1. A 60-year-old man was hospitalzed at the intensive care for 1 week.

He arrived at the
emergency un t with chief complaint of severe sharp wpigastric and backpain 6 hours
before admission. During his pain, he ever lost his consciusness and lots of
perspiration. The history of illness was hypertension used amlodipin 5 mg twice daily.
On physical examination was found blood pressure 180/100 mmHg, heart rate 110
x/minutes and others within the normal limit. An electrocardiogram showed left
ventrical hypertrophy. A chest x-ray revealed mediastirum enlargement. Blood study
showed Hb g/dL Ht 40 vol%, WBC 12.000/cL, D-dmer 19.000. CT angio
unenhanceent of axial view showed crescent shape aortic appearance just after left
subclavian artery branch lengthened to diaphragms. However, an CT enhancement
was seen contrast passed entry site fill limited length portion of false lumen about 0,5
cm. Aortic arch was seen space among right inominate artery, left carotid artery and
left subclavian artery were very close. CT angio of aortic dissection in the case above
is correlated with pathophysiology as following?

a) Connective tissue disorders and injury

b) None of them
c) Microcirculation rupture
d) Atherosclerotic
e) Liatrogenic

2. A 36-year-old women who emigrated to the United States is referred to you by her
cynecologist for evaluation of hypertension that was noted 1 week ago, when she
sought an evaluation for infertiity. She was first told that she had hype tenson at 20
years of age, but did ot follow up with a physician untill recently. On your advice, her
gynecologist initiated treatment with amlodixine, 5 mg, after obtaining a blood
pressure of 200/100 mmHg. The patient has frequent headaches and also has cold
feet and leg cramping when she walks long distances. Physical examination shows
blood pressure of 160/90 mmHg in the left arm while sitting and heart rate of 70/min.
Juguar venous pressure is normal. Carot d pulses are brisk bilaterally. Cardiac
examination shows a sustained apical impulse. S1 is normal and s@ is physiologically

1
 split. An early systolic ejection sound is noted, and an early peaking murmur is noted
at the second right intercostal space. A short diastolic murmur is audible along the left
sternal border. Lungs are clear to auscultation. Electrocardiogram shows left
ventricular hypertrophy. Fndings on urinalysis are normal. Which of the following is
the most appropriate next step in the evaluation of this patient?

a) Measure the blood pressure in the lwer axtremities

b) Order a 24 hour urine test for metanephrine and vani lylmandelic acid
c) Measure serum thyroid-stimulating hormone
d) Obtain a chest radiograph
e) Order an echocardiogram

3. Patients who develop heparin-induced thrombocytopenia have an in vitro cross-

reactivity with low-molecular-weight heparin (LMWH) by what percent?

a) 5% to 10%
b) 90% to 100%
c) 60% to 70%
d) 25% to 45%

4. A 29-year-old woman comes to ypur office for a second opinion She had peripartum
cardiomyopathy and wants to get prenant again. You obtain a TTE e=which shows a
normal LV. What should yo recommend?

a) She should not have anothe rpregnancy because she lis likely to have recurrent
cardiomyopathy
b) She should undergo exercise testing for better assessment
c) She may conceive again because her LV is normal. Her chance of having
recurrent cardiomyopathy is less than 5%
d) She may conceive again because her LV is normal. Howecer, her chance of
having recurrent cardiomyopathy is 30% to 50%

2
5. A 77-year-old man walks into the emergency room reporting palpitations and
dizziness. A 12-lead ECG shows wide complex tachycardia at a rate ogf 160 bpm. His
BP is 110/50 mmHg. He reports that he recently sustained an MI. He has not had any
similiar symptoms before. Which of the following should be included in further
evaluation and treatment of his asshytmia?

a) Procanamide, 15 mg/kg IV over 30 to 60 minutes

b) Digoxin, 1 mg IV over 6 hours in four diivided doses
c) Verapamil, 10-mg IV bolus, to treat SVT with aberraficy, as the patient is
hemodynaiclly stable
d) Immediate DC cardioversion
e) Immediate cardiac catheterization and agioplasty as needed

6. A 71-year-old man presents with the sudden onset of tearing chest pain. On
presentation, he has a heart rate of 130 beats, min with a sstolic blood pressure of 80
mmHg. A bedside TEE demonstrates the presence of a proximal aortic diszection. A
pericardial effusion with partial diastolic collapse of the right ventricle is also presennt.
Significant respiratory variation is notd across mitral and tricuspid Doppler inflows.
Appropriate treatment is:

a) Intra-aortic ballon pump to staboloze the hemodynamics, followed by surgery

b) Emergency angiography to define coronary anatomy, followed by surgery
c) to proceed immediately to the operating room
d) Immediate percutaneous pericardiocentesis to relieve the tampoade, followed by
surgery to replace the ascending aorta.

7. You 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.

3
 ECG findings reveal a superior axis, absent right ventricular voltages, and a large P
wave. Wha is the most likely diagnosis?

a) Critical pulmonary stenosis

b) Complete atroventricular septal defect
c) Tricuspid atresia
d) Transposition of the grest arteried
e) Total anomalous pulmonary venous connection (TAPVC)

8. A 66-year-old man admitted to hospital with sudden worsening shortness of breath

preceding by sharp chest pain and not relieved by resting. Before having chest pain,
patient was walking about 400 meters 3 days before patient having typical anginal
chest pain and diaphoresis, but patient refuse to seek medical assistant. Patient was
an active smoker, had history of diabetes and uncontrolled hipertension. On physical
examinatoin, the patients found to have a blood pressure of 100/70 mmHg, pulse 96
times perminutes. His JVP were raise and found a 3/6 harsh systolic murmur at the
left stermal border. Blood studies showed Hb 34 g/dL, Hi 43,7%, WBC 11900/uL, ck-
mb 55. Which of the following is the most likely anatomic diagnosis for this patient?

a) Ventricular Septal Rupture

b) Acute Long Edema
c) Acute Ischemic Mitral Regurgitation
d) Ventricular Septal Defect
e) Acute myocardial infarction

9. A 60-year-old man presents for further evaluation of recurrent congestive heart failure.
He appears to be in no acute distress on your evaluation. BP is 100/60 mmHg. Carotid
upstrokes are weak, but not delayed. Chest examination shows minimal bibastar

4
 rales. PMI is displaced and sustained. A summation gallop is resent. There is am
increased P2. there is mild peripheral edema. An echocardiogram reveaks a dilzted
LV with an ejection fraction of 25%. The ortic valve does have some calcification, with
rwstricted leaflet excursion. Peak/mean gradients are 25/15 mmHg. By the continulty
equation, the aortic valve area is calculated as 0.7 cm2. What is your next step?

a) Referral for cariac transplant

b) Start anACEI
c) Immediate referral for aortic valve replacement (AVR)
d) Dobutamine echocardiogram

10. A young patient ais admitted to the intensive care unit with ambryptyline overdises.
Three hours later gastric lavage, he developes hypotension and wide complex
tachycardia tat ih recurrent dspite cardioversion. Appropriate management includes
which of the following?

a) Temporary pacemaker with overdrive pacing

b) IV bretylium
c) IV hypertonic sodium bicarbonate
d) IV magnesium sulfate
e) IV cardium gluconatE

11. A 46-year-old man is status post hip replacement. He develops sudden-onset

shortness of breath. On examination, he is hypotensive with s BP of 80/40 mmHg. An
ECG shows sinus tachycardia at 100 beats peminute with ST elevation in V1 to V2. A
bedside echo is performed (Fig.3-3). What is the most appropriate intervention?
a) Perform a CT angiogram to rule out a dissection
b) Activate catheterization laboratory to perform a primary PCI
c) Initiate antibiotics and perform blood cultures
d) Initiate intravenous heparin and assess risks and benefits of fibrinolysis.
e) Perform a saline contrast study to assess right-to-left shunt.

5
12. A 61-year—old man with a history of PCI 3 years previously asks for your advice with
respect to his pharmacologic treatment. He is asymptomatic and jis CV risk factors
include smoking, hypertension, hypercholesterolemia, and impaired glucose
tolerance. His medications include aspirin, atovastarin, metoprolol, metoformin, and
lisinopril. His friend told him that clopidogrel should be added to his regimen. What is
the correct statement about that suggestion in this particular patient?

a) There is no significant benefit associated wiith clopidogrel plus apirin as

compared with placebo plus aspirin in reducing the incidence of the primary
endpoinc of MJ, stroke, or death from CV causes.
b) The rate of severe or moderate bleeding is not significanntly greater with
clopidogrel and aspirin compared with aspirin alone.
c) There is a significant benefit associated with clopidogrel plus aspirin in reducing
the
d) Answers a and d are correct
e) The rate of severe or moderate bleeding is significantly greater wth clopidrogel
and aspirin compared with aspirin alone.

13. A 26-year-old man is referred to you for an abnormal heart sound. The patient is
asymtomatis and very active. BP is 130/50 mmHg. He has a continuous murmur at
the left upper stermal border. A TTE reveals a small PDA with mildly diated left atrium
(LA) and mildly dilated LV but normal RV size and norrmal RV size and noral
pulmonary presures. How would the patient be best managed?

a) Ligation or percutaneous closure of the PDA

b) Pulmonary vasodilator
c) TEE
d) Stress echocardiography to determine LV enlargement or dysfunction
postexercise

6
 e) Repeat TTE in 1 year

14. A 63-year-old man is admitted with chronic obstructive pulmonary disease (COPD)
and mild left ventricular (LV) dysfunction (ejection fraction [EP] 45%) as will as
symptomatic, recurrent atrial fibrillation (heart rate [HR] 123% to 150s) despite
antiarrhytmic drug terapy and direct current cardioversion in the past. After rate control
with intravenous (IV) 7-blockers, the HR improves and the patient feels better. Given
his recurrent atrial fibrilation despite optimal medical therapy, the patient is referred
for radiofrequency ablation of atrial fibrillation (pulmonary vein isolation) procedure.
The procedure is performed on anticoagulation (international normalized ratio > 2.0)
and is deemed a success, with no inducible atrial fibriliation at the end of the case. A
small atrial septal defect (ASD) was noted with intracardia echocardiography at the
end of the case, with no other remarkable findings. That evening in the post-
anesthesia care-unit (PACU), the patient is noted to be hypotensive and tachycardic
with increasing dyspnea. There is a concern for cardiac tamponade; however, the
arterial line does not show a significant respiraton, variation of the blood pressure (BP)
waveform (pulsus paradoxus). An echocardiogram is performed, demontrating a large
circumferential effution and the patient is referred for urgent pericardiocentesis. Whch
of the following explains why the patient did not develop a pulsus on the arterial ine,
despite a large, hemodynamically significant pericardia effusion?

a) Administration of excess IV fluid during the ablation

b) LV dysfunction
c) Presence of an ASD
d) COPD
15. A 79-year-old retired federal judge comes to your office to follow up. He has long
standing HTN and has undergone PTCA, stent for a mild-LAD lesion. He has normal
LV function and is active and healthy. Currently he is on ramipril (Altace),
atorvastation, and aspirin. He heard on television that the combination of aspirin and
ramipril increases mortalitty. He wants your opinion. What is your answer?

7
 a) This has been shown in large trials; we should change aspirin to clopidogrel
bisulfate or ramipril to metoprolol tartrate
b) There are randomized studies to support thiss; however, the sample size was
too small to make any conclusive recommendations. Continue he current
regiment.
c) There are only obsevational studies, and they have not been proven. Continue
the current regimen.
d) Although this has been seen in retrospective trials. It has not been vaidated in a
randomized trial; therefore, continue te current regimen.

16. A 67-year-old man with diabetes with no hypertension but end-stage renal failure
treated with hemodialysis in the last 15 years presents with worsening dyspnea and
suspicion of ischemia at the stress imaging. What are the most characteristc findings
relating to the coronary arteries to be found at angiography?

a) Normal coronary arteries (symptoms caused by small-vessel disease)

b) Tortuous coronary vessels
c) Ectatic coronary arteries
d) Calcifield coronary arteries
e) Coronary arteries with anomalous origins

17. An 81-year-old man with severe AS is turned downl for surgical AVR due to significant
comorbidities. he is referred to you for consideration for trascatheter AVR. Which of
the following findings is considered a contraindication for this procedure?

a) Life expectancy <1year

b) Calcified and tortuous femoral arteries
c) Annulus size of 20mm
d) The apex is not accessible

8
 e) A history of treated endocarditis

18. M.R. is a 75-year-old man with a history of hypercholesterolemia treated with

simvastatin. Two months ago he had a permanent pacemaker placed for sick sinus
syyndrome. He now presents with a 1-month history od fever, chills, and unexplained
weight loss. On physical examination he has a new tricuspid regurgitation murmur. A
transesophageal echocardiogram confirms your suspiction of endocarditis. Which of
the following antibiotics increases he risk of rhabdomyolysis when given with
simvastatin?

a) Daptomycin
b) Vancomycin
c) Ceftriaxone
d) Linezolid

19. A 77-year-old man walks into the emergency room reporting palpitations and
dizziness. A 12-lead ECG shows wide complex tachycardia at a rate of 160 bpm. His
BP is 110/90 mmHg. He reports that he recently sustained an MI. He has not had any
smiliar symptoms before. Which of the following should be included in further
evaluation and treatment of his arrhytmia?

a) Procainamade, 15 mg/kg IV over 30 to 60 minutes

b) Digoxin, 1 mg IV over 6 hours in four divided doses
c) Verapamil, 10-mg IV bolus, to treat SVT with abberancy, as the patient is
hermodynamically stable
d) Immediate DC cardioversion
e) Immediate cardiac caheterization and angiopathy, as needed

20. Recently, a 44-year-old lawyer received heart transplantation. His hospital course was
unremarkable, and he was discharged. He found out from the heart failure nurses that
allograft vasculopathy is the leading cause of long-term morbidity and mortality in

9
 transplant patients. He wants to now what proven treatments prevent allograft
vasculopathy. Which of the following treatments should you recommend?

a) No known treatment
b) Statins
c) Annual stres test
d) Biannual stress test
e) Annual cardiac catheterization, intravascular ultrasound, and percutaneous
coronary intervention (PCI), as needed

21. Which of the following are associated with patent foramen ovale (PFO)?

a) Migraine
b) Paradoxical embolism & stroke
c) Decomprssion sickness
d) Platypnea-orthodeoxia
e) All of the above

22. A 30-year-old woman with known insulin-dependent diabetes melitus was found
unconscious 1 hour after an office party. Initial assesment by the emergency medical
servuce team showed a BP of 90/60 mmHg. Her pulse was 120, and her blood sugar
was 870 mg/dL. She was given SC insulin and rushed to the emergency depatment.
You are called to see her because of her abnormal ECG (Fig. 13. 16). She is noted to
be semiconscious. The emergency physician has alrready started her on IV insulin
drip and hydration. What is your recommendation at this juncture?

a) She has ECG evidence of hyperkalemia and she needs IV calcium and, possibly,
dialysis
b) She is having an acute MI, and immediate restoration of coronary flow is
essential

10
 c) Continue the current management; the ECG will improve with the resolution of
ketoacidosis
d) Her ECG prdicts high-degree atrioventricular block; a standby external
pacemaker should be available

23. A 60-year-old morbidly obese woman is admitted for cholecystectomy and

postopearatively is placed on deep venous thrombosis (DVT) prophylaxis with mini-
dose subcutaneous heparin. On hospital day 2, a peripherally inserted central venous
catheter is placed in the right arm. The patient is discharged to a rehabilitation facility
on hospital day after removal of the venous catheter. Two days later she presents to
the emergency room with right upper extremity pain and swelling. She reports she has
not felt well enough to participate with physical therapy since being discharged from
the hospital. Venous duplex of the right arm demonstrates acute thrombosis of the
right cephalic vein. Complete blood count (CBC) and chemistries are within normal
range with a platelet count of 180 K/µL. What should the target activated partial
thromboplastin time (aPTT) be to avhieve optimal efficacy and safety if anticoagulation
with a DTI were to be initiated in this patient?

a) An aPTT of 1.5 to 2.0 times the baseline value

b) An aPTT of 2.5 to 3.0 times the baseline value
c) An aPTT of 2.0 to 3.0 times the baseline value
d) An aPTT of 3.0 to 4.0 times the baseline value
24. A 46-year old business executive presents to A&E with a 2-hour history of central
crushing chest pain and breathlessness. He is a non-smoker, previously very fit and
wel and attends a gym four times a week. There is no family history of ischemic heart
disease. His cholesterol measured at an insurance medical was 3.3 mmol/L. His
observations on admission are as follows; pulse 105 bpm. Right-axis deviation and
non-spesific T-wave inversion in leads III, aVF, V2-V4. As a business executive, all of
the following aspects of the history and examination would help you to establish
diagnosis, EXCEPT?

11
 a) Radiographic evidene of pulmonary edema
b) Family history of thromboemblic disease
c) Accentuated pulmonary second sound
d) The patient may have recently been on a long-haul flight
e) Absence of exertional angina

25. A 48-year old man with constrictive pericarditis is undergoing an echocardiogram for
follow-up. The sonographer asks you to explain rhe difference between the annulus
reversus and annulus paradicus phenomena. Which of the following stateents is
correct?

a) Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler
velocities (E’ septal > E’ lateral) and annulus paradoxus refers to inverse
correlation of E/E’ and LV end-diastolic pressure
b) Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler
velocities (A’ septal > A’ lateral) and annulus paradoxus refers to inverse
correlation of E/E’ and LV end-diastolic pressure
c) Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler
velocities (A’ septal > A’ lateral) and annulus paradoxus refers to inverse
correlation of E/E’ and LV end-diastolic pressure
d) Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler
velocities (E’ septal < E’ lateral) and annulus paradoxus refers to inverse
correlation of E/E’ and LV end-diastolic pressure
e) Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler
velocities (A’ septal < A’ lateral) and annulus paradoxus refers to inverse
correlation of E/E’ and LV end-diastolic pressure

26. A 54-year-old male with a history of obesity, obstructive sleep apnea, hypertension,
and hypercholesterolemia presents to the cardiovascular clinic complaining of a
nonhealing ulcer on his left ankle present for the past month. His blood pressure is
160/80 mmHg. His physical exam is remarkable for mild bilateral lower leg edema as

12
 well as lipodermatosclerosis and hyperpigmentation around the ankles. A mildly
tender, superficial ulceration is observed with an irregular pink base above his medical
malleolus. His feet and toes are wwarm pink, and have 2-second capilary refill and
intact sensation. laboratory test on this patient include a random blood sugar of 160
mg/dL, creatinine of 1.1 mg/dL, calcium 10.2 mg/dL, phosphorus of 4.4 mg/dL. What
is the most likely etiology of the ulceration?

a) Chronic venous insufficiency

b) peripheral arterial disease
c) Diabetes melitus
d) Critical limb ischemia
e) Calciphylaxis

27. A 71-year-old man presesnts to your office with complaints of exertional dyspnea. He
is mildly hypertensive on examination. Carotid upstroes are brisk, with a secondary
upstroke. A loud III/VI systolic murmur is heard along the sternal border radiating to
the neck. S1 and s2 are normal. An S4 is heard. The murmur increases in intensity
with valsalva and decreases with handgrip. An echocardiogram reveals a < 2-m/s jet
across the LVOT. What is your next step?
a) Repeat the echocardiogram,, but have Doppler interrogation performed in other
views and with a nonimaging transducer. The degree of AS has been
underestimated
b) Coronary angiography
c) Repeat the echocardiogram with amyl nitrate
d) Transesophageal echocardiogram to better assess the valves

28. A 35-year-old gentleman reports a history of TOF, Blalock-taussig hunt at 10 months,

and complete repair at age 3. Although he has been reasonaably active for several
years, he has noted, progressive exercise intolerance in recent onths. Examination
revelas 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 pulseis not

13
 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 miliseconds. The most reasonable next step
in the evaluation of this patient would be

a) Repeat echocardiogram eith a saline bubble study

b) Electrophysiologic study for ventricular arrhytmias
c) cardiac catheterization
d) Diuretic and digitalis
e) Cardiac magnetic resonance imaging study

29. You are following a 51-year-old man with moderate mitral stenosis, who had been
symptomatic. He presents the emergency room with complaints of mild exertional
dyspnea and palpitations, presents for the past 3 to 4 days. On arrival, he appears
comfortable, with an O2 saturation of 99% on room air. His pulse rate is 140 bpm and
irregular. BP is 130/75 mmHg. Electrocardiogram reveals atrial fibrillation. The above
patient spntaneously converts to sinus rhythm. Which of thw following are you most
likely to recommend?
a) No change in therapy
b) percutaneous valvuloplasty
c) therapy with warfarin
d) Mitral valve replacement

30. A 65-year-old woman is evaluated for acute dyspnea 3 days after discharge following
an inferior myocardial infarction. When she was hospitalized, urgent coronary
angiography showed single-vessel coronary artery disease with occlusion of her mi-
right coronary artery. Se underwent successful stenting of her righ coronary artery,
and was discharged on her third hospital day. Her ejection fraction was 50% with
inferior wall hypokinesis before discharge. The patients dyspnea began 30 minutes
ago. On physical examination, her puse rate is 110/min, respiration rate is 34/min, and

14
 blood pressure is 100/60 mmHg. Jugular venous pressure is elevated at 10 cm H2O,
crackers are heard halfway up both lung fields, a parasternal lift is appreciated, and
there is a new grade 3/6 systolic murmur at the left sternal border with an S3 gallop.
The electrocardiogram shows sinus tachycardia with Q waves and T wave inversions
in leads II,III, and avF, and is unchanged from the discharge electrocardiogram. A
pulmonary artery catheter is placed, which shows the following: Pressure (mmHg)
Oxygen Saturation (%) Right atrium 12 (normal2-7) 49 (normal 60-75) right ventricle
60/12 (normal 20-30/2-7) 78 (normal 60-75) Pulmonary artery 60/32 (normal 20-30/10-
15) 80 (normal 60-75) Pulmonary capillary wedge 24 (normal< 14) 98 (normal > 93).
Which of the following is the most likely diagnosis?

a) Papillary muscle rupture

b) Atrial septal defect
c) Recurrent myocardial infarction
d) Pericardial tamponade
e) Ventricular septal defect

31. Which of the following is true regarding adjunctive medical therapy in patients with
acute MI receiving primary PCI?

a) Mortality benefit with routine intravenous nitroglycerin is not established

b) Routine intravenous β–blocker within 24 hours impproves mortality
c) Intravenous angiotensin-converting enzyme inhibitor (ACEI) within 24 hours
improves mortality
d) Intravenous magnesium improves mortality when used as an adjunct to
reperfusion

32. A 77-year-old man walks into the emergency room reporting palpitations and
dizziness. A 12-lead ECG shows wide complex tachycardia at a rate of 160 bpm. His
BP is 110/50 MMhg. He reports that he recently sustained an MI. He has not any

15
 similar symptoms before. Which of the follwing should be included in further evaluation
and treatment of his arrhytmia?

a) Digoxin, 1 mg IV over 6 hours in four divided doses

b) Procainamide, 15 mg/kg IV over 30 to 60 minutes
c) Immediate DC cardioversion
d) Immediate cardiac catheterization and arigioplasty, as needed
e) Verapamil, 10-mg IV bolus, to treat SVT with aberrancy, as the patient is
hemodynamically stable

33. The same patient was investigated with stress imaging before and after PCI to assess
the extension of myocardial ischemia. Which of the following statements is correct
regarding the benefit of PCI over medical therapy in this setting?

a) All of the above

b) A greater resolution of angina episodes
c) A greater improvement in symptoms
d) A greater reduction in the extension of residual myocardial ischemia
e) An increased benefit of ischemia reduction in patients with extensive ischemic
areas at baseline

34. A 66-year-old man presents after an arrest while eating at alocal restaurant. On arrival,
paramedics documented ventriclar fibrillation (VF), and he was successfully
resuscitated. he has a history of myocardial infarction (MI) and congestive heart failure
(CHF). Serum electrolytes are remarkable only for mild hypokalemia. MI is ruled out
by ECG and serial blood test of myocardial enzymes. Subsequent evaluation includes
cardiac catheterization, which shows severe three-vessel coronary artery disease
(CAD) and severe left ventricular (LV) systolic dysfunction. A nuclear myocardial
perfusion scan shows a large area of myocardial scar without significant viablity in the
territory of the left anterior descending coronary artery. The decision is made to treat

16
 the CAD medically. Whic of the following is the best management strategy for his
arrhytmia?

a) ICD implantation
b) PO amiodarone
c) Implantable cardioverter defibrillator (ICD) implantation if an electrophysiologic
(EP) study shows inducible VT or VF
d) β-blocker medication

35. A 36-year-old woman at 24 weeks of pregnancy is found to have several blood

pressure readings in the range of 145 to 158 mmhg systolic, 80 to 92 mmhg diasyolic.
This is her first pregnancy and she has no prior hitory of hypertension. She reports
bilateral mild ankle swelling and nausea, but no right upper quadrant pain, visual
changes, headaches, or dyspnea. A 24-hour urine collection shows 360 g protein. The
hemoglobin is 8.0 g/dL and the plaelet count is 43.000 cells/mm3. Which of the
following is the corrct diagnosis?

a) Chronic hypertension
b) Gestional hypertension
c) Eclampsia
d) Preeclampsia

36. A.F is a 53-year-old man with a history of Afib, transient ischemic attacks,
hypertension (HTN), and rheumatic heart disease. The recommendations from the
Sixth American College aof Chest Physicians (ACCP) Consensius Conference on
Antithrombotic Therapy suggest that this patient be initiated on _______ for
antithrombotic therapy because of Afib

a) Aspirin, 325 mg daily

b) Warfarin, with a target goal INR of 3.5
c) Warfarin, with a target goal international normalized ratio (INR) of 2.5

17
 d) Aspirin, 81 mg daily

37. A 42-year-old man presents to the CCU with CHF symptoms. On examination, he has
elevated neck veins, severe peripheral edema, and S3 gallop. He is started on
medication has improvement in all of his symptoms. He has a PET scan, which shows
a large area of hibernating myocardium. His cardiac catheterization reveals mild
disease in the right coronary artery, a focal 80% lesion in the circumflex, and a focal
70% lesion in the LAD. All of his lesions are type A American college of
cardiologist/American Heart Association score. His EF is 15%. According to
randomized clinical trials, which of the following is the best treatment for this patient?

a) Percutaneous transluminal coronary angioplasty (PTCA)/stent with abciximab

and clopidogrel bisulfate
b) CABG
c) PTCA/stent with abciximab and IABP
d) PTCA/stent with cardiothoracic surgery backup

38. Which of the following statements is incorrect with regard to acute MI?

a) Routine PCI of the totally occluded infarct-related artery should be avoided after
24 hours of presentation in hermodynamically stable patients without signs of
ischemia
b) Primary PCI is associated with reduced rate of intracerebral hemorrhage as
compared with fibrinolysis
c) Fibrinolysis should be considered 12 hous after symptom onset in
hermodynamically stable patients with signs of ongoing ischemia
d) If rapidly available, primary PCI provides a mortaity benefit as compared with
fibrinolysis

18
 e) Primary PCI may be considered 12 hours after symptom onset with signs of
ongoing ischemia

39. During physical examination, you notice an elevated system venous pressure with
sharp y descent Kussmaul sign and quiet pericardium. What might the patient have?

a) Pulmonary HTN
b) Tamponade
c) Restrictive myocardial disorder
d) Tricuspid regurgitation
e) Constrictive pericarditis

40. B.T. is a 57-year-old woman with long-standing HTN that is difficult to control. She is
currently being treated with amlodipine 10 mg daily, lisinopril 40 mg daily,
hydrocjlorothiazde 25 mg daily, and clonidine 0.4 mg three times daily. She presented
to the emergency room, and her initial BP was 200/110 mmHg. She states she had
run out of one of her medications. Which one of her medications would most likely be
implicated in causing hypertensive urgency?

a) Lisinopril
b) Amiodipine
c) Hydrochicrothiazide
d) Clonidine

41. A 60 year old woman with CHF and an EF of 30% comes to your office for follow up.
She is on carvediol (Cored), enalapril, aspirin, atorvastatin calcium, dogoxin, and
furosemide. She has been doing well without any rehospitalization. However, she
wants to improve her exercise tolerance. What should you recommend?

a) Cardiac transplantation
b) Enrolling her in an exercise training program

19
 c) Higher doses of ACE inhibitor
d) IV dobutamine
e) Adding spironolacton

42. By which of the following mechanisms do diltiazem and verapamil slow ventricular rate
in patients with Afib?

a) They decrease the refractory period of nodal tissue

b) They decrease the conduction velocity within the atrioventricular (AV) node
c) They stimulate vagal tone
d) They prolong the refractory period of atrial tissue

43. A 36-year-old woman with no past medical history, not receiving oral contraceptives,
and with a family history of hypertension presents with a gradual increase in blood
pressure over the past few years. Today in clinic her blood pressure is 155/95 mmHg.
What is the most appropriate next step?

a) Renal magnetic resonance imaging (MRI)

b) She is asymtomatic; therefore, observe patient and have her follow-up in 1 year
c) Patient has essential hypertension; start thiazide diuretic
d) Have her follow-up in a few weeks for repeat blood pressure measurements

44. An 84-year-old woman presents to cardiology clinic for follow-up of her hypertension
and coronary artery disease. Her only current symtom is dizziness on standing from
a sitting position. The dizziness caused her to lose balance and fail on two occasions.
Her current resting blood pressure is 144/90 mmHg with pulse 60 betas per minute
(bpm). Her medications include hydrochlorothiazide 25 mg daily, doxazosin 2 mg
daily, metoprolol XL 50 mg daily, simvastatin 40 mg daily, and aspirin 81 mg daily.
What changes in medication therapy would you recommend?

a) Discontinue doxazosin and increase metoprolol to 100 mg daily

20
 b) Discontinue doxazosin and start lisinopril 5 mg daily
c) Discontinue hydrochidrothiazide and start lisinopril 20 mg daily
d) Discontinue doxazosin and initiate clodinine 0.4 mg twice daily
e) Discontinue atenolol and increase hydrochlorothiazide to 50 mg daily

45. 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 compared of pain and was diagnsed 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 bilateraly. he has palpable pulsses in all
extremities. What did you recommed?

a) Begin a weight based unfractioned heparin infusion

b) Bolus subcutaneous low-molecular-weight heparin (LMWH) 80 mg/kg, then at 1
mg/kg subcutaneously every 12 hours
c) Placement of a retrievable inferior vena cava filter
d) Begin a DTI
e) catheter-directed thrombolysis
46. A 59 year old man, with cardiac risk factors of tobacco use, hypertension, and
hypercholesterolemia, presented to the emergeny department a few days ago with an
acute onset of left-sided chest pain. His evaluation revealed a diaphoretic man in
moderate discomfort. An ECG was performed and showed a [attern consistent with
an inferior wall acute MI. The patient was treated with thrombolytics. Forty-five minutes
after the initial dose of the thrombolytics, he left better and had complete resolution of
his symptoms and normalization of the ECG. On the third day after the event, he
reports midstermal chest pain, vague in nature, with mild diaphoresis and shortness
of breath. An ECG is performed, as shown in Figure 13.5. Which of the following
should you tell the patient is the next step in managing his condition?

21
 a) There is evidence of reocclusion of the infarct-related artery, and rebolus with
thrombolytics and heparin is indicated
b) He is showing signs of early postinfarction pericarditis, and a nonsteroidal anti-
inflammatory medication should be started
c) There is evidence of reocclusion of the infarct-related artery, and a percutaneous
intervention is needed
d) An LV aneurysm has developed, and a TTE is needed to evaluate the extent of
the aneurysm

47. A 66-year-old man presents to the clinic with complaints of episodic burning pain
involving the soles of his feet and toes. He reports symptoms are most severe weather
becomes hot and generally occurs when he is outside in the heat. His feet and toes
turn red and feel hot to touch during episodes. When he returns to an air-conditioned
area, symptoms as does walking barefoot on cold tile floors. His past medical history
includes hypertension, well controlled with atenolol, and he takes once daily low-dose
aspirin for primary prevention. Physical examination blood pressure is 120/70 mmHg
and pulse is 84 bpm. The cardiac and lung examinations are normal. The abdomen is
soft and nontender with a normal-sized palpable aortic pulsation. No bruit can be
heard over the neck, abdomen, or either groin. Radial, dorsalis pedis, and posterior
tibial pulses are 2+/2 bilaterally. A mild erythema and increased warmth are noted in
toes and soles of the feet. Which of the following is the most likely diagnosis?

a) Raynauld phenomenon
b) Chilblains (perniosis)
c) Heat urticaria
d) Erythromelalgia

48. A 46-year-old woman with a history of treated carcinoma of the breast presents to the
local emergency department with a few days of severe chest pain. In the emergency
department, she appears ill and pale and in moderate discomfort. Her BP is 135/60
mmHg; her respiratory rate is 24 breaths per minute; her HR is 82 bpm; and her

22
 temperature is 100.8oF. The resident on call reads her chest X-ray (CXR) as
unremarkable. Her ECG is shown in Figure 13.1. What is the most reasonable next
step?

a) Call the cardiac intervention team and rush the patient to the catheterization
laboratory for emergency coronary intervention
b) Discharge the patient and refer her for a gastroenterology follow-up as an
outpatient
c) Give aspirin and nitroglycerin and prepare to administer thrombloytics
d) Give a nonsterodal anti-inflammatory medication

49. You 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) Transposition of the great arteries

b) Critical pulmonary stenosis
c) Complete atroventricular septal defect
d) Total anomalous pulmonary venous connection (TAPVC)
e) Tricuspid atresia

50. An 81-year-old man presents to your office with complaints of chest tightness when
climbing up a flight of stairs. His past medical history is unremarkable. On physical
examination, he is in no acute distress. BP is 140/80 mmHg; pulse is 78 bpm and
regular. Chest is clear. Carotid upstrokes are diminished. The PMI is sustained but
not displaced. A fourth heart sound is present. The second heart sound is diminished
and single. A loud late peaking systolic murmur is heard, loudest at the second
intercostal space, radiating to the neck. The aboove patient is found to have an aortic
valve area of 0.7 cm2 with a mean gradient of 60 mmHg. Following cateterization, he
develops massive upper gastrointestinal bleeding. Endoscopy reveals a gastric ulcer

23
 with a bleeding vessel at its base. Cauterization is performed, which temporarily
sstops the bleeding. However, the bleeding recurs and urgent partial gastrectomy is
recommended. He complains of chest pain during these bleeding episodes. What is
the best curse of action?

a) Start nitroprusside and proceed with gastriic surgery

b) Proceed with gastric surgery directly
c) Refer for percutaneous ballon valvuloplasty, followed by gastrectomy
d) Proceed to AVR first

51. A 63-year-old man with a history of rheumatic heart disease presents to your office
with complaints of exertional dyspnea. No constitutional complaints are present. He
had undergone a mitral valve replacement with a bileaflet tilting disk mechanical valve
11 years prior. He is normotensive with a heart rate of 73 bpm. On examination, you
note a gradeII/VI holosystolic murmur at the apex. An echocardiogram is performed,
which reveals normal LV and RV function. Peak mitral gradient is 30 mmHg. Mean
transmitral gradient is 7 mmHg. Pressure half-time is 80 miliseconds. What is your
next diagnostic step?

a) Transesophageal echocardiogram
b) Invasive assesment of hemodynamics
c) Draw blood cultures
d) Fluoroscopy of the valve

52. A previously healthy and independently functional 78-year-old-man is brought to the

cateterization laboratory after developing sudden-onset chest pain radiating to the jaw
and shortnes of breath. ECG by EMS during transfer revealed ST elevation in V2 to
V4 and leads I and aVL. The patient was in respiratory distress during transfer requiring
emergent endotracheal intubation. Hs BP is 70/30 mmHg and heart rate is 110 per
minute. Angiogram reveals fresh mural thrombus in proximal LAD, which is stended
with BMS with resultant TIMI-2 flow. No significant disease is noted in the RCA and

24
 circumflex vessels. An echo receals a left ventricular ejection fration (LVEF) of 30%
with no significant valvular pathology. He is subsequently transferred to the critica care
unit (CCU) in critical condition. His current vital signs are as follows; BP 80/40 mmHg,
HR 120 beats per minute, and Sao of 90% on 60% FiO 2. A PA catheter is placed.
Which of the following readings is associated with worst prognosis in this patient?

a) PCWP 16, CI 2.4

b) PCWP 24, CI 3.2
c) Pulmonary capillary wedge pressure (PCWP) 30, Cardiac Index (CI) 1.6
d) PCWP 10, CI 1.8

53. A 61-year-old male patient was treated 2 years earlier with PCI and the implanation
of BMS in the LAD for NSTEMI. He complains about recurrent worsening exertional
chest pain in the last week. Coronary angiography reveals ISR. What are the
predisposing factors for BMS restenosis?

a) Increasing stent lenght

b) Diabetes
c) All of the above
d) Decreasing stent diameter
e) Increasing stent number

54. A 67-year-old man with stable angina at low exertion level was investigated wit coroary
angiography that showed an isolated significant lesion (70%) of the ostium and mid-
portion of the left main coronary artery in the presence of a normal left ventricular
function. What is the correct statement rearding the recommended approach?

a) Coronary artery bypasss grafting (CABG) iss the recommended approach for all
patients with left main disease.
b) The choice of treatment is independent of the clinical presentations (stable
angina or acute coronary)

25
 c) A calculation of the society of thoracic surgeons (STS) and SYNTAX (Synergy
between PCI with TAXUS and Cardiac Surgery) scores is not recommended at
this stage
d) Heart team discussion between the interventiona cardiologist and the cardiac
surgeon to select the best treatment option is the recommended approach.
e) PCI i the rcommended approach for all patients with left main disease

55. Which of the following statements is true regarding antiarrhymic drugs with reverse-
use dependence?

a) Antiarrhytmic drugs with reverse-use dependence have less efficacy for

arrhytmia prevention than termination and have greater risk for ventricular
proarrhytmia at slower heart rates
b) Antiarrhytmic drugs with reverse-use dependence have less efficacy for
arrhytmia prevention than termination and have less risk for ventricular
proarrhytmia at slower heart rates
c) Antiarrhytmic drugs with reverse-use dependence have greater efficacy for
arrhytmia prevention than termination and have greater risk for ventricular
proarrhytmia at slower heart rates
d) Antiarrhytmic drugs with reverse-use dependence have greater efficacy for
arrhytmia prevention than termination and have less risk for ventricular
proarrhytmia at slower heart rates

56. Which of the following is a correct statement concerning external cardioversion of

Afib?

a) Inadequate synchronization may occur with peaked T waves, low-amplitude

signal, and malfunctioning pacemakers
b) Digoxin therapy should be discontinued for 48 hours before efective
cardioversion

26
 c) Acute MI is a contraindication to cardioversion, as it results in further myocardial
damage
d) A nonsynchronized shock should be delivered because the rhythm is irregular
e) Patients with pacemakers should not undergo cardoversion because of the risk
of pacemaker damage

57. Which of the following treatment options has been most consistenly shown to be
effective for the primary prevention of suddenn cardiac death in patients with CAD and
recent MI?

a) β-blocker medications
b) Amiodarone
c) D-Sotalol
d) Dofetilide

58. Which of the following statements is true regarding Brugada syndrome?

a) It is effectively treated with β-blockers

b) The ECG manifetations can be exacerbated by sotalol
c) It is the leading cause of death in young men in the Middle East
d) It is characterized by ST elevation and a pseudo-RBBB pattern in the right
precordial leads with persistent ST elevation
e) Afib is the most frequently reported arrhythmia

59. During coronary angioplasty of the RCA, this 73-year-old patiient developed sharp
chet pain with rapid development of hypotension and tachycardia. The etiology based
on Figure 4.4 is

a) abrupt closure of the RCA

27
 b) distal embolization of an atherosclerotic plaque
c) Dissection of the RCA
d) perforation of the RCA
e) Allergic reaction

60. A 73-year-old man known with a history of coronary heart disease presents typical
chest pain. During the trasnport to te PCI center, the patient had two episodes of
ventricular fibrillation requiring electrical reanimation. ECG shows inferolateral ST
depression. What does the angiography show (Fig. 4.3)?

a) Stenosis of the ostium of the LAD

b) Stenosis of the distal left main trunk
c) Stenosis of the ostium of the LCX
d) All of the above
e) Lesions at bifurcation

61. An 83-year-old woman calls 911 after devloping sudden onset chest pain, nasea, and
lightheadedness. An ECG done by emergency medical service (EMS) reveals 3-mm
ST elevation in leads II,III, and aVF. The nearest catheterization laboratory is activated
and the patient undergoes PCI to the right coronary artery (RCA) with drug-elutiing
stent. She is transferred to the intensive care unit (ICU) in stable condition after the
procedure. Two days later, the patient develops sudden-onst lightheadedness and
left-sided chest pain. Her vitals reveal BP of 115/60 mmHg, heart rate of 90 perminute
and SaO2 of 92% on ambient air. Physical examination reveals new systolic murmur
at the left sternal border that radiates to the apex. An ECG done immediately reveals
basal septal VSR with left-to-right shunt and moderate mitral regurgitation. A
pulmonary artery (PA) catheter is placed and shunt fraction (Q p/Qs) is calculated at
1.3. What is the next step in management?

a) Intra-aortic ballon pulsation (IABP) placement

b) Left heart catheterization with ventriculography for better assessment of septum

28
 c) Cardiac magnetic resonance imaging (MRI) to better assesss the size of septal
rupture
d) Urgent surgical repair
e) Intravenous nitroprusside for afterload reduction

62. Which of the following is true about reteplase in Global Use of Strategies to Open
Occluded Coronary Arteries (GUSTO-III)?

a) It had a significantly higher rate of stroke than alteplase

b) It had similar rates of mortality sompared with alteplase
c) It siignificantly reduced mortality, but increased stroke compared with alteplase
d) It significantly reduced mortalityy compared with altepase

63. A 26 year old woman presents with exertional dyspnea and orthopnea in the 30th wk
of her first pregnancy. She has a history of rheumatic fever in childhood and has not
had a recent cardiac evaluation. She is currently on no medications. Physical
examination reveals a pulse of 100 bpm with a regular rhythm. The BP is 110/76
mmHg. There is mild JVD. A and V waves are visible. The lungs are clear. Cardiac
examination reveals a palpable first heart sound and a parasternal lift. The scond heart
sound is somewhat increased,. There is an opening snap followed by a grade 2/6
diastolic rumble noted at the apex and LSB. The ECG demonstrates sinus rhythm with
LA abnormality. A TTE is performed and this demostrates MS. The patient is started
on medical therapy. She returns with persistent symptoms of dyspnea and orthopnea
after 1 wk of therapy. Physical examination demonstrates a HR at 65 bpm. Thh cardiac
exxamination findings are similar to those previously noted. A limited TTE is repeated.
Thi demonstrates similar mitral valve morpology. The calculated RSVP is 60 mmHg.
Which of the following is the most appropriate at this time?

a) Open mitral commissurotomy

b) MVR
c) Urgent cesarean delivery

29
 d) Change medical therapy
e) PMBV

64. A 61-year-old man presnts to the emergency room with complaints of weakness,
lethargy, and severe dyspnea. One week prior, is family notes that he complained of
chest pressure that lasted for several hours. On physical xamination, he appears to
be in respiratory distress. Blood pressure (BP) is 80/50 mmHg. Heart rate is 130 bpm.
His oxygen saturation is 87% on room air. chest examination reveals diffuse crackles.
cardiac examination reveals a nondisplaced poniy of maximum impulse (PMI). Third
and fourth heart sounds are heard, as is an apical systolic murmur. No thrill is present.
Electrocardiogram reveals inferior Q waves without ST-segment elevation. He is
urgently intubated and pressors are started. An intra-aortic ballon pump is placed. A
surface echocardiogram reveals a normal-sized left atrium and a mild jet of mitral
regurgitation (MR). A TEE is performed urgently (Fig. 2.1 shows a 3D view of the mitral
valve from above). What is the most likely diagnosis?
a) Severe mitral valve prolapse secondary o recent myocardial infarction
b) Anterior papilarry muscle rupture as it has a single blood supply
c) Endocarditis involving the mitral valve
d) Posterior papillary muscle rupure as it has a single blood supply

65. The best echocardiographic scan plane for demonstrating a secundum ASD is

a) subcostal four-chamber view

b) parasternal long-axis view
c) suprasternal long-axis view
d) parasternal short-axis view
e) apical four-chamber view

66. A 59-year-old man, with acardiac risk factors of tobacco use, hypertension, and
hypercholesterolemia, presented to emergency department a few days ago with an
acute onset of left-sided chest pain. His evaluation revealed a diaphoretic man in

30
 moderate discomfort. An ECGG was performed and showed pattern consistent with
an inferior wall acute MI. The patient was treated with thrombolytics. Forty-five minutes
after the initial close of the thrombolytics, he felt better and had complete resolution of
his symptoms and normalization of the ECG. On the third day after the event, he
reposrts midsternal chest pain, vague in nature, with mild diahoresis and shortness of
breath. An ECG is performed, as shown in Figure 13.5. Which of the following should
you tell the patient is the next step in managing his condition?

a) There is evidence of reocclusion of the infarct-related artery, and a percutaneous

intervention is needed
b) An LV aneurysm has developed, and a TTE is needed to evaluate the extent of
the abeurysm
c) There is evidence of reocclusion of the infarct-rrelated artery, and rebolus wih
thrombolytocs and heparin is indicated
d) he is showing signs of early postinfarction pericarditis, and a nonsteroidal anti-
inflammatory medication should be started

67. A 20-year-old male college student presents to his local physician for evaluation of a
dry cough. His symptoms started 3 days ago but now appear to be resolving. He had
planned a trip overseas but was concerned and is now seeking advice. His physical
examination is unremarkable. A CXR is performed and is read as showing an enlarged
right cardiac silouette. A Tte is ordered, which is shown in Figure 13.6. The patient
most likely has which of the following conditions?

a) He has a pleural effusion

b) he has mesothelioma
c) There is no athology. The CXR was misread
d) he has cardiac tamponade requiring a pericardial tap
e) He has a pericardial cyst that is benign; no further treatment should be offered

31
68. A 66-year-old man prsents for routine physical examination. During the interview he
complains about swelling behind his right knee. You orde an ultrasound of the area
(findings illustrated in Fig 7.1). After findng the results illustrated in Figure 7.1 you refer
the patient for ultrasonic of the abdomen and contralateral popliteal artery. No
additional abnormalities are discovered. What is the next appropriate step in his
management?

a) Repeat the ultrasound in 6 months.

b) The finding is benign and no intervention is indicated
c) Repeat the ultrasound in 3 months
d) Refer for the repair of the aneurysm
e) Repeat the ultrasound in 1 year

69. A 61 years old woman with diabetic melitus since one year had complaints difficult
recovery ulcer in her right toe wth painful and paraesthesia especially at the, so she
was having sleep disturb. The pulsation of right dorsalls pedis and tibialis posterior
distal was weaker than the left side. ABI resulted about 1,4 in the right lower limb and
laser fluksimetry study was found class III of microangipathy score. If the TCPO2 resut
16 mmHg and healing potential index 75%. What is noninvasive diagnostic to guide
next management?

a) CT angiography aorta of lower limb

b) Duplex ultrasound
c) None of themm
d) Phletysmography
e) Doppler ultrasound

70. A 39-year-old man came to emergency department with chief complain shortness of
breath, non radiating 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 ppain and swelling on

32
 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/m 2),
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 ties/minute and regular, respiratory rate 26 breaths/minute, temperature 36oc,
and oxygen saturation 89%. Other physical examinations were unremarkable. Below
is Ecg findings that can be found in the above patient, EXCEPT:

a) ST elevation with Right Bundle Branch Block in V1-V2

b) Left Bundle Branch Block
c) Atrial arrhytmia with P pulmonale
d) Inverted T wave in anterior lead
e) Sinus Tachycardia

71. A 59-year-old obese man with hypertension, diabetes melits, hyperlipideia, and recent
myocardial infarction presnts for his annual physical examination. He is currently
presribed atenolol, hydrochlorothiazide, amlodipine, and quinapril. His blood pressure
is at target values. His HbA1c is at goal. However, he has noted increasing lower
extremity edema over the past few months and had a near-fatal car accident after
falling aleep while driving. His echocardiogram reveals an ejction fraction of 65% with
no evidence of diastolic dysfunction. Which of the following management decisions
would b most appropriate at this time?

a) maintain current regimen with advisement that his symptoms are typical with
aging
b) Adding of loop diuretic
c) Polysomnography
d) Discontinue calcium channel blocker

33
72. Amiodarone use is contraindicated in which patient population?

a) 1st degree AV block

b) NYHA class IV heart failure
c) Post-acute myocardial infacrtion
d) Severe renal impairment

73. Which of the following glycoprotein Iib/IIIa inhibitors has the highest incidence of
severe thrombocytopenia?
a) Abciximab
b) The incidence is not different between the different agents
c) Eptifibatide
d) Tirofiban
74. A 76-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 week
apart. She tells you that in one occasion she was gardening and trying to lift a heavy
plant pot. She had no warning and 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 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 quickly. She is currently taking aspirin, a beta-
blocker, an ACE inhibitor, aloop 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. What is the most appropriate immediate investigation should be
performed?

a) 12-lead ECG

34
 b) Chest X-ray
c) Echocardiogram
d) Carotid sinus massage
e) Lying and standing blood pressure

75. A 25-year-old female medical student presnts to urgent care with 5 days of fever and
shortness of breath. She is diagnosed with a viral infection and sent home. Five
months later during her physical exaination class, she is found to have an S3 by her
fellow students. She presents to your office for a second opinion. On examination, she
appears healthy and in no distress. Her BP is 96/50 mmHg, with an HR of 71 bpm and
a respiratory rate of 12. Her neck veins are not distended, and her examination is
unremarkable except for an enlarged heart. You do not appresciate an S3. You order
a TTE, which shows an EF of 20% with a dilated heart. There is no valvular
abnormality. Which of the following is your recommendation?

a) Begin ACE inhibitor, β-blockers, and steroid

b) Begin ACE ihibitor, β-blockers diuetics and digoxin
c) She is well compensated; nothing needs to be done
d) Begin ACE inhibitor and β-blockers
e) Begin ACE inhibitor, βblockers, diuretics, and spironolactone

76. Patients who develop heparin-induced thrombocytopenia have an in vitro cross-

reactivity with low-molecular-weight heparin (LMWH) by what percent?

a) 90% to 100%
b) 60% to 70%
c) 25% to 45%
d) 5% to 10%

77. A 59-year-old man presents for further evaluation of recurrent congestive heart
failure. He appears to be in no acute distress on your evaluation. BP is 100/60

35
 mmHg. Carotid upstrokes are weak, but not delayed. Chest examination shows
minimal bibasilar rales. PMI is displaced and sustained. A summation gallop is
present. There is an increased P2. There is mild peripheral edema. An
echocardiogram reveals a dilated LV with an ejection fraction of 25%. The aortic
valve does have some calcification, with restricted leaflet excursion. Peak/mean
gradients are 25/15 mmHg. By the continuity equation, the aortic valve area is
calculated as 0.7 cm2. What is your next step?

a) Immediate referral for aortic valve replacement (AVR)

b) Referral for cardiac transplant
c) Dobutamine echocardiogram
d) Start an ACEI

78. What is the mechanism of action of the antihypertensive medication aliskiren?

a) ACEI
b) Nonselective P-blockade
c) Angiotensin receptor blocker (ARB)
d) Direct renin inhibitor

79. A 62-year-old man is admitted with chronic obstructive pulmonary disease (COPD)
and mild left ventricular (LV) dysfunction (ejection fraction [EF] 45%) as well as
symptomatic, recurrent atrial fibrillation (heart rate [HR] 120s to 150s) despite
antiarrhythmic drug therapy and direct current cardioversion in the past. Afer rate
control with intravenous (IV) P-blockers, the HR improves and the patient feels better.
Given his recurrent atrial fibrillation despite optimal medical therapy, the patient is
referred for radiofrequency ablation of atrial fibrillation (pulmonary vein isolation)
procedure. The procedure is performed on anticoagulation (international normalized
ratio >2.0) and is deemed a success, with no inducible atrial fibrillation at the end of
the case. A small atrial septal defect (ASD) was noted with intracardiac
echocardiography at the end of the case, with no other remarkable findings. That

36
 evening in the post-anesthesia care-unit (PACU), the patient is noted to be
hypotensive and tachycardic with increasing dyspnea. There is a concern for cardiac
tamponade; however, the arterial line does not show a significant respiratory variation
of the blood pressure (BP) waveform (pulsus paradoxus). An echocardiogram is
performed, demonstrating a large circumferential effusion and the patient is referred
for urgent pericardiocentesis. Which of the following explains why the patient did not
develop a pulsus on the arterial line, despite a large, hemodynamically significant
pericardial effusion?

a) Presence of an ASD
b) Administration of excess IV fluid during the ablation
c) LV dysfunction
d) COPD

80. You 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) Tricuspid atresia
b) Total anomalous pulmonary venous connection (TAPVC)
c) Transposition of the great arteries
d) Complete atrioventricular septal defect
e) Critical pulmonary stenosis

81. A 25-year-old man is referred to you for an abnormal heart sound. The patient is
asymptomatic and very active. BP is 130/50 mmHg. He has a continuous murmur at
the left upper sternal border. A TTE reveals a small PDA with mildly dilated left atrium

37
 (LA) and mildly dilated LV but normal RV size and normal pulmonary pressures. How
would the patient be best managed?

a) Ligation or percutaneous closure of the PDA

b) Repeat TTE in 1 year
c) Stress echocardiography to determine LV enlargement or dysfunction
postexercise
d) Pulmonary vasodilator
e) TEE

82. A 76-year-old man walks into the emergency room reporting palpitations and
dizziness. A 12-lead ECG shows wide complex tachycardia at a rate of 160 bpm His
BP is 110/50 mmHg. He reports that he recently sustained an MI. He has not had any
similar symptoms before. Which of the following should be included in further
evaluation and treatment of his arrhythmia?

a) Verapamil, 10-mg IV bolus, to treat SVT with aberrancy, as the patient is

hemodynamically stable
b) Immediate DC cardioversion
c) Procainamide, 15 mg/kg IV over 30 to 60 minutes
d) Immediate cardiac catheterization and angioplasty, as needed
e) Digoxin, 1 mg IV over 6 hours in four divided doses

83. A 45-year-old man is status post hip replacement. He develops sudden-onset

shortness of breath. On examination, he is hypotensive with a BP of 80/40 mmHg. An
ECG shows sinus tachycardia at 100 beats per minute with ST elevation in V to V 2. A
bedside echo is performed (Fig. 3-3). What is the most appropriate intervention?

a) Activate catheterization laboratory to perform a primary PCI.

38
 b) Perform a CT angiogram to rule out a dissection.
c) Initiate intravenous heparin and assess risks and benefits of fibrinolysis.
d) Perform a saline contrast study to assess right-to-left shunt.
e) Initiate antibiotics and perform blood cultures

84. A 65-years-old man admitted to hospital with sudden worsening shortness of breath
preceding by sharp chest pain and not relieved by resting. Before having chest pain,
patient was walking about 400 meters. 3 days before patient having typical angina
chest pain and diaphoresis, but patient refuse to seek medical assistant. Patient was
an active smoker, had history of diabetes and uncontrolled hypertension. On
physical examination, the patient found to have a blood pressure of 100/70 mmHg,
pulse 96 timer per minutes, His JVP were raise and found a 3/6harsh systolic
murmur at the left sternal border. Blood studies showed Hb. 14g/dL, Ht 43,7% WBC
11900/uL, platelet 213.000/uL, CK 240, ck-mb 55. Which of the following is the most
likely anatomic diagnosis for this patient?

a) Ventricular Septal Defect

b) Ventricular Septal Rupture
c) Acute Ischemic mitral regurgitation
d) Acute myocardial infarction
e) Acute lung edema

85. A 60-year-old man with a history of PCI 3 years previously asks for your advice with
respect to his pharmacologic treatment. He is asymptomatic and his CV risk factors
include smoking, hypertension, hypercholesterolemia, and impaired glucose
tolerance. His medications include aspirin, atorvastatin, metoprolol, metformin, and
lisinopril. His friend told him that clopidogrel should be added to his regimen. What is
the correct statement about that suggestion in this particular patient?

a) There is no significant benefit associated with clopidogrel plus aspirin as

compared with placebo plus aspirin in reducing the incidence of the primary

39
 endpoint of MI, stroke, or death from CV causes.
b) There is a significant benefit associated with clopidogrel plus aspirin as
compared with placebo plus aspirin in reducing the incidence of the primary
endpoint of MI, stroke, or death from CV causes.
c) The rate of severe or moderate bleeding is not significantly greater with
clopidogrel and aspirin compared with aspirin alone.
d) The rate of severe or moderate bleeding is significantly greater with clopidogrel
and aspirin compared with aspirin alone.
e) Answers a and d are correct.

86. A 66-year-old man with diabetes with no hypertension but end-stage renal failure
treated with hemodialysis in the last 15 years presents with worsening dyspnea and
suspicion of ischemia at the stress imaging. What are the most characteristic findings
relating to the coronary arteries to be found at angiography?

a) Tortuous coronary vessels

b) Calcified coronary arteries
c) Ectatic coronary arteries
d) Coronary arteries with anomalous origins
e) Normal coronary arteries (symptoms caused by small vessel disease)

87. A young patient is admitted to the intensive care unit with amitriptyline overdose.
Three hours after gastric lavage, he develops hypotension and wide complex
tachycardia that is recurrent despite cardioversion. Appropriate management includes
which of the following?

a) IV bretylium
b) Temporary pacemaker with overdrive pacing
c) IV calcium gluconate
d) IV hypertonic sodium bicarbonate
e) IV magnesium sulfate

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88. An 80-year-old man with severe AS is turned down for surgical AVR due to
significant comorbidities. He is referred to you for consideration for transcatheter
AVR. Which of the following findings is considered a contraindication for this
procedure?

a) Calcified and tortuous femoral arteries

b) The apex is not accessible
c) Life expectancy <1 year
d) A history of treated endocarditis
e) Annulus size of 20 mm
89. A 70-year-old man presents with the sudden onset of tearing chest pain. On
presentation, he has a heart rate of 130 beats/min with a systolic blood pressure of 80
mm Hg. A bedside TEE demonstrates the presence of a proximal aortic dissection. A
pericardial effusion with partial diastolic collapse of the right ventricle is also present.
Significant respiratory variation is noted across mitral and tricuspid Doppler inflows.
Appropriate treatment is

a) Immediate percutaneous pericardiocentesis to relieve the tamponade, followed

by surgery to replace the ascending aorta
b) to proceed immediately to the operating room
c) Emergency angiography to define coronary anatomy, followed by surgery
d) Intra-aortic balloon pump to stabilize the hemodynamics, followed by surgery

90. A 78-year-old retired federal judge comes to your office for follow-up. He has long-
standing HTN and has undergone PTCA/stent for a mid-LAD lesion. He has normal
LV function and is active and healthy. Currently he is on ramipril (Altace), atorvastatin,
and aspirin. He heard on television that the combination of aspirin and ramipril
increases mortality. He wants your opinion. What is your answer?

a) These are only observational studies, and they have not been proven. Continue

41
 the current regimen.
b) There are randomized studies to support this; however, the sample size was too
small to make any conclusive recommendations. Continue the current regimen.
c) This has been shown in large trials; we should change aspirin to clopidogrel
bisulfate or ramipril to metoprolol tartrate.
d) Although this has been seen in retrospective trials, it has not been validated in a
randomized trial; therefore, continue the current regimen.

91. M. R. is a 74-year-old man with a history of hypercholesterolemia treated with

simvastatin. Two months ago he had a permanent pacemaker placed for sick sinus
syndrome. He now presents with a 1-month history of fever, chills, and unexplained
weight loss. On physical examination he has a new tricuspid regurgitation murmur. A
transesophageal echocardiogram confirms your suspicion of endocarditis. Which of
the following antibiotics increases the risk of rhabdomyolysis when given with
simvastatin?

a) Ceftriaxone
b) Vancomycin
c) Daptomycin
d) Linezolid

92. A 28-year-old woman comes to your office for a second opinion. She had peripartum
cardiomyopathy and wants to get pregnant again. You obtain a TTE, which shows a
normal LV What should you recommend?

a) She should not have another pregnancy because she is likely to have recurrent
cardiomyopathy.
b) She may conceive again because her LV is normal. Her chance of having
recurrent cardiomyopathy is less than 5%.

42
 c) She may conceive again because her LV is normal. However, her chance of
having recurrent cardiomyopathy is 30% to 50%.
d) She should undergo exercise testing for better assessment

93. A 35-year-old woman who emigrated to the United States is referred to you by her
gynecologist for evaluation of hypertension that was noted 1 week ago, when she
sought an evaluation for infertility. She was first told that she had hypertension at 20
years of age, but did not follow up with a physician until recently. On your advice, her
gynecologist initiated treatment with amlodipine, 5 mg, after obtaining a blood
pressure of 200/100 mm Hg. The patient has frequent headaches and also has cold
feet and leg cramping when she walks long distances. Physical examination shows
blood pressure of 160/90 mm Hg in the left arm while sitting and heart rate of 70/min.
Jugular venous pressure is normal. Carotid pulses are brisk bilaterally. Cardiac
examination shows a sustained apical impulse. S1 is normal and S2 is physiologically
split. An early systolic ejection sound is noted, and an early peaking murmur is noted
at the second right intercostal space. A short diastolic murmur is audible along the left
sternal border. Lungs are clear to auscultation. Electrocardiogram shows left
ventricular hypertrophy. Findings on urinalysis are normal. Which of the following is
the most appropriate next step in the evaluation of this patient?

a) Measure serum thyroid-stimulating hormone.

b) Measure the blood pressure in the lower extremities.
c) Order an echocardiogram.
d) Order a 24-hour urine test for metanephrine and vanillylmandelic acid.
e) Obtain a chest radiograph

94. A 60-year-old man has hospitalized at the intensive care for 1 week. He arrived at
emergency unit with chief complaint of severe sharp epigastric and backpain 6 hours
before admission. During his pain, he ever lost his consciousness and lots of
perspiration. The history of illness was hypertension used amlodipine 5 mg twice daily.

43
On physical examination was found blood pressure 180/100 mmHg, heart rate 110
x/minutes and others within the normal limit. An electrocardiogram showed left
ventricular hypertrophy. A chest x-ray revealed mediastinum enlargement. Blood
study showed Hb 12 g/dL, Ht 40%, WBC 12.000, D dimer 19.000. CT angio
unenhancement of axial view showed crescent shape aortic appearance just after left
subclavian artery branch lengthened to diaphragms. However, an CT enhancement
was seen contrast passed entry site fill limited length portion of false lumen about 0.5
cm. Aortic arch was seen space among right innominate artery, left carotid artery and
left subclavian artery were very close. CT angio of aortic dissection in the case above
is correlated with pathophysiology as folowing?

a. Connective tissue disorders and injury (jawaban ini ragu2)

b. Microcirculation rupture
c. Atherosclerotic
d. Iatrogenic
e. None of them

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