Course Directors:


Pathology        Pathophysiology     Pharmacology


Calvin Oyer, M.D.        Douglas Burtt, M.D.       Robert Patrick, Ph.D


Questions 1 – 8:  A twenty eight year old white male is brought to the Emergency Room after an episode of syncope (transient loss of consciousness) while playing basketball. Physical examination reveals a bifid carotid pulse and a mid-peaking systolic murmur which accentuates with standing up or Valsalva maneuver.


1.  This patient would be expected to have all of the following echocardiographic findings, except:


A)    systolic anterior motion of the mitral valve leaflets

B)     a normal appearance of the aortic valve

C)    left ventricular systolic dysfunction

D)    disproportionate upper septal thickening

E)     diastolic left ventricular dysfunction



2. Subsequent treatment of this patient might include each of the following, except:


A)    Surgical resection of a portion of the upper intraventricular septum

B)     Alcohol septal ablation of a localized area of the upper septum

C)    Medical therapy with a calcium channel blocker

D)    Medical therapy with digoxin

E)     Medical therapy with a beta blocker



3. In comparing propranolol to atenolol, all of the following statements are correct EXCEPT:


A. Both drugs can be used to treat hypertrophic cardiomyopathy

B. Propranolol would be preferred for usage in a patient with asthma

C. Neither drug blocks catecholamine alpha-1 receptors

D. Both drugs inhibit norepinephrine-induced stimulation of cyclic AMP production in the heart

E. Both drugs block catecholamine beta-1 receptors




4. This patient’s syncope may have been caused or contributed to by any of the following, except:


A)    severe hypertension due to increased LV contractility

B)     dehydration worsening the LV outflow tract gradient

C)    a transient ventricular arrhythmia (e.g. ventricular tachycardia)

D)    adrenergic stimuli leading to increased outflow tract obstruction

E)      decreased cardiac output secondary to a decreased stroke volume


5.  A cardiac catheterization is performed, and a pullback pressure tracing starting at the apex of the left ventricle is made. Identify which tracing is associated with this patient’s condition:




6.  Gross pathological examination of the myocardium of a patient with the same condition is shown here. All of the following statements regarding this patient’s heart are true except:  (5 points)


A. There was severe left ventricular outflow tract obstruction

B. He carried an increased risk for sudden death

C. The ratio of the thickness of the septum to the thickness of the left ventricular free wall is greater than 1.3/1

D. The compliance of the left ventricle was greater than normal

E. Microscopic examination would show large hyperchromatic nuclei in the myofibers and focal areas of myofiber disarray





7.  Two diastolic filling curves are shown in figure 1. At which of the labeled points was this patient most likely to have been at the time of his syncopal episode?




8.  Two Frank-Starling relationships are shown in figure 2. At which of the labeled points on these curves was this patient most likely to be at the time of his syncopal episode?



            Questions 8 – 13:  A 57 year old female develops progressive dyspnea on exertion several weeks after a prolonged viral upper respiratory illness. She also notes fatigue, orthopnea and PND. An echocardiogram confirms a markedly dilated and hypocontractile left ventricle, with a left ventricular ejection fraction of 20%.

She presents to the hospital with worsening shortness of breath.


9.  At which of the labeled points in figure 1 above (diastolic filling curves) was this patient most likely to be at the time of admission to the hospital?


10.  At which of the labeled points in figure 2 above (Frank-starling curves) was this patient most likely to be at the time of admission to the hospital?


11.  As part of her treatment, this patient received an ACE-inhibitor, enalapril.

All of the following statements concerning enalapril are correct, except:


A. It may produce a persistent dry cough as a side effect

B. It produces an increase in circulating aldosterone levels

C. It produces a decrease in vascular resistance

D. It inhibits the formation of angiotensin II

E. It should not be used in pregnant women


12.  As additional pharmacologic therapy, this patient received an inotropic drug. Indicate which of the following drugs produces an inotropic effect via inhibition of the cardiac Na+/K+-ATPase:


A. Captopril

B. Furosemide

C. Dobutamine

D. Digoxin

E. Amrinone



13.  Gross pathological examination of a similar patient’s heart is shown in this photo of the open left ventricle :


The thickness of the LV wall is 1.0 cm. Similar pathologic findings could be found in any of the following circumstances, except:  (5 points)


A. Idiopathic dilated cardiomyopathy

B. Longstanding essential hypertension, poorly controlled

C. Prolonged alcoholism and deficiency of intake of thiamine

D. A mother without history of previous heart disease who developed congestive heart failure 2 weeks postpartum

E. A 21 year old man with recent adenoviral infection who died suddenly while sleeping




Questions 14 – 20:  A 64 year old black male presents to the hospital nearly 24 hours after the onset of severe substernal chest pressure. Physical examination reveals a heart rate of 110/minute, a blood pressure of 80/50, jugular venous distention, rales two thirds of the way up the lung fields and an S-3 gallop on cardiac exam. The EKG reveals sinus tachycardia at 110/minute with Q waves and ST segment elevations in the anterior leads.


14.  At which point on the Frank-Starling curves in figure 2 would this patient be?


15.  The most likely cause of this patient’s hypotension is:


A)    increased vagal tone

B)     decreased stroke volume due to large anterior MI

C)    vasodilation in compensation for the rapid heart rate

D)    right ventricular infarction causing decreased preload

E)     acute left ventricular free wall rupture


A Swan-Ganz right heart catheter is place in the patient, revealing the following:

            RA pressure: 15 mm Hg

            PA pressure:  50/30 mm Hg

            PC wedge pressure:  30 mm Hg with normal V-waves

            Cardiac output:  3 liters/minute (Cardiac index ~ 1.6 lit/min/m2)


16.  Based on this patient’s hemodynamic profile, his survival rate treated medically is:

A)    greater than 90%

B)     70 - 80%

C)    40 - 50%

D)    10 - 15%


17.    True statements about this patient’s biochemical markers and pathological findings include all of the following, except:


A)    Serum CPK enzymes are likely to be significantly elevated

B)     Histological inspection would be likely to demonstrate coagulation necrosis

C)    Serum troponin I would not be likely to be significantly elevated yet

D)    Gross pathological inspection of the heart would likely reveal a purplish discoloration at the site of infarction

E)     CPK enzymes would continue to remain elevated for at least 48 hours


Shortly after arrival to the hospital, the patient develops atrial fibrillation.

18.    The pathophysiological mechanism of this arrhythmia is most likely:

      1. increased automaticity in the atrium
      2. increased automaticity in the A-V node
      3. increased conduction through the A-V node
      4. multiple areas of re-entry within the A-V node
      5. multiple areas of re-entry within the atrium


19.  Digoxin can be used to treat atrial fibrillation because of its ability to:


A. Inhibit monoamine oxidase activity in the heart

B. Inhibit catecholamine reuptake in the heart

C. Increase parasympathetic input to the heart

D. Inhibit cyclic AMP metabolism in the heart

E. Stimulate cyclic GMP production in the heart


20.  Indicate which of the following drugs would be the most appropriate for the treatment of this patient’s hypotension and CHF:


A. Isosorbide

B. Propranolol

C. Amiodarone

D. Neostigmine

E. Dobutamine



Questions 21 – 23:  A 75 year-old female has been under treatment for arthritis with four weeks of non-steroidal anti-inflammatory drugs. She now notes two days of increasing chest pressure with exertion and black, tarry stools. On examination she appears pale and her vital signs are: Pulse 110/min; BP: 90/60; Resp: 16; Temp: 98.6 F.

21.  Pathophysiologic mechanisms for her accelerated angina pectoris might include all of the following, except:

    1. Increased myocardial oxygen demand due to sinus tachycardia
    2. Increased left ventricular wall tension due to increased preload
    3. Increased myocardial contractility due to increased sympathetic tone
    4. Decreased diastolic coronary perfusion pressure due to hypotension
    5. Decreased oxygen carrying capacity due to anemia

22.  During episodes of chest pressure, all of the following pathophysiologic mechanisms may be taking place, except:

A.     increased local adenosine levels, causing local vasodilation (to increase coronary blood flow)

B.     increased local EDRF or nitric oxide levels, causing local vasodilation (to increase coronary blood flow)

C.     increased catecholamine production, causing increase in heart rate and contractility (increasing myocardial oxygen demand)

D.     increased external compression of the coronary vessels, causing increased coronary vascular resistance

E.      increased local cyclic-AMP levels, causing local vasoconstriction (decreasing coronary blood flow)

23.  Part of the medical treatment of this patient included long-acting nitrate therapy. All of the following statements regarding nitrate therapy are true, except:

A)    Tolerance may develop to long-term nitrate therapy

B)     Nitrates reduce LV preload more than afterload

C)    Nitrates can cause hypotension, especially in volume-depleted patients

D)    Nitrates cause coronary vasodilation, augmenting coronary blood flow

E)     Nitrates increase levels of intra-coronary nitric oxide (EDRF)


   Questions 24 – 30:  A middle aged male patient with stable angina is found to have markedly elevated total cholesterol and elevated serum triglycerides. Treatment with dietary modification as well as pharmacologic therapy is advised.

24.  This patient is recommended by his physician to start a cardiac prudent diet. Components of this diet should include:


    1. A diet high in n-6 polyunsaturated fats.
    2. Less than 7% of calories total fat diet with multivitamin, flaxseed, and fish oil supplements.
    3. A diet rich in fruits and vegetables, fish and nuts.
    4. Low carbohydrate, Atkins type diet.


25.  After placing this patient on a low saturated fat, low cholesterol diet, his serum total and LDL cholesterol both increase. The most likely explanation of this is:


A)    Regression to the mean

B)     Genetic polymorphism

C)    Compensatory raising of serum cholesterol due to lowering of serum HDL cholesterol

D)    Saturated fats in diet replaced with carbohydrates which increases total and LDL cholesterol


26.  This patient is recommended to increase his fish intake by his physician. The most plausible mechanism by which this dietary change may reduce the patient’s risk of a second coronary event is:


A)    Lowers oxidized LDL cholesterol in the atherosclerotic plaques

B)     Lowers serum LDL cholesterol

C)    Increases expression of leukocyte adhesion molecules in atherosclerotic plaques

D)    Promotes nitrous oxide induced endothelial relaxation


27.  Simvastatin lowers plasma cholesterol via:


A. Binding bile acids

B. Stimulation of lipoprotein lipase activity

C. Inhibition of HMG-CoA reductase activity

D. Stimulation of cholesterol excretion

E. Inhibition of lipolysis, resulting in a reduction of free fatty acids


28.  Indicate which of the following would have the greatest efficacy for lowering blood

triglyceride levels:


A. Gemfibrozil

B. Niacin

C. Atorvastatin

D. Ezetimibe

E. Colesevelam


29.  A major toxicity associated with the statin drugs (e.g., lovastatin):


A. Hypotension

B. Myositis

C. Bladder cancer

D. Lowered white blood cell count

E. Male sterility


30.  A lipid-lowering drug that inhibits lipolysis in adipose tissue is:


A. Simvastatin

B. Probucol

C. Gemfibrozil

D. Niacin

E. Colesevelam



Questions 31 – 35:  Match each question with the single best answer (A - E)



Decreased diastolic aortic pressure;

increased left ventricular end-diastolic pressure;

volume overload of the left ventricle;

bounding peripheral pulses



Constrictive Pericarditis



Impaired diastolic filling of ventricles;

Elevated jugular venous pressure with rapid "y-descent";

left ventricular diastolic pressure tracing with "dip and plateau" configuration



Restrictive Cardiomyopathy




Impaired diastolic filling of ventricles; 

cyclical decrease in systolic blood pressure during inspiration;

elevated jugular venous pressure without Kussmaul’s sign



Aortic Regurgitation



Impaired diastolic filling of the left ventricle;

normal left ventricular end-diastolic pressure;

increased pulmonary venous pressure with occasional "reactive" pulmonary hypertension


Cardiac Tamponade



Impaired diastolic filling of the ventricles;

 fibrosis, scarring, or infiltration of the myocardium;

 normal pericardial tissue



Mitral Stenosis




36.  The AV node is a requisite component of the reentrant circuit in:


a.  Atrial fibrillation

b.  Atrial flutter

c.  Orthodromic tachycardia associated with Wolff-Parkinson-White Syndrome

d.  Ventricular tachycardia following remote myocardial infarction

e.  Intra-atrial reentry


37.  The majority of the duration of the PR interval reflects conduction through the:


a.       Sinus node

b.      Atrium

c.       AV node

d.      His bundle

e.       Purkinje system


38.  The current responsible for depolarization of atrial and ventricular myocardial cells is carried predominantly by which ion?


a.   Sodium

b.      Potassium

c    Calcium

d.      Magnesium

e.       Lithium


39.  The current responsible for depolarization of sinus and AV node cells is carried predominantly by which ion?


a.       Sodium

b.      Potassium

c.       Calcium

d.      Magnesium

e.       Fluoride





40.  A 72 year old female presents to the doctor’s office with exertional dyspnea and is found to have a systolic murmur consistent with mitral regurgitation (MR). The following statements regarding chronic and acute MR are all correct, except:


A. Acute MR is associated with a larger left atrium than chronic MR

  1. Acute MR is associated with a higher left atrial pressure than chronic MR
  2. Acute MR has a harsher, less holosystolic murmur than chronic MR
  3. Acute MR is associated with recent inferior myocardial infarction, while chronic MR is not
  4. Both acute and chronic MR can lead to atrial fibrillation due to left atrial stretch

Match the ischemic syndrome with pathological findings.(each answer 3 points)

41.  Acute plaque changes with occlusive coronary thrombosis

42.  Plaque erosion or rupture with microthrombi and microemboli

43.  Fixed lesions with at least one lesion showing 75% or greater cross-sectional area reduction of lumen

A. Stable angina pectoris   

B.  Myocardial infarction    

C.  Unstable angina pectoris


Match the occluded coronary artery with the area of infarction or clinical event. (each answer 3 points)

44.  Right coronary artery in a right dominant system

45.  Left main coronary artery

46.  Proximal left anterior descending coronary artery

A.  Global dysfunction of the left ventricle

B.  Anteroseptal infarct      

C.  Posterior wall infarct 


Are the following developments normal (A) or abnormal (B)?  (each answer 3 points)

            47.  L-loop of the ventricles.

48.  Partial involution of the left horn of the sinus venosus

and persistence of a portion to form the coronary sinus.

49.  Closure of the ductus arteriosus at the onset of labor.

50.  Migration of cells from the neural crest to participate in the formation of the



51.  All of the following adaptive changes in the myocardium would be expected in the presence of significant aortic stenosis, except: (3 points)

A.     Increase in length and diameter of myocardial fibers

B.     Additional sarcomeres

C.     Decreased messenger RNA and contractile proteins

D.     Increase in size of myocyte nuclei with increased DNA content

E.      Increase in number of mitochondria


Match the time after onset of myocardial infarction with the histological features/clinical event .(each answer 3 points)


52.  Coagulation necrosis, wavy fibers, early nuclear changes, infiltration of the interstitium by a few polymorphonuclear leukocytes

53.  A scar with dense collagen fibers   

54.  Thrombotic coronary artery occlusion with no histopathology in the myocardium    

55.  Rupture of ventricular wall with cardiac tamponade


A.     2 hours

B.     12 hours

C.     4-7 days

D.     6 weeks

56.  Relative to fibrinous pericarditis, all of the following are true, except: (3 points)


It can occur a few days after a transmural acute myocardial infarct and usually is associated with a friction rub                                          

B.     It is due to spread of tuberculosis from the mediastinum            

C.     Histology shows an inflammatory reaction and deposition of fibrin         

D.     It is unlikely to be followed by constrictive pericarditis              



The histological diagnosis of myocarditis requires the presence of 2 features. For each of the choices below, choose True (A) or False (B).  (3 points)

57.  Myocardial damage as shown by myocyte necrosis, myocyte dropout, or myocytolysis                  

58.  Recent intake of a drug known to cause myocarditis

59.  An interstitial infiltrate of inflammatory cells

60.  The presence of giant cells            


Questions 61 – 67:  True (A) or False (B) (each answer 3 points)


61.  Wegener’s granulomatosis is a large vessel vasculitis in which a test for p-ANCA is likely to be positive.


62.  Hyaluronate in the wall of group A streptococci is identical to that in human connective tissue


63.  The Aschoff body consists of an area of fibrinoid degeneration surrounded by lymphocytes, plasma cells, large macrophages, and giant cells.


64.  The predominant type of lymphocyte found in the infiltrate in viral myocarditis is the B cell.


65.  A patient undergoes thrombolysis 2 hours after coronary occlusion. There is a possibility of salvage of some myocardium. The preserved area will be subepicardial.


66.  A myocardial infarct occurring as a result of prolonged shock in a young accident victim with no significant coronary disease is usually transmural and in the zone of a specific coronary artery branch.


67.  BNP, a test for the level of brain natriuretic peptide in serum, is useful in differentiating dyspnea due to lung disease from dyspnea due to heart failure.




68. This is a view of the mitral valve from the open left atrium. The most likely scenario to explain this severe deformity is: (5 points)


A. The patient had undergone a surgical procedure to repair papillary muscle rupture

B. The patient has noted dyspnea on exertion, has increased stroke volume, left ventricular dilation, and a prominent holosystolic murmur at the apex

C. There is a history of streptococcal pharyngitis with fever and subsequent joint pain and swelling in childhood and the patient has now been experiencing orthopnea and paroxysmal nocturnal dyspnea

D. The patient also has aortic root dilation and a family history of Marfan syndrome

E. The patient had recently migrated from Bolivia and has marked cardiomegaly






69.  Choose the correct statement about this microscopic section of myocardium. The infiltrating cells are neutrophils. (5 pts)


A. This ventricular wall carried a great risk for rupture


B. It represents an area of infarction in which the onset of symptoms was approximately 2 days prior to death


C. The patient almost certainly had a transient right bundle branch block


D. It is from a child who recently had an adenoviral infection


E. The patient traveled in Africa and now has febrile episodes




70.  All of the following statements are true except: (5 points)


A. There is an anteroseptal infarct with onset about 24 hours prior to death

B. There is an anteroseptal infarct with onset about 5 days prior to death

C. There was risk of rupture of the ventricular wall and/or the ventricular septum

D. There was a possibility of formation of a ventricular aneurysm if the patient survived

E. Microscopic study would show macrophages and early granulation tissue













71.  The following statements about the aortic valve pictured at left are all true, except:  (5 points)


A. The underlying anomaly is one of the most frequently encountered congenital cardiac defects

B. The valve pictured above has undergone thickening of the cusps and is stenotic

C. The problem is probably compounded in this case by severe mitral stenosis

D. This type of anomaly is often associated with coarctation of the aorta

E. This patient probably had concentric left ventricular hypertrophy




72.  The potency of a drug is defined as:


A. The minimal concentration of a drug needed to produce a physiological response

B. The concentration of a drug needed to produce a maximal effect

C. The concentration of a drug needed to produce 50% of the maximal effect

D. The maximal physiological effect that can be achieved with the drug

E. The minimal concentration of a drug needed to counter the effect of a competitive inhibitor


73. The efficacy of a drug is defined as:


A. The concentration of a drug needed to produce a maximal effect

B. The minimal concentration of a drug needed to counter the effect of a non-competitive inhibitor

C. The minimal concentration of a drug needed to produce a physiological response

D. The concentration of a drug needed to produce 50% of the maximal effect

E. The maximal physiological effect that can be achieved with the drug


74.  In the presence of a competitive receptor antagonist the following will be observed with regard to binding of the agonist to the receptor:


A. An increase in the Kd  and an increase in the Bmax

B. An increase in the Kd and no change in the Bmax

C. No change in the Kd and a decrease in the Bmax

D. A decrease in the Kd and a decrease in the Bmax

E. An increase in the Kd and a decrease in the Bmax


75.   Drug A has an TD50 of  6 mg/kg and a Therapeutic Index (TI) of 30. What is the ED50 of Drug A?


A. 180 mg/kg

B. 5 mg/kg

C. 2 mg/kg

D. 0.5 mg/kg

E. 0.2 mg/kg


76. The following will occur when “spare receptors” are present:


A. The receptors will only respond to maximal concentrations of agonist

B. Receptor binding will not saturate as the agonist concentration is increased

C. Only non-competitive inhibitors, but not competitive inhibitors, will be able to inhibit agonist binding

D. The ED50 will have a lower value compared to the Kd

E. All of the above



77. At opiate receptors, heroin is a full agonist and buprenorphine is a partial agonist. This means that:


A. Heroin will have a greater efficacy compared to buprenorphine

B. Heroin will have a lower ED50 compared to buprenorphine

C. Heroin will have both a greater efficacy and a lower ED50 compared to buprenorphine

D. Heroin will have both a greater efficacy and a greater ED50 compared to


E. Heroin will have a greater therapeutic index compared to buprenorphine



78.  W.G. is a 44-year-old female patient who has been treated for 2 months with

propranolol to help lower her blood pressure. She complains of experiencing nightmares

which began shortly after starting the propranolol treatment. She is told to immediately

stop taking the propranolol. Indicate which of the following consequences/explanation

are the most appropriate to describe the results of an abrupt stopping of the propranolol



A. Continued drop in blood pressure/Due to loss of alpha1 receptors on vascular smooth


B. Continued drop in blood pressure/Due to loss of beta1 receptors in the heart

C. Heart palpitations/Due to increased number of beta1 receptors in the heart

D. Bronchoconstriction/Due to loss of beta2 receptors in the lung

E. Bradycardia/Due to increased number of muscarinic receptors in the heart



79.  Which drug blocks L-type calcium channels, as its major mode of action?


            A.  procainamide

            B.   quinidine

            C.  disopyramide

            D.  verapamil


80.  Which drug is most likely to cause marked prolongation of the QT interval, and polymorphic ventricular tachycardia (torsade de pointes)?


            A.  sotalol

            B.   diltiazem

            C.  verapamil

            D.  propranolol

81.  Drugs that have as their primary effect slowing of conduction and prolongation of refractoriness in atrial and ventricular muscle include all of the following, except:


            A.  procainamide

            B.   flecainide

            C.  digitalis

            D.  quinidine




Questions 82 – 84  pertain to the diagram to the left.  A normal patient has a baseline pressure-volume loop labeled "Baseline".

82.  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


83. 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

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

a.       cardiac output

b.      preload

c.       afterload

d.      stroke volume

e.       end-systolic volume


An 82 year old female with a long standing history of a “heart murmur” presents to the ER with acute shortness of breath and palpitations. Physical exam reveals:


            Pulse 120, irregularly irregular;   BP: 150/60;    Resp: 28, rapid

            Neck: Increased JV pressure to ~ 20 mmHg

            Chest:  Rales 1/3 the way up

Heart: Irregular S1 and S2 with a III/VI diastolic decrescendo blow at the left sternal border; an S3 gallop is present


85.  Her irregular heart rhythm most likely is due to:


    1. sinus tachycardia
    2. frequent ventricular premature beats
    3. ventricular tachycardia
    4. torsades des pointes
    5. atrial fibrillation


86.  Her predominant valvular abnormality is:


A.     aortic stenosis

B.     aortic insufficiency

C.     mitral stenosis

D.     mitral insufficiency

E.      Pulmonic insufficiency


87.  Her left ventricle suffers from:


A.     chronic pressure overload

B.     chronic volume overload

C.     acute pressure overload

D.     acute volume overload

E.      acute coronary ischemia


88.  Medical therapy for her dyspnea and palpitations might include:


A.     Digoxin to slow her heart rate

B.     Diuretics to reduce preload

C.     ACE-inhibitors to reduce preload and afterload

D.     Arterial vasodilators to reduce afterload

E.      All of the above


89.    This patient’s heart may be subject to all of the following, except:


  1. Decreased LV wall thickness, decreasing wall stress
  2. Increased LV cavity size, increasing stroke volume
  3. Increased LV end diastolic pressure, causing subendocardial ischemia
  4. Increased LV mass, increasing myocardial oxygen demand
  5. Decreased diastolic blood pressure, decreasing myocardial oxygen supply



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