COMBINED CARDIAC PATHOPHYSIOLOGY,
PHARMACOLOGY & PATHOLOGY EXAM
Questions 1 - 9:
A 54 year old male presents to the hospital with progressive symptoms of shortness of breath. Physical examination reveals a systolic heart murmur and lung findings consistent with congestive heart failure. An echocardiogram is performed and reveals a significant cardiac structural abnormality.
For further diagnosis, a cardiac catheterization is performed, and the following tracing is obtained while pulling back the catheter from the left ventricular apex to the aorta:
A) mitral stenosis
B) aortic stenosis
C) hypertrophic cardiomyopathy with
D) pulmonic stenosis
E) coarctation of the aorta
Questions 2 -
Questions 2 - 7:
Please indicate (true or false), whether each of the following is associated with this patient’s condition:
2. Impaired systolic
3. Impaired diastolic
4. Increased risk of sudden cardiac death
5. Mitral regurgitation
6. Delayed and diminished carotid upstrokes
7. Reduction of heart murmur intensity with standing up
Annotated answers to Questions 1 - 9:
This case represents a
classic case of hypertrophic cardiomyopathy with outflow tract obstruction, in
which a gradient is seen between the
This condition is associated with
normal to hypernormal systolic function with impaired
Delayed and diminished carotid pulses (pulsus “parvus et tardus”) are associated with aortic stenosis.
ANSWERS: 1. C 2. B 3. A 4. A 5. A 6. B 7. B
The following sets of tracings are obtained before and after an intervention:
8. The most likely intervention to cause this change in pressures was:
A) Valsalva maneuver
C) Passive leg raising
D) Volume infusion with normal saline
This same patient develops palpitations and lightheadedness. An EKG reveals rapid atrial fibrillation with a ventricular response rate of 130 beats per minute.
9. All of the following medications may help slow his heart rate, except:
E) A beta-blocker
Answers to Questions 9 & 10: 9. A 10. A
10. The best drug to use for rapidly controlling the ventricular response in a patient with new onset atrial fibrillation is:
11. Which of the following statements best describes the normal conduction of electrical impulses through the AV node?
A) Transmembrane calcium currents are responsible for activation of AV nodal cells, resulting in relatively slow conduction, in comparison to working ventricular myocytes.
B) Transmembrane sodium currents are responsible for activation of AV nodal cells, resulting in relatively slow conduction, in comparison to working ventricular myocytes.
C) Parasympathetic stimulation has little effect during the resting state on the behavior of AV nodal cells
D) Sympathetic stimulation has little effect during the resting state on the behavior of AV nodal cells
12. The mechanism responsible for the majority of pathologic clinical cardiac arrhythmias is:
A) Intramyocardial reentry due to functionally-based circuits.
B) Intramyocardial reentry due to anatomically-based circuits.
C) Triggered activity due to delayed afterdepolarizations.
D) Triggered activity due to early afterdepolarizations.
E) Abnormal automaticity
13. The major antiarrhythmic actions of digitalis are due to:
A) Sympathetic blockade
B) Inhibition of the Na/K ATPase pump
C) Parasympathomimetic actions
D) Improvement in ventricular function resulting from its positive inotropic effects.
14. Which of the following agents should never be used to treat atrial fibrillation in a 50 year old man who experienced myocardial infarction 5 years previously:
15. Development of a prolonged QT interval and torsade de pointes is unlikely to occur with which of the following antiarrhythmic agents?
Questions 16 - 22:
A 75 year-old Middle Eastern female presents to the hospital with progressive fatigue, abdominal swelling and ankle edema. She has gained over 25 pounds over the last month, and has been sleeping in a recliner chair.
The patient relates a remote history of tuberculosis, which has been treated and “eradicated”.
On examination, her jugular veins are distended, her lung fields are clear, and she has evidence of ascites and peripheral edema.
Right heart catheterization is
performed and the following tracings are obtained (RA = right atrium; RV = right
The patient is likely to manifest each of the following features:
( A/True or B/False ):
16. Kussmaul’s sign
17. Pulsus paradoxus
18. Equalization of diastolic pressures
19. Auscultatory finding of a pericardial “Knock”
20. Reduced forward cardiac output
21. Calcification of the heart border on Chest X-ray
22. Reduced left ventricular systolic function
Q. 16 – 22: This is a classic case of a patient with
constrictive physiology – rapid y descent on the RA tracing, and equalization of
Pericardial constriction is associated with all of the following:
A pericardial knock
Equalization of diastolic pressures
Rapid y descent
Reduced cardiac output due to decreased
Calcification of the heart border on chest X-ray
It is usually not associated
with pulsus paradoxus, and
16 – A
17 – B
18 – A
19 – A
20 – A
21 – A
22 – B
Questions 23 - 31:
A forty five year old male with history of hypertension, high cholesterol and cigarette smoking presents to the emergency room with severe mid-sternal chest “heaviness”, radiating to his neck and arms, of one hour’s duration.
An electrocardiogram reveals ST-segment elevation in the inferior leads.
On examination, the patient’s pulse is slow, 50 beats per minute, and the blood pressure is mildly reduced, at 90/60 mm Hg.
23. Causes of this patient’s bradycardia (slow heart rate) might include all of the following, except:
A) a re-entry circuit within the left ventricle
B) sinus node ischemia
C) A-V node ischemia, causing Mobitz I (Wenckebach) 2nd degree block
D) Increased vagal (parasympathetic) tone
E) A-V node ischemia, causing 3rd degree AV block with a junctional escape rhythm
24. The most likely major contributing cause to this patient’s low blood pressure at the present time is:
A) Acute mitral regurgitation from papillary muscle rupture
B) Acute right ventricular infarction, causing decreased
C) Significant left ventricular
infarction, causing markedly reduced
D) Acute ventricular septal rupture
E) Pericardial tamponade from
25. All of the following statements about this patient’s acute myocardial infarction are true, except:
A) the “ischemic cascade” starting at the onset of his myocardial infarction includes diastolic dysfunction, systolic dysfunction, EKG changes and chest pain
B) the myocardial infarction proceeds in a “wavefront” manner, proceeding from epicardium to endocardium
C) systolic dysfunction caused by the infarction may lead to further ischemia by decreasing coronary perfusion pressure
D) diastolic dysfunction caused by the infarction may lead to increased wall tension and decreased oxygen delivery to the myocardium
E) sympathetic stimulation due to the pain of the infarction may increase myocardial oxygen demand (MVO2)
Several days after the patient’s initial myocardial infarction, the patient develops worsening shortness of breath and is noted to have a new, harsh systolic murmur. Right heart catheterization reveals the following findings:
Pressure (mm Hg)
Pulmonary Capillary Wedge
V-waves to 50
26. This patient’s echocardiogram might be expected to show:
A) Acute mitral regurgitation
B) Acute ventricular septal defect
C) Acute right ventricular infarction
D) Cardiac tamponade
27. Treatment of the patient at this time might include all of the following, except:
A) administration of thrombolytic therapy
B) emergency cardiac catheterization
C) placement of an intra-aortic balloon pump
D) surgical consultation for possible open-heart surgery
E) vasodilatory drugs to augment forward cardiac output
28. Intra aortic balloon pump placement may do all of the following, except:
C) Increase coronary blood flow
D) Reduce myocardial oxygen demand
E) Increase cardiac output
Unfortunately, despite your team’s best medical efforts, the above patient dies of congestive heart failure. The following photograph shows a cross-section of the patient’s right coronary artery. Please answer the questions below the photo.
29. The object indicated by the oval is:
A) the central core of an atherosclerotic plaque
B) a thrombus occluding the lumen of the artery
C) a large calcium deposit in a thickened intima
30. The rectangle is positioned in:
A) a thrombus occluding the lumen of the artery
B) a large calcium deposit
C) the central core of an atherosclerotic plaque
31. The arrow points to:
A) the media
B) the intima, which in that location is uninvolved
C) the adventitia
Questions 32 - 37:
A patient presents to the hospital with an acute anterior myocardial infarction associated with congestive heart failure. A right heart catheterization is performed in the CCU.
This patient’s Frank Starling curve is represented below as the lower of the two curves below.
Please answer the next TRUE or FALSE questions based on this diagram (A = TRUE; B = FALSE).
32. This patient’s prognosis is worse if he is on point A rather than point B on the curve.
33. This patient can be moved from point B to point C by administering fluids.
34. This patient can be moved from point A to point B by administering fluids.
35. Patients falling into Quadrant IV have a mortality rate of less than 30 percent.
36. Patients falling into Quadrant III usually have pulmonary congestion and a normal blood pressure.
37. Patients in Quadrant II have the worst prognosis of all.
32. True – Point B is located in quadrant I, and confers a better prognosis than Quadrant II
33. False – B to C is accomplished via inotropic drugs
35. False – mortality in this group is greater than 80% treated medically, and ~50% treated with primary intervention.
37. False – patients in Quadrant IV have the worst prognosis.
Answers: 32. A 33. B 34. A 35. B 36. A 37. B
Questions 38 - 40:
A 48-year-old Saudi Arabian female with a history of rheumatic fever at age 20 presents to the office with progressive fatigue and dyspnea on exertion. Physical examination reveals:
Heart rate: 90, regular; Blood Pressure: 120/70; Respirations: 18
Neck: 8 cm JVD with prominent jugular V-waves; normal carotid upstrokes
Chest: Fine rales at the bases
Cor: Prominent S1, increased pulmonic component of S2; high-pitched snap shortly after S2; soft, II/VI systolic blowing murmur at the left sternal border, increasing with inspiration; soft diastolic rumble with pre-systolic accentuation
Extremities: trace edema; no cyanosis
38. One would expect that this patient’s valvular abnormalities would include:
A) Mitral stenosis and tricuspid insufficiency
B) Aortic insufficiency and mitral regurgitation
C) Aortic stenosis and mitral regurgitation
D) Mitral stenosis and aortic insufficiency
E) Hypertrophic cardiomyopathy with outflow tract obstruction
39. On echocardiography, one would expect that this patient’s left ventricle would demonstrate:
A) Concentric left ventricular hypertrophy
B) Cavity dilation and global left ventricular hypokinesis
C) Normal cavity size and normal left ventricular function
D) Discrete sub-aortic septal hypertrophy
40. Cardiac catheterization might demonstrate a gradient between which two pressures:
A) Left ventricular and pulmonary capillary wedge pressure during diastole
B) Ascending aortic pressure and left ventricular pressure during systole
C) Right atrial and right ventricular pressure during diastole
D) Right ventricular and pulmonary artery pressure during systole
Q. 38 – 40:
This is a somewhat difficult question, in which a patient with a remote history of rheumatic fever develops mitral stenosis, leading to right heart failure and secondary tricuspid regurgitation.
The clues to these diagnoses are:
Systolic blowing murmur which accentuates with inspiration indicates tricuspid regurgitation. Also, the prominent jugular V-waves indicate TR. The diastolic rumble with pre-systolic accentuation is classic for mitral stenosis.
Despite the signs of
right heart failure, the left ventricular function in mitral stenosis is usually
normal. There is a gradient between the
41. An 82 year-old woman presents to the Emergency Room with a history of new-onset syncope. Upon arrival, she is awake and oriented and has a small laceration on her forehead. Her blood pressure is 165/86 mmHg and her heart rate is 43 beats /minute. She is receiving unknown medications for chest discomfort provoked by exertion and relieved by rest. Which of the following combinations of drugs would most likely explain this patient’s presentation?
A) Diltiazem, nitroglycerin spray
B) Verapamil, Atenolol, Isosorbide dinitrate
C) Nifedipine, Isosorbide Mononitrate patch
D) Amlodipine, sublingual nitroglycerin
42. Indicate which of the choices below describes the effects of a competitive antagonist on drug ED50 and efficacy.
A) A decrease in ED50 with no change in efficacy
B) A decrease in ED50 and a decrease in efficacy
C) No change in ED50 and a decrease in efficacy
D) An increase in ED50 and no change in efficacy
E) An increase in ED50 and an increase in efficacy
43. An example of a ligand-gated receptor:
A) Muscarinic receptor
B) b-1 receptor
C) Nicotinic receptor
D) b-2 receptor
E) a-1 receptor
44. Indicate which of the drugs below has the greatest potency for producing ganglionic blockade:
D) Pralidoxime (2-PAM)
45. Indicate which of the agents below is used most often to help diagnose myasthenia gravis:
46. All of the following statements regarding neuromuscular blockers are correct EXCEPT:
A) Atracurium is a competitive blocker
B) Succinycholine-induced blockade can be reversed by acetylcholinesterase inhibitors
C) Anesthesia with halothane enhances competitive blockade
D) Competitive blockers do not cross the blood-brain barrier
E) Atracurium-induced blockade can be reversed by acetylcholinesterase inhibitors
47. When a partial agonist is administered together with a full agonist, the response will be less than that achieved compared to when the full agonist is given alone.
48. Following peripheral administration of the two drugs, neostigmine has better access to the brain compared to physostigmine.
49. For receptor binding of a ligand to a receptor measured in the test tube, a linear plot of ligand bound on the y-axis vs. a linear plot of ligand concentration on the x-axis produces a sigmoid (S-shaped) curve.
50. Drug A has a lower ED50 compared to Drug B for a specific response. Therefore
Drug A has a greater potency compared to Drug B for this response.
51. All G-protein coupled receptors produce their cellular responses by altering cyclic AMP levels in the cell.
Mr. Mucho Regurgitation has
recently had a successful mitral valve
replacement operation for severe mitral regurgitation. His
echocardiogram 3 months after his open-heart surgery showed a good
functioning prosthetic mitral valve, but an enlarged left ventricle with
an ejection fraction of 35% and global hypokinesis. He does not complain
of any symptoms of heart failure, and is walking daily with a very good
52. Which of the following drugs
would be expected to
have the SMALLEST or NO benefit on his long term survival?
E. Sustained Release Metoprolol
53. Which of the following statements regarding the cholinergic system is correct?
A. Acetylcholine is the transmitter released by postganglionic sympathetic neurons
B. The most important mechanism for removal of acetylcholine from the synaptic cleft is enzymatic metabolism
C. Stimulation of the M2 muscarinic receptor in the heart leads to increased myocardial contractility
D. Administration of methacholine is likely to produce bronchodilation in a patient with asthma
E. Only two muscarinic receptor types (M1 and M2) are known to exist in humans
54. A 70 year-old man has slowing of conduction in his atrioventricular (AV) node resulting in a significant reduction in his ventricular rate and hypotension. Given this information, which of the following medications would be most appropriate for this patient?
55. Parasympathomimetic drugs are categorized as either direct-acting or indirect-acting. Which of the following statements is correct?
A) Pilocarpine is an example of an indirect-acting parasympathomimetic drug
B) A direct-acting parasympathomimetic drug works by directly blocking the muscarinic receptor on the target organ
C) An indirect-acting parasympathomimetic drug works by decreasing the breakdown of acetylcholine
D) Donepezil (Aricept) is an example of a direct-acting parasympathomimetic drug
E) Both direct- and indirect-acting parasympathomimetic drugs are approved for the treatment of gastrointestinal hypermotility
56. Which of the following statements is correct regarding the autonomic nervous system?
A) The sympathetic nervous system arises primarily from craniosacral outflow tracts
B) The division of the autonomic nervous system activated in response to emotional and physical stress is called the parasympathetic nervous system
C) The primary catecholamine released by chromaffin cells in the adrenal medulla is epinephrine
D) Nicotine is the neurotransmitter released by preganglionic neurons
E) The neurotransmitter released by postganglionic parasympathetic neurons is norepinephrine
A 24 year old man arrives at the emergency room after taking an overdose of amphetamines. His blood pressure is 180/100 and his heart rate is 120.
57. What is the mechanism of his hemodynamic changes?
A) Direct effects of amphetamine on alpha-1 and beta-1 receptors.
B) Increased stimulation of presynaptic alpha-2 receptors.
C) Increased release of norepinephrine into the synaptic cleft.
D) Inhibition of reuptake of norepinephrine from the synaptic cleft.
A 70 year old man is being started on terazosin for symptoms related to his benign prostatic hyperplasia. He has no other medical diagnoses.
58. Which of the following adverse effects should you warn him about?
A) Dizziness caused by low blood pressure
B) Excessively slowed heart rate caused by direct effects on the SA node
C) Constipation caused by relaxation of GI smooth muscle
D) Shortness of breath caused by bronchoconstriction
All available beta-adrenergic antagonists block beta-1 receptors but their administration may result in different therapeutic or adverse outcomes due to additional properties.
59. Which of the following is INCORRECT?
A) Due to its blockade of beta-2 receptors, propranolol should not be administered to patients with asthma.
B) Intrinsic sympathomimetic activity (ISA) of pindolol causes a relative increase in resting heart rate during sleep.
C) Concurrent blockade of alpha-2 receptors by carvedilol increases the likelihood of hypotension with the drug.
D) While membrane-stabilizing activity is a characteristic of propranolol, it is not apparent at therapeutic doses.
60. An 85 year old man with Alzheimer's Disease is given donepezil. Which of the following should you anticipate as an adverse effect of the drug?
B) Urinary incontinence
C) Dry eyes
D) Sinus tachycardia
61. Which of the following statements is correct regarding the parasympathetic nervous system?
A) Acetylcholine is synthesized in the postganglionic neuron and is released passively into the synaptic cleft.
B) Activation of presynaptic M1 receptors decreases release of acetylcholine into the synaptic cleft.
C) Removal of acetylcholine from the synaptic cleft is primarily through reuptake and the process is inhibited by cocaine.
D) Stimulation of M3 receptors in the heart result in decreased calcium permeability and slowing of heart rate and AV nodal conduction.
62. A 6 year old child is seen in the emergency room and has signs of severe organophosphate poisoning after ingesting an unknown quantity of pesticide. Which of the following statements is correct?
A) Organophosphates are classified as irreversible cholinesterase inhibitors.
B) Atropine improves symptoms in patients with organophosphate poisoning by increasing production of acetycholinesterase.
C) Respiratory muscle fatigue and paralysis are effectively treated with high doses of atropine.
D) Due to its toxicity profile, pralidoxime should be withheld for the first 24 hours.
63. A 52 year-old male presents to your office with complaints of exertional chest pressure, which occurs either with physical activity or with emotional upset. You diagnose him with angina pectoris and initiate treatment.
Therapy for angina may work by all of the following mechanisms, except:
A) reducing preload, thereby decreasing wall stress, decreasing MVO2
B) reducing heart rate, thereby reducing MVO2
C) reducing blood pressure, thereby reducing wall stress, decreasing MVO2
D) dilating coronary arterioles, thereby increasing coronary blood flow
E) increasing contractility, thereby increasing coronary blood flow
64. For which of the following anti-anginal agents has a secondary prevention benefit been demonstrated?
A) Isosorbide dinitrate
B) Sublingual nitroglycerin
65. The mechanism of action of ranolazine is:
A) Reduces blood pressure and therefore myocardial oxygen consumption
B) Reduces both heart rate and blood pressure and therefore reduced myocardial oxygen consumption
C) Increases coronary blood flow
D) Is unknown but may involve glucose metabolism
66. As part of the patient’s treatment, anti-platelet therapy is also administered. Which of the following agents interferes with the binding of ADP to its platelet receptor?
Questions 67 - 71:
A 35 year old female presents to the hospital four weeks after delivering her second child, with signs and symptoms of congestive heart failure. Left ventricular ejection fraction is measured at 25% by bedside echocardiography. Regarding her diagnosis of cardiomyopathy:
67. Ischemic cardiomyopathy and non-ischemic cardiomyopathy have all of the following features in common, except:
A) Decreased left ventricular compliance
B) Decreased left ventricular systolic function
C) Compensatory left ventricular dilation
D) Compensatory increase in circulating catecholamines
E) Diffuse sub-epicardial left ventricular necrosis
68. In patients such as this, one is likely to find all of the following, except:
A) Pulsus alternans
D) Coolness of the extremities
E) Pulsus paradoxus
This patient is represented by the Pressure-Volume loop shown above, labeled “Baseline”:
69. 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
70. The patient may have gone from the loop labeled “X” to her current “baseline” by:
A) Giving volume
B) Giving an inotropic drug
C) Giving a diuretic
D) Giving an ACE-inhibitor
E) Giving hydralazine
The distance “Z” may be increased by doing all of the following, except:
A) Increasing only contractility
B) Increasing only afterload
C) Increasing only preload
D) Giving an ACE-inhibitor
In the photo below, the fetal heart has been rotated to the right.
Answer true (A) or false (B) for each of the following questions about the structure marked with a white square. (1 point each)
In a normal fetus, it carries well-oxygenated blood, a large portion of which enters the aortic arch and supplies blood flow to the brain. B
Postnatally, in the presence of certain cardiovascular anomalies prostaglandin is given to maintain patency. A
In a normal fetus, the amount of blood flow through this structure is only 25% as great as flow through the pulmonary arteries. B
Answer true (A) or false (B) for the following statement: (1 point)
the features which differentiates the left ventricle
from the right ventricle is a smooth upper septal surface with no attached chordae tendineae. A
The lesion illustrated above was on the extremity of an infant. Microscopically it showed aggregates of thin-walled capillaries, closely packed and lined by endothelium. No capsule was present. Which of the following is a correct statement regarding this lesion? (3 points)
A) Though this patient was an infant, this entity is most common in middle age
B) This is the most common vascular tumor and can present as a “strawberry type” in newborns
C) The lesion is always flat with no elevation
D) These lesions occur only in skin and mucous membranes
Answer true (A) or false (B) for each of the following statements. (1 point each)
Dilated cardiomyopathy and myocarditis are entirely unrelated entities. B
Myocardial disarray is a microscopic feature of hypertrophic
causes of dilated cardiomyopathy is chronic consumption of alcohol. A
Lymphocytic myocarditis is usually secondary to drug hypersensitivity. B
Which of the following vasculitides is not associated with antineutrophil cytoplasmic antibodies (ANCA)? (1 point)
A) Polyarteritis nodosa
B) Churg-Strauss syndrome
C) Wegener granulomatosis
D) Microscopic polyangiitis
Match the region of the heart with the coronary vessel supplying oxygenated blood to that region when the coronary circulation is right dominant. (1 point each)
82. The anteroseptal region B
83. The posterior wall of the left ventricle A
84. The AV bundle and the posterior aspect of the upper septum A
85. The lateral wall of the left ventricle C
A) Right coronary artery
B) Left anterior descending coronary artery
C) Left circumflex coronary artery
D) The coronary sinus
The least likely association with mitral annular calcification is - (1 point)
A) Calcification of the aortic cusps
B) Calcification extending into the cardiac skeleton (central fibrous body)
C) The presence of a parathyroid tumor causing hypercalcemia
D) Old age
A random Pathophysiology Question:
Which of the following is not a determinant of myocardial oxygen demand (MVO2)?
a) heart rate
d) hemoglobin content
The above photo is of a mitral valve. The pathology illustrated has developed over a period of: (1 point each)
A) 5-6 days
B) 5-6 months
C) at least several years
D) the entire lifetime of a 70 year old person.
The initial event starting this disease process was most likely:
A) an episode of diphtheritic myocarditis
B) pharyngitis due to group A beta–hemolytic streptococci
C) endocarditis due to Streptococcus viridans
During the acute phase of this disease histopathology is least likely to show:
B) bacterial colonies in endocardial vegetations
C) Aschoff bodies
D) Anitchkow cells
The following question is related to the photo above. In the photo the large dark nuclei are indicative of : (3 points)
A) A rhabdomyoma
B) Glycogen storage disease
C) Myocyte hypertrophy
D) Premalignant dysplasia
E) Mutation of a myosin gene in a case of dilated cardiomyopathy
Fill in the blanks – 1 word each (1 point each)
There is an easily fragmented, “benign” tumor which grows from the endocardium to form a sessile or polypoid mass, usually in the left atrium. It is the most common primary cardiac tumor in the adult. The name of the tumor is __MYXOMA___________.
__FIBRINOUS______ pericarditis often develops a few days after onset of transmural myocardial infarction and occasionally develops later as Dressler syndrome. (Supply the adjective)
In one or two sentences describe a clinical scenario which results in cardiac tamponade. (2 points)