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100
What is the classic cardiotoxicity of anthracyclines and its mechanism?
Dilated cardiomyopathy; free radical-mediated oxidative damage to cardiomyocytes — dose-dependent and largely irreversible
100
What shunt direction occurs in an uncorrected VSD and what murmur does it produce?
Left-to-right shunt; harsh holosystolic murmur at left lower sternal border
100
Type A vs Type B aortic dissection — define and first-line management of each?
Type A: involves ascending aorta → emergent surgery. Type B: descending only → medical management (beta-blocker, BP control) unless complicated
100
What ECG finding in an athlete is normal and does not require further workup?
Sinus bradycardia, first-degree AV block, early repolarization, incomplete RBBB, voltage criteria for LVH — all training-related normal variants
100
Digoxin toxicity classic ECG finding?
Scooped ST depression ("Salvador Dali" sign) — also bradyarrhythmias, heart block, bidirectional VT in severe toxicity
100
A physician has no federal taxes withheld on 1099 moonlighting income until April — what IRS penalty applies?
Underpayment penalty — quarterly estimated taxes required; safe harbor is paying 100% of prior year tax liability quarterly, otherwise 8% penalty on underpayment amount
200
Trastuzumab cardiotoxicity differs from anthracyclines in what two key ways?
largely reversible with drug discontinuation
not dose-dependent — mechanism is HER2 receptor blockade impairing cardiomyocyte repair rather than direct toxic injury
200
Eisenmenger syndrome — define it and name two absolute contraindications once established?
Reversal of left-to-right to right-to-left shunt due to pulmonary hypertension; contraindications: defect closure (fatal) and pregnancy (maternal mortality up to 50%)
200
What genetic syndrome has hypertelorism, bifid uvula/cleft palate, arterial tortuosity — TGFBR1/2 mutation?
Loeys-Dietz syndrome
200
Athlete's heart vs HCM — what wall thickness is the gray zone where differentiation is difficult?
13–15mm — below this is almost always athlete's heart; above 16mm is almost always pathologic
200
QT prolonging drugs — name the four drug classes most commonly responsible for drug-induced torsades?
antiarrhythmics (sotalol, dofetilide, amiodarone),
antipsychotics (haloperidol, quetiapine)
antibiotics (azithromycin, fluoroquinolones),
antiemetics (ondansetron, metoclopramide)
200
What is the self-employment tax rate?
Bonus: what income does it apply to?
15.3%
- Social Security portion (12.4%) only applies up to the wage base — $176,100 for 2025
- Medicare (2.9%) applies to all net SE income, no cap
- An additional 0.9% Medicare surtax kicks in above $200K (single) / $250K (married filing jointly) in combined wages + SE income
300
Fluorouracil cardiotoxicity — mechanism and which patients are highest risk?
Coronary vasospasm causing demand ischemia
highest risk in patients with pre-existing CAD or prior chest radiation — occurs in up to 10% of patients
300
In repaired TOF, what is the most common cause of late sudden death and its substrate?
Ventricular tachycardia via scar-mediated reentry at RVOT surgical scar (ventriculotomy or transannular patch); QRS duration >180ms is the strongest non-invasive risk marker — distinct from overall late mortality which is dominated by RV failure from chronic pulmonary regurgitation
300
Complicated vs uncomplicated Type B dissection — name three complications mandating intervention?
malperfusion (renal, mesenteric, spinal)
rupture or impending rupture
rapid expansion >1cm/year
refractory pain
hypertension despite maximal medical therapy
300
What is the physiologic explanation for athlete's bradycardia and high vagal tone?
Enhanced parasympathetic tone + increased stroke volume from cardiac remodeling → lower resting HR required to meet cardiac output needs; intrinsic SA node rate also decreases with sustained training
300
Tricyclic antidepressant overdose — mechanism of cardiotoxicity and ECG finding?
Sodium channel blockade → wide QRS; also alpha blockade (hypotension) and anticholinergic effects (tachycardia); terminal R wave in aVR >3mm predicts arrhythmia risk
300
What is the difference between a revocable and irrevocable trust and why would a high-earning physician choose the latter?
Revocable: you control it, can change it, assets still in your estate for tax purposes.
Irrevocable: you give up control, assets removed from your taxable estate — used for asset protection from malpractice, Medicaid planning, and reducing estate tax exposure above the $13.6M federal exemption (2024)
400
Per ACC cardio-oncology guidelines, when should cardioprotective therapy be started during anthracycline treatment?
ACE inhibitor/ARB + beta-blocker initiated when EF drops ≥10% or GLS declines >15% — some centers start prophylactically in high-risk patients (prior cardiac disease, high cumulative dose.
400
Scimitar syndrome — describe the anatomy and its hemodynamic consequence?
Partial anomalous pulmonary venous return of right lung to IVC — left-to-right shunt; scimitar sign on CXR (curved vessel shadow); associated with right lung hypoplasia and dextroposition of heart
400
Loeys-Dietz syndrome vs Marfan — which has more aggressive aortic disease and why?
Loeys-Dietz — TGFBR1/2 mutation causes more diffuse arterial tortuosity and aneurysms throughout entire arterial tree (not just aorta); dissection occurs at smaller diameters than Marfan; surgical threshold 4.0–4.5 cm vs 4.5–5.0 cm in Marfan; also intracranial aneurysms, cervical spine instability — requires whole-body MRA surveillance annually
400
In exercise-induced hypertension, what is the SBP definition (men and women), and significance?
SBP >210 mmHg in men or >190 mmHg in women at peak exercise — associated with increased risk of future resting hypertension and LVH; consider antihypertensive therapy if exaggerated response with normal resting BP
400
Clozapine cardiac toxicity — what life-threatening complication occurs and when in treatment course?
Myocarditis — occurs in first 4–8 weeks of treatment; also cardiomyopathy with chronic use; monitor troponin and CRP weekly for first month; discontinue immediately if myocarditis suspected
400
Name the two most important disability optional riders and why each matters?
(1) Future increase option (FIO) — locks in ability to increase coverage as attending income grows without new medical underwriting; critical before any health changes occur.
(2) Own-occupation rider — ensures benefit pays if you can't perform subspecialty specifically even if you can still practice general medicine; without it, policy may deny claim if you can see office patients
500
Clonal hematopoiesis of indeterminate potential (CHIP) — why is it relevant to cardio-oncology?
CHIP mutations (TET2, DNMT3A) independently increase cardiovascular risk — accelerate atherosclerosis and heart failure; also increases risk of chemotherapy cardiotoxicity; emerging screening target in cardio-oncology
500
Name four specific long-term complications of Fontan circulation and their mechanisms?
Protein-losing enteropathy (elevated venous pressure → gut lymphatic leak)
Fontan-associated liver disease (hepatic venous congestion → fibrosis → HCC)
plastic bronchitis (lymphatic casts in airways)
atrial arrhythmias (massively dilated atria from chronic high pressure)
500
Ehlers-Danlos Type IV — why is surgical mortality so high and what is the management strategy?
COL3A1 mutation causes Type III collagen deficiency — arterial walls extremely fragile, tear with minimal manipulation; sutures pull through tissue; surgical mortality 5–10x higher than standard aortic surgery;
Management: avoid elective surgery, angiography only if absolutely necessary, conservative management of dissection/rupture when possible — most patients die from spontaneous arterial rupture not amenable to repair
500
Wolff-Parkinson-White in an asymptomatic athlete — when is ablation recommended per current guidelines?
Electrophysiology study recommended to risk-stratify; ablation recommended if SPERRI <250ms or ERP <250ms during EP study — asymptomatic WPW with high-risk EP findings warrants ablation before competitive sport clearance
500
Chloroquine/hydroxychloroquine overdose — ECG findings and how do you treat it?
Wide QRS, QT prolongation, ventricular arrhythmias — sodium channel blockade similar to TCA; sodium bicarbonate alkalinizes serum, reduces drug-channel binding, narrows QRS; also treat hypokalemia aggressively
500
Explain how S-corp election reduces self-employment tax, the IRS reasonable salary requirement, and the risk of underpaying salary.
S-corp splits income into W2 salary (subject to FICA 15.3%) and distributions (not subject to FICA); IRS requires "reasonable compensation" for services — typically 40–60% of net profit; underpaying salary triggers IRS audit, back FICA taxes, penalties; savings of $10,000-$30,000/year at high income levels if structured correctly