CVS Quiz Week 1 to 5

Question 1

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 1

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

Question 2

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 2

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

Question 3

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 3

b.
S2
S2 is due to closure of semilunar valves

Question 4

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 4

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

Question 5

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 5

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 6

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 6

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

Question 7

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 7

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

Question 8

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 8

a.
QRS prolongation

Question 9

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 9

Reduced ventricular ejection
Ventricles relaxed, not associated with ECG waves

Question 10

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 10

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

Question 10

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 10

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 11

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 11

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 11

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 11

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

Question 12

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 12

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 12

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 12

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 13

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 13

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

Question 14

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 14

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 15

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 15

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 16

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 16

e.
Emergencyhypertension

Question 17

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 17

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

Question 18

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 18

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

Question 19

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 19

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 20

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 20

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

Question 21

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 21

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 22

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 22

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

Question 23

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 23

c. Angiotensin II  Angiotensin II is a potent vasoconstrictor

Question 24

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 24

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 24

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 24

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

Question 24

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 24

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 25

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 25

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

Question 26

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 26

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 27

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 27

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

Question 28

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 28

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 29

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 29

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 30

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 30

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 31

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 31

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 32

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 32

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 32

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 32

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

Question 33

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 33

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 34

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 34

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

Question 34

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 34

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

Question 35

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 35

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

Question 36

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 36

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

Question 37

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 37

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 38

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 38

acute decompensated heart failure (ADHF)

Question 39

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 39

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 39

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 39

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

Question 40

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 40

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

Question 41

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 41

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 42

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 42

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 43

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 43

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

Question 44

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 44

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 45

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 45

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 46

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 46

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 47

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 47

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 48

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 48

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 49

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 49

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 50

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 50

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 51

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 51

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

Question 52

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 52

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 53

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 53

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 54

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 54

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 55

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 55

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 56

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 56

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 57

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 57

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 58

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 58

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 59

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 59

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 60

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 60

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 61

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 61

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 62

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 62

- Potassium channels - Fast sodium channels - Slow calcium channels

Question 63

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 63

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