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  • 1. (Chapters 80-94) CARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANSDIRECTIONS: For each question below, select the ONE A. Patients with CKD are at increased risk of bleeding butBEST response. decreased risk of thrombotic events when compared with normal individuals B. The outcomes of patients with CKD who present withQUESTION 630 acute coronary syndromes are similar to those of patients with normal renal functionA 24-year-old man who is training for the Olympic decath- C. Renal dysfunction is the most significant independentlon team experiences a presyncopal event and is referred predictor of mortality of patients in coronary carefor evaluation. He has been training aggressively for the unitspast 2 years and aside from occasional single palpita- D. Patients with CKD who present to the hospital withtions has not noticed any prior lightheadedness, other chest pain comprise a relatively low-risk group ofcardiac symptoms, or physical limitations. He has no acute coronary syndromes, with a cardiac event ratehistory of hypertension and his family history is free of of <5% at 30 dayspremature coronary disease or sudden cardiac death. On E. Uremia is associated with enhanced plateletphysical examination his blood pressure and heart rate aggregationare normal. A grade II/VI rough crescendo-decrescendosystolic murmur is auscultated along the left sternalborder, which becomes louder when the patient stands. QUESTION 632The patient is anxious to return to his training regimen.Which of the following statements is TRUE? A 20-year-old female student presents to the emergencyA. Voltage criteria for left ventricular hypertrophy on this department with recent malaise, myalgias, fevers, sweats, patient’s ECG would establish the diagnosis of hyper- and claudication of the right lower extremity and left trophic cardiomyopathy and should prohibit him arm. On physical examination the blood pressure is from resuming competitive athletics 160/90 mm Hg in the right arm and 120/85 mm Hg inB. An echocardiographic end-diastolic septal wall thick- the left arm. The left radial and right femoral pulses are ness of 14 mm would be diagnostic of hypertrophic diminished and a left-sided subclavian bruit is auscul- cardiomyopathy tated. The erythrocyte sedimentation rate is markedlyC. Persistent left ventricular hypertrophy by echocardiog- elevated. Which of the following statements about this raphy months after cessation of exercise is consistent condition is TRUE? with hypertrophic cardiomyopathy A. Arterial biopsy would reveal a polymorphonuclearD. A maximum oxygen uptake >45 mL/kg/min on car- infiltrate diopulmonary exercise testing is more consistent with B. Aortic aneurysm formation is more common than hypertrophic cardiomyopathy than “Athlete’s Heart” arterial stenosesE. The most common cause of sudden cardiac death C. This condition is 10 times more common in women in athletes is anomalous origin of the left coronary than men artery D. Claudication occurs more commonly in the lower extremities than the upper extremities E. Coronary vasculitis is not typical in this syndromeQUESTION 631A 66-year-old man with chronic kidney disease (CKD) is QUESTION 633referred for office evaluation after a recent admission foran acute coronary syndrome. Which of the following A 58-year-old woman complains of a new-onset severestatements is TRUE concerning chronic kidney disease headache, jaw pain with chewing, and temporal(CKD) and cardiovascular disease? artery tenderness. Laboratory examination shows an 285
  • 2. 286 erythrocyte sedimentation rate (ESR) of 80 mm/hr. B. Clinical and hemodynamic findings in PPCM are Which of the following is TRUE regarding treatment indistinguishable from those of other forms of dilated of this condition? cardiomyopathy A. Corticosteroids should not be administered until C. The incidence of PPCM is greatest in first pregnan- biopsy evidence confirms the diagnosis cies B. Clinical improvement with appropriate treatment D. Approximately 50% of PPCM patients show recoveryCARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS generally occurs over several weeks within the first 6 months after delivery C. Anti-TNF therapies have been shown to be beneficial E. Subsequent pregnancies in women with PPCM carry in this condition a 30% risk of relapse D. In the absence of contraindications, low-dose aspirin should be prescribed for all patients with this condition QUESTION 637 E. Normalization of the ESR is a reliable indicator of treatment response A 67-year-old man with multivessel coronary disease is scheduled for coronary artery bypass graft surgery (CABG). Which of the following statements regarding QUESTION 634 CABG and perioperative complications is TRUE? A. Perioperative myocardial infarction occurs, on average, A 35-year-old woman with hypertension is considering in 5% to 10% of elective procedures pregnancy. She is currently taking lisinopril 10 mg daily. B. Early postoperative cognitive decline occurs in <10% Which of the following statements is TRUE? of patients after CABG surgery A. She should remain on her current antihypertensive C. Atrial fibrillation appears in approximately 40% of regimen before and during pregnancy patients after CABG surgery B. An angiotensin receptor blocker should be substi- D. Of patients who develop postoperative atrial fibrilla- tuted tion, only 20% will spontaneously revert to sinus C. Labetalol is unsafe during pregnancy rhythm within 24 hours D. Women with preexisting hypertension have a higher E. N-Acetylcysteine prevents renal dysfunction after incidence of preeclampsia compared with those with CABG new-onset hypertension during pregnancy E. Antihypertensive therapy is effective in preventing pre- eclampsia during pregnancy QUESTION 638 The patient in Question 637 undergoes CABG without QUESTION 635 complication. At his first postoperative office visit he reports resolution of his anginal symptoms and he asks All of the following statements about heart disease in how long the benefit will last. Which of the following women are true EXCEPT: statements regarding coronary artery bypass grafts is A. Cardiovascular disease is the leading cause of death TRUE? in women A. Fewer than 2% of saphenous vein grafts become B. In recent decades, age-adjusted cardiovascular mor- occluded in the early perioperative period tality in the United States has increased in women B. Internal mammary artery grafts typically develop while it has declined in men intimal hyperplasia over time C. Coronary heart disease presents approximately 10 C. Saphenous vein grafts have a 10-year patency rate of years later in women than in men >75% D. Cardiovascular disease is twice as common in women D. Radial artery grafts are less likely to develop vaso- with diabetes compared with nondiabetics spasm than internal mammary grafts E. Hormone replacement therapy with estrogen does E. Patients who receive internal mammary artery grafts not reduce the risk of cardiac events in postmeno- suffer fewer late deaths and myocardial infarctions pausal women than those who receive only saphenous vein grafts QUESTION 636 QUESTION 639 A 36-year-old woman with no prior history of cardiac A previously healthy 17-year-old high school athlete col- disease develops exertional dyspnea and orthopnea 1 lapses during a basketball game. He is noted to have brief month after delivering a healthy full-term infant. Echo- seizure-like activity and has no initial pulse but is cardiography demonstrates a dilated left ventricle with immediately resuscitated by a brisk precordial thump. globally reduced contractile function. Each of the fol- Assuming that this event represents sudden cardiac death lowing statements about peripartum cardiomyopathy (SCD), each of the following statements is true EXCEPT: (PPCM) is correct EXCEPT: A. Arrhythmogenic right ventricular cardiomyopathy is A. Symptoms of PPCM arise during the last month of responsible for approximately 30% of SCD in young pregnancy or within 5 months of delivery athletes
  • 3. 287B. Anomalous origin of the left main coronary artery Which of the following statements is TRUE regarding from the right coronary cusp is the most common of the use of hormone replacement therapy and cardi- the congenital coronary abnormalities that result in ovascular risk? SCD in young athletes A. Current guidelines recommend hormone replace-C. His normal pretraining history and physical examina- ment therapy for postmenopausal women who do not tion do not exclude the possibility of hypertrophic have a history of coronary artery disease CARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS cardiomyopathy (HCM) B. The prospective Women’s Health Initiative trial showedD. Patients who experience SCD due to HCM often have a reduced rate of coronary events in postmenopausal no history of prior cardiac symptoms women randomized to estrogen-only treatmentE. Congenital aortic stenosis is a cause of SCD in young C. The Women’s Health Initiative showed no difference athletes in the rate of stroke or pulmonary embolism in patients randomized to estrogen therapy D. The American Heart Association guidelines assign aQUESTION 640 Class III recommendation to starting or continuing estrogen plus progestin therapy for primary or second-A 68-year-old woman with a history of hypertension pre- ary prevention of cardiovascular diseasesents to the emergency department with the new onsetof dyspnea and nausea. The ECG shows anterolateralST-segment depressions, and the initial serum measure- QUESTION 643ment of cardiac troponin T is elevated. Which of the fol-lowing statements is TRUE regarding women who present A 55-year-old overweight man with type 2 diabetes mel-with acute coronary syndromes (ACS)? litus, coronary artery disease, and atrial fibrillation isA. Most women presenting with an acute myocardial scheduled for coronary artery bypass graft (CABG) infarction do not describe chest pain surgery in 1 week. Which of the following conditions isB. Women presenting with myocardial infarction are less associated with increased perioperative mortality in this likely than men to have accompanying cardiovascular patient? comorbidities A. AgeC. Women with ACS are more likely to present earlier in B. Timing of surgery the course of symptoms than men C. Diabetes mellitusD. Women who present with chest discomfort are more D. Atrial fibrillation likely than men to have nonatherosclerotic causes of E. Obesity ischemia, such as vasospasmE. Women are admitted to the hospital for the evaluation of chest pain less often than men QUESTION 644 A 38-year-old woman presents at the 37th week of preg-QUESTION 641 nancy because of severe substernal chest pain over the past 30 minutes. An ECG demonstrates 4-mm ST-segmentYou are asked to evaluate a 72-year-old man who under- elevations in leads V1 to V4. Which of the following state-went coronary artery bypass graft (CABG) surgery 8 ments is true?hours ago. He is hemodynamically stable. You review his A. Coronary artery spasm is the most common cause oflaboratory studies and note a platelet count of 87,000/μL, this finding during pregnancya potassium level of 5.3 mg/dL, a normal phosphate level, B. Coronary artery dissection is the most likely cause inand an elevated cardiac troponin T of 1.6 ng/mL. Which the peripartum periodof the following statements regarding laboratory assess- C. Pregnancy does not alter the risk of sustaining a myo-ment after CABG is TRUE? cardial infarctionA. Platelet count <100,000/μL is rare D. Inferior wall myocardial infarction is more commonB. Potassium levels typically vary little and do not require than anterior wall myocardial infarction during frequent monitoring pregnancyC. The cardiac troponin concentration in the serum is E. Urgent angiography should be avoided in this setting often elevated but is not prognostically importantD. The cardiac troponin concentration is often elevated but is only prognostic in regard to short-term outcomes QUESTION 645E. Hypophosphatemia is common and is associated with prolonged mechanical ventilation An 83-year-old man with hypertension and diabetes underwent a coronary artery bypass graft (CABG) opera- tion 14 hours ago on an emergency basis. PreoperativeQUESTION 642 angiography revealed severe stenoses of the left main and right coronary arteries. During the operation, the leftA 58-year-old postmenopausal women presents for a internal mammary artery was grafted to the native leftroutine office visit. She was recently prescribed oral anterior descending artery and saphenous vein graftshormone replacement therapy by her gynecologist. were placed to the first obtuse marginal branch of the
  • 4. 288 circumflex coronary artery and to the posterior descend- A. Clinical studies have not established the effective- ing artery. The surgeon consults you because he is con- ness of therapy for mild diastolic hypertension in cerned that the patient may have suffered a perioperative the elderly myocardial infarction (MI). Each of the following state- B. Therapy for isolated systolic hypertension in the ments is true EXCEPT: elderly does not reduce the incidence of future A. His age, the emergency nature of his procedure, and cardiac eventsCARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS the presence of left main coronary artery disease put C. Clinical trials have shown that beta blockers offer less this patient at increased risk for perioperative MI cardiovascular protection than diuretic therapy B. Chest pain is not a reliable sign of MI in the post-CABG D. The presence of left ventricular hypertrophy in hyper- patient tensive patients >age 65 is not an independent risk C. An elevation of the CK-MB isoenzyme > two times the factor for adverse cardiovascular outcomes upper limit of normal is considered diagnostic of MI E. Hypertensive hypertrophic cardiomyopathy of the in this setting elderly is more common in men D. The finding of new Q waves on the ECG is a reliable sign of perioperative MI E. Paradoxical motion of the interventricular septum QUESTION 649 on echocardiography is a common finding after car- diac surgical procedures and does not necessarily Each of the following statements regarding hemody- indicate MI namic changes during normal pregnancy is correct EXCEPT: A. Total blood volume increases QUESTION 646 B. Cardiac output increases C. Stroke volume increases A 78-year-old man presents with chest pain and new D. Heart rate increases 2-mm ST-segment elevations in leads V1 to V3. Which of E. Systemic vascular resistance increases the following statements is TRUE regarding the manage- ment of acute myocardial infarction (MI) in elderly patients? QUESTION 650 A. Mortality rates associated with acute MI are higher in older men than in older women A 64-year-old woman presents to the emergency depart- B. Fibrin-specific fibrinolytic agents are not associated ment with nausea and vomiting. Her ECG shows with heightened intracerebral bleeding rates in ST-segment depressions in the inferior leads and the patients >75 years serum troponin T is elevated. Each of the following state- C. Antiplatelet therapy with prasugrel leads to superior ments regarding acute coronary syndromes (ACS) in outcomes compared with clopidogrel in patients >75 women is true EXCEPT: years of age who undergo percutaneous intervention A. Women are more likely to develop symptoms of D. Angiotensin-converting enzyme inhibitors have been angina than to present initially with a myocardial shown to reduce fatal and nonfatal events after MI in infarction (MI) elderly patients B. Women tend to be older than men at the time of E. Elderly patients are less likely than younger patients to presentation benefit from beta blockade for secondary prevention C. In the setting of an MI, women are more likely than men are to present with nausea, palpitations, shortness of breath, and neck, jaw, and back pain QUESTION 647 D. Women have a higher prevalence of vasospastic and microvascular angina than men Preoperative factors that portend an increased risk of E. Women <50 years of age have lower mortality rates cardiac complications after major noncardiac surgery in during ACS than men of the same age patients >40 years of age include which of the following? A. Presence of an S3 gallop B. Active cigarette smoking C. Remote myocardial infarction without active angina QUESTION 651 D. Mitral stenosis with calculated valve area of 2.0 cm2 E. Controlled hypertension A 60-year-old woman with a history of hypertension and diabetes mellitus is admitted to the hospital because of an acute severe headache, nausea, and vomiting. QUESTION 648 Physical examination demonstrates a blood pressure of 180/90 mm Hg, normal jugular venous pressure, bibasi- A 69-year-old woman presents for a routine office visit. lar rales, no cardiac gallops or murmurs, and no focal She has a history of hypertension and her blood pres- neurologic signs. The troponin I is elevated at 0.62 ng/ sure today is 145/90 mm Hg. Her only medication is dL (normal: <0.10 ng/dL). Computed tomography of the metoprolol succinate 25 mg daily. Which of the follow- brain demonstrates an acute subarachnoid hemorrhage. ing statements regarding hypertension in the elderly is The patient’s ECG is shown in Figure 5-1. Which of the TRUE? following statements is TRUE?
  • 5. 289 I aVR V1 V4 CARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS II aVL V2 V5 III aVF V3 V6 FIGURE 5-1 Courtesy of Dr. Charles Fisch, Indiana University School of Medicine, Indianapolis.A. A ruptured coronary plaque with partially occlusive D. Heart rate during exercise increases less in older, com- thrombus is likely present pared with younger, individualsB. QT interval prolongation is uncommon in this setting E. The resting ejection fraction tends to remain constantC. All of the cardiac abnormalities can be attributed to with age in the absence of cardiac disease autonomic dysfunction in the setting of acute brain injuryD. Beta blockers are not effective at controlling ventricu- QUESTION 654 lar tachycardia and fibrillation in this situationE. The magnitude of electrocardiographic abnormalities A 58-year-old diabetic man develops fever and tender- in such a patient correlates with a poor cardiovascular ness at the sternal wound site 12 days after coronary outcome artery bypass graft surgery. All of the following have been associated with the development of deep sternal wound infection after cardiac surgery EXCEPT:QUESTION 652 A. Prolonged cardiopulmonary bypass time B. Use of both internal mammary arteries as bypassA 68-year-old man with a history of myocardial infarction vesselsis scheduled for elective hernia repair. Which of the fol- C. Diabeteslowing statements regarding perioperative medication D. History of cigarette smoking prior to surgeryuse in coronary disease patients undergoing noncardiac E. Preoperative atrial fibrillationsurgery is TRUE?A. Cardiac adverse event rates are reduced when high- dose beta-blocker therapy is initiated immediately QUESTION 655 before surgeryB. Nitrates decrease intraoperative myocardial ischemia A 27-year-old woman undergoes right-sided heart cathe- and reduce rates of adverse cardiac outcomes terization for the assessment of suspected pulmonaryC. Most cardiac medications should be discontinued 2 arterial hypertension. The mean pulmonary artery pres- to 3 days before surgery and resumed as soon as the sure (PAP) is 44 mm Hg, and the pulmonary capillary patient can tolerate oral intake wedge pressure (PCWP) is 11 mm Hg. Infusion of epo-D. Statin therapy has been associated with reduced prostenol reduces the mean PAP to 31 mm Hg with no perioperative cardiovascular event rates in high-risk significant change in systemic blood pressure or PCWP . patients Each of the following statements is true EXCEPT: A. Both intravenous adenosine and inhaled nitric oxide are alternative useful agents to assess vasoreactivityQUESTION 653 B. The observed drop in mean PAP is predictive of a favorable response to oral calcium channel blockersTrue statements regarding alterations in cardiovascular C. The failure of the systemic blood pressure to dec-function with aging include each of the following line suggests that the vasodilator challenge wasEXCEPT: ineffectiveA. Endothelial production of nitric oxide decreases D. Very high doses of chronic calcium channel blocker with age therapy would likely be necessary to realize full clini-B. Left ventricular myocardial cells typically develop cal benefit moderate hypertrophy E. A rise in PCWP in response to vasodilator therapyC. There is a fall in stroke volume and ejection fraction would be of concern for impending left ventricular due to a decrease in peak contractile force failure
  • 6. 290 QUESTION 656 B. A direct thrombin inhibitor, such as lepirudin, could be safely substituted for heparin Which of the following interventions has been shown C. Intravenous heparin should be continued, because to reduce the incidence of contrast nephropathy after the low platelet count represents a laboratory artifact coronary angiography in patients with chronic renal without clinical significance insufficiency? D. Antibodies directed against the platelet glycoproteinCARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS A. Infusion of 20% mannitol before angiography IIb/IIIa receptor participate in this disorder B. Administration of atrial natriuretic peptide E. This is a transient reaction to heparin and does not C. Normal saline administration before and after ang- preclude future heparin treatment for this patient iography D. Intravenous furosemide administration before angiography QUESTION 660 E. Low-dose dopamine infusion A 64-year-old man is brought to the emergency depart- ment because of confusion over the past 12 hours. Two QUESTION 657 weeks earlier he had undergone cardiac catheterization and a drug-eluting stent was placed in the right coronary A 42-year-old woman presents to her primary care physi- artery. His medications include captopril, metoprolol, cian with recent fatigue and weight gain. Laboratory atorvastatin, aspirin, and clopidogrel. In the emergency evaluation reveals a markedly elevated thyroid-stimulating department, he is febrile (101.3°F) and has a diffuse pete- hormone level. Common cardiac findings in patients chial rash. The remainder of his physical examination is with hypothyroidism include all of the following EXCEPT: unremarkable. Laboratory studies are notable for a new A. Hypotension elevation in serum creatinine (3 mg/dL), a fall in the B. Decreased heart rate hematocrit to 22%, and the platelet count is reduced C. Pericardial effusion at 52,000/μL. Which medication is likely responsible for D. Decreased cardiac output this patient’s illness? E. Prolonged QT interval on the ECG A. Captopril B. Metoprolol C. Atorvastatin QUESTION 658 D. Clopidogrel E. Aspirin A 28-year-old woman with Marfan syndrome presents for an office visit. Her echocardiogram shows mitral valve prolapse, an aortic root diameter of 4.5 cm, and mild QUESTION 661 aortic regurgitation. Each of the following statements regarding cardiovascular disease in patients with Marfan Which of the following statements regarding metastatic syndrome is true EXCEPT: disease involving the heart is TRUE? A. Sixty to 80 percent of patients with Marfan syndrome A. Tumor metastases frequently involve the cardiac have mitral valve prolapse on echocardiography valves B. The development of aortic regurgitation correlates B. The most common primary tumor producing cardiac with the aortic root diameter metastases is renal cell carcinoma C. Patients with Marfan syndrome should be considered C. A chylous pericardial effusion is characteristic of for elective aortic root replacement once the aortic metastatic breast carcinoma root diameter exceeds 6 cm D. More than 40% of patients with malignant melanoma D. Beta blockers should be administered to all patients have cardiac metastases with Marfan syndrome unless a contraindication exists E. A solitary cardiac mass is more likely to be malignant E. The risk of aortic dissection during pregnancy in than benign patients with Marfan syndrome is increased if the diameter of the aortic root exceeds 4 cm QUESTION 662 QUESTION 659 While on rotation at a medical clinic in rural India A 54-year-old man was admitted to the hospital because you are asked to examine a 12-year-old girl who presents of acute pulmonary embolism. Intravenous administra- with fever, migratory polyarthritis, and an erythematous tion of heparin was begun. On admission, the platelet rash on her trunk that forms a snakelike ring with central count was 223,000/μL. Four days later it had fallen to clearing. Her cardiac examination is notable for a soft, 16,000/μL, although the patient remained asymptomatic. blowing, high-pitched pansystolic murmur at the apex. Which of the following statements regarding this patient’s She recalls a prolonged painful pharyngitis a few weeks condition is TRUE? ago. Two older family members are known to have mitral A. Low-molecular-weight heparin can be safely substi- stenosis. In addition to the “major manifestations” consid- tuted for intravenous unfractionated heparin ered diagnostic of this patient’s likely condition, other
  • 7. 291supporting evidence would include all of the following B. During initial therapy, amiodarone decreases thyroid-EXCEPT: stimulating hormone (TSH) levelsA. Prolonged QT interval C. Amiodarone contains 30% iodine by weightB. Fever D. Amiodarone’s iodine content inhibits synthesis andC. Elevated C-reactive protein release of T4 from the thyroid glandD. Normochromic, normocytic anemia E. Glucocorticoid therapy is beneficial for patients with CARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANSE. Rising streptococcal antibody titers amiodarone-induced hyperthyroidism who have ele- vated circulating levels of interleukin-6QUESTION 663 QUESTION 666A 42-year-old woman with rheumatoid arthritis (RA) pres-ents with exertional dyspnea. An echocardiogram shows A 54-year-old man presents for evaluation of excessivea small circumferential pericardial effusion without evi- daytime sleepiness. His wife has observed his prominentdence of hemodynamic compromise. Each of the follow- snoring and gasping at night. Each of the following state-ing statements regarding cardiovascular involvement in ments regarding sleep-related breathing disorders andrheumatoid arthritis is correct EXCEPT: cardiovascular disease is true EXCEPT:A. The pericardium is the most common site of cardio- A. Individuals with obstructive sleep apnea exhibit per- vascular involvement in RA sistently increased sympathetic activity, even duringB. Conduction system disease in RA is associated with daytime wakefulness rheumatoid nodules impinging on the conduction B. Obstructive sleep apnea is associated with drug- pathways resistant hypertension, automatic tachycardias, andC. Myocarditis is rare in RA nocturnal bradycardiasD. Epicardial coronary arteritis is seen in over half of C. Positive airway pressure therapy in obstructive sleep patients with RA apnea is associated with reduced cardiovascularE. Symptomatic involvement of the aorta and heart morbidity valves is rare D. Unlike obstructive sleep apnea, central sleep apnea is not associated with cardiovascular disease E. Positive airway pressure benefits central sleep apneaQUESTION 664 as well as obstructive sleep apneaA 76-year-old man with hypertension and dyslipidemia isfound to have atrial fibrillation for the first time on a QUESTION 667routine office ECG. He has no history of cardiac symp-toms, and an echocardiogram shows normal left ven- A 65-year-old man is evaluated by the cardiology consulttricular contractile function and no valvular disease or team 28 hours after completion of coronary artery bypasspericardial effusion. His physician initiates dabigatran graft (CABG) surgery because the ECG demonstratesetexilate for long-term anticoagulation. Which of the fol- new Q waves in the anterior precordial leads. Which oflowing statements is TRUE? the following statements about perioperative myocardialA. Anticoagulation for this patient is not warranted infarction (MI) in coronary artery bypass graft (CABG) because his risk of thromboembolism is low surgery is TRUE?B. Dabigatran etexilate is an oral factor Xa inhibitor A. Perioperative MI occurs in 5% to 10% of patients whoC. The risk of stroke or systemic embolism with dabiga- undergo CABG surgery tran 150 mg twice daily is lower than that with warfarin B. Serum creatine kinase levels are rarely elevated after anticoagulation and a target international normalized cardiac surgery in the absence of MI ratio (INR) of 2.0 to 3.0 C. Off-pump CABG is associated with lower serum con-D. Dabigatran 150 mg twice daily is associated with a higher centrations of cardiac biomarkers and reduced mor- rate of hemorrhagic stroke than warfarin anticoagulation tality than conventional CABGE. Hepatotoxicity is the major gastrointestinal side effect D. The presence of new Q waves after CABG is unreliable of dabigatran for the diagnosis of myocardial infarction E. A prolonged pump time and older age are associated with perioperative MIQUESTION 665A 66-year-old man with a history of atrial fibrillation QUESTION 668successfully suppressed by amiodarone presents withtremors and recent weight loss. His physician suspects All of the following statements regarding perioperativeamiodarone-induced thyroid dysfunction. Each of the fol- cardiac risk in patients undergoing noncardiac surgerylowing statements about amiodarone and thyroid func- are true EXCEPT:tion is correct EXCEPT: A. Emergency surgery carries a 2.5- to 4-fold increasedA. Amiodarone inhibits the peripheral conversion of thy- risk of postoperative myocardial infarction (MI) and roxine (T4) to triiodothyronine (T3) cardiac death compared with an elective operation
  • 8. 292 B. Insulin-dependent diabetes mellitus is a risk factor for QUESTIONS 675 TO 678 postoperative adverse cardiac outcomes C. Transurethral prostate surgery is considered a low-risk Match the cardiac medication with the potential hema- procedure with respect to cardiac complications tologic adverse effect: D. There is a 20% risk of reinfarction if surgery is per- A. Heparin formed 6 months after an acute MI B. Alpha-methyldopaCARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS E. Most surgical procedures are well tolerated by patients C. Procainamide with a history of angina who can carry groceries up D. Nitroglycerin one flight of stairs without stopping 675. Erythematous rash, leukopenia 676. Coombs-positive hemolysis 677. Chocolate-brown blood, normal PO2 QUESTION 669 678. Thrombocytopenia A previously healthy 36-year-old woman presents to her primary care physician 3 weeks after the delivery of her second child because of new dyspnea, orthop- nea, and peripheral edema. On examination, she QUESTIONS 679 TO 683 appears fatigued. The blood pressure is 100/70 mm Hg and the heart rate is 120 beats/min. The jugular venous Match the description with the associated disease: pressure is 12 cm H2O. There are basilar rales, a promi- A. Takayasu arteritis nent apical S3 gallop, hepatomegaly, and bilateral lower B. Giant cell arteritis extremity edema. An echocardiogram shows four- C. Both chamber cardiac enlargement and severe, global red- D. Neither uction of biventricular systolic function, compared with 679. Occurrence is predominantly in women a normal study before pregnancy. Each of the following 680. Onset is typically during teenage years statements regarding this patient’s condition is true 681. Jaw muscle claudication suggests the diagnosis EXCEPT: 682. Fever is almost always present A. The incidence of this disorder is greater with twin 683. Steroid therapy is a cornerstone of management pregnancies B. Approximately half of the patients with this disorder will completely recover normal cardiac function C. Subsequent pregnancies are usually well tolerated QUESTIONS 684 TO 688 D. This condition becomes symptomatic in most patients during the last trimester of gestation or in the early Match the chemotherapeutic agent with the likely cardiac postpartum period complication: E. The incidence of this disorder is higher among African- A. Myocardial infarction American women than among whites B. Acute myopericarditis C. Capillary leak syndrome DIRECTIONS: Each group of questions below con- D. Arrhythmias (acutely) and dilated cardiomyopathy sists of lettered headings followed by a set of numbered (chronically) questions. For each question, select the ONE lettered E. Hypertension heading with which it is most closely associated. Each 684. Interleukin-2 lettered heading may be used once, more than once, or 685. 5-Fluorouracil not at all. 686. Cyclophosphamide 687. Doxorubicin 688. Sunitinib QUESTIONS 670 TO 674 For each description listed below, match the appropriate diagnosis: QUESTIONS 689 TO 693 A. Behçet syndrome B. Systemic sclerosis Match the cardiac finding with the most likely endocrine C. Ankylosing spondylitis abnormality: D. Reiter syndrome A. Hyperparathyroidism E. Giant cell arteritis B. Hypothyroidism C. Hyperaldosteronism 670. Granuloma formation in the coronary arteries D. Cushing syndrome 671. Aortitis, uveitis, and urethritis E. Hyperthyroidism 672. Myocardial fibrosis and contraction band necrosis 673. Histologically similar to syphilitic aortitis 689. U waves on the ECG 674. Occlusion of the subclavian artery and aneu- 690. Cardiac myxoma rysms of the common carotid artery 691. Means-Lerman scratch
  • 9. 293 692. Shortened QT interval C. Both 693. Pericardial effusion D. Neither 698. Hyperkalemia 699. Bioavailability after subcutaneous injection isQUESTIONS 694 TO 697 >90% CARDIOVASCULAR DISEASE IN SPECIAL POPULATIONS; CARDIOVASCULAR DISEASE AND DISORDERS OF OTHER ORGANS 700. Inactivates clot-bound thrombusMatch the description to the associated fibrinolytic agent: 701. ThrombocytopeniaA. Streptokinase 702. Increases vascular permeabilityB. Tissue-type plasminogen activatorC. UrokinaseD. Tenecteplase 694. Both single- and two-chain forms demonstrate QUESTIONS 703 TO 706 proteolytic activity 695. Synthesized in renal tubular epithelial cells and Match the following complications with the associated endothelial cells rheumatologic disorder: 696. Prolonged half-life allows administration as a A. Aortitis and headaches single bolus B. Libman-Sacks endocarditis 697. Must form complex with plasminogen to exhibit C. Pulmonary hypertension enzymatic activity D. Aneurysmal dilatation of the subclavian and carotid arteriesQUESTIONS 698 TO 702 703. Behçet syndrome 704. Systemic lupus erythematosus 705. Giant cell arteritisMatch the finding to the associated anticoagulant: 706. SclerodermaA. Unfractionated heparinB. Low-molecular-weight heparin