Questions 1 – 4:

An 82 year-old male presents to the hospital with the acute onset of shortness of breath. On examination he has an irregularly irregular pulse of 130, a blood pressure of 110/90, and a respiratory rate of 24. His jugular veins are distended to an estimated RA pressure of 14 and his carotid upstrokes are delayed. His chest exam reveals dullness to percussion 1/3 the way up bilaterally. His cardiac exam reveals a grade III/VI late peaking systolic ejection murmur with a normal first heart sound and a single second heart sound. His extremities reveal 1+ edema.

1. This patient’s heart rhythm is most likely to be:

1. normal sinus rhythm
2. atrial fibrillation
3. sinus rhythm with Mobitz I (Wenckebach) A-V block
4. re-entry induced paroxysmal atrial tachycardia

1. elevation of the pulmonary capillary wedge pressure
2. elevation of the right atrial pressure
3. a significant gradient across the aortic valve
4. a "dip and plateau" in the right ventricular diastolic pressure
5. absence of an oxygen saturation "step-up" between the right atrium and the pulmonary artery

1. aortic stenosis
2. aortic insufficiency
3. mitral stenosis
4. acute mitral regurgitation
5. chronic mitral regurgitation

1. Point A
2. Point B
3. Point C
4. Point D

A normal patient has a baseline pressure-volume loop shown below (labeled "Baseline").

5) The pressure-volume loop labeled "X" might be generated by:

A) giving volume

B) giving an ACE-inhibitor

C) giving a diuretic

D) giving an inotropic agent

6) The pressure-volume loop labeled "Y" might be generated by:

A) giving volume

B) giving an ACE-inhibitor

C) giving a diuretic

D) giving an inotropic agent

7) The distance "Z" (shown by the labeled double arrow) represents:

A) cardiac output

B) preload

C) afterload

D) stroke volume

E) end-systolic volume

Questions 10 - 14: Match each question with the single best answer (A - E).
 

10. Impaired diastolic filling of ventricles; jugular venous pressure with rapid "y descent"; left ventricular diastolic pressure tracing with "dip and plateau" configuration	A Constrictive Pericarditis
11. Decreased diastolic aortic pressure; increased left ventricular end-diastolic pressure; volume overload of the left ventricle; bounding peripheral pulses	B Restrictive Cardiomyopathy
12. Impaired diastolic filling of ventricles;  cyclical decrease in systolic blood pressure during inspiration; elevated jugular venous pressure without Kussmaul’s sign	C Aortic Regurgitation
13. Impaired diastolic filling of the left ventricle; loud first heart sound (S1); increased pulmonary venous pressure with occasional "reactive" pulmonary hypertension	D Cardiac Tamponade
14.  Impaired diastolic filling of the ventricles; fibrosis, scarring, or infiltration of the myocardium; normal pericardial tissue	E Mitral Stenosis

15) A patient's pulmonary capillary wedge pressure generally reflects the patient's left ventricular end-diastolic pressure. Which valvular abnormality would make the pulmonary capillary wedge pressure significantly higher than the true left ventricular end-diastolic pressure?

A) mitral stenosis

B) mitral insufficiency

C) pulmonic stenosis

D) tricuspid stenosis

E) aortic insufficiency

16) Echocardiography is an excellent, non-invasive test for assessing myocardial viability.

17) Trans-esophageal echocardiography is an excellent test to assess fine details of valvular structure and intra-cardiac thrombi and masses.

18) Thallium imaging tests are excellent at determining velocity of flow through all four heart valves.

19) Coronary angiography is very useful in detecting details of coronary artery stenoses, including detection of intra-coronary thrombi.

Questions 24 – 27:

A 52-year-old male presents to the hospital with chest pressure of two hours duration, which radiates to his left arm. On examination, his heart rate is 110 and regular, his blood pressure is 160/80 and he appears pale and short of breath. The remainder of his examination is unremarkable save for a question of rales at the bases of the lungs.

His electrocardiogram reveals ST segment elevation in the anterior leads with reciprocal ST depression in the inferior leads.

24) Reasonable pathophysiologic explanations for his rapid heart rate might include all of the following, except:

A) hypertension

B) decreased stroke volume

C) increased catecholamines

D) hypoxia (low oxygen saturation)

25) Potential complications of his condition might include all the following, except:

A) acute ventricular septal defect, several days later

B) pulmonary embolism from RV apical thrombus

C) systemic embolism from LV apical thrombus

D) cardiogenic shock

E) ventricular tachycardia

26) If this patient developed myocardial rupture several days later, one would expect to find all of the following, except:

A) a rapid "y-descent" on the jugular venous tracing

B) pulsus paradoxus

C) elevation of jugular venous pressure

D) hypotension (low blood pressure)

E) increased respiratory variability in systolic blood pressure

27) His ischemia could potentially be made worse by all the following, except:

A) decreased coronary blood flow due to thrombus

B) decreased coronary blood flow due to coronary spasm

C) decreased hemoglobin content of the blood

D) decreased contractility due to myocardial injury

E) increased heart rate in compensation for decreased stroke volume

---

A patient presents to the hospital with fatigue and peripheral edema, and is found to have very low blood pressure.

While in intensive care, the patient's arterial blood pressure is recorded and is shown below:

True or False:

28) This patient has high intrapericardial pressure

29) This patient has pulsus paradoxus > 10 mm Hg.

30) This patient is likely to have jugular venous pressure (JVP) elevation, but without inspiratory decline in JVP

31) Besides cardiac conditions, the above hemodynamic phenomenon is also encountered in patients with severe asthma

Questions 32 – 35 are TRUE or FALSE (A = True ; B = False):

Dilated cardiomyopathy is associated with:

32) A decrease in end diastolic volume

33) A decrease in stroke volume

34) Thromboembolic complications

35) High levels of angiotensin II production

Left ventricular end diastolic pressure (LVEDP) is elevated in:

36) hypertrophic cardiomyopathy

37) dilated cardiomyopathy

38) restrictive cardiomyopathy

39) mitral stenosis

40) acute myocardial infarction

41) isolated right ventricular infarction

Questions 42 – 44:

A 52-year-old male with hypertension and high cholesterol presents to the hospital with mid-sternal chest pressure and on electrocardiogram is found to have ST segment elevation in the inferior leads, with reciprocal ST depressions in the anterior leads. On examination, the patient is pale and sweaty, and has a blood pressure of 80/50 mm Hg. The jugular veins are distended to an estimated pressure of 15 mm Hg, and the lung fields are clear.

42) The most likely cause for the patient's low blood pressure is:

A) Cardiac tamponade

B) Acute ventricular septal defect

C) Acute papillary muscle rupture

D) Right ventricular infarction

E) Acute pericarditis

43) All the following tests might help with the diagnosis, except:

A) Right precordial (right chest) EKG leads

B) A bedside echocardiogram

C) Right heart catheter placement with pressure measurement

D) A resting Thallium imaging study

E) A cautious trial of intravenous fluids

44) Pathophysiologically, one would expect the patient's:

A) Left ventricular end-diastolic pressure to be high

B) Jugular venous distention to increase with inspiration

C) Anterior portion of the left ventricle to be hypokinetic (decreased contraction)

D) Pulmonary capillary wedge pressure to be high

E) Left ventricular stroke volume to be low
 

45) The magnitude of the resting membrane potential in normal myocardial cells is determined by:

1. the concentration gradient of Na⁺
2. the concentration and electrostatic gradients of potassium
3. the concentration and electrostatic gradients of calcium
4. the threshold potential

1. Phase 0
2. Phase 1
3. Phase 2
4. Phase 3
5. Phase 4

1. Right bundle branch block
2. Acute myocardial infarction
3. Left bundle branch block
4. Left ventricular hypertrophy

1. altered automaticity
2. impaired conduction
3. bradycardia
4. triggered activity

1. atrial flutter
2. atrial fibrillation
3. ventricular tachycardia
4. ventricular fibrillation

A patient with hypertrophic obstructive cardiomyopathy undergoes several maneuvers.

Indicate the effect of each maneuver on the systolic murmur.
 

50.	Valsalva Maneuver	Increased Decreased No change
51.	Standing up	Increased Decreased No Change
52.	Exercise	Increased Decreased No change
53.	Amyl nitrate administration	Increased Decreased No change
54.	Hypovolemia	Increased Decreased No change
55.	Isometric Handgrip	Increased Decreased No change
56.	Squatting	Increased Decreased No change

 

Questions 57 - 62: For the following two Frank-Starling relationships, please answer the following True/False questions:

58) In order to move from point B on the lower curve to point C on the upper curve one could administer a positive inotropic agent.

59) A patient with an acute myocardial infarction whose hemodynamics fall into quadrant III is said to be in "cardiogenic shock".

60) A patient in either quadrant III or quadrant IV is in "pulmonary edema".

61) The patient whose hemodynamic profile is shown on the lower curve has normal left ventricular function.

62) Patients with acute myocardial infarction who fall into quadrant I have an early mortality rate of less than 10%.

63) True statements regarding the pathological time course in acute myocardial infarction include all the following, except:

1. Yellow softening from resorption of dead tissue by macrophages generally occurs within two days of the infarction
2. Fibrosis and scarring generally occurs by two months after infarction
3. Irreversible cellular injury usually occurs within 20-30 minutes of the onset of the infarction
4. ATP levels fall and regional systolic function drops within one to two minutes of the onset of the infarction
5. Coagulation necrosis generally occurs within 24 hours of the onset of infarction

1. This patient's infarction is likely to cause A-V nodal ischemia/injury and this may lead to 1^st, 2^nd. or 3^rd degree heart block
2. This patient's infarction may lead to necrosis of the postero-medial papillary muscle, which may lead to acute mitral regurgitation
3. This patient's infarction is likely to cause a new left bundle branch block due to extensive involvement of the His-Purkinje system
4. This patient's infarction is likely to lead to hypotension with elevated neck veins if the right ventricle is involved in the infarction
5. This patient's infarction is likely to lead to bradycardia due to involvement of the sino-atrial (SA) node

1. Dysfunctional endothelium has impaired release of endogenous vasodilator substances, which may lead to local vasoconstriction
2. Dysfunctional endothelium has increased release of EDRF-NO and prostacyclin, which may lead to an increased anti-platelet effect
3. Unstable coronary plaques often manifest plaque fissuring, which may lead to platelet aggregation at the edges of the plaque
4. Macrophages play an important role in the pathophysiology of soft plaques
5. Fatty streaks often occur in young individuals and have been demonstrated at post-mortem examination of 20 year olds

 

 
 
 

---