Self-Assessment Test

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ITEM 37

(C) Smoking cessation counseling and varenicline On physical examination, blood pressure is 108/72 mm
(D) Weight loss Hg, pulse rate is 54/min, and respiration rate is 20i min. The
remainder of the physical examination is normal.
An ECG shows sinus rhythm. A chest radiograph is
Item 40 normal.
A 56 year-old woman is evaluated before starting treatment
with trastuzumab fbrearly stage HER2 positive breast cancer. Which of the following is the most appropriate
She has no cardiovascular symptoms and has no exercise management?
related limitations. She has hypertension and hyperlipidemia.
Medications are losartan and atorvastatin.
(A) Addition of clopidogrel
On physical examination, vital signs and other flndings (B) Addition of isosorbide mononitrate
are normal. The breast surgery site has healed. (C) Coronaryangiography
Results of routine laboratory studies are normal. (D) Exercise echocardiography
Findings on echocardiogram are normal. Left ventri
cular ejection fraction is 55',1,.
Item 42
Which of the following is the most appropriate cardiac
A 70 year old man is referred fbr evaluation after a 6.1 cm
surveillance for this patient?
abdominal aortic aneurysm was discoverecl on routine
(A) Cardiac magnetic resonance imaging screening ultrasonography. Medical history is significant fbr
(B) Echocardiography hypertension and hyperlipidemia. lle has a 50'pack-year
(C) Multigated acquisition (MUGA) scan history of cigarette smoking, stopping 6 years ago. Medic:r
tions are rosuvastatin and chlorthalidone.
(D) No surveillance On physical examination, vital signs are normal. BMI
is 28. A bruit is heard over the abdomen, and a pulsatile
Item 41 abdominal mass is present to the left of the midline.
A 69 year-old man is evaluated for persistent angina
despite maximally tolerated antianginal therapy. Symp Which of the following is the most appropriate next step in
management?
toms appear alter walking less than one half mile and
interfere with his quality of life and occupation as a mail (A) Abdominalaortography
carrier. He has no pain at rest or heart lailure symptoms. (B) ACE inhibitor therapy
He f requently experiences light headedness when arising
(C) CT angiography
from a seated position. He has a 20 pack year history of
smoking but stopped 25 years ago. Medications are aspirin,
(D) Open abdominal aortic aneurysm repair
metoprolol, sublingual nitroglycerin, and rosuvastatin. (E) Repeat duplex ultrasonography in 6 months

135
 Self-Assessment Test

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Item 43 Which of the following is the most appropriate tre"atment?
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A S5-year old woman is evaluated for a 6-month history (A) Add ivabradine
(D of progressive fatigue and dyspnea while walking on level
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(B) Decreasevalsartan-sacubitril
ground.
(C) Increasecarvedilol
o On physical examination, blood pressure is normal and
(D) Increase furosemide
pulse rate is BO/min. Cardiac examination reveals an open
.D
ing snap and a diastolic rumble heard best at the cardiac
ur apex. Estimated central venous pressure is normal.
A resting echocardiogram shows a left ventricular
ejection fraction greater than 55% and a normal size right
Item 46
A 75 year old man is evaluated in the emergency depart
tr
ventricle with preserved function. The mitral valve is thick ment for a 2 day history of left leg pain. The pain started
ened and appears rheumatic, with restricted opening of the abruptly and has been constant. He has diabetes mellitus.
leaflet tips. The mitral gradient and calculated valve area are hypertension, peripheral artery disease, and hyperlipid
consistent with moderate mitral stenosis. emia. Medications are metfbrmin. chlorthalidone. atonla
statin. cilostazol. and lor,v dose aspirin.
Which of the following is the most appropriate On physical examination, pulse rate is 108'min and
management? irrcgular: other vital signs are normal. Cardiac eramina
tion reveals an irregularly irregular rhythm. The left lon'er
(A) Exerciseechocardiography extremity is cold and mottled. The lelt popliteal and ankle
(B) Cardiaccatheterization pulses are absent. Passive range ol motion is normal in the
(C) Cardiac magnetic resonance imaging left leg. but the patient has significant pain and is unable to
(D) Percutaneousballoon mitralcommissurotomy actively flex the left knee lully. Left leg sensation is intact.
The remainder of the physical examination is unremark
(E) Transesophagealechocardiography
able.
ECG shows atrial flbrillation.

tr Item 44
A74 year old man is evaluated in the emergency depart
Which of the following is the most appropriate next step in
management?
ment fbr somnolence. He resides in a skilled nursing lacility.
His transfer note indicates that he has moderately severe (A) Angiography
Alzheimer disease treated with donepezil. (ts) Apixaban
On physical examination, bktod pressure is 70i 40 mm (C) Intravenoustenecteplase
tlg and pulse rate is 30/min; other vital signs are normal. (D) Unlirrt'tionated heparin
Oxygen saturation with the patient breathing ambient air is
97"/,,.The patient is diflicult to arouse. Cardiac eramination
(E) Venous duplex ultrasonography
reveals bradycardia but is otherwise unremarkable.
Complete blood count and electrolyte levels are nor
ma[.
Cardiac telemetry shows sinus bradycardia with heart
Item 47
A 28 year <,rldwoman is evaluated in the emergency depart
tr
rate ol30/min. mcnt for substernal chest tightness that started several hours
ago. She is 2 weeks postpartum after an uncomplicated preg
Which of the following is the most appropriate treatment? nancy and delivery. She has no history of cardiopuhnonary
disease and has no risk factors for atherosclerotic cardiovas
(A) Amiodarone cular disease.
(B) Chest compressions On physical examination. blood pressure is 122i72 mm
(C) lntravenousatropine I Ig in both arms. pulse rate is 90i min and regular. and respi
(D) Isoproterenol ration rate is 24'min. The estimated central venous pressure
and apical impulse are normal. An S.r is present. The rest of'
thc examination is unremarkable.
Item 45 Laboratory studies are significant for an elevated
A 78 year old woman is evaluated for a 3-month history of high sensitivity cardiac troponin level (>99th percentile
heart failure with reduced ejection fraction (ejection frac upper ref'erence limit).
tion, 20%). She has stable dyspnea when walking up stairs An ECG shou,s ST segment elevation in the anterior
but has no other symptoms. Her medical history is other precordial leads. An echocardiogram shows anterior wall
wise unremarkable. Medications are valsartan-sacubitril, hypokinesis. Estimated ejection fiaction is,10'iI,.
carvedilol, furosemide, and spironolactone. Carvedilol is at
half maximum dosage; all other medications are at maxi- Which of the following is the most likely diagnosis?
mum recommended dosages. (A) Atheroscleroticplaque rupture
On physical examination, blood pressure is 118/74 mm
(B) Peripartum cardionryopathy
Hg and pulse rate is 88/min. BMI is 27, unchanged from her
last visit. Central venous pressure and the remainder of the (C) Spontaneous coronary artery dissection
examination are normal. (D) Stress induced (takotsubo) cardiomyopathy

136
 Self-Assessment Test

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tr Item 48
A 42 year old man is evaluated in tl-re emergency deparl
Which of the following is the most appropriate treatment?
(A) Additionofvalsartan-sacubitril
l-
o
ment lbr sudden onset right sided weakness. His symp (B) Implantable cardioverter-deflbrillator therapy
tonrs resolved fully over the past hour. Ilc has no knowr.r =
tl
(C) Replacement of metoprolol with carvedilol tt
medical problems ar.rd takes no meclications. o
t
On pl.rysical examination, vital signs are norntal. llis (D) Septal reduction therapy l,!
heart rhythm is regular. Ner-rrologic cxamination is normal.
No carotid bruits <.rr heart murmurs are noted. t
o
Laboratttry stud)/ results are normal.
Magnctic resonance angiogram of the brain demon
Item 51
A 73 year old m:rn is evaluated in the emergency depart tr
strates a snrall left sided ischemic stroke but no other ment for a 2 hour history ol crushing chest pain and dia
iesions. ECC, carotid ultrasouncl, telemetry, and lower plroresis. An admission EC(l is shown.
extremity ultrasouncl are nrtnnal. A transesophagcal echo
cardiogranr demonstrates a patent fbramen ovale (PFO)
with right to left shunt noted with cough and Valsalva
release. No other abnormalities are identified.

Which of the following is the most appropriate v2

management?
(A) Aspirin
(B) PIrO device cl<tsure Iu V3

(C) Warf arin

(D) Observation

Item 49
A 49 year-old woman is evaluated during a new patient
visit. She has no medical problems or concerning symptoms
and takes no medications.
On physical examination, vital signs are normal. The t5

S, is diminished, and there is an aortic ejection click shortly

after the S,. The S, is normal. There is a grade 216,high-
pitched, decrescendo early diastolic murmur heard best at A drug eluting stent is placed in the proximal right cor
the left sternal border. The murmur is accentuated when the onary artery, and he is transf'erred to the coronary care unit.
patient leans forward. On physical examination, blood pressure is 80/50 mm
Hg. pulse rate is 120/min, respiration rate is 22lmin, and
Which ofthe following is the most appropriate diagnostic test? oxygen saturatior.r is 94'X, rvith the patient breathing ambient
(A) Cardiac catheterization air. An S., is heard; there is no pericardial rub. Central venous
pressure is clevated.'lhe lungs are clear to auscultation.
(B) Cardiac magnetic resonance imaging
(C) Stressechocardiography Which of the following is the most appropriate treatment?
(D) Transesophagealechocardiography
(E) Transthoracicechocardiography (A) Intra aortic balloon pump placement
(B) lntravenous dobutanrine
(C) [ntravenous 0.9'], saline
Item 50 (D) Oral metoprolol
A 42 year old man is evaluated for dyspnea that occurs
while walking on a flat surface and causes him to stop
when walking uphill. He has hypertrophic cardiomyopa,
thy, which was diagnosed at age 38 years. He has no other
Item 52
An B4-year old man is evaluated before hospital discharge tr
symptoms and has no family history of sudden cardiac following an exacerbation of heart failure. Ile has an
death. Medications are metoprolol and disopyramide. implantablc cardioverter deflbrillator. Medications are lis
An echocardiogram shows asymmetric septal hyper inopril, lurosemicle, carvedilol, and spironolactone. I)uring
trophy with maximal septal thickness of 24 mm. Systolic hospitalization, the patient received intravenous Iurose
anterior motion of the mitral valve is present with dynamic micle at a dosage twice that of his home oral dosage.
left ventricular outflow tract obstruction and peak gradient On physical examination. vital signs are normal. BMI
of 64 mm Hg at rest. is 28. Centralvenous pressure is not elevated. 'lhere is no S.,,
Six months ago, 24-hour ECG monitoring performed and there are no pulmonary crackles.
as part ofsurveillance showed sinus bradycardia and single Serum creatinine level has returnecl to the baseline
premature ventricular contractions averaging 6 per hour. level, and clectrolytes are normal.

137
 Self-Assessment Test

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1I| Echocardiogram from this hospitalization shows fbrce her to stop several times. Medical history is otherwise
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EJ ejection fraction of 25'1, rn'ith left ventricular end cliastolic signiflcant for hypertension and hyperlipidemia. She has a
l,l coNi dimension of 72 mm. 50 pack year smoking history but quit 10 years ago. Medi
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(,l cations are aspirin, cilostazol, lisinopril, and amlodipine. She
Which of the following is most likely to prevent early was prescribed atorvastatin, but she took the medication for
(D
hospital readmission in this patient? only 1 week after reading that muscle ache is an adverse effect.

.D
(A) Echocardiograpl.ry in 3 rnor.rths
Which of the following is the most appropriate treatment?
Ut (B) Follorn, up officc visit in 30 days
(C) Folkrw up telephone call in 2 clays (A) Atorvastatin
(D) Decrease in turoscmide to original hclme dosage (B) Colestipol
(C) Ezetimibe
(D) Icosapent ethyl
Item 53
A 75 year old man is evaluated for dyspnea and an episode
of exertional syncope. He is diagnosed on clinical examina- Item 55
tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita
An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion.
hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They
cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not
tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages,
However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history.
a mean aortic gradient and aortic valve area consistent with She takes no medications.
moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and
greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg
ular, with premature beats associated with cannon o waves
Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is
management? unremarkable.
(A) Cardiac catheterization Laboratory studies, including complete blood count
and thyroid stimulating hormone level, are normal. Preg
(B) CToftheaorticvalve nancy test results are negative.
(C) Exercise stress testing ECG is shown. Echocardiogram is normal.
(D) Surgical aortic valve replacement
(E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management?

(A) Amiodarone
Item 54 (B) Exercise ECG
A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol
artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance

aVFl VI v4

lt aVl- v? v5

ilt aVF V3 W

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ITEM 55

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138 !
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 Self-Assessment Test

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Item 55 Ou chesl. raclkrgrullh, stcnrotoltl\ uilcs :rnri vasci-rhr
(,
A 35 year-old man is evaluated for exertional dyspnea. His clips are seen. irnd snrall bihte rai plcr.rr:li cf lirsious l"c pn se n1"
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history is otherwise unremarkable.
On physical examination, vital signs and oxygen sat- Which of the following is the most likell, cliagnosisl' ta
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uration are normal. Central venous pressure is elevated. (A) Cardiac tirmponrlclc {,
t
A left parasternal impulse is present. A grade 2/6 systolic t
(B) Chronic live r diseasc
murmur is heard at the second left intercostal space, and
a diastolic flow rumble is heard at the left sternal border. (C) Constrictive pericartlitis c,
t/t
Fixed splitting of the S, is present. The remainder of the (D) Itestrictive crrrtlior.nvop;rthv
physical examination is normal.
An ECG demonstrates sinus rhythm with right axis
deviation and incomplete right bundle branch block. A Item 59
transthoracic echocardiogram demonstrates a 1.5 cm A 65 year olcl ntatr is evlltt;t l er-l li ir rr 2 ti:tr' lr ir t r.rr_l. ol srlcrlr l
ostium secundum atrial septal defect, with moderate right episocles of chest clisctltrt[irrt rrntl d1,s1lr-rc';r ()!:ci.lri'in! iti-,lh ;l
heart enlargement. Left ventricular cavity size and function rr'st and n'itlt e.rcrtion. I'orlir-r, lrr prtjsr,rrn rr-!lh :i holrrs rrl'
are normal. the estimated right ventricular systolic pressure persislerll severt' ccntral ehi:sl prrssurc.
is 30 mm Hg. On ph1'sicaIerantirtlIion. Irlood Jr-r-,ssrilr.ii I55 9{.} il}lt
IIg. pttlse rille is 9(-).n1in. r'csllirrrlion nilc is l.l(l rnin.:,urri
Which of the following is the most appropriate oxygen saturdtioll is 9:l'i, \\'ilh thc l)rtir,11l brcething ri;thi
management? ent air. UNll is 29. .\n S, is prcscnt. llul llrr rrri.rilritr-ll'1lrc
carcliac erarninlliorr is nonn;rl.
(A) Atrial septal defect closure liigh scnsitivilr' clrrli.rc l roplnin lt'r'rl ir ,,'lr:r';rtr'el
(B) Cardiopulmonaryexercisetesting (>991h percenlile trppe r rclcrcrrce limil).
(C) Coronaryangiography An L-(l(l is shou'u.
(D) Echocardiographicsurveillance

tr Item 57
A 71-year-old man is evaluated fbr a 6-month history of
exertional chest pain. lhe pain has incre:rsed in {iequency
and now occurs earlier during his exercise regimen. Jhe
pain is relieved by subiingual nitroglycerin. He underwent
coronary artery bypass gralt surgery 4 years ago. History is
also signiflcant fbr hypertension and hyperlipidemia. Medi-
cations are metoprolol, Iisinopril, atorvastatin, and aspirin.
Physical examination findings, ir-rcluding vital signs,
are normal.
ECG shows left bundle branch block.

Which of the following is the most appropriate test?

(A) Dobutamine echocardiography
(B) Exercise ECG
(C) Exercise single photon emission CT
(D) Vasodilator single-photon emission CT
He is given lspirin. c'L4rickrgrcl. ilrtr.l\j(rlotls illtfi-tL
tionated heparitr. lncl a nitt-ogl_\'ccrir.l iillllsi{rtt, llir t'hi'st
pain initiirlll. inrprovcs hut rt'turns dr:piie tiilrt:dl-r'L:i'ritt
tr Item 58
A74 year old manisevaluatedinthehospitirl fbra 6 month
infusion ancl rnorph i ne.
history ofprogressive fatigue and exertional dyspnea. along
Which of the following is the most appropriate managenrent?
with increasing peripheral edema and abdominal girth
] over the past 3 months. IJe also has corouary artery dis (A) t'.cltoc:trcliographl'
ease, fbr which he had a coronary artery bypass gral't at age (13) F.plerenone
62 years. Medications are metoprolol, 1ow-dose aspirin. and
(C) O.xygen pcr ttrrsal cal11ltll.t
atorvastatin.
On physical examination. vital signs are normal. Jugtt
(D) Urgent (orollilr! angir.,grrplr-'"'
lar venous distention with prominent waveforms is noted'
There is no discernable fall in the central venous pressure
during inspiration. An early diastolic sound is present.
Item 60
The liver is enlarged and pulsatile. Ascites is present, and A 26-year-old woman is evaluated for palpitations that
peripheral edema extends to the knees bilaterally. began 2 months ago. The palpitations begin with no speciflc

139
 :

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Self-Assessment Test :

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inciting factors, Iast 5 to 15 minutes, and are alleviated by Chest radiograph reveals a widened mediastinum, and
ra rest or deep breathing. Ihey occur a few times per week. a C'l'angiogram shows a type A aortic dissection.
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.D Between events, she engages in usual daily activities with
l,l no limitations. She has no other pertinent history and takes Which of the following is the most appropriate treatment?
la
no medications.
(D (A) Coronaryangiography
Physical examination flndings, including vital signs,
are normal. (B) Intravenous nitroprussicle
.D
aa Resting l2-lead ECG shows sinus rhythm and no (C) Open aortic repair
abnormalities. (D) thoracic endovascular aortic repair

Which of the following is the most appropriate diagnostic

testing option? Item 63 :

(A) Exercise ECG A 45 year-old woman is evaluated for occasional palpita-

(B) Implantable loop recorder tions. She also has hypertension. Medications are chlortha
lidone and diltiazem. 1
(C) Mobile cardiac telemetry On physical examination, vital signs are normal. Car
(D) 30-Day event monitor diac examination reveals an irregular rhythm. There is a .
midsystolic click and late systolic murmur at the apex, radi
ating to the back. There are no signs ofheart failure.
tr Item
A
61
76 year old woman is evaluated in the en-rergency depart
An ECG shows atrial flbrillation. with a ventricular rate
of 80/min.
\
menl lor acute onset substernal chest discomfort with asso A transthoracic echocardiogram shows severe poste-
ciated dyspnea. The symptoms developed tl-ris morning after riorly directed mitral regurgitation, with a left ventricular
her husband's unexpected death. She has hypertension ejection fraction of 557, and left ventricular end-systolic :

treated with chlorthalidone. dimension of 60 mm. There is severe anterior mitral valve !
Or.r physical examination, blood pressure is 140/70 mn.t prolapse; hemodynamic measurements indicate severe
llg and pulse rate is 90/min. Oxygen saturation is 9B'1, with mitral regurgitation.
the patient breathing ambicnt air. Other than an S.,, the
carcliopulmonary examination is norma[. Which of the following is the most appropriate next step in
Serum high sensitivity cardiac troponin level is ele management?
.

vatecl (>99th percentile upper reference limit).

An ECG demonstrates S'l' segment elevation in the (A) Cardiac magnetic resonance imaging
I
irnterior precordial leads. ancl echocardiogram shows (B) Surgical mitral valve repair
preserved basal left ventricular flnction with apical and (C) Transcatheter mitral valve repair
rnicl ventricular hypokinesis. The lefl ventricular ejection (D) Transesophagealechocardiography :
fraction is 35',1,. Valve function and the ascending aorta
appear normal. Coronary ar.rgiography shows normal cor
()nrry arteries.
Item 64
tr l
Which of the following is the most likely diagnosis?
A 69 year old man is evaluated fbr a 1 week history of'
redness at the site <,rf his pacenraker. Medical history is sig
(A) Ascending aortic dissection nificrnt fbr diabetes mellitus and hypeftension. Medications
(B) Coronary artery dissection are metfbrmin. atorvastatin, and Iisinopril.
(C) Coron:rry artery embolism On physical examinatiorr, the patient is afebrile:
other vital signs are normal. The pacemaker site is shown
(l))'l'akotsubo cardiomyopathy (top of next page). The renrainder of the examination is
unremarkable.
Item 62 Laboratory studies, including lcukoc-y,te count. are within
EX A 5,1 year old man is evaluated in the emergency depart
normal limits. Three sets of blood cultures are ohtained.
mcnt 2 hours after the orrset of acute, sharp, central chest
pain that radiates to the back and has intensified over time. Which of the following is the most appropriate additional
l le has hypertension. lle cluit smoking 2 years ago. Medica management?
Iions are hydrochlorothiazidc and lisinopril. (A) Aspiration ofthedevice pocket
On physical examination. blood pressure in the right (U) Pacemakerextraction !
rlrnl is 90,,56 mm Hg. blood pressure in the left arm is not
obtainable, and pulse rate is l20r'min. He is confused and
(C) 1'opical mupirocin
ciiaphoretic. Cardiac examination reveals a summation gal (D) Clinical observation and rcassessment
lop ancl a grade 3i 6 diastolic murmur at the right upper
stenral border. Puln-ronary examination reveals crackles. q
Itadial pulses are weakly prcsent on the right and absenl on Item 65
the left. l-ower extremity pulses are diminished. Skin is cool A 78-year old woman is evaluated 4 months after placement \
and mottled. of a drug-eluting stent for treatment of chronic stable angina
:
140
i
 Self-Assessment Test

tt
An echocardiogram shows a lelt ventricular ejection o,
fraction of 5O%, increased left and right ventricular wall
thickness, and abnormal left ventricular diastolic function. (,
The estimatedright ventricular systolic pressure is 64 mm Hg. E
aa
ra
(l,
Which ofthe following is the most appropriate management? a
t

(A) Cardiac resynchronizationtherapy

(l,
(ts) Cardiac transplanlation tl
(C) Implantablecardioverter deflbrillator
(D) Pulmonary vein isolation

Item 67
A 46-year old man is evaluatecl fbr exertional chest pain
that started 2 months ago. His pain is substernal and can
tr
also be provoked by stressful <lr emotional situations. The
pain subsides in 2 to 3 minutes with rest. He has no other
medical problems and takes no medications.
Physical examination findings, including vital signs,
are normal.
ECG shows sinus rhythm with first degree atrioven
tricular block.
ITEM 64
Which ofthe following is the most appropriate management?
pectoris. She is asymptomatic. She has hypertension, gas- (A) Coronary artery calcium scoring
troesophageal reflux disease, and a history ofseveral colonic (B) Exercise ECG
angiodysplasias treated with electrocoagulation 8 months
(C) Exerciseechocardiography
ago. Medications are pravastatin, aspirin, clopidogrel, metop-
rolol, hydrochlorothiazide, ferrous sulfate, and omeprazole. (D) 48 Hour ambulatory ECG
On physical examination, blood pressure isl32l72mm
Hg, pulse rate is 78/min, and respiration rate is 2Olmin. BMI
is 17. Scattered ecchymoses are evident over both lower Item 68
extremities. A 28-year-old woman is seen for pregnancy planning. She
Results of laboratory studies show a hematocrit of 34%. underwent mitral valve replacement with a mechanical
prosthesis 4 years ago for congenital mitral valve stenosis.
Which of the following is the most appropriate initial She is asymptomatic. Medications are warfarin, 4 mg/d, and
management? low-dose aspirin. Her INR measurements have been within
the therapeutic range for the past 18 months, including her
(A) Assess platelet reactivity most recent INR measurement of 3.0.
(B) Discontinueaspirin Other than a mechanical-sounding Sr, vital signs and
(C) Discontinue clopidogrel all physical examination flndings are normal.
(D) Discontinueomeprazole Echocardiography shows a normally functioning
mitral valve prosthesis and normal left ventricular function
and estimated pulmonary artery pressure.

tr Item 66
A 65-year-old man is evaluated in the hospital for progres
The patient would like to attempt pregnancy as soon as
possible. During this time, aspirin will be continued.

sive dyspnea with light exertion. He was diagnosed with

Which of the following is the most appropriate
restrictive cardiomyopathy 2 years ago and atrial flbrillation
anticoagulation stratery during the first trimester?
18 months ago. Attempts at pharmacologic rhythm control
have been unsuccessful. Medications are apixaban, spirono- (A) Stop warfarin and start bivalirudin
lactone, torsemide, and potassium chloride. (B) Stop warfarin and start dabigatran
On physical examination, blood pressure is 106/68 mm (C) Stop warfarin and start subcutaneous dose-adjusted
Hg, pulse rate is 86/min and irregularly irregular, and oxy-
unfractionated heparin
gen saturation is 94% with the patient breathing ambient
air. Central venous pressure is elevated. Bibasilar crackles
(D) Continue warfarin
are present. Hepatomegaly is noted. There is bilateral pitting
edema to the knees.
ECG shows atrial fibrillation with a ventricular rate of
Item 69
86/min, right bundle branch block, and QRS duration of A 72-year-old man is evaluated in the office following a
136 ms. non-ST-elevation myocardial infarction. He underwent

141
 Self-Assessment Test

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percutaneous coronary intervention and is currently lntravenous furosemide and bilevel positive airway
asymptomatic. Medications are low-dose aspirin, ticagrelor, pressure are initiated.
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.D lisinopril, metoprolol, and atorvastatin.
l^
(a On physical examination, blood pressure is 140/72 mm Which of the following is the most appropriate additional
Hg; other vital signs are normal. Femoral bruits are pres treatment?
.D
ent bilaterally. Femoral and pedal pulses are diminished (A) Bisoprolol
bilaterally.
.D (B) Diltiazem
(,t
Ankle-brachial index testing: (C) Enalapril
Right systolic brachial pressure 140 mm Hg
(D) Ivabradine
Left systolic brachial pressure 95 mm Hg
Right dorsalis pedis pressure 112 mm Hg
Left dorsalis pedis pressure 120 mm Hg Item 71 \
Right posterior tibialis pressure 100 mm Hg A 25-year old man is evaluated fbr recurrent syncope. The
Left posterior tibialis pressure 116 mm Hg syncopal episodes are abrupt and without prodrome and I
have occurred several times during the past year. He reports
Which of the following is the most appropriate test to no chest pain or exertional symptoms' He has no other
perform next? pertinent personal history. His father died in his sleep at age
(A) Exercise ankle brachial index testing 45 years. He takes no medications.
(B) Lower extremity CT angiography On physical examination, vital signs are normal. There
is no heart murmur. The remainder of the examination is
(C) Toe-brachial index testing unremarkable.
(D) No additional testing Laboratory studies, including a comprehensive meta
bolic panel, are within normal limits.
ECG is shown. Echocardiogram is normal.

tr Item 70
A 27- year-old woman is hospitalized for a l-day history of Which of the following is the most likely diagnosis?
orthopnea and paroxysmal nocturnal dyspnea. She deliv-
(A) Brugada syndrome
ered a healthy baby boy 6 days ago. She is breastfeeding.
On physical examination, blood pressure is 134/78 mm (B) Coronary artery disease :

Hg, pulse rate is 98/min, respiration rate is 26lmin. and (C) Long QT syndrome
oxygen saturation is 94'7, with the patient breathing ambi (D) Vasovagal syncope
ent air. There is jugular venous distention and an Sr. Crack-
,
les are heard about halfway up the lungs. There is lower
extremity edema to the knees.
Laboratory studies show an elevated B-type natriuretic
Item 72
A 30-year-old man is hospitalized for a 3 day history of pro tr i
peptide level, a normal high-sensitivity troponin level gressive fatigue, fever, and shortness ofbreath. He under
(<99th percentile upper reference limit), and a serum cre- went surgical aortic valve replacement 3 years ago. He also
atinine level of 1.2 mg/dl (106.1 pmol/L). has end-stage kidney disease. fbr which he receives hemo
Chest radiograph shows pulmonary edema. Echocar dialysis. Medications are lisinopril, sevelamer, and warf'arin.
diogram shows an ejection fraction of20% and di{Iuse hypo On physical examination, blood pressure is 145/34 mm
kinesis. I'tg and pulse rate is l20i min. Cardiac examination reveals

'{- --1- ''

I
--l- -v
+- -"i
tv n ;*r l
:

ITEM 71

142
 Self-Assessment Test

r,D

tr
CONT.
bounding pulses and a loud decrescendo diastolic murmur at
the left sternal border. Crackles are heard at the lung bzrses.
An tiCG shows prolonged first degree atrioventricu
Today, the hemoglobin Ievel is 74.8 gldL (148 g/L), and
iron studies are compatible with iron deficiency.
F6'
E
o,
lar btock. A chest radiograph reveals pulmonary edema. E
Which of the following is the most appropriate initial Ut
Ul
A transthoracic echocardiogrant reveals a left ventricular management? o
t^
ejection fiaction of 60'1, with nornral left ventricular dinren UI
(A) Hysterectomy
sions and a 1.S-cm vegetation on the aclrtic valve biopros
thesis associated with severe aortic regurgitation. (B) Oral iron therapy so
Multiple blood cultures are obtained, irnd empiric (C) Phlebotomy vt
intravenous antibiotic therapy is initiated. (D) Supplemental oxygen therapy

Which ofthe following is the most appropriate management?

(A) Cardiac cetheterizxtion
(B) Early surgical aortic valve replacement
Item 74
A 58 year old man is evaluated in the emergency depart- tr
ment 30 minutes after onset of severe and persistent chest
(C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His
(D) No change in therapy medical diagnoses include hypertension and hyperlipid
emia treated with amlodipine and atorvastatin. An ECG is
shown.
Item 73 On physical examination, blclod pressure is 159/84 mm
A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy
progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient
the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are
symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable.
Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI)
riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav.
ication is bosentan for pulmonary arterial hypertension.
On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate
Hg; the remaining vital signs are normal. Oxygen saturation management?
with the patient breathing ambient air is 92'2, in the upper (A) CT angiography
extremities and B2'7, in the lower extremities. There is jugu
(B) Thrombolysis and admission to a telemetry bed
lar venous distention with a prontinent o wave, and a prom
inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center
of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI

$L 1,.

r1? 1.6
m

il

vt
ITEM 74

143
 Self-Assessment Test

ull
.D
Item 75 Which of the following is the most appropriate treatment?
lrt An 18-year old man is evaluated before participating on his (A) Cardiacresynchronizationtherapy defibrillator
rrt
.D
ut college basketball team. He has no history of hypertension (B) Implantable cardioverter-deflbrillator
UI or other pertinent medical history. He has no history of (C) Implantable pulmonary artery pressure sensor
palpitations, chest pain, or unusual dyspnea, and there is no
.D (D) Wearablecardioverter deflbrillator
family history of sudden cardiac death or cardiomyopathy.
{
(D On physical examination, blood pressure is 110/70 mm
UI Hg and pulse rate is 52/min. BMI is 22. No murmur is heard.

left
ECG shows sinus bradycardia, with voltage criteria for
ventricular (LV) hypertrophy. The corrected QT interval
Item 78
A 72 year old man is evaluated in the emergency depafi
tx
is 400 ms. Early repolarization is noted. ment fbr sudden-onset anterior chest pain radiating to his
An echocardiogram shows a mildly dilated LV cavity. back. I te has no history of heart murmur or aortic disease.
The ejection fraction is greater than 55% without regional I{e has hypertension treated with chlorthalidone ancl val
abnormality. Symmetric LV hypertrophy is noted, with LV sartan.
wall thickness of 12 mm. LV diastolic fllling, left atrial size, On physical examination, bloocl pressure is 182/54 mm
and valvular structure and function are normal. IIg in the right arm and 12.5i 63 mm Hg in the left arm. lhere
is a grade 2/6 decrescendo diastolic murmur heard at the
Which of the following is the most likely diagnosis? left sternal border. Central venous pressure is elevated. and
there are crackles at the lung bases.
(A) Athlete heart
Chest radiograph shows pulmonary edema and a rvid
(B) Fabrydisease ened mediastinum. A CT angiogram short's an ascending
(C) Hypertensive heart disease aortic dissection extending into the aortic arch. An echo-
(D) Nonobstructive hypertrophic cardiomyopathy cardiogram sl.rows a left ventricular ejection fraction of 55'X,
and moderate aortic regurgitation.

Item 76 Which of the following is the most appropriate

A 42-year old woman is evaluated for a 3-month history of management?
exertional dyspnea and a burning sensation in her throat.
She had Hodgkin lymphoma at age 22 years treated with
(A) Cardiac rnitgnetic res()nunce intlging
chemotherapy and mantle irradiation. She has no history (B) Emergent surgery
of hypertension, hyperlipidemia, or diabetes mellitus and (C) h-rtra aortic balloon counterpulsation
has never smoked. (D) Transesophageal echocarcliography
On physical examination, vital signs are normal. No
jugular venous distention is seen. Heart sounds are normal.
No murmur or early diastolic sound is heard. There is no Item 79
peripheral edema.
A chest radiograph and 12 lead ECG are normal. A 68-year-old man is evaluated during a routine follow up
visit. Medical history is signiflcant for type 2 diabetes melli-
Which of the following is the most likely diagnosis? tus, hyperlipidemia, hlpertension, and aortofemoral bypass
surgery 2 years ago. Previous evaluation documented a left
(A) Aortic stenosis ventricular ejection fraction of50% and stage G3bA2 chronic
(B) Constrictivepericarditis kidney disease. Medications are metformin, atenolol, lisin
(C) Coronary artery disease opril, amlodipine, aspirin, rivaroxaban, and atorvastatin.
(D) On physical examination, vital signs are normal. BMI is
Mitral stenosis
30. An aortofemoral bypass surgical scar is present. Pulses
(E) Restrictivecardiomyopathy
are present and moderately strong in the lower extremities.
The most recent hemoglobin A,. level is7.l%.
Item 77
A 63-year old man is evaluated during a follow up visit for Which of the following is the most appropriate additional
a 6 month history of heart failure. He currently has New treatment?
York Heart Association functional class III symptoms. His (A) Clopidogrel
only hospitalization was at the time of diagnosis. Medica- (B) Liraglutide
tions are valsartan sacubitril, carvedilol, furosemide, and
(C) Niacin
spironolactone.
On physical examination, blood pressure is 110/76 mm (D) Pramlintide
Hg and pulse rate is 64lmin. The remainder of the examina
tion is unremarkable.
Laboratory studies are within normal limits.
ECG demonstrates left bundle branch block with a
Item 8O
A 48-year old woman is evaluated in the hospital for trirn- tr
QRS duration of 130 ms. Since beginning guideline-directed sient left facial droop and right sided weakness, which
medical therapy, his ejection fraction has increased from lasted 15 minutes and completely resolved. She also has a
15"/,'to25%. 1-month history of recurrent f'evers and night sweats. She

144
 Self-Assessment Test

Ut
reports lack ot appetite and unintentional weight loss of
f_tll Which of the following is the most appropriate treatment? Fo,
lll z s kg (5 lb). She has no orher symptoms or medical prob,
c0Nl 1.-r and has not undergone a rec.ent medical proceclure. (A) Atropine o
She takes no medicatior.rs. (ts) Intravenous unfractionated hcparin tr
Ut
Orr physical examinaticln. vital signs are nonnal. Car, ((l) Temporary pacing U!
g,
diac examination reveals a normal S, and Sr, with a so{t early (D) Urgentdual chamberpacemakcr UI
ra
diastolic sound heard best at the apex.
ECG dcmonstrates normal sinus rhythm.
o
tt
CT of'the head with and without contrast is normal. Item 82
Echocarcliogram (shown) denlonstrates normal chamber
A 78 year-old woman is evaluated for 6 weeks of exertional
size and ventricular function (LV = left ventricler RA = right
dyspnea. She has hypertension and paroxysmal atrial flbril
irtrium; RV = right ventricle).
lation. Medications are apixaban, enalapril, and chlortha-
lidone.
On physical examination, blood pressure is 148/90 mm
Hg; other vital signs are normal. BMI is 38. Central venous
pressure is normal, and lungs are clear. An Sr, but no mur
mur, is noted.
B-type natriuretic peptide level is 211 pg/ml (2ttnglL).
An ECG demonstrates sinus rhythm and left ventric
ular hypertrophy. An echocardiogram shows an ejection
fraction of55% and increased left ventricular wall thickness.
The calculated cardiac index is 2.9 L/min/m2. There is no rest
or dynamic outflow tract obstruction. The estimated right
ventricular systolic pressure is 40 mm Hg. The left atrium
is enlarged.

Which of the following is the most likely diagnosis?

(A) Heart failure with preserved ejection fraction
(B) High output heart failure
(C) Hypertrophic obstructive cardiomyopathy
(D) Noncardiac dyspnea

Which of the following is the most appropriate Item 83

management?
A 76 year-old woman is evaluated during a wellness visit.
(A) Administer a direct oral anticr,ragulant She reports that she fatigues easily, and her husband notes
(B) Administerintravenousthrombolytic therapy that she snores loudly. Medical history is signiflcant for
(C) Obtain blood cultures and begin empiric antibiotics hypertension. Her only medication is metoprolol.
(D) Urgcnt surgicrl excision On physical examination, pulse rate is 75lmin and
irregular; other vital signs are normal. Cardiac examination
reveals irregular heart sounds with no murmurs or gallops.
No signs of heart failure are present.
tr Item 81
A 53 year old woman is evaluated in the coronary care
An ECG shows
ischemic changes.
atrial flbrillation at 75lmin without

l
unit. She underwent successtirl primary percutaneous
coronary intcrvention with drug-eluting stent placement
Which of the following is the most appropriate
in the mid right coronary artery fbr an inferior S'l' elevation management?
myocardial infarction. ln the catheterization laboratory.
she had several episodes of symptornatic 2:1 atrioventric (A) Add aspirin
ular block with sinus bradycardia. After returning to the (B) Emergent cardioversion
coronary care unit, she has symptomatic intermittent 2:l (C) Increase metoprolol dosage
atrioventricular block and several episodes of c<lmplete (D) Initiate oral anticoagulation
heart block with a narrou, complex escape rhythrn (heart
rate at 58i min). Meclications are atorvastalin. aspirin. and (E) Reassurance
clopidogrel.
On physical examination. blood pressure is 1lBiB2
mm FIg. pulse rate is 681min. respiration rate is lB/min. Item 84
and oxygen saturation is 96'7, with the patient breath A 55 year old man is evaluated for a 6 week history of
ing ambient air. Cardiac examination reveals a regularly cough and worsening exertional dyspnea and orthopnea.
irregular rhythm. The remainder ol the examination is He has heart failure, for which he has received guideline-
normal. directed medical therapy for 4 months.

145
 Self-Assessment Test

arr
.D
On physical examination, blood pressure is 130/67 mm (C) Pentoxifylline
D
(,t Hg and pulse rate is 90/min and regular. There is an early (D) Revascularization
gt
.D systolic click and a holosystolic murmur loudest at the apex (E) Supervised exercise training
UI
UI and radiating to the back. The central venous pressure is
elevated, and there are crackles at both lung bases.
(D
An ECG is normal. A chest radiograph reveals pulmo Item 87
nary edema. A transthoracic echocardiogram shows a left
(D' A 28 year old woman r.tith Marfan syndrome is seen fol
t^ ventricular ejection fraction greater than 55%. The echocar
lowing recent transthoracic echocardiography obtained as
diographic data are consistent with moderate mitral regur-
part of a prepregnancy evaluation. Her mother has l\4arfan
gitation.
syndrome and had emergency surgery for ascending aortic
dissection B years ago. The patient's only medication is
Which of the following is the most appropriate next step in metoprolol succinate.
management? On physical examination, blood pressure is 110i 60 mm
(A) Cardiac magnetic resonance imaging Hg and pulse rate is 60imin and regular. The patient has
(B) Repeat echocardiography in 1 year phenotypical features of Marfan syndrome. The remainder
of the examination is normal.
(C) Surgical mitral valve repair
Transthoracic echocardiogram reveals a dilated proxi
(D) Transcatheter mitral valve repair mal ascending aorta with a dimension of 4.3 cm; the
dimension was 3.7 cm 1 year ago. No aortic or mitral valve
regurgitation is present. Left ventricular size and func-
Item 85
tion are normal. A CT scan confirms the aortic dimension
A 67-year-old man is evaluated for a 3 month history of obtained by echocardiography.
progressive dyspnea and peripheral edema. He also has a
6-month history of exertional chest "heaviness." Medical Which of the following is the most appropriate management?
history is otherwise significant for hypertension and type 2
diabetes mellitus. He is a former cigarette smoker. quitting (A) Add atorvastatin
6 months ago. Medications are hydrochlorothiazide, ator- (B) Add losartan
vastatin, metlormin, and liraglutide. (C) Aortic repair before pregnancy
On physical examination, blood pressure is 122l86 mm
(D) Proceed with pregnancy
Hg and pulse rate is 96lmin; other vital signs are normal.
BMI is 27. Jugular venous distention and an S, are present.
Lower extremity edema to the mid thigh is noted.
Item 88
ECG shows left bundle branch block. Echocardiogram
shows ejection fraction of 25"/,, with anterior hypokinesis A 66 year old woman is evaluated for a 6 month history
and normal wall thickness. of right shoulder pressure that occurs after walking half
a mile and improves with 5 minutes of rest. She has no
dyspnea, nausea, or tatigue. The frequency and duration of
Which of the following is the most appropriate test?
her symptoms have not changed. Her history is otherwise
(A) Cardiac catheterization unremarkable.
(B) Cardiac magnetic resonance imaging On physical examination, vital signs are normal. BMI is
(C) Cardiac PET 33. Other than a paradoxically split Sr, the cardiac examina
(D) Technetium 99m pyrophosphate scintigraphy tion is normal. The lungs are clear to auscultation.
A chest radiograph is normal. ECG is shown (top o1'
next page).
Item 86
A 56 year old man is evaluated for a 3 month history of Which of the following is the most appropriate test?
progressive left calf discomfort that is exacerbated when (A) Coronaryangiography
walking stairs and hills and is absent at rest. Medical history (B) Exercise ECG
is signiflcant for hypertension, hyperlipidemia, and coro
(C) Pharmacologic myocardial perfusion imaging
nary artery disease. He also has a 50 pack-year smoking
history but quit smoking 3 years ago. Medications are aspi (D) Transthoracic echocardiography
rin, rosuvastatin, metoprolol, and amlodipine. (E) No further testing is required
On physical examination, vital signs are normal. BMI is
28. Left femoral, popliteal, and pedal pulses are faint.
The ankle brachial index is 0.68 on the left and 0.98 on
the right.
Item 89
A .12
1.'ear old nran is evaluatcd in the eurergcncl, depart tr
ment tbr pxlpitatiorls. neck pulsations. and light headedness
Which of the following is the most appropriate that bcgarr,15 minlltes irgo. IIe reitorts no chest pain or
management? breathlessness. He hls been unrler pressure at rtork irnd
l-ras becn anxious and sleepless. llrere is no other relevant
(A) CT angiography personal or familv history. He cloes not use illicit drugs or
(B) Ethylenediaminetetraaceticacid supplements.

146
 Self-Assessment Test

l,I
q,
F
j-t (l,
E
aVR. vt
,
o
vt
t

o,
vt
n
II aVL v5

avF v6

vl

ITEM 88

m On physical examination, blood pressure is 90/70 mm Central venous pressure is elevated. There are crackles at
E IIg and pulse rate is 160/min; other vital signs are normal. the lung bases.
c0NL 6rr*., saturation is 9B'X, with the patient breathing ambi Laboratory studies demonstrate a B-type natriuretic
ent air. Intermittent cannon o waves are noted on neck peptide Ievel of 2000 pg/ml (2000 ng/L).
examination. Other than a rapid regular rhythm, cardiac An ECG shows normal sinus rhythm without ST-
examinatior.r is unremarkable. Lungs are c1ear. T-wave changes. An echocardiogram shows a moder
ECG reveals ventricular tachycardia. He is successfully ately thickened, partially mobile aortic valve, with left
cardioverted. ventricular ejection fraction of 45'/,' and hemodynamic
Complete blood count and metabolic panel, including measurements compatible with Iow flow, low-gradient
! severe aortic stenosis.
electrolytes, are normal.
Echocardiogram and subsequent ECG are both normal.
Which of the following is the most appropriate
Which of the following is the most appropriate initial management?
management? (A) Cardiaccatheterization
(A) Cardiac magnetic resonance imaging with stress per (B) Dobutaminestressechocardiography
'.
fusion (C) Surgical aortic valve replacement
a (B) Electrophysiologystudy (D) Transcatheter aortic valve implantation
(C) lmplantable cardioverter-defibrillator
(D) Implantable loop recorder
Item 91
A 62-year-old woman is hospitalized for a non-ST-elevation
Item 90 myocardial infarction. She has hypertension, type 2 diabe
:
A 76-year-old man is evaluated for a 4 week history of tes mellitus, newly symptomatic aortic stenosis, and coro-
shortness of breath and chest discomfort with minimal nary artery disease, for which she underwent percutaneous
exertion. Medical history is signiflcant for hlpertension, coronary intervention 1 year ago. Medications are low -dose
hyperlipidemia, and coronary artery disease. Medications aspirin, ticagrelor. metoprolol, ran.ripril, metformin, and
are low dose aspirin, amlodipine, atorvastatin, lisinopril, high intensity atorvastttin.
and metoprolol. On physical examinatiort, vital signs are nonnal. A
On physical examination, blood pressure is 135/83 grade 3/6 harsh midsystolic murnlur is noted at the right
mm Hg; other vital signs are normal. Cardiac examination upper sternal border.
reveals a late-peaking crescendo-decrescendo systolic mur An echocardiogram reveals normal left ventricular
mur heard at the right upper sternal border with loss of Sr. ejection fraction, severe aortic stenosis, and an enlarged

147
 Self-Assessment Test

rtt

tr
.D
fi thoracic aortar the maximal diameter of the ascending aorta Item 94
D
UI
lll is 5.6 cm. Coronary angiography reveals diffuse in-stent A 35-year-old woman is evaluated in the emergency depart-
la c0NT 1g51sn6sis of the proximal left circumflex stent (intarct-
.D ment for a 1 week history of fever and chest pain. The pain
UI
UI related artery), focal proximal left anterior descending is sharp and midsternal, worse lying down, and improved
artery stenosis. and chronic total occlusion of the right leaning forward.
(D
coronary artery.
Coronary bypass graft surgery is planned.
On physical examination, temperature is 38.5 'C l
(101.3 'F), blood pressure is 120/70 mm Hg with pulsus para-
.D
Ut doxus of 10 mm Hg, and pulse rate is 92lmin. A three-phase
Which of the following is the most appropriate additional friction rub is heard along the left sternal border and apex'
intervention? ECG shows normal sinus rhythm and normal voltage
(A) Ac.rrtic valve replacement with diffuse ST-segment elevation of 1 to 2 mm. An echo-
cardiogram shows a pericardial eflusion without evidence
(B) Aortic valve replacement and aortic repair
of tamponade.
(C) Transcatheter aortic valve implantation
(D) No additional intervention Which of the follou'ing is the most appropriate
management?
(A) Discharge on ibuprofen and colchicine
tr Item 92
A 38-year-old man undergoes a preoperative evaluation
(B) Discharge on prednisone
(C) tlospitalize and begin ibuprofen and colchicine
before repair of a torn anterior cruciate ligament. His car
diovascular history includes repaired tetralogy of Fallot. He (D) Hospitalize and begin methylprednisolone
has no symptoms.
On physical examination, vital signs are normal.
Jugular venous distention and a prominent o wave are
noted. A right ventricular heave is present. A single S,
is heard, as is a grade 1/6 early systolic murmur local-
Item 95
A S7-year-old man is evaluated in the emergency depart-
tr
ment af'ter a cardiac arrest. Bystander cardiopulmonary
ized to the left second intercostal space and a grade 2/6 resuscitation and use of an automated external deflbrillator
diastolic murmur best heard in the left second and third resulted in a return of sinus rhythm. An initial ECG revealed
intercostal spaces. The diastolic murmur increases with ST-segment depression in leads Vr and Vu. After irritiation of
inspiration. aspirin, unfractionated heparin, and ticagrelor, angiogra
phy revealed no significant obstructive lesions. He is admit-
Which of the following is the most likely diagnosis? ted to a monitored bed, where he develops acute persistent
(A) chest pain, hypotension, and the ECG changes shown.
Aortic coarctation
(B) Aorticregurgitation
(C) Mitral stenosis
(D) Pulmonaryregurgitation

Item 93 l
A S9-year old man is evaluated during a routine visit. He
has type 2 diabetes mellitus. One year ago, he had an athero-
sclerotic stroke with no residual neurologic deflcits. Medica-
tions are aspirin, metformin, candesartan, and rosuvastatin.
He remains active and has no symptoms.
On physical examination, blood pressure is 132/80 mm
Hg; other vital signs are normal. BMI is 25. The remainder of
the examination is unremarkable.
Laboratory studies show a serum LDL cholesterol level vl-
of 66 mg/dl (t.Zt mmol/L) and an estimated glomerular
flltration rate of 60 ml/min 11.73 m2. A hemoglobin Ar. level
measured 3 months ago was 6.8%.

Which of the following is the most appropriate

management of this patient's atherosclerotic Blood pressure is 95/60 mm Hg, pulse rate is 55/min,
cardiovascular disease? respiration rate is 24lmin, and oxygen saturation is 96'2,
(A) Begin empagliflozin with the patient breathing ambient air. Cardiac examina-
(B) Begin ezetimibe tion is normal. tsibasilar pulmonary crackles are present.
The initial high-sensitivity troponin level is elevated
(C) Obtain exercise ECG (>99th percentile upper reference limit); urine toxicology
(D) No changes in management screen is negative for drugs.

148