Cardiology

Question 1

The risk for cardiac transplant rejection is highest within the first 6 months after transplantation and then within the first year; how do you diagnose acute rejection?

Answer 1

Endomyocardial biopsy should be routinely performed within the first year after cardiac transplantation to diagnose rejection.

Note: Presenting signs and symptoms of acute heart failure, including abdominal discomfort, exertional dyspnea, and an S3.

Question 2

Patients with a non–ST-elevation acute coronary syndrome who have a high or intermediate TIMI risk score should be treated with?

Answer 2

An early invasive strategy, such as urgent angiography

Question 3

For chronic severe primary mitral regurgitation in symptomatic patients with left ventricular EF >30%, asymptomatic patients with left ventricular dysfunction, & patients undergoing another cardiac surgical procedure, what’s the next step in management?

Answer 3

Surgical Mitral valve repair is generally preferred to surgical valve replacement because it is associated with improved survival

Question 4

The monoclonal antibody bevacizumab is associated with the development of significant but reversible

Answer 4

HTN

Question 5

Is characterized by clinical features of upper extremity hypertension and a radial artery–to–femoral artery pulse delay as well as radiographic findings of “figure 3 sign” and rib notching, what’s the diagnosis?

Answer 5

Aortic coarctation

Question 6

Management of a patient with acute limb ischemia?

Answer 6

Invasive angiography should be performed immediately to define the anatomic level of occlusion and plan for revascularization

Question 7

For most patients with high-risk atrial fibrillation and stable coronary artery disease, what’s the most appropriate treatment?

Answer 7

Discontinue aspirin & begin oral anticoagulation

Question 8

In patients with suspected coronary artery disease who have baseline electrocardiographic (ECG) abnormalities that preclude the use of ECG stress testing, such as ST-segment depressions greater than 0.5 mm, left bundle branch block, ventricular paced complexes, digitalis effect, and preexcitation?

Answer 8

Stress testing with adjunctive imaging e.g. exercise stress echocardiography or a nuclear perfusion study

Question 9

Subacute signs of elevated right heart pressure, Pulsus paradoxus is present, and the echo w/ moderately sized pericardial effusion with evidence of tamponade. The intrapericardial pressure is reduced to normal following drainage, whereas the intracardiac pressures remain elevated & equalized despite drainage, consistent w/ a diagnosis of effusive constrictive pericarditis. What’s the treatment?

Answer 9

Ibuprofen & colchicine

Question 10

In patients with findings of low-flow, low-gradient aortic stenosis, the primary abnormality may be either severe ventricular dysfunction with pseudostenosis or critical aortic stenosis; what’s the next step in management?

Answer 10

Dobutamine echocardiography is needed to distinguish between the two entities.

Question 11

Treatment of cardiogenic shock?

Answer 11

Inotropes such as dobutamine or milrinone may be considered to improve cardiac function.

Question 12

Treatment for atrial flutter refractory to medical therapy?

Answer 12

Catheter ablation

Question 13

A continuous murmur beneath the left clavicle that envelops the S₂ but no other cardiovascular features?

Answer 13

Patent ductus arteriosus

Question 14

Is characterized by angina and stress testing abnormalities in the absence of angiographically significant coronary artery disease?

Answer 14

Cardiac syndrome X

Question 15

Treat a patient with intermittent claudication with?

Answer 15

Supervised exercise training is recommended to improve symptoms and walking distance.

Question 16

In patients with an indication for abdominal aortic aneurysm repair, the choice between open surgical repair and endovascular aneurysm repair is driven in part by the location of the aneurysm and involvement of the renal and mesenteric arteries, therefore, what should be done prior to repair?

Answer 16

CT angiography of the abdominal aorta & iliac vessels

Question 17

Which risk factors most increases a patient’s risk for cardiovascular disease?

Answer 17

Hyperlipidemia

Question 18

In patients with heart failure, each follow-up visit should include evaluation of:

Answer 18

current symptoms and functional capacity; assessment of volume status, electrolytes, and kidney function; and review of the patient’s medication regimen for adequacy.

Question 19

Patients suspected of having Wolff-Parkinson-White syndrome should undergo

Answer 19

Electrophysiology testing for risk stratification for sudden cardiac death

Question 20

Women with Marfan syndrome considering pregnancy, should be advise?

Answer 20

Against pregnancy & have an increased risk for pregnancy-related aortic dissection and rupture.

Note: In women with Marfan syndrome and an ascending aortic diameter of 4.5 cm or greater, aortic repair surgery is recommended before pregnancy to reduce this risk. Generally, pregnancy is considered safe if the aortic diameter is smaller than 4.0 cm.

Question 21

Are small, independently mobile cardiac tumors that are typically attached to the left-sided valvular endocardium by a stalk; they may be associated with stroke, TIA, angina, MI, & peripheral embolization

Answer 21

Papillary fibroelastomas

Question 22

In patients with cyanotic conditions, such as Eisenmenger syndrome, iron deficiency is common, and should be treated with

Answer 22

Short-term iron therapy will improve exercise capacity and quality of life.

Question 23

For patients with ST-elevation myocardial infarction when symptom onset is within 12 hours and primary PCI is not available within 120 minutes of first medical contact, management should include?

Answer 23

Thrombolytic therapy e.g full-dose reteplase

Question 24

In patients with an ankle-brachial index greater than 1.40, what is the most appropriate diagnostic test to perform?

Answer 24

a toe-brachial index may be used to diagnose peripheral artery disease.

Note: Exercise ABI is not indicated to diagnose PAD, when resting ABI value is > 1.40.

Question 25

Treat a patient with infective endocarditis and refractory bacteremia with

Answer 25

Cardiac valve surgery, for persistent infection lasting longer than 5 to 7 days while on appropriate antimicrobial therapy; symptomatic heart failure; left-sided involvement with Staphylococcus aureus, fungal infections, or highly resistant organisms; complications such as heart block, annular or aortic abscess, or destructive penetrating lesions; and prosthetic valve infective endocarditis and relapsing infection.

Question 26

Recognize the potential for underestimation of cardiovascular risk in patients with?

Answer 26

HIV infection, there is a 1.5- to 2-fold increased risk for CAD.

Question 27

In patients with an intermediate probability of obstructive coronary artery disease, a normal baseline electrocardiogram, and the ability to exercise, what’s the next most appropriate diagnostic test?

Answer 27

Exercise electrocardiography

Question 28

Patients with left ventricular dysfunction due to ischemic cardiomyopathy, left bundle branch block, and heart failure symptoms should receive guideline-directed medical therapy with?

Answer 28

Beta-blocker e.g Carvedilol, before initiation of device therapy

Question 29

Patient presents with HFpEF, w/ elevated BNP & concordant rise & fall of left & right systolic pressures w/ respiration, the absence of pericardial thickening on cardiac MRI, & the presence of delayed enhancement of myocardium consistent with myocardial fibrosis on cardiac MRI.

Answer 29

Restrictive cardiomyopathy Note: B-type natriuretic peptide level (often <100 pg/mL [100 ng/L] in constrictive pericarditis)

Question 30

Patients with uncomplicated type B aortic dissection may be initially treated with medical therapy, including

Answer 30

β-blockers, sodium nitroprusside, and opioids.

Question 31

Definitive treatment of cardiac tamponade is

Answer 31

Pericardiocentesis or surgical pericardial drainage

Question 32

_______ is a well-recognized and often self-limited side effect of ticagrelor therapy.

Answer 32

Dyspnea

Question 33

is a syndrome of reversible ventricular systolic dysfunction that is usually precipitated by an acute emotional or physiologic stressor; the hallmark is wall motion abnormalities that extend beyond a single coronary territory, identified by echocardiography or other imaging studies with normal coronary arteries found on heart cath?

Answer 33

Takotsubo cardiomyopathy

Question 34

Is recommended for patients with symptomatic pulmonary valve stenosis who have appropriate valve morphology, a peak Doppler gradient of greater than 50 mm Hg or a mean gradient greater than 30 mm Hg, and valve characteristics favorable for percutaneous intervention?

Answer 34

Balloon valvuloplasty

Late-peaking systolic murmur located at the second left intercostal space; absence of an ejection click= pulmonic stenosis

Question 35

Baseline ECG abnormalities that limit the ability to interpret exercise ECG findings are an indication for stress testing with adjunctive imaging or anatomic assessment of coronary arteries with test such as:

Answer 35

Coronary CT angiography (CTA)

Question 36

In patients with sinus bradycardia & equivocal symptoms, what’s the next step in management?

Answer 36

Exercise stress testing may be used to assess for chronotropic incompetence and determine suitability for pacemaker placement.

Question 37

What are the agents of choice in treating pregnant patients with hypertension?

Answer 37

Labetalol and methyldopa

Question 38

In patients with asymptomatic severe mitral regurgitation with preserved left ventricular function who do not have an indication for surgery, clinical and echocardiographic surveillance every?

Answer 38

6 to 12 months is recommended

Question 39

In this patient with asymptomatic peripheral artery disease (PAD) and acute coronary syndrome treated with percutaneous coronary intervention, the most appropriate next step in management is?

Answer 39

cardiac rehabilitation

Question 40

Notably, the guideline recommends that all patients with HCM, regardless of the presence of obstruction, should undergo assessment for

Answer 40

Sudden cardiac death risk factors at the time of diagnosis and every 1 to 2 years. The guideline also suggests that, for most patients with HCM, mild- to moderate-intensity recreational exercise is beneficial if done for the purpose of leisure.

HCM murmur = A grade 3/6 systolic crescendo-decrescendo murmur is heard best along the left sternal border; it decreases with squatting & is more pronounced in the upright position.

Question 41

Is a rare complication of MI that produces sudden-onset chest pain or syncope with rapid progression to pulseless electrical activity?

Answer 41

Ventricular free wall rupture

Question 42

patient has signs of right-sided heart failure, but low BNP equal to <100, accompanied by fever, leukocytosis, an elevated ESR, & friction rub. Echo shows ventricular interdependence & equalization of diastolic pressures in all heart chambers. Cardiac MRI shows pericardial thickening with evidence of active inflammation. These features are consistent with the diagnosis of?

Answer 42

Transient constrictive pericarditis

Transient constrictive pericarditis most often is idiopathic but may follow cardiac surgery. Initial therapy consists of an NSAID plus colchicine.

Note: patients with restrictive cardiomyopathy would not demonstrate evidence of enhanced ventricular interdependence, and the BNP is typically > 400 pg/mL

Question 43

The cornerstone of treatment for patients with heart failure with preserved ejection fraction is

Answer 43

Diuretic therapy to maintain euvolemia

Question 44

Fixed splitting of the S₂, a mitral regurgitation murmur, and left-axis deviation on electrocardiogram are consistent with an?

Answer 44

Ostium primum ASD

Note: Patients with ostium secundum ASD have right heart volume overload but do not generally have mitral regurgitation. The ECG may demonstrate first-degree AV block & incomplete RBBB, or it may be normal. This patient’s ECG finding of left axis deviation is not seen in patients with ostium secundum ASD.

Question 45

Routine screening for lipid disorders and calculation of 10-year atherosclerotic cardiovascular disease risk by using the Pooled Cohort Equations should be performed in adults aged?

Answer 45

40 to 75 years

Question 46

In patients with a mechanical prosthetic valve, what is the most appropriate antithrombotic therapy?

Answer 46

Warfarin & Aspirin (if low risk of bleed)

Question 47

Atrial fibrillation w/ aberrant conduction results in an irregularly irregular rhythm & a wide-complex tachycardia w/ a QRS morphology (rSR pattern in lead V₁, deep terminal S waves in leads I and V₆) on ECG typical of RBBB. What’s the most appropriate next step in management?

Answer 47

BB therapy & anticoagualtion

Question 48

In patients with a thoracic aortic aneurysm greater than 4.5 cm in diameter who require coronary artery bypass graft surgery or surgery to repair valve pathology,

Answer 48

aortic repair should be performed at the time of cardiac surgery

Question 49

The most likely cause of stroke in this patient with a left ventricular assist device (LVAD) is

Answer 49

LVAD-related thrombosis

The incidence of hemorrhagic and embolic strokes approaches 20% at 1 year after insertion of a left ventricular assist device.

Question 50

Short, soft systolic murmurs (grade <3) that are well localized to the left sternal border and are not associated with symptoms often?

Answer 50

Do not require further investigation

Question 51

Duration of dual antiplatelet therapy in a patient with stable angina treated with drug-eluting stent placement?

Answer 51

Dual antiplatelet therapy is recommended for at least 6 months.

Note: Patients with ACS treated with PCI (bare metal or drug-eluting stent placement) should be optimally treated with DAPT for at least 12 months.

Question 52

Patients with an atrial myxoma may present with constitutional symptoms, embolic phenomena from tumor fragmentation, or symptoms referable to intracardiac obstruction (dyspnea, syncope); treatment is?

Answer 52

Urgent surgical excision

Question 53

An autosomal dominant D/O commonly associated with congenital cardiac lesions, including pulmonary stenosis; the valve is usually dysplastic. ________________ should be considered in all patients with pulmonary stenosis, particularly those with short stature, variable intellectual impairment, unique facial features, neck webbing, hypertelorism, and other cardiac abnormalities, including hypertrophic cardiomyopathy, atrial septal defect, and ventricular septal defect.

Answer 53

Noonan syndrome

NOTE: Turner syndrome is a genetic disorder that affects girls & women & is characterized by complete or partial absence of one of the X chromosomes. Affected persons have short stature, webbed neck, low-set ears, low hairline, & primary infertility. Cardiac defects include bicuspid aortic valve, aortic coarctation, & aortic aneurysm.

Question 54

This is indicated in patients with nonischemic cardiomyopathy who have a EF less than or equal to 35% and who have NYHA functional class II or III symptoms; It is also reasonable for patients with nonischemic cardiomyopathy & unexplained syncope & significant LV dysfunction?

Answer 54

Implantable cardioverter-defibrillator (ICD) placement

Question 55

In patients with mitral stenosis who have a discrepancy between the clinical findings and the echocardiographic findings, what should be done next?

Answer 55

Exercise echocardiography, should be pursued to assess the response of the mitral gradient and pulmonary pressures.

Question 56

Patients with ST-elevation myocardial infarction complicated by cardiogenic shock should undergo

Answer 56

Emergent revascularization with primary percutaneous coronary intervention.

Question 57

Patients with a bicuspid aortic valve and a thoracic aortic aneurysm should undergo echocardiography every

Answer 57

6 months if the aortic diameter is larger than 4.5 cm or the rate of enlargement exceeds 0.5 cm/year.

Question 58

is left ventricular systolic dysfunction with onset toward the end of pregnancy or in the months following delivery in the absence of another identifiable cause; patients often present with features of heart failure?

Answer 58

Peripartum cardiomyopathy

Question 59

In patients with infrequent episodes of palpitations, presyncope, or syncope, that occurs once or twice per week, is the most appropriate diagnostic testing option?

Answer 59

External event recorder

Question 60

Common factors other than ventricular wall stress that influence B-type natriuretic peptide (BNP) levels include:

Answer 60

Kidney failure, older age, and female sex, all of which increase BNP levels; obesity reduces BNP levels.

Question 61

In patients with critical limb ischemia, what’s the next step in management?

Answer 61

Immediate invasive angiography with endovascular revascularization is often the most effective strategy to preserve tissue viability.

Question 62

Patients with atrioventricular block and evidence of acute coronary syndrome should undergo

Answer 62

Cardiac catheterization for diagnosis and possible revascularization.

Question 63

For patients with severe aortic regurgitation, indications for surgery are the presence of attributable symptoms, left ventricular ejection fraction less than 50%, or significant left ventricular dilatation; in the absence of these findings, surveillance echocardiography every

Answer 63

6 to 12 months is recommended.

Aortic regurgitation = diastolic decrescendo murmur best heard at the left lower sternal border.

Question 64

In patients with ST-elevation myocardial infarction, an ACE inhibitor should be initiated within 24 hours of presentation; if the patient is intolerant of ACEI?

Answer 64

An angiotensin receptor blocker may be used

Question 65

Patients with atrial fibrillation in the setting of hypertrophic cardiomyopathy should receive?

Answer 65

DOACs e.g. Dabigatran

Question 66

In patients with symptoms of aortic stenosis and discrepancies between the physical examination and echocardiographic findings, the severity of stenosis should be established with?

Answer 66

Cardiac catheterization before aortic valve replacement is performed.

Surgical or transcatheter aortic valve replacement is not indicated in this patient until there is certainty that the aortic valve lesion is severe & can account for the patient’s symptoms.

Question 67

What’s the most appropriate management of patients with a small uncomplicated ventricular septal defect?

Answer 67

Periodic follow-up with clinical evaluation and imaging in 3-5 years

Question 68

Findings of congestion, hypotension, pulsus paradoxus, enlarged cardiac silhouette on chest radiograph, and electrical alternans on electrocardiogram support the diagnosis of?

Answer 68

Cardiac tamponade

Question 69

In patients with borderline or intermediate 10-year risk for atherosclerotic cardiovascular disease, ______________________ may be used to further risk-stratify patients to guide primary prevention therapy.

Answer 69

Coronary artery calcium scoring

Question 70

In patients with heart failure with reduced EF on ACEI and furosemide, what should be added?

Answer 70

β-blocker (specifically, metoprolol succinate, carvedilol, or bisoprolol), and an aldosterone antagonist (in symptomatic patients).

Question 71

Treatment of a patient with multivessel coronary artery disease & left ventricular dysfunction with?

Answer 71

Coronary artery bypass graft surgery (CABG)

Question 72

Patients with premature ventricular contraction–induced cardiomyopathy should be treated with

Answer 72

Catheter ablation

First-line therapy for symptomatic or frequent PVCs includes β-blockers or calcium channel blockers. Patients w/ continued frequent PVCs despite medical therapy or those who develop left ventricular dysfunction should undergo catheter ablation, which resolves most cases of PVC-induced left ventricular dysfunction.

Question 73

_________________________ is indicated for symptomatic patients with degenerative mitral regurgitation who are not surgical candidates.

Answer 73

Transcatheter mitral valve repair

Two surgical options are available: mitral valve repair & mitral valve replacement. Mitral valve repair is typically preferred to valve replacement because it is associated w/ better clinical outcomes. A nonoperative procedure, transcatheter mitral valve repair, is indicated for symptomatic patients with degenerative mitral regurgitation who are at prohibitive surgical risk, such as this patient. With this technique, the mitral valve is plicated using an approach from the femoral vein. In experienced centers, success rates are approximately 90%, with procedural mortality of approximately 2%.

Question 74

Patients with peripheral artery disease should be treated with aspirin, diet, exercise &?

Answer 74

statins

Question 75

Patients with end-stage heart failure should be considered for

Answer 75

Cardiac transplantation or mechanical circulatory support with left ventricular assist device (LVAD) placement.

Note: Cardiac transplantation remains the gold standard therapy for patients w/ end-stage heart failure. Indications: age <65 to 70 years, no medical contraindications (diabetes w/ end-organ complications, malignancies within 5 years, kidney dysfunction, other chronic illnesses that will decrease survival), & good social support & adherence.

Question 76

__________________, presenting with a single S₂, a parasternal lift, and a soft systolic pulmonary outflow murmur, is the most common structural disorder resulting from tetralogy of Fallot repair.

Answer 76

Pulmonary regurgitation

Question 77

Patients with an abdominal aortic aneurysm smaller than 5.5 cm should undergo surveillance

Answer 77

Ultrasonography, with frequency determined by aneurysm size.

For AAAs <4.0 cm, the 5-year risk for rupture is 2%, & some guidelines recommend a surveillance interval of 24-36 months. AAAs between 4.0 cm & 5.0 cm have a 5-year risk for rupture of 3% to 12%, and surveillance imaging is recommended more frequently (for example, every 6 to 12 months). AAAs 5.0 & 6.0 cm have a 5-year risk for rupture of 25%. Once an AAA reaches 5.5 cm in maximum diameter, surgical or endovascular repair is warranted.

Question 78

The preferred imaging modality for evaluating patients with a high pretest probability of infective endocarditis or with potential complications of endocarditis, such as abscess, is?

Answer 78

Transesophageal echocardiography

Note: Transthoracic echo can help identify the presence of a vegetation; however, there is an increased likelihood of detecting perivalvular abscess w/ TEE because of the closer proximity of the ultrasound probe to the valve structures. TEE is preferred to TTE if this diagnosis is a consideration.

Question 79

Patients w/ refractory angina symptoms while receiving optimal medical therapy, those who are unable to tolerate optimal medical therapy owing to side effects, or those with high-risk features on noninvasive exercise & imaging tests. What is the most appropriate management?

Answer 79

Diagnostic angiography and percutaneous coronary intervention

Question 80

In pregnant patients with a mechanical valve prosthesis, what’s the anticoagulation?

Answer 80

Warfarin is the preferred anticoagulation therapy during the first trimester if the dose is 5 mg daily or less; warfarin is preferred to all other anticoagulants during the second and early third trimesters.

Question 81

QT-interval prolongation has many causes, including medications such as:

Answer 81

antiarrhythmic agents, antibiotics (macrolides and fluoroquinolones), antipsychotic drugs, and antidepressants; structural heart disease; and electrolyte abnormalities.

Question 82

Asymptomatic patients w/ a bicuspid aortic valve & severe aortic regurgitation when the left ventricular end-systolic diameter reaches 50 mm or the left ventricular ejection fraction is less than 50%, what’s the appropriate management?

Answer 82

Aortic valve & root replacement

In patients undergoing cardiac surgery, repair of the ascending aorta is indicated when the diameter exceeds 45 mm; thus, concomitant aortic root replacement, in addition to aortic valve replacement, is indicated in this patient.

Question 83

Following heart failure hospitalization, _________________________________should be scheduled to reinforce heart failure education, ensure proper medication use, evaluate volume status, and uptitrate or initiate medications as needed.

Answer 83

Early follow-up (within 1 week)

Question 84

for patients with hypertrophic cardiomyopathy (HCM) and for all first-degree family members of patients with HCM who have an identified genetic mutation, regardless of the presence or absence of symptoms, should have?

Answer 84

Genetic counseling & testing

Question 85

Patients with rheumatoid arthritis have a 1.5- to 2-fold elevated risk for?

Answer 85

CAD compared with the general population.

Question 86

Is characterized by elevated resting heart rate, with exaggerated increases in heart rate with light activity. The sinus rates typically decrease during sleep, as identified on this patient’s ambulatory electrocardiographic monitor, what is the diagnosis?

Answer 86

Inappropriate sinus tachycardia (IST)

Question 87

In patients with left bundle branch block, the preferred diagnostic test for coronary artery disease is?

Answer 87

A vasodilator stress test (such as Adenosine single-photon emission CT) because myocardial perfusion imaging with exercise or dobutamine stress may result in a false-positive perfusion defect in the basilar septum

Question 88

The initial laboratory evaluation of patients with new-onset heart failure should include a B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide assay, complete blood count, serum electrolyte measurement, kidney function tests, liver chemistry tests, and

Answer 88

TSH measurement

Question 89

A patient with evidence of a recent inferolateral MI presenting w/ decompensated heart failure & a soft, early systolic murmur with an S₃ is audible in the apical area, what’s the most likely diagnosis?

Answer 89

Mitral regurgitation, likely secondary to papillary muscle dysfunction (or rupture) and/or ventricular dysfunction.

Question 90

In all patients with NSTEMI, who declines angiography, in addition to aspirin, what antithombotic regimen should be given?

Answer 90

Ticagrelor

Note: Prasugrel is only given after PCI. Clopidogrel is inferior to Ticagrelor.

Question 91

Commonly characterized by symptoms of right-sided heart failure, low or normal B-type natriuretic peptide level, & the finding of pericardial thickening or calcification on imaging studies, what’s the most likely diagnosis?

Answer 91

Constrictive pericarditis

Question 92

Elevated central venous pressure, fixed splitting of the S₂, a right ventricular heave, andright-axis deviation and incomplete RBBB on ECG are characteristic findings in patients with?

Answer 92

Ostium secundum atrial septal defect (ASD)

Question 93

In the evaluation of cryptogenic stroke, what’s the most appropriate diagnostic testing option?

Answer 93

30-Day event-triggered loop recording

Noninvasive ambulatory electrocardiographic (ECG) monitoring for 30 days improves the detection of atrial fibrillation by fivefold compared with short-term ECG monitoring.

Question 94

The mainstay of therapy for acute decompensated heart failure is

Answer 94

Intravenous diuretics

Question 95

What is the first-line imaging modality used in patients suspected of having infective endocarditis to identify vegetations, determine the severity of valvular lesions, assess ventricular function, &detect complications?

Answer 95

Transthoracic echocardiography (TTE)

Note: because of cost, accessibility, & invasiveness, TEE, chest MRI, and cardiac CT are not the best initial imaging choices.

Question 96

In patients with non–ST-elevation acute coronary syndrome, an ischemia-guided approach is appropriate for patients at low risk based on clinical risk score. What’s the most appropriate management?

Answer 96

Exercise stress testing

Question 97

Smoking cessation, exercise training, and __________________ are recommended to improve limb symptoms in patients with peripheral artery disease and intermittent claudication, already on aspirin.

Answer 97

Medical therapy (cilostazol)

Note: If this patient does not have improvement in his symptoms with cilostazol or cannot tolerate cilostazol therapy, he should be referred for invasive management (endovascular or surgical revascularization).

Question 98

Hemodynamically stable patients with supraventricular tachycardia refractory to vagal maneuvers should be given?

Answer 98

Adenosine

Question 99

This diagnosis should be suspected in Black patients older than 50 years who have left ventricular wall thickening that is not explained by loading conditions (for example, hypertension or aortic stenosis) and present with heart failure or features of diastolic dysfunction & severe pHTN?

Answer 99

Cardiac amyloidosis

Note: Diagnosis is established by histopathology; endomyocardial biopsy is more sensitive than abdominal fat pad biopsy.

Question 100

In a patient with aortic coarctation with an end-to-end anastomosis performed at 4 years of age with a grade 2/6 mid-peaking systolic murmur noted at the second right intercostal space, what’s the most likely cause of this patient’s systolic murmur?

Answer 100

Aortic stenosis

A bicuspid aortic valve is present in more than 50% of patients with aortic coarctation.

Question 101

All patients with heart failure with reduced ejection fraction should be treated with an ACE inhibitor and a β-blocker; β-blocker dosage should be

Answer 101

uptitrated every 2 to 4 weeks until the patient achieves a heart rate of approximately 60/min or has symptomatic hypotension.

Question 102

Mobitz type 2 second-degree atrioventricular block is an uncommon but potentially life-threatening electrical complication of anterior myocardial infarction; what’s the most appropriate treatment?

Answer 102

Emergent temporary or permanent pacing is indicated in this setting.

Question 103

Bicuspid valve disease is commonly associated with abnormalities of the aorta, including aneurysm, dissection, and coarctation; therefore, all patients with a bicuspid aortic valve should be evaluated for possible aortopathy with?

Answer 103

CT or cardiac magnetic resonance imaging.

Question 104

The factor associated with the highest risk for atherosclerotic cardiovascular disease (ASCVD) in a patient with DM, HTN & hyperlipidemia?

Answer 104

Diabetes mellitus

Question 105

In all patients suspected of having infection of a cardiac implanted electronic device, what is the most appropriate management?

Answer 105

a minimum of two blood cultures should be drawn from separate sites.

Question 106

In a patient with COPD & heart failure presenting with symptoms of dyspnea, paroxysmal nocturnal dyspnea, orthopnea, and peripheral edema. What’s the most likely cause of this patient’s symptoms?

Answer 106

Acute exacerbation of heart failure

Question 107

What is the preferred method of reperfusion in patients with ST-elevation myocardial infarction, noted as new LBBB on EKG?

Answer 107

Primary percutaneous coronary intervention

Question 108

Symptoms of upper extremity peripheral artery disease may include arm claudication, arm ischemia, or dizziness with arm activity; what’s the most appropriate diagnostic test to perform next?

Answer 108

CT angiography of the chest & neck is useful to confirm the diagnosis and plan for intervention.

Question 109

Patients with acute type A aortic dissection should be treated emergently with

Answer 109

Open surgical repair

Note: CT scan reveals a dissection plane extending through the aortic arch (arrow).

Question 110

This diagnostic test is indicated for patients with systolic murmurs grade 3/6 or higher, late or holosystolic murmurs, diastolic or continuous murmurs, & murmurs with accompanying symptoms?

Answer 110

Transthoracic echocardiography

Note: Innocent murmurs are characteristically brief, are often midsystolic, do not radiate, & are associated with normal heart sounds & no hemodynamic abnormalities. Patients with grade 1 or 2 midsystolic murmurs (grade 1, faintest murmur that can be heard; grade 2, faint murmur but can be identified immediately) who are asymptomatic with no associated findings & those w/ continuous murmurs suggestive of a venous hum or mammary souffle (a continuous murmur heard over the breast in lactating women) do not warrant echo evaluation.

Question 111

In patients suspected of having tricuspid regurgitation, with a grade 3/6 holosystolic murmur noted at the left lower sternal border, what is indicated to evaluate lesion severity, determine the cause, assess the size and function of the right-sided chambers, & estimate pulmonary artery pressures.

Answer 111

transthoracic echo

Question 112

Ranolazine decreases symptoms of angina and modestly increases exercise times in patients with stable angina; it should not be used with strong CYP3A inhibitors, and dosage should be reduced when used in conjunction with moderate CYP3A inhibitors, such as

Answer 112

Diltiazem and verapamil

Question 113

Asymptomatic first-degree atrioventricular block with bifascicular block, what’s the most appropriate management?

Answer 113

Does not require pacemaker implantation

Question 114

Guideline-directed medical therapy for symptomatic heart failure with reduced ejection fraction includes

Answer 114

an ACE inhibitor, β-blocker (specifically, metoprolol succinate, carvedilol, or bisoprolol), and aldosterone antagonist.

Question 115

Indications for device closure of an ostium secundum atrial septal defect?

Answer 115

Right heart enlargement & symptomatic disease

Question 116

This is indicated for symptomatic patients with aortic stenosis and intermediate or high surgical risk, as assessed by a multidisciplinary heart team?

Answer 116

Transcatheter aortic valve replacement has been found to be comparable to surgical intervention

Question 117

In patients with ST-elevation myocardial infarction, left ventricular ejection fraction of 40% or less, and either heart failure symptoms or diabetes mellitus, already on ACEI, BB, & DAPT, what other medication should be added?

Answer 117

An aldosterone antagonist

Question 118

__________________ occurs in approximately 1% of patients who undergo catheter ablation procedures for atrial fibrillation; it is the most common serious complication and is likely to result in death if not recognized and treated urgently. Patient present with pulses paradoxes & muffled hear sounds

Answer 118

Cardiac tamponade

Question 119

Is indicated in patients with an ejection fraction less than or equal to 35%, New York Heart Association functional class II to IV heart failure symptoms despite guideline-directed medical therapy, sinus rhythm, and left bundle branch block with a QRS duration of 150 ms or greater?

Answer 119

Cardiac resynchronization therapy

Question 120

In patients with acute pericarditis, first-line treatment is?

Answer 120

High-dose aspirin or NSAIDs and adjuvant colchicine therapy

Note: an ECG demonstrating widespread ST-segment elevation & PR-segment depression, and a small pericardial effusion. The elevated C-reactive protein level also supports acute pericarditis.