CVS Exam 4 Final Quiz on the day

Question 1

An 87-year-old woman is admitted with pneumonia,
complicated by septic shock. She develops atrial fibrillation with an
uncontrolled ventricular response. Her temperature is 101.8 F, blood pressure
80/40 mm Hg, respirations 20 per minute and heart rate 148 beats per minute.
Prior to the atrial fibrillation, her blood pressure was similarly low. Which
of the following is the next appropriate step in management?
A. Intravenous metoprolol
B. Intravenous diltiazem
C. Intravenous amiodarone
D. Emergent direct current cardioversion
E. Emergent chemical cardioversion with ibutilide

Answer 1

Correct Answer: C. Intravenous amiodarone

Question 2

Explanation: When a patient is hypotensive due to atrial fibrillation

Answer 2

then emergent cardioversion is necessary; however

Question 3

A 24-year-old female presents with dyspnea and edema. She
is noted to have a holosystolic murmur at the left lower sternal border as well
as a short early diastolic murmur at the same location. An echocardiogram
reveals the presence of a supracristal ventricular septal defect. Which of the
following explains the diastolic murmur?
A. Aortic regurgitation
B. Mitral stenosis
C. Cor triatriatum
D. Ebstein’s anomaly
E. Pulmonic regurgitation

Answer 3

Correct Answer: A. Aortic regurgitation

Question 4

Explanation: Supracristal ventricular septal defects occur just beneath the aortic valve at the left ventricular outflow tract. A Venturi effect can occur from the left to right shunt

Answer 4

causing the aortic valve leaflet to prolapse into the ventricular septal defect and resulting in significant aortic valve regurgitation.

Question 5

A 57-year-old man with no cardiovascular past medical
history presents with acute onset palpitations and intermittent dizziness. He
presents to the emergency department 8 hours after the onset of symptoms and
has never had symptoms like this before. He is found to have atrial
fibrillation with an uncontrolled ventricular response (heart rate 170 beats
per minute). An ECG is completely normal, as is laboratory evaluation with a
basic metabolic panel, complete blood count and a thyroid stimulating hormone
level. Which of the following is a reasonable strategy?
A. Direct current cardioversion with aspirin alone for
thromboembolism prophylaxis
B. Direct current cardioversion with full anticoagulation
for 3 to 4 weeks afterwards for thromboembolism prophylaxis
C. Transesophageal echocardiography to exclude a left atrial
appendage thrombus followed by direct current cardioversion and aspirin alone
for thromboembolism prophylaxis
D. Transesophageal echocardiography to exclude a left atrial
appendage thrombus followed by direct current cardioversion and full
anticoagulation for 3 to 4 weeks afterwards for thromboembolism prophylaxis

Answer 5

Correct Answer: A. Direct current cardioversion with aspirin alone for

Question 6

thromboembolism prophylaxis

Question 7

Explanation: When the duration of atrial fibrillation is thought to be less than 48 hours

Answer 7

transesophageal echocardiography is not required to evaluate for left atrial appendage thrombus. Direct current cardioversion can safely be performed with very low risk for thromboembolism in this situation.

Question 8

A 58-year-old woman with asthma and a history of
hypertension, type 2 diabetes and a prior stroke presents to the emergency
department with substernal chest pains radiating to her left arm. She is short
of breath, diaphoretic and nauseated. She is afebrile with a blood pressure of
150/90 mm Hg, heart rate of 90 beats per minute, respirations 22 per minute and
oxygen 92% on room air. Physical examination reveals an S4 heart sound and
significant wheezing on lung examination. Her ECG is below:
Enlarge

Image: Learn the Heart
Which of the following combinations of initial medical
therapy is appropriate?
A. Aspirin, clopidogrel, unfractionated heparin,
beta-blocker, oxygen, nitroglycerin
B. Aspirin, prasugrel, low molecular weight heparin,
non-dihydropyridine calcium channel blocker, oxygen, nitroglycerin
C. Aspirin, clopidogrel, low molecular weight heparin,
non-dihydropyridine calcium channel blocker, oxygen, nitroglycerin
D. Aspirin, prasugrel, unfractionated heparin, beta-blocker,
oxygen, nitroglycerin

Answer 8

Correct Answer: C. Aspirin

Question 9

non-dihydropyridine calcium channel blocker

Answer 9

oxygen

Question 10

Explanation: The non-dihydropyridine calcium channel blockers diltiazem and verapamil can be used when there is a contraindication to beta-blockers (such as asthma) and there is no heart failure or significant left ventricular systolic dysfunction present. They are especially helpful to lower heart rate and reduce oxygen demand in this situation. Sublingual nifedipine is contraindicated due to a reflexive increase in the sympathetic nervous system

Answer 10

which can be harmful.

Question 11

Recall that prasugrel is contraindicated if a prior stroke or transient ischemic attack is present. Also

Answer 11

either low molecular weight heparin or unfractionated heparin are considered reasonable choices for anticoagulation.

Question 12

A 58-year-old man is undergoing a treadmill ECG stress
test for evaluation of chest pain. After 6 minutes on a Bruce protocol, he
develops substernal chest pain radiating to his left arm and there is 4 mm of
ST depression in leads V5 and V6. His vital signs are stable. Which of the
following would you expect to find on his physical examination?
A. An S3 heart sound and a systolic ejection murmur
B. An S3 heart sound and a holosystolic murmur at the
cardiac apex
C. An S4 heart sound and a systolic ejection murmur
D. An S4 heart sound and a holosystolic murmur at the
cardiac apex

Answer 12

Correct Answer: D. An S4 heart sound and a holosystolic murmur at the

Question 13

cardiac apex

Question 14

Explanation: Physical examination findings are relatively non-specific usually only present during the anginal episode making this a less helpful means of diagnosis. When examined during an anginal attack

Answer 14

the heart rate and blood pressure may be elevated due to increased sympathetic tone. An S4 heart sound may be present during myocardial ischemia due to the lack of adenosine triphosphate production impairing left ventricular relaxation. Recall that myocardial relaxation is an active process requiring adenosine triphosphatewhich is reduced during ischemia and a S4 heart sound occurs when a non-compliant

Question 15

During inferior ischemia

Answer 15

posteromedial papillary muscle dysfunction can cause mitral regurgitation resulting in a holosystolic murmur at the cardiac apex radiating to the axilla. This rarely occurs during anterior or lateral ischemia since the anterolateral papillary muscle has dual supply from the left anterior descending and circumflex coronary artery.

Question 16

When the left ventricular end-diastolic pressure increases during myocardial ischemia

Answer 16

that pressure can be transmitted backward to the pulmonary veins and into the pulmonary vasculature causing transient pulmonary edema resulting in dyspnea and rales on lung examination.

Question 17

A 38-year-old woman presents with the acute onset of
palpitations. Her 12-lead ECG is below. She is afebrile with a heart rate of
180 beats per minute, blood pressure of 120/80 mm Hg and respirations of 18 per
minute. Which of the following is an appropriate course of action?
Enlarge

A. Emergent direct current cardioversion
B. Adenosine 6 mg intravenously, followed by a saline flush
C. Intravenous procainamide
D. Intravenous amiodarone

Answer 17

Correct Answer: B. Adenosine 6 mg intravenously

Question 18

Explanation: When a narrow QRS complex tachycardia is present

Answer 18

and the diagnosis is unclear

Question 19

There is no need for emergent direct current cardioversion

Answer 19

as the patient is hemodynamically stable. Antiarrhythmic drug therapy is not recommended until the rhythm is diagnosed. Procainamide is not commonly used

Question 20

A 58-year-old man presents to the emergency department
after experiencing intermittent chest pain for 2 days. He describes substernal
chest pressure radiating to his jaw. He is short of breath and diaphoretic. His
temperature is 100 F, blood pressure is 140/90 mm Hg, respirations are 22
breaths per minute, heart rate is 70 beats per minute and oxygen is 92% on room
air.
He is taken for emergency percutaneous coronary
intervention. This discovers thrombus in the mid-left anterior descending
coronary artery, and primary percutaneous coronary intervention is performed;
however, there was sluggish forward flow afterwards despite the left anterior
descending artery remaining widely patent.
After a diagnosis ofanterior ST-elevation
myocardial infarction complicated by no-reflow, he is followed and discharged
home. During a clinic follow-up visit 6 weeks later, he is diagnosed with left
ventricular aneurysm.
Four months later, he calls 911 due to sudden onset of
weakness and pre-syncope. He is short of breath, diaphoretic and feels
significant palpitations. He is afebrile with a blood pressure of 80/40 mm Hg,
heart rate of 240 beats per minute, respirations 26 breaths per minute and
oxygen 88% on room air. His ECG is below:
Enlarge

Image: Learn the Heart
Which of the following is the correct diagnosis?
A. Ventricular fibrillation
B. Monomorphic ventricular tachycardia
C. Polymorphic ventricular tachycardia
D. Wolff-Parkinson-White with pre-excitation and atrial
fibrillation

Answer 20

Correct Answer: B. Monomorphic ventricular tachycardia

Question 21

Explanation: See theVentricular Tachycardia ECG Reviewfor a complete summary.

Question 22

The four main complications of a left ventricular aneurysm include the following:

Question 23

Ventricular tachycardia: The scar within the left ventricular aneurysm is a focus for ventricular arrhythmias which can lead to sudden cardiac death.

Question 24

Heart failure: The portion of the heart that contains the aneurysm is not contractile and is frequently “dyskinetic.” This results in overall decrease in heart function and the development of congestive heart failure.

Question 25

Left ventricular thrombus formation: When blood stagnates in any area of the body

Answer 25

there is a risk of platelet aggregation and thrombus formation. The aneurysmal portion of the left ventricle is no different. Embolization of left ventricular thrombi can lead to embolic stroke or other systemic embolisms.

Question 26

Angina pectoris: The aneurysmal tissue can still cause symptoms of angina

Answer 26

even if revascularized.

Question 27

There is a surgical procedure during which the surgeon resects the aneurysm and uses a Dacron patch. This is called the “Dor procedure” or the endoventricular circular patch plasty. This procedure is indicated when medical therapy fails to control or acceptably improve the above mentioned complications/symptoms from the left ventricular aneurysm.

Question 28

A 21-year-old man has been progressively short of breath and fatigued. He has not seen a physician since childhood. Physical examination reveals a loud IV/VI systolic ejection murmur at the left lower sternal border much louder with Valsalva as well as a mid-systolic murmur at the cardiac apex. An echocardiogram shows an interventricular septal thickness of 35 mm. Which of the following is the likely cause of the murmur at the cardiac apex? A. Left ventricular outflow tract obstruction B. Tricuspid regurgitation C. Austin-Flint murmur D. Venturi effect E. A ventricular septal defect

Answer 28

Correct Answer: D. Venturi effect

Question 29

Explanation: This patient has hypertrophic obstructive cardiomyopathy

Answer 29

or HOCM

Question 30

The Venturi effect is described as a decrease in pressure when blood flows through a stenosis at a high velocity. This relates to the hemodynamics in HOCM

Answer 30

in which the increased velocity in the left ventricular outflow tract decreases pressure in this region causing the anterior leaflet of the mitral valve to be pulled in that direction. This is called “systolic anterior motion

Question 31

A 58-year-old woman presents with chest pains. She has had no recent bleeding or trauma and has no history of stroke. She is afebrile with a heart rate of 70 beats per minute, blood pressure 140/90 mm Hg and respirations 20 per minute. Her ECG is below: Enlarge  Image: Learn the Heart She is given aspirin, clopidogrel, metoprolol and unfractionated heparin. Nitrates have completely relieved her chest pains. Her troponin measured 15 mg/L. Which of the following is an appropriate treatment strategy? A. Thrombolytic therapy B. Initial conservative therapy with medical management C. Early invasive angiography

Answer 31

Correct Answer: C. Early invasive angiography

Question 32

Explanation: An early invasive strategy refers to proceeding to coronary angiography with possible percutaneous coronary intervention (percutaneous coronary intervention or coronary stenting) within 4 to 24 hours of hospital admission. An initial conservative management consists of medical therapy only without plans to proceed to coronary angiography and percutaneous coronary intervention.

Question 33

The following factors would warrant an early invasive strategy:

Question 34

Increased cardiac biomarkers (troponin

Answer 34

creatine kinase-myocardial band)

Question 35

New ST segment depression

Question 36

Signs or symptoms of congestive heart failure (rales on examination

Answer 36

hypoxia with pulmonary edema on chest X-ray)

Question 37

Hemodynamic instability

Question 38

Sustained ventricular tachycardia or ventricular fibrillation

Question 39

Recent coronary intervention within 6 months

Question 40

Prior coronary artery bypass grafting

Question 41

High Thrombolysis in Myocardial Infarction risk score

Question 42

Reduced left ventricular systolic function (ejection fraction < 40%)

Question 43

Recurrent angina at rest or with low-level activity

Question 44

High-risk findings from non-invasive testing

Question 45

The ICTUS trial showed no difference in the above approaches in 3 years.

Question 46

The RITA-3 trial showed no difference at 1 year

Answer 46

but there was a reduction of death or myocardial infarction at 5 years in the early invasive arm ― mainly in high-risk patients

Question 47

A 58-year-old man presents to the emergency department after experiencing intermittent chest pain for 2 days. He describes substernal chest pressure radiating to his jaw. He is short of breath and diaphoretic. His temperature is 100 F, blood pressure is 140/90 mm Hg, respirations are 22 breaths per minute, heart rate is 70 beats per minute and oxygen is 92% on room air. He is taken for emergency percutaneous coronary intervention. This discovers thrombus in the mid-left anterior descending coronary artery, and primary percutaneous coronary intervention is performed; however, there was sluggish forward flow afterwards despite the left anterior descending artery remaining widely patent. After a diagnosis of anterior ST-elevation myocardial infarction complicated by no-reflow, he is followed and discharged home. During a clinic follow-up visit 6 weeks later, the below ECG is obtained. Enlarge  Image: Learn the Heart Which of the following is the correct diagnosis? A. Pericarditis B. Normal ECG changes after an anterior myocardial infarction C. Left ventricular aneurysm D. Left bundle branch block

Answer 47

Correct Answer: C. Left ventricular aneurysm

Question 48

Explanation: A left ventricular aneurysm can form after a ST-elevation myocardial infarction. Most commonly

Answer 48

the apex of the heart is involved; however

Question 49

Without knowing a patient's past medical history

Answer 49

the ECG changes of an aneurysm may mimic an acute ST segment elevation myocardial infarction. With an anterior or apical aneurysm

Question 50

A 55-year-old man presents with acute onset chest pain and diaphoresis. His ECG reveals an acute myocardial infarction, and emergency intervention is performed. He is treated medically and discharged home in stable condition. Five days later, he is found nearly unresponsive and brought to the ED. His temperature is 95, blood pressure 70 mm Hg systolic/30 mm Hg diastolic, heart rate 120 beats per minute and respirations 30 per minute. No murmur is appreciated, and examination otherwise reveals rales throughout both lung fields. Repeat angiography shows a patent stent and hyperdynamic left ventricular systolic function, but there are large V waves in the pulmonary capillary wedge pressure tracing. Which of the following is the most likely diagnosis? A. Acute ventricular septal defect B. Free wall rupture causing cardiac tamponade C. Acute mitral regurgitation D. Aortic rupture

Answer 50

Correct Answer: C. Acute mitral regurgitation

Question 51

Explanation: Acute mitral valve regurgitation can occur as a complication of a myocardial infarction from papillary muscle rupture. When a large pressure is forced into the left atrium from the mitral regurgitant volume during systole

Answer 51

a large pressure wave is created in the pulmonary capillary wedge pressure tracing. This is termed the V wave. Normal V waves are small but become quite large with severe mitral regurgitation.

Question 52

Frequently

Answer 52

no murmur is heard on examination in the setting of acute mitral regurgitation because the pressure in the left ventricle and left atrium equalize quickly (the left atrium has not had time to remodel and dilate). At times

Question 53

A 53-year-old man with type 2 diabetes has an inferior myocardial infarction. His ejection fraction remains 30% afterward. He then develops atrial fibrillation with an uncontrolled ventricular response. He is rate-controlled on carvedilol and digoxin but continues to have significant palpitations, dyspnea and fatigue despite optimal heart failure therapy and coronary revascularization. An electrical cardioversion was not successful to maintain sinus rhythm to relieve his symptoms. Amiodarone is initiated; however, he has significant side effects and is not able to tolerate this therapy. Which of the following antiarrhythmic drug therapies would be considered appropriate for this patient? A. Dofetilide B. Sotalol C. Dronedarone D. Flecainide E. Procainamide

Answer 53

Correct Answer: A. Dofetilide

Question 54

Explanation: Remember that amiodarone and dofetilide are the only two antiarrhythmic drugs considered safe in the setting of left ventricular systolic function.

Question 55

A 66-year-old woman presents to the emergency department with chest pain, shortness of breath, nausea and vomiting. She has had symptoms for 3 days and thought it was indigestion; however, it is now worse. Her temperature is 99.2 F, blood pressure 140/90 mm Hg, heart rate 70 beats per minute, respirations 20 per minute and oxygen normal on room air. She has an S4 heart sound, but no murmurs are appreciable. Her ECG is below. Enlarge  Image: Learn the Heart She is treated appropriately for an acute inferior wall myocardial infarction with aspirin, clopidogrel, heparin, a beta-blocker, oxygen and percutaneous coronary intervention of the right coronary artery. On day two of her hospitalization, she becomes acutely short of breath. She remained afebrile with a heart rate of 90 beats per minute, respirations 36 per minute and blood pressure 80/40 mm Hg. Physical examination revealed once again an S4 heart sound and no murmur. Her pulsus paradoxus is 8 mm Hg. A chest X-ray showed pulmonary edema. She is brought back for coronary angiography and her stent in the right coronary artery remains patent. Right heart catheterization reveals a large V wave in the pulmonary capillary wedge tracing. The oxygen saturation measured in the right atrium was 65%, right ventricle 66% and pulmonary artery 65%. Which of the following is the correct diagnosis? A. Acute ventricular septal defect B. Acute left ventricular free wall rupture C. Acute mitral valve regurgitation D. Right ventricular infarction

Answer 55

Correct Answer: C. Acute mitral valve regurgitation

Question 56

Explanation: The two complications of a myocardial infarction that can cause hypotension with pulmonary edema are an acute ventricular septal defect or acute mitral valve regurgitation.

Question 57

Acute severe mitral regurgitation is a life-threatening disorder. Papillary muscle rupture after acute myocardial infarction can occur as a complication of an inferior myocardial infarction (right coronary artery supply)

Answer 57

as the posteromedial papillary muscle is the most likely to rupture.

Question 58

There are two papillary muscles that comprise part of the complex anatomy of the mitral valve. The anterolateral papillary muscle receives dual blood supply from the left anterior descending coronary artery and the left circumflex coronary artery in most individuals

Answer 58

whereas the posteromedial papillary muscle receives its sole blood supply from the right coronary artery. Complete infarction of the posteromedial papillary muscle can occur during an inferior myocardial infarction

Question 59

When a large pressure is forced into the left atrium during systole from the mitral regurgitant volume

Answer 59

a large pressure wave is created

Question 60

Recall that acute mitral regurgitation may not cause a murmur. The pressures of the left ventricle and left atrium equalize very quickly in systole

Answer 60

as there has been no time for the chambers to adapt to the acute change (dilate). This results in a very short duration of turbulent flow backward through the mitral valve

Question 61

Emergent surgical repair or replacement of the mitral valve is indicated for acute mitral regurgitation. Mortality approaches 100% if not surgically fixed.

Question 62

An acute ventricular septal defect does not cause large V waves and frequently does create a holosystolic murmur. An acute free wall rupture results in cardiac tamponade from a rapidly accumulating pericardial effusion. This increases the pulsus paradoxus to greater than 12 mm Hg. Right ventricular infarction is a complication of inferior myocardial infarction and can cause shock

Answer 62

but not pulmonary edema. Again

Question 63

A 32-year-old woman presents to the emergency department after a syncopal episode. She is experiencing palpitations and is dizzy. Her blood pressure is 90/60 mm Hg and her heart rate is 220 beats per minute. Her ECG strip is below: Enlarge  What is the initial appropriate medical management? A. Intravenous diltiazem B. Intravenous metoprolol C. Intravenous procainamide D. Intravenous digoxin

Answer 63

Correct Answer: C. Intravenous procainamide

Question 64

Explanation: The ECG reveals atrial fibrillation with “pre-excitation

Answer 64

” which occurs in the setting of Wolff-Parkinson-White syndrome. Emergent direct current cardioversion would be reasonable if a patient is definitely hemodynamically unstable; however

Question 65

The combination of atrial fibrillation and Wolff-Parkinson-White syndrome can be fatal due to rapid conduction of the atrial activity through the accessory pathway

Answer 65

resulting in rapid ventricular rates causing ventricular fibrillation. Atrioventricular nodal blocking agents (diltiazem

Question 66

When atrial fibrillation is seen in a patient with Wolff-Parkinson-White

Answer 66

ablation of the accessory pathway is recommended to prevent future rapid conduction to the ventricles.

Question 67

A 45-year-old man with a history of dilated cardiomyopathy presents with increased dyspnea and palpitations. He is known to have an ejection fraction of 20% and is already taking carvedilol 25 mg orally twice daily. He is afebrile with a heart rate of 140 beats per minute, blood pressure 110/60 mm Hg and respirations 20 per minute. He has elevated jugular venous pressure, or JVP, and rales on lung examination. His laboratory evaluation is normal. Which of the following would be best to either lower heart rate or maintain sinus rhythm in this case? A. Diltiazem B. Dronedarone C. Digoxin D. Sotalol E. Propafenone

Answer 67

Correct Answer: C. Digoxin

Question 68

Explanation: Digoxin is best indicated to control heart rate in patients with atrial fibrillation with known left ventricular systolic dysfunction (class I indication). Digoxin receives a class IIa indication to be used in combination with beta-blockers and/or nondihydropyridine calcium channel blockers in any situation to control the heart rate in atrial fibrillation. There is a IIb indication to control the heart rates at rest in the presence of persistent atrial fibrillation and a class III (not recommended

Answer 68

may cause harm) indication to use digoxin as the sole agent to treat paroxysmal atrial fibrillation. Digoxin toxicity is always a concern.

Question 69

An 84-year-old man has undergone bypass surgery on three occasions. All of his saphenous vein grafts are occluded and he has anginal symptoms with minimal exertion. He is not considered to be a revascularization candidate. He is afebrile, with a heart rate of 55 beats per minute, respirations 20 breaths per minute and blood pressure 110/70 mm Hg. He is taking isosorbide mononitrate 240 mg orally daily, atenolol 100 mg orally daily, amlodipine 10 mg orally daily, ranolazine 1,000 mg orally twice daily, aspirin and simvastatin. Which of the following is the next most appropriate course of action? A. Heart transplant evaluation B. Enhanced external counterpulsation C. Chelation therapy D. Add doxazosin E. Insert a left ventricular assist device

Answer 69

Correct Answer: B. Enhanced external counterpulsation

Question 70

Explanation: Enhanced external counterpulsation is used in the outpatient setting in patients refractory to medical therapy. The technique consists of ECG-gated rapid sequential compression of the lower extremities during diastole followed by simultaneous decompression during systole. Although the exact mechanism(s) of action of enhanced external counterpulsation remains unclear

Answer 70

significant anginal relief has been shown in small studies (MUST-EECP trial).

Question 71

Left ventricular assist devices are not approved for treatment of refractory angina. Left ventricular assist devices are most often used in the management of refractory heart failure. Chelation therapy has a class III indication for the treatment of angina and coronary disease

Answer 71

ie

Question 72

A 38-year-old previously healthy man presents with acute onset palpitations and dizziness 8 hours prior to emergency department arrival. Atrial fibrillation with an uncontrolled ventricular response is present. He is afebrile with a heart rate of 140 beats per minute, blood pressure 120/80 mm Hg and respirations 20 per minute. Laboratory evaluation is normal and a transthoracic echocardiogram is normal. Which of the following is an appropriate management strategy? A. Ibutilide infusion for chemical cardioversion B. Transesophageal echocardiography followed by direct current cardioversion C. Intravenous digoxin alone D. Oral amiodarone

Answer 72

Correct Answer: A. Ibutilide infusion for chemical cardioversion

Question 73

Explanation: Ibutilide is a class III anti-arrhythmic drug underutilized as a means of chemical cardioversion. As long as electrolytes are normal

Answer 73

the baseline corrected QT interval is normal

Question 74

Since this patient has a CHA2DS2-VASc score of 0 and presented within 48 hours

Answer 74

a transesophageal echocardiogram is not indicated to exclude left atrial appendage thrombus. Digoxin alone is never recommended to control atrial fibrillation. Amiodarone is not a good option in young individuals when there are alternative antiarrhythmic drug options due to amiodarone toxicity.

Question 75

A 79-year-old woman with chronic hypertension presents with palpitations and dizziness. She is found to be in atrial fibrillation with an uncontrolled ventricular response (heart rate 160 beats per minute). Her blood pressure is 132/82 mm Hg, respirations 18 per minute and she is afebrile. Physical examination is normal, except for the irregularly irregular heart rhythm and tachycardia. Which of the following is the appropriate next step in management? A. Intravenous amiodarone B. Emergent direct current cardioversion C. Intravenous digoxin D. Intravenous diltiazem or metoprolol E. Flecainide 300 mg orally once

Answer 75

Correct Answer: D. Intravenous diltiazem or metoprolol

Question 76

Explanation: The initial management in a hemodynamically-stable patient with uncontrolled heart rates from atrial fibrillation is a nondihydropyridine calcium channel blockers (diltiazem

Answer 76

verapamil) or beta-blocker. If heart failure is present

Question 77

Amiodarone to restore sinus rhythm (rhythm control strategy) is not appropriate in a stable patient when rate controlling has not even been attempted. This drug has many toxicities and should be avoided if possible.

Question 78

Emergent direct current cardioversion is reserved for hemodynamically-unstable patients (hypotension

Answer 78

chest pain

Question 79

Digoxin alone is not recommended for initial therapy due to less efficacy to lower the heart rate and possible toxicities. If systolic dysfunction is present

Answer 79

it would be a reasonable choice. Digoxin is also frequently used in combination with nondihydropyridine calcium channel blockers (diltiazem

Question 80

Flecainide 300 mg orally once can be used in “lone atrial fibrillation” patients (no structural heart disease or coronary artery disease);

Question 81

A 26-year-old man who is an athletic runner experiences palpitations after a 1 mile race. He is found to have atrial fibrillation with an uncontrolled heart rate. He frequently feels nauseated and flushed after sprinting or after races. Which of the following medications is classically used to prevent future episodes of this arrhythmia? A. Amiodarone B. Bretylium C. Sotalol D. Disopyramide

Answer 81

Correct Answer: D. Disopyramide

Question 82

Explanation: The patient has vagally-mediated atrial fibrillation. The classic therapy is disopyramide. Atrial fibrillation triggered by situations of vagal stimulation has been well described (nausea

Answer 82

vomiting

Question 83

A 55-year-old man presents with acute onset chest pain and diaphoresis. His ECG reveals an acute myocardial infarction, and emergency intervention is performed. He is treated medically and discharged home in stable condition. Five days later, he is found nearly unresponsive and brought to the ED. His temperature is 95, blood pressure 70 mm Hg systolic/30 mm Hg diastolic, heart rate 120 beats per minute and respirations 30 per minute. No murmur is appreciated, and examination otherwise reveals rales throughout both lung fields. Repeat angiography shows a patent stent and hyperdynamic left ventricular systolic function, but there are large V waves in the pulmonary capillary wedge pressure tracing. Which of the following coronary artery and papillary muscle combination is most commonly involved? A. Left anterior descending coronary artery and the anterolateral papillary muscle B. Left circumflex coronary artery and the anterolateral papillary muscle C. Left anterior descending coronary artery and the posteromedial papillary muscle D. Right coronary artery and the posteromedial papillary muscle

Answer 83

Correct Answer: D. Right coronary artery and the posteromedial papillary

Question 84

muscle

Question 85

Explanation: Papillary muscle rupture after acute myocardial infarction most commonly occurs as a complication of an inferior MI (right coronary artery supply)

Answer 85

as the posteromedial papillary muscle is the most likely to rupture.

Question 86

There are two papillary muscles that comprise part of the complex anatomy of the mitral valve. The anterolateral papillary muscle receives dual blood supply from the left anterior descending coronary artery and the left circumflex coronary artery in most individuals

Answer 86

whereas the posteromedial papillary muscle receives its sole blood supply from the right coronary artery. Complete infarction of the posteromedial papillary muscle can occur during an inferior MI (from thrombosis of the right coronary artery)

Question 87

A 52-year-old man presents for a routine physical examination, which reveals a III/VI systolic ejection murmur with a systolic ejection click and a soft S2 heart sound. He has no dyspnea or chest pains and has never had a syncopal episode. Echocardiography reveals aortic stenosis with a mean pressure gradient of 35 mm Hg with an aortic valve area of 1.2 cm2. The aortic root was measured at 5.2 cm. Which of the following is the recommended approach in this situation? A. Start an angiotensin-converting enzyme inhibitors, and repeat an echocardiogram in 1 year or earlier if symptoms develop B. Start a beta-blocker, and repeat an echocardiogram in 1 year or earlier if symptoms develop C. Start a HMG-CoA reductase inhibitor, and repeat an echocardiogram in 1 year or earlier if symptoms develop D. No medical therapy and repeat an echocardiogram in 1 year or earlier if symptoms develop E. Surgical aortic valve replacement and repair of the ascending aortic aneurysm

Answer 87

Correct Answer: E. Surgical aortic valve replacement and repair of the

Question 88

ascending aortic aneurysm

Question 89

Explanation: When the aortic root or ascending aorta reaches greater than 5.0 cm

Answer 89

then surgical repair of the aneurysm is recommended. If the aortic stenosis is at least moderate in severity

Question 90

A 45-year-old woman has coronary artery disease and asthma. She underwent coronary artery bypass grafting for left main coronary stenosis. She is taking diltiazem hydrochloride 120 mg once daily and oral pravastatin 10 mg once a day at bedtime. She is allergic to aspirin. Which of the following is the best course of action? A. Allergist referral for aspirin desensatization B. Add clopidogrel C. Add ticlopidine D. No change in therapy is needed

Answer 90

Correct Answer: B. Add clopidogrel

Question 91

Explanation: Every patient with documented coronary artery disease should be taking antiplatelet therapy

Answer 91

usually in the form of aspirin

Question 92

When a high risk patient is allergic to aspirin

Answer 92

an allergist can “desensitize” the patient so that the allergy is no longer present. This is used only if no alternative to aspirin exists (clopidogrel allergy as well).

Question 93

A 25-year-old woman who is 33 weeks into her pregnancy is becoming increasingly short of breath with some lower-extremity edema. She is afebrile with a heart rate of 110 beats per minute, respirations 20 per minute and blood pressure 100 mm Hg systolic/60 mm Hg diastolic. Physical examination reveals a II/IV early diastolic decrescendo murmur at the cardiac apex. Which of the following is the likely diagnosis? A. Aortic stenosis B. Aortic regurgitation (with Austin-Flint murmur) C. Mitral stenosis D. Mitral regurgitation E. Atrial septal defect

Answer 93

Correct Answer: C. Mitral stenosis

Question 94

Explanation: Pregnant women do not tolerate stenotic valvular problems very well

Answer 94

due to the required increase in cardiac output needed in this state. Regurgitant valve problems are very well-tolerated

Question 95

An 82-year-man is experiencing substernal chest pressure radiating to his left arm with exertion relieved with rest. There is associated shortness of breath. His physical examination reveals an S4 heart sound. There is a III/VI late-peaking systolic ejection murmur at the right upper sternal border with a soft S2 heart sound. There is also a III/VI holosystolic murmur at the apex. His ECG is below (shows left ventricular hypertrophy with strain). A coronary angiogram shows only minimal non-obstructive coronary artery disease. What is the likely explanation for this patient's anginal symptoms? A. Small vessel coronary disease B. Syndrome X or Da Costa’s syndrome C. Coronary vasospasm D. Increased wall stress E. Left ventricular aneurysm

Answer 95

Correct Answer: D. Increased wall stress

Question 96

Explanation: This patient has severe aortic valve stenosis on physical examination. This can cause angina due to increased myocardial oxygen demand from increased wall stress. Remember the Law of LaPlace:

Question 97

An 18-year-old athletic man had been experiencing exertional chest pains typical for angina.  He suddenly collapsed during football practice and was found to be in ventricular fibrillation. He was successfully cardioverted. His vital signs stabilize. His cardiovascular physical examination is normal. His ECG is below: Enlarge  Which of the following is the most likely diagnosis? A. Hypertrophic obstructive cardiomyopathy B. Congenital coronary anomaly C. Coronary vasospasm D. Coronary embolus E. Brugada syndrome

Answer 97

Correct Answer: B. Congenital coronary anomaly

Question 98

Explanation: There are many types of congenital variations of the coronary arteries. A majority of these are benign

Answer 98

however some anomalous coronary arteries can pass between the aorta and the pulmonary artery (known as an interarterial course) which can cause compression

Question 99

A 78-year-old man presents to the emergency department with palpitations. He is afebrile with a heart rate of 140 beats per minute, blood pressure 120/80 mm Hg and respirations 22 per minute. Laboratory evaluation is normal. His ECG is below. What is the appropriate initial management strategy? Enlarge  A. Intravenous diltiazem B. Intravenous lidocaine C. Emergent direct current cardioversion D. Adenosine infusion

Answer 99

Correct Answer: A. Intravenous diltiazem

Question 100

Explanation: Differentiating ventricular tachycardia from atrial fibrillation (a form of supraventricular tachycardia) can at time be difficult. This patient had a widened QRS complex with a left bundle branch block. When atrial fibrillation developed

Answer 100

a wide QRS complex tachycardia was seen. Because a ventricular tachycardia is a life-threatening wide complex QRS tachycardia

Question 101

A 58-year-old man presents to the emergency department with chest pains. He is afebrile with a heart rate of 70 beats per minute, blood pressure 130/90 mm Hg, respirations 20 per minute. He is given appropriate therapy with aspirin, clopidogrel, unfractionated heparin and a beta-blocker. His ECG is below: Enlarge  Image: Learn the Heart The nearest hospital capable of percutaneous coronary intervention is 80 minutes away. Which of the following is the most appropriate course of action? A. Immediate transfer for primary percutaneous coronary intervention (PCI) B. Administration of a direct thrombin inhibitor C. Administration of fibrinolytic therapy D. Administration of fibrinolytic therapy and transfer for PCI (facilitated PCI)

Answer 101

Correct Answer: C. Administration of fibrinolytic therapy

Question 102

Explanation: The decision regarding primary PCI vs. fibrinolytic therapy is important. Many major medical facilities have PCI capabilities because this is the treatment of choice for ST-elevation myocardial infarction. However

Answer 102

smaller hospitals or those located in rural areas may not. Those facilities frequently have capabilities to quickly transfer patients experiencing a ST-elevation myocardial infarction to a primary PCI facility. When there is no primary PCI available and transfer to a primary PCI facility is not able to be done in a timely fashion ― that is

Question 103

Facilitated PCI refers to using fibrinolytic therapy to stabilize the patient while transport to a primary PCI facility is being arranged. This strategy receives a class IIb indication for high-risk patients with a low bleeding risk when primary PCI is not readily available. The patient in this case does not have any high-risk features (i.e. arrhythmia

Answer 103

shock

Question 104

A 65-year-old man is post-operative day 2 from aortic valve replacement and coronary bypass surgery when he develops acute onset tachycardia with the below ECG tracing. He has mild palpitations but no other symptoms. He has been taking atenolol 100 mg orally daily. He is afebrile with a heart rate of 140 beats per minute, blood pressure 120/80 mm Hg and respirations 20 per minute. Laboratory evaluation is normal. What is the appropriate initial management strategy? Enlarge  A. Intravenous amiodarone B. Flecainide 300 mg by mouth once C. Emergent direct current cardioversion D. Transesophageal echocardiography, followed by elective direct current cardioversion

Answer 104

Correct Answer: A. Intravenous amiodarone

Question 105

Explanation: Atrial fibrillation very commonly occurs after open heart surgery

Answer 105

in about 10% to 50% of cases. Amiodarone is safe and effective to convert patients to sinus rhythm in this setting. In a large majority of cases

Question 106

A 68-year-old male who had delayed treatment of syphilis presents with generalized fatigue. He denies dyspnea, lower extremity edema or orthopnea. His blood pressure is 170/90 mm Hg and heart rate 80 bpm. A III/IV, short, early diastolic murmur is heard at the right upper sternal border. Systolic pulsation of the uvula and systolic capillary pulsations are seen upon light compression of the nail bed. Echocardiography confirms severe aortic valve regurgitation from a dilated aortic root. The ejection fraction is 60%. The left ventricular end-systolic dimension is 5.7 cm and the left ventricular end-diastolic dimension is 7.6 cm. Which of the following is the most appropriate course of action? A. Start nifedipine and repeat an echocardiogram in 6 months B. Start an ACE inhibitor and repeat an echocardiogram in 6 months C. Start a beta-blocker and repeat an echocardiogram in 6 months D. Surgical aortic valve replacement

Answer 106

Correct Answer: D. Surgical aortic valve replacement

Question 107

Explanation: One of the indications for aortic valve replacement (AVR) is asymptomatic severe aortic regurgitation with evidence of pathologic remodeling: a left ventricular end-systolic dimension of greater than 50 mm (class 2a) or end-diastolic dimension of 65 mm (class 2 b)

Answer 107

as in this case.

Question 108

According to the 2020 American College of

Question 109

Cardiology/American Heart Association Guideline for the Management of Patients

Question 110

with Valvular Heart Disease

Answer 110

AVR is indicated in patients with:

Question 111

symptomatic severe aortic regurgitation (class I)

Question 112

severe aortic regurgitation with no symptoms and left ventricular ejection

Question 113

fraction ≤ 55% (class 1)

Question 114

severe aortic regurgitation with no symptoms who are undergoing another cardiac

Question 115

surgery

Answer 115

such as CABG

Question 116

dilation of the aortic root or ascending aorta (class 1)

Question 117

severe aortic regurgitation with no symptoms

Answer 117

a normal left ventricular ejection

Question 118

fraction

Answer 118

but left ventricular end-systolic dimension greater than 50 mm

Question 119

(class 2a)

Question 120

severe aortic regurgitation with no symptoms

Answer 120

but progressive decrease in left

Question 121

ventricular ejection fraction to < 55%-60% or increase in left

Question 122

ventricular end-diastolic dimension to > 65 mm on at least three

Question 123

studies (class 2b)

Question 124

moderate aortic regurgitation who are undergoing another cardiac surgery

Answer 124

such as

Question 125

CABG

Answer 125

mitral valve surgery or replacement of the ascending aorta (class

Question 126

2a).

Question 127

No medical therapy has been shown to prolong the need for

Question 128

valve replacement

Answer 128

although decreasing the afterload with nifedipine or an ACE

Question 129

inhibitor can improve symptoms.

Question 130

Question 67/95 Flag A 78-year-old women presents to the emergency department with weakness and shortness of breath. The “indigestion” she has been having for 1 week is getting better. She is afebrile, with a heart rate of 120 beats per minute, respirations 26 per minute and blood pressure 80/40 mm Hg. Her physical examination reveals rales on lung examination and a loud V/VI holosystolic murmur at the left lower sternal border radiating throughout the precordium. Chest X-ray reveals pulmonary edema. Her ECG is below: Enlarge  Image: Learn the Heart Coronary angiography is done emergently, and her right coronary artery is completely occluded. Right heart catheterization shows normal V waves in the pulmonary capillary wedge pressure tracing. The oxygen saturation measured in the right atrium was 65%, in the right ventricle 88% and in the pulmonary artery 88%. The right atrial pressure is 20, right ventricle pressure 50/10 and pulmonary artery pressure 42/12. What is the correct diagnosis? A. Acute ventricular septal defect B. Acute left ventricular free wall rupture C. Acute mitral valve regurgitation D. Right ventricular infarction

Answer 130

Correct Answer: A. Acute ventricular septal defect

Question 131

Explanation: This case is an example of an inferior ST segment elevation myocardial infarction complicated by an acute ventricular septal defect. When infarction of the interventricular septum occurs

Answer 131

this area can thin with the remodeling process and

Question 132

With an acute ventricular septal defect

Answer 132

right heart catheterization will show an “oxygen step-up” between the right atrium and right ventricle or pulmonary artery

Question 133

Question 70/95 Flag A 51-year-old male with a history of uncontrolled hypertension presents to the ED with acute onset substernal chest pain that is sharp in nature and radiates to the mid-back. He is short of breath and weak. His temperature is 99.0, blood pressure 80/30 mm Hg, heart rate 130 bpm and respirations 30 per minute. Physical examination reveals rales on lung exam and a short, III/IV early diastolic murmur at the right upper sternal border. Which of the following is the most likely diagnosis? A. Acute myocardial infarction B. Acute pulmonary embolus C. Acute aortic regurgitation D. Acute ventricular septal defect

Answer 133

Correct Answer: C. Acute aortic regurgitation

Question 134

Explanation: This patient has an acute aortic dissection

Answer 134

resulting in acute severe aortic valve regurgitation and causing shock. This is apparent based on this description of the sudden onset chest pain

Question 135

Question 74/95 Flag A 42-year-old healthy man presents with increasing dyspnea, lower extremity edema and fatigue. He denies chest pain, palpitations or syncope. Physical examination reveals a II/IV early diastolic short murmur with a systolic ejection click. There is also a II/IV diastolic murmur at the cardiac apex. Which of the following is the most likely finding on echocardiography? A. Aortic stenosis B. Aortic regurgitation C. Mitral valve stenosis D. Pulmonic valve regurgitation E. Atrial septal defect

Answer 135

Correct Answer: B. Aortic regurgitation

Question 136

Explanation: Aortic regurgitation causes an early diastolic decrescendo murmur. The more severe the regurgitation

Answer 136

the shorter the murmur becomes because the aortic and left ventricular pressure equalize quickly. A systolic ejection click is indicative of a bicuspid aortic valve as the etiology.

Question 137

Question 75/95 Flag A 72-year-old man with no cardiac history is admitted to the hospital with a low-grade fever and weakness. He has a history of leukemia and active chemotherapy treatment. He suddenly has the acute onset of palpitations and mild shortness of breath. His ECG reveals atrial fibrillation with an uncontrolled ventricular response. His respiratory rate is 20 per minute, blood pressure is 100/60 mm Hg, heart rate is 145 beats per minute and oxygen saturation is 98% on room air. IV diltiazem is administered to the patient and the heart rate remains 140 bpm  in atrial fibrillation; however, the blood pressure decreases to 80/40 mm Hg and the patient becomes dizzy and confused. A fever of 102.2 F develops. Laboratory evaluation is available, revealing a white blood cell count of 0.9 thousand/mm3. What is the next step in management for his atrial fibrillation? A. Emergent direct current cardioversion B. Intravenous diltiazem C. Intravenous metoprolol D. Intravenous amiodarone E. Intravenous digoxin

Answer 137

Correct Answer: D. Intravenous amiodarone

Question 138

Explanation: It is important to remember to think of the etiology of the atrial fibrillation when determining management strategies. This patient appears to be experiencing severe sepsis (perhaps septic shock) related to a neutropenic fever. Sepsis is a common cause of atrial fibrillation

Answer 138

and treating the uncontrolled ventricular rate with non-dihydropyridine calcium channel blockers (diltiazem

Question 139

Question 77/95 Flag A 72-year-old man with no cardiac history is admitted to the hospital with a low-grade fever and weakness. He has a history of leukemia and active chemotherapy treatment. He suddenly has the acute onset of palpitations and mild shortness of breath. His ECG reveals atrial fibrillation with an uncontrolled ventricular response. His respiratory rate is 20 per minute, blood pressure is 100/60 mm Hg, heart rate is 145 beats per minute and oxygen saturation is 98% on room air. What is the appropriate next step in management? A. Emergent direct current cardioversion B. Intravenous diltiazem or metoprolol C. Intravenous digoxin D. Intravenous amiodarone E. Intravenous procainamide

Answer 139

Correct Answer: B. Intravenous diltiazem or metoprolol

Question 140

Explanation: In patients with uncontrolled ventricular rates

Answer 140

atrioventricular blocking agents are important to slow the heart rate and decrease symptoms from atrial fibrillation. Intravenous nondihydropyridine calcium channel blockers (diltiazem

Question 141

Question 78/95 Flag A 42-year-old man with no past cardiovascular medical history comes to the emergency department with a complaint of shortness of breath and lower extremity edema for 1 month. He is afebrile with a heart rate of 160 beats per minute, respirations 20 per minute, blood pressure 140/90 mm Hg and oxygen saturation 92% on room air. His jugular venous pressure is markedly elevated. Lung exam reveals diffuse rales. A II/VI systolic ejection murmur is appreciated at the right upper sternal border. An S3 heart sound is present, and the point of maximal impulse is laterally displaced; no S4 is heard. There is 3+ pitting edema up to his knees. His ECG confirms atrial fibrillation with an uncontrolled ventricular rate. What is the most appropriate initial management? A. Intravenous amiodarone B. Intravenous ibutilide C. Intravenous diltiazem or metoprolol D. Intravenous digoxin E. Emergent direct current cardioversion

Answer 141

Correct Answer: C. Intravenous diltiazem or metoprolol

Question 142

Explanation: The patient’s heart rate is significantly elevated in the setting of atrial fibrillation

Answer 142

and he is hemodynamically stable; thus

Question 143

A 52-year-old man presents for a routine physical examination, which reveals a III/VI systolic ejection murmur with a systolic ejection click and a soft S2 heart sound. He has no dyspnea or chest pains and has never had a syncopal episode. Echocardiography reveals aortic stenosis with a mean pressure gradient of 35 mm Hg with an aortic valve area of 1.2 cm2. The aortic root was measured at 5.2 cm. Which of the following is the most likely etiology? A. Senile calcific degeneration B. Bicuspid aortic valve C. Rheumatic valvular disease D. Fabry’s disease

Answer 143

Correct Answer: B. Bicuspid aortic valve

Question 144

Explanation: A bicuspid aortic valve is the most common cardiac congenital anomaly

Answer 144

is considered a connective tissue disorder and is the most common cause of aortic stenosis in patients aged younger than 70 years old. The aortic valve is normally tricuspid or trileaflet. When two of the cusps are fused together

Question 145

An asymptomatic 45-year-old man is being seen for a routine physical examination. His blood pressure is 110 mm Hg systolic/85 mm Hg diastolic. A IV/VI mid-systolic murmur is appreciated at the cardiac apex, radiating to the axilla, occurring after a mid-systolic click. The murmur becomes louder with transient arterial occlusion, or TAO, and moves earlier in systole with standing from a squatting position. Assuming the condition is severe upon echocardiography, with an ejection fraction of 65%, what is the most appropriate course of action? A. Start an ACE inhibitor, and repeat the echocardiogram in 1 year B. Start nifedipine, and repeat the echocardiogram in 1 year C. Mitral valve repair D. Mitral valve replacement

Answer 145

Correct Answer: C. Mitral valve repair

Question 146

Explanation: This patient has severe mitral valve regurgitation

Answer 146

from mitral valve prolapse

Question 147

Question 91/95 Flag A 32-year-old man presents with dyspnea and hemoptysis. He is afebrile, with a heart rate of 100 beats per minute, blood pressure is 120 mm Hg systolic/80 mm Hg diastolic and respirations are 22 per minute. His cardiac physical examination reveals a soft, II/IV early diastolic murmur at the cardiac apex. A bronchoscopy is negative for any lesion or malignancy. Echocardiography will likely reveal: A. Aortic regurgitation (with Austin-Flint phenomenon) B. Patent ductus arteriosis C. Ventricular septal defect D. Atrial septal defect E. Mitral stenosis

Answer 147

Correct Answer: E. Mitral stenosis

Question 148

Explanation: “Pulmonary apoplexy” refers to hemoptysis that occurs from rupture of a bronchial vein due to severe mitral valve stenosis

Answer 148

causing pulmonary venous hypertension.

Question 149

One of the modifiable risk factors for atherosclerosis is hyperlipidaemia. What type of drug is given toreduce plasma lipids? a. Clopidogrel b. Diuretics c. Aspirin d. β-blockers e. Statins

Answer 149

The correct answer is: Statins Raised cholesterol levels can be reduced by the statin family of drugs which areHMG CoA reductase inhibitors

Question 150

A 46-year-old obese man on an antihypertensive drug visits a clinic to get his routine health checkupdone. Blood investigation revealed high cholesterol levels more than 200 mg/dl. Which of the following drugs recommended for the lowering of blood cholesterol inhibits the synthesisof cholesterol by blocking 3-hydroxy-3-methylglutaryl–coenzyme A (HMG-CoA) reductase? a. Nicotinic acid b. Clofibrate c. Atorvastatin d. Gemfibrozil e. Ezetimibe

Answer 150

The correct answer is: Atorvastatin Atorvastatin mechanism of action – Statins exert their major effect—reduction of LDL levels—through a mevalonic acid–like moiety thatcompetitively inhibits HMG-CoA reductase

Question 151

When blood flow to the myocardium is compromised, ischaemia occurs, causing pain. Which of thefollowing is likely to cause ischaemic symptoms of the heart? a. Severe pulmonary artery stenosis b. Vertebro-basilar artery spasm c. Pericarditis d. Carotid artery thrombi e. Stenosis ofthecoronaryartery

Answer 151

The correct answer is: Stenosis of the coronary artery Most ischaemic symptoms of the heart are caused by atherosclerosis,either via stenosis of the coronary artery or atherosclerosis withsuperimposed thrombi

Question 152

A 25-year-old man presents to the ER with complaints of chest pain radiating to the left arm and jaw.He gives a history of consuming cocaine 3 hours back. On examination his heart rate is 110/min,respiratory rate is 24/min and his ECG shows wide QRS complex and ST segment elevation. Whichserum cardiac enzyme is the most reliable in this condition? a. CKMB b. TroponinI Troponin I is highly specific to cardiac muscle, and its levels in the bloodincrease within hours of myocardial damage and remain elevated for anextended period. This makes it the most reliable marker for myocardialinfarction c. Troponin T d. Myoglobin e. Troponin C

Answer 152

Troponin I Troponin I is highly specific to cardiac muscle, and its levels in the bloodincrease within hours of myocardial damage and remain elevated for anextended period. This makes it the most reliable marker for myocardialinfarction

Question 153

A 62-year-old man was admitted to the coronary care unit for an evaluation of a recent episode of chestpain. Three days prior to admission, he had woken up in the middle of the night with a tight precordialpain which was intense and lasted 20 minutes. The pain radiated to the left upper limb and wasaccompanied by dyspnoea, which led him to seek medical attention. His troponin levels were notincreased, and the ECG was not suggestive of acute myocardial ischemia. He was then diagnosed withvariant angina associated with superimposed arteriosclerotic coronary artery disease. Which of thefollowing drug is most likely to be avoided in this presentation? a. Glyceryl trinitrate b. Amlodipine c. Verapamil d. Nifedipine e. Propranolol

Answer 153

Propranolol β Blockers are not useful for vasospastic angina and, if used in isolation,may worsen that condition because of the unopposed action by alphareceptor mediated vasoconstriction by endogenous catecholamines

Question 154

Endothelial damage to arteries precipitates plaque development in arteriosclerosis. Excess low-densitylipoprotein (LDL) leaks into the extracellular space and becomes oxidised. Oxidised LDL is toxic toendothelial cells, and promotes inflammation and the laying down of fatty streaks. What is acharacteristic of very low-density lipoprotein (VLDL)? a. Produced from intermediate-density lipoprotein b. Carries dietary lipids c. Transports cholesterol from peripheral tissues to the liver d. Transports cholesterol from the liver to peripheral tissues e. Produced in the liver from endogenous lipids

Answer 154

The correct answer is: Produced in the liver from endogenous lipids

Question 155

Inadequate blood flow to the cardiac muscle as a result of abnormalities in the coronary circulationgives rise to the clinical symptom of chest pain: angina. What is true of Prinzmetal’s angina? a. Coronary artery spasm caused by intense sympathetic stimulation b. Occurs as a result of the transient blockage of a coronary artery by a thrombus that has formedat the site of an atheromatous plaque c. Rare condition inwhich vasospasms ofthe coronary arteryoccur at rest, often inthe early hours of themorning d. Occurs consistently with exercise and subsides after 3–10 min of rest e. Related to valvular heart disease

Answer 155

c. Rare condition inwhich vasospasms ofthe coronary arteryoccur at rest, often inthe early hours of themorning  Variant angina, also known as Prinzmetal’s angina, is a rarecondition in which vasospasm of the coronary arteries occurs atrest, often in the early hours of the morning. It is thought to becaused by an exaggerated response to vasoconstrictors such asadrenaline and 5-HT

Question 156

The main disease process underlying cardiovascular disease is atherosclerosis. Which of the following isa risk factor for coronary artery disease? a. Age < 30 years b. Female sex c. Family history of arrhythmia d. Poordiet e. Previous DVT episodes

Answer 156

Poordiet  A poor diet can indirectly influence the development of cardiovascular disease byincreasing obesity and associated risk factors such as hypertension,hypertryglyceridaemia or type 2 diabetes. A diet containing high levels ofsaturated fats can increase the risk of coronary artery disease

Question 157

A 34-year-old businessman experienced crushing retrosternal chest pain during a business meeting. Hewas brought to the emergency room of the nearest hospital where an ECG helped diagnosed amyocardial infarction involving the apex and majority of the interventricular septum of the heart. Whatis the most probable coronary artery involved? a. Left marginal artery b. Atrioventricular nodal branch c. Left anteriordescendingartery d. Right marginal branch e. Circumflex branch of the left coronary artery

Answer 157

c. Left anteriordescendingartery  The left anterior descending artery (LAD) supplies blood to the front ofthe left ventricle, the interventricular septum, and the apex of the heart

Question 158

Atherosclerosis is ‘hardening’ of arteries. Which of the following is a feature of atherosclerosis? a. It predisposes to coarctation of the aorta b. It is associated with moderate alcohol consumption c. It is a majorpredisposingfactor forischaemicheartdisease d. It mainly affects arterioles e. It is associated with a Mediterranean diet

Answer 158

c. It is a majorpredisposingfactor forischaemicheartdisease  Atherosclerosis affects large and medium-sized arteries. Lesions oftenbegin as fatty streaks. In those who are predisposed to arteriosclerosis,lesions may progress to fibrolipid plaques. Haemorrhage and thrombi mayoccur in the plaques. This may lead to total occlusion of the blood supplyto important organs such as the coronary arteries

Question 159

SAQ: There is a 62-year-old man who presents with a chest pain that is classic for an acute myocardialischemia, including precordial discomfort radiating to the arm and neck that started 30 minutes agowhile he was watching television. He has risk factors for coronary artery disease, including elevatedcholesterol, high blood pressure, and an extensive smoking history. He has a carotid bruit on exam thatsuggests significant underlying atherosclerosis. An acute surge of catecholamines is responsible for thepatient’s tachycardia, elevated blood pressure, and diaphoresis. His ECG is diagnostic: 1. What is the most likely diagnosis? 2. What are some important features of his presenting history 3. What is the most important initial therapeutic maneuver? 4. Discuss the pathophysiology of a STEMI 5. Discuss the differential diagnosis of a STEMI\n

Answer 159

1. What is the most likely diagnosis? Answer = Anterior ST segment elevation myocardial infarction 2. What are some important features of his presenting history? Answer = acute onset of pain that radiates to the arm and neck, has a history of coronary artery disease,has a history of smoking and high blood pressure 3. What is the most important initial therapeutic maneuver? Answer = Prompt coronary revascularization ST elevation myocardial infarction is a true medical emergency that requires immediate recognition andprompt treatment. Time is the most important factor to consider at presentation because survival ofmyocardial tissue (as well as the patient) depends on prompt and early coronary revascularization. “Time is muscle” is a commonly used expression in emergency departments and catheterizationlaboratories around the world for good reason; the faster we recognize and treat STEMI, the more liveswe save. 4. Discuss the pathophysiology of a STEMI Answer = An ST segment elevation myocardial infarction (STEMI) is most commonly the result ofatherosclerotic plaque rupture with subsequent acute thrombus formation and completion occlusion ofthe arterial lumen. Rupture of the fibrous cap reveals the highly thrombogenic extracellular lipid core,initiating platelet activation and aggregation as well as thrombin activation. 5. Discuss the differential diagnosis of a STEMI Answer = The differential diagnosis for STEMI is extensive and includes other cardiovascular disorders,pulmonary pathology, and gastrointestinal (GI) disease. Perhaps the most important diagnosis to ruleout is the presence of an aortic dissection. This is critical as fibrinolytics and anticoagulants arecontraindicated in aortic dissection. One should suspect dissection in a patient with risk factors fordissection, including a history of uncontrolled blood pressure or Marfan’s disease.

Question 160

Which of the following is included in the major Jones criteria for the diagnosis of acute rheumatic fever? a. Erythema marginatum b. Elevated acute phase reactants c. Fever d. Arthralgia e. History of streptococcal infection

Answer 160

a. Erythemamarginatum  Erythema marginatum is one of the major Jones criteria for thediagnosis of acute rheumatic fever

Question 161

A 42-year-old woman presents with a febrile illness and embolic phenomena suggestive of infectiveendocarditis. She had been otherwise fit and healthy, with no past medical or surgical history. Thepresenting illness is mild and has been progressive. What is the most likely responsible pathogen? a. Viridansstreptococci b. Coxiella burnetii c. Chlamydia psittaci d. Staphylococcus aureus e. Streptococcus bovis

Answer 161

a. Viridansstreptococci  Viridans streptococci are the most common cause of subacute infectiousendocarditis, which is characterized by a mild progressive illness

Question 162

A 34-year-old male with a history of intravenous drug use presents with fever, night sweats,unintentional weight loss and vomiting. His physical exam uncovers a new cardiac murmur as well asconjunctival and palmar pallor. Echocardiography shows involvement of his tricuspid heart valve. Which of the following microbes is the most likely source of infection? a. Staphylococcus epidermidis b. Staphylococcusaureus c. Viridans Streptococci d. Candida species e. Pseudomonas spp.

Answer 162

b. Staphylococcusaureus  Staphylococcus aureus is the most common cause of infectiveendocarditis in intravenous drug abusers accounting for 50% cases andis thus the most correct answer

Question 163

An 8-year-old girl presented to the emergency department with fevers, chest pain and painful joints.Her physical exam shows small painless nodules beneath the skin and a new cardiac murmur. Her throatswab performed in the last month shows isolation of group A streptococci. You tentatively diagnoseacute rheumatic fever. Which of the following investigations should you order for further confirmationof the diagnosis? a. Christie, Atkins and Munch-Peterson (CAMP) reaction b. Blood Cultures c. C-reactive protein d. Antistreptolysin O(ASO) test e. Culture of throat swab

Answer 163

d. Antistreptolysin O(ASO) test  An ASO test with significant titre of 1:200 is an indicator of priorgroup A streptococcal infection

Question 164

Which of the following statements correctly describes an aspect of myocarditis? a. Myocarditis only presents with heart failure symptoms b. Myocarditis always results in bradycardia c. Myocarditis is mainly caused by bacterial infections d. Viral invasion causes cellnecrosis and inflammationin myocarditis e. Autoimmune reactions are not involved in myocarditis

Answer 164

d. Viral invasion causes cellnecrosis and inflammationin myocarditis  Viral myocarditis typically involves direct viral invasion ofcardiomyocytes, leading to cell damage and aninflammatory response

Question 165

Which antibodies are useful to monitor myocarditis in the active stage? a. Anti-actin b. Anti-formin c. Anti-myosin d. Anti-troponin e. Anti-phospholipid

Answer 165

c. Anti-myosin  Anti-myosin antibodies are useful in monitoring myocarditis in the active stage,as they are directed against cardiac myosin and can indicate ongoing cardiacinflammation

Question 166

Colchicine used in the treatment of acute pericarditis acts by inhibiting the chemotaxis and phagocyticfunction of which white blood cells? a. Basophils b. Monocytes c. Lymphocytes d. Eosinophils e. Neutrophils

Answer 166

Neutrophils Colchicine inhibits the chemotaxis and phagocytic function of neutrophils,reducing inflammation in conditions such as acute pericarditis

Question 167

An 8-year-old girl presents to the paediatric emergency department with symptoms of fever, painfuland tender joints and chest pain. Physical examination shows small painless nodules beneath the skin aswell as a new cardiac murmur. Radiological, microbiological and serological investigations confirm thediagnosis of acute rheumatic fever. Which of the following pathogenic mechanisms underlies thiscondition? a. None of the answers b. Direct cytotoxic effect by streptococcal toxins and enzymes c. Autoimmuneresponse tocross-reacting orsharedantigens d. Autoimmune response to hidden or sequestered antigen e. Hypersensitivity to streptococcal components

Answer 167

c. Autoimmuneresponse tocross-reacting orsharedantigens  Autoimmune response occurs due to cross-reacting of antibodies, orshared antigens, between group A streptococci and myocardial cells.Antibodies produced against group A streptococci cross-react withhuman heart and joint tissue antigens and produce injury

Question 168

A 54-year-old woman presents with a history of intermittent shortness of breath, palpitations, andrecent onset of dizziness. On physical examination, a diastolic murmur is noted. An echocardiogramreveals a mass in the left atrium. Which of the following is the most likely diagnosis? a. Pulmonary embolism b. Mitral valve prolapse c. Endocarditis d. Atrial septal defect e. Atrialmyxoma

Answer 168

e. Atrialmyxoma  Atrial myxoma is the most likely diagnosis given the presence of a mass in theleft atrium on echocardiogram, along with symptoms like shortness of breath,palpitations, dizziness, and a diastolic murmu

Question 169

Autopsy is conducted for a 15-year-old girl who died in a road traffic accident. Microphotograph of asection from the heart displays granulomatous nodules with central fibrinoid necrosis surrounded bychronic inflammatory cells. The findings are suggestive of which of the following diseases? a. Cardiac myxoma b. Rheumaticheartdisease c. Infective endocarditis d. Myocarditis e. Hypertrophic cardiomyopathy

Answer 169

b. Rheumaticheartdisease  Rheumatic heart disease often shows Aschoff bodies, which aregranulomatous nodules with central fibrinoid necrosis surrounded by chronicinflammatory cells. These histopathological features are indicative ofrheumatic fever affecting the heart

Question 170

SAQ: A 27-year-old IV drug user is presenting with fevers, chills, night sweats, cough, and chest pain for2 weeks. He has a murmur on exam and evidence of septic pulmonary emboli on chest x-ray. He is ill-appearing, febrile, and tachycardic. His murmur is consistent with tricuspid regurgitation. He hasabnormal breath sounds over multiple lung fields. His skin exam reveals Janeway lesions on his rightpalm. His white blood cell count is 19,000 cells/mm3 with 78% neutrophils and 11% bands. His ECGshows sinus tachycardia with no evidence of atrioventricular conduction delay. What is the most likely diagnosis? What is the most likely next diagnostic step? What other diagnostic tests may be considered?

Answer 170

What is the most likely diagnosis? Answer = Infective endocarditis What is the most likely next diagnostic step? Answer =Blood cultures What other diagnostic tests may be considered? Answer =Echocardiogram, ECG

Question 171

What is the definitive treatment of patient diagnosed with constrictive pericarditis with worseningbreathlessness and leg edema? a. Pericardiocentesis b. Pericardiectomy c. Non-steroidal anti-inflammatories d. Corticosteroids e. Cardiac transplantation

Answer 171

b. Pericardiectomy  Pericardiectomy, the surgical removal of the fibrous layer of thepericardium, is the definitive treatment for constrictive pericarditis. Thisprocedure is aimed at relieving the heart from the restrictive andnoncompliant pericardium, which is impeding normal cardiac filling andfunction, thereby addressing the direct cause of symptoms likebreathlessness and edema

Question 172

A 17-year-old girl who is playing volleyball collapses and requires cardiopulmonary resuscitation. Shehad been healthy except for occasional episodes of chest pain while playing. Her cardiac biopsy is likelyto show which of the following findings? a. Foci of myocardial necrosis and inflammation b. Haphazardlyarrangedhypertrophiedmyocytes c. Extensive myocardial hemosiderin deposition d. Large, friable vegetations with destruction of aortic valve cusps

Answer 172

b. Haphazardlyarrangedhypertrophiedmyocytes  The description of hypertrophied, disorganized myocytes is characteristicof hypertrophic cardiomyopathy (HCM), a common cause of suddencardiac death in young athletes. HCM often presents with symptoms likechest pain during physical activity and can lead to fatal arrhythmiasduring intense exercise

Question 173

A 32-year-old man is brought to the emergency department 10 minutes after he sustained a stabwound to the left chest just below the clavicle. On arrival, he is hypotensive with rapid and shallowbreathing and appears anxious and agitated. He is intubated and mechanically ventilated. Infusion of0.9% saline has begun. Five minutes later, his pulse is 137/min and blood pressure is 84/47 mm Hg. Examination shows a 3-cm single stab wound to the left chest at the 4th intercostal space at themidclavicular line without active external bleeding. Cardiovascular examination shows muffled heartsounds and jugular venous distention. Breath sounds are normal bilaterally. Further evaluation of thispatient is most likely to show which of the following findings? a. A 15 mmHgdecreasein systolicpressureduringinspiration b. Holosystolic blowing murmur best heard at the apex c. Opening snap and mid-systolic murmur loudest at the apex d. Irregularly irregular pulse with displaced cardiac apex

Answer 173

a. A 15 mmHgdecreasein systolicpressureduringinspiration  This is indicative of pulsus paradoxus, a sign commonly associated withcardiac tamponade. This condition occurs when fluid accumulation in thepericardium (blood, in this case) compresses the heart and impairs its abilityto pump effectively, leading to the described clinical findings includinghypotension, tachycardia, and muffled heart sounds

Question 174

Which of the following is the least common type of cardiomyopathy? a. Restrictive cardiomyopathy b. Dilated cardiomyopathy c. Arrhythmogenicright ventricularcardiomyopathy d. Hypertrophic cardiomyopathy

Answer 174

c. Arrhythmogenicright ventricularcardiomyopathy  ARVC is also relatively rare. It is primarily noted for affecting the rightventricle and being a significant cause of sudden cardiac death in theyoung and athletes. However, it is more common than restrictivecardiomyopathy but less common than dilated or hypertrophiccardiomyopathies

Question 175

Which of the following is a heart muscle disorder characterized by impaired systolic function of the leftventricle or both the ventricles, in the absence of coronary artery disease, valvular abnormality orpericardial disease? a. Arrhythmogenic right ventricular cardiomyopathy b. Dilatedcardiomyopathy c. Restrictive cardiomyopathy d. Hypertrophic cardiomyopathy

Answer 175

b. Dilatedcardiomyopathy  Dilated cardiomyopathy (DCM) is characterized by dilation andimpaired contraction of one or both ventricles and is typically notassociated with coronary artery disease, significant valvular disease, orpericardial disease. This condition fits the description of havingimpaired systolic function of the ventricles in the absence of otherheart diseases

Question 176

Which of the following is included in the triad of histological features of hypertrophic cardiomyopathy? a. Hypertrophiccardiomyocytes,myocardialdisarray, andfibrosis b. Normal cardiomyocytes, granulomas and fibrosis c. Hypertrophic cardiomyocytes, myocardial necrosis and fibrosis d. Hypertrophic cardiomyocytes, deposition of amyloid and fibrosis

Answer 176

a. Hypertrophiccardiomyocytes,myocardialdisarray, andfibrosis  Hypertrophic cardiomyopathy is characterized by hypertrophiedcardiomyocytes, often irregularly arranged, leading to myocardialdisarray. Additionally, there is usually some degree of fibrosis withinthe myocardium. These features together contribute to the impairedcardiac function seen in HCM

Question 177

In dilated cardiomyopathy, a section from the heart will show which of the following? a. Mild increase in collagen b. Fibroadiposetissue replacingthecardiomyocytes c. Dense fibrosis with disarray of cardiomyocytes d. Hypertrophic cardiomyocytes

Answer 177

b. Fibroadiposetissue replacingthecardiomyocytes  Replacement of cardiomyocytes by fibroadipose tissue ischaracteristic of arrhythmogenic right ventricular cardiomyopathy,particularly affecting the right ventricle

Question 178

Epsilon (ε) wave in ECG is a characteristic feature of which of the following? a. Restrictive cardiomyopathy b. Arrhythmogenicright ventricularcardiomyopathy c. Dilated cardiomyopathy d. Hypertrophic cardiomyopathy

Answer 178

b. Arrhythmogenicright ventricularcardiomyopathy  The Epsilon wave is a distinct finding in the ECG that is indicative ofArrhythmogenic Right Ventricular Cardiomyopathy (ARVC). Itrepresents localized delayed conduction in the right ventricle due tothe fibrofatty replacement of the myocardium that is characteristic ofARVC. The presence of this wave on the ECG, particularly in V1-V3leads, is highly suggestive of ARVC and is used as part of thediagnostic criteria for the disease

Question 179

A 54-year-old who recently immigrated to the US from India presents with progressively worseningfatigue, breathlessness on lying flat and swelling of his legs. For the past one year, he has hadintermittent fever, night sweats and cough. His pulse is 110/min and blood pressure 125/65 mmHg. Chest x-ray of the patient is shown. Furtherevaluation is most likely to show which of the following findings? a. Jugularvenousdistensiononinspiration b. Opening snap and mid-systolic murmur c. Head bobbing in synchrony with the heart beat d. Harsh ejection systolic murmur loudest in the aortic area

Answer 179

a. Jugularvenousdistensiononinspiration  The symptoms of fatigue, breathlessness while lying flat, and swelling of thelegs suggest right-sided heart failure or increased central venous pressure,which could be related to conditions like constrictive pericarditis or rightheart failure. Jugular venous distension (JVD), especially notable oninspiration (known as Kussmaul's sign), is indicative of these issues andaligns with the patient's presentation

Question 180

A 25-year-old man who suffers a sudden cardiac arrest is resuscitated. ECHO shows marked thinningwith dilation of the right ventricle with a normal left ventricle. MR imaging of his chest shows fibrofattyreplacement of the myocardium. The above features are diagnostic of which one of the following? a. Ischemic cardiomyopathy b. Arrhythmogenicright ventricularcardiomyopathy c. Restricted cardiomyopathy d. Hypertrophic cardiomyopathy e. Dilated cardiomyopathy

Answer 180

b. Arrhythmogenicright ventricularcardiomyopathy  ARVC is characterized by progressive fibrofatty replacement of theright ventricular myocardium. This condition often leads to ventriculararrhythmias and sudden cardiac arrest, particularly in youngindividuals. The described ECHO and MRI findings of right ventricularthinning and dilation along with fibrofatty replacement are classic forARVC

Question 181

SAQ: A 21-year-old healthy man with no active complaints but with a history of unexplained syncope isfound to have brisk carotid upstrokes, a grade 2/6 early systolic murmur along the left lower sternalborder whose intensity increases on a Valsalva maneuver and decreases when the patient moves from astanding position to a squatting position, performing a passive leg lift while recumbent and performingisometric handgrip exercises. An S4 gallop is also noted. Electrocardiogram (ECG) shows sinusbradycardia and left ventricular hypertrophy (LVH) by voltage. His review of systems and family historyraises concern for an increased risk for sudden cardiac death. A. What is the most likely diagnosis? B. What is considered the best diagnostic step? C. What is considered one of the best therapies?

Answer 181

A. What is the most likely diagnosis? Answer = Hypertrophic cardiomyopathy (HCM) B. What is considered the best diagnostic step? Answer = Transthoracic echocardiogram (TTE) C. What is considered one of the best therapies? Answer = Implantable cardioverter defibrillator (ICD)

Question 182

Chronic venous insufficiency is characterized by ambulatory venous hypertension of the lower limbwhich is due to which of the following? a. Lymphatic obstruction of the lower limb b. Valvularincompetenceof thesuperficialveins c. Frequent movement of the lower limb d. Increased muscle tone of the lower limb

Answer 182

b. Valvularincompetenceof thesuperficialveins  Valvular incompetence of the superficial veins leads to blood pooling andincreased venous pressure in the lower limbs. The failure of the valves tofunction properly allows blood to flow backward, causing ambulatoryvenous hypertension, which is a hallmark of chronic venous insufficiency

Question 183

A 56-year-old male who is a known case of Marfan syndrome and history of long-standinghypertension complains of sudden onset chest pain and back pain. He died on the way to the hospital.Autopsy reveals blood in the pericardial sac. What will the wall of the aorta in this patient show? a. Fibrosis b. Cystic medial degeneration c. Aggregates of foamy macrophages d. Granulomatousreaction

Answer 183

d. Granulomatousreaction  This type of inflammatory response is not associated with Marfansyndrome. Granulomatous inflammation is seen in conditions such astuberculosis or certain vasculitides, which are not related to theconnective tissue abnormalities seen in Marfan syndrome

Question 184

A 35-year-old women, 4 weeks post childbirth has come to visit you in the GP practice. She has nosignificant past medical history and is a non-smoker. She has trialled compressions stockings, however,would like more definitive management given the appearance of her varicose veins. Prior to referringthis patient, you decide you must perform an investigation before referring. What is the gold standardfor investigating a patient with varicose veins? a. Lower limb XR b. Venous MRI c. CT lower limb d. Venousduplexultrasound

Answer 184

d. Venousduplexultrasound  Venous duplex ultrasound is the gold standard for investigating varicoseveins. It combines traditional ultrasound and Doppler ultrasound to visualizethe veins and measure blood flow, allowing for accurate assessment ofvenous reflux and valve function

Question 185

All the following are risk factors for peripheral vascular disease EXCEPT a. Hypertension b. Ischemicheart disease c. Diabetes mellitus d. Low levels of homocysteine

Answer 185

b. Ischemicheart disease  This condition shares many risk factors with PVD, such as atherosclerosis,which can affect multiple vascular beds

Question 186

for several years. She reports that these veins do not cause her any pain or discomfort. Onexamination, there are visible varicose veins, but there are no signs of ulceration or venous eczema. Thepatient has palpable lower limb pulses and her Ankle-Brachial Index (ABI) is 1.0. Which of the followingdo not warrant treatment of varicose veins? a. No signs of ulceration or venous eczema b. Both "there arepalpable lowerlimb pulses"and "no signs ofulceration orvenous eczema" c. There are palpable lower limb pulses d. ABI < 0.6

Answer 186

b. Both "there arepalpable lowerlimb pulses"and "no signs ofulceration orvenous eczema"  Varicose veins typically do not require treatment if there are no signsof severe complications such as ulceration or venous eczema, and ifthe arterial supply, indicated by palpable pulses, is adequate. Thiscombination suggests that the varicose veins are more of a cosmeticconcern rather than a medical necessity for treatment

Question 187

All of the followings are examples of small vessels vasculitis associated with ANCA Except: a. Microscopicpolyangiitis b. Churg-Strauss syndrome c. Goodpasture disease d. Granulomatosis with polyangiitis

Answer 187

The correct answer is: Goodpasture disease

Question 188

The triad of ruptured abdominal aortic aneurysm include all the following EXCEPT a. Pulsusparadoxus b. Pulsatile abdominal mass c. Hypotension d. Abdominal pain

Answer 188

a. Pulsusparadoxus  Pulsus paradoxus, which is an abnormal decrease in systolic blood pressureduring inspiration, is not associated with a ruptured AAA but is morecommonly linked with conditions such as cardiac tamponade, constrictivepericarditis, and severe asthma or COPD exacerbations

Question 189

The main clinical manifestations of Kawasaki disease are all the following Except: a. Heart failure b. Conjunctivitis c. Cervicallymphadenopathy d. Peeling of the skin of fingers

Answer 189

The correct answer is: Heart failure

Question 190

A 27-year-old woman presents to the ED with complaints of sudden onset severe chest pain at 28thweek of pregnancy. On examination, pulse: 100/min and BP in the right arm is 150/88 mm of Hg andleft arm is 120/80 mm Hg. CT scan shows intimal flap and widening of the aorta with double lumen. Allthe following genetic conditions are associated with this condition EXCEPT a. Turner syndrome b. Ehler Danlos syndrome c. Marfan syndrome d. Achondroplasia

Answer 190

d. Achondroplasia  This condition primarily affects bone growth, leading to dwarfism, andis not associated with an increased risk of aortic dissection

Question 191

A 80-year -old female, presented a small left leg ulcer over the medial malleolus. She is fully activeproviding care for her husband. The skin around the ulcer is erythematous, crusted and appearingdarker than the with atrophie blanche, the ankle is slightly edematous and you could feel the posteriortibial artery pulsation with ABI of 0.95. The ulcer itself is filled with yellow-green slough and is notpainful but towards the end of the day her left leg gets sore, but the pain goes away when she is in bed.She has a history of varicose veins 10 years ago treated by vein stripping. What is the most appropriatenext step? a. Empirical oral antibiotics b. Steroidapplicationto theulcer c. Below knee compression stocking d. Vein sclerotherapy

Answer 191

The correct answer is: Below knee compression stocking

Question 192

It is a busy day in your rural emergency department. You pick up a patient, a 45 year old female whosepresenting complaint is that of a aching leg. She has no past medical history, and is a non smoker. Ontaking a more detailed history, you notice as a part of her medication history that she has been on theoral contraceptive pill for the past 15 years. Which of the following reflects the pathogenesis of DVT? a. Decreased platelet count, increased fibrinolysis, and hyperviscosity b. Vasodilation, increased capillary permeability, and decreased blood pressure c. Increased cardiac output, arterial hypertension, and venous distension d. Hypercoagulability,stasis, andendothelial injury

Answer 192

d. Hypercoagulability,stasis, andendothelial injury  These three factors constitute Virchow's triad, which describes theprimary mechanisms that lead to the development of DVT. The useof oral contraceptive pills can contribute to hypercoagulability,increasing the risk of thrombosis

Question 193

When describing the general phases of the cardiac myocyte action potential, which phase has rapiddepolarisation due to a transient increase of Na conductance into the cell? a. Phase0 b. Phase 2 c. Phase 3 d. Phase 4 e. Phase 1

Answer 193

a. Phase0 upstroke phase that causes rapid depolarisation due to transient increase of Naconductance into the cell

Question 194

Are you able to describe the proper electrical conductance (in the correct order ) through the heart? a. SA node -> AV node -> Bundle if his -> Purkinje fibers -> Bundle branches -> b. SA node -> AV node -> Bundle if his ->Bundle branches -> Purkinje fibers c. SA node -> AV node -> Bundle branches -> Bundle if his -> Purkinje fibers d. AV node -> SA node -> Bundle if his -> Bundle branches -> Purkinje fibers

Answer 194

b. SA node -> AV node -> Bundle if his ->Bundle branches -> Purkinje fibers This is the correct order of electrical conductance through the heart

Question 195

Closure of the aortic and pulmonary valves produces which heart sound? a. S1 b. S2 S2 is due to closure of semilunar valves c. S4 d. S3

Answer 195

b. S2 S2 is due to closure of semilunar valves

Question 196

Which of the following regarding anatomy of the heart is true? a. The right atrium is posterior to the left atrium b. The apex is formed by the right ventricle c. The right coronary artery suppliespart of left ventricle d. The ascending aorta is entirely outside the pericardial sac e. The left coronary artery supplies right atrium

Answer 196

c. The right coronary artery suppliespart of left ventricle The right coronary artery supplies part of leftventricle (diaphragmatic surface)

Question 197

In terms of anatomical relations, which of the following is correct? a. The lung is inferior to the heart b. The diaphragm is superior to the mediastinum c. The apex of the heartis anterior to its base d. The aorta is superficial to the sternum e. Sternum is superior to the heart

Answer 197

c. The apex of the heartis anterior to its base The apex is anterior and part of the left ventricle while the base isthe posterior surface formed mainly by left atrium

Question 198

In which structure of the nervous system would damage cause increased parasympathetic activity? a. Nucleus solitarius b. Cardiac decelerator centre c. Dorsal motor nucleus of the vagus d. Rostral ventrolateralmedulla (RVLM)

Answer 198

d. Rostral ventrolateralmedulla (RVLM) Damage to RVLM will decrease sympathetic

Question 199

When the left ventricular stroke volume is 40 ml/beat and the heart rate is 80 beats/minutes, thecardiac output is? Select one: a. 4.5 Litres/minute b. 6 Litres/minute c. 3.2 Litres/minute d. 5 Litres/minute e. 2 Litres/minute

Answer 199

c. 3.2 Litres/minute Cardiac output= SV X HR. 40 x 80= 3.2 L/min

Question 200

During your Emergency Medicine rotation, you see a patient where physical examination reveals ananxious, diaphoretic patient with unstable vital signs and hypoxemia. He denies any medical problemsbut admits to daily use of cocaine, including intranasal cocaine approximately 30 minutes ago. Thinkingabout some of the effects of cocaine use on the body, which of the following is true? a. QRS prolongation b. heart failure as a main issue c. decreased binding to Na channels d. increased Phase 0 depolarization

Answer 200

a. QRS prolongation

Question 201

The T wave of the electrocardiogram occurs during which phase of the cardiac cycle? a. Isovolumetric relaxation b. Rapid ventricular ejection c. Isovolumetric contraction d. Reduced ventricular ejection e. Atrial systole

Answer 201

Reduced ventricular ejection Ventricles relaxed, not associated with ECG waves

Question 202

Which of the following structures separates the diaphragmatic surface of the heart from the base? a. Thecoronarysulcus b. The left atrium c. The posterior interventricular groove d. The anterior interventricular groove e. The right ventricle

Answer 202

a. Thecoronarysulcus The coronary sulcus (atrioventricular sulcus) separates the diaphragmaticsurface of the heart from the base

Question 203

Which of the following is true when differentiating between the pacemaker (SA, AV node) and non-pacemaker (cardiac muscle) AP? a. AP SA Node has no automaticity b. AP Cardiac muscle has three phases c. AP Cardiac muscle can occur in cardiac muscles other than SA & AV d. AP Cardiac muscle driven by funny current Na channels

Answer 203

c. AP Cardiac muscle can occur in cardiac muscles other than SA & AV See chart below to help with differentiating: AP SA Node AP Cardiac muscle Occur in pacemaker cells Occur in cardiac muscles other than SA and AV Driven by funny current Na channels Driven by stimulus, no funny current Unstable RMP (-50 to -90 mV) Stable RMP -90 mV Only 3 phases 4 phases Automaticity is possible No automaticity

Question 204

Which of the following best describes the histological structure of the atrioventricular valves? a. Characterized by a thin layer of endothelial cells overlying a thick myocardial layer b. Contains a fibrous skeleton that provides attachment sites for cardiac muscle c. Composed mainly of dense connective tissue with a central core of endocardium d. Predominantly made of cardiac muscle tissue for enhanced contractility e. Composed of three parts:collagen with some elasticfibres leaflets; fine, strongfibrous ligaments andpapillary muscles

Answer 204

e. Composed of three parts:collagen with some elasticfibres leaflets; fine, strongfibrous ligaments andpapillary muscles The atrioventricular valves are indeed composed of threeparts: cusps- collagen with some elastic fibres leaflets;chordae tendineae- fine, strong fibrous ligaments that arisefrom the powerful papillary muscles of the respectiveventricles

Question 205

All cardiac valves are normally closed during which of the following phases of cardiac cycle? a. Atrial contraction b. Systolic ejection c. Ventricular filling d. Isovolumetricrelaxation

Answer 205

d. Isovolumetricrelaxation Semilunar valves close after ejection and atrioventricular valves are stillclosed from the end of previous diastole

Question 206

The repolarization phase of the cardiac action potential depends upon which type of channels? a. Both fast sodium channels and slow calcium channels b. Potassiumchannels c. Fast sodium channels d. Sodium potassium pumps e. Slow calcium channels

Answer 206

b. Potassiumchannels Opening of these channels results in potassium exiting cardiac muscle celland hence repolarization both during phase 1 (initial repolarization- rapidpotassium channels) and phase 3 (rapid repolarization- slow potassiumchannels)

Question 207

Which of the following best describes the structure of the myocardium? a. Striated muscle tissuearranged in abranching pattern b. Smooth muscle tissue that contracts involuntarily c. Connective tissue providing elasticity to the heart chambers d. A single layer of epithelial cells lining the heart chambers

Answer 207

a. Striated muscle tissuearranged in abranching pattern The myocardium is composed of striated muscle tissue arrangedin a branching pattern, allowing for the coordinated contractionof the heart

Question 208

Regarding hormonal control of the cardiovascular system, which of the following statements is correct? a. Adrenaline/epinephrine causes vasodilatation in skeletal muscle by acting on β 1 receptors. b. Angiotensin-converting enzyme is predominately found in the vascular bed of thegastrointestinal tract. c. Antidiuretic hormone is released when arise in osmolarity is detected. d. Renin is converted to angiotensin I by angiotensinogen. e. Adrenaline is secreted from the adrenal cortex.

Answer 208

c. Antidiuretic hormone is released when arise in osmolarity is detected.

Question 209

Which of the following is true of the baroreceptor reflex? a. Baroreceptors in the carotid body are innervated by the glossopharyngeal nerve. b. Decreased loading of baroreceptors increases venous tone by reducing parasympatheticactivity. c. It is central to the long-term regulation of blood pressure d. Constriction of cutaneous arteriolesbrought about by the baroreceptorreflex can be overcome bythermoregulatory changes in vasculartone. e. Increased stretch in the arterial wall causes a decrease in baroreceptor firing.

Answer 209

d. Constriction of cutaneous arteriolesbrought about by the baroreceptorreflex can be overcome bythermoregulatory changes in vasculartone.  The baroreceptor reflex is important in thecutaneous circulation if the temperature isneutral but can be overcome if there is peripheralvasodilation due to high temperature

Question 210

Which of the following best describes the anatomical feature that distinguishes arteries from veins? a. Veins possess semilunar valves throughout their length to facilitate blood flow to the tissues b. Veins are responsible for the oxygenation of blood, which is why they have thinner wallscompared to arteries c. Arteries typically have higher bloodpressure, necessitating thicker, moreelastic walls than veins d. Arteries have thinner walls than veins, allowing for higher rates of gas exchange e. Arteries contain a single layer of smooth muscle, whereas veins are composed of multiplelayers, including a thick tunica adventitia

Answer 210

c. Arteries typically have higher bloodpressure, necessitating thicker, moreelastic walls than veins  Arteries have thicker, more elastic walls thanveins to handle the higher pressure of bloodflow

Question 211

A 40-year-old female has a blood pressure of 300/200 mmHg. Without further information, what is theclinical classification? a. Secondary hypertension b. Surgical hypertension c. Benign hypertension d. Essential hypertension e. Emergencyhypertension  Acute, severe elevation of blood pressure (>220/130) most likelyassociated with objective findings of acute end-organ damage

Answer 211

e. Emergencyhypertension

Question 212

thecommonly used antihypertensive agents. Below is a list of adverse effects seen with different classes ofantihypertensive agents, together with some important properties of selected agents. Which of thebelow antihypertensive agents would you be cautious about using if your hospitalized patient is havinga hard time regulating their electrolytes? a. Thiazide diuretics —hypercholesterolaemia, hyperglycaemia, thrombocytopenia and gout b. Angiotensin II receptor blockers —similar to ACE inhibitors but cough is less common c. Calcium channel blockers —headaches, sweating, palpitations and ankle oedema d. Beta-blockers —bradycardia, postural hypotension, depression and cold peripheries e. ACE inhibitors —angio-oedema, cough, postural hypotension, hyperkalaemia, progression ofrenal failure and first-dose hypotension

Answer 212

e. ACE inhibitors —angio-oedema, cough, postural hypotension, hyperkalaemia, progression ofrenal failure and first-dose hypotension

Question 213

A 55-year-old female presents to your clinic complaining of a headache. During a physical examinationshe is found to have an arterial blood pressure of 190/120 mmHg. What would direct the attention tothe diagnosis of malignant hypertension in this case? a. There is positive family history of ischemic heart disease b. She does not exercise c. Her diastolic blood pressure is recorded more than 100 mmHg on the next visit d. There is a history of smoking for more than 3 years e. There is evidence of rapidly progressive end organ damage

Answer 213

e. There is evidence of rapidlyprogressive end organ damage  Malignant hypertension is often associated with acuteend-organ damage, including the eyes

Question 214

After a mild hemorrhage, compensatory responses initiated by the baroreceptor reflex keeps bloodpressure at or close to its normal value. Which one of the following values is less after compensationthan it was before the hemorrhage? a. Ventricular contractility b. Coronary blood flow c. Venouscompliance d. Heart rate e. Total peripheral resistance

Answer 214

c. Venouscompliance  Baroreceptor reflex after bleeding will lead to sympathetic stimulationresulting in venous constriction as a result of decreased venous complianceto allow for increased venous return

Question 215

A 41-year-old female with long standing hypertension presents to your clinic. She has been onAngiotensin converting enzyme (ACE) Inhibitors for two years. This medication works by inhibitingwhich one of the following steps? a. Angiotensin I + Renin to Angiotensinogen b. Renin to Angiotensinogen c. Angiotensinogen to Angiotensin II d. Angiotensinogen to Angiotensin I e. Angiotensin I toAngiotensin II

Answer 215

e. Angiotensin I toAngiotensin II  ACE inhibitors stop action of ACE to convert Angiotensin I toangiotensin II

Question 216

It is important to have a commanding knowledge of the properties and adverse effects of thecommonly used antihypertensive agents. Below is a list of adverse effects seen with different classes ofantihypertensive agents, together with some important properties of selected agents. Which of thebelow antihypertensive agents would you be cautious about in a patient that has uncontrolleddiabetes? a. ACE inhibitors —angio-oedema, cough, postural hypotension, hyperkalaemia, progression ofrenal failure and first-dose hypotension. b. Calcium channel blockers —headaches, sweating, palpitations and ankle oedema c. Angiotensin II receptor blockers —similar to ACE inhibitors but cough is less common d. Beta-blockers —bradycardia, postural hypotension, depression and cold peripheries e. Thiazide diuretics —hypercholesterolaemia,hyperglycaemia,thrombocytopenia and gout

Answer 216

e. Thiazide diuretics —hypercholesterolaemia,hyperglycaemia,thrombocytopenia and gout  Your concern is the risk factor of hyperglycaemia from athiazide diuretic with a patient who already hadhyperglycaemia from uncontrolled diabetes

Question 217

Blood flow through an organ would be increased by decreasing which of the following parameters? a. Number of open arteries b. Arterial pressure c. Diameter of veins d. Hematocrit e. Diameter of artery

Answer 217

d. Hematocrit  Hematocrit reflect blood viscosity, if it decreases resistance is decreased andallow to increase blood flow to the organ

Question 218

Systemic arteriolar constriction may result from an increase in local concentration of which of thefollowing compounds? a. Nitric oxide b. Beta agonist c. Angiotensin II d. Arial natriuretic peptide (ANP) e. Hydrogen ion

Answer 218

c. Angiotensin II  Angiotensin II is a potent vasoconstrictor

Question 219

Which type of vessel or location has the lowest velocity of flow in the systemic (peripheral) circuit? a. Arterioles b. Large arteries c. Aorta d. Capillaries e. Veins

Answer 219

d. Capillaries  The capillaries have the lowest velocity of flow in the systemic circuit. Thisreduced flow rate is essential for allowing sufficient time for the exchange ofgases, nutrients, and waste products between blood and tissues

Question 220

You have just diagnosed a 45-year-old man with essential hypertension. Which of the following is amodifiable risk factor for hypertension? a. Age b. Ethnicity c. Gender d. Family size e. Obesity

Answer 220

e. Obesity  Obesity is a modifiable risk factor for hypertension

Question 221

Thinking about the positive inotropic effects of sympathetic stimulation on the heart and how theyincrease cardiac output, which of the following is correct? a. leads to a decrease in intracellular calcium levels and increased contractility b. deactivates the cyclic AMP (cAMP) second messenger system c. decreases heart rate, which also decreases cardiac output d. decreases the release of norepinephrine e. binds to β1-adrenergicreceptors on cardiacmyocytes

Answer 221

e. binds to β1-adrenergicreceptors on cardiacmyocytes  this is one of the responses to positive inotropic effects ofsympathetic stimulation on the heart and how it increasescardiac output

Question 222

What is the mechanism of action of angiotensin II? a. Increases bradykinin secretion and increases potassium serum levels b. Increases aldosterone secretion andincreases vasoconstriction c. Increases stroke volume and heart rate d. Increases bradykinin secretion and decreases potassium serum levels e. Decreases aldosterone secretion and increases vasoconstriction

Answer 222

b. Increases aldosterone secretion andincreases vasoconstriction  It is a powerful vasoconstrictor and stimulatesadrenal glands to produce aldosterone

Question 223

A patient presents to the emergency department and examination reveals elevated jugular venouspressure, muffled heart sounds and worsening hypotension. Which of the following best describes thetype of circulatory shock? a. Cardiogenic shock b. Distributive shock c. Obstructiveshock d. Hypovolaemic shock e. Anaphylactic shock

Answer 223

c. Obstructiveshock  This patient has cardiac tamponade (Beck’s triad- reveals elevated jugularvenous pressure, muffled heart sounds and worsening hypotension) whichis an obstructive shock

Question 224

A 55-year-old man presents to your office with worsening heart failure. You notice symptoms and signsof congestion and low perfusion. Which of the following is a SIGN of LOW PERFUSION? a. Cool extremities b. Elevated jugular venous pressure c. Fatigue d. Hyperthermia e. Lower extremity edema

Answer 224

a. Cool extremities  Cool extremities is a sign of low perfusion

Question 225

Activation of the sympathetic system and release of catecholamines from adrenal medulla maintains theblood pressure and cardiac output in which of the following phases of shock? a. Progressive phase b. Irreversible phase c. Non-progressivephase

Answer 225

c. Non-progressivephase  In this phase activation of the sympathetic system and release ofcatecholamines from adrenal medulla leading to widespreadvasoconstriction to maintain BP and cardiac output

Question 226

Cardiac (heart) failure occurs when the heart is unable to maintain the necessary cardiac output. Whichof the following statements would you associate with cardiac failure? a. Cardiac failure often results in ventricular atrophy b. Cardiac failure may becompensated for in the earlystages by increasedventricular end-diastolicvolume c. Cardiac failure may be associated with a decrease in cardiac output with exercise d. Cardiac failure cannot occur if the cardiac output is over 5 litres per minute. e. Cardiac failure may be precipitated by polycythaemia vera

Answer 226

b. Cardiac failure may becompensated for in the earlystages by increasedventricular end-diastolicvolume  In the early stages of heart failure, the heart may pumpsufficient blood by its compensating mechanisms (e.g.by increasing ventricular end-diastolic volume,according to Starling’s law)

Question 227

A 72-year-old woman attends the clinic with isolated ankle swelling over the past 3 months. She is nottroubled by breathlessness. She has a history of hypertension, indigestion and migraine. She has beenstarted on a number of medicines recently. She has a normal echocardiogram that day. Whichmedication is most likely to blame? a. Amlodipine b. Lansoprazole c. Furosemide d. Bendroflumethiazide e. Propranolol

Answer 227

a. Amlodipine  Calcium channel blockers of the dihydropyridine class (amlodipine,nifedipine, etc.) commonly cause ankle swelling as a side effect. This mayseem like a picky question but it is just to help you practice yourpharmacology and consider the side effects of certain drugs. Also to remindyou that some antihypertensive drugs can also cause vasodilation hence theresulting ankle swelling in your patient

Question 228

A 74-year-old man is admitted with shortness of breath. On examination, crepitations are heard up tothe mid-zones. A diagnosis of acute left ventricular failure is made. Which of the following treatmentswould be started first? a. β-Blockers b. Diuretics c. Oxygen d. Continuous positive airway pressure (CPAP) e. Morphine

Answer 228

b. Diuretics Why is this the most correct answer? In acute left ventricular failure (LVF), the primary issue is pulmonary congestion due to fluid overload. Diuretics, such as intravenous furosemide, are the first-line treatment because they rapidly reduce preload (the volume of blood returning to the heart) by promoting diuresis. This alleviates pulmonary congestion and improves symptoms like shortness of breath.

Question 229

Heart failure occurs when the heart is unable to maintain necessary cardiac output despite normalvenous pressures. Which of the following events occurs in congestive cardiac failure? a. Glomerular filtration rate is increased b. Reabsorption of sodium in renal tubules is reduced c. The parasympathetic nervous system is stimulated d. Totalbodysodiumisincreased e. Aldosterone secretion is reduced

Answer 229

d. Totalbodysodiumisincreased  Cardiac failure typically stems from reduced myocardial contractility,prompting compensatory activation of the sympathetic nervous system andthe renin-angiotensin system. This response decreases renal blood flow andfiltration, increases sodium and water reabsorption, and reduces their urinaryexcretion, ultimately causing edema

Question 230

65-year-old man develops worsening ankle swelling and is found to have right ventricular failure.Which other clinical sign is most likely to be elicited on examination? a. Wheeze b. Hepatomegaly c. Bilateral basal crepitations d. Hypertension e. Mid-diastolic murmur

Answer 230

b. Hepatomegaly  Hepatomegaly occurs in right ventricular failure due to hepaticcongestion.

Question 231

A 68-year-old man was admitted to intensive care unit with the complaints of breathlessness and pedaledema. He was diagnosed with congestive heart failure. Angiotensin converting enzyme has known todelay the progression of heart failure by various beneficial effects. Which of the following effect ofAngiotensin converting enzyme would help in reducing the incidence of sudden death? a. ACE inhibitors decrease cardiac output and increases afterload b. ACE inhibitor reduces arterial compliance by potentiating Angiotensin II activity c. ACE inhibitors increase preload and increases ventricular dilation d. ACE inhibitors increase venous tone by augmenting Angiotensin II activity e. ACE inhibitors reverseventricular remodelling byattenuating cardiacfibrosis induced byAngiotensin II

Answer 231

e. ACE inhibitors reverseventricular remodelling byattenuating cardiacfibrosis induced byAngiotensin II  ACE inhibitors may reverse ventricular remodelling viachanges in preload/afterload by preventing the growtheffects of Angiotensin II on myocytes and by attenuatingcardiac fibrosis induced by Angiotensin II

Question 232

A 65-year-old man in congestive heart failure (CHF) is unable to climb a flight of stairs withoutexperiencing shortness of breath. Digoxin is administered to improve cardiac muscle contractility. Innext two weeks, he has a marked improvement in his symptoms. What cellular action of digoxin inrelieving symptoms of congestive heart failure? a. Inhibition of β-adrenergic stimulation b. Inhibition of adenosine triphosphate (ATP) degradation c. Inhibition of the sodium (Na+) pump d. Inhibition of mitochondrial calcium (Ca2+) release e. Inhibition of cyclic adenosine 5′-monophosphate (cAMP) synthesis

Answer 232

c. Inhibition of the sodium (Na+) pump  Digoxin acts by inhibiting sodium (Na+) pump

Question 233

Which of the following treatments should be used first in a patient presenting to their generalpractitioner with signs of heart failure but no evidence of pulmonary oedema? a. Spironolactone (potassium sparing diuretic) b. Ramipril(ACEinhibitor) c. Furosemide (loop diuretic) d. Losartan (ARB) e. Atenolol (Beta- blocker)

Answer 233

b. Ramipril(ACEinhibitor)  Angiotensin-converting enzyme inhibitors (ACEI) should be part of thefirst line therapy for anyone with heart failure

Question 234

A 65-year-old man complains of increasing dyspnea on exertion and orthopnea. His physicalexamination reveals an S3 heart sound, pulmonary rales, jugular venous distension, and lower extremityedema. He is normotensive, and his extremities are warm to touch. An echocardiogram confirms anejection fraction of 25% and a dilated left ventricle. What is the most appropriate next step inmanagement? a. Sublingual nitroglycerin b. Oral beta blocker c. NSAID d. Oral furosemide e. Intravenousfurosemide

Answer 234

e. Intravenousfurosemide  Intravenous furosemide is indicated in this patient with warm/wetprofile decompensated heart failure

Question 235

In terms of capillary haemodynamics, which of the following describes hypoalbuminaemia? a. Decreases plasma oncoticpressure b. Decreases plasma hydrostatic pressure c. Decreases interstitial fluid hydrostatic pressure d. Increases plasma oncotic pressure e. Increases interstitial fluid hydrostatic pressure

Answer 235

a. Decreases plasma oncoticpressure  This describes low plasma proteins(hypoalbuminaemia)

Question 236

A 58-year-old woman presents to the emergency department with pulmonary edema, hypoxia, elevatedjugular venous pressures, and tachycardia. Her heart rate is 165 beats per minute, her blood pressure is100/60, and oxygen is 84% on room air, improving to 92% on 6 liters per minute of oxygen by nasalcannula. Before treating her for congestion, you want to clarify the cause of her heart failure andtachycardia. Which test is the MOST likely to provide an answer in this case? a. Troponin level b. ECG c. Chest radiograph d. Thyroid stimulating hormone e. Electrolyte levels

Answer 236

b. ECG  ECG can help diagnose wide range of abnormalities and possible causes of heartfailure such as ischemia, arrhythmia, conduction disorder or ventricular hypertrophy

Question 237

SAQ: A 54-year-old woman presents to the ED with progressive respiratory distress, exertional dyspnea,orthopnea, and paroxysmal nocturnal dyspnea in the setting of heavy nonsteroidal anti-inflammatorydrug (NSAID) use. She is tachycardiac, hypertensive, and hypoxemic. Her physical exam is notable for elevated jugularvenous pressure, an audible S3, bilateral rales, a pulsatile liver, and lower extremity edema. Laboratory evaluation reveals acute kidney injury and elevated brain natriuretic peptide. Arterial bloodgas reveals hypoxia and hypercapnia. A chest x-ray shows cardiomegaly, diffuse bilateral infiltrates, andsmall bilateral pleural effusions. What is the most likely diagnosis?

Answer 237

acute decompensated heart failure (ADHF)

Question 238

Calcium channel blockers target the gating mechanism of voltage-gated Ca2+ ion channels. Which ofthe following drugs is not a calcium channel blocker? a. Amlodipine b. Amiodarone c. Verapamil d. Lercanidipine e. Diltiazem

Answer 238

b. Amiodarone  Amiodarone is not a calcium channel blocker. It is an antiarrhythmic whichworks by prolonging the action potential duration, prolonging therefractory period by acting at potassium channels, and affecting the flow ofions across the membrane.

Question 239

The electrical activity of heart muscle can be recorded on the surface of the body as anelectrocardiogram (ECG). What is the normal duration of the QRS interval? a. 0.06–0.10secs b. 0.12–0.20 secs c. 0.30 secs d. 0.11 secs e. Varies with the heart rate

Answer 239

a. 0.06–0.10secs  ventricular depolarization represented by QRS complex is normally 0.06-0.10 secs

Question 240

A 67-year-old man was found collapsed at home. The paramedic’s acquired an ECG. What is the mostlikely diagnosis from the list below? a. Atrial flutter b. Ventricularfibrillation c. Complete heart block d. Left ventricular hypertrophy e. Atrial fibrillation

Answer 240

b. Ventricularfibrillation  In ventricular fibrillation, the electrocardiogram is bizarre and ordinarilyshows no tendency toward a regular rhythm of any type

Question 241

The electrical activity of heart muscle can be recorded on the surface of the body as anelectrocardiogram (ECG). Which of the following does the S wave indicate on an ECG? a. Depolarization of the atria b. Depolarization of the interventricular septum from left to right c. Ventricular repolarization d. Depolarizationof the area ofthe heart nearthe base e. Depolarization of the main mass of the ventricles

Answer 241

d. Depolarizationof the area ofthe heart nearthe base  The QRS complex shows the depolarization of the ventricles, whichalso masks the repolarization of the atria. The S wave represents thedepolarization of the area of the heart near the base

Question 242

Atrial fibrillation is a condition in which the pulse rate is irregularly irregular. Which of the followingstatements about atrial fibrillation is true? a. The ventricular rate exceeds the atrial rate b. The ventricular rhythm is regular c. It is associated with tricuspid incompetence d. There are multiple P waves on the ECG e. It may bedue tomultiple re-entrantexcitationwaves in theatria

Answer 242

e. It may bedue tomultiple re-entrantexcitationwaves in theatria  Atrial fibrillation is due to multiple circulating re-entrant excitation in theatria. This results in an irregular and fast atrial rate (up to 500 per minute).Hence the AV node also discharges at an irregular, but slower rate (about90–150 beats per minutes). P waves cannot usually be detected on theECG

Question 243

What is the approximate heart rate, in beats/min, indicated by the ECG strip? a. 60 b. 150 c. 75 d. 100 e. 50

Answer 243

c. 75  Large square method: Divide 300 by the number of large squares between R-Rinterval

Question 244

Abnormal rhythms of the heart occur when the normal conduction is disrupted. What is first-degreeheart block? a. Conduction through theatrioventricular node takeslonger than normal,prolonging the PR interval b. Atria and ventricles are completely separated and beat independently c. Heart rate varies with occasional extra beats d. PR interval lengthens progressively until a ventricular beat is dropped e. Not all atrial impulses are conducted to the ventricles

Answer 244

a. Conduction through theatrioventricular node takeslonger than normal,prolonging the PR interval  First-degree atrioventricular (AV) block occurs whenconduction through the AV node takes longer thannormal. This prolongs the PR interval, slowing the heartrate

Question 245

To gather information about impulse conduction from the atria to the ventricles, which ECG componentwill provide this information? a. ST segment b. PRinterval c. P wave d. T wave

Answer 245

b. PRinterval  The PR interval is the time from the onset of the P wave to the start of the QRScomplex. It reflects conduction through the AV node

Question 246

Cardiac output is determined by stroke volume and heart rate. Which of the following options increasesheart rate in sinus rhythm? a. Atropine b. Digoxin c. Atenolol d. Propranolol e. Verapamil

Answer 246

a. Atropine  Atropine is a muscarinic receptor antagonist, producing an initial bradycardiabecause of central stimulation, followed by tachycardia (the vagus is blockedso that sympathetic effect is unopposed)

Question 247

Which term best describe the rhythm observed in the following ECG? a. Sinus bradycardia b. Normalsinusrhythm c. First degree heart block d. Sinus tachycardia e. Ventricular ectopic beats

Answer 247

b. Normalsinusrhythm  The above ECG contains all characteristics of normal sinus rhythm with a rate of75 bpm and p wave is preceding every QRS complex which is narrow. Normal pwave and PR intervals ≥0.12 seconds

Question 248

SAQ: A 54-year-old man with obesity, hypertension, obstructive sleep apnea, and excessive alcoholconsumption comes to the emergency room with a 3-day history of palpitations, fatigue, and shortnessof breath. He has had similar symptoms in the past, but these were always short-lived and he did notpreviously seek medical attention. On physical examination, his heart rate is 110 bpm irregularlyirregular, and blood pressure is 126/87 mmHg. Cardiopulmonary examination is normal apart from theirregular rhythm. What is the most likely diagnosis? What is the next diagnostic step? What is the next step in therapy?

Answer 248

What is the most likely diagnosis? Answer = Paroxysmal atrial fibrillation What is the next diagnostic step? Answer = Electrocardiogram What is the next step in therapy? Answer = Anticoagulation and rate control

Question 249

A 68-year-old male with a history of syphilis presents with generalized fatigue. He denies dyspnea,lower extremity edema or orthopnea. His BP is 170/90 mmHg and heart rate 80 beats/minute. A III-IVshort early diastolic murmur is heard at the right upper sternal border. Systolic pulsation of the uvulaand systolic capillary pulsations are seen upon light compression of the nail bed. Echo confirms severeaortic regurgitation from a dilated aortic root. The ejection fraction is 60%. The left ventricular endsystolic dimension is 5.7 cm and the left ventricular end diastolic dimension is 7.6 cm. Which of thefollowing is the most appropriate course of action? a. Start an ACE inhibitor and repeat an echocardiogram in 6 months b. Start nifedipine and repeat an echocardiogram in 6 months c. Surgicalaortic valvereplacement d. start a beta-blocker and repeat and echocardiogram in 6 months

Answer 249

c. Surgicalaortic valvereplacement  Given the patient's severe aortic regurgitation, significantly dilated leftventricular dimensions, and symptoms, suggests that the patient is at riskfor developing irreversible heart damage, making immediate surgery amore suitable option than medical management

Question 250

An electrocardiogram (ECG) of a patient with diagnosed mitral stenosis reveals a P mitrale pattern. ThisECG finding is typically indicative of changes within the atrial chambers of the heart. Which combinationof changes is most likely responsible for the presence of P mitrale in this patient? a. Left atrialenlargementand leftatrialhypertrophy b. Left ventricular enlargement and left ventricular hypertrophy c. Left atrial enlargement and left ventricular hypertrophy d. Right atrial enlargement and right atrial hypertrophy e. Right atrial enlargement and right ventricular hypertrophy

Answer 250

a. Left atrialenlargementand leftatrialhypertrophy  P mitrale is a characteristic finding in patients with mitral stenosis,representing left atrial enlargement and hypertrophy. The enlarged leftatrium can cause a broad, notched P wave in the ECG, especially in lead II,as well as a biphasic P wave in lead V1

Question 251

A 70-year-old man with known severe aortic stenosis experiences an episode of syncope while walkingup the stairs. Considering his cardiac history, which underlying mechanism or etiology is most likelyresponsible for his syncope? a. Orthostatic hypotension b. Decreased cerebralperfusion frominadequate cardiacoutput c. Bradyarrhythmias including advanced AV blocks d. Ventricular arrhythmia e. Vasovagal syncope

Answer 251

b. Decreased cerebralperfusion frominadequate cardiacoutput  Severe aortic stenosis can lead to decreased cardiac output,especially during exertion, resulting in insufficient cerebralperfusion and syncope

Question 252

25-year-old woman is brought to the emergency department following a motor vehicle accident. She has a heart rate of 120 bpm and a blood pressure of 85/55 mmHg. She is saturating 89% while breathing ambient air. A chest radiograph shows pulmonary edema, and an echocardiogram reveals severe mitral regurgitation. Which of the following would be contraindicated in this patient? a. Placement of an intraaortic balloon pump b. Initiation of dobutamine c. Initiation of sodium nitroprusside d. Initiation ofphenylephrine e. Immediate surgical evaluation

Answer 252

d. Initiation ofphenylephrine  Initiation of phenylephrine, a selective α1-adrenergic receptor agonist, would increase afterload and thereby worsen the MR. Although this doesnot exactly fit the TLO of outlining the management of MR, it doeshowever help you practice your pharmacology and logically think aboutcontraindications for certain meds and why. For example, you want tothink that a selective α1-adrenergic receptor agonist causesvasoconstriction which would then increase the afterload.

Question 253

A 60-year-old woman with a bicuspid aortic valve complicated by chronic aortic regurgitation is seeking a second opinion. Her most recent echocardiogram showed severe AR but normal LV function and size. Additionally, the ascending aorta was normal. She is quite active in her community and denies symptoms of congestive heart failure. She insists on being referred to a cardiac surgeon for replacement. What is the next step in therapy? a. Reassure the patient and tell her to return only when she develops symptoms b. Obtain serial echocardiograms to monitorfor the onset of LV dysfunction or dilatation c. Start an ACE inhibitor to slow the progression of disease d. Refer her to a cardiac surgeon for aortic valve repair e. Refer her to a cardiac surgeon for aortic valve replacement

Answer 253

b. Obtain serial echocardiograms to monitorfor the onset of LV dysfunction or dilatation  In patients with asymptomatic severe AR,serial echocardiograms should be obtained to monitor for the onset of LVdysfunction or dilatation.

Question 254

A 60-year-old female presents with progressive shortness of breath on exertion over several months.She has also experienced episodes of palpitations and was diagnosed with rheumatic fever as a child.On examination: she is flushed on her cheeks, has an irregularly, irregular pulse. On palpation of thechest a tapping impulse is felt over the heart. On auscultation there is an opening snap and rumbling mid-diastolic murmur, best heard when thepatient is lying on her left side. Lungs are clear on auscultation. Where would an abnormal heart soundbe heard on the anatomy of the heart? a. Left mid-axillary line b. Left 2nd intercostal space, sternal edge c. Right 2nd intercostal space, sternal edge d. Left 5th intercostalspace, midclavicularline e. Right 4th intercostal space, mid-sternal border

Answer 254

d. Left 5th intercostalspace, midclavicularline  Mitral murmurs are best heard over the apex of the heart, whichmay be displaced downwards and towards the axilla with heartfailure

Question 255

A 50-year-old man presents complaining of chest pain that occurs at gradually diminishing levels ofphysical exertion, as well as two recent episodes of syncope while golfing. Cardiovascular examinationreveals a blood pressure of 120/90 mmHg, a loud crescendo-decrescendo systolic murmur bestappreciated at the upper right sternal border (with radiation to both carotid arteries), and a weak anddelayed carotid upstroke. What is the best next step? a. ECGandEcho b. Right heart catheterization c. Ventriculography d. CXR and CTPA

Answer 255

a. ECGandEcho  The combination of ECG and echocardiography (Echo) is the best initial diagnosticapproach for suspected aortic stenosis, given the patient's symptoms and physicalexamination findings. ECG can provide information on heart rhythm andhypertrophy, while an echo is crucial for assessing valve structure, function, andventricular performance

Question 256

Abnormalities in blood flow through damaged heart valves produce murmurs. Which murmur isproduced by mitral regurgitation? a. Ejection systolic murmur b. Mid-diastolic murmur c. Early diastolic murmur d. Machinery murmur e. Pansystolicmurmur

Answer 256

e. Pansystolicmurmur  Incompetent atrioventricular valves allow blood to flow back into the atriaduring ventricular systole. This regurgitation of blood produces a longmurmur that lasts the whole length of systole, called a pansystolic murmur

Question 257

A 78-year-old woman with severe mitral regurgitation is preparing to undergo surgery for a mechanicalmitral valve replacement. You are explaining to her the risks associated with having a mechanical heartvalve. Which of the following treatments will she require for the rest of her life? a. Vitamin Kantagonists b. ACE inhibitors c. Antibiotics d. Calcium channel blockers e. Beta blockers

Answer 257

a. Vitamin Kantagonists  Patients with mechanical heart valves require lifelong anticoagulation toprevent thromboembolism. Vitamin K antagonists, such as warfarin, arecommonly used to maintain an appropriate INR range and prevent clotformation on the mechanical valve

Question 258

Heart sounds are produced by the opening and closing of heart valves, heard on auscultation using astethoscope. Which of the following conditions is associated with the correct abnormality of the secondheart sound? a. Left bundle branch block – wide splitting Right bundle branch block is associated with wide splitting b. Mitral stenosis – soft aortic component c. Pulmonary stenosis – reverse splitting d. Left ventricular outflow obstruction – fixed splitting e. Pulmonaryhypertension –loudpulmonarycomponent

Answer 258

e. Pulmonaryhypertension –loudpulmonarycomponent  The types of second heart sound abnormalities can be deduced by thefact that closure of the aortic heart valve usually precedes thepulmonary valve, and that the difference is more pronounced ininspiration than expiration

Question 259

A 50-year-old man with asymptomatic severe chronic MR secondary to myxomatous degeneration presents to the clinic for routine follow-up. He is an attorney and has been quite busy with work. He denies symptoms of congestive heart failure. His examination is unchanged from his prior visit. His echocardiogram today shows interval worsening of his LV ejection fraction to 45%. What is the next best step in management? a. Refer for mitral valve replacement with bioprosthetic valve b. Refer for mitral valve replacement with mechanical valve c. Repeat echocardiogram in 3 months d. Start an ACE inhibitor e. Refer for mitral valverepair.

Answer 259

e. Refer for mitral valverepair  In asymptomatic patients with primary severe MR and LVdysfunction, mitral valve repair is preferred over mitral valve replacementbecause studies suggest better postoperative LV function and survival with repair.

Question 260

Which of the following is a known cause of functional tricuspid regurgitation? a. Endocarditis b. Tricuspid valve prolapse c. Dilatedcardiomyopathy d. Pulmonary stenosis e. Rheumatic heart disease

Answer 260

c. Dilatedcardiomyopathy  Dilated cardiomyopathy can lead to enlargement of the ventriculardimensions and, subsequently, the tricuspid annulus. This dilation canprevent the tricuspid leaflets from closing properly, resulting infunctional tricuspid regurgitation without direct damage to the valveleaflets

Question 261

SAQ: A previously healthy 55-year-old man presents to the primary care clinic with mild but progressiveexertional dyspnea and exercise intolerance. He also describes recent-onset orthopnea. His physicalexamination is remarkable for “water hammer” peripheral pulses and a hyperdynamic, laterallydisplaced apical impulse. Auscultation reveals a soft S1 and an S3 with an early, diastolic decrescendomurmur that is heard at the left upper sternal border. Extremity exam is notable for mild pitting edemaup to the midshin bilaterally. What is the most likely diagnosis? What is the next step in diagnosis? What is the next step in therapy?

Answer 261

What is the most likely diagnosis? Answer = Chronic aortic regurgitation Feedback = Chronic aortic regurgitation (AR) results from abnormalities in the valve leaflets or in theaortic root. Bicuspid aortic valves, rheumatic heart disease, and endocarditis are the leading causes ofleaflet dysfunction. Longstanding hypertension is a leading cause of aortic root disease What is the next step in diagnosis? Answer = Electrocardiogram and echocardiography. Feedback = Echocardiography, both transthoracic and transesophageal, is the mainstay for diagnosisand is used to determine both the severity and the mechanism of valvular dysfunction. Additionally,echocardiography provides insight into LV function and aortic root anatomy. In chronic AR, the ECGmay show left-axis deviation. Chest radiograph may reveal cardiomegaly, and a dilated aortic knob androot may be seen in chronic AR (just thought I would mention this last detail since we looked at thecardiac silhouette the first week with a check radiograph). What is the next step in therapy? Answer = Surgical evaluation if the regurgitation is severe. Feedback = Patients with symptomatic severe chronic left-sided valvular regurgitation should beconsidered for surgical treatment. Symptoms in the setting of severe aortic regurgitation, includingdyspnea or exercise intolerance, provide a clear indication for surgical management of that patient.Aortic valve surgery is indicated in symptomatic or asymptomatic patients with severe AR and either anLV ejection fraction of <50% or those undergoing cardiac surgery for another reason.

Question 262

Knowledge Check 1: Cardiac Muscle Question: In cardiac muscle, what is the order in which ion channels open to complete an action potential cycle? (Reorder the following): - Potassium channels - Fast sodium channels - Slow calcium channels

Answer 262

- Potassium channels - Fast sodium channels - Slow calcium channels

Question 263

Knowledge Check 2: SA Node Action Potential Question: Which of the following is a characteristic of the SA node action potential? Options: - Low resting membrane potential below the ventricular muscle - Funny current of Na, causing a slow drift of membrane potential toward the threshold - The action potential begins with the opening of potassium channels - The plateau phase results from the slow calcium channels

Answer 263

- Funny current of Na, causing a slow drift of membrane potential toward the threshold (This option is selected)

Question 264

Which of the following is the most common cause of coronary artery disease?

Answer 264

D) Atherosclerosis

Question 265

A 65-year-old male presents with sudden onset chest pain radiating to his left arm. ECG shows ST-segment elevation in leads V2-V4. Which of the following is the most likely diagnosis?

Answer 265

C) STEMI

Question 266

Which of the following organisms is most commonly associated with infective endocarditis in intravenous drug users?

Answer 266

B) Staphylococcus aureus

Question 267

A patient presents with fever, new murmur, and positive blood cultures for Streptococcus gallolyticus. Which of the following investigations is crucial to perform?

Answer 267

A) Colonoscopy

Question 268

Which of the following is a major Duke's criterion for infective endocarditis?

Answer 268

D) Positive blood culture with typical microorganism consistent with IE from two separate cultures

Question 269

Which of the following best describes rheumatic fever?

Answer 269

B) An autoimmune disease triggered by Group A Streptococcus infection.

Question 270

A 10-year-old child presents with chorea, carditis, and migratory polyarthritis after a recent sore throat. Which of the following is the most appropriate long-term management?

Answer 270

B) Penicillin prophylaxis

Question 271

Which of the following is the most common cause of restrictive cardiomyopathy?

Answer 271

B) Amyloidosis

Question 272

A patient with known hypertrophic cardiomyopathy presents with syncope during exertion. Which of the following is the most likely underlying mechanism?

Answer 272

B) Outflow tract obstruction

Question 273

Which of the following is the primary mechanism by which statins reduce the risk of cardiovascular events?

Answer 273

B) Lowering LDL cholesterol

Question 274

A 70-year-old patient with a history of peripheral vascular disease presents with new onset claudication. Which of the following is the most appropriate initial investigation?

Answer 274

B) Ankle-brachial index (ABI)

Question 275

Which of the following is a common symptom of chronic venous insufficiency?

Answer 275

C) Edema, skin discoloration, and ulceration

Question 276

Which of the following structures forms the apex of the heart?

Answer 276

B) Left ventricle

Question 277

The SA node is the primary pacemaker of the heart. Where is it located?

Answer 277

C) In the superior aspect of the right atrium, near the superior vena cava opening

Question 278

Which of the following waves on an ECG represents atrial depolarization?

Answer 278

A) P wave

Question 279

The first heart sound (S1) is produced by the closure of which valves?

Answer 279

B) Mitral and tricuspid valves

Question 280

Which of the following is the correct order of electrical conduction through the heart?

Answer 280

C) SA node -> AV node -> Bundle of His -> Purkinje fibers

Question 281

Which of the following statements about cardiac output is true?

Answer 281

A) It is the product of heart rate and stroke volume.

Question 282

Frank-Starling mechanism of the heart describes the relationship between:

Answer 282

B) End-diastolic volume and stroke volume.

Question 283

Which of the following is the main determinant of arterial blood pressure?

Answer 283

B) Cardiac output and total peripheral resistance

Question 284

Renin is secreted by the kidneys in response to:

Answer 284

B) Decreased renal perfusion pressure

Question 285

Angiotensin-converting enzyme (ACE) inhibitors primarily act by:

Answer 285

C) Preventing the conversion of angiotensin I to angiotensin II

Question 286

Which of the following is a common side effect of ACE inhibitors?

Answer 286

A) Hyperkalemia

Question 287

Beta-blockers are contraindicated in patients with:

Answer 287

C) Decompensated heart failure

Question 288

Which of the following is true regarding dihydropyridine calcium channel blockers (e.g., amlodipine)?

Answer 288

B) They are potent vasodilators.

Question 289

Which of the following congenital heart defects is characterized by a "boot-shaped" heart on chest X-ray?

Answer 289

D) Tetralogy of Fallot

Question 290

A continuous "machinery-like" murmur heard best in the left infraclavicular area is characteristic of:

Answer 290

C) Patent Ductus Arteriosus

Question 291

Which of the following is a common complication of an unrepaired large ventricular septal defect (VSD)?

Answer 291

B) Pulmonary hypertension

Question 292

During fetal circulation, the ductus arteriosus connects which two structures?

Answer 292

B) Pulmonary artery and aorta

Question 293

Which of the following is the most common congenital heart defect?

Answer 293

B) Ventricular Septal Defect

Question 294

Which of the following is typically seen on an ECG in a patient with an anterior myocardial infarction?

Answer 294

B) Q waves in leads V1-V4

Question 295

Which of the following is the most common cause of coronary artery disease?

Answer 295

Atherosclerosis

Question 296

A 65-year-old male presents with sudden onset chest pain radiating to his left arm. ECG shows ST-segment elevation in leads V2-V4. Which of the following is the most likely diagnosis?

Answer 296

STEMI

Question 297

Which of the following organisms is most commonly associated with infective endocarditis in intravenous drug users?

Answer 297

Staphylococcus aureus

Question 298

A patient presents with fever, new murmur, and positive blood cultures for Streptococcus gallolyticus. Which of the following investigations is crucial to perform?

Answer 298

Colonoscopy

Question 299

Which of the following is a major Duke's criterion for infective endocarditis?

Answer 299

Positive blood culture with typical microorganism consistent with IE from two separate cultures

Question 300

Which of the following best describes rheumatic fever?

Answer 300

An autoimmune disease triggered by Group A Streptococcus infection.

Question 301

A 10-year-old child presents with chorea, carditis, and migratory polyarthritis after a recent sore throat. Which of the following is the most appropriate long-term management?

Answer 301

Penicillin prophylaxis

Question 302

Which of the following is the most common cause of restrictive cardiomyopathy?

Answer 302

Amyloidosis

Question 303

A patient with known hypertrophic cardiomyopathy presents with syncope during exertion. Which of the following is the most likely underlying mechanism?

Answer 303

Outflow tract obstruction

Question 304

Which of the following is the primary mechanism by which statins reduce the risk of cardiovascular events?

Answer 304

Lowering LDL cholesterol

Question 305

A 70-year-old patient with a history of peripheral vascular disease presents with new onset claudication. Which of the following is the most appropriate initial investigation?

Answer 305

Ankle-brachial index (ABI)

Question 306

Which of the following is a common symptom of chronic venous insufficiency?

Answer 306

Edema

Question 307

Which of the following structures forms the apex of the heart?

Answer 307

Left ventricle

Question 308

The SA node is the primary pacemaker of the heart. Where is it located?

Answer 308

In the superior aspect of the right atrium

Question 309

Which of the following waves on an ECG represents atrial depolarization?

Answer 309

P wave

Question 310

The first heart sound (S1) is produced by the closure of which valves?

Answer 310

Mitral and tricuspid valves

Question 311

Which of the following is the correct order of electrical conduction through the heart?

Answer 311

SA node -> AV node -> Bundle of His -> Purkinje fibers

Question 312

Which of the following statements about cardiac output is true?

Answer 312

It is the product of heart rate and stroke volume.

Question 313

Frank-Starling mechanism of the heart describes the relationship between:

Answer 313

End-diastolic volume and stroke volume.

Question 314

Which of the following is the main determinant of arterial blood pressure?

Answer 314

Cardiac output and total peripheral resistance

Question 315

Renin is secreted by the kidneys in response to:

Answer 315

Decreased renal perfusion pressure

Question 316

Angiotensin-converting enzyme (ACE) inhibitors primarily act by:

Answer 316

Preventing the conversion of angiotensin I to angiotensin II

Question 317

Which of the following is a common side effect of ACE inhibitors?

Answer 317

Hyperkalemia

Question 318

Beta-blockers are contraindicated in patients with:

Answer 318

Decompensated heart failure

Question 319

Which of the following is true regarding dihydropyridine calcium channel blockers (e.g., amlodipine)?

Answer 319

They are potent vasodilators.

Question 320

Which of the following congenital heart defects is characterized by a "boot-shaped" heart on chest X-ray?

Answer 320

Tetralogy of Fallot

Question 321

A continuous "machinery-like" murmur heard best in the left infraclavicular area is characteristic of:

Answer 321

Patent Ductus Arteriosus

Question 322

Which of the following is a common complication of an unrepaired large ventricular septal defect (VSD)?

Answer 322

Pulmonary hypertension

Question 323

During fetal circulation, the ductus arteriosus connects which two structures?

Answer 323

Pulmonary artery and aorta

Question 324

Which of the following is the most common congenital heart defect?

Answer 324

Ventricular Septal Defect

Question 325

Which of the following is typically seen on an ECG in a patient with an anterior myocardial infarction?

Answer 325

Q waves in leads V1-V4

Question 326

Which layer of the heart wall is primarily responsible for its pumping action?

Answer 326

Myocardium

Question 327

Which of the following valves prevents backflow of blood from the left ventricle into the left atrium?

Answer 327

Mitral valve

Question 328

The right coronary artery typically supplies blood to which of the following areas?

Answer 328

Right atrium and right ventricle

Question 329

The circumflex artery is a branch of which major coronary artery?

Answer 329

Left main coronary artery

Question 330

Which of the following electrolytes plays a crucial role in myocardial contraction and relaxation?

Answer 330

Calcium

Question 331

What is the approximate normal resting membrane potential of a cardiac muscle cell?

Answer 331

-90 mV

Question 332

The plateau phase of the cardiac action potential is primarily maintained by the influx of which ion?

Answer 332

Ca2+

Question 333

Which of the following is true regarding the absolute refractory period in cardiac muscle?

Answer 333

It ensures that the heart can fully relax before the next contraction.

Question 334

What is the physiological term for the resistance that the ventricles must overcome to eject blood into the arteries?

Answer 334

Afterload

Question 335

Which of the following would decrease cardiac output?

Answer 335

Significant bradycardia

Question 336

The mean arterial pressure (MAP) is calculated by which of the following formulas?

Answer 336

Diastolic BP + 1/3 (Systolic BP - Diastolic BP)

Question 337

Which of the following is a primary mechanism for long-term blood pressure regulation?

Answer 337

Renal control of fluid volume

Question 338

A patient with uncontrolled hypertension is at increased risk for which of the following complications?

Answer 338

Renal failure

Question 339

Which of the following factors contributes most to the pathogenesis of atherosclerosis?

Answer 339

Endothelial injury and dysfunction

Question 340

Foam cells, a hallmark of atherosclerotic plaques, are derived from which type of cells?

Answer 340

Macrophages

Question 341

Stable angina pectoris is typically relieved by which of the following?

Answer 341

Nitroglycerin

Question 342

Prinzmetal's angina is characterized by:

Answer 342

Chest pain at rest due to coronary artery spasm.

Question 343

What is the most common cause of sudden cardiac death in adults?

Answer 343

Ischemic heart disease

Question 344

The primary goal of reperfusion therapy in STEMI is to:

Answer 344

Limit infarct size.

Question 345

Which of the following cardiac enzymes is most specific for myocardial injury?

Answer 345

Troponin I and T

Question 346

What is the most common complication of acute myocardial infarction?

Answer 346

Arrhythmias

Question 347

A patient presents with classic symptoms of infective endocarditis. Which imaging modality is most sensitive for detecting vegetations on heart valves?

Answer 347

Transesophageal echocardiography (TEE)

Question 348

Janeway lesions are described as:

Answer 348

Nontender erythematous macules on palms and soles.

Question 349

Which of the following is a common presenting symptom of left-sided heart failure?

Answer 349

Orthopnea and paroxysmal nocturnal dyspnea

Question 350

Right-sided heart failure is most commonly caused by:

Answer 350

Left-sided heart failure

Question 351

Which of the following medications is a loop diuretic, commonly used in the management of heart failure with fluid overload?

Answer 351

Furosemide

Question 352

Digoxin exerts its positive inotropic effect by:

Answer 352

Inhibiting the Na+/K+ ATPase pump.

Question 353

What is the most common cause of dilated cardiomyopathy?

Answer 353

Ischemic heart disease

Question 354

Hypertrophic cardiomyopathy is often characterized by:

Answer 354

Asymmetric septal hypertrophy.

Question 355

Which of the following cardiac murmurs is typically described as a "systolic ejection murmur" heard best at the right upper sternal border, radiating to the carotids?

Answer 355

Aortic stenosis

Question 356

A "diastolic rumble" murmur with an opening snap is characteristic of which valvular heart disease?

Answer 356

Mitral stenosis

Question 357

The QRS complex on an ECG represents:

Answer 357

Ventricular depolarization

Question 358

A prolonged PR interval on an ECG indicates a delay in conduction through which structure?

Answer 358

AV node

Question 359

What is the normal heart axis in the frontal plane on an ECG?

Answer 359

0 to +90 degrees

Question 360

Atrial fibrillation is characterized by:

Answer 360

Irregularly irregular rhythm with absent P waves and fibrillatory waves.

Question 361

Which of the following antiarrhythmic drugs is a Class III agent that blocks potassium channels and prolongs repolarization?

Answer 361

Amiodarone

Question 362

The Valsalva maneuver can be used to terminate which type of arrhythmia?

Answer 362

Supraventricular tachycardia (SVT)

Question 363

What is the most common cause of transudative pleural effusion in the context of cardiovascular disease?

Answer 363

Congestive heart failure

Question 364

Which of the following is a common cause of dependent edema in patients with right-sided heart failure?

Answer 364

Increased capillary hydrostatic pressure

Question 365

Lymphedema is caused by:

Answer 365

Impaired lymphatic drainage.

Question 366

The umbilical arteries in the fetus carry:

Answer 366

Deoxygenated blood from the fetus to the placenta.

Question 367

What is the normal physiological adaptation of the mother's cardiovascular system during pregnancy?

Answer 367

Increased heart rate and stroke volume

Question 368

The foramen ovale in the fetal heart allows blood to bypass which circulation?

Answer 368

Pulmonary circulation

Question 369

Failure of the neural tube to close during embryonic development can lead to:

Answer 369

Spina bifida

Question 370

Which of the following is a key feature of the development of the heart tubes in early embryonic development?

Answer 370

They fuse to form a single heart tube.

Question 371

The sinus venosus contributes to the formation of which part of the adult heart?

Answer 371

Smooth part of the right atrium (sinus venarum)

Question 372

The bulbus cordis contributes to the formation of which structures?

Answer 372

Trabeculated parts of the ventricles and outflow tracts

Question 373

Which of the following is a common symptom of pulmonary hypertension?

Answer 373

Syncope and dyspnea

Question 374

A patient with severe pulmonary hypertension is likely to develop which of the following?

Answer 374

Right ventricular hypertrophy

Question 375

Which of the following is the most common cause of chronic hypertension?

Answer 375

Essential (primary) hypertension

Question 376

Long-standing hypertension can lead to which of the following changes in the heart?

Answer 376

Left ventricular hypertrophy

Question 377

Which of the following is a common adverse effect of nitrates used in the treatment of angina?

Answer 377

Headache

Question 378

Aspirin exerts its antiplatelet effect by inhibiting which enzyme?

Answer 378

Cyclooxygenase (COX)

Question 379

Which of the following is a common side effect of beta-blockers?

Answer 379

Bronchospasm

Question 380

A patient with stable angina is prescribed a calcium channel blocker. Which of the following would be an appropriate choice?

Answer 380

Amlodipine

Question 381

Which of the following receptors does epinephrine primarily act upon to increase heart rate and contractility?

Answer 381

Beta-1 adrenergic receptors

Question 382

The vagus nerve primarily innervates which part of the heart to decrease heart rate?

Answer 382

Atria

Question 383

A patient presents with a history of recurrent syncope. Which of the following investigations is most likely to identify an underlying cardiac arrhythmia?

Answer 383

24-hour Holter monitor

Question 384

Which of the following is a common complication of untreated atrial fibrillation?

Answer 384

Stroke

Question 385

The P wave on an ECG is absent, and the rhythm is irregularly irregular. This finding is most consistent with:

Answer 385

Atrial fibrillation

Question 386

Which of the following conditions is characterized by a widened pulse pressure and a "water-hammer" pulse?

Answer 386

Aortic regurgitation

Question 387

The second heart sound (S2) is produced by the closure of which valves?

Answer 387

Aortic and pulmonary valves

Question 388

A split S2 that widens on inspiration is characteristic of:

Answer 388

Atrial septal defect (ASD)

Question 389

The most common cause of peripheral arterial disease (PAD) is:

Answer 389

Atherosclerosis

Question 390

Which of the following describes intermittent claudication?

Answer 390

Muscle pain in the legs that occurs with exercise and is relieved by rest.

Question 391

Raynaud's phenomenon is characterized by:

Answer 391

White

Question 392

Which of the following is a key component of Virchow's triad, predisposing to thrombosis?

Answer 392

Endothelial injury

Question 393

Deep vein thrombosis (DVT) most commonly occurs in which veins?

Answer 393

Deep veins of the leg

Question 394

The most serious complication of deep vein thrombosis is:

Answer 394

Pulmonary embolism