146 Section II: Organ Systems Questions
Q U E ST I O N S
1. A physician decides to place a patient on a cal-
cium channel blocker for treatment of her an-
gina. Calcium channel blockers can relax the
smooth muscle of blood vessels and can also
have various effects on cardiac contractility,
conduction, and heart rate. Which of the fol-
lowing calcium channel blockers would be
most effective in reducing heart rate and con-
tractility?
HIGH-YIELD SYSTEMS
(A) Dihydropyridine
(B) Diltiazem
(C) Nifedipine
(D) Nimodipine
(E) Verapamil
2. A 28-year-old African-American man presents
to the physician with fever, weight loss, and ab-
dominal pain. His blood pressure is 168/92
mm Hg, his pulse is 83/min, and his respira-
tory rate is 18/min. On physical examination,
there is palpable purpura on his lower extremi-
ties; a fundoscopic examination reveals fluffy,
white spots on his retina. His past medical his-
tory is significant for a previous hepatitis B in-
fection. An arterial biopsy is shown in the im-
age. Which of the following is the most
Cardiovascular
prominent morphologic feature of the affected
arteries in this patients disease process?
Reproduced, with permission, from USMLERx.com.
Reproduced, with permission, from PEIR Digital Library
(http://peir.net).
(A) Caseating necrosis
(B) Eosinophilic infiltrate
(C) Fibrinoid necrosis
(D) Granulomatous inflammation
(E) Langhans giant cells
(F) Onion skinning
3. A 50-year-old man with diabetes receives the
results of a fasting lipid profile that reveals hy-
percholesterolemia. To reduce the patients
mortality risk, his physician recommends life-
style changes and initiates therapy with a sta-
tin. Which of the following mechanisms de-
scribes the action of statins in reducing serum
levels of LDL cholesterol?
(A) Competitive inhibition of 3-hydroxy-
3-methylglutaryl coenzyme A reductase
(B) Inactivation of 3-hydroxy-3-methylglutaryl
coenzyme A synthase
(C) Negative feedback to decrease thiolase ac-
tivity
(D) Noncompetitive inhibition of citrate syn-
thase
(E) Positive feedback to increase 3-hydroxy-
3-methylglutaryl coenzyme A lyase activity
4. A 45-year-old man who takes spironolactone
and digoxin for his congestive heart failure is
admitted to the hospital because he is experi-
encing an altered mental status. The ECG
changes shown in the image are noted on test-
ing. Urinalysis would most likely reveal which
of the following?

(A) High K+, high Na+, high-normal volume
(B) High K+, low Na+, low volume
(C) High K+, low Na+, normal volume
(D) Low K+, high Na+, high-normal volume
(E) Low K+, low Na+, normal volume
5. A medical student working in the emergency
department sees a female baby, born 2 weeks
ago, who is brought in by her anxious mother.
The mother tells the student that her baby
seems purple, especially her fingers and toes,
and looks extremely blue when crying. On
physical examination the sleeping baby has
mild cyanosis of the face and trunk, but mod-
erate cyanosis of the extremities. Which of the
following is the most common cause of cyano-
sis within the first few weeks of life?
(A) Atrial septal defect
(B) Patent ductus arteriosus
(C) Tetralogy of Fallot
(D) Transposition of the great vessels
(E) Ventricular septal defect
6. A 55-year-old man with hypertension is pre-
scribed an antiarrhythmic agent that alters the
flow of cations in myocardial tissue. The image
is a trace of a myocardial action potential.
Each phase is associated with the opening and/
or closing of various ion channels. Which of
the following would be affected by an agent
that affects phase 2 of the myocardial action
potential?
Ventricular muscle fiber
1
2
30 ms
Reproduced, with permission, from USMLERx.com.
0
3
Reproduced, with permission, from USMLERx.com.
Chapter 8: Cardiovascular Questions 147
(A) Ligand-gated Ca2+ channels opening
(B) Ligand-gated Na+ channels opening
(C) Voltage-gated Ca2+ channels opening
(D) Voltage-gated Na+ channels closing
(E) Voltage-gated Na+ channels opening
7. A 48-year-old man presents to the emergency
department 1.5 hours after the onset of severe
substernal chest pain radiating to his left arm.
The pain is accompanied by diaphoresis and
shortness of breath. His blood pressure is
165/94 mm Hg, pulse is 82/min, and respira-
tory rate is 18/min. Which of the following tests
HIGH-YIELD SYSTEMS
is the most important tool in the initial evalua-
tion of patients in whom acute myocardial in-
farction (MI) is suspected?
(A) Aspartate aminotransferase
(B) Creatine kinase-myocardial bound
(C) ECG
(D) Echocardiogram
(E) Lactate dehydrogenase
8. This image depicts the administration of drug
X, which produces an increase in systolic, dia-
stolic, and mean arterial pressure. Drug Y is
then added, resulting in little or no change to
the blood pressure. Drug X is then readminis-
tered, causing a net decrease in blood pressure.
Cardiovascular
Which of the following drug combinations are
drug X and drug Y, respectively?
X Y X
(A) Epinephrine, phentolamine
(B) Isoproterenol, clonidine
(C) Norepinephrine, propranolol
(D) Phenylephrine, metoprolol
(E) Phenylephrine, phentolamine
 148 Section II: Organ Systems Questions
9. A 56-year-old woman arrives in the emergency
department complaining of dizziness and
headache. Her blood pressure is 210/140 mm
Hg. She is currently not taking any medica-
tions and has not seen a doctor for several
years. The physician decides to address her hy-
pertension urgently. Which of the following
drugs is contraindicated in this patient?
(A) Intravenous diltiazem
(B) Intravenous labetalol
(C) Intravenous metoprolol
(D) Oral captopril
HIGH-YIELD SYSTEMS
(E) Sublingual nifedipine
10. A 65-year-old man presents to the emergency
department with chest pain that he noticed af-
ter climbing a set of stairs. The emergency
physician sends him for an exercise stress test.
Which of the following physiologic mecha-
nisms does the heart use to deal with increased
work demand during an exercise stress test?
(A) Decreased coronary artery diameter
(B) Decreased metabolite production
(C) Decreased oxygen extraction
(D) Increased coronary blood flow
(E) Increased oxygen extraction
11. A 16-year-old Japanese exchange student pres-
Cardiovascular
ents to the physician with a history of fevers,
joint pain, night sweats, and muscle pain. On
physical examination, the patient has extremely
weak pulses in her upper extremities. Labora-
tory abnormalities in which of the following
parameters is most likely?
(A) Anti-IgG antibodies
(B) Antinuclear antibodies
(C) Cytoplasmic antineutrophil cytoplasmic
antibody
(D) Erythrocyte sedimentation rate
(E) Perinuclear antineutrophil cytoplasmic
antibody
12. A 72-year-old African-American man under-
goes hip surgery. On his third hospital day he
experiences chest pain, tachycardia, dyspnea,
and a low-grade fever. The man goes into car-
diac arrest, and efforts to resuscitate him are
unsuccessful. On autopsy a massive pulmonary
embolus is discovered. Which of the following,
if present, would most likely predispose the pa-
tient to this event?
(A) Factor VIII deficiency
(B) Low serum homocysteine levels
(C) Mutation in the Factor V gene
(D) Overproduction of protein C
(E) von Willebrand factor deficiency
13. A 70-year-old woman with a history of type 2
diabetes mellitus, a body mass index of 30 kg/
m2, and an MI 10 years prior presents to the
emergency department with crushing subster-
nal chest pain radiating to her neck and jaw.
Emergency cardiac catheterization with percu-
taneous coronary intervention (PCI) shows a
99% occlusion of her left anterior descending
artery, and an ECG reveals an anterior wall ST
segment elevation MI. The patient remains
stable after PCI, and echocardiography shows
a mildly impaired ejection fraction (EF) of
45%. Three days later, the patient becomes
acutely hypotensive and dyspneic, and physical
examination reveals a high-pitched holosystolic
murmur, loudest at the apex and radiating to
the axilla, that had not been heard on previous
exams. An emergency echocardiogram shows
an EF of 25%. This patient has developed
which of the following?
(A) Aortic stenosis
(B) Dresslers syndrome
(C) Ruptured interventricular septum
(D) Ruptured left ventricular free wall
(E) Ruptured papillary muscle
(F) Ventricular aneurysm
14. A 67-year-old woman presents to the emer-
gency department with dizziness, syncope, and
palpitations. She states she is taking a medica-
tion for heart troubles but cannot remember
its name. Results of an ECG are shown in the
image. Which of this patients current medica-
tions might have caused this abnormal ECG
pattern?

Reproduced, with permission, from USMLERx.com.
(A) Adenosine
(B) Bretylium
(C) Propranolol
(D) Quinidine
(E) Verapamil
15. A 35-year-old man with no significant medical
history presents to his primary care physician
with a 2-week history of progressive shortness
of breath that occurs with activity. He previ-
ously exercised regularly and has never had
symptoms like this before, but now he finds
that he can walk only one block before becom-
ing symptomatic. He has also noticed a 7-lb
(3.2-kg) weight gain during this time. He does
not smoke or use alcohol or illicit drugs and
has not traveled recently. In addition, he has
no family history of cardiac disease and does
not have any sick contacts, but recalls having
an upper respiratory infection about a month
ago that improved on its own. Physical exami-
nation reveals crackles in his lungs bilaterally
and an S3 gallop. X-ray of the chest reveals car-
diomegaly. What is the most likely mechanism
causing this patients heart failure?
(A) Antibodies to a variety of cardiac proteins
that cause immune-mediated damage to
myocytes
(B) Direct cytotoxicity via receptor-mediated
entry of virus into cardiac myocytes
(C) Granulomatous inflammation of myocytes
(D) Hyperadrenergic state leading to dilated
cardiomyopathy
(E) Ischemic damage to cardiac myocytes
Chapter 8: Cardiovascular Questions 149
16. A 25-year-old pregnant woman goes to her gy-
necologist for her 36-week checkup. She com-
plains of light-headedness when she goes to
bed at night. In the office, her blood pressure
is 120/70 mm Hg while sitting upright and
90/50 mm Hg while lying supine. Which of
the following is the most likely cause of this hy-
potension?
(A) Cardiogenic shock
(B) Inferior vena cava compression
(C) Neurogenic shock
(D) Third spacing of fluid
HIGH-YIELD SYSTEMS
(E) Vasodilation
17. A 48-year-old obese man presents to his pri-
mary care physician with complaints of lower
leg pain that occurs after he walks a few city
blocks and is relieved with rest. He has no
other complaints. His blood pressure is 165/85
mm Hg, his pulse is 83/min, and his respira-
tory rate is 18/min. After further questioning,
he admits to smoking two packs of cigarettes
per day. Which of the following types of vessels
is most likely involved in the pathologic pro-
cess surrounding this patients symptoms?
(A) Arteries
(B) Arterioles
(C) Capillaries
Cardiovascular
(D) Veins
(E) Venules
 150 Section II: Organ Systems Questions

18. Jugular venous pressure (JVP) curves are de-
signed to show the pressure changes that nor-
mally take place in the right atrium through-
out the cardiac cycle. A JVP curve consists of
two, or sometimes three, positive waves and
two negative troughs. A normal JVP curve is
shown in the image. Which of the following
points on the normal jugular venous tracing in
the image would be most prominently affected
in tricuspid regurgitation?
R (B) Hepatic artery
HIGH-YIELD SYSTEMS
20. The classic location for an abdominal aortic
aneurysm is inferior to the renal arteries and
extending to the bifurcation of the common
iliac arteries. Repair involves resecting the dis-
eased portion of the aorta and replacing it with
a synthetic graft. Based on anatomic consider-
ations, which of the following visceral arteries
would likely be resected along with the dis-
eased aortic tissue during the repair of an infra-
renal abdominal aortic aneurysm?
(A) Gastroduodenal artery

(C) Inferior mesenteric artery

(D) Left gastric artery
P T (E) Splenic artery
ECG
tracing (F) Superior mesenteric artery
Q
mm Hg

S 21. A 52-year-old African-American man is brought

a c v
to the emergency department unresponsive,
Jugular x y and efforts to resuscitate him are unsuccessful.
tracing On autopsy, it is found that he suffered from a
ruptured aneurysm of the aortic root. His di-
Reproduced, with permission, from USMLERx.com. lated aorta, as seen on autopsy, is shown in the
image. In addition, inspection of the mans
skin revealed several ulcerated lesions. Which
(A) A and C of the following is most likely associated with
(B) A and Y the underlying etiology of this patients aneu-
(C) C and X rysm?
(D) V and Y
Cardiovascular

19. A 62-year-old breast cancer survivor visits her

physician because of weakness, fatigue, fever,
and weight gain 5 years following her radiation
therapy. The physician also elicits complaints
about abdominal discomfort and exertional
dyspnea. Physical examination reveals hepato-
megaly and jugular venous distention that fails
to subside on inspiration, but shows no evi-
dence of hypotension or pulsus paradoxus. An
echocardiogram shows reduced end-diastolic
volumes and elevated diastolic pressures in
both ventricles. Which of the following is the
most likely diagnosis?
(A) Cardiac tamponade
(B) Congestive heart failure
(C) Constrictive pericarditis
(D) Dilated cardiomyopathy Reproduced, with permission, from PEIR Digital Library
(E) Recurrence of breast cancer (http://peir.net).

(A) Atherosclerosis
(B) Congenital medial weakness
(C) Cystic medial necrosis
(D) Disruption of the vasa vasorum
(E) Hypertension
22. A baby is observed at birth to be noncyanotic.
The mother is known to have been infected
with rubella during the pregnancy. On physi-
cal examination the patient is found to have a
continuous murmur that is present in both sys-
tole and diastole. A nonsteroidal anti-inflam-
matory drug is prescribed, and on follow-up
the murmur has disappeared. Which of the fol-
lowing is the most likely congenital lesion?
(A) Patent ductus arteriosus
(B) Tetralogy of Fallot
(C) Transposition of the great vessels
(D) Truncus arteriosus
(E) Ventricular septal defect
23. A 25-year-old white woman with no past medi-
cal history presents to the emergency depart-
ment for a racing heartbeat. It is determined
that she has paroxysmal supraventricular tachy-
cardia. Which of the following is the drug of
choice used for diagnosing and abolishing
atrioventricular nodal arrhythmias by virtue of
its effectiveness and its low toxicity?
(A) Adenosine
(B) Bretylium
(C) Encainide
(D) Lidocaine
(E) Sotalol
24. A 62-year-old man was admitted to the inten-
sive care unit for overwhelming sepsis. The pa-
tient has received 4 L of normal saline bolus
fluids. Empirical antibiotics were begun with
no improvement in his condition. His blood
pressure is 60/30 mm Hg, pulse is 112/min,
temperature is 40.6 C (105 F), and respira-
tory rate is 23/min. The physician orders intra-
venous norepinephrine. Which of the follow-
ing is a direct effect of norepinephrine in this
clinical scenario?
Chapter 8: Cardiovascular Questions 151
(A) Bradycardia
(B) Bronchoconstriction
(C) Coronary vasodilation
(D) Decreased inotropy
(E) Periphearl vasodilation
25. An 85-year-old man dies from aspiration pneu-
monia as a complication of Alzheimers dis-
ease. Autopsy reveals a small (230-g) heart that
appears grossly dark brown in color. Hematoxy-
lin and eosin staining of cardiac muscle cells
reveals brownish perinuclear pigmentation.
HIGH-YIELD SYSTEMS
The pathologist determines this phenomenon
to be a consequence of age and not a causative
agent in the patients death. Accumulation of
which of the following substances is the most
likely cause of the brown pigmentation seen
most often in the heart, liver, or spleen of the
elderly?
(A) Bilirubin
(B) Calcium
(C) Cholesterol
(D) Glycogen
(E) Iron
(F) Lipofuscin
26. A 72-year-old woman has a 1-month history of
left-sided jaw pain when chewing food, head-
Cardiovascular
ache, fever, and fatigue. Laboratory studies re-
veal an elevated erythrocyte sedimentation
rate. Which of the following arteries is most
likely involved?
(A) External carotid artery
(B) Facial artery
(C) Ophthalmic artery
(D) Postauricular artery
(E) Superficial temporal artery
 152 Section II: Organ Systems Questions
27. A 67-year-old woman with a long history of
poorly controlled diabetes mellitus and chronic
renal failure is admitted to the hospital for
treatment of cellulitis. Two days into her hospi-
tal stay she complains of chest pain that is re-
lieved when she leans forward. An ECG shows
diffuse ST segment elevations with PR depres-
sions; her echocardiogram is normal. Which of
the following is the most appropriate treatment
at this time?
(A) Cardiac catheterization
(B) Dialysis
HIGH-YIELD SYSTEMS
(C) Nonsteroidal anti-inflammatory drugs
(D) Pericardiocentesis
(E) Switch her to another antibiotic regimen
28. A 75-year-old woman arrives at the emergency
department and states that her left arm is
numb. She is diaphoretic. Laboratory studies
show an elevated troponin I level and the pa-
tient is treated for an acute MI. A subsequent
echocardiogram shows a wall motion abnor-
mality of the posterior interventricular septum.
Stenosis of which of the following arteries
would most likely cause this condition?
(A) Acute marginal artery
(B) Circumflex artery
(C) Left anterior descending artery
Cardiovascular
(D) Posterior descending artery
(E) Right coronary artery
29. A 24-year-old man presents to the emergency
department with a fever, chills, night sweats,
malaise, and fatigue that started 3 days ago. In
the past day he has also become short of
breath. He admits to using intravenous drugs
regularly. At presentation, the patient is shak-
ing and appears pale. Physical examination is
remarkable for a temperature of 39.4 C (103
F), hypoxia to 88% on room air, jugular venous
distention, bilaterally decreased breath sounds
at the bases with dullness to percussion at the
bases, and a grade III/VI systolic murmur heard
best at the lower left sternal border. The pa-
tient states that he never had anything wrong
with his heart before. Which pathogen is most
likely responsible for this patients condition?
(A) Enterococcus faecalis
(B) Haemophilus aphrophilus
(C) Staphylococcus aureus
(D) Streptococcus bovis
(E) Viridans streptococci
30. Drugs such as cholestyramine and colestipol
have been shown to decrease circulating serum
LDL cholesterol and to slightly elevate triglyc-
erides. These drugs work by which of the fol-
lowing mechanisms?
(A) Binding and excretion of bile-soluble
lipids
(B) Decreased peripheral lipolysis
(C) Increased lipoprotein lipase activity
(D) Inhibition of cholesterol absorption at the
small intestine brush border
(E) Inhibition of the rate-limiting enzyme of
cholesterol formation
(F) Retention of bile acid resins in hepatocytes
31. A 30-year-old patient comes to an ophthalmol-
ogist with complaints of decreased vision. On
examination, angiomatous lesions are visible in
the retina. The patient also has documented
cerebellar and spinal hemangioblastomas,
bilateral renal cysts, and pancreatic microcystic
adenomas. A previous chromosomal analysis on
this patient showed a deleted tumor suppressor
gene. A detailed family history shows similar
problems in the patients brother, father, aunt,
and grandfather. Which of the following is the
inheritance pattern of this patients disease?
(A) Autosomal dominant
(B) Autosomal recessive
(C) Mitochondrial
(D) Spontaneous
(E) X-linked recessive
32. A 25-year-old Massachusetts college student
presents to his primary care physician. He said
he first started to notice problems a few months
ago after returning from a hike in the woods.
He originally had an expanding rash starting
on his calf and flu-like symptoms that resolved
spontaneously. Recently, he started having
symptoms of dizziness, syncope, dyspnea, chest
 Chapter 8: Cardiovascular Questions 153

pain, and palpitations for several weeks dura-
tion. His physician obtains an ECG, as shown
in the image. The vector that carries the organ-
ism responsible for the students symptoms is
also responsible for transmitting which of the
following diseases?
aspartate aminotransferase (AST), creatine ki-
nase-MB fraction (CK-MB), lactate dehydroge-
nase (LDH), and troponin is one indication
that a MI has occurred. The image shown is a
representation of the average length of time it
takes to see an elevation in these four enzymes.
What is the correct order of cardiac enzyme el-
evation after an MI?

P P P P P P P P P P P P

HIGH-YIELD SYSTEMS
Reproduced, with permission, from USMLERx.com.

(A) Babesiosis
Reproduced, with permission, from USMLERx.com.
(B) Epidemic typhus
(C) Malaria
(D) Plague
(A) AST, CK-MB, troponin, LDH
(E) Rocky Mountain spotted fever
(B) AST, LDH, troponin, CK-MB
(C) CK-MB, AST, troponin, LDH
33. A 57-year-old white man presents to his pri-
(D) CK-MB, troponin, AST, LDH
mary care physician with dyspnea. He says that
(E) LDH, CK-MB, troponin, AST
he likes to maintain his yard and garden, but
(F) Troponin, AST, CK-MB, LDH
that he has recently had trouble doing the
(G) Troponin, CK-MB, AST, LDH
work, and becomes short of breath even walk-
ing up the one flight of stairs in his house. On

Cardiovascular
35. A 73-year-old man with a history of hyperten-
further questioning, he says that sometimes he
sion and type 2 diabetes mellitus presents with
wakes up short of breath in the middle of the
the sudden onset of right-sided paralysis. An ul-
night. Physical examination demonstrates pit-
trasound study shows significant atherosclerosis
ting ankle edema. Which of the following find-
in a major artery that is embryologically
ings would also be expected in this patient?
derived from one of the aortic arches. The ar-
(A) Decreased sympathetic outflow tery that is most likely involved in this patients
(B) Decreased venous pressure paralysis is derived from which of the following
(C) Increased aldosterone secretion aortic arches?
(D) Increased effective arterial blood volume
(A) First aortic arch
(E) Increased glomerular filtration rate
(B) Second aortic arch
(C) Third aortic arch
34. A number of tests are used to diagnose an MI.
(D) Fourth aortic arch
Measuring an elevation in the cardiac enzymes
(E) Sixth aortic arch
 154 Section II: Organ Systems Questions
36. A 76-year-old woman visits the emergency de-
partment complaining of increased fatigue. She
states that she tires easily even with very low lev-
els of activity. Her temperature is 36.7 C (98.1
F), heart rate is 123 beats/min, and blood pres-
sure is 85/43 mm Hg. The woman has a history
of coronary artery disease and diabetes. She also
notes a recent traumatic episode when her
grandson kicked her in the chest when she was
picking him up. On physical examination, her
doctor notices a disappearing arterial pulse on
inspiration. The doctor orders an echocardio-
HIGH-YIELD SYSTEMS
gram to confirm the diagnosis. What invasive
procedure will be necessary to treat this patient?
(A) Angioplasty
38. A 3-year-old boy comes to the pediatrician with
(B) Aortic valve replacement
(C) Mitral valve replacement
(D) Pericardiocentesis
(E) Surgical reduction of an aortic aneurysm
37. A 60-year-old woman dies in a car accident.
On autopsy, the cause of death is determined
to be a massive brain hemorrhage due to a
skull fracture. An additional abnormality,
shown below in the image of the opened left
atrium, is also found and determined to be un-
related to the cause of death. This abnormality
could have led to which of the following physi-
Cardiovascular
cal examination findings when the woman was
alive?
39. A 54-year-old woman comes to the physician
Reproduced, with permission, from PEIR Digital Library
(http://peir.net).
(A) Continuous murmur throughout both dias-
tole and systole, loudest at the end of ven-
tricular systole
(B) Decrescendo murmur in early ventricular
diastole
(C) Sharp, high-pitched sound in early ventric-
ular diastole, followed by a decrescendo,
crescendo murmur
(D) Sharp, high-pitched sound in early ventric-
ular systole, followed by a crescendo,
decrescendo murmur
(E) Sharp, high-pitched sound in mid ven-
tricular systole, followed by a uniform
murmur
fever, conjunctivitis, erythema in the oral mu-
cosa, and cervical lymphadenopathy. The boy
suddenly becomes hypotensive and goes into
cardiac arrest and dies shortly thereafter. Au-
topsy shows aneurysmal dilations of the left cir-
cumflex and right coronary arteries. The boys
disease is characterized as a self-limiting dis-
ease that most commonly affects the coronary
arteries. Which of the following diseases is the
correct diagnosis?
(A) Buergers disease
(B) Kawasakis disease
(C) Polyarteritis nodosa
(D) Takayasus arteritis
(E) Wegeners granulomatosis
3 months after a undergoing a root canal be-
cause of persistent general malaise and fever.
The symptoms developed slowly over the
weeks following her root canal, but have not
abated. On physical examination, the patient is
found to have a temperature of 38.3 C (101
F). Ophthalmic examination reveals retinal
hemorrhages with clear central regions. Exam-
ination of the extremities reveals painful red
nodules on her digits and dark macules on her
palms and soles. On cardiac examination, a
click and a systolic murmur are auscultated
over the mitral valve. She tells the physician
that the click is due to a mechanical valve
replacement done 4 years ago due to rheu-
 Chapter 8: Cardiovascular Questions 155

matic fever as a child. Given this history, which that mediates the compensatory coronary artery
of the following is the most appropriate treat- vasodilation during periods of increased myo-
ment for this patient? cardial oxygen demand?
(A) Caspofungin (A) Acetylcholine
(B) Clindamycin (B) Adenosine
(C) Mebendazole (C) Carbon dioxide
(D) Metronidazole (D) Lactate
(E) Nafcillin (E) Norepinephrine
(F) Penicillin
(G) Pentamidine 42. The image depicts the relationship of ventricu-
lar pressure and volume in the cardiac cycle.
40. A 67-year-old woman who has recently begun The various phases of the cardiac cycle are

HIGH-YIELD SYSTEMS
to take a new antihypertensive medication labeled I through IV. Which phase occurs be-
presents to her primary care physician with tween aortic valve closing and mitral valve
complaints of new-onset fatigue and depressed opening?
mood. Her physical examination is unremark-
able except for a heart rate of 56/min. Labora-
tory tests show:
Na+: 137 mEq/L 110
K+: 4.0 mEq/L
III
Blood urea nitrogen: 12 mg/dL
Pressure, mm Hg

Creatinine: 0.5 mg/dL

Glucose: 82 mg/dL
IV II
Which of the following is most likely the new
20
medication that this patient has started?
(A) Furosemide
(B) Hydrochlorothiazide I

Cardiovascular
(C) Losartan
(D) Metoprolol
(E) Nifedipine 40 80 120 160
(F) Prazosin Volume, cc

41. A dysfunctional myocardial endothelium un- Reproduced, with permission, from USMLERx.com.
derlies one form of heart disease. In patients
with this common disease process, there is a
lack of autoregulatory coronary artery vasodila- (A) Phase I
tion needed to provide increased blood flow in (B) Phase II
states of increased physical exertion or emo- (C) Phase III
tional stress. The pathogenesis is most often (D) Phase IV
from severe narrowing of atherosclerotic coro-
nary vessels and typically manifests as chest
pain, relieved by rest or nitroglycerin tablets.
Which of the following is a soluble metabolite
 156 Section II: Organ Systems Questions

43. A 32-year-old man with diabetes presents to his (A) Angina

physician with orthostatic hypotension. This (B) Cardiotoxicity
suggests a deficiency in the normal physiologic (C) First-dose orthostatic hypotension
response carried out by arterial baroreceptors (D) Nephrotoxicity
located in the aortic arch and the carotid sinus. (E) Pulmonary embolism
What is the normal physiologic response to
hypotension? 46. A 76-year-old man receives a pacemaker to
treat a dangerous form of heart block. This
(A) Decreased baroreceptor afferent firing in
form of heart block is characterized by a con-
the aortic arch leads to increased sympa-
stant PR interval with randomly blocked QRS
thetic efferent firing
complexes. The patients ECG prior to treat-
(B) Decreased baroreceptor afferent firing in
ment is shown in the image. Which of the fol-
the carotid sinus leads to increased para-
HIGH-YIELD SYSTEMS

lowing is the abnormality responsible for this

sympathetic efferent firing
type of heart block?
(C) Decreased baroreceptor afferent firing in
the carotid sinus leads to increased sympa-
thetic efferent firing
(D) Increased baroreceptor afferent firing in
the aortic arch leads to increased parasym-
pathetic efferent firing
(E) Increased baroreceptor afferent firing in
the carotid sinus leads to increased para-
sympathetic efferent firing Reproduced, with permission, from USMLERx.com.

44. A 56-year-old woman presents to her physician

because of recent onset of chest pain and dysp-
nea. Six weeks earlier the patient suffered an
MI. Her physical examination is remarkable
for a friction rub over the fifth intercostal space
Cardiovascular
(A) Atrioventricular nodal abnormality
(B) Defect in the His-Purkinje system
(C) Independently contracting atria and
ventricles

in the midclavicular line together with an ele- (D) Retrograde conduction

vated jugular venous pressure. Which of the
following myocardial complications is this in-
dividual most likely suffering from?
(A) Cardiac arrhythmia
(B) Dresslers syndrome
(C) Left ventricular failure
(D) Thromboembolism
(E) Ventricular rupture
45. A patient presents for treatment of his severe
essential hypertension. He is being treated with
numerous medications for high blood pressure,
and hydralazine was recently added to his med-
ication regimen. He explains that he has been
experiencing flushing and headaches since his
last visit, when hydralazine therapy was started.
Which of the following is an adverse effect of
hydralazine?
(E) Sinoatrial nodal abnormality
47. A 56-year-old white man is rushed to the emer-
gency department with crushing substernal
chest pain. He is morbidly obese, sweating pro-
fusely, breathing very rapidly, and clutching at
his chest. The patient is stabilized and seems
to be doing well when he suddenly goes into
cardiac arrest and dies. Which of the following
is the most likely cause of death in this patient?
(A) Fatal arrhythmia
(B) Mural thrombosis
(C) Myocardial failure
(D) Myocardial rupture
(E) Ruptured papillary muscle
48. A previously healthy 31-year-old woman is seen
in the emergency department because of com-

plete visual loss in her right eye. The patients
history is significant for a 3-day history of mal-
aise, chills, and fatigue and some oral pain sec-
ondary to her recent wisdom tooth removal.
Ophthalmologic examination reveals a gray-
white retina with an associated cherry-red spot,
two blot hemorrhages, and several segmented
vessels with optic edema. Physical examination
reveals a murmur consistent with mitral valve
insufficiency. Which of the following is the
most likely cause of this patients loss of vision?
(A) Carotid artery stenosis
(B) Collagen vascular disease
(C) Diabetes mellitus
(D) Endocarditis
(E) Hypertensive crisis
49. Cardiac output is a function of stroke volume
and heart rate. Stroke volume increases when
contractility increases, preload increases, or
afterload decreases. There are a number of fac-
tors that affect each of these components and
Chapter 8: Cardiovascular Questions 157
ultimately cardiac output. Which of the follow-
ing variations would increase cardiac output?
(A) -Blocker treatment
(B) Aortic stenosis
(C) Cardiac glycoside administration
(D) Decreased intracellular calcium concen-
tration
(E) Increased extracellular sodium concentra-
tion
50. A 54-year-old woman presents to her physician
with swelling in her extremities. Palpation pro-
HIGH-YIELD SYSTEMS
duces significant pitting. Which of the follow-
ing conditions is the underlying physiologic
basis of this physical finding?
(A) Decreased capillary permeability
(B) Decreased capillary pressure
(C) Increased interstitial fluid colloid osmotic
pressure
(D) Increased interstitial fluid pressure
(E) Increased plasma protein levels
Cardiovascular