Braunwald's Heart Disease Review and Assessment PDF 12th Edition

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Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at http://ebooks.health.elsevier.com/ and may not be transferred to another party by resale, lending, or other means. 2022v1.0  BRAUNWALD’S HEART DISEASE REVIEW AND ASSESSMENT EDITION 12 BRAUNWALD’S HEART DISEASE REVIEW AND ASSESSMENT Edited by LEONARD S. LILLY, MD Professor of Medicine Harvard Medical School Chief, Brigham and Women’s/Faulkner Cardiology Section Brigham and Women’s Hospital Boston, Massachusetts Elsevier 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 BRAUNWALD’S HEART DISEASE REVIEW AND ASSESSMENT, ISBN: 978-0-323-83513-8 TWELFTH EDITION Copyright © 2023 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein.Because of rapid advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous edition copyrighted 2019. Content Strategist: Robin Carter/Melanie Tucker Content Development Manager: Meghan Andress Content Development Specialist: Nicole Congleton Publishing Services Manager: Shereen Jameel Project Manager: Haritha Dharmarajan Design Direction: Renee Duenow Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1  Contributors David D. Berg, MD, MPH Leonard S. Lilly, MD Instructor in Medicine Professor of Medicine Cardiovascular Division Harvard Medical School Department of Medicine Chief, Brigham and Women’s/Faulkner Cardiology Section Brigham and Women’s Hospital Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts Boston, Massachusetts Bradley A. Maron, MD Brian A. Bergmark, MD Associate Professor Instructor in Medicine Department of Medicine Department of Medicine Division of Cardiovascular Medicine Division of Cardiovascular Medicine Harvard Medical School Brigham and Women’s Hospital Brigham and Women’s Hospital Harvard Medical School Department of Cardiology Boston, Massachusetts VA Boston Healthcare System Boston, Massachusetts Akshay S. Desai, MD, MPH Director, Cardiomyopathy and Heart Failure Victor Nauffal, MD, MSc Cardiovascular Division Fellow Department of Medicine Department of Medicine Brigham and Women’s Hospital Division of Cardiovascular Medicine Associate Professor of Medicine Brigham and Women’s Hospital Harvard Medical School Harvard Medical School Boston, Massachusetts Boston, Massachusetts Sanjay Divakaran, MD Fidencio Saldaña, MD, MPH Instructor in Medicine Assistant Professor Harvard Medical School Dean for Students Cardiovascular Division Department of Medicine Brigham and Women’s Hospital Division of Cardiology Boston, Massachusetts Brigham and Women’s Hospital Harvard Medical School Vivek T. Kulkarni, MD, MHS, EdM Boston, Massachusetts Assistant Professor Department of Medicine Division of Cardiovascular Diseases Cooper Medical School of Rowan University Camden, New Jersey v  Preface Review and Assessment is a comprehensive study guide expertly authored new questions and updated material designed to accompany the 12th edition of Braunwald's carried forward from the previous edition: Dr. David Berg, Heart Disease: A Textbook of Cardiovascular Medicine, Dr. Brian Bergmark, Dr. Akshay Desai, Dr. Sanjay Divakaran, edited by Dr. Peter Libby, Dr. Robert Bonow, Dr. Douglas Dr. Vivek Kulkarni, Dr. Bradley Maron, Dr. Victor Nauffal, Mann, Dr. Gordon Tomaselli, Dr. Deepak Bhatt, and Dr. and Dr. Fidencio Saldaña. I also acknowledge with appre- Scott Solomon. It consists of 706 questions that cover key ciation the following colleagues who provided additional topics in the broad eld of cardiovascular medicine. A material or support to this edition: Dr. Ron Blankstein, Dr. detailed answer is provided for each question, often com- Sharmila Dorbala, Dr. Raymond Kwong, and the Brigham prising a “minireview” of the subject matter. Each answer and Women's Hospital team of cardiac imagers, who refers to specic pages, tables, and gures in Braunwald's expertly obtained many of the images that appear in this Heart Disease and to additional pertinent citations. Topics book. of greatest clinical relevance are emphasized, and subjects It has been a pleasure to work with the editorial and pro- of particular importance are intentionally reiterated in duction departments of our publisher, Elsevier, Inc. Specif- subsequent questions for reinforcement. ically, I thank Ms. Robin Carter, Meghan Andress, Nicole Review and Assessment is intended primarily for cardiol- Congleton, Haritha Dharmarajan, and their associates for ogy fellows, practicing cardiologists, internists, advanced their expertise and professionalism in the preparation of medical residents, and other professionals wishing to this edition of Review and Assessment. Finally, I am very review contemporary cardiovascular medicine in detail. thankful to my family for their support and patience during The subject matter is suitable to help prepare for the Sub- the long hours required to prepare this text. specialty Examination in Cardiovascular Disease offered On behalf of the contributors, I hope that you nd this by the American Board of Internal Medicine. book a helpful guide in your review of cardiovascular All questions and answers in this book were designed medicine. specically for this edition of Review and Assessment. I Leonard S. Lilly, MD am grateful for the contributions by my colleagues who Boston, Massachusetts vii  Contents SECTION I (CHAPTERS 1 TO 23) Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient, 1 SANJAY DIVAKARAN, LEONARD S. LILLY Questions, 1 Answers, Explanations, and References, 47 SECTION II (CHAPTERS 24 TO 45) Preventive Cardiology; Atherosclerotic Cardiovascular Disease, 83 BRIAN A. BERGMARK, LEONARD S. LILLY Questions, 83 Answers, Explanations, and References, 103 SECTION III (CHAPTERS 46 TO 71) Heart Failure; Arrhythmias, Sudden Death, and Syncope, 141 AKSHAY DESAI, VICTOR NAUFFAL, AND LEONARD S. LILLY Questions, 141 Answers, Explanations, and References, 163 SECTION IV (CHAPTERS 72 TO 89) Diseases of Heart Valves, Myocardium, Pericardium, and Pulmonary Vascular Bed, 201 FIDENCIO SALDAÑA, BRADLEY A. MARON, VIVEK KULKARNI, AND LEONARD S. LILLY Questions, 201 Answers, Explanations, and References, 231 SECTION V (CHAPTERS 90 TO 102) Cardiovascular Disease in Special Populations; Cardiovascular Disease and Disorders of Other Organs, 279 DAVID D. BERG, LEONARD S. LILLY Questions, 279 Answers, Explanations, and References, 287 ix  Braunwald’s Heart Disease Family of Books LILLY HERRMANN DI CARLI Heart Disease Cardio-Oncology Practice Manual Nuclear Cardiology and Multimodal Cardiovascular Imaging BHATT OTTO AND BONOW KIRKLIN AND ROGERS Opie’s Cardiovascular Drugs Valvular Heart Disease Mechanical Circulatory Support CREAGER FELKER AND MANN ISSA, MILLER, AND ZIPES Vascular Medicine Heart Failure Clinical Arrhythmology and Electrophysiology xi BRAUNWALD’S HEART DISEASE FAMILY OF BOOKS xii LILLY MANNING AND PENNELL SOLOMON, WU, AND GILLAM Braunwald’s Heart Disease Cardiovascular Magnetic Resonance Essential Echocardiography DE LEMOS AND OMLAND BAKRIS AND SORRENTINO MORROW Chronic Coronary Artery Disease Hypertension Myocardial Infarction BHATT MCGUIRE AND MARX BALLANTYNE Cardiovascular Intervention Diabetes in Cardiovascular Disease Clinical Lipidology Downloaded for dolores meloni ([email protected]) at Elsevier - Demonstration Account from ClinicalKey.com by Elsevier on July 17, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.  BRAUNWALD’S HEART DISEASE REVIEW AND ASSESSMENT SECTION I QUESTIONS (CHAPTERS 1 TO 23) Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient SANJAY DIVAKARAN, LEONARD S. LILLY Directions: QUESTION 3 For each question below, select the ONE BEST response. A state-of-the-art blood test has been developed for the rapid, noninvasive diagnosis of coronary artery dis- QUESTION 1 ease. The assay has a sensitivity of 90% and a speci- ficity of 90% for the detection of at least one coronary A 54-year-old African-American man with a history of hyper- stenosis of greater than 70%. In which of the following tension and hypercholesterolemia undergoes a treadmill scenarios is the blood test likely to be of most value to exercise test using the standard Bruce protocol. He stops the clinician? at 11 minutes 14 seconds because of fatigue, at a peak heart A. A 29-year-old man with exertional chest pain who has rate of 152 beats/minute and peak systolic blood pressure of no cardiac risk factors 200mm Hg. The diastolic blood pressure declines by 5mm B. A 41-year-old asymptomatic premenopausal woman Hg during exercise. During recovery, the systolic blood C. A 78-year-old diabetic woman with exertional chest pressure decreases to 15mm Hg below his pre-exercise pres- pain who underwent two-vessel coronary stenting 6 sure. There are no ischemic changes on the ECG during or weeks ago after exercise. Which of the following is correct? D. A 62-year-old man with exertional chest pain who has A. His peak systolic blood pressure during exercise hypertension, dyslipidemia, and a two-pack-per-day exceeds that normally observed smoking history B. The change in diastolic blood pressure during exercise E. A 68-year-old man with chest discomfort at rest accom- is indicative of signicant coronary artery disease panied by 2mm of ST-segment depression in the infe- C. This test is nondiagnostic owing to an inadequate peak rior leads on the ECG heart rate D. These results are consistent with a low prognostic risk of a coronary event QUESTION 4 E. The postexercise reduction in systolic blood pressure is suggestive of severe coronary artery disease A murmur is auscultated during routine examination of an 18-year-old asymptomatic college student, at the second left intercostal space, close to the sternum. The murmur QUESTION 2 is crescendo-decrescendo, is present throughout systole and diastole, and peaks simultaneously with S 2. It does not Which of the following statements regarding the second change with position or rotation of the head. Which of the heart sound (S2) is TRUE? following best describes this murmur? A. Earlier closure of the pulmonic valve with inspiration A. This is a continuous murmur, most likely a venous hum results in physiologic splitting of S 2 commonly heard in adolescents B. Right bundle branch block results in widened splitting B. This is a continuous murmur resulting from mixed aor- of S2 tic valve disease C. Paradoxical splitting of S 2 is the auscultatory hallmark C. This is a continuous murmur due to a congenital shunt, of an ostium secundum atrial septal defect likely a patent ductus arteriosus D. Fixed splitting of S2 is expected in patients with a right D. Continuous murmurs of this type can only be congen- ventricular electronically paced rhythm ital; murmurs due to acquired arteriovenous connec- E. Severe pulmonic valvular stenosis is associated with a tions are purely systolic loud P2 1  2 QUESTION 5 QUESTION 9 I Unequal upper extremity arterial pulsations would be Which of the following combinations does NOT have the QUESTIONS (CHAPTERS 1 TO 23) unlikely in which of the following disorders? potential for signicant pharmacologic interaction? A. Aortic dissection A. Simvastatin and erythromycin B. Takayasu disease B. Sildenal and nitroglycerin C. Supravalvular aortic stenosis C. Pravastatin and ketoconazole D. Subclavian artery atherosclerosis D. Cyclosporine and St. John’s wort E. Subvalvular aortic stenosis E. Digoxin and verapamil QUESTION 6 QUESTION 10 A 58-year-old woman with metastatic breast cancer pres- It would be reasonable and safe to order a treadmill exer- ents with exertional dyspnea and is found to have a large cise stress test for a patient with which of the following circumferential pericardial effusion, jugular venous disten- conditions? tion, and hypotension. Which of the following echocardio- A. Symptomatic hypertrophic obstructive cardiomyopathy graphic signs is likely present? B. Advanced aortic stenosis A. Collapse of the right ventricle throughout systole C. Acute myocarditis B. Exaggerated decrease in tricuspid inow velocity D. Abdominal aortic aneurysm with transverse diameter during inspiration of 5.5cm C. Exaggerated decrease in mitral inow velocity during E. Unstable angina inspiration D. Exaggerated increase in left ventricular outow tract velocity during inspiration QUESTION 11 E. Markedly increased E/A ratio of the transmitral Doppler velocity prole A 42-year-old woman with hypertension and dyslipid- emia underwent a 1-day rest-stress exercise myocardial perfusion single-photon emission computed tomography QUESTION 7 (SPECT) study with technetium-99m imaging to evaluate symptoms of “atypical” chest pain. Her resting ECG showed Which of the following statements about pulsus paradoxus left ventricular hypertrophy. She exercised for 12 minutes is correct? 30 seconds on the standard Bruce protocol and attained a A. Inspiration in normal individuals results in a decline of peak heart rate of 155 beats/minute. She developed a brief, systolic arterial pressure of up to 18mm Hg sharp parasternal chest pain during the test that resolved B. Accurate determination of pulsus paradoxus requires quickly during recovery. Based on the images in Fig. 1.1, intra-arterial pressure measurement which of the following statements is correct? C. Pulsus paradoxus is unlikely to be present in patients A. The SPECT myocardial perfusion images are diagnostic with advanced aortic regurgitation, even in the pres- of transmural myocardial scar in the distribution of the ence of tamponade mid–left anterior descending coronary artery D. Pulsus paradoxus is common in patients with hypertro- B. The anterior wall defect on the SPECT images is likely phic cardiomyopathy an artifact due to breast tissue attenuation C. Thallium-201 would have been a better choice of radio- tracer to image this patient QUESTION 8 D. Gated SPECT imaging cannot differentiate attenuation artifacts from a true perfusion defect A 57-year-old man with a history of hypertension and E. A transmural scar is associated with reduced wall elevated low-density lipoprotein cholesterol presents motion but normal wall thickening on gated SPECT to the emergency room with the acute onset of sub- imaging sternal chest pressure, dyspnea, and diaphoresis. His blood pressure is 158/96 mm Hg, and the heart rate is 92 beats/minute. Physical examination reveals clear QUESTION 12 lung fields and no cardiac gallop or murmurs. The ECG shows sinus rhythm with a prominent R wave in lead An 82-year-old man with a history of coronary artery dis- V2, 0.5mm of ST elevation in lead III, and 2mm of hori- ease underwent coronary artery bypass grafting surgery zontal ST depression in leads V 1 to V 3. Which of the fol- 6 years ago. He presents to the emergency department lowing would be diagnostically useful to plan a course with right upper quadrant abdominal pain and anorexia. of action? His medications include aspirin, metoprolol succinate, A. Repeat the ECG with right-sided precordial leads and atorvastatin. Physical examination, laboratory assess- B. Repeat the ECG with V 7 to V9 leads ment, and abdominal ultrasound conrm the diagnosis C. Await results of serum cardiac biomarkers of acute cholecystitis. The patient has normal vital signs, D. Obtain a chest computed tomography to assess for pul- and his pain is improved with analgesia. The cardiovascu- monary embolism lar consultation service is called to perform perioperative  3 End diastolic frame End systolic frame Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient Stress Rest Stress Rest Stress Rest FIG. 1.1 XXX risk assessment prior to cholecystectomy. The patient B. His risk of death due to an acute myocardial infarction lives with his spouse in a two-oor home. He does not rou- during the next year is greater than 50% tinely exercise but is able to walk up one ight of stairs to C. He should proceed directly to coronary angiography his bedroom each night without chest pain or shortness D. The test predicts a 25% risk of cardiac events over the of breath. He denies recent current angina or dyspnea on next 5 years, most likely the development of angina exertion. There has been no orthopnea, paroxysmal noc- E. This is likely a false-positive test turnal dyspnea, or peripheral edema. The cardiovascular examination is normal, and his ECG in the emergency room is unchanged from a prior tracing 4 months earlier. What is QUESTION 14 the next appropriate step? A. Recommend percutaneous cholecystostomy rather In which of the following clinical scenarios do ST-segment than laparoscopic or open cholecystectomy due to the depressions during standard exercise testing increase high risk of surgery the diagnostic probability of signicant coronary artery B. Recommend vasodilator stress myocardial perfusion disease? imaging prior to surgery A. A 56-year-old man with left bundle branch block and a C. Recommend that he proceed with surgery with no fur- family history of premature coronary disease ther cardiac testing B. A 45-year-old woman with diabetes and hypertension, D. Stop metoprolol succinate prior to surgery with left ventricular hypertrophy on her baseline ECG C. A 76-year-old woman with new exertional dyspnea, a history of cigarette smoking, and a normal baseline QUESTION 13 ECG D. A 28-year-old woman with pleuritic left-sided chest pain A 56-year-old asymptomatic man with a history of hyper- after a gymnastics class tension and cigarette smoking is referred for an exercise E. A 63-year-old man with exertional dyspnea on beta treadmill test. After 7 minutes on the standard Bruce pro- blocker, digoxin, and nitrate therapies tocol, he is noted to have 1mm of at ST-segment depres- sion in leads II, III, and aVF. He stops exercising at 9 minutes because of leg fatigue and breathlessness. The peak heart QUESTION 15 rate is 85% of the maximum predicted for his age. The ST segments return to baseline by 1 minute into recovery. Which of the following statements regarding cardiac cath- Which of the following statements is correct? eterization is TRUE? A. This test is conclusive for severe stenosis of the proxi- A. The risk of a major complication from cardiac catheter- mal right coronary artery ization is 2.0% to 2.5%  4 B. The incidence of contrast-induced nephrotoxicity in jugular venous pressure, bibasilar crackles, and 1+ pit- I patients with renal dysfunction is decreased with intra- ting edema of both ankles. On auscultation, there is a II/VI venous administration of mannitol before and after the early systolic murmur between the left sternal border and QUESTIONS (CHAPTERS 1 TO 23) procedure apex. The ECG reveals sinus tachycardia with inferior Q C. High osmolar nonionic contrast agents demonstrate a waves that were not present on a tracing 6 months earlier. reduced incidence of adverse hemodynamic reactions The chest x-ray is consistent with pulmonary edema. She compared with low osmolar ionic contrast agents is admitted to the hospital, and a transthoracic echocar- D. One French unit (F), a measurement of catheter diame- diogram is obtained that is technically limited due to her ter, is equivalent to 0.33mm body habitus. It reveals a left ventricular ejection fraction E. Retrograde left-sided heart catheterization is generally of 60%, with inferior wall hypokinesis. The mitral valve is a safe procedure in patients with tilting-disc prosthetic not well visualized but appears thickened, and there is an aortic valves anteriorly directed jet of mitral regurgitation that is dif- cult to quantitate. A diuretic is administered. Which of the following is the next most reasonable QUESTION 16 approach in her management? A. Urgent coronary angiography with planned percutane- A 75-year-old woman was brought urgently to the car- ous coronary intervention diac catheterization laboratory in the setting of an acute B. Nuclear stress testing to evaluate for ongoing ischemia ST-elevation myocardial infarction. She had presented C. Transesophageal echocardiography and surgical con- with chest pain, epigastric discomfort, and nausea. Phys- sultation ical examination was pertinent for diaphoresis, heart rate D. Initiate long-term management with aspirin, angiotensin- 52 beats/minute, blood pressure 85/50 mm Hg, jugular converting enzyme inhibitor, and beta blocker thera- venous distention, and slight bilateral pulmonary rales. pies Coronary angiography demonstrated ostial occlusion of E. Urgent right heart catheterization to evaluate for a left- a dominant right coronary artery, without signicant left- to-right shunt sided coronary artery disease. Which of the following statements is correct? A. Isolated infarction of the right ventricle, without left QUESTION 19 ventricular involvement, is likely B. ST-segment elevation in leads V 1 and V2 would be Which of the following statements regarding altered elec- expected to accompany inferior ST elevation trolytes and electrocardiographic abnormalities is TRUE? C. The abnormal heart rate and blood pressure are likely a A. Hypokalemia causes peaked T waves consequence of vagal stimulation B. Hyperkalemia causes QRS narrowing and increased P D. ST-segment depression is expected in lead V 4R wave amplitude C. Hypomagnesemia is associated with monomorphic ventricular tachycardia QUESTION 17 D. Hypocalcemia causes prolongation of the QT interval E. Severe hypocalcemia has been associated with the Using Doppler echocardiography, the following values are presence of a J wave (Osborn wave) obtained in a patient with a restrictive ventricular septal defect (VSD) and mitral regurgitation: systolic transmitral ow velocity = 5.8 m/second and systolic ow velocity at QUESTION 20 the site of the VSD = 5.1 m/second. The patient’s blood pressure is 144/78mm Hg. What is the estimated right ven- A 46-year-old woman with progressive exertional dyspnea tricular systolic pressure? was recently found to have bilateral hilar adenopathy on A. 20mm Hg chest x-ray and rst-degree atrioventricular block on her B. 30mm Hg ECG. A transbronchial biopsy demonstrated noncaseating C. 40mm Hg granulomas consistent with sarcoidosis and she is referred D. 50mm Hg to you for assessment of cardiac involvement. Which of E. Not able to be determined from the provided informa- the following statements is TRUE regarding the diagnostic tion evaluation of cardiac sarcoidosis? A. Left ventricular regional wall motion abnormalities in sarcoidosis are typically present in coronary distribu- QUESTION 18 tions B. An elevated serum angiotensin-converting enzyme level A 68-year-old woman with a history of diabetes, cigarette has low sensitivity but high specicity for the diagnosis smoking, and previously normal cardiac examination is of sarcoidosis admitted to the hospital with the new onset of exertional C. Sarcoid-associated late gadolinium enhancement on dyspnea and orthopnea. She describes having experienced cardiac magnetic resonance imaging is usually local- a “muscle ache” in her anterior chest 10 days earlier that ized to the endocardial border lasted several hours and has not recurred. Her blood pres- D. 18F-uorodeoxyglucose uptake on cardiac positron sure is 109/88 mm Hg, the heart rate is 102beats/minute, emission tomography differentiates active cardiac sar- and she is afebrile. Her examination reveals an elevated coidosis from inactive scar tissue  5 Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient FIG. 1.2 From Marriott HJL. Rhythm Quizlets: Self Assessment. Philadelphia: Lea & Febiger; 1987:14. QUESTION 21 B. The c wave is a reection of ventricular diastole and becomes visible in patients with diastolic dysfunction Which of the following statements about the ECG depicted C. The x descent is less prominent than the y descent in in Fig. 1.2 is correct? cardiac tamponade A. The basic rhythm is wandering atrial pacemaker D. Phasic declines in venous pressure (the x and y B. The fth QRS complex on the tracing is likely a prema- descents) are typically more prominent to the eye than ture ventricular beat the positive pressure waves (the a, c, and v waves) C. The Ashman phenomenon is present, and it occurs E. Cannon a waves indicate intraventricular conduction because the refractory period is directly related to the delay length of the preceding RR interval D. The bundle of His is the likely anatomic location of con- duction delay in the fth beat, because it has the lon- QUESTION 24 gest refractory period of conduction tissue Which of the following statements regarding the measure- ment of cardiac output is correct? QUESTION 22 A. In the thermodilution method, cardiac output is directly related to the area under the thermodilution curve The timing of an “innocent” murmur is usually: B. The thermodilution method tends to underestimate A. Early systolic cardiac output in low-output states B. Presystolic C. In the presence of tricuspid regurgitation, the thermodi- C. Midsystolic lution method is preferred over the Fick technique for D. Holosystolic measuring cardiac output E. Early diastolic D. A limitation of the Fick method is the necessity of mea- suring oxygen consumption in a steady state E. Cardiac output is directly proportional to systemic vas- QUESTION 23 cular resistance Which of the following statements about the jugular venous wave form is correct? QUESTION 25 A. The Kussmaul sign is pathognomonic for constrictive pericarditis Which of the following conditions is associated with the Doppler transmitral inow pattern shown in Fig. 1.3? FIG. 1.3 XXX  6 I QUESTIONS (CHAPTERS 1 TO 23) FIG. 1.4 XXX A. Gastrointestinal hemorrhage B. The Kussmaul sign may result from acute pulmonary B. Constrictive pericarditis embolism C. Normal aging C. This patient’s estimated pulmonary artery systolic D. Restrictive cardiomyopathy pressure is 64mm Hg E. Hyperthyroidism D. This patient’s right atrial pressure should be estimated as approximately 15mm Hg QUESTION 26 QUESTION 28 A 66-year-old woman is referred by her primary care physi- cian for further evaluation of dyspnea on exertion. On exam- Which of the following statements is TRUE regarding the ination, both an opening snap and mid-diastolic rumble are response of healthy older adults to aerobic exercise? appreciated at the apex. An echocardiogram is obtained. A. Ventricular stroke volume decreases with age, such that Which of the following CANNOT be assessed from the trans- there is an age-related fall in cardiac output during exercise mitral Doppler tracing shown in Fig. 1.4? B. Systolic and diastolic blood pressures each rise signi- A. The presence and severity of mitral stenosis cantly during aerobic exercise B. The presence of mitral regurgitation C. A decline in beta-adrenergic responsiveness contributes C. The transmitral diastolic pressure gradient to a fall in the maximum heart rate in older individuals D. The etiology of the valvular lesion D. A normal adult’s cardiac output doubles during maxi- E. The mitral valve area mum aerobic exercise E. Maximum aerobic capacity does not change signi- cantly with age in sedentary individuals QUESTION 27 A 37-year-old woman with no signicant past medical his- QUESTION 29 tory presents to the emergency department with acute shortness of breath and pleuritic chest pain. Her only Physiologic states and dynamic maneuvers alter the char- medication is an oral contraceptive. Her examination is acteristics of heart murmurs. Which of the following state- notable for sinus tachycardia. Chest computed tomogra- ments is correct? phy shows subsegmental pulmonary emboli, and she is A. In acute mitral regurgitation, the left atrial pressure started on anticoagulation therapy. An echocardiogram rises dramatically so that the murmur is heard only is performed that demonstrates the McConnell sign as during late systole well as mild tricuspid regurgitation with the following B. Rising from a squatting to a standing position causes values: the murmur of mitral valve prolapse to begin later in Peak systolic velocity across the tricuspid valve = 3m/ systole second C. The diastolic rumble of mitral stenosis becomes more Inferior vena cava diameter = 1.9cm, with less than 50% prominent during the strain phase of a Valsalva maneuver collapse with inspiration D. The murmur of aortic stenosis, but not mitral regurgita- Which of the following statements is correct? tion, becomes louder during the beat after a premature A. The McConnell sign refers to localized dyskinesis of the ventricular contraction right ventricular apex in patients with acute pulmonary E. The murmur of acute aortic regurgitation can usually embolism be heard throughout diastole  7 QUESTION 30 B. The J point is the proper isoelectric reference point on the ECG Which of the following statements regarding the computed C. J point depression during exercise is diagnostic for sig- Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient tomograms of the chest shown in Fig. 1.5 is TRUE? nicant cardiac ischemia A. The patient’s disorder should be managed medically, D. Persistence of ST-segment depression for 60 to 80 mil- with surgical intervention considered only if there is liseconds after the J point is necessary to interpret the evidence of secondary organ involvement electrocardiographic response as abnormal B. The left common carotid artery is spared by this pro- E. ST-segment depression must be present both cess during exercise and in recovery to be interpreted as C. The sensitivity of computed tomography for the diag- abnormal nosis of this condition is greater than 95% D. Fewer than 50% of patients with this condition will report chest pain QUESTION 32 E. Transesophageal echocardiography is necessary to conrm the diagnosis An ECG is obtained as part of the routine preoperative evaluation of an asymptomatic 45-year-old man scheduled to undergo wrist surgery. The tracing is shown in Fig. 1.6 QUESTION 31 and is consistent with: A. Right ventricular hypertrophy Which of the following statements regarding ST-segment B. Left posterior fascicular block changes during exercise testing is TRUE? C. Reversal of limb lead placement A. The electrocardiographic localization of ST-segment D. Left anterior fascicular block and counterclockwise depression predicts the anatomic territory of coronary rotation obstructive disease E. Dextrocardia with situs inversus A B FIG. 1.5 Courtesy of RC Gilkeson, MD, Case Western Reserve University, Cleveland, OH. I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 FIG. 1.6 XXX  8 QUESTION 33 A. Echocardiographic reevaluation in 6 to 12 months I B. Referral for aortic valve replacement Which of the following statements is correct regarding C. Dobutamine stress echocardiography QUESTIONS (CHAPTERS 1 TO 23) exercise test protocols? D. Exercise stress echocardiography A. Regardless of the exercise protocol, the heart rate and systolic and diastolic blood pressures all must increase substantially to achieve a valid test QUESTION 36 B. Bicycle, treadmill, and arm ergometry protocols all pro- duce approximately equal heart rate and blood pres- Which of the following statements regarding nuclear imag- sure responses ing and acute myocardial infarction (MI) is TRUE? C. The standard Bruce protocol is characterized by only A. The size of the resting myocardial perfusion defect after small increases in oxygen consumption between stages acute MI does not correlate with the patient’s prognosis D. A fall in systolic blood pressure during exercise is asso- B. Increased lung uptake of radioisotope at rest correlates ciated with severe coronary artery disease with an unfavorable prognosis E. An optimal graded treadmill exercise test rarely C. Submaximal exercise imaging soon after MI is a better requires more than 5 minutes of exercise on the Bruce predictor of late complications than adenosine myocar- protocol dial perfusion imaging D. Technetium-99m sestamibi imaging is inaccurate in assessing the effectiveness of reperfusion therapy QUESTION 34 Which of the following patients is LEAST likely to have a QUESTION 37 cardiac cause of his/her recent onset of dyspnea? A. An active 54-year-old man with a congenitally bicus- A 61-year-old man presents for a treadmill exercise test pid aortic valve who has recently noticed shortness of because of intermittent chest pain. He believes he had a breath walking his usual 18 holes of golf “small heart attack” in the past. He has a history of prior B. A 70-year-old woman who sustained an anterior myo- tobacco use, and his father died of a myocardial infarc- cardial infarction 1 year ago with a left ventricular tion at age 68 years. His baseline ECG shows normal sinus ejection fraction of 50% at that time. She has not had rhythm with Q waves in the inferior leads. At 6 minutes recurrent angina but has noted dyspnea during her into the Bruce protocol he develops mild anterior chest usual housework over the past 2 months heaviness, and the ECG demonstrates ST elevation in leads C. A 46-year-old woman with a history of asymptomatic I, aVL, V5, and V6. Which of the following statements regard- rheumatic mitral stenosis who recently noticed irregu- ing ST-segment elevation during exercise testing is correct? lar palpitations and shortness of breath while climbing A. ST-segment elevation during exercise testing is a com- stairs mon nding in patients with coronary artery disease D. A 38-year-old woman with a previously asymptomatic B. ST-segment elevation in a lead that contains a patho- ostium secundum atrial septal defect, now 8 months logic Q wave at baseline indicates severe myocardial pregnant, who has noted shortness of breath during ischemia her usual weekly low-impact aerobics class C. The electrocardiographic leads that manifest E. A 22-year-old man with trisomy 21 and a heart murmur ST-segment elevation during exercise localize the ana- who has described shortness of breath carrying gro- tomic regions of ischemia cery bundles over the past 3 months D. ST-segment elevation that develops during exercise is usually a manifestation of benign early repolarization E. ST-segment elevation during exercise is commonly QUESTION 35 associated with the development of complete heart block A 79-year-old woman with a history of hypertension and dyslipidemia is referred to a cardiologist because of recent exertional dyspnea and a systolic murmur. Examination is QUESTION 38 notable for a heart rate of 91 beats/minute, blood pressure 117/68 mm Hg, jugular venous pressure 12 cm H 2O, and a Which of the following statements regarding coronary cal- grade III/VI late-peaking crescendo-decrescendo systolic cium assessment by electron beam tomography (EBT) is murmur at the upper right sternal border with diminished TRUE? intensity of the second heart sound. There is trace bilateral A. The amount of calcium on EBT strongly correlates ankle edema. A transthoracic echocardiogram reveals mild with the severity of coronary disease detected by left ventricular hypertrophy, normal biventricular systolic angiography function, a transaortic valve peak velocity of 3.5 m/second, B. Patients who benet most from screening with EBT are mean gradient 29 mm Hg, and a calculated aortic valve area those at a high risk for coronary events based on tradi- of 0.8 cm2 using the continuity equation. The dimensionless tional risk factors index is 0.23, and the left ventricular stroke volume index C. The absence of coronary calcium completely excludes is 47 mL/m2 (normal stroke volume index is ≥35 mL/m 2). the presence of severe obstructive coronary artery She undergoes cardiac computed tomography imaging that stenosis reveals an aortic valve calcium score of 2531 Agatston units D. Interpretation of the calcium score is independent of (Fig. 1.7). What is the most appropriate recommendation? the patient’s age and gender  9 Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient FIG. 1.7 Courtesy of Yee-Ping Sun, MD, Brigham and Women’s Hospital, Boston, Massachusetts. E. A coronary calcium score higher than the median con- dyspnea, weakness, and weight loss. One day before hos- fers an increased risk of myocardial infarction and pitalization he was unable to climb one ight of stairs death because of shortness of breath. On examination, he appears fatigued, with mild respiratory distress. His blood pressure is 110/70mm Hg without pulsus paradoxus. His QUESTION 39 heart rate is 110 beats/minute and regular. The jugular veins are distended without the Kussmaul sign. Pulmo- Which of the following statements is TRUE regarding prog- nary auscultation reveals scant bibasilar rales. The heart nosis as determined by myocardial perfusion imaging? sounds are distant. There is mild bilateral ankle edema. A. Patients with normal perfusion in the presence of angi- As part of the evaluation, he undergoes cardiac magnetic ographically documented coronary artery disease have resonance imaging. A short-axis view at the midventricu- very low rates of cardiac events ( Base) Str Rst TID Ratio: 1.37 Defect Blackout Map HLA (Post –> Ant) Str GATED STRESS [Rec GATED STRESS [Recon Reversibility Rst GATED STRESS GATED REST VLA (Sep –> Lat) Str Rst FIG. 1.11 XXX  13 Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient 5.0 m/s FIG. 1.12 XXX QUESTION 54 B. The sensitivity of transthoracic echocardiography (TTE) for detection of vegetations is less than 70% Which of the following is NOT commonly associated with C. After successful antibiotic therapy, previously detected the disorder illustrated in Fig. 1.13? vegetations should not be visible by echocardiography A. Tricuspid regurgitation D. Functional and structural consequences of valvular B. Patent foramen ovale infection are rarely observed by transthoracic echo- C. Wolff–Parkinson–White syndrome cardiographic evaluation, such that a transesophageal D. Systemic hypertension study (TEE) is always mandatory E. Atrial brillation E. TTE and TEE have similar sensitivities for detection of myocardial abscess formation QUESTION 55 QUESTION 56 Which of the following statements is TRUE regarding the echocardiographic evaluation of suspected infective Which of the following statements is TRUE regarding exam- endocarditis? ination of the arterial pulse? A. Vegetations of the mitral valve typically appear on the A. A reduced-volume brachial pulse with a late systolic ventricular aspect of the leaets peak is the most characteristic arterial nding on phys- ical examination in patients with severe aortic stenosis B. A bisferious pulse is characterized by a systolic and then a diastolic peak and is typical of mixed mitral valve disease C. The carotid artery is the blood vessel used to best appreciate the contour, volume, and consistency of the peripheral vessels D. In coarctation of the aorta, the femoral pulse demon- strates a later peak than the brachial pulse. TV E. The normal abdominal aorta is palpable both above and below the umbilicus QUESTION 57 Which of the following statements regarding cardiac cath- eterization is TRUE? A. When catheterization is performed from the groin, the FIG. 1.13 TV, Tricuspid valve. risk of retroperitoneal hemorrhage is decreased when  14 the femoral artery puncture is made above the inguinal A. Stress testing should be pursued in the 45-year-old man I ligament with atypical chest pain because, if positive, the test B. An international normalized ratio of less than 2.2 is will have the best positive predictive value of the cases QUESTIONS (CHAPTERS 1 TO 23) acceptable for radial artery catheterization shown C. Patients with shellsh allergy are at greater risk of intra- B. Stress testing should be pursued in the 55-year-old man venous contrast reactions than patients with other food with typical chest pain because, if negative, the test will allergies have the best negative predictive value of the cases shown D. Pseudoaneurysm formation is more likely to occur if C. The positive and negative predictive values cannot be the femoral artery puncture is made above the bifurca- determined for these patients from the given information tion of the common femoral artery D. A 45-year-old asymptomatic man without risk factors who has a positive stress test is less likely to have CAD than is a man of the same age with atypical chest pain QUESTION 58 and a negative stress test E. The pretest probability of coronary artery disease in Which of the following statements regarding the use of car- a 45-year-old man depends solely on the presence of diopulmonary exercise testing in patients with congestive symptoms heart failure is correct? A. A peak oxygen consumption of less than 14mL/kg/min- ute identies patients who would benet from cardiac QUESTION 61 transplantation B. Patients with ejection fractions less than 20% con- Which of the following statements concerning imaging nd- sistently have peak oxygen consumptions less than ings in hypertrophic cardiomyopathy (HCM) is correct? 10mL/kg/min, and exercise testing is of little utility in A. Septal thickness is always abnormal in patients with this population HCM C. The exercise limitation in severe heart failure is due pri- B. Diastolic notching of the aortic valve on M-mode examina- marily to an inability to raise the heart rate tion is typical in patients with outow tract obstruction D. Exercise training in congestive heart failure patients C. The presence of systolic anterior motion of the mitral improves functional capacity but has no effect on valve is consistent with dynamic outow tract obstruction abnormalities of autonomic and ventilatory responsive- D. Myocardial relaxation velocities measured by tissue ness or increased lactate production Doppler imaging are typically normal E. Results of exercise testing are rarely useful when mak- ing clinical decisions about heart failure patients, such 55 y/o M. Typical angina as timing of cardiac transplantation QUESTION 59 45 y/o M. Atypical chest pain In which of the following clinical scenarios would an alter- 45 y/o M. Asymptomatic. HBP, ↑Chol, D.M. native imaging modality be preferred over magnetic reso- nance imaging? A. Diagnosis of iron overload cardiomyopathy in a pediat- 100 ric patient with beta-thalassemia major and congestive heart failure B. Diagnosis of arrhythmogenic right ventricular cardio- 45 y/o M. Asymptomatic, no risk factors myopathy in a 24-year-old man who recently survived 80 Post-test probability of CAD (%) a cardiac arrest C. Diagnosis of aortic coarctation in a 17-year-old girl with hypertension and radial-femoral artery delay on physi- (+) ST cal examination 60 D. Serial evaluation of left ventricular function in a 54-year- old woman with metastatic breast cancer receiving doxorubicin chemotherapy 40 E. Diagnosis of renal artery stenosis in a 78-year-old man with refractory hypertension 20 QUESTION 60 (–) ST Fig. 1.14 shows the post-test probability of coronary artery disease (CAD) as a function of the pretest probability of 0 CAD and results of exercise electrocardiography—either a 0 20 40 60 80 100 positive [(+) ST, red bars] or negative [(−) ST, blue bars] Pre-test (clinical) probability of CAD (%) response. Four different patient examples are plotted. FIG. 1.14 CAD, Coronary artery disease; Chol, cholesterol; D.M., Which of the following statements is correct? diabetes mellitus; HBP, high blood pressure; M., man.  15 QUESTION 62 C. Initiate anti-ischemic therapy with intravenous nitro- glycerin and a beta blocker Which of the following statements regarding cardiac hemo- D. Proceed directly to cardiac catheterization if ST- Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient dynamics is true? segment/T wave abnormalities fail to quickly normalize A. The y descent of the right atrial pressure wave form with anti-ischemic therapy represents relaxation of the atrium and downward E. Obtain a head computed tomography scan tugging of the tricuspid annulus by right ventricular contraction B. In the right atrium, in contrast to the left atrium, the v QUESTION 65 wave is more prominent than the a wave C. The y descent is blunted in cardiac tamponade Which of the following statements about diastolic mur- D. Tricuspid stenosis results in prominence of the y descent murs is FALSE? A. Diastolic murmurs are classied according to their time of onset as early diastolic, middiastolic, or late QUESTION 63 diastolic B. In aortic regurgitation due to aortic root dilatation, the Which of the following statements regarding the effects murmur typically radiates to the right sternal border of maneuvers on the auscultation of cardiac murmurs is C. It is possible to differentiate the murmur of acute severe true? aortic regurgitation from that of chronic aortic regurgi- A. In patent ductus arteriosus, the diastolic phase of the tation at the bedside murmur is softened by isometric handgrip D. Late diastolic (presystolic) accentuation of the murmur B. The murmur of hypertrophic obstructive cardiomyop- indicates that the patient is in atrial brillation. athy becomes softer with standing or during a Valsalva E. The Graham Steell murmur begins in early diastole strain maneuver after a loud P2 C. The murmur of a ventricular septal defect decreases with isometric handgrip D. Isometric handgrip decreases the diastolic murmur of QUESTION 66 aortic regurgitation E. The diastolic murmur of mitral stenosis becomes Which of the following statements regarding coronary louder with exercise artery anatomy is correct? A. At cardiac catheterization, the left main coronary artery is best visualized in the left anterior oblique projection QUESTION 64 with cranial angulation B. A ramus intermedius branch is present in fewer than A 62-year-old previously healthy man is brought to the 25% of people emergency department because of severe headache and C. The left circumex artery is the dominant vessel in 45% dizziness. He has no chest pain or dyspnea. He takes no med- of people ications. His blood pressure is 186/98mm Hg; his heart rate D. The most densely vascularized area of the heart is the is 56 beats/minute and regular. The presenting ECG is shown interventricular septum in Fig. 1.15. Which of the following actions is appropriate? E. The abnormality shown in Fig. 1.16 is the most common A. Initiate antiplatelet therapy with aspirin and clopidogrel type of coronary congenital abnormality that is hemo- B. Initiate antithrombotic therapy with heparin dynamically signicant I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 FIG. 1.15 XXX  16 I QUESTIONS (CHAPTERS 1 TO 23) A B FIG. 1.16 XXX QUESTION 67 D. Dobutamine pharmacologic scintigraphy increases cor- onary blood ow less than adenosine A 25-year-old asymptomatic man presents for routine medical evaluation. The patient is tall with unusually QUESTION 70 long limbs and pectus excavatum. There is no family history of Marfan syndrome. Which of the following is Which of the following statements regarding the ausculta- among the “major criteria” for the diagnosis of Marfan tory ndings of mitral stenosis is correct? syndrome? A. The opening snap (OS) is a late diastolic sound A. Mitral valve prolapse B. A long A2-OS interval implies severe mitral stenosis B. Mild pectus excavatum C. In atrial brillation, the A 2-OS interval does not vary C. Joint hypermobility with cycle length D. Descending aortic aneurysm D. The “snap” is generated by rapid reversal of the posi- E. Ectopia lentis tion of the posterior mitral leaet E. The presence of an opening snap implies a mobile body of the anterior mitral leaet QUESTION 68 QUESTION 71 Which one of the following echocardiographic ndings suggests that aortic regurgitation is severe? Which of the following statements about digitalis-induced A. Diastolic ow reversal in the descending thoracic aorta arrhythmias is correct? B. Premature closure of the aortic valve A. Atrial tachycardia with block is diagnostic of digitalis C. Pressure half-time of the aortic regurgitation Doppler toxicity spectrum of 500 milliseconds B. Nonparoxysmal junctional tachycardia is highly sug- D. A color Doppler regurgitant jet that extends to the tips gestive of digitalis toxicity of the papillary muscles C. The development of atrioventricular dissociation in a E. A left ventricular outow tract systolic gradient of patient taking digitalis is a sign of digitalis therapy, but 64mm Hg not an indication of digitalis toxicity D. Frequent ventricular premature beats are rarely a sign of digitalis toxicity QUESTION 69 Which of the following statements regarding pharmaco- QUESTION 72 logic agents used in myocardial perfusion stress testing is NOT correct? An 82-year-old man presents after a recent non–ST- A. Radiopharmaceutical agents should be injected 1 to 2 elevation myocardial infarction. Coronary angiography minutes before the end of exercise revealed severe three-vessel disease with 100% occlu- B. During perfusion stress testing, administration of ade- sion of the proximal left anterior descending (LAD) nosine or regadenoson typically provokes myocardial coronary artery, 100% mid–right coronary artery occlu- ischemia in patients with coronary artery disease sion, and 70% stenosis of the proximal left circumflex C. Dipyridamole blocks the cellular uptake of adenosine, coronary artery. Echocardiography demonstrated aki- an endogenous vasodilator nesis of the entire anterior wall, septum, and mid- and  17 ANT Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient SEP LAT INF REST(G) 82 Rb-flow ANT SEP LAT INF FDG(G) F18 FDG – Metabolism Apical Short axis ANT SEP LAT INF REST(G) ANT SEP LAT INF FDG(G) Septal Vertical axis Lateral APEX SEP LAT BASE REST(G) APEX SEP LAT BASE FDG(G) Inferior Horizontal axis Anterior FIG. 1.17 XXX apical anterolateral wall, with an estimated left ventric- B. This nding is consistent with the presence of scarred ular ejection fraction of 20%. Myocardial viability was nonviable myocardium evaluated using cardiac positron emission tomography C. Radionuclide techniques are less sensitive than mea- (PET) with rest rubidium-82 ( 82Rb flow tracer) and 18F-la- surement of inotropic contractile reserve by dobu- beled fluorodeoxyglucose ( 18F-FDG metabolism tracer), tamine echocardiography for the detection of viable as shown in Fig. 1.17. Which of the following statements myocardium is TRUE? D. Survival benet associated with revascularization of A. The images show a large region of PET perfusion metab- hibernating myocardium has been demonstrated in olism mismatch in the mid-LAD distribution. randomized clinical trials  18 QUESTION 73 A. These agents are as effective as warfarin for prevention I of thromboemboli in patients with atrial brillation and Which of the following statements regarding physical nd- mechanical heart valves QUESTIONS (CHAPTERS 1 TO 23) ings that distinguish the murmur of aortic stenosis (AS) B. Each of these drugs can be used safely in patients with from the murmur of hypertrophic cardiomyopathy (HCM) advanced renal disease is TRUE? C. Intravenous idarucizumab rapidly reverses the antico- A. The strain phase of the Valsalva maneuver decreases agulant effect of dabigatran the intensity of the murmurs of both AS and HCM D. For patients whose international normalized ratio lev- B. The carotid upstroke in HCM is brisker than in AS els on warfarin have varied due to noncompliance, C. The murmurs of AS and HCM both radiate to the carotid rivaroxaban is an excellent alternative, given its once- arteries daily dosing D. If a systolic thrill is present, it is most often located in the second right intercostal space in HCM and at the apex in AS QUESTION 75 E. Squatting increases the intensity of the murmur of HCM A 73-year-old woman with exertional angina is referred for a standard Bruce protocol exercise tolerance test with thallium-201 single-photon emission computed tomogra- QUESTION 74 phy. Her nuclear images are shown in Fig. 1.18. What is the likely diagnosis? Which of the following statements is correct regarding the A. Dilated cardiomyopathy oral anticoagulants dabigatran, rivaroxaban, and apixaban B. Single-vessel coronary artery disease involving the left in the treatment of patients with atrial brillation? circumex artery SA (Apex→Base) StrAC RstAC StrAC RstAC HLA (INF→ANT) StrAC RstAC VLA (SEP→LAT) StrAC RstAC FIG. 1.18 XXX  19 C. Prior inferior myocardial infarction with high-grade ste- C. Even mild right ventricular hypertrophy produces diag- nosis of the right coronary artery nostic electrocardiographic abnormalities D. Left main or severe multivessel coronary artery disease D. A deep S wave in V6 is typical Foundations of Cardiovascular Medicine; Individualizing Approaches to Cardiovascular Disease; Evaluation of the Patient E. Normal coronary arteries; the images demonstrate E. Precordial lead transition is typically rotated in a coun- breast attenuation artifact terclockwise fashion (early transition) QUESTION 76 QUESTION 80 Which of the following statements regarding pulsus alternans Which of the following statements regarding shunt detec- in patients with marked left ventricular dysfunction is true? tion is TRUE? A. It is usually associated with electrical alternans of the A. When an “anatomic” shunt is present, arterial oxygen QRS complex saturation normalizes with administration of 100% B. It is less readily detected in the femoral compared with oxygen the radial arteries B. Methods of shunt detection include oximetry, echocar- C. It cannot be detected by noninvasive sphygmomanometry diography, and magnetic resonance imaging, but not D. It can be enhanced by the assumption of erect posture radionuclide imaging E. It is uncommon for patients with pulsus alternans also C. Among the sources of right atrial venous blood, the to have an S3 gallop inferior vena cava has the lowest oxygen saturation D. Due to the low sensitivity of oximetry for shunt detec- tion, most clinically relevant left-to-right shunts cannot QUESTION 77 be detected using this method E. The Flamm formula is used to estimate mixed venous Which of the following statements regarding exercise test- oxygen content proximal to a left-to-right shunt at the ing is TRUE? right atrial level A. Frequent ventricular ectopy in the early postexer- cise phase predicts a worse long-term prognosis than ectopy that occurs only during exercise QUESTION 81 B. Patients who develop QT interval prolongation during exercise testing are good candidates for class IA antiar- Which of the following conditions is NOT often associated rhythmic drugs with a prominent R wave in electrocardiographic lead V 1? C. The appearance of sustained supraventricular tachy- A. Right ventricular hypertrophy cardia during exercise testing is diagnostic of underly- B. Wolff–Parkinson–White syndrome ing myocardial ischemia C. Duchenne muscular dystrophy D. Exercise-induced left bundle branch block is not predic- D. Left anterior fascicular block tive of subsequent cardiac morbidity and mortality E. Misplacement of the chest leads E. Tachyarrhythmias are commonly precipitated during exercise testing in patients with Wolff–Parkinson–White syndrome QUESTION 82 The hemodynamic tracing illustrated in Fig. 1.19 is associ- QUESTION 78 ated with which of the following features? A. Advanced valvular aortic stenosis Which of the following statements regarding extra systolic B. A bid aortic pulse contour sounds is TRUE? C. Normal left ventricular end-diastolic pressure A. Ejection sounds are high-frequency “clicks” that occur in mid-late systole B. The ejection sound associated with pulmonic stenosis decreases in intensity during inspiration ECG C. Aortic ejection sounds vary with respiration, occurring later in systole during inspiration LV Mid-cavity/aorta D. The bedside maneuver of standing from a squatting 180 position causes the click of mitral valve prolapse to 160 Pressure (mm Hg) occur later in systole 140 120 Subaortic LV outflow tract/aorta 100 QUESTION 79 80 60 Which of the following statements regarding the ECG in 40 chronic obstructive lung disease with secondary right ven- 20 tricular hypertrophy is correct? A. The mean QRS axis is typically less than 15 degrees B. The amplitude of the QRS complex is abnormally high Time in the precordial leads FIG. 1.19 LV, Left ventricular.  20 I QUESTIONS (CHAPTERS 1 TO 23) FIG. 1.20 Courtesy of Mark Weinfeld, MD, Brigham and Women’s Hospital, Boston, Massachusetts. D. A delayed rise in the carotid artery pulsation D. Valve area calculation is more strongly inuenced by E. Expected clinical improvement with transcatheter aor- errors in the pressure gradient measurement than by tic valve replacement errors in cardiac output measurement QUESTION 83 QUESTION 85 A 53-year-old woman with a history of hypertension and A 56-year-old man who underwent coronary artery bypass obesity is diagnosed with triple negative (estrogen recep- graft surgery 6 years ago has experienced exertional chest tor–negative, progesterone receptor–negative, HER-2 neg- discomfort in recent months. He is not able to perform an ative) left breast cancer. She undergoes echocardiography exercise test because of chronic hip pain. He undergoes that shows a left ventricular (LV) ejection fraction of 65% an adenosine positron emission tomography vasodilator and average global longitudinal strain (GLS) of –18.3% stress test, images from which are shown in Fig. 1.21. What (Fig. 1.20A). She undergoes neoadjuvant therapy with pacl- is the correct interpretation of this study? itaxel and cisplatin. After surgery, she is treated with adri- A. No perfusion defects amycin (total of 240 mg/m 2) and cyclophosphamide. She B. A partially reversible defect of the entire inferior wall