A
B
C
D
100
A 48-year-old man is evaluated for a 6-month history of dyspnea and near-syncope with exertion. He has no other medical problems and takes no medication.
On physical examination, vital signs are normal. A grade 3/6 systolic ejection-quality murmur is heard along the left sternal border. The carotid impulse is brisk. The murmur decreases significantly in intensity with the patient squatting. There is no radiation of the murmur to the carotid arteries. No ejection sound or systolic click is heard. There is no variation with respiration, and no diastolic murmur is present.
What is the most likely diagnosis?
Hypertrophic cardiomyopathy
Bicuspid aortic stenosis
Restrictive membranous ventricular septal defect
Ruptured sinus of Valsalva aneurysm
100
A 42-year-old woman is evaluated in the emergency department for abrupt-onset palpitations. For the past year, she has been having similar episodes with increasing frequency. She has been able to stop these previous episodes by coughing. She reports no syncopal episodes.
On physical examination, blood pressure is 95/68 mm Hg, pulse rate is 200/min, and respiration rate is 16/min. All other physical examination findings are unremarkable.
ECG is shown. A previous ECG showed sinus rhythm with a heart rate of 72/min without any abnormalities.
What is the most likely rhythm diagnosis?
Atrioventricular nodal reentrant tachycardia
Atrial fibrillation
Atrial tachycardia
Ventricular tachycardia
100
A 65-year-old woman is evaluated in follow-up for a recent diagnosis of nonischemic dilated cardiomyopathy. Her symptoms included dyspnea with minimal exertion and orthopnea. The initial evaluation also revealed echocardiographic findings compatible with severe secondary mitral regurgitation (mitral annular dilation without any mitral leaflet abnormalities) and a left ventricular ejection fraction of 40%. Image quality was excellent. Lisinopril, carvedilol, spironolactone, and furosemide have been titrated to achieve maximal therapeutic effectiveness. Her symptoms are now New York Heart Association functional class I.
On physical examination, blood pressure is 95/62 mm Hg and pulse rate is 70/min; other vital signs are normal. A holosystolic murmur is loudest at the apex. Central venous pressure is slightly elevated. Lungs are clear.
What is the most appropriate additional management?
No additional therapy
Cardiac magnetic resonance imaging
Cardiac resynchronization therapy
Surgical mitral valve repair
100
A 42-year-old man is evaluated during a follow-up visit for a patent ductus arteriosus (PDA) identified early in life. He had regular follow-up visits through adolescence but has not had a medical evaluation recently. He is asymptomatic.
On physical examination, blood pressure is 120/70 mm Hg. Apical impulse is displaced laterally. A continuous murmur that envelops the S2 is heard beneath the left clavicle. The remainder of the cardiac examination is unremarkable.
Echocardiogram demonstrates a PDA with left-to-right shunt. The left atrium and left ventricle are moderately enlarged, and the left ventricular ejection fraction is 63%. The right heart chambers are normal in size. The estimated right ventricular systolic pressure is 30 mm Hg.
What is the most appropriate management?
PDA device closure
Cardiac magnetic resonance imaging
Indomethacin
Serial echocardiographic monitoring
200
A 74-year-old man is evaluated for a 6-month history of progressive bilateral calf pain. The discomfort is worse with walking and improves quickly with rest. Medical history is significant for hypertension and hyperlipidemia. He has a 50-pack-year history of smoking but quit 5 years ago. Medications are rosuvastatin, quinapril, and metoprolol.
On physical examination, vital signs are normal. A right femoral bruit is noted. Bilateral femoral pulses and pedal pulses are faint. Motor and sensory examinations are normal; reflexes are normal.
The ankle-brachial index is 0.92 on the right and 0.94 on the left.
What is the most appropriate test to perform next?
Exercise ankle-brachial index testing
Invasive angiography
Magnetic resonance angiography
Segmental lower extremity blood pressure testing
200
A 57-year-old woman is evaluated in the emergency department for an acute anterior ST-elevation myocardial infarction.
Aspirin, ticagrelor, unfractionated heparin, and intravenous nitroglycerin are initiated. Emergent coronary angiography reveals an acutely occluded proximal left anterior descending (LAD) coronary artery and 70% stenosis of the mid right coronary artery. The LAD lesion is treated with drug-eluting stent placement, resulting in resolution of chest pain and improvement in the ST-segment elevation seen on ECG.
Following successful percutaneous coronary intervention, blood pressure is 138/82 mm Hg, pulse rate is 78/min, respiration rate is 18/min, and oxygen saturation is 94% with the patient breathing ambient air. The remainder of the examination is unremarkable.
What is the most appropriate additional management?
Right coronary artery revascularization
Glycoprotein IIb/IIIa inhibitor infusion
Predischarge exercise ECG
Supplemental oxygen
200
A 41-year-old man is evaluated for a 2-week history of daily palpitations that last minutes at a time and resolve spontaneously. The palpitations are not associated with any specific activity. He is otherwise healthy and takes no medications.
Physical examination findings, including vital signs, are normal.
What is the most appropriate initial test?
12-Lead resting ECG
Exercise ECG
30-Day event monitor
24-Hour ambulatory ECG monitor
200
A 56-year-old man is evaluated in the emergency department for acute shortness of breath and the sensation of a racing heart. His only medical problem is hypertension treated with chlorthalidone.
On physical examination, blood pressure is 89/52 mm Hg and pulse rate is 150/min. Cardiac examination reveals a regular tachycardia. Jugular venous distention and pulmonary crackles are present.
ECG is shown. The patient is successfully cardioverted.
What is the most appropriate additional treatment?
Catheter ablation
Amiodarone
Flecainide
Metoprolol
No additional treatment
300
A 68-year-old man is evaluated 1 month after atherectomy and stenting of the right superficial femoral artery for severe claudication. Since the procedure, he can walk and perform all of his customary activities without claudication. Medical history is significant for hypertension, hyperlipidemia, and coronary artery disease. He exercises 150 minutes weekly and consumes a heart-healthy diet. He quit smoking 15 years ago. Medications are low-dose aspirin, low-dose rivaroxaban, metoprolol, ramipril, and high-intensity rosuvastatin.
On physical examination, blood pressure is 124/70 mm Hg. The remainder of the physical examination is unremarkable.
Laboratory studies reveal a serum total cholesterol level of 120 mg/dL (3.1 mmol/L), serum LDL cholesterol level of 50 mg/dL (1.3 mmol/L), and serum HDL cholesterol level of 48 mg/dL (1.2 mmol/L).
What is the most appropriate additional treatment?
No additional treatment
Cilostazol
Evolocumab
Ticagrelor
300
A 47-year-old man is evaluated for a heart murmur. He is asymptomatic and has no exercise limitations.
On physical examination, vital signs, including blood pressure, are normal. There is a grade 1/6 decrescendo diastolic murmur heard at the left sternal border. The remainder of the examination is normal.
Echocardiogram shows a left ventricular ejection fraction of 55%, a bicuspid aortic valve with mild aortic regurgitation, and a normal left ventricular end-systolic dimension. The ascending aorta is enlarged, with a dimension of 4.2 cm. Echocardiographic imaging quality of the aortic sinuses, sinotubular junction, and ascending aorta is excellent.
What of the following is the most appropriate management?
Echocardiographic surveillance
Aortic valve replacement and repair of the ascending aorta
Cardiac magnetic resonance imaging
Initiation of losartan
300
A 48-year-old man is evaluated for recurrent pericarditis. Six months ago, he had acute pericarditis treated with ibuprofen and colchicine. His symptoms resolved completely within 3 weeks of initiation of therapy. Evaluations for an infectious cause and connective tissue disease were negative. The patient's symptoms recurred after ibuprofen was tapered over 1 month with continuation of colchicine. Ibuprofen was re-initiated at a high dose with resolution of symptoms and tapered over a 2-month period. His current symptoms began 24 hours ago. Currently, his only medication is colchicine.
On physical examination, temperature is 38.0 °C (100.4 °F); other vital signs are normal. Pulsus paradoxus of 10 mm Hg is present. There is no jugular venous distention. The lungs are clear to auscultation. A friction rub is heard at the left sternal border and apex.
ECG shows normal sinus rhythm with widespread ST-segment elevation of 0.5 to 1.0 mm. Echocardiogram shows a small circumferential pericardial effusion (diastolic echo-free space, 3 mm) without evidence of tamponade.
What is the most appropriate treatment?
Ibuprofen, colchicine, and prednisone
Anakinra
Colchicine and intravenous immune globulin
Ibuprofen
300
A 61-year-old man is evaluated in the emergency department for palpitations that began this morning. He has a history of coronary artery disease treated with coronary artery stenting 18 months ago and left ventricular dysfunction. Medications are aspirin, metoprolol, spironolactone, and lisinopril.
On physical examination, blood pressure is 100/65 mm Hg and pulse rate is 130/min; other vital signs are normal. Oxygen saturation is 98% with the patient breathing ambient air. Intermittent cannon a waves are noted on neck examination. Other than tachycardia, cardiac examination is normal. Breath sounds are clear.
ECG with rhythm strips is shown.
What is the most likely diagnosis?
Monomorphic ventricular tachycardia
Preexcited tachycardia
Supraventricular tachycardia with aberrancy
Torsades de pointes
400
A 45-year-old man is seen for cardiovascular risk reduction. Hyperlipidemia was diagnosed 4 years ago and is treated with atorvastatin. He has a 35-pack-year history of cigarette smoking and is a current smoker. Six months ago, prediabetes was diagnosed. He occasionally has a depressed mood. He does not take aspirin on a regular basis.
On physical examination, vital signs are normal. BMI is 29. The remainder of the examination is unremarkable.
What is the most appropriate management?
Smoking cessation counseling and varenicline
Depression screening and treatment
Low-dose aspirin
Weight loss
400
A 56-year-old woman is evaluated before starting treatment with trastuzumab for early-stage HER2-positive breast cancer. She has no cardiovascular symptoms and has no exercise-related limitations. She has hypertension and hyperlipidemia. Medications are losartan and atorvastatin.
On physical examination, vital signs and other findings are normal. The breast surgery site has healed.
Results of routine laboratory studies are normal.
Findings on echocardiogram are normal. Left ventricular ejection fraction is 55%.
What is the most appropriate cardiac surveillance for this patient?
Echocardiography
Cardiac magnetic resonance imaging
Multigated acquisition (MUGA) scan
No surveillance
400
A 69-year-old man is evaluated for persistent angina despite maximally tolerated antianginal therapy. Symptoms appear after walking less than one-half mile and interfere with his quality of life and occupation as a mail carrier. He has no pain at rest or heart failure symptoms. He frequently experiences light-headedness when arising from a seated position. He has a 20-pack-year history of smoking but stopped 25 years ago. Medications are aspirin, metoprolol, sublingual nitroglycerin, and rosuvastatin.
On physical examination, blood pressure is 108/72 mm Hg, pulse rate is 54/min, and respiration rate is 20/min. The remainder of the physical examination is normal.
An ECG shows sinus rhythm. A chest radiograph is normal.
What is the most appropriate management?
Coronary angiography
Addition of clopidogrel
Addition of isosorbide mononitrate
Exercise echocardiography
400
A 70-year-old man is referred for evaluation after a 6.1-cm abdominal aortic aneurysm was discovered on routine screening ultrasonography. Medical history is significant for hypertension and hyperlipidemia. He has a 50-pack-year history of cigarette smoking, stopping 6 years ago. Medications are rosuvastatin and chlorthalidone.
On physical examination, vital signs are normal. BMI is 28. A bruit is heard over the abdomen, and a pulsatile abdominal mass is present to the left of the midline.
Wat is the most appropriate next step in management?
CT angiography
Abdominal aortography
ACE inhibitor therapy
Open abdominal aortic aneurysm repair
Repeat duplex ultrasonography in 6 months
500
A 47-year-old man is evaluated for management of heart failure with reduced ejection fraction (ejection fraction, 30%) diagnosed 3 years ago. He has New York Heart Association functional class III symptoms and has been stable for the past year. His medical history also includes ACE inhibitor–induced angioedema, spironolactone-induced gynecomastia, and atrial fibrillation. An implantable cardioverter-defibrillator is in place. Medications are losartan, carvedilol, empagliflozin, furosemide, and apixaban.
On physical examination, blood pressure is 120/68 mm Hg and pulse rate is 78/min and irregular. Other than an irregularly irregular heart rhythm, the remainder of the examination is normal.
Serum creatinine and electrolyte levels are normal.
What is the most appropriate treatment?
Add eplerenone
Add ivabradine
Switch carvedilol to metoprolol succinate
Switch losartan to valsartan-sacubitril
500
A 55-year-old woman is evaluated for a 6-month history of progressive fatigue and dyspnea while walking on level ground.
On physical examination, blood pressure is normal and pulse rate is 80/min. Cardiac examination reveals an opening snap and a diastolic rumble heard best at the cardiac apex. Estimated central venous pressure is normal.
A resting echocardiogram shows a left ventricular ejection fraction greater than 55% and a normal-size right ventricle with preserved function. The mitral valve is thickened and appears rheumatic, with restricted opening of the leaflet tips. The mitral gradient and calculated valve area are consistent with moderate mitral stenosis.
What is the most appropriate management?
Exercise echocardiography
Cardiac catheterization
Cardiac magnetic resonance imaging
Percutaneous balloon mitral commissurotomy
Transesophageal echocardiography
500
A 74-year-old man is evaluated in the emergency department for somnolence. He resides in a skilled nursing facility. His transfer note indicates that he has moderately severe Alzheimer disease treated with donepezil.
On physical examination, blood pressure is 70/40 mm Hg and pulse rate is 30/min; other vital signs are normal. Oxygen saturation with the patient breathing ambient air is 97%. The patient is difficult to arouse. Cardiac examination reveals bradycardia but is otherwise unremarkable.
Complete blood count and electrolyte levels are normal.
Cardiac telemetry shows sinus bradycardia with heart rate of 30/min.
What is the most appropriate treatment?
Intravenous atropine
Amiodarone
Chest compressions
Isoproterenol
500
A 78-year-old woman is evaluated for a 3-month history of heart failure with reduced ejection fraction (ejection fraction, 20%). She has stable dyspnea when walking up stairs but has no other symptoms. Her medical history is otherwise unremarkable. Medications are valsartan-sacubitril, carvedilol, furosemide, empagliflozin, and spironolactone. Carvedilol is at half-maximum dosage; all other medications are at maximum recommended dosages.
On physical examination, blood pressure is 118/74 mm Hg and pulse rate is 88/min. BMI is 27, unchanged from her last visit. Central venous pressure and the remainder of the examination are normal.
What is the most appropriate treatment?
Increase carvedilol
Add ivabradine
Decrease valsartan-sacubitril
Increase furosemide