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B
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100
A 67-year-old woman is evaluated during a follow-up visit for heart failure with reduced ejection fraction. She reports stable dyspnea with exertion when carrying groceries from her car or walking up a hill. She has no other symptoms. Medications are carvedilol, spironolactone, maximum-dose lisinopril, dapagliflozin, and furosemide.
On physical examination, blood pressure is 108/72 mm Hg and pulse rate is 60/min. The remainder of the examination is unremarkable.
Laboratory studies reveal a serum creatinine level of 1.3 mg/dL (114.9 μmol/L).
A previous echocardiogram showed a left ventricular ejection fraction of 37%.
What is the most appropriate treatment?
Switch lisinopril to valsartan-sacubitril
Add digoxin
Add ivabradine
Increase carvedilol dosage
100
A 76-year-old man is evaluated in follow-up for a 4-month history of intermittent claudication, for which he completed an exercise rehabilitation program. He continues to experience left lower extremity discomfort with exertion, which has limited his walking ability. Medical history is significant for hypertension and hyperlipidemia. He quit smoking 2 years ago. Medications are low-dose aspirin, atorvastatin, and enalapril.
Serum total cholesterol level is 150 mg/dL (3.8 mmol/L), serum LDL cholesterol level is 68 mg/dL (1.7 mmol/L), and serum HDL cholesterol level is 49 mg/dL (1.3 mmol/L).
What is the most appropriate additional treatment to improve this patient's leg pain?
Cilostazol
Clopidogrel
Evolocumab
Pentoxifylline
Vitamin B-complex supplementation
100
An 18-year-old man is evaluated for a heart murmur noted on a preparticipation sports examination. He remembers being told about a murmur in the past, but he has had no prior testing or intervention. He is asymptomatic, without known medical problems, and takes no medications.
On physical examination, vital signs are normal. The estimated central venous pressure is normal. Apical impulse is normal, and a thrill is noted along the left sternal border. A grade 4/6 holosystolic murmur is heard at the left sternal border, obscuring the S2. The remainder of the physical examination is unremarkable.
An ECG and chest radiograph are normal.
What is the most likely diagnosis?
Ventricular septal defect
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
100
A 57-year-old man is evaluated for a 2-month history of exertional chest pain.
The physical examination, including vital signs, is normal.
Baseline ECG is normal. During treadmill stress testing, he develops 2-mm horizontal ST-segment depression in leads V5 through V6 associated with chest pain that resolves with rest. Coronary angiographic findings include a 60% distal left main bifurcation stenosis with extension into the proximal left circumflex artery. There is an additional 80% stenosis involving the bifurcation of the left anterior descending artery and large first diagonal branch. The right coronary artery is large and without significant stenosis. Left ventriculogram shows global left ventricular dysfunction with a left ventricular ejection fraction of 42%.
What is the most appropriate management?
Coronary artery bypass grafting
Medical therapy without revascularization
Myocardial viability testing
Percutaneous coronary intervention
200
A 78-year-old woman with progressive exertional dyspnea and chest pain is evaluated for aortic valve replacement. Results show severe aortic stenosis in the absence of obstructive coronary artery disease. Medical history is significant for hypertension, chronic kidney disease (stage G3a), hyperlipidemia, COPD, and atrial fibrillation. Medications are amlodipine, atorvastatin, lisinopril, metoprolol, apixaban, furosemide, and an albuterol-ipratropium inhaler.
Her Society of Thoracic Surgeons adult cardiac surgery risk score is consistent with high risk.
What is the most appropriate next step in treatment?
Transcatheter aortic valve implantation
Balloon aortic valvuloplasty
Continued medical therapy
Surgical aortic valve replacement
200
A 21-year-old woman is evaluated in the hospital following cardiac arrest that occurred during a collegiate cross-country race. She received cardiopulmonary resuscitation at the scene and has recovered while at the hospital. She has no pertinent personal medical history. The patient takes no medications.
On physical examination, vital signs are normal. The remainder of the examination is unremarkable.
Laboratory studies are within normal limits.
Echocardiogram shows normal left ventricular function and right ventricular dilation and dysfunction. Results from cardiac catheterization are normal.
Metoprolol is initiated.
What is the most appropriate additional management before discharge?
Implantable cardioverter-defibrillator
Amiodarone
Genetic testing
Lisinopril
200
A 43-year-old man is evaluated during a follow-up visit for heart failure with mildly reduced ejection fraction (ejection fraction, 45%) and type 2 diabetes mellitus. He is currently asymptomatic. Medications are metformin, valsartan-sacubitril, metoprolol, spironolactone, and atorvastatin.
On physical examination, blood pressure is 108/72 mm Hg and pulse rate is 64/min. There is no S3, jugular venous distention, or peripheral edema.
Hemoglobin A1c level is 6.9%.
What is the most appropriate additional treatment?
Empagliflozin
Digoxin
Furosemide
Ivabradine
200
A 57-year-old man is evaluated for a 6-month history of stable chest pain. He experiences chest pressure that occurs after walking 1 mile and resolves promptly with rest. He has no symptoms at rest. His history includes aspirin allergy manifesting as hives and difficulty breathing after taking 325 mg of aspirin as a teenager. He is a never smoker. He has hyperlipidemia. His only medication is atorvastatin.
On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is normal.
Resting ECG is normal, and an exercise ECG is scheduled. The patient receives counseling on lifestyle interventions to reduce his risk for disease progression. Antianginal medications will be initiated.
What is the most appropriate cardioprotective treatment?
Clopidogrel
Low-dose aspirin
Prasugrel
Ticagrelor
300
A 70-year-old man is evaluated for fatigue and dyspnea with exertion that have progressed over 1 year. He reports no chest pain. Medical history is significant for hypertension, hyperlipidemia, and bilateral carpal tunnel syndrome. Medications are losartan, hydrochlorothiazide, and atorvastatin.
On physical examination, vital signs are normal. Central venous pressure is elevated, and crackles are heard at the lung bases. The remainder of the physical examination is normal.
Laboratory studies show a B-type natriuretic peptide level of 640 pg/mL (640 ng/L).
An ECG is shown. An echocardiogram shows normal left ventricular (LV) cavity size and moderate concentric LV hypertrophy. The LV ejection fraction is 50%. Valve structure and function are normal. Right ventricular hypertrophy is present, cavity size is normal, and function is normal. Estimated right ventricular systolic pressure is 40 mm Hg.
What is the most appropriate test?
Cardiac magnetic resonance imaging with gadolinium contrast
Exercise echocardiography
Right and left heart catheterization
Serum α-galactosidase level
300
A 70-year-old man is evaluated for recently diagnosed paroxysmal atrial fibrillation that is mildly symptomatic. Medical history is significant for hypertension and previous stroke. Medications are rivaroxaban and metoprolol. He has experienced no episodes of bleeding on anticoagulation therapy.
On physical examination, blood pressure is 128/74 mm Hg and pulse rate is 72/min and regular. The remainder of the examination is unremarkable.
An echocardiogram reveals an enlarged left atrium and normal left ventricle. Forty-eight–hour ambulatory ECG monitoring shows atrial fibrillation prevalence of 10% with a controlled ventricular rate less than 90/min and no other abnormalities.
What is the most appropriate treatment?
Rhythm control
Left atrial appendage occlusion
Pacemaker implantation
Switch rivaroxaban to warfarin
No additional therapy
300
A 72-year-old man is hospitalized with decompensated heart failure. Initial overnight treatment consisted of intravenous furosemide equal to his total oral outpatient dose (40 mg). Overnight urine output was 250 mL, with no change in his symptoms. Medical history is significant for hyperlipidemia and hypertension. Outpatient medications are lisinopril, metoprolol succinate, furosemide, and atorvastatin.
On physical examination, blood pressure is 122/82 mm Hg, pulse rate is 88/min, respiration rate is 26/min, and oxygen saturation is 95% with the patient breathing 2 L/min of oxygen by nasal cannula. He is alert, and his skin is warm and dry. Central venous pressure is elevated. Cardiac examination does not reveal an S3. There is pitting edema to his knees.
Serum electrolytes are normal, creatinine level is 1.5 mg/dL (132.6 μmol/L), and B-type natriuretic peptide level is elevated.
What is the most appropriate treatment?
Increase intravenous furosemide
Add intravenous milrinone
Add intravenous nitroglycerin
Discontinue metoprolol
300
A 75-year-old man is evaluated for a 3-week history of shortness of breath and intermittent fevers. He underwent transcatheter aortic valve implantation for aortic stenosis 3 years ago. He was admitted to the hospital 1 month ago with diverticulitis and was treated with antibiotic therapy; he developed intermittent fevers 1 week later. His only medication is low-dose aspirin.
On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 145/72 mm Hg, and pulse rate is 90/min. Cardiac examination reveals a normal S1 and S2 and no murmurs. There is no evidence of heart failure.
An ECG shows no notable findings. A transthoracic echocardiogram shows a left ventricular ejection fraction of 55% with normal right ventricular function. A bioprosthetic aortic valve is evident, with fully mobile and normal-appearing leaflets.
Three sets of blood cultures are negative.
What is the most appropriate diagnostic test?
Transesophageal echocardiography
Cardiac CT
Cardiac magnetic resonance imaging
No further testing
400
An 84-year-old man is evaluated during a routine physical examination. His only concern is a gradual loss of stamina and low energy. He can no longer complete his routine 2-mile run without stopping to rest with a prolonged recovery time. He has hypertension, for which he takes lisinopril.
On physical examination, blood pressure is 125/78 mm Hg and pulse rate is 52/min. Heart rate is regular. The remainder of the examination is unremarkable.
Laboratory studies are within normal limits, including a recent thyroid-stimulating hormone measurement.
ECG is shown. Ambulatory 48-hour ECG monitoring shows a maximum heart rate of 72/min during vigorous aerobic activity. An echocardiogram and exercise stress test performed 1 year ago for chest pain revealed normal left ventricular function and no ischemia, with appropriate augmentation of heart rate.
What is the most appropriate management?
Reassurance and clinical monitoring
Hospital admission
Pacemaker implantation
Switch lisinopril to amlodipine
400
A 60-year-old woman is evaluated for severe abdominal pain. She was admitted to the hospital 2 days ago with an acute type B aortic dissection and treated medically. Her admission CT angiogram revealed an aortic dissection beginning just distal to the left subclavian artery and extending to the distal aorta just below the inferior mesenteric artery. Her symptoms initially resolved with morphine, esmolol, and nitroprusside. Yesterday, esmolol was replaced with metoprolol. She is taking no other medications.
On physical examination today, temperature is 37.2 °C (99 °F), blood pressure is 120/80 mm Hg, pulse rate is 64/min, and respiration rate is 20/min. Oxygen saturation is 98% with the patient breathing ambient air. The patient is restless. She has recurrent abdominal pain, but palpation reveals mild to moderate tenderness and no guarding. The skin is cool and mottled from the knees to the feet, with diminished femoral arterial pulses.
What is the most appropriate next step in management?
Repair the descending aorta
Add intravenous enalaprilat
Increase nitroprusside infusion
Switch nitroprusside to amlodipine
400
A 72-year-old man is evaluated during a routine physical examination. He feels well and reports no exertional limitations. He has no pertinent personal or family history. He takes no medications.
On physical examination, pulse rate is 72/min with occasional irregularity; other vital signs are normal. On cardiac examination, heart sounds are regular, with occasional premature beats associated with cannon a waves on neck examination. The remainder of the examination is unremarkable.
Laboratory studies, including complete blood count and thyroid-stimulating hormone level, are normal.
ECG shows one premature ventricular contraction and is otherwise normal.
What is the most appropriate management?
Reassurance
Cardiac magnetic resonance imaging
Exercise ECG
Metoprolol
400
A 42-year-old woman is seen to establish care. She is asymptomatic. Medical history is significant only for hypertension, for which she takes losartan; she has no history of diabetes mellitus or smoking. She does not take aspirin. Family history is noncontributory.
On physical examination, blood pressure is 118/74 mm Hg. The remainder of the examination is unremarkable.
Laboratory studies (nonfasting):
Total cholesterol 241 mg/dL (6.24 mmol/L)
HDL cholesterol 99 mg/dL (2.56 mmol/L)
LDL cholesterol 116 mg/dL (3.00 mmol/L)
Triglycerides 128 mg/dL (1.45 mmol/L)
What is the most appropriate next step in management?
Calculate 10-year risk for atherosclerotic cardiovascular disease
Begin high-intensity statin therapy
Begin high-intensity statin therapy and ezetimibe
Repeat lipid profile while fasting
500
A 59-year-old woman is evaluated in the emergency department for two episodes of crushing chest pain occurring at rest during the past 24 hours. The last episode occurred 2 hours ago; she is currently pain-free. She has no history of coronary artery disease or heart failure symptoms. History is notable only for hypertension treated with amlodipine; she takes no other medications. Aspirin, intravenous unfractionated heparin, and metoprolol are initiated.
On physical examination, vital signs are normal. The remainder of the examination is unremarkable.
The initial high-sensitivity cardiac troponin level is normal (<99th percentile upper reference limit).
ECG is shown.
The calculated TIMI score is 1.
What is the most appropriate additional management?
Clopidogrel
Nitroglycerin infusion
Tirofiban infusion
Urgent coronary angiography
500
A 56-year-old man is evaluated during a follow-up visit for ischemic cardiomyopathy (ejection fraction, 20%). He has had two heart failure hospitalizations in the past year. He can no longer perform household chores. He also has hypertension and chronic kidney disease, with a baseline serum creatinine level of 1.5 mg/dL (132.6 μmol/L). He is receiving maximally tolerated heart failure therapy consisting of losartan, carvedilol, empagliflozin, furosemide, and spironolactone.
Physical examination findings, including vital signs, are normal.
Serum creatinine level is 1.9 mg/dL (168 μmol/L), serum potassium level is 5.3 mEq/L (5.3 mmol/L), and serum sodium level is 129 mEq/L (129 mmol/L).
The patient wishes to pursue care that will restore functionality.
What is the most appropriate long-term treatment?
Heart transplantation
Left ventricular assist device placement
Tolvaptan
Digoxin
500
A 22-year-old woman is evaluated in the emergency department for orthopnea and paroxysmal nocturnal dyspnea. She is 8 days postpartum. Delivery was uncomplicated, and she was discharged home the following day. She has no other medical problems and takes no medications.
On physical examination, blood pressure is 108/82 mm Hg in both arms, pulse rate is 112/min and regular, and respiration rate is 26/min. The central venous pressure is elevated, and an S3 and bilateral pulmonary crackles are present.
A chest radiograph shows pulmonary edema. An ECG reveals sinus tachycardia without ischemic changes. Transthoracic echocardiogram shows left ventricular dilatation with global hypokinesis; ejection fraction is 38%. Right heart size and function are normal.
What is the most likely diagnosis?
Peripartum cardiomyopathy
Acute pulmonary embolism
Ascending aortic dissection
Spontaneous coronary artery dissection
500
A 68-year-old man is evaluated in the hospital for a 1-month history of nonproductive cough, dyspnea, and constant chest pressure. He is a never-smoker.
On physical examination, blood pressure is 106/62 mm Hg with 18 mm Hg pulsus paradoxus, and pulse rate is 100/min. Central venous pressure is elevated, and heart sounds are distant.
A focused echocardiogram shows a 2-cm circumferential pericardial effusion with evidence of tamponade. Pericardiocentesis yields 650 mL of sanguinous fluid with marked improvement in symptoms.
A transthoracic echocardiogram (apical four-chamber view) after pericardiocentesis is shown (RA = right atrium, RV = right ventricle, LV = left ventricle, EFF = pericardial effusion). A chest CT scan with contrast after pericardiocentesis reveals a 4-mm right middle lobe nodule and a small pericardial effusion with drain in place. A 3 × 3–cm right atrial mass is present, contiguous with the lateral wall of the right atrium.
What is the most likely diagnosis?
Cardiac angiosarcoma
Atrial myxoma
Bronchogenic carcinoma with cardiac metastasis
Papillary fibroelastoma