CARDIO: Practice Questions (Exam 2)
Which of the following is associated with mitral valve stenosis? A. Elevated left atrial pressure during atrial systole B. Elevated left ventricular end-diastolic pressure C. Elevated pressure gradient across the mitral valve during ventricular systole D. Left ventricular dilation
Answer: A Explanation: *Mitral valve stenosis will elevate left atrial pressure during atrial systole.* Mitral valve stenosis results from a narrowing of the opened mitral valve orifice so that it is more difficult for blood to flow from the left atrium into the left ventricle during ventricular diastole. The high resistance across the stenotic mitral valve causes blood to back up into the left atrium, thereby increasing LA pressure to even 25 mmHg (normally ~10 mmHg).
An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse
Answer: A Explanation: *The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina.* Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area. Patients with aortic regurgitation are likely to complain of an uncomfortable awareness of their heart, especially when lying down. These patients develop sinus tachycardia with exertion and complain of palpitations and head pounding with activity. The symptoms related to mitral stenosis are related to increased pulmonary pressure after the left atrium can no longer overcome the outflow obstruction. Patients with mitral valve prolapse are typically asymptomatic throughout their lives, although a wide range of symptoms is possible. When symptoms do occur, palpitations from arrhythmias are most common along with lightheadedness. Syncope is not part of this disease process.
75 year-old female with a history of long-standing hypertension presents with shortness of breath. On examination you note a diastolic murmur at the left upper sternal border. Which of the following maneuvers would accentuate this murmur? A. Sitting up and leaning forward B. Lying on left side C. Performing Valsalva maneuver D. Standing upright
Answer: A Explanation: *This patient has history findings consistent with aortic insufficiency which is characterized by a diastolic murmur that is accentuated when the patient sits up and leans forward.* The left lateral decubitus position accentuates the murmur of mitral stenosis. Valsalva and standing maneuvers help to differentiate the murmurs associated with aortic stenosis and hypertrophic cardiomyopathy.
A 24 year-old female presents complaining of palpitations described as occasional "skipped" beats. The patient denies chest pain, lightheadedness, syncope, or dyspnea. On examination you note a midsystolic click without murmur. Which of the following is the most likely diagnosis in this patient? A. Mitral valve prolapse B. Aortic stenosis C. Atrial septal defect D. Pulmonic
Answer: A Explanation: Patients with mitral valve prolapse will often present with complaint of palpitations. Auscultation would reveal a mid-systolic click with or without a late systolic murmur. Aortic stenosis presents with a systolic murmur with no click. Patients may complain of chest pain, dyspnea or syncope. Atrial septal defect is not associated with a midsystolic click.
An 18 year-old male high school basketball player comes to clinic for a routine physical exam. His height is 193 cm (76 in.); arm span is 201 cm (79 in.). He has long fingers and toes. Blood pressure is 146/62 mmHg and pulse is 64/min. Which of the following exam findings is most consistent with the diagnosis? A. Grade 2/6 high-frequency diastolic murmur at the third right intercostal space B. Grade 2/6 systolic ejection murmur at the second left intercostal space with a fixed widely split S2 C. Grade 2/6 continuous murmur heard best at the high left sternal border D. Grade 2/6 systolic murmur at the fourth left intercostal space that decreases with squatting
Answer: A Explanation: This murmur is most consistent with aortic regurgitation which can be present in patients with Marfans syndrome and a dilated aortic root.
A 37 year-old female with history of Turner's syndrome and coarctation of the aorta repaired at the age of 3 presents for routine examination. The patient is without complaints of chest pain, dyspnea, palpitations, or syncope. On examination vitals signs reveal a BP of 130/76, HR 70, regular, RR 16. On cardiac examination you note a grade II/VI systolic ejection murmur at the left sternal border and a grade III/VI blowing diastolic murmur. Which of the following does this patient require? A. antibiotic prophylaxis B. beta blocker therapy C. chest CT D. exercise stress test
Answer: A Explanation: This patient has a history of congenital heart disease and presently has a murmur consistent with aortic regurgitation. This patient requires antibiotic prophylaxis against infective endocarditis. Beta blocker therapy may increase the amount of regurgitation because of increased diastolic time and is not indicated in this patient. This patient should undergo serial echocardiograms, chest CT will not give information regarding any changes in the aortic regurgitation or ejection fraction. This patient is without any complaints; exercise stress test is not indicated.
The most common arrhythmia encountered in patients with mitral stenosis is A. atrial flutter. B. atrial fibrillation. C. paroxysmal atrial tachycardia. D. atrio-ventricular dissociation.
Answer: B Explanation: *Mitral stenosis leads to enlargement of the left atrium.* LAE is the major predisposing risk factor for the development of atrial fibrillation.
A 60 year-old male with history of hypertension and hyperlipidemia presents with intermittent chest heaviness for one month. The patient states he has had occasional heaviness in his chest while walking on his treadmill at home or shoveling snow. He also admits to mild dyspnea on exertion. His symptoms are relieved with 2-3 minutes of rest. He denies lightheadedness, syncope, orthopnea or lower extremity edema. Vitals reveal a BP of 130/90, HR 70, regular, RR 14. Cardiac examination revealed a normal S1 and S2, without murmur or rub. Lungs were clear to auscultation. Extremities are without edema. EKG reveals no acute change and cardiac enzymes are negative. Which of the following is the most appropriate next diagnostic study? A. cardiac catheterization B. nuclear exercise stress test C. helical (spiral) CT D. transthoracic Echocardiogram
Answer: B Explanation: *This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient*. Helical CT is used in the diagnosis of pulmonary embolism, not in the evaluation of angina. Echocardiogram is used in the evaluation of valvular heart disease not in the evaluation of suspected myocardial ischemia. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings, a stress test is a better initial diagnostic study for this patient.
Which of the following is associated with aortic valve regurgitation? A. Reduced left ventricular end-diastolic pressure B. Increased left ventricular stroke volume C. Decreased left ventricular stroke volume D. No change in left ventricular stroke volume
Answer: B Explanation: *Aortic regurgitation will increase left ventricular stroke volume.* Aortic regurgitation occurs when the aortic valve fails to close completely and blood flows back from the aorta into the left ventricle after ejection into the aorta is complete and during the time that the left ventricle is also being filled from the left atrium. Because the ventricle is being filled from two sources (aorta and LA), this leads to much greater LV filling; therefore, LV end-diastolic volume is increased as well as LV end-diastolic pressure. The increased ventricular end-diastolic volume (preload) leads to an increase in the force of contraction through the Frank-Starling mechanism, which causes a greater than normal stroke volume into the aorta.
Which of the following would you expect on physical examination in a patient with mitral valve stenosis? A. Systolic blowing murmur B. Opening snap C. Mid-systolic click D. Paradoxically split S2
Answer: B Explanation: *Mitral stenosis is characterized by a mid-diastolic opening snap.* Mitral stenosis is a diastolic, not a systolic murmur. Mid-systolic clicks are noted in mitral valve prolapse, not mitral stenosis. Paradoxical splitting of S2 occurs in aortic stenosis not mitral stenosis.
A 55 year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a visible jugular venous pulse and a systolic flow murmur on the right side of the sternum. Which of the following is the most likely diagnosis? A. mitral insufficiency B. tricuspid insufficiency C. hepatic vein thrombosis D. aneurysm of the thoracic aorta
Answer: B Explanation: *Tricuspid insufficiency will result in blood being put back into the right side of the body with increased jugular pulsation in the neck, along with a palpable venous pulse in the liver.* Mitral insufficiency results in the accumulation of blood primarily in the pulmonary system and not the right side of the heart. Hepatic vein thrombosis or Budd-Chiari syndrome is associated with cirrhosis and liver clotting abnormalities and is not due to right-sided heart failure. Thoracic aorta aneurysm results in a widened mediastinum that is fairly asymptomatic until it results in rupture or dissection. These are typically found as incidental findings unless they are symptomatic from dissection or rupture, which causes severe chest pain or a severe tearing sensation in the chest.
A 60-year-old male complains of shortness of breath on exertion. His past medical history is significant for aortic stenosis, hypertension, and hyperlipidemia. Which of the following best explains the reason for the exertional dyspnea? A. Extensive narrowing of the coronary blood vessels B. Impaired oxygen exchange in the lungs due to pulmonary edema C. Increased diastolic pressure due to lack of vasodilation D. Increase in ventricular inotropy due to an underlying heart failure
Answer: B Explanation: Aortic stenosis can lead to ventricular hypertrophy, which reduces the compliance of the ventricles. Since the blood can't be "accepted," it starts to back up into the left atrium, pulmonary veins, and eventually into lungs. Fluid from the pulmonary capillaries leaks into the alveoli, leading to impaired oxygen exchange. The inadequate oxygenation of the blood causes changes in blood gases - arterial PO2 and pH decrease and PCO2 increases. When this occurs, a chemoreceptor reflex is triggered, which stimulates respiration. Therefore, exertional dyspnea is accompanied by an increased rate and depth of respiration as the body attempts to normalize blood gases. The patient does not have coronary artery disease. The lack of vasodilation (s/t the hypertension) may cause increased diastolic pressure, but this does not explain extertional dyspnea. Aortic stenosis can lead to left-sided heart failure; however, heart failure will decrease inotropy, not increase.
Perfusion of the coronary arteries occurs primarily during which of the following? A. Systole B. Diastole C. Afterload D. Preload
Answer: B Explanation: Coronary artery perfusion occurs during diastole mostly.
A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A. Intra-aortic balloon counterpulsation B. Mitral valve replacement C. Coronary artery bypass surgery D. Immediate fluid bolus
Answer: B Explanation: MVR is the definitive intervention to correct MR caused by papillary muscle rupture. Although part of the primary treatment to reduce mitral regurgitation, it is not definitive. CABG may be necessary if significant blockage is found, but it will not correct the mitral regurgitation. A fluid bolus is indicated if the patient is hypotensive.
A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient's physical features? A. right atrial enlargement B. aortic root dilation C. pulmonic stenosis D. ventricular septal defect
Answer: B Explanation: This patient has the signs and symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease. Patients with Marfan's syndrome commonly have mitral valve prolapse and possibly aortic regurgitation. Right atrial enlargement, pulmonic stenosis and ventricular septal defect are not commonly seen.
Which diagnostic study is considered to be the strategy of choice for symptomatic patients with recurrent ischemia, hemodynamic instability or impaired left ventricular dysfunction? A. Stress echocardiography B. Exercise treadmill testing C. Coronary angiography D. Cardiac magnetic resonance imaging
Answer: C Explanation: *Coronary or cardiac catheterization (w/ angiography) is the gold standard technique in the evaluation of patients with significant cardiac symptoms.* Anatomical information along with the degree of coronary artery blockages are provided and patients may be able to undergo coronary revascularization during or after this procedure. Stress echocardiography should not be performed in the setting of a patient who is acutely symptomatic. Exercise treadmill testing should not be performed in the setting of an unstable patient with ongoing cardiac symptoms. Cardiac magnetic resonance imaging has limited availability and is not part of national guidelines for evaluation of the cardiac patient.
A 63 year-old male with history of hypertension and tobacco abuse presents complaining of dyspnea on exertion for two weeks. The patient admits to one episode of chest discomfort while shoveling snow which was relieved after five minutes of rest. Vital signs are BP 130/70, HR 68, RR 14. Heart exam reveals regular rate and rhythm, normal S1 and S2, no murmur, gallop, or rub. Lungs are clear to auscultation bilaterally. There is no edema noted. Which of the following is the most appropriate initial diagnostic study for this patient? A. Helical CT scan B. Chest x-ray C. Nuclear stress test D. Cardiac catheterization
Answer: C Explanation: In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease. Helical CT scan aids in the diagnosis of pulmonary embolism, not in the evaluation of angina. Chest x-ray is not used as a diagnostic study to evaluate symptoms of angina or coronary heart disease. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings.
A 10 year-old female experiences fever and polyarthralgia. On examination you note a new early diastolic murmur. Laboratory results are positive for antistreptolysin O. The patient has no known drug allergies. Which of the following is the recommended prophylaxis for this condition? A. Doxycycline B. Erythromycin C. Benzathine penicillinG D. Bactrim
Answer: C Explanation: Recurrences of rheumatic fever are most common in patients who have had carditis during their initial episode and in children. The preferred method of prophylaxis is Benzathine penicillin G every four weeks.
A 72 year-old male with a new diagnosis of congestive heart failure and atrial fibrillation, develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi? A. Electrocardiogram B. Chest x-ray C. Transesophageal Echocardiogram D. C-reactive protein
Answer: C Explanation: Transesophageal echocardiography allows for determination of mural thrombi that may have resulted from atrial fibrillation. Electrical conduction will not assess for mural thrombi. A chest x-ray will not visualize the left atria and ventricles to assess for mural thrombi. C-reactive protein is not going to give you any information regarding thrombi. This test is used to identify the presence of inflammation.
Cardiac nuclear scanning is done to detect what? A. electrical conduction abnormalities. B. valvular abnormalities. C. ventricular wall dysfunction. D. coronary artery patency/occlusion
Answer: C Explanation: Visualization of the cardiac wall can be done with cardiac nuclear scanning. This is done to determine hypokinetic areas from akinetic areas. An EKG is used to determine electrical conduction abnormalities. An echocardiogram is a non-invasive test used to determine valvular abnormalities and wall motion. Patency or occlusion is assessed with cardiac catheterization (invasive).
Which of the following is the most likely initial effect on the left ventricle from aortic stenosis? A. Dilitation of the ventricle with diastolic dysfunction B. Wall stiffness due to ischemia from decreased coronary blood flow C. Paradoxical wall motion abnormalities due to increased preload D. Concentric hypertrophy with preserved function
Answer: D Explanation: *Hypertrophy would be the initial changes of the left ventricle as a response to the increased pressure*. Dilation of the ventricle is a later finding. Preload is the end-diastolic pressure or volume within the ventricle, ischemic heart disease or infarct would cause paradoxical wall motion abnormalities due to the increased preload.
Which of the following physical exam findings suggests worsening or severe aortic stenosis? A. An ejection click preceding the murmur B. A split S2 with respiration variation C. Grade 2/6 systolic murmur radiating to the carotids D. Palpable thrill over the right second intercostal space
Answer: D Explanation: A palpable thrill or LV heave with associated murmur suggests severe AS.
According to Poiseuille's equation, if the radius of the opened orifice of a valve is reduced by 50%, the pressure gradient across the valve at a given flow rate will be increased how much above normal? A . 4-fold B. 2-fold C. 20-fold D. 16-fold
Answer: D Explanation: There are three primary factors that determine the resistance to blood flow within a single vessel: vessel diameter (or radius), vessel length, and viscosity of the blood. Of these three factors, the most important quantitatively and physiologically is vessel diameter. Poiseuille's equation states that vessel resistance (R) is directly proportional to the length (L) of the vessel and the viscosity (η) of the blood, and inversely proportional to the radius to the fourth power (r4).
A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition? A. A grade III/VI diastolic murmur heard best at the apex without radiation. B. A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle. C. A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation. D. A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.
Answer: D Explanation: This is a classic description of mitral regurgitation. The papillary muscle rupture is a complication of an acute inferior transmural myocardial infarction, and results in a failure of the mitral valve leaflets to close. *The direction of regurgitant flow of blood in mitral insufficiency is toward the left axilla.*
A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains non- active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis? A. Acute myocardial infarction B. Prinzmetal variant angina C. Stable angina D. Unstable angina
Answer: D Explanation: Pain in unstable angina is precipitated by less effort than before or occurs at rest. Pain does not resolve in an acute MI, it gradually gets worse. Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. This patient has just started to develop pain at rest. Pain in stable angina is relieved with rest and usually resolves within 10 minutes. Stable angina does not have pain at rest.