Question

1

of 60

Which of the following CVD risk prediction tools could be used in low-resource settings, where lab testing is not readily available, yet provides effective risk discrimination?

A.The Framingham Heart Study risk equation with additional novel risk factors.

B.The Reynolds Risk Score.

C.The Harvard-derived NHANES risk score using age, sex, systolic blood pressure, smoking, and diabetes status and that replaces BMI for cholesterol can predict high-risk patients equally as well when compared to the Framingham risk score.

D.Just using blood pressure is sufficient because identifying patients at high absolute risk for CVD is not a cost-effective prevention strategy.

The correct answer is C. The Harvard NHANES score can predict high-risk patients equally as well when compared to the Framingham risk score. Novel risk factors, when added to the traditional risk factors (gender, age, diabetes status, smoking status, blood pressure, total or LDL and HDL cholesterol) used in the Framingham CVD or CHD risk equations, have not been shown to significantly increase the discriminatory power (C-statistic) of the risk equations. The Reynolds Risk Score, which adds hs-CRP, and glycated hemoglobin, and family history, did not significantly increase the C-statistic, but did lead to reclassification of patients to higher- and lower-risk classifications. Identifying patients at high risk using risk scores has been proven to be cost-effective in preventing CVD even in low-resource settings.

Wang TJ, Gona P, Larson MG, et al. Multiple Biomarkers for the Prediction of First Major Cardiovascular Events and Death. N Engl J Med 2006;355:2631-9.

1.

Ware JH. The limitations of risk factors as prognostic tools. N Engl J Med 2006;355:2615-7.2.Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. JAMA 2007;297:611-9.

3.

Mendis S, Lindholm LH, Mancia G, et al. World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries. J Hypertens 2007;25:1578-82.

4.

Gaziano TA, Young CR, Fitzmaurice G, Atwood S, Gaziano JM. Laboratory-based versus non-laboratory-based method for assessment of cardiovascular disease risk: the NHANES I Follow-up Study cohort. Lancet 2008;371:923-31.

5.

Gaziano TA, Steyn K, Cohen DJ, Weinstein MC, Opie LH. Cost-effectiveness analysis of hypertension guidelines in South Africa: absolute risk versus blood pressure level. Circulation 2005;112:3569-76.

6.

References

ACCSAP8 Exam1&2Friday, September 07, 20127:11 AM

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Question

2

of 60

A novel biomarker is being evaluated for its ability to diagnose PE in patients presenting to the emergency department with suggestive symptoms. Previous studies have suggested that a biomarker level over 500 U is diagnostic for PE. One hundred patients are enrolled; their levels of this biomarker are measured, but not revealed to the treating physicians in the emergency department, who are asked to determine whether the patient has a PE based on standard testing alone.

The study results are as follows:

PE Diagnosed

No PE Diagnosed Biomarker level >500 U

40

10Biomarker level

The correct answer is E. PPV is calculated as (true positives)/(true positives + false positives). For this example, the PPV is: (40)/(40 + 10) = 40/50 = 0.80 or 80%.

Question

3

of 60

A 79-year-old woman with a long history of hypertension who ran out of her medications about 2 weeks ago, presents to the clinic with dyspnea on exertion, lower extremity edema, and mild orthopnea. Her blood pressure is 170/110 mm Hg. Her ECG shows normal sinus rhythm and suggests LV hypertrophy. A transthoracic echocardiogram confirms mild, concentric LV hypertrophy and a normal LV ejection fraction.

Which of the following is the most important long-term intervention for this patient?

A.Evaluation and treatment of diabetes mellitus.

B.Lifestyle modification (diet/exercise).

C.Identification and treatment of CAD.

D.Intensive lipid management.

E.Intensive blood pressure control.

The correct answer is E. The case presents a patient with diastolic heart failure, or heart failure with preserved systolic function. Approximately 90% of patients with diastolic heart failure have a history of hypertension. The treatment of hypertension reduces incident heart failure (especially in the elderly), and exacerbations of heart failure (e.g., flash pulmonary edema) are often associated with hypertension. In such patients, there have been no studies showing improved mortality with any of the medications studied in randomized trials (e.g., ACE inhibitors, angiotensin II receptor blockers). While all of the interventions are reasonable, hypertension control is the most important intervention. For her current congestive symptoms, a diuretic will be indicated, and may also play a long-term role in her management.

Lindenfeld J, Albert NM, Boehmer JP, et al., on behalf of the Heart Failure Society of America. HFSA 2010 Comprehensive Heart Failure Practice Guideline. Section 11: Evaluation and Management of Patients with Heart Failure and a Preserved Left Ventricular Ejection Fraction. J Card Fail 2010;16:e126-33.

1.

Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 2009;53:e1-e90.

2.

References

Question

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Question

4

of 60

A 55-year-old man with previous coronary bypass surgery notes worsening dyspnea on exertion, fatigue, and pedal edema. On exam, he is noted to have elevated JVP that increases with inspiration and a loud early diastolic sound. He is most likely to have which of the following?

A.Mitral stenosis.

B.Ischemic dilated cardiomyopathy.

C.Constrictive pericarditis.

D.ASD.

The correct answer is C. This patient has signs and symptoms of elevated RA pressure, a Kussmaul sign, and a pericardial knock, which are all consistent with constrictive pericarditis. With mitral stenosis, a low frequency, rumbling diastolic murmur should be present, as well as signs and symptoms of an elevated left atrial pressure. The absence of an S3 and/or S4, AV valve regurgitation makes ischemic cardiomyopathy less likely. Although right heart failure occurs in patients with longstanding uncorrected large ASD, a fixed split S2 and systolic flow murmur (due to increased flow across the pulmonary valve) would be expected.

Question

5

of 60

A 45-year-old woman with a Framingham risk score of 2% and a family history of premature CHD presents for risk assessment.

Referral for a calcium score in this patient would be considered which of the following?

A.Appropriate.

B.Uncertain appropriateness.

C.Inappropriate.

D.Unknown appropriateness.

The correct answer is A. The American College of Cardiology Foundation Cardiac CT Appropriate Use Criteria

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The correct answer is A. The American College of Cardiology Foundation Cardiac CT Appropriate Use Criteria and other Expert Consensus documents primarily identify patients with an intermediate risk of CHD as appropriate candidates for calcium scoring. The basis for this recommendation lies in the potential to alter patient management through reclassification of risk to a higher or lower level according to the scan findings. One exception when low-risk patients are appropriate for scanning is in the presence of a family history of CHD.

Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56:1864-94.

1.

Greenland P, Bonow RO, Brundage BH, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2007;49:378-402.

2.

References

Question

6

of 60

A 52-year-old woman undergoes cardiac catheterization to evaluate dyspnea, which has become progressive over the last year. She smoked one pack of cigarettes per day for 12 years but quit 20 years ago. She had noted some lower extremity edema and some weight gain. Four months ago, her physician prescribed furosemide 20 mg/day, which improved her lower extremity edema, but her dyspnea continued to progress. The mean RA and LA pressures are 20 mm Hg, the PA pressure is 42/24 mm Hg, and the Fick cardiac index is 2.1 l/m/m2. The RV and LV pressure tracings are shown in Figure 1.

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Based on the hemodynamic findings, which of the following is the most likely cardiac diagnosis?

A.Hypertrophic obstructive cardiomyopathy.

B.Cor pulmonale.

C.Restrictive cardiomyopathy.

D.Constrictive pericarditis.

E.Primary pulmonary hypertension.

The correct answer is D. The hemodynamic finding of elevated and equal filling pressures and ventricular discordance with respiration is consistent with the diagnosis of constrictive pericarditis. Restrictive cardiomyopathy causes elevated filling pressures but ventricular concordance with respiration. Cor pulmonale and primary pulmonary hypertension do not cause elevated left-sided filling pressures. Hypertrophic cardiomyopathy can cause elevated filling pressures but does not cause ventricular discordance.

Question

7

of 60

A 52-year-old woman with hypertension presents to the emergency department with the acute onset of chest

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A 52-year-old woman with hypertension presents to the emergency department with the acute onset of chest pain and markedly elevated blood pressure. You discover that she is not having an acute ST elevation myocardial infarction, but are concerned she may be having an aortic dissection.Based on the results of the imaging study (Figure 1), which of the following do you recommend as the next best step in management of this patient?

A.Medical therapy to reduce her blood pressure and repeat imaging in 1 week.

B.Medical therapy to reduce her blood pressure and immediate surgical repair.

C.Medical therapy to reduce her blood pressure and surgical repair once her hypertension is under control.

D.Medical therapy to reduce her blood pressure and endovascular stent placement.

E.Medical therapy alone.

The correct answer is B. The image shows a Stanford type A or DeBakey type I aortic dissection. Therapy for this type of dissection is immediate surgical repair, because mortality increases with time; therefore, options A, C, D, and E are incorrect.

Question

8

of 60

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An 85-year-old male patient is undergoing precatheterization evaluation and is found to have a Cr of 2.8 mg/dl, heart failure, anemia, and diabetes. You plan to use approximately 100 cc of iodinated contrast. He is hemodynamically stable. You have time to provide a prophylaxis.

Which of the following would be the best management approach?

A.Intravenous half normal saline 75 cc/h, 1 hour before and during the procedure.

B.Intravenous sodium bicarbonate solution, 300 cc 1-3 hours before the procedure.

C.Intravenous normal saline 300 cc 1-3 hours before the procedure at 150 ml/h for up to 6 hours after the procedure as feasible to ensure a post-procedure urine output of 150 cc/h.

D.Increase oral hydration the day before the procedure, and then intravenous normal saline 75 cc/h during the procedure.

The correct answer is C. There are no proven preventive agents for CI-AKI. Volume depletion is recognized to be a risk factor for all forms of AKI, and thus, the use of intravenous fluids reduces this contributing factor. Indirect evidence suggests that an elevated urine flow rate may allow more urinary losses of contrast and less uptake in proximal tubular cells, thus, less CI-AKI.

Goldfarb S, McCullough PA, McDermott J, Gay SB. Contrast-induced acute kidney injury: specialty-specific protocols for interventional radiology, diagnostic computed tomography radiology, and interventional cardiology. Mayo Clin Proc 2009;84:170-9.

1.

Stevens MA, McCullough PA, Tobin KJ, et al. A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy: results of the P.R.I.N.C.E. Study. Prevention of Radiocontrast Induced Nephropathy Clinical Evaluation. J Am Coll Cardiol 1999;33:403-11.

2.

References

Question

9

of 60

A 64-year-old tobacco farmer is seen in clinic on referral from his primary care physician for vascular evaluation. The patient has a 40-year history of smoking and family history of vascular disease. He reports that he has worked hard for most of his life, and over the last year, has noted an increase in pain in his buttocks and calves with walking. He states that when walking up a hill to a barn on the property (200 yards or so), he has significant discomfort in both legs and sometimes now has to stop to rest. His left leg takes longer to resolve than his right leg.

His physical examination is notable for blood pressure of 148/85 mm Hg and heart rate of 44 bpm with regular rhythm. He has bilateral carotid bruits, evidence of tobacco staining on his fingernails, no evidence of enlarged abdominal aorta on examination, +2 femoral pulses bilaterally, +1 popliteal pulses, and palpable DP and PT pulses in both legs. He has a rest and exercise ABI performed; the results are shown (Figures 1a, b).

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Which of the following is your interpretation and plan?

A.Normal rest and exercise ABIno evidence of PAD.

B.Normal rest ABIevaluate for sciatica.

C.Normal rest ABI with abnormal exercise ABI consistent with PADrecommend pentoxifylline.

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D.Normal rest ABI with abnormal exercise ABIrecommend angiography.

E.Normal rest ABI with abnormal exercise ABI consistent with PADrecommend structured exercise and cilostizol.

The correct answer is E. The question identifies a prototypical patient with intermittent claudication. In the face of normal resting ABI, an exercise ABI helps to confirm the diagnosis. These findings are not consistent with sciatica, and the exercise ABI demonstrates ABI

B.Statin for an LDL

The correct answer is E. Among patients under age 50, acute MI mortality is higher in women than men.1 This may be surprising to many, because CHD events lag 10 years in women compared to men.2

CVD, not breast cancer, is the leading cause of death in women.3

Systemic autoimmune collagen-vascular disease is listed as a criterion for the at risk status.4

The presence of diabetes is a relatively greater risk factor for CHD in women compared with men, increasing a womans risk of CHD by three- to sevenfold with only a two- to threefold increase in diabetic men.5

Goal HDL-C in women is 50 mg/dl and in men is 40 mg/dl.4

Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med 1999;341:217-25.

1.

Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: A 26-year follow-up of the Framingham population. Am Heart J 1986;111:383-90.

2.

Roger VL, Go AS, Lloyd-Jones DM, et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation 2011;123:e18-e209.

3.

Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. Circulation 2011;123:1243-62.

4.

Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ 2006;332:73-8.

5.

References

Question

12

of 60

Which of the following agents is/are reversible P2Y12 receptor inhibitor/s?

A.Ticlopidine.

B.Clopidogrel.

C.Prasugrel.

D.Ticagrelor.

E.All of the above.

The correct answer is D. Ticlopidine, clopidogrel, and prasugrel are thienopyridines. These prodrugs undergo hepatic conversion to active metabolites that bind irreversibly to the P2Y12 receptor. Ticagrelor is a direct

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hepatic conversion to active metabolites that bind irreversibly to the P2Y12 receptor. Ticagrelor is a direct P2Y12 receptor inhibitor that binds irreversibly to the P2Y12 receptor.

Question

13

of 60

Which one of the following conditions or diagnoses is an absolute contraindication to fibrinolytic administration?

A.ICH 4 months prior to presentation.

B.Acute ischemic stroke with onset of symptoms 2 hours before presentation.

C.Prolonged CPR >10 minutes.

D.Pregnancy.

E.Active treatment with warfarin with therapeutic international normalized ratio between 2 and 3.

The correct answer is A. Prior ICH is an absolute contraindication to fibrinolysis, regardless of the interval before presentation. An acute ischemic stroke is not an absolute contraindication and in fact may benefit from fibrinolytic therapy (although the dose/agent may differ from treatment of acute MI). Prolonged CPR, pregnancy, and active anticoagulation may require caution but are all relative contraindications to fibrinolytic therapy and are not absolute.

Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44:671-719.

1.References

Question

14

of 60

A-75-year old diabetic man is admitted to the coronary care unit after a drug-eluting stent (DES) placement in his mid right coronary artery following an acute inferior wall MI. He had earlier received 600 mg of clopidogrel in the emergency department and had been administered a bolus of bivalirudin followed by an IV infusion. He smokes one pack of cigarettes per day and has a history of a prior ischemic stroke with no residual in the remote past. He has a history of mild claudication in the calf when walking uphill. On arrival to the unit, his ECG shows sinus rhythm at 72, inferior Q waves with almost complete resolution of his inferior ST elevation.

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ECG shows sinus rhythm at 72, inferior Q waves with almost complete resolution of his inferior ST elevation. He is pain free, blood pressure is 148/70 mm Hg, and lungs are clear to auscultation with adequate air entry. Cardiac examination reveals an LV fourth heart sound and a loud aortic component of the second heart sound. Initial labs are pertinent for a troponin T of 0.03 ng/ml, a creatinine of 1.3 mg/dl, and blood glucose of 180 mg/dl.

Which of the following medical interventions is unwarranted?

A.Initiate treatment with Lopressor 25 mg orally every 8 hours.

B.Initiate treatment with ramipril 5 mg/day.

C.Initiate IV insulin to target blood sugar control of 80-100 mg/dl.

D.Continue treatment with clopidogrel 75 mg/day.

E.Initiate treatment with pantoprazole 40 mg/day.

The correct answer is C. In the absence of absolute contraindications, beta-blockade benefits most hemodynamically stable patients with an STEMI. An ACEI is a preferred agent in a diabetic individual with hypertension. Extrapolating data from a stable CAD population, the initiation of ramipril in this subject may also reduce the long-term risk of recurrent MI, stroke, and death. Dual antiplatelet therapy is indicated in the setting of stent placement, and the use of a proton pump inhibitor (PPI) will decrease the risk of gastrointestinal bleeding. Although a PPI should be used with caution, concerns for a PPI/clopidogrel interaction have not translated into confirmed clinical harm. While achieving blood sugar control is reasonable in this setting, current targets support a more conservative target in the 180 mg/dl range with IV insulin and not a target in the 80-100 mg/dl range.

Question

15

of 60

A 71-year-old woman presents with dyspnea and fatigue. She reports that the dyspnea comes on while going up one flight of stairs and when walking her dog, though if she slows down and rests, she can often continue walking. She does not have any history of CAD, but has hypertension and type 2 diabetes. She is taking metformin. Her ECG reveals LV hypertrophy with strain. She underwent an exercise stress test with radionuclide imaging and exercised for 430 on a standard Bruce protocol. Her blood pressure response was normal. She developed dyspnea and epigastric tightness at 4 minutes, eventually stopping due to the dyspnea. Her ECG did not change. Her radionuclide images demonstrated areas of reversible ischemia in the apical anterior, inferoseptal, and apical segments. Her calculated ejection fraction was 42%.

Which of the following is the next most appropriate test?

A.Stress echocardiography.

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B.CTA.

C.Coronary angiography.

D.No testing is needed at this time; begin optimal medical therapy.

The correct answer is C. This patient has several features that indicate that she is at an intermediate-to-high risk for future CV disease. Her intermediate features are a mildly reduced LV function and an intermediate-risk treadmill score (even without calculable ST-segment depression, her DTS would be -5). The next appropriate test would be coronary angiography to define the degree of atherosclerosis. Treatment decisions could then be best determined based on the extent of disease. In this case, another stress test with echocardiography would not give additional value, although a standard echocardiography would offer further data regarding LV function, wall-motion abnormalities, and valvular disease. CTA is not indicated because this patient should proceed to catheterization, and the CTA would only expose her to additional contrast and radiation.

Fox K, Garcia MA, Ardissino D, et al. Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 2006;27:1341-81.

1.

Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina-summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 2003;41:159-68.

2.

Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40:1531-40.

3.

References

Question

16

of 60

A 63-year-old man is evaluated for symptoms of chest discomfort. He reports a 3-month history of substernal chest tightness provoked by moderate exertion, such as walking uphill to his mailbox. The symptoms occur almost daily. His medications include aspirin 81 mg daily, simvastatin 20 mg daily, and ibuprofen as needed. Stress testing demonstrated a mild reversible apical perfusion defect, and coronary angiography revealed a focal 80% stenosis in the mid-LAD artery and no other obstructive lesions.

Which of the following is the most appropriate next step in his treatment?

A.Refer for CABG with a LIMA graft.

B.Prescribe metoprolol and sublingual nitroglycerin.

C.Refer for PCI of the LAD artery.

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C.Refer for PCI of the LAD artery.

D.Increase simvastatin to 40 mg daily.

E.Refer for PCI of the LAD artery and start metoprolol.

The correct answer is B. This patient has chronic stable CCS class II angina. Low-risk findings were demonstrated on noninvasive stress testing, and angiography revealed single-vessel CAD involving the mid-LAD artery. In this case, maximal medical therapy is recommended with an antianginal agent such as a beta-blocker or a long-acting nitrate. Revascularization is not recommended in patients with single-vessel CAD, mild symptoms, and low-risk noninvasive findings.1

Patel MR, Dehmer, GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization. J Am Coll Cardiol 2009;53:530-53.

1.References

Question

17

of 60

A 73-year-old man with diabetes and hyperlipidemia is admitted to the hospital with heart failure. As part of your evaluation, you determine that he has an LVEF of 20% and significant three-vessel CAD.

Which of the following results would be most predictive of identifying hibernating, viable myocardium that is likely to recover function after revascularization in this patient?

A.A biphasic response with augmentation in wall motion and endocardial thickening at low doses of dobutamine and deterioration at higher doses of dobutamine.

B.Continued deterioration of wall motion and endocardial thickening with increasing doses of dobutamine.

C.A biphasic response with deterioration of wall motion and endocardial thickening at low doses of dobutamine and augmentation in wall-motion abnormalities at higher doses of dobutamine.

D. No change in wall-motion abnormalities with either low or high doses of dobutamine.

E.Sustained improvement in wall motion and endocardial thickening with increasing doses of dobutamine.

The correct answer is A. Options B, C, D, and E are incorrect because they have not been shown to best correlate with improvement in wall motion and endocardial thickening after revascularization.

Question

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18

of 60

A 62-year-old woman presents to your office complaining of chest discomfort, which has been increasing in frequency over the past 2 years. At first she noticed the discomfort with extreme exertion, while running with her grandchildren. The discomfort began in her substernal region and radiated to her back and left shoulder, and resolved with rest. She attributed these symptoms to getting old and being out of shape. About 9 months ago, she noticed that these episodes were occurring about once a week and now were precipitated by either physical activity (walking up or down the stairs, doing household chores with her arms) or emotional stress related to her job as a teacher of autistic children.

Although these episodes continue to resolve with rest, she is concerned about whether she should retire. She has a 50 pack-year smoking history and quit 2 years ago when these episodes first started. She admits to poor dietary habits, history of hypertension, and infrequent migraine both diagnosed in her late 40s and currently treated with enalapril 10 mg daily and hydrochlorothiazide 12.5 mg daily. She has dyslipidemia treated with lovastatin 20 mg daily for 2 years with total cholesterol of 215 mg/dl, low-density lipoprotein (LDL) of 125 mg/dl, high-density lipoprotein of 32 mg/dl, and triglycerides of 178 mg/dl. She does not have diabetes. She has never seen a cardiologist and has never had an ECG or any other cardiovascular testing.

Her father died of a fatal myocardial infarction at the age of 62, and her mother died of lung cancer at the age of 58. Her older brother has had coronary artery bypass grafting, and her younger sister has dyslipidemia and diabetes.

Other than being overweight (5 feet 3 inches, 174 lbs) with a blood pressure today of 162/89 mm Hg, her exam is unremarkable.

Her cardiologist determines that she has stable angina, and that her blood pressure and LDL need better control. Before addressing her retirement question and per ACC/American Heart Association (AHA) guidelines, the cardiologist discusses the need for additional noninvasive cardiac risk stratification. Her resting ECG was normal, and enalapril was increased to 20 mg, hydrochlorothiazide to 25 mg daily, and lovastin to 40 mg daily. After a lengthy discussion, the patient was not interested in taking a long-acting nitrate, fearing that it would provoke her migraine. Likewise, she did not want to take a beta-blocker or calcium antagonist because she had experienced fatigue and edema when she had been prescribed these agents over the previous years for hypertension.

The patient returns to the office nurse for blood pressure checks over the next 3 weeks. Then an exercise stress test was done using the Bruce protocol with Duke treadmill scoring. Her stress test results are as follows:

Resting heart rate: 80 bpm; resting blood pressure 128/78 mm Hg.

Time on treadmill: 9 minutes and 30 seconds without chest discomfort.

Peak heart rate: 142 bpm; peak blood pressure 185/92 mm Hg.

At peak exercise, she exhibits a 1.5 mm horizontal to downsloping ST depression in inferior leads, consistent with ischemia with fairly high workload. She did not have any symptoms. An immediate postexercise echocardiogram reveals an ejection fraction of 65% and no wall motion abnormalities. Her ST-segment depression resolved completely in 1 minute.

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depression resolved completely in 1 minute.

The patient returns to your office for post-test discussion and counseling. Her blood pressure has been 125/80 to 135/84 mm Hg systolic at home. She states that she has had no further episodes of chest discomfort, but notes that it has only been 4 weeks.

You explain that she is most likely to benefit from which of the following?

A.A nuclear perfusion study with adenosine.

B.An elective coronary angiogram.

C.Yearly exercise stress tests.

D.Retiring from teaching position early.

E.An exercise program.

The correct answer is E. Her clinical findings are clearly abnormal (angina, hypertension, hypercholesterolemia, ST-segment depression with exercise), and are associated with mild impairment of her prognosis compared with women of similar age without these findings. Yet other than better blood pressure and LDL-C control and an exercise program, she is not likely to derive additional benefit from any of the above additional tests. Because her LV wall motion was not impaired and the ST-segment shifts resolve promptly and she is currently asymptomatic, it is very unlikely that she has multiple vessel severe obstructive CAD. She also could have nonobstructive CAD with microvascular dysfunction. Finally, if she remains asymptomatic at her work place, there is no benefit to recommending early retirement or a change in her job.

Question

19

of 60

An otherwise healthy 54-year-old man was referred to your office for evaluation of a heart murmur. He has no significant medical history and takes no medications. On physical examination, his blood pressure was 110/78 mm Hg, with a heart rate of 56 bpm, and he had a grade I/IV decrescendo diastolic murmur. An echocardiogram revealed a BAV with a horizontal commissure, mild aortic insufficiency, an aortic root diameter of 3.6 cm, and an ascending thoracic aortic diameter of 5.1 cm.

Based on these findings, the most appropriate management strategy would be to do which of the following?

A.Prescribe antibiotic prophylaxis for dental visits.

B.Prescribe a beta-blocker.

C.Prescribe an angiotensin-converting enzyme inhibitor.

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D.Refer the patient for surgery to repair the ascending thoracic aorta.

E.Obtain annual surveillance echocardiograms to monitor the diameter of the ascending thoracic aorta and the severity of the aortic insufficiency.

The correct answer is D. Whereas the threshold for surgery for idiopathic ascending thoracic aortic aneurysms is a diameter of 5.5 cm, in patients with a BAV, surgery is indicated once the ascending aorta reaches a diameter of 5.0 cm.

The remaining answers are incorrect for the following reasons. Based on the most recent ACC/AHA guidelines, native valvular heart disease is no longer an indication for antibiotic prophylaxis. Beta-blockers have been shown to slow the rate of growth of aortic aneurysms in patients with Marfan syndrome, and by extension, they have also been used routinely in the treatment of TAAs of other etiologies. However, in this case, the patient's blood pressure and heart rate are too low to reasonably add a beta-blocker.

Although afterload reduction may be considered in hypertensive patients with aortic insufficiency, this patient's blood pressure is too low to justify adding an angiotensin-converting enzyme inhibitor. Also, if the aortic diameter was too small to merit surgical repair, then annual surveillance imaging to monitor aortic size would be appropriate; however, given this patient's aortic diameter, surgery is indicated.

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol 2010;55:e27-e129.

1.References

Question

20

of 60

A 78-year-old man with a known history of coronary artery disease, including three-vessel coronary artery bypass graft (CABG) 7 years ago (left internal mammary artery [LIMA] to left anterior descending [LAD], saphenous vein graft [SVG] to obtuse marginal [OM], SVG to posterior descending artery [PDA]), presents with exertional chest discomfort. On physical examination, his blood pressure (BP) is 128/70 mm Hg in the right arm. Carotid, left supraclavicular, and bilateral femoral bruits are identified. Pulse examination discloses 2+ pulses throughout the body except for the left brachial and radial pulses, which are trace to 1+.

Which of the following pairs of physical examination and noninvasive imaging studies most likely would disclose the lesion responsible for the patients angina?

A.Bilateral arm BPs and computed tomography angiography (CTA) of the thorax.

B.An ABI and CTA of the pelvis with lower extremity runoff.

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C.Auscultation of the abdomen and abdominal duplex.

D.Doppler assessment of the pedal pulses and exercise ABI.

The correct answer is A. The physical examination finding of diminished pulses in the left arm raises suspicion for left subclavian artery (LSA) stenosis. The fact that this patient has angina after prior CABG surgery, which included a LIMA graft to the LAD, suggests the possibility of LIMA graft insufficiency (or potentially "steal") in the context of LSA stenosis. Measuring bilateral arm BPs should disclose a lower BP in the left arm than the right (>15 mm Hg discrepancy is strongly suggestive of LSA stenosis) and a CTA of the thorax would show the left subclavian lesion.

The other suggestions would be appropriate to evaluate lower extremity PAD (choice B or D) or to rule out abdominal aortic aneurysm or renal artery stenosis (choice C), but none of these would shed light on a source of angina.

Question

21

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A 63-year-old woman is seen in her primary care physicians office for routine follow-up. She has a history of diabetes and hypertension. Last year, she underwent successful right coronary artery stenting for an acute coronary syndrome. At that time, she quit tobacco use, having had a previous 75 pack/year history. She has no complaints.

On exam, her blood pressure is 132/82 mm Hg, heart rate is 68 bpm, height is 167 cm, and weight is 48 kg. Her lungs are clear; her heart has regular rate and rhythm; and normal S1, S2 without murmurs, rubs, or gallops. There are normal bowel sounds; scaphoid abdomen is without masses or tenderness. There is no edema of the lower extremities. Carotid, femoral, and distal pulses are unremarkable. There is a bruit present over the left femoral artery.

On her visit last year, she weighed 61 kg. She has not made an effort to lose weight or changed her exercise routine. On review of systems, she reports that she has noticed diffuse abdominal pain after eating. She has been unable to correlate this with any particular foods or to position. The pain is difficult to localize. She has learned to avoid meals as a solution to this abdominal pain

Which of the following is the next best step in the management of this patient?

A.Recommend over-the-counter proton pump inhibitor.

B.Right upper quadrant ultrasound to exclude cholecystitis.

C.Right upper quadrant ultrasound to exclude cholelithiasis.

D.Abdominal CT with contrast to exclude tumor.

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E.Abdominal duplex ultrasound of visceral vessels.

The correct answer is E. This woman has a history of known atherosclerosis with coronary stenting last year. She has a history of tobacco abuse, placing her at threefold increased risk for peripheral arterial disease. On examination, there is a bruit present in her left femoral artery, suggesting that she in fact has peripheral arterial disease. The absence of a bruit on abdominal exam does not exclude the presence of stenosis of the visceral vessels. She has lost 13 kg in 1 year, an unintended weight loss. Her abdominal pain is difficult to localize or characterize. She has learned to avoid food to minimize her pain.

An abdominal duplex ultrasound is a good screening test for CMI. It can be accomplished in 85% of elective cases, with a 90% accuracy for the detection of >70% stenosis. This is in contrast to patients with acute mesenteric ischemia, where the abdominal pain and tenderness, combined with bowel ischemia makes imaging challenging. Duplex ultrasound can be completed without radiation or contrast exposure and is a good initial screening test.

There is no evidence of fever or infection, making cholecystitis unlikely. The presence of stones in the gall bladder alone does not make the diagnosis of biliary colic. Further, the absence of a stone in the gall bladder does not preclude biliary colic, as the stone may be in the bile duct and not seen on the ultrasound. Biliary colic is typically localized to the right upper quadrant, and more often correlated with fatty foods in particular.

Although cancer may cause weight loss, she has no other constitutional complaints. There is no abdominal mass on exam. Her history of coronary artery disease, and the presence of peripheral arterial disease on exam make the diagnosis of CMI more likely. Thus, the test without the risk of contrast and radiation should be the initial test performed. Although CTA can visualize visceral artery stenosis, it must be performed with a dedicated CTA protocol. Typical scan protocols for abdominal studies will not provide sufficient resolution.

Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006;47:1239-312.

1.References

Question

22

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Atherosclerosis is the etiology of the vast majority of carotid artery stenotic disease. Nonatherosclerotic carotid artery disease must always be considered, however, as this potentially alters treatment strategies.

Which of the following statements is TRUE regarding characteristics suggestive of nonatherosclerotic carotid disease?

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A.Radiation-induced carotid stenosis is most commonly a focal stenotic lesion localized to the carotid bulb and proximal ICA.

B.Carotid artery dissection typically involves the proximal ICA and is not accompanied by cranial nerve palsy.

C.Fibromuscular dysplasia rarely involves more than one cervical vessel and is not associated with intracranial aneurysm.

D.Giant cell arteritis can involve the carotid arteries, but does not affect the aorta or its other branch vessels.

E.Takayasu arteritis involving the carotid artery should be suspected in a young adult presenting with neck pain and noted to have diminished brachial pulses.

The correct answer is E. Option A is incorrect. Radiation-induced carotid artery disease often affects long segments of the CCA and/or ICA, with preferential involvement of the CCA.1

Option B is incorrect. Carotid artery dissection typically begins more than 2 cm above the carotid bifurcation within the mobile segment of the ICA.2

Option C is incorrect. Fibromuscular dysplasia often involves more than one cervical vessel and is associated with a high incidence of intracranial aneurysm.3

Option D is incorrect. Though most commonly appreciated for its involvement of the temporal and other facial arteries, it can also involve the cervical arteries, aortic branch vessels, and the aorta, the latter potentially causing aneurysm and rupture.4

Option E is correct. Takayasu arteritis, or "pulseless disease", most commonly causes stenosis of the arteries to the upper extremities, but can also involve the carotid arteries and the aortic branch vessels.5

Lam WW, Liu KH, Leung SF, et al. Sonographic characterisation of radiation-induced carotid artery stenosis. Cerebrovasc Dis 2002;13:168-73.

1.

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009;8:668-78.

2.

Olin JW, Sealove BA. Diagnosis, management, and future developments of fibromuscular dysplasia. J Vasc Surg 2011;53:826-36.e1.

3.

Martinez-Valle F, Solans-Laque R, Bosch-Gil J, Vilardell-Tarres M. Aortic involvement in giant cell arteritis. Autoimmun Rev 2010;9:521-4.

4.

Arnaud L, Haroche J, Toledano D, et al. Cluster analysis of arterial involvement in Takayasu arteritis reveals symmetric extension of the lesions in paired arterial beds. Arthritis Rheum 2011;63:1136-40.

5.

References

Question

23

of 60A 72-year-old man presents to the emergency room with progressive dyspnea, now present at rest. He has had two prior myocardial infractions (MIs) and underwent coronary artery bypass grafting 12 years ago. He is on simvastatin, a nitroglycerin patch, and atenolol. On examination, his blood pressure is 145/90 mm Hg, his

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on simvastatin, a nitroglycerin patch, and atenolol. On examination, his blood pressure is 145/90 mm Hg, his pulse is 98 bpm, and his saturation is 93% on room air. His neck veins are distended. His lungs are clear. Cardiac examination shows a regular S1 and S2, with a II/VI holosystolic murmur at the apex and a S3 gallop. His chest X-ray shows cardiomegaly and vascular redistribution without focal infiltrates. His electrocardiogram demonstrates sinus rhythm and a left bundle branch block pattern. A stat echocardiogram demonstrates a dilated LV, with end-diastolic dimension of 7.2 cm, and an ejection fraction of 25% with moderate mitral regurgitation.

With regard to the 72-year-old man described earlier, which of the following combinations of neurohormonal abnormalities should be targeted in guidelines-based therapy of his heart failure?

A.Elevated vasopressin, angiotensin II, and aldosterone.

B.Elevated renin, BNP, and norepinephrine.

C.Elevated norepinephrine, angiotensin II, and aldosterone.

D.Elevated endothelin, vasopressin, and reduced nitric oxide.

The correct answer is C. Several classes of neurohormonal-blocking drugs reduce morbidity and mortality in chronic systolic HF, while others have not been shown to be useful in clinical trials. Blockade of the adrenergic and the RAAS improves symptoms and prolongs survival. Blockade of endothelin and vasopressin does not improve outcomes in clinical trials. The effect of direct renin inhibitors in HF has not been tested in large-scale clinical trials.

Question

24

of 60

A 43-year-old Caucaisan woman is referred to a heart failure clinic for evaluation and consideration of advanced therapeutics (ventricular assist device, transplantation). She has a 6-year history of nonischemic dilated cardiomyopathy, atrial fibrillation, and an implantable defibrillator was placed 4 years ago. She has had progressive symptoms despite optimal medical therapy. In reviewing her medical records, several findings are suggestive of a poor prognosis.

Which of the following conditions is associated with a worse prognosis in patients with heart failure?

A.Patient does not require loop diuretics.

B.Low cholesterol.

C.Obesity.

D.Hypouricemia.

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E.Resting sinus bradycardia.

The correct answer is B. Lower cholesterol has been linked to worse prognosis in heart failure patients and is likely related to poor nutritional status (cardiac cachexia) and elevated circulating inflammatory cytokines. In general, patients requiring higher doses of loop diuretics have worse outcomes, so the fact that the case patient does not require loop diuretics portends a better prognosis. The obesity paradox suggests that obese patients have better outcomes compared with their thin counterparts. Hyperuricemia has been associated with worse outcomes, as has resting sinus tachycardia.

Question

25

of 60

A 50-year-old man is referred to your clinic for evaluation of exertional dyspnea. Over the past 3 months he has noted increasing shortness of breath during daily activities, such as walking short distances or carrying light bundles. He has no prior history of MI and denies chest pain. His past medical history is notable only for hypertension and hypercholesterolemia. He takes only atenolol 25 mg once daily and simvastatin 20 mg once daily. He drinks one glass of wine with dinner each night, and denies use of tobacco or illicit drugs. His family history is notable for a paternal uncle who died suddenly in his 50s.

His exam is notable for blood pressure 170/80 mm Hg, pulse 80 bpm, mild jugular venous distention at 12 cm H20, clear lungs to auscultation, and mild peripheral edema. S1 is normal, S2 is paradoxically split, and there is a soft S3 gallop with a grade 2/6 holosystolic murmur at the apex. His ECG reveals sinus rhythm, with left bundle branch block and a QRS duration of 150 ms. Echocardiogram reveals a dilated LV with eccentric hypertrophy, anterior hypokinesis, and EF 25%.

He receives appropriate medical therapy with diuretics, an angiotensin-converting enzyme inhibitor, and a beta-blocker.

Which of the following is the most reasonable next step in the diagnostic evaluation of this patient?

A.Endomyocardial biopsy.

B.Genetic testing.

C.Measurement of BNP.

D.Coronary angiography.

E.Cardiac MRI.

The correct answer is D. In this gentleman with cardiac risk factors and regional wall motion abnormality on echocardiography, exclusion of coronary heart disease is the most important next step. Endomyocardial biopsy is a consideration, but is likely low yield in the setting of an already dilated ventricle and a subacute HF

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biopsy is a consideration, but is likely low yield in the setting of an already dilated ventricle and a subacute HF presentation. Although the patient may have a familial cardiomyopathy, genetic testing is premature and the history is not characteristic of any stereotypical genetic syndromes (such as cardiolaminopathy).

Cardiac MRI might help to exclude infiltrative or inflammatory processes affecting the myocardium or to quantitate the burden of scar, but is likely most useful after definitive evaluation of the coronary arteries is completed. Invasive evaluation of ischemia is preferred when the pretest probability for coronary artery disease is high. Measurement of BNP can be helpful in the initial diagnosis of HF and for prognostication, but has little diagnostic role in this patient for whom HF is established based on the physical examination.

Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Fail 2010;16:e1-194.

1.References

Question

26

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A 58-year-old women with HCM and a maximal wall thickness of 22 mm is found to have an exercise-induced LV outflow tract gradient of 90 mm Hg (normal blood pressure response to exercise) and moderate mitral regurgitation with exertional dyspnea, with symptoms consistent with early NYHA class II symptoms. She has a normal 24-hour Holter monitor, and no family history of sudden death.

Which of the following would you recommend next?

A.Surgical myectomy.

B.ASA.

C.Beta-blockers.

D.ICD.

The correct answer is C. ICD therapy is reserved only for HCM patients at increased risk for sudden death. LV outflow tract obstruction is not a primary risk factor, and this patient also has none of the five traditional primary risk factors for sudden death. Therefore, she would likely not benefit from this treatment. Invasive septal reduction therapy with either surgical myectomy or ASA is indicated only in patients with advanced heart failure symptoms consistent with NYHA class III or IV, who have failed medical therapy. This patient should be initiated on beta-blockers for treatment of heart failure symptoms in the setting of a high provocable outflow tract gradient.

Question

27

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of 60

A 56-year-old man status post anterior myocardial infarction with an LVEF 25% and mild right ventricular dysfunction presents urgently to the clinic with complaints of orthopnea, paroxysmal nocturnal dyspnea, and abdominal bloating for 2 days. He recently traveled to visit family for the holidays, and admitted to having difficulty maintaining sodium and fluid restriction, although he was compliant with his medications. Upon his return home, he noted that his weight had increased 10 lbs and his legs were swollen. His outpatient medical regimen includes enalapril 10 mg twice daily, carvedilol 12.5 mg twice daily, spironolactone 25 mg once daily, furosemide 80 mg twice daily, atorvastatin 40 mg once daily, and aspirin 81 mg once daily. He does not smoke cigarettes or drink alcohol.

His physical examination reveals a blood pressure of 130/80 mm Hg, heart rate 88 bpm, jugular venous pressure of 14 cm of water, decreased breath sounds at the left base, and a soft holosystolic murmur at the left lower sternal border. The liver edge is palpable 3 fingerbreadths below the right costal margin, and the lower extremities are warm with 1+ pitting edema to the mid-calves bilaterally.

You decide to directly admit this patient to the inpatient cardiology service for management of ADHF. According to the ACCF/AHA and HFSA guidelines, in addition to a 2-liter fluid restriction, which of the following would be the safest and most effective initial order for fluid management?

A.Furosemide 40 mg IV bolus every 12 hours.

B.Furosemide 80 mg IV bolus every 12 hours.

C.Bumetanide 2 mg orally every 12 hours.

D.Bedside venovenous ultrafiltration at 100 ml/hr.

E.Bedside venovenous ultrafiltration at 200 ml/hr.

The correct answer is B. This patient presents urgently with symptoms and signs of congestion and normal systemic perfusion. The likely precipitant to this admission is nonadherence with sodium and fluid restriction, which can often occur during travel away from home. When patients are admitted to the hospital with ADHF, initiating an effective diuresis with IV loop diuretics is critical to lowering cardiac filling pressures and reliving congestive symptoms. According to the ACCF/AHA 2009 Focused Update of the 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults, if patients are already receiving loop diuretics, the initial IV dose should equal or exceed the chronic oral dose (option B, not A).1

Bumetanide is a more potent loop diuretic than furosemide, but 2 mg twice a day is equivalent to furosemide 80 mg twice a day (option C) and should be given intravenously, per guidelines. The recent DOSE-AHF study showed no benefit of a continuous infusion (option C),2 and while pilot studies suggest that early ultrafiltration (options D and E) is associated with greater fluid removal than medical therapy alone,3 the HFSA guidelines raise concerns about safety, cost, and need for specialized medical and nursing support.4

Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 2009;53:e1-e90.

1.

Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. 2.

References

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Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364:797-805.

2.

Costanzo MR, Guglin ME, Saltzberg MT, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007;49:675-83.

3.

Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail 2010;16:e1-194.

4.

Question

28

of 60

A 60-year-old woman presents to the emergency room with NYHA class IV dyspnea. She has been admitted with HF three times in the past year. She had a large anterior myocardial infarction 2 years ago and despite coronary stenting of her left anterior descending artery, she was left with an EF of 10%, end-diastolic dimension of 8 cm, and moderately severe mitral regurgitation. Her medications include carvedilol, lisinopril, spironolactone, furosemide, aspirin, and simvastatin.

On exam, she is mildly tachypneic with a heart rate of 90 bpm and a blood pressure of 100/70 mm Hg. Her venous pressure is 16 cm H20. The lungs are clear. The heart has audible and palpable gallop; murmur of mitral regurgitation is present. The liver edge is palpable. The extremities are warm; there is pedal edema. An ECG demonstrates sinus rhythm with an anterior myocardial infarction pattern and a narrow QRS.

A cardiopulmonary exercise test demonstrates an oxygen consumption of 9.0 cc/kg/min with a respiratory quotient of 1.15, a ventilatory efficiency of 25, and a peak blood pressure of 130 mm Hg.

Which of the following is the primary indication for transplantation?

A.End-diastolic volume of 8 cm.

B.EF of 10%.

C.Ventilatory efficiency of 25.

D.Oxygen consumption of 9.0 cc/kg/min.

E.NYHA IV symptoms.

The correct answer is D. Although the increased heart size, low EF, and advanced symptoms predict increased mortality, cardiopulmonary exercise capacity is the most potent predictor of prognosis. The ventilatory efficiency of CO2 removal is characterized by the Ve/VC02 ratio and values over 35 predict worse prognosis. NYHA class is dynamic and waxes and wanes over time, and should be assessed in the chronic ambulatory state.

Question

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Question

29

of 60

A 76-year-old African-American female with nonischemic cardiomyopathy, history of breast carcinoma status/post mastectomy, and radiation therapy 30 years prior, as well as type 2 diabetes complicated by chronic kidney disease (creatinine clearance of 22), is hospitalized with worsening creatinine, decreased appetite/failure to thrive, cool lower extremities, and confusion by family report. Her ECG showed a left bundle branch block. A Swan-Ganz catheterization is performed, which reveals a right atrial pressure of 24 mm Hg, pulmonary capillary wedge pressure (PCWP) of 34 mm Hg, and a cardiac index of 1.4 L/min. Milrinone is instituted with a decrease of PCWP to 22 mm Hg and an improvement in cardiac index to 1.9 L/m. Mentation improves, but creatinine does not change. Within 24 hours of weaning the inotrope, the patient is noted to be confused and her creatinine increased further.

Which of the following would be the next step for this patient?

A.Implantation of a CRT.

B.Continuous infusion of inotrope.

C.Initiation of oral inotrope.

D.Use of intermittent IV inotrope.

E.Initiation of dialysis.

The correct answer is B. The decision to use chronic infusions of inotropic therapy is clinical and must take into account patient preferences and cost. The major reason to initiate therapy is palliation. Mortality is very high in this patient cohort. Implantation of a CRT has not been rigorously studied in inotrope-dependent patients, although case series have been presented. There are no oral inotropes currently approved for use. Use of intermittent IV inotropic agents is a Class III recommendation; there are no double blinded clinical trials to support the practice. Dialysis should only be considered under extenuating circumstances during terminal care; dialysis will not change the natural history of heart failure in this setting.

Allen L, Stevenson LW, et al. AHA Position Paper: Advanced Heart Failure: Prognosis, Communication, and Decision Making. Circulation [submission anticipated July 2011].

1.

Hauptman PJ, Mikolajczak P, George A, et al. Chronic inotropic therapy in end-stage heart failure. Am Heart J 2006;152:1096.e1-8.

2.

References

Question

30

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In which of the following clinical scenarios should an EMB be performed?

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In which of the following clinical scenarios should an EMB be performed?

A.A patient who presents to the emergency department with crushing chest pain, orthopnea, leg edema, and an ECG showing a QRS duration of 150 msec.

B.A 20-year-old woman with acute heart failure, an EF of 25%, and third-degree AV block.

C.A 35-year-old man who complains of acute pleuritic chest pain and a normal EF on echocardiogram.

D.A 65-year-man with atypical chest pain and delayed gadolinium enhancement in the lateral walls.

The correct answer is B. Patient A has coronary disease until proven otherwise. Patient C has no evidence of myocardial dysfunction. Patient D has evidence of coronary disease. EMB is a class I recommendation in patients who develop new-onset heart failure and heart block. In this situation, infiltrative disorders including sarcoid need to be considered, and the diagnosis is best established by biopsy.

Cooper LT, Baughman KL, Feldman AM, et al. The Role of Endomyocardial Biopsy in the Management of Cardiovascular Disease: A Scientific Statement From the American Heart Association, the American College of Cardiology, and the European Society of Cardiology Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. J Am Coll Cardiol 2007;50:1914-31.

1.References

Question

31

of 60

A 50-year-old man with a history of paroxysmal atrial fibrillation and coronary artery disease is to be initiated on dofetilide. His medications include aspirin 81 mg daily, lisinopril 10 mg daily, simvastatin 40 mg daily, metoprolol 50 mg twice daily, and isosorbide dinitrate 20 mg three times daily. His heart rate is 55 bpm, blood pressure is 123/75 mm Hg, and the remainder of the examination is unremarkable. His ECG shows sinus bradycardia at 54 bpm with a nonspecific intraventricular conduction delay, and a QRS duration of 105 ms and QT interval of 430 ms. Laboratory panel shows normal renal function, but with a slightly increased potassium level of 5.6 mEq/L.

Which of the following effects of dofetilide may increase the risk for torsade de pointes in this patient?

A.Reverse use dependence that is exacerbated by bradycardia.

B.Use dependence that is exacerbated by bradycardia.

C.Decreased potassium efflux exacerbated by hyperkalemia.

D.Increased potassium efflux exacerbated by hyperkalemia.

E.Decreased drug metabolism in the presence of simvastatin.

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E.Decreased drug metabolism in the presence of simvastatin.

The correct answer is A. Dofetilide exhibits reverse use dependence, with an increased effect at slow heart rates. Bradycardia in this patient may exacerbate dofetilides QT prolonging effects. Dofetilide does not have a drug interaction with simvastatin.

Darbar D. Standard antiarrhythmic drugs. In: Zipes DP, Jalife J. Cardiac Electrophysiology: From Cell to Bedside. 5th ed. Philadelphia: Saunders; 2009: 970-1.

1.References

Question

32

of 60

A 65-year-old man is admitted to the intensive care unit with recurrent episodes of VT that have been ongoing for 12 hours. His past history includes CAD. Five days ago, he had an acute ST elevation inferior wall myocardial infarction with a drug-eluting stent in the right coronary and was discharged home 2 days ago. Four months ago, he had an anterior wall myocrdial infarction with a drug-eluting stent in the proximal left anterior descending artery. His LVEF is 15% by echocardiogram, performed 3 days ago. His other past history includes diabetes type 2, hyperlipidemia, chronic kidney disease stage 3, and emphysema. His current medications are aspirin 81 mg/day, clopidogrel 75 mg/day, lisinopril 2.5 mg/day, carvedilol 3.125 mg twice daily, rosuvastatin 20 mg/day, and insulin glargine 15 U/day.

His vital signs are blood pressure 110/60 mm Hg with a heart rate of 135 bpm, respirations of 14 breaths/minute with a pulse oximetry of 93% on 2 liters of oxygen by nasal cannula. On physical examination, the jugular venous pulse is seen at about 9 cm H2O, and there are bibasilar crackles on examination. His ECG confirms VT at a rate of 135 bpm, and telemetry shows VT to break periodically to sinus rhythm for about 1 minute before reinitiating back to VT. Six hours ago in the emergency room, he was initiated on amiodarone with a 150 mg IV bolus and a drip of 1 mg/min, and a second 150 mg IV bolus was given about 1 hour ago. He remains predominantly in VT. His lab work is notable for a potassium of 3.8 mEq/L and a creatinine of 2.2 mg/dl.

In considering whether to add lidocaine, which of the following clinical features, in addition to possible interaction with amiodarone, places this patient at increased risk for lidocaine toxicity?

A.Systolic heart failure.

B.Renal disease.

C.Low serum potassium.

D.Recent myocardial infarction.

E.Emphysema.

The correct answer is A. Lidocaine is metabolized in the liver, and features that can impair hepatic blood flow,

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The correct answer is A. Lidocaine is metabolized in the liver, and features that can impair hepatic blood flow, particularly heart failure, can increase the risk of toxicity. In the setting of heart failure, lidocaine should be used cautiously, and the dose should be reduced by 50%. Lidocaine, a class IB agent, can be used in the setting of a recent myocardial infarction, but class IC agents are contraindicated.

Woosley RL. Pharmacokinetics and pharmacodynamics of antiarrhythmic agents in patients with congestive heart failure. Am Heart J 1987;114:1280-91.

1.References

Question

33

of 60

A 25-year-old woman presents with complaints of palpitations, exercise intolerance, fatigue, near syncope, and syncope. She was completely well until 6 months ago, when she contracted a severe flu-like illness, after which her symptoms began and have continued since.

Her 12-lead electrocardiogram and echocardiogram are normal, as are her thyroid profile and complete blood count. Findings from her physical examination are normal, except that when going from sitting to standing her blood pressure decreases from 110/70 mm Hg to 100/60 mm Hg and her pulse goes from 80 bpm while sitting to 120 bpm while standing.

Which of the following conditions is the most likely diagnosis?

A.Panic attacks.

B.Postural tachycardia syndrome.

C.Neurocardiogenic syncope.

D.Occult hypothyroidism.

E.Multiple system atrophy.

The correct answer is B. The history and hemodynamics are consistent with postural tachycardia syndrome, demonstrating an increase in heart rate when going from sitting to standing.1

Grubb BP, Kanjwal Y, Kosinski DJ. The postural tachycardia syndrome: a concise guide to diagnosis and management. J Cardiovasc Electrophysiol 2006;17:108-12.

1.References

Question

34

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34

of 60A 64-year-old man is referred to the clinic for evaluation of an abnormal ECG (Figure 1). His past medical history is significant for hypertension, for which he is treated with lisinopril. He denies cardiac symptomatology. He is active, works full-time as a car salesman, and plays golf regularly.

Which of the following is the next best diagnostic step for this patient?

A.Echocardiogram.

B.Carotid sinus massage.

C.Blood cultures.

D.Pacemaker.

E.Cardiac magnetic resonance imaging (MRI).

The correct answer is B. The ECG is consistent with sinus rhythm with 2:1 AV block. The differential is Mobitz type I (Wenckebach) second-degree AV block versus Mobitz type II second-degree AV block. Noninvasive vagal and sympathetic maneuvers can help to distinguish one from the other, since Mobitz I block is usually AV nodal, and Mobitz II block is usually in the His-Purkinje system. In a patient with AV nodal block, carotid sinus massage will slow the sinus rate and worsen AV conduction, which will worsen the AV block. The slowing of sinus rate and depression of AV conduction will have a protective effect on the distal conduction system, so conduction in the His-Purkinje may improve. Exercise (sympathetic stimulation) will improve AV nodal conduction, and worsen His-Purkinje conduction. His ECG (Figure 1) is suggestive of Mobitz I second-degree block, based on the long PR interval and narrow QRS interval.

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Option A is not correct: Although the detection of structural heart disease may help guide patient therapy, it is not the next best diagnostic maneuver to assess the degree and level of AV block.

Option C is not correct: There is no clinical evidence of endocarditis.

Option D is not correct. If the site of block is within the AV node in an asymptomatic patient, a pacemaker is not indicated.

Option E is not correct. Cardiac MRI is not indicated.

Question

35

of 60A 67-year-old obese male patient with diabetes mellitus and obstructive sleep apnea presents with profound dyspnea and a blood pressure of 69/40 mm Hg. The ECG shows evidence of a narrow complex tachycardia at 210 bpm, and a short RP interval.Which of the following is the most appropriate initial therapy?

A.Adenosine 12 mg IV stat.

B.Diltiazem 20 mg IV stat.

C.Electrical cardioversion.

D.Metoprolol 5 mg IV stat.

The correct answer is C. Electrical cardioversion should always be utilized as first-line therapy in a hemodynamically unstable patient.1

Hazinski MF, Nolan JP, Billi JE, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122:S250-75.

1.References

Question

36

of 60

A 78-year-old male presents to your office for routine yearly evaluation. He feels well and has no current symptoms or limitations. He has a past history of coronary artery disease and coronary artery bypass graft

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symptoms or limitations. He has a past history of coronary artery disease and coronary artery bypass graft surgery 7 years ago, chronic obstructive pulmonary disease, diabetes mellitus type 2 (diet controlled), and hypertension. You obtain a 12-lead ECG (Figure 1).

His examination reveals: well-nourished male in no distress. Blood pressure is 124/74 mm Hg. Pulse is mostly regular (rate 70 bpm). No jugular venous pressure elevation and a soft carotid bruit. Well healed median sternotomy scar. Normal heart sounds, no murmurs, and clear lung fields.

Current medications are: atenolol 50 mg daily, lisinopril 20 mg daily, and aspirin 325 mg daily.

At this time, you advise which of the following?

A.No change in medications or therapy.

B.Addition of clopidogrel to aspirin therapy.

C.Long-term warfarin therapy.

D.Cardioversion with anticoagulation coverage.

E.Catheter ablation.

The correct answer is C. Long-term warfarin therapy is appropriate, as he is at increased risk of stroke (CHADS2 score = 3). The risk of stroke in patients with AFL is the same as that associated with AF.

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Question

37

of 60

A 52-year-old female is seen in a cardiology clinic with complaints of increasing episodes of palpitations.- She has been diagnosed with paroxysmal AF and experiences episodes about once every month.- Initially they lasted about a half hour, but now they persist for almost an entire day. During the episodes she feels palpitations. As the event persists, she develops fatigue and has to stop her daily activities and rest.

The patients other medical history is significant for hypertension and gastroesophageal reflux disease. Her current medications are aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, metoprolol 25 mg twice a day, and omeprazole 20 mg daily.

On exam today, her blood pressure is 127/74 mm Hg, heart rate is 51 bpm, and the rest of her exam is within normal limits. Labs are unchanged from the previous visit and show sodium 139, potassium 4.1, magnesium 2.2, BUN 23, creatinine 1.5, and INR 1.1.

A treadmill stress echocardiogram earlier this year shows normal biventricular function, no evidence of LVH, normal chamber sizes, and normal response with exercise with no evidence of ischemia. A 12-lead ECG is shown (Figure 1).

Which of the following is the next best pharmacologic option?

A.Pill in the pocket approach with propafenone.

B.Amiodarone.

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B.Amiodarone.

C.Dofetilide.

D.Sotalol.

E.Increase daily metoprolol.

The correct answer is A. This is an ideal patient for a pill in the pocket approach, who can self-administer her antiarrhythmic during an episode of AF.1 She seems to tolerate the arrhythmia for a short period before becoming increasingly symptomatic. Note that the ECG shows sinus rhythm with a heart rate of 58 bpm and a prolonged QTc interval (Figure 1).

Rate control will likely be insufficient in controlling her symptoms, particularly with her already low baseline heart rate. Amiodarone would not be optimal in such a young patient. Sotalol should be avoided with renal dysfunction, and dofetilide should not be initiated with QTc intervals >440 ms or used concurrently with hydrochlorothiazide.2 Propafenone would be a good option for this patient.

Alboni P, Botto GL, Baldi N, et al. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. N Engl J Med 2004;351:2384-91.

1.

Fuster V, Rydn LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 2011;57:e101-98.

2.

References

Question

38

of 60

A 14-year-old boy, diagnosed with CPVT at age 8 and treated with nadolol 2.5 mg/kg/day, comes to a follow-up visit. During an exercise stress test, two runs of nonsustained VT (5 beats) occur after 10 minutes (maximal tolerated with Bruce protocol).

Which of the following drugs could be considered on top of beta-blockers?

A.No further treatment is required.

B.Quinidine.

C.Verapamil.

D.Flecainide.

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D.Flecainide.

E.Amiodarone.

The correct answer is D. The evidence of nonsustained VT during exercise suggests poor protection from adrenergically-induced arrhythmias in CPVT. The first approach is to increase beta-blocker dose. The standard dose is 1-1.5 mg/kg/day of nadolol. In this case, the dosage is already at the usual tolerated level. Recent evidence suggests that flecainide might achieve an additional antiarrhythmic effect.1 Since the arrhythmic pattern in CPVT is often reproducible, the use of oral flecainide may be considered. The patient should be reassessed after 2-3 weeks with an exercise stress test.

van der Werf C, Kannankeril PJ, Sacher F, et al. Flecainide therapy reduces exercise-induced ventricular arrhythmias in patients with catecholaminergic polymorphic ventricular tachycardia. J Am Coll Cardiol 2011;57:2244-54.

1.References

Question

39

of 60

A 34-year-old male presents to the emergency room with palpitations and lightheadedness. The ECG shown in Figure 1 is obtained. Sinus rhythm is restored with administration of intravenous lidocaine, and the ECG shown in Figure 2 is obtained. Coronary angiography shows normal coronaries and anLV ejection fraction of 45% with global hypokinesis.

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Cardiac MRI with assessment of gadolinium is most likely to reveal which of the following?

A.No areas of delayed enhancement.

B.Fat infiltration of the RV.

C.Delayed enhancement of the anterior wall of the LV.

D.Severe ventricular hypertrophy.

The correct answer is C. Figure 1 shows a wide QRS tachycardia at approximately 150 bpm. VT is indicated by AV dissociation (well seen in V1),with lead aVR showing an initial broad Q wave. Following conversion (Figure 2), the ECG shows sinus rhythm with first-degree AV block and RBBB with left-axis deviation. The patient's relatively young age raises the question of idiopathic VT, in which case no abnormalities would be expected on MRI. The abnormal sinus rhythm ECG, however, suggests underlying disease.

Most monomorphic VTs are due to scar that defines the origin of the VT. The VT has anRBBB-like configuration in V1 consistent with an origin in the LV. The inferior axis suggests origin in the superior portion of the ventricle. Thus, MRI is likely to show delayed enhancement of the anterior wall of the LV. ARVC, which often is associated with fatty infiltration of the RV on MRI, can have a similar presentation with VT, but AV block is rare, and VT is more likely to originate in the RV and have anLBBB configuration.

It is now also recognized that intramyocardial fat on MRI can be a normal variant. Monomorphic VT can occur in hypertrophic cardiomyopathy, but is uncommon, and the sinus rhythm ECG does not suggest LV hypertrophy. This patient's VT and scar were due to cardiac sarcoidosis.

Aliot EM, Stevenson WG, Almendral-Garrote JM, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association

1.References

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of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Heart Rhythm 2009;6:886-933.Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am CollCardiol. 2006;48:247-346.

2.

Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation 2010;121:1533-41.

3.

Muthappan P, Calkins H. Arrhythmogenic right ventricular dysplasia. ProgCardiovasc Dis 2008;51:31-43.4.

Question

40

of 60

A 71-year-old woman with an ischemic cardiomyopathy and atrial fibrillation underwent biventricular ICD implantation 6 months prior. She has NYHA class III symptoms and continues to complain of very limited functional capacity, with no change since resynchronization therapy was initiated.

She is currently taking carvedilol 25 mg BID, lisinopril 10 mg QD, furosemide 40 mg BID, simvastatin 20 mg QD, aspirin 325 mg QD, and warfarin 5 mg QD. Her vital signs in the office today are blood pressure 90/60 mm Hg, heart rate 111 bpm, respiration rate 20, oxygen saturation (SaO2) 94% room air, and she is afebrile. Her exam is significant for bibasilar rales, irregularly irregular heartbeat, and 1+ bilateral lower extremity edema.

Interrogation of her biventricular ICD reveals good pacing and sensing thresholds. The battery status and lead impedances are adequate. There have been two episodes of nonsustained ventricular tachycardia (VT), up to 15 beats, but no shocks have been required. She is 25% paced.

Which of the following should be the next step in her management?

A.Antiarrhythmic drug treatment for VT with amiodarone.

B.Increase carvedilol dose.

C.AV nodal ablation.

D.Referral for heart transplant evaluation.

E.Decrease carvedilol dose.

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The correct answer is C. Recent data support this approach for management of AF patients with CHF. Asymptomatic nonsustained VT is not an indication for amiodarone therapy, and studies have shown that antiarrhythmic drug agents increase mortality. Her blood pressure is tenuous, so increasing her beta-blocker is risky. Because she is asymptomatic of her borderline blood pressure and not in decompenstated HF, there is no reason to decrease her beta-blocker. She is not class IV, and therefore, would not be an appropriate candidate for a heart transplant evaluation.

Question

41

of 60

The patient is a 58-year-old male with witnessed sudden collapse in Chicago OHare airport. A bystander performed CPR and an automated external defibrillator (AED) was obtained and applied. EMS was simultaneously alarmed. The AED detected a shockable rhythm and a single shock was performed. The AED detected a nonshockable rhythm and additional chest compressions were begun. EMS arrived and detected a pulse. Chest compressions were halted and a pulse of 110 with a blood pressure (BP) of 150/90 was documented. However, the patient remained unresponsive. He is transported to the nearest hospital. The ECG in the ED shows only sinus tachycardia.

Which of the following is the optimal post-resuscitation care?

A.Begin therapeutic hypothermia in the ED with rapid iced-saline infusion (1-2 liters), admit to ICU and continue therapeutic hypothermia with a commercial mechanical surface cooling system to a goal of 33C for 24 hours. Rewarm slowly (0.3-0.5C/h) after 24 hours.

B.Provide comfort care and prepare the family for an inevitable poor outcome (i.e., either death or significant and incapacitating anoxic brain injury).

C.Call the catheterization laboratory for emergency coronary angiography and potential PCI. Afterwards admit the patient to the ICU for consideration of therapeutic hypothermia induction.

D.Begin therapeutic hypothermia in the ED while simultaneously calling the catheterization laboratory for emergency coronary angiography. Attempt PCI for any acute coronary occlusion or unstable, high grade presumed culprit lesion thought responsible for the cardiac arrest. Continue hypothermia in the catheterization laboratory and later in the ICU, to a goal of 33C for 24 hours. Rewarm slowly (0.3-0.5 C/h) after 24 hours.

The correct answer is D. This patient is ideal for aggressive post-resuscitation care. He had a witnessed VFCA, received immediate bystander CPR, and received early defibrillation with an AED. His time to ROSC was short and he was hemodynamically stable upon arrival at the ED. He remained comatose upon presentation and hence was a good candidate for therapeutic hypothermia to preserve central nervous system function and improve his chance for meaningful long-term survival. Such hypothermia should be begun immediately upon his arrival and continued for 24 hours, with a goal of 33C.

His etiology of circulatory collapse is almost certainly cardiac, as manifested by its sudden, unexpected occurrence. He deserves a careful search for an acute coronary ischemic event as the precipitating cause of

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occurrence. He deserves a careful search for an acute coronary ischemic event as the precipitating cause of this cardiac arrest. This is best accomplished by emergency coronary angiography even though his post-resuscitation ECG does not show ST elevation. One in four of such patients are identified as having an acutely occluded or culprit coronary lesion that is responsible for their cardiac arrest, which can be treated with emergent coronary angiography and PCI.

Question

42

of 60

A 75-year-old woman is hospitalized for shortness of breath with chest pain. A pulmonary embolism is diagnosed and she is initiated on heparin. Several hours later, she becomes hypotensive and does not respond to a fluid bolus. One hour later, she collapses on the way to the bathroom and a code arrest is called. The monitor shows a slow, wide, complex rhythm at 35 bpm, without a pulse, and chest compressions are started. External pacing through the defibrillator patches is attempted, but there is no ventricular capture. Chest compressions have been ongoing for 4 minutes.

Which of the following is the next step that should be taken?

A.Administration of atropine 1 mg IV.

B.Placement of a transvenous temporary pacing wire.

C.Endotracheal intubation.

D.Administration of epinephrine 1 mg IV.

E.Thrombolytic therapy.

The correct answer is D. In PEA, the first administered drug is epinephrine. Vasopressin can be substituted for the first or second dose of epinephrine. A transvenous pacing wire would require undue interruptions in chest compressions, and should not be attempted prior to administration of a vasopressor agent, epinephrine. Atropine can be considered after epinephrine is given, but is unlikely to be of benefit.

Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S729-67.

1.References

Question

43

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of 60

The aortic and peripheral vasculature in elderly patients differs from that of younger patients. These differences can significantly affect the pressure in the periphery and can affect the data derived from direct measurements of the gradient in AS.

Which of the following is the correct answer regarding the effect of aging on the hemodynamics observed in elderly patients compared to young patients?

A.In general, the central aortic pressure is higher than the femoral artery pressure in younger patients, and it is just the opposite in elderly patients.

B.The capillary bed microvessels are more likely to have pulsatile flow in younger patients than in elderly patients.

C.There is a greater disparity between the central aortic pressure and the femoral artery pressure in a younger patient than in an elderly patient.

D.When using the LV pressure and the femoral artery sheath pressure to measure the gradient across the aortic valve, the gradient in the young patient will be greater than the gradient in the elderly patient for the same severity of aortic stenosis.

The correct answer is C. Aging results in a progressive decline in collagen and elastin in the arterial walls, and an increase in vascular rigidity. With age, the pulse pressure becomes greater.

Aging also results in arterial dilatation and, while the conduit function of the arterial system is generally not affected, the cushioning function of the arterial tree is greatly affected. The pulse pressure is wider when the arterial compliance is poor and there is loss of the cushioning effect in the central aorta.

The practical consequence is that the central aortic pressure is generally significantly lower than the femoral artery pressure in young patients, but less so in elderly patients. When one measures the gradient using the femoral artery sheath and the LV, the gradient will appear to be lower in the young patient than if the LV and central aortic pressure was used. These differences are less marked in the elderly. The stiff aortic vessels