Preparing for the American Board of Internal Medicine Maintenance of Certification

The following questions can assist candidates for the Maintenance of Certification Exam in Cardiovascular Disease prepare for this test. We hope you find this helpful and welcome your feedback.

Questions

1. At a routine office visit, a 67-year-old man describes exertional leg (right calf) discomfort. He notes no diabetes or hypertension but does have a former (35 pack-year) smoking history. On physical exam you note a blood pressure of 160/90 mm Hg, a heart rate of 88 bpm, and a respiratory rate of 16 bpm. He has no jugular venous distention (JVD) or hepatojugular reflux (HJR). His lungs are clear bilaterally. You detect an S₄; no murmur is detected despite provocative maneuvers. He has good femoral pulses. However, the dorsalis pedis pulses are difficult to palpate bilaterally. No ischemic changes are present on the lower extremities. You obtain blood pressures, in the supine position, in his brachial artery, doralis pedis, and posterior tibial arteries on both sides (right: 146, 96, and 92 mm Hg, respectively; left 155, 94, and 91 mm Hg, respectively). What can be said about the presence of peripheral arterial disease?

1. The patient has severe arterial obstructive disease.
2. The patient has moderate arterial obstructive disease.
3. The patient has mild arterial obstructive disease.
4. The patient has no arterial obstructive disease and requires no intervention.
5. The patient may have spinal cord or orthopedic issues.

2. What drug decreases the serum level of cyclosporin?

1. Phenytoin.
2. Erythromycin.
3. Diltiazem.
4. Verapamil.
5. Cimetidine.

3. A 61-year-old previously healthy gentleman is admitted to the intensive care unit after a 4-day history of upper respiratory tract infection with now sudden onset of shortness of breath and mental status changes. When you see him he is unresponsive. His blood pressure is 80/50 mm Hg and his heart rate is 123 bpm. He is not breathing on his own and is rapidly intubated. Electrocardiogram reveals a sinus tachycardia with diffuse ST elevations. He has JVD to the angle of the jaw and bibasilar rales. He has no murmurs. No peripheral edema is present and his extremities are cool. A pulmonary artery catheter is placed, revealing a central venous pressure of 17 mm Hg, pulmonary artery pressure 60/30 mm Hg, and a pulmonary capillary wedge pressure of 26 mm Hg with a cardiac output 2.8 L/min. He is currently on norepinephrine, dopamine at 8 µg/kg/min, and a lasix infusion. The next step should be:

1. Implantation of a left ventricular assist device.
2. Initiation of intravenous levosimendan.
3. Start intravenous nesiritide.
4. Initiate ultrafiltration.
5. Start intravenous dobutamine.

4. You are asked to consult on a 45-year-old woman with chest tightness. She has had shortness of breath over a 1-year period of time that has not responded to antibiotics or inhalers. A chest computed tomography (CT) reveals only bilateral hilar lymphadenopathy. On exam, she has a blood pressure of 121/87 mm Hg, a heart rate of 125 bpm, and a respiratory rate of 25 bpm. She has diminished breath sounds bilaterally. A chest radiograph is unremarkable. A dobutamine stress echocardiogram is unremarkable except for baseline septal wall thickening and a right ventricular systolic pressure estimated at 25 mm Hg. No wall motion abnormalities are detected. Cardiac magnetic resonance imaging reveals discontinuous hyperenhancement within the myocardium in the septal, basilar anterior, anterolateral, and lateral walls, sparing the endocardium. In addition, T2-weighted imaging revealed subtle myocardial abnormalities in the same anatomic locations. The left ventricle was normal in size and shape, with mildly globally depressed function (left ventricular ejection fraction [LVEF] = 0.47). What cardiovascular complication is she most likely to subsequently develop?

1. Myocardial ischemia.
2. Pericardial tamponade.
3. Conduction abnormality/heart block.
4. Constrictive pericarditis.
5. Pulmonary hypertension.

5. A 51-year-old woman comes to your office with a history of an idiopathic dilated cardiomyopathy of 6 years duration. In the past 3 months, she has been hospitalized twice for acutely decompensated heart failure, the last time requiring inotrope-assisted diuresis. At that time, a biventricular pacemaker and an implantable cardiac defibrillator were implanted. Today, she reports continued dyspnea and fatigue when walking more than 50 feet. On exam, her heart rate is 92 bpm, blood pressure is 85/50 mm Hg, and respiratory rate is 28 bpm. She has JVD at 12 cm with positive HJR. She has bilateral rales, half way up in both lung fields. She has a laterally displaced point of maximal impulse, a II/VI holosystolic murmur at the apex radiating to the axilla, bilateral pitting edema to the knees, and warm extremities. She reports being compliant with her medical regimen, which includes carvedilol 25 mg twice a day, lisinopril 40 mg once a day, spironolactone 25 mg once a day, lasix 80 mg twice a day, metolazone 5 mg once a day, and dioxin 0.125 mg once a day. Laboratory results included: hematocrit 12.5 mg/dL, sodium 129 meq/dL, blood urea nitrogen 35 mg/dL, and creatinine 1.1 mg/dL. An echocardiogram, unchanged from 1 year ago, reveals biventricular heart failure with an LVEF of 20% to 25%. She has moderate mitral regurgitation and tricuspid insufficiency. Her VO₂ max on cardiopulmonary exercise testing was 11 mL/min/kg. All of the following should be considered except:

1. Addition of amlodipine for enhanced rate control.
2. Admission for intravenous diuretics.
3. Consideration of inotrope or vasodilator-assisted diuresis.
4. Evaluation for left ventricular assist device implantation.
5. Evaluation for cardiac transplantation.

6. You are asked to consult on a 38-year-old woman with breast cancer who is being treated with a chemotherapeutic regimen that includes anthracycline (200 mg/m²) and trastuzumab for a HER2+ tumor with metastases. Radionucleotide ventriculography revealed a baseline ejection fraction of 59%. On follow-up, her ejection fraction is now 49%. She is scheduled for trastuzumab. What would you recommend next?

1. Do not initiate the trastuzumab.
2. Substitute trastuzumab with a lower dose of anthracycline.
3. Repeat radionucleotide ventriculography in 3 months and to reassess use of trastuzumab.
4. Give trastuzumab and follow ejection fraction at 3 weeks.
5. Consider alternative medical regimen.

7. A 22-year-old woman presents to you for a second opinion. She was diagnosed with peripartum cardiomyopathy during which time her LVEF was 20%. A repeat echocardiogram, 1 year after delivery reveals an LVEF of 40%. She jogs 1 mile a day without shortness of breath. What is the current recommendation of future pregnancies?

1. Allow pregnancy with serial echocardiograms every 3-6 weeks.
2. Allow pregnancy but delivery at 33 weeks with cesarean section.
3. Allow pregnancy but switch lisinopril to hydralazine/oral nitrates.
4. Allow pregnancy, stop β blocker, and switch lisinopril to hydralazine/oral nitrates.
5. Caution against future pregnancy.

8.A 62-year-old woman is admitted to the hospital with acutely decompensated heart failure. Until recently, she had led a fit and active life but had noted increasing breathlessness and swollen ankles over the past 2 months. She now describes 4 pillow orthopnea without chest pain or palpitations. On exam, her blood pressure is 101/78 mm Hg, heart rate regular at 98 bpm, and respiratory rate is 18 bpm. She has JVD to the angle of the jaw and a holosystolic murmur, but otherwise the cardiac exam is benign. She has a positive fluid wave sign, bilateral pitting edema to the knees, and is warm to touch in her extremities. Interventions known to improve her 1-year survival include:

1. The use of intravenous diuretics only.
2. Inotrope-assisted diuresis.
3. Intravenous nesiritide-assisted diuresis.
4. Ultrafiltration to euvolemia.
5. Initiation of ACE inhibition when hemodynamically stable.

9. You are asked to see a 48-year-old man with an ischemic cardiomyopathy and a prior history of symptomatic heart failure with episodes of paroxysmal atrial fibrillation (PAF). He was placed on amiodarone 1 year ago but this was discontinued 2 months ago due to increasing shortness of breath and a high suspicion of pulmonary toxicity on CT scanning. During the past 2 weeks, however, he has had several episodes of PAF associated with shortness of breath and requiring acute administration of higher doses of diuretics. He is currently on an ACE inhibitor, β blocker, mineralocorticoid inhibitor, and is euvolemic. Most recent laboratory analysis shows a potassium level of 4.2 meq/L and a creatinine of 1.0 mg/dL. Prior to considering atrioventricular ablation, which of the following may be tried?

1. Propofenone.
2. Flecainide.
3. Verapamil.
4. Dofetilide.
5. Ibutilide.

10. A 67-year-old woman presents with severe valvular aortic stenosis. Which of the following has the least affect on her surgical risk?

1. The presence of concomitant moderate aortic insufficiency.
2. The presence of a 95% left anterior descending artery disease.
3. The presence of left ventricular systolic dysfunction and ventricular thinning.
4. The presence of atrial fibrillation (AF) with a dilated left atrium.
5. An aortic valve area of .6 cm².

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