1
Q
The major determinants of myocardial oxygen demand (MVO2) are:
A
-heart rate
-myocardial contractility
-myocardial wall tension (stress)
2
Q
In the absence of significant flow-limiting atherosclerotic obstructions, R1 is trivial; the major determinant of coronary resistance is found in
A
R2 and R3
prearteriolar vessels (R2), and arteriolar and intramyocardial capillary vessels (R3)
3
Q
The major risk factors for atherosclerosis
A
-high levels of plasma LDL
-cigarette smoking
-hypertension
-diabetes mellitus
4
Q
The incidence of false-positive stress tests is significantly increased in patients with low probabilities of IHD, such as
A
-asymptomatic men age <40
-premenopausal women with no risk factors for premature atherosclerosis
-patients taking cardioactive drugs, such as digitalis and antiarrhythmic agents
-intraventricular conduction disturbances, resting ST-segment and T-wave abnormalities, ventricular hypertrophy
-abnormal serum potassium levels
5
Q
Obstructive disease limited to which artery may result in a false-negative stress test?
A
the circumflex coronary
since the posterolateral portion of the heart that this vessel supplies is not well represented on the surface 12-lead ECG
6
Q
When can exercise tests be preformed safely in patients post MI?
a) after uncomplicated MI
b) maximal exercise tet
A
a) Modified (heart rate limited) 6 days after uncomplicated MI
b) maximal (symptom limited) exercise stress test may be carried out 4–6 weeks after infarction
7
Q
Contraindications to exercise stress testing
A
-rest angina within 48 h
-unstable rhythm
-severe aortic stenosis
-acute myocarditis
-uncontrolled heart failure
-severe pulmonary hypertension
-active infective endocarditis
8
Q
Antithrombotics
a. Bare stent
b. Drug eluting stent
c. NSTEMI
d. AF + PCI
A
a. DAPT x 3 months then ASA ♾️
b. DAPT x 1 year then ASA ♾️
c. DAPT x 1 year
d. Shift DOAC to parenteral anticoagulant for triple antithrombotics (TAT) x 1 week or discharge or 4 week; then DAT (Clopidogrel + DOAC) x 1 year; then DOAC ♾️
9
Q
This ratio suggests but is not diagnostic of a myocardial rather than a skeletal muscle source for the CK-MB elevation
A
A ratio (relative index) of CK-MB mass to CK activity ≥2.5
10
Q
Can perfusion scanning distinguish acute infarcts from chronic scars?
A
Although perfusion scanning is extremely sensitive, IT CANNOT distinguish acute infarcts from chronic scars and, thus, is not specific for the diagnosis of acute MI
11
Q
The prognosis in STEMI is largely related to the occurrence of two general classes of complications:
A
(1) electrical complications (arrhythmias v fib) OUT OF HOSPITAL
(2) mechanical complications (“pump failure)
IN HOSPITAL
12
Q
Target HR NSTEMI
A
Harrisons 50-60
13
Q
O2 administration in ACS
A
O2 sat <90
14
Q
ECG for patient who should be considered a candidate for reperfusion therapy
A
ST-segment elevation of at least 2 mm in two contiguous precordial leads and 1 mm in two adjacent limb leads
15
Q
Goal in initiating PCI in non PCI capable hospital
A
Within 120 mins of FMC
16
Q
Because of the risk of an allergic reaction, patients should not receive streptokinase if that agent had been received within _______
A
Preceding 5 days to 2 years
17
Q
Cardiac catheterization and coronary angiography should be carried out after fibrinolytic therapy if there is evidence of either
A
1) failure of reperfusion (persistent chest pain and ST-segment elevation >90 min), in which case a rescue PCI should be considered; or
(2) coronary artery reocclusion (re-elevation of ST segments and/or recurrent chest pain) or the development of recurrent ischemia (such as recurrent angina in the early hospital course or a positive exercise stress test before discharge), in which case an urgent PCI should be considered
18
Q
The typical coronary care unit diet should provide
A
</=30% of total calories as fat
</=300 mg/day cholesterol content
50-55% complex carbohydrates
High in potassium, magnesium, fiber
Low sodium
19
Q
Cardiac death in patients with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes before cTn values became available or abnormal
A
Type 3 MI
20
Q
Postmortem demonstration of acute atherothrombosis in the artery supplying the infarcted myocardium meets criteria for what type of MI
A
Type 1 MI
21
Q
Coronary procedure–related MI <48 h after the PCI (type 4) is arbitrarily defined by an elevation of cTn of howe many times the percentile URL in patients with normal baseline values?
A
> 5 times
22
Q
Coronary procedure–related MI <48 h after the CABG (type 5) is arbitrarily defined by an elevation of cTn of howe many times the percentile URL in patients with normal baseline values?
A
> 10 times
23
Q
Development of what findings will meet the type 4a MI or type 5 MI criteria with either revascularization procedure if cTn levels are elevated and rising, but less than the prespecified thresholds for PCI and CABG?
A
Isolated development of new pathologic Q waves
24
Q
What is the aPTT during maintenance therapy of UFH in STEMI?
A
should be 1.5–2 times the control value
25
hypokalemia and hypomagnesemia are risk factors for ventricular fibrillation in patients with STEMI; to reduce the risk, what is the target K and Mg?
K 4.5 mmol/L
Mg 2 mmol/L
26
One third of inferior MI develop RV infarction. . Catheterization of the right side of the heart often reveals a distinctive hemodynamic pattern resembling ______?
constrictive pericarditis (steep right atrial “y” descent and an early diastolic dip and plateau in RV waveforms
27
In which patients is long term survival excellent?
a. patients who develop ventricular fibrillation secondary to severe pump failure
b. patients who develop ventricular fibrillation that is a primary response to acute ischemia that occurs during the first 48 h
c. patients who develop ventricular tachycardia or ventricular fibrillation late in their hospital course (>48 h)
B
Although the in-hospital mortality rate is increased, the long-term survival is excellent in patients who survive to hospital discharge after primary ventricular fibrillation
28
What is the arrhythmia that often occurs transiently during fibrinolytic therapy at the time of reperfusion?
AIVR or slow vtach
29
What is the most common supraventricular arrhythmia?
Sinus tachycardia
30
What is usually the treatment of choice for supraventricular arrhythmias if heart failure is present?
Digoxin
31
What is usually the treatment of choice for supraventricular arrhythmias if heart failure is NOT present?
Bb, verapamil, diltiazem
32
What are the class 1 indications for ICD?
1) LVEF <40, Post MI (<40 days and/or revasc <90 days), inducible sustained VT on EPS
2) NYHA class 1 with EF 30
3) NYHA class 2 and 3 with EF 35
33
Activities post MI
a. First 1-2 weeks
b. After 2 weeks
First 1-2 weeks: walking, sex
2 weeks: exercise
2-4 weeks: return to work
34
What is an early consequence of hypertension-related heart disease and is exacerbated by left ventricular hypertrophy and ischemia
Diastolic dysfunction
35
What is the strongest risk factor for stroke
Elevated blood pressure (SBP)
Stroke=systolic
36
What is the renal lesion associated with malignant hypertension?
fibrinoid necrosis of the afferent arterioles
37
Definition of cardiac cachexia
Edema-free weight loss of at least 5% in 12 months or less in the presence of underlying illness (or a BMI <20 kg/m2) and at least three of the following criteria:
• Decreased muscle strength (lowest tertile)
• Fatigue (physical and/or mental weariness resulting from exertion)
• Anorexia (limited food intake [<70% of usual] or poor appetite)
• Low fat-free BMI (lean tissue depletion by DEXA <5.45 in women and <7.25 in men)
• Abnormal biochemistry:
• Increased inflammatory markers (CRP >5.0 mg/L, IL-6 >4.0 pg/mL)
• Anemia (hemoglobin <12 g/dL)
• Low serum albumin (<3.2 g/dL)
38
elicited by applying firm continuous pressure over the liver for 15–30 s while observing the neck veins. Higher levels of venous pressure approaching the angle of the jaw are common in chronic right HF
Hepatojugular reflux
39
increase in right atrial pressure during 10 s of firm midabdominal compression followed by an abrupt drop on pressure release, suggests elevated left-sided filling pressure
Abdominojugular test
40
rise in JVP with inspiration; may be due to severe biventricular HF and is a marker of poor outcome
Kussmaul’s sign
41
parameters associated with worse outcomes in heart failure:
BUN >43 mg/dL (to convert to mmol/L, multiply by 0.357)
SBP <115 mmHg
creatinine level >2.75 mg/dL (to convert to μmol/L, multiply by 88.4)
elevated cardiac biomarkers
42
Restrictive cardiomyopathy is now defined more on the basis of what parameter, which is also present but initially less prominent in dilated and hypertrophic cardiomyopathy
abnormal diastolic function
43
What is the primary presentation for fulminant myocarditis?
Acute Cardiogenic Shock
44
Peripartum cardiomyopathy develops when
Last trimester and first 6 months after pregnancy
45
Risk factors for PPCM
increased maternal age, increased parity, twin pregnancy, malnutrition, use of tocolytic therapy for premature labor, and preeclampsia or toxemia of pregnancy
46
heart failure presenting earlier in pregnancy has been termed?
Pregnancy associated cardiomyopathy (PACM)
47
What is the most common toxin implicated in chronic DCM?
Alcohol
48
Estimates of the alcohol intake necessary to cause cardiomyopathy have been?
4–5 ounces or 80–100 g of pure ethanol daily for 5–10 years, about 1 L of wine, 8 beers, or 1/2 pint of hard liquor
49
What are the most common drugs implicated in toxic cardiomyopathy?
Chemotherapy agents
50
What is the most common restrictive cardiomyopathy?
amyloidosis
Amyloidosis should be suspected when ventricular myocardium appears thick on imaging with low ECG voltage. Longitudinal strain is frequently more preserved at the apex, creating a “bull’s-eye” pattern. MRI shows diffuse late gadolinium enhancement
51
First line agents to reduce severity of LVOT in Hypertrophic Cardiomyopathy by decreasing heart rate, enhancing diastolic filling and decreasing contractility
B adrenergic blockers
L type Ca channel blockers (e.g., verapamil)
52
What is the most common valve lesion among adult patients with chronic valvular heart disease?
Aortic stenosis
53
What is the most common congenital heart valve defect?
Bicuspid aortic valve
54
AS is rarely of clinical importance until the valve orifice has narrowed to what orifice area?
~1cm^2
55
What are the 3 cardinal symptoms of AS?
S A D
Exertional dyspnea, angina pectoris, and syncope are the three cardinal symptoms
56
In AS, the average time to death after the onset of various symptoms was as follows:
Syncope
Angina
Dyspnea
Heart failure
syncope 3 years;
angina pectoris 3 years;
dyspnea 2 years;
heart failure 1.5–2 years
57
What constitutes the major hemodynamic compensation for AR?
increase in the LV end-diastolic volume (increased preload)
58
What is the hemodynamic hallmark of MS?
abnormally elevated left atrioventricular (AV) pressure gradient
59
What is the physical examination hallmark of PR that can be difficult to distinguish from the more frequently appreciated murmur of AR
(Graham Steell murmur)
is a high-pitched, decrescendo diastolic murmur heard along the left sternal border
60
4 principal diagnostic features of Acute Pericarditis
Chest pain
Pericardial friction rub
ECG
Pericardial effusion
61
Anemia in HF
Use of IV irom using iron sucrose or carboxymaltose if
Ferritin?
TSAT?
Ferritin <100
TSAT <20%
62
4 stages of ECG changes in pericarditis
stage 1, there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2–V6, with reciprocal depressions only in aVR and occasionally V1. In addition, there is depression of the PR segment below the TP segment, reflecting atrial involvement, an early change that may occur prior to ST segment elevation. Usually there are no significant changes in QRS complexes unless a large pericardial effusion develops (see below).
Stage 2 After several days, the ST segments return to normal
Stage 3 the T waves become inverted
Stage 4 Weeks or months after the onset of acute pericarditis, the ECG returns to normal
63
a patch of dullness, increased fremitus, and egophany beneath the angle of the left scapula
Ewart’s sign
64
Acute Pericarditis treatment
Aspirin 2-4g/day
NSAIDs (ibuprofen 600-800mg tid or Indomethacin 25-50mg TID)
colchicine (0.5 mg qd [<70 kg] or 0.5 mg bid [>70 kg]) should be administered for 3 months
**in patients who failed therapy or cannot tolerate NSAIDs and colchicine: Glucocorticoids (prednisone 1mg/kg/d) for 2-4 days then tapered
**NO ANTICOAGULANTS
65
The three principal features of tamponade (Beck’s triad)
hypotension
soft or absent heart sounds
jugular venous distention with a prominent x (early systolic) descent but an absent y (early diastolic) descent
66
important clue to the presence of cardiac tamponade consists of a greater than normal (10 mmHg) inspiratory decline in systolic arterial pressure
Pulsus paradoxus
67
Echo findings in tamponade
is late diastolic inward motion (collapse) of the right ventricular free wall and the right atrium
68
The most frequent complication in acute idiopathic pericarditis
recurrent (relapsing) pericarditis,
69
What is the most prominent deflection in constrictive pericarditis which is absent in tamponade?
y descent
Atrial pressures M shaped
Ventricular pressures “square root” signs
70
In chronic constrictive pericarditis, The apical pulse is reduced and may retract in systole
Broadbent’s sign
71
In chronic constrictive pericarditis, an early third heart sound occurring at the cardiac apex with the abrupt cessation
pericardial knock
72
What is the only definitive treatment of constrictive pericarditis and should be as complete as possible
Pericardial resection
73
regulate the supply of oxygen and substrate to the myocardium
Metabolic regulation
74
adapt to physiologic alterations in blood pressure to maintain coronary blood flow at levels appropriate to myocardial needs
Autoregulation
75
most common clinical indication for PCI
Symptom limiting angina pectoris
76
early consequence of hypertension-related heart disease and is exacerbated by left ventricular hypertrophy and ischemia
Diastolic dysfunction
77
provides the most accurate assessment of diastolic function
Cardiac catheterization
78
is the strongest risk factor for stroke
Elevated BP (SBP)
79
Hypertension is associated with _______, a major pathologic factor in dementia
beta amyloid deposition
80
the “gold standard” for evaluation and identification of renal artery lesions
Contrast Arteriography
81
In patients with an elevated PA/PRA ratio, the diagnosis of primary aldosteronism can be confirmed by demonstrating failure to suppress PA to any one of four suppression tests:
oral sodium loading, saline infusion, fludrocortisone, or captopril
81
What is the cause of aldosteronism?
PA tends to increase with upright posture in patients with hyperplasia, reflecting the normal postural response of the renin-angiotensin-aldosterone axis
Adrenal hyperplasia
More responsive to angiotensin
82
What is the cause of aldosteronism?
higher PA in the early morning that decreases during the day, reflecting the diurnal rhythm of ACTH
Adenoma
More responsive to ACTH
83
the most accurate means of differentiating unilateral from bilateral forms of primary aldosteronism
Bilateral adrenal venous sampling
84
First line vasopressor and inotropic agent for PE
Norepinephrine and Dobutamine respectively
85
An 88-year-old male with known CAD, HTN, and T2DM fairly compliant to medications was brought to the ER for sudden onset of dyspnea associated with 3 pillow orthopnea, PND, oliguria, and edema. VS were BP 110/90 mmHg, HR 133 bpm, RR 30s,Temp 37.0 degC, and O2st 90%. Examination revealed a confused, lethargic, speaking in phrases, an elevated JVP, bibasal crackles, irregular heart rate, and bipedal edema. Labs showed Hgb 100 Hct 33 Plt 320 BUN 41 mg/dL, Crea 2.7 mg/dL Na 127 K 4.1. Troponin I, NTproBNP, and rest of workup pending. Which of the following parameters is associated with a worse prognosis?
a. BP 110/90
b. BUN 41 mg/dL
c. Crea 2.7 mg/dL
d. Change in sensorium
A. BP 110/90
Analysis of in-hospital registries has identified several parameters associated with worse outcomes in patients with heart failure:
* BUN > 43 mg/dL
* SBP < 115 mmHg
* Crea > 2.75 mg/dL
* Elevated cardiac biomarkers – BNP and Troponins
86
A prominent RV pulsation in the left parasternal region and a blowing holosystolic murmur along the lower left sternal margin, which may be intensified during inspiration is seen in?
a. Pulmonic stenosis
b. Pulmonic regurgitation
c. Tricuspid stenosis
d. Tricuspid regurgitation
D. Tricuspid regurgitation
This is called the Carvallo’s sign. prominent RV pulsation in the left parasternal region and a blowing holosystolic murmur along the lower left sternal margin, which may be intensified during inspiration (Carvallo’s sign) and reduced during expiration or the strain phase of the Valsalva maneuver
87
In a patient with normal systolic function and cardiac output, which peak systolic gradient across the pulmonic valve is consistent for moderate PS?
a. 20 mmHg
b. 35 mmHg
c. 50 mmHg
d. 65 mmHg
C. 50 mmHg
Severe PS: Peak systolic gradient > 64 mmHg (Doppler jet velocity >4 m/s)
Moderate PS: Peak systolic gradient 36 - 64 mmHg (Doppler jet velocity 3-4 m/s)
Mild PS: Peak systolic gradient < 36 mmHg (Doppler jet velocity < 3 m/s)
88
What is the most common tumor in the heart?
a. Myxoma
b. Cardiac Lipoma
c. Papillary fibroelastoma
d. Metastatic breast cancer
D. Metastatic breast cancer
Metastatic cardiac tumors are much more common than primary cardiac tumors. Although cardiac metastases may occur with any tumor type, the relative incidence is especially high in malignant melanoma and, to a somewhat lesser extent, leukemia and lymphoma. In absolute terms, the most common primary sites from which cardiac metastases originate are carcinoma of the breast and lung, reflecting the high incidence of these malignancies.
89
FY a 45 year-old female came to the ER presenting with crushing substernal chest pain radiating to the right arm associated with dyspnea and diaphoresis for the past hour. She had a CVD infarction 18 months ago and an intracranial hemorrhage 5 years ago. At the ER, BP was 180/110, INR of 1.8, and ECG showing ST-elevation on V3-V6. No history of invasive or surgical procedures. She was treated with BPUD 4 weeks ago and is on her 2nd day of menses. Which of the following risk factors is a clear contraindication for fibrinolysis in this patent?
a. BPUD 4 weeks ago
b. CVD infarct 18 months ago
c. Chronic ICH 5 years ago
d. 2nd day of Menses
ANSWER: C. Chronic ICH 5 years ago
Clear contraindications to the use of fibrinolytic agents:
–History of cerebrovascular hemorrhage at any time
–Nonhemorrhagic stroke or other cerebrovascular event within the past year
–Marked hypertension (a reliably determined systolic arterial pressure >180 mmHg and/or a diastolic pressure >110 mmHg) at any time during the acute presentation
–suspicion of aortic dissection
–Active internal bleeding (excluding menses).
*Advanced age is associated with an increase in hemorrhagic complications, the benefit of fibrinolytic therapy in the elderly appears to justify its use if no other contraindications are present and the amount of myocardium in jeopardy appears to be substantial.
Relative contraindications to fibrinolytic therapy:
–Current use of anticoagulants (international normalized ratio ≥2)
–Known bleeding diathesis
–Hemorrhagic ophthalmic condition (e.g., hemorrhagic diabetic retinopathy)
–Recent (<2 weeks) invasive or surgical procedure
–Prolonged (>10 min) cardiopulmonary resuscitation
–Pregnancy
–Active peptic ulcer disease
–History of severe hypertension that is currently adequately controlled
90
_____________ is the most common pathology associated with an ascending aortic aneurysm whereas _______________ is the most frequently associated with descending thoracic aorta aneurysm.
a. Atherosclerosis; Medial degeneration
b. Atherosclerosis; Intramural hematoma
c. Intramural hematoma; Atherosclerosis
d. Medial degeneration; Atherosclerosis
D. Medial degeneration; Atherosclerosis
Thoracic aortic aneurysm
Medial degeneration is the most common pathology associated with ascending aortic aneurysm
Atherosclerosis is the condition most frequently associated with aneurysms of the descending thoracic aorta
The average growth rate of thoracic aneurysms is 0.1–0.2 cm per year.
91
A 23 year-old female came in with episodic pallor, cyanosis, and warm erythema of his fingers after exposure to cold areas. Physical examination only revealed non-scarring alopecia and malar rash. Which drug will help in managing the patient's symptoms?
a. Aspirin
b. Cilostazol
c. Taladafil
d. Vorapaxar
. Taladafiil
PDE-5 inhibitors such Sildenail, Taladafil, and Vardenafil may improve symptoms in patients with secondary Raynaud’s phenomenon, as occurs with systemic sclerosis
92
56/F came in for consultation for a 2-yr history of intermittent unilateral right leg pain and swelling. On examination, the right leg had pitting edema with xerosis and hyperpigmented patches. A prominent varicose veins seen on the right leg with a 1.5 x 0.5 cm shallow ulcer with irregular borders and granulation tissue near the medial malleoli. Which of the following tests will you use to determine whether a varicose vein is secondary to deep venous insufficiency?
a. Perthes test
b. Syndesmosis squeeze test
c. Talar tilt test
d. Brodie-Trendelendburg test
D. Brodie-Trendelendburg test
BI PO
The BRODIE-TRENDELENBURG TEST determines whether varicose veins are secondary to deep-venous insufficiency
-Maneuver: As the patient is lying supine, the leg is elevated and the veins allowed to empty. Then, a tourniquet is placed on the proximal part of the thigh and the patient is asked to stand
-Filling of the varicose veins within 30s -> varicose veins are caused by deep-venous insufficiency and incompetent perforating veins
-Refilling promptly after tourniquet removal -> primary varicose veins with superficial venous insufficiency
PERTHES TEST assesses the possibility of deep-venous obstruction
-Maneuver: A tourniquet is placed on the midthigh after the patient has stood, and the varicose veins are filled. The patient is then instructed to walk for 5 minutes
-A patent deep-venous system and competent perforating veins enable the superficial veins below the tourniquet to collapse
-Deep-venous obstruction is likely to be present if the superficial veins distend further with walking
93
A 30-year-old healthy male came in due to sudden onset severe boring epigastric pain radiating to the back. The patient had low HDL and TG 900 mg/dL, Lipase and amylase were five times and four times elevated, respectively. Family history was unremarkable for premature cardiac death and cardiovascular disease. On examination, no jaundice,(+) hepatosplenomegaly, small yellow-white papules on back and extensor surface of arms and legs. What is the likely diagnosis of this patient?
a. Familial hypercholesterolemia
b. Familial chylomicronemia syndrome
c. Familial hypobetalipoproteinemia
d. Familial LCAT deficiency
FAMILIAL CHYLOMICRONEMIA SYNDROME
–Deficiency or inactivity of LPL (lipoprotein lipase) results in impaired lipolysis and profound elevations in plasma TGs, mostly in chylomicrons
–Fasting TG levels are >500 mg/ dL and usually >1000 mg/dL
–Can present in childhood or adulthood with severe abdominal pain due to acute pancreatitis. In this setting, the diagnosis should be suspected if a fasting TG level is >500 mg/dL
–Eruptive xanthomas, which are small, yellowish-white papules, may appear in clusters on the back, buttocks, and extensor surfaces of the arms and legs
–Retinal blood vessels may be opalescent (lipemia retinalis)
–Hepatosplenomegaly is sometimes noted as a result of uptake of circulating chylomicrons by reticuloendothelial cells in the liver and spleen
–Premature ASCVD is not generally a feature of FCS.
–Diagnosis of FCS is a clinical diagnosis based on persistence and severity of HTG, with a history of acute pancreatitis or eruptive xanthomas increasing the suspicion
In Familial hypercholesterolemia, LDL is usually elevated and the patient presents with tendon xanthomas and premature atherosclerotic cardiovascular disease
Familial hypobetalipoproteinemia is part of the hypolipidemic syndromes where LDL is reduced. These patients present with fatty liver and are associated with a reduced risk of atherosclerotic cardiovascular disease
Familial LCAT deficiency is also known as the fish-eye disease, presenting with corneal opacities and markedly reduced HDL
94
Which of the following patient characteristics will more likely have slow improvement in ejection fraction with guideline directed therapy?
A. 30-year-old postpartum patient developing heart failure
B. 55-year-old post MI patient with myocardial fibrosis
C. 25-year-old with fulminant myocarditis
D. 40-year-old post chemotherapy heart failure
B. myocardial fibrosis
Predictors of HFrecEF include younger age, shorter duration of HF, nonischemic etiology, smaller ventricular volumes, and absence of myocardial fibrosis.
Specific clinical examples include:
-Fulminant myocarditis
-Stress cardiomyopathy
-Peripartum cardiomyopathy
-Tachycardia-induced CMP
-Reversible toxin exposures (chemotherapy, immunotherapy, or alcohol)
95
Hypertensive urgency BP threshold
Goal?
180/120 and above
Goal: lower by 25% over 24h
96
Malignant hypertension goal
Lower MAP no more than 25% within minutes to 2 hours or BP 160/100-110
97
Target BP for stroke patients with a systolic blood pressure ≥220 mmHg or a diastolic blood pressure ≥120 mmHg, who are not candidates for thrombolytic therapy or endovascular treatment
If thrombolytic therapy or endovascular treatment is to be used, what is the recommended goal
Lower BP by 15% during the first 24h
If for thrombolysis: BP <185/110
98
According to the 2017 ACC/AHA-led Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults, a clinic blood pressure of 135/85 mmHg is:
A. Normal blood pressure
B. Elevated blood pressure
C. Stage 1 hypertension
D. Stage 2 hypertension
C. Stage 1
99
What is the expected finding in an elderly patient with a previous history of frequent hospital admissions for pulmonary congestion; requiring high doses of an ACE-inhibitor, a calcium channel blocker, a beta blocker and a diuretic for
control of hypertension, with carotid and flank bruit and the absence of edema?
A. A 24-hr urine collection with protein of 4 g
B. C. D. Urinalysis with red blood cells and RBC casts
Imaging study with unilateral small kidney
Imaging study with distal renal artery lesions
C. Imaging study with unilateral small kidneys
Case fits the description of atherosclerotic renovascular hypertension.
• A> Proteinuria is in the nephrotic range (protein excretion greater than 3.5g/24 hours). Renovascular disease is more often associated with minimal-to-moderate degrees of proteinuria.
• B> Red blood cells or red blood cell casts are hallmark features of glomerulonephritis.
• C› Unilateral involvement of the kidney is more likely because the patient is able to tolerate an ACE inhibitor.
- D> Patient falls more into the atherosclerotic group of patients, with proximal
100
Expected PA/PRA and PA in primary hyperaldosteronim
PA/PRA >30:1
PA >20 ng/dl
Most accurate study to identify laterality is: Bilateral adrenal venous sampling
-an ipsilateral/contralateral aldosterone ratio >4, with symmetric ACTH-stimulated cortisol levels is indicative of unilateral aldosterone production
101
Patient with abrupt increase in blood pressure to 210 / 130 m m g with tearing pain in the epigastric area radiating to the back. What is the recommended agent?
A. Enaliprat
B. Nicardipine
C. Nitroprusside
D. Phentolamine
C. Nitroprusside
102
Which of the following disease conditions is associated with a reduced LDL-C level?
A. Nephrotic Syndrome
B. Cushing's Syndrome
C. Type 2 Diabetes Mellius
D. Hyperthyroidism
D. Hyperthyroidism
103
According to the 2020 CPG for the Management of Dyslipidemia in the Philippines, statin therapy is recommended for the prevention of cardiovascular events in which patient?
A. 36-year-old male, LDL = 105 mg/di, clinic blood ABPM 130/80 mmHg, BMI 26, unremarkable family history
B. 38-year-old female, LDL = 109 mg/dl, clinic blood pressure 120/80 mmHg, HbA1c level of 7.5%, with unremarkable family history
C. 42-year-old female, LDL 150 mg/dl, home blood pressure 129/75 mmHg, HbA1c level of 6.0%, 5 pack-years smoker, social drinker
D. 65-year-old male, LDL = 183 mg/dl, average 24hr ABPM 124/73 mmHg, normal results on urinalysis and 2D Echo
B.
• For individuals with diabetes without evidence of ASCVD, statins are RECOMMENDED for primary prevention of CV events.
• Statins are RECOMMENDED for the prevention of CV events for individuals without diabetes aged ≥ 45 years with LDL-C ≥ 130 mg/dL AND ≥ 2 risk factors
**Risk factors:
Male sex or postmenopausal women
Smoker
Hypertension
BMI >25 kg/m2
Proteinuria
LV hypertrophy
Family history of premature CHD) ASCVD
104
A 39-year-old female sought consult regarding her lipid profile results showing an LDL level of 360 mg/dl. She was diagnosed with hypertension at age 30. Family history: father had myocardial infarction at age 48. Her 2D echo showed left ventricular hypertrophy and she has 2+ proteinuria on urinalysis.
What is the recommended target level for her LDL-C?
A. < 40 mg/di
B. < 55 mg/dl
C. < 70 mg/dl
D. < 100 mg/di
The patient fulfills the criteria for familial hypercholesterolemia (See Dutch lipid network criteria table above).
• For FH individuals with evidence of target end organ damage, it is recommended to target an LDL-C level <55 mg/dl.
105
A 34-year-old female presents with easy fatigability, bipedal edema and abdominal enlargement. There is an accentuated P2 component of the second heart sound and systolic murmur. What is the most important initial screening test?
A. Abdominal ultrasound
B. Chest radiograph
C. Creatinine and electrolytes
D. Echo with bubble study
D. Echocardiography with agitated saline (bubble) study is the most important initial screening test.
P U L M O N A RY H Y P E RT E N S I O N
• Most will present with dyspnea and/or fatigue
Advanced stages:
>Signs of right ventricular failure
>Elevated jugular venous pressure
>Lower extremity edema
>Ascites
Cardiovascular examination:
>Accentuated P2 component of the second heart sound
>Right-sided S3 or S4
>Holosystolic tricuspid regurgitant murmur
106
What is the WHO classification of pulmonary hypertension from a large atrial septal defect?
A. Group 1
B. Group 2
C. Group 3
D. Group 4
A. Group 1
106
Treatment goals for PH to achieve a low risk clinical profile with mortality <5%
minimal symptoms, WHO FC I or II, 6-WMD >440 m, and cardiac index ≥2.5 L/min per m2
107
A patient with mitral valve prolapse with moderate regurgitation and chronic obstructive pulmonary disease had right heart catheterization done for his pulmonary hypertension. The PAWP is 12 mmHg. What is the most likely WHO group of this patient's pulmonary hypertension?
A. Group 1
B. Group 2
C. Group 3
D. Group 4
B. Group 3
108
Which treatment is the sole approved pharmacotherapy for WHO Group 4 PH in whom pulmonary endarterectomy is contraindicated?
A. Iloprost
B. Bosentan
C. Sildenafil
D. Riociguat
D. Riociguat
Significantly improved exercise capacity, pulmonary hemodynamics, WHO FC, and time to clinical worsening in patients with PAH
Sole approved pharmacotherapy for CTEPH patients for whom surgical pulmonary endarterectomy is ineffective or contraindicated
109
134. A 40-year-old male patient came into the ER due to palpitations. Initial vital signs showed stable BP and HR of 180s. On hooking to cardiac monitor, a narrow complex tachycardia was noted. The patient was given adenosine 6 mg with noted abrupt termination of the tachycardia. Which is the LEAST likely arrhythmia in the patient?
A. Atrioventricular nodal reentry tachycardia
B. Atrioventricular reciprocating tachycardia
C. Fascicular ventricular tachycardia
D. Focal atrial tachycardia
C. Fascicular VT
110
Which of the following patients with atrial fibrillation would have the highest risk for stroke?
A. 70-year-old female with diabetes with previous myocardial infarction
B. A 64-year-old male with heart failure due to rheumatic heart disease
C. A 68-year-old male with a prior stroke and is bedridden
D. An 80-year-old male previous smoker with peripheral artery disease
A. 4
111
Which of the following causes of sudden cardiac arrest is associated with episodes occurring during exertion particularly swimming?
A. Long QT Syndrome 1
B. Long QT Syndrome 2
C. Short QT Syndrome
D. Brugada Syndrome
A. Long QT Syndrome 1
LQT-1 episodes tend to occur during exertion particularly swimming.
LQT-2 episodes are precipitated by auditory stimuli or emotional upset.
LQT-3, sudden death may occur during sleep.
In Brugada syndrome, cardiac arrest usually occurs during sleep or may be provoked by febrile illness.
112
Among patients with Staphylococcus aureus bacteremia, which characteristic would prompt further workup with an echocardiography?
A. Nosocomial acquisition
B. Presence of meningitis
C. Greater than 2 positive cultures
D. Bacteremia persistent for more than 2 days
B. Meningitis
113
Which characteristic would prompt same day surgical management in patients with infective endocarditis?
A. Valve obstruction
B. Rupture into the pericardial sac
C. Progressive paravalvular prosthetic regurgitation
D. Acute mitral regurgitation with heart failure (NYHA Class Ill or IV)
B. Rupture into the pericardial sac
114
What is the recommended prophylaxis for a patient with rheumatic heart disease - mitral stenosis with prior endocarditis who will undergo endoscopy?
A. Amoxicillin 2 g PO 1 hour prior to the procedure
B. Ampicillin 2 g IV 1 hour prior to the procedure
C. Doxycycline 100 mg PO 1 hour prior to the procedure
D. No prophylaxis is needed
Prophylaxis is not advised for patients undergoing **gastrointestinal or genitourinary tract procedures.**
In at risk patients, maintaining good dental hygiene is recommended and antibiotic prophylaxis is recommended only when there is manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa (including with respiratory tract surgery).
115
S1: MV > TV then S2: AV > PV
What causes widened/split S1?
What causes paradoxical split of seconda heart sound?
Fixed split of S2?
Widened S1: RBBB
Paradoxical split S2: LBBB
Fixed split: ASD
116
Cardiac auscultation a 70-year-old man revealed an ejection systolic crescendo-decrescendo murmur heard best at the left upper sternal border. The murmur was noted to radiate to the apex. What is this finding called?
a. Gallavardin effect
b. Austin-Flint mumur
c. Carey-Coombs
d. Graham-steel
A. Gallavardin effect
-Gallavardin effect- Seen in calcific aortic stenosis
b. Austin-Flint murmur- Middiastolic murmur over the apex, associated with AR
c. Carey-Coombs- Soft middiastolic murmur in acute rheumatic fever
d. Graham-Steell- Early blowing diastolic murmur heard along the left border of the sternum due to functional regurgitation through the pulmonic valve
PSBIM 2026 👯♀️
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