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The Big Heart Disease Lie

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25. Stable angina is characterized by all of the following

EXCEPT

(A) episodic chest pain lasting 30 to 45 min

(B) may be accompanied by light-headedness, palpitations, diaphoresis, dyspnea, nausea, or vomiting

(C) auscultation may reveal transient S4 or apical systolic murmur indicative of mitral regurgitation

(D) provoked by exertion or stress

(E) an ECG taken during an acute attack may show ST-segment depression or T-wave inversion

26. Unstable (crescendo or preinfarction) angina is characterized by all of the following EXCEPT

(A) exertional angina of recent onset, usually defined as within 4 to 8 weeks

(B) elevated troponin and new Q waves

(C) angina of worsening character, characterized by increasing severity and duration

(D) angina at rest (angina decubitus)

(E) increased requirement for nitroglycerin to control angina

27. What percentage of AMI patients have diagnostic changes on their initial ECG?

28. An ECG with abnormal Q waves and ST-segment elevation in I, aVL, and V4-V6 would represent infarction in which area of the myocardium?

(A) Inferior

(B) Anteroseptal

(C) Lateral

(D) Anterolateral

(E) Posterior

29. What percentage of unstable angina patients can be identified by positive troponin assays?

30. How long after coronary artery occlusion can echocardiography detect wall-motion abnormalities?

(A) Within a few heartbeats

31. Rupture of a papillary muscle is usually associated with an infarction of which area of myocardium?

(A) Inferior

(B) Inferior-posterior

(C) Lateral

(D) Anterior

(E) Anteroseptal

32. Postmyocardial infarction (Dressler's) syndrome is characterized by all of the following EXCEPT

(A) chest pain

(C) pleuropericarditis

(D) mediastinitis

(E) pleural effusion

33. All of the following should be used in the initial management of AMI EXCEPT

(A) nifedipine

(B) nitroglycerin

(C) oxygen

(D) aspirin

(E) heparin or low-molecular-weight heparin (LMWH)

34. The Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial found a reduced mortality rate in groups taking heparin intravenously with tPA rather than streptokinase. For which of the following subgroups of patients were these relatively small benefits of tPA over streptokinase fewer or nonexistent?

(A) Patients younger than 75 years

(B) Patients with anterior MI

(C) Patients with inferior MI

(D) Patients with posterior MI

(E) Patients in whom thrombolysis was not initiated within 2 h of symptom onset

35. Of the following criteria, which is the BEST for thrombolytic therapy?

(A) > 1-mm ST-segment depression in a single limb lead

(B) > 2-mm ST-segment elevation in two or more contiguous limb leads in a patient with signs of cardiogenic shock

(C) > 2-mm ST-segment elevation in two or more contiguous precordial leads

(D) New right bundle branch block

(E) New left bundle branch block with evidence of cardiogenic shock

36. Absolute contraindications to thrombolytic therapy include all of the following EXCEPT

(A) recent head trauma

(B) stroke within the past 6 months or any history of hemorrhagic stroke

(C) suspected aortic dissection

(E) suspected pericarditis

37. By which percentage does aspirin (by itself) reduce cardiovascular mortality when given in the early stages of coronary occlusion?

38. Nitrates have all of the following effects EXCEPT

(A) reducing cardiac preload

(B) reducing cardiac afterload

(C) dilating major capacitance vessels of the coronary system thereby improving collateral flow

(D) inhibiting vasospasm

(E) improving clinical outcome when used orally during AMI

39. Contraindications to (3 blockade include all of the following EXCEPT

(A) heart rate < 60 beats per minute

(B) first-degree AV block

(C) severe left ventricular dysfunction

(D) severe chronic obstructive pulmonary disease

(E) systolic blood pressure < 100 with signs of hypoperfusion

40. Which of the following is the MOST appropriate intravenous heparin dose in the setting of AMI?

(A) loading dose: 75 U/kg, maintenance infusion: 13 U/kg per hour

(B) loading dose: 7.5 U/kg, maintenance infusion: 13 U/kg per hour

(C) no loading dose, maintenance infusion: 1100 U/h

(D) loading dose: 10,000 U, maintenance infusion: 1000 U/h

(E) loading dose: 1000 U, maintenance infusion: 1200 U/h

41. A 70-year-old man presents to the ED after a 1-min episode of loss of consciousness while eating dinner. Potential cardiac causes of this syncopal episode include all of the following EXCEPT

(A) bradycardia

(B) tachycardia

(C) aortic stenosis

(D) aortic regurgitation

(E) ischemia

42. All of the following drugs may contribute to syncope EXCEPT

(A) spironolactone

(B) digitalis

(C) metoprolol

(D) nitrates

(E) synthroid

43. Which artery is MOST likely to be diseased in a patient who suffers a syncopal episode secondary to cerebral ischemia?

(A) Carotid

(B) Vertebrobasilar

(C) Anterior communicating artery

(D) Anterior cerebral artery

(E) Posterior communicating artery

44. A 44-year-old man complains of recurrent syncope associated with upper extremity exercise. What is the MOST likely cause?

(A) Trigeminal neuralgia

(B) Hypoglycemia

(C) Carotid sinus hypersensitivity

(D) Subclavian steal syndrome

(E) Vasovagal syncope

45. What diagnosis should be suspected in an elderly patient who experiences a syncopal episode after head turning or shaving?

(A) vasovagal syncope

(B) carotid sinus hypersensitivity

(C) orthostatic syncope

(D) cardiomyopathy

(E) seizure disorder

46. Which of the following conditions is NOT associated with a risk of aortic dissection?

(A) Aortic regurgitation

(B) Aortic stenosis

(C) Bicuspid aortic valve

(D) Marfan's syndrome

(E) Coarctation of the aorta

47. All of the following findings support the diagnosis of pericarditis EXCEPT

(A) pain relieved by sitting up and leaning forward

(B) presence of a pericardial friction rub

(C) ECG with diffuse ST segment depression

(D) ECG with PR segment depression

(E) pericardial effusion

48. Which of the following statements regarding chest pain is FALSE?

(A) Burning or gnawing pain may be present with AMI

(B) An acid or foul taste in the mouth suggests dypepsia is more likely than angina

(C) Tenderness to palpation in the epigastric region may be elicited with AMI

(D) Relief of pain with antacids strongly suggests a gastrointestinal etiology

(E) Epigastric or lower chest discomfort may be described with both cardiac and noncardiac causes

49. Risk factors for coronary artery disease include all of the following EXCEPT

(B) hypercholesterolemia

(C) estrogen replacement medications

(D) diabetes

(E) cigarette smoking

50. Physical examination and laboratory findings that may be present in AMI include all of the following EXCEPT

(A) chest wall tenderness

(B) sinus tachycardia or bradycardia

(C) hypertension or hypotension

(D) crackles on pulmonary examination

(E) non-anion-gap metabolic acidosis

51. A patient has a blood pressure of 210/140 accompanied by severe headache, nausea, and vomiting. Which category of hypertension BEST describes this presentation?

(A) Hypertensive emergency

(B) Hypertensive urgency

(C) Uncomplicated hypertension

(D) Transient hypertension

(E) Chronic hypertension

52. How quickly and to what level should the blood pressure be lowered in a patient with a hypertensive emergency?

(A) 120/80 as quickly as possible

(C) 120/80 within 30 to 60 min

(D) A level that is "normal" for that patient within 30 to 60 min

(E) A level that is "normal" for that patient within 4 h

53. A patient, 8 months' pregnant, with no medical history presents with a BP of 160/100 and seizures. Which of the following is the BEST drug for lowering BP in this setting?

(A) Sodium nitroprusside

(B) Hydralazine

(C) Intravenous nitroglycerin

(D) Nifedipine

(E) Furosemide

54. Sodium nitroprusside has all of the following actions EXCEPT

(A) arteriolar dilator

(B) venodilator

(C) decreasing preload and afterload

(D) near immediate onset of action

(E) duration of action of 1 to 2 h

55. Labetalol is an excellent drug for lowering blood pressure in all of the following conditions EXCEPT

(A) pheochromocytoma

(B) MAO inhibitor-induced hypertensive emergencies

(C) clonidine withdrawal

(D) dissecting aortic aneurysm

(E) in patients with congestive heart failure and hypertension after AMI

56. Each of the following is a risk factor for venous thrombosis EXCEPT

(A) hormone replacement therapy

(C) central line placement

(E) extensive burns

57. A 50-year-old man presents with a painful, swollen leg that occurred over 2 days. He smokes two packs of cigarettes per day, and he is moderately overweight. He recalls striking his calf against a coffee table 3 days before and suffered an abrasion. His temperature is 100.5°F, and the leg is visibly swollen to the groin with moderate erythema. Pulses are normal. Which of the following statements is correct?

(A) Absence of palpable cords and a negative Homans' sign make DVT unlikely

(B) The fever and erythema make a diagnosis of DVT very unlikely

(C) The patient may be started on heparin anticoagulation immediately

(D) Because there is no evidence of pulmonary embolism, the patient may be started on coumadin alone

(E) A venogram must be performed within 24 h

58. An elderly man with a history of smoking complains of sudden, severe pain in the left leg beginning 2 h previously. The leg is cool, pale, and mottled from the mid-thigh distally, and sensation is decreased. All of the following are true EXCEPT

(A) the patient likely had an embolus that originated in the heart

(B) the patient should immediately receive throm-bolytic therapy with streptokinase or recombinant tPA because there is only a 4-h window during which reperfusion must be achieved to preserve limb function

(C) a vascular surgeon should be consulted immediately

(D) the patient has an overall mortality rate of about 15 percent

(E) intravenous heparin is indicated

59. In a heart transplant recipient, each of the following statements is true EXCEPT

(A) Sinus tachycardia at rest can be normal

(B) The effect of atropine is exaggerated in the denervated heart

(C) The response to p-adrenergic drugs is normal or increased

(D) The ECG is often read as atrial fibrillation or flutter

(E) The patient will be immunosuppressed for life

60. A 55-year-old man is 2 years post-heart transplantation for dilated cardiomyopathy. He presents with 1 day of fatigue, nausea, vomiting, and diarrhea. He is currently taking cyclosporine, prednisone, and azathioprine. All of the following statements are true EXCEPT

(A) The patient may have a cytomegalovirus infection

(B) The patient must be evaluated for possible acute rejection

(C) The patient should immediately receive 1 g intravenous methylprednisolone

(D) This illness may cause an episode of rejection

(E) The patient must receive antibiotics before endoscopic procedures

61. Regarding abdominal aortic aneurysms, all of the following statements are true EXCEPT

(A) Aneurysms larger than 5 cm should be treated surgically

(B) Fusiform aneurysms smaller than 4 cm can be managed conservatively

(C) Tenderness of an aneurysm may be an indication for surgery

(D) Most patients complain of back pain

(E) The most common presentation of an aneurysm is as an incidental finding

62. A 67-year-old man is brought to the ED by ambulance after a syncopal episode. He was well before the event, except for mild chronic hypertension. He fell on pavement, striking his head, so paramedics placed him in a cervical collar and strapped him to a spine board. He complains of low back pain, which he attributes to the spine board. BP is 100/50, and heart rate (HR) is 80 beats per minute. Which of the following is the best course of action?

(A) Analgesia, ECG, and outpatient referral to cardiologist

(B) ECG, cardiac enzymes, admit for telemetry monitoring

(C) Lateral abdominal x-ray, with aortogram if inconclusive

(D) Intravenous fluids, morphine, computed tomography (CT) of the abdomen

(E) Immediate surgical consultation, multiple large-bore intravenous lines, type and cross-match blood

63. A 60-year-old man presents with 1 h of chest and upper back pain "like I'm being ripped apart!" BP is 170/110 in the right arm and 110/50 in the left arm. ECG shows sinus rhythm with left ventricular hypertrophy. Chest x-ray is unremarkable. Which of the following is the most appropriate intervention?

(A) Nitroglycerin sublingual X 3, cardiac enzymes, admit

(B) Intravenous r-tPA or streptokinase, admit to cardiac care unit

(C) Intravenous heparin 80 U/kg bolus and 18 U/kg per hour as continuous infusion, ventilation/perfusion lung scan, admit

(D) Intravenous nitroprusside to keep systolic BP

< 110, intravenous propranolol to keep HR

< 60, contrast-enhanced CT of the thorax

(E) Intravenous morphine sulfate, emergency gastrointestinal consultation for endoscopy

64. All of the following are acceptable strategies for diagnosis of DVT EXCEPT

(A) duplex ultrasonography

(C) contrast venography

(D) elevated D-dimer fragments

65. Each of the following may be a manifestation of rejection in a cardiac transplant patient EXCEPT

(A) dysrhythmias

(B) myocardial infarction

(C) ascites

(D) renal insufficiency

(E) hypotension

66. All of the following statements are true of geriatric trauma patients EXCEPT

(A) Symptoms of intracranial hemorrhage may be delayed compared with symptoms in younger patients

(B) A normal heart rate is a good prognostic sign

(C) Cervical spine fractures are less common with increasing age

(D) Elderly patients have decreased pulmonary reserve

(E) Orthopedic injuries alone may cause significant hypovolemia

67. All of the following statements are TRUE with regard to mitral valve stenosis (MVS) EXCEPT

(A) Rheumatic heart disease is the most common cause

(B) Symptoms may be precipitated by atrial fibrillation, pregnancy, and anemia

(C) Syncope is the most common presenting symptom

(D) Hemoptysis is the second most common presenting symptom

(E) If the defect is not corrected, atrial fibrillation almost always develops

68. All of the following statements are TRUE regarding mitral valve prolapse (MVP) EXCEPT

(A) There is an increased incidence of sudden death and dysrhythmias

(B) In patients younger than 45 years, there is an increased incidence of TIAs

(C) Approximately 1 percent of the population has MVP

(D) A mid-systolic snap is a classic auscultatory finding

(E) Most patients are asymptomatic

69. Which of the following statements is FALSE with respect to aortic stenosis (AS)?

(A) Congential heart disease is the most common cause

(B) Left ventricular hypertrophy (LVH) is the most common ECG finding

(C) Sudden death occurs in 25 percent of patients

(D) Endocarditis occurs in 15 percent of patients

(E) Exertional angina is a common presenting symptom

70. For which of the following procedures should patients with valvular heart disease receive prophylactic antibiotics?

(A) Incision and drainage of an abscess

(B) Anoscopy

(C) Endotracheal intubation

(E) All of the above

71. Which valvular disease is MOST commonly associated with sudden death in younger patients?

(A) Aortic stenosis

(B) Mitral stenosis

(D) Tetralogy of Fallot

(E) Mitral valve prolapse

72. Afterload reduction is an important therapeutic modality in all of the following patients with symptomatic valvular disease EXCEPT

(A) a patient with BP of 125/70, with acute mitral incontinence secondary to an inferior MI

(B) a patient with aortic insufficiency (AI) with BP of 135/55 with pulmonary edema

(C) a patient with AS with a BP of 135/70 and angina

(D) a patient with mitral stenosis (MS) with a BP of 135/65 and pink frothy sputum

(E) a patient with chronic mitral and aortic insufficiency, a BP of 130/80 and CHF

73. A 25-year-old runner is brought to the ED by ambulance after experiencing witnessed syncope on the track. Paramedics arrived within 3 min and found the patient in ventricular fibrillation. A 200-J shock converted the rhythm to sinus tachycardia, and the patient has remained stable. He complains of some chest discomfort and tells you he has a familial heart problem and was told he should not run. BP is 100/80, respiratory rate (RR) is 20 breaths per minute, and pulse oximetry is 93 percent. The ECG shows sinus tachycardia at 115 beats per minute with septal Q and upright T waves. In addition to oxygen administration, which of the following is the MOST important therapeutic intervention?

(A) Aspirin and nitroglycerin

(B) Intravenous fluids and 5 mg intravenous labetalol

(C) Nitroglycerin and a lidocaine drip

(D) CPAP, nitroglycerin, and furosemide

(E) Aspirin, nitroglycerin, and dopamine

74. All of the following statements are TRUE regarding emergent pericardiocentesis EXCEPT

(A) Complications include pneumothorax, dys-rhythmias, laceration of coronary arteries, and liver lacerations

(B) Associated mortality with a blind approach is 6 percent

(C) The technique of choice is the left paraxyphoid approach aiming toward the right shoulder

(D) An ECG unipolar electrode attached to V1 is the guidance technique of choice

(E) There is a 7 to 15 percent complication rate with a blind approach

75. A 62-year-old man is brought to the ED by ambulance with confusion and dyspnea. BP is 80/60. With inspiration, SBP decreases to 55. The monitor shows a HR of 121 beats per minute, with vacillating amplitude of the QRS complex. RR is 26 breaths per minute, and oximetry saturation is 91 percent. Physical examination shows jugular venous distention (JVD), distant heart sounds, cool extremities, and diaphoresis. Chest x-ray is grossly normal. Which of the following would be the MOST effective therapeutic intervention?

(A) Large-volume resuscitation with crystalloid, oxygen, and emergent diagnostic spiral CT

(B) Large-volume resuscitation with crystalloid, oxygen, and dopamine

(C) Immediate intubation, large-volume resuscitation, and dopamine

(D) Large-volume resuscitation, oxygen, and immediate involvement of cardiology consult for placement of an intraaortic balloon pump

(E) Large-volume resuscitation, oxygen, and pericardiocentesis

76. Which of the following statements is FALSE with regard to cardiomyopathy (CM)?

(A) Hypertrophic CM is a familial disease associated with decreased compliance, outflow obstruction, and septal Q waves

(B) The work-up of a newly diagnosed dilated CM patient should include a check of thyroid-stimulating hormone (TSH), phosphate, and iron, HIV status, and an endocardial biopsy

(C) Patients with restrictive CM secondary to amyloidosis should be started on a triple regimen of diuretics, afterload reduction agents, and digoxin

(D) Fever and myalgias are not part of the presenting symptoms of CM

(E) Most CM patients are best treated with diuretics, afterload reduction agents, and digoxin

77. Which of the following statements is FALSE with regard to myocarditis?

(A) Most patients with myocarditis return to their baseline cardiac function within several months of initial presentation

(B) Up to 60 percent of patients with chronic cardiomyopathy have histologic evidence of myocarditis

(C) On polymerase chain reaction analysis of endocardial biopsy, adenovirus is found to be the most frequent etiologic agent of acute myocarditis

(D) Forty percent of patients with acute cardiomy-opathy have histologic evidence of myocarditis

(E) Cocksackie, influenza B, and Epstein-Barr (EBV) viruses have all been implicated in acute myocarditis

78. A previously healthy 25-year-old woman with no medical history presents to the ED complaining of 4 h of sub-sternal chest pain, shortness of breath, dyspnea on exertion, and "not feeling well" during the past few days. She denies illicit drug use or alcoholism. Vital signs are remarkable for a BP of 92/60, HR of 135, RR of 30, and temperature of 101.5°F. ECG shows normal sinus rhythm with nonspecific T-wave changes. Chest x-ray is normal. In addition to oxygen, which one of the following represents the BEST initial treatment regimen?

(A) Aspirin, nitroglycerin, check troponin and myoglobin levels

(B) Aspirin, (3 blocker, check TSH

(C) Intravenous fluids, analgesia, emergent echocardiogram

(D) Aspirin, nitroglycerin, emergent ventilation perfusion (V/Q) scan

(E) Intravenous fluids, lorazepam, antacids

79. All of the following statements are TRUE with regard to acute pericarditis EXCEPT

(A) Acute pericarditis is associated with transient dysrhythmias that are usually clinically insignificant

(B) Aspirin, 650 mg every 4 h for 7 days, should be initiated if the diagnosis is suspected, so long as no contraindications are present

(C) Electrical alternans or low-voltage ECG suggests the presence of pericardial effusion

(D) Concomitant pericardial effusion is common

(E) Sixty percent of patients have complete recovery within a week

80. All of the following statements are TRUE about ure-mic pericarditis EXCEPT

(A) Uremic pericarditis is one of most common causes of cardiac tamponade

(B) Pericarditis is detected clinically in 20 percent of uremic patients

(C) ECG changes of pericarditis are more common in uremic patients

(D) Hemodialysis daily for 2 to 6 weeks is the treatment of choice for uremic pericarditis

(E) Hemodialysis-associated pericarditis requires a diligent work-up for infectious causes

81. A 32-year-old man presents with 1 week of flulike symptoms and 2 days of sharp intermittent substernal chest and left shoulder pain that wakes him at night. The pain is partly relieved by sitting up. BP is 130/65, HR is 100, RR is 16, and temperature is 100.6°F. On physical examination, you hear a triphasic whispering heart sound over the precordium. All of the following are TRUE with regard to ECG findings associated with this condition EXCEPT

(A) Diffuse concave ST elevation and PR depression may be present

(B) ST-segment elevation of less than one-fourth of the T-wave amplitude is more consistent with this patient's condition than with early repolarization

(C) ST-segment elevation is most prominent in the limb leads and lateral precordial leads

(D) ST-segment elevation in this condition can be distinguished from that seen in AMI because there are no associated T-wave inversions

(E) The PR depression seen with this condition does not occur with early repolarization

82. Which represents the BEST matches of valvular diseases from the left column with ECG findings in the right column?

1.

MS

6.

acute inferior ischemia

2.

AS

7.

LVH and bundle branch block

3.

mitral valve prolapse

8.

biphasic P waves and right axis

4.

mitral insufficiency

9.

normal sinus rhythm

5.

IHSS

10.

pseudoinfarction pattern

(A)

1 + 8; 3 H

- 10

(B)

5 + 7; 2 +

- 10

(C)

4 + 6; 2 H

7

(D)

3 + 9; 1 H

6

(E)

2 + 9; 5 H

8

83. All of the following statements are TRUE regarding the treatment of valvular emergencies EXCEPT

(A) An intraaortic counterpulsation balloon is contraindicated in AI

(B) Thrombolytic agents may be helpful in acute mitral insufficiency

(C) Emergent surgery is usually indicated in acute aortic and mitral insufficiency

(D) Patients with AS and syncope require urgent surgical intervention

(E) Patients with decompensated MS and atrial fibrillation should be considered for cardioversion

84. A 28-year-old intravenous drug user presents with dyspnea, agitation, diaphoresis, cool extremities, and cough productive of pink frothy sputum. He has had fevers and chills for 2 days but suddenly became short of breath 1 h before. Vital signs are BP of 105/40, HR of 126, RR of 38 with oximetry saturation of 88 percent, and temperature of 103.5°F. He has quick, upsweeping pulses and a diastolic murmur. In addition to emergent intubation and intravenous furosemide administration, what is the MOST important immediate action?

(A) Administer naloxone and nitrates

(B) Call for a cardiac surgeon

(C) Perform emergent echocardiography

(D) Draw blood cultures and give intravenous antibiotics

(E) Administer naloxone and intravenous antibiotics and place an intraaortic counterpulsation balloon

85. All of the following statements are TRUE about infectious endocarditis EXCEPT

(A) Cardiac valve leaflets are susceptible to infection because of their limited blood supply

(B) Fatality rates for right-sided disease are greater than those for left-sided disease

(C) Streptococcus viridans is the most common organism implicated in left-sided disease

(D) More than three-fourths of cases of right-sided endocarditis are caused by Staphyloccus aureus

(E) Murmurs are detected in fewer than 50 percent of patients with right-sided disease

86. All of the following statements are TRUE concerning subacute infectious endocarditis EXCEPT

(A) The diagnosis is frequently missed

(B) Ten percent of patients have evidence of peripheral vasculitic embolic lesions

(C) Splenomegaly is present in 25 percent of patients

(D) Subacute presentations are unusual in right-sided disease

(E) Neurologic signs from septic emboli are seen in up to 40 percent of patients

87. All of the following statements are TRUE about CHF

EXCEPT

(A) Patients with CHF have a 50 percent mortality risk within 5 years

(B) Ventricular ejection fraction is the best predictor of mortality

(C) Sudden death occurs in 40 percent of CHF patients

(D) ACE inhibitors have decreased the incidence of sudden death

(E) (3 Blockers have been shown to be a useful treatment adjunct

88. A 59-year-old man presents to the ED by ambulance with a 1-h history of severe substernal chest pain and diaphoresis 12 h before presentation. Several hours after initial resolution of the pain, he developed increasing shortness of breath and chest heaviness. The patient is pale, cyanotic, and dyspneic, puffing out one to two words at a time. Vital signs are BP 102/60, HR 121 (sinus tachycardia), and RR 36 with pulse oximetry showing 87 percent saturation. ECG shows deep Q waves in leads Vx through V4 and no ST-segment changes. The chest x-ray shows normal heart size, Kerly B lines, and bilateral perihilar infiltrates. All of the following statements are CORRECT with regard to this patient EXCEPT

(A) He should be placed on positive pressure ventilation by face mask and given intravenous furosemide and nitroglycerin

(B) On insertion of a pulmonary artery catheter, wedge pressure would be at least 20 mm Hg

(C) The principal role of morphine is to calm the patient

(D) Dopamine should be started to keep the SBP between 90 and 100 mm Hg

(E) The patient should receive aspirin and metoprolol

89. All of the following statements are TRUE with regard to the treatment of pulmonary edema EXCEPT

(A) Higher doses of nitroglycerin are needed to alleviate the symptoms of APE than to relieve stable angina

(B) An appropriate estimate of intravenous furosemide dose is 1 mg/kg

(C) Dopamine produces a more favorable balance between myocardial oxygen supply and demand than does dobutamine

(D) Nitroprusside may induce ischemia in patients with coronary artery disease

(E) Digoxin has no role in the acute management of CHF

90. You respond to a "code blue" on the labor-and-deliv-ery ward. The nurse tells you that the patient is a previously healthy 41-year-old African-American woman, 4 days status post normal spontaneous vaginal delivery. She complained of chest pain and dyspnea and then fell to the floor unconscious. No seizure activity was noted. Although initially pulseless, vital signs returned with assisted ventilations. You find the patient confused, grunting, and cyanotic. Vital signs are BP 68/50 mm Hg, HR 121 beats per minute (sinus tachycardia), and RR 28, with pulse oximetry of 78 percent on high-flow oxygen. Physical examination shows distended neck veins, normal heart sounds with a prominent S2, a thready pulse with cool, cyanotic extremities, and adequate tidal volume with no rales or wheezes. Chest x-ray is normal. Bedside ultrasound of the heart shows a dilated right ventricle with parodoxical septal wall motion. In addition to immediate intubation and fluid resuscitation, what is the MOST appropriate therapeutic intervention?

(A) Emergent diagnostic spiral CT

(B) Heparin bolus of 80 U/kg intravenously followed by 18 U/kg infusion

(E) Emergent transfer to the angiography suite for pulmonary arteriography and local infusion of urokinase

91. All of the following statements are TRUE about diagnostic tests for PE EXCEPT

(A) The V/Q scan is 98 percent sensitive and 35 percent specific for PE

(B) Duplex ultrasound is 95 percent sensitive and 95 percent specific for DVT

(C) The difficulty in using V/Q scan findings for the diagnosis of PE is the lack of a standardized definition for "clinical suspicion"

(D) A D-dimer of less than 500 U/mL has a negative predictive value of 90 percent

(E) Spiral CT is up to 90 percent sensitive and 96 percent specific for PE

92. A 29-year-old man presents to the ED complaining of the acute onset of shortness of breath and chest discomfort. He was discharged from the ICU 2 weeks before, after surgical correction of a perforated viscus secondary to blunt trauma. Vital signs are BP of 120/60 mm Hg, HR of 100 beats per minute, and RR of 17, with a room air pulse oximetry of 97 percent. Chest x-ray is normal, as are initial electrolytes and hematocrit. A Doppler duplex scan of the lower extremities is normal. All of the following statements are TRUE with regard to this presentation EXCEPT

(A) PE is more common in men than in women before age 50 years

(B) If the patient has a low-probability V/Q scan, no further work-up is warranted

(C) A normal chest x-ray in the setting of acute dyspnea and hypoxemia is suggestive of PE

(D) Intravenous heparin administration should be strongly considered if the V/Q scan is "intermediate probability"

(E) Diffuse wheezing on examination would not reduce clinical suspicion for PE

93. All of the following statements are TRUE about PE

EXCEPT

(A) The risk for embolism from proximal DVT is highest in the first week

(B) The majority of the patients with PE have at least one risk factor

(C) Tachypnea is defined as a RR of greater than 16 breaths per minute

(D) Syncope is the presenting complaint in up to 5 percent of cases

(E) The right lower lobe is the most common part of the lung involved

94. All of the following statements are TRUE about PE

EXCEPT

(A) Seventy percent of the pulmonary vasculature must be occluded to produce hypoxia and hypotension

(B) Massive PE presenting with hypotension and hypoxemia accounts for 5 percent of all cases

(C) The most common ECG abnormality is nonspecific ST and T-wave changes

(D) ECG changes are seen in about 40 percent of patients with PE

(E) New right bundle branch block should raise the clinical suspicion for PE

95. Match the items in the left column with their MOST appropriate counterparts in the right column.

1.

ankle brachial index = 0.6

6.

vascular emergency

2.

ankle brachial index = 1.0

7.

triphasic wave over tibialis pedis

3.

apteriovenous fistula

8.

Doppler flow sound in diastole

4.

ankle brachial index = 0.3

9.

monophasic wave over dorsalis pedis

5.

monophasic wave every 3 s

10.

venous flow

(A)

1 + 9; 2 + 10

(B)

2 + 7; 3 + 10

(C)

4 + 6; 5 + 8

(D)

1 + 9; 4 + 6

(E)

2 + 9; 3 + 8

96. All of the following statements are TRUE about the use of nuclear medicine in cardiac disease EXCEPT

(A) Thallium 201 is a potassium cation analog that is taken up by active well-perfused myocytes during exercise and redistributes to less well-perfused myocardium during rest

(B) Technetium-99m sestamibi accumulates in well-perfused myocytes and does not redistribute at rest

(C) Thallium 201 has a stronger signal and shows better contrast on positron emission tomography than does technetium-99m sestamibi

(D) Nuclear stress tests for coronary ischemia are more sensitive than ECG stress tests

(E) The role of nuclear cardiac stress tests in the ED is to evaluate for coronary ischemia

97. A 56-year-old man with a history of hypertension and tobacco use complains of intermittent substernal chest pain without radiation or associated shortness of breath, nausea, or diaphoresis. Chest pain occurs both with exertion and at rest and lasts 5 to 10 min at a time. He is currently pain free, but his ECG shows LVH and inverted T waves in leads V4 to V6. Two sets of cardiac enzymes are negative. Which of the following diagnostic tests would be MOST appropriate?

(A) An ECG exercise stress test

(B) A T99 exercise stress test

(C) Echocardiography for evaluation of wall motion abnormalities

(D) Coronary angiography

(E) A 24-h Holter monitor

98. All of the following statements are TRUE regarding the role of echocardiography in the ED EXCEPT

(A) Normal left ventricular wall motion during chest pain suggests noncardiac chest pain

(B) Among patients with nonspecific ECG abnormalities and chest pain, echocardiography changes the admission diagnosis in up to 40 percent of cases

(C) The presence of thin hyperechoic myocardium implies an area of infarct more than 2 weeks before presentation

(D) Cardiac ultrasound is superior to clinical assessment of Killip classification and superior to ECG in predicting death and major complications

(E) Localized or small wall motion abnormalities may be apparent on echocardiogram, even in the presence of nonspecific ECG changes

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