CARDIOLOGY

Question 1

Which of the following extremity vein is considered part of the superficial venous system?

a. Small saphenous vein
b. Superficial femoral vein
c. Anterior tibial vein
d. Posterior tibial vein

Answer 1

Small saphenous vein

Question 2

Pulmonary hypertension is best defined in mmHg as:

a. Mean PAP >20
b. Mean PAP >22
c. Mean PAP >24
d. Mean PAP >26

Answer 2

b. Mean PAP >22

Question 3

This is a class Ia antiarrhythmic that has also an additional property of alpha-adrenergic blockade:

a. Quinidine
b. Procainamide
c. Lidocaine
d. Amiodarone

Answer 3

a. Quinidine

Question 4

Which anatomical site determines most of the peripheral vascular resistance?

a. Medium-sized arteries and arterioles
b. Small and medium-sized arteries
c. Small arteries and arterioles
d. Arterioles and venoules

Answer 4

c. Small arteries and arterioles

Question 5

In which of the following situations is CABG the preferred revascularization strategy?

a. Significant right main coronary artery involvement
b. Two-vessel CAD with significant left anterior descending involvement
c. Depressed left ventricular function (EF <50%)
d. Heavy cigarette smokers

Answer 5

c. Depressed left ventricular function (EF <50%)

Question 6

A 50-year old male who was recently diagnosed to have hypertension asks regarding lifestyle modifications that effectively lower blood pressure. He is also a known diabetic, a chronic smoker and alcoholic. What is best to recommend for this case?

a. Maintain a BMI <23 kg/m2
b. Reduce total sodium intake to <5g/day
c. Regular aerobic activity for >30mins minimum of 3x a week
d. Reduce alcohol intake to 2 or ess drinks per day

Answer 6

d. Reduce alcohol intake to 2 or less drinks per day

Question 7

At this level of coronary artery stenosis, blood flow at rest may be reduced and further decreases may produce ischemia at rest or with little effort:

a. 50%
b. 60%
c. 70%
d. 80%

Answer 7

d. 80%

Question 8

In which of the following situations is coronary angiography NOT indicated to evaluate angina pectoris?

a. Severely symptomatic patients despite optimal medical therapy and are being considered for revascularization
b. Patients with known or suspected angina pectoris who have survived cardiac arrest
c. Patients with angina symptoms and nondiagnostic stress test but are experiencing psychological stress regarding the definitive diagnosis
d. None of the above

Answer 8

d. None of the above

Question 9

Ramon, a newborn baby, was immediately referred to the cardiology section for sudden dyspnea and cyanosis. The 12 L ECG read ST depression at V1-V4 and cardiac enzymes were elevated. Which of the following can explain the cause of the infarction?

a. Ostial narrowing due to aortitis
b. Origin of LAD from pulmonary artery
c. Severe LVH due to aortic stenosis
d. Severe atherosclerosis brought by familial hypercholesterolemia

Answer 9

b. Origin of LAD from pulmonary artery

Question 10

Robert was doing his brisk walking when he suddenly felt severe pain at his left chest. He suddenly placed his hand over his sternum, clutching it with a clenched fist because of discomfort. What is the medical term when Robert clutched his sternum because of pain?

a. Waterhammer sign
b. Osler’s sign
c. Levine’s sign
d. Turner’s sign

Answer 10

c. Levine’s sign

Question 11

A 55-year old man being treated for chronic stable angina pectoris consulted for worsening exertional dyspnea. His medications include a beta blocker, an ACE inhibitor and as needed furosemide for dyspnea symptoms. Transthoracic 2D echo revealed LVH, mild mitral regurgitation and an EF of 38%. What is the most appropriate next step?

a. Increase furosemide to a regular dose to relieve the dyspnea
b. Add an aldosterone-antagonist
c. Add a nitrate
d. Refer to coronary angiography

Answer 11

d. Refer to coronary angiography

Question 12

A 74 year-old woman, with hypertension for 15 years and recently diagnosed with type 2 diabetes mellitus consults for a 2-week history of increasing fatigability and bipedal edema. She is maintained on Telmisartan, Hydrochlorothiazide, Pioglitazone and Rosuvastatin. A complete blood count, creatinine and electrolyte panel done two days ago are all within normal. Transthoracic 2d-echocardiogram showed concentric LVH and ejection fraction of 40%. Which medical strategy can be used to optimize heart failure control and potentially decrease mortality?

a. Add a long-acting nitrate
b. Add Atenolol
c. Shift Telmisartan to Olmesartan
d. Add Bisoprolol

Answer 12

d. Add Bisoprolol

Question 13

Which of the following may cause transient elevations of cardiac troponins in a patient without a clear history of myocardial ischemia?

a. Liver failure
b. Bradycardia
c. Hypothyroidism
d. Aortic aneurysm

Answer 13

c. Hypothyroidism

Question 14

A 54 year old diabetic woman is in the emergency room for acute onset crushing chest pain. ECG showed T-wave inversions in V2-V6 and high sensitivity troponin T taken 6 hours after the onset of chest pain was 10x elevated. She was pale and diaphoretic, BP of 100/80mmHg, HR of 115, RR of 30, with engorged neck veins and crackles all over both lung fields and ongoing chest pain. She was immediately hooked to non-invasive positive pressure ventilation wherein her tachypnea lessened.Which of the following medications are indicated and can be safely given?

a. Metoprolol 50mg PO every 6 hours
b. Verapamil 5 mg IV every 6 hours
c. Morphine 2 mg IV every 30 mins and as needed
d. Rivaroxaban 20 mg BID

Answer 14

c. Morphine 2 mg IV every 30 mins and as needed

Question 15

Which of the following patient conditions is an absolute contraindication for fibrinolysis in STEMI?

a. Traumatic subarachnoid hemorrhage during childhood
b. 2 cm infrarenal aortic aneurysm
c. Third trimester pregnancy
d. Heavy menstruation

Answer 15

a. Traumatic subarachnoid hemorrhage during childhood

Question 16

According to the Philippine Guidelines in the treatment of dyslipidemia what is appropriate to advise a 55 year old male executive, previously asymptomatic individual came in to your clinic for routine executive checkup, non-hypertensive, 27 pack-year smoker with the following laboratory results: Hba1c- 7.5%, Total cholesterol- 130 mg/dL, LDL cholesterol- 95 mg/dL, HDL cholesterol- 35 mg/dL, Triglycerides- 140 mg/dL, Creatinine- 0.80 umol/L?

a. Low fat, low cholesterol diet
b. Diet high in fruits and vegetables
c. Smoking cessation
d. All of the above

Answer 16

d. All of the above

Question 17

In which of the following situations is CABG the preferred revascularization strategy according to the Philippine Heart Association Guidelines?

a. Significant right main coronary artery involvement
b. Two-vessel CAD with significant left anterior descending involvement
c. Depressed left ventricular function (EF <50%)
d. Heavy cigarette smokers

Answer 17

c. Depressed left ventricular function (EF <50%)

Question 18

Following an episode of myocardial infarction, the following are recommended medications by the Philippine Heart Association:

a. Aspirin for 12 months in patients treated with PCI and drug eluting stents
b. Clopidogrel for 12 months in patients treated with PCI and drug eluting stents
c. Prasugrel for 12 months in patients treated with medical management alone
d. Ticagrelor for 12 months in patients treated with PCI and bare metal stents

Answer 18

b. Clopidogrel for 12 months in patients treated with PCI and drug eluting stents

Question 19

Which of the following is not included in the GRACE risk model to assess risk of death and MI in patients with NSTE-ACS and UA:

a. Age
b. Serum creatinine
c. History of heart failure
d. Diabetes

Answer 19

d. Diabetes

Question 20

Which of the following is part of the criteria for metabolic syndrome under the Harmonizing Definition Criteria for Metabolic Syndrome?

a. Fasting triglyceride level of >180 mg/dL or medication
b. HDL cholesterol level <50 mg/dL for men
c. Fasting plasma glucose level of >100 mg/dL
d. Blood pressure of >130 mmHg systolic

Answer 20

d. Blood pressure of >130 mmHg systolic

Question 21

The following is/are indication/s for emergent cardiac surgery in patients with infective endocarditis:

a. Vegetation obstructing valve tract
b. Septal perforation
c. Rupture into pericardial sac
d. All of the above

Answer 21

d. All of the above

Question 22

What is the most widely accepted theory regarding the pathogenesis of rheumatic fever?

a. Delayed type hypersensitivity
b. Antigen-antibody deposition
c. Direct streptococcal invasion to heart valves
d. Molecular mimicry

Answer 22

d. Molecular mimicry

Question 23

An 18-year old female who had a bout of acute rheumatic fever 5 years ago came in for follow-up. She is asymptomatic and her surveillance 2D echocardiogram showed moderate mitral regurgitation, stable since her initial episode. What is the most appropriate recommendation for secondary prevention of Acute Rheumatic Fever in this case?

a. Penicillin G 1.2 Million units IM every 3 weeks for at least 10 years or until she reaches 40 years of age
b. Penicillin G 1.2 Million units IM every 3 weeks for at least 5 years or until she reaches 21 years of age
c. Penicillin V 250 mg once a day for at least 10 years or until she reaches 40 years of age
d. Penicillin V 250 mg once a day for at least 5 years or until she reaches 21 years of age

Answer 23

a. Penicillin G 1.2 Million units IM every 3 weeks for at least 10 years or until she reaches 40 years of age

Question 24

Which of the following statements is true about physical examination findings in aortic stenosis:

a. Atrial fibrillation often occurs early in the disease course, and may signal mitral valve involvement
b. Pulse pressure widening and systolic blood pressure decline may happen in later stages of aortic stenosis
c. There is often an ejection, mid-systolic murmur that begins shortly after S1
d. The carotid artery rises sharply, thus the classic pulsus parvus et tardus

Answer 24

c. There is often an ejection, mid-systolic murmur that begins shortly after S1

Question 25

The following classic murmurs of aortic regurgitation is matched correctly with the description: a. Corrigan’s pulse: a rapidly rising pulse and collapses suddenly as arterial pressure falls rapidly during late systole and diastole b. Quincke’s pulse: paradoxical nail pallor when pressure is applied to the tip of the finger c. Traube’s sign: to-and-fro murmur audible if the femoral artery is compressed lightly by a stethoscope d. Duroziez’s sign: booming “pistol shot” sound heard over the femoral arteries

Answer 25

a. Corrigan’s pulse: a rapidly rising pulse and collapses suddenly as arterial pressure falls rapidly during late systole and diastole

Question 26

Which of the following statements correctly describes mitral valve prolapse? a. In MVP, the anterior leaflet is more often affected than the posterior leaflet b. Auscultation findings may reveal an early to mid non-ejection systolic click that is generated by sudden tensing of the slack, elongated chordae tendinae c. The murmur of MVP occur earlier during standing and Valsalva maneuver d. Squatting and isometric exercises increase the MVP murmur

Answer 26

c. The murmur of MVP occur earlier during standing and Valsalva maneuver

Question 27

A 64-year old female consulted for a non-healing wound in her left leg. She is non-diabetic and non-hypertensive and lipid profile is unremarkable. On physical examination, there is a dried and healed venous ulcer in the dorsal aspect of the left foot, lichenification in the left leg. Leg duplex ultrasound with doppler showed chronic venous incompetence in the left great and lesser saphenous veins. What is the recommended management for this case? a. Prescribe diosmin+hesperidin to lessen venous incompetence b. Prescribe low molecular weight heparin c. Prescribe elastic stockings and stretch bandages d. Refer to surgeon for interventional procedures

Answer 27

d. Refer to surgeon for interventional procedures

Question 28

A 54 year old woman complained of progressive fatigue and dyspnea. A year ago, she also complained of mouth and eye drying, and difficulty swallowing and swallowing. She denies fever, weight loss and other constitutional symptoms. On physical examination, she is awake, and not in distress. She has limited mouth opening and cutaneous thickening at the dorsal aspects of the hands. Vital signs are normal, there’s a holosystolic murmur at the 5th ICS left parasternal border. 2D echo which showed markedly increased PAP (45 mmHg). Under what group classification of pulmonary hypertension does the patient belong? (based on the WHO Classification) a. Group I b. Group II c. Group III d. Group IV

Answer 28

a. Group I

Question 29

This abnormality can also present with an ST Segment elevation and can be confused as a myocardial infarction: a. Hypocalcemia b. Hypokalemia c. Hypothermia d. Hypothyroidism

Answer 29

c. Hypothermia

Question 30

Infiltration of abnormal substances between myocytes, storage of abnormal metabolic byproducts within myocytes or fibrotic injury are the usual causes of: a. Dilated cardiomyopathy b. Restrictive cardiomyopathy c. Constrictive cardiomyopathy d. Hypertrophic cardiomyopathy

Answer 30

b. Restrictive cardiomyopathy

Question 31

A 27 year old female developed fever, malaise, cough and nasal congestion 2 weeks ago. She does not have chest pain nor dyspnea. Her ECG showed diffuse T wave inversions in all leads. Troponin and CK-MB are elevated. How is this patient classified in the consideration of myocarditis? a. Possible subclinical acute myocarditis b. Probable acute myocarditis c. Definite myocarditis d. Chronic myocarditis

Answer 31

b. Probable acute myocarditis

Question 32

Peripartum cardiomyopathy develops during the last trimester of pregnancy and/or how many months after pregnancy? a. 1 b. 2 c. 3 d. 6

Answer 32

d. 6

Question 33

Which medication is given to patients with hypertrophic cardiomyopathy as first line agent to alleviate symptoms of LV outflow tract obstruction? a. Disopyramide b. ACE inhibitor c. Diuretic d. Beta blocker

Answer 33

d. Beta blocker

Question 34

Which of the following is a chest x-ray finding in patients with mitral stenosis? a. Straightening of the upper right border of the cardiac silhouette b. Diminution of the main pulmonary arteries c. Constriction of the upper lobe pulmonary veins d. Posterior displacement of the esophagus by an enlarged LA

Answer 34

d. Posterior displacement of the esophagus by an enlarged LA

Question 35

Which of the following statements correctly describes the pathologic consequences of hypertension? a. Aggressive control of hypertension cannot reverse left ventricular hypertrophy once it sets in b. Treatment of hypertension decreases the incidence of hemorrhagic stroke, but not of ischemic stroke c. Risk of renal complications from hypertension is equally affected by both systolic and diastolic pressure d. Hypertension is related to the development of dementia via beta amyloid deposition

Answer 35

a. Aggressive control of hypertension cannot reverse left ventricular hypertrophy once it sets in

Question 36

A 45 year-old man consults for dizziness and weakness. He is a known hypertensive and is adherent to his multiple antihypertensive medications, but still records usual resting blood pressures of 150-160/100-115 mmHg. Current BP is 156/78, non-ambulatory due to bilateral lower extremity weakness. Electrolytes showed Na-140 mmol/L, K-2.9 mmol/L, Cl- 105 mmol/L, serum bicarbonate- 28 mmol/L. What is the most possible diagnosis? a. Primary Aldosteronism b. Renal artery stenosis c. Pheochromocytoma d. Renal vein thrombosis

Answer 36

a. Primary Aldosteronism

Question 37

Which of the following is not a basic laboratory test recommended in the initial evaluation of hypertension? a. Hba1c b. Serum potassium c. Serum triglyceride d. Urinary albumin excretion

Answer 37

a. Hba1c

Question 38

Which statement is correct regarding the side effects of ACE inhibitor or ARB therapy? a. May cause renal insufficiency by efferent renal arteriolar vasoconstriction b. Can cause hyperkalemia by increasing circulating aldosterone levels c. Dry cough occurs in less than 1% of patients taking ACE inhibitors d. Heart failure may increase the risk of renal insufficiency

Answer 38

d. Heart failure may increase the risk of renal insufficiency

Question 39

Which of the ff causes of pulmonary hypertension is characterized by an elevated LA pressure and elevated pulmonary venous hypertension? a. Idiopathic pulmonary arterial hypertension b. Pulmonary hypertension associated with left heart disease c. Pulmonary hypertension associated with lung disease d. Pulmonary hypertension associated with chronic thromboembolic disease

Answer 39

b. Pulmonary hypertension associated with left heart disease

Question 40

Injection drug use-associated infective endocarditis usually affects which cardiac valve? a. mitral valve b. tricuspid valve c. aortic valve d. pulmonic valve

Answer 40

b. tricuspid valve

Question 41

Which of the following is a major criterion in the modified Duke criteria for the clinical diagnosis of infective endocarditis? a. HACEK group organism isolated from a single blood culture b. Fever >38.0 C c. Increase in preexisting murmur d. Coxiella burnetii phase I IgG antibody titer of >1:800

Answer 41

d. Coxiella burnetii phase I IgG antibody titer of >1:800

Question 42

Mr. Cooper is a 68-year old Australian who complained of intermittent claudication was diagnosed with peripheral artery disease. One of the listed drugs he received blocks the protease activator receptor-1 that reduces acute limb ischemia but is also associated with moderate bleeding. Which drug is it? a. Ticagleclor b. Vorapaxar c. Rivaroxaban d. Pentoxyfylline

Answer 42

b. Vorapaxar

Question 43

A 58/M, has been complaining of intermittent claudication for three months now. He is also hypertensive on Losartan 50 mg/tab but is not compliant with his medications. He is a 30-pack year smoker. Which of the following is NOT true regarding his condition? a. This condition affects mostly the proximal vessels b. The internal elastic lamina is preserved c. Migratory superficial vein thrombophlebitis is seen d. Later stages are characterized by perivascular fibrosis

Answer 43

a. This condition affects mostly the proximal vessels

Question 44

Ella underwent a coronary angiogram for recurrent chest pains. The procedure was successful, and she stayed in the cardiac care unit for one day. When she was about to be transferred to her room, the nurse in charge noticed that her right big toe was bluish in color. When the nurse tried touching the toe, she would grimace in pain. Which of the following treatment option be given to Ella? a. Low molecular weight heparin b. Warfarin c. Amputation d. Clopidogrel

Answer 44

c. Amputation

Question 45

Helena, a German national, has been experiencing mottled, reddish area in her legs and thighs during wintertime. It is not itchy or swollen and would go away during the summer. When she visited the Philippines, she noticed that the mottling returned when she went to Baguio for two weeks. What is the diagnosis for Helena’s condition? a. Raynaud’s Phenomenon b. Erythromelalgia c. Livedo reticularis d. Acrocyanosis

Answer 45

c. Livedo reticularis

Question 46

Luis, 51/M, a jackhammer operator, was seen at the emergency room for pallor in his hands. The pallor would go away a few hours after rest from operating the equipment. During a routine physical in his company, his BP was 140/90, and he was given by his company physician a medication for his hypertension. However, he noticed that his hands now turned pale even if he was not operating the machinery. What antihypertensive medication could have caused this? a. Nifedipine b. Verapamil c. Atenolol d. Losartan

Answer 46

c. Atenolol

Question 47

is a 69/M who came to emergency room for labored breathing. On history, he is a 30 pack year smoker and works as a construction worker. On PE, he has pale nailbeds, bipedal edema. Pulmonary PE showed expiratory wheezes in the bibasal lung fields. Cardiac PE showed an RV heave and S3 gallop. A 12 L ECG was requested. What ECG finding would be expected for this patient? a. Sinus rhythm b. Left ventricular hypertrophy c. Right axis deviation with p pumonale d. Paroxysmal ventricular contractions

Answer 47

c. Right axis deviation with p pumonale

Question 48

Which of the following factors that has been shown to have worst outcomes in heart failure patients in registries? a. Creatinine >2.75 mg/dl b. Systolic BP >140 mmHg c. Blood Urea Nitrogen <30 mg/dl d. HbA1C >7.0%

Answer 48

a.Creatinine >2.75 mg/dl

Question 49

Dr. Espiritu was called for a referral in the emergency room. The patient, a 54/M, is presented with dizziness and light-headedness. On the cardiac monitor, the tracing showed non-sustained ventricular tachycardia. Dr. Espiritu is planning to start an antiarrhythmic drug that targets the sodium ion channel with the highest potency but with slowest kinetics. Which of the following drugs describes Dr. Espiritu’s choice? a. Flecainide b. Quinidine c. Procainamide d. Lidocaine

Answer 49

Classes of antiarrhythmic actions Class I – local anesthetic effect due to blockade of the Na current Class Ia – moderate potency and intermediate kinetics (quinidine, procainamide) Class Ib – low potency and rapid kinetics (lidocaine, mexiletine) Class Ic – high potency and slowest kinetics (flecainide, propafenone) Class II – interference with the action of catecholamines at the beta adrenergic receptor Class III – delay of repolarization due to inhibition of K current or activation of depolarizing current Class IV -interference with Calcium conductance The correct answer is: Flecainide

Question 50

Stephanie is a football athlete who was referred for cardiology clearance. She has been playing football since she was 10 years old. She has no symptoms at all. Her heart rate is slow, about 54 beats/min, but her cardiac exam is essentially normal. A 12 L ECG showed occasional no visible P waves of up to 3sec. What is the 12 L ECG reading of the patient? a. Sinus Arrest b. Sinus Pause c. Type I SA block d. Type II SA block

Answer 50

Sinus pauses and sinus arrest result from failure of the SA node to discharge, producing a pause without P waves visible on the ECG. Sinus pauses of up to 3s are common in awake athletes, and pauses of this duration or longer may be seen in asymptomatic elderly subjects Sinus bradycardia is a rhythm driven by the SA node with a rate of < 60 beats/min. A sinus rate of < 40 beats/min in the awake state in the absence of physical condition is considered abnormal The correct answer is: Sinus Pause

Question 51

Karen has been experiencing light headedness for one month. She would experience “black outs” almost daily. She would have 1 episode of this black outs, but the episodes have been occurring 2-3x a day, that is why she requested for a consult. Her cardiologist advised her to have a pacemaker implanted. Which of the following is a Class I indication for pacemaker implantation? a. Atrial fibrillation with bradycardia and pauses >5 sec b. Mildly symptomatic patients with heart rates <40 beats/min c. Syncope of unknown origin d. SA node dysfunction with HR <40 beats/min on drug treatment

Answer 51

Class I indication SA node dysfunction with symptomatic bradycardia or sinus pause Symptomatic SA node dysfunction as a result of essential long term drug therapy with no acceptable alternatives Symptomatic chronotropic incompetence Atrial Fibrillation with bradycardia and pauses >5s The correct answer is: Atrial fibrillation with bradycardia and pauses >5 sec

Question 52

George is undergoing a laparoscopic surgery for acute cholelithiasis. He started to have right sided abdominal pain last night. His surgeon, Dr. Harris, requested for a 12 L ECG and she noticed an aberrancy in the tracing. He was immediately referred to Dr. Reyes, a cardiologist. What is the diagnosis? a. First degree AV block b. Mobitz Type 1 AV block c. Mobitz Type 2 AV block d. High Grade AV block

Answer 52

First degree AV block (PR interval > 200 ms) is a slowing of conduction through the AV junction, the site of delay is typically in the AV node but may be in the atria, bundle of His or His-Purkinje system. A wide QRS suggests delay in the distal conduction system, while a narrow QRS suggests delay in the AV node proper or in the bundle of His The correct answer is: First degree AV block

Question 53

Chris, 68/M, was rushed to the emergency room for persistent palpitations and light headedness. A 12 L ECG was immediately done and the ECG reader diagnosed it to be a Permanent Junctional Reciprocating Tachycardia. What is the configuration of PJRT in the 12L ECG? a. Presence of delta waves and short PR interval b. Narrow QRS and a right bundle branch block c. Narrow QRS tachycardia with ventriculoatrial block d. Negative P waves in leads II, III and aVF

Answer 53

Permanent Junctional Reciprocating Tachycardia (PJRT) Have negative P waves in leads II, III and aVF, and slow AP conduction facilitates reentry, often leading to nearly incessant tachycardia AV Reentry Tachycardia - The QRS is narrow or may have typical right or left bundle branch block, but without preexcitation during tachycardia Junctional Tachycardia - Presents as a narrow QRS tachycardia, often with a ventriculoatrial block Accessory Pathways (WPW) - ECG shows a short PR interval (<0.12 s), slurred initial portion of the QRS (delta wave), and prolonged QRS duration produced by slow conduction The correct answer is: Negative P waves in leads II, III and aVF

Question 54

Cooper was having palpitations and chest pains three months ago especially during exercise. However, he would be asymptomatic if he is at rest or not stressed. He underwent 24 hour Holter monitoring and results showed non-sustained ventricular tachycardia. He was given a medication to lower down the heart rate which eventually improved his condition. Two weeks ago, he started to have lethargy, cold intolerance, hair loss and noticed that he was gaining weight. What medication could have caused this? a. Flecainide b. Quinidine c. Amiodarone d. Diltiazem

Answer 54

Amiodarone and Dronaderone – amiodarone blocks multiple cardiac tonic currents and has sympatholytic activity; and is the most effective antiarrhythmic drug for suppressing ventricular arrhythmias; bradyarrhythmias are the major cardiac event, hyper or hypothyroidism are related to the iodine content of the drug. Dronaderone has structural similarities to amiodarone without the iodine moiety The correct answer is: Amiodarone

Question 55

Tyler, a 24/M, was rushed to emergency room for sudden loss of consciousness. He is a perfectly fit young man, no previous symptoms of chest pain, palpitations or dizziness. He was complaining that he had a slight fever and colds yesterday. One hour ago, his girlfriend saw him unconsciousness and was rushed to the ER. What would you look for in the 12 L ECG if you are suspecting Brugada Syndrome for Tyler? a. Negative T waves in V1-V3 b. Prolonged QTc >440 ms c. Alternating QRS morphology d. J-point elevation

Answer 55

Brugada syndrome Rare syndrome characterized by > 0.2 mV of ST segment elevation with a coved ST segment and negative T wave in more than one anterior precordial lead (V1-V3) Episodes of syncope or cardiac arrest may occur during sleep or provoked by febrile illness due to polymorphic VT can occur in the absence of structural heart disease ICD is indicated for individuals with unexplained syncope or been resuscitated from cardiac arrest Quinidine and catheter ablation have been successful to suppress frequent episodes of VT The correct answer is: Negative T waves in V1-V3

Question 56

Regie was diagnosed with rheumatic heart disease since he was 12 years old. He had limited follow ups to his cardiologist because of financial constraints. One year ago, he started to have persistent tachycardia and a 12 L ECG showed Atrial Fibrillation. His cardiologist wanted to give him an antithrombin inhibitor which would lessen his INR monitoring. However, his concern was the cost of the medication. Which of the following is the prescribed drug for Regie? a. Warfarin b. Rivaroxaban c. Dabigatran d. Apixaban

Answer 56

Major options for anticoagulation are Antithrombin inhibitor - dabigatran, Factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the Vitamin K antagonist warfarin. Antiplatelet agents are generally not sufficient. Warfarin is an inconvenient agent that requires several days to reach a therapeutic effect (INR >2) The correct answer is: Dabigatran

Question 57

Jasper is a 24 year old vegan who has been experiencing difficulty of breathing. It started 4 months ago when he started to feel tired and exhausted after work. He would be be awaken at night just to catch his breath. Last month he noticed that his ankles were swollen. Physical examination showed pale nailbeds and conjunctivae. He had a grade 2/6 systolic murmur at the 4th ICS LPSB. His cardiologist ordered a 2D echocardiogram and results showed an EF of 45%. What is the cause of the heart failure? a. Chronic pressure overload b. Pathologic hypertrophy c. High output states d. Chronic volume overload

Answer 57

Cause of heart failure: chronic anemia and possible nutritional disorders because patient is vegan. The correct answer is: High output states

Question 58

Quimson is a 63 year old, male, hypertensive with no maintenance anti-hypertensives. He consults for edema of 1 month duration, associated with exertional dyspnea. There is a family history of heart attack. He is also a 20 pack year smoker and occasional alcoholic drinker. He lives a sedentary lifestyle. On PE, he has bipedal edema, S3 gallop and a TR murmur. Which among the risk factors in this case is known to contribute to the development of heart failure the most? a. Hypertension b. Age c. Family history d. Smoking

Answer 58

Hypertension contributes to the development in 75% of patients, including most patients with CAD The correct answer is: Hypertension

Question 59

Walid, a 45 year-old male underwent an annual check up for his company. A 2D echocardiogram was done and showed LV hypertrophy with an EF of 48%. He is essentially asymptomatic. The only pertinent in the history is a family history of heart attack and his 10 pack year smoking. What compensatory mechanism would allow the functional capacity to be preserved despite of the presence of cardiac injury? a. Decreased vasodilatory molecules such as nitric oxide b. Activation of parasympathetic nervous system c. Activation of the RAAS d. Decreased myocardial contractility

Answer 59

Compensatory mechanisms that have been activated in the presence of cardiac injury which modulates LV function so that functional capacity of patient is preserved, allowing patients to remain asymptomatic or mildly symptomatic • Activation of the RAAS and the adrenergic nervous system • Increased myocardial contractility • Countervailing vasodilatory molecules are activated including ANP, BNP, bradykinins, PGE2 and PGI2, and nitric oxide The correct answer is: Activation of the RAAS

Question 60

Hannah a 60 year old retired teacher was seen at the OPD for difficulty breathing at night. She would be awaken 3-4x at night because of having to catch her breath. Which of the following statements is consistent with the pathophysiology of her symptom? a. Redistribution of fluid from splanchnic circulation b. Increased sensitivity of the respiratory center to arterial PCO2 c. Reduction in stroke volume d. Increased pressure in bronchial arteries

Answer 60

Paroxysmal Nocturnal Dyspnea (PND) refers to acute episodes of severe shortness of breath and coughing that generally occurs at night and awaken the patient from sleep. This is due to increased pressure in the bronchial arteries leading to airway compression, along with interstitial pulmonary edema that leads to increased airway resistance The correct answer is: Increased pressure in bronchial arteries

Question 61

Niel, 51/M, is diagnosed with Type 2 DM, and hypertension. For the latter, he is on Valsartan once a day. He had an acute MI last year and underwent PTCA for left circumflex artery. Six months ago, he experienced exertional dyspnea. The shortness of breath is progressive, he now has difficulty of breathing when walking for a few meters. He also has ankle swelling on both legs. He would also be awaken at night and has a 4 pillow orthopnea. He also feels weak most of the time. Based on the New York Heart Association, what is his heart failure classification? a. Class I b. Class II c. Class III d. Class IV

Answer 61

The NYHC: Class I : Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea or pain Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain Class III: Patients with cardiac disease resulting in marked limitation of physical activity. Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased The correct answer is: Class III

Question 62

Choi is a 69/M who came to emergency room for labored breathing. On history, he is a 30 pack year smoker and works as a construction worker. On PE, he has pale nailbeds, bipedal edema. Pulmonary PE showed expiratory wheezes in the bibasal lung fields. Cardiac PE showed an RV heave and S3 gallop. A 12 L ECG was requested. What ECG finding would be expected for this patient? a. Sinus rhythm b. Left ventricular hypertrophy c. Right axis deviation, p pulmonale d. Paroxysmal ventricular contractions

Answer 62

Cor Pulmonale 12 L ECG findings ECG in severe pulmonary hypertension shows P pulmonale, right axis deviation and RV hypertrophy The correct answer is: Right axis deviation, p pulmonale

Question 63

King, a known chronic bronchial asthma patient, is seen at the OPD clinic for increased exertional dyspnea. A 2D echo was requested and showed EF of 55%. A diagnosis of HFpEF was made. Which of the following medications may be effective in improving filling pressures and RV function? a. Candesartan b. Isosorbide mononitrate c. Digoxin d. Sildenafil

Answer 63

HF with Preserved Ejection Fraction • Control of congestion • Stabilization of heart rate and blood pressure • Improving exercise tolerance • Regression of ventricular hypertrophy in hypertensive heart disease • Use of lusitropic agents has been disappointing • The use of Candesartan (CHARM trial) showed reduction in hospitalizations but no difference in HFpEF, same with Irbesartan • Digitalis has no role in HFpEF • Sildenafil improved filling pressures and RV function in a cohort of HFpEF patients with pulmonary venous hypertension The correct answer is: Sildenafil

Question 64

Which of the following factors that has been shown to have worst outcomes in heart failure patients in registries? a. Creatinine >2.75 mg/dl b. Systolic BP >140 mmHg c. Blood Urea Nitrogen <30 mg/dl d. HbA1C >7.0%

Answer 64

Worst outcomes in in-hospital registries: • BUN > 43 mg/dl • Systolic BP < 115 mmHg • Creatinine >2.75 mg/dl • Elevated troponin I level The correct answer is: Creatinine >2.75 mg/dl

Question 65

Mr. Nicolas, 69/M, is a known heart failure patient on Losartan 50 mg/tab once daily, Bisoprolol 5 mg/tab 1 tab once a day and Spironolactone 25 mg/tab 1 tab once daily. His wife noticed that during sleep, he would have episodes of no breathing followed by gasping for air, thus this consult. What is the type of respiration being described by Mr. Nicolas? a. Biot respiration b. Cheyne-stokes respiration c. Central neurogenic hypoventilation d. Kussmaul respiration

Answer 65

Cheyne-Stokes Respiration is a periodic or cyclic respiration and is present in 40% of patients with advanced HF. This is caused by an increased sensitivity of the respiratory center to arterial PCO2 and a lengthy circulatory time Biot respiration - Biot's respiration is an abnormal pattern of breathing characterized by groups of regular deep inspirations followed by regular or irregular periods of apnea Kussmauls respiration - it's characterized by a deep, rapid breathing pace throughout its duration. Central neurogenic hypoventilation - is an abnormal pattern of breathing characterized by deep and rapid breaths at a rate of at least 25 breaths per minute. The correct answer is: Cheyne-stokes respiration

Question 66

Charlie, 59/M, consults for ankle swelling, bilateral for one month now. He is a known hypertensive since 2010 on Losartan 50 mg/tab once daily. Last year, he started to have intermittent chest pains especially when he is stressed, gasps for air every time he would climb the stairs of the LRT station. He was given a medication that reduces systemic vascular resistance and induces arterial vasodilation by his physician. Which of the following medications would have this particular mechanism of action? a. Beta blocker b. Aldosterone antagonist c. Hydralazine d. Nitroglycerin

Answer 66

Hydralazine reduces systemic vascular resistance and induces arterial vasodilation Nitrates are transformed in smooth muscle cells into nitric oxide which stimulates cyclic GMP and consequent arterial-venous vasodilation Aldosterone antagonism is associated with a reduction in mortality in all stages of symptomatic NYHA class II to IV HFrEF • Aldosterone promote sodium imbalance • Electrolyte imbalance • Endothelial dysfunction • Myocardial fibrosis Beta blockers and RAAS blockers form the cornerstone of pharmacotherapy The correct answer is: Hydralazine

Question 67

Joe Santiago, a known diabetic, has been recently been diagnosed with congestive heart failure. He was experiencing worsening exertional dyspnea, 3 pillow orthopnea and bipedal edema. In the review of medications, he was on four anti-diabetic medications. Which of the following medications should avoided for heart failure patients? a. DPP4 antagonists b. Thiazolinediones c. SGLT inhibitors d. GLP-1 receptor antagonists

Answer 67

Prior studies using thiazolidinediones (activators of peroxisome proliferator activated receptors) have been associated with worsening heart failure. Glucagon-like peptide 1 (GLP-1) agonists such as liraglutide have also been tested and do not lead to greater post-hospitalization clinical stability or worsening in heart failure. Recently, the drug empagloflozin was tested in the EMPA-REG study and demonstrated a decrease in cardiovascular mortality The correct answer is: Thiazolinediones

Question 68

Rodney, 49/M obese, hypertensive and diabetic, is complaining of worsening exertional dyspnea for 8 months now. He has 3 pillow orthopnea, bidepal edema and right sided abdominal pain. He has continuous follow up with his cardiologist and the medications improved his condition. Recently, he had elevation of blood pressures of 140-150/80-85 mmHg. He sought telemedicine consult and was given a particular medicine that worsened the exertional dyspnea. Which of the following medications should be avoided in his case due to its effect destabilization of heart failure? a. Verapamil b. Felodipine c. Nimodipine d. Amlodipine

Answer 68

Amlodipine and felodipine can safely and effectively reduce blood pressure in HFrEF but do not affect morbidity, mortality or QoL Verapamil and Diltiazem exert negative inotropic effect and destabilize previously asymptomatic patients The correct answer is: Verapamil

Question 69

True statement about the signs and symptoms of heart failure: a. Orthopnea tends to appear early in the course of heart failure than exertional dyspnea b. The coughing and wheezing of paroxysmal nocturnal dyspnea tend to persist even after the patient has assumed the upright position c. Giant a-waves may indicate presence of tricuspid regurgitation d. Unilateral pleural effusions can occur, and are more common on the left side because of the location of the heart on the left side of the chest

Answer 69

The correct answer is: The coughing and wheezing of paroxysmal nocturnal dyspnea tend to persist even after the patient has assumed the upright position

Question 70

The following patient/s may be having angina pectoris or its equivalents: a. 65 year old male, chronic smoker, who suddenly complained of acute heavy pain in the right parasternal area while doing his routine morning jog. He also complained that the pain involved the right chest up to the middle portion of his back b. 54 year old female, uncontrolled diabetic who suddenly complained of pain in the hypogastric area occurring while she was doing grocery. c. A 24 year old athlete who had a brief (3 minutes) episode of severe, crushing and heavy chest pain after he performed his gymnastics routine d. All of the above patients may be experiencing angina or anginal equivalents

Answer 70

The correct answer is: A 24 year old athlete who had a brief (3 minutes) episode of severe, crushing and heavy chest pain after he performed his gymnastics routine

Question 71

Which of the following pathophysiologic mechanism is true regarding transient ECG changes during ischemia? (P 1862) a. Transient T wave inversion reflects non-transmural ischemia b. Transient ST segment elevation may be seen in transmural myocardial ischemia c. Deep ST depression reflects transmural ischemia d. Deep T wave inversion reflects intramyocardial infarction

Answer 71

ECG changes during ischemia includes: • Transient T wave inversion – non-transmural, intramyocardial ischemia • Transient ST segment depression – patchy subendocardial ischemia • ST segment elevation – reflects more severe transmural ischemia • Repolarization abnormalities ( T wave inversion) and when severe, ST segment displacement The correct answer is: Transient T wave inversion reflects non-transmural ischemia

Question 72

Robert was doing his brisk walking when he suddenly felt severe pain at his left chest. He suddenly placed his hand over his sternum, clutching it with a clenched fist because of discomfort. What is the medical term of Robert’s attitude of clutching the mid-chest because of pain? (p 1863) a. Waterhammer sign b. Osler’s sign c. Levine’s sign d. Turner’s sign

Answer 72

Localize pain over the sternum, sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort (Levine’s sign) Waterhammer sign - abrupt distension and collapse of carotid arteries as a sign indicating aortic incompetence. Osler’s sign - A patient who has a palpable, although pulseless, radial artery while the blood pressure cuff is inflated above systolic pressure Turner’s sign - refers to bruising of the flanks, the part of the body between the last rib and the top of the hip The correct answer is: Levine’s sign

Question 73

Dr. Ignacio was observing the treadmill exercise test of Evan, a 54/M, who complains of occasional epigastric pain whenever he goes up a flight of stairs. After 10 minutes, Dr. Ignacio stopped the exercise test. Which of the following may lead to discontinuation of the test? a. ST elevation 0.1 mV above baseline b. Fall of systolic blood pressure by 5 mmHg c. Bradycardia during exercise d. Severe shortness of breath

Answer 73

Indications for discontinuation of Treadmill Test • chest discomfort • severe shortness of breath • dizziness • severe fatigue • ST-segment depression >0.2 mV (2 mm) • a fall in systolic blood pressure >10 mmHg • the development of a ventricular tachyarrhythmia The correct answer is: Severe shortness of breath

Question 74

Geneis a 38 y.o. male, was having intermittent chest pains aggravated by running and climbing a flight of stairs and relieved by rest. He was given anti-anginal medications however, he was advised coronary arteriography. Which of the following is an indication for coronary arteriography in his case? (p 1857) a. Diagnosed angina pectoris and are relieved by medications b. There is a need to confirm or rule out IHD c. Patients with low risk of sustaining coronary events d. Patients with known angina pectoris with no known history of cardiac arrest

Answer 74

Indications Coronary arteriography is indicated in (1) patients with chronic stable angina pectoris who are severely symptomatic despite medical therapy and are being considered for revascularization,i.e., a percutaneous coronary intervention (PCI) or coronary arterybypass grafting (CABG); (2) patients with troublesome symptoms that present diagnostic difficulties in whom there is a need to confirm or rule out the diagnosis of IHD; (3) patients with known or possible angina pectoris who have survived cardiac arrest; (4) patients with angina or evidence of ischemia on noninvasive testing with clinical or laboratory evidence of ventricular dysfunction; and (5) patients judged to be at high risk of sustaining coronary events based on signs of severe ischemia on noninvasive testing, regardless of the presence or severity of symptoms The correct answer is: There is a need to confirm or rule out IHD

Question 75

Fr. Edgar, the parish priest, was diagnosed with angina pectoris by the primary care physician in their town. He was having occasional chest pain during his sermons but would be relieved whenever he sits down. He was given an unknown medication which relieved his symptoms. However, he started to have dizziness especially when standing up, headaches, and palpitations whenever he stops his medication. Which of the following may have caused the symptoms? (p 1862) a. Metoprolol b. Diltiazem c. Amlodipine d. Nitroglycerin

Answer 75

The correct answer is: Nitroglycerin

Question 76

Dr. Reyes was working on an alternative medication for chest pains. The medication’s mechanism of action opens ATP-sensitive potassium channels in myocytes, which leads to a reduction of free intracellular ions. Which of the following medications has the abovementioned mechanism of action? (p 1862) a. Nicorandil b. Ivabradine c. Ranolazine d. Sacubutril

Answer 76

Another class of agents opens ATP-sensitive potassium channels in myocytes, leading to a reduction of free intracellular calcium ions. The major drug in this class is nicorandil. Ranolazine, a piperazine derivative, may be useful for patients with chronic angina despite standard medical therapy. Its antianginal action is believed to occur via inhibition of the late inward sodium current (INa) Ivabradine (2.5–7.5 mg orally twice daily) is a specific sinus node inhibiting agent that may be helpful for preventing cardiovascular events in patients with IHD who have a resting heart rate ≥70 beats/min (alone or in combination with a beta blocker) and LV systolic dysfunction. The correct answer is: Nicorandil

Question 77

What among the statements is an indication for percutaneous coronary intervention (PCI)? a. Left main coronary artery disease b. Left ventricular Ejection fraction <50% c. Two-vessel coronary artery disease d. Presence of diabetes mellitus

Answer 77

It is now recommended that patients with an unacceptable level of angina despite optimal medical management be considered for coronary revascularization. Patients with single- or two-vessel disease with normal LV function and anatomically suitable lesions ordinarily are advised to undergo PCI. The correct answer is: Two-vessel coronary artery disease

Question 78

Which of the following is true regarding cardiac biomarkers? a. At least one value is above the 90th percentile of the upper reference limit b. Creatine phosphokinase rises within 2-4 hours of the event c. The MM isoenzyme of the creatine phosphokinase is considerably specific d. A relative index of CK-MB to CK activity >=2.5 suggestive of myocardium

Answer 78

CK rises within 4–8 h and generally returns to normal by 48–72 h (Fig. 269-3). An important drawback of total CK measurement is its lack of specificity for STEMI, as CK may be elevated with skeletal muscle disease or trauma, including intramuscular injection. The MB isoenzyme of CK has the advantage over total CK that it is not present in significant concentrations in extracardiac tissue and, therefore, is considerably more specific. However, cardiac surgery, myocarditis, and electrical cardioversion often result in elevated serum levels of the MB isoenzyme. A ratio (relative index) of CK-MB mass to CK activity ≥2.5 suggests but is not diagnostic of a myocardial rather than a skeletal muscle source for the CK-MB The correct answer is: A relative index of CK-MB to CK activity >=2.5 suggestive of myocardium

Question 79

What is the definition of a PCI-related myocardial infarction? a. Elevation of cardiac troponin >2x the upper limit of normal baseline values b. Elevation of cardiac troponin >90th percentile above the upper limit of normal baseline values c. Cardiac Troponin >20% above if the baseline values are elevated d. Cardiac Troponin >95th percentile above if the baseline values are elevated

Answer 79

Myocardial infarction associated with PCI is arbitrarily defined by elevation of cardiac troponin (cTn) values >5 Å~ 99th percentile upper reference limit (URL) in patients with normal baseline values (≤99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, either (i) symptoms suggestive of myocardial ischemia, or (ii) new ischemic ECG changes or new LBBB, or (iii) angiographic loss of patency of a major coronary artery or a side branch or persistent slow or no flow or embolization, or (iv) imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality is required. The correct answer is: Cardiac Troponin >20% above if the baseline values are elevated

Question 80

Andy was rushed to the emergency room for chest pains. Unfortunately, the hospital he was brought initially, does not have a cardiac care facility. How fast must Andy be transferred to a cardiac care facility with a goal of initiating PCI? a. 60 min b. 90 min c. 120 min d. 150 min

Answer 80

This may involve transfer from a non-PCI hospital to one that is PCI capable, with a goal of initiating PCI within 120 min of first medical contact The correct answer is: 120 min

Question 81

A 32/F, non-diabetic, non-hypertensive, diagnosed case of Cervical Cancer Stage III presented at the ER for 1 week history of exertional dyspnea followed by a 2 hour history of sudden, crushing chest pain. Her ECG showed acute anterior wall myocardial infarction. Further history showed one month of incessant vaginal bleeding. Her hemoglobin is only 5 g/L. Using the Universal Definition of Myocardial Infarction, what type of myocardial infarction does this patient most likely have? (HPIM 20th Ed. P. 1877) a. Type 1 b. Type 2 c. Type 3 d. Type 4

Answer 81

Type 1 – Spontaneous Myocardial Infarction Type 2 – MI sec to an ischemic imbalance Type 3 – MI resulting in Death when values are unavailable Type 4 - MI related to PCI/Stent The correct answer is: Type 2

Question 82

The anatomical site that determines most of the peripheral vascular resistance: a. Medium-sized arteries and arterioles b. Small and medium-sized arteries c. Small arteries and arterioles d. Arterioles and venoules

Answer 82

The correct answer is: Small arteries and arterioles

Question 83

Which of the following statements correctly describes the pathologic consequences of hypertension? a. Aggressive control of hypertension cannot reverse left ventricular hypertrophy once it sets in b. Treatment of hypertension decreases the incidence of hemorrhagic stroke, but not of ischemic stroke c. Risk of renal complications from hypertension is equally affected by both systolic and diastolic pressure d. Hypertension is related to the development of dementia via beta amyloid deposition

Answer 83

The correct answer is: Hypertension is related to the development of dementia via beta amyloid deposition

Question 84

Which of the following is true regarding genetic considerations of hypertension? a. Genetic determinants account for 25% of all blood pressure variants. b. The gene coding for alpha adducin is associated with decreased sodium reabsorption c. Genetic determinants have been linked to CHD and stroke d. Detailed genome-wide epigenetic modifications in hypertension have pinpointed specific genes for hypertension

Answer 84

Specific genetic variants have been linked to CHD and stroke. Identified genetic determinants account for ~1% of blood pressure variance Genes that encode components of the renin-angiotensin-aldosterone system, atrial natriuretic peptide, the beta-2 adrenoreceptor, and alpha adducin (associated with increased renal tubular reabsorption of sodium). Current results of detailed genome-wide epigenetic modifications of DNA are limited and conflicting. The correct answer is: Genetic determinants have been linked to CHD and stroke

Question 85

Chung, a Chinese national, visited the out-patient clinic for hypertension. She is 63 years old and a retired teacher. Her blood pressure readings were 150-160/90 mmHg and is associated with nape pains and palpitations. When asked about her diet, she loves to eat a typical Chinese meal heavy on salt. Which of the following is true regarding salt-dependent hypertension? (p 1892) a. This is caused by an increased capacity of the kidney to excrete salt b. There is increased production of mineralocorticoid resulting to sodium secretion c. There is decreased neural activity of the kidney d. There is increased activity of the renin-angiotensin system

Answer 85

NaCl-dependent hypertension may be a consequence of a decreased capacity of the kidney to excrete sodium, due either to intrinsic renal disease or to increased production of a salt-retaining hormone (mineralocorticoid) resulting in increased renal tubular reabsorption of sodium. Renal tubular sodium reabsorption also may be augmented by increased neural activity to the kidney. In each of these situations,a higher arterial pressure may be required to achieve sodium balance. Conversely, salt-wasting disorders are associated with low blood pressure levels. ESRD is an extreme example of volume-dependent hypertension. In ~80% of these patients, vascular volume and hypertension can be controlled with adequate dialysis; in the other 20%, the mechanism of hypertension is related to increased activity of the renin-angiotensin system and is likely to be responsive to pharmacologic blockade of renin-angiotensin. The correct answer is: There is increased activity of the renin-angiotensin system

Question 86

George is a 23 year-old basketball player who complains of nape pains and elevated BP. Work up has been done and secondary causes have been ruled out. He is very active and watches his diet very well. He decided to join this experiment which measures his sympathetic nervous system, and the results showed that his BP elevation is caused by hyperactivity of the SNS. Which of the following is FALSE regarding the impact of the autonomic nervous system? (p 1892) a. Upregulation of receptors may be a consequence of high levels of catecholamines b. Increased firing in stretch-sensitive sensory nerve endings in the carotid sinuses may elevated blood pressure c. Norepinephrine, epinephrine and dopamine all play important roles in SNS regulation d. Both normal weight and obese individuals may be associated with increased sympathetic outflow.

Answer 86

Downregulation of receptors maybe a consequence of sustained high levels of catecholamines and providesan explanation for decreasing responsiveness, or tachyphylaxis, to catecholamines. Rest are true The correct answer is: Upregulation of receptors may be a consequence of high levels of catecholamines

Question 87

Which of the following is not a stimuli for renin secretion? a. Decreased NaCL transport in the distal portion of the thick ascending limb of the loop of Henle b. Angiotensin II inhibition of renin secretion on the JG cells c. Decreased pressure or stretch in the renal afferent arteriole d. SNS stimulation of renin-secreting cells via beta1 receptors

Answer 87

Three primary stimuli for Renin production: - decreased NaCl transport in the distal portion of the thick ascending limb of the loop of Henle that abuts the corresponding afferent arteriole (macula densa), - decreased pressure or stretch within the renal afferent arteriole (baroreceptor mechanism), and - sympathetic nervous system stimulation of renin-secreting cells via β1 adrenoreceptors. The correct answer is: Angiotensin II inhibition of renin secretion on the JG cells

Question 88

In the Hypertension in the Very Elderly clinical trial, the results using a diuretic was very promising in lowering blood pressure. Dr. Ramos decided to give indapamide to his 84 year old patient. However, four days prior to taking the medication, his patient was rushed to the eergency room for dehydration. Dr. Ramos was looking for an alternative medication for the BP elevation. Which of the following pathophysiologic consequences of hypertension would Dr. Ramos consider for his patient? a. Increased Renin-angiotensin-aldosterone activation b. Hyperactive autonomic nervous system c. Arterial stiffness d. Salt dependent hypertension

Answer 88

An association between arterial stiffness and hypertension is well established. A stiffened vasculature is less able to buffer shorttermalterations in flow. Although it has been assumed that arterial stiffness is a manifestation of hypertension, recent evidence suggests that vascular stiffness may also represent a cause of hypertension. The correct answer is: Arterial stiffness

Question 89

Tony, a 55 year old male noticed that his BP readings were sustained at 140/90 mmHg since last year. He is not complaining of any symptoms. Recently, he stopped exercising because of work and gained a few extra pounds. Laboratory results showed proteinuria. Which of the following kidney structures is primarily affected in his case to produce proteinuria? a. Preglomerular arterioles b. Postglomerular arterioles c. Intraglomerular cells d. Glomerular capillary

Answer 89

Atherosclerotic, hypertension-related vascular lesions in the kidney primarily affect preglomerular arterioles, resulting in ischemic changes in the glomeruli and postglomerular structures. Glomerular injury also may be a consequence of direct damage to the glomerular capillaries due to glomerular hyperperfusion. Studies of hypertension-related renal damage, primarily in experimental animals, suggest that loss of autoregulation of renal blood flow at the afferent arteriole results in transmission of elevated pressures to an unprotected glomerulus with ensuing hyperfiltration, hypertrophy, and eventual focal segmental glomerular sclerosis. The correct answer is: Preglomerular arterioles

Question 90

Myra, a 30 year old school teacher was rushed to the emergency room for high grade fever. She has experiencing occasional tremors, diarrhea, weight loss and hair loss. Which blood pressure characteristic is to be expected in this case? a. Elevated systolic and diastolic BP b. Elevated diastolic BP c. Widened pulse pressure d. High mean arterial pressure

Answer 90

Systolic Hypertension with Wide Pulse Pressure 1. Decreased vascular compliance (arteriosclerosis) 2. Increased cardiac output a. Aortic regurgitation b. Thyrotoxicosis c. Hyperkinetic heart syndrome d. Fever e. Arteriovenous fistula f. Patent ductus arteriosus The correct answer is: Widened pulse pressure

Question 91

Dorie, an 84 year old, was rushed to the emergency room for sudden elevation of blood pressure. She has been hypertensive since she was 80 years old and was controlled on amlodipine 5 mg once daily. However, her BP reading last year started to increase some more. Two weeks ago, she went to her cardiologist. She was given an unrecalled medication. However, three days on the medication, her BP shot up to 160 systolic with associated nape pains. What condition may have caused this? (p 1897) a. Chronic kidney disease b. Pheochromocytoma c. Isolated systolic hypertension d. Renovascular hypertension

Answer 91

Renovascular hypertension should be considered in patients with other evidence of atherosclerotic vascular disease. Severe or refractor hypertension, recent loss of hypertension control or recent onset of moderately severe hypertension, and unexplained deterioration of renal function or deterioration of renal function associated with an ACE inhibitor should raise the possibility of renovascular hypertension. Approximately 50% of patients with renovascular hypertension have an abdominal or flank bruit, and the bruit is more likely to be hemodynamically significant if it lateralizes or extends throughout systole into diastole. The correct answer is: Renovascular hypertension

Question 92

Jane has been experiencing bilateral leg weakness. Yesterday she had another attack of leg weakness and was immediately brought to the company clinic. Her BP reading was 148/86 mmHg at the clinic. She was given Gatorade which improved her weakness and was advised to see a specialist. Her laboratory results showed a low potassium of 3.0 mg/dl. The specialist decided to measure the plasma aldosterone and renin activity. Which of the following results is highly sensitive to her diagnosis? a. Plasma aldosterone concentration/plasma renin activity (PAC/PRA) of >10:1 b. PAC/PRA >20:1 c. PAC/PRA >30:1 d. PAC/PRA >40:1

Answer 92

The ratio of plasma aldosterone to PRA (PA/PRA) is a useful screening test. These measurements preferably are obtained in ambulatory patients in the morning. A ratio >30:1 in conjunction with a plasma aldosterone concentration >555 pmol/L (>20 ng/dL) reportedly has a sensitivity of 90% and a specificity of 91% for an aldosterone-producing adenoma. The correct answer is: PAC/PRA >30:1

Question 93

Ronald has been having headaches, flushing and elevated blood pressures. He would have several visits to the emergency room for BP as high as 200 mmHg systolic. He is already on four antihypertensive medications, but his BP is still elevated. Which of the following medication is the most appropriate for Ronald? a. Phentolamine b. Clonidine c. Alpha methyldopa d. Guanfacine

Answer 93

Catecholamine-secreting tumors are located in the adrenal medulla (pheochromocytoma) or in extra-adrenal paraganglion tissue (paraganglioma) and account for hypertension in ~0.05% of patients. If unrecognized, pheochromocytoma may result in lethal cardiovascular consequences. Medical treatment involves alpha blockers, and surgical management is the definitive treatment. The correct answer is: Phentolamine

Question 94

Which of the following genetic causes is associated with polycystic kidney disease? a. Mutation in chromosome 16 b. Mutation in the RET protooncogene c. Random mutation in chromosome 10 d. Mutation in chromosome 8q21

Answer 94

Polycystic kidney disease - Mutations in the PKD1 gene on chromosome 16 and PKD2 gene on chromosome 4 Pheochromocytoma - Mutations in the RET protooncogene 17α-hydroxylase deficiency - Random mutations of the CYP17 gene on chromosome 10 11β-hydroxylase deficiency - Mutations of the CYP11B1 gene on chromosome 8q21-q22 The correct answer is: Mutation in chromosome 16

Question 95

Marlon is a newly diagnosed hypertensive. His BP readings range from 140-150/70-80 mmHg. He had a high predisposition to hypertension as both his parents were hypertensive. During his consult, he asked what lifestyle change he needs to implement to help in lowering his BP. Which of the following is correct? a. Attain a BMI of <30 kg/m2 b. Consume <2 drinks/day in women c. Salt reduction of <8 g NaCl/day d. Brisk walking 30 min/day

Answer 95

Weight reduction – attain and maintain < 25 kg/m2 Dietary salt reduction - < 6 g NaCl Diet rich in potassium, vegetables, low fat dairy (DASH diet) Regular aerobic exercise for 30 min/day For those who drink alcohol, consume ≤2 drinks/d in men and ≤1 drink/d in women The correct answer is: Brisk walking 30 min/day

Question 96

Dave is a 49 y.o. male with a difficult-to-treat hypertension. He is presently on four anti-hypertensive medications and with BP readings 130-140/70-75 mmHg. However, two weeks ago, his right big toe became painful and inflamed. Which of the following medications may have caused this? a. Spironolactone b. Amiloride c. Chlorthalidone d. Triamterene

Answer 96

Thiazide and loop diuretics may lead to gout. More common side effects of aldosterone blockers and K- sparing diuretics are renal failure and hyperkalemia The correct answer is: Chlorthalidone

Question 97

Leo is a 54 year old man who complains of intermittent calf pains whenever he exercises in the morning for the past 6 months. He describes it as cramping and aching sensation when he exercises and would be relieved by rest. The pain was increasing in intensity, thus the consult. What physical finding is commonly seen in this condition? a. Increased pulses in the popliteal area b. Gain in muscle mass c. Hair loss d. Absence of bruits distal to obstruction

Answer 97

Important physical findings of PAD include decreased or absent pulses distal to the obstruction, the presence of bruits over the narrowed artery, and muscle atrophy. With more severe disease, hair loss, thickened nails, smooth and shiny skin, reduced skin temperature, and pallor or cyanosis are common physical signs The correct answer is: Hair loss

Question 98

Ming, 64/F, was seen in the out patient clinic for left leg pain. She had been complaining of the leg pain whenever she starts walking and would be relieved by rest. However, the pain was increasingly bothersome so she went in for a consult. The primary care physician measured both brachial and ankle blood pressures. What value of the ankle:brachial index (ABI) would be indicative of valvular calcification? a. <0.90 b. 0.91- 0.99 c. 1.0 – 1.40 d. >1.40

Answer 98

The ratio of the ankle and brachial artery pressures (termed the ankle:brachial index, or ABI) is 1.00–1.40 in normal individuals. ABI values of 0.91–0.99 are considered “borderline,” and those <0.90 are abnormal and diagnostic of PAD. ABIs >1.40 indicate noncompressible arteries secondary to vascular calcification The correct answer is: >1.40

Question 99

Mr. Cooper is a 68 year old Australian was diagnosed with peripheral artery disease for intermittent claudication in both his legs. He was given a medication that blocks the protease activator receptor-1 that reduces acute limb ischemia but is also associated with moderate bleeding. Which of the following is the drug given to Mr. Cooper? (p. 1924) a. Ticagleclor b. Vorapaxar c. Rivaroxaban d. Pentoxyfylline

Answer 99

The ratio of the ankle and brachial artery pressures (termed the ankle:brachial index, or ABI) is 1.00–1.40 in normal individuals. ABI values of 0.91–0.99 are considered “borderline,” and those <0.90 are abnormal and diagnostic of PAD. ABIs >1.40 indicate noncompressible arteries secondary to vascular calcification The correct answer is: Vorapaxar

Question 100

Janise 24/F complains of elevated blood pressures of 140 mmHg systolic. Her BP started to be elevated two years ago. She had no other symptoms except of intermittent calf pains when walking. The interventional cardiologist decided to do an angiogram on her iliac arteries and identified a “string of beads” appearance. Which of the following is true regarding her condition? (p 1925) a. It is characterized by alternating areas of thinned media and fibromuscular ridges b. Polymorphonuclear leukocytes infiltrate the walls of small and medium-sized arteries and veins c. Arterial occlusion results in the sudden cessation of blood flow to an extremity d. It involves compression of the neurovascular bundle at the legs which leads to the claudication

Answer 100

Fibromuscular dysplasia is a hyperplastic disorder that affects medium-size and small arteries. It occurs predominantly in females and usually involves the renal and carotid arteries but can affect extremity vessels such as the iliac and subclavian arteries. The histologic classification includes intimal fibroplasia (also classified as focal), medial dysplasia (multifocal), and adventitial hyperplasia. Medial dysplasia is subdivided into medial fibroplasia, perimedial fibroplasia, and medial hyperplasia. Medial fibroplasia is the most common type and is characterized by alternating areas of thinned media and fibromuscular ridges. The correct answer is: It is characterized by alternating areas of thinned media and fibromuscular ridges

Question 101

Jun, 58/M, has been complaining of intermittent calf pains since three months ago. He noticed that whenever he climbs a flight of stairs riding the MRT, he would experience the pain but would be relieved by rest. He is also hypertensive on Losartan 50 mg/tab but is not compliant with his medications. He is also a 30 pack year smoker. Which of the following is NOT true regarding his condition? a. This condition affects mostly the proximal vessels b. The internal elastic lamina is preserved c. Migratory superficial vein thrombophlebitis is seen d. Later stages are characterized by perivascular fibrosis

Answer 101

``` Thromboangiitis obliterans (Buerger’s disease) is an inflammatory occlusive vascular disorder involving small and medium-size arteries and veins in the distal upper and lower extremities. Cerebral, visceral, and coronary vessels may be affected rarely. This disorder develops most frequently in men <40 years of age. The prevalence is higher in Asians and individuals of Eastern European descent. Although the cause of thromboangiitis obliterans is not known, there is a definite relationship to cigarette smoking in patients with this disorder. The internal elastic lamina is preserved, and a cellular, inflammatory thrombus develops in the vascular lumen. As the disease progresses, mononuclear cells, fibroblasts, and giant cells replace the neutrophils. Later stages are characterized by perivascular fibrosis, organized thrombus, and recanalization. ``` The correct answer is: This condition affects mostly the proximal vessels

Question 102

Mrs. Santos was rushed immediately to the emergency room for severe pain in the left foot. She is 68 years old, suffered a heart attack last year but was lost to follow up because of financial constraints. A few hours ago, she was doing household chores when she suddenly felt pain in her left foot. When the resident examined her, the left foot was painful, numb and cold to touch. What treatment should be given to Mrs. Santos? (p 1926) a. Abstinence from tobacco is the treatment of choice b. Thrombolytic therapy is most effective even if occlusion is chronic c. Limb amputation is performed when the limb is nonviable d. Surgical revascularization is preferred within 48 hours to prevent limb loss

Answer 102

Once the diagnosis of acute limb ischemia is made, the patient should be anticoagulated with intravenous heparin to prevent propagation of the clot and recurrent embolism. Catheter-directed thrombolysis/ thrombectomy, surgical thromboembolectomy, and arterial bypass procedures are used to restore blood flow to the ischemic extremity promptly, particularly when a large proximal vessel is occluded. Intraarterial thrombolytic therapy with recombinant tissue plasminogen activator, reteplase, or tenecteplase is most effective when acute arterial occlusion is recent (<2 weeks) and caused by a thrombus in an atherosclerotic vessel, arterial bypass graft, or occluded stent. Surgical revascularization is preferred when restoration of blood flow must occur within 24 h to prevent limb loss or when symptoms of occlusion have been present for >2 weeks. Amputation is performed when the limb is not viable, as characterized by loss of sensation, paralysis, and the absence of Doppler-detected blood flow in both arteries and veins. The correct answer is: Limb amputation is performed when the limb is nonviable

Question 103

Ella underwent a coronary angiogram for recurrent chest pains. The procedure was successful, and she was stayed in the cardiac care unit for one day. When she was about to be transferred to her room, the nurse in charge noticed that her right big toe was bluish in color. When the nurse tried touching the toe, she would grimace in pain. Which of the following treatment option be given to Ella? (p 1927) a. Low molecular weight heparin b. Warfarin c. Amputation d. Clopidogrel

Answer 103

Once the diagnosis of acute limb ischemia is made, the patient should be anticoagulated with intravenous heparin to prevent propagation of the clot and recurrent embolism. Catheter-directed thrombolysis/ thrombectomy, surgical thromboembolectomy, and arterial bypass procedures are used to restore blood flow to the ischemic extremity promptly, particularly when a large proximal vessel is occluded. Intraarterial thrombolytic therapy with recombinant tissue plasminogen activator, reteplase, or tenecteplase is most effective when acute arterial occlusion is recent (<2 weeks) and caused by a thrombus in an atherosclerotic vessel, arterial bypass graft, or occluded stent. Surgical revascularization is preferred when restoration of blood flow must occur within 24 h to prevent limb loss or when symptoms of occlusion have been present for >2 weeks. Amputation is performed when the limb is not viable, as characterized by loss of sensation, paralysis, and the absence of Doppler-detected blood flow in both arteries and veins. The correct answer is: Amputation

Question 104

Romy is a 24/M star runner in the university. During practices, he would occasionally experience bilateral calf pains, but the pain would go away when he rests. The pain was increasingly unbearable, so he decided to have it checked. The school physician noted essentially lower extremity findings. However, the doctor was able to elicit the pain when he performed ankle dorsiflexion to Romy. What could be the diagnosis? a. Popliteal artery aneurysm b. Outlet compression syndrome c. Arteriovenous fistula d. Popliteal artery entrapment

Answer 104

Popliteal artery entrapment typically affects young athletic men and women when the gastrocnemius or popliteus muscle compresses the popliteal artery and causes intermittent claudication. Thrombosis, embolism, or popliteal artery aneurysm may occur Patients with popliteal artery aneurysms often have aneurysms of other arteries, especially the aorta. The most common clinical presentation is limb ischemia secondary to thrombosis or embolism Abnormal communications between an artery and a vein, bypassing the capillary bed, may be congenital or acquired Outlet compression syndrome is a symptom complex resulting from compression of the neurovascular bundle (artery, vein, or nerves) The correct answer is: Popliteal artery entrapment

Question 105

Nick was born with a pulsatile birthmark in his right thigh. He did not notice it until one month ago when the birthmark was beginning to increase in size. When he touches it, he would feel a thrilling sensation. His right leg was beginning to swell and the right leg was beginning to look pale. He sought consult to his primary care physician who referred him to a vascular surgeon. What is the best option for treatment for Nick? (p 1928) a. Conservative treatment b. Surgical treatment of the fistula c. Radiotherapy d. Chemoembolization of the AV fistula

Answer 105

The correct answer is: Conservative treatment

Question 106

Charo, 36/F, would notice that her hands would become pale whenever she is stressed or when she goes to a cold climate country. It would be whitish and feels cold. But when she relaxes or wears gloves, her hands would finally turn reddish at first and eventually would become “normal”. She is afraid that one day her fingers will just fall off. She was given a medication that made the pallor less tolerable. Which of the following medications has been shown to be effective to decrease the frequency and severity of her disease? (p 1928) a. Losartan b. Nifedipine c. Verapamil d. Atenolol

Answer 106

Drug treatment should be reserved for severe cases of Raynaud’s phenomenon. Dihydropyridine calcium channel antagonists such as nifedipine, isradipine, felodipine, and amlodipine decrease the frequency and severity of Raynaud’s phenomenon. Diltiazem may be considered but is less effective. The postsynaptic α1-adrenergic antagonist prazosin has been used with favorable responses; doxazosin and terazosin may also be effective. The correct answer is: Nifedipine

Question 107

Helena, a German national, has been experiencing mottled, reddish area in her legs and thighs during wintertime. It is not itchy or swollen and would go away during the summer. When she visited the Philippines, she noticed that the reddish patch returned when she went to Baguio for two weeks. What is the diagnosis for Helena’s condition? a. Raynaud’s Phenomenon b. Erythromelalgia c. Livedo reticularis d. Acrocyanosis

Answer 107

Livedo Reticularis - localized areas of the extremities develop a mottled or rete (netlike) appearance of reddish to blue discoloration The mottled appearance may be more prominent after cold exposure Acrocyanosis there is arterial vasoconstriction and secondary dilation of the capillaries and venules with resulting persistent cyanosis of the hands and, less frequently, the feet. Erythomelalgia is characterized by burning pain and erythema of the extremities. The feet are involved more frequently than the hands, and males are affected more frequently than females. Raynaud’s phenomenon is characterized by episodic digital ischemia, manifested clinically by the sequential development of digital blanching, cyanosis, and rubor of the fingers or toes after cold exposure and subsequent rewarming. The correct answer is: Livedo reticularis

Question 108

Luis, 51/M, a construction worker, was seen at the emergency room for pallor in his hands. He would notice that his hands would become pale whenever he would operate the jackhammer in the construction site. The pallor would go away a few hours after resting. During a routine physical in his company, his BP was 140/90, and he was given by his company physician a medication for his hypertension. However, he noticed that his hands turned white even if he was not operating the machinery. What antihypertensive medication could have caused this? (p 1929) a. Nifedipine b. Verapamil c. Atenolol d. Losartan

Answer 108

Several drugs have been causally implicated in Raynaud’s phenomenon. They include ergot preparations, methysergide, β-adrenergic receptor antagonists, and the chemotherapeutic agents bleomycin, vinblastine, cisplatin, and gemcitabine. The correct answer is: Atenolol

Question 109

Cora is the medical intern who was assigned to take care of the IM patients. She asked her attending physician regarding pain, tingling sensation of the right arm and pallor pf her right hand when she would reach for objects or do arm exercises. Which of the following diagnostic results would be appropriate to clinch her diagnosis? a. Chest x-ray will indicate the absence of cervical ribs b. Electromyogram have high sensitivity in neurogenic compression c. Duplex ultrasonography may demonstrate arterial compression d. Contrast angiography has no role in the diagnosis

Answer 109

In thoracic outlet compression syndrome, a chest x-ray will indicate the presence of cervical ribs. Duplex ultrasonography, MRA, and contrast angiography can be performed during provocative maneuvers to demonstrate thoracic outlet compression of the subclavian artery. Neurophysiologic tests such as the electromyogram, nerve conduction studies, and somatosensory evoked potentials may be abnormal if the brachial plexus is involved, but the diagnosis of neurogenic thoracic outlet syndrome is not necessarily excluded if these tests are normal owing to their low sensitivity. The correct answer is: Duplex ultrasonography may demonstrate arterial compression

Question 110

Based on the latest Philippine CPG on dyslipidemia, what is the optimal level of LDL-C? a. <50 mg/dl b. <100 mg/dl c. <150 mg/dl d. <120 mg/dl

Answer 110

The correct answer is: <100 mg/dl

Question 111

Latest studies have shown that apolipoproteins may have a role in cholesterol formation. In the cholesterol synthesis pathway, which of the following apolipoproteins inhibit lipoprotein lipase? a. apoB-100 b. apoC-II c. apoE d. apoC-III

Answer 111

Apolipoproteins (apo) C-I and C-III are known to inhibit lipoprotein lipase (LPL) activity, but the molecular mechanisms for this remain obscure. The correct answer is: apoC-III

Question 112

Which statin causes the least amount of LDL reduction? a. Rosuvastatin 20 mg b. Atorvastatin 40 mg c. Simvastatin 20mg d. Fluvastatin 40 mg

Answer 112

The correct answer is: Fluvastatin 40 mg

Question 113

James had another heart attack two weeks ago. He underwent PTCA and was released on different medications. His LDL-c was already at 70 mg/dl, however, his HDL-c was at 30 mg/dl. His cardiologist decided to put him on Niacin. What is the most common side effect of niacin that we need to warn our patients? a. Myalgia b. Flushing c. Increase cholesterol level d. Joint pains

Answer 113

``` Niacin have been shown to cause the following adverse events: • Severe skin flushing combined with dizziness. • Rapid heartbeat. • Itching. • Nausea and vomiting. • Abdominal pain. • Diarrhea. • Gout. • Liver damage The correct answer is: Flushing ```

Question 114

Which of the following is part of the criteria for metabolic syndrome under the Harmonizing Definition Criteria for Metabolic Syndrome? a. Fasting triglyceride level of >180 mg/dL or medication b. HDL cholesterol level <50 mg/dL for men c. Fasting plasma glucose level of >100 mg/dL d. Blood pressure of >130 mmHg systolic

Answer 114

The correct answer is: Blood pressure of >130 mmHg systolic

Question 115

Coco is a 64/F who suffered a heart attack three months ago. She underwent a successful PTCA and is ready to be discharged. Her cardiologist decided to put her on ezetimibe on top of a high dose atorvastatin to prevent future cardiovascular event. Based on the IMPROVE-IT trial, when is it expected to see the use of ezetimibe on top of a statin therapy in preventing cardiovascular events? a. After 1 year of use b. After 2 years of use c. After 3 years of use d. After 4 years of use

Answer 115

In IMPROVE-IT, the between-group difference in LDL cholesterol was calculated as the difference in the observed LDL cholesterol level in patients from whom blood samples were obtained at 1 year. The correct answer is: After 1 year of use

Question 116

Jenny has bilateral masses on her elbows. The masses were soft, doughy and movable. She had them checked by her primary care physician. On history, her sister also has the same masses but is located on her knees. Their father died of a heart attack when he was only 48 years old. Based on the Dutch Lipid Score, what level would indicate that Jenny has DEFINITE familial hypercholesterolemia? a. Score of 3 b. Score of 5 c. Score of 7 d. Score of 9

Answer 116

Refer to the Dutch Lipid Network criteria on the diagnosis of heterozygous familial hypercholesterolemia The correct answer is: Score of 9

Question 117

Mary suffered a heart attack four months ago. She went home a few days after a successful bypass. Dr. Gonzales, her cardiologist, placed on atorvastatin 80 mg/dl. A repeat LDL-c on follow up showed a level of 140mg/dl. Which of the following drugs may be added to lower her LDL-c to target of < 100 mg/dl? a. Niacin b. PCSK-9 inhibitors c. CETP inhibitors d. Clofibrate

Answer 117

Proprotein Convertase Subtilisin/Kexin Type 9 inhibitors (PCSK9-I), are available worldwide as an adjunct to statins in lowering cholesterol levels. These are monoclonal antibodies which bind to and inactivate an enzyme in the liver called proprotein convertase subtilisin kexin 9 (PCSK-9), which inactivates the need receptors on the liver cell surface that transport LDL-C into the liver for metabolism. Evolucumab is already available in the country, while Alirocumab, the other PCSK-9 inhibitor, is only available in other countries. Bococizumab showed no benefit in cardiovascular morbidity and mortality in phase 3 clinical trials. The use of PCSK-9 inhibitors can lower LDL-C by < 70mg/dl (59% lower than the baseline) and can go as low as 30 mg/dl. The correct answer is: PCSK-9 inhibitors

Question 118

Mario, a 48 year old engineer has the following annual examination findings: LDL-c, 138 mg/dl. He is sedentary lifestyle as he is confined in the office and has recently gained two pounds but is not obese (BMI 24 kg/m2). His father died of a heart attack at 50 years old. His diet consists of mostly salty food. Which of the following risk factors that is present in Mario may prompt his physician to start statin therapy? a. BMI of 24 kg/m2 b. Sedentary lifestyle c. Family history d. Diet

Answer 118

In the 2015 CPG, we identified Risk Factor Counting as the method in identifying the risk of the Filipino individual for cardiovascular disease. We continue to recommend this as the available risk factor scores advocated by the different guidelines (eg: ASCVD score) are not validated for the Filipino individuals. The following risk factors were identified and if the individual has more than two (2) risk factors, the individual has a risk for cardiovascular disease: male sex, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family history of premature CHD, proteinuria, and left ventricular hypertrophy The correct answer is: Family history

Question 119

Which of the following types of cardiomyopathy presents with decreased left ventricular diastolic dimension and predominance of right-sided heart failure symptoms? a. Dilated b. Restrictive c. Constrictive d. Hypertrophic

Answer 119

The correct answer is: Restrictive

Question 120

Infiltration of abnormal substances between myocytes, storage of abnormal metabolic byproducts within myocytes or fibrotic injury are the usual causes of: a. Dilated cardiomyopathy b. Restrictive cardiomyopathy c. Constrictive cardiomyopathy d. Hypertrophic cardiomyopathy

Answer 120

The correct answer is: Restrictive cardiomyopathy

Question 121

What is the most infectious cause of cardiomyopathy worldwide? a. HIV infection b. Tuberculosis c. Chagas’ disease d. Coxsackie virus

Answer 121

The correct answer is: Chagas’ disease

Question 122

A 27 year old female developed fever, malaise, cough and nasal congestion 2 weeks ago. She does not have chest pain nor dyspnea. Her ECG showed diffuse T wave inversions in all leads. Troponin and CK-MB are elevated. Under what classification of myocarditis will this patient belong? a. Possible subclinical acute myocarditis b. Probable acute myocarditis c. Definite myocarditis d. Chronic myocarditis

Answer 122

The correct answer is: Possible subclinical acute myocarditis

Question 123

In a patients considered to have myocarditis, which diagnostic test with a positive result makes it a case of definite myocarditis? a. 2D Echo b. Cardiac MRI c. Myocardial perfusion scintigraphy d. Endomyocardial biopsy

Answer 123

The correct answer is: Endomyocardial biopsy

Question 124

Which of the following is TRUE of the most common infective cause of cardiomyopathy? a. Histology reveals chronic granulomatous inflammation with Langhans type giant cells b. It is transmitted by the bite of a reduviid bug c. It is acquired from a bite of the tsetse fl d. Its larva may invade the myocardium and is transmitted via ingestion of uncooked meat.

Answer 124

Histology reveals chronic granulomatous inflammation with Langhans type giant cells - TB It is transmitted by the bite of a reduviid bug – Trypanosoma cruzi causing Chagas’ disease It is acquired from a bite of the tsetse fly – Trypanosoma brucei causing African sleeping sickness Its larva may invade the myocardium and is trasmitted via ingestion of uncooked meat. – Trichinella The correct answer is: It is transmitted by the bite of a reduviid bug

Question 125

Peripartum cardiomyopathy develops during the last trimester of pregnancy and/or how many months after pregnancy? a. 1 b. 2 c. 3 d. 6

Answer 125

The correct answer is: 6

Question 126

Which is the most common toxin implicated in chronic dilated cardiomyopathy? a. Alcohol b. Methamphetamine c. Cocaine d. Doxorubicin

Answer 126

The correct answer is: Alcohol

Question 127

The echocardiographic finding of global ventricular dilatation with basal contraction is typical of: a. Duchenne’s muscular dystrophy b. Lyme carditis c. Diphtheritic myocarditis d. Takotsubo cardiomyopathy

Answer 127

The correct answer is: Takotsubo cardiomyopathy

Question 128

Which medication is given to patients with hypertrophic cardiomyopathy as first line agent to alleviate symptoms of LV outflow tract obstruction? a. Disopyramide b. ACE inhibitor c. Diuretic d. Beta blocker

Answer 128

The correct answer is: Beta blocker

Question 129

Pulsus parvus et tardus, or the slow rise of the carotid pulse to a delayed peak, is a physical examination finding in which valvular disease? a. Aortic stenosis b. Pulmonic stenosis c. Tricuspid stenosis d. Mitral stenosis

Answer 129

The correct answer is: Aortic stenosis

Question 130

Aortic stenosis is said to be severe is the aortic valve area is less than: a. 1.0 cm2 b. 1.5 cm2 c. 2.0 cm2 d. 2.5 cm2

Answer 130

The correct answer is: 1.0 cm2

Question 131

In patients with aortic stenosis, which manifestation portends the worst prognosis as patients usually die within 1.5 – 2 years of symptoms onset? a. Angina pectoris b. Syncope c. Dyspnea d. Congestive heart failure

Answer 131

The correct answer is: Congestive heart failure

Question 132

Which of the following is TRUE of the medical treatment of aortic stenosis? a. Asymptomatic patients with severe AS can participate in strenuous physical activity and competitive sports. b. Dehydration must be avoided. c. All patients must be given infective endocarditis prophylaxis d. Nitroglycerin is not helpful in relieving angina pectoris

Answer 132

The correct answer is: Dehydration must be avoided.

Question 133

What is the major hemodynamic compensation in aortic regurgitation? a. Increased LV end-systolic volume b. Increased LV end-diastolic volume c. Decreased LV end-systolic volume d. Decreased LV end-diastolic volume

Answer 133

The correct answer is: Increased LV end-diastolic volume

Question 134

What is the leading cause of mitral stenosis? a. Congenital b. Annular calcification c. Infective endocarditis d. Rheumatic fever

Answer 134

The correct answer is: Rheumatic fever

Question 135

Which chamber is enlarged in cases of mitral regurgitation but is of normal size in patients with mitral stenosis? a. RA b. RV c. LA d. LV

Answer 135

LV – the LV is not enlarged in MS because it is distal to the obstructed mitral valve. All the others are enarged bec they are proximal to the obstruction. The correct answer is: LV

Question 136

Which of the following is NOT a consequence of severe mitral stenosis? a. RV enlargement b. LV enlargement c. Pulmonary hypertension d. Pulmonary regurgitation

Answer 136

All the rest are consequences of MS because of backward pressure HPIM 20e, p. 1815 The correct answer is: LV enlargement

Question 137

Which of the following is a chest x-ray finding in patients with mitral stenosis? a. Straightening of the upper right border of the cardiac silhouette b. Diminution of the main pulmonary arteries c. Constriction of the upper lobe pulmonary veins d. Posterior displacement of the esophagus by an enlarged LA

Answer 137

The correct answer is: Posterior displacement of the esophagus by an enlarged LA

Question 138

Atrial septal defect may be mistaken for which valvular lesion since both conditions may have evidence of RV enlargement and accentuation of pulmonary vasculature? a. Aortic stenosis b. Mitral stenosis c. Tricuspid regurgitation d. Pulmonic regurgitation

Answer 138

The correct answer is: Mitral stenosis

Question 139

Which finding is seen in atrial septal defect? a. RV enlargement b. LA enlargement c. Kerley B lines d. Variable splitting of S2

Answer 139

RV enlargement is because of L to R shunt. There is no LV enlargement nor Kerley B lines. There may be fixed splitting of S2. The correct answer is: RV enlargement

Question 140

True about clinical manifestations of acute rheumatic fever: a. The most commonly affected valve is the mitral valve, and the characteristic manifestation in previously affected individuals is mitral regurgitation b. Joint involvement in ARF is usually symmetric and migratory, affecting large joints c. Sydenham chorea can occur in isolation, without other features of rheumatic fever and are more common in females d. Joint involvement often requires corticosteroids to control and suppress inflammation

Answer 140

The most commonly affected valve is the mitral valve, and the characteristic manifestation is mitral regurgitation. Joint involvement in ARF is usually asymmetric and migratory, highly responsive to steroids. Sydenham chorea can occur in isolation, without other features of rheumatic fever and are more common in females The correct answer is: Sydenham chorea can occur in isolation, without other features of rheumatic fever and are more common in females

Question 141

What is the indication of giving penicillin to patients with rheumatic mitral stenosis for what reason? a. Prevention of infective endocarditis b. Secondary prevention of rheumatic fever c. Reduction in heart rate to allow diastolic filling d. Prevention of thromboembolism

Answer 141

The correct answer is: Secondary prevention of rheumatic fever

Question 142

What is the optimal time to do cardioversion after patients with mitral stenosis and recent onset atrial fibrillation has achieved a therapeutic INR? a. 3 days b. 3 weeks c. 30 days d. 3 months

Answer 142

The correct answer is: 3 weeks

Question 143

Which of the ff best describes the murmur of mitral regurgitation? a. early systolic and crescendo b. mid systolic and plateau c. late systolic and crescendo d. holosystolic and plateau

Answer 143

The correct answer is: holosystolic and plateau

Question 144

What is the most common abnormality that lead to primary mitral regurgitation? a. mitral valve prolapse b. acute rheumatic fever c. infective endocarditis d. ruptured chordae tendineae

Answer 144

The correct answer is: mitral valve prolapse

Question 145

Which of the following is NOT part of the treatment of mitral valve prolapse? a. Infective endocarditis prophylaxis in those with history of endocarditis b. Beta blockers to relieve chest pain and palpitations c. Anticoagulation in those with atrial fibrillation d. Secondary rheumatic fever prophylaxis

Answer 145

The correct answer is: Secondary rheumatic fever prophylaxis

Question 146

Which of the following is a secondary cause of mitral regurgitations wherein the leaflets and chordae are “innocent bystanders?” a. myxomatous b. radiation c. rheumatic fever d. annular dilatation

Answer 146

The correct answer is: annular dilatation

Question 147

Which of the following is a chronic cause of mitral regurgitation? a. infective endocarditis b. papillary muscle rupture c. chordal rupture d. mitral valve prolapse

Answer 147

The correct answer is: mitral valve prolapse

Question 148

What is the most common cause of tricuspid stenosis? a. congenital b. rheumatic fever c. infective endocarditis d. carcinoid

Answer 148

The correct answer is: rheumatic fever

Question 149

In which valvular abnormality is the a wave extremely tall and the y descent prolonged? a. mitral regurgitation b. mitral stenosis c. tricuspid regurgitation d. tricuspid stenosis

Answer 149

The correct answer is: tricuspid stenosis

Question 150

Which of the following is TRUE of the signs and symptoms of tricuspid stenosis? a. Edema, ascites and hepatomegaly are due to co-occurrence of mitral stenosis b. Pulmonary congestion and fatigue are present when TS is severe c. Jugular veins are characteristically flat. d. The murmur of TS is increased during inspiration.

Answer 150

The correct answer is: The murmur of TS is increased during inspiration.

Question 151

The presence of tall peaked T waves and the absence of RV hypertrophy on ECG should prompt us to consider which valvular disease? a. aortic stenosis b. mitral stenosis c. pulmonic stenosis d. tricuspid stenosis

Answer 151

The correct answer is: tricuspid stenosis

Question 152

Pulsation of the liver during systole is a characteristic PE finding in which valvular abnormality? a. tricuspid stenosis b. tricuspid regurgitation c. pulmonic stenosis d. pulmonic regurgitation

Answer 152

The correct answer is: tricuspid regurgitation

Question 153

The most common cause of pulmonic stenosis is: a. congenital b. rheumatic c. myxomatous d. carcinoid

Answer 153

The correct answer is: congenital

Question 154

Which of the following is TRUE of the normal pericardium? a. The visceral pericardium is a fibrous membrane while the parietal pericardium is a serous membrane. b. Normal pericardial fluid volume is 150-500 mL c. Pericardial fluid is an ultrafiltrate of plasma d. Total absence of the pericardium, whether congenital or surgical, leads to deleterious effects.

Answer 154

Pericardial fluid is an ultrafiltrate of plasma The visceral pericardium is a fibrous membrane while the parietal pericardium is a serous membrane – visceral is serous while parietal is fibrous. Normal pericardial fluid volume is 15 to 50 mL only. Total absence of the pericardium, whether congenital or surgical no deleterious effect The correct answer is: Pericardial fluid is an ultrafiltrate of plasma

Question 155

Which is a characteristic feature of chest pain in acute pericarditis which may differentiate it from acute myocardial infarction? a. retrosternal or left precordial in location b. referred to the neck, arms or left shoulder c. radiates to the trapezius ridge or into either arm d. intensified by lying supine and relieved by leaning forward

Answer 155

The correct answer is: intensified by lying supine and relieved by leaning forward

Question 156

True statement about the clinical presentation of acute pericarditis: a. Chest pain is pleuritic, and is relieved by lying supine or leaning forward b. The classic pericardial friction rub is heard only in a minority of the patients c. In larger pericardial effusions, the friction rub may be heard less d. Widespread elevations of ST-segment elevations may occur, with downward concavity

Answer 156

Chest pain is pleuritic and is relieved by leaning forward and worsened by lying supine. The classic pericardial friction rub is heard in 85% of the patients. Widespread elevations of ST-segment elevations may occur, with upward concavity In larger pericardial effusions, the friction rub may be heard less. The correct answer is: In larger pericardial effusions, the friction rub may be heard less

Question 157

In acute pericarditis, what ECG finding suggests atrial involvement? a. diffuse ST segment elevation b. upwardly concave ST segment c. Depression of the PR segment d. Low voltage complexes

Answer 157

The correct answer is: Depression of the PR segment

Question 158

A 60-year old heavy smoker was admitted because of progressive easy fatigability that became dyspnea at rest in the past day. He also reported occasional hemoptysis in the past month. He appears diaphoretic, tachypneic and pale. BP is 110/60 that does not vary throughout the respiratory cycle, heart rate is 99 regular, RR is 25. His neck veins are engorged and rises during inspiration. Cardiac examination revealed displaced apex beat 6th ICS left anterior axillary line. What is the most likely diagnosis? a. Cardiac tamponade b. Constrictive pericarditis c. Constrictive-effusive pericarditis d. Acute pericarditis

Answer 158

The correct answer is: Constrictive pericarditis

Question 159

In patients with acute pericarditis, which of the following medicines is usually given for a period of 3 months, while the others should only be given for a few days to weeks? a. anticoagulant b. indomethacin c. prednisone d. colchicine

Answer 159

The correct answer is: prednisone

Question 160

Which of the following is NOT part of the Beck’s triad in cardiac tamponade? a. Paradoxical pulse b. Hypotension c. Soft or absent heart sounds d. jugular venous distention

Answer 160

The correct answer is: Paradoxical pulse

Question 161

In constrictive pericarditis, the inspiratory enlargement of the RV causes leftward bulging of the IV septum and reduced LV volume, stroke volume and arterial systolic pressure. These explain which finding? a. electrical alternans b. low voltage QRS complexes c. pulsus paradoxus d. pericardial friction rub

Answer 161

The correct answer is: pulsus paradoxus

Question 162

Grossly sanguineous pericardial fluid is not expected in which cause of pericardial effusion? a. cancer b. tuberculosis c. renal failure d. SLE

Answer 162

The correct answer is: SLE

Question 163

Which of the following is TRUE of the incidence of infective endocarditis (IE)? a. Highest in the first 6-12 months after surgery for prosthetic valve b. Bioprosthetic valves have higher risk for IE than mechanical prosthetic valves c. Implantable cardioverter-defibrillators have the same risk as permanent pacemakers. d. Incidence is higher in young adults compared to the elderly

Answer 163

The correct answer is: Highest in the first 6-12 months after surgery for prosthetic valve

Question 164

Injection drug use-associated infective endocarditis is usually due to what organism? a. Viridans streptococci b. Corynebacterium sp c. Staphylococcus aureus d. Haemophilus sp

Answer 164

The correct answer is: Staphylococcus aureus

Question 165

Injection drug use-associated infective endocarditis usually affects which cardiac valve? a. mitral valve b. tricuspid valve c. aortic valve d. pulmonic valve

Answer 165

The correct answer is: tricuspid valve

Question 166

Which of the following etiologies of infective endocarditis will manifest with high fever and rapidly progressing disease? a. beta hemolytic streptococci b. Bartonella sp. c. Tropheryma whipplei d. Coxiella burnetti

Answer 166

The correct answer is: beta hemolytic streptococci

Question 167

The most frequent symptom of infective endocarditis is: a. Fever b. Chills and sweats c. Anorexia, weight loss, malaise d. Myalgias, arthralgias

Answer 167

The correct answer is: Fever

Question 168

Which among the following is the most common sign of infective endocarditis? a. heart murmur b. arterial emboli c. splenomegaly d. petechiae

Answer 168

The correct answer is: heart murmur

Question 169

Which of the following is a major criterion in the modified Duke criteria for the clinical diagnosis of infective endocarditis? a. HACEK group organism isolated from a single blood culture b. fever >38.0 C c. Increase in preexisting murmur d. Coxiella burnetii phase I IgG antibody titer of >1:800

Answer 169

The correct answer is: Coxiella burnetii phase I IgG antibody titer of >1:800

Question 170

True about the etiology of infective endocarditis: a. Endocarditis due to enterococci enter the bloodstream via the genitourinary tract b. Injection drug use-associated endocarditis is usually caused by viridans streptococci c. Health-care associated endocarditis is usually caused by gram-negative organisms d. Up to 50% of endocarditis cases have negative blood cultures

Answer 170

Endocarditis due to enterococci enter the bloodstream via the genitourinary tract Injection drug use-associated endocarditis is usually caused by S. aureus Health-care associated endocarditis is usually caused by S. aureus, CONS, enterococci. Up to only 5-15% have culture-negative endocarditis. The correct answer is: Endocarditis due to enterococci enter the bloodstream via the genitourinary tract

Question 171

According to the modified Duke criteria, which of the following manifestations of infective endocarditis is a vascular phenomenon and not an immunologic phenomenon? a. Janeway lesions b. Osler’s nodes c. Roth’s spots d. glomerulonephritis

Answer 171

The correct answer is: Janeway lesions

Question 172

Which of the following test is nondiagnostic but important to be performed in the management of infective endocarditis? a. electrocardiogram b. blood culture c. echocardiogram d. PCR of microbial DNA

Answer 172

The correct answer is: electrocardiogram

Question 173

Which of the following conditions will warrant emergent (same day) surgery for infective endocarditis? a. Fungal endocarditis b. Septal perforation c. Valve dysfunction with pulmonary edema or cardiogenic shock d. Valve dysfunction plus persisting infection after >7-10 days of antimicrobial infection

Answer 173

The correct answer is: Valve dysfunction with pulmonary edema or cardiogenic shock

Question 174

In which of the following procedures is infective endocarditis prophylaxis indicated among patients with high-risk cardiac lesions? a. Manipulation of gingival tissue b. Upper GI endoscopy c. Colonoscopy d. Cystoscopy

Answer 174

The correct answer is: Manipulation of gingival tissue

Question 175

A 25 year old male known to have RHD has been having low grade fever for the past 3 weeks. He now presents with fatigue and dyspnea. Which empiric therapy will you start if you are considering infective endocarditis? a. Oxacillin + gentamicin b. Vancomycin + ceftriaxone c. Penicillin + gentamicin d. Ampisulbactam + doxycycline

Answer 175

The correct answer is: Vancomycin + ceftriaxone

Question 176

What is the standard oral regimen for infective endocarditis prophylaxis involving amoxicillin? a. 500 mg x 1 capsule, single dose 1 hour before procedure b. 500 mg x 4 capsules, single dose 1 hour before procedure c. 500 mg TID starting 1 day before the procedure d. 500 mg TID starting 7 days before the procedure

Answer 176

The correct answer is: 500 mg x 4 capsules, single dose 1 hour before procedure