KRISNA

1. Blood cultures are positive for Streptococcus viridans and the patient is treated for infective
endocarditis (IE). A small mobile echodensity is noted adjacent to the VSD. At clinic review 3
months later he is much improved, repeat blood cultures are negative, and transesophageal
echocardiography (TEE) is negative for vegetations. The patient asks whether his VSD should
now be closed. What is the best answer?
a. Closure is indicated in those with a VSD complicated by IE.
b. VSD closure is NOT indicated in those with a VSD complicated by IE.
c. VSD closure is only indicated in the presence of a significant shunt (Qp/Qs, pulmonary to
systemic blood flow ratio 2.0).
d. VSD closure is only indicated in the presence of a significant shunt accompanied by
symptoms.

2. A patient arrives at the emergency department after experiencing multiple shocks from his ICD.
The shocks were not preceded by any symptoms. He is noted to be in sinus rhythm on
presentation, and, while on the monitor, he receives several more shocks from the ICD without
any arrhythmias noted. Which of the following is the most appropriate initial step in the
management of this patient?
a. Immediately arrange for a programmer for interrogation and reprogramming of the ICD.
b. Arrange for urgent surgery in the EP laboratory.
c. Initiate antiarrhythmic drug therapy.
d. Place a donut magnet over the ICD site.

3. A 28-year-old woman is referred for evaluation of persistent dyspnea related to mitral stenosis.
The patient is 30 weeks' pregnant, and her dyspnea persists despite treatment with metoprolol,
furosemide, and digoxin. Her heart rate is 70/min. An echocardiogram shows severe mitral
valve stenosis, with a mean gradient of 14 mm Hg and a mitral valve area of 1 cm2. Trivial
mitral valve regurgitation is noted. The estimated right ventricular systolic pressure is 50 mm
Hg. She has crackles in both lung bases and bilateral lower extremity edema.
Which of the following interventions do you recommend?
a. Diagnostic cardiac catheterization
b. Surgical mitral valvotomy
c. transesophageal echocardiography followed by percutaneous mitral balloon valvuloplasty
d. Fetal echocardiogram
e. Urgent delivery of the fetus followed by reassessment of maternal cardiac status

4. You are asked to see a 50 year old female dietitian in consultation for HTN. She was found to
have an elevated BP on an medical check up 4 yrs ago. She followed her physician's
recommendations and uses only sodium substitutes, limits alcohol consumption, and exercises.
She adopted a vegetarian lifestyle. Despite these measures, her BP remained above normal and
her health care provider prescribed several medication regimens. However, her BP could not
be maintained at <160/90mmHg. Her medications include: Metoprolol: 25 mg twice daily,
Lisinopril: 20 mg twice daily, Amlodipine: 10 mg daily. Your examination detects the
following: BP: 188/100 mmHg (seated), 190/100 mmHg (standing); HR: 70 bpm, sitting, 80
bpm standing, Normal funduscopic examination, Normal peripheral pulses and no abdominal
bruits, Normal cardiopulmonary examination. This patient has continued medical therapy and
improves somewhat with addition of triamterene/HCTZ (37.5/25 mg) daily. Her BP is now 160
mmHg systolic. Laboratory results include: CBC: Normal Creatinine: 1.9 mg/dL Sodium:
145mEg/L Potassium: 3.5mEg/L Uric acid: 3.0 mg/dL ECG: LVH by voltage criteria Chest X-
ray: Normal. This patient has continued medical therapy and improves somewhat with addition
of triamterene/HCTZ (37.5/25 mg) daily. Her BP is now 160 mmHg systolic. Laboratory results
include: CBC: Normal. Creatinine: 1.9 mg/dL. Sodium: 145mEg/L. Potassium: 3.5mEg/L. Uric
 acid: 3.0 mg/dL. ECG: LVH by voltage criteria. Chest X-ray: Normal. The most likely
secondary form of HTN in this setting is:
a. Phenochromocytoma
b. Primary aldosteronism
c. Chronic renal failure
d. Renovascular stenosis

5. are asked to review an ECG of a baby on the intensive care unit. The baby was well at birth,
but soon became unwell and cyanosed. There was no heart murmur. ECG findings reveal a
superior axis, absent right ventricular voltages, and a large P wave. What is the MOST likely
diagnosis?
a. Complete atrioventricular septal defect
b. Tricuspid atresia
c. Critical pulmonary stenosis
d. Transposition of the great arteries
e. Total anomalous pulmonary venous connection (TAPVC)

6. A 35-year-old man presents to your office for evaluation of valvular heart disease. He
complains of shortness of breath with only modest amounts of exertion, as well as two-pillow
orthopnea. He also complains of easy fatigability, as well as lower extremity edema and
abdominal fullness. On examination, he is in no acute distress. He is normotensive. Jugular
venous pressure is elevated, with a prominent a wave. The v wave is not easily discerned. S1 is
loud. S2 is normal. A sound is heard in diastole, 0.07 milliseconds after S2. A diastolic rumble
is heard at the apex. A diastolic murmur is also heard along the left sternal border, which
increases with inspiration. Mild hepatomegaly is present. There is 2+ peripheral edema.
What is your diagnosis?
a. Mitral stenosis and AS
b. Mitral stenosis with tricuspid insufficiency
c. Tricuspid stenosis
d. Mitral stenosis
e. Mitral and tricuspid stenosis

7. 80 year old hypertensive male referred to cardiology clinic with stable NYHA FC III angina
for 3 months treated with aspirin, metoprolol succinate 150 mg daily, isosorbide mononitrate
120 mg daily, and simvastatin 40 mg daily. On exam, the heart rate is 57, the blood pressure is
98/60 mmHg, and the cardiopulmonary exam is unremarkable. Resting ECG is within normal
limits. An exercise stress test is significant for 2 mm horizontal ST depression and exercise
limiting chest discomfort at 6 METs.
The Duke Treadmill Score for this patient is:
a. -14, intermediate risk
b. -9, intermediate risk
c. -9, high risk
d. -14, high risk
e. -10, intermediate risk

8. 60 year old man with AF was started on warfarin 8 months ago. He present to the emergency
room with severe bleeding. Blood work levels that INR of 4.9. hemoglobin 12 mg/dL and
platelet count 200.000. you decide to immediately reverse his warfarin with?
a. Thrombocyte transfusion
b. Dyalisis
c. Vitamin K
d. Cryoprecipitate
9. A 70 -year old woman is admitted via ambulance to emergency room. She is very dyspneic and
unable to give history. Medications found with her are as follows: furosemide 80 mg po od,
atenolol 50 mg po od, warfarin, digoxin 0.125 mg po od. Routine observations are as follows:
temperature 37oC, pulse 130 bpm, irregularly irregular, blood pressure 190/100 mmHg,
respiratory rate 40 breath/min, 02 saturations are 88% on 10 U/min 02 through rebreathe mask.
Examination reveals central cyanosis and cool peripheries. Auscultation of the chest reveals
widespread inspiratory crepitations; pulses are absent below the femoral arteries in both legs.
The following investigations are available: arterial blood gases, pH 7.12; p02 5.8 kPa; pC02
3,2 kPa; bicarbonate 6.0 mmol/L. Routine electrolytes; sodium 130 mmol/L; potassium 5.5
mmol/L; creatinine 3.3 mg/dl; glucose 108 mg/dl. Her CXR shows cardiomegaly, air
shadowing and Kerley B-lines. EKG recording demonstrate widespread ST depression and ST
elevation in lead aVR.
All of the following are the findings on the arterial blood gases, EXCEPT?
a. A ventilation perfusion mismatch
b, Metabolic acidocis relelated to renal failure
c. Type 1 respiratory failure
d. Profound lactic acidosis
e. Severe hyperkalemia due to renal dysfunction

10. Regarding trans-thoracal echocardiography, which of the following statement is appropriate to

perform trans-thoracal echocardiography:
a. Initial evaluation in patient with murmur or click without other signs and symptoms of
structural heart disease
b. Routine surveillance (<1 y) of mild stenosis without change in clinical status/ cardiac exam
c. Routine perioperative evaluation of cardiac structure and function prior to noncardiac solid
organ transplantation
d. Routine surveillance (>3 y) of mild stenosis without change in clinical status/ cardiac
exam e. To evaluate arrhythmias in infrequent APC/ VPC without evidence of heart disease

11. Among patients with class n angina and one- or two-vessel disease, PCI is indicated for which
of the following:
a. Prevention of MI
b. To alleviate asymptomatic ischemia
c. To prevent progression of CAD
d. To improve symptoms
e. Prevention of death

12. 75-year-old woman is referred urgently to the cardiology clinic. She had a myocardial infarction
4 years earlier, percutaneous coronary intervention with a stent for angina 12 months earlier
and has had two blackouts in the last month, 3 weeks apart. She tells you that in one occasion
she was gardening and trying to lift a heavy plant pot. She had no warning and suddenly found
herself on the ground. She was alert on recovery. There was no seizure-like activity. She does
have exertional breathlessness although she can manage 400m on the flat and a single flight of
stairs. She has not had angina since her coronary stent 12 months earlier. Occasionally she feels
light-headed if she stand up too guickly. She is currently taking aspirin, a beta-blocker, an ACE
inhibitor, a loop diuretics and a statin. Her physical examination reveals blood pressure 130/55
mmHg, resting pulse 55 bpm, regular, normal volume. The JVP is raised by 2 cm, her apex beat
is displaced to the lateral clavicular line, sixth intercostal space and there is a systolic murmur
heard all over the precordium and in the carotids. The lung field are clear and there is mild
pitting edema at the level of her shins.
All of the following would be the cause of blackout in this patient, EXCEPT?
a. A bradycardia caused by Stokes-Adam attack
b. Transient ischemic attack
c. Orthostatic hypotension
d. A tachycardia caused by ventricular tachycardia
 e. Severe aortic stenosis

13. A 21-year-old woman with Turner syndrome has a history of surgical repair for periductal
coarctation of the aorta at age 4 years. Her presentation was for HTN and heart failure, both of
which resolved after the procedure. She was lost to follow-up after childhood and recently
reestablished with a cardiologist. She has been experiencing dyspnea and claudication in the
past year. Physical examination : BP188/94 mmHg (left arm); 192/100 mmHg (right arm);
100/60 mmHg (right leg). Pulses are notable for normal upper extremity and reduced lower
extremity pulses with a brachialfemoral delay. Cardiac examination is notable for normal S1
and paradoxically split S2 with an ejection click and S4 gallop. A continuous murmur III/VI in
intensity is heard under the left scapula.
Which of the following statements is correct regarding the echocardiographic image from this
patient obtained from the abdominal aorta (Fig. 6.5)?

a. The hallmark of coarctation is the presence of low systolic velocities

b. The presence of coarctation cannot be determined without knowing the timing of the pulse
delay relative to aortic ejection
c. The hallmark of coarctation is the presence of persistent antegrade flow in diastole
d. The presence of coarctation cannot be determined without additional Doppler images
proximal to the coarctation site

14. Which of the following agents is effective for converting AFib to sinus rhythm and for
maintaining sinus rhythm after it is restored?
 a. Digoxin
b. Amiodarone
c. Diltiazem
d. Propranolol

15. A 60-year-old man known for current smoking is admitted to the emergency department for
prolonged typical chest pain. The 12-lead ECG is shown in Figure 4.7. What is the most likely
finding at the coronary angiography?

a. Occlusion of the first marginal branch of the left circumflex coronary artery
b. Occlusion of the proximal left anterior descending coronary artery
c. Occlusion of the dominant RCA
d. Occlusion of the left main trunk
e. Occlusion of the first diagonal branch

16. C. P. is a 46-year-old white man admitted with worsening headache, and nausea and vomiting
over 48 hours. The patient is status post single-lung transplant secondary to 1-antitrypsin
deficiency. His immunosuppression regimen includes cyclosporine, prednisone, and
azathioprine. As a result of the cyclosporine, he has HTN and renal dysfunction (baseline serum
creatinine, 1.9 mg/dL). His BP is controlled with clonidine 0.2 mg twice daily and metoprolol
tartrate 25 mg twice daily. Two months ago, he was changed to metoprolol from amlodipine
because of peripheral edema. The patient was in his usual state of health until approximately 1
week ago, when he experienced diarrhea, which has since resolved. On admission, his BP was
208/110 mmHg and his serum creatinine was 3.8 mg/dL. What is the most appropriate regimen
to control this patients BP?
a. Change back to amlodipine 10 mg daily
b. Initiate nitroprusside drip and give IV fluids
c. Add captopril to the regimen and titrate to effect
d. Give sublingual nifedipine
17. A 32-year-old man with known bicuspid aortic valve is referred to you for management of
aortic insufficiency (AI). He is completely asymptomatic and jogs 3 miles a day as well as
doing other aerobic exercise for 30 minutes daily. He has a grade III/VI systolic and diastolic
murmur at his left sternal border, a collapsing pulse on examination, and his BP 170/70 mmHg.
An echocardiogram
reveals a mildly dilated LV (end-diastolic dimension of 6.0 cm) with an ejection fraction of
65%. There is prolapse of the conjoined aortic leaflet with 3 to 4+ insufficiency.
What is your recommendation?
a. Referral for surgery
b. Addition of vasodilator therapy
c. Observation for now, return for follow-up in 3 years
d. Cardiac catheterization

18. A 65-year-old man presents for a routine physical examination. During the interview he
complains about swelling behind his right knee. You order an ultrasound of the area (findings
illustrated in Fig.
7.1).

What is the most common complication of untreated, symptomatic popliteal artery aneurysms
measuring more than 2.5 cm in greatest dimension?
a. Rupture
b. Thromboembolism
c. Infection
d. No complications
e. Popliteal vein thrombosis

19. Your patient is a 50-year-old woman with nonischemic cardiomyopathy who just received an
orthotopic heart transplant. Which of the following is NOT important to help prevent transplant
vasculopathy?
a. Empirically starting statin therapy
b. Strict control of hypertension (HTN) and diabetes
 c. Use of rapamycin as part of the immunosuppressive regimen
d. Abstinence from smoking

20. Which of the following is a prodrug and requires bioactivation?

a. Aspirin
b. Clopidogrel
c. Prasugrel
d. Ticagrelor
e. Both b and c

VIANNEY

21. 50-year-old man with chronic obstructive pulmonary disease related to chronic smoking
presents to the emergency room with palpitations. ECG shows narrow QRS tachycardia at 165
bpm. His BP is 125/60 mmHg. Expiratory wheezes are heard on lung examination. His
medications include albuterol inhaler and theophylline. The most appropriate initial treatment
includes which of the following?
a. Adenosine IV bolus
b. Digoxin loading over 6 hours
c. Verapamil IV bolus
d. Propafenone IV bolus
e. Immediate cardioversion

22. What is the diagnosis of the following cardiac catheterization still-frame slides?
a. Coarctation of the aorta
b. Patent ductus arteriosus (PDA)
c. Hypertrophic cardiomyopathy
d. Pulmonic stenosis
e. VSD

23. 59-year-old man with a history of coronary artery disease (CAD) and remote coronary bypass
surgery presents with progressive dyspnea and vague chest pain. He had a stress
echocardiogram for these symptoms that demonstrated normal LV function with no stress-
induced wall motion abnormalities. However, he returned to the emergency department a few
days later with recurrent symptoms. This time the house officer examining the patient notes 3+
pedal edema. The patient is admitted and started on diuretics. His blood tests are as follows:
White blood cell count = 11,000, Hemoglobin = 14.2, Platelets = 172,000, Albumin = 4.6, Urea
= 11, Creatinine = 0.9. Owing to the recurrent symptoms, his cardiologist decides to refer him
 for a right and left heart catheterization. The coronary grafts are all patent. The tracings from
the study are shown in Figure 13.2. What is the most logical explanation for this patients
symptoms?
a. Constrictive pericardial disease
b. Small-vessel CAD
c. Diastolic dysfunction related to his chronic CAD
d. Cardiac amyloid
e. Cardiac tamponade

24. 28-year-old woman with aortic and mitral mechanical valve prostheses that were placed for
congenital heart disease comes to your office for a prepregnancy consultation. She is active and
asymptomatic. Physical examination shows normal prosthetic, aortic, and mitral valve
prosthesis auscultation. Results of laboratory studies are normal, except for a therapeutic
international normalized ratio on warfarin anticoagulation. Which of the following
recommendations is appropriate for the management of this patient during pregnancy?

A. Discontinue warfarin anticoagulation and initiate treatment with aspirin and dipyridamole
for the first trimester
B. Continue warfarin administration throughout pregnancy and start heparin 5,000 U
subcutaneously three times daily, plus aspirin
C. Discontinue warfarin administration and initiate treatment with enoxaparin, 30 mg
subcutaneously twice daily for the rest of the pregnancy
D. Discontinue warfarin and initiate dose-adjusted unfractionated heparin subcutaneously
during the first trimester and resume treatment with warfarin for the rest of the pregnancy
until shortly before delivery
E. Discontinue warfarin anticoagulation and initiate treatment with clopidogrel and aspirin
during the first trimester and resume treatment

25. A 50-years old male patient brough this treadmill test result that performed after he had finished
phase II of cardiac rehabilitation program after undergone elective PCI. His baseline HR was
70bpm. There was no ST-T changes, no arrhythmia, normal response of BP and HR during
exercise. The test was stopped at 9 minutes of exercise (Bruce protocol), with HR 150 (Rate
Perceived Exertion: Borg Scale 17). What is his HR target for treadmill at home using 65-75%
HRR (Heart Rate Reserve) formula?
A. 102 107bpm
B. Cant be measured
C. 110 127bpm
D. 122 130bpm
 E. 97 112bpm

26. A 55-year-old male presents with shortness of breath for 6 months. He's been sleeping in a chair
for the past month because he coughs whenever he lies back. He's also noticed that his heart is
racing most of the time. He's had no antecedent illnesses. He tells you that his brother died
suddenly several years ago in his 30s. He drinks socially. He appears confortable with a BP of
110/75 and a regular HR of 115. His jugular venous pressure is 18 cm of water, lungs are clear,
and the heart is enlarged on palpation. He has a gallop rhythm and a difuse precordial systolic
murmur. The abdomen is mildly tender in the RUQ with a liver edge easily palpable. He is a
warm with a trace pedal edema. An ECG demonstrates sinus tachycardia and narrow QRS. In
addition to diuretic management, you initiate:
a. Aldosterone antagonist
b. Angiotension converting enzyme (ACE) inhibitor
c. Angiotensin receptor blocker (ARB)
d. Digoxin
e. Beta-blocker

27. Inducers of smooth muscle cell proliferation include the following except
a. platelet-derived growth factor-.
b. basic fibroblast growth factor (bFGF).
c. transforming growth factor- (TGF-).
d. thrombin.
e. oxidized low-density lipoprotein (LDL).

28. A 42-year-old man presents for a routine physical examination. He is noted to have a body mass
index of 30 kg/m2, impaired fasting glucose, and a blood pressure of 135/85 mmHg. What is
the best treatment plan for this individual?
a. Aggressive lifestyle modification
b. Institute thiazide diuretic regimen
c. No treatment at this time
d. Initiate ACEI.

29. A 61-year-old woman with an EF of 50% is admitted with an AFib with rapid ventricular
response. She is started on metoprolol tartrate with excellent rate control and heparin. Her
daughter, who is a nurse, wants to know why you did not start her on dofetilide because this is
the best new drug. What is your response?
a. Dofetilide showed increased mortality when compared with amiodarone and would be a
bad choice for her mother.
b. Dofetilide had safety and efficacy comparable to those of -blockers.
c. Dofetilide was used in patients with an EF less than 35%.
d. Dofetilide has safety and efficacy comparable to those of calcium channel blockers.
e. Dofetilide is reserved for patients with chronic renal insufficiency.

30. A 50-year-old man presents for his first physical examination in several years. He notes that a
murmur had been documented a number of years ago. He is entirely asymptomatic. On
examination, he has a BP of 120/70 mmHg with a pulse rate of 58 bpm. Neck veins are not
distended. Carotid up strokes are brisk. Lungs are clear. Cardiac examination reveals a
nondisplaced PMI. S1 is soft; S2 is normal (with a preserved A2). An S3 is heard. A III/VI
holosystolic murmur is heard at the apex radiating to the base and carotids, which increases
with handgrip. Echocardiogram reveals myxomatous mitral valve disease with posterior leaflet
prolapse and severe MR. The prolapse involves the P2 (middle) segment and is severe. There
 is no calcification of the valve. End-systolic dimension is 3.0 cm; end-diastolic dimension is
5.6 cm. Ejection fraction is 65%. TR velocity is 2.9 m/s.

Which of the following would be most appropriate at this time?

a. Referral for mitral valve replacement
b. Consider elective mitral valve repair at a hospital where repair is performed with a high
degree of success or if he wishes to defer surgery, follow up at 6 monthly intervals with echo
c. The addition of an ACEI and follow-up in 2 years
d. The addition of amiodarone to prevent atrial fibrillation
e. Follow-up in 2 years without an echocardiogram

31. A 68-year-old man with hypertension and history of a stroke presents for further management
of his hypertension. He is currently prescribed a thiazide diuretic; however, his blood pressure
remains elevated. From the standpoint of decreasing his future risk of stroke, which of the
following drug classes would be most beneficial?
a. Calcium channel blocker
b. ACEI
c. ARB
d. -Blocker

32. A. F. is a 52-year-old man with a history of AFib, transient ischemic attacks, hypertension
(HTN), and rheumatic heart disease. The recommendations from the Sixth American College
of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy suggest that
this patient be initiated on _____ for antithrombotic therapy because of AFib.

a. aspirin, 81 mg daily
b. aspirin, 325 mg daily
c. warfarin, with a target goal international normalized ratio (INR) of 2.5
d. warfarin, with a target goal INR of 3.5

33. A 65-year-old hypertensive man was hospitalized for non-ST-segment-elevation myocardial

infarction (NSTEMI). The clinical examination shows a fourth heart sound (S4). What is
expected to be found at the echocardiography?
a. Reduction in left ventricular compliance
b. Rapid deceleration of transmitral flow during protodiastolic filling of the left ventricle
c. Increased inflow into the left ventricle
d. Reduced left ventricular systolic function
e. Aortic sclerosis

34. Echocardiography confirms doming valvular pulmonary stenosis with a mean Doppler gradient
of 40 mmHg. There is no significant pulmonary regurgitation or TR. ECG is normal. The
patient undergoes cardiac catheterization (results below):
 What is the most appropriate management for this patient?
a. Referral to a pulmonary hypertension specialist
b. Repeat cardiac catheterization with vasodilator challenge
c. Balloon valvotomy
d. Surgical repair
e. Diuretics

35. Which of the following is not a direct thrombin inhibitor?

a. Bivalirudin
b. Argatroban
c. Hirudin
d. Dabigatran
e. Apixaban

36. You are consulted for recommendations regarding a deep vein thrombosis in a patient who is
status post aortic valve replacement with a bioprosthetic valve 4 days prior. Earlier on the day
of
consult he complained of pain and was diagnosed with a partially occlusive left femoral vein
thrombosis. His postoperative course has been otherwise uncomplicated. On examination, the
patient is tender around the surgical site. There is moderate pitting edema in the legs bilaterally.
He has palpable pulses in all extremities. What do you recommend?
a. Bolus subcutaneous low-molecular-weight heparin (LMWH) 80 mg/kg, then dose at 1
mg/kg subcutaneously every 12 hours
b. Placement of a retrievable inferior vena cava filter
c. Catheter-directed thrombolysis
d. Begin a DTI
e. Begin a weight-based unfractionated heparin infusion

37. Y. J. is a 67-year-old African American man with HF who has been treated with lisinopril 20
mg daily, metoprolol succinate 25 mg daily, furosemide 40 mg twice daily, and spironolactone
12.5 mg daily. Despite his current therapy, he still complains of shortness of breath while
conducting usual daily activities. What is the most appropriate change that should be made to
his regimen?
a. Increase spironolactone
b. Start hydralazine
c. Initiate isosorbide dinitrate and hydralazine
d. Increase lisinopril

38. A 70-year-old man is admitted to the telemetry unit for workup of dizziness of 2 days duration.
He denies chest pain or shortness of breath. His heart rate is 60 bpm and blood pressure is
130/50 mmHg. On physical examination, a systolic murmur is heard over the left sternal border.
 Carotid duplex ultrasound is performed demonstrating the spectral waveforms of the bilateral
internal carotid and vertebral arteries illustrated in Figure 7.5.

Which of the following conditions is suggested by the carotid duplex waveforms?

a. Pulmonary valve stenosis
b. Systolic heart failure
c. Pericardial tamponade
d. Aortic valve stenosis
e. Mitral regurgitation

39. A 26-year-old woman with a history of hypertrophic obstructive cardiomyopathy is referred for
consideration for septal myectomy. She has NYHA class III dyspnea on exertion despite
maximal medical therapy. On echocardiography, there is severe asymmetric septal hypertrophy
with severe systolic anterior motion of the mitral valve. There is a late-peaking gradient across
the LVOT of 60 mmHg, which increased to 105 mmHg with Valsalva. She has a structurally
normal mitral valve on cardiac MRI with moderately severe posteriorly directed MR (Fig. 2.8).
 What would you advise her regarding surgery?
a. She will probably require mitral valve replacement at the time of surgery.
b. She will probably require mitral valve repair during surgery.
c. She will probably not need surgery on her mitral valve.
d. She may need plication of her papillary muscles.

40. Lupa ke screenshot. Maafkan ya teman-teman.

HENDY

41. Which of the following is true regarding use of GP IIb/IIIa inhibitors in STEMI?
a. Routine upstream use of GP IIb/IIIa inhibitors has been shown to reduce target vessel
revascularization (TVR).
b. Routine GP IIb/IIIa inhibitor use is associated with reduced incidence of recurrent MI.
c. Routine GP IIb/IIIa inhibitor use is associated with increased risk of bleeding.
d. Small-molecule GP IIb/IIIa inhibitor use has been shown to reduce 30-day mortality.
e. Upstream use of GP IIb/IIIa inhibitors is given a class I indication in current American
College of Cardiology (ACC)/American Heart Association (AHA) guidelines.

42. A 34-year-old gentleman reports a history of TOF, Blalock-Taussig shunt at 10 months, and
complete repair at age 3. Although he has been reasonably active for several years, he has noted
progressive exercise intolerance in recent months. Examination reveals a III/VI systolic ejection
murmur loudest at the second left intercostal space and a II/IV diastolic murmur along the left
sternal edge. Jugular venous pulse is not elevated. Lungs are clear and there is no hepatomegaly
or peripheral edema. An echocardiogram demonstrates RV dilatation, moderate-to-severe
pulmonic regurgitation but no significant TR. The ECG shows sinus rhythm and right bundle
branch block with a QRS duration of 160 milliseconds. The most reasonable next step in the
evaluation of this patient would be?
a. repeat echocardiogram with a saline bubble study.
b. electrophysiologic study for ventricular arrhythmias.
c. cardiac catheterization.
d. cardiac magnetic resonance imaging study.
e. diuretics and digitalis

43. A 22-year-old white man is newly diagnosed with non-Hodgkin lymphoma. He undergoes a
metastatic workup that includes an MRI of the chest and abdomen, which is shown in Figure
 13.11. The plan is for chemotherapy, but you are consulted for cardiac assessment before
beginning chemotherapy. Radionuclide ventriculography shows a normal LV EF of 65%.

What should you recommend?

a. Ordering a TTE to delineate the abnormality
b. Cardiothoracic surgical consultation before starting chemotherapy
c. Exercise stress testing
d. Proceeding with chemotherapy without further cardiac evaluation

44. A 47-year-old man with constrictive pericarditis is undergoing an echocardiogram for follow-
up. The sonographer asks you to explain the difference between the annulus reversus and
annulus paradoxus phenomena. Which of the following statements is correct?

a. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities
(Eseptal > E lateral) and annulus paradoxus refers to inverse correlation of E/E and LV
enddiastolic pressure.
b. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities
(Aseptal > A lateral) and annulus paradoxus refers to inverse correlation of E/E and LV
enddiastolic pressure.
c. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities
(Eseptal < E lateral) and annulus paradoxus refers to positive correlation of E/E and LV
enddiastolic pressure.
d. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities
(Aseptal < A lateral) and annulus paradoxus refers to a positive correlation of E/E and LV
enddiastolic pressure.

45. A 66-year-old man is seen by his internist for an annual evaluation. Past medical history is
notable for HTN and tobacco use. His BP is 136/80 mmHg on monotherapy. Cardiac and
 abdominal examinations are unremarkable. He has a friend who was detected to have an AAA
on routine screening and asks his physician whether it is indicated for him to be screened.
Which of the following statements regarding AAA screening is correct?
a. Consensus guidelines recommend routine screening of all women >60 years of age or older
b. Screening men >65 years old is associated with a reduction in aneurysm-related deaths
compared with unscreened males of similar ages
c. Sensitivity and specificity of ultrasound screening in appropriate patients in accredited
laboratories are >70%, respectively
d. After a negative screening examination in a man aged 65 years or older, a repeat
examination should be performed 5 years later

46. A 70-year-old man is admitted to the telemetry unit for workup of dizziness of 2 days duration.
He denies chest pain or shortness of breath. His heart rate is 60 bpm and blood pressure is
130/50 mmHg. On physical examination, a systolic murmur is heard over the left sternal border.
Carotid duplex ultrasound is performed demonstrating the spectral waveforms of the bilateral
internal carotid and vertebral arteries illustrated in Figure 7.5.

Which of the following conditions is suggested by the carotid duplex waveforms?

a. Pulmonary valve stenosis
b. Systolic heart failure
c. Pericardial tamponade
d. Aortic valve stenosis
e. Mitral regurgitation

47. A 47-year-old man with coronary artery disease, diabetes mellitus, and hypertension is
currently taking clonidine. He is found to have a blood pressure of 170/90 mmHg after
forgetting to take his medication for 48 hours. What is the best strategy to control his blood
pressure?
 a. Restart clonidine.
b. Start nitroprusside.
c. Start esmolol.
d. Add thiazide diuretic.

48. By which of the following mechanisms do diltiazem and verapamil slow ventricular rate in
patients with AFib?
a. They decrease the conduction velocity within the atrioventricular (AV) node.
b. They decrease the refractory period of nodal tissue.
c. They stimulate vagal tone.
d. They prolong the refractory period of atrial tissue.

49. Which of the following characterizes heart failure?

a. Downregulation of 1- and 2-receptors
b. Downregulation primarily of 1-receptors with little change in 2-receptors
c. Downregulation of G proteins and 1- and 2-receptors
d. Increase in myocardial norepinephrine stores
e. Intact baroreceptor function

50. The following are endothelium-independent vasodilators except

a. nitroglycerin.
b. papaverine.
c. adenosine.
d. acetylcholine (ACh).
e. verapamil.

51. an 80-year-old man with chronic AFib of 15 years duration is admitted with recurrent
episodes of dizziness and a recent episode of syncope. He has normal LV function and no
evidence of CAD. In-hospital telemetry confirms the presence of slow ventricular rate and
frequent pauses (4 seconds) that correlate with his lightheadedness. His medications consist of
warfarin (Coumadin). A decision was made to proceed with a permanent pacemaker.
Which would be the most suitable pacing modality?

a. Dual-chamber system programmed to DDDR

b. Single-chamber system in the ventricle programmed to VVIR
c. Single-chamber system in the atrium programmed to AAIR
d. Dual-chamber system programmed to DDIR
e. Dual-chamber system programmed to DDDR with mode switching

52. a 21-year-old intravenous drug abuser came to the hospital with fever and malaise of 3 weeks
duration. His chest X-ray showed right sided pneumonia and bilateral plural effusions. The
initial examination was remarkable for inspiratory wheezes and dullness at the right base.
There were prominent c-v waves in his jugular venous pulse and a hyperdynamic precordium
was noted. A grade 3/6 systolic murmur was audible most prominently along the left sternal
border. Five of six blood cultures were positive for Pseudomonas aeruginosa and he was
started on tobramycin and piperacillin. However, after 3 weeks he had persistent fever to
43C and 1+ pedal edema, and blood cultures were again positive for Pseudomonas.
Appropriate therapy at this time would be:

a. antibiotics changed to tobramycin and ceftazidime and given for an additional 4 weeks
b. tricuspid valvulectomy with replacement by a prosthetic valve and antibiotic treatment for
 4 weeks
c. tricuspid valvulectomy with replacement by a Hancock porcine prosthesis and antibiotics
for 4 weeks
d. tricuspid valvulectomy with replacement by a St. Jude mechanical prosthesis and
continued antibiotics for 4 weeks
e. an additional 4 weeks of treatment with higher doses of tobramycin and piperacillin

53. A 25-year-old man presents to your clinic with 48-hour history of documented fever and
chills. He has a history of a hole in the heart and examination reveals a 4/6 systolic murmur
heard loudest at the lower left sternal edge. A restrictive muscular VSD is confirmed on
echocardiogram. Which of the following is the most appropriate next step?
a. Oral antibiotics
b. Intravenous (IV) antibiotics
c. Blood cultures
d. Transesophageal echocardiogram
e. Cardiac surgery consult

54. A 38-year-old man came to emergency department with chief complaint shortness of breath,
nonradiating chest tightness and 2 sincopal episodes. The symptom has been felt since 1
month before admission, but it was going worse in the recent 1 week. From the anamnesis,
one week before admission the patient felt pain and swelling on upper right leg, after he drove
a car for two and a half hours. The leg was then being massaged and the symptoms were
going worse and he started feeling shortness of breath. From the medical history, the patient
was obese (Body Mass Index 31kg/m2), and has history of smoking for 19 years. The patient
was a frequent distance traveler (average duration 4 to 6 hours for about 12 times/month).
Patient has no history of hypertension and diabetes. On admission, his blood pressure was
90/60 mmHg, pulse 120 times/minute and regular, respiratory rate 26 breaths/minute,
temperature 36oc, and oxygen saturation 89%. Other physical examinations were
unremarkable. What is the golden diagnostic tool for the above patient?
a. Chest CT Angiography
b. Coronary Angiography
c. Cardiac Marker
d. Electrocardiography
e. Echocardiography

55. A 70-year-old man comes to your office for evaluation before transurethral resection of the
prostate
gland. He has a history of hypertension, feels well, leads an active life, and has no symptoms.
On physical examination, blood pressure is 140/70 mm Hg, and heart rate is 70/min and
regular. Jugular venous pressure and carotid upstroke are normal, and an S4 is heard. The
patient has no S3, no murmurs, and no peripheral edema. A preoperative chest radiograph
shows cardiomegaly. Echocardiogram performed to evaluate cardiomegaly shows left
ventricular hypertrophy, with global left ventricular dysfunction and an ejection fraction of
33%. No valvular abnormalities are noted. ACE inhibitor therapy is initiated.

Which of the following medications should also be given to this patient?

a. Angiotensin receptor blocker
b. Digoxin
c. Diuretic
d. Spironolactone
e. Beta-blocker
56. A 45 year-old man is admitted to a hospital due to typical chest pain after exercise with 4
hours onset. He reveals that this not the first time, the symptoms were already develop over
one year and he had a syncope last month. The patient was a heavy smoker, his father already
passed away at his 50's due to heart disease. On physical examination the blood pressure is
140/80 mmHg, normal SI and S2 with a grade 3/6 holosystolic murmur at the apex and axilla.
An Electrocardiogram shows left ventricular hyperthropy with strain, left atrial enlargement.
Cardiac enzyme were normal.
This patient could possibly having :
a. Aortic Stenosis
b. Farby Disease
c. Hypertensive Heart Disease
d. Hypertrophic Cardiomyopathy
e. Amyloidosis

57. A 50 years old male patient brough this treadmill test result that performed after he had
finished phase II of cardiac rehabilitation program after undergone elective PCI. His baseline
HR was 70bpm. There was no ST-T changes, no arrhythmia, normal response of BP and HR
during exercise. The test was stopped at 9 minutes of exercise (Bruce protocol), with HR 150
(Rate Perceived Exertion : Borg Scale 17). What is his HR target for treadmill at home using
65-75% HRR (Heart Rate Reserve) formula?
a. 122 - 130bpm
b. 102- 107bpm
c. 97 - 112bpm
d. Can't be measured
e. 110- 127bpm

58. B-Blockers may be even more widely used in the future because of their likely ability to
prevent which of these?
a. Control hypertension
b. Peptic ulcer disease
b. Myocardial infarction
d. Peripheral vascular disease
c. Hyperuricemia and gout

59. 26-year-old woman with a history of hypertrophic obstructive cardiomyopathy is referred for
consideration for septal myectomy. She has NYHA class III dyspnea on exertion despite
maximal medical therapy. On echocardiography, there is severe asymmetric septal hypertrophy
with severe systolic anterior motion of the mitral valve. There is a late-peaking gradient across
the LVOT of 60 mmHg, which increased to 105 mmHg with Valsalva. She has a structurally
normal mitral valve on cardiac MRI with moderately severe posteriorly directed MR (Fig. 2.8).
 What would you advise her regarding surgery?
a. She will probably require mitral valve replacement at the time of surgery.
b. She will probably require mitral valve repair during surgery.
c. She will probably not need surgery on her mitral valve.
d. She may need plication of her papillary muscles.

60. A 65-year-old man with diabetes presented typical chest pain on exertion in the previous 2
months. Coronary angiography revealed significant complex multivessel coronary disease
(SYNTAX score, 34). What is the expected benefit of a revascularization with CABG versus
PCI?
a. CABG is associated with a reduction of death only.
b. CABG is associated with a reduction of stroke only.
c. CABG is associated with a reduction of death and of MI, but not of stroke.
d. CABG is associated with a reduction of all following individual endpoints: stroke,
myocardial infraction, and death.
e. CABG is associated with a reduction of MI only.