3.

Question 1

History & Physical/Cardiology An 18 year-old male high school basketball player comes to clinic for a routine physical exam. His height is 193 cm (76 in.); arm span is 201 cm (79 in.). He has long fingers and toes. Blood pressure is 146/62 mmHg and pulse is 64/min. Which of the following exam findings is most consistent with the diagnosis? A. Grade 2/6 high-frequency diastolic murmur at the third right intercostal space B. Grade 2/6 systolic ejection murmur at the second left intercostal space with a fixed widely split S2 C. Grade 2/6 continuous murmur heard best at the high left sternal border D. Grade 2/6 systolic murmur at the fourth left intercostal space that decreases with squatting

Answer 1

Explanations (c) A. This murmur is most consistent with aortic regurgitation which can be present in patients with Marfans syndrome and a dilated aortic root. (u) B. This murmur is most consistent with an atrial septal defect. (u) C. This murmur is most consistent with a patent ductus arteriosus and unlikely in this age patient. (u) D. This murmur is most consistent with hypertrophic obstructive cardiomyopathy.

Question 2

Scientific Concepts/Cardiology Which of the following is the most likely initial effect on the left ventricle from aortic stenosis? A. Dilitation of the ventricle with diastolic dysfunction B. Wall stiffness due to ischemia from decreased coronary blood flow C. Paradoxical wall motion abnormalities due to increased preload D. Concentric hypertrophy with preserved function

Answer 2

xplanations (u) A. Dilitation of the ventricle is a later finding. (u) B. This is not an effect from aortic stenosis but coronary artery blockage. (u) C. Preload is the end-diastolic pressure or volume within the ventricle, ischemic heart disease or infarct would cause paradoxical wall motion abnormalities due to the increased preload. (c) D. Hypertrophy would be the initial changes of the left ventricle as a response to the increased pressure

Question 3

Diagnosis/Cardiology A 65 year-old female who recently had an anterior MI returns to clinic for follow-up six weeks after. She has no chest pain, but reports decreased exercise tolerance. Electrocardiogram (ECG) shows persistent ST elevation in leads V2- V4. Which of the following is the most likely diagnosis? A. Right ventricular infarction B. Re-occlusion of the right coronary artery C. Pericarditis D. Ventricular aneurysm

Answer 3

Explanations (u) A. RV infarction is present in one-third of patients who had an inferior wall MI and typically show ST elevation in V4 along with the inferior leads. (u) B. Occlusion of the right coronary artery would show ST elevation in the inferior ECG leads. (u) C. Pericarditis shows ST elevation in multiple leads with a history consistent of a viral illness or fever. (c) D. Persistent ST elevation in the leads where a previous or recent anterior MI occurred is most likely due to ventricular aneurysm.

Question 4

Diagnostic Studies/Cardiology A 15 year-old male is brought to the emergency department 1 hour after an episode of syncope while running in a 400-meter race. He had a similar episode 2 years ago. His mother and maternal first cousin died suddenly at the ages of 32 and 17 years, respectively. Examination shows abrasions of the face, hands, and knees. Neurologic examination shows no abnormalities. Which of the following is the most appropriate initial test? A. Tilt table test B. CT scan of the head C. Electrocardiogram D. Electroencephalography

Answer 4

Explanations (u) A. Tilt table testing should be performed after structural heart disease has been ruled out. (u) B. CT scanning of the head would not be the initial test of choice. (c) C. ECG is the most appropriate to rule out any underlying rhythm abnormalities, Holter or event monitoring would also be included. (u) D. EEG testing routinely would not be helpful as an initial test in this patient.

Question 5

Clinical Therapeutics/Cardiology What is the optimal INR for a patient with a mechanical mitral valve prosthesis on warfarin (Coumadin)? A. 1.5-2.5 B. 2.0-3.0 C. 2.5-3.5 D. 3.5-4.5

Answer 5

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Patients with mechanical MV prostheses should maintain an INR between 2.5-3.5. Aortic mechanical valves can be maintained at an INR of 2.0-3.0. (u) D. See C for explanation.

Question 6

Clinical Intervention/Cardiology Which of the following can optimize quality of life and is an definitive treatment for a patient with refractory heart failure? A. Ventricular assist device B. Intra-aortic balloon counterpulsation C. Cardiac transplantation D. Partial resection of the left ventricle

Answer 6

Explanations (u) A. Ventricular assist devices can help to provide temporary circulatory support to those awaiting transplantation. (u) B. IABC is useful in cardiogenic shock, but does not improve quality of life. (c) C. Cardiac transplantation is effective, with survival rates of 80-90% in 1 year, 60-70% over 5 years. It does improve quality of life despite the immunosuppression medications. (u) D. Partial resection of the left ventricle is still experimental and has not shown to have successful results.

Question 7

History & Physical/Cardiology Which of the following physical exam findings suggests worsening or severe aortic stenosis? A. An ejection click preceding the murmur B. A split S2 with respiration variation C. Grade 2/6 systolic murmur radiating to the carotids D. Palpable thrill over the right second intercostal space

Answer 7

Explanations (u) A. This finding is typical in mild to moderate AS. (u) B. This can be a normal finding. (u) C. This is the typical murmur for aortic stenosis, but does not suggest the degree of severity by the grade. (c) D. A palpable thrill or LV heave with associated murmur suggests severe AS.

Question 8

Scientific Concepts/Cardiology Perfusion of the coronary arteries occurs primarily during which of the following? A. Systole B. Diastole C. Afterload D. Preload

Answer 8

Explanations (u) A. See B for explanation. (c) B. Coronary artery perfusion occurs primarily during diastole. (u) C. See B for explanation. (u) D. See B for explanation.

Question 9

Clinical Therapeutics/Cardiology What is the mechanism of action for aspirin? A. Inhibits platelet aggregation by blocking cyclooxygenase-1 activity B. Exerts antiplatelet effects by blocking the platelet membrane adenosine diphosphate receptors C. Inhibits the platelet membrane glycoprotein IIb/IIIa receptor D. Converts plasminogen to the natural fibrinolytic agent plasmin

Answer 9

Explanations (c) A. Aspirin inhibits platelet aggregation by blocking cyclooxygenase-1 activity. (u) B. This the mechanism of action for ADP antagonists such as clopidogrel or ticlopidine. (u) C. This is the mechanism of action for glycoprotein IIb/IIIa receptors such as abciximab (ReoPro). (u) D. This is the mechanism of action for tissue plasminogen activators (tPA).

Question 10

History & Physical/Cardiology A 56 year-old male with a 30 pack-year smoking history presents with substernal chest pain. The pain is described as a pressure that radiates to his jaw. The pain has lasted consistently for 30 minutes with variable relief. His current medications include atorvastatin (Lipitor) and glyburide (Micronase). Which of the following aggravating or relieving factors about the pain would support the diagnosis? A. Precipitated by exercise and relieved with rest B. Unrelieved by nitroglycerin C. Aggravated by deep breaths D. Relieved with food

Answer 10

Explanations (u) A. Precipitated by exercise and relief with rest is consistent with angina. (c) B. Patient is having a myocardial infarction which is unrelieved by rest or nitroglycerin. (u) C. Aggravated by deep breaths suggests pericarditis. (u) D. Relieved with food suggests peptic ulcer disease.

Question 11

Health Maintenance/Cardiology A 26 year-old female presents to clinic with a left arm that is swollen and non-tender with bluish discoloration along the upper arm and forearm. She is status post pacemaker insertion in the left upper chest for third degree heart block, one week ago. Pulses are present and the arm is warm, but not red. The pacemaker incision is healing well despite a hematoma and tenderness at the site. Which of the following statements would be appropriate patient education about this condition? A. Reassurance that the discoloration is an expected finding. B. Apply cold compresses to the site of the hematoma. C. Elevation of the involved extremity will increase the swelling. D. Aspirin should be taken to help manage pain.

Answer 11

Explanations (c) A. This is indicative of migratory ecchymosis and expected after insertion of a pacemaker. (u) B. Warm compresses will help to decrease the hematoma. (u) C. Elevation will help to decrease the swelling. (u) D. ASA is not the pain medicine of choice in a patient with a hematoma due to its non-clotting properties.

Question 12

Clinical Intervention/Cardiology A 66 year-old female with a history of coronary artery disease presents with a new onset of dizziness and fatigue for two weeks. She recalls nearly passing out on one occasion. Examination is unremarkable except for bradycardia. Electrocardiogram (ECG) reveals a heart rate of 50 with a normal PR interval followed by a normal QRS. There are several non-conducting P waves and no lengthening of the PR interval. Which of the following interventions is the therapy of choice? A. Permanent pacemaker B. Radio-frequency ablation C. Maze procedure D. Automatic Implantable Cardioverter Defibrillator

Answer 12

Explanations (c) A. This patient has symptomatic second degree type II heart block and requires a pacemaker. (u) B. Radio-frequency ablation is useful for supraventricular tachyarrhythmias. (u) C. Maze procedure is a surgical procedure for decreasing the incidence of atrial fibrillation by creating cuts simulating a pathway in the atriums. (u) D. Automatic Implantable Cardioverter Defibrillator (AICD) is used in patients at risk for sudden death.

Question 13

Diagnostic Studies/Cardiology Pulmonary capillary wedge pressure indirectly measures which of the following? A. Right ventricular end-diastolic pressure B. Right atrial filling pressure C. Left ventricular systolic pressure D. Left atrial filling pressure

Answer 13

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Pulmonary capillary wedge pressure indirectly measures left atrial filling pressures.

Question 14

History & Physical/Cardiology A 26 year-old male presents with increased dyspnea with exercise. He has noted a decrease in his exercise tolerance over the past several months. He denies chest pain or skipped heart beats. Echocardiogram reveals left ventricular hypertrophy with asymmetric septal hypertrophy. Ejection fraction is 65%. Which of the following is the most likely presenting history or physical exam finding? A. He has an older brother with the same diagnosis. B. An S3 gallop is heard. C. Patient notes completing a course of adriamycin. D. Elevated jugular venous distension is noted.

Answer 14

Explanations (c) A. Hypertrophic cardiomyopathy can be genetic and present in 25% of first degree relatives. (u) B. Dilated cardiomyopathy may present with an S3 gallop due to volume overload. (u) C. Adriamycin chemotherapy can lead to cardiac dysfunction, dilated cardiomyopathy and eventually heart failure. (u) D. Restrictive or dilated cardiomyopathy may present with JVD due to abnormalities of filling.

Question 15

Health Maintenance/Cardiology Which of the following lifestyle recommendations would most benefit the heart failure patient’s quality of life? A. Begin a regular exercise program B. Total salt restriction C. Home monitoring of blood pressure D. Increase home oxygen requirements

Answer 15

Explanations (c) A. Exercise training improves activity tolerance and deconditioning offering some recompensation. (u) B. Although salt restriction is a recommendation total salt restriction would be unrealistic to achieve. (u) C. Home monitoring of blood pressure will not improve a heart failure patient’s quality of life. (u) D. Increasing the requirements for home oxygen could signal that they are worsening and is palliative for their quality of life.

Question 16

History & Physical/Cardiology A newborn presents with blue discoloration of the peripheral extremities which worsens with exposure to cold and improves with warming. Which of the following is the most likely cause? A. Raynauds phenomenon B. Livedo reticularis C. Erythromelagia D. Acrocyanosis

Answer 16

Explanations (u) A. Raynauds phenomenon has a triphasic color response and is exacerbated by cold or emotions. (u) B. Livedo reticularis is characterized by a lacy pattern on the skin of the lower extremities. (u) C. Erythromelagia is red, painful extremities. (c) D. Acrocyanosis is a blue discoloration of the digits, usually of the peripheral extremities in newborns, which worsens with exposure to cold and improves with warming.

Question 17

Diagnosis/Cardiology A two month-old infant appeared well until three weeks ago when he became dyspneic and had difficulty feeding. A 4/6 holosystolic murmur is heard at the left lower sternal border in the 3rd ICS. An electrocardiogram (ECG) shows left and right ventricular hypertrophy. Which of the following is the most likely diagnosis? A. Atrial septal defect B. Pulmonary hypertension C. Ventricular septal defect D. Tricuspid insufficiency

Answer 17

Explanations (u) A. An ASD usually presents with a soft mid-systolic murmur in the second left ICS with a widely split and fixed S2. (u) B. With pulmonary hypertension the murmur may be most consistent with pulmonary or tricuspid insufficiency. (c) C. This is a classic presentation for a ventricular septal defect. (u) D. Tricuspid insufficiency is a systolic murmur heard best at the 4th ICS that may radiate to the apex.

Question 18

Diagnostic Studies/Cardiology Which of the following laboratory tests would be elevated in a patient with symptomatic heart failure? A. Lactate dehydrogenase (LDH) B. Troponin I (TnI) C. C-reactive protein (CRP) D. Brain natriuretic peptide (BNP)

Answer 18

Explanations (u) A. LDH is not a sensitive marker in patients with heart failure. (u) B. Troponin measurements are specific for myocardial infarctions. (u) C. Increased serum levels of CRP are found in patients with unstable angina and MI. They can be a strong predictor of coronary events. (c) D. BNP is expressed in the ventricles and is a sensitive assay in patients with heart failure.

Question 19

Clinical Therapeutics/Cardiology When prescribing loop diuretics which of the following electrolytes should be most closely monitored? A. Calcium B. Potassium C. Sodium D. Chloride

Answer 19

Explanations (u) A. See B for explanation. (c) B. Potassium along with magnesium should be monitored when prescribing loop diuretics. (u) C. See B for explanation. (u) D. See B for explanation.

Question 20

Diagnostic Studies/Cardiology Which of the following studies is the best initial diagnostic evaluation to estimate ventricular size and hypertrophy? A. Electrocardiogram (ECG) B. Cardiac CT scan C. Echocardiogram D. Myocardial perfusion imaging

Answer 20

Explanations (u) A. ECG is not sensitive or reliable to estimate ventricular size and hypertrophy. (u) B. Cardiac CT scan can detect coronary calcification, but is most sensitive to assess disorders of the aorta. (c) C. Echocardiogram provides the safest and most reliable means to evaluate ventricular size, hypertrophy and function. (u) D. Myocardial perfusion imaging is used for measurement of LV ejection fraction and assess regional wall motion abnormalities.

Question 21

Diagnosis/Cardiology A 44 year-old female presents to clinic for evaluation of a syncopal episode that occurred while walking her dog two days ago. She denies amnesia or head trauma. She has had increasing dyspnea on exertion and pedal edema. Physical examination reveals clubbing of her fingers and central cyanosis. Auscultation of the heart reveals tricuspid insufficiency, widely split second heart sound with a palpable P2. Echocardiogram reveals a large ostium secundum atrial septal defect with bidirectional flow. Which of the following is a secondary complication in this patient? A. Left heart failure B. Ebsteins anomaly C. Tricuspid stenosis D. Pulmonary hypertension

Answer 21

Explanations (u) A. This patient would more likely have right heart failure than left heart failure. (u) B. Ebsteins anomaly is apical displacement of the septal tricuspid leaflet and not caused by an ASD. (u) C. Tricuspid stenosis is not caused by an ASD. (c) D. Her symptoms and exam findings are consistent with pulmonary hypertension and in her case, Eisenmengers disease, which is a late finding.

Question 22

Clinical Intervention/Cardiology Which of the following treatments will most benefit the diabetic patient with two vessel coronary disease? A. Stent placement B. Percutaneous balloon angioplasty C. Medical management D. Coronary artery bypass graft

Answer 22

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. CABG is the treatment of choice in a diabetic with two or three vessel disease.

Question 23

Diagnosis/Cardiology A 24 year-old male comes to the clinic with a one week history of pain and swelling that involves the entire right upper extremity. He exercises frequently and has noticed the pain worsening while lifting weights. Examination shows enlarged cutaneous veins over the right anterior chest wall with a palpable cord. His right hand appears dusky. Which of the following is the most likely diagnosis? A. Axillary-subclavian venous thrombosis B. Thromboangiitis obliterans C. Superficial thrombophlebitis of the cephalic vein D. Brachial artery occlusion

Answer 23

Explanations (c) A. Axillary-subclavian venous thrombosis can occur in someone who strenuously exercises, has had a central venous catheter or history of venous thrombosis. (u) B. Thromboangiitis obliterans involves the arteries, although the smaller veins can be included and is linked to tobacco use. (u) C. This presentation is not consistent with superficial thrombophlebitis and there is no history of varicosities or previous IVs. (u) D. Symptoms are not consistent with brachial arterial occlusion.

Question 24

History & Physical/Cardiology When performing a pre-participation sports physical in the adolescent population, a murmur with which of the following qualities indicates a risk for sudden death during exercise? A. Increases with the Valsalva maneuver B. Increases with squatting maneuver C. Associated with a mid-systolic click D. Mid-systolic without radiation to the carotids

Answer 24

Explanations (c) A. Hypertrophic cardiomyopathy (HCM) is a known cause of sudden death during or just after physical exertion and competitive sports. The murmur associated with HCM is worsened by conditions that cause reduced ventricular volume such as the Valsalva maneuver, sudden standing, and tachycardia. (u) B. Typical systolic flow murmurs will become accentuated with maneuvers which increase venous blood flow to the heart and these murmurs do not place athletes at risk for sudden cardiac death. (u) C. Mitral valve prolapse is the most common type of heart murmur that is associated with a mid-systolic click. Mitral valve prolapse does not place the patient at risk for sudden cardiac death. (u) D. A mid-systolic heart murmur that fails to radiate into the carotids is most commonly associated with a benign systolic flow murmur and does not place the athlete at risk for sudden cardiac death.

Question 25

Clinical Therapeutics/Cardiology Which of the following antiarrhythmic drugs can be associated with hyper- or hypothyroidism following long-term use? A. Quinidine B. Amiodarone C. Digoxin D. Verapamil

Answer 25

Explanations (u) A. See B for explanation. (c) B. Amiodarone is structurally related to thyroxine and contains iodine, which can induce a hyper- or hypothyroid state. (u) C. See B for explanation. (u) D. See B for explanation.

Question 26

Diagnosis/Cardiology A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg to be cool to the touch and the toes to be cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis? A. Venous thrombosis B. Arterialthrombosis C. Thromboangiitis obliterans D. Thrombophlebitis

Answer 26

Explanations (u) A. See B for explanation. (c) B. Arterialthrombosishasoccurredandisevidencedbythelossofthepoplitealanddorsalispedispulse.Thisis a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse. (u) C. See B for explanation. (u) D. See B for explanation.

Question 27

History & Physical/Cardiology A 25 year-old female presents with a three day history of chest pain aggravated by coughing and relieved by sitting and leaning forward. She is febrile and a CBC with differential reveals leukocytosis. Which of the following physical examination signs is characteristic of her problem? A. Pulsus paradoxus B. Localized crackles C. Pericardial friction rub D. Wheezing

Answer 27

Explanations (u) A. Pulsus paradoxus is a classic finding for cardiac tamponade. (u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis. (c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis. (u) D. Wheezing is characteristic for pulmonary disorders, such as asthma.

Question 28

Diagnosis/Cardiology During physical examination an elderly patient is noted to have a painless, brown-colored ulceration in the area of the medial malleolus. Which of the following is the most likely diagnosis? A. Arterial ulcer B. Venous ulcer C. Arterial insufficiency D. Diabetic ulcer

Answer 28

Explanations (u) A. Arterial ulcers typically are the last in the sequence of events of peripheral arterial disease; which include decreased or absent pulses distal to the blockage, muscle atrophy, hair loss, thickened nails, smooth and shiny skin, reduced skin temperature, pallor, cyanosis, ulcers, and gangrene. Arterial ulcers typically occur on the feet in the areas of pressure points. (c) B. Venous ulceration develops in the lower extremity secondary to venous incompetence and chronic edema. The medial aspect of the ankle is the most common location. (u) C. Arterial insufficiency is most likely to present with symptoms of claudication prior to the development of skin ulcers. When these ulcers do occur, they are most commonly seen as arterial ulcers and not venous ulcers. (u) D. Diabetic ulcers typically occur due to atherosclerosis and arterial insufficiency along with diabetic peripheral neuropathy. These ulcers are more likely to occur on pressure points on the foot and fail to heal because of poor circulation to these areas.

Question 29

Health Maintenance/Cardiology Which of the following is a proven risk factor for the development of abdominal aortic aneurysm? A. Infective endocarditis B. Diabetes mellitus C. Cigarette smoking D. Alcohol abuse

Answer 29

Explanations (u) A. Infective endocarditis is not associated with the development of abdominal aortic aneurysm. (u) B. Diabetic patients do have a higher rate of atherosclerosis, but there is no clear causal evidence of diabetics being at higher risk for the development of abdominal aortic aneurysm. (c) C. Cigarette smoking is the primary risk factor for the development of aortic aneurysms. (u) D. Alcohol abuse is not related to development of abdominal aortic aneurysm.

Question 30

Clinical Therapeutics/Cardiology When instituting diuretic therapy for patients with heart failure, which of the following is considered the treatment of choice as first-line therapy in a failing kidney due to its improved sodium clearance? A. Hydrochlorothiazide (Diuril) B. Bumetanide (Bumex) C. Spironolactone (Aldactone) D. Acetazolamide (Diamox)

Answer 30

Explanations (u) A. Thiazide diuretics may have better hypertension control than the short acting loop diuretics but they are generally ineffective when the glomerular filtration rate falls below 30-40 mL/min. (c) B. Loop diuretics remain active in severe renal insufficiency and are the most effective type of diuretics used in the management of heart failure symptoms. These agents have a rapid onset and result in natriuresis due to their activity in the ascending limb in the Loop of Henle. (u) C. Potassium-sparing diuretics have very weak diuretic properties and are useful as adjunctive therapy in patients with Stage 3 or Stage 4 heart failure who are already on a first-line diuretic and other agents. (u) D. Acetazolamide is a carbonic anhydrase inhibitor and works by causing a metabolic acidosis with loss of bicarbonate in the failing kidney. It is a weak diuretic and does not work in the setting of a failing kidney

Question 31

Diagnostic Studies/Cardiology High ventricular filling pressures are indicated by a rise in which of the following? A. Brain natriuretic peptide B. Troponin C. Myoglobin D. Creatinine

Answer 31

Explanations (c) A. Brain natriuretic peptide (BNP) is a hormone released from the myocardium when stretched such as with high ventricular filling pressures from CHF. It can indicate or be used as prognostic evaluation in patients with acute CHF. (u) B. Troponin is a marker for cardiac muscle damage as in an acute myocardial infarction or ischemia. (u) C. Myoglobin is a byproduct of muscle destruction or damage from ischemia or other causes of skeletal muscle damage. Myoglobin may rise with high ventricular pressures, however it is nonspecific. (u) D. Creatinine is a marker of renal function.

Question 32

Clinical Intervention/Cardiology Which of the following is first-line treatment for a symptomatic bradyarrhythmia due to sick sinus syndrome? A. Permanent pacemaker B. Radiofrequencyablation C. Antiarrhythmic therapy D. Anticoagulation therapy

Answer 32

Explanations (c) A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome. (u) B. Radiofrequency ablation is used for the treatment of accessory pathways in the heart. (u) C. See A for explanation. (u) D. See A for explanation.

Question 33

Scientific Concepts/Cardiology What is the most likely mechanism responsible for retinal hemorrhages and neurologic complications in a patient with infective endocarditis? A. Metabolicacidosis B. Embolizationofvegetations C. Hypotension and tachycardia D. Activation of the immune system

Answer 33

xplanations (u) A. See B for explanation. (c) B. The vegetations that occur during infective endocarditis can become emboli and can be dispersed throughout the arterial system. (u) C. See B for explanation. (u) D. Glomerulonephritis and arthritis result from activation of the immune system.

Question 34

Diagnostic Studies/Cardiology Which of the following is a non-invasive quick method of evaluating a patient with suspected lower extremity arterial insufficiency? A. Ankle-Brachial Index B. Striker Tonometry C. CT Angiography D. Lower extremity arteriography

Answer 34

Explanations (c) A. The single most useful index is the ankle pressure. This can be obtained with an Ankle-Brachial Index (ABI) which the severity of signs and symptoms of arterial insufficiency are correlated to the findings on the ABI. It is a non-invasive study that can be performed in an office setting. (u) B. Striker Tonometry is used to evaluate compartment pressures. (u) C. CT angiography is an invasive test involving radiation and contrast that cannot be done in an office setting. (u) D. Lower extremity arteriography is an invasive test involving radiation and contrast that cannot be done in an office setting.

Question 35

History & Physical/Cardiology Which of the following is the earliest symptom for patients with left ventricular failure? A. Dependentedema B. Dyspneaonexertion C. Congestion D. Chest pain

Answer 35

Explanations (u) A. Right ventricular failure is manifested by dependent edema and congestion in the lungs. (c) B. Patients with left ventricular heart failure may be comfortable at rest and may experience their first symptoms with dyspnea with conversation or with mild exertion. (u) C. Right ventricular failure is manifested by congestion in the lungs with cough being a possible manifestation of this congestion. (u) D. Patients who have on-going left ventricular failure may have underlying coronary heart disease. When the heart failure is progressing, chest pain (manifested by angina) and myocardial infarction may be manifestations of ongoing, progressive heart failure. Acute decline in heart failure may lead to acute myocardial infarction but this tends to be a very late symptom.

Question 36

Clinical Therapeutics/Cardiology When utilizing medical treatment for hypertension, which of the following classes of medications should be used with caution in those with elevated potassium levels or intrinsic renal disease? A. Beta blockers B. Calcium channel blockers C. Central alpha agonists D. ACE inhibitors

Answer 36

Explanations (u) A. Beta blockers primarily work by decreasing cardiac contraction and slowing the heart rate. There is no association with hyperkalemia. (u) B. Calcium channel blockers (especially the dihydropyridines) act as vasodilators with some effect at lessening cardiac contraction. Their use is not associated with hyperkalemia. (u) C. Central alpha agonists stimulate the alpha receptors in the brain resulting in decreased vessel wall pressures. This process is responsible for causing a lowering of the blood pressure. There is little effect on the kidney and these agents do not cause hyperkalemia. (c) D. ACE inhibitors are recognized as valuable agents in the management of hypertension but they may result in hyperkalemia in patients with intrinsic renal disease. They should be used with caution in patients who are taking potassium-sparing diuretics. These agents reduce glomerular filtration pressure resulting in retention of potassium since less filtration occurs in the kidney.

Question 37

Clinical Intervention/Cardiology A 60 year-old male has unstable angina, but is otherwise healthy. A 90% lesion is found in the left main coronary artery. Which of the following interventions is most appropriate? A. Thrombolysis with t-PA B. Medical management with nitrates C. Coronary artery bypass graft (CABG) D. Percutaneous transluminal coronary angioplasty

Answer 37

Explanations (u) A. Thrombolysis is recommended in acute embolic occlusion, not chronic. (u) B. Medical management is appropriate only for patients who are not surgical candidates. (c) C. CABG is indicated in patients with stenosis of the left main coronary artery and those with three-vessel coronary artery disease. (u) D. Percutaneous transluminal coronary angioplasty is not the management of choice in left mainstem artery disease because of increased potential complications and mortality.

Question 38

Scientific Concepts/Cardiology Which of the following pathogens has been linked with the development of acute myocarditis? A. Human papilloma virus B. Rotavirus C. Human Herpes Virus 6 D. Coxsackie B virus

Answer 38

Explanations (u) A. Human papilloma virus most commonly is associated with venereal warts and not myocarditis. (u) B. Rotavirus is primarily responsible for acute diarrhea. (u) C. Human Herpes Virus 6 is the causative organism for Roseola. (c) D. Although associated with a number of infectious and systemic diseases, myocarditis is most frequently the result of a viral infection, with Coxsackie B virus and echovirus being the most frequently implicated in the infection.

Question 39

Diagnosis/Cardiology A patient is having a routine physical examination. Funduscopic examination reveals AV narrowing and venous nicking. The nasal border of the optic disc appears blurred. Which of the following is the most likely underlying cause? A. Hypertension B. Maculardegeneration C. Retinal detachment D. Diabetes mellitus

Answer 39

Explanations (c) A. Hypertensive retinopathy may cause AV narrowing and venous nicking due to these blood vessels having increased pressures. (u) B. Macular degeneration is associated with the formation of Drusen and neoproliferation. (u) C. Retinal detachment is observed funduscopically by the retina being displaced from its attachment. Patients will present with complaints of floaters in the eye field or abrupt loss of vision if the detachment is complete. (u) D. Diabetes mellitus is most closely associated with neovascularization and microaneurysms as its primary manifestations.

Question 40

History & Physical/Cardiology A 33 year-old female presents to the office with a complaint of palpitations. There is no history of any significant heart disease in the past and her symptoms begin and end abruptly on their own. Which of the following is the most likely explanation for these symptoms? A. Atrialfibrillation B. Atrialflutter C. Benign supraventricular tachycardia D. Sinus tachycardia

Answer 40

Explanations (u) A. Atrial fibrillation, the most common cause of sustained irregular heart rates, tends to present in an older population or in patients that have underlying heart disease such as mitral stenosis. (u) B. Atrial flutter is not commonly seen in young patients without underlying heart disease although it does tend to be intermittent in nature when it does occur. (c) C. Benign supraventricular tachycardia tends to occur in a young patient without pre-existing heart disease. Symptoms begin and end abruptly without therapy and occurrences happen only intermittently. It is the most likely diagnosis in this setting. (u) D. Sinus tachycardia may occur in a young patient without underlying heart disease but the palpitations and tachycardia tends to start and stop gradually rather than abruptly.

Question 41

Diagnosis/Cardiology A patient’s EKG reveals widened P waves in lead II and large negative deflection of the P wave in lead V1. Which of the following is the most likely underlying cause for this? A. Right atrial enlargement B. Left atrial enlargement C. Right ventricular hypertrophy D. Left ventricular hypertrophy

Answer 41

Explanations (u) A. Right atrial enlargement is found on EKG with peaked P waves in lead II and a large positive deflection on the initial P wave in lead V1. (c) B. Wide P waves in lead II and a deep negative deflection in lead V1 is due to P-mitrale which is caused by left atrial enlargement. (u) C. Right ventricular hypertrophy is noted on the EKG by having a large R wave in lead AvR along with a deep S wave in leads V5 or V6. (u) D. On an EKG, left ventricular hypertrophy is associated with tall R waves in leads V5 and V6, deep S waves in AvR and V1, and tall R waves in AvL and AvF.

Question 42

Health Maintenance/Cardiology According to the American College of Cardiology/American Heart Association classification of heart failure, which of the following patients fits the Stage B Classification system? A. Asymptomatic patient with no structural disease or patients who are at high risk for the development of heart failure. B. Asymptomatic patient with structural heart disease. C. Symptomatic patient with structural heart disease. D. Patients with refractory symptoms despite intervention.

Answer 42

Explanations (u) A. According to the ACC/AHA 2005 guidelines, patients with risk factors for heart disease but who have yet to develop symptoms are categorized as Stage A. These patients have hypertension and lipid disorders treated along with lifestyle modifications. (c) B. According to the ACC/AHA 2005 guidelines, patients with structural heart disease who have not yet experienced symptoms are classified as Stage B. This is the initial stage in which medication therapy other than just ACE inhibitors are recommended. (u) C. According to the ACC/AHA 2005 guidelines, patients with symptoms and structural heart disease are classified as Stage C. (u) D. According to the ACC/AHA 2005 guidelines, patients with refractory symptoms are classified as Stage D.

Question 43

Diagnosis/Cardiology A 15 year-old male presents acutely to the office. His legs are cool to the touch. Examination reveals that his pulses and blood pressure are higher in the upper extremities than the lower extremities. Femoral pulses are delayed and weakened. Which of the following is the most likely underlying diagnosis? A. Pheochromocytoma B. Conn’s Syndrome C. Cushing’sSyndrome D. Coarctationoftheaorta

Answer 43

Explanations (u) A. Pheochromocytoma is most commonly associated with palpitations and feelings of warmth along with episodic (later sustained) hypertension. (u) B. Conn’s Syndrome, also known as primary hyperaldosteronism, is found in a patient with hypertension who has unprovoked hypokalemia. (u) C. Cushing’s Syndrome is associated with hypertension but is associated with the typical appearance of sustained elevated cortisol levels such as purple striae, buffalo hump, and central obesity. (c) D. Coarctation of the aorta typically has narrowing of the aorta proximal to the left subclavian artery with resultant high blood pressure in the upper extremities and decreased run off to the lower extremities following this narrowed segment.

Question 44

Diagnostic Studies/Cardiology Which of the following valvular heart abnormalities will most likely be seen on echocardiography as a complication of acute myocardial infarction? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral regurgitation

Answer 44

Explanations (u) A. Aortic stenosis puts additional strain on the left ventricle and contributes to a patient developing an acute myocardial infarction and does not occur as a result of one. (u) B. Aortic regurgitation is not a consequence of acute myocardial infarction and most commonly occurs as a result of an incompetent valve or dilation of the proximal aorta. (u) C. Mitral stenosis most commonly occurs as a complication of rheumatic fever and not because of an acute myocardial infarction. (c) D. In patients with acute myocardial infarction, echocardiogram can show the severity of mitral regurgitation and the presence of ventricular septal defect if one is present. Acute inferior wall myocardial infarction is associated with acute mitral regurgitation due to necrosis of the posterior papillary muscle which is supplied by the right coronary artery.

Question 45

History & Physical/Cardiology Which of the following conditions is most closely associated with an increased intensity of the P2 heart sound? A. Atrial septal defect B. Aortic stenosis C. Ventricular septal defect D. Mitral valve prolapse

Answer 45

Explanations (c) A. Atrial septal defect can cause a left to right shunt with resultant increased volume in the right ventricle. The net result of this is that the P2 heart sound will be accentuated because of the increased blood flow in the right ventricle and increased force of contraction in the right ventricle to remove this blood. Atrial septal defect will also cause a fixed split S2 heart sound. (u) B. Aortic stenosis primarily affects the left ventricle and causes left ventricular hypertrophy. As the left ventricle contracts harder against increased valvular resistance, a systolic ejection murmur occurs. (u) C. Ventricular septal defect most commonly causes a holosystolic murmur as its most notable ausculatory finding. (u) D. Mitral valve prolapse most commonly is associated with a mid-systolic click with or without a systolic heart murmur.

Question 46

Clinical Therapeutics/Cardiology Which of the following medication classes is considered first-line therapy for patients with Raynaud’s phenomenon? A. Beta blockers B. Calcium channel blockers C. Central alpha agonists D. Oral nitrates

Answer 46

Explanations (u) A. Beta blockers do not cause vasodilation against this vasospasm which makes them less effective as treatment. (c) B. Calcium channel blockers are first line therapy for patients who have uncontrolled symptoms related to Raynaud’s phenomenon. They are vasodilating agents which may play a role in preventing the vasospasm that occurs with this disorder. (u) C. See B for explanation. (u) D. Second line agents for Raynaud’s phenomenon may include topical but not oral nitrates.

Question 47

Scientific Concepts/Cardiology Elevated levels of LP(a) (Lipoprotein a) are considered to be a risk factor for coronary artery disease through which of the following proposed mechanisms? A. Direct inhibition of HDL B. Increasing the formation of VLDL cholesterol C. Competes for binding to the plasminogen receptor D. Enhancement of naturally circulating triglycerides

Answer 47

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Lp(a) lipoproteins are secreted by the liver, constitute 10% or less of the total plasma lipoprotein mass, possess kringle domains homologous to plasminogen, and are associated with vascular disease risk. Having domains homologous to plasminogen, Lp(a) will compete with actual plasminogen for its receptor sites. Plasminogen activates plasmin, which facilitates degradation of fibrin and matrix components. The main component of LP (a) is LDL, a known risk factor for atherosclerosis. (u) D. See C for explanation.

Question 48

Clinical Therapeutics/Cardiology Which of the following medication classes is the recommended treatment for patients who have an anterior wall myocardial infarction with poor left ventricular function? A. Beta blockers B. Calcium channel blockers C. Potassium sparing diuretics D. ACE inhibitors

Answer 48

Explanations (u) A. Beta blockers need to be used with caution in a patient with severe left ventricular dysfunction as they will worsen left ventricular contractility and may make this dysfunction worse. They are used, however, in the early stages of chronic heart failure. (u) B. Calcium channel blockers have no proven mortality benefit in patients with myocardial infarctions and left ventricular dysfunction. (u) C. Although potassium sparing diuretics are part of the later stage treatment of congestive heart failure and tend to potentiate the other therapies, they are not first-line therapy in a patient with left ventricular dysfunction. (c) D. ACE inhibitors have been proven to be effective in the therapy of heart failure, especially in the setting of left ventricular dysfunction. They are considered first-line therapy in patients with symptomatic left ventricular systolic function.

Question 49

Diagnosis/Cardiology The 35 year-old patient presents after a syncopal episode while throwing a football with his son. Examination reveals regular heart rate and EKG is normal. There were no symptoms prior to the episode. Right radial pulse is decreased. Which of the following is the most likely explanation for the syncope? A. Carotid sinus hypersensitivity B. Vasovagal episode C. Cardiac dysrhythmia D. Subclavian steal syndrome

Answer 49

Explanations (u) A. Carotid sinus hypersensitivity typically presents with syncope that is related to turning of the head (such as backing a car out of a driveway) or from tight collars. (u) B. Vasovagal episodes may result in syncope but there would not be abnormal pulse findings. (u) C. Cardiac dysrhythmia may occur in the setting of exercise but this would not produce a decreased pulse on the affected side. (c) D. Subclavian steal syndrome occurs if the subclavian artery is occluded proximal to the origin of the vertebral artery which results in reversal in the direction of blood flow in the ipsilateral vertebral artery. Exercise of the ipsilateral arm may increase demand on the vertebral flow which produces a “subclavian steal”.

Question 50

Scientific Concepts/Cardiology Which of the following is the most common complication that occurs in the setting of acute pericarditis? A. Pericardial effusion B. Left ventricular failure C. Superior vena cava syndrome D. Subclavian steal syndrome

Answer 50

Explanations (c) A. Accumulation of transudate, exudate or blood in the pericardial sac can occur due to pericardial inflammation. (u) B. Patients with acute pericarditis may have problems with filling which affects the right ventricle more than the left ventricle. (u) C. Patients with lung malignancy may develop superior vena cava syndrome as a result of tumor invasion into the superior vena cava. (u) D. Patients with subclavian steal syndrome typically present with arm ischemia and syncope and is not related to pericarditis.

Question 51

Diagnostic Studies/Cardiology
Which diagnostic study is considered to be the strategy of choice for symptomatic patients with recurrent ischemia, hemodynamic instability or impaired left ventricular dysfunction?
A. Stress echocardiography
B. Exercise treadmill testing
C. Coronary angiography
D. Cardiac magnetic resonance imaging