MOC Questions

Cardiology Review® Online, February 2008, Volume 25, Issue 2

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 Alexander S. Asser, MD.

Preparing for the American Board of Internal Medicine Maintenance of Certification

Questions

  1. A 51-year-old man who yesterday underwent left anterior descending coronary artery stenting for an acute anterior wall ST-elevation myocardial infarction begins having frequent premature ventricular contractions (PVCs). All of the following are correct, except: Frequent PVCs and ventricular couplets signify an increased mortality risk in the peri-infarct time period. Suppression of frequent PVCs in the peri-infarct period with a Class I anti-arrhythmic reduces mortality. Beta blockers reduce the risk of postinfarction ventricular fibrillation. Amiodarone has been shown to reduce postinfarction arrhythmias but it has not been shown to reduce mortality.
  2. A 45-year-old woman undergoes percutaneous intervention with stenting of her left anterior descending artery in the setting of an acute anterior wall myocardial infarction. The following morning her fasting lipid panel reveals a low-density lipoprotein (LDL) cholesterol level of 96 mg/dL and a high-density lipoprotein (HDL) cholesterol level of 68 mg/dL. Regarding management of her cholesterol, which of the following is true? Aggressive dietary and lifestyle prevention is recommended, but given that her LDL is at goal (ie, less than 100 mg/dL) and her HDL is high, medical therapy is not indicated. The lowest dose of a statin should be started initially and then titrated slowly as an outpatient to achieve a goal LDL of below 80 mg/dL. In similar patients, aggressive LDL lowering below 70 mg/dL has been shown to increase risk of side effects such as rhabdomyolysis, without reducing cardiovascular events. Lipid-lowering medical therapy should be initiated within the first month of hospital discharge, but there is no proven benefit from starting at time of discharge. Aggressive lipid-lowering therapy, such as with atorvastatin 80 mg, should be initiated before hospital discharge, with a goal LDL below 70 mg/dL.
  3. A 42-year-old man is admitted for recurrence of the arrhythmia seen on the electrocardiogram below: Concerning his arrhythmia, all of the following are true, except: This is an isthmus-dependent macro-reentrant arrhythmia that travels in a counterclockwise circuit in the right atrium. If electrical cardioversion fails to maintain sinus rhythm, pulmonary vein isolation and radiofrequency ablation has a high cure rate for this arrhythmia. Although the atria continue to contract, the risk of thrombus formation and systemic embolization remains high and anticoagulation is recommended. Treatment with atrioventricular nodal blockers is the usual first step in the acute management of stable patients with this tachyarrhythmia. Atrioventricular conduction is typically in a 2:1 or 4:1 pattern giving ventricular rates of 150 and 75 beats per minute respectively.
  4. Based on the most recent American Heart Association recommendation, antibiotic prophylaxis for infective endocarditis should be given prior to dental procedures for all of the following conditions, except: Mitral valve prolapse with a mitral regurgitation murmur. Prosthetic aortic valve. Previous episode of infective endocarditis. Unrepaired cyanotic heart lesions. Repaired congenital defects within the first 6 months after repair.
  5. A 32-year-old woman presents to the emergency department (ED) after having a cardiac arrest while bicycling. When paramedics arrived on the scene the initial rhythm was polymorphic ventricular tachycardia and defibrillation was successful. Her initial 12-lead electrocardiogram upon admission to the ED is shown below: All the following are correct, except: Hypomagnesemia could be a cause of this arrhythmia. If an acquired cause for this abnormality is not found, genetic testing and/or familial screening should be undertaken. Medications are a common cause of this abnormality. Implantable cardioverter defibrillator (ICD) implantation is not recommended for the congenital form of this disease. Immediate management of this abnormality includes magnesium, cardioversion, and/or temporary atrial pacing.
  6. A 42-year-old woman with medical history significant for coarctation of the aorta repair as an infant presents to your office complaining of progressive dyspnea for the last month. Physical exam reveals a loud, late-peaking systolic murmur, heard loudest over the right upper sternal border. Which of the following cardiac pathologies associated with coarctation could be the cause of her symptoms? Ventricular septal defect. Atrial septal defect. Bicuspid aortic valve with aortic stenosis. Tricuspid regurgitation. Pulmonic stenosis.
  7. A 22-year-old man presents for evaluation of his hypertrophic cardiomyopathy (HCM) and considers whether to undergo placement of an ICD. All of the following characteristics would indicate an increased risk for sudden cardiac death and indication to place an ICD, except: Unexplained syncope. Left ventricular hypertrophy >30 mm. Nonsustained ventricular tachycardia on Holter monitoring. Resting left ventricular outflow obstruction. Family history of HCM-related sudden cardiac death in first-degree relative.
  8. A 42-year-old man presents in cardiogenic shock secondary to an anterior wall myocardial infarction. An intra-aortic balloon pump (IABP) is inserted. All the following are true concerning IABP counterpulsation, except: Proper placement is in the descending aorta distal to the left subclavian artery. Balloon deflation should be timed to occur at the dicrotic notch of the arterial pressure waveform. Severe aortic insufficiency is an absolute contraindication. Use is indicated in the management of myocardial infarctions complicated by acute mitral regurgitation. Coronary blood flow is increased and myocardial oxygen consumption is reduced.
  9. A 76-year-old man with a history of hypertension and diabetes presents complaining of 4 days of constant palpitations and dyspnea. An electrocardiogram reveals atrial fibrillation. Which of the following is true concerning management of his atrial fibrillation? Electrical cardioversion can be done without a transesophageal echocardiogram because onset of his atrial fibrillation has been less than a week. A strategy of rhythm control has been proven to reduce mortality when compared to rate control. Based on his yearly risk for stroke, aspirin should be initiated, but warfarin can be withheld because of the increased risk of bleeding. Pulmomary vein isolation is curative in approximately 95% of procedures. If anticoagulation is not initiated, his yearly risk of embolic stroke is approximately 4%.
  10. A 45-year-old woman with history of active breast cancer presents with acutely worsening dyspnea and orthopnea requiring hospitalization. The echocardiogram reveals a large pericardial effusion. All of the following findings are consistent with cardiac tamponade, except: Collapse of the right ventricle during early diastole. An increase in systolic pressure with inspiration of greater than 10 mm Hg. An exaggerated decrease in mitral inflow velocity with inspiration. An increase in tricuspid inflow velocity during inspiration.

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