CARDIOVASCULAR PATHOPHYSIOLOGY

CARDIOVASCULAR PATHOPHYSIOLOGY FINAL EXAM - 9/24/96

1. Select the cardiac condition usually associated with reduced left ventricular systolic function.
A) Constrictive pericarditis

B) Dilated cardiomyopathy

C) Hypertrophic cardiomyopathy

D) Mitral stenosis

2. Acute inferior myocardial infarction is commonly associated with all of the following complications except:

A) Right ventricular infarction

B) Mobitz I second degree AV block

C) Left ventricular apical thrombus formation

D) Ventricular tachycardia

E) Hypotension (low blood pressure) associated with JVD and clear lung fields

3. Acute anterior myocardial infarction is commonly associated with all of the following complications except:

A) Sinus bradycardia

B) Ventricular tachycardia

C) Pulmonary edema (pulmonary congestion)

D) Left bundle branch block

E) Left ventricular apical thrombus formation

4. Select the least common pathophysiologic mechanism involved in acute myocardial infarction from the following:

A) Coronary plaque fissuring

B) Platelet aggregation

C) Local thrombus formation

D) Intraplaque hemorrhage

E) Coronary embolization

Questions 5 - 6:

A 64-year-old woman presents to the hospital complaining of shortness of breath which has progressed over three days. Her heart rate is 150 beats per minute and is irregularly irregular. Rales are present over the bases of both lung fields and a late diastolic rumble is heard on auscultation at the apex. An opening snap is heard immediately after the second heart sound. 5. Pathophysiologically, the most likely cause for her valvular heart disease is:

A) Rheumatic deformity of the mitral valve

B) Myxomatous degeneration of the mitral valve

C) Dilation of the ascending aorta from long-standing hypertension

D) Bacterial endocarditis involving the mitral leaflets

E) Bacterial endocarditis involving the aortic leaflets

6. Pathophysiologically, the mechanism of this patient’s arrhythmia is:

A) A large single re-entry circuit within the right atrium

B) Increased automaticity of both atria

C) AV nodal re-entry

D) Multiple small sites of re-entry in the atria

E) Re-entry through an accessory pathway

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Questions 7 - 11: Match each question with the single best answer (A - E).

7. Impaired diastolic filling of ventricles; jugular venous A) Constrictive pericarditis

pressure with rapid "y descent"; left ventricular

pressure tracing with "dip and plateau" configuration B) Restrictive cardiomyopathy

8. Impaired diastolic filling of left ventricle; systolic

anterior motion of the mitral valve; systolic murmur C) Hypertrophic cardiomyopathy

which accentuates with standing up

9. Impaired diastolic filling of ventricles; cyclical D) Cardiac tamponade

decrease in systolic blood pressure during inspiration;

elevated jugular venous pressure without Kussmaul’s sign E) Mitral stenosis

10. Impaired diastolic filling of the left ventricle; loud first

heart sound (S1); increased pulmonary venous pressure

with occasional "reactive" pulmonary hypertension

11. Impaired diastolic filling of the ventricles; fibrosis, scarring,

or infiltration of the myocardium; normal pericardial tissue

12. Tetralogy of Fallot is a constellation of four associated anomalies:

A) Ventricular septal defect; pulmonic insufficiency; transposition of the great vessels; right ventricular hypertrophy

B) Atrial septal defect; tricuspid stenosis; right ventricular hypertrophy; Eisenmenger’s syndrome

C) Ventricular septal defect; infundibular, valvular or supravalvular pulmonic stenosis; an anteriorly displaced aorta that receives blood flow from both ventricles; right ventricular hypertrophy

D) Atrial septal defect; pulmonic stenosis; right ventricular hypertrophy; an anteriorly displaced aorta that receives blood flow from both ventricles

E) Ventricular septal defect; pulmonary atresia; left ventricular hypertrophy; left atrial enlargement

13. Eisenmenger’s syndrome occurs when: A) A congenital membranous VSD spontaneously closes around 12 months of age

B) RV compliance exceeds LV compliance, resulting in a right-to-left shunt

C) Atrial fibrillation occurs in Tetralogy of Fallot

D) Pulmonary hypertension from the chronic shunt overload leads to right-to-left shunting

E) A cleft mitral valve occurs in association with a VSD

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Questions 14 - 18: Match each question with the single best answer (A - E):

14. Imaging technique most effective in determining A) Resting thallium nuclear

precise anatomical coronary artery information imaging

15. Imaging technique most useful in visualizing valvular B) Exercise and resting

and sub-valvular structures thallium nuclear imaging

16. Imaging technique most useful in determining severity C) 2-D echocardiography

of valve stenoses non-invasively

D) Doppler examination

17. Imaging technique most useful in determining severity during 2-D

of coronary stenoses non-invasively echocardiography

18. Imaging technique most useful in determining E) Cardiac catheterization

myocardial viability non-invasively (coronary angiography)

Questions 19 - 23: Match each question with the single best answer (A - E).

19. {Pressure x Radius} / {2 x wall thickness} A) Preload

measured during systole

B) Afterload

20. {Pressure x Radius} / {2 x wall thickness}

measured during diastole C) Wall tension

21. {Pressure x Radius} / {2 x wall thickness} D) Compliance

measured at any point in time

E) Stiffness

22. Change in pressure / Change in volume

23. Change in volume / Change in pressure

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EKG/Arrhythmia questions

24. Rhythms with a heart rate < 60/min are known as:

A) Triggered early after depolarizations

B) Bradyarrhythmias

C) Reentrant rhythms

D) Tachyarrhythmias

25. All of the following are necessary for reentrant tachyarrhythmias except:

A) Unidirectional block

B) Slowed retrograde conduction

C) AV nodal suppression

D) Pathways with differing conduction properties

26. Which of the following is characteristic of a right bundle branch block (RBBB)?

A) Large Q wave in lead V₁

B) RSR¢ complex in lead V₁

C) ST elevation in lead V₆

D) AV dissociation

27. Prolongation of this interval can lead to "torsade de pointes" rhythm

A) QT interval

B) PR interval

C) QRS interval

D) TP interval

28. For cells with automaticity, which of the phases of the cardiac action potential determines the rate of firing? A) Phase 1

B) Phase 2

C) Phase 3

D) Phase 4

29. Which of the following rhythms requires immediate treatment with a device that can deliver electrical energy? A) Asymptomatic sinus bradycardia at 55/min

B) Ventricular fibrillation

C) Left bundle branch block

D) 1° AV block

30. A "saw-tooth" pattern of atrial activity is seen in:

A) Ventricular tachycardia

B) Mobitz II heart block

C) Atrial flutter

D) Sinus tachycardia

31. PR segment depression is often seen in:

A) Pericarditis

B) Right bundle branch block

C) Wolf-Parkinson-White pre-excitation

D) Anterior wall myocardial infarction

32. Tachyarrhythmias may be harmful for all of the following reasons except:

A) Decreased coronary perfusion time

B) They require a pacemaker

C) Increased myocardial oxygen demand

D) Some have the potential to degenerate into ventricular fibrillation

33. AV dissociation means that

A) The atria and ventricle are depolarizing independently

B) There is delayed but preserved conduction of impulses from atria to ventricles

C) The QRS interval is prolonged

D) A U wave is present

Nuclear Cardiology questions

34. A 90% stenosis of the left anterior descending coronary artery should produce myocardial perfusion defect(s) in the: A) Anterior and septal walls

B) Inferior and inferolateral walls

C) Posterior wall

D) Right ventricle

35. In which of the following cases must a stress nuclear cardiology study, as opposed to a standard ECG exercise stress test, be used to diagnose coronary disease? A) A 20-year-old female with a normal baseline ECG

B) A 55-year-old male following a myocardial infarction

C) A 56-year-old male with chest pain and a left bundle branch block

D) A 50-year-old male with three-vessel disease and a normal baseline ECG

36. For patients who are unable to exercise, pharmacologic myocardial perfusion imaging can be performed using which of the following: A) Nitroglycerin

B) Propranolol

C) Nifedipine

D) Dipyridamole

37. (End-diastolic volume - end-systolic volume) ¸ end-diastolic volume =

A) Preload

B) Cardiac output

C) Ejection fraction

D) Diastolic blood pressure

E) Stroke volume ratio

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Valvular Heart Disease Questions 38 - 42: Match the following cardiac lesions with the bedside physical and auscultatory findings described below.

38. Valvular aortic stenosis A) Brisk carotid upstrokes, normal S1, early

peaking systolic ejection murmur, soft S2,

39. Hypertrophic cardiomyopathy diastolic blow at left sternal border which

with obstruction increases with squatting, soft diastolic rumble at

the apex

40. Chronic aortic insufficiency

B) Brisk, bifid carotid upstrokes, prominent S4

41. Atrial septal defect with left to gallop, normal S1, mid-to-late peaking systolic

right shunting ejection murmur which increases in intensity

from squatting to standing, normal S2

42. Severe mitral stenosis with

with pulmonary hypertension C) Normal carotid upstrokes, increased S1, short

systolic murmur at left sternal border, increase

P2, A2-OS interval of 0.08 sec, long diastolic

rumble at the apex

D) Normal carotid upstrokes, normal S1, systolic murmur at left sternal border and the base, widely split S2, short diastolic rumble at the apex

E) Diminished carotid upstrokes, prominent S4, mid-to-late peaking systolic ejection murmur at the base radiating to the carotids, single S2

******************************************************************************** 43. Endocardial ischemia occurs prior to epicardial ischemia due to: A) Less collateral supply

B) Higher MVO₂ of the endocardium

C) Less systolic coronary flow in the endocardium

D) More shortening performed by endocardial myocytes

D) All of the above

44. Which of the following is not associated with acute myocardial infarction A) EKG with ST segment elevation

B) Atherosclerotic plaque rupture

C) Sharp left-sided chest pain worse with inspiration

D) Thrombotic occlusion of coronary artery

D) Wavefront evolution of myocardial necrosis

45. All of the following are associated with hypertrophic cardiomyopathy except:

A) Myocyte hypertrophy with myocardial fiber disarray

B) Increased myocardial oxygen consumption

C) Impaired left ventricular filling

D) Fixed outflow tract obstruction

E) Elevated left atrial pressure

Questions 46 - 52: Ventricular volume and/or pressure overload can occur in many different valvular, congenital and cardiomyopathic disease states, often leading to compensatory ventricular hypertrophy. What is the primary overload pattern for each of the following conditions?

46. Hypertrophic cardiomyopathy with obstruction A) LV volume overload

47. Dilated cardiomyopathy B) LV pressure overload

48. Congenital atrial septal defect with C) RV volume overload

left to right shunting

D) RV pressure overload 49. Congenital ventricular septal defect

with left to right shunting

50. Chronic rheumatic mitral insufficiency

51. Chronic rheumatic mitral stenosis

52. Tricuspid insufficiency

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53. Acute myocardial infarction can be complicated by acute mitral regurgitation secondary to papillary muscle rupture. This catastrophic event most commonly occurs:

A. Within the first few hours of MI, due to hemorrhage/edema in the papillary muscle.

B. As a result of necrosis of the anterolateral papillary muscle head.

C. Several days after MI, due to rupture of the posteromedial papillary muscle.

D. Several weeks after MI, due to yellow softening of the papillary muscle.

E. Following the administration of thrombolytic therapy, which may result in hemorrhagic myocardial necrosis.

Bonus Essay Question:

The hemodynamic hallmark of valvular stenosis is the pressure gradient across the valve. The resting gradient in severe valvular aortic stenosis is 10X greater than in severe mitral stenosis. Give two or three reasons why this is so. In addition, describe the relationship between the gradient and the progression of symptoms for the patient with varying degrees of mitral stenosis and contrast than to the patient with aortic stenosis. Essay Answer

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