CARDIOLOGY

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10. Coarctation of the aorta is commonly associated with which of the following syndromes:

Options are:

A. Down
B. Turner
C. Pataue
D. Edward

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Explanation:

Correct answer is B : Turner.

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12. Which of the following is the most dangerous to a patient in terms of risk for CAD?

Options are:

A. Elevated triglycerides.
B. Elevated total cholesterol.
C. Decreased high density lipoprotein (HDL)
D. Elevated low density lipoprotein (LDL).
E. Obesity.

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Explanation:

Correct answer is D : Elevated low density lipoprotein (LDL).

Marked elevation in LDL is by far the most dangerous portion of a lipid profile for a patient.
A low HDL is also

associated with a poor long-term prognosis, but is not as dangerous as an elevated LDL.
Although elevations in triglyceride levels are

potentially dangerous, this is not as reproducible in terms of poor outcome as the elevated
LDL. The proper treatment of an isolated

elevation of triglyceride level is not as clearly beneficial as treatment of an elevated LDL

level. Obesity, particularly that resulting in

in creasing abdominal girth, is associated with increased cardiac mortality. However, much
of the danger of obesity is from its association with other abnormalities such as
hyperlipidemia, diabetes, and hypertension.

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13. A postmenopausal woman develops chest pain immediately on hearing the news of her
son’s death in a war. She develops acute chest pain, dyspnea, and ST segment elevation in
leads V2 to V4 on electrocardiogram. Elevated levels of troponin confirm an acute myocardial
infarction. Coronary angiography is normal including an absence of vasospasm on provocative
testing. Echocardiography reveals apical left ventricular “ballooning.”
What is the presumed mechanism of this disorder?

Options are:

A. Absence of estrogen.
B. Massive catecholamine discharge.
C. Plaque rupture.
D. platelet activation.
E. Emboli to the coronary arteries

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Explanation:

Correct answer is B : Massive catecholamine discharge.

Tako-Tsubo cardiomyopathy is acute myocardial damage most often occurring in

postmenopausal women immediately

following an overwhelming, emotionally stressful event. Examples are divorce, financial

issues, earthquake, lightning strike, and

hypoglycemia. This leads to “ballooning” and left ventricular dyskinesis. As with ischemic
disease, manage with beta blockers and

ACE inhibitors. Revascularization will not help, since the coronary arteries are normal.

Sudden, overwhelming emotional stress and anger can cause chest pain and sudden
death.

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14. Correcting which of the following risk factors for CAD(Coronary Artery Disease) will result
in the most immediate benefit for the patient?

Options are:

A. Diabetes mellitus.
B. Tobacco smoking.
C. Hypertension.
D. Hyperlipidemia.
E. Weight loss.

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Explanation:

Correct answer is B : Tobacco smoking.

Smoking cessation results in the greatest immediate improvement in patient outcomes for
CAD.

Within a year after stopping smoking, the risk of CAD decreases by 50%. Within 2 years
after stopping smoking, the risk is reduced by 90%.

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15. A man with atypical chest pain is found to have normal nuclear isotope uptake in his
myocardium at rest. On exercise, there is decreased uptake in the inferior wall. Two hours
after exercise, the uptake of nuclear isotope returns to normal. What is the right thing to do?

Options are:

A. Coronary angiography.
B. Bypass surgery.
C. Percutaneous coronary intervention (e.g.,
angioplasty).
D. Dobutamine echocardiography
E. Nothing; it is an artifact.

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Explanation:

Correct answer is A : Coronary angiography.

This patient has reversible ischemia on the stress test: This is exactly the person who
needs angiography. If the presentation of anginal chest pain is 100% specific for coronary
disease, there is not much point in doing a stress test. Even if it comes back negative, the
patient likely has coronary disease. The stress test is precisely for when you are not sure of
etiology. When isotope uptake is normal at rest and decreases on exercise, you have found
the person who can benefit from revascularization.

You cannot determine what type of revascularization until after you know the anatomy. If
there is no reversibility in ischemia between rest and exercise, there is little to be gained
from revascularization. Irreversible (“fixed”) defects mean dead (infarcted) myocardium.
There is not much point in revascularizing dead tissue; it is too late. There is a lot of point in
revascularizing reversible defects. The tissue can be saved, and you can prevent infarction.

Reversible perfusion defects need catheterization. Catheterization indicates which patients

get bypass versus angioplasty versus medications alone.

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16. A 48-year-old woman comes to the office with chest pain that has been occurring over
the last several weeks. The pain is not reliably related to exertion. She is comfortable now.
The location of the pain is retrosternal. She has no hypertension, and the EKG is normal.
What is the most appropriate next step in management?

Options are:

A. CK-MB.
B. Troponin.
C. Echocardiogram.
D. Exercise tolerance testing
E. Angiography.
F. CT angiography
G. Cardiac MRI.
H. Holter monitor.

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Explanation:

Correct answer is D : Exercise tolerance testing

Enzymes are to evaluate acute coronary syndromes. Serial troponin measurements are
done prior to stress test.

Echocardiography is to evaluate valve function, wall motion, and ejection fraction. Exercise
tolerance testing is to evaluate stable

patients with chest pain whose diagnoses are not clear. ETT is not used in acute coronary
syndrome cases in which the patient is

currently having pain and the diagnosis is already clear. Also, don’t put patients on a
treadmill to exercise if they are currently

having chest pain.

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Explanation:

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17. Which of the following is the most common adverse effect of statin medications?

Options are:

A. Rhabdomyolysis.
B. Liver dysfunction.
C. Renal failure.
D. Encephalopathy.
E. Hyperkalemia.

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Explanation:

Correct answer is B : Liver dysfunction.

At least 1% of patients taking statin medications will develop elevation of transaminases to

the level where you will need to discontinue the medication. Myositis, elevation of CPK
levels, or rhabdomyolysis will occur in less than 0.1% of patients. It is very rare to have to
stop statins because of myositis. There is no recommendation to routinely test all patients
for CPK levels in the absence of symptoms. On the other hand, all patients started on
statins should have their AST and ALT tested as a matter of routine monitoring, even if no
symptoms are present.

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18. A 70-year-old woman comes to the emergency department with crushing substernal
chest pain for the last hour. The pain radiates to her left arm and is associated with anxiety,
diaphoresis, and nausea. She describes the pain as “sore”and “dull” and clenches her fist in
front of her chest. She has a history of hypertension.
Which of the following is most likely to be found in this patient?

Options are:

A. 10 mm Hg decrease in blood pressure on inhalation.

B. Increase in jugular venous pressure on inhalation.
C. Triphasic scratchy sound on auscultation.
D. Continuous “machinery” murmur.
E. S4 gallop.
F. Point of maximal impulse displaced towards the axilla.

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Explanation:

Correct answer is E : S4 gallop.

Acute coronary syndromes are associated with an S4 gallop because of ischemia leading
to noncompliance of the left ventricle. The S4 gallop is the sound of atrial systole as blood
is ejected from the atrium into a stiff ventricle. A decrease of blood pressure of greater than
10 mm Hg on inspiration is a pulsus paradoxus and is associated with cardiac tamponade.

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19. A 70-year-old woman comes to the emergency department with crushing substernal
chest pain for the last hour.
Which of the following EKG findings would be associated with the worst progn

Options are:

A. ST elevation in leads II, III, aVF.

B. PR interval >200 milliseconds.
C. ST elevation in leads V2-V4.
D. Frequent premature ventricular complexes (PVCs).
E. ST depression in leads V1 and V2.
F. Right bundle branch block (RBBB)

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Explanation:

Correct answer is C : ST elevation in leads V2-V4.

Leads V2 to V4 correspond to the anterior wall of the left ventricle. ST segment elevation
most often signifies an acute myocardial infarction.

ST elevation in leads II, III, and aVF is also consistent with an acute myocardial infarction,
but of the inferior wall. Untreated, the mortality associated with an IWMI is less than 5% at
1 year after the event. With an AWMI, mortality untreated is closer to 30% to 40%.

PR interval greater than 200 milliseconds is first-degree atrioventricular (AV) block. First-
degree AV block has little pathologic potential and, when isolated, requires no additional
therapy.

Ectopy such as PVCs and atrial premature complexes (APCs) are associated with the later
development of more severe arrhythmias, but no additional therapy is needed for them if
magnesium and potassium levels are normal. We don’t like to see PVCs,

but their presence does not require any changes in management.

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Explanation:

ST depressions in leads V1 and V2 are suggestive of a posterior wall myocardial infarction.

These leads are read in the opposite direction of the rest of the leads. In other words, ST
depression in leads V1 and V2 would be like ST elevation elsewhere an acute infarction.
Infarctions of the posterior wall are associated with a very low mortality, and again, there is
no additional therapy to give because of it.

Right bundle branch block (RBBB) is relatively benign compared to a new left bundle
branch block.

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20. A 70-year-old woman comes to the emergency department with crushing substernal
chest pain for the last hour. An EKG shows ST segment elevation in V2 to V4.
What is the most appropriate next step in the management of this patient?

Options are:
A. CK-MB level. K. Tro
B. Oxygen L. Morphine.
C. Nitroglycerin sublingual. M. Angiography.
D. Aspirin. N. Clopidogrel
E. Thrombolytics.
F. Metoprolol
G. Atorvastatin.
H. Angioplasty
I. Consult cardiology
J. Transfer the patient to the intensive care unit

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Explanation:

Correct answer is D : Aspirin.

Aspirin lowers mortality with acute coronary syndromes, and it is critical to administer it as
rapidly as possible. With only 1 hour since the onset of pain, neither the CK-MB level nor
the troponin level would be elevated yet. Morphine, oxygen, and nitroglycerin should all be
administered, but they do not lower mortality and are therefore not as important as aspirin.
Aspirin should be given simultaneously with activating the catheterization lab.

Clopidogrel, prasugrel, or ticagrelor is indicated when the patient has an intolerance of

aspirin or has undergone angioplasty with stenting.

The patient should be transferred to an intensive care unit (ICU), but you must always
initiate therapy and testing before you simply move the patient to another part of the
hospital. It is much more important to start proper care than to move the patient, even if it is
a movement to an area of increased observation and potential treatment. Thrombolytics or
angioplasty should be done and it is critical to do them quickly; however, aspirin is simply
recommended to be given first. Aspirin is then followed with another form of acute
revascularization.

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21. A 70-year-old woman comes to the emergency department with crushing substernal
chest pain for the last hour. An EKG shows ST segment elevation in V2 to V4. Aspirin has
been given to the patient to chew.
What is the most appropriate next step in the management of this patient?

Options are:

A. Angioplasty
B. Oxygen.
C. Nitroglycerin sublingual.
D. Morphine.
E. Thrombolytics.
F. Metoprolol
G. Atorvastatin.
H. Atorvastatin.

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Explanation:

Correct answer is A : Angioplasty

Angioplasty is associated with the greatest mortality benefit of all the steps listed in this
question. All of the answers are partially correct in that all of them should be done for the
patient. Again, morphine, oxygen, and nitrates should be given to the patient immediately,
but they do not clearly lower mortality.

Enzyme tests should be done, but within the first 4 hours of the onset of chest pain, they
will certainly be normal. Even if they are elevated, CK-MB and troponin levels would not
alter the management.

Beta blockers are associated with a decrease in mortality, but they are not critically
dependent upon time. As long as the

patient receives metoprolol sometime during the hospital stay and at discharge, she will
derive benefit. The same is true of the use of

statins and ACE inhibitors.

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