1. A 55 year old man with a long history of hypertension presents to the emergency room with 2 hours of substernal chest pain radiating to the left arm, diaphoresis, and nausea. His blood pressure is 180/95 mmHg, equal in both arms; the pulse is 110bpm and regular; he is afebrile with a respiratory rate of 28 per minute. An electrocardiogram shows 3mm ST elevations in V2 through V5, I and aVL; ST depressions ~1mm are found in aVR and III. Which of the following should NOT be administered [1]:

   A. Lidocaine 1mg/kg bolus and 2mg/minute drip intravenously
   B. Aspirin 325mg po
   C. Glucose+insulin+potassium infusion
   D. Metoprolol (Toprol®) 5mg iv followed by 2.5-5mg to control pulse (and blood pressure)
   E. Nitroglycerin intravenously titrated to blood pressure

2. Over the next 24 hours, the patient's blood pressure drops to 110/70 and his chest pain is completely gone. An echocardiogram shows akinesis of the anterior wall and diffuse hypokinesis of the remaining walls of the left ventricle. The estimated ejection fraction is 20%. Which of the following medications should be administered [2]:

I. Nifedipine (Procardia®) 10mg orally every 8 to 12 hoursII. Carvidilol (Coreg®), low dose with gradual escalation as toleratedIII. Digoxin, 0.25mg iv loading dose followed by 0.125 to 0.25mg every dayIV. An angiotensin converting enzyme (ACE) inhibitor, titrated to blood pressure
V. Dobutamine, intravenous drip titrated to blood pressure and cardiac output
A. I, II, and III should be administered
B. I and III should be administered
C. II and IV should be administered
D. V alone should be administered
E. All of the above should be administered

3. The patient improves over the next several days and is transferred out of the intensive care unit. There are 5-7 premature ventricular complexes per minute on telemetry monitoring. The appropriate treatment is [3]:

   A. No additional treatment is required
   B. Insure that the patient is a ß-blocking agent as tolerated by pulse and blood pressure
   C. Add sotalol to the medical regimen while carefully monitoring QTc interval
   D. Loading dose of amiodarone followed by high doses to prevent ventricular tachycardia
   E. Add procainamide to the medical regimen while carefully monitoring QTc interval

4. The patient undergoes a submaximal exercise thallium treadmill test (ETT). He completes 10 minutes on the treadmill without symptoms. The electrocardiogram shows no significant changes. The pulse increases from 60 resting to 72 at full capacity (while taking carvidilol), and the blood pressure increases from 110/65 resting to 140/75 at full exercise. The next step in the evaluation is [4]:

   A. No additional testing is needed at this time
   B. Schedule a full, maximal exercise treadmill test with thallium
   C. Schedule an echocardiogram within 2 weeks
   D. Advise the patient to undergo cardiac catheterization with possible revascularization
   E. Reduce the ß-blocker dosage and repeat the submaximal exercise test

5. A 50 year old patient seen in your outpatient clinic describes intermittant episodes of headaches, blurred vision, diaphoresis, palpitations, and feeling hot. The episodes come on fairly quickly and go away after 45-120 minutes. His blood pressure in the office is 145/95mm equal in both arms. In addition to considering medical therapy, which test is most likely to confirm the suspected diagnosis [5] ?

   A. Urinary 5-HIAA (hydroxyindole acetic acid)
   B. Serum norepinephrine level
   C. Serum aldosterone and renin levels
   D. Thyroid Stimulating Hormone (TSH) level
   E. Urinary VMA (vanylmendilic acid) and metanephrines

6. A 28 year old woman presents to your outpatient clinic after being screened at a community health center and found to have a blood pressure of 150/100 mm Hg. She has no other symptoms, does not smoke, and takes no medications. Her family history is notable for a father with high blood pressure and a mother with a history of transient ischemic attacks (TIA), now on clopidogrel (Plavix®) and low dose (81mg/d) aspirin. You confirm the blood pressure; her pulse is 72bpm. Physical examination is unremarkable. Which of the following tests should be ordered to confirm the diagnosis [6] ?

I. Serum TSH LevelII. Serum Renin and Aldosterone LevelIII. Urinary VMA and metanephrinesIV. Captopril-Renin Kidney Perfusion Scan
V. Serum Glucorticoid Levels with Dexamethasone Suppression
A. I, II and III should be ordered to confirm the diagnosis
B. I and III should be ordered to confirm the diagnosis
C. II and IV should be ordered to confirm the diagnosis
D. V alone should be ordered to confirm the diagnosis
E. All of the above tests should be ordered to confirm the diagnosis

7. Which of the following agents is most likely to maintain sinus rhythm in a patient with atrial fibrillation for less than one year [7] ?

   A. Procainamide
   B. Metoprolol
   C. Quinidine
   D. Amiodarone
   E. Digoxin

8. Which of the following is NOT a risk factor for development of atrial fibrillation [8] ?

   A. Cardiac Bypass Surgery (CABG)
   B. Hypertension
   C. Aortic Insufficiency
   D. Mitral Stenosis
   E. Hyperthyroidism

9. Which of the following is NOT associated with prolongation of the QTc interval [9] ?

I. HypomagnesemiaII. QuinidineIII. Moxifloxacin (Avelox®)IV. Sotalol (Sotacor®, Betapace®)
V. Hypercalcemia
A. I, II and III are NOT associated with prolongation of the QTc interval
B. I and III are NOT associated with prolongation of the QTc interval
C. II and IV are NOT associated with prolongation of the QTc interval
D. V alone is NOT associated with prolongation of the QTc interval
E. All of the above are associated with prolongation of the QTc interval

10. A 45 year old patient presents with 6 months of intermittant fevers, weight loss, and fatigue. He has also noted intermittant palpitations. He had two episodes of near syncope. He takes no medications. Physical examination reveals normal vital signs, an irregular pulse, and a small digital ulcer of the 3rd right toe. Laboratory analysis reveals an anemia with low serum iron, low total iron binding capacity, and high ferritin. The white count is 10.5K/µL with a normal differential, platelets elevated at 550K/µL, and the sedimentation rate is 85mm/hr. An electrocardiogram shows atrial fibrillation with a ventricular response ot 92bpm and no other abnormalitis. The most likely diagnosis is [10]:
A. Lymphoma
B. Cardiac Sarcoma
C. Systemic Vasculitis, Takayasu vs. Giant Cell
D. Giant Cell Myocarditis
E. Atrial Myxoma

Answers

1. A
2. C
3. B
4. D
5. E
6. C
7. D
8. C
9. D
10. E