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B
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D
100
A 27-year-old woman is hospitalized for a 1-day history of orthopnea and paroxysmal nocturnal dyspnea. She delivered a healthy baby boy 6 days ago. She is breastfeeding.
On physical examination, blood pressure is 134/78 mm Hg, pulse rate is 98/min, respiration rate is 26/min, and oxygen saturation is 94% with the patient breathing ambient air. There is jugular venous distention and an S3. Crackles are heard about halfway up the lungs. There is lower extremity edema to the knees.
Laboratory studies show an elevated B-type natriuretic peptide level, a normal high-sensitivity troponin level (<99th percentile upper reference limit), and a serum creatinine level of 1.2 mg/dL (106.1 μmol/L).
Chest radiograph shows pulmonary edema. Echocardiogram shows an ejection fraction of 20% and diffuse hypokinesis.
Intravenous furosemide and bilevel positive airway pressure are initiated.
What is the most appropriate additional treatment?
Enalapril
Bisoprolol
Diltiazem
Ivabradine
100
A 25-year-old man is evaluated for recurrent syncope. The syncopal episodes are abrupt and without prodrome and have occurred several times during the past year. He reports no chest pain or exertional symptoms. He has no other pertinent personal history. His father died in his sleep at age 45 years. He takes no medications.
On physical examination, vital signs are normal. There is no heart murmur. The remainder of the examination is unremarkable.
Laboratory studies, including a comprehensive metabolic panel, are within normal limits.
ECG is shown. Echocardiogram is normal.
What is the most likely diagnosis?
Brugada syndrome
Coronary artery disease
Long QT syndrome
Vasovagal syncope
100
A 30-year-old man is hospitalized for a 3-day history of progressive fatigue, fever, and shortness of breath. He underwent surgical aortic valve replacement 3 years ago. He also has end-stage kidney disease, for which he receives hemodialysis. Medications are lisinopril, sevelamer, and warfarin.
On physical examination, blood pressure is 145/34 mm Hg and pulse rate is 120/min. Cardiac examination reveals bounding pulses and a loud decrescendo diastolic murmur at the left sternal border. Crackles are heard at the lung bases.
An ECG shows prolonged first-degree atrioventricular block. A chest radiograph reveals pulmonary edema. A transthoracic echocardiogram reveals a left ventricular ejection fraction of 60% with normal left ventricular dimensions and a 1.5-cm vegetation on the aortic valve bioprosthesis associated with severe aortic regurgitation.
Multiple blood cultures are obtained, and empiric intravenous antibiotic therapy is initiated.
What is the most appropriate management?
Early surgical aortic valve replacement
Cardiac catheterization
Placement of a temporary pacemaker
No change in therapy
100
A 44-year-old woman is evaluated for a 6-month history of progressive exertional dyspnea and fatigue coincident with the onset of heavy menstrual periods. Before the onset of symptoms, her hemoglobin level was 17.9 g/dL (179 g/L). Medical history is significant for a large patent ductus arteriosus and resultant Eisenmenger syndrome. Her only medication is bosentan for pulmonary arterial hypertension.
On physical examination, blood pressure is 100/65 mm Hg; the remaining vital signs are normal. Oxygen saturation with the patient breathing ambient air is 92% in the upper extremities and 82% in the lower extremities. There is jugular venous distention with a prominent a wave, and a prominent left parasternal impulse is noted. S2 is loud. Clubbing of the toes and central cyanosis are present.
Today, the hemoglobin level is 14.8 g/dL (148 g/L), and iron studies are compatible with iron deficiency.
What is the most appropriate initial management?
Oral iron therapy
Hysterectomy
Phlebotomy
Supplemental oxygen therapy
200
A 58-year-old man is evaluated in the emergency department 30 minutes after onset of severe and persistent chest pain at rest associated with diaphoresis and nausea. His medical diagnoses include hypertension and hyperlipidemia treated with amlodipine and atorvastatin. An ECG is shown.
On physical examination, blood pressure is 159/84 mm Hg, pulse rate is 50/min, respiration rate is 18/min, and oxygen saturation is 94% with the patient breathing ambient air. BMI is 25. All other physical examination findings are unremarkable.
The nearest percutaneous coronary intervention (PCI) center is located at least 140 minutes away.
What is the most appropriate management?
Thrombolysis and transfer to a PCI center
CT angiography
Thrombolysis and admission to a telemetry bed
Transfer to a PCI center for primary PCI
200
A 72-year-old man is evaluated in the emergency department for sudden-onset anterior chest pain radiating to his back. He has no history of heart murmur or aortic disease. He has hypertension treated with chlorthalidone and valsartan.
On physical examination, blood pressure is 182/54 mm Hg in the right arm and 125/63 mm Hg in the left arm. There is a grade 2/6 decrescendo diastolic murmur heard at the left sternal border. Central venous pressure is elevated, and there are crackles at the lung bases.
Chest radiograph shows pulmonary edema and a widened mediastinum. A CT angiogram shows an ascending aortic dissection extending into the aortic arch. An echocardiogram shows a left ventricular ejection fraction of 55% and moderate aortic regurgitation.
What is the most appropriate management?
Emergent surgery
Intra-aortic balloon counterpulsation
Transesophageal echocardiography
Cardiac magnetic resonance imaging
200
A 78-year-old woman is evaluated for 6 weeks of exertional dyspnea. She has hypertension and paroxysmal atrial fibrillation. Medications are apixaban, enalapril, and chlorthalidone.
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 S4, but no murmur, is noted.
B-type natriuretic peptide level is 211 pg/mL (211 ng/L).
An ECG demonstrates sinus rhythm and left ventricular hypertrophy. An echocardiogram shows an ejection fraction of 55% 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.
What is the most likely diagnosis?
Heart failure with preserved ejection fraction
High-output heart failure
Hypertrophic obstructive cardiomyopathy
Noncardiac dyspnea
200
A 56-year-old man is evaluated for a 3-month history of progressive left calf discomfort that is exacerbated when walking stairs and hills and is absent at rest. Medical history is significant for hypertension, hyperlipidemia, and coronary artery disease. He also has a 50-pack-year smoking history but quit smoking 3 years ago. Medications are aspirin, rosuvastatin, metoprolol, and amlodipine.
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.
What is the most appropriate management?
Supervised exercise training
CT angiography
Ethylenediaminetetraacetic acid
Pentoxifylline
Revascularization
300
An 18-year-old man is evaluated before participating on his college basketball team. He has no history of hypertension or other pertinent medical history. He has no history of palpitations, chest pain, or unusual dyspnea, and there is no family history of sudden cardiac death or cardiomyopathy.
On physical examination, blood pressure is 110/70 mm Hg and pulse rate is 52/min. BMI is 22. No murmur is heard.
ECG shows sinus bradycardia, with voltage criteria for left ventricular (LV) hypertrophy. The corrected QT interval is 400 ms. Early repolarization is noted.
An echocardiogram shows a mildly dilated LV cavity. The ejection fraction is greater than 55% without regional abnormality. Symmetric LV hypertrophy is noted, with LV wall thickness of 12 mm. LV diastolic filling, left atrial size, and valvular structure and function are normal.
What is the most likely diagnosis?
Athletes heart
Fabry disease
Hypertensive heart disease
Nonobstructive hypertrophic cardiomyopathy
300
A 68-year-old man is evaluated during a routine follow-up visit. Medical history is significant for type 2 diabetes mellitus, hyperlipidemia, hypertension, and aortofemoral bypass surgery 2 years ago. Previous evaluation documented a left ventricular ejection fraction of 50% and stage G3bA2 chronic kidney disease. Medications are metformin, atenolol, lisinopril, amlodipine, aspirin, rivaroxaban, and atorvastatin.
On physical examination, vital signs are normal. BMI is 30. An aortofemoral bypass surgical scar is present. Pulses are present and moderately strong in the lower extremities.
The most recent hemoglobin A1c level is 7.1%.
What is the most appropriate additional treatment?
Liraglutide (GLP1)
Clopidogrel
Niacin
Pramlintide
300
A 76-year-old woman is evaluated during a wellness visit. She reports that she fatigues easily, and her husband notes that she snores loudly. Medical history is significant for hypertension. Her only medication is metoprolol.
On physical examination, pulse rate is 75/min 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.
An ECG shows atrial fibrillation at 75/min without ischemic changes.
What is the most appropriate management?
Initiate oral anticoagulation
Add aspirin
Emergent cardioversion
Increase metoprolol dosage
Reassurance
300
A 28-year-old woman with Marfan syndrome is seen following recent transthoracic echocardiography obtained as part of a prepregnancy evaluation. Her mother has Marfan syndrome and had emergency surgery for ascending aortic dissection 8 years ago. The patient's only medication is metoprolol succinate.
On physical examination, blood pressure is 110/60 mm Hg and pulse rate is 60/min and regular. The patient has phenotypical features of Marfan syndrome. The remainder of the examination is normal.
Transthoracic echocardiogram reveals a dilated proximal 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 function are normal. A CT scan confirms the aortic dimension obtained by echocardiography.
What is the most appropriate management?
Aortic repair before pregnancy
Add atorvastatin
Add losartan
Proceed with pregnancy
400
A 42-year-old woman is evaluated for a 3-month history of exertional dyspnea and a burning sensation in her throat. She had Hodgkin lymphoma at age 22 years treated with chemotherapy and mantle irradiation. She has no history of hypertension, hyperlipidemia, or diabetes mellitus and has never smoked.
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 peripheral edema.
A chest radiograph and 12-lead ECG are normal.
What is the most likely diagnosis?
Coronary Artery Disease
Aortic stenosis
Constrictive pericarditis
Mitral stenosis
Restrictive cardiomyopathy
400
A 48-year-old woman is evaluated in the hospital for transient left facial droop and right-sided weakness, which lasted 15 minutes and completely resolved. She also has a 1-month history of recurrent fevers and night sweats. She reports lack of appetite and unintentional weight loss of 2.3 kg (5 lb). She has no other symptoms or medical problems and has not undergone a recent medical procedure. She takes no medications.
On physical examination, vital signs are normal. Cardiac examination reveals a normal S1 and S2, with a soft early diastolic sound heard best at the apex.
ECG demonstrates normal sinus rhythm.
CT of the head with and without contrast is normal. Echocardiogram (shown) demonstrates normal chamber size and ventricular function (LV = left ventricle; RA = right atrium; RV = right ventricle).
What is the most appropriate management?
Urgent surgical excision
Administer a direct oral anticoagulant
Administer intravenous thrombolytic therapy
Obtain blood cultures and begin empiric antibiotics
400
A 55-year-old man is evaluated for a 6-week history of cough and worsening exertional dyspnea and orthopnea. He has heart failure, for which he has received guideline-directed medical therapy for 4 months.
On physical examination, blood pressure is 130/67 mm Hg and pulse rate is 90/min and regular. There is an early systolic click and a holosystolic murmur loudest at the apex and radiating to the back. The central venous pressure is elevated, and there are crackles at both lung bases.
An ECG is normal. A chest radiograph reveals pulmonary edema. A transthoracic echocardiogram shows a left ventricular ejection fraction greater than 55%. The echocardiographic data are consistent with moderate mitral regurgitation.
What is the most appropriate next step in management?
Cardiac magnetic resonance imaging
Repeat echocardiography in 1 year
Surgical mitral valve repair
Transcatheter mitral valve repair
400
A 66-year-old woman is evaluated for a 6-month history of right shoulder pressure that occurs after walking half a mile and improves with 5 minutes of rest. She has no dyspnea, nausea, or fatigue. The frequency and duration of her symptoms have not changed. Her history is otherwise unremarkable.
On physical examination, vital signs are normal. BMI is 33. Other than a paradoxically split S2, the cardiac examination is normal. The lungs are clear to auscultation.
A chest radiograph is normal. ECG is shown.
What is the most appropriate test?
Pharmacologic myocardial perfusion imaging
Coronary angiography
Exercise ECG
Transthoracic echocardiography
No further testing is required
500
A 63-year-old man is evaluated during a follow-up visit for a 6-month history of heart failure. He currently has New York Heart Association functional class III symptoms. His only hospitalization was at the time of diagnosis. Medications are valsartan-sacubitril, carvedilol, furosemide, and spironolactone.
On physical examination, blood pressure is 110/76 mm Hg and pulse rate is 64/min. The remainder of the examination is unremarkable.
Laboratory studies are within normal limits.
ECG demonstrates left bundle branch block with a QRS duration of 130 ms. Since beginning guideline-directed medical therapy, his ejection fraction has increased from 15% to 25%.
What is the most appropriate treatment?
Cardiac resynchronization therapy–defibrillator
Implantable cardioverter-defibrillator
Implantable pulmonary artery pressure sensor
Wearable cardioverter-defibrillator
500
A 53-year-old woman is evaluated in the coronary care unit. She underwent successful primary percutaneous coronary intervention with drug-eluting stent placement in the mid right coronary artery for an inferior ST-elevation myocardial infarction. In the catheterization laboratory, she had several episodes of symptomatic 2:1 atrioventricular block with sinus bradycardia. After returning to the coronary care unit, she has symptomatic intermittent 2:1 atrioventricular block and several episodes of complete heart block with a narrow-complex escape rhythm (heart rate at 58/min). Medications are atorvastatin, aspirin, and clopidogrel.
On physical examination, blood pressure is 118/82 mm Hg, pulse rate is 68/min, respiration rate is 18/min, and oxygen saturation is 96% with the patient breathing ambient air. Cardiac examination reveals a regularly irregular rhythm. The remainder of the examination is normal.
What is the most appropriate treatment?
Temporary pacing
Urgent dual-chamber pacemaker
Atropine
Intravenous unfractionated heparin
500
A 67-year-old man is evaluated for a 3-month history of progressive dyspnea and peripheral edema. He also has a 6-month history of exertional chest “heaviness.” Medical history is otherwise significant for hypertension and type 2 diabetes mellitus. He is a former cigarette smoker, quitting 6 months ago. Medications are hydrochlorothiazide, atorvastatin, metformin, and liraglutide.
On physical examination, blood pressure is 122/86 mm Hg and pulse rate is 96/min; other vital signs are normal. BMI is 27. Jugular venous distention and an S3 are present. Lower extremity edema to the mid-thigh is noted.
ECG shows left bundle branch block. Echocardiogram shows ejection fraction of 25% with anterior hypokinesis and normal wall thickness.
What is the most appropriate test?
Cardiac catheterization
Cardiac magnetic resonance imaging
Cardiac PET
Technetium-99m pyrophosphate scintigraphy
500
A 42-year-old man is evaluated in the emergency department for palpitations, neck pulsations, and light-headedness that began 45 minutes ago. He reports no chest pain or breathlessness. He has been under pressure at work and has been anxious and sleepless. There is no other relevant personal or family history. He does not use illicit drugs or supplements.
On physical examination, blood pressure is 90/70 mm Hg and pulse rate is 160/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 a rapid regular rhythm, cardiac examination is unremarkable. Lungs are clear.
ECG reveals ventricular tachycardia. He is successfully cardioverted.
Complete blood count and metabolic panel, including electrolytes, are normal.
Echocardiogram and subsequent ECG are both normal.
What is the most appropriate initial management?
Cardiac magnetic resonance imaging with stress perfusion
Electrophysiology study
Implantable cardioverter-defibrillator
Implantable loop recorder