Cardiovascular

Question 1

Which one of the following NSAIDs is safest for patients with a previous history of myocardial infarction? (check one)
- Ibuprofen
- Celecoxib (Celebrex)
- Diclofenac (Zorvolex)
- Meloxicam (Mobic)
- Naproxen (Naprosyn)

Answer 1

Naproxen (Naprosyn)

All oral NSAIDs increase the risk of myocardial infarction (relative risk versus placebo from 1.5 for ibuprofen to 1.7 for celecoxib), with the exception of naproxen. Cardiac risks are greater in older patients, those with a history of cardiac events, and with higher dosages.

Question 2

A 65-year-old male comes to your office to establish care after hospitalization for an acute myocardial infarction. While reviewing his hospital record you see that he has normal renal function and had an echocardiogram showing a left ventricular ejection fraction of 40%. His current medications include metoprolol succinate (Toprol-XL), lisinopril (Prinivil, Zestril), atorvastatin (Lipitor), and aspirin. In your office today his blood pressure is 132/84 mm Hg and he is still feeling somewhat weak. He has 1+ pitting edema in his legs and mild dyspnea with exertion.

Which one of the following, when added to his current regimen, has evidence to support its use in preventing all-cause mortality? (check one)
Chlorthalidone
Spironolactone (Aldactone)
Ezetimibe (Zetia)
Losartan (Cozaar)
Fish oil

Answer 2

Spironolactone (Aldactone)

Spironolactone is an aldosterone antagonist. This class of drugs has been found to reduce all-cause mortality and cardiac death when initiated after a myocardial infarction in patients with a low left ventricular ejection fraction (LVEF) and signs of heart failure. Guidelines from the American College of Cardiology and the American Heart Association recommend the use of aldosterone blockers in patients who have heart failure or diabetes mellitus, have an LVEF :40%, are receiving ACE inhibitors and p-blockers, and have a serum potassium level <5.0 mEq/L (5.0 mmol/L) and a creatinine level >2.5 mg/dL in men or >2.0 mg/dL in women. None of the other medications listed has this level of evidence to support its use.

Question 3

A 75-year-old male with a history of hypertension, TIA, and atrial fibrillation sees you for follow-up. Ten days ago he was on vacation in another state when he developed chest pain. He went to a local hospital where he was diagnosed with an ST-elevation myocardial infarction (STEMI) and was taken immediately for cardiac catheterization. He had a drug-eluting stent placed in his left anterior descending artery. He brings some discharge paperwork with him, including a medication list, but has not yet seen a local cardiologist. He is concerned that he is taking too many blood thinners. He feels well and does not have any chest pain, shortness of breath, or excessive bleeding or bruising.

Prior to his STEMI the patient was taking lisinopril (Prinivil, Zestril), 10 mg daily; warfarin (Coumadin), 2.5 mg daily; and metoprolol succinate (Toprol-XL), 25 mg daily. Upon discharge he was instructed to continue all of those medications and to add clopidogrel (Plavix), 75 mg daily, and aspirin, 81 mg daily.

The patient’s vital signs and physical examination are normal except for an irregularly irregular rhythm on the cardiovascular examination. His INR is 2.5.

Which one of the following would be most appropriate at this time? (check one)
Continue the current regimen
Discontinue aspirin
Discontinue clopidogrel
Discontinue warfarin
Decrease warfarin with a goal INR of 1.5–2.0

Answer 3

Continue the current regimen

Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago and he should continue triple therapy.

Question 4

A 72-year-old previously healthy male presents with a 3-week history of mild, intermittent chest pressure that occurs when he walks up a steep hill.

Which one of the following EKG abnormalities would dictate the use of a pharmacologic stress test as opposed to an exercise stress test? (check one)
First degree atrioventricular block
Left bundle branch block
Poor R-wave progression in leads V1 through V3
Q-waves in the inferior leads
Ventricular trigeminy

Answer 4

Left bundle branch block

Left bundle branch block makes the EKG uninterpretable during an exercise stress test, and can also interfere with nuclear imaging performed during the test. It is associated with transient positive defects in the anteroseptal and septal regions in the absence of a lesion within the left anterior descending coronary artery. This leads to a high rate of false-positive tests and low specificity. Pharmacologic stress tests using vasodilators such as adenosine with nuclear imaging have a much higher specificity and positive predictive value for LAD lesions, and the same is true for dobutamine stress echocardiography, which is why these are the preferred methods for evaluating patients with left bundle branch block. Pharmacologic stress testing would not be preferred for evaluating the other EKG abnormalities listed.

Question 5

A 70-year-old white female with hypertension and atrial fibrillation has been chronically anticoagulated. A higher dosage of warfarin (Coumadin) would be required to achieve a therapeutic INR if the patient were found to have (check one)
malnutrition
hypothyroidism
heart failure
acute kidney injury
progressive nonalcoholic cirrhosis

Answer 5

hypothyroidism

Medical conditions that decrease responsiveness to warfarin and reduce the INR include hypothyroidism, visceral carcinoma, increased vitamin K intake, diabetes mellitus, and hyperlipidemia. Conditions that increase responsiveness to warfarin, the INR, and the risk of bleeding include vitamin K deficiency caused by decreased dietary intake, malabsorption, scurvy, malnutrition, cachexia, small body size, hepatic dysfunction, moderate to severe renal impairment, hypermetabolic states, fever, hyperthyroidism, infectious disease, heart failure, and biliary obstruction (SOR B, SOR C).

Question 6

A 53-year-old male complains of fatigue, dyspnea, and orthopnea. Which one of the following would have the highest specificity for heart failure? (check one)
Ankle edema
A third heart sound (S3 gallop)
Crackles
Cardiomegaly on a chest radiograph
Elevated BNP

Answer 6

A third heart sound (S3 gallop)

Among the constellation of history and physical findings that can be found in patients with heart failure, none provides a proof-positive diagnosis alone, as most are found in other disease states as well. Each of the options listed raises the possibility of heart failure but the only one that has a specificity >90% is the third heart sound, which is 99% specific for the diagnosis of heart failure. Other findings with >90% sensitivity include a displaced point of maximal impulse, interstitial edema or venous congestion on a chest radiograph, jugular vein distention, and hepatojugular reflux. The other options listed here have specificities for heart failure that fall within the range of 65%–80%.

Question 7

A 48-year-old female sees you because she recently felt flutters in her chest while watching television. These were not associated with exertion. She has no significant past medical history and she does not take any medications or use illicit substances.

On examination you hear a regular rhythm with occasional premature beats. An EKG reveals multiple unifocal PVCs. You order 48-hour Holter monitoring, which shows a 15% PVC burden that is unifocal with no episodes of ventricular tachycardia.

Which one of the following would be most appropriate at this time? (check one)
No further evaluation and reassurance that her palpitations are benign
Initiation of a β-blocker
Initiation of flecainide
Echocardiography
Left heart catheterization

Answer 7

Echocardiography

Patients found to have a PVC burden >10% are at risk for PVC-induced dilated cardiomyopathy (PVC-CM). In fact, a PVC burden of 16% has a sensitivity of almost 80% for PVC-CM. Echocardiography should be performed in patients with a PVC burden >10%. Treatment with anti-arrhythmic drugs or radiofrequency ablation reverses cardiomyopathy and its associated increase in morbidity, mortality, and health care spending. Further evaluation for ischemic heart disease may be performed if the patient has risk factors for ischemia. Symptomatic palpitations may be treated with β-blockers or calcium channel blockers, even in patients with lower PVC burdens and no cardiomyopathy. Left heart catheterization would not be appropriate.

Question 8

An asymptomatic 56-year-old male has an echocardiogram that demonstrates trivial mitral regurgitation. Which one of the following is the recommended follow-up for this patient if he remains asymptomatic? (check one)
No repeat echocardiography
Repeat echocardiography in 1 year
Repeat echocardiography in 2 years
Repeat echocardiography in 5 years
Repeat echocardiography in 10 years

Answer 8

No repeat echocardiography

The American Society of Echocardiography recommends that physicians NOT order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram (SOR C). Trace mitral, tricuspid, and pulmonic regurgitation can be detected in 70%–90% of normal individuals and has no adverse clinical implications. The clinical significance of a small amount of aortic regurgitation with an otherwise normal echocardiographic study is unknown.

Question 9

A healthy 40-year-old male is concerned about his risk for myocardial infarction (MI) because his father had an MI at age 45. The patient is a nonsmoker and does not take any medications. He states that he plans to start a regular exercise program, and asks for your advice regarding the best dietary approach for him. His vital signs are normal, including his BMI.

Which one of the following would be most likely to reduce this patient’s cardiovascular risk? (check one)
Intermittent fasting (fasting for up to 16 hours each day, or eating only one meal on certain days)
A low-fat, low-cholesterol diet
A low-carbohydrate diet (Atkins diet)
A very-low-carbohydrate, high-fat diet (ketogenic diet)
A Mediterranean diet

Answer 9

A Mediterranean diet

The Mediterranean diet has moderate to strong evidence for reducing the incidence of cardiovascular disease and associated mortality, preventing type 2 diabetes, decreasing overall mortality, and treating obesity. Intermittent fasting has been shown to be effective in weight loss, although not clearly more effective than overall calorie restriction, but a decrease in cardiovascular risk has not been shown. Low-fat, low-cholesterol diets may lead to substituting foods with increased sugar and overall calories. A low-carbohydrate diet has been shown to have more beneficial effects on lipid profiles than a low-fat diet. Additionally, mono- and polyunsaturated fats are actually beneficial in cardiovascular health, so focusing on a low-fat diet may be counterproductive. Low-carbohydrate diets can be useful to promote weight loss and decrease the incidence of type 2 diabetes, but their impact on cardiovascular disease is less clear. It is recommended that less than 5%–10% of total calories should come from added sugars, but a diet very low in carbohydrates may excessively limit healthy carbohydrates such as those found in whole grains, fruits, and vegetables.

Question 10

A 67-year-old male presents for a preoperative evaluation before a knee replacement. His past medical history is significant for well-controlled type 2 diabetes, hypertension, and atrial fibrillation, for which he is taking apixaban (Eliquis).

Which one of the following would be the most appropriate approach to managing anticoagulation prior to surgery? (check one)
Continuing apixaban therapy during the perioperative period
Discontinuing apixaban for 2 days prior to the procedure without bridging
Discontinuing apixaban for 2 days prior to the procedure, and bridging with enoxaparin (Lovenox)
Discontinuing apixaban for 5 days prior to the procedure without bridging
Discontinuing apixaban for 5 days prior to the procedure, and bridging with enoxaparin

Answer 10

Discontinuing apixaban for 2 days prior to the procedure without bridging

Patients taking apixaban for stroke prevention in atrial fibrillation should discontinue the medication for 1–2 days prior to the procedure without bridging. This approach is associated with a low risk of bleeding complications without increasing the incidence of thromboembolism. The choice between 1 and 2 days depends on the bleeding risk associated with the procedure.

Question 11

A previously healthy 16-year-old male presents to your office after having a syncopal episode at the start of track practice. An EKG revealed a QTc of 520 ms. This was confirmed on a subsequent EKG.

This finding is associated with which one of the following rhythm abnormalities? (check one)
Sinus arrest
Third degree atrioventricular block
Paroxysmal supraventricular tachycardia
Polymorphic ventricular tachycardia
Atrial fibrillation with a rapid ventricular response

Answer 11

Polymorphic ventricular tachycardia

Patients with repeated EKGs showing a QTc interval >480 ms with a syncopal episode, or >500 ms in the absence of symptoms, are diagnosed with long QT syndrome if no secondary cause such as medication use is present. This syndrome occurs in 1 in 2000 people and consists of cardiac repolarization defects. It is associated with polymorphic ventricular tachycardia, including torsades de pointes, and sudden cardiac death. It may be treated with p-blockers and implanted cardioverter defibrillators.

Question 12

A 62-year-old African-American male is admitted to the hospital for the third time in 6 months with heart failure. He has dyspnea with minimal activity. Echocardiography reveals an ejection fraction of 40%.

Which one of the following combinations of medications is most appropriate for long-term management of this patient? (check one)
Enalapril (Vasotec) plus digoxin
Hydralazine plus isosorbide dinitrate
Losartan (Cozaar) plus amlodipine (Norvasc)
Spironolactone (Aldactone) plus bisoprolol (Zebeta)

Answer 12

Hydralazine plus isosorbide dinitrate

The combination of the vasodilators hydralazine and isosorbide dinitrate has been shown to be effective in the treatment of heart failure when standard treatment with diuretics, β-blockers, and an ACE inhibitor (or ARB) is insufficient to control symptoms or cannot be tolerated. This combination is particularly effective in African-Americans with NYHA class III or IV heart failure, with advantages including reduced mortality rates and improvement in quality-of-life measures. Digoxin, a long-time standard for the treatment of heart failure, is useful in reducing the symptoms of heart failure but has not been shown to improve survival. Amlodipine and other calcium channel blockers do not have a direct role in the treatment of heart failure.

Question 13

In which one of the following cardiac emergency cases should atropine be used?
(check one)
Symptomatic Mobitz type II atrioventricular block
Cardiac arrest with pulseless electrical activity
Asystolic cardiac arrest
Acute cardiac ischemia and a heart rate <60 beats/min
Sinus bradycardia with hypotension

Answer 13

Sinus bradycardia with hypotension

The main use of atropine in cases of cardiac arrest is for symptomatic bradycardia. It has little effect with
complete heart block and Mobitz type II atrioventricular block. It is not recommended or effective for
cardiac arrest with pulseless electrical activity or in cases of asystole. It has been removed from these
algorithms by the ACLS committee. During an acute myocardial infarction or acute cardiac ischemia, an
increase in heart rate may increase the amount of ischemia.

Question 14

A 72-year-old white female is admitted to the hospital with her first episode of acute heart
failure. She has a history of hypertension treated with a thiazide diuretic. An echocardiogram
reveals no evidence of valvular disease and no segmental wall motion abnormalities. Left
ventricular hypertrophy is noted, and her ejection fraction is 55%. Her pulse rate is 72
beats/min.

The most likely cause of her heart failure is (check one)
systolic dysfunction
diastolic dysfunction
hypertrophic cardiomyopathy
high out-put failure

Answer 14

diastolic dysfunction

Diastolic dysfunction is now recognized as an important cause of heart failure. It is due to left ventricular
hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax
or fill adequately, thus limiting its forward output. The typical patient is an elderly person who has systolic
hypertension, left ventricular hypertrophy, and a normal ejection fraction (50%–55%).

Question 15

A 39-year-old male presents to the emergency department with a 2-hour history of chest discomfort, dyspnea, dizziness, and palpitations. He has no history of coronary artery disease. He states that he has had several similar episodes in the last year. On examination he has a temperature of 36.8°C (98.2°F), a respiratory rate of 25/min, a heart rate of 193 beats/min, a blood pressure of 134/82 mm Hg, and an O2 saturation of 96% on room air. The physical examination is otherwise normal. An EKG reveals a regular narrow QRS complex tachycardia with no visible P waves.

He converts to normal sinus rhythm with intravenous adenosine (Adenocard). Which one of the following would be most useful in the long-term management of this patient’s condition? (check one)
Adenosine
Digoxin
Vagal maneuvers
Pacemaker placement
Radiofrequency ablation

Answer 15

Radiofrequency ablation

This patient presents with a classic description of supraventricular tachycardia (SVT). The initial management of SVT centers around stopping the aberrant rhythm. In the hemodynamically stable patient initial measures should include vagal maneuvers (SOR C), intravenous adenosine or verapamil (SOR B), intravenous diltiazem or β-blockade, intravenous antiarrhythmics, or cardioversion in refractory cases. While digoxin is occasionally useful in atrial fibrillation with a rapid ventricular rate, it is not recommended for SVT. Radiofrequency ablation is fast becoming the first-line therapy for all patients with recurrent SVT, not just those refractory to suppressive drug therapies. Observational studies have shown that this therapy results in improved quality of life and lower cost as compared to drug therapy (SOR B).

Question 16

Which one of the following is most characteristic of the pain associated with acute pericarditis? (check one)
Improvement when sitting up and leaning forward
Improvement when lying supine
Worsening with the Valsalva maneuver
Radiation to the right scapula
Radiation to both arms

Answer 16

Improvement when sitting up and leaning forward

While there is substantial overlap in the signs, symptoms, and physical findings for the various etiologies of chest pain, a good history and physical examination can help determine which patients require immediate further evaluation for a potentially serious cause. The chest pain associated with pericarditis is typically pleuritic, and is worse with inspiration or in positions that put traction on the pleuropericardial tissues, such as lying supine. Patients with acute pericarditis typically get relief or improvement when there is less tension on the pericardium, such as when sitting and leaning forward. This position brings the heart closer to the anterior chest wall, which incidentally is the best position for hearing the pericardial friction rub associated with acute pericarditis.

Question 17

A 65-year-old male with type 2 diabetes mellitus is having increasing symptoms of angina pectoris. His cardiologist has recommended that he undergo heart catheterization and possible intervention if coronary artery disease is found. He comes to your office prior to the procedure and asks for your thoughts regarding treatment options presented by the cardiologist.

In addition to optimal medical treatment, if this patient is found to have multivessel coronary disease at the time of heart catheterization, you would recommend which one of the following? (check one)
Angioplasty without stenting
Angioplasty with bare-metal stents
Angioplasty with drug-eluting stents
Angioplasty of the most significantly blocked artery, followed by coronary artery bypass graft surgery
Coronary artery bypass graft surgery

Answer 17

Coronary artery bypass graft surgery

The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial funded by the National Heart, Lung, and Blood Institute concluded that in patients with diabetes mellitus and advanced coronary artery disease, coronary artery bypass graft surgery was superior to percutaneous coronary intervention (PCI) in that it significantly reduced rates of death and myocardial infarction, although stroke rates were higher in the 30-day perioperative period. The FREEDOM trial suggested that these outcomes are similar whether PCI is performed without stents, with bare-metal stents, or with drug-eluting stents. These results were consistent with reports from other smaller or retrospective studies of revascularization in patients with diabetes mellitus.

Question 18

A 62-year-old female with known systolic heart failure has a 2-month history of increased fatigue and worsening shortness of breath with ambulation. She says she has adhered to her medication regimen. Her oxygen saturation is 96% on room air and a physical examination is within normal limits. Laboratory studies, chest radiographs, and an EKG are ordered. The echocardiogram shows an ejection fraction of 35% and normal right heart function. Her estimated pulmonary pressure is 45 mm Hg.

The best option for treatment of her pulmonary hypertension at this point is to (check one)
add a vasodilator
begin oxygen therapy
recommend lifelong anticoagulation
maximize treatment for heart failure
schedule right heart catheterization

Answer 18

maximize treatment for heart failure

This patient has pulmonary hypertension due to left heart failure. The recommended treatment is to maximize treatment for her heart failure and any other comorbidities. Vasodilators are not recommended in the treatment of pulmonary hypertension due to left heart failure and may be harmful (SOR C). Oxygen therapy is recommended only for patients with hypoxia (SOR C). Lifelong anticoagulation is recommended if pulmonary hypertension is due to chronic thromboembolic disease but not if it is due to left heart failure (SOR C). Anticoagulation is not recommended in systolic left heart failure unless there is another indication.

Right heart catheterization is not recommended for pulmonary hypertension due to left heart disease because vasodilators are not a treatment option. Right heart catheterization is recommended in pulmonary hypertension prior to initiating vasodilator therapy in appropriate patients (SOR C).

Question 19

You are counseling a 45-year-old obese male regarding weight loss. The patient has elevated triglycerides, low HDL-cholesterol, and stage 1 hypertension. He does not currently take medications and would like to avoid taking medications in the future. The patient has heard good things about low-carbohydrate diets and asks your opinion.

A low-carbohydrate diet in a patient such as this is most likely to result in? (check one)
Increased LDL-cholesterol
Increased triglycerides
Increased blood pressure
Development of metabolic syndrome
Better short-term weight loss than with a low-fat diet

Answer 19

Better short-term weight loss than with a low-fat diet

Emerging data on low-carbohydrate diets is mostly encouraging, in that these diets do not seem to cause the expected increases in blood pressure, LDL-cholesterol levels, or triglyceride levels that the medical community had first assumed. Although low-carbohydrate diets have been shown to result in clinically meaningful weight loss, reduced-calorie diets appear to result in similar weight loss regardless of which macronutrients they emphasize. This patient has symptoms of metabolic syndrome and has a higher risk of glucose intolerance or diabetes mellitus. Low-carbohydrate diets have been shown to reduce insulin resistance at least as well as, if not better than, traditional diet plans

Question 20

Which one of the following is the most common cause of sudden cardiac death in young athletes?

(check one)
Coronary artery abnormalities
Myocarditis
Hypertrophic cardiomyopathy
Brugada syndrome
Idiopathic left ventricular hypertrophy

Answer 20

Hypertrophic cardiomyopathy

Structural non-atherosclerotic heart disease is the predominant cause of sudden death in young athletes.
Hypertrophic cardiomyopathy, an autosomal dominant condition with variable expression, accounts for
more than one-third of these cases. Coronary artery abnormalities are second in frequency as a cause of
sudden cardiac death in this population, with idiopathic ventricular hypertrophy third.

Question 21

A 62-year-old male with a 20-year history of diabetes mellitus presents with bilateral calf and buttock pain that occurs after he walks 2 blocks. The symptoms are relieved with rest. On examination his pedal pulses are not palpable and his ankle-brachial index is 1.45.

Which one of the following would be most appropriate?
(check one)
Reassuring the patient that his ankle-brachial index is normal
MRI of the lumbar spine
A repeat evaluation in 6 months if the symptoms persist
MR or CT angiography of the lower extremities

Answer 21

MR or CT angiography of the lower extremities

The National Health and Nutrition Examination Survey (NHANES) found that 1.4% of adults over 40 have an ankle-brachial index (ABI) >1.4; this group accounts for approximately 20% of all adults with peripheral artery disease. An ABI >1.4 indicates noncompressible arteries (calcified vessels). In patients with arterial calcification, such as diabetic patients, more reliable information is often obtained by using toe pressures to calculate a toe-brachial index and from pulse volume recordings.

Vascular imaging should be used to confirm peripheral vascular disease. MR or CT arteriography, duplex scanning, and hemodynamic localization are noninvasive methods for lesion localization and may be helpful when symptoms or findings do not correlate with the ABI. Contrast arteriography is used for definitive localization before intervention.

Question 22

Which one of the following cardiovascular changes is a recognized age-related effect?

(check one)
Decreased maximal heart rate with exercise
Decreased myocardial collagen
Decreased myocardial mass
Increased left ventricular compliance
Increased heart rate at rest

Answer 22

Decreased maximal heart rate with exercise

Maximal heart rate with exercise generally decreases with age. A frequently used formula for predicting maximal heart rate is 220 minus age, with a correction factor of 0.85 often applied for females, who have a lower peak heart rate and a more gradual decline.

Myocardial collagen and mass both increase with age. The increase in collagen may play a role in decreasing left ventricular compliance. The resting heart rate, like the maximal exercising heart rate, decreases with normal aging. Tachycardia at rest may suggest a pathologic state.

Question 23

A 55-year-old male has New York Heart Association class III chronic systolic heart failure due to hypertensive cardiomyopathy. Which one of the following is CONTRAINDICATED in this patient?

(check one)
Carvedilol (Coreg)
Digoxin
Ramipril (Altace)
Spironolactone (Aldactone)
Verapamil (Calan)

Answer 23

Verapamil (Calan)

ACE inhibitors and β-blockers improve mortality in heart failure (HF). Digoxin and furosemide improve symptoms and reduce hospitalizations in systolic HF, and furosemide may decrease mortality. Spironolactone, an aldosterone antagonist, reduces all-cause mortality and improves ejection fractions in systolic HF. Verapamil, due to its negative inotropic effect, is associated with worsening heart failure and an increased risk of adverse cardiovascular events.

Question 24

A 62-year-old male underwent percutaneous coronary intervention and placement of two stents for a myocardial infarction yesterday. He is currently taking simvastatin (Zocor), aspirin, lisinopril (Prinivil, Zestril), and hydrochlorothiazide. His last LDL-cholesterol level was 70 mg/dL and his blood pressure is 130/80 mm Hg.
Which one of the following additions to his current regimen would be most appropriate at this time?
(check one)
Amlodipine (Norvasc)
Diltiazem (Cardizem)
Verapamil (Calan, Verelan)
Metoprolol (Lopressor, Toprol-XL)
No changes

Answer 24

Metoprolol (Lopressor, Toprol-XL)

β-Blockers are first-line antihypertensive medications for patients with coronary artery disease (CAD) and have been shown to reduce the risk of death by 23% at 2 years. They should also be given to normotensive patients with CAD if tolerated. Cardioselective (β1) β-blockers such as metoprolol and atenolol are preferred, as they cause fewer adverse effects.

Question 25

A 56-year-old white male reports lower leg claudication that occurs when he walks approximately one block and is relieved by standing still or sitting. He has a history of diabetes mellitus and hyperlipidemia. His most recent hemoglobin A1c was 5.9% and his LDL-cholesterol level at that time was 95 mg/dL. Current medications include glyburide (DiaBeta), metformin (Glucophage), simvastatin (Zocor), and daily aspirin. He stopped smoking 1 month ago and began a walking program. A physical examination is normal except for barely palpable dorsalis pedis and posterior tibial pulses. Femoral and popliteal pulses are normal. Noninvasive vascular studies of his legs show an ankle-brachial index of 0.7 bilaterally and decreased flow.

Which one of the following would be most appropriate for addressing this patient’s symptoms? (check one)
Fish oil
Warfarin (Coumadin)
Cilostazol (Pletal)
Dipyridamole (Persantine)
Clopidogrel (Plavix)

Answer 25

Cilostazol (Pletal)

The patient described has symptomatic arterial vascular disease manifested by intermittent claudication. He has already initiated the two most important changes: he has stopped smoking and started a walking program. His LDL-cholesterol is at target levels; further lowering is not likely to improve his symptoms. In the presence of diffuse disease, interventional treatments such as angioplasty or surgery may not be helpful; in addition, these interventions should be reserved as a last resort. Cilostazol has been shown to help with intermittent claudication, but additional antiplatelet agents are not likely to improve his symptoms. Fish oil and warfarin have not been found to be helpful in the management of this condition.

Question 26

A patient with chronic atrial fibrillation treated with dabigatran (Pradaxa) sees you for follow-up. She says she can no longer afford the dabigatran and would like to switch to warfarin (Coumadin). She has normal renal function.

Which one of the following would be the most appropriate approach? (check one)
Start warfarin and stop dabigatran when her INR is 2.0–3.0
Start warfarin now and stop dabigatran in 3 days
Stop dabigatran, start warfarin, and start low molecular weight heparin and enoxaparin (Lovenox) every 12 hr until her INR is 2.0–3.0
Stop dabigatran for 24 hr and then start warfarin
Hospitalize the patient, stop dabigatran, start warfarin, and treat with heparin until her INR is 2.0–3.0

Answer 26

Start warfarin now and stop dabigatran in 3 days

The recommendation for switching to warfarin in a patient treated with dabigatran is to start warfarin 3 days prior to stopping dabigatran. Bridging with a parenteral agent is not necessary. Dabigatran is known to increase the INR, so the INR will not reflect warfarin’s effect until dabigatran has been withheld for at least 2 days.

Question 27

Patients with symptomatic heart failure associated with a reduced systolic ejection fraction or left ventricular remodeling should be initially treated with which one of the following agents? (check one)
An ACE inhibitor
Hydralazine (Apresoline)
Warfarin (Coumadin)
Amiodarone (Cordarone)
Verapamil (Calan, Isoptin)

Answer 27

An ACE inhibitor

It has been shown that congestive heart failure (CHF) patients treated with ACE inhibitors survive longer, and all such patients should take these agents if tolerated. Warfarin and/or antiarrhythmic drugs should be given only to selected CHF patients. Verapamil may adversely affect cardiac function and should be avoided in patients with CHF. Hydralazine can be used, but because of its side effect profile would be a second-line agent.

Question 28

A previously healthy 50-year-old male presents with a heart rate of 156 beats/min and a blood
pressure of 126/84 mm Hg. An EKG shows a regular, narrow-complex tachycardia. Vagal
maneuvers have no effect, and the patient appears anxious.

Administration of which one of the following medications is the best initial treatment?
(check one)
Vasopressin (Pitressin)
Verapamil (Calan)
Diltiazem
Adenosine (Adenocard)
Digoxin

Answer 28

Adenosine (Adenocard)

Patients with persistent supraventricular tachycardias require immediate medical attention. A patient who
has no underlying heart disease and a regular, narrow complex tachycardia should be treated with
adenosine. If the patient does not respond to this treatment, cardioversion should be considered.
Vasopressin would be useful if the patient were unstable with a ventricular tachycardia.

Question 29

A 63-year-old male presents to your office because of intermittent chest pain with exertion. He has been building a new deck and noted the onset of chest pain following particularly intense workdays. He reports that the pain always resolves with rest, and he has not noticed any lower extremity edema or difficulty breathing. His past medical history is notable only for hypertension and coronary artery disease diagnosed 3 years ago. His current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Zestril), 10 mg daily; and aspirin, 81 mg daily.

His vital signs include a weight of 80 kg (176 lb), a height of 178 cm (70 in), a blood pressure of 138/78 mm Hg, a pulse rate of 80 beats/min, a respiratory rate of 12/min, and an oxygen saturation of 96% on room air. A physical examination is normal. An EKG reveals normal sinus rhythm without ST-segment, T-wave, or Q-wave abnormalities.

In addition to prescribing as-needed, immediate-release nitroglycerin, which one of the following would be the most appropriate pharmacotherapy at this time? (check one)
Diltiazem (Cardizem LA), 180 mg daily
Ezetimibe (Zetia), 10 mg daily
Isosorbide mononitrate, 30 mg daily
Metoprolol succinate (Toprol-XL), 100 mg daily
Ranolazine (Ranexa), 500 mg twice daily

Answer 29

Metoprolol succinate (Toprol-XL), 100 mg daily

This patient has coronary artery disease with symptoms of angina but without symptoms of heart failure. In addition to lifestyle modifications, management of blood pressure and lipids, and antiplatelet therapy, the management of coronary artery disease includes pharmacotherapy for the symptoms of angina. Immediate-release nitroglycerin is appropriate for the short-term relief of angina. However, β-blockers are first-line treatments for long-term relief. Nondihydropyridine calcium channel blockers may be used in addition to β-blockers if symptoms are not controlled with a β-blocker alone or if β-blockers are contraindicated due to conditions such as asthma or elderly age. This patient does not have any of these contraindications, and metoprolol succinate is likely to provide relief for his angina. Ezetimibe is used as add-on therapy to statins for cholesterol management but does not have a role in the medical management of angina. The addition of long-acting nitrates and ranolazine may be considered if his angina persists despite treatment. If medical management does not control anginal symptoms, surgical treatment such as percutaneous coronary intervention or coronary artery bypass grafting may be considered.

Question 30

A 55-year-old male has New York Heart Association Class II heart failure. He becomes dyspneic with significant exertion. His only medication is an ACE inhibitor. Which one of the following additional medications has been shown to improve longevity in this situation? (check one)
Digitalis
Warfarin (Coumadin)
β-Blockers
Amiodarone (Cordarone)
Non-dihydropyridine calcium channel blockers

Answer 30

β-Blockers

β-Blockers are recommended to reduce mortality in symptomatic patients with heart failure (SOR A). The role that digoxin will ultimately play in heart failure is unclear. The Digitalis Investigation Group study revealed a trend toward increased mortality among women with heart failure who were taking digoxin, but digoxin levels were higher among women than men. There is no evidence that warfarin decreases mortality in patients with heart failure. There is also no evidence that amiodarone decreases mortality from heart failure in patients with no history of atrial fibrillation. Calcium channel blockers should be used with caution in patients with heart failure because they can cause peripheral vasodilation, decreased heart rate, decreased cardiac contractility, and decreased cardiac conduction.

Question 31

A 90-year-old female sees you regularly for follow-up of several chronic medical conditions including systolic hypertension, coronary artery disease, previous ischemic stroke, and heart failure with preserved ejection fraction. Her systolic blood pressure is usually >160 mm Hg while her diastolic blood pressure is usually <50 mm Hg, making management challenging.

In managing this patient’s blood pressure, an important physiologic consideration is that coronary artery perfusion is determined by which one of the following? (check one)
Diastolic blood pressure
Systolic blood pressure
Mean arterial pressure
Pulse pressure
Ejection fraction

Answer 31

Diastolic blood pressure

Perfusion of the myocardium occurs during diastole; therefore, the diastolic blood pressure (DBP) determines the coronary artery perfusion pressure. The systolic blood pressure (SBP), mean arterial pressure, pulse pressure (PP), and cardiac ejection fraction do not determine the coronary artery perfusion pressure.

PP is the SBP minus the DBP. The wide PP observed in older patients results from arterial stiffness. This causes an increase in the SBP and PP and a decrease in the DBP. This stiffness results from both arterial structural and functional changes with aging, including wall hypertrophy, calcifications, atheromatous lesions, changes in the extracellular matrix, and impairment of vascular endothelial function and smooth muscle cell reactivity. A wide PP makes it challenging to manage blood pressure with the goal of lowering SBP while ensuring a DBP that maintains coronary artery blood flow and avoids cardiac ischemia.

Guidelines from the American Heart Association, American College of Cardiology, and the American Society of Hypertension recommend that blood pressure should be lowered slowly in patients with an elevated DBP and coronary artery disease with evidence of myocardial ischemia. The guidelines further recommend caution in lowering DBP to <60 mm Hg in patients older than 60 or who have diabetes mellitus.

Question 32

For patients with atrial fibrillation requiring anticoagulation, which one of the following concomitant conditions would indicate a need for treatment with warfarin instead of a direct oral anticoagulant? (check one)
Congestive heart failure
Diabetes mellitus
A history of stroke
Hypertension
Severe mitral stenosis

Answer 32

Severe mitral stenosis

In general, direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, or edoxaban are preferred over warfarin for patients with atrial fibrillation and a CHA2DS2-VASc score of at least 3 for women and at least 2 for men. However, if the patient has concomitant moderate or severe mitral stenosis or a mechanical heart valve, warfarin is preferred.

Question 33

A 67-year-old male with a history of hypertension comes to your clinic for a follow-up visit. He has had two myocardial infarctions in the past 5 years and has undergone stent placement. He is currently asymptomatic. His vital signs are stable and his blood pressure is well controlled. Laboratory studies reveal a normal hemoglobin A1c and lipid profile. In addition to high-dose statin therapy, his current medication regimen includes the following:

Aspirin
Carvedilol (Coreg)
Chlorthalidone
Clopidogrel (Plavix)
Lisinopril (Zestril)

Adding which one of the following would help to provide secondary prevention of cardiovascular events in this patient? (check one)
Azithromycin (Zithromax)
Colchicine (Colcrys)
DHA
Niacin
Omega-3 supplements

Answer 33

Colchicine (Colcrys)

The central role of inflammation in the progression of coronary disease is well recognized and the use of an anti-inflammatory medication may improve outcomes in these patients. The low-dose colchicine (LoDoCo2) trial evaluated colchicine, 0.5 mg daily, versus placebo in patients with chronic coronary artery disease and found a 30% risk reduction in cardiovascular deaths, spontaneous myocardial infarctions, ischemic stroke, and ischemia-driven revascularization. It did not find any observable difference with regard to new-onset atrial fibrillation, deep vein thrombosis, diabetes mellitus, or pulmonary embolism. Of note, the trial excluded individuals with heart failure or renal impairment.

At one time, azithromycin had shown some evidence in the secondary prevention of cardiovascular disease, but subsequent trials did not show the same benefit. Studies of fish oil capsules that contain marine omega-3 fatty acid supplements mixed with EPA/DHA formulations have failed to show cardiovascular benefit in patients with known cardiovascular disease. Similarly, niacin does not reduce overall mortality, cardiovascular mortality, or noncardiovascular mortality. The benefits of niacin therapy in the prevention of cardiovascular disease events are not well proven.

Question 34

A 75-year-old male with long-standing diabetes mellitus, tobacco use, and venous insufficiency presents to your office with bilateral leg heaviness and recent oozing from his left leg. A physical examination reveals venous stasis dermatitis, edema of both legs, and a well-circumscribed 3×4-cm area of superficial ulceration on the left medial shin with a thin layer of purulent exudate overlying a pink base. The surrounding skin has no erythema, warmth, or tenderness. Pedal pulses are nonpalpable bilaterally.

In addition to smoking cessation counseling and local wound care, which one of the following would be the most appropriate next step? (check one)
An ankle-brachial index
A medical-grade compression stocking
A zinc oxide–impregnated Unna boot
A wound culture specimen
A skin biopsy of the ulcer

Answer 34

An ankle-brachial index

This patient’s presentation is typical for a venous ulcer resulting from long-standing venous hypertension. Patients with venous disease may have leg heaviness, pain, and swelling that worsens throughout the day. Common physical manifestations of venous disease include leg edema, varicose veins, and venous stasis dermatitis. Ulcers also may develop, often over a bony prominence in the lower leg, such as the medial malleolus. Venous ulcers are typically shallow with an exudative appearance over a granulating base and well-defined borders.

The mainstay treatment of venous ulcers is compression, which may be accomplished through various methods that are often used in combination. Options include elastic sleeves, compression stockings, non-elastic wraps such as Unna boots, and intermittent pneumatic compression. However, when underlying significant peripheral arterial disease is also present, compression therapy may further compromise distal circulation and cause unintentional harm. Therefore, patients with suspected arterial disease should have distal pulses evaluated and ankle-brachial indexes (ABIs) measured prior to starting compression therapy. When noninvasive testing suggests underlying arterial disease, consultation with a vascular surgeon is indicated. This patient has several risk factors for peripheral arterial disease, including an abnormal pedal pulse examination, and therefore should be evaluated further with ABI measurements before treating his ulcer with either a medical-grade compression stocking or an Unna boot. Although ulcers are often colonized with bacteria, antibiotics are not indicated in the absence of infection. This patient does not have symptoms or signs to suggest active infection and a culture swab would have no impact on his present management. Obtaining a biopsy of a skin ulcer may be indicated in the setting of suspected connective tissue disease, vasculitis, or malignancy but is not indicated in this situation.

Question 35

A 54-year-old male presents to the emergency department with an acute onset of chest pain. His cardiac risk factors include hypertension, hyperlipidemia, and a positive family history. His temperature is 37.0°C (98.6°F), pulse rate 80 beats/min, blood pressure 155/86 mm Hg, and respiratory rate 22/min. His oxygen saturation is 95% on room air. An EKG shows rare unifocal PVCs and nonspecific ST-T–wave changes. Initial cardiac markers are negative.
Which one of the following would be most appropriate at this point?
(check one)
Helical (spiral) CT of the chest
Echocardiography
PA and lateral chest films
A ventilation-perfusion scan
Magnetic resonance angiography

Answer 35

PA and lateral chest films

PA and lateral chest radiographs are still valuable in the early evaluation of patients with chest pain. While they do not confirm or rule out the presence of myocardial ischemia, other causes of chest pain may be evident, such as pneumothorax, pneumonia, or heart failure. The chest film may also provide clues about other possible diagnoses, such as pulmonary embolism, aortic disease, or neoplasia. The other tests listed often have a role in the evaluation of chest pain, but none has supplanted the plain chest film as the best initial imaging study.

Question 36

A 63-year-old female with a history of obesity and hypertension sees you for evaluation of shortness of breath on exertion and lower extremity edema. Echocardiography shows grade 2 diastolic dysfunction and an ejection fraction of 50%. You diagnose heart failure with preserved ejection fraction.

Which one of the following medications has the best evidence to reduce hospitalization due to heart failure or cardiovascular death in patients such as this? (check one)
Carvedilol (Coreg)
Empagliflozin (Jardiance)
Lisinopril (Zestril)
Sacubitril/valsartan (Entresto)
Spironolactone (Aldactone)

Answer 36

Empagliflozin (Jardiance)

Heart failure with preserved ejection fraction (HFpEF), defined as an EF 50%, has a relative paucity of evidence-based treatments leading to improved patient outcomes compared to heart failure with reduced ejection fraction (HFrEF), defined as an EF <40%. While all of the options listed have good evidence of benefit in HFrEF, only the SGLT2 inhibitor empagliflozin has been shown to improve the composite outcome of hospitalization due to heart failure or cardiovascular death in HFpEF. The 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America guideline for the management of heart failure recommends SGLT2 inhibitors as having the best evidence of benefit in HFpEF.

β-Blockers such as carvedilol may be used for rate control in patients with atrial fibrillation and HFpEF but are not clearly beneficial otherwise. Clinical trials of ACE inhibitors such as lisinopril and angiotensin receptor blockers such as valsartan have not shown improved outcomes for patients with HFpEF. Sacubitril/valsartan similarly did not achieve the primary end point of improvement in time to HF hospitalization or cardiovascular death in this patient population. The mineralocorticoid antagonist spironolactone is associated with improved diastolic function in patients with HFpEF and was found to improve hospitalizations but not cardiovascular death as a primary outcome.

Question 37

A 55-year-old male sees you for a health maintenance examination. He tells you that his father had a myocardial infarction at age 55 and asks you how he can reduce his risk for coronary artery disease. He exercises regularly and does not smoke. His vital signs include a blood pressure of 128/78 mm Hg, a pulse rate of 75 beats/min, and a BMI of 28 kg/m2. A physical examination is unremarkable.

Which one of the following is needed to calculate this patient’s American College of Cardiology/American Heart Association 10-year atherosclerotic cardiovascular disease event risk using the Pooled Cohort Equations? (check one)
An ankle-brachial index
A high-sensitivity C-reactive protein level
A lipid panel
A coronary artery calcium score

Answer 37

A lipid panel

A lipid panel provides total cholesterol and HDL-cholesterol data, which are two of the components necessary to calculate the American College of Cardiology/American Heart Association 10-year atherosclerotic cardiovascular disease (ASCVD) event risk using the Pooled Cohort Equations. Other components required to compute the ASCVD event risk score include race, sex, age, systolic blood pressure level, smoking status, presence of diabetes mellitus, and antihypertension treatment. An ankle-brachial index, a high-sensitivity C-reactive protein level, and a coronary artery calcium score are not used in the Pooled Cohort Equations to calculate a patient’s 10-year ASCVD event risk.

Question 38

A 52-year-old female presents to the emergency department with a complaint of chest pain. The symptoms began 2 hours ago while she was shopping. She describes the pain as a tightness on the left side of her chest that radiates to her left shoulder. She has some shortness of breath with the pain, but no nausea or diaphoresis. Her past medical history is significant for panic disorder.Her vital signs and a physical examination are within normal limits.Which one of the following would be the most appropriate next step in the management of this patient? (check one)
Admit to a monitored bed for further evaluation
Obtain a CBC, a blood chemistry profile, liver function tests, and an EKG
Administer a short-acting benzodiazepine and observe for 60 minutes
Consult with a cardiologist for immediate heart catheterization
Obtain a troponin I measurement and an EKG

Answer 38

Obtain a troponin I measurement and an EKG

This patient has symptoms that suggest acute coronary syndrome, which includes chest pain with activity that radiates to the shoulder. An EKG is essential early in the evaluation of a patient with chest pain, and the initial evaluation should also include a troponin I measurement. The patient should neither be admitted nor given a benzodiazepine until the EKG is performed. The diagnosis of acute coronary syndrome should be established prior to heart catheterization. Other laboratory tests may be appropriate, but they are not the most important initial tests.

Question 39

A 55-year-old male comes to your clinic for follow-up of his recent diagnosis of New York Heart Association class II heart failure with an ejection fraction of 40%. His past medical history is notable only for coronary artery disease. His current medications include the following:

Aspirin, 81 mg daily
Atorvastatin (Lipitor), 80 mg daily
Furosemide (Lasix), 40 mg daily
Lisinopril (Zestril), 40 mg daily
Metoprolol succinate (Toprol-XL), 100 mg daily
Spironolactone (Aldactone), 25 mg daily

Today he is asymptomatic. His vital signs include a temperature of 37.0°C (98.6°F), a blood pressure of 118/75 mm Hg, and a heart rate of 60 beats/min. A physical examination is unremarkable.

Which one of the following additional medications would be most appropriate to reduce his risk for worsening heart failure? (check one)
Dapagliflozin (Farxiga)
Digoxin
Isosorbide dinitrate/hydralazine (BiDil)
Ivabradine (Corlanor)
Liraglutide (Victoza)

Answer 39

Dapagliflozin (Farxiga)

The prevalence of heart failure has continued to increase due to the aging population in the United States. Dapagliflozin is approved by the FDA for the treatment of New York Heart Association class II–IV heart failure with reduced ejection fraction regardless of the presence of diabetes mellitus. Notably, recent studies showed a reduction in the worsening of heart failure and death from cardiovascular causes. Digoxin may be initiated in patients who remain symptomatic despite optimal therapy with other agents, but it does not affect morbidity or mortality. Isosorbide dinitrate/hydralazine provides a mortality benefit in patients who are unable to tolerate an ACE inhibitor or angiotensin receptor blocker. Ivabradine is a sinus node modulator and may reduce hospitalization or cardiovascular death in patients with a resting heart rate 70 beats/min who are taking a β-blocker at maximal dosage. Liraglutide reduces cardiovascular events in patients with diabetes but has no role in the treatment of heart failure.

Question 40

A 45-year-old male with no known medical history presents as a new patient for a physical examination. A review of symptoms is negative. He notes that his father died in his fifties of heart disease, but the patient does not know any further details. An examination is notable for a systolic murmur at the lower left sternal border.

Which one of the following additional findings in this patient would be most consistent with hypertrophic cardiomyopathy? (check one)
Decreased intensity of the murmur when supine
Decreased intensity of the murmur with the Valsalva maneuver
Elevated jugular venous distention
Elevated pulse pressure
A differential in blood pressure between the arms

Answer 40

Decreased intensity of the murmur when supine

Hypertrophic cardiomyopathy (HCM), formerly known as idiopathic hypertrophic subaortic stenosis, is a common and underdiagnosed form of inherited heart disease with a prevalence of 1:500 in the United States and worldwide. HCM is associated with a systolic murmur at the lower left sternal border with an intensity that changes along with changes to preload of the heart. Lying down increases preload, which decreases the murmur. The Valsalva maneuver decreases preload and increases the murmur. Advanced HCM may cause heart failure and jugular venous distention, but at that stage symptoms would be expected. Elevated pulse pressures are classically seen with aortic insufficiency rather than HCM. Differential blood pressures in the arms would not be expected with HCM.

Question 41

A 75-year-old white male presents to your office following hospitalization for an episode of heart failure. His edema has resolved but he still becomes symptomatic with minor exertion such as walking less than a block. A recent chest radiograph shows cardiomegaly, and echocardiography reveals an ejection fraction of 25%. He is currently taking furosemide (Lasix), 20 mg daily; carvedilol (Coreg), 25 mg twice daily; and lisinopril (Prinivil, Zestril), 20 mg daily. His vital signs include a pulse rate of 60 beats/min, a blood pressure of 110/70 mm Hg, a respiratory rate of 18/min, and a temperature of 37.0°C (98.6°F). No crackles or hepatojugular reflux are noted on auscultation.

Which one of the following would improve this patient’s symptoms and decrease his mortality risk? (check one)
Digoxin
Hydralazine and isosorbide dinitrate (BiDil)
Hydrochlorothiazide
Spironolactone (Aldactone)

Answer 41

Spironolactone (Aldactone)

For patients with left ventricular systolic dysfunction, clinical trials have demonstrated that ACE inhibitors, β-blockers, angiotensin receptor blockers, and aldosterone antagonists decrease hospitalizations and all-cause mortality. In African-American patients, all-cause mortality and hospitalizations have been reduced by hydralazine and isosorbide dinitrate.

Aldosterone antagonists such as spironolactone, as well as β-blockers, decrease mortality in patients with symptomatic heart failure (SOR A). Digoxin improves symptoms of heart failure but does not improve mortality.

Question 42

A 64-year-old male with midsternal chest pain is brought to the emergency department by ambulance. He is on oxygen and an intravenous line is in place. Shortly after arrival he loses consciousness and becomes pulseless and apneic, and CPR is begun. Cardiac monitoring shows ventricular tachycardia with a rate of 160 beats/min.

Which one of the following would be most appropriate at this point? (check one)
Amiodarone, intravenous infusion, followed by synchronized cardioversion
Adenosine (Adenocard), rapid intravenous push, repeated in 1–2 minutes if needed
Epinephrine, intravenous push, followed by synchronized cardioversion
Lidocaine (Xylocaine), intravenous push, repeated in 5 minutes if needed
Defibrillation

Answer 42

Defibrillation

Pulseless ventricular tachycardia (VT) should be treated the same as ventricular fibrillation. The first step is defibrillation. If that is unsuccessful, epinephrine is administered and defibrillation is reattempted. Lidocaine, adenosine, and procainamide may be used for the initial treatment of a wide-complex tachycardia of uncertain type, but should not be used for the initial treatment of pulseless VT. Synchronized cardioversion alone would be indicated for the initial treatment of rapid unstable tachycardia with a pulse.

Question 43

A 68-year-old female presents for evaluation of shortness of breath with activity for the past several weeks. She used to walk 2 miles daily for exercise but can no longer do so because of dyspnea and chest tightness. She also reports mild lower extremity edema. She has a history of a bicuspid aortic valve and aortic stenosis. Echocardiography 1 year ago showed moderately severe aortic stenosis with a mean valve area of 1.1 cm2.

Echocardiography today shows aortic stenosis with an aortic valve area of 0.9 cm2, a mean pressure gradient of 42 mm Hg, and a transaortic velocity of 4.3 m/sec. The ejection fraction is estimated to be 50%.

Which one of the following is indicated at this time? (check one)
Atorvastatin (Lipitor)
Furosemide (Lasix)
Lisinopril (Prinivil, Zestril)
Metoprolol succinate (Toprol-XL)
Referral for aortic valve replacement

Answer 43

Referral for aortic valve replacement

This patient has severe symptomatic aortic stenosis. The only therapy shown to improve symptoms and mortality in such patients is an aortic valve replacement. In patients with asymptomatic disease, watchful waiting is usually the recommended course of action. No medications or other therapies have been shown to prevent disease progression or alleviate symptoms. Patients with coexisting hypertension should be managed medically according to accepted guidelines. Diuretics should be used with caution due to their potential to reduce left ventricular filling and cardiac output, which leads to an increase in symptoms.

Question 44

A 73-year-old female with a history of obesity, essential hypertension, hyperlipidemia, and well-controlled type 2 diabetes presents to the emergency department (ED) with severe, crushing chest pain. She has a blood pressure of 115/64 mm Hg, a pulse rate of 90 beats/min, a respiratory rate of 15/min, a temperature of 37.2°C (99.0°F), and an oxygen saturation of 95% on room air. A point-of-care troponin level is 1.0 ng/mL (N <0.04) and an EKG is normal, and you diagnose a non–ST-elevation myocardial infarction.

Which one of the following interventions in the ED has the greatest benefit with regard to decreasing mortality in this patient? (check one)
Supplemental oxygen
Aspirin
Metoprolol
Morphine
Nitroglycerin

Answer 44

Aspirin

Based on a large, randomized, multicenter trial with 17,187 participants, the administration of aspirin for suspected acute myocardial infarction (MI) saves one life for every 24 patients. Supplemental oxygen appears to have no benefit in patients with an oxygen saturation >94%. Excessive oxygen can be toxic to endothelial cells and may decrease coronary blood flow and increase systemic vascular resistance. β-Blockers given immediately after MI do not decrease mortality, likely due to increased cardiogenic shock, although β-blockers administered in the subacute period following the event do have benefit. Morphine does not appear to have benefit and may increase mortality. The use of nitroglycerin does not lower the risk of mortality.

Question 45

A 30-year-old female presents for follow-up after an emergency department visit for an episode of symptomatic supraventricular tachycardia that was diagnosed as Wolff-Parkinson-White syndrome. Which one of the following would be most appropriate for the initial long-term management of this patient? (check one)
Adenosine (Adenocard)
Amiodarone (Cordarone)
Diltiazem (Cardizem)
Metoprolol
Catheter ablation

Answer 45

Catheter ablation

Catheter ablation is the most appropriate treatment for a patient with symptomatic Wolff-Parkinson-White
syndrome (WPW). Catheter ablation has a very high immediate success rate (96%–98%). The most
significant risk associated with the procedure is permanent atrioventricular block, which occurs in
approximately 0.4% of procedures. Adenosine and amiodarone are used for the acute management of
supraventricular tachycardia, but not for long-term management. Node-blocking medications such as
diltiazem and metoprolol should not be used for the long-term treatment of WPW, due to the increased risk
of ventricular fibrillation.

Question 46

A 78-year-old male presents to the emergency department (ED) after experiencing a syncopal event witnessed by his spouse. The patient reports that he has been easily fatigued and has not been able to walk as long as usual during the past few months. He recently saw his cardiologist and completed Holter monitoring but has not received the results yet. Laboratory studies during the ED visit were unremarkable. However, an EKG showed sinus bradycardia with 44 beats/min as well as pauses of more than 3 seconds, during which the patient reported dizziness. He says he wants to recover quickly so he can resume his regular activities.

Which one of the following is the first-line treatment for the presumed diagnosis?

(check one)
Atropine
Cilostazol
Dopamine
Glucagon
Permanent pacemaker placement

Answer 46

Permanent pacemaker placement

Sinus node dysfunction, also known as sick sinus syndrome, is defined by an abnormal initiation and propagation of electrical impulses from the sinoatrial node, causing sinus pauses of more than 3 seconds, sinus arrest, and bradycardia (heart rate <50 beats/min). Due to the resulting hypoperfusion, patients may experience decreased tolerance of physical activity, palpitations, dizziness, easy fatigability, and syncope. The diagnosis is made using heart rate monitoring. If symptoms are associated with exertion, an exercise stress test should be performed. Patients not reaching a heart rate of at least 80% of their predicted maximum (220 beats/min minus age) may have chronotropic incompetence. If the diagnosis of sinus node dysfunction is confirmed, the first-line treatment is placement of a permanent pacemaker.

Medication control of sinus node dysfunction, such as with cilostazol, is an option for patients unwilling to receive a permanent pacemaker, which is not the case in this patient. Atropine, dopamine, and glucagon are used in advanced cardiac life support protocols for patients who are acutely unstable. These medications are not appropriate for long-term management.

Question 47

A 32-year-old female requests a physical examination prior to participating in an adult soccer league. Her blood pressure is 118/70 mm Hg and her pulse rate is 68 beats/min. The examination is otherwise normal except for a systolic murmur that intensifies with Valsalva maneuvers. She says that she has recently been experiencing mild exertional dyspnea and moderate chest pain. The chest pain has been atypical and is not necessarily related to exertion. Echocardiography reveals hypertrophic cardiomyopathy.
In addition to referring the patient to a cardiologist, you recommended initiating therapy with (check one)
amiodarone (Cordarone)
amlodipine (Norvasc)
furosemide (Lasix)
lisinopril (Prinivil, Zestril)
metoprolol

Answer 47

metoprolol

Hypertrophic cardiomyopathy is the most common primary cardiomyopathy, with a prevalence of 1:500 persons. Many patients with hypertrophic cardiomyopathy are asymptomatic and are diagnosed during family screening, by auscultation of a heart murmur, or incidentally after an abnormal result on electrocardiography. On examination physicians may hear a systolic murmur that increases in intensity during Valsalva maneuvers. The main goals of therapy are to decrease exertional dyspnea and chest pain and prevent sudden cardiac death. β-Blockers are the initial therapy for patients with symptomatic hypertrophic cardiomyopathy. Nondihydropyridine calcium channel blockers such as verapamil can be used if β-blockers are not well tolerated.

Question 48

At a routine visit, a 40-year-old female asks about beginning an exercise regimen. She has a family history of heart disease and hypertension. She currently has no medical problems, but she is sedentary.

Which one of the following would be the most appropriate recommendation for this patient? (check one)
A baseline EKG and rhythm strip
An exercise stress test prior to beginning exercise
Jogging for 30 minutes twice a week
Fast walking for 30 minutes 5 or more days per week

Answer 48

Fast walking for 30 minutes 5 or more days per week

This patient would benefit from exercise to prevent or delay the onset of heart disease and hypertension, and to manage her weight. Exercise stress testing is not specifically indicated for this patient. Current recommendations are for healthy adults to engage in 30 minutes of accumulated moderate-intensity physical activity on 5 or more days per week.

Question 49

A 38-year-old previously healthy Ethiopian female presents with a 4-day history of sharp chest pain that improves when she sits up. She entered the United States 1 week ago to begin a postdoctoral research position. She had a recent negative HIV-1/HIV-2 test. She has no history of allergies and is not pregnant. Her only medication is ibuprofen, 400 mg every 8 hours as needed for menstrual cramps. The remainder of her history and physical examination are notable only for a pericardial friction rub. After further evaluation she is presumptively diagnosed with pericarditis.

Which one of the following is the most likely cause of this patient’s symptoms? (check one)
Ibuprofen hypersensitivity
Candida infection
Enterovirus infection
Myocardial infarction
Metastatic cancer

Answer 49

Enterovirus infection

Most pericarditis is presumed to be viral in origin. Enteroviruses, herpesviruses, adenovirus, and parvovirus B19 are common agents. Tuberculosis infection is also possible in this patient, considering the high prevalence of tuberculosis in sub-Saharan Africa. Candida infection is much less common, especially in an HIV-negative patient. Post–myocardial infarction syndrome, secondary metastatic tumor, and drug reaction are infrequent causes, especially in a previously healthy patient. Ibuprofen may be used to treat pericarditis.

Question 51

A 75-year-old male is noted to have palpitations. He has COPD from smoking for many years and uses an albuterol (Proventil, Ventolin) inhaler and inhaled corticosteroids. On examination his blood pressure is 130/70 mm Hg, his pulse rate is 110 beats/min, and his rhythm is irregularly irregular. Auscultation of the lungs reveals a few scattered wheezes and rhonchi. An EKG shows irregular R-R intervals with narrow QRS complexes and no P waves.

Which one of the following would be the best choice to control this patient’s heart rate? (check one)
Cardioversion
Amiodarone (Cordarone)
Digoxin (Lanoxin)
Diltiazem (Cardizem)
Propranolol

Answer 51

Diltiazem (Cardizem)

Atrial fibrillation is the most common cardiac arrhythmia and can be a source of morbidity and mortality. If this is suspected, a 12-lead EKG should be obtained to confirm the diagnosis. Patients need evaluation for possible cardioversion, rate versus rhythm control, and anticoagulation. The first-line agent to achieve a target heart rate of <80 beats/min would be either a β-blocker or a nondihydropyridine calcium channel blocker. This patient has significant COPD, which eliminates the use of a nonselective β-blocker such as propranolol. A nondihydropyridine calcium channel blocker such as verapamil or diltiazem would be a better choice. Adding digoxin could be considered if the initial therapy is unsuccessful in controlling the heart rate. Amiodarone has significant toxicity and is usually not recommended unless the first-line options fail.

Question 52

A 60-year-old male presents for evaluation of mild pitting edema of both lower extremities for several months. He has daytime fatigue and drowsiness but no orthopnea or paroxysmal nocturnal dyspnea. His only medications are hydrochlorothiazide and lisinopril (Prinivil, Zestril).

A physical examination reveals normal vital signs but a BMI of 30.3 kg/m2. His lungs are clear and his heart sounds are normal. There is no organomegaly. The patient has mild pitting edema of both lower extremities up to the midcalf but no associated skin changes, ulcerations, or decrease in pulses. A CBC, a comprehensive metabolic panel, a prealbumin level, and a chest radiograph are all normal.

In addition to a sleep study, which one of the following would be the most appropriate next step in the evaluation of this patient? (check one)
An ankle-brachial index
A D-dimer assay
Lymphoscintigraphy
Echocardiography
Magnetic resonance venography

Answer 52

Echocardiography

When evaluating bilateral lower extremity edema, one should first look for systemic etiologies that would result in edema, such as hepatic, renal, or cardiac failure. In patients with obesity or a history of loud snoring, daytime drowsiness, or unrestful sleep, obstructive sleep apnea is likely. These patients can be diagnosed through polysomnography. Echocardiography is also recommended to detect pulmonary hypertension.

Chronic venous insufficiency would be associated with skin changes such as hemosiderin deposits or venous ulcerations. If these findings are present, duplex ultrasonography should be ordered. If there is suspected arterial insufficiency an ankle-brachial index can be determined. For those with a low likelihood of deep vein thrombosis (DVT), a D-dimer assay can be ordered, but duplex ultrasonography is a more definitive test. For those with negative ultrasonography, magnetic resonance venography may be needed to rule out a pelvic or thigh DVT. Patients with suspected lymphedema can usually be diagnosed clinically, although lymphoscintigraphy may be required.

Question 53

An otherwise healthy 64-year-old male presents with mild shortness of breath and lightheadedness with exertion. He has a grade 3/6 systolic ejection murmur at the right second intercostal space radiating to the neck. A transthoracic echocardiogram and cardiac catheterization with normal coronary arteries reveals severe aortic stenosis.

Which one of the following would be the most appropriate management of this patient? (check one)
No treatment, and monitoring for increasing symptoms every 6 months
No treatment, and monitoring with echocardiography every 6 months
Medical management with an ACE inhibitor and continued monitoring
Medical management with a β-blocker and continued monitoring
Prompt aortic valve replacement

Answer 53

Prompt aortic valve replacement

This patient should have his aortic valve replaced. He meets criteria for severe aortic stenosis with a transthoracic velocity ≥4.0 m/sec and an aortic valve area <1.0 cm2. Symptomatic patients with severe aortic stenosis have 2-year mortality rates of more than 50%. After valve replacement the 10-year survival rate is almost identical to that of patients without aortic stenosis. Watchful waiting with monitoring for symptoms and periodic echocardiograms is indicated for asymptomatic patients with moderate to severe aortic stenosis who have a normal ejection fraction. There is no medical treatment that delays the progression of aortic valve disease or improves survival. Measures to reduce cardiovascular risk, including treatment of hypertension, are indicated. Rate-slowing calcium channel blockers and β-blockers that depress left ventricular function should be avoided if possible. ACE inhibitors may improve symptoms in patients with aortic stenosis who are not surgical candidates.

Question 54

A 72-year-old male has newly diagnosed systolic heart failure due to hypertensive cardiomyopathy. The patient has an estimated left ventricular ejection fraction of 30% and was dyspneic at rest and with minimal exertion at the time of diagnosis.

Which one of the following drugs is indicated to reduce mortality in this patient? (check one)
Atenolol (Tenormin)
Digoxin
Furosemide (Lasix)
Lisinopril (Prinivil, Zestril)
Nifedipine (Procardia)

Answer 54

Lisinopril (Prinivil, Zestril)

Medications shown to improve mortality in patients with heart failure with a reduced ejection fraction include ACE inhibitors, angiotensin receptor blockers, β-blockers, aldosterone antagonists, and in African-American patients, direct-acting vasodilators. Among the β-blockers, carvedilol, bisoprolol, and metoprolol succinate have this indication. Diuretics, along with digoxin, may improve symptoms but do not alter disease mortality.

Question 55

A 64-year-old male presents with a 2-week history of a worsening constant burning pain in his right foot. The physical examination reveals an absent dorsalis pedis pulse, and pallor develops with elevation of the foot. The resting right ankle-brachial index is 0.45 and Doppler waveform analysis indicates an isolated severe stenosis of the right posterior tibial artery.

Which one of the following therapeutic interventions would be most appropriate at this point? (check one)
A supervised walking program
Cilostazol (Pletal)
Warfarin (Coumadin)
Revascularization

Answer 55

Revascularization

Medication and/or a walking program have been shown to improve functional capacity in patients with symptomatic peripheral artery disease (PAD). However, this patient has critical limb ischemia and needs urgent revascularization. Endovascular therapy of isolated disease below the knee is not recommended. These patients should undergo femoral-tibial bypass. Warfarin is not recommended for the treatment of PAD.

Question 56

A 75-year-old male with a history of hypertension, TIA, and atrial fibrillation sees you for follow-up. Ten days ago he was on vacation in another state when he developed chest pain. He went to a local hospital where he was diagnosed with an ST-elevation myocardial infarction (STEMI) and was taken immediately for cardiac catheterization. He had a drug-eluting stent placed in his left anterior descending artery. He brings some discharge paperwork with him, including a medication list, but has not yet seen a local cardiologist. He is concerned that he is taking too many blood thinners. He feels well and does not have any chest pain, shortness of breath, or excessive bleeding or bruising.

Prior to his STEMI the patient was taking lisinopril (Prinivil, Zestril), 10 mg daily; warfarin (Coumadin), 2.5 mg daily; and metoprolol succinate (Toprol-XL), 25 mg daily. Upon discharge he was instructed to continue all of those medications and to add clopidogrel (Plavix), 75 mg daily, and aspirin, 81 mg daily.

The patient’s vital signs and physical examination are normal except for an irregularly irregular rhythm on the cardiovascular examination. His INR is 2.5.

Which one of the following would be most appropriate at this time? (check one)
Continue the current regimen
Discontinue aspirin
Discontinue clopidogrel
Discontinue warfarin
Decrease warfarin with a goal INR of 1.5–2.0

Answer 56

Continue the current regimen

Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago and he should continue triple therapy.

Question 57

A 75-year-old male smoker presents with intermittent, throbbing pain in both lower extremities that is relieved with rest. An ankle-brachial index is 0.7.

All of the following would be appropriate for this patient EXCEPT: (check one)
apixaban (Eliquis), 5 mg twice daily
enteric-coated aspirin, 81 mg daily
rosuvastatin (Crestor), 10 mg daily
a structured exercise program
tobacco cessation

Answer 57

apixaban (Eliquis), 5 mg twice daily

This patient has confirmed peripheral artery disease (PAD) with an abnormal ankle-brachial index. Guideline-directed therapy for PAD includes low-dose aspirin, moderate- to high-intensity statin therapy, an ACE inhibitor or angiotensin receptor blocker, a structured exercise program, and smoking cessation. Apixaban is a novel oral anticoagulant that is used for stroke prevention in nonvalvular atrial fibrillation as well as treatment of deep vein thrombosis and pulmonary embolism. Apixaban is not used for the treatment of PAD.

Question 58

You order an NT-proBNP level in a patient with symptoms and signs of heart failure. Which one of the following would contribute to a result that is higher than expected? (check one)
Male sex
Elevated BMI
Elevated albumin
Elevated creatinine

Answer 58

Elevated creatinine

Elevated levels of NT-proBNP are known to indicate an increased likelihood of heart failure, and lower levels can rule out heart failure. However, certain patient characteristics can lead to higher levels of NT-proBNP even in healthy individuals. The use of one normal cutoff level for elevated NT-proBNP may not be appropriate. Even healthy female patients and those >65 years of age will have higher levels of NT-proBNP than younger male patients (SOR A).

NT-proBNP is negatively correlated with kidney function as measured by the estimated glomerular filtration rate (GFR) and albumin levels. Patients with a low GFR or a low level of albumin have higher NT-proBNP levels (SOR A). Interestingly, grip strength is negatively correlated with NT-proBNP as well.

A higher BMI is associated with a lower NT-proBNP. Thus, the utility of NT-proBNP to rule out heart failure in obese patients is decreased (SOR A).

Question 59

An 85-year-old female presents to your office with her daughter to discuss the benefits and risks of oral anticoagulation, and to address her fall risk. She has chronic atrial fibrillation and mild cognitive impairment, and meets the criteria for frailty. She lives with the daughter and uses a walker but is independent for basic activities of daily living (ADLs) such as feeding, bathing, and toileting. She does need assistance with paying bills and other instrumental ADLs. Her quality of life is good overall and she enjoys interacting with friends and family. She has been falling about once a month but has not sustained a serious injury.

Her blood pressure is 140/70 mm Hg. She does not use tobacco, alcohol, or illicit drugs. She takes alendronate (Fosamax), 70 mg weekly, and hydrochlorothiazide, 12.5 mg daily. She has been on warfarin (Coumadin) for about 3 years for the atrial fibrillation, with an INR of 2–3. She has not had a stroke. Laboratory findings are significant for a serum creatinine level of 0.9 mg/dL (N 0.6–1.2) and normal liver enzyme levels.

You engage in shared decision making with the patient and her daughter regarding oral anticoagulation. Which one of the following would you advise them about the risks and benefits of oral anticoagulation for this patient? (check one)
The benefits outweigh the risks
The risks outweigh the benefits because of her age
The risks outweigh the benefits because of her frequency of falls
The risks outweigh the benefits because of her cognitive impairment
The risks outweigh the benefits because of her frailty

Answer 59

The benefits outweigh the risks

The European Society of Cardiology 2016 Guidelines for Atrial Fibrillation state that the benefits of oral anticoagulation outweigh the risks in the majority of patients with atrial fibrillation who meet CHA2DS2-VASc criteria for oral anticoagulation. This includes the elderly and patients with cognitive impairment, frailty, or frequent falling. Oral anticoagulation is superior to aspirin for the prevention of stroke, while the bleeding risk with aspirin is not different than that of oral anticoagulation.

Use of the CHA2DS2-VASc criteria significantly increases the number of patients eligible for anticoagulation therapy compared with the CHADS2 scoring system. If there is concern about bleeding risk, particularly in patients older than 65 years of age, the HAS-BLED scoring system has been well validated, with a score of 3 or more indicating that a patient has a high likelihood of hemorrhage. This patient’s HAS-BLED score is 1 (age) and her estimated risk of major bleeding with 1 year of anticoagulation is 1.88%–3.3%. Her adjusted stroke risk is high (4.8% per year), as she has a CHA2DS2-VASc score of 4 (age ≥75, female, history of hypertension).

Question 60

A 75-year-old male presents with a 12-month history of chest pressure radiating to his left arm that occurs predictably after he walks briskly for 2 blocks and goes away with rest. A treadmill stress test suggests coronary artery disease. The patient would prefer medical therapy over revascularization if possible.

The patient’s blood pressure is 120/85 mm Hg. His heart rate is 52 beats/min and has been in the low 50s at past visits. You initiate daily aspirin and a high-intensity statin, and prescribe sublingual nitroglycerin to use as needed for chest pain.

Which one of the following additional treatments is recommended for management of his angina? (check one)
Isosorbide mononitrate
Ivabradine (Corlanor)
Metoprolol succinate (Toprol-XL)
Ranolazine (Ranexa)
Verapamil (Calan)

Answer 60

Isosorbide mononitrate

In addition to aspirin, a high-intensity statin, and sublingual nitroglycerin as needed, patients with chronic stable angina may be treated with β-blockers, calcium channel blockers, and/or long-acting nitrates. β-Blockers and heart rate–lowering calcium channel blockers should be avoided in this patient who already has bradycardia. Ranolazine, which affects myocardial metabolism, is not used as a first-line agent. Ivabradine is not a first-line agent and is used only in patients with heart failure. A long-acting nitrate or a dihydropyridine calcium channel blocker would be appropriate for this patient.

Question 61

One of your patients recently went into atrial fibrillation and you order an echocardiogram. The diameter of which one of the following structures best predicts the likelihood that sinus rhythm will be maintained after successful cardioversion? (check one)
The left atrium
The right atrium
The left ventricle
The right ventricle
The aortic root

Answer 61

The left atrium

If atrial fibrillation is converted back to sinus rhythm, the likelihood of the patient staying in sinus rhythm is best predicted from the diameter of the left atrium on the patient’s echocardiogram. Significant left atrium enlargement means the patient is unlikely to stay in sinus rhythm after successful conversion.

Other factors that predict a lack of success in maintaining sinus rhythm after cardioversion include a longer time in atrial fibrillation before cardioversion, or the presence of underlying heart disease, especially rheumatic heart disease.

Question 62

A 63-year-old male sees you after carotid ultrasonography at a local health fair showed a 50% occlusion of his left proximal internal carotid artery. He has no significant past medical history and has never had a TIA or stroke.

In addition to a healthy diet and exercise, you would recommend (check one)
no further treatment or follow-up
observation, and repeat ultrasonography in 1 year
statin therapy, and repeat ultrasonography in 1 year
statin therapy and referral to a vascular surgeon for consideration of a carotid artery stent
statin therapy and referral to a vascular surgeon for consideration of carotid endarterectomy

Answer 62

statin therapy, and repeat ultrasonography in 1 year

Asymptomatic carotid artery disease is considered a coronary artery disease risk equivalent; therefore,
statin therapy is indicated. Repeating ultrasonography annually to monitor for progression of the disease
and to guide intervention is also considered reasonable. According to the 2014 guidelines for the primary
prevention of stroke issued by the American Heart Association/American Stroke Association, prophylactic
carotid artery stenting might be considered in highly selected asymptomatic patients with >70% carotid
stenosis, but the effectiveness of this intervention compared with statin therapy alone is not well
established. The guidelines also state that it is reasonable to consider carotid endarterectomy for
asymptomatic patients with >70% stenosis if the risks of perioperative complications are low.

Question 63

A 55-year-old male comes to your clinic for follow-up of his recent diagnosis of New York Heart Association class II heart failure with an ejection fraction of 40%. His past medical history is notable only for coronary artery disease. His current medications include the following:

Aspirin, 81 mg daily
Atorvastatin (Lipitor), 80 mg daily
Furosemide (Lasix), 40 mg daily
Lisinopril (Zestril), 40 mg daily
Metoprolol succinate (Toprol-XL), 100 mg daily
Spironolactone (Aldactone), 25 mg daily

Today he is asymptomatic. His vital signs include a temperature of 37.0°C (98.6°F), a blood pressure of 118/75 mm Hg, and a heart rate of 60 beats/min. A physical examination is unremarkable.

Which one of the following additional medications would be most appropriate to reduce his risk for worsening heart failure? (check one)
Dapagliflozin (Farxiga)
Digoxin
Isosorbide dinitrate/hydralazine (BiDil)
Ivabradine (Corlanor)
Liraglutide (Victoza)

Answer 63

Dapagliflozin (Farxiga)

The prevalence of heart failure has continued to increase due to the aging population in the United States. Dapagliflozin is approved by the FDA for the treatment of New York Heart Association class II–IV heart failure with reduced ejection fraction regardless of the presence of diabetes mellitus. Notably, recent studies showed a reduction in the worsening of heart failure and death from cardiovascular causes. Digoxin may be initiated in patients who remain symptomatic despite optimal therapy with other agents, but it does not affect morbidity or mortality. Isosorbide dinitrate/hydralazine provides a mortality benefit in patients who are unable to tolerate an ACE inhibitor or angiotensin receptor blocker. Ivabradine is a sinus node modulator and may reduce hospitalization or cardiovascular death in patients with a resting heart rate 70 beats/min who are taking a β-blocker at maximal dosage. Liraglutide reduces cardiovascular events in patients with diabetes but has no role in the treatment of heart failure.

Question 64

A 25-year-old female has a heart murmur on her postpartum visit. This was first noted at the age of 20. She has been asymptomatic. The murmur is systolic and increases in intensity with Valsalva maneuvers. Further questioning reveals that her two sisters died suddenly from cardiac problems in their early twenties.

This patient should be evaluated for (check one)
dilated cardiomyopathy
hypertrophic cardiomyopathy
peripartum cardiomyopathy
restrictive cardiomyopathy

Answer 64

hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is the most common type of cardiomyopathy, with a prevalence of 1:500.
It involves left ventricular hypertrophy without chamber dilatation. It is caused by autosomal dominant
genetic mutations and is associated with sudden death. Dilated cardiomyopathy is a leading cause of heart
failure but most patients are symptomatic. Peripartum cardiomyopathy may occur during and after
pregnancy and presents as heart failure. Restrictive cardiomyopathy presents with right-sided heart failure.

Question 65

A 71-year-old male is hospitalized for community-acquired pneumonia. He has a past medical history of hypertension and a small, stable abdominal aortic aneurysm.

Which one of the following antibiotics is likely to increase the risk of rupture of this patient’s aneurysm? (check one)
Aztreonam (Azactam)
Ceftriaxone
Doxycycline
Levofloxacin

Answer 65

Levofloxacin

The FDA issued a warning that systemic fluoroquinolones can increase the occurrence of aortic dissections
or ruptures. Drugs in this group should be avoided in patients with an existing aortic aneurysm or in
patients at increased risk for developing an aortic aneurysm unless there are no other treatment options
available. Patients at increased risk include those with peripheral vascular disease, hypertension, Marfan
syndrome, or Ehlers-Danlos syndrome. Similarly, the use of systemic fluoroquinolones should be avoided
in the elderly. Aztreonam, ceftriaxone, and doxycycline are not associated with this side effect (SOR A).

Question 66

A 90-year-old male presents to the emergency department with chest pain, dyspnea, and diaphoresis. He has experienced these symptoms intermittently since his wife died last week. An EKG shows ST elevation in the anterior leads, and cardiac enzymes are elevated. An echocardiogram shows apical ballooning of the left ventricle. Cardiac catheterization does not reveal coronary vascular disease. You plan to discharge the patient after observation overnight.
Which one of the following would be the most appropriate management of this patient’s stress-induced (Takotsubo) cardiomyopathy after discharge? (check one)
Home medications only
A cardiac event monitor to detect any rhythm abnormalities
A diuretic, ACE inhibitor, and β-blocker until his symptoms and the abnormalities seen on the echocardiogram resolve
A statin, diuretic, ACE inhibitor, and β-blocker to be continued indefinitely
Pacemaker placement

Answer 66

A diuretic, ACE inhibitor, and β-blocker until his symptoms and the abnormalities seen on the echocardiogram resolve

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, can develop following
emotional distress and is characterized by the abrupt onset of dysfunction of the left ventricle. The clinical
presentation and laboratory studies can mirror acute coronary syndrome and should be treated similarly.
Once symptoms and cardiac abnormalities resolve, treatment is no longer indicated and may be withdrawn
if there are no signs of coronary disease. Because this patient currently has cardiomyopathic abnormalities,
a diuretic, ACE inhibitor, and -blocker are indicated. Ambulatory cardiac monitors are not indicated for
this patient with a known diagnosis of Takotsubo cardiomyopathy. A pacemaker is not indicated in the
absence of arrhythmias caused by conduction abnormalities.

Question 67

A 54-year-old male develops chest pain while running. He is rushed to the emergency department of a hospital equipped for percutaneous coronary intervention. An EKG shows 3 mm of ST elevation in the anterior leads. He is diaphoretic and cool with ongoing chest pain. His blood pressure is 80/50 mm Hg, his pulse rate is 116 beats/min, and his oxygen saturation is 98% on room air.

You would immediately administer (check one)
a β-blocker
dual antiplatelet therapy and an anticoagulant
intravenous fibrinolytic therapy
an intravenous vasopressor

Answer 67

dual antiplatelet therapy and an anticoagulant

This patient is likely experiencing an acute anterior wall myocardial infarction with possible incipient
cardiogenic shock. Along with initiating the hospital’s protocol for myocardial infarction, immediate
treatment should include dual antiplatelet therapy with a 325-mg dose of nonenteric aspirin, a P2Y12
inhibitor (clopidogrel, prasugrel, or ticagrelor), and an anticoagulant (unfractionated heparin or
bivalirudin). Given the possibility of cardiogenic shock, -blockers should not be used. Unless more than
a 2-hour delay in percutaneous coronary intervention is expected, fibrinolytics should not be administered.
An intravenous vasopressor is not indicated.

Question 68

A 67-year-old male presents to your office because of fatigue and a syncopal episode. His vital signs in the office are normal. An examination reveals a harsh systolic murmur best heard over the second right intercostal space radiating to the neck. Echocardiography confirms your suspected diagnosis.

Which one of the following is the only treatment that improves mortality with this condition? (check one)
β-Blockers
Antimicrobial prophylaxis for bacterial endocarditis
Aortic valve replacement
Mitral valve repair
Ventricular septal defect closure

Answer 68

Aortic valve replacement

This patient has symptomatic severe aortic stenosis. The only treatment that improves this condition is
aortic valve replacement (SOR B). Transcutaneous aortic valve replacement may be an alternative for
patients who are not candidates for surgery. -Blockers must be used with caution due to the risk of
depressing left ventricular systolic function. They have not been shown to improve mortality. Antimicrobial
prophylaxis is not indicated unless a patient has undergone valve replacement or has a history of
endocarditis (SOR C). Atrial fibrillation is common in patients with aortic stenosis and rate control is
important. Symptomatic mitral valve regurgitation may require mitral valve intervention. However, these
murmurs are holosystolic, high pitched, and best heard at the cardiac apex. A ventricular septal defect can
cause a loud holosystolic murmur with an associated thrill heard best at the third/fourth interspace along
the sternal border.

Question 69

An 80-year-old former smoker sees you for a 6-month follow-up for hypertension. He is taking carvedilol (Coreg), amlodipine (Norvasc), and low-dose aspirin. His home blood pressure readings have been 130–150/80–90 mm Hg. Over the last 4 months he has developed pain in his thighs when walking to his mailbox a block away. The pain resolves after he sits for a few minutes.

On examination he has a blood pressure of 135/85 mm Hg, a heart rate of 72 beats/min, a BMI of 26 kg/m2, and an oxygen saturation of 95% on room air. Examinations of the heart and lungs are normal. There is dependent rubor of both legs but posterior tibial pulses are palpable. No ulcerations are noted. You obtain ankle-brachial indices of 0.85 on the left and 0.80 on the right. You prescribe a daily walking program.

Which one of the following additional measures would be most appropriate for this patient? (check one)
Add atorvastatin (Lipitor)
Add clopidogrel (Plavix)
Add lisinopril (Prinivil, Zestril) to achieve a goal blood pressure <120/80 mm Hg
Discontinue aspirin and start warfarin (Coumadin)
Refer to a vascular surgeon

Answer 69

Add atorvastatin (Lipitor)

Management of asymptomatic peripheral artery disease (PAD) should initially be conservative and should
include a walking program (SOR A), smoking cessation, and a healthy diet. Statins should be started for
all patients with PAD regardless of their LDL-cholesterol levels (SOR A). High-intensity statins should
be used if tolerated. A single antiplatelet agent is recommended for patients with PAD. Both aspirin and
clopidogrel are effective in the reduction of stroke, but the combination of the two is recommended only
after revascularization surgery.
Blood pressure control is indicated in patients with PAD but no antihypertensive class is clearly superior
to another, although there is some evidence that ACE inhibitors may have additional benefits in terms of
walking and pain. In an 80-year-old patient, lowering blood pressure below 120/80 mm Hg can be
associated with significant side effects, including a greater risk of falls. Anticoagulants have not been
shown to reduce the risk of major cardiovascular events in patients with PAD and they increase the risk
of life-threatening bleeding. Referral to a vascular surgeon or for angiography is indicated if conservative
therapy fails or symptoms worsen acutely, pain occurs at rest, or the patient develops ulcerations or loss
of tissue.

Question 70

A 65-year-old male is discharged following placement of a drug-eluting stent in the left anterior descending artery. Which one of the following is NOT appropriate first-line therapy in this patient? (check one)
Aspirin plus clopidogrel (Plavix)
Diltiazem (Cardizem)
Metoprolol
Rosuvastatin (Crestor)

Answer 70

Diltiazem (Cardizem)

β-Blockers are first-line therapy for antihypertensive therapy and antianginal therapy, whereas calcium channel blockers are second-line agents in patients who are unable to tolerate β-blockers. Calcium channel blockers may also be added as additional therapy when hypertension and angina symptoms are not controlled with β-blockers alone. Patients who have been treated with a drug-eluting stent require dual antiplatelet therapy for 6–12 months. All patients with coronary artery disease should be on high-dose statin therapy.

Question 71

In older patients with aortic stenosis and a systolic murmur, which one of the following would
be most concerning? (check one)
Weight loss
Frequent urination
Jaundice
Worsening headache
Exertional dyspnea

Answer 71

Exertional dyspnea

When symptoms begin to appear in a patient with aortic stenosis the prognosis worsens. It is therefore
important to be aware of systolic murmurs in older patients presenting with exertional dyspnea, chest pain,
or dizziness. This can be the first presentation of a downward spiral and the need for rapid valve
replacement. Weight loss, frequent urination, jaundice, and worsening headache are not as closely
associated with a generally worse outlook for patients with aortic stenosis.