1.

Of the following patients, who is the most likely to carry the diagnosis of sick sinus
syndrome (SSS)?
a. A 65-year-old woman with a resting sinus arrhythmia varying from 70 to 85 bpm
b. A 30-year-old with sinus pauses 1.5 seconds in duration
c. A 20-year-old athletic man with sinus bradycardia at 25 bpm while sleeping
d. A 73-year-old man with persistent AFib and a ventricular rate of 40 bpm during
peak treadmill test
e. A 70-year-old with sinus bradycardia and AV block secondary to a β-blocker
overdose

2. A 21 year old college student is evaluated for palpitaion. She has noticed a rapid
pounding in her chest on several occasions. She first noticed it in middle school. Most
episodes last less than 1 minute, but a few have lasted one half our. During an episode,
she feels lightheaded, but is not short of breath and does not have syncope or chest pain.
She is most aware of the pounding sensation in her neck. Symptoms usually occur
without warning while she is at rest. If she breathes slowly and deeply, the episodes
usually stop on their own. They have never interfered with her activities, and she
continous to run cross-country. Recently, the episodes have been longer and more
frequent. She has never had the rhytm documented. Physical examination and
electrocardiogram findings are normal. She has no family history of heart disease. Which
of the following is the most likely diagnosis?
a. Paroxysmal supraventricular tachycardia
b. Palpitations related to mitral valve prolapse
c. Paroxysmal atrial flutter
d. Ventricular tachycardia
e. Benign premature atrial contraction

3. A 73-year-old man presents to the emergency room with severe mid-sternal chest
discomfort. He appears anxious and in distress. His heart rate is 66 bpm, blood pressure is
92/68 mmHg, and respiratory rate is 14. There is marked jugular venous distention.
Cardiac auscultation is unremarkable and the lungs are clear. ECG reveals 2-mm ST-
segment elevation in leads II, III, and aVF. The most likely diagnosis is
a. acute pericarditis.
b. acute aortic dissection.
c. pneumothorax.
d. inferior wall myocardial infarction (MI) with right ventricular infarction.
e. pneumonia.

4. A 61-year-old man known for diabetes, hypercholesterolemia, hypertension, and a history

of PCI with stenting of the mid-left anterior descending coronary artery 10 years earlier
presents with worsening typical angina on exertion and a positive stress test. Coronary
angiography (Fig. 4.13) shows
 a. ISR of the left descending coronary artery.
b. significant stenosis of LCX.
c. stenosis of the ostium of the left main trunk.
d. normal coronary arteries.
e. none of the above.

5. Which of the following is true regarding adjunctive medical therapy in patients with
acute MI receiving primary PCI?
a. Routine intravenous β-blocker within 24 hours improves mortality.
b. Intravenous angiotensin-converting enzyme inhibitor (ACEI) within 24 hours
improves mortality.
c. Mortality benefit with routine intravenous nitroglycerin is not established.
d. Intravenous magnesium improves mortality when used as an adjunct to
reperfusion.

6. Which of the following are potential indications for IABP in the setting of acute MI?
a. Refractory ischemia despite intensive medical therapy
b. STEMI and secondary acute mitral regurgitation
c. STEMI and refractory polymorphic VT
d. STEMI and refractory cardiogenic shock
e. All of the above

7. A 59-year-old man presents for further evaluation of recurrent congestive heart failure.
He appears to be in no acute distress on your evaluation. BP is 100/60 mmHg. Carotid
upstrokes are weak, but not delayed. Chest examination shows minimal bibasilar rales.
PMI is displaced and sustained. A summation gallop is present. There is an increased P2.
There is mild peripheral edema. An echocardiogram reveals a dilated LV with an ejection
fraction of 25%. The aortic valve does have some calcification, with restricted leaflet
excursion. Peak/mean gradients are 25/15 mmHg. By the continuity equation, the aortic
valve area is calculated as 0.7 cm2. With dobutamine echocardiography, the gradients
 across the valve increase to 60/40 mmHg, and the calculated valve area stays at 0.7 cm2.
What do you recommend?
a. AVR
b. Continued medical management
c. Cardiac transplant evaluation
d. Balloon aortic valvuloplasty

8. A 26 years old pregnant woman (G1P0A0, gestational age 32 weeks) was admitted to the
hospital with main complaint shortness of breath and orthopnea. She never complained
this symptons before. Patient also complaint hemptysis. On physical examination, BP
100/60 mmHg, HR 132 x/minute irregularly irregular, RR 28 bpm. Patient had distended
jugular vein and left parasternal heave. Cardiac auscultation revealed low pitched
rumbling mid diastolic murmur. CXR revealed congested upper lobe vein and Kerley B
lines. Which one of the following is the indication for surgery or repair in this patient?
a. Pulmonary artery systolic pressure <60 mmHg during exercise
b. Hemoptysis
c. Valve area > 1.5 cm2
d. Pulmonary artery systolic pressure < 50 mmHg at rest
e. Thromboembolic event

9. Which of the following is an absolute contraindication to pregnancy?

a. Surgically corrected transposition of great arteries
b. Congenitally corrected transposition of great arteries
c. Ebstein anomaly
d. Eisenmenger syndrome
e. Status post Fontan operation

10. 11 day old baby is admitted to PICU with severe cyanoses. The parents and midwives
have noted the appearance of their baby since he was born. The parents did not bring the
baby to the tertiary hospital because they refused to be referred. In the last 24 hours the
baby looked very sick and fatigue so that finally he was brought to our hospital. On
physical examination the baby is cyanotic with poor periphery perfussion. He was
intubated and saturating at 45%. He got a normal S1 with enhacement of S2. Continous
murmur grade III/6 heard ICS 2 LSB. No gallop is heard. On chest X ray the lung is
oligemic. Which of the following ia apossible diagnosis differential:
a. AP window
b. A lesion of Duct dependent pulmonary circullation
c. Patent Ductus Arteriosus
d. Edward syndrome
e. Ventricle septal defect

11. A 46 year old woman presents to the emergency departement with eight hours of chest
pain. The pain is constant, severe, and midsternal in location. She notes that it is worse
when she lies down. She denies exposure to sick friends or relatives. Past history is
notable for tobacco use, borderline hypertension, and elevated cholesterol. Her father
died of a myocardial infarction at age 67 years. Examination is notable for a heart rate of
 104, and BP 125/80 in both arms. Her lungs are clear. On cardiac examination, she has a
prominent friction rub with two out three components present. The remainder of the
examination is unremarkable. Which of the following ECG abnormalities does not
suggest pericarditis in the absence of an effusion?
a. PR segmen elevation in lead aVR
b. Concave upward ST segmen elevation
c. Sinus tachycardia
d. Electrical alternans
e. PR segment depression

12. A 29-year-old woman with known insulin-dependent diabetes mellitus was found
unconscious 1 hour after an office party. Initial assessment by the emergency medical
service team showed a BP of 90/60 mm Hg. Her pulse was 120, and her blood sugar was
870 mg/dL. She was given SC insulin and rushed to the emergency department. You are
called to see her because of her abnormal ECG (Fig. 13.16). She is noted to be
semiconscious. The emergency physician has already started her on IV insulin drip and
hydration. What is your recommendation at this juncture?
a. She is having an acute MI, and immediate restoration of coronary flow is
essential.
b. She has ECG evidence of hyperkalemia, and she needs IV calcium and, possibly,
dialysis.
c. Continue the current management; the ECG will improve with the resolution of
ketoacidosis.
d. Her ECG predicts high-degree atrioventricular block; a standby external
pacemaker should be available.

13. A 58-year-old man presents to the clinic with a complaint of bilateral lower extremity
cramping muscular pain with exertion relieved after a few minutes of rest. His medical
history includes coronary artery disease status post left anterior descending artery stent 2
years ago, diabetes mellitus type 2, and essential hypertension. An ABI is performed in
your office demonstrating a right ABI of 1.10 and left ABI of 1.04. What is the most
appropriate next step in the evaluation of this patient?
a. Reassurance and suggest low-impact exercise, i.e., swimming
b. Referral to a peripheral vascular interventionalist for lower extremity angiogram
c. Order bilateral ABI measurements in the vascular laboratory at rest and following
an exercise protocol
d. Order magnetic resonance imaging of the lumbosacral spine to confirm the likely
diagnosis of pseudoclaudication
e. Have him return in 6 months and repeat the resting ABI measurements

14. A 45-year-old woman with a history of fibromuscular dysplasia presents to the ER with
an acute Stelevation inferior MI. She is taken immediately to the cardiac catheterization
laboratory for primary percutaneous intervention of the right coronary artery (RCA).
The first injection of the RCA shows a dissection extending from the ostium to the
posterior descending artery. A subsequent aortogram after stenting of the RCA is
performed (Fig. 6.11). What does the aortogram show?
 a. Aortic root aneurysm
b. Aortic root pseudoaneurysm
c. Anomalous RCA from the left cusp
d. Aortic root localized dissection

15. A 39 year old man came to emergency department with chief complaint shortness of
breath, non radiating chest tightness and 2 sincopal episodes. The symptom has been felt
since 1 month before admission, but it was going worse in the recent 1 week. From the
anamnesis, one week before admission the patient felt pain and swelling on upper right
leg, after he drove a car for two and half hours. The leg was then being massaged and
the symptoms were going worse and he started feeling shortness of breath. From the
medical history, the patient was obese (BMI 31 kg/m2), and has history of smoking for
19 years. The patient was a frequent distance traveler (average duration 4 to 6 hours for
about 12 times/month). Patient has no history of hypertension and diabetes. On
admission, his BP was 90/60 mmHg, pulse 120 x/min and regular, respiratory rate 26
bpm, T 36oC, and oxygen saturation 89%. Other physical examination were
unremarkable. Which of the following echocardiogrhapic findings that can be found in
oabove patient?
a. RV free wall hypokinesis in the presence of normal RV apical
b. Visualization of true lumen and false lumen
c. RV acceleration time > 60 ms in the presence f tricuspid insufficiency pressure
gradient > 60 mmHg
d. Aortic mitral regurgitation
e. Hypokinesis of the anterior and inferior wall

16. 42-year-old woman presents for post hospitalization follow-up. She was recently
admitted to hospital for 3 days due to sudden-onset dyspnea. Her blood pressure on
presentation was 164/98 mmHg. Her examination and chest radiograph were consistent
with pulmonary edema. She responded well to intravenous diuretics and was discharged
on lisinopril. She has no family history of hypertension. On examination during the
clinic visit, her blood pressure is 158/90 mmHg. She is normal in weight and has a
normal cardiovascular examination except for a rightsided carotid bruit. Her blood tests
 are notable for a rise in creatinine from 0.9 to 1.8 mg/dL since hospital discharge. What
is the most appropriate follow-up investigation?
a. Coronary angiogram
b. Duplex ultrasonography of the renal arteries
c. Urinary catecholamines
d. 24-Hour urinary-free cortisol

17. M. G., a 50-year-old man, collapsed at home after shoveling his sidewalk. His son
initiated cardiopulmonary resuscitation immediately, and an emergency medical service
was called. When the squad arrived, it was determined that M. G. was in ventricular
fibrillation (VF), and he was cardioverted with 200, 300, and 360 J. Epinephrine was
given, and M. G. was shocked again. M. G. was still in VF. It was decided to initiate
antiarrhythmic therapy. Choose the most appropriate agent from the list below.
a. Lidocaine
b. Amiodarone
c. Procainamide
d. Bretylium

18. Which of the following is not a risk factor for intracranial hemorrhage in patients
receiving fibrinolytic therapy in the treatment of ST-segment-elevation MI?
a. HTN
b. Body weight
c. Age
d. Time to presentation

19. Again you notice an elevated systemic venous pressure without obvious x or y descent
and quiet precordium and pulsus paradoxus. What does the patient have?
a. Constrictive cardiomyopathy
b. Restrictive cardiomyopathy
c. Tricuspid regurgitation
d. Pulmonary HTN
e. Tamponade

20. A 57-year-old woman, who experienced inferior wall MI in 1992, has an EF of 30% and
was diagnosed with nonsustained ventricular tachycardia (VT) (four beats of VT) at
another hospital on a routine ECG that she needed before cataract surgery. She has been
in excellent health and has never been hospitalized for CHF. She has never had
palpitation or syncopal episodes. Her doctors advised her that she would need an
implantable defibrillator. She does not agree and wants a second opinion. She wants to
know whether there is any evidence to support the implantable defibrillators. What is
your advice?
a. Place an implantable defibrillator.
b. Do not place an implantable defibrillator: A single episode is probably
insignificant.
c. Perform an electrophysiologic (EP) study.
d. Begin β-blockers with amiodarone.NSWERS