Internal medicine - Cardiology (167) Flashcards

Question 1

Q

INT - 1.1
These can be heard in mitral stenosis, except for:

A) apical holosystolic murmur radiating towards the axilla
B) low-frequency apical diastolic murmur
C) opening snap
D) loud first heart sound

Answer

A

ANSWER
A) apical holosystolic murmur radiating towards the axilla

EXPLANATION
Holosystolic heart murmurs that radiate towards the axilla and are best heard at the apex are characteristic of mitral regurgitation, therefore they cannot be heard in mitral stenosis. Severe mitral stenosis might be accompanied by tricuspidal insufficiency that can cause a holosystolic, apical murmur, but it never radiates towards the axilla. The pathomechanism behind the low-frequency, diastolic murmur is the fast, turbulent flow through the stenotic mitral valve. The opening snap (o.s.) is heard as the mitral leaflets buckle in their attempt to open and it cannot be heard when the valve is severely calcified. The loud, tapping first heard sound is especially easy to notice when the heart is in sinus rhythm and when it is introduced by a presystolic murmur.

Question 2

Q

INT - 1.2
Part of the therapy of decompensated heart failure, except for:
A) mineralocorticoid-antagonists
B) diuretics
C) digoxin
D) parenteral volume expansion
E) ACE-inhibitors

Answer

A

ANSWER
D) parenteral volume expansion

EXPLANATION
In chronic decompensated heart failure the body is in a state of fluid overload. Treatment with diuretics and mineralocorticoid-antagonists is essential. Digoxin should be given because of its positive inotropic and negative chronotropic effects, while ACE-inhibitors improve long-term survival. Parenteral administration of fluids (infusions) is contraindicated as it increases the preload on the left atrium and the left ventricle and worsens the symptoms. Acute left ventricle failure might be caused by acute myocardial infarction, hypertensive crisis or severe aortic stenosis as well since these all strain the left ventricle while bronchial asthma exerts the right ventricle.

Question 3

Q

INT - 1.3
Causes of acute left ventricle failure, except for:
A) asthma bronchiale
B) acute myocardial infarction
C) hypertensive crisis
D) severe aortic stenosis

Answer

A

ANSWER
A) asthma bronchiale

EXPLANATION
Acute left ventricle failure might be caused by acute myocardial infarction, hypertensive crisis or severe aortic stenosis as well since these all strain the left ventricle while bronchial asthma exerts the right ventricle.

Question 4

Q

INT - 1.4
Characteristics of hypertrophic obstructive cardiomyopathy, except for:
A) might be combined with mitral insufficiency
B) digoxin is important in the early stage
C) it often shows a familial distribution
D) diastolic dysfunction is common
E) syncope is a common symptom

Answer

A

ANSWER
B) digoxin is important in the early stage

EXPLANATION
Hypertrophic cardiomyopathy has a genetic background in most of the cases, so it is usually familial. Characteristic symptoms include syncope and it is often accompanied by mitral insufficiency because the mitral valve is primarily damaged. The valve has functional damage, too: because of the Venturi effect its anterior leaflet moves toward or contacts the interventricular septum (it is called systolic anterior motion: SAM) and the valve doesn’t close completely during systole which can result in severe mitral insufficiency (these changes can be diagnosed with echocardiography). As the hypertrophic myocardium’s ability to relaxe is damaged, the diastolic filling decreases which leads to diastolic dysfunction. Digitalis (Digoxin) is not recommended either in early or in late stages unless the disease reaches its „burn-out”, dilated phase.

Question 5

Q

INT - 1.5
Features of atrial myxoma, except for:
A) the most common form of primary cardiac tumors
B) it can be diagnosed with echocardiography
C) it is often metastatic
D) it can mimic mitral stenosis during physical examination

Answer

A

ANSWER
C) it is often metastatic

EXPLANATION
Left atrial myxoma is the most common benign, primary neoplasm in the heart. It can be diagnosed with echocardiography because of its pathognomic features. As it is a benign, in situ tumor, metastases are extremely rare. It can mimic the auscultation characteristics of mitral stenosis by protruding into the mitral orifice and causing an obstruction during diastole.

Question 6

Q

INT - 1.6
Which one is true about the mechanism of action of digoxin?
A) it inhibits the Na-K-ATPase
B) it lowers intracellular Na+ concentration
C) it increases intracellular ATP levels
D) it enhances cAMP-production
E) it decreases Ca-release from the sarcoplasmic reticulum

Answer

A

ANSWER
A) it inhibits the Na-K-ATPase

EXPLANATION
Digoxin inhibits the Na/K-ATPase. This causes a temporary rise in intracellular sodium levels, which increases intracellular calcium concentration through the sodium-calcium exchanger. Consequently, it is the elevated intracellular calcium level that increases myocardium contractility and has a positive inotropic effect.

Question 7

Q

INT - 1.7
All of the following statements about nitroglycerine are true, except for:
A) it increases intracellular cGMP levels
B) it is primarily metabolised in the liver
C) it can induce significant reflex tachycardia
D) it significantly prolongs AV-conduction
E) it can lead to postural hypotension

Answer

A

ANSWER
D) it significantly prolongs AV-conduction

EXPLANATION
Nitrates don’t alter atrioventricular conduction.

Question 8

Q

INT - 1.8
The typical side effect of nitrates is:
A) hypertension
B) headache
C) bradycardia
D) sexual dysfunction
E) anaemia

Answer

A

ANSWER
B) headache

EXPLANATION
The most common adverse effect of nitrate therapy is headache. In severe cases it could result in the discontinuation of the therapy but most of these headaches resolve in a few days, therefore it is recommended to continue the treatment for a few days.

Question 9

Q

INT - 1.9
The typical feature of Prinzmetal angina:
A) ST segment depression during angina
B) negative T waves during angina
C) pathologic Q waves during angina
D) elevated necroenzymes
E) ST segment elevation during angina

Answer

A

ANSWER
E) ST segment elevation during angina

EXPLANATION
Prinzmetal angina is a unique type of angina pectoris that is caused by coronary spasm which can affect healthy and stenotic arteries, too. Chest pain is accompanied by ST segment elevation indicating subepicardial or transmural ischemia. ST segment depression during chest pain means subendocardial ischemia, while negative T waves are non-specific features. Pathologic Q waves and elevated necroenzymes are signs of myocardial infarction.

Question 10

Q

INT - 1.10
Types of unstable angina pectoris, except for:
A) angina at rest
B) crescendo angina
C) effort angina
D) new-onset angina

Answer

A

ANSWER
C) effort angina

EXPLANATION
Unstable angina pectoris could be defined as a new-onset angina (it presents for the first time), or it might occur with a crescendo pattern (increase in frequency, severity and duration), and it could develop at rest or sometimes during minimal exertion. Contrarily, stable or effort angina pectoris is usually provoked by the same level of exertion in the same circumstances.

Question 11

Q

INT - 1.11
The most common pathology of myocardial infarction:
A) coronary embolism
B) rupture of an atherosclerotic plaque
C) dissection of coronary walls
D) growing of an atherosclerotic plaque
E) coronary inflammation

Answer

A

ANSWER
B) rupture of an atherosclerotic plaque

EXPLANATION
The pathomechanism behind acute myocardial infarction is usually the rupture of an atherosclerotic plaque of a coronary artery and the following thrombus formation. The so-called soft plaques are more prone to rupture because their lipid-rich core is only covered by a thin, vulnerable fibrous cap. Coronary endarteritis is a rare cause of acute myocardial infarction

Question 12

Q

INT - 1.12
Normal mean electrical axis in the front plane, except for:
A) +60°
B) +90°
C) –45°
D) 0°
E) +45°

Answer

A

ANSWER
C) –45°

EXPLANATION
The mean electrical axis is considered normal between 0° and +90° in the frontal plane. 0° leftward axis can be physiological, while a +90° axis is common in young people. A -45° axis means distinct left axis deviation, a typical feature in left anterior fascicular block.

Question 13

Q

INT - 1.13
If acute myocardial infarction is suspected, the following diagnostic procedures should be carried out, except for:
A) ECG
B) blood tests (to measure CK-MB and troponin)
C) physical examination
D) cardiac stress test
E) echocardiography

Answer

A

ANSWER
D) cardiac stress test

EXPLANATION
Cardiac stress test is contraindicated if acute myocardial infarction is suspected. The other choices could be diagnostic steps in NSTEMI

Question 14

Q

INT - 1.14
Ischemic heart disease can present with, except for:
A) acute myocardial infarction
B) stable angina
C) deep vein thrombosis
D) sudden cardiac death
E) ischemic cardiomyopathy

Answer

A

ANSWER
C) deep vein thrombosis

EXPLANATION
Deep vein thrombosis isn’t directly connected to the thrombotic processes in the coronary circulation.

Question 15

Q

INT - 1.15
The most important risk factor of atherosclerosis:
A) elevated serum LDL-cholesterol level
B) elevated serum HDL-cholesterol level
C) elevated serum triglyceride level
D) elevated serum cholesterol level

Answer

A

ANSWER
A) elevated serum LDL-cholesterol level

EXPLANATION
Chronic hypercholesterolemia and changes in the LDL/HDL ratio play key roles in the pathomechanism of atherosclerosis. LDL is released into the bloodstream and the toxic metabolites of its oxidation propagate the mechanism that eventualy leads to plaque formation. Elevated LDL concentration is the most significant proatherogenic risk factor. HDL cholesterol has protective qualities. Elevated triglyceride levels are less significant but they are proatherogenic, too.

Question 16

Q

INT - 1.16
Risk factors of coronary artery disease, except for:
A) positive family history
B) diabetes mellitus
C) smoking
D) elevated serum HDL-cholesterol level
E) metabolic syndrome X

Answer

A

ANSWER
D) elevated serum HDL-cholesterol level

EXPLANATION
Risk factors are variables that are associated with the later development of atherosclerosis in healthy people. The risk factors of coronary heart disease are (among other things) stress, lack of physical exercise, elevated cholesterol, diabetes, obesity, male sex, age, smoking and family history. Metabolic syndrome X is a cluster term for several of these risk factors (impaired glucose tolerance, dyslipidemia, obesity, hypertension) and it significantly inreases the risk of atherosclerosis. Elevated HDL-cholesterol levels have a protective role against the devlopment of atherosclerosis.

Question 17

Q

INT - 1.17
The ideal target value of serum LDL-cholesterol in a diabetic patient after myocardial infarction:
A) < 1,8 mmol/l
B) > 2,6 mmol/l
C) < 3,5 mmol/l
D) > 3,5 mmol/l

Answer

A

ANSWER
A) < 1,8 mmol/l

EXPLANATION
Total serum cholesterol and HDL/LDL ratio are main factors of atherosclerosis. The target level of LDL in very high-risk patients is below 1.8 mmol/l, lower than in primary prevention

Question 18

Q

INT - 1.18
A 65-year-old patient with a history of smoking presents with sudden pain in his left leg. The limb feels cold, the toes are pale and peripheral pulse can not be palpated. What is the most likely diagnosis?
A) deep vein thrombosis
B) Buerger’s disease
C) embolism in the peripheral arteries
D) Raynaud’s disease

Answer

A

ANSWER
C) embolism in the peripheral arteries

EXPLANATION
These symptoms indicate embolism as they developed quickly. Deep vein thrombosis doesn’t present suddenly, the arterial pulse is palpable and has different symptoms. In Raynaud’s syndrome the tip of the fingers are cold on both sides and it resolves spontaneously. Buerger’s disease has a gradual onset, too.

Question 19

Q

INT - 1.19
Paramedics arrive to a 55-year-old patient with chest pain that started 3 hours ago. On the patient’s ECG they notice ST segment elevation in leads I, aVL, V5 and V6. What should they do?
A) transfer the patient to the regional Emergency Department
B) transfer the patient to the regional Coronary Care Unit
C) transfer the patient to the regional Cardiology Department for a troponin test and if it’s positive, transfer to a PCI center
D) transfer the patient directly to the nearest PCI center

Answer

A

ANSWER
D) transfer the patient directly to the nearest PCI center

EXPLANATION
The patient has an ST Segment Elevation Myocardial Infarction (STEMI). In most of the cases this is caused by a complete coronary occlusion. The opening of the occlusion by percutaneous coronary intervention (PCI) is a life-saving procedure, any unnecessary delay increases the rate of mortality.

Question 20

Q

INT - 1.20
Upon the physical examination of a 45-year-old man without any symptoms a soft systolic murmur and ejection click can be heard in 2L2. These have been known since he was a child. What is the most likely diagnosis?
A) patent ductus arteriosus
B) coarctation of the aorta
C) ventricular septal defect
D) Ebstein’s anomaly
E) pulmonary valve stenosis

Answer

A

ANSWER
E) pulmonary valve stenosis

EXPLANATION
An organic heart disease that has been known since childhood and doesn’t cause any symptoms is most likely a mild pulmonary stenosis. Based on the physical examination and the mild signs and symptoms patent ductus arteriosus (its typical feature is a continuous murmur), coarctation of the aorta (elevated blood pressure on the upper limbs), ventricular septal defect (very loud systolic murmur) or the very rare Ebstein’s anomaly are highly unlikely diagnoses.

Question 21

Q

INT - 1.21
Correct statements about aortic stenosis, except for:
A) it causes pulsus parvus et tardus
B) it can cause syncope
C) it can cause anginalike chest pain
D) Austin-Flint murmur can be heard upon auscultation
E) it causes concentric left ventricular hypertrophy

Answer

A

ANSWER
D) Austin-Flint murmur can be heard upon auscultation

EXPLANATION
The patients’ pulse in aortic stenosis is usually parvus et tardus (slow-rising and anacrotic). A hemodynamically significant aortic stenosis might cause exercise-related syncope. The chest pain that is typically associated with ischemic heart disease might occur in significant aortis stenosis. The increased preload of the heart induces concentric left ventricular hypertrophy. Its severity can be measured with echocardiography. Severe left ventricle might cause strain signs on the ECG. The Austin-Flint murmur can be heard in aortic regurgitation and not in aortic stenosis

Question 22

Q

INT - 1.22
Correct statements about aortic insufficiency, except for:
A) it causes pulsus celer et altus (Corrigan’s pulse).
B) it can be acute and chronic too.
C) it usually doesn’t lead to left ventricle dilation.
D) it can be congenital.
E) it predisposes to infective endocarditis.

Answer

A

ANSWER
C) it usually doesn’t lead to left ventricle dilation.

EXPLANATION
The patients’ pulse in aortic insufficiency is usually celer et altus (rapidly increasing and suddenly collapsing). It might have a rapid onset (e.g. infective endocarditis, aortic dissection), but its chronic form is the most common. In young adults it is usually predisposed to by congenital bicuspid aortic valve. Aortic regurgitation increases the risk of infective endocarditis because the blood forcefully, turbulently regurgitates from the aorta into the left ventricle. Hemodynamically significant, chronic aortic insufficiency leads to substantial left ventricle dilation through volume overload.

Question 23

Q

INT - 1.23
Accessory pathway-mediated reentry tachycardy (AVRT) can be terminated with, except for:
A) propafenone
B) adenosine
C) lidocaine
D) radiofrequency ablation
E) verapamil

Answer

A

ANSWER
C) lidocaine

EXPLANATION
Drugs that delay the conduction in the AV node or in the bundle are able to terminate an AVRT. Lidocaine doesn’t have this effect. Ablation can be done during tachycardia (e.g. incessant AVRT).

Question 24

Q

INT - 1.24
A regular wide QRS complex tachycardia can not be:
A) ventricular tachycardia
B) supraventricular tachycardia with bundle branch block
C) atrial fibrillation with bundle branch block
D) antidromic atrioventricular reentry tachycardia (WPW-syndrome)
E) atrial flutter with bundle branch block

Answer

A

ANSWER
C) atrial fibrillation with bundle branch block

EXPLANATION
Atrial fibrillation might have narrow and wide QRS complexes, too, but it is always an irregular rhythm. Monomorphic ventricular tayhcardia (most common in patients after myocardial infarction) has a regular rhythm with wide QRS complexes. Antidromic atrioventricular tachycardia has a regular rhythm, too. The ventricular activation happens through an accessory pathway which results in pre-excited, wide QRS complexes. Supraventricular tachycardia with (either right or left) bundle branch block always creates wide QRS complexes and has a regular rhythm. Atrial flutter might appear as regular tachycardia if it has a fixed conduction or as an irregular rhythm if the AV-block is variable.

Question 25

Q

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

A

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.

Question 26

Q

INT - 1.26
Which one is the most common permanent arrhythmia?
A) ventricular extrasystoles
B) atrial fibrillation
C) ventricular tachycardia
D) supraventricular tachycardia
E) junctional escape rhythm

Answer

A

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.

Question 27

Q

INT - 1.27
A patient who has been taking amiodarone for a long time was prescribed a fluoroquinolone antibiotic because of a respiratory infection. She had recurring short-term syncopes that had never occurred before. Which one is the most likely cause of the syncopes?
A) hypotension induced by the medications
B) torsade de pointes ventricular tachycardia induced by the medications
C) sinus bradycardia induced by the medications
D) her symptoms are not induced by her medications, it is just a coincidence
E) AV block induced by the medications

Answer

A

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.

Question 28

Q

INT - 1.28
These could be the first ECG findings in the acute phase of myocardial infarction, except for:
A) pathologic Q waves
B) inverted T waves
C) ventricular fibrillation
D) ST segment elevation
E) ST segment depression

Answer

A

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.

Question 29

Q

INT - 1.29
Pathologic Q wave in leads II, III and aVF with isoelectric ST segment and positive T waves indicate:
A) acute ischemia
B) acute phase of a progressing myocardial infarction
C) previous myocardial infarction
D) aneurysm after myocardial infarction
E) subendocardial ischemia

Answer

A

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.

Question 30

Q

INT - 1.30
In the diagnostic workup of a 60-year-old patient with a history of smoking who has chest pain at exertion, the first step should be:
A) stress echocardiography
B) exercise test
C) stress perfusion scintigraphy
D) Holter ECG monitoring
E) stress MRI

Answer

A

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).

Question 31

Q

INT - 1.31
The best first-choice drug for bradycardia during myocardial infarction is:
A) isoproterenol
B) theophyllin
C) atropine
D) dobutamine

Answer

A

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.

Question 32

Q

INT - 1.32
The most common side effect of ACE inhibitors is:
A) diarrhea
B) cough
C) vomiting
D) erythema
E) anasarca

Answer

A

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.

Question 33

Q

INT - 1.33
Which disease(s) cause(s) systolic hypertension?
1) aortic insufficiency
2) thyreotoxicosis
3) beriberi
4) atherosclerosis

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 34

Q

INT - 1.34
Aortic aneurysm can be caused by:
1) arteriosclerosis
2) Marfan’s syndrome
3) vascular syphilis
4) giant-cell arteritis

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 35

Q

INT - 1.35
The possible cause(s) of pericarditis:
1) uremia
2) transmural myocardial infarction
3) tuberculosis
4) metastatic cancer

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 36

Q

INT - 1.36
Secondary cardiomyopathy can be caused by:
1) hyperthyroidism
2) beriberi
3) amyloidosis
4) glycogenosis

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 37

Q

INT - 1.37
ACE inhibitors:
1) decrease blood pressure
2) decrease aldosterone levels
3) increase bradykinin levels
4) stop the deterioration of the left ventricle ejection fraction

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 38

Q

INT - 1.38
Which one(s) is/are correct?
1) Aspirin has no effect on the prostacyclin production of the endothelial cells.
2) According to multicenter trials aspirin reduces the chance of a second myocardial infarction.
3) It takes 24 hours for heparin to build up its anticoagulant effect.
4) Heparin and alteplase are treatment options in pulmonary embolism.

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 39

Q

INT - 1.39
Which diuretic side effect combination(s) is/are correct?
1) furosemide - hyperuricemia
2) chlortalidone – ototoxicity
3) spironolactone – gynecomasty
4) etacrynic acid - hyperuricemia

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 40

Q

INT - 1.40
Risk factors of ischemic heart disease:
1) smoking
2) hypercholesterolemia
3) hypertension
4) family history

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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).

Question 41

Q

INT - 1.42
Treatments that reduce morbidity and mortality after myocardial infarction (secondary prevention):
1) beta-blockers
2) antiplatelet drugs
3) HMG-CoA reductase inhibitors
4) ACE inhibitors

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 42

Q

INT - 1.43
Diagnostic options to determine myocardial viability:
1) low-dose dobutamine stress test
2) positron-emission tomography
3) stress perfusion scintigraphy with Tl-201 reinjection
4) Doppler ultrasound

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 43

Q

INT - 1.44
Contraindications of cardiac exercise tests:
1) acute myocardial infarction
2) chronic heart failure
3) unstable angina
4) beta-blocker therapy

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 44

Q

INT - 1.45
Diagnostic tests with the ability to detect asymptomatic angina pectoris (silent ischemia):
1) dobutamine stress echocardiogram
2) Holter ECG monitoring
3) exercise test
4) ABPM

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 45

Q

INT - 1.46
Early and late complications of acute myocardial infarction:
1) ventricular fibrillation
2) left ventricular aneurysm formation
3) cardiogenic shock
4) pericardial effusion

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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).

Question 46

Q

INT - 1.47
Treatment option(s) of heart failure:
1) pharmacotherapy
2) heart transplant
3) mechanical circulatory support devices
4) cardiac resynchronization therapy

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 47

Q

INT - 1.48
Risk factors of atherosclerosis:
1) stress
2) AV-nodal reentry-tachycardia
3) smoking
4) hypotension

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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

Question 48

Q

INT - 1.49
Drugs that lower serum cholesterol level:
1) rosuvastatin
2) ezetimibe
3) atorvastatin
4) ivabradine

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 49

Q

INT - 1.50
Drugs that lower serum triglyceride levels:
1) special diet
2) niacin
3) fibrates
4) alcohol

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 50

Q

INT - 1.51
Characteristic features of Prinzmetal angina:
1) it usually occurs at dawn during rest
2) ST segment elevation can be seen during angina
3) it is caused by coronary spasm
4) it should be treated with calcium-channel blockers

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 51

Q

INT - 1.52
Possible complication(s) of deep vein thrombosis:
1) pulmonary infarction
2) crural ulcer
3) pulmonary embolism
4) Raynaud’s syndrome

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 52

Q

INT - 1.53
Possible complication(s) of atherosclerosis:
1) dry gangraena of the feet
2) aortic aneurysm
3) myocardial infarction
4) stroke

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

ANSWER
E) All of the answers are correct

EXPLANATION
Atherosclerosis can cause a wide range of symptoms depending on which vessels are affected.

Question 53

Q

INT - 1.54
Might mimic the ECG findings of myocardial infarction:
1) pericarditis
2) pancreatitis
3) myocarditis
4) pulmonary embolism

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 54

Q

INT - 1.55
Enzyme(s) that is/are elevated in myocardial infarction:
1) creatine kinase (CK-MB)
2) lactate dehydrogenase
3) troponin
4) alkaline phosphatase

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 55

Q

INT - 1.56
A 55-year-old patient with a history of hypertension has been rushed to the emergency room because of severe chest pain and ST segment elevation. Possible diagnosis/diagnoses:
1) peptic ulcer
2) acute myocardial infarction
3) mitral valve prolapse
4) aortic dissection

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 56

Q

INT - 1.58
A 70-year-old patient had an anterior wall myocardial infarction three weeks ago. He suddenly develops a fever and complains of chest pain. On his ECG there are no new Q waves and his CK-MB level is normal. What is/are the most likely diagnose(s)?
1) myocardial reinfarction
2) pulmonary embolism
3) lobar pneumonia
4) Dressler’s syndrome

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 57

Q

INT - 1.59
Correct statements about mitral insufficiency:
1) it leads to the dilation of all heart chambers
2) it might be the complication of infective endocarditis
3) left atrial pressure can be elevated even when the ejection fraction is preserved
4) its severe form requires surgical treatment

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 58

Q

INT - 1.60
Correct statements about mitral stenosis:
1) it doesn’t increase the risk of atrial fibrillation
2) it predisposes to left atrial thrombus formation
3) during auscultation a muffled first heart sound and a mesosystolic click can be heard
4) it might be a late complication of rheumatic fever

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 59

Q

INT - 1.61
Echocardiographic findings of aortic stenosis:
1) the end-diastolic diameter of the left ventricle is not significantly enlarged
2) concentric left ventricle hypertrophy can often be seen
3) the left atrial diameter can be abnormally large
4) a pathologic transvalvular gradient can be measured at the level of the aortic valve with Doppler ultrasound

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 60

Q

INT - 1.62
Echocardiographic findings of isolated mitral stenosis:
1) large left atrial diameter
2) the unidirectional movement of the anterior and posterior leaflets in M-mode
3) an abnormal transvalvular gradient can be measured in diastole at the level of the mitral valve with continuous wave Doppler ultrasound
4) the calcification of the whole mitral valve can be visualised with 2D-echocardiography

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 61

Q

INT - 1.63
Characteristic(s) of mitral valve prolapse:
1) it can cause ventricular extrasystoles
2) it can present with chest pain
3) it is common in Marfan’s syndrome
4) an opening snap can be heard during auscultation of the heart

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 62

Q

INT - 1.64
Hypertrophic cardiomyopathy:
1) is caused by genetic mutations.
2) can cause dynamic left ventricle outflow obstruction.
3) can cause sudden cardiac death.
4) should not be treated with beta-blockers.

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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

Question 63

Q

INT - 1.65
The treatment of ventricular extrasystoles:
1) All cases must be treated with antiarrhythmic agents.
2) Frequent, symptomatic extrasystoles require antiarrhythmic pharmacological therapy.
3) Class Ic agents have been proven to be the best choice.
4) In most cases antiarrhythmic treatment is not required.

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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.

Question 64

Q

INT - 1.66
In the differential diagnosis of wide QRS complex tachycardia helps:
1) Knowing the organic status of the heart
2) Frequency of tachycardia
3) Physical or ECG signs of atrioventricular dissociation
4) Hemodynamic instability of the tachycardia

A) Answers 1, 2 and 3 are correct
B) Answers 1 and 3 are correct
C) Answers 2 and 4 are correct
D) Only answer 4 is correct
E) All of the answers are correct

Answer

A

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 65

A

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 66

A

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 67

A

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 68

A

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 69

A

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 70

A

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 71

A

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 72

A

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 73

A

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 74

A

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 75

A

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 76

A

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 77

A

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

Answer 78

A

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 79

A

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 80

A

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 81

A

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 82

A

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 83

A

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 84

A

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 85

A

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.
In patients who have undergone a myocardial infarction, the use of aspirin and β-blockers significantly reduces the

Answer 86

A

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 87

A

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 88

A

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 89

A

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 90

A

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 91

A

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 92

A

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 93

A

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 94

A

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 95

A

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 96

A

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 97

A

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 98

A

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 99

A

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 100

A

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 101

A

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 102

A

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 103

A

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 104

A

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 105

A

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 106

A

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 107

A

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 108

A

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 109

A

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 110

A

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 111

A

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 112

A

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 113

A

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 114

A

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 115

A

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 116

A

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 117

A

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 118

A

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 119

A

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 120

A

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 121

A

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 122

A

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 123

A

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 124

A

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 125

A

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 126

A

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 127

A

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 128

A

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 129

A

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 130

A

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 131

A

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 132

A

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 133

A

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 134

A

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 135

A

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 136

A

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 137

A

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 138

A

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 139

A

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 140

A

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 141

A

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 142

A

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 143

A

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 144

A

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 145

A

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 146

A

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 147

A

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 148

A

ANSWER
D) mitral valve chordae tendineae rupture

EXPLANATION
In aortic dissection the mitral valve and the mitral apparatus are never affected.

Answer 149

A

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 150

A

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 151

A

ANSWER
C) hypertension

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

Answer 152

A

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 153

A

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 154

A

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.

Ventricular demand pacing (ventricle paced, ventricle sensed, and pacemaker inhibited in response to a sensed beat)

Answer 155

A

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 156

A

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 157

A

ANSWER
B) first-degree atrioventricular block

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

Answer 158

A

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 159

A

ANSWER
D) Cumarin

EXPLANATION
Cumarin is an anticoagulant, the others are antiplatelets.

Answer 160

A

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 161

A

ANSWER
D) Aspirin

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

Answer 162

A

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 163

A

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 164

A

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 165

A

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 166

A

ANSWER
B) right ventricle

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

Answer 167

A

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

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Internal medicine - Cardiology (167) Flashcards

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