Circulation

Questions

DIRECTIONS (Questions 76-149): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

76. A hypertensive woman is well controlled by amlodipine and quinapril, and she is planned for cholecystectomy. According to the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery, her antihypertensive medications should be

(A) continued during the perioperative period

(B) held on the morning of surgery

(D) replaced by intravenous medications on day of surgery

(E) reduced by 50% for 24 h before surgery

77. A 62-year-old woman is seen in the preoperative clinic prior to undergoing a total knee replacement. Routine laboratory results include a serum potassium concentration of 5.7 mEq/L. This could be an effect of which one of these medications?

(A) hydrochlorothiazide

(B) bumetanide

(D) triamterene

(E) chlorthalidone

78. A 58-year-old woman has a preoperative B-type natriuretic peptide (BNP) level of 200 pg/mL four years after aortic valve replacement. This substance

(A) decreases urine production

(B) is produced by the kidneys

(D) is a product of immunological B-cells

(E) is a marker of inflammation and myocardial damage in heart failure

79. A 43-year-old woman is in the PACU following facial cosmetic surgery when suddenly her cardiac rhythm changes to supraventricular tachycardia. The PACU resident decides to administer adenosine. The effects of this medication usually last for just a few seconds, but may be prolonged by the prior administration of

(A) caffeine

(B) theobromine

(D) dipyridamole

(E) ketamine

80. A 70-year-old man underwent coronary surgery with the aids of cardiopulmonary bypass and heparin. His chance of postoperative heparin-induced thrombocytopenia (HIT) is approximately

(A) 2%

(B) 20%

(D) 80%

(E) 99%

81. A 72-year-old woman takes aspirin and clopidogrel because of the recent insertion of a drug-eluting coronary stent. She has a reducible ventral hernia that will require repair at some point, but the surgeon wants her to stop the clopidogrel a week prior to the surgery. Based on the 2007 advisory from the American College of Cardiology and the American Heart Association, it is recommended that she delay elective repair of her hernia until how long after her stent procedure?

(A) 1 month

(B) 3 months

(D) 12 months

(E) 24 months

82. High saturation of hemoglobin with oxygen is planned in a patient with sickle cell disease. A factor that tends to increase the affinity of hemoglobin for oxygen is

(A) acidosis

(B) hyperthermia

(D) hypercarbia

(E) diphosphoglycerol

83. A 70-year-old man with a palpable pulsatile abdominal mass underwent CT evaluation and was found to have an aortic aneurysm 4.5 cm in diameter. His approximate annual risk of rupture is

(A) 0.5-5%

(B) 10-20%

(D) 30-50%

(E) 50-70%

84. A 25-year-old man has suffered hemorrhagic trauma in a motor vehicle accident. He bears blood group A and can receive

(A) whole blood of type AB

(B) red cells of type A or O

(D) red cells of any type

(E) whole blood of type O

85. A 30-year-old man has fainted several times and has familial hypertrophic obstructive cardiomyopathy. Hemodynamic goals during anesthesia for inguinal hernia repair include

(A) decreased preload

(B) decreased afterload

(D) increased heart rate

(E) low hematocrit

86. A 60-year-old patient with aortic valve area of 0.8 cm² is planned for laparoscopic cholecystectomy. In an effort to optimize hemodynamics in aortic stenosis, the goals generally include

(A) low preload

(B) low afterload

(D) low hematocrit

(E) high pulmonary vascular resistance

87. A 60-year-old man with mean arterial pressure of 50 mm Hg is considered for intraaortic balloon counterpulsation. The device can be beneficial in the following conditions EXCEPT

(A) aortic regurgitation

(B) mitral regurgitation

(D) myocardial ischemia

(E) myocardial stunning

88. A preoperative patient is noted to have elevated mean red cell volume. This could indicate the following EXCEPT

(A) aplastic anemia

(B) anemia of chronic liver disease

(D) anemia of folate or vitamin B12 deficiency

(E) chemotherapy

89. A 50-year-old with von Willebrand disease requires thyroidectomy. Hemostatic aids might include the following EXCEPT

(A) desmopressin (DDAVP)

(B) cryoprecipitate

(D) tranexamic acid

(E) vitamin K

90. A critically ill patient is monitored with the aid of a dorsalis pedis arterial catheter after failure of a femoral catheter. As the pressure monitoring site moves distally from the aorta the

(A) pulse pressure increases

(B) upstroke is sooner

(D) diastolic pressure increases

(E) dicrotic notch is earlier

91. A 65-year-old man has a type II aortic aneurysm. In the Crawford classification of thoracoabdominal aortic aneurysm extent, the following are true EXCEPT

(A) type I does not involve the renal arteries

(B) the renal arteries are involved in types II, III, and IV

(D) type II arises near the left subclavian and reaches the abdominal bifurcation

(E) type III arises in the midportion of the descending thoracic

92. Hypoxia general elicits vasodilation in patients. However, hypoxic vasoconstriction is prominent and clinically important in the

(A) lungs

(B) brain

(D) liver

(E) skin

93. A 64-year-old male with a past medical history significant for coronary artery disease and peripheral vascular disease is found unresponsive in his bed. It is two days since he underwent right femoro-popliteal bypass grafting, and his postoperative course had been complicated by ventricular arrhythmias. Upon arrival of the rapid response team, the airway is secured, and an ECG is obtained that shows a polymorphic tachycardia that is oscillating around the baseline, and intermittent sinus rhythm with T-wave alternans. This arrhythmia

(A) may be elicited by procainamide

(B) is a type of supraventricular tachycardia

(D) is characterized by a short QT interval

(E) is more frequent in men than women

94. Pain control fails to improve the tachycardia of a patient in the PACU. At equianalgesic doses, the opioid most likely to increase heart rate is

(A) morphine

(B) meperidine

(D) sufentanil

(E) hydromorphone

95. A 60-year-old man is suspected of acute coronary syndrome. Myocardial oxygen demand may be decreased by

(A) tachycardia

(B) decreased preload

(D) increased contractility

(E) increased wall tension

96. A 70-year-old woman is under anesthesia in preparation for coronary surgery. Coronary perfusion pressure is increased as a result of

(A) increased diastolic blood pressure

(B) increased left ventricular end-diastolic pressure

(D) tachycardia

(E) hypocapnia

97. A patient with mild aortic stenosis is undergoing splenectomy. At a constant stroke volume, cardiac output is

(A) proportional to resistance

(B) a linear function of heart rate

(D) related to potassium concentration

(E) inversely proportional to arterial blood pressure

98. Your patient is in normal sinus rhythm. The intrinsic rate of the sinoatrial node is generally

(A) 20 to 40 beats per minute

(B) 40 to 60 beats per minute

(D) 80 to 100 beats per minute

(E) 100 to 120 beats per minute

99. Electrocardiographic monitoring is indicated during anesthesia to detect all of the following EXCEPT

(A) efficacy of pump function

(B) arrhythmias

(D) electrolyte disturbance

(E) pacemaker function

100. Your patient has a history of deep venous thrombosis and pulmonary embolism. An endogenous inhibitor of intravascular coagulation is

(A) factor V Leiden

(B) activated protein C

(D) Hageman factor

(E) argatroban

101. A 40-year-old skier is hypotensive after a femur fracture and is suspected of fat embolus. Other clinical manifestations of fat emboli include the following EXCEPT

(A) petechiae

(B) hypoxemia

(D) bradycardia

(E) cyanosis

102. A preoperative patient is noted to have a low platelet count. The minimum number of platelets needed for surgical hemostasis is approximately

(A) 10,000/mm³

(B) 50,000/mm³

(D) 120,000/mm³

(E) 1,000,000/mm³

DIRECTIONS: Use the following figure to answer Questions 103-106:

103. Left ventricular end-diastolic pressure is most closely approximated by

(A) arterial blood pressure

(B) central venous pressure

(D) pulmonary capillary wedge pressure

(E) right atrial pressure

104. The curves marked 3 and 4 in the graph shown could be seen in patients

(A) with increased contractility

(B) on digoxin or epinephrine

(D) who have been treated with glucagon

(E) who respond to increased left ventricular end-diastolic pressure (LVEDP) with increased stroke volume

105. If a patient’s status is represented by point A on curve 4 in the graph shown, then administration of intravenous fluid may

(A) shift the patient to the normal curve

(B) shift the patient to point B or C

(D) have no effect

(E) shift the patient to curve 2

106. Administration of an inotrope to a patient at point B on curve 4 is intended to

(A) shift the patient to curve 3

(B) shift the patient to point A

(D) maintain the patient at point B

(E) shift the patient to curve 1

107. A 5-foot, 7-inch, 40-year-old man weighing 320 pounds is planned for laparoscopic gastric bypass. Morbid obesity is associated with

(A) decreased cardiac output

(B) hypertension

(D) decreased blood volume

(E) decreased cardiac workload

108. A newborn has persistent patency of the ductus arteriosus. This may close in response to

(A) hypoxemia

(B) alprostadil (prostaglandin E₁)

(D) indomethacin

(E) nitrous oxide

109. You are hyperventilating a neurosurgery patient to an arterial PCO₂ value of 28 mm Hg. The coronary circulation responds to hyperventilation with

(A) no change

(B) an increase in flow

(D) a transient increase followed by an intense vasodilatation

(E) intense vasoconstriction

110. Your patient’s blood pressure is 160/100. The mean pressure is approximately

(A) 110 mm Hg

(B) 120 mm Hg

(D) 140 mm Hg

(E) 150 mm Hg

111. A small bubble is noted in the saline-filled plastic tubing connected to an arterial catheter of your patient. The bubble

(A) is not significant

(B) leads to an artificially high reading

(D) leads to a damping of the tracing

(E) has a greater effect on the mean blood pressure

112. Under normal circumstances, the plasma protein (colloid) osmotic pressure is

(A) 0 mm Hg

(B) 5 mm Hg

(D) 50 mm Hg

(E) 100 mm Hg

113. Pulmonary edema may result from all of the following EXCEPT

(A) altered permeability

(B) decreased pulmonary capillary pressure

(D) increased negative airway pressure

(E) head injury

114. You encounter a cyanotic patient. Net right-to-left shunt is a feature of

(A) atrial septal defect

(B) ventricular septal defect

(D) tetralogy of Fallot

(E) increased ventricular filling pressure

115. You notice an increase in heart size before revascularization of a patient undergoing coronary surgery. If the size of the ventricle increases

(A) wall tension needed to pump the same amount of blood is less

(B) less oxygen is needed to pump blood

(D) wall tension will increase proportionally with the radius

(E) wall tension will be proportional to wall thickness

116. Your goal is to maintain coronary blood flow while a patient with coronary disease undergoes cholecystectomy. The flow

(A) is independent of the systolic pressure

(B) is not affected by humoral agents

(D) is increased by a fast heart rate

(E) occurs almost entirely in systole

117. You are monitoring a patient with the aid of a pulmonary artery catheter. Pulmonary artery pressure

(A) increases passively with increases of cardiac output

(B) remains constant with change of cardiac output

(D) is not dependent on the radius of the vessels

(E) depends entirely on cardiac output

118. You are evaluating the degree of congestive heart failure in a preoperative patient with dyspnea on exertion. Increased sympathetic tone in congestive heart failure may be indicated by

(A) memory loss

(B) weakness

(D) confusion

(E) anxiety

119. A 56-year-old female is undergoing left pneumonectomy for lung cancer. A few hours after the surgery, the patient is noted to have progressive hypoxemia, and hypotension requiring vasopressor support. A stat transthoracic echocardiogram obtained at the bedside is suggestive of right-heart failure. The next best step in management would be

(A) administration of selective pulmonary vasodilators

(B) afterload reduction with infusion of intravenous nicardipine

(D) a reduction in FIO₂

(E) endotracheal intubation and permissive hypercarbia

120. Cardiopulmonary bypass is initiated in a 70-year-old man planned for coronary surgery. Unexpected hypotension (mean aortic pressure of 30 mm Hg) is rapidly encountered and may be due to all of the following EXCEPT

(A) hemodilution

(B) decreased catecholamines

(D) persistent systemic to pulmonary shunt

(E) aortic dissection

121. Your patient requires cardiopulmonary bypass. Myocardial preservation during that procedure may include all of the following EXCEPT

(A) maintaining the ventricle in a distended state

(B) cardioplegia

(D) avoidance of ventricular fibrillation

(E) maintaining the heart at a low temperature

122. Following breast surgery under general anesthesia, your patient in the recovery room exhibits elevated blood pressure readings of about 190/110 mm Hg. Your approach should be

(A) treat the blood pressure with small doses of an antihypertensive medication

(B) do nothing, but wait to see if the hypertension is a transient problem associated with emergence from anesthesia

(D) recheck the blood pressure yourself to make sure the cuff is the correct size

(E) arrange a cardiology consultation

123. A 97-year-old woman undergoes bowel resection under general anesthesia. Cardiovascular changes that occur with advancing age are

(A) decreasing blood pressure

(B) increase in cardiovascular reserve

(D) increased number of myofibrils

(E) increase in cardiac output

124. Poor right ventricular contractility is noted in the operating room soon after mitral valve replacement. The right ventricle

(A) has little function in the adult patient

(B) is very easily cooled in the patient undergoing cardiopulmonary bypass

(C) can overcome pulmonary vascular resistance very effectively, and, therefore, is not of concern in terminating cardiopulmonary bypass

(D) is more likely to be injured by intracoronary air than is the left ventricle during cardiopulmonary bypass

(E) is unaffected by PEEP

125. A preoperative patient is planned for surgery prompted by workup of hypertension. A cause of systemic hypertension that is amenable to surgical correction is

(A) essential hypertension

(B) secondary aldosteronism

(D) pheochromocytoma

(E) long-standing renal artery stenosis

DIRECTIONS: Use the following scenario to answer Questions 126–127. A 24-year-old female is admitted for evaluation of chest pain. The pain is sharp and aggravated by breathing. A chest x-ray shows an enlarged heart, ECG shows decreased voltage, and there is a pericardial friction rub. Pericardiocentesis demonstrates purulent fluid. Serial x-rays show widening of the cardiac shadow, and the patient is scheduled for pericardial drainage.

126. On physical examination, you would expect to find

(A) a water-hammer pulse

(B) an increased cardiac output

(D) decreased arterial pressure

(E) low central venous pressure

127. A pulsus paradoxus is a pulse that has the following properties EXCEPT that it

(A) reduces in amplitude >10 mm Hg on inspiration

(B) can occur in hemorrhage and in severe obstructive lung disease

(D) is stronger on inspiration

(E) is associated with tamponade, pulmonary embolism, and tension pneumothorax

128. A 68-year-old is noted to have an abnormal Allen test before cardiac surgery. The test is

(A) used to assess adequacy of radial artery perfusion

(B) of little predictive value

(D) negative if good flow occurs

(E) independent of hand position

129. Central venous cannulation is indicated in all the following procedures EXCEPT

(A) a surgical procedure in which there is an unusual position, e.g., head-down position

(B) patients in shock

(D) intravenous administration of vasopressors

(E) inadequate venous access in a patient with extensive burns

130. A 42-year-old patient with a past medical history of insulin dependent diabetes mellitus and end-stage renal disease requiring hemodialysis is admitted to the intensive care unit with signs and symptoms of septic shock secondary to community acquired pneumonia. The patient has very poor peripheral access, and a decision for placement of a central venous catheter, as well as an arterial catheter for blood pressure monitoring, is made. With respect to potential sites of vessel cannulation it is true that

(A) chylothorax is common with right internal jugular cannulation

(B) brachial plexus trauma is common with the antecubital approach for central venous cannulation

(D) the Allen test rules out ischemic complications related to a radial arterial catheter

(E) the dorsalis pedis is not the artery of choice for blood pressure monitoring in a patient with diabetes

131. You are asked by a member of the orthopedic team to do a preoperative evaluation on an 87-year-old female admitted from the emergency department for left femur fracture. The patient has a heart murmur, and an echocardiogram obtained by the medical consultant shows aortic stenosis with a valve area of 0.6 cm². The patient with severe aortic stenosis usually has

(A) a rapidly deteriorating course once symptoms are present

(B) a large left ventricular cavity

(D) protection against ischemia due to the large ventricle

(E) a very compliant ventricle

132. A bridge-to-transplant patient with biventricular heart failure is stabilized by placement of a left ventricular assist device and by administration of inhaled nitric oxide. The inhaled drug has the following properties EXCEPT that it

(A) may cause methemoglobinemia

(B) often lowers mean pulmonary artery pressure

(D) often decreases systemic oxygenation

(E) increases vascular smooth muscle cyclic GMP

133. Following cardiac surgery, a patient is noted to exhibit equalization of diastolic filling pressures (central venous, right ventricular diastolic, pulmonary artery diastolic, pulmonary capillary wedge) that tends to occur in

(A) mitral stenosis

(B) pulmonary embolus

(D) cardiac tamponade

(E) atrial fibrillation

134. Vitamin K

(A) is required for synthesis of functional clotting factors VII, IX, X, and II (prothrombin)

(B) antagonizes heparin

(D) antagonizes protamine sulfate

(E) is a prominent citrus product

135. A patient in renal failure is receiving erythropoietin in preparation for cardiac surgery. This substance

(A) is normally produced by the liver

(B) increases platelet production

(D) increases white blood cell production

(E) is a breakdown product of heme

136. A 20-year-old tachycardic patient improves following an intravenous dose of adenosine. The drug

(A) inhibits phosphodiesterase

(B) is inactivated by catechol O-methyltransferase

(D) is a β-adrenergic agonist

(E) is primarily cleared by the kidneys

137. A preoperative 3-year-old exhibits “tet spells.” An agent that may reduce right-to-left shunt in tetralogy of Fallot is

(A) sodium nitroprusside

(B) labetolol

(D) phenylephrine

(E) diltiazem

138. Seven years after heart transplantation, a 60-year-old woman is planned for appendectomy. The transplanted, denervated heart responds to

(A) circulating catecholamines

(B) circulating acetylcholine

(D) vagal stimulation

(E) muscarinic blocking agents

139. A 58-year-old man with chest pain exhibits elevation of the ST segments of precordial ECG leads. This finding can occur in all of the following conditions EXCEPT

(A) Prinzmetal’s angina (coronary spasm)

(B) acute pericarditis

(D) myocardial contusion

(E) during normal exercise in an individual without coronary disease

140. You consider verapamil for a tachycardic patient. The drug may exacerbate all of the following diseases or symptoms EXCEPT

(A) sick sinus syndrome

(B) atrial fibrillation

(D) Wolff–Parkinson–White syndrome

(E) congestive heart failure

141. You measure cardiac output in order to calculate systemic vascular resistance in a septic patient. Cardiac output is

(A) identical in the left and right heart

(B) usually 2 to 3 L/min in a 70-kg man

(D) the product of heart rate and stroke volume

(E) the product of heart rate and mean arterial pressure

142. You consider reduction of myocardial contractility in a cardiac patient. Contractility is decreased by

(A) sympathetic stimulation

(B) parasympathetic tone

(D) norepinephrine

(E) epinephrine

DIRECTIONS: Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) atrial fibrillation

(B) hypertrophic obstructive cardiomyopathy

(D) aortic regurgitation

(E) pulmonary embolism

(F) Eisenmenger syndrome

(G) tricuspid regurgitation

(H) myocardial infarction

For each patient with a cardiac symptom or sign, select the most likely mechanism causing the symptoms or sign.

143. A 50-year-old man has dyspnea on mild exertion, bounding pulses, and a diastolic murmur.

144. A 40-year-old woman with a long-standing heart murmur has shortness of breath, cyanosis, and a systolic heart murmur

145. A 20-year-old man becomes profoundly hypotensive after modest intraoperative bleeding.

146. A 70-year-old woman with an irregular pulse suffers sudden loss of the right lower quadrant of the visual field.