretics may be indicated in the acute treatment of heart failure; however they may not be needed long term. (c) D. Patients with atrial fibrillation have an increased risk for stroke, therefore these patients need anticoagulation with warfarin to an INR of 2.0-3.0

Question 28

Diagnostic Studies/Cardiology Which of the following ECG findings is consistent with hyperkalemia? A. prolonged QT interval B. delta wave C. peaked T waves D. prominent U waves

Answer 28

Explanations (u) A. Prolonged QT interval is seen in hypocalcemia. (u) B. Delta wave is a sign of ventricular preexcitation seen in Wolf-Parkinson-White (WPW) Syndrome. (c) C. Narrowing and peaking of T waves are the beginning EKG changes associated with hyperkalemia. (u) D. Prominent U waves are a sign of prolonged ventricular repolarization seen in hypokalemia

Question 29

History & Physical/Cardiology A 58 year-old male presents with chest pain. Vital signs include blood pressure of 210/175, pulse 80, RR 20. Which of the following would you expect to find on physical examination? A. papilledema B. carotid bruit C. diastolic murmur D. absent peripheral pulses

Answer 29

Explanations (c) A. Malignant hypertension is characterized by marked blood pressure elevation with papilledema, often with encephalopathy or nephropathy. (u) B. Carotid bruits are associated with carotid artery stenosis. (u) C. Diastolic murmurs are associated with valvular heart disease such as aortic regurgitation and mitral stenosis. (u) D. Peripheral pulses are absent in acute arterial occlusion or severe peripheral arterial disease.

Question 30

Clinical Therapeutics/Cardiology A 55 year-old diabetic female presents for a 3 month blood pressure follow-up. At the last visit the BP was 160/90 for the third consecutive visit. She was placed on an ACE inhibitor and educated regarding lifestyle modifications. At today’s visit the patient complains of persistent annoying dry cough that has been going on since the last visit. BP today is 120/70. What is the best recommendation to control her BP? A. add a diuretic B. stop the ACE inhibitor and continue lifestyle modifications C. switch patient to an Angiotensin II Receptor Blocker (ARB) D. do nothing and recheck BP in 3 months

Answer 30

Explanations (u) A. This patient’s blood pressure is controlled; there is no indication at this time to add an additional drug. (u) B. This patient’s chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped, however the patient needs something for blood pressure control. (c) C. This patient’s chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped. Angiotensin II Receptor Blockers (ARBs) are similar to ACE inhibitors for BP control, but do not cause cough. (u) D. This patient’s chronic dry cough is likely secondary to the ACE inhibitor, the medication should be stopped to encourage compliance.

Question 31

Diagnosis/Cardiology A newborn is seen for an initial two week visit. Physical examination reveals a thrill and a continuous machinery murmur in the left second intercostal space. Which of the following is the most likely diagnosis? A. patent ductus arteriosus B. ventricular septal defect C. tetralogy of Fallot D. coarctation of the aorta

Answer 31

Explanations (c) A. Patent ductus arteriosus is characterized by a classic harsh, machinery-like murmur that is continuous through systole and diastole. This is heard best at the left second interspace and is commonly associated with a thrill. (u) B. Ventricular septal defect is characterized by a holosystolic murmur at the lower left sternal border. (u) C. Tetralogy of Fallot is characterized by a systolic thrill at the left sternal border with a systolic ejection murmur that may or may not have an associated systolic click. (u) D. Coarctation of the aorta is associated with a systolic ejection click or a short systolic murmur at the left sternal border.

Question 32

History & Physical/Cardiology A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition? A. A grade III/VI diastolic murmur heard best at the apex without radiation. B. A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle. C. A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation. D. A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

Answer 32

Explanations (u) A. This is a classic description of mitral stenosis. (u) B. This is a classic description for pulmonic stenosis. (u) C. This is a classic description for mitral valve prolapse. (c) D. This is a classic description of mitral regurgitation. The papillary muscle rupture is a complication of an acute inferior transmural myocardial infarction, and results in a failure of the mitral valve leaflets to close. The direction of regurgitant flow of blood is toward the left axilla.

Question 33

Clinical Intervention/Cardiology A 58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is A. daily aspirin to prevent MI. B. nitrate therapy for the angina. C. aggressive risk factor reduction. D. referral for coronary artery revascularization.

Answer 33

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.

Question 34

Diagnostic Studies/Cardiology A 17 year-old woman presents to the office with recurrent episodes of palpitations and near syncope. Initial ECG was normal. She is concerned about these episodes since they can occur at any time. Which of the following is the most appropriate step to pursue in her evaluation? A. cardiac catheterization B. tilt table testing C. echocardiogram D. Holter monitoring

Answer 34

Explanations (u) A. A cardiac catheterization will not be useful since the patient is at low risk for actual coronary artery disease. (u) B. Tilt table testing is useful only in trying to determine vasodepressor syncope that is related to position. (u) C. An echocardiogram shows valves and left ventricle function, not pathways of conduction. (c) D. Holter monitoring will identify the heart rhythm; an event recorder may also be useful in this setting if the Holter monitor is not diagnostic.

Question 35

Health Maintenance/Cardiology A 37 year-old female with history of Turner’s syndrome and coarctation of the aorta repaired at the age of 3 presents for routine examination. The patient is without complaints of chest pain, dyspnea, palpitations, or syncope. On examination vitals signs reveal a BP of 130/76, HR 70, regular, RR 16. On cardiac examination you note a grade II/VI systolic ejection murmur at the left sternal border and a grade III/VI blowing diastolic murmur. Which of the following does this patient require? A. antibiotic prophylaxis B. beta blocker therapy C. chest CT D. exercise stress test

Answer 35

Explanations (c) A. This patient has a history of congenital heart disease and presently has a murmur consistent with aortic regurgitation. This patient requires antibiotic prophylaxis against infective endocarditis. (u) B. Beta blocker therapy may increase the amount of regurgitation because of increased diastolic time and is not indicated in this patient. (u) C. This patient should undergo serial echocardiograms, chest CT will not give information regarding any changes in the aortic regurgitation or ejection fraction. (u) D. This patient is without any complaints; exercise stress test is not indicated.

Question 36

Diagnostic Studies/Cardiology A 60 year-old male with history of hypertension and hyperlipidemia presents with intermittent chest heaviness for one month. The patient states he has had occasional heaviness in his chest while walking on his treadmill at home or shoveling snow. He also admits to mild dyspnea on exertion. His symptoms are relieved with 2-3 minutes of rest. He denies lightheadedness, syncope, orthopnea or lower extremity edema. Vitals reveal a BP of 130/90, HR 70, regular, RR 14. Cardiac examination revealed a normal S1 and S2, without murmur or rub. Lungs were clear to auscultation. Extremities are without edema. EKG reveals no acute change and cardiac enzymes are negative. Which of the following is the most appropriate next diagnostic study? A. cardiac catheterization B. nuclear exercise stress test C. helical (spiral) CT D. transthoracic Echocardiogram2

Answer 36

Explanations (u) A. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings, a stress test is a better initial diagnostic study for this patient. (c) B. This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient. (u) C. Helical CT is used in the diagnosis of pulmonary embolism, not in the evaluation of angina. (u) D. Echocardiogram is used in the evaluation of valvular heart disease not in the evaluation of suspected myocardial ischemia.

Question 37

History & Physical/Cardiology A 28 year-old patient presents with complaint of chest pain for two days. The patient describes the pain as constant and sharp. It is worse with lying down, better with sitting up and leaning forward. Vital signs are BP 120/80, HR 80, regular, RR 14 and Temperature 100.1 degrees F. Which of the following would you expect to find on physical examination? A. lower extremity edema B. carotid bruit C. pericardial friction rub D. splinter hemorrhages

Answer 37

Explanations (u) A. Lower extremity edema is seen with heart failure or venous insufficiency, not pericarditis. (u) B. Carotid bruits are associated with carotid artery stenosis, not pericarditis. (c) C. This patient has signs and symptoms of pericarditis. A pericardial friction rub is characteristic of acute pericarditis. (u) D. Subungual (splinter) hemorrhages are characteristic of infective endocarditis, not pericarditis.

Question 38

History & Physical/Cardiology A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of A. pulmonary edema. B. wide pulse pressure. C. distended neck veins. D. an early diastolic murmur.

Answer 38

Explanations (u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade. (u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade. (c) C. Cardiac tamponade will manifest with distended neck veins and cold clammy skin. (u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade.

Question 39

Clinical Intervention/Cardiology A 45 year-old female presents with complaint of lower extremity discomfort. The patient admits to dull aching of the left lower extremity. The discomfort is worse after standing for long periods of time. Examination reveals dilated, tortuous and elongated veins on the medial aspect of the left leg. Pedal pulses are +2/4 bilaterally. There are no skin changes or lower extremity edema noted. Which of the following is the most appropriate initial treatment of choice in this patient? A. heparin B. compression stockings C. furosemide (Lasix) D. thrombectomy

Answer 39

Explanations (u) A. Heparin is used in the treatment of deep vein thrombosis not varicose veins. (c) B. This patient has signs and symptoms of varicose veins. Initial treatment with compression stockings may prolong or avoid the need for surgery. (u) C. This patient has no signs of edema or venous insufficiency requiring diuretic therapy. (u) D. Thrombectomy is indicated in a patient with an arterial thrombus, this patient has intact pulses and no pallor.

Question 40

Diagnosis/Cardiology A 55 year-old male presents with complaint of sudden ripping chest pain that radiates into the abdomen. On examination the patient is found to have diminished peripheral pulses and a diastolic murmur. EKG reveals left ventricular hypertrophy. Which of the following is the most likely diagnosis? A. acute myocardial infarction B. pulmonary embolism C. acute pericarditis D. aortic dissection

Answer 40

Explanations (u) A. Pain associated with a myocardial infarction is commonly a retrosternal pressure, squeezing, or heaviness. ST segment elevation on EKG would be expected. (u) B. A pulmonary embolism is associated with retrosternal pain; however chest pain is not always present. Patients more commonly will have a sudden onset of dyspnea. PE is not usually associated with a diastolic murmur or diminished pulses. (u) C. Acute pericarditis is characterized by sharp, knife-like pain that is worse with lying supine and better with sitting up and leaning forward. One would expect to find a pericardial friction rub on auscultation. (c) D. Aortic dissection is characterized by a ripping or tearing type pain with radiation to the neck, back or abdomen. Left ventricular hypertrophy is often seen on EKG secondary to longstanding hypertension. A diastolic murmur is often present secondary to aortic insufficiency.

Question 41

History & Physical/Cardiology A 78 year-old patient who is in acute distress with near-syncope and lightheadedness is being examined. The patient’s pulse is 40/min and blood pressure is 90/56 mm Hg. Examination of the patient at 45 degrees of elevation reveals cannon “a” waves. Which of the following is the most likely explanation for these abnormal waves? A. atrioventricular dissociation B. aortic stenosis C. systolic hypertension D. left ventricular hypertrophy

Answer 41

Explanations (c) A. The patient is in a third-degree heart block with the atria contracting against a closed atrioventricular valve, which would be the scenario in a patient who has an escape rate of 40. Elderly patients are at risk for heart conduction problems such as complete heart block. (u) B. Left ventricular hypertrophy, systolic hypertension, and aortic stenosis are not causes of “a” waves. (u) C. See B for explanation. (u) D. See B for explanation.

Question 42

Scientific Concepts/Cardiology Which of the following occurs as a result of pulmonary hypertension? A. left atrial enlargement B. aortic stenosis C. coronary artery spasm D. right ventricular enlargement

Answer 42

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. In pulmonary hypertension increased resistance within pulmonary circulation causes the right ventricle to work harder and eventually enlarge in response. Other changes that may occur are right atrial enlargement, decreased left ventricular cavity size, and tricuspid regurgitation.

Question 43

Diagnostic Studies/Cardiology A 56 year-old male presents to the office with a history of abdominal aortic aneurysm. He was told that he will need ongoing evaluation to assess whether the aneurysm is expanding. What is the recommended study to utilize in this situation? A. plain film of the abdomen B. serial abdominal exam C. ultrasound of the abdomen D. angiography of the abdominal aorta

Answer 43

Explanations (u) A. Although some abdominal aortic aneurysms are calcified, abdominal radiography may demonstrate the calcified outline of the aneurysm. However, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. (u) B. Serial abdominal exams are not sensitive in detecting progression of abdominal aortic aneurysms. (c) C. An abdominal ultrasound can delineate the transverse and longitudinal dimensions of an abdominal aortic aneurysm and may detect mural thrombus. Abdominal ultrasound is best used to screen patients at risk for the development of this condition. (u) D. Contrast aortography is used commonly for the evaluation of patients with aneurysms before surgery, but it has no role in the serial assessment of patients being followed on a chronic basis.

Question 44

Diagnosis/Cardiology A 55 year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a visible jugular venous pulse and a systolic flow murmur on the right side of the sternum. Which of the following is the most likely diagnosis? A. mitral insufficiency B. tricuspid insufficiency C. hepatic vein thrombosis D. aneurysm of the thoracic aorta

Answer 44

Explanations (u) A. Mitral insufficiency results in the accumulation of blood primarily in the pulmonary system and not the right side of the heart. (c) B. Tricuspid insufficiency will result in blood being put back into the right side of the body with increased jugular pulsation in the neck, along with a palpable venous pulse in the liver. (u) C. Hepatic vein thrombosis or Budd-Chiari syndrome is associated with cirrhosis and liver clotting abnormalities and is not due to right-sided heart failure. (u) D. Thoracic aorta aneurysm results in a widened mediastinum that is fairly asymptomatic until it results in rupture or dissection. These are typically found as incidental findings unless they are symptomatic from dissection or rupture, which causes severe chest pain or a severe tearing sensation in the chest.

Question 45

Clinical Intervention/Cardiology A 68 year-old patient presents after a syncopal episode. The patient has a history of coronary artery disease and ischemic cardiomyopathy. Echocardiogram shows an ejection fraction of 20%. Electrophysiology study reveals inducible sustained ventricular tachycardia from the left ventricle. Which of the following is the most appropriate therapy in this patient? A. implantable defibrillator B. metoprolol (Lopressor) C. radiofrequency ablation D. warfarin (Coumadin)

Answer 45

Explanations (c) A. Patients with symptomatic ventricular tachycardia (VT) or sustained VT and left ventricular dysfunction are at increased risk for sudden cardiac death. An implantable defibrillator is the treatment of choice. (u) B. Beta blockers are used in patients with nonsustained VT and normal ventricular function. They may be used as an adjunct to, but not in place of, implantable defibrillator therapy in patients with symptomatic VT or sustained VT. (u) C. Radiofrequency ablation is indicated in patients with outflow tract or fascicular tachycardia, not left sided VT. (u) D. Anticoagulation therapy is indicated in patients with atrial fibrillation not VT.

Question 46

Scientific Concepts/Cardiology Which of the following is the most common cause of infective endocarditis in an IV drug abuser? A. Haemophilus parainfluenza B. Enterococci C. Staphylococcus aureus D. Viridans streptococci

Answer 46

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. S. aureus accounts for more than 60% of all cases of endocarditis in IV drug abusers. (u) D. See C for explanation

Question 47

History & Physical/Cardiology Which of the following is an expected finding in a patient with a diagnosis of an arterial embolism? A. lower extremity edema B. stasis dermatitis C. palpable cord D. pulselessness

Answer 47

Explanations (u) A. Lower extremity edema is commonly associated with venous insufficiency, not arterial embolism. (u) B. Stasis dermatitis is commonly seen in patients with venous insufficiency, not arterial embolism. (u) C. A palpable cord is commonly found in a patient with a DVT, not arterial embolism. (c) D. Pulselessness is a sign of acute ischemia secondary to arterial embolism.

Question 48

Scientific Concepts/Cardiology Which of the following factors in patients with chronic venous insufficiency predisposes them to development of skin ulcers? A. Increased intravascular oncotic pressure B. Leakage of fibrinogen and growth factors into the interstitial space C. Decreased capillary leakage D. Inherited deficiency of protein C

Answer 48

Explanations (u) A. Decreased intravascular oncotic pressure can cause swelling (c) B. Leakage of fibrinogen and growth factors into the interstitial space, leukocyte aggregation and activation, and obliteration of the cutaneous lymphatic network can predispose a patient to skin ulcers (u) C. Increased capillary leakage causes venous insufficiency. (u) D. Inherited deficiency of protein C predisposes patients to thrombosis.

Question 49

Diagnosis/Cardiology A newborn is being evaluated for perioral cyanosis while feeding associated with sweating. Vital signs are rectal temperature, 37.8 degrees C (100 degrees F), blood pressure 80/45 mmHg, pulse 180/min, and respirations 40/min. A grade 3/6 harsh systolic ejection murmur with a single loud S2 is heard at the left upper sternal border. Electrocardiogram (ECG) shows right ventricular hypertrophy with right axis deviation. Chest x-ray shows a boot- shaped heart and decreased pulmonary vascular markings. Which of the following is the most likely diagnosis? A. Atrial septal defect B. Total anomalous pulmonary venous return C. Coarctation of the aorta D. Tetralogy of Fallot

Answer 49

Explanations (u) A. Although the murmur may be consistent with an ASD with pulmonary hypertension the chest x-ray would not show decreased pulmonary vascular markings. With a large left to right shunt large pulmonary arteries and increased vascularity would be seen. (u) B. The murmur for TAPVR is a soft systolic murmur at the left upper sternal border with a split S2 in addition to a short mid-diastolic murmur at the low left sternal border. (u) C. Cyanosis is usually not the presenting sign for coarctation of the aorta. Infants may present with heart failure, ECG will show evidence of LVH. (c) D. This is a common presentation for tetralogy of fallot.

Question 50

Clinical Therapeutics/Cardiology A hospitalized patient is found with confirmed pulseless ventricular tachycardia. IV access is obtained following the second shock given. Which of the following medications is to be administered immediately? A. Amiodarone B. Magnesium C. Atropine D. Epinephrine

Answer 50

Explanations (u) A. Antiarrhythmics are given after the third shock and epinephrine has been administered. (u) B. Magnesium is useful for torsades de pointes. (u) C. Atropine may be used for asystole or a slow pulseless electrical activity (PEA) rate. (c) D. Epinephrine should be given as soon as IV access is obtained before or after the second shock.

Question 51

iagnosis/Cardiology An electrocardiogram (ECG) shows a sinus rhythm with varying T wave heights, axis changes every other beat and a wandering baseline. Which of the following is most likely the diagnosis? A. Artifact B. Digoxin toxicity C. Pericardial effusion D. Poor lead placement

Answer 51

Explanations (u) A. Artifact could show a wandering baseline, but not the distinct axis changes. (u) B. Digoxin toxicity can cause bidirectional tachycardia, but not electrical alternans. (c) C. This ECG pattern best represents pericardial effusion due to a swinging heart in fluid and is known as electrical alternans. (u) D. Poor lead placement would show different patterns per the leads.

Question 52

Clinical Therapeutics/Cardiology A 25 year-old female presents to the emergency department after an episode of substernal chest pain with radiation to the middle of her back that came on suddenly and lasted for about four minutes this morning while in bed. She denies previous episodes. Examination is unremarkable, but she appears jittery. Toxicology screen is positive for cocaine. Which of the following medications is contraindicated in this patient? A. Lorazepam (Ativan) B. Diltiazem (Cardizem) C. Nitroglycerin (Nitrostat) D. Propanolol (Inderal)

Answer 52

Explanations (u) A. Lorazepam is not contraindicated and can help with agitation, psychosis or seizures. (u) B. Diltiazem is not contraindicated but does not have a definitive role in treating cocaine toxicity. (u) C. Nitroglycerin is not contraindicated but does not have a definitive role in treating cocaine toxicity. (c) D. Pure Beta blockers, such as propranol, can cause a paradoxical hypertension because of unopposed alpha- adrenergic effects.

Question 53

Clinical Intervention/Cardiology A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A. Intra-aortic balloon counterpulsation B. Mitral valve replacement C. Coronary artery bypass surgery D. Immediate fluid bolus

Answer 53

Explanations (u) A. Although part of the primary treatment to reduce mitral regurgitation, it is not definitive. (c) B. MVR is the definitive intervention to correct MR caused by papillary muscle rupture. (u) C. CABG may be necessary if significant blockage is found, but it will not correct the mitral regurgitation. (u) D. A fluid bolus is indicated if the patient is hypotensive.

Question 54

Clinical Therapeutics/Cardiology A 16 year-old male with a history of tetralogy of Fallot presents to clinic for a follow-up visit status post replacement of his right ventricle to pulmonary artery conduit. He has complaints of chest pain with inspiration, fever and general malaise. Cardiac examination reveals a rub with muffled heart sounds. Labs show an elevated erythrocyte sedimentation rate (ESR) and leukocytosis. Which of the following is the most effective treatment? A. Acetaminophen/oxycodone B. Azithromycin C. Indomethacin D. Furosemide

Answer 54

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Indomethacin is suitable for controlling pain in Dressler’s syndrome. ASA is preferred. Narcotics, diuretics or antibiotics are not recommended. (u) D. See C for explanation.

Question 55

Diagnostic Studies/Cardiology A 72 year-old male presents to the emergency department with crushing chest pain, dyspnea and palpitations for 2 hours in duration. Enzymes are pending and he has been given aspirin and sublingual nitroglycerin. He is rushed to the catheterization lab where they find a totally occluded distal right coronary artery. Which of the following electrocardiogram (ECG) findings supports the diagnosis? A. Q waves in leads I, aVL, V5-V6 B. ST segment elevation in leads II, III, aVF C. Hyperacute T waves in leads I, aVL D. Flipped T waves with repolarization changes in leads V1-V4

Answer 55

Explanations (u) A. Q waves in leads I, aVL, V5-V6 represent infarction involving the circumflex artery. (c) B. ST segment elevation in leads II, III, aVF, represents an acute process in the right coronary artery. (u) C. Hyperacute T waves in leads I, aVL can represent the initial changes of an infarction involving the circumflex artery. (u) D. Flipped T waves with repolarization changes in leads V1-V4 can represent early stages of infarction involving the left anterior descending artery.

Question 56

Health Maintenance/Cardiology Which of the following population groups represent the greatest risk for developing primary hypertension? A. White non-Hispanic B. Hispanic C. Mediterranean D. Black non-Hispanic

Answer 56

Explanations (u) A. White non-Hispanic adults have a low risk of hypertension compared to Hispanic and Black non-Hispanics. (u) B. Hispanic adults are lower risk of hypertension than Black non-Hispanic, but not compared to White non- Hispanic. (u) C. Mediterranean adults have a lower risk of hypertension than Black non-Hispanics. (c) D. Black non-Hispanic adults have the highest risk of hypertension.

Question 57

Diagnosis/Cardiology A 60 year-old male with hypertension is brought to the emergency department 30 minutes after the sudden onset of severe chest pain that radiates to his back and arms. His blood pressure is 180/80 mmHg in his left arm; no blood pressure reading can be obtained from the right arm. ECG shows sinus tachycardia with left ventricular hypertrophy. A high pitched decrescendo diastolic murmur is heard along the left mid-sternal border. Which of the following is the most likely diagnosis? A. Acute myocardial infarction B. Aortic dissection C. Pulmonary embolism D. Right subclavian arterial embolus

Answer 57

Explanations (u) A. Although included as part of the differential the presentation is not consistent with AMI. ECG may show ST changes and a murmur of mitral regurgitation may be present with papillary muscle rupture. (c) B. This is a classic presentation for aortic dissection. (u) C. Patients will also present with shortness of breath, feelings of impending doom and chest pain that varies with respirations. (u) D. Arterial embolus will present with symptoms related to the location of the occlusion. Pain and paresthesias are usually the earliest symptoms.

Question 58

History & Physical/Cardiology Which of the following conditions is most suggestive of an abdominal aortic aneurysm? A. Abdominal mass B. Hypertension C. Chest pain D. Syncope

Answer 58

Explanations (c) A. An abdominal aortic aneurysm presents with a pulsatile upper abdominal mass. (u) B. Hypertension is not suggestive of an abdominal aortic aneurysm. (u) C. Abdominal aortic aneurysm presents with midabdominal or lower back pain. (u) D. Syncope is not common in abdominal aortic aneurysm, unless it ruptures.

Question 59

Health Maintenance/Cardiology Who is most likely to require subacute bacterial endocarditis (SBE) prophylaxis prior to a dental procedure? A. 22 year-old female with mitral valve prolapse B. 36 year-old male with a bio-prosthesic mitral valve C. 45 year-old female with an ASD closure 8 months ago with no residual defect D. 15 year-old male with a bicuspid aortic valve

Answer 59

Explanations (u) A. See B for explanation. (c) B. The AHA recommends that patients with prosthetic heart valves receive antibiotic prophylaxis. As should cardiac transplant recipients with valve disease, unrepaired cyanotic CHD, repaired CHD with prosthetic material or device during the first six months of the procedure and repaired CHD with residual defects at site of patch or prosthetic device. (u) C. See B for explanation. (u) D. See B for explanation.

Question 60

Scientific Concepts/Cardiology When evaluating jugular venous pulsations a prominent a wave represents which of the following? A. Atrial contraction against a closed tricuspid valve B. Rapid filling of the right atrium C. Tricuspid regurgitation D. Poor left ventricle compliance

Answer 60

Explanations (c) A. The a wave corresponds to right atrial contraction. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.