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B
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D
100
A 76-year-old man is evaluated for a 4-week history of shortness of breath and chest discomfort with minimal exertion. Medical history is significant for hypertension and hyperlipidemia. Medications are low-dose aspirin, amlodipine, atorvastatin, lisinopril, and metoprolol.
On physical examination, blood pressure is 135/83 mm Hg; other vital signs are normal. Cardiac examination reveals a late-peaking crescendo-decrescendo systolic murmur heard at the right upper sternal border with loss of S2. Central venous pressure is elevated. There are crackles at the lung bases.
Laboratory studies demonstrate a B-type natriuretic peptide level of 2000 pg/mL (2000 ng/L).
An ECG shows normal sinus rhythm without ST-T–wave changes. An echocardiogram shows a moderately thickened, partially mobile aortic valve, with left ventricular ejection fraction of 45% and hemodynamic measurements compatible with low-flow, low-gradient severe aortic stenosis.
What is the most appropriate management?
Dobutamine stress echocardiography
Cardiac catheterization
Surgical aortic valve replacement
Transcatheter aortic valve implantation
100
A 57-year-old man is evaluated in the emergency department after a cardiac arrest. Bystander cardiopulmonary resuscitation and use of an automated external defibrillator resulted in a return of sinus rhythm. An initial ECG revealed ST-segment depression in leads V5 and V6. After initiation of aspirin, unfractionated heparin, and ticagrelor, angiography revealed no significant obstructive lesions. He is admitted to a monitored bed, where he develops acute persistent chest pain, hypotension, and the ECG changes shown.
Blood pressure is 95/60 mm Hg, pulse rate is 55/min, respiration rate is 24/min, and oxygen saturation is 96% with the patient breathing ambient air. Cardiac examination is normal. Bibasilar pulmonary crackles are present.
The initial high-sensitivity troponin level is elevated (>99th percentile upper reference limit); urine toxicology screen is negative for drugs.
Following intravenous nitroglycerin, blood pressure increases and chest pain subsides. Follow-up ECG is shown.
What is the most likely diagnosis?
Coronary vasospasm
Coronary embolism
Pulmonary embolism
Stress (takotsubo) cardiomyopathy
100
A 55-year-old man is evaluated for easy bruising. The patient underwent mechanical mitral valve replacement 1 year ago. He reports no bleeding. His only medication is warfarin.
On physical examination, vital signs are normal. Cardiac examination reveals a normal mechanical valve sound without murmur. The remainder of the cardiopulmonary examination is normal. Examination of the arms reveals numerous ecchymoses.
Laboratory studies reveal a normal hemoglobin level; INR is 3.4 and has ranged between 2.6 and 3.5 over the past 3 months.
What is the most appropriate treatment?
Continue current warfarin dosage
Decrease warfarin dosage
Discontinue warfarin and start aspirin
Discontinue warfarin and start dabigatran
Discontinue warfarin and start rivaroxaban
100
A 73-year-old woman is evaluated in the emergency department for a 1-day history of recurrent ischemic chest pain. The last episode began 30 minutes ago and is ongoing despite escalating doses of sublingual and parenteral nitroglycerin. History is significant for hypertension and dyslipidemia. Medications are enalapril and atorvastatin.
On physical examination, blood pressure is 119/84 mm Hg, and pulse rate is 104/min. Other than an S4, the cardiopulmonary examination is normal.
The first set of cardiac biomarker levels is normal.
ECG shows sinus tachycardia and new 2-mm ST-segment depressions in the inferior leads.
What is the most appropriate imaging test in this patient?
Invasive coronary angiography
Coronary artery calcium scoring
Coronary CT angiography
Transthoracic echocardiography
200
A 62-year-old woman is hospitalized for a non–ST-elevation myocardial infarction. She has hypertension, type 2 diabetes mellitus, newly symptomatic aortic stenosis, and coronary artery disease, for which she underwent percutaneous coronary intervention 1 year ago. Medications are low-dose aspirin, ticagrelor, metoprolol, ramipril, metformin, and high-intensity atorvastatin.
On physical examination, vital signs are normal. A grade 3/6 harsh midsystolic murmur is noted at the right upper sternal border.
An echocardiogram reveals normal left ventricular ejection fraction, severe aortic stenosis, and an enlarged thoracic aorta; the maximal diameter of the ascending aorta is 5.6 cm. Coronary angiography reveals diffuse in-stent restenosis of the proximal left circumflex stent (infarct-related artery), focal proximal left anterior descending artery stenosis, and chronic total occlusion of the right coronary artery.
Coronary bypass graft surgery is planned.
What is the most appropriate additional intervention?
Aortic valve replacement and aortic repair
Transcatheter aortic valve implantation
No additional intervention
Aortic valve replacement
200
A 68-year-old man is evaluated for increasingly frequent angina. One month ago, coronary angiography was performed because of the occurrence of angina at lower levels of exertion. It showed diffuse coronary disease without lesions amenable to revascularization and preserved left ventricular function. Following coronary angiography, the patient increased his dosage of isosorbide mononitrate to twice daily; however, his exertional chest discomfort worsened. He also has hypertension and diabetes mellitus. Previously, diltiazem was substituted for metoprolol because of intolerance. Medications are aspirin, metformin, liraglutide, atorvastatin, lisinopril, diltiazem, and isosorbide mononitrate.
On physical examination, blood pressure is 135/80 mm Hg, pulse rate is 67/min, and respiration rate is 18/min. The remainder of the examination is unremarkable.
ECG shows sinus rhythm and nonspecific intraventricular conduction delay, unchanged from 1 month ago.
What is the most appropriate management?
Reduce isosorbide mononitrate dosage to once daily
Add amlodipine
Decrease lisinopril dosage
Repeat coronary angiography
200
A 50-year-old man is evaluated for 8 weeks of progressive exertional dyspnea and a syncopal event. He has been well otherwise and takes no medications.
On physical examination, vital signs are normal. Cardiac examination reveals a late-peaking systolic crescendo-decrescendo murmur heard at the right upper sternal border with loss of S2. The remainder of the examination is normal.
An ECG shows normal sinus rhythm and left ventricular hypertrophy with repolarization abnormalities.
An echocardiogram shows a severely thickened, minimally mobile bicuspid aortic valve. Hemodynamic measurements on echocardiogram are consistent with severe aortic stenosis and normal left ventricular function. The ascending aorta could not be adequately assessed.
What is the most appropriate management?
CT angiography of the thoracic aorta
Cardiac catheterization
Exercise treadmill stress testing
Transcatheter aortic valve implantation
200
A 74-year-old man is evaluated for shortness of breath that occurs when walking around the house and occasionally when getting dressed. History is significant for ischemic cardiomyopathy and three heart failure hospitalizations over the past 6 months. He was treated for colon cancer 2 years ago; there is no evidence of recurrence. He has an implantable cardioverter-defibrillator. Medications are lisinopril, high-dose furosemide, empaglifozin, and spironolactone. He previously took carvedilol and isosorbide dinitrate–hydralazine, which were discontinued because of symptomatic hypotension.
On physical examination, blood pressure is 94/66 mm Hg and pulse rate is 88/min. Cardiac examination reveals an S3 but no jugular venous distention or dependent edema.
Laboratory studies show a serum creatinine level of 1.7 mg/dL (150 μmol/L) and a serum sodium level of 132 mEq/L (132 mmol/L).
Echocardiogram performed during his last hospitalization showed an ejection fraction of 10%.
The patient is engaged in a discussion regarding management options.
What is the most reasonable next step in management?
Left ventricular assist device placement
Heart transplant
Hospitalization
Low-dose β-blocker
300
A 38-year-old man undergoes a preoperative evaluation before repair of a torn anterior cruciate ligament. His cardiovascular history includes repaired tetralogy of Fallot. He has no symptoms.
On physical examination, vital signs are normal. Jugular venous distention and a prominent a wave are noted. A right ventricular heave is present. A single S2 is heard, as is a grade 1/6 early systolic murmur localized to the left second intercostal space and a grade 2/6 diastolic murmur best heard in the left second and third intercostal spaces. The diastolic murmur increases with inspiration.
What is the most likely diagnosis?
Pulmonary regurgitation
Aortic coarctation
Aortic regurgitation
Mitral stenosis
300
A 70-year-old man is evaluated in the emergency department for 3 days of palpitations and dyspnea. New-onset atrial fibrillation is diagnosed. He also has chronic lymphocytic leukemia. He began ibrutinib 1 month ago.
On physical examination, pulse rate is 128/min and irregularly irregular. Oxygen saturation is 95% with the patient breathing ambient air. Other than a rapid, irregular rhythm, the cardiopulmonary examination is normal. Splenomegaly is present. There is no lower extremity edema.
Laboratory studies show a normal D-dimer level. The initial high-sensitivity cardiac troponin level is normal (<99th percentile upper reference limit). Thyroid-stimulating hormone and free thyroxine levels are normal.
ECG shows atrial fibrillation with rapid ventricular response, nonspecific ST-T abnormality, and incomplete right bundle branch block. Echocardiogram shows normal biventricular size and function, normal valvular structure and function, and normal atrial size.
What is the most likely contributor to the patient's atrial fibrillation?
Ibrutinib
Pulmonary thromboembolism
Thyrotoxicosis
Acute myocardial infarction
300
An 80-year-old man is evaluated for a 6-week history of resting right foot and first toe pain. He has type 2 diabetes mellitus, hypertension, and hyperlipidemia. He has a 50-pack-year smoking history but quit 10 years ago. Medications are low-dose aspirin, metformin, lisinopril, and atorvastatin.
On physical examination, vital signs are normal. The right foot is pale and mottled. A 4 × 4–cm ulceration is noted on the lateral aspect of the right fifth metatarsal. Pedal pulses are diminished on the left and absent on the right.
The ankle-brachial index is 0.62 on the left and 0.44 on the right.
What is the most appropriate next step in management?
Invasive angiography
CT angiography
Hyperbaric oxygen treatment
Primary below-the-knee amputation
300
A 69-year-old woman is evaluated during a follow-up visit 7 months after coronary stent placement for non–ST-elevation myocardial infarction. History is also notable for paroxysmal atrial fibrillation, hypertension, and gastrointestinal bleeding due to diverticulosis 5 years ago. Medications are aspirin, clopidogrel, rivaroxaban, metoprolol, lisinopril, and rosuvastatin.
On physical examination, vital signs are normal. The patient weighs 80 kg (176.4 lb). Bruising is present on the arms and legs. The remainder of the examination is unremarkable.
Serum creatinine level is 1.0 mg/dL (88.4 μmol/L).
What is the most appropriate management?
Discontinue aspirin
Discontinue rivaroxaban
Switch rivaroxaban to reduced-dose apixaban
Switch rivaroxaban to warfarin
400
A 59-year-old man is evaluated during a routine visit. He has type 2 diabetes mellitus. One year ago, he had an atherosclerotic stroke with no residual neurologic deficits. Medications 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 of 66 mg/dL (1.71 mmol/L) and an estimated glomerular filtration rate of 60 mL/min/1.73 m2. A hemoglobin A1c level measured 3 months ago was 6.8%.
What is the most appropriate management of this patient's atherosclerotic cardiovascular disease?
Begin empagliflozin
Begin ezetimibe
Obtain exercise ECG
No changes in management
400
A 71-year-old woman is hospitalized with cardiogenic shock.
On physical examination, blood pressure is 87/51 mm Hg, pulse rate is 112/min, respiration rate is 22/min, and oxygen saturation is 92% with the patient breathing 40% FIO2. An S3, jugular venous distention, pulmonary crackles, and cool extremities are present.
Laboratory studies show an elevated serum high-sensitivity cardiac troponin level (>99th percentile upper reference limit) and serum creatinine level of 1.8 mg/dL (159 μmol/L).
An ECG demonstrates 2-mm ST-segment depressions in leads V4 through V6.
Emergent cardiac catheterization shows critical lesions in the left anterior descending and circumflex arteries, and stents are placed. Following stenting, the patient's clinical status is unchanged.
Medications are aspirin, prasugrel, furosemide, and norepinephrine.
What is the most appropriate additional management?
Intra-aortic balloon pump placement
Digoxin
Metoprolol
Urgent cardiac transplantation
Vasopressin
400
A 42-year-old woman is evaluated for an episode of syncope that occurred 2 weeks ago while she was hurrying to catch a bus. She has hypertrophic cardiomyopathy. Before this episode, her symptoms had been very well controlled. She continues to accomplish activities of daily living with only occasional mild dyspnea. She has no family history of sudden cardiac death. Her only medication is metoprolol.
Twenty-four–hour ambulatory ECG monitoring shows one three-beat run of nonsustained ventricular tachycardia. Echocardiogram shows maximum left ventricular wall thickness of 30 mm, asymmetric septal hypertrophy, and systolic anterior motion of the mitral valve. Resting left ventricular outflow tract gradient is 24 mm Hg, increasing to 36 mm Hg during Valsalva maneuver.
What is the most appropriate treatment?
Implantable cardioverter-defibrillator
Disopyramide
Septal reduction therapy
Verapamil
400
A 35-year-old man is evaluated during a routine office visit. He underwent atrial septal defect closure with a transcatheter device 1 year ago. His past medical history is otherwise unremarkable, and he has no other medical problems. He takes no medications.
On physical examination, vital signs and the remainder of the examination are normal.
The patient will have periodontal cleaning next week.
What is the most appropriate endocarditis prophylaxis?
No endocarditis prophylaxis
Amoxicillin
Azithromycin
Ceftriaxone
Clindamycin
500
A 35-year-old woman is evaluated in the emergency department for a 1-week history of fever and chest pain. The pain is sharp and midsternal, worse lying down, and improved leaning forward.
On physical examination, temperature is 38.5 °C (101.3 °F), blood pressure is 120/70 mm Hg with pulsus paradoxus of 10 mm Hg, and pulse rate is 92/min. A three-phase friction rub is heard along the left sternal border and apex.
ECG shows normal sinus rhythm and normal voltage with diffuse ST-segment elevation of 1 to 2 mm. An echocardiogram shows a pericardial effusion without evidence of tamponade.
What is the most appropriate management?
Hospitalize and begin ibuprofen and colchicine
Hospitalize and begin methylprednisolone
Discharge on ibuprofen and colchicine
Discharge on prednisone
500
A 66-year-old man is seen in the office after hospitalization for an embolic stroke 7 days ago. His initial neurologic findings were minimal and have since resolved. An embolic source has not been identified. He has no other pertinent personal or family history. Medications are aspirin and clopidogrel.
Physical examination, including vital signs and neurologic examination, is normal.
Ambulatory 48-hour ECG monitoring showed no arrhythmias.
What is the most reasonable management?
Loop recorder implantation
Discontinue aspirin and clopidogrel; begin warfarin
Left atrial appendage occlusion
Test for thrombophilia
500
A 77-year-old woman is hospitalized for intermittent recurrent chest pain. Her ECG is shown.
The patient had a moderately severe ischemic stroke 2 years ago and has oxygen-dependent COPD. Medications are aspirin, atorvastatin, and inhaled albuterol and tiotropium.
On physical examination, blood pressure is 145/85 mm Hg, pulse rate is 82/min, and respiration rate is 18/min. Oxygen saturation is 90% on 2 L of oxygen by nasal cannula. BMI is 18. An expiratory wheeze is heard on auscultation of the lungs. Cardiac examination reveals an S4. Estimated central venous pressure is 10 cm H2O. Minimal left-sided weakness is present.
The initial high-sensitivity troponin level is elevated (>99th percentile upper reference limit).
Intravenous unfractionated heparin is initiated, and coronary angiography is planned for the morning.
What is the most appropriate additional treatment?
Clopidogrel
Prasugrel
Reteplase
Tirofiban
500
A 63-year-old man is evaluated during a follow-up examination for rheumatic aortic valve disease. He is asymptomatic and has no exercise limitations. He has no other medical problems.
On physical examination, blood pressure is 134/32 mm Hg. A grade 3/6 holodiastolic murmur is heard best at the left sternal border. Peripheral pulses are bounding. There is no evidence of heart failure.
A transthoracic echocardiogram with good image quality shows a left ventricular ejection fraction greater than 55% and a tricuspid aortic valve with severe aortic regurgitation. The left ventricular end-systolic dimension is elevated at 45 mm.
What is the most appropriate management?
Repeat evaluation in 6 months
Surgical aortic valve replacement
Transcatheter aortic valve implantation
Transesophageal echocardiography