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1

Diagnostic Studies/Cardiology
Which diagnostic study is considered to be the strategy of choice for symptomatic patients with recurrent ischemia, hemodynamic instability or impaired left ventricular dysfunction?
A. Stress echocardiography
B. Exercise treadmill testing
C. Coronary angiography
D. Cardiac magnetic resonance imaging

Explanations
(h) A. Stress echocardiography should not be performed in the setting of a patient who is acutely symptomatic.
(h) B. Exercise treadmill testing should not be performed in the setting of an unstable patient with ongoing cardiac symptoms.
(c) C. Coronary or cardiac catheterization is the gold standard technique in the evaluation of patients with significant cardiac symptoms. Anatomical information along with degree of coronary artery blockages are provided and patients may be able to undergo coronary revascularization during or after this procedure.
(u) D. Cardiac magnetic resonance imaging has limited availability and is not part of national guidelines for evaluation of the cardiac patient.

2

Clinical Therapeutics/Cardiology
A 48 year-old male with diabetes mellitus presents for routine physical examination. Of note his blood pressure each of his last two follow-up visits was 150/90 mmHg. Today the patient's BP is 148/88 mmHg. The patient denies complaints of chest pain, change in vision, or headache. Which of the following is the most appropriate management for this patient?
A. Atenolol (Tenormin)
B. Nifedipine (Procardia)
C. Hydralazine (Apresoline)
D. Lisinopril (Zestril)

Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. ACE inhibitors are the first line treatment of choice in a patient with hypertension and diabetes.

3

Health Maintenance/Cardiology
A 36 year-old female presents for a routine physical. She has no current complaints and her only medication is oral contraceptives. The patient is preparing for a trip to Australia and is worried about the long flight as her mom has a history of deep vein thrombosis after a long trip several years ago. Physical examination reveals BP 110/60 mmHg, HR 66 bpm, regular. Heart is regular rate and rhythm without murmur, lungs are clear to auscultation bilaterally and extremities are without edema. Which of the following is the most appropriate recommendation for your patient?
A. Discontinue oral contraceptives
B. Recommend walking frequently during the flight
C. Begin daily aspirin therapy
D. Increase fluid intake 2-3 days prior to the flight

Explanations
(u) A. See B for explanation.
(c) B. The risk of deep vein thrombosis after air travel increases with flight duration. Preventive measures for patients include using support hose and performing in-flight exercises and walking.
(u) C. See B for explanation.
(u) D. See B for explanatio

4

Diagnostic Studies/Cardiology
A 3 month-old female presents with her mom for physical examination. The patient's mom denies any complaints. On examination you note a well-developed, well-nourished infant in no apparent distress. There is no cyanosis noted. Heart examination reveals a normal S1 with a physiologically split S2. There is a grade III/VI high-pitched, harsh, pansystolic murmur heard best at the 3rd and 4th left intercostal spaces with radiation across the precordium. Which of the following is the initial diagnostic study of choice in this patient?
A. CT angiogram
B. Electrocardiogram
C. Echocardiogram
D. Cardiac catheterization

Explanations
(u) A. This patient has signs and symptoms consistent with a ventricular septal defect (VSD). CT angiogram and electrocardiogram are not indicated in establishing the diagnosis of a VSD.
(u) B. See A for explanation.
(c) C. Echocardiogram is the initial diagnostic study of choice in the diagnosis of a VSD.
(u) D. Cardiac catheterization may be necessary to accurately measure pulmonary pressures or if a VSD can not be well localized on echocardiogram, but it is not the initial diagnostic study of choice.

5

Clinical Intervention/Cardiology
A 20 year-old male presents with complaint of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. He admits to associated shortness of breath and lightheadedness. He denies syncope. Electrocardiogram reveals a delta wave prominent in lead II. Which of the following is the most appropriate long-term management in this patient?
A. Implantable cardio defibrillator
B. Radiofrequency ablation
C. Verapamil (Calan)
D. Metoprolol (Lopressor)

Explanations
(u) A. Implantable cardio defibrillators are indicated in the treatment of ventricular arrhythmias, not Wolf-Parkinson- White (WPW) syndrome.
(c) B. Radiofrequency ablation is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms.
(u) C. Calcium channel blockers and beta-blockers are not the best options for the long-term management of WPW. They may decrease the refractoriness of the accessory pathway or increase the refractoriness of the AV node in patients with atrial fibrillation or atrial flutter who have an antegrade conducting bypass tract. This may lead to faster ventricular rates.
(u) D. See C for explanation.

6

Diagnosis/Cardiology
A 60 year-old female recently discharged after an 8 day hospital stay for pneumonia presents complaining of pain and redness in her right arm. The patient thinks this was the area where her IV was placed. The patient denies fever or chills. Examination of the area reveals localized induration, erythema and tenderness. There is no edema or streaking noted. Which of the following is the most likely diagnosis?
A. Acute thromboembolism
B. Thrombophlebitis
C. Cellulitis
D. Lymphangitis

Explanations
(u) A. Acute thromboembolism is usually associated with edema of the extremity and warm temperature. Thromboembolism is unusual after thrombophlebitis.
(c) B. This patient's signs and symptoms are consistent with thrombophlebitis. Short-term venous catheterization of a superficial arm vein is commonly the cause and thrombophlebitis characterized by dull pain, induration, redness and tenderness along the course of the vein.
(u) C. Cellulitis is usually associated with fever, increased warmth over the affected area and associated edema. (u) D. Lymphangitis is associated with fever, malaise, chills, and streaking.

7

History & Physical/Cardiology
A patient with a history of chronic venous insufficiency presents for routine follow-up. Which of the following findings is most likely on physical examination?
A. Cold lower extremities
B. Diminished pulses
C. Lower extremity edema
D. Palpable cord

Explanations
(u) A. Cold lower extremities are more commonly seen in peripheral arterial, not venous, disease.
(u) B. Diminished pulses are seen in peripheral arterial disease.
(c) C. Patients with chronic venous insufficiency will commonly have lower extremity edema.
(u) D. A palpable cord is more common in superficial thrombophlebitis

8

Diagnostic Studies/Cardiology
A 29 year-old female with history of IV drug abuse presents with ongoing fevers for three weeks. She complains of fatigue, worsening dyspnea on exertion and arthralgias. Physical examination reveals a BP of 130/60 mmHg, HR 90 bpm, regular, RR 18, unlabored. Petechiae are noted beneath her fingernails. Fundoscopic examination reveals exudative lesions in the retina. Heart examination shows regular rate and rhythm, there is a grade II-III/VI systolic murmur noted, with no S3 or S4. Lungs are clear to auscultation bilaterally, and the extremities are without edema. Which of the following is the diagnostic study of choice in this patient?
A. Electrocardiogram
B. CT angiogram of the chest
C. Cardiac catheterization
D. Transesophageal echocardiogram

Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. This patient's signs and symptoms are consistent with infective endocarditis. The diagnostic study of choice would be a transesophageal echocardiogram.

9

Clinical Therapeutics/Cardiology
A 49 year-old female presents complaining of several episodes of chest pain recently. Initial ECG in the emergency department shows no acute changes. Two hours later, while the patient was having pain, repeat electrocardiogram revealed ST segment elevation in leads II, III, and AVF. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice in this patient?
A. Nifedipine (Procardia)
B. Metoprolol (Lopressor)
C. Lisinopril (Zestril)
D. Carvedilol (Coreg)

Explanations
(c) A. This patient is most likely having coronary artery spasm. This can be treated prophylactically with calcium channel blockers such as nifedipine.
(h) B. Beta-blockers may exacerbate the symptoms of coronary vasospasm.
(u) C. ACE inhibitors are not effective in the treatment or prevention of coronary vasospasm.
(u) D. Carvedilol is not effective in the treatment or prevention of coronary vasospasm.

10

History & Physical/Cardiology
A 75 year-old female with a history of long-standing hypertension presents with shortness of breath. On examination you note a diastolic murmur at the left upper sternal border. Which of the following maneuvers would accentuate this murmur?
A. Sitting up and leaning forward
B. Lying on left side
C. Performing Valsalva maneuver
D. Standing upright

Explanations
(c) A. This patient has history findings consistent with aortic insufficiency which is characterized by a diastolic murmur that is accentuated when the patient sits up and leans forward.
(u) B. The left lateral decubitus position accentuates the murmur of mitral stenosis.
(u) C. Valsalva and standing maneuvers help to differentiate the murmurs associated with aortic stenosis and hypertrophic cardiomyopathy.
(u) D. See C for explanation.

11

Diagnosis/Cardiology
A 50 year-old male with history of alcohol abuse presents with complaint of worsening dyspnea. Physical examination reveals bibasilar rales, elevated jugular venous pressure, an S3 and lower extremity edema. Chest x-ray reveals pulmonary congestion and cardiomegaly. Electrocardiogram shows frequent ventricular ectopy. Echocardiogram shows left ventricular dilatation and an ejection fraction of 30%. Which of the following is the most likely diagnosis in this patient?
A. Hypertrophic cardiomyopathy
B. Dilated cardiomyopathy
C. Restrictive cardiomyopathy
D. Tako-Tsubo cardiomyopathy

Explanations
(u) A. Hypertrophic cardiomyopathy is characterized by a hyperdynamic left ventricle with asymmetric left ventricular hypertrophy.
(c) B. Dilated cardiomyopathy is often caused by chronic alcohol use. It is characterized by signs and symptoms of left-sided heart failure, a dilated left ventricle and decreased ejection fraction.
(u) C. Restrictive cardiomyopathy is characterized more commonly by right-sided heart failure than by left-sided heart failure. There is rapid early filling with diastolic dysfunction. Patients with restrictive cardiomyopathy will have a small thickened left ventricle and a normal or near normal ejection fraction on echocardiogram.
(u) D. Tako-Tsubo cardiomyopathy (broken heart syndrome) is characterized by signs and symptoms of acute coronary syndrome, ST segment elevation on ECG and left ventricular apical dyskinesia.

12

Clinical Therapeutics/Cardiology
A 76 year-old active female with history of hypertension and hypothyroidism presents with complaints of palpitations and dyspnea on exertion. On examination vital signs are BP 120/80 mmHg, HR 76 bpm, irregular, RR 16. Heart examination reveals an irregularly, irregular rhythm without murmur. Lungs are clear to auscultation and extremities are without edema. Which of the following is the most important medication to initiate for chronic therapy in this patient?
A. Warfarin (Coumadin)
B. Verapamil (Calan)
C. Amiodarone (Cordarone)
D. Digoxin (Lanoxin)

Explanations
(c) A. Anticoagulation is necessary in all patients with atrial fibrillation to prevent thromboembolic events unless there is contraindication.
(u) B. This patient currently has a controlled ventricular rates and does not require chronic calcium channel blockers or digoxin at this time.
(u) C. Antiarrhythmic therapy may be indicated in some patients with atrial fibrillation, but anticoagulation is indicated in all patients unless there is contraindication.
(u) D. See B for explanation.