PALESTINIAN

MEDICAL COUNCIL

PALESTINIAN BOARD EXAMINATION

WRITTEN PAPER NO. 1

TIME ALLOWED: 210 minutes

For all the following questions, please, choose the

single best answer:
1.

A 65-year-old man with a one-year history of heart failure has severe left
ventricular dysfunction (Ejection fraction 20%) and markedly impaired
exercise tolerance on metabolic stress test (peak oxygen consumption = 12
ml/kg/min). He underwent a six-month period of intense physical training
with improvement in peak oxygen consumption up to 18 ml/kg/min.

Compared to baseline, the following

enzymatic/biochemical changes are likely to be seen at the
end of the physical training:
a.
b.
c.
d.

Upregulation of vascular ACE.

Upregulation of TNF-a.
Upregulation of cNOS.
Increased release of endoperoxides.

2. The following drugs can precipitate heart failure,

EXCEPT:
a.
b.
c.
d.
e.

Non-steroidal anti-inflammatory drugs.

Ca++ channel blockers.
Thiazolidinediones.
Trastuzumab.
Aspirin.

3. The hospital readmission rate after an admission for heart failure is over 30%
within 90 days of discharge. The bulk of the health care expenditures for
heart failure are for inpatient care. Efforts to reduce hospitalization
readmissions are therefore cost-effective. A 65-year-old man with diabetes and
renal insufficiency has been admitted three times over the past six months for
heart failure exacerbations. The patient does not restrict sodium from his

diet. The patients primary care physician is concerned that the patient has
developed refractory heart failure.

Elderly patients with comorbidities (renal insufficiency and

diabetes) and recurrent admissions may benefit from which of
the following:
a.
b.
c.
d.
e.

Out-patient intermittent inotropic infusions.

Multidisciplinary case management.
The addition of a calcium channel blocker to the medical regimen.
Addition of Metolazone
Addition of rosiglitazone to improve glucose control.

4. In distinguishing systolic from diastolic heart failure,

which of the following are useful:

a. Chest X-ray.
b. Elevated jugular venous distention.
c. Third heart sound.
d. BNP = 250 pg/ml.

5. In the ECG,

the following are true,

EXCEPT:

a. Secundum ASD causes right bundle branch block.

b. Hypertrophic cardiomyopathy frequently causes left bundle branch
block.
c. Small Q-waves are usually seen on left chest leads in the presence of
left bundle branch block.
d. If left bundle branch block affects only the posterior left fascicle, it
causes right axis deviation.

6. A 34-year-old woman presents with a 10-year history of congestive

cardiac failure secondary to idiopathic cardiomyopathy. Over the past
six months, she has had four admissions for congestive cardiac failure
and recently was started on intravenous Dobutamine. Evaluation
reveals a cachectic female, with rales and JVD. Haemodynamics show a
systemic pressure of 90/60mmHg and pulmonary artery pressures of
64/24mmHg with a pulmonary capillary wedge pressure of 22 mmHg.
with V-waves to 34. Cardiac index on 5mcg/kg/min of Dobutamine is
1.7 L/m2. Echocardiogram shows an ejection fraction of 10%, 3-4+

mitral valve regurgitation and an EDD of 9.0 cm. Dobutamine cannot

be weaned off.

What is the best option for this patient:

a. Mitral valve repair.
b. Mitral valve replacement with a mechanical valve because of her
young age.
c. List for transplantation.
d. Insert an LVAD, hoping that the myocardium will recover.
e. Perform a mitral valve repair and resect a portion of the ventricle
to make it smaller (Batista procedure).

7. In peripartum cardiomyopathy, one of the following is

incorrect:

a. It is more common with twin pregnancies.

b. Toxaemia of pregnancy is a predisposing cause.
c. Excessive salt intake is an important precipitating factor in
African women.
d. It usually occurs during the third trimester of pregnancy.
e. It is more common in Caucasian women.

8. In cardiac auscultation, the following are incorrect,

EXCEPT:

a. In PDA, the continuous systolic and diastolic murmur obscures the

second heart sound.
b. Mitral valve prolapse causes mid diastolic click.
c. Bradycardia causes loud first heart sound due to a better ventricular
filling.
d. P2 is loud and is heard earlier than A2 over the pulmonary area.

9. Which one of the following statements is not true

regarding arrhythmogenic right ventricular dysplasia

(ARVD):
a. Ventricular tachy-arrhythmias show left bundle branch block
pattern.
b. Fat replaces the myocardium of the right ventricular wall.
c. Dilated, poorly contractile right ventricle.
d. More common in women.
e. Left ventricular involvement has been reported.

10. In mitral valve disease. Which statement is incorrect:

a. The most common cause of mitral valve regurgitation is ischaemic
heart disease.
b. Mitral valve regurgitation can be secondary to shortening of the
papillary muscles.
c. Bacterial endocarditis affecting native floppy valves has no medical
cure.
d. Most cases of mitral valve stenosis are due to chronic rheumatic
valve disease.
e. Left ventricular function can be worse than what we see on an
echocardiogram.

11.

In severe valvular aortic regurgitation (AR), all of the

following are correct, EXCEPT:
a. In chronic severe valvular AR, the normal left ventricular pressure
volume curve is shifted downward and to the right such that a large
LVEDV may be accommodated at near normal LVEDPs.
b. Patients with severe chronic AR will always have an abnormal
exercise capacity with exercise treadmill testing.
c. In acute valvular AR, marked elevation of the LVEDP occurs and
often preclosure of the mitral valve is present.
d. Systemic hypertension will increase the regurgitation fraction in
chronic AR.
e. In an acute AR, not only has the ventricle not had time to
accommodate to the increased diastolic volume and increase its
compliance, but also the pericardium has not had time to increase
its compliance. Both result in a marked elevation in LVEDP.

12. All, but one of the following represents an absolute

indication for surgical replacement of an infected

prosthetic valve:

2
3
4

a. Relapse after a six week course of antibiotics.

b. Recurrent systemic embolization.
c. Vegetation more than 10mm.
d. New heart block.
e. Severe congestive cardiac failure.

13. In chronic heart failure, the following are

correct, Expect:

5
6
7

a. Raised plasma catecholamine levels in severe dysfunction.

b. Reduced mortality with beta-blocker therapy.
c. Beta-blockers are well tolerated.
d. There is 50% up-regulation of beta-adrenoceptors.
e. Beta-blockers reduce the risk of sudden death.

14. Patients with the Brugada syndrome may demonstrate intermittent

normalization of their ECG. The ST-segment elevation in leads V1-V3
characteristic of the syndrome may be precipitated by intravenous
Procainamide.

This action of Procainamide is the result of one of the

following actions:
a. K + - channel blocking action of the parent compound.

b. Na+ channel-blocking action.

c. Combined K + and Na+ channel-blocking action of its metabolite
NAPA.

15. In which patient population would invasive EP testing be

most likely to have diagnostic utility:

a.

b.

c.
d.
e.

Individuals with recurrent syncope or sinus bradycardia

but no diagnostic arrhythmias on Holter monitor with normal
echocardiograms.
Patients with recurrent syncope, isolated right bundle
branch block, left anterior bundle branch block, and no other
evidence of structural heart disease on echocardiogram and
physical examination.
Post myocardial infarction patients with LVEF less than
40% and recurrent syncope.
Patients with long QT syndrome and recurrent syncope.
Patients with dilated non-ischaemic cardiomyopathy.

16. In evaluating a patient with known reno-vascular

hypertension and renal insufficiency, which of the

following is more predictive of a successful outcome
after trans-catheter therapy:
a.
b.
c.
d.
e.

Low plasma renin level.

Proteinuria.
Creatinine clearance of 45ml/minute.
Duration of hypertension of two years.
6cm longitudinal lengths of both kidneys.

17. Which of the following statements is true about

dofetilide:
a.

It has significant renal excretion.

b.
c.
d.
e.

It is effective for the treatment of paroxysmal atrial

fibrillation.
It is a class III anti-arrhythmic drug with associated
with beta-blocking effects.
It rarely causes torsades de pointes.
It may be initiated as an out-patient.

18. In ischaemic heart disease, one of the following

statements is incorrect:

a. The NCEP (National Cholesterol Education Programme) recommends

lowering
LDL-cholesterol to less than 100mg/dl.
b. Statins reduce the risk of stroke post myocardial infarction.
a. Triglyceride level is an independent risk factor.
d. Statins result in plaque regression.
e. Early reduction in mortality in patient taking statins is due to LDLcholesterol reduction alone.

19. A 55-year-old post-menopausal woman with a history of breast cancer

and type 2 diabetes was referred with exertional chest discomfort.
There is a history of a non-Q-wave myocardial infarction one year ago.
She is currently taking Aspirin, Statin and oral hypoglycaemic agents.
Blood pressure 155/90mmHg. LDL-cholesterol 110mg/dl. Thallium
scan shows mild reversible anterior defect. Coronary angiography
shows mild diffuse disease.

Which of the following is the most appropriate

medication to add to her current treatment:
a.
b.
c.
d.
e.

Calcium channel blocker.

Estrogen replacement therapy.
A long-acting beta-blocker.
An alpha-blocker.
A long-acting nitrate.

20. A 23-year-old woman was routinely examined. She has no symptoms.

Her pulse 70bpm regular, blood pressure 120/70mmHg, loud S1, and
P2, grade 2/6 diastolic murmur and an opening snap. JVP 8cm H2O.
Echocardiogram shows mitral valve stenosis (valve area 1.5cm2).

What therapy you should prescribe to this patient:

a.
b.
c.
d.
e.

Digoxin.
Penicillin.
Warfarin.
Metoprolol.
Captopril.

a
21. A 50-year-old patient returns after one month on Hydrochlorothiazide 25mg
daily with an unchanged blood pressure (170/80mmHg). You then order an
MR angiography and that shows 90% osteal stenosis of the right renal
artery. The patient undergoes stenting of the lesion with haemodynamic
success.

The discharge plan from the hospital should include:

a.
b.
c.
d.
e.

Discontinuation of all antihypertensive medications in

anticipation of the patient being cured.
Discontinue the diuretic because of an anticipated
improvement in renal function and salt handling.
Half the dose of current antihypertensive agents in
anticipation of a drastic fall in blood pressure.
Repeat MR angiography in one month to assess patency of
the stent.
Addition of Plavix to the regimen, but with continuation of
currently prescribed antihypertensive agents and an appointment
for early follow up.

22. Which of the following anatomic findings would be best

managed by percutaneous revascularization in a patient

with ischaemic rest pain:

10

a.
b.
c.
d.

25cm long superficial femoral artery occlusion.

Occlusion of the common and external iliac arteries.
5cm stenosis of the proximal common iliac artery.
5cm stenosis of the popliteal artery, occluded anterior and
posterior tibial arteries, and diffuse disease of the proximal
peroneal artery.
e.
Severe diffuse stenosis of the common femoral artery.
23.

Which of the following statements regarding

preoperative risk assessment for patients with carotid
artery disease is true:
a.

Patients with an asymptomatic bruit, scheduled for noncardiac surgery should undergo a non-invasive imaging study to
determine the haemodynamic severity of the lesion.
b.
Patients needing coronary surgery and carotid surgery
benefit from a combined procedure.
c.
To allow adequate healing, at least six months should
separate elective surgery from a moderately large stroke.
d.
Patients with a symptomatic carotid stenosis (> 70%)
should preferably be offered CAS as a staged procedure prior to
undergoing elective cardiac surgery.

24. Which of the following statements regarding venous

thromboembolism (VTE) prophylaxis is

a.

FALSE:

High-risk populations (e.g., neurosurgical patients)

benefit from a combination of mechanical and pharmacologic
prophylactic strategies.
b.
Warfarin, Enoxaparin, Fondaparinux and Ximelagatran
have all been shown to reduce the risk of VTE in orthopaedic
patients.
c.
Extended-duration out-of-hospital prophylaxis has been
shown to be safe and effective in patients undergoing general
surgery for malignancy.
d.
VTE prophylaxis may be discontinued in orthopaedic
patients after the fifth postoperative day.

11

25. A 72-year-old man is referred to you from his family practitioner for
evaluation and management. He had an uncomplicated inferior wall
infarction at another hospital last year and medical management was
selected following coronary angiography at that time. He does not
smoke, but is diabetic. He tries to follow a low-fat eating plan, but
admits that he craves salt. He denies shortness of breath, and walks
at least thirty minutes daily. His blood pressure in your office is
148/63mmHg, his resting heart rate is 68bpm, his lungs are clear,
and his cardiac auscultation is normal. His left ventricular function
demonstrates an ejection fraction of 48% with mild mitral valve
regurgitation. His creatinine is 1.7mg/dl and his potassium is
4.2mg/dl. He takes Aspirin, a low dose of a beta-blocker, Lisinopril,
Hydrochlorothiazide and Insulin.

The most appropriate next step in treatment should be:

a.
b.
c.
d.
e.

Increase the beta-blocker.

Start him on the DASH diet.
Increase the Lisinopril and add Verapamil.
Begin Doxazocin.
Switch the Hydrochlorothiazide to Lasix.

26. You are seeing a 58-year-old man in your office following a coronary
calcium scan he obtained by self-referral. He is currently
asymptomatic. Blood pressure is 158/98mmHg. He does not smoke.
He does not exercise regularly. Body mass index (BMI) is 28kg/m2. He
takes Aspirin, 325mg/day. Total cholesterol is 242mg/dl, triglyceride
level is 176mg/dl, HDL is 36mg/dl, and calculated LDL-C is
171mg/dl. You advise the patient to follow a Step I diet, lose weight,
and exercise more regularly. He sees a dietitian. You reassess the
lipids and dietary response three months later. He has been compliant
with the diet, according to him and the dietitian. He states, however,
that his diet is not much different than before other than slightly
smaller portion sizes now. He has lost five pounds, and BMI is now 27.
He has begun to take Niacin (self-medication), 50mg TID with meals.
He asks if he can take vitamin E, vitamin A, vitamin C and folic acid in
light of his obviously increased coronary risk. Lipids now are: total
cholesterol 228mg/dl, LDL-C: 164mg/dl, HDL-C: 34mg/dl,
triglycerides: 150mg/dl.

Which one of the following is the best plan at this time:

12

a.
b.
c.

d.
e.

Further reduce portion sizes and reassess patient in

three months.
Order homocysteine level. If elevated, start folic acid
supplement, 0.5mg/day.
Ask dietitian to perform micronutrient analysis. If
vitamin E, vitamin A (beta-carotene) and vitamin C dietary intakes
are low, add vitamin E, vitamin A and vitamin C in doses equal to
three times the recommended daily allowance (RDA).
Increase Niacin to 100mg TID with meals and reassess
lipid/lipoprotein response in six weeks.
Advise Step 2 diet and start a statin to reduce LDL-C <
130mg/dl. Reassess in six weeks.

27. A 63-year-old male with a 10-year history of angina and diabetes

presents to you for evaluation. Risk stratification including coronary
angiography indicates a course of medical management. He has been
treated with metformin 850mg bid for the last five years with HgA1c of
7.8%. He also takes 20mg of Atorvastatin and 81mg of Aspirin daily.
His most current lipids are a total cholesterol of 163mg/dl, LDL of
89mg/dl, triglycerides of 180mg/dl, HDL of 38mg/dl, and creatinine
of 1.4mg/dl. He is reluctant to take additional medications. He is 70
inches, 171lb (BMI 24.5kg/m2 and blood pressure is 128/72mmHg.

The best next step is:

a.
b.
c.
d.

Double the dose of the statin.

Start Rosiglitazone 4mg daily.
Add a long-acting Niacin (Niaspan) 1000mg daily.
Increase the metformin to 1000mg daily.

28. All, but one of the following contribute to growth of a

stenosis in a coronary artery:

a.
b.
c.

Recurrent subclinical thrombosis.

Accelerated smooth muscle proliferation.
Intra-plaque thrombosis.

13

d.
e.

Failure of arterial wall remodeling.

Increased thickness of fibrous cap of a plaque.

29. A 68-year-old male arrives in the emergency department reporting that

since going to work in the morning, he has had three episodes of leftsided chest pressure lasting 15-20 minutes at rest. He is currently
symptom-free with his longest episode of chest pain having occurred
eight hours previously. He denies any known hypertension, diabetes
or dyslipidaemia. He quit smoking two years previously. On review of
symptoms, he reports an aching discomfort in his left thigh when he
walks more than three city blocks. He has been taking one Aspirin a
day for the past five years. On examination, his blood pressure is
145/90mmHg and heart rate is 82bpm. His chest clear and cardiac
auscultation reveals normal S1 and S2 without any murmurs or
gallops. In the emergency department, he has an episode of chest
discomfort relieved within five minutes after one sublingual
Nitroglycerin. A 12-lead ECG performed during symptoms shows 1mm
of downsloping ST depression in leads II, III and aVF. Cardiac marker
levels measured from blood drawn at presentation are: CK-MB: <
5ng/ml; cTnI < 0.03ng/dl.

Which of the following is most correct regarding the

patients diagnosis and risk assessment:
a.
b.
c.
d.
e.

He presents
He presents
He presents
He presents
He presents
intermediate risk.

with
with
with
with
with

high probability of UA and high risk.

NSTEMI.
high probability of UA and low risk.
low likelihood of UA and low risk.
intermediate probability of UA and low-

30. An invasive strategy with adjunctive GP IIb/IIIa

inhibition compared with a conservative strategy has

been shown to:
a.
b.
c.
d.

Have a higher mortality.

Have a lower mortality.
Reduce death or MI.
Increase death or MI.

14

31. Which of the following statements is most correct

regarding the use of ACE inhibitors in patients following

AMI:
a.
b.

c.
d.

e.

IV Enalapril should be used in the first 24 hours and later

converted to an oral preparation.
Oral ACE inhibitors should not be started in the first 2448 hours post-MI due to increased incidence of hypotension and
renal insufficiency in clinical trials.
Oral ACE inhibitors should be started in all patients with
ST-elevation AMI for a minimum of six weeks.
ACE inhibitors have no mortality benefit following AMI,
but are associated with reductions in other adverse cardiac
outcomes such as reinfarction and development of heart failure.
ACE inhibitors have dramatic mortality benefit in patients
with ST-elevation AMI that exceeds the treatment effect of Aspirin
or fibrinolysis in some studies.

32. A 60-year-old female presented to the emergency department with oneday history of intense left-sided chest pressure, 10 out of 10
associated with nausea, vomiting and diaphoresis. Vital signs were: BP
141/91mmHg, pulse: 80bpm. Physical examination reveled bilateral
carotid bruits, no elevated jugular venous pressure. Heart examination
showed S1, S2 with S4, no murmur and clear lungs. Initial ECG is
shown. Initial troponin I was 1.04 (peaked at 35ng/dl). 2D
echocardiogram showed 35% ejection fraction with postero-inferior
hypokinesis and no major valvular heart disease. The patient had
more chest pain on day 4 and was referred for heart catheterisation.
Cardiac catheterisation revealed 90% lesion in the mid circumflex
artery and non-obstructive disease in the left anterior descending
artery and the right coronary artery. Awaiting angioplasty of the
circumflex artery, the patient suddenly became pulseless and
unresponsive. ECG showed sinus tachycardia. Cardio-pulmonary
resuscitation was initiated for pulseless electrical activity.

15

What is the cause of the pulseless electrical activity

arrest:
a. Ventricular septal rupture.
b. Acute mitral valve regurgitation due to papillary muscle
rupture.
c. Free wall rupture and tamponade.
d. Right ventricular infarction.

33. Which of the following statements is NOT true regarding

treatment of hypertension among patients with chronic

coronary artery disease (CAD):
a.

Based on results of the ALLHAT trial, thiazide diuretics

are recommended as initial therapy for patients with hypertension
and concomitant CAD.
b.
ACE inhibitors have been shown to prevent death and
cardiac events in patients with chronic CAD, even if hypertension
and left ventricular dysfunction are absent.
c.
Most patients with chronic CAD and hypertension will
require combination therapy, including a diuretic to achieve blood
pressure goals.
d.
The blood pressure goal for patients with diabetes and/or
chronic kidney disease is 130/80mmhg or lower.

34. A 60-year-old female diabetic is admitted to a coronary care unit with a

45-minute history of severe chest pain and 2mm ST elevation in leads
V1-V4. She is haemodynamically stable.

Compared with a similar non-diabetic patient, which one

of the following statements is false:
a.

The presence of diabetes is an independent risk factor for

adverse, short-term outcome following AMI.
b.
Administration of lytic therapy will be less beneficial.

16

c.
d.
e.

She is more likely to have extensive, multivessel CAD.

The benefits of beta-blocker therapy on mortality and
recurrent MI will be greater.
In both diabetics and non-diabetics, the presence of
proteinuria is an indicator of increased risk of adverse cardiac
events.

35. A 73-year-old woman with a previous myocardial infarction five

years earlier now presents with progressive episodes of anxiety
and shortness of breath for the last ten months. She cannot
exercise well because of peripheral vascular disease. She
continues to smoke cigarettes despite intensive counseling. A
recent adenosine perfusion scan showed evidence of a prior apical
myocardial infarction, but no reversible ischaemia. Her current
episodes of anxiety and shortness of breath occur primarily at
times of mental or emotional upset. She feels a choking sensation
when she is upset and cannot catch her breath for 5-10 minutes.
She denies angina or chest discomfort of any kind. If she relaxes,
the sensations resolve, but it takes almost twenty minutes for her
to feel improvement.
She is in the middle of difficult family circumstances and she cannot
avoid stress in her life. Her current medical regimen includes nitrates,
Aspirin and a beta-blocker. Resting blood pressure is 135/90mmHg
and heart rate is 70bm. Her resting ECG shows minor non-specific
ST and T-wave abnormalities.

Which of the following would be the most appropriate

next step in her care:
a.
b.
c.
d.

Refer her to a psychiatrist for emotional counseling.

Repeat the perfusion scintigraphy scan.
Refer to a pulmonologist to evaluate shortness of breath
Perform 24-hour AECG monitoring (Holter) during periods of
known emotional stress to evaluate for heart rate responses and STsegment deviation.
e. Prescribe anti-anxiety medications.

36. A 42-year-old female police officer presents with an exercise ECG

report from a test in an outside laboratory to evaluate several months
of episodic right inframammary chest discomfort of 5-10 minutes
duration that is unrelated to effort, meals, position or anxiety. Her

17

examination and resting ECG were normal prior to the test. On the
treadmill, she was limited by fatigue and dyspnoea after one minute of
Stage IV of the Bruce protocol at which time the heart rate was
162bpm and the blood pressure was 170/80mmHg. At peak exercise,
there was 1.0-1.5mm of horizontal and downsloping ST-segment
depression 60msec after the J-point, which slowly resolved to normal
by four minutes of recovery. There were occasional multiform single
ventricular premature complexes recorded early in exercise and during
mid-recovery. The exercise test was reported as positive.

Which of the following statements is correct:

a.

The likelihood that this test is a true positive test is

between 50-70%.
b.
The likelihood that this test is a true positive test is more
than 70%.
c.
The likelihood that this test is a false positive test is
more than 70%.
d.
The likelihood that this test is a false positive test is
between 50-70%.
37. A 67-year-old woman with two previous myocardial infarctions with
exertional dyspnoea, but no angina. She has type 2 diabetes mellitus,
but is otherwise well. A Dobutamine echo is requested to assess the
presence/extent of viable myocardium. The resting echo shows mild
left ventricular dysfunction (i.e., ejection fraction 40%) with severe
hypokinesis of the basal and mid-inferior and basal posterior segments
and the antero-apical segment. No angina or ST-segment changes are
provoked by Dobutamine, and the haemodynamic response to stress is
normal. There is mild augmentation of all infero-posterior and anteroapical segments, but the ejection fraction at low dose is unchanged. At
peak dose, there is worsening of function in the apex.

Which of the following statements is correct:

a.

Myocardial revascularization will lead to an improvement in

ejection fraction.
b.
Myocardial revascularization will lead to an improvement
in functional capacity.
c.
Myocardial revascularization is justified to improve
Prognosis.

18

d.
e.

The infero-posterior wall is likely to improve with

myocardial revascularization.
None of the above.

38. In patients with chronic coronary artery disease (CAD)

without prior myocardial infarction, the best predictor

of future cardiac death or myocardial infarction on stress
nuclear MPI is:
a.
b.
c.
d.

The
Left
The
Left

presence and extent of fixed defects.

ventricular function.
presence and extent of transient defects.
ventricular wall thickness.

39. A 50-year-old man with diabetes mellitus and history of cigarette

smoking underwent PTCA of his mid left anterior descending artery
two months ago. At the time of his procedure, he was noted to have a
total cholesterol of 350mg/dl, LDL cholesterol of 180mg/dl, HDL
cholesterol of 20mg/dl and triglycerides of 280mg/dl. He was placed
on Atorvastatin 40mg daily and repeat laboratory tests obtained today
show a total cholesterol of 200mg/dl, LDL cholesterol of 98mg/dl, HDL
cholesterol of 23mg/dl and triglycerides of 230mg/dl.

Which of the following is the most appropriate next step:

a.
b.
c.
d.
e.

Increase Atorvastatin dose to 80mg daily.

Initiate Probucol therapy.
Instruct the patient to take Gemfibrozil and Atorvastatin.
Prescribe a long-acting preparation of nicotinic acid in
addition to Atorvastatin.
Stop the statin and initiate therapy with a bile acid
Sequestrant.

40. In the treatment of de novo obstructive coronary

lesions, which of the following modalities has shown a

definitive benefit in reducing the incidence of restenosis
after PCI:

19

a.
b.
c.
d.
e.

Rotational atherectomy of calcified lesions.

Directional atherectomy of saphenous vein graft lesions.
Bare metal stents in vessels > 3.0mm in diameter
All of the above.
None of the above.

41. All things being otherwise equal, surgery would be

preferred over PCI for all of the following patients,

EXCEPT:
a.

Coronary anatomy amenable to both therapies in a

patient with diabetes.
b.
Three-vessel disease with 95% proximal left anterior
descending artery disease and impaired left ventricle.
c.
Two-vessel disease with 75% mid left anterior descending
artery lesion.
d.
Two-vessel disease with 95% proximal left anterior
descending artery lesion.

42.

A 57-year-old man with type 2 diabetes mellitus presents for a

scheduled diagnostic cardiac catheterisation. He has a threemonth history of exertional chest discomfort and a stress thallium
study that was abnormal, showing anterior and possibly inferior
ischaemia. He is receiving a beta-blocker and long-acting nitrate.
His diabetes is controlled with insulin and metformin and the
metformin is discontinued the day of procedure.
His creatinine is 1.7mg/dl. He receives one liter of intravenous
hydration before the procedure. Coronary angiography shows threevessel disease. Surgical consultation is obtained and the operation is
scheduled in two weeks because he has some business to conduct
before surgery.

After the coronary angiogram procedure, which of the

following is most appropriate management of his
medications:

20

a.
Resume all pre-procedure medications immediately.
b.
Hold all medications until surgery.
c.
Resume all medications except metformin.
d. Resume all medications, but hold metformin and insulin for 48
hours pending laboratory results.
e. Resume all medications and restart metformin in 48 hours after
showing the creatinine is stable.

43. A 77-year-old man presents with severe congestive heart failure (CHF). He
has a jugular venous pressure of 10cm water and moist rales in the lower
one-half of his lung fields. In addition to a third heart sound, he has a 2/6
systolic ejection murmur heard best in the second left intercostal space.
Echocardiography shows a large left atrium and poor left ventricular
function with an estimated ejection fraction of 20%. Doppler
echocardiography demonstrates mild mitral valve regurgitation and transaortic valve gradient of 20mmHg with an estimated aortic valve area of
0.9cm2 . he is referred to you for cardiac catheterisation. His mean PCWP
is 30 mmHg. His mean aortic valve gradient is 22 mHg and his cardiac
output is 2.4 L/minute. His aortic valve area, calculated using the Gorlin
equation is 0.9cm2. Coronary angiography shows mild diffuse coronary
artery disease with no stenosis greater than 40% in severity.

Which of the following would you recommend as the next

step in patient care:
a.
b.

Immediate aortic valve replacement.

Elective aortic valve replacement after optimizing his
clinical status.
c. Dobutamine infusion during the catheterization procedure. If both
the CO and valve area increase, aortic valve replacement should
be considered.

21

d. Dobutamine infusion during the catheterization procedure. If both

the CO and gradient increase, aortic valve replacement should be
considered.
e. Aortic valvuloplasty.

44. A 48-year-old woman presents with episodes of rest and exertional

chest pain over the past 48 hours. Her initial troponin value is
elevated twofold above normal and she has 1.5mm of ST-segment
depression in the inferior-lateral leads; this is new compared with prior
tracing. In the emergency department, she received a bolus and then
continuous infusion of IV UFH and IV Nitroglycerin. She also received
Aspirin 325mg and Clopidogrel 600mg by mouth. About six hours
later, her coronary angiogram showed a severe stenosis in the midright coronary artery. This was treated successfully by stent
placement. Her other vessels had only mild atherosclerosis. Drug
therapy for the PCI consisted of UFH and abciximab in standard doses.
Aspirin 325mg and Clopidogrel 75mg daily are continued following the
procedure. A complete blood count was obtained six hours after the
PCI. The nurse calls you to report that the patients haemoglobin is
14.1mg/dl and the white blood cell count is 7.800. Her platelet counts
75.000 and the smear is reported as clumped.

Which of the following is the most appropriate next step

in her management:
a.
b.
c.
d.
e.

Stop the abciximab infusion.

Repeat the platelet count with heparinized blood.
Stop the Clopidogrel.
Be sure there is no heparin in any of intravenous flushes.
Administer 6 U of platelets.

45. A patient with unstable angina is referred for coronary artery by-pass
surgery following failed PCI. Tirofiban has been administered during
the attempted PCI.

Which management plan is most appropriate:

a.

If symptoms can be controlled, delay surgery 8-12 hours

while Tirofiban is being metabolized.
b.
Transfuse platelets and proceed to surgery immediately.
c.
Proceed immediately to surgery.
d.
Haemodialyze the patient and proceed to surgery.

22

e. Administer epsilon-amino- caproic acid (Amicar) and proceed to

surgery immediately.
46. A 70-year-old patient with a preoperative ejection fraction of 20%
develops oliguria following coronary artery by-pass surgery and mitral
valve repair. His cardiac index is 1.8, blood pressure is 110/60mmHg
and rhythm is AV paced. His chest X-ray shows an enlarged cardiac
silhouette and a left pleural effusion. Chest tube drainage has been
minimal.

Which of the following tests should be considered next:

a.
b.
c.

Chest C-T scan to rule out pulmonary embolism.

Coronary angiograms to exclude graft closure.
Trans-oesophageal echocardiogram to rule out
pericardial
effusion.
d.
Renal ultrasound to exclude obstruction.
47. A 22-year-old with d-TGA status/post-Mustard operation presents to
the clinic to establish CV care. The patient denies any symptoms.
Exam reveals heart rate of 44bpm, lungs are clear and on CV exam,
there is an RV lift, 2/6 systolic ejection murmur and a single S2. ECG
demonstrates a junctional rhythm, RV hypertrophy and right axis
deviation. Chest X-ray reveals mild cardiomegaly and clear lung fields.
Echocardiography demonstrates an enlarged RV with reduced systolic
function, mild tricuspid regurgitation and the baffle assessment is
suboptimal.

Your plan at this point would be to:

a.

Admit for congestive cardiac failure and begin transplant

work-up.
b.
Place a 24-hour ambulatory monitor and consider trans
oesophageal echocardiography to assess for baffle obstruction.
c. Recommend pacemaker placement.
d. Recommend a cardiac catheterisation for arterial switch procedure.

48. A 42-year-old patient with a history of an unrepaired ventricular-septal

defect is cyanotic and presents for routine care. He has limited his
activities, but is essentially asymptomatic with daily life. You are able

23

to document his diagnosis as Eisenmenger physiology. His laboratory

work reveals a haemoglobin of 21g/dl, haematocrit of 68% and a mean
corpuscular volume of 80.

Based on this information, you recommend:

a.
b.
c.
d.

Phlebotomy based on haematocrit more than 64%.

Coumadin to thin out the blood.
No therapy is indicated at this time.
Repeat laboratory work in one month.

49. Which of the following are known risk factor for pregnancy:
a.
b.
c.
d.

Ventricular systolic dysfunction.

Cyanosis.
Left-sided obstructive lesions.
Prior arrhythmia.

50. A 55-year-old with known ischaemic cardiomyopathy, ejection fraction

20%, presents with acute appendicitis. Medications include an ACE
inhibitor, a beta-blocker and a diuretic. His cardiac status has been
stable with no paroxysmal nocturnal dyspnoea, orthopnoea or chest
pain. Coronary angiography two years ago showed proximal occlusion
of the left anterior descending artery. ECG shows an old anterior wall
myocardial infarction, unchanged compared to prior tracings. He
works as a used car salesman and walks two miles around his
neighborhood with his wife at least twice per week. Exam shows no
rales, oedema, jugular venous distention or gallop.

Which of the following is the most appropriate course of

action:
a.
b.
c.

Preoperative coronary angiography and PCI if indicated.

Treadmill exercise test with either nuclear perfusion
imaging or echocardiography.
Resting echocardiogram with ejection fraction and wall
motion analysis.

24

d.
e.

Pulmonary artery catheter placement for intraoperative

monitoring.
Postoperative ECG and troponin.

51. Options for drug therapy for hypertension in pregnancy

include all of the following,

a.
b.
c.
d.

EXCEPT:

Methyldopa.
Nifedipine.
Valsartan.
Labetolol.

52. A 50-year-old man just diagnosed with multiple myeloma presents with
peripheral oedema, jugular venous distension, and ascites. Chest C-T
scan was normal; no pericardial abnormalities were noted. ECG
showed low QRS voltage.

An echocardiogram will most likely show:

a.

b.
c.
d.
e.

53.

A moderate circumferential pericardial effusion with right

ventricular diastolic collapse and accentuated respiratory variation
in the Doppler left ventricular filling pattern.
Normal diameter of the inferior vena cava with normal
response to sniff.
Marked thickening of the left ventricular wall.
Vegetations of the aortic valve with severe aortic
regurgitation.
LVEF 20%.

In venous thromboembolism (VTE), which of the

following statements is FALSE:

25

a.
b.

c.
d.

54.

The treating physician should always establish a pretest

probability of VTE before ordering the diagnostic battery.
There is no gold standard algorithm for VTE diagnosis
and the algorithm may vary from institution to institution,
depending on local resources and expertise.
A V/Q scan should be the first test ordered for work-up of
VTE when the patient has an abnormal baseline chest x-ray.
A spiral CTA is usually indicated when VTE is suspected
in the presence of other likely alternative diagnoses.

An 85-year-old woman with longstanding mild hypertension, but no

cardiac history presents to the emergency department with a 24-hour
history of dyspnoea without chest pain, nausea or diaphoresis. She
has an irregular pulse at 124/minute and her blood pressure is
190/110mmHg. She denies any history of cardiac arrhythmia.

The most likely cause of dyspnoea in this patient is:

a.
b.
c.
d.
e.

Tachycardia-induced cardiomyopathy.
Diastolic heart failure precipitated by acute atrial fibrillation.
Apathetic hyperthyroidism.
Acute myocardial infarction with secondary atrial fibrillation.
Hypertensive urgency causing systolic heart failure.

55. Which of the following statements about the management of

older persons with severe mitral valve regurgitation is

FALSE:
a.

Mitral valve surgery should be performed in older persons

with chronic severe mitral valve regurgitation and a resting LVEF of
less than 30%.
b.
Trans-oesophageal echocardiogram provides an accurate
anatomic assessment of the etiology of mitral valve regurgitation
and assists in determining whether the mitral valve can be repaired
or must be replaced.
c.
Mitral valve surgery is indicated in persons with chronic
severe mitral vale, NYHA class II, III, or IV symptoms and normal
left ventricular function.
d.
Mitral valve surgery is indicated in symptomatic or
asymptomatic persons with chronic severe mitral valve who have
mild or moderate left ventricular dysfunction.

26

e.

ACE inhibitors effective in treating selected persons with

symptomatic chronic mitral valve regurgitation.

56. The following are well recognized causes of high-output

heart failure, EXCEPT:

a.
b.
c.
d.
e.

Cor pulmonale.
Hepatic failure.
Rupture sinus of Valsalva.
Ventricular septal defect.
Beri-beri.

57. A 79-year-old man with coronary artery disease and a history of

coronary artery by-pass surgery four years previously presents with
recurrent palpitations. He has had two prior myocardial infarctions
and his LVEF is moderately reduced at 35%. He has class III heart
failure that is well compensated with an ACE inhibitor, beta-blocker,
diuretic and potassium supplement. He also is receiving long-term
Aspirin and Simvastatin therapy. ECG shows sinus rhythm with
evidence for old anterior and inferior wall myocardial infarctions.
Ambulatory ECG shows ten episodes of non-sustained ventricular
tachycardia and frequent premature ventricular beats. Programmed
electrical stimulation results in induction of monomorphic sustained
ventricular tachycardia at rate of 128bpm without hypotension.
Cardiac catheterisation confirms patent by-pass grafts with a 60%
stenosis in the saphenous vein graft to the left circumflex coronary
artery.

The most appropriate next step in the management of

this elderly patient is:
a.
Stress test to evaluate for ischaemia.
b.
PCI with stent implantation.
c.
Insertion of an ICD.
d.
Initiation of Amiodarone therapy.
e. No further treatment is required because the patient is minimally
symptomatic and not haemodynamically compromised.

58. Upon referral from her family physician, an 86-year-old widow is brought by her
daughter to your office from her assisted-living facility because of a recent syncopal

27

episode that resulted in a fall. Your evaluation discloses that she has hypertension
(186/82mmHg), bilateral carotid bruits, and atrial fibrillation. The referral note from
her primary care physician indicates that she has dyslipoproteinemia (total
cholesterol 220mg/dl, HDL: cholesterol 33mg/dl). In addition, you note that she has
lost 12 lbs in the past year, walks slowly and hesitatingly across your waiting room,
reports that she rarely leaves her room at the facility, eats sparingly and complains of
exhaustion with any attempted activity.
She grasps your hand with a weak grip and requires assistance from
her daughter to rise from her chair, undress and get onto your
examining table. Your clinical judgement suggests that she may derive
limited benefit from aggressive CVD intervention because of frailty, a
geriatric syndrome.

This diagnostic impression is justified on the bases of

her:
a.
b.
c.
d.
e.

Hypertension.
Low activity level.
History of syncope.
Dyslipoproteinemia.
Atrial fibrillation.

59. Which of the following results in decreased pulmonary

vascularity on chest X-ray:

a.
b.
c.
d.

Atrial septal defect (ASD) with patent ductus arteriosus.

ASD with restrictive ventricular septal defect (VSD).
ASD with tricuspid atresia and restrictive VSD.
ASD with partial anomalous pulmonary venous drainge.

60. A 55-year-old previously healthy man experienced syncope while sitting

at the dinner table. He fell face forward on the table, without warning
and he regained consciousness in approximately 1.5 minutes, at which
time he was asymptomatic. Physical examination performed
approximately half hour later, demonstrated a blood pressure of
110/80mmHg and heart rate of 80bpm. There was an left ventricular
thrust, a quiet, single second heart sound, and a grade III/IV systolic
ejection murmur at the base, which peaked in mid-systole and radiated
into the carotids. The upstroke velocity of the carotid pulse was only
slightly slowed. The remainder of the examination was normal. The

28

ECG demonstrated right bundle branch block and left anterior

hemiblock. The PR interval measured 0.24 seconds.

What is the most likely explanation for the patients

syncope:
a.
b.
c.
d.
e.

Aortic stenosis.
Neurally mediated, vasodepressor syncope.
Neurally mediated, cardioinhibitory syncope.
Mobitz II atrio-ventricular block.
Postprandial syncope in the elderly.

61. A 71-year-old woman consults you with the complaint of blue toes. These
have developed during winter of the year, each of the past three years and
have cleared spontaneously in the spring of the year. She does not smoke
and takes no medication. Past history reveals that she has always been well
and has sustained no injury except for having had chilblains at age eight
after walking two miles from school in the snow. Physical examination
reveals a normal blood pressure, normal cardiac exam and normal
peripheral arterial pulses. There is cyanosis of the toes and vesiculation of
the tips of both great toes.

What is the diagnosis:

a.
b.
c.
d.
e.

Chronic pernio.
Secondary Raynauds phenomenon.
Digital artery occlusion.
Atheroembolism.
Thrombocytosis.

62. The plasma half-life a drug is influenced by its:

a.
b.
c.
d.
e.

Lipid solubility.
Receptor binding characteristics.
Clearance.
Percentage of oral absorption.
Formulation (pill vs. capsule).

29

63. Peripheral plasma renin activity may be elevated prior to

therapy with each of the following causes of hypertension,

EXCEPT:
a.
b.
c.
d.
e.

Renovascular hypertension.
Malignant hypertension.
Oral contraceptive use.
Secondary aldosteronism.
Primary aldosteronism.

64. A previously healthy 48-year-old man presents to the emergency

department of a 300-bed hospital with on-site catheterization facilities
and reports 45 minutes of severe retrosternal chest discomfort, nausea
and diaphoresis. The ECG shows 2-3mm ST elevation in leads I, aVL
and V5-6. On examination, he is sweaty, but warm. Heart rate is
82bpm and regular, blood pressure is 124/78mmHg and temperature
is 99.1. Jugular venous pressure is normal. Chest is clear. S1, S2 are
normal; +S4. No murmur. Pulses intact; no oedema.

Which statement is true regarding acute re-perfusion

therapy in this patient:

a.

Tenecteplase TPA would be more effective than

accelerated-dose TPA for reducing the risk of death.
b. Primary PCI would be contraindicated in the absence of shock.
c. Primary PCI should be recommended if the on-call
interventionalist has performed at least 50 PCI in the past year.
d. The risk of intra-cranial haemorrhage and stroke would be less
with primary PCI than with fibrinolytic therapy.
e. Stenting the infarct-related artery would reduce the risk of shortterm death.

65. A 42-year-old man is referred for evaluation of a systolic murmur. Your

exam shows normal carotid pulses, a prominent apical impulse, an
early systolic sound and a grade III/VI mid-systolic murmur at the
base. Respiration did not change the character of these auscultatory
findings. After an extrasystole, the systolic murmur increased in

30

intensity. Handgrip did not alter the systolic murmur. Valsalva

decreased the intensity of the murmur and it returned to baseline
intensity after seven heart beats.

Which one of the following diagnoses is most likely:

a.
b.
c.
d.
e.

Congenital pulmonic stenosis.

Innocent murmur.
Mitral valve prolapse.
Hypertrophic obstructive cardiomyopathy.
Bicuspid aortic valve.

66. Etiology possibilities to consider in occlusion of a

subclavian artery include all of the following,

a.
b.
c.
d.
e.

EXCEPT:

Takayasus arteritis.
Thromboangiitis obliterans (Buergers disease).
Cranial (temporal) arteritis.
Atherosclerosis.
Acute aortic dissection.

67. You have been following a 31-year-old woman with childhood repair of
tetralogy of Fallot. She has been active and healthy and now is considering
pregnancy. Examination revealed: HR: 74bpm, BP: 110/70mmHg. JVP
6cm, lungs clear. There is a right ventricular lift, grade 2/6 mid-systolic
murmur at upper left sternal border, grade 2 decrescendo diastolic murmur
at left sternal border, and no oedema or cyanosis. ECG; normal sinus
rhythm, right bundle branch block. Echocardiography; no residual shunt
flow across VSD patch, LVEF 0.55, mild reduction of right ventricular
systolic function and 3-4+ / 4+ PR, peak estimated pulmonary artery
pressure 32mmHg.

You would advise:

a.

Risk of pregnancy for mother and fetus is too high and

must be avoided.
b.
Risk to fetus for development of congenital heart disease
25%.
c.
Pulmonary valve replacement before pregnancy.
d.
Pregnancy should be manageable with careful follow-up.

31

68. On routine physical examination, the blood pressure of an

asymptomatic 46-year-old obese woman is 160/90mmHg. She has
mild pedal oedema at the end of the day, but it resolves by morning.
An innocent flow murmur and a fourth heart sound (S4) are detected
on cardiac auscultation.

Which of the following conclusions is correct, and what

is the next step:
a.
b.
c.

d.
e.

Because the patient is asymptomatic, these are innocent

findings; repeat blood pressure measurements in one week.
S4 suggests left ventricular systolic failure and should be
quantified by a first-pass sestamibi radio-nuclide study.
S4 most likely indicates diastolic dysfunction due to
hypertension; echocardiography is appropriate to better quantify
the haemodynamics, particularly diastolic function.
Further testing is not needed; begin antihypertensive treatment
immediately.
The patient probably has silent ischaemia and an exercise radionuclide study is appropriate.

69. A 60-year-old man is referred by a primary physician with question of

significant aortic stenosis. The patient says he does not have any
physical limitations. He is still active as a farmer and says he has not
had dyspnoea on exertion or orthopnoea. He has never experienced
syncope or dizziness and says he has not had palpitations.

Which of the following physical findings would make you

question the diagnosis of significant aortic stenosis:
a.
b.
c.
d.
e.

Carotid upstroke significantly parvus et tardus.

The arterial or central pulse is bisferiens.
Displaced and forceful apical impulse.
Presence of the A2 component of the second heart sound.
A late-peaking systolic murmur, followed by a 3/6 diastolic
murmur.

32

70. A 21-year-old male colleague athlete has severe orthopnoea and

dyspnoea on exertion. Within six weeks, he has gone from having
excellent health to being unable to walk up a flight of stairs. Also, he
has noted peripheral oedema and about an 8 lb weight gain. He has
felt bloated and has noted that his heart rate has increased from a
previously bradycardic rate of 48 bpm to the current 86 bpm. On
physical examination, you note that the patient is slender, 180 cm
tall, weight 65 Kg, and does not have a previous history of cardiac
disease, fever, chest pain, hypertension or rheumatic fever.
He denies drug or alcohol use and has not had a previous heart
murmur. He displays a dry cough and has marked effort fatigue. On
further examination, his blood pressure is 110/70mmHg and heart
rate is 96bpm. Jugular venous pulse is 9cm. A hepato-jugular reflux
maneuver performed by you is positive.

Which of the following signs would be associated with the

condition:
a.
b.
c.
d.
e.

A tall V-wave in the jugular venous pulse.

A non-displaced apical impulse.
A loud systolic murmur, late peaking over the left
ventricular outflow tract.
A third heart sound (S3).
A delayed carotid upstroke.

71. A 17-year-old girl collapsed suddenly while running track. When the
paramedics arrived, she was found to be in ventricular fibrillation.
Defibrillation was successful. A 12-lead electrocardiogram obtained at
admission is shown in the figure. During the first hour of cardiac
monitoring in the cardiac care unit, several episodes of non-sustained
polymorphic ventricular tachycardia were observed.

33

Which of the following would not be appropriate at this

time:
a.
b.
c.
d.
e.

Potassium supplement.
Magnesium supplement.
Procainamide.
Esmolol infusion.
Lidocaine.

72. A 74-year-old man with a previous inferior wall myocardial infarction

was found to have a wide complex tachycardia. He is stable
haemodynamically and without chest pain.

Which of the following would best indicate a

supraventricular tachycardia with aberrancy instead of
ventricular tachycardia:
a.
b.
c.
d.
e.

P-wave that march through the QRS complexes.

Right bundle branch block pattern with rsR pattern.
Northwest axis (axis between 900 and - 1800 ).
A different QRS morphology in patients with pre-existing
bundle branch block.
A history of structural heart disease.

73. A 65-year-old man had an anterior myocardial infarction followed by an

emergency by-pass operation five years ago. Now, he has stable exertional
angina. His ejection fraction postoperatively was 30%. Over the past
month, he has noted increasing symptoms of angina which now awaken
him at 2;00 A.M.. He is still able to perform his daily activities without
limitation which amount to a moderately active lifestyle. Currently, he is
taking Lisinopril 20mg daily, Metoprolol 50mg twice daily and one Aspirin
daily. On physical examination, his blood pressure is 120/70mmHg and
the pulse rate is 60bpm. The venous pressure is mildly increased at 14cm
H2O. Bibasilar rales are present. The left ventricular impulse is displaced
to the anterior axillary line and enlarged. A soft third heart sound is
audible. No murmur is audible.

What is the most appropriate choice of therapy for this

patient:

34

a.

Coronary angiography with percutaneous transluminal

coronary angioplasty.
b.
Intravenous administration of glycoprotein IIb/IIIa
inhibitor.
c.
Diuresis.
d.
Increase the beta-adrenergic blocker dose.
e.
Add a calcium channel blocker.

74. A patient has percutaneous transluminal coronary angioplasty and

stenting of the mid left anterior descending coronary artery for
unstable angina.

Which of the following drugs should you give to decrease

the incidence of re-stenosis after a catheter-based
intervention:
a.
b.
c.
d.
e.

Aspirin.
Calcium channel blocker.
Angiotensin-converting enzyme inhibitor.
Fish oil and vitamin E.
None of the above medications can prevent restenosis.

75. A 53-year-old woman is referred for an opinion about progressive

abdominal swelling, exertional dyspnoea and orthopnoea. She has no
chest discomfort to suggest angina pectoris. Two years earlier, she had
mitral valve replacement with a mechanical prosthesis for rheumatic
mitral valvular disease. At that time, tricuspid annuloplasty was
performed. Preoperative coronary angiographic results at that time
were normal. She has no known risk factors for the development of
premature atherosclerotic disease. Her heart rate is 92bpm and blood
pressure is 105/70mmhg.
The jugular venous pressure is markedly increased and rapid descents
are present. There is no V-wave. Prosthetic sounds are crisp and there
are no cardiac murmurs. The liver is enlarged and tender. There is no
peripheral oedema. There is dullness to percussion and decreased
breath sounds halfway up the right lung. Chest radiography

35

demonstrates a moderate-sized right pleural effusion. The

electrocardiogram shows normal sinus rhythm, and is normal.

What is the most likely diagnosis:

a.
b.
c.
d.
e.

Severe ischaemic heart disease.

Constrictive pericarditis.
Mitral prosthetic regurgitation.
Mitral prosthetic obstruction.
Severe tricuspid valve regurgitation.

76. Dominant R-wave in lead V1 in ECG is seen in the

following conditions, EXCEPT:

a.
b.
c.
d.
e.

Duchenne muscular dystrophy.

Young black men.
D-transposition of great vessels.
Wolff- Parkinson- White syndrome.
Posterior myocardial infarction.

77. On chest X-ray, the following is characteristic finding in

pulmonary hypertension:
a.
b.
c.
d.
e.

78.

Prominent pulmonary knuckle.

Straightening of left heart border.
Posterior displacement of the oesophagus.
Calcification of pulmonary arteries.
Pulmonary central plethora with peripheral prunning.

During pregnancy, the following cardio-vascular

changes are false, EXCEPT:

36

a.

The increase in cardiac output exceeds the increase in

oxygen consumption.
b.
Increased glomerular pressure.
c.
Increased systemic vascular resistance.
d.
Increased blood pressure during second trimester of
pregnancy.
e.
Thiazide diuretics increase uterine blood flow.

79. During acclimatization at high attitude, the following

occur,
a.
b.
c.
d.
e.

EXCEPT:

Shift of oxygen dissociation curve to the right.

Decreased oxygen affinity for haemoglobin.
Reduces 2.3 diphosphoglycerate level.
Increased ventilatory response to raised PCO2.
Polycythaemia.

80. In signal-averaged ECG, the following is correct:

a.
b.
c.
d.
e.

Late potentials detected by signal-averaged ECG are

common after myocardial infarction.
It has low negative predictive value for arrhythmic death.
Signal-averaged ECG is indicated for risk stratification
after myocardial infarction.
Is useful for supra-ventricular tachycardia.
Present in 70% of patients with ventricular tachycardia.

81. In HOCM, risk of sudden cardiac death (SCD), the

following are correct,

a.
b.

EXCEPT:

Direct evidence of septal myectomy and reduction of risk

of sudden cardiac death.
Presence of left ventricular hypertrophy more than 30mm
increases risk of SCD.

37

c.
of SCD.
d.
patient.
e.

Patients with history of ventricular tachycardia are at risk

Positive family history of SCD increases risk of SCD in the
Failure to increase blood pressure with exercise increases
risk for SCD.

82. The following denote poor prognosis in patients with

heart failure,
a.
b.
c.
d.
e.

EXCEPT:

Cardiac index less than 2.

Increase pulmonary artery pressure more than 50mmHg.
Increase PCWP more than 12mmHg.
Increase peak oxygen consumption.
Hyponatraemia.

83. In Sarcoid disease of the heart, the following are

incorrect,

EXCEPT:

a.
b.

MRI scan usually shows scarring of left ventricle.

Q waves on ECG due to involvement of small intramural
coronary vessels.
c.
Complete heart block occurs in 20-30% of cases.
d.
Echocardiogram usually shows scarring and thinning of
the septum.
e.
Congestive cardiac failure is the most common
presentation.

84. In anti-platelet and anti-thrombotic therapies, the following

are correct,

a.
kidneys.
b.
c.
d.

EXCEPT:

Low molecular weight heparins are excreted by the

Abciximab is metabolized by the liver.
Aspirin and Clopidogrel can be given in presence of renal
insufficiency.
Unfractionated heparin should be avoided with renal
insufficiency.

38

e.
heparins.

Anti-Xa activity is used to monitor low molecular weight

85. Ducket-Jones major criteria for the diagnosis of

rheumatic fever include:

a.
b.
c.
d.
e.

Chorea gravidarum.
Tender nodules over pre-tibial areas.
Arthritis of proximal interphalangeal joints.
Erythema marginatum.
Oslers nodes.

86. In dysrrhythmia, the following are incorrect,

EXCEPT:

a.
Automaticity in the most common mechanism of
arrhythmia.
b.
Triggered activity arises from after depolarization.
c.
In treatment of atrial fibrillation, we should always aim for
rhythm control.
d.
Digitalis-induced junctional tachycardia is due mainly to
re-entry.
e.
Acute ischaemia is the most common cause of multifocal
atrial tachycardia.

87. The following signs are present in severe mitral valve

stenosis,

EXCEPT:

a.
b.
c.
d.
e.

Third heart sound.

Graham-steel murmur.
Early opening snap.
Long diastolic murmur.
Diminished intensity of first heart sound.

39

88. In abdominal aortic aneurysm, which statement is

incorrect:

a.
b.
c.
d.
e.

diagnosis.

Majority of patients are asymptomatic at time of

Majority of aneurysms are infra renal.

Pain from aneurysm means impending rupture.
Expansion of aneurysm can cause ureteric obstruction.
15% of aneurysms with diameters greater than 6cm
rupture within one year.

89. On assuming the squatting posture from standing, the

following occur,

a.
occur early.
b.
cardiomyopathy.
c.
d.
e.

EXCEPT:

Mid systolic click and murmur of mitral vale prolapse

Decreased intensity of murmur of obstructive
Increase in venous returns.
Increase in peripheral systemic resistance.
Increase in left ventricular size.

90. In Doxorubicin cardiotoxicity, the following are incorrect,

EXCEPT:
a.
b.
c.
d.
e.

Toxicity is idiosyncretic.
Peak blood level of Doxorubicin is the most important
factor in determining cardiotoxicity.
Acute toxicity is usually irreversible and lead to death.
Endomyocardial biopsy is essential for the diagnosis.
Radio-nuclide angiography is contraindicated.

91. In vitamin K, the following are correct,

oils.

a.
b.

EXCEPT:

Is required for synthesis of factors II, VII, IX and X.

Dietary vitamin K is present in green leafy vegetables and

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c.
d.

Vitamin K is stored mainly in liver and bone.

Vitamin K is transported in plasma by triglyceride-rich
lipoproteins.
e.
Vitamin K is present in high concentration in human
breast milk.

92. In X-Syndrome, the following are incorrect,

a.
b.
c.
d.
e.

93.

EXCEPT:

It has a poor prognosis with accelerated course.

It occurs only in patients with a single X-chromosome.
Is characterized by normal exercise tolerance test and
abnormal coronary vessels.
Usually resolves with reassurance.
The coronary artery flow reserve is reduced.

In cardiac tumours, all are incorrect,

EXCEPT:

a.
Metastatic tumours are more common than primary
neuplasms.
b.
Pulmonary embolism is frequently seen with myxomas.
c.
Myxomas typically arise in the right atrium.
d. M-mode-echocardiography is efficient in demonstrating shape and
attachment of the tumours.
d.
Tumour plop is characteristically heard after second
heart sound.

94. In research, which statement is correct:

a.

b.

c.

GISS1-1 was the first of the trials of thrombolysis in acute

myocardial infarction which was large enough on its own to
confirm the effectiveness of thrombolysis.
A systematic review of previous small studies has shown
that compression stockings fail to reduce the incidence of deep
venous thrombosis (DVT).
When undertaking a meta-analysis, it is important to
include only trials which reached statistical significance.

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d.
e.

Systematic reviews of small trials are a good substitute for

large case-controlled prospective studies.
Evidence based medicine was designed as a means to ration health
care.

95. Conns Syndrome is characterized by:

a.
b.
c.
d.
e.

Low serum sodium.

High serum potassium.
Low urinary potassium.
Peripheral oedema.
Circumoral parasthesia.

96. In primary pulmonary hypertension, which statement is

incorrect:
a.
b.
c.
d.
e.

Syncopal attacks.
Raised pulmonary capillary wedge pressure.
Raynauds phenomenon may occur.
Dull retrosternal chest pain.
ECG shows right ventricular hypertrophy.

97. In coarctation of the aorta, the following statements are

correct,

a.
occurs.
b.
c.
d.
e.

EXCEPT:

Infective endocarditis on the bicuspid aortic valve rarely

Aortic dissection is a recognized complication.
Rib notching.
Cerebral haemorrhage is a known sequel.
Congestive cardiac failure is a common presentation.

98. In atrial-septal defect, all are correct,

a.
b.

EXCEPT:

Wide fixed splitting of second heart sound.

Atrial fibrillation is common.

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c.
d.
inspiration.

The murmur is produced by flow across the defect.

Mid diastolic murmur increases in intensity during

99. A 72-year-old man with a long history of hypertension is evaluated

because of back pain. On physical examination, his peripheral pulses
are intact, and blood pressure is 180/80mmhg in both arms. His pain
persists despite administration of nitrates and morphine. Transoesophageal echocardiography shows a crescent-shaped area of
increased thickness in the wall of the midsection of the descending
thoracic aorta, but no dissection flap is seen. A C-T scan of the chest
is consistent with an aortic intramural haematoma and shows clear
displacement of intimal calcification by the haematoma.

Which of the following is most appropriate initial

management for this patient:
a.
b.
c.
d.
e.

Prompt surgical intervention.

Administration of a beta-blockers.
Administration of a diuretic.
Administration of Heparin.
Administration of a non-steroidal anti-inflammatory drugs.

100. The presence of which of the following conditions

portends the poorest long-term prognosis in patients

with aortic stenosis:
a.
b.
c.
d.
e.

Angina.
Syncope.
Calcification of the valve.
Valve area of less than 0.5 cm2.
Congestive cardiac failure.

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