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Sectiom 1 cardiac electrophysiology

4. What is the most common mechanism involved in clinically important cardiac


arrhythmias?
a. Triggered activity
b. Abnormal automaticity
c. Reentry
d. Early afterdepolarizations
e. Parasystole

Answer c.
Reentry is the most common mechanism underlying cardiac tachyarrhythmias,
including AVNRT, atrial flutter, AVRT with an accessory pathway, and VT in a
diseased heart.

15. All of the following statements regarding the AV node are true except:
a. Conduction through the node displays decremental behavior
b. It is positioned in the subendocardium at the base of the triangle of Koch
c. It is composed of nodal cells and transitional cells
d. It is a right atrial structure

15. Answer b.
The AV node is positioned in the low RA at the apex, rather than the base, of the triangle
of Koch. The triangle of Koch is comprised of the ostium of the CS, tendon of
Todaro, and septal attachment of the tricuspid valve leaflet. The region within the triangle
is comprised of nodal and transitional cells.

17. Conduction velocity is most rapid in which tissue?


a. Atrial
b. AV node
c. His-Purkinje
d. Ventricular

17. Answer c.
The conduction velocity is the most rapid in the His-Purkinje tissue.

18. Repolarization of the myocardial cells is determined mostly by which current?


a. Outgoing sodium
b. Ingoing calcium
c. Outgoing potassium
d. Ingoing chloride
e. Ingoing sodium

18. Answer c.
The outgoing potassium current is the principal determinant of repolarization of
myocardial cells.

24. Patients with the Wolff-Parkinson-White syndrome typically show each of the
following features except:
a. A wide QRS complex during normal sinus rhythm
b. A narrow complex SVT
c. A delta wave on the surface QRS
d. A long H–V interval on the His-bundle recording

24. Answer d.
The H–V interval in Wolff-Parkinson-White syndrome can be negative or very short
with antidromic tachycardia because the ventricle is activated prematurely by the
accessory pathway or normal in orthodromic tachycardia since conduction proceeds
down the AV node to the ventricle and returns retrograde through an accessory pathway.
The more typical form of Wolff-Parkinson-White syndrome is orthodromic and
the QRS is narrow, even in tachycardia, unless functional bundle branch block occurs
since the antegrade conduction proceeds through the AV node and His-Purkinje system.
29. The most common mechanism of arrhythmia in sustained VT is:
a. Sympathetically facilitated enhanced automaticity
b. Reentry involving ventricular myocardium
c. Triggered automaticity arising from early afterdepolarizations
d. Reflection of propagated impulses

29. Answer b.
The most common mechanism of arrhythmias in sustained VT is reentry involving
ventricular myocardium, most often from scars due to underlying CAD.

53. A common form of SVT in teenagers is:


a. Atrial ectopic tachycardia
b. Atrial flutter
c. Junctional ectopic tachycardia
d. AVNRT
e. Familial AF

53. Answer d.
AVNRT is a rare form of SVT in infants, but gradually increases with time. In
teenagers, this rhythm and accessory-pathway mediated tachycardia account for nearly
95% of the SVT cases. AVNRT is more common in females. All the other arrhythmias
listed are uncommon in this age group.

61. Risk factors associated with AF include all of the following except:
a. HTN
b. Sick sinus syndrome
c. Obstructive sleep apnea
d. Wolff-Parkinson-White syndrome
e. None of the above

61. Answer e.
Each of answers a to d has been shown to be a risk factor for AF. Other established
causes include advancing age, valvular heart disease, excessive alcohol intake, thyrotoxicosis,
pericarditis, cardiac surgery, acute pulmonary disease, and MI.

80. A clinical history of a gradual onset of palpitations that become more rapid over
time favors which diagnosis?
a. AVNRT
b. AVRT
c. Atrial tachycardia
d. AF

80. Answer c.
Patients with automatic atrial tachycardia often report a gradual onset of symptoms
that become more rapid (warm-up). In contrast, patients with AVNRT and AVRT
tend to paroxysms of palpitations with an abrupt onset and offset.

109. All of the following are neurally mediated reflex syncopal syndromes except:
a. Vasovagal
b. Postmicturition
c. Gastrointestinal stimulation (swallow, defecation, visceral pain)
d. Carotid sinus
e. Parkinson disease with autonomic failure

109. Answer e.
Parkinson disease with autonomic failure typically results in orthostatic syncope.
Answers a to d are all neurally mediated reflex syncopal syndromes. Others causes of
neurally mediated reflex syncope include: acute hemorrhage, cough, sneeze, postexercise
glossopharyngeal and trigeminal neuralgia, and a situational faint.
110. The following factors are associated with noncardiogenic syncope except:
a. Young age
b. Isolated syncope without underlying CV disease
c. Normal examination and ECG
d. Abrupt onset
e. Symptoms consistent with a vasovagal cause

110. Answer d.
An abrupt onset of syncope, particularly with exertion or while supine, is more consistent
with a cardiogenic mechanism. All the other factors other than the correct answer
d are more suggestive of a noncardiac mechanism. Factors suggestive of a cardiac mechanism
include: CAD, CHF, older age, abrupt onset, serious injuries, abnormal cardiac
examination, structural heart disease, and an abnormal ECG (presence of a Q wave,
bundle branch block, sinus bradycardia).

Section 2 coronary artry disease risk factor

Pick the best answer(s); some questions have more than one correct answer.

3. Which substance(s) is/are secreted by the endothelium?


a. Procoagulants
b. Anticoagulants
c. Vasoconstrictors
d. Vasodilators
e. Pro-proliferative substances

3. Answers a, b, c, d, and e.

6. The major cell type of the normal coronary artery intima is the:
a. Macrophage
b. Smooth muscle cell
c. Lymphocyte
d. Endothelial cell
e. Foam cell

6. Answer b.

11. Which of the following is/are true of the “vulnerable” plaque?


a. The vulnerable plaque typically has a fibrous cap covering a lipid-rich layer
b. These plaques often rupture at the central portion of the fibrous layer, where
hydrodynamic forces are increased
c. Evidence suggests that vulnerable plaque may come from hemorrhage into
the coronary artery vessel wall at certain locations
d. The vulnerable plaque is typically associated with a severe angiographic stenosis
e. There is evidence suggesting that more than 90% of deaths caused by MIs are
associated with plaque rupture or ulceration

11. Answers a, b, c, and e.


Vulnerable plaques are often hemodynamically insignificant (_50%) until rupture
and thrombosis causes abrupt flow limitation. It should be noted that vulnerable
plaques also often fissure and rupture at the sides as the shear forces are elevated there
as well.
12. Which of the following is/are true of calcification of coronary artery plaque?
a. Coronary calcification may proceed in a biochemical fashion similar to that
in bone
b. The principal component of plaque calcification is calcium carbonate and,
thus, is related to vitamin D intake
c. The degree of calcification is related to the overall volume of atherosclerotic
plaque in coronary arteries
d. Calcific medial sclerosis as a cause of coronary arterial calcification is associated
with increased probability of an ACS
e. The coronary artery develops calcification late in plaque development and
nearly always is associated with large plaque burden

12. Answers a and c.


Of note, in selected young patients presenting with acute atherothrombotic MI, there
is little calcification around their vulnerable plaque. Hence, lack of calcification does not
completely rule out vulnerable plaque, and presence or absence of calcium is therefore
only a tool for risk stratification and should not supplant clinical decision making.

For the remainder of the questions in this section, select the one best answer.

17. How do ACE inhibitors affect the bradykinin system?


a. Increase degradation of bradykinin
b. Decrease degradation of bradykinin
c. Increase production of bradykinin
d. Increase kallikrein production

17. Answer b.
Degradation of bradykinin relies on ACE. Inhibition with ACE inhibitor allows
build-up of bradykinin, which likely mediates the “cough” found in some patients
intolerant of ACE inhibitor.

18. NO regulates which of the following processes?


a. Vasodilation
b. Platelet aggregation
c. Matrix synthesis
d. Smooth muscle cell migration
e. All of the above

18. Answer e.
All of the above

19. The most potent vasoconstrictor is:


a. Bradykinin
b. Endothelin
c. Acetylcholine
d. PAI-1

19. Answer b.
Endothelin is correct. Bradykinin is not a potent vasoconstrictor; acetylcholine mediates
constriction if endothelium is denuded or dysfunctional (but not as potently as
endothelin); PAI-1 is the main inhibitor of the serine proteases tPA and urokinase and
prevents fibrinolysis.

30. Endothelin exerts its vasoconstriction through:


a. Activation of cGMP
b. Direct effect on smooth muscle cells
c. Injuring the endothelium
d. Specific endothelin receptors

30. Answer d.
The endothelin receptors are G-protein coupled receptors located on smooth muscle
cells. Their role in proliferation and contraction of PA smooth muscle cells is the
rationale behind their targeted antagonism with bosentan in pulmonary HTN.
Secion 4 Myocardial infarction

43. Which of the following is least likely to be a cause of unstable angina?


a. Anemia
b. Fever
c. Hypothyroidism
d. Severe AS
e. Severe HTN

43. Answer c.
Hyperthyroidism—but not hypothyroidism—may precipitate unstable angina.

46. Which of the following diagnoses should be considered in the differential diagnosis
of unstable angina?
a. Aortic dissection
b. Pericarditis
c. Pneumothorax
d. Pulmonary embolus
e. None of the above
f. All the above

46. Answer f.
The differential diagnosis of unstable angina includes all the above.

48. Which of the following is an indication for the use of calcium channel blockers
in patients with unstable angina?
a. Vasospastic angina
b. Ischemic symptoms associated with subacute stent thrombosis
c. Unstable angina occurring in association with AS
d. Unstable angina in the setting of hyperparathyroidism
e. Unstable angina in the periopertive period

48. Answer a.
Aspirin, heparin, beta blockers, and nitrates have been shown to be beneficial in unstable
angina. Calcium channel blockers are indicated in subsets of patients with vasospastic
angina or increased systolic BP or in those refractory to conventional treatment.

53. The administration of beta blockers after MI:


a. Should be avoided in patients with reduced ventricular function
b. Is less likely to benefit patients with reduced ventricular function than
patients with normal ventricular function
c. May paradoxically reduce symptoms of CHF in certain patients with a low EF
d. Should never be considered in patients with a history of CHF

53. Answer c.
Patients, especially with depressed LV EF benefit from titration of beta blockers. Mortality
is decreased by ~30% with therapeutic doses of beta blockers, especially after MI.
SECTION V Congestive Heart Failure and Cardiac Transplantation

31. Which one of the following does not represent abnormal LV diastolic function?
a. Restrictive filling pattern
b. Impaired LV relaxation filling pattern
c. Pseudonormal LV filling pattern
d. Diastolic predominant filling pattern

31. Answer d.
(See figure to Answer 11.) There are 3 abnormal filling patterns that can be observed
echocardiographically and correlate with filling pressures and diastolic abnormalities.
The most common pattern observed is impaired relaxation, which reflects reduced filling
in early diastole and increased contribution of filling by atrial contraction. LV relaxation
and compliance are abnormal, but filling pressures are normal at rest. A more
advanced pattern of diastolic dysfunction is termed pseudonormal as it resembles the
normal filling pattern, although diastolic abnormalities are clearly present. Patients
with advanced diastolic dysfunction may demonstrate a restrictive filling pattern, with
vigorous filling in early diastole and little filling at atrial contraction because of atrial
failure. This can be either reversible or irreversible, but clearly reflects elevated filling
pressures. A diastolic predominant pattern has little meaning because it does not specify
when diastolic filling is occurring.

52. Biologic actions of ANPs and BNPs include which of the following?
a. Inhibition of natriuresis
b. Activation of the renin–angiotensin–aldosterone system
c. Pro-fibrotic
d. Vasodilatation
e. Inhibition of guanylate cyclase

52. Answer d.
Natriuretic peptides (ANP and BNP) have multiple biologic actions including, but
not limited to, regulation of myocardial function, antifibrotic and natriuretic inhibition
of the renin–angiotensin–aldosterone system, and vasodilatation via smooth muscle
relaxation

57. Which of the following answers is correct regarding BNP?


a. Indicates increased ventricular volume and/or wall stress
b. Is not affected by renal function
c. Is elevated in only systolic, but not diastolic heart failure
d. Will always be elevated in heart failure

57. Answer a.
BNP is activated when there is elevated atrial and ventricular volume and/or wall stress.
Glomerular filtration rate is inversely related to BNP concentration and thus elevated values
do not always indicate high filling pressures, particularly in patients with renal insufficiency.
Studies have shown that BNP is elevated with LV systolic and, to a lesser degree,
diastolic heart failure. Finally, BNP may not always be elevated in heart failure. For example,
the value may be normal with flash pulmonary edema and is also reduced in obesity.

60. Diuretic therapy, particularly the use of loop diuretics, is mainstay therapy for
symptomatic heart failure.
Which of the following is incorrect regarding loop diuretics in heart failure?
a. Provides the greatest sodium and water excretion of all diuretics
b. Acts on the thick ascending loop of Henle
c. Action is amplified if thiazide diuretic (ie, metolazone) given ~30 minutes
prior to loop diuretic
d. Potential side effects include hypovolemia, electrolyte abnormalities (ie,
hypokalemia, hypomagnesemia, hypocalcemia) and ototoxicity
e. Does not require higher dosing in renal insufficiency or heart failure
60. Answer e.
Loop diuretics act on the thick ascending loop of Henle to block sodium and water
reabsorption. In renal insufficiency or heart failure, organic acids may accumulate in
that location and cause diuretics to be less effective, thus mandating higher dosing or
switching to another mode of water removal (ie, diuretic resistance). All of the other
statements are correct regarding loop diuretics.

Section 8 cardiac pharmacology

8. Most complications of cardiac drugs can be classed generally as:


a. Dose-dependent
b. Allergic
c. Drug-drug interactions
d. Dose-independent only
e. Idiosyncratic

8. Answer a.
Drug side effects may be dose-dependent or immunogenically-mediated. Most commonly,
they are concentration- or dose-dependent.

9. Renal insufficiency impacts the use of the following beta blockers, except:
a. Nadolol
b. Metoprolol
c. Sotalol
d. Acebutolol
e. Atenolol

9. Answer b.
Metoprolol is predominantly eliminated through the hepatic system and hence is
unaffected by renal function. The remainder should all be used with caution in
patients with renal insufficiency.

36. ACE inhibitors have which of the following actions?


a. Increase degradation of bradykinin
b. Decrease degradation of bradykinin
c. Increase production of bradykinin
d. Increase kallikrein production
e. Impair the conversion of prekallikrein to kallikrein

36. Answer b.
ACE increases the degradation of bradykinin, hence ACE inhibitors decreased this
degradation. ARBs have no effect on bradykinin metabolism.

39. The most potent vasoconstrictor is:


a. Bradykinin
b. Endothelin
c. Acetylcholine
d. PAI-1
e. Adenosine

39. Answer b.
Endothelin is the most potent vasoconstrictor. Adenosine is a potent vasodilator.

41. Response to which agent can be used to measure endothelial function?


a. Methergine
b. Ergonovine
c. Acetylcholine
d. Adenosine
e. Endothelin
41. Answer c.
Acetylcholine causes endothelial-dependent vasodilation. In the absence of endothelial
function, acetylcholine causes paradoxical vasodilation. Adenosine causes endothelialindependent
vasodilation.

51. Which of the following agents is least likely to cause hyperkalemia?


a. Spironolactone
b. Amiloride
c. Captopril
d. Ethacrynic acid
e. Losartan

51. Answer d.
Loop diuretics such as ethacrynic acid decrease serum potassium.

56. Which antiarrhythmic agent is best employed to treat digoxin-induced rhythm


disturbances?
a. Magnesium
b. Potassium
c. Lidocaine
d. Amiodarone
e. Quinidine

56. Answer c.
While antiarrhythmics, amiodarone and quinidine may both potentially exacerbate
arrhythmias caused by digitalis toxicity.

57. Which of the following therapies does not have proven survival benefit in
patients with low EF heart failure?
a. Carvedilol
b. Enalapril
c. Spironolactone
d. Candesartan
e. Digoxin

57. Answer e.
Digoxin is the only listed therapy without proven effect on survival in patients with
low EF heart failure.

63. Which of the following agents is most efficacious in the conversion of acute AF
into sinus rhythm?
a. Metoprolol
b. Digoxin
c. Amiodarone
d. Diltiazem
e. Esmolol

63. Answer c.
Amiodarone is the only agent that will convert the rhythm from AF to sinus. The
other agents are useful agents for rate control.

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