MOC Questions

Cardiology Review® Online, April 2008, Volume 25, Issue 4

Exam preparation materials

Preparing for the American Board of Internal Medicine Maintenance of Certification

The following questions can assist candidates for the Maintenance of Certification Exam in Cardiovascular Disease prepare for this test. We hope you find this helpful and welcome your feedback.

These questions were prepared by Hal A. Skopicki, MD, PhD.


  1. A 46-year-old gentleman with aortic stenosis comes to your office noting dyspnea upon climbing 1 flight of stairs. He denies chest pain, palpitations or syncope. On exam, his blood pressure is 125/80 mm Hg, heart rate 88 beats per minute and respiratory rate is an unlabored 16 breaths per minute. He has no jugular venous distention (JVD). You note a delayed carotid upstroke that is decreased in volume. S1 is normal, S2 is physiologically split. No click is appreciated. An S4 is present. He has a late peaking, II/VI systolic ejection murmur. You refer him for an echocardiogram that reveals a left atrium of 5.5 cm (upper limit of normal 4.5 cm), septal and posterior wall thicknesses of 1.3 cm (both upper limits of normal 1.0 cm), a left ventricular internal diastolic dimension of 6.6 cm (upper limit of normal of 5.5 cm) with moderate aortic stenosis, and a peak gradient of 30 m/sec with an aortic valve area of 1.1 cm2. His left ventricular ejection fraction (LVEF) is 58%. Of the following choices, the next best step is: Reevaluate in 12 months with a transthoracic echocardiogram. Reevaluate in 6 months with a transthoracic echocardiogram. Cardiac catheterization. Cardiopulmonary exercise testing. Referral for urgent surgery.

  1. You are asked to lecture a group of medicine interns on the preoperative management of patients. All of the following are true, except: Obtaining a preoperative resting 12-lead electrocardiogram (ECG) is a class I indication prior to all operations. Noninvasive testing is not indicated for patients without clinical risk factors undergoing intermediate- risk noncardiac surgery. Coronary revascularization before moderate risk noncardiac surgery is useful in patients with stable angina who have significant left main or major 3-vessel coronary artery disease (especially when LVEF is < 0.50) or 2-vessel disease with significant proximal left anterior descending stenosis and an LVEF < 0.50. Coronary revascularization before noncardiac surgery is useful in patients with demonstrable ischemia on noninvasive testing, high-risk unstable angina or non—ST-segment elevation myocardial infarction (MI) or acute ST elevation MI. Beta blockers should be continued in patients who are receiving them to treat angina, symptomatic arrhythmias, or hypertension or initiated in patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing.

  1. Adequate secondary prevention in the management of cholesterol for patients with coronary vascular disease includes all the following except: Goal low-density lipoprotein cholesterol (LDL-C) < 120 mg/dL and total cholesterol to < 200 mg/dL. If triglycerides are >200 mg/dL, non—high-density lipoprotein cholesterol should be < 130 mg/dL. Initiating dietary therapy with a reduction in the intake of saturated fats. Recommending the addition of plant stanol/sterols and viscous fiber to further lower LDL-C. Encouraging increased consumption of omega-3 fatty acids in the form of fish or in capsule form is a level IIB indication. With an acute cardiovascular or coronary event, further reduction of target LDL-C to < 70 mg/dL.

  1. Prior to considering undergoing a heart transplantation for an idiopathic dilated cardiomyopathy (LVEF 25% with a maximal myocardial oxygen consumption of 11 mL/kg/min), one of your patients presents you with a list of potential medications that she will have to take to understand and include in her risk:benefit decision-making process. All of the following agents are matched with their mechanism of action and potential side effects except: Cyclosporin (calcineurin inhibition)—hypertension, renal insufficiency, gingival hyperplasia, and hirsuitism. Aziothioprine (antimetabolite)—Gastrointestinal (GI) complaints, liver failure, and bone marrow suppression. Mycophenolate (antimetabolite inhibiting inosine monophosphate dehydrogenase)—GI complaints, viral infection, and leucopenia. Sirolimus (macrolide antibiotic that inhibits cell cycle proliferation)—Pancytopenia, hyperlipidemia with hypertriglyceridemia. Steroids (immunosuppressive and anti-inflammatory agents)—Hypertension, cataracts, myopathy, hirsutism, moon facies, buffalo hump, weight gain, and diabetes mellitus.

  1. All of the following are true of dual-antiplatelet therapy with aspirin and clopidogrel except: It lowers the risk of stent thrombosis and adverse cardiac events in patients who have undergone percutaneous coronary intervention. It is more effective than aspirin alone at lowering the risk of atherothrombotic events in patients with stable cardiovascular disease or multiple risk factors. It is associated with an increased risk of bleeding in the elderly (age >75 years) with acute coronary syndromes. It may both safely and effectively reduce mortality and the occurrence of major adverse vascular events in patients presenting with acute MI. Desensitization for clopidogrel-sensitive patients appears safe and highly effective in inducing a sustained remission for patients who require prolonged therapy after drug-eluting stents.

  1. A patient with diabetes arrives at the emergency department with an acute inferior wall ST-elevation MI. Emergency cardiac catheterization 2 hours after the onset of chest pain reveals a 30% distal left main stenosis, 80% proximal left anterior descending (LAD) stenosis, 80% ostial left circumflex artery (LCx) stenosis, and a 95% mid right coronary artery (RCA) stenosis with thrombus. His LVEF is 35%. He is hemodynamically stable with a blood pressure of 110/60 mm Hg. Appropriate therapy could include all of the following except: Urgent percutaneous coronary intervention (PCI) of the RCA, LCx, and LAD lesions. PCI of the RCA followed by staged procedures for the LAD and LCx. PCI of the RCA, placement of an intra-aortic balloon pump and coronary artery bypass graft surgery. PCI of the RCA with follow-up nuclear perfusion study to consider staged procedures for the LAD and LCx.

  1. Properties of the vulnerable atherosclerotic plaque may include: Erosion of atherosclerotic plaque. Rupture of the atherosclerotic plaque. Calcium nodules within the periluminal area of the intima. Local endothelial dysfunction. Vasospasm.

  1. A local internist refers a patient and includes an echocardiogram report noting a sinus venosus atrial septal defect. You should consider all of the following except: Surgical closure if there is a pulmonary to systemic flow ratio of < 1.5 or less to prevent right ventricular dysfunction. Surgical closure in patients with irreversible pulmonary vascular disease and pulmonary hypertension to forestall the need for cardiac transplantation. Cardiac magnetic resonance imaging to look for partial anomalous drainage of the pulmonary veins. Be reassured if the left-to-right shunting noted on prior echocardiograms begins to decrease. Be reassured of the diagnosis if inverted P waves, signifying a junctional or low atrial rhythm, are present in the inferior leads.

  1. Which of the following statements about endomyocardial biopsy is true? In a 44-year-old man with cardiogenic shock, unexplained, new-onset heart failure of less than 2 weeks duration associated with a normal-sized left ventricle is a class II, level of evidence B, indication for endomyocardial biopsy. In a 52-year-old woman, with new-onset heart failure of approximately 1 month duration, third degree heart block with a dilated left ventricle is a class I, level of evidence B indication for endomyocardial biopsy. Unexplained atrial fibrillation is a class I, level of evidence B indication for endomyocardial biopsy. Hypertrophic cardiomyopathy, believed to be due to a spontaneous mutation is a class I, level of evidence B indication for endomyocardial biopsy. Suspected arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy is a class I, level of evidence B indication for endomyocardial biopsy

  1. In patients with heart failure and systolic left ventricular dysfunction, an absolute contraindication (class III) for all angiotensin-converting enzyme (ACE)-inhibitor therapy includes: An episode of angioedema in a patient on an ACE inhibitor for 4 months. A history of hypotensive shock. A serum creatinine of 2.1 mg/dL or greater. Bilateral renal artery stenosis. Cough exacerbated by recumbency.


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