CARDIOVASCULAR QUESTIONS 1-45

 B Cardiomyopathy
Question 1
 C Mitral valve stenosis

A 63-year-old woman has the sudden onset of 'knife-like' pain in the chest
radiating to the back. She has been previously healthy except for a history of poorly
controlled hypertension. She is transported to the hospital and on arrival she has a
heart rate of 90/minute, respirations 20/minute, temperature 36.8°C, and blood
pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest
radiograph reveals a widened mediastinum. Laboratory findings include a total
serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL.
Which of the following is the most likely diagnosis?
 A Fibrinous pericarditis
 D Aortic coarctation
 E Patent foramen ovale
(C) CORRECT. Mitral valve stenosis leads to left atrial enlargement,
but the left ventricle is usually small. THere is typically a 'fishmouth'
shaped mitral valve that has stenosis as well as insufficiency, since it does
not close completely. Most mitral valvular disease in adults results from
rheumatic valvulitis. The episode(s) of rheumatic fever occurred years
before and the scarring of the valve developed slowly.

 B Aortic dissection Question 4

 C Infective endocarditis A 16-year-old healthy adolescent is involved in a schoolyard gang fight and is
stabbed in the chest with a knife in the left midclavicular line. He is taken to the
 D Dilated cardiomyopathy emergency department and on arrival his blood pressure is barely obtainable. His
lungs are clear to auscultation. His heart sounds are barely audible. Which of the
 E Myocardial infarction following is the most useful therapeutic approach for this boy?

(B) CORRECT. This is a classic history for an aortic dissection. A tear in the aortic
intima is followed by dissection of blood outward, into the medial layer, and then  A Coronary angioplasty
through the adventitia, often into the thoracic cavity, with fatal hemothorax. The
risk factors in most adults include atherosclerosis and hypertension. In Marfan  B Aortic repair
syndrome, the risk for aortic dilation and dissection results from cystic medial
necrosis, but this occurs at a much younger age.  C Pericardiocentesis

Question 2  D Antibiotic therapy

 E Antiarrhythmic drugs
A 45-year-old man was rushed to the hospital following the sudden onset of an
episode of crushing substernal chest pain. He receives advanced life support
measures. An EKG shows changes consistent with a large transmural anterolateral (C) CORRECT. A stab wound into heart can lead to hemopericardium with
area of infarction involving wall of the left ventricle. He develops cardiogenic shock. cardiac tamponade. The blood around the heart interferes with cardiac motion,
Which of the following microscopic findings is most likely to be present in this area reducing the ejection fraction, and diminishes the heart sounds.
4 days following the onset of his chest pain?
Question 5

 A Fibroblasts and collagen deposition A 19-year-old woman has had increasing malaise for the past 5 months. On
physical examination she has a cardiac murmur characterized by a mid systolic click.
 B Capillary proliferation and macrophages An echocardiogram demonstrates mitral insufficiency with upward displacement of
one leaflet. There is aortic root dilation to 4 cm. She has a dislocated right ocular
 C Myofiber necrosis with neutrophils crystalline lens. A year later she dies suddenly and unexpectedly. The medical
examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of
 D Granulomatous inflammation chordae tendineae. A mutation involving which of the following genes is most likely
to be present in this patient?
 E Perivascular lymphocytic infiltrate

(C) CORRECT. After 3 to 4 days following infarction, the muscle will still be  A Beta-myosin
necrotic and many neutrophils will persist, while macrophage infiltration will be
beginning.  B CFTR

Question 3  C FGFR

 D Fibrillin
A 45-year-old woman has had worsening shortness of breath for 3 years. She
now has to sleep sitting up on two pillows. She has had difficulty swallowing for the
 E Spectrin
past year. She has no history of chest pain. A month ago, she had a 'stroke' with
resultant inability to move her left arm. She is afebrile. A chest radiograph reveals a
 F Dystrophin
near-normal left ventricular size with a prominent left atrial border. Which of the
following conditions is most likely to account for her findings?
(D) CORRECT. Marfan syndrome is a connective tissue disorder that is
associated with floppy mitral valve and also with cystic medial necrosis that
predisposes to aortic dissection. The sudden cardiac death in this case is due to the
 A Essential hypertension
valvular abnormality.
Cardiovascular
 Question 6 has diminished pulses in the lower extremities. There is a pulsatile abdominal mass.
His serum creatine kinase is not elevated. He has had fasting blood glucose
measurements in the range of 140 to 180 mg/dL for over 20 years. Which of the
A 72-year-old woman has had no major illnesses throughout her life. She has
following conditions is he most likely to have?
had 3 syncopal episodes during the past 2 weeks. Over the past 2 days she has
developed shortness of breath and a cough with production of frothy white
sputum. On physical examination she is afebrile. Her blood pressure is 135/90 mm
Hg. She has no peripheral edema. A chest radiograph reveals a prominent left heart  A Superior mesenteric artery thrombosis
border in the region of the left ventricle, but the other chambers do not appear to
be prominent. There is marked pulmonary edema. Laboratory studies show a total  B Atherosclerotic aortic aneurysm
serum cholesterol of 170 mg/dL. Which of the following is the most likely diagnosis?
 C Polyarteritis nodosa

 A Acute rheumatic fever  D Acute coronary syndrome

 B Mitral valve insufficiency  E Monckeberg's medial calcific sclerosis

 C Atherosclerotic aortic aneurysm (B) CORRECT. The infrarenal portion of the abdominal aorta typically involved
with an atherosclerotic aneurysm is markedly enlarged and filled with thrombus.
 D Calcific aortic stenosis Risk for rupture increases with size of the aneurysm. Risk factors for atherosclerosis
here include both diabetes mellitus and hypertension.
 E Infective endocarditis
Question 9
(D) CORRECT. Senile calcific aortic stenosis is a condition in which there is
gradual calcification of an aortic valve with three cusps. The condition is seen in the
A 49-year-old woman had atrial fibrillation that was poorly controlled, even
elderly and is idiopathic. Aortic valvular stenosis may not manifest itself clinically
with amiodarone therapy. She suffered a 'stroke' and died. At autopsy, her 600 gm
until there is critical narrowing of the outflow orifice to less than 1 square
heart is noted to have a mitral valve with partial fusion of the leaflets along with
centimeter. Aortic valve disease can remain silent and then suddenly result in
thickening and shortening of the chordae tendineae. There is an enlarged left
symptoms.
atrium filled with mural thrombus. Which of the following underlying causes of
death is she most likely to have?
Question 7

A 17-year-old girl is short in stature for her age. She has not yet shown any  A Systemic lupus erythematosus
changes of puberty. On physical examination her vital signs include T 37°C, RR
18/minute, P 75/minute, and BP 165/85 mm Hg. She has a continuous murmur  B Coronary atherosclerosis
heard over both the front of the chest as well as her back. Her lower extremities are
cool with diminished pulses and poor capillary filling. She has a webbed neck. A  C Marantic endocarditis
chest radiograph reveals a prominent left heart border, no edema or effusions, and
rib notching. Which of the following cardiovascular abnormalities is she most likely  D Rheumatic heart disease
to have?
 E Cardiac amyloidosis

 A Shortening and thickening of chordae tendineae of the (D) CORRECT. Bouts of rheumatic fever can eventually lead to rheumatic mitral
mitral valve stenosis with left atrial enlargement.

 B Narrowing of the aorta past the ductus arteriosus

Question 10
 C Supravalvular narrowing in the aortic root
A 23-year-old woman has had worsening malaise along with a malar skin rash
 D Lack of development of the spiral septum and partial persisting for 3 weeks. On physical examination, she has an audible friction rub on
absence of conus musculature auscultation of the chest, along with a faint systolic murmur. An echocardiogram
reveals small vegetations on the mitral valve and adjacent ventricular endocardium.
 E Single large atrioventricular valve Laboratory studies show a positive serologic test for anti-Smith antibody, with a
titer of 1:2048. Which of the following is the most likely diagnosis?
(B) CORRECT. She has coarctation of the aorta, and the constriction is
postductal, allowing prolonged survival. Blood pressure is elevated in the upper
body but reduced in the lower body. Her physical characteristics also suggest  A Polyarteritis nodosa
Turner syndrome (monosomy X).
 B Scleroderma, diffuse

 C Systemic lupus erythematosus

 D ANCA-associated granulomatous vasculitis

Question 8
A 65-year-old man has sudden onset of severe abdominal pain that has
persisted for 3 hours. Physical examination reveals his temperature is 37°C, heart
rate 110/minute, respirations 25/minute, and blood pressure 145/100 mmHg. He
 E Adenocarcinoma of the pancreas
(C) CORRECT. Patients with systemic lupus erythematosus can develop Libman-
Sacks endocarditis, but the sterile, non-infectious vegetations are never large and

Cardiovascular
they rarely embolize, so the endocarditis is not clinically significant in most cases.
She probably has a friction rub from fibrinous pericarditis as a result of uremia from  B Diabetes mellitus, type II
renal failure.
 C Hypercholesterolemia
Question 11
 D Malignant hypertension
A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks
 E Monckeberg's sclerosis
gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver,
head, and extremities appear normal. However, the fetus has a heart with a
membranous ventricular septal defect, overriding aorta, and marked pulmonic (D) CORRECT. The small arteries of the kidney are affected by hyperplastic
atresia. If the baby were to be liveborn, which of the following characteristics on arteriolosclerosis. Malignant hypertension with markedly elevated blood pressure is
physical examination would most likely result from these cardiac defects? often preceded by chronic hypertension that leads to left ventricular hypertrophy.
Hypertension is a risk for CNS hemorrhage.

 A Systemic hypertension Question 14

 B Weak lower extremity pulses A 24-year-old woman with rheumatic heart disease becomes febrile. On
physical examination she has a systolic murmur. An echocardiogram shows
 C Clubbing of digits vegetations of the aortic valve cusps. A blood culture is positive for Staphylococcus
epidermidis. She receives a porcine bioprosthesis because of her desire to have
 D Telangiectasias children and not to take anticoagulant medication. After ten years, she must have
this prosthetic valve replaced. Which of the following pathologic findings in the
 E Cyanosis bioprosthesis has most likely led to the need for replacement?

(E) CORRECT. The features described are those of tetralogy of Fallot, which
producces a right-to left shunt with cyanosis from mixing of right heart blood with  A Dehiscence
left heart blood.
 B Endocarditis
Question 12
 C Strut failure

A 50-year-old man has the sudden onset of substernal chest pain. The pain  D Calcification
persists for the next three hours. He then becomes short of breath and diaphoretic.
He goes to the emergency department and on physical examination his vital signs
 E Thrombosis
include T 37°C, P 100/minute, RR 26/minute, and BP 130/90 mm Hg. A chest x-ray
shows a slightly enlarged heart and mild pulmonary edema. An EKG shows ST
segment elevation in anterior leads V1 - 6. Which of the following serum laboratory (D) CORRECT. The bioprosthesis has the advantage of not requiring
test findings is most likely to be present in this man? anticoagulation, but it does not wear well with time, and typically must be replaced
within 5 to 10 years when its leaflets undergo progressive calcification leading to
stenosis.
 A Urea nitrogen of 110 mg/dL
Question 15
 B Sodium of 115 mmol/L
A 25-year-old previously healthy woman collapses suddenly and unexpectedly.
 C ALT of 876 U/L Echocardiography shows global hypokinesis with increased left ventricular end
diastolic and systolic size, along with systolic left ventricular dysfunction with
 D Troponin I of 32 ng/mL decreased ejection fraction. An endomyocardial biopsy is obtained and
microscopically, the myocardium shows infiltration by small lymphocytes, with focal
 E HDL cholesterol of 55 mg/dL myocyte necrosis. Which of the following infectious agents is most likely to have
caused these findings?
(D) CORRECT. The findings suggest an early ischemic event as part of an acute
coronary syndrome with developing myocardial infarction. The troponin I can be
elevated within a few hours, and it will remain elevated for 10 to 14 days, while the  A Coxsackie B virus
CK-MB will peak in a day and subside by 3 days.
 B Candida albicans
Question 13
 C Aspergillus fumigatus

A 44-year-old woman dies as a consequence of a 'stroke'. At autopsy, she is  D Streptococcus, viridans group
found to have a large right basal ganglia hemorrhage. She has an enlarged 550 gm
heart with predominantly left ventricular hypertrophy. Her kidneys are small, about
 E Staphylococcus aureus
80 gm each, with cortical scarring, and microscopically they demonstrate small
renal arterioles that have luminal narrowing from concentric intimal thickening.
 F Cytomegalovirus
Which of the following is the most likely condition associated with her findings?
 G Streptococcus, group A

 A Autosomal dominant polycystic kidney disease

(A) CORRECT. The most common cause for a primary myocarditis is a virus
(such as Coxsackie virus). The myocardial fiber necrosis with lymphocytic infiltrates
Cardiovascular
are consistent with viral infection. Viral myocarditis can be a cause for sudden shows thinning of the right ventricular wall with reduced ejection fraction. Which of
death in a young person. the following is the most likely etiology for her cardiac disease ?

Question 16
A 22-year-old man has had increasing malaise over the past 3 weeks. On
physical examination his vital signs show T 39.2°C, P 105/minute, RR 30/minute,
and BP 80/40 mm Hg. On auscultation of his chest a loud systolic cardiac murmur is
heard, and his lungs have bibasilar crackles. Needle tracks are seen in his left
antecubital fossa. He has splinter hemorrhages noted on fingernails, as well as
painful erythematous nodules on palmar surfaces. A tender spleen tip is palpable. A
chest radiograph shows pronounced pulmonary edema. Which of the following
laboratory test findings is most likely to be present in this patient's peripheral
blood?
 A Creatine kinase-MB of 8% with a total CK 389 U/L
 B Positive blood culture for Pseudomonas aeruginosa
 C Total serum cholesterol of 374 mg/dL
 D Blood urea nitrogen of 118 mg/dL
 E Antinuclear antibody titer of 1:512
(B) CORRECT. The history points to infectious endocarditis and acute congestive
heart failure. Staphylococcus aureus and Pseudomonas aeruginosa are the most
likely organisms to be found with a history of injection drug use.
Question 17
 A Atherosclerosis
 B Chronic alcohol abuse
 C Gene mutation
 D Hypertension
 E Viral infection
(C) CORRECT. The findings suggest the rare arrhythmogenic right ventricular
cardiomyopathy, which is inherited in an autosomal dominant pattern. There is
thinning with fatty replacement, beginning in the right ventricle but eventually
involving the left ventricle, unless a fatal arrhythmia occurs.
Question 19
A 26-year-old previously healthy woman has had worsening fatigue with
dyspnea, palpitations, and fever over the past week. On physical examination her
vital signs show T 38.9°C, P 104/minute, RR 30/minute, and BP 95/65 mm Hg. Her
heart rate is slightly irregular. An ECG shows diffuse ST-T segment changes. A chest
x-ray shows mild cardiomegaly. An echocardiogram shows slight mitral and
tricuspid regurgitation but no valvular vegetations. Laboratory studies show a
troponin I of 12 ng/mL. She recovers over the next two weeks with no apparent
sequelae. Which of the following laboratory test findings best explains the
underlying etiology for these events?

A 2-year-old child has had failure to thrive for a year, becoming increasingly  A Anti-streptolysin O titer of 1:512
listless. On examination she is found to have a soft, rumbling systolic ejection
murmur. An echocardiogram reveals a large membranous ventricular septal defect.  B Total serum cholesterol of 537 mg/dL
Which of the following complications is she most likely to experience as an adult 2
decades later if this lesion remains untreated?  C Echovirus serologic titer of 1:160

 D Blood culture positive for Streptococcus, viridans group

 A Rib notching
 E ANCA titer of 1:80
 B Mitral valve prolapse
(C) CORRECT. She has a febrile illness with findings that suggest myocarditis,
 C Pulmonary hypertension which can have features of cardiomyopathy because of the diffuse myocardial
involvement. The most likely organisms are enteroviruses (coxsackie B virus,
 D Myocardial infarction echovirus) as well as adenoviruses.

 E Cardiac tamponade Question 20

(C) CORRECT. The left-to-right shunt from the VSD eventually leads to
pulmonary hypertension and then reversal of the shunt (Eisenmenger complex)
when the right heart pressures increase.
A 45-year-old man has had no major medical problems throughout his life,
except for arthritis pain involving all extremities for the past 5 years. He has had
worsening orthopnea and pedal edema in the past 6 months. There is no chest
pain. On examination he is afebrile. A chest radiograph shows cardiomegaly with
prominent left and right heart borders, along with pulmonary edema. Laboratory
studies show serum sodium 139 mmol/L, potassium 4.3 mmol/L, chloride 99
mmol/L, CO2 25 mmol/L, urea nitrogen 18 mg/dL, creatinine 1.3 mg/dL, and glucose
167 mg/dL. Which of the following additional laboratory test findings is he most
likely to have?

Question 18  A Spherocytes on his peripheral blood smear

 B Hemoglobin of 10.7 g/dL with MCV of 72 fL

A 53-year-old woman has noted increasing dyspnea for the past 2 years. On
examination she is afebrile. She has an irregular pulse. A chest radiograph shows an
 C Erythrocyte sedimentation rate of 79 mm/Hr
enlarged right cardiac silhouette and bilateral pleural effusions. Echocardiography
 D Anti-centromere antibody titer of 1:320
Cardiovascular
 A 66-year-old man has had congestive heart failure with increasing pulmonary
 E Serum ferritin of 800 ng/mL congestion and edema for the past year. He had been previously healthy all his life
with no major illnesses. On physical examination his blood pressure is 125/85 mm
Hg and he is afebrile. A systolic ejection click is auscultated. A chest x-ray shows
(E) CORRECT. He has findings of a cardiomyopathy with right and left heart
cardiomegaly with a prominent left heart border and pulmonary edema. Laboratory
failure. Hereditary hemochromatosis can produce iron deposition in visceral organs,
studies show a serum glucose of 95 mg/dL and total serum cholesterol of 175
including the heart. The serum ferritin is a good indicator of body iron stores.
mg/dL. His serum creatine kinase is not elevated. Which of the following underlying
Hemochromatosis affects the pancreas as well, leading to diabetes mellitus.
diseases is he most likely to have?
Deposition of iron in joints leads to arthritis. There is a gradual increase in body iron
stores, so that the onset of disease is typically in the 40's in males and 60's in
females.
 A Alcoholic cardiomyopathy
Question 21
 B Calcified bicuspid aortic valve

A 37-year-old previously healthy man has had worsening dyspnea along with  C Tricuspid valve endocarditis
peripheral edema for the past two years. On physical examination he has diffuse
crackles auscultated over both lungs. A chest radiograph shows that the heart  D Aortic dissection
nearly fills the chest. A chest CT scan demonstrates a 10 cm mass involving the right
ventricle that appears to have areas of hemorrhage and necrosis within it. Which of
 E Cardiac amyloidosis
the following neoplasms is this man most likely to have?

(B) CORRECT. Although bicuspid aortic valves are present from birth, they do
not manifest with significant calcification and stenosis until later adult life. The
 A Rhabdomyosarcoma presence of pulmonary edema but lack of peripheral edema points to a left-sided
cause for his congestive failure. He does not have systemic hypertension.
 B Mesothelioma

 C Myxoma Question 24

 D Angiosarcoma A 35-year-old man was found down, was delirious, and talking incoherently. On
examination in the emergency department his temperature is 39.3°C, pulse
 E Papillary fibroelastoma 110/minute, and blood pressure 70/palpable. He has a heart murmur, palpable
spleen tip, and splinter hemorrhages of fingernails. Which of the following
 F Kaposi sarcoma laboratory findings is most likely to be present in this man?

 G Rhabdomyoma
 A Positive urine screen for opiates
(D) CORRECT. Angiosarcoma is a rare cardiac neoplasm (all primary cardiac
neoplasms are rare) but the size alone suggests a malignancy.  B Elevated anti-streptolysin O (ASO)

 C Increased urinary free catecholamines

Question 22

 D Elevated Coxsackie B viral titer

A 20-year-old primigravida delivers a term baby girl following an uncomplicated
pregnancy. No anomalies are noted at the time of birth. Five weeks later, the  E Rising creatine kinase (CK) in serum
mother brings the baby to the clinic because she has difficulty breathing and
occasionally turns pale. On physical examination a pansystolic murmur is audible.
Which of the following congenital cardiac anomalies is most likely to be present in (A) CORRECT. This history points to an infective endocarditis. A common risk
this infant? factor for infective endocarditis, particularly with more severe and acute disease, is
intravenous drug use.

 A Hypertrophic subaortic stenosis Question 25

 B Hypoplastic left heart syndrome A 69-year-old woman with a 7 kg weight loss over the past 6 months now has
developed painless jaundice over the past 2 weeks. On physical examination she is
 C Coarctation of the aorta afebrile. An abdominal CT scan shows a large mass involving the head of the
pancreas, along with widespread nodules in the liver. Nodules are seen in both
 D Ventricular septal defect lungs by chest radiograph. Which of the following cardiac abnormalities is she most
likely to develop?
 E Bicuspid aortic valve

(D) CORRECT. The most common congenital cardiac defect in livebirths is a VSD.  A Dilated cardiomyopathy
The baby may first become symptomatic when the pulmonary arteries dilate fully
after the first month of life and the shunting from left-to-right increases to promote  B Non-bacterial thrombotic endocarditis
congestive heart failure.
 C Acute fibrinous pericarditis
Question 23
 D Endocardial fibrosis

 E Acute myocardial infarction

Cardiovascular
 (B) CORRECT. Such pancreatic cancers can produce paraneoplastic syndromes
and be associated with a hypercoagulable state (Trousseau's syndrome) with  A Contraction band necrosis
formation of marantic cardiac valvular vegetations.
 B Lymphocytic myocarditis
Question 26
 C Myofiber disarray
A 51-year-old woman has had several syncopal episodes over the past year.
 D Coronary thrombosis
Each episode is characterized by sudden but brief loss of consciousness. She reports
no chest pain. On physical examination her vital signs show T 36.9°C, P 80/minute,
 E Pericardial tamponade
RR 16/minute, and BP 110/75 mm Hg. She has no pedal edema. On brain MR
imaging there is a 1.5 cm cystic area in the left parietal cortex. A chest radiograph
shows no cardiac enlargement, and her lung fields are normal. Her serum total (A) CORRECT. This finding has been associated with sudden death and cocaine
cholesterol is 165 mg/dL. Which of the following cardiac lesions is she most likely to use. It is thought that it may be mediated by high norepinephrine levels through
have? blockage of catecholamine reuptake. Continued use may promote arteriopathy in
small peripheral coronary branches.

 A Cardiac amyloidosis Question 29

 B Left atrial myxoma A 49-year-old man has the sudden onset of substernal chest pain with radiation
to his left arm. This persists for the next 6 hours. He goes to the emergency
 C Tuberculous pericarditis department and on examination is afebrile. Laboratory studies show a serum
troponin I of 18 ng/mL. Angiography reveals a thrombosis of the anterior
 D Mitral valve prolapse interventricular (left anterior descending) coronary artery. During the next 24
hours, which of the following is the most likely complication he will experience?
 E Ischemic cardiomyopathy

(B) CORRECT. Primary cardiac neoplasms are uncommon. Of these, the most  A Constrictive pericarditis
common is myxoma. Atrial myxomas are more often on the left. Though benign,
they can occlude the mitral valve and produce sudden loss of cardiac output. They  B Arrhythmia
may embolize small portions of themselves or thrombus formed over their surface.
 C Hepatic necrosis
Question 27
 D Thromboembolism
A 58-year-old man develops deep venous thrombosis during a hospitalization
 E Cardiac tamponade
for prostatectomy. He exhibits decreased mental status 10 days postoperatively,
with right hemiplegia. A CT scan of the head shows an acute cerebral infarction in
the distribution of the left middle cerebral artery. A chest radiograph reveals (B) CORRECT. A primary reason for putting a patient with an acute myocardial
cardiac enlargement and prominence of the main pulmonary arteries consistent infarction in hospital is to prevent arrhythmias.
with pulmonary hypertension. Laboratory studies show a serum troponin I of <0.4
ng/mL. Which of the following lesions is most likely to be present on
Question 30
echocardiography?

A 60-year-old man had chest pain and was hospitalized. On the first day of
admission, his troponin I is elevated. A coronary angiogram revealed 75% stenosis
 A Coarctation of the aorta of the anterior interventricular (left anterior descending) artery. Four days later he
suddenly becomes worse, with marked hypotension. A pericardiocentesis is
 B Tetralogy of Fallot performed and returns 150 cc of bloody fluid. Which of the following microscopic
findings is most likely to be present in his left ventricular myocardium at the time of
 C Atrial septal defect this hypotensive episode?

 D Pulmonic stenosis
 A Extensive transmural collagen deposition
 E Dextrocardia
 B Lymphocytic infiltrates
(C) CORRECT. This is the infamous 'paradoxical embolus' from right to left. This
can only happen if there is a defect that allows passage from right-to left. This can  C Coronary arterial dissection
happen across a patent foramen ovale. In this case, the pulmonary hypertension
suggests that there may have been a shunt persistent for a long time--a so-called  D Necrosis with neutrophils and macrophages
Eisenmenger complex. An atrial or a ventricular septal defect can provide the shunt.
 E Interstitial edema and loss of myofiber cross striations
Question 28
(D) CORRECT. He has had an acute myocardial infarction complicated by
A 25-year-old man dies suddenly and unexpectedly while at a nightclub late one rupture. This is a typical complication about 3 to 7 days following the onset of
evening. The medical examiner performs an autopsy. There is no evidence for infarction. 75% arterial narrowing is the point at which coronary occlusion becomes
trauma on external examination of the body. There are no gross pathologic findings very serious with increased risk for acute coronary syndromes.
of internal organs. Postmortem toxicologic findings are significant for high blood
levels of cocaine and its metabolite benzoylecgonine. Which of the following is the
Question 31
most likely histopathologic finding involving his heart?
Cardiovascular
 A 27-year-old man has become severely ill with fever and malaise over the past
3 days following tooth extraction. On examination he has a temperature of 38.8°C,
heart rate of 105/minute, respiratory rate of 24/min, and blood pressure of 80/40
mm Hg. He has a widely split S2 heart sound and a rumbling mid-diastolic murmur.
He has small hemorrhages visible on nail beds. His spleen tip is palpable. Which of
the following cardiac conditions is most likely to predispose him to this acute
illness?
(A) CORRECT. These are classic findings for temporal arteritis, the most typical
involvement with giant cell arteritis. Corticosteroid therapy typically produces a
diminution in the symptoms. Biopsy of the artery can remove the offending site of
inflammation and relieve symptoms (don't worry--there are collateral branches).
Not treating this condition puts the patient at risk for involvement of other
branches of the external carotid artery, the worst of which would be the
ophthalmic branch. The elevation of the sed rate is way out of proportion to the
extent and amount of inflammation in this one arterial segment.

 A Hypoplastic left heart syndrome Question 34

 B Atrial septal defect A 17-year-old girl experiences syncope while out running for exercise one
afternoon, as she has done for many years. Physical examination, chest radiograph,
 C Chagas disease head CT scan, CBC, and chemistry panel are all normal. Over the next year, she
develops mild dyspnea and fatigue. She experiences several episodes of near-
 D Coronary atherosclerosis syncope. After another syncopal episode, she is referred to a cardiologist who
orders an EKG that shows changes of left ventricular hypertrophy and broad Q
 E Hypertrophic cardiomyopathy waves. An echocardiogram reveals left ventricular and septal hypertrophy, small left
ventricle, and reduced septal excursion. The septum has a 'ground glass'
appearance. Which of the following is the most likely microscopic feature of her
(B) CORRECT. This congenital condition can predispose to infective endocarditis. If
disease process?
such conditions are known, then antibiotic prophylaxis can be given prior to
invasive or dental procedures that increase the risk for bacteremia.

Question 32  A Aschoff bodies

 B Lymphocytic infiltrates
An epidemiologic study of eating habits is performed. Dietary patterns of adult
patients are recorded and compared to risk for cardiovascular diseases. It is  C Pericarditis
observed that persons who eat bacon for breakfast are more likely to have
cardiovascular disease than persons who eat oat bran cereal. Which of the
 D Myofiber disarray
following conditions is the 'bacon' group most likely to have?
 E Atheroma formation

 A Mitral annulus calcification

(D) CORRECT. Myofiber disarray is the key feature of hypertrophic
cardiomyopathy. The abnormal myocardium can be the focus for development of
 B Ventricular aneurysm arrhythmias.

 C Left atrial dilation

Question 35
 D Thoracic aortic aneurysm
A 78-year-old woman has had increasing dyspnea for the past 5 years. On
 E Aortic valve stenosis examination her blood pressure is 130/85 mm Hg. Her BMI is 35. Rales are
auscultated in both lungs. Her B-type natriuretic peptide, C-reative protein and LDL
cholesterol are elevated. A chest x-ray shows infiltrates in all lung fields and an
(B) CORRECT. The ventricular aneurysm is a complication of myocardial
infarction. The incidence of MI is increased with an atherogenic diet. enlarged heart. Echocardiography shows decreased ejection fraction with
segmental wall motion abnormalities. Which of the following forms of
cardiomyopathy is she most likely to have?
Question 33

A 74-year-old man has had increasingly severe headaches for 2 months,  A Alcoholic
centered on the right. His vital signs include T 36.9°C, P 82/minute, RR 14/minute,
and BP 130/85 mm Hg. There is a palpable tender cord-like area over his right  B Arrhthmogenic
temple. His heart rate is regular with no murmurs, gallops, or rubs. Pulses are equal
and full in all extremities. A biopsy of this lesion is obtained, and microscopic  C Hypertrophic
examination reveals a muscular artery with luminal narrowing and medial
inflammation with lymphocytes, macrophages, and occasional giant cells. He
 D Infiltrative
improves with a course of high-dose corticosteroid therapy. Which of the following
laboratory test findings is most likely to be present with this man's disease?
 E Ischemic

(E) CORRECT. The risk factors of obesity, elevated CRP and cholesterol, and age
 A Erythrocyte sedimentation rate of 110 mm/hr
point toward ischemic heart disease, which can sometimes globally affect the heart,
in the manner of a cardiomyopathy. The focal wall motion abnormalities suggest
 B Rheumatoid factor titer of 80 IU/mL areas of ischemia/infarction. Her elevated BNP is consistent with congestive heart
failure, as are the pulmonary edema infiltrates.
 C HDL cholesterol of 15 mg/dL

 D Anti-double stranded DNA titer of 1:1024 Question 36

 E pANCA titer of 1:160

Cardiovascular
 A 51-year-old man has the sudden onset of substernal chest pain which
radiates to his left arm and neck. He becomes light-headed and diaphoretic over
the next 3 hours. He goes to the emergency room. On examination he is afebrile
but has a heart rate of 96/minute with an irregular rhythm. Laboratory studies
show an increased serum troponin I. Which of the following features would be most
prominent by histopathologic examination of his myocardium at this point in time?
 A Macrophage infiltration
 B Contraction band necrosis
 E Tertiary syphilis
 F ANCA-associated vasculitis
(E) CORRECT. Treponema pallidum is the organism that causes syphilis. Tertiary
syphilis may have neurologic, joint, and cardiovascular complications. The
endaortitis of the vasa vasora affects the media of the aorta, leading to buckling of
the intimal surface in a 'tree bark' pattern, and aneurysmal dilation, including the
aortic root, causing aortic regurgitation. This happens decades following initial
infection.

 C Neutrophilic infiltration Question 39

 D Capillary proliferation
A 23-year-old primigravida gives birth following an uncomplicated pregnancy to
 E Collagen deposition a 2870 gm girl infant. The baby initially does well, but 12 hours following delivery
she develops respiratory difficulty. On examination the infant has a poor color,
weak pulses, and oxygen saturation of only 90%. Which of the following cardiac
(B) CORRECT. Contraction band necrosis is an initial change as the myocardial findings is this infant most likely to have?
fibers begin to die within the first day of onset of myocardial infarction. Neutrophils
become more numerous following the first day.

 A Muscular ventricular septal defect

Question 37
 B Hypoplastic left heart
A 58-year-old man has had an enlarging abdomen for 5 months. He has
experienced no abdominal or chest pain. On physical examination he has a non-  C Complete transposition with no shunt
tender abdomen with no masses palpable, but there is a fluid wave. An abdominal
CT scan shows a large abdominal fluid collection with a small cirrhotic liver. A chest  D Secundum type atrial septal defect
radiograph shows a globally enlarged heart. He has vital signs showing T 37.1°C, P
78/minute, RR 16/minute, and BP 115/75 mm Hg. Which of the following  E congenital Group B Streptococcus infection
cardiovascular conditions is he most likely to have?
(B) CORRECT. The poor outcome so soon after birth suggests a severe defect,
and lack of sufficient left heart to provide appropriate cardiac output can explain
 A Severe occlusive coronary atherosclerosis these findings. There can be varying degrees of hypoplasia which determine how
long the child survives.
 B Lymphocytic myocarditis
Question 40
 C Myocardial amyloid deposition

 D Nonbacterial thrombotic endocarditis A 66-year-old man has had increasing malaise for the past year. On physical
examination auscultation of the chest reveals a friction rub. Laboratory studies
 E Dilated cardiomyopathy show a serum urea nitrogen of 100 mg/dL and creatinine of 9.8 mg/dL. Which of
the following forms of pericarditis is he most likely to have?

 A Fibrinous
(E) CORRECT. The cardiomyopathy of chronic alcohol abuse has a dilated
appearance. The shrunken, cirrhotic liver suggests alcohol abuse as an etiology.  B Hemorrhagic

Question 38  C Purulent

A 77-year-old man with decreasing mental function has developed increasing  D Serous
dyspnea for the past 3 years. On physical examination he has a diastolic murmur. A
chest CT scan shows an enlarged heart and prominent aorta. He dies from  E Constrictive
complications of pneumonia. At autopsy, the thoracic aorta is aneurysmally dilated.
A microscopic section of the aorta shows chronic inflammation and luminal
narrowing of vasa vasora. There is disruption of the aortic medial elastic fibers.
Which of the following conditions is most likely to cause these findings?
(A) CORRECT. The uremia leads to exudation of fibrin onto the epicardial and
pericardial surfaces. There is often accompanying fluid, and the term serofibrinous
exudate may be used.
 A Hypercholesterolemia
Question 41
 B Marfan syndrome

 C Polyarteritis nodosa A clinical study is performed to document complications in persons with

glomerulonephritis and with laboratory studies showing an elevated antinuclear
 D Takayasu arteritis antibody and anti-ds-DNA titer. Which of the following cardiac abnormalities is
most likely to be present?
Cardiovascular
 astrocytoma. He is treated with radiation and chemotherapy. Two months later he
 A Pancarditis experiences left upper quadrant abdominal pain, accompanied by hematuria. He
then has an episode of sudden dyspnea and a chest CT scan shows large
 B Libman-Sacks endocarditis thromboemboli filling both main pulmonary arterial branches. Which of the
following cardiovascular lesions is most likely to be found in this man?
 C Hemorrhagic pericarditis

 D Lipofuscin deposition  A Tear in the ascending aortic intima

 E Coronary artery vasculitis  B Occlusive coronary atheromatous plaques

(B) CORRECT. Libman-Sacks endocarditis is most often seen in patients with  C Hypertrophic cardiomyopathy
autoimmune diseases such as systemic lupus erythematosus, and SLE often has
renal complications with glomerulonephritis.  D Epicardial metastases

 E Mitral marantic vegetations

Question 42

(E) CORRECT. A He has both venous and arterial thromboembolic disease that
A 53-year-old man has had malaise for the past 3 months. On physical
suggests Trousseau syndrome. Non-bacterial thrombotic endocarditis (NBTE) is
examination he is afebrile. On auscultation of the chest, heart sounds are distant
seen with this paraneoplastic condition. Though the small vegetations are bland,
and there is a friction rub. An echocardiogram shows a pericardial fluid collection. A
they often embolize, in this case in the systemic circulation to spleen and kidney.
pericardiocentesis yields 10 mL of bloody fluid. Which of the following conditions is
The highest rate of Trousseau syndrome occurs with high grade gliomas--about 25%
most likely to give rise to these findings?
of patients.

Question 45
 A Autoimmune disease

 B Chronic renal failure A 50-year-old man has noted increasing swelling of his lower legs along with
shortness of breath for 5 months. On physical examination he is afebrile, but diffuse
 C Rheumatic fever crackles are heard over the lung bases. His heart rate is 80/minute and regular, with
no murmurs, rubs, or gallops, but there is a prominent widened split S2. A chest
 D Metastatic carcinoma radiograph reveals an increased size to the right heart border, along with bilateral
pleural effusions. Laboratory studies show a serum troponin I of <0.4 ng/mL. Which
of the following conditions is he most likely to have?
 E Acute myocardial infarction

(D) CORRECT. Pericardial tumor and tuberculosis are the typical causes for a
hemorrhagic pericarditis.  A Alcoholic cardiomyopathy

 B Viral myocarditis
Question 43
 C Bicuspid aortic valve
A 56-year-old man has a routine checkup. He is found to have a blood pressure
of 175/110 mm Hg. A month later his blood pressure is 170/105 mm Hg. He elects  D Constrictive pericarditis
to do nothing about this, because he feels fine. If he remains untreated, this man is
at greatest risk for which of the following conditions?  E Pulmonary interstitial fibrosis

(E) CORRECT. The findings suggest a predominantly right-sided congestive

 A Pleural effusions heart failure, which would be characteristic for cor pulmonale. Pulmonary
hypertension most often results from obstructive or restrictive lung
 B Pulmonary congestion diseases. The second heart sound (S2) is comprised of aortic valve closure
(A2) happening first and pulmonic valve closure (P2) occurring second.
 C Hyperplastic arteriolosclerosis Normally, these are nearly superimposed. Normally, P2 is soft and heard
only in the 2nd intercostal space at the left parasternal border. Increased
 D Tricuspid insufficiency pulmonary arterial pressure will increase the split and the loudness of P2.

 E Myocardial infarction

(B) CORRECT. The pressure load on the left ventricle will always lead to left
venricular hypertrophy, and if untreated eventually the heart can no longer
compensate and there is left heart failure, which leads to pulmonary congestion
and edema.

Question 44

A 48-year-old man has had worsening severe headaches over the past 3
months. There are no abnormal findings on physical examination. Brain MR imaging
shows a large 8 cm mass in the right posterior parietal region that extends across
the splenium of the corpus callosum. A stereotaxic biopsy reveals an anaplastic
Cardiovascular