48-year-old male with a history of anteroseptal STEMI 4 days ago.

Asymptomatic to
this day, he went to the emergency room with continuous chest pain, which
increased with forced inspiration and cough. Stable vital signs

What is the cause of progression from pericardial effusion to cardiac

tamponade?
a) Left ventricular diameter and BP
b) Establishment rate and FC
c) Right ventricular diameter and pulmonary pressure
d) BP and right ventricular function

The speed of establishment is decisive in causing hemodynamic instability, since in

cases of neoplasia the chronic appearance allows greater effusions without clinical
signs of tamponade until advanced stages. The second most important would be the
heart rate, since it is responsible for compensating for stroke volume and low cardiac
output.

Percentage of cases with cardiac tamponade in which Beck's triad occurs

a) 10- 20%
b) 10- 40%
c) 0%
d) 100%

Beck's triad (hypotension, distended jugular veins, dull heart sounds) is classic, but
only occurs in 40% of patients. Its absence does not exempt diagnosis, it is
important to corroborate with echocardiogram

In addition to the low voltage, what other electrocardiographic data makes us

suspect cardiac tamponade?
a) Q waves in all precordial leads
b) long PR
c) mirror images
d) electrical alternation

The heart is floating in a pericardial effusion, which causes it to change its

anatomical position, thus interfering with its electrical position. Electrical alternans is
a sign of significant pericardial effusion

Post-infarction autoimmune disease

a) Brugada syndrome
b) Dressler syndrome
 c) Wolff Parkinson syndrome
d) Rheumatoid arthritis

A picture of pericarditis and pericardial effusion plus pleural effusion and pleuritic
pain together with arthritis raise suspicion of Dressler Syndrome in a post-infarction
patient (20%), especially if the location of the AMI was anterior.

A 70-year-old woman was treated for dyspnea caused by minimal physical activity
accompanied by palpitations and occasional chest pain that subsides at rest. APP:
diabetes for 12 years and using 2 pillows to sleep. EF: Jugular engorgement at 45º,
slight lung crackles and edema ++ in the pelvic limbs. Laboratories: EGO: proteinuria
+ X-ray shown

Treatment of choice
a) Diuretic/Digital
b) Amlodipine/Beta blocker
c) Thiazide + Calcium antagonist
d) ACEI or ARAII + diuretic

ACEI or ARB drugs improve the pre- and post-load of the heart and decrease
aldosterone production, which leads to less sodium and water retention. They help
stop myocardial remodeling and apoptosis. The Loop Diuretic is also useful as it
helps with edema and/or pulmonary congestion.

What functional class does the patient belong to according to the NYHA?
a) Yo
b) II
 c) III
d) IV

In functional class III there is dyspnea with minimal physical activity but NOT at rest.

Your heart rate is likely to be:

a) >3.8 liters/minute/m2SC
b) 5-6 liters/minute/m2SC
c) <2.5 liters/minute/m2SC
d) 2.5-3.8 liters/minute/m2SC

The cardiac index is equal to Cardiac Output/body surface area, its normal value
ranges from 2.5-3.8 liters/minute/m2SC. In a patient with functional class III, the
cardiac index is expected to be decreased.

A 52-year-old man with a history of a myocardial infarction 2 years ago. Presented to

the emergency room with a 7-hour history of acute severe substernal chest
discomfort

The coronary artery occluded is:

a) Right coronary artery
b) Previous descendant
c) Septal branches
d) Diagonal artery

ECG shows an anteropetal infarction, an occlusion of the left anterior descending

artery.

The best treatment would be:

a) Fibrinolysis
b) primary angioplasty
c) An IIb- III' inhibitor
d) Facilitated angioplasty
This is a 7 hour established myocardial infarction, the patient doesn't have any
contraindication for fibrinolysis.

What is the success rate for fibrinolysis?

a) 60- 70% rate for coronary permeability
b) 80- 100% rate for coronary permeability
c) 40% rate for coronary permeability
d) The rate for coronary patency is variable

After fibrinolysis the rate of success coronary permeability is 60-70%.

How long after the treatment do you have to reevaluate the patient to consider
a successful fibrinolysis?
a) 60 minutes
b) 90 minutes
c) 120 minutes
d) 95 minutes

The success rate of fibrinolysis is measured after 90 mins, in which the ST elevation
should've been reduced.

How much the ST segment elevation has to be reduced?

a) 50%
b) 70%
c) 80%
d) 100%
ST segment elevation should be reduced at least 50% to consider the fibrinolysis
successful

A 75-year-old man, a patient at the National Institute of Cardiology, reports taking

three different medications: one is to control blood pressure, another is to reduce
cholesterol values, and the last is taken daily, resting on Saturday and Sunday. He
comes for vomiting, diarrhea, blurred vision and difficulty identifying colors. In the
emergency room an EKG is taken:
What is seen on the EKG?
a) normal EKG
b) Mobitz II
c) delta wave
d) digital cuvette

Digitalis cuvette is characteristic of digitalis poisoning

What is the required treatment?

a) Does not require
b) Pacemaker
c) Discontinue the medication and Ac Fab
d) Adenosine rapid infusion

In case of digitalis poisoning, the first thing to do is suspend the drug, administer ac
Fab and measure the concentration in the blood, if necessary, perform a
hemodialysis session.

A 10-year-old male patient presents with a history of fever 2 weeks ago. He reported
dyspnea on medium exertion, orthopnea and bimalleolar edema, migratory
inflammation of the right knee and later the left knee.
EF: apical holosystolic murmur and salmon rash on the trunk and upper limbs.

What is the etiological agent of your suspected diagnosis?

a) Group A beta hemolytic streptococcus
b) Group B beta hemolytic streptococcus
c) Group A alpha hemolytic streptococcus
d) Staphylococcus Aureus

According to the CPG: Prevention and timely diagnosis of rheumatic fever, group A
beta hemolytic streptococcus is the most common agent of rheumatic fever.
The murmur described coincides with the following pathology:
a) mitral stenosis
b) Mitral regurgitation
c) Aortic stenosis
d) Tricuspid regurgitation

The CPG for rheumatic fever states that carditis mainly affects the mitral and aortic
valves. At first it produces valvular regurgitation. It presents as an apical holosystolic
murmur with or without a middiastolic flow murmur,

What is the treatment of choice for the patient?

a) Rest, water and salt restriction, ceftriaxone 1 gram DU
b) Amoxicillin 250mg/d for 7 days
c) Benzathine Penicillin 1,200,000 U IM DU + ASA
d) Rest, water and salt restriction, and weekly observation

According to the GPC: Prevention and timely diagnosis of rheumatic fever in children
over 20 kg in weight, adolescents and adults, it is recommended: benzathine
penicillin G, 1, 200,000 IU intramuscularly, single dose

70-year-old male with SAH, type 2 diabetes, dyslipidemia and smoking. STEMI with
high and low lateral location. Due to his TIMI and GRACE scale, cardiac
catheterization was performed.

What artery was responsible for the heart attack?

a) circumflex artery
b) anterior descending artery
c) right coronary artery
d) Anterior septal branches

The right coronary artery is mostly responsible for inferior wall infarctions. Right
dominance occurs in 85% of cases, 10% circumflex and 5% co-dominance.

What is a high-risk score according to the GRACE scale?

a) More than 140
b) More than 160
c) More than 120
d) More than 100

A score greater than 140 points confers a significant in-hospital mortality greater
than 3%.
Cardiac catheterization was performed and a 50% stenosis of the left main coronary
artery was found.
How much percentage of stenosis is considered significant in the left main
coronary artery?
a) 30%
b) 70%
c) 60%
d) 50%

A stenosis greater than 70% is considered significant in normal coronary arteries,

however due to the large territory irrigated by the left coronary artery, a stenosis
greater than 50% in the trunk is already considered significant.

22-year-old, previously healthy medical student. He went to the emergency room

due to oppressive chest pain that had been going on for 12 hours, intensity 10/10,
with radiation to the trapezius, without other accompanying symptoms. He denies
any history of ischemic heart disease in the family.

Which of the following helps you differentiate chest pain from pericarditis?
a) Pain that improves with forced inspiration
b) There is no maneuver that helps
c) Relieving pain in squatting position
d) Pain that increases in the supine position and improves with sitting and
leaning forward

Acute pericarditis is a very intense pleuritic pain that increases with cough, forced
inspiration, and supine position. Improves with sitting and leaning forward.

The most common etiology is:

a) Bacterial 60%
b) Autoimmune 40%
c) 90% viral
d) Tuberculosis, requires culture

90% of acute pericarditis are caused by Coxsackie virus B, Coxsackie virus A,

Echovirus and Epstein Barr virus.

What is the morphology of ST segment elevation?

a) elevated peaked t
b) Concave ST depression except in AVR and V1
c) Convex ST depression except in AVR and V1
d) Concave ST elevation except in AVR and V1
ST segment elevation is concave (flag) and diffuse, except in AVR and V1. At least 2
different electrocardiographic locations are affected. Mirror images are not displayed

What percentage of patients with acute pericarditis may have moderate to

significant pericardial effusion?
a) 20%
b) 7- 10%
c) less than 1%
d) 5%

A 45-year-old man, without comorbidities, came 1 month after the diagnosis of

Hypertension, followed non-pharmacological measures and currently has BP 145/95
mmHg.

Mechanism of action of the drug you would use

a) Sympathetic action blocker
b) Angiotensin II Inhibitors
c) Calcium channel inhibitors
d) Decreasing intravascular volume

Thiazides act in the initial portion of the distal convoluted tubule, preventing the
reabsorption of Sodium and Chlorine, which decreases intravascular volume.
According to the GPC, diuretics are the group of drugs of choice to use once
antihypertensive therapy has started.

15-year-old man with Chronic Kidney Disease due to renal hypoplasia. APP:
Hypertension for a year, managed with calcium antagonists, hydralazine and
furosemide. Currently on peritoneal dialysis.

Mention the figures to consider that the TA is in control

a) <120/80 mmHg
b) <130/80 mmHg
c) <140/90 mmHg
d) <150/90 mmHg

To prevent the progression of CKD, BP <130/80 mmHg and reduction of proteinuria

to <0.5g in 24-hour urine is required.
75-year-old, sedentary male patient with hypertension of 10 years' duration.
Unknown treatment. The EKG shows:

The approximate axis of the QRS would be:

a) 0º
b) + 30º
c) + 60º
d) - 90º

The QRS axis is determined from the perpendicular of the most isophasic lead
(AVF), which is DI, which, being positive, results in a QRS axis at 0º.

What is the derivation perpendicular to AVR and how many degrees is it?
a) DI at 0º
b) DII at +60º
c) DIII at +120º
d) AVL at 30º

The perpendicular lead of AVR is DIII.

Calculate the Cornell index for the presented EKG:

a) +32
b) + 42
c) + 25
d) + 31

The Cornell index is calculated with the sum of the R of AVL and the S of V3. In this
case + 32 mm.

For this patient, at what value is the Cornell index considered positive?
a) + 20
 b) + 28
c) + 25
d) + 45

The Cornell index is positive in men if it is > 28 mm and in women if it is > 20 mm.

Cut-off value for the classic and modified Lyon-Sokolow index

a) +35 classic and +45 modified
b) +20 classic and +28 modified
c) +35 classic and +35 modified
d) +45 classic and +35 modified

The classic Lyon-Sokolow index takes the S wave of V1 and R wave of V6 and has
a cut-off of + 35. The modified one takes the deepest S and the highest R, having +
45 mm as the cut-off point.

48-year-old male patient with alcohol-induced dilated cardiomyopathy and systemic

arterial hypertension. NYHA functional class II. He went to the consultation because
his blood pressure was 160/90 mmHg despite treatment with ACE inhibitors.

What drug would you add?

a) ARAs
b) Alpha blockers
c) beta blocker
d) Calcium antagonist

In this patient with CHF and HTN, the most recommended drugs due to their benefit
in reducing mortality are ACEIs and beta blockers. Beta blockers are used as
antihypertensives only if they are ischemic patients or with heart failure.

What stage of JNC is this patient in?

a) Grade 1
b) Grade 2
c) 3rd grade
d) Grade 0

According to the JNC, the patient is in grade 2: ≥ 160 mmHg / ≥100 mmHg

By having adequate control of blood pressure, the most preventable

complication is:
a) myocardial infarction
b) Nephropathy
c) Chronic heart failure
d) atrial fibrillation
25-year-old medical student, who comes to the clinic due to sudden palpitations,
accompanied by dyspnea and dizziness, which last up to 4 hours.
In which arrhythmia is it important to measure the PR interval and the RP for
its classification as a typical and atypical form?
a) Intranodal reentry
b) atrial fibrillation
c) Atrial flutter
d) Ectopic atrial tachycardia

Nodal reentry arrhythmias are classified as typical and atypical, depending on their
intervals and consist of a macroreentry within the AV node, secondary to a slow and
a fast pathway, and this mechanism determines the RP and PR interval. They do not
present instability, it is common in young people and can last for hours.

In the arrhythmia that you suspected for the patient, if the patient presents
hemodynamic instability, what is the first-line treatment?
a) Metoprolol 5 mg IV
b) electrical cardioversion
c) Adenosine 6 mg IV bolus
d) Verapamil 5 mg IV bolus
Electrical cardioversion is recommended for any tachyarrhythmia with hemodynamic
instability.

If the patient presents with hemodynamic stability, you perform vagal

maneuvers and there is no response. What medication and what dose should
be administered?
a) Metoprolol 5 mg IV
b) Adenosine 6 mg IV IV infusion
c) Verapamil 5 mg IV bolus
d) Adenosine 6 mg IV bolus

If vagal maneuvers fail, an initial adenosine bolus of 6 mg IV is recommended and

transient AV block is observed immediately. If this fails, the dose is doubled to 12 mg
as an IV bolus.

What is the differential diagnosis of atypical intranodal reentry tachycardia?

a) Accessory route (Wolff-Parkinson-White)
b) Ectopic atrial tachycardia
c) Atrial flutter
d) atrial fibrillation

It is difficult to differentiate from a Wolff-Parkinson-White type accessory pathway

but without pre-excitation (Delta wave), as it usually occurs. In atypical intranodal
reentry, the RP segment is larger than the PR and the shunt cycles through the fast
and then slow pathway.

What is the success rate of ablation as a definitive treatment, in WPW?

a) 50%
b) This arrhythmia is not amenable to ablation
c) 20%
d) 90%

The definitive treatment for intranodal reentry tachycardia is ablation using

electrophysiological study, and has a success rate of 90%. Anticoagulation is not
indicated in this type of arrhythmias.

A 32-year-old man came to the emergency room due to a first-time episode of

sudden palpitations plus dyspnea, which appeared while he was at a soccer game.
Currently with chest pain and diaphoresis with disorientation. On physical
examination, the first variable sound and alternating peripheral pulse were found,
without murmurs but with a “cannon” A wave. The following electrocardiogram is
obtained.

Which is the diagnosis?

a) Wolff-Parkinson-White
b) Polymorphic ventricular tachycardia
c) Atrial flutter
d) Monomorphic ventricular tachycardia

In the EKG we observed wide QRS complexes at a speed of more than 150 bpm,
which is why it is considered ventricular tachycardia, being monomorphic and
presenting A waves intermittently, intertwined and dissociated.

In this arrhythmia, how is AV conduction?

a) Driving 3:1
 b) Retrograde A waves
c) Complete AV dissociation
d) Driving 2:1

In ventricular tachycardia, accelerated ventricular conduction predominates and

atrial conduction is irrelevant; it is accompanied by complete AV dissociation.

Which of the following is the clinical triad of ventricular tachycardia?

a) A waves in cannon, alternating pulse and 1st noise of variable intensity.
b) Cannon A waves, hypotension and no pulse.
c) Hypotension, decreased heart sounds and paradoxical pulse.
d) Paradoxical pulse, canyon A waves, and alternating pulse.

The clinical triad of ventricular tachycardia is canyon A waves, alternating pulse and
first sound of variable intensity.

What is the first-line treatment in this patient?

a) Pharmacological bolus cardioversion
b) Biphasic electrical cardioversion 50 J
c) Defibrillation
d) Biphasic electrical cardioversion 200 J

In unstable patients who present VT with pulse, pharmacological cardioversion is

performed in biphasic 200 J or monophasic 360 J.

Once the patient is stabilized in sinus rhythm, it is identified that the patient has a
baseline EKG with complete right bundle branch block and saddle pattern in V1-V3.
What is the underlying pathology and its corresponding mutation?
a) Sx long QT due to K channel mutation
b) Arrhythmogenic dysplasia due to tropomyosin mutation
c) Brugada syndrome due to SCN5A mutation
d) Hypertrophic cardiomyopathy due to myosin mitosis
Brugada syndrome is characteristically complete right bundle branch block and
saddle pattern in V1-V3 and is associated with the classic SCN5A sodium channel
mutation.

72-year-old female patient, without any other comorbidity. He comes to report that 6
days ago he started with occasional, rapid palpitations that last minutes and even
hours. Baseline EKG found atrial fibrillation.
To guide anticoagulant treatment, what should be defined, according to the
atrial fibrillation guidelines?
a) Valve etiology.
b) Time of evolution
c) Embolic sequelae.
d) Fast or medium ventricular response.

The most important thing is to define whether it is valvular or non-valvular and the
use of anticoagulant will depend on that.

If the patient has non-valvular AF, what scale should be applied to determine
her treatment?
a) CHADS2
b) PURSUIT
c) TIMI
d) CHA2DS2VASc

The PURSUIT, TIMI and GRACE scales are to evaluate acute myocardial infarction.
The recommended scale to evaluate this risk is the CHA2DS2VASc. It is more
sensitive and specific to identify patients who are at risk of CVD.

How many points does this patient have on the CHA2DS2-VASc scale?
a) 3
b) 2
c) 4
d) 5
2 points are awarded for age > 75 years and 1 point for being a woman. The patient
has 3 points in total.

How many points are needed to grant total anticoagulation to the patient,
according to the CHA2DS2VASc scale?
a) This scale is not useful to answer this question
b) 3 or more
c) 2 or more
d) 4 or more
According to this scale, 2 or more points are necessary to justify an embolic risk.

What is the anticoagulant of choice for this patient, if she has normal kidney
function?
a) Apixaban 2.5 mg every 24 hours.
b) Dabigatran 150 mg every 24 hours
c) Acenocoumarin for an INR 1.5 to 2.5
d) Rivaroxaban 20 mg every 24 hours

Rivaroxaban is administered every 24 hours at a dose between 15 and 20 mg.

Lower doses of rivaroxaban are prophylactic or adjusted to impaired renal function,
which is not the case.

You treat a 19-year-old young man for chest pain that is associated with exercise,
accompanied by dyspnea, orthopnea, and lower extremity edema. The patient is
very tall and disproportionately thin. He is treated in ophthalmology for myopia and
lens dislocation. In the precordial area he heard a pandiastolic murmur in the second
EID and third EII.

According to what was heard, what pathology does the cardiac focus
correspond to?
a) Aortic insufficiency
b) Mitral regurgitation
c) Aortic stenosis
d) mitral stenosis
Characteristically in aortic insufficiency, the murmur will be diastolic, at Erb's focus,
which is located in the left third intercostal space.

Mention, What underlying disease does this patient have?

a) Giantism
b) Homocystinuria
c) Ehlers Danlos
d) Marfan syndrome
Marfan syndrome is considered one of the congenital causes of aortic insufficiency,
due to a connective tissue defect.

What is the cause of death of patients who do not receive timely treatment?
a) Aortic dissection
b) cardioembolic stroke
c) YO SOY
d) Infectious endocarditis
Aortic dissection is also a cause of acute aortic insufficiency, as well as endocarditis.
65-year-old patient, with type 2 diabetes, obesity, smoking and SAH. On treatment
with aspirin as primary prevention. He attended the emergency room due to
continuous oppressive chest pain that had been going on for 12 hours.
EF: HR 90 bpm, BP 140/90, SaO2 in room air 95%, lactate 1.0. Electrocardiogram
with ST segment depression of 1 mm V1 to V6.
Given negative cardiac enzymes.

What is the diagnostic of this patient?

a) Due to the evolution time, the enzymes have already decreased
b) Acute myocardial infarction without ST segment elevation
c) Decompensated stable angina
d) Unstable angina

In a patient with a clinical picture of acute coronary syndrome, risk factors and
electrocardiographic changes, with negative cardiac enzymes, the diagnosis should
be unstable angina.

How many TIMI points does this patient have?

a) 2
b) 4
c) 7
d) 5

5 TIMI points: age > 65 years (1 point), ≥3 cardiovascular risk factors (1 point),
previous aspirin use (1 point), pain characteristics or more than 2 episodes in 24 h (1
point) and ST segment changes (1 point).

What is the dose of clopidogrel that should be administered initially?

a) 75 mg adjusted for age
b) 300 mg orally
c) 600 mg due to high risk
d) 300 mg chewed for faster effect

The initial dose in SICA without ST elevation, in children under 75 years of age, is
300 mg. Once they are over 75 years of age, no bolus is given and only 75 mg are
given. The 600 mg dose is only reserved for primary angioplasty in ACIS with ST
elevation. It is given orally, only aspirin is chewed.

The patient has a GRACE score of 160 points and a TIMI score already mentioned.
What is the diagnostic-therapeutic approach for this patient?
a) Pharmacological treatment and cardiac scan
b) Pharmacological treatment and coronary angiotomography
c) Pharmacological treatment and Coronary angiography and angioplasty
 d) Pharmacological treatment and stress test

Based on TIMI and GRACE scores, the patient is a candidate for coronary
angiography and angioplasty, based on the anatomical findings.

How long should the diagnostic-therapeutic approach take?

a) Less than 12 hours
b) Less than 24 hours
c) In the first 72 hours
d) Immediately

The clinical practice guidelines mention that high-risk patients should be

catheterized within the first 24 hours. Low-risk patients can undergo catheterization
for up to 72 hours.

35-year-old woman with asthenia, adynamia and weight gain. EF: bradylalia, cold
and thick skin. TA 110/66, FR 16, Temperature 36ºC. He orders general tests, a
thyroid profile, and an EKG that shows the following:

What is seen on the EKG?

a) normal EKG
b) nodal bradycardia
c) sinus bradycardia
d) first degree AV block

The EKG shows a HR less than 50 bpm with the presence of p waves followed by
QRS complexes, with a normal PR interval in all cases.

Treatment required by the patient in the case

a) Does not require
 b) Levothyroxine
c) Atropine
d) follow-up every 6 months

The patient has hypothyroidism, so treatment must be given for the underlying
disease. Sinus bradycardia is a secondary finding, so the use of atropine in this case
is not useful.

50-year-old female with high blood pressure. She witnesses the death of her
husband and begins to have oppressive chest pain 10/10, she goes to the
emergency room after 8 hours. The patient has bilateral basal rales. FC 120, TA
160/95, SaO2 85% in ambient air. Electrocardiogram with ST segment elevation of
V1-V6. Positive cardiac enzymes.

What is the most likely initial diagnosis in this case?

a) SICA SEST
b) Unstable angina
c) Pulmonary thromboembolism
d) SICA CEST

Initially due to the characteristics of pain, positive enzymes and EKG changes. It
should be treated as a SICA CEST.

What is the therapeutic diagnostic approach in this case?

a) Medical treatment and thrombolysis
b) Medical treatment and urgent cardiac catheterization
c) Medical treatment and coronary angiotomography
d) Medical treatment and cardiac scan

In the case of CEST SICA of 8 hours of evolution, cardiac catheterization is always

better once the 6 hours have passed. Furthermore, the patient presents signs of
heart failure due to rales and desaturation, which is why catheterization is better.

Cardiac catheterization is performed and coronary arteries are found without

lesions. What pathology does this patient most likely have?
a) Syndrome
b) Prinzmetal's angina
c) Pulmonary thromboembolism
d) Takotsubo disease

In the context of a female patient, with significant emotional stress, ST elevation

EKG changes, and uninjured coronary arteries, the most likely diagnosis is
Takotsubo stress cardiomyopathy.
What is the most common cause of unstable angina?
a) Plaque rupture and thrombosis
b) Secondary causes (i.e. HTN)
c) Coronary vasospasm
d) Embolization of thrombus
The lipid-rich plaque is vulnerable to rupture and its exposure to blood is a potent
activator of platelets and thrombus formation