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  1. QUESTIONS CARDIAC PROCEDURES & VALVULAR HEART DISEASES Ronald D’Agostino D.O., F.A.C.C., F.A.C.P. Director of Non-Invasive Cardiology Long Island Cardiovascular Manhasset, NY

  2. Question 1 • Pharmacologic or nonpharmacologic intervention, in individuals post-MI who are identified as high risk for death based on noninvasive risk stratification, has been determined to improve mortality in a subgroup of:  A. Patients with > 10 PVCs/hr or nonsustained VT on Holter monitor treated with amiodarone.  B. Patients with poor heart rate variability treated with beta blockers.  C. Patients with T-wave alternans treated with CABG.  D. Patients with impaired LV function, spontaneous nonsustained VT on Holter, and inducible VT at EP study treated with an ICD.  E. Patients with a positive SAECG and impaired LV function treated with CABG.

  3. Question 1 • Pharmacologic or nonpharmacologic intervention, in individuals post-MI who are identified as high risk for death based on noninvasive risk stratification, has been determined to improve mortality in a subgroup of:  A. Patients with > 10 PVCs/hr or nonsustained VT on Holter monitor treated with amiodarone.  B. Patients with poor heart rate variability treated with beta blockers.  C. Patients with T-wave alternans treated with CABG.  D. Patients with impaired LV function, spontaneous nonsustained VT on Holter, and inducible VT at EP study treated with an ICD.  E. Patients with a positive SAECG and impaired LV function treated with CABG.

  4. Question 2 • In which patient population would invasive electrophysiologic testing be most likely to have diagnostic utility?  A. Individuals with recurrent syncope or sinus bradycardia but no diagnostic arrhythmias on Holter monitor with normal echocardiograms.  B. Patients with recurrent syncope, isolated RBBB, left anterior bundle branch block, and no other evidence of structural heart disease on echocardiogram and physical examination.  C. Post-MI patients with LVEF < 40% and recurrent syncope.  D. Patients with long QT syndrome and recurrent syncope.  E. Patients with dilated nonischemic cardiomyopathy.

  5. Question 2 • In which patient population would invasive electrophysiologic testing be most likely to have diagnostic utility?  A. Individuals with recurrent syncope or sinus bradycardia but no diagnostic arrhythmias on Holter monitor with normal echocardiograms.  B. Patients with recurrent syncope, isolated RBBB, left anterior bundle branch block, and no other evidence of structural heart disease on echocardiogram and physical examination. C. Post-MI patients with LVEF < 40% and recurrent syncope.  D. Patients with long QT syndrome and recurrent syncope.  E. Patients with dilated nonischemic cardiomyopathy.

  6. Question 3 • In a patient presenting with a wide complex tachycardia, which statement is true?  A. With a history of prior MI, ventricular tachycardia is the most likely arrhythmia.  B. The presence of 1:1 P to QRS association is diagnostic of supraventricular tachycardia with aberrancy or fixed bundle branch block.  C. A "pre-excited" tachycardia can be excluded based on morphologic characteristics of the surface ECG.  D. A QRS width less than 140msec favors the diagnosis of ventricular tachycardia.  E. AV dissociation is seen in approximately 2/3 of ECGs with ventricular tachycardia.

  7. Question 3 • In a patient presenting with a wide complex tachycardia, which statement is true? A. With a history of prior MI, ventricular tachycardia is the most likely arrhythmia.  B. The presence of 1:1 P to QRS association is diagnostic of supraventricular tachycardia with aberrancy or fixed bundle branch block.  C. A "pre-excited" tachycardia can be excluded based on morphologic characteristics of the surface ECG.  D. A QRS width less than 140msec favors the diagnosis of ventricular tachycardia.  E. AV dissociation is seen in approximately 2/3 of ECGs with ventricular tachycardia.

  8. Question 4 • All but one of the following statements about PTCA versus CABG is true. Which one is false? A. CABG appears superior to PTCA in treated diabetics with coronary artery disease. B. Up to 20% of patients randomized to an initial strategy of PTCA required subsequent revascularization procedures. C. CABG and PTCA yield similar rates of mortality and nonfatal myocardial infarction in patients with multivessel disease who are candidates for either procedure. D. CABG results in a greater relief of angina compared with PTCA over the first year after revascularization. E. Long-term costs of PTCA and CABG are similar.

  9. Question 4 • All but one of the following statements about PTCA versus CABG is true. Which one is false? A. CABG appears superior to PTCA in treated diabetics with coronary artery disease. B. Up to 20% of patients randomized to an initial strategy of PTCA required subsequent revascularization procedures. C. CABG and PTCA yield similar rates of mortality and nonfatal myocardial infarction in patients with multivessel disease who are candidates for either procedure. D. CABG results in a greater relief of angina compared with PTCA over the first year after revascularization. E. Long-term costs of PTCA and CABG are similar.

  10. Question 5 • You are asked for "medical clearance" for a 72-year-old man to undergo transurethral resection of the prostate for benign prostatic hypertrophy, manifested by bothersome and recurrent symptoms of urinary hesitancy and urgency. The patient has required urethral catheterization on two occasions for urinary tract obstruction.

  11. Question 5 • Two years earlier, the patient underwent coronary surgical revascularization, with grafts placed to the left anterior descending and right coronary arteries. The revascularization was "complete" in that there were no additional vessels involved. Left ventricular function was normal preoperatively. The patient has not undergone any cardiac testing since the operation.

  12. Question 5 • On a few occasions, the patient has experienced angina with vigorous activity, for instance when walking up a steep hill or playing golf; on each occasion, the chest discomfort resolved with rest and did not recur as the patient continued his activity. The patient is retired. He does not engage in a structured exercise program. He does golf, work in the garden and around the house, and mows his small lawn with a self-propelled, push mower.

  13. Question 5 • At physical examination, the blood pressure is 130/80. The cardiovascular examination is normal. The ECG shows normal sinus rhythm with a normal QRS and nonspecific ST-T abnormalities.

  14. Question 5 • With this information, you would recommend: A. Coronary cineangiography. B. Exercise stress test. C. Proceed with urologic surgery. D. Nuclear stress test. E. Holter monitor.

  15. Question 5 • With this information, you would recommend: A. Coronary cineangiography. B. Exercise stress test. C. Proceed with urologic surgery.D. Nuclear stress test. E. Holter monitor.

  16. Question 6 • You are called to the emergency room to evaluate a previously healthy 42-year-old Asian man who presented with progressive dyspnea on exertion for the past 6 months and the inability to sleep flat comfortably for the past two nights. When asked, he reports that he also has gained 15lbs and noted new ankle edema over the past 2 weeks. He denies any history of chest pain or known heart disease. He works as a computer programmer, is fairly sedentary, and takes no regular medications. He quit his half-pack-per-day smoking habit about a year ago. He consumes two glasses of wine per night.

  17. Question 6 • His mother had a heart attack in her late 60s but is alive and active now in her 70s, and he has no other relevant family history.On exam he appears moderately overweight and in mild respiratory distress, lying at 30 degrees on the gurney, but is able to speak in complete sentences. His blood pressure is 130/90, pulse 88/min and regular. He has jugular venous distension to the mandible at 30 degrees and rales over the bases of both lungfields. Cardiac exam reveals a laterally displaced PMI, a 2/6 holosystolic murmur at the left sternal border and apex, and a loud S3 gallop. The liver is mildly enlarged and pulsatile and there is pretibial edema.

  18. Question 6 • His electrocardiogram shows sinus rhythm with mild repolarization abnormalities, but a normal axis and intervals and no pathologic Q waves. Chest radiograph shows moderate cardiomegaly and venous redistribution of the pulmonary flow. A bedside echocardiogram reveals moderate global hypokinesis of the left ventricle and 2+ mitral regurgitation.He begins breathing much more comfortably a half hour after a dose of intravenous furosemide. He is admitted to the CCU for monitoring and it is Monday morning; his initial CPK and troponin levels are normal.

  19. Question 6 • What diagnostic test would be most important to recommend be done next? A. A stress echocardiogram using dobutamine. B. A rest thallium scan. C. Coronary arteriography. D. Endomyocardial biopsy. E. Serial cardiac enzymes.

  20. Question 6 • What diagnostic test would be most important to recommend be done next? A. A stress echocardiogram using dobutamine. B. A rest thallium scan. C. Coronary arteriography. D. Endomyocardial biopsy. E. Serial cardiac enzymes.

  21. Question 7 •  Late potentials have been shown to give prognostic information concerning survival in patients with which of the following? A. Sustained ventricular tachycardia. B. Nonsustained ventricular tachycardia. C. Recent myocardial infarction. D. Syncope of unexplained etiology. E. Long QT syndrome. E. long QT syndrome.

  22. Question 7 •  Late potentials have been shown to give prognostic information concerning survival in patients with which of the following? A. Sustained ventricular tachycardia. B. Nonsustained ventricular tachycardia.C. Recent myocardial infarction. D. Syncope of unexplained etiology. E. Long QT syndrome. E. long QT syndrome.

  23. Question 8 • A 24-year-old Indian man is seen after a syncopal episode that occurred while he was watching a football game on TV. His wife noticed that after a particularly exciting play, the patient suddenly slumped over. She shook him hard, and, after about 30 seconds, he woke up and said that he remembered nothing of the incident. This has never happened before. Up until this time, he has had no limitation of physical activity. His past medical history is significant in that he had repair of tetralogy of Fallot at age 4, at which time a VSD was patched and a right ventricular infundibulectomy was done.

  24. Question 8 • Physical examination finds no cyanosis. Blood pressure is 100/70 mmHg, and pulse is 65 per minute with an occasional premature contraction. The lungs are clear to auscultation and percussion. Neck veins are 4cm. There is a mid sternal incision that is well healed. There is a slight precordial systolic lift. S2 is single. There is a Grade II/VI systolic ejection murmur with a short Grade II/VI diastolic low-pitched murmur along the left sternal border. There is no S3 or S4.

  25. Question 8 • The ECG shows right bundle branch block with left anterior hemiblock. The PR interval is 0.12 seconds. The echocardiogram reveals a slightly dilated right ventricle and paradoxical motion of the interventricular septum. Doppler gradient across the right ventricular outflow tract is 35 mmHg. There is evidence of moderately severe pulmonic regurgitation, and there are no left-to-right or right-to-left shunts.

  26. Question 8 • What is the most important diagnostic test needed for this patient? A. TEE. B. Electrophysiology study. C. Cardiac catheterization and angiography. D. Tilt table test. E. 24-hour ambulatory ECG.

  27. Question 8 • What is the most important diagnostic test needed for this patient? A. TEE.B. Electrophysiology study. C. Cardiac catheterization and angiography. D. Tilt table test. E. 24-hour ambulatory ECG.

  28. Question 9 • The Allen test is useful to confirm which of the following? A. Occlusion of the ulnar artery. B. Occlusion of the radial artery. C. Occlusion of the superficial palmar arch. D. All of the above. E. None of the above.

  29. Question 9 • The Allen test is useful to confirm which of the following? A. Occlusion of the ulnar artery. B. Occlusion of the radial artery. C. Occlusion of the superficial palmar arch.D. All of the above. E. None of the above.

  30. Question 10 • An index population of 1,000 patients selected for the evaluation of a new test is divided, after disease verification, into subpopulations defined in terms of numbers of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) as follows:

  31. Question 10 • All of the following statements are true except: A. Test sensitivity is 0.75, specificity is 0.80. B. CAD prevalence is 80%, the prevalence of no disease is 20%. C. The (+) PV for the test is 75%, the (-) PV is 55%. D. All of the above are true.

  32. Question 10 • All of the following statements are true except: A. Test sensitivity is 0.75, specificity is 0.80. B. CAD prevalence is 80%, the prevalence of no disease is 20%. C. The (+) PV for the test is 75%, the (-) PV is 55%. D. All of the above are true.

  33. Question 11 • A 63-year-old woman has a history of an old inferior myocardial infarction with an LV ejection fraction of 50%. She was doing well on digoxin .125 mg/day (serum digoxin level 0.8mg) and 10mg Lasix. While watching an exciting TV adventure show, she became extremely dyspneic and was brought to the hospital. A sublingual nitroglycerin made her much more comfortable.

  34. Question 11 • On physical examination, she was slightly dyspneic, BP 140/70, pulse 85. Lung exam showed rales halfway up the chest. JVP was 6cm. Carotid pulse was normal. The apex beat was within the MCL and appeared normal. S4, S1, S2 were present with A2 > P2. A grade 1/6 systolic ejection murmur was heard along the left sternal border.

  35. Question 11 • Of the following diagnostic choices, which one would be the most helpful at this point? A. Electrophysiologic study with programmed stimulation. B. Cardiac cath with coronary angiography. C. Ventilation/perfusion lung scan. D. Transesophageal echo. E. Holter monitor.

  36. Question 11 • Of the following diagnostic choices, which one would be the most helpful at this point? A. Electrophysiologic study with programmed stimulation.B. Cardiac cath with coronary angiography. C. Ventilation/perfusion lung scan. D. Transesophageal echo. E. Holter monitor.

  37. Question 12 • A 39-year-old woman with a family history of CAD (father had MI at age 61) presents complaining of palpitations and shortness of breath with intermittent chest tightness. She notes this when emotionally stressed but with no particular association to exertional activity. Her primary care physician performed a standard ETT. She went 11 minutes (12 METS) and complained of sharp left-sided chest pain during peak exercise. There were no ECG changes.

  38. Question 12 • She thought that her chest pain was similar but not exactly the same as that which prompted her to seek medical attention. Her primary care physician feels she should have further evaluation. She is thus referred to you. You find no abnormalities on physical exam.

  39. Question 12 • Which of the following should be performed? A. No further workup is needed. B. Proceed with ETT-Thallium. C. Proceed with coronary angiography. D. Proceed with stress echo. E. Recommend Ultrafast CT.

  40. Question 12 • Which of the following should be performed? A. No further workup is needed.B. Proceed with ETT-Thallium. C. Proceed with coronary angiography. D. Proceed with stress echo. E. Recommend Ultrafast CT.

  41. Question 13 • You are consulted to assess the perioperative risk for a 69-year-old man who is scheduled to undergo abdominal aortic aneurysmectomy for an asymptomatic aneurysm, the diameter of which measures 5.6cm by ultrasound.

  42. Question 13 • The patient sustained myocardial infarction 6 months earlier. He has not undergone cardiac testing since the event. He is unable to return to work as an accountant since the infarction because he experiences angina whenever attempting to climb the one flight of stairs to his office. He can walk about his house without difficulty and can walk short distances with his wife on shopping trips. Angina prevents him from golfing, working in his lawn, or walking around his city block.

  43. Question 13 • The patient continues to smoke 1.5 packs of cigarettes a day. He has been diagnosed with chronic obstructive pulmonary disease, and he experiences dyspnea with any moderate activity, such as walking short distances. His medications include theophylline, an inhaler, isosorbide, and diltiazem

  44. Question 13 • Physical examination demonstrates a blood pressure of 118/58. The AP diameter of the chest is increased, and breath sounds diminished, with a prolonged expiratory phase and quiet wheeze. The heart is not palpable, and the heart sounds are quiet; no murmur is heard. The peripheral pulses are normal, and the abdominal aneurysm is neither palpable nor tender. The ECG shows left bundle branch block.

  45. Question 13 • With this information, what would you recommend? A. Coronary cineangiography. B. Surgery. C. Dobutamine stress echo. D. Persantine thallium scintigraphy.

  46. Question 13 • With this information, what would you recommend? A. Coronary cineangiography. B. Surgery. C. Dobutamine stress echo. D. Persantine thallium scintigraphy.

  47. Question 14 • The incidence of major complication of diagnostic cardiac catheterization is: A. Less than 0.05%. B. Between 0.11-0.15%. C. Between 1-2%. D. Between 3-5%. E. Greater than 5%.

  48. Question 14 • The incidence of major complication of diagnostic cardiac catheterization is: A. Less than 0.05%. B. Between 0.11-0.15%. C. Between 1-2%. D. Between 3-5%. E. Greater than 5%.

  49. Question 15 • Which one of the following laboratory tests is the best to determine the severity of aortic stenosis? A. Echocardiographic demonstration of aortic valve calcification. B. ECG evidence of left ventricular hypertrophy. C. Doppler echo calculations using continuity equation. D. Cardiomegaly on chest x-ray. E. Measurement of the pressure gradient at cardiac catheterization.

  50. Question 15 • Which one of the following laboratory tests is the best to determine the severity of aortic stenosis? A. Echocardiographic demonstration of aortic valve calcification. B. ECG evidence of left ventricular hypertrophy.C. Doppler echo calculations using continuity equation. D. Cardiomegaly on chest x-ray. E. Measurement of the pressure gradient at cardiac catheterization.