Questions 1 3:

A 45-year-old male presents to the hospital 12 hours after the onset of an anterior myocardial infarction. His initial examination reveals findings consistent with congestive heart failure. A Swan-Ganz catheter is placed and a Frank-Starling performance curve is generated:



    1.    Administering a positive inotropic agent (e.g. Digitalis) to this patient will:

      1. Move the curve upwards and to the left
      2. Move the curve downwards and to the right
      3. Decrease the slope of the curve
      4. Move the patient leftward along the same curve
      5. Move the patient rightward along the same curve
    2.    If the patient is on the portion of the curve in quadrant 3, he can be improved by moving him to the left into quadrant This could be accomplished by giving a drug which:
      1. Increases contractility
      2. Decreases contractility
      3. Increases preload
      4. Decreases preload
      5. Decreases afterload
3. In general, a patient would be described as being in cardiogenic shock if they were in which quadrant:
      1. Quadrant 1
      2. Quadrant 2
      3. Quadrant 3
      4. Quadrant 4
A 50-year-old male presented to the hospital with a large inferior myocardial infarction. Questions 4 12 refer to this patient:

4. On initial presentation to the hospital, the patient's pulse was 50 per minute (Normal pulse = 60 100 per minute). Pathophysiologic reasons for this relatively slow pulse might have included all of the following, except:

    1. increased vagal tone associated with the inferior MI
    2. third-degree A-V block with a junctional (A-V nodal) escape rhythm
    3. sinus bradycardia due to SA (sino-atrial) node ischemia
    4. second-degree A-V block with two-to-one A-V conduction
    5. increased sympathetic tone associated with the inferior MI
5. On initial presentation to the hospital the patient's blood pressure was low, with a reading of 90/60 mm Hg. Pathophysiologic reasons for his low blood pressure might have included all of the following, except:
    1. right ventricular infarction causing increased vascular resistance
    2. right ventricular infarction causing low LV preload
    3. hypovolemia (low intravascular volume)
    4. reduced vascular resistance from increased vagal tone
    5. reduced cardiac output related to the MI
6. The pathophysiology of his acute myocardial infarction might have involved all of the following, except:
    1. a "wavefront" spread of ischemia and infarction from the endocardium to the epicardium
    2. plaque rupture with platelet aggregation and thrombosis
    3. release of serum catecholamines exacerbating ischemia
    4. increase in left ventricular wall tension
    5. increase in left ventricular compliance

 
 

7. All of the following are determinants of this patient's myocardial oxygen supply, except:

    1. viscous coronary resistance
    2. compressive coronary resistance
    3. hemoglobin content
    4. wall tension
    5. cardiac output
On day four of the hospitalization, the patient develops a new systolic heart murmur and the following oxygen saturations and pressure curves are obtained with a Swan-Ganz catheter:
Oxygen Saturation
Pressure (mm Hg)
Right Atrium
62%
8
Right Ventricle
61%
30/8
Pulmonary Artery
61%
30/22
Pulmonary Capillary Wedge
60%
22 mean

V-waves to 50

8. This patient's echocardiogram might be expected to show:

    1. Acute ventricular septal defect
    2. Acute mitral regurgitation
    3. Acute left ventricular free wall rupture
    4. Acute right ventricular infarction
    5. Acute left ventricular apical aneurysm formation
9. An intra-aortic balloon pump placed in this patient might improve his hemodynamics by:
    1. Decreasing left ventricular afterload during systole
    2. Increasing left ventricular afterload during systole
    3. Decreasing left ventricular preload during diastole
    4. Increasing left ventricular preload during diastole
10. The likely gross pathologic finding in the affected portion of this patient's heart muscle is:
    1. White, fibrotic thinned myocardium
    2. Red, hemorrhagic thickened myocardium
    3. Normal appearing myocardium
    4. Purple, discolored firm myocardium
    5. Yellow, softened myocardium
This patient's pulmonary capillary wedge pressure tracing is seen below.
  1. What is the correct title for the section labeled 1?
    1. Pulmonary capillary wedge pressure
    2. The dicrotic notch
    3. The A-wave
    4. A small V-wave
    5. A giant V-wave

   
  12. What is the correct title for the section labeled 2?
    1. Pulmonary capillary wedge pressure
    2. The dicrotic notch
    3. The A-wave
    4. A small V-wave
    5. A giant V-wave

 
 

Questions 13 16:

A 60-year-old male patient presents with a history of palpitations, shortness of breath on exertion, and fatigue. The patient indicates that his palpitations are felt as irregular heartbeats, occasionally rapid, and sometimes associated with lightheadedness. An electrocardiogram is obtained and lead II is shown below:

The electrocardiogram shows:
    1. a chaotic atrial rhythm without discrete P waves
    2. deep "sawtooth" flutter waves
    3. advanced heart block
    4. ventricular fibrillation
14. This patient's arrhythmia has been shown to :
    1. be present in up to 5% of adults over 65 years of age
    2. never occur in patients with pneumonia
    3. predominantly occur in children
    4. rarely require hospital admission for evaluation and treatment
15. The patient is worried about the possible complications associated with his arrhythmia. Warfarin (coumadin) might be indicated to:
    1. prevent ventricular tachycardia
    2. reduce the risk of bleeding complications
    3. correct thyroid function abnormalities
    4. anticoagulate the patient and prevent embolic strokes
16. The patient is treated with quinidine, and following only a few doses, you are informed that he has had syncope and that the electrocardiogram shows "twisting of the points". You conclude that:
    1. the patient has Wolff-Parkinson-White syndrome
    2. the patient has developed "Torsades de pointes", as a pro arrhythmic complication of quinidine
    3. the patient has probably not been taking his quinidine
    4. the patient is having an acute myocardial infarction

 

A 38 year old Hispanic woman presents to the Emergency Room complaining of marked shortness of breath which began suddenly about two hours ago. On exam, her heart rate is 140 beats per minute. Cardiac auscultation is difficult because of her rapid heart rate. She has moist rales over both lung fields. Her chest X-ray shows pulmonary edema with elevation of the left mainstem bronchus, a double density and straightening of the left heart border.

  1. What two diagnostic tests would be most helpful to further evaluate this patient?

  2.  
    1. transthoracic echocardiography and an electrocardiogram
    2. cardiac catheterization and cardiac MRI
    3. phonocardiography and transesophageal echocardiography
    4. radioisotope nuclear stress testing and cardiac MRI
    5. transthoracic echo and transesophageal echo
18. What is her most likely valve lesion?
    1. Aortic stenosis
    2. Aortic insufficiency
    3. Mitral stenosis
    4. Mitral insufficiency
    5. Tricuspid insufficiency
19. Why did she develop pulmonary edema?
    1. increased left ventricular preload
    2. increased left ventricular afterload
    3. decreased left ventricular systolic function
    4. increased left atrial pressure
    5. pulmonary embolic disease
20. All of these next choices can be used to help treat this patient, except:
    1. medication to slow the heart rate and increase diastolic filling time
    2. diuretics to lower pulmonary capillary wedge pressure
    3. cardioversion, if the heart rhythm is atrial fibrillation
    4. anticoagulants to prevent left atrial thrombus formation
    5. medication to lower left ventricular afterload
 Questions 21 23:

Withdrawal pressure tracing from the left ventricle to the aorta

A 25-year-old male with a diagnosis of cardiomyopathy experienced dizziness while playing basketball. Examination revealed a blood pressure of 130/85 mm. Hg; regular pulse at 85/minute, and normal respirations. He had no jugular venous pressure elevation, his lungs were clear, and cardiac examination revealed a forceful apical impulse, normal S1 and S2; an S4 was present as well as a grade 3/6 systolic murmur between the apex and left lower sternal border.

21. Based on the left ventricular to aortic pullback pressure tracing shown in the figure above, what advice would you give this patient regarding participation in sports?

    1. Avoid all sports
    2. Avoid prolonged aerobic sports
    3. Avoid contact sports
    4. Avoid table tennis
22. Medical management should aim at (choose one):
    1. reducing preload
    2. decreasing contractility
    3. increasing contractility
    4. reducing afterload
23. What effect would the Valsalva maneuver have on the murmur?
    1. Murmur intensity would be accentuated.
    2. Murmur intensity would be diminished
    3. No change.
Questions 24 25:

Electrocardiogram (top tracing)

IN = inspiration

EX = expiration

Arterial Blood
Pressure (bottom tracing)
 
 

A 45-year-old male with history of metastatic disease from bronchogenic carcinoma was admitted with hypotension and diaphoresis. His arterial pressure tracing is shown in the figure.

  1. What is the two-word term for this pathophysiologic phenomenon?
  2. (Please write into the answer sheet)
  3. What condition does this patient have?
    1. Dilated cardiomyopathy
    2. Acute right ventricular infarction
    3. Hypertrophic cardiomyopathy
    4. Constrictive pericarditis
    5. Cardiac tamponade
26. "Kussmaul's sign" is most prominent in which one of the following conditions?
    1. Dilated cardiomyopathy
    2. Acute ventricular septal defect
    3. Hypertrophic cardiomyopathy
    4. Constrictive pericarditis
    5. Cardiac tamponade
27. What is the pathophysiologic mechanism of Kussmaul's sign?
    1. During inspiration, right ventricular filling is augmented, and left ventricular filling falls, thereby lowering blood pressure
    2. During expiration, right ventricular filling is augmented, and jugular venous pressure rises
    3. During inspiration, negative intrathoracic pressure is not transmitted to the right atrium and right ventricle, and jugular venous pressure rises
    4. During expiration, positive intrathoracic pressure is not transmitted to the right ventricle, and the intraventricular septum bulges to the right, causing jugular venous pressure to rise
Questions 28 - 29:

A 30-year-old woman develops progressive shortness of breath and fatigue two months after delivery of a child. Blood pressure is 140/90 and her pulse is 60/minute. She has jugular venous pressure elevation, minimal rales bilaterally and a third heart sound (S3). She has mild pitting edema of her legs. Her cardiac size on chest x-ray is mildly enlarged. An echocardiogram shows no structural defects but the left ventricular ejection fraction is 30%.

28. The most likely diagnosis is:

    1. Hypertrophic cardiomyopathy
    2. Dilated cardiomyopathy
    3. Restrictive cardiomyopathy
    4. Congenital V.S.D.
29. The most appropriate treatment combination is:
    1. Diuretics and an angiotensin converting enzyme inhibitor
    2. Nitrates and diuretics
    3. Digoxin and diuretics
    4. Beta-blocker and diuretics
    5. Beta-blocker and calcium-channel blocker
* * * * * * * * * * * * * * * * * *

30. The compliance of the left ventricle can be defined by relating change in pressure to change in volume during left ventricular filling. This LV compliance is defined as:

      1. V/  P
      2. P/  V
      3. P x  V
      4. P x  V / 2h
      5. P x r / 2h
(where  V = change in volume,  P = change in pressure, h = wall thickness, and r = LV radius)
 
 

Questions 31 36 have True or False answers (1/2 point each):

There are three shunt pathways that are instrumental in the fetal circulation.

  1. One of these pathways is called truncus arteriosus
  2. One of these pathways is called ductus venosus
  3. One of these pathways is called the interventricular foramen
  4. One of these pathways is called the foramen ovale
  5. One of these pathways is called septum primum
  6. One of these pathways is called ductus arteriosus

  7.  

    - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

  8. A one-year-old boy has a congenital ventricular septal defect. Which of the following is not a determinant of the amount and direction of shunted blood flow through the abnormal communication?
    1. The size of the defect
    2. The location of the defect
    3. The pulmonary vascular resistance
    4. The aortic (systemic) vascular resistance
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Questions 38 40:

A 72-year-old male with long-standing hypertension has an echocardiogram, which demonstrates concentric left ventricular hypertrophy with normal systolic function, and impaired diastolic filling. His electrocardiogram shows normal sinus rhythm.

38. This patient's "compensatory" left ventricular hypertrophy:

    1. Increases wall tension (wall stress)
    2. Decreases wall tension
    3. Increases afterload
    4. Increases preload
    5. Decreases myocardial oxygen demand
39. If this patient's rhythm changed to atrial fibrillation, there would be loss of the "atrial kick", which might cause a 10 30% fall in cardiac output. This "atrial kick" occurs:
    1. Immediately before opening of the mitral valve
    2. Immediately after opening of the mitral valve
    3. Immediately before closure of the mitral valve
    4. Immediately after closure of the mitral valve
  1. This patient's myocardial oxygen demand might be increased because of:
    1. Decreased contractility from left ventricular hypertrophy
    2. Increased contractility from left ventricular hypertrophy
    3. Decreased wall tension from left ventricular hypertrophy
    4. Increased wall tension from left ventricular hypertrophy
* * * * * * * * * * * * * * * * * * * * *

Questions 41 - 43:

You are asked to see three patients in consultation. Each has been told that he/she has valvular heart disease as determined by a catheterization performed at a distant hospital. Each patient was given a copy of his or her catheterization report. Based on the information provided, what primary valvular abnormality best explains the findings for each patient?
 
 

Patient A  Patient B Patient C
Aortic Pressure 160/50 120/80 110/90
LV Pressure 160/10 120/6 200/18
PCW Pressure a=6,v=10
mean=8
a=25,v=22
mean=20
a=18, v=22
mean = 18
PA Pressure 25/12 75/35 40/15
RV Pressure 25/5 75/15 40/8
RA Pressure a=4,v=4
mean=4
a=15, v=25
mean=18
a= 5, v=6
mean = 5
Murmur(s) Diastolic Diastolic and systolic Systolic
LV ejection fraction 85% 55%  60%

(where LV = left ventricle, PCW = pulmonary capillary wedge, PA = pulmonary artery,
RV = right ventricle, RA = right atrium)

  1. Patient A has:
    1. Aortic stenosis
    2. Aortic insufficiency
    3. Mitral stenosis (primary) and tricuspid regurgitation (secondary)
    4. Acute mitral insufficiency
    5. Chronic mitral insufficiency
42. Patient B has:
    1. Aortic stenosis
    2. Aortic insufficiency
    3. Mitral stenosis (primary) and tricuspid regurgitation (secondary)
    4. Acute mitral insufficiency
    5. Chronic mitral insufficiency
43. Patient C has:
    1. Aortic stenosis
    2. Aortic insufficiency
    3. Mitral stenosis (primary) and tricuspid regurgitation (secondary)
    4. Acute mitral insufficiency
    5. Chronic mitral insufficiency
* * * * * * * * * * * * * * * * * * * * * * * * * *

Workspace area

This diagram of normal pressures is included to help you work through Questions 41 43.

BONUS QUESTION

  44. In the above flow-volume loop, the patient might be moved from curve 3 to curve 1 by:

    1. Administering a diuretic
    2. Administering an inotropic agent
    3. Administering a venous dilator
    4. Administering an arterial vasodilator
    5. Decreasing left ventricular contractility