Cardiovascular Practice Questions

A 68-year-old man with a history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with a 3-day history of shortness of breath at rest. He has found it difficult to walk short distances due to shortness of breath. He reports orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is acutely dyspneic. He is afebrile but tachypneic and diaphoretic. There is a diminished first heart sound, S3 gallop, and laterally displaced PMI. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. A bedside chest X-ray revealed pulmonary vascular congestion and Kerley B lines. Question What additional finding is expected in this patient? 1 Bibasilar rales 2 Hyperresonance to percussion 3 Warm and dry skin 4 Depressed jugular venous pressure 5 Bradycardia

1 Bibasilar rales

A 70-year-old woman presents with a 3-day history of shortness of breath at rest. She has been finding it difficult to walk short distances due to shortness of breath. Additionally, she is experiencing orthopnea and nocturnal dyspnea. Her past medical history is significant for hypertension, hyperlipidemia, and myocardial infarction. The patient denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, abdominal pain, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is short of breath; she requires numerous pauses during conversation. She is afebrile but tachycardic and diaphoretic; her extremities are cool. The exam reveals a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, dullness to percussion, and expiratory wheezing. There is no JVD noted, but 2+ pitting edema of the lower extremities to the level of the mid-calf is evident. Question What is the most likely diagnosis? 1 Congestive heart failure 2 Pulmonary embolism 3 Myocardial infarction 4 Chronic obstructive pulmonary disease 5 Bacterial pneumonia

1 Congestive heart failure

A 55-year-old man with no significant past medical history presents for a routine evaluation and fasting bloodwork. He does not note any symptoms at this time. His physical examination reveals an obese body mass index with a waist circumference of 120 cm and a blood pressure of 140/90 mm Hg. Physical exam is otherwise unremarkable. His fasting bloodwork is drawn. Question What laboratory finding would qualify a diagnosis of metabolic syndrome in this patient? 1 HDL value of 35 mg/dL 2 Total cholesterol of 230 mg/dL 3 Triglyceride value of 125 mg/dL 4 LDL measurement of 110 mg/dL 5 Fasting plasma glucose of 95 mg/dL

1 HDL value of 35 mg/dL (According to the National Cholesterol Education Program and Adult Treatment Panel III, the diagnostic criteria of the metabolic syndrome include three or more of the following: Central obesity: waist circumference >102 cm (M), >88 cm (F) Hypertriglyceridemia: triglyceride level ≥150 mg/dL or medication for treatment of hypertriglyceridemia. Low HDL cholesterol: <40 mg/dL in men and <50 mg/dL in women, or medication for treatment for low HDL. Hypertension: blood pressure ≥130 mm Hg systolic or ≥85 mm Hg diastolic, or medication for treatment of hypertension. Fasting plasma glucose level ≥100 mg/dL, medication for treatment of elevated blood glucose, or previously diagnosed type 2 diabetes.)

A 73-year-old male patient presents with worsening shortness of breath. He is unable to complete as many physical activities during the day compared to 3 months ago. Vital signs include BP 100/60 mm Hg and HR 96 bpm. The extremities are somewhat cool to the touch, and he has expiratory wheezing and rhonchi on pulmonary exam. There is a diminished first heart sound with an S3 gallop heard during the cardiac exam. The lower extremities reveal 2+ pitting edema to the ankles. Question What would be the most critical lifestyle modification necessary for this patient? 1 Limiting salt 2 Limiting calories 3 Limiting fiber 4 Limiting physical activity 5 Limiting sleep

1 Limiting salt

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and ankle swelling. Symptoms started 6 weeks ago; she dismissed them as stress-related, but they have worsened in intensity and frequency. She becomes short of breath with any exertion, such as climbing stairs. She feels like she may pass out and has to sit when she gets lightheaded. Her breathing is worse when lying down. She denies productive cough, fever, or chest pain. She notes she has had no medical care in the past few years and is post-menopausal. She denies any other past medical or surgical history. Social history is unremarkable. Vitals are notable for pulse 101, BP 158/98, and BMI 28.5. Exam reveals bibasilar crackles and 2+ pitting edema of the lower extremities. Chest X-ray - Perivascular edema, slightly enlarged cardiac shadow 12-lead electrocardiogram - Mild left ventricular hypertrophy Based on the most likely diagnosis, what medication is most appropriate for long-term therapy? 1 Lisinopril 2 Salmeterol 3 Diltiazem 4 Omega-3 fatty acids 5 Digoxin

1 Lisinopril (This patient presents with an acute exacerbation of heart failure (HF). HF is a common chronic condition, and during exacerbation, it may present with fatigue, dyspnea on exertion, and fluid overload. In this patient with no prior known disorders, several causes could have precipitated HF. Lisinopril (ACE inhibitor) is recommended for nearly all HF patients. ACE inhibitors have been linked with increased survival, fewer hospitalizations, and improved quality of life for patients with HF.)

A 62-year-old woman is being treated for chronic congestive heart failure. She has been put on hydrochlorothiazide therapy. Her serum electrolyte levels are being monitored and show a persistent hypokalemia. Question What would be most appropriate to add to her therapeutic regimen? 1 Acetazolamide 2 Amiloride 3 Furosemide 4 Indapamide 5 Mannitol

2 Amiloride (Amiloride is a potassium-sparing diuretic. Its diuretic effect is not very potent, so it is good to use in combination with other diuretics. Acetazolamide is a carbonic anhydrase inhibitor. It causes a mild diuresis, a marked elevation of urinary pH, and a significant loss of potassium. Furosemide is a loop diuretic. It has a rapid onset of action and is a potent diuretic, but it also causes potassium depletion and would only worsen the hypokalemia. Indapamide is a thiazide analog with a long duration of action. If anything, it would exacerbate the hypokalemia. Mannitol is an osmotic diuretic and would not be recommended in this patient. Furthermore, it would not have a potassium-sparing effect.)

A 56-year-old man presents with a 1-week history of palpitations and shortness of breath. He has a longstanding history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure, mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Echocardiogram reveals concentric left ventricular hypertrophy without significant valvular abnormalities. Question What drug is beneficial in the treatment of the patient's condition by causing afterload and preload reduction? 1 Loop diuretic 2 Angiotensin-converting enzyme inhibitor 3 Positive inotropic agent 4 Sodium channel blocker 5 Arterial vasodilator

2 Angiotensin-converting enzyme inhibitor (ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II (AII) through ACE, resulting in the favorable modification of the neurohormonal activation in heart failure. They cause favorable hemodynamic effects by causing peripheral vasodilatation, afterload, and blood pressure reduction. They also bring about a reduction in the preload through the reduction of aldosterone, which in turn decreases sodium and fluid retention. Loop diuretics (furosemide) reduce preload by reducing fluid volume. Positive inotropic agents (digoxin) act primarily by increasing cardiac contractility. They have less impact on afterload and preload. Sodium channel blocker (procainamide) is a class Ia antiarrhythmic agent used in ventricular and supraventricular arrhythmias. Arterial vasodilators (hydralazine) are used to reduce the afterload by decreasing peripheral vascular resistance and increasing heart rate, stroke volume, and cardiac output.)

A 73-year-old male patient presents with worsening shortness of breath. He is unable to complete as many physical activities during the day compared to 3 months ago. Vital signs include BP 100/60 mm Hg and HR 96 bpm. The extremities are somewhat cool to the touch, and he has expiratory wheezing and rhonchi on pulmonary exam. There is a diminished first heart sound with an S3 gallop heard during the cardiac exam. The lower extremities reveal 2+ pitting edema to the ankles. Question You order an ECG, but before receiving the results, you are highly suspicious that the patient has what diagnosis? 1 Pulmonary embolism 2 Congestive heart failure 3 Myocardial infarction 4 First-degree heart block 5 Pulmonary hypertension

2 Congestive heart failure

A 68-year-old man with a history of obesity, hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest making it difficult to walk short distances. He reports orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies fever, chills, chest pain, nausea, vomiting, diarrhea, rashes, lightheadedness, or giddiness. Pulse 120/min, blood pressure 150/92 mm Hg, respirations 24/min. Physical examination shows excessive perspiration and pitting edema over lower extremities to the level of mid-calf. Auscultation over the chest reveals diminished first heart sound, S3 gallop, and laterally displaced point of maximal impulse; bibasilar rales are heard over the lungs. Abdominal exam reveals distension with hepatomegaly in the right upper quadrant. A chest X-ray reveals pulmonary vascular congestion. Oxygen saturation is 92% on room air. Serum electrolytes are unremarkable, and BMI is 22 kg/m2. Question In addition to treating the presenting condition, what health maintenance recommendation will most likely benefit this patient? 1 Increased intake of monounsaturated fatty acids 2 Dietary sodium restriction 3 Home-based oxygen therapy 4 Fluid restriction to 2 L/day 5 Intensive exercise regimen

2 Dietary sodium restriction (Dietary sodium restriction to 2-3 g/day is an important health maintenance recommendation for patients with heart failure because it reduces water retention and reduces cardiac work.)

A 60-year-old man presents for routine follow-up. He has no present concerns. He denies fevers/chills, changes in vision, headaches, chest pain, shortness of breath, PND, orthopnea, peripheral edema, dizziness, and syncope. Past medical history is significant for a coronary artery bypass grafting x 4 approximately 3 years ago, GERD, and obesity. He is currently on isosorbide mononitrate, metoprolol, and aspirin. Routine lipid panel: Triglycerides 145 mg/dL HDL 34 mg/dL LDL 135 mg/dL Question Given his lipid profile, how can this patient most appropriately be managed? 1 Fenofibrate, 134 mg daily 2 Simvastatin, 20 mg daily 3 Atorvastatin, 80 mg daily 4 Pravastatin, 20 mg daily 5 Lovastatin, 10 mg daily

3 Atorvastatin, 80 mg daily (Hyperlipidemia contributes to the accelerated atherogenesis in vein grafts, so aggressive control of hyperlipidemia is vitally important for the patency of the grafts. Patients with known cardiovascular disease and an LDL cholesterol >70 mg/dL need high-intensity statin therapy with rosuvastatin (20-40 mg/day) or atorvastatin (40-80 mg per day). According to the National Cholesterol Education Program, this patient's serum triglycerides level fall within the normal range.)

A 73-year-old male patient presents with worsening shortness of breath. He is unable to complete as many physical activities during the day compared to 3 months ago. Vital signs include BP 100/60 mm Hg and HR 96 bpm. The extremities are somewhat cool to the touch, and he has expiratory wheezing and rhonchi on pulmonary exam. There is a diminished first heart sound with an S3 gallop heard during the cardiac exam. The lower extremities reveal 2+ pitting edema to the ankles. Question What kind of medication is most likely to help alleviate this patient's symptoms? 1 Antiarrhythmic 2 Anticoagulant 3 Diuretic 4 Statin 5 Vasodilator

3 Diuretic (Diuretics are the most effective way to provide symptomatic relief in patients with moderate to severe heart failure resulting in dyspnea and fluid overload. Inhibitors of the renin-angiotensin-aldosterone system (ACE inhibitors, ARBs) are often used in conjunction with diuretics; a beta blocker may be included in a multimodal regimen.)

A 55-year-old man presents for re-evaluation of his blood pressure; he has no significant past medical history. At his visit 3 weeks ago, his blood pressure was 145/90 mm Hg. He admits to somnolence, confusion, and non-specific bilateral visual disturbances over the past month; he denies any eye pain, blindness, ocular discharge, or floaters. His blood pressure today is 185/110 mm Hg. His fundoscopic exam reveals the following. Refer to the image. Question What is an additional expected manifestation in this case? 1 Scleral icterus 2 Rhinitis 3 Headache 4 Fruity breath 5 Erythema nodosum

3 Headache (Mild-to-moderate primary (essential) hypertension is largely asymptomatic for many years. The most frequent symptom, which is a headache, is also very non-specific. Accelerated hypertension is associated with somnolence, confusion, visual disturbances, and nausea and vomiting; they are common to hypertensive encephalopathy. Hypertensive retinopathy may cause papilledema, intraretinal hemorrhages, nerve fiber layer infarcts (cotton-wool spots), arteriovenous (AV) nicking, banking or beading, or copper or silver wiring of the retinal vessels. The fundoscopic picture shows AV nicking and copper wiring.)

A 71-year-old woman, previously in excellent health and taking no medications, presents with new shortness of breath when she lies down at night. She denies any difficulty breathing during the day and states she is able to maintain her usual level of light activity. She denies any chest pain or palpitations. She noticed some mild ankle edema around the time the respiratory symptoms started. Office spirometry is normal, but her EKG reveals a widened QRS complex and her laboratory results reveal an elevated BNP (brain naturietic peptide). Question What is the most likely diagnosis? 1 Asthma 2 COPD 3 Heart failure 4 Myocardial infarction 5 Viral URI

3 Heart failure

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and swelling in her ankles. Symptoms started around the time of her son's wedding 6 weeks ago. She dismissed them as stress-related, but symptoms have worsened in intensity and frequency. Now she becomes very short of breath with any exertion, such as climbing stairs in her home. She feels like she may pass out and has to sit when she gets lightheaded. Her breathing is more difficult when lying down. She denies productive cough, fever, or chest pain. She has had no medical care for several years. Her past medical history is unremarkable, with no known medical conditions and no surgeries. She is menopausal and does not take any medications, nor does she have any allergies. She denies the use of tobacco, alcohol, and drugs. Vitals are shown in the table. Physical exam was performed by the provider on an earlier shift, and the patient's care was turned over to you. Weight - 171 lb Height 65" BMI 28.5 Pulse 101 Blood pressure 158/98 Temperature 97.9°F/36.6°C Chest x-ray - Perivascular edema,slightly enlarged cardiac shadow 12-lead electrocardiogram - Mild left ventricular hypertrophy Question What physical exam findings would be expected given this patient's history and test results? 1 Absent breath sounds over single lung lobe 2 Dullness to percussion over left upper lung fields 3 Hepatojugular reflux 4 Pericardial friction rub 5 Positive Homan sign

3 Hepatojugular reflux (The hepatojugular reflex can be elicited with right sided heart failure. With right sided HF, blood backs up into the liver. Pressing on the upper right quadrant, at the area of the liver, causes this pooled blood to go up into the veins of the neck --> increased JVD)

A 55-year-old woman presents with bumps around her eyes. She states they have been worsening over the past 3-4 months. They are not painful, but she is worried they may be something serious, especially since they seem to be increasing in size. The patient is currently taking a regular dose aspirin, which was suggested by her gynecologist, but she is not on any other daily medications. Family history is pertinent for her father dying at age 82 due to a heart attack and her mother still living at the age of 79 with a known medical history of hypertension and high cholesterol. On physical examination, slightly raised yellowish well-circumscribed plaques along the nasal portion of both eyelids are noted. Question What is the most likely diagnosis? 1 Congestive heart failure 2 Diabetes mellitus 3 Hypercholesterolemia 4 Hypertension 5 Lupus

3 Hypercholesterolemia

A 70-year-old woman with a history of hypertension, hyperlipidemia, and myocardial infarction presents with a 3-day history of shortness of breath at rest. She has found it difficult to walk short distances due to shortness of breath and is experiencing orthopnea and nocturnal dyspnea. She denies cough, fever, chills, nausea, abdominal pain, vomiting, diarrhea, or rashes. Upon physical examination, the patient is short of breath, requiring numerous pauses during conversation. General assessment reveals the patient is tachycardic and diaphoretic Cool extremities. Heart exam reveals a diminished first heart sound, S3 gallop, and laterally displaced PMI. Lung exam reveals dullness to percussion, bibasilar rales, and expiratory wheezing. 2+ pitting edema of the lower extremities to the level of the mid-calf. 1 Pericardiocentesis 2 Intravenous beta blocker 3 Intravenous diuretic 4 Oral calcium channel blocker 5 Subcutaneous Lovenox

3 Intravenous diuretic (Patient is in congestive heart failure. The bibasilar rales indicate fluid, so the patient also has pulmonary edema. Loop diuretics (furosemide) remain the mainstay and first line of therapy in congestive heart failure. IV diuretic therapy is indicated for the treatment of acute pulmonary edema.)

A 72-year-old man with a history of poorly controlled HTN and previous myocardial infarction presents with a nocturnal cough, bilateral ankle swelling, and dyspnea on exertion. He denies any fever, chills, URI symptoms, chest pain, headache, N/V, diaphoresis, or syncope. He further denies smoking, alcohol, or drug use. Physical exam reveals bipedal edema and bibasilar crackles. A chest X-ray is remarkable for enlargement of the cardiac silhouette and interstitial infiltrates, while EKG analysis indicates deep S waves in lead V1 and tall R waves in lead V5. Question What is the most appropriate next step in the evaluation and management of this patient? 1 Biopsy of the endocardium 2 Chest CT scan with IV contrast 3 Transthoracic echocardiography 4 Bronchoalveolar lavage 5 Coronary angiography

3 Transthoracic echocardiography (This patient has clinical manifestations and initial diagnostic test results suggestive of congestive heart failure. The most useful test is an echocardiogram, which is a noninvasive and ionizing-free imaging modality that reveals the size and function of both ventricles and atria. It can also be used to evaluate for the presence of pericardial effusions, valvular abnormalities, intracardiac shunts, and segmental wall-motion abnormalities.)

A 70-year-old woman presents with shortness of breath at rest over the past 3 days. She has found it difficult to walk short distances due to shortness of breath. Additionally, she is experiencing confusion, orthopnea, nocturnal dyspnea, and lightheadedness. She denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, nausea, abdominal pain, vomiting, diarrhea, rashes, and syncope. On physical examination, the patient is short of breath, requiring numerous pauses during conversation. She is afebrile, but she is tachycardic, diaphoretic, and her extremities are cool. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, and dullness to percussion and expiratory wheezing noted. An elevated JVD and 2+ pitting edema of the lower extremities is evident. Question What statement regarding this patient's condition is correct? 1 The most common etiology of this condition is infiltrative diseases. 2 Increased caloric and sodium intake improves patient outcomes. 3 Confusion is the most common presenting complaint in older patients. 4 Activation of the renin-angiotensin-aldosterone system occurs. 5 The electrocardiogram is the most useful diagnostic test.

4 Activation of the renin-angiotensin-aldosterone system occurs. (In CHF, lower cardiac output leads to a reduction of renal blood flow and glomerular filtration rate, causing sodium and fluid retention. In CHF, the renin-angiotensin-aldosterone system is activated, leading to further increases in peripheral vascular resistance and left ventricular afterload as well as sodium and fluid retention. Heart failure is also associated with increased circulating levels of arginine vasopressin, which also serves as a vasoconstrictor and inhibitor of water excretion.)

A long-standing patient is experiencing acutely worsening symptoms and signs of dilated cardiomyopathy. Symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, and clubbing. Physical exam is significant for an S3 gallop and jugular venous distention. Daily medications include a beta blocker, adult dose aspirin, and an ACE inhibitor. Question Initiation of what medication is the best next step in helping resolve this patient's current symptoms? 1 Calcium channel blocker 2 Aldosterone antagonist 3 Statin 4 Diuretic 5 Angiotensin II antagonist

4 Diuretic (Diuretics are the most effective means of providing symptomatic relief to patients with exacerbations of signs and symptoms relating to significant heart failure. Many of the signs and symptoms in this patient point to significant pulmonary edema or congestion. This is a key characteristic in the overall pathology of dilated cardiomyopathy, along with other related consequences of ventricular dilation/dysfunction. Dilated cardiomyopathy is the cause in about 25% of all patients suffering from congestive heart failure.)

A 78-year-old man with known left-sided congestive heart failure presents due to cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms? 1 Tricuspid insufficiency 2 Left ventricular hypertrophy 3 Decreased peripheral vascular resistance 4 Increased pulmonary venous pressure 5 Mucus plugging

4 Increased pulmonary venous pressure (In left-sided congestive heart failure, the predominant feature is low cardiac output and elevated pulmonary venous pressure, resulting in dyspnea. As dyspnea worsens, the patient will also begin to experience shortness of breath at rest, which is worsened in the supine position.)

A 72-year-old man presents for worsening shortness of breath, orthopnea, and chest pain for the last few weeks. He admits some chronic heart problems, fatigue, dyspnea, and non-productive cough, but he feels like symptoms have worsened recently. He denies fever, chills, and productive cough. On physical exam, he has mildly increased respiratory effort but does not appear in distress. He is barrel-chested. Breath sounds are diminished bilaterally, with dullness to percussion over right and left lower lungs. No pleural friction rub noted. S3 gallop, mild tachycardia (110 bpm), clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention are noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on chest X-ray. Question What is the most plausible explanation for this patient's dependent edema? 1 Absence of venous valves leading to venous reflux 2 Hepatic fibrosis and decreased protein production with increased portal resistance 3 Large renal loss of protein leading to hypoalbuminemia and edema 4 Renal sodium and fluid retention leading to increased capillary pressure 5 Suppression of antidiuretic hormone release

4 Renal sodium and fluid retention leading to increased capillary pressure (This patient presents with an acute exacerbation of heart failure (HF). HF is a common chronic condition and can have acute exacerbations. Common HF presentations include fatigue, dyspnea with exertion, and fluid overload. Peripheral (dependent) edema takes time to develop and is renal in origin. Poor output from the heart results in low blood flow to the kidneys, which respond by activating the renin-angiotensin-aldosterone system, which also leads to increased antidiuretic hormone (ADH or vasopressin) release. The result is renal sodium and fluid retention leading to increased capillary pressure (choice D). The serous fluid leaks out into the interstitial tissue, causing edema.)

A 16-year-old boy with no significant past medical history presents to learn the results of a lipid panel that was performed. The lipid panel was ordered due to periorbital and extensor tendon xanthomas on the patient's body. The patient consumes a low-fat and low-calorie diet, and he exercises daily. He denies any bothersome symptoms, and his physical exam is otherwise unremarkable. Question What is the most likely mechanism for this patient's metabolic disorder? 1Increased production of high-density lipoprotein 2Undiagnosed diabetes mellitus 3Hypersecretion of triglyceride-carrying chylomicrons from the small intestine 4Reduction in the amount of LDL receptors on hepatocytes 5Increased VLDL synthesis by the liver

4Reduction in the amount of LDL receptors on hepatocytes (When there is a decrease in LDL receptors on hepatocytes, or when LDL levels exceed receptor availability, the amount of LDL that is removed by scavenger cells is greatly increased. The LDL receptors are deficient or defective in the genetic disorder known as familial hypercholesterolemia (type 2A). Patients with this primary hypercholesterolemia disorder may be heterozygotes or homozygotes, with homozygotes developing cutaneous xanthomas and myocardial infarctions in childhood.)

A 64-year-old man with a history of a remote myocardial infarction and congestive heart failure presents for his 3-month follow-up. A recent echocardiogram reveals severe left ventricular dysfunction. Question What intervention has been shown to reduce the risk of sudden cardiac death in similar patients? 1 Long-term calcium channel blocker therapy 2 Chronic daily lidocaine therapy 3 Daily administration of digitalis 4 Magnesium oxide therapy 5 Implantation of a cardioverter-defibrillator device

5 Implantation of a cardioverter-defibrillator device

A 73-year-old man presents with worsening shortness of breath on activity over the last few months. Another issue he mentions is not being able to complete as many physical activities during the day as he could perform 3 months ago. He states he has to use at least three pillows to allow him to sleep at night; otherwise, he cannot breathe. Physical examination confirms the suspected diagnosis. Question What sign would be consistent with this patient's most likely diagnosis? 1 Diminished lower extremity pulses 2 Diminished second heart sound 3 Hypertension 4 Non-healing ulcer 5 S3 gallop

5 S3 gallop (This patient displays multiple key symptoms of heart failure. Heart failure may consist of primarily left ventricular or right ventricular heart failure. Patients will often exhibit signs and symptoms of both right- and left-sided heart failure, including dyspnea, exertional dyspnea, orthopnea, chronic non-productive cough, edema, hepatic congestion, loss of appetite, and nausea. Tachycardia, hypotension, reduced pulse pressure, cold extremities, diaphoresis, crackles in the lungs, expiratory wheezing, and rhonchi may also be present. Cardinal cardiac signs include a parasternal lift, enlarged/sustained left ventricular impulse, and even an S3 gallop.)

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and swelling in her ankles. Symptoms started around the time of her son's wedding 6 weeks ago. She dismissed them as stress-related, but symptoms have worsened in intensity and frequency. Now she becomes very short of breath with any exertion, such as climbing stairs in her home. She feels like she may pass out and has to sit when she gets lightheaded. Breathing is more difficult when lying down. She denies productive cough, fever, or chest pain. She has had no medical care for several years. Past medical history is unremarkable, with no known medical conditions and no surgeries. She is menopausal, takes no medications, and has no allergies. She denies use of tobacco, alcohol, and recreational drugs. Weight - 171 lb Height 65" BMI 28.5 Pulse 101 Blood pressure 158/98 Temperature 97.9°F/36.6°C Chest x-ray - Perivascular edema,slightly enlarged cardiac shadow 12-lead electrocardiogram - Mild left ventricular hypertrophy Question: Once this patient is stabilized and educated about her diagnosis and treatment, she asks what she could have done to prevent her condition. What is the greatest modifiable contributing factor to this condition at the population level? 1 High dietary sodium intake 2 Inability to maintain ideal body weight 3 Sedentary lifestyle 4 Stress 5 Untreated hypertension

5 Untreated hypertension (This patient presents with an acute exacerbation of heart failure (HF). Common HF presentations include fatigue, dyspnea with exertion, and fluid overload. In this patient with no prior known disorders, several causes could have precipitated HF. The most common modifiable risk factor leading to heart failure is untreated hypertension. Hypertension is a major factor in 75% of HF cases in the US, and treatment of hypertension is associated with a 50% reduction in HF.)

Which of the following studies is not usually required in the routine diagnosis and management of heart failure? A Cardiac CT scanning B ECG C Chest radiography D Echocardiography

A Cardiac CT scanning

A 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A Daily weights B Daily spirometry C Daily blood glucose D Daily fat intake

A Daily weights (Home monitoring weights can alert the health care provider to the early recognition of worsening heart failure)

22 year-old black male with total cholesterol 440mg/dL, HDL 35mg/dL, LDL 200mg/dL, systolic BP 130mmHg, not a diabetic, non smoker is started on Atorvastatin (Lipitor) 80mg daily. His repeat LDL is 120 mg/dL. What medication is recommended next to add to Atorvastatin? A Ezetimibe (Zetia) B Niacin C Gemfibrizol (Lopid) D Simvastatin (Zocor) E Fish Oil

A Ezetimibe (Zetia)

A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis? A Heart failure B Subacute bacterial endocarditis C Pulmonary embolus D Pneumonia

A Heart failure

A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test's mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis? A Right ventricular failure B Pericarditis C Exacerbation of COPD D Cirrhosis

A Right ventricular failure (This pt's signs are consistent with right ventricular failure - edema, hepatic congestion / hepatomegaly, possible ascites)

Eliciting a history from a patient presenting with dyspnea due to early heart failure the severity of the dyspnea should be quantified by A amount of activity that precipitates it. B how many pillows they sleep on at night. C how long it takes the dyspnea to resolve. D any associated comorbidities.

A amount of activity that precipitates it.

Which changes in cardiac output variables are most consistent with systolic heart failure? Ejection Fraction / End Diastolic Volume / Contractility / Compliance A. 35% increased decreased normal B. 35% increased normal decreased C. 55% increased decreased normal D. 60% decreased normal decreased

A. 35% increased decreased normal (In systolic heart failure, stroke volume (SV) decreases due to decreased myocyte contractility. Since less blood is pumped out of the ventricles during systole (i.e. decreased SV), there is more blood left in the ventricle. This left over blood contributes to an increased preload and leads to an increased end diastolic volume (EDV). Since Ejection Fraction (EF) = SV/EDV, a lowered SV and an increased EDV leads to a decreased EF. A change in compliance is not a factor in systolic heart failure.)

Which type of anti-hypertensive agent is NEVER recommended in pregnancy? A. ACE inhibitors B. Diuretics C. Beta blockers D. Alpha adrenergic blockers

A. ACE inhibitors

A 65-year-old male with a history of benign prostatic hypertrophy develops hypertension. Which of the following would be the best treatment option for this patient's hypertension? A. Alpha blocker B. Beta blocker C. ACE inhibitor D. Diuretic

A. Alpha blocker

A 50-year-old construction worker continues to have an elevated blood pressure of 160/95 even after a third agent is added to his antihypertensive regimen. Physical exam is normal, electrolytes are normal, and the patient is taking no over-the-counter medications. The next helpful step for this patient is to A. Check pill count B. Evaluate for Cushing syndrome C. Check chest x-ray for Coarctation of the aorta D. Obtain a renal angiogram E. Obtain an adrenal CT scan

A. Check pill count

The major hazard associated with antihypertensive therapy in the elderly is: A. Hypotension B. Depression C. Hypokalemia D. Congestive heart failure E. Central nervous system effects

A. Hypotension

A 58-year-old male presents with chest pain. Vital signs include blood pressure of 210/175, pulse 80, RR 20. Which of the following would you expect to find on physical examination? A. papilledema B. carotid bruit C. diastolic murmur D. absent peripheral pulses

A. papilledema

An echocardiogram of a patient with a long history of alcohol abuse and heart failure shows increased left ventricular chamber size. Which ejection fraction is most consistent with this patient's condition? A.35% B.55% C.65% D.75%

A.35% (Chronic alcohol abuse can lead to dilated cardiomyopathy. Dilated cardiomyopathy causes decreased contractility and consequently, systolic heart failure. Systolic heart failure is associated with eccentric hypertrophy, a compensatory cardiac remodeling mechanism in which sarcomeres grow in series, resulting in a large, floppy heart chamber that is inefficient at ejecting blood during systole. As a result, patients with systolic heart failure have ejection fractions that are less than 40% (normal left ventricular ejection fraction ranges from 55% to 80%).)

Which of the following statements is most accurate regarding the clinical manifestations of left-sided and right-sided heart failure? A.Bibasilar crackles are more commonly seen in isolated left-sided heart failure than in right-sided heart failure. B.Centrilobular necrosis of the liver is more commonly seen in isolated left-sided heart failure than in right-sided heart failure. C.Left-sided heart failure is secondary to systolic heart failure and right-sided heart failure is secondary to diastolic heart failure. D.Orthopnea is more commonly seen in isolated right-sided heart failure than left-sided heart failure.

A.Bibasilar crackles are more commonly seen in isolated left-sided heart failure than in right-sided heart failure. (Whereas right-sided heart failure presents with signs and symptoms of systemic vascular congestion, left-sided heart failure primarily affects the pulmonary vasculature and presents with respiratory symptoms. Failure of the left ventricle causes blood to back up into the pulmonary vasculature. The congested pulmonary vasculature causes increased hydrostatic pressure in the capillary beds, which forces fluid to leak out into the lung interstitium (pulmonary edema) and eventually into the alveoli (alveolar transudate). The bibasilar crackles that are heard in the lungs on inspiration are the sound of fluid-filled alveoli popping open. The crackles are most prominent at the base of both lungs (i.e. bibasilar) because gravity pulls the fluid down to the bases)

Regarding the pathophysiology of congestive heart failure, coronary artery disease leads to: A.Both systolic and diastolic heart failure B.Diastolic heart failure only C.Neither systolic nor diastolic heart failure D.Systolic heart failure only

A.Both systolic and diastolic heart failure (In coronary artery disease, occlusive plaque deprives the myocardium of oxygen, leading to ischemia. The ischemic myocardium has decreased contractility, which can lead to systolic heart failure. Additionally, ischemic events can lead to formation of less compliant myocardium, resulting in diastolic heart failure. Thus, patients with coronary artery disease can present with a mixture of systolic and diastolic heart failure.)

A 19-year-old soccer player collapses during a game and cannot be resuscitated. On autopsy, his heart is found to have asymmetric ventricular septal hypertrophy. What type of heart failure did this patient likely have and what was the underlying cause? A.Diastolic heart failure and hypertrophic cardiomyopathy B.Systolic heart failure and acute myocardial infarction C.Diastolic heart failure and aortic stenosis D.Systolic heart failure and ventricular septal defectA left to right shunt from ventricular septal defect (VSD) can lead to systolic heart failure. However, asymmetric ventricular septal hypertrophy is not observed in VSD

A.Diastolic heart failure and hypertrophic cardiomyopathy (Hypertrophic cardiomyopathy (HOCM) is an inherited condition that is characterized by asymmetric ventricular hypertrophy. It can cause sudden death in young, otherwise healthy individuals. The enlarged septum gets in the way of proper ventricular filling, leading to diastolic heart failure.)

Left-sided heart failure causes increased pressure and congestion in the pulmonary circulation. This damages the endothelial lining of the pulmonary vasculature and eventually leads to remodeling of the pulmonary vasculature and pulmonary hypertension. Which of the following statements about the response of the pulmonary vasculature to pulmonary congestion is most accurate? A.In response to damage caused by pulmonary congestion, pulmonary vascular endothelial cells produce less nitric oxide and more endothelin. B.In response to congestion of the pulmonary vasculature, collagen and elastase deposit in the medial layer of the vessel. C.In response to damage caused by pulmonary congestion, pulmonary vascular endothelial cells produce less nitric oxide and less endothelin D.In response to pulmonary congestion, smooth muscle cells proliferate, leading to hypertrophy of the intimal layer of the vessel

A.In response to damage caused by pulmonary congestion, pulmonary vascular endothelial cells produce less nitric oxide and more endothelin. (The vascular endothelium responds to damage caused by left-sided heart failure by producing less of the vasodilator, nitric oxide and more of the vasoconstrictor, endothelin. The net result is vasoconstriction and increased vascular tone.)

In right-sided heart failure, increased right heart pressure is directly related to increased jugular venous pressure. On physical exam, this presents as jugular venous distention (JVD). Kussmaul's sign in an exam finding related to JVD. Which of the following is the most accurate statement about Kussmaul's sign? A.It is a paroxysmal increase in jugular venous distension during inspiration. B.It is an increased filling of the jugular veins that occurs upon applying pressure to the right upper quadrant of the abdomen. C.It refers to the pain that is elicited when pressure is applied to the right upper quadrant of the abdomen. D.It refers to the reflex tachypnea that is triggered by hypoxia.

A.It is a paroxysmal increase in jugular venous distension during inspiration. (During inspiration, there is a drop in intrathoracic pressure, which normally causes an increase in venous return to the right heart, allowing the jugular veins to empty. This is seen as a decrease in JVD with inspiration. However, in right-sided heart failure, whether it is secondary to diastolic or systolic dysfunction, the increased venous return either cannot properly enter the right ventricle (filling dysfunction i.e. diastolic heart failure) or it cannot be pumped out of the right ventricle properly (i.e. systolic heart failure). In either case, there will be a backup of blood into the jugular veins and, thus, a paradoxical rise in JVD during inspiration. This phenomenon is called Kussmaul's sign.)

What is the most common cause of right-sided heart failure? A.Left-sided heart failure B.Primary pulmonary arterial hypertension C.Pulmonary stenosis D.Saddle pulmonary embolus

A.Left-sided heart failure (Left sided heart failure --> pulmonary congestion --> pulmonary hypertension --> increased afterload for right ventricle --> right sided heart failure)

48 year-old African American female with Diabetes, total cholesterol 180 mg/dL, HDL 55 mg/dL, LDL 89 mg/dL, systolic BP 130/80 mm Hg, taking antihypertensive medication, taking aspirin, taking Simvastatin 20mg daily. + diabetic, + smoker. Calculate the 10 year ASCVD risk https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/ What is recommended? AChange to high-intensity statin BContinue the moderate-Intensity statin CDiscontinue the statin.

AChange to high-intensity statin

Which patient should get a high intensity statin? (click all that apply) A 60 year-old with a recent TIA B 48 year old with PAD C 24 year old with an LDL of 240 D 37 year old with a history of MI

All of them

Which of the following would be best for a patient who has isolated hypertriglyceridemia of 700mg/dL (click all that apply)? A Ezetimibe B Gemfibrozil or Fenofibrate C Alirocumab or evolvocumab D Omega 3 fish oil

B Gemfibrozil or Fenofibrate D Omega 3 fish oil

42 year-old African American male, total cholesterol 180 mg/dL, HDL 40mg/dL, LDL 120mg/dL, BP 140/84 mm Hg, not taking antihypertensive medication, not on a statin, not on aspirin, not diabetic, + current smoker. Calculate his 10 year ASCVD risk https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/ What is recommended? A High-Intensity statin B Moderate-Intensity statin C Statin therapy not recommended

B Moderate-Intensity statin

57 year-old white male with total cholesterol of 255, HDL 45mg/dL, LDL 144 mg/dL, systolic BP 110/70 mg Hg, not taking antihypertensive medication, not on a statin, not taking aspirin, not diabetic, non-smoker. Calculate his 10 year-ASCVD risk: https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/ What is recommended? A High-Intensity statin B Moderate-Intensity statin C Statin therapy not recommended

B Moderate-Intensity statin

What is (are) the drug( s) of choice for the treatment of isolated hypertriglyceridemia? A nicotinic acid B gemfibrozil C lovastatin D a and b E all of the above

B gemfibrozil

In congestive heart failure the mechanism responsible for the production of an S3 gallop is A contraction of atria in late diastole against a stiffened ventricle. B rapid ventricular filling during early diastole. C vibration of a partially closed mitral valve during mid to late diastole. D secondary to closure of the mitral valve leaflets during systole.

B rapid ventricular filling during early diastole.

A 56-year-old male came to the Emergency Room with complaints of palpitations and shortness of breath since 1 week ago. He has a longstanding history of poorly controlled hypertension. Physical examination reveals an elevated blood pressure of 190/98 mm Hg, elevated jugular venous pressure (JVP), mild hepatomegaly, bilateral pedal edema, and rales at the lung bases. Diagnostic studies reveal concentric left ventricular hypertrophy without significant valvular abnormalities on echocardiogram. Which of the following drugs is beneficial in the treatment of the patient's condition by virtue of both afterload and preload reduction? A. Loop diuretics (furosemide) B. Angiotensin-converting enzyme inhibitor- enalapril C. Positive inotropic agents (digoxin) D. Thiazide diuretics (hydrochlorothiazide) E. Arterial vasodilators (hydralazine)

B. Angiotensin-converting enzyme inhibitor- enalapril

How is secondary HTN different from essential HTN? A. Systolic BP does not exceed 200 mm Hg B. BP is often refractory to antihypertensives C. The onset is in the patient's late twenties D. There is a positive history of HTN E. In the majority of cases no cause can be est.

B. BP is often refractory to antihypertensives

A 66-year-old female with a history of diabetes and hypertension presents for routine evaluation. Since beginning her ACE inhibitor and diuretic therapy her blood pressures have averaged 138/85 mmHg. Which of the following is the next best step in the management of this patient? A. Congratulate her for being "at goal" with a blood pressure of less than 140/90 mmHg. B. Increase ACE inhibitor to achieve blood pressure of less than 130/80 mmHg. C. Convert ACE inhibitor to angiotensin receptor blocker. D. Explain blood pressure is a little lower than needed so discontinue diuretic.

B. Increase ACE inhibitor to achieve blood pressure of less than 130/80 mmHg.

A 48-year-old male presents to the emergency department with an alteration in consciousness after cocaine ingestion. On presentation, the patient's blood pressure is 254/162, with an oxygen saturation of 83% on room air. Physical examination is notable for depressed consciousness. The patient does not follow commands but purposely withdraws from pain in all extremities. His pupils are equal and reactive. The cardiovascular exam is notable for a hyperdynamic precordium with a loud S4 gallop. There are no murmurs. Crackles are heard diffusely in both lung fields. The chest radiograph is consistent with pulmonary edema. CT scan of the head reveals diffuse cerebral edema without hemorrhage.EKG shows LVH with T-wave inversions in V3 to V6. UA shows 1+ proteinuria with 25 to 50 RBC's/HPF. Creatinine is 2.6 mg/dL. What is the most appropriate management for this patient? A. Administer a single dose of intravenous metoprolol. B. Initiate nitroprusside by continuous infusion. C. Administer a single dose of sublingual nifedipine and assess the response to therapy. D. Initiate enalapril by continuous infusion. E. Initiate fenoldopam by continuous infusion.

B. Initiate nitroprusside by continuous infusion.

An ambulance transports a patient to your facility from the nursing home with anuria and diminished level of consciousness. Paramedics report a blood pressure of 225/130mm Hg. Which of the following medications is most appropriate for this patient? A. Esmolol (Brevibloc) B. Nitroprusside sodium (Nipride) C. Nitroglycerine (Nitrostat) D. Nifedipine (Procardia)

B. Nitroprusside sodium (Nipride)

During the physical exam of a patient with heart failure, an extra heart sound (S3 or S4) may be appreciated on cardiac auscultation. Which of the following statements about S3 and S4 is most accurate? A. S3 is most commonly associated diastolic heart failure. B. S3 occurs during early diastole. C. S3 occurs in late diastole during the atrial kick. D. S4 is most commonly associated with systolic dysfunction.

B. S3 occurs during early diastole. (S3 is a low frequency sound that can be heard during early diastole, soon after S2. River converging with ocean analogy - a lot of turbulence when blood enters ventricle S3 is associated with systolic dysfunction - in systolic heart failure, the ejection fraction is reduced and excess blood remains in the ventricles after systole - S3 is caused by atrial blood hitting against excess ventricular blood during diastole)

A 59-year-old man who was lost to follow-up after a myocardial infarction two years ago now presents to his primary care physician for a work physical. When he walks into the office he asks for a minute to catch his breath and the doctor notices that, in addition to being short of breath, he is wheezing with every breath that he lets out. The patient notes that he used to be able to walk everywhere but now he gets short of breath after walking increasingly shorter distances. He then coughs into a tissue, and shows you a pink frothy substance on the tissue. On exam, crackles are heard at the bases of his lungs and an extra heart sound is noted during early diastole. All the following answer choices link this patient's sign or symptom to the correct underlying cause, except: A.Dyspnea on exertion is due to reduced lung compliance. B.Bibasilar crackles are due to increased oncotic pressure in the pulmonary vasculature. C.Expiratory wheezing is due to peribronchial edema. D.Pink frothy sputum is due to intra-alveolar transudate.

B.Bibasilar crackles are due to increased oncotic pressure in the pulmonary vasculature. (This pt's presentation is consistent with left-sided heart failure. Bibasilar crackles do occur in left sided heart failure, however, they are due to increased hydrostatic pressure NOT increased oncotic pressure. Increased hydrostatic pressure caused by pulmonary congestion causes fluid to leak out into the lung interstitium and then into the alveoli - the crackles are the sound of the fluid filled alveoli snapping open on inspiration.)

There are several chest x-ray (CXR) findings that are signs of left-sided heart failure. Which of the following CXR findings is paired with the correct underlying pathology? A.Air Bronchogram: intra-alveolar fluid accumulation B.Cephalization: pulmonary vascular congestion in superior zone C.Fluffy opacities: fluid accumulated between two lobes of the lung D.Kerley B lines: peribronchiolar and interstitial fluid accumulation

B.Cephalization: pulmonary vascular congestion in superior zone (Cephalization refers to dilation of pulmonary vessels in the upper lobes with respect to the lower lobes. Cephalization occurs due to the diffuse congestion of the pulmonary vasculature. In the setting of pulmonary congestion, such as from left-sided heart failure, the normally ill-defined superior zone vessels appear abnormally well-defined on CXR.)

An echocardiogram is performed on a patient with suspected heart failure. Findings reveal thick ventricular walls with reduced chamber size and an ejection fraction of 56%. Which underlying condition and histological finding are most consistent with this patient's clinical picture? A.Aortic insufficiency and eccentric hypertrophy B.Chronic hypertension and concentric hypertrophy C.Constrictive pericarditis and concentric hypertrophy D.Ventricular septal defect and eccentric hypertrophy

B.Chronic hypertension and concentric hypertrophy (The heart of a patient with hypertension is pumping against a higher systemic pressure (i.e., increased afterload). Since blood flows down a pressure gradient, when the heart has to pump against a higher afterload it requires a higher ventricular pressure to maintain a normal cardiac output. With longstanding hypertension, the overworked cardiac muscles of the left ventricle may eventually undergo concentric hypertrophy to compensate for the pressure overload and reduce wall stress. This compensatory remodeling, in which sarcomeres are added in parallel, results in a thickening of ventricle walls and a reduction in chamber size, as seen on this patient's echocardiogram. The thicker, less compliant ventricle walls and reduced chamber size can lead to a filling dysfunction and thus diastolic heart failure. Additionally, in diastolic heart failure, ejection fraction is preserved, as demonstrated on this patient's echocardiogram.)

Which of the following clinical features is most consistent with the clinical presentation for isolated right-sided heart failure? A.Hemosiderin-laden macrophages B.Jugular venous distension C.Paroxysmal nocturnal dyspnea D.Tachypnea

B.Jugular venous distension (Blood from a failing right heart backs up into the superior vena cava and further still into the jugular veins, causing jugular venous distention. This is a sign of right-sided heart failure.)

Valvular dysfunction and cardiac arrhythmias can be seen as sequelae to both left-sided and right-sided heart failure. Which of the following findings is most likely to be seen as sequelae to left-sided heart failure? A.Aortic regurgitation and atrial fibrillation B.Mitral regurgitation and atrial fibrillation can be seen as a direct consequence of left-sided heart failure. C.Mitral stenosis and atrial flutter D.Tricuspid regurgitation and atrial fibrillation can be seen as a direct consequence of left-sided heart failure.

B.Mitral regurgitation and atrial fibrillation can be seen as a direct consequence of left-sided heart failure. (Left-sided heart failure can lead to mitral regurgitation. Elevated pressure in the failing left ventricle can cause dilation of the ventricle, which can stretch the fibrous ring attached to the mitral valve. Furthermore, mitral regurgitation causes volume and pressure overload of the left atrium, which can lead to dilation of the left atrium. Chronic left atrial dilation can cause atrial fibrillation, which is characterized as an irregularly irregular cardiac rhythm.)

A 56 year-old male with CAD and a history of multiple MI's on Atorvastatin 80mg daily and Ezetimibe 10mg daily. His current LDL is 107 mg/dL. Which of the following would be the best option to add to this patient's regime? A Add Ezetimibe B Add Gemfibrozil or Fenofibrate C Add alirocumab or evolocumab D Add Omega 3 fish oil

C Add alirocumab or evolocumab (PCSK9 inhibitors)

A 45-year-old obese Caucasian gentleman arrives at your clinic for a routine check-up after having some blood work done during a workplace health screening. He is found to have an LDL cholesterol level of 720 mg/dL. He states that his father and brother had high cholesterol and both died at a young age from a heart attack. He has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes. He is started on high dose statin and his LDL at 12 weeks is 350 mg/dL. What is the next best step in this patient's management? A Continue high dose statin, the patient's LDL is at goal B Add niacin 100 mg three times daily C Add ezetimibe 10 mg daily D Add a PCSK9 inhibitor

C Add ezetimibe 10 mg daily

A 48 year-old male with a history of coronary artery disease and two myocardial infarctions complains of shortness of breath at rest and 2-pillow orthopnea. His oxygen saturation is 85% on room air. The patient denies any prior history of symptoms. The patient denies smoking. Results of a beta-natriuretic peptide (BNP) are elevated. What should be your next course of action for this patient? A Send him home on 20 mg furosemide (Lasix) p.o. every day and recheck in one week B Send him home on clarithromycin (Biaxin) 500 mg p.o. BID and recheck in 1 week C Admit to the hospital for workup of left ventricular dysfunction D Admit to the hospital for workup of pneumonia

C Admit to the hospital for workup of left ventricular dysfunction (An elevated BNP is seen in a situation where there is increased pressure in the ventricle during diastole. This is representative of the left ventricle being stretched excessively when a patient has CHF. Sending a patient home would be inappropriate in this case.)

A 60 year-old male received Percutanteous intervention (PCI) with 2 Drug eluding stents (DES): 1 to the RCA and 1 to the PDA. Which of the following is the best option? A Fluvastatin 40 mg bid B Pitavastatin 2mg daily C Rosuvastatin (Crestor) 40mg daily D Simvastatin 40mg daily

C Rosuvastatin (Crestor) 40mg daily

You are completing a physical on a patient and his blood pressure is 160/100. According to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. What category would this blood pressure qualify as? What category would this blood pressure qualify as? A. Prehypertension B. Stage 1 hypertension C. Stage 2 hypertension D. Stage 3 hypertension

C. Stage 2 hypertension

A 68-year-old woman previously diagnosed with breast cancer is in complete remission following lumpectomy and radiation therapy. She now presents to her physician with worsening dyspnea. Echocardiogram reveals elevated end diastolic pressure with normal end diastolic volume. In addition to these findings, this patient's echocardiogram is most likely to demonstrate which of the following? A.A decreased ejection fraction and decreased contractility B.A decreased ejection fraction and normal compliance C.A normal ejection fraction and decreased compliance D.Decreased contractility and normal compliance

C.A normal ejection fraction and decreased compliance (A patient with a history of radiation to the chest is at increased risk of radiation fibrosis of the myocardium, which can cause restrictive cardiomyopathy. The fibrotic tissue restricts movement of the ventricular wall (decreased compliance), leading to a filling dysfunction and diastolic heart failure. Diastolic heart failure is characterized by elevated left ventricular filling pressures with normal filling volumes, as is seen in this patient. Ejection fraction is preserved in diastolic heart failure.)

Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are cardiac neurohormones released in response to heart failure. Which of the following statements about the physiological mechanism of ANP and BNP is most accurate? (→ : leads to) A.ANP and BNP release→ afferent arteriolar vasoconstriction→ increase in glomerular filtration rate (GFR)→ an increase in natriuresis and diuresis→ decrease in preload B.ANP and BNP release→ an increase in free water reabsorption from the collection tubules→ decrease in afterload C.ANP and BNP release→ decrease in renin→ decrease in aldosterone→ increase in natriuresis and diuresis→ decrease in preload D.ANP and BNP release→ increase in renin→ increase of angiotensin II→ vasoconstriction→ an increase in systemic vascular resistance (SVR) → decrease in afterload

C.ANP and BNP release→ decrease in renin→ decrease in aldosterone→ increase in natriuresis and diuresis→ decrease in preload (ANP and BNP are released from stretched atrial and ventricular cardiomyocytes, respectively. The overall goal of these hormones is to reduce the work of the heart by decreasing preload and afterload. One mechanism by which these hormones decrease preload is through a reduction in renin. This leads to a reduction in aldosterone which then reduces sodium reabsorption in the renal tubules, promoting natriuresis and diuresis. In short, ANP and BNP are released from fluid-overloaded, stretched heart chambers to counteract this fluid-overload by promoting salt and fluid loss.)

A patient with worsening heart failure is found to be tachycardic. Which compensatory mechanism is directly responsible for her elevated heart rate? A.Antidiuretic hormone release in response to decreased cardiac output. B.Atrial natriuretic peptide release from stretched atrial myocytes in the setting of volume overload. C.Norepinephrine release in response to decreased cardiac output. D.Renin release in response to decreased cardiac output.

C.Norepinephrine release in response to decreased cardiac output. (Heart failure is associated with a decrease in cardiac output, which the body interprets as low blood pressure. As a result, the following compensatory mechanisms are initiated to increase blood pressure: activation of the renin-angiotensin-aldosterone system (RAAS), antidiuretic hormone release, and an increase in sympathetic tone. The increase in sympathetic tone stimulates norepinephrine (NE) release, which triggers an increase in heart rate and myocyte contractility in an effort to restore cardiac output. NE also increases arterial vasoconstriction in order to increase systemic vascular resistance and maintain mean arterial pressure. These compensatory mechanisms temporarily address the adverse effects of heart failure (e.g., low cardiac output and decreased end-organ perfusion). However in the long-term, these compensatory mechanisms promote a vicious cycle of cardiac deterioration by directly activating deleterious cardiac remodeling and by increasing afterload, further reducing cardiac output, which leads to more neurohormonal activation.)

A 70 year-old male has stable angina. Which of the following is the best option? A Diet and exercise alone B Pravastatin (Pravachol) 40mg daily C Fenofibrate (Tricor) 200mg daily D Atorvastatin (Lipitor) 80mg daily

D Atorvastatin (Lipitor) 80mg daily (High intensity statin because pt has known CAD)

Which of the following should be avoided in patients with heart failure? A Diuretics B Digoxin C Anticoagulants D Calcium channel blockers

D Calcium channel blockers (The ACC/AHA guidelines advise that nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers, and most antiarrhythmic agents may exacerbate heart failure and should be avoided in most patients. NSAIDs can cause sodium retention and peripheral vasoconstriction and can attenuate the efficacy and enhance the toxicity of diuretics and ACE inhibitors.)

A 67 year-old female has peripheral arterial disease. Her LDL is 100. Which of the following is the best option? A Diet and exercise alone B Simvastatin (Zocor) 20mg daily C Fenofibrate (Tricor) 200mg daily D Rosuvastatin (Crestor) 20mg daily

D Rosuvastatin (Crestor) 20mg daily (High intensity statin because she has PAD - high risk even though the LDL isn't super high)

Which of the following is a cause of high output heart failure? A myocardial ischemia B complete heart block C aortic stenosis D thyrotoxicosis

D thyrotoxicosis (High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget's disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.)

An 80-year-old male from an assisted living facility is brought in for evaluation of repeated near-syncopal episodes when getting up from a seated position. His past medical history is significant for diabetes and hypertension for which he takes enalapril (Vasotec). Which of the following would you expect on physical examination? A. A drop in systolic blood pressure of at least 5 mmHg and a rise in pulse rate of 30 beats per minute after arising from a supine position. B. A rise in systolic blood pressure of 10 mmHg and a fall in pulse rate of 10 beats per minute after arising from a supine position. C. A rise in systolic blood pressure of 15 mmHg or a fall in heart rate by more than 15 beats per minute after arising from a supine position. D. Drop in systolic blood pressure of at least 20 mmHg and a rise in pulse rate of more than 15 beats per minute immediately upon arising from a supine position.

D. Drop in systolic blood pressure of at least 20 mmHg and a rise in pulse rate of more than 15 beats per minute immediately upon arising from a supine position.

All of the following statements about severe hypertension are true EXCEPT A. In the absence of ongoing target organ damage, patients with severe hypertension do not require immediate blood pressure reduction B. Severely elevated blood pressure is often discovered incidentally without symptoms or specific physical findings C. Aortic dissection may be the presenting manifestation of a hypertensive patient D. In a hypertensive emergency, blood pressure should be lowered rapidly to normotensive levels E. Patients receiving a continuous intravenous infusion of nipride must be carefully monitored for thiocyanate intoxication

D. In a hypertensive emergency, blood pressure should be lowered rapidly to normotensive levels

A 61-year-old man with coronary artery disease complains of progressive orthopnea and pedal edema. He is hospitalized with a blood pressure of 190/105mm Hg. The cardiac enzymes and EKG are normal. Intravenous furosemide has been administered. What is the best next step? A. Prescribe a beta-blocker to decrease myocardial oxygen demands B. Start intravenous dopamine C. Observe D. Start an ACE inhibitor

D. Start an ACE inhibitor

Which of the following is the drug of choice for antihypertensive therapy during pregnancy? A. benazepril B. atenolol C. amlodipine D. methyldopa E. losartan

D. methyldopa

A 46-year-old female is being evaluated for a new-onset hypertension that was discovered on screening at her workplace. The patient had several readings revealing systolic and diastolic hypertension. Patient is currently on no medications. Physical examination is unremarkable. A complete laboratory evaluation revealed hypokalemia as the only abnormality. Which of the following is the most likely diagnosis for this patient? A. pheochromocytoma B. renal artery stenosis C. coarctation of the aorta D. primary aldosteronism

D. primary aldosteronism

A 40-year-old man presents to the emergency room with worsening shortness of breath. Auscultation of the lung fields reveal bibasilar crackles and a harsh holosystolic murmur heard loudest at the left lower sternal border is appreciated. He is admitted and cardiac workup demonstrates an ejection fraction of 38%. When compared to a normal heart, this patient's left ventricular end diastolic (LVED) volume and LVED pressure are: A.Decreased and decreased, respectively. B.Decreased and increased, respectively. C.Increased and decreased, respectively. D.Increased and increased, respectively.

D.Increased and increased, respectively. (This patient's clinical presentation is consistent with systolic heart failure secondary to ventricular septal defect (VSD). VSD causes a left-to-right shunt in the heart, which can lead to volume overload and systolic heart failure. In addition to reduced ejection fraction, systolic heart failure is characterized by elevated filling volumes (increased LVED volume) in combination with elevated filling pressures (LVED pressure).)

Which of the following statements about the clinical manifestations of right-sided heart failure is true? A.Ascites is the direct result of hepatic vein congestion. B.Non-pitting edema is a common sign of right-sided heart failure. C.Nutmeg liver is the result of portal vein congestion. D.Right-sided heart failure can result in pericardial effusion.

D.Right-sided heart failure can result in pericardial effusion. (Systemic congestion caused by right-sided heart failure can lead to fluid buildup in extravascular spaces such as around the heart and lungs, which is seen as pericardial effusion and pleural effusion on imaging.)

Determination of ejection fraction, an objective measure of cardiac function, is important in the diagnosis and classification of heart failure. How is ejection fraction calculated? A.Preload divided by afterload B.Preload divided by end diastolic volume (EDV) C.Stroke volume (SV) divided by afterload D.Stroke volume (SV) divided by end diastolic volume (EDV)

D.Stroke volume (SV) divided by end diastolic volume (EDV) (Ejection fraction is the fraction of total blood inside the left ventricle that is ejected during systole. It is calculated by dividing stroke volume (the blood ejected from the left ventricle during systole, or end diastolic volume minus end systolic volume) by end diastolic volume (blood in left ventricle at the end of diastole). In other words, it is the blood pumped out divided by the total blood initially inside the ventricle. In systolic heart failure, ejection fraction is reduced.)

A 58-yis a blood pressure of 150/96 mmHg. He has smoked 1 pack of cigarettes per day for 10 years, but he quit 20 years back. Family history is significant for diabetes and hypertension in 2 elder siblings. Past medical history is insignificant, except for an appendectomy 30 years back and fractured right radius 15 years back. Repeat BP recordings show a BP of 148/98 mmHg and 150/98 mmHg. Fasting blood glucose is 122 mg/dl. Which drug would you prefer to initiate anti-hypertensive therapy in this patient? A. Nifedepine B. Prazosin C. Atenololear-old patient is seen in your office for a routine physical exam. The only abnormal finding D. Hydrochlorthiazide E. Enalapril

E. Enalapril

Which of the following antihypertensive drugs is incorrectly matched with the indication for therapy? A. ACE inhibitor—diabetic nephropathy B. Beta blocker—coronary artery disease C. Calcium channel blocker—angina D. Diuretics—heart failure E. Loop diuretic—gout

E. Loop diuretic—gout

A 62-year-old African-American male is seen for his yearly physical exam. He has no complaints. He denies any current medications or medical problems, but the occupational medicine nurse has taken his blood pressure several times in the past year and told him it was high. He denies any tobacco or alcohol use. His blood pressure is 156/92 today. What is the most likely cause of his elevated blood pressure? A. sleep apnea B. primary aldosteronism C. pheochromocytoma D. renal artery stenosis E. essential hypertension

E. essential hypertension

42 year-old white man with total cholesterol 250mg/dL, HDL 40mg/dL, LDL 154mg/dL, Trig 480 m/dL, Blood pressure 130/72 mm Hg, Not taking antihypertensive medication, not on aspirin, not a diabetic, + smoker, calculated 10-year risk of CHD or stroke is 9%. ASCVD risk is 9%. What factors could be considered in the decision to initiate a statin in this patient?

LDL, BP, Lifestyle (Would use calculator on this pt)