Cardiology MCQ

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1. A 29 year old male with a C. Mitral valve prolapse (patient has Marfan
history of ectopia lentis pre- syndrome)
sents for a routine physi- Marfan's syndrome is associated with mi-
cal examination. He is not- tral valve prolapse and aortic aneurysms.
ed to have pectus excava- Specifically, the ascending aorta may di-
tum, pes planus, a high arched late and predispose patients to acute aortic
palate and a positive wrist and dissection, which can be fatal. Also, when
thumb sign. Which of the fol- the ascending aorta dilates, the aortic valve
lowing cardiac disorders is as- annulus stretches causing the valve leaflets
sociated with his condition? to fail to coapt which results in aortic regur-
A. Aortic valve stenosis gitation.
B. Coarctation of the aorta Coartaction of the aorta: associated with
C. Mitral valve prolapse Turner's syndrome and presents with hy-
D. Ventricular septal defect pertension in the upper extremities and
E. Eibstein's anomaly hypotension in the lower extremities. "Rib
notching" is seen on the chest x-ray.

2. A 67 year old female with a his- E. Cardiac tamponade

tory of breast cancer and to-
bacco use complains of dizzi- Cancer is the most common cause of peri-
ness and dyspnea on exer- cardial effusion and when enough fluid ac-
tion. Her heart sounds are dis- cumulates in the pericardial space, cardiac
tant and her systolic blood tamponade occurs. "Pulsus paradoxus" is
pressure is noted to marked- when there is a decrease in systolic blood
ly decrease with inspiration. pressure during inspiration due to failure
Which of the following is the of the right ventricle to accept the normal
likely diagnosis? increased venous return that occurs with
A. Restrictive cardiomyopathy inspiration. This also results in a "Kussmal's
B. Mitral valve regurgitation sign" or elevated jugular venous distension
C. Congestive heart failure during inspiration (normally the opposite
D. Pulmonary embolus occurs). Treatment is with emergent peri-
E. Cardiac tamponade cardiocentesis.

3. A 22 year old female is not- D. Aortic dissection

ed to have a reduced upper The leading cause of death in patients with
to lower body segment ratio, Marfan syndrome is acute ascending aortic
positive Walker and Steinberg dissection and/or aortic rupture. Aortic dis-
signs and pectus carinatum. section presents with sudden onset tearing
Her father died suddenly at chest and upper back pain and can result
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the age of 34. She is subse- in aortic rupture, cardiac tamponade, coro-
quently diagnosed with Mar- nary artery dissection resulting in myocar-
fan's syndrome. Which of the dial infarction, acute aortic insufficiency or
following was the likely cause stroke all of which can be fatal.
of death of her father?
A. Mitral valve prolapse
B. Aortic valve regurgitation
C. Myocardial infarction
D. Aortic dissection
E. Congestive heart failure

4. An 18 year old male dies C. Idiopathic hypertrophic subaortic steno-

suddenly during a track and sis (IHSS)
field event. During a recent IHSS or hypertrophic obstructive cardiomy-
sports physical he was not- opathy (HOCM) and is an autosomal dom-
ed to have a II/VI systolic inant inherited disorder in about 50% of
crescendo-decrescendo mur- cases (the rest are sporadic). HOCM is as-
mur at the right upper ster- sociated with mostly exertional symptoms.
nal border that became loud- During exercise (when the heart contracts
er with Valsalva. A paradoxi- harder), the abnormally large interventicu-
cal split S2 heart sound was lar septum obstructs blood from flowing out
heard. Which of the following of the aortic valve resulting in a markedly
is his likely diagnosis? reduced cardiac output. This leads to syn-
A. Congenital coronary anom- cope (loss of consciousness). It can also
aly lead to life-threatening arrhythmias such as
B. Comotio cordis ventricular tachycardia and ventricular fib-
C. Idiopathic hypertrophic rillation, thus HOCM is the most common
subaortic stenosis (hyper- cause of sudden death in young athletes.
trophic obstructive cardiomy- The classic murmur may mimic aortic
opathy) stenosis and is a systolic crescendo-de-
D. Dilated cardiomyopathy crescendo murmur at the right upper ster-
nal border that gets louder with Valsalva
due to lessened blood return to the left ven-
tricle, allowing more obstruction to occur.
On histologic examination you would see
the myocardial myocytes in a chaotic pat-
tern commonly described as "myocardial
disarray", not a normal organized pattern.

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5. A 34 year old male expe- A. Restrictive cardiomyopathy
riences shortness of breath Amyloidosis of the heart causes a re-
with minimal exertion. Phys- strictive cardiomyopathy and a majority of
ical examination reveals el- the cases are due to a mutation in the
evated jugular venous pres- transthyretin gene resulting in the abnormal
sure markedly worse with in- deposition of this protein in the myocardial
spiration, a regular rhythm tissue. Restrictive cardiomyopathy can also
with an S4 heart sound and occur from sarcoidosis or hemachromoti-
2+ lower extremity pitting ede- sis.
ma. Laboratory studies are The typical stain for amyloid is the con-
normal. Cardiac biopsy re- go red stain which displays an "apple
vealed apple green birefrin- green birefringence." Physical examination
gence with congo red stain- reveals an S4 heart sound due to impaired
ing. Genetic testing reveals a relaxation and a Kussmal's sign which is
mutation in the transthyretin marked elevation in the jugular venous
gene. Which of the following is pressure with inspiration (the opposite of
the correct diagnosis? what usually happens).
A. Restrictive cardiomyopathy
B. Dilated cardiomyopathy
C. Constrictive pericarditis
D. Hypertrophic obstructive
cardiomyopathy
E. Chagas cardiomyopathy

6. A 35 year old female with a C. Mitral valve prolapse

history of anxiety and panic Mitral valve prolapse (MVP) is usually a
attacks presents for a routine benign disorder very common in young fe-
physical examination. She in- males and has been associated with anxi-
termittently experiences pal- ety and panic attacks. Also known as "Bar-
pitations but in general feels lowe syndrome" or "floppy mitral valve,"
well. Physical examination re- histologic examination shows myxomatous
veals a mid-systolic click at degeneration of the valve and papillary
the cardiac apex which moves muscles. Severe cases of MVP can be as-
earlier in systole with stand- sociated with mitral regurgitation in which
ing from a squatting position. a holosystolic murmur would be heard. Pa-
No murmur is present. Which tients with connective tissue disorders such
of the following is the likely as Marfan's syndrome are more likely to
diagnosis? have MVP. No specific treatment is needed
A. Mitral valve regurgitation
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B. Mitral valve stenosis unless heart failure develops from mitral
C. Mitral valve prolapse regurgitation.
D. Normal mitral valve

7. A 56 year old female with a C. Streptococcus viridans

history of mitral valve pro- Subacute bacterial endocarditis is most
lapse has been experiencing commonly due to Streptococcus viridans
fevers and joint pains for 3 which is a normal flora of the mouth and
weeks. She recently under- thus frequently enters the blood stream af-
went a tooth extraction. Phys- ter dental procedures.
ical examination reveals a Pre-existing valvular heart disease increas-
III/VI holosystolic murmur at es the risk of endocarditis and a new regur-
the cardiac apex which was gitant murmur should raise suspicion as the
not present on prior exami- pathogen can destroy valve leaflets.
nations. Her erythrocyte sedi- NB: if Streptococcus bovis is the culprit,
mentation rate is markedly el- concominant colon cancer may be present.
evated. A painful nodule on Osler's nodes (painful lesions on finger
the pad of her left index fin- pads - Osler's = Ouch), Janeway's lesions
ger has developed. Which of (painless lesions on the palms and soles),
the following is the most likely splinter hemorrhages in the fingernails and
culprit? Roth spots on fundoscopic examination
A. Staphalococcus aureus (retinal hemorrhages with white/pale cen-
B. Pseudomonas auriginosa ters) are all a result of peripheral emboliza-
C. Streptococcus viridans tion or immune complex deposition related
D. Candida albicans to endocarditis.
Also, endocarditis elevated the erythro-
cyte sedimentation rate (as all inflammatory
conditions do) and can cause a false pos-
itive RPR test for syphilis (similar to sys-
temic lupus).

8. A 45 year old male presents B. Beta-blocker administration

with substernal chest pres- Beta-blockers decrease heart rate and in-
sure and is found to have el- otropy, two major determinants of myocar-
evated troponin levels consis- dial oxygen demand. All acute coronary
tent with a large myocardial in- syndromes (myocardial infarctions or un-
farction. Which of the follow- stable angina) should be given beta-block-
ing interventions can best de- ers such as metoprolol immediately un-
crease myocardial oxygen de- less an obvious contraindication exists

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mand and potentially reduce (bradycardia, hypotension, severe conges-
the size of the infarction? tive heart failure, severe asthma or obstruc-
A. Nitroglycerine infusion tive pulmonary disease).
B. Beta-blocker administra- Nitroglycerine infusion (A) and loop diuret-
tion ics (D) will reduce preload by venodilation
C. Aspirin and decreased total body volume respec-
D. Loop diuretic administra- tively which will have some reduction in my-
tion ocardial oxygen demand, but not profound.
E. Dobutamine infusion Nitroglycerine has never been shown to re-
duce mortality in myocardial infarction. As-
pirin (C) which does reduce mortality rather
dramatically, does not affect myocardial
oxygen demand, but rather inhibits platelets
to prevent thrombus propagation. Dobuta-
mine infusion (D), which can be used in
myocardial infarction if severe cardiogenic
shock is present, actually increases heart
rate and inotropy resulting in increased
myocardial oxygen demand by stimulating
beta-1 receptors.

9. An 84 year old male with a A. Left sided congestive heart failure

history of severe emphysema Left-sided congestive heart failure (CHF)
and a prior myocardial infarc- occurs when the left ventricle is not able to
tion becomes short of breath produce adequate cardiac output to meet
with exertion. Physical exami- the demands of the body resulting in in-
nation reveals a III/VI holosys- creases in left ventricular pressure which
tolic murmur at the cardiac are then transmitted to the pulmonary veins
apex, a S3 heart sound and resulting in pulmonary edema and short-
rales in the lower lung fields. ness of breath. Essentially any cardiac dis-
No lower extremity edema is order can reach the endpoint of left ven-
present. Which of the follow- tricular failure (valve disease such as mitral
ing is the likely diagnosis? regurgitation, prior myocardial infarctions,
A. Left-sided congestive heart cardiomyopathies, etc.)
failure
B. Right-sided congestive
heart failure
C. Left and right sided conges-

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tive heart failure
D. Cor pulmonale

10. A 56 year old female has a B. Diabetes mellitus type II

history of hypertension, dia- Diabetes mellitus (DM) type II is considered
betes mellitus type II, elevated an atherosclerotic heart disease equivalent
low density lipoprotein levels meaning when diabetes type II is present,
and smokes tobacco. Which so is atherosclerotic heart disease. The
of the above is the most sig- other choices to significantly increase the
nificant risk factor for the de- risk of developing atherosclerotic heart dis-
velopment of atherosclerotic ease, but not as much as diabetes mellitus
heart disease? type II.
A. Hypertension
B. Diabetes mellitus type II
C. Elevated low density
lipoprotein
D. Tobacco use

11. A 28 year old female with A. Coxsackie B virus

no prior past medical histo- This patient has the typical presentation
ry becomes markedly short of of a viral myocarditis leading to a dilated
breath and hypotensive over cardiomyopathy. About 1/3 of cases recov-
a 3 day time period. She had er left ventricular function spontaneously,
been suffering from an up- 1/3 remain unchanged and 1/3 worsen. The
per respiratory tract infection most common pathogen is coxsackie virus
starting 1 week prior. Phys- B.
ical examination reveals no
murmurs, an S3 heart sound
is present, elevated jugular
venous pressure, pulmonary
rales and lower extremity ede-
ma. An echocardiogram con-
firms an ejection fraction of
10%. Which of the following is
the most common culprit of
her condition?
A. Coxsackie B virus
B. Human immunodeficiency
virus

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C. Epstein-Barr virus
D. Influenza A virus

12. A 65 year old male with a his- C. B-type natriuric peptide

tory of congestive heart fail- B-type naturic peptide (BNP) and A-type
ure and severe chronic ob- naturitic peptide (ANP) get released in high
structive pulmonary disease concentrations with the myocardial stretch
complains of increasing dysp- that occurs in congestive heart failure. The
nea on exertion, lower extrem- physiologic properties of BNP and ANP in-
ity edema, paroxysmal noctur- clude vasodilation (reducing afterload) and
nal dyspnea and orthopnea. naturesis (excretion of sodium reducing
His ejection fraction is not- preload). ANP and BNP are the bodies nat-
ed to be 15%. Physical ex- ural mechanism to maintain a normal vol-
amination reveals an S3 heart ume status in the setting of heart failure,
sound, pulmonary rales and but frequently are not enough. Exogenous
lower extremity pitting ede- BNP can be administered (a.k.a. nesiritide)
ma. Which of the following to enhance the preload/afterload/naturesis
elevates in the serum with effects and improve heart failure symptoms.
congestive heart failure, re- Measuring BNP levels in the serum is help-
duces preload and afterload ful to diagnose heart failure as a cause of
and causes diuresis? dyspnea. A newer assay called NT-pro BNP
A. Aldosterone is more sensitive.
B. Carbon dioxide
C. B-type naturitic peptide
D. endothelin

13. A 23 year old male presents D. Pericarditis

to the emergency room with Etiologies of pericarditis include uremia
sharp chest pains radiating (this patient), viral, tuberculosis, autoim-
to his left neck and altered mune and iatrogenic (post-heart surgery).
mental status. For the past 3 Symptoms include a sharp chest pain
days he has had severe nau- worse with lying flat and better sitting up
sea and vomiting attributed to and leaning forward. The pain radiates to
viral gastroenteritis. Physical the left trapezius muscle. Electrocardio-
examination reveals a loud ab- gram findings include diffuse ST segment
normal scratching sound in elevation and PR segment depression. A
end systole and all of diastole pericardial friction rub is frequently auscul-
located near the cardiac apex. tated near the cardiac apex and can be
Chest x-ray is normal. His lab- quite loud and overbear the normal heart

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oratory studies are below: sounds. Treatment is aimed at the cause
Serum and symptoms can be relieved with nons-
Na+ 145 mEq/LK+ 5.4 teroidal anti-inflammatory drugs.
mEq/LCl- 103 mEq/LHCO3-
22 mEq/LUrea nitrogen 112
mEq/LCr 5.2 mEq/LTroponin I
- negative
Which of the following is likely
causing his chest pain?
A. Myocardial ischemia
B. Aortic dissection
C. Esophageal rupture
D. Pericarditis

14. A 26 year old male is noted to B. Ventricular septal defect

have a V/VI holosystolic mur- A ventricular septal defect (VSD) can range
mur associated with a thrill at from small and asymptomatic to large and
the left lower sternal border. life threatening. The smaller the VSD the
He has no health complaints louder the murmur as is seen in this pa-
and is able to exercise regu- tient. Many VSDs will close spontaneous-
larly without difficulty. Which ly and require no intervention. Recall that
of the following is the likely a VSD is a left to right shunt. A large
diagnosis? VSD would eventually cause right ventric-
A. Atrial septal defect ular overload and pulmonary hypertension.
B. Ventricular septal defect As the right-sided heart pressures exceed
C. Mitral valve regurgitation that of the left ventricle, the shunt can
D. Tricuspid valve regurgita- change to right to left and severe symptoms
tion of heart failure can develop. This is known
as Eisenmenger's syndrome.

15. A 36 year old female with no D: Mitral valve balloon valvotomy

significant past medical histo- Mitral stenosis occurs most commonly due
ry is being evaluated for in- to rheumatic heart disease and the mitral
creasing shortness of breath. valve is the most common valve affected.
Her physical examination re- Only half of patients will recall an initial
veals a II/IV early diastolic de- episode of rheumatic fever. Medications (B)
crescendo murmur occurring are not effective to treat mitral stenosis
after an early diastolic open- since the problem itself is anatomical, thus
ing snap. Which of the follow- relieving the stenosis is key. The less inva-

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ing is the ideal therapy for her sive procedure of mitral valve balloon valvo-
cardiac disorder? tomy is preferred over open surgical repair
A. Observation (C) if possible.
B. Angiotensin converting en-
zyme inhibitor
C. Surgical mitral valve repair
D. Mitral valve balloon valvoto-
my

16. A 55 year old male com- B: Heavy alcohol abuse

plains of increasing dyspnea Alcoholic cardiomyopathy is a form of dilat-
on exertion and orthopnea. ed cardiomyopathy (causing systolic con-
His physical examination re- gestive heart failure) which can occur in ge-
veals an S3 heart sound, pul- netically susceptible individuals from as lit-
monary rales, jugular venous tle as two alcoholic drinks per day. A major-
distension and lower extrem- ity of cases resolve with alcohol cessation,
ity edema. Coronary angiog- but some never recover left ventricular func-
raphy is normal. An echocar- tion. Other causes of dilated cardiomyopa-
diogram confirms an ejection thy include viruses (most commonly cox-
fraction of 5% indicating se- sackie B), pregnancy and idiopathic or ge-
vere congestive heart failure netic.
and dilated cardiomyopathy.
Which of the following could
explain the above findings?
A. A history of heroin abuse
B. Heavy alcohol use
C. Tuberculosis infection
D. Prior chemotherapy with
cisplatin

17. An infant becomes cyanot- A. Prostaglandin E2

ic soon after birth. Emer- The anomaly described is transposition of
gent echocardiogram reveals the great vessels in which the aorta and the
the aorta originating from pulmonary artery arise from the incorrect
the right ventricle and the ventricle resulting in two closed circuits of
pulmonary artery originating blood flow. The first circuit (right ventricle to
from the left ventricle. Which aorta to organs to right atrium and back to
of the following interventions right ventricle) delivers only deoxygenated
can be done to improve the blood to the organs resulting in cyanosis.

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cyanosis until surgical correc- The second circuit (left ventricle to pul-
tion is performed? monary artery to lungs for oxygenation to
A. Prostaglandin E2 left atrium back to left ventricle) oxygenates
B. Hyperbaric oxygen admin- the blood but does not allow it to get to
istration the systemic circulation. Vital to the survival
C. Indomethacin of these infants is a left to right shunt of
D. No intervention is needed some kind such as an atrial or ventricular
septal defect or a patent ductus arteriosis.
Prostaglandin E2 (A) helps to keep the duc-
tus arteriosus open until surgical correction
can be done

18. A 72-year-old female with no B. Aortic valve stenosis

significant past medical his- AS presents with one of the classic triad:
tory passes out while ex- syncope (passing out), exertional angina
ercising. She has intermit- or exertional dyspnea (from heart failure).
tent exertional chest pain Over the age of 70 years, the most likely
and dyspnea on exertion. Her cause is degenerative calcific AS, while un-
physical examination reveals der the age of 70, a bicuspid aortic valve is
a III/VI late-peaking crescen- the likely culprit. Rheumatic heart disease
do-decrescendo murmur at is the third-leading cause. Physical exam-
the right upper sternal border ination reveals a crescendo-decrescendo
and a III/VI holosystolic mur- murmur at the aortic listening post (right
mur at the apex. Her S2 heart upper sternal border), which radiates to the
sound is very soft and her carotids. The more severe the aortic steno-
carotid upstroke is weak and sis, the later the peak of the murmur in
delayed. Which of the follow- systole and the softer the A2 component of
ing is most likely causing her the S2 heart sound.
symptoms?
A. Aortic valve regurgitation
B. Aortic valve stenosis
C. Mitral valve regurgitation
D. Mitral valve stenosis
E. Mitral valve prolapse

19. A 2 day old full term male in- D. Observation

fant is noted to have a systolic This infant has a patent ductus arteriosus
and diastolic continuous mur- (PDA) which is a communication between
mur at the right upper sternal the pulmonary artery and the aorta. Since

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border. His vital signs are nor- the blood pressure in the aorta is always
mal and he is overall doing higher than that in the pulmonary artery
well. Which of the following in- (in both systole and diastole), blood is con-
terventions should be done at tinuously flowing from left (aorta) to right
this time? (pulmonary artery) causing a continuous
A. Administration of a diuretic murmur.
B. Administration of in-
domethacin
C. Surgical ligation
D. Observation

20. Which of the following de- D. Ventricular septal defect, right ventricular
scribes the cardiac anomalies hypertrophy, pulmonic valve stenosis, and
associated with the tetralogy an overriding aorta
of Fallot? Tetralogy of fallot occurs from embryologic
A. Atrial septal defect, ventric- anterior and superior displacement of the
ular septal defect, a common infundibular septum resulting in a ventric-
atrioventricular valve, and pul- ular septal defect, pulmonic valve stenosis
monic valve stenosis which leads to right ventricular hypertrophy,
B. Atrial septal defect, right and an aorta which is large and accepts
ventricular hypertrophy, pul- blood from the right ventricle "overriding"
monic valve stenosis, and an the stenotic pulmonic valve. This results in
overriding aorta right to left shunting and early cyanosis
C. Ventricular septal defect, (in infancy or early childhood). Chest x-ray
left ventricular hypertrophy, would show a "boot shaped" heart due to
aortic valve stenosis, and an the right ventricular hypertrophy. Affected
overriding aorta individuals may have "tet spells" in which
D. Ventricular septal defect, they may suddenly become cyanotic and
right ventricular hypertrophy, pass out. Frequently affected children will
pulmonic valve stenosis, and squat during these spells to increase ve-
an overriding aorta nous return and improve right ventricular
filling resulting in more blood ejecting into
the pulmonic artery to become oxygenated.

21. A 62 year old female with a his- E. Tricuspid valve stenosis

tory of hypertension presents This patient has carcinoid syndrome which
with increasing shortness of consists of diarrhea, facial flushing, reac-
breath, abdominal pain and tive airways causing shortness of breath
diarrhea. Computed tomogra- and cardiac valvular disease specifically of

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phy reveals a mass in the right-sided heart valves since the toxins
appendix and multiple nod- produced by the tumor are filtered by the
ules in the liver. Chest x-ray lungs and never reach the left sided heart
is normal. Serum 5-hydroxyin- valves (unless pulmonary metastasis are
doleacetic acid levels are ele- present).
vated. Which of the following
cardiac disorders is she likely
to have?
A. Aortic valve stenosis
B. Aortic valve regurgitation
C. Mitral valve stenosis
D. Mitral valve regurgitation
E. Tricuspid valve stenosis

22. A 48 year old male with a his- C. Elevated myoglobin, normal troponin I,
tory of hypertension and high and normal CK-MB
cholesterol presents to the During myocardial infarction, certain car-
emergency department with diac biomarkers are released into the
chest pains for 60 minutes. He bloodstream early and others late. Myoglo-
describes a substernal chest bin is non-specific enzyme which only takes
pressure "like an elephant on 30 minutes to elevate in the serum after
my chest" associated with the onset of myocardial infarction. Troponin
shortness of breath and di- I and CK-MB elevate 3-4 hours after onset.
aphoresis. His ECG shows ST Troponin I will stay elevated for 7-10 days
elevations consistent with my- and CK-MB for only 3-4 days, thus CK-MB
ocardial infarction. Which of is the preferred test to check for re-infarction
the following laboratory re- (for example 5 days after a prior MI).
sults would be expected?
A. Elevated myoglobin, elevat-
ed troponin I, and elevated
CK-MB
B. Normal myoglobin, elevat-
ed troponin I, and normal
CK-MB
C. Elevated myoglobin, nor-
mal troponin I, and normal
CK-MB
D. Normal myoglobin, nor-
mal troponin I, and elevated
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CK-MB
E. Normal myoglobin, normal
troponin I, and normal CK-MB

23. A 29 year old male with C. Coarctation of the aorta

no past medical history has Coarctation of the aorta occurs when the
been experiencing headaches congenital narrowing of the aorta occurs.
for the past few months. His About two thirds of patients with coarctation
blood pressure is noted to of the aorta have a bicuspid aortic valve as
be 210/110. Physical examina- well. Depending on the location of the nar-
tion reveals an S4 heart sound rowing differing presentations may occur.
and reduced femoral pulses. Infantile coarctation of the aorta presents
Which of the following is asso- when the stenosis is proximal or next to the
ciated with his condition? ductus arteriosus. When the ductus arterio-
A. Atrial septal defect sus closes (as it should in normal infants),
B. Wolff-Parkinson-White syn- a severe increase in afterload occurs result-
drome ing in congestive heart failure (since blood
C. Bicuspid aortic valve was normally able to traverse the patent
D. Mitral valve regurgitation ductus arteriosus resulting in lower resis-
tance, then suddenly is unable to).
Adult coarctation of the aorta occurs distal
to the ductus arteriosus and is usually di-
agnosed in the 2nd or 3rd decade of life.
Patients present with hypertension and di-
astolic congestive heart failure. The blood
pressure in the legs (and hence pulses) are
markedly lower than in the arms. Collateral
arterial circulation develops to allow blood
to reach the lower extremities, mostly in
the internal mammary arteries (which give
rise to the intercostals arteries). The inter-
costals arteries then become enlarged due
to the pressure overload and can be visibly
seen on chest x-ray as small boney deficits
in the ribs termed "rib notching".

24. A 68 year old male suffers C. Dressler's syndrome

a myocardial infarction. Six Dressler's syndrome is an autoimmune
weeks later he begins to have pericarditis what occurs weeks to months

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sharp substernal chest pains after myocardial infarction. The typical ECG
radiating to his left neck worse changes of pericarditis occur (diffuse ST
with laying flat and better segment elevation in a concave upward
while sitting up and lean- shape with PR depression). Symptoms
ing forward. His electrocardio- of pericarditis include sharp chest pain
gram is below. Which of the worse with lying flat and better with lean-
following is his likely diagno- ing forward and pain that radiates to the
sis? left trapezius muscle. Dressler's syndrome
A. Ventricular free wall rupture is thought to be due to antibodies pro-
B. Acute mitral valve regurgi- duced against an unknown myocyte pro-
tation tein. Those antibodies crossreact with peri-
C. Dressler's syndrome cardial antigens resulting in inflammation
D. Left ventricular aneurysm and pericarditis. The physical exam findings
E. Aortic dissection of pericarditis include a pericardial friction
rub, however it is not always present. Treat-
ment includes NSAIDs such as ibuprofen
and if needed corticosteroids. Avoiding anti-
coagulation is recommended due to the risk
of spontaneous hemorrhage into the peri-
cardium in Dressler's syndrome resulting in
cardiac tamponade.

25. A 76 year old female with B. Mitral valve regurgitation

a history of coronary artery Mitral regurgitation occurs as a complica-
disease and prior inferior tion of an inferior wall myocardial infarction
wall myocardial infarction pre- due to papillary muscle dysfunction result-
sents with gradual onset of in- ing in failure of the mitral valve leaflets to
creased shortness of breath coapt normally. Recall the cardiac anatomy
on exertion and lower ex- of the mitral valve, specifically that there
tremity swelling. Her physi- are two papillary muscles, the anterolat-
cal examination reveals a IV/VI eral and posteromedial. The anterolateral
holosystolic murmur at the papillary muscle is perfused by the left an-
5th intercostals space at the terior descending AND the left circumflex
mid-clavicular line. Which of coronary arteries, thus dysfunction of the
the following is likely the anterolateral papillary muscle is uncommon
cause of her symptoms? (since it would require two major artery oc-
A. Tricuspid valve regurgita- clusions). The posteromedial papillary mus-
tion cle receives its sole blood supply from the
B. Mitral valve regurgitation right coronary artery (which also supplies
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C. Ventricular septal defect the inferior wall in 80% of people). Thus a
D. Mitral valve stenosis right coronary artery occlusion resulting in
E. Left ventricular aneurysm inferior wall myocardial infarction frequently
causes mitral regurgitation due to concomi-
tant papillary muscle infarction. Rarely, rup-
ture of a papillary muscle can cause acute
mitral regurgitation and cardiogenic shock
which requires emergent surgical correc-
tion.

26. An 81 year old female with a B. Elevated international normalized ratio

history of pulmonary embo- (INR)
lus is taking warfarin for anti- Warfarin (coumadin) elevates the protrom-
coagulation. She is given an- bin time (PT) by inhibition of vitamin K de-
tibiotics for pneumonia and pendent clotting factors II, VII, IX and X. The
has noted blood in her stool. international normalized ratio (INR) is an-
Which of the following labo- other measure of PT which was standard-
ratory abnormalities would be ized due to inconsistencies between differ-
expected? ent PT assays used in different hospitals.
A. Elevated activated partial Many drug interactions exist with warfarin
thromboplastin time (PTT) which include antibiotics (since the eradi-
B. Elevated international nor- cate normal gastrointestinal flora which pro-
malized ratio (INR) duce vitamin K), verapamil, cimetidine and
C. Elevated bleeding time foods rich in vitamin K.
D. Elevated factor Xa assay

27. A 72 year old male with a his- B. Left ventricular aneurysm

tory of diabetes mellitus and LV aneurysm: complication of an anterior
hypertension presents to the wall myocardial infarction that can cause
emergency department with significant clinical issues e.g. congestive
chest pains. He is diagnosed heart failure, ventricular arrhythmias, left
with an anterior wall myocar- ventricular thrombus formation, and left
dial infarction and appropri- ventricular rupture, leading to cardiac tam-
ate therapy is undertaken. Two ponade. On ECG t -> ST segment eleva-
months later he is seen by tion anywhere from lead V1 to lead V4, Q
his cardiologist for dyspnea waves in those leads and a history of a
on exertion and lower extrem- previous anterior wall myocardial infarction
ity swelling. His ECG is below. more than 6 weeks prior.
What is his most likely diagno- Pericarditis: diffuse ST segment elevation

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sis? (concave upward) and PR depression.
A. Pericarditis Early repolarization: "J point elevation", oc-
B. Left ventricular aneurysm curs most commonly in young healthy peo-
C. Early repolarization ple.
D. Cardiac tamponade Cardiac tamponade is not able to be di-
agnosed on ECG, although you may see
low voltage due to the pericardial effusion
dampening the ECG signal or "electricle
alternans" due to the heart wobbling in
the pericardial effusion causing every other
beat to be dampened.

28. An 18 year old male with no D. Ventricular septal defect

significant past medical his- 3 causes of holosystolic murmurs: mitral
tory presents to his prima- regurgitation, tricuspid regurgitation & ven-
ry care physician for a rou- tricular septal defect. A small ventricular
tine physical examination. He septal defect is quite benign and can cause
has no physical complaints. a very loud holosystolic murmur with a thrill.
His blood pressure is 115/85,
heart rate 80, respirations 12,
and he is afebrile. His physical
examination reveals normal
lung sounds, a V/VI holosys-
tolic murmur with a thrill at the
left lower sternal border and
no change in intensity with
inspiration, no gallops or ex-
tra heart sounds, and normal
jugular venous pressures. His
ECG and laboratory studies
are normal. What is his most
likely diagnosis?
A. Mitral regurgitation
B. Patent ductus arteriosis
C. Tricuspid regurgitation
D. Ventricular septal defect

29. A 24 year old female with no C. Wolff-Parkinson-White syndrome

significant past medical his- Wolff-Parkinson-White syndrome (WPW)

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tory presents to her primary occurs when an abnormal conduction path-
care physician due to intermit- way connects the atrium directly to the ven-
tent palpitations. She states tricles allowing conduction to bypass the
that they occur randomly, can AV node at times. This abnormal pathway
last for many minutes at a time is termed an "accessory pathway" or a
and make her dizzy. She de- "bypass tract". The typical ECG finding of
nies any syncope. Her blood WPW is a short PR interval and a "delta
pressure is 120/80, heart rate wave". A delta wave is slurring of the up-
70 and respirations 12. Phys- stroke of the QRS complex. This occurs
ical examination is normal. since the action potential from the SA node
Laboratory studies are nor- is able to conduct to the ventricles very
mal including thyroid function fast through the accessory pathway, so the
testing. Her ECG is below. QRS occurs immediately after the P wave
What is her diagnosis? making the delta wave.
A. Congenital prolonged QT
syndrome
B. Lown-Ganong-Levine syn-
drome
C. Wolff-Parkinson-White syn-
drome
D. Ventricular tachycardia

ECG SHOWS SHORT PR IN-

TERVAL AND DELTA WAVE
(slurring upstroke of the QRS
complex)

30. A 72 year old female with a his- B. Unstable angina

tory of diabetes mellitus and The patient in this question is clearly suf-
no history of heart disease fering from chest pain due to myocardial is-
presents to the emergency de- chemia. Since the pain occurred at rest and
partment with chest pains at she has no prior history of heart disease,
rest intermittently for the past then she has unstable angina.
4 hours radiating down her Remember there are 3 different patient pre-
left arm. She has associat- sentations that can be classified into unsta-
ed shortness of breath and ble angina:
diaphoresis. Her heart rate - New onset cardiac chest pain (even if it
is 59, blood pressure 134/72, gets worse with exertion and better with
respiratory rate 20, and oxy- rest, the first time it occurs it is considered
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gen saturation 95% on room UA),
air. Physical examination re- - Cardiac chest pain at rest without ST ele-
veals normal lung sounds and vation on the ECG and with negative serum
an S4 gallop. Her ECG re- biomarkers (troponins)
veals ST segment depression - Worsening of known stable angina (used
in leads V1 to V3. She is given to be able to walk 1 block before getting
aspirin immediately. Her tro- chest pain and can now only walk 1/2
ponin levels remain negative. block).
She is currently chest pain ECG findings in unstable angina can vary
free.Which of the following is from a normal ECG to dramatic ST segment
the correct diagnosis? depressions.
A. Stable angina
B. Unstable angina
C. Non-ST segment elevation
myocardial infarction
D. ST segment elevation my-
ocardial infarction

31. A 22 year old college student C. Atrial fibrillation

with no prior past medical With atrial fibrillation, no discrete P waves
history presents to the emer- can be seen, however sometimes coarse
gency room with complaints "fibrillatory waves" may be present. In atrial
of palpitations and dizziness. flutter a "sawtooth" pattern is seen. In mul-
He states he was at a party tifocal atrial tachycardia there are at least 3
recently and had been drink- distinct P wave morphologies present. Our
ing heavily when he noted the patient had been drinking alcohol heavily
symptoms. No chest pains or which resulted in his atrial fibrillation. This is
shortness of breath. His blood known as "holiday heart" as it frequently oc-
pressure is 90/60, heart rate curs in people who do not commonly drink
160, respirations 20, and oxy- then binge on a certain occasion, even in
gen saturation 95% on room the setting of a structurally normal heart.
air. A portion of his ECG is
below. What is his most likely
diagnosis?
A. Multifocal atrial tachycardia
B. Ventricular tachycardia
C. Atrial fibrillation
D. Atrial flutter

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ECG shows no discrete P
waves

32. A 42 year old male with a his- A. Pulsus bisferens

tory of hypertension has been Patient has severe aortic regurgitation with
experiencing dyspnea on ex- symptoms of congestive heart failure (i.e.
ertion. He denies any chest dyspnea on exertion, lower extremity ede-
pain. His blood pressure is ma, generalized fatigue). The murmur of
140/40, heart rate 90, and res- aortic regurgitation is an early diastolic de-
pirations 18. Physical exami- crescendo murmur. An additional diastolic
nation reveals elevated jugu- murmur can sometimes be heard at the
lar venous pressure and an apex due to the regurgitant blood striking
early systolic ejection sound the anterior leaflet of the mitral valve caus-
is heard. A III/IV early diastolic ing it to vibrate (Austin-Flint murmur).
decrescendo murmur heard
best at the right upper ster- Also, due to the high flow state across the
nal border is present along aortic valve, an aortic flow systolic ejection
with a I/IV diastolic rumble murmur can be heard at the aortic listen-
at the apex. Also noted is a ing post (since a good portion of the blood
II/VI systolic ejection murmur ejected out of the left ventricle goes back-
at the right upper sternal bor- ward into the left ventricle, a proportional-
der. What other physical exam ly larger amount must be ejected forward
finding might you expect? to maintain normal cardiac output). This is
A. Pulsus bisferens the one cardiac condition that can mimic
B. Pulsus alternans the murmur of a patent ductus arteriosus
C. Pulsus paradoxus since they both have audible murmurs in
D. Pulses parvus et tardus systole and diastole. Lastly, the pulse pres-
sure is widened since again there is sig-
nificant backflow of blood in diastole into
the left ventricle which reduces the diastolic
pressure. This patient has an extra systolic
sound which may be from a bicuspid aortic
valve.

Pulsus bisferens occurs in patients with

significant aortic valve regurgitation. There
is a double pulse felt due to the backflow
of blood in early diastole. The first carotid
pulse felt is normal systole. The second is
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actually early diastolic due to the regurgi-
tating blood.

Pulsus alternans: severe left ventricular fail-

ure.
Pulsus paradoxus: cardiac tamponade/se-
vere asthma exacerbations.
Pulsus parvus et tardus: aortic stenosis.

33. An 48 year old male with a his- B. Dressler's syndrome

tory of hypertension presents Dressler's syndrome is an autoimmune
to the emergency room with pericarditis which occurs weeks to months
chest pain. He is diaphoret- after myocardial infarction. The typical ECG
ic and also complaining of changes of pericarditis occur (diffuse ST
shortness of breath. His tem- segment elevation in a concave upward
perature is 37.1 C, blood pres- shape with PR depression). Our patient
sure 120/82, heart rate 82 and had the typical symptoms of pericarditis
respirations 20. His physical which include sharp chest pain worse with
examination is significant for lying flay and better with leaning forward
an S4 heart sound. ECG re- and pain that radiates to the left trapez-
veals an inferior wall ST el- ius muscle. Dressler's syndrome is thought
evation myocardial infarction to be due to antibodies produced against
and appropriate treatment is an unknown myocyte protein. Those anti-
undertaken. He is discharged bodies crossreact with pericardial antigens
home and was doing well. Two resulting in inflammation and pericarditis.
months later he develops a The physical exam findings of pericarditis
sharp chest pain worse with include a pericardial friction rub, howev-
laying flat radiating to his left er it is not always present. Treatment in-
neck. He returns to his cardi- cludes NSAIDs and, if needed, corticos-
ologist and his temperature is teroids. Avoiding anticoagulation is recom-
38.5 C, blood pressure 118/82, mended due to the risk of spontaneous he-
heart rate 80 and respirations morrhage into the pericardium in Dressler's
18. Physical examination is syndrome resulting in cardiac tamponade.
normal. ECG reveals ST seg-
ment elevation in leads I, II, III,
aVF, aVL and V1-V4 as well as
PR depression in lead II. What
is the most likely diagnosis at
this time?
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A. Left ventricular rupture
B. Dressler's syndrome
C. Anterior myocardial infarc-
tion
D. Early repolarization

34. A 44 year old male with no D. No therapy needed

significant past medical his- According to the ATP III guidelines for LDL
tory presents to his prima- management, a person with 0-1 risk fac-
ry care physician for a rou- tors for coronary artery disease (see be-
tine physical examination. He low) should have an LDL of less than 160
has no physical complaints. mg/dL. If the LDL is between 160-190, then
His blood pressure is 115/85, diet/lifestyle modifications should be initiat-
heart rate 80, respirations 12, ed. If the LDL is > 190, then medications
and he is afebrile. His phys- (HMG-CoA reductase inhibitor or "statin")
ical examination reveals nor- should be started. Coronary heart disease
mal lung sounds and normal risks factors include tobacco use, hyper-
heart sounds. His ECG is nor- tension, low HDL levels, a family history of
mal. Laboratory studies reveal premature heart disease (male < 55 years
an total cholesterol of 220 old or female < 65 years old), and age (men
mg/dL, LDL 145 mg/dL, HDL > 45 and women > 55). An HDL cholesterol
40 mg/dL and triglycerides of of > 60 mg/dL counds as a negative risk
145 mg/dL. What is the most factor (cancels out 1 risk factor).
appropriate treatment?
A. Diet/lifestyle modifications
B. Diet/lifestyle modifications
and a HMG-CoA reductase in-
hibitor
C. Diet/lifestyle modifications,
a HMG-CoA reductase in-
hibitor and niacin
D. No therapy needed

35. A 62 year old male with a D. Streptococcus bovis

history of mitral valve pro- This case is a classic presentation of sub-
lapse, rheumatoid arthritis, acute endocarditis. Some pathogens are
and colon cancer presents to more aggressive than others and can ac-
the emergency room with in- tually present with septic shock such as
creased dyspnea on exertion, Staph aureus and Pseudomonas aurigi-

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 Cardiology MCQ
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lower extremity swelling, and nosa. Candidal endocarditis is rare in im-
fevers slowly worsening over munocompetent persons and the vegeta-
the past month. His tempera- tions seen are quite large (usually > 1 cm).
ture is 38.0 C, blood pressure Streptococcus viridins group is the most
95/65, heart rate 80, respira- common cause of endocarditis and pre-
tions 20, and oxygen satura- sents in a subacute fashion (similar to Ente-
tion 92% on room air. Phys- rococcus endocarditis). Specifically, Strep-
ical examination reveals nor- tococcus bovis (a type of Strep viridins) is
mal breath sounds, a II/VI strongly correlated with active colon cancer,
holosystolic murmur at the thus if blood cultures were indeed positive
apex, and 1+ bilateral lower for this organism, a colonoscopy should be
extremity pitting edema. Lab- performed
oratory studies show a WBC
count of 20 thousand and an
ESR of 100. Echocardiogram
reveals an 8 mm mobile veg-
etation on the anterior leaflet
of the mitral valve. Which of
the following is the most likely
pathogen?
A. Staphylococcus aureus
B. Pseudomonas auriginosa
C. Candida albicans
D. Streptococcus bovis

36. A 17 year-old-male with no B. Hypertrophic obstructive cardiomyopa-

significant past medical histo- thy
ry passes out while running. The murmur of HOCM can mimic that
He states that he was feel- of aortic valve stenosis: a mid-systolic
ing a little dizzy prior to the crescendo-decrescendo murmur heard at
event, but no chest pains or the right upper sternal border. The main
palpitations. His blood pres- difference is that the murmur of HOCM in-
sure is 115/85, heart rate 80, creases in intensity with Valsalva (due to
respirations 12 and he is decreased left ventricular volume/chamber
afebrile. His physical exam- size allowing more obstruction to occur).
ination reveals normal lung
sounds, a II/VI mid-systolic
crescendo-decrescendo mur-
mur is heard at the right upper
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sternal border which increas-
es in intensity with Valsalva,
an S4 heart sound is also pre-
sent. Laboratory studies are
normal. What is his most likely
diagnosis?
A. Congenital pulmonic valve
stenosis
B. Hypertrophic obstructive
cardiomyopathy
C. Congenital aortic valve
stenosis
D. Commotio cordis
E. Atrial septal defect

37. A 68 year old female with a E. Constrictive pericarditis

history of hypertension, dia- Constrictive pericarditis occurs when the
betes, coronary artery disease pericardium scars and prevents the right
treated with coronary artery ventricle from filling properly. This results in
bypass grafting 20 years ago, severe right-sided congestive heart failure
presents to the emergency consisting of lower extremity edema, mas-
room with increasing short- sive hepatomegaly and a pulsatile liver, as-
ness of breath and lower ex- cites and even hepatic cirrhosis from blood
tremity edema. She denies "congesting" the liver. The physical exam
any chest pains and does not findings also include a pericardial knock on
drink alcohol. Her tempera- cardiac auscultation (an extra-systolic heart
ture is 37.0 C, blood pressure sound just after S1) and Kussmal's sign
110/70, heart rate 110, and res- which is a paradoxical increased in jugular
pirations 20. Physical exami- venous pressure with inspiration (normally
nation reveals a cachectic ap- inspiration increases venous return and the
pearance, marked jugular ve- right ventricle can easily accept the blood,
nous distension worse with however with pericardial constriction it can
inspiration, decreased breath accept only a small amount of blood and
sounds at the left base, pul- the rest backs up resulting in the jugular
monary rales throughout the venous distension). The only treatment is
lung fields, a regular rhythm surgical pericardial stripping which carries
with an extrasystolic heart a high mortality rate.
sound, hepatomegaly with as-
cites, and 3+ pitting lower
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 Cardiology MCQ
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extremity edema above the
knees. ECG is normal. Labo-
ratory studies reveal elevated
AST, ALT, and total bilirubin.
A hepatitis profile is normal.
Which of the following is the
most likely diagnosis?
A. Restrictive cardiomyopathy
B. Systolic congestive heart
failure
C. Tricuspid regurgitation
D. Cardiac tamponade
E. Constrictive pericarditis

38. A 70 year old female with A. Intravenous fluids

a history of coronary artery This patient has cardiac tamponade. Re-
disease, hypertension, arthri- member that the right-sided heart cham-
tis, and breast cancer pre- bers are the lowest pressure chambers,
sents with dyspnea on ex- thus as intrapericardial pressure rises,
ertion and dizziness slowly these chambers will be first compressed.
progressing over the past 2 Also recall that right sided heart pressures
weeks. She denies any chest reflect "preload" which is determined by
pains. Her blood pressure is 2 things: 1. intravenous volume (hydration
80/40, heart rate 120, respira- status) and 2. venous tone (dilated vs con-
tions 24 and oxygen satura- stricted). Giving fluids will allow the right
tion 88% on room air. Physi- ventricle to fill better and increase pre-
cal exam revealed pulmonary load will improve the blood pressure. Nitro-
rales at the left lung base, glycerine decreases preload by venodilat-
distant heart sounds, and el- ing. Eventually pericardiocentesis would be
evated jugular venous pres- needed.
sures especially with inspira-
tion. Her pulsus paradoxus is
20 mm Hg. Laboratory studies
are normal. Which of the fol-
lowing is the best initial man-
agement of this patient?
A. Intravenous fluids
B. Intravenous beta-blockers

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C. Pericardiocentesis
D. Coronary angiography

39. Diagnosis of bacterial endo- D. mitral and tricuspid: atrial surface

carditis is made and gentam- aortic and pulmonary: ventricular surface
icin therapy is initiated. In
a patient with endocarditis,
where are the sites of bacterial
deposition usually located?
A. mitral and tricuspid: ven-
tricular surface, aortic and
pulmonary: ventricular sur-
face
B. mitral and tricuspid: ven-
tricular surface, aortic and
pulmonary: vascular surface
C. mitral and tricuspid: atri-
al surface, aortic and pul-
monary: vascular surface
D. mitral and tricuspid: atri-
al surface, aortic and pul-
monary: ventricular surface
E. mitral and tricuspid: ven-
tricular surface, aortic and
pulmonary: atrial surface

40. A 27 year old female with no D. Mitral valve stenosis

significant past medical histo- Patients with severe mitral valve stenosis
ry is 40 weeks pregnant and frequently are unable to hemodynamically
labor has just begun. She be- tolerate the stress of pregnancy or labor
gins to complain of short- resulting in congestive heart failure, in our
ness of breath which wors- case acute pulmonary edema. The physical
ens throughout delivery to exam findings are typical for mitral steno-
the point of requiring intuba- sis which include an early diastolic murmur
tion. She had never previously with an opening snap (see heart murmurs).
complained of any dyspnea or The only good treatment is mitral valve
chest pains. Her temperature valvuloplasty or surgical repair. Remember
is 37.0, blood pressure 90/50, almost 100% of cases of mitral stenosis are
heart rate 130, respirations 26 from rheumatic heart disease.

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and oxygen saturation 100%
on 60% FiO2 on the ventilator.
Physical examination reveals
diffuse pulmonary rales, a II/IV
early diastolic murmur, and no
lower extremity edema. Lab-
oratory studies are normal.
ECG shows sinus tachycar-
dia and left atrial enlargement.
Her chest x-ray has significant
pulmonary edema. Which of
the following is the most likely
diagnosis?
A. Aortic dissection
B. Coronary artery dissection
C. Aortic valve stenosis
D. Mitral valve stenosis

41. Which of the following mecha- A increased sympathetic stimulation

nisms is responsible of sinus
tachycardia?
A increased sympathetic stim-
ulation
B reduced sympathetic stimu-
lation
C increased parasympathetic
vagal stimulation
D atrial fibrillation
E all of the above mechanisms

42. The clinical presentation of E the detection of petechiae, janeway le-

infective endocarditis (IE) in- sions, roth spots, osler nodes, and splinter
cludes a number of signs haemorrhages is a specific feature of IE
and symptoms. Which of the and so we can make a definite diagnosis
following sentences best de-
scribes it:
A fever is always present, of if
no fever we can rule out the
diagnosis of suspected infec-

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 Cardiology MCQ
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tive endocarditis
B patients with IE rarely pre-
sent with congestive heart
failure, and frequently present
with strokes
C the most frequent complica-
tion of IE is congestive heart
failure, but patients may also
have stoke or renal dysfunc-
tion
D All patients with IE present
with fever and murmur is au-
dible on auscultation
E the detection of petechiae,
janeway lesions, roth spots,
osler nodes, and splinter
haemorrhages is a specific
feature of IE and so we can
make a definite diagnosis

43. A 28 year old female with e. coxsackie B virus

no prior medical history be-
comes markedly short of
breath and hypotensive over
a 3 day time period. She
had been suffering from up-
per respiratory tract infection
starting 1 week ago. PE re-
veals no murmurs, an S3 heart
sound is present, elevated
jugular venous pressure, pul-
monary rales and lower ex-
tremity oedema. An ECG con-
firms an EF=10%. Which of the
following is the most common
culprit of her condition ?
a. hepatitis B virus
b. human immunodeficiency
virus
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c. epstein-barr virus
d. influenza A virus
e. coxsackie B virus

44. A 65y old man admitted to ER D. acute myocardial infarction (STEMI)

for oppressive chest pain and
dyspnea since 1h. ECG shows
pattern of ST segment eleva-
tion. Which is the following di-
agnosis ?
A. ventricular fibrillation
B. acute pericarditis
C. arterial hypertension
D. acute myocardial infarction
(STEMI)
E. pulmonary embolism

45. A 62y old man presents grad- B. maximise medical therapy for heart fail-
ual onset fatigue, DOE (dys- ure
pnea on exertion), and low-
er extremity edema. He has
a history of CAD and under-
went 3-vessel coronary by-
pass surgery 10 years ago.
His examination is remarkable
for a JVP of 10mmHg, and
S3 gallop and displaced apical
impulse, crocodile sounds in
the base of his lungs bilater-
ally and 2+ lower extremities
oedema bilaterally. An ECG
shows: sinus rhythm with ev-
idence of a previous ante-
rior MI and LV EF of 40%
with anterior akinesia from
the base of the heart to the
apex. A myocardial perfusion
study showed no reversible
ischemia. An 24h Holter test

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did not reveal any significant
arrhythmias. What is the next
step in his care?
A. refer to ICD (implantable
cardioveter defibrillator) im-
plantation
B. maximise medical therapy
for heart failure
C. refer to invasive coronary
angiography
D. initiate anti-arrythythmic
medications
E. refer for coronary bypass
grafting

46. A 62y old men with hyper- A. myocardial oxygen demand exceeds my-
tension and smoking habits ocardial oxygen supply
refers stable exertion angi-
na. His cardiologist recom-
mends a stress test that re-
sults positive for inducible is-
chemia. Which of the follow-
ing is the pathophysiological
mechanism underlying MI?
A. myocardial oxygen demand
exceeds myocardial oxygen
supply
B. myocardial oxygen demand
retain stable and myocardial
oxygen supply increases
C. myocardial oxygen demand
is inferior to myocardial oxy-
gen supply
D. myocardial oxygen demand
is mismatched by myocardial
oxygen supply
E. none of the above

47.

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A 64y old man presents symp- D. percutaneous coronary intervention
toms of progressive angina (PCI) with stent implantation
pectoris. Coronary artery an-
giography is performed and
shows sub occlusion of the
distal portion of the left an-
terior descending (LAD) coro-
nary artery. Which is the op-
timal therapeutical approach
for this patient
A. start anti-platelet therapy
with aspirin and clopidogrel
B. intensify beta-blockers
therapy
C. coronary bypass surgery
D. percutaneous coronary in-
tervention (PCI) with stent im-
plantation
E. none

48. 78y old man with diabetes C. Doppler and tissue doppler ECG
and hypertension presents to
your office with progressive
dyspnea and lower extremity
swelling. In addition to order-
ing an ECG for assessment of
LV systolic function, what is
currently the most appropri-
ate next test to asses his dias-
tolic function?
A. Cardiac MR
B. Cardiac CT
C. Doppler and tissue doppler
ECG
D. left heart catheterization
E. BNP essay

49. A 63y old with severe aortic E. oral vitamin K antagonists

RG undergoes surgical aor-

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tic valve replacement with the C) for bypass performed on patients with
implantation of a mechanical stable coronary artery disease (CAD)
heart valve. Which of the fol- D) for bypass performed on patients with
lowing medications should be acute coronary syndromes (P2Y12 = more
recommended in this patient a profound platelet inhibition as compared
to prevent thrombosis and its to the clopidogrel)
complications?
A. statins
B. aspirin
C. dual anti-platelet therapy:
aspirin and clopidogrel
D. dual anti-platelet thera-
py: aspirin and new P2Y12
inhibitor (prasugrel or tica-
grelor)
E. oral vitamin K antagonists

50. A patient arrives at the ER A. pulmonary embolism

with a sudden onset of
breathlessness and hemopt-
ysis (coughing of blood). He
had history of chronic ob-
structive pulmonary disease
(COPD) and underwent surgi-
cal hip replacement 2 weeks
previously. On examination,
his pulse was 110 beats per
min. ECG showed a sinus
rhythm. His blood pressure
was 140/80 mmHg. The JVP
was not raised and there
was no ankle oedema. Chest
auscultation revealed scantly
wheeze. Lab results showed
an elevated D-Dimer. Which of
the following is the most likely
diagnosis?
A. pulmonary embolism
B. acute pericarditis
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C. atrial fibrillation
D. hyperventilation syndrome
E. acute coronary syndrome

51. A 46y old Marfan syndrome, C. dissection of the aorta

aortic insufficiency/RG and
mitral RG, comes to the
ER due to severe subster-
nal chest pain for the past 3
hours. He describes the pain
as: tearing in quality and ra-
diating to the neck. One week
earlier, he experienced similar
but less severe chest pain and
treated himself with aspirin.
Which of the following is the
most likely underlying cause
of this worsening symptoms?
A. acute bacterial endocardi-
tis
B. acute myocardial infarction
C. dissection of the aorta
D. oesophageal reflux with
spasm
E. perforated peptic ulcer

52. A 80y old female with type 2 di- D. depends on the heart team discussion
abetes mellitus refers to DOE between interventional cardiologist, clinical
since 6 months. She was eval- cardiologist and cardiac surgeon
uated with cardiac MR show-
ing inducible ischemia in the
anterior and posterior walls
with preserved global sys-
tolic function (LVEF=60%). A
coronary angiogram shows a
3 vessel CAD with complex
coronary anatomy, involving
the proximal LAD (left anterior
descending) and bifurcation

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with the 1st diagonal branch,
the proximal circumflex artery
and the proximal and distal
segment of the right coronary
artery. In this case, the deci-
sion between PCI and CABG
should be:
A. always taken by the inter-
ventional cardiologist at the
time of the coronary angiogra-
phy
B. always taken by the cardiac
surgeon
C. always postponed to the
day after coronary angiogra-
phy
D. depends on the heart
team discussion between in-
terventional cardiologist, clin-
ical cardiologist and cardiac
surgeon
E. none

53. A 66y old male with histo- B. primary angiography to allow mechanical
ry of prior MI is admitted to reperfusion to the culprit coronary artery
the ER complaining for chest
pain. An ECG shows ST-eleva-
tion in the inferior leads, de-
termining a diagnosis of ST-el-
evation MI. Which of the fol-
lowing represents the princi-
pal treatment strategy?
A. non-invasive assessment
with coronary CT scan in the
acute setting to confirm diag-
nosis prior to any treatment
B. primary angiography to al-
low mechanical reperfusion to
the culprit coronary artery
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C. implantation of an im-
plantable cardiac defibrillator
(ICD)
D. CABS for complete reperfu-
sion
F. Anti-thrombotic medical
therapy followed by watchful
clinical monitoring for 24h pri-
or to any additional treatment

54. A 51y old woman is admitted A. Acute pericarditis

to the ER complaining of com-
pressive chest pain and dys-
pnea. An ECG report shows
the pattern below (st elevation
in various leads). Which is the
following correct diagnosis?
A. Acute pericarditis
B. Hyperventilation syndrome
C. Acute MI
D. Ventricular fibrillation
E. Pulmonary embolism

55. A 70 year old man is brought C. valve closure contact line on the vascular
to the ER by his wife be- surfaces of the aortic and pulmonary valves
cause of fever and shortness and the atrial surfaces of the mitral and
of breath since 2 days. He un- tricuspid valves
derwent an oral surgical pro-
cedure 6 weeks earlier. His
respiration rate is 22/ min
and blood pressure is 140/60
mmHg. A soft diastolic mur-
mur is heard. After diagnos-
tic work- up, the diagnosis of
bacterial endocarditis is made
and gentamicin therapy is ini-
tiated. In patients with infec-
tive endocarditis, where are
the sites of bacterial deposi-

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tion usually located:
A. valve closure contact line
on the ventricular surfaces
of the aortic and pulmonary
valves and the ventricular sur-
faces of the mitral and tricus-
pid valves
B. valve closure contact line
on the vascular surfaces of
the aortic and pulmonary
valves and the ventricular sur-
faces of the mitral and tricus-
pid valves
C. valve closure contact line
on the vascular surfaces of
the aortic and pulmonary
valves and the atrial surfaces
of the mitral and tricuspid
valves
D. valve closure contact line
on the ventricular surfaces
of the aortic and pulmonary
valves and the atrial surfaces
of the mitral and tricuspid
valves
E. none

56. A 55y old man has 6 months A. Renal artery stenosis

history of dilated cardiomy-
opathy (EF=35%). The patient
was previously healthy and
his only traditional CV risk
factor was age. He also has 1
year history of systolic HTN.
His current medications are:
- Metoprolol 100mg twice daily
- Hydrocholorothiazide 25mg
once daily
- Lisinopril 20mg daily:
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ACE-inhibitor
- Amlodipine10 mg once daily
Despite this treatment, the pa-
tient's BP remains elevated
(165/78 mmHg) with a resting
HR of 92 bpm. This clinical
presentation is most consis-
tent with:
A. Renal artery stenosis
B. viral myocarditis
C. pheochromocytoma
D. amyloid heart disease
E. essential hypertension

57. A 25-year-old man dies sud- A Contraction band necrosis

denly and unexpectedly while
at a nightclub late one
evening. The medical examin-
er performs an autopsy. There
is no evidence for trauma
on external examination of
the body. There are no gross
pathologic findings of inter-
nal organs. Postmortem tox-
icologic findings are signif-
icant for high blood levels
of cocaine and its metabolite
benzoylecgonine. Which
of the following is the most
likely histopathologic finding
involving his heart?
A Contraction band necrosis
B Lymphocytic myocarditis
C Myofiber disarray
D Coronary thrombosis
E Pericardial tamponade

58. A 27-year-old man has be- B. Atrial septal defect

come severely ill with fever

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and malaise over the past 3
days following tooth extrac-
tion. On examination he has
a temperature of 38.8°C, heart
rate of 105/ minute, respirato-
ry rate of 24/min, and blood
pressure of 80/40 mm Hg. He
has a widely split S2 heart
sound and a rumbling mid-di-
astolic murmur. He has small
hemorrhages visible on nail
beds. His spleen tip is palpa-
ble. Which of the following car-
diac conditions is most like-
ly to predispose him to this
acute illness?
A. Hypoplastic left heart syn-
drome
B. Atrial septal defect
C. Chagas disease
D. Coronary atherosclerosis
E. Hypertrophic cardiomyopa-
thy

59. A 23-year-old primigravida B Hypoplastic left heart

gives birth following an un-
complicated pregnancy to a
2870 gm girl infant. The baby
initially does well, but 12
hours following delivery she
develops respiratory difficul-
ty. On examination the infant
has a poor color, weak pulses,
and oxygen saturation of only
90%. Which of the following
cardiac findings is this infant
most likely to have?
A Muscular ventricular septal
defect
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B Hypoplastic left heart
C Complete transposition
with no shunt
D Secundum type atrial septal
defect
E Congenital Group B Strepto-
coccus infection

60. 53-year-old man has had d Metastatic carcinoma

malaise for the past 3 months.
On physical examination he Pericardial tumor and tuberculosis are the
is afebrile. On auscultation of typical causes for a hemorrhagic
the chest, heart sounds are pericarditis.
distant and there is a fric-
tion rub. An echocardiogram
shows a pericardial fluid col-
lection. A pericardiocentesis
yields 10 mL of bloody fluid.
Which of the following condi-
tions is most likely to give rise
to these findings?
a Autoimmune disease
b Chronic renal failure
c Rheumatic fever
d Metastatic carcinoma
e Acute myocardial infarction

61. 81 year old female with histo- B. elevated international normalised ratio
ry of PE is taking warfarin for (INR)
anticoagulation. She is given
antibiotics for pneumonia and
has noted blood in her stools.
Which of the following labo-
ratory abnormalities would be
expected ?
A. elevated activated partial
thromboplastin time (PTT)
B. elevated international nor-
malised ratio (INR)

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C. Elevated troponin
D. elevated factor Xa assay
E. elevated bleeding time

62. 65y old man with history of C. b-type natriuretic peptide

congestive heart failure and
severe COPD complains of in-
creasing dyspnea on exertion,
lower extremity edema, parox-
ysmal nocturnal dyspnea and
orthopnea. His ejection frac-
tion is 15%. On PE, S3 heart
sound, pulmonary rales, and
lower extremity pitting edema.
Which of the following ele-
vates in the serum with con-
gestive heart failure, reduces
preload and after load and
causes diuresis?
A. aldosterone
B. carbon dioxide
C. b-type natriuretic peptide
D. endothelin
E. cortisol

63. Which of the following is a D. age

non-modifiable risk factor for
CV risks ?
A. dyslipedemia
B. physical inactivity
C. obesity
D. age
E. none of the above

64. A 51y old female patient with E. pulmonary artery hypertension

advanced systemic sclerosis
and a recent hospital admis-
sion reported to the ER with
progressive worsening of fa-

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tigue, dyspnea and chest dis-
comfort. She has been recent-
ly admitted and discharged
with diagnosis of pericarditis
and medicated with NSAIDs
and diuretics.
She returns to ER with persist-
ing symptoms. ECG showed
moderate pericardial effusion
but no cardiac tamponade,
impaired left ventricular re-
laxation with normal ejection
fraction, dilatation of right
heart chambers with signs
of right-sided overload and
elevated estimated systolic
pulmonary arterial pressure
(98mmHg). A thoracic an-
gio-CT excluded PE. Right
heart catheterisation reports
as follows:
- mean pulmonary arterial
pressure : 43 mmHg (normal
value btw 9-19mmHg/ aver-
age:15)
- right atrial pressure : 7
mmHg (normal value between
1-5mmHg/ average:3)
- pulmonary capillary or
wedge pressure : 11 mmHg
(normal value btw 4-12mmHg/
average 9)
- pulmonary arterial resis-
tance: 7.8 wood
- cardiac index: 2.25 l/min/m2
(normal range of cardiac
index at rest is 2.6-4.2
L/min/m2.)
Which is the diagnosis ? A.
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acute PE
B. pulmonary hypertension
due to left heart disease
C. acute heart failure
D. constrictive pericarditis
E. pulmonary artery hyperten-
sion

65. A 55 year old male com- B. Heavy alcohol use

plains of increasing dyspnea
on exertion and orthopnea.
His physical examination re-
veals an S3 heart sound, pul-
monary rales, jugular venous
distension, and lower extrem-
ity edema. Coronary angiog-
raphy is normal. An echocar-
diogram confirms an ejection
fraction of 5% indicating se-
vere congestive heart failure
and dilated cardiomyopathy.
Which of the following could
explain the above findings?
A. A history of heroin abuse
B. Heavy alcohol use
C. Tuberculosis infection
D. Prior chemotherapy with
cisplatin
E. none of the above

66. A 36 year old female with no D. Mitral valve balloon valvotomy

significant past medical histo-
ry is being evaluated for in- Mitral stenosis occurs most commonly due
creasing to rheumatic heart disease and the mitral
shortness of breath. Her phys- valve is the most common valve affected.
ical examination reveals a II/IV Only half of patients will recall an initial
early diastolic decrescendo episode of rheumatic fever.Medications (B)
murmur occurring after an are not effective to treat mitral stenosis
early diastolic opening snap. since the problem itself is anatomical, thus

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Which of the following is the relieving the stenosis is key. The less inva-
ideal therapy for her cardiac sive procedure of mitral valve balloon valvo-
disorder? tomy is preferred over open surgical repair
A. Observation (C) if possible.
B. Angiotensin converting en-
zyme inhibitor
C. Surgical mitral valve repair
D. Mitral valve balloon valvoto-
my
E. none of the above

67. Which of the following de- C. Ventricular septal defect, left ventricular
scribes the cardiac anomalies hypertrophy, aortic valve stenosis, and an
associated with the tetralogy overriding aorta
of Fallot?
A. Atrial septal defect, ventric-
ular septal defect, a common
atrioventricular valve, and pul-
monic
valve stenosis
B. Atrial septal defect, right
ventricular hypertrophy, pul-
monic valve stenosis, and an
overriding aorta
C. Ventricular septal defect,
left ventricular hypertrophy,
aortic valve stenosis, and an
overriding aorta
D. Ventricular septal defect,
right ventricular hypertrophy,
pulmonic valve stenosis, and
and overriding aorta
E. none of the above

68. A 29 year old male with C. Bicuspid aortic valve

no past medical history has
been experiencing headaches
for the past few months. His
blood pressure is noted to

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be 210/110. Physical examina-
tion reveals an S4 heart sound
and reduced femoral pulses.
Which of the following is asso-
ciated with his condition?
A. Atrial septal defect
B. Wolff-Parkinson-White syn-
drome
C. Bicuspid aortic valve
D. Mitral valve regurgitation
E. none of the above

69. A 22 year old female is not- D. Aortic dissection

ed to have a reduced upper
to lower body segment ratio,
positive Walker and Steinberg
signs, and pectus carinatum.
Her father died suddenly at
the age of 34. She is subse-
quently diagnosed with Mar-
fan's syndrome. Which of the
following was the likely cause
of death of her father?
A. Mitral valve prolapse
B. Aortic valve regurgitation
C. Myocardial infarction
D. Aortic dissection
E. Congestive heart failure

70. A 72y old female with a his- C unstable angina

tory of diabetes mellitus with
no history of heart diseases
goes to ER because of chest
pain at rest for the past 4
hours. She has associated
shortness of breath and di-
aphoresis. Her heart rate is
59, blood pressure 134/72, res-
piratory rate 20 and oxygen

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saturation 95%. On PE, nor-
mal lungs and S4 gallop. On
ECG, ST segment depression
in leads V1 to V3. She is giv-
en aspirin. Her troponin lev-
els are negative. She is cur-
rently chest pain free. Which
of the following is correct di-
agnosis?
A silent ischemia
B stable angina
C unstable angina
D non-ST segment elevation
MI
E ST segment elevation MI

71. A 34y old male experiences D. hypertrophic obstructive cardiomyopath

shortness of breath with min-
imal exertion. PE, revels JVP
markedly worse with inspira-
tion, a regular rhythm with a
S4 heart sound and 2+ low-
er extremity pitting edema.
Lab results are normal. Car-
diac biopsy revealed apple
green birefringence with con-
go red staining. Genetic test-
ing reveals a mutation in the
transthyretin gene. Which of
the following is the correct di-
agnosis ?
A. restrictive cardiomyopathy
B. dilated cardiomyopathy
C. constrictive pericarditis
D. hypertrophic obstructive
cardiomyopathy
E. chagas cardiomyopathy

72. B. ventricular septal defect

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A 26 year old male is noted
with a V/VI holosystolic mur-
mur associated with a thrill at
the left lower sternal border.
He has no health complaints
and is able to exercise regu-
larly without difficulty. Which
of the following is the likely
diagnosis?
A. atrial septal defect
B. ventricular septal defect
C. mitralvalve RG
D. tricuspidvalve RG
E. pericardial effusion

73. A 35y old man presented with C CT pulmonary angiography for chronic
a 10-day history of progres- thromboembolic pulmonary hypertension
sive shortness of breath. He
was free of chest pain, did
not have any syncope. He was
diagnosed with extra-hepatic
portal vein thrombosis follow-
ing episodes of haemateme-
sis (vomiting blood) from 3
years ago, resulting in recur-
rent oesophageal varies re-
quiring banding on several oc-
casions.
PE revealed blood pressure
100/60 mmHg, pulse rate of
88 beats per min, respiration
rate of 16 breaths/min, JV dis-
tention, ascites, a narrow split
second heart sound and ac-
centuation of pulmonic clo-
sure on cardiac auscultation.
TTE shows enlarged right
chambers, moderate tricuspid
RG with severe pulmonary
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hypertension. Although dilat-
ed there was no evidence of
thrombus in the main right
and left pulmonary arteries.
Blood D-Dimer and fibrinogen
were normal. Which examina-
tion would you recommend to
reach diagnosis?
A chest x-ray for pneumonia
B pulmonary angiography for
acute pulmonary embolism
C CT pulmonary angiography
for chronic thromboembolic
pulmonary hypertension
D right heart catheterization
for pulmonary hypertension
E coronary angiography for
obstructive coronary artery
disease

74. A 84 year old male with se- A left-sided congestive HF

vere emphysema and a prior
MI becomes short of breath
with exertion. PE reveals a
III/VI holosystolic murmur at
the cardiac apex, a S3 heart
sound, and rales in the lower
lung fields. No lower extremity
oedema is present. Which of
the following is likely?
A left-sided congestive HF
B right-sided congestive HF
C left and right sided conges-
tive HF
D Cor pulmonale
E MI

75. 46. Which of the following ven- C. inferior

tricular myocardial segments

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is explored by the combina-
tions of: II, III and aVF ECG
leads ?
A. antero-lateral
B. antero-apical
C. inferior
D. antero-septal
E. none of the above

76. Which of the following is not a D. V3

limb lead?
A. aVF
B. II
C. aVL
D. V3
E. all of the above

77. Which of the following ECG B. II

leads is not unipolar ?
A. aVF
B. II
C. aVL
D. V3
E. none of the above

78. Which of the intervals from a D. ST

single ECG beat complex cor-
responds to the timing of a
ventricular repolarization?
A. QT
B. PR
C. RT
D. ST
E. none of the above

79. Which of the intervals from a B PR

single ECG beat complex cor-
responds to the timing of the
atrioventricular conduction?
A. QT
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B. PR
C. PS
D. PT
E. none

80. Which phase of the action po- D. phase 2 to 3 (intermediate to late repo-
tential a myocardial ventricu- larisation)
lar cell corresponds to the T
wave on the surface ECG ?
A. phase 0 (depolarisation)
B. phase 0 to 1 (depolarisation
plus early repolarisation)
C. phase 1 to 2 (early to inter-
mediate repolarisation)
D. phase 2 to 3 (intermediate
to late repolarisation)
E. none

81. During the cardiac electrical A. the left septum

activation in a normal heart,
which of the following seg-
ments of the myocardial ven-
tricle is depolarised the earli-
est?
A. the left septum
B. the right septum
C. the left free wall
D. the right free wall
E. none of the above

82. During the cardiac electrical C. the left free wall

activation, which of the follow-
ing segments of the myocar-
dial ventricle is depolarised
the latest?
A. the left septum
B. the right septum
C. the left free wall

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D. the right free wall
E. none of the above

83. Which activation of what ven- A myocardial septal activation

tricular myocardial segment
does the Q wave of a single
beat ECG complex reflect
A myocardial septal activation
B activation of the right bun-
dle of the specific conduction
system
C activation of the left bun-
dle of the specific conduction
system
D activation of the right ven-
tricular free wall
E none of the above

84. In the ventricular myocardi- B. because repolarisation occurs earlier at

um, why is the repolarisation the epicardial site while depolarisation oc-
dominant vector (T wave) con- curs
cordant
In direction with the depolari-
sation dominant vector (QRS
complex)?
A. because depolarisation and
repolarisation both occur ear-
lier at the endocardial site
B. because repolarisation oc-
curs earlier at the epicardial
site while depolarisation oc-
curs
earlier at the endocardial site
C. because repolarisation oc-
curs earlier at the endocardial
site while depolarisation oc-
curs
earlier at the epicardial site

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D. is unknown
E. all of the above

85. Which of the following mecha- B. reduced depolarisation

nisms is NOT responsible for
tachyarrythmia?
A. enhanced automaticity
B. reduced depolarisation
C. triggered activity
D. uni directional block and
re-entry
E. none of the above

86. Which of the following is D. reduced automaticity

responsible of bradyarrhyth-
mia?
A. enhanced automaticity
B. unidirectional block and
re-entry
C. triggered activity
D. reduced automaticity
E. none of the above

87. Which of the following mech- C. unidirectional block and re-entry

anisms is not responsible for
reduced automaticity?
A. reduced depolarisation
slope
B. increased negativity of
maximum diastolic potential
C. unidirectional block and
re-entry
D. reduced negativity of
threshold potential
E. none of the above

88. Which of the following mecha- A. increased sympathetic stimulation

nisms is responsible of sinus
tachycardia ?
A. increased sympathetic
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stimulation
B. reduced sympathetic stim-
ulation
C. increased parasympathetic
(vagal) stimulation
D. all of the above
E. none of the above

89. Which of the following ar- D. torsades de pointes

rhythmia is not supra ventric-
ular?
A. atrio-ventricular nodal
tachycardia
B. atrial tachycardia
C. sinus bradycardia
D. torsades de pointes
E. none of the above

90. Which of the following ar- A. atrio-ventricular nodal tachycardia

rhythmia is not ventricular?
A. atrio-ventricular nodal
tachycardia
B. torsades de pointes
C. ventricular ectopy
D. ventricular flutter
E. none of the above

91. Which of the following is NOT B. hyperthyroidism

responsible for sinus brady-
cardia?
A. increased vagal stimulation
B. hyperthyroidism
C. aging
D. cardiomyopathy
E. none of the above

92. Which of the following is D. hyperthyroidism

NOT responsible for acute AV
block?
A. myocardial infarction
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B. bacterial endocarditis
C. myocarditis
D. hyperthyroidism
E. none of the above

93. Which of the following is re- A. connective tissue disorders

sponsible for a chronic AV
block?
A. connective tissue disorders
B. hyperthyroidism
C. myocardial infarction
D. myocarditis
E. none of other

94. Which of the following con- A. symptomatic bradyarrythmias

ditions is an indication of
pace-maker therapy ?
A. symptomatic bradyarryth-
mias
B. angina pectoris
C. myocardial infarction
D. myxoedema
E. none of the above

95. Which is the most significant B. diabetes

risk factor for death due to
CAD ?
A. hypertension
B. diabetes
C. elevated LDL
D. tobacco use
E. obesity

96. A 52 year old fame without B coronary artery dissection

CAD and no history of CAD
comes to ER for chest pain as-
sociated to dyspnea. The ECG
shows a ST-segment elevation
and her troponin values are
not normal. Acute MI is diag-
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nosed and the patient under-
goes a coronary angiogram
that is NOT ABLE to identi-
fy plaque rupture or throm-
botic occlusion of the coro-
nary arteries. All of the follow-
ing conditions can also cause
an MI due to an imbalance
between myocardial oxygen
supply and demand EXCEPT:
A coronary artery spasm
B coronary artery dissection
C coronary endothelial dys-
function
D tachy or bradyarrhythmias
E hypotension

97. A 69 year old man reports D. all of the above

stable angina despite optimal
medical therapy. A stress test
documents inducible is-
chemia and is, therefore,
scheduled for a coronary an-
giogram. In which of the fol-
lowing cases is myocardial
revascularisation indicated in
this patient to improve prog-
nosis:
A. left main coronary artery
stenosis > 50%
B. proximal left anterior de-
scending artery stenosis >
50%
C. large area of ischemia
(>10%)
D. all of the above
E. none of the above

98. B. is it recommended to start statins

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A 63y old man with a his-
tory of diabetes and hyper-
tension suffers from an an-
terior STEMI. He is prompt-
ly repressed with primary PCI
without complications. Which
of the following statements is
true regarding long-term med-
ical management of this pa-
tient ?
A. a diastolic blood pressure
goal of < 60 mmHh is recom-
mended
B. is it recommended to start
statins
C. cardiac rehabilitation pro-
grams are indicated only in
patients with LV: EJ<25%
D. the benefit of non-statin
lipid-lowering agents in addi-
tion to statin therapy has not
been
demonstrated
E. dual anti-platelet therapy
should be avoided

99. A 34 male goes to the ER for F. tension pneumothorax

recent-onset dyspnea and fa-
tigue. No medical history ex-
cept for a mild respiratory ill-
ness 1 week ago. His BP is
80/60 mmHg. His pulse is 120
bpm, regular but weak. The
pulse becomes undetectable
to palpation during each inspi-
ration. The jugular veins are
distended. The lungs are clear
to auscultation. What is his di-
agnosis.
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A. acute fibrinous pericarditis
B. acute MI
C. septic shock
D. constrictive pericarditis
E. cardiac tamponade
F. tension pneumothorax

100. A 58 year old F with no history C. mechanical reperfusion with primary an-
of cardiac disorders is admit- gioplasty
ted to ER because chest pain
and shortness of breath since
30min. An ECG shows a STE-
MI. Which is the next step?
A. non-invasive assessment
with a cardiac MR in acute set-
ting
B. implantation of a ICD
C. mechanical reperfusion
with primary angioplasty
D. Coronary bypass surgery
E. watchful clinical monitoring
for 24 hours

101. A 74y old female with CAD B. mitral regurgitation

and prior inferior wall MI pre-
sents gradual onset of in-
creased shortness of breath
on exertion and lower ex-
tremity swelling. Her physi-
cal examination reveals a 4/6
holosystolic murmur at the
5th intercostal space at the
mid-clavicular line. Which of
the following cause of her
symptoms?
A. tricuspid valve regurgita-
tion
B. mitral regurgitation
C. ventricular septal defect

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D. mitral stenosis
E. left ventricular aneurysm

102. A 28y old with no prior A. coxsakie B virus

past medical history becomes
markedly short of breath and
hypotensive over a 3 day pe-
riod after an upper respirato-
ry tract infection 1 week ago.
What pathogen could cause
this?
A. coxsakie B virus
B. HIV
C. epstein-barr virus
D. influenza A vrius
E. echovirus

103. A 56y old M comes for a C. hydrochlorothiazide

return visit. During the last
3 visits he has elevated BP
in range of systolic pressure
of 150-160mmHg and dias-
tolic pressure 90-95 mmHg.
Despite 3-6 months of a new
diet and exercise, nothing has
changed. His past medical
record, except his BP, is good.
He is concerned about his
high BP since his brother died
of a MI in his 60s. Today his BP
is 162/92 mmHg. What do you
do?
A. acetazolamide
B. clonidine
C. hydrochlorothiazide
D. none, continue diet
E. spironolactone

104.

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What patient could benefit B. a teacher with new-onset angina when
best from a routine tread- she has breakfast
mill/exercise stress test ?
A. A 49y old lawyer with
long-standing uncontrolled
high BP
B. a teacher with new-onset
angina when she has break-
fast
C. a 42y old M with a broken
left-arm since 1 week and pre-
sents chest pain after running
3 blocks with a normal resting
ECG
D. A65y with current chest
pain and ECG showing 2mm
ST elevation in multiple leads
E. a 35y old pilot with
left-sided chest pain and nor-
mal ECG

105. A 78y old man with diabetes C. doppler and tissue dopplerUS
and hypertension presents
with progressive dyspnea and
lower extremity swelling. In
addition to ordering a US for
assessment of LV function
what else do you do?
A. cardiac MR
B. cardiac CT
C. doppler and tissue
dopplerUS
D. left heart catheterisation
E. BNP assay

106. A 63y old man presents B. PCI

with symptoms of progres-
sive angina pectoris. Coro-
nary angiography shows an

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affected left-anterior descend-
ing artery while the left main
coronary artery, the circum-
flex artery and the right coro-
nary artery appear free from
CAD. What do you do ?
A. increase statin therapy
B. PCI
C. CABG
D. initiate anti-platelet therapy
with aspirin
E. none

107. A 67y old female with a his- B decreased LV compliance

tory of breast cancer and to-
bacco use complains of dizzi-
ness and dyspnea on exer-
tion (DOE). Her heart sounds
are distant and her systolic
blood pressure is noted to
markedly decrease with inspi-
ration. You suspect a cardiac
tamponade. A leftward shift
in the LV end diastolic pres-
sure-volume curve suggests
which one of the following ?
A increased LV compliance
B decreased LV compliance
C pericardial constraint
D decreased LV systolic func-
tion
E increased LV systolic func-
tion

108. A 17y old male with no sig- B. Hypertrophic obstructive cardiomyopa-

nificant past medical history thy
passes out while running. He
was
feeling dizzy prior to the event

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but no chest pain. His BP:
115/85 mmHg, heart rate: 80,
respirations 12, and he is
afrebile. His PE reveals nor-
mal lungs, a II/VI mid-systolic
crescendo-decrescendo mur-
mur is heard at the right upper
sternal border and increases
with intensity with valsalva, an
S4 heard sound is also pre-
sent. Lab results are normal.
What is the diagnosis?
A. congenital pulmonic valve
stenosis
B. Hypertrophic obstructive
cardiomyopathy
C. congenital aortic valve
stenosis
D. commoti cordis
E. atrial septal defect

109. . A 55y old man with hyperten- A. diet and lifestyle modification because
sion and blood results: total cholesterol < 250 mg/dL
- total cholesterol: 240 mg/dL
- LDL cholesterol: 98mg/dL
- HDL cholesterol: 35mg/dL
- triglycerides: 140 mg/dL

Which is the best treatment ?

A. diet and lifestyle modifica-
tion because total cholesterol
< 250 mg/dL
B. niacin treatment
C. gemfibrozil treatment
D. start statins
E. start aspirin

110. A 78y old man has a syn- C. aortic valve replacement

cope on a treadmill after feel-

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 Cardiology MCQ
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ing dizzy. He had noted chest
pain in the past but transient
and harmless. All vital signs
are good and lab results are
normal. Chest auscultation re-
veals lung sounds, a III/VI late
peaking systolic murmur at
right upper sternal border ra-
diating to coronary arteries
and weak and delayed carotid
impulse. What is the best ini-
tial treatment ?
A. beta-blockers
B. aortic valvuloplasty
C. aortic valve replacement
D. PCI
E. no treatment at this time

111. A 29y M with no past medical C. coarctation of the aorta

therapy has had headaches
for the past few months. His
BP is noted 210/110. On PE, S4
sound and reduced femoral
pulse. Which is the associated
problem ?
A. atrial septal defect
B. wolff-parkinson-white syn-
drome
C. coarctation of the aorta
D. mitralRG
E. MI

112. 68y old man patient with STE- B. primary angioplasty with stent implanta-
MI what is the best treatment tion and dual anti platelet therapy for 1year
?
A. pace-maker implantation
with 4 weeks of rehabilitation
and 1year of anti platelet ther-
apy

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B. primary angioplasty with
stent implantation and dual
anti platelet therapy for 1year
C. primary angioplasty with
stent implantation and aspirin
for 1year
D. no intervention and oral an-
ticoagulation therapy
E. aortic valve replacement

113. A 23y M presents to ER with D pericarditis

sharp chest pain radiating to
the neck and altered mental
status. For the past 3 days he
has severe nausea and vom-
iting attributed to viral gas-
troenteritis. PE, reveals a loud
abnormal scratching sound in
the end systolic and all of di-
astole located near the car-
diac apex. Chest x-ray is nor-
mal. His lab test are below:
- Na+: 145 mEq/L
- K+: 5,4 mEq/L
- Cl-: 103 mEq/L
- HCO3-: 22 mEq/L
- creatinine: 0,9 mg/dl - tro-
ponin I: negative
Which of the following is most
likely his cause of chest pain?
A myocardial ischemia
B aortic dissection
C oesophageal rupture
D pericarditis
E mitral valve rupture

114. A 52 year old female under- B. Polymorphic ventricular tachycardia

went total thyroidectomy due
to thyroid cancer. Her post-op- This patient's scenario is a perfect set-

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 Cardiology MCQ
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erative course was complicat- up for a prolonged QT interval resulting
ed by pneumonia for which in polymorphic ventricular tachycardia (aka
she is being treated with mox- Torsades de pointes). A known complica-
ifloxacin. Post-operative day 5 tion of thyroidectomy is hypocalcemia if
she passed out briefly while the parathyroid glands are accidentally re-
walking in the hallway. Imme- moved as well. Hypocalcemia causes a pro-
diately afterwards her temper- longed QT interval on the ECG. Medica-
ature is 37.0 C (98.6 F), blood tions can do so as well which include flu-
pressure is 120/80, heart rate oroquinolones such as moxifloxacin. Other
70, respirations 16. Physical common culprits include hypokalemia, hy-
examination is unremarkable. pomagnesemia, myocardial ischemia, and
What most likely caused her other medications such as macrolide an-
syncope? tibiotics, antipsychotic medications such as
A. Vasovagal syncope haloperidol, and some antiarrhythmic drugs
B. Polymorphic ventricular such as sotalol. Below is a rhythm strip of
tachycardia polymorphic ventricular tachycardia:
C. Atrial fibrillation
D. Ventricular septal defect

115. A 50 year old male with a his- B. Start lisinopril and hydrochlorothiazide
tory of diabetes mellitus pre-
sents for a routine clinic vis-
it. He has been feeling well
and has no complaints. He
has been exercising regularly
and dieting as instructed for
his diabetes. His medications
include metformin and glyp-
izide. His blood pressure is
180/90, heart rate 70 and res-
pirations 20. His physical ex-
amination is normal. Which of
the following is the most ap-
propriate management at this
time?
A. Continue diet and lifestyle
modifications for 6 months
B. Start lisinopril and hy-
drochlorothiazide
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C. Start amlodipine
D. Start hydrochlorothiazide
E. Start spironolactone

116. A 70 year old female with A Intravenous fluids

a history of coronary artery
disease, hypertension, arthri- Patient has cardiac tamponade. Remem-
tis, and breast cancer pre- ber that the right-sided heart chambers are
sents with dyspnea on ex- the lowest pressure chambers, thus as in-
ertion and dizziness slowly trapericardial pressure rises, these cham-
progressing over the past 2 bers will be first compressed. Also recall
weeks. She denies any chest that right sided heart pressures reflect "pre-
pains. Her blood pressure is load" which is determined by 2 things: 1. in-
80/40, heart rate 120, respira- travenous volume (hydration status) and 2.
tions 24 and oxygen satura- venous tone (dilated vs constricted). Giving
tion 88% on room air. Physi- fluids will allow the right ventricle to fill better
cal exam revealed pulmonary and increase preload will improve the blood
rales at the left lung base, pressure. Nitroglycerine decreases preload
distant heart sounds, and el- by venodilating. Eventually pericardiocente-
evated jugular venous pres- sis would be needed.
sures especially with inspira-
tion. Her pulsus paradoxus is
20 mm Hg. Laboratory studies
are normal. Which of the fol-
lowing is the best initial man-
agement of this patient?
A. Intravenous fluids
B. Intravenous beta-blockers
C. Pericardiocentesis
D. Coronary angiography
The correct answer is: A

117. A 65 year old male with a D. Emergent current cardioversion

history of hypertension, stage
IV kidney disease on dialysis The ECG reveals atrial flutter with a rapid
presents to the emergency de- ventricular rate. The patient is not tolerat-
partment with dizziness and ing it from a hemodynamic standpoint (hy-
palpitations for 1 hour. He de- potensive), thus immediate restoration of
nies chest pains. His temper- sinus rhythm is indicated with direct current

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 Cardiology MCQ
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ature is 37.0 C, blood pres- cardioversion (a shock). A majority of pa-
sure 80/40, heart rate 150, tients will actually tolerate atrial flutter (or
respirations 24 and oxygen atrial fibrillation) quite well. Remember that
saturation 85% on room air. atrial flutter patients need anticoagulation
Physical examination reveals for stoke prevention exactly the same as
pulmonary rales throughout atrial fibrillation patients. Note the sawtooth
his lung fields, elevated jugu- pattern on the ECG which is typical for atrial
lar venous pressure, a regu- flutter.
lar tachycardic rhythm with-
out murmurs, and trace lower
extremity pitting edema. Lab-
oratory studies are normal.
ECG shows atrial flutter.
Which of the following is the
most appropriate initial thera-
py?
A. Intravenous amiodarone
B. Intravenous beta-blockers
C. Intravenous calcium chan-
nel blockers
D. Emergent direct current
cardioversion

118. An 18 year old cross coun- A. Early repolarization

try runner is referred to a
cardiologist for an abnormal Early repolarization is a benign ECG finding
ECG. He states that overall frequently encountered in young athletes
he feels well and denies any which consists of "J point" elevation which
chest pains or shortness of can mimic pathologic ST segment eleva-
breath. He also denies syn- tion.
cope or palpitations. His ECG
is below (shows J point eleva-
tion and ST elevation). Which
of the following is the most
likely diagnosis?
A. Early repolarization
B. Wolff-Parkinson-White syn-
drome

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C. Pericarditis
D. Brugada syndrome

119. A 42 year old female with no A. Mitral valve stenosis

significant past medical histo-
ry presents to the emergency Mitral valve stenosis results in a uniquely
department with hemoptysis shaped, low-pitched diastolic murmur best
of acute onset. She has not- heard at the cardiac apex. The opening
ed recent dyspnea on exertion of the mitral valve produces an "opening
now to the point where she snap" due to the high left atrial pressures,
can only walk ½ blocks be- which is immediately followed by a de-
fore having to rest. She de- crescendo murmur as blood flows passive-
nies chest pain. Her tempera- ly from the left atrium to the left ventricle
ture is 37.0 C, blood pressure through the stenosed mitral valve creating
110/60, heart rate 100, respi- turbulence.
rations 20 and oxygen satura-
tion 95% on room air. Phys-
ical examination reveals nor-
mal lung sounds, an irregular-
ly irregular rhythm, a II/IV ear-
ly diastolic murmur heard best
at the cardiac apex, and 1+
lower extremity pitting edema.
Laboratory studies are nor-
mal. ECG shows sinus tachy-
cardia and left atrial enlarge-
ment. Which of the following
is causing this patient's symp-
toms?
A. Mitral valve stenosis
B. Mitral valve prolapse
C. Mitral valve regurgitation
D. Aortic valve stenosis
E. Aortic valve regurgitation

120. A 24 year old female with A. Ostium primum atrial setpal defect
no significant past medical
history presents to her pri- An atrial septal defect is an abnormal com-
mary care physician with ex- munication between the left and right atri-

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 Cardiology MCQ
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ercise intolerance. She has um. This is a congenital defect that initially
been trying to exercise to lose causes blood to flow from the left atrium
weight but becomes short of (higher pressure) directly to the right atri-
breath after only minimal ef- um (lower pressure) resulting in a left to
fort. Her temperature is 37.0, right shunt. Depending on these size of the
blood pressure 110/70, heart ASD symptoms can vary from no symp-
rate 110, respirations 20 and toms to severe heart failure symptoms.
oxygen saturation 94% on Over time pulmonary hypertension devel-
room air. Physical examina- ops due to the abnormally large amount
tion reveals normal jugular ve- of blood coursing through the pulmonary
nous pressure, normal breath vasculature. As the pulmonary pressures
sounds, a II/VI systolic mur- increase the right ventricle fails resulting in
mur at the left upper sternal elevated right atrial pressure.
border and a fixed split S2 Remember that an ostium primum ASD has
heart sound. Laboratory stud- a right bundle branch block and left axis de-
ies are normal. ECG reveals viation on the ECG while an ostium secun-
normal sinus rhythm, a right dum ASD has a right bundle branch block
bundle branch block, and left and right axis deviation on the ECG. The
axis deviation. Which of the physical exam findings of an ASD include
following is her likely diagno- a pulmonic valve flow murmur (due to the
sis? large amount of blood passing through this
A. Ostium primum atrial setpal valve) and a fixed split S2 heart sound.
defect
B. Ostium secundum atrial
septal defect
C. Ventricular septal defect
D. Patent ductus arteriosis
E. Ebstein's anomaly

121. A 48 year old African Amer- C. 200/220

ican male presents to the
emergency department with This is a case of hypertensive emergency
headache, blurry vision, and which occurs when severely elevated blood
mild chest pains. His tempera- pressure results in end-organ damage (re-
ture is 37.0 C, blood pressure nal failure and troponin elevation in this
250/150, heart rate 80 and res- case). Hypertensive urgency is severely el-
pirations 18. Physical exami- evated blood pressure along with symp-
nation reveals normal breath toms (such as headache, blurry vision, or
sounds, an S4 heart sound, chest pains) without evidence of end-organ
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and a normal neurological ex- damage). The goal of therapy is to reduce
amination. Laboratory studies the mean blood pressure by 20% in the first
show a creatinine of 3.5 and hour and to less than 160/100 within the
a mild elevation in troponin I. first 6 hours.
ECG is normal sinus rhythm
with left ventricular hypertro-
phy. He is started on a nitro-
glycerine drip to control his
blood pressure. Which of the
following is his target blood
pressure at this time?
A. 120/80
B. 175/105
C. 200/120
D. 225/135

122. A 35 year old female with a his- A. Tricuspid valve regurgitation

tory of HIV presents with in-
creasing dyspnea on exertion. This patient has pulmonary hypertension
Her temperature is 37.0, blood most likely related to her HIV disease. Her
pressure 120/80, heart rate chest x-ray reveals enlarged pulmonary
110, respirations 20 and oxy- arteries and right-sided heart chambers.
gen saturation 95% on room The murmur described in the question is
air. Physical examination re- that of tricuspid regurgitation. Remember
veals normal breath sounds, that there are only 3 holosystolic murmurs:
elevated jugular venous pres- mitral regurgitation, tricuspid regurgitation
sure with large V waves, a and a ventricular septal defect. Tricuspid
III/VI holosystolic murmur at regurgitation gets louder with inspiration
the right lower sternal border (Carvallo's sign) due to increased venous
which becomes louder with in- return to the right heart. B
spiration, a pulsatile liver and
2+ lower extremity edema.
Which of the following is most
likely contributing to her dys-
pnea?
A. Tricuspid valve regurgita-
tion
B. Tricuspid valve stenosis

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C. Mitral valve regurgitation
D. Mitral valve stenosis

123. An 82 year old male with a his- D. Coumadin

tory of hypertension presents
to his primary care physician
for a routine visit. He has had
some generalized fatigue but
attributed it to aging. His tem-
perature is 37.0, blood pres-
sures 110/60, heart rate 70
and respirations 20. Physical
examination reveals normal
lung sounds, an irregularly ir-
regular rhythm, and no low-
er extremity edema. Labora-
tory studies including thyroid
tests and a complete blood
count are normal. Below is his
ECG (atrial fibrillation). Which
of the following is the most ap-
propriate therapy at this time?
A. B blocker
B. CCB
C. Digoxin
D. Coumadin

124. A 68 year old female with D. Right coronary artery

a history of hypertension
and diabetes presents with This patient has acute mitral valve regur-
chest pains intermittently for gitation resulting in pulmonary edema and
4 days and now significantly cardiogenic shock. Remember that the pos-
worse acute onset shortness teromedial palpillary muscle receives its
of breath. Her temperature is sole blood supply from the right coronary
37.1, blood pressure 85/65, artery, thus thrombosis of this vessel can
heart rate 110, respirations 24 completely disrupt this papillary muscle's
and oxygen saturation 79% function resulting in severe mitral regurgita-
on room air. Physical exam- tion and even palpillary muscle rupture (as
ination reveals diffuse pul- in our case which occurs a few days after

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monary rales, a II/VI holosys- the infarction). Treatment is emergent surgi-
tolic murmur at the cardiac cal repair. The anteromedial papillary mus-
apex radiating to the axilla and cle has dual blood supply from the left an-
elevated jugular venous pres- terior descending and left circumflex coro-
sure. A Swan-Ganz catheter nary artery, thus thromboses of those ves-
is inserted and the pulmonary sels do not result in mitral regurgitation. The
capillary wedge pressure trac- large V waves on the pulmonary capillary
ing shows large V waves. Her wedge tracing (which represents left atrial
ECG shows significant ST pressure) indicates backflow of blood from
segment elevation. Which of the left ventricle to the atrium. The murmur
the following coronary arter- that our patient has is also typical for mitral
ies is the most likely culprit? regurgitation.
A. Left main coronary artery
B. Left anterior descending
coronary artery
C. Left circumflex coronary
artery
D. Right coronary artery

125. A 55 year old male with a C. Aortic dissection

history of hypertension pre-
sents to the emergency room
with acute onset chest pains.
His temperature is 37.0, blood
pressure 190/70 in the left
arm and 150/70 in the right
arm, heart rate 110, respira-
tions 22 and oxygen satura-
tion 94% on room air. Physical
examination reveals normal
lung sounds, elevated jugu-
lar venous pressures and a
II/IV early diastolic murmur at
the right upper sternal bor-
der. ECG shows normal sinus
rhythm and left ventricular hy-
pertrophy. Which of the follow-
ing is the most likely diagno-
sis?
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A. Pulmonary embolus
B. Mitral valve stenosis
C. Aortic dissection
D. Ascending aortic aneurysm
E. Myocardial ischemia

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