UNIVERSITY OF THE PHILIPPINES MANILA

PHILIPPINE GENERAL HOSPITAL

DEPARTMENT OF MEDICINE
RESIDENTS EXAM
CARDIOLOGY
February 21, 2007
MULTIPLE TRUE OR FALSE. There are 5 statements after each question. Determine
whether each statement is true or false. On the answer sheet, place an x in the box
corresponding to your answer.
1. As defined by the New York Heart Association, the elements of a complete cardiac
diagnosis include consideration of the following: (HPIM p. 1301)
a. age of onset
b. underlying etiology
c. anatomic abnormalities
d. acuteness or chronicity
e. functional disability
2. TRUE of the anatomy of the conducting system of the heart: (HPIM p. 1333)
a. the sinoatrial node lies at the junction of the right atrium and the inferior vena
cava
b. The SA node is supplied by the sinus node artery which more commonly arises
from the left circumflex coronary artery (LCX) rather than from the right
coronary artery (RCA)
c. The electrophysiologic properties of the AV node result in slow conduction,
which is responsible for the normal delay in AV conduction.
d. Vagal influences increase the automaticity of the SA node.
e. Sympathetic influences shorten AV nodal conduction and refractoriness.
3. TRUE of sinus node dysfunction: (HPIM p. 1335-1336)
a. The SA nodes intrinsic discharge rate is the highest of all potential cardiac
pacemakers.
b. Heart rates of <60/min always suggest a pathologic state.
c. Sinus bradycardia is associated with hypothyroidism, hypothermia, typhoid
fever and brucellosis
d. Asymptomatic patients with sinus bradycardia need not be tested, since no
therapy is indicated.
e. Permanent pacemakers are the mainstay of therapy for patients with
symptomatic SA node dysfunction.
4. TRUE of the tachyarrhythmias: (HPIM p. 1342-1343)
a. Atrial premature complexes are recognized on the ECG as early P waves with a
similar morphology as the sinus P wave.
b. In patients without heart disease, ventricular premature contractions (VPCs)
have been shown to be associated with increased morbidity and mortality.

c. Two successive VPCs are termed pairs or couplets while three or more
consecutive VPCs are termed ventricular tachycardia when the rate is
>100/min.
d. A ventricular premature contraction is a wide, bizarre QRS complex preceded
by a P wave.
e. Sinus tachycardia rarely exceeds >200/minute but in these instances should be
considered as a primary arrhythmia.
5. The morbidity associated with atrial fibrillation is related to: (HPIM p. 1345)
a. decreased ventricular rate which may lead to hypotension - excessive
b. the pause following cessation of AF, which can cause syncope
c. systemic embolization
d. loss of the contribution of atrial contraction to cardiac output
e. anxiety secondary to palpitations
6. TRUE of Atrial Fibrillation: (HPIM p. 1345-6)
a. In acute AF, precipitating factors should be sought such as hypothermia,
hypothyroidism, pulmonary embolism, CHF or pericarditis. fever,
thyrotoxicosis
b. Digitalis preparations are more (less) effective, more rapidly acting but are
associated with more toxicity compared to beta blockers.
c. The goal of therapy in patients in whom AF cannot be converted to sinus rhythm
is the control of palpitations. ventricular response
d. The risk of hemorrhage in anticoagulation is largely associated with INRs above
2.0 to 3.0.
e. Direct-current electrical cardioversion is not an effective method to restore sinus
rhythm. is highly effective
7. Clinical risk factors associated with stroke in patients with chronic AF include: (HPIM p.
1346)
a. pulmonary embolism
b. immobility
c. hypotension
d. prosthetic heart valve
e. congestive heart failure
8. TRUE of heart failure: (HPIM p. 1368)
a. Heart failure may occur without any detectable abnormality of myocardial
function.
b. Any infection may precipitate heart failure, and is not limited to pneumonia.
c. Tachyarrhythmias reduce the time for ventricular filling and contribute to systolic
heart failure. diastolic heart failure
d. The prognosis in patients with heart failure in whom a precipitating cause is
identified, treated and eliminated is more favorable than in patients in whom the
underlying disease has progressed to the point of producing HF without a
detectable precipitating cause.
e. HF should be distinguished from conditions with circulatory congestion such as
hypovolemic shock (renal failure), and from those of noncardiac causes of low
cardiac output such as renal failure.( hypovolemic shock) -

9. TRUE of the various forms of heart failure: (HPIM p. 1369)

a. diastolic heart failure is caused by increased resistance to ventricular inflow and
increased (reduced) ventricular diastolic capacity.
b. Hyperthyroidism, anemia and pregnancy cause high-output HF while beriberi,
AV fistulas and Pagets disease cause low-output HF (high output)
c. The hemodynamic burden placed on the myocardium by many forms of highoutput failure resembles that of aortic stenosis. (AI)
d. In acute HF, the sudden decrease in cardiac output often results in systemic
hypotension without edema.
e. In most patients with HF, systolic and diastolic heart failure are not exclusive of
each other and may actually coexist.
10. TRUE of the clinical manifestations of heart failure: (HPIM p. 1370-1)
a. Orthopnea is usually a later manifestation of HF than exertional dyspnea.
b. Polydipsia (nocturia) is common in HF and may actually contribute to insomnia.
c. Third and fourth heart sounds are often audible in HF and are highly specific
(nonspecific) PE findings.
d. Pulsus alternans, a sign of severe HF, may be detected by sphygmomanometry
and even by palpation.
e. Cardiac cachexia may be due to abnormal levels of cytokines, such as
decreased (increased) levels of tumor necrosis factor (TNF).
11. TRUE of the general treatment measures for HF: (HPIM p. 1372)
a. immunization with influenza and pneumococcal vaccines to prevent respiratory
infections
b. In acute, severe HF, meals should be small in quantity but more frequent
c. Absolute bed rest is a (rarely advisable) mainstay for severe HF
d. In ambulatory patients with chronic HF, rest periods during weekends allow
continuation of gainful employment
e. Once the patient has become compensated, regular isometric (isotonic)
exercises such as walking or riding may be encouraged.
12. TRUE of the diuretics used on the management of HF: (HPIM p. 1373-4)
a. Potassium depletion and metabolic acidosis (alkalosis) are the chief adverse
metabolic effects of thiazides, metolazone and loop diuretics.
b. Metolazone is a quinethazone derivative that has a site of action and potency
similar to spironolactone (thiazide).
c. Loop duretics may produce rates of urine formation as high as one-fourth of the
glomerular filtration rate.
d. Potassium-sparing diuretics act on the distal tubule and are effective even when
used as monotherpy (rarely as monotherapy).
e. Spironolactone, amiloride and triamterene should not be administered to
patients with K >5 mmol/L, renal failure and hyponatremia.
13. TRUE of the medical management of HF: (HPIM p. 1374)
a. Aldosterone antagonists play a central role in the prevention and treatment of
HF at almost all stages (class 4).

b. ACE inhibitors slow done the maladaptive remodeling of the injured or

abnormally burdened ventricle.
c. In patients with HF treated with ACE inhibitors, cardiac output rises, pulmonary
wedge pressure rises (falls), and signs and symptoms of HF are relieved.
d. Metoprolol, carvedilol and bisoprolol have been shown to improve survival in
HF; the first two (metoprolol and bisoprolol) being selective and block only beta1 receptors, while the third (carvedilol) blocks both alpha, beta-1 and beta-2
receptors.
e. In those patients who cannot tolerate target doses of beta blockers, low-dose
beta blockers is preferred to no therapy.
14. TRUE of digitalis: (HPIM p. 1375)
a. cardiac glycosides inhibit the Na-2Cl-K ATPase (Na-K-ATPase)
b. Digitalis does not improve survival in patients with systolic HF and sinus rhythm.
c. The following factors reduce tolerance to digitalis: advanced age, hypokalemia,
hypomagnesemia, hypercalcemia, renal insufficiency, and acute myocardial
infarction.
d. Chronic digitalis intoxication may be characterized by exacerbations of heart
failure, green vision (yellow), weight gain (weight loss) and gynecomastia. neuralgia
e. Use of the Fab fragment of digitalis antibodies is a potentially lifesaving
approach to the treatment of severe intoxications.
15. TRUE of sympathomimetic amines and phosphodiesterase inhibitors: (HPIM p. 1376)
a. Dopamine and dobutamine are administered as continuous IV infusions and
may be used in patients with refractory HF as a bridge to cardiac
transplantation.
b. Dopamine (dobutamine) has a modest cardioaccelerating effect and lowers
peripheral vascular resistance.
c. Dobutamine is useful in the treatment of HF without hypotension
d. A major problem with all sympathomimetics is the loss of responsiness from
downregulation of receptors, becoming evident after 24 (8) hours of continuous
administration.
e. Amrinone and milrinone are non-catecholamine, nonglycoside agents that have
both positive inotropic and vasodilator actions.
16. Direct vasodilators which may be used in HF: (HPIM p. 1376)
a. sodium nitroprusside
b. nesiritide
c. nitroglycerin
d. hydralazine
e. chlorthalidone - diuretic
17. TRUE of right ventricular afterload: (HPIM p. 1377)
a. It decreases (increases) with extensive pulmonary resection
b. It increases in restrictive lung disease in which pulmonary vessels are
compressed and disorted
c. It decreases (rises) with hypoxic pulmonary vasoconstriction
d. The severity of RV enlargement in cor pulmonale is a function of RV afterload

e. Cor pulmonale is caused principally by ventilatory problems, rather than

pulmonary vascular or parenchymal disease. pulmonary vascular
18. TRUE of the clinical manifestations of acute cor pulmonale from pulmonary embolism:
(HPIM p. 1377)
a. A sudden large embolus causes a high-output failure(low output) state from the
resulting tachycardia.
b. It is suggested by a history of sudden onset of dyspnea and cardiovascular
collapse in a patient with, or predisposed to, venous thrombosis
c. Neck veins may exhibit prominent a waves (v wave) from tricuspid regurgitation
d. Arterial blood gas frequently shows normal (low) paO2 but low paCO2.
e. The liver may be pulsatile, distended, and tender.
19. TRUE of congenital heart disease in adults : (HPIM p. 1381)
a. Substantial numbers of affected infants reach adulthood because the alteration
caused in cardiac physiology is well tolerated, and (is not) due to successful
medical / surgical management.
b. The presence of pulmonary hypertension determines the clinical manifestations,
the course and feasibility of surgical repair.
c. The chronic hypoxemia in cyanotic CHD results in polycythemia
(erythrocytosis); the commonly used term erythrocytosis is a misnomer.
d. Acute phlebotomy for hyperviscosity is safe, and (does not) require
isovolumetric replacement with isotonic saline.
e. Oral contraceptives are contraindicated for cyanotic women because of the
increased risk for vascular thrombosis.
20. Poorly-tolerated congenital cardiac malformations among pregnant patients include:
(HPIM p. 1383)
a. Severe mitral stenosis
b. NYHA heart failure Functional Class I
c. well-repaired Tetralogy of Fallot
d. Eisenmengers syndrome
e. Marfans syndrome
21. TRUE of atrial septal defect (ASD): (HPIM p. 1385)
a. The most common type is the ostium primum type. (ostium secundum)
b. The left-to-right shunt causes systolic (diastolic) overloading of the right
ventricle and increased pulmonary blood flow.
c. The second heart sound is widely split and is relatively fixed in relation to
respiration.
d. The risk of infective endocarditis is high (low) and all patients with(complicated
val regurg and ASD) ASD need to receive IE prohylaxis.
e. Operative repair should be advised to patients with uncomplicated secundum
ASD with significant left-to-right shunting.
22. TRUE of ventricular septal defect (VSD): (HPIM p. 1386)
a. The functional disturbance is dependent on the size and status of the
pulmonary vascular bed, rather than on the location of the defect.
b. Spontaneous closure is more common in patients born with a small VSD.

c. Symptoms of Eisenmenger syndrome in adult life include exertional dyspnea,

chest pain, syncope and hemoptysis.
d. Unlike the other CHDs, the degree of pulmonary vascular resistance elevation
before surgery of VSD is (critical) not important in determining prognosis.
e. It is part of the tetralogy of Fallot.
23. Examples of acyanotic congenital heart disease without a shunt: (HPIM p. 1385-1389)
a. atrial septal defect
b. aneurysm of an aortic sinus of Valsalva with fistula
c. valvular aortic stenosis
d. coarctation of the aorta
e. Ebsteins anomaly
24. TRUE of mitral stenosis: (HPIM p., 1390-1)
a. In terms of etiology, half of all MS cases are congenital while another half are
rheumatic (MS are rarely congenital)
b. The normal mitral valve orifice in adults is 4 to 6 cm2.
c. The development of first degree AV block (AF) marks a turning point in the
patients course and is generally associated with acceleration of the rate at
which symptoms occur.
d. Pulmonary embolization (systemic) may be the presenting complaint in
otherwise asymptomatic patients with mild MS.
e. Jugular venous pulse reveals prominent a waves.
25. X-ray findings in mitral stenosis include: (HPIM p. 1392)
a. straightening of the left border of the cardiac silhouette
b. prominent main pulmonary arteries
c. Backward displacement of the esophagus by an enlarged left atrium
d. Kerley B lines
e. Enlargement of all chambers upstream to the narrowed mitral valve
26. TRUE of mitral regurgitation: (HPIM p. 1393-1395)
a. Chronic rheumatic heart disease is the cause of severe MR in only about onethird of cases
b. The resistance to LV emptying is increased (reduced) in patients with MR.
c. Since ejection fraction rises in severe MR in the presence of normal LV function,
even a modest reduction in this parameter reflects significant dysfunction.
d. The S1 is generally loud (absent, soft, buried).
e. A systolic murmur of at least grade I/VI (III/VI)intensity, is the most characteristic
auscultatory finding in severe MR.
27. TRUE of mitral valve prolapse (MVP): (HPIM p. 1395-6)
a. Excessive or redundant mitral leaflet tissue is associated with myxomatous
degeneration and greatly decreased (increased) concentrations of acid
mucopolysaccharide.
b. Frequent finding in Marfan syndrome, Ehler-Danlos syndrome and
osteogenesis imperfecta

c. The early- or mid-systolic click (mid or late) is generated by the sudden tensing
of short (long) chordae tendineae or by the prolapsing mitral valve leaflet when
it reaches its maximum excursion
d. Echocardiographic definition is the diastolic (systolic) displacement of the mitral
valve leaflet on short axis view by at least 5 mm(2) into the left atrium superior
to the plane of the mitral annulus.
e. The clinical course is often benign.
28. Which of the following is TRUE of the conditions associated with pulmonary
hypertension? (HPIM p. 1405-6)
a. All of the collagen vascular diseases may be associated with it, occurring more
commonly with the CREST syndrome, and less frequently in SLE.
b. Treatment of pulmonary hypertension does not change the natural history of the
underlying collagen vascular disease.
c. It is common for pre-tricuspid cardiac shunts (post) to cause pulmonary
hypertension, and less commonly they may also occur in post-tricuspid cardiac
shunts (pre).
d. Portal hypertension is associated with pulmonary arterial hypertension.
e. Treatment of HIV infection does not alter the severity or natural history of the
associated pulmonary hypertension.
29. Which of the following is associated with pulmonary venous hypertension? (HPIM p.
1405-7)
a. systemic sclerosis
b. left atrial myxoma
c. mitral regurgitation
d. mitral stenosis
e. diastolic dysfunction of the left ventricle
30. TRUE of the cardiomyopathies: (HPIM p. 1408-9)
a. Moderate to marked cardiac silhouette enlargement on chest x-ray is seen in
restrictive (dilated) cardiomyopathy.
b. Low voltage and conduction defects are seen on the ECG in restrictive
cardiomyopathy.
c. Hypertrophic cardiomyopathy is (not) associated with diminished cardiac output,
as demonstrated by cardiac catheterization. - DCMP
d. A reversible form of dilated cardiomyopathy may be found with alcohol abuse,
pregnancy, thyroid disease, cocaine use, and chronic uncontrolled tachycardia.
e. Alcohol abuse typically causes restrictive cardiomyopathy. - DCMP
31. TRUE of dilated cardiomyopathy: (HPIM p. 1408)
a. About one in three cases of congestive heart failure is due to dilated
cardiomyopathy.
b. Dilated cardiomyopathy may be the late sequelae of acute viral myocarditis.
c. Calcium channel blockers and NSAIDs should be avoided in dilated
cardiomyopathy.
d. Death is due to either CHF or ventricular tachy- or bradyarrhythmias.

e. Those who recover from peripartum cardiomyopathy should not be advised to

avoid getting pregnant again as they usually tolerate subsequent pregnancies.
should be advised not to get pregnant
32. TRUE of hypertrophic cardiomyopathy: (HPIM p. 1410)
a. asymmetric LVH, with preferential hypertrophy of the LV free wall (IV septum)
b. fixed (dynamic) left ventricular outflow tract pressure gradient
c. Histology shows bizarre and disorganized arrangement of cardiac muscle cells.
d. Like Chagas disease, it demonstrates vigorous posterior wall motion and
reduced septal excursion. Chagas, hypokinesia of wall
e. The first clinical manifestation may be sudden death.
33. Causes of restrictive cardiomyopathy which may be treated: (HPIM p. 1412)
a. amyloid
b. hemochromatosis treat with deferroxamine
c. Fabrys disease treat with glucose
d. Scleroderma
e. Endomyocardial fibrosis
34. TRUE of acute pericarditis (HPIM p. 1414)
a. Pain is often absent (present) in tuberculous and neoplastic pericarditis, but is
common in uremic and postirradiation pericarditis.
b. Characteristically, pain may be relieved by sitting up and leaning forward and
intensified by lying supine.
c. Pulses paradoxus (Friction rub) is the most important physical sign.
d. On ECG, there is widespread ST segment elevation, often with upward
concavity.
e. Depression of the PR segment reflects atrial involvement.
35. TRUE of pericardial effusion: (HPIM p. 1414)
a. Ewarts sign is a patch of dullness beneath the angle of the right (left) scapula
due to the compression of the right lung by pericardial fluid.
b. Bloody fluid is common in tuberculosis, neoplasm, (but not) heart failure.
c. This is important clinically when it develops over a relatively short time.
d. The volume of fluid required to produce tamponade varies directly with the
thickness of the ventricular myocardium.
e. The volume of fluid required to produce tamponade varies directly (inversely)
with the thickness of the parietal pericardium.
36. Physiologic alterations in pericardial effusion that contribute to the finding of
paradoxical pulse: (HPIM p. 1416)
a. Inspiratory enlargement of the RV in cardiac tamponade compresses and
reduces LV volume
b. Leftward bulging of the IV septum reduces LV cavity volume
c. In cardiac tamponade, the normal inspiratory augmentation of RV volume leads
to an exaggerated reciprocal increase (decrease) in LV volume.
d. Respiratory distress increases the fluctuations in intrathoracic pressure.
e. The right ventricle enlarges during inspiration.

37. TRUE of the various causes of acute pericarditis: (HPIM p. 1416-8)

a. HIV associated pericarditis is usually secondary to infection (often
mycobacterial) or neoplasm, rather than a direct effect of the human
immunodeficiency virus
b. Pleuritis and pneumonitis may frequently accompany pericarditis.
c. Anticoagulants should be avoided.
d. In post-cardiac injury syndrome, it may result from a hypersensitivity reaction in
which the antigen originates from injured myocardial tissue and/or pericardium.
e. Treatment of uremic pericarditis may include anti-inflammatory agents,
intensification of hemodialysis, and pericardial instillation of glucocorticoids.
38. TRUE of chronic restrictive pericarditis: (HPIM p. 1418-9)
a. This usually results from obliteration of the pericardial cavity with formation of
granulation tissue.
b. Ventricular filling is impeded throughout diastole (early diastole), like in cardiac
tamponade.
c. Fibrotic process may extend into the myocardium causing myocardial scarring.
d. 2D-echocardiography is similar to MRI and CT scanning (more accurate) in
demonstrating a thickened pericardium.
e. The y descent in the venous pulse is prominent in constrictive pericarditis, while
it is absent in cardiac tamponade.
39. Which of the following factors INCREASE ventricular end-diastolic volume and,
consequently, ventricular performance, as reflected in the stroke volume, cardiac
output and ventricular work? (HPIM p. 1363)
a. upright posture
b. prolonged bouts of coughing
c. pericardial restraint
d. atrial fibrillation
e. pumping action of skeletal muscles
40. Radiographic findings of Tetralogy of Fallot: (HPIM p. 1388)
a. couer en sabot
b. increased (decreased) pulmonary vascular markings
c. aortic knob may be on the right
d. normal-sized heart
e. prominent right ventricle
41. Complications of Tetralogy of Fallot include: (HPIM p. 1389)
a. infective endocarditis
b. pulmonary embolism paradoxical embolism, erythrocytosis, and coagulation
c. stroke
d. cerebral abscess
e. paradoxical embolism
42. TRUE of myxomas: (HPIM p. 1420-1)
a. most are sporadic, some are familial or part of a syndrome

b. sporadic (familial) myxomas tend to occur in younger individuals, be multiple, or

are ventricular in location
c. familial or myxoma syndrome tumors have post-operative recurrence due to
inadequate resection (multicentric nature)
d. most common clinical presentation mimics that of mitral valve disease
e. most common type of primary cardiac tumor
43. Signs and symptoms of cardiac tumors, many of which are present in more common
forms of heart disease, include: (HPIM p. 1420)
a. chest pain
b. syncope
c. heart failure
d. arrhythmia
e. pericardial effusion
f. other signs, murmurs and conduction disturbances
44. TRUE of cardiac tumors: (HPIM p. 1421-2)
a. rhabdomyomas and fibromas are the most frequent tumors in adults (children)
b. almost all primary cardiac tumors are sarcomas
c. primary cardiac sarcomas usually have a rapidly downward course, leading to
death in weeks to months
d. surgical excision utilizing cardiopulmonary bypass is curative for myxomas
e. 2D-echo is useful for the diagnosis
45. TRUE of diabetes mellitus and heart disease: (HPIM p. 1422)
a. Coronary artery disease is the most common cause of death in adults with DM
b. Myocardial infarcts are more frequent but tend to be smaller (larger) and less
(more) likely to cause heart failure, shock and death
c. Patients are more likely to have an abnormal or absent pain response to
ischemia, probably as a result of autonomic nervous system dysfunction
d. Since coronary artery disease is more common in diabetic patients and often
not associated with typical anginal symptoms, threshold for diagnosis should be
high (low).
e. There is an increased incidence of large vessel atherosclerosis in both insulinand non-insulin-dependent DM.
46. TRUE of the pathogenesis of atherosclerosis: (HPIM p. 1425)
a. Even if many generalized or systemic risk factors predispose to its
development, atherosclerosis affects various regions of the circulation
preferentially.
b. In the coronary circulation, the left circumflex artery (LAD) exhibits a particular
predilection for developing atherosclerosis
c. Atherosclerotic lesions usually form at branching points of arteries
d. Growth of atherosclerotic plaques occurs in a smooth, linear fashion
(discontinuous) over time
e. Atherosclerosis is the leading cause of death and disability in the developed
world.
47. Characteristics of atherosclerotic plaques which are prone to rupture: (HPIM p. 1429)

a.
b.
c.
d.
e.

thin fibrous cap

relatively small lipid core (large core)
high content of macrophages
site of rupture contains relatively few smooth muscle cells
Macrophages and T lymphocytes predominate at point of rupture

48. ATP (Adult Treatment Panel) III recommends cholesterol screening in adults
_________, repeated every _______. (HPIM p. 1430)
a. > 20 years old, 1 year
b. > 30 years old, 2 years
c. > 20 years old, 5 years
d. > 40 years old, 3 years
e. >30 years old, 3 years
49. TRUE of lipid-lowering therapies: (HPIM p. 1431)
a. They do not appear to exert their beneficial effects on cardiovascular events by
causing a marked regression of obstructing coronary lesions
b. Angiographically monitored studies have shown at best a modest reduction in
coronary artery stenosis
c. However, these same studies (mentioned in choice B) show substantial
decrease in coronary events.
d. Benefit may derive from stabilization of atherosclerotic lesions without
decreasing stenosis.
e. LDL goal for patients with CHD or CHD risk equivalents is <100 mg/dL
50. TRUE of diabetic dyslipidemia: (HPIM p. 1431)
a. DM patients often have LDL cholesterol levels near average
b. LDL particles tend to be bigger and less (more) dense, and thus more
atherogenic
c. Low HDL
d. Low triglycerides (high)
e. High LDL (near average)
51. TRUE of DM, insulin resistance and metabolic syndrome as atherosclerotic risk
factors: (HPIM p. 1432)
a. strict glycemic control reduces risk of macrovascular complications (no
evidence)
b. strict glycemic control reduces risk of microvascular complication
c. multiple clinical trials have demonstrated unequivocal benefit of HMGCoA
reductase inhibitors in DM patients over all ranges of LDL cholesterol levels
d. DM populations appear to derive benefit from anti-hypertensive strategies that
block the action of catecholamines (Angio II)
e. DM is a CHD risk equivalent
52. TRUE of the clinical profile of patients with stable angina pectoris
a. typically a man > 60 years old (>50), or a woman >50 years old (>60)
b. angina is usually crescendo-decrescendo in nature
c. can radiate to the left shoulder and left arm, but (not) to both arms
d. rarely localized above the mandible (and below the umbilicus)

e. diagnosis of angina should be suspect if it does not respond to rest and

sublingual nitroglycerin
53. TRUE of the diagnostic tests in ischemic heart disease: (HPIM p. 1436)
a. 12L-ECG at rest is normal in half of patients with typical angina pectoris
b. Repolarization abnormalities (e.g. ST segment and T wave changes) are
specific for IHD (not specific)
c. Typical ST segment and T wave changes that accompany episodes of angina
and disappear thereafter are not (more) specific for IHD since these can occur
in pericardial, myocardial and valvular heart diseases.
d. Obstructive disease limited to the circumflex artery may result in false negative
stress test since the posterior portion of the heart is not represented in the
surface 12L-ECG.
e. Chest x-ray may show cardiac enlargement or signs of heart failure.
54. Contraindications to exercise stress testing: (HPIM p. 1437)
a. rest angina within 48 hours
b. severe aortic insufficiency (AS)
c. unstable rhythm
d. acute myocarditis
e. uncontrolled heart failure
55. TRUE of diagnostic tests for IHD: (HPIM p. 1437)
a. Exercise stress test in which target heart rate of 85% of maximal heart rate for
age is not achieved is considered to be non-diagnostic.
b. A negative stress testing by ECG does not exclude coronary artery disease
c. Dobutamine (Thallium) echocardiography shows development of transient
perfusion defect with a tracer during episodes of ischemia
d. Coronary angiography provides no information regarding the arterial wall.
e. Stress echocardiography entails a lower cost than stress perfusion imaging.
56. TRUE of nitrates for IHD (HPIM p. 1440)
a. cause systemic venodilation, thereby inceasing (reducing) myocardial wall
tension and decrerasing oxygen requirement
b. absorption is most rapid and complete through the mucous membranes
c. hypotension is the most common side effect (headache)
d. patients may be instructed to take the medication to relieve angina.
e. There is no value in taking it before stress that is likely to induce angina.
57. TRUE of long-acting nitrates: (HPIM p. 1440-1)
a. They are as (not) effective as sublingual nitroglycerine for acute relief of angina
b. Tolerance with loss of efficacy develops with 12-24 hours of exposure
c. Tolerance is due to depletion of oxygen free radicals (sulfhydryl groups) and to
counterregulatory alterations in intravascular fluid balance.
d. To minimize tolerance, minimum effective dose should be used and a minimum
of 8 hours each day kept free of the drug.
e. These can be swallowed, chewed, or administered by transdermal route.
58. TRUE of the treatment regimens for IHD: (HPIM p. 1441)

a. Beta blockers reduce myocardial oxygen demand similarly during exercise and
at rest (most at rest)
b. Relative contraindication to beta blockers include AV conduction disturbance,
Raynauds phenomenon, and history of mental disturbance
c. Sudden discontinuation of beta blockers can intensify ischemia
d. Beta blockers with beta-2 receptor specificity may be preferable for patients
with bronchial obstruction (beta 1)
e. Beta blockers reduce myocardial demand by inhibiting increases in heart rate.
59. Beta blockers improve life expectancy after AMI while Ca channel blockers do not.
However, Ca channel blockers may be indicated in patients with: (HPIM p. 1441)
a. adverse reactions to beta blockers
b. angina and history of asthma or COPD
c. symptomatic peripheral arterial disease
d. inadequate response to beta blockers and nitrates
e. severe heart failure (Functional Class IV)
60. TRUE of the pathophysiology of AMI: (HPIM p. 1449)
a. Slowly developing but high grade coronary artery stenoses commonly
precipitate ST elevation MI. (do not)
b. Vascular injury is facilitated by cigarette smoking, HPN and lipid accumulation
c. All cases of AMI are due to coronary artery thrombosis - rare
d. Von Willebrands factor (vWF) and fibrinogen are multivalent molecules. They
bind to 2 different platelets simultaneously causing platelet crosslinking and
aggregation.
e. Hypercoagulability, collagen vascular disease, cocaine abuse are also
predisposing conditions.
61. TRUE of clinical presentation of AMI: (HPIM p. 1449)
a. clusters of cases are seen in the evening, usually after dinner (morning)
b. the frequent location of pain beneath the xiphoid and patients denial that they
may be suffering from heart attack are chiefly responsible for the common
mistaken impression of indigestion
c. A mere unexplained drop in arterial pressure may be the presenting sign of
STEMI
d. Temperature elevations up to 38 degrees C may be observed during the first
week after STEMI.
e. Precipitating factors include vigorous physical exercise, emotional stress, or a
medical or surgical illness.
62. TRUE of the lab findings in STEMI: (HPIM p. 1450)
a. When the obstructing thrombus is not totally occlusive or if obstruction is
transient, no Q wave is seen on ECG ST elevation is seen
b. Rate of liberation of specific proteins used as cardiac biomarkers differs
depending on their intracellular locations, molecular weight and local blood and
lymphatic flow.
c. Creatine kinase rises within 4 to 8 hours and generally returns to normal by 48
to 72 hours

d. Intramuscular injections may cause elevations in CK, causing confusion among

patients with chest pain.
e. An elevated erythrocyte sedimentation rate is a specific indicator of necrosis
and inflammation in AMI. ESR is not specific
63. TRUE of cardiac markers: (HPIM p. 1450)
a. Total CK elevation may be seen in skeletal muscle disease, hypothyroidism,
stroke, surgery and electrical cardioversion.
b. Myoglobin is released into the blood after 24 (30 min 2 hours) hours from
infarct
c. It is not cost-effective to measure both a cardiac-specific troponin and CK-MB at
all time points in every patient.
d. Total quantity of cardiac protein released, rather than the peak serum
concentration, correlates with size of the infarct.
e. The troponin level is crucial in the management of a patient especially for
urgent reperfusion therapy. temporal pattern of enzyme release
64. TRUE of cardiac imaging in STEMI: (HPIM p. 1451)
a. abnormal wall motion seen on 2D-echocardiography is almost universal
b. 2D-echocardiography can differentiate between acute STEMI and old MI. cannot
c. Myocardial perfusion scanning can (not) differentiate acute STEMI from an old
MI.
d. Myocardial perfusion scanning shows concentrated uptake of the tracer (hot
spot) in the injured myocardium. cold spot
e. Echocardiographic detection of reduced LV function serves as an indication for
therapy with aspirin. (ace-i)
65. TRUE of emergency department management of STEMI: (HPIM p. 1452)
a. Aspirin is effective across the entire spectrum of acute coronary syndromes
b. In patients with normal arterial O2 saturation, supplemental oxygen is still
helpful in decreasing the size of the infracted myocardium
c. Nitrates may increase (decrease) preload, thus decreasing myocardial oxygen
demand
d. Sudden marked hypotension, an idiosyncratic reaction to nitrates, may be
reversed promptly by IV atropine.
e. Morphine, an effective analgesic, may cause venous pooling leading to
increased (decreased) cardiac output and hypotension.
66. Typical diet in a coronary care unit for AMI patients: (HPIM p. 1454)
a. <30% of total calories as fat
b. Cholesterol content <500 mg/dL (<300)
c. Complex carbohydrates make up 50-55% of total calories
d. Enriched with foods high in magnesium and fiber, but low in Na and (high in K)
K.
e. Patients are placed on NPO or receive only clear liquids for the first 4 to 12 hrs
after MI because of the risk of emesis or aspiration.
67. TRUE of adrenal hypertension: (HPIM p. 1467)

a. normal individuals given aldosterone develop elevated BP only if they also

ingest Na
b. hyperkalemia is a prominent feature (hypoK)
c. measurement of serum K is a simple screening test
d. in pheochromocytoma, excess production of hormones stimulates
mineralocorticoid (adrenergic) receptor leading to Na retention (cardiac
stimulation)
a. In primary aldosteronism, there is a clear relationship between the aldosteroneinduced sodium retention and the hypertension.
68. TRUE of the cardiac and neurologic effects of HPN: (HPIM p. 1467)
a. cardiac compensation for the excessive workload imposed by the elevated BP
is sustained by eccentric left ventricular hypertrophy(concentric
b. LVH is more frequently observed by (2decho) 12L-ECG rather than 2Dechocardiography
c. Frontal headaches, (occipital)usually in the afternoon, are among the most
prominent early symptoms of HPN
d. Cerebral infarction (hemorrhage) is the result of elevated BP and development
of Charcot-Bouchard microaneurysms
e. Ophthalmoscopic examination provides the opportunity to observe the progress
of vascular effects of hypertension since the retina is the only tissue in which
arteries and arterioles can be examined directly.
69. TRUE of the clinical manifestations of HPN: (HPIM p. 1468-9)
a. Most patients have no specific symptoms to their elevated BP.
b. Primary aldosteronism may present with polyuria and polydipsia, aside from
hypokalemia,
c. Cushings syndrome may present with weight loss (weight gain) and emotional
lability
d. Seconday hypertension often develops before age 35 or after age 55.
e. Diastolic (systolic) blood pressure has a greater effect on morbidity and
mortality than systolic blood pressure.
70. Indications for chronic anticoagulation because of increased risk of pulmonary or
systemic thromboemolism: (HPIM p. 1455)
a. anterior location of myocardial infarct
b. atrial fibrillation
c. mural thrombus demonstrated by 2D-echo
d. severe LV dysfunction
e. congestive heart failure, history of embolism
MULTIPLE CHOICE: Choose the BEST answer.
1. A hormone that is highly accurate for identifying or excluding heart failure from other
causes of dyspnea:
a. arginine vasopressin
b. brain natriuretic peptide
c. renin

d. vasoactive intestinal peptide (VIP)

e. norepinephrine
2. Considerable thickening of the LV wall occurs in what chronic valvular lesion, which at
autopsy the hearts of these patients may be among the largest encountered? (HPIM
p., 1399)
a. aortic stenosis
b. aortic regurgitation
c. mitral regurgitation
d. mitral stenosis
e. aortic calcification
3.
a.
b.
c.
d.
e.

Pulsus parvus et tardus is a PE finding in: (HPIM p. 1397)

mitral stenosis
mitral regurgitation
aortic stenosis
tricuspid regurgitation
aortic regurgitation

4.
a.
b.
c.
d.
e.

The most common cause of pulmonary hypertension worldwide is:

chronic pulmonary thromboembolism
schistosomiasis
chronic obstructive pulmonary disease
pulmonary tuberculosis
sleep apnea

5.
a.
b.
c.
d.

Hallmark of restrictive cardiomyopathy: (HPIM p. 1412)

abnormal diastolic function
secondary mitral regurgitation
abnormal Q waves on ECG
elevated right- and left-sided filling pressures

6. A thickened myocardial wall with a distinctive speckled appearance is seen in the 2dechocardiogram of patients with: (HPIM p. 1412)
a. HIV myocarditis
b. Trypanosoma cruzi infection
c. Amyloidosis
d. Loefflers endocarditis
e. Diphtheritic myocarditis
7.
a.
b.
c.
d.

Most effective imaging technique for pericardial effusion: (HPIM p. 1414)

nuclear scintigraphy
cardiac catheterization with ventriculography
2D-echocardiography
Chest x-ray

8. Paradoxical pulse is defined as a greater than normal (___ mmHg) inspiratory decline
in systolic arterial pressure. (HPIM p. 1416).
a. 5

b.
c.
d.
e.

10
15
20
25

9.
a.
b.
c.
d.
e.

Most common cardiac manifestation of HIV infection: (HPIM p. 1417)

coronary atherosclerosis
endocarditis
myocarditis
pericarditis
arrhythmia

10. Ejection fraction is equal to: (HPIM p. 1363)

a. stroke volume divided by end-systolic volume
b. stroke volume divided by end-diastolic volume
c. (end-diastolic volume end-systolic volume) divided by end-systolic volume
d. End-diastolic volume divided by stroke volume
11. Downward displacement of the tricuspid valve into the right ventricle due to anomalous
attachment of the leaflets is seen in: (HPIM p. 1388)
a. Caplans syndrome
b. Ebsteins anomaly
c. Single ventricle
d. Truncus arteriosus
e. Lutembacher syndrome
12. Which factor determines the clinical presentation of Tetralogy of Fallot? (HPIM p. 1389)
a. severity of the RV outflow obstruction
b. size of the VSD
c. location of the VSD
d. site of stenosis along the RV outflow tract
13. For surgically modified congenital heart disease, cardiac operations involving the atria
may be followed years later, in particular, by this complication: (HPIM p. 1389-90)
a. sinus node dysfunction, av node dysfunction
b. infective endocarditis
c. thrombus formation
d. RV decompensation
14. In doing a 12-lead ECG, precordial lead V2 is placed on the: (HPIM p. 1313)
a. 2nd ICS right parasternal border
b. 4th ICS left parasternal border
c. Between V1 and V3
d. 5th ICS left anterior axillary line
15. Most common site of involvement of cardiac metastases: (HPIM p. 1422)
a. Pericardium (followed by myocardium)
b. myocardium
c. valvular surfaces

d. great vessels
16. Major determinant of signs and symptoms of cardiac tumors: (HPIM p. 1420-22)
a. size and location
b. histologic type
c. chromosomal abnormalities
d. patients age
e. presence of co-morbidities
17. Initial process of atherosclerosis is: (HPIM p. 1426-7)
a. recruitment of WBCs
b. focal increase in contents of lipoproteins within regions of the intima
c. foam cell formation
d. apoptosis of lipid-laden macrophages
18. Most common cause of myocardial ischemia: (HPIM p. 1434)
a. obstructive atherosclerotic disease of epicardial coronary arteries
b. abnormal constriction of conductance vessels
c. abnormal constriction of inramyocardial arterioles
d. obstructive atherosclerotic disease of resistance vessels
19. A patient would press on the sternum, sometimes with a clenched fist, to indicate
squeezing, central, substernal discomfort. This is called: (HPIM p 1435)
a. Leriches sign
b. Levs sign
c. Levines sign
d. Lenegres sign
20. Variant (Prinzmetals) angina responds particularly well to (HPIM p. 1441)
a. beta blockers
b. antiplatelets
c. calcium channel blockers
d. ACE inhibitors
21. This is at the center of the decision pathway for the management of patients with acute
coronary syndromes:
a. 2D-echocardiogram
b. Creatine kinase MB isoform
c. Cardiac specific-Troponin
d. 12L-electrocardiogram
22. Most common cause of out-of-hospital deaths from STEMI: (HPIM p. 1451).
a. pulmonary congestion
b. chordal rupture
c. ventricular fibrillation
d. left ventricular rupture

23. Biggest delay in pre-hospital care of MI patients occurs between: (HPIM p. 1451)
a. onset of chest pain and patients decision to call for help
b. call for help and the arrival of emergency medical team
c. arrival of emergency medical team and transport to hospital
d. arrival of emergency medical team and performance of defibrillation
24. Ideally, fibrinolytic therapy should be initiated within _______ of presentation (door-toneedle time): (HPIM p. 1453)
a. 30 minutes
b. 60 minutes
c. 90 minutes door to balloon
d. 120 minutes
25. Most frequent and potentially most serious complication of thrombolysis: (HPIM p.
1454).
a. allergic reaction
b. hemorrhage
c. hypotension
d. reperfusion arrhythmia
26. Most common pathologic condition associated with aortic aneurysm is: (HPIM p. 1481)
a. cystic medial necrosis
b. diabetes mellitus
c. atherosclerosis
d. Takayasus arteritis
e. Marfan syndrome
27. Thromboangitis obliterans has been demonstrated to have a direct relationship with:
(HPIM p. 1488) buergers
a. elevated triglycerides
b. cigarette smoking
c. hypertension
d. protein C deficiency
28. Which can either be a major or minor Framingham criterion for the diagnosis of
congestive heart failure: (HPIM p. 1371)
a. S3 gallop
b. Hepatomegaly
c. Weight loss >4.5 kg over 5 days treatment
d. Paroxysmal nocturnal dyspnea
29. Most common cause of heart failure, responsible for three quarters of all cases: (HPIM
p. 1368)
a. rheumatic heart disease
b. ischemic heart disease
c. cardiomyopathies
d. hypertensive heart disease
30. A biphasic P wave in V1 with a broad negative component is seen in: (HPIM p. 1314)

a.
b.
c.
d.

right atrial overload

left atrial overload
right ventricular hypertrophy
acute pericarditis

Important!
JNC VII
Description of murmurs
Classic ECG findings what type
Lipid guidelines get a copy
IE, management
Digoxin treatment
Anticoagulation
Criteria for RHD, RF, DVT
Cardiac tumors
Applications cases (must know!)
HTN, MI, IE
Multiple true-false (must know!)
Multiple choices (nice to know!)
Clinical signs of RHD MS, AS
Aortic aneurysm and dissection