ACCF Cardiovascular

Board Review 2017

Multiple Choice Questions: General Review

S. Wamique Yusuf, MD, FACC,FRCPI

Q.1 A 70 year old man with history of Diabetes Mellitus for the last 10 years. He has
smoked for 10 years during his youth and drinks a glass of wine every night for the last
20 years. He still works as a lawyer , lives a normal life and walks 2 miles each day with
his dog. About 5 years ago he was hospitalized with chest pain which was attributed to
pneumonia. He has now moved to your locality and visits you for a routine cardiac
evaluation. His medications include Metformin 500 mg daily. Examination shows a
healthy looking man, with no pallor or cyanosis. Pulse 74 bpm, BP 130/70, heart
sounds are normal. Both femoral and popliteal pulses were palpable , with absent
dorsalis pedis and posterior tibial on the left. In the right leg , the posterior tibial was
palpable with absent dorsalis pedis. ABI = 0.90 .What should be your
recommendation?

• A. Arrange for a fasting lipid profile and start aspirin .

• B. Low dose Warfarin will reduce the risk of cardiovascular events.

• C. Arrange a Duplex ultrasound or magnetic resonance angiogram (MRA ), as he may

need revascularization.

• D. He should be referred for a supervised exercise training program.

• E. He should undergo peripheral angiogram and further intervention accordingly.

 • Antiplatelet agents are indicated ( class 11a) for patients with asymptomatic PAD.
Aspirin 75-325 mg daily is recommended. Clopidogrel (75 mg daily) is an effective
alternative for patients allergic to aspirin.

• Oral anticoagulation with Warfarin is not recommended and in fact is a class 3

indication for such patients.

• A program of supervised exercise training is recommended as initial treatment

modality (class I), for patients with intermittent claudication ( the patient in question is
asymptomatic)

• In the above example the patient has Asymptomatic PAD. Also for individuals with
asymptomatic lower extremity PAD, there is currently no evidence that additional
vascular laboratory diagnostic tests (e.g. segmental pressure studies, Duplex ultrasound
magnetic resonance angiogram (MRA or contrast angiography) provides incremental
information that can improve outcome.( Ref: ACC/AHA guidelines 2005).

Anderson JL et al. ACC/AHA PAD guidelines ( Compilation of 2005 & 2011 ).

JACC 2013;61:1555-70.
Symptomatic Asymptomatic

Anderson JL et al. ACC/AHA PAD guidelines ( Compilation of 2005 & 2011 ).

JACC 2013;61:1555-70.
Q. 2 A 30 year old woman, smoker for the last 10 years. She has
been hospitalized on numerous occasions with pulmonary
edema. She has been extensively investigated by a cardiologist
in her home town . Her previous investigations included an
echocardiogram which showed normal left ventricular systolic
function. On each occasion the patient responds extremely
well to diuretics and nitrates. On examination her Pulse is 92
bpm. BP 160/80, normal peripheral pulses and heart sounds.
JVP was not elevated and there were no other signs of heart
failure. Routine laboratory shows: Creat: 0.8. Hb:11.0. For
further investigation this woman should undergo:
• A. Duplex renal ultrasound to exclude underlying renal artery
stenosis.
• B. Myocardial biopsy as recurrent myocarditis needs to be
excluded.
• C. Captopril renal scintigraphy.
• D. Plasma renin and aldosterone level.
• E. Thyroid function test to exclude hypothyroidism as a
precipitating factor for her heart failure.
• Individuals with RAS may experience sudden onset “flash
pulmonary edema”. Percutaneous revascularization is indicated (
class 1 ) for patients with hemodynamically significant RAS and
recurrent , unexplained heart failure or sudden unexplained
pulmonary edema . (Anderson et al. PAD guidelines. JACC
2013; 61:1555–70 ).
• The above case is of Renal artery stenosis due to fibromuscular
dysplasia (FMD). FMD predominantly typically affects younger
women, presents as hypertension with no family history and
rarely causes renal impairment )( For brief review of renal artery
stenosis see BMJ 2000;320;1124-27)
Q. 3 A 70 year old man has a previous history of Diabetes Mellitus,
Hypertension and CAD. He has smoked for 30 years. He has been referred
to you and during routine evaluation was found to have a mass in the
popliteal area. He noticed this mass one year ago but did not seek
consultation. It has remained stable in size with no symptoms. On
examination ; Pulse 80 bpm. All peripheral pulses are bounding and
palpable. BP 130/80, with a normal cardiac examination.
A Duplex scan confirms a popliteal aneurysm which measures 2.4cm in
diameter with no thrombus. The patient has an outside report which
shows that the popliteal aneurysm measured 2.2cm six months ago as well.

What will be your recommendation ?

A. Start treatment with Aspirin 81 mg daily
B. Long term anticoagulation with warfarin to prevent thrombus formation
within the aneurysm.
C. Serial follow up with repeat Duplex scan in 6 – 12 months.
D. He should undergo repair of his popliteal aneurysm.
E. Long term therapy with a combination of warfarin and Clopidogrel is
indicated.
• Comment:
• He should undergo repair of his popliteal aneurysm, to reduce the risk of
thromboembolic complications. For symptomatic popliteal aneurysm either
surgery or catheter based thrombolyis is recommended . For asymptomatic
popliteal aneurysm, if diameter is >2cm : operate. If diameter is < 2cm then
yearly Duplex scan ( See ACC guidelines 2005 ).
• Use of antiplatelet agents in patients with femoral or popliteal aneurysm
is a class 2 indication,
• A wide range of normal dimensions makes it difficult to determine an
arbitrary size at which true femoral aneurysms should be repaired. By
convention, Femoral aneurysms measuring > 3cm or larger appear likely to
cause compressive symptoms and therefore most likely to be treated
surgically.
• Expect Questions on “Pseudo aneurysm of femoral artery ( See ACC
guidelines ).
Anderson et al. JACC 2013:61;1555–70
Q.4.A 35 year old female presents with palpitations. She has been exercising
regularly and has no previous history of any cardiovascular disease. In the
past she had surgery for enlarged tonsils and carpal tunnel syndrome. She
works as a shop assistant and her work involves handling and re-shelving
merchandise. Her medications include multivitamin and oral contraceptives.
Examination reveals a healthy looking lady with no cyanosis or clubbing.
Examination of extremities show that she has evidence of a subungal
hematoma. (See image) She was afebrile and cardiac examination shows a
heart rate of 70/min BP: 110/60 mm Hg, heart sounds are normal. Rest of
the examination was unremarkable. During investigations an echocardiogram
was obtained which showed a small isolated secundum atrial septal defect. All
cardiac chambers were normal in size and EF was 55%.
Based on these findings what would be your
recommendation?
A. Patient should proceed with closure of the defect,
with an umbrella device via a percutaneous route.
B. Patient should proceed with surgical closure of the
defect.
C. Advise the patient to continue living a normal life
and to take antibiotic prophylaxis to prevent
endocarditis.
D. Patient should have a TEE to exclude endocarditis.
E.Reassure the patient that her peripheral sign is not
due to endocarditis. She should continue to live a
normal and no endocarditis prophylaxis is needed.e to
live a normal life and no endocarditis pr
• Ref : ACC/AHA 2006 and 2008 guidelines on valves

• Comment: See ACC/AHA 2006 and 2008 guidelines on valves. In patients with isolated
secundum atrial septal defect, antibiotic prophylaxis is not needed.

• Endocarditis prophylaxis is needed for :

• Patients with
• 1.Prosthetic valves or prosthetic material used for cardiac valve repair.
• 2.Previous infective endocarditis.
• 3.Patients with Congenital heart disease (CHD):
• a)Unrepaired cyanotic CHD, including palliative shunt and repair.
• b) CHD repaired with prosthetic material or device , whether placed surgically or with by
catheter intervention during 6 months after the procedure.
• c) Repaired CHD with residual defect at the site or adjacent to the site of a prosthetic
patch or prosthetic device ( both of which inhibit endothelialization)
• 4.Cardiac transplant receipts with valve regurgitation due to a structurally abnormal
valve.

• Endocarditis prophylaxis is not recommended for: patients with 6 or more months after
successful surgical or percutaneous repair of ASD, VSD or PDA.
•
• Her subungal hematoma is related to work, as she has no other signs of endocarditis.
•
• Comment: Expect at least 1-2 questions on antibiotic prophylaxis in the examination.
Nishimura R A et al. JACC 2014;63:e57–185
Eur Heart J 2015;36:3075-23
 Q. 5 A35 year old woman was recently found to have breast carcinoma. She
has been referred to you for pre-operative evaluation. She complains of
sharp left sided chest pain which occurs during period of stress and lasts
for 2-3 minutes. Her last episode of similar chest pain was six months
ago, while she was playing tennis but she did not seek any medical help,
as it resolved spontaneously. She smokes 1-2 cigarettes a month and
works as a school teacher, plays tennis for 1-2 hours regularly. On
examination her pulse is 70/min, BP: 111/60, normal heart sounds with
no signs of heart failure. The 12 lead ECG shows sinus rhythm with T
wave inversion in lead V1 and a small Q in lead 111.
What would be your recommendation to the surgeon?
A. She should have an exercise myocardial perfusion study.
B. Proceed with planned surgery without any further cardiac
investigations.
C. Evaluate with a baseline echocardiogram to see if there are wall
motion abnormalities.
D. The ECG abnormality may be due to cardiomyopathy and an
echocardiogram is indicated.
E. Her chest pain is typical of angina and she should have a cardiac
catheterization pre-operatively.
• See Pre-op guidelines
• Comments: In a patient with atypical chest pain
and minor non specific ECG findings, with very
good functional capacity, no further
investigations are needed pre-operatively.
 Q.6 A 35 year old man presents to the hospital after successful resuscitation
following a ventricular fibrillation arrest. His admission ECG is shown. What
should be the best management plan?

A. Proceed with coronary angiography and primary PCI.

B. If there is no neurological damage, proceed with fibrinolytic therapy.
C. Implant an AICD.
D. Perform programmed electrical stimulation (PES).
E. Implant a BiV pacemaker.
• The typical electrocardiographic features of the
Brugada Syndrome-Type 1 are illustrated in the Figure.
They consists of an rSr' pattern suggestive of RBBB
with downsloping ST segment elevation in leads V1 to
V3 often with inverted T waves.
• PES is not considered necessary given the classic ECG
findings and history of resuscitated VF.
Mizusawa Y, Wilde AAM. Circ Arrhythm Electrophysiol. 2012;5:606-
616
Q.7 You are called to see a patient who has sustained an anterior myocardial
infarction 8 hours ago for which he was given reteplase. He was noted to be
having frequent PVC’s including couplets. You are called to review the
telemetry strip shown. The patient’s blood pressure is 110/70 and heart rate is
68 bpm; he is lying comfortably in bed. Based on this ECG strip, what would
you recommend?

A. Give metoprolol tartrate 5 mg intravenously in order to keep HR < 60bpm.

B. Start intravenous amiodarone.
C. Start intravenous lidocaine.
D. Reassure the patient and nurse and continue to observe.
E. Check serial ECG and cardiac enzymes , as this is a marker of ongoing
ischemia.
Q.8 A 65 year old woman was found to have the following rhythm
after completion of tenecteplase for an STEMI. On your arrival
her blood pressure if 90/60.

What would you do for this rhythm?

A. Administer lidocaine
B. Give metoprolol tartrate 5 mg intravenously and repeat every 6
hours.
C. Coronary angiography.
D. Observation
E. Intravenous magnesium 2 gm.
• Ref: STEMI guidelines. JACC 2004.

• PVC’s, nonsustained VT not associated with

hemodynamic compromise, and accelerated
idioventricular rhythms that emerge after
reperfusion are not indicative of increased SCD risk
and do not require specific therapy in the acute
phase of STEMI.
Ref: O’Gara et al. JACC 2013;61: e78–140
Zipes DP et al. J. Am. Coll. Cardiol. 2006;48;e247-e346
Q.9 A 63 year old man who works as supervisor in a hospital and has come to you for a
routine check up. He has a history of Hypertension for the last 10 years and has
smoked 20 cigarettes a day for 20 years, but quit smoking 4 years ago. He walks 3-4
miles a day and on has no symptoms to report. His current medications include;
Lisinopril 20 mg daily and Aspirin 81 mg daily. On examination he is a well built
gentleman. Cardiovascular examination shows a pulse of 86/min, BP 140/70 mmHg,
a late peaking ejection systolic murmur in the aortic area with radiation to the neck.
The second heart sound is single and the carotid upstroke is diminished. Chest is clear
to auscultation and rest of the examination is unremarkable. An echocardiogram
shows an ejection fraction of 42% with a peak velocity of 4.5 meter/seconds across
the aortic valve. He is currently in NYHA class I with unlimited exercise tolerance.

What would be your recommendation?

A . As he has unlimited exercise tolerance, he can continue with therapy for hypertension
with repeat echocardiogram in 1 year.

B. Add Carvedilol to his medications, as beta blockers are cardio protective.

C. Discuss with him that he will need surgery once he develops symptoms.

D. Discuss with him that he needs surgical intervention for his aortic valve now.

E. Statin would reverse his aortic stenosis and he may not need surgery.
• See ACC guidelines 2006, 2008; AVR is recommended for severe AS and
LV systolic dysfunction (class 1).Even if asymptomatic but EF<50%,
proceed with AVR.

• 3.1.7 Indications for Aortic Valve Replacement: Class I

– 1 AVR is indicated for symptomatic patients with severe AS.*

– 2 AVR is indicated for patients with severe AS* undergoing

coronary artery bypass graft surgery (CABG), undergoing surgery
on the aorta or other heart valves.

– 3. AVR is recommended for patients with severe AS* and LV

systolic dysfunction (ejection fraction less than 0.50).
Nishimura R A et al. JACC 2014;63:e57–185
 Aortic Stenosis. Timing of Surgery
Class I indications JACC 2014;63:e57–185

• Symptomatic patients, with severe high

gradient AS who have symptoms by history
or Ex.testing.

• Asymptomatic patients with severe AS (stage

C2) and EF<50%.

• Patients with severe AS ( stage C or D ) when

undergoing other cardiac surgery
Nishimura R A et al. JACC 2014;63:e57–185
 Classic findings of severe AS
• Loud (grade 4/6), late-peaking systolic murmur that
radiates to the carotids,

• A single or paradoxically split second heart sound (S2),

• A delayed and diminished carotid upstroke .

• However, in the elderly, the carotid upstroke may be normal

because of the effects of aging on the vasculature, and the
murmur may be soft or may radiate to the apex. The only
physical examination finding that is reliable in excluding the
possibility of severe AS is a normally split second heart
sound
Q.10 A 28 year old man is being investigated for syncope. During
investigation he undergoes numerous tests at an outside facility. His
family brings you the following test and wants to know the
abnormality. They are not sure of what was told to them by his
cardiologist. What is your diagnosis?

A. Hypertrophic cardiomyopathy
B. Midventricular obstruction
C. Pulmonic stenosis
D. Corrected transposition
E. Coarctation of the aorta.
 Q.11 A 25 year old woman has a history of narrow complex tachycardia. She
has failed medical therapy. A catheter ablation was carried out. After initial
failed attempt at arterial access via femoral artery, it was obtained via right
brachial artery. During the EP procedure she was found to have an accessory
pathway for which ablation was being carried out. Midway through the
procedure the arterial line showed that her systolic blood pressure had
dropped to 60mm Hg and fluoroscopy shows some pericardial staining. The
patient is alert but feels tired and sleepy due to benzodiazepine given at the
start of the procedure.

What would be next step ?

A. Give bolus of normal saline as this may be due to excess sedation.

B. Arrange for blood transfusion and obtain CT scan of abdomen as she may be
bleeding into the retroperitoneal area.
C. Discontinue the procedure and start IV normal saline bolus of 500cc.
D. This is life threatening situation and another invasive procedure is needed
emergently at the bedside.
E. Continue the EP procedure as this may be vasovagal.
Q.12. A 22 year old woman is 8 months pregnant with her first child. She had had no
childhood illness and has enjoyed good health. Recently she has noticed a feeling of
her heart pounding without any other symptoms. This lasts only for few seconds and
is not troublesome enough for her to seek any medical treatment or medications. She
is on a telemetry unit and the nurses have not noticed any arrhythmias during these
episodes. However the primary service is concerned and wants a cardiology evaluation.
Patient has no other symptoms to report but on examination you find a soft grade 1 to
2 mid systolic murmur along the mid to upper left sternal edge. Her carotid upstroke is
normal and the intensity of second heart sound is also within normal limits. In
addition you notice another systolic murmur over left breast when she is in supine
position and it disappears on standing or when the stethoscope is applied with a firm
pressure. A third heart sound is also audible. Which of the following statement is true.

• A. She may have peripartum cardiomyopathy and above findings are typical of this
condition.
• B. Murmur is suggestive of a patent ductus arteriosus and further investigation for this
should be done.
• C. An echocardiogram should be done as she may have underlying severe aortic
stenosis , as murmurs of aortic stenosis attenuate during pregnancy.
• D. Reassure the patient that her physical examination is due to physiological changes
of pregnancy.
• E. Start beta blockers for symptomatic relief.
• Ref: ACC valve Valve guidelines JACC 2006( page
e83 ).
• All above findings are due to physiological changes of
pregnancy. Diastolic murmurs are unusual .

• Murmurs of stenotic lesions may accentuate during

pregnancy. On the other hand murmur of MR, AR can
actually attenuate or become in audible as systemic
vascular resistance is lowered.
 Strategy for evaluating heart murmurs

Bonow et al. ACC/AHA guidelines 2008. JACC 2008;52; e1–142

 Strategy for evaluating heart murmurs

ACC/AHA guidelines 2008

Bonow et al. ACC/AHA guidelines 2008. JACC 2008;52; e1–142

Q.13.A 35 year old man comes in with palpitations. On arrival to ER his HR is
140 bpm, BP 110/60, well perfused. He has history of HTN and DM and
recent creatinine is 3.4. A 12 lead ECG shows atrial fibrillation.
His last echocardiogram shows no left ventricular hypertrophy or structural
heart disease. He is started on anticoagulants. Which of the following
medication would be the best choice for conversion of his Atrial fibrillation.

A.Sotalol
B.Propafenone
C.Dofetilide
D.Flecainide
E.Digoxin
• Sotalol and Dofetilide are primary excreted by renal
route and should be used cautiously if at all in renal
insufficiency.
• Flecainide undergoes primary hepatic ( 75% ) and renal
( 25%).
• Propafenone is primarily excreted by liver ( 99%)

• COMMENT: expect questions on what medications to

use in patients with structural heart disease, renal
failure, liver failure.
Q.14.A 26 year old man presents with a history of palpitations. He is
otherwise well and is currently empolyed as a finance manager at the
local company. He smokes and takes a glass of wine with lunch.
Recently he been under considerable stress and has noticed some
palpitations. On arrival his ECG is obtained which is shown below.
What is the best medication to use.

A. IV adenosine as it may terminate this arrythmias.

B. IV metoprolol
C. IV procainamide
D. IV verapamil
E. IV Digoxin
Q.15 A 65 year old woman who has been a life long heavy smoker presents with
abdominal discomfort, flushing and right upper quadrant fullness, She has a history
of asthma which was diagnosed 2 years ago.She also has diarrhea which she
attributes to a change in her eating habits and has lost 4 pounds in last 6 months.
On examination her pulse rate is 89 bpm, BP 110/60mmHg and she has leg edema,
ascites and tender hepatomegaly. The apex beat is not displaced and a systolic and a
diastolic murmur is heard along the lower left sternal border which increases with
inspiration. A pan systolic murmur is also audible in this area.

Her most likely diagnosis is:

A. Primary pulmonary hypertension likely due to chronic lung disease.

B. A chest x ray is needed as a neoplasm with metastasis can be the main etiology.

C. Cirrhosis of the liver with resultant AV fistula can cause referred murmur as above.

D. Urine testing would be helpful in the diagnosis and octreotide would help control
symptoms and diarrhea.

E. A previous silent myocardial infarction.

• Plasma and platelet sertonin and urinary 5 HIAA which is
cleared by the kidneys are usually elevated in the setting of
carcinoid syndrome. Measurement of urinary 5-HIAA excretion
is the most useful diagnostic test and approximately 75% of
patients excrete >80mircromol/d ( 15mg/d). Specificity of the
test approaches 100% after exclusion of ingested substances
known to elevate 5-HIAA levels; these include bananas,
plantain,pineapple,kiwi fruit,walnuts, plum, pecan,avocados,
guafenesin and acetaminophen ( Harrison 13th ed, page 1537-39)
Q.16.A 70 year old man comes with a history of COPD and is now in the
intensive care unit with increasing shortness of breath. The nurse is
concerned that his heart rate fluctuates and his blood pressure drops when he
has these episodes.She provides you with this ECG. Next step would be.
A. Control heart rate with beta blocking drugs.
B. Correct the underlying hypoxemia and electrolyte imbalance.
C. DC cardioversion .
D. Underlying rhythm is Atrial fibrillation which is not uncommon in ICU
patients and IV Amiodarone would be a reasonable choice.
E. Start Digoxin
Q.17. A 20 yr old girl visits you for routine cardiac evaluation. Her mother is concerned
that her other sister has been recently diagnosed with Hypertrophic obstructive
cardiomyopathy. In the past patient has had episodes of fainting while playing
basketball. During previous evaluations her mother was told that the patient has a
murmur but as she is young she does not need to worry about it. She takes oral
contraceptives and has in the past taken some over the counter medications for a
sinus problem. On examination she has a systolic murmur in the aortic area with
radiation to the right carotid artery. The murmur decreases in intensity with valsalva
maneuver. She has an early systolic sound, a 4th heart sound and the carotid pulse is
slow rising. All peripheral pulses were palpable and equal. Which of the following
statement is true.

A. Physical exam findings are typical of discrete membranous sub aortic stenosis.
B. Clinical picture is suggestive of bicuspid Aortic Stenosis.
C. Clinical picture is suggestive of Hypertrophic obstructive cardiomyopathy.
D. Her fainting spells may be related to degenerative Aortic Stenosis.
E. Physical findings are typical of supravalvular aortic stenosis.
 (Ref: Ref:ACC guidelines on Valvular Heart disease. JACC 1998 and
JACC 2006 ( Table on page e 11 ).

1. In subvalvular stenosis, AR is usually present

2. Yes: She has Bicuspid Aortic stenosis ( click ) . In this case, presence of 4th
Heart sound signifies severe AS
3. HOCM: No, as pulse is not brisk , jerky. Also in HOCM murmur increases
with valsalva maneuver
4. Ejection click and age suggest Bicupid AV.
5. Fourth HS is uncommon in supravalvular aortic stenosis. Also pulse is
unequal in supravalvular aortic stenosis.
 Interventions Used to Alter the Intensity of Cardiac Murmurs
Respiration
Right-sided murmurs generally increase with inspiration. Left-sided murmurs usually are louder during expiration.
Valsalva maneuver
Most murmurs decrease in length and intensity. Two exceptions are the systolic murmur of HCM, which usually becomes much louder, and that
of MVP, which becomes longer and often louder. After release of the Valsalva, right-sided murmurs tend to return to baseline intensity earlier than
left-sided murmurs.
Exercise
Murmurs caused by blood flow across normal or obstructed valves (e.g., PS and MS) become louder with both isotonic and isometric (handgrip)
exercise. Murmurs of MR, VSD, and AR also increase with handgrip exercise.
Positional changes
With standing, most murmurs diminish, 2 exceptions being the murmur of HCM, which becomes louder, and that of MVP, which lengthens and
often is intensified. With brisk squatting, most murmurs become louder, but those of HCM and MVP usually soften and may disappear. Passive
leg raising usually produces the same results as brisk squatting.
Postventricular premature beat or atrial fibrillation
Murmurs originating at normal or stenotic semilunar valves increase in intensity during the cardiac cycle after a VPB or in the beat after a long
cycle length in AF. By contrast, systolic murmurs due to atrioventricular valve regurgitation do not change, diminish (papillary muscle
dysfunction), or become shorter (MVP).
Pharmacological interventions
During the initial relative hypotension after amyl nitrite inhalation, murmurs of MR, VSD, and AR decrease, whereas murmurs of AS increase
because of increased stroke volume. During the later tachycardia phase, murmurs of MS and right-sided lesions also increase. This intervention
may thus distinguish the murmur of the Austin-Flint phenomenon from that of MS. The response in MVP often is biphasic (softer then louder
than control).
Transient arterial occlusion
Transient external compression of both arms by bilateral cuff inflation to 20 mm Hg greater than peak systolic pressure augments the murmurs of
MR, VSD, and AR but not murmurs due to other causes.
Bonow et al ACC/AHA Practice Guidelines Circulation. 2006;114:e84 – e231
Brown DW. UpToDate 2016
Q.18.A 55 year old man presents with acute shortness of breath, His wife
reports that 8 days ago he had chest pain which lasted for >1 hour but
patient did not come to the hospital as he thought it was due to
indigestion and heart burn.
On examination he is cold, pulse is 110/min, BP 80/50, S3 is audible ,
but no murmur is audible, Chest; fine crackles bilaterally. Rest of the
examination was normal. His ECG shows Q wave in inferior leads
with less than 1mm ST elevation.

The best step that would be helpful in the management.

A. Give IV fluids
B. Proceed with emergent cardiac catherization as this may be an acute
silent infarct and emergent PTCA is needed.
C. Start Fibrinolytic therapy and proceed to cath lab if no resolution of
STsegment in 90 minutes.
D. Emergent bedside echocardiogram would be most helpful.
E. A CT angiogram should be arranged to exclude a large pulmonary
embolism.
• COMMENT: Expect questions of pump failure post MI. Know how to differentiae VSD from
papillary muscle rupture.

• The murmur of rupture of IVS is characterized by new harsh, holosystolic murmur that is best heard
at the lower left sternal border and is usually accompanied by a thrill.

• In severe MR a murmur may not be audible.? ( A new murmur is found in only 50% of cases:
Braunwald text book)

• On echocardiogram : rupture of IVS with an anterior infarction tends to be apical in location,

whereas inferior infarctions are associated with perforation of the basal septum and with a worse
prognosis than those in anterior location ( Braunwald ).

• Inferior wall infarction can lead to rupture of postero-medial papillary muscle which occurs more
commonly than rupture of antero-lateral muscle , a consequence of antero-lateral MI.The
posteromedial papillary muscle is typically perfused by the RCA and antero-lateral papillary has dual
blood supply. Because of dual blood supply the antero-lateral papillary muscle is less susceptible to
ischemic injury than the postero-medial papillary muscle.

• On invasive monitoring : Patients with rupture VSD show a step up in oxygen saturation in blood
sample from the right ventricle and pulmonary artery compared to those with right atrium.

• Patients with Acute MR ( papillary muscle rupture ) may show c-v wave in pulmonary capillary and
pulmonary artery pressure tracings.

• In both conditions the murmur may become softer or even disappear as arterial pressure falls.
Q.19. A 70 year old woman with six year history of diabetes mellitus and hypertension
presents with progressive exertional dyspnea for the last few months. She was born in
India and spent her childhood in different countries. She recalls being hospitalized
with recurrent infection in the past. She has chronic diarrhea and weight loss. On
examination she is a thin woman, pale, with palpable goiter. Cardiac examination
shows a heart rate of 90bpm, regular, BP: 100/60 mmHg, JVP: elevated, an extra
sound is heard just after the second heart sound. A high pitched holsystolic murmur is
heard along left lower sternal border that increases with inspiration. A systolic and a
mid diastolic murmur is also heard at the apex. Pulmonary component of the second
heart sound is loud. Chest; few basal crepts. Rest of the examination was
unremarkable.

Which of the following is likely to be responsible for her clinical signs.

A. Thyrotoxicosis
B. Primary pulmonary hypertension.
C. Pulmonary stenosis with Mitral regurgitation.
D. Aortic and Mitral stenosis with Tricupsid regurgitation.
E. Mixed mitral valve disease with Pulmonary hypertension.
• COMMENT; Expect questions on the ability to
diagnose by examination only.
Q.20. A 24 year old man with history of Insulin dependent diabetes mellitus
now presents for routine physical evaluation. On examination his pulse is
70bpm, BP: 160/90, right arm lying. Cardiac auscultation reveals an ejection
click and a harsh ejection systolic murmur in the aortic area. The murmur
radiates to the carotids, with more marked radiation on left side. There is an
additional systolic murmur audible underneath the left clavicle and posterior
on the scapular region.

Which of the following would be the next step.

A. Echocardiogram to evaluate for aortic stenosis.

B. 24 hour urine and serum for cathecholamine.
C. Serum potassium, renin and angiotensin.
D. Blood pressure measurement in the leg.
E. Renal Doppler for evaluation of renal artery stenosis.
• Note: ejection clicks usually associated with bicuspid
valve, that is not heavily calcified.
• COMMENT: expect questions of various clinical
scenario with aortic stenosis, supra valvular, sub-
valvular, Coarcatation of aorta etc.
Q.21.A 55 year old man presents to the ER with vague symptoms
of tiredness, pleuritic chest pain. He has a known history of
Hypertension, but has not taken his anti-hypertensive medication
for the last 2-3 days as he ran out of his medications. His home
medications includes: nifedipine, Lisinopril, Spironolactone,
Hydrochlorthiazide and Clonidine. On arrival his BP is 200/100.
Of the following medications which is one most likely to be
implicated for the hypertensive emergency.

A. Nifedipine
B.Lisinopril
C.Spironolactone
D.Clonidine.
E. Hydrochlorthiazide.
Q.22. A 55 year old lady presents to your office for cardiac evaluation. She has a
history of Rheumatic fever, type 2 Diabetes Mellitus and had a stroke 2 years
ago from which she has recovered completely. She recently had an episode
stuttering of speech and transient weakness of her arm, which resolved
completely within 4 hours. Cardiac examination reveals a loud 1st sound and a
mid diastolic murmur in the apical area. Rest of the cardiac examination is
unremarkable. A CT scan of the brain did not show any new findings in
comparison to old which showed few areas of small infarct.
Electrocardiogram ( ECG ) shows her to be in normal sinus rhythm with left
atrial abnormality/enlargement. All previous ECG including a 48 hour holter
shows her to be in normal sinus rhythm.

Regarding prevention of systemic embolization, what would be the best

treatment regimen for this patient.
A. Start treatment with Aspirin
B. Combination of Aspirin and Clopidogrel (Plavix )has been shown to be better
than Aspirin alone in such patients.
C. Start Aggrenox, which is a combination of Aspirin and Dipyridamole and has
been found to be superior to Aspirin alone.
D. She needs long term anticoagulation.
E. An event monitor should be arranged and anticoagulation started if patient
has any evidence of atrial fibrillation.
 MITRAL STENOSIS Bonow et al. JACC 2008;52; e1–142

Nishimura et al. JACC 2014:63:e57–185

ACC/AHA guidelines 2008

Q.23. A 75 year old man who has recently moved to a new town. He now
presents with shortness of breath and was found to be in congestive heart
failure. He has a previous history of hypertension. On arrival his BP was
190/90 mm Hg . Urine shows no proteinuria and fundal examination was
normal. He has also consumed excessive amount of alcohol during his youth.
Following chest-x-ray was obtained after acute treatment of heart failure.
Based on this Chest-X-ray what is the most likely cause of his heart failure.

A. Uncontrolled hypertension.
B. Alcoholic cardiomyopathy.
C. Previous anterior myocardial infarction.
D. Severe mitral stenosis.
E. Viral myocarditis
Q.24. A 22 year old female with intermittent self limiting palpitations. On
examination her Pulse is 70bpm, equal in both arms, BP: 160/90, right arm
lying. Cardiac auscultation reveals an ejection click and a harsh ejection
systolic murmur in the aortic area. The murmur radiates to the carotids, with
more marked radiation on left side. There is an additional systolic murmur
audible underneath the left clavicle and posterior on the scapular region.
Based on clinical examination what is the most likely diagnosis ?

A. Bicuspid aortic valve.

B. Supra-valvular aortic stenosis.
C. Sub-valvular aortic stenosis.
D. Bicuspid aortic valve with Coarctation of the Aorta.
E. Calcific aortic stenosis.
Brown DW. UpToDate 2016
Q 25. Regarding medical treatment for hypertension associated with unilateral
RAS, which statement is correct.

• A. ACE-I is contraindicated.

• B. ARB is contraindicated.

• C. Calcium channel blockers are ineffective.

• D. Beta-blockers are ineffective.

• E. ACE- I is an effective medication.

 Regarding medical treatment for hypertension associated with unilateral RAS,
which statement is correct.

• A. ACE-I is contraindicated.

• B. ARB is contraindicated.

• C. Calcium channel blockers are ineffective.

• D. Beta-blockers are ineffective.

• E. ACE- I is an effective medication.

Hirsch AT e al. ACC/AHA 2005 Guidelines for PAD.J Am Coll Cardiol 2006;47:1239-312
 .
Q.26 A 70 year old woman was admitted with pneumonia and heart failure. On
her third day of admission the nurse notices frequent runs of arrythmias
which are self limiting . Following rhythm is obtained during one of these
episodes.On your arrival her blood pressure if 110/60.

What would you do for this rhythm?

A. Administer lidocaine
B. Give metoprolol tartrate 5 mg intravenously and repeat every 6 hours
C. Coronary angiography
D. Observation
E. Intravenous magnesium