1 >>The patient described in Question VII-45 becomes refractory to the above agents and develops chronic atrial fibrillation. In addition to pharmacologic control of his ventricular rate, which of the following interventions would you suggest? ?
- (A) Low-dose aspirin (75 mg/d)
- (B) High-dose aspirin (325 mg/d)
- (C) Warfarin to an INRgoal of 1.8 to 3.0
- (D) Warfarin to an INRgoal of 3.0 to 4.0
2 >>A 65-year old man with long-standing hypertension presents to the emergency room complaining of palpitations. The patient is found to be in atrial fibrillation, and verapamil is administered to slow his ventricular rate. The patient spontaneously converts to normal sinus rhythm. A workup for cardiac ischemia and hyperthyroidism is negative. Over the next 48 h the patient has multiple episodes of paroxysmal atrial fibrillation. Which of the following antiarrhythmic agents would be most successful in treating his paroxysmal atrial fibrillation (PAFib)? ?
- (A) Verapamil
- (B) Sotalol
- (C) Propafenone
- (D) Amiodarone
3 >>A 22-year-old Michigan woman presents to her local emergency room complaining of dizziness over the past several days, including two syncope episodes followed in each case by unresponsiveness for several minutes. She has always been in excellent health, having played varsity soccer in college. Her last illness occurred 4 months ago, when she developed fever, chills, and generalized weakness; those symptoms cut short a 2-week camping trip to the Cape Cod National Seashore. She uses oral contraceptives but no other prescription medications. She admits to inhaling cocaine over the last 4 months. Physical examination reveals blood pressure of 100/62 and pulse of 30 but is otherwise unremarkable. Chest xray and serum chemistries are unremarkable. ECG demonstrates complete heart block with nonspecific ST- and T-wave changes. There is no evidence of prior myocardial infarction. The most likely cause of her complete heart block is ?
- (A) myocardial infarction from cocaine use
- (B) myocardial infarction caused by a coronary artery embolus
- (C) infection resulting from Ixodes dammini
- (D) infection caused by Borrelia burgdorferi
4 >>A 70-year-old man is admitted to the hospital with chest pain of 8 h duration. ECG demonstrates anterior ST elevation, for which he is given tissue plasminogen activator, heparin, and intravenous nitroglycerin. His symptoms resolve, and serum chemistries reveal a peak CPK of 1400 and a CK-MB fraction of 80. He is eventually started on oral medications and transferred out of the cardiac intensive care unit. His subsequent hospital course is uneventful until day 4, when he develops severe shortness of breath. Blood pressure is 110/70, and pulse is 120. Examination reveals a new systolic murmur. The most appropriate therapeutic intervention would be ?
- (A) emergent cardiac surgery consultation and transfer to the operating room
- (B) IV heparin
- (C) IV heparin and streptokinase
- (D) IV sodium nitroprusside
5 >>Which of the following would be the most appropriate drug of choice in the management of torsades de pointes? ?
- (A) Atropine
- (B) Procainamide
- (C) Isoproterenol
- (D) Magnesium sulfate
6 >>Which of the following is appropriate initial therapy in the clinical scenario described in question XI-25? ?
- (A) Heat and an exercise program
- (B) 2 weeks of joint rest
- (C) Glucocorticoid injection of the affected joint(s)
- (D) A short course of systemic glucocorticoid
7 >>A 60-year-old man without a significant medical history presents for his annual physical. An electrocardiogram demonstrates two ventricular premature complexes (VPCs) within the 12-lead tracing. Which of the following statements is true? ?
- (A) VPCs are seen only in patients with a history of coronary disease
- (B) This patient’s VPCs predict a higher incidence of cardiac mortality
- (C) VPCs such as those documented in this patient rarely cause symptoms
- (D) Both the frequency and the nature of VPCs can be correlated with increased mortality in patients with known coronary artery disease
8 >>A female infant is born to a consanguineous marriage of second cousins without complications. In utero, the fetal heart rate was between 80 and 90 beats per minute. The bradycardic heart rate persisted after birth. Approximately 2 weeks after birth the child underwent audiography, which demonstrated bilateral sensory neural deafness. These tests were repeated 2 weeks later with similar results. Unfortunately the mother suffered a cardiac arrest 7 months later and died. She had normal hearing. Which of the following statements concerning this patient’s disorder is true? ?
- (A) The child has Romano-Ward syndrome
- (B) Romano-Ward and Jervell and Lang-Nielsen syndromes are genetically distinct
- (C) The patient’s electrocardiogram revealed a shortened QT interval
- (D) The mutation lies within a cardiac ion channel
9 >>Which of the following statements regarding the activation of cardiac myocytes is true? ?
- (A) The force of contraction of cardiac muscle is not related to muscle length
- (B) The intracellular concentration of sodium is low
- (C) The rise in intracellular sodium is the triggering event in myocyte contraction
- (D) Calcium binds to troponin C and releases cells from the inhibitory influence of this repressor
10 >>A 72-year-old woman with a prior history of hypertension is receiving low-dose atenolol, an unknown diuretic, and long-acting diltiazem. She has no other significant cardiac history. The patient is brought to the emergency room after having passed out while getting up to go to the bathroom at 6 A.M. this morning. She is seen by the surgical service, which finds her to have an orbital fracture from when she struck the sink. Internal medicine consultation is requested when an ECG reveals sinus bradycardia at 40 with occasional sinus arrest with pauses of 2 to 3 s but no other abnormalities. She remains somewhat light-headed. Blood pressure is 90/50. Physical examination is otherwise benign. She has been without oral intake since the previous evening. The next steps in treating this patient’s arrhythmia would consist of ?
- (A) placement of a temporary wire; implant permanent pacer this afternoon
- (B) placement of a temporary wire; discontinue diltiazem and atenolol and follow
- (C) placement of external pacing pads; implant permanent pacer this afternoon
- (D) discontinue diltiazem and admit
11 >>Tetralogy of Fallot consists of which of the following abnormalities? ?
- (A) Atrial septal defect (ASD), ventricular septal defect, an aorta that overrides the outflow, and right ventricular hypertrophy
- (B) ASD, ventricular septal defect, an aorta that overrides the outflow, and a left ventricular hypertrophy
- (C) ASD, ventricular septal defect, an aorta that overrides the outflow, and coronary artery anomalies
- (D) Ventricular septal defect, an aorta that overrides the left and right ventricles, obstruction of the right ventricular outflow tract, and right ventricular hypertrophy
12 >>A 64-year-old man with known allergies to penicillin and lobster undergoes a left hip replacement. Recovery is uneventful until the day before discharge, when he begins experiencing palpitations. ECG reveals his baseline right bundle branch block and new atrial flutter at a rate of 110 to 120. He is otherwise asymptomatic. Heparin is started. He remains in atrial fibrillation over the next 2 days while a workup demonstrates normal potassium, magnesium, thyroid-stimulating hormone, and chest x-ray. The decision is made to proceed with chemical cardioversion. He is given intravenous procainamide. Halfway though the infusion, the telemetry suddenly reveals a rate of 240 with narrow QRS complexes. He is found to be pulseless, CPRis begun, and he is defibrillated with 100 J, which restores sinus rhythm that degenerates into atrial fibrillation. This reaction could have been prevented if ?
- (A) the patient’s allergy to procainamide had been known
- (B) the infusion of procainamide had been administered more slowly
- (C) pretreatment before procainamide had been undertaken with digoxin, propranolol, or verapamil
- (D) quinidine had been used instead of procainamide
13 >>Which of the following statements concerning Eisenmenger’s syndrome is true? ?
- (A) Eisenmenger’s syndrome is a complication of a ventricular septal defect but not of an atrial septal defect.
- (B) Eisenmenger’s syndrome arises due to right to left intracardiac shunting.
- (C) The initial morphologic changes are irreversible.
- (D) As the disease progresses, pulmonary vascular resistance increases and the intracardiac shunt reverses.
14 >>Which of the following statements regarding cardiac imaging is correct? ?
- (A) Sestamibi imaging can be readily used to identify hibernating myocardium
- (B) Thallium cannot be readily used to identify hibernating myocardium
- (C) Dipyridamole stress testing is safe in patients with chronic obstructive pulmonary disease (COPD)
- (D) The effects of dipyridamole can be reversed with intravenous theophylline
15 >>Which of the following statements concerning ventricular free-wall rupture after a myocardial infarction is true? ?
- (A) Typically occurs late in the post-MI course (> 2 weeks)
- (B) Often occurs in the center of the infarcted area
- (C) It is more common in patients with left ventricular hypertrophy
- (D) Due to the thinness of the right ventricular wall, patients with inferior myocardial infarctions are at greatest risk
16 >>Cystic medial necrosis is prevalent in which of the following disorders? ?
- (A) Takayasu’s arteritis
- (B) Ehlers-Danlos syndrome type IV
- (C) Congenital aortic aneurysms
- (D) Syphilitic aortitis
17 >>A 16-year-old boy is referred by his high school VII-66. (Continued) coach for a physical examination before joining the football team. His older brother died suddenly during football practice; no autopsy was obtained. The patient has a loud systolic murmur. Which of the following would be consistent with hypertrophic cardiomyopathy? ?
- (A) A crescendo-decrescendo systolic murmur
- (B) Radiation into the neck
- (C) Delayed carotid upstrokes
- (D) A decrease in the murmur on Valsalva or standing
18 >>Which of the following disorders can lead to both cardiogenic and noncardiogenic pulmonary edema? ?
- (A) Exposure to high altitude
- (B) Heroin overdose
- (C) Central nervous system disorders
- (D) Sarcoidosis
19 >>In patients with established coronary artery disease and elevated LDL levels, which of the following statements regarding HMG-CoA reductase inhibitors is true? ?
- (A) The affect on both endothelial damage and thrombotic complications can be seen with only 6 months of therapy
- (B) Although there is a significant change in mortality from cardiovascular events, there is no significant decrease in total mortality
- (C) Treatment is associated with a decrease in the number of invasive cardiac procedures, both angioplasty and coronary bypass
- (D) The average decrease in LDL cholesterol of these agents is > 50%
20 >>You are asked to give medical clearance for a 75- year-old man prior to an elective carotid endarterectomy. His past medical history is significant for hypercholesteremia and hypertension. He also has diet-control diabetes mellitus. His current medications include simvastatin and hydrochlorothiazide. He denies any current or prior cardiac symptoms and has never had a myocardial infarction. His physical examination is unrevealing with the exception of a right carotid bruit. His electrocardiogram is unremarkable with the exception of VPCs at a rate of 2 to 3 per minute. Laboratory analysis is unremarkable including normal renal function and liver function tests. His oxygen saturations are also normal. What would be the expected serious complication rate (perioperative MI, pulmonary edema, or ventricular tachycardia) in this patient? ?
- (A) 0.001
- (B) 0.1- 1.0%
- (C) 1.0- 3.0%
- (D) 3.0- 10%