GRABER and WILBUR CARDIO

Question 11 of 14 You obtain an ECG on this patient that shows a pattern consistent with pericarditis. Which of the following patterns can be seen in a patient with pericarditis? A Diffuse ST-segment elevation B Normal ECG C LBBB D A and B E All of the above

The answer is "D." Both diffuse ST-segment elevations and a normal ECG can be seen with pericarditis, as can electrical alternans (Fig. 2-2). A PR depression (Fig. 2-3) can also be seen in pericarditis and is almost pathognomonic. There is one caveat: If there are onlyinferior wall ST elevations, isolated PR depression in aVL may be associated with an inferior wall MI. The initial ECG is only 80% sensitive for pericarditis. Small (low voltage) QRS complexes or electrical alternans can also be seen if there is a pericardial effusion. "C" is incorrect since bundle branch blocks have nothing to do with pericarditis.

Question 1 of 14 A 53-year-old male with a history of hypertension and smoking, but no family history of cardiac disease, presents to your office complaining of a chest pain. The pain is substernal, radiates to his left arm, and is associated with exertion. The patient notes that this same pain has been going on for the last 6 months and has not changed at all in duration, intensity, or characteristic. It generally lasts 5 minutes or so and resolves with rest. You tell the patient that: A Without doing any test, you know that the probability that this pain is cardiac is greater than 85% B If his ECG in the office is normal, his pain is unlikely to represent cardiac disease C Even with risk factors, his probability of having CAD with "typical angina" is about 50% D The only interventions indicated at this point are lifestyle modifications (e.g., stop smoking) and addressing his cholesterol and hypertension E It is likely that he has unstable angina

The correct answer is "A." A 50-year-old male with "classic" angina symptoms has greater than a 90% probability of having CAD. "B" is incorrect because patients with angina who are pain free may have a normal electrocardiogram (as will many patients with active angina or even a myocardial infarction). Thus, his pain could still be cardiac in origin. "C" is incorrect because, based on demographic data, his risk of CAD is much higher than 50%. "D" is incorrect because he needs a further evaluation and treatment of his chest pain. "E" is incorrect since this pain represents "stable angina." There has been no change in quality, duration, amount of exertion required to bring on symptoms, etc., eliminating unstable angina as a diagnosis. Use of tools such as the TIMI Risk Score (https://www.mdcalc.com/timi-risk-score-stemi) and/or Grace Risk Model (https://www.mdcalc.com/grace-acs-risk-mortality-calculator) can assist in estimation of the level of risk and to help guide management decisions.

Question 4 of 6 The post-exercise ankle-brachial indices are as follows: 0.9 in the right leg, 0.4 in the left leg. The proper interpretation of this information is: A 95% probability of some degree of occlusive disease in the right leg, severe occlusive disease in the left B No occlusive disease in the right leg, mild disease in the left C Moderate occlusive disease on both legs D No occlusive disease in either leg

The correct answer is "A." A normal ABI should be 0.95 to 1.29. An ABI of 0.9 is 95% sensitive for finding some degree of occlusive disease on arteriography (although it may not be hemodynamically significant). An ABI of 0.81 to 0.94 represents mild arterial disease that may or may not be associated with claudication. An ABI of 0.41 to 0.80 is classified as moderate arterial disease and is usually associated with some degree of claudication. An ABI of ≤0.4 represents severe disease and may be associated with rest pain. Paradoxically, an ABI > 1.30 represents noncompressible arteries and may be a marker for arterial calcification. In these cases, a toe-brachial index should be measured (really). (Don't ask us ... we don't know where to find a toe BP cuff either. Maybe you can use a full-sized gnome or pixie cuff. We'd love to sell you one.)

Question 1 of 3 A 22-year-old female presents to your office with a history of palpitations. You are able to capture the arrhythmia on the monitor in your office: the rhythm strip shows evidence of isolated premature atrial contractions (PACs). She is otherwise healthy and taking no medications, and there is no family history of heart disease. All of the following are salient points of the history with regard to PACs EXCEPT: A Aged cheese consumption B Caffeine use C Tobacco use D Alcohol use E COPD

The correct answer is "A." Aged cheese can cause problems in combination with monoamine oxidase inhibitors (MAOIs). In combination with an MAOI, aged cheese and other sources of tyramine can cause a hypertensive emergency. However, this patient is not taking any medications. All of the other conditions and drugs listed can cause PACs. While there are conflicting data about the strength of the association caffeine, it is clear that COPD, tobacco, and alcohol can all cause an increase in sympathetic tone, leading to PACs. Neurologic abnormalities (e.g., stroke) can also be associated with PACs, as can some drugs (e.g., theophylline).

Question 2 of 14 You send the patient home on aspirin with a prescription for sublingual nitroglycerin for PRN use and arrange for a stress test. All of the following are considered absolute contraindications to exercise stress testing EXCEPT: A Left bundle branch block (LBBB) B Presence of severe heart failure C Critical aortic stenosis D Myocarditis E Unstable angina

The correct answer is "A." An LBBB is a relative—not absolute—contraindication to stress testing. In the setting of LBBB, there are already repolarization abnormalities that limit the usefulness of the ECG component of a stress test. One should add an imaging modality, such as myocardial perfusion scanning or echocardiography, in cases of LBBB. The same holds for any baseline ECG pattern that would interfere with ST-segment interpretation (baseline ST changes, LVH with repolarization changes involving the ST-T wave, intraventricular conduction delay, paced rhythm, preexcitation, or ST-T changes due to digoxin therapy). The rest are all "absolute" contraindications to exercise stress testing. See Table 2-4 for a list of contraindications to stress testing.

Question 3 of 16 All of the following statements are true EXCEPT: A All myocardial infarctions present with chest pain B Dyspnea may be the only presenting symptom of myocardial infarction C Patients with myocardial infarction can present with syncope D Females, the elderly, and diabetic patients are more likely to present with atypical symptoms of myocardial infarction

The correct answer is "A." As the saying goes, "Never say never, and never say always." Many elderly and diabetic patients ("D") will present with atypical symptoms or painless, "silent" myocardial infarctions. In fact, up to 30% of myocardial infarctions are pain free. "B" is a correct statement because, especially in the elderly, dyspnea may be the only presenting symptom due to left ventricular failure secondary to ischemia. "C" is a correct statement because syncope (as well as lightheadedness and fatigue) can be presenting symptoms of a myocardial infarction.

Question 5 of 6 You decide to start the patient on a medication to help control his claudication. Which of the following statements is correct? A Pentoxifylline is relatively contraindicated in heart failure B Cilostazol is the best choice for claudication in patients with heart failure C Beta-blockers are good arterial dilators and are thus useful in claudication D The main mechanism of action of pentoxifylline and cilostazol is selective vasodilation E Tobacco smoking paradoxically alleviates claudication

The correct answer is "A." Cilostazol (Pletal®) and pentoxifylline (Trental®) are phosphodiesterase inhibitors. Their mechanism of action in improving walking distance is poorly understood. Other phosphodiesterase inhibitors (such as milrinone) increase mortality in patients with heart failure. Thus, pentoxifylline and cilostazol ("B") should be used with extreme caution, if at all, in patients with heart failure. Selective beta-blockers actually cause peripheral arterial constriction, not arterial dilation; therefore, "C" is also incorrect. The purported benefit of pentoxifylline is to increase RBC malleability and thus reduce the viscosity of blood in the microcirculation. It has no vasodilative effects. However, cilostazol does have some vasodilative effects. Therapeutic benefit with these drugs may take several weeks. A dedicated and supervised walking program is of paramount importance and underutilized. Given the strong association between smoking and peripheral artery disease, smokers should be encouraged to quit, so "E" is incorrect. Statins should also be initiated and have been shown to have benefit (Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000123). Therapy of PAD should include antiplatelet therapy and cardiovascular risk factor modification.

Question 7 of 12 You wish to start an appropriate drug regimen for this patient's heart failure. All of the drugs below have been shown to reduce mortality in patients with HFrEF EXCEPT: A Digoxin B Metoprolol succinate C ACE inhibitors D Hydralazine and long-acting nitrates used in combination in patients intolerant of ACE inhibitors E Spironolactone

The correct answer is "A." Digoxin is an inotropic agent, and as such, would intuitively make sense as an effective drug for HFrEF. However, digoxin has not been shown to increase survival and in fact may worsen outcomes, especially in women and those with atrial fibrillation (J Am Coll Cardiol. 2018;71(10)). Its use is primarily for symptomatic relief. If using digoxin in HFrEF, the therapeutic target is a dose that achieves a plasma concentration of drug in the range of 0.5 to 0.9 ng/mL. The common daily dosage to achieve that target is typically 0.125 to 0.25 mg/day in patients <70 years of age with normal renal function and body mass. For patients with abnormal renal function, low body mass, or age >70, low doses (0.125 mg daily or every other day) are recommended initially with the dose titrated to the target therapeutic range. Digoxin does reduce hospitalizations and improve symptoms in those with HFrEF who are symptomatic despite use of maximal guideline-directed therapy. As noted above, digoxin seems to worsen mortality in those with atrial fibrillation, however. Avoid digoxin in patients with atrial fibrillation and significant sinus or AV nodal block unless they have a pacemaker. NOTE: Other cardiac medications such as amiodarone, dronedarone, verapamil, propafenone, and quinidine as well as noncardiac meds such as clarithromycin, erythromycin, itraconazole, and cyclosporine can increase the serum digoxin concentrations and may precipitate digoxin toxicity. All of the other options, including the combination of isosorbide dinitrate and hydralazine, have been shown to reduce mortality. However, hydralazine and isosorbide dinitrate are generally reserved for those patients who are unable to tolerate ACE inhibitors or angiotensin receptor blockers (ARBs) or remain symptomatic despite maximal medical therapy with the other medications. This combination seems particularly effective in African Americans. However, enalapril reduces mortality by 28% when compared with hydralazine and nitrates. Thus, hydralazine and nitrates are second line. None of the "traditional" loop diuretics such as furosemide, bumetanide, etc., have been shown to positively affect mortality.

Question 3 of 12 You decide on further testing. Assuming every test is easily available to you (which might not be the case depending on the setting in which you work), what is the one best test that you would use to determine if this patient has heart failure? A Echocardiography B Brain natriuretic peptide (BNP) level C Chest radiograph looking for evidence of pulmonary edema (Kerley B lines, etc.) D SPECT myocardial perfusion imaging (MPI) E Positron emission tomography (PET) testing

The correct answer is "A." Echocardiography is the procedure of choice for the diagnosis of heart failure. This is for two reasons. First, you can assess left ventricular systolic function as well as look for diastolic dysfunction to determine if this is HFrEF or HFpEF. Second, you can evaluate the potential causes of heart failure including valvular heart disease, ischemic heart disease, pericardial disease, deposition disease (amyloidosis, hemochromatosis), etc. "B" is incorrect because the BNP will give you less concrete information about the patient compared to echocardiography. In this patient, with a high pretest probability of heart failure, BNP will most likely be elevated (though not always). "D" and "E" are incorrect because MPI and PET testing are best used to diagnose ischemia due to CAD.

The patient does not respond to IV amiodarone and you choose to cardiovert him. Which of the following is the recommended energy (in joules) for an initial attempt at synchronized cardioversion? A 200 joules, monophasic B 360 joules, monophasic C 300 joules, biphasic D 360 joules, biphasic E None of the above

The correct answer is "A." For cardioversion of stable ventricular tachycardia, start with 100 to 200 joules for monophasic waveforms and 100 to 200 joules for biphasic waveforms. The rest are incorrect.

Question 2 of 4 The patient returns at age 75. He is 20 years older. You, however, have not aged a day because doctors are immortal, right? He is now hypertensive, and diabetic, and he requires a cholecystectomy. Apparently, he only sees you for pre-op exams. His CHA2-DS2-VASC score is now 4 and he has been on warfarin for the past 5 years. Which of the following approaches is the best for controlling his anticoagulation, given that he needs surgery? A Stop the warfarin several days before surgery to allow his INR to normalize. Restart the warfarin after surgery B Hospitalize the patient a couple of days ahead of time and start heparin. Then stop his warfarin. Restart the warfarin after surgery C Use low-molecular-weight heparin at home and stop the warfarin once this is started. Restart the warfarin after surgery D Stop the warfarin several days before surgery to allow his INR to normalize. Start heparin after surgery and simultaneously restart warfarin

The correct answer is "A." For patients with nonvalvular atrial fibrillation who are undergoing surgery or invasive diagnostic procedures, it is reasonable to interrupt anticoagulation for up to 1 week without substituting heparin (assuming they haven't had a recent stroke or other thromboembolic event). "Bridge" therapy with IV heparin or low-molecular-weight heparin confers no benefit (Circulation 2015;131(5):488). The risk of perioperative bleeding with heparin is actually greater than the risk of thromboembolism from atrial fibrillation. "B," "C," and "D" are incorrect because the patient does not need heparin. Bridging therapy is typically indicated for patients at higher risk for thromboembolic events such as those with mechanical heart valves, prior stroke, or CHA2DS2-VASc score >5.

Question 6 of 14 The ambulatory blood pressure monitor reveals that the patient's blood pressure is >140/90 mm Hg more than 40% of the time, indicating that he is indeed hypertensive. The initial evaluation of the hypertension includes the following: A History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, and lipids B History, physical, CBC, uric acid, glucose, BUN, creatinine, electrolytes, and lipids C History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, lipids, and echocardiography D History, physical, and labs only as indicated by history and physical

The correct answer is "A." History, physical, CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG, and lipids are the generally agreed-upon initial workup of the hypertensive patient. "C" includes echocardiography, which is not recommended as part of the routine evaluation but may be indicated if signs of cardiac disease are present.

Question 5 of 14 Hypertension is defined as an ambulatory 24-hour monitor average blood pressure of: A 135/85 mm Hg during the day and 125/75 mm Hg at night B 140/90 mm Hg during the day and 130/85 mm Hg at night C 130/85 mm Hg over 24 hours D 140/90 mm Hg over 24 hours

The correct answer is "A." Hypertension is diagnosed via ambulatory monitoring when patients have an average blood pressure of >135/85 mm Hg during the day and >125/75 mm Hg at night, as defined by JNC 8. Another published criterion is a blood pressure of >140/90 mm Hg more than 40% of the time. The ACC/AHA would like to make things more difficult. Their criteria are 24-hour mean of 125/75 mm Hg, daytime average of >/=130/80 mm Hg or nighttime average of >/= 110/65 mm Hg.

Question 6 of 7 Being the astute clinician that you are, you realize that 50% of atrial fibrillation will spontaneously convert to normal sinus rhythm, especially if present <72 hours. A transthoracic echocardiogram was performed and did not demonstrate any structural heart disease or vegetations. Thus, you choose to give verapamil and monitor the patient. At 24 hours, he still is in atrial fibrillation, although the rate is controlled well (90-110 bpm) with verapamil and he is normotensive. You discuss his case with your friendly neighborhood cardiologist who suggests that you plan cardioversion in 3 to 4 weeks. How would you anticoagulate this patient should you choose anticoagulation? A Start warfarin alone B Start heparin and rivaroxaban at the same time C Start heparin alone D Start aspirin alone

The correct answer is "A." If the onset of atrial fibrillation is indeterminate or >48 hours (as with this patient), one should withhold cardioversion and anticoagulate the patient for 3 weeks before cardioversion. A second strategy is to anticoagulate the patient and arrange for a trans-esophageal echocardiogram. If the trans-esophageal echocardiogram shows no vegetations, you can proceed with cardioversion. For those with <48 hours of atrial fibrillation, immediate cardioversion is a viable option. Since we now are planning to cardiovert this patient in the future, "A" is the most reasonable option provided. Some physicians will start heparin or low-molecular-weight heparin at the initiation of warfarin; however, the combination is not necessary in patients with nonvalvular atrial fibrillation. This scenario is much different than when patients have a PE/DVT. For nonvalvular atrial fibrillation, starting warfarin (or a DOAC) alone is sufficient. "B" is incorrect. There is no need to bridge patients starting rivaroxaban or apixaban with heparin; the anticoagulant effect is "immediate" and there is no transient hypercoagulable state. Dabigatran still requires 5 to 10 days of heparin, enoxaparin, etc. Heparin ("C") or aspirin ("D") alone would not be the best choices in this case.

Question 4 of 16 Her ECG shows nonspecific ST-T changes. Which of the following drug(s) is/are indicated in the initial management of this patient? A Aspirin B Thrombolytic such as tPA or streptokinase C Heparin D Glycoprotein IIb/IIIa inhibitor (e.g., abciximab [ReoPro]) E All of the above

The correct answer is "A." Immediate therapy in the ED requires ASA 325 mg orally (chewed). Since we are not sure that this patient has AMI or unstable angina, there is no indication for thrombolytic therapy ("B"), heparin ("C"), or glycoprotein IIb/IIIa inhibitor ("D"). Since she is currently pain free, heparin carries more of a risk than a benefit at this juncture and is not recommended. However, all patients with possible angina or an AMI should have aspirin unless they are truly allergic (e.g., hives, anaphylaxis). "B" is incorrect because thrombolytics are indicated for acute ST elevation myocardial infarctions (STEMI), not for a simple chest pain evaluation.

Question 9 of 14 Time to digress a bit. Which of the following drugs is the best choice as your initial agent for the treatment of hypertension in a patient with diabetes and known microalbuminuria? A Lisinopril B Metoprolol C Losartan D Verapamil E Amlodipine

The correct answer is "A." In a diabetic patient who has proteinuria, an ACE inhibitor is indicated to slow down the progression of renal disease. An ARB or non-dihydropyridine CCB (verapamil, diltiazem) is a viable alternative for those who cannot tolerate an ACE inhibitor. (Note: Some patients may not tolerate verapamil or diltiazem due to bradycardia or may not be candidates due to LV systolic dysfunction). However, ACE inhibitors are still first-line. These recommendations stem from the renal and cardiac benefits of ACE inhibitors.

Question 10 of 12 You treat this patient with metoprolol succinate, lisinopril, furosemide, atorvastatin, and aspirin. This regimen seems to help, and the patient's symptoms improve. However, a few weeks later, he presents to the ED with increased dyspnea. There have been no changes in his medications, and he assures you that he is taking his medications as directed. His examination reveals that he has elevated JVD, rales over the lower half of his lung fields bilaterally, and pedal edema. Common causes of decompensation in patients with otherwise stable heart failure include all of the following EXCEPT: A Inactivity B Fever C Arrhythmia D Dietary indiscretion E Ischemia

The correct answer is "A." Inactivity will not generally cause an exacerbation of heart failure (though may have been an underlying cause!). The major causes of acute exacerbations of chronic heart failure include dietary indiscretion (increased salt and fluid consumption), increased metabolic demand (e.g., from infection), anemia, medication noncompliance, arrhythmia, and ischemia. The inappropriate use of medications, such as some calcium channel blockers and the institution of beta-blockers when heart failure is decompensated, is also a common cause of exacerbations of HF.

Question 3 of 4 Two years later, the patient returns for a checkup and states that he believes he has been having symptoms from his aortic stenosis. All of the following can occur with symptomatic aortic stenosis EXCEPT: A Left-to-right intracardiac shunt B Exertional dyspnea C Syncope D Angina E Lightheadedness

The correct answer is "A." Intracardiac shunts don't occur with aortic stenosis. If you got this one wrong, back to anatomy for you! An isolated, fixed valvular lesion as an adult cannot cause intracardiac shunting. Exertional dyspnea, lightheadedness (presyncope), syncope, and chest pain are common symptoms in severe aortic stenosis.

Question 16 of 16 While this patient had a STEMI (or "Q-wave" MI), it is also important to recognize some of the differences between STEMI and non-STEMI. Regarding non-STEMI, which of the following statements is TRUE? A Patients with a non-STEMI have the same, or perhaps a bit worse, outcomes long term than do patients with a STEMI B Patients with a non-STEMI have worse in-hospital outcomes when compared with patients with a STEMI C Unstable angina and non-STEMI can be readily differentiated from one another on presentation D None of the above is true

The correct answer is "A." Patients with a non-STEMI actually have the same, or perhaps even slightly worse, outcomes long term when compared to patients with a STEMI. This makes sense; there is still myocardium left to infarct after a non-STEMI. As to the other answers, patients with a STEMI do have worse in-hospital outcomes, and unstable angina and non-STEMI look similar on ECG with T-wave inversion, etc., but without the ST elevations that are classically seen in a transmural infarction.

Question 2 of 4 The patient would like to know how often he should have a repeat echocardiogram given that he has mild disease. Your answer is: A Every 3 to 5 years B Every year C Every 6 months D When he develops symptoms E None of the above

The correct answer is "A." Patients with mild aortic stenosis who are asymptomatic can be followed by echocardiogram every 3 to 5 years. Patients with severe disease should have yearly echocardiography to evaluate for left ventricular dysfunction. See Table 2-7.

Question 3 of 14 Exercise stress testing is best suited to which group of individuals? A Men with an intermediate probability of cardiac disease B Women with a high risk of cardiac disease C Men at a high risk of cardiac disease D Men at a low risk of cardiac disease E Women with a low risk of cardiac disease

The correct answer is "A." Stress testing is best suited to patients with an intermediate pretest probability of cardiac disease (between 25% and 75%). "B" and "C" are incorrect since patients with a high risk of cardiac disease should go directly to another study, such as nuclear myocardial perfusion imaging study (MPI, also sometimes termed "thallium stress testing") or stress echocardiography. "D" and "E" are incorrect since these are not the best groups in whom to use exercise stress testing; there will be a greater proportion of false-positive results in these low-risk patients. Exercise stress testing in these groups is best used to allay patient fears that they do not have cardiac disease, not to prove they do have cardiac disease. However, a false-positive stress test may lead to other unnecessary invasive testing!

Question 2 of 3 By the time the patient arrives at the hospital, she is having a rapid, chaotic rhythm, which appears to be atrial fibrillation on the monitor. It seems as though there are also episodes of atrial flutter with 2:1 block. The most likely diagnosis in this patient with varying rate is: A Sick sinus syndrome (bradycardia-tachycardia syndrome) B Hypothyroidism C Hyperthyroidism D Hyperkalemia

The correct answer is "A." The most likely diagnosis in this patient is "sick sinus syndrome," also known as "tachy-brady" syndrome and "bradycardia-tachycardia" syndrome. This syndrome is most common in elderly individuals and reflects the replacement of the SA node with fibrous tissue. "B" is incorrect because hypothyroidism should cause bradycardia without intermittent tachycardia. "C" is incorrect because hyperthyroidism should cause tachycardia without bradycardia. "D" is incorrect because hyperkalemia generally causes a widened QRS complex on ECG and eventually ventricular tachycardia. Note: With Mobitz type II second degree heart block, the problem is infra-nodal, below the AV node, and can result in complete heart block. Sick sinus syndrome is due to disease of the SA node.

Question 4 of 4 Which of the following statements about aortic valve disease is INCORRECT? A Aortic stenosis can be treated quite effectively with balloon valvulotomy with good long-term outcomes B There are no known medical treatments that reduce the need for aortic valve replacement C Risk factors for the development of aortic stenosis are similar to CAD D Valve replacement surgery is the preferred treatment of symptomatic aortic stenosis

The correct answer is "A." Valvulotomy (balloon aortic valvuloplasty) is not a long-term solution for the management of severe symptomatic aortic stenosis. While it may be indicated as a "bridge" to definitive treatment (surgery or transcatheter aortic valve replacement [TAVR]), durability of the valvulotomy results are poor, only lasting 3 to 6 months. The procedure carries the attendant risk of cerebral embolism causing stroke, aortic rupture, or acute severe aortic insufficiency. The epidemiological risk factors for aortic stenosis and CAD are similar (as is the pathophysiology). Unfortunately, there are no drugs that are effective at reducing the need for valve replacement. You can provide symptomatic relief but that is all.

Question 4 of 4 The new lead placement continues to show asystole. Which of the following drugs and doses are considered appropriate in asystole? A Epinephrine 1 mg B Atropine 0.5 mg C Atropine 1 mg D Epinephrine 10 mg E A and C

The correct answer is "A."Atropine is no longer in the ACLS guidelines for asystole. Older ACLS recommendations for asystole included both epinephrine and atropine.

Question 1 of 5 Your patient with heart failure does well and is discharged from the hospital after a couple of days. You are just beginning to think that the authors are tired of writing questions about heart failure ... but you are wrong. The patient's 70-year-old wife shows up with shortness of breath. Her physical examination is consistent with heart failure. Since you have learned so much from the previous case already, you send her to get an echocardiogram. You also order the recommended tests: CBC, electrolytes, ECG, thyroid functions, etc. The results of the echocardiogram show a concentric thickening of the left ventricle with an ejection fraction of 75%. This is most consistent with: A Ischemic cardiomyopathy B HFpEF C Viral cardiomyopathy D Hypertrophic cardiomyopathy E None of the above

The correct answer is "B." "A" is incorrect since there would likely be evidence of RWMA if there had been an old myocardial infarction. Also, this patient has a preserved ejection fraction, which is consistent with HFpEF rather than the decreased ejection fraction associated with ischemic cardiomyopathy. "C" is incorrect. Viral cardiomyopathy is associated with a dilated ventricle rather than a hypertrophic one, and there would be global dyskinesia with decreased ejection fraction. "D" is incorrect; hypertrophic cardiomyopathy is usually associated with asymmetric hypertrophy, often septal, rather than concentric hypertrophy of the left ventricle. Hypertrophic cardiomyopathy may lead to HFpEF in addition to left ventricular outflow tract obstruction.

Question 10 of 14 Your patient has a CABG and comes into your office complaining of chest pain and fever 3 weeks after the surgery. He has had the pain and fever for 4 days and does not seem to be getting any better. He has no cough, no sputum production, and the pain seems to be worse when he breathes or lies down. He reports no dyspnea and has 97% oxygen saturation on room air. The wound from the surgery is well healed, and a chest radiograph shows no evidence of abnormalities. Which of these studies is LEAST likely to be abnormal in this patient? A ECG B Ventilation/perfusion (V/Q) scan C Echocardiogram D Sedimentation rate (ESR)

The correct answer is "B." A V/Q scan is not likely to be positive in this patient. This patient is unlikely to have a pulmonary embolism (PE), given the duration of symptoms, the fact that the patient has chest pain that worsens with inspiration (found in only 59% of those with PE), fever, absence of dyspnea, and has normal oxygen saturation. Certainly, this could still be a PE, but it would be less likely than other, more plausible, explanations. The most likely diagnosis in this patient, given the lack of other symptoms, is post-pericardiotomy syndrome. This is similar to Dressler syndrome, which occurs after a myocardial infarction and presents with fever and chest pain several days to weeks after the inciting event. The white blood count is often elevated, as is the ESR. The ECG can be helpful as can an echocardiogram.

Question 3 of 3 This patient is bothered by her PACs. She is rather aware of them and finds them disconcerting. What is the best pharmacologic therapy to consider at this point? A Sotalol B Metoprolol C Trasylol D Amiodarone E Mountain Dew—lots of it

The correct answer is "B." A beta-blocker may help to reduce this patient's PACs. "A" is incorrect because, while sotalol can be used for both atrial and ventricular arrhythmias, it is proarrhythmic and can cause torsades de pointes. Thus, it should be initiated in the hospital with monitoring and reserved for those with severe arrhythmias. "C" is incorrect because Trasylol is the trade name for aprotinin, an enzyme that was used to reduce bleeding during surgical procedures. "D" is incorrect because, like sotalol, amiodarone is proarrhythmic, and its use should be limited to those with significant arrhythmias.

Question 4 of 12 The patient has an echocardiogram that shows a left ventricular ejection fracture (LVEF) of 35% and a regional wall motion abnormality (RWMA). This is the most consistent with a diagnosis of: A HFrEF secondary to myocarditis B HFrEF secondary to CAD C HFpEF secondary to hypertension D HFrEF secondary to constrictive pericarditis E Age-related changes; therefore, a normal variant

The correct answer is "B." A regional wall motion abnormality (RWMA) suggests that this patient has ischemic or infarcted myocardium. "A" is not the best choice since those with myocarditis (fulminant or acute) typically have global hypokinesis (although RWMA has been reported) and the patient would typically appear more clinically ill. "C" is incorrect by definition. HFpEF requires an LVEF of at least 50%, recognizing that this group may not have an entirely normal LVEF, but the major abnormality is not a reduction in LV systolic function. HFpEF is associated with a hypertrophied left ventricle and a preserved LVEF. HFrEF is defined by an LVEF of <40%. The echocardiogram in constrictive pericarditis ("D") generally shows normal left ventricular systolic function. It may reveal pericardial thickening, dilated inferior vena cava or hepatic veins, and abnormal mitral and tricuspid in-flow Doppler.

Question 2 of 3 Which of the following statements about PACs is true? A Mitral valve prolapse is associated with PACs B Mitral valve stenosis is associated with PACs C Bicuspid aortic valve is associated with PACs D None of the above is true

The correct answer is "B." Anything that can cause an increase in left atrial pressures (and therefore atrial wall stretching) is associated with an increase in the number of PACs. Mitral stenosis causes increased pressures in the left atrium, wall stretching, and enlargement and thus predisposes to PACs. "A" is incorrect. Even though multiple problems have been blamed on mitral valve prolapse, a study done as part of the Framingham study showed that the symptoms blamed on mitral valve prolapse (anxiety, PACs, tachycardia, etc.) are no more prevalent in those with mitral valve prolapse than in those without it. "C" is incorrect. A bicuspid aortic valve may cause PACs as a result of heart failure when the patient decompensates and has increased left-sided heart pressures. However, a bicuspid aortic valve itself is not a source of PACs. Similarly, hypertrophic cardiomyopathy, other causes of heart failure, drugs (e.g., theophylline and digoxin), and neurologic diseases can be associated with PACs.

Question 5 of 5 Which of the following drugs or drug classes is theoretically the best choice for the treatment of HFpEF? A ACE inhibitors B Beta-blockers C Diuretics D Hydralazine E ARBs

The correct answer is "B." Beta-blockers, especially metoprolol succinate, are useful as initial therapy in HFpEF. Beta-blockers (1) slow down the heart to permit longer LV filling duration during diastole and (2) help to relax the myocardium to promote a less restrictive filling pattern. If a patient fails beta-blockers, try a CCB (e.g., verapamil, diltiazem). Unlike HFrEF, the treatments of HFpEF are not well established, and there is no convincing evidence that beta-blockers or ACE inhibitors reduce mortality.

Question 2 of 4 Cor pulmonale may result from all of these disease processes EXCEPT: A Sickle cell anemia B Left ventricular failure C Pulmonary embolus (PE) D Chronic obstructive lung disease E Interstitial lung disease

The correct answer is "B." Cor pulmonale is the term used for right heart failure caused by diseases primarily affecting the lungs and pulmonary vasculature. The chronic pressure overload of the right ventricle as it ejects in to the high resistance pulmonary vasculature results initially in RVH with normal RV systolic function but over time, the RV contractility declines leading to RV dilation and right-sided heart failure with associated significant tricuspid regurgitation and right atrial dilation.

Question 10 of 14 Digressing a bit further ... Which of the following drugs might you want to use as your initial agent for the treatment of hypertension in a 72-year-old male who you also diagnosed with symptomatic benign prostatic hypertrophy (BPH)? A Amlodipine B Doxazosin C Captopril D Losartan E Verapamil

The correct answer is "B." Doxazosin is an alpha-blocker that is useful in the treatment of symptomatic BPH. None of the other choices can be used for this indication. Of course, alpha-blockers are also antihypertensives, and thus serve a useful purpose by killing two birds with one stone (Why would you want to kill two birds? And why with stones? Isn't there a better way?). As noted above, alpha-blockers do not confer as much benefit for the hypertensive patient as other classes of drugs. Thus, alpha-blockers are not the best choice in general but could be used as the initial agent if you have a compelling reason. The point of these digressions is that you should look at the patient's other underlying conditions when deciding what to recommend at initial therapy. Another example would be a patient with CAD and angina starting on a beta-blocker as initial treatment rather than a thiazide (since the beta-blocker may improve angina symptoms and is indicated for CAD). Recall that not all beta-blockers are created equal. Atenolol is least preferred and metoprolol succinate is among the best. If the patient has renal disease, consider an ACE inhibitor or ARB as first-line treatment for hypertension.

Question 12 of 16 The patient requires heparin with the thrombolytic that you choose (and is indicated, by guidelines, for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days or until revascularization is performed). Which of the following dosing regimens is the best accepted for use in AMIs? A Enoxaparin 30 mg subcutaneously (SC) every 12 hours B Enoxaparin 1 mg/kg SC every 12 hours C Heparin 5,000 units bolus and a drip at 1,000 units per hour D Heparin 100 unit/kg bolus with a drip at 25 units/kg/hr E None of the above represents the best dosing option in this situation

The correct answer is "B." For anticoagulation in AMI, the dose of enoxaparin is 1 mg/kg SC every 12 hours. "A" is incorrect since 30 mg SC every 12 hours is the dose for DVT prophylaxis in post-op joint replacement patients, not for anticoagulation. "C" is incorrect. This is the classic way that heparin has been dosed but it is not the best option listed. "D" is incorrect as well. The correct dose for heparin when given with a thrombolytic is 60 units/kg bolus (maximum of 4,000 units) with a drip of 15 units/kg/hr (maximum dose of 1,000 units/hr), with rate adjusted to achieve an activated partial thromboplastin time (aPTT) of 1.5 to 2 times control (for 48 hours or until revascularization). The bottom line here is that either enoxaparin or heparin can be used in this setting, and they are more or less equivalent. If you choose to use heparin, do not use fixed dose heparin but rather weight-based dosing. One advantage to unfractionated heparin is that the half-life is 30 minutes, so it is rapidly cleared. Additionally, it can be reversed with protamine zinc. (Did you know that protamine was originally extracted from fish sperm? Who came up with that idea? It is now produced by recombinant technology.)

Question 11 of 16 After conferring with your closest cath center, you give a thrombolytic—and cross your fingers. Unfortunately, the patient develops a new LBBB. In addition, the ECG shows evidence of a first-degree heart block (a prolonged PR interval), although the heart rate remains normal at 80 bpm. The proper response to this is to: A Insert a Swan-Ganz catheter to monitor central pressures B Insert a temporary pacemaker regardless of the heart rate C Administer atropine to this patient D Administer isoproterenol to this patient E Do nothing, other than observe this patient

The correct answer is "B." For patients with an AMI, a transvenous pacemaker should be inserted if the patient develops (1) complete heart block, (2) second-degree heart block type II (Mobitz II), or (3) new LBBB with first-degree AV block. See Tables 2-2 and 2-3 for more on arrhythmia and pacemakers in the setting of AMI. "A" is incorrect because a Swan-Ganz catheter will be of no help in arrhythmias. "C" is incorrect because atropine is indicated for symptomatic bradycardia and not for a bundle branch block. "D" is incorrect for the same reason as "C." In addition, isoproterenol is arrhythmogenic and is no longer recommended. "E" is incorrect because the patient may rapidly progress into a complete heart block. Of note and importantly, the placement of a transvenous pacemaker should not delay transfer for catheterization since a pacemaker may also be placed in the cath lab. However, apply an external pacemaker as required.

Question 3 of 6 The ABI results are normal. However, you strongly suspect claudication. The next step should be: A Catheter-based arteriography B Repeat ABI after an exercise stress test C Magnetic resonance arteriography D CT arteriography E None of the above

The correct answer is "B." In patients in whom you strongly suspect peripheral vascular disease, ABIs after exercise can be positive when a resting test is negative. This would be the least invasive and most cost-effective test of the options given.

Question 4 of 4 Pulmonary function testing and chest radiography support an underlying diagnosis of COPD. You counsel the patient to quit smoking, prescribe pulmonary rehabilitation, and treat him with bronchodilator therapy. Besides stopping smoking, the best treatment of this patient's cor pulmonale and pulmonary hypertension (PHTN) is: A Continuous prostacyclin infusion B Continuous, low-flow oxygen C Calcium channel blockers (CCBs) D Nitroglycerin E Antibiotics to reduce pulmonary inflammation secondary to infection

The correct answer is "B." In this patient who is a smoker with cor pulmonale, the best drug is continuous, low-flow oxygen. This will help to reverse the pulmonary vasoconstriction caused by chronic hypoxia. It should go without saying that you must do everything you can to get him to stop smoking. His disease process will progress much faster if he continues to smoke. "A" is incorrect because prostacyclin infusion is useful in primary pulmonary hypertension (PHTN), not this type of cor pulmonale. "C" is incorrect. In some cases of primary PHTN, CCBs, PDE5 inhibitors (e.g., sildenafil), and several other medications, which serve as direct vasodilators to dilate the pulmonary vascular bed, can be useful. However, this is not the best choice for this patient with COPD. "D" is incorrect because patients with cor pulmonale are dependent on high right heart-filling pressures to get blood through the pulmonary vasculature. Nitroglycerin will reduce preload, thereby lowering right ventricular pressure and resulting in worsening of his symptoms. "E" is also incorrect. Antibiotics might be needed in this patient for pneumonia, bronchiectasis, etc., but they are not going to help with the treatment of cor pulmonale.

Question 9 of 16 The patient's pain continues despite treatment with nitroglycerin, and you obtain another ECG (Fig. 2-1). FIGURE 2-1. ECG for patient in question 2.1.9. View Full Size|Favorite Figure |Download Slide (.ppt) Which of the following is TRUE regarding this ECG? A This injury pattern on ECG is most consistent with an anterior wall MI B In this situation, percutaneous transluminal coronary angioplasty (PTCA) and stent placement is superior to tPA or other thrombolytic C This injury pattern on ECG is most consistent with pericarditis D This injury pattern on ECG proves that this patient does not have an aortic dissection E This pattern on ECG is totally fine. What, me worry?

The correct answer is "B." Intervention in the cath lab with PTCA and/or stent placement is superior to thrombolytic therapy in the treatment of AMI, provided that the "door to balloon" time is 90 minutes or less. In cases where the patient is located in a facility without a cardiac catheterization laboratory, the patient may receive thrombolytic therapy. "A" is incorrect because this pattern is indicative of an inferior wall, not an anterior wall, MI. You will note that this ECG shows ST elevations in leads II, III, and aVF (inferior leads) along with reciprocal ST-segment depression in leads V1 and V2. An anterior wall MI is defined by ST elevations in leads V3, V4, and V5, and an anteroseptal MI shows ST elevations in leads V1, V2, and V3. For IAMI concerning for RV infarction, consider "right-sided chest leads." "D" is incorrect because patients with pericarditis should have ST elevations in all leads (although an ECG is only 80% sensitive for pericarditis). "D" is incorrect because patients with an aortic dissection can present with an abnormal ECG that looks similar to an infarct pattern. So, ECG changes do not prove that the patient does not have an aortic dissection. "E" is just plain wrong and you should be worried if you see this pattern!

Question 5 of 12 Which of the following is the most appropriate next strategy to work up this patient's HFrEF? A Cardiac MRI to assess myocardial viability B Coronary angiogram C Measure serial troponins to rule out acute coronary syndrome (ACS) D Electrophysiologic study to assess for inducible ventricular arrhythmia E CT to assess calcium scores

The correct answer is "B." Ischemic heart disease causes most HFrEF. If you can reverse the ischemia, mortality is decreased from 16% annually to 3.2% annually. Of all the options listed above, coronary angiography remains the gold standard to evaluate for CAD in this setting. Coronary angiograms provide information about anatomy and feasibility of revascularization but do not predict recovery of function after revascularization. This patient does not have chest pain or ECG changes to suggest ACS; therefore, "C" is incorrect. "D" is incorrect, as there is no indication for an electrophysiologic study in the absence of any arrhythmia. "E" is incorrect, because, as noted, the presence or absence of coronary calcification would not change the overall management plan for this patient. CT calcium scoring may be used as an additional risk stratification tool in intermediate-risk patients (similar to CRP, in addition to traditional risk factors such as hypertension, dyslipidemia, vascular or renal disease, etc.) but not in high-risk, symptomatic patients. 61% of users answered corre

Question 2 of 14 The patient returns to your office with blood pressures measured six times over a period of 2 weeks at a local pharmacy. Only three of the six readings suggest that the patient is hypertensive. The patient states that the elevated blood pressures were while he was under stress at work. Your best response at this point is to: A Start an antihypertensive B Send the patient for a 24-hour ambulatory blood pressure measurement C Don't worry about the blood pressure since half of the readings were within a normal range D Get a nephrology consult to help in decision making E Make another office visit so you can buy that Porsche

The correct answer is "B." One way to determine if a patient with contradictory readings is hypertensive is to perform 24-hour ambulatory blood pressure monitoring. This can be useful in patients who have elevated blood pressures in the office but not at home or vice versa. It can also be used if you do not trust the blood pressure readings taken outside of your office. "A" is incorrect since we have not yet established that this patient is hypertensive. "C" is incorrect since we have not yet established that this patient is not hypertensive. "D" is incorrect because you are smarter than that and should be able to work through this kind of case yourself! As to "E," whoops, we forgot. We're family physicians, not radiologists. No Porsche for us!

Question 3 of 4 A possible finding on the ECG of this patient would include: A P-mitrale (an "m" shaped, notched P wave in lead II) B P-pulmonale (an enlarged, peaked, P wave in lead II) C Absent P waves D Inverted P waves

The correct answer is "B." Patients with cor pulmonale often have an enlarged and peaked P wave in lead II reflecting right atrial enlargement. "P-mitrale" is found in left atrial enlargement and is characterized by a prolonged and/or notched ("m-shaped") p-wave in lead II.

Question 9 of 12 You reduce the dose of metoprolol succinate and consider starting this patient on another medication. Which of the following patients is/are good candidates for spironolactone? A A patient with NYHA Class I and Class II heart failure B A patient with NYHA Class III and Class IV heart failure C Both A and B D Neither A nor B

The correct answer is "B." Spironolactone has been shown to reduce mortality in patients with New York Heart Association (NYHA) Class III and Class IV heart failure. It has not been studied in Class I (thus "A" is wrong). However, it may be useful in symptomatic patients with Class II with an EF of <30%. Serum potassium needs to be monitored closely after initiation of spironolactone, especially since it will generally be used with an ACE inhibitor or ARB, both of which can increase the serum potassium. This drug should be avoided in patients with renal insufficiency or patients with serum potassium >5 mEq/L. Spironolactone is indicated for patients with NYHA Classes II-IV and who have LVEF ≤35% and a creatinine of <2.5 mg/dL in males or <2 mg/dL in females (or estimated GFR >30 mL/min/1.73 m2). Eplerenone is another aldosterone inhibitor but is much more expensive with little, if any, advantage. Remember that trimethoprim-sulfamethoxazole can lead to fatal hyperkalemia in those on an ACE/ARB/spironolactone and other potassium sparing drugs with even a couple of doses.

Question 5 of 14 You are considering whether to order an MPI or a stress echocardiogram. Which of the following is true? A Stress echocardiography is more sensitive for cardiac disease than is an MPI B Stress echocardiography is more specific than is a stress MPI C MPI is more specific for cardiac disease than is stress echocardiography D None of the above is true

The correct answer is "B." Stress echocardiography is more specific for cardiac disease than is MPI. Alternatively, MPI is more sensitive. Table 2-5 summarizes this data. Remember that positive and negative predictive values of these tests will vary depending on the pretest probability of disease in the patient and severity of disease. Numbers given above are overall.

Question 14 of 16 The patient remains pain free while in the hospital. She is ready to be discharged 4 days later—but she's still getting enoxaparin for a total of 8 days, as recommended in the guidelines. Which of the following tests is the most appropriate for this patient prior to discharge? A Coronary angiography B Submaximal stress test plus echocardiography C Full Bruce protocol, symptom limited, stress test D Spiral CT to assess for coronary artery calcification E Ping test

The correct answer is "B." Submaximal stress testing is considered the standard of care; a noninvasive evaluation of left ventricular ejection fraction (e.g., echocardiogram or radionuclide study) is also indicated. Patients with a positive submaximal stress test should be referred for catheterization. Patients with a borderline stress test can be sent for a radionuclide study. Coronary angiography is not routinely recommended for all patients who have had a myocardial infarction unless they are considered to be at high risk (continued symptoms, positive screening test such as submaximal stress test, heart failure, cardiogenic shock, etc.). "C" is incorrect because a symptom-limited, full-protocol stress test should be done only 14 to 21 days after an infarction. Finally, spiral CT ("D") to assess for coronary artery calcification has no role in risk stratification after a myocardial infarction ... their risk is 100%! Also, keep in mind that the weight of the clinical evidence favors transfer for early catheterization, especially for higher risk patients. "E," a ping test, is a test to see if your internet service is working.

Question 2 of 6 His examination shows decreased pulses in the lower extremities bilaterally. You would like to confirm your suspicion that this patient has peripheral vascular disease. What is the first study you would order in this patient? A Spiral CT to confirm vascular calcification B Ankle-brachial index (ABI) C Color Doppler to assess flow D Catheterbased arteriography E None of the above.

The correct answer is "B." The ABI is sensitive and specific for peripheral arterial disease in the lower extremity. The pressure in the ankle should be higher than that in the brachial artery in a healthy person. The highest sensitivity is achieved by measuring pressures in both brachial arteries, both dorsalis pedis, and both posterior tibial arteries. Neither spiral CT or color Doppler are recommended as the initial screening test for the presence of peripheral vascular disease (although CT angiogram may be useful in the future to define the degree and location of narrowing in preparation for bypass or angioplasty). Catheter-based arteriography is an option but should be reserved for patients with known peripheral artery disease in whom intervention is being considered.

Question 1 of 16 A 35-year-old female presents with a 1-hour history of chest pain, which resolved spontaneously. The pain is described as a chest pressure radiating to both arms. The patient is a smoker but has no other risk factors (no family history of cardiac disease, hypertension, diabetes, hyperlipidemia, etc.). The patient is diaphoretic and has a normal blood pressure. Physical examination reveals that the patient has tenderness to palpation of the anterior chest wall that reproduces the chest pressure. She is now otherwise free of chest pain and all her lab assays, including cardiac enzymes, are normal. Which of the following is true about this patient's physical findings and history? A Pain radiating to both arms makes it unlikely that this patient's pain is cardiac B The physical findings that are most highly associated with an acute myocardial infarction (AMI) include hypotension, diaphoresis, and a new S3 gallop C The absence of risk factors makes it unlikely that this patient has cardiac disease D The fact that the pain is reproducible on palpation of the chest wall effectively rules out cardiac disease E Based on the information available, further cardiac evaluation is unnecessary

The correct answer is "B." The findings that are most likely to be associated with an AMI are hypotension, diaphoresis, and a new S3 gallop. "A" is not true because pain radiating to both arms can still be associated with cardiac disease. In fact, compared with left arm radiation, right arm radiation or bilateral arm radiation doubles the likelihood of the pain being cardiac (LR 2.3 for radiation to the left arm vs. LR 4.1-4.7 for radiation to the right or bilateral arms [JAMA 2005;294(20):2623-2629]). Women with AMI often present atypically and may experience more chest pain radiating to the right arm/shoulder and the anterior neck or with abdominal pain, as compared to men. "C" is incorrect. The absence of risk factors is only one consideration in the evaluation of this patient. Smoking, hypertension, family history, etc., do not change the prior probability of cardiac disease enough to allow them to be used to rule out or rule in cardiac disease. Of note, male gender and diabetes do increase the pretest probability of coronary artery disease (CAD). But luckily our patient is female! Evaluation of pretest probability is important in the diagnostic algorithm, but should be used in addition to, not in exclusion of, clinical judgment and findings. "D" is incorrect. It is true that chest pain reproduced by palpation of the chest wall makes cardiac disease less likely. However, 15% of patients with cardiac disease and 17% of patients with a pulmonary embolism (PE) will have their pain reproduced by chest wall pressure (BMJ 2005;330:452-453). This does not mean that you are making their cardiac pain worse. It is likely because of the patient's inability to discriminate between the types of pain (cardiac vs. chest wall).

He gets admitted to a cardiac inpatient bed and you give a bolus of 1 liter 0.9% saline IV on the way to the hospital. Despite this, he remains dyspneic with elevated neck veins and has a pulsus paradoxus of 14 mm Hg (normal <10 mm Hg). The next step for this patient is: A Change the patient to steroids from indomethacin B Perform a pericardiocentesis C Start a positive inotrope (e.g., dopamine) to improve right heart function D Start an afterload reducer to reduce cardiac demand

The correct answer is "B." The patient is clearly not doing well if he is getting more dyspneic and not responding to your treatment. The pulsus paradoxus is 14 mm Hg. This is indicative of possible cardiac tamponade, but it may be seen in constrictive pericarditis, severe asthma, or anything else that reduces right heart filling (e.g., tension pneumothorax). This patient's clinical picture is consistent with decompensated cardiac tamponade, and drastic action is indicated to relieve the symptoms of right heart failure. The definitive treatment is pericardiocentesis. "A" is incorrect because more drastic action is required. You would be correct to change the patient to prednisone or to add colchicine if not done already. "C" is incorrect since an inotrope will do little to help this problem. "D" is incorrect for two reasons: the first is that this is a right heart problem and reducing afterload (systemic vascular resistance) will not help the right heart, which pumps against pulmonary resistance; second, most drugs that reduce systemic vascular resistance will also decrease preload to some degree, worsening the symptoms of tamponade.

Question 2 of 4 The patient is really worried that this aneurysm will rupture and kill him. You educate him that the benefit of having the aneurysm repaired is greater than the risk of the surgery when the aneurysm reaches: A ≥4.5 cm B 5 to 5.5 cm C 5.5 to 6 cm D >6 cm E No repair is indicated until the patient becomes symptomatic

The correct answer is "B." The risk of the surgery outweighs the benefits until the aneurysm reaches somewhere between 5 and 5.5 cm. The rest are incorrect. It would be an especially bad idea to wait until an aneurysm is symptomatic, as a ruptured aortic aneurysm can be lethal in a matter of minutes.

Question 3 of 4 You cardiovert the patient, and the rhythm in Figure 2-6 is on the monitor. Is it getting hot here, or is it just you? FIGURE 2-6. ECG for patient in question 2.11.3. View Full Size|Favorite Figure |Download Slide (.ppt) Of the following, what is the first step you will take (while maintaining good compressions and ventilations, of course)? A Re-shock the patient at the same energy level B Check another lead to assure the readout is accurate C Give epinephrine, 1 mg IV D Give atropine, 1 mg IV

The correct answer is "B." This rhythm is asystole. It is important to quickly check another lead and make sure that all of the leads are connected properly. "A" is incorrect because cardioversion/defibrillation is not routinely indicated in the treatment of asystole. "C" and "D" are incorrect because it is important to ensure that the patient actually is in asystole prior to treating with any medications.

Question 5 of 16 The patient tells you that she is allergic to aspirin, which causes hives and bronchospasm. She can, however, take other nonsteroidal anti-inflammatory drugs (NSAIDs) without difficulty. Oh, great. Now you need to go to plan B (no, not the "morning after pill"). Which of the following is an acceptable substitute for aspirin in this situation? A Dipyridamole B Ticagrelor (Brillinta) C Ibuprofen or naproxen D Celecoxib (Celebrex) E Salsalate

The correct answer is "B."Ticagrelor (Brillinta) 180 mg as a loading dose is the correct choice. Alternatively, clopidogrel (Plavix) in a loading dose of 600 mg can be used as a substitute for aspirin in the setting of unstable angina or AMI. The other options are incorrect. "A" is incorrect because dipyridamole (in combination with aspirin) is indicated only for stroke prevention. Dipyridamole itself is a relatively weak platelet inhibitor. "C" is incorrect because ibuprofen and naproxen are reversible platelet inhibitors that do not give adequate platelet inhibition and have NOT been shown to be of benefit in angina/AMI. In addition, both ibuprofen and naproxen can block the effect of aspirin by making its binding sites on platelets unavailable. In fact, stopping NSAIDs in any patient being admitted for possible CAD is considered good practice since they are known to increase the risk of a cardiac event. "D" and "E" are both incorrect because celecoxib and salsalate have not been shown to inhibit platelets to a significant degree and thus would be of no use in this situation.

Question 1 of 7 A 24-year-old male presents to your clinic with a 50-hour history of an irregular heart rate. He is generally well but has a history of hypertension (too many super-jumbo burgers ... with bacon ... he's been "supersized"), which he has been trying to control with exercise and diet (he switched to tofu burgers yesterday). There is no prior history of cardiac disease or palpitations. He did "have a bit to drink" celebrating ... well, whatever, just celebrating ... who needs a reason! He was embarrassed about his drinking and thus waited 2 days to seek care. There is no family history of heart disease and the patient does not smoke. Vital signs reveal an irregular pulse of 130 bpm and a blood pressure of 160/100 mm Hg. The patient is afebrile and has normal respirations. He has no heart murmur. The ECG is shown below (Fig. 2-4).

The correct answer is "C," atrial fibrillation. This is characterized by the lack of P waves and an irregularly irregular rhythm. "A" and "B" are incorrect. While both MAT and a wandering atrial pacemaker are irregularly irregular, both have P waves. "D" is incorrect. Ventricular tachycardia is a wide complex tachycardia and is regular. "E" is incorrect. While there are no P waves, an accelerated junctional rhythm should be a regular, organized rhythm.

Question 1 of 4 Your "congestive heart failure couple," as they now call themselves, are doing so well that the wife refers her cousin to you (... and we still aren't tired of writing heart failure questions). Her cousin, a 65-year-old male, arrives at your office and you immediately notice the smell of tobacco leaching from his clothing. The small burns in his sleeves confirm to you that he smokes, and he informs you that he has smoked three packs per day "since birth." He recently has noticed some swelling in his feet and increased shortness of breath. He denies a history of cardiac disease. An ECG performed in the office shows right-axis deviation and a right bundle branch block (RBBB). An echocardiogram shows that he has normal left ventricular function, but a hypertrophied right heart with paradoxical bulging of the ventricular septum into the left ventricle was noted. This clinical picture is most consistent with which of the following? A Constrictive pericarditis B Chronic mitral valve prolapse C Cor pulmonale D Old right ventricular infarction with subsequent dysfunction E Chiari network

The correct answer is "C." A typical picture of cor pulmonale is right ventricular hypertrophy (RVH) with paradoxical bulging of the septum into the left ventricle, right-axis deviation on ECG, and partial or complete RBBB. "A" is incorrect. Constrictive pericarditis is associated with pericardial thickening, dilated inferior vena cava or hepatic veins, and abnormal mitral and tricuspid flow. "B" is incorrect because mitral valve prolapse in the absence of severe mitral regurgitation is not likely to be hemodynamically significant. "D" is incorrect because with a right ventricular infarct, you would expect to see a poorly functioning right ventricle. "E" is incorrect because a Chiari network is normal vestigial variant in the right atrium and would not cause RVH.

Question 8 of 14 The echocardiogram is normal. You have decided to start this patient on treatment for his hypertension. Based on outcome data, which of the following is the LEAST effective drug to start on this patient? A An Angiotensin Converting Enzyme inhibitor (ACEI), such as lisinopril B An Angiotensin Receptor Blocker (ARB), such as losartan C An alpha-blocker, such as doxazosin D A thiazide diuretic, such as chlorthalidone E A Calcium Channel Blocker (CCB), such as amlodipine

The correct answer is "C." Alpha-blockers have worse outcomes in hypertension when compared to other antihypertensives. The JNC 8 recommendations suggest that the first-line agent, in the general non-Black population including those with diabetes, could appropriately be a thiazide-type diuretic, CCB, ACEI, or ARB. Notice that beta-blockers do not make the list of first-line antihypertensives. For the Black population (in general), including those with diabetes, the initial antihypertensive treatment should include a thiazide-type diuretic or a CCB.

Question 8 of 12 You start this patient on furosemide for diuresis and lisinopril for HFrEF. You also decide to initiate metoprolol succinate for its survival benefits. However, the patient's symptoms worsen. Which of these is true about the use of metoprolol succinate in HFrEF? A Metoprolol succinate is the only beta-blocker indicated for use in HFrEF B Metoprolol succinate is best used in those patients who are still symptomatic since it will help to control symptoms C Metoprolol succinate should only be initiated in patients with well-controlled HFrEF who are not currently having significant symptoms D Metoprolol succinate can lead to significant hypokalemia when combined with diuretics, so potassium levels should be monitored closely E Metoprolol succinate is contraindicated in patients who have both COPD and HFrEF

The correct answer is "C." Beta-blockers should not be initiated in patients who are significantly symptomatic or decompensated. While beta-blockers do reduce mortality, they can increase symptoms and further exacerbate heart failure. Therefore, they are best initiated in the stable patient (as an outpatient or 24 to 48 hours prior to hospital discharge and on a stable drug regimen). Even then some patients cannot tolerate the introduction of beta-blockers without worsening of symptoms, which may require additional diuresis, discontinuation of the beta-blocker, a reduction in dose, or other measures. "A" is incorrect. Long-acting metoprolol succinate, bisoprolol, and carvedilol all have a benefit in HFrEF. Specifically avoid atenolol which does not seem to improve outcomes. "B" is incorrect because beta-blockers may actually worsen heart failure symptoms. "D" is incorrect since beta-blockers do not cause hypokalemia. "E" is incorrect. Beta-blockers can be used in patients with COPD with the same caveats that apply to any other patient: if the patient is becoming more symptomatic on the beta-blocker, reduce the dose, or discontinue the drug. In fact, beta-blockers may improve survival in COPD.

Question 1 of 12 A 74-year-old male presents to your office with a chief complaint of a "long cold" with an intermittent cough for 5 months. He has also noticed that he gets up to urinate twice a night although he has no trouble with his urine stream, starting urination, or dribbling afterward. He has been a bit more tired lately and notices that his exercise tolerance has decreased to several blocks, limited mainly by shortness of breath. He has not had any chest pain. He has no history of asthma or COPD and has not had any exposures to drugs or chemicals. He has a history of hypertension and noncompliance with medical recommendations. In fact, he is taking no medications except for an aspirin a day. His pulse is 100 bpm with a blood pressure of 160/95 mm Hg. He looks comfortable. On examination, you find only trace pitting edema of the lower extremities. Which of the following is NOT a possible cause of cough in this patient? A Heart failure B Asthma C Deconditioning D COPD E GERD

The correct answer is "C." Deconditioning may cause dyspnea on exertion but should not cause a cough. The purpose of this question is to point out the fact that a "chronic cold" or "chronic cough" in an elderly person can be due to a myriad of causes, including "occult" heart failure (systolic dysfunction (HFrEF) or diastolic dysfunction (HFpEF)). Do not make the assumption that the patient's diagnosis (e.g., a "chronic cold") is necessarily the correct diagnosis.

Question 8 of 14 Since a reversible defect was not found on the stress test, you conclude that there is no myocardium currently at risk. However, the patient continues to have chest pain and now at an increasing frequency with less exertion. He is asymptomatic when he presents to your office. He was noted at the last visit to have an elevated glucose at 350 mg/dL. What is the next step in the evaluation or treatment of this patient? A Stress echocardiogram to document what segments are involved B Start the patient on insulin to control his blood sugars C Proceed directly to cardiac catheterization D Since there were no reversible deficits on stress testing, schedule the patient to see a gastroenterologist E Give a trial of NSAIDs to help differentiate chest wall pain from other causes

The correct answer is "C." Given that this high-risk patient has worsening angina and now is even at higher risk since he probably has diabetes, he should have the definitive test done. "A" is incorrect since we already have done a noninvasive test. We already know what segment was previously infarcted, as noted on the MPI. "B" is incorrect for two reasons. First, addressing his diabetes will not address the immediate problem of what you must presume is unstable angina. Second, insulin is not necessarily the first drug to use in this patient who presumably has type 2 diabetes. Certainly, the blood glucose needs to be addressed but so does the chest pain. Which is going to kill him first? "D" is incorrect. The sensitivity of MPI is in the 88% range (see Table 2-5), so it will miss 12% of disease. Thus, we still have not proven in this high-risk patient that he does not have treatable cardiac disease causing his chest pain. "E" is incorrect for the same reason.

Question 4 of 4 The patient misunderstands your instructions and takes an extra dose of warfarin that evening and for the next 2 days. He returns to your clinic and his INR is now 13. What is the best option for therapy at this point? A Vitamin K 5 mg IV × 1 B Fresh frozen plasma C Vitamin K 5 mg PO × 1 D Vitamin K 10 mg IV × 1

The correct answer is "C." Giving this patient 5 mg of PO vitamin K is the best solution. This has been found to reduce the INR while still allowing the patient to be anticoagulated relatively easily after treatment. "B" is incorrect because there is no call for FFP in this asymptomatic patient. The other answers are incorrect because there is no advantage to higher doses or IV doses of vitamin K in this patient, and the higher doses will make continued anticoagulation more difficult.

Question 7 of 16 The patient's pain recurs in the ED. You suspect that she is having a myocardial infarction, but do not yet have unequivocal proof, such as ECG changes or elevated cardiac enzymes. The patient becomes markedly hypotensive in response to another dose of sublingual nitroglycerin. Which of the following is TRUE? A Intravenous nitroglycerin is contraindicated in this patient B Hypotension caused by nitroglycerin is usually unresponsive to IV saline C Hypotension caused by nitroglycerin may be indicative of a right ventricular infarction, which is most commonly associated with an inferior wall myocardial infarction (IAMI) D Hypotension caused by nitroglycerin is diagnostic of cardiogenic shock, suggesting that this patient will have a poor outcome

The correct answer is "C." Hypotension in response to nitroglycerin may be indicative of a right ventricular infarct, which is most commonly associated with an inferior wall acute MI (IAMI). Since the right ventricle is dependent on filling pressure (preload), nitroglycerin, which drops the preload, will frequently result in hypotension in those with a right ventricular infarct. "A" is incorrect because hypotension from sublingual nitroglycerin is not a contraindication to additional nitrates once the patient's blood pressure is stable. A typical sublingual dose is 400 μg (0.4 mg). A typical IV dose starts at 20 μg/min. Thus, the sublingual dose is quite a bit larger than the IV dose. In such a situation, you could consider starting IV nitroglycerin at 10 to 20 μg/min and titrating up as the blood pressure allows. "B" is incorrect because hypotension from nitroglycerin will generally respond to a saline bolus. "D" is incorrect. Certainly, patients with cardiogenic shock will be hypotensive, but hypotension with nitroglycerin is a common result of the drug itself and does not define cardiogenic shock.

Question 8 of 16 Which of the following is TRUE of patients with an IAMI? A They will likely continue to have problems with right ventricular functioning in the future B They will need to increase their salt intake in order to increase preload and right ventricular filling pressure C Their right ventricular function should return to normal or close to normal following their infarction D A and B

The correct answer is "C." Most patients will have return of right ventricular functioning following a myocardial infarction. "B" is incorrect because there will be no need to increase right ventricular filling pressure (which is what IV saline does acutely) once right ventricular function returns to normal.

Question 3 of 4 The patient goes to Texas (or Arizona or Florida—somewhere warmer than Iowa) for the winter as part of the re-establishment of human annual migration. When he returns, he calls you complaining of back pain that is somewhat sharp and radiating into his legs. You meet him in the ED and suspect that he is having a dissection of his aneurysm. All of the following are true regarding aortic dissection EXCEPT: A A substantial number of patients will have palpable pulses below the level of the dissection B Patients may have an elevated LDH and microangiopathic findings on RBC examination C Blood pressure should be kept on the high side to ensure perfusion below the area of the aneurysm D The pain may migrate down from the chest to the lower abdominal area over time E The pain may be episodic

The correct answer is "C." One does not want to keep the blood pressure on the high side. In fact, reducing the blood pressure is the initial treatment of choice for a dissecting aneurysm. "A," "B," "D," and "E" are all correct statements. Patients may have an elevated LDH and microangiopathic findings on RBC smear as a result of trauma and cell lysis. "D" is a correct statement, but patients often do not have this "classic" migrating pattern of pain. "E" is often true of pain in aortic dissection—it may be episodic.

Question 4 of 7 The patient confides that he was indeed at a bachelor party several days ago (so that was what he was celebrating) and had a bit too much to drink. This is quite unusual for the patient. He generally drinks 2 to 3 beers per week, but on this particular night had 12 or more (hmm ... now we're wondering). The patient's pulse increases to 160 bpm, but he remains asymptomatic. The INITIAL goal for this patient, suspected of having 50 hours of atrial fibrillation, is: A Anticoagulation B Immediate cardioversion (DCCV) C Rate control D Blood pressure lowering E Treatment of alcohol withdrawal

The correct answer is "C." Since this patient has had > 48 hours of atrial fibrillation, rate control is the goal. One should consider anticoagulation ("A"), but rate control is the most immediate concern. In real life, one would simultaneously address the patient's rate and anticoagulation needs, but—hey—a test isn't real life! If the onset of atrial fibrillation is indeterminate or >48 hours, one should withhold cardioversion due to the risk of thrombus formation in the atria and subsequent embolization; therefore, "B" is incorrect. "D" is incorrect because control of blood pressure is a secondary goal in this situation, and "E" is incorrect as this patient's tachycardia is not due to alcohol withdrawal.

Question 3 of 7 Other states that can cause atrial fibrillation include all of the following EXCEPT: A Valvular disease, especially mitral disease B Hyperthyroidism C Stroke D Heart failure E Pulmonary embolism (PE)

The correct answer is "C." Stroke does not generally cause atrial fibrillation but can be a result of atrial fibrillation. Certainly, stroke and other intracranial injuries can be associated with arrhythmias. However, these are generally isolated PVCs. Stroke may also be associated with heart failure and ischemic changes on the ECG (the etiology is unknown...call it "neurohumeral" and you will sound smart), but it is rarely an isolated cause of atrial fibrillation. Valvular heart disease, hyperthyroidism, heart failure, and PE have all been demonstrated to be causes of atrial fibrillation. Valvular heart disease, heart failure, and PE have a similar mechanism: stretching of the atrium leading to atrial irritability. Atrial fibrillation is found in 10% to 20% of those with hyperthyroidism, especially in the elderly.

Question 1 of 14 A 35-year-old male presents to the office with upper respiratory symptoms. He is taking no medications except for a bit of pseudoephedrine for his cold. You notice when looking at his vital signs that his blood pressure is 180/106 mm Hg. Repeat measurement confirms that the blood pressure is elevated at 175/105 mm Hg. What is your initial approach to this patient? A Start a chronic antihypertensive since he is at risk for a stroke within the next couple of days with a blood pressure at this level B Administer clonidine in the office to reduce the blood pressure to a safe level of about 150/100 mm Hg C Watch the patient over the next 2 weeks and get additional blood pressure readings before deciding what to do and instruct him to discontinue pseudoephedrine D Schedule the patient for outpatient labs and electro-cardiogram E Fire the patient from your practice. He's messing up your quality measures

The correct answer is "C." The diagnosis of hypertension requires two elevated blood pressures on two different occasions. This patient's elevated blood pressure could be situational, related to decongestants and current illness (though decongestants only increase systolic blood pressure by 2-3 mm Hg if at all). Neither "A" nor "B" is correct because a blood pressure of 175/105 mm Hg does not pose a risk of acute stroke, and the pressure need not be lowered acutely unless there is evidence of end-organ injury (e.g., angina, heart failure, hypertensive encephalopathy). "D" is incorrect because you cannot definitively establish that this patient has hypertension based on only one in office blood pressure measurement. As for "E"...really? Is this why we went into medicine?

Question 2 of 7 What is the most likely cause of this patient's dysrhythmia? A Congenital prolonged QT syndrome B Hypertrophic cardiomyopathy C Alcohol use D Marijuana use E Ischemic cardiac disease

The correct answer is "C." The most likely cause of atrial fibrillation in this 24-year-old is alcohol. This is also known by the moniker "holiday heart." It occurs after episodes of significant alcohol intake. The underlying mechanism is not known, but alcohol is known to be cardiotoxic at higher doses which varies by individual. "A" is incorrect because prolonged QT typically causes polymorphic ventricular tachycardia (torsades de pointes). "B," hypertrophic cardiomyopathy, is unlikely since the patient has never had a murmur, and hypertrophic cardiomyopathy generally presents with signs of aortic outlet obstruction (syncope or angina with exercise) although a subset of patients do not have obstructive physiology. "D" is incorrect because marijuana is not implicated in causing atrial fibrillation, and "E" is incorrect because a patient who is 24 years old is unlikely to have ischemic cardiac disease.

Question 7 of 14 The patient's ECG comes back showing evidence of LVH. This finding suggests that: A You should initiate this patient's therapy with an ACE inhibitor since ACE inhibitors prevent disadvantageous cardiac remodeling B The patient has heart failure C You should recommend an echocardiogram for this patient D You should order a BNP level to screen for LVH and early heart failure

The correct answer is "C." The sensitivity of ECG for LVH is only in the 30% to 60% range with a specificity of 80%. Thus, a "positive" ECG is not a strong enough indication to initiate therapy for LVH. For this reason, an echocardiogram should be done to confirm the diagnosis of LVH. "A" is incorrect since an ACE inhibitor is not necessarily the first drug one would start. In addition, we really don't know if this patient has LVH yet, though ACE inhibitors do prevent harmful cardiac remodeling. "B" is incorrect. Certainly, long-standing hypertension and significant LVH can cause heart failure. However, we cannot conclude that this patient has heart failure on the basis of an ECG, especially in the absence of symptoms. "D" is incorrect since the sensitivity of the BNP as a screening tool in an asymptomatic population is poor.

Question 15 of 16 The patient passes her stress test with flying colors (and you pass your Board Examination). Patients after a myocardial infarction should be routinely discharged on all of the following medications EXCEPT: A Aspirin B Beta-blocker C Continuous nitroglycerin (e.g., patch or isosorbide) D HMG-CoA reductase inhibitor ("statin") E Sublingual nitroglycerin for PRN use

The correct answer is "C." There is no benefit to scheduled nitrates unless needed for a specific indication (e.g., recurrent angina). All post-myocardial infarction patients should be discharged on aspirin, a beta-blocker, a statin, nitroglycerin PRN, and an angiotensin-converting enzyme (ACE) inhibitor—if they are tolerated, of course. A P2Y12 inhibitor should be continued for up to 12 months in those with no stent (options include clopidogrel 75 mg daily, ticagrelor 90 mg BID). See "helpful tip" for treatment of those with a stent (after question 2.2.9).

Question 13 of 14 The patient returns the next day and is now feeling short of breath. On examination, you notice JVD and peripheral edema. His blood pressure is 90/50 mm Hg with a pulse of 130 bpm. You rightly call an ambulance. The best initial treatment of this patient is: A Furosemide B Nitroglycerin C IV saline D Morphine

The correct answer is "C." This patient is in "pure" right heart failure secondary to possible cardiac tamponade. He is preload dependent. The treatment is to increase his preload by using IV saline. All the other options reduce the preload and will worsen this patient's symptoms.

Question 12 of 12 You treat the patient with nitroglycerin, he improves, and you admit him to the floor. While in the hospital, the patient develops some additional chest pain that lasts for 10 minutes and responds to additional sublingual nitroglycerin. His BNP is noted to be elevated. His hemoglobin (Hb) is 7.2 g/dL and hematocrit (HCT) is 22%. He is still in congestive failure. The pathologist tells you that there is blood available in the blood bank to transfuse this gentleman if you so choose. There is a problem, of course: he is in heart failure, appearing fluid-overloaded, and now is somewhat tachycardic at 110 bpm. You tell the pathologist that: A Hb of 7.2 g/dL is not an indication for transfusion B Transfusing this gentleman is inappropriate since he is already in heart failure and may become more fluid-overloaded with a blood transfusion C You would like to go ahead with transfusing this patient D Making this patient's blood more viscous with a transfusion will increase the stress on his heart E Erythropoiesis-stimulating agents (ESAs), such as darbepoetin (Aranesp®) and erythropoietin, are safer and more effective than blood transfusions for patients with HF

The correct answer is "C." This patient should be transfused. Guidelines suggest triggering transfusion in heart disease when the Hb is <8 to 10g/dL and if the patient is symptomatic (i.e., tachycardic, chest pain). There is no benefit to transfusing patient with a higher Hb (Ann Intern Med. 2013;159:770). Use clinical judgment, of course, as there are no guidelines for transfusion in an individual with ACS. ESAs ("E") seems to increase thromboembolic events without providing any benefit in those with stable HF and mild-to-moderate anemia. They should generally be avoided in this population. Regarding non-STEMI, there are no official ACC/AHA recommendations regarding transfusion. However, the mortality at 30 days is increased if the Hb is <11 mg/dL in a patient with a non-STEMI. Whether or not transfusion will help this is not known: it may just be that patients with anemia are sicker at baseline. Patients with an HCT of <20% to 24% likely benefit from a transfusion while those with an HCT >27% to 30% do not. For 25% to 26% use your judgment. HF is different. Blood transfusion should be reserved for patients with heart failure that are severely anemic and the transfusion be undertaken slowly and with the concurrent use of diuretics to avoid volume overload (Am Heart J. 2009;158:653-658). "A" and "B" are incorrect because this patient should be transfused carefully as noted above. "D" is incorrect since transfusing this patient to a normal Hb and HCT will not cause excess blood viscosity.

Question 4 of 14 You decide to do an exercise stress test on this patient. It turns out to be negative. Your next step is to: A Reassure the patient that he does not have cardiac disease B Suggest a chest CT scan to rule out possible aortic aneurysm C Schedule the patient for another cardiac test such as stress echocardiogram, exercise myocardial perfusion test, or angiography D Schedule the patient for endoscopy to rule out gastroesophageal disease as a cause of these symptoms E Start an anxiolytic to treat the panic disorder, which is the underlying cause of his chest pain

The correct answer is "C." This patient who is in his 50s and who has a "classic" history for angina has greater than a 90% pretest probability of cardiac disease. Thus, it is likely that the negative stress test is a false negative. What was the point of that stress test anyway? It probably should not have been done in this patient since a negative test just leads to further testing (as would have a positive test, probably resulting in angiography). For this reason, "A" is incorrect. "B," "D," and "E" are also incorrect because you have not yet eliminated a cardiac cause.

Question 10 of 16 You now have all the evidence that you need to show that this patient is indeed having an ongoing myocardial infarction. Since your rural hospital is "just around the corner from nowhere," stenting is not going to happen within 90 minutes. You decide to initiate thrombolytic therapy. All of the following are true statements EXCEPT: A Patients who are candidates for thrombolytics must have at least 1 mm of ST-segment elevation in at least 2 contiguous limb leads or at least 1 to 2 mm of ST-segment elevation in at least 2 contiguous precordial leads B Patients who are candidates for thrombolytics must have an absence of prior history of hemorrhagic stroke C Patients who are candidates for thrombolytics should have no active bleeding, including menstrual bleeding D Patients who are candidates for thrombolytics should have no history of recent head trauma E Patients who are candidates for thrombolytics should not be pregnant

The correct answer is "C." While active internal bleeding is a contraindication to the use of thrombolytics (or fibrinolytics, as these terms are used interchangeably), menstrual bleeding is not. While there are no controlled trials, anecdotal evidence suggests that thrombolytics are safe with menstrual bleeding. "A" is true. See Table 2-1A for more clarity on the definition of STEMI as the ST-segment definition depends on the sex of the patient, to some degree. For thrombolytics, patients with only ST-segment depression or a normal ECG, even with symptoms, do not benefit. "B," "D," and "E" are all true statements. Patients are not candidates for thrombolytics if they have recent head trauma, are pregnant, or have had a hemorrhagic stroke ever. See Table 2-1B for a more comprehensive list of contraindications.

Question 1 of 3 A 75-year-old female presents to your office complaining of episodic palpitations with episodes of lightheadedness that are not concurrent with the palpitations. You perform an electrocardiogram in your office, and the rhythm is shown in Figure 2-7. FIGURE 2-7. ECG for patient in question 2.12.1. View Full Size|Favorite Figure |Download Slide (.ppt) What rhythm does this represent? A First-degree heart block B Second-degree heart block type I (Wenckebach) C Second-degree heart block type II D Third-degree heart block E Atrial flutter with variable block

The correct answer is "C." Your patient's ECG shows a second-degree heart block, type II (Mobitz II). This is characterized by a fixed PR interval with an intermittently nonconducting P wave and resultant dropped beats. "A" is incorrect. First-degree heart block is characterized by a prolonged PR interval without any blocked beats (meaning every QRS is preceded by a P wave conducted with a long PR interval). The upper limit of normal of the PR interval is 0.2 seconds (and we admit that this one is darn close, but Mobitz II is the issue here). A second-degree heart block, Mobitz type I (Wenckebach), is defined by a progressively prolonged PR interval ending with a non-conducted P wave and a dropped beat. A third-degree heart block is characterized by no consistent pattern between the P waves and the QRS complex. "E" is incorrect because, by definition, atrial flutter is represented by a rapid atrial rate. In this patient, the rate is slow.

Question 3 of 3 The echocardiogram and stress test are normal, and the patient does well for the next 3 months but then becomes symptomatic with prolonged episodes of ventricular tachycardia. While all of the episodes are self-limited, the patient has had two episodes of syncope. Which of the following is the best next step in treating this patient? A Sotalol B Implantable defibrillator C Amiodarone D Electrophysiologic study E Tocainide (an oral lidocaine equivalent)

The correct answer is "D." An electrophysiologic study is indicated to induce and characterize the ventricular tachycardia. Certain types of ventricular tachycardia respond very well to radiofrequency ablation so this should be the next step. Some of you may have answered "B." This is true in patients with ischemic heart disease, left ventricular dysfunction, and symptomatic ventricular tachycardia. These patients should get an implantable defibrillator as should "all" heart failure patients with an ejection fraction of <30% to 35% (there are literally over 200 variations of this recommendation based on heart failure class, QRS duration, etc., but this is the basic idea). Our patient may yet get an implantable defibrillator since she is now symptomatic (syncope), but do the EP study first.

Question 1 of 4 A 75-year-old male presents to your office for a complete physical examination before prostate surgery. On examination, you notice a 3/6 harsh, mid-systolic ejection murmur heard best at the upper right sternal border and radiating to the neck. S1 and S2 are normal. An echocardiogram demonstrates mild aortic stenosis. Currently he is asymptomatic. The indications for valve replacement surgery include: A Grade 4/6 murmur B Requirement for major, semi-elective surgery such as prostatectomy C Severe aortic stenosis without symptoms and normal LV function D Severe aortic stenosis in a patient undergoing coronary bypass grafting E All of the above

The correct answer is "D." As a general rule, aortic stenosis is repaired when it becomes symptomatic. Repair of asymptomatic, severe aortic stenosis is indicated in the following scenarios: undergoing CABG or other valve or aorta surgery, LVEF < 50%, hypotension in response to exercise, or high likelihood of rapid progression. "A" is incorrect because the loudness of the murmur does not always correlate with its functional significance. "B" is incorrect as well. As long as the lesion is not hemodynamically significant, the patient should tolerate prostate surgery. "C" is incorrect because surgery is not usually necessary even in severe valvular disease without symptoms as long as the left ventricular function is normal. Note that it is not uncommon that patients with severe aortic stenosis report that they are asymptomatic, but they have modified their activity to avoid symptoms which may have occurred gradually so that they don't recognize the decline.

Question 6 of 6 In and of themselves, indications for further intervention for peripheral artery disease (e.g., bypass, stenting) include all of the following EXCEPT: A Rest pain B Persistent pain that interferes with day-to-day functioning C Tissue loss D 80% occlusion of the femoral artery

The correct answer is "D." Classic indications for invasive treatment of lower extremity PAD are (1) salvage of a threatened limb (rest pain, nonhealing ulceration, or gangrene) and (2) improvement in functional capacity. An 80% occlusion of the femoral artery, in and of itself, is not an indication for percutaneous or surgical revascularization in a patient who is asymptomatic. Endovascular therapy is generally preferred. Note that claudication is a marker for a high risk of mortality (up to 31% over 10 years). There is also an increased risk of limb loss.

Question 12 of 14 After a complete history, physical examination, ECG, and echocardiogram, you determine that he has pericarditis. Which of the following drugs might be helpful in this patient? A Heparin B Warfarin C Furosemide D Colchicine

The correct answer is "D." Colchicine is the only drug in the list that is a treatment for pericarditis. It can be used first line with an NSAID such as aspirin, indomethacin, or naproxen (Lancet 2014;383(9936):2232-2237). Steroids are reserved for those who fail NSAIDs and colchicine. Do not use anticoagulation, either heparin or warfarin, in patients with pericarditis. This can cause bleeding into the pericardial space and tamponade. Thus, "A" and "B" are incorrect. "C" is incorrect because furosemide will likely make this patient worse. Patients with increased pericardial pressures are dependent on circulating preload volume in order to fill the right heart. Decreasing the preload may cause dyspnea in this patient.

Question 7 of 7 All of the following can be used to cardiovert atrial fibrillation EXCEPT: A Ibutilide B Electrical cardioversion C Quinidine D Digoxin E Procainamide

The correct answer is "D." Digoxin does not work to cardiovert atrial fibrillation. Digoxin may facilitate cardioversion in patients with heart failure by reducing atrial stretching. However, it does not convert atrial fibrillation. All of the other answers are correct. Because of potential induction of arrhythmias with the other agents, electrical cardioversion is becoming the preferred method of restoring normal sinus rhythm.

Question 2 of 5 HFpEF is associated with which of the following? A A prolonged history of untreated hypertension B Poor relaxation of the ventricular wall C Thyroid disease D A and B E B and C

The correct answer is "D." HFpEF is often associated with long-standing hypertension as well as a stiff ventricular wall that does not relax to allow good filling during diastole (therefore "diastolic dysfunction"). For these reasons (and others), HFpEF is more common in the elderly. "C" is not correct because hyper- and hypothyroidism are usually associated with a dilated cardiomyopathy.

Question 3 of 5 HFpEF represents approximately what percentage of HF? A <5% B Approximately 10% C Approximately 25% D Approximately 50% E >75%

The correct answer is "D." HFpEF represents between 40% and 60% of cases of HF when looking at the population as a whole. The other answers are incorrect. The point here is that, as discussed earlier, patients with HF need an echocardiogram to determine what type of heart failure they have.

Question 3 of 3 Which of the following is the definitive treatment of sick sinus syndrome? A Mexiletine B Hydralazine C Quinidine D Pacemaker E Implantable defibrillator

The correct answer is "D." In general, patients with sick sinus syndrome become symptomatic because of the bradycardia episodes. Thus, pacing is necessary. Note: A pacemaker would also be indicated in patients with Mobitz type II second-degree heart block without tachy-brady syndrome. "A" and "C" are incorrect because these two drugs are aimed primarily at ventricular arrhythmias; sick sinus syndrome is a problem with the SA node. "B" is incorrect because hydralazine is an afterload reducer with no direct effect on cardiac rhythm. "E" is incorrect because patients with sick sinus syndrome do not have ventricular fibrillation or ventricular tachycardia, and thus there is no need for a defibrillator.

Question 1 of 6 A 58-year-old male smoker with a history of type 2 diabetes mellitus presents with complaints of easy fatigability and pain in his thighs when exerting himself. The left leg is worse than the right. The pain resolves after resting and is no worse going downhill than uphill. He works as a carpenter, and the leg pain is now limiting his ability to work. He will not quit smoking ("It's the only thing I truly love, Doc"). The patient states that his symptoms are better when he hangs his leg over the side of the bed at night. The etiology of this patient's leg pain is most likely: A Peripheral venous disease (e.g., venous insufficiency, varicose veins) B Spinal stenosis C Diabetic neuropathy D Peripheral arterial disease (e.g., arterial stenosis) E None of the above

The correct answer is "D." Intermittent claudication is the classic presenting symptom of peripheral arterial disease. When rest pain is present, relief of symptoms occurs by making the affected area dependent (e.g., hanging the legs over the side of the bed), letting gravity help increase blood flow. The pain associated with diabetic neuropathy begins distally, has a burning quality, and is not typically relieved with rest. In fact, patients often notice it more at rest (e.g., during the night). Patients with peripheral venous disease will often have worsening of their symptoms when their legs are in a dependent position. Spinal stenosis is often made worse by walking downhill and better when walking uphill or leaning forward (a kyphotic/forward flexed position opens up the foramen, thereby decreasing nerve root compression).

Question 3 of 14 The following are all well-accepted indications for 24-hour ambulatory blood pressure monitoring EXCEPT: A Suspected white coat hypertension B Patients with difficult-to-control hypertension C Patients having hypotensive symptoms on their antihypertensive treatment D Follow-up after initiating antihypertensive treatment E Evaluation of patient for autonomic dysfunction

The correct answer is "D." One need not do 24-hour ambulatory blood pressure monitoring to document response to antihypertensive therapy in patients in whom most or all measurements post-treatment are normal. All of the other answer choices are considered reasonable indications for 24-hour ambulatory blood pressure monitoring.

Question 4 of 5 Which of the following drugs is the LEAST desirable in patients with HFpEF? A Diuretics B ACE inhibitors C Nitrates D Digoxin E Negative inotropes such as beta-blockers and CCBs

The correct answer is "D." Poor digoxin. It is not good for almost anything. Nesiritide, digoxin, and other positive inotropes (e.g., milrinone) are not very useful in HFpEF. This makes sense. The problem here is not a lack of contractility but alternatively a lack of muscle relaxation. While there has not been a superior therapeutic regimen identified by randomized control trials, the goals of therapy are blood pressure control, the use of diuretics to relieve congestion and edema, treatment of ischemia if present, and control of the heart rate to avoid tachycardia.

Question 4 of 4 The patient has a blood pressure of 160/105 mm Hg and a pulse of 115 bpm. Clearly, this is too high in a patient who has an ongoing dissection. You decide to treat this patient before transferring him to a tertiary care center where he can be surgically managed. The best medication(s) to use in this patient to control his blood pressure is/are: A Sublingual nifedipine plus metoprolol B Amlodipine C Intravenous hydralazine D Intravenous esmolol plus nitroprusside E Intravenous nitroglycerin

The correct answer is "D." The goal of therapy here is not only blood pressure reduction but also control of shear forces on the aorta, which requires the prevention of tachycardia. Intravenous beta-blockers such as labetalol, propranolol, metoprolol, or esmolol are the first-line agents. Esmolol is preferred because of the short half-life; you easily can turn it off if there is hypotension. Shoot for a pulse of 60 bpm. Nitroprusside (or our favorite, IV nitroglycerin) can be added if the blood pressure control remains suboptimal even after beta-blockade. In this scenario, nitroprusside should never be given without beta-blockade, as it may cause reflex tachycardia induced by vasodilation and thus further aortic shear stress. The same rationale is true for not using intravenous hydralazine without beta-blockers in this scenario. "A" is incorrect for two very good reasons. First, nifedipine should never be used sublingually. Syncope, heart block, MI, stroke, and other serious adverse consequences have been reported. Second, nifedipine increases heart rate causing an increase in shear forces on the aorta. "B" is incorrect since amlodipine does nothing to reduce heart rate, is not titratable to any useful degree, and the onset of action is too slow to be used when prompt blood pressure lowering is desired. "E" is incorrect because nitroglycerin alone causes reflex tachycardia.

The 75-year-old patient has his surgery and returns to your clinic for a postoperative check-up 1 month after his surgery. You check his INR and it is noted to be 5.2. There is no active bleeding. The most appropriate action at this point is to: A Hospitalize the patient for observation since he is at a high risk of bleeding B Give the patient 5 mg of vitamin K orally C Give the patient 2 units of fresh frozen plasma to reverse his anticoagulation D Hold the next warfarin dose and reduce the maintenance dose E A, B, and C

The correct answer is "D." The risk of bleeding in a relatively healthy patient with an INR of 5.2 is very low. Thus, simply holding the next one to two doses of warfarin and reducing the maintenance dose of warfarin is appropriate. "A" is incorrect because the patient does not need hospitalization. "B" is incorrect because it will be difficult to anticoagulate the patient after vitamin K is administered. "C" is incorrect because there is no active bleeding.

Question 9 of 14 The patient has a catheterization done that shows three-vessel disease including left main CAD. The cardiologist calls you with the report the next day and suggests PTCA with stenting, since, in his opinion, "This is the best modality for diabetics and diabetics are high-risk candidates when it comes to surgery." Your opinion is that: A Patients with stents generally have better outcomes in terms of control of angina with stenting when compared with coronary artery bypass grafting (CABG) B Diabetic patients do particularly well with stenting when compared with CABG C Medical control of symptoms is indicated as the best management in this diabetic patient with three-vessel disease D Diabetic patients do better with CABG when compared with stenting E You don't have an opinion. You just do what the nice cardiologist says

The correct answer is "D." This patient should probably have surgery for his three-vessel disease because diabetic patients generally have worse outcomes with stenting than do nondiabetic patients in terms of angina relief and need for repeat revascularization. "A" is incorrect because a proportion of patients with stents have to go on to have an open CABG due to in-stent restenosis or incomplete revascularization with percutaneous revascularization. "B" is incorrect. Diabetic patients have a much higher rate of in-stent restenosis or secondary occlusion (meaning a narrowing/stenosis somewhere else in the diseased vessel). "C" is incorrect. The indications for CABG are significant left main CAD (>50%), three-vessel disease with evidence of LV dysfunction (ejection fraction <50%), or origin/proximal LAD/LCX disease (left main equivalent). This patient has left main vessel disease and thus medical control is NOT the best option for this patient. He is also young and, from the available data, appears to be a good surgical candidate. Therefore, CABG is the guideline-recommended option for this patient. "E" is incorrect because you went to medical school and have a brain.

Question 11 of 12 The patient notes that he did have some chest pain earlier in the day. You want to initiate therapy. You take his vitals, and his pulse is 100 bpm, blood pressure 140/95 mm Hg, oxygen saturation 89% on room air, and respiratory rate 32. Besides oxygen, the one best drug to initiate first in the ED to treat this patient with an acute exacerbation of his chronic HFrEF is: A Furosemide B Digoxin C A positive inotrope, such as dobutamine D Nitroglycerin E An ACE inhibitor

The correct answer is "D." This patient will benefit from nitroglycerin for several reasons. First, the patient has told you that he had chest pain earlier today. Thus, it is possible that this patient's heart failure exacerbation is due to ischemic disease. Nitroglycerin will help this via vasodilation. The second reason is that the goal here is to restore normal cardiac function by causing vasodilation and decreasing preload and afterload. Nitroglycerin will do both of these. "A," furosemide, is also a good choice but not the one best choice. By inducing diuresis, furosemide will also significantly decrease preload and provide symptomatic relief. But remember not all heart failure patients are fluid-overloaded (such as with flash edema from ischemia). "B" is incorrect because it will take some time for digoxin to have a significant impact on this patient's symptoms. "C" is incorrect because dobutamine is a second-line drug reserved for those not responding to more conservative therapy for "cardiogenic shock," and it would not be indicated in active ischemia due to increasing myocardial oxygen demand. Norepinephrine would generally be the preferred alternative if a positive inotrope is needed in cardiogenic shock. "E" is technically not incorrect, but it is not the best answer. There is ample evidence that ACE inhibitors, which work as afterload reducers, can be used in acute HF exacerbations either IV (e.g., enalapril) or sublingual (e.g., captopril). However, these drugs should be reserved as second-line therapy for patients who do not respond to more appropriate initial measures, and they would not be the first-line to address ischemia among choices listed.

Question 2 of 12 You decide that this patient may have heart failure. An ECG shows no evidence of prior or ongoing ischemia. There are no signs of atrial enlargement or ventricular hypertrophy on the ECG. The proper conclusion from this is: A The patient does not have cardiac chamber enlargement or hypertrophy and therefore is unlikely to have heart failure B The absence of evidence for prior infarct makes heart failure unlikely C Regardless of the ECG results, clinical judgment alone is sufficient to make the diagnosis of heart failure, being correct 85% of the time D The patient's edema is likely from venous insufficiency E Despite a normal ECG, further testing is needed in this patient to evaluate for heart failure

The correct answer is "E." "A" is not correct because only 30% to 60% of moderate-to-severe left ventricular hypertrophy (LVH) is detectible on ECG. "B" is incorrect because patients with HFpEF (discussed later) may not have any evidence of prior ischemia or infarct. "C" is incorrect. The clinical diagnosis of heart failure is incorrect up to 50% of the time. For this reason, confirmation is required before embarking upon a therapeutic adventure for heart failure. "D" is unlikely, since the patient has other symptoms of heart failure (exertional dyspnea, cough, etc.) that make simple venous insufficiency unlikely. Plus, have you ever known "get further information" to be the wrong answer?

Question 2 of 16 You decide that further testing is warranted, including an ECG and cardiac enzymes. Which of the following statements is TRUE? A A normal initial ECG in the emergency department (ED) effectively rules out cardiac disease B Creatine phosphokinase MB fraction (CPK-MB) is more sensitive but less specific than troponin C Serum troponin is an unreliable marker of cardiac ischemia in patients with renal failure D The serum troponin is 100% specific for myocardial infarction E A normal high sensitivity troponin and ECG in the ED 3 hours after the pain began can be used to make decisions about who to admit

The correct answer is "E." Newer "rule out" protocols allow ED physicians to categorize chest pain patients into a low-risk pool within 3 hours after pain onset. If the patient is found to be at low risk using a validated risk assessment tool (see "HEART" calculator at: https://www.mdcalc.com/heart-score-major-cardiac-events) and has a normal ECG and has a negative high-sensitivity troponin at 3 hours after presentation, one can rule out myocardial infarction without an admission. Remember, these are low-risk patients to begin with, not the 70-year-old with a history of CAD who is puffing like chimney. Note that the HEART score incorporates the ECG and troponin. There is a 16% discordance in how physicians score the same low-risk patients vis-à-vis HEART (Acad Emerg Med. 2018 Nov 14). "A" is incorrect since 9% of patients with AMI will have a normal initial ECG in the ED. In fact, only about 50% of those with AMI have a diagnostic ECG in the ED. Even a normal ECG obtained during chest pain does not reliably rule out AMI (Acad Emerg Med. 2009;16:495). "B" is incorrect since the CPK-MB is overall less sensitive and may have a later rise than a high-sensitivity troponin. CPK-MB and myoglobin add little, if anything, to the troponin. Eighty percent of AMIs will have one positive marker within the first 3 hours of ED arrival (but 20% will not). "C" is incorrect. Patients with renal disease may have a mildly elevated troponin at baseline due to poor clearance, but troponin can still be useful in these patients if it continues to rise. It helps to know the patient's baseline troponin in renal failure, but this is NOT an indication to start drawing a baseline troponin on all of your patients with renal failure. "D" is incorrect because we now know that other processes, such as PE, can elevate the serum troponin.

Question 2 of 3 You check a panel of laboratory studies including thyroid function tests, electrolytes, magnesium, glucose, and CBC. They are all within normal limits. You suggest that the patient avoid potential triggers such as caffeine and sympathomimetics. "Darn," she sighs. "I have to quit my crystal meth?" The next step for this patient is to: A Start an antiarrhythmic such as quinidine or mexiletine to control the heart rhythm B Refer the patient to a cardiologist for an EP study to determine the best drug to control this rhythm C Implant an automatic defibrillator to prevent sudden death D Start a beta-blocker E Order transthoracic echocardiogram to rule out structural heart disease

The correct answer is "E." Nonsustained ventricular tachycardia is associated with sudden cardiac death in the presence of structural heart disease such as hypertrophic cardiomyopathy or ischemic heart disease. An echocardiogram as well as stress test will be helpful in evaluating for these underlying conditions. There is no evidence that nonsustained, asymptomatic ventricular tachycardia worsens outcomes as long as the patient has no underlying cardiac disease. In an otherwise healthy, asymptomatic patient, the risk of using antiarrhythmic drugs to suppress ventricular ectopy leads to worse outcomes than doing nothing. Quinidine, mexiletine, amiodarone, and other antiarrhythmics all have proarrhythmic effects. In general, there is more sudden death in these patients if they are treated with antiarrhythmic drugs than if they are watched. Therefore, "A" is incorrect because these drugs will actually increase mortality. "B" is incorrect since the patient has asymptomatic, self-limited episodes. The reason to do an EP study is to determine if there is an inducible arrhythmia and to determine treatment. This patient does not (yet) need treatment. "C" is incorrect because this patient has asymptomatic nonsustained ventricular tachycardia. Thus, an implantable defibrillator is not indicated. After your evaluation is complete, you may prescribe a beta-blocker ("D") for relief from palpitations. A beta-blocker (metoprolol or carvedilol) is considered the first-line drug in this type of patient. You can add diltiazem or verapamil to this should she still feel palpitations. Amiodarone would be third line should she continue to be bothered by the palpitations after trying beta-blockers and calcium channel blockers.

Question 5 of 7 The patient's heart rate remains elevated at 160 bpm with occasional forays into the 170 bpm range. Which of the following is the best drug to administer to this patient? A Digoxin B Lidocaine C Amiodarone D Adenosine E Diltiazem

The correct answer is "E." Of the options listed, diltiazem should be the first choice for rate control. "A" is incorrect. Digoxin will be of limited use since it takes at least 30 minutes to have an effect. As an aside, digoxin is associated with higher mortality rates in those with atrial fibrillation. Don't use it; we have better drugs. Digoxin can be used in those with atrial fibrillation secondary to heart failure but will still not significantly help with rate control—especially in younger patients with robust sympathetic tone. "B" is incorrect because lidocaine is indicated for a wide complex tachycardia. "C" is incorrect. Amiodarone will work as a treatment of atrial fibrillation but is a second-line drug because it can cause torsades de pointes. It can be used in patients with atrial fibrillation and congestive failure, where verapamil or diltiazem might be contraindicated. Amiodarone is considered to be advantageous in maintaining sinus rhythm, especially when given as pretreatment prior to cardioversion, but is not as efficacious in prompt heart rate control due to longer onset of action. Be aware that amiodarone can lead to "chemical cardioversion' with the attendant stroke risk. "D" is incorrect. Adenosine is ultra-short-acting, blocks the AV node, and can be used to convert a paroxysmal supraventricular tachycardia (PSVT) or slow down the rate of the arrhythmia temporarily if you are not sure what the diagnosis is (e.g., a rapid atrial flutter vs. PSVT). However, adenosine will not reduce the ventricular rate in atrial fibrillation since atrial fibrillation does not require the AV node to propagate. A beta-blocker could also be used in this situation.

Question 6 of 16 Well, not all chest pain is cardiac, and this patient may have another cause for hers. Which of the following is TRUE? A Giving a "GI cocktail" (e.g., combination of Maalox and viscous lidocaine) can reliably differentiate cardiac from esophageal/GI causes of chest pain B A normal chest radiograph and symmetrical pulses in the upper extremities reliably rules out a thoracic aortic dissection C Most patients with a spontaneous pneumothorax should be treated with a chest tube D If nitroglycerin relieves the chest pain, then the pain is certainly cardiac E Pain is a finding in only about 60% of patients with a PE

The correct answer is "E." Only a small majority (59%) of patients with pulmonary emboli have pain as a feature. "A" is incorrect because about 20% of patients with cardiac pain will have their pain relieved by a GI cocktail. Conversely, "D" is incorrect because nitroglycerin can relieve pain from esophageal spasm as it is a nonselective smooth muscle relaxer. "B" is incorrect because only 50% of patients with an aortic dissection will have unequal pulses and blood pressures, and only 75% will have an abnormal chest x-ray. The consideration of an aortic dissection mandates a chest CT scan with contrast, transesophageal echo, or angiogram. Remember that about 20% of the population will have unequal blood pressures in the upper extremities at baseline. "C" is incorrect because most patients with spontaneous pneumothorax can be treated with a "pigtail" catheter with a Heimlich valve. This type of treatment reduces the morbidity associated with a chest tube.

Question 1 of 4 A 65-year-old male presents to your clinic for a complete history and physical examination. You notice that his abdominal examination reveals a pulsatile mass, which you suspect may represent an aortic aneurysm (now we are tired of writing heart failure questions). This finding is confirmed by ultrasound. The radiologist reports that the patient has a 3.5-cm abdominal aortic aneurysm without evidence of dissection or thrombus formation. The best advice to this patient is: A Have the aortic aneurysm fixed now while he is still healthy B Have a follow-up ultrasound every 3 months C Have a stent placed to prevent further aortic dilatation D Have an angiogram in the next several days to rule out vascular disease below the aorta (femoral arteries, iliac arteries, etc.) E Have a repeat ultrasound at 1 year

The correct answer is "E." Patients with an abdominal aortic aneurysm less than 4 cm in diameter should have an ultrasound yearly to check progression. Those with an aneurysm 4 to 5 cm in diameter should have an ultrasound every 6 months. An ultrasound on an every 3 to 6 months basis is also indicated for aneurysms that are growing >0.5 cm per year. Bottom line: the larger the aneurysm, the more frequently one should do an ultrasound. "A" is incorrect (see next question for an explanation). "C" is incorrect since a stent is not indicated at this point. "D" is incorrect. The only reason to do an angiogram at this point is if the patient is symptomatic or if you are planning surgical intervention.

Question 4 of 14 Elevated blood pressure in response to stress (especially in the doctor's office) is called "white coat hypertension." Which of the following statements is true about white coat hypertension? A As long as the majority of blood pressure readings are normal, the patient does not require treatment because there is no increased risk of adverse cardiac outcomes B Patients with white coat hypertension have an intermediate risk for adverse outcomes when compared with patients with normal blood pressure and those with chronically elevated blood pressure C White coat hypertension is more common in young patients D Patients with white coat hypertension have an elevated left ventricular mass when compared to patients with normal blood pressures E B and D

The correct answer is "E." Patients with white coat hypertension have outcomes that are intermediate between normotensive and hypertensive patients. In addition, they have an elevated left ventricular mass. Surprisingly, white coat hypertension is more common in the elderly.

Question 1 of 3 A 62-year-old female presents to your office with a history of occasional palpitations that are of great concern to her. She notes that she feels a racing heart that lasts for a matter of seconds and occurs every 7 days or so. However, when she has the symptoms, she will generally get four to five episodes during that day. She denies any chest pain, dyspnea, lightheadedness, or other associated symptoms. You order an event monitor and it shows that the patient is having nonsustained episodes of monomorphic ventricular tachycardia lasting 4 beats or less each. She is asymptomatic except for the palpitations. The best approach at this point is to: A Start an antiarrhythmic such as quinidine or mexiletine to control the heart rhythm B Refer the patient to a cardiologist for an electrophysiologic (EP) study to determine the best drug to control this rhythm C Implant an automatic defibrillator to prevent sudden death D Implant a pacemaker E Check serum potassium, magnesium, TSH, glucose, CBC

The correct answer is "E." The first step in determining the treatment of this patient is to make sure that there is not an underlying metabolic abnormality that could predispose to this rhythm abnormality.

Question 6 of 12 The coronary angiogram shows diffuse CAD; no coronary lesions are considered to be amenable to angioplasty and there are no vessels considered to be viable targets for bypass surgery. You decide to initiate medical therapy in this patient. In addition, you advise the patient regarding the nonpharmacologic therapies for heart failure treatment. Possible nonpharmacologic therapies for HFrEF include all of the following EXCEPT: A Fluid restriction of <2 L/day B Sodium restriction of <3 g/day C Dietary consultation D Cardiac risk factor modification E Monthly weight monitoring.

The correct answer is "E." The keystone of an effective heart failure treatment regimen is sodium and fluid balance as well as management of comorbidities ("A" and "B"). Cardiac risk factors, including hypertension, diabetes, hyperlipidemia, sleep apnea, obesity, sedentary lifestyle, smoking/alcohol/drug use, etc. need to be treated with the same aggressiveness as in a patient with an ACS. Patients should be advised about daily weight monitoring rather than monthly monitoring ("E"). A weight gain of more than 3 to 5 lb may necessitate additional doses of a diuretic. Note that significant fluid restriction to 1.5 to 2 L/day is typically, though not exclusively, reserved for Stage D advanced heart failure patients who are hyponatremic or diuretic resistant. Conversion of patients in atrial fibrillation via ablation (but not drugs) to normal sinus rhythm is also of benefit and reduces mortality, hospitalizations, and improves left ventricular function (N Engl J Med. 2018;378(5):417-427).

Question 1 of 4 A 60-year-old male presents with dizziness and palpitations. The patient has a blood pressure of 100/60 mm Hg and a pulse of 160 bpm. His ECG is shown in Figure 2-5. FIGURE 2-5. ECG for patient in question 2.11.1. View Full Size|Favorite Figure |Download Slide (.ppt) Which of the following interventions are appropriate options in the treatment of this patient? A Amiodarone, lidocaine, defibrillation, metoprolol B Amiodarone, lidocaine, defibrillation, diltiazem C Amiodarone, lidocaine, cardioversion, diltiazem D Procainamide, lidocaine, adenosine, defibrillation E Amiodarone, procainamide, lidocaine, cardioversion

The correct answer is "E." The rhythm is stable ventricular tachycardia. Procainamide, lidocaine, amiodarone, and synchronized cardioversion can all be used for ventricular tachycardia. "A" is incorrect for two reasons. The rhythm is ventricular tachycardia and is stable, and neither metoprolol nor defibrillation is appropriate. Defibrillation could be appropriate if the patient was unstable, pulseless (including pulseless ventricular tachycardia), or had ventricular fibrillation. "B" is incorrect because of the inclusion of diltiazem and defibrillation. "C" is incorrect because of the inclusion of diltiazem. "D" is incorrect because adenosine, which is used for atrial arrhythmias, is useless in ventricular arrhythmias and because, again, defibrillation is inappropriate.

Question 13 of 16 The patient receives her thrombolytic, enoxaparin, and transvenous pacing, and she is admitted to the hospital to a monitored bed. You get a call from the nursing staff 5 hours later. The rhythm strip shows 3 PVCs per minute. Your patient remains pain free and is hemodynamically stable. The nurse (who has more than a few gray hairs) would like an order for lidocaine. Your response is: A "Do it. Give the lidocaine" B "Give amiodarone—it works better than lidocaine" C "Give no antiarrhythmic at this point in time" D "Check labs including potassium and magnesium" E C and D

The correct answer is "E." The use of lidocaine in this setting incurs no benefit and is proarrhythmic. The same is true for prophylactic amiodarone, which can cause torsades de pointes, albeit at a lower frequency than other antiarrhythmics (such as quinidine, procainamide, sotalol, and newer Class III antiarrhythmic agents). In the setting of AMI, antiarrhythmics may be indicated only for complex arrhythmias (PVC couplets, triplets, nonsustained ventricular tachycardia [<30 seconds], or >10 PVCs per minute). More than 90% of patients will have isolated PVCs in the peri-infarct period, and there is no association with increased mortality. Correcting hypokalemia and hypomagnesemia can help to reduce arrhythmias, and checking these labs is prudent.

Question 6 of 14 You decide to send the patient for an MPI. However, since you last saw him, he fell and sprained his ankle...just to help us write this case (taking one for the team). So, you decide to stress him chemically. The patient is taking theophylline (really—in the 21st century!) for chronic obstructive pulmonary disease (COPD). The LEAST desirable pharmacologic agent to administer for stressing this patient is: A Adenosine B Dobutamine C Dipyridamole D All of the above are equally acceptable methods of chemically stressing this patient E Neither A nor C is desirable

The correct answer is "E." Theophylline (and caffeine) interact with both adenosine and dipyridamole, attenuating their effect. Additionally, adenosine may precipitate bronchospasm and should be avoided in patients with COPD or asthma. Thus, neither drug is a good choice for stressing this patient. Dobutamine is an acceptable method of chemically stressing those on theophylline or caffeine (like us), but it would only be used with an echocardiogram—not an MPI. On the other hand, COPD patients often have poor echocardiographic windows. Is this patient headed to a cath? We'll see...

Question 1 of 4 A 55-year-old male with a history of newly identified atrial fibrillation is referred to you for "medical clearance" for surgery. He has a history of hypertension and hypercholesterolemia (to calculate his CHA2-DS2-VASC score, see Table 2-6A). He has normal cardiac function otherwise with a normal ejection fraction and no valvular disease on echocardiogram. His atrial fibrillation has not been addressed since it was discovered by the surgeon at a pre-op visit. His heart rate is 80 bpm when you see him, his rhythm is irregularly irregular, and he has no signs of heart failure. TABLE 2-6ACALCULATING THE CHA2DS2-VASc SCOREView Table|Favorite Table |Download (.pdf) Which of the following options would be appropriate for this patient? A Anticoagulate the patient with warfarin or a direct oral anticoagulant (DOAC) and allow him to stay in atrial fibrillation B Place the patient on aspirin and allow him to stay in atrial fibrillation C Give digoxin to cardiovert the patient D Recommend DC cardioversion immediately since sustained normal sinus rhythm yields the best long-term outcomes E A and B

The correct answer is "E." This patient's CHA2-DS2-VASC (see Table 2-6A) score is "1" allowing him to take aspirin or be anticoagulated with either a DOAC or warfarin. For a CHA2-DS2-VASC score of 1, it is still a matter of clinical judgment based on patient-specific risk factors (see Table 2-6B). Prior to deciding on an approach to anticoagulation in a particular patient, calculate a HAS-BLED score (https://www.mdcalc.com/has-bled-score-major-bleeding-risk) to determine risk of bleeding. Balance stroke and bleeding risk when making a decision. A CHA2-DS2-VASC score of "0" corresponds to what we used to call "lone atrial fibrillation" and does not necessitate anticoagulation. In a 2019 update to the ACC/AHA Guidelines for the Management of Patients with Atrial Fibrillation, it was recommended to initiate anticoagulation with a DOAC (preferred) over warfarin for nonvalvular atrial fibrillation in men with a CHA2-DS2-VASC score of ≥2 and for women with a score ≥3. Please see Table 2-6B for anticoagulation recommendations based on CHA2-DS2-VASC score Renal and hepatic function should be evaluated at initiation of anticoagulation and at least annually. "C" is incorrect since this patient does not require rate control and digoxin is not effective for cardioversion. "D" is wrong. Long term, it is reasonable to allow most patients to remain in atrial fibrillation as long as they are properly anticoagulated based on the CHA2-DS2-VASC score. Outcomes of patients who stay in atrial fibrillation and are given appropriate therapy are the same (or a bit better) than in patients in whom one tries to maintain sinus rhythm with drugs such as amiodarone, etc.

Question 11 of 14 Remember the 35-year-old guy? You start him on chlorthalidone, but his blood pressure does not respond at a dose of 12.5 mg/day (have your patients cut the 25-mg tabs in half). His blood pressure on follow-up is 148/96 mm Hg. The best approach for such a patient is to: A Push his chlorthalidone to 25 mg daily before starting another medication B Stop the chlorthalidone and start another medication C Rely on exercise and diet to normalize the blood pressure D Start a second drug before you have maximized the dose of the first drug E Start a workup for secondary causes of hypertension F A or D

The correct answer is "F." Per the JNC 8 guidelines, both "A" and "D" are acceptable strategies; you could push up the dose of a first drug or add a second drug. There is a lack of randomized controlled trials to guide these recommendations. JNC 8 urges us to tailor therapy based on individual circumstances, clinician and patient preference, and drug tolerability. Low-dose chlorthalidone (12.5 mg) provides the greatest blood pressure reduction per mg of drug, and there is little clinical benefit of utilizing >25 mg daily of HCTZ or chlorthalidone. Higher doses are associated with increased adverse effects with minimal clinical gain in hypertension management. "B" is incorrect because a patient with this level of blood pressure elevation will generally require more than one drug to achieve a normalized blood pressure. "C" is incorrect because the majority of patients are unable to maintain an adequate diet or exercise regimen to effectively treat blood pressure. Exercise and dietary change are certainly laudable goals and should be encouraged in all patients. However, they are not likely to normalize blood pressure in most hypertensive patients. "D" is also correct as it represents one of the acceptable JNC 8 guideline strategies to dose antihypertensive drugs. "E" is incorrect since this patient has not yet proven to be resistant to treatment.