Cardiology Flashcards
1
Q
- Which of the following require a 2D-echo for diagnosis?
A. Mitral valve prolapse
B. Hypertrophic cardiomyopathy
C. Congestive heart failure
D. Cardiac tamponade
E. Atrial septal defect
A
B. Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy requires a 2D-echo for diagnosis. All the other conditions do not need a 2D-echo to confirm diagnosis.
2
Q
- In which scenario is 2D-echo with doppler NOT generally necessary?
A. A 25-year-old man with grade II continuous murmur
B. A 45-year-old woman with grade II mid-diastolic murmur but asymptomatic
C. A 20-year-old woman with a grade II mid-systolic murmur but asymptomatic
D. A 50-year-old male with grade III late-systolic murmur
E. A 20-year-old man with grade II holosystolic murmur but asymptomatic
A
C. A 20-year-old woman with a grade II mid-systolic murmur but asymptomatic
2D-echo with doppler is required for: LOUD systolic murmurs (grade >/= III/VI), holosystolic or late systolic murmurs, diastolic or continuous murmurs
3
Q
- Malar telangiectasia is a cutaneous manifestation of which cardiovascular disease?
A. Severe mitral stenosis
B. Significant coronary artery disease
C. Malignant hypertension
D. Osler-Weder-Rendu syndrome
E. Carney’s syndrome
A
A. Severe mitral stenosis (or Advanced mitral stenosis)
- Osler-Weber-Rendu syndrome is hereditary form of hemorrhagic telagiectasia located at the lips, tongue, and mucus membrane
- Carney’s syndrome is characterized by excessive lentigenosis, developmental delay, and multiple myxomas
4
Q
- The presence of peripheral edema in the setting of a normal venous pressure is characteristic of which condition?
A. Constrictive pericarditis
B. Venous insufficiency
C. Cardiac tamponade
D. Severe congestive heart failure
E. Severe atherosclerosis
A
B. Venous insufficiency (more common cause)
- Differentials: lymphatic obstruction, venous obstruction (e.g. DVT)
- Peripheral edema + increase in JVP: chronic HF, constrictive pericarditis
5
Q
- A patient is seen at the Emergency Room in respiratory distress with a notable drop in his blood pressure from 110/80 to 90/770 on inspiration. Which of the following conditions is the most likely cause?
A. Severe aortic stenosis
B. Dilated cardiomyopathy
C. Restrictive cardiomyopathy
D. Cardiogenic shock
E. Pericardial effusion
A
E. Pericardial effusion
- Other possible causes of pulsus paradoxus (>10mmHg decrease in SBP with inspiration): cardiac tamponade, massive PTE, hemorrhagic shock, severe COPD, tension pneumothorax
6
Q
- An anacrotic pulse with shrill is most likely due to:
A. Aortic stenosis
B. Hypertrophic cardiomyopathy
C. Advanced aortic regurgitation
D. Severe dilated cardiomyopathy
E. Premature ventricular contractions
A
A. Aortic stenosis
- Anacrotic pulse: slow, notced, or interrupted upstroke
- Bifid or bisferiens pulse: AR, HCMP
- Pulsus bigeminus: PVCs
- Pulsus alternans: PVCs, severe HF
- Corrigan’s pulse (water hammer): AR
7
Q
- A 60-year-old diabetic man with persistent chest discomfort consults at your outpatient clinic. On checking his blood pressures, you noticed that his right arm BP is 140/80 mmHg while his left arm BP is 120/80 mmHg. What can cause the above finding?
A. Aortic dissection
B. Essential hypertension
C. Aortic regurgitation
D. Large AV fistula
E. It is a normal finding in his age group
A
A. Aortic dissection
- Normal BP difference between arms is <10mmHg
- Possible causes of higher BP differential: atherosclerotic or inflammatory subclavian artery disease, supraclavicular aortic stenosis, aortic coarctation, aortic dissection
8
Q
- Reversed split S1
A. Complete RBBB
B. Complete LBBB
C. RA myxoma
D. Normal in young patients
E. Atrial septal defect
A
B. Complete LBBB
- Others: severe MS, LA myxoma
9
Q
- Wide split S2
A. Pulmonary hypertension
B. Severe aortic stenosis
C. RBBB
D. Hypertrophic cardiomyopathy
E. Acute myocardial infarction
A
C. RBBB
- Differentials: severe MR
- Fixed split: ASD
- Paradoxical/Reverse split: LBBB, right ventricular pacing, severe AS, HOCM, AMI
10
Q
- Which of the following is a systolic sound?
A. Click-murmur complex
B. Opening snap
C. Pericardial knock
D. Tumor plop of atrial myxoma
E. 4th heart sound (S4)
A
C. Click-murmur complex (associated with MVP)
- All the rest are diastolic sounds, including S3
11
Q
- Inspiration increases the intensity of the following cardiac sounds, EXCEPT:
A. Tricuspid regurgitation murmur
B. Tricuspid stenosis murmur
C. Pulmonic regurgitation murmur
D. ASD murmur
E. Pulmonic ejection sounds
A
E. Pulmonic ejection sounds
- All right-sided murmurs and sounds EXCEPT Pulmonic ejection sound
- Pulmonic ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the pulmonary valve
- The diastolic correlate of a pulmonic ejection sound or click is the opening snap in tricuspid stenosis while the valves are still flexible
12
Q
- Which of the following maneuvers can increase the murmur of mitral valve prolapse?
A. Standing
B. Squatting
C. Passive leg raising
D. Inspiration
E. After a premature ventricular beat
A
A. Standing
- Other maneuvers: Valsalva or coughing
- Murmur of MVP DECREASES with: squatting, passive leg raising, AF or a premature ventricular beat (the latter two also may not have any effect on MVP murmur)
- Similar maneuvers also affect HOCM (and it is additionally decreased with near maximum handgrip exercise)
13
Q
- Which of the following presents with early diastolic murmur?
A. Carey-Coomb’s murmur
B. Austin-Flint murmur
C. Mitral stenosis
D. Severe mitral regurgitation
E. Aortic regurgitation
A
E. Aortic regurgitation
- Other that can present as early diastolic murmur: PR due to pulmonary HTN
14
Q
- A 65-year-old male ESRD patient is seen to have rapid shallow breathing with acidotic breath. He has missed his dialysis sessions for at least 1 week now. ABGs revealed severe metabolic acidosis. Your requested for stat ECG. What findings would be consistent with the given clinical picture?
A. Prominent “u” wave
B. Prolonged QT interval
C. Peaked P waves
D. Peaked T waves
E. Narrowed QRS
A
D. Peaked T waves
- Hyperkalemia: narrowing and peaking (tenting) of the T waves –> AV conduction disturbances, decrease in P wave amplitude, increase in QRS interval –> cardiac arrest with a slow sinusoidal type of mechanism (“sine-wave” pattern) –> asystole
15
Q
- Which ECG finding is most consistent with hypokalemia?
A. Prolonged QT interval
B. Narrowing and tenting of the T wave
C. Widening of the QRS
D. Decrease in P wave amplitude
E. Widened QRS complex
A
A. Prolonged QT interval
- Prolonged QT interval (pseudo-prolongation when “u” wave merges with the T wave”
16
Q
- Which of the following ECG findings would be characteristic of right atrial enlargement?
A. Notched upright P wave in limb leads
B. Biphasic P wave in V1
C. Tall peaked P waves at least 2.5mm in limb leads
D. R in V5 more than 10mm
E. S in V1 + R in V6 more than 35mm
A
C. Tall peaked P waves at least 2.5mm in limb leads
- Right Atrial Enlargement (RAE) : tall peaked P waves (>/= 2.5mm) in limb and precordial leads
- Left Atrial Enlargement (LAE) is seen as biphasic (with broad negative component) P wave in limb leads or notched in limb leads
- LVH: R V5 or R V6 > 25mm; OR S V1 + R V5 or V6 >/= 35mm
- RVH: R>S on V1 with RAD; or R, RS, qR pattern in V1; or ST depression and T-wave inversion in the right to midprecordial leads
17
Q
- What is the ECG pattern shown below?
A. LBBB
B. RBBB
C. RVH
D. LVH
E. RAE
A
B. RBBB
- Criteria for RBBB: terminal QRS vector is oriented anteriorly and to the right (rSR’ in V1 and qRS in V6)
18
Q
- Triggered automaticity secondary to afterdepolarizations during an action potential can lead to which arrhythmia?
A. Reperfusion Ventricular tachycardia
B. Digitalis-associated ventricular tachycardia
C. Ischemic ventricular fibrillation
D. Atrial fibrillation
E. Torsades de Pointes
A
E. Torsades de Pointes
- EAD (Early after depolarizations) - during an action potential
- DAD (Delayed after depolarizations) - following an action potential: digitalis toxicity, reperfusion VT
- Repolarization abnormality characterized by AP shortening: AF
- Suppression of phase 0: ischemic VF
19
Q
- A 58-year-old man, hypertensive with recent history of NSTEMI consults for episodes of palpitations and dizziness. His 12-LECG tracing shown below is read as:
A. First degree AV block
B. Mobitz type I
C. Mobitz type II
D. Third degree AV block
E. Atrial fibrillation
A
C. Mobitz type II
- 2nd degree AV block, Mobitz type II, 2:1 AV block
- 2:1 stands for the P:QRS ratio
20
Q
- A 50-year-old woman, with DM and hypertension is given maintenance Metformin and Atenolol. She later complained of occasional episodes of lightheadedness but was otherwise comfortable and productive. Her PE findings are essentially normal except for a heart rate of 55bpm. 12-LECG tracing is shown below. What is the appropriate management of this patient?
A. Maintain current medications and repeat ECG after 1 week
B. Maintain current medications and have a temporary pacemaker implanted
C. Change Atenolol to Diltiazem and repeat ECG after a week
D. Change Atenolol to Enalapril and repeat ECG after a week
E. Stop Metformin and Atenolol and repeat ECG after a week
A
D. Change Atenolol to Enalapril and repeat ECG after a week
- ECG reading: 2nd degree AV block, Mobitz type I
- there is increasing PR interval until a non-conducted P wave
21
Q
- What does the ECG tracing below represent?
A. Atrial fibrillation in slow ventricular response
B. Third degree AV block
C. Wenckebach phenomenon
D. First degree AV block
E. Sinus node dysfunction
A
B. Third degree AV block
22
Q
- What is the tachyarrhythmia primarily seen among patients with chronic pulmonary disease during acute exacerbations of the pulmonary insufficiency?
A. Multifocal atrial tachycardia
B. Atrial fibrillation
C. Macroreentrant atrial tachycardia
D. Wolff-Parkinson-White syndrome
E. Junctional ectopic tachycardia
A
A. Multifocal atrial tachycardia (MAT)
23
Q
- A 50-year-old woman with stage IV breast cancer complains of sudden-onset of shortness of breath and palpitations but no chest pain. You saw her diaphoretic with coarse tremors. Her blood pressure was 110/80mmHg, heart rate of 170 beats per minute, respiratory rate of 24breaths/min. Breath sounds are clear. You did a stat 12-LECG shown below. What is your initial intervention?
A. Carotid sinus massage
B. Give Esmolol IV
C. Give Adenosine 6mg rapid IV bolus
D. Give Diltiazem IV
E. Sedate and cardiovert using 100J biphasic shock
A
A. Carotid sinus massage
- If unresponsive to vasovagal maneuvers –> IV Adenosine or Verapamil/Diltiazem –> IV Ibutilide + AV nodal blocking agent –> Biphasic shock 100J
24
Q
- A 70-year-old man, known hypertensive and diabetic was noted to have recent onset atrial fibrillation on ECG. His previous ECG about 24hours prior to the present one showed a regular sinus rhythm. His heart rate is 78 beats per minute, irregularly irregular. He is not in distress and his vital signs are within acceptable limits. He has been able to tolerate regular activities until present consult. What is the most appropriate next step in the management of this patient?
A. Perform transesophageal echocardiography
B. Give Verapamil to control the heart rate
C. Start Amiodarone or Ibutilide
D. Perform electrical cardioversion under sedation
E. Anticoagulate before electrical cardioversion
A
E. Anticoagulate before electrical cardioversion
- CHA2DS2-VASc score of the patient is 3
Age is 70 y/o: +1
Hypertension: +1
DM: +1
- Recall: CHA2DS2-VASc
CHF = +1 HTN = +1 Age (>/= 75, +2; 65 to 74, +1)
DM = +1 Stroke/TIA/Thromboembolism = +1 Sex (Female = +1)
Vascular Disease = +1
25
24. A 60-year-old man, known hypertensive consults you for episodes of palpitations of 4hours duration. You previously saw the patient a day earlier with an ECG showing regular sinus rhythm. On chest, auscultation you noticed an irregularly irregular rhythm with a heart rate of about 108. The rest of your PE findings are normal. You did a stat 12-LECG with the following tracing. Your computed heart rate is 110. What is the most appropriate initial intervention?
A. Control the heart rate
B. Sedate patient and deliver 200J synchronous shock
C. Give Amiodarone IV loading dose
D. Anticoagulate before electrical cardioversion
E. Perform transesophageal echocardiography
A. Control the heart rate
- ECG tracing: Atrial fibrillation in RVR
- If AF is persistent, assess risk for stroke prior to electrical cardioversion (anticoagulate first if CHA2DS2-VASc is at least 2)
- CHA2DS2-VASc
C- CHF
H - Hypertension
A - Age (65 to 74, +1; \>/= 75, +2)
D - Diabetes
S - Stroke/TIA/Thromboembolism, +2
- Sex (Female, +1)
VASc - Vascular Disease
26
26. A 60-year-old male patient with 3 months or progressive exertional dyspnea and orthopnea is examined at your clinic with irregularly irregular rhythm with a heart rate of 80 bpm. An ECG done a day earlier showed a regular sinus rhythm but latest ECG showed irregular RR interval with absent P waves. If pharmacologic cardioversion is indicated, which of the following drugs is appropriate given his clinical condition
A. Propafenone
B. Verapamil
C. Procainamide
D. Sotalol
E. Amiodarone
E. Amiodarone
27
27. A 58-year-old man admitted for the last three days for acute ST elevation AMI has frequent PVCs on 12-LECG. He is otherwise asymptomatic. What do you advice this patient?
A. He will benefit from ICD placement
B. He will benefit with prophylactic anti-arrhythmic therapy
C. He will have to have his serum potassium and magnesium levels determined
D. Even if asymptomatic he has to be started on Amiodarone to reduce his risk of dying
E. He will benefit from catheter ablation therapy
C. He will have to have his serum potassium and magnesium levels determined
- For asymptomatic patients: Correct hypokalemia and/or hypomagnesemia, start beta-blocker therapy
- Amiodarone reduces the risk of sudden death BUT overall mortality risk is not improved
- ICD placement: indicated for certain high-risk groups among survivors of AMI
- Survived \>40days after the AMI and LVEF = 0.3 or EF \< 0.35 + symptomatic HF (NYHA FC II-III)
- \> 5days after MI + LVEF, non-sustained VT, and inducible sustained VT or VF on electrophysiologic testing
28
28. What is the role of cardiac MRI with gadolinium contrast in the work-up of patients with monomorphic ventricular tachycardia?
A. Determine degree of depression of ventricular function
B. Determine presence of outflow tract abnormality
C. Detect areas of ventricular scars
D. Diagnosis of hypertrophic cardiomyopathy
E. Document occurrence of ventricular tachycardia during exercise
C. Detect areas of ventricular scars
- Detect areas of ventricular scars which predispose to sustained monomorphic VT
29
29. Which of the following correctly describes the association of ventricular tachycardia and coronary artery disease?
A. The presence of evidence of acute MI rules out scar-related VT
B. Majority of patients with VT during an AMI will not have recurrence in the next 2 years
C. Scar-related VT is dependent on recurrent AMI
D. Coronary revascularization prevents recurrence of VT
E. It occurs in the setting of a large prior MI with markedly depressed LV ejection fraction
E. It occurs in the setting of a large prior MI with markedly depressed LV ejection fraction
- Prior history of large AMI with markedly decreased LVEF and cardiac remodelling
30
30. A 40-year-old man on maintenance Haloperidol was brought to the emergency room for repeated syncopal episodes. Vital signs are stable. 12-LECG as shown below. What is the most appropriate management?
A. Immediate defibrillation after adequate sedation
B. Synchronized monophasic DC cardioversion using 100J shock
C. Placement of ICD
D. IV Magnesium sulfate
E. IV Lidocaine
D. IV Magnesium sulfate
- ECG tracing: Torsade de pointes
- IV Magnesium sulfate for Torsade de pointes
- There must be documentation of a prolonged QT
- Causes of acquired prolonged QT: electrolyte abnormalities, bradycardia, medications (sotalol, dofetilide, ibutilide, erythromycin, pentamidine, haloperidol, phenothiazines, methadone)
31
31. What is the first line treatment of symptomatic idiopathic VT?
A. Catheter ablation
B. ICD
C. Amiodarone
D. Lidocaine
E. Beta-blocker therapy
A. Catheter ablation
32
32. Which of the following can be primarily managed initially with QRS synchronous cardioversion in the setting of hemodynamic compromise?
A. Non-sustained monomorphic VT
B. Sustained polymorphic VT
C. Sustained monomorphic VT
D. Ventricular fibrillation
E. Ventricular flutter
C. Sustained monomorphic VT
33
32. Which of the following etiologies of heart failure will almost always present with systolic heart failure?
A. Cor pulmonale
B. Drug-induced dilated cardiomyopathy
C. Restrictive cardiomyopathy
D. Hypertrophic cardiomyopathy
E. LVH secondary to Hypertension
B Drug-induced dilated cardiomyopathy
34
34. On a global perspective, the single most common cause of heart failure is:
A. Rheumatic heart disease
B. Hypertensive heart disease
C. Alcohol-induced dilated cardiomyopathy
D. Coronary artery disease
E. Virus-induced dilated cardiomyopathy
D. Coronary artery disease
35
35. Which of the following events can ultimately lead to cardiac decompensatin in heart failure?
A. Activated autonomic nervous system
B. Activated RAAS
C. Increased inflammatory
D. Increased peptides and growth factors
E. All of the above
E. All of the above
- Activated autonomic nervous system
- Activated RAAS
- Increased inflammatory
- Increased peptides and growth factors
36
36. Which of the mechanisms contribute to the pathogenesis of heart failure?
A. Increased expression of the alpha-myosin heavy chain
B. Increased activity of the sarcoplasmic calcium-ATPase
C. Beta-adrenergic desensitization
D. Decreased expression of angiotensin II and endothelin
E. Inhibition of hypertrophic signaling pathways
C. Beta-adrenergic desensitization
37
37. Which mechanism explains the development of Cheyne-Stokes respiration in heart failure?
A. Decreased sensitivity of the respiratory center to arterial pO2
B. Decreased sensitivity of the respiratory center to arterial pCO2
C. Increased pressure in the bronchial arteries leading to airway compression
D. The presence of interstitial pulmonary edema leading to increased airway resistance
E. Activation of the juxtacapillary J receptors in the setting of pulmonary congestion causing rapid shallow breathing
B. Decreased sensitivity of the respiratory center to arterial pCO2
- Increased pressure in the bronchial arteries leading to airway compression and the presence of interstitial pulmonary edema leading to increased airway resistance (choices C. and D.): mechanisms of PND
- Activation of the juxtacapillary J receptors in the setting of pulmonary congestion causing rapid shallow breathing (choice E.): mechanism of exertional dyspnea
38
38. What can explain the manifestation of early satiety with abdominal pain and fullness in a patient with early stage of heart failure?
A. Presence of ascites
B. Presence of hepatosplenomegaly
C. Presence of bowel wall edema
D. Early activation of the satiety center
E. Increased levels of circulating estrogens
C. Presence of bowel wall edema
- Early satiety and abdominal pain and fullness may be due to presence of bowel wall edema and/or liver congestion
39
39. Which of the following PE findings may be an indicator of the severity of hemodynamic compromise in heart failure:
A. Presence of a third heart sound (S3)
B. Presence of a fourth heart sound (S4)
C. Sustained point of maximal impulse that is displaced laterally
D. Presence of peripheral edema
E. Absence of peripheral edema
A. Presence of a third heart sound (S3)
40
40. The most useful index of left ventricular function:
A. Cardiac index
B. LV End-diastolic volume
C. Stroke volume
D. Ejection fraction
E. LV size
D. Ejection fraction
- EF limitations: may be increased in MR
- Depressed EF (\<30-40%) indicates poor cardiac contractility
- Normal EF (\>/= 50%) indicates adequate systolic function
41
41. Which statement correctly describes the value of routine laboratory tests in the work-up of heart failure?
A. In chronic heart failure, chest x-ray is useful in diagnosing pulmonary hypertension
B. The presence of a normal ECG virtually excludes LV systolic dysfunction
C. 2D-echocardiography accurately quantifies LV mass and volume
D. Measurement of LV contractility based on ejection fraction is not influenced by changes in the afterload and preload
E. Standard testing for all heart failure cases include determining for thyroid abnormalities
B. The presence of a normal ECG virtually excludes LV systolic dysfunction
42
42. A 56-year-old man presents with a 4-month-history of progressive exertional and orthopnea. He has been previously diagnosed with chronic stable angina and has been on ISMN for the last 2 years. He is non-hypertensive and non-diabetic, and a past smoker with 20 pack-years history. Pertinent PE findings include fine bibasal crackles, displaced apex beat at 5th ICS left anterior axillary line, soft heart sounds, no murmurs and a grade II bipedal edema. Which laboratory test will be useful to support your diagnosis of congestive heart failure?
A. 12-LECG
B. 2D-echocardiography
C. Chest x-ray
D. CRP and ESR determination
E. Serum BNP determination
B. 2D-echocardiography
- BNP would be useful if the diagnosis is UNCERTAIN. The clinical SSx of the case are consistent with CHF thus 2D-echo will support the diagnosis, evaluate cardiac function, and help identify possible underlying causes
43
43. What is the role of exercise stress testing in patients with heart failure?
A. Serves to guide advice on limitations to be observed by the patient when performing activities
B. Determines the presence of an underlying ischemic heart disease as the cause of the heart failure
C. Differentiates conclusively between heart failure with preserved EF from that with reduced ejection fraction
D. Assessment of need for cardiac transplantation in patients with advanced heart failure
E. Helps in improving exercise capacity and tolerance of patients with heart failure
D. Assessment of need for cardiac transplantation in patients with advanced heart failure
- If peak oxygen uptake is \<14mL/kg/min, the patient will have better survival with transplantation than medical therapy
44
44. A 56-year-old male patient with chronic heart failure is maintained on Enalapril 20mg OD, Furosemide 10mg OD, Spironolactone 25mg OD, and Metoprolol 12.5mg OD. For the last 3 weeks there was noted increase in the peripheral edema from grade I to grade II, with increase in the liver size by PE. His dyspnea, however, improved and is now able to tolerate climbing one flight of stairs when he previously can only tolerate walking 10meters on level ground. Which of the following can best explain the current changes in the patient's condition?
A. Presence of RV failure
B. Improvement of HF symptoms
C. Adverse drug reaction
D. Concurrent infection
E. Presence of infective endocarditis
A. Presence of RV failure
- Occurrence of RV failure can explain worsening of edema and increased liver size, as well as the improvement in dyspnea
45
45. Which finding differentiates acute from chronic cor pulmonale?
A. Presence of RV dilation and failure
B. Absence of RV hypertrophy
C. Presence of elevated jugular venous pressure
D. Presence of secondary LV failure
E. Absence of an elevated pulmonary artery hypertension
B. Absence of RV hypertrophy
46
46. A 65-year-old man with COPD comes in with history of progressive shortness of breath for the last 3 months. He also complains of recent onset 2-pillow orthopnea and waking up in the middle of the night with shortness of breath and coughing. He has a 40-pack-year smoking history, non-hypertensive, non-diabetic, and no history of alcohol abuse. PE revealed the following: BP= 130/80, HR=98, RR=24, JVP at 13cmH2O. He has prominent RV heave, loud P2, and grade II holosystolic murmur at the left parasternal border. Breath sounds are harsh with minimal bibasal rales. He has protuberant abdomen with liver edge around 10cms below the right subcostal margin. He has grade III bipedal edema. What is correct about cor pulmonale in the given case?
A. Concurrent left heart failure
B. Spiral chest CT scan is useful to establish the underlying lung parenchymal etiology
C. 12-LECG will confirm the presence of co-existing CAD
D. In the setting of pure right ventricular failure, BNP and NT pro-BNP levels will be low
E. Cyanosis is an early finding as is a consequence of reduced cardiac output in the presence of systemic vasoconstriction and V/Q mismatch
A. Concurrent left heart failure
- Concurrent left heart failure is suggested by the symptoms of orthopnea and PND
47
47. Which of the following is most useful in the management of heart failure with preserved ejection fraction?
A. Low dose beta-blocker therapy
B. ACE inhibitor slowly titrated to the maximum tolerable or allowable dose
C. Addition of spironolactone to a diuretic-ACE inhibitor combination therapy
D. Detection and treatment of sleep apnea
E. Aggressive lowering of preload to control congestion
D. Detection and treatment of sleep apnea
- There are no approved or proven pharmacologic or devide therapy for HFpEF
- Therapeutic goals:
- Control congestion but DO NOT reduce preload excessively
- Stabilize HR and BP
- Maintain atrial contraction and prevent tachycardia: maybe beneficial to maintain a sinus rhythm if with AF
- Treat and prevent myocardial ischemia
- Detect and treat sleep apnea (can cause systemic HTN, pulmonary HTN, and right heart dysfunction)
- Improve exercise tolerance
48
48. A patient with known congestive heart failure and maintained on low-dose Metoprolol, Enalapril, and Furosemide for the last 6months is admitted for sudden worsening of dyspnea for the last 2 days despite good compliance to medications. His blood pressure is 100/60 with a heart rate of 110. A 2D-echocardiography done showed an ejection fraction of 15% from a previous of 45% done about a month ago. What should be the first principle of management of this patient?
A. Maximize the doses of his anti-heart failure drugs
B. Identify and manage any precipitant of decompensation
C. Schedule for urgent coronary angiography
D. Insert a pulmonary artery catheter to guide in the acute management of decompensation
E. Maximize vasodilator therapy with the addition of hydralazine-ISDN
B. Identify and manage any precipitant of decompensation
- For acute decompensated HF, the first principle of management is to identify and address any precipitant of decompensation
49
49. Which of the following findings in a patient admitted for acute decompensated heart failure portends a worse outcome?
A. Resting heart rate of 110bpm
B. Serum creatinine of 1.5mg/dL
C. Systolic blood pressure of 100mmHg
D. Jugular venous pressure of 15cmH2O
E. Hemoglobin of 10g/dL
C. Systolic blood pressure of of 100mmHg
- Findings that portends a worse outcome for patients with acute decompensated heart failure:
1. BUN \> 43 mg/dL
2. SBP \< 115 mmHg
3. Serum creatinine \> 2.75 mg/dL
4. Elevated troponin I level
50
50. In a normotensive patient with the typical type of acute decompensated heart failure, the most important component of acute management is:
A. Vasodilator therapy
B. Inotropic therapy
C. Diuretic therapy
D. Non-invasive ventilator support
E. Use of opiates
C. Diuretic therapy
- Typical ADHF with normal BP are usually volume overloaded so it will require diuretic therapy while those with HTN are usually NOT volume overloaded thus should be managed with vasodilators
51
51. Components of management of patients with cardiogenic phenotype of acute decompensated heart failure include:
A. Inotropic therapy
B. Percutaneous ventricular assist device
C. Vasodilator therapy
D. A and B
E. All of the above
D. A and B
- Inotropic therapy (choice A), Percutaneous ventricular assist device/mechanical circulatory support (choice B) and diuretic therapy for congestion and renal failure
52
52. All of the above beta-blockers have been proven to be useful and safe in the management of heart failure, EXCEPT:
A. Metoprolol
B. Nebivolol
C. Carvedilol
D. Bisoprolol
E. Atenolol
E. Atenolol
53
53. In heart failure patients who remain symptomatic despite combined optimized therapy with Enalapril, Bisoprolol and Spironolactone, with residual heart rate above 70 beats per minute, which of the following agents when added can help control symptoms, and reduce further the frequency of hospitalizations and incidence of cardiovascular-related deaths?
A. Amlodipine
B. Ivabradine
C. Digoxin
D. Atorvastatin
E. Hydralazine + ISDN
B. Ivabradine
54
54. In which scenario/s would ICD implantation be definitely useful in preventing sudden cardiac death in heart failure?
A. Concurrent with Amiodarone prophylaxis
B. Terminally ill with predicted lifespan less than 6 months
C. NYHA functional class IV refractory to medications who are not candidates for transplant
D. NYHA class II to III with LVEF less than 35% regardless of etiology
E. Post-MI on optimal medical therapy with residual LVEF not more than 50% and asymptomatic
D. NYHA class II to III with LVEF less than 35% regardless of etiology
- Other: Post-MI on optimal medical therapy but with LVEF \<30% even if asymptomatic (beyond 40days of an MI)
- Risk-benefit must be weighed for choices B and C
55
55. Correct about erythrocytosis in cyanotic congenital heart disease:
A. Compensated cases that are iron replete are symptomatic of hyperviscosity when hematocrits exceed 50%
B. Therapeutic phlebotomy is required for all cases
C. Therapeutic phlebotomy allows temporary relief of symptoms but causes iron depletion
D. Progressive symptoms after repeated phlebotomy are usually due to rapid production and re-accumulation of RBCs
E. The mechanism involves an increase in iron absorption as a consequence of reduced hepcidin secretion
C. Therapeutic phlebotomy allows temporary relief of symptoms but causes iron depletion
56
56. A 42-year-old woman consults for easy fatigability. She appeared cachectic and had been repeatedly admitted in a secondary hospital for repeated episodes of pneumonia. PE findings are as follows: BP=90/60, HR=80, RR=18, irregularly irregular rhythm, (+) RV heave, palpable P2, fixed-split S2, (+) II/VI midsystolic murmur at the left sternal border, (+) II/VI mid-diastolic rumbling murmur at the 4th ICS left sternal border. 12-LECG revealed absent P waves, irregular R-R interval, RAD with an rSr' pattern in the right precordial leads. What is the most likely diagnosis?
A. MS with AF in CVR
B. MS/MR with AF in CVR
C. VSD with AF in CVR
D. ASD with AF in CVR
E. TOF
D. ASD with AF in CVR
57
57. All of the following are acceptable standard medical management of atrial septal defect EXCEPT:
A. Treatment of recurrent pulmonary infections
B. Prophylaxis against infective endocarditis
C. Diuretic therapy for evidence of peripheral edema
B. Prophylaxis against infective endocarditis
- Patients with atrial septal defect are low risk for IE unless complicated by valvular regurgitation or repaired with patch or device
58
58. Which of the following statements is TRUE about ventricular septal defect?
A. Most commonly the defect is single and located in the membranous or mid-muscular portion of the septum
B. Functional disturbance depends primarily on the location of the defect
C. Diagnosed cases in adults usually have isolated large defects
D. Clinical manifestations, course and feasibility of repair are dependent on the left ventricular function
E. Disease progression is highly likely even if the pulmonary vascular resistance is less than one-third of the systemic vascular resistance
A. Most commonly the defect is single and located in the membranous or mid-muscular portion of the septum
- The status of the pulmonary vascular bed is the principa; determinant of the clincal course, manifestatons, and feasibility of repair
- Disease progression unusual if pulmonary vascilar resistance = 1/3 of systemic value
- Cases seen initially during adulthood are only small or moderate-size defects
59
59. Which is NOT component of the Tetralogy of Fallot?
A. Downward displacement of the tricuspid valve into the RV
B. Ventricular septal defect
C. RV Outflow Obstruction
D. RV hypertrophy
E. Aortic override of the VSD
A. Downward displacement of the tricuspid valve into the RV
60
60. A 65-year-old male is admitted at the ER for 2 episodes of syncope in the past 5 days. He complains of progressive exertional dyspnea for the last 3 months as well as chest discomfort described as heaviness on climbing 1 flight of stairs. He has a 3-pillow orthopnea. He has hypertension and has been maintained on Amlodipine for the last 5 years. His usual BP is 150/90. He is non-diabetic, has a 15-pack-year smoking history, and does not take alcoholic drinks. PE showed the following BP=100/80, HR=100, RR=24, (+) bibasal rales, apex beat at 5th ICS left anterior axillary line with visible LV impulse; grade IV midsystolic, low-pitched, rasping murmur best heard at the 2nd right ICS radiating to the carotid arteries. No significant abdominal findings, (+) grade I bipedal edema. Which finding is consistent with the given case?
A. Mitral stenosis
B. Mitral regurgitation
C. Aortic stenosis
D. Aortic regurgitation
E. Pulmonic stenosis
C. Aortic stenosis
61
61. A 65-year-old male is admitted at the ER for 2 episodes of syncope in the past 5 days. He complains of progressive exertional dyspnea for the last 3 months as well as chest discomfort described as heaviness on climbing 1 flight of stairs. He has a 3-pillow orthopnea. He has hypertension and has been maintained on Amlodipine for the last 5 years. His usual BP is 150/90. He is non-diabetic, has a 15-pack-year smoking history, and does not take alcoholic drinks. PE showed the following BP=100/80, HR=100, RR=24, (+) bibasal rales, apex beat at 5th ICS left anterior axillary line with visible LV impulse; grade IV midsystolic, low-pitched, rasping murmur best heard at the 2nd right ICS radiating to the carotid arteries. No significant abdominal findings, (+) grade I bipedal edema. Which finding is consistent with the given case?
A. Bisferiens pulse
B. Corrigan's pulse
C. ECG showing atrial fibrillation and LAE
D. Prominent a wave of the jugular venous pulsation
E. Fixed split S2
D. Prominent a wave of the jugular venous pulsation
- Prominent a wave of the jugular venous pulsation due to diminished distensibility of the RV cavity due to bulging of the hypertrophied IV septum
- Pulse: pulsus parvus et tardus
- S2 is synchronous or paradoxically split
- ECG shows LVH
62
62. Which of the following will likely cause aortic regurgitation primarily involving the aortic root?
A. Rheumatic fever
B. Aortic dissection
C. Endocarditis
D. Ankylosing spondylitis
E. Myxomatous
B. Aortic dissection
63
63. A 45-year-old man, a known case of ankylosing spondylitis, consults you for increased awareness of his heartbeat especially when lying flat on bed. He has occasional episodes of exertional chest pain that is spontaneously relieved after about 10 minutes of rest. You noticed that his head appears to bob regularly and on time with his pulse which was also very rapidly forceful with sudden drop. BP is 160/30, HR=90, RR=20. Visible neck pulsations, PMI and apex beat are displaced to the 5th ICS left mid-axillary line, grade IV blowing diastolic murmur at the 3rd ICS left parasternal border. Breath sounds are clear. Peripheral pulses are prominent and bounding. What is your most likely diagnosis?
A. Mitral stenosis
B. Mitral regurgitation
C. Aortic stenosis
D. Aortic regurgitation
E. Pulmonic stenosis
D. Aortic regurgitation
64
64. A 45-year-old man, a known case of ankylosing spondylitis, consults you for increased awareness of his heartbeat especially when lying flat on bed. He has occasional episodes of exertional chest pain that is spontaneously relieved after about 10 minutes of rest. You noticed that his head appears to bob regularly and on time with his pulse which was also very rapidly forceful with sudden drop. BP is 160/30, HR=90, RR=20. Visible neck pulsations, PMI and apex beat are displaced to the 5th ICS left mid-axillary line, grade IV blowing diastolic murmur at the 3rd ICS left parasternal border. Breath sounds are clear. Peripheral pulses are prominent and bounding. Pathophysiologic changes expected include the following, EXCEPT:
A. Increase in the total stroke volume
B. Increase in the left ventricular end-diastolic volume
C. Early in the course of the disease the LV ejection fraction is normal in the setting of an increased LV end diastolic pressure
D. An increase in stroke volume is brought about by concentric hypertrophied LV
E. Late in the course of the disease the forward stroke volume decreases with consequent decrease in LV ejection fraction
D. An increase in stroke volume is brought about by concentric hypertrophied LV
- Eccentric LV hypertrophy and LV dilation will increase the LV stroke volume
65
65. A 24-year-old female patient consults for a history of progressive effort-related dyspnea for the last 4 months. PE findings include an irregularly irregular rhythm with a HR of 105, accentuated P2, closely split S2, OS, and diastolic murmur at the apex. She has grade II bipedal edema. What is your most likely diagnosis?
A. Mitral stenosis
B. Mitral regurgitation
C. Aortic stenosis
D. Aortic regurgitation
E. Pulmonic stenosis
A. Mitral stenosis
66
66. A 30-year-old woman consults at your clinic for worsening dysplnea. Physical examination findings include an irregularly irregular rhythm, accentuated first heart sound, and a prominent P2. There is a low-pitched rumbling diastolic murmur heard best at the apex. Her neck veins are engorged and there are bilateral crackles. She has tender hepatomegaly with pulsations. Which statements are NOT correct regarding this case?
A. Ejection fraction may be preserved
B. Ejection fraction may be depressed
C. She has significant tricuspid regurgitation
D. She likely has S4
E. If she has atrial fibrillation, it is likely to be chronic
D. She likely has S4
- She likely has AF thus S4 is not expected to be observed
- Obstructive valvular heart disease may cause either HFrEF or HFpEF
67
67. A 60-year-old female patient with long-standing history grade II/VI holosystolic apical murmur is admitted for sudden onset dyspnea at rest. She has no history of CAD and has no other risk factors apart for age. Initial PE showed a BP=90/70, HR=110, RR=30, JVP=12cmH2O. Cardiac auscultation revealed a cooing systolic murmur at the left sternal border. What is your diagnosis?
A. Aortic stenosis
B. Chronic MR
C. Acute MR due to ruptured chordae tendinae
D. Acute MR due to flail leaflets
E. Papillary muscle rupture
C. Acute MR due to ruptured chordae tendinae
- Ruptured chordae tendinae: systolic murmur with cooing or "seagull" quality
- Predisposition: myxomatous degeneration often seen among females of advanced age (MVP)
- Flail leaflet: murmur with a musical quality
68
68. A 35-year-old man presents with a 6-month history of progressive exertional dyspnea, orthopnea and PND. He remembered being diagnosed with a heart murmur in highschool but had no work-up done. On consult, PE findings are as follows: BP=110/70, HR=88, RR=24. The apex beat is displaced laterally and on auscultation, he has a grade III holosystolic murmur at the apex radiating to the axilla that decreases in intensity on straining. A third heart sound is distinct. Which of the following pathophysiologic changes is consistent with the diagnosis?
A. Increased left AV gradient
B. Increased LV afterload
C. Incomplete LV emptying
D. Increased transaortic valvular pressure gradient
E. Increase in ejection fraction
E. Increase in ejection fraction
- Reduced resistance to LV emptying (LV afterload) with LV decompressed into the LA during ejection
- Rapid decline in LV tension during systole
- Initial compensatin: more complete LV emptying
- LV volume increases progressively with increasing severity of regurgitation and decreasing LV contractility
- Ejection fraction (EF) rises in severe MR in the presence of normal LV function that even a modest decrease in EF (\<60%) reflects significant dysfunction
69
69. A 35-year-old man presents with a 6-month history of progressive exertional dyspnea, orthopnea and PND. He remembered being diagnosed with a heart murmur in highschool but had no work-up done. On consult, PE findings are as follows: BP=110/70, HR=88, RR=24. The apex beat is displaced laterally and on auscultation, he has a grade III holosystolic murmur at the apex radiating to the axilla that decreases in intensity on straining. A third heart sound is distinct. Which of the following is a consistent clinical finding?
A. Reduced arterial pressure with a narrow pulse pressure
B. Loud and distinct first heart sound with opening snap
C. Intensity of the murmur increases with isometric exercise like handgrip exercise
D. 12-LECG showing right atrial enlargement even in the absence of severe pulmonary hypertension
E. Chest x-ray showing prominent RV
C. Intensity of the murmur increases with isometric exercise like handgrip exercise
70
70. A 25-year-old female consults for cardiac evaluation with previous findings of cardiac murmur, palpitations (documented to be recurrent SVTs by Holter monitoring) and an electrocardiogram showing T-wave inversions in leads II, III, and aVF. There was a history of atypical chest pain, but nothing to suggest congestive heart failure. The patient's father and one paternal uncle had elevated blood cholesterol levels and myocardial infarctions in their early 40's. There is no family or personal history of diabetes mellitus. Her blood sugar 2 hours after breakfast was 102mg/dL and her serum HDL-C, LDL-C, and triglycerides were normal. On examination, the patient's gallop rhythm was audible but there was grade II/VI late systolic murmur heard best at the apex and increased in length during Valsalva maneuver. There was a click during systole. There were no signs of congestive heart failure and her heart was not enlarged. Based on your clinical diagnosis, which of the following is correct?
A. Her chest pain is probably due to excessive stress on the papillary muscle
B. An exercise stress test will probably be positive
C. Pre-operative antibiotic prophylaxis would be indicated should she undergo any surgery
D. An echocardiogram followed by CT angiography is indicated
E. Therapy with beta-blockers is potentially dangerous
A. Her chest pain is probably due to excessive stress on the papillary muscle
- Diagnosis: MVP
71
71. A 30-year-old female presents with episodes of palpitations and chest pains with no other complaints or symptoms. She has no significant medical problems in the past. Initial PE showed the following: BP=100/60, HR=95, RR=18, regular rhythm, with a late systolic click and a late systolic "whooping" murmur on cardiac auscultation that is exaggerated upon standing. 12-LECG was normal. Which is an appropriate treatment?
A. ACE-inhibitor therapy
B. Beta-blocker therapy
C. Low-dose aspirin
D. Antibiotic prophylaxis
E. Warfarin anticoagulation
B. Beta-blocker therapy
- Beta-blocker therapy for MVP with chest pain
72
72. Most common valvular involvement in Carcinoid syndrome?
A. Mitral valve
B. Tricuspid valve
C. Pulmonic valve
D. Aortic valve
C. Pulmonic valve
73
73. What drug therapy is useful across all types of the most common valvular heart diseases?
A. Diuretics
B. Beta-blockers
C. ACE-inhibitors
D. Angiotensin receptor blockers
E. Hydralazine + Isosorbide dinitrate
A. Diuretics
74
74. In the classification of cardiomyopathies, the restrictive type is defined on the basis of:
A. Pericardial thickening
B. Abnormal diastolic function
C. Abnormal systolic function
D. Preserved ejection fraction
E. Dallas criteria
B. Abnormal diastolic function
- Dallas criteria is for the diagnosis of myocarditis (lymphocytic infiltration with evidence of myocyte necrosis)
75
75. Restrictive cardiomyopathy is the principal type found in:
A. Viral myocarditis
B. Peripartal cardiomyopathy
C. Alcoholic cardiomyopathy
D. Amyloidosis
E. "Holiday heart" syndrome
D. Amyloidosis
- The rest (i.e Viral myocarditis, peripartal cardiomyopathy, alcoholic cardiomyopathy, and Holiday heart syndrome) are DILATED CARDIOMYOPATHY
- Holiday heart syndrome is due to Acute alcohol intake, may manifest with AF
76
76. TRUE about the presentation of most cardiomyopathies:
A. The earliest symptoms is exertional intolerance due to inadequate cardiac reserve during exercise
B. The resting filling pressure is generally decreased with the cardiac output further reduced by an increase in outflow resistance
C. Peripheral edema is consistently seen despite minimal fluid retention
D. AV valve regurgitation is seen only with the dilated type
E. Embolic events are exclusively seen in the dilated type
A. The earliest symptoms is exertional intolerance due to inadequate cardiac reserve during exercise
- Exertional intolerance is common early manifestation in all types
77
77. TRUE about genetic etiologies of cardiomyopathies EXCEPT:
A. At least 30% of dilated CMP is inherited even in the absence of clear etiology
B. Most familiar CMP are inherited in an autosomal recessive pattern
C. It is established in hypertrophic CMP
D. In the presence of defective metabolic enzymes, the management is replacement therapy
E. Current therapy therapy for most cases is based on phenotype rather than on genotype
B. Most familiar CMP are inherited in an autosomal recessive pattern
- Most common pattern for CMP is autosommal DOMINANT
78
78. Characteristic feature of restrictive cardiomyopathy:
A. LV diastolic dimension is often decreased
B. LV wall thickness is decreased
C. Atrial size is decreased
D. Rarely with mitral or tricuspid regurgitation
E. Predominant right-sided congestive symptoms
E. Predominant right-sided congestive symptoms
79
79. A 23-year-old woman, with a prior history of URTI with fever and muscle pain two weeks earlier, is brought to the emergency department with a 2-hour history of severe chest pain. Initial PE showed the following findings: BP=100/60, HR=110, RR=24, JVP=5cm H2O, soft S1, (+)S3, (+)grade II apical holosystolic murmur. 12-LECG done showed diffuse ST-segment elevation. What laboratory finding is supportive of your diagnosis?
A. Elevated total creatinine kinase
B. Elevated troponin I
C. Normal left ventricular ejection fraction
D. Absence of wall motion abnormality on 2D-echo
E. Absence of pericardial effusion on 2D-echo
B. Elevated troponin I
- Elevated cardiac enzymes: CK-MB, Troponin T or I
80
80. The diagnosis of definite myocarditis requires:
A. Presence of histotologic or immunologic evidence of inflammation on endomyocardial biopsy
B. Elevation of Troponin I
C. History of shortness of breath or chest pain
D. A+B
E. A+B+C
A. Presence of histotologic or immunologic evidence of inflammation on endomyocardial biopsy
81
81. Hypersensitivity myocarditis is most commonly attributed to:
A. Antibiotic therapy
B. NSAID use
C. Sulfonamide use
D. Exposure to aeroallergens
E. Aspergillus infection
A. Antibiotic therapy
82
82. TRUE about peripartal cardiomyopathy:
A. Occurs during the 1st trimester of pregnancy
B. Most cases are elderly primigravids
C. Recurrence is not common
D. The risk with subsequent pregnancies is substantially reduced
E. Failure to reverse within 6 months is a poor prognosticator
E. Failure to reverse within 6 months is a poor prognosticator
83
83. Which of the following is NOT a major risk factor for sudden death in hypertrophic CMP:
A. Syncope
B. LV thickness \> 30mm
C. Abnormal blood pressure response to exercise
D. Age \< 25 years
E. Family history of sudden cardiac death
D. Age \< 25 years
- Other risk factors for sudden death in hypertrophic CMP:
- family history of cardiac arrest or spontaneous sustained ventricular tachycardia
- spontaneous non-sustained ventricular tachycardia
84
84. The principal diagnostic features of acute pericarditis include all of the following, EXCEPT:
A. Presence of pericardial effusion
B. Characteristic elevation in cardiac enzymes
C. Characteristic chest pain
D. Characteristic ECG changes
E. Presence of pericardial friction rub
B. Characteristic elevation in cardiac enzymes
- 4 Principal features of pericarditis:
1. Presence of pericardial effusion
2. Characteristic chest pain
3. Characteristic ECG changes
4. Presence of pericardial friction rub
85
85. Which of the following best describes the chest pain of acute pericarditis?
A. Severe retrosternal often pleuritic and referred to the back and the left trapezius
B. Severe retrosternal often pleuritic with associated diaphoresis and referred to the left shoulder and the jaw
C. Heavy burning retrosternal diffuse and referred to the back and the left trapezius
D. Heavy burning retrosternal diffuse with associated diaphoresis and referred to the left shoulder and the jaw
E. Mild pleuritic exacerbated by coughing or inspiration and steady over the retrosternal area
A. Severe retrosternal often pleuritic and referred to the back and the left trapezius
- Severe retrosternal often pleuritic and referred to the back and the left trapezius, although may resemble the pain of myocardial ischemia
86
86. Which of the following features characterizes acute pericarditis?
A. It is not associated with cardiac tamponade
B. Pain may be steady and constricting that radiates into either or both arms
C. Elevation of serum cardiac markers indicate presence of co-existing MI
D. Pericardial friction rub is uncommon and if present indicates severity
E. ST segment elevations on ECG generally are convex and return to normal within hours with changes in the QRS
B. Pain may be steady and constricting that radiates into either or both arms
- Pericardial pain is usually severe and sharp with a pleuritic characteristic (aggravated by inspiration, coughing and changes in body position) '
- Pain may also resemble that of AMI but may be differentiated by its being relieved by sitting or leaning forward
- Modest elevations in cardiac serum markers (CK-MB, Troponin) may be observed but these are quite modest given the extensive ST segment elevation
- Concave ST segment elevations are seen on ECG and persist for several days
87
87. What is the first line treatment of acute idiopathic pericarditis?
A. Aspirin
B. Ibuprofen
C. Prednisone
D. Colchicine
E. Indomethacin
A. Aspirin
- Alternatives: Ibuprofen, Indomethacin
- If unresponsive to NSAID: Colchicine
- Prednisone for failed anti-inflammatory therapy but given only for 2-14days then tapered due to increased risk of recurrence
88
88. Which findings favor a diagnosis of cardiac tamponade over constrictive pericarditis?
A. Kussmaul's sign
B. Pulsus alternans
C. Thickened pericardium
D. RA and RV diastolic collapse
E. Equalization of diastolic pressures
D. RA and RV diastolic collapse
- Both: equalization of diastolic pressures
- Constrictive: Kussmaul's sign, prominent y descent, thickened pericardium
- Cardiac tamponade: pulsus paradoxus, electrical alternans, right atrial and RV diastolic collapse
89
89. What is the most frequent complication of viral and idiopathic forms of acute pericarditis?
A. Cardiac tamponade
B. Constrictive pericarditis
C. Relapsing pericarditis
D. AV conduction abnormalities
E. Pleural effusion
C. Relapsing pericarditis
- Relapsing or recurrent pericarditis (seen in 25% of cases)
90
90. What clinical feature distinguishes viral acute pericarditis from post-cardiac injury form of acute pericarditis?
A. Simultaneous occurrence of pain and fever
B. Concave and diffuse ST segment elevation
C. Presence of pericardial effusion
D. Presence of pericardial friction rub
E. Leukocytosis and elevation of ESR
A. Simultaneous occurrence of pain and fever
- In post-cardiac injury form of acute pericarditis: pain is then followed by fever
91
91. The most common primary malignant tumor of the heart is:
A. Sarcoma
B. Carcinoma
C. Myxoma
D. Adenocarcinoma
E. Lymphoma
A. Sarcoma
92
92. Which cancer has the highest risk of CARDIAC metastasis?
A. Lung
B. Breast
C. Malignant melanoma
D. Leukemia
E. Lymphoma
C. Malignant melanoma
- In absolute terms, the most common causes of metastases: lung, breast
93
93. In estimating the ASCVD risk, which of the following is NOT considered as pertinent informatin?
A. Gender
B. LDL-Cholesterol level
C. Race
D. Systolic blood pressure
E. Therapy for hypertension
B. LDL-Cholesterol level
- LDL-C level defines who to consider for ASCVD risk estimation (LDL-C 70-189mg/dL), or who requires high intensity treatment without calculating the ASCVD risk (LDL-C \>/= 190mg/dL)
- Other pertinent information: Nine pertinent information required:
- gender - therapy for HTN
- HDL-C level - SBP
- total cholesterol level - smoking status
- race (white, African-American, others) (smoker, non-smoker)
- DM diagnosis
- Use ASCVD calculator for: DM or non-DM who are 40-75years old and with LDL-C of 70-189mg/dL
- Optimal risk factors:
- Total cholesterol of 170mg/dL - Not taking medications for HTN
- HDL-cholesterol of 50mg/dL - Not a diabetic
- SBP of 110mmHg - Not a smoker
94
94. Which of the following patient profiles will necessitate high-intensity statin therapy?
A. 50-year-old DM patient with LDL-C of 50mg/dL
B. 25-year-old man, non-diabetic, non-hypertensive with LDL-C of 191mg/dL
C. 78-year-old man, non-diabetic, with prior history of myocardial infarction and an LDL-C of 100mg/dL
D. 50-year-old man, diabetic, hypertensive, with LDL-C of 120mg/dL
E. 45-year-old man, non-diabetic, non-hypertensive with LDL-C of 120mg/dL
B. 25-year-old man, non-diabetic, non-hypertensive with LDL-C of 191mg/dL
- The ff would necessitate statin:
- LDL-C \>/= 190mg/dL: high-intensity
- Clinical ASCVD (age \> 21 and a candidate for statin therapy)
- If = 75 y/o: high-intensity (moderate-intensity if not a candidate for high-intensity)
- If \> 75 y/o: moderate-intensity
- DM, with age 40-75
- If 10-year ASCVD risk \>/= 7.5%: high-intensity (otherwise, moderate-intensity)
- Age 40-75, no DM, 10-year ASCVD risk \>/= 7.5%: moderate-to-high intensity
95
95. A 79-year-old man with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and 30-pack years smoking, presents to the ER with discomfort across his left chest wall, radiating into his jaw and left arm. He notes that the pain began approximately 10 hours prior to admission and was initially mild, but it progressed in intensity and was associated with shortness of breath and diaphoresis. While in the ambulance he was given an aspirin and sublingual nitroglycerin en route to the hospital. On presentation, he is still complaining of chest pain, appears ashen, and is visibly short of breath. BP=110/80, RR=22 breaths/min, pulse oximetry 90% on room air. PE shows jugular venous distention to the level of his jaw while sitting upright, regular heart rhythm without murmurs and a loud S4 gallop, decreased breath sounds at the bases with placed on oxygen. After transfer from the stretcher to the examination room, the patient's heart rate is 110bpm with a blood pressure of 70/59mmHg. Troponin I is positive. A 12-LECG is quickly obtained. What is the next step in this patient's mangement to improve his chances of survival?
A. Activate the coronary intervention team for emergent cardiac catheterization within 90minutes of first medical contact
B. Administer IV thrombolytics and IV heparin within 30minutes of arrival
C. Start a glycoprotein IIb/IIIa inhibitor and IV heparin, admit to the CCU, and perform cardiac catheterization within the next 24hours
D. Wide-open IV fluids through 2 large-bore catheters, initiate IV dobutamine at 20ug/kg/min, and immediately obtain a transthoracic echocardiogram
A. Activate the coronary intervention team for emergent cardiac catheterization within 90minutes of first medical contact
- Diagnosis: STEMI, anteroseptal, with features of cardiogenic shock
- STEMI + cardiogenic shock: benefit from early reperfusion via percutaneous coronary intervention with potential intra-aortic balloon placement
- Treat with dual antiplatelet therapy as well as anticoagulation with either heparin or enoxaparin prior to cardiac catheterization
- IV Dobutamine is generally not indicated in the setting of acute MI because it can worsen myocardial ischemia
96
96. A 64-year-old woman presents to the ER with crushing substernal chest pain that lasted for 90minutes. PE: HR=110bpm, BP=75/40, RR=22, JVP=12cmH2O, clear lungs, normal S1 and S2, and a right-sided S3 with no evidence of mitral or aortic murmur. A 3-mm ST-elevation in leads II, III, and aVF are noted as well as a 1-mm ST-elevation in leads V1 and V2. What is the most appropriate first step in this patient's management?
A. Intravenous (IV) nitroglycerin
B. IV Dopamine
C. Intra-aortic balloon pump (IABP)
D. Furosemide
E. IV Fluid administration
E. IV Fluid administration
- Inferior wall AMI with RV MI (need to test for cardiac enzyme)
- Fluid administration to increase preload and cardiac output is the critical initial step to stabilize patient for PCI (if BP fails to improve, inotropics preferably Dobutamine can be used)
- Immediate reperfusion of RV branches decreases 30-day mortality and improves RV function
- Right heart catheterization may also be important to prevent volume overload
- Goal: CVP= 14-16mmHg
97
97. A 50-year-old man, recently discharged from the hospital after an UGIB from a peptic ulcer presents with 45minutes of unremitting, constricting chest pain with radiation to his jaw and down the left arm associated with cold sweats and unrelieved with 3 sublingual ISDN tablets. There was a history of effort-related angina. When seen, his BP is 150/80 and pulse is 104 regular. Lungs were clear, neck veins were flat and there was no edema. Stool was negative for blood. 12-LECG showed 0.4mV ST segment depression at V4 - V6. What test should be prioritized?
A. Serum amylase and lipase
B. Serum Troponin T
C. 2D-echo
D. Right precordial lead ECG
E. Cardiac perfusion scan
B. Serum Troponin T
- Cardiac biomarkers should be taken to establish diagnosis
98
98. A 45-year-old male patient known hypertensive is brought to the emergency room with severe chest pain that started 30 minutes earlier upon waking up and unrelieved with 3 doses of SL ISDN. He is non-diabetic, with 15-pack year smoking history. He was previously diagnosed with CSAP and has been maintained on Metoprolol 50mg BID for about 6 months now. His highest recorded BP is 150/90mmHg and allegedly had a BP of 130-140/80-90 while on Metoprolol. No prior hospitalization, no history of acid peptic disease. PE: BP=130/80, HR=98bpm, RR=18breaths/min, JVP= 7cmH2O, temp=38 deg C, soft S1, no other adventitious cardiac sounds while lungs are clear. Troponin I is positive. CBC: Hb=130, WBC=13,000/uL. ECG showed ST segment elevation on V1-V4. He was given Aspirin, Morphine, and started on NTG drip. What is the most important subsequent management?
A. 2D-echo to further confirm diagnosis
B. Start on LMWH SQ
C. Start on UFH, give 5000U IV bolus and start infusion at 15U/kilo/hr
D. Refer for primary PCI
E. Give Streptokinase or tPA
E. Give Streptokinase or TPA
- Within 30minuts of presentation: Fibrinolysis, if without contrainidication; otherwise, do primary PCI
99
99. Components of a DASH-type diet, EXCEPT:
A. Rich in potassium
B. Rich in protein
C. Reduced saturated fat
D. Use of low-fat dairy products
E. Carbohydrates consisting of 70% of daily caloric requirement
E. Carbohydrates consisting of 70% of daily caloric requirement
- Carbohydrates should only be 55% of caloric requirements
- Features of DASH diet:
- Emphasizes vegetables, fruits and fat-free or low-fat dairy products
- Includes whole grains, fish, poultry, beans, seeds, nuts and vegetable oils
- Limits sodium, sweets, sugary beverages, and red meats
- Low in saturated and trans fats
- Rich in potassium, calcium, magnesium, fiber and protein
- Total fat: 27% of calories
- Saturated fat: 6% of calories
- Protein: 18% of calories
- Carbohydrates: 55% of calories
- Based on a 2,000 calories diet:
- Cholesterol: 150mg
- Sodium: 2,300mg (better if 1,500mg)
- Potassium: 4,700mg
- Calcium: 1,250mg
- Magnesium: 500mg
- Fiber: 30g
- Other non-pharmacologic approaches:
- BMI \< 25
- Limit alcohol to = 2 drinks/day in men, = 1 drink/day in women
- Aerobic exercise for \>/= 30mins/day
- Dietary salt restriction \< 6g NaCl/day
100
100. What is an appropriate BP goal based on the ACC/AHA 2017 guidelines?
A. Diabetes mellitus: \<130/80
B. Chronic kidney disease: \<125/75
C. Diabetic patients with CKD: \<125/75
D. Less than 60 years of age: \<140/90
E. At least 60 years of age: \<150/90
A. Diabetes mellitus: \<130/80
