BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
1. Match the following antihypertensive agents/
medications: *
2. You are evaluating a 19-year-old woman in a travel clinic
at your university. She complains of a nonpainful swelling
of the lower extremity. On examination, the leg has
thickened skin and a woody texture. A bedside
ultrasound confirms patent lower extremity veins
without thrombus. You suspect lymphedema and think
that this is likely due to the most common cause of
secondary lymphedema worldwide. What cause do you
suspect? *
a. Cancer involving the inguinal lymph nodes
b. Lymphogranuloma venereum
c. Lymphatic filariasis
d. Recurrent bacterial lymphangitis
e. Tuberculosis
3. You are evaluating a 65-year-old man who has a 15-year
history of nonischemic cardiomyopathy with a dilated
left ventricle and an ejection fraction of 15%. Yearly
echocardiograms over the past 5 years have shown
severe mitral regurgitation. On optimal medical therapy,
the patient has NYHA class II symptoms. Today, he
specifically asks whether his valve should be fixed in
order to improve his survival. You should tell him: *
a. “If you were to have high pulmonary artery
pressures or develop new atrial fibrillation, we
would move forward with valve repair.”
b. “In patients like you, valve repair has never
been shown to improve survival”
c. “We should consider valve surgery only if repair
is possible. Replacement would not improve
your survival.”
d. “While surgical methods have not shown
survival benefit, percutaneous mitral valve
repair has been shown to reduce mortality in
patients like you."
e. “Yes, your valve should have been fixed years
ago.”
4. A 78-year-old man is admitted to the intensive care unit
with decompensated heart failure. He has longstanding
ischemic cardiomyopathy. ECG shows atrial fibrillation
and left bundle branch block. Chest radiograph shows
cardiomegaly and bilateral alveolar infiltrates with Kerley
B lines. Which of the following is least likely to be present
on physical examination? *
a. Fourth heart sound
b. Irregular Heart Rate
c. Kussmaul Sign
d. Reversed splitting of the second heart sound
e. Third Heart Sound
5. A 62-year-old man is being evaluated for mitral valve
replacement surgery for severe mitral regurgitation. As
part of his evaluation, he undergoes a transesophageal
echocardiogram that demonstrates a small jet of right-
to-left Doppler flow during systole across the atrial
septum. The jet is located roughly in the middle of the
septum and occurs when a small flap of tissue swings
open <1 mm. There is no diastolic flow, nor is there a
visible opening in any part of the septum during diastole.
Which of the following explains the finding on
echocardiography? *
a. Ostium primum atrial septal defect
b. Ostium secundum atrial septal defect
c. Partial anomalous pulmonary venous return
d. Patent foramen ovale
e. Sinus venosus atrial septal defect
6. You are called to the bedside to see a patient with
Prinzmetal’s angina who is having chest pain. The patient
had a cardiac catheterization 2 days prior showing a 60%
stenosis of the right coronary artery with associated
spasm during coronary angiogram. At the patient’s
bedside, which finding is consistent with the diagnosis of
Prinzmetal’s angina? *
a. Chest pain reproduced by palpation of the chest
wall
b. Nonspecific-ST-T-wave abnormalities
c. Relief of pain with drinking cold water
d. ST-segment elevation in II, III, and aVF
e. ST-segment depression in I, AVL, and V6
7. A 29-year-old healthy woman with a past medical
history of ARF as a child is seen in the clinic because her
12-year-old daughter has recently been diagnosed with
ARF. She is concerned that ARF may be running in her
family and that her 2year-old son may thus be at
increased risk of having ARF. Which of the following
genetic factors has been associated with the
development of ARF? *
a. Human leukocyte antigen (HLA) Class II alleles
b. Polymorphisms of transforming growth factor-
β1
c. Immunoglobulin genes
d. Certain B-cell alloantigens
e. All of the above
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
8. A 31-year-old man with a prior history of rheumatism in
every joint at the age of 15 presented to the emergency
department complaining of pain in the left hip and right
knee. His physical examination revealed a systolic
murmur, loudest at the apex and radiating to the axilla.
Which of the following statements about the antibodies
that contribute to this rheumatic valvulitis is false? *
a. They target the N-acetyl-β-D-glucosamine–
dominant epitope of the GAS carbohydrate
b. They recognize sequences in α-helical proteins
(eg, myosin and tropomyosin)
c. They are neutralized by appropriate
antibiotic therapy
d. Their serum levels fall significantly after surgical
removal of inflamed valves
e. None of the above
9. Which of the following conditions will usually result in
right axis deviation in an EKG?
a. Systemic hypertension
b. Aortic valve stenosis
c. Aortic valve regurgitation
d. Excess abdominal fat
e. Pulmonary hypertension
10. Which of the following is most likely to cause the heart
to go into spastic contraction? *
a. Increased body temperature
b. Increased sympathetic activity
c. Decreased extracellular fluid potassium ions
d. Excess extracellular fluid potassium ions
e. Excess extracellular fluid calcium ions
11. A 69-year-old man with a prior history of type 2
diabetes and dyslipidemia was referred by his GP to the
cardiology clinic because of a heart murmur. He was a
very active person without any cardiovascular
symptoms. Physical examination revealed a holosystolic
murmur best heard at the apex and radiating to the
axilla. An echocardiogram was obtained demonstrating
severe prolapse with loss of coaptation, LVEF of 63%,
and LVESD of 38 mm. According to the ACC/AHA
guidelines, which of the following statements does not
justify prompt correction of MR in general? *
a. Severe MR is not a benign condition
b. Surgical correction in patients with severe MR is
unavoidable
c. Patients with severe MR may or may not develop
symptoms
d. Mitral valve prolapse is almost always a
repairable disease in reference centers
e. The risk of operative mortality in mitral valve
repair surgery is, on average, only 10%
12. What is the correct interpretation of this
electrocardiogram (ECG) tracing? *
a. Atrial fibrillation
b. Complete heart block with junctional escape
rhythm
c. Idioventricular sinus arrhythmia
d. Mobitz type 2 AV block
e. Respiratory sinus arrhythmia
13. A 68-year-old man with a history of myocardial
infarction and congestive heart failure is comfortable at
rest. However, when walking to his car, he develops
dyspnea, fatigue, and sometimes palpitations. He must
rest for several minutes before these symptoms resolve.
Which of the following is his New York Heart
Association classification? *
a. Class I
b. Class II
c. Class III
d. Class IV
14. You are treating a patient with stable angina pectoris.
She is a postmenopausal woman with refractory angina
despite therapy with metoprolol and isosorbide
dinitrate, as well as her other anti-ischemic medications.
Past medical history is significant for coronary artery
bypass grafting (CABG), chronic obstructive pulmonary
disease, first-degree atrioventricular block, left bundle
branch block, and dyslipidemia. A recent cardiac
catheterization showed coronary artery disease not
amenable to percutaneous intervention, and the patient
is not interested in redo of the CABG. Renal function is
normal. Her left ventricular ejection fraction is 15%, and
she has New York Heart Association class II heart failure
symptoms. Blood pressure and pulse allow for the
addition of a calcium channel blocker to her regimen.
Which calcium channel–blocking medication is
appropriate for this patient? *
a. Amlodipine
b. Diltiazem
c. Immediate-release nifedipine
d. Verapamil
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
15. A 45-year-old man with a history of obesity presents to
the emergency department with dyspnea, fatigue, and
a nocturnal cough that has been worsening for the past
several months. He denies any chest pain or pressure at
rest or with exertion. On evaluation, he has evidence of
cardiomegaly with a displaced PMI and elevated filling
pressures with bilateral pulmonary rales and elevated
jugular venous pulse. Echocardiography reveals a
globally depressed left ventricular ejection fraction of
25% with a dilated left ventricle. Which of the following
tests is a Level I recommendation for further workup? *
a. Cardiac MRI
b. Coronary Angiography
c. Erythrocyte Sedimentation Rate
d. Serum iron and Transferrin Saturation
e. Thyroid-Stimulating Hormone Level
16. A 75-year-old man goes to the hospital emergency
department and faints. Five minutes later he is alert. An
EKG shows 75 P waves per minute and 35 QRS waves
per minute with a normal QRS width. Which of the
following is the likely diagnosis?
a. First-degree A-V block
b. Stokes-Adams syndrome
c. Atrial paroxysmal tachycardia
d. Electrical alternans
e. Atrial premature contractions
17. The ECG most likely was obtained from which of the
following patients? *
a. A 33-year-old female with acute-onset severe
headache, disorientation, and intraventricular
blood on head CT scan
b. A 42-year-old male with sudden-onset chest
pain while playing tennis
c. A 54-year-old female with a long history of
smoking and 2 days of increasing shortness
of breath and wheezing
d. A 64-year-old female with end-stage renal
insufficiency who missed dialysis for the last 4
days
e. A 78-year-old male with syncope, delayed
carotid upstrokes, and a harsh systolic murmur
in the right second intercostal space
18. A 38-year-old Bolivian man is admitted to the cardiac
intensive care unit with decompensated heart failure.
He has no known past medical history and takes no
medications. He emigrated from Mexico 10 years ago
and currently works in a retail store. On physical
examination, he has signs of congestion and poor
perfusion. An electrocardiogram shows first-degree
atrioventricular block and right bundle branch block. An
echocardiogram shows dilated and thinned ventricles.
He has an apical aneurysm in the left ventricle with
thrombus formation. You treat his heart failure
symptomatically and begin anticoagulation. A cardiac
catheterization shows normal coronaries without
atherosclerosis. Which statement is true regarding this
patient’s prognosis? *
a. Aggressive lipid lowering (low-density
lipoprotein <70 mg/dL) has been shown to be
beneficial in this condition.
b. Calcium channel blockers will prevent
progression of his disease.
c. Cardiac transplantation offers the only cure
for this condition.
d. His cardiac function will improve over time.
e. Nifurtimox offers a reasonable chance for cure.
19. A 62-year-old male loses consciousness in the street,
and resuscitative efforts are undertaken. In the
emergency room an electrocardiogram is obtained, part
of which is shown below. Which of the following
disorders could account for this man’s presentation? *
a. Hypokalemia
b. Hyperkalemia
c. Intracerebral hemorrhage
d. Digitalis toxicity
e. Hypo calcemic tetany
20. A 50-year-old man has a blood pressure of 140/85 and
weighs 200 lb. He reports that he is not feeling well, his
EKG has no P-waves, he has a heart rate of 46, and the
QRS complexes occur regularly. What is his likely
condition?
a. First-degree heart block
b. Second-degree heart block
c. Third-degree heart block
d. Sinoatrial heart block
e. Sinus bradycardia
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease

21. All the following may cause elevation of serum troponin 25. A patient with coronary artery disease has been doing
except * regular aerobic exercise on a treadmill. if the patient
a. Congestive heart failure fails to comply in taking prescribed beta-blocker
b. Myocarditis medication and continues to exercise, what potential
c. Myocardial infarction rebound effect could result? *
d. Pneumonia a. Increase in blood pressure and decrease in
e. Pulmonary embolism heart rate during exercise
b. Decrease in blood pressure and heart rate
22. You are evaluating a new patient in your clinic who during exercise
brings in this electrocardiogram (ECG) to the visit. The c. Increase in blood pressure and heart rate
ECG was performed on the patient 2 weeks ago. What during exercise
complaint do you expect to elicit from the patient? * d. Decrease in blood pressure and increase in
heart rate during exercise

26. A 35-year-old woman is admitted to the hospital with

malaise, weight gain, increasing abdominal girth, and
edema. The symptoms began about 3 months ago and
gradually progressed. The patient reports an increase in
waist size of ~15 cm. The swelling in her legs has gotten
increasingly worse such that she now feels her thighs
are swollen as well. She has dyspnea on exertion and
a. Angina
two pillow orthopnea. She has a past history of Hodgkin
b. Hemoptysis
disease diagnosed at age 18. She was treated at that
c. Paroxysmal nocturnal dyspnea
time with chemotherapy and mediastinal irradiation. On
d. Tachypalpitations
physical examination, she has temporal wasting and
appears chronically ill. Her current weight is 96 kg, an
23. A 29-year-old woman is in the intensive care unit with
increase of 11 kg over the past 3 months. Her vital signs
rhabdomyolysis due to compartment syndrome of the
are normal. Her jugular venous pressure is ~16 cm, and
lower extremities after a car accident. Her clinical course
the neck veins do not collapse on inspiration. Heart
has been complicated by acute renal failure and severe
sounds are distant. There is a third heart sound heard
pain. She has undergone fasciotomies and is admitted
shortly after aortic valve closure. The sound is short and
to the intensive care unit. An electrocardiogram (ECG) is
abrupt and is heard best at the apex. The liver is
obtained (shown below). What is the most appropriate
enlarged and pulsatile. Ascites is present. There is
course of action at this point? *
pitting edema extending throughout the lower
extremities and onto the abdominal wall.
Echocardiogram shows pericardial thickening, dilatation
of the inferior vena cava and hepatic veins, and abrupt
cessation of ventricular filling in early diastole. Ejection
fraction is 65%. What is the best approach for treatment
of this patient? *
a. Aggressive diuresis only
b. Cardiac transplantation
a. 18-lead ECG c. Mitral valve replacement
b. Coronary catheterization d. Pericardial resection
c. Hemodialysis e. Pericardiocentesis
d. Intravenous fluids and a loop diuretic
e. Ventilation/perfusion imaging 27. Which of the following conditions will result in a dilated,
flaccid heart? *
24. All of the following are classic definitional features of a. Excess calcium ions in the blood
the tetralogy of Fallot EXCEPT: * b. Excess potassium ions in the blood
a. Obstruction to RV outflow c. Excess sodium ions in the blood
b. Overriding aorta d. Increased sympathetic stimulation
c. RV hypertrophy e. Increased norepinephrine concentration in the
d. Tricuspid atresia blood
e. Ventricular septal defect
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
28. A 78-year-old man is evaluated for the onset of dyspnea
on exertion. He has a long history of tobacco abuse,
obesity, and diabetes mellitus. His current medications
include metformin, aspirin, and occasional ibuprofen.
On physical examination, his peripheral pulses show a
delayed peak, and he has a prominent left ventricular
heave. He is in a regular rhythm with a IV/VI mid-systolic
murmur, loudest at the base of the heart and radiating
to the carotid arteries. A fourth heart sound is present.
Echocardiography confirms severe aortic stenosis
without other valvular lesions. Which of the following
most likely contributed to the development of his
cardiac lesion? *
a. Congenital bicuspid aortic valve
b. Diabetes mellitus
c. Occult rheumatic heart disease
d. Underlying connective tissue disease
e. None of the above
29. In which phase of the ventricular muscle action
potential is the potassium permeability the highest?
a. 0
b. 1
c. 2
d. 3
e. 4
30. Mr. Milsap is one of your longstanding clinic patients
who has a history of rheumatic heart disease. His last
echocardiogram noted a mean mitral valve gradient of
11 mmHg with a calculated valve area of 1.3 cm2 at a
heart rate of 60 bpm. He presents today complaining of
worsening shortness of breath, and his ECG shows atrial
fibrillation at a rate of 60 bpm. He has never had any
bleeding episodes and had normal hematologic counts
on his last check 2 weeks earlier. Which of the following
options for thromboembolic prophylaxis is
appropriate? *
a. Apixaban
b. Dabigatran
c. Rivaroxaban
d. Warfarin
e. More information is needed prior to initiating
thromboembolic prophylaxis.
31. Sympathetic stimulation of the heart
a. Releases acetylcholine at the sympathetic
endings
b. Decreases sinus nodal discharge rate
c. Decreases excitability of the heart
d. Releases norepinephrine at the sympathetic
endings
e. Decreases cardiac contractility
32. Which of the following statements regarding the
pathophysiologic consequences of an atheroma is true?
a. An atheroma resulting in total vascular
occlusion invariably causes infarction
b. An enlarging atheroma does not generally
encroach on the arterial lumen until the
plaque exceeds 40% of the internal elastic
lamina.
c. Most atheromas will eventually produce
symptoms in the patient.
d. Upon initial formation, the atheromatous
plaque usually grows inward toward the vessel
lumen.
e. Vessels affected by atherogenesis tend to
contract and get smaller in diameter.
33. Mr. George is a 52-year-old man with longstanding
hypertension and poorly controlled diabetes. He
presents complaining of several months of
breathlessness with exertion, acute episodes of
shortness of breath when recumbent, and lower
extremity edema. On examination, he has an elevated
jugular venous pulse and an S4 on auscultation.
Echocardiography shows a left ventricular ejection
fraction of 55% with a large left atrium. You suspect this
patient has the syndrome of heart failure with preserved
ejection fraction (HFpEF). Drugs targeting which of the
following have convincingly demonstrated mortality
reduction for patients with HFpEF? *
a. Angiotensin-converting enzyme
b. Angiotensin receptor
c. Phosphodiesterase-5
d. Sodium-potassium-ATPase
e. None of the above
34. All the following patients should be evaluated for
secondary causes of hypertension EXCEPT: *
a. a 37-year-old male with strong family
history of hypertension and renal failure
who presents to your office with a blood
pressure of 152/98
b. a 26-year-old female with hematuria and a
family history of early renal failure who has a
blood pressure of 160/88
c. a 63-year-old male with no past history with a
blood pressure of 162/90
d. a 58-year-old male with a history of
hypertension since age 45 whose blood
pressure has become increasingly difficult to
control on four antihypertensive agents
e. a 31-year-old female with complaints of severe
headaches, weight gain, and new-onset
diabetes mellitus with a blood pressure of
142/89
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
35. A 45-year-old accountant with no prior past medical
history has experienced occasional fevers, symmetric
arthralgias, and fatigue for the past 3 months. Two
weeks ago, she experienced the sudden onset of left-
hand weakness, which resolved within 1 hour. Multiple
blood cultures have been negative. Emergent
evaluation at her local emergency department included
a head CT that was unrevealing. Last week, she had a
transthoracic echocardiogram that showed a solitary, 2-
cm mass in the left atrium arising from the interatrial
septum in the vicinity of the fossa ovalis that appeared
pedunculated on a fibrovascular stalk. You are seeing
her back in clinic today. What is the most appropriate
next step? *
a. Cardiothoracic surgical removal of the mass
b. Catheter-based biopsy of the mass
c. Repeat blood cultures and inform the
microbiology laboratory to plate on special
media to evaluate for HACEK organisms
d. Serologies for antinuclear antibodies (ANAs),
anti-DNA, and anticardiolipin antibodies
e. Whole-body PET scan to evaluate for
malignancy
36. Which of the following conditions at the A-V node will
cause a decrease in heart rate? *
a. Increased sodium permeability
b. Decreased acetylcholine levels
c. Increased norepinephrine levels
d. Increased potassium permeability
e. Increased calcium permeability
37. You are evaluating a 50-year-old woman with idiopathic
pulmonary arterial hypertension. Her last transthoracic
echocardiogram noted severe tricuspid regurgitation in
addition to a dilated hypokinetic right ventricle and
estimated pulmonary artery systolic pressures
exceeding 70 mmHg. On your exam, she has lower
extremity edema, hepatomegaly with a pulsatile liver,
jugular venous pulse elevated to the mandible with
marked c-v waves and a prominent y descent, and an
RV heave. She reports breathlessness with moderate
exertion. What is the best treatment for her severe
tricuspid regurgitation? *
a. Diuretics and salt restriction accompanied
by medical therapy targeting her elevated
pulmonary artery pressures
b. Percutaneous balloon valvotomy
c. Percutaneous tricuspid valve repair
d. Surgical mitral valve replacement
e. Surgical tricuspid valve repair
38. A 45-year-old woman with a prior history of diet-
controlled type 2 diabetes and chronic obstructive
pulmonary disease (COPD) was referred by her GP to
the cardiology clinic because of a heart murmur. She
was very active and without any cardiovascular
symptoms. Physical examination revealed a soft late-
systolic murmur best heard at the apex and radiating to
the axilla. An echocardiogram was obtained
demonstrating mild prolapse and leaflet thickening with
normal coaptation. Left ventricular function and
dimensions are normal (ejection fraction 65%). Which of
the following is the best next step in the management
of this patient? *
a. Vasodilator therapy
b. Beta-blocker therapy
c. Elective mitral valve repair
d. Elective mitral valve replacement
e. Observe with echocardiographic annual
follow-up
39. Which of the following statements regarding the
epidemiology of congenital heart disease (CHD) in the
United States is true? *
a. CHD remains extremely rare, complicating 0.1%
of all live births.
b. Given advances in surgical techniques and
pre- and postnatal care, survival for a
neonate with CHD now approaches 90%.
c. Given the declining rates of pregnancy in
women with CHD, the incidence of CHD in
neonates is declining.
d. The population of adults with CHD is declining
given improved prenatal screening efforts.
e. Women with CHD are at no increased risk for
complications during pregnancy compared
with the normal population.
40. A 49-year-old man presents to clinic with pleuritic chest
pain, myalgia, and fever. Which of the following findings
is not a diagnostic criterion for acute pericarditis? *
a. New widespread ST elevation or PR depression
on ECG
b. Sharp chest pain that is worse on inspiration
c. Fever > 38°C
d. Pericardial friction rub
e. New or worsening pericardial effusion
41. Which of the following malignancies carries the highest
relative risk of metastasis to the heart? *
a. Glioblastoma
b. Hepatocellular Carcinoma
c. Malignant Melanoma
d. Pancreatic Adenocarcinoma
e. Small-Cell Lung Cancer
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
42. Which of the following phases of the cardiac cycle
follows immediately after the beginning of the QRS
wave? *
a. Isovolumic relaxation
b. Ventricular ejection
c. Atrial systole
d. Diastasis
e. Isovolumic contraction
43. A 55-year-old woman with no prior cardiac history was
referred by her GP to the cardiology clinic because of a
heart murmur. She admitted to living a sedentary
lifestyle, and she denied overt cardiovascular
symptoms. Physical examination revealed a mid-to-late
systolic murmur best heard at the apex and radiating to
the axilla. An echocardiogram was obtained, clearly
demonstrating moderate to severe mitral valve
prolapse and regurgitation without flail segments. Left
ventricular function and dimensions were normal
(ejection fraction 62%). Which of the following is the
best next step in the management of this patient? *
a. Exercise Doppler echocardiography
b. Cardiac CT
c. Cardiac magnetic resonance
d. Nuclear perfusion scan
e. Cardiac catheterization
44. Which of the following statements about cardiac muscle
is most accurate? *
a. The T-tubules of cardiac muscle can store much
less calcium than T-tubules in skeletal muscle
b. The strength and contraction of cardiac
muscle depends on the amount of calcium
surrounding cardiac myocytes
c. In cardiac muscle the initiation of the action
potential causes an immediate opening of slow
calcium channels
d. Cardiac muscle repolarization is caused by
opening of sodium channels
e. Mucopolysaccharides inside the T-tubules bind
chloride ions
45. A 47-year-old woman with a body mass index (BMI) of
37 kg/m2 was recently diagnosed with type 2 diabetes
mellitus. As part of her patient education, you inform
her that which of the following is the most common
cause of death in adults with type 2 diabetes mellitus? *
a. Coronary Artery Disease
b. Infection
c. Neuropathy
d. Renal Failure
e. Stroke
46. A 78-year-old man is evaluated for the onset of dyspnea
on exertion. He has a long history of tobacco abuse,
obesity, and diabetes mellitus. His current medications
include metformin, aspirin, and occasional ibuprofen.
On physical examination, his peripheral pulses show a
delayed peak, and he has a prominent left ventricular
heave. He is in a regular rhythm with a IV/VI mid-systolic
murmur, loudest at the base of the heart and radiating
to the carotid arteries. A fourth heart sound is present.
Echocardiography confirms severe aortic stenosis
without other valvular lesions. Which of the following
most likely contributed to the development of his
cardiac lesion? *
a. Congenital bicuspid aortic valve
b. Diabetes mellitus
c. Occult rheumatic heart disease
d. Underlying connective tissue disease
e. None of the above
47. You are seeing a 21-year-old woman for the first time
today in the primary care clinic. She has never seen a
physician before because her parents did not believe in
Western medicine. On history, she states that she feels
tired occasionally and feels like she could not quite keep
up with her peers in college physical education classes.
On examination, you note a systolic murmur in the left
second interspace preceded by a presystolic click.
Transthoracic echocardiogram confirms the presence of
pulmonic stenosis with a peak gradient of 60 mmHg
and doming of the pulmonic valve without any
pulmonic regurgitation. What is her best treatment
option? *
a. Diuretics and salt restriction
b. No therapy needed
c. Percutaneous balloon valvotomy
d. Percutaneous pulmonic valve replacement
e. Surgical pulmonic valve replacement
48. Which of the following statements regarding blood
pressure measurements is true? *
a. Systolic pressure increases and diastolic
pressure decreases when measured in more
distal arteries.
b. Systolic leg blood pressures are usually as much
as 20 mmHg lower than arm blood pressures.
c. The concept of “white coat hypertension”
(blood pressures measured in office or hospital
settings significantly higher than in nonclinical
settings) has been shown to be a myth.
d. The difference in blood pressure measured in
both arms should be less than 20mmHg.
e. Using a blood pressure cuff that is too small will
result in a marked underestimation of the true
blood pressure.
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
49. You are caring for a 42-year-old woman with a prior
history of rheumatic fever and resultant mitral stenosis.
Her valvular disease is currently moderate. You know
that mitral stenosis causes an elevation in left atrial
pressure, which over time can cause cardiogenic
pulmonary edema and pulmonary hypertension. All of
the following will result in an elevation of left atrial
pressure and potential worsening of lung function
EXCEPT: *
a. Anemia
b. Isoproterenol
c. Metoprolol
d. Pregnancy
e. Running on a treadmill
50. A 75-year-old man presents to your emergency
department appearing quite ill. His family says he has
not had his normal energy for the last 6 months, and
they noted he was confused and lethargic for the last
day or two. As you take a history from the family, you
palpate the patient’s radial pulse and notice a regular
beat-to-beat variability of pulse amplitude, although his
rhythm is regular. Indeed, as you later take his blood
pressure, you note that only every other phase I
(systolic) Korotkoff sound is audible as the cuff pressure
is slowly lowered and that this is independent of the
respiratory cycle. Based on this, you suspect this patient
has which of the following?
a. Atrial fibrillation
b. Cardiac tamponade
c. Constrictive pericarditis
d. Pulmonary embolism
e. Severe left ventricular dysfunction
51. You are evaluating a 65-year-old man who has a 15-
year history of nonischemic cardiomyopathy with a
dilated left ventricle and an ejection fraction of 15%.
Yearly echocardiograms over the past 5 years have
shown severe mitral regurgitation. On optimal medical
therapy, the patient has NYHA class II symptoms. Today,
he specifically asks whether his valve should be fixed in
order to improve his survival. You should tell him: *
a. “If you were to have high pulmonary artery
pressures or develop new atrial fibrillation, we
would move forward with valve repair.”
b. “In patients like you, valve repair has never
been shown to improve survival”
c. “We should consider valve surgery only if repair
is possible. Replacement would not improve
your survival.”
d. “While surgical methods have not shown
survival benefit, percutaneous mitral valve
repair has been shown to reduce mortality in
patients like you.”
e. “Yes, your valve should have been fixed years
ago.”
52. A 34-year-old man with rheumatic mitral stenosis is
referred to you for evaluation. He enjoys playing
recreational soccer and has no limitations or symptoms.
His heart rate is 65 bpm at rest. Transthoracic
echocardiogram reveals a normal LV size and function,
a moderately dilated left atrium, a mitral valve area of
1.7 cm2, and relatively thin noncalcified leaflets. ECG
shows left atrial enlargement and sinus rhythm. On
exercise stress testing, his calculated pulmonary artery
systolic pressure at peak exercise is 40 mmHg. Which of
the following treatment plans do you recommend? *
a. Metoprolol 25 mg orally twice daily
b. Percutaneous mitral balloon valvotomy
c. Periodic cardiology assessments and
echocardiographic monitoring
d. Sildenafil 20 mg twice daily
e. Surgical mitral valve replacement
53. Your 57-year-old clinic patient is seeing you in follow-
up for chronic stable angina. He is a former heavy
tobacco smoker who maintained an unhealthy diet and
exercise routine until recently. Since initiating a healthy
diet and commencing an exercise regimen, he has lost
weight and improved his blood pressure control. A
cardiac catheterization 1 month ago showed two
nonobstructive coronary lesions in the left circumflex
artery. He still has angina, which is reproducible with
moderate exercise that is fully relieved by one
sublingual nitroglycerin. Which of the following factors
is least likely to be contributing to his angina? *
a. Epicardial coronary resistance
b. Heart rate
c. Hemoglobin concentration
d. Diffusion capacity of the lung
54. A 28-year-old man presents to the emergency
department for dyspnea on exertion. He had an
orthotopic heart transplant for non-ischemic
cardiomyopathy 5 years ago and, in general, has done
quite well except for one cytomegalovirus reactivation
within the first year. He reports that for the past 3
months, he has noticed that with decreasing amounts
of exertion he has been having limiting dyspnea. He is
adamant that he is experiencing no chest pain or
pressure during these episodes. He has been perfectly
compliant with his regimen of tacrolimus,
mycophenolate mofetil, and low-dose prednisone.
Echocardiography reveals a normal LV function with
normal LV wall thickness. His resting ECG shows normal
sinus rhythm at a rate of 80 bpm. Which of the following
is the most likely cause of his symptoms? *
a. Antibody-Mediated rejection
b. Cellular Rejection
c. Coronary Artery Disease
d. Endocarditis
e. Medication Side effect
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease

55. Acute hyperkalemia is associated with which of the 61. You are evaluating a new patient in clinic. On cardiac
following electrocardiographic changes? * auscultation, there is a high-pitched, blowing,
a. QRS widening decrescendo diastolic murmur heard best in the third
b. Prolongation of the ST segment intercostal space along the left sternal border. A second
c. A decrease in the PR interval murmur is heard at the apex, which is a low-pitched
d. Prominent U waves rumbling mid-diastolic murmur. Sustained hand-grip
e. T-wave flattening increases the intensity of the murmurs. The murmurs
are heard best at end-expiration. There are also an S3
56. A 30-year-old man has an ejection fraction of 0.25 and and a systolic ejection murmur. The left ventricular
an end systolic volume of 150 ml. What is his end impulse is displaced to the left and inferiorly. Radial
diastolic volume? * pulses are brisk with a prominent systolic component.
a. 50 mL Blood pressure is 170/70 mmHg, heart rate is 98
b. 100 mL beats/min, respiratory rate 18 breaths/min. An
c. 150 mL electrocardiogram (ECG) is obtained in clinic. Which of
d. 200 mL the following findings do you expect on the ECG tracing
e. 250 mL for this patient? *
a. Diffuse ST-segment elevation and PR-segment
57. A 37-year-old male with Wolff-Parkinson-White depression
syndrome develops a broad-complex irregular b. Inferior Q-waves
tachycardia at a rate of 200 beats per minute. He c. Left-ventricular hypertrophy
appears comfortable and has little hemodynamic d. Low voltage
impairment. Useful treatment at this point might e. Right-atrial enlargement
include *
a. Digoxin 62. Which of the following is most characteristic of atrial
b. Amiodarone fibrillation?
c. Propranolol a. Occurs less frequently in patients with atrial
d. Verapamil enlargement
e. Direct-current cardioversion b. Ventricular heart rate is about 40 beats per min
c. Efficiency of ventricular pumping is
58. Which of the following events occurs at the end of the decreased 20 to 30 percent
period of ventricular ejection? * d. Ventricular beat is regular
a. A-V valves close e. Atrial P wave is easily seen
b. Aortic valve opens
c. Aortic valve remains open 63. A 54-year-old male is brought to the emergency
d. A-V valves open department with 1 hour of substernal crushing chest
e. Pulmonary valve closes pain, nausea, and vomiting. He developed the pain
while playing squash. The pain was improved with the
59. In the tracing below, what type of conduction administration of sublingual nitroglycerine in the field.
abnormality is present and where in the conduction His ECG is shown below. Emergent cardiac
pathway is the block usually found? * catheterization is most likely to show acute thrombus in
which of the following vessels? *

a. First-degree AV block; intranodal

b. Second-degree AV block type 1; intranodal
c. Second-degree AV block type 2; infranodal
d. Second-degree AV block type 2; intranodal

60. All of the following are associated with a high risk of a. Left anterior descending coronary artery
stroke in patients with atrial fibrillation except * b. Left circumflex coronary artery
a. Diabetes mellitus c. Left main coronary artery
b. Hypercholesterolemia d. Obtuse marginal coronary artery
c. Congestive heart failure e. Right main coronary artery
d. Hypertension
e. Age over 65
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
64. A 59-year-old woman with a prior history of depression
and childhood asthma was referred by her GP to the
cardiology clinic because of a new onset atrial
fibrillation. During the visit, the patient denied any
cardiovascular symptoms. Physical examination
revealed a holosystolic murmur best heard at the apex
and radiating to the axilla. The ECG showed atrial
fibrillation with a controlled ventricular response. An
echocardiogram was obtained demonstrating severe
mitral valve prolapse with loss of coaptation, LVEF of
66%, and LVESD of 36 mm. Which of the following is the
best next step in the management of this patient? *
a. Vasodilator therapy
b. Exercise Doppler echocardiography
c. Elective mitral valve repair
d. Elective mitral valve replacement
e. Observe with echocardiographic annual follow-
up
65. During auscultation of the heart, the therapist hears S1
and S2 heart sounds. During early diastole the therapist
also hears a low frequency sound of turbulence. What
suspected abnormal heart sound should the therapist
record? *
a. S4 sound
b. S3 sound
c. Heart Murmur
d. Pericardial friction rub
66. Which of the following is most likely at the “J point” in
an EKG of a patient with a damaged cardiac muscle?
a. Entire heart is depolarized
b. All the heart is depolarized except for the
damaged cardiac muscle
c. About half the heart is depolarized
d. All of the heart is repolarized
e. All of the heart is repolarized except for the
damaged cardiac muscle
67. A 67-year-old man with a prior medical history of
hypertension and atrial fibrillation was referred for
cardiac consultation following a 2-year history of chest
discomfort on minimal exertion. His physical
examination revealed a late peaking 3/6 ejection
systolic murmur with a soft and single S2. An echo was
obtained showing left ventricular hypertrophy with an
EF of 62%, moderate right ventricular dysfunction,
moderate mitral regurgitation, a calcified aortic valve
with a mean gradient of 29 mm Hg, and AVA of 0.7 cm2.
Which of the following parameters may not be a
contributor to paradoxical low-flow, low gradient severe
aortic stenosis? *
a. Hypertensive heart disease
b. Atrial fibrillation
c. Right ventricular dysfunction
d. Occult aortic regurgitation
e. Mitral regurgitation
68. A 30-year-old male is transported to the emergency
room after a motor vehicle accident. He is complaining
of moderate chest pain. He becomes hypotensive, and
his blood pressure pattern reveals a pulsus paradoxus.
The heart sounds appear distant. An examination of the
neck veins fails to reveal a Kussmaul’s sign. An
electrocardiogram is unremarkable, and a chest x-ray
reveals an enlarged cardiac silhouette. A right heart
catheter is placed. Which of the following values is
consistent with this patient’s diagnosis? *
a. A
b. B
c. C
d. D
e. E
69. A 60-year-old man’s EKG shows that he has an R-R
interval of 0.55 sec. Which of the following best explains
his condition? *
a. He has fever
b. He has a normal heart rate
c. He has excess parasympathetic stimulation of
the S-A node
d. He is a trained athlete at rest
e. He has hyperpolarization of the S-A node
70. 55-year-old man complains of 6 months of shortness of
breath. He has new dyspnea on exertion and three
pillow orthopnea. Lung auscultation reveals rales 2/3
bilaterally. He has 2+ pitting lower extremity edema.
Jugular venous pressure is estimated to be 14 cmH20
measured at a 45° angle. Chest radiograph reveals
pulmonary infiltrates and an enlarged cardiac
silhouette. Electrocardiography shows low-voltage in
the precordial and limb leads. An echocardiogram
shows a dilated left ventricle, ejection fraction of 20%,
mild mitral regurgitation, and a small pericardial
effusion. Which finding on cardiac examination would
be consistent with this patient's diagnosis? *
a. Absent S2
b. Narrow pulse pressure
c. Paradoxical splitting of S2 with inspiration
d. Pulsus bisferiens
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
71. New York Heart Association Classification (NYHA) *
72. A 65-year-old former factory worker with a past medical
history of rheumatoid arthritis presents to your primary
care clinic complaining of fatigue. She also states that
she has the following symptoms: constipation,
constantly feeling cold even when the thermostat is set
on 80°F, brittle hair, and some lower extremity swelling.
You expeditiously measure her thyroid-stimulating
hormone, which is greatly elevated at 79.4 mIU/L. In
regard to the present condition of her cardiovascular
system, you expect a decrease in all of the following
measurements EXCEPT: *
a. Cardiac output
b. Heart rate
c. Pulse pressure
d. QT interval
e. Systolic Blood Pressure
73. Mortality after mitral valve repair in patients with
degenerative disease correlates with age, with an
average risk of 1% for patients below 65 years, 2% for
those aged 65 to 80 years, and 4% for octogenarians.
Which of the following is not an independent predictor
of postoperative survival? *
a. Severe symptoms (NYHA class III or IV)
b. LV dysfunction
c. A regurgitant orifice area ≥ 40 mm2
d. A large color Doppler jet appearance
e. The presence of long-standing atrial fibrillation
74. A 65-year-old man was referred for cardiac consultation
following a 2-year history of dyspnea on minimal
exertion. He had a coronary angiography in the past
that revealed normal coronaries. His physical
examination revealed a 3/6 systolic ejection systolic
murmur across the precordium. An echo was obtained
showing left ventricular dysfunction with an EF of 38%,
a calcified aortic valve with a mean gradient of 29 mm
Hg, and AVA (aortic valve area) of 0.9 cm2. Which of the
following is the best next step in the management of
this patient? *
a. SAVR after coronary angiography
b. Left and right cardiac catheterization
c. Exercise treadmill testing
d. TAVR
e. Dobutamine stress echocardiography (DSE)
75. What is expected hemodynamic response for a patient
on a beta-adrenergic blocking agent during exercise?
a. Heart rate to be low at rest and rise
minimally wit exercise
b. Heart rate to be low at rest and rise
continuously to expected levels as exercise
intensity increases
c. Systolic BP to be low at rest and not rise with
exercise
d. Systolic BP to be within normal limits at rest and
progressively falls as exercise intensity
increases
76. You are evaluating Mr. Estevez, a 67-year-old owner of
a wildly successful chain of sushi restaurants. He
complains of shortness of breath with exertion, lower
extremity edema, and awakening at night feeling
acutely short of breath. You wish to assess his volume
status, and know that jugular venous pulse (JVP)
assessment is the single most important physical
examination measurement to aid you in this component
of your evaluation. Which of the following statements
regarding JVP measurement is true?
a. If done properly, the angle of inclination
matters little to the measurement of JVP.
b. In normal patients, the JVP rises with inspiration
due to the augmented volume loading of the
right heart
c. Measurement of the elevation of the top of the
JVP and the sternal inflection point (angle of
Louis) will provide a highly accurate
measurement of central venous pressure.
d. The external jugular is preferred over the
internal jugular vein due to its ease of visibility.
e. Venous pulsations above the clavicle in the
sitting position are abnormal.
 BASIC MEDICAL SCIENCES / PATHOPHYSIOLOGY
Week 1 – Cardiac Disease
77. An 80-year-old man had an EKG taken at his local
doctor’s office, and the diagnosis was atrial fibrillation.
Which of the following statements are likely conditions
in someone with atrial fibrillation?
a. Ventricular fibrillation normally accompanies
atrial fibrillation
b. P waves of the EKG are strong
c. Rate of ventricular contraction is irregular
and fast
d. Atrial “a” wave is normal
e. Atria have a smaller volume than normal
78. All the following ECG findings are suggestive of left
ventricular hypertrophy except *
a. (S inV1 + R in V5 or V6) > 35 mm
b. R in aVL > 11 mm
c. R in aVF > 20 mm
d. (R in I + S in III) > 25 mm
e. R in aVR > 8 mm
79. In the cardiac care unit, you are caring for a 69-year-old
man with an inferior ST-segment elevation myocardial
infarction (MI). He has undergone successful urgent
percutaneous coronary intervention and is recovering.
Later that day, he complains of shortness of breath and
orthopnea. His vital signs show blood pressure of
118/74 mmHg, heart rate of 63 beats/min, respiratory
rate of 20 breaths/min, and oxygen saturation of 91%
on room air. Lung examination shows crackles
bilaterally. On cardiac examination, the jugular venous
pressure is elevated. There is a grade III/VI musical
systolic murmur heard at the base of the heart with a
crescendo-decrescendo pattern. The intensity of the
murmur does not change with respiration. The murmur
does not radiate to the axilla. A two-dimensional
echocardiogram is requested. Which of the following
echocardiographic findings is most likely? *
a. Eccentric mitral regurgitant jet
b. High frequency fluttering of the anterior mitral
leaflet
c. Respiratory variation in velocity across the
mitral valve
d. Systolic anterior motion of the aortic (anterior)
mitral valve
e. Ventricular septal defect
80. What is the most common cause of obstruction to left
ventricular inflow? *
a. Congenital mitral valve disease
b. Cor triatriatum
c. Infective endocarditis with large mitral valve
vegetations
d. Mitral annular calcification
e. Rheumatic mitral disease
81. Which of the following is correct regarding the normal
anatomy and physiology of the pericardium? *
a. It allows great distention of the cardiac
chambers and increased cardiac filling
b. Congenital absence or surgical removal of the
pericardium is fatal
c. The human pericardium consists of two
distinct layers, the inner serosa and the
outer fibrosa
d. Most of the innervation of the pericardium
occurs via the vagus nerves
e. All of the above
82. You are working in a rural health clinic in Northern India.
You evaluate an 8-year-old boy who has never seen a
physician. His mother tells you that he is unable to keep
up with his peers in terms of physical activity. On your
initial examination of his skin, you notice clubbing and
cyanosis in his feet, but his hands appear normal.
Without any further examination, you suspect that he
has which of the following congenital abnormalities? *
a. Atrial Septal Defect
b. Dextro-Transposition of the great arteries (TGA)
c. Patent ductus arteriosus with secondary
pulmonary hypertension
d. Tetralogy of Fallot
83. A 45-year-old man is admitted to the intensive care unit
with symptoms of congestive heart failure. He is
addicted to heroin and cocaine and uses both drugs
daily via injection. His blood cultures have yielded
methicillin-sensitive Staphylococcus aureus in four of
four bottles within 12 h. His vital signs show a blood
pressure of 110/40 mmHg and a heart rate of 132
beats/min. There is a IV/VI diastolic murmur heard
along the left sternal border. A schematic
representation of the carotid pulsation is shown in the
figure below. What is the most likely cause of the
patient’s murmur? *
a. Aortic regurgitation
b. Aortic stenosis
c. Mitral stenosis
d. Mitral regurgitation
e. Tricuspid regurgitation
84. A patient with angina pectoris has been instructed to
use sublingual nitroglycerine in case of acute anginal
attack. What are the primary effects of this medication?
*
a. Vasoconstriction of the peripheral vessels
b. Vasodilation of the coronary vessels
c. Increasing myocardial oxygen consumption
d. Increasing the left ventricular end-diastolic
volume