Study Questions/Answers and Explanations
A 52-year-old man presents with fever, chills, and arthralgia. On physical examination: temperature is 102.2آ°F, pulse is 106 bpm, blood pressure is 100/60 mm Hg, respiratory rate is 22. S1 is soft. There is a short II/VI diastolic blowing murmur at the left sternal border. There are no rashes or petechiae. The results of the rest of the examination are unremarkable.
1. What is the most likely diagnosis?
A Viral syndrome with flow murmur
B Acute systemic lupus erythematosus with aortic valve involvement
C Infective endocarditis of the aortic valve with probably mild insufficiency
D Infective endocarditis of the mitral valve
E Infective endocarditis of the aortic valve with probably severe insufficiency
View Answer
1. The answer is E [IV C 3 b (2)]. The diastolic murmur is typical of that of aortic insufficiency. The fever chills and arthralgia suggest infection, making infective endocarditis the most likely diagnosis. The soft S1 suggests mitral valve preclosure, indicating severe disease. This syndrome could be seen in acute lupus, but this is less likely in a man without other evidence of the disease. Increased flow from any cause does not produce aortic insufficiency. A lesion on the mitral valve creates systolic, not diastolic, murmurs.
2. Which of the following statements is true of the condition of the patient in question 1?
A The cardiac physical examination is hyperdynamic.
B S1 is soft because of aortic valve preclosure.
C Mitral valve preclosure indicates a poor prognosis without aortic valve replacement.
D The appearance of a diastolic murmur is usually benign.
E Hill's sign is a good predictor of severity.
View Answer
2. The answer is C [IV C 3 b]. Mitral valve preclosure, caused by high ventricular diastolic filling pressure, greater than left atrial pressure, indicates severe disease that is usually fatal without aortic valve replacement. In acute aortic insufficiency such as that seen in endocarditis, Left ventricular dilation has not yet occurred, stroke volume is not increased very much, and thus the circulation is not hyperdynamic. Therefore Hill's sign is also absent. In general, diastolic murmurs are not benign and indicate valve pathology.
3. The diagnostic test(s) that should be performed next is/are
A A chest x-ray
B Blood cultures
C Cardiac catheterization
D A radionuclide ventriculogram
E Exploratory thoracotomy
View Answer
3. The answer is B [IV C 4]. Blood cultures to confirm a bloodstream infection and echocardiography to identify valve lesions and valve function are the mainstays of diagnosis in infective endocarditis. Although a chest x-ray might be useful, it is never diagnostic of endocarditis. Valve surgery would not be contemplated without the diagnosis of endocarditis being established first. Cardiac catheterization is rarely indicated in endocarditis today because echocardiography provides more information more safely. A radionuclide ventriculogram would give information about cardiac performance but would not confirm the diagnosis.
A 56-year-old man enters the emergency department complaining of dyspnea that began about 3 weeks ago and has progressed so that he now has difficulty walking across a room. He has begun sleeping on three pillows. On physical examination: temperature is 99(F, pulse 102 bpm, BP 130/90 mm Hg, respiratory rate 24. There is jugular venous distention, and estimated central venous pressure is 10 cm H2O. Other findings include bibasilar rales and an S3 gallop.
4. What is the most likely diagnosis in this patient?
A Pulmonary embolism
B Congestive heart failure
C Emphysema
D Pneumonia
E Atrial septal defect
View Answer
4. The answer is B [I D 1–2]. The gradual onset of dyspnea, the pulmonary rales, and the S3 gallop are all typical of congestive heart failure. Although a pulmonary embolus could cause all of the findings in this patient, even a right-sided S3, sudden onset is the norm in that condition. The other conditions all could cause dyspnea but would not cause gallop rhythm.
5. Which of the following tests is most appropriate to aid in establishing therapy for this patient?
A A chest x-ray
B An echocardiogram
C An electrocardiogram
D A heart catheterization
E A radionuclide ventriculogram
View Answer
5. The answer is B [I E (3)]. An echocardiogram will yield data about systolic and diastolic function, chamber size, and valvular abnormalities. All of the other tests are useful, but all except catheterization give less information than the echocardiogram. Cardiac catheterization has a higher risk and is only employed when the information gained outweighs that risk. Thus, in CHF, echocardiography provides the “biggest bang for the buck.â€
6. Which of the following is true about the treatment of the condition of the patient in question 4?
A The cause of the condition should be treated whenever possible.
B Systolic versus diastolic dysfunction usually cannot be established.
C ACE inhibitors improve symptoms but do not prolong life.
D Diuretics are the court of last resort.
E خ²-blockers are dangerous and should be avoided.
View Answer
6. The answer is A [I F (1)]. Congestive heart failure is a syndrome, and its cause should be sought and treated directly whenever possible. It is usually helpful to establish whether the root cause is systolic or diastolic dysfunction, a distinction made easily with echocardiography. Diuretics form the mainstay of therapy, but adding both ACE inhibitors and خ²-blockers prolongs life.
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On a routine office visit, a 45-year-old man complains that recently he has noted right-sided chest pain while mowing his lawn with a push lawn mower. The pain develops suddenly, lasts 2–3 minutes, and subsides when he rests. He denies smoking or a history of hypertension, diabetes, or hyperlipidemia. His physical examination is unremarkable. An ECG shows nonspecific T-wave abnormalities.
7. This patient most likely has which of the following?
A Angina pectoris
B Hiatal hernia
C Pleuritis
D A nonspecific chest pain syndrome
E There is not enough information to arrive at a diagnosis.
View Answer
7. The answer is E [III A 5 a (1)]. His presentation with exertional pain is typical of angina, but the location, duration, and lack of risk factors are atypical. No diagnosis can be made based on this information.
8. What should be the next step in establishing the diagnosis for this patient?
A Repeat the ECG
B Perform a cardiac catheterization
C Obtain cardiac enzymes and a troponin level
D Perform a stress ECG
E Perform a stress echocardiogram
View Answer
8. The answer is E [III A 5 a (3)]. A stress echocardiogram will give information about cardiac function and the presence of coronary disease (90% sensitivity). Repeating the ECG is unlikely to give new information. The brevity of the pain makes it very unlikely that myocardial damage has occurred, and thus troponin is likely to be normal. The stress ECG will be of limited use because the resting ECG is already abnormal. Cardiac catheterization could be employed, but because of its invasive nature it is usually not the first step in arriving at a diagnosis.
9. If coronary disease is found in this patient, indications for surgical revascularization would include which of the following?
A Occasional angina
B Left main coronary stenosis of 20%
C Three-vessel coronary artery disease with left ventricular systolic dysfunction
D Disease of the right and circumflex arteries
E A severe lesion in one coronary artery
View Answer
9. The answer is C [III A 5 a (4) (e)]. Surgical revascularization has shown a mortality benefit for patients with disease of >70% of all three epicardial coronary arteries and associated left ventricular dysfunction. In addition, a mortality benefit has been shown for patients with >50% stenosis of the left main coronary artery, irrespective of ventricular function. Given the risks of surgical revascularization, medical therapy and/or percutaneous intervention should be considered first for patients who are not likely to experience a mortality benefit from bypass surgery.
A 56-year-old man with a history of hypertension is seen for the evaluation of chest pain that began an hour ago. The pain was centered in the left side of the chest and radiates to the left arm. It was associated with nausea and vomiting. His physical examination findings are:
Blood pressure 80/60 mm Hg, pulse 58 bpm, and respiratory rate 16
Chest: clear
Heart: no gallops or murmurs
ECG: Acute anterior myocardial infarction and sinus bradycardia
10. What should be the next step in management of this patient?
A Insertion of a temporary pacemaker
B Administration of nitrates
C Fluid resuscitation
D Insertion of an intra-aortic balloon pump
E Administration of a خ²-blocker
View Answer
10. The answer is C [III A 5 b (4)]. The patient is hypotensive, as he has no signs of volume overload or heart failure; thus, fluid resuscitation should be performed first. Although both خ²-blockers and nitrates are indicated in MI, their use here would only exacerbate the hypotension. A pacemaker might improve blood pressure but only if AV sequential pacing were used, a sometimes complex procedure. In fact, pacemakers are rarely used for mild sinus bradycardia. Intra-aortic balloon pumping would be used only if other measures failed to restore blood pressure.
11. After the patient in question 10 is stabilized, he should:
A Be transferred to the critical care unit
B Undergo immediate percutaneous coronary angioplasty if available
C Receive warfarin
D Receive nifedipine
E Receive intravenous lidocaine
View Answer
11. The answer is B [III A 5 b (4) (b)]. If acute angioplasty is available, it should be performed immediately to restore coronary blood flow without transferring the patient to the coronary care unit (CCU), because every minute counts in preserving myocardium. Dihydropyridine calcium channel blockers such as nifedipine are contraindicated in MI because they increase mortality. Lidocaine is no longer used prophylactically against cardiac arrhythmias because of possible cardiac standstill. Although heparin is an essential part of therapy, warfarin, which takes days to become effective, is not.
12. On the second hospital day, the patient becomes diaphoretic and hypotensive. A III/VI holosystolic murmur is heard. Which of the following is likely?
A He has developed pericardial tamponade.
B There has been acute ventricular septal rupture.
C He has an acute atrial septal defect.
D He has developed mitral valve endocarditis.
E The murmur was old but obscured by the reduced cardiac output from his MI.
View Answer
12. The answer is B [III A 5 b (6) (e)]. Hemodynamic decompensation and a new cardiac murmur after MI indicate either acute ventricular septal rupture or acute mitral valve dysfunction. Atrial septal defect is not a consequence of MI. There is no indication that the patient has developed endocarditis. If anything, the patient's output has been still further reduced, as indicated by his change in vital signs. There are no signs of tamponade, such as pulsus paradoxus or neck vein distention.
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13. Ultimately this patient's prognosis will be determined most by which of the following?
A The amount of myocardial damage he has sustained.
B His LDL cholesterol level
C His HDL cholesterol level
D The ratio of LDL to HDL cholesterol
E Blood pressure control
View Answer
13. The answer is A [III A 5 b (5) (a)]. Prognosis is dependent most on the amount of muscle damage (and therefore the amount the ventricular dysfunction that develops), the patient's age, and the extent of coronary disease. Although improving the status of known coronary risk factors such as hyperlipidemia and hypertension reduces subsequent risk, the effect on prognosis is not as large as are muscle damage, age, and extent of disease.
A 25-year-old woman presents with chest pain that worsens when she inspires. Her physical examination findings are blood pressure of 120/70 mm Hg, pulse 76 bpm, respiratory rate 14, Heart: three-component friction rub.
14. Which of the following statements is true of the friction rub?
A It is generated by movement of the parietal and visceral layers of the pericardium.
B It is generated by the visceral layers of the pericardium and pleura.
C It indicates the absence of an effusion.
D It indicates that the cause of the pericarditis is a malignancy.
E It often persists through effective therapy.
View Answer
14. The answer is A [VI A 2 b]. The rub is caused by movement of the inflamed parietal and visceral layers of the pericardium. A rub is indicative of pericarditis from any cause and does not imply malignancy. Rubs can still occur even when an effusion separates the two layers of the pericardium. Rubs usually disappear with effective therapy.
15. What would be the best first-line therapy for the patient in question 14?
A Acetaminophen
B Aspirin
C Ibuprofen
D Prednisone
E Colchicine
View Answer
15. The answer is C [VI A 4]. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen form the first line of therapy. High-dose aspirin is effective but is more likely to cause gastrointestinal tract side effects. Although acetaminophen might relieve the pain, it would not treat the inflammation. Prednisone and colchicine are reserved for NSAID failures.
16. Several days later, the patient develops dyspnea and jugular venous distension. The likely diagnosis now is:
A Right-sided heart failure
B Myocardial infarction
C Pulmonary embolism
D Pericardial tamponade
E Pneumonia
View Answer
16. The answer is D [VI C 2]. The onset of dyspnea and neck vein distention should immediately trigger concern for tamponade in a patient with known pericarditis. As fluid builds up in the pericardial sac, it compresses the heart, limits its output, and raises the pressure in all four cardiac chambers; hence the neck vein distention. Whereas MI, right-sided failure, pulmonary embolism, and pneumonia are all possible occurrences, there are no findings to confirm their presence in this otherwise healthy young woman.
A 75-year-old man complains of chest pain while climbing stairs. On physical examination, there is a II/VI systolic ejection murmur that radiates to the neck. The carotid upstrokes are delayed and diminished in volume.
17. The most likely diagnosis is:
A Hypertrophic cardiomyopathy
B Aortic stenosis
C Mitral stenosis
D Pulmonary stenosis
E Vasovagal syncope
View Answer
17. The answer is B [IV A 3 a–b]. The murmur and delayed carotid upstrokes are typical of the fixed LV outflow obstruction of aortic stenosis. Pulmonary stenosis also can cause chest pain and a systolic ejection murmur but would not cause carotid delay. Hypertrophic cardiomyopathy causes a spike and dome of the carotid upstrokes; that is, a sharp upstroke followed by fall and a flatter secondary rise. The murmur of mitral stenosis is diastolic. Although the syncope could have been attributable to a vasovagal faint, this could only be a diagnosis of exclusion in the face of obvious aortic stenosis.
18. The best test to confirm the diagnosis is:
A An ECG
B An exercise stress test
C An echocardiogram
D A radionuclide ventriculogram
E A chest x-ray
View Answer
18. The answer is C [IV A 4]. Echocardiography with Doppler interrogation of the valve will show the aortic stenosis, quantify its severity, and assess left ventricular function. The ECG and chest x-ray are nonspecific in this disease. Although useful in asymptomatic patients, stress testing is dangerous in symptomatic aortic stenosis. A radionuclide study would give information about left ventricular function but not about lesion severity.
19. The recommended therapy is:
A Urgent aortic valve replacement
B An ACE inhibitor
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C Nitroglycerine
D A calcium channel blocker
E A خ²-blocker
View Answer
19. The answer is A [IV A 5 b]. The only accepted therapy for symptomatic aortic stenosis is aortic valve replacement. Nitrates can be used cautiously for angina until the valve is replaced but only as a temporizing measure. The other agents listed could cause hypotension and should not be used.
A murmur is detected on the routine examination of a 35-year-old woman. She is entirely asymptomatic and engages in aerobic exercise classes without difficulty. On physical examination, there is II/VI systolic ejection murmur heard best in the left second interspace. S1 is normal. S2 is widely split and does not vary with respiration.
20. The likely diagnosis is:
A Pulmonary stenosis
B Aortic stenosis
C Ventricular septal defect
D Atrial septal defect
E A flow (innocent) murmur
View Answer
20. The answer is D [VII A 3 b]. The widely split S2 that does not vary with respiration is pathognomonic of atrial septal defect. The murmur is caused by increased flow across the pulmonic valve, which is not stenotic. The murmur of a ventricular septal defect is holosystolic. The murmur of aortic stenosis is associated with a soft single S2 because the aortic valve neither opens nor closes well.
21. Which of the following is true about this abnormality?
A This abnormality, when identified, should always be repaired.
B All types of this defect are associated with an increased risk of endocarditis.
C Uncorrected, this defect may lead to pulmonary hypertension and right heart failure.
D Ventricular arrhythmias are frequently associated with this abnormality.
E The murmur is due to turbulent flow across the defect.
View Answer
21. The answer is C [VII A 3 a]. Atrial septal defects may occur in different locations, and may be of different sizes. Large, nonrestrictive defects may lead to pulmonary hypertension and eventual right-sided heart failure if left uncorrected. Not all atrial septal defects are associated with an increased incidence of endocarditis. Endocarditis is more common is ostium primum atrial septal defects due the associated abnormality of the anterior mitral valve (cleft mitral valve). Ostium secundum defects, the most common type, are not associated with an increased risk. Atrial arrhythmias commonly occur late in the natural history of the disease, but ventricular arrhythmias are not commonly associated with atrial septal defects. The murmur associated with an atrial septal defect is due to the relative increase in blood flow across the pulmonic valve, and is not directly related to shunt flow across the atrial septal defect.
A 50-year-old man presents with mild dyspnea on exertion of recent onset. He was told that he had “a murmur†during childhood, but he has not seen a physician in many years. On examination, his pulses are bounding and his blood pressure is 160/60 mm Hg. S1 is soft and S2 is normal. There is a soft apical diastolic low-pitched rumble heard at the apex, and there is a diastolic decrescendo murmur heard along the left sternal border extending to S1. Chest x-ray demonstrates cardiomegaly.
22. The most likely diagnosis is
A Aortic stenosis
B Aortic insufficiency
C Mitral stenosis
D Mitral insufficiency
E Mixed aortic insufficiency and mitral stenosis
View Answer
22. The answer is B [IV C 1-2]. The bounding pulses and widened pulse pressure are characteristic of significant aortic insufficiency and represent both the increased stroke volume and the enhanced aortic “run-off†due to the incompetent valve. Because of retrograde diastolic flow across the aortic valve into the left ventricle, the left ventricular diastolic pressure rises rapidly, leading to a nearly or completely closed mitral valve at the time of ventricular systole, accounting for the soft S1. In mitral stenosis, S1 is usually loud until very late stages of the disease. The “preclosure†of the mitral valve is also possibly the cause of a relative mitral stenosis/diastolic rumble, termed the “Austin Flint†murmur. Cardiomegaly is present in the volume overloaded state of severe aortic insufficiency. By comparison, the left ventricle is protected from volume overload with pure mitral stenosis, and it is generally small in size.
23. An echocardiogram confirms your clinical suspicions. The left ventricular function is normal, but the left ventricle is dilated to 6 cm at end-systole. You should recommend which of the following treatments?
A Careful titration of a خ²-blocker
B Afterload reduction with an ACE inhibitor
C Mitral valve replacement
D Aortic valve replacement
E Mitral and aortic valve replacement
View Answer
23. The answer is D [IV C 5]. Patients with severe aortic valvular insufficiency with left ventricular dilation to this degree should be referred for aortic valve replacement. Medical therapy at this point is more likely to result in worse postoperative left ventricular function and more symptoms of heart failure. The use of خ²-blockers in patients with significant aortic insufficiency is controversial, as they prolong the diastolic interval and may, therefore, increase the regurgitant fraction of blood. Afterload reduction in patients with significant aortic regurgitation, but without this degree of ventricular dilation would be prudent and can delay left ventricular dilation and compromise of function.
A 35-year-old white woman enters the emergency department complaining of episodic chest pain that usually lasts for 5–10 minutes. Sometimes it is related to exercise, but on other occasions it occurs at rest. The pain does not radiate. The woman is a nonsmoker and has no history of hypertension. Two other family members have died of heart disease, one at 50 years of age and the other at 56 years of age. On physical examination, the patient is in no acute distress. Her blood pressure is 120/70 mm Hg and her pulse is 70 bpm. Examination of the precordium finds that the PMI is forceful. There is a II/VI systolic ejection murmur heard along the left sternal border that increases in intensity when the patient stands up. The ECG shows nonspecific ST-segment and T-wave abnormalities.
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24. Which of the following is the most likely diagnosis?
A Innocent flow murmur
B Aortic stenosis
C Hypertrophic cardiomyopathy
D Mitral stenosis
E Pulmonic stenosis
View Answer
24. The answer is C [V B 4]. The most likely diagnosis is hypertrophic cardiomyopathy, as evidenced by the increased intensity of the systolic ejection murmur when the patient stands. When a patient with hypertrophic cardiomyopathy stands, blood pools in the legs, decreasing left ventricular size and bringing the anterior leaflet of the mitral valve in closer contact with the hypertrophied ventricular septum. This increases the obstruction and makes the murmur louder. Conversely, innocent flow murmurs and the murmurs associated with pulmonic and aortic stenosis decrease when the patient stands, because the temporary pooling of central volume in the legs decreases forward cardiac output, thereby decreasing turbulent flow in the valve. The murmur of mitral stenosis is a diastolic murmur, not a systolic murmur.
25. Which of the following tools would be best to use when diagnosing this patient?
A Chest radiograph
B Cardiac catheterization
C Thallium scanning
D Echocardiography
E Myocardial biopsy
View Answer
25. The answer is D [V B 5(b)]. The echocardiogram is a highly effective diagnostic tool in hypertrophic cardiomyopathy, provided the patient can be visualized adequately. Asymmetric hypertrophy of the septum compared with the free cardiac wall confirms the diagnosis. If obstruction is present, there will also be systolic anterior motion of the mitral valve. There are no particular features of hypertrophic cardiomyopathy demonstrable on a chest radiograph. Thallium scintigraphy may show the hypertrophied septum, but this is not the optimum form of imaging. Cardiac catheterization can certainly confirm the diagnosis, but this invasive test needs to be performed in only a minority of patients when echocardiography cannot adequately visualize the patient's heart.
26. Which of the following therapies is most appropriate for this patient?
A Immediate surgery
B A خ²-blocker
C Vasodilators
D Digoxin
E Furosemide
View Answer
26. The answer is B [V B 6 a]. Symptoms of hypertrophic cardiomyopathy may be relieved with propranolol, a خ²-adrenergic blocking agent. By decreasing heart rate, propranolol allows increased left ventricular filling, thereby increasing separation of the anterior leaflet of the mitral valve and the septum and reducing the amount of obstruction. Unlike valvular aortic stenosis (where death may be imminent after the development of symptoms unless surgery is performed) in hypertrophic cardiomyopathy, there is no evidence that surgery prolongs life. Both digoxin (by increasing the force of that contraction) and furosemide (by decreasing left ventricular size) would worsen the obstruction and likely exacerbate the patient's symptoms.
27. Which of the following is true regarding percutaneous coronary intervention?
A There is no benefit over the use of intravenous thrombolytic agents for the treatment of acute myocardial infarction.
B In patients with stable anginal symptoms it provides symptom relief and a mortality benefit.
C Stents bonded with drugs such as sirolimus or paclitaxel have eliminated the risk of re-stenosis.
D One third of patients who undergo balloon angioplasty alone will develop re-stenosis within 6 months.
E Periprocedural administration of glycoprotein IIb/IIIa antagonists enhances short-term, but not long-term patency rates and clinical success.
View Answer
27. The answer is (D) [III A 5 a (4) (d)]. The restenosis rate associated with balloon angioplasty alone is 33% within 6 months. Stents were developed, in part, to decrease the incidence of restenosis. While they have achieved this goal, they have not eliminated the risk totally. The use of glycoprotein IIb/IIIa antagonists has improved both short- and long-term clinical success rates and angiographic patency rates. When percutaneous intervention is readily accessible for patients undergoing treatment for acute myocardial infarction, the angiographic patency rates and clinical outcomes are better with the use of direct PCI. Patients with stable anginal symptoms may have symptomatic benefit from PCI, but do not enjoy a mortality benefit related to the procedure.
A 52-year-old man presents with fever, chills, and arthralgia. On physical examination: temperature is 102.2آ°F, pulse is 106 bpm, blood pressure is 100/60 mm Hg, respiratory rate is 22. S1 is soft. There is a short II/VI diastolic blowing murmur at the left sternal border. There are no rashes or petechiae. The results of the rest of the examination are unremarkable.
1. What is the most likely diagnosis?
A Viral syndrome with flow murmur
B Acute systemic lupus erythematosus with aortic valve involvement
C Infective endocarditis of the aortic valve with probably mild insufficiency
D Infective endocarditis of the mitral valve
E Infective endocarditis of the aortic valve with probably severe insufficiency
View Answer
1. The answer is E [IV C 3 b (2)]. The diastolic murmur is typical of that of aortic insufficiency. The fever chills and arthralgia suggest infection, making infective endocarditis the most likely diagnosis. The soft S1 suggests mitral valve preclosure, indicating severe disease. This syndrome could be seen in acute lupus, but this is less likely in a man without other evidence of the disease. Increased flow from any cause does not produce aortic insufficiency. A lesion on the mitral valve creates systolic, not diastolic, murmurs.
2. Which of the following statements is true of the condition of the patient in question 1?
A The cardiac physical examination is hyperdynamic.
B S1 is soft because of aortic valve preclosure.
C Mitral valve preclosure indicates a poor prognosis without aortic valve replacement.
D The appearance of a diastolic murmur is usually benign.
E Hill's sign is a good predictor of severity.
View Answer
2. The answer is C [IV C 3 b]. Mitral valve preclosure, caused by high ventricular diastolic filling pressure, greater than left atrial pressure, indicates severe disease that is usually fatal without aortic valve replacement. In acute aortic insufficiency such as that seen in endocarditis, Left ventricular dilation has not yet occurred, stroke volume is not increased very much, and thus the circulation is not hyperdynamic. Therefore Hill's sign is also absent. In general, diastolic murmurs are not benign and indicate valve pathology.
3. The diagnostic test(s) that should be performed next is/are
A A chest x-ray
B Blood cultures
C Cardiac catheterization
D A radionuclide ventriculogram
E Exploratory thoracotomy
View Answer
3. The answer is B [IV C 4]. Blood cultures to confirm a bloodstream infection and echocardiography to identify valve lesions and valve function are the mainstays of diagnosis in infective endocarditis. Although a chest x-ray might be useful, it is never diagnostic of endocarditis. Valve surgery would not be contemplated without the diagnosis of endocarditis being established first. Cardiac catheterization is rarely indicated in endocarditis today because echocardiography provides more information more safely. A radionuclide ventriculogram would give information about cardiac performance but would not confirm the diagnosis.
A 56-year-old man enters the emergency department complaining of dyspnea that began about 3 weeks ago and has progressed so that he now has difficulty walking across a room. He has begun sleeping on three pillows. On physical examination: temperature is 99(F, pulse 102 bpm, BP 130/90 mm Hg, respiratory rate 24. There is jugular venous distention, and estimated central venous pressure is 10 cm H2O. Other findings include bibasilar rales and an S3 gallop.
4. What is the most likely diagnosis in this patient?
A Pulmonary embolism
B Congestive heart failure
C Emphysema
D Pneumonia
E Atrial septal defect
View Answer
4. The answer is B [I D 1–2]. The gradual onset of dyspnea, the pulmonary rales, and the S3 gallop are all typical of congestive heart failure. Although a pulmonary embolus could cause all of the findings in this patient, even a right-sided S3, sudden onset is the norm in that condition. The other conditions all could cause dyspnea but would not cause gallop rhythm.
5. Which of the following tests is most appropriate to aid in establishing therapy for this patient?
A A chest x-ray
B An echocardiogram
C An electrocardiogram
D A heart catheterization
E A radionuclide ventriculogram
View Answer
5. The answer is B [I E (3)]. An echocardiogram will yield data about systolic and diastolic function, chamber size, and valvular abnormalities. All of the other tests are useful, but all except catheterization give less information than the echocardiogram. Cardiac catheterization has a higher risk and is only employed when the information gained outweighs that risk. Thus, in CHF, echocardiography provides the “biggest bang for the buck.â€
6. Which of the following is true about the treatment of the condition of the patient in question 4?
A The cause of the condition should be treated whenever possible.
B Systolic versus diastolic dysfunction usually cannot be established.
C ACE inhibitors improve symptoms but do not prolong life.
D Diuretics are the court of last resort.
E خ²-blockers are dangerous and should be avoided.
View Answer
6. The answer is A [I F (1)]. Congestive heart failure is a syndrome, and its cause should be sought and treated directly whenever possible. It is usually helpful to establish whether the root cause is systolic or diastolic dysfunction, a distinction made easily with echocardiography. Diuretics form the mainstay of therapy, but adding both ACE inhibitors and خ²-blockers prolongs life.
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On a routine office visit, a 45-year-old man complains that recently he has noted right-sided chest pain while mowing his lawn with a push lawn mower. The pain develops suddenly, lasts 2–3 minutes, and subsides when he rests. He denies smoking or a history of hypertension, diabetes, or hyperlipidemia. His physical examination is unremarkable. An ECG shows nonspecific T-wave abnormalities.
7. This patient most likely has which of the following?
A Angina pectoris
B Hiatal hernia
C Pleuritis
D A nonspecific chest pain syndrome
E There is not enough information to arrive at a diagnosis.
View Answer
7. The answer is E [III A 5 a (1)]. His presentation with exertional pain is typical of angina, but the location, duration, and lack of risk factors are atypical. No diagnosis can be made based on this information.
8. What should be the next step in establishing the diagnosis for this patient?
A Repeat the ECG
B Perform a cardiac catheterization
C Obtain cardiac enzymes and a troponin level
D Perform a stress ECG
E Perform a stress echocardiogram
View Answer
8. The answer is E [III A 5 a (3)]. A stress echocardiogram will give information about cardiac function and the presence of coronary disease (90% sensitivity). Repeating the ECG is unlikely to give new information. The brevity of the pain makes it very unlikely that myocardial damage has occurred, and thus troponin is likely to be normal. The stress ECG will be of limited use because the resting ECG is already abnormal. Cardiac catheterization could be employed, but because of its invasive nature it is usually not the first step in arriving at a diagnosis.
9. If coronary disease is found in this patient, indications for surgical revascularization would include which of the following?
A Occasional angina
B Left main coronary stenosis of 20%
C Three-vessel coronary artery disease with left ventricular systolic dysfunction
D Disease of the right and circumflex arteries
E A severe lesion in one coronary artery
View Answer
9. The answer is C [III A 5 a (4) (e)]. Surgical revascularization has shown a mortality benefit for patients with disease of >70% of all three epicardial coronary arteries and associated left ventricular dysfunction. In addition, a mortality benefit has been shown for patients with >50% stenosis of the left main coronary artery, irrespective of ventricular function. Given the risks of surgical revascularization, medical therapy and/or percutaneous intervention should be considered first for patients who are not likely to experience a mortality benefit from bypass surgery.
A 56-year-old man with a history of hypertension is seen for the evaluation of chest pain that began an hour ago. The pain was centered in the left side of the chest and radiates to the left arm. It was associated with nausea and vomiting. His physical examination findings are:
Blood pressure 80/60 mm Hg, pulse 58 bpm, and respiratory rate 16
Chest: clear
Heart: no gallops or murmurs
ECG: Acute anterior myocardial infarction and sinus bradycardia
10. What should be the next step in management of this patient?
A Insertion of a temporary pacemaker
B Administration of nitrates
C Fluid resuscitation
D Insertion of an intra-aortic balloon pump
E Administration of a خ²-blocker
View Answer
10. The answer is C [III A 5 b (4)]. The patient is hypotensive, as he has no signs of volume overload or heart failure; thus, fluid resuscitation should be performed first. Although both خ²-blockers and nitrates are indicated in MI, their use here would only exacerbate the hypotension. A pacemaker might improve blood pressure but only if AV sequential pacing were used, a sometimes complex procedure. In fact, pacemakers are rarely used for mild sinus bradycardia. Intra-aortic balloon pumping would be used only if other measures failed to restore blood pressure.
11. After the patient in question 10 is stabilized, he should:
A Be transferred to the critical care unit
B Undergo immediate percutaneous coronary angioplasty if available
C Receive warfarin
D Receive nifedipine
E Receive intravenous lidocaine
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11. The answer is B [III A 5 b (4) (b)]. If acute angioplasty is available, it should be performed immediately to restore coronary blood flow without transferring the patient to the coronary care unit (CCU), because every minute counts in preserving myocardium. Dihydropyridine calcium channel blockers such as nifedipine are contraindicated in MI because they increase mortality. Lidocaine is no longer used prophylactically against cardiac arrhythmias because of possible cardiac standstill. Although heparin is an essential part of therapy, warfarin, which takes days to become effective, is not.
12. On the second hospital day, the patient becomes diaphoretic and hypotensive. A III/VI holosystolic murmur is heard. Which of the following is likely?
A He has developed pericardial tamponade.
B There has been acute ventricular septal rupture.
C He has an acute atrial septal defect.
D He has developed mitral valve endocarditis.
E The murmur was old but obscured by the reduced cardiac output from his MI.
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12. The answer is B [III A 5 b (6) (e)]. Hemodynamic decompensation and a new cardiac murmur after MI indicate either acute ventricular septal rupture or acute mitral valve dysfunction. Atrial septal defect is not a consequence of MI. There is no indication that the patient has developed endocarditis. If anything, the patient's output has been still further reduced, as indicated by his change in vital signs. There are no signs of tamponade, such as pulsus paradoxus or neck vein distention.
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13. Ultimately this patient's prognosis will be determined most by which of the following?
A The amount of myocardial damage he has sustained.
B His LDL cholesterol level
C His HDL cholesterol level
D The ratio of LDL to HDL cholesterol
E Blood pressure control
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13. The answer is A [III A 5 b (5) (a)]. Prognosis is dependent most on the amount of muscle damage (and therefore the amount the ventricular dysfunction that develops), the patient's age, and the extent of coronary disease. Although improving the status of known coronary risk factors such as hyperlipidemia and hypertension reduces subsequent risk, the effect on prognosis is not as large as are muscle damage, age, and extent of disease.
A 25-year-old woman presents with chest pain that worsens when she inspires. Her physical examination findings are blood pressure of 120/70 mm Hg, pulse 76 bpm, respiratory rate 14, Heart: three-component friction rub.
14. Which of the following statements is true of the friction rub?
A It is generated by movement of the parietal and visceral layers of the pericardium.
B It is generated by the visceral layers of the pericardium and pleura.
C It indicates the absence of an effusion.
D It indicates that the cause of the pericarditis is a malignancy.
E It often persists through effective therapy.
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14. The answer is A [VI A 2 b]. The rub is caused by movement of the inflamed parietal and visceral layers of the pericardium. A rub is indicative of pericarditis from any cause and does not imply malignancy. Rubs can still occur even when an effusion separates the two layers of the pericardium. Rubs usually disappear with effective therapy.
15. What would be the best first-line therapy for the patient in question 14?
A Acetaminophen
B Aspirin
C Ibuprofen
D Prednisone
E Colchicine
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15. The answer is C [VI A 4]. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen form the first line of therapy. High-dose aspirin is effective but is more likely to cause gastrointestinal tract side effects. Although acetaminophen might relieve the pain, it would not treat the inflammation. Prednisone and colchicine are reserved for NSAID failures.
16. Several days later, the patient develops dyspnea and jugular venous distension. The likely diagnosis now is:
A Right-sided heart failure
B Myocardial infarction
C Pulmonary embolism
D Pericardial tamponade
E Pneumonia
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16. The answer is D [VI C 2]. The onset of dyspnea and neck vein distention should immediately trigger concern for tamponade in a patient with known pericarditis. As fluid builds up in the pericardial sac, it compresses the heart, limits its output, and raises the pressure in all four cardiac chambers; hence the neck vein distention. Whereas MI, right-sided failure, pulmonary embolism, and pneumonia are all possible occurrences, there are no findings to confirm their presence in this otherwise healthy young woman.
A 75-year-old man complains of chest pain while climbing stairs. On physical examination, there is a II/VI systolic ejection murmur that radiates to the neck. The carotid upstrokes are delayed and diminished in volume.
17. The most likely diagnosis is:
A Hypertrophic cardiomyopathy
B Aortic stenosis
C Mitral stenosis
D Pulmonary stenosis
E Vasovagal syncope
View Answer
17. The answer is B [IV A 3 a–b]. The murmur and delayed carotid upstrokes are typical of the fixed LV outflow obstruction of aortic stenosis. Pulmonary stenosis also can cause chest pain and a systolic ejection murmur but would not cause carotid delay. Hypertrophic cardiomyopathy causes a spike and dome of the carotid upstrokes; that is, a sharp upstroke followed by fall and a flatter secondary rise. The murmur of mitral stenosis is diastolic. Although the syncope could have been attributable to a vasovagal faint, this could only be a diagnosis of exclusion in the face of obvious aortic stenosis.
18. The best test to confirm the diagnosis is:
A An ECG
B An exercise stress test
C An echocardiogram
D A radionuclide ventriculogram
E A chest x-ray
View Answer
18. The answer is C [IV A 4]. Echocardiography with Doppler interrogation of the valve will show the aortic stenosis, quantify its severity, and assess left ventricular function. The ECG and chest x-ray are nonspecific in this disease. Although useful in asymptomatic patients, stress testing is dangerous in symptomatic aortic stenosis. A radionuclide study would give information about left ventricular function but not about lesion severity.
19. The recommended therapy is:
A Urgent aortic valve replacement
B An ACE inhibitor
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C Nitroglycerine
D A calcium channel blocker
E A خ²-blocker
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19. The answer is A [IV A 5 b]. The only accepted therapy for symptomatic aortic stenosis is aortic valve replacement. Nitrates can be used cautiously for angina until the valve is replaced but only as a temporizing measure. The other agents listed could cause hypotension and should not be used.
A murmur is detected on the routine examination of a 35-year-old woman. She is entirely asymptomatic and engages in aerobic exercise classes without difficulty. On physical examination, there is II/VI systolic ejection murmur heard best in the left second interspace. S1 is normal. S2 is widely split and does not vary with respiration.
20. The likely diagnosis is:
A Pulmonary stenosis
B Aortic stenosis
C Ventricular septal defect
D Atrial septal defect
E A flow (innocent) murmur
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20. The answer is D [VII A 3 b]. The widely split S2 that does not vary with respiration is pathognomonic of atrial septal defect. The murmur is caused by increased flow across the pulmonic valve, which is not stenotic. The murmur of a ventricular septal defect is holosystolic. The murmur of aortic stenosis is associated with a soft single S2 because the aortic valve neither opens nor closes well.
21. Which of the following is true about this abnormality?
A This abnormality, when identified, should always be repaired.
B All types of this defect are associated with an increased risk of endocarditis.
C Uncorrected, this defect may lead to pulmonary hypertension and right heart failure.
D Ventricular arrhythmias are frequently associated with this abnormality.
E The murmur is due to turbulent flow across the defect.
View Answer
21. The answer is C [VII A 3 a]. Atrial septal defects may occur in different locations, and may be of different sizes. Large, nonrestrictive defects may lead to pulmonary hypertension and eventual right-sided heart failure if left uncorrected. Not all atrial septal defects are associated with an increased incidence of endocarditis. Endocarditis is more common is ostium primum atrial septal defects due the associated abnormality of the anterior mitral valve (cleft mitral valve). Ostium secundum defects, the most common type, are not associated with an increased risk. Atrial arrhythmias commonly occur late in the natural history of the disease, but ventricular arrhythmias are not commonly associated with atrial septal defects. The murmur associated with an atrial septal defect is due to the relative increase in blood flow across the pulmonic valve, and is not directly related to shunt flow across the atrial septal defect.
A 50-year-old man presents with mild dyspnea on exertion of recent onset. He was told that he had “a murmur†during childhood, but he has not seen a physician in many years. On examination, his pulses are bounding and his blood pressure is 160/60 mm Hg. S1 is soft and S2 is normal. There is a soft apical diastolic low-pitched rumble heard at the apex, and there is a diastolic decrescendo murmur heard along the left sternal border extending to S1. Chest x-ray demonstrates cardiomegaly.
22. The most likely diagnosis is
A Aortic stenosis
B Aortic insufficiency
C Mitral stenosis
D Mitral insufficiency
E Mixed aortic insufficiency and mitral stenosis
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22. The answer is B [IV C 1-2]. The bounding pulses and widened pulse pressure are characteristic of significant aortic insufficiency and represent both the increased stroke volume and the enhanced aortic “run-off†due to the incompetent valve. Because of retrograde diastolic flow across the aortic valve into the left ventricle, the left ventricular diastolic pressure rises rapidly, leading to a nearly or completely closed mitral valve at the time of ventricular systole, accounting for the soft S1. In mitral stenosis, S1 is usually loud until very late stages of the disease. The “preclosure†of the mitral valve is also possibly the cause of a relative mitral stenosis/diastolic rumble, termed the “Austin Flint†murmur. Cardiomegaly is present in the volume overloaded state of severe aortic insufficiency. By comparison, the left ventricle is protected from volume overload with pure mitral stenosis, and it is generally small in size.
23. An echocardiogram confirms your clinical suspicions. The left ventricular function is normal, but the left ventricle is dilated to 6 cm at end-systole. You should recommend which of the following treatments?
A Careful titration of a خ²-blocker
B Afterload reduction with an ACE inhibitor
C Mitral valve replacement
D Aortic valve replacement
E Mitral and aortic valve replacement
View Answer
23. The answer is D [IV C 5]. Patients with severe aortic valvular insufficiency with left ventricular dilation to this degree should be referred for aortic valve replacement. Medical therapy at this point is more likely to result in worse postoperative left ventricular function and more symptoms of heart failure. The use of خ²-blockers in patients with significant aortic insufficiency is controversial, as they prolong the diastolic interval and may, therefore, increase the regurgitant fraction of blood. Afterload reduction in patients with significant aortic regurgitation, but without this degree of ventricular dilation would be prudent and can delay left ventricular dilation and compromise of function.
A 35-year-old white woman enters the emergency department complaining of episodic chest pain that usually lasts for 5–10 minutes. Sometimes it is related to exercise, but on other occasions it occurs at rest. The pain does not radiate. The woman is a nonsmoker and has no history of hypertension. Two other family members have died of heart disease, one at 50 years of age and the other at 56 years of age. On physical examination, the patient is in no acute distress. Her blood pressure is 120/70 mm Hg and her pulse is 70 bpm. Examination of the precordium finds that the PMI is forceful. There is a II/VI systolic ejection murmur heard along the left sternal border that increases in intensity when the patient stands up. The ECG shows nonspecific ST-segment and T-wave abnormalities.
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24. Which of the following is the most likely diagnosis?
A Innocent flow murmur
B Aortic stenosis
C Hypertrophic cardiomyopathy
D Mitral stenosis
E Pulmonic stenosis
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24. The answer is C [V B 4]. The most likely diagnosis is hypertrophic cardiomyopathy, as evidenced by the increased intensity of the systolic ejection murmur when the patient stands. When a patient with hypertrophic cardiomyopathy stands, blood pools in the legs, decreasing left ventricular size and bringing the anterior leaflet of the mitral valve in closer contact with the hypertrophied ventricular septum. This increases the obstruction and makes the murmur louder. Conversely, innocent flow murmurs and the murmurs associated with pulmonic and aortic stenosis decrease when the patient stands, because the temporary pooling of central volume in the legs decreases forward cardiac output, thereby decreasing turbulent flow in the valve. The murmur of mitral stenosis is a diastolic murmur, not a systolic murmur.
25. Which of the following tools would be best to use when diagnosing this patient?
A Chest radiograph
B Cardiac catheterization
C Thallium scanning
D Echocardiography
E Myocardial biopsy
View Answer
25. The answer is D [V B 5(b)]. The echocardiogram is a highly effective diagnostic tool in hypertrophic cardiomyopathy, provided the patient can be visualized adequately. Asymmetric hypertrophy of the septum compared with the free cardiac wall confirms the diagnosis. If obstruction is present, there will also be systolic anterior motion of the mitral valve. There are no particular features of hypertrophic cardiomyopathy demonstrable on a chest radiograph. Thallium scintigraphy may show the hypertrophied septum, but this is not the optimum form of imaging. Cardiac catheterization can certainly confirm the diagnosis, but this invasive test needs to be performed in only a minority of patients when echocardiography cannot adequately visualize the patient's heart.
26. Which of the following therapies is most appropriate for this patient?
A Immediate surgery
B A خ²-blocker
C Vasodilators
D Digoxin
E Furosemide
View Answer
26. The answer is B [V B 6 a]. Symptoms of hypertrophic cardiomyopathy may be relieved with propranolol, a خ²-adrenergic blocking agent. By decreasing heart rate, propranolol allows increased left ventricular filling, thereby increasing separation of the anterior leaflet of the mitral valve and the septum and reducing the amount of obstruction. Unlike valvular aortic stenosis (where death may be imminent after the development of symptoms unless surgery is performed) in hypertrophic cardiomyopathy, there is no evidence that surgery prolongs life. Both digoxin (by increasing the force of that contraction) and furosemide (by decreasing left ventricular size) would worsen the obstruction and likely exacerbate the patient's symptoms.
27. Which of the following is true regarding percutaneous coronary intervention?
A There is no benefit over the use of intravenous thrombolytic agents for the treatment of acute myocardial infarction.
B In patients with stable anginal symptoms it provides symptom relief and a mortality benefit.
C Stents bonded with drugs such as sirolimus or paclitaxel have eliminated the risk of re-stenosis.
D One third of patients who undergo balloon angioplasty alone will develop re-stenosis within 6 months.
E Periprocedural administration of glycoprotein IIb/IIIa antagonists enhances short-term, but not long-term patency rates and clinical success.
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27. The answer is (D) [III A 5 a (4) (d)]. The restenosis rate associated with balloon angioplasty alone is 33% within 6 months. Stents were developed, in part, to decrease the incidence of restenosis. While they have achieved this goal, they have not eliminated the risk totally. The use of glycoprotein IIb/IIIa antagonists has improved both short- and long-term clinical success rates and angiographic patency rates. When percutaneous intervention is readily accessible for patients undergoing treatment for acute myocardial infarction, the angiographic patency rates and clinical outcomes are better with the use of direct PCI. Patients with stable anginal symptoms may have symptomatic benefit from PCI, but do not enjoy a mortality benefit related to the procedure.
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