Cardiology Lecture to IMCardiology Lecture to IMBoard Exam orientedBoard Exam oriented

MCQSPicture Quiz

Explanatory notes

Dr Ihab SulimanDr Ihab Suliman

20/October 201320/October 2013

Outline

MCQS Picture Quiz Explanatory notes

Old/Prior MI

Prognosis in AMI

Risk of dying is highest in first hour, one third of all MI deaths occur in first hour

Many of these early deaths are due to arrhythmias, usually ventricular fibrillation (VF)

Introductory MCQsIntroductory MCQs

The best BB associated with The best BB associated with significant & proven Mortality significant & proven Mortality benefit post MI ?benefit post MI ?

a- Atenolola- Atenolol b- Propranololb- Propranolol c- Timololc- Timolol d- carvedilol (Dilatrend)d- carvedilol (Dilatrend) e-Metoprolol tartrate, Short actinge-Metoprolol tartrate, Short acting

d- carvedilol (Dilatrend)d- carvedilol (Dilatrend)

Other Medications with mortality Other Medications with mortality benefit post MI are benefit post MI are

Metoprolol succinate , bisoprolol Metoprolol succinate , bisoprolol ( Concor), ACEI, ARBs , ( Concor), ACEI, ARBs , Spironolactone, statins Spironolactone, statins

The pathophysiology of heart failure can best be described

as:

A. a failure of protective mechanismsB. activation of harmful pathwaysC. introduction of pathogenic

influencesD. inappropriate activation of normal

mechanismsE. all of the above

Physiologic effects of Angiotensin II include:

A. vasoconstrictionB. activation of thirstC. sodium retentionD. aldosterone releaseE. all of the above

The following is a feature of the heart failure state:

A.reduced circulating catecholaminesB. increased left ventricular end

diastolic pressureC.reduced plasma volumeD.increased renal sodium excretionE.reduced pulmonary capillary wedge

pressure

B

increased left ventricular end diastolic pressure

All the following medications can precipitate heart failure in

susceptible patient except:

A. metoprololB. spironolactoneC. procainamideD. diltiazemE. rosiglitazone

The following are all adverse effects of beta blockers except:

A. bronchospasmB. bradycardiaC. hypotensionD. depressionE. anxiety

Q 1 A 56 year old obese female presents for a routine

physical examination. Her lipid profile  reveals a significantly elevated triglyceride level of 355 mg/dL. Which of the following medications can act to lower her triglyceride level by stimulating the synthesis of lipoprotein lipase?

A) gemfibrozil B) rosuvastatin C) cholestyramine D) ezetimibe E) ketoconazole

A 1 A) gemfibrozil

Gemfibrozil acts by stimulating the synthesis of lipoprotein lipase to degrade triglycerides  into fatty acids increasing their metabolism and lowering blood levels. Elevated triglyceride levels can lead to atherosclerosis and coronary artery disease.

Rosuvastatin (B) is an HMG-CoA reductase inhibitor which can cause rhabdomyolysis or hepatic dysfunction (elevation in AST and ALT levels). Cholestyramine (C) is a bile acid binding resin used to treat elevated low-density lipoprotein levels (LDL). Ezetimibe (D) is also used to treat elevated LDL levels and acts by inhibiting cholesterol absorption at the brush border of the small intestine. Ketoconazole (E), an anti-fungal medication, significantly reduces LDL levels as well. 

Q 2 A 19 year old boy with no past medical history

passes out while running at a school evnt. He states that he was feeling a little dizzy prior to the event, but does not complains of chest pain or palpitations. His blood pressure is 120/85, heart rate 85/min, Respiratory Rate 12/min, and he is afebrile. His physical examination reveals normal lung sounds, a II/VI mid-sytolic creshendo-decreshndo murmur is heard at the right upper sternal border which increases in intensity with Valsalva, an S4 heart sound is also present. Laboratory studies are normal. What is the most appropriate treatment at this time?

A) Start a Diuretic  B) Permanent

Pacemaker Implantation  C) AICD Implantation  D) Observation  E) Start  Beta Blocker

A 2

C) AICD Implantation

Q 3Q 3

The commonest cardiovascular manifestation of the Coxsackie infective agent is

a) cardiac tamponadeb) congenital Pericardial Defectsc) acute viral Pericarditisd) pericardial Cystse) bronchogenic carcinoma

A 3A 3

c) acute viral Pericarditis

Q 4Q 4

35 year old obese women develops painful leg on the 10th post operative day following emergency surgery for a ruptured ectopic pregnancy. She is likely to have ?

a) a) thromboangitis obliterans thromboangitis obliterans b) b) ruptured baker`s cyst ruptured baker`s cyst c) c) deep vein thrombosis of the lower limb deep vein thrombosis of the lower limb d) d) aortoiliac artery artherosclerosis aortoiliac artery artherosclerosis e) e) embolusembolus

A 4A 4

c) c) deep vein thrombosis of the lower deep vein thrombosis of the lower limb limb 

Specially if she is homozygous or Specially if she is homozygous or heterozygous for coagulopathy heterozygous for coagulopathy factor ?factor ?

Q 5 A 56 year old gardener complains of

sudden pain with swelling behind the right knee. He also complains of associated pain and swelling in the calf. On examination a crescentic hematoma is noted below the medial malleolus of the ankle.

a) Acute hemarthrosis b) Osteonecrosis c) Baker’s cyst d) pigmented villonodular synovitis e) rheumatoid arthritis

A 5 A 5

A Baker cyst is sometimes called a popliteal cyst. When an excess of knee joint fluid is compressed by the body weight between the bones of the knee joint, it can become trapped and separate from the joint to form the fluid-filled sac of a Baker cyst. The name of the cyst is in memory of the physician who originally described the condition, the British surgeon William Morrant Baker (1839-1896).

Rheumatoid HandsRheumatoid Hands

Question 6 Question 6 All of the following is correct about Atrial All of the following is correct about Atrial

Fibrillation except ?Fibrillation except ? A- The most common persistent A- The most common persistent

arrhythmia.arrhythmia. B- Incidence or prevalence increases with B- Incidence or prevalence increases with

age.age. C- if hemodynamically unstable patient in C- if hemodynamically unstable patient in

ER should be cardioverted .ER should be cardioverted . D- Dabigatran( Pradaxa) new antithrombin D- Dabigatran( Pradaxa) new antithrombin

associated with Decresed GI bleed associated with Decresed GI bleed compared to Warfarincompared to Warfarin

A 6A 6

D- Dabigatran new antithrombin D- Dabigatran new antithrombin associated with Decresed GI bleed associated with Decresed GI bleed compared to Warfarincompared to Warfarin

The correct answer is The correct answer is Dabigatran (Oral Thrombin Dabigatran (Oral Thrombin

inhibitor) new antithrombin inhibitor) new antithrombin associated with INCREASED GI associated with INCREASED GI bleed compared to Warfarinbleed compared to Warfarin

Atrial fibrillation is a common Atrial fibrillation is a common arrythmiaarrythmia In the FHS, the lifetime risk of atrial fibrillation (AFib) for adults age

40 is 26% for men and 23% for women1

Prevalence of AFib in the US is estimated > 2.2 million adults with an incidence > 70 000 2

Prevalence increases steeply with age 2

1.Lloyd-Jones DM, et al. Circulation 2004;110:1042–1046

2. Go et al. JAMA 2001;285:2370-5

AFib: a common but serious AFib: a common but serious arrythmiaarrythmia

AFib increases the risk of stroke 5-foldAFib increases the risk of stroke 5-fold11

The increase in risk of stroke is similar The increase in risk of stroke is similar for paroxysmal, persistent and for paroxysmal, persistent and permanent AFibpermanent AFib22

Strokes associated with AFib are Strokes associated with AFib are usually more severe than those from usually more severe than those from other causes, conferring an increased other causes, conferring an increased risk of morbidity, mortality and poor risk of morbidity, mortality and poor functional outcomefunctional outcome11

1. Savelieva et al. Ann Med 2007;39:371–3912. Hart R et al. JACC 2000; 35:183-187

Dabigatran etexilate – a new, Dabigatran etexilate – a new, reversible, oral DTIreversible, oral DTI

Dabigatran etexilate is an oDabigatran etexilate is an oral ral prodrug,prodrug, converted to dabigatran, a potent reversible DTIconverted to dabigatran, a potent reversible DTI

No interaction with food No interaction with food No participation with CYP450No participation with CYP450 Predictable anticoagulant effectPredictable anticoagulant effect Fixed doseFixed dose No need for routine coagulation monitoringNo need for routine coagulation monitoring Very recently some genetic variation for Very recently some genetic variation for

response response

36

Q 7 A 68-year-old gentleman is admitted with

an Anterior myocardial infarction (MI) and receives thrombolysis, aspirin, atenolol, atorvastatin and lisinopril. His ECG shows good ST segment resolution.

The next day he develops some pain in the legs and a dusky discolouration of the lower limbs. On closer examination there is a diffuse petechial rash over the lower limbs, particularly the feet, but all peripheral pulses are palpable.

CBC showed elevated eosinophils

Q7

Which of the following is the most likely cause for his current situation?

A)Polyarteritis Nodosa B)Aspirin Allergy C)Periphral Vascular Disease D)Cholesterol Emboli E)Post Thrombolysis Allergy

A 7

D)Cholesterol EmboliThe  above patient is an arteriopath as

suggested by the acute Myocardial Infarction, and one day after thrombolysis he develops a petechial rash in the lower limbs with raised white cell count - marked eosinophilia and raised IgE. This suggests cholesterol embolisation syndrome rather than allergy. 

Question 8Question 8 Catheter-delivered balloon expansion techniques Catheter-delivered balloon expansion techniques

are now the treatment of choice for which one of are now the treatment of choice for which one of the following lesions in adults?the following lesions in adults?

 A. Valvular pulmonic stenosis. A. Valvular pulmonic stenosis.

 B. Valvular aortic stenosis. B. Valvular aortic stenosis.

 C. Coarctation of the aorta. C. Coarctation of the aorta.

 D. Ebstein's anomaly of the tricuspid valve. D. Ebstein's anomaly of the tricuspid valve.

 E. Severe mitral stenosis with Significant  E. Severe mitral stenosis with Significant regurgitation.regurgitation.

Answer to 8Answer to 8 CommentComment

The correct answer is A. The correct answer is A.

Although catheter balloon valvuloplasty and aortoplasty Although catheter balloon valvuloplasty and aortoplasty have been attempted in all these conditions, only have been attempted in all these conditions, only pulmonary valvotomy has achieved a success level pulmonary valvotomy has achieved a success level consistent with being the treatment of choice in adults. consistent with being the treatment of choice in adults. Aortic stenosis responds initially to balloon expansion and Aortic stenosis responds initially to balloon expansion and may serve as a bridge to valve replacement surgery, but is may serve as a bridge to valve replacement surgery, but is associated with rapid restenosis. Success rates with associated with rapid restenosis. Success rates with coarctation and Ebstein's anomaly are not uniform enough coarctation and Ebstein's anomaly are not uniform enough to displace surgery except in selected patients. to displace surgery except in selected patients.

Mitral stenosis in the absence of severe subvalvular Mitral stenosis in the absence of severe subvalvular disease can be successfully treated by balloon disease can be successfully treated by balloon valvuloplasty, but the presence of moderate to severe valvuloplasty, but the presence of moderate to severe regurgitation is an indication for surgery.regurgitation is an indication for surgery.

Q 9 A 72 year old female with a history of breast cancer and

tobacco use complains of dizziness and dyspnea on exertion. Her heart sounds are distant and her systolic blood pressure is noted to markedly decrease with inspiration. Which of the following is the most likely diagnosis?

A) Constrictive cardiomyopathy B) Mitral valve Stenosis C) Congestive heart failure D) Pulmonary embolus E) Cardiac Tamponade

A 9 E) Cardiac Tamponade

     Cancer is the most common cause of pericardial effusion and when enough fluid accumulates in the pericardial space, cardiac tamponade occurs. “Pulsus paradoxus” is when there is a decrease in systolic blood pressure during inspiration due to failure of the right ventricle to accept the normal increased venous return that occurs with inspiration. This also results in a “Kussmal’s sign” or elevated jugular venous distension during inspiration (normally the opposite occurs). Treatment is with emergent pericardiocentesis.

Q 10Q 10 In which of the following diseases is pregnancy difficult, but not highly In which of the following diseases is pregnancy difficult, but not highly

risky to mother and fetus?risky to mother and fetus?

 A. Eisenmenger's syndrome. A. Eisenmenger's syndrome.

 B. Primary pulmonary hypertension. B. Primary pulmonary hypertension.

 C. Hypertrophic obstructive cardiomyopathy. C. Hypertrophic obstructive cardiomyopathy.

 D. Prior peripartum cardiomyopathy with heart failure. D. Prior peripartum cardiomyopathy with heart failure.

 E. The Marfan syndrome with dilated aortic root. E. The Marfan syndrome with dilated aortic root.

Answer to Q10Answer to Q10

  CommentCommentThe correct answer is C. The correct answer is C.

The cardiovascular system must be able to handle a doubling of cardiac The cardiovascular system must be able to handle a doubling of cardiac output during pregnancy. Thus, cardiopulmonary diseases that obstruct output during pregnancy. Thus, cardiopulmonary diseases that obstruct blood flow are usually contraindications to pregnancy because both the blood flow are usually contraindications to pregnancy because both the mother and fetus get inadequate blood flow. Thus, obstruction to mother and fetus get inadequate blood flow. Thus, obstruction to pulmonary flow due to the Eisenmenger reaction or primary pulmonary pulmonary flow due to the Eisenmenger reaction or primary pulmonary hypertension fits into this category, but hypertrophic cardiomyopathy does hypertension fits into this category, but hypertrophic cardiomyopathy does not. The increased cardiac output increases venous return to the left heart not. The increased cardiac output increases venous return to the left heart resulting in left ventricular enlargement and less obstruction. In fact, resulting in left ventricular enlargement and less obstruction. In fact, during pregnancy the murmur of hypertrophic obstructive cardiomyopathy during pregnancy the murmur of hypertrophic obstructive cardiomyopathy may lessen or even disappear, causing the diagnosis to be missed. may lessen or even disappear, causing the diagnosis to be missed.

Prior peripartum cardiomyopathy with heart failure is a contraindication to Prior peripartum cardiomyopathy with heart failure is a contraindication to pregnancy because of the high incidence of recurrent failure and death. pregnancy because of the high incidence of recurrent failure and death.

Hormonal changes during pregnancy alter vascular walls, making them Hormonal changes during pregnancy alter vascular walls, making them more distensible. This is a normal mechanism to adapt to higher cardiac more distensible. This is a normal mechanism to adapt to higher cardiac output; however, in the patient with the Marfan syndrome and an enlarged output; however, in the patient with the Marfan syndrome and an enlarged aortic root, it can lead to increased wall stress and aortic rupture or aortic root, it can lead to increased wall stress and aortic rupture or dissection.dissection.

Q 11 A 50 year old gentleman is admitted to the CCU with an

acute Inferior wall infarction. Three hours after the admission his B.P is 90/50 mmHg. The heart rate is 38 beats per minute with sinus rhythm. Which of the following will be the most appropriate initial therapy?

A)Immediate insertion of temporary pacemaker B)Intravenous administration of of Isoproterenol 5

micrograms/min C)Intravenous administration of Dobutamine 0.35 mg/min D) Administration of Intravenous Normal saline, 300 ml

over 15 mins E) Intravenous administration of atropine sulfate , 0.6 mg

A 11

E) Intravenous administration of atropine sulfate , 0.6 mg

Q 12 A 50 year old gentleman with a history of hypertension and

high cholesterol presents to the emergency department with pain in chest for one hour. He describes a substernal chest pressure associated with shortness of breath and sweating. His ECG shows ST elevations consistent with myocardial infarction. Which of the following laboratory results would be expected?

A) Elevated myoglobin, normal troponin I, and normal CK-MB  B)Normal myoglobin, elevated troponin I, and normal CK-

MB  C)Normal myoglobin, normal troponin I, and elevated CK-

MB  D)Normal myoglobin, normal troponin I, and normal CK-MB

A 12 A) Elevated myoglobin, normal troponin I,

and normal CK-MB Myoglobin is a heme protein found in

skeletal and cardiac muscle that has attracted considerable interest as an early marker of MI. Its low molecular weight accounts for its early release profile:

myoglobin typically rises1- 2hours after onset of infarction, peaks at 6-12 hours, and returns to normal within 24-36 hours.

Q13 A 60 year old man with a histoty of Diabetes, hypertension

and congestive heart failure was brought to the ER after he complained of blurred vision and headache. He was found to have Blood Pressure of 220/90 mm Hg. The intern who examined her wanted to give her drug X, but the attending doctor rejects this choice because of its tendency to cause compensatory tachycardia and exacerbate fluid retention. The drug can also cause lupus like syndrome with long term use. What is the mechanism of action of Drug X?

 A)Blocks Calcium Channels B)Increases Production of cGMP C)Decreases Production of cGMP D)Inhibits Angiotensin Converting Enzyme e)Inhibits carbonic Anhydrase

A 13 Hydralazine increases  (cGMP) levels, increasing

the activity of protein kinase G (PKG). Active PKG adds an inhibitory phosphate to myosin light-chain kinase (MLCK) – a protein involved in the activation of cross-bridge cycling (i.e. contraction) in smooth muscle. This results in blood vessel relaxation.

It dilates arterioles more than veins. Hydralazine requires the endothelium to provide

NO) thus only provides the effects of NO in vivo with functional endothelium. It will not work to vasodilate in vitro in an isolated blood vessel.

Activation of  has been suggested as a mechanism

Q 14

A 46 year old gentleman came to the Emergency department with c/o sudden dyspnea. Patient had similar episode of dyspnea two days earlier which was associated with profuse sweating. Patient is a reformed smoker and a social drinker. ECG is displayed below. Let`s interpret the ECG and decide the next step in the management.

Sinus; PVCs; LAD; anterior symmetric T wave inversion - and almost "Wellens"-like in V2,V3 - so patient will probably need cath in short order (looking for a tight LAD lesion ...).

Q 15 A 30 year old female with no significant past medical history is

42 weeks pregnant and labor has just begun. She begins to complain of difficulty in breathing which worsens throughout delivery to the point of requiring intubation. She had never previously complained of any shortness of breath or chest pain. Her temperature is 37.0, blood pressure 90/60, heart rate 135, respirations 25, and oxygen saturation 100% on 60% FiO2 on the ventilator. Physical examination reveals diffuse pulmonary rales, a II/IV early diastolic murmur, and no lower extremity edema. Laboratory studies are normal. ECG shows sinus tachycardia and left atrial enlargement. Her chest x-ray has pulmonary edema. Which of the following is the most likely diagnosis?

A) Aortic Dissection B)Dissection of Coronary Artery C)Aortic valve Stenosis D) Mitral Valve Stenosis

A15

D) Mitral Valve Stenosis

Q 16 A 60 year old gentleman with a history of dyslipidemia,

hypertension and CHF presents to the emergency department with acute onset swelling of the lips, eyes, and tongue causing airway obstruction and respiratory distress. He also has an urticarial rash. Which of the following medications is the likely culprit of his current symptoms?

 A)Pindolol  B)Clonidine  C)Felodipine  D)Captopril  E)Methyldopa

A 16

 D)Captopril

Butter fly skin rash of SLE

Q 17 A 72 year old female with no significant past medical

history passes out while exercising. She has intermittent exertional chest pains and dyspnea on exertion as well. Her physical examination reveals a III/VI late-peaking creshendo-decreshendo murmur at the right upper sternal border and a III/VI holosystolic murmur at the apex. Her S2 heart sound is very soft and her carotid upstroke is weak and delayed. Which of the following is most likely causing her symptoms?

A) Aortic valve regurgitation B) Aortic valve stenosis C) Mitral valve regurgitation D) Mitral valve stenosis E) Mitral valve prolapse

A 17 Aortic valve stenosis (AS) presents with one of the classic triad:

syncope (passing out), exertional angina, or exertional dyspnea (from heart failure).  Over the age of 70 the most likely cause is degenerative calcific aortic stenosis while under the age of 70 a bicuspid aortic valve is the likely culprit. Rheumatic heart disease is the third leading cause. Physical examination reveals a crescendo-decrescendo murmur at the aortic listening post (right upper sternal border) which radiates to the carotids. The more severe the aortic stenosis the later the peak of the murmur in systole and the softer the A2 component of the S2 heart sound. The murmur is depicted below:

“Pulses parvus et tardus” is present upon carotid artery

examination. Remember parvus means weak and tardus means late. The murmur can radiate to the apex and sound holosystolic mimicking mitral regurgitation (this is known as the Galiverdin phenomenon). No medical treatment is available for aortic stenosis. Aortic valve replacement surgically is indicated for anyone who is symptomatic.

Q 18 A 56 year old African American female

with a history of asthma is diagnosed with hypertension. Laboratory studies reveal a creatinine of 3.0 mg/dL and a potassium level of 5.1 mg/dL. Which of the following medications is appropriate to treat her hypertension?

A) amlodipine B) hydrochlorothiazide C) enalapril D) propranolol E) spironolactone

Calcium channel blockers

Mechanism of Action Calcium channel blockers (CCB) are a group of medications that

act to inhibit either central or peripheral calcium channels. This results in decreased calcium influx and smooth muscle relaxation.

Dihydropyridine calcium channel blockers act predominantly in the periphery causing arterial vasodilation.

Non-dihydropyridine calcium channel blockers act predominantly centrally to decreased heart rate (chronotropy) and contractility (inotropy).

Indications Calcium channel blockers are used to treat hypertension and

stable angina. The non-dihydropyridine calcium channel blockers are used to

lower heart rate during tachyarrhythmias especially atrial fibrillation and atrial flutter as well as during acute coronary syndromes when beta-blockers are contraindicated.

Verapamil has been studied to treat hypertrophic obstructive cardiomyopathy as well as multifocal atrial tachycardia.

Q 18 A 29 year old male with a history of ectopia lentis

presents for a routine physical examination. He is noted to have pectus excavatum, pes planus, a high arched palate, and a positive wrist and thumb sign. Which of the following cardiac disorders is associated with his condition?

A) Aortic valve stenosis B) Coarctation of the aorta C) Mitral valve prolapse D) Ventricular septal defect E) Ebstein’s anomaly

A 18 C) Mitral valve prolapse Marfan’s syndrome is associated with mitral valve prolapse

and aortic aneurysms. Specifically, the ascending aorta may dilated and predispose patient’s to acute aortic dissection which can be fatal. Also, when the ascending aorta dilates, the aortic valve annulus stretches causing the valve leaflets to fail to coapt which results in aortic regurgitation.

Aortic stenosis (A) is not associated with Marfan’s syndrome and is caused be either senile calcific degeneration of the valve or from a congenital bicuspid aortic valve . Coartaction of the aorta (B) is associated with Turner’s syndrome and presents with hypertension in the upper extremities and hypotension in the lower extremities. “Rib notching” is seen on the chest x-ray.  Ventricular septal defects  (D) and Ebstein’s anomaly  (E) are not associated with Marfan’s. 

Q19Q19 In long-term follow-up of patients after surgical In long-term follow-up of patients after surgical

repair of tetralogy of Fallot, the most common repair of tetralogy of Fallot, the most common dysrhythmia observed is:dysrhythmia observed is:

 A. Sinus bradycardia. A. Sinus bradycardia.

 B. Atrial fibrillation. B. Atrial fibrillation.

 C. Atrial tachycardia. C. Atrial tachycardia.

 D. Ventricular tachycardia. D. Ventricular tachycardia.

 E. Junctional tachycardia. E. Junctional tachycardia.

Answer Q19 Answer Q19 CommentComment

The correct answer is D. The correct answer is D.

Complex ventricular arrhythmias often occur during Complex ventricular arrhythmias often occur during long-term follow-up of patients with tetralogy of long-term follow-up of patients with tetralogy of Fallot. The incidence correlates with age at repair Fallot. The incidence correlates with age at repair and with higher residual postoperative right and with higher residual postoperative right ventricular systolic and end-diastolic pressures. ventricular systolic and end-diastolic pressures. Sudden death accounts for a significant proportion of Sudden death accounts for a significant proportion of the late mortality among these patients. In patients the late mortality among these patients. In patients with ventricular tachycardia, the site of origin is with ventricular tachycardia, the site of origin is typically found to be in the right ventricular outflow typically found to be in the right ventricular outflow tract related to the previous ventriculotomy and tract related to the previous ventriculotomy and infundibular resection.infundibular resection.

Question 20Question 20 A 42-year-old man is referred for evaluation of a systolic murmur. A 42-year-old man is referred for evaluation of a systolic murmur.

Your exam shows normal carotid pulses, a prominent apical Your exam shows normal carotid pulses, a prominent apical impulse, an early systolic sound, and a grade III/VI mid-systolic impulse, an early systolic sound, and a grade III/VI mid-systolic murmur at the base. Respiration did not change the character of murmur at the base. Respiration did not change the character of these auscultatory findings. After an extrasystole, the systolic these auscultatory findings. After an extrasystole, the systolic murmur increased in intensity. Handgrip did not alter the systolic murmur increased in intensity. Handgrip did not alter the systolic murmur. Valsalva decreased the intensity of the murmur, and it murmur. Valsalva decreased the intensity of the murmur, and it returned to baseline intensity after seven heart beats.returned to baseline intensity after seven heart beats.

 Which one of the following diagnoses is most likely? Which one of the following diagnoses is most likely?

 A. Congenital pulmonic stenosis. A. Congenital pulmonic stenosis.

 B. Innocent murmur. B. Innocent murmur.

 C. Mitral valve prolapse. C. Mitral valve prolapse.

 D. Hypertrophic obstructive cardiomyopathy. D. Hypertrophic obstructive cardiomyopathy.

 E. Bicuspid aortic valve. E. Bicuspid aortic valve.

Answer to Q 20Answer to Q 20 CommentComment

The correct answer is E. The correct answer is E.

A systolic murmur that increases in intensity in the beat A systolic murmur that increases in intensity in the beat following an extrasystole is usually due to turbulent flow following an extrasystole is usually due to turbulent flow out of the ventricles. Mitral regurgitation is less likely out of the ventricles. Mitral regurgitation is less likely because this murmur does not change following an because this murmur does not change following an extrasystole. The murmur of hypertrophic obstructive extrasystole. The murmur of hypertrophic obstructive myopathy usually decreases with handgrip exercise. An myopathy usually decreases with handgrip exercise. An innocent flow murmur is less likely because of the innocent flow murmur is less likely because of the presence of an early systolic sound and grade III intensity. presence of an early systolic sound and grade III intensity. With pulmonic stenosis, there are characteristic changes With pulmonic stenosis, there are characteristic changes in the intensity of the murmur and the ejection sound in the intensity of the murmur and the ejection sound during respiration. The ejection sound establishes the during respiration. The ejection sound establishes the diagnosis of an abnormal aortic valve, a bicuspid valve diagnosis of an abnormal aortic valve, a bicuspid valve being the most common abnormality.being the most common abnormality.

Q 21 Q 21 Regarding the Renin-Angiotensin system, Regarding the Renin-Angiotensin system,

which if the following is falsewhich if the following is false ? ? a.a. Chronic renal hypoperfusion leads to Chronic renal hypoperfusion leads to

catecholamine release, hypertension, cardiac catecholamine release, hypertension, cardiac hypertrophy and salt and water retentionhypertrophy and salt and water retention

b.b. Angiotensin Converting Enzyme (ACE) Angiotensin Converting Enzyme (ACE) inhibitors work by inhibiting Angiotensinogen inhibitors work by inhibiting Angiotensinogen cleavage to Angiotensin Icleavage to Angiotensin I

c.c. ACE-2 is not inhibited by Angiotensin ACE-2 is not inhibited by Angiotensin Converting Enzyme (ACE) inhibitorsConverting Enzyme (ACE) inhibitors

d.d. Bradykinin is thought to mediate the cough Bradykinin is thought to mediate the cough associated with ACE inhibitorsassociated with ACE inhibitors

Answer to Q 21Answer to Q 21

b.b. Angiotensin Converting Enzyme Angiotensin Converting Enzyme (ACE) inhibitors work by inhibiting (ACE) inhibitors work by inhibiting Angiotensinogen cleavage to Angiotensinogen cleavage to Angiotensin IAngiotensin I

Q 22Q 22

Which of the following structures Which of the following structures are not found in the right are not found in the right atrium?atrium?

a. Tendon of Todaroa. Tendon of Todaro b. Moderator bandb. Moderator band c. Koch's trianglec. Koch's triangle d. Pectinate muscled. Pectinate muscle c.c. Koch's triangle Koch's triangle d.d. Pectinate muscle Pectinate muscle

Answer to Q 22 Answer to Q 22

b. Moderator bandb. Moderator band The moderator band, located in the The moderator band, located in the

right ventricle, is a muscular bridge right ventricle, is a muscular bridge that connects the distal septum and that connects the distal septum and the right ventricular free wall at the the right ventricular free wall at the anterior papillary muscle. anterior papillary muscle.

The tendon of Todaro is a fibrous The tendon of Todaro is a fibrous band located between the valves of band located between the valves of the inferior vena cava and coronary the inferior vena cava and coronary sinus in the right atrium. sinus in the right atrium.

Koch's triangle is located in the Koch's triangle is located in the lower medial portion of the right lower medial portion of the right atrium, overlying the AV node atrium, overlying the AV node and the proximal His bundle. and the proximal His bundle. Pectinate muscles arise from the Pectinate muscles arise from the crista terminalis and course as crista terminalis and course as bands on the right atrial free bands on the right atrial free wall.wall.

32 years old male came with fever and acute CVA

Zoomed view at MV

M V vegetations ( endocarditis)

Major CriteriaMajor Criteria 11. Positive blood culture. Positive blood culture Typical organism from 2 separate Typical organism from 2 separate

cultures- Viridans streptococci, cultures- Viridans streptococci, Strptococcus bovis, HACEK, S. aureus, Strptococcus bovis, HACEK, S. aureus, enterococcienterococci

OROR Persistently + blood culture- all of three/ Persistently + blood culture- all of three/

majority 4 blood culturesmajority 4 blood cultures

OROR Single +ve blood culture for Coxiella or Single +ve blood culture for Coxiella or

phase IgG > 1:800phase IgG > 1:800

2. Evidence of endocardial 2. Evidence of endocardial involvementinvolvement

ECHO- oscillating intracardiac massECHO- oscillating intracardiac mass

OROR AbscessAbscess

OROR New partial deheiscence of prosthetic New partial deheiscence of prosthetic

valve/ new regurgitationvalve/ new regurgitation

Minor criteriaMinor criteria

Predisposing heart conditionPredisposing heart condition Fever > 100.4FFever > 100.4F Vascular- Emboli, pulmonary infarct, Vascular- Emboli, pulmonary infarct,

mycotic aneurysm, Janeway lesionsmycotic aneurysm, Janeway lesions Immune- Osler’s nodes, Roth spots, Immune- Osler’s nodes, Roth spots,

glomerulonephritisglomerulonephritis Microbiological evidenceMicrobiological evidence

Modified Duke CriteriaModified Duke Criteria Definite IEDefinite IE

Microorganism (via culture or histology) in a valvular Microorganism (via culture or histology) in a valvular vegetation, embolized vegetation, or intracardiac vegetation, embolized vegetation, or intracardiac abscessabscess

Histologic evidence of vegetation or intracardiac Histologic evidence of vegetation or intracardiac abscessabscess

2 Major2 Major 1 Major + 3 minor1 Major + 3 minor 5 Minor5 Minor

Possible IEPossible IE 1 major and 1 minor1 major and 1 minor 3 minor3 minor

Janeway LesionsJaneway Lesions

1. More specific2. Erythematous, blanching macules 3. Nonpainful4. Located on palms and soles5. Microabscess of the dermis with marked necrosis and

inflammatory infiltrate not involving the epidermis.

The most common infecting organism in patients with right

sided endocarditis:

A. Staph epidermidisB. Staph aureusC. Strep viridansD. Strep faecalisE. Enterococci

Q 23Q 23 2. Which of the following statements 2. Which of the following statements

about the pericardium is false?about the pericardium is false? a.a. The pericardium contains 80 to 90 mL The pericardium contains 80 to 90 mL

of pericardial fluid.of pericardial fluid. b.b. It is connected to the diaphragm, It is connected to the diaphragm,

sternum, and pleurae.sternum, and pleurae. c.c. It encloses the entire main pulmonary It encloses the entire main pulmonary

artery.artery. d.d. The ligament of Marshall is a The ligament of Marshall is a

pericardial fold that contains the remnant pericardial fold that contains the remnant of the embryonic left superior vena cava.of the embryonic left superior vena cava.

Answer Q 23Answer Q 23

a.a. The pericardium contains 80 to 90 The pericardium contains 80 to 90 mL of pericardial fluid.mL of pericardial fluid.

The Correct answer is 10—50 mlsThe Correct answer is 10—50 mls

Q 24 A 45 year old female with a history of

hypertension previously controlled with diet and lifestyle modifications presents to here primary care physician with increasing headaches. Her blood pressure is 160/90. She is diagnosed with worsening migraine headaches. Which of the following medications is appropriate to treat her hypertension and headaches simultaneously?

A) hydrochlorothiazide B) metoprolol C) clonidine D) methyldopa E) lisinopril

A 24

Metoprolol is a lipid soluble beta-blocker which can cross the blood-brain barrier easily and have been shown to be effective in the prophylaxis of migraine headaches as well as the treatment of hypertension. They have slight sedating effects and therefore can also be used for stage freight or panic attacks as well.

Q 25Q 25

5. Which of the following 5. Which of the following statements about the tricuspid statements about the tricuspid valve is true?valve is true?

a.a. It has three leaflets: anterior, It has three leaflets: anterior, lateral, and posterior.lateral, and posterior.

b.b. It is the largest heart valve. It is the largest heart valve. c.c. It is the most anterior heart valve. It is the most anterior heart valve. d.d. The posterior leaflet is the largest The posterior leaflet is the largest

and most mobileand most mobile

Dimeter of Dimeter of ValvesValves

AV:AV:TRICUSPID TRICUSPID 13 cm13 cm

MITRAL MITRAL 11 cm11 cm

SEMILUNAR:SEMILUNAR:PULMONIC PULMONIC 8 cm8 cm

AORTIC AORTIC 6 cm6 cm

Answer is b: The tricuspid valve is Answer is b: The tricuspid valve is the largest heart, whereas the the largest heart, whereas the pulmonic valve is the most anterior. pulmonic valve is the most anterior.

The tricuspid valve consists of three The tricuspid valve consists of three leaflets, anterior, septal, and leaflets, anterior, septal, and posterior. The anterior leaflet is the posterior. The anterior leaflet is the largest and most mobile. The largest and most mobile. The posterior leaflet is the smallest, posterior leaflet is the smallest, whereas the septal leaflet is the whereas the septal leaflet is the least mobile and occasionally absent.least mobile and occasionally absent.

Q 26Q 26 1. Which of the following statements about the 1. Which of the following statements about the

assessment of the severity of a valvular assessment of the severity of a valvular abnormality are abnormality are notnot true? true?

a.a. Severe acute aortic regurgitation results in a Severe acute aortic regurgitation results in a holodiastolic murmur.holodiastolic murmur.

b.b. Severe aortic stenosis results in a long-duration and Severe aortic stenosis results in a long-duration and late-peaking systolic ejection murumur.late-peaking systolic ejection murumur.

c.c. An S2-OS interval of less than 70 milliseconds is An S2-OS interval of less than 70 milliseconds is consistent with severe mitral stenosis with normal heart consistent with severe mitral stenosis with normal heart rates and absence of other left-sided valve disease.rates and absence of other left-sided valve disease.

d.d. Severe aortic stenosis may be present with a soft Severe aortic stenosis may be present with a soft murmur.murmur.

e.e. The duration of a tricuspid stenosis murmur The duration of a tricuspid stenosis murmur correlates with the severity of stenosiscorrelates with the severity of stenosis

Answer to Q 26Answer to Q 26 The answer is a: The severity of AS is best The answer is a: The severity of AS is best

determined by the duration and time to peak of determined by the duration and time to peak of the murmur. Long-duration and late peaking are the murmur. Long-duration and late peaking are consistent with severe AS. The intensity of an AS consistent with severe AS. The intensity of an AS murmur is dependent on the stroke volume, so a murmur is dependent on the stroke volume, so a soft murmur may occur with severe AS and LV soft murmur may occur with severe AS and LV dysfunction. Similarly, the duration of TS or MS dysfunction. Similarly, the duration of TS or MS murmurs are helpful in determining severity, as murmurs are helpful in determining severity, as is the duration of the S2-OS interval. However, is the duration of the S2-OS interval. However, the S2-OS interval is also affected by heart rate the S2-OS interval is also affected by heart rate and other valvular lesions that affect LA and LV and other valvular lesions that affect LA and LV pressure. Severe pressure. Severe

Q 27 A 67 year old male suffers a large myocardial

infarction complicated by sustained ventricular tachycardia. He is started on a lidocaine infusion. He subsequently develops shock liver from hypotension during the ventricular tachycardia and his serum lidocaine levels become significantly elevated. Which of the following is a manifestation of lidocaine toxicity?

A) Stroke B) Seizures C) Renal failure D) Congestive heart failure E) Hyperkalemia

A 27 B) Seizures

Lidocaine which is used to treat ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation, can easily reach toxic levels and can cause seizures and may progress to coma and death.

Lidocaine at high levels first inhibits the inhibitory neurons in the brain resulting in seizures. Eventually all neurons are inhibited and coma ensues. No specific treatment or antidote exists.

Q 28 A 62 year old female with a history of

hypertension presents with increasing shortness of breath, abdominal pain, and diarrhea. Computed tomography reveals a mass in the appendix and multiple nodules in the liver. Chest x-ray is normal. Serum 5-hydroxyindoleacetic acid levels are elevated. Which of the following cardiac disorders is she likely to have?

A) Aortic valve stenosis B) Aortic valve regurgitation C) Mitral valve stenosis D) Mitral valve regurgitation E) Tricuspid valve stenosis

A 28 E) Tricuspid valve stenosis This patient has carcinoid syndrome which

consists of diarrhea, facial flushing, reactive airways causing shortness of breath, and cardiac valvular disease specifically of right-sided heart valves since the toxins produced by the tumor are filtered by the lungs and never reach the left sided heart valves (unless pulmonary metastasis are present).

Others are all left-sided heart valves which would not be affected in carcinoid syndrome unless pulmonary metastasis are present (which is rare).

Q 29 A 29 year old male with no past medical

history has been experiencing headaches for the past few months. His blood pressure is noted to be 210/110. Physical examination reveals an S4 heart sound and reduced femoral pulses. Which of the following is associated with his condition?

A) Atrial septal defect B) Wolff-Parkinson-White syndrome C) Bicuspid aortic valve D) Mitral valve regurgitation

A 29 C) Bicuspid aortic valve Coarctation of the aorta occurs when the congenital

narrowing of the aorta occurs. About two thirds of patients with coarctation of the aorta have a bicuspid aortic valve as well. Depending on the location of the narrowing differing presentations may occur.

Infantile coarctation of the aorta presents when the stenosis is proximal or next to the ductus arteriosus. When the ductus arteriosus closes (as it should in normal infants), a severe increase in afterload occurs resulting in congestive heart failure (since blood was normally able to traverse the patent ductus arteriosus resulting in lower resistance, then suddenly is unable to).

Q 30Q 30

Which of the following will Which of the following will notnot cause cause a continuous murmur?a continuous murmur?

a.a. An right coronary sinus to the right An right coronary sinus to the right atrial fistula.atrial fistula.

b.b. A stenotic and regurgitant aortic valve. A stenotic and regurgitant aortic valve. c.c. A venous hum. A venous hum. d.d. An aorta-to-pulmonary artery An aorta-to-pulmonary artery

connection.connection. e.e. A high-grade coarctation of the aorta. A high-grade coarctation of the aorta.

Answer to Q 30 Answer to Q 30

The answer is b: A continuous murmur The answer is b: A continuous murmur must extend uninterrupted through S2. must extend uninterrupted through S2. An aorta-pulmonary connection such as An aorta-pulmonary connection such as a PDA, a coronary sinus-to-RA a PDA, a coronary sinus-to-RA connection such as with a ruptured sinus connection such as with a ruptured sinus of Valsalva, a severe coarctation, and a of Valsalva, a severe coarctation, and a venous hum all result in continuous venous hum all result in continuous murmurs. The combination of a systolic murmurs. The combination of a systolic and diastolic murmur of AS and AR is and diastolic murmur of AS and AR is not considered a continuous murmur.not considered a continuous murmur.

Q 31 An 82 year old male with a history of long

standing atrial fibrillation and hypertension presents with increasing dyspnea on exertion. Chest x-ray shows a honeycoming pattern and pulmonary function testing shows a severe restrictive defect. Which of the following is likely causing his symptoms?

A) Congestive heart failure B) amiodarone C) ramipril D) sotalol E) diltiazem

A 31 B) amiodarone C) ramipril D) sotalol E) diltiazem Amiodarone used to treat atrial fibrillation and ventricular

arrhythmias, can cause pulmonary fibrosis after long-term use.

Amiodarone also causes hypothyroidism, hyperthyroidism, and on rare occasion liver failure.

Remember to check PFTs (pulmonary function tests), LFTs (liver function tests), and TFTs (thyroid function tests) on all patients on amiodarone. Blue man syndrome can occur as well due to deposition of amiodarone metabolites in the skin resulting in a blue hue.

Q 32Q 32 Which of the following about Which of the following about

differentiating AS from HCM on differentiating AS from HCM on examination is true?examination is true?

a.a. The murmur of AS decreases and the The murmur of AS decreases and the murmur of HCM increases with amyl nitrite.murmur of HCM increases with amyl nitrite.

b.b. Post-PVC, the pulse pressure of HCM Post-PVC, the pulse pressure of HCM decreases and that of AS increases.decreases and that of AS increases.

c.c. The murmur of AS and HCM decrease The murmur of AS and HCM decrease with standing.with standing.

d.d. With Valsalva, the murmur of AS and With Valsalva, the murmur of AS and HCM decrease.HCM decrease.

Answer to Q 32Answer to Q 32

The answer is b: Amyl nitrite results in The answer is b: Amyl nitrite results in an increase in the murmur of AS and an increase in the murmur of AS and HOCM. Valsalva (straining phase) and HOCM. Valsalva (straining phase) and standing result in an increase of the standing result in an increase of the murmur of HOCM and decreases the murmur of HOCM and decreases the murmur of AS. Post-PVC, the murmur of murmur of AS. Post-PVC, the murmur of AS and HOCM increases but the pulse AS and HOCM increases but the pulse pressure of HOCM decreases pressure of HOCM decreases (Brockenbrough phenomenon) while (Brockenbrough phenomenon) while that of AS increases.that of AS increases.

Q 33

A 52 year old female is experiencing difficulty hearing. Which of the following drugs may be the cause?

A) bumetinide B) clonidine C) minoxidil D) triamterene

A 33

A) bumetinide Ototoxicity occurs with high dose loop

diuretics such as furosemide, bumetinide, or torsemide. Aminoglycosides can cause similar hearing loss (also nephrotoxicity). Remember that congenital ear malformations are associated with congenital kidney problems to help remember the connection between medications that act on the kidney and cause hearing loss such as loop diuretics.

Q 34 Q 34 Regarding cardiac myxoma, all of the Regarding cardiac myxoma, all of the

following statements are true except:following statements are true except: a.a. It can arise anywhere within the heart. It can arise anywhere within the heart. b.b. It is the most common primary cardiac It is the most common primary cardiac

tumor.tumor. c.c. Approximately 75% occur in the left Approximately 75% occur in the left

atrium.atrium. d.d. Most are familial. Most are familial. e.e. Myxomas may be associated with Myxomas may be associated with

syncope, TIA, or strokesyncope, TIA, or stroke

Q 34Q 34

Answer is d: Cardiac myxoma is the Answer is d: Cardiac myxoma is the most common primary cardiac most common primary cardiac tumor, accounting for 50% of tumor, accounting for 50% of primary cardiac tumors in adults. primary cardiac tumors in adults. Though it can be found anywhere in Though it can be found anywhere in the heart, the most common location the heart, the most common location is the left atrium attached is the left atrium attached

Q 35Q 35

What of the following What of the following malignancies has the highest malignancies has the highest likelihood of cardiac metastasis?likelihood of cardiac metastasis?

a.a. Lung cancer Lung cancer b.b. Renal cell carcinoma Renal cell carcinoma c.c. Melanoma Melanoma d.d. Breast cancer Breast cancer e.e. Colon cancer Colon cancer

Answer to Q 35Answer to Q 35

Answer is C : The malignancy with Answer is C : The malignancy with the highest likelihood of cardiac the highest likelihood of cardiac metastasis is melanoma, though in metastasis is melanoma, though in absolute numbers, cardiac absolute numbers, cardiac metastases are more common, with metastases are more common, with lung and breast cancers reflecting lung and breast cancers reflecting the higher incidence of these the higher incidence of these cancers.cancers.

Q 36

A 55 year old female with a history of congestive heart failure is found to have breast cancer requiring chemotherapy. Which of the following chemotherapeutic agents should be avoided?

A) doxorubicin B) bleomycin C) paclitaxel D) cyclophosphamide

A 36 A) doxorubicin

Doxorubicin and daunorubicin are anthracycline chemotherapeutic agents that are well known to cause systolic congestive heart failure especially at higher doses and should be avoided if pre-existing heart failure is present.

Bleomycin (B) can cause pulmonary fibrosis. Paclitaxel (C) also causes pulmonary toxicity. Cyclophosphamide (D) can cause hemorrhagic cystitis (resulting in hematuria and bladder pain).  

Q 37Q 37 Digitalis is a cardiac glycoside that does Digitalis is a cardiac glycoside that does

all of the following except:all of the following except: a.a. indirectly activates a Na+/Ca++ indirectly activates a Na+/Ca++

exchanger found in the cardiac cell exchanger found in the cardiac cell membranemembrane

b.b. inhibits the Na+/K+ ATPase found in the inhibits the Na+/K+ ATPase found in the cardiac cell membranecardiac cell membrane

c.c. increases chronotropy by increasing increases chronotropy by increasing intracellular Ca++intracellular Ca++

d.d. leads to a sodium gradient across the leads to a sodium gradient across the cardiac cell membrane that is favorable for cardiac cell membrane that is favorable for Ca++ influxCa++ influx

e.e. increases parasympathetic tone increases parasympathetic tone

Answer to Q 37Answer to Q 37 Answer is c: Digitalis inhibits the Na+/K+ ATPase Answer is c: Digitalis inhibits the Na+/K+ ATPase

found in the cardiac cell membrane which maintains found in the cardiac cell membrane which maintains a high intracellular K+ concentration and high a high intracellular K+ concentration and high extracellular Na+ concentration. Ca2+ is removed extracellular Na+ concentration. Ca2+ is removed from the cytosol into the extracellular fluid by a from the cytosol into the extracellular fluid by a sodium-calcium exchange pump driven by the pre-sodium-calcium exchange pump driven by the pre-existing Na+ gradient. Inhibiting the Na+/K+ existing Na+ gradient. Inhibiting the Na+/K+ ATPase promotes enhanced Na+/Ca2+ exchange ATPase promotes enhanced Na+/Ca2+ exchange ultimately leading to increased intracellular Ca2+ ultimately leading to increased intracellular Ca2+ available to the contractile apparatus increasing available to the contractile apparatus increasing myocardial contractility. myocardial contractility.

Chronotropy would not be increased with digitalis Chronotropy would not be increased with digitalis and in fact it is often used for the opposite effect of and in fact it is often used for the opposite effect of heart rate control in patients with atrial fibrillation.heart rate control in patients with atrial fibrillation.

Pic Quiz 45 years old with recent MI, This Skin lesion was noted on his Leg

Answer 2 pic quiz

Necrobiosis lipoidica of DM

How is it treated ?

Q 38Q 38 All of the following are class III recommendations All of the following are class III recommendations

in the treatment of unstable coronary syndromes, in the treatment of unstable coronary syndromes, except:except:

a.a. Use of fibrinolytic therapy for non-ST-elevation acute Use of fibrinolytic therapy for non-ST-elevation acute coronary syndromescoronary syndromes

b.b. Use of abciximab for conservatively managed high- Use of abciximab for conservatively managed high-risk patients who continue to have ischemic symptomsrisk patients who continue to have ischemic symptoms

c.c. The use of a low-molecular-weight heparin instead of The use of a low-molecular-weight heparin instead of unfractionated heparin for conservatively managed unfractionated heparin for conservatively managed unstable coronary syndromesunstable coronary syndromes

d.d. Use of nitroglycerin within 24 hours of sildenafil Use of nitroglycerin within 24 hours of sildenafil (Viagra)(Viagra)

e.e. Invasive therapy in low-risk patients who present Invasive therapy in low-risk patients who present with a chest pain syndromewith a chest pain syndrome

Answer to Q 38Answer to Q 38 Answer is c: There may be a marginal benefit of low-Answer is c: There may be a marginal benefit of low-

molecular-weight heparin over unfractionated molecular-weight heparin over unfractionated heparin for conservatively managed patients, and this heparin for conservatively managed patients, and this strategy is a class IIa recommendation. Nitroglycerin strategy is a class IIa recommendation. Nitroglycerin should not be used within 24 hours from the last dose should not be used within 24 hours from the last dose of sildenafil. Fibrinolytics should only be used for ST-of sildenafil. Fibrinolytics should only be used for ST-elevation myocardial infarctions. Ideally, high-risk elevation myocardial infarctions. Ideally, high-risk patients should be managed invasively, but for high-patients should be managed invasively, but for high-risk individuals who defer invasive therapy or who risk individuals who defer invasive therapy or who have extensive co-morbidities and continue to have have extensive co-morbidities and continue to have ischemic symptoms, the use of a glycoprotein IIb/IIIa ischemic symptoms, the use of a glycoprotein IIb/IIIa inhibitor is a class IIa recommdation. However, inhibitor is a class IIa recommdation. However, eptifibitide or tirofiban should be used in this setting, eptifibitide or tirofiban should be used in this setting, while abciximab should be used only during invasive while abciximab should be used only during invasive management.management.

Q 39Q 39

Which of the following are causes of Which of the following are causes of secondary angina OR Type 2 MI (Type 1 secondary angina OR Type 2 MI (Type 1 Sontaneous)?Sontaneous)?

a.a. An anemic patient from a gastrointestinal An anemic patient from a gastrointestinal bleedbleed

b.b. A dialysis patient with an arterio-venous A dialysis patient with an arterio-venous fistulafistula

c.c. A dyspneic patient with underlying A dyspneic patient with underlying emphysemaemphysema

d.d. a and c a and c e.e. a, b, and c a, b, and c

Answer to Q 39Answer to Q 39

Answer is e: Anemia, anterior-Answer is e: Anemia, anterior-venous shunting, and hypoxemia can venous shunting, and hypoxemia can all cause demand ischemia. Note all cause demand ischemia. Note that a left-arm arterio-venous fistula that a left-arm arterio-venous fistula can produce shunting as well as can produce shunting as well as subclavian steal in patients with a subclavian steal in patients with a previous left internal mammary previous left internal mammary artery graft.artery graft.

Q 40Q 40

Which of the following is not Which of the following is not included in the differential diagnosis included in the differential diagnosis for electrocardiographic ST for electrocardiographic ST elevations?elevations?

a.a. ST-elevation myocardial infarction ST-elevation myocardial infarction b.b. Left ventricular aneurysm Left ventricular aneurysm c.c. Hypokalemia Hypokalemia d.d. Pericarditis Pericarditis e.e. Left ventricular hypertrophy Left ventricular hypertrophy

Answer to Q 40Answer to Q 40

Answer is C: Among the electrolyte Answer is C: Among the electrolyte abnormalities, hyperkalemia, not abnormalities, hyperkalemia, not hypokalemia can cause ST elevations hypokalemia can cause ST elevations that mimic ST-elevation myocardial that mimic ST-elevation myocardial infarctions.infarctions.

Q 41 Q 41

Risk factors for intracranial Risk factors for intracranial hemorrhage during administration hemorrhage during administration of fibrinolytics include all of the of fibrinolytics include all of the following except:following except:

a.a. Uncontrolled hypertension Uncontrolled hypertension b.b. Advanced age Advanced age c.c. Female gender Female gender d.d. Preexisting coagulopathy Preexisting coagulopathy e.e. Morbid obesity Morbid obesity

Answer to Q 41 Answer to Q 41

Answer is E: Low body weight, not Answer is E: Low body weight, not morbid obesity, is a risk factor for morbid obesity, is a risk factor for intracranial hemorrhage. intracranial hemorrhage.

Q 42 Q 42

Digoxin toxicity may present with all Digoxin toxicity may present with all the following except?the following except?

a- Color visual defecta- Color visual defect b-GI upset b-GI upset c- Bidirectional VTc- Bidirectional VT d-headached-headache e –all of the above e –all of the above

Answer to Q 42Answer to Q 42

E –all of the aboveE –all of the above

Q 43Q 43

Digoxin toxicity is more found exceptDigoxin toxicity is more found except a-young mena-young men b- elederly females.b- elederly females. c-Renal impairement.c-Renal impairement. d-Liver impairmentd-Liver impairment e- a,d e- a,d

A 43A 43

E- a,d E- a,d

Q 44Q 44

All of the following clinical findings All of the following clinical findings are consistent with severe mitral are consistent with severe mitral stenosis stenosis exceptexcept

A. atrial fibrillationA. atrial fibrillation B. opening snap late after S2B. opening snap late after S2 C. pulmonary vascular congestionC. pulmonary vascular congestion D. pulsatile liverD. pulsatile liver E. right-ventricular heaveE. right-ventricular heave

Answer to Q 44Answer to Q 44

B. opening snap late after S2B. opening snap late after S2

Q 45Q 45

A patient is found to have a holosystolic A patient is found to have a holosystolic murmur on physical examination.With deep murmur on physical examination.With deep inspiration, the intensity of the murmur inspiration, the intensity of the murmur increases.This is consistent with which of increases.This is consistent with which of the following?the following?

A. Atrial-septal defectA. Atrial-septal defect B. Austin Flint murmurB. Austin Flint murmur C. Carvallo’s signC. Carvallo’s sign D. Chronic mitral regurgitationD. Chronic mitral regurgitation E. Gallavardin effectE. Gallavardin effect

Answer to Q 45Answer to Q 45

C. Carvallo’s sign of TRC. Carvallo’s sign of TR

Carvallo's signCarvallo's sign is a clinical sign found is a clinical sign found in patients with tricuspid regurgitation. in patients with tricuspid regurgitation.

The pansystolic murmur found in this The pansystolic murmur found in this condition becomes louder during condition becomes louder during inspiration this sign enables it to be inspiration this sign enables it to be distinguished from mitral regurgitationdistinguished from mitral regurgitation

Pectus excavatumPectus excavatum Associated Marfan SyndromeAssociated Marfan Syndrome

77 years old male with CHF,CRF

Q 46Q 46

Which of the following findings would be Which of the following findings would be suggestive of critical ischemia of the suggestive of critical ischemia of the right foot?right foot?

A. Ankle-brachial index <0.3A. Ankle-brachial index <0.3 B. Ankle-brachial index <0.9B. Ankle-brachial index <0.9 C. Ankle-brachial index >1.2C. Ankle-brachial index >1.2 D. Lack of palpable dorsalis pedis pulseD. Lack of palpable dorsalis pedis pulse E. Presence of pitting edema of the E. Presence of pitting edema of the

extremitiesextremities

Answer to Q 46Answer to Q 46

A. Ankle-brachial index <0.3A. Ankle-brachial index <0.3

Q 47Q 47

All the following electrocardiogram All the following electrocardiogram (ECG) findings re suggestive of left (ECG) findings re suggestive of left ventricular hypertrophy ventricular hypertrophy exceptexcept

A. (S in V1 + R in V5 or V6) >35 mmA. (S in V1 + R in V5 or V6) >35 mm B. R in aVL >11 mmB. R in aVL >11 mm C. R in aVF >20 mmC. R in aVF >20 mm D. (R in I + S in III) >25 mmD. (R in I + S in III) >25 mm E. R in aVR >8 mmE. R in aVR >8 mm

Answer to Q47Answer to Q47

E. R in aVR >8 mmE. R in aVR >8 mm

Q 48Q 48

55 years old saudi male , investigated 55 years old saudi male , investigated for recent onset of exertional syncope , for recent onset of exertional syncope , found to have AS , the most likely found to have AS , the most likely aetiology is ?aetiology is ?

A. Age-related degenerationA. Age-related degeneration B. DyslipidemiaB. Dyslipidemia C. Glucose intoleranceC. Glucose intolerance D. HypertensionD. Hypertension E. ObesityE. Obesity

Answer to Q 48Answer to Q 48

A. Age-related degenerationA. Age-related degeneration

Q 49Q 49

In peripartum cardiomyopathy Which In peripartum cardiomyopathy Which of the following factors is the most of the following factors is the most valuable predictor of mortality with valuable predictor of mortality with subsequent pregnancies?subsequent pregnancies?

A. Age >30 yearsA. Age >30 years B. African ancestryB. African ancestry C. Interpartum left ventricular C. Interpartum left ventricular

functionfunction D. Male childD. Male child

Answer to Q 49 Answer to Q 49

C. Interpartum left ventricular C. Interpartum left ventricular functionfunction

55 Years old lady with SOB & fatigability ECG & ECHO done

55 Years old lady with SOB & fatigability ECG & ECHO done

NSR , Low Voltage ECG

Moderate Size Pericardial effusion

Myxedema in Hypothyroidism

Atrial fibrillation might be the sole presentation of thyrotoxicosis.

Atrial fibrillation may occur with Hypothyroidism

Both Hypo-or Hyperthyroidism may cause Cardiomyopathy, wait for 3- 6 months before repeating ECHO after treament .

Q 50Q 50 HMG-CoA reductase inhibitor reduces HMG-CoA reductase inhibitor reduces

coronary events. This Medication will coronary events. This Medication will exert all the following beneficial effects exert all the following beneficial effects except?except?

A. direct action on atheroma progressionA. direct action on atheroma progression B. improvement in endothelial-dependent B. improvement in endothelial-dependent

vasomotionvasomotion C. long-term reduction of serum LDLC. long-term reduction of serum LDL D. regression of existing coronary stenosisD. regression of existing coronary stenosis E. stabilization of existing atherosclerotic E. stabilization of existing atherosclerotic

lesionslesions

Answer to Q 50Answer to Q 50

D. Regression of existing coronary D. Regression of existing coronary stenosisstenosis

Tendon xanthomas at the wrists, Tendon xanthomas at the wrists, knees, and achilles, With ostial RCAknees, and achilles, With ostial RCA

Haemorrhagic herpes zosterHaemorrhagic herpes zoster

Q 51Q 51

Which vein has the highest Which vein has the highest oxygen saturation?oxygen saturation?

Which vein has the lowest oxygen Which vein has the lowest oxygen saturation?saturation?

In which situation is coronary In which situation is coronary sinus saturation elevated?sinus saturation elevated?

Answer to Q 51 Answer to Q 51

Renal vein has the highest oxygen Renal vein has the highest oxygen saturation. Hence the inferior vena saturation. Hence the inferior vena caval (IVC) blood is more saturated caval (IVC) blood is more saturated than superior vena caval blood. The than superior vena caval blood. The saturation is higher in the inferior saturation is higher in the inferior vena cava above the renal veins vena cava above the renal veins (high IVC) than the low IVC. (high IVC) than the low IVC.

Answer Q 51Answer Q 51

Coronary sinus has the lowest Coronary sinus has the lowest oxygen saturation as the oxygen oxygen saturation as the oxygen extraction is maximum in the extraction is maximum in the coronary circulation. Coronary sinus coronary circulation. Coronary sinus saturation does not fall with exercise saturation does not fall with exercise as the extraction reserve is fully as the extraction reserve is fully utilized in the coronary circulation utilized in the coronary circulation and increase in oxygen consumption and increase in oxygen consumption can occur only by increasing the flow can occur only by increasing the flow

Q 52Q 52

Janeway lesion:Janeway lesion: a) Tendera) Tender

b) Nodularb) Nodularc) Most common in trunkc) Most common in trunkd) Blanches on pressured) Blanches on pressure

A 52A 52

Answer:Answer: d) Blanches on pressure d) Blanches on pressure Nodular and tender lesions are Nodular and tender lesions are

Osler’s nodes. Janeway lesions are Osler’s nodes. Janeway lesions are seen on the palms and soles. They seen on the palms and soles. They are non tender, macular lesions. are non tender, macular lesions. These are lesions seen in infective These are lesions seen in infective endocarditisendocarditis

Q 53Q 53

HACEK organisms causing HACEK organisms causing endocarditis includes:endocarditis includes:

a) Cardiobacteriuma) Cardiobacteriumb) Acinetobacterb) Acinetobacterc) E. colic) E. colid) Klebsiellad) Klebsiella

A 53A 53

Answer:Answer: a) Cardiobacterium a) Cardiobacterium HACEK is an acronym for a group of gram-HACEK is an acronym for a group of gram-

negative bacilli: Haemophilus species negative bacilli: Haemophilus species (Haemophilus parainfluenzae, Haemophilus (Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus), aphrophilus, Haemophilus paraphrophilus), Actinobacillus actinomycetemcomitans, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella Cardiobacterium hominis, Eikenella corrodens, and Kingella species. They have a corrodens, and Kingella species. They have a higher potential to produce endocarditis and higher potential to produce endocarditis and is responsible for about three percent of is responsible for about three percent of native valve endocarditisnative valve endocarditis

Q 54Q 54 Which of the following statements about Which of the following statements about

infective endocarditis is wrong?infective endocarditis is wrong? a) Splenomegaly is more common in a) Splenomegaly is more common in

acute than sub acute infective acute than sub acute infective endocarditisendocarditis

b) Disease manifestation occurs within b) Disease manifestation occurs within two weeks of the cause of bacteremiatwo weeks of the cause of bacteremia

c) Cerebral embolism is more common in c) Cerebral embolism is more common in the middle cerebral artery territorythe middle cerebral artery territory

d) 5% chance of intracranial hemorrhaged) 5% chance of intracranial hemorrhage

A 54A 54

a) Splenomegaly is more common in a) Splenomegaly is more common in acute than sub acute infective acute than sub acute infective endocarditisendocarditis

Q55Q55

Gene defective in Marfan syndrome:Gene defective in Marfan syndrome: a) Collagena) Collagen

b) Fibrillinb) Fibrillinc) Elastinc) Elastind) Cathepsind) Cathepsin

A 55A 55

b) Fibrillinb) Fibrillin Marfan syndrome is caused by Marfan syndrome is caused by

defects in a gene called fibrillin-1 defects in a gene called fibrillin-1 (FBN1), located on chromosome 15. (FBN1), located on chromosome 15.

Q 56Q 56

For blood pressure measurement, For blood pressure measurement, least important is:least important is:

a) Arm cuff at heart levela) Arm cuff at heart levelb) Manometer at heart levelb) Manometer at heart levelc) Arm cuff >80% arm c) Arm cuff >80% arm circumferencecircumferenced) Manometer should be verticald) Manometer should be vertical

A 56A 56 b) Manometer at heart levelb) Manometer at heart level

Manometer need not be at heart level as the Manometer need not be at heart level as the difference involved will be only the weight of the difference involved will be only the weight of the air column in the tubing, which is negligible air column in the tubing, which is negligible compared to that of mercury. But the mercury compared to that of mercury. But the mercury level should be at the level of your eye to avoid level should be at the level of your eye to avoid parallax error. A slanting mercury column will parallax error. A slanting mercury column will increase the reading. Position of arm cuff is increase the reading. Position of arm cuff is important as level difference will alter the important as level difference will alter the recorded pressure which will depend on the recorded pressure which will depend on the column of blood in the vessel above or below the column of blood in the vessel above or below the heart level. Cuffs which are shorter will not heart level. Cuffs which are shorter will not provide adequate compression during inflation provide adequate compression during inflation and is likely to record falsely elevated pressuresand is likely to record falsely elevated pressures

Q 57Q 57

QT interval shortens in:QT interval shortens in: a) Hypothermiaa) Hypothermia

b) Hypokalemiab) Hypokalemiac) Hypocalcemiac) Hypocalcemiad) Acidosisd) Acidosis

A57A57

Answer:Answer: d) Acidosis d) Acidosis Acidosis is associated with shift of Acidosis is associated with shift of

potassium out of the cells and potassium out of the cells and hyperkalemia. QT prolongation in hyperkalemia. QT prolongation in hypocalcemia is due to ST segment hypocalcemia is due to ST segment prolongation. Digitalis and prolongation. Digitalis and congenital short QT syndrome are congenital short QT syndrome are other causes of a short QT interval.other causes of a short QT interval.

60 years old male with CHF

Acromegally

Q 58Q 58

According to BMI (body mass index), According to BMI (body mass index), the cut off for obesity is:the cut off for obesity is:

a) 25 Kg/m2a) 25 Kg/m2b) 30 Kg/m2b) 30 Kg/m2c) 35 Kg/m2c) 35 Kg/m2d) 40 Kg/m2d) 40 Kg/m2

A58A58 Answer:Answer: b) 30 Kg/m2 b) 30 Kg/m2 The International Classification of adult The International Classification of adult

underweight, overweight and obesity according underweight, overweight and obesity according to BMI (World Health Organization) is as follows:to BMI (World Health Organization) is as follows:

UnderweightUnderweight <18.50 <18.50 Normal rangeNormal range 18.50 – 24.99 18.50 – 24.99 OverweightOverweight ≥25.00 ≥25.00

Pre-obese 25.00 – 29.99 Pre-obese 25.00 – 29.99 ObeseObese ≥30.00 ≥30.00

Obese class I: 30.00 – 34.99Obese class I: 30.00 – 34.99Obese class II: 35.00 – 39.99Obese class II: 35.00 – 39.99Obese class III: ≥40.00 Obese class III: ≥40.00

Q 59Q 59

A 59A 59

Tamponade can be acute or subacute, depending on the etiology:Acute: Rapid accumulation (usually blood) within a stiff,

noncompliant pericardium Subacute: Gradual increase of a preexisting effusion,

with limited accommodative pericardial stretch

Q 60 Q 60

A60A60

Q 61Q 61

A 61A 61

Q 62Q 62

A 62A 62

D- VMA D- VMA

Q 63 ???????Q 63 ???????

Q 63Q 63

A 63A 63

DextrocardiaDextrocardia Associated with situs inversus and Associated with situs inversus and

kartageners syndrome.kartageners syndrome.

Sometimes polysplenismSometimes polysplenism

Q 64 ?????????? 25 years Q 64 ?????????? 25 years old with Fluold with Flu

A 64 A 64

Diffuse ST elevation with PR Diffuse ST elevation with PR segment depression Inferior segment depression Inferior Leads.This is Acute Pericarditis.Leads.This is Acute Pericarditis.

Treatment First LineTreatment First Line A- High dose ASA 2- grams per dayA- High dose ASA 2- grams per day B- ParacetamolB- Paracetamol C-CholchicineC-Cholchicine Avoid NSAIDs and steroids at least Avoid NSAIDs and steroids at least

as first line , in post MI.as first line , in post MI.

Q 65 ?????? 60 male with Q 65 ?????? 60 male with CADCAD

Where is the delta wavesWhere is the delta waves

WPW syndrome with pseudo inferior MI pattern

A 65A 65

WPW WPW Next step is Echo is needed because Next step is Echo is needed because

of increased incidence of associated of increased incidence of associated structural heart disease with WPW.structural heart disease with WPW.

Treatment Treatment A- Asymptomatic Leave AloneA- Asymptomatic Leave Alone B- Symptomatic offer EPS + ablationB- Symptomatic offer EPS + ablation C- found and difficult to ablate in C- found and difficult to ablate in

Ebstein anomalyEbstein anomaly

Q 66Q 66

A 66A 66

Atrial Flutter with 2:1 Block.Atrial Flutter with 2:1 Block.

B

25 year old female has a butterfly rash on her face, photosensitivity and oral ulcers. She is diagnosed with SLE. Which of the following is another characteristic of SLE?

a) polyuria b) polydipsia  c) polyphagia d) pericarditis e) Philadelphia chromosom

d) pericarditis 

You are reviewing a patient in the intensive care unit with acute renal failure. Which antimicrobial agent is LEAST likely to require a dose adjustment in renal failure?

a) gentamicinb) amitriptylinec) carbonic anhydrase inhibitorsd) streptomycine) erythromycin

e) erythromycin

A 44 year old woman with a long history of multiple sclerosis complains of severe pain on the right side of her face. The most likely pathology is in the

a) the right facial nerveb) the right long thoracic nervec) the right trigeminal nerved) the left trigeminal nervee) the right recurrent laryngeal nerve

Correct Answer: CPain typical of trigeminal neuralgia

occasionally affects patients with lesions in the brain stem as a result of multiple sclerosis. They may also occur with vasculitis involving the descending root of the fifth cranial nerve. Trigeminal neuralgia usually occurs after other symptoms of MS. Of all patients with MS, however, about 10% have facial pain as a presentation, and other symptoms of MS may not appear for 6 yea

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