Internal medicine - Cardiology Flashcards

Question

INT - 1.25 A patient was admitted to the Emergency Department because of a palpitation that started three hours earlier. On his ECG an atrial fibrillation with rapid (150 bpm) ventricular response was seen. His blood pressure was 130/90 Hgmm. In the patient’s history there wasn’t anything that indicated structural heart disease. What is the best first step in this situation? A) pharmacological cardioversion B) immediate electrical cardioversion C) coronarography D) immediate anticoagulation to prevent thromboembolism E) cardiac stress test

Answer 1

ANSWER A) pharmacological cardioversion EXPLANATION The patient is hemodynamically stable, doesn’t require immediate electrical cardioversion and long-term anticoagulation is not needed in atrial fibrillation that is only a few hours old. Exercise testing and coronarography are later diagnostic steps if ischemic heart disease is suspected. Pharmacological cardioversion is the logical first step.

Answer 2

ANSWER B) atrial fibrillation EXPLANATION The prevalence of atrial fibrillation is 0.4-14% depending on the age, which means that it the most common permanent (longer than 30 seconds) arrhythmia. Everyone has ventricular extrasystoles but they are not permanent. The other arrhythmias aren’t nearly as common as atrial fibrillation.

Answer 3

ANSWER B) torsade de pointes ventricular tachycardia induced by the medications EXPLANATION Both Class III antiarrhythmic agent amiodarone and fluoroquinolone antibiotics can prolong the QT interval (long QT syndrome). Their concomitant administration increases the chance of polymorphic ventricular tachycardia (torsade de pointes), syncope because of ventricular arrhythmia and sudden cardiac death. At the onset of these symptoms the therapy or therapies should be immediately discontinued.

Answer 4

ANSWER A) pathologic Q waves EXPLANATION ST segment elevation with lasting chest pain are characteristic of ST Segment Elevation Myocardial Infarction. However, in Non-ST-Segment Myocardial Infarction the ECG findings range from ST segment depression to T wave inversion. Sometimes the first ECG recording of a severe myocardial infarction already shows ventricular fibrillation. The manifestation of pathologic Q waves takes hours, sometimes days.

Answer 5

ANSWER C) previous myocardial infarction EXPLANATION The typical ECG findings of acute myocardial ischemia are ST segment elevations and depressions. ST segment depression and T wave abnormalities (changes in amplitude, inversion) indicate subendocardial ischemia. During the progression of a myocardial infarction these changes are accompanied by a decrease in R wave amplitude, the appearing of pathologic Q waves and T wave inversion. In the recovery phase of the myocardial infarction the ST segment becomes isoelectric and in most cases the T wave normalizes, too. The pathologic Q wave is permanent. If the ST segment stays elevated for more than 2-3 weeks after the onset of the symptoms, a left ventricle aneurysm is likely.

Answer 6

ANSWER B) exercise test EXPLANATION The patient’s symptoms are most likely to be caused by significant coronary artery disease. Unless stress testing is contraindicated, an exercise test should be the next step. If significant ST segment changes appear during the test, then an invasive diagnostic procedure is necessary. If the results of the stress test are questionably or the symptoms are atypical, diagnostic imaging tests (echocardiography, coronary CT angiography) or stress tests with imaging (stress echocardiography, stress MRI) should be considered. Holter ECG is not suitable to detect significant coronary artery disease, this test is only recommended if we need additional information (e.g. the duration of ischemic burden, possibility of Prinzmetal angina).

Answer 7

ANSWER C) atropine EXPLANATION Myocardial infarction, especially posterior wall infarction often induces bradycardia. These usually respond well to atropine since they are partially caused by an increase in vagal tone. Sympathomimetic drugs should be avoided because they raise the myocardial oxygen demand which is unfavorable in ischaemia. Although diaphyllin elevates the heart rate but it should be avoided in myocardial infarction because of its proarrhythmogenic effect.

Answer 8

ANSWER B) cough EXPLANATION The most common side effect of ACE inhibitor therapy is cough (5-10%). It is a consequence of the elevated bradykinin concnentration (its metabolism is inhibited). All of the other side effects are rare or non-existent.

Answer 9

ANSWER E) All of the answers are correct EXPLANATION Patients with aortic insufficiency have increased cardiac output because of the regurgitated volume. In thyreotoxicosis the thyroid hormone accelerates the circulation which also leads to a higher cardiac output. Beriberi (vitamin B1 deficiency) can induce a special form of dilated cardiomyopathy with extremely high cardiac output, so all of these conditions can lead to systolic hypertension. Arteriosclerosis causes systolic hypertension through the increased vascular resistance.

Answer 10

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Arteriosclerosis, Marfan’s snydrome and vascular syphilis can all cause aortic aneurysm. All of these diseases damage the arterial wall’s tunica media that leads to its weakening, the loss of its elastic elements and the consequent dilation (aneurysm). Aneurysm formation is unusual in giant-cell arteritis, its characteristic feature is the throbbing pain of the temporal arteries.

Answer 11

ANSWER E) All of the answers are correct EXPLANATION The most common causes of pericarditis are tuberculosis, uremia, metastatic cancer and (less frequently) transmural myocardial infarction.

Answer 12

ANSWER E) All of the answers are correct EXPLANATION Secondary or specific cardiomyopathies can be caused by endocrine disorders, e.g. hyperthyroidism (dilated cardiomyopathy); deficiency diseases, e.g. beriberi (vitamin B1 deficiency) might induce dilated cardiomyopathy while amyloidosis can precipitate restrictive infiltrative cardiomyopathy; and metabolic (storage) diseases, like glycogenosis can lead to hypertrophic-restrictive secondary cardiomyopathy.

Answer 13

ANSWER E) All of the answers are correct EXPLANATION Due to the inhibition of the ACE the serum level of angiotensin II decreases in parallel with an increase in the production of bradykinin and a reduction in blood pressure. In heart failure the increased pre- and afterload lead to the gradual dilation and remodeling of the left ventricle and its ejection fraction progressively deteriorates. Treatment with ACE-inhibitors decelerates this process.

Answer 14

ANSWER C) Answers 2 and 4 are correct EXPLANATION Aspirin works by inhibiting the cyclooxigenase enzyme and by blocking the synthesis of prostacyclin. Several multicenter trials proved that low-dose aspirin reduces cardiovascular mortality. Heparin enhances the activity of antithrombin-III and thus has an anticoagulant effect by inhibiting the fibrinogen-thrombin reaction. Both intravenous and subcutaneous heparin have a rapid onset of action. Fibrinolytics (e.g. alteplase) are used to dissolve fibrin-bound thrombin.

Answer 15

ANSWER B) Answers 1 and 3 are correct EXPLANATION Furosemide and chlortalidone can occasionally provoke gout by reducing uric acid excretion. Spironolactone can cause gynecomasty through its antialdosterone effect. Etacrynic acid (and furosemide) therapy can lead to temporary, and in some cases permanent hearing loss.

Answer 16

ANSWER E) All of the answers are correct EXPLANATION The risk factors of ischemic heart disease are variables that have a positive correlation with the development and progression of atherosclerosis. These are: smoking, lack of physical exercise, obesity, hyperlipidemia (hypercholesterolemia, hypertriglyceridemia), diabetes mellitus, hypertension, age, male sex, family history (a history of coronary heart disease or its risk factors in the family).

Answer 17

ANSWER E) All of the answers are correct EXPLANATION Heart-rate-lowering beta-blockers reduce both mortality and (through their antiarrhythmic effect) the risk of sudden cardiac death in patients after acute myocardial infarction. They also reduce the oxygen demand of the myocardium, decrease myocardial ischaemia and are especially recommendatory in cases of hypertension and ventricular arrhythmias. It has also been proven that inhibition of platelet aggregation has a favorable effect on survival, microcirculation, vasoconstriction and atherogenesis. Inhibition of HMG-CoA reductase: by lowering serum cholesterol statins mitigate and even reverse atherogenesis. Several clinical trials proved that reducing serum total cholesterol, LDL and triglycerides (all major risk factors of ischaemic heart disease) improve the survival and quality of life of patients suffering from coronary artery disease. 4S (Scandinavian Simvastatin Survival Study) was the first large-scale (n=4444) clinical trial to prove their favorable effect on survival: mortality decreased by 30%, coronary-mortality by 42% and myocardial infarction by 37% during the 8-year follow-up. ACE inhibitors: their most important effect is to stop the postinfarction remodeling, therefore (unless contraindicated) all patients who have suffered a myocardial infarction should be given ACE inhibitors as soon as possible.

Answer 18

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Methods to measure the metabolism of the myocardium in vivo: positron-emission tomography (PT) and thallium-201 myocardial perfusion scintigraphy. Low-dose dobutamine stress helps the motion of the viable myocardium walls through its positive inotropic effect. PET is highly sensitive and specific in detecting perfusion-metabolism mismatches. Myocardial perfusion scintigraphy using Tl-201 reinjection is highly sensitive but it is less specific while dobutamin stress testing is very specific but has a slightly lower sensitivity. Conventional Doppler ultrasound isn’t suitable for determining myocardial viability, but the newer tissue Doppler ultrasound seems to be promising.

Answer 19

ANSWER B) Answers 1 and 3 are correct EXPLANATION The 1. and 3. answers are absolute contraindications of exercise stress tests. In chronic heart failure symptom-limited exercise testing is a safe and optimal way to measure the patient’s current condition. Beta-blocker treatment (an essential medication of ischemic heart disease) doesn’t contraindicate exercise stress testing but it limits the maximum achievable heart rate and might prevent the appearance of repolarization abnormalities and arrhythmias.

Answer 20

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION The first-line diagnostic test of ischemic heart disease is exercise testing. If the results are questionable or if the test is contraindicated then the next step is stress echocardiography using dobutamine. Ischemic signs (ST segment depression or wall motion abnormalities) without any symptoms indicate silent ischemia. Holter ECG monitor can be used to detect episodes of angina to determine a silent/symptomatic ratio. Ambulatory Blood Pressure Monitoring, a 24-hour measurement of blood pressure is obviously unable to detect silent ischemia.

Answer 21

ANSWER E) All of the answers are correct EXPLANATION Cardiogenic shock can be an early complication of acute myocardial infarction. Ventricular fibrillation can be an early ischemic complication and because of the ischemic scarring it can present in the later stages, too. Left ventricular aneurysm is considered a late complication. Pericardial effusion typically develops 4 to 6 weeks after the infarction and it is a consequence of pericarditis (Dressler’s syndrome).

Answer 22

ANSWER E) All of the answers are correct EXPLANATION Early stages of heart failure are treated conservatively with medication. However, in severe heart failure non-pharmacologic treatment options (in addition to pharmacotherapy) have recently been given a more important role. Examples are cardiac resynchronization therapy, mechanical circulatory support devices and as a final option, heart transplant.

Answer 23

ANSWER B) Answers 1 and 3 are correct EXPLANATION Stress and smoking are well-known risk factors of atherosclerosis. AV-nodal reentry tachycardia doesn’t have a role in the development of atherosclerosis, but if it presents frequently and for longer durations, it might cause tachycardia-induced cardiomyopathy. Hypotension, unlike hypertension, is not an atherosclerotic risk factor

Answer 24

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Statins can reduce serum cholesterol levels. They work by inhibiting the HMG-COA reductase and the intracellular cholesterol production. Currently the most effective statins are rosuvastatin and atorvastatin. Ezetimibe lowers serum cholesterol levels by blocking the absorption of cholesterol in the small intestine. They are mostly used in combination with statins. Ivabradine acts by blocking the If (funny) Na-K channel, it is used to decrease resting sinus heart rate in ischemic heart disease.

Answer 25

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Elevated serum triglyceride levels were considered to be the risk factors solely of pancreatitis but recently it has been recognized as a risk factor of coronary heart disease. It can be lowered by diet, fibrates and niacin. Statins (with a few exceptions) only have a modest effect on triglyceride levels. Moderate to heavy alcohol intake raises triglyceride levels.

Answer 26

ANSWER E) All of the answers are correct EXPLANATION Prinzmetal angina is caused by coronary vasospasm that can affect healthy and stenotic arteries, too. The symptoms usually present in the early morning at rest and temporary ST segment elevation can be seen on the ECG.

Answer 27

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Blood clots that break off from deep vein thrombi can cause pulmonary embolism and infarction. Crural ulcers are local complications. Raynaud’s syndrome consists of vasospastic attacks, it is not a thromboembolic disease.

Answer 28

ANSWER E) All of the answers are correct EXPLANATION Atherosclerosis can cause a wide range of symptoms depending on which vessels are affected.

Answer 29

ANSWER E) All of the answers are correct EXPLANATION ST segment elevation in the precordial leads is not exclusive for myocardial infarction. Pericarditis and myocarditis can cause ST elevation (sometimes in every lead), too. Acute pancreatitis might present with aspecific ST segment and T wave abnormalities. Pulmonary embolism can mimic the ECG findings of a posterior wall myocardial infarction.

Answer 30

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION CK-MB, troponin and LDH serum levels can be used in the diagnostic workup of myocardial damage. Elevated alkaline phosphatase levels indicate gastrointestinal, bone or hematologic diseases.

Answer 31

ANSWER C) Answers 2 and 4 are correct EXPLANATION Chest pain with ST elevation might be the sign of myocardial infarction and aortic dissection, too. Peptic ulcers and mitral valve prolapse can both cause chest pain but they don’t cause ST segment elevation.

Answer 32

ANSWER D) Only answer 4 is correct EXPLANATION The onset of Dressler’s syndrome is typically three weeks after myocardial infarction and it presents with recurring chest pain and fever but cardiac marker levels are usually normal. In reinfarctions and pulmonary embolism cardiac enzymes are often elevated. Although lobar pneumonia can not be ruled out, in the combination of the above-mentioned findings you should always think of Dressler’s syndrome at first instead of other, less likely diagnoses.

Answer 33

ANSWER E) All of the answers are correct EXPLANATION Significant mitral regurgitation can lead to the dilation of every heart chamber because of the substantial volume overload. A number of acute mitral regurgitations are caused by infective endocarditis through the destruction of the valve. In hemodynamically significant mitral regurgation the left atrial pressure can be notably elevated. The left ventricle ejection fraction might be preserved for a long time because during the ventricular systole the left ventricle empties itself quite easily into the left atrium. Symptomatic cases with significant left ventricle dilation might require surgical solutions.

Answer 34

ANSWER C) Answers 2 and 4 are correct EXPLANATION Mitral stenosis increases the risk of thrombus formation in the left atrium. It can be a late complication of rheumatic fever. The narrowing of the mitral valve predisposes to atrial fibrillation. Muffled first heart sound and mesosystolic click are not characteristic auscultation findings of mitral stenosis. A loud first heart sound and an opening snap can be heard in patients with mitral valve stenosis.

Answer 35

ANSWER E) All of the answers are correct EXPLANATION During the echocardiographic assessment of isolated aortic stenosis the left ventricle has a normal size, but concentric left ventricle hypertrophy can be visualised. The parasternal diameter of the left atrium is often abnormally large. The pathologic transvalvular gradient can be measured in four chamber view at the level of the aortic valve.

Answer 36

ANSWER E) All of the answers are correct EXPLANATION During the echocardiographic assessment of isolated mitral stenosis the following signs are characteristic: increased left atrium end-systolic diameter and the unidirectional movement of the anterior and posterior leaflets in M-mode. A pathologic transvalvular gradient can be measured at the level of the mitral valve during diastole. In 2D-echo the mitral calcification can be visualised.

Answer 37

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Mitral valve prolapse syndrome is quite common in Marfan’s syndrome and it can cause chest pain and ventricular extrasystoles. The opening snap cannot be heard, as it can be evidence of mitral and tricuspidal stenosis, too.

Answer 38

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Point mutations of the genes that code different parts of the sarcomer (beta-myosin heavy chain, troponin T, tropomyosin, myosin-binding protein C) can be detected in most cases of hypertrophic cardiomyopathy. Septal hypertrophy can cause left ventricle outflow obstruction and a systolic gradient. The sudden cardiac deaths of hypertrophic cardiomyopathy patients are most likely caused by ventricular arrhythmias. Beta-blockers are the recommended first-line therapy because with the right dosage they decrease ventricular contractility and they can reduce the outflow obstruction. In addition to this they have antiarrhythmic potential, too

Answer 39

ANSWER C) Answers 2 and 4 are correct EXPLANATION Basically everyone has ventricular extrasystoles. They are considered important only if they accompany organic heart diseases, especially after myocardial infarction. So far no medication has been proven to improve survival by decreasing the number of ventricular extrasystoles and a few of them (Class Ic agents) worsened mortality. Ventricular extrasystoles that present without any symptoms and/or without organic heart disease don’t require any treatment, but in cases of frequent, symptomatic, monomorphic extrasystoles ablation therapy should be considered to prevent tachycardia-incuded cardiomyopathy and to improve quality of life.

Answer 40

ANSWER B) Answers 1 and 3 are correct EXPLANATION Ventricular tachycardia occurs as wide QRS-complex tachycardia or supraventricular tachycardia in case of bundle branch block or accessorius pathway conduction. The more common mechanism is ventricular tachycardia, this is especially true in organic heart disease, primarily in post-infarction state, this helps in the differential diagnosis based on probability. The sure sign of ventricular tachycardia is atrioventricular dissociation. Dissociated p-waves and QRS-complexes, fusion and capture beats can be observed on the ECG, the Cannon-wave on the jugular pulse can be seen during physical examination and the I. sound (cannon sound) with varying intensity can be heard during auscultation which indicate the atrioventricular asynchrony. The frequency of the tachycardia and the hemodynamic status of the patient doesn’t help to differentiate.

Answer 41

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION If we have doubts about the mechanism of the wide QRS tachycardia, we make less of a mistake if we treat as ventricle tachycardia, because the medicines (amiodarone, procainamide, lidocaine) used in the treatment of ventricle tachycardia is effective as well in some cases of supraventricular tachycardia, but at least do not worsen the patient’s state. Contrary to this, the intravenous Verapamil which is most commonly used as the treatment of supraventricular tachycardia may cause immediate circulatory collapse in case of ventricle tachycardia. Carotid-sinus massage can terminate the supraventricular tachycardia which involve the AV-node, in case of ventricle tachycardia it doesn’t help, but doesn’t worsen the patient’s state. In case of hemodynamic instability any kind of tachycardia (regular or irregular, narrow or wide QRS-complex) require cardioversion with synchronized DC-shock. Echocardiography is a basic test method for evaluation of the organic heart status in any kind of arrhythmia, but not during acute treatment, but rather after it.

Answer 42

ANSWER E) All of the answers are correct EXPLANATION Atrial fibrillation could be associated with all the listed disease. The most common etiologic factor is the ischemic heart disease and hypertension which is not listed here.

Answer 43

ANSWER D) Only answer 4 is correct EXPLANATION The 4th point contains the correct definition of pro-arrhythmia. The risk of pro-arrhythmia partly depends on the patient and partly depends on the medication used. Bad left ventricular function, active ischemia increases the risk of pro-arrhythmia. Among the medicines chinidin has the largest, beta blockers have the smallest pro-arrhythmic potential.

Answer 44

ANSWER E) All of the answers are correct EXPLANATION All the listed answers are correct. In the congenital form the most important element of the clinical picture is the recurrent syncope (physical and psychic load), mostly in childhood, caused by polymorph tachycardia and sudden death, which show familiar accumulation. The more common form is the autosomal dominant inherited Romano-Ward syndrome, less common is the recessive inherited, deafness associated Jervell-Lange-Nielsen syndrome.

Answer 45

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION Digitalis is not appropriate for treating ventricular tachycardia. The statements in the first three point are true.

Answer 46

ANSWER E) All of the answers are correct EXPLANATION Although left chest pain is typical during myocardial infarction, primarily the infarction of the posterior wall often begins with epigastric and back pain. Hemodynamic changes during the infarction (transient cardiac output decrease) are usually experienced by the patient as sweating.

Answer 47

ANSWER C) Answers 2 and 4 are correct EXPLANATION Persistent chest pain unresponsive to nitrate and associated with ST-elevation is an indication of percutaneous coronary intervention. Additional tests will only delay the launch of this therapy, therefore they are causeless. During all acute ischemic cases strict observation is required in order to remedy all possible arrhythmia.

Answer 48

ANSWER B) Answers 1 and 3 are correct EXPLANATION During acute myocardial infarction decreased cardiac output often leads to pulmonary circulation edema, pulmonary edema. The first choice drug to treat this, is fast acting diuretic, which should be supplemented with oxygen enrichment of the breathed air. Nitrate may be beneficial for reducing the pre-load but instead of the difficult to control transdermal route, intravenous infusion should be chosen. Beta-blocker should be used carefully in myocardial infarction. It is contraindicated to use in case of heart failure, bradyarrhythmia or hypotension.

Answer 49

ANSWER C) Answers 2 and 4 are correct EXPLANATION Big clinical trials proved the mortality reducing effects of ACE-inhibitors and beta-blockers in heart failure. Despite the good symptomatic effect of the diuretics, they do not affect mortality, furthermore nifedipine worsens the mortality in the same group of patient.

Answer 50

ANSWER A) Answers 1, 2 and 3 are correct EXPLANATION In case of untreated hypertension or aortic stenosis the excessive loading of the left ventricle musculature, in case of viral myocarditis the reduced contractility due to ventricular dysfunction (inflammation) could be the cause of heart failure. Deep vein thrombosis doesn’t affect directly the left ventricle performance.

Answer 51

ANSWER C) Answers 2 and 4 are correct EXPLANATION Because of the right-sided heart failure peripheral edema (for example leg edema), and because of the left-sided heart failure pulmonary edema and consequential dyspnoe can occur.

Answer 52

ANSWER B) Answers 1 and 3 are correct EXPLANATION Nocturia might occur for a patient with heart failure, as the insufficient circulation can reduce and empty the edema at nighttime rest. The increase in adrenergic hormone levels as the consequence of peripheral hypoperfusion causes tachycardia. The heart then provides the required cardiac output not by the pulse volume, but by the increasing heart rate.

Answer 53

ANSWER INT - 1.79 - amiodarone - D) INT - 1.80 - furosemide - C) INT - 1.81 - urapidil (Ebrantil) - A) INT - 1.82 - pacemaker therapy - B)

Answer 54

ANSWER INT - 1.83 - Mitral valve prolapse - D) INT - 1.84 - Detect of rejection after heart transplantation - B) INT - 1.85 - Post myocardial infarction, detection of viability - C) INT - 1.86 - Sick sinus syndrome - E) INT - 1.87 - Suspected intracardiac thrombus (for example underlying chronic embolisation) - A)

Answer 55

ANSWER INT - 1.88 - Bronchoconstriction - C) INT - 1.89 - Cold extremities - C) INT - 1.90 - Pulmonary fibrosis - A) INT - 1.91 - Hyperthyroidism - A) INT - 1.92 - Angioneurotic edema - B) INT - 1.93 - Dry cough - B)

Answer 56

ANSWER INT - 1.94 - Reduction of the frequency and the left ventricular contractility - C) INT - 1.95 - Mainly reducing the preload - D) INT - 1.96 - Inhibiting the platelets aggregation - A) INT - 1.97 - They have lipid reducing and pleiotropic effect - B)

Answer 57

ANSWER INT - 1.98 - Antiarrhythmic effect - D) INT - 1.99 - Platelet aggregation inhibiting effect - A) INT - 1.100 - „funny” Na-K-channel inhibitor - B) INT - 1.101 - Anticoagulant effect - C)

Answer 58

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION Both parts of the sentence are correct. In aortic stenosis the left ventricle has an increased load, under the narrow aortic valve in the left ventricle there is a greater pressure which leads to left ventricle hypertrophy. The left ventricle hypertrophy can be most easily and accurately established with echocardiography.

Answer 59

ANSWER C) The first part is correct, the second one is wrong EXPLANATION Most of the diuretics used during heart failure treatment cause hypokalemia, therefore the laboratory monitoring of serum electrolytes (se-K,-Na) is recommended, during the treatment potassium replacement can be necessary. Other diuretics, called „potassium sparing” such as Verospiron, Aldacton, Triamteren doesn’t cause hypokalemia, but awareness of serum electrolyte levels is also recommended (possible hyperkalemia!).

Answer 60

ANSWER E) Both of them are incorrect EXPLANATION After myocardial infarction associated with left ventricular aneurysm, it’s necessary to adjust anticoagulant therapy due to risk of developing intracardial thrombus.

Answer 61

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION Myocardialis infarctuson átesett betegeknél aspirin és β-blokkoló alkalmazása szignifikánsan csökkenti a.

Answer 62

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION The SOLVD Study proved in mild and moderate, the CONSENSUS Trial proved the decrease of mortality in case of severe heart failure and therefore the use of ACE inhibitors is indicated also in NYHA I-IV. stage.

Answer 63

ANSWER B) Both of them are correct, but there is no causal relationship between them EXPLANATION Life-threatening arrhythmias are common in heart failure, it can lead to sudden death, but also with electrophysiological examination can’t always predict the predisposition to sudden cardiac death. There is no correlation between the two statements.

Answer 64

ANSWER B) Both of them are correct, but there is no causal relationship between them EXPLANATION Abnormal prolongation of the QT-interval can be caused by drugs or in the congenital forms can be caused by Na- and K-channel dysfunction. The prolonged QT-interval is really predisposing to the "torsades de pointes" type (potentially lethal) ventricular tachycardia. The second part of the sentence is also true, but there is no cause and effect relation between the two.

Answer 65

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION The systemic use of nitrates primarily causes the small veins expansion, their arterial effect rather develop at intracoronary delivery. Based on this, with their pre-load reducing effect they can reduce the myocardium oxygen demand in angina pectoris.

Answer 66

ANSWER C) The first part is correct, the second one is wrong EXPLANATION The angina pectoris which was first described by Prinzmetal is called vasospastic or variant angina (1959). The cause is the large coronary arteries spasm, which occurs during resting (often at dawn-in a variant manner), when there is no load. It has been clinically not proven that all the arteries have increased spasticity, but it could be developed due to general endothelial dysfunction

Answer 67

ANSWER D) The first part is wrong, the second one is correct EXPLANATION The level of CK starts to elevate 3 hours after the myocardial infarction. The significance of this is that the indication of thrombolysis is beyond the optimum. The situation is similar with the recently used troponin T-, and troponin I-level measurements, though they show slightly earlier and more sensitively the myocardial necrosis.

Answer 68

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION Silent ischemic and symptomatic angina practically don’t differ from each other in pathology and prognosis, so they should be treated in the same way.

Answer 69

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION We often indicate TEE before cardioversion of atrial fibrillation to exclude atrial thrombus. If we detect thrombus during this that could require the postponement of the cardioversion and the indication of immediate anticoagulant

Answer 70

ANSWER E) Both of them are incorrect EXPLANATION In the diagnostic of infectious endocarditis transesophageal and transthoracic echocardiography doesn’t equal to each other, because TEE is more sensitive and more specific in this disease. The reason for this is that TEE examines the heart more closely, and during its application there is very little absorption and diffusion medium between the heart and the transducer probe, so the image quality and resolution is much better. The two methods examine the heart from different directions.

Answer 71

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION TEE has a prominent role in the diagnosis of aortic dissection. With this test method, most part of the thoracic aorta can be examined from the esophagus with good resolution. Another advantage of this method is that it is less invasive than angiography.

Answer 72

ANSWER E) Both of them are incorrect EXPLANATION The laboratory diagnostic of infectious endocarditis requires to take series of hemoculture. Antibiotic treatment can be initiated when the breeding results two identical pathogens. Once in a while only from some of the hemocultures can the pathogen be bred, the other results may be negative. Previous antibiotic treatment could significantly reduce the chances of detection of the pathogens.

Answer 73

ANSWER C) The first part is correct, the second one is wrong EXPLANATION In hemodynamically significant aortic stenosis the presence of angina pectoris and syncope are bad prognostic signs. This group of patients have high mortality without surgery. The surgical solution also has a good influence on the long-term pathology of the disease at this stage, angina pectoris is not a contraindication of the surgery.

Answer 74

ANSWER C) The first part is correct, the second one is wrong EXPLANATION For fertile women who have acquired valvular heart disease, biological valve replacement can be indicated, which doesn’t require long-term anticoagulant therapy. Mechanical prosthetic valve replacement requires anticoagulant therapy. In the first trimester of pregnancy coumarin anticoagulant treatment may cause fetal damage. Mechanical prosthetic valves do not cause fetal damage by autoimmune mechanism.

Answer 75

ANSWER E) Both of them are incorrect EXPLANATION Beta blockers are the first choice medications in the treatment of hypertrophic cardiomyopathy. Applying these medications in a correct dose decreases the outflow tract obstruction of the left ventricle and improves clinical symptoms.

Answer 76

ANSWER B) Both of them are correct, but there is no causal relationship between them EXPLANATION Eosinophilia in the bloodstream is often observed in Löffler type of endocarditis. Substances released from the eosinophilic granules first lead to endocardial necrosis, which is followed by the thrombotic and endocardial fibrotic phase. This last disorder causes restrictive type of myocardial dysfunction. The statement and the explanation are correct, but there is no direct cause and effect relationship between them.

Answer 77

ANSWER E) Both of them are incorrect EXPLANATION There is no need for potassium supplementation in all type of diuretics, because the use of so-called „potassium sparing” diuretics (spironolactones, triemteren) usually do not justify potassium supplementation. Potassium excretion with urine is reduced when using the same group of medication.

Answer 78

ANSWER C) The first part is correct, the second one is wrong EXPLANATION Long-term use of ACE-inhibitors reduce the left ventricle hypertrophy. As the effect of the same group of drugs, serum bradykinin level is increased as these agents inhibit bradykinin degradation. 5-10% of treated patients develop hacking cough which is explained by higher bradykinin levels.

Answer 79

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION Radiofrequency ablation results definitive healing in case of accessory pathway driven arrhythmia, AV-nodal reentry tachycardia, atrial flutter or atrial tachycardia. In case of atrial fibrillation AV-node ablation is a palliative, ventricular rate reducing intervention. In practice, despite of this the first usual therapy is medication, due to the limitations of the possibility of the interventional treatment, if this is fails or in case of arrhythmias with hemodinamic collapse then occurs radiofrequency ablation.

Answer 80

ANSWER C) The first part is correct, the second one is wrong EXPLANATION Implantable cardioverter defibrillator is able to automatically detect arrhythmias and eliminate it with low or high energy DC-shock with a set algorythm. It can’t prevent arrhythmia or treat the underlying disease.

Answer 81

ANSWER E) Both of them are incorrect EXPLANATION Asymptomatic ventricular extrasystole in healthy patients don’t require treatment. None of the currently available medicines has proven to improve the survival in ventricular extrasystole.

Answer 82

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION Young patient’s lone atrial fibrillation does not have higher thromboembolic risk. In contrary to this there is higher thromboembolic risk during bad left ventricle function, dilated heart chambers, valvular disease, hypertension and diabetes associated with atrial fibrillation, and in these cases the most important in the treatment is the adequately adjusted anticoagulant. CHA2DS2-VASc Score is appropriate for measuring the risk of thromboembolism and for setting the indication of anticoagulant treatment for patients with atrial fibrillation.

Answer 83

ANSWER E) Both of them are incorrect EXPLANATION Supraventricular arrhythmias are very rare and only in less than 17 % of the cases are lethal. Combined antiarrhythmic treatment usually doesn’t improve the effectiveness but increases the chance of the side effect of the drugs. In drug refractory cases transcatheter ablation is an effective and safe alternative of the pharmacotherapy.

Answer 84

ANSWER A) Both of them are correct, there is causal relationship between them EXPLANATION During myocardial infarction it is desirable to reduce oxygen demand of the myocardium, therefore negative inotropic and chronotropic beta-blockers are preferred to use.

Answer 85

ANSWER C) the statement is true, but the explanation is false; EXPLANATION In the procession of coronary atherosclerosis the developing myocardial infarct because of the sudden occlusion of the vessel is life threatening for the patient. The initial step is the rupture of the lipid plaque of the wall of the vessel, which is followed by the developing of thrombus because the platelets hit each other. This process is attended by the urgent stenosis of the vessel. The antiplatelet drug, the acetylsalicylic acid plays an important role to slow down this thrombotic procedure.

Answer 86

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION From the severe occlusion distal located myocardium area, which is alive beacuse of the minimal perfusion, the movement capacity can get better after reperfusion. The preoperative recognition of these areas are executed by examination methods (18-FDG-PET, dobutamin-echocardiography, perfusion myocardium scintigraphy at rest). As the result of the examinations there is any chance to the postoperative function improvement in the movement disorder areas, the reperfusion therapy means more risk than gain, that is why the completion is not explainable.

Answer 87

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION In acute myocardial infarct the severe pain provoke sympathicotony, which worsen the status of the patient because of the increase of oxygen demand. That is why using painkillers is justified. The use of opiate painkillers in cardiac diseases are not contraindicated, most of the time we use these painkillers.

Answer 88

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION In the first 48 hours after a myocardial infarct the continuos ECG-monitoring of the patient is justified because we need to treat malignant arrhythmias promptly. The incidence is quite high in cases which are complicated by heart failure.

Answer 89

ANSWER E) both the statement and the explanation are false EXPLANATION In myocardial infarct we need to start mobilization immadiately. A patient with myocardial infarct without any complication after 24 hours can wash hisself/herself, in the second/third day the patient can move limited in the room. The early mobilisation and the anticoagulants therapy can decrease the risk of thromboembolic complications.

Answer 90

ANSWER C) the statement is true, but the explanation is false; EXPLANATION ACE.inhibitors are inhibiting the activity of ACE (angiotensin converting enzyme). This enzyme is catalising the transformation of angiotensin I into angiotensin II (that is why the second part of the statement is false), the inhibiting decrease the serum level of angiotensin II. (first part of the statement is true).

Answer 91

ANSWER A) both the statement and the explanation are true and a causal relationship exists between them; EXPLANATION The ACE-inhibitors are inhibiting the activity of ACE (angiotensin converting enzyme). This enzyme is catalising the transformation of angiotensin I into angiotensin II, that is why the inhibiting decrease the serum level of angiotensin II, which can effectively activating the vascular oxigenase (second part of the statement is true). The increase in the activity of the vascular oxigenase worsen the endothelfunction because of the decrease of the tissue NO-level, that is why the inhibition of this enzyme cause the progress of the endothelfunction (first part of the statement is true, there is connection between the two statements).

Answer 92

ANSWER E) both the statement and the explanation are false EXPLANATION Not every calcium channel blockers are prohibited in heart failure (for example: we can use amlodipine) and not every calcium channel blocker have a negative inotropic effect in therapic concentration (vasoselective calcium channel blocker), that is why any part of the sentence are true.

Answer 93

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION Dihidropiridin type calcium channel blockers are not suggestible in heart failure without a few exception (for example the basic molecule, nifedipine is unadaptable), that is why first part of the statement is false. But, all of these molecules have different degree of vasoselectivity, that is why the second part of the statement is true.

Answer 94

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION In acute circumstances beta-blockers have a negative inotropic effects (second part of the sentence is true), to start in small dose, to increase the dose continuesly prove the survival of the patients in heart failure after long-term clinical trials, that is why as far as possible we should use them (first part of the sentence is false).

Answer 95

ANSWER B) alcoholic myocardium laesion EXPLANATION The patient has pulmonary and body circulation decompensation symptoms, the patient drinks regularly alcoholic beverages. He/She has not got any risk factors for coronary atherosclerotic disease. There are any signs for hereditary cardiac disease, asymmetrical septal hypertrophy has different symptoms (e.g. angina, syncope, etc.). First of all we can think about alcoholic myocardium lesion or alcoholic cardiomyopathy after the sypmtoms and signs.

Answer 96

ANSWER D) loud diastolic thrill at the region of apex of the heart EXPLANATION The suspected diagnosis, alcoholic cardiomyopathy (with left and right ventricular dysfunction) are veryfied by the following physical signs: cardiomegaly, gallop rythm, dyspnoe. Hepatomegaly and ankle swelling might be the physical signs of the decompensation of the body circulation with lips and finger cyanosis without drumstick fingers. The loud diastolic thrill at the region of apex of the heart is not typical as a physical sign, mostly it could be a systolic thrill because of the dilatated left ventricular and the dilatated mitral annulus with the complicated mitral regurgitation

Answer 97

ANSWER D) tallium perfusion scintigraphy at rest EXPLANATION To diagnose alcoholic cardiomyopathy the most important device examinations are: echocardiography (to award the accurate left and right ventricular function), ECG: SA node or electrical conduction system dysfunction, left ventricular hypertrophy, repolarisation dysfunction. Chest X-ray: to adjudicate the size of the heart and the stasis of the lung. In dilatative cardiomyopathy the myocardial perfusion scintigraphy at rest has not got a direct diagnostic role, because the isotope examination shows prior myocardial infarct, in which regional and not diffuse myocardium lesion is typical.

Answer 98

ANSWER D) thrombolysis EXPLANATION The alcoholic cardiomyopathy which goes hand in hand with reduced left ventricular function, demand the use of diuretics, physical tolerance and the prohibition of alcohol. By the edification of multicentric megatrial ACE inhibitor is very necessary because it can improve the survival. Antiarrhythmic therapy can be necessary too, because there could be ventricular or life-threatening arrhythmias, and atrial fibrillation is also quite common. In these cases thrombolyis is not to be thought of.

Answer 99

ANSWER B) left ventricular aneurysm after an extensive anterior myocardial infarct EXPLANATION Left ventricular aneurysm after an extensive anterior myocardial infarct, which cause left-sided heart failure. Dyskinesis of the affected heart area allude to the development of an aneurysm, which verified by echocardiography and radionuclid-ventriculography. It cannot be a decompensated aortic vitium, the patient does not have a thrill. The segmental dyskinesis is dominant in the failure of the left ventricular function. The failure of the other parts of the left ventricular function is caused by the “remodelling-effect”. Tricuspid valve insufficiency has a thrill and it could detached by echocardiography. Left atrial myxoma has a special echocardiographic image too. The symptoms of a stent thrombosis do not develop progressively, acute myocardial infarct came forward as cardiogenic shock

Answer 100

ANSWER F) nifedipine EXPLANATION The applicable conservative medical therapy consist: ACE inhibitors (they improve long-term the left ventricular function and the survival, prevent the left ventricular remodelling), statins (in post-infarct patients improve the survival because of the anti-atherosclerotic effect). Diuretics because of the pulmonary stasis made by the left-sided heart failure, salicylates as antiplatelets, anticoagulants (Syncumar) as thromboembolic prophylaxis. The use of Nifedipin is contraindicated, because it worsens the systolic function of the left ventricle (negative inotropic effect), moreover it causes tachycardia.

Answer 101

ANSWER C) pericarditis exsudativa after a virus infection, with a lot of pericardial fluid, with threatening of cardiac tamponade EXPLANATION The right diagnosis: pericarditis exsudativa with massive pericardial fluid. The auscultation status is not typical for mitral vitium, the heart sounds are soft, labor or echocardiography results do not verify rheumatic carditis. On chest X-ray there are cor bovinum with sluggish heart contour-pulsations. In echocardiography in this case the left ventricular function is good.

Answer 102

ANSWER E) pericardiac punction guided by echocardiography EXPLANATION Although the patient does not have a paradox pulse, the jugular vein distension, hepatomegaly, cyanosis and tachycardia suggest the possibility of a life-threatening pericardiac tamponade. In echocardiography “swinging-heart”and the big amount of pericardial fluid support the possibility of pericardiac tamponade. Because of the life-threatening pericardiac tamponade we should perform a pericardiac punction guided be echocardiography as soon as possible. Anticoagulant and digitalis therapy in acute case is contraindicated. Acute pericardiocentesis is necessary. Depending on the type of pericarditis later we should give salicylat, steroid or antibiotics.

Answer 103

ANSWER E) treadmill exercise test EXPLANATION Right answer: treadmill exercise ECG test, because of the anamnesis there is a clinical opportunity to have pulmonary embolism, where treadmill exercise ECG test is contraindicated

Answer 104

ANSWER A) heparin EXPLANATION From the listed medication the initiation of anticoagulants therapy is justified, so the use of heparin. First of all in the embolism which concern small and medium vessels. In big-vessel-embolism thrombolytic therapy and embolectomy come into question.

Answer 105

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION In pulmonary embolism the frontal line R-vector with left axis deviation is not pathological.

Answer 106

ANSWER B) 1st and 3rd answers are correct EXPLANATION There are two right answers. The obvious answer is pericarditis and consequently pericardiac fluid, because fever and „big silent heart” is typical for pericarditis. If there are more options, we need to think of other options, for example that the patient has a major disease (an unknown dilatative cardiomyopathy) with a concomitant disease. This is a less possible solution, but it could fit to the symptoms.

Answer 107

ANSWER C) transthoracic echocardiography EXPLANATION Every disease in cardiology, moreover the obvious differentiation in the listed diagnosis the rutine transthoracic echocardiography is the best diagnostic method. Even pericardiac fluid, even dilatative cardiomyopathy can differentiate with echocardiography. In severe, decompensated aorta vitium the physical status is high-frequented diastolic murmur, it can easily recognize with color Doppler. In hyperkinetic circulation this is diagnostic that there are any organic variance in echocardiography.

Answer 108

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Because of pericardiac tamponade there are inhibition in filling, this cause jugular vein distension, because of the reduced filling as a compenzation mechanism we observe tachycardia. Pulsus paradoxus also caused by the reduced filling. Laterally displaced apical impulse is not typical, because in pericardiac fluid or in pericardiac tamponade apical impulse disappear.

Answer 109

ANSWER A) Mantoux-test EXPLANATION In infective endocarditis Mantoux-test is not diagnostic. CRP, microscopic hematuria in urine, positive hemocultures, moreover vegetations in transesophageal echocardiography enhance the diagnosis of infective endocarditis

Answer 110

ANSWER E) all of the answers are correct EXPLANATION All answers are right, in the vegetation all of the listed components are founded. Vegetation is an infected thrombus, that is why it can cause septic embolism, if one piece comes away. With transthoracic echocardiography in 60%, with transesophageal echocardiography in 100% could be detected.

Answer 111

ANSWER C) intravenous verapamil immediately EXPLANATION The blood pressure and as far as possible the heart rate are definitely decreasable, however the specifically negative inotropic verapamil should not be used instead of captopril and digoxin. The last one is quite favourable beacuse of the positive inotropic effect. The immediate use of diuretics decrease the shortness of breath and help the recovery of diuresis.

Answer 112

ANSWER B) 1st and 3rd answers are correct EXPLANATION Echocardiography plays an important role to judge the myocardium function and to demonstrate a vitium or a prior myocardial infarct which can be a cause. ECG plays a role to diagnose arrhythmias caused by heart failure and (same as echo) to adjudicate atrial load, myocardium hypertrophy and ischaemia. Abdominal ultrasound usually do not give any information about heart failure. Lung scintigraphy sould perform in the suspect of pulmonary embolism.

Answer 113

ANSWER C) short-acting calcium channel blocker EXPLANATION STE-ACS local care includes effective pain relief (Morphin), except rare cases (cardiogenic schock, right ventricular infarct) nitroglycerin, oxigen in nasal probe and antiplatelet therapy. Short-acting calcium channel blocker can provoke undesired hypotension and heart failure.

Answer 114

ANSWER C) ST-elevation at least two cohesive leads, chest pain EXPLANATION The diagnose of STEMI can set up after chest pain and significant ST-elevation at least two cohesive leads. More affirmative examination, e.g. biomarker test is not necessary, it means unnecessary loss of time. An early reperfusion therapy is necessary.

Answer 115

ANSWER D) the first sign of a significant aortic stenosis EXPLANATION All of the mentioned causes can cause coronary occlusion. In aortic dissection, if the coronary ostia get into a fail lumen because of the rupture of the intima the aortic valve stenosis does not cause coronary occlusion. Because of the haemodinamic effect the main symptoms are effort syncope, heart failure an effort angina.

Answer 116

ANSWER B) high content of lipid, without infective cells EXPLANATION The so called vulnerable plaque, which is liable for rupture consists of: high lipidcontent, the exist of inflammatory cells and thin fibrotic „cap”. The content of whitewash of these plaques are typically low and do not or not necessarily cause stenosis in the lumen.

Answer 117

ANSWER C) ventricular tachycardia EXPLANATION All of the listed complications can be the complication of myocardial infarct, but we do not regard ventricular tachycardia as a mechanical complication, because this is an arrhythmia.

Answer 118

ANSWER B) with big dosage of statins EXPLANATION According to the testimony of clinical studies plaque regression is available only with the use of high dose statin therapy (40mg rosuvastatin, 80mg atorvastatin), any other medical treatment combination is unadapted.

Answer 119

ANSWER B) percutan coronary intervention (PCI) EXPLANATION In STE-ACS an early reperfusion is the aim, the opening of a coronary occlusion. This is available with thrombolysis or with PCI. In point of mortality and complications PCI is the primary, thrombolysis is well-founded in special cases, if the interventional centre is not available. The intravenous anticoagulants-, beta-blocker- and antiplatelet-therapy are belong to the STE-ACS therapy, but from this therapy we could not wait for reperfusion.

Answer 120

ANSWER D) NSTE-ACS EXPLANATION In all of the listed diseases fibrinolysis could be justified, except in NSTE-ACS, in this case fibrinolysis is contraindicated, harmful.

Answer 121

ANSWER E) all statement in one case EXPLANATION All of the listed conditions indicate very high risk of NSTE-ACS, the immediate coronarography is justified.

Answer 122

ANSWER E) pericarditis acuta EXPLANATION All the listed disease cause chest pain, however pericarditis acuta is not life-threatening. The possible pericardiac fluid evolve during days.

Answer 123

ANSWER C) CT-angiography EXPLANATION Both echocardiography (proximal aorta, aortic root), and chest X-ray help to set up the diagnosis, but the correct enlargement of the aneurysm discover the CT-angiography. Coronarography is a not-suitable examination.

Answer 124

ANSWER D) mitral valve chordae tendineae rupture EXPLANATION In aortic dissection the mitral valve and the mitral apparatus are never affected.

Answer 125

ANSWER A) proximal aortic dissection EXPLANATION The proximal aortic dissection – the risk of the complications- demand an urgent operation. If only the descendent is affected, it could attempt by controlled hypotension. The treatment of the other three is non-surgical.

Answer 126

ANSWER A) Marfan- syndrome EXPLANATION Marfan-syndrome, whice cause the weakness of connected tissues directly predispose aortic dissection, the others causes the progression of atherosclerosis, but directly they are not predisposing factors.

Answer 127

ANSWER C) hypertension EXPLANATION Hypertension increases the risk of atherosclerosis, the other diseases increase the risk of pulmonary embolism with different mechanisms.

Answer 128

ANSWER B) increased pulmonary pressure for example measured by echocardiography EXPLANATION The increased pulmonary pressure allude to extended pulmonary embolism. The other signs can show pulmonary embolism as well (none of them is specific), but alone none of them has a prognostic role.

Answer 129

ANSWER B) left bundle branch block, symptomatic systolic heart failure with optimal medical treatment, ejection fraction (EF) < 35% EXPLANATION III. degree atrioventricular block means pacemaker indication, but to implant biventricular device is not necessary. Clinical studies showed, that if there is left bundle branch block cardiac resynchronization therapy improve the prognosis and the functional status.

Answer 130

ANSWER C) VVI pacemaker EXPLANATION The left ventricular function is good, biventricular device or malignant ventricular arrhythmia in this case do not come up. In permanent atrial fibrillation atrial pacing is meaningless.

Answer 131

ANSWER B) long QT-syndrome, sudden cardiac death of the parents EXPLANATION In I. degree atrioventricular block ICD is not to be thought of. In postinfarct status, in HOCM and in primary DCM ICD implantation might justified, but the exist of other predisposable factors are necessary.

Answer 132

ANSWER D) antitachycardia pacing function EXPLANATION Antitachycardia pacing function is owned by ICD devices. The role is to terminate the arrhythmia with a faster rate than the detected ventricular tachycardia before the DC shock.

Answer 133

ANSWER B) first-degree atrioventricular block EXPLANATION I. degree atrioventricular block does not require neither pacemaker implantation, usually nor suspense beta-blocker.

Answer 134

ANSWER C) sedation, electrical cardioversion EXPLANATION In fast ventricular tachycardia which cause hemodinamic instability the patient is in an acute life-threatening status, we need to do cardioversion.

Answer 135

ANSWER D) Cumarin EXPLANATION Cumarin is an anticoagulant, the others are antiplatelets.

Answer 136

ANSWER A) After myocardial infarct one year long combined acetylcalicilic acid (ASA) + Clopidogrel treatment is supposed. EXPLANATION Clinical studies proved, that one year long after a myocardial infarct – independently from the method of the revascularization, or there was any revascularization at all – double antiplatelet therapy is suggested.

Answer 137

ANSWER D) Aspirin EXPLANATION In high thromboembolic risk Aspirin does not substitute the effective anticoagulant therapy.

Answer 138

ANSWER A) it is the consequence of neointima proliferation EXPLANATION The neointima proliferation is responsible for the development of instent restenosis. Slow procedure, which causes myocardial infarct very rare. It presents in the first 6 months after stent implantation.

Answer 139

ANSWER C) effective anti-platelet medical treatment EXPLANATION In the background of instent restenosis stays neointima proliferation. Antiplatelet therapy do not affect to the procedure. The drug eluting stents are expanded to interfere this proliferation.

Answer 140

ANSWER A) in effort angina pectoris + heart rate > 70/min EXPLANATION The cardiac effect of ivabradin is to slow down the heart rate because to inhibit the sinoatrial node. It is useful to slow down the frequency of sinoatrial node, for example in effort angina pectoris beside or instead of beta-blocker.

Answer 141

ANSWER C) RCA (right coronary artery) EXPLANATION RCA gives the right ventricular vessels and usually the IVP (interventricular posterior), that is why RCA is responsible for the inferior and right ventricular STE-ACS.

Answer 142

ANSWER B) right ventricle EXPLANATION The ICD shock electrode comes through the central venous cannula into the right ventricle.

Answer 143

ANSWER D) myocardial infarct EXPLANATION The myocardial infarct does not cause the dilatation of aortic ascendent, the other diseases potentially does. Hypertension through pressure loading and through causing atherosclerosis, the Marfan-syndrome through connective tissue disease, the chronis aortic valve insufficienty through high volume oscillation